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Coding Guidelines 3
Lesson 3
| Question | Answer |
|---|---|
| Guideline I.B.10: If the same condition is described as both acute and chronic, look for a combination code in the Alphabetic Index. If no combination code exists how do you code this? | code both conditions and sequence the acute code first. |
| Guideline I.B.13. Impending or threatened conditions: If you look under main term 'threatened' and a code for the condition does not exist under there what do you code? | Signs & sypmtoms of the threatened condition (that did not occur) |
| Guideline I.B.16. Documentation for BMI (body mass index) and pressure ulcer stages. Why is the rule an exception for what is written in the chart by the attending physician? | Since it's usually the nurse or other clinician it's appropriate to obtain the information needed to stage pressure ulcers and record BMI from other clinicians' notes, rather than the main provider of care. |
| in the ICD-9-CM coding manual, Infectious and Parasitic Diseases you'll find guidelines that pertain particularly to three classes of diagnoses. What are they? | Human immunodeficiency virus (HIV) Various kinds of sepsis, which include diseases found in other chapters that are caused by different infections agents & Methicillin-resistant Staphylococcus aureus (MRSA) |
| What are symtoms of sepsis? | The blood pressure elevates, the patient experiences chills, confusion, decreased urine output, fever, and other symtoms. If the infection begins to attack organ systems like the liver, lungs, or kidneys, the patient is considered to be in sepsis. |
| When sepsis begins to shut down organ function it is called what? | Severe sepsis. |
| When sepsis completely shuts down organ function it is called what? | Septic shock |
| Term that describes sepsis if no infection is documented. In other words, the patient has all the symptoms of sepsis, but no infection has been found yet. | Systemic inflammatory response syndrome (SIRS) |
| When you're coding SIRS, sepsis, or severe sepsis, you need to have at least how many codes? | at least two codes. One is for the underlying cause—for example, infection or trauma. The second code identifies whether SIRS, sepsis, or severe sepsis is present. |
| When coding neoplasms, where do you begin the coding process. | Table of Neoplasms |
| What section includes the structure and conventions of the classification and general guidelines that apply to the entire classification, and chapter specific guidelines that correspond to the chapters as they are arranged in the classification? | Section I of the coding guidlines |
| Which section of the coding guidlines includes guidelines for selection of principal diagnosis for non-outpatient settings? | Section II |
| Which section includes guidelines for reporting additional diagnoses in non-outpatient settings? | Section III |
| Which section is for outpatient coding and reporting? | Section VI |
| Punctuation mark used in the index to identify manifestation codes. It is used in the tabular list to enclose synonyms, alternative wording or explanatory phrases. | [brackets] |
| Coding of late effects generally requires two codes sequenced in what order? what is the exception. | The condition or nature of the late effect is sequenced first. The late effect code is sequenced second. An exception are those instances where the code for late effect is followed by a manifestation code. |
| If a patient is admitted for an HIV-related condition how would you code this? | the principal diagnosis should be B20, followed by additional diagnosis codes for all reported HIV-related conditions. |
| If a pt with HIV disease is admitted for an unrelated condition how would you code this? | the code for the unrelated condition should be the principal diagnosis. Other diagnoses would be B20. |
| During pregnancy, childbirth or the puerperium, a patient admitted because of an HIV-related illness should receive a principal diagnosis code of what? | HIV-related illness a Pdx code of O98.7-, [HIV] disease complicating pregnancy, childbirth and the puerperium, followed by B20 and the code(s) for the HIV-related illness(es). Codes from Chapter 15 always take sequencing priority. |
| The coding of SIRS, sepsis and sever sepsis requires a minimum of what 2 codes? | 2. A code for the underlying cause (ex infection or trauma) and a code from subcategory R65 SIRS...Severe sepsis requires additional codes for the associated organ dysfunction |
| Refers to a systemic disease associated with the presence of pathological microorganism or toxins in the blood, which can include bacteria, ciruses, fungi or other organisms. | Septicemia |
| 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 what code do you use? | Z status-code, Personal history of malignant neoplasm |
| If a patient admission/encounter is solely for the administration of chemotherapy, immunotherapy or radiation therapy what code should be assigned as principle or 1st listed diagnosis? | Encounter for radiation therapy, or Z-code, Encounter for antineoplastic chemotherapy, or Z-code, Encounter for antineoplastic immunotherapy. The malignancy for which the therapy is being administered should be assigned as a secondary diagnosis. |
| When a patient is admitted for the purpose of radiotherapy, immunotherapy or chemotherapy and develops complications such as uncontrolled nausea and vomiting or dehydration, the principal or first-listed diagnosis is what? | Encounter for radiotherapy, or, Encounter for antineoplastic chemotherapy, or, Encounter for antineoplastic immunotherapy followed by any codes for the complications. (Z-codes) |
| When the reason for admission/encounter is to determine the extent of the malignancy, or for a procedure such as paracentesis or thoracentesis what is the principal or first-listed diagnosis? | The primary malignancy or appropriate metastatic site is designated as the principal or first-listed diagnosis, even though chemotherapy or radiotherapy is administered. |
| Chapter-Specific Guidelines begin with the capital letter __ | C |
| General Coding Guidelines begin with the capital letter _ | B |
| If a definite diagnosis is not established before a patient leaves the physician's office, code the signs or symptoms from Chapter __________ of the ICD-9-CM. | 18 |
| What are symptoms of sepis? | Symptoms such as blood pressure elevation, cold chills, confusion, decrease in urine output, fever, and other signs and symptoms. |
| When coding neoplasms, start with the __________. | Table of Neoplasms the refer to the tabular |
| According to the Official Coding Guidelines, if a patient is admitted for chemotherapy and develops complications, sequence the ___code first followed by the complication. | chemotherapy |
Created by:
marrufotheresa