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AAPC CPC study notes
Important Guidelines, etc
| Question | Answer |
|---|---|
| A and B codes: _____ diseases | infectious |
| C and most D codes: _____ | neoplasms |
| Some D codes: ____ disorders/diseases, anemia, etc. | blood |
| _____ codes: endocrine | E |
| F codes :____ health and behavioral | mental |
| G codes: ______ system | nervous |
| H codes: ____ and ear | eye |
| I codes: _______ system | circulatory |
| J codes: _____ system | respiratory |
| K codes: _____ system | digestive |
| L codes: _____ and subcutaneous diseases | skin |
| M codes: _____ and connective tissue | musculoskeletal |
| ____ codes: urinary system | N |
| O codes: childbirth and _____ | pregnancy |
| P: ____ codes, newborns | perinatal |
| Q codes: congenital malformation, _____, etc. | deformities |
| R codes: signs/symptoms and _____ clinical and lab findings, not elsewhere classified. | abnormal |
| S and T codes: injury, _____ and external causes consequences. | poisoning |
| V, W, X and Y codes: external _____ of morbidity. | causes |
| Z codes: health _____ | services |
| U codes: codes for ____ purposes: example Covid-19 | special |
| MRSA: code underlying cause, use ____ code if applicable. | combination |
| Severe sepsis: code for underlying _____ then code from R65.2 | infection |
| Reason for admit is respiratory symptoms from Covid-19, first code U07.1 for covid then code for ______ caused by this. | manifestations |
| Covid-19 sequenced 1st, then manifestations except for _____, sepsis and transplant complications -these coded first. | pregnancy |
| Asymptomatic with exposure or suspected exposure of ____: code Z20.822. | Covid |
| Admitted for HIV related illness: code ____ followed by additional code for all reported HIV related conditions. | B20 |
| HIV: with any known prior diagnosis, should be coded _____ always. | B20 |
| Malignant neoplasm of ectopic tissue: coded to the ____ of origin. Ex: pancreatic neoplasm involving the stomach coded as pancreatic neoplasm. | site |
| If reason for admission is chemo, immunotherapy or radiation (external beam) code this ____. | first |
| When addmission is for anemia associated with the malignancy, and treatment is ONLY for anemia, code first for the ______. | malignancy |
| Admission for anemia associated with chemo or immunotherapy adverse effects and treatment is ONLY for anemia, code the _____ first. | anemia |
| Admission for dehydration d/t malignancy and ONLY dehydration being treated, code ______ first. | dehydration |
| Admission ONLY for chemo, immunotherapy, radiation: code first for this then the ______ | malignancy |
| Reason for encounter is for treatment of primary malignancy assign the malignancy as _____ diagnosis. | first |
| Encounter is for primary malignancy with metastasis and treatment is for the metastatic site only, the metastatic site is _____ diagnosis. | primary |
| Encounter for complication associated with neoplasm such as dehydration, and treatment only for this, code for the ______ first. | complication |
| When pathological fracture d/t neoplasm and treatment focused on fracture, code this _____ followed by neoplasm code. | first |
| Malignancy due to transplanted organ: code first the complications of ______ organ followed by neoplasm code. | transplanted |
| If documentation doesn't state what type of diabetes but says pt uses insulin: code for DM type ____ | 2 |
| G89 codes (pain) listed as primary when: pain control is the _____ for admission/encounter. When admitted for insertion of neurostimulator for pain control, underlying condition coded second. | reason |
| If encounter is for any other reason except pain control and a related definitive diagnosis has not been ____, code for the specific site of pain first followed by code from _____. | established, G89 |
| When encounter is for pain control assign code from G89 followed by code for specific _____ of pain. | site |
| Neoplasm r/t pain: when reason for admission is for pain management code G89.3- pain associated with cancer coded ____. | first |
| Pain: Reason for admission is for management of neoplasm , code pain as ______ diagnosis. | secondary |
| R03.0: elevated blood ____ reading without hypertension diagnosis. | pressure |
| Hyptertension, Resistant: bp that remains high even after antihyptertensives. Code I1A.0, Code for the ____type of existing hyptertension FIRST. | specific |
| Coronary artery disease admitted d/t acute MI the acute MI sequenced ____ then CAD | first |
| Acute MI: encounters after 4 weeks and pt is still recieving care r/t the MI- ______ code should be used rather than code from I21 | aftercare |
| For old or healed MI's not requiring further care, code I25.2 for ____ MI may be assigned. | old |
| Subsequent acute MI: I22 code- type I or unspecified acute MI, within _____ weeks of previous acute MI. | 4 |
| If subsequent MI of one type occurs within 4 weeks of a MI of a _____ type, code from I21 to identify each type. Code I22 is only for type 1 or unspecified. | different |
| Acute respiratory failure 1st diagnosis when: condition established after ____ to be cheifly responsible for admision, but specific coding guidelines as in HIV etc take precedence. | study |
| Pt admitted for acute resp failure and another acute condition: sequencing based on ______ of admision. If both resp failure and other condition are equally responsible there's no sequencing rules. | circumstances |
| Pt admited for one type of pneumonia and develops VAP- code the pneumonia at _____ first. | admission |
| If admitted with pressure ulcer and healed during stay: assign code for _____ at time of admission. | stage |
| Pregnancy codes: last character indicates _____. | trimester. |
| Pathologic fracture: pt recieving active treatment for it- 7th character ____. Pt completed treatment and is now receiving routine care during healing phase- 7th character _____. | A, D |
| Pathologic fracture: pt being seen for sequela of fracture- 7th character _____ | S |
| If condition being seen for is affecting the pregnancy: code for the ______ using O code. | condition |
| If condition being seen for isn't affecting the pregnancy and documentation specifically says it isn't, report the condition not using O codes and report _____-pregnant state, incidental. | Z33.1 |
| 7th character 0 for when ______ gestations, documentation insufficient to determine fetus affected and no way to confirm, when not _____ to clinically determine fetus affected (for some O codes) | single, possible |
| Prenatal visits with high-risk pregnancy: code from O09 "supervision of high risk pregnancy" reported ____ | first |
| When pt admitted and delivers baby during that stay, the condition that ____ admission reported first. | promted |
| Code from Z37 should be on every maternal record when a ____ has occured. | delivery |
| DM in pregnancy: code from _____, followed by appropriate diabetes codes (E08-E13). | O24 |
| Do Not use codes Z79.4, Z79.84 (long term insulin/hypoglycemic) with _____- "Gestational DM" | O24.4 |
| Alcohol , tobacco, drug use during pregnancy: code from O99-coded first followed by code from ____ category | F |
| Code ____ for normal full term pregnancy, always principal diagnosis and outcome of delivery- _____ "single live birth" | O80, Z37.0 |
| Physical, psychological or sexual abuse of pregnant pt code from _____ used. | O9A |
| Perinatal (chapter 16) codes may be used throughout the ____ of the pt. | life |
| If multiple coma scales done within the 1st 24 H of admission only report scale at ______. | admission |
| When SIRS with a non-infectious condition, no subsequent infection such as an injury, code for this first followed by appropriate ______ code. | SIRS |
| Injury with sequela: code for specific type of sequela _____ (Ex: scar) then code for the injury code with 7th character _____ (Ex: burn). | first, S |
| The code for the most ____ injury and focus of treatment reported 1st. | serious |
| Superficial injuries (abrasions, contusions, etc) are not coded with more severe injuries of same ____. | site |
| When primary injury results in damage to blood vessels/nerves, code for ______ injury first followed by blood vessel/nerve damage. | primary |
| Code from M80, not a _____ fracture code, should be used with known osteoporosis who suffers a fracture even if pt had a minor fall or trauma, if that fall or trauma would _____ usually break a normal healthy bone. | traumatic, not |
| Non healing burns are coded as _____ burns. Necrosis of burned skin coded as non-_____ burn. | acute, healed |
| Codes for underdosing should _____ be used as primary diagnosis. | never |
| Conditions that affect the function of the transplanted kidney other than CKD, code from T86.1 and a secondary code describing _____. | complication |
| External causes of morbidity/external cause codes should never be ______ code. | primary |
| Sequela external cause codes never used with a related current nature of _____ code. | injury |
| Code _____ is for encounters for prophylactic vaccine. | Z23 |
| Status code to indicate pt is either a carrier of the disease or has _____ or residual of past disease or condition. Not the same as _____ codes. | sequela, history |
| Z68: _____. Z79: _____-term drug therapy. | BMI, long |
| Two types of history Z codes: _____ and family. | personal |
| Personal history codes: pt's past medical condition that no _____ exists and is not receiving any treatment. | longer |
| Screenings, Z codes: pt with s/s that prompted the test , code for the _____ that prompted the test. | sign/symptom |
| Screening, Z codes: pt does not have s/s to prompt the test, report a _____ code. If condition discovered during testing, it may be assigned as additional diagnosis. | screening |
| Observation codes listed as ____ diagnosis . May be reported as secondary when pt observed for a condition that is ruled _____ and unrelated to the principal/first listed diagnosis. | primary, out |
| Aftercare Z codes not used if treatment directed at ____, acute disease. | current |
| Aftercare visit codes for situations when the initial treatment of a disease has been performed and the pt requires _____ care during the healing phase. | continued |
| Admitted for treatment then treatment not carried out, still report the code for _____ for admission. | reason |
| When admission for treatment of a complication resulting from surgery or other medical care, the _____ code is sequenced first. | complications |
| Pt admitted for observation and condition ______ and then pt admitted as inpatient for same condition and hospital, the principal diagnosis is condition which led to ____. | worsens, admission |
| Outpatient surgery and develops complications requiring admission, code for reason for _____ first, followed by complications codes. | surgery |
| Pt receiving only diagnostic services during encounter: first code _____ for encounter. | reason |
| If routine testing done during same encounter for non-routine test to eval a s/s assign both the _____ code and the reason for the non-routine test. | Z |
| Outpatient: diagnostic tests that have been interpreted by a physician and the final report available, code any confirmed ______ in the interpretation, and do not code for realted s/s as ______. | diagnosis, additional |
| Pt's receiving therapeutic services only: first code the reason for encounter. Exception to this: primary reason is for _____ or radiation- first report Z code for the service then the reason service being _____. | chemo, performed |
| Pt's receiving pre-op evals only: sequence first code from Z01.81 "encounter for pre-op exams" then code for the condition to describe _____ for surgery then code any ______. | Reason, findings |
| Ambulator surgery: code diagnosis for which surgery performed. If post-op diagnosis _____ from preoperative then code this. | different |
| Exam with abnormal findings: code for the exam with abnormal findings first then code for the ______ findings. | abnormal |
| Leave "present on admission" ____ if the condition is on the list of ICD-10 codes for which this field isn't applicable, and this is the only circumstance for this blank field. | blank |
Created by:
mlovest
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