Deck 5: Diagnostic Coding Guidelines

Question 1

For bilateral sites, the first character of the codes in ICD-10-CM indicates laterality.

Answer 1

False

Question 2

Sally Smith was placed on observation due to pain in the upper right quadrant, vomiting, and jaundice. She was then placed on inpatient status for a removal of her gallbladder due to cholecystitis. The principal diagnosis for the admission is _____.

A) RUQ pain
B) vomiting
C) pain, jaundice, and vomiting
D) cholecystitis

Answer 2

D

Question 3

When a definitive diagnosis has been established, codes such as pain and fever are not coded.

Answer 3

True

Question 4

A sequela is the acute illness or injury that has caused a permanent condition.

Question 5

Section I of the ICD-10-CM Official Guidelines for Coding and Reporting provides guidelines only for outpatient services.

Question 6

ICD-10-CM code I25.110, ASHD, native artery with unstable angina is a ______ code.

A) combination
B) late effect
C) sequela
D) residual

Question 7

Signs and symptoms that are associated routinely with a disease process should not be assigned as additional codes.

Question 8

Diagnoses documented as probable, suspected, or questionable are _____.

A) reported in all settings
B) reported in outpatient settings
C) reported by physician choice
D) reported in the inpatient setting

Question 9

A three-digit code is to be used only if it is not further subdivided.

Question 10

Which section of the ICD-10-CM Official Guidelines for Coding and Reporting includes guidelines for the selection of principal diagnosis for non-outpatient settings?

A) Section I
B) Section II
C) Section III
D) Section IV

Question 11

At the time of discharge, the following diagnosis is recorded: "Confirmed threatened spontaneous abortion." The coder should select a code for spontaneous abortion.

Question 12

ICD-10-CM diagnosis codes are composed of up to eight characters.

Question 13

Which of the following is false?

A) Each unique ICD-10-CM diagnosis code may be reported only once for an encounter.
B) The guidelines for reporting inpatient and outpatient services are identical.
C) Ruled-out conditions are reported in the inpatient setting.
D) NCHS is a member of the Cooperating Parties.

Question 14

In the outpatient setting, the term "first-listed" diagnosis is used in lieu of _____ diagnosis.

A) first-referenced
B) primary
C) principal
D) final

Question 15

For ambulatory surgery, if the preoperative and postoperative diagnoses are different, select the postoperative diagnosis for coding.

Question 16

Which of the following is not a member of the Cooperating Parties for ICD-10-CM?

A) AHA
B) AMA
C) AHIMA
D) CMS

Question 17

A dash at the end of an ICD-10-CM Index to Diseases and Injuries entry indicates that additional characters are required for a valid code.

Question 18

Dr. Cook records the following diagnosis at the time of an inpatient discharge: "Abdominal pain ruled out colitis or gastritis." The principal diagnosis is_____.

A) abdominal pain
B) colitis
C) gastritis
D) either gastritis or colitis

Question 19

If the same condition is described as both acute (subacute) and chronic, and separate subentries exist in the Index at the same indentation level, code_____.

A) only the acute
B) only the chronic
C) either; query the provider
D) both, and sequence the acute (subacute) first

Question 20

A patient is admitted with nausea, vomiting, diarrhea, and abdominal pain. Testing has revealed colitis. The principal diagnosis is _____. abdominal pain

A) nausea and vomiting
B) ​
C) colitis
D) diarrhea

Question 21

When an admission is for treatment of a complication resulting from surgery, the ____________________ code is sequenced as the principal diagnosis.

Question 22

To select an ICD-10-CM code, first locate the main term in the ICD-10-CM Index to Diseases and Injuries and then verify the code in the ____________________.

Question 23

Section IV of the ICD-10-CM Official Guidelines for Coding and Reporting contains the Diagnostic Coding and Reporting Guidelines for ___________________ Services.

Question 24

When there is a "code first" note and an underlying condition is present, the ____________________ condition should be sequenced first.

Question 25

Codes that describe symptoms and signs, as opposed to diagnoses, are acceptable for reporting purposes when a related ____________________diagnosis has not been established by the provider.

Question 26

When a patient is admitted for observation for a medical condition, assign a code for the __________ condition as the first listed diagnosis.

Question 27

The condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care is known as the ____________________ diagnosis.

Question 28

Codes with three digits are included in ICD-10-CM as the heading of a/an ____________________ of codes.

Question 29

A patient is admitted for severe back pain, and it is determined that the patient has kidney stones. The principal diagnosis is ____________________.

Question 30

A/An ____________________ code is a single code used to classify two diagnoses, or a diagnosis with an associated secondary process or complication.