Chapter 1 - Introduction to ICD-10-CM

Question 1

flush (documents) [3 terms]

Answer 1

(adj) Aligned along a margin.

For example, text that is flush left is aligned along the left margin. Flush-right text is aligned along the right margin.

The opposite of flush is ragged.

Text that is both flush left and flush right is said to be justified.

Question 2

main terms

Answer 2

ICD-10-CM entries printed in boldface and flush with the left margin of each column; they are located in the ICD-10-CM indexes.

Question 3

What are the two indices and two tables in ICD-10-CM, located before the Tabular List?

Answer 3

Index to Diseases and Injuries
External Causes of Injuries Index
Table of Neoplasms
Table of Drugs and Chemicals

Question 4

What are the four types of main terms in ICD-10-CM?

Answer 4

Diseases such as influenza or bronchitis
Conditions such as fatigue, fracture, or injury
Nouns such as disease, disorder, or syndrome
Adjectives such as double, kink, or large

Question 5

What is the first and second place that a coder goes to locate ICD-10-CM codes for a patient’s disease or condition?

Answer 5

First place: The two indices of ICD-10-CM, also called the Alphabetic Index.
Second place: The Tabular List.

Question 6

subterms

Answer 6

Also called essential modifiers.

They are in regular type and begin with a lowercase letter. They are indented one standard indentation to the right under the main term and are listed in alphabetic order.

They describe essential differences in the site, cause, or clinical type of the condition.

More specific subterms (sub-subterms) are indented farther to the right as needed and are also listed in alphabetic order. They are also lowercase and regular.

(Note: Eponyms do not start with a lowercase letter, as they are proper nouns.)

Question 7

carryover lines

Answer 7

They are basically a form of word wrap used when the number of words cannot fit on a single line. Example below:

Delivery (childbirth) (labor)
cesarean (for)
occurring after 37 completed weeks of gestation but before 39 completed
weeks of gestation due to (spontaneous) onset of labor (O75.82)

The last two lines, starting with “occurring after”, are the carryover lines.

Question 8

nonessential modifiers

Answer 8

Also called supplementary terms.

They are a term or series of terms that appear in parenthesis and that follow a main term or subterm. These parenthetical terms are not considered important descriptors of the diagnosis or condition in the ICD-10-CM system.

Nonessential modifiers apply to the main term and to subterms following the main term. However, there is an exception: When a nonessential modifier term and a subterm are mutually exclusive, the subterm takes precedence.

For example: “Enteritis (acute)” also has a subterm called “chronic (noninfectious)”; the chronic in the subterm overrides the acute in the main term.

Question 9

“see” and “see also” (ICD-10-CM)

Answer 9

The “see” note is a cross-reference term that tells the coder to look elsewhere in the index before assigning a code. It points to an alternative term.

The “see also” note tells the coder to look elsewhere in the index, but only if all the needed information cannot be found under the first main term. It is not necessary to follow the “see also” note when the original main term provides the necessary code.

Note: “see” and “see also” are called cross-reference terms.

Examples below:

rheumatoid arthritis–see
Rheumatoid, polyneuropathy

Aberrant (congenital)–see also Malposition, congenital

Question 10

“code also” (ICD-10-CM)

Answer 10

The “code also” note means that two codes may be required to fully describe a condition, but this note does not provide sequencing directions. The sequencing depends on the circumstances of the encounter.

Question 11

default code (ICD-10-CM)

Answer 11

It is the code listed next to a main term. It represents the condition that is most commonly associated with the main term.

Example:

Pancake heart R93.1
(Note: Pancake heart appears to be a very uncommon term for a chest problem that causes a compression of the heart.)

Question 12

Tabular List (ICD-10-CM)

Answer 12

A structured list of codes divided into 21 chapters based on body system or condition. It makes up the bulk of the ICD-10-CM book.

Question 13

What is the ICD-10-CM code format?

Answer 13

The first three characters are called the category. They represent a single disease or a group of similar or closely related conditions. A three-character category that has no further subdivision is equivalent to a code.

The fourth character is called the subcategory. The fifth and sixth characters are called the sub-classification. Together these three characters give information about the etiology (cause of the disease), site (anatomic location), severity, or manifestation of the disease.

The seventh character is called the extension code. It adds more information, such as whether it is an initial or subsequent encounter.

Question 14

placeholder character (ICD-10-CM)

Answer 14

ICD-10-CM utilizes a placeholder character, which is always the letter X, and it has two uses:

1. The X provides for future expansion without disturbing the overall code structure
   (e. g. T42.3X1A, Poisoning by barbiturates, accident, initial encounter)
2. It is also used when a code has fewer than six characters and a seventh character extension 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.
   (e. g. T58.11XA, Toxic effect of carbon monoxide from utility gas, accidental, initial encounter)

Question 15

not elsewhere classifiable (NEC)

Answer 15

NEC appears when a more specific code is not available and you are only able to use the more general code provided.

Question 16

not otherwise specified (NOS)

Answer 16

It is the equivalent of unspecified. This is used when the documentation provided by the provider does not provide enough information to assign a more specific code.

Question 17

square brackets vs slanted brackets

Answer 17

Square brackets are a punctuation mark used to enclose synonyms, abbreviations, alternative wording, or explanatory phrases. In other words, they provide information.
(e.g. B20, Human immunodeficiency virus [HIV] disease)

Slanted brackets are used to identify manifestation codes. Manifestation codes represent the secondary condition that is present in addition to the underlying or primary disease that caused the secondary condition. Two codes are required when the patient has both the underlying disease and the secondary condition.

The use of the slanted bracket in the Alphabetic Index provides sequencing directions. You must code the slanted bracket second.
(e.g. Amyloid heart (disease) E85.4 [I43]
First code: E85.4 Organ-limited amyloidosis
Second code: I43 Cardiomyopathy in diseases classified elsewhere)

Question 18

colon (:) (ICD-10-CM)

Answer 18

The colon is a punctuation mark used after an incomplete term that needs one or more additional terms to be coded. Some versions have “includes” and “excludes” notes included with it.

Example:
F02 Dementia in other diseases classified elsewhere
Code first the underlying physiological condition, such as:
Alzheimer’s (G30.-)
cerebral lipidosis (E75.4)
Creutzfeldt-Jakob disease (A81.0-)

Question 19

“other” or “other specified”

Answer 19

“other” and “other specified” are used when the information in the health record is more descriptive than the available codes in ICD-10-CM. Often seen with NEC.

(e.g. R93.89 Abnormal finding on diagnostic imaging of other specified body structures)

Question 20

“unspecified”

Answer 20

a term used when the information in the health record is insufficient to assign a more specific code

(e.g. J45.909 Unspecified asthma, uncomplicated)

Question 21

inclusion terms

Answer 21

a list of conditions for which a code is to be used

Example:
I51.7 Cardiomegaly
Cardiac dilatation
Cardiac hypertrophy
Ventricular dilatation

Question 22

“includes” note

Answer 22

A type of inclusion term that appears immediately under a three-character code to further define, or give examples of, the content of the category.

Example:
J44 Other chronic obstructive pulmonary disease
 Includes: asthma with chronic obstructive pulmonary disease
 chronic asthmatic (obstructive) bronchitis
 chronic bronchitis with airways obstruction

Question 23

Excludes1

Answer 23

Excludes1 indicates that the condition after it cannot ever be used at the same time as the code above the Excludes1 note. In other words, a patient cannot have both conditions at the same time. The coder must determine which condition the patient actually has in order to code correctly.

Example:

E06 Thyroiditis
Excludes1: postpartum thyroiditis (O90.5)

In this example, a patient who is in the postpartum period and has thyroiditis would have the diagnosis code O90.5 assigned. Other patients who have thyroiditis and are not in the postpartum period would have the disease coded as E06. This is an either/or situation. Both codes cannot be used on the same patient during the same episode of care.

Question 24

Excludes2

Answer 24

Excludes2 means that two codes are applied when both conditions are present. The conditions that appear as an Excludes2 note are not part of the code that is listed above it.

Example:

G47 Sleep disorders
Excludes2: nightmares (F51.5)
nonorganic sleep disorders (F51.-)
sleep terrors (F51.4)
sleepwalking (F51.3)

In this example, a patient can have sleep disorders and nightmares at the same time. The Excludes2 note means that code G47 for sleep disorders does not include the condition of nightmares. When the patient has both a sleep disorder and nightmares, two codes must be used: a code from the category G47 and the code F51.4.

Question 25

etiology vs manifestation (ICD-10-CM)

Answer 25

In the context of ICD-10-CM coding, the etiology is the first initial disease and the manifestation is a secondary disease directly caused by the first initial disease.

Question 26

“code first” vs “use additional code”

(two principles)

Answer 26

1. The “code first” note is your hint that two codes may be needed, along with sequencing direction. The “code first” note is an instructional note. If you see “in diseases classified elsewhere” terminology you will assign two codes, with the manifestation code being sequenced after the underlying condition.
2. Certain conditions have both an underlying etiology and multiple body system manifestations due to the underlying etiology. For such conditions, the ICD-10-CM has a coding convention that requires the underlying condition be sequenced first, if applicable, followed by the manifestation. Wherever such a combination exists, there is a “use additional code” note at the etiology code, and a “code first” note at the manifestation code. These instructional notes indicate the proper sequencing order of the codes, etiology followed by manifestation.

Question 27

“code, if applicable, a causal condition first”

Answer 27

In this code, it is an instruction to find the cause of the condition first and code that, if it is available. Otherwise, the code can be assigned as a principal diagnosis when the causal condition is unknown or not applicable.

If, for example, a patient has urinary retention, and the cause of that urinary retention is discovered to be an enlarged prostate, the code for the enlarged prostate is coded first followed by a second code for urinary retention.

Question 28

indiscriminate multiple coding rules

Answer 28

Rules that are designed to prevent indiscriminate coding, which is another way of saying unnecessary coding.

Some examples are:

1. Signs and symptoms that are characteristic of an illness are generally not coded. For example, abdominal pain is integral to acute pancreatitis and thus is not coded.
2. Coding of conditions listed in diagnostic test results should be avoided. Diagnosis should be confirmed by the physician and not by a test.
3. Diagnoses should be excluded that relate to an earlier episode that has no bearing on the current hospital stay.
4. Coding both a specified and an unspecified type of condition is usually not done to describe the same general condition in the same healthcare visit.

Question 29

“and”

Answer 29

Often interpreted as meaning and OR or when it appears in a code title.

Example: Z51.1, Encounter for antineoplastic chemotherapy and immunotherapy

Code Z51.1 is used if the patient’s encounter is for the purpose of receiving antineoplastic chemotherapy or for the purpose of receiving antineoplastic immunotherapy. If the patient is receiving both chemotherapy and immunotherapy, the code is also appropriate to use.

Question 30

“with”

Answer 30

In the Alphabetic Index, the term “with” will appear immediately following the main term or subterm. It helps to link terms.

e.g. Alphabetic Index:
Bronchiolitis
with
bronchospasm or obstruction J21.9
chemical (chronic) J68.4

In the Tabular List, the term “with” appearing in a code title means that two conditions (condition A with condition B) must be present in the patient to use that particular code.

e.g. Tabular List: B15.0 Hepatitis A with hepatic coma

Question 31

connecting words

Answer 31

also called connecting terms

these are words or phrases that are subterms that appear after a main term and serve to indicate a relationship between the main term and an associated condition or etiology

Examples include:
“associated with”
“complicated by”
“due to”
“during”
“following”
“in”
“secondary to”
“with”
“with mention of”
“without”

Question 32

What does a dash (-) after an entry in the Alphabetic Index indicate?

Answer 32

It means that more characters are necessary to complete the code and fully describe the patient’s condition.

Example: O88.21-

Question 33

combination code

Answer 33

a single code used to classify one of three things:

1. two diagnoses
2. a diagnosis with an associated secondary process or manifestation
3. a diagnosis with an associated complication

Question 34

How often can a unique diagnosis code be used in an encounter?

Answer 34

A unique ICD-10-CM diagnosis code can only be reported once for each encounter.

Question 35

How is laterality coded in ICD-10-CM?

Answer 35

If the condition is bilateral, use a bilateral code.
If the condition is bilateral and there is no bilateral code available, use two codes: one for the left and one for the right.
If the condition is just on one side, use the lateral code for that side.
If only one code is available and doesn’t specify laterality, you have to use that.

Question 36

ascites

Answer 36

a condition in which fluid collects in spaces within your abdomen

Question 37

coloboma

Answer 37

An eye abnormality that occurs before birth. Colobomas are missing pieces of tissue in structures that form the eye.

Question 38

choanal atresia

Answer 38

A narrowing or blockage of the nasal airway by tissue. It is a congenital condition, meaning it is present at birth.

(choanal refers to the nasal passages, atresia means narrowing or closure)

Question 39

What are the basic steps in ICD-10-CM coding?

Answer 39

Part One: Alphabetic Index

1. Identify all main terms included in the diagnostic statement
2. Locate each main term in the Alphabetic Index
3. Refer to any subterms indented under the main term
4. Follow the instructions provided in the Alphabetic Index (see, see also) if the needed code is not located under the first main entry consulted

Part Two: Tabular List

1. Verify the code selected in the Tabular List
2. Read and be guided by any instructional terms in the Tabular List
3. Assign codes to their highest level of specificity
4. Continue coding the diagnostic statement until all component elements are fully identified

Question 40

When can signs and symptoms be coded in ICD-10-CM?

Answer 40

Signs and symptoms can be coded when the signs and symptoms are the highest degree of certainty known about the patient. If the patient comes in and complains about something, and the patient either does not return for a diagnosis or the doctor cannot find a diagnosis, then you simply code the sign or symptom.

Question 41

unstageable vs unspecified

Answer 41

Unstageable means the doctor cannot determine a stage; used when the ulcer could be either one or the other stage and is probably in an intermediate state that is too difficult to determine.

Unspecified stage means doctor doesn’t know yet or hasn’t stated it. Also the phrase “not identified with a stage” means the same thing.

Question 42

What is meant by the phrase “ICD-10-CM and ICD-10-PCS are closed classification systems”?

Answer 42

ICD-10-CM and ICD-10-PCS are closed classification systems–they provide one and only one place to classify each condition and procedure. Despite the large number of different conditions to be classified, the system must limit its size to be usable.

Certain conditions that occur infrequently or are of low importance are often grouped together in residual codes labeled “other” or “not elsewhere classified.” A final residual category is provided for diagnoses not stated specifically enough to permit more precise classification. Occasionally, these two residual groups are combined in one code.

Question 43

principal diagnosis vs admitting diagnosis

Answer 43

The principal diagnosis is the condition, established after study, that is determined to be chiefly responsible for admission of the patient to the hospital for care. After study means that after everything is said and done, we have discovered the true cause of the admission.

The admitting diagnosis is the reason the patient is first admitted into the hospital. It is possible that the doctor may believe that one diagnosis is the cause but, after admission, will determine it to be something else or they will have a more specific understanding of what is wrong.

For example:

Patient is admitted to hospital due to a lump in the right breast. The lump is later determined to be a carcinoma of the right breast. The lump at first could be either benign or malign, but is later determined to be malign. The lump of right breast itself is the admitting diagnosis, but the carcinoma of right breast is the principal diagnosis.

Patient is admitted to the hospital because they have gastrointestinal bleeding. It is later determined that the specific cause is acute duodenal ulcer with hemorrhage. The gastrointestinal bleeding is the admitting diagnosis, the acute duodenal ulcer with hemorrhage is the principal diagnosis.