Medical coding 1 FINAL EXAM
6th 7th - answer-tabular: Some publishers place a symbol in front of a code to indicate
that an additional character is needed for the code to be complete. The symbols shown
here are examples. A code with any of these symbols before it is an invalid code.
7th character for Fetus Identification - answer-Assign 7th character "0":
• For single gestations
• When the documentation in the record is insufficient to determine the fetus affected
and it is not possible to obtain clarification.
• When it is not possible to clinically determine whichfetus is affected.
Activity and external cause status codes are assigned following all causal (intent)
external cause codes. - answer-The first-listed external cause code should correspond
to the cause of the most serious diagnosis due to an assault, accident, or self-harm,
following the order of hierarchy listed above.
Alcohol use during pregnancy, childbirth and the
puerperium - answer-Codes under subcategory O99.31, Alcohol use complicating
pregnancy, childbirth, and the puerperium, should be assigned for any pregnancy case
when a mother uses alcohol during the
pregnancy or postpartum. A secondary code from category F10, Alcohol related
disorders, should also be assigned to identify manifestations of the alcohol use.
All clinically significant conditions noted on routine newborn examination should be
coded. A condition is clinically significant if it requires: - answer-clinical evaluation; or
therapeutic treatment; or
diagnostic procedures; or
extended length of hospital stay; or
increased nursing care and/or monitoring; or
has implications for future health care needs
all the letters are utilized in ICD-10-CM excpet - answer-the letter U. It has been
reserved by WHO for new diseases of uncertain etiology (U00-U49) and for bacterial
agents resistant to antibiotics (U80-U89) none of those codes are valid for use in the US
Although present at birth, malformation/deformation/or chromosomal abnormality may
not be identified until later in life. - answer-Whenever the condition is diagnosed by the
physician, it is appropriate to assign a code from codes Q00- Q99
An exception to the Excludes1 definition - answer-is the circumstance when the two
conditions are unrelated to each other. If it is not clear whether the two conditions
involving an Excludes1 note are related or not, query the provider.
An external cause code should be used with burns and
corrosions to identify - answer-the source and intent of the burn, as well
,as the place where it occurred.
And - answer-and/or
Anemia associated with chemotherapy, immunotherapy
and radiation therapy - answer-When the admission/encounter is for management of an
anemia associated with an adverse effect of the administration of chemotherapy or
immunotherapy and the only treatment is for
the anemia, the anemia code is sequenced first followed by the appropriate codes for
the neoplasm and the adverse effect (T45.1X5-, Adverse effect of antineoplastic and
immunosuppressive drugs).
When the admission/encounter is for management of an anemia associated with an
adverse effect of radiotherapy, the anemia code should be sequenced first, followed by
the appropriate
neoplasm code and code Y84.2, Radiological procedure and radiotherapy as the cause
of abnormal reaction of the patient, or of later complication, without mention of
misadventure at the time of the procedure.
Assign code G89.3 Neoplasm related pain (acute) (chronic) when pain is documented
as either acute or chronic for any of the following: - answer-neoplasm related
cancer related
due to malignancy
tumor associated.
Also assign a code(s) for the neoplasm and/or metastases.
Refer to OGCR I.C.6.b.3) for instructions coding postoperative pain.
NOTE: Be careful to distinguish codes for chronic pain (G89.2-), chronic pain syndrome
(G89.4), and complex regional pain syndrome (CRPS) (G90.5-) based on the
physician's documentation.
Assign codes from category I12, Hypertensive chronic kidney disease, when - answer-
both hypertension and a condition classifiable to
category N18, Chronic kidney disease (CKD), are present. CKD should not be coded as
hypertensive if the physician has specifically documented a different cause.
The appropriate code from category N18 should be used as a secondary code with a
code from category I12 to identify the stage of chronic kidney disease. See Section
I.C.14. Chronic kidney disease.
If a patient has hypertensive chronic kidney disease and acute renal failure, an
additional code for the acute renal failure is required.
Assign codes from combination category I13, Hypertensive
heart and chronic kidney disease, when - answer-there is hypertension with both heart
and kidney involvement. If heart failure is present, assign an additional code from
category I50 to identify
the type of heart failure. The appropriate code from category N18, Chronic kidney
disease, should be used as a secondary code with a code from
, category I13 to identify the stage of chronic kidney disease. See Section I.C.14. Chronic
kidney disease.
The codes in category I13, Hypertensive heart and chronic kidney disease, are
combination codes that include hypertension, heart disease and chronic kidney disease.
The Includes note at I13 specifies that the conditions included at I11 and I12 are
included together in I13. If a patient has
hypertension, heart disease and chronic kidney disease, then a code from I13 should be
used, not individual codes for hypertension, heart disease and chronic kidney disease,
or codes
from I11 or I12. For patients with both acute renal failure and chronic kidney disease, an
additional code for acute renal failure is required.
Assign separate codes for each burn site - answer-When coding burns, assign separate
codes for each burn site. Category T30, Burn and corrosion, body region unspecified is
extremely vague and should rarely be used.
assigning codes for hearing loss - answer-Coders may use the main term Deafness for
any condition described as hearing loss or deafness. Hearing loss in Indexed under the
main term Loss and the subterm hearing. Five second-level subterms direct coders to
the same code, H90.5 Unspecified sensorineural hearing loss. A cross-reference note
states see also Deafness. The main term Deafness provides over 40 subterms which
direct coders to specific codes, including the ones listed under the main term Loss,
hearing. Therefore, it is more efficient for coders to go directly to Deafness when
assigning codes for hearing loss or deafness.
Assigning Codes for Otitis Media - answer-The Index entry Otitis, media contains
numerous cross-references between second-level subterms, which may seem
confusing. Nearly all types of OM can be located under the two second-level subterms
nonsuppurative and suppurative. Third- and fourth-level subterms further identify the
specific subtype of OM.
NOTE: To make navigating the Index for OM easier, highlight the subterm entries for
nonsuppurative and suppurative.
Boldface (heavy type - answer-Tabular: Code titles.
Index: Main terms.
Care of complications of fractures, such as malunion and
nonunion, - answer-should be reported with the appropriate 7th character for
subsequent care with nonunion (K, M, N,) or subsequent care with malunion (P, Q, R).
category G89 Pain, not elsewhere classified. - answer-Use this category only when pain
is specified as acute or chronic, post-thoracotomy, post-procedural, or neoplasm
related.
Chapter 15 codes have sequencing priority over codes from
6th 7th - answer-tabular: Some publishers place a symbol in front of a code to indicate
that an additional character is needed for the code to be complete. The symbols shown
here are examples. A code with any of these symbols before it is an invalid code.
7th character for Fetus Identification - answer-Assign 7th character "0":
• For single gestations
• When the documentation in the record is insufficient to determine the fetus affected
and it is not possible to obtain clarification.
• When it is not possible to clinically determine whichfetus is affected.
Activity and external cause status codes are assigned following all causal (intent)
external cause codes. - answer-The first-listed external cause code should correspond
to the cause of the most serious diagnosis due to an assault, accident, or self-harm,
following the order of hierarchy listed above.
Alcohol use during pregnancy, childbirth and the
puerperium - answer-Codes under subcategory O99.31, Alcohol use complicating
pregnancy, childbirth, and the puerperium, should be assigned for any pregnancy case
when a mother uses alcohol during the
pregnancy or postpartum. A secondary code from category F10, Alcohol related
disorders, should also be assigned to identify manifestations of the alcohol use.
All clinically significant conditions noted on routine newborn examination should be
coded. A condition is clinically significant if it requires: - answer-clinical evaluation; or
therapeutic treatment; or
diagnostic procedures; or
extended length of hospital stay; or
increased nursing care and/or monitoring; or
has implications for future health care needs
all the letters are utilized in ICD-10-CM excpet - answer-the letter U. It has been
reserved by WHO for new diseases of uncertain etiology (U00-U49) and for bacterial
agents resistant to antibiotics (U80-U89) none of those codes are valid for use in the US
Although present at birth, malformation/deformation/or chromosomal abnormality may
not be identified until later in life. - answer-Whenever the condition is diagnosed by the
physician, it is appropriate to assign a code from codes Q00- Q99
An exception to the Excludes1 definition - answer-is the circumstance when the two
conditions are unrelated to each other. If it is not clear whether the two conditions
involving an Excludes1 note are related or not, query the provider.
An external cause code should be used with burns and
corrosions to identify - answer-the source and intent of the burn, as well
,as the place where it occurred.
And - answer-and/or
Anemia associated with chemotherapy, immunotherapy
and radiation therapy - answer-When the admission/encounter is for management of an
anemia associated with an adverse effect of the administration of chemotherapy or
immunotherapy and the only treatment is for
the anemia, the anemia code is sequenced first followed by the appropriate codes for
the neoplasm and the adverse effect (T45.1X5-, Adverse effect of antineoplastic and
immunosuppressive drugs).
When the admission/encounter is for management of an anemia associated with an
adverse effect of radiotherapy, the anemia code should be sequenced first, followed by
the appropriate
neoplasm code and code Y84.2, Radiological procedure and radiotherapy as the cause
of abnormal reaction of the patient, or of later complication, without mention of
misadventure at the time of the procedure.
Assign code G89.3 Neoplasm related pain (acute) (chronic) when pain is documented
as either acute or chronic for any of the following: - answer-neoplasm related
cancer related
due to malignancy
tumor associated.
Also assign a code(s) for the neoplasm and/or metastases.
Refer to OGCR I.C.6.b.3) for instructions coding postoperative pain.
NOTE: Be careful to distinguish codes for chronic pain (G89.2-), chronic pain syndrome
(G89.4), and complex regional pain syndrome (CRPS) (G90.5-) based on the
physician's documentation.
Assign codes from category I12, Hypertensive chronic kidney disease, when - answer-
both hypertension and a condition classifiable to
category N18, Chronic kidney disease (CKD), are present. CKD should not be coded as
hypertensive if the physician has specifically documented a different cause.
The appropriate code from category N18 should be used as a secondary code with a
code from category I12 to identify the stage of chronic kidney disease. See Section
I.C.14. Chronic kidney disease.
If a patient has hypertensive chronic kidney disease and acute renal failure, an
additional code for the acute renal failure is required.
Assign codes from combination category I13, Hypertensive
heart and chronic kidney disease, when - answer-there is hypertension with both heart
and kidney involvement. If heart failure is present, assign an additional code from
category I50 to identify
the type of heart failure. The appropriate code from category N18, Chronic kidney
disease, should be used as a secondary code with a code from
, category I13 to identify the stage of chronic kidney disease. See Section I.C.14. Chronic
kidney disease.
The codes in category I13, Hypertensive heart and chronic kidney disease, are
combination codes that include hypertension, heart disease and chronic kidney disease.
The Includes note at I13 specifies that the conditions included at I11 and I12 are
included together in I13. If a patient has
hypertension, heart disease and chronic kidney disease, then a code from I13 should be
used, not individual codes for hypertension, heart disease and chronic kidney disease,
or codes
from I11 or I12. For patients with both acute renal failure and chronic kidney disease, an
additional code for acute renal failure is required.
Assign separate codes for each burn site - answer-When coding burns, assign separate
codes for each burn site. Category T30, Burn and corrosion, body region unspecified is
extremely vague and should rarely be used.
assigning codes for hearing loss - answer-Coders may use the main term Deafness for
any condition described as hearing loss or deafness. Hearing loss in Indexed under the
main term Loss and the subterm hearing. Five second-level subterms direct coders to
the same code, H90.5 Unspecified sensorineural hearing loss. A cross-reference note
states see also Deafness. The main term Deafness provides over 40 subterms which
direct coders to specific codes, including the ones listed under the main term Loss,
hearing. Therefore, it is more efficient for coders to go directly to Deafness when
assigning codes for hearing loss or deafness.
Assigning Codes for Otitis Media - answer-The Index entry Otitis, media contains
numerous cross-references between second-level subterms, which may seem
confusing. Nearly all types of OM can be located under the two second-level subterms
nonsuppurative and suppurative. Third- and fourth-level subterms further identify the
specific subtype of OM.
NOTE: To make navigating the Index for OM easier, highlight the subterm entries for
nonsuppurative and suppurative.
Boldface (heavy type - answer-Tabular: Code titles.
Index: Main terms.
Care of complications of fractures, such as malunion and
nonunion, - answer-should be reported with the appropriate 7th character for
subsequent care with nonunion (K, M, N,) or subsequent care with malunion (P, Q, R).
category G89 Pain, not elsewhere classified. - answer-Use this category only when pain
is specified as acute or chronic, post-thoracotomy, post-procedural, or neoplasm
related.
Chapter 15 codes have sequencing priority over codes from
