Ch 3

Question 1

ICD-10-CM

Answer 1

Broken down into the alphabetic index and the tabular list. Used to assign diagnosis codes to assign medical necessity.

Question 2

Alphabetic Index Definition

Answer 2

Diagnostic terms organized in alphabetic order for the diseases found in the Tabular list. Terms used interchangeably.

Question 3

Tabular List Definition

Answer 3

Diagnosis codes organized in numerical order and divided into chapters based on body system or condition.

Question 4

IDC-10-PCS

Answer 4

Includes procedure codes and is typically used by facilities for inpatient services. Hospitals use it in the outpatient facility for tracking purposes only.

Question 5

Tabular List

Answer 5

Organized in 3-character category codes and their titles. Most are subdivided with a decimal point, followed by up to 4 additional characters. Each character may be a number or letter, and the code can be from 3-7 characters long. The 1st character is a letter, followed by 2 numbers or alpha characters.

Question 6

Tabular List 4th character

Answer 6

Further defines the site, etiology, and manifestation. Includes the 3 character category plus a decimal with an additional character.

Question 7

Tabular List 5th/6th character

Answer 7

Further represent the most accurate level of specificity regarding patient’s diagnosis or condition.

Question 8

Tabular List 7th character

Answer 8

Some codes require a 7th character. Some codes are only 3 or 4 characters long, but require the 7th character extension so an ‘x’ is used as a placeholder in between for the appropriate character spots.

Question 9

NEC

Answer 9

Not Elsewhere Classifiable. Used when the ICD-10-CM system doesn’t provide a code specific for the patient’s condition. Selecting a code with NEC means the provider documented more specific info, but there’s no ICD code to accurately report it.

Question 10

NOS

Answer 10

Not Otherwise Specified. Used only when the coder lacks the info necessary to report a more specific code.

Question 11

[ ] Brackets

Answer 11

Used in the Tabular List to enclose synonyms, alternate wording, or explanatory phrases. Used in the Alphabetic Index to indicate multiple codes are required.

Question 12

( ) Parenthesis

Answer 12

Used to enclose supplementary words that may be present or absent in the statement of a disease/procedure without affecting the code number assigned. Aka nonessential modifiers.

Question 13

Excludes 1

Answer 13

Represents that the condition is not coded here. The code excluded shouldn’t be used at the same time as the code above the Excluded 1 note if the conditions are related. Can indicate when two conditions shouldn’t be reported together.

Question 14

Excludes 2

Answer 14

Indicates that the condition is not included in here. The condition excluded isn’t part of the condition represented by the code, but a patient may have both conditions at the same time.

Question 15

Code first

Answer 15

Requires the underlying disease to be recorded first, and then the manifestation recorded second.

Question 16

Use additional code, if applicable

Answer 16

Code may be assigned as a diagnosis when the casual condition is unknown or not applicable.

Question 17

Combination code

Answer 17

When a single code is used to classify two diagnoses, a diagnosis with an associated secondary process (manifestation), or a diagnosis with an associated complication.

Question 18

Notes

Answer 18

Used to define terms, clarify info, or list choices for additional characters.

Question 19

Other

Answer 19

Used when info in the medical record provides detail for which a specific code doesn’t exist.

Question 20

See

Answer 20

Directs you to a more specific term where the correct code can be found.

Question 21

See also

Answer 21

Additional info is available that might provide an additional diagnosis code.

Question 22

See category

Answer 22

You should review the category specified before assigning a code.

Question 23

Unspecified

Answer 23

Used when info in the medical record isn’t available, and should only be selected when there is no other option.

Question 24

‘And’

Answer 24

The word ‘and’ in a code description can mean either ‘and’ or ‘or’

Question 25

'With'

Answer 25

Is listed immediately under the main term. Terms indented under the term 'with' are presumed to have a casual relationship between the 2 conditions.

Question 26

Steps for diagnosis code

Answer 26

Determine main form of diagnosis via med record, look up main term in alphabetic index, review all sub terms, refer to referenced code in tabular list, and then review includes, excludes 1, excludes 2, and additional notes.

Question 27

Conditions that are integral to disease process

Answer 27

Codes for symptoms, signs, and ill-defined conditions are not to be used as first-listed diagnoses when a related definitive diagnosis is established

Question 28

Conditions NOT integral to disease process

Answer 28

Should be reported related to appropriate disease, sign, or symptoms.

Question 29

Combination code

Answer 29

Used to identify an instance where two diagnoses, or a diagnosis with an associated secondary process/complication, are included in the description of a single code. Only use when that code fully identifies the diagnostic condition or instructed via alphabetic index.

Question 30

Acute and chronic

Answer 30

When documented and a separate code for each, the acute code is sequenced first.

Question 31

Sequelae (late effects)

Answer 31

The residual effect (condition produced) after the acute phase of an injury or illness has terminated. No time limit on when it can be coded. Should be coded according to the nature of the residual condition of the late effect, usually requiring 2 codes. Residual condition is coded first, then the late effect.

Question 32

Laterality

Answer 32

Codes meaning left, right, or bilateral. For bilateral sites, the final character of the code is the indicator. If no bilateral code is provided with a bilateral condition, assign separate codes for left and right.

Question 33

Borderline diagnosis

Answer 33

Coded as confirmed diagnosis unless there's an index entry of borderline for that classification.

Question 34

Signs/symptoms/unspecified codes

Answer 34

Reported unless a definitive diagnosis has been established.