CPC GUIDELINES
When is it acceptable to code signs and symptoms? - Answer-When a diagnosis has not been confirmed
Should signs and symptoms that are associated routinely with a disease process be assigned as
additional codes? - Answer-No, unless otherwise instructed by the classification
Should signs and symptoms that are not associated routinely with a disease process be assigned as
additional codes? - Answer-Yes.
If the same condition is described as both acute and chronic, and separate sub-entries exist in the
Alphabetic Index at the same indentation level, how should the encounter be coded? - Answer-Code
both and sequence the acute code first.
A single code used to classify two diagnoses, or a diagnosis with an associated secondary
process(manifestation), or a diagnosis with an associated complication is referred to as? - Answer-
Combination Code
The residual effect after the acute phase of an illness or injury has terminated is referred to as? -
Answer-Sequela (Late Effect)
,Is there a time limit on when a sequela can be used - Answer-No
When coding sequela how many codes are required? - Answer-Two
The condition of the sequela is sequenced first
The sequela code is sequenced second
The only exception to this is when manifestations exist
When coding sequela should the code for the acute phase of an illness or injury that led to the sequela
be used? - Answer-No
When coding conditions described as "impending" or "threatened", what should be reported if it did
occur? - Answer-Code as a confirmed diagnosis
How many times can each unique ICD-10-CM diagnosis code be reported per encounter? - Answer-
Once.
This applies to bilateral conditions when there are no distinct codes identifying laterality or two different
conditions classified to the same ICD-10-CM code
If no bilateral code is provided and the condition is bilateral, how should the encounter be coded? -
Answer-Assign separate codes for both the left and right side. If the side is not identified in the MR
assign the code for the unspecified side
Which physician should be the one responsible for documenting BMI, non-pressure ulcers, and pressure
ulcer stages? - Answer-Patient's primary provider
, When should BMI codes be reported as first listed diagnosis?? - Answer-Never
How should we code syndromes using ICD-10-CM guidelines - Answer-Follow the alphabetic index
guidance
When coding syndromes and the alphabetic index does not proving any guidance, how should the
encounter be coded? - Answer-Assign codes for the documented manifestations of the syndrome
Additional codes for manifestations that are not an integral part of the disease process may also be
assigned when the condition does not have a unique code
When is it appropriate to assign codes for complications of care? - Answer-There must be a cause and
effect relationship between the care provided and the condition, and an indication in the
documentation that it is a complication
If the provider documents "borderline" diagnosis at the time of discharge, how is the diagnosis coded? -
Answer-Diagnosis is coded as confirmed unless the classification provides a specific entry (e.g.,
borderline diabetes)
If a definitive diagnosis has not been established by the end of the encounter, it is appropriate to report
codes for __________________ in lieu of a definitive diagnosis. - Answer-Sign(s0 and/or symptom(s)
When sufficient clinical information isn't known or available about a particular health condition to assign
a more specific code, how should the encounter be coded? - Answer-It is acceptable to report the
appropriate unspecified code
When it is appropriate to code HIV infection/illness(es)?? - Answer-Code only confirmed cases of
HIV/illness
When is it acceptable to code signs and symptoms? - Answer-When a diagnosis has not been confirmed
Should signs and symptoms that are associated routinely with a disease process be assigned as
additional codes? - Answer-No, unless otherwise instructed by the classification
Should signs and symptoms that are not associated routinely with a disease process be assigned as
additional codes? - Answer-Yes.
If the same condition is described as both acute and chronic, and separate sub-entries exist in the
Alphabetic Index at the same indentation level, how should the encounter be coded? - Answer-Code
both and sequence the acute code first.
A single code used to classify two diagnoses, or a diagnosis with an associated secondary
process(manifestation), or a diagnosis with an associated complication is referred to as? - Answer-
Combination Code
The residual effect after the acute phase of an illness or injury has terminated is referred to as? -
Answer-Sequela (Late Effect)
,Is there a time limit on when a sequela can be used - Answer-No
When coding sequela how many codes are required? - Answer-Two
The condition of the sequela is sequenced first
The sequela code is sequenced second
The only exception to this is when manifestations exist
When coding sequela should the code for the acute phase of an illness or injury that led to the sequela
be used? - Answer-No
When coding conditions described as "impending" or "threatened", what should be reported if it did
occur? - Answer-Code as a confirmed diagnosis
How many times can each unique ICD-10-CM diagnosis code be reported per encounter? - Answer-
Once.
This applies to bilateral conditions when there are no distinct codes identifying laterality or two different
conditions classified to the same ICD-10-CM code
If no bilateral code is provided and the condition is bilateral, how should the encounter be coded? -
Answer-Assign separate codes for both the left and right side. If the side is not identified in the MR
assign the code for the unspecified side
Which physician should be the one responsible for documenting BMI, non-pressure ulcers, and pressure
ulcer stages? - Answer-Patient's primary provider
, When should BMI codes be reported as first listed diagnosis?? - Answer-Never
How should we code syndromes using ICD-10-CM guidelines - Answer-Follow the alphabetic index
guidance
When coding syndromes and the alphabetic index does not proving any guidance, how should the
encounter be coded? - Answer-Assign codes for the documented manifestations of the syndrome
Additional codes for manifestations that are not an integral part of the disease process may also be
assigned when the condition does not have a unique code
When is it appropriate to assign codes for complications of care? - Answer-There must be a cause and
effect relationship between the care provided and the condition, and an indication in the
documentation that it is a complication
If the provider documents "borderline" diagnosis at the time of discharge, how is the diagnosis coded? -
Answer-Diagnosis is coded as confirmed unless the classification provides a specific entry (e.g.,
borderline diabetes)
If a definitive diagnosis has not been established by the end of the encounter, it is appropriate to report
codes for __________________ in lieu of a definitive diagnosis. - Answer-Sign(s0 and/or symptom(s)
When sufficient clinical information isn't known or available about a particular health condition to assign
a more specific code, how should the encounter be coded? - Answer-It is acceptable to report the
appropriate unspecified code
When it is appropriate to code HIV infection/illness(es)?? - Answer-Code only confirmed cases of
HIV/illness
