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ICD-10-PCS
An Applied approach
| Question | Answer |
|---|---|
| When is a code considered invalid? | A code is invalid if it is not coded to the full number of characters required, including the 7th character if applicable. |
| What is an “Includes” note? | An “Includes” note appears under a code to further define or give examples of the content of a category. |
| What does “Code First” mean? | Code First” instructs coders to sequence the underlying condition first, followed by the manifestation code. |
| What do parentheses ( ) indicate in ICD-10-CM? | Parentheses enclose supplementary words that may be present or absent in the statement of a disease without affecting code assignment. |
| What is the structure of an ICD-10-CM code? | ICD-10-CM codes are alphanumeric and can be 3 to 7 characters long. The first character is always a letter; the others can be letters or numbers. |
| What does a colon (:) indicate in ICD-10-CM? | A colon is used after an incomplete term that needs one or more modifiers following the colon to make it assignable to a given category. |
| How is laterality indicated in ICD-10-CM? | Laterality specifies whether the condition is on the left, right, or bilateral. If no bilateral code exists, assign separate codes for left and right. |
| What are “Excludes1” and “Excludes2” notes? | Excludes1: The condition listed is not coded here; two conditions cannot be coded together. Excludes2: The condition is not included here, but both conditions may be coded together if both are present. |
| What is a subcategory in ICD-10-CM? | Subcategories are 4 or 5 characters and provide greater detail under a category. Codes may expand up to 7 characters for specificity. |
| What is the placeholder character in ICD-10-CM? | The placeholder character is “X”, used when a code requires a 6th or 7th character but lacks a 5th or 6th character. |
| When are signs and symptoms coded separately? | Signs and symptoms are coded only when they are not routinely associated with a disease process or when a definitive diagnosis has not been established. |
| What does “See” and “See Also” mean in the Alphabetic Index? | See” directs the coder to another term for the correct code. “See Also” suggests another term may provide additional useful information. |
| What is a category code? | A category code is a three-character code that represents a general condition or disease. If not subdivided further, it can be used as a code. |
| How are acute and chronic conditions coded? | If both acute and chronic forms of a condition are documented and separate codes exist, code both and sequence the acute code first. |
| What do brackets [ ] indicate in ICD-10-CM? | Brackets enclose synonyms, alternate words, or explanatory phrases in the Tabular List and Alphabetic Index. |
| What does “Use Additional Code” mean? | This instruction means an additional code should be assigned to provide more information about a condition, such as a manifestation or underlying caus |
| What does NEC stand for and when is it used? | NEC stands for “Not Elsewhere Classified” and is used when a specific code is not available for a condition, even though the documentation is detailed. |
| What does NOS stand for and when is it used? | NOS stands for “Not Otherwise Specified” and is used when the documentation lacks specificity to assign a more detailed code. |
| What is the purpose of the 7th character in ICD-10-CM codes? | The 7th character provides additional information, such as episode of care (e.g., initial, subsequent, sequela), and must always be in the 7th position. |
Created by:
cinthiajones31