ICD-10-CM Coding Guidelines Flashcards

When a patient is admitted with localized infection and develops sepsis during the stay, how should codes be sequenced?

Answer: Sepsis code is sequenced first per sepsis guidelines, with localized infection additionally

Per Section I.C.1.d, when sepsis develops during an encounter, the sepsis code is sequenced first as principal.

How are pre-existing conditions handled during pregnancy under Chapter 15?

Answer: Coded with Chapter 15 O-codes indicating the pre-existing condition complicates pregnancy, followed by the standard code

Chapter 15 provides specific O-codes for pre-existing conditions complicating pregnancy, followed by the underlying condition code.

What exception exists to the rule that only provider documentation can be used for coding?

Answer: BMI, pressure ulcer staging, and social determinants may be coded from non-physician sources like nursing or dietitian notes

Certain clinical assessments are within non-physician scope, but the related diagnosis must still be documented by a provider.

How do guidelines handle conditions that are 'integral' to a disease process versus 'not integral'?

Answer: Integral signs and symptoms should not be coded separately, but non-routine findings should be coded additionally

Section I.B.5: integral symptoms (e.g., chest pain with MI) are not coded separately, but non-routine findings should be coded.

A provider documents 'uncontrolled diabetes.' What code should be assigned?

Answer: E11.65 for diabetes with hyperglycemia

The ICD-10-CM Alphabetic Index directs 'uncontrolled' to 'with hyperglycemia,' meaning E11.65 for Type 2.

When should a combination code be used versus multiple separate codes?

Answer: Use the combination code when it accurately describes all documented conditions

Section I.B.9: use the combination code when it captures all elements. Only add codes if the combination lacks necessary specificity.