ICD-10

The ICD-9-CM classification begins with 0 and continues through 9 and
ICD-10-CM begins with A and continues through Z

How many types of Excludes ICD-10 has?
ICD-10 CM has two types of Excludes.
1. Excludes1. An Excludes1 note is a pure excludes. It means “NOT CODED HERE!”
2. Excludes2. An Excludes2 note represents “Not included here.”
When an Excludes2 note appears under
a code, it is acceptable to use both the code and the Excludes2 code togethe

The code title “in diseases classified elsewhere” indicates
that the code is a manifestation code.”In diseases classified elsewhere” codes are never first-listed codes.

Sometimes the Z code will be the first-listed code, and sometimes the Z code will be a supplemental code.

If a patient comes in for screening test and presents no symptom at the time of encounter ____ code can be first-listed
Z code

depending on the circumstances of the encounter. Certain Z
codes may only be used as first-listed or
principal diagnosis.

Status codes indicate that a patient is either
a carrier of a disease or has the sequelae or residual of a past disease or condition. This includes such things as the presence of prosthetic or mechanical devices resulting from past treatment.

The ____________ codes are never reported as a first-listed diagnosis.
External Cause

When an external cause code is reported, it is reported in addition to an
injury code from the Tabular List of the I-10.

Often, the patient record states that there is a “history of” a disease: for example, “history of
diabetes type 2 mellitus without complications.” This does not mean that the patient no longer
has diabetes mellitus
but that the patient’s medical history includes diabetes mellitus. You would not assign a Z code to indicate a previous history of diabetes mellitus but instead would
assign the code for the current disease of diabetes mellitus (E11.9).

In an inpatient setting, uncertain diagnoses are reported, but in the ________ setting these
uncertain diagnoses are not reported
outpatient

What is rule for coding CHRONIC DISEASES?
If a patient has a chronic condition that is treated on an ongoing basis, you can report the
condition as many times as the patient receives care or treatment for the condition.

What is the procedure to code DOCUMENTED CONDITIONS?
Code all documented conditions that coexist at the time of the encounter/visit, and require or affect patient care treatment or management. Do not code conditions that were previously treated and no longer exist. However, history codes (categories Z80-Z87) may be used as secondary codes if the historical condition or family history has an impact on current care or influences treatment.

Patients receiving diagnostic services only
For patients receiving diagnostic services only 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 outpatient services provided during the encounter/
visit. Codes for other diagnoses (e.g., chronic conditions) may be sequenced as additional
diagnoses.

Patients receiving diagnostic services only continues…
For encounters for routine laboratory/radiology testing in the absence of any signs, symptoms,or associated diagnosis, assign Z01.89, Encounter for other specified special examinations. If routine testing is performed during the same encounter as a test to evaluate a sign, symptom, or diagnosis, it is appropriate to assign both the Z code and the code describing the reason for the
non-routine test

What is the coding rule when Patients receiving therapeutic services only?
For patients receiving therapeutic services only 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 outpatient services provided during the encounter/visit. Codes for other diagnoses (e.g., chronic conditions) may be sequenced as additional diagnoses.
The only exception to this rule is that when the primary reason for the admission/encounter is chemotherapy or radiation therapy, the appropriate Z code for the service is listed first, and the diagnosis or problem for which the service is being performed listed second.

Coding rule to report diagnosis when Patients receiving preoperative evaluations only
For patients receiving preoperative evaluations only, sequence first a code from subcategory Z01.81, Encounter for pre-procedural examinations, to describe the pre-op consultations. Assign a code for the condition to describe the reason for the surgery as an additional diagnosis. Code also any findings related to the pre-op evaluation.

Patients receiving pre-operative evaluations only
[continues…]
Usually, a surgeon will want a preoperative clearance performed by the patient’s primary care provider, often due to a chronic or pre-existing condition. When the primary care provider reports the diagnosis for this visit, the first-listed diagnosis will be the appropriate Z code to indicate the encounter is for preop clearance; then the reason for the upcoming surgery is reported followed by the condition requiring the clearance.

Coding rule for Routine outpatient prenatal visits
For routine outpatient prenatal visits when no complications are present, a code from category Z34, Encounter for supervision of normal pregnancy, should be used as the first-listed diagnosis. These codes should not be used in conjunction with chapter 15 codes.

Coding rule for “Prenatal outpatient visits for high-risk patients”
For routine prenatal outpatient visits for patients with high-risk pregnancies, a code from category O09, Supervision of high-risk pregnancy, should be used as the first-listed diagnosis. Secondary chapter 15 codes may be used in conjunction with these codes if appropriate.

When coding an encounter for preoperative evaluation, the reason that the patient is having the surgery or procedure performed is the first-listed diagnosis?
True/False
False.
Explanation:For patients receiving preoperative evaluations only, sequence first a code from subcategory Z01.81, Encounter for pre-procedural examinations, to describe the pre-op consultations. Assign a code for the condition to describe the reason for the surgery as an additional diagnosis. Code also
any findings related to the pre-op evaluation.

Established patient presents with dyspnea and lower extremity edema. The physician determined that the patient’s symptoms were due to an exacerbation of congestive heart failure.
What would be first-listed diagnosis, dyspnea, lower extremity edema or congestive heart failure?
The answer is, Congestive heart failure, I50.9 because dyspnea and lower extremity edema are not coded as they are symptoms of the patient’s CHF exacerbation.

What is procedure to report signs and symptoms?
When the signs or symptoms are due to a diagnosed 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.
Additional signs and symptoms that may not be associated routinely with a disease process
should be coded when present.

Laterality
Some ICD-10-CM codes indicate laterality, specifying whether the condition occurs on the left, right or is bilateral. If no bilateral code is provided and the condition is bilateral, assign separate codes for both the left and right side. If the side is not identified in the medical record, assign the code for the unspecified side

Infections resistant to antibiotics
Many bacterial infections are resistant to current antibiotics. It is necessary to identify all infections
documented as antibiotic resistant. Assign a code from category Z16, Resistance to antimicrobial drugs, following the infection code only if the infection code does not identify drug resistance.

SIRS
systemic inflammatory response syndrome

Septic shock indicates the presence of severe sepsis. Code R65.21, Severe sepsis with
septic shock, must be assigned if septic shock is documented in the medical record, even if
the term severe sepsis is not documented.

MOD
multiple organ dysfunction (MOD),

A partial dislocation is also known as a
Subluxation

Right elbow is also known as
ulnohumeral joint

SIRS stands for
systemic inflammatory response syndrome (severe bacteremia)

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ICD-9-CM chapters are arranged according to body system and etiology. True In ICD-9-CM, E and V codes are located in supplementary classifications. True WE WILL WRITE A CUSTOM ESSAY SAMPLE ON ANY TOPIC SPECIFICALLY FOR YOU FOR ONLY $13.90/PAGE Write …

Sepsis and severe sepsis as principal diagnosis If sepsis or severe sepsis is present on admission, and meets the definition of principal diagnosis, the systemic infection code (e.g., 038.xx, 112.5, etc) should be assigned as the principal diagnosis, followed by …

Anthrax which is the responsible organism in this case would be sequenced first. 022.1 (anthrax) + 484.5 (pneumonia). Sequence pneumonia in anthrax: pneumonia = 484.5, anthrax = 022.1. 1.) False. A diagnosis that mentions the affected lobe is not classified …

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