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Outpatient coding and reporting guidelines > learning objectivies > Flashcards

learning objectivies Flashcards

1
Q

in the outpatient setting-

A

the term first-listed diagnosis is used in lieu of principle diagnoisis

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2
Q

T/F it may take two or more visits before the diagnosis is confirmed

A

T

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3
Q

outpatient surgery-guidelines

A

pt presents for outpatient surgery (same day surgery) code the reason for the surgery as the 1st listed diagnosis (reason for the encounter), even if the surgery is not perofrmed due to a contraindication.

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4
Q

unconfirmed dx: initial office visit for a 28-year old male with persistent abdominal pain, and bloody diarrhea. pt schedued for small bowel x-rays and colonoscopy

A

R10.9 abdominal pain, K92.1 blood in stool

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5
Q

unconfirmed dx: initial office ivsit for 55 yr old male with fatigue and jaundice. Lab test ordered and pt will return in 1 week

A

R53.83 fatigue, R17 jaundice

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6
Q

T/F when reporting the first listed diagnosis, the coding conventions and specific guidelines of the icd-10-cm take precedence over the outpatient guidelines

A

T

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7
Q

Identify 1st listed dx: pt complaining of painful urination and frequency. type 2 dm. lab work revealed a UTI and blood glucose was within normal limits

A

urinary tract infection

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8
Q

indentify 1st listed dx: pt requiring equal management of COPD and CHF

A

COPD and CHF

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9
Q

identify the 1st listed dx: male pt admitted as an outpt for transurethral prostatic resection for symptomatic benign prostatic hypertrophy

A

benign prostatic hypertrophy

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10
Q

identify the 1st listed dx: pt admitted as an outpt for cystoscopy for hematuria

A

hematuria

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11
Q

codes from A00.0 through T88.9, Z00-Z99 - guidelines for coding and reporting

A

codes from A00.0 through T88.9, Z00-Z99 must be used to identify diagnoses, symptoms, conditions, problems, complaints, or other reasons for the encounter

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12
Q

T/F-Z codes are used more frequently in the outpt setting

A

T

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13
Q

Accurate reporting of icd-10-cm diagnosis codes - guidelines

A

documentation should describe the pts condition, using terminology which includes specific dx as well as symptoms, problems, or reasons for the encounter

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14
Q

codes that describe symptoms and signs - guidelines

A

codes that describe symptoms and signs, as opposed to diagnosis, are acceptabe for reporting purposes when a diagnosis has not been established (confirmed) by the provider

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15
Q

encounters for circumstances other than a disease or injury - guidelines

A

icd-10 provides codes to deal with encounters for circumstances other than a disease or injury

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16
Q

Z00-Z99 are used for what

A

provided to deal with occasions when circumstances other than a disease or injury are recorded as diagnosis or problems

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17
Q

factors influencing health status and contact with health services are what codes

A

Z00-Z99

18
Q

T/F certain Z codes may only be used as first-listed or principal dx

A

T

19
Q

Status - guidelines

A

indicate that a pt is either a carrier of a disease or has sequelae or residual of a past disease or condition

20
Q

external codes are (external cause index)

A

environmental events-tornados, floods, circumstances and other conditions as the casue of injury and other adverse effects

21
Q

external codes are located where

A

after the table of drugs and chemicals in the I-10

22
Q

external codes are never what

A

first listed dx-these codes are reported to clarify injury or adverse effects

23
Q

observation stay - guidelines

A

pt is admitted for observation for a medical condition, assign a code for the medical condition as the 1st listed dx

24
Q

Z03 and Z04 report what

A

observation-these codes are reported only as the 1st listed dx for medical observation for suspected conditions and conditions ruled out.

25
Q

codes Z05.0-Z05.9 are used for what observation

A

observation and evaluation of newborns during the neonatal period-1st 28 days of life- for suspeted conditions that are not found

26
Q

T/F uncertain diagnoses can be used in an out pt setting

A

F - in an inpatient setting, uncertain diagnosis are reported, but in theoutpatient setting these uncertaindiagnoses are not reported .

27
Q

chronic diseases-guidelines

A

chronic diseases treated on an ongoing basis may be coded and reported as many times as the pt receives treatment and care for the conditions

28
Q

code all documented conditions that coexist-guidelines

A

code all documented conditions that coexist at the time of the encounter/visit. do not code conditions that were previously treated and no longer exist, history codes (Z80-Z87)

29
Q

patients receiving therapeutic services only-quidelines

A

during an encounter/visit, sequence first the diagnosis, condition, problem or other reason for encounter/visit shown in the medical record to be chiefly responsible for the out pt services provided during the encounter/visit

30
Q

patients receiving preoerative evaluation only-guidelines

A

sequence first a code from subcategory Z01.81, encounter for pre procedural examinations, to describe the pe op consultations, assignn a code for the condition to describe the reason for the surgery as an additional dx.

31
Q

what are the 8 steps to accurate coding

A
  1. identify the main term in the diagnostic statement
  2. locate the main termr in the alphabetic index
  3. review any subterms under the main term in the index
  4. follow any cross reference instructions such as see.
  5. verify the code selected from the index in the tabular list
  6. refer to any intructional notations in the tabular
  7. assign codes tothe highest level of specificity
  8. code the diagnosis until all elements are completely identified
32
Q

conditions that are not an integral part of a disease process-guidelines

A

additional signs and syptoms that may not be associated routinely with a disease process should be coded when present

33
Q

level of detail in coding-guidelines

A

dx codes are to be used and reported at their highest number of characters available

34
Q

integral conditions should be coded how

A

when signs or symptoms are due to a dx condition, the signs or symptoms are not reported separately. if the signs or symptoms are not due to a diagnosed condition, the signs and symptoms should be reported

35
Q

multiple coding for a single condition-guidelines

A

in addition tothe etiology/manifestation convention that requires 2 codes to fully describe a single ocndition that affects multiple body systems, “use additional code” notes are found in the tabular list at codes that are not part of an etiology/manifestation pair where a secondary code is useful to fully describe a condition

36
Q

acute and chronic conditions-guidelines

A

same condition is described as both acute (subacute) and chronic, and separate subentries exist in the index at the sam indentation level, code both and sequence the acute code first.

37
Q

combination code-guideline

A

combination code is a single code used to classify 2 dx or a diagnosis with an associated secondary process (manifestation), a dx with an associated complication

38
Q

combination code-guideline

A

are identified by referring to subterm entries in the index and by reading the inclusion and exlusion notes in the tabular list

39
Q

sequela (late effects)-guidelines

A

sequela is the residual effect (condition produced) after the acute phase of an illness or injury has terminated.

40
Q

reporting same dx code more than once-guidelines

A

dx code may be reported only once for an encounter, this applies to bilateral conditions when there are no distinct codes identifying laterality or two different condtions calssified to the same icd-10 dx

41
Q

Laterality-guidelines

A

specifying whether the condition occurs on the left, right, or is bilateral

Outpatient coding and reporting guidelines (1 decks)

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