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Questions and Answers
Which coding convention is used in the description of an ICD-10-CM code when the information in the medical record provides detail, but no specific code exists?
Which coding convention is used in the description of an ICD-10-CM code when the information in the medical record provides detail, but no specific code exists?
NEC
What is a default code?
What is a default code?
The default code represents that condition is the most commonly associated with the main term.
What is the ICD-10-CM code for benign prostatic hyperplasia with urinary retention?
What is the ICD-10-CM code for benign prostatic hyperplasia with urinary retention?
N40.1, R33.8
Applying the coding concept from ICD-10-CM guideline I.B.1., which of the following is the recommended method for using your ICD-10-CM code book?
Applying the coding concept from ICD-10-CM guideline I.B.1., which of the following is the recommended method for using your ICD-10-CM code book?
What is the ICD-10-CM code for essential hypertension?
What is the ICD-10-CM code for essential hypertension?
Which option would be appropriate reporting for a diagnosis of nausea and vomiting?
Which option would be appropriate reporting for a diagnosis of nausea and vomiting?
Which ICD-10-CM code(s) are reported for right and left ankle fractures?
Which ICD-10-CM code(s) are reported for right and left ankle fractures?
Which ICD-10-CM code(s) are reported for a laparoscopic oophorectomy that was cancelled due to an upper respiratory infection?
Which ICD-10-CM code(s) are reported for a laparoscopic oophorectomy that was cancelled due to an upper respiratory infection?
Which ICD-10-CM code(s) is/are reported for a suspicious skin lesion referred to a dermatologist?
Which ICD-10-CM code(s) is/are reported for a suspicious skin lesion referred to a dermatologist?
What ICD-10-CM code(s) are reported for monitoring severe postoperative pain after an outpatient cholecystectomy?
What ICD-10-CM code(s) are reported for monitoring severe postoperative pain after an outpatient cholecystectomy?
How would you report a patient with cyclic neutropenia with an associated fever?
How would you report a patient with cyclic neutropenia with an associated fever?
What effect do supplementary words enclosed in parenthesis have on coding?
What effect do supplementary words enclosed in parenthesis have on coding?
Three-character ICD-10-CM codes represent what level of code?
Three-character ICD-10-CM codes represent what level of code?
What is the ICD-10-CM code for a bruised left knee, initial encounter?
What is the ICD-10-CM code for a bruised left knee, initial encounter?
What is/are the ICD-10-CM code(s) for bilateral hip pain?
What is/are the ICD-10-CM code(s) for bilateral hip pain?
What is the time limit when assigning codes as sequela?
What is the time limit when assigning codes as sequela?
How are the codes sequenced when a patient presents with an acute exacerbation of a chronic condition and no single code captures both?
How are the codes sequenced when a patient presents with an acute exacerbation of a chronic condition and no single code captures both?
What is the appropriate action when a physician documents an impending condition that had not occurred by the time of discharge?
What is the appropriate action when a physician documents an impending condition that had not occurred by the time of discharge?
What ICD-10-CM code(s) are reported for a patient with chest pain, fever, and cough who is being evaluated for pneumonia?
What ICD-10-CM code(s) are reported for a patient with chest pain, fever, and cough who is being evaluated for pneumonia?
Flashcards
NEC Coding Convention
NEC Coding Convention
Used in ICD-10-CM when the record provides detail, but no specific code exists.
Default Code
Default Code
The code representing the condition most commonly associated with the main term.
BPH with Urinary Retention
BPH with Urinary Retention
N40.1, R33.8
ICD-10-CM Coding Method
ICD-10-CM Coding Method
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Essential Hypertension Code​
Essential Hypertension Code​
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Nausea and Vomiting Code
Nausea and Vomiting Code
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Right and Left Ankle Fractures
Right and Left Ankle Fractures
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Cancelled Laparoscopic Oophorectomy
Cancelled Laparoscopic Oophorectomy
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Suspicious Skin Lesion Referral
Suspicious Skin Lesion Referral
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Postoperative Pain Monitoring
Postoperative Pain Monitoring
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Cyclic Neutropenia with Fever
Cyclic Neutropenia with Fever
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Parenthetical Words Effect
Parenthetical Words Effect
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Three-Character Codes
Three-Character Codes
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Bruised Left Knee, Initial Encounter
Bruised Left Knee, Initial Encounter
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Bilateral Hip Pain
Bilateral Hip Pain
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Sequela Time Limit
Sequela Time Limit
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Acute Exacerbation Sequencing
Acute Exacerbation Sequencing
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Impending Condition Documentation
Impending Condition Documentation
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Chest Pain, Fever, and Cough
Chest Pain, Fever, and Cough
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Study Notes
ICD-10-CM Coding Concepts
- NEC (Not Elsewhere Classified) is used when additional detail is provided in the medical record, but there is no specific code available.
- Default Code represents the most commonly associated condition with the main term as per ICD-10-CM guidelines.
Specific ICD-10-CM Codes
- Benign prostatic hyperplasia with urinary retention: N40.1, R33.8
- Essential hypertension: I10
- Nausea and vomiting diagnosis: R11.2
- Right and left ankle fractures: S82.891A, S82.892A
- Cyclic neutropenia with associated fever: D70.4, R50.81
- Bruised left knee, initial encounter: S80.02XA
- Bilateral hip pain: M25.551, M25.552
- Observation after outpatient cholecystectomy for gallstones with severe postoperative pain: K80.20, G89.18
- Wellness exam with suspicious skin lesion referral: Z00.01, L98.9
Coding Procedures and Guidelines
- Always consult the Alphabetic Index first before using the Tabular List for code location (ICD-10-CM Guideline I.B.1).
- Time limit for sequelae: No limit (ICD-10-CM Guideline I.B.10).
- In cases of acute exacerbation of a chronic condition, code the acute condition first (ICD-10-CM Guideline I.B.8).
- For impending conditions not documented by discharge, code existing underlying conditions (ICD-10-CM Guideline I.B.11).
Additional Notes
- Supplementary words in parentheses do not impact the code assignment.
- Three-character codes represent a Category in ICD-10-CM.
- For a patient with chest pain, fever, and cough, the reported codes include: R07.9, R50.9, R05.
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