Test 1 Part 3

Question 1

In the _________ setting, the term first-listed diagnosis is used in lieu of principal
diagnosis.

Answer 1

Outpatient

Question 2

In determining the ________ diagnosis the coding conventions of ICD-10-CM, as
well as the general and disease specific guidelines take precedence over the outpatient
guidelines.

Answer 2

First-listed

Question 3

________often are not established at the time of the initial encounter/visit. It may
take two or more visits before the diagnosis is confirmed.

The most critical rule involves beginning the search for the correct code assignment
through the Alphabetic Index. Never begin searching initially in the Tabular List as
this will lead to coding errors.

Answer 3

Diagnoses

Question 4

When a patient presents for ___________ (same day surgery), code the
reason for the surgery as the first-listed diagnosis (reason for the encounter),
even if the surgery is not performed due to a contraindication.

Answer 4

Outpatient surgery

Question 5

When a patient is admitted for observation for a medical condition, assign a
code for the medical condition as the first-listed diagnosis.

When a patient presents for outpatient surgery and develops complications
requiring admission to observation, code the reason for the surgery as the first
reported diagnosis (reason for the encounter), followed by codes for the
complications as secondary diagnoses.

Answer 5

Observation Stay