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ICD - 10 - CM > Chapter 4 - Introduction to ICD-10-CM > Flashcards

Chapter 4 - Introduction to ICD-10-CM Flashcards

Terminology

1
Q

Placeholder X

A
  • X stands for nothing
  • X is a placeholder only
  • X is used when you need extra characters, (for example 7 digits) when there are no published digits
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2
Q

The appropriate 7th character is to be added to each code from Category (whatever Category listed):

A 
• A = initial encounter (active treatment)
• D = subsequent encounter 
• S = sequela
 Or
• X = placeholder
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3
Q

NEC

A

means “Not elsewhere classifiable”

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4
Q

NEC (Not elsewhere classifiable)

A

This abbreviation is used when the ICD-10-CM does not provide a specific code for a patient’s condition. Selecting a code with a NEC classification means the provider documented more specific information regarding the patient’s condition, but there is not a code in the ICD-10-CM that reports the code accurately.

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5
Q

NOS

A

Means “Not otherwise specified”

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6
Q

NOS (Not otherwise specified)

A

This abbreviation is the equivalent of “unspecified” and is used only when the information lacks the information necessary to report to a more specific code.

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7
Q

[Brackets]

• have two different meanings

A
  • brackets are used in the Tabular List to enclose synonyms, alternate wording, or explanatory phrases.
  • Brackets are used in the Alphabetic Index to indicate multiple codes are required.
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8
Q

(Parenthesis)

A

Parenthesis are used 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. The terms in the parentheses are known as non-essential modifiers.

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9
Q

BOLDFACE TYPE

A

“Boldface type” is used for all codes and titles in the Tabular List and for the main terms in the Alphabetic Index.

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10
Q

EXCLUDES1 Note

A

A type EXCLUDES1 note represents that the condition is not coded here. This note indicates that the code excluded should not be used at the same time as the code above the EXCLUDES1 note, IF THE CONDITIONS ARE RELATED. They indicate when two conditions should not be reported together, for example A congenital form versus an acquired form of the same condition.

• In SOME cases the two codes MAY be used together when the conditions are unrelated to each other.

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11
Q

EXCLUDES2 Note

A

A type EXCLUDES2 note represents that the condition is not included here. It indicates that the condition excluded is not part of the condition represented by the code, but a patient may have both conditions at the same time. When a type EXCLUDES2 note appears under a code, it is acceptable to use both the code and the excluded code together.

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12
Q

INCLUDES Note

A

The INCLUDES note appears immediately after a three character code title to further Define or clarify the category.

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13
Q

Conventions used:

A
  • NEC
  • NOS
  • [Brackets]
  • Slanted Brackets [ ]
  • (Parenthesis)
  • BOLDFACE TYPE
  • EXCLUDES1 Note
  • EXCLUDES2 Note
  • INCLUDES Note
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14
Q

Etiology / Manifestation Codes

A
  • Use Additional Code
  • Use Additional Code, if applicable
  • Code First
  • Combination Code
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15
Q

Use Additional Code

A

This instruction signals the coder that in additional code should be used, if the information is available, to provide a more complete picture of the diagnosis.

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16
Q

ICD-10-CM Diagnosis Codes

A
  • Used by ALL health care providers and facilities
  • Report WHY the patient needed care (Medical necessity)

• A12.3K5LA (3, up to 7 alphanumeric)
(ALWAYS a dot between 3rd and 4th numbers)

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17
Q

Acute

A

Severe, serious

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18
Q

Adverse Effect

A

An unexpected bad reaction to a drug or other treatment

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19
Q

Alphabetic Index

A

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

☆ (aka Index to Diseases and Injuries); is the part of the code book that lists all of the diagnosis and other reasons to provide Health Care by their main word or term, alphabetically from A to Z.

• you will use the alphabetic index to guide you to the correct page or area in the tabular list. Codes in the alphabetic index are only suggested codes.

Conditions are shown in the alphabetic index by:
• Condition (e.g., infections, fractures, and wounds)
• Eponyms (e.g., Epstein-Barr syndrome and Cushing’s disease)
• Other descriptors (e.g., history, family history)

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20
Q

Anatomical Site

A

A specific location within the anatomy (body).

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21
Q

Chronic

A

Long duration; continuing over an extended period of time.

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22
Q

Condition

A

The state of abnormality or dysfunction

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23
Q

Confirmed

A

Found to be true or definite

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24
Q

Differential Diagnosis

A

When the physician indicates that the patient’s signs and symptoms may closely leads to two different diagnoses; usually written as “Diagnosis A vs. Diagnoses B.”

• In the case where a provider indicates differential diagnosis by using the word “versus” or “or” between two diagnostic statements, you need to code both as if they were confirmed, and either may be listed first. This means that the physician has determined that the patient’s signs and symptoms lead equally to two different diagnoses.

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25
Q

Eponym

A

A disease or condition named for a person

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26
Q

External Cause

A

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

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27
Q

First-Listed

A

“First-listed diagnosis” is used, when reporting outpatient encounters, instead of the term “principal diagnosis.”

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28
Q

Index to External Causes

A

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

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29
Q

Inpatient Facility

A

An establishment that provides Health Care Services to individuals who stay overnight on the premises.

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30
Q

Manifestation

A

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

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31
Q

Neoplasm Table

A

The neoplasm table list all possible codes for benign and malignant neoplasms, in alphabetical order by anatomical location of the tumor.

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32
Q

Nonessential Modifiers

A

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.

33
Q

Other Specified

A

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

34
Q

Outpatient Services

A

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

35
Q

Principal Diagnosis

A

Set condition, after study, that is the primary, or main, reason for the admission of a patient to the hospital for care; the condition that requires the largest amount of Hospital resources for care.

36
Q

Sequela

A

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

37
Q

Systemic Condition

A

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.

38
Q

Table of Drugs and Chemicals

A

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.

39
Q

Tabular List of Diseases and Injuries

A

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

40
Q

Underlying Condition

A

One disease that affects or encourages another condition.

41
Q

Unspecified

A

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

42
Q

Italicized or Slanted Brackets [ ]

A

Italicized, or slanted, brackets, used in the Alphabetic Index, will surround an additional code or codes (for example secondary codes) that must be included with the initial code.

• it is the Alphabetic index’s way of telling you that you may need to report more than one code, as well in what order to sequence these codes.

43
Q

Colon :

A

A colon (two dots, one on top of the other), used in the Tabular List, emphasizes that one or more of the following descriptors are required to make the code valid for the diagnosis.

44
Q

The term “With”

A

The term “with” can be seen in both the Alphabetic Index and the Tabular List, and you should read this as a connection confirmed by the physician.

45
Q

The term “See”

A

In the Alphabetic Index of ICD-10-CM, you may look up a term and notice that the book instructs you to see another term. This is an instruction in the index that the information you are looking for is listed under a different term.

46
Q

The term “See Also”

A

In other places in the Alphabetic Index, you may see that the instruction “see also” is next to the term you are investigating. “See also” explains that additional details may be found under a different term. The index is providing you with an alternate main term that may show descriptions more accurate to the physician’s documentation.

47
Q

The term “See Condition”

A

The Alphabetic Index may also point you in a less concrete way, such as when you look up a term and the notation tells you to “see condition”. This can be confusing. The index is not telling you to look up the term condition. What it is instructing you to do is to find the term that describes the health-related situation involved with this diagnosis and look up that term. You will see this most often next to the listing for an anatomical site.

Example:
Heart - see condition
Leg - see condition
Patellar - see condition

48
Q

Additional Characters Required

Box with a Checkmark and Number

A

Located to the left of a code in the tabular list is a symbol that notifies you that an additional character is required.

  • the number tells you which character - 4th, 5th, 6th, or 7th - is needed.
  • some publishers of ICD-10-CM code books use a bullet ● rather than a box. In addition, some versions of the ICD-10 CM book will use a box with a check mark, 2 x’s and a number, alerting you to the need for a placeholder - the letter X - to be used prior to the 7th character.
49
Q

Hyphen -

A

A hyphen is used in the Alphabetic Index to indicate that additional characters are required. This alerts you to an incomplete code.

50
Q

Code Sequencing

A

When more than one diagnosis code is required to tell the whole story of the encounter accurately, you then must determine in which order the code should be listed. (Yes, it does matter!) The code reporting the most important reason for the encounter is called the principal diagnosis.

51
Q

Official Guidelines for Coding and Reporting: use so you can make certain that the codes you report….

A
  1. Are presented in the legal manner

2. Support clear Communications with all parties involved in the care and reimbursement of patients.

52
Q

How many codes do you need?

A

A professional coding specialist’s job is to tell the whole story about the encounter between the healthcare provider and the patient. With diagnosis codes, you relate the whole story about why the physician provided the services, treatment, and procedures to the patient at this time. You must support medical necessity for all of these procedures.

53
Q

Unconfirmed diagnosis

A

The Official Guidelines are different for reporting on confirm diagnosis for patients who are treated as outpatient vs. Inpatient.

  • Outpatient / Section IV.H, Uncertain diagnosis; states that you are to use the code or codes that identify the condition to its highest level of certainty. This means that you code only what you know for a fact. You are not permitted to assign a ICD-10-CM diagnostic code for a condition that is described by the provider as probable, suspected, possible, questionable, or to be ruled out. If the health care professional has not been able to confirm a diagnosis, then you must code the signs, symptoms, abnormal test results, or other element stated as the reason for the visit or service.
  • Inpatient/ Section II.H, Uncertain diagnosis; if the diagnosis is described as probable, possible, suspected, likely, or still to be ruled out at the time of discharge, you must code that condition as if it existed.
54
Q

2 principles important to becoming a good ICD-10-CM coder:

A
  1. Abstract the main term(s) from the physician’s documentation so that you can determine the best, most accurate code or codes.
  2. In case of an injury, poisoning, or adverse effect, you will need to add an external cause code.
55
Q

Remember, you may never report a code directly from the alphabetic index without checking it in the….

A

Tabular list of diseases and injuries.

56
Q

Neoplasm table

A

Listin the suggested codes for benign and malignant neoplasms.

• 7 column tables:

  1. The anatomical location of the tumor, in alphabetic order
  2. Malignant, primary
  3. Malignant, secondary
  4. Ca in situation
  5. Benign
  6. Uncertain Behavior
  7. Unspecified Behavior
57
Q

Table of drugs and chemicals

A

• 7 Columns:

  1. Substance
  2. Poisoning, accidental (unintentional)
  3. Poisoning, intentional self-harm
  4. Poisoning, assault
  5. Poisoning, undetermined
  6. Adverse effect
  7. Underdosing
58
Q

If two (or more) diagnoses are of equal severity, then report them in order of anatomical site _______________.

(P. 66)

A

head to toe

59
Q

2020 ICD-10-CM Tabular List -

Chapter 1: Certain Infectious and Parasitic Diseases

A

A00 - B99

60
Q

2020 ICD-10-CM Tabular List -

Chapter 2: Neoplasms

A

C00 - D49

61
Q

2020 ICD-10-CM Tabular List -

Chapter 3: Diseases of Blood/Blood-Forming Organs & Disorders Involving Immune Mechanism

A

D50 - D89

62
Q

2020 ICD-10-CM Tabular List -

Chapter 4: Endocrine, Nutritional and Metabolic Diseases

A

E00 - E89

63
Q

2020 ICD-10-CM Tabular List - Chapter 5: Mental, Behavioral and Neurodevelopmental Disorders

A

F01 - F99

64
Q

2020 ICD-10-CM Tabular List -

Chapter 6: Diseases of the Nervous System

A

G00 - G99

65
Q

2020 ICD-10-CM Tabular List -

Chapter 7: Diseases of the Eye and Adnexa

A

H00 - H59

66
Q

2020 ICD-10-CM Tabular List -

Chapter 8: Diseases of the Ear and Mastoid Process

A

H60 - H95

67
Q

2020 ICD-10-CM Tabular List -

Chapter 9: Diseases of the Circulatory System

A

I00 - I99

68
Q

2020 ICD-10-CM Tabular List -

Chapter 10: Diseases of the Respiratory System

A

J00 - J99

69
Q

2020 ICD-10-CM Tabular List -

Chapter 11: Diseases of the Digestive System

A

K00 - K95

70
Q

2020 ICD-10-CM Tabular List -

Chapter 12: Diseases of the Skin and Subcutaneous Tissue

A

L00 - L99

71
Q

2020 ICD-10-CM Tabular List -

Chapter 13: Diseases of the Musculoskeletal System and Connective Tissue

A

M00 - M99

72
Q

2020 ICD-10-CM Tabular List -

Chapter 14: Diseases of the Genitourinary System

A

N00 - N99

73
Q

2020 ICD-10-CM Tabular List -

Chapter 15: Pregnancy, Childbirth and the Puerperium

A

O00 - O9A

74
Q

2020 ICD-10-CM Tabular List -

Chapter 16: Certain Conditions Originating in the Perinatal Period

A

P00 - P96

75
Q

2020 ICD-10-CM Tabular List -

Chapter 17: Congenital Malformations, Deformations, and Chromosomal Abnormalities

A

Q00 - Q99

76
Q

2020 ICD-10-CM Tabular List -

Chapter 18: Symptoms, Signs, and Abnormal Clinical and Laboratory Findings, Not Elsewhere Classified

A

R00 - R99

77
Q

2020 ICD-10-CM Tabular List -

Chapter 19: Injury, Poisoning, and Certain Other Consequences of External Causes

A

S00 - T88

78
Q

2020 ICD-10-CM Tabular List -

Chapter 20: External Causes of Morbidity

A

V00 - Y99

79
Q

2020 ICD-10-CM Tabular List -

Chapter 21: Factors Influencing Health Status and Contact With Health Services

A

Z00 - Z99

ICD - 10 - CM (8 decks)

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