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ICD10-CM And CPT Guidelines

Terms in this set (72)

The ____________ for the ICD-10-CM are the general rules for use of the classification independent of the guidelines.
conventions
alphabetical list of terms and their corresponding code
Alphabetic Index
structured list of codes divided into chapters based on body system or condition.
Tabular Index
The Alphabetical index consists of the following parts:
1) Index of diseases and injury
2) Index of External Causes of Injury
3) Table of Neoplasms
4) Table of Drugs and Chemicals
All categories are ______ characters.
three
A three character category that has no further subdivision is equivalent to a ________
code
Codes may be up to ____ characters
seven
Each level of subdivision after a category is a ?
subcategory
Used as a placeholder to allow for future expansion of certain codes.
X
If a code that requires a 7th character is not 6 characters, a ____________________ must be used to fill in the empty characters.
placeholder X
"not elsewhere classified"
represents "other specified"
when a specific code is not available for a condition, the alphabetic index directs coder to this code in the tabular list.
NEC
equivalent of unspecified.
NOS
used in the Tabular list to enclose synonyms, alternative wording or explanatory phrases.
used to identify manifestation codes.
[ ]
used in both the Alphabetic index and tabular list to enclose supplementary words that may be present in the statement of a disease or procedure without affecting the code number to which it is assigned.
*nonessential modifiers.
( )
used in the tabular list after an incomplete term which needs one or more of the modifiers following the colon to make it assignable to a given category
:
for use when the information in the medical record provides detail for which a specific code does not exist.
"other codes"
for use when the information in the medical record is insufficient to assign a more specific code.
"unspecified codes"
appears under a three character code title to further define, or give examples of, the content of the category.
includes notes
terms are the conditions for which that code is to be used. terms may be synonyms of the code title, or, list of the various conditions assigned to that code.
inclusion terms
"not coded here" indicates that the code excluded should never be used at the same time as the code above the note.
used when two conditions cannot occur together.
UPDATE 2016- can USE
excludes 1
"not included here" indicates that the condition excluded is not part of the condition represented by the code, but a patient may have both conditions at the same time. when this note appears under a code, it is acceptable to use both the code and the excluded code together.
excludes 2
When a condition has both an underlying etiology and multiple body system manifestations due to the underlying etiology, the _____________________ is sequenced first, followed by the ____________.
underlying condition
manifestation.
should be interpreted as and or or when it appears in a code title
"and"
interpreted to mean "associated with" or "due to"
"with"
indicates that another term should be referenced. it is necessary to go to the main term referenced with this note to locate the correct code.
"see"
instructs that there is another main term that may also be referenced that may provide additional alphabetic index entries that may be useful. not necessary to follow this note when the original main term provides necessary code.
"see also"
instructs that two codes may be required to fully describe a condition.
"code also"
code listed next to a main term in the ICD-10-CM Alphabetic Index.
default codes
to select a code first locate the term in the ___________
verify the code in the ____________
alphabetic index
tabular index
diagnosis codes are to be used and reported at their ____________ number of characters available.
highest
codes that describe symptoms and signs, as opposed to diagnoses, are acceptable for reporting purposes when a related _______________ diagnosis has not be established by the provider.
definitive
signs and symptoms that are associated routinely with a disease process should _____ be assigned as additional codes, unless otherwise instructed by the classification.
NOT
if the same condition is described as both acute and chronic, code both and sequence ____________ before _______
acute before chronic
additional signs and symptoms that may not be associated routinely with a disease process ___________ be coded when present.
should
combination code is a single code used to classify:
two diagnoses
a diagnosis with an associated secondary process
a diagnosis with an associated complication
residual effect (condition produced) after the acute phase of an illness or injury has terminated.
sequela
coding of a sequela generally requires ____ codes.
with _____________ coded first.
and ______________ coded second.
condition or nature of sequela
sequela
all conditions that coexist at the time of admission, that develop subsequently, or that affect the treatment received and/or the length of stay. diagnoses that related to an earlier episode which have no bearing on the current hospital stay are to be excluded.
"other diagnoses"
"other diagnosis" is interpreted as additional conditions that affect patient care in terms of requiring:
clinical evaluation
therapeutic treatment
diagnostic procedures
extended length of hospital stay
increased nursing care or monitoring
abnormal findings are _________ coded unless the provider indicates their clinical significance
NOT
if the diagnosis documented at the time of discharge is qualified as "probable" "suspected" "likely" "questionable" "possible" or other similar terms indicating uncertainty code the condition as if it _______________ or was established.
existed
in the outpatient setting _________________ is used in lieu of principal diagnosis
first-listed condition
in determining the first listed diagnosis, the ___________________ take precedence over outpatient guidelines.
coding conventions as well as the general and disease specific guidelines
when a patient presents for outpatient surgery, code ___________________________ as the first listed diagnosis, even if the surgery is not performed due to a contraindication.
reason for the surgery
when a patient is admitted for observation for a medical condition, assign a code for _____________________ as the first listed diagnosis.
medical condition
when a patient presents for outpatient surgery and develops complications requiring admission to observation, code ___________________________ as the first listed diagnosis, followed by________________.
reason for the surgery,
codes for complications
codes that describe symptoms and signs, as opposed to diagnoses, are acceptable when a diagnosis has _______ been established.
NOT
codes to deal with encounters for circumstances other than a disease or injury.
Z codes
for ambulatory surgery, code the ______________________ for which surgery was performed.
surgery
if the postoperative diagnosis is known to be different from the preoperative diagnosis at the time the diagnosis is confirmed, select the _______________ diagnosis for coding.
postoperative
for patients receiving preoperative evaluations only, sequence first a code from subcategory _____________, and then code ________________ as additional diagnosis.
Z01.81
for the condition to describe reason for surgery
chronic diseases treated on an ongoing basis may be coded and reported ________ __________ __________ as the patient receives treatment and care for the condition.
as many times
should a general medical examination result in an abnormal finding, the code for general medical examination with ___________________ should be assigned as the first listed diagnosis.
abnormal findings
for patients receiving therapeutic services only during an encounter/visit, sequence first the _____________ shown in the medical record to be chiefly responsible for the outpatient services provided during the encounter/visit.
condition, diagnosis, problem
code ________________that coexist at the time of the encounter/visit and require or affect patient care treatment or management. do ______ code conditions that were previously treated and no longer exist. however, history codes may be used as secondary codes.
documented conditions
NOT
do ____ code diagnoses documented as "probable" "suspected" "questionable" or other similar terms indicating uncertainty. rather, code the condition to the _________________________ degree of certainty for that encounter/visit, such as symptoms, signs, abnormal test results.
NOT
highest
for patients receiving diagnostic services only during an encounter/visit, sequence first the _____________________________ for encounter/visit shown in the medical record to be chiefly responsible for the outpatient services provided during the encounter/visit.
diagnosis, condition, problem, or other reason for encounter/visit
for encounters for routine laboratory/radiology testing in the absence of any signs, symptoms, or associated diagnosis, assign ______
Z01.89
if routine testing is performed during the same encounter as a test to evaluate a sign, symptom or diagnosis, it is appropriate to assign both the _____ code and the code describing the ____________________ for the non-routine test.
Z, reason
for outpatient encounters for diagnostic tests that have been interpreted by a physician, and the final report is available at the time of coding, code any ____________________________________________ diagnoses documented in the interpretation. do ____ code related signs and symptoms as additional diagnoses.
confirmed or definitive diagnoses,
NOT
no service within the past 3 years
different specialty and subspecialty
new patient
service within the past 3 years
same specialty and subspecialty
(if patient's dr is out of town and another dr is covering for him)
established patient
E/M COMPONENTS
history
exam
medical decision making
coding panel CPT in path and lab
in order to code have to have ALL
WHEN GIVING SHOTS YOU NEED?
2 codes (1 administration, 1 for drug)
What category CPT code is optional?
2
What category CPT code is for new technology?
How many years before it gets trashed or becomes a code?
3
5 years
assignment of a diagnosis code is based on the providers diagnostic statement that the _________________ exists.
condition
when a patient has a bilateral condition and each side is treated during separate encounters, assign the ____________ code including for encounter to treat the first side.
for encounter where condition is healed, code ________ code.
bilateral
unilateral
BMI, Coma scale, NIH stroke scale, code assignment may be based on medical documentation from clinicians who are _____ the patient's provider.
NOT
code only ____________ cases for ZIKA
confirmed
pressure ulcers as healing, code for site and stage at time of ______________
admission
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