NURSING MISC QUESTIONS & ANSWERS FLASHCARDS GRADED A VERIFIED

1. Question: A word or phrase used by a physician to identify a disease from which an individual suffers Answer: Diagnosis 2. Question: A term or a series of terms that appear in parentheses following the main term or the subterm, the presence or absence of which has no effect on the selection of the codes listed for that main term Answer: Nonessential Modifier 3. Question: An indicator used to differentiate between a condition that developed during a particular hospital encounter and a condition present at the time of admission Answer: Present on Admission 4. Question: The condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care Answer: Principal Diagnosis 5. Question: Criteria or guidelines for what is determined to be reasonable and necessary for a particular medical service Answer: Medical Necessity 6. Question: The procedure performed for definitive treatment rather than for diagnostic or exploratory purposes or for treatment of a complication Answer: Principal Procedure 7. Question: All conditions that coexist at the time of admission, that develop subsequently, or that affect the treatment received or the length of stay Answer: Other Diagnosis 8. Question: A procedure that is surgical in nature or carries a procedural or anesthetic risk or requires specialized training Answer: Significant Procedure 9. Question: Organizations that contract with Medicare to work with consumers, physicians, hospitals, and other caregivers to refine care delivery systems to make sure patients receive the right care at the right time Answer: Quality Improvement Organization 10. Question: Organizations that contract with Medicare to perform reviews of medical records with the corresponding Medicare claim to detect and correct improper payments Answer: Recovery Audit Contractors 11. Question: Entries in the Alphabetic Index to Disease and Injuries that represent diseases, conditions, nouns, and adjectives Answer: Main Term 12. Question: A system for grouping similar disease and procedures and organizing related information for easy storage and retrieval Answer: Classification System 13. Question: A system of names that are used as preferred terminology Answer: Nomenclature 14. Question: The transformation of verbal descriptions into numbers; the process of assigning numeric or alphanumeric representations to clinical documentation Answer: Coding 15. Question: An additional diagnosis that describes a pre-existing condition that, because of its presence with a specific principal diagnosis, will cause an increase in the patient’s length of stay Answer: Comorbidity 16. Question: An additional diagnosis that describes a condition arising after the beginning of hospital observation and treatment and then modifies the course of the patient’s illness or medical care required Answer: Complication 17. Question: Note that indicates that the conditions listed after it cannot ever be used at the same time as the code above the note Answer: Excludes1 18. Question: Note that means that two codes are applied when both conditions are present Answer: Excludes2 19. Question: A cross reference term in the Alphabetic Index that provides direction to look elsewhere in the Index before assigning a code Answer: See 20. Question: Suggests that there may be another main term in the Alphabetic Index that may also be referenced to provide additional Alphabetic Index entries that may be useful Answer: See Also 21. Question: Two codes may be required to fully describe a condition, but this note does not provide sequencing direction. Answer: Code Also 22. Question: Method of payment by Medicare for inpatient acute care hospital services, based on Medicare Severity Diagnosis-Related Groups (MS-DRGs) Answer: Inpatient Prospective Payment System Question: Adenocarcinoma of descending colon with extension to mesenteric lymph nodes. Answer: C18.6, C77.2 (Rationale: Adenocarcinoma—see neoplasm, malignant, by site. Go to Table of Neoplasms, intestine, large, colon, descending, malignant, and primary. Table of Neoplasms, lymph, gland, mesenteric, malignant, and secondary) 2. Question: Gangrene of lower leg due to uncontrolled type I diabetes. Answer: E10.52, E10.65 (Rationale: Diabetes, type 1, with, gangrene. Diabetes, out of control—code to Diabetes, by type, with hyperglycemia: Diabetes, type 1, with hyperglycemia) 3. Question: Iron deficiency anemia due to chronic blood loss. Answer: D50.0(Rationale: Anemia, iron deficiency, secondary to blood loss (chronic)) 4. Question: Lyme disease with associated arthritis. Answer: A69.23 (Rationale: Arthritis, due to or associated with, Lyme Disease) 5. Question: Diabetic hypoglycemic coma in a patient with uncontrolled type 1 diabetes. Answer: E10.641, E10.65 (Rationale: Diabetes, type 1, hypoglycemic, with coma, Diabetes, type 1, out of control (uncontrolled)—see Diabetes, by type (1), with hyperglycemia) 6. Question: Secondary thrombocytopenia due to hypersplenism. Answer: D69.59, D73.1 (Rationale: Thrombocytopenia, secondary. Hypersplenism) 7. Question: Chlamydial vaginitis. Answer: A56.02 (Rationale: Vaginitis, chlamydial) 8. Question: Infiltrating duct breast carcinoma, right upper outer quadrant, with metastases to bone (female patient). Answer: C50.411, C79.51 (Rationale: Neoplasm, breast, upper outer quadrant, malignant, primary, female, right breast. Neoplasm, bone, malignant, secondary) 9. Question: Malignant lymphoma, undifferentiated Burkitt type, Intrathoracic. Answer: C83.72 (Rationale: Lymphoma, Burkitt) 10. Question: Patient admitted for her first round of antineoplastic chemotherapy after a total abdominal hysterectomy and salpingo-oophorectomy for right ovarian carcinoma with known metastases to intrapelvic lymph nodes. Answer: Z51.11, C56.1, C77.5 (Rationale: Chemotherapy (session) (for) neoplasm. Neoplasm, ovary, malignant, primary. Neoplasm, lymph, intrapelvic, malignant, secondary) 11. Question: Patient with a history of bladder carcinoma seen for a follow-up examination related to his past partial cystectomy treatment, no recurrence found. Answer: Z08, Z85.51 (Rationale: Examination, follow-up, malignant neoplasm. History, personal, malignant neoplasm, bladder) Question: Paranoid schizophrenia Answer: F20.0 (Rationale: Schizophrenia, paranoid) 2. Question: Obstructive hydrocephalus Answer: G91.1 (Rationale: Hydrocephalus, obstructive) 3. Question: Parkinsonism secondary to haloperidol neuroleptic drug therapy, initial encounter; drug was discontinued Answer: G21.11, T43.4X5A (Rationale: Parkinsonism, due to, drugs, neuroleptic. Table of Drugs and Chemicals, Haloperidol, Adverse Effect, Initial encounter. Seventh character of "A" for initial encounter.) 4. Question: Infiltrative tuberculosis of both lungs Answer: A15.0 (Rationale: Tuberculosis, lungs—see Tuberculosis, pulmonary) 5. Question: Reye’s syndrome Answer: G93.7 (Rationale: Syndrome, Reye's) 6. Question: Moderate mental retardation as the sequela of acute bacterial meningitis 10 years ago Answer: F71, G09 (Rationale: Retardation, mental—see Disability, intellectual, moderate. Sequela, meningitis, bacterial. Sequencing guideline: See "Code first" note under category G09, Sequelae of inflammatory diseases of central nervous system: Code first condition resulting from (sequela) of inflammatory diseases of central nervous system.) 7. Question: Altered mental status due to Hashimoto’s encephalopathy Answer: E06.3, G94 (Rationale: Hashimoto’s disease or thyroiditis. Encephalopathy, G94 is assigned for encephalopathy in diseases classified elsewhere.) 8. Question: Severe stage primary open angle glaucoma, right eye Answer: H40.11x3 (Rationale: Glaucoma, open angle, primary. The seventh character of ‘3’ identifies the stage of glaucoma.) 9. Question: Sensorineural hearing loss of the right ear Answer: H90.41 (Rationale: Loss, hearing see also Deafness, sensorineural, unilateral, right ear.) 10. Question: Benign paroxysmal positional vertigo Answer: H81.10 (Rationale: Vertigo, benign positional.) Questions: Chronic kidney disease, ESRD, dependence on renal dialysis Answer: N18.6, Z99.2 (Rationale: Disease, end stage renal (ESRD). Dependence, on, renal dialysis.) 2. Questions: COPD with asthma Answer: J44.9, J45.909 (Rationale: Disease, lung, obstructive, with asthm Answer: See the instructional "Code Also" note under category J44: Code also type of asthma if applicable (J45.-)) 3. Questions: Unstable angina Answer: I20.0 (Rationale: Angina, unstable) 4. Questions: Hypertensive heart and kidney disease with chronic kidney disease, stage 3 Answer: I13.10, N18.3 (Rationale: Hypertensive, heart, with, kidney disease—see hypertension, cardiorenal, without heart failure, with stage 1 through stage 4 chronic kidney disease. Disease, kidney, chronic, stage 3.) 5. Questions: Organic brain syndrome due to cerebral arteriosclerosis Answer: I67.2, F09 (Rationale: Arteriosclerosis, cerebral. Syndrome, organic, brain. Note: There is a "code first" note under category F09: Code first the underlying physiological condition. In this case, the underlying condition is the cerebral arteriosclerosis.) 6. Questions: Inflamed seborrheic keratosis of right face Answer: L82.0 (Rationale: Keratosis, seborrheic, inflamed) 7. Questions: Pneumonia due to Staphylococcus aureus; fiberoptic bronchoscopy, tracheobronchial tree Answer: J15.211 (Rationale: Pneumonia, in (due to) Staphylococcus, aureus) 8. Questions: Peptic ulcer of the lesser curvature of the stomach, acute, with hemorrhage Answer: K25.0 (Rationale: Ulcer, stomach (peptic), acute, with, hemorrhage. The site of stomach is used to code the ulcer condition. The code for "peptic" ulcer, K27 is for peptic ulcer, site unspecified, so the site of the ulcer is more important for coding purposes than the type of ulcer being peptic.) 9. Questions: Coronary artery disease with previous autologous vein bypass grafts in the left anterior descending, left circumflex, and right posterior descending arteries. Answer: I25.810 (Rationale: Disease, coronary artery—see Disease, heart ischemic, atherosclerotic, coronary artery bypass graft, see Arteriosclerosis, coronary (artery), bypass graft, autologous vein.) 10. Questions: Chronic hidradenitis suppurativa, subcutaneous tissue, right axilla Answer: L73.2 (Rationale: Hidradenitis) 11. Questions: Cystic pancreatitis Answer: K86.1 (Rationale: Pancreatitis, cystic) Question: Complete elective abortion, first trimester, 8 weeks, due to maternal rubella, with suspected damage to fetus affecting management of pregnancy. Answer: Z33.2, O35.3XX0, Z3A.08 (Rationale: Abortion, induced (encounter for). Rubella, maternal, suspected damaged to fetus affecting management of pregnancy. Note: the seventh character 0 is used for a single gestation because this case does not describe it to be a twin or other multiple gestation. Because the seventh character is required for code O35.3, two placeholder XX characters are used to complete the code before the seventh character is added. Pregnancy, weeks of gestation, 8 weeks.) 2. Question: Postpartum abscess of breast; patient discharged 5 days ago following spontaneous delivery of live triplets. Answer: O91.22 (Rationale: Abscess, breast, puerperal, postpartum, gestational—see Mastitis, obstetric, purulent, and associated with puerperium) 3. Question: Newborn twin, male, delivered by cesarean delivery (in hospital) with syndrome of infant of diabetic mother. Answer: Z38.31, P70.1 (Rationale: Newborn, twin, born in hospital, by cesarean. Syndrome, infant, of diabetic mother) 4. Question: Ovarian retention cyst Answer: N83.29 (Rationale: Cyst, retention (ovary) or Cyst, ovary, retention) 5. Question: Rapidly progressive glomerulonephritis Answer: N01.9 (Rationale: Glomerulonephritis, rapidly progressive) 6. Question: Degenerative joint disease, bilateral knees Answer: M17.0 (Rationale: Disease, joint, degenerative—see Osteoarthritis, knees bilateral) 7. Question: Postprocedural stricture of urethra with urinary retention Answer: N99.12, R33.8 (Rationale: Stricture, urethra, postprocedural, female. Retention, urine, specified (with stricture). Note: There is a "Code first" note under code R33.8 to code first, if applicable, any causal condition, such as enlarged prostate N40.1. In this question, the underlying condition is the postprocedural stricture of the urethra, so N99.12 is coded first.) 8. Question: Traumatic arthritis of left wrist secondary to old fracture-dislocation of lower end of radius, left Answer: M12.532, S52.502S (Rationale: Arthritis, traumatic—see Arthropathy, traumatic, wrist. Sequelae (of) fracture—code to Injury with seventh character S. Fracture, traumatic, radius, and lower end. 9. Question: Pregnancy, preterm labor with preterm delivery at 35 weeks, single liveborn infant; postpartum fever of unknown origin; patient with known continuous marijuana drug dependence. Answer: O60.14x0, Z3A.35, Z37.0, O86.4, O99.323, F12.20 (Rationale: Pregnancy, complicated by preterm labor, third trimester, with third term preterm (35 weeks) delivery. Seventh character 0 is for single infant. Pregnancy, weeks of gestation, 35 weeks. Outcome of delivery, single, liveborn. Postpartum—see Puerperal, fever (of unknown origin). Pregnancy, complicated by drug use, third trimester. Dependence, drug, marijuana—see Dependence, drug, cannabis. 10. Question: Internal derangement of lateral meniscus, old tear, posterior horn, right knee Answer: M23.251(Rationale: Derangement, joint, knee—see Derangement, knee, due to old tear, lateral, posterior horn, right) Question: Unexplained dizziness Answer: R42 (Rationale: Dizziness) 2. Question: Third-degree burn of chest and second-degree burn of right leg, Initial encounter Answer: T21.31xA, T24.201A (Rationale: Burn, chest, third degree. Burn, leg, see Burn, lower limb, right, second degree) 3. Question: Abnormal prothrombin time, cause to be determined Answer: R79.1 (Rationale: Abnormal, prothrombin time) 4. Question: Newborn born in community hospital transferred to university medical center. Code for the infant at the university medical center treated for hypoplastic left heart syndrome. Answer: Q23.4 (Rationale: Syndrome, hypoplastic left heart. Note: See coding guideline 1.C.16. Answer: 2: Principal diagnosis for birth record. When coding the birth episode in a newborn record, assign a code from category Z38, liveborn infants according to place of birth and type of delivery, as the principal diagnosis. A code from category Z38 Is assigned only once, to a newborn at the time of birth. If a newborn is transferred to another institution, a code from category Z38 should not be used at the receiving hospital.) 5. Question: Ingestion of 30 doxepin (Sinequan) tablets resulting in an overdose, determined to be a suicide attempt; tachycardia [Doxepin is a tricyclic antidepressant drug] Initial episode of care Answer: T43.012A, R00.0 (Rationale: Table of Drugs and Chemicals, Sinequan, Poisoning, Intentional Self-Harm, initial episode. See the instructional note under section T36–T50, poisoning, adverse effects of and underdosing of drugs, medicaments, and biological substances that states, “use additional code" to specify manifestations of poisoning Tachycardi Answer: ) 6. Question: Heroin poisoning, accidental overdose; acute lung edema; multiple drug dependence including heroin and barbiturates, initial encounter Answer: T40.1X1A, J81.0, F11.20, F13.20 (Rationale: Table of Drugs and Chemicals, Heroin, poisoning, accidental. Edema, lung, acute. Dependence, drug, heroin—see dependence, drug, opioid. Dependence, drug, barbiturate—see dependence, drug, sedative.) 7. Question: Positive tuberculosis skin test Answer: R76.11 (Rationale: Positive, skin test, tuberculin (without active tuberculosis)) 8. Question: Congenital hypertrophic pyloric stenosis Answer: Q40.0 (Rationale: Stenosis, pylorus, congenital) Question: Fracture of frontal bone with subarachnoid hemorrhage and concussion with no loss of consciousness due to motor vehicle accident collision with another car (patient driver of car) initial encounter. Answer: S02.0xxA, S06.5x0A, V43.52xA (Rationale: Fracture, frontal (bone). Hemorrhage, subdural—see Hemorrhage, intracranial, subdural, traumatic—see Injury, intracranial, subdural, hemorrhage, traumatic. Note: A separate code for the concussion is not assigned. See the Excludes1 note at subcategory S06.0, Concussion. Note states concussion with other intracranial injuries classified to category S06—code to specified intracranial injury. Index to External Causes, Accident, motor vehicle, see also Accident, transport, car occupant, driver, collision (with) car.) 2. Question: History of allergic reaction to penicillin Answer: Z88.0 (Rationale: History, personal, allergy, penicillin) 3. Question: Fracture, right shoulder, humerus upper end (head), as the result of a fall from a chair she was standing on to reach a high shelf, occurred at her single family residence, kitchen while cooking; initial episode of care. Patient is retired. Answer: S42.201A, WA, Y92.010, Y93.G3, Y99.8 (Rationale: Fracture, traumatic, humerus, upper end (right). Index to external causes, fall from chair. Index to external causes, place of occurrence, residence, house, single family, kitchen. Index to external causes, activity, cooking. Status of external cause, specified (retirement). Note: See Coding Guideline 1.C.20.d. Place of occurrence, activity, and status codes used with other external cause code. When applicable, place of occurrence, activity, and external cause status codes are sequenced after the main external cause code(s). Regardless of the number of external cause codes assigned, there should be only one place-of-occurrence code, one activity code, and one external cause status code assigned to an encounter.) 4. Question: Patient with a history of bladder carcinoma seen for a follow-up examination related to his past partial cystectomy treatment; no recurrence found; cystoscopy with biopsy of bladder. Answer: Z08, Z85.51 (Rationale: Examination, follow-up, malignant neoplasm. History, personal, malignant neoplasm, and bladder.) 5. Question: Gunshot wound of chest with massive intrathoracic injury to right lung with laceration; shot by another person with a handgun who was charged with attempted homicide; injury occurred on a local residential street; patient died during an exploratory thoracotomy to examine right lung. Answer: S27.331A, XA, Y92.414 (Rationale: Gunshot wound, internal organs—see Injury, by site. Injury, lung—see Injury, intrathoracic, laceration, unilateral (right). Index to external causes, shooting, homicide (attempt)—see discharge, firearm, by type (handgun), homicide. Index to external causes, place of occurrence, street, local residential. (No statement of activity of patients or status, therefore, no codes assigned)) 6. Question: Patient admitted for her first round of antineoplastic chemotherapy after a total abdominal hysterectomy and salpingo-oophorectomy for right ovarian carcinoma with known metastases to intrapelvic lymph nodes. Answer: Z51.11, C56.1, C77.5 (Rationale: Chemotherapy (session) (for) neoplasm. Neoplasm, ovary, malignant, primary. Neoplasm, lymph, intrapelvic, malignant, secondary.) Lessons Introduction to ICD-10-CM/PCS The International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) has been used in the United States since 1977 to classify diagnosis codes for all healthcare settings (hospitals, physician offices, ambulatory surgery centers, nursing homes, and laboratories) and procedures for inpatient hospital services. As of October 1, 2014, ICD-10-CM will replace Volumes 1 and 2 of ICD-9-CM for diagnosis coding and ICD-10-PCS will replace Volume 3 of ICD-9-CM for inpatient procedural coding. Many describe coding as trying to solve a mystery or a puzzle. One must first locate all the pieces and then determine which of the pieces belong and how they fit together. When you code, you will utilize the health record to find all of the pieces to this puzzle. Without it, the puzzle cannot be completely or accurately solved. As a coder, you will translate the clinical terminology used in the health record into alphanumeric codes to represent specific diseases, conditions, or procedures. “The primary purpose of health record documentation is continuity of patient care, serving as a means of communication among all healthcare providers. Documentation is also used to evaluate the adequacy and appropriateness of quality care, provide clinical data for research and education, and support reimbursement, medical necessity, quality of care measures, and public reporting for services rendered by a healthcare entity” (AHIMA, 2008, pp. 83–88). The first piece to the puzzle is learning how to use the ICD-10-CM coding manual. You need to become very familiar with the contents and layout of the book. Take some time to thumb through it before we begin the coding exercises. You will find the coding book divided into sections. There is an Alphabetic Index to Diseases and Injuries, Neoplasm Table, Table of Drugs and Chemicals, Index to External Causes, and Tabular List of Diseases and Injuries. You will use the index to look up the diseases and conditions, and then reference the tabular listing to confirm your code. The next step is to ensure that you have a firm understanding of the ICD-10-CM conventions. The Official Conventions, as well as the Official Guidelines for Coding and Reporting, also are included in the ICD-10-CM coding manual. The conventions include the structure and format of the codes, as well as the general rules to follow when coding. Before you begin the coding process, it is important to become familiar with the terminology, punctuation, abbreviations, instructional notes, sequencing guidelines, and overall structure and format of ICD-10-CM. The following is an example of ICD-10-CM formatting retrieved from the American Academy of Professional Coders ICD-10 Conversion and Mapping (AAPC, 2013). ICD-10-CM codes can be up to seven characters. The first character is always alpha (it can be any letter except U ), the second character is always numeric, and the remaining five characters can be any combination. Image Description The following example shows an ICD-10-CM code for chronic gout due to renal impairment, left shoulder, without tophus. Image Description Chapter 1 of the Basic ICD-10-CM/PCS Coding textbook outlines the basic steps to the coding process. It is imperative that these steps be followed each and every time you are assigning codes to ensure complete and accurate coding. It is critical that you complete all practice exercises throughout this course in order to determine whether you are truly grasping the concepts. The only way to learn coding is through hands-on applications. I will say it again: In order to fully understand the concepts taught and apply that knowledge to the coding process, practice and repetition will be vital. Practice, practice, practice! For additional information on the profession of medical coding, visit Introduction to the Uniform Hospital Discharge Data Set and Official ICD-10-CM Coding Guidelines The Official Guidelines for Coding and Reporting are published by the National Center for Health Statistics (NCHS) and were approved by the Cooperating Parties for ICD-10-CM (AHA, AHIMA, CMS, and NCHS). These guidelines are a set of rules that must supplement the conventions and instructions provided within ICD-10-CM, but note that the instructions and conventions within ICD-10-CM itself take precedence over the guidelines. According to the Health Insurance Portability and Accountability Act (HIPAA), all coders must adhere to the official coding guidelines. In addition to being included in the actual ICD-10-CM coding manual, you can always find the most recent version of the guidelines at As previously mentioned above, clinical data are used for many different purposes. In order to effectively use data, they must be captured in a consistent manner. Part of the consistency is following all of the coding conventions and guidelines, and the other part is following the Uniform Hospital Discharge Data Set (UHDDS) standards. The purpose of the UHDDS is to provide the ability to track and compare healthcare data from inpatient discharges in a uniform way. The UHDDS outlines specific items that must be collected on each episode of care from non-outpatient settings. The UHDDS also defines certain concepts so that they are captured consistently, such as the definition of principal diagnosis or significant procedure. There is a direct correlation between the diagnoses and procedures reported and the reimbursement that the hospital will receive. For this reason, it is crucial that you have a solid understanding of the UHDDS standards and data elements discussed in Chapter 3 of the Basic ICD-10-CM/PCS Coding text. Some terms to memorize include the definitions of principal diagnosis, other diagnosis, and significant procedure for the inpatient settings. Coding and Reimbursement It is important to remember that the purpose of documenting the ICD-10-CM codes in both inpatient and outpatient settings is to demonstrate medical necessity. This is the component that, when tied to a procedure, explains the "Why was this done?" question. When done correctly, anyone reviewing the medical record or the coded summary of that record will understand why the visit occurred, why there was a surgical procedure, or why a test was run. The hospital inpatient prospective payment system (IPPS) is the payment system for which CMS reimburses for acute care hospital inpatient services. When payment is made to a facility, the primary reason for admitting the patient drives the total reimbursement the facility can expect. The method for this reimbursement is frequently based on Medicare severity diagnosis-related groups, or MS-DRGs. Although this method of payment was developed by CMS, many other third-party payers also provide reimbursement based on MS-DRGs. The UB-04 is the claim form used for billing institutional (or facility) fees as opposed to the physician professional fees, which are billed on a CMS 1500 claim form. The coder is responsible for designating a principal diagnosis and up to 24 additional diagnoses, as well up to 25 procedure codes. The order of the assignment of each code is of absolute importance to the resulting payment. So how does this determine the amount of reimbursement, you might ask? Based on how you code an inpatient admission and what MS-DRG you arrive at, each MS-DRG has a relative weight assigned to it. Reimbursement is determined by the MS-DRG’s relative weight multiplied by the hospital’s base payment rate per case, minus any deductibles. CMS has some great web-based training courses available, including ones on the UB-04, CMS 1500, and the Inpatient Prospective Payment System. To access the courses, visit There are 25 major diagnostic categories in the MS-DRG-based reimbursement system. DRGs are classified as either medical, with the principal diagnosis driving the assignment, or surgical, in which a procedure code indicates that a surgical procedure was performed during the hospital stay. Often when a surgery is performed, it will be the primary driver of the DRG assigned to the chart and the payment for that hospitalization. Additionally, many DRGs are split into one, two, or three MS-DRGs according to whether or not any one of the secondary diagnoses represents an MCC, a CC, or no CC. The issues that relate to record abstracting are well illuminated. Frequently, entities such as quality improvement organizations (QIOs) or recovery audit contractors (RACs) will retrospectively review medical records to verify that the assignment of the diagnoses and/or procedures are correct. The severity of illness (SI) and the intensity of service (IS) performed also are important. This SI/IS matchup also drives the facilities' case mix index (CMI). The higher the SI/IS, the higher the CMI. Facilities with high CMI are generally reimbursed at a higher rate than those with lower CMI, so the overall income to a hospital is significantly affected with improper documentation of the severity of illness or the intensity of service provided. Likewise, the outpatient side of facility coding, including ambulatory payment classifications (APCs), is designed to reimburse the facility for the precise procedure performed. This is generated by utilizing Current Procedural Terminology (CPT) codes as well as Healthcare Common Procedure Coding System (HCPCS) Level II codes to generate an APC assignment. Depending on which APC is assigned, the facility is paid accordingly. For the physician billing, both the ICD-10-CM and CPT assignments are critical for reimbursement. Even though not affected directly by APC or MS-DRG assignment, the physician is the primary documentation specialist for any chart and must have an ongoing knowledge of how the documentation drives the resultant reimbursement for both the facility and for the physicians themselves. Occasionally, the documentation may be unclear or ambiguous. In these instances, you may need to seek additional clarification from the clinical provider. This is what we refer to as the physician query process. According to the ICD-10-CM Official Guidelines for Coding and Reporting, “A joint effort between the healthcare provider and the coder is essential to achieve complete and accurate documentation, code assignment, and reporting of diagnoses and procedures” (NCHS, 2013). AHIMA has developed a practice brief (AHIMA, 2008, pp. 83–88) that outlines an effective physician query process. Queries may be necessary when there are clinical indicators of a diagnosis but no documentation of the condition, when there is clinical evidence for a higher degree of specificity or severity, to clarify a cause-and-effect relationship between two conditions or organisms, to determine an underlying cause when admitted with symptoms, when only the treatment is documented without a diagnosis, or when present-on-admission (POA) indicator status is unclear. There are specific guidelines that should be followed as part of the query process. Coders should never question the judgment of the physician, nor should they attempt to lead the physician to a specific response. Be sure to review the practice brief, “Managing an Effective Query Process,” available in Doc Sharing. Ethics in coding has become a significant issue in the past several years because of fraudulent coding and billing practices. Healthcare fraud involves misrepresentation or deception for the purpose of collecting inappropriate payments from Medicare or other insurers. In most hospitals and clinics, a coder must sign an ethics agreement to show that he or she will code correctly and without any fraudulent intent. One particularly virulent fraudulent coding activity is upcoding, which is coding a higher level procedure or service than the documentation supports for the specific purpose of increasing reimbursement. However, do not underestimate the potential threat of downcoding. The Balanced Budget Act of 1997 placed the Office of the Inspector General (OIG) in charge of stopping fraud and abuse. In verified cases of fraud and abuse, millions of dollars have been recovered from hospitals and doctors, and in some cases, individuals have even been prosecuted and jailed. Many of these cases have come to the government's attention through whistle-blowing (also known as qui tam). As a coder, always remember, “If it isn’t documented, it didn’t happen!” No matter what, the codes that you assign must always be supported by the documentation in the health record. The OIG now strongly recommends that physicians and hospitals institute compliance programs to ensure the quality of data and claim submissions. Special programs called beneficiary incentive programs help to encourage people with Medicare, for example, to report bill and report discrepancies to the secretary of the Department of Health and Human Services. Precise coding helps to ensure compliance with regulatory requirements. Furthermore, coders should make sure that they are up to date on compliance requirements at least once a year. AHIMA has created a code of ethics that all of its members must follow. It can be found on the AHIMA website ( Certain Infectious and Parasitic Diseases ICD-10-CM contains 21 chapters. Chapter 1 of ICD-10-CM represents certain infectious and parasitic diseases. Within each chapter, subchapters are arranged in what are referred to as blocks. You will notice that in each chapter in the Tabular List of ICD-10-CM, you are provided with a list of the blocks for that particular chapter. This gives you a good overview of the contents for each chapter. In addition to reviewing the blocks, you will want to ensure that you always review the instruction notes found at the beginning of each chapter. Here is an example of the instruction notes found at the beginning of Chapter 1 in ICD-10-CM. Chapter 1 Certain infectious and parasitic diseases (A00-B99) Includes: diseases generally recognized as communicable or transmissible Use additional code to identify resistance to antimicrobial drugs (Z16-) Excludes 1: certain localized infections—see body system-related chapters infectious and parasitic diseases complicating pregnancy, childbirth and the puerperium (O98.-) influenza and other acute respiratory infections (J00-J22) Excludes 2: carrier or suspected carrier of infectious disease (Z22.-) infectious and parasitic diseases specific to the perinatal period (P35-P39) These notes provide important guidelines that are critical to complete and accurate coding. When found at the beginning of the chapter, these instruction notes apply to the entire chapter. That is why it is vital to always review the instruction notes at the beginning of the chapter to ensure that you do not overlook these guidelines. Combination codes and mandatory multiple coding are a couple of the coding concepts introduced this week. Combination coding is where a single code represents both the condition and the causative organism. You will see good examples of this when coding infectious and parasitic diseases. Here is an example: Conjunctivitis due to adenovirus (B30.1). A single code captures the condition (conjunctivitis), as well as the causative organisms (adenovirus). Mandatory multiple coding, on the other hand, is when you are required to use more than one code to adequately describe both the etiology and manifestation of a condition. In this scenario, the underlying condition must always be sequenced first followed by an additional code for the manifestation. In the Alphabetic Index, both conditions are listed together, with the etiology code listed first followed by an additional code in brackets. The code in brackets must always to be sequenced second. An example of this is Alzheimer’s disease with dementia G30.9 [F02.80]. G30.9 represents the Alzheimer's disease (which is the underlying condition), and F02.80 represents the dementia (which is the manifestation, a result of the Alzheimer’s disease). There is also the concept of discretionary multiple coding. In this scenario, the instruction note would read, “code, if applicable, any causal condition first.” You would only assign the additional code if the causal condition is documented. Sepsis is a condition that is frequently seen in hospital settings. There are varying degrees of sepsis in terms of severity, each indicated by a different code. When sepsis is associated with acute organ dysfunction, you will need to assign a code for the underlying infection, as well as an additional code for the specific acute organ dysfunction such as acute kidney failure. HIV is also included in this chapter. Once again, you will need to review the chapter-specific coding guidelines for HIV coding. There are some very specific guidelines relevant to whether the condition is asymptomatic versus symptomatic, suspected versus confirmed, and so on. Neoplasms Chapter 2 of ICD-10-CM represents neoplasms. When coding neoplastic diseases, you will need to make use of the Neoplasm Table found in the Alphabetic Index of ICD-10-CM. The Neoplasm Table lists neoplasm by anatomical site. Once you have located the correct site, use the table to select the appropriate code based on whether the neoplasm is malignant, benign, uncertain, or unspecified behavior. Malignant neoplasm codes are further divided based on primary site, secondary site, or in situ. The location at which the cancer started or originated is known as the primary site. A secondary site is a place to which the cancer has metastasized or spread. A neoplasm is in situ if it is confined to its point of origin and has yet to invade surrounding tissue. A benign neoplasm is one that is not malignant in nature and so will not spread. A neoplasm is of uncertain behavior when the pathologist cannot ascertain its type. When there is no additional or supporting information, use the unspecified nature. As a general rule, you would always start with the Neoplasm Table unless a specific morphology is stated, such as “sarcoma.” When the morphology is stated, you would refer to that specific term in the Alphabetic Index first rather than going directly to the Neoplasm Table. Using sarcoma as an example, when you reference sarcoma in the Alphabetic Index, you will find “ Sarcoma (of) — see also Neoplasm, connective tissue, malignant.” This provides guidance on the correct use of the Neoplasm Table and the appropriate column to select from once there. In this scenario, per the instruction found in the Alphabetic Index for sarcoma, you would first locate connective tissue in the Neoplasm Table, then select the appropriate code from the column for malignant. Metastasis is the spreading of the malignancy from its original site. Sometimes the terms metastasis or metastatic are used a bit ambiguously. When the health record states metastatic to, such as a patient with lung cancer that has metastasized to the liver, this means that the lung would be the point of origin (primary malignancy) which has spread to the liver (secondary site). They may also state metastatic liver cancer from the lung. Again, this tells you that the lung is the primary (from) and the liver is the secondary (to). At times, you will find the documentation unclear, such as “patient with metastatic lung cancer.” What does that statement actually mean? Is it telling you that the lung is the point of origin, or that the lung is where the cancer has spread to? In this scenario, you will need to query the physician. There are times when the primary site is unknown. For this situation, you would assign C80.1 for malignant (primary) neoplasm, unspecified. Similarly, if the doctors know that the cancer has spread but have not yet identified the secondary site, it would be appropriate to use C79.9 for secondary malignant neoplasm of unspecified site. This code includes metastatic cancer not otherwise specified. Diseases of the Blood and Blood-Forming Organs and Certain Disorders Involving the Immune Mechanism Chapter 3 of ICD-10-CM covers diseases of the blood and blood-forming organs and certain disorders involving the immune mechanism. You will find that there aren’t any chapter-specific guidelines for this chapter. One of the most common blood-related diseases is anemia. There are several different types of anemia and there is usually a specific cause for anemia. As such, the physician must include specific information in the documentation in order for you to code to the highest level of specificity possible. When the documentation indicates a particular reason, such as acute blood-loss anemia or an iron or other nutritional deficiency, then a specific code is needed to indicate that reason. Occasionally, two codes may be needed to explain the manifestation and the disease causing it. It is important to pay close attention to the instructional notes such as “code first” and “use additional code” to ensure that you are coding accurately and completely. Although there aren’t any specific guidelines for Chapter 3 in the ICD-10-CM Official Guidelines for Coding and Reporting, Chapter 2 provides guidelines for coding anemia associated with malignancies and for anemia associated with chemotherapy, immunotherapy, and radiation therapy. Endocrine, Nutritional, and Metabolic Diseases Chapter 4 of ICD-10-CM represents endocrine, nutritional, and metabolic diseases. The most frequently used codes in this section are for diabetes mellitus. This is another section where you will see extensive use of combination codes to identify the type of diabetes mellitus, the body system affected, and the complications affecting that body system. Diabetes is classified as type 1 or type 2. If the type of diabetes is not documented in the health record, the default is type 2. There are also categories for secondary diabetes, such as diabetes that is due to another underlying cause or an adverse effect of a drug. It is not uncommon for diabetic patients to have more than one type of complication from diabetes, such as neuropathy, retinopathy, skin ulcers, etc. The coder must assign as many codes as necessary to fully capture all associated conditions that the patient has. You might also see documentation of diabetes that is stated as “inadequately controlled,” “poorly controlled,” or “out of control.” ICD-10-CM classifies this by reporting the diabetes, by type, with hyperglycemia. This chapter also includes conditions such as malnutrition, obesity, and dehydration. These are fairly common conditions found in inpatient records. When coding obesity, you must also use an additional code to capture the patient’s body mass index, or BMI. Often, the documentation to support the correct BMI code is found in documentation from other clinical staff such as the nutritionist or nurse. Per the ICD-10-CM Official Guidelines for Coding and Reporting (1.B.14), “For the Body Mass Index (BMI), depth of non-pressure chronic ulcers and pressure ulcer stage codes, code assignment may be based on medical record documentation from clinicians who are not the patient’s provider (i.e., physician or other qualified healthcare practitioner legally accountable for establishing the patient’s diagnosis), since this information is typically documented by other clinicians involved in the care of the patient (e.g., a dietitian often documents the BMI and nurses often documents the pressure ulcer stages). However, the associated diagnosis (such as overweight, obesity, or pressure ulcer) must be documented by the patient’s provider.” Mental, Behavioral, and Neurodevelopmental Disorders Chapter 5 of ICD-10-CM covers mental, behavioral, and neurodevelopmental disorders. Coding of behavioral health or psychiatric disorders including psychoses, neurotic disorders, personality disorders, and other nonpsychotic mental disorders are included here. You will also find substance abuse and dependence coded in this section. The codes in Chapter 5 correspond to the codes in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR). DSM-IV-TR, published by the American Psychiatric Association, is the code set that is widely used by mental health professionals. As a result, coders may benefit from becoming familiar with this system and the definitions used, because psychiatrists tend to document according to DSM-IV-TR nomenclature. Coders must remember, though, that actual code assignment is based on ICD-10-CM and must be supported by the documentation in the health record. Learn more about DSM-IV-TR at There are a couple of key points to remember for this section: Codes for “in remission” are based on the clinical documentation; and according to ICD-10-CM guideline Section 1.C.5.c.2., if documentation refers to use, abuse, and dependence of the same substance, only one code should be assigned to identify the pattern of use based on the following hierarchy: •If both use and abuse are documented, assign only the code for abuse. •If both abuse and dependence are documented, assign only the code for dependence. •If use, abuse, and dependence are all documented, assign only the code for dependence. •If both use and dependence are documented, assign only the code for dependence. Diseases of the Nervous System Chapter 6 of ICD-10-CM contains diseases of the nervous system. In this chapter, you will find conditions such as Alzheimer’s disease, cerebral palsy, epilepsy, and migraines. Some of the conditions in this chapter, such as hemiplegia and hemiparesis, require identification of whether the right or left dominant or nondominant side is affected. According to the ICD-10-CM Official Guidelines for Coding and Reporting, Section 1.C.6.a., should the affected side be documented but not specified as dominant or nondominant, and should the classification system not indicate a default, then code selection is as follows: •For ambidextrous patients, the default should be dominant. •If the left side is affected, the default is nondominant. •If the right side is affected, the default is dominant. When coding, always remember to read the instructional notes when verifying your code in the Tabular List. You will find many instances of “code also,” “use additional code,” or “code first,” which not only helps ensure complete and accurate coding, but may also offer sequencing guidelines. An example of this is Alzheimer’s dementia. Under category G30 for Alzheimer’s disease, there is an instruction note stating, “Use additional code to identify,” with a few options listed. This would be your clue that an additional code is needed to capture the dementia in addition to the Alzheimer’s disease itself. You are directed to F02.8-. Notice that when you arrive there, there is a note to code first the underlying condition (the Alzheimer’s). Diseases of the Eye and Adnexa Chapter 7 of ICD-10-CM covers diseases of the eye and adnexa (accessory structures). Various types of eye disorders such as glaucoma and cataracts are coded here. You will find lots of codes with laterality included, such as right or left eye, as one of the criteria for selecting the correct code. A good resource for understanding some of the common eye disorders is the Centers for Disease Control and Prevention (CDC) at Diseases of the Ear and Mastoid Process Chapter 8 of ICD-10-CM captures diseases of the ear and mastoid process. You are probably familiar with many of these conditions, such as ear infections and hearing loss. One thing to note is that there aren’t any chapter-specific coding guidelines for this chapter. However, once again there are instructional notes that are commonly seen throughout this chapter, which will aid you in complete and accurate coding, such as the following. Use additional code for any associated perforated tympanic membrane (H72.-). Use additional code to identify exposure to environmental tobacco smoke (Z77.22); exposure to tobacco smoke in the perinatal period (P96.81); history of tobacco use (Z87.891); occupational exposure to environmental tobacco smoke (Z57.31); tobacco dependence (F17.-); and tobacco use (Z72.0). Diseases of the Circulatory System Chapter 9 of ICD-10-CM represents diseases of the circulatory system. What you will find in this chapter represents coronary, cerebral, and vascular diseases. A few examples include conditions such as hypertension, heart attack (myocardial infarction), and strokes. Throughout the chapter, you will notice that many of the code categories contain instructional notes to use an additional code to identify exposure to, history of, current use of, and dependence on tobacco. To reiterate, it is important to thoroughly read the health record to abstract out pertinent details for complete and accurate coding. This should be a recurring theme by now. Another example of this is heart failure. There are several different types of heart failure that each have different codes. You will need to determine based on the documentation whether the patient has diastolic, systolic, congestive, or hypertensive heart failure, for example. There are also several different types of cardiac arrhythmias and heart blocks. Be sure that you understand and recognize the terminology used and the differences between many of these conditions. There are also many details that need to be determined when coding myocardial infarctions (MI). Is it acute, subsequent, healed, or diagnosed on EKG but currently presenting no symptoms? What type is it—ST elevation or non-ST elevation—and which wall is involved? A physician query may be necessary if the documentation is unclear. There are some critical guidelines that must be followed when coding many of the conditions in this chapter. Examples include guidelines specific to hypertension with manifestations such as heart and kidney disease that outline when a cause-and-effect relationship can be assumed and when it must be explicitly documented. There are also guidelines outlining the time frames for coding acute myocardial infarctions versus using aftercare codes. Be sure to review the chapter specific guidelines (Section 1.C.9.-) when coding conditions from this chapter. Diseases of the Respiratory System Chapter 10 of ICD-10-CM represents diseases of the respiratory system. There are some helpful guidelines here regarding the sequencing of acute respiratory failure and other acute conditions. When determining the principal diagnosis, you must keep in mind the UHDDS definition of principal diagnosis; “that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care.” The circumstances of the admission will drive your decision for which condition is appropriate to sequence as the principal diagnosis, unless the coding conventions in the Tabular List or Alphabetic Index provide specific sequencing instruction. Another important guideline to remember is the one pertaining to influenza (Section I.C.10.c.). In the inpatient setting, the guidelines for uncertain conditions (Section II.H.) state, “If the diagnosis documented at the time of discharge is qualified as ‘probable’, ‘suspected’, ‘likely’, ‘questionable’, ‘possible’, or ‘still to be ruled out’, or other similar terms indicating uncertainty, code the condition as if it existed or was established.” Influenza due to certain identified influenza viruses is one of the exceptions to this rule. In this case, the guidelines state, “Code only confirmed cases of influenza due to certain identified influenza viruses.” When coding asthma, there are some terms that you will want to become familiar with. ICD-10-CM classifies asthma according to the severity: intermittent, mild persistent, moderate persistent, and severe persistent. For accurate coding, you will also need to determine whether the patient was in status asthmaticus or suffered an acute exacerbation of the asthma. This is yet another example of collecting all of the pieces to the puzzle in order to have a complete and accurate picture of the patient’s condition. Per the ICD-10-CM Official Guidelines for Coding and Reporting, “A joint effort between the healthcare provider and the coder is essential to achieve complete and accurate documentation, code assignment, and reporting of diagnoses and procedures.” Diseases of the Digestive System Diseases of the digestive system are found in chapter 11 of ICD-10-CM. This chapter contains conditions that occur from infections of the mouth and upper GI tract as well as diseases of the appendix, gallbladder, small bowel, colon, and liver. There are no chapter-specific guidelines published for this chapter of ICD-10-CM. You will find that there are combination codes for many of the GI conditions; hernia codes representing the type and presence or absence of obstruction, ulcer codes representing location and the inclusion of perforation or hemorrhage, Crohn’s disease according to the site affected and associated manifestations, and so on. Additional codes may also be necessary to reflect the nature of a specific complication resulting from a GI condition. Also coded here are complications of artificial openings, as well as intraoperative and postoperative complications specific to the digestive system. Of note, ICD-10-CM describes blood loss as hemorrhage when referring to ulcers, and bleeding is used to describe gastritis, duodenitis, diverticulosis, and diverticulitis. Diseases of the Skin and Subcutaneous Tissue Our final section covered this week deals with diseases of the skin and subcutaneous tissue, found in Chapter 12 of ICD-10-CM. Some of the more common conditions found here include pressure and nonpressure ulcers, forms of dermatitis, cellulitis, and abscess. Many of the codes in this chapter provide specificity as to the location where the condition exists, such as cellulitis of the right lower limb. Notice that laterality was also captured in that example, right versus left. Some of the codes in the chapter also require an additional code, if applicable, to identify the specific drug as the cause, such as allergic contact dermatitis due to drugs in contact with skin. You would assign one code for the dermatitis, and an additional code for the adverse effect of a drug. Classification of pressure ulcers is based on the stage in addition to the specific location. The depth of the ulcer is identified as stage I, stage II, stage III, or stage IV, unspecified or unstageable. You may also need to assign multiple codes to represent multiple ulcers in different locations, if applicable. There are several ICD-10-CM guidelines specific to ulcer staging, which you should review and become familiar with. Once again, you will be relying on the clinical documentation in order to assign codes to the highest degree of specificity. Diseases of the Musculoskeletal System and Connective Tissue Chapter 13 of ICD-10-CM covers diseases of the musculoskeletal system and connective tissue. It includes acute and chronic conditions of bone, joints, ligaments, muscles, and intervertebral discs. Most codes include the anatomic site of the condition, representing the bone, joint, or muscle involved, and laterality. You may need to brush up on your anatomy! Make note of the instructional note found at the beginning of ICD-10-CM Chapter 13, which states, “Use an external cause code following the code for the musculoskeletal condition, if applicable, to identify the cause of the musculoskeletal condition.” You may also find instructional notes throughout the chapter to “use additional code” to identify the infectious agent. Remember to thoroughly review all instructional notes found within the tabular list as they are there to provide additional guidance during the coding process. Infectious arthropathies are coded in this chapter. Some are classified as either direct or indirect infection of the joint. The following definitions are provided to distinguish the difference. Direct infection of joint—where organisms invade synovial tissue and microbial antigen is present in the joint Indirect infection of joint—either a relative arthropathy, where microbial infection of the body is established but neither organisms nor antigens can be identified in the joint; or postinfective arthropathy, where microbial antigen is present but recovery of an organism is inconstant and evidence of local multiplication is lacking Some conditions of the musculoskeletal system, such as pathological fractures, require the use of a seventh character to identify the episode of care as either initial encounter, subsequent encounter, or encounters for sequela (late effects). The appropriate seventh characters are as follows. A = initial encounter for the fracture D = subsequent encounter for fracture with routine healing G = subsequent encounter for fracture with delayed healing K = subsequent encounter for fracture with nonunion P = subsequent encounter for fracture with malunion S = sequela In order to accurately assign the correct seventh character, there are some definitions that you will need to understand. Seventh character A for initial encounter is to be used for patients receiving active treatment such as surgical treatment, emergency department encounter, and evaluation and management by a new physician. Subsequent encounter reflects encounters after the patient has completed active treatment, such as cast change or removal, removal of external or internal fixation device, medication adjustment and other aftercare, and follow-up visits. Sequela , according to the ICD-10-CM Official Guidelines for Coding and Reporting Section I.B.10., is the residual effect after the acute phase of an illness or injury has terminated. There is no time limit on when a sequela code can be used. A nonunion of a fracture is the failure of the bone ends to align or heal. A malunion of a fracture refers to a fracture that was reduced but in which the bone ends did not align properly during the healing process. Diseases of the Genitourinary System Diseases of the genitourinary system are found in Chapter 14 of ICD-10-CM. This includes codes for the urinary system, male and female reproductive systems, disorders of the breast, and complications occurring in the intraoperative and postoperative periods. Once again, you will find instructional notes throughout the chapter to indicate when additional codes should be used, such as those below. •Code also associated kidney failure •Use additional code to identify infectious agent •Code also associated underlying condition •Code first any associated (certain) condition •Use additional code to identify kidney transplant status Also remember to pay attention to the Excludes1 and Excludes2 notes. Recall that Excludes1 means “not coded here” and is used to indicate when the two conditions cannot occur together. Excludes2, on the other hand, means “not included here” and indicates that the condition excluded is not part of the condition represented by the code, but a patient may have both conditions at the same time. In that scenario, it would be appropriate to use both the code and the excluded code together. Some of the more common conditions found in this chapter include acute and chronic kidney diseases, bladder disorders, disorders of the prostate, menopause, and disorders of the breast. Codes for chronic kidney disease (CKD) require the identification of the stage (stages 1–5) to designate the severity of the condition based on the glomerular filtration rate. When the patient requires dialysis or a kidney transplant, he or she is considered to have end-stage renal disease (ESRD). Stage Description GFR* mL/min/1.73 m 2 1 Slight kidney damage with normal or increased filtration More than 90 2 Mild decrease in kidney function 60 to 89 3 Moderate decrease in kidney function 30 to 59 4 Severe decrease in kidney function 15 to 29 5 Kidney failure Less than 15 (or dialysis) *GFR is glomerular filtration rate, a measure of the kidney's function. (Source: Chronic kidney disease is often caused by other underlying conditions. Recall from previous chapters that CKD may be due to underlying hypertension or diabetes, for example. Don’t forget about multiple mandatory coding and the use of combination codes when applicable. Sequencing guidelines for CKD instruct you to code the underlying diabetic or hypertensive kidney disease first, and to use an additional code to represent kidney transplant status (Z94.0), if applicable. Also note that acute and chronic kidney diseases are classified differently. As opposed to chronic kidney disease, acute renal failure (ARF) is often the result of trauma, infection, inflammation, or toxicity rather than the manifestation of a chronic medical condition. You would “code also” the underlying condition as the cause of the ARF. Remember, code also instructions do not provide sequencing guidelines; the circumstances of the encounter determine which code should be sequenced first. Benign prostatic hypertrophy (BPH) is a common male genitourinary condition. BPH is often accompanied by urinary tract symptoms such as incomplete bladder emptying, nocturia, straining on urination, frequency, hesitancy, incontinence, and so on. When lower urinary tract symptoms are present, coders are instructed to use an additional code for the associated symptom, such as urinary frequency (R35.0). Pregnancy, Childbirth, and the Puerperium Chapter 15 of ICD-10-CM includes conditions related to pregnancy, childbirth, and the puerperium. This is one of the more challenging coding sections. Coding of obstetrical conditions requires a great attention to details and a clear understanding of the definitions. Be sure to thoroughly review the chapter-specific guidelines pertaining to this chapter of ICD-10-CM, including the general rules for coding obstetric cases, sequencing guidelines for principal diagnosis, and coding of pre-existing conditions versus conditions due to the pregnancy. There are many guidelines for this chapter and you will need to refer back to them often during the coding process. Many of the conditions in this chapter can be located by referencing the main term pregnancy, complicated by. Below are a couple of points to remember when coding from this chapter: • These codes are always used on mother’s record, never on the infant’s record. •An instruction note at the beginning of ICD-10-CM Chapter 15 instructs the coder to use an additional code from category Z3A to identify the specific week of pregnancy. •You must identify the trimester of pregnancy in which the condition occurred.◦First trimester: less than 14 weeks 0 days ◦Second trimester: 14 weeks 0 days to less than 28 weeks 0 days ◦Third trimester: 28 weeks 0 days until delivery •Certain categories in Chapter 15 of ICD-10-CM distinguish between pre-existing conditions of the mother and those that are a direct result of pregnancy. When assigning codes from Chapter 15, it is important to determine whether a condition was pre-existing or developed during or due to the pregnancy in order to assign the correct code. •Certain categories require the addition of a seventh character to identify the fetus for which the complication code applies. •When coding for delivery, there should be a minimum of three codes. Below is an example of an admission with normal delivery.◦O80, Encounter for full-term uncomplicated delivery ◦Z3A.-, Completed weeks of gestation ◦Z37.-, Outcome of delivery •Terms to know:◦Antepartum—the period of pregnancy from conception to childbirth ◦Peripartum—the period involving the last month of pregnancy to 5 months postpartum ◦Postpartum—the period beginning right after delivery and continues 6 weeks following delivery ◦Puerperium—the clinical term for the postpartum period ◦Preterm—delivery before 37 completed weeks ◦Term—delivery between 38 and 40 completed weeks ◦Postterm—delivery between 41 and 42 completed weeks ◦Prolonged—pregnancy advanced beyond 42 completed weeks ◦Elderly gravida—pregnancy for a female 35 years and older at expected date of delivery ◦Young gravida—pregnancy for a female less than 16 years old at expected date of delivery Abortion is also covered in this chapter. Some additional terms to become familiar with include the following. •Missed abortion—early fetal death before completion of 20 weeks of gestation with retention of dead fetus •Spontaneous abortion—expulsion or extraction from the uterus of all or part of the products of conception: an embryo or a nonviable fetus weighing less than 500 grams •Complete abortion—expulsion of all of the products of conception from the uterus prior to the episode of care •Incomplete abortion—expulsion of some, but not all, of