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ch-18 basic coding

symptoms, signs, and ill defined conditions 780-799

What is the title and code numbers for chapter 16 of ICD-9-CM? Symptoms, signs and ill-defined conditions (780-799)
Objective evidence of a disease observed by the physiscian Sign
Any subjective evidence of disease reported by the patient to the physician Symptom
What types of symtoms are located in chapter 16? Symtoms associated with many systems or are of unknown cause.ex) fever, cp, cough, coma, vomiting.
What are some instances when it is ok to use a code from chapter 16? No diagnosis for the signs or symtoms can be made, including if the pt failed to return for further investigation or care or was sent somewhere else for care.
When is it ok to code a symptom as an additional code for a known cause or disease? When certain symtoms represent important problems in medical care or the symptoms are not integral to the disease.
Code: Nause and vomiting with gastroenteritis. 558.9
code:Pt w metastases to brain admitted in comatose state 198.3; 780.01. - coma is a significant condition that is not routinely associated with brain metastases.
A non epileptic fever associated seizure that is focal, prolonged (more than 15min)or recurs within 24hrs in children between 6mo and 5yrs. Febrile seizures "complicated or atipical"
What words/phrases would you look up in the alphabetic index to code signs or nonspecific findings from laboratory, x-ray or other diagnostic test. Abnormal,findings, elevation, high or positive.
Code: elevated prostate specific antigen (PSA) 790.93
Code: attending physician- fracute, left tibia; radiologis describes fracture on the shaft of the tibia 823.20
What system is followed for reporting abnormal Pap smears? The Bethesda System of Cytologic Examination
Code: Asymptomatic pt who tested positive for anthraxby nasal swab. 795.31(non-specific findings category)
Code: individual has been exposed to anthrax but has not tested positive. V01.81 (non-specific findings category)
What do you code 1st when a symptom is coded and is followed by a contrasting/comparative diagnoses. For example, abdominal pain due to either pancreatitis or cholecyctitis. Symptom is sequenced 1st so code only abdomial pain.
For inpatients or long (or short) -term what is the guideline for coding a diagnosis when a physician documents the diagnosis as "probable" "suspected" "questionable" or "likely"? Code as if it existed or was established.
For out patients only what is the guideline for coding a diagnosis when a physician documents the diagnosis as "probable" "suspected" "questionable" or "rule out"? Ex)rule our pneumoinia for symptoms of fever, cough, and malaise. Only code the 3 symtoms
What is the title and codes for chapter 18 of ICD-10-CM? Symptoms, signs, abnormal clinical and laboratory findings, not elsewhere classified (R00-R99)
A coded statement used only in ICD-10-CM. It is frequently used by physicians as the explanation of why a patient was receiving a health evaluation. R29.6, Repeated falls
Created by: marrufotheresa
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