ICD-10-CM Chapters 1-4 Flashcards
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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?

<p>A system of names that are used as preferred terminology</p> Signup and view all the answers

What is classification in the context of ICD-10?

<p>Type of system that groups together similar items for easy storage and retrieval</p> Signup and view all the answers

What is a closed classification system, and can you provide an example?

<p>In a closed classification system, a disease, condition, or procedure can only be classified in one place. Example: ICD-10-CM</p> Signup and view all the answers

How is the ICD-9-CM code book organized?

<p>Volume 1: Tabular listing of diseases &amp; conditions, Volume 2: Alphabetic index of diseases, Volume 3: Tabular and alphabetic index of procedures</p> Signup and view all the answers

What does NOS stand for in coding terminology?

<p>Not otherwise specified</p> Signup and view all the answers

What does NEC stand for in medical coding?

<p>Not elsewhere classified</p> Signup and view all the answers

What is the significance of an italicized code?

<p>This code should never be the principal diagnosis or listed first</p> Signup and view all the answers

Must modifiers that follow a term with a colon be present in the diagnostic or procedural statement in order to use that code category?

<p>True</p> Signup and view all the answers

What is a default code?

<p>A code listed next to a main term that represents the condition most commonly associated with the main term</p> Signup and view all the answers

What two broad disease categories can be found in table format in Volume 2?

<p>Neoplasms and table of drugs and chemicals</p> Signup and view all the answers

Physician services use CPT and HCPCS codes for procedures and do not use ICD-10-PCS.

<p>True</p> Signup and view all the answers

See and see also do not mean the same thing.

<p>True</p> Signup and view all the answers

Abnormal findings are always coded and reported when they are found.

<p>False</p> Signup and view all the answers

In ICD-10-CM, external cause of injury codes are found in the main alphabetic index.

<p>False</p> Signup and view all the answers

You can always find adequate and complete documentation in the discharge summary, so you can code right from there.

<p>False</p> Signup and view all the answers

ICD-10-CM is both a diagnosis and procedural coding system.

<p>False</p> Signup and view all the answers

What are the two major divisions within ICD-10-CM?

<p>Tabular list of diseases and alphabetic index of diseases</p> Signup and view all the answers

What does UHDDS stand for?

<p>Uniform Hospital Discharge Data Set</p> Signup and view all the answers

What is the definition of principal diagnosis?

<p>The condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care</p> Signup and view all the answers

Terms for anatomical sites are good to use as main terms in searching for codes in the alphabetic index.

<p>False</p> Signup and view all the answers

Is it ever permissible to code directly from the index?

<p>False</p> Signup and view all the answers

Who are the cooperating parties and what is their role?

<p>AHIMA, AHA, NCHS, CMS; They manage/approve the ICD-10-CM official coding guidelines for coding and reporting</p> Signup and view all the answers

What are physician orders?

<p>Instructions given to hospital staff from the physician to care for the patient</p> Signup and view all the answers

An inclusion note under a code indicates that the terms excluded from the code are to be coded elsewhere.

<p>False</p> Signup and view all the answers

Adherence to the ICD-10-CM/PCS guidelines are a requirement for compliance to HIPAA.

<p>True</p> Signup and view all the answers

CCA stands for?

<p>Certified Coding Associate</p> Signup and view all the answers

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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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.

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