Chapter 5 Diagnostic Code Guidelines Flashcards
Principal diagnosis
The condition defined after study as the main reason for admission of a patient to the hospital
Secondary diagnoses
Conditions that are not responsible for admission but that exist at the time of treatment.
Sequela (late effect)
The residual effect (condition produced) after the acute phase of an illness or injury has terminated.
The four cooperative parties that approved the ICD-10-CM official guidelines for coding and reporting are:
•American Hospital Association (AHA)
•American Health Information Management Association (AHIMA)
•Centers for Medicare and Medicaid Services (CMS)
•National Center for Health Statistics (NCHS)
How many sections are the guidelines organized into?
4
Section I
Conventions, General Coding Guidelines, and Chapter-Specific Guidelines.
Section II
Selection of Principal Diagnosis
Section III
Reporting Additional Diagnoses.
Section IV
Diagnostic Coding and Reporting Guidelines for Outpatient Services.
True or False
A three digit code is to be used only if it is not further subdivided.
True
True or False
Each unique ICD-10-CM diagnosis code may be reported only once for an encounter.
True
True or False
When the purpose for the admission/encounter is rehabilitation, sequence first the code for the condition for which the service is being performed.
True
