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AAPC CPC Chapter 5
ICD coding chapters 12-22
| Question | Answer |
|---|---|
| Cellulitis and lymphangitis: codes based on ____ site, type of inflammation or infection, if it is ____ and laterality | anatomical, acute |
| Dermatitis: Atopic eczema most ____ type | common |
| Dermatitis: codes based on the _____ of substance that caused it | type |
| If pressure ulcers get worse during hospital stay, _____ codes required | 2 |
| Pressure ulcer gets worse during hospital stay: code for site and stage of ulcer on _____, code for the _______ stage for that site during stay. | admission, highest |
| Pressure ulcer stages: stage 1-persistant focal edema. Stage 2- _____ thickness skin loss of epidermis, dermis or both. Stage 3- full thickness skin loss, damage or necrosis of _____ tissue. Stage 4- necrosis of soft tissue, extending to _____ structure. | partial, subcutaneous, underlying |
| If ulcer present on admission but healed during stay, code for site and stage at _____ | admission |
| Codes for pressure ulcer based on location, ______ and stage | laterality |
| Pressure ulcer: for each location option for stages 1-4, deep tissue pressure injury, _____ stage, and unstagable | unspecified |
| If unstagable revealed after debridement only code for stage revealed _____ debridement | after |
| Pressure ulcer: first code for any _____. Code for ulcer being treated, if all are being treated code for the most ____ ulcer 1st | gangrene, severe |
| Chronic non pressure ulcer: healed at discharge, code for site and severity of ulcer at _____ | admission |
| SLE stands for systemic ______ erythematosus | lupus |
| Osteo Arthritis type such as _____, secondary or post traumatic used for coding | primary |
| Osteoarthritis: primary doesn't have known cause. Secondary from _____ or disease | injury |
| Rheumatoid arthritis: codes determined by site, laterality, complication and with or w/o Rheumatoid ______ | factor |
| Rheumatoid factor is an ______ present in blood of most with Rheumatoid arthritis. | antibody |
| Pathalogic fracture: broken bone in an area of _____ bone. Cause is usually from _____ such as osteoporosis or neoplasm. | weakened, disease |
| Pathalogic fracture: codes not reported as _____ fracture. | traumatic |
| Stress fracture is from _____ over- use and not coded as traumatic | repeated |
| 7th character for phase of treatment for pathalogical fractures: A- initial, D- Subsequent encounter for fracture with _____ healing, G- delayed healing, K- fracture with _____, P- fracture with malunion. S-Sequela | routine, nonunion |
| Pathological fractures, phase of treatment 7th character: A for use as long as pt receiving ____ treatment for fracture. D- encounters after the pt has completed active treatment and receiving routine care during ______ or recovery phase. | active, healing |
| Osteoporosis: based on type and with or w/o current ______ fracture. | pathologic |
| Osteoporosis: site isn't required when there's no current _____ fracture | pathologic |
| Osteoporosis with pathological fracture: need _____. One combination code. Use additional note for identifying ____ osseous defect. | site, major |
| Osteoporosis with pathological fracture: don't use traumatic fracture code even if known osteoporosis and suffers fracture, even for _____ fall or trauma, if that trauma would not usually break normal, ______ bone. | minor, healthy |
| Osteoporosis with current pathological fracture, a _____ code shold be reported if pt had fracture in the past. | history |
| CKD: select code with proper 4th character to identify the _____ | stage |
| CKD: _____ used to determine stage. There are 5 stages. | GFR |
| CKD end stage: pt is on chronic dialysis or undergoing _____ transplant. | kidney |
| If CKD and ESRD documented, report N18.6- _____ stage only and also code for dialysis status | end |
| Kidney transplant: code for CKD and code kidney transplant ______ | status |
| ARF has _____ onset. Look up "failure/renal/acute" | onset |
| Urinary incontinence: 2 common types- urge and ____. Need the type and if underlying cause is known then code that ____ | stress, first |
| UTI: if specific _____ documented then select code for that rather than UTI. Use additional code to identify _____ agent. | organ, infectious |
| BPH: 4th character indicates whether pt has urinary ______ and other urinary tract symptoms. | obstruction |
| Usually you do not code for symptoms when definitive disease is identified unless there's a _____ | note |
| Uterine fibroids: directs you to see leiomyoma/uterus and look here for specific _____ | locations |
| Cervical Dysplasia: CIN, abnormal _____ or premalignant cells of cervix. Different grades diagnosed with ____ | growth, pap smear |
| 1st trimester less than 14 weeks, 2nd trimester 14 weeks to less than ____ weeks | 28 |
| _____ trimester 28 weeks to delivery | 3rd |
| Pt admitted during one trimester and then goes into another trimester- code for trimester on ______ | admission |
| When there's no code option "in childbirth" code for describing current ____ | trimester |
| Pregnancy: condition that prompts admission sequenced ____ | first |
| Gestational diabetes: codes selected based on how the diabetes is ______- diet, insulin or oral meds. | controlled |
| When gestational diabetes controlled by diet and oral meds, code only for controlled by _____ meds. | oral |
| Weeks of gestation reported. This is not reported for pregnancies with abortive outcomes, elective _____ or postpartum. | termination |
| 7th character assigned for certain categories to identify the fetus for which the ______ code applies. | complication |
| Completed gestation weeks refers to ____ weeks. Ex: 39 wks 6 days, code for 39 weeks. | full |
| High risk pregnancy codes for over _____ and younger than 16 | 35 |
| 035 or 036- fetal condition affecting management of ______ person | pregnant |
| HIV and pregnant: code 098.7 category followed by codes for _____ related illness. | HIV |
| DM and pregnancy: 2 codes required- principal code from 024- DM in pregnancy followed by code to report the ____ | DM |
| DM and pregnancy: secondary code reports type of diabetes and must report code from E08-E13 also if type 2 being treated with ____ report Z79.4 or oral antidiabetic meds Z79.84 | insulin |
| DM and pregnancy: Additional codes for multiple ____ used- each type is reported separately | meds |
| Sepsis and septic shock complicating pregnancy: specific type of _____ as additional code | infection |
| Puerperal sepsis: infection in ____ tract that develops during postpartum period. 085 with additional code that describes causual organism | genital |
| Covid 19 reason for encounter during pregnancy code 098.5 followed by covid 19 _____ | manifestations |
| Pt + for covid but that's not reason for admission- code for reason for admission as ____ diagnosis followed by 098.5 and U07.1, manifestations codes also | principal |
| Pregnant pt has poisoning, toxic effects or underdosing: code from 09A.2 (injury poisoning external causes, pregnancy) followed by the ______, poisoning etc. Additional codes to specity the condition caused by this. | injury |
| Peripartum: last ____ of pregnancy to 5 months postpartum | month |
| Peripartum Cardiomyopathy: only when develops as result of _____ who didn't have pre existing heart disease. | pregnancy |
| Retained _____ of conception (POC) | products |
| Missed abortion: fetal death before ____ weeks gestation, not missed if contents expelled or induced abortion. | 20 |
| Abortions that are a result of complication in pregnancy require ____ code from 004, 007 and 008 categories | additional |
| Hemmorrhage after elective abortion code 004.6 and code for encounter for elective termination _____ used (Z33.2) | not |
| Suspected and confirmed abuse on pregnant pt: report code for physical abuse complicating pregnancy, sexual abuse an psychological abuse as _____ code and additional codes to specify current _____ due to abuse. | primary, injury |
| Perinatal: immediatly before birth to ____days following. | 28 |
| General perinatal rule: all significant conditions noted on routine newborn exam should be _____. | coded |
| Should condition in perinatal stage continue through out life: continue to use perinatal code regaurdless of patients ____ | age |
| Code from Z38- _____ of birth | type |
| Z05- newborn observed for suspected conditition that's not found, only _____ babies. | healthy |
| Prematurity and Fetal growth: not based on birth _____ but on provider's clinical assessment. | weight |
| Prematurity: birth weight sequenced _____ gestational age. | before |
| Newborn + for covid 19: see if _______ was specified and use correct code for this. Ex: in utero or birthing process. | transmission |
| Congenital abnormalities: if abnormality has been ____, personal history code reported. Reported at time of birth category Z38 reported 1st _____ by congenital abnormality code. | corrected, followed |
| Congenital abnormalities: code Q00-Q99 used until abnormality ______ | corrected |
| Repeated fall: code R29.6 and reason being ______. Pt fallen in the past is at risk for _____ falls, code Z91.81 | investigated, future |
| Coma scale: include 1 code from each of categories: eyes open, best ____ response and motor response. | verbal |
| Coma scale: only report total _____ when documented | score |
| Coma scale: multiple scores in 24 hours, only report score at ______. | admission |
| SIRS: systemic inflammatory _____ syndrome | response |
| Death NOS: pt who already died, pronounced dead upon arrival and _____ is unknown, use code R99 | cause |
| 3 main character codes: A- initial encounter, D- ____ encounter, when pt has completed treatment of condition and receiving routine care for condition during healing phase. S- Sequela | subsequent |
| Example of Subsequent encounter: cast _____, x ray to check healing, med change | change |
| Injuries classified by ____. List 1st the code for the most ______ injury. | type, serious |
| When primary injury results in damage to peripheral nerves or blood vessels (minor), the _____ injury coded first with additional code for injury of nerves/spinal cord. | primary |
| Iatrogenic injuries: occur during or result of ______ intervention | medical |
| Traumatic fractures: coded by ____ and type | site |
| Traumatic fractures: when open or closed isn't specified use ____ | closed |
| Traumatic fractures: 7th character identifies ____ or closed | open |
| Traumatic fractures: when displaced or non displaced not specifed use _____for coding. There are specified 7th character codes to indicate _____ of care. | displaced, episode |
| Initial encounter codes for fracture: A- initial for ____ fracture, B- initial for open fracture type I or II, C- for open fracture, initial, type IIIA, IIIB, _____ | closed, IIIC |
| Fractures: 7th character to identify subsequent care and also for _____ codes. | complication |
| Malunion (fractures) reported with 7th characters: P, Q, R ____, M, N | K |
| Open fractures based on _____ open fracture classification. When this isn't specified use type I or I I, 7th character. _____ determines sequencing. | Gustilo, severity |
| Burns and corrosions: corrosions are due to ____. | chemicals, |
| 2nd degree burns, 4th character 2 for burns and ____ for corrosions | 6 |
| Burns classified by depth, extent, ______ | agent |
| 1st degree burns: only through epdermis. 4th character ____ for burns, 5 for corrosions | 1 |
| 2nd degree burns: _____ thickness burns. epidermis and dermis. Nerve endings exposed, extreme pain | partial |
| 3rd degree burns: ____ thickness burns, epidermis, dermis and varying levels of subqutaneous and underlying structures. | full |
| 3rd degree: 4th character 3 for burns, ____ for corrosions | 7 |
| Non-healing burns: coded as ____ burns | acute |
| Necrosis: burned skin coded _____ | non healing |
| Burns to eye and internal organs classified by ____ not degree | site |
| Multiple burns: code for ____ degree of burn first. | highest |
| Internal and external burns (both): reason for _____ is principal diagnsosis. Always code greatest _____ of burn. | admission, depth |
| Sequence 1st the diagnosis that reflects the highest degree of burn when ______ burns present. | multiple |
| T31 or T32 classifies burns according to extent of body surface involved when site isn't ______, use also as additional code when 3rd degree burn involving 20% or more of _____ surface. | specified, body |
| Assigning from T31 or T32: 4th characters identify % of ____ body surface (TBSA) in burn or corrosion (all degrees) | total |
| T31 or T32: 5th character "0" assigned when less than _____ % of the body surface involved in 3rd degree burn or corrosion | 10 |
| TBSA: rule of _____ to determine it | nines |
| Infections, associated injuries and co-morbid conditions coded in addition to _____ codes | burn |
| Sequela of burns or corrosions: 7th character "S." Being seen for current burn and sequela of old burn 7th character "A" and "____" and then also "S" | D |
| Lund-Bower class of burns: head and neck 9%, trunk/back- _____%, whole arm- 9%, perineum -1%, whole ____ 18 % | 18, leg |
| Table of drugs and chemicals classifies drug toxicity into 4 categories: adverse effect, poisoning, _____, toxic effect | underdosing |
| Adverse effect: when coding for this, use 2 codes. 1st code to identify manifestation, 2nd code to identify the ____ causing reaction. | drug |
| Adverse effect: use adverse effect ______ in table of drugs and chemicals. 5th or 6th character for adverse effect. | column |
| Adverse effect: T36-T65 are _____ codes that include substance and intent | combination |
| Poisoning requires 2 codes: 1st code identifies ____, 2nd code indicates condition/manifestation that _____ from poisoning. Additional codes to identify abuse or dependence of the substance. | drug, resulted |
| Poisoning: when no documentation for intent report codes from poisoning, _____ (unintentional) column | accidental |
| _____ codes are never used as primary | Underdosing |
| Underdosing: additional codes for non-_______ or complication of care used. | compliance |
| Adult and child abuse, neglect and or maltreatment: if suspected but ruled out during the encounter, report appropriate ____ out code (Z04-) | ruled |
| Abuse/neglect: additional codes for rape or _____ abuse, ruled out, adult and child, also for forced sexual expoitation. | sexual |
| Abuse or neglect confirmed: external cause code from X92-Y08 used to identify ____ of injuries. Perpatrator code from Y07 reported. | cause |
| Complications from medical surgical care, visit to providers office or hospital a complication code reported as ______ diagnosis | primary |
| Intraoperative and postprocedural complications: sequenced ____ followed by code for specific complication. | first |
| External causes of morbidity: 4 main terms- type of accident: fall or _____ or intentional: stabbing, shooting. | collision |
| Land transport accidents: must be _____ or running vehicle first 2 characters indentify the vehicle. Additional codes to identify what the pt was doing at the ______ of injury. External cause codes _____ sequenced 1st | moving, time, never |
| Z codes when pt isn't sick or _____ and presnts for specific care | injured |
| Z codes that can only be and must be principal code: list of these in ______ I.C.21.c.16 | guideline |
| Contact/exposure: Z codes in guidelines. Z28- Vaccination ____ carried out and reason why not carried out coded. | not |
| Z23- vaccines and prophylactic innoculations against ______ | disease |
| Status codes: indicate pt is carrier of a disease or has sequela or residual of past disease or _____. Z codes | condition |
| Complication of disease- complication code reported and no ____ code. | status |
| Personal history: pt no longer has disease. _____ for encounter sequenced 1st. | Reason |
| Screening: when purpose for enounter is screening and doctor finds abnormality- 1st code ______ then abnormal findings. | screening |
| Observation Z codes: being observed or ruled _____ | out |
| After care codes: during healing/recovery _____ | phase |
| Follow up codes: survelliance of condition that has _____ fully and no longer exists. Z codes | healed |
| Donor: Z52, pt donates _____ or blood | tissue |
| Routine exams Z codes: if test ordered during exam but results not back and no _____ finding mentioned- without abnormal findings coded | abnormal |
| Social determinants of health (SDOH): Z codes, Ex: pt doesn't have ____ to refill prescriptions | money |
Created by:
mlovest
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