B&C Chapter 6: ICD-10-CM Coding

Question 1

adverse effect

Answer 1

development of a pathologic condition that results from a drug or chemical substance that was properly administered or taken.

Question 2

benign

Answer 2

not cancerous.

Question 3

carcinoma (Ca) in situ

Answer 3

a malignant tumor that is localized, circumscribed, encapsulated, and noninvasive (has not spread to deeper or adjacent tissues or organs).

Question 4

comorbidity

Answer 4

concurrent condition that coexists with the first-listed diagnosis (outpatient care) (or principal diagnosis for inpatient care), has the potential to affect treatment of the first-listed diagnosis (outpatient care) (or principal diagnosis for inpatient care), and is an active condition for which the patient is treated and/or monitored.

Question 5

complication

Answer 5

condition that develops after outpatient care has been provided or during an inpatient admission.

Question 6

computer-aided coding (CAC)

Answer 6

see computer-assisted coding (CAC).

Question 7

computer-assisted coding (CAC)

Answer 7

uses a natural language processing engine to “read” patient records and generate ICD-10-CM and HCPCS/CPT codes.

Question 8

contiquous sites

Answer 8

also called overlapping sites; occurs when the origin of the tumor (primary site) involves two adjacent sites.

Question 9

Cooperating Parties for ICD-10-CM/PCS

Answer 9

AHA, AMA, CMS, and NCHS organizations and agencies that approve official guidelines for coding and reporting ICD-10-CM and ICD-10-PCS.

Question 10

encoder

Answer 10

automates the coding process using computerized or web-based software; instead of manually looking up conditions (or procedures) in the coding manual’s index, the coder uses the software’s search feature to locate and verify diagnosis and procedure codes.

Question 11

encounter

Answer 11

face-to-face contact between a patient and a health care provider (e.g., physician, nurse practitioner) who assesses and treats the patient’s condition.

Question 12

essential modifier

Answer 12

see subterm.

Question 13

evidence-based coding

Answer 13

coding auditor clicks on codes that CAC software generates to review electronic health record documentation (evidence) used to generate the code.

Question 14

first-listed diagnosis

Answer 14

reported on outpatient claims (instead of inpatient principal diagnosis); it reflects the reason for the encounter, and it is often a sign or symptom.

Question 15

general equivalence mapping (GEM)

Answer 15

translation dictionaries or crosswalks of codes that can be used to roughly identify ICD-10-CM/PCS codes for their ICD-9-CM equivalent codes (and vice versa). See also legacy coding system.

Question 16

iatrogenic illness

Answer 16

illness that results from medical intervention (e.g., adverse reaction to contrast material injected prior to a scan).

Question 17

ICD-10-CM coding conventions

Answer 17

general coding rules that apply to the assignment of codes, independent of official coding guidelines.

Question 18

and

Answer 18

when two disorders are separated by the word “and,” it is interpreted as “and/or” and indicates that either of the two disorders is associated with the code number.

Question 19

brackets

Answer 19

used in the index to identify manifestation codes and in the index and tabular list to enclose abbreviations, synonyms, alternative wording, or explanatory phrases.

Question 20

code also

Answer 20

ICD-10-CM tabular list instruction that indicates two codes may be required to fully describe a condition with sequencing depending on circumstances of the encounter.

Question 21

code first underlying disease

Answer 21

appears when the code referenced is to be sequenced as a secondary code; the code, title, and instructions are italicized.

Question 22

code first underlying disease, such as

Answer 22

see code first underlying disease.

Question 23

code, if applicable, any casual condition first

Answer 23

requires casual condition to be sequences first if present; a casual condition is a disease that manifests (or results in) another condition.

Question 24

colon

Answer 24

used after an incomplete term and is followed by one or more modifiers (additional terms).

Question 25

default code

Answer 25

listed next to a main term in the ICD-10-CM alphabetic index and represents the condition that is most commonly associated with the main term or is the unspecified code for the condition.

Question 26

due to

Answer 26

located in the index in alphabetical order to indicate the presence of a cause-and-effect (or casual) relationship between two conditions.

Question 27

eponym

Answer 27

diseases and procedures named for people, such as Barlow’s disease.

Question 28

etiology and manifestation rules

Answer 28

include the following notes in the ICD-10-CM Tabular List of Diseases and Injuries: Code first underlying disease; Code first underlying disease, such as; Code, if applicable, any casual condition first; Use additional code; and In diseases classified elsewhere.

Question 29

Excludes1 note

Answer 29

a “pure” excludes, which means “not coded here” and indicates mutually exclusive codes; in other words, two conditions that cannot be reported together.

Question 30

Excludes2 note

Answer 30

means “not included here” and indicates that although the excluded condition is not classified as part of the condition it is excluded from, a patient may be diagnosed with all conditions at the same time; therefore, it may be acceptable to assign both the code and the excluded code(s) together if supported by medical documentation.

Question 31

in

Answer 31

located in alphabetical order blow the main term; to assign a code from the list of qualifiers below the word “in,” the provider must document both conditions in the patient’s records; ICD-10-CM classifies certain conditions as if there were a cause-and-effect relationship present because they occur together much of the time, such as pneumonia in Q fever.

Question 32

in diseases classified elsewhere

Answer 32

indicates that the manifestation codes are a component of the etiology/manifestation coding convention.

Question 33

includes note

Answer 33

appear below certain tabular list categories to further define, clarify, or provide examples.

Question 34

manifestation

Answer 34

condition that occurs as the result of another condition; manifestation codes are always reported as secondary codes.

Question 35

NEC (not elsewhere classifiable)

Answer 35

means “other” or “other specified” and identifies codes that are assigned when information needed to assign a more specific code cannot be located.

Question 36

NOS (not otherwise specified)

Answer 36

indicates that the code is unspecified; coders should ask the provider for a more specific diagnosis before assigning the code.

Question 37

other and other specified code

Answer 37

assigned when patient record documentation provides detail for which a specific code does not exist in ICD-10-CM.

Question 38

parentheses

Answer 38

enclose supplementary words that may be present or absent in the diagnostic statement, without affecting assignment of the code number.

Question 39

see

Answer 39

directs the coder to refer to another term in the index to locate the code.

Question 40

see also

Answer 40

located after a main term or subterm in the index and directs the coder to another main term (or subterm) that may provide additional useful index entries.

Question 41

see category

Answer 41

instruction directs the coder to the ICD-10-CM tabular list, where a code can be selected from the options provided there.

Question 42

see condition

Answer 42

directs the coder to the main term for a condition, found in the index.

Question 43

Table of Drugs and Chemicals

Answer 43

alphabetical index of medicinal, chemical, and biological substances that result in poisonings, adverse effects, and underdosings.

Question 44

Table of Neoplasms

Answer 44

alphabetical index of anatomic sites for which there are six possible codes according to whether the neoplasm in question is malignant, benign, in situ, of uncertain behavior, or of unspecified nature.

Question 45

unspecified codes

Answer 45

assigned because patient record documentation is insufficient to assign a more specific code.

Question 46

use additional code

Answer 46

indicates that a second code is to be reported to provide more information about the diagnosis.

Question 47

with

Answer 47

when codes combine one disorder with another (e.g., code that combines primary condition with a complication), the provider’s diagnostic statement must clearly indicate that both conditions are present and that a relationship exists between the conditions.

Question 48

ICD-10-CM Diagnostic Coding and Reporting Guidelines for Outpatient Services - Hospital-Based Outpatient Services and Provider-Based Office Visits

Answer 48

developed by the federal government, outpatient diagnoses that has been approved for use by hospitals/providers in coding and reporting hospital-based outpatient services and provider-based office visits.

Question 49

ICD-10-CM Index of Diseases and Injuries

Answer 49

an alphabetical listing of terms and their corresponding codes, which include specific illnesses, injuries, eponyms, abbreviations, and other descriptive diagnostic terms.

Question 50

ICD-10-CM Index to External Causes of Injury

Answer 50

arranged in alphabetical order by main term indicating the event; are secondary codes for use in any health care setting; capture how the injury or health condition happened (case), the intent (unintentional or accidental; or intentional, such as suicide or assault), the place where the event occurred, the activity of the patient at the time of the event, and the person’s status.

Question 51

ICD-10-CM Official Guidelines for Coding and Reporting

Answer 51

prepared by CMS and NCHS and approved by the cooperating parties for ICD-10-CM/PCS; contain rules that were developed to accompany and complement coding conventions and instructions provided in ICD-10-CM; adherence when assigning diagnosis codes is required under HIPAA.

Question 52

ICD-10-CM Tabular List of Diseases and Injuries

Answer 52

chronological list of codes contained within 22 chapters, which are based on body system or condition.

Question 53

ICD-10-CM/PCS Coordination and Maintenance Committee

Answer 53

responsible for overseeing all changes and modifications to ICD-10-CM (diagnosis) and ICD-10-PCS (procedure) codes; discusses issues such as the creation and update of general equivalence mappings (GEMs).

Question 54

ICD-10-PCD Official Guidelines for Coding and Reporting

Answer 54

prepared by CMS and NCHS and approved by the cooperating parties for ICD-10-CM/PCS; contain rules that were developed to accompany and complement official conventions and instructions provided in ICD-10-PCS; adherence when assigning procedure codes is required under HIPAA.

Question 55

International Classification of Diseases, 11th Revision (ICD-11)

Answer 55

developed by the World Health Organization (WHO) and released in 2018 to begin the implementation process (e.g., translation into languages other than English).

Question 56

legacy classification system

Answer 56

see legacy coding system.

Question 57

legacy coding system

Answer 57

system that is no longer supported or updated, such as ICD-9-CM once ICD-10-CM/PCS replaced it effective October 1, 2015.

Question 58

lesion

Answer 58

any discontinuity of tissue (e.g., skin or organ) that may or may not be malignant.

Question 59

main term

Answer 59

bold-faces term located in the ICD-10-CM index; listed in alphabetical order with subterms and qualifiers indented below each main term.

Question 60

malignant

Answer 60

cancerous.

Question 61

metastasis

Answer 61

spread of cancer from primary to secondary site(s).

Question 62

morbidity

Answer 62

pertaining to illness or disease.

Question 63

morphology

Answer 63

indicates the tissue type of a neoplasm; morphology codes are reported to state cancer registries.

Question 64

mortality

Answer 64

pertaining to death.

Question 65

neoplasm

Answer 65

new growth, or tumor, in which cell reproduction is out of control.

Question 66

nonessential modifier

Answer 66

supplementary words located in parentheses after an ICD-10-CM main term that do not have to be included in the diagnostic statement for the code number to be assigned.

Question 67

outpatient

Answer 67

person treated in one of three settings: health care provider’s office; hospital clinic, emergency department, hospital same-day surgery unit, or ambulatory surgical center (ASC) where the patient is released within 23 hours; or hospital admission solely for observation where the patient is released after a short stay.

Question 68

overlapping sites

Answer 68

see contiguous sites.

Question 69

physician query process

Answer 69

when coders have questions about documented diagnoses or procedures/services, they contact the responsible physician to request clarification about documentation and the code(s) to be assigned.

Question 70

placeholder

Answer 70

use of character “X” as a placeholder to allow for future expansion of certain codes; used when a code contains fewer than six characters and a seventh character applies.

Question 71

poisoning: accidental (unintentional)

Answer 71

poisoning that results from an inadvertent overdose, wrong substance administered/taken, or intoxication that includes combining prescription drugs with nonprescription drugs or alcohol.

Question 72

poisoning: assault

Answer 72

poisoning inflicted by another person who intended to kill or injure the patient.

Question 73

poisoning: intentional self-harm

Answer 73

poisoning that results from a deliberate overdose, such as a suicide attempt, of substance(s) administered/taken or intoxication that includes purposely combining prescription drugs with nonprescription drugs or alcohol.

Question 74

poisoning: undertermined

Answer 74

subcategory used if the patient record does not document whether the poisoning was intentional or accidental.

Question 75

preadmission testing (PAT)

Answer 75

completed prior to an inpatient admission or outpatient surgery to facilitate the patient’s treatment and reduce the length of stay.

Question 76

primary malignancy

Answer 76

original cancer site.

Question 77

principal diagnosis

Answer 77

condition determined, after study, that resulted in the patient’s admission to the hospital.

Question 78

qualified diagnosis

Answer 78

working diagnosis that is not yet proven or established; reported for inpatient cases only.

Question 79

qualifiers

Answer 79

supplementary terms in the ICD-10-CM Index to Diseases and Injuries that further modify subterms and other qualifiers.

Question 80

re-excision

Answer 80

occurs when the pathology report recommends that the surgeon perform a second excision to widen the margins of the original tumor site.

Question 81

secondary diagnosis

Answer 81

coexists with the primary condition, has the potential to affect treatment of the primary condition, and is an active condition for which the patient is treated or monitored.

Question 82

secondary malignancy

Answer 82

tumor has metastasized to a secondary site, either adjacent to the primary site or to a remote region of the body.

Question 83

sequela

Answer 83

residual late effects of injury or illness.

Question 84

subterm

Answer 84

qualifies the main term by listing alternative sites, etiology, or clinical status; it is indented two spaces under the main term.

Question 85

trust the index

Answer 85

concept that inclusion terms listed below codes in the tabular list are not meant to be exhaustive, and additional terms found only in the index may also be associated to a code.

Question 86

uncertain behavior

Answer 86

it is not possible to predict subsequent morphology or behavior from the submitted specimen.

Question 87

underdosing

Answer 87

taking less of a medication than is prescribed by a provider or a manufacturer’s instruction.

Question 88

unspecified nature

Answer 88

neoplasm is identified, but no further indication of the histology or nature of the tumor is reflected in the documented diagnosis.