HIT 205- ICD Coding II with lab Final review 2024 SOLUTIONS GRADE A+ GUARANTEED

Coding transformation of verbal descriptions into numbers provided in a classification system Alphabetic Index to Diseases and Injuries an alphabetic listing of terms and their corresponding codes; has two parts: Index to Diseases and Injury (contains Neoplasm table, and a Table of Drugs and Chemicals), Index to external causes of injury Main Terms set in boldface type and represent diseases, conditions, nouns such as disease, disorder or syndrome, adjectives such as double, kink or large External Cause codes capture: the cause of the injury or health condition, the intent of the event, the place where the event occurred, the activity of the patient at the time of the event, and the patient's status. External Cause codes cannot be assigned as: first listed, principal, or only listed diagnosis codes True or false: the use of external cause codes is mandatory for physicians and healthcare facilities false Y92 Place of occurrence external cause codes Y93 Activity codes Y99 External cause codes Place of occurrence guideline states: The following category is for use, when relevant, to identify the place of occurrence of the external cause. Use in conjunction with an activity code. Generally, the place of occurrence should be recorded ONLY at the initial encounter for treatment. However, in the rare instance that a new injury occurs during hospitalization, an additional place of occurrence code may be assigned Activity code guideline states: Category Y93 is provided for use to indicate the activity of the person seeking healthcare for an injury or health condition, such as a heart attack while shoveling snow, which resulted from, or was contributed to, by the activity. -to be recorded only ONCE during the initial encounter External cause status code guideline states: "A single code from category Y99 should be used in conjunction with the external cause code(s) assigned to a record to indicate the status of the person at the time the event occurred -indicates the work status of the person at the time the event occurred -to be recorded only ONCE during the initial encounter If the reporting format limits the number of external cause codes that can be used in reporting clinical data, the coder should: report the code for the cause or intent most relevant to the principal diagnosis The 7th character(s) required to identify the encounter (V00-Y99): A- Initial Encounter D- Subsequent Encounter S- Sequela The external cause code is organized by: the main term describing the accident, circumstance, event, or specific agent that caused the injury or illness, such as a car accident, earthquake, or dog bite Identify the main term, subterm(s) and code in this example: Patient was injured when he was kicked by another person in a fight and brought to the Emergency Department (ED) for treatment Main term: Kicked by Subterm: person Subterm: in, fight Code: Y04.0XXA The first-listed external cause code will be selected in the following order: 1. External codes for child and adult abuse take priority over all other external cause codes. 2.External cause codes for terrorism events take priority over all other external cause codes except child and adult abuse. 3.External cause codes for cataclysmic events take priority over all other external cause codes except child and adult abuse and terrorism. 4.External cause codes for transport accidents take priority over all other external cause codes except cataclysmic events, child and adult abuse, and terrorism. 5.Activity and external cause status codes are assigned following all causal (intent) external cause codes. Adult and child abuse, neglect, and maltreatment are classified as: assault A code from Y07 represents: confirmed cases of abuse, neglect and maltreatment, when the perpetrator is known. for suspected cases of abuse and maltreatment, the coder: does not report an external cause of injury or perpetrator All transport accident categories assume _______ accidental intent if the intent of the event is unknown, the coder can assume: the intent is accidental a sequela external cause code should never be used with: a related current nature of injury code. Typically, a patient with a sequela of a past injury or illness is coded as follows: 1.Residual effect or the condition the patient has at present, which is found in the Alphabetic Index to Diseases and Injuries 2.Sequela or late effect or the condition the patient originally had that produced the residual effect found in the Alphabetic Index to Disease and Injuries under the term "sequelae." 3.External cause code for the original accident or event, found in the Index to External Causes with the seventh character of "S" for sequelae. transport accidents relating to land transport (V00-V89) reflect: the victim's mode of transportation and are subdivided to identify the victim's counterpart or the type of event a transport accident is: one in which the vehicle involved must be moving or running or in use for transport purposes at the time of the accident Never events include wrong site surgery, wrong surgery, and wrong patient surgery; main terms include misadventures to patient during surgical or medical care; wrong, or the problem itself the two categories of military operations external cause codes: Operations of War (Y36), Military Operations (Y37); this codes are not to be used together; Operations of war describes injuries caused by war, civil insurrections, and peacekeeping missions; Military Operations describes injuries occurring during peacetime on military property and during routine military exercises and operations Terrorism External Cause codes: Y38, when the cause of an injury is identified by the FBI as an act of terrorism; use an additional code for place of occurrence (92-); more than one code may be used to identify each injury due to terrorist act; suspected cases should be classified as assault; Y38.9 is for conditions occurring subsequent to the terrorist event; main term is "Terrorism" Place of Occurrence codes: Y92, to identify, when documented, where the event occurred; used in conjunction with an activity code when the activity is stated; only coded at initial encounters; only one code from Y92 should be in the medical record; main term to be used is "Place of Occurrence" Activity Codes: Y93 To describe the activity of the patient at the time the injury or other health condition occurred ; used only once at the initial encounter; only one Y93 code should be used in the medical record; used in conjunction with place of occurrence code; not applicable to poisonings, adverse affects, misadventures, or sequelas; appropriate to be used with external cause and intent codes if the activity provides more information about the event; main term would be "activity" External Cause Status Codes: Y99, indicates whether the event occurred during military activity, whether a nonmilitary person was at work, or whether an individual including a student or volunteer was involved in a nonwork activity at the time of the causal event; should be assigned when applicable with other external cause codes; used only once at the initial encounter; may terms may be "external cause status" or "status of external cause" The patient is a 50-year-old female who was admitted to the hospital for chemotherapy for carcinoma of the lower-outer quadrant of her right breast. The intravenous chemotherapy was given through a central vein by percutaneous approach. The patient was discharged the second day. The codes for this admission are as follows: Z51.11, Encounter for antineoplastic chemotherapy C50.511, Malignant neoplasm of lower-outer quadrant of right female breast 3E04305, Administration through central vein, percutaneous approach, antineoplastic, other antineoplastic (Introduction of substance, vein, central, antineoplastic) Chapter 21: Factors influencing health status and contact with health services Z00-Z99; represent reasons for encounters; diagnosis codes; provided for encounters when circumstances other than a disease or injury are recorded in the health record as the diagnosis—the problem or reason for the encounter; used for patients who may or may not be sick but need healthcare services; may be used as either first listed or secondary diagnosis CONTINUED...