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2020 Coding For CPT Prep PHS > Chapter 5 -ICD-10-CM Coding Chapters 12-21 > Flashcards

Chapter 5 -ICD-10-CM Coding Chapters 12-21 Flashcards

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1
Q

Cellulitis

A

Bacterial infection of the skin and subcutaneous tissue.

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2
Q

Lymphangitis

A

Infection of the lymph vessels. Can be a sign that skin infection is getting worse.

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3
Q

Dermatitis

A

Inflammation of the skin. Seborrheic, atopic, contact are some types.

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4
Q

Eczema

A

Skin inflammation with red patches, itching and small blisters that burst. Atopic is the most common eczema.

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5
Q

Dermatitis and eczema

A

Skin inflammation. Used synonymously.

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6
Q

Pressure ulcer completely healed

A

No code is reported for the pressure ulcer.

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7
Q

Pressure ulcer gets worse after admission

A

Code for site and stage upon admission followed by highest stage at that site for the day.

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8
Q

Pressure ulcer healed before discharge

A

Code for the level and site of the pressure ulcer upon admission.

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9
Q

Stage 1 pressure ulcer

A

Persistent focal edema

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10
Q

Stage 2 pressure ulcer

A

Partial thickness skin loss involving epidermis, dermis, or both

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11
Q

Stage 3 pressure ulcer

A

Full thickness skin loss involving damage or necrosis of subcutaneous tissue

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12
Q

Stage 4 pressure ulcer

A

Necrosis of soft tissue extending to underlying muscle, tendon, or bone

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13
Q

Unstageable ulcer

A

When the base of the ulcer is covered in eschar or slough so that it cannot be determined how deep the ulcer is. Determined based on documentation. Do not code unstageable if the stage is not documented. Used unspecified.

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14
Q

Multiple site pressure ulcers

A

Code first for the site being treated. If multiple sites are treated code most severe site first.

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15
Q

Chronic nonpressure ulcers

A

Can be caused by other disease processes like vascular insufficiency, diabetes or injury. Typically last more than 3 months. Follows same rules as other ulcers.

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16
Q

Hidr/o

A

Sweat

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17
Q

Ichthy/o

A

Dry, scaly

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18
Q

Kerat/o

A

Hard

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19
Q

Ungu/o

A

Nail

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20
Q

Arthritis

A

Inflammation of the joints. May involves muscles and connective tissues. Common signs are pain, stiffness, inflammation, and movement limitations

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21
Q

Osteoarthritis

A

Degenerative joint disease. Chronic condition that results from cartilage in joints wearing down over time.

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22
Q

Primary arthritis

A

No known cause

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23
Q

Secondary arthritis

A

Develops as a result of injury or disease

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24
Q

Rheumatoid arthritis

A

Autoimmune disease that affects the whole body. Common symptoms are joint pain and swelling, stiffness, red puffy hands, and fatigue.

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25
Q

Rheumatoid factor

A

Antibody present in the blood of most people with rheumatoid arthritis. Coded as with or without when coding rheumatoid arthritis.

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26
Q

Pathologic fracture

A

Caused typically by another disease such as a neoplasm or osteoporosis.

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27
Q

Stress fracture

A

Fracture caused by repeated force or overuse.

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28
Q

Malunion fracture

A

Fracture that healed in an undesirable position

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29
Q

Nonunion fracture

A

Fracture that is not healing. New bone tissue is not growing to bridge the gap between broken bones.

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30
Q

Osteoporosis

A

Systemic bone disease that decreases bone density. No code needed for site if there is no fracture. One combo code for pathological fracture and osteoporosis.

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31
Q

GFR

A

Glomerular filtration rate. Used to stage chronic kidney disease.

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32
Q

Chronic kidney disease and end stage renal disease

A

Only code the end stage renal disease. Also use a code to identify dialysis status if applicable

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33
Q

Acute renal failure (ARF)

A

Rapid decrease of the kidneys to function. Rapid onset. Document location of lesion of necrosis if known.

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34
Q

Urge incontinence

A

Sudden urge to urinate followed by involuntary release of urine

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35
Q

Stress incontinence

A

Occurs after activity like sneezing, coughing, or exercise.

36
Q

Urinary tract infection

A

Code for specific organ if known. Use additional code to identify infectious agent. Depending on organism you will report two codes or one combo code.

37
Q

Benign Prostatic Hyperplasia (BPH)

A

Enlargement of the prostate. Code if there are urinary complications or not. Also need to code for symptoms.

38
Q

Endometriosis

A

Very painful disorder. Lining of the uterus grows outside the uterus. Code for location if known.

39
Q

Leiomyoma

A

Uterine fibroids. Benign uterine tumors.

40
Q

Submucous leiomyoma

A

Uterine fibroids beneath the endometrium

41
Q

Intramural leiomyoma

A

Uterine fibroid within the uterine wall

42
Q

Subserous leiomyoma

A

Uterine fibroid under the serous surface of the uterus.

43
Q

Cervical Intraepithelial Neoplasia (CIN)

A

Cervical dysplasia. Abnormal growth or premalignant cells of the cervix. Staged 1-3. Stage is considered carcinoma in situ of the cervix and found in the neoplasm table.

44
Q

Pregnancy, childbirth, and puerperium codes

A

Only reported on the maternal record. Have priority over all other codes in ICD-10.

45
Q

Puerperium

A

Period immediately after delivery to complete involution of the uterus. Usually define as 42 days or 6 weeks.

46
Q

First trimester

A

Less than 14 weeks and 0 days

47
Q

2nd trimester

A

14 weeks 0 days to less than 28 weeks 0 days

48
Q

3rd trimester

A

28 weeks 0 days until delivery.

49
Q

Coding trimester when admission crosses trimesters

A

Code for the date of admission or if it is a complication code for the trimester the complication develops.

50
Q

Delivery during admission

A

In childbirth is coded. Used for complications that’s develop that admission as well

51
Q

Weeks of gestation code

A

Z3A. Not used for abortive outcomes, elective termination of pregnancy, or postpartum conditions.

52
Q

Encounter for supervision of normal pregnancy code

A

Z34

53
Q

Pregnant state, incidental code

A

Z33.1. Used when pregnant but seen for another condition. Documentation must note that the condition is not affecting the pregnancy

54
Q

Supervision of high risk pregnancy code

A

O09. Only to be used during the prenatal period.

55
Q

Supervision of elderly primigravida or multigravida code

A

O09.5. Used for age 35 and older for expected delivery date

56
Q

Supervision of a young primigravida or multigravida code

A

O09.6. Used for age of younger than 16 for expected delivery date

57
Q

HIV in pregnancy, childbirth or the puerperium.

A

Always code 098.7- first followed by the codes for the HIV illnesses. (Z21 or B20)

58
Q

Puerperal sepsis

A

Infection of the genital tract that develops during the postpartum phase. O85. Follows normal sepsis rules after the special code

59
Q

Drug, alcohol, or tobacco use in pregnancy

A

Code from O99.3- and also report the specific usage

60
Q

Code for the outcome of delivery

A

Required for normal or complicated delivery. Z37.- Subcategory reports the outcome of the delivery.

61
Q

General Perinatal Period Rule

A

All clinically significant conditions noted on routine newborn exam should be coded. Should a condition originate in the perinatal period it should continue throughout the life of the patient regardless of age.

62
Q

Coding for birth of a patient

A

Use code from Z38 category. Only used once and is the principal diagnosis.

63
Q

Newborn observed for a suspected condition that is not found code

A

Z05. Secondary after birth code or primary after the birth if not found.

64
Q

Prematurity and growth retardation

A

Only code for this is it documented by the assessing physician. Do not use recorded birth weight or estimated gestational age. When birth weight and gestational age are available code birth weight first.

65
Q

Perinatal period

A

Birth to 28 days

66
Q

Coding for multiple injuries

A

Code for each site unless a combination code is available. List most serious injury first.

67
Q

Superficial injuries or contusions when associated with a more serious injury.

A

Do not code for the minor injury.

68
Q

Major injury resulting in damage to peripheral nerves or blood vessels

A

Code primary injury first then the codes to report the additional injury follows

69
Q

Coding multiple traumatic fractures

A

Code by site based on severity

70
Q

Open fracture

A

Exposed to outside elements. Not coded unless specified in documentation. If unspecified the fracture is considered closed. Do not code for open unless the fracture is diagnosed as such. Closed fractures can be treated with open procedures!

71
Q

Displaced fracture

A

Bone breaks into two or more parts so that it is no longer aligned in a normal position. If not indicated as displaced/nondisplaced assigned code for displaced.

72
Q

Classification of open fractures

A

Type I, II, IIIA, IIIB, IIIC. If not specified type I or II should be assigned.

73
Q

Burns

A

Coded for injury from thermal sources except for sunburn.

74
Q

Corrosion injury

A

Burn due to chemicals.

75
Q

Adverse effect coding

A

Code at least two codes. First code the manifestations of the adverse effect, then code the drug or agent that caused the adverse reaction.

76
Q

Coding for poisoning

A

Code first the drug or chemical and identify the nature. Code second the manifestations of the poisoning and finally any codes for abuse or dependence

77
Q

No documentation of intent of poisoning code

A

Code for the accidental column

78
Q

Underdosing

A

Codes for underdosing should never be primary diagnosis. When causing relapse the medical condition should be coded first. Also report codes for non-compliance

79
Q

Complications

A

Code first the complication if it is the reason for the visit. Code the specific complication in addition if available.

80
Q

External cause codes

A

Are supplemental and never coded first. Used for the length of treatment if only required by the payer.

81
Q

Activity code, place of occurrence, and activity status code

A

Only reported on initial encounter following external cause of injury

82
Q

External events sequencing code rules

A
  1. Child and adult abuse
  2. Terrorism
  3. Cataclysmic events
  4. Transport accidents
  5. Activity and external cause status codes are coded after causal (intent) external cause codes
  6. First listed code should correspond to most serious injury after these rules
83
Q

Status code for a medical device

A

Also include the condition for use of the medical device

84
Q

Abnormality found in a screening

A

Code first the screening then the abnormality

85
Q

Aftercare vs follow up care

A

Aftercare is the healing phase. Follow up is after the condition is fully healed

86
Q

Nonmosaic trisomy

A

Affects all cells. Mosaic trisomy only affects some cells

2020 Coding For CPT Prep PHS (16 decks)

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