Clinical Classification Systems and Coding Flashcards

In ICD-10-CM, what is the maximum number of characters a code can have?

Answer: 7

ICD-10-CM codes can have up to 7 characters, with the first three characters identifying the category and additional characters providing specificity.

Which coding guideline requires that the condition established after study to be chiefly responsible for occasioning the admission is sequenced first?

Answer: Principal diagnosis definition

The principal diagnosis is defined as the condition established after study to be chiefly responsible for occasioning the admission to the hospital, per the UHDDS definition.

CPT codes are organized into how many main sections (categories)?

Answer: 6

CPT is organized into 6 main sections: Evaluation and Management, Anesthesia, Surgery, Radiology, Pathology and Laboratory, and Medicine.

HCPCS Level II codes are used primarily to report what type of services?

Answer: Supplies, equipment, and non-physician services not in CPT

HCPCS Level II codes supplement CPT to cover supplies, durable medical equipment, ambulance services, and other services not represented in CPT.

The MS-DRG system is used to classify inpatient cases primarily for which payer?

Answer: Medicare

Medicare Severity-Diagnosis Related Groups (MS-DRGs) are used by Medicare under the Inpatient Prospective Payment System (IPPS) to determine hospital reimbursement.

In ICD-10-CM, the instruction 'Code first' is used to indicate what type of coding sequence?

Answer: An underlying condition must be coded before the manifestation

'Code first' instructs the coder to sequence the underlying etiology before the manifestation when both are present, following the etiology/manifestation convention.

Which ICD-10-CM convention indicates that two codes may be required to fully describe a condition?

Answer: Use additional code

'Use additional code' instructs the coder to assign a secondary code to provide more complete information about the condition or its manifestation.