ICD-10 Ch. 4-5 Flashcards
ICD-10 Ch. 6
Something objectively observable, which may be an indication of a disease process.
sign
Manifestation of a disease process subjectively reported by a patient. May lead a physician to diagnose one or more disease processes.
symptom
Condition for which there is NOT a diagnosis code elsewhere classified.
ill-defined condition
Neurological scale used to document the level of consciousness assessments for eye, verbal and motor responses.
Glasgow coma scale
Database that collects information about incidents of trauma.
trauma registry
Term used to describe symptoms that are general. i.e. fever, headache, pain, malaise and fatigue.
constitutional symptom
When can symptoms be reported as a secondary code with a definitive diagnosis code.
When that symptom is NOT routinely associated with the diagnosis. i.e. Dysphagia caused by a CVA. Code CVA and then code dysphagia.
Where should a code for skull fracture or intracranial injury with a come be coded.
Code the skull fx. or intracranial injury first.
When should the symptom code for quadriplegia be assigned.
Only if specifically documented and not associated with neuro deficit or injury.
The alcohol level code should be added when reporting what?
Findings of alcohol in the blood.
When should the code R99 - Ill-Defined and Unknown Cause of Mortality be used??
Pt. expires prior to establishment of any diagnosis and without the presence of signs or signs. Patient pronounced DOA to facility.
Lasting for a short time and not permanent.
transient
What are general signs and sx. associated with?
The body as a whole rather than a specific organ s system.
What is CEA
carcinoembryonic antigen
What is CA-125?
cancer antigen 125
