Deck 3: ICD-10-CM Outpatient Coding and Reporting Guidelines

Question 1

If the pre- and postoperative diagnoses are different, the preoperative diagnosis should be reported.

Answer 1

False

Question 2

When an encounter is for a therapeutic service, the first-listed code is the diagnosis, condition, or problem shown to be chiefly responsible for the therapeutic service.

Answer 2

True

Question 3

Code all the documented conditions that coexist at the time of an encounter/visit and require or affect patient care, treatment, or management.

Answer 3

True

Question 4

Corneal ulcer with hypopyon of left eye.
ICD-10-CM Code: ___________________

Question 5

A patient may have an unconfirmed diagnosis for more than three visits if a definitive diagnosis has not been stated by the physician in the medical documentation.

Question 6

For an outpatient service, a history code (Z80-Z87) may be assigned as a secondary code if the historical condition or family history has an impact on the current care or has an influence on the treatment.

Question 7

In the outpatient setting, a diagnosis that is documented as "rule out" should not be reported.

Question 8

The term "primary diagnosis" is the same as the first-listed diagnosis.

Question 9

Long-term (current) use of systemic steroids.
ICD-10-CM Code: ___________________

Question 10

A multigravida 48-year-old patient presents for routine prenatal visit, first trimester. No complications are noted.
ICD-10-CM Code: ___________________

Question 11

Section IV of the Official Guidelines for Coding and Reporting applies to both the inpatient and outpatient settings.

Question 12

Assign Z01.89, Encounter for other specified special examinations, for encounters for routine laboratory/radiology testing in the absence of any signs, symptoms, or associated diagnoses.

Question 13

Long-term (current) use of aspirin.
ICD-10-CM Code: ___________________

Question 14

In the inpatient hospital setting, probable, suspected, and rule-out diagnoses cannot be reported by the facility as though the condition exists.

Question 15

Screening for respiratory tuberculosis.
ICD-10-CM Code: ___________________

Question 16

Preoperative examination for a patient who will receive a renal transplant due to ESRD, currently on dialysis.
ICD-10-CM Codes: ________________, ________________, ________________

Question 17

A patient is admitted to an observation unit for a medical condition that has worsened and is then admitted as an inpatient to the same hospital for the same medical condition. The primary diagnosis would be the medical condition that led to the admission.

Question 18

Encounter for blood type testing prior to surgery.
ICD-10-CM Code: ___________________

Question 19

Z codes cannot be used in the outpatient setting.

Question 20

Z codes may be assigned as first-listed or a secondary diagnosis.

Question 21

An established patient is seen for migraines and seizures, to rule out the possibility of a brain tumor. ____________________

Question 22

Screening colonoscopy for colon cancer.
ICD-10-CM Code: ___________________

Question 23

An established patient is seen for management of diabetes and hypothyroidism and the physician spends equal time on each diagnosis. ____________________

Question 24

Exposure to German measles.
ICD-10-CM Code: ___________________

Question 25

Established patient presents with chest pain. He has a history of previous myocardial infarction and coronary artery bypass surgery.
____________________

Question 26

Established patient seen for redness and sensitivity to light in her right eye. The documentation states the diagnosis is iritis. ____________________

Question 27

Initial office visit for patient with nausea and vomiting. Physician documented the nausea and vomiting were due to acute appendicitis. ____________________

Question 28

Patient admitted to observation following a highway accident in which he was the driver of the car that was struck by another car. No injuries indicated during this initial encounter.
ICD-10-CM Codes: ___________________, ______________________