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A comprehensive set of questions and answers related to the icd-10-cm (international classification of diseases, tenth revision, clinical modification) coding guidelines. It covers various aspects of the guidelines, including the roles of cooperating parties, the use of signs and symptoms in coding, and the application of coding guidelines across different healthcare settings. The material addresses key concepts such as principal and additional diagnoses, outpatient diagnosis coding, and present on admission (poa) reporting guidelines. It also includes exercises to identify and assign appropriate icd-10-cm codes for various medical conditions, making it a valuable resource for students and professionals in medical coding and healthcare administration.
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The official Guidelines for Coding and Reporting are approved by the ______________ for ICD- 10 - CM to accompany and complement the official conventions and instructions provided within ICD- 10 - CM - ANSWERS - cooperating parties Signs and Symptoms associated with a disease should not be assigned as additional codes (if a patient complains of shortness of breath and is diagnosed with pneumonia the only codes assigned is for pneumonia since shortness of breath is a symptom of pneumonia) - ANSWERS - Coding guidelines use the term ______________ for all health care settings including inpatient hospital admissions - ANSWERS - encounter Coding guidelines use the term ___________ to mean physician or any qualified health care practitioner who is legally accountable for establishing the patient's diagnosis. - ANSWERS - provider The ______________ regulations for electronic transactions require providers and third-party payers including Medicare administrative contractors (MACs) to adhere to the Official Guidelines for coding and Reporting - ANSWERS - HIPAA Section I of the Official Guidelines for Coding and Reporting includes the _______________ of the classification and general guidelines that apply to the entire classification and chapter-specific guidelines that correspond to the chapters as they are arranged in the classification. - ANSWERS - structure and conventions Section II of the Official Guidelines for Coding and Reporting includes guidelines for selection of the ____________ for non outpatient settings - ANSWERS - Principal diagnosis Section III of the Official Guidelines for Coding and Reporting includes guidelines for reporting ______________ in non outpatient settings - ANSWERS - additional diagnoses Inpatient Care requires the reporting of additional diagnoses which are called - ANSWERS - comorbidities Section IV of the Official Guidelines for Coding and Reporting covers ________________ coding and reporting - ANSWERS - outpatient diagnosis Appendix I of the Official Guidelines for Coding and Reporting covers _________________ reporting guidelines - ANSWERS - present on admission (POA) If The provider documents "a borderline diagnosis" at the time of discharge code the diagnosis as confirmed even when the ICD- 10 - CM Index to Diseases and Injuries provides a specific entry that includes the word "borderline" (True or False) - ANSWERS - False When reviewing ICD- 10 - CM Index to Disease and Injuries entries if the code listed contains a
fifth, sixth, ore seventh character it is unnecessary to verify the code in the ICD- 10 - CM Tabular List of Diseases and Injuries. - ANSWERS - False Upon verification of codes in the ICD- 10 - CM Tabular List of Diseases and Injuries when seventh characters are provided they must be assigned - ANSWERS - True Certain Z codes can be reported as a first-listed code for outpatient care. - ANSWERS - True Codes that describe symptoms and signs are always reported with established diagnoses - ANSWERS - False Some symptoms, signs, and ill-defined condition codes are found in ICD- 10 - CM chapters other than Chapter 18, Symptoms, Signs, and Abnormal Clinical and Laboratory Findings Not Elsewhere Classified (R00-R99) - ANSWERS - True Signs and symptoms that are integral to the disease process should be assigned as additional codes because they are included in the disease process. - ANSWERS - False Conditions that are not considered an integral part of a disease process such as additional signs and symptoms that may not be associated routinely with a disease process, should be coded when present - ANSWERS - True Etiology/manifestation conditions often require that two codes be reported to completely describe a single condition that affects multiple body systems. - ANSWERS - True If the same condition is described as acute (or subacute) and chronic always assign a combination code. - ANSWERS - False One multiple code can be assigned as a single code to classify two entirely different conditions. - ANSWERS - False Combination codes are located by referring to subterm entries in the disease index and by reading "includes" and "excludes" notes in the tabular list - ANSWERS - True A late effect is the condition produced after the acute phase of an illness or injury has ended - ANSWERS - True Residual conditions are coded as such only if they occur at least one year after the previous condition has resolved - ANSWERS - false (no time limit) Conditions described at the time of visit as impending or threatened are always coded as if the condition is confirmed regardless of the type of patient encounter. - ANSWERS - False Underline the main term in each diagnosis statement and assign the appropriate ICD- 10 - CM code(s) - ANSWERS -
Episodic cocaine abuse - ANSWERS - F14. Major Depressive disorder - ANSWERS - F33. Central Pain Syndrome - ANSWERS - G89. Bell's Palsy - ANSWERS - G51. Acute pain due to trauma; cervicalgia - ANSWERS - G89. Congenital quadriplegia - ANSWERS - G80. Intraspinal abscess - ANSWERS - G06. Primary open-angle glaucoma, mild stage right eye - ANSWERS - H40. Vitreous hemorrhage, left eye - ANSWERS - H43. Degenerative Myopia, bilateral eyes - ANSWERS - H44. Alternating exotropia - ANSWERS - H50. Cystoid macular degeneration bilateral eyes -
Swimmer's ear, right ear - ANSWERS - H60. Acute serous otitis media, left ear - ANSWERS - H65. Central perforation of tympanic membrane, left ear - ANSWERS - H72. Vertigo of central origin, bilateral - ANSWERS - H81. Granulation of postmastoidectomy cavity, left ear