Icd-10-Cm And Icd-10-Pcs Coding Handbook / Nelly Leon-Chisen

Front 1

What are some of the coding coventions in ICD-10-CM?

Back 1

NEC, NOS, Exclude1, Exclude2, Instructional notes, Abbreviations, Cross references, Punctuation Marks....

Front 2

What do inclusion notes tell the coder?

Back 2

Tells what disorders are in that particular category or code

Front 3

Remember, any and all includes/excludes notes under a category go with all the codes in that category

Back 3

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Front 4

Excludes2 notes codes can be used together
Excludes1 notes codes can NOT be used together

Back 4

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Front 5

Remember, if there is a red box to the left of a code it indicates that there are more digits needed to finalize the code

Back 5

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Front 6

What does the abbreviation "NOS" mean?

Back 6

Unspecified, and you should try to limit the use of this code-find a more specific code

Front 7

Are "see cross references" mandatory?

Back 7

Yes

Front 8

"See also notes" are NOT mandatory

Back 8

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Front 9

"See category" is mandatory

Back 9

It will give you a category code to reference in tabular to select the correct code

Front 10

If an entry in the alphabetic index tells you to "see condition", what does that mean

Back 10

Select another main term

Front 11

Terms in parenthesis by a main term are called what?

Back 11

Non-essential modifiers, they are not required to use the code, they are used to reassure the coder that they are in the right place

Front 12

The subterms or "essential modifiers" have to be in the chart to use the code by them

Back 12

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Front 13

What does "due to" show the coder?

Back 13

it shows a casual relationship between conditions

Front 14

Is the admitting diagnosis a part of UHDDS?

Back 14

No

Front 15

UHDDS is used on what type of charts?

Back 15

Inpatient charts

Front 16

What types of payers use UHDDS criteria?

Back 16

Medicare and Medicaid

Front 17

What are the 3 data elements of UHDDS?

Back 17

Principal diagnosis, other diagnosis and all significant procedures

Front 18

What is the principal diagnosis?

Back 18

Condition that is established after study, chiefly responsible for admission

Front 19

Principal diagnosis, coded correctly is vital because it determines payment

Back 19

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Front 20

Admitting and principal diagnosis are two vastly different things.....

Back 20

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Front 21

If a patient is admitted after medical observation, how is principal diagnosis defined?

Back 21

The condition that led to the patient admission to the hospital

Front 22

How about if admitted after surgery observation?

Back 22

You use whats chiefly responsible for admitting the patient

Front 23

How about if 2 diagnosis equally meet the definition of principal diagnosis?

Back 23

If treatment was not focused more on one or the other then either can be listed as principal diagnosis

Front 24

If you have a case where a M.D. states the conditions are either/or for contrasting/comparable diagnosis how would you distinguish the principal diagnosis?

Back 24

Either may be listed first but if one condition is focused on more or investigated more then use that one

Front 25

If you have a symptom followed by contrasting/comparative diagnosis how do you code the principal diagnosis?

Back 25

Symptom code first then the comparative diagnoses but if the symptom is an integral part of the conditions then you dont code the symptom you only code the contrasting diagnoses

Front 26

If a patient comes in for gastric bypass surgery due to obesity, then decides not to go through with it, what would you code as the principal diagnosis?

Back 26

Obesity, as your diagnosis code because it was the original treatment plan and the gastric bypass is a result of the obesity. (gastric bypass is not a diagnosis code)

Front 27

If a patient came in for pneumonia but had a toe abscess that required treatment during the stay would you code the toe abscess?

Back 27

Yes, the condition can effect the current stay (even if they are history of conditions)

Front 28

What are some chronic conditions that might affect a current stay?

Back 28

Diabetes, Hypertension, COPD, Parkinsons.....

Front 29

History codes that have a current impact on condition should be coded.

Back 29

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Front 30

If a patient has shortness of breath but is found to have pneumonia, do you code the shortness of breath?

Back 30

No

Front 31

Can you code an abnormal finding from a radiology report for an inpatient stay?

Back 31

No, the attending M.D. must document the significance to code it

Front 32

How about if you see a white blood count is high on a patient and no evidence of documentation from M.D. except that they gave the patient antibiotics, what would you do?

Back 32

Query the M.D., since it looks like he treated some type of infection

Front 33

What is the source document for coders in knowing what to code for a patient?

Back 33

The medical record is the source document

Front 34

What document in the record is very important to the coder to see a total picture of the stay?

Back 34

Discharge summary, some facilities will not wait for them to be on the chart before they want coding done

Front 35

Should coders code right from the discharge diagnosis listed on the discharge summary?

Back 35

Yes, be sure and read the chart to ensure the listed code is correct....remember M.D.s are not taught coding, thats why you review the entire record and it will give you clues of things not listed on the discharge summary

Front 36

Can you code from pathology reports?

Back 36

No

Front 37

Can you code from xrays?

Back 37

No

Front 38

Coding can be done from consults, progress notes or anything the attending M.D. documents on

Back 38

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Front 39

Can you code from documentation from a nonphysician professional (physical therapist,...)?

Back 39

You cant use their documentation for diagnosis coding but you can use it for procedure coding