Diagnositic Code Guidelines Chapter Review

Chapter Review Chapter 5 Diagnostic Code Guidelines (Practice) True or False 1. The ICD-10-CM Official Guidelines for Coding and Reporting were developed by the American Health Information Management Association. False 2. For outpatient and physician office visits, the code that is listed first for coding and reporting purposes is the reason for the encounter. True 3. Codes that describe symptoms and signs are acceptable for coding when a definitive diagnosis has not been established in a physician’s office. Ture 4. If signs and symptoms exist that are not routinely associated with a disease process, the signs and symptoms should not be coded. False 5. Sequela codes should be used only within six months after the initial injury or diseases. False 6. The principal diagnosis is defined as “that condition established after study to be chiefly responsible for occasioning the outpatient visit of the patient to the hospital for care.” False 7. If the diagnosis documented at the time of discharge is qualified as “probable” or “suspected,” do not code the condition. False 8. Codes from chapter 18 of ICD-10-CM, “Symptoms, Signs, and Abnormal Clinical and Laboratory Findings, Not Elsewhere Classified,” are not to be used as a principal diagnosis when a related definitive diagnosis has been established. True 9. A patient is admitted because of severe abdominal pain. After diagnostic testing, it is determined that the patient has appendicitis. The abdominal pain is the principal diagnosis. False 10. In a physician’s office, a chronic disease treated on an ongoing basis may be coded and reported as many times as the patient receives treatment and care for the condition. True Enter the appropriate term(s) to complete each statement 11. A ______ is the residual effect (condition produced) after the acute phase of an illness or injury has terminated. Sequela 12. For ambulatory surgery, if the postoperative diagnosis is known to be different from the preoperative diagnosis at the time the diagnosis is confirmed, select the ______ diagnosis for coding. Postoperative 13. In the ______ setting, the definition of principal diagnosis does not apply. Outpatient 14. All conditions that coexist at the time of admission, that developed subsequently, or that affect the treatment received and length of stay, or both, are know as the ______ diagnosis. Secondary 15. Rule-out conditions are not coded in the ______ setting. Outpatient 16. In the outpatient setting, do not code conditions that were previously ______ and no longer exist. Treated 17. Abnormal findings are not coded and reported for unless the ______ indicates their clinical significance. Provider 18. In the outpatient setting, the term ______ diagnosis is used in lieu of principal diagnosis. First-listed 19. In most cases, when coding sequela, two codes are required, with the ______ sequenced first, followed buy the sequela code. Condition Enter the appropriate term(s) to complete each statement. 20. Each unique ICD-10-CM code may be reported ______ for an encounter. Only once 21. If the condition for which a rehabilitation service is no longer present, report the appropriate ______ code as the first-listed or principal diagnosis. Aftercare 22. For reporting purposes, the definition for “other diagnoses” is interpreted as additional conditions that affect patient care in terms of requiring: ______ evaluation; or therapeutic treatment; or diagnostic procedures; or extended length of hospital stay; or increased ______ care and/or monitoring. Clinical; nursing 23. Information about the use of certain abbreviations, punctuation, symbols, and other conventions used in the ICD-10CM Tabular List (code numbers and titles) can be found in Section ______ of the ICD-10-CM Official Guidelines for Coding and Reporting. I.A 24. In the ICD-10-CM Official Guidelines for Coding and Reporting, Section ______ contains general guidelines that apply to the entire classification. I.B. 25. In the ICD-10-CM Official for Coding and Reporting, Section ______ contains chapter-specific guidelines that correspond to the chapters as they are arranged in the classification. I.C.