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CCS Exam Prep/116 Questions and answers
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CCS Exam Prep/116 Questions andanswers
"code also" - -two codes may be required to fully describe a condition, but it
does not provide sequencing direction
-"see" & "see also" - -"see" means you must go to the main term to locate
correct code; 'see also' means another code may apply
-7th characters - -Certain ICD-10-CM categories have applicable 7th
characters. The applicable
7th character is required for all codes within the category, or as the notes in
the
Tabular List instruct. The 7th character must always be the 7th character in
the
data field. If a code that requires a 7th character is not 6 characters, a
placeholder X must be used to fill in the empty characters.
-admission/encounter due to illness related to HIV infection in pregnancy,
childbirth and the puerperium - -Principal dx is O98.7- (Complicating
pregnancy, childbirth & puerperium)
Then B20, then codes for the illness. Codes from Ch15 always take
sequencing priority; if patient has Z21 (Asymp HIV), report Z21 instead of
B20
-Alphabetic Index - -alphabetical list of terms and their corresponding code
-Alphabetic Index consists of... - -Index of Diseases & Injury, Index of
External Causes of Injury, The Table of Neoplasms, and the Table of Drugs &
Chemicals
-can a diagnosis of sepsis be used even if lab testing is negative or
inconclusive? - -Yes, but the provider should be queried
-Code first is found where? Use additional code? - -"code First" with etiology
terms, "additional code" with manifestation terms
-Code ranges - -A00.0 - T88.9 & Z00 - Z99.8
-coding chapter 18 symptoms/signs/abnormal findings w/ a primary
malignancy - -the signs/symptoms cannot replace the malignancy as
principal/first listed dx (regardless of # of admission for treatment/care of
the neoplasm)
, -default codes - -a code listed next to a main term in the alphabetic index;
represents that condition that is most commonly associated with the main
term; if a condition is documented in a medical record w/o additional info
(acute vs chronic, etc) the default code should be assigned
-describe type 1 DM - -age is not the sole determining factor, though most
type 1 DM pts develop the condition before puberty --> also referred to as
juvenile DM
-Do you code symptoms that are not an integral part of a disease process? -
-Yes; if they are not routinely present w/ a disease process then they should
be coded
-Etiology / Manifestation - which is coded first? - -Certain conditions have
both an underlying etiology and multiple body system manifestations due to
the underlying etiology. For such conditions, the ICD- 10-CM has a coding
convention that requires the underlying condition be
sequenced first, if applicable, followed by the manifestation. Wherever such
a combination exists, there is a "use additional code" note at the etiology
code,
and a "code first" note at the manifestation code. These instructional notes
indicate the proper sequencing order of the codes, etiology followed by
manifestation.
-Exceptions to hospital inpatient guideline Section II, H (Uncertain Diagnosis)
- -Code only confirmed cases of HIV, zika & flue d/t certain identified flu
viruses (Category J09) and d/t other identified flu virus (Category J10).
-Excludes 1 Note exception - -two conditions are unrelated to each other. If
it is not clear
whether the two conditions involving an Excludes1 note are related
or not, query the provider. For example, code F45.8, Other
somatoform disorders, has an Excludes1 note for "sleep related
teeth grinding (G47.63)," because "teeth grinding" is an inclusion
term under F45.8. Only one of these two codes should be assigned
for teeth grinding. However psychogenic dysmenorrhea is also an
inclusion term under F45.8, and a patient could have both this
condition and sleep related teeth grinding. In this case, the two
conditions are clearly unrelated to each other, and so it would be
appropriate to report F45.8 and G47.63 together.
-Excludes 2 Notes - -A type 2 Excludes note represents "Not included here."
An excludes2
note indicates that the condition excluded is not part of the condition
represented by the code, but a patient may have both conditions at the
same time. When an Excludes2 note appears under a code, it is
, acceptable to use both the code and the excluded code together, when
appropriate
-Excludes1 Notes - -A type 1 Excludes note is a pure excludes note. It
means "NOT
CODED HERE!" An Excludes1 note indicates that the code excluded
should never be used at the same time as the code above the Excludes1
note. An Excludes1 is used when two conditions cannot occur together, such
as a congenital form versus an acquired form of the same
condition
-explain laterality coding - -Some ICD-10-CM codes indicate laterality,
specifying whether the condition occurs on the left, right or is bilateral. If no
bilateral code is provided and the condition is bilateral, assign separate
codes for both the left and right side. If
the side is not identified in the medical record, assign the code for the
unspecified side
-explain Remission vs Hx of - leukemia, multiple myeloma, other blood
neoplasms - -remission is when counts have returned to stable/normal
values - hx of is when it has been completely eradicated and is rare for these
diseases - usually go into long-term remission. if unclear query provider.
-how are combination codes identified? - -by referring to subterm entries in
the Alphabetic Index and by reading the inclusion and exclusion notes in the
Tabular List.
-How are diabetes codes determined? - -combination codes - type of DM,
body system affected & the complications affecting that body system;
sequence complications based on reason for encounter.
-how are these codes justified? - -The assignment of a diagnosis code is
based on the provider's diagnostic statement that the condition exists. The
provider's statement that the patient has a particular condition is sufficient.
Code assignment is not based on clinical criteria used by the provider to
establish the diagnosis
-How detailed should a code be? When can you use only 3 characters? - -
Codes can be 3, 4, 5, 6 or 7 characters and should be as detailed as possible.
3 character codes should only be used if not further subdivided. Codes are
invalid if not fully coded, including 7th character
-How do you code a borderline diagnosis? - -If the provider documents a
"borderline" diagnosis at the time of discharge, the diagnosis is coded as
confirmed, unless the classification provides a specific
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