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2020 Coding For CPT Prep PHS > Chapter 4 - ICD-10-CM Coding Chptrs 1-11 > Flashcards

Chapter 4 - ICD-10-CM Coding Chptrs 1-11 Flashcards

1
Q

HIV infection/illness

A

Only coded for confirmed cases. Physicians statement of HIV positive or HIV related illness is enough to code.

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2
Q

HIV proper sequencing

A

When admitted for HIV related conditions B20 is coded first followed by additional codes for HIV related conditions

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3
Q

Conditions always considered HIV related

A

Kaposi’s sarcoma, lymphoma, pneumocystis carinii pneumonia (PCP) cryptococcal meningitis, and cytomegalovirus disease. All considered opportunistic infections.

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4
Q

Admitted for a condition unrelated to HIV

A

Code the unrelated diagnosis first. B20 is reported as an additional diagnosis, as are any HIV related conditions. HIV affects treatment of any condition in addition to any reported HIV related conditions. Documentation should support reporting of HIV

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5
Q

Asymptomatic human immunodeficiency virus.

A

Z21. HIV positive but no symptoms of an HIV related illness. Do not use if AIDS term is used.

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6
Q

Inconclusive lab evidence of HIV

A

R75 is used when patient’s have inconclusive HIV serology, and no definitive diagnosis or manifestations of the illness.

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7
Q

HIV status during pregnancy, childbirth, or the puerperium

A

Reported from the subcategory 098.7. Codes from chapter 15 always take sequencing priority.

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8
Q

Encounter for screening for HIV

A

Z11.4 is used. If signs, symptoms, or illness or confirmed HIV diagnosis be tested coded the sign, symptoms, or the diagnosis. If test is positive code B20

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9
Q

Patient suspects contact with HIV

A

Code Z20.6

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10
Q

Resistance to anti microbial drugs

A

Z16. Used if infection is antibiotic resistant and the infection code does not identify antibiotic resistance

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11
Q

Sepsis

A

Refers to an infection due to an organism that triggers a systemic inflammatory response, or systemic inflammatory response syndrome (SIRS)

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12
Q

Severe sepsis

A

Associated with acute organ failure. Requires a minimum of two codes. First code underlying systemic infection then code from R65.2 for severe sepsis.

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13
Q

Organ dysfunction not related to sepsis

A

Do not code severe sepsis.

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14
Q

Urosepsis

A

Non specific term and should not be considered synonymous with sepsis. Needs further clarification from provider.

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15
Q

Septic shock

A

Circulatory failure associated with severe sepsis

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16
Q

Admission for sepsis or severe sepsis and a localized infection

A

Code the systemic infection first then the localized infection second

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17
Q

Admitted for localized infection then sepsis develops after admission

A

Code the localized infection first then the appropriate sepsis/severe sepsis code.

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18
Q

Post procedural sepsis

A

If there is a causal relationship between procedure and sepsis code first the complication followed by the code for the specific infection.

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19
Q

Non-infectious process that leads to sepsis

A

If the non-infectious condition meets the definition for principal diagnosis it should be coded first followed by the code for the resulting infection.

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20
Q

MRSA

A

Methicillin Resistant Staphylococcus Aureus. Do not assign codes from the subcategory for resistance to penicillins.

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21
Q

Carrier of MRSA but not active infection

A

Z22.332. Carrier or suspected carrier of MRSA

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22
Q

Personal history of MRSA with no mention of colonization.

A

Z86.14

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23
Q

Neoplasm

A

Abnormal growth of new tissue

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24
Q

Primary malignancy

A

Site where cancer originates

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25
Q

Secondary malignancy

A

Results from metastasis and form a new focus of malignancy. Primary cancer has invaded adjacent structure.

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26
Q

In situ

A

Malignancy confined to the origin site. Encapsulated. May be called non-infiltrating, non-invasive or pre-invasive. Pathologist designates a Dx of Ca In Situ and not a physician.

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27
Q

Benign neoplasm

A

Do not contain precancerous or cancerous cells.

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28
Q

Uncertain behavior

A

Needs to be noted by a pathologist. Neoplasm of transition. Not benign and not malignant.

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29
Q

Unspecified neoplasm

A

Provider did not wait for pathology report. Recommended to wait for the pathology to be reported.

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30
Q

Overlapping lesion

A

When a malignant neoplasm is in a site next to each other (contiguous) use an overlapping code. Same site but not contiguous use a separate code for each

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31
Q

Metastatic

A

Indicates a secondary malignancy

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32
Q

Anemia caused by cancer

A

Code malignancy first then the anemia

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33
Q

Anemia caused by chemo or radiotherapy

A

Code first the anemia followed by the codes for the for the neoplasm and then the adverse affect code

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34
Q

Successful treatment of a neoplasm

A

Inappropriate to code for the neoplasm. Use a code for the personal history of malignant neoplasms

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35
Q

Surgery followed by chemo or radiation in the same visit

A

Neoplasm listed as primary followed by codes for the therapy.

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36
Q

Encounter with main reason for administration of chemo, immuno, or radiotherapy

A

Report the proper Z Code first followed by the code for the neoplasm even if it is removed. When treatment for an eradicated neoplasm is complete then code from the history section.

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37
Q

Complications during chemo, immuno, or radiotherapy

A

Code for therapy first then the complication.

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38
Q

Pregnant patient with malignant neoplasm

A

Code from subcategory O9A.1- is sequenced first then the code for the neoplasm

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39
Q

Complication associated with a neoplasm

A

Complication is coded first then the neoplasm code. Exception is anemia.

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40
Q

Pathologic fracture due to neoplasm

A

Code first the fracture if it is the focus of the treatment. If not then code the neoplasm first

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41
Q

Malignant neoplasm of transplanted organ requires:

A

3 codes. First the transplant complication, then C80.2,followed by the code for the malignancy

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42
Q

Merkel cell carcinoma

A

Rare and aggressive form of a skin tumor. Most commonly seen in older people. Has own section of codes based on anatomic site

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43
Q

Melanoma

A

Skin cancer that originates in the melanocytes. Often starts as a mole. Asymmetry, border irregularity, color and size.

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44
Q

Lymphoma

A

Cancer of the lymphatic system. Hodgkins and non-Hodgkins

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45
Q

Hodgkin’s lymphoma

A

Has Reed Steinberg cells not found in other types of lymphoma

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46
Q

Follicular lymphoma

A

Slow growing lymphoma that arises from B cells. Coded based on grade 1-3. Grade based on how many centroblasts in a high powered field.

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47
Q

Neoplasm related pain visit

A

G89.3. Used when pain is related to a primary or secondary cancer. Primary when the pain is the reason for the visit. If a secondary reason for the visit code as an additional diagnosis.

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48
Q

Bx

A

Biopsy

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49
Q

Mets

A

Metastases/metastatic

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50
Q

Cac/o

51
Q

Sarc/o

A

Flesh, connective tissue

52
Q

Type 1 diabetes

A

Autoimmune disease that results in destruction of insulin producing cells in the pancreas. Most often occurs early in life

53
Q

Type 2 diabetes

A

Still produce insulin but not enough to keep blood sugar levels within normal limits

54
Q

Long term use of insulin

A

Added to categories E08-E09 and E11-E13 even if the patient is not insulin dependent, but uses insulin for diabetic management.

55
Q

Insulin pump failure

A

Code first T85.6 Mechanical complication of other specified internal or external prosthetic device, implant, or graft then code for the type of failure then code for the diabetes

56
Q

Overweight/obesity

A

Separate codes for overweight and obesity. Obesity includes the reason. Secondary codes from Z68 should be used to note BMI when overweight and obesity are used.

57
Q

Crin/o

58
Q

Dips/o

59
Q

Anemia caused by chemotherapy is coded:

A

Anemia first, then neoplasm, and then the code for adverse effect of antineoplastic chemotherapy

60
Q

Code for diabetes controlled with oral anti diabetic medications or oral hypoglycemic medications

61
Q

Pain documented with psychological factors code

A

F45.42 and the associated codes for pain from category G89

62
Q

Pain that is exclusively psychological

63
Q

Selection of in remission codes

A

F10-F19. Requires provider’s clinical judgement before assigning. Requires documentation

64
Q

Use, abuse, and dependence

A

Always dependence assigned if documented dependence. If use and abuse assign abuse. Pay attention to the Excludes1 notes

65
Q

Factitious disorder imposed on another

A

Reported on the perpetrators record. Victim should have a code assigned for confirmed or suspected abuse

66
Q

Intellectual disability

A

Code first physical and developmental disorders followed by codes for the intellectual disorder.

67
Q

ADHD

A

Broken down by type. Hyperactive,inattentive, or combination

68
Q

Dementia

A

Two codes needed. First underlying physiological condition then the dementia.

69
Q

Neuroleptic medications

A

Antipsychotic medications

70
Q

Seizure without epilepsy

A

See Convulsions in the alphabetic list

71
Q

Epilepsy

A

Seizure disorder. Two types. Focal or generalized. Code based on type of seizure and whether it is epilepticus or intractable.

72
Q

Intractable seizure

A

Hard to control. Pharmacoresistant, treatment resistant, refractory, and poor controlled are equivalent.

73
Q

Epilepticus seizure

A

Seizure that lasts an abnormally long time. Generally longer than 5 minutes

74
Q

Migranosus

A

Migraine ongoing for more than 72 hours

75
Q

Intractable

A

Cannot be controlled by medications

76
Q

Dominant/non dominant

A

If not specified in documentation the dominant side is right and non-dominant is left.

77
Q

Encounter for pain management

A

Code from G89- followed by underlying condition

78
Q

Pain encounter to treat underlying disease

A

Code the underlying condition first then the pain code

79
Q

Pain associated with a specific complication

A

Code complication first then pain code from G89 is reported second

80
Q

Glaucoma

A

Can be different stages for each eye. If bilaterally the same use one code for the bilateral dx.

81
Q

Nuclear cataract

A

Affects the center of the lens

82
Q

Cortical cataract

A

Affects the edges of the lens

83
Q

Posterior/anterior subcapsular cataract

A

Occurs behind the lens capsule

84
Q

Congenital catarct

A

Present at birth

85
Q

Morgagnian cataract

A

Hyper mature cataract

86
Q

Traumatic cataract

A

Cataract caused by injury

87
Q

Hypertension with heart disease

A

Code I11 and include code from I50 to indicate type of heart failure. If specifically not related to hypertension each condition is coded separately.

88
Q

Hypertensive heart and chronic kidney disease

A

I13 captures both diagnosis. Include codes for type of heart failure and to identify stage of kidney disease

89
Q

Hypertension and chronic kidney disease

A

I12. Include code for stage of kidney disease

90
Q

Elevated blood pressure without further specificity

A

Use code R03.0. Found under Elevated in alphabetic index

91
Q

STEMI

A

ST elevation myocardial infarction. Type 1 MI. Coronary artery is completely blocked and heart muscle supplied by the artery starts to die.

92
Q

Myocardial infarction

A

Heart attack. 5 classes. Class 3-5 are acute. Acute is less than 4 weeks.

93
Q

NSTEMI

A

Non-ST elevation myocardial infarction. Blood clot partially occluded a blood vessel.

94
Q

I22 Subsequent STEMI or NSTEMI

A

Only used to report type 1 myocardial infarctions or unspecified AMI.

95
Q

Anticoagulant therapy code

A

Z79.01. When a patient has vascular disorder and it is documented that the patient taking anticoagulant medication.

96
Q

Status asthmaticus

A

Patient not responding to asthma treatments

97
Q

Respiratory failure

A

If reason for the encounter code first. If multiple reasons for admission code first condition that required the most care.

98
Q

Influenza

A

When the type of virus responsible is identified code for the type of virus. If unknown code from J11

99
Q

Pneumonia

A

Inflammation of the lungs usually by infection. Code for cause if known. Can also include location if known.

100
Q

Pleural effusion

A

If a symptom only code the underlying disease. If treating pleural effusion and no documentation of underlying disease code for pleural effusion. Can be malignant if documented.

101
Q

Reflux esophagitis

A

Inflammation of the esophagus due to reflux. Not GERD.

102
Q

Glaucoma

A

Can be different stages for each eye. If bilaterally the same use one code for the bilateral dx.

103
Q

Nuclear cataract

A

Affects the center of the lens

104
Q

Cortical cataract

A

Affects the edges of the lens

105
Q

Posterior/anterior subcapsular cataract

A

Occurs behind the lens capsule

106
Q

Congenital catarct

A

Present at birth

107
Q

Morgagnian cataract

A

Hyper mature cataract

108
Q

Traumatic cataract

A

Cataract caused by injury

109
Q

Hypertension with heart disease

A

Code I11 and include code from I50 to indicate type of heart failure. If specifically not related to hypertension each condition is coded separately.

110
Q

Hypertensive heart and chronic kidney disease

A

I13 captures both diagnosis. Include codes for type of heart failure and to identify stage of kidney disease

111
Q

Hypertension and chronic kidney disease

A

I12. Include code for stage of kidney disease

112
Q

Elevated blood pressure without further specificity

A

Use code R03.0. Found under Elevated in alphabetic index

113
Q

STEMI

A

ST elevation myocardial infarction. Type 1 MI. Coronary artery is completely blocked and heart muscle supplied by the artery starts to die.

114
Q

Myocardial infarction

A

Heart attack. 5 classes. Class 3-5 are acute. Acute is less than 4 weeks.

115
Q

NSTEMI

A

Non-ST elevation myocardial infarction. Blood clot partially occluded a blood vessel.

116
Q

I22 Subsequent STEMI or NSTEMI

A

Only used to report type 1 myocardial infarctions or unspecified AMI.

117
Q

Anticoagulant therapy code

A

Z79.01. When a patient has vascular disorder and it is documented that the patient taking anticoagulant medication.

118
Q

Status asthmaticus

A

Patient not responding to asthma treatments

119
Q

Respiratory failure

A

If reason for the encounter code first. If multiple reasons for admission code first condition that required the most care.

120
Q

Influenza

A

When the type of virus responsible is identified code for the type of virus. If unknown code from J11

121
Q

Pneumonia

A

Inflammation of the lungs usually by infection. Code for cause if known. Can also include location if known.

122
Q

Pleural effusion

A

If a symptom only code the underlying disease. If treating pleural effusion and no documentation of underlying disease code for pleural effusion. Can be malignant if documented.

123
Q

Reflux esophagitis

A

Inflammation of the esophagus due to reflux. Not GERD.

2020 Coding For CPT Prep PHS (16 decks)

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