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2020 Coding For CPT Prep PHS > Chapter 4 - ICD-10-CM Coding Chptrs 1-11 > Flashcards

Chapter 4 - ICD-10-CM Coding Chptrs 1-11 Flashcards

1
Q

HIV infection/illness

A

Only coded for confirmed cases. Physicians statement of HIV positive or HIV related illness is enough to code.

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2
Q

HIV proper sequencing

A

When admitted for HIV related conditions B20 is coded first followed by additional codes for HIV related conditions

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3
Q

Conditions always considered HIV related

A

Kaposi’s sarcoma, lymphoma, pneumocystis carinii pneumonia (PCP) cryptococcal meningitis, and cytomegalovirus disease. All considered opportunistic infections.

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4
Q

Admitted for a condition unrelated to HIV

A

Code the unrelated diagnosis first. B20 is reported as an additional diagnosis, as are any HIV related conditions. HIV affects treatment of any condition in addition to any reported HIV related conditions. Documentation should support reporting of HIV

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5
Q

Asymptomatic human immunodeficiency virus.

A

Z21. HIV positive but no symptoms of an HIV related illness. Do not use if AIDS term is used.

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6
Q

Inconclusive lab evidence of HIV

A

R75 is used when patient’s have inconclusive HIV serology, and no definitive diagnosis or manifestations of the illness.

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7
Q

HIV status during pregnancy, childbirth, or the puerperium

A

Reported from the subcategory 098.7. Codes from chapter 15 always take sequencing priority.

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8
Q

Encounter for screening for HIV

A

Z11.4 is used. If signs, symptoms, or illness or confirmed HIV diagnosis be tested coded the sign, symptoms, or the diagnosis. If test is positive code B20

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9
Q

Patient suspects contact with HIV

A

Code Z20.6

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10
Q

Resistance to anti microbial drugs

A

Z16. Used if infection is antibiotic resistant and the infection code does not identify antibiotic resistance

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11
Q

Sepsis

A

Refers to an infection due to an organism that triggers a systemic inflammatory response, or systemic inflammatory response syndrome (SIRS)

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12
Q

Severe sepsis

A

Associated with acute organ failure. Requires a minimum of two codes. First code underlying systemic infection then code from R65.2 for severe sepsis.

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13
Q

Organ dysfunction not related to sepsis

A

Do not code severe sepsis.

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14
Q

Urosepsis

A

Non specific term and should not be considered synonymous with sepsis. Needs further clarification from provider.

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15
Q

Septic shock

A

Circulatory failure associated with severe sepsis

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16
Q

Admission for sepsis or severe sepsis and a localized infection

A

Code the systemic infection first then the localized infection second

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17
Q

Admitted for localized infection then sepsis develops after admission

A

Code the localized infection first then the appropriate sepsis/severe sepsis code.

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18
Q

Post procedural sepsis

A

If there is a causal relationship between procedure and sepsis code first the complication followed by the code for the specific infection.

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19
Q

Non-infectious process that leads to sepsis

A

If the non-infectious condition meets the definition for principal diagnosis it should be coded first followed by the code for the resulting infection.

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20
Q

MRSA

A

Methicillin Resistant Staphylococcus Aureus. Do not assign codes from the subcategory for resistance to penicillins.

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21
Q

Carrier of MRSA but not active infection

A

Z22.332. Carrier or suspected carrier of MRSA

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22
Q

Personal history of MRSA with no mention of colonization.

A

Z86.14

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23
Q

Neoplasm

A

Abnormal growth of new tissue

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24
Q

Primary malignancy

A

Site where cancer originates

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25
Secondary malignancy
Results from metastasis and form a new focus of malignancy. Primary cancer has invaded adjacent structure.
26
In situ
Malignancy confined to the origin site. Encapsulated. May be called non-infiltrating, non-invasive or pre-invasive. Pathologist designates a Dx of Ca In Situ and not a physician.
27
Benign neoplasm
Do not contain precancerous or cancerous cells.
28
Uncertain behavior
Needs to be noted by a pathologist. Neoplasm of transition. Not benign and not malignant.
29
Unspecified neoplasm
Provider did not wait for pathology report. Recommended to wait for the pathology to be reported.
30
Overlapping lesion
When a malignant neoplasm is in a site next to each other (contiguous) use an overlapping code. Same site but not contiguous use a separate code for each
31
Metastatic
Indicates a secondary malignancy
32
Anemia caused by cancer
Code malignancy first then the anemia
33
Anemia caused by chemo or radiotherapy
Code first the anemia followed by the codes for the for the neoplasm and then the adverse affect code
34
Successful treatment of a neoplasm
Inappropriate to code for the neoplasm. Use a code for the personal history of malignant neoplasms
35
Surgery followed by chemo or radiation in the same visit
Neoplasm listed as primary followed by codes for the therapy.
36
Encounter with main reason for administration of chemo, immuno, or radiotherapy
Report the proper Z Code first followed by the code for the neoplasm even if it is removed. When treatment for an eradicated neoplasm is complete then code from the history section.
37
Complications during chemo, immuno, or radiotherapy
Code for therapy first then the complication.
38
Pregnant patient with malignant neoplasm
Code from subcategory O9A.1- is sequenced first then the code for the neoplasm
39
Complication associated with a neoplasm
Complication is coded first then the neoplasm code. Exception is anemia.
40
Pathologic fracture due to neoplasm
Code first the fracture if it is the focus of the treatment. If not then code the neoplasm first
41
Malignant neoplasm of transplanted organ requires:
3 codes. First the transplant complication, then C80.2,followed by the code for the malignancy
42
Merkel cell carcinoma
Rare and aggressive form of a skin tumor. Most commonly seen in older people. Has own section of codes based on anatomic site
43
Melanoma
Skin cancer that originates in the melanocytes. Often starts as a mole. Asymmetry, border irregularity, color and size.
44
Lymphoma
Cancer of the lymphatic system. Hodgkins and non-Hodgkins
45
Hodgkin’s lymphoma
Has Reed Steinberg cells not found in other types of lymphoma
46
Follicular lymphoma
Slow growing lymphoma that arises from B cells. Coded based on grade 1-3. Grade based on how many centroblasts in a high powered field.
47
Neoplasm related pain visit
G89.3. Used when pain is related to a primary or secondary cancer. Primary when the pain is the reason for the visit. If a secondary reason for the visit code as an additional diagnosis.
48
Bx
Biopsy
49
Mets
Metastases/metastatic
50
Cac/o
Bad
51
Sarc/o
Flesh, connective tissue
52
Type 1 diabetes
Autoimmune disease that results in destruction of insulin producing cells in the pancreas. Most often occurs early in life
53
Type 2 diabetes
Still produce insulin but not enough to keep blood sugar levels within normal limits
54
Long term use of insulin
Added to categories E08-E09 and E11-E13 even if the patient is not insulin dependent, but uses insulin for diabetic management.
55
Insulin pump failure
Code first T85.6 Mechanical complication of other specified internal or external prosthetic device, implant, or graft then code for the type of failure then code for the diabetes
56
Overweight/obesity
Separate codes for overweight and obesity. Obesity includes the reason. Secondary codes from Z68 should be used to note BMI when overweight and obesity are used.
57
Crin/o
Secrete
58
Dips/o
Thirst
59
Anemia caused by chemotherapy is coded:
Anemia first, then neoplasm, and then the code for adverse effect of antineoplastic chemotherapy
60
Code for diabetes controlled with oral anti diabetic medications or oral hypoglycemic medications
Z79.84
61
Pain documented with psychological factors code
F45.42 and the associated codes for pain from category G89
62
Pain that is exclusively psychological
F45.41
63
Selection of in remission codes
F10-F19. Requires provider’s clinical judgement before assigning. Requires documentation
64
Use, abuse, and dependence
Always dependence assigned if documented dependence. If use and abuse assign abuse. Pay attention to the Excludes1 notes
65
Factitious disorder imposed on another
Reported on the perpetrators record. Victim should have a code assigned for confirmed or suspected abuse
66
Intellectual disability
Code first physical and developmental disorders followed by codes for the intellectual disorder.
67
ADHD
Broken down by type. Hyperactive,inattentive, or combination
68
Dementia
Two codes needed. First underlying physiological condition then the dementia.
69
Neuroleptic medications
Antipsychotic medications
70
Seizure without epilepsy
See Convulsions in the alphabetic list
71
Epilepsy
Seizure disorder. Two types. Focal or generalized. Code based on type of seizure and whether it is epilepticus or intractable.
72
Intractable seizure
Hard to control. Pharmacoresistant, treatment resistant, refractory, and poor controlled are equivalent.
73
Epilepticus seizure
Seizure that lasts an abnormally long time. Generally longer than 5 minutes
74
Migranosus
Migraine ongoing for more than 72 hours
75
Intractable
Cannot be controlled by medications
76
Dominant/non dominant
If not specified in documentation the dominant side is right and non-dominant is left.
77
Encounter for pain management
Code from G89- followed by underlying condition
78
Pain encounter to treat underlying disease
Code the underlying condition first then the pain code
79
Pain associated with a specific complication
Code complication first then pain code from G89 is reported second
80
Glaucoma
Can be different stages for each eye. If bilaterally the same use one code for the bilateral dx.
81
Nuclear cataract
Affects the center of the lens
82
Cortical cataract
Affects the edges of the lens
83
Posterior/anterior subcapsular cataract
Occurs behind the lens capsule
84
Congenital catarct
Present at birth
85
Morgagnian cataract
Hyper mature cataract
86
Traumatic cataract
Cataract caused by injury
87
Hypertension with heart disease
Code I11 and include code from I50 to indicate type of heart failure. If specifically not related to hypertension each condition is coded separately.
88
Hypertensive heart and chronic kidney disease
I13 captures both diagnosis. Include codes for type of heart failure and to identify stage of kidney disease
89
Hypertension and chronic kidney disease
I12. Include code for stage of kidney disease
90
Elevated blood pressure without further specificity
Use code R03.0. Found under Elevated in alphabetic index
91
STEMI
ST elevation myocardial infarction. Type 1 MI. Coronary artery is completely blocked and heart muscle supplied by the artery starts to die.
92
Myocardial infarction
Heart attack. 5 classes. Class 3-5 are acute. Acute is less than 4 weeks.
93
NSTEMI
Non-ST elevation myocardial infarction. Blood clot partially occluded a blood vessel.
94
I22 Subsequent STEMI or NSTEMI
Only used to report type 1 myocardial infarctions or unspecified AMI.
95
Anticoagulant therapy code
Z79.01. When a patient has vascular disorder and it is documented that the patient taking anticoagulant medication.
96
Status asthmaticus
Patient not responding to asthma treatments
97
Respiratory failure
If reason for the encounter code first. If multiple reasons for admission code first condition that required the most care.
98
Influenza
When the type of virus responsible is identified code for the type of virus. If unknown code from J11
99
Pneumonia
Inflammation of the lungs usually by infection. Code for cause if known. Can also include location if known.
100
Pleural effusion
If a symptom only code the underlying disease. If treating pleural effusion and no documentation of underlying disease code for pleural effusion. Can be malignant if documented.
101
Reflux esophagitis
Inflammation of the esophagus due to reflux. Not GERD.
102
Glaucoma
Can be different stages for each eye. If bilaterally the same use one code for the bilateral dx.
103
Nuclear cataract
Affects the center of the lens
104
Cortical cataract
Affects the edges of the lens
105
Posterior/anterior subcapsular cataract
Occurs behind the lens capsule
106
Congenital catarct
Present at birth
107
Morgagnian cataract
Hyper mature cataract
108
Traumatic cataract
Cataract caused by injury
109
Hypertension with heart disease
Code I11 and include code from I50 to indicate type of heart failure. If specifically not related to hypertension each condition is coded separately.
110
Hypertensive heart and chronic kidney disease
I13 captures both diagnosis. Include codes for type of heart failure and to identify stage of kidney disease
111
Hypertension and chronic kidney disease
I12. Include code for stage of kidney disease
112
Elevated blood pressure without further specificity
Use code R03.0. Found under Elevated in alphabetic index
113
STEMI
ST elevation myocardial infarction. Type 1 MI. Coronary artery is completely blocked and heart muscle supplied by the artery starts to die.
114
Myocardial infarction
Heart attack. 5 classes. Class 3-5 are acute. Acute is less than 4 weeks.
115
NSTEMI
Non-ST elevation myocardial infarction. Blood clot partially occluded a blood vessel.
116
I22 Subsequent STEMI or NSTEMI
Only used to report type 1 myocardial infarctions or unspecified AMI.
117
Anticoagulant therapy code
Z79.01. When a patient has vascular disorder and it is documented that the patient taking anticoagulant medication.
118
Status asthmaticus
Patient not responding to asthma treatments
119
Respiratory failure
If reason for the encounter code first. If multiple reasons for admission code first condition that required the most care.
120
Influenza
When the type of virus responsible is identified code for the type of virus. If unknown code from J11
121
Pneumonia
Inflammation of the lungs usually by infection. Code for cause if known. Can also include location if known.
122
Pleural effusion
If a symptom only code the underlying disease. If treating pleural effusion and no documentation of underlying disease code for pleural effusion. Can be malignant if documented.
123
Reflux esophagitis
Inflammation of the esophagus due to reflux. Not GERD.

2020 Coding For CPT Prep PHS (16 decks)

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