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134 terms


When two or more diagnoses equally meet the definition for principal diagnosis?
Either one can be selected as the principal diagnosis.
It is acceptable to assign codes in the inpatient setting to diagnoses that are documented as?
Being "probable," "suspected," or "likely".
In the inpatient setting, the physician documents possible aspiration peneumonia in the discharge summary?
The aspiration pneumonia is coded as if it exists
In an inpatient setting Primary Diagnosis is defined as the?
Most serious condition during a patient's hospital stay.
In the out-patient setting, the Primary Diagnosis is not called the?
"First-listed" Diagnosis.
Patient is admitted with dysuria due to a severe urinary tract infection. What diagnoses should be reported?
Urinary Tract Infection
The discharge summary states the patient's diagnoses are peptic ulcer disease versus chronic cholecystitis. Which diagnoses should be reported?
Both Peptic Ulcer disease and Chronic Cholecystitis "either one can be principal."
The discharge summary states the patient's diagnosis is acute abdominal pain due to peptic ulcer disease or cholecystitis. Which diagnoses should be reported?
Abdominal Pain, Peptic Ulcer disease, Cholecystitis
Patient is admitted following an outpatient procedure because of an exacerbation of the patient's asthma. What is the principal diagnosis?
Exacerbation of Asthma
The ICD-10-C M, does not?
include a procedure classification Volume 3
There are 17,000 Codes in the ICD-9-C M. How many codes are in the ICD-10-C M?
141,000 Codes
This crosswalks ICD-9-C M codes to ICD-10-C M codes:
When coding gastrointestinal hemorrhage the patient does not?
Have to be actively bleeding.
An ectopic pregnancy occurs when the fertilized ovum implants?
Outside the uterus, usually in the fallopian tube.
A V27 "outcome of delivery" code is not assigned as an additional code?
to the baby's record.
A pathologic fracture is a?
A broken bone caused by disease leading to weakness of the bone.
The perinatal period extends through the first?
28 days following birth.
Non-healing burns should be coded as?
Acute Burns.
A complicated open wound occurs when there is?
Delayed healing,
delayed treatment,
foreign body,
or a primary infection is involved.
An adverse effect occurs when a drug has been?
Correctly prescribed and properly administered and the patient develops a reaction.
HIV infection cannot be reported if it is documented as?
"suspected" or "possible".
ICD-9-C M presumes a cause-and-effect relationship between hypertension and?
Chronic kidney disease.
A fifth digit of 3 "in remission" should be assigned to 305.0X for someone who has abused alcohol in the past?
But no longer drinks alcohol.
The site to which a malignant neoplasm has spread is the?
Secondary site.
Status asthmaticus is a term used for a very severe type of?
Asthmatic attack.
If a patient is admitted for dehydration due to chemotherapy, the dehydration is the?
First-listed diagnosis.
There are different coding guidelines for inpatient and?
Outpatient settings
In the outpatient setting the term "first-listed diagnosis" is used instead of?
"Primary Diagnosis".
In the outpatient setting a diagnosis that is documented as "rule-out" should not be?
Coded as if it exsits.
V codes can be assigned as either?
First-listed or secondary diagnoses.
For hemiplegia and hemiparesis and other paralytic syndromes, report the affected side as dominant if?
The documentation does not specify which side is dominant.
If a patient is admitted for observation for a medical condition, a code is assigned for the medical condition as the?
First-listed diagnosis.
It is acceptable to use codes that describe signs or symptoms when a definitive diagnosis?
Has not be established by the provider.
The Official Guidelines for Coding and Reporting are updated?
The routinely associated signs and symptoms should not be coded in addition to a code for?
The particular disease or condition.
A late effect is the residual condition that is present after?
The illness or injury has passed.
There is no time limit.
Impending conditions should not be coded as?
if it exists.
For coding purposes, urosepsis is not considered?
When sequencing codes for residuals and late effects?
The residual code is generally sequenced first followed by the late effect code.
Multiple coding is when it takes more than one code to?
Fully describe the condition,
or manifestation.
Always verify the code from the Alphabetic Index in the?
Tabular List
to assure accurate coding.
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 should not be used when?
There is a combination code that identifies all the elements documented in the diagnosis.
A combination code is a single code used to claissify:
two diagnoses,
a diagnosis with an associated secondary process "manifestation,"
a diagnosis with an associated complication
Terms that may be used to describe a threatened condition include:
ICD-9-C M codes are used to translate verbal or narrative descriptions into?
Numeric Designations.
The "Includes" notes further define or provide?
Examples to clarify assignment.
In ICD-9-C M coding, the words "AND" means either/or and "WITH" means?
Two conditions are included
The "Excludes" notes are informational and necessary?
For coding purposes.
Italicized type codes cannot be assigned as a first-listed diagnosis,because?
They are always listed after another code.
Eponyms are syndromes?
Named for a person.
Name three cross-references terms used in ICD-9-C M?
Main terms in the Alphabetic Index are in bold type, and subterms are?
Indented under main terms two spaces to the right.
The acronym ICD-9-C M means:
International Classification of Diseases, 9th Revision, Clinical Modification.
The three volumes of ICD-9-C M are:
Volume 1 Diseases: Tabular List,
Volume 2 Diseases: Alphabetic Index,
Volume 3 Procedures: Tabular List and Alphabetic Index
E codes are used to report:
External causes of injury and poisoning.
Name ICD-9-C M Conventions?
Symbols, abbreviations, punctuation, and notations.
"N E C" is the acronym for:
Not Elsewhere Classifiable
ICD-9-C M codes translate?
Medical necessity of services provided from verbal and narrative descriptions to nationally accepted reporting standards.
"N O S" is the acronym for:
Not Otherwise Specified
Words contained within the brackets "[ ]" provide the coder with:
Alternative wording,
Explanatory phrases
Colons (:) are used in the tabular list?
After an incomplete term that needs one or more of the modifiers that follow in order to make it assignable to a given category.
Italicized Font
Italicized type is used for all exclusion notes and to identify codes that should not be used to describe the first-listed or principal diagnosis.
In the Alphabetic Index of Volume 2, ICD-9-C M, nonessential modifiers are:
Terms enclosed in parentheses that have no effect on the selections of the code.
Codes that have mandatory fifth digits are codes that:
Always require a 5th digit to fully describe them.
All ICD-9-C M codes must be supported by:
Physician documentation in the medical record.
ICD-9-C M contains four active appendices in the?
Tabular List of Volume 1.
When the histological type of neoplasm is documentated, reference the?
Alphabetical Index first.
The ICD-9-C M manual was developed based on a text by what organization?
World Health Organization
Volume 2 of the ICD-9-C M manual is also known as the?
Alphabetic Index.
"E" Codes are used to?
Report external causes of injury
or poisoning.
Hospitals use Volume three of the ICD-9-C M manual to?
Report services provided to inpatients.
What is the main term:
Gouty nephropathy.
What is the main term:
Fractured clavicle.
What is the main term:
Globe adhesions.
What is the main term:
Cluster headache.
What is the main term:
Observation for high-risk pregnancy.
What is the main term:
Acute pneumonia.
What is the main term:
Pitting edema.
What is the main term:
Knee pain.
What is the main term:
Auditory neuritis.
What is the main term:
Urinary retention.
Another name for the Supplementary Classification of Factors Influencing Health Status, Contact and Health Services is:
V Codes
What organization, in conjunction with the National Centers for Health Statistics, is responsible for maintenance of the diagnosis classifications of ICD-9-C M, Volume 3?
Centers for Medicare and Medicaid Services
Identify first listed diagnosis:
Established patient presents with chest pain and has a history of previous myocardial infarction.
History of chest pain.
Identify first listed diagnosis:
Initial office visit for patient with diarrhea. Physician documented gastroenteritis.
Identify first listed diagnosis:
Established patient seen for redness and discharge from right eye. A diagnosis of bacterial conjunctivitis was made.
Bacterial conjunctivitis
Identify first listed diagnosis:
An established patient is seen for management of diabetes and rheumatoid arthritis and the physician spends equal time on each diagnosis.
Diabetes and rheumatoid arthritis
Viral hepatitis codes are divided based on?
Type of hepatitis and if condition is with or without hepatic coma.
If a patient is admitted with pneumonia and while hospitalized develops severe sepsis, report the?
Pneumonia first, followed by the severe sepsis.
When an encounter is for treatment of anemia due to malignancy, the first-listed diagnosis would be the?
Malignancy followed by the anemia.
When a neoplasm is not clearly benign or malignant, it is considered?
septic shock is considered?
Organ failure
When reporting hyptertensive chronic kidney disease, an additional code to report the type of chronic kidney disease?
Is required.
The Q-wave or transmural myocardial infarction, also known as STEMI, is the most severe type of?
Sepsis is classified as severe sepsis when there is?
Multiple organ dysfunction "MOD"
American Health Information Management Association
American Hospital Association
Ambulatory Payment Classification
a patient classification that provides a payment system for outpatients
Debridement techniques include?
sharp and blunt dissection
forceful irrigation
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.
According to Medicare LCD for Debridement Services L27373, 8/1/10, the following is considered when reporting debridement:
The care of minor wounds, either postoperative, traumatic, or otherwise, is?
incidental to other covered services.
According to Medicare LCD for Debridement Services L27373, 8/1/10, reporting debridement: the only service provided is the non-surgical cleansing of the wound or ulcer with or without the application of a surgical dressing, the provider should?
bill this service with an appropriate E/M code and not the debridement code(s).
According to Medicare LCD for Debridement Services L27373, 8/1/10, the following is considered when reporting debridement:
there is no necrotic, devitalized, fibrotic, or other tissue or foreign matter present, the debridement service is?
not medically necessary.
According to Medicare LCD for Debridement Services L27373, 8/1/10, the following is considered when reporting debridement:
of devitalized tissue from wounds, non-selective debridement, without anesthesia, including topical application(s), is part of a?
active wound care management.
According to Medicare LCD for Debridement Services L27373, 8/1/10, the following is considered when reporting debridement: CPT code selected should report the level of debrided tissue, not the?
extent, depth, or grade of the ulcer or wound.
According to Medicare LCD for Debridement Services L27373, 8/1/10, the following is considered when reporting debridement: Select the most specific ICD-9-C M code that describes the?
primary reason for the service, at its highest level of specificity, as the diagnosis on the claim.
According to Medicare LCD, when reporting debridement: When the patient has required 5 or more debridement services (11043 and/or 11044), per patient, per wound, in the outpatient setting, the claim form must also include, as secondary diagnoses?
ICD-9-C M codes reflecting neuropathic, vascular, metabolic, or other comorbid conditions that have resulted in in excessive frequency of service.
According to Medicare LCD for Debridement Services L27373, 8/1/10, the following is considered when reporting debridement: The medical record should include an operative note for the debridement service, describing?
the anatomical location treated, the instruments used, anesthesia used if required, type of tissue removed, the depth and area of the wound and the immediate post procedure care and follow-up instructions.
According to Medicare LCD for Debridement Services L27373, 8/1/10, the following is considered when reporting debridement Photographic documentation?
is recommended for prolonged or repetitive debridement services
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 what type of report done?
Since the codes for excision of skin lesions are divided based on whether the excised lesion is malignant or benign, the billing for the excision is not submitted to the 3rd party payer until the?
Pathology report has been completed.
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.
If multiple skin lesions are treated, code the most complex lesion procedure first, followed by the other using modifier?
51 to indicate that multiple procedures were performed.
3 types of closures included in the codes for lesion excision is?
3 factors to consider when reporting wound repair are?
length of wound in cm
complexity of the repair
site of the wound repair
3 types of wound repair are?
3 things are considered components of wound repair and are not reported separately.
simple ligation: tying of small vessels

simple exploration of surrounding tissue, nerves, vessels and tendons

normal debridement
What acronym is used for split thickness skin graft on a patients record?
A full thickness skin graft is often referred to on the pt record as?
What 2 items are needed to correctly code for local treatment of burns?
Percentage of body surface and depth of burn.
A major change took place in Medicare in 1989 with the enactment of the?
Omnibus Budget Reconciliation Act.
Who is the largest third-party payer in the nation?
The Government
are activities involving the transfer of health care information.
means the movement of electronic data between two entities and the technology that supports the transfer.
The following models are used to deliver managed health care.
Health Maintenance Organizations "HMO"
Preferred Provider Organizations "PPO"
Individual Practice Associations "IPA"
Medicare Part B services are billed using?
Medicare Part A pays for?
hospital/facility care
If a surgeon performs more than one procedure on the same patient on the same day, and discounts were made on all subsequent procedures, Medicare would pay what percentages for the first, second, third, fourth, and fifth procedures?
The Medicare program was established in?
The Table of Drugs and Chemicals is located in?
Volume 2
What volume of the ICD-9-C M is used by hospitals to report inpatient procedures?
Volume 3