Module 2 ICD-10-CM

Question 1

ABC Index

Answer 1

alphabetical listing of terms with corresponding codes

Question 2

Tabular list

Answer 2

A list of codes divided into chapters basked on body systm or condition

Question 3

ICD-10-CM # is characters

Answer 3

3-7 characters

Question 4

A 3-character code

Answer 4

typically represents the heading of a category of codes representative of a single disease or group of similar conditions. 3-charactr code without further subdivision is = to a code

Question 5

Most 3 charactr codes

Answer 5

are futher subdivided into subcategories and each subcategory provides addtnl levels of specificity

Question 6

Placeholder character

Answer 6

X

Question 7

2 uses for placeholder charactr

Answer 7

1. allows for future expansion of the code without disrupting the code structure 2. when the code has fewer than 6 complete charactrs, but a 7th charactr is req, the placeholder is used to fill in the empty space.

Question 8

All letters are used except

Answer 8

U

Question 9

Instructional notes

Answer 9

included in the index provide addtn; directions for assignmnt of codes

Question 10

ICD-10-CM 1st step

Answer 10

ID the Main Term & refer to any subterms in the ABC index

Question 11

ICD-10-CM 2nd step

Answer 11

The code found in the ABC index must be verified in the Tabular list & all instructional notes must be read & followed.

Question 12

ICD-10-CM 3rd step

Answer 12

Turn to the Tabular list of Injuries & Diseases

Question 13

Dash (-)

Answer 13

if it appears at the end of a code in the ABC index, it indicates that addtnl characters are needed & can only be found in the Tabular list

Question 14

A complete code is found in ABC Index

Answer 14

the coder MUST ALWAYS to verify the code in the Tabular list.

Question 15

ICD-10-CM 4th step

Answer 15

Continue coding the diagnostic sttmt until all elements are completely ID’d.

Question 16

Adverse effects

Answer 16

when a Rx or drug or test causes a reaction in the pt.

Question 17

co-morbidities

Answer 17

a disease or condition that is separate from the primary diagnosis

Question 18

complication

Answer 18

an unexpected condition that develops after surgery, procedure, test or treatment while pt is in hospital.

Question 19

diagnosis

Answer 19

a pt’s condition, illness, injury as determined by the PCP & documented in the pt’s chart

Question 20

double billing

Answer 20

sending a claim thru 2x for the same service & date

Question 21

Eponym

Answer 21

a condition or disease named after the person who discovered it.

Question 22

Etiology

Answer 22

a PCP’s study of & determination of the CAUSE of a disease or condition

Question 23

Exacerbation

Answer 23

an increase in severity of an existing condition or illness

Question 24

Manifestations

Answer 24

a condition that is caused by, and is a result of, a prev condition

Question 25

Medically necessity

Answer 25

A diagnosis that provides a valid health REASON for services provided for the pt.

Question 26

NEC

Answer 26

Not Elsewhere Classified: details in the docs that are not provided or described in any code in the code book

Question 27

NOS

Answer 27

Not Otherwise Specified: the absence of details in the docs that might be used to code more specifically

Question 28

Other Specified

Answer 28

Information that the PCP has documented, but is not found in the code descriptions avail.

Question 29

Risk factor

Answer 29

a condition or illness that increases a pt’s susceptibility to a disease or condition.

Question 30

Sequela

Answer 30

a late effect of 1 condition or disease that causes a 2nd condition

Question 31

Sign

Answer 31

a measurable effect of a disease or condition

Question 32

Symptom

Answer 32

an abnormal state or sensation that a pt indicates they are experiencing (my)

Question 33

Supporting documentation

Answer 33

data in a pt’s chart that supports the codes assigned

Question 34

Unbundling

Answer 34

Using multiple codes when one code has been provided in the code book

Question 35

upcoding

Answer 35

using a code that indicates higher-level service than the documentation indicates

Question 36

HAC

Answer 36

Hospital Acquired Condition (previously nosocimal): CMS will not pay for conditions that did not exist at time of pt’s admission & could have been preventable.

Question 37

POA

Answer 37

Present on Admission: assigned to each code by the coder for ipt discharges about whether a condition that was present on admission

Question 38

CDI

Answer 38

Clinical documentation improvement: improves the accuracy & completeness of pt’s medical record. Must be complete for the coder to safely code the pt encounter.