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What are the conventions for the ICD-10-CM?
What are the two main components of the ICD-10-CM?
What is the format and structure of the Tabular List in the ICD-10-CM?
What is the purpose of the Alphabetic Index in the ICD-10-CM?
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What is the significance of a 7th character in an ICD-10-CM code?
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What is the purpose of the codes in the ICD-10-CM?
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What does the term 'Excludes Notes' refer to in the ICD-10-CM?
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What is the purpose of an Excludes1 note?
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When is it appropriate to use both a code and a condition listed under its Excludes2 note?
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How should the word 'and' be interpreted when it appears in a code title?
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What is the meaning of the word 'with' or 'in' when it appears in a code title or instructional note?
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When is provider documentation required to link two conditions in the ICD-10-CM?
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What is the purpose of the 'Inclusion Terms' in the ICD-10-CM?
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Where can additional terms be found that may be assigned to a particular code in the ICD-10-CM?
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How is the word 'with' sequenced in the Alphabetic Index of the ICD-10-CM?
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What is the purpose of the 'Excludes Notes' in the ICD-10-CM?
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What is the purpose of the placeholder character 'X' in the ICD-10-CM coding system?
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What is the purpose of the 7th character in the ICD-10-CM coding system?
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What does the abbreviation 'NEC' mean in the ICD-10-CM Alphabetic Index?
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What does the abbreviation 'NOS' mean in the ICD-10-CM Alphabetic Index?
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What is the purpose of the brackets [] in the ICD-10-CM Tabular List?
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What is the purpose of the parentheses () in the ICD-10-CM Tabular List and Alphabetic Index?
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What is the purpose of the colon : in the ICD-10-CM Tabular List?
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What do "other" codes in the ICD-10-CM Tabular List represent?
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What do "unspecified" codes in the ICD-10-CM Tabular List represent?
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What is the purpose of the Alphabetic Index in the ICD-10-CM?
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What is the structure of the ICD-10-CM Tabular List?
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How are codes represented in the ICD-10-CM?
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What is the significance of a 7th character in an ICD-10-CM code?
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What is the purpose of the Inclusion Terms in the ICD-10-CM?
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What do the 'Excludes Notes' refer to in the ICD-10-CM?
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What is the purpose of the placeholder character 'X' in the ICD-10-CM coding system?
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When is a 7th character required for an ICD-10-CM code?
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What does the abbreviation 'NEC' mean in the ICD-10-CM Alphabetic Index?
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What does the abbreviation 'NOS' mean in the ICD-10-CM Tabular List?
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What is the purpose of the brackets [] in the ICD-10-CM Tabular List?
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What do 'other' codes in the ICD-10-CM Tabular List represent?
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What is the purpose of the colon (:) in the ICD-10-CM Tabular List?
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What do 'unspecified' codes in the ICD-10-CM Tabular List represent?
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What is the purpose of the parentheses () in the ICD-10-CM Tabular List and Alphabetic Index?
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What is the purpose of the 'Inclusion Terms' in the ICD-10-CM?
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How should you code a condition described as 'impending' or 'threatened' at the time of discharge?
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When a patient has a bilateral condition and each side is treated during separate encounters, how should the laterality be coded?
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When can code assignment be based on documentation by clinicians other than the patient's provider?
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What is the rule for reporting the same ICD-10-CM diagnosis code more than once for an encounter?
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If a patient has a bilateral condition and the treatment on the first side did not completely resolve the condition, how should the laterality be coded?
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What should be done if there is conflicting medical record documentation regarding the affected side of a condition?
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When should 'unspecified' side codes be used in ICD-10-CM?
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What is the purpose of the 'Excludes Notes' in the ICD-10-CM?
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What is the purpose of the Alphabetic Index in the ICD-10-CM?
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What is the purpose of the 7th character in the ICD-10-CM coding system?
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What must be documented by the patient's provider for the associated diagnosis?
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What should the provider do if there is conflicting medical record documentation?
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How should syndromes be coded according to the text?
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What is the purpose of a 'use additional code' note in the ICD-10-CM?
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When should an underlying condition be sequenced first according to the ICD-10-CM guidelines?
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What does a 'code, if applicable, any causal condition first' note indicate in the ICD-10-CM?
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In the ICD-10-CM, what is required to fully describe a sequela?
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What is the significance of a 'code first' note under certain codes in the ICD-10-CM?
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What does a 'combination code' represent in the ICD-10-CM?
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When is it appropriate to assign only a combination code in the ICD-10-CM?
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What is the purpose of 'code, if applicable, any causal condition first' notes in diagnostic coding?
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How should you sequence an acute (subacute) and chronic condition in ICD-10-CM?
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What is the purpose of an Excludes1 note in the ICD-10-CM?
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What does the word 'with' or 'in' imply when it appears in a code title or instructional note in the ICD-10-CM?
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When is it appropriate to use both a code and a condition listed under its Excludes2 note?
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How should the word 'and' be interpreted when it appears in a code title in the ICD-10-CM?
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What is the purpose of the 'Inclusion Terms' in the ICD-10-CM?
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When is provider documentation required to link two conditions in the ICD-10-CM?
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What is the purpose of an Excludes2 note in the ICD-10-CM?
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Where can additional terms be found that may be assigned to a particular code in the ICD-10-CM?
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What is the meaning of the word 'see' in the Alphabetic Index of the ICD-10-CM?
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What does the 'see also' instruction in the Alphabetic Index of the ICD-10-CM indicate?
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What should be done if there is conflicting medical record documentation?
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When should additional codes be assigned for manifestations that are not an integral part of the disease process?
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What must be documented by the patient's provider for the associated diagnosis?
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When is a cause-and-effect relationship between care provided and a condition necessary to report a complication?
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How should complications of care be coded?
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What does it mean when it is stated that 'not all conditions following medical care or surgery are classified as complications'?
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What is the purpose of a 'code also' note in the ICD-10-CM?
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What is a 'default code' in the ICD-10-CM?
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How is the code assignment based on in the ICD-10-CM?
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What is the purpose of using both the Alphabetic Index and Tabular List when locating and assigning an ICD-10-CM code?
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What is the level of detail required when coding in the ICD-10-CM?
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How should signs and symptoms be coded in the ICD-10-CM?
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How should conditions that are an integral part of a disease process be coded in the ICD-10-CM?
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How should conditions that are not an integral part of a disease process be coded in the ICD-10-CM?
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How should multiple codes be used to describe a single condition in the ICD-10-CM?
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What are the conventions for the ICD-10-CM?
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What is the purpose of the Alphabetic Index in the ICD-10-CM?
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How are categories, subcategories, and codes represented in the ICD-10-CM Tabular List?
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What is the structure of the codes in the ICD-10-CM?
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Why are codes with applicable 7th characters still referred to as codes in the ICD-10-CM?
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What is the purpose of using codes in the ICD-10-CM for reporting purposes?
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Which code should be assigned when an injury is incurred as a result of flooding caused by a levee breaking related to the hurricane?
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Which code should be assigned when an injury is from flooding resulting directly from the storm?
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When should code X36.0.-, Collapse of dam or manmade structure, be assigned?
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When should code X37.0-, Hurricane, be assigned?
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How should injuries that are not a direct result of the hurricane be coded?
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When should code X37.0-, Hurricane, be assigned if it is not clear whether the injury was a direct result of the hurricane?
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What is the purpose of the Z codes mentioned in the text?
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When should confirmed cases of HIV infection/illness be coded?
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What is the purpose of the 'Excludes Notes' in the ICD-10-CM?
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What is the purpose of the Alphabetic Index in the ICD-10-CM?
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What is the placeholder character used in ICD-10-CM for future expansion?
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What does the 7th character signify in ICD-10-CM codes?
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In the Alphabetic Index, what does the abbreviation 'NEC' stand for?
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What does 'NOS' stand for in the Tabular List of ICD-10-CM?
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What is the function of brackets in the Tabular List and Alphabetic Index of ICD-10-CM?
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How are parentheses used in both the Alphabetic Index and Tabular List of ICD-10-CM?
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What does the colon punctuation after an incomplete term signify in the Tabular List of ICD-10-CM?
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'Other' codes in ICD-10-CM are used for what purpose?
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'Unspecified' codes are utilized in ICD-10-CM for what reason?
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What is the purpose of 'Includes note' in ICD-10-CM?
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What does an Excludes1 note indicate in the ICD-10-CM?
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When should a query be sent to the provider regarding an Excludes1 note?
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What does an Excludes2 note indicate in the ICD-10-CM?
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How should an Excludes2 note be interpreted when it appears under a code?
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When is it acceptable to use both a code and an excluded code listed under an Excludes2 note?
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What is the difference between an Excludes1 note and an Excludes2 note in the ICD-10-CM?
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Under what circumstances should a provider query a patient regarding Excludes1 notes?
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When is it appropriate to report codes for sign(s) and/or symptom(s) in lieu of a definitive diagnosis?
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What is the appropriate way to code healthcare encounters for hurricane victims when no injury, adverse effect or poisoning is involved?
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When should 'unspecified' codes be reported according to the guidelines?
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What is the appropriate sequencing of external cause of morbidity codes in the aftermath of a hurricane?
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How many external cause of morbidity codes should be assigned for each healthcare encounter related to the hurricane aftermath?
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What is the purpose of assigning external cause of morbidity codes in the aftermath of a hurricane?
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When should external cause of morbidity codes be assigned for healthcare encounters related to the hurricane aftermath?
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What is the appropriate way to sequence the external cause of morbidity codes and the injury codes for healthcare encounters related to the hurricane aftermath?
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What is the appropriate way to code a definitive diagnosis that has not been established by the end of the healthcare encounter?
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How should HIV cases be sequenced when a patient is admitted for an HIV-related condition?
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How should HIV cases be sequenced when a patient with HIV disease is admitted for an unrelated condition?
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How should asymptomatic HIV infections be coded?
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How many characters are codes in the ICD-10-CM typically?
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What is the final level of subdivision in the ICD-10-CM Tabular List?
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What is the purpose of the 'Alphabetic Index' in the ICD-10-CM?
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In the ICD-10-CM, what does a three-character category without further subdivision represent?
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What does the term 'invalid' refer to in the ICD-10-CM coding system?
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What are the types of characters used for categories, subcategories, and codes in the ICD-10-CM?
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What is the purpose of the placeholder character 'X' in the ICD-10-CM coding system?
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What does the abbreviation 'NEC' mean in the ICD-10-CM Tabular List?
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What is the purpose of the 7th character in the ICD-10-CM coding system?
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What does the abbreviation 'NOS' mean in the ICD-10-CM Alphabetic Index?
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What is the purpose of the brackets '[]' in the ICD-10-CM Tabular List?
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What is the purpose of the parentheses '()' in the ICD-10-CM Tabular List and Alphabetic Index?
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What is the meaning of the term 'other' codes in the ICD-10-CM?
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What is the meaning of the term 'unspecified' codes in the ICD-10-CM?
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What is the purpose of the 'Inclusion Terms' in the ICD-10-CM?
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What is the purpose of the colon ':' in the ICD-10-CM Tabular List?
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When should a code from subcategory R65.2 be assigned for severe sepsis?
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How should sepsis/severe sepsis with a localized infection be coded if the reason for admission is the sepsis/severe sepsis?
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If a patient is admitted with a localized infection and sepsis/severe sepsis develops after admission, how should it be coded?
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If the documentation is unclear whether severe sepsis was present on admission, what should be done?
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When should a code from subcategory R65.2 be assigned for severe sepsis in addition to the codes for the underlying systemic infection?
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How should a localized infection be coded if sepsis/severe sepsis is also present?
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What is the purpose of Excludes1 notes in the ICD-10-CM?
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How should the word 'and' be interpreted in a code title or the Alphabetic Index?
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When is an additional code from Chapter 1 required to identify the organism for certain infections classified in other chapters?
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What does an Excludes2 note indicate in the ICD-10-CM?
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How should the word 'with' or 'in' be interpreted when it appears in a code title or the Alphabetic Index?
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When is provider documentation required to link two conditions in the ICD-10-CM?
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What is the purpose of the Inclusion Terms in the ICD-10-CM?
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How is the word 'with' sequenced in the Alphabetic Index of the ICD-10-CM?
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When should a query be sent to the provider regarding an Excludes1 note?
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What do the 'Excludes Notes' in the ICD-10-CM refer to?
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How should antibiotic resistant infections be coded?
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How should sepsis with unspecified organism be coded?
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How should negative or inconclusive blood cultures be coded in the presence of clinical evidence of sepsis?
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How should the term 'urosepsis' be coded?
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How should sepsis with associated acute organ dysfunction or multiple organ dysfunction (MOD) be coded?
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How should acute organ dysfunction not clearly associated with sepsis be coded?
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What is the minimum number of codes required to code severe sepsis?
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How should septic shock be coded?
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Study Notes
Conventions for ICD-10-CM
- Conventions are general rules for using the ICD-10-CM classification
- Incorporated into the Alphabetic Index and Tabular List as instructional notes
Alphabetic Index and Tabular List
- ICD-10-CM divided into:
- Alphabetic Index: an alphabetical list of terms with corresponding codes
- Tabular List: structured list of codes divided into chapters by body system or condition
- Alphabetic Index consists of:
- Index of Diseases and Injury
- Index of External Causes of Injury
- Table of Neoplasms
- Table of Drugs and Chemicals
Format and Structure of the Tabular List
- Contains categories, subcategories, and codes
- Characters for categories, subcategories, and codes can be letters or numbers
- Categories are 3 characters; subcategories are 4 or 5 characters; codes can be 3, 4, 5, 6, or 7 characters
- Final level of subdivision is a code; codes with applicable 7th characters are still referred to as codes
Use of Codes for Reporting Purposes
- Codes represent conditions for which that code is to be used
- Inclusion terms are not exhaustive; additional terms may be found only in the Alphabetic Index
- A code that requires a 7th character is invalid without it
Excludes Notes
- Two types of Excludes notes: Excludes1 and Excludes2
- Excludes1 note means "NOT CODED HERE!"
- Excludes2 note means "Not included here"
- Excludes notes indicate codes excluded from each other are independent of each other
Placeholder Character
- "X" is used as a placeholder in certain codes to allow for future expansion
7th Characters
- Certain ICD-10-CM categories have applicable 7th characters
- 7th character is required for codes within a category
- 7th character must always be the 7th character in the data field
Abbreviations in the Alphabetic Index and Tabular List
- NEC: "Not elsewhere classifiable", represents "other specified"
- NOS: "Not otherwise specified", equivalent to unspecified
Punctuation
- Brackets: used to enclose synonyms, alternative wording, or explanatory phrases in the Tabular List
- Brackets: used to identify manifestation codes in the Alphabetic Index
- Parentheses: used to enclose supplementary words in the Alphabetic Index and Tabular List
- Colons: used after incomplete terms in the Tabular List to indicate the need for modifiers
Other Codes
- "Other" codes: for use when no specific code exists
- "Unspecified" codes: for use when information is insufficient to assign a more specific code### Etiology/Manifestation Convention
- Requires two codes to fully describe a single condition that affects multiple body systems
- "Use additional code" notes indicate that a secondary code is useful to fully describe a condition
Use Additional Code Notes
- Found in the Tabular List at codes that are not part of an etiology/manifestation pair
- Indicate that a secondary code should be added, if known
- Example: bacterial infections require a secondary code from category B95 or B96 to identify the bacterial organism causing the infection
Code First Notes
- Found under certain codes that are not specifically manifestation codes but may be due to an underlying cause
- When an underlying condition is present, it should be sequenced first, if known
Sequencing Multiple Codes
- Multiple codes may be needed for sequela, complication codes, and obstetric codes to fully describe a condition
- See specific guidelines for each condition for further instruction on how to code
Combination Codes
- A single code used to classify two diagnoses, or a diagnosis with an associated secondary process (manifestation) or complication
- Identified by referring to subterm entries in the Alphabetic Index and reading the inclusion and exclusion notes in the Tabular List
- Assign only the combination code when it fully identifies the diagnostic conditions involved or when the Alphabetic Index directs to do so
Sequela
- Residual effect (condition produced) after the acute phase of an illness or injury has terminated
- No time limit on when a sequela code can be used
- Examples: scar formation resulting from a burn, deviated septum due to a nasal fracture, and infertility due to tubal occlusion from old tuberculosis
- Coding of sequela generally requires two codes sequenced in the following order:
- The condition or nature of the sequela is sequenced first
- The sequela code is sequenced second
Impending or Threatened Conditions
- Code any condition described at the time of discharge as "impending" or "threatened" as follows:
- If it did occur, code as a confirmed diagnosis
- If it did not occur, reference the Alphabetic Index to determine if the condition has a subentry term for "impending" or "threatened" and also reference main term entries for "Impending" and for "Threatened"
- If the subterms are listed, assign the given code
- If the subterms are not listed, code the existing underlying condition(s) and not the condition described as impending or threatened
Laterality
- Some ICD-10-CM codes indicate laterality, specifying whether the condition occurs on the left, right, or is bilateral
- If no bilateral code is provided and the condition is bilateral, assign separate codes for both the left and right side
- If the side is not identified in the medical record, assign the code for the unspecified side
Placeholder Character
- "X" is used as a placeholder at certain codes to allow for future expansion
- Example: poisoning, adverse effect, and underdosing codes, categories T36-T50
7th Characters
- Required for certain ICD-10-CM categories
- The applicable 7th character must always be the 7th character in the data field
- If a code that requires a 7th character is not 6 characters, a placeholder X must be used to fill in the empty characters### Conventions for ICD-10-CM
- The conventions for ICD-10-CM are general rules for using the classification, independent of the guidelines.
- These conventions are incorporated within the Alphabetic Index and Tabular List as instructional notes.
Structure of ICD-10-CM
- The ICD-10-CM is divided into two main components: the Alphabetic Index and the Tabular List.
- The Alphabetic Index is an alphabetical list of terms and their corresponding codes.
- The Alphabetic Index consists of:
- Index of Diseases and Injury
- Index of External Causes of Injury
- Table of Neoplasms
- Table of Drugs and Chemicals
- The Tabular List is a structured list of codes divided into chapters based on body system or condition.
Format and Structure of the Tabular
- The Tabular List contains categories, subcategories, and codes.
- Characters for categories, subcategories, and codes may be either a letter or a number.
- Categories are 3 characters and may have further subdivision into subcategories and codes.
- Codes can be 3, 4, 5, 6, or 7 characters in length.
Use of Codes for Reporting Purposes
- Codes for external causes of morbidity and mortality should be assigned in addition to the code for the injury or disease.
- External cause codes should be sequenced in a specific order (e.g., hurricane, then building collapse).
- Z codes may be assigned to further explain the reasons for presenting for healthcare services.
Coding for HIV Cases
- Code only confirmed cases of HIV infection/illness.
- Use code B20, Human immunodeficiency virus [HIV] disease, as the principal diagnosis.
- Assign additional diagnosis codes for all reported HIV-related conditions.
- Use code Z21, Asymptomatic human immunodeficiency virus [HIV] infection status, for patients without symptoms or manifestations of HIV disease.
Other Coding Guidelines
- Use placeholder character "X" when necessary.
- 7th characters are required for certain categories and must be the 7th character in the data field.
- NEC (not elsewhere classifiable) and NOS (not otherwise specified) codes are used when no specific code exists.
- Brackets are used to enclose synonyms, alternative wording, or explanatory phrases.
- Parentheses are used to enclose supplementary words that may be present or absent in the statement of a disease or procedure.
- Colons are used to indicate that a modifier is required to make the term assignable to a given category.
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Description
Test your knowledge on the conventions of ICD-10-CM, which are the general rules for using the classification system. Learn about the Alphabetic Index and Tabular List within the ICD-10-CM.