ICD-10 Section I. Conventions, General Guidelines, and Chapter Specific Guidelines Flashcards
Unconfirmed diagnosis
Dx has not been established
Code only signs + symptoms
Additional diagnosis
Are coded in cases of complications, canceled procedures, or other conditions.
If a patient has a “History of” a condition/dx, how should you proceed?
Code history w/ reason for visit
Remember to code if patient currently has disease
Uncertain diagnosis
Cannot be coded in outpatient setting
Documented as probable, suspected, questionable, working dx, or rule out
Code signs + symptoms
The term First Listed Diagnosis is used in what setting?
Outpatient
The term Primary Diagnosis is used in what setting?
Acute care; inpatient
Chief complaint
CC: reason for encounter
Diagnostic services
is ordered by a physician to diagnose or monitor a current disease
*Reason for test is coded and sequenced first
What is the goal of therapeutic services
Goal is to change patient health status over a period of time
Code reason for service first
Are annual examinations considered a type of diagnostic encounter?
Yes
Is allergy testing considered a therapeutic service?
Yes
Do official guidelines or chapter guidelines take precedence when applicable?
Chapter guidelines take precedence
All guidelines should be reviewed
Should an acute or chronic diagnosis be coded first one both are present?
Acute
When a specific code is not available for a condition, the Alphabetic Index directs the coder to the “other specified“ code in the Tabular List with this abbreviation.
NEC “ not elsewhere classifiable” (specified condition without a specific code)
What is the abbreviation NEC used to identify in the Tabular List?
Represents “other specified” (as “not elsewhere classifiable”) to identify the code as the “other specified” code when a specific code is not available for a condition.
NEC in the alphabetic index redirects coder to ____.
Redirects coder to the tabular list.
NEC in the tabular list ___.
Identifies the code for an “other specified” condition/dx
*The NEC identified code describes a code for a condition/dx with a specification that isn’t listed in the tabular.
*specified but not listed
NOS means ___.
“Not otherwise specified” or unspecified.
*Refers to the code for a condition that normally requires further specification.
Brackets are used in the tabular list to ___.
Add context (through synonyms, alternative wording, or explanatory phrases)
Brackets used in the Alphabetic Index are used to identify ___.
manifestation codes
True or false. Parentheses are used in both the alphabetic index and a tabular list to enclose supplementary words that may be present or absent in the statement of a disease or procedure, without affecting the code number to which it is assigned.
True
What are terms within the parentheses used in the tabular list or alphabetic index referred to as?
Nonessential modifiers
True or false. Nonessential modifiers always apply to sub entries following the main term.
False. When a nonessential modifier and a sub entry are mutually exclusive, the sub entry takes precedence.
If there is information in the medical record that provides detail for which specific code does not exist what kind of code is used?
“Other” codes, or “other specified” codes
When the information in the medical record is insufficient to assign a more specific code, what kind of code is used?
“Unspecified” codes
Use “other” code if “unspecified” does not exist.
When can you use in Excludes1 note at the same time as the code above the Excludes1 note?
When the condition coded and the condition in the Excludes1 note are unrelated to each other.
(This should be the only way that they exist at the same. Check w/ physician)
An Excludes2 note indicates that ___.
The condition excluded is not part of the condition represented by the code, but a patient may have both conditions at the same time.
Etiology
The cause, set of causes, or manner of causation of a disease or condition
“Code first“, “use additional code“ and “in diseases classified elsewhere“ notes are part of which convention?
Etiology/Manifestation Convention
True or false? When using a sequela code, it is coded AFTER the code for condition or nature of the sequela.
True
When are sequela not coded before the nature or condition of the sequela?
When the sequela code is followed by the manifestation code in the tabular list, and title, or the code has been expanded to more characters to include manifestations.
How should a bilateral condition be coded if there is no bilateral code?
A code should be assigned for both sides
If a bilateral condition is being treated on one side, and the condition that still exists on the opposite side, how should the condition be coded?
The bilateral code should be assigned
If a patient is being treated for bilateral condition on one side, and the other side has previously been treated and no longer exists, how should the condition be coded?
Assigned the appropriate unilateral code for the side, where the condition still exists
How would you code a syndrome without Alphabetic Index guidance?
Assign codes for the documented manifestations of the syndrome.
(Additional codes for manifestations that are not an integral part of the disease process may also be assigned when the condition does not have a unique code)
True or false. A “borderline“ diagnosis is coded as confirmed unless the classification provides a specific entry.
True
In what section of the ICD would you find instruction for Documentation of Complications of Care?
General coding guidelines, Appendix I
What are Z codes used for?
(Other reasons for health care encounters) may be assigned as appropriate to further explain the reasons for presenting for healthcare services to
If there are two or more interrelated conditions, each, potentially meeting the definition for principal diagnosis, which is coded first?
Either condition can be sequenced first.
(unless the circumstances of the admission, the therapy provided, the tabular list, or the alphabetic index indicate otherwise)
Why are Uncertain Diagnoses coded as if the condition exists or is established?
In settings where an uncertain diagnosis is applicable, the treatment and future care corresponds most closely with the established diagnosis
Where in the ICD are instructions, found for previous conditions, such as historical conditions, family, history, resolved conditions, or diagnoses?
Official Guidelines
(Section III. Reporting Additional Diagnosis)
Abnormal findings (lab, x-ray, other diagnostic results) are only coded when ___.
The provider indicates their clinical significance
(is findings are outside the normal range in the provider orders other tests to evaluate the condition. It is appropriate to ask what are the abnormal findings should be added)
NOTE: this differs from the coding practices in the outpatient setting for coding and counters for diagnostic tests that have been interpreted by a provider)
The term “first-listed dx” is used in what setting?
Outpatient
Which code is assigned as the first listed-diagnosis when an outpatient is admitted for observation for a medical condition?
The condition is assigned as first-listed.
Which code is used as the first listed-diagnosis when a patient presents for outpatient surgery?
Reason for surgery (encounter)
What needs to be included in an outpatient’s documentation for accurate reporting of the ICD diagnosis codes?
Description of the patient’s condition, using terminology including specific diagnoses, symptoms, problems, or reasons for the encounter.
What chapter of the ICD contains many codes that describe symptoms and signs as opposed to diagnoses?
Chapter 18 (Symptoms, Signs, and Abnormal Clinical and Laboratory Findings Not Elsewhere Classified)
*not all codes for symptoms are included here
Which codes are used to deal with occasions when circumstances other than a disease or injury are recorded as diagnoses or problems?
Z codes
True or false? Chronic diseases should only be coded as first listed diagnosis for a patients’ first encounter.
False
What is a simple note to describe Excludes1?
Only one or the other code may be used, not both. (Unless completely unrelated)
What is a simple note to describe Excludes2?
The encounter MAY require both codes, if documentation supports.
Code does not include another code that may be required.
True or false? An Excludes1 note only applies to the line right above it.
True
