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Intro to ICD-10-CM and ICD-10-PCS Coding Questions and Answers
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Intro to ICD-10-CM and ICD-10-PCS Coding Questions and Answers International Classification of Diseases (ICD) published by the World Health Organization (WHO) used to classify mortality (death) data from death certificates International Classification of Diseases, Tenth Revision, Clinical M...

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  • November 23, 2024
  • 5
  • 2024/2025
  • Exam (elaborations)
  • Questions & answers

Subjects

  • intro to icd 10 cm and icd 10 pcs coding questions
  • international classification of diseases icd pub
  • medical necessity defined by medicare as the dete

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  • PCSS

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Intro to ICD-10-CM and ICD-10-PCS
Coding Questions and Answers
International Classification of Diseases (ICD) - answer published by the World Health
Organization (WHO)

used to classify mortality (death) data from death certificates

International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-
CM)

- a clinical modification of the original ICD

- developed in the US to code and classify morbidity (disease) data from inpatient and
outpatient records

- a closed classification system used in the US to classify diagnoses, meaning ICD-10-
CM provides just one place to classify each condition

International Classification of Disease, Tenth Revision, Procedure Classification System
(ICD-10-PCS)

- used to code and classify procedure data from hospital inpatient records only

the ICD-10-CM/PCS coding system is a tool in the classification of morbidity data for
indexing of patient records, reviewing quality of care, and compiling basic health
statistics - the clinical picture of the patient

Medical Necessity - answer defined by Medicare as "the determination that a service
or procedure rendered is reasonable and necessary for the diagnosis or treatment of an
illness or injury"

the measure of whether a health care procedure or service is appropriate for the
diagnosis and treatment of a condition

determined by:

purpose - the procedure or service is performed to treat a medical condition

scope - the most appropriate level of service is provided, taking into consideration
potential benefit and harm to the patient

evidence - the treatment is known to be effective in improving health outcomes

, value - the treatment is cost-effective for this condition when compared to alternative
treatments or no treatment

ICD-10-CM Basics - answer ICD-10-CM composition
- index to diseases and injury: an alphabetical list of terms and corresponding codes
[includes Neoplasm Table, Table of Drugs and Chemicals, Index to External Causes]
- tabular list of diseases and injury: alphanumeric list of codes divided into chapters
based on body system or condition

consist of at least 3 characters, and most are followed by a decimal point and 1-4
additional characters

the first character is always a letter

placeholder = involves the use of the letter "x" in certain codes to allow for future
expansion

main term = conditions in bold

nonessential modifiers = qualifying words contained in parentheses after the main term
that don't have to be included in the documented diagnostic or procedural statement for
the code listed after the parentheses to be assigned

subterms (essential modifiers) = qualify the main term by listing alternative sites,
etiology, or clinical status

INDEX

default code = listed next to the main term, represents the code for the condition most
commonly associated with the main term or may represent an unspecified code for the
condition

never code just from the index, always check the tabular

Step 1 - locate the main term in the index, review subterms and qualifiers

Step 2 - if the instructional phrase is "-see condition", then a different part of the
description is the main term

Step 3 - when the condition in the diagnosis statement is not easily found, use these
main terms:

abnormal
anomaly
complication

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