CPC Exam Prep
NEC - Answer-not elsewhere classifiable; when a specific code is not available for a condition, the alpha.
index direct you to other specified code in tubular list.
NOS - Answer-Not otherwise specified; equivalent of unspecified.
Exlcudes1 - Answer-Means NOT CODED HERE; the two conditions cannot occur together.
Excludes2 - Answer-The condition is excluded as not being part of the condition represented by the
code, but if the patient actually has both conditions, both may be codes.
And - Answer-Interpret as either or
With - Answer-Interpreted as associated with or due to
Uncertain Diagnosis - Answer-diagnosis documented at the time of discharge as "probable,"
"suspected," "likely," "questionable," "possible," or "rule out".
,Do not doe for uncertain diagnosis in outpatient settings, code for the signs and symptoms instead.
Acute and Chronic conditions - Answer-If the same condition is described as both acute (subacute) and
chronic, and separate subentries exist in the Alphabetic Index at the same indentation level, code both
and sequence the acute (subacute) code first.
combination code - Answer-Single code used to classify two diagnoses
Borderline Diagnosis - Answer-If the provider documents a "borderline" diagnosis at the time of
discharge, the diagnosis is coded as confirmed, unless the classification provides a specific entry (e.g.,
borderline diabetes). If a borderline condition has a specific index entry in ICD-10-CM, it should be coded
as such. Since borderline conditions are not uncertain diagnoses, no distinction is made between the
care setting ( inpatient versus outpatient) Whenever the documentation is unclear regarding a
borderline condition, coders are encouraged to query for clarification.
Episode of care involves surgical removal of neoplasm - Answer-code for the neoplasm first, then the
episode of care
patient encounter solely for chemotherapy, immunotherapy, etc. - Answer-assign Z50.- or Z51.-
Patient admitted due to chemotherapy/radiation - Answer-Code for the chemo/radiation first then the
complication
Type of diabetes is not documented - Answer-default to type 2
adjacent tissue transfer - Answer-Transfer of a section of skin or flap from that immediately next to the
damaged skin and than can be moved without completely detaching it.
Reasoned performed: to repair or replace damaged skin.
, autograft - Answer-use of a patients own tissue from one sire to replace damaged tissue at another site.
Avulsion - Answer-forceful tearing of the nail plate
reason performed: to treat onychocryptosis, perform biopsy, or treat an infection
chemosurgery - Answer-use of chemical agent to destroy tissue
Cryotherapy - Answer-use of liquid nitrogen to destroy tissue
destruction - Answer-rendering tissue into tiny fragments
electrocauterization - Answer-use of a hot instrument to destroy tissue
electrosurgical destruction - Answer-use of high frequency electric current to destroy tissue
excision - Answer-process of cutting out
full thickness removal of disease or damaged tissue
Flap transfer - Answer-moving a section of skin and subcutaneous tissue with blood vessels intact from
one site to another; with anastomosis to vessels at the recipient site.
intralesional injection - Answer-injection of medications into a lesion or scar
NEC - Answer-not elsewhere classifiable; when a specific code is not available for a condition, the alpha.
index direct you to other specified code in tubular list.
NOS - Answer-Not otherwise specified; equivalent of unspecified.
Exlcudes1 - Answer-Means NOT CODED HERE; the two conditions cannot occur together.
Excludes2 - Answer-The condition is excluded as not being part of the condition represented by the
code, but if the patient actually has both conditions, both may be codes.
And - Answer-Interpret as either or
With - Answer-Interpreted as associated with or due to
Uncertain Diagnosis - Answer-diagnosis documented at the time of discharge as "probable,"
"suspected," "likely," "questionable," "possible," or "rule out".
,Do not doe for uncertain diagnosis in outpatient settings, code for the signs and symptoms instead.
Acute and Chronic conditions - Answer-If the same condition is described as both acute (subacute) and
chronic, and separate subentries exist in the Alphabetic Index at the same indentation level, code both
and sequence the acute (subacute) code first.
combination code - Answer-Single code used to classify two diagnoses
Borderline Diagnosis - Answer-If the provider documents a "borderline" diagnosis at the time of
discharge, the diagnosis is coded as confirmed, unless the classification provides a specific entry (e.g.,
borderline diabetes). If a borderline condition has a specific index entry in ICD-10-CM, it should be coded
as such. Since borderline conditions are not uncertain diagnoses, no distinction is made between the
care setting ( inpatient versus outpatient) Whenever the documentation is unclear regarding a
borderline condition, coders are encouraged to query for clarification.
Episode of care involves surgical removal of neoplasm - Answer-code for the neoplasm first, then the
episode of care
patient encounter solely for chemotherapy, immunotherapy, etc. - Answer-assign Z50.- or Z51.-
Patient admitted due to chemotherapy/radiation - Answer-Code for the chemo/radiation first then the
complication
Type of diabetes is not documented - Answer-default to type 2
adjacent tissue transfer - Answer-Transfer of a section of skin or flap from that immediately next to the
damaged skin and than can be moved without completely detaching it.
Reasoned performed: to repair or replace damaged skin.
, autograft - Answer-use of a patients own tissue from one sire to replace damaged tissue at another site.
Avulsion - Answer-forceful tearing of the nail plate
reason performed: to treat onychocryptosis, perform biopsy, or treat an infection
chemosurgery - Answer-use of chemical agent to destroy tissue
Cryotherapy - Answer-use of liquid nitrogen to destroy tissue
destruction - Answer-rendering tissue into tiny fragments
electrocauterization - Answer-use of a hot instrument to destroy tissue
electrosurgical destruction - Answer-use of high frequency electric current to destroy tissue
excision - Answer-process of cutting out
full thickness removal of disease or damaged tissue
Flap transfer - Answer-moving a section of skin and subcutaneous tissue with blood vessels intact from
one site to another; with anastomosis to vessels at the recipient site.
intralesional injection - Answer-injection of medications into a lesion or scar
