ICD-10-CM Diagnosis Coding Flashcards
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Read the first 7 ICD-10-CM Diagnosis Coding flashcards as text
According to ICD-10-CM guidelines, when should signs and symptoms be coded in addition to a confirmed diagnosis?
Answer: When the sign or symptom is not routinely associated with the confirmed diagnosis
Signs and symptoms that are NOT integral to (routinely associated with) a confirmed diagnosis should be coded as additional codes.
What does a 'Code First' instruction in ICD-10-CM direct the coder to do?
Answer: Sequence the underlying etiology before the manifestation code
A 'Code First' note instructs the coder to sequence the underlying condition (etiology) before the manifestation code, following the etiology/manifestation convention.
What is a combination code in ICD-10-CM?
Answer: A single code that classifies two diagnoses, a diagnosis with a complication, or a diagnosis with an associated manifestation
A combination code is one code that captures multiple clinical concepts simultaneously, such as a condition and its associated complication or manifestation.
What does an 'Excludes1' note in ICD-10-CM indicate?
Answer: The two conditions cannot coexist, so both codes should never be reported together
An Excludes1 note is a 'pure' exclusion meaning the two conditions are mutually exclusive and can never be coded together for the same patient at the same time.
What does an 'Excludes2' note in ICD-10-CM mean?
Answer: The excluded condition is not included here, but both conditions may coexist and be coded simultaneously
An Excludes2 note means the excluded condition is not included in the current code, but a patient may have both conditions at the same time, in which case both codes may be assigned.
When is it appropriate to use an unspecified ICD-10-CM code?
Answer: When the medical record lacks sufficient information to assign a more specific code
Unspecified codes are valid when the medical record documentation genuinely does not support assignment of a more specific code.
ICD-10-CM Z codes are primarily used to represent:
Answer: Factors influencing health status and reasons for encounters not due to illness or injury
Z codes capture reasons for encounters such as preventive screenings, immunizations, history of conditions, and other factors affecting health status that are not diseases or injuries.