ICD-10-CM Coding Conventions Quiz

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Questions and Answers

What is the purpose of the Alphabetic Index in the ICD-10-CM?

To list all the conventions and general rules for using the ICD-10-CM

To provide a structured list of codes divided into chapters based on body system or condition

To provide guidelines for coding specific conditions

To list terms and their corresponding codes in alphabetical order (correct)

Which of the following is true about the format and structure of the ICD-10-CM Tabular List?

A three-character category that has no further subdivision is not equivalent to a code

Codes are always represented by numbers

All categories are 5 characters long

Subcategories can be either 4 or 5 characters long (correct)

What takes precedence over the guidelines in the ICD-10-CM?

The conventions and instructions of the classification (correct)

The Alphabetic Index

The general coding guidelines

The chapter-specific guidelines

Which of the following is NOT a part of the Alphabetic Index in the ICD-10-CM?

Table of Coding Guidelines Signup and view all the answers

What is the purpose of the Tabular List in the ICD-10-CM?

To provide a structured list of codes divided into chapters based on body system or condition Signup and view all the answers

Which of the following statements is true about the characters used in the ICD-10-CM?

Characters for categories, subcategories, and codes can be either letters or numbers Signup and view all the answers

What is the purpose of the "code first" and "use additional code" notes in the ICD-10-CM coding guidelines?

To provide sequencing rules for coding conditions that involve an underlying etiology and a manifestation. Signup and view all the answers

How should the word "and" be interpreted when it appears in a title in the ICD-10-CM coding guidelines?

It should be interpreted to mean either "and" or "or" depending on the context. Signup and view all the answers

What does the word "with" or "in" generally imply when it appears in a code title, the Alphabetic Index, or an instructional note in the Tabular List?

It implies an association or causal relationship between the two conditions. Signup and view all the answers

What is the purpose of a "see" instruction following a main term in the ICD-10-CM Alphabetic Index?

It indicates that another term should be referenced to locate the correct code. Signup and view all the answers

What does a "code also" note in the ICD-10-CM coding guidelines signify?

It instructs the coder to use two codes to fully describe a condition, but without providing sequencing direction. Signup and view all the answers

What is a default code in the ICD-10-CM Alphabetic Index?

It is the code that represents the condition that is most commonly associated with the main term or is the unspecified code for the condition. Signup and view all the answers

What should be the default code assigned if a condition is documented in a medical record without specifying whether it is acute or chronic?

Assign a code based on the provider's diagnostic statement Signup and view all the answers

Where should one locate a code in the ICD-10-CM when corresponding to a diagnosis documented in a medical record?

First in the Alphabetic Index, then verify in the Tabular List Signup and view all the answers

How many characters can an ICD-10-CM diagnosis code consist of?

3, 4, 5, 6, or 7 characters Signup and view all the answers

Which type of Excludes note indicates that two conditions should never be coded together?

Excludes1 Signup and view all the answers

If a patient has both psychogenic dysmenorrhea and sleep-related teeth grinding, which codes should be assigned?

Both F45.8 and G47.63 Signup and view all the answers

When should a three-character code be used from ICD-10-CM?

When it is not further subdivided Signup and view all the answers

Which range of codes must be utilized to identify diagnoses, symptoms, conditions, and problems for an encounter or visit?

A00.0-T88.9, Z00-Z99.8, U00-U85 only Signup and view all the answers

What is the purpose of the 'Inclusion terms' listed under some codes?

To list conditions that should be assigned to that code, but the list may not be exhaustive Signup and view all the answers

What is the purpose of the 'Etiology/manifestation convention' in ICD-10-CM?

To require coding the underlying etiology first, followed by the manifestation, when applicable Signup and view all the answers

When should additional signs and symptoms that are not routinely associated with a disease process be coded?

When they are present Signup and view all the answers

When an Excludes2 note appears under a code, what does it indicate?

The excluded condition is not part of the condition represented by the code, but the two can be coded together when appropriate Signup and view all the answers

What is the purpose of the 'Notes' that appear immediately under a three-character code title?

To provide additional clarification or examples of the content of that category Signup and view all the answers

How should a sequela be coded when it is followed by a manifestation code?

As a single combination code Signup and view all the answers

What does a 'code first' note indicate in ICD-10-CM coding guidelines?

The underlying condition present should be sequenced before other codes if known Signup and view all the answers

When should a combination code be assigned in ICD-10-CM coding?

When a single code fully represents all elements of a diagnosis Signup and view all the answers

In cases of both acute and chronic conditions with separate subentries at the same level, how should they be coded?

Code both conditions and sequence the acute code first Signup and view all the answers

When is there no time limit for using a sequela code in ICD-10-CM coding?

Whenever a residual effect remains after an illness or injury has ended Signup and view all the answers

What does assigning multiple codes for sequela usually involve?

Having the sequela code sequenced first followed by the nature of the sequela Signup and view all the answers

What is the role of a placeholder character 'X' in the ICD-10-CM coding system?

To allow for future expansion at certain codes Signup and view all the answers

When can a code be considered invalid in the ICD-10-CM coding system?

When it lacks a 7th character where required Signup and view all the answers

What does the abbreviation 'NEC' stand for in the ICD-10-CM coding system?

Not elsewhere classifiable Signup and view all the answers

In the ICD-10-CM, what do brackets [ ] indicate in the Tabular List?

Enclose synonyms or alternative wording Signup and view all the answers

When can 'other' codes be used in the ICD-10-CM coding system?

When there is insufficient information in the medical record Signup and view all the answers

What is the purpose of using colons in the Tabular List of the ICD-10-CM?

To indicate that more modifiers are needed Signup and view all the answers

What should be done if there is conflicting medical record documentation regarding the affected side?

Query the patient's provider for clarification. Signup and view all the answers

When coding syndromes, what should be done in the absence of Alphabetic Index guidance?

Assign codes for only documented manifestations. Signup and view all the answers

What is the rule for reporting the same ICD-10-CM diagnosis code more than once for an encounter?

Each unique diagnosis code may be reported only once. Signup and view all the answers

What should be done if there is no bilateral code provided for a condition that is bilateral?

Assign codes for both sides separately. Signup and view all the answers

When laterality is not documented, what should be done?

Assign codes for 'unspecified' side. Signup and view all the answers

What should be done if there are contradicting medical records about a patient's condition?

Query the patient's provider for clarification. Signup and view all the answers

How should one handle underimmunization status codes when coding diagnoses?

'Underimmunization status' codes are reported as secondary diagnoses. Signup and view all the answers

How should one handle BMI codes when documenting patient encounters?

BMI codes should be reported as secondary diagnoses. Signup and view all the answers

What should be done with coma scale scores when coding?

Coma scale scores should only be reported as secondary diagnoses. Signup and view all the answers

Study Notes

ICD-10-CM Purpose and Structure

The Alphabetic Index is used to locate codes in the ICD-10-CM Tabular List
The Tabular List provides the official codes and their descriptions
Clinical concepts take precedence over guidelines in the ICD-10-CM

Format and Structure

The ICD-10-CM Tabular List is structured with a combination of letters and numbers
There are 21 characters in an ICD-10-CM diagnosis code ( Range: A00-Z99, 000-999)
Codes can be 3, 4, 5, 6, or 7 characters long
The 'X' character is used as a placeholder

Guidelines and Notes

"Code also" notes signify that additional codes should be assigned
"Code first" notes indicate that a primary diagnosis should be coded before secondary diagnoses
"Use additional code" notes indicate that another code should be used in addition to the main code
"See" instructions direct the coder to another term in the Alphabetic Index
"Excludes" notes indicate that two conditions should never be coded together
"Inclusion terms" provide additional information about the code
"Etiology/manifestation convention" separates causes and effects of a condition
"Notes" under three-character code titles provide additional information

Coding Practices

Default codes are used when the level of specificity is not documented
Codes should be assigned based on the diagnosis documented in the medical record
Multiple codes can be assigned for sequela
Combination codes should be used when two or more conditions are present
Bilateral conditions require separate codes
Laterality should be specified when documented
Syndromes should be coded according to the Alphabetic Index guidance
The same ICD-10-CM diagnosis code can be reported only once for an encounter
"Other" codes can be used when a specific code is not available
BMI codes and underimmunization status codes should be handled according to specific guidelines
Coma scale scores should be documented but not coded

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Test your knowledge on the conventions, general coding guidelines, and chapter-specific guidelines for the ICD-10-CM coding system. Understand the importance of following these rules when assigning diagnostic codes in healthcare settings.

ICD-10-CM Coding Conventions Quiz

Podcast Beta

Questions and Answers

What is the purpose of the Alphabetic Index in the ICD-10-CM?

Which of the following is true about the format and structure of the ICD-10-CM Tabular List?

What takes precedence over the guidelines in the ICD-10-CM?

Which of the following is NOT a part of the Alphabetic Index in the ICD-10-CM?

What is the purpose of the Tabular List in the ICD-10-CM?

Which of the following statements is true about the characters used in the ICD-10-CM?

What is the purpose of the "code first" and "use additional code" notes in the ICD-10-CM coding guidelines?

How should the word "and" be interpreted when it appears in a title in the ICD-10-CM coding guidelines?

What does the word "with" or "in" generally imply when it appears in a code title, the Alphabetic Index, or an instructional note in the Tabular List?

What is the purpose of a "see" instruction following a main term in the ICD-10-CM Alphabetic Index?

What does a "code also" note in the ICD-10-CM coding guidelines signify?

What is a default code in the ICD-10-CM Alphabetic Index?

What should be the default code assigned if a condition is documented in a medical record without specifying whether it is acute or chronic?

Where should one locate a code in the ICD-10-CM when corresponding to a diagnosis documented in a medical record?

How many characters can an ICD-10-CM diagnosis code consist of?

Which type of Excludes note indicates that two conditions should never be coded together?

If a patient has both psychogenic dysmenorrhea and sleep-related teeth grinding, which codes should be assigned?

When should a three-character code be used from ICD-10-CM?

Which range of codes must be utilized to identify diagnoses, symptoms, conditions, and problems for an encounter or visit?

What is the purpose of the 'Inclusion terms' listed under some codes?

What is the purpose of the 'Etiology/manifestation convention' in ICD-10-CM?

When should additional signs and symptoms that are not routinely associated with a disease process be coded?

When an Excludes2 note appears under a code, what does it indicate?

What is the purpose of the 'Notes' that appear immediately under a three-character code title?

How should a sequela be coded when it is followed by a manifestation code?

What does a 'code first' note indicate in ICD-10-CM coding guidelines?

When should a combination code be assigned in ICD-10-CM coding?

In cases of both acute and chronic conditions with separate subentries at the same level, how should they be coded?

When is there no time limit for using a sequela code in ICD-10-CM coding?

What does assigning multiple codes for sequela usually involve?

What is the role of a placeholder character 'X' in the ICD-10-CM coding system?

When can a code be considered invalid in the ICD-10-CM coding system?

What does the abbreviation 'NEC' stand for in the ICD-10-CM coding system?

In the ICD-10-CM, what do brackets [ ] indicate in the Tabular List?

When can 'other' codes be used in the ICD-10-CM coding system?

What is the purpose of using colons in the Tabular List of the ICD-10-CM?

What should be done if there is conflicting medical record documentation regarding the affected side?

When coding syndromes, what should be done in the absence of Alphabetic Index guidance?

What is the rule for reporting the same ICD-10-CM diagnosis code more than once for an encounter?

What should be done if there is no bilateral code provided for a condition that is bilateral?

When laterality is not documented, what should be done?

What should be done if there are contradicting medical records about a patient's condition?

How should one handle underimmunization status codes when coding diagnoses?

How should one handle BMI codes when documenting patient encounters?

What should be done with coma scale scores when coding?

Study Notes

ICD-10-CM Purpose and Structure

Format and Structure

Guidelines and Notes

Coding Practices

Studying That Suits You

Description

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