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For the most accurate assignment of ICD-10-CM codes, coders review __________ to locate
conditions and diseases.
patient records
The subcategories for encounters for general adult medical examinations, Z00.0-, provide codes for
with and without abnormal findings. When a general medical examination results in abnormal
findings, the code for __________ is assigned as the first-listed diagnosis. A secondary code for the
abnormal finding should also be assigned.
general adult medical examination with abnormal finding
The testing of a person to rule out or confirm a suspected diagnosis because the patient has some
sign or symptom is a __________.
diagnostic examination
A screening code may be a __________ code if the reason for the visit is specifically the screening
exam.
first-listed
For patients receiving __________ only, assign and report first the appropriate code from ICD-10-CM
subcategory Z01.81 (encounter for preprocedural examinations), to describe the preoperative
consultations.
preoperative evaluations
Codes that describe symptoms and signs instead of __________ are acceptable for reporting
purposes when the physician has not documented an established diagnosis or confirmed diagnosis.
definitive diagnoses
The patient presents for elective inguinal hernia repair (outpatient surgery). The surgery is canceled
due to increased blood pressure upon administration of anesthesia. Which is reported as the
first-listed diagnosis?
inguinal hernia
For accurate reporting of ICD-10-CM diagnosis codes, documentation should describe the
__________, using terminology that includes specific diagnoses as well as symptoms, problems, or
reasons for the encounter.
patient's condition
ICD-10-CM provides codes to deal with encounters for circumstances other than a disease or an
injury in the __________ chapter.
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