Coding Flashcards
SEE
To refer another term
SEE ALSO
Refer another term if you full information is not located under the 1st term
MULTIPLE CODES
Use of more than one code for the identification of complex diagnostic statement s
COMBINATION CODES
One code for dx with secondary manifestation or associated complication
NON ESSENTIAL MODIFIERS
Subs that follow the main term in closed parenthesis
NON ESSENTIAL MODIFIERS
Subs that follow the main term in closed parenthesis
ESSENTIAL MODIFIERS
Sub terms under main term that are in alphabetic order and intended
Boxed tick
Incomplete code
7th Character A D S
A- initial encounter
D - Subsequent encounter
S - sequela
Example of sequela
Complication or late effect of an injury
Scar formation after a burn
Types of codes
Specified
Unspecified
Specified NEC
NOS
Not otherwise specified
Unspecified
NEC
Not elsewhere classified
Other specified codes
No specific code to represent the condition
Types of medical coding
ICD
CPT
HCPS
PLACE HOLDER
X
to fill 6th position to code with 7th character
IMPENDING / THREATENED CONDITION
conditions / risk at time of discharge
Guidelines of impending conditions
- if condition occurred, code as confirmed dx
- if condition not occurred yet, code as impending
- if impending condition not listed, assign code for underlying condition
Guideline for borderline dx
If there is no borderline index, then code as confirmed dx
What is 7th character ?
Additional information required to complete the code
what is coma?
deep state of unconsciousness
what is coma scale called ?
glassgow scale
what is glassgow scale used for ?
to measure the level of unconsciousness in a coma patient
guideline for coma codes?
(1) dx code first, coma code second, glassgow score code third.
(2) if multiple coma scores are documented, code coma score at the time of admission only.
(3) 7th character indicates when the coma scale was recorded.
(4) Non traumatic coma - code underlying condition first.
what is disease?
any harmful deviation from the normal structural and functioning state of an organism
what is a sign ?
any objective evidence of a disease that can be observed by someone other than the patient.
symptom
any subjective evidence that is experienced by the patient only.
guidelines for coding signs and symptoms?
(1) When there is a confirmed dx documented, then code for the dx
(2) when there is no confirmed dx documented, code as signs and symptoms
(3) when there is possible dx or probable dx documented, code as signs and symptoms only.
Guidelines for coding kidney diseases
(1) if both CKD and ESRD are documented, code for ESRD only
(2) if CKD 5 + chronic renal dialysis is documented, code as ESRD
(3) If CKD + renal dialysis is documented, code appropriately for CKD and dialysis seperately.
Guidelines for BPH
(1) if pt has dx of BPH + symptoms other than LUTS, code as BPH, signs and symptoms only
(2)
Guidelines for EAR
(1) Code specifically for laterality of ears
(2) if both L and R ears documented, code as Bilaterla
(3) if side is not mentioned, code as unspecified
Types of Otitis Media
Acute Otitis
Serous Otitis Media / Otitis media with effusion
Chronic Otitis Media
What is glaucoma ?
disease that damages the optic nerve due to buildup of eye fluids.
Main classifications of glaucoma ?
open angle glaucoma
closed angle glaucoma
types of glaucoma
normal tension glaucoma
low tension glaucoma
pigmented glaucoma
secondary glaucoma
Guidelines for coding glaucoma
(1) compulsorily identify and code for type, stage, side
(2) if stage of glaucoma is not documented, code as unspecified
(3) if stage cannot be determined, code as indeterminate stage.
(4) if both eyes are affected with the same stage and same type pf glaucoma, code as bilateral.
(5) if pt has bilateral glaucoma but if the stage or type is different, code appropriately for each.
(6) if pt is admitted with glaucoma and the stage progresses during the admission, assign the code for highest stage documented.
what is cataract ?
cloudy/opaque area in the lens of the eye
guidelines of cataract
if cataract is not documented as age related, then don’t code as age related cataract even if the pt is senile.
what is pressure ulcer ?
injuries to skin and underlying tissue resulting from prolonged pressure on the skin
guidelines for pressure ulcers ?
(1) code for stages of pressure ulcer
(2) if stage cannot be determined clinically, then document as unstageable.
(3) pressure ulcers are combination codes
(4) if pressure ulcer is documented as healing, then code for stage of the pressure ulcer only. Don’t code for healing.
(5) if pressure ulcer was documented at the time of admission and it healed completely during the stay, then code for the stage at time of admission
(6) if pt is admitted and stage progresses during the stay, code stage at time of admission first, then code for the progressed stage as second.
(7) if stage is unstageable first and the revealed after debridement, assign code for stage after debrediment.
What are status codes ?
Status codes are Z codes used when a patient visits a healthcare provider for reasons other than an injury or pathology
What are status codes ?
Status codes are Z codes used when a patient visits a healthcare provider for reasons other than an injury or pathology
Example of status code
Routine healthcare examination
What are psychoactive substances?
Substances which when taken into one’s system, affects the mental health process.
What is substance abuse?
refers to when an individual who uses drugs, even though they are aware of it having an adverse effect on their health and well being.
what is substance dependence ?
it is when an individual develops tolerance to a particular substance upon repeated use and shows withdrawal symptoms on stopping or reducing that particular substance
what is withdrawal symptom?
unpleasant physical and mental illness experienced by a substance addict on stopping or reducing that particular substance
Guidelines for use (U), abuse (A) and dependence.(D)
(1) If U, and A documented, code for A
(2) If U and D documented, code for D
(3) If A and D documented, code for D
(4) If U, A and D documented, code for D.
What is poisoning ?
Poisoning occurs when any substance interferes with the normal bodily functions, when swallowed, inhaled, injected or absorbed.
Guidelines for poisoning ?
(1) If the intent is unspecified or unknown, code as accidental
(2) if intent is documented as cant be determined, code as undetermined.
(3) First code for the poisoning, second code for manifestation
What is adverse effect ?
ill reaction to a drug taken correctly by the patient on correct prescription
what is underdosing?
take less dose of a medication, prescribed by the doctor
Guideline for adverse effect ?
(1) code for manifestation
(2) code for adverse effect
(3) code for purpose of taking the drug
guidelines for underdosing ?
(1) code for manifestation of underdosing
(2) code for underdosing
(3) code for purpose of taking the drug
What is neoplasm ?
abnormal growth of tissue
types of neoplasm ?
(1) Benign - non cancerous
(2) Malignant - cancerous
(3) uncertain -not cancerous yet but has the potential to be cancerous
(4) unspecified - not specified
Types of malignant neoplasm
(1)primary - cancer in primary site, has not spread
(2) secondary - secondary site where cancer has spread
(3) carcinoma in situ - stayed in primary site and will not spread
Guideline for neoplasm
