Icd 10 Guidelines Study Guide

AMA 152 Chapter 3: ICD-10-CM Outpatient Coding and Reporting Guidelines Study Guide

GuidelinesThe rules of coding are represented in the Official __________ for Coding and Reporting/
Inpatient guidelinesIf there is no clear cut outpatient guideline to follow, which type of guideline would you refer to?
TrueIt is important to code all the conditions that are being managed during an encounter.
EtiologyThe cause of disease or condition is also known as its _________.
First-listedWhen two or more interrelated conditions exist, either could be the __________ diagnosis.
Z codesWhich codes are used when a person who is not ill receives health care services?
21How many chapters are located in Volume 1, Tabular list of ICD-10-CM?
Signs and symptomsWhen a specific diagnosis is not yet known what do you report?
uncertain diagnosisIn an outpatient setting, _________ _________ are not reported.
PrimaryWhich term is now used in place of principle diagnosis?
OutpatientThe majority of the services that a physician will provide are _________ services.
Uniform Hospital Discharge Data SetUHDDS
UHDDSdefinition of principal diagnosis applies only to inpatients in acute, short-term, long-term care, and psychiatric hospitals.
First-listed diagnosisIn the outpatient setting, the term _________ ________ is used in lieu of principal diagnosis.
chief complaintMost physicians will document the _______ ________ of the patient for each encounter in the medical record. The _______ ________ is the reason the patient presents for the medical visit. The ______ ________ is one of the keys to determining the first-listed diagnosis. The ________ _________ is the reason for the visit from the patient’s perspective.
Z23Code _______ is for encounters for inoculations and vaccinations; may be used as a secondary code if the inoculation is given as a routine part of preventive health care, such as a well-baby visit.
FalseWhen a patient is to have outpatient surgery and the surgery is not performed due to contraindication, the reason that the surgery was not performed is the first listed diagnosis.
TrueIt is appropriate to code postoperative diagnosis as it is the most definitive diagnosis for ambulatory surgery.
TrueChronic diseases that are treated on an ongoing basis should be coded and reported as often as the patient receives treatment and care for the chronic conditions.
TrueIn the physician office it is acceptable to report Z codes as a first-listed diagnosis.
FalseIn the outpatient setting it is unacceptable to have a sign or symptom as the first-listed diagnosis.
FalseWhen coding an encounter for preoperative evaluation, the reason that the patient is having the surgery or procedure performed is the first-listed diagnosis.
TrueIn the outpatient setting, diagnoses that are documented as “probable”, “suspected”, “rule out”, or “questionable” are reported to the highest degree of certainty.
FalseThe first-listed diagnosis is defined as the diagnosis that is the most serious.
FalseIt is acceptable to report a code from Chapter 15 in conjunction with Z34.00 or Z34.80.
FalseIt is acceptable to code signs and symptoms even when a definitive diagnosis has been confirmed.
FalseSection IV Diagnostic Coding and Reporting Guidelines for Outpatient Services take precedence over the general and disease specific guidelines.
TrueAlways begin the search for the correct code assignment in the Alphabetic Index.
FalseWhen a patient presents for outpatient surgery and the surgery is canceled, report the reason why the surgery was canceled as the first-listed diagnosis.
FalseThe codes from A00 through Z99 are always reported as first-listed diagnoses.
TrueWhen a final diagnosis has not been established by the provider, it is acceptable to report codes for the presenting signs and symptoms.
FalseExternal Cause codes are located in the Alphabetical Index for Diseases under External Causes.
FalseReport all conditions that coexist, even if they are not addressed or do not affect management/treatment during that encounter.
TrueFor patients receiving diagnostic services only during an encounter/visit, sequence first the reason for the encounter/visit indicated in the medical record.
FalseA patient with primary lung cancer with metastasis to the spine presents for radiation treatment of the spine. The first-listed diagnosis reported is the primary lung cancer.
FalseFor patients receiving preoperative evaluations, sequence first a code from the subcategory Z01.81, Encounter for preprocedural examinations, followed by findings related to the preoperative evaluation.
TrueRoutine prenatal outpatient visits for high-risk patients are reported with a first-listed diagnosis from category O09, Supervision of high-risk pregnancy.
TrueZ codes may be reported as a principal diagnosis in the hospital setting.
TrueHeart transplant status code Z94.1 should not be reported with a code from subcategory T86.2, Complications of heart transplant.
FalseThe External Cause codes can be reported as a first-listed diagnosis.
FalseWhen a patient is admitted to observation for a complication following outpatient surgery, report the complication as the first-listed diagnosis.