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the rules of coding are represented in the official ? for coding and reporting | guidelines |
if there is no clear cut outpatient guidelines would you refer to | inpatient guidelines |
it is important to code all the conditions that are being managed during an encounter t/f | true |
the cause of a disease or condition is aka its | etiology |
when two or more interrelated conditions exist, either could be the ? diagnosis | first listed |
which codes are used when a person who is not ill receives health care services? | V codes |
how many chapters are located in Vol 1, tabular list of icd-9 | 17 |
when a specific diagnosis is not yet known what do you report | signs and symptoms |
a(n) ? ? is a residual effect I(condition) produced after the acute phase of an illness or injury has ended | late effect |
which term is now used in place of principle diagnosis | first listed |
the same dcoding guidelines apply to both the inpatient and outpatient settings. t/f | false |
in the outpatient setting, the term first listed diagnosis is use instead of principal | true |
the first listed diagnosis is the diagnosis that the physician lists first in all circumstances t/f | false |
in the outpatient setting, a diagnosis that is documented as 'rule out' should be coded as if it exists t/f | false |
v codes can be assigned as first listed or secondary diagnoses. t/f | true |
if a patient is admitted to observation status for a medical condition a code is assigned for the medical condition as the first listed diagnosis t/f | true |
it is acceptable to use codes that descibe signs or symptoms when a definitive diagnosis has not been established by the provider. t/f | true |
if the pre and postoperative diagnoses are different, the preoperative diagnosis should be coded first t/f | false - code post op only |
code - personal history of peptic ulcer | digestive system v12.71 |
Screening for sickle cell | screening, sickle cell V78.2 |
long term use of high risk medication | long term, high risk V58.69 |
family history of breast cancer, female | history, family, malignant, breast v16.3 female |
preoperative evaluation for elective cholecystectomy due to gallstones. pt is seen by pulmonologist because of copd | look up how v72.82 - 574.20 - 496 |
a multi-gravida pt presents for routine prenatal visit. no complications are noted | look for directions v22.1 |
encounter for paternity testing | v70.4 paternity - testing |
exposure to tuberculosis | v01.1 exposure - tuberculosis |
pt admitted to observation following accident at work. no injuries found | v71.3 observation - accident - work |
screening for osteoporosis | v82.81 screening - osteoporosis |
id first listed diagnosis established pt presents with chest pain. has a history of previous myocardial infarction | chest pain |
id first diagnosis initial office visit for pt with diarrhea. physician documented gastroenteritis. | |
id first diagnosis established pt seen for redness and discharge from right eye. a diagnosis of bacterial conjunctivitis was made | |
an established patient is seen for management of diabetes and rheumatoid arthritis | |
an established pt is seen for amenorrhea and galactorrhea to rule out pituitary tumor | |
coders should assign a code to the highest level of ? | specificity |
the first step to accurate coding is to identify the ? ? in the diagnosistic statement | main terms |
a ? code can be used when a condition that is both acute and chronic exists | combination |
a three digit code is to only be used if it is not further ? | SUB divided |
a single code that entails two diagnoses is called an | combination code |
always assign codes from the icd 9 index | false |
when locating and assigning a correct diagnosis code use this index | both alphabetical index and tabular index |
which is the correct code for unspecificed acute pericarditis | 420.90 |
an ? ? is a residual effect (condition) produced after the acute phase of an illness or injury has ended | late effect |
what is the max number of digits an icd9 code contain | five |
the official guidelines for coding and reporting are updated every year | true |
if there are separate codes for both the acute and chronic forms of a condition, the code for the chronic condition is sequenced first | false |
the routinely associated signs and symptoms should not be coded in addition to a code for the particular disease or condition | true |
a late effect is the residual condition that is still present 2 months after the acute illness or injury | false (no time limit) |
it is unacceptable to code an impending condition as if it exists | true |
it is acceptable to assign codes directly from the the alphabetic index of the icd9 | false |
when sequencing codes for residuals and late effect, the residual code is generally sequnced first followed by the late effect code. | true |
it is important to follow any cross referenced instructions such as see also | true |
always verify the code from the alph index in the tabular list to assure accurate coding | true |
a combination code is a single code that may be used to classify two diagnoses | true |
multiple coding should not be used when there is a combination code that identifies all the elements documented in the diagnosis | true |
a combination code is a single code used to classify | 1. 2 diagnoses 2. a diagnosis w/ an associated secondary process (manifestation) 3. a diagnosis with an associated complication |
terms that may be used to describe a threatened condition include | evolving, impending, threating |
the correct code for a threatened spontaneous abortion is | 640.03 |
the correct code for impending shock is | no code assigned |
the correct code for cough due to pneumonia is/are | code pneumonia first 486, 786.2 |
the correct codes for dehydration due to pneumonia i/are | code pneumonia first 486, 276.51 |
correct codes for acute cystitis due to e.coli are | e.coli first574.40, 574.30 |
the correct code for viral pneumonia is/are | |
the correct code for acute and chronic laryngitis is/are | acute first 464.00, 476.0 |
acute on chronic diastolic heart failure | |
acute on chronic respiratory failure | |
calculus of the bile duct with acute and chronic cholecystitis | |
impending sirs (systemic inflammatory response syndrome) | |
acute bronchitis due to respiratory syncytial virus (rsv) | |
pneumonia due to respiratory syncytial virus (rsv) | |
malunion of previous humeral fracture | |
facial droop due to previous cva | |
dysphagia, oropharyngeal phase, due to previous stroke | |
acute and chronic renal failure IN PT WITH HYPERTENSION | |
when a pt is to have outpt surgery and the surgery is not perfored due to contraindication, the reason that the surg was not performed is the 1st dia | false |
it is appropriate to code the postoperative diagnosis as it is the most definitive diagnosis for ambulatory surgery | true |
chronic disease that are treated on an ongoing basis should be coded and reported as often as the pt receives treatment and care for the chronic conditions | true |
in the phy office it is acceptable to code v codes as the first listed diag | true |
in the outpt setting it is unacceptable to have a sign or symptom as the 1st listed diagnosis | false |
when coding an encounter for preoperative evaluation the reason that the pt is having the surgery or procedure performed is the 1st listed | true |
in the outpt setting, diag that are documented as 'prob' 'susp' 'r/o' or quest are coded only to the highest degree | false |
the 1st listed diag is defined as the diag that is the most serious | true |
it is acceptable to use a code from the icd9 manual, ch 11 in conjunction w/ v22.0 or v22.1 | false |
it is acceptable to code signs and sympt even when a definitive diagn has been confirmed | false |
it is not acceptable to code a symp when a definitive diag has been confirmed | true |
Codes from ch 11 should not be reported in conjunction w v 22.0 and v 22.1 | true |
it is acceptable to codee suspected pneumonia to the pneumonia code | false |
the phy office v codes shold only be assigned as the secondary codes | false |
when a pt is to have outpt surg and the surg is canncled the v code to indicate the reason for the canncellation is the frist listed diag | false |
when coding an encounter for a preoperative evaluation the approp v code that indicates the type of preoperative evaluation is the 1st list diag | true |
the guidlenes for coding and reporting are the same for inpt and out pt service | false |
the difinition for principal diagnos applies only to inpt in acute sht term long term care psychiatric hosp | true |