When a related definitive diagnosis has not been established by the provider.
When are codes that describe symptoms and signs acceptable for reporting purposes?
When the sign or symptom is not routinely associated with that diagnosis.
When can codes for signs and symptoms be reported in addition to a related definitive diagnosis?
The definitive diagnosis.
If you use a sign and symptom code with a related definitive diagnosis, which gets sequenced first?
Otherwise instructed by the classification.
Signs or symptoms that are associated routinely with a disease process should ot be assigned as additional codes, unless.....?
ICD-10 contains a number of combination codes that identify both the definitive diagnosis and common symptoms of that diagnosis. Should you use an additional code for the symptom when using combination codes?
When a patient has recently fallen and the reason for the fall is being investigated, what code is assigned?
1. traumatic brain injury codes
2. cerebrovascular disease
3. sequale to cerebrovascular disease
Coma scale codes (R40.2) can be used in conjunction with:
Coma scale codes are primarily used by ______ _____, but they may be used in any setting where this information is gathered.
When only the total score is documented in the medical record and not the individual score(s).
When can the Glascow coma scale, total score code be used?
The lack of ability to use one's limbs or to ambulate due to extreme debility
What is functional quadriplegia?
Only when functional quadriplegia is specifically documented in the medical record.
When should code R53.2 be assigned.
The initial score documented on presentation at your facility.
For coma scale scores, you should report at least.....?
EMT documentation or in the emergency department.
Where can initial presentation coma scale scores come from?
2. Malignant neoplasm.
Examples of SIRS developing from certain non-infectious disease processes.
assign the code for the underlying condition followed by R65.11.
What should be coded when SIRS is documented with a noninfectious condition and no subsequent infection is documented?
What is the code for systemic inflammatory response syndrome (SIRS) of non-infections origin without acute organ dysfunction? With acute organ dysfunction?
Query the physician.
If you use SIRS with acute organ dysfunction is documented, but it cannot be determined if the acute organ dysfunction is associated with SIRS or due to another condition, what should be done?
when a patient who has already died is brought into an emergency department or other healthcare facility and is pronounced dead upon arrival.
When is Code R99 (Death NOS) used.