Medical Coding & Billing ICD-10 Final
Terms in this set (25)
ICD-10CM codes are used for reporting ______.
a. A patient's diagnosis or reason for visiting the provider and related information that might influence the diagnosis or treatment.
b. Only a patient's diagnosis, if known or determined by the provider.
c. The procedures and services offered by the provider
d. Only the patient's past medical and social history
The first-listed diagnosis is always the _____.
a. Patient's symptoms and signs
b. Patient's most serious diagnosis or symptom
c. Provider's choice based on the expense of providing care
d. Patient's specific reason for seeing the physician or being admitted to the hospital
Z codes allow reporting of ______.
a. Diagnoses that are not serious enough to be listed in the other ICD-10-CM chapters
b. Only factors that influence a patient's treatment
c. Information that influences the diagnosis and reasons for seeing the provider in which the patient is not ill
d. External causes of accidents, injuries, or illnesses
The GEMs allow _____.
a. A coder to simply look a new code up in the GEM if the ICD-9-CM code is known without having to follow the complicated coding process
b. Coders to substitute ICD-9-CM codes for ICD-10-CM codes by looking up the codes in the GEM
c. Conversion or mapping of an ICD-9-CM code to the new ICD-10-CM code and vice versa
d. Replacement of the coding step-by-step process with an electronic mapping directory
Z codes _____.
a. Cannot be listed first as the first-listed diagnosis for patients who have a documented diagnosis
b. Can be listed first as the first-listed diagnosis in specific situations
c. Can be listed first if the provider determines that the factor is significant enough to alter the diagnosis
d. Are only used to describe non-diagnosible patient encounters, so cannot be listed first since they do not describe a diagnosis
ICD-10-CM code _____.
a. Must have at least three characters in the code but may have up to 7
b. Must have 7 characters in the code
c. Always starts with a numerical 3-character set of codes
d. Begins with either a letter or number depending upon the code
Information in the code description found in square brackets refers to _____.
a. Diagnosis excluded from the specific code
b. Supplementary words or explanatory information
c. Synonyms, abbreviations, alternative wording, or explanatory phrases to help select the correct code
d. Information that indicates the coed is incomplete alone and must have additional characters to fully code the diagnosis
Excldues1 Notes describe _____.
a. Diagnoses that may be required as additional codes to fully explain the diagnosis
b. Diagnoses that are not included in the code, but may also be present and may be coded along with the diagnosis code
c. Diagnoses that should never be coded for a patient
d. Diagnoses that may NOT be coded with the codes in the group
Code First Notes tell the coder to _____.
a. Code the more serious diagnosis first before the codes listed in the set
b. Code the first-listed diagnosis first
c. Code the diagnosis listed under the note first before the codes in the group, such as an underlying infection
d. Never code the items under the note as the first-listed diagnosis
After determining the main terms from the patients record, an excellent coder _____.
a. Uses either the Alphabetic Index or the Tabular List to locate the code
b. First locates the main term(s) in the Alphabetic Index
c. First locates the code in the Tabular List and then references the Alphabetic Index as needed
d. Uses the GEMs to select the correct code for ICD-10-CM
When coding infections, ______.
a. Select the code for the infecting microorganism plus any resistance to drugs using only the A codes
b. It is only necessary to note the type of infection and not the specific infecting organism
c. Select a code that clearly identifies the specific microorganism causing the infection, if known and referenced in the patient record
d. It is only necessary to code for the specific manifestations of the infection
ICD-10-CM codes are _____.
a. Mose specific, detailed, and current than ICD-9-CM codes
b. More general and easier to use than ICD-9-CM codes
c. More complicated and tedius than ICD-9-CM codes making finding the correct and most specific code more difficult
d. Shorter and less specific than ICD-9-CM codes encompassing more diagnoses in a single code allowing fewer codes to be used
When he physician has indicated in the patient record that she suspects HIV infection or HIV infection is probable, _____.
a. Code as probably HIV infection using B codes
b. Assume that the patient is infected and code using the appropriate HIV infection code
c. Do NOT code an HIV infection using the B codes
d. Code as an HIV infection using Z codes rather than B codes
After identifying the type of neoplasm in the patient's record, the next step in coding a neoplasm is to _____.
a. Reference the type in the Neoplasm Table and determine the appropriate column then reference this code in the Tabular List.
b. Go to the Alphabetic List and code as you would any other diagnosis
c. Use the Neoplasm Table to find the correct code
d. Go to the Tabular List and then cross-reference the identified code in the Neoplasm Table
When coding diagnoses from the nervous system, you must select the code for the dominant side which is _____.
a. The right side since most people are right-handed
b. The side that correlates with the patient's dominant handedness
c. The side that will impact the patient in the most significant way as determined by the physician
d. The right side if the patient is ambidextrous
When coding diagnoses for the eyes and ears, _____.
a. It is not necessary to know the condition of both eyes or ears of only one is affected
b. It is often necessary to know the condition of the opposite eye or ear even if only one is affected
c. The codes reflect the condition of both eyes or both ears and distinguishing between right and left side it not reflected in the code
d. It is important to know which eye or ear is dominant
When coding hypertension, _____.
a. Typically list essential hypertension as the first-listed diagnosis
b. Always code secondary hypertension as the first-listed diagnosis
c. Code essential or malignant hypertension as an additional code to the code for an underlying cause since it is always caused by some other disease
d. Code hypertension as the first-listed diagnosis when coding hypertensive cerebrovascular disease
When coding respiratory infection diseases, _____.
a. Use either the J code that includes the infective agent or an additional code that identifies the infective agent if a combination code does not exist
b. Use only the code for the type of respiratory infection; additional codes for infections are not appropriate
c. Use only combination codes to describe the infectious agent
d. It is only necessary to describe the infection and not the infective agent
When coding a non-pressure chronic ulcer using L codes, _____.
a. Select the code that reflects the appropriate stage of the ulcer
b. Select the code that reflects the appropriate anatomical site and stage of the skin ulcer
c. First code the underlying condition that is causing the ulcer from the circulatory system codes
d. Do not report underlying conditions since non-pressure chronic ulcers are skin diseases and are reported using L codes
When coding diseases and disorders for a pregnant patient, _____.
a. Only report the specific trimester for high risk pregnancy problems
b. Determine the specific trimester from the patient's medical record or query the physician; avoid codes reflecting unspecified treatment if possible
c. Report the specific week of gestation using O codes if the physician has specified a specific week
d. Use O codes to report a normal pregnancy without complications if the patient is pregnant.
If a pregnant patient is seeing the physician for a routine outpatient prenatal check-up and there are no complications, _____.
a. Use the appropriate O code for normal, non-complicated pregnancy and report the week of gestation; query the physician if the gestational week is not indicated in the patient record
b. Use the appropriate O code for normal, non-complicated pregnancy and report the trimester or the pregnancy
c. Use codes from Z34 rather than O codes to report the patient encounter
d. Report only the reason for the visit that is not associated with the pregnancy
An abnormal finding on a neonatal screening should be reported using _____.
a. P codes that report disorders of the newborn rather than O codes that report problems with pregnancy, labor, and delivery
b. O codes that report problems with pregnancy, labor, and delivery
c. Z codes that report problems with the fetus and neonate rather than O codes that report problems with the mother
d. O codes since problems with the neonate reflect maternal factors
If a patient sees her physician with a symptom, _____.
a. Only code the visit if the physician makes a definitive diagnosis
b. Query the physician for her best guess for the diagnosis since all encounters must have a diagnosis code
c. Report the reason for the visit using an R code if the physician cannot make a definitive diagnosis and refers the patient somewhere else for additional study
d. Report the reason for the visit using an R code if the physician wants the patient to return in two weeks to see how the patient responds to medication
A patient sees the physician because of a fractured leg. You should report the diagnosis with _____.
a. The general code for the fracture identifying the bone that is damaged; it doesn't matter the cause of the fracture
b. The code for the underlying condition of a pathological fracture or the code for the external cause; these causes should be the first-listed diagnosis
c. The most specific S code and no other code unless the fractured area has become infected
d. S codes describing the fracture plus appropriate codes from Chapter 20 that describe the external cause of the fracture
When coding a burn injury, it is important to _____.
a. Select the code that describes the degree of burn as well as provide a code that describe the cause of the burn
b. Select the code that describes the anatomical site of the code and the lowest degree of the burn
c. Sequence the site of the lowest degree burn first
d. Only report the site of the highest-degree burn