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Step-By-Step Medical Coding Chapter 4: Using ICD-10-CM Flashcards

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7957754633Patient has Rheumatoid Arthritis and Anemia. The Anemia is integral to the Rheumatoid Arthritis.FALSE0
7957762467Patient has Dyspnea due to Congestive Heart Failure. Dyspnea should be assigned as an additional code.FALSE1
7957786643Multiple coding should be used when the classification provided the classification code that identifies all of the elements documented in the diagnosis.FALSE2
7957794076The code for the acute phase of an illness or injury that led to the sequela can be used with a code for the late effect.FALSE3
7957799242The residual effect is reported as a secondary code.FALSE4
7957805826In sequela effect, the code is either a current injury or a condition caused by a prior injury. It cannot be both.TRUE5
7957811871Although each diagnosis code may be reported only once per encounter, each code can be reported more than once per patient.TRUE6
7957819700In an outpatient setting, an impending condition should be coded as if it actually exists.FALSE7
7957824443Additional signs and symptoms that may not routinely be associated with the disease process being reported should be coded when present.TRUE8
7957839827An example of a late effect is hemorrhage after a surgery requiring a return to the operating room.FALSE9
7957842973You may report a code from the Index without verifying in the Tabular when there is no indication that the code requires additional characters.FALSE10
7957858310If a patient has a confirmed diagnosis, the signs and symptoms related to that condition should also be reported.FALSE11
7957871514If the same condition is described as both acute and chronic, and separate subentries exist in the Alphabetic Index at the same indentation level, report both codes and sequence the acute code first.TRUE12
7957883582A dash (-) at the end of an Index entry indicates that an additional character or characters is/are required.TRUE13
7957895789Cholelithiasis with chronic cholecystitis without obstruction (K80.10) is an example of a dual code.FALSE14
7957904697A code is invalid if it has not been reported to the full number of characters available, including the 7th character, if applicable.TRUE15
7957904698In most cases the manifestation codes will have in the code title, "in disease classified elsewhere."TRUE16
7957919191A late effect usually occurs within 1 month of the illness or injury.FALSE17
7957925656In diabetic retinopathy, the retinopathy is the etiology and the diabetes is the manifestation.FALSE18
7957937382In the outpatient setting, it is correct to report a "probable" condition as if it exists, such as probable appendicitis as appendicitis.FALSE19
7957948482When sequencing codes for residuals and late effects, the late effect code is sequenced first followed by a code describing the residual condition.FALSE20
7957955996Section II of the ICD-10-CM Official Guidelines for Coding and Reporting includes instructions on outpatient coding and reporting.FALSE21
7957961451Diagnosis codes are always reported to the highest number of characters available.TRUE22
7957970701The cooperating parties for the development and approval of the Official Guidelines for Coding and Reporting are CMS, AMA, and NCHS.FALSE23
7957979908List 5 common symptoms associated with acute myocardial infarction.1. Chest pain 2. Shortness of breath 3. Nausea and/or vomiting 4. Palpitations 5. Lightheadedness24
7957995359List 5 common symptoms associated with gastroesophageal reflux.1. Heartburn 2. Acid regurgitation 3. Belching 4. Hoarseness in the morning 5. Reflux 6. Pain in chest 7. Trouble swallowing 8. Choking feeling 9. Dry cough25
7958018636List 4 common symptoms associated with seasonal allergies.1. Runny nose 2. Itchy and/or watery eyes 3. Sneezing 4. Coughing26
7958027362List 4 symptoms of a broken nose.1. Swelling 2. Pain 3. Discoloration 4. Disfiguration27
7958035004Acute renal failure due to previous viral encephalitis.Residual: Acute renal failure Cause: Viral encephalitis28
7958043749Constrictive pericarditis due to old tuberculosis infection.Residual: Constrictive pericarditis Cause: Tuberculosis infection29
7958055722Hemiplegia/hemiparesis affecting right dominant side due to cerebrovascular accident 4 months ago.Residual: Hemiplegia/hemiparesis of right dominant side Cause: Cerebrovascular accident 4 months prior30
7958416755List the four cooperating parties that agree on coding principles.1. AHA 2. AHIMA 3. CMS 4. NCHS31
7958420014ICD-10-CM Section I Guidelines covers what guidelines?Structure and conventions, general guidelines, & chapter specific guidelines32
7958424177ICD-10-CM Section II Guidelines covers what guidelines?Selection of principal diagnosis for non-outpatient (hospital) settings33
7958429226ICD-10-CM Section III Guidelines covers what guidelines?Reporting additional diagnoses in non-outpatient settings34
7958433553ICD-10-CM Section IV Guidelines covers what guidelines?Outpatient coding and reporting35
7958440444List the steps for accurate coding in order:1. Identify the main term(s) in the diagnostic statement 2.Locate the main terms in the Alphabetic Index 3. Review any subterms under the main terms in the Tabular 4. Follow any cross-reference instructions, such as see 5. Verify the code(s) selected from the Index in the Tabular List 6. Refer to any instructional notations in the Tabular 7. Assign codes to the highest level of specifity 8. Code the diagnosis until all elements are completely identified36
7958444224Which guideline goes over the steps to coding?Section I.B 1. Locating a code in the ICD-10-CM37
7958447521What is used at the end of an Alphabetic entry to indicated that additional characters are required?Dash (-)38
7958450972It is necessary to refer to the Tabular list to verify that no _______ is required.7th character39
7958454826ICD codes are composed of codes with ________ characters.3, 4, 5, 6, or 740
7958460875Codes with three characters are included in the ICD-10-CM as the heading of a ______ of codes that may be further subdivided by the use of 4th, 5th, 6th, and 7th characters, which provide greater detail.Category41
7958463571A code is _____ if it has not been coded to the full number of characters required for that code, including 7th character, if applicable.Invalid42
7959008154A patient presents with the chief complaint of headache of three days duration and frequent urination. Would you report both the headache and urination?Yes43
7959008155If the patient's medical record stated SOB due to asthma, would you report the SOB?No44
7959022187What cross-reference is used when notes are found in the Tabular List at codes that are not part of an etiology/ manifestation pair where a secondary code is useful to fully describe a condition or a secondary code should be added?Use additional codes45
7959029112What should be sequenced first when there is a "code first" note and an underlying disease is present?The underlying condition46
7959033023What note indicates that a code may be assigned as a principal diagnosis when the casual condition is unknown or not applicable?Code, if applicable, any casual condition first47
7959042268What would you code first if the same condition is described as both acute (subacute) and chronic, and separate subentries exist in the Alphabetic Index at the same indentation level?Code both and sequence the acute (subacute) code first48
7959045032What is the term for a single code used to classify two diagnoses?Combination Code49
7959049118A combination code is a single code used to classify _______.1. two diagnoses 2. a diagnosis with an associated manifestation 3. a diagnosis with an associated complication50
7959061681When the combination code lacks necessary specificity in describing the manifestation or complication, a(n) __________ code should be used as a(n) _______ code.Additional; Secondary51
7959067513What is the residual effect (condition produced) after the acute phase of an illness or injury has terminated called?Sequela (late effects)52
7959071502What is generally coded first when coding Sequela effects?The condition or nature of the sequela is sequenced first. The sequela code sequenced second53
7959080153An exception to the Sequela rule are those instances where the code for the sequela is followed by a ________ code identified in the ______ _____ and title or the sequela code has been expanded (at the fourth, fifth, or sixth character levels) to include the manifestations.Manifestation; Tabular List54
7959112568The code for the acute phase of an illness or injury that led to the sequela is never used with a code for the _____ _____.Late effect55
7959120726Many codes have a ________ to identify the sequela within the Tabular. What is used to identify the sequela in the Tabular?7th character, character S56
7959123408If the medical documentation indicates that the patient has two different conditions that are both included in one diagnosis code, how many times would you report the diagnosis code?Once57
7959129917What term is used to specify whether the condition occurs on the left, right, o bilateral side?Laterality58
7959133536How would you assign codes if no bilateral code is provided and the condition is bilateral?Assign the code for the unspecified side59
7959137266In some cases, bilaterally can be reported with a ______ code.Single60
7959142273How often are the Official Guidelines for Coding and Reporting updated?Annually61
7959144640The diagnostic statement in the medical record indicates that the patient has a history of diabetes mellitus. In this example, the coder should assign the code forDiabetes Mellitus62

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