CPB Chapter 4

Question 1

Information required to determine medical necessity?

Answer 1

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

Question 2

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

Answer 2

Tabular list of diseases

Question 3

first three characters of a code represent?

Answer 3

the category

Question 4

characters 4-6 represent

Answer 4

etiology, anatomic site, severity, or other details

Question 5

what does the 7th character represent

Answer 5

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

Question 6

how many characters is the highest level of specificity

Answer 6

characters 5 and 6

Question 7

identified neoplasms by behavior and by anatomical location

Answer 7

Table of Neoplasms

Question 8

How to correctly code neoplasms?

Answer 8

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

Question 9

Correct sequencing for neoplasm codes?

Answer 9

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

Question 10

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

Answer 10

Z85.9 - Personal history of malignant neoplasm, unspecified

Question 11

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

Answer 11

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

Question 12

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

Answer 12

NEC = Not Elsewhere classifiable

Question 13

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

Answer 13

NOS = Not Otherwise Specified

Question 14

used to enclose synonyms, explanatory phrases, or alternate wording

Answer 14

Brackets [ ]

Question 15

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

Answer 15

Parentheses ( )

Question 16

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

Answer 16

EXCLUDES1 note

Question 17

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

Answer 17

Excludes1 note

Question 18

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

Answer 18

EXCLUDES2 note

Question 19

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

Answer 19

Excludes2 note

Question 20

notation used in categories not intended to be the principal diagnosis

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

Answer 20

Code First note

Question 21

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

Answer 21

Use Additional Code note

Question 22

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

Answer 22

Use Additional Code note

Question 23

Step one to look up diagnosis code

Answer 23

Look for the diagnosis in the assessment and plan

Question 24

Step two to look up diagnosis code

Answer 24

look up the main term in the alphabetic index

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

Question 25

Step three to look up diagnosis code

Answer 25

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

Question 26

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

Answer 26

CMS and National Center for Health Statistics

Question 27

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

Answer 27

Subsection B - official guidelines

Question 27

includes the conventions and punctuation

Answer 27

Subsection A - Official guidelines

Question 28

Chapter-specific rules concerning each chapter

Answer 28

Subsection C - official guidelines

Question 29

How to report combination codes?

Answer 29

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

Question 30

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

Answer 30

Signs and symptoms codes (R00-R99)

Question 31

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

Answer 31

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

Question 32

Conditions that are not integral part of a disease process?

Answer 32

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

Question 33

Alphabetic Index when multiple coding for a single condition

Answer 33

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

Question 34

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

Answer 34

Combination code

Question 35

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

Answer 35

combination code

Question 36

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

Answer 36

combination code

Question 37

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

Answer 37

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

Question 38

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

Answer 38

Sequela effects

Question 39

How to code sequela effects?

Answer 39

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

Question 40

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

Answer 40

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

Question 41

____ Should only be reported as secondary diagnoses?

Answer 41

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

Question 42

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

Answer 42

code the documented manifestations of the syndrome

Question 43

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

Answer 43

Borderline diagnosis

Question 44

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

Answer 44

Section I.C. Chapter-specific coding guidelines

Question 45

Codes always listed after the primary diagnosis

Answer 45

external cause codes

Question 46

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

Answer 46

external cause codes

Question 47

What external code takes priority over all others when sequencing

Answer 47

External codes for child and adult abuse

Question 48

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

Answer 48

terrorism, cataclysmic events, and transport accidents

Question 49

What should the first-listed external cause code correspond with

Answer 49

the cause of the most serious diagnosis

Question 50

acronym for the order external causes should be coded

Answer 50

catct ash

Question 51

codes that identify the reason why a patient is seeking services

Answer 51

Z codes

Question 52

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

Answer 52

U codes

Question 53

Outpatient encounters for receiving diagnostic services only

Answer 53

code the reason for encounter first, then the diagnostic findings

Question 54

Outpatient encounters for receiving therapeutic services only

Answer 54

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

Question 55

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

Answer 55

Encounter for chemotherapy then malignant neoplasm of rectosigmoid junction

Question 56

coding for ambulatory surgery

Answer 56

code the diagnosis for which the surgery was performed

Question 57

when a pt is seen for medical exam with abnormal findings

Answer 57

Z code with code for abnormal findings