introduction to icd-10-cm

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Feb 20, 2024

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Introduction to ICD-10-CM Diagnosis Coding Completion Instructions: Write the term that completes each statement based on the information you learned in this chapter. Choose from the list below. Some choices may be used more than once and some choices may not be used at all. - Code Also ( ) Code First * : [ ] Excludes1 Excludes2 Includes POA See Use Additional Code With X 1. The ___________ convention identifies nonessential modifiers that describe the default variations of a term. 2. The ___________ convention identifies mutually exclusive codes that should not be used together. 3. The ___________ convention appears after the code number and tells the coder to assign additional characters. 4. The ___________ convention is used in the Index to identify a code that should be sequenced second. 5. The ___________ convention means that one condition is associated with or due to the other. 6. The ___________ convention is a placeholder in codes with less than six characters that require a seventh character. 7. The ___________ convention indicates that the condition excluded is not part of the condition represented by the code, but the patient may have both conditions at the same time. 8. The ___________ convention instructs the coder to sequence the etiology first.

9. The ___________ convention instructs the coder to sequence the manifestation second. 10. The ___________ convention instructs the coder to reference another Main Term or condition to locate the correct code. Multiple Choice Instructions: Circle the letter of the best answer to each question based on the information you learned in this chapter. 1. When should signs and symptoms be coded in the inpatient setting? A. When they are relevant to the current admission and are not integral to the confirmed diagnosis. B. When the diagnosis is uncertain. C. When they are an integral part of the confirmed diagnosis. D. When they are related to a previous, resolved condition. 2. What is the name for the diagnosis, in the outpatient setting, that describes the diagnosis, condition, problem, or other reason for the encounter shown in the medical record to be chiefly responsible for the services provided ? A. Principal B. Uncertain C. First-listed D. Main Term 3. What type of diagnoses are preceded by the words probable , possible , suspected , questionable , rule out , working diagnosis , or a similar word? A. Principal B. Uncertain C. First-listed D. Main Term 4. What is the name for the diagnosis, in an inpatient setting, that is the condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care ? A. Principal B. Uncertain C. First-listed

D. Main Term 5. What are the rules that complement the conventions and instructional notes to provide additional information and direction in identifying the diagnoses to be reported A. OGCR B. Conventions C. Exclusions D. Instructional notes 6. What is the term for the use of symbols, typeface, and layout features to succinctly convey interpretive information? A. OGCR B. Conventions C. Exclusions D. Instructional notes 7. Which coding step means to read the medical record and determine which elements of the encounter require codes? A. Abstracting B. Assigning C. Arranging D. Cross-referencing 8. What is the name of a contiguous range of codes within a chapter in ICD-10-CM? A. Block B. Category C. Section D. Subcategory 9. Which OGCR topic defines separate codes for the right and left sides of the body? A. Bilateral B. Multiple coding C. Arranging D. Laterality 10. What type of condition can qualify a patient for a higher-paying DRG? A. Etiology B. Nonessential modifier C. HAC D. MCC

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Instructions: Read the diagnostic statement and underline the Main Term. Then use the Index and Tabular List to assign and sequence ICD-10-CM diagnosis codes. Write the code(s) on the line provided. 1. Acquired flat foot, left. ICD-10-CM Code(s) __________________________________________________________________ ___ 2. Encounter for immunotherapy. ICD-10-CM Code(s) _______________________________________________________________ 3. Stage 3 pressure ulcer, left buttock. ICD-10-CM Code(s) ____________________________________________________________ 4. Alcohol dependence. ICD-10-CM Code(s) __________________________________________________________________ ____ 5. Fistula, left elbow. ICD-10-CM Code(s) __________________________________________________________________ ______ 6. Family history of alcohol abuse. ICD-10-CM Code(s) _______________________________________________________________ 7. Body mass index of 38 in an adult. ICD-10-CM Code(s) _____________________________________________________________ 8. Benign hypertension. ICD-10-CM Code(s) __________________________________________________________________ _____ 9. Dysphagia following a cerebral infarction with difficulty swallowing. ICD-10- CM Code(s) ____________________________________ 10. Severe rebound abdominal pain in the left lower quadrant. ICD-10-CM Code(s) ___________________________________________ 11. Repeated falls. ICD-10-CM Code(s) __________________________________________________________________ __________ 12. Merkel cell carcinoma of the right eyelid. ICD-10-CM Code(s) _________________________________________________________ 13. Pain due to malignant neoplasm. ICD-10-CM Code(s) ______________________________________________________________ 14. Type 2 diabetes mellitus. ICD-10-CM Code(s) __________________________________________________________________ _

15. Insect bite, left ankle, subsequent encounter. ICD-10-CM Code(s) ______________________________________________________ 16. Second- and third-degree chemical burns, right ankle, initial encounter. ICD- 10-CM Code(s) _________________________________ 17. Fused toes, bilateral. ICD-10-CM Code(s) __________________________________________________________________ ______ 18. Chronic cystitis with hematuria. ICD-10-CM Code(s) _______________________________________________________________ 19. Pneumocystis pneumonia. ICD-10-CM Code(s) __________________________________________________________________ _ 20. Anemia. ICD-10-CM Code(s) __________________________________________________________________ _______________ 21. Encounter for blood typing. ICD-10-CM Code(s) __________________________________________________________________ _ 22. Ventilator-associated pneumonia. ICD-10-CM Code(s) ______________________________________________________________ 23. Head lice. ICD-10-CM Code(s) __________________________________________________________________ ______________ 24. Polyhydramnios, second trimester, fetus 3. ICD-10-CM Code(s) _______________________________________________________ 25. Acute otitis externa, right ear. ICD-10-CM Code(s) ____________________________________

Instructions: Read the mini-medical-record, then answer the questions that follow to abstract, assign, and arrange (sequence) the correct codes. Part 1: Abstract 1. Read through the mini-medical-record. Observe the patient demographics. Compare the chief complaint to the final assessment. a. What symptom did the patient report in the chief complaint? b. What two conditions are stated in the assessment? 2. a. Is the symptom integral to one of the conditions stated in the assessment? b. Should you code for the symptom? c. Why or why not? d. What is the first condition due to? Part 2: Assign 3. You can look up the conditions in any order you wish, as long as you sequence them correctly in the end based on the instructional notes you find during this exercise. Today, begin by coding the underlying condition, the condition that the heart failure is due to . a. Look up the Main Term Hypertension in the Index, then

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the subterm heart, with, heart failure . What code is listed? b. Verify this code in the Tabular List. Is there a symbol in front of this code indicating that you need additional characters? 4. a. What does the instructional note under the code say? b. Based on this instructional note, should the code for Hypertension be sequenced first or second? 5. a. Locate the beginning of this block for Hypertensive diseases . Read the instructional notes. Now refer back to the mini-medical-record. What lifestyle habit is documented? b. Which instructional note applies to this patient? ( Tip: History describes a past condition that no longer exists.) You will verify this code later in this exercise. c. Review the instructional notes at the beginning of ICD-10-CM Chapter 9. Do any of these notes apply to this patient? 6. a. Now determine the code for heart failure. Look again at the instructional note under the code for Hypertension . What code is listed in the instructional note? b. What does the short dash (-) at the end of the code mean? 7. a. Verify the code listed in the instructional note. Review the four-character subcategories under this heading and locate the one that describes Combined systolic and diastolic heart failure . Write down the subcategory code. b. Now review the five-character codes under this subcategory. What code describes Chronic combined systolic and diastolic heart failure ? 8. Cross-reference the three-character category heading for Heart failure . Read through the instructional notes. What condition should be coded first that applies to this patient. This code should match the one you assigned in step 3a. The instructional note confirms that you assigned the correct first code or alerts you to the fact that the first code was not correct. 9. Now you need to assign a third code for the lifestyle habit you

listed in step 5a above. List the code here. Verify the code. (This code is sequenced last.) Part 3: Arrange 10. You have identified three codes for this case. Review your answers in the previous questions to determine the correct sequencing. a. What code is sequenced first based on the instructional notes in steps 4b and 8? b. What code is sequenced second? c. What code is sequenced third?

introduction to icd-10-cm

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