ICD-10-CM Z Codes Flashcards: Chapters 11 & 12

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Questions and Answers

What defines objective evidence of disease observed through physician examination?

Sign

What is defined as subjective observation reported by the patient?

Symptom

Which block contains the code for history of brain cancer?

Z77-Z99

What is the correct code for Hypovolemic Shock?

R57.1 Signup and view all the answers

What is the correct Z-code for Osteoporosis Screening?

Z13.820 Signup and view all the answers

Which term refers to inpatient coding?

All of the above Signup and view all the answers

Which symptom would not be considered an integral part of pneumonia?

Hematuria Signup and view all the answers

All symptom codes are found in Chapter 18 in the ICD-10-CM Tabular Listing.

False Signup and view all the answers

When time is a factor, a coder should skip the index and go straight to the tabular listing to find the code.

False Signup and view all the answers

What is the code for Dyspnea?

R06.00 Signup and view all the answers

What is the diagnosis code for an outpatient case of lower abdominal pain with possible gastroenteritis?

R10.30 Signup and view all the answers

What code is assigned for Heart Murmur?

R01.1 Signup and view all the answers

What is the Z-code for a routine examination of a three-month-old child?

Z00.129 Signup and view all the answers

What is the Z-code for the removal of cardiac pacemaker battery?

Z45.010 Signup and view all the answers

What Z-code indicates family history of stroke?

Z82.3 Signup and view all the answers

What is the code for a patient admitted with low back pain, possible lumbar degenerative disc?

M51.36 Signup and view all the answers

What do Z codes represent?

Codes for factors influencing health status and contact with health services Signup and view all the answers

What is the definition of palliative care?

Care focused on the management of pain and other symptoms of patients who are in the terminal phase of an illness. Signup and view all the answers

What do external cause of morbidity codes indicate?

Codes for external causes to provide information for injury research and evaluation of injury prevention strategies. Signup and view all the answers

What represents continued care during the healing phase due to the consequences of a disease?

Aftercare management Signup and view all the answers

What are the categories used for various patient history and status-related codes?

Z85-Z92 Signup and view all the answers

What is indicated by status codes?

They indicate that a patient is a carrier of a disease or has sequelae from a past condition. Signup and view all the answers

What do problem codes from categories Z55-Z65 indicate?

Problems that may affect the patient's care or compliance. Signup and view all the answers

What does category Z79 indicate?

A patient's continuous use of a prescribed drug for long-term treatment. Signup and view all the answers

Code Z51.81 is used to report encounters for ______ drug monitoring.

therapeutic Signup and view all the answers

What should be added if the drug being monitored is one that the patient has been receiving long-term?

A code from category Z79 Signup and view all the answers

Which of the following is an exception to using History, Status, and Problem Codes as principal diagnoses?

All of the above Signup and view all the answers

What does genetic susceptibility refer to?

A genetic predisposition for contracting a disease Signup and view all the answers

Codes from category Z15 should not be used as ______ or first-listed codes.

principal Signup and view all the answers

When coding for encounters related to genetic counseling, which code should be assigned first?

Code Z31.5 Signup and view all the answers

Z Codes can be assigned as the principal diagnosis.

True Signup and view all the answers

What is the code for a visit to change a surgical dressing?

Z48.01 Signup and view all the answers

What is the code for a family history of polyps of the colon?

Z83.71 Signup and view all the answers

What is the code for status post aortocoronary bypass procedure?

Z95.1 Signup and view all the answers

What code is assigned for an encounter for gastrostomy tube irrigation?

Z43.1 Signup and view all the answers

What is the code for adjustment of cardiac pacemaker pulse generator?

Z45.010 Signup and view all the answers

What code represents long-term use of anticoagulant therapy?

Z79.01 Signup and view all the answers

What is the code for dependence on respirator?

Z99.11 Signup and view all the answers

What code indicates aftercare for end of life care?

Z51.5 Signup and view all the answers

What code is used for an encounter for a screening mammogram?

Z12.31 Signup and view all the answers

What is the code for an encounter for radiation therapy?

Z51.0 Signup and view all the answers

What does code Z91.130 represent?

Noncompliance with medication, unintentional, due to patient's advanced age Signup and view all the answers

What is the code for an encounter for removal of sutures?

Z48.02 Signup and view all the answers

What do the symptoms, signs, and ill-defined conditions refer to in medical records?

Symptoms, Signs, and Ill-Defined Conditions Signup and view all the answers

A sign is objective evidence of disease that can be observed by the examining physician.

True Signup and view all the answers

A symptom is objective and confirmed by the physician.

False Signup and view all the answers

How are signs and symptoms classified in ICD-10-CM?

Two ways: unexplained etiology and specific diagnosis Signup and view all the answers

Codes for symptoms, signs, and ill-defined conditions cannot be used as principal diagnoses.

True Signup and view all the answers

What happens to diagnoses described as possible or probable during inpatient or outpatient discharge?

Inpatient: considered established; Outpatient: not considered established Signup and view all the answers

When can symptom codes be used as the principal diagnosis?

When no related condition is identified Signup and view all the answers

What is the main purpose of outpatient encounters regarding diagnosis?

Relieving symptoms rather than treating underlying conditions Signup and view all the answers

When are codes from chapter 18 assigned as secondary codes?

Both A and B Signup and view all the answers

What is the purpose of coding nonspecific abnormal findings?

For conditions when a definitive related diagnosis is not available Signup and view all the answers

What does the Glasgow Coma Scale assess?

Degree of consciousness after a head injury Signup and view all the answers

What is the code for Coma in subcategory R40.2?

Codes in subcategory R40.2 Signup and view all the answers

What is NIHSS used for?

To evaluate and document neurological status in acute stroke patients Signup and view all the answers

Code R99 can be used as a discharge disposition of death.

False Signup and view all the answers

What does R30.0 indicate?

Dysuria Signup and view all the answers

What is the code for acute chest pain due to influenzal pleurisy?

J11.1 Signup and view all the answers

What is the code for gross, painless hematuria with an undetermined cause?

R31.0 Signup and view all the answers

What code indicates pyuria, intermittent, cause undetermined?

N39.0 Signup and view all the answers

What code represents an enlarged lymph node in the left axilla?

R59.0 Signup and view all the answers

What code is assigned for elevated glucose tolerance tests?

R73.02 Signup and view all the answers

What codes indicate severe vertigo, left temporal headache, and nausea?

All of the above Signup and view all the answers

What is the code for syncope with an undetermined cause?

R55 Signup and view all the answers

What is the code for chest pain, probably angina pectoris (inpatient discharge)?

I20.9 Signup and view all the answers

What does the code F45.8 signify?

Psychogenic dysuria Signup and view all the answers

What is the code for arteriosclerotic gangrene in the left foot?

I70.262 Signup and view all the answers

What is the code for chronic epistaxis, severe, requiring nasal packing?

R04.0; 2Y41x5z Signup and view all the answers

What is the code for hereditary epistaxis?

I78.0 Signup and view all the answers

What codes indicate generalized abdominal pain due to possible pancreatitis or cholecystitis?

Both A and B Signup and view all the answers

What is the code for chronic fatigue syndrome?

R53.82 Signup and view all the answers

What is the code for fever and malaise due to viral syndrome?

B34.9 Signup and view all the answers

What codes represent fever of unknown etiology and headache?

Both A and B Signup and view all the answers

What is the code for prediabetes?

R73.03 Signup and view all the answers

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.