– General Theory Questions Flashcards
What does the cross reference ‘See also’ used in the ICD-10 5th Edition Alphabetical Index instruct the coder to do?
This is a reminder to look under another lead term if the term the coder is looking for cannot be found modified in any way under the first lead term.
Describe the standard that must be applied when assigning OPCS-4 codes
for ‘maintenance’ and ‘attention to’ procedures.
A supplementary code from Chapter Y must be added in addition to the
maintenance / attention to code, when doing so provides additional
information.
When is it applicable to assign ICD-10 5th Edition code Z75.1 Persons
awaiting admission to adequate facility elsewhere in a secondary
position?
When the medical record clearly state that they are ‘bed-blocking’ or
medically fit for discharge (MFD) but awaiting suitable accommodation
elsewhere, such as a nursing or residential home.
A code from category Y80 General anaesthetic must be assigned following
which intervention?
Radiotherapy
What must be considered when applying the standard for the coding of ‘high
cholesterol’ or ‘Cholesterol’?
They must only be coded to E78.0 Pure hypercholesterolaemia if confirmed
to be a definitive diagnosis of hypercholesterolaemia by the responsible
consultant and it is not merely an abnormal test result.
Abnormal cholesterol detected from a blood test without a definitive diagnosis
of hypercholesterolaemia must be coded to R79.8 Other specified abnormal
findings of blood chemistry instead.
If both congestive cardiac failure (CCF) (I50.0) and left ventricular failure
(LVF) (I50.1) are documented in the medical record, what must be coded and
why?
Only assign code I50.0 Congestive heart failure as this code includes both
right and left ventricular failure
Describe the OPCS-4 standard when a patient is admitted for a
gastrointestinal tract endoscopy and the patient is unable to tolerate the
scope and it is documented as a ‘failed intubation’.
The procedure must not be coded unless the point of abandonment is beyond
the mouth.
If a patient is admitted for the removal of an indwelling urinary catheter or trial
without catheter (TWOC), and on removal the patient is unable to void
resulting in the catheter being reinserted, how should this be coded in OPCS-4?
This must be coded to M47.3 Removal of urethral catheter from bladder
and M47.9 Unspecified urethral catheterisation of bladder in this
sequence.
When conditions such as deep vein thrombosis (DVT) are linked to travel,
what fourth character must be assigned to the external cause code X51
Travel and motion, and why?
As it is impossible to define at which point on a journey a DVT occurred, the
place of occurrence fourth character .9 must be used.
Describe when and how a code from Chapter S must be assigned to enhance
a code from another body system chapter.
• When it provides further information about the procedure that is not
specified in the primary body system code.
• In a secondary position, directly after the body system code it is
enhancing.
Describe the standard when a patient is diagnosed with sepsis in the medical
record but the description of the ICD-10 5th Edition code assigned does not
specifically classify sepsis.
An additional code that specifically classifies sepsis must be assigned in any
secondary position, in order to describe the condition fully.
Name the two anatomical structures that determine the coding for the release
of tennis elbow in OPCS-4.
Tendon or joint.
Describe the standard when the medical record documents a secondary
neoplasm or metastases from a haematological malignancy.
Codes in the range C77-C79 must never be assigned to indicate a secondary
neoplasm due to/from a haematological malignancy.
Diagnostic statements indicating that metastases are the result of a
haematological malignancy must be referred back to the responsible
consultant to clarify that this is spread of the haematological malignancy. If
this is confirmed only the code from categories C81-C96 is assigned.
What are the two occasions when the OPCS-4 code Q55.6 Genital swab
can be used?
It must only be used for outpatient coding, or if the patient is admitted solely
for the purpose of this procedure.
When discectomy is performed in order to decompress, only the OPCS-4
code that classifies the spinal decompression operation is necessary, as long
as what two criteria are met?
• The decompression and discectomy must have been performed on the
same disc or group of vertebrae or motion segment
and
• The responsible consultant must have stated that discectomy was
performed in order to result in decompression.
What is the duration stated in categories I21-I25 Ischaemic heart diseases
relating to the interval elapsing between the onset of the ischaemic episode
and admission to hospital?
Four weeks (28 days)
What should be coded when a patient with chronic kidney disease stages 1-3
is stated to have renal failure, and why?
Patients with CKD stages 1-3 (codes N18.1 to N18.3) are not always
considered to have renal failure. When it is documented in the medical record
that the patient also has renal failure this must be coded in addition.
When 3D mapping of the heart is performed with an ablation of the heart,
does the 3D mapping require coding? Explain the reason for your answer.
3D mapping of the heart must not be assigned in addition to an ablation code,
as it is an inherent part of ablation of the conducting system of the heart and
is rarely performed on its own
Describe the sequencing rule when assigning codes from categories P00-P04
Fetus and newborn affected by maternal factors and by complications
of pregnancy, labour and delivery.
They must be sequenced in a secondary position to the code that classifies
the morbid condition, except when the baby is stillborn and the cause is
known.
Name the type of image control always used for obstetric scans (R36-R43) in
OPCS-4.
Ultrasound
Describe the use of the ‘Brace’ punctuation in the Tabular List.
Braces are used in inclusion and exclusion notes to indicate that both the
listed condition and one of its modifiers must be present in order to complete
the instruction. Braces enclose a series of terms, modified by the statement
appearing at the right of the brace.
Describe the use of the relational term ‘With’.
This is used either when two or more conditions combine to form another
condition or to provide additional four character specificity. These terms
indicate that both elements in the code description must be present in the
diagnostic statement in order to assign the code.
These terms do not necessarily indicate a cause-effect relationship.
For the purposes of clinical coding, what is a co-morbidity defined as?
• Any condition which co-exists in conjunction with another disease that is
currently being treated at the time of admission or develops subsequently,
and
• affects the management of the patient’s current consultant episode.
Describe the use of the fifth character in Chapter XIX Injury, poisoning and
certain other consequence of external causes.
Supplementary fifth characters are used in this chapter to identify open and
closed fractures, intracranial injuries with or without open intracranial wound
and internal injuries with or without open wound into cavity. They must be
assigned when instructed by the note at code, category or block level.
An injury not indicated as ‘open’ or ‘closed’ must be recorded using fifth
character ‘0’.
Describe the standard for the coding of burns and corrosions.
Burns and corrosions of the same site that exhibit multiple degrees must be
coded to the most severe degree of that site using codes in categories T20-
T30 Burns and corrosions.
A code from categories T31.- Burns classified according to extent of body
surface involved or T32.- Corrosions classified according to extent of
body surface involved must be assigned in addition to a code from
categories T20-T25 Burns and corrosions of external body surface,
specified by site or T29.- Burns and corrosions of multiple body regions
when the total percentage of body surface involved in a burn or corrosion is
documented.
When the site of the burn is unspecified and only the total percentage of body
surface is documented only a code from categories T31.- or T32.- is required.
Describe the standard for the use of Y10-Y34 Event of undetermined
intent.
Event of undetermined intent codes (Y10-Y34) must only be used when
undetermined intent is stated by a medical or legal authority, such as a
coroner at an inquest. It must not be used when no information has been
given about the circumstances of an event. If the intent is not known, a code
that classifies an accidental external cause must be assigned.
The Note instructional notes provide instructions for coding; describe how
they may be used.
• To advise coders to include or omit additional or subsidiary codes
• To direct coders elsewhere in the classification for more appropriate
categories
• To clarify the intended use of codes in a particular chapter, category or
subcategory
• To provide specific instruction on the correct sequencing of codes when
used together (paired codes
Describe the use of surgical eponyms for the assignment of procedural
codes.
Section II Alphabetical Index of Surgical Eponyms within Volume II -
Alphabetical Index must only be used as a guide when coding.
Where an eponym is used in the medical record the coder must analyse the
procedural information and ensure that code assignment fully reflects the
procedure performed.
Where the coder is unsure what procedure the eponym describes, they must
seek advice from the responsible consultant to ensure that the correct codes
are assigned
Within the OPCS-4 classification what does HFQ stand for and describe its
use?
HFQ (However Further Qualified)
Signifies that a statement may be further qualified/described in a number of
ways, which will not affect the code assignment, It refers to the part of the
procedural statement that immediately precedes the abbreviation HFQ.
Describe the coding standard for the removal of bypass grafts in Chapter L
Arteries and Veins.
The removal of bypass grafts must be coded to the original operation bypass
category with the fourth-character to describe an ‘other specified’ procedure
(.8) plus a code from Chapter Y to specify the removal of repair material
(Y26.4 Removal of other repair material from organ NOC) unless there is
a specific fourth-character code that classifies removal of the bypass graft.