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AAPC Chapter 4
ICD-10-CM coding
| Question | Answer |
|---|---|
| For HIV code only _____ cases. | confirmed |
| Code ____ if pt is admitted for HIV related condition. And this is always first unless the ______ | B20, exception |
| Infectious and Parasitic Diseases: 2 codes- one for organism and one for _____, or combination code or _____ code. | condition, single |
| Infectious Diseases: B20 should be _____ code and use additional code to identify any associated _____ listed. | principal, manifestations |
| Coding for HIV: is it _____ or known to have had HIV or related condition in the past? What is the purpose of the _____ or encounter? | asymptomatic, admission |
| HIV sequencing rules : follow when pt being treated for HIV related or non- _____ related condition. | HIV |
| Inpatient. HIV is only condition that MUST be confirmed as: stating ____, or pt is being ____ for any documented HIV related illness or has condition _____ from HIV status | AIDS, treated, resulting |
| HIV sequencing depends on the _____ for admission or encounter. Exception to this: reason for admission is hemolytic- uremic syndrome associated with the HIV and then this is reported _____, B20 is 2nd. | reason, first |
| Pt with HIV admitted for _____ condition, the code for this is coded first. | unrelated |
| Z21- Asymptomatic HIV: pt HIV ____ but no documented symptoms. Do not use if ____ term is used. If pt being treated for any HIV illness or described as having any condition resulting from HIV + status use code _____ | positive, AIDS, B20 |
| Pts with inconclusive HIV serology and definite diagnosis or manifestations of it use code _____ for inconclusive laboratory evidence of HIV | R75 |
| HIV: never assign R75 or Z21 to a pt with an _______ diagnosis of AIDS or symptomatic HIV | earlier |
| HIV during pregnancy: code from Z3A for the _____ of gestation. | weeks |
| Pt believes has been exposed to HIV code ______ | Z20.6 |
| Code Z79.899 for long term use of _____ meds | antiviral |
| Code Z16 category code for resistance to _____ drugs | antimicrobial |
| Sepsis diagnosis: code the ______ systemic infection | underlying |
| R65.2: _____ sepsis | severe |
| Sepsis with acute organ dysfunction is considered _____ sepsis | severe |
| If sepsis and acute organ dysfunction but med record says acute organ dysfunction is related to medical condition other than sepsis, don't code ______ | R65.2 |
| Severe sepsis: 2 codes- code for underlying _____ then code from category R65.2 | infection |
| A41.9: sepsis, ______ organism | unspecified |
| Pt has sepsis with MOD: list a code to identify ____ organ dysfunction | each |
| Septic shock: code _____ the underlying systemic infection followed by R65.21- severe sepsis with septic shock | first |
| Pt may develop sepsis following a procedure. If provider notes causual _____ between the sepsis and procedure is it considered Post-procedural complication. | relationship |
| T81.44 is code for _____ following a procedure | sepsis |
| If the infection meets the definition of principal diagnosis it should be sequenced before non-_____ condition | infectious |
| If the reason for infection is hemolytic-uremic syndrome associated with sepsis code hemolytic-uremic syndrome _____ | first |
| MRSA: there are ______ codes to report the infection and causual agent | combination |
| If pt is a carrier to MRSA and doesn't have an ____ infection code Z22.322-carrier or suspected carrier of MRSA | active |
| Z86.14 code for personal ____ of MRSA | history |
| Zika Virus: only ______ diagnosis reported. | confirmed |
| Zika virus: code A92.5 unless it says probable, possible or suspected then _____ or exposure codes reported. | symptoms |
| Coronavirus: only code _____ diagnosis. U07.1- Covid 19 | confirmed |
| Pt admitted for manifestations of Covid -19, ______ is reported, followed by manifestations code. | U07.1 |
| Even if + covid test but ______ use code U07.1 since they're + | asymptomatic |
| Pt had exposure or _____ exposure of covid and is asymptomatic report code Z20.822 | suspected |
| If pt has Covid symptoms and has had or suspected of having _____, code Z20.822 in addition to _____ codes | exposure, symptoms |
| Z86.16: history of _____ | Covid-19 |
| Pt seen for f/u with history of Covid with residual symptoms and negative test, report Z09- encounter for f/u after completed treatment for conditions and the personal ____ code reported | history |
| Covid antibody testing Z01.84 unless the visit is to confirm _____ infection or is f/u test after resolution | current |
| When pt has pos covid-19 condition or sequelae, report the specific ______ and code U09.9 | condition |
| Both U09.9 and U07.1 can be reported when manifestation and sequalae of prior conditions exists at the _____ time of a new active covid 19 infection | same |
| Pt with HIV admitted for unrelated condition, code the ______ condition first | unrelated |
| Severe sepsis: _____ code for underlying condition then from R65.2 category | first |
| J15.212- pneumonia due to ______ | MRSA |
| Neoplasms: if histology is known look for the term in _____ or in table of neoplasms | Index |
| Primary malignancy: where the cancer ______ | originates |
| Secondary Malignancy: results from ______ and forms a new focus of malignancy elsewhere | metastasis |
| In situ: confined to the ____ site | origin |
| In Situ: encapsulated and doesn't ______ neighboring tissue | invade |
| In situ also called non-______, non-invasive and pre-invasive | filtrating |
| Atypia or dysplasia: neoplasm is in transition from _____ to malignant. Also has _____ behavior. | benign, uncertain |
| Neoplasms: Pathology report is best for most _____ code | specific |
| Neoplasms: Reccomended to hold claims until _____ report is returned | pathology |
| Neoplasms: until pathology is recieved use code ____ from table of neoplasms | unspecified |
| For malignant: determine primary and secondary site and code 1st the site _____ care. | requiring |
| If Primary cancer is still ____ and represents the reason for the service list the code for the primary site 1st | active |
| Neoplasms: if secondary growth is the reason (primary) for care, choose from secondary column in neoplasms and list _____ | first |
| Multiple malignant neoplasms of same site: when sites are next to each other- category for ____ lesion should be used | overlaping |
| Contiguous: when sites are ____ to each other | next |
| When malignancies are the same site but not next to each other code for ____ site. | each |
| Malignant neoplasms of ectopic tissue: coded to the site of ____ mentioned. | origin |
| Malignant neoplasms of ectopic tissue: if primary site not available when encounter is directed at secondary (metastic) site select code for _____ site first then code C80.1 for unspecified. | primary |
| Anemia because of the neoplasm and getting treatment for anemia: the code for the ______ is listed first followed by code for Anemia | malignancy |
| If anemia is caused by chemo or radiation: anemia code reported ____ then code for neoplasm and adverse effect | first |
| Dehydration because of malignancy and only dehydration is being treated: first code for ______ then code for malignancy | dehydration |
| Neoplams: when encounter directed at a surgery complication: the surgery complication is _____ diagnosis | primary |
| After neoplasm treated successfully: inapropriate to use _____ codes for f/u care | neoplasm |
| Z85: personal history of ______ neoplasm. The primary malignancy has been removed and no longer being treated. Also, pt not receiving chemo or radiation for an _____ neoplasm. No evidence of any _____ malignancy | malignant, active, remaining |
| Surgical removal of neoplasm: code as if it ____ exists, don't use history of code | still |
| When treatment for eradicated cancer is complete: ____ code can be assigned | history |
| If complications develop during chemo, radiation or immunotherapy: code for those first followed by code for _____ | complications |
| Determining the extent of malignancy visit or procedure: the primary malignancy or metastatic site is designated as the ____ listed diagnosis despite the administration of chemo etc. | first |
| Sequencing neoplasms: primary malignancy, secondary malignancy, _____ pt with malignant neoplasm, complication associated with neoplasm, complication from ______ for treatment of neoplasm, pathalogic fracture due to neoplasm. | pregnant, surgery |
| Leukemia and multiple myeloma and malignant plasma cells: have codes for when in ______ | remission |
| Malignant neoplasm of transplanted organ requires 3 codes: first report the transplant ______, next code C80.2, then code to _____ malignancy. | complication, specify |
| Follicular lymphoma: coded by _____, often a scale of 1-3 which designates how many large cells are found in a high power field (centroblasts. | grade |
| Follicular Lymphoma: to code understand not only the grades but also _____ affected | nodes |
| When pt has primary cancer that metastasized to to lymph nodes the ____ is not reported with C81-C96, tabular list refers you to C77 | node |
| Lymphoma that metastasizes beyond the lymph node assign code C81-C85 with final character of ____ rather than code for secondary malignancy of the solid organ. | 9 |
| Neoplasm with pain: code G89.3. Doesn't have to state whether ____ or chronic. Pain coded first the _____ code as additional | acute, neoplasm |
| When reason for visit is management of neoplasms and pain associated with neoplasm: code ____ is additional code | G89.3 |
| Functional activity: functional neoplasms make and release hormones and other substances that cause _____ | symptoms |
| Functional activity codes: endocrine, nutritional and _____ diseases. | metabolic |
| Anemia: see if provider documented the cause. When cause isn't documented the code for _____ anemia (D64.9) is only option. | unspecified |
| If anemia is caused by ____ and the treatment is focused on the anemia the ____ code is 1st followed by code for the neoplasm then adverse effect of antineoplastic chemo | chemo, anemia |
| Anemia caused by CKD: code for _____ reported 1st then code for anemia | CKD |
| When coding from (D63), diseased classified elsewhere, code the _____ condition causing the anemia first | chronic |
| When pt admitted for management of anemia d/t malignancy and treatment is _____ for anemia code for malignancy first, followed by anemia code. | only |
| Thyroidoxicosis: code for with and without thyroid _____ | storm |
| DM: combination codes that include: type of DM, body system affected and _____ affecting that body system | complications |
| ____ diabetes melitus categories | 5 |
| All diabetes categories have notes directing to use additional code for use of _____, oral antidiabetic drugs and oral hypoglycemic meds. Ecept E10- type ___ DM | insulin , 1 |
| E10.52: Type 1 DM with diabetic peripheral angiopathy with _____ | gangrene |
| DM E10-E13 sequenced first followed by codes for _____ complications | additional |
| DM E08-E09: code first note indicating that diabetes is sequenced _____ the underlying condition, drug or chemical responsible for the diabetes. | after |
| Assign codes E08-E13 as many times needed to identify all associated _____ the pt has | conditions |
| Long term use of insulin (Z79.4) should _____ be used if insulin given temporarily to bring type 2 pt blood sugar under control | not |
| If pt takes insulin long-term and injectable non-insulin diabetic drug code for ____ | both |
| DM _____ pt, always sequenced first | pregnant |
| Pre-existing DM and becomes pregnant: code 024 (DM in pregnancy) followed by the ____ code | diabetes |
| DM: 4th character identifies ____ of diabetes as pre existing, type 1, Type 2, unspecified or _____ | type, gestational |
| DM: pregnant : 5th character indicates whether the diabetes is treated during ____, childbirth or puerperium. | pregnancy |
| DM: pregnant: 6th character indicates whether the gestational diabetes is diet controlled, _____ controlled or controlled by hypoglycemic drugs or unspecified control | insulin |
| Insulin pump failure: under ____ of insulin due to pump failure code T85.6. | dose |
| Mechanical complications of internal/external implants as first code followed by code T38.3X6 (underdosing of insulin and or hypoglycemic drugs) Then add codes for ____ of DM and associated symptoms. | type |
| Secondary diabetes: E08 &E09- identify _____/manifestations associated with secondary DM | complications |
| Secondary diabetes: caused by something other than ____ or environmental factors | genetics |
| High blood sugar levels that develop as the result of another medical condition: _____ diabetes. | secondary |
| Secondary diabetes: may also develop when _____tissue responsible for the production of insulin is absent because it is destroyed by a disease. | pancreatic |
| Secondary diabetes is ____caused by another condition or event | always |
| Post pancreatectomy DM code E89.1- postprocedural hypoinulinemia. Code from category E13 and code from Z90.41-aquired absence of pancreas as ____ | additional |
| Code Z90.41 has "use additional" to code insulin use ______ pancreatectomy. | post |
| Coding for obesity includes ____ of obesity | cause |
| Obesity: also code for if it's considered ____ | morbid |
| Obesity: secondary code from Z68 also used when the codes for underweight, _____and obesity are used. Z68.37- BMI 37.0-37.9, adult. | overweight |
| If code for psychiatric services the ____ should be used as a reference | DSM-5 |
| Code F45.42 when pain with psychiatric factors with an additional code for acute or chronic _____ | pain |
| Mental and behavioral disorders due to psychoactive substance use: When documentation says: use, abuse and dependence of the same_____, only 1 code is assigned to identify the pattern. | substance |
| Mental and behavioral disorders due to psychoactive substance use: In remission- assigned _____ on the basis of provider documentation | only |
| Psychoactive substance use: Remember excludes 1 notes to identity the correct way to code for "use," "______," and "dependence" | abuse |
| Mental and behavioral disorders due to psychoactive substance use: the type of _____ use is identified with the 3rd character. The 4th character indicates abuse, _____ or use | substance, dependence |
| Mental and behavioral disorders due to Psychoactive substance use: 5th character indicates the ____ of condition (such as intoxication, etc). The 6th character indicates further specific _____ (such as delusions) | state, complications |
| The blood alcohol level _____ need to be documented by provider | doesn't |
| Depression classified by episodes in addition to types: mild, _____, severe and without psychotic features. | moderate |
| Factitious disorders: imposed on self code F68.1, Imposed on another code F68.A and adult and child ____ confirmed or adult and child abuse, suspected | abuse |
| Intellectual disabilites: first code any associated ____ or developmental disorder and then code for intellectual disorder. | physical |
| Intellectual disabilities: coded by stage such as mild, moderate, severe and _____. Stage determined by _____ level. | profound, IQ |
| ADHD: coding is either predominately, hyperactive, _____, or combined type. | inattentive |
| Dementia: there is a note to code 1st the underlying physiological condition- this says ____ codes required and the code for dementia sequenced 2nd. | 2 |
| Dementia: if severity progresses during hospital stay (inpatient) the _____ level of severity during stay is reported. | highest |
| Parkinson's disease: codes have additional notes for reporting if dyskinesis or _______ present. | fluctuations |
| Alzheimer's disease: code based on _____ or late onset | early |
| If dementia with Alzheirmer's is documented ____ codes required | 2 |
| Focal (partial) seizure: only occur in ____ part of the brain | one |
| Generalized seizures: both ____ of brain and include absence, tonic, ____, tonic-clonic, myotonic and atonic | sides, clonic |
| Focal Seizures include: simple and ______ | complex |
| Simple focal seizures: pt remains conscious but has _____ and feelings that's abnormal | sensations |
| Type of focal seizure where pt has change in loss of consciousness: | Complex |
| Absence seizures: (petit mal) _____ into space or have twitching muscles. | stare |
| Tonic seizures: stiffening of _____. Clonic: repeated jerking of muscles on ___ sides of body. Tonic-clonic (grand mal): _____ | muscles, both, mixture |
| Atonic: loss of normal muscle _____. Myoclonic seizure: jerks and twitches of the upper body, arms and _____ | tone, legs |
| Status Epilepticus: when seizure lasts an _____ long time. Usually longer than 5 mins. | abnormally |
| "poorly controlled": _____ | intractable |
| Intractable migrain: cannot be controlled with _____ | medication |
| Migrains: 5th character identifies if ______, 6th character identifies with or without _____ migrainosus (ongoing for longer than 72 hours) | status |
| Migrain with aura: classic, without aura: ______ migrain | common |
| If affected side is not specified as dominant or non dominant and there's no default use the ____ for coding | rules |
| Ambidextrous: default is _____ | dominant side |
| If left side is affected: default is _____ | non- dominant side |
| If right side is affected: default is ____ side. | dominant |
| Need to know if it's acute or chronic to code correctly: | pain |
| Pain management: code from G89 then code for _____ condition | underlying |
| Pain: When encounter is to treat the underlying disease, 2 codes required. First code for underlying condition followed by ____ code | pain |
| Routine or expected post-op ____ is not reported. (immediately following surgery) | pain |
| Post-op pain not recorded as acute or chronic is coded as _____ | acute |
| Post-op pain associated with specific complication the code for complication is ____ code, with code from G89 as second | primary |
| Pt admitted for insertion of neurotransmitter for pain control assign appropriate ____ code as 1st listed | pain |
| Glaucoma H40: 4th character indicates _____, 7th character needed for many to indicate ____ | site, stage |
| Glaucoma: when both eyes affected by same _____ of glaucoma and same stage and there is a bilateral code, only 1 code reported. | type |
| Glaucoma: "4" for 7th character used as inderminate stage for when documented stage ____ be determined | cannot |
| Glaucoma: 7th character "0" when stage _____ | unspecified |
| Blindness: category based on visual acuity with the ____ possible correction | best |
| Blindess: when category not documented the code is based on ____ eye | affected |
| Use code H54.7 for ___ visual loss when neither visual impairment category or affect are aren't documented | unspecified |
| Blepharitis and conjunctivitis based on ____ and eye/eyelid affected | type |
| Acute otitis media: one or more of these symptoms: otalgia, _____, otorrhea, recent onset anorexia, irritability, vomiting, and ____ | fever, diarrhea |
| MEE: middle ear _____ | effusion |
| OM (otitis media) with effusion is is MEE of any duration _____ s/s of infection and usually follows AOM (acute otitis media) | lacking |
| Chronic suppurative OM: at least 6 weeks, ottorhea through _____ TM , an indwelling tympanostomy tube or sugical myrinotomy | perforated |
| Providers must document the ____ and effect relationship between care provided and the condition and the indication that it is a ______ | cause, complication |
| Hypertension: pay attention to Exludes and Includes notes, also use _____ for exposure to tobacco smoke, history of use and current use of tobacco | additional |
| Hypertension and CKD code _____. Only code separate when clearly states they're not _____ | together, related |
| HTN transient: increased BP _____ hypertension. (ex: white coat syndrome). | without |
| Pulmonary HTN: reason for encounter determins sequencing _____ for adverse effects- follow guidelines for adverse effects | except |
| Secondary pulmonary HTN: pulmonary HTN as result of another _____ or medication | condition |
| CAD: code to report the areas of _____ | atherosclerosis |
| CABG in the past: code is selected based on type of _____ | graft |
| Combination code for angina, heart disease and _____ | atherosclerosis |
| CVA sequelae codes specify hemiplagia, hemiparesis, and monoplegia, specify whether ____ or non dominant side affected. | dominant |
| CVA: use additional notes to report condition, syndrome or ____ as secondary code | sequelae |
| MI: 5 types: Type 1, Type 2 , with code for underlying _____ | cause |
| MI: type 3-5: _____ MI's | acute |
| Acute MI is if duration is ____ weeks or less | 4 |
| This type of MI can also be classified whether there's ST segmnet elevation: | Type 1 |
| STEMI: if location isn't specified use code | I21.3 |
| MI: code selection identifies the episode of care. Episode options include: episode of care _____, intitial episode of care, _____ episode of care | unspecified, subsequent |
| Intraoperative and postprocedural complications: 4th and 5th characters indicate type of _____ except codes ending in .8, .88 or .89 | complication |
| Intraoperative and postprocedural complications: 6th character indicates complication followed by a ____ or procedure | surgery |
| If STEMI converts to NSTEMI from thrombolytic treatment it is still coded as _____ | STEMI |
| HTN and CKD doesn't require cause and effect relationship to be documented it has "______ effect" | presumed |
| COPD: look for ____/pulmonary/chronic/ obstructive. J44.0 | disease |
| Asthma: severity should be documented as severe persistant, ____ persistant or moderate persistant, and intermittent | mild |
| _____: determin if it's exacerbated | Asthma |
| Respiratory failure: codes selected by acute, chronic, unspecified and if presence of _____ or hypercapnia. | hypoxia |
| ARF: sequencing determined by the ____ for encounter. If pt is admitted for ARF code for ARF _____ | reason, first |
| ARF: if pt admitted for multiple reasons select the condition that required the ___ care | most |
| Pneumonia: code selected based on _____ that caused it | infection |
| VAP: ventilator associated pneumonia- provider must ____ it is associated | document |
| Plueral effusion: if it's a symptom of an underlying disease only ___ code for underlying disease | one |
| Reflux esophagitis: code based on whether it's with or without _____ | bleeding |
| Cholelithiasis: acute, chronic, or _____ or without cholecystitis or without obstruction | both |
| Hernias: diagnosis selected based on anatomic site and whether an ____ or gangrene is present | obstruction |
| _____ hernias: make sure to indicate unilateral or bilateral | Inguinal |
| Recurrent means they had hernia in the ____ | past |
| Diagnosis code sequincing first listed diagnosis is: Eval and Management documentation- the primary ____ for the visit. Progress notes or ____ notes- the primary reason for the visit. Operative reports- the reason the ____ was performed | reason, procedure, procedure |
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