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Questions and Answers
What defines objective evidence of disease observed through physician examination?
What defines objective evidence of disease observed through physician examination?
Sign
What is defined as subjective observation reported by the patient?
What is defined as subjective observation reported by the patient?
Symptom
Which block contains the code for history of brain cancer?
Which block contains the code for history of brain cancer?
Z77-Z99
What is the correct code for Hypovolemic Shock?
What is the correct code for Hypovolemic Shock?
What is the correct Z-code for Osteoporosis Screening?
What is the correct Z-code for Osteoporosis Screening?
Which term refers to inpatient coding?
Which term refers to inpatient coding?
Which symptom would not be considered an integral part of pneumonia?
Which symptom would not be considered an integral part of pneumonia?
All symptom codes are found in Chapter 18 in the ICD-10-CM Tabular Listing.
All symptom codes are found in Chapter 18 in the ICD-10-CM Tabular Listing.
When time is a factor, a coder should skip the index and go straight to the tabular listing to find the code.
When time is a factor, a coder should skip the index and go straight to the tabular listing to find the code.
What is the code for Dyspnea?
What is the code for Dyspnea?
What is the diagnosis code for an outpatient case of lower abdominal pain with possible gastroenteritis?
What is the diagnosis code for an outpatient case of lower abdominal pain with possible gastroenteritis?
What code is assigned for Heart Murmur?
What code is assigned for Heart Murmur?
What is the Z-code for a routine examination of a three-month-old child?
What is the Z-code for a routine examination of a three-month-old child?
What is the Z-code for the removal of cardiac pacemaker battery?
What is the Z-code for the removal of cardiac pacemaker battery?
What Z-code indicates family history of stroke?
What Z-code indicates family history of stroke?
What is the code for a patient admitted with low back pain, possible lumbar degenerative disc?
What is the code for a patient admitted with low back pain, possible lumbar degenerative disc?
What do Z codes represent?
What do Z codes represent?
What is the definition of palliative care?
What is the definition of palliative care?
What do external cause of morbidity codes indicate?
What do external cause of morbidity codes indicate?
What represents continued care during the healing phase due to the consequences of a disease?
What represents continued care during the healing phase due to the consequences of a disease?
What are the categories used for various patient history and status-related codes?
What are the categories used for various patient history and status-related codes?
What is indicated by status codes?
What is indicated by status codes?
What do problem codes from categories Z55-Z65 indicate?
What do problem codes from categories Z55-Z65 indicate?
What does category Z79 indicate?
What does category Z79 indicate?
Code Z51.81 is used to report encounters for ______ drug monitoring.
Code Z51.81 is used to report encounters for ______ drug monitoring.
What should be added if the drug being monitored is one that the patient has been receiving long-term?
What should be added if the drug being monitored is one that the patient has been receiving long-term?
Which of the following is an exception to using History, Status, and Problem Codes as principal diagnoses?
Which of the following is an exception to using History, Status, and Problem Codes as principal diagnoses?
What does genetic susceptibility refer to?
What does genetic susceptibility refer to?
Codes from category Z15 should not be used as ______ or first-listed codes.
Codes from category Z15 should not be used as ______ or first-listed codes.
When coding for encounters related to genetic counseling, which code should be assigned first?
When coding for encounters related to genetic counseling, which code should be assigned first?
Z Codes can be assigned as the principal diagnosis.
Z Codes can be assigned as the principal diagnosis.
What is the code for a visit to change a surgical dressing?
What is the code for a visit to change a surgical dressing?
What is the code for a family history of polyps of the colon?
What is the code for a family history of polyps of the colon?
What is the code for status post aortocoronary bypass procedure?
What is the code for status post aortocoronary bypass procedure?
What code is assigned for an encounter for gastrostomy tube irrigation?
What code is assigned for an encounter for gastrostomy tube irrigation?
What is the code for adjustment of cardiac pacemaker pulse generator?
What is the code for adjustment of cardiac pacemaker pulse generator?
What code represents long-term use of anticoagulant therapy?
What code represents long-term use of anticoagulant therapy?
What is the code for dependence on respirator?
What is the code for dependence on respirator?
What code indicates aftercare for end of life care?
What code indicates aftercare for end of life care?
What code is used for an encounter for a screening mammogram?
What code is used for an encounter for a screening mammogram?
What is the code for an encounter for radiation therapy?
What is the code for an encounter for radiation therapy?
What does code Z91.130 represent?
What does code Z91.130 represent?
What is the code for an encounter for removal of sutures?
What is the code for an encounter for removal of sutures?
What do the symptoms, signs, and ill-defined conditions refer to in medical records?
What do the symptoms, signs, and ill-defined conditions refer to in medical records?
A sign is objective evidence of disease that can be observed by the examining physician.
A sign is objective evidence of disease that can be observed by the examining physician.
A symptom is objective and confirmed by the physician.
A symptom is objective and confirmed by the physician.
How are signs and symptoms classified in ICD-10-CM?
How are signs and symptoms classified in ICD-10-CM?
Codes for symptoms, signs, and ill-defined conditions cannot be used as principal diagnoses.
Codes for symptoms, signs, and ill-defined conditions cannot be used as principal diagnoses.
What happens to diagnoses described as possible or probable during inpatient or outpatient discharge?
What happens to diagnoses described as possible or probable during inpatient or outpatient discharge?
When can symptom codes be used as the principal diagnosis?
When can symptom codes be used as the principal diagnosis?
What is the main purpose of outpatient encounters regarding diagnosis?
What is the main purpose of outpatient encounters regarding diagnosis?
When are codes from chapter 18 assigned as secondary codes?
When are codes from chapter 18 assigned as secondary codes?
What is the purpose of coding nonspecific abnormal findings?
What is the purpose of coding nonspecific abnormal findings?
What does the Glasgow Coma Scale assess?
What does the Glasgow Coma Scale assess?
What is the code for Coma in subcategory R40.2?
What is the code for Coma in subcategory R40.2?
What is NIHSS used for?
What is NIHSS used for?
Code R99 can be used as a discharge disposition of death.
Code R99 can be used as a discharge disposition of death.
What does R30.0 indicate?
What does R30.0 indicate?
What is the code for acute chest pain due to influenzal pleurisy?
What is the code for acute chest pain due to influenzal pleurisy?
What is the code for gross, painless hematuria with an undetermined cause?
What is the code for gross, painless hematuria with an undetermined cause?
What code indicates pyuria, intermittent, cause undetermined?
What code indicates pyuria, intermittent, cause undetermined?
What code represents an enlarged lymph node in the left axilla?
What code represents an enlarged lymph node in the left axilla?
What code is assigned for elevated glucose tolerance tests?
What code is assigned for elevated glucose tolerance tests?
What codes indicate severe vertigo, left temporal headache, and nausea?
What codes indicate severe vertigo, left temporal headache, and nausea?
What is the code for syncope with an undetermined cause?
What is the code for syncope with an undetermined cause?
What is the code for chest pain, probably angina pectoris (inpatient discharge)?
What is the code for chest pain, probably angina pectoris (inpatient discharge)?
What does the code F45.8 signify?
What does the code F45.8 signify?
What is the code for arteriosclerotic gangrene in the left foot?
What is the code for arteriosclerotic gangrene in the left foot?
What is the code for chronic epistaxis, severe, requiring nasal packing?
What is the code for chronic epistaxis, severe, requiring nasal packing?
What is the code for hereditary epistaxis?
What is the code for hereditary epistaxis?
What codes indicate generalized abdominal pain due to possible pancreatitis or cholecystitis?
What codes indicate generalized abdominal pain due to possible pancreatitis or cholecystitis?
What is the code for chronic fatigue syndrome?
What is the code for chronic fatigue syndrome?
What is the code for fever and malaise due to viral syndrome?
What is the code for fever and malaise due to viral syndrome?
What codes represent fever of unknown etiology and headache?
What codes represent fever of unknown etiology and headache?
What is the code for prediabetes?
What is the code for prediabetes?
Flashcards
Sign
Sign
Objective evidence of disease observed by a physician.
Symptom
Symptom
Subjective observation reported by the patient.
ICD-10-CM Coding
ICD-10-CM Coding
System used for coding and classifying diagnoses and conditions.
Z Codes
Z Codes
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Principal Diagnosis
Principal Diagnosis
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Hypovolemic Shock Code
Hypovolemic Shock Code
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Aftercare Management
Aftercare Management
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External Cause Codes
External Cause Codes
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Osteoporosis Screening Code
Osteoporosis Screening Code
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Dyspnea Code
Dyspnea Code
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Non-integral Symptom of Pneumonia
Non-integral Symptom of Pneumonia
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Admission Follow-Up Codes
Admission Follow-Up Codes
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Z Code for Palliative Care
Z Code for Palliative Care
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Z Codes for Family History
Z Codes for Family History
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Problem Codes
Problem Codes
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Glasgow Coma Scale (GCS)
Glasgow Coma Scale (GCS)
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NIH Stroke Scale
NIH Stroke Scale
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Aftercare Z Codes Usage
Aftercare Z Codes Usage
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Routine Examination Code for Child
Routine Examination Code for Child
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Heart Murmur Code
Heart Murmur Code
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Z Code for Dyspnea
Z Code for Dyspnea
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Signs and Symptoms Coding
Signs and Symptoms Coding
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Hematuria
Hematuria
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Preoperative Evaluations Z Codes
Preoperative Evaluations Z Codes
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Follow-Up After Treatment
Follow-Up After Treatment
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Status Codes
Status Codes
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Abnormal Findings Codes
Abnormal Findings Codes
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Z Codes Classification
Z Codes Classification
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Code for Chest Pain
Code for Chest Pain
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Study Notes
Definitions of Medical Terms
- Sign: Objective evidence of disease observed through a physician's examination.
- Symptom: Subjective observation reported by the patient.
ICD-10-CM Coding
- History of Brain Cancer Code Block: Z77-Z99 is the relevant block for coding history of brain cancer.
- Hypovolemic Shock: Correct code is R57.1.
- Osteoporosis Screening: Corresponds to Z13.820 code.
- Principal Diagnosis in Inpatient Coding: Usually refers to the First Listed Diagnosis, also known as Principal or Primary Diagnosis.
Symptoms and Integral Parts of Conditions
- Non-integral Symptom of Pneumonia: Hematuria is not considered an integral part of pneumonia, while cough, shortness of breath, and fever are.
Coding Practices
- Symptom Codes Location: All symptom codes are not exclusively found in Chapter 18.
- Index vs. Tabular Listing: When time is critical, coders may skip the index and go directly to the tabular listing.
- Code for Dyspnea: R06.00 is the designated code for dyspnea.
Outpatient and Inpatient Coding Specifics
- Lower Abdominal Pain Case: R10.30 is the code assigned for outpatient cases described with possible conditions.
- Heart Murmur Code: The relevant code is R01.1, found under "murmur" in the Disease Index.
- Routine Examination for Child: Z00.129 is the Z-code assigned for a routine examination of a 3-month-old child.
- Cardiac Pacemaker Battery Removal Code: Z45.010 is assigned based on guidelines of the Disease Index.
Z Codes Overview
- Definition of Z Codes: Indicate factors influencing health status and contact with health services, ranging from Z00-Z99.
- Palliative Care Code: Z51.5 is used for encounters for palliative care, covering end-of-life and hospice care.
- External Cause of Morbidity Codes: Codes from V00-Y99 provide information for injury research and prevention strategies.
Aftercare and Management
- Aftercare Management: Refers to continued care during healing or long-term care due to disease consequences.
- Using Z Codes: Certain Z codes can be principal diagnoses; others serve as additional codes for health history.
External Cause Codes Usage
- Purpose: Indicate causes and intent behind injuries, including situational contexts of events.
Z Code Classification
- Locating Z Codes: Key terms in the Alphabetic Index include Admission, Examination, History, Observation, Aftercare, Problem, and Status.
- Z Codes for Family and Personal History: Codes cover a range of health histories, from previous conditions to family disease backgrounds.
Problem Codes and Status Codes
- Problem Codes Z55-Z65: Address issues affecting patient care compliance (e.g., housing problems, economic concerns).
- Status Codes: Indicate carrier states or residual conditions from past diseases; history codes differ by representing conditions no longer present.
Genetic Codes
- Z15 Codes: Refer to genetic susceptibility but are not used as principal diagnosis codes.
Special Coding Principles
- Preoperative Evaluations: Specific Z01 codes apply for preoperative exams related to various bodily systems.
- Screening Examinations: Z11-Z13 codes apply to tests for early detection, where abnormal findings lead to additional coding requirements.
Key Guidelines
- Admission Follow-Up and Observation Codes: Specific coding rules apply when transitioning from observation to admission.
- Aftercare Z Codes Usage: Should not be used for current acute diseases but reserved for ongoing treatment phases.
Important Considerations in Coding
- Compliance with Guidelines: Accuracy in code assignment reflects the necessity of comprehensive care reflected in patient encounters and histories.### Z Codes as Principal/First-Listed Diagnosis
- Z codes can only be assigned as principal diagnoses in specific circumstances, such as multiple encounters on the same day or when multiple Z codes meet the definition.
- Z codes are not to be reported when they do not qualify as principal or first-listed diagnoses.
Follow-Up After Treatment
- Follow-up codes should be assigned first, followed by personal history (Z85.- to Z87.-) and genetic susceptibility codes (Z15.-).
- For genetic counseling related to reproductive management, use code Z31.5 followed by an appropriate Z15 code, including any relevant family or personal history codes.
Various Z Codes
- Z48.01: Visit to change surgical dressing.
- Z83.71: Family history of polyps of the colon.
- Z95.1: Status post aortocoronary bypass procedure.
- Z43.1: Encounter for gastrostomy tube irrigation.
- Z45.010: Adjustment of cardiac pacemaker pulse generator.
- Z79.01: Long-term use of anticoagulant therapy.
- Z99.11: Dependence on respirator.
- Z51.5: Aftercare for end-of-life care.
- Z12.31: Encounter for screening mammogram.
- Z51.0: Encounter for radiation therapy.
- Z91.130: Noncompliance with medication due to advanced age.
- Z48.02: Encounter for removal of sutures.
Signs and Symptoms Coding
- Signs: Objective evidence observed by the physician.
- Symptoms: Subjective experiences reported by the patient without objective confirmation.
- Chapter 18 of ICD-10-CM categorizes signs and symptoms based on their diagnostic significance and the specificity of their etiology.
Principal Diagnoses for Signs and Symptoms
- Codes from Chapter 18 cannot be principal diagnoses if a related diagnosis has been established.
- In outpatient settings, symptom codes can be first-listed as there may not be sufficient study to establish a definitive diagnosis.
Additional Diagnoses and Historical Codes
- Signs and symptoms from Chapter 18 can be secondary codes if they are not integral to the main diagnosis, and they contribute to care decisions.
- Abnormal findings under categories R90 through R97 should typically be assigned only in specific circumstances where no definitive diagnosis exists.
Glasgow Coma Scale (GCS)
- GCS assesses consciousness after a head injury based on eye opening, verbal responsiveness, and motor responsiveness.
- Codes include individual scores and total scores; a seventh character indicates when the scale was recorded.
National Institutes of Health Stroke Scale (NIHSS)
- NIHSS evaluates neurological status in acute stroke patients, assessing various cognitive and physical functions.
- These scores are recorded as secondary codes; the primary diagnosis remains related to acute cerebral infarction.
Ill-Defined Conditions and Specific Diagnoses
- Code R99 is limited to cases where a patient is pronounced dead on arrival.
- Proper coding for conditions like dysuria and chest pain must adhere to the specified definitions and categories to ensure accuracy in documentation.
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Description
Test your knowledge on ICD-10-CM Z codes, symptoms, and signs through these flashcards covering chapters 11 and 12. Each card provides definitions and codes that are essential for understanding ill-defined conditions in medical coding.
