Chapter 4

Question 1

A

Answer 1

Initial encounter

Question 2

D

Answer 2

Subsequent encounter

Question 3

S

Answer 3

Sequela

Question 4

Condition meaning and examples

Answer 4

The state of abnormality or dysfunction.

Fracture, wound, and infection

Question 5

Eponym meaning and examples

Answer 5

A disease or condition named for a person.

Epstein-Barr, Cushing’s, and Beck’s

Question 6

Section IV

Answer 6

Diagnostic Coding and Reporting Guidelines for Outpatient Services

Question 7

Section II

Answer 7

Selection of Principal Diagnosis

Question 8

Section I

Answer 8

Conventions, General Coding Guidelines and Chapter-Specific Guidelines

Question 9

Section III

Answer 9

Reporting Additional Diagnoses

Question 10

INCLUDES

Answer 10

This notation provides you with additional terms and diagnoses that are also reported with the above code or includes in this code’s description.

Question 11

EXCLUDES 2

Answer 11

This notation is warning you to— Stop and Double-Check the Documentation so you don’t report the code above the notation when a code shown in the notation may be more accurate.

Question 12

EXCLUDES1

Answer 12

This notation identifies codes that cannot be used on the same health claim form with the originally listed code.

Question 13

CODE FIRST

Answer 13

This notation is a reminder that you are going to need another code to identify the underlying disease that caused this condition. This notation is also telling you in what order to report the two codes: the underlying condition first, followed by the code for the manifestation.

Question 14

USE ADDITIONAL CODE

Answer 14

This notation is informing you that you may need to report another code as well as the code above to the the whole story.

Question 15

CODE ALSO

Answer 15

This notation is alerting you that the physician’s notes may contain some additional condition or issue that should be reported with a seperate code, in addition to the code above the notation.

Question 16

AND

Answer 16

This notation indicates a code description as “and/or.” Therefore, if the physician’s notes only include one part but not the oher, the code may still be correct.

Question 17

NOS

Answer 17

This notation means that the physician did not document any additional details that are identified in any of the other available code descriptions.

Question 18

SEE

Answer 18

This notation is an instruction in the index that explains that additional details may be found under another term as well as what you see here.

Question 19

OTHER SPECIFIED

Answer 19

Additional information the physician specified that isn’t included in any other code description.

Question 20

NEC

Answer 20

Specifics that are not described in any other code in the ICD-10-CM book; also known as not elsewhere classified.

Question 21

UNSPECIFIED

Answer 21

The absence of additional specifics in the physician’s documentation.

Question 22

SEE ALSO

Answer 22

explains that additional details may be found under a different term.

Question 23

SEE CONDITION

Answer 23

instructs you to find the term that describes the health-related situation involved with this word and look up the term.

Question 24

[ ]

Answer 24

This punctuation will show you alternate terms, alternate phrases, and/or synonyms to provide additional detail or explanation to the description.

Question 25

( )

Answer 25

This punctuation with show you additional descriptions, terms, or phrases that are also included with the initial code.

Question 26

:

Answer 26

This punctuation will emphasize that one or more of the following descripts are required to make the code valid for the diagnosis.

Question 27

The ICD-10-CM Official Guidelines I.A.16 are guidelines with instructions concerning which words?

Answer 27

“See” and “See Also”

Question 28

Table of Drugs and Chemicals

Answer 28

The section of the ICD-10-CM code book listing drugs, chemicals, and other biologicals that may poison a patient or result in an adverse reaction.

Question 29

Alphabetic Index

Answer 29

The section of a code book showing all codes, from A to Z, by the short code descriptions

Question 30

Neoplasm Table

Answer 30

The Neoplasm Table lists all possible codes for benign and malignant neoplasms, in alphabetic order by anatomical location of the tumor.

Question 31

Tabular List of Diseases and Injuries

Answer 31

The section of the ICD-10-CM code book listing all of the codes in alphanumeric order.

Question 32

Index to External Causes

Answer 32

The alphabetic listing of the external causes that might cause a patient’s injury, poisoning, or adverse reaction.

Question 33

Sequelae

Answer 33

A cause-and-effect relationship between an original condition that has been resolved with a current condition; also known as a late effect.

Question 34

Confirmed

Answer 34

Found to be true or definite.

Question 35

Anatomical Site

Answer 35

A specific location within the anatomy (body).

Question 36

Outpatient Services

Answer 36

Health care services provided to individuals without an overnight stay in the facility.

Question 37

Inpatient Facility

Answer 37

An establishment that provides health care services to individuals who stay overnight on the premises.

Question 38

Adverse Effect

Answer 38

An unexpected bad reaction to a drug or other treatment.

Question 39

External Cause

Answer 39

An event, outside the body, that causes injury, poisoning, or an adverse reaction.

Question 40

Systemic Condition

Answer 40

A condition that affects the entire body and virtually all body systems, therefore requiring the physician to consider this in his or her medical decision making for any other condition.

Question 41

Nonessential Modifiers

Answer 41

Descriptors whose inclusion in the physician’s notes are not absolutely necessary and that are provided simply to further clarify a code description; optional terms.

Question 42

Not Otherwise Specified (NOS)

Answer 42

The absence of additional details documented in the notes.

Question 43

Underlying Condition

Answer 43

One disease that affects or encourages another condition.

Question 44

Manifestation

Answer 44

A condition caused or developed from the existence of another condition.

Question 45

Principal Diagnosis

Answer 45

The condition that is the primary, or main, reason for the encounter.

Question 46

Differential Diagnosis

Answer 46

When the physician indicates that the patient’s signs and symptoms may closely lead to two different diagnoses.

Question 47

Chronic

Answer 47

Long duration; continuing over a long period of time.

Question 48

Acute

Answer 48

Severe; serious.

Question 49

What code range identifies the diseases of the digestive system?

Answer 49

K00-K95

Question 50

Acode surrounded with italicized, or slanted, brakcets____

Answer 50

must be included

Question 51

Turn to Hypertension in the ICD-10CM Alphabetic Index. All of the following are listed as nonessential modifiers except___.

Answer 51

organic

Question 52

The correct code for acute and chronic respiratory failure with hypoxia is___

Answer 52

J96.21.