Chapter 3 - Intro to ICD-10-CM

Question 1

Acute

Answer 1

Condition with a rapid and short course

Question 2

And

Answer 2

Can mean either “and” or “or” when it is in a code description

Question 3

BMI

Answer 3

Body mass index

Question 4

Brackets [ ]

Answer 4

Symbol to enclose synonyms, alternate wording or explanatory phrases int he Tabular List. Used to identify manifestation codes in which multiple coding and sequencing rules will apply

Question 5

Chronic

Answer 5

Condition that develops slowly and lasts a long time

Question 6

Code First

Answer 6

Note in the Tabular List written in Italics requiring the underlying disease be reported first

Question 7

Colon :

Answer 7

Used in the Tabular List after an incomplete term that needs one or more of the modifiers that follow to make it assignable to a given category

Question 8

Combination Code

Answer 8

Single code used to classify two diagnosies

Question 9

COPD

Answer 9

Chronic Obstructive Pulmonary Disease (look-up “Obstruction/Pulmonary”)

Question 10

Default Code

Answer 10

The code listed next to the main term and represents the condition most commonly associated with the main term

Question 11

Etiology

Answer 11

Cause of the disease

Question 12

Eponym

Answer 12

Disease or syndrome named after a person

Question 13

Essential Modifiers

Answer 13

Subterms that are listed below the main term in alphabetical order and are indented

Question 14

Excludes1

Answer 14

Note in the Tabular List to indicate the terms listed are to be reported with a code from another category and are not to be reported with the current selected code

Question 15

Excludes2

Answer 15

Note in the Tabular List to indicate the terms listed are to be reported from another category and may be reported with the current selected code if BOTH conditions exist

Question 16

Includes

Answer 16

Note in the Tabular List under a three-character code title to define further, or to give an example of the contents of the category

Question 17

Index to Diseases and Injuries

Answer 17

AKA Alphabetic Index. Diagnosis codes organized by main term.

Question 18

Main Term

Answer 18

The key word to reference the disease, condition, or symptom in the Alphabetic Index

Question 19

NEC

Answer 19

Not elsewhere classified

Question 20

Nonessential Modifiers

Answer 20

Subterms that follow the main term and are enclosed in parentheses used to clarify the diagnosis but are not required.

Question 21

NOS

Answer 21

Not otherwise specified

Question 22

Parentheses ( )

Answer 22

Symbol to enclose supplementary words that may be present or absent in the statement of a disease or procedure, without affecting the code number to which it is assigned

Question 23

Point Dash . -

Answer 23

This symbol is found in the Alphabetic Index after certain codes. It indicated that the code is incomplete and to go to that category/subcategory to complete the code

Question 24

Rubrics

Answer 24

Three character categories

Question 25

See Also

Answer 25

Indicated additional information is available that may provide an additional diagnostic code

Question 26

See

Answer 26

Note that directs you to a more specific term under which that correct code can be found

Question 27

Septicemia

Answer 27

Systemic disease associated with microorganisms in the blood

Question 28

Sepsis

Answer 28

Whole body inflammatory state. Generally refers to SIRS that is due to an infection

Question 29

Sequela (late effect)

Answer 29

An inactive, residual effect produced after the acute portion of an injury/illness has passed

Question 30

Severe Sepsis

Answer 30

Sepsis with associated acute organ dysfunction

Question 31

Subterms

Answer 31

Terms indented under the main term to describe differences in site, etiology or clinical type. Add specificity to the main terml

Question 32

Tabular List

Answer 32

Diagnosis codes organized in numerical order

Question 33

Unspecified

Answer 33

Codes are used when the information in the medical record is not available for coding more specificity

Question 34

Use Additional Code

Answer 34

Note in the Tabular List instructing you to report a second code, if the info is available, to provide a more complete picture of the diagnosis

Question 35

Z Codes

Answer 35

Used to describe circumstances that could influence patient care

Question 36

With

Answer 36

Means “associated with” or”due to”

Question 37

Bruise in ICD-10-CM

Answer 37

Contusion

Question 38

Pre-Operative Coding

Answer 38

1. Code the examination/preoperative
2. Code the condition for which the patient is having the surgery
3. Code the results of the pre-operative exam

Question 39

When a patient presents for outpatient surgery and develops complications requiring observation, how do you code?

Answer 39

1. The reason for the surgery is the primary diagnosis
2. The complications is the secondary diagnosis

Question 40

Sickle cell anemia (CPT lookup)

Answer 40

Look up disease/sickle cell