Podcast
Questions and Answers
What do Z Codes primarily indicate?
What do Z Codes primarily indicate?
Z Codes are only used for diagnoses related to physical health.
Z Codes are only used for diagnoses related to physical health.
False
What is the purpose of Chapter 22 in the coding guidelines?
What is the purpose of Chapter 22 in the coding guidelines?
Codes for special purposes
Codes for symptoms, signs, and ill-defined conditions can be found in Section __________.
Codes for symptoms, signs, and ill-defined conditions can be found in Section __________.
Signup and view all the answers
Which of the following categories is NOT listed under the selection of principal diagnosis?
Which of the following categories is NOT listed under the selection of principal diagnosis?
Signup and view all the answers
Match each section with its focus regarding principal diagnosis selection:
Match each section with its focus regarding principal diagnosis selection:
Signup and view all the answers
An original treatment plan not carried out is an important consideration in diagnosis coding.
An original treatment plan not carried out is an important consideration in diagnosis coding.
Signup and view all the answers
Which of the following statements about sequela codes is true?
Which of the following statements about sequela codes is true?
Signup and view all the answers
A diagnosis code for an impending condition should always be reported as a confirmed diagnosis.
A diagnosis code for an impending condition should always be reported as a confirmed diagnosis.
Signup and view all the answers
What should be done if a bilateral condition does not have a distinct code for laterality?
What should be done if a bilateral condition does not have a distinct code for laterality?
Signup and view all the answers
If no bilateral code is provided and the condition is bilateral, assign separate codes for both the ______.
If no bilateral code is provided and the condition is bilateral, assign separate codes for both the ______.
Signup and view all the answers
Match the following concepts with their correct actions in ICD-10-CM coding:
Match the following concepts with their correct actions in ICD-10-CM coding:
Signup and view all the answers
Which option describes patients receiving therapeutic services only?
Which option describes patients receiving therapeutic services only?
Signup and view all the answers
Patients receiving diagnostic services only may also be receiving therapeutic services.
Patients receiving diagnostic services only may also be receiving therapeutic services.
Signup and view all the answers
What should be coded in the case of uncertain diagnosis?
What should be coded in the case of uncertain diagnosis?
Signup and view all the answers
During routine outpatient prenatal visits, it is important to code all documented __________ that coexist.
During routine outpatient prenatal visits, it is important to code all documented __________ that coexist.
Signup and view all the answers
Match the type of encounter with its description:
Match the type of encounter with its description:
Signup and view all the answers
What is the highest level of specificity in coding?
What is the highest level of specificity in coding?
Signup and view all the answers
What is the primary purpose of the first-listed condition in outpatient services coding?
What is the primary purpose of the first-listed condition in outpatient services coding?
Signup and view all the answers
Chronic diseases must be coded even if not the primary focus of the visit.
Chronic diseases must be coded even if not the primary focus of the visit.
Signup and view all the answers
ICD-10-CM codes can include up to 7 characters.
ICD-10-CM codes can include up to 7 characters.
Signup and view all the answers
Identify one reason for encounters that would typically require coding.
Identify one reason for encounters that would typically require coding.
Signup and view all the answers
What are codes that describe symptoms and signs classified as?
What are codes that describe symptoms and signs classified as?
Signup and view all the answers
The section related to uncertain diagnosis is identified as Section ___ in the coding guidelines.
The section related to uncertain diagnosis is identified as Section ___ in the coding guidelines.
Signup and view all the answers
Encounters for __________ with abnormal findings require additional coding for any noted conditions.
Encounters for __________ with abnormal findings require additional coding for any noted conditions.
Signup and view all the answers
Match the following coding concepts with their descriptions:
Match the following coding concepts with their descriptions:
Signup and view all the answers
What are patients receiving diagnostic services mainly focused on?
What are patients receiving diagnostic services mainly focused on?
Signup and view all the answers
Which of the following statements is true regarding coding for outpatient surgery?
Which of the following statements is true regarding coding for outpatient surgery?
Signup and view all the answers
Encounters for circumstances other than a disease or injury are represented in the coding guidelines.
Encounters for circumstances other than a disease or injury are represented in the coding guidelines.
Signup and view all the answers
What guideline should be followed for the level of detail in coding?
What guideline should be followed for the level of detail in coding?
Signup and view all the answers
Previous conditions are categorized under Section ___ of the coding guidelines.
Previous conditions are categorized under Section ___ of the coding guidelines.
Signup and view all the answers
What does a dash (-) at the end of an Alphabetic Index entry indicate?
What does a dash (-) at the end of an Alphabetic Index entry indicate?
Signup and view all the answers
Diagnosis codes should always be reported using the least specific code available.
Diagnosis codes should always be reported using the least specific code available.
Signup and view all the answers
What are the character lengths that ICD-10-CM diagnosis codes can have?
What are the character lengths that ICD-10-CM diagnosis codes can have?
Signup and view all the answers
Codes from ____ through T88.9 must be used to identify diagnoses.
Codes from ____ through T88.9 must be used to identify diagnoses.
Signup and view all the answers
Match the coding categories with their descriptions:
Match the coding categories with their descriptions:
Signup and view all the answers
Why is it necessary to refer to the Tabular List when using the Alphabetic Index?
Why is it necessary to refer to the Tabular List when using the Alphabetic Index?
Signup and view all the answers
Codes describing symptoms and signs cannot be used if a definitive diagnosis is absent.
Codes describing symptoms and signs cannot be used if a definitive diagnosis is absent.
Signup and view all the answers
What is the consequence of using a three-character code when further subdivision is required?
What is the consequence of using a three-character code when further subdivision is required?
Signup and view all the answers
ICD-10-CM codes must be reported at their highest number of characters available and to the highest level of ____ documented in the medical record.
ICD-10-CM codes must be reported at their highest number of characters available and to the highest level of ____ documented in the medical record.
Signup and view all the answers
Which of the following sections is dedicated to codes for symptoms, signs, and abnormal findings?
Which of the following sections is dedicated to codes for symptoms, signs, and abnormal findings?
Signup and view all the answers
Study Notes
ICD-10-CM Official Guidelines for Coding and Reporting
- FY 2025 - Updated October 1, 2024 (October 1, 2024 - September 30, 2025)
- Narrative changes are in bold text
- Italics are used to indicate heading revisions
- Underlined items have been moved within the guidelines since the April 2024, FY 2024 version
- CMS (Centers for Medicare & Medicaid Services) and NCHS (National Center for Health Statistics), within the U.S. Federal Government's Department of Health and Human Services (DHHS), provide guidelines for ICD-10-CM coding and reporting.
- The ICD-10-CM is a morbidity classification used by the United States for classifying diagnoses and reasons for visits in health care settings.
- The ICD-10-CM is based on the ICD-10, the statistical classification of diseases published by the World Health Organization (WHO).
- Guidelines are approved by the Cooperating Parties: AHA (American Hospital Association), AHIMA (American Health Information Management Association), CMS, and NCHS.
- Guidelines complement the ICD-10-CM, with the conventions and instructions of the classification taking precedence.
- HIPAA (Health Insurance Portability and Accountability Act) requires adherence to assigned ICD-10-CM diagnosis codes in all healthcare settings.
- Accurate coding requires complete documentation of the medical record in detailing the reason for the encounter and the treated conditions.
- The term "provider" in the guidelines refers to physicians or other qualified healthcare practitioners legally accountable for patient diagnoses.
- Guidelines are organized into sections: Section I (conventions, general coding guidelines and chapter-specific guidelines), Section II (selection of principal diagnosis for non-outpatient settings), Section III (reporting additional diagnoses in non-outpatient settings), Section IV (outpatient coding and reporting), for a full comprehension.
Conventions, general coding guidelines and chapter-specific guidelines
-
Conventions applicable to all health care settings
-
Guidelines should follow conventions and instructions in the ICD-10-CM Tabular List and Alphabetic Index, including notes.
-
Codes for categories, subcategories, and codes in the Tabular List may be letters or numbers only.
-
Categories are 3 characters; subcategories are either 4 or 5 characters, and codes are 3, 4, 5, 6 or 7 characters.
-
The ICD-10-CM uses an indented format for easy referencing.
-
For reporting purposes only codes—not categories or subcategories—are permissible and any applicable 7th character is required.
-
Placeholders are used for codes that require future expansion (e.g., "X").
-
Punctuation symbols (e.g., brackets, parentheses) are used for abbreviations, synonyms, or explanatory phrases in the Alphabetic Index and Tabular List.
-
Other and Unspecified codes ("Other" codes use when detail is available but specific not and "Unspecified" codes use when insufficient detail to give specific code) are used when information is not detailed for specific code.
-
Includes notes and the list of terms under certain codes to provide further detail, may include synonyms or additional codes for that code.
-
Excludes notes are of two types that indicate independence and exclusivity (e.g., “Excludes 1” and “Excludes 2” notes).
Etiology/manifestation convention ("code first")
- When conditions have underlying etiology and multiple manifestations due to the etiology, code first the etiology followed by the manifestation.
- Codes for manifestations often include the phrase "in diseases classified elsewhere".
- Codes for manifestations are used in conjunction with the underlying condition.
"And" and "With"
- "And" can mean "and" or "or" in the title and "with" or "in" mean associated with or due to.
- For conditions that are related, these terms indicate a causal relationship; documentation of a linkage is not essential.
Additional topics
- Code assignment based on provider documentation, not clinical criteria
- Locating a code in the ICD-10 CM (use Alphabetic Index and Tabular List)
- Diagnoses are sequenced in the maximum detail possible
- Reporting signs and symptoms (when diagnosis is not established from provider)
- Coding for multiple conditions and their relationship
- Combination codes
- Sequela (Late Effects)
Reporting Same Diagnosis Code More Than Once
- A code for a single condition must be reported only once per encounter/visit.
- This applies to bilateral conditions that lack specific codes distinguishing laterality.
Laterality
- When laterality is documented (left, right, bilateral), use the appropriate code.
- Use unspecified side code only when sufficient information is absent or contradictory.
- Multiple encounters require individual codes for each side.
Code assignment based on clinicians other than the patient's provider
- Code assignment is based on provider documentation (physician or qualified healthcare practitioner).
- Exceptions may occur based on documentation from other clinicians (e.g., dietitian, nurse).
- Provider queries may be necessary.
Other topics
- Impending/threatened conditions
- Coding for healthcare encounters in Hurricane Aftermaths
- External cause of morbidity codes
- Sequencing of external causes of morbidity codes.
- Other issues related to external cause of morbidity codes.
- Chapter-specific coding guidelines.
Studying That Suits You
Use AI to generate personalized quizzes and flashcards to suit your learning preferences.
Related Documents
Description
Test your knowledge on the ICD-10-CM coding guidelines with this quiz. Explore crucial topics such as Z Codes, the principal diagnosis selection process, and the significance of sequela codes. This quiz will reinforce your understanding of coding standards and practices.