Chapters 1-6 study guide Questions and Answers

Chapters 1-6 study guide Questions and Answers What is the definition of "Principal Diagnosis"? The condition established After Study to be chiefly responsible for why the patient was admitted Why is the designation of the correct principal diagnosis so important? info used in cost comparisons, in care analysis, and utilization review. Crucial for reimbursement 3 of the guidelines for designating the principal diagnosis •Two or more diagnoses that equally meet the definition. •Original treatment plan not carried out. •2 or more comparable or contrasting conditions. What conditions must be met in order for a diagnosis to be listed as "other" diagnosis? clinical evaluation, therapeutic treatment, further evaluation by studies, procedures, or consultation, extended length of hospital stay, increased nursing care or monitoring The admission diagnosis must always be the same as the principal diagnosis for inpatient admissions. True or False? False in the case of outpatient reporting, if the physician does NOT identify a definitive condition or problem at the conclusion of a visit, what should the coder do? Report the documented chief complaint as the reason for the visit Accurate and ethical ICD-10-CM and ICD-10-PCS coding depends on correctly following which of the items below? All instructions in the coding manuals All official guidelines developed by the Cooperating Parties Coding advice published in the AHA Coding Clinic How many chapters does the tabular list have? 22 What is the most amount of characters a code can have? 7 What is used as a placeholder character? x to allow for future expansion main terms identify disease conditions or injuries Subterms indicate site, type or etiology for conditions or injuries. a dash indicates (-) additional characters are required Carryover lines are used only when the complete entry cannot fit on a single line. Alphabetization rules ignores the following: single spaces between words, single hyphens within words, the final s in the possessive forms of words Late effects of an earlier condition may be found in the Alphabetic Index under which of the following terms? Sequelae The Alphabetic Index consists of the Index of Diseases and Injuries, the Index to External Causes, the Neoplasm Table, the Hypertension Table, and the Table of Drugs and Chemicals. True or False? False The system of alphabetization in the ICD-10-CM Alphabetic Index ignores single hyphens within words. True or False? True Words such as "with," "in," "due to," and "associated with" are used to express the relationship between the main term or a subterm and an associated condition or etiology. True or False? True Which type of instructional note is used in the Tabular List of Diseases to identify a code for a condition that is a manifestation of an underlying disease? "Code first underlying condition" note. What do the abbreviations NEC and NOS mean? NEC (not elsewhere classified) is used in the Alphabetic Index to indicate that there is no separate code for the condition. NOS (not otherwise specified) is the equivalent of "unspecified" and is used only in the Tabular List. Terms in parentheses should always be present and will always affect the code to which a given term is assigned. True or False? False What does the word "and" mean when it appears in a code title, such as "Unspecified anomalies of face and neck"? The condition may be present in both the face and the neck, or in the face, or in the neck Which of the following punctuation marks are not used in ICD-10-CM? Parentheses Colons Semicolons Square brackets Semicolons The information below is a reproduction from the Alphabetic Index. Which of the following terms is a nonessential modifier that will not affect code assignment? Absence (of) (organ or part) (complete or partial) -adrenal (gland) (congenital) Q89.1 --acquired E89.6 Gland The information below is a reproduction from the Alphabetic Index. What does the instructional note "see category" indicate? Pyelitis (congenital) (uremic)—see also Pyelonephritis -with --calculus—see category N20 The coding professional must refer to category N20 in the Tabular List and select one of the codes provided under N20 In ICD-10-CM, what is the difference between "excludes1" and "excludes2" notes? An "excludes1" note means "not coded here." An "excludes1" note instructs the user that the code excluded should never be used at the same time as the code above the "excludes1" note. This instruction is used when two conditions cannot occur together, and therefore both codes cannot be used together. An "excludes2" note means "not included here." An "excludes2" note instructs the user that the condition excluded is not part of the condition represented by the code. However, 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. A patient is admitted with acute myocardial infarction; the physician notes in the history that the patient is status post cholecystectomy and had been hospitalized one year earlier for pneumonia. At discharge, the physician documents the final diagnoses as acute myocardial infarction, status post cholecystectomy, and history of pneumonia. Which of the following diagnosis(es) should be coded and reported? Acute myocardial infarction A patient is admitted following a hip fracture, and a diagnosis of Parkinson's disease and type 2 diabetes mellitus on insulin are noted in the history and physical examination. Nursing notes indicate that the patient required additional care because of the Parkinson's disease, and because the insulin levels had to be monitored. Which of the following diagnosis(es) should be coded and reported? Hip fracture Parkinson's disease Type 2 diabetes mellitus Which of the following actions is NOT appropriate for providers to resolve coding disputes with payers? Select the closest payable code to get the claim paid. Why is it important to review the entire medical record before assigning diagnosis codes? It is important to review the entire medical record because some diagnoses, operations, and procedures are frequently not listed on the face sheet or are not described in sufficient detail, making a review of operative reports, pathology reports, and other special reports imperative. Reviewing the entire medical record will ensure complete and accurate coding. Code assignment is based solely on the attending physician documentation. True or False? False Where does a physician list the final diagnoses? Admission record (face sheet) Progress notes Discharge summary Any of the above The coding professional must be sure that the medical record documentation supports code assignment. True or false? True For inpatient coding, if the attending physician does not confirm the pathological or radiological findings, the coding professional may code the findings without additional confirmation. True or False? False It is appropriate to assign a procedure code based on documentation by the nonphysician professional who provided the service. True or False? True If there are conflicts in the documentation from different physicians, what should the coding professional do? Query the attending physician for clarification.