Coding Guidelines & Conventions Flashcards

In ICD-10-CM, what does the instruction 'Code first' indicate?

Answer: The listed code must be sequenced first when a causal condition exists

'Code first' directs the coder to sequence the underlying cause or manifestation code before the current condition code.

What is the purpose of the 'Excludes2' note in ICD-10-CM?

Answer: The excluded condition may be coded together with the code when both conditions are present

Excludes2 means the excluded condition is not part of the indexed condition but both may be reported simultaneously if documented.

When coding an encounter for a condition that is both acute and chronic, which form should generally be sequenced first?

Answer: Acute form

ICD-10-CM guidelines direct coders to sequence the acute condition first when separate codes exist for both acute and chronic forms.

In CPT, what is a 'separate procedure' designation?

Answer: A procedure integral to a larger service and not separately reported when performed as part of that service

Procedures labeled 'separate procedure' in CPT are commonly bundled into larger services and should not be reported separately unless performed independently.

What does the abbreviation 'NEC' mean in the ICD-10-CM index?

Answer: Not Elsewhere Classified

NEC (Not Elsewhere Classified) directs the coder to use this code when a specific code for the condition does not exist.

Which CPT modifier indicates a distinct procedural service performed on the same day as another procedure?

Answer: -59

Modifier -59 identifies a procedure or service that is distinct or independent from other services performed on the same day.

In ICD-10-CM, how should a condition described as 'probable' be coded in the outpatient setting?

Answer: Code the signs and symptoms, not the unconfirmed diagnosis

Outpatient coding guidelines prohibit coding unconfirmed diagnoses; signs, symptoms, or test findings should be reported instead.