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CCS Exam > ICD 10 CM > Flashcards

ICD 10 CM Flashcards

(65 cards)

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1
Q

Severe Sepsis

A
  1. Systemic infection
  2. R65.2 subcategory
  3. Additional for organ failure
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2
Q

Septic Shock

A
  1. system infection
  2. R65.21, Severe sepsis with septic shock
  3. additional for organ failure
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3
Q

Admitted due to pneumonia and sepsis

A
  1. A41.9 (sepsis, unspecified org)

2. pneumonia

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4
Q

Admitted with pneumonia, develop sepsis after admission

A
  1. Pneumonia

2. A41.9 (sepsis)

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5
Q

Sepsis due to postprocedural infection

A
  1. Infection following procedure (T81.40 - T81.43) or OB code (if OB)
  2. Specific infection code (A40 or A41 or B37.7)
  3. Sepsis following a procedure (T81.44-) or OB (086.04)
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6
Q

Infections following transfusion, infusion, injection, immunization

A
  1. infection following the tx code

2. specific agent

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7
Q

Bacteremia

A

R78.81

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8
Q

Admitted with SIRS due to pneumonia (not septic)

A

Pneumonia (J18.9)

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9
Q

Admitted with sepsis due to aspiration pnemonia

A
  1. Sepsis (A41.9)
  2. Pneumonia
  3. Pneumonitis due to inhalation of food and vomit
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10
Q

Toxic shock

A

Caused by bacterial infection

  1. Toxic shock syndrome (A48.3 )
  2. code for organism
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11
Q

Nosocomial infections

A

Add Y95 , Nosocomial conditions

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12
Q

multi drug resistant/ specified drug resistant condition

A

infection + Z16- (resistance, organisms, to drug) as long as not in title of infection

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13
Q

colonization

A

not indicative of disease
must be documented by provider
positive = MRSA screen positive or MRSA nasal swab positive

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14
Q

MRSA infection and MRSA colonization

A
  1. MRSA infection

2. Carrier or suspected of MRZ22.32-

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15
Q

Severe sepsis with local infection

A
  1. Systemic infection
  2. Local infection
  3. R65.2 severe sepsis
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16
Q

SIRS of non infectious process

A

SIRS non infectious process coded to R65.1-

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17
Q

Severe sepsis documentation

A

Severe sepsis

Or sepsis with associated organ dysfunction (must associate or query)

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18
Q

Metastatic to

A

Site mentioned is secondary

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19
Q

Metastatic from

A

Indicates the site mentioned is primary

Example: met ca from breast
Breast is primary

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20
Q

One site stated metastatic

Metastatic renal ca of the lung

A

Kidney is primary

Lung secondary

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21
Q

Primary is not know in malignancy

A

Malignant primary unspecified c80.1

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22
Q

Multiple metastatic sites
Primary unspecified

Metastatic carcinoma of brain and lung

A

Code secondary mets
C80.1 primary unspecified

C79.31
C78.00
C80.1

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23
Q

Metastatic carcinoma of bronchus

Metastasic adenocarcinoma of transverse colon

Osteocarcinoma with Mets

Metastic infiltrating duct cell ca

A

Bronchus primary
Metastic ca - c79.9 (secondary)

Colon primary
Metastic ca - c79.9

Breast primary
Mets c79.9 (secondary )

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24
Q

Anemia
Neutropenia
Thrombocytopenia

A

Code to panocytopenia

D61.818

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25
Includes note
Appears immediately under a three character code title to further define or give examples of that category
26
Inclusion terms
List of terms are conditions for which that code is to be used . Synonyms
27
Excludes 1
Pure excludes note NOT CODEd HERE Exception when they are unrelated If not clear query
28
Excludes 2
Not included here | Not part of that condition
29
See
Another term should be referenced | Necessary to go somewhere else
30
See also
Another may be referenced | Do not have to
31
Code also
Two codes may be needed to describe DOES NOT provide sequencing direction
32
Default codes
Code listed next to main term | The unspecified code
33
In diseases classified elsewhere
NEVER as PDX Must be used in conjunction with another code Listed following the underlying condition
34
Use additional code
These are manifestation codes that don’t have in diseases classified elsewhere in title Additional code note at etiology Code first at manifestation
35
Code first
This is the manifestation
36
Code can be taken from clinician
``` BMI Depth of non pressure chronic ulcer Pressure ulcer stage Coma scale Stoke nih scale Social determinants of health ```
37
Admit to obv and same condition gets worse - what is pdx
Medical condition that leads to hospital admission
38
Pdx for admit following ops to obv to Ip
Apply condition established after study to be chiefly responsible
39
Ops to ip due to complication
Complication
40
Ops to Ip - no reason and no complication
Code reason for op surgery
41
Ops to Ip - unrelated to surgery
Unrelated to surgery assign unrelated
42
Op to obv - due to complications
Reason for surgery
43
Secondary dx list
``` Evaluate Therapeutic tx Further eval by dx studies prof or consult Extended los Increases nursing care and or monitoring ``` Perinatal - has implications for future health care needs
44
Smoker
Dependence
45
Pain control or pain management reason for admission
G89 category pdx | Underlying cause added as additional
46
Admitted for insertion of pain stimulator
G89 pain code- pdx
47
Admission for procedure to treat underlying condition and neuro stim inserted for pain during same admission
Underlying condition - pdx | Pain- Sdx
48
G89 and site specific pain
G89 can be used with site specific pain if code that describes site of pain does not fully describe pain Example - acute chrinic Sequencing dependent on circumstances
49
Sequencing pain
Encounter for pain control or pain management G89- pdx Site specific pain- sdx If for any other reason and relative dx has not been established Site specific pain - pdx G89- sdx
50
Post op pain
Routine post op pain not coded
51
Chronic pain
G89.2 | No time frame
52
Neoplasm related pain
G89.3 | Documented as related due to cancer or the tumor or malignancy
53
Neoplasm pain sequencing Reason for admission is pain control related to neoplasm
Pain g893 as pdx | Neoplasm- sdx
54
Neoplasm pain sequence Reason for admission Management of neoplasm Pain associated with neoplasm documented
Neoplasm - pdx | Pain G893 - sdx
55
Spondylolisthesis
Bony vertebrae slips | Not intervertebral disc disorder
56
How to look up main term alpha
Review sub terms and non essential modifiers related to main term cross reference instructions notes in the alpha index A dash at end of index entry indicates additional characters required
57
Verify in the tabular
Read code title Read and follow instruction notes Determine whether any additional character must be added Determine laterally and any applicable extensions
58
Borderline dx
Not same as uncertain | Code as confirmed unless there is an entry for that condition as borderline
59
Coding clinic approved by
Ahima Cms CDC Nchs
60
Case mix complexity
``` Severity of illness Prognosis Treatment difficulty Need for intervention Resource intensity ```
61
Msdrg use
``` Pdx Additional dx Principal procedure Additional procedure Sex Discharge status ```
62
Drg hierarchy
1. Is it pre mdc or body system drg 2. Pre mdc are extremely resource intense Organ implant Bone marrow transplant Trach Pdx not taken into consideration in pre mdc
63
How Many mdc s
25
64
What classifies a cc
It’s presence with the pdx would increase los by at least one day in at least 75% of patients
65
Cc exclusion list
Mdc and ccs not considered a cc or mcc for a given pdx

CCS Exam (6 decks)

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