Question 1

When can "other" codes be used in the ICD-10-CM?

Accepted Answer

"Other" and "other specified" codes should only be used when a code does not exist for the detail that is provided in the medical record. "Other" codes can be found in the Tabular list and are listed as "NEC" or "not elsewhere classified" in the Alphabetic Index entry.
"Other" codes should only be used when a code truly does not exist. If another code exists for that particular diagnosis or sign/symptom then that code should be utilized. The Alphabetic Index and Tabular List should both be utilized to identify proper codes or absence of a code.

Question 2

Do "borderline" codes exist in the ICD-10-CM?

Accepted Answer

"Borderline" codes do exist for some diagnoses and must be confirmed using the notations in the ICD-10-CM coding book. These codes may only be used if the provider specifically states this in the medical record.
If "borderline" is unclear in the documentation and there are any questions about the diagnosis in the documentation, then the coder should query the provider for clarification.

Question 3

What is the correct sequencing for severe sepsis in the ICD-10-CM?

Accepted Answer

Severe sepsis is only coded as the secondary code and never as the primary. This is due to the fact that there is always an underlying infection in sepsis and that systemic infection needs to be coded first.
Sepsis does have subcategories and it is important to use a subcategory when the cause is known and only when it is clearly documented in the medical record. Severe sepsis can never be assigned as the primary/principal diagnosis. If severe sepsis develops during an encounter, than the admitting or initial diagnosis is used as the primary code and severe sepsis is listed as the secondary code along with the underlying systemic infection.

Question 4

When can pain codes be used when using ICD-10-CM?

Accepted Answer

Pain codes can be used independently or with other codes as appropriate. Pain codes can be used as the primary or secondary code depending upon why the patient is being encountered. With ICD-10-CM coding, if laterality is listed in the medical record, then the appropriate laterality code should be used.

Question 5

How do you report bilateral glaucoma where each eye is documented as having a different type or stage?

Accepted Answer

It is important to always refer to the Alphabetic Index and Tabular List when obtaining the correct codes. There are different codes for the types of glaucoma and some of these codes do have laterality specified. The stages will need to be identified by using the appropriate seventh character and the Tabular List will aid in the correct code identification.
If it is documented that different types of glaucoma are in different eyes, then the coding needs to reflect this and not just reflect the most severe. Stages are identified by the seventh character.

Question 6

Is there a national requirement for external causes of morbidity codes to be used?

Accepted Answer

No, there is no national requirement for mandatory ICD-10-CM external cause reporting, however certain states may require mandatory reporting and certain payers may require this as well. When not a mandatory requirement, providers are still encouraged to voluntarily report these codes when able.

Question 7

What are "Z" codes in the ICD-10-CM?

Accepted Answer

Z codes are not procedure codes and only indicate the reason for an encounter. They may be used as either primary or secondary codes and cannot be used independently. These codes are used to identify health factors influencing health status and contact with health services for things such as contact/exposures, vaccinations, patient status codes, screenings, observation, aftercare, follow up, and counseling.

Question 8

How are coexisting conditions that the patient has but are not the primary reason for the encounter coded? Which answer is incorrect regarding coexisting conditions?

Accepted Answer

Conditions in the patient's medical history do not need to be coded unless they require or affect that patient's treatment care plan. Only those codes that directly apply to the encounter should be utilized. However there are "history codes" that can be used to indicate previous medical history that directly impacts the current diagnoses and treatment plan.

Question 9

A patient with HIV is admitted for enterocolitis due to Clostridium difficile. What is the correct ICD-10-CM code(s) and what is the correct sequence?

Accepted Answer

A04.7, B20 is the correct answer because code A04.7 is the primary code for enterocolitis due to Clostridium difficile, which is the primary reason for admission. The HIV is subsequent in this particular case because it is not the main reason the patient was being admitted. However, it is still necessary to consider for best plan of care and treatment of the patient.
B20 is not the primary code so should not be listed first. R75 is the code for inconclusive serologic evidence of HIV which is incorrect for this patient since this patient has been diagnosed with HIV in the past.

Question 10

A patient with acute lymphoblastic leukemia is currently undergoing chemotherapy and radiation therapy and develops anemia as a result. He requires admission and a blood transfusion because of this complication caused by the chemotherapy. What ICD-10-CM codes should be used and what is the correct sequence?

Accepted Answer

D64.81, C91.00, T45.1X5A is the correct code sequence for a patient who was admitted for anemia requiring a blood transfusion due to the chemotherapy, from the treatment he is undergoing for acute lymphoblastic leukemia. The anemia code is the primary code and is specific to the chemotherapy. The secondary code is the type of leukemia that he has; he is currently undergoing treatment, so he is not in remission. The last code is for an adverse effect of antineoplastic and immunosuppressive drugs, initial encounter.
C91.10 is incorrect because this is not the right code for acute lymphoblastic leukemia.

Question 11

A 35-year-old male with type 1 diabetes, who has an insulin pump, also has diabetic retinopathy without macular edema. He is admitted to the hospital with ketoacidosis without coma. What are the correct ICD-10-CM codes and what is the correct sequence?

Accepted Answer

E10.10 is the correct code for Type 1 diabetes mellitus with ketoacidosis without coma. E10.319 is the correct code for Type 1 diabetes mellitus with unspecified diabetic retinopathy without macular edema. Code Z79.4 is the code used for patients who routinely use insulin and this patient has an insulin pump.
Code E10.11 is incorrect because this code is for Type 1 diabetes mellitus with ketoacidosis with coma. Code E10.311 is incorrect because this code is for Type 1 diabetes mellitus with unspecified diabetic retinopathy with macular edema.

Question 12

A 33-year-old woman follows up with her psychiatrist for ongoing major depressive disorder that is considered moderate. She is on a daily medication for this disorder. She also follows up with him for generalized anxiety disorder. She smokes 1.5 packs of cigarettes per day and she reports that this helps her anxiety and, when she doesn't smoke, her anxiety increases. What ICD-10-CM codes are correct and what sequence should they be listed?

Accepted Answer

F33.1, F41.1, F17.210 is the correct ICD code sequence for this patient. F33.1 is the correct code for moderate recurrent major depressive disorder. F41.1 is the correct code for generalized anxiety disorder and F17.210 is the correct code for nicotine dependency by cigarettes without complications.
F33.0 is incorrect because this code is for mild recurrent major depressive disorder. F41.9 is incorrect because this code is for unspecified anxiety disorder. F17.200 is incorrect because this code is for unspecified uncomplicated nicotine dependence and this patient's nicotine of choice is cigarettes.

Question 13

A 21-year-old patient with chronic tension-type headaches that are not intractable relies on daily prophylactic medications to help relieve the headaches. What is the correct ICD-10-CM code for this type of headache?

Accepted Answer

G44.229 is the correct code for chronic tension type headache that is not intractable.
Code G43.10 is incorrect because this code is for migraine with aura and G44.019 is incorrect because this code is for episodic cluster headaches. Code G44.201 is incorrect because this code is for unspecified tension-type headaches that are intractable.

Question 14

A 45-year-old patient has a chalazion of her right upper eyelid. What is the correct ICD-10-CM code indicating laterality for this patient?

Accepted Answer

H00.11 is the correct code for a chalazion of the right upper eyelid.
Code H00.12 is incorrect because this code is for a chalazion of the right lower eyelid. Code H00.13 is incorrect because this is the code for a chalazion of the right eye without the eyelid specified. Code H00.14 is incorrect because this code is for a chalazion of the left upper eyelid.

Question 15

A 2-year-old patient is here for initial examination and is found to have a right acute serous otitis media and impacted cerumen of the left ear. What are the correct ICD-10-CM codes for this patient in the correct sequence?

Accepted Answer

H65.01, H61.22 is the correct sequence for this patient. H65.01 is the correct code for right acute serous otitis media. H61.22 is the correct code for impacted cerumen in the left ear.
Code H65.02 is incorrect because this code is for left acute serous otitis media. Code H65.03 is incorrect as well because this code is for bilateral acute serous otitis media. Code H61.21 is incorrect because this code is for cerumen impaction in the right ear.

Question 16

A patient with a history of asthma is seen in the office for an acute nasopharyngitis (common cold) and increasing difficulty breathing, even using her albuterol inhaler at home 2-3 times a day. She is diagnosed with a common cold and mild intermittent asthma with acute exacerbation. What is the correct sequence of ICD-10-CM codes for this patient?

Accepted Answer

J45.21, J00 is the correct sequence of codes for this patient because J45.21 is the correct code for mild intermittent asthma with acute exacerbation and J00 is the correct code for acute nasopharyngitis, also known as the common cold.
Code J45.20 is incorrect because this code is for uncomplicated mild intermittent asthma. Code J45.31 is incorrect because this code is for mild persistent asthma with acute exacerbation and J22 is incorrect because this code is for unspecified lower respiratory infection.

Question 17

A 26-year-old man has been diagnosed with Crohn's disease of the large and small intestine without complications. What is the correct ICD-10-CM code for this diagnosis?

Accepted Answer

K50.8 is the correct code for Crohn's disease of both small and large intestines without complications.
Code K50.0 is incorrect because this code is specific to the small intestine and K50.1 is incorrect because this code is for disease of the large intestine. Code K50.9 is incorrect because this code is for unspecified Crohn's disease.

Question 18

An elementary school student who wrestles has been diagnosed with non-bullous impetigo. What is the correct ICD-10-CM code for this type of infectious skin disease?

Accepted Answer

L01.01 is the correct code for non-bullous impetigo.
Code L01.00 is incorrect because this is for impetigo that hasn't been specified. Code L01.02 is incorrect because this code is for Bockhart's impetigo, also known as perifolliculitis, and code L01.03 is incorrect because this is for bullous impetigo.

Question 19

A 2-month-old infant is diagnosed with torticollis due to not having enough tummy time and always preferring to lay on one side of her head. What is the correct ICD-10-CM code for this patient?

Accepted Answer

M43.6 is the correct code for torticollis. This code excludes certain types of torticollis, but the patient described above doesn't fit any of the exclusion criteria listed.
Code M43.2 is incorrect because this code is for fusion of the spine. Code M43.5 is incorrect because this is the code for recurrent vertebral dislocation and M43.8 is incorrect because this is the code for other specified deforming dorsopathies.

Question 20

A 28-year-old woman will be undergoing a lithotripsy for bilateral kidney stones. The stones are secure within the kidney and have not begun to migrate. What is the correct ICD-10-CM code for this patient's kidney stones?

Accepted Answer

N20.0 is the correct code for calculus of the kidney.
Code N20.1 is incorrect because this code is for calculus of the ureter. Code N20.2 is incorrect because this is the code for calculus of kidney and calculus of ureter. N21.0 is incorrect because this code is for calculus in the bladder.

Quiz 8: ICD 10 Cm Volumes 1 and 2