Coding Guidelines & Conventions Flashcards

What does ICD-10-CM stand for?

Answer: International Classification of Diseases – 10th Revision – Clinical Modification

ICD-10-CM stands for International Classification of Diseases, 10th Revision, Clinical Modification. This system is used in the United States to code all diagnoses, symptoms, and procedures recorded in conjunction with hospital care. It provides a standardized way to classify diseases for billing, statistical, and research purposes.

When coding a diagnosis, which should be reported first?

Answer: Principal diagnosis

When coding a diagnosis, the principal diagnosis should always be reported first. The principal diagnosis is defined as the condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care. All other conditions are considered secondary diagnoses.

What symbol in ICD-10-CM indicates that another code is needed to fully describe the condition?

Answer: Use additional code

In ICD-10-CM, the 'Use additional code' note indicates that the code selected may not fully describe the patient's condition and that another code is required to provide a complete picture. This convention ensures comprehensive and accurate reporting of diagnoses. It's a crucial instruction for coders to follow to avoid incomplete coding.

Which section of the CPT manual contains evaluation and management codes?

Answer: Evaluation and Management

The CPT (Current Procedural Terminology) manual is divided into several main sections, and the Evaluation and Management (E/M) section contains codes for physician services related to assessing and managing patient health. These codes are used to report office visits, hospital visits, consultations, and other types of patient encounters. It is typically the first section of the CPT manual.

How should a coder handle a diagnosis described as 'probable' or 'suspected' in outpatient coding?

Answer: Use a symptom code

In outpatient coding, diagnoses described as 'probable,' 'suspected,' 'possible,' or 'rule out' should not be coded as if they are confirmed. Instead, the coder should report the signs, symptoms, or abnormal test results that led to the suspected diagnosis. This guideline prevents coding for conditions that have not yet been definitively established.

Which of the following is a placeholder character used in ICD-10-CM?

Answer: X

The character 'X' serves as a placeholder in ICD-10-CM codes. It is used when a code requires a seventh character but does not have a sixth character, ensuring that the seventh character is in the correct position. This placeholder maintains the structural integrity and specificity of the code.

What is the correct sequence if both acute and chronic conditions are coded?

Answer: Acute before chronic

When both acute and chronic conditions are present and coded, the acute condition should be sequenced before the chronic condition. This sequencing rule applies when there is no specific combination code available for both. For example, acute exacerbation of chronic bronchitis would be coded with the acute condition first.

What does the term 'code also' mean in coding guidelines?

Answer: Another code may be required

The 'code also' note in coding guidelines indicates that two codes may be required to fully describe a condition, but the sequencing of these codes is not specified. It suggests that the condition represented by the 'code also' note may be a manifestation of the primary condition or a co-existing condition. Coders must use clinical judgment to determine if the additional code is appropriate.

Which coding convention is used to indicate a condition that should not be coded together with another?

Answer: Excludes1

The 'Excludes1' convention in ICD-10-CM indicates that the code excluded should never be used with the code above the 'Excludes1' note. This means the two conditions are mutually exclusive and cannot occur together. It's a strict instruction to prevent incorrect coding of separate, distinct conditions.