AAPC CPC Coding Guidelines Questions & Answers

AAPC CPC Coding Guidelines Finding main dx term--try reading dx right to left - Answer-EX: COPD (chronic obstructive pulmonary disease) can be found under "disease" as well as "obstruction" Ex2: URI (upper respiratory infection) can be found under "infection" Always code to the highest degree of specificity. - Answer-Ex: aged related Osteoporosis with current fracture of left shoulder, follow up visit; M80.012D: M80 (osteoporosis with current fracture) + M80.0 (age related) + M80.012 (age related w/current fracture of left shoulder + M80.012D (subsequent visit) Outpatient visits--SUSPECTED Dx NEVER coded. If a definitive Dx has not been reported then code: 1--Signs 2--Sx 3--Abnormal Test results - Answer-Terms of suspected Dx: Probable Suspected Questionable Rule Out Differential Working Inpatient Visits--SUSPECTED Dx MAY BE CODED, with exception to HIV. HIV Dx must be confirmed before coding. - Answer- Sx that are an INTEGRAL part of a disease do NOT need to be coded. - Answer-Ex: Pt presents w/severe AB pain, nausea, vomiting. Diagnosed w/acute appendicitis. Code only acute appendicitis K35.80. Sx that are NOT INTEGRAL part to a disease DO NEED TO BE CODED. - Answer-Ex: Patient presents with runny nose & cough as well as Rt shoulder pain. Physician diagoses URI. Code URI as well as Sx of Rt Shoulder pain. URI--J06.9 Rt Shldr Pn--M25.511 MULTIPLE CODING FOR A SINGLE CONDITION-- Some Diseases require multiple Dx codes and will indicate ETIOLOGY & MANIFESTATION. It will appear in the alphabetic index as one code followed by another code in brackets. - Answer-Ex: Amyloid Heart Disease E85.4 [I43] BOTH etiology AND manifestation codes are required to record this condition. ACUTE & CHRONIC CONDITIONS DOCUMENTED AT THE SAME TIME-- when both are documented, code acute first then chronic - Answer-EX: