Chapter 1, 3, 21

Question 1

[ ]

Answer 1

Brackets enclose synonyms, alternative wording, or explanatory phrases.

Question 2

Slanted [ ]

Answer 2

Used in the alpha index to enclose a code that must be used with a code for the underlying/primary disease

codes that should be listed second

Question 3

( )

Answer 3

Parenthesis enclose nonessential modifiers; supplementary words that may be present OR absent in the statement of the disease or procedure without affecting code assignment.

Question 4

:

Answer 4

Incomplete term that needs one or more additional terms to make a code assignable

Question 5

NEC

Answer 5

Not elsewhere classifiable. Used when a more specific code is not available

Question 6

NOS

Answer 6

Not otherwise specified. Used when information in record is insufficient, i.e. unspecified.

Question 7

Includes

Answer 7

Further define, clarify, or give examples of the content of the code category

Question 8

Excludes 1

Answer 8

Indicates conditions listed after it can never be used in with the code above the note

Question 9

Excludes 2

Answer 9

Two codes are assigned when both conditions are present

Question 10

And

Answer 10

Interpreted as “and/or”

Question 11

With/Without

Answer 11

When these 2 options are present the default is ‘without’

Question 12

Steps to correct coding

Answer 12

1. review the coding conventions and the general coding guidelines
2. look up the main term (boldface type) in the alphabetic index and scan the subtermk entries as appropriate
3. note all parenthetical terms (nonessential modifiers) that help in code selection but do not affect code assignment

Question 13

Code first

Answer 13

When an underlying condition is present, the underlying condition should be sequenced first

Question 14

Use additional code

Answer 14

Serves as a reminder that an additional code might be required to fully describe the condition. This also indicates the sequencing required.

Question 15

Code also

Answer 15

Two codes may be required to fully describe the condition. No sequencing direction.

Question 16

ICD-10-CM codes are alphanumeric

Answer 16

True

Question 17

Codes consist of

Answer 17

3-7 characters

Question 18

The first character is always an _____________

Answer 18

alphabetic letter

Question 19

All letters utilized except letter ___

Answer 19

U

Question 20

The second character is always ______

Answer 20

numeric

Question 21

Can characters 3 through 7 can be alphabetic or numeric?

Answer 21

True

Question 22

A decimal is placed after the first ___ characters of a code

Answer 22

three

Question 23

Alpha characters are not ____

Answer 23

case sensitive

Question 24

Placeholder character has 2 rules

Answer 24

Provides for future expansion without disturbing the overall code structure

When a code has less than six characters and a seventh character is required. The X is assigned for all characters less than six in order to meet the requirement of coding to the highest level of specificity.

Question 25

What does a dash at the end of the code mean?

Answer 25

Additional characters are necessary to complete the code.

Question 26

The 5th and 6th characters were added to the code format for what purpose?

Answer 26

To provide greater code specificity

Question 27

A _____________ code is a single code used to classify two diagnoses, a diagnosis with a manifestation or associated complication.

Answer 27

Combination code

Question 28

Signs and symptoms that are not commonly associated with a disease process should:

Answer 28

be coded when present

Question 29

In the Tabular List of Diseases and Injuries, what do the brackets enclose?

Answer 29

alternative wordings, explanatory phrases, and synonyms

Question 30

Principal diagnosis

Answer 30

The condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care

Question 31

Other diagnoses

Answer 31

All conditions that coexist at the time of admission, that develop subsequently, or that affect treatment received and/or length of stay.

Question 32

UHDDS

Answer 32

Uniform Hospital Discharge Data Set

Question 33

Complication

Answer 33

additional diagnosis that describes a condition arising after the beginning of the hospital observation and treatment and then modifying the course of the patients illness or the medical care required.

Question 34

Comorbidity

Answer 34

pre-existing condition that because of its presence with a specific principal diagnosis, will cause an increase on the patients length of stay.

Question 35

Principal Procedure

Answer 35

procedure performed for definitive treatment rather than diagnostic purposes

Question 36

Significant Procedure

Answer 36

is a procedure that is surgical in nature, carries a procedural risk, carries an anesthetic risk, and requires specialized training

Question 37

Per ICD-10-CM guidelines for coding nonspecific abnormal findings, when can abnormal findings from lab or x-ray results be coded and reported? Please answer for if an inpatient and if an outpatient.

Answer 37

Inpt: When the physician documents the clinical significance of the finding in the record it can be coded Outpt: Codes can be assigned based upon reports from diagnostic tests, but not based upon a lab result alone

Question 38

Abnormal findings (laboratory, x-ray, pathologic, and other diagnostic results)

Answer 38

are not coded and reported unless the provider indicates their clinical significance. If the findings are outside the normal range and the attending provider has ordered other tests to evaluate the condition or prescribed treatment, it is appropriate to ask the provider.