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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