The principal diagnosis is defined as the most serious condition during a patient's hospital stay.
A principal procedure is one that is performed for definitive treatment rather than for diagnostic or exploratory purposes, or one necessary to take care of a complication.
Carries an anesthetic shock.
Is surgical in nature.
Requires specialized training.
A significant procedure is one that:
The root operation that is defined as cutting out or off, without replacement, all of a body part is:
The Centers for Medicare and Medicaid Services (CMS) is responsible for the development of ICD-10-PCS.
In the inpatient setting, the physician documents possible aspiration pneumonia in the discharge summary. The aspiration pneumonia is coded as if it exists.
Abdominal pain, peptic ulcer disease, cholecystitis
The discharge summary states the patient's diagnosis is acute abdominal pain due to peptic ulcer disease or cholecystitis. Which diagnosis should be reported?
It is unacceptable to assign codes in the inpatient setting to diagnoses that are documented as being "probable," "suspected," or "likely."
The root operation that is defined as taking into or letting out of fluids and/or gases in a part of a body is:
In the inpatient setting, the principal diagnosis is also called the "first-listed" diagnosis.
Exacerbation of asthma
Patient is admitted following an outpatient procedure because of an exacerbation of the patient's asthma. What is the principal diagnosis?
Revision of device in
The root operation is defined as correcting a portion of a previously performed procedure is:
In the inpatient setting, a procedure code from ICD-9-CM Volume 3 would be assigned to identify a procedure.
Urinary tract infection
Patient is admitted with dysuria due to a severe urinary tract infection. Which diagnosis should be reported?
The use of a POA indicator is required for all acute-care facilities that are reimbursed under MS-DRGs.
Both peptic ulcer disease and chronic cholecystitis (either can be principal)
The discharge summary states the patient's diagnoses are peptic ulcer disease versus chronic cholecystitis. Which diagnoses should be reported?
When two or more diagnoses equally meet the definition for principal diagnosis, either one can be selected as the principal diagnosis.
A two digit ___ may be added after the main CPT number when necessary to indicate that additional factors should be considered or to further explain the situation.
An ____ patient has been seen by the doctor or a doctor from that practice within the past three years.
If the index shows the following suggested numbers 99211-99214, this is called a ____ of numbers.
Physical status modifiers, qualifying circumstances
When coding anesthesia, there are two types of modifiers you add when given the information. List one of these modifiers.
A patient who has not been formally admitted to a health care facility like a hospital is called an:
1. Never code directly from the index.
2. Analyze the statement or description provided that designates the item that requires a code.
3. Identify the main term in the index.
4. Check for relevant subterms under the main term.
5. Note the code(s) found after the selected main term or subterm.
6. Verify the code in the tabular.
CPT Coding Process: