29 Questions
Which chapter in the ICD-10-CM classification system covers congenital malformations, deformations, and chromosomal abnormalities?
Chapter 17
When should additional codes be assigned for manifestations that are not an inherent component of a congenital malformation or chromosomal abnormality?
When the code assignment does not specifically identify the malformation or abnormality
What should be used to identify the history of a corrected congenital malformation or deformity?
A personal history code
When is it appropriate to assign a code from Chapter 17 (Congenital malformations, deformations, and chromosomal abnormalities)?
Whenever the condition is diagnosed by the provider, regardless of when it was first identified
When should manifestations that are an inherent component of a congenital malformation or chromosomal abnormality be coded separately?
When the code assignment specifically identifies the malformation or abnormality
What should be done when a congenital malformation or deformity does not have a unique code assignment?
Assign additional code(s) for any manifestations that may be present
What is the purpose of using codes from Chapter 17 (Congenital malformations, deformations, and chromosomal abnormalities)?
To track the progression of the condition over the patient's lifetime
When should a code from Chapter 17 be used to identify a congenital malformation or deformity?
Whenever the condition is documented, regardless of whether it is the principal or a secondary diagnosis
What should be done if a congenital malformation or deformity is diagnosed later in life, even though it was present at birth?
Assign a code from Chapter 17, as the condition is congenital regardless of when it is diagnosed
How should a corrected congenital malformation or deformity be coded?
Assign a personal history code to indicate the history of the condition
What is the correct code for Systemic Inflammatory Response Syndrome (SIRS) of non-infectious origin without acute organ dysfunction?
R65.10
If acute organ dysfunction is documented with Systemic Inflammatory Response Syndrome (SIRS) of non-infectious origin, which additional code(s) should be assigned?
Code R65.11 and code(s) for the specific type of organ dysfunction(s)
When should the code R99 be used?
When a patient who has already died is brought into a healthcare facility and pronounced dead upon arrival
Which of the following statements about the NIH Stroke Scale (NIHSS) codes is correct?
The NIHSS codes can be used in conjunction with acute stroke codes to identify the patient's neurological status and severity of the stroke
When reporting the NIH Stroke Scale (NIHSS) codes, which of the following is correct?
Multiple stroke scale scores can be captured if desired by the facility
What code or codes should be assigned for functional quadriplegia?
No code is available for functional quadriplegia
If acute organ dysfunction is documented, but it cannot be determined if it is associated with SIRS or due to another condition, what action should be taken?
The provider should be queried
Which of the following statements about the NIHSS stroke scale documentation is correct?
The NIHSS stroke scale documentation can be done by clinicians other than the patient's provider
If a patient with SIRS of non-infectious origin also has an underlying injury, which codes should be assigned?
The code for the underlying injury followed by the code for SIRS of non-infectious origin
Which of the following statements about the code R99 is correct?
It does not represent the discharge disposition of death
Where should the appropriate code from category Z38 be sequenced for birth admission?
Before any congenital anomaly codes
When is it acceptable to report symptom codes for reporting purposes?
When a related definitive diagnosis has not been established
Which code should be assigned for a patient who has recently fallen and the reason for the fall is being investigated?
Code R29.6
In what situations should code R40.20, Unspecified coma, be assigned?
When the underlying cause of the coma is not known
What should be sequenced after the diagnosis code(s) when using coma scale codes in conjunction with traumatic brain injury codes?
The coma scale codes from each subcategory
When should code R40.24, Glasgow coma scale, total score, be assigned?
When only the total score is documented in the medical record
Which code should be used for history of falling in a patient who has fallen in the past and is at risk for future falls?
Code Z91.81
What is the purpose of using combination codes in ICD-10-CM?
To identify both definitive diagnosis and common symptoms of that diagnosis
Which statement is true about using symptom codes with a definitive diagnosis code?
Symptom codes may be reported in addition to a related definitive diagnosis.
Study Notes
Congenital Malformations, Deformations, and Chromosomal Abnormalities
- Assign codes Q00-Q99 for congenital malformations, deformations, and chromosomal abnormalities, which can be principal or secondary diagnoses
- Additional codes should be assigned for manifestations not inherent to the anomaly
- Codes from Chapter 17 can be used throughout the patient's life
- If a congenital malformation or deformity has been corrected, use a personal history code to identify the history of the malformation or deformity
Systemic Inflammatory Response Syndrome (SIRS)
- SIRS can develop as a result of non-infectious disease processes, such as trauma, malignant neoplasm, or pancreatitis
- Assign code R65.10 for SIRS of non-infectious origin without acute organ dysfunction, or R65.11 with acute organ dysfunction
Death NOS
- Code R99 is for use in the limited circumstance when a patient who has already died is brought into an emergency department or other healthcare facility and is pronounced dead upon arrival
NIHSS Stroke Scale
- NIHSS codes (R29.7-) can be used in conjunction with acute stroke codes (I60–I63) to identify the patient's neurological status and the severity of the stroke
- Sequence NIHSS codes after the acute stroke diagnosis code(s)
Symptoms, Signs, and Abnormal Clinical and Laboratory Findings
- Chapter 18 includes symptoms, signs, abnormal results of clinical or other investigative procedures, and ill-defined conditions
- Codes for signs and symptoms may be reported in addition to a related definitive diagnosis when the sign or symptom is not routinely associated with that diagnosis
- Combination codes that include symptoms should not be assigned an additional code for the symptom
Coma Scale
- Coma scale codes (R40.21- to R40.24-) can be used in conjunction with traumatic brain injury codes
- These codes cannot be used with code R40.2A, Nontraumatic coma due to underlying condition
- The coma scale codes should be sequenced after the diagnosis code(s)
Test your knowledge of assigning appropriate codes from categories Q00-Q99 for congenital malformations, deformations, and chromosomal abnormalities. Practice identifying principal and secondary diagnoses related to malformations, deformations, and chromosomal abnormalities.
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