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CBCS ICD-10-CM
ICD-10-CM
| Question | Answer |
|---|---|
| Routine outpatient prenatal visit code from category...? | Z34 (if high risk pregnancy exist a code from O09, Supervision of high risk pregnancy, should be listed first) |
| Patient receiving preoperative evaluation only code from...? | subcategory Z 01.81 |
| Patient receiving therapeutic Services related to chemo/radiation therapy use code..? | Z |
| Encounters for routine laboratory/radiology testing in absence of signs or symptoms are coded to...? | Z01.89 |
| Routine Health screening are coded in chapter...? | 21 (Z00-Z13 Codes) |
| First listed diagnosis in outpatient settings | always code the reason for encounter first |
| First listed diagnosis in outpatient settings for outpatient surgery | Code reason for surgery (even if not performed due to a contraindication) |
| First listed diagnosis observation stay due medical condition | assign code for medical condition |
| First listed diagnosis for observation stay due to development of complication following outpatient surgery | code reason for surgery |
| For symptoms,signs, abnormal Clinical and laboratory findings, Not elsewhere classified use codes from chapter...? | 18 |
| Codes for Encounters for circumstances or reasons other than disease or injury can be found in chapter...? | 21 (Z80-87) |
| ICD-10-CM codes are composed of_______ characters? | 3-7 |
| When a code with fewer than 6 characters requires 7th character use...? | X as placeholder (dummy X) |
| Codes in ICD-10-CM: First Character is always ...? | alphaphetic |
| 3 Character code | Capital letter followed by 2 digits or 1 digit and 1 letter (R58) |
| 4 Character code (subcategory) | 3 character code followed by period (.) and 1 number (R58.2) |
| 5 Character code (subcategory) | 3 character code followed by period (.) and 2 numbers (R58.20) subdivision of 4 character code |
| 6 Character code (subcategory) | 3 character code followed by period (.) and 3 numbers (R58.200) subdivision of 5 character code |
| 7th character code ( extension) | additional character for additional information -can be letters or numbers |
| Injury, Poisoning and Certain other Consequences of external cause are found in chapter...? | 19 |
| Certain Conditions Originating in the prenatal Period are found in Chapter...? | 16 (specific to newborn for conditions during prenatal period (before birth - 28th day of life) |
| Pregnancy, Childbirth and the puerperium are found in Chapter...? | 15 (conditions affecting mother during and 6 month after pregnancy) |
| External Causes of Morbidity use codes from Chapter...? | 20 (these codes are used as secondary with conditions classifiable to there ICD-10-CM chapters) |
| Main terms are printed in ...? | bold and flush left |
| Nonessential modifiers are...? | enclosed in parentheses () and do not affect code assignment |
| Essential modifiers are...? | called soubrettes and affect code assignments |
| What is the External Cause of Injuries Index Found in alphabetic index? | alphabetic list of term describing accidents and acts of violence |
| What is the Table of drugs and chemicals Found in alphabetic index.? | An alphabetic list of drugs and chemicals with diagnosis codes for poisoning, adverts affect and underdosing? |
| What is the Index to diseases and Injuries Found in alphabetic index.? | alphabetic list of diseases, conditions, injuries, signs, symptoms and reasons for encounter or services |
| () Parentheses in the Tabular list enclose...? | conditions excluded from a particular category/range of codes included in a chapter/category block |
| () Parentheses in the Alphabetic Index mean...? | nonessential modifiers, words or statements that do not affect the code |
| [] Square brackets are used in the tabular list for...? | enclosing synonyms, alternative wording or explanatory phrases |
| slanted square brackets are used to..? | identify codes for conditions that are manifestations of underlying conditions |
| .- point dash is used in Tabular list to...? | indicate the code is incomplete- additional code is needed |
| What must be listed first? Manifestation or underlying condition? | underlying condition |
| What must be listed first if the diagnoses says acute and chronic? | Acute |
| "Excludes 1" means? | not coded here (excluded note should never be used at the same time as the code above) |
| "Excludes "2 means? | not included here (the excluded condition is not part of the condition represented by the code preceding the note) |
| "Include" note indicates...? | describe information included in a specific category |
| "Code also" in the tabular list is used to..? | alert the bill or coder that 2 codes may be required to fully describe a condition |
| Cross references "see" found in the alphabetic index, is a..? | -followed by a main term is a mandatory instruction - coder must go to referenced main term |
| Abbreviation NEC in tabular and alphabetic list means...? | not elsewhere classified (diagnosis or condition does not have a separate code) |
| Abbreviation NOS in tabular and alphabetic list means...? | not otherwise specified (documentation does not provide enough detail to select specific code) |
| What codes should be used when a diagnoses is not definitive or confirmed? | Symptoms and Signs -found in chapter 18 |
| In what order to code Late effect (sequela) conditions? | late effect condition first -followed by the reason for the condition |
| What is a late effect? (Sequela) | Is a condition that remains after acute phase of illness. |
| In the alphabetic index what does "see condition" means? | indicates anatomic site or adjective was used as main term |
| What diagnosis to list first for Examination resulting in abnormal findings? | List examination with abnormal finding |
| Using codes for Sign, symptoms and ill defined conditions in an non-outpatient setting as principal code is not allowed when...? | a related definitive diagnoses has been established |
| What is the principal diagnosis for Symptoms followed by contrasting/Comparative Diagnosis? | symptom code is the principal and coded first |
| What is the principal diagnosis when original treatment plan is not carried out? | condition that was reason for admission is the principal and coded first |
| What is the principal code when the diagnoses is uncertain and described as probably, suspected, likely, questionable? | List the uncertain diagnoses first |
| What does sequencing mean? | Assigning the diagnostic codes in the correct order |
| What is a concurrent conditions? | it is a condition that coexists with the first listed condition and complicates treatment. |
| What is the difference between principal and first listed diagnosis? | Principal diagnosis= applies to inpatient care, first listed diagnosis= outpatient care(reason for encounter,Visit) |
| What is a secondary condition? | it is a condition that coexists with the first listed condition but doesn't affect directly the outcome of treatment |
| - dash are used to | identify an incomplete code in the alphabetic Index |
| How many chapters are in the tabular list? | 21 |
| Where can you find the table for neoplasm? | Index to diseases and Injuries |
| In what chapter can you find neoplasm? | 2 |
| In what chapter can you find conditions present since the time of birth? | 17 (Congenital Malformation, Deformation and chromosomal abnormalities) |
| Codes for pregnancy are found in chapter...? | 15 |
| What is the perinatal period? | before birth up to the 25th day of life |
| What is the puerperium period? | end of 3rd stage of labor up to 6 weeks |
| ICD-10-CM is published by...? | WHO- World Health Organization |
| The 3 Volumes of the ICD-10-CM are ...? | 1: Tabular list 2: Instruction Manual 3: Alphabetic Index |
| Who is responsible for developing the clinical modification of ICD-10-CM? | NCHS-National Center for Health Statistics |
| What does ICD-10-CM stand for? | International Classification of Diseases, 10th revision, Clinical Modification |
| Who are the cooperating Parties responsible for maintaining and updating ICD-10-CM? | AHA-American Hospital Association AHIMA-American Health Information Management association CMS-Centers for Medicare and Medicaid Services NCHS-National Center for Health Statistics |
| When do the annual changes and updates to ICD-10-CM become effective? | October 1. |
| Z CODES IN CHAPTER 21 | factores influencing health status and contact with health services |
| O CODES IN CHAPTER 15 | pregnancy, childbirth and puerperium |
| A-B CODES indicate IN CHAPTER 1 | infectious diseases |
| F CODES IN CHAPTER 5 | mental, behavioral disorders |
| K CODES IN CHAPTER 11 | DIGESTIVE SYSTEM |
| J CODES IN CHAPTER 10 | REPIRATORY SYSTEM |
| S-T CODES IN CHAPTER 19 | INJURY POISENING |
| V CODES IN CHAPTER 20 | EXTERNAL CAUSE OF MORBIDITY |
| I CODES CHAPTER 9 | CIRCULATORY SYSTEM |
| J CODES | REPIRATORY SYSTEM |
| G CODES | NERVOUS SYSTEM |
| R CODES | SYMPTOMS SIGNS AND OTHER FINDINGS, NOT ELSEWHERE CLASSIFIED |
Created by:
liajo