CPB Chapter 4 Flashcards
Information required to determine medical necessity?
Knowledge of emergent nature and severity
All signs and symptoms
Justified with the medical record
22 chapters to classify diseases and injuries by etiology or anatomical sites
Tabular list of diseases
first three characters of a code represent?
the category
characters 4-6 represent
etiology, anatomic site, severity, or other details
what does the 7th character represent
an extension used for episodes of care or injuries / external causes
how many characters is the highest level of specificity
characters 5 and 6
identified neoplasms by behavior and by anatomical location
Table of Neoplasms
How to correctly code neoplasms?
correct code selection is driven by the behavior of the neoplasm in the medical record, then if primary or secondary
Correct sequencing for neoplasm codes?
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
What code is used to document personal history of malignancy that is not being currently treated?
Z85.9 - Personal history of malignant neoplasm, unspecified
Correct coding when a patient presents solely for administration of chemotherapy, radiation or immunotherapy?
Z code reported as the primary diagnosis, followed by the code for malignancy being treated on DOS
convention when: the provider docuemented more specific information regarding the patients condition, but there is not a code to report the condition accurately
NEC = Not Elsewhere classifiable
when the medical record lacks the information necessary to code to a more specific code
NOS = Not Otherwise Specified
used to enclose synonyms, explanatory phrases, or alternate wording
Brackets [ ]
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
Parentheses ( )
the code excluded should never be used at the same time as the code above the “ “ note.
EXCLUDES1 note
when two conditions cannot occur together, such as congenital form vs an acquired form of the same condition
Excludes1 note
the condition excluded is not part of the condition represented by the code, but a patient may have both conditions at the same time
EXCLUDES2 note
What note appears when it is acceptable to use both the code and the excluded code together?
Excludes2 note
notation used in categories not intended to be the principal diagnosis
- note requires that the underlying disease be recorded first, and the manifestation second
Code First note
used to indicate that an additional code is needed to provide a more complete picture of the diagnosis, such as manifestation
Use Additional Code note
notation indicates that the code(s) listed should be coded as additional (secondary) codes
Use Additional Code note
Step one to look up diagnosis code
Look for the diagnosis in the assessment and plan
Step two to look up diagnosis code
look up the main term in the alphabetic index
main term = disease, illness, or condition of the patient
Step three to look up diagnosis code
look for the code referenced in the alphabetic index up in the Tabular list to verify accuracy of code
instructions for proper code selection and code sequencing rules - provided by who?
CMS and National Center for Health Statistics
locating a code, details about the level of coding, signs and symptoms, multiple coding for a single condition, acute and chronic condition, combination code
Subsection B - official guidelines
includes the conventions and punctuation
Subsection A - Official guidelines
Chapter-specific rules concerning each chapter
Subsection C - official guidelines
How to report combination codes?
Sequenced based on the reason for a particular encounter. Identify as many codes necessary to identify the condition
appropriate codes to use when a more specific diagnosis cannot be made even after additional review of the condition has been conducted.
Signs and symptoms codes (R00-R99)
possible, probable, suspected, questionable, and rule out diagnoses should never be reported in the outpatient setting - what code to use instead?
Signs and symptoms code (R00-R99) to most accurately describe the encounter
Conditions that are not integral part of a disease process?
additional signs and symptoms that may not be associated routinely with a disease process should be coded when present
Alphabetic Index when multiple coding for a single condition
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
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
Combination code
assign this code when that code fully identifies the diagnostic conditions involved or when instructed in the alphabetic index
combination code
Acute exacerbation of a chronic condition - what kind of code?
combination code
how to sequence codes of same condition but there is not a combination code?
Report the acute code first followed by the code for the chronic condition
the residual effect or condition produced after the acute phase of an injury or illness has terminated
Sequela effects
How to code sequela effects?
the residual code is reported first, followed by the code for the cause
How to code an impending or threatened condition when a suitable code does not exist?
report the signs and symptoms that led the provider to suspect an impending or threatened condition
main term = threatened
____ Should only be reported as secondary diagnoses?
BMI, coma scale, NIHSS codes, and categories Z55-Z65
What to code if a syndrome is not located in the ICD-10?
code the documented manifestations of the syndrome
coded as confirmed diagnoses unless there is an index entry of borderline for that classification
Borderline diagnosis
section that includes instructions for the correct code selection and sequencing specific to each chapter
Section I.C. Chapter-specific coding guidelines
Codes always listed after the primary diagnosis
external cause codes
codes that provide data for injury research and evaluation of injury prevention strategies
external cause codes
What external code takes priority over all others when sequencing
External codes for child and adult abuse
After codes for child and adult abuse, what order should external causes be reported
terrorism, cataclysmic events, and transport accidents
What should the first-listed external cause code correspond with
the cause of the most serious diagnosis
acronym for the order external causes should be coded
catct ash
codes that identify the reason why a patient is seeking services
Z codes
provisional assignment of codes for new diseases of uncertain etiology or emergency use
U codes
Outpatient encounters for receiving diagnostic services only
code the reason for encounter first, then the diagnostic findings
Outpatient encounters for receiving therapeutic services only
code the diagnosis related to the encounter first, then other diagnoses. Only exception is when being seen for oncology treatment
EX: Pt presents to the outpatient department for chemotherapy to treat cancer of the rectosigmoid junction. How should these codes be reported
Encounter for chemotherapy then malignant neoplasm of rectosigmoid junction
coding for ambulatory surgery
code the diagnosis for which the surgery was performed
when a pt is seen for medical exam with abnormal findings
Z code with code for abnormal findings
