Kinn's Chapter 14


Terms in this set (...)

Babies are considered newborn or perinatal for their first _____ days?
newborn -- 28 days following birth
what code is first coded for newborns?
Z38 (goes on babies chart)
what is the term used for a patient who takes less of the medication prescribed?
what is the code Z37 used for?
the outcome of delivery (goes on moms chart)
a term that describes a melignant neoplasm site where there is NO invasion of the surrounding tissues...?
carcinoma in situ - no invasion of the surrounding tissue

Ca in situ
the second most common documentation where you can extract diagnostic information is.....?
treatment, progress, soap notes
which section of the ICD-10-CM includes the guidelines for reporting additional diagnoses in NON-OUTPATIENT settings?
Section III -- circumstances of outpatient/ additional disgnosises
what section of the ICD-10-CM is for inpatient admissions?
Section II
how are burns coded?
coded by the site, degree, and the percentage of the body surface involved (by rule of 9s)

each body extremity is 9% -- both arms = 18%
which letter in the ICD-10-CM is reserved by the WHO to assign new diseases of unknown etiology?
how are sub-terms arranged in the alphabetical index of diseases & injury
indented 2 spaces from the main term
1 space from the essential modifier
what does "code first" indicate?
indicates the order that codes need to be sequenced in
indicates that the underlying condition must be sequenced first, before the manifesation
what code do you use for a full term uncomplicated delivery?
O80 -- when a woman is admitted for a full term vaginal delivery and delivers a single healthy infant
what does the note .... "see" and "see also" mean?
see = see another word for code
see also = look there just in case for better classification code
what does etiology mean?
the cause of a disorder; a claim may be classified by its etilolgy
to find the code you need to know the _____ term, then you can look it up in the ______ index?
main term
tabular index
how do you code sequelae conditions?
the original condition or nature of the sequela is sequenced first the sequela code is sequenced second
where do you find the 7th character in a code (if needed)
in the pink box related to the category
Malignant neoplasms are what letter codes?
"C" codes
benign neoplasms are what letter codes?
"D" codes
what are "Z" codes
encounters, testing, examination, vaccines
blue box next to a code means?
a placeholder is needed to reach the needed number of digits in the code
a red box mean?
do not stop till you reach the number of digits needed for code
What letter codes will never use a 7th character?
"Y" codes
when is/are 'a' condition(s) that occur during or following a medical care or surgery classified as a complication?
two criteria must be met:
a cause and effect relationship must be established
the documentation must indicate that the condition is a complication
how do you code for a patient who has been admitted for an HIV related disease?
if a patient is admitted for an HIV-related condition, the principle diagnosis should be B20 [HIV], then the condtion/disease
how do you code for a patient who is admitted for a unrelated condition but has HIV?
you code for the unrelated injury/disease then code for HIV [B20]
Classifications for Neoplasms....
Primary : originating anatomic site
Secondary : sites of mystification
Ca in situ : carcinoma that doesn't invade the surrounding tissues
what do the different types of punctuation mean in the ICD-10-CM mean?
[ ] : mean enclosed symptoms, alternative wording, or explanatory phrases

( ) : supplementary words which may be present or absent in the statement of disease or procedure

: - tabular index after an incomplete term that needs one or more modifiers

{ } : enclose series of terms, each of which modified by the statement appearing right before the brace.
where can you find specific rules for coding each chapter index?
at the beginning of the chapter. there is specific directions on how to code each term.
Where are the essential modifiers located?!
1 space indented from the BOLD main term
Main terms have what identifiers?
BOLD Term with a 3 digit code on left side

Ex: Z37
Drugs and chemicals are what letter codes?!
T - codes