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aapc > CPB Chapter 4 > Flashcards

CPB Chapter 4 Flashcards

1
Q

Information required to determine medical necessity?

A

Knowledge of emergent nature and severity
All signs and symptoms
Justified with the medical record

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2
Q

22 chapters to classify diseases and injuries by etiology or anatomical sites

A

Tabular list of diseases

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3
Q

first three characters of a code represent?

A

the category

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4
Q

characters 4-6 represent

A

etiology, anatomic site, severity, or other details

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5
Q

what does the 7th character represent

A

an extension used for episodes of care or injuries / external causes

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6
Q

how many characters is the highest level of specificity

A

characters 5 and 6

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7
Q

identified neoplasms by behavior and by anatomical location

A

Table of Neoplasms

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8
Q

How to correctly code neoplasms?

A

correct code selection is driven by the behavior of the neoplasm in the medical record, then if primary or secondary

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9
Q

Correct sequencing for neoplasm codes?

A

first determine which neoplasm was treated on the day of the encounter. If it is for metastasis, it is appropriate to put secondary site as principal diagnosis

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10
Q

What code is used to document personal history of malignancy that is not being currently treated?

A

Z85.9 - Personal history of malignant neoplasm, unspecified

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11
Q

Correct coding when a patient presents solely for administration of chemotherapy, radiation or immunotherapy?

A

Z code reported as the primary diagnosis, followed by the code for malignancy being treated on DOS

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12
Q

convention when: the provider docuemented more specific information regarding the patients condition, but there is not a code to report the condition accurately

A

NEC = Not Elsewhere classifiable

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13
Q

when the medical record lacks the information necessary to code to a more specific code

A

NOS = Not Otherwise Specified

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14
Q

used to enclose synonyms, explanatory phrases, or alternate wording

A

Brackets [ ]

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15
Q

used to enclose supplementary words that may be present or absent in the statement of a disease or procedure, without affecting the assigned code number

A

Parentheses ( )

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16
Q

the code excluded should never be used at the same time as the code above the “ “ note.

A

EXCLUDES1 note

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17
Q

when two conditions cannot occur together, such as congenital form vs an acquired form of the same condition

A

Excludes1 note

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18
Q

the condition excluded is not part of the condition represented by the code, but a patient may have both conditions at the same time

A

EXCLUDES2 note

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19
Q

What note appears when it is acceptable to use both the code and the excluded code together?

A

Excludes2 note

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20
Q

notation used in categories not intended to be the principal diagnosis

  • note requires that the underlying disease be recorded first, and the manifestation second
A

Code First note

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21
Q

used to indicate that an additional code is needed to provide a more complete picture of the diagnosis, such as manifestation

A

Use Additional Code note

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22
Q

notation indicates that the code(s) listed should be coded as additional (secondary) codes

A

Use Additional Code note

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23
Q

Step one to look up diagnosis code

A

Look for the diagnosis in the assessment and plan

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24
Q

Step two to look up diagnosis code

A

look up the main term in the alphabetic index

main term = disease, illness, or condition of the patient

25
Q

Step three to look up diagnosis code

A

look for the code referenced in the alphabetic index up in the Tabular list to verify accuracy of code

26
Q

instructions for proper code selection and code sequencing rules - provided by who?

A

CMS and National Center for Health Statistics

27
Q

locating a code, details about the level of coding, signs and symptoms, multiple coding for a single condition, acute and chronic condition, combination code

A

Subsection B - official guidelines

27
Q

includes the conventions and punctuation

A

Subsection A - Official guidelines

28
Q

Chapter-specific rules concerning each chapter

A

Subsection C - official guidelines

29
Q

How to report combination codes?

A

Sequenced based on the reason for a particular encounter. Identify as many codes necessary to identify the condition

30
Q

appropriate codes to use when a more specific diagnosis cannot be made even after additional review of the condition has been conducted.

A

Signs and symptoms codes (R00-R99)

31
Q

possible, probable, suspected, questionable, and rule out diagnoses should never be reported in the outpatient setting - what code to use instead?

A

Signs and symptoms code (R00-R99) to most accurately describe the encounter

32
Q

Conditions that are not integral part of a disease process?

A

additional signs and symptoms that may not be associated routinely with a disease process should be coded when present

33
Q

Alphabetic Index when multiple coding for a single condition

A

Alphabetic index codes for both etiology and manifestation of a disease appear following the subentry term, with the second code in brackets.

Assign both codes in the same sequence in which they appear in the alphabetical index

34
Q

code used to fully identify an instance in which two diagnoses or a diagnosis with an associated secondary process (manifestation) or complication, are included in the description of a single code number

A

Combination code

35
Q

assign this code when that code fully identifies the diagnostic conditions involved or when instructed in the alphabetic index

A

combination code

36
Q

Acute exacerbation of a chronic condition - what kind of code?

A

combination code

37
Q

how to sequence codes of same condition but there is not a combination code?

A

Report the acute code first followed by the code for the chronic condition

38
Q

the residual effect or condition produced after the acute phase of an injury or illness has terminated

A

Sequela effects

39
Q

How to code sequela effects?

A

the residual code is reported first, followed by the code for the cause

40
Q

How to code an impending or threatened condition when a suitable code does not exist?

A

report the signs and symptoms that led the provider to suspect an impending or threatened condition

main term = threatened

41
Q

____ Should only be reported as secondary diagnoses?

A

BMI, coma scale, NIHSS codes, and categories Z55-Z65

42
Q

What to code if a syndrome is not located in the ICD-10?

A

code the documented manifestations of the syndrome

43
Q

coded as confirmed diagnoses unless there is an index entry of borderline for that classification

A

Borderline diagnosis

44
Q

section that includes instructions for the correct code selection and sequencing specific to each chapter

A

Section I.C. Chapter-specific coding guidelines

45
Q

Codes always listed after the primary diagnosis

A

external cause codes

46
Q

codes that provide data for injury research and evaluation of injury prevention strategies

A

external cause codes

47
Q

What external code takes priority over all others when sequencing

A

External codes for child and adult abuse

48
Q

After codes for child and adult abuse, what order should external causes be reported

A

terrorism, cataclysmic events, and transport accidents

49
Q

What should the first-listed external cause code correspond with

A

the cause of the most serious diagnosis

50
Q

acronym for the order external causes should be coded

A

catct ash

51
Q

codes that identify the reason why a patient is seeking services

A

Z codes

52
Q

provisional assignment of codes for new diseases of uncertain etiology or emergency use

A

U codes

53
Q

Outpatient encounters for receiving diagnostic services only

A

code the reason for encounter first, then the diagnostic findings

54
Q

Outpatient encounters for receiving therapeutic services only

A

code the diagnosis related to the encounter first, then other diagnoses. Only exception is when being seen for oncology treatment

55
Q

EX: Pt presents to the outpatient department for chemotherapy to treat cancer of the rectosigmoid junction. How should these codes be reported

A

Encounter for chemotherapy then malignant neoplasm of rectosigmoid junction

56
Q

coding for ambulatory surgery

A

code the diagnosis for which the surgery was performed

57
Q

when a pt is seen for medical exam with abnormal findings

A

Z code with code for abnormal findings

aapc (8 decks)

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