CPC GUIDELINES Questions and answers. Verified. Latest update.

CPC GUIDELINES Questions and answers. Verified. Latest update. When is it acceptable to code signs and symptoms? - When a diagnosis has not been confirmed Should signs and symptoms that are associated routinely with a disease process be assigned as additional codes? - No, unless otherwise instructed by the classification Should signs and symptoms that are not associated routinely with a disease process be assigned as additional codes? - Yes. If the same condition is described as both acute and chronic, and separate sub-entries exist in the Alphabetic Index at the same indentation level, how should the encounter be coded? - Code both and sequence the acute code first. A single code used to classify two diagnoses, or a diagnosis with an associated secondary process(manifestation), or a diagnosis with an associated complication is referred to as? - Combination Code The residual effect after the acute phase of an illness or injury has terminated is referred to as? - Sequela (Late Effect) Is there a time limit on when a sequela can be used - No When coding sequela how many codes are required? - Two The condition of the sequela is sequenced first The sequela code is sequenced second The only exception to this is when manifestations exist When coding sequela should the code for the acute phase of an illness or injury that led to the sequela be used? - No When coding conditions described as "impending" or "threatened", what should be reported if it did occur? - Code as a confirmed diagnosis How many times can each unique ICD-10-CM diagnosis code be reported per encounter? - Once. This applies to bilateral conditions when there are no distinct codes identifying laterality or two different conditions classified to the same ICD-10-CM code If no bilateral code is provided and the condition is bilateral, how should the encounter be coded? - Assign separate codes for both the left and right side. If the side is not identified in the MR assign the code for the unspecified side Which physician should be the one responsible for documenting BMI, non-pressure ulcers, and pressure ulcer stages? - Patient's primary provider When should BMI codes be reported as first listed diagnosis?? - Never How should we code syndromes using ICD-10-CM guidelines - Follow the alphabetic index guidance When coding syndromes and the alphabetic index does not proving any guidance, how should the encounter be coded? - Assign codes for the documented manifestations of the syndrome Additional codes for manifestations that are not an integral part of the disease process may also be assigned when the condition does not have a unique code When is it appropriate to assign codes for complications of care? - There must be a cause and effect relationship between the care provided and the condition, and an indication in the documentation that it is a complication If the provider documents "borderline" diagnosis at the time of discharge, how is the diagnosis coded? - Diagnosis is coded as confirmed unless the classification provides a specific entry (e.g., borderline diabetes) If a definitive diagnosis has not been established by the end of the encounter, it is appropriate to report codes for __________________ in lieu of a definitive diagnosis. - Sign(s0 and/or symptom(s) When sufficient clinical information isn't