MEDICAL CODING 1 FINAL EXAM
QUESTIONS WITH CORRECT
ANSWERS
Z21, Asymptomatic human immunodeficiency virus
[HIV] infection status, is to be applied when - Answer-the patient without any
documentation of symptoms is listed as being "HIV positive," "known HIV," "HIV test
positive," or similar terminology. Do not use this code if the term "AIDS" is used or if
the patient is treated for any HIV-related illness or is described as having any
condition(s) resulting from his/her HIV positive status; use B20 in these cases.
Patients with inconclusive HIV serology, but no
definitive diagnosis or manifestations of the illness, may
be assigned code - Answer-R75, Inconclusive laboratory evidence
of human immunodeficiency virus [HIV].
Patients with any known prior diagnosis of an
HIV-related illness should be coded to B20 - Answer-Once a patient has developed
an HIV-related illness, the patient should always be assigned code B20 on every
subsequent admission/encounter. Patients previously diagnosed with any HIV illness
(B20) should never be assigned to R75 or Z21, Asymptomatic human
immunodeficiency virus [HIV] infection status.
During pregnancy, childbirth or the puerperium, a
patient admitted (or presenting for a health care
encounter) because of an HIV-related illness should receive a principal diagnosis
code of - Answer-O98.7-, Human immunodeficiency [HIV] disease complicating
pregnancy, childbirth and the puerperium, followed by B20 and the code(s) for the
HIV-related illness(es).
Codes from Chapter 15 always take sequencing priority.
Patients with asymptomatic HIV infection status admitted (or presenting for a health
care encounter) during pregnancy, childbirth, or the puerperium should receive
codes of O98.7- and Z21.
Encounters for testing for HIV - Answer-If a patient is being seen to determine
his/her HIV status, use code Z11.4, Encounter for screening for
humanimmunodeficiency virus [HIV]. Use additional codes for any associated high
risk behavior. If a patient with signs or symptoms is being seen for HIV testing, code
the signs and symptoms. An additional counseling code Z71.7, Human
immunodeficiency virus [HIV] counseling, may be usedif counseling is provided
during the encounter for the test.
When a patient returns to be informed of his/her HIV test results and the test result is
negative, use code Z71.7, Human immunodeficiency virus [HIV]
counseling.
,Psychoactive Substance Use Disorders - Answer-the codes for psychoactive
substance use disorders (F10.9-, F11.9-, F12.9-, F13.9-, F14.9-,
F15.9-, F16.9-) should only be assigned based on provider documentation and when
they meet the definition of a reportable diagnosis (see Section III, Reporting
Additional Diagnoses). The codes are to be used only when the psychoactive
substance use is associated with a physical, mental or behavioral disorder, and such
a relationship is
documented by the provider.
The appropriate codes for "in remission" - Answer-are assigned only on the basis of
provider documentation (as defined in the Official Guidelines for Coding and
Reporting),
unless otherwise instructed by the classification.
Mild substance use disorders in early or sustained remission are classified to the
appropriate codes for substance abuse in remission, and moderate or severe
substance use disorders in early or sustained remission are classified to the
appropriate codes for substance dependence in remission.
Codes from category G81, Hemiplegia and hemiparesis, and
subcategories G83.1, Monoplegia of lower limb, G83.2, Monoplegia of upper limb,
and G83.3, Monoplegia, unspecified, identify whether the dominant or nondominant
side is affected. - Answer-Should the affected side be documented, but not specified
as dominant or nondominant, and the
classification system does not indicate a default, code selection is as follows:
• For ambidextrous patients, the default should be dominant.
• If the left side is affected, the default is non-dominant.
• If the right side is affected, the default is dominant.
The classification presumes a causal relationship between hypertension - Answer-
and heart involvement and between hypertension and kidney involvement, as the
two conditions are linked by the term "with" in the Alphabetic Index. These conditions
should be coded as related even in the absence of provider documentation explicitly
linking them, unless the documentation clearly states the conditions are unrelated.
For hypertension and conditions not specifically linked by relational terms such as
"with," "associated with" or "due to" in the classification, provider documentation
must link the conditions in order to code them as related.
Hypertension with heart conditions classified to I50.- or I51.4- I51.9, are assigned to
a code - Answer-from category I11, Hypertensive heart disease. Use additional
code(s) from category I50, Heart
failure, to identify the type(s) of heart failure in those patients with heart failure.
The same heart conditions (I50.-, I51.4-I51.9) with hypertension are coded
separately if the provider has specifically documented a different cause. Sequence
according to the circumstances of
the admission/encounter.
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.
Psychoactive Substance Use, Abuse And Dependence - Answer-When the provider
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.
Use of a symptom code with a definitive diagnosis code - Answer-Codes for signs
and symptoms may be reported in addition to a related definitive diagnosis when the
sign or symptom is not routinely associated with that diagnosis, such as the various
signs and symptoms associated with complex syndromes. The definitive diagnosis
code should be sequenced before the symptom code.
Signs or symptoms that are associated routinely with a disease process - Answer-
should not be assigned as additional codes, unless otherwise instructed
by the classification.
Use of Z codes in any healthcare setting - Answer-Z codes are for use in any
healthcare setting. Z codes may be used as either a first-listed (principal diagnosis
code in the inpatient setting) or secondary code, depending on the circumstances of
the encounter. Certain Z codes may only be used as first-listed or principal
diagnosis.
CM codes - Answer-can be used in any setting
PCS codes - Answer-in patient procedure codes
PCS codes have a logical, consistent structure that contains seven (7) alphanumeric
positions, called characters - Answer-, consisting of the ten digits (0 - 9) and 24
letters (A - H, J - N, and P - Z).
the first character of an ICD-10-CM code is - Answer-always a letter
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
QUESTIONS WITH CORRECT
ANSWERS
Z21, Asymptomatic human immunodeficiency virus
[HIV] infection status, is to be applied when - Answer-the patient without any
documentation of symptoms is listed as being "HIV positive," "known HIV," "HIV test
positive," or similar terminology. Do not use this code if the term "AIDS" is used or if
the patient is treated for any HIV-related illness or is described as having any
condition(s) resulting from his/her HIV positive status; use B20 in these cases.
Patients with inconclusive HIV serology, but no
definitive diagnosis or manifestations of the illness, may
be assigned code - Answer-R75, Inconclusive laboratory evidence
of human immunodeficiency virus [HIV].
Patients with any known prior diagnosis of an
HIV-related illness should be coded to B20 - Answer-Once a patient has developed
an HIV-related illness, the patient should always be assigned code B20 on every
subsequent admission/encounter. Patients previously diagnosed with any HIV illness
(B20) should never be assigned to R75 or Z21, Asymptomatic human
immunodeficiency virus [HIV] infection status.
During pregnancy, childbirth or the puerperium, a
patient admitted (or presenting for a health care
encounter) because of an HIV-related illness should receive a principal diagnosis
code of - Answer-O98.7-, Human immunodeficiency [HIV] disease complicating
pregnancy, childbirth and the puerperium, followed by B20 and the code(s) for the
HIV-related illness(es).
Codes from Chapter 15 always take sequencing priority.
Patients with asymptomatic HIV infection status admitted (or presenting for a health
care encounter) during pregnancy, childbirth, or the puerperium should receive
codes of O98.7- and Z21.
Encounters for testing for HIV - Answer-If a patient is being seen to determine
his/her HIV status, use code Z11.4, Encounter for screening for
humanimmunodeficiency virus [HIV]. Use additional codes for any associated high
risk behavior. If a patient with signs or symptoms is being seen for HIV testing, code
the signs and symptoms. An additional counseling code Z71.7, Human
immunodeficiency virus [HIV] counseling, may be usedif counseling is provided
during the encounter for the test.
When a patient returns to be informed of his/her HIV test results and the test result is
negative, use code Z71.7, Human immunodeficiency virus [HIV]
counseling.
,Psychoactive Substance Use Disorders - Answer-the codes for psychoactive
substance use disorders (F10.9-, F11.9-, F12.9-, F13.9-, F14.9-,
F15.9-, F16.9-) should only be assigned based on provider documentation and when
they meet the definition of a reportable diagnosis (see Section III, Reporting
Additional Diagnoses). The codes are to be used only when the psychoactive
substance use is associated with a physical, mental or behavioral disorder, and such
a relationship is
documented by the provider.
The appropriate codes for "in remission" - Answer-are assigned only on the basis of
provider documentation (as defined in the Official Guidelines for Coding and
Reporting),
unless otherwise instructed by the classification.
Mild substance use disorders in early or sustained remission are classified to the
appropriate codes for substance abuse in remission, and moderate or severe
substance use disorders in early or sustained remission are classified to the
appropriate codes for substance dependence in remission.
Codes from category G81, Hemiplegia and hemiparesis, and
subcategories G83.1, Monoplegia of lower limb, G83.2, Monoplegia of upper limb,
and G83.3, Monoplegia, unspecified, identify whether the dominant or nondominant
side is affected. - Answer-Should the affected side be documented, but not specified
as dominant or nondominant, and the
classification system does not indicate a default, code selection is as follows:
• For ambidextrous patients, the default should be dominant.
• If the left side is affected, the default is non-dominant.
• If the right side is affected, the default is dominant.
The classification presumes a causal relationship between hypertension - Answer-
and heart involvement and between hypertension and kidney involvement, as the
two conditions are linked by the term "with" in the Alphabetic Index. These conditions
should be coded as related even in the absence of provider documentation explicitly
linking them, unless the documentation clearly states the conditions are unrelated.
For hypertension and conditions not specifically linked by relational terms such as
"with," "associated with" or "due to" in the classification, provider documentation
must link the conditions in order to code them as related.
Hypertension with heart conditions classified to I50.- or I51.4- I51.9, are assigned to
a code - Answer-from category I11, Hypertensive heart disease. Use additional
code(s) from category I50, Heart
failure, to identify the type(s) of heart failure in those patients with heart failure.
The same heart conditions (I50.-, I51.4-I51.9) with hypertension are coded
separately if the provider has specifically documented a different cause. Sequence
according to the circumstances of
the admission/encounter.
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.
Psychoactive Substance Use, Abuse And Dependence - Answer-When the provider
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.
Use of a symptom code with a definitive diagnosis code - Answer-Codes for signs
and symptoms may be reported in addition to a related definitive diagnosis when the
sign or symptom is not routinely associated with that diagnosis, such as the various
signs and symptoms associated with complex syndromes. The definitive diagnosis
code should be sequenced before the symptom code.
Signs or symptoms that are associated routinely with a disease process - Answer-
should not be assigned as additional codes, unless otherwise instructed
by the classification.
Use of Z codes in any healthcare setting - Answer-Z codes are for use in any
healthcare setting. Z codes may be used as either a first-listed (principal diagnosis
code in the inpatient setting) or secondary code, depending on the circumstances of
the encounter. Certain Z codes may only be used as first-listed or principal
diagnosis.
CM codes - Answer-can be used in any setting
PCS codes - Answer-in patient procedure codes
PCS codes have a logical, consistent structure that contains seven (7) alphanumeric
positions, called characters - Answer-, consisting of the ten digits (0 - 9) and 24
letters (A - H, J - N, and P - Z).
the first character of an ICD-10-CM code is - Answer-always a letter
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
