Chapter 9

Question 1

behavioral disturbance

Answer 1

a type of common behavior that includes mood disorders (such as depression, apathy, and euphoria), sleep disorders (such as insomnia and hypersomnia), psychotic symptoms (such as delusions and hallucinations), and agitation (such as pacing, wandering and aggression)

Question 2

sedative

Answer 2

a tranquilizer, a drug used to calm or soothe

Question 3

hypnotic

Answer 3

a drug that induces sleep

Question 4

anxiolytic

Answer 4

a drug used to reduce anxiety

Question 5

use

Answer 5

occasional consumption of a substance without clinical manifestations

Question 6

abuse

Answer 6

regular consumption of a substance with manifestations

Question 7

depedndence

Answer 7

ongoing, regular consumption of a substance with resulting significant clinical manifestations and a dramatic decrease in the effect of the substance with continued used, therefore requiring an increased quantity of the substance to achieve intoxication

Question 8

anxiety

Answer 8

the feeling of apprehension and fear, sometimes manifested with physical manifestations such as sweating and palpitations

Question 9

manic

Answer 9

an emotional state that includes elation, excitement, and exuberance

Question 10

depressive

Answer 10

an emotional state that includes sadness hopelessness and gloom

Question 11

schizophrenia

Answer 11

a psychotic disorder with no known cause

Question 12

phobia

Answer 12

irrational and excessive fear of an object, activity, or situation

examples

F40.0 Agoraphobia
F40.1 Social phobia
F40.23 Blood, injection, injury type phobia
F41.0 Panic disorder (episodic paroxysmal anxiety)
F41.1 Generalized anxiety disorder

Question 13

somatoform disorder

Answer 13

the sincere belief that one is suffering an illness that is not present

F45.0 Somatization disorder (Multiple psychosomatic disorder)

F45.22 Body dysmorphic disorder

F45.41 Pain disorder exclusively related to psychological factors

F45.42 Pain disorder with related psychological factors

Question 14

acute

Answer 14

severe, serious

Question 15

chronic

Answer 15

long duration, continuing over an extended period of time

Question 16

Pain is an inclusive symptom except when

Answer 16

the principle purpose of the encounter is pain management and the encounter does not include treatment or management of the underlying condition

the pain is noted as acute and or chronic, documenting that the pain suffered by the patient is above and beyond the level typical of the underlying condition

Question 17

A mental disorder can be caused by a…?

Answer 17

physiological condition

examples-

an infarction of the brain
hypertensive

cerebrovascular disease

a disease such as Creutzfeldt-Jakob disease, Parkinson’s disease, or trypanosomiasis

an endocrine disorder, exogenous hormone, or toxic substance that can cause cognitive and/or intellectual malfunction

Question 18

Provide Examples of Mood (Affective) Disorders

Answer 18

Bipolar disorders

Major depressive disorders

Question 19

Do Bipolar disorder codes change frequently for each patient? Why?

Answer 19

yes. they may or may not experience psychotic features. those features may be mild to moderate

Question 20

What happens when someone has Catatonic (schizophrenic catalepsy, catatonia, or flexibilitas cerea)?

Answer 20

they cannot move,.

Question 21

What are the five different types of schizophrenia?

Answer 21

paranoid (paraphrenic schizophrenia) F20.0

Disorganized (hebephrenic schizophrenia or hebephrenia) F20.1

Catatonic (schizophrenic catalepsy, catatonia, or flexibilitas cerea)? F20.2

Undifferentiated (atypical schizophrenia) F20.3

residual (restzustand) F20.5

Question 22

Schizoid Personality Disorder

Answer 22

patient exhibit a limited range of emotions and an aversion to social relationships and personal interactions, and have a flat affect

F60.1 Schizoid personality disorder

Question 23

Excludes 1 note

Answer 23

never code with

Question 24

Excludes 2 note

Answer 24

you can code with another code

Question 25

Panic disorder is also?

Answer 25

Panic attack

Both coded

F41.0

Question 26

Post-traumatic stress disorder (P T S D)

Answer 26

a condition in which a horrible experience leaves a lasting imprint on the patient’s sense of danger

(look for unspecified, acute, or chronic when coding)

When Reporting PTSD, remember to include external cause codes to explain the specifics about the traumatic event

Examples

F43.10 PTSD, unspecified
F43.11 PTSD, acute
F43.12 PTSD, chronic

Question 27

Inflammatory Conditions of the CNS

Answer 27

G00.1 Pneumoccoccal meningitis

G00.8 Other bacterial meningitis (Meningitis due to Escherichia coli)

G03.0 Nonpyogenic meningitis

Question 28

Hereditary and Degenerative Diseases of the CNS

Answer 28

G31.01 Frontotemporal dementia (Pick’s disease)

G31.83 Dementia with Lewy bodies (Lewy body dementia)

Question 29

communicating hydrocephalus (secondary normal pressure hydrocephalus)

CODE

Answer 29

G91.0 Communicating hydrocephalus

Question 30

Noncommunicating hydrocephalus (obstructive hydrocephalus)

CODE

Answer 30

G91.1 Obstructive hydrocephalus

Question 31

(Idiopathic) normal pressure hydrocephalus (N P H)- we don’t know what causes it

CODE

Answer 31

G91.2 (Idiopathic) Normal pressure hydrocephalus

Question 32

Post-traumatic hydrocephalus ex-vacuo)

CODE

Answer 32

G91.3 Post-traumatic hydrocephalus, unspecified

Question 33

Hydrocephalus may also occur as a manifestation of another condition, such as a neoplasm or congenital syphilis

CODE

Answer 33

G91.4 Hydrocephalus in diseases classified elsewhere

Question 34

What details are required to code a Migraine Accurately?

Answer 34

Code category G43 Migraine

Is it a(n)

Aura
Intractable
Status migrainosus
chronic
other types of migraines

Question 35

Dominant Sides

Physiological Conditions Affecting the Peripheral Nervous System

Answer 35

if the documentation states the right side is affected–report as dominant

Question 36

Nondominant Sides

Physiological Conditions Affecting the Peripheral Nervous System

Answer 36

If the documentation states the left side is affected–report as nondominant

Question 37

Ambidextrous

Physiological Conditions Affecting the Peripheral Nervous System

Answer 37

whichever side is documented as affected should be reported as the patient’s dominant side

Question 38

Carpal Tunnel Syndrome

Answer 38

Condition that causes numbness, tingling, or weakness in your hand. It happens because of pressure on your median nerve, which runs the length of your arm, goes through a passage in your wrist called the carpal tunnel, and ends in your hand.

G56.01 Carpel tunnel syndrome, right upper limb or
G56.02 Carpel tunnel syndrome, left upper limb
or
G56.03 Carpel tunnel syndrome, bilateral upper limbs

Question 39

Plexus Disorders

Answer 39

many plexus disorders are the result of a specific point in the peripheral neural pathway for that plexus becoming compressed

G54.0 Brachial plexus disorders
or
G54.1 Lumbosacral plexus disorders

Question 40

CRPS-I (reflex sympathetic dystrophy syndrome)

{Complex Regional Pain Syndrome (CRPS)}

Answer 40

patient denies the occurrence of any nerve injury

Examples

G90.511 Complex regional pain syndrome I of right upper limb

G90.512 Complex regional pain syndrome I of left upper limb

Question 41

CRPS- II (causaligia)

{Complex Regional Pain Syndrome (CRPS)}

Answer 41

with a confirmed nerve injury prior to diagnosis

examples

G57.71 Causalgia of right lower limb

G57.72 Causalgia of left lower limb

Question 42

Numeric Pain Scale

Answer 42

0- No pain

1-3 Mild pain (nagging, annoying, interfering little with A D L s)

4-6 Moderate pain (interferes significantly with A D L s)

7-10 Severe pain (Disabling, unable to perform A D L s)

Question 43

ADLs

Answer 43

activities of daily living

Question 44

Pain is considered to be an inclusive symptom, EXCEPT when

Answer 44

• the principal purpose of the encounter is pain management and the encounter does not include treatment or management of the underlying condition
• the pain is noted as acute and or chronic, documenting that the pain suffered by the patient is above and beyond the level typical of the underlying

Report from code category G89 Pain, not elsewhere classified

Question 45

Postprocedural Pain

Answer 45

G89.18 Other acute postprocedural pain (postprocedural pain N O S)

G89.28 Other chronic postprocedural pain

One of these codes may be reported only when the pain is documented as:

• more intense or lasting longer than the expected level of pain that is considered normal immediately after a surgical procedure
• not related to a detailed complication of the surgical procedure

Question 46

Site- Specific Pain Codes

Answer 46

there are several code categories used to report pain located in a specific anatomical site.

Code category G89 Pain, not elsewhere classified, does not include any site- specific information. Anatomical site- specific code categories include:

M54.5 Low back pain lumbago)
M79.602 Pain in the left arm
M79.672 Pain in the left foot

Question 47

Sequencing Pain Codes with Other Codes

Answer 47

The first question to be answered from the documentation is, “Why was this encounter necessary?”

If the answer is for PAIN MANAGEMENT, the code from category G89 should be first-listed or the principal diagnosis reported.

If the encounter is for ANY OTHER REASON and the attention to pain management is secondary to the purpose for the encounter, then the first-listed or principle diagnosis code would report that other reason and the code from category G89 would be reported afterward.