Coding

Question 1

If a congenital deformity had been corrected what code should be used

Answer 1

History-personal

Question 2

Coding for birth episode of a new born what to do

Answer 2

Take code with z38 as principal diagnosis following the other diagnosis

Question 3

definition of medical coding

Answer 3

the process of converting diseases , treatment and medical supplies and implants used for the treatment from a medical report into a universal accepted alphanumeric code format

Question 4

Purpose of coding

Answer 4

Quality care
easier electronic payment in healthcare facility
protection of PHI
saving space
eliminate the chance of missing documents

Question 5

types of codes ?

Answer 5

ICD
CPT
HCPCS

Question 6

Who developed ICD and when ?

Answer 6

WHO 1979

Question 7

For what purpose the ICD developed

Answer 7

to monitor birth rate ,death rate and disease rate

Question 8

Expand ICD 10 CM

Answer 8

International classification of diseases 10 th revision ,clinical modification

published in october 1,2015

Question 9

what all things are coded in ICD ?

Answer 9

Diagnosis
signs and symptoms
external causes
injuries
poisoning
supplementary information

Question 10

what are the 2 parts of ICD book

Answer 10

alphabetic index
tabular list

Question 11

what makes the section 1

Answer 11

index to disease and injuries

Question 12

what includes in section 2 ?

Answer 12

table of neoplasam
table of drugs and chemicals

Question 13

what in section 3 ?

Answer 13

index to external cause of injuries

Question 14

what does ‘see’ means ?

Answer 14

another term should be referenced

Question 15

what does ‘see also’ implies?

Answer 15

instruction to review another main term if all needed information is not located under the first main term

Question 16

what are the multiple codes, when it is used and where it can be found?

Answer 16

use of more than one code for the identification of certain elements of a complex diagnostic statement

found in alphabetic index by the use of a second code listed in brackets

Question 17

what are combination codes?

Answer 17

single code used to classify :
two diagnosis
a diagnosis with manifestation
a diagnosis with complication

Question 18

what are non essential modifiers

Answer 18

sub terms follow the main term and enclosed in parenthesis
optional

Question 19

essential modifiers

Answer 19

sub terms listed below the main term in the alphabetic order and are indented

additional characters for the additional information about the procedure

Question 20

which are the 7th characters?

Answer 20

A,D,S

Question 21

what does the letter A indicate?

Answer 21

initial encounter
patient is receiving active treatment for the condition
eg: surgical treatment,evaluation and treatment by physician

Question 22

what does the letter D indicate

Answer 22

subsequent encounter
received the active treatment, receiving routine care for the injury during the healing or recovery phase

eg: cast removal,follow up visit or aftercare following injury treatment

Question 23

what does the letter S indicate?

Answer 23

sequela
complication or late effect of an injury
eg : scar after burn

Question 24

what does the letter X shows?

Answer 24

place holder
append 7 th character when the code is less than 6 characters in length

Question 25

what is mean by NEC

Answer 25

not elsewhere classified equivalent to word "other" or "other specified codes" these codes are used when there is no specific code available to represent the condition

Question 26

expand NOS?

Answer 26

Not otherwise specified equivalent to "unspecified" indicate the condition or documentation does not provide enough information to assign more specified code

Question 27

how to code if a condition described as both acute and chronic

Answer 27

code both and sequence acute code first

Question 28

how to code an impending or threatened condition documented at the time of discharge?

Answer 28

if it occur - confirmed diagnosis if it did not occur - assign code as impending or threatened condition not listed in the alphabetic index - code for underlying conditions

Question 29

how to code if the document shows "borderline" diagnosis at the time of discharge?

Answer 29

alphabetic index - borderline if subentry not there code the diagnosis as confirmed

Question 29

use of include terms or notes?

Answer 29

included under some codes to define it further or give examples to the content category or block categories

Question 30

what is the context of excludes 1?

Answer 30

codes excluded should never be used at the same time as the code above the excludes 1 note

Question 31

what does it mean by excludes 2?

Answer 31

code is not the part of selected condition, but a patient may have the both conditions at the same time if present both codes can be used

Question 32

difference between signs and symptoms

Answer 32

signs - objective symptoms - subjective

Question 33

how to code if a diagnosis is given

Answer 33

code for the diagnosis if definitive diagnosis is not given code for signs and symptoms if signs and symptoms are given along with definitive diagnosis code is needed for the diagnosis only

Question 34

how to code coma?

Answer 34

used in conjunction with traumatic brain injury codes,acute cerebrovascular diseases,or sequelae of cerebrovascular disease codes sequenced after diagnosis codes three codes from each subcategory to complete the scale (R40.21,R40.22,R40.23) The coma scale codes (R40.2- to R40.24-) are primarily for use by trauma registries, such as for patients who have suffered traumatic brain injuries, but may be used in any setting where the information is collected. The coma scale codes include one code from each of the three subcategories (eyes open, best verbal response, and best motor response). The coding guidelines state to report the total score when only the total score is documented in the medical record. When multiple coma scores are reported within the first 24 hours, only report the coma score at the time of admission. An unspecified coma (R40.20) may be assigned in addition to any medical condition. Do not report codes for unspecified coma, individual or total Glasgow coma scale scores for a patient with a medically induced coma or for a sedated patient.

Question 35

what to do if multiple codes are documented within first 24 hours after hospital admission

Answer 35

code for score at time of admission

Question 36

if patient has recently fallen and reason for fall is being investigated what to do?

Answer 36

assign code R29.6 repeated falls

Question 37

if the patient has fallen in the past and is at risk of future falls what code should be assigned?

Answer 37

Z91.81 as history of fall

Question 38

define ckd

Answer 38

type of kidney disease in which there is gradual loss of kidney function over a period of months or years

Question 39

which are the stages of ckd?

Answer 39

stage 1 stage 2 stage3 stage 3a stage 3b stage 4 stage5 ESRD

Question 40

If CKD &ESRD are documented what to do ?

Answer 40

assign code only for ESRD

Question 41

How to code if the person undergoing dialysis?

Answer 41

code stage of CKD Additional code to identify dialysis status

Question 42

how to code if the patient has transplanted kidney?

Answer 42

use the additional code to report kidney transplant status(Z94.0)

Question 43

if patient has stage 5 CKD had undergoing dialysis how to code?

Answer 43

code stage 5 CKD Dialysis status code

Question 44

what if patient has stage 5 CKD and undergoing chronic dialysis

Answer 44

code for ESRD dialysis status code

Question 45

common signs and symptoms of BPH

Answer 45

Frequent urge to urinate Nocturia difficulty starting urination weak urine stream or a stream that starts and stops dribbling at the end of urination inability to completely empty the bladder

Question 46

guidelines to code BHP or nodular prostate

Answer 46

if patient has any LUTS assign additional codes for LUTS if patients have symptoms other than LUTS report code only for BHP or nodular prostate

Question 47

Define glaucoma

Answer 47

due to fluid buildup in the front part of eye increases the intraocular pressure inside eye cause damage to the optic nerve

Question 47

types of glaucoma

Answer 47

open angle / primary glaucoma angle closure glaucoma other types normal tension glaucoma pigmentary glaucoma secondary glaucoma low tension glaucoma

Question 48

stages of glaucoma

Answer 48

mild moderate severe indeterminate - stage cannot be determined clinically unspecified - stage of glaucoma is not documented

Question 49

what are the guidelines in coding glaucoma

Answer 49

identify : type of glaucoma stage * if both eyes are affected and both have the same stages and type of glaucoma assign the code for bilateral glaucoma *if a patient has bilateral glaucoma but the type and stages are different assign the appropriate code for each eye rather that code for bilateral glaucoma. *if the patient admitted with glaucoma and the stage progress during the admission assign code for highest stage documented

Question 50

define cataract

Answer 50

a cloudy opaque area in the normally clear lens of eye

Question 51

types of cataract

Answer 51

senile juvenile and infantile traumatic complicated drug induced

Question 52

general guidelines for codind conditions in ear

Answer 52

specific codes to report laterality for both ears assign bilateral code if laterality is not given, assign unspecified code

Question 53

types of otitis media

Answer 53

AOM SOM OME chronic OM with effusion

Question 54

what are pressure ulcers

Answer 54

injuries to skin and underlying tissues from prolonged pressure on the skin synonyms- bed sore ,decubitus ulcer, pressure sore

Question 55

stages of pressure ulcer

Answer 55

stage 1 - epidermis stage 2 - epidermis and dermis stage 3 - epidermis, dermis and subcutaneous tissue syage 4 - extend below subcutaneous fat to deep tissues like muscles , tendons, cartilage or bone additional stages pressure induced deep tissue injury unstageable pressure ulcer - stages cannot be determined clinically

Question 56

what is pressure induced deep tissue injury

Answer 56

serious form of pressure ulcer caused by direct pressure to the skin and soft tissue that causes ischemia

Question 57

coding guidelines for pressure ulcers

Answer 57

combination codes specify both size and stage of ulcer multiple sites - code of stage of pressure ulcer at the time of admission as principal diagnosis

Question 58

how to code if the ulcer is documented as healing?

Answer 58

assign appropriate pressure ulcer stage for pressure ulcer code documented as healing

Question 59

how to code if the ulcer healed at the time of discharge?

Answer 59

assign the code for the stage at the time of admission no code is assigned if documentation stages that pressure ulcer completely healed at the time of admission no history code for pressure ulcer

Question 60

how to code if the patient is admitted with a pressure ulcer at one stage and if the stage progresses to higher stage

Answer 60

report 2 codes : one code for stage of pressure ulcer at the time of admission second code for the stage documented during hospital stay

Question 61

if during an encounter a stage of an unstageable pressure ulcer reveled after debriment ,

Answer 61

assign the code for the stage revealed following debriment

Question 62

how to code non pressure chronic ulcers

Answer 62

similar guidelines as pressure ulcers

Question 63

what is a congenital disease?

Answer 63

medical conditions present at or before birth

Question 64

where the codes for congenital absence of an organ is documented?

Answer 64

Q codes

Question 65

where acquired absence of organs documented?

Answer 65

Z89 ,Z90

Question 66

coding guidelines of congenital malformations

Answer 66

codes from q chapter is used throughout the life of the patient. if the deformity is corrected a personal history code should be used

Question 67

how to code the birth episode of a new born record

Answer 67

assign appropriate code from the category Z38 as principal diagnosis , followed by congenital abnormality codes

Question 68

what are z codes called

Answer 68

status codes codes used to describe circumstances or problems which influences a patient's health

Question 69

what all included in the status codes

Answer 69

contact/exposure inoculations and vaccinations status history screening observation aftercare follow up donor counselling encounters for reproductive and obstetric services newborns and infants routine and administrative examinations

Question 70

define psychoactive substance abuse and dependance

Answer 70

abuse refers the individual continues to use the drug even though they know the substance is causing an adverse effect on their mental and physical well being dependance occurs when an individual develops tolerance to a particular drug upon the repeated use of that drug and shows withdrawal symptoms on stopping or reducing the use of that particular drug

Question 71

when use ,abuse,dependance of same substance is given how many codes needed and what is the heirarchy

Answer 71

use only single code heirarchy is : for use and dependance code for dependence fore abuse and dependance - dependance for for use and abuse code for abuse

Question 72

when a medical condition or disease is documented due to substance use , abuse and dependance

Answer 72

first assign code for medical condition then assign code for substance use abuse and dependance

Question 73

if clinical note include the blood alcohol level

Answer 73

assign code from category Y90 in addition to the codes assigned from category f10

Question 74

personal history of psycho active substance usage

Answer 74

shouuld be reported history - personal

Question 75

dementia is progressed to higher level than at the time of admission how to assign code

Answer 75

code for the highest severity level reported during the stay

Question 76

types of poisoning

Answer 76

accidental intentional self harm assault undetermined

Question 77

coding a poison or reaction due to the improper use of a medication

Answer 77

assign code for poisoning from drugs and chemicals table manifestations must be coded additionally

Question 78

what is mean by adverse effect of a drug

Answer 78

if a person take medicine or drug according to the physicians instruction and the patient develop reaction to the medication

Question 79

how to code adverse effect

Answer 79

first code for manifestations next code for the drug

Question 80

what is underdosing?

Answer 80

the patient takes less of a medicaton than prescribed by a physicians instruction

Question 81

how to code underdosing?

Answer 81

code for manifestations then code for drug