The official Guidelines for Coding and Reporting are approved by the ______________ for ICD-10-
CM to accompany and complement the official conventions and instructions provided within
ICD-10-CM - Answers cooperating parties
Signs and Symptoms associated with a disease should not be assigned as additional codes (if a
patient complains of shortness of breath and is diagnosed with pneumonia the only codes
assigned is for pneumonia since shortness of breath is a symptom of pneumonia) - Answers
Coding guidelines use the term ______________ for all health care settings including inpatient
hospital admissions - Answers encounter
Coding guidelines use the term ___________ to mean physician or any qualified health care
practitioner who is legally accountable for establishing the patient's diagnosis. - Answers
provider
The ______________ regulations for electronic transactions require providers and third-party
payers including Medicare administrative contractors (MACs) to adhere to the Official
Guidelines for coding and Reporting - Answers HIPAA
Section I of the Official Guidelines for Coding and Reporting includes the _______________ of the
classification and general guidelines that apply to the entire classification and chapter-specific
guidelines that correspond to the chapters as they are arranged in the classification. - Answers
structure and conventions
Section II of the Official Guidelines for Coding and Reporting includes guidelines for selection of
the ____________ for non outpatient settings - Answers Principal diagnosis
Section III of the Official Guidelines for Coding and Reporting includes guidelines for reporting
______________ in non outpatient settings - Answers additional diagnoses
Inpatient Care requires the reporting of additional diagnoses which are called - Answers
comorbidities
Section IV of the Official Guidelines for Coding and Reporting covers ________________ coding
and reporting - Answers outpatient diagnosis
Appendix I of the Official Guidelines for Coding and Reporting covers _________________ reporting
guidelines - Answers present on admission (POA)
If The provider documents "a borderline diagnosis" at the time of discharge code the diagnosis
as confirmed even when the ICD-10-CM Index to Diseases and Injuries provides a specific entry
that includes the word "borderline" (True or False) - Answers False
When reviewing ICD-10-CM Index to Disease and Injuries entries if the code listed contains a