Chapter 6

Question 1

adverse effect

Answer 1

taking less of a medication than is prescribed by a provider or a manufacturer’s instruction.

Question 2

Benign

Answer 2

not cancerous.

Question 3

carcinoma (Ca) in situ

Answer 3

a malignant tumor that is localized, circumscribed, encapsulated, and noninvasive (has not spread to deeper or adjacent tissues or organs).

Question 4

Comorbidity

Answer 4

concurrent condition that coexists with the first-listed diagnosis (outpatient care) (or principal diagnosis for inpatient care), has the potential to affect treatment of the first-listed diagnosis (outpatient care) (or principal diagnosis for inpatient care), and is an active condition for which the patient is treated and/or monitored.

Question 5

Complication

Answer 5

condition that develops after outpatient care has been provided or during an inpatient admission.

Question 6

computer-aided coding (CAC)

Answer 6

see computer-assisted coding (CAC).

Question 7

computer-assisted coding (CAC)

Answer 7

uses a natural language processing engine to “read” patient records and generate ICD-10-CM and HCPCS/CPT codes.

Question 8

contiguous sites

Answer 8

also called overlapping sites; occurs when the origin of the tumor (primary site) involves two adjacent sites.

Question 9

Cooperating Parties for ICD-10-CM/PCS

Answer 9

AHA, AMA, CMS, and NCHS organizations and agencies that approve official guidelines for coding and reporting ICD-10-CM and ICD-10-PCS.

Question 10

Encoder

Answer 10

automates the coding process using computerized or web-based software; instead of manually looking up conditions (or procedures) in the coding manual’s index, the coder uses the software’s search feature to locate and verify diagnosis and procedure codes.

Question 11

Encounter

Answer 11

face-to-face contact between a patient and a health care provider (e.g., physician, nurse practitioner) who assesses and treats the patient’s condition.

Question 12

essential modifier

Answer 12

see subterm.

Question 13

evidence-based coding

Answer 13

coding auditor clicks on codes that CAC software generates to review electronic health record documentation (evidence) used to generate the code.

Question 14

first-listed diagnosis

Answer 14

reported on outpatient claims (instead of inpatient principal diagnosis); it reflects the reason for the encounter, and it is often a sign or symptom.

Question 15

general equivalence mapping (GEM)

Answer 15

translation dictionaries or crosswalks of codes that can be used to roughly identify ICD-10-CM/PCS codes for their ICD-9-CM equivalent codes (and vice versa). See also legacy coding system.

Question 16

iatrogenic illness

Answer 16

illness that results from medical intervention (e.g., adverse reaction to contrast material injected prior to a scan).

Question 17

ICD-10-CM coding conventions and brackets

Answer 17

general coding rules that apply to the assignment of codes, independent of official coding guidelines.

Question 18

code first underlying disease

Answer 18

appears when the code referenced is to be sequenced as a secondary code; the code, title, and instructions are italicized.

Question 19

code first underlying disease, such as

Answer 19

see code first underlying disease.

Question 20

code, if applicable, any causal condition first

Answer 20

requires causal condition to be sequenced first if present; a causal condition is a disease that manifests (or results in) another condition.

Question 21

Colon

Answer 21

used after an incomplete term and is followed by one or more modifiers (additional terms).

Question 22

due to

Answer 22

located in the index in alphabetical order to indicate the presence of a cause-and-effect (or causal) relationship between two conditions.

Question 23

Eponym

Answer 23

disease or syndrome named for a person; listed in appropriate alphabetical sequence as main terms in the index.

Question 24

etiology and manifestation rules

Answer 24

include the following notes in the ICD-10-CM Tabular List of Diseases and Injuries: Code first underlying disease; Code first underlying disease, such as; Code, if applicable, any causal condition first; Use additional code; and In diseases classified elsewhere.

Question 25

Excludes1 note

Answer 25

a “pure” excludes, which means “not coded here” and indicates mutually exclusive codes; in other words, two conditions that cannot be reported together.

Question 26

Excludes2 note

Answer 26

means “not included here” and indicates that although the excluded condition is not classified as part of the condition it is excluded from, a patient may be diagnosed with all conditions at the same time; therefore, it may be acceptable to assign both the code and the excluded code(s) together if supported by medical documentation

Question 27

In

Answer 27

located in alphabetical order below the main term; to assign a code from the list of qualifiers below the word “in,” the provider must document both conditions in the patient’s record; ICD-10-CM classifies certain conditions as if there were a cause-and-effect relationship present because they occur together much of the time, such as pneumonia in Q fever.

Question 28

in diseases classified elsewhere

Answer 28

indicates that the manifestation codes are a component of the etiology/manifestation coding convention.

Question 29

includes note

Answer 29

appear below certain tabular list categories to further define, clarify, or provide examples.

Question 30

Manifestation

Answer 30

condition that occurs as the result of another condition; manifestation codes are always reported as secondary codes.

Question 31

NEC (not elsewhere classifiable)

Answer 31

means “other” or “other specified” and identifies codes that are assigned when information needed to assign a more specific code cannot be located.

Question 32

parentheses

Answer 32

enclose supplementary words that may be present or absent in the diagnostic statement, without affecting assignment of the code number.

Question 33

See

Answer 33

directs the coder to refer to another term in the index to locate the code.

Question 34

see also

Answer 34

located after a main term or subterm in the index and directs the coder to another main term (or subterm) that may provide additional useful index entries.

Question 35

see category

Answer 35

instruction directs the coder to the ICD-10-CM tabular list, where a code can be selected from the options provided there.

Question 36

see condition

Answer 36

directs the coder to the main term for a condition, found in the index.

Question 37

Table of Drugs and Chemicals

Answer 37

alphabetical index of medicinal, chemical, and biological substances that result in poisonings, adverse effects, and underdosing.

Question 38

Table of Neoplasms

Answer 38

alphabetical index of anatomic sites for which there are six possible codes according to whether the neoplasm in question is malignant, benign, in situ, of uncertain behavior, or of unspecified nature.

Question 39

unspecified codes

Answer 39

assigned because patient record documentation is insufficient to assign a more specific code.

Question 40

use additional code

Answer 40

indicates that a second code is to be reported to provide more information about the diagnosis.

Question 41

With

Answer 41

when codes combine one disorder with another (e.g., code that combines primary condition with a complication), the provider’s diagnostic statement must clearly indicate that both conditions are present and that a relationship exists between the conditions.

Question 42

ICD-10-CM Diagnostic Coding and Reporting Guidelines for Outpatient Services—Hospital-Based Outpatient Services and Provider-Based Office Visits

Answer 42

developed by the federal government, outpatient diagnoses that have been approved for use by hospitals/providers in coding and reporting hospital-based outpatient services and provider-based office visits.

Question 43

ICD-10-CM Index to Diseases and Injuries

Answer 43

an alphabetical listing of terms and their corresponding codes, which include specific illnesses, injuries, eponyms, abbreviations, and other descriptive diagnostic terms.

Question 44

ICD-10-CM Index to External Cause of Injuries

Answer 44

arranged in alphabetical order by main term indicating the event; are secondary codes for use in any health care setting; capture how the injury or health condition happened (cause), the intent (unintentional or accidental; or intentional, such as suicide or assault), the place where the event occurred, the activity of the patient at the time of the event, and the person’s status.

Question 45

ICD-10-CM Official Guidelines for Coding and Reporting

Answer 45

prepared by CMS and NCHS and approved by the cooperating parties for ICD-10-CM/PCS; contain rules that were developed to accompany and complement coding conventions and instructions provided in ICD-10-CM; adherence when assigning diagnosis codes is required under HIPAA.

Question 46

ICD-10-CM Tabular List of Diseases and Injuries

Answer 46

arranged in alphabetical order by main term indicating the event; are secondary codes for use in any health care setting; capture how the injury or health condition happened (cause), the intent (unintentional or accidental; or intentional, such as suicide or assault), the place where the event occurred, the activity of the patient at the time of the event, and the person’s status.

Question 47

ICD-10-CM/PCS Coordination and Maintenance Committee

Answer 47

responsible for overseeing all changes and modifications to ICD-10-CM (diagnosis) and ICD-10-PCS (procedure) codes; discusses issues such as the creation and update of general equivalence mappings (GEMs).

Question 48

ICD-10-PCS Official Guidelines for Coding and Reporting

Answer 48

prepared by CMS and NCHS and approved by the cooperating parties for ICD-10-CM/PCS; contain rules that were developed to accompany and complement official conventions and instructions provided in ICD-10-PCS; adherence when assigning procedure codes is required under HIPAA.

Question 49

International Classification of Diseases, 10th Revision (ICD-10)

Answer 49

developed by the World Health Organization (WHO) and released in 2018 to begin the implementation proces (e.g., translation into languages other than English).

Question 50

legacy classification system

Answer 50

see legacy coding system.

Question 51

legacy coding system

Answer 51

system that is no longer supported or updated, such as ICD-9-CM once ICD-10-CM/PCS replaced it effective October 1, 2015. (See also general equivalence mapping.)

Question 52

lesion

Answer 52

any discontinuity of tissue (e.g., skin or organ) that may or may not be malignant.

Question 53

main term

Answer 53

bold-faced term located in the ICD-10-CM index; listed in alphabetical order with sub terms and qualifiers indented below each main term.

Question 54

Malignant

Answer 54

Malignantcancerous

Question 55

Metastasis

Answer 55

spread of cancer from primary to secondary site(s).

Question 56

morbidity

Answer 56

pertaining to illness or disease.

Question 57

morphology

Answer 57

pertaining to death.

Question 58

Neoplasm

Answer 58

growth, or tumor, in which cell reproduction is out of control

Question 59

nonessential modifier

Answer 59

supplementary words located in parentheses after an ICD-10-CM main term that do not have to be included in the diagnostic statement for the code number to be assigned.

Question 60

Outpatient

Answer 60

person treated in one of three settings: health care provider’s office; hospital clinic, emergency department, hospital same-day surgery unit, or ambulatory surgical center (ASC) where the patient is released within 23 hours; or hospital admission solely for observation where the patient is released after a short stay.

Question 61

overlapping sites

Answer 61

see contiguous sites.

Question 62

physician query process

Answer 62

when coders have questions about documented diagnoses or procedures/services, they contact the responsible physician to request clarification about documentation and the code(s) to be assigned.

Question 63

poisoning: accidental (unintentional)

Answer 63

poisoning that results from an inadvertent overdose, wrong substance administered/taken, or intoxication that includes combining prescription drugs with nonprescription drugs or alcohol.

Question 64

poisoning: assault

Answer 64

poisoning inflicted by another person who intended to kill or injure the patient.

Question 65

poisoning: intentional self-harm

Answer 65

poisoning that results from a deliberate overdose, such as a suicide attempt, of substance(s) administered/taken or intoxication that includes purposely combining prescription drugs with nonprescription drugs or alcohol.

Question 66

poisoning: undetermined

Answer 66

subcategory used if the patient record does not document whether the poisoning was intentional or accidental.

Question 67

preadmission testing (PAT)

Answer 67

completed prior to an inpatient admission or outpatient surgery to facilitate the patient’s treatment and reduce the length of stay.

Question 68

primary malignancy

Answer 68

original cancer site.

Question 69

principal diagnosis

Answer 69

condition determined, after study, that resulted in the patient’s admission to the hospital.

Question 70

qualified diagnosis

Answer 70

working diagnosis that is not yet proven or established; reported for inpatient cases only.

Question 71

Qualifiers

Answer 71

supplementary terms in the ICD-10-CM Index to Diseases and Injuries that further modify subterms and other qualifiers.

Question 72

re-excision

Answer 72

occurs when the pathology report recommends that the surgeon perform a second excision to widen the margins of the original tumor site.

Question 73

secondary diagnosis

Answer 73

coexists with the primary condition, has the potential to affect treatment of the primary condition, and is an active condition for which the patient is treated or monitored.

Question 74

secondary malignancy

Answer 74

tumor has metastasized to a secondary site, either adjacent to the primary site or to a remote region of the body.

Question 75

sequela

Answer 75

residual late effects of injury or illness

Question 76

subterm

Answer 76

qualifies the main term by listing alternative sites, etiology, or clinical status; it is indented two spaces under the main term.

Question 77

trust the index

Answer 77

concept that inclusion terms listed below codes in the tabular list are not meant to be exhaustive, and additional terms found only in the index may also be associated to a code.

Question 78

uncertain behavior

Answer 78

it is not possible to predict subsequent morphology or behavior from the submitted specimen.

Question 79

underdosing

Answer 79

taking less of a medication than is prescribed by a provider or a manufacturer’s instruction.

Question 80

unspecified nature

Answer 80

neoplasm is identified, but no further indication of the histology or nature of the tumor is reflected in the documented diagnosis.