Coding Flashcards
If a congenital deformity had been corrected what code should be used
History-personal
Coding for birth episode of a new born what to do
Take code with z38 as principal diagnosis following the other diagnosis
definition of medical coding
the process of converting diseases , treatment and medical supplies and implants used for the treatment from a medical report into a universal accepted alphanumeric code format
Purpose of coding
Quality care
easier electronic payment in healthcare facility
protection of PHI
saving space
eliminate the chance of missing documents
types of codes ?
ICD
CPT
HCPCS
Who developed ICD and when ?
WHO 1979
For what purpose the ICD developed
to monitor birth rate ,death rate and disease rate
Expand ICD 10 CM
International classification of diseases 10 th revision ,clinical modification
published in october 1,2015
what all things are coded in ICD ?
Diagnosis
signs and symptoms
external causes
injuries
poisoning
supplementary information
what are the 2 parts of ICD book
alphabetic index
tabular list
what makes the section 1
index to disease and injuries
what includes in section 2 ?
table of neoplasam
table of drugs and chemicals
what in section 3 ?
index to external cause of injuries
what does ‘see’ means ?
another term should be referenced
what does ‘see also’ implies?
instruction to review another main term if all needed information is not located under the first main term
what are the multiple codes, when it is used and where it can be found?
use of more than one code for the identification of certain elements of a complex diagnostic statement
found in alphabetic index by the use of a second code listed in brackets
what are combination codes?
single code used to classify :
two diagnosis
a diagnosis with manifestation
a diagnosis with complication
what are non essential modifiers
sub terms follow the main term and enclosed in parenthesis
optional
essential modifiers
sub terms listed below the main term in the alphabetic order and are indented
additional characters for the additional information about the procedure
which are the 7th characters?
A,D,S
what does the letter A indicate?
initial encounter
patient is receiving active treatment for the condition
eg: surgical treatment,evaluation and treatment by physician
what does the letter D indicate
subsequent encounter
received the active treatment, receiving routine care for the injury during the healing or recovery phase
eg: cast removal,follow up visit or aftercare following injury treatment
what does the letter S indicate?
sequela
complication or late effect of an injury
eg : scar after burn
what does the letter X shows?
place holder
append 7 th character when the code is less than 6 characters in length
what is mean by NEC
not elsewhere classified
equivalent to word “other” or “other specified codes”
these codes are used when there is no specific code available to represent the condition
expand NOS?
Not otherwise specified
equivalent to “unspecified”
indicate the condition or documentation does not provide enough information to assign more specified code
how to code if a condition described as both acute and chronic
code both and sequence acute code first
how to code an impending or threatened condition documented at the time of discharge?
if it occur - confirmed diagnosis
if it did not occur - assign code as impending or threatened condition
not listed in the alphabetic index - code for underlying conditions
how to code if the document shows “borderline” diagnosis at the time of discharge?
alphabetic index - borderline
if subentry not there code the diagnosis as confirmed
use of include terms or notes?
included under some codes to define it further or give examples to the content category or block categories
what is the context of excludes 1?
codes excluded should never be used at the same time as the code above the excludes 1 note
what does it mean by excludes 2?
code is not the part of selected condition, but a patient may have the both conditions at the same time
if present both codes can be used
difference between signs and symptoms
signs - objective
symptoms - subjective
how to code if a diagnosis is given
code for the diagnosis
if definitive diagnosis is not given code for signs and symptoms
if signs and symptoms are given along with definitive diagnosis code is needed for the diagnosis only
how to code coma?
used in conjunction with traumatic brain injury codes,acute cerebrovascular diseases,or sequelae of cerebrovascular disease codes
sequenced after diagnosis codes
three codes from each subcategory to complete the scale (R40.21,R40.22,R40.23)
The coma scale codes (R40.2- to R40.24-) are primarily for use by trauma registries, such as for patients who have suffered traumatic brain injuries, but may be used in any setting where the information is collected.
The coma scale codes include one code from each of the three subcategories (eyes open, best verbal response, and best motor response).
The coding guidelines state to report the total score when only the total score is documented in the medical record. When multiple coma scores are reported within the first 24 hours, only report the coma score at the time of admission.
An unspecified coma (R40.20) may be assigned in addition to any medical condition.
Do not report codes for unspecified coma, individual or total Glasgow coma scale scores for a patient with a medically induced coma or for a sedated patient.
what to do if multiple codes are documented within first 24 hours after hospital admission
code for score at time of admission
if patient has recently fallen and reason for fall is being investigated what to do?
assign code R29.6 repeated falls
if the patient has fallen in the past and is at risk of future falls what code should be assigned?
Z91.81 as history of fall
define ckd
type of kidney disease in which there is gradual loss of kidney function over a period of months or years
which are the stages of ckd?
stage 1
stage 2
stage3
stage 3a
stage 3b
stage 4
stage5
ESRD
If CKD &ESRD are documented what to do ?
assign code only for ESRD
How to code if the person undergoing dialysis?
code stage of CKD
Additional code to identify dialysis status
how to code if the patient has transplanted kidney?
use the additional code to report kidney transplant status(Z94.0)
if patient has stage 5 CKD had undergoing dialysis how to code?
code stage 5 CKD
Dialysis status code
what if patient has stage 5 CKD and undergoing chronic dialysis
code for ESRD
dialysis status code
common signs and symptoms of BPH
Frequent urge to urinate
Nocturia
difficulty starting urination
weak urine stream or a stream that starts and stops
dribbling at the end of urination
inability to completely empty the bladder
guidelines to code BHP or nodular prostate
if patient has any LUTS assign additional codes for LUTS
if patients have symptoms other than LUTS report code only for BHP or nodular prostate
Define glaucoma
due to fluid buildup in the front part of eye increases the intraocular pressure inside eye cause damage to the optic nerve
types of glaucoma
open angle / primary glaucoma
angle closure glaucoma
other types
normal tension glaucoma
pigmentary glaucoma
secondary glaucoma
low tension glaucoma
stages of glaucoma
mild
moderate
severe
indeterminate - stage cannot be determined clinically
unspecified - stage of glaucoma is not documented
what are the guidelines in coding glaucoma
identify :
type of glaucoma
stage
- if both eyes are affected and both have the same stages and type of glaucoma assign the code for bilateral glaucoma
*if a patient has bilateral glaucoma but the type and stages are different assign the appropriate code for each eye rather that code for bilateral glaucoma.
*if the patient admitted with glaucoma and the stage progress during the admission assign code for highest stage documented
define cataract
a cloudy opaque area in the normally clear lens of eye
types of cataract
senile
juvenile and infantile
traumatic
complicated
drug induced
general guidelines for codind conditions in ear
specific codes to report laterality
for both ears assign bilateral code
if laterality is not given, assign unspecified code
types of otitis media
AOM
SOM
OME
chronic OM with effusion
what are pressure ulcers
injuries to skin and underlying tissues from prolonged pressure on the skin
synonyms- bed sore ,decubitus ulcer, pressure sore
stages of pressure ulcer
stage 1 - epidermis
stage 2 - epidermis and dermis
stage 3 - epidermis, dermis and subcutaneous tissue
syage 4 - extend below subcutaneous fat to deep tissues like muscles , tendons, cartilage or bone
additional stages
pressure induced deep tissue injury
unstageable pressure ulcer - stages cannot be determined clinically
what is pressure induced deep tissue injury
serious form of pressure ulcer caused by direct pressure to the skin and soft tissue that causes ischemia
coding guidelines for pressure ulcers
combination codes specify both size and stage of ulcer
multiple sites - code of stage of pressure ulcer at the time of admission as principal diagnosis
how to code if the ulcer is documented as healing?
assign appropriate pressure ulcer stage for pressure ulcer code documented as healing
how to code if the ulcer healed at the time of discharge?
assign the code for the stage at the time of admission
no code is assigned if documentation stages that pressure ulcer completely healed at the time of admission
no history code for pressure ulcer
how to code if the patient is admitted with a pressure ulcer at one stage and if the stage progresses to higher stage
report 2 codes :
one code for stage of pressure ulcer at the time of admission
second code for the stage documented during hospital stay
if during an encounter a stage of an unstageable pressure ulcer reveled after debriment ,
assign the code for the stage revealed following debriment
how to code non pressure chronic ulcers
similar guidelines as pressure ulcers
what is a congenital disease?
medical conditions present at or before birth
where the codes for congenital absence of an organ is documented?
Q codes
where acquired absence of organs documented?
Z89 ,Z90
coding guidelines of congenital malformations
codes from q chapter is used throughout the life of the patient.
if the deformity is corrected a personal history code should be used
how to code the birth episode of a new born record
assign appropriate code from the category Z38 as principal diagnosis , followed by congenital abnormality codes
what are z codes called
status codes
codes used to describe circumstances or problems which influences a patient’s health
what all included in the status codes
contact/exposure
inoculations and vaccinations
status
history
screening
observation
aftercare
follow up
donor
counselling
encounters for reproductive and obstetric services
newborns and infants
routine and administrative examinations
define psychoactive substance abuse and dependance
abuse refers the individual continues to use the drug even though they know the substance is causing an adverse effect on their mental and physical well being
dependance occurs when an individual develops tolerance to a particular drug upon the repeated use of that drug and shows withdrawal symptoms on stopping or reducing the use of that particular drug
when use ,abuse,dependance of same substance is given how many codes needed and what is the heirarchy
use only single code
heirarchy is :
for use and dependance code for dependence
fore abuse and dependance - dependance
for
for use and abuse code for abuse
when a medical condition or disease is documented due to substance use , abuse and dependance
first assign code for medical condition
then assign code for substance use abuse and dependance
if clinical note include the blood alcohol level
assign code from category Y90 in addition to the codes assigned from category f10
personal history of psycho active substance usage
shouuld be reported
history - personal
dementia is progressed to higher level than at the time of admission how to assign code
code for the highest severity level reported during the stay
types of poisoning
accidental
intentional self harm
assault
undetermined
coding a poison or reaction due to the improper use of a medication
assign code for poisoning from drugs and chemicals table
manifestations must be coded additionally
what is mean by adverse effect of a drug
if a person take medicine or drug according to the physicians instruction and the patient develop reaction to the medication
how to code adverse effect
first code for manifestations
next code for the drug
what is underdosing?
the patient takes less of a medicaton than prescribed by a physicians instruction
how to code underdosing?
code for manifestations
then code for drug
