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This document serves as a study guide for medical coding, focusing on icd-10-cm and cpt coding systems. It covers key concepts such as the characters in i-10 diagnosis codes, the determination of cpt codes for lesion excisions, and guidelines for reporting diagnoses and procedures. The guide also addresses specific coding scenarios, including those involving chemotherapy, miscarriages, and various surgical procedures, providing a concise overview of essential coding principles and practices. This study guide is designed to enhance coding accuracy and improve communication with physicians, making it a valuable resource for medical coding students and professionals. It includes practical examples and explanations to aid in understanding complex coding rules and regulations. The guide emphasizes the importance of accurate documentation and the proper application of coding guidelines to ensure compliance and accurate reimbursement.
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seventh - ANS-The _____________________ character of I-10 diagnosis codes provides information regarding the encounter of care such as inital,subsequent and sequela fourth, etiology - ANS-The ___________________ character of an I-10 diagnosis code captures ______________________ fifth, anatomic site - ANS-The _____________ character of an I-10 diagnosis captures
skin - ANS-Melanomas,tumors, lipomas, and lesions are often located on the ______ of different areas of the body Tabular - ANS-A code in the index with a dash/hypen (-) after it indicates that it will need additional characters which can be found in the _________________ section EX: D45. three - ANS-I-10 codes must have at least ____________ characters and no more than seven capture more detail, thus improving coding accuracy - ANS-I-10 has expanded codes that _____________________ procedures, CMS - ANS-ICD-10-PCS is the code book edition used to code inpatient hospital __________ and is updated by ______________ three-character code category - ANS-Notes appearing under the __________________ applies to all codes within that category CPT - ANS-The _______ code book is used to code medical procedures and services sixth, severity - ANS-The __________ character of I-10 captures ______________ diameter, margins, body area - ANS-when a malignant lesion is excised from the skin, the CPT code is determined by the __________ of the lesions, the narrowest __________ required to excise the lesion as documented in the operative report, and the __________ from which the lesion was excised
retention, complex - ANS-If ____________ sutures are used to repair a laceration, the closure is considered ______ two - ANS-If a patient is given an epidural for a vaginal delivery but the delivery is converted to a C-section report _____ anesthesia codes for the anesthesiologist. One for the epidural and one for the C-section miscarriage, O03 - ANS-If a patient present for treatment due to spotting a few weeks after a spontaneous abortion occured and it is found that all the products of conception were not expelled back then, a code for ___________ should be reported as ________ principal diagnosis - ANS-If a patients admission or encounter is solely for the administration of chemotherapy , immunotherapy, or radiation therapy assign the appropriate Z51 code as the ______________ and the reason for the therapy as the secondary diagnosis not - ANS-The term " urosepsis" is a nonspecific term and is _________ codable in I-10. It is not synonymous with sepsis. If a provider uses the term urosepsis he/she MUST be queried for diagnosis clarification principal diagnosis - ANS-When a patient is admitted to the hospital with two diagnosis that are equally treated, either diagnosis may be listed as the _____________ Receives clinical evaluation on therapeutic treatment or diagnostic procedures on exterdo the length n stay on increases nursing care and monitoring - ANS-According to UHDDS the definition of "other diagnosis" are those Volume 3, ICD-10-PCS - ANS-______________ of the ICD-9-CM contains procedure codes used for inpatient hospital services/procedures, but ICD-10-CM does not have a Volume 3, instead a separate edition/book is published and contains inpatient procedure codes known as ___________ codes Melanoma - ANS-A skin lesion is removed from a patients right arm and sent to pathology for testing. The report states that the patient has melanoma. The coder should bill the claim with a diagnosis of __________ if the report comes back before the claim has been filed unspecified - ANS-If the report is not back in the above scenario and the coder submits the claim, the diagnosis reported should indicate that the behavior of the lesion is ____________ since it is not known if it is benign, malignant, melanoma or basal cell carcinoma personal history - ANS-If a patient had cancer years ago that was removed or "cured" and presents with symptoms related to the previous episode of cancer or has cancer of another organ, a code indicating that the patient has a ___________ of cancer should be reported
Social History - ANS-Documenting that a patient smokes cigars and drinks beer is allograft - ANS-tissue grafted from one individual and transplanted to another individual is an autograft - ANS-tissue grafted from an individuals thigh and transplanted to his/her face is an pathologist and the surgeon - ANS-The surgeon acts as both the _______________ in Mohs micrographic surgery with manipulation - ANS-If a surgeon attempts to align a fracture using manipulation instead of open surgery, but is not sucessful, the coder would still report a code that includes" ________". Although the physician was not successful, he did perform the work Selective Catheterization - ANS-is a process by which the tip of the catheter is manipulated from the insertion into the aorta and then out into another artery first point of entry - ANS-Even though in the above scenarion two locations are entered, only code for the____________, which is the aorta