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ICD-10-CM Official Guidelines for Coding and Reporting Exam/64 Questions with Correct Answers
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ICD-10-CM Official Guidelines for Coding and Reporting Exam/64 Questions with Correct Answers
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ICD-10-CM Official Guidelines for Coding andReporting Exam/64 Questions with Correct Answers
Who provides the Coding Guidelines? - -CMS and NCHS
-Where are theses Coding Guidelines found? - -in the front of the ICD-10-CN
book
-What do these Coding Guidelines provide? - -instructions for proper code
selection and sequencing rules
-Section I of Coding Guidelines: - -includes conventions, guidelines, chapter
specific guidelines
-Subsection A of Coding Guidelines: - -includes the conventions and
punctuation
-Subsection B of Coding Guidelines: - -includes general guidelines
-Section C of Coding Guidelines - -includes chapter specific coding
guidelines.
-Referencing the Guidelines: - -Section (roman numeral), chapter (letter),
and sub section (number) of the guidelines being referred to. Start in Table
of Contents. A documented reference looks like this: Section I.C.4.a.2.-
Section I. Conventions, General Coding Guidelines and Chapter Specific
Guidelines, Section I.C. Chapter-Specific Coding Guidelines, Section I.C.4
Endocrine, Nutritional, and Metabolic Diseases (E))-E89), Section I.C.4.a.
Diabetes Mellitus, Section I.C.4.a.2. Type of diabetes mellitus not
documented.
-Section I.B - -General Coding Guidelines; Locate each term in the
Alphabetic Index, verify the code in the Tabular list
-Level of Detail in Coding - -code to the highest degree of specificity, a code
is invalid if not coded to the full number of characters required for that code
-Signs and Symptoms: OP - -do not code a diagnosis unless it is certain:
uncertain-probable, suspected, questionable, rule out, differential, working.
when no definitive diagnosis has been determined, code the signs,
symptoms, and abnormal test result(s) or other reasons for the visit.
-Signs and Symptoms: IP - -is appropriate to report suspected or rule out
diagnosis as if the condition does exist, only true for IP, for all diagnosis
, except HIV, HIV is the only condition that must be confirmed to be reported
in the IP setting.
-Conditions Integral Part of a Disease Process - -codes for symptoms, signs,
and ill-defined conditions are not to be reported as diagnosis when a related
definitive diagnosis has been established, unless otherwise instructed by the
classification. If you are unsure query the physician.
-Conditions Not an Integral Part of a Disease Process - -code for signs and
symptoms that are not routinely associated with other definite diagnosis
should be separately reported.
-Multiple Coding for a Single Condition - -required for certain conditions not
subject to the rules for combination codes: In Index- codes for both etiology
and manifestation of a disease appear following the subentry term, with the
second code in brackets [ ]. Assign both codes in the same sequence in
which they appear. In Tabular-instructional notes indicate when to use more
than one code (code first, code, any causal first, code also, use addl code)
-Acute and Chronic - -when both are documented and there is a separate
code for each, report both codes. The acute code first. Chronic conditions
treated on an ongoing basis may be coded as many times as required for
treatment and care, or when applicable to the patient's care.
-Previously Treated or conditions that no longer exist - -do not code
-History of - -should be coded using a Z code if it affect the patient care or
provides the need for a patient to seek medical attention
-Combination Code - -used to fully identify an instance in which two
diagnosis, or a diagnosis with an associated secondary process
(manifestation) or complication, are included in the description of a single
code number. assign only when that code fully identifies the diagnostic
conditions involved, or when instructed in the Index.
-Sequela - -"residual effect (condition produced)after the acute portion of an
illness or injury has terminated". Key phrases: "due to an old injury" or "due
to previous illness", may be apparent early after acute phase or occur much
later. should be coded according to the nature of the sequela. Two codes are
usually required. Residual condition coded first and cause of sequela
reported secondary. May need to use External Cause of Injuries index.
-Sequela (add'l) - -may be used as principal diagnosis when no residual
diagnosis is identified. acute phase that leads to sequela is never used with a
code for the cause of the sequela. in some instances both the sequela and
manifestation is in one code so only 1 code is reported.
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