ICD-10 Section I. Conventions, General Guidelines, and Chapter Specific Guidelines

Question 1

Unconfirmed diagnosis

Answer 1

Dx has not been established

Code only signs + symptoms

Question 2

Additional diagnosis

Answer 2

Are coded in cases of complications, canceled procedures, or other conditions.

Question 3

If a patient has a “History of” a condition/dx, how should you proceed?

Answer 3

Code history w/ reason for visit

Remember to code if patient currently has disease

Question 4

Uncertain diagnosis

Answer 4

Cannot be coded in outpatient setting

Documented as probable, suspected, questionable, working dx, or rule out

Code signs + symptoms

Question 5

The term First Listed Diagnosis is used in what setting?

Answer 5

Outpatient

Question 6

The term Primary Diagnosis is used in what setting?

Answer 6

Acute care; inpatient

Question 7

Chief complaint

Answer 7

CC: reason for encounter

Question 8

Diagnostic services

Answer 8

is ordered by a physician to diagnose or monitor a current disease

*Reason for test is coded and sequenced first

Question 9

What is the goal of therapeutic services

Answer 9

Goal is to change patient health status over a period of time

Code reason for service first

Question 10

Are annual examinations considered a type of diagnostic encounter?

Answer 10

Yes

Question 11

Is allergy testing considered a therapeutic service?

Answer 11

Yes

Question 12

Do official guidelines or chapter guidelines take precedence when applicable?

Answer 12

Chapter guidelines take precedence

All guidelines should be reviewed

Question 13

Should an acute or chronic diagnosis be coded first one both are present?

Answer 13

Acute

Question 14

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.

Answer 14

NEC “ not elsewhere classifiable” (specified condition without a specific code)

Question 15

What is the abbreviation NEC used to identify in the Tabular List?

Answer 15

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.

Question 16

NEC in the alphabetic index redirects coder to ____.

Answer 16

Redirects coder to the tabular list.

Question 17

NEC in the tabular list ___.

Answer 17

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

Question 18

NOS means ___.

Answer 18

“Not otherwise specified” or unspecified.

*Refers to the code for a condition that normally requires further specification.

Question 19

Brackets are used in the tabular list to ___.

Answer 19

Add context (through synonyms, alternative wording, or explanatory phrases)

Question 20

Brackets used in the Alphabetic Index are used to identify ___.

Answer 20

manifestation codes

Question 21

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.

Answer 21

True

Question 22

What are terms within the parentheses used in the tabular list or alphabetic index referred to as?

Answer 22

Nonessential modifiers

Question 23

True or false. Nonessential modifiers always apply to sub entries following the main term.

Answer 23

False. When a nonessential modifier and a sub entry are mutually exclusive, the sub entry takes precedence.

Question 24

If there is information in the medical record that provides detail for which specific code does not exist what kind of code is used?

Answer 24

“Other” codes, or “other specified” codes

Question 25

When the information in the medical record is insufficient to assign a more specific code, what kind of code is used?

Answer 25

“Unspecified” codes

Use “other” code if “unspecified” does not exist.

Question 26

When can you use in Excludes1 note at the same time as the code above the Excludes1 note?

Answer 26

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)

Question 27

An Excludes2 note indicates that ___.

Answer 27

The condition excluded is not part of the condition represented by the code, but a patient may have both conditions at the same time.

Question 28

Etiology

Answer 28

The cause, set of causes, or manner of causation of a disease or condition

Question 29

“Code first“, “use additional code“ and “in diseases classified elsewhere“ notes are part of which convention?

Answer 29

Etiology/Manifestation Convention

Question 30

True or false? When using a sequela code, it is coded AFTER the code for condition or nature of the sequela.

Answer 30

True

Question 31

When are sequela not coded before the nature or condition of the sequela?

Answer 31

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.

Question 32

How should a bilateral condition be coded if there is no bilateral code?

Answer 32

A code should be assigned for both sides

Question 33

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?

Answer 33

The bilateral code should be assigned

Question 34

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?

Answer 34

Assigned the appropriate unilateral code for the side, where the condition still exists

Question 35

How would you code a syndrome without Alphabetic Index guidance?

Answer 35

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)

Question 36

True or false. A “borderline“ diagnosis is coded as confirmed unless the classification provides a specific entry.

Answer 36

True

Question 37

In what section of the ICD would you find instruction for Documentation of Complications of Care?

Answer 37

General coding guidelines, Appendix I

Question 38

What are Z codes used for?

Answer 38

(Other reasons for health care encounters) may be assigned as appropriate to further explain the reasons for presenting for healthcare services to

Question 39

If there are two or more interrelated conditions, each, potentially meeting the definition for principal diagnosis, which is coded first?

Answer 39

Either condition can be sequenced first.

(unless the circumstances of the admission, the therapy provided, the tabular list, or the alphabetic index indicate otherwise)

Question 40

Why are Uncertain Diagnoses coded as if the condition exists or is established?

Answer 40

In settings where an uncertain diagnosis is applicable, the treatment and future care corresponds most closely with the established diagnosis

Question 41

Where in the ICD are instructions, found for previous conditions, such as historical conditions, family, history, resolved conditions, or diagnoses?

Answer 41

Official Guidelines

(Section III. Reporting Additional Diagnosis)

Question 42

Abnormal findings (lab, x-ray, other diagnostic results) are only coded when ___.

Answer 42

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)

Question 43

The term “first-listed dx” is used in what setting?

Answer 43

Outpatient

Question 44

Which code is assigned as the first listed-diagnosis when an outpatient is admitted for observation for a medical condition?

Answer 44

The condition is assigned as first-listed.

Question 45

Which code is used as the first listed-diagnosis when a patient presents for outpatient surgery?

Answer 45

Reason for surgery (encounter)

Question 46

What needs to be included in an outpatient’s documentation for accurate reporting of the ICD diagnosis codes?

Answer 46

Description of the patient’s condition, using terminology including specific diagnoses, symptoms, problems, or reasons for the encounter.

Question 47

What chapter of the ICD contains many codes that describe symptoms and signs as opposed to diagnoses?

Answer 47

Chapter 18 (Symptoms, Signs, and Abnormal Clinical and Laboratory Findings Not Elsewhere Classified)

*not all codes for symptoms are included here

Question 48

Which codes are used to deal with occasions when circumstances other than a disease or injury are recorded as diagnoses or problems?

Answer 48

Z codes

Question 49

True or false? Chronic diseases should only be coded as first listed diagnosis for a patients’ first encounter.

Answer 49

False

Question 50

What is a simple note to describe Excludes1?

Answer 50

Only one or the other code may be used, not both. (Unless completely unrelated)

Question 51

What is a simple note to describe Excludes2?

Answer 51

The encounter MAY require both codes, if documentation supports.

Code does not include another code that may be required.

Question 52

True or false? An Excludes1 note only applies to the line right above it.

Answer 52

True