Chapter 4- Cpc Class

Front 1

When you look up a code and you see xxx.x [xxx.x] what does it mean?

Back 1

this note is important because it identifies 2 codes are required and it provides the proper sequence of the codes. The brackets indicate that the code within the brackets are sequenced after the code preceding the brackets.

Front 2

The proper sequencing for HIV depends on?

Back 2

the reason for the admission or encounter. When a patient is admitted for an HIV related condition 042 is always sequenced first.

once a patient receives an 042 code they never go back to 795.01 or V08

Front 3

If a patient has HIV and is admitted for an unrelated condition such as a fracture what is the sequence?

Back 3

fracture code first then, 042

Front 4

V08

Back 4

is the code for asymptomatic HIV. This codes is used when the term AIDS is absent and the patient is HIV positive but has no symptoms at all.

Front 5

HIV infection during pregnancy, childbirth, or puerperium

Back 5

647.6x also use v08 is the mom is asymptomatic

Front 6

If the patient is being seen to determine HIV status

Back 6

use code V73.89

Front 7

Septicemia

Back 7

is a systemic disease associated with microorganisms or toxins in the blood such as bacteria, virus, fungi, or other organisms

when reporting 2 codes are required- the infection reason is first.

Front 8

SIRS- systemic inflammatory response syndrome

Back 8

the systemic response to infection, burns, trauma, or cancer

symptoms include fever, tachycardia, tachypnea, and leukocytosis- do not report these symptoms when you code SIRS

when reporting 2 codes are required- the infection reason is first.

Front 9

Sepsis

Back 9

Sepsis is a whole body inflammatory state. It generally refers to SIRS due to an infection

sever sepsis is associated with acute organ dysfunction

when reporting 2 codes are required- the infection reason is first.

Front 10

In which situation do you put sepsis or septic shock first?

Back 10

if it complicates an abortion, ectopic pregnancy, or molar pregnancy

Front 11

If the patient is a carrier of MRSA but does not have a current infection

Back 11

V02.54

Front 12

if the pt has a MRSA infection

Back 12

There are often combination codes

Front 13

A primary malignancy is

Back 13

where the cancer originates

Front 14

in situ

Back 14

describes a malignancy that is confined to the origin site without invading neighboring tissues

a.k.a non-infiltrating carcinoma, non-invasive carcinoma, pre-invasive carcinoma. A pathologist rather then the physician designates a diagnosis ca in situ

Front 15

if the pathology report returns with indications of atypic or dysplasia

Back 15

the neoplasm is in transisition from being benign to malignant (precancerous). This is a neoplasm of uncertain behavior.

a diagnosis of uncertain behavior only comes from the pathologist's report. If a physician writes "uncertain behavior" you can not code it as such. It would be instead coded for the mass.

Front 16

when coding neoplasms wait for the .....

Back 16

pathology report. Until you have the pathology report an unspecified code must be reported. The pathology report allows for the most specific code to be recorded.

Front 17

which neoplasms are not in the table?

Back 17

Many including Merkel cells, lipoma, and melanoma. look these up in the index of diseases.

Front 18

when coding for chemo-therapy or radiation....

Back 18

chemo (V58.11)
Radiation (V58.0)
The V code goes first before the neoplasm code even if the neoplasm has already been removed.

Front 19

malignant neoplasm in a transplanted organ

Back 19

first code complications of transplanted organ
then code neoplasm "associated with transplanted organ" (Make sure you look up ASSOCIATED in the neoplasm table.)
LASTLY code neoplasm of that organ.

Front 20

If melanoma is found in multiple areas

Back 20

code for each are it is found.

Front 21

Lymphoma

Back 21

Hodgkins and non-hodgkins. The cells found in hodgkins lymphoma are reed-steinberg cells. the codes for this are 200-202

When a patient has primary cancer that spreads to a lymph-node the code is no longer 200-202 it is 196

Front 22

pain associated with a tumor

Back 22

first code the neoplasm. Then look up pain then neoplasm related 338.3

Front 23

Manifestations that may appear with diabetes are coded how?

Back 23

by using a forth digit.

Front 24

gestational diabetes

Back 24

diabetes that comes about in the second or third trimester

Front 25

HTN means

Back 25

Hypertension

Front 26

OA means

Back 26

osteoarthritis

Front 27

some diseases which are always considered to be related to HIV disease

Back 27

Kaposi's sarcoma, Lymphoma, Pneumocystis carinii pneumonia, Cryptococcal meningitis, and
Cytomegaloviral disease.
These diseases will always change an HIV-positive diagnosis to an AIDS diagnosis.

Front 28

In the event that acute organ dysfunction is also identified,

Back 28

a third code is required. the order would be infection, sirs #, then organ dysfunction

Front 29

Septic shock

Back 29

is circulatory failure associated with severe sepsis.
To completely code septic shock, multiple codes are be required. The first code should be the systemic infection. A systemic infection occurs throughout the body. The next two codes are for severe sepsis and septic shock. Then add codes for any acute organ dysfunction identified.

Front 30

Urosepsis

Back 30

can be a result of an untreated urinary tract infection. The bacteria backs up into the
kidneys. Diagnosis is typically made by performing an ultrasound of the kidneys. If a provider writes urosepsis, it is important to clarify if it is a urinary tract infection, or sepsis.

urosepsis=599.00
-meaning sepsis=995.91
-meaning urinary tract 599.00

Front 31

Post oophorectomy for ovarian CA. The MRI picks up secondary CA in the brain. In this case, the patient’s primary ovarian cancer has been removed and the patient has been diagnosed with secondary brain cancer

Back 31

Report the secondary brain cancer as the primary diagnosis, and report the history of ovarian cancer secondarily.

Remember the rule: When a primary malignancy has been previously excised or eradicated from its site and there is no further treatment directed to that site and there is no evidence of any existing primary malignancy, a code from category V10 Personal history of malignant neoplasm should be used to indicate the former site of the malignancy.

Front 32

When admission/encounter is for the management of an anemia associated with the malignancy, and the treatment is

Back 32

only for anemia, the appropriate anemia code (285.22 Anemia in neoplastic disease) is designated the principal diagnosis

Front 33

If all a chart says is “diabetes,” the default code, according to the guidelines, is

Back 33

is 250.00. That’s because 90 percent of the people with diabetes have type II diabetes, and because the diabetes is not stated as uncontrolled.

Front 34

Diabetes- The only time it is appropriate to use fifth digits 2 (type II, uncontrolled) or 3 (type I, uncontrolled) is when the clinical documentation supports a diagnosis of

Back 34

“uncontrolled.” Terms like “poorly controlled” do not qualify as uncontrolled.

Front 35

Diabetes- pump failure

Back 35

When the result is an under dose of insulin, the cod
es reported should be 996.57 for the mechanical
complications due to insulin pump failure, then
for the appropriate diabetes mellitus code based on
the documentation

When the failure results in an over dose, it is considered a poisoning. The first code reported should be the mechanical failure code 996.57, then 962.3 for the poisoning by insulin and antidiabetic agents. A third code should be reported for the diabetes based on the documentation

Front 36

The codes for substance abuse and dependence are determined based on

Back 36

the substance the patient abuses, or is dependent on and the pattern of use.

Front 37

Intractable epilepsy

Back 37

epilepsy that does not respond to medication.

Front 38

If the pain is not acute or chronic

Back 38

a code from category 338 should not be reported unless it is for post-thoracotomy pain, postoperative pain, neoplasm related pain, or central pain syndrome

When the pain is the primary reason for the encounter, pain should be the first diagnosis reported
for the encounter. When the treatment is for an underlying condition, the underlying condition is
the diagnosis reported.

Front 39

operative report coding tips

Back 39

Code the diagnosis from the body of the report and/
or the Postoperative Diagnosis or from the Pathology Report if it’s available

The Postoperative diagnosis is the primary diagnosis

Reference other parts of the patient’s chart by exa
mining the pathology report,
history, etc., to ensure the correct diagnosis code
(s) for the procedure(s) performed
are chosen. For example, a pathology report would indicate if a biopsied skin lesion was benign or malignant. These findings will determine the selection of a diagnosis code.

Front 40

a causal relationship can be assumed between hypertension and

Back 40

chronic kidney disease

When both conditions are documented, a code from
category 403 should be reported. An additional code from category 585 should be reported to indicate the stage of chronic kidney disease.

Front 41

When coding for hypertensive retinopathy,

Back 41

two codes are required. The first code is for hypertensive retinopathy, code 362.11. Then an additional code from category 401-405 should be reported to indicate the type of hypertension

Front 42

Hypertensive Cerebrovascular Disease

Back 42

requires two codes to be assigned. One code from 430-438 for the cerebrovascular disease, and the appropriate hypertension code from category 401-405.

Front 43

When both hypertensive heart disease and chronic kidney disease

Back 43

report a code from category 404. Remember, a causal relationship can be assumed between hypertension and chronic kidney disease. An additional code from category 585 should be reported to indicate the stage of chronic kidney disease and, if the patient also has heart failure, an additional code should be reported to specify the type of heart failure

Front 44

transient hypertension

Back 44

change in activity or a strong emotion can cause an
increased blood pressure reading. This is referred to as “White Coat Syndrome.” In the hypertension table, you will notice the entry under hypertension for transient refers you to code 796.2.

Front 45

Pneumonia

Back 45

The codes for pneumonia are selected based on the infection that caused the pneumonia. If the infection is not documented, the only choice is 486 Pneumonia, organism unspecified.

Front 46

Pleural effusion

Back 46

abnormal fluid accumulation in the pleural spaces. Symptoms may include difficulty breathing and chest pain. Pleural effusion usually develops as a result of another condition such as congestive heart failure (CHF) or COPD. If pleural effusion is a symptom of an
underlying disease, only code for the underlying disease. If the treatment is directed to the pleural
effusion or there is not documentation of an underlying disease, a code for pleural effusion is
reported.

Front 47

Conditions assumed to be associated with HIV

Back 47

Cytomegaloviral disease

cryptoccocal menignitis

pneumocystis carinii pneumonia (PCP)

lymphoma

karposis' sarcoma

Front 48

Crin/o

Back 48

secrete

Front 49

dips/o

Back 49

thirst

Front 50

troponin-

Back 50

act upon

Front 51

-in

Back 51

a substance

Front 52

an example of when a problem caused by diabetes is not sequenced after the code for diabetes

Back 52

when an insulin pump malfunctions

Front 53

-globulin

Back 53

protein

Front 54

ranul/o

Back 54

granules

Front 55

ESR

Back 55

erythrocyte sedimentation rate

Front 56

when selecting a pain code

Back 56

first code chronic or acute, or underlying condition THEN select a pain code wich will will bea a 700#

Front 57

MI

Back 57

Myocardial infarction are considered acute if the duration is 8 weeks or less. These are based on the location and it is reported with a fourth digit.

Front 58

STEMI

Back 58

ST elevation myocardial infarction

coded with the subcategories 410.0-410.6 and 410.8

in this case the coronary artery is completely blocked.

Front 59

NSTEMI

Back 59

non ST elevation myocardial infarction describes when the blood clot only partly occludes the artery 410.7

Front 60

If the pt has or has not had CABG

Back 60

if the doctor does not document it code 414.01

If the doctor notes that the pt has had CABG this code is based on the type of graph. the most common graph is from the saphenous vein.

Front 61

Hypertensive retinopath

Back 61

2 codes are necessary. First assign 362.11 hypertensive retinopathy then code from the circulatory categories 401-405

Front 62

high blood pressure without hypertension diagnosis

Back 62

transient hypertension 796.2

642.3x for during pregnancy

Front 63

long-term use of anti-coagulants

Back 63

found under long-term prophylactic drug use/anticoagulants

v58.61

Front 64

status asthmaticus

Back 64

when a patient is not responding to treatment

Front 65

hypertensive retinopathy

Back 65

first code retinopathy then code hypertension

Front 66

CHF

Back 66

symptoms include pleural effusion and shortness of breath. Only code for CHF

Front 67

The pt has been on anti-coaculation drugs for awhile and will be on it further....

Back 67

Look up "long-term" anticoagulation V58.61