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ICD 10 CM Flashcards

1
Q

Severe Sepsis

A
  1. Systemic infection
  2. R65.2 subcategory
  3. Additional for organ failure
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2
Q

Septic Shock

A
  1. system infection
  2. R65.21, Severe sepsis with septic shock
  3. additional for organ failure
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3
Q

Admitted due to pneumonia and sepsis

A
  1. A41.9 (sepsis, unspecified org)

2. pneumonia

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4
Q

Admitted with pneumonia, develop sepsis after admission

A
  1. Pneumonia

2. A41.9 (sepsis)

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5
Q

Sepsis due to postprocedural infection

A
  1. Infection following procedure (T81.40 - T81.43) or OB code (if OB)
  2. Specific infection code (A40 or A41 or B37.7)
  3. Sepsis following a procedure (T81.44-) or OB (086.04)
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6
Q

Infections following transfusion, infusion, injection, immunization

A
  1. infection following the tx code

2. specific agent

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7
Q

Bacteremia

A

R78.81

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8
Q

Admitted with SIRS due to pneumonia (not septic)

A

Pneumonia (J18.9)

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9
Q

Admitted with sepsis due to aspiration pnemonia

A
  1. Sepsis (A41.9)
  2. Pneumonia
  3. Pneumonitis due to inhalation of food and vomit
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10
Q

Toxic shock

A

Caused by bacterial infection

  1. Toxic shock syndrome (A48.3 )
  2. code for organism
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11
Q

Nosocomial infections

A

Add Y95 , Nosocomial conditions

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12
Q

multi drug resistant/ specified drug resistant condition

A

infection + Z16- (resistance, organisms, to drug) as long as not in title of infection

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13
Q

colonization

A

not indicative of disease
must be documented by provider
positive = MRSA screen positive or MRSA nasal swab positive

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14
Q

MRSA infection and MRSA colonization

A
  1. MRSA infection

2. Carrier or suspected of MRZ22.32-

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15
Q

Severe sepsis with local infection

A
  1. Systemic infection
  2. Local infection
  3. R65.2 severe sepsis
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16
Q

SIRS of non infectious process

A

SIRS non infectious process coded to R65.1-

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17
Q

Severe sepsis documentation

A

Severe sepsis

Or sepsis with associated organ dysfunction (must associate or query)

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18
Q

Metastatic to

A

Site mentioned is secondary

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19
Q

Metastatic from

A

Indicates the site mentioned is primary

Example: met ca from breast
Breast is primary

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20
Q

One site stated metastatic

Metastatic renal ca of the lung

A

Kidney is primary

Lung secondary

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21
Q

Primary is not know in malignancy

A

Malignant primary unspecified c80.1

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22
Q

Multiple metastatic sites
Primary unspecified

Metastatic carcinoma of brain and lung

A

Code secondary mets
C80.1 primary unspecified

C79.31
C78.00
C80.1

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23
Q

Metastatic carcinoma of bronchus

Metastasic adenocarcinoma of transverse colon

Osteocarcinoma with Mets

Metastic infiltrating duct cell ca

A

Bronchus primary
Metastic ca - c79.9 (secondary)

Colon primary
Metastic ca - c79.9

Breast primary
Mets c79.9 (secondary )

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24
Q

Anemia
Neutropenia
Thrombocytopenia

A

Code to panocytopenia

D61.818

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25
Q

Includes note

A

Appears immediately under a three character code title to further define or give examples of that category

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26
Q

Inclusion terms

A

List of terms are conditions for which that code is to be used . Synonyms

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27
Q

Excludes 1

A

Pure excludes note
NOT CODEd HERE

Exception when they are unrelated
If not clear query

28
Q

Excludes 2

A

Not included here

Not part of that condition

29
Q

See

A

Another term should be referenced

Necessary to go somewhere else

30
Q

See also

A

Another may be referenced

Do not have to

31
Q

Code also

A

Two codes may be needed to describe

DOES NOT provide sequencing direction

32
Q

Default codes

A

Code listed next to main term

The unspecified code

33
Q

In diseases classified elsewhere

A

NEVER as PDX
Must be used in conjunction with another code
Listed following the underlying condition

34
Q

Use additional code

A

These are manifestation codes that don’t have in diseases classified elsewhere in title

Additional code note at etiology
Code first at manifestation

35
Q

Code first

A

This is the manifestation

36
Q

Code can be taken from clinician

A 
BMI
Depth of non pressure chronic ulcer
Pressure ulcer stage
Coma scale
Stoke nih scale
Social determinants of health
37
Q

Admit to obv and same condition gets worse - what is pdx

A

Medical condition that leads to hospital admission

38
Q

Pdx for admit following ops to obv to Ip

A

Apply condition established after study to be chiefly responsible

39
Q

Ops to ip due to complication

A

Complication

40
Q

Ops to Ip - no reason and no complication

A

Code reason for op surgery

41
Q

Ops to Ip - unrelated to surgery

A

Unrelated to surgery assign unrelated

42
Q

Op to obv - due to complications

A

Reason for surgery

43
Q

Secondary dx list

A 
Evaluate
Therapeutic tx
Further eval by dx studies prof or consult 
Extended los
Increases nursing care and or monitoring

Perinatal - has implications for future health care needs

44
Q

Smoker

A

Dependence

45
Q

Pain control or pain management reason for admission

A

G89 category pdx

Underlying cause added as additional

46
Q

Admitted for insertion of pain stimulator

A

G89 pain code- pdx

47
Q

Admission for procedure to treat underlying condition and neuro stim inserted for pain during same admission

A

Underlying condition - pdx

Pain- Sdx

48
Q

G89 and site specific pain

A

G89 can be used with site specific pain if code that describes site of pain does not fully describe pain
Example - acute chrinic

Sequencing dependent on circumstances

49
Q

Sequencing pain

A

Encounter for pain control or pain management
G89- pdx
Site specific pain- sdx

If for any other reason and relative dx has not been established
Site specific pain - pdx
G89- sdx

50
Q

Post op pain

A

Routine post op pain not coded

51
Q

Chronic pain

A

G89.2

No time frame

52
Q

Neoplasm related pain

A

G89.3

Documented as related due to cancer or the tumor or malignancy

53
Q

Neoplasm pain sequencing

Reason for admission is pain control related to neoplasm

A

Pain g893 as pdx

Neoplasm- sdx

54
Q

Neoplasm pain sequence
Reason for admission
Management of neoplasm
Pain associated with neoplasm documented

A

Neoplasm - pdx

Pain G893 - sdx

55
Q

Spondylolisthesis

A

Bony vertebrae slips

Not intervertebral disc disorder

56
Q

How to look up main term alpha

A

Review sub terms and non essential modifiers related to main term

cross reference instructions

notes in the alpha index

A dash at end of index entry indicates additional characters required

57
Q

Verify in the tabular

A

Read code title
Read and follow instruction notes
Determine whether any additional character must be added
Determine laterally and any applicable extensions

58
Q

Borderline dx

A

Not same as uncertain

Code as confirmed unless there is an entry for that condition as borderline

59
Q

Coding clinic approved by

A

Ahima
Cms
CDC
Nchs

60
Q

Case mix complexity

A 
Severity of illness
Prognosis
Treatment difficulty
Need for intervention
Resource intensity
61
Q

Msdrg use

A 
Pdx
Additional dx
Principal procedure 
Additional procedure
Sex
Discharge status
62
Q

Drg hierarchy

A
  1. Is it pre mdc or body system drg
  2. Pre mdc are extremely resource intense
    Organ implant
    Bone marrow transplant
    Trach

Pdx not taken into consideration in pre mdc

63
Q

How Many mdc s

64
Q

What classifies a cc

A

It’s presence with the pdx would increase los by at least one day in at least 75% of patients

65
Q

Cc exclusion list

A

Mdc and ccs not considered a cc or mcc for a given pdx

CCS Exam (6 decks)

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