Coding and Coding Guidelines Flashcards
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Read the first 6 Coding and Coding Guidelines flashcards as text
What is the difference between an 'excludes 1' and 'excludes 2' note in ICD-10-CM?
Answer: Excludes 1 means never code together; excludes 2 means the excluded condition is not included in the code but can be coded together if both conditions are present
'Excludes 1' means the two conditions cannot occur together (mutually exclusive) and should never be coded simultaneously. 'Excludes 2' means the excluded condition is not part of the current code but may exist with it and can be coded separately.
What does 'code first' instruction mean in ICD-10-CM?
Answer: An instruction to sequence a causal/underlying condition before the manifestation code when both conditions are present
'Code first' indicates that an etiology/underlying condition code must be sequenced before the current code when the underlying condition is present. It is a sequencing instruction.
How do you code a surgical complication in ICD-10-CM?
Answer: Code the specific complication code from Chapter 19 (T80–T88) for postprocedural complications, sequenced based on the reason for the encounter
Postprocedural complications are coded using specific complication codes (T80–T88 range) in Chapter 19, or organ-specific complication codes in other chapters, with sequencing based on the circumstances of the encounter.
What does the 'Z' category of ICD-10-CM codes represent?
Answer: Codes for factors influencing health status and contact with health services (non-disease reasons for encounters)
Z codes (Chapter 21) represent encounters for reasons other than illness or injury, such as preventive care, screenings, immunizations, family history, status codes, and follow-up visits.
What is the guideline for coding 'uncertain diagnoses' in the outpatient setting?
Answer: Do not code uncertain diagnoses (possible, probable, suspected, rule out); code the sign or symptom instead
ICD-10-CM Official Guidelines for outpatient coding state that uncertain diagnoses (qualified as possible, probable, suspected, or rule out) should NOT be coded. Instead, code the sign, symptom, or finding that prompted the visit.
What is meant by 'combination code' in ICD-10-CM?
Answer: A single code that fully describes two or more conditions, a condition and its complication, or a condition and its causative organism
A combination code in ICD-10-CM classifies two diagnoses, or a diagnosis with an associated complication or causative organism, into a single code, simplifying documentation and coding.