learning objectivies Flashcards
in the outpatient setting-
the term first-listed diagnosis is used in lieu of principle diagnoisis
T/F it may take two or more visits before the diagnosis is confirmed
T
outpatient surgery-guidelines
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.
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
R10.9 abdominal pain, K92.1 blood in stool
unconfirmed dx: initial office ivsit for 55 yr old male with fatigue and jaundice. Lab test ordered and pt will return in 1 week
R53.83 fatigue, R17 jaundice
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
T
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
urinary tract infection
indentify 1st listed dx: pt requiring equal management of COPD and CHF
COPD and CHF
identify the 1st listed dx: male pt admitted as an outpt for transurethral prostatic resection for symptomatic benign prostatic hypertrophy
benign prostatic hypertrophy
identify the 1st listed dx: pt admitted as an outpt for cystoscopy for hematuria
hematuria
codes from A00.0 through T88.9, Z00-Z99 - guidelines for coding and reporting
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
T/F-Z codes are used more frequently in the outpt setting
T
Accurate reporting of icd-10-cm diagnosis codes - guidelines
documentation should describe the pts condition, using terminology which includes specific dx as well as symptoms, problems, or reasons for the encounter
codes that describe symptoms and signs - guidelines
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
encounters for circumstances other than a disease or injury - guidelines
icd-10 provides codes to deal with encounters for circumstances other than a disease or injury
Z00-Z99 are used for what
provided to deal with occasions when circumstances other than a disease or injury are recorded as diagnosis or problems
factors influencing health status and contact with health services are what codes
Z00-Z99
T/F certain Z codes may only be used as first-listed or principal dx
T
Status - guidelines
indicate that a pt is either a carrier of a disease or has sequelae or residual of a past disease or condition
external codes are (external cause index)
environmental events-tornados, floods, circumstances and other conditions as the casue of injury and other adverse effects
external codes are located where
after the table of drugs and chemicals in the I-10
external codes are never what
first listed dx-these codes are reported to clarify injury or adverse effects
observation stay - guidelines
pt is admitted for observation for a medical condition, assign a code for the medical condition as the 1st listed dx
Z03 and Z04 report what
observation-these codes are reported only as the 1st listed dx for medical observation for suspected conditions and conditions ruled out.
codes Z05.0-Z05.9 are used for what observation
observation and evaluation of newborns during the neonatal period-1st 28 days of life- for suspeted conditions that are not found
T/F uncertain diagnoses can be used in an out pt setting
F - in an inpatient setting, uncertain diagnosis are reported, but in theoutpatient setting these uncertaindiagnoses are not reported .
chronic diseases-guidelines
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
code all documented conditions that coexist-guidelines
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)
patients receiving therapeutic services only-quidelines
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
patients receiving preoerative evaluation only-guidelines
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.
what are the 8 steps to accurate coding
- identify the main term in the diagnostic statement
- locate the main termr in the alphabetic index
- review any subterms under the main term in the index
- follow any cross reference instructions such as see.
- verify the code selected from the index in the tabular list
- refer to any intructional notations in the tabular
- assign codes tothe highest level of specificity
- code the diagnosis until all elements are completely identified
conditions that are not an integral part of a disease process-guidelines
additional signs and syptoms that may not be associated routinely with a disease process should be coded when present
level of detail in coding-guidelines
dx codes are to be used and reported at their highest number of characters available
integral conditions should be coded how
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
multiple coding for a single condition-guidelines
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
acute and chronic conditions-guidelines
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.
combination code-guideline
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
combination code-guideline
are identified by referring to subterm entries in the index and by reading the inclusion and exlusion notes in the tabular list
sequela (late effects)-guidelines
sequela is the residual effect (condition produced) after the acute phase of an illness or injury has terminated.
reporting same dx code more than once-guidelines
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
Laterality-guidelines
specifying whether the condition occurs on the left, right, or is bilateral
