Medical Coding

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For hemiplegia and hemiparesis and other paralytic syndromes, report the ______ side as dominant if the documentation does not specify which side is dominant

Affected

Diabetes mellitus codes are __________ codes that include the type of diabetes as well as the body system involved and complications affecting the body system.

Combination

For reporting purposes, urosepsis is not considered _______.

Sepsis

Multiple coding is?

when it takes more than one code to fully describe the condition, circumstance, or manifestation.

SIRS is the diagnosis, when all of the following are diagnosed?

hypothermia or fever
tachycardia
tachypnea
increased or decreased WBC

Combination code?

Single ICD-9-CM code used to identify etiology and manifestation of a disease.

When reporting an infection that is antibiotic resistant, report the _____ first, followed by _____,

Infection then infection with drug resistant microorganisms.

If the medical documentation indicates the patient has 2 conditions that are both included in one diagnosis code?

Report that diagnosis code only once.

Multiple coding is also known as?

Dual coding

Multiple coding/Dual coding is?

The use of more than one ICD-9-CM code to identify both etiology and manifestation of a disease, as contrasted with combination coding.

When the histological type of neoplasm is documentated, reference the______ first.

Alphabetical Index

Viral hepatitis codes are divided based on?

Type of hepatitis if condition is with or without hepatic coma.

If a patient is admitted with pneumonia and while hospitalized develops severe sepsis, report the ____ first, followed by the ____.

Pneumonia
Severe sepsis

When an encounter is for treatment of anemia due to malignancy, the first-listed diagnosis would be the _____, followed by the ____.

Malignancy
Anemia

When a neoplasm is not clearly benign or malignant, it is considered?

Uncertain

septic shock is considered?

Organ failure

hepatitis A was formerly known as?

Infectious or epidemic hepatitis

When reporting hyptertensive chronic kidney disease?

An additional code to report the type of chronic kidney disease is required.

The _____, or transmural myocardial infarction, also known as STEMI, is the most severe type of infarction.

Q-wave

Sepsis is classified as severe sepsis when there is _____ _______ _______.

Multiple organ dysfunction MOD.

AHA

American Hospital Association

AHIMA

American Health Information Management Association

APC

Ambulatory Payment Classification
a patient classification that provides a payment system for outpatients

Codes 11042-11047 are based on depth of tissue removed and surface area for wound.
How is reporting for one wound different from reporting for multiple wounds?

One wound: report depth of the deepest level of the tissue removed.
Multiple wounds: sum the surface area of the wound at the same depth. Do not combine sums of different depths.

Skin Lesion excision and destruction methods: To code these procedures properly, you must know the?

Site, number, and size of the excised lesion (s)s, as well as whether the lesion is malignant or benign.

The pathology report following skin lesion excision is used to identify the size of the lesion only if?

No other record of the size can be documented because the solution the lesion is stored in shrinks the lesion.

All skin lesions excised will have a ______ report ?

Pathology

Since the codes for excision of skin lesions are divided based on whether the excised lesion is ___ or ____, the billing for the excision is not submitted to the 3rd party payer until the __ __ has been completed.

Malignant
Benign
Pathology report

Why is there no pathology report for lesions that have been destroyed by laser, chemicals, electrocautery, or other methods?

Destruction of lesions destroys the lesion, leaving no available tissue for biopsy. In these cases you will have to take the type of lesion from the physician's notes only, as there is no pathology report.

3 types of closures included in the codes for lesion excision are?

Direct,
Primary
Simple

You would not report both a biopsy and an excision performed at the same time because?

Biopsy is bundled into the excision service.

When closure is required following biopsy, _____ closure is bundled into the biopsy codes?

Simple

If closure of the biopsy site is more than a simple closure, you would report?

The more extensive closure separately.

11100 reports a single lesion, and 11101 is an add-on code for each additional lesion.
The correct coding for 3 lesions would be?

11100 for lesion one and 11101X2 for lesions 2 and 3
Do not assign modifier -51 with these biopsy codes

Do not use modifier -51 with skin tag codes, as the codes are based on the?

Number of lesions removed.

Shaving of a skin lesion - Shaving codes are defined according to ___ and __ of the lesion.
If more than one lesion was removed,

Location and size

Add modifier -51 to any codes after the first code, placing the more intensive procedure first.

A pilonidal cyst is considered complicated when it is larger than ___ cm.

2

3 factors to consider when reporting wound repair.

1. length of wound in cm
2. complexity of the repair
3. site of the wound repair

Wound repair is classified by?

The type of repair necessary to repair the wound.

Simple wound repair is coded as?

superficial wound repair (12001-12021)
involves epidermis, dermis and subcutaneous tissue and requires only simple, one-layer suturing.

Intermediate wound repair code requires?

Closure of one or more layers of subcutaneous tissue and superficial "non-muscle" fascia, in addition to the skin closure.

You can report intermediate closure? (12031-12057)

When the wound has to be extensively cleaned, even if the closure was a single-layer "simple" closure.

Complex wound closure?

Involves complicated wound closure including revision, debridement, extensive undermining, stents or retention sutures, and more than layered closure (13100-13160)

3 types of wound repair?

1. simple
2. intermediate
3. complex

3 things are considered components of wound repair and are not reported separately.

1. simple ligation: tying of small vessels

2. simple exploration of surrounding tissue, nerves, vessels and tendons

3. normal debridement

Types of grafting procedures are?

Adjacent tissue transfers or rearrangements,

Skin replacement surgery and skin substitutes
flaps.

Types of adjacent tissue transfer or rearrangement (14000-14350).

Z-plasty
W-plasty
V-Y plasty
Rotation flaps
Advancement flaps

Adjacent tissue transfers are reported according to?

Size of the recipient site in square cm.

Adjacent Tissue Transfer or Rearrangement (1400-14350) in the CPT manual is divided based on?

The location of the defect and the size of the defect.

A split thickness skin graft is often referred to on the patient's record as?

STSG

A full thickness skin graft is often referred to on the patient's record as?

FTSG

Codes for skin graft flaps do not include _____ or ______.

Extensive immobilization that may be necessary, such as a large plaster cast, or
the closure of the donor site.
These must be reported in addition to the flap procedure.

How is the percentage of body area calculated in adults for reporting burns?

Rule of Nines

How are burn dressing and/or debridement areas defined?

Small = >5% of total body surface.
Medium = whole face or whole extremity, or 5% - 10% of total body surface area.
Large = more than one extremity or > 10% of total body area.

What 2 items are needed to correctly code for local treatment of burns?

Percentage of body surface and depth of burn.

Incision and drainage codes are divided into subcategories according to the?

Condition for which the procedure is performed.

Excision defined as full thickness would be through the?

Dermis

_____ is a type of crosswalk to find corresponding diagnosis codes between ICD-9-CM and ICD-10-CM?

GEMs "General Equivalence Mappings"

GEMs "General Equivalence Mappings" is a tool?

That assist with the conversion of International Classification of Diseases, 9th Edition, Clinical Modification "ICD-9-CM" codes to International Classification of Diseases, 10th Edition "ICD-10".
And the conversion of ICD-10 codes back to ICD-9-CM.

The maximum number of characters in an ICD-10-CM code is?

7

V codes may be assigned as?

first listed or a secondary diagnosis.

Certain V codes may be used as the principal/first-listed diagnosis.
Others may be assigned only as additional codes.
Still others may be sequenced as either principal/first-listed or secondary.

V codes identify?

Circumstances for encounter related to circumstances other than a disease or injury and are also used to report problems or factors that may influence present or future care.

The V code chapter is a ?

Supplemental classification of ICD-9-CM.

If there are separate codes for the acute and chronic condition, code for the _____ condition first as long as both codes are listed at the same indentation level of the Index.

Acute

Late effect is?

The residual effect after the acute phase of an illness or injury has passed.

If the type of diabetes mellitus is not documented in the medical record, the default is ______ diabetes mellitus.

Type 2

Osteoporosis is a _____ condition, meaning that all bones of the musculoskeletal system are affected.

Systemic

A major change took place in Medicare in ____ with the enactment of the Omnibus Budget Reconciliation Act.

1989

______are activities involving the transfer of health care information and ____ means the movement of electronic data between two entities and the technology that supports the transfer.

Transactions
Transmission

Models that are used to deliver managed health care are?

Health Maintenance Organizations "HMO"
Preferred Provider Organizations "PPO"
Individual Practice Associations "IPA"

Medicare Part B services are billed using?

ICD-9-CM, CPT and HCPCS

Medicare Part A pays for?

Hospital/facility care

The Medicare program was established in?

1965

In the ICD-9-CM, the Table of Drugs and Chemicals is located in?

Volume 2

In ICD-9-CM, Term "NOS" means?

Not otherwise specified

What volume of the ICD-9-CM is used by hospitals to report inpatient procedures?

Volume 3

Words contained within the brackets "[ ]" provide the coder with?

Synonyms, alternative wording, or explanatory phrase.

Symbols, abbreviations, punctuation, and notations in ICD-9-CM are termed?

Conventions

ICD-9-CM contains ____ active appendices in the Tabular List of Volume 1.

5

The three volumes of ICD-9-CM are?

Volume 1-Diseases: Tabular List,
Volume 2-Diseases: Alphabetic Index,
Volume 3-Procedures: Tabular List and Alphabetic Index.

In the outpatient setting the term "first-listed diagnosis" is used instead of?

Principal diagnosis

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