Questions and Answers
What does ICD-10-CM stand for?
International classification of diseases, 10th revision, clinical modification
What is the significance of "cm" in ICD-10-CM?
Unique revision to ICD-10 that added more options to account for the U.S.'s higher incidence of chronic disease
What organization is responsible for maintaining ICD-10 and when was it first published?
WHO (World Health Organization), 1990
What is nomenclature?
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What is classification in the context of ICD-10?
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What is a closed classification system, and can you provide an example?
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How is the ICD-9-CM code book organized?
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What does NOS stand for in coding terminology?
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What does NEC stand for in medical coding?
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What is the significance of an italicized code?
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Must modifiers that follow a term with a colon be present in the diagnostic or procedural statement in order to use that code category?
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What is a default code?
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What two broad disease categories can be found in table format in Volume 2?
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Physician services use CPT and HCPCS codes for procedures and do not use ICD-10-PCS.
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See and see also do not mean the same thing.
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Abnormal findings are always coded and reported when they are found.
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In ICD-10-CM, external cause of injury codes are found in the main alphabetic index.
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You can always find adequate and complete documentation in the discharge summary, so you can code right from there.
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ICD-10-CM is both a diagnosis and procedural coding system.
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What are the two major divisions within ICD-10-CM?
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What does UHDDS stand for?
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What is the definition of principal diagnosis?
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Terms for anatomical sites are good to use as main terms in searching for codes in the alphabetic index.
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Is it ever permissible to code directly from the index?
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Who are the cooperating parties and what is their role?
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What are physician orders?
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An inclusion note under a code indicates that the terms excluded from the code are to be coded elsewhere.
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Adherence to the ICD-10-CM/PCS guidelines are a requirement for compliance to HIPAA.
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CCA stands for?
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Study Notes
ICD-10-CM Overview
- ICD-10-CM stands for International Classification of Diseases, 10th Revision, Clinical Modification.
- "CM" indicates a unique U.S. revision that addresses the higher incidence of chronic diseases.
Organization and History
- Maintained by the World Health Organization (WHO).
- First published in 1990.
Nomenclature and Classification
- Nomenclature refers to a systematic naming of terminology.
- Classification organizes similar items for easier storage and retrieval.
Classification Systems
- Closed Classification System, such as ICD-10-CM, means each disease or condition has a single classification location.
ICD-9-CM Code Book Organization
- Volume 1: Diseases and conditions in a tabular list.
- Volume 2: Alphabetic index of diseases.
- Volume 3: Procedures in both tabular and alphabetic formats.
Coding Terminology
- NOS (Not Otherwise Specified): Describes vague conditions without specific code assignment.
- NEC (Not Elsewhere Classified): Specific narrative without an exact matching code.
- Italicized codes should not be the principal diagnosis.
Code Requirements
- Modifiers linked with colons must be present in the statement to apply the respective code category.
- Default codes indicate the most common condition associated with main terms.
Disease Category Tables
- Volume 2 features key disease categories like neoplasms and drug/chemical tables.
Coding Practices
- Physician services use CPT and HCPCS codes, not ICD-10-PCS.
- "See" and "See Also" have different implications in coding references.
- Abnormal findings are coded only if deemed clinically relevant by a physician.
Coding Instructions
- External cause of injury codes are found in a separate index, not the main alphabetic index.
- Complete documentation is not always available in discharge summaries; consult other records as needed.
ICD-10-CM and ICD-10-PCS
- ICD-10-CM is strictly for diagnosis coding, while ICD-10-PCS is for procedural coding.
- Major divisions within ICD-10-CM include the tabular list of diseases and the alphabetic index.
Data Sets and Diagnoses
- UHDDS stands for Uniform Hospital Discharge Data Set, a core data collection standard for healthcare facilities.
- Principal diagnosis is defined as the condition chiefly responsible for patient admission.
Coding Guidelines and Compliance
- Anatomical site terms are not main terms in search; they guide to "see condition".
- Coding should never be done directly from the index.
- Cooperating parties (AHIMA, AHA, NCHS, CMS) approve ICD-10-CM coding guidelines.
- Adherence to ICD-10-CM/PCS guidelines is essential for HIPAA compliance.
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Description
Test your knowledge of the ICD-10-CM classification system with this set of flashcards. Covering the basics and significance of the disease classification, these cards are perfect for students and healthcare professionals alike. Enhance your understanding of the ICD-10-CM through engaging content.
