Chapter 2: ICD-10-CM Coding Steps

Question 1

What is the first step to correctly assign the ICD-10-CM Code for patients health care encounter?

Answer 1

Disease: (hypertension, Diabetes, etc)
Condition: (pregnancy, blinding, etc)
Injury: (fracture, laceration, etc)
Symptom: (fever, pain, etc)

Question 2

What is the second step to correctly assign the ICD-10-CM Code for patients health care encounter?

Answer 2

If a diagnosis has not been established at the patient’s visit, only code the symptoms (the definitive diagnosis of MI has not yet been established).

Question 3

What is the third step to correctly assign the ICD-10-CM Code for patients health care encounter?

Answer 3

Locate the main term of a diagnosis is the disease, condition or injury.

Question 4

Are the main terms adjectives like acute, chronic, congestive, allergic or viral?

Answer 4

No.

Question 5

Are the main terms body parts like lung, colon, bladder, knee or fibula?

Answer 5

No.

Question 6

What is the main term in “ulcerative colitis”?

Answer 6

Colitis.

Question 7

What is the main term in “adenocarcinoma of the rectum”?

Answer 7

Adenocarcinoma.

Question 8

What is the main term in “heart murmur”?

Answer 8

Murmur.

Question 9

What is the fourth step to correctly assign the ICD-10-CM Code for patients health care encounter?

Answer 9

Consult the Alphabetic Index

Question 10

Which will be the code for a patient who had an exposure to COVID-19?
Alphabetic Index of ICD-10-CM:
COVID-19:
condition post U09.9
contact (with) Z20.822
exposure (to) Z20.822
history of (personal) Z86.16

Answer 10

exposure (to) Z20.822

Question 11

What is the fifth step to correctly assign the ICD-10-CM Code for patients health care encounter?

Answer 11

Verify the Code in the Tubular List (assign the code with the highest level of specificity).