Question | Answer |
How many volumes are in the codebook? | 3 volumes |
Which volumes are used in physicians offices? | Volumes 1 and 2 |
Which volumes are used in hopspitals? | Volume 3 |
When do you code Acute (something has changed in an otherwise stable condition ~ short, but severe course) conditions? | 1st |
When do you code Chronic (condition that persists for a long period of time or reccurent) conditions? | 2nd |
Etiology | underlying cause *code 1st* |
Manifestation | signs and symptoms associated with disease *code 2nd* |
How many ICD codes can be used on a claim? | 4 |
HTN | Hypertension |
Benign | low risk, under control |
Secondary | caused by another primary condition (tumor- appears cancer has spread as a result) |
Essential | no cause found |
Malignant | high risk, life threatening |
Neoplasm | tumor, or new growth ~ classification: benign (or uncertain behavior) or malignant (primary CA in SITU (cancer in situation)) |
Lesion | abnormality of tissue ~ classification: benign or malignant |
Sequence of V codes when coding | may be listed primary or secondary depending on the condition |
Poisioning | considered an intentional overdose ~ ex. suicide (E code classification) |
Adverse effect | appropriate dose given resulting in and adverse reaction (E code classification) |
Accident | accidental overdose (E code classification) |
Theraputic use | identify agent of an adverse effect (E code classification) |
Late effect | inactive condition produced after acute phase of illness |
And/With | two conditions are present & BOTH must be present to use |
NEC | Nowhere Else Classified |
NOS | Not Otherwise Specific |
How do you code fractures? | Always coded as closed, unless stated as open (an open fracture is also known as a compound fracture) |
Primary diagnosis (diagnosis = dx) | 1st diagnosis listed on the claim form |
Encounter form | lists chief complaint |
Admitting | diagnosis given after addmission into the hospital |
Secondary | diagnosis that contributes to patient's condition |
Principal | diagnosis obtained after inpatient setting |
Italicized bracket | need for another code |
Brackets | synomyn or same meaning |
Black circle | new code |
parenthesis | add additional words to the code |
triangle | revised code |