Chapter 6 - ICD-10-CM

Question 1

Adverse effect

Answer 1

development of a pathologic condition that results from a drug or chemical substance that was properly administered or taken

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

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 health care provider (e.g., physician, nurse practitioner) who assesses and treats the patients 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 cod e

Question 14

first-listed diagnosis

Answer 14

reported on outpatient claims (instead of inpatient principal diagnosis); it reflects the reason for the encounter, and 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

Answer 17

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

Question 18

and

Answer 18

when two disorders are separated by the word “and,” and “it is interpreted as” and/or” and indicates that either of the two disorders is associated with the code number

Question 19

brackets

Answer 19

used in the index to identify manifestation codes and in the index and tabular list to enclose abbreviations, synonyms, alternative wording, or explanatory phrases

Question 20

code also

Answer 20

ICD-10-CM tabular list instruction that indicates two codes may be required to fully describe a condition with sequencing depending on circumstances of the encounter