Final Exam Review

Question 1

Indicates there is no separate code for the condition, even though the diagnostic statement may be very specific…

Answer 1

NEC (note elsewhere classified)

Question 2

Indicates the code to use when a condition is not completely described…

Answer 2

NOS (not otherwise specified)

Question 3

Not coded here…

Answer 3

Excludes 1

Question 4

Not included here, the condition is not part of the condition that the code represents, however the patient may have both conditions together…

Answer 4

Excludes 2

Question 5

Residual problem after the acute phase of an illness or injury has terminated…

Answer 5

Late Effect

Question 6

How many codes do late effects require?

Answer 6

2, unless there is no residual in the diagnosis

Question 7

Other words to notice when looking for late effects…

Answer 7

Late, old, sequela, due to previous injury

Question 8

Care designed not to treat an illness but to provide physical and emotional comfort…

Answer 8

Palliative care

Question 9

What is the principle diagnosis when a patient is admitted for the purpose of surveillance after initial treatment for a disease or injury has been completed?

Answer 9

Follow-up

Question 10

When can you code “follow-up” as principle?

Answer 10

If there is a reoccurrence/ related condition

Question 11

What is it called when a patient without a diagnosis is suspected to be at risk for an abnormal condition, but after the evaluation, the suspected condition is not identified?

Answer 11

Observation

Question 12

To test or examine for the presence of something…

Answer 12

Screening

Question 13

If screening identifies a disease, how is it coded?

Answer 13

It is coded as principle with an additional code for the disease that was found

Question 14

Normal delivery is coded how?

Answer 14

080- single live born, no complications
Z37
Z30.2
Z codes can only be coded with this and never as the principle

Question 15

How is sterilization coded?

Answer 15

Z30.2- can be coded for male or female, it is secondary when listed after delivery but principle when it is the primary reason for a visit

Question 16

1st trimester length

Answer 16

< 14 weeks

Question 17

2nd trimester length

Answer 17

14- <28 weeks

Question 18

3rd trimester length

Answer 18

28 weeks to delivery

Question 19

Outcome of delivery code

Answer 19

Z37 is assigned for the admission of which the delivery occurred, it is only on the moms record and never listed first

Question 20

Newborn Z code

Answer 20

assigned for the admission when the baby is born, only on the baby’s record and never used again

Question 21

I21 acute STEMI and NSTEMI time period

Answer 21

(initial) 4 weeks or less from onset of original MI

Question 22

Code for subsequent encounter, suffrage of a new AMI within 4 weeks of an AMI

Answer 22

I22

Question 23

If a patient’s test results come back positive for HIV and the patient is symptomatic, what code should be used?

Answer 23

B20

Question 24

What code is used for a patient that is HIV positive and does not have any documented symptoms of an HIV related illness?

Answer 24

Z21

Question 25

What is the sequencing of HIV when admitted for treatment of AIDS complications?

Answer 25

B20 is first, condition is second

Question 26

When is B20 sequenced when patient is admitted for an unrelated condition?

Answer 26

B20 is second, the condition is first

Question 27

How is poisoning sequenced?

Answer 27

Poisoning is first, manifestations are second

Question 28

How are adverse effects sequenced?

Answer 28

Nature of the effect is first, then the code from the D&C table

Question 29

Underdosing sequencing rule...

Answer 29

Never the principle

Question 30

What is it called when something is wrong with a device?

Answer 30

Mechanical issue

Question 31

What is it called when there is an infection caused by a device, but nothing actually wrong with the device itself?

Answer 31

Nonmechanical issue

Question 32

What does the 7th character "A" represent?

Answer 32

Initial encounter

Question 33

What does the 7th character "D" represent?

Answer 33

Subsequent encounter

Question 34

What does the 7th character "S" represent?

Answer 34

Sequela

Question 35

Code for diabetes due to an underlying condition...

Answer 35

E08

Question 36

Code for drug or chemical induced diabetes...

Answer 36

E09

Question 37

Code for type 1 diabetes...

Answer 37

E10

Question 38

Code for type 2 diabetes...

Answer 38

E11

Question 39

What's included in a combination code for diabetes?

Answer 39

1. Type of diabetes 2. Body system affected 3. Complications affecting that body system

Question 40

What is a type of diabetes caused by another disease or certain drugs or chemicals?

Answer 40

Secondary diabetes

Question 41

These are not necessarily coded as a complication of surgery, unless the MD says they are...

Answer 41

Chronic/ acute anemia

Question 42

How do you code anemia/ chronic kidney disease?

Answer 42

Code the chronic kidney disease and it's stage first, then anemia

Question 43

How to code anemia due to chemotherapy?

Answer 43

D68.4 for the chemotherapy plus the adverse effect T code

Question 44

How to code hemaplegia?

Answer 44

Unless specified, left side is non-dominant, right side is dominant

Question 45

T/F: Do you code for hemaplegia that has gone away before discharge?

Answer 45

True

Question 46

When a patient is admitted for _____ and the stage increases during the stay, you code the highest stage that was presented...

Answer 46

Glaucoma

Question 47

What is the 7th character for glaucoma indicating intermediate stage?

Answer 47

"4"

Question 48

What does "ruled out" indicate?

Answer 48

Indicates that a diagnosis once considered likely is no longer possible