Buck: Chapter 10

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Medical Coding & Billing

If the type of diabetes mellitus is not documented in the medical record, the default is Type 2 diabetes mellitus.


A STEMI is also known as a Q-wave transmural myocardial infarction.


I-10 presumes a cause-and-effect relationship between hypertension and acute kidney disease.


I-10 presumes a cause-and-effect relationship between hypertension and heart and renal disease.


A code from subcategory R65.2, Severe sepsis, should not be assigned unless sever sepsis or an associated acute organ dysfunction is documented.


If the patient has documented HIV, the HIV must be the first-listed diagnosis even if the patient is seen for a condition unrelated to HIV.


The secondary cancer should be listed before the primary cancer if the secondary cancer is the reason for the visit.


When the reason for the encounter is to determine the extent of the malignancy, or for a procedure such as paracentesis or thoracentesis, the primary malignancy or appropriate metastatic site is designated as the first-listed diagnosis.


Code C80.0, Disseminated malignant neoplasm, unspecified, is reported only in those cases where the patient has advanced metastatic disease and no known primary or secondary sites are specified.


If a patient is admitted for dehydration due to chemotherapy, the dehydration is the first-listed diagnosis.


If a patient is seen for a pathological fracture due to a neoplasm, the neoplasm should be the first-listed diagnosis.


If a patient with coronary artery disease is admitted due to an acute myocardial infarction (AMI), the AMI should be sequenced before the coronary artery disease.


G89 category codes (Pain) can be assigned as the first-listed or primary diagnoses.


Identify all infections documented as antibiotic resistant with code Z16, Infection with drug resistant microorganisms, which is placed before the infection code.


Septic shock does not indicate the presence of severe sepsis.


A code from category G89 (Pain) should not be assigned if the underlying (definitive) diagnosis is known unless the reason for the encounter is pain control/management.


Mood disorders are also known as affective disorders with the main characteristic of disturbance in mood, most commonly anxiety, depression, and bipolar disorders.


Central pain and chronic pain have the same meaning.


The Eustachian tube is part of the inner ear.


Entropion is the outward turning of the margin of the eyelid.


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