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Coding Chapter 2
Coding and Converntions
| Question | Answer |
|---|---|
| ICD-10-CM was developed to classify _________ data from inpatient and outpatient records, including physician office records. | Morbidity |
| General equivalence mappings are translation dictionaries or _________ of codes. | crosswalks |
| Outcome of delivery, follow-up, history, and vaccination are examples of ICD-10-CM | factors influencing health status |
| The Table of Neoplasms is located in the ICD-10-CM | Index to Diseases and Injuries |
| A patient is diagnosed with "tactile agnosia involving body image and other senses." Referring to the ICD-10-CM Index to Diseases and Injuries, which is the main term for this condition? | agnosia |
| A patient is diagnosed with "traumatic hematoma with intact skin surface." Referring to the ICD-10-CM Index to Diseases and Injuries, which is the main term for this condition? | hematoma |
| ICD-10-CM _________ codes are reported by all health care settings. | disease |
| Adhering to official coding guidelines is | Required by the Health Insurance Portability and Accountability Act |
| Which organization approves the ICD-10-CM Official Guidelines for Coding and Reporting | Cooperating Parties for the ICD-10-CM/PCS |
| If an index entry is too lengthy to fit on one line, additional text is | printed on the next line and indented 5 spaces |
| ICD-10-CM index contains the abbreviation NEC and verification of the code in the tabular list validates the assignment of code, which coding convention explains this code assignment? | Whenever a specific code is not available on the Index for condition, the coder is directed to the "other specified" code in the tabular list |
| ICD-10-CM tabular list contains the abbreviation NOS, which coding convention is followed to determine code assignment? | If information to assign a more specific code was not documents by the provider, the coder assigns an "unspecified" code |
| The use of a colon in the ICD-10-CM tabular list indicates | one or more additional terms are needed in the diagnostic statement to classify a condition |
| Includes notes appear | below the ICD-10-CM category in the tabular list |
| Excludes1 and Excludes2 notes appear in the | ICD-10-CM tabular list only |
| Trust the index is an ICD-10-CM concept that is used when | a subterm located in the index is not listed in the tabular list |
| Unspecified codes | often contain a fourth and/or fifth character of 8 or 9 |
| Etiology codes | contain a use additional code instruction in the ICD-10-CM tabular list |
| The –see also instruction in the ICD-10-CM index follows a main term, subterm, or qualifier, and it refers the coder to another main term that | may provide additional useful index entries. |
| Using both the ICD-10-CM index and tabular list when assigning codes results in | accurate code assignment. |
| When a related definitive diagnosis has not been established (or confirmed) by the provider for an outpatient or physician office encounter, codes are assigned to | signs and symptoms. |
| When the provider documents the same condition as acute (or subacute) and chronic during an encounter, and the ICD-10-CM index contains subentries for each | code both and sequence the acute (or subacute) code first. |
| When a residual effect is documented after the acute phase of injury or illness has ended, a code for the _________ condition is sequenced first. | residual |
| To initially locate an ICD-10-CM external causes code, go to the | Index to External Cause of Injuries. |
| "Persons with unavailability and inaccessibility of health care facilities" is an example of a(n) | chapter of Z codes in ICD-10-CM. |
| Which set of codes is used to report how an injury or condition happened, the intent, the place of occurrence, the activity of the patient at the time of the event, and the person's status? Responses | ICD-10-CM external causes codes |
| The ICD-10-CM Tabular List of Diseases and Injuries is referenced | to verify codes selected and to review instructions. |
| Which type of note is usually found below the infectious disease code in the ICD-10-CM tabular list, indicating the need to report the organism code as a secondary code? Responses | Use additional code |
| When the causal condition is known, the code for that condition should be reported as the __________ diagnosis. Responses | principal |
| When the same condition is described as both acute (or subacute) and chronic and separate subentries exist in the ICD-10-CM index at the same indentation level, | code both and sequence the acute (or subacute) code first. |
| For a diagnosis of headaches due to intracranial injury without loss of consciousness that occurred several years ago, which is considered the sequela (residual condition)? Responses | Headaches |
| ICD-10-CM codes that indicate laterality specify whether the condition occurs | on the left, right, or bilaterally. |
| When assigning codes for a syndrome, follow guidance in the | ICD-10-CM index. |
| How are etiology and manifestation codes reported in the ICD-10-CM? | Etiology code is reported first, followed by the manifestation code. |
| The "see also" instruction in ICD-10-CM | does not have to be followed if the original main term provides the correct code. |
| Which information must be included in the diagnostic statement to classify a condition in the ICD-10-CM tabular list? | Modifying term(s) located after the colon |
| The description for code J00 in the ICD-10-CM Tabular List of Diseases and Injuries is "acute nasopharyngitis [common cold]." How is this code description interpreted? Responses | Acute nasopharyngitis and common cold are synonymous. |
| The concept "trust the index" in the ICD-10-CM disease index means that when | a term has been used to correctly locate a code in the disease index, but that term is not described in the tabular list code entry, trust that the index directed you to the correct code. |
| Which instruction in the ICD-10-CM tabular list allows only one code to be reported if a secondary condition is not documented? | Code, if applicable, any causal condition first |