76 terms

ICD 10 CM: Ch 7-15 Guidelines

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axis
Type of hypertension is not used as an _____.
causal relationship, hypertension, heart disease, type of heart failure
Heart conditions are assigned to Hypertensive Heart Disease when a ______ is stated or implied between ____ and ____. Use an additional code to identify _______ in patients with heart failure.
hypertension, chronic kidney disease, CKD stage
Assign codes from Hypertensive Chronic Kidney Disease when both _____ and _______ are present. Assign also the appropriate code for _____.
cause and effect relationship, hypertensive chronic kidney disease
ICD 10 presumes a ______ between hypertension and CKD and classifies it as _____.
acute renal failure
If a patient has hypertensive chronic kidney disease and acute renal failure, and additional code for _____ is required.
hypertensive heart disease, hypertensive kidney disease, type of heart failure, chronic kidney disease
Assign code Hypertensive heart and chronic kidney disease when ____ and ____ are stated in the diagnosis. If heart failure is present, assign additional code to identify _____. The appropriate code for _______ should be used as a secondary code.
transient hypertension
Assign _____ unless a patient has an established diagnosis of hypertension.
causal relationship, combination code
A _____ can be assumed in a patient with both atherosclerosis and angina pectoris and therefore a ______ can be assigned.
MI, CAD
If patient with CAD is admitted due to an acute MI, the _____ should be sequenced first followed by ____.
STEMI, STEMI
If NSTEM evolves to STEMI, assign ____ code. IF STEMI converts to NSTEMI, assign ____.
4 weeks, continued care
To be considered a new MI, it must be _____ or less. Initial MI may continue to be reported if patient required _____ for that MI during that period.
subsequent AMI, initial AMI
When coding an AMI that occurs within 4 weeks of an initial MI, a code for _____ must be used in conjunction with a code for _____.
circumstances of the encounter
The sequencing of initial and subsequent AMIs depends on ______.
initial MI, old MI
If a person has an AMI over 4 weeks following an initial AMI, it should be coded as _____ following by ____.
mild intermittent
In coding asthma, if the frequency of daytime symptoms is less than or equal to 2x per week, it is _____.
mild persistent
In coding asthma, if the frequency of daytime symptoms is more than 2x per week, it is _____.
moderate persistent
In coding asthma, if the frequency of daytime symptoms is daily and restricting physical activity, it is _____.
severe persistent
In coding asthma, if the frequency of daytime symptoms is throughout the day with frequent severe attacks, it is _____.
lower anatomical site
Respiratory condition occurring in more than one site is classified to _____.
bronchitis
Tracheobronchitis would be classified to _____.
identify infectious agent, identify virus, code first underlying disease
In the respiratory chapter you will use additional codes to ____, _____, and ____.
acute exacerbation
Worsening or decompensation of a chronic condition.
secondary diagnosis
Respiratory failure may be listed as _____ if it occurs after admission, or if it is present on admission, but does not meet the definition of principal diagnosis.
complications
Crohn's disease now has combination codes for commonly associated _____.
hernia with gangrene
Hernia with gangrene and obstruction is classified to _____.
site, stage, laterality
Pressure ulcer codes are combination codes that identify ______ as well as _____ and _____.
documentation
Assignment of the code for unstageable pressure ulcer should be based on _____.
unstageable, clinical documentation
For pressure ulcers whose stage cannot be clinically determined, assign ______. This should be based on ______.
nursing documentation
To determine the level of severity for pressure ulcers, you may refer to ______.
unspecified
When there is no documentation of the stage for pressure ulcer, code _____.
highest stage
If patient is admitted with a pressure ulcer at one stage and it progresses to a higher stage, assign the code for the _____.
surgical treatment, emergency department encounter, evaluation and treatment by new physician
Active treatment includes ____, _____, _____,
spontaneous rupture of the synovium and tendon
This occurs when normal force is applied to tissues that are inferred to have less than normal strength.
osteoporosis with current pathologic fracture
What code would be assigned for any patient with known osteoporosis who suffers a fracture that would not usually break a normal bone?
neoplastic disease, osteoporosis, other specified disease
Which three diseases are most likely to cause pathological fractures?
CKD, stage, kidney transplant status
If a patient with CKD has had a kidney transplant, assign codes for _____, _____, and _____.
trimester
The new axis of classification for pregnancy is _____.
first day of last menstrual period
Trimesters are determine by counting from _____.
first
A woman who is less than 14 weeks pregnant is in her _____ trimester.
second
A woman who is between 14 weeks and less than 28 weeks pregnant is in her _____ trimester.
third
A woman who is over 28 weeks pregnant is in her ____ trimester.
pregnant state incidental
If the provider documents that a condition occurring during pregnancy is incidental, code ____.
pregnancy
______ codes should take precedence over all other types of codes.
maternal record
Chapter 15 (pregnancy) codes are only used on ____.
complication developed
Instances when a patient is admitted to a hospital for complications of pregnancy during one trimester and remains in the hospital into a subsequent trimester, the trimester character for antepartum complication code should be assigned on the basis of the trimester when ______
at time of admission
If a complication/condition developed prior to the current admission or represents a pre-existing condition, assign code for trimester _____
single gestation, insufficient documentation, clinically undetermined
When identifying the fetus for which a complication code applies, assign 7th character 0 for _____, _____, or _____.
outcome of delivery
For all pregnant women who deliver, in addition to proper delivery codes, code also _____.
encounter for supervision of normal pregnancy, encounter for supervision of high risk pregnancy
When encounter is for outpatient prenatal visits with no complications, code first _____. For high risk pregnancy, code first _____.
condition that occasioned admission, that condition, reason for admission
In cases of cesarean delivery, the principal diagnosis should be ____. If patient was admitted with a condition that resulted in performance of cesarean, the principal diagnosis should be _____. If the reason for admission, was unrelated to condition resulting in cesarean, code _____ as principal diagnosis.
HIV complicating pregnancy, asymptomatic HIV
Patients with asymptomatic HIV infection status admitted during pregnancy should receive codes for ______ and _____.
diabetes in pregnancy, diabetes code
Pregnancy women who are diabetic should be assigned a code for _____ and ______.
gestational diabetes, code for how its controlled
For pregnant women who develop diabetes in their second or third trimester, code ____ and _____.
insulin controlled
If a patient with gestational diabetes is treated with both diet and insulin, code only for ____.
abnormal glucose complicating pregnancy
An abnormal glucose tolerance in pregnancy is assigned a code from ____.
alcohol complicating pregnancy, manifestations of alcohol use
For any pregnancy case where the mother uses alcohol during the pregnancy or postpartum, code _____. A secondary code from alcohol related disorders should also be assigned to identify _____.
smoking complicating pregnancy, type of nicotine dependence
For any pregnancy case where the mother uses tobacco during the pregnancy or postpartum, code _____. A secondary code from nicotine dependence should also be assigned to identify _____.
poisoning, toxic effects, or adverse effects complicating pregnancy, appropriate effect code, condition caused
For poisoning, toxic effects or adverse effects in pregnancy, code first ____, followed by _____, and _____.
single live infant, complications in antepartum, during delivery, or postpartum, principal diagnosis, pregnancy complication
Normal delivery code can only be assigned if mother delivers _____ without ______. It is always _____. It cannot be used in conjunction with any _____ codes.
immediately after delivery, six weeks
Postpartum period begins _____ and continues for _____ following delivery.
last month of pregnancy, five months postpartum
Peripartum period is the _____ to _____.
encounter for care of mother after delivery
When a mother delivers outside the hospital prior to admission and is admitted for routine postpartum care with no complications, code _____.
encounter for elective termination of pregnancy, outcome of delivery
When an attempted termination of pregnancy results in a liveborn fetus, code _____ and _____.
fetal death
When a mother has an abortion at 20 weeks or later, it is considered a _____.
37 completed weeks, 41 and 42 completed weeks, 42 weeks
Preterm delivery occurs before _____ of gestation. Postterm delivery occurs between _____ of gestation. Prolonged delivery occurs beyond _____.
20 weeks
In pregnancy, it is considered early vomiting if it occurs prior to ____.
abuse complicating pregnancy, associated injury
If a pregnancy patient has been abused, code first _____ then ____.
fetus 2
If you have two fetuses, fetus A and B, and fetus B creates a complication for the mother, fetus B would be coded as _____.
type, affected eye, stage
Glaucoma codes are combination codes indicating _____, ____, and _____.
type of glaucoma bilateral, stage
When a patient has bilateral glaucoma and both eyes are documented as being the same type and stage, and there is a code for bilateral, report only code for ________ with the seventh character for _____.
one code, type of glaucoma, stage
When a patient has bilateral glaucoma and both eyes are documented as same type and stage and code does not provide a code for bilateral, report _____ for _____ with seventh character for _____.
each eye
When a patient has bilateral glaucoma and each eye is documented as having a different type or stage, and the classification distinguishes laterality, assign code for _____.
indeterminate stage, unspecified
When stage for glaucoma is documented as unable to be clinically determined, it should be coded as _____. When there is not documentation as to the stage of glaucoma, it should be coded as ______.
external cause code
Use an ______ following code for ear condition if applicable to identify cause of ear condition.
perforated tympanic membrane
When coding otitis media, use additional code for associated ____.
tobacco use or dependence
When coding otitis media, use additional code to identify any _____.