Medical Coding Chapter 4-5 Study Guide

Questions and Answers

If a patient with HIV disease is admitted for an _ condition, the code for the __ condition should be the principal diagnosis.

unrelated, unrelated

The Tabular List section of the ICD-10-CM book lists every code and its complete description in ______ order by code.

alphanumeric

If two (or more) diagnoses are of equal severity, then report them in order of anatomical site— ______.

head to toe

According to the ICD-10-CM Official Guidelines, section ____ corresponds to Selection of Principal Diagnosis.

II Signup and view all the answers

_____ is the reaction of tissues to infection or injury; characterized by pain, swelling, and erythema.

Inflammation Signup and view all the answers

The section of the ICD-10-CM code book listing drugs, chemicals, and other biologicals that may poison a patient or result in an adverse reaction is known as the:

Table of Drugs and Chemicals Signup and view all the answers

Exposure due to physical interaction with blood, bodily fluids, nonintact skin, and mucous membranes can enable a long list of bloodborne pathogens to make their way from one person to another. This type of exposure is known as:

touch exposure Signup and view all the answers

The coder reports a code directly from the Alphabetic Index without checking it in the Tabular List.

False Signup and view all the answers

A _____ located to the left of a code in the Tabular List is a symbol that notifies you that an additional character is required.

box with a checkmark and number Signup and view all the answers

According to the ICD-10-CM Official Guidelines, I.C.21.c.5: ______ is the testing for disease or disease precursors in seemingly well individuals so that early detection and treatment can be provided for those who test positive for the disease.

screening Signup and view all the answers

What is the first step in looking up an ICD-10-CM diagnosis code?

Look up the main term in the Alphabetic Index. Signup and view all the answers

Mushrooms, yeast, and mold are edible forms of:

fungi Signup and view all the answers

Staphylococcus aureus is what type of infection?

bacterial Signup and view all the answers

Janie was diagnosed with salmonella poisoning. The coder should assign code(s) for:

salmonella Signup and view all the answers

In order to code a diagnosis of meningitis, you have to know the specific virus or bacterium at the core of the inflammation. This can typically be found in the ______ report.

Pathology Signup and view all the answers

A patient complains of dizziness. The physician states that she has hypertension. The coder should assign a code for:

hypertension Signup and view all the answers

Debbie Simmons is diagnosed with influenza with respiratory manifestations. The main term is _; the correct diagnosis code is __.

Influenza, J11.1 Signup and view all the answers

Signs and symptoms of an existence of infection include all except a(n): rash.

True Signup and view all the answers

In the ICD-10-CM Alphabetic Index turn to Disease>Alzheimer's. What punctuation(s) do you find?

Slanted Brackets Signup and view all the answers

_______ will show you alternate terms, alternate phrases, and/or synonyms to provide additional detail or explanation to the description.

Brackets Signup and view all the answers

George Honker is diagnosed with acute hepatitis B without delta-agent with hepatic coma. The main term is _; the correct diagnosis code is __.

Hepatitis, B16.2 Signup and view all the answers

Outpatient coders cannot assign a diagnosis code for a diagnosis documented as: All of these.

True Signup and view all the answers

Lice and mites are examples of:

parasites Signup and view all the answers

Tetanus is an infection of the nervous system and is caused by the entry of _______ into the body through a break in the skin.

bacteria Signup and view all the answers

ICD-10-CM code range V00-Y99 identifies:

External Causes of Morbidity Signup and view all the answers

Malaria, a disease spread by mosquitoes, is an example of a:

parasitic infestation Signup and view all the answers

______ is severe; serious.

Acute Signup and view all the answers

The physician's notes state, 'Chest congestion, possible pneumonia.' The coder in the physician's office should code:

chest congestion Signup and view all the answers

The word or phrase _____ means the same thing as NEC: The physician specified additional information that the ICD-10-CM book doesn't have in any of the other codes in the category.

other specified Signup and view all the answers

The diagnosis of severe sepsis must include:

identification of the underlying infection and which organ failed Signup and view all the answers

If one code exists with a description that includes two or more diagnoses identified in one patient at the same time, you must choose the code that includes as many conditions as available. These codes are known as:

combination codes Signup and view all the answers

An infection can spread through:

all of these Signup and view all the answers

When an infection or virus spreads throughout the entire body it is known as:

Systemic Signup and view all the answers

In your ICD-10-CM turn to code L03.211 in the Tabular List. What notation is found under the code?

Excludes2 Signup and view all the answers

The correct sequence for coding SIRS is:

Code for the underlying condition, code the SIRS, code the acute organ dysfunction Signup and view all the answers

The ______ notation provides you with additional terms and diagnoses that are included in the above code (this code's description).

Includes Signup and view all the answers

A condition that affects the entire body and virtually all body systems, therefore requiring the physician to consider this in his or her medical decision-making for any other condition is known as a:

systemic condition Signup and view all the answers

One disease that affects or encourages another condition is known as a:

underlying condition Signup and view all the answers

A breakout section of the Alphabetic Index listing the suggested codes for benign and malignant neoplasms is known as the:

Neoplasm Table Signup and view all the answers

Refer to the ICD-10-CM Official Guidelines Section I. How many parts does Section I have?

3 Signup and view all the answers

ICD-10-CM code range J00-J99 identifies the Diseases of the:

Respiratory System Signup and view all the answers

The code description that states 'diseases classified elsewhere' means that:

the condition has its own code within this code set Signup and view all the answers

The diagnosis of sepsis must include:

a specified pathogen Signup and view all the answers

Which of the following punctuation is found in the Alphabetic Index?

Italicized brackets and parentheses Signup and view all the answers

Which of the following are named by their shape?

Bacteria Signup and view all the answers

Which of the following embed themselves in host cells and can be difficult to isolate?

Viruses Signup and view all the answers

The Neoplasm Table is set up as a seven-column table organized by the information in column 1—the anatomical location of the tumor, in alphabetic order. Moving to the right, what information is found in column four?

Ca in situ Signup and view all the answers

Coding for septic shock will require:

3 codes Signup and view all the answers

Refer to the ICD-10-CM Official Guidelines Section IV.C. This guideline concerns:

Accurate reporting of ICD-10-CM diagnosis codes Signup and view all the answers

When the physician indicates that the patient's signs and symptoms may closely lead to two different diagnoses and using the word versus or or between two diagnostic statements this is known as a/an:

differential diagnosis Signup and view all the answers

Throughout the ICD-10-CM code book you will find which of the following to help guide you to the most accurate code for a patient encounter?

All of these Signup and view all the answers

What are hookworms, pinworms, and tapeworms examples of?

parasites Signup and view all the answers

The condition, after study, that is the primary, or main, reason for the admission of a patient to the hospital for care; the condition that requires the largest amount of hospital resources for care is known as the:

principal diagnosis Signup and view all the answers

____ is/are any agent that causes disease; a microorganism such as a bacterium or virus.

Pathogen Signup and view all the answers

Chickenpox is a:

viral infection Signup and view all the answers

Primary immunodeficiency disorders include all of the following except: AIDS.

True Signup and view all the answers

Refer to the ICD-10-CM Official Guidelines I.C.1.d.2.a which states: _______ generally refers to circulatory failure associated with severe sepsis, and therefore, it represents a type of acute organ dysfunction.

Septic shock Signup and view all the answers

Exposure due to some diseases, such as influenza, can be transmitted by coughing, spitting, talking, and sneezing. This type of exposure is known as:

droplet exposure Signup and view all the answers

____ identifies that pneumonia has developed in a patient who has not recently been in the hospital or another health care facility.

Community-acquired pneumonia Signup and view all the answers

NEC stands for:

not elsewhere classifiable Signup and view all the answers

The ______ notation identifies codes that cannot be used together on the same health claim form with the originally listed code.

Excludes1 Signup and view all the answers

_____ is of long duration; continuing over an extended period of time.

Chronic Signup and view all the answers

The coder report a code for HIV infection or illness without a specific physician diagnostic statement-a confirmed diagnosis.

False Signup and view all the answers

The Table of Drugs and Chemicals' first column shows a list of substances. Moving to the right, the sixth column identifies which of the following?

Adverse effect Signup and view all the answers

Which of the following can lay dormant for long periods of time?

Viruses Signup and view all the answers

When a patient acquires a condition that develops as a result of being in a health care facility it is known as a(n) _____ condition.

nosocomial Signup and view all the answers

A/An ____________ notation is a warning to stop and double-check the documentation so you don't report the code above the notation when a code shown in the notation may be more accurate.

Excludes2 Signup and view all the answers

A physical reaction, such as fever and chills, to an unspecified pathogen is a diagnosis referred to by the acronym:

SIRS Signup and view all the answers

The presence of unknown bacteria in the blood may be diagnosed as:

bacteremia Signup and view all the answers

The rules for coding uncertain diagnoses for patients of an inpatient facility are different from those for outpatients. You will find the guideline in which section?

Section II.H Signup and view all the answers

When there are no symptoms or manifestations this is known as:

Asymptomatic Signup and view all the answers

Signs of Cellulitis include all of the following except:

False Signup and view all the answers

All of the following are types of pneumonia except:

False Signup and view all the answers

Dysentery is transmitted by:

drinking contaminated water Signup and view all the answers

A _____ is used in the Alphabetic Index to indicate that additional characters are required.

hyphen Signup and view all the answers

What is the most common nail fungus infection?

Onychomycosis Signup and view all the answers

In the ICD-10-CM Tabular List turn to code G04.01. What notation do you find under this code?

Excludes1 Signup and view all the answers

The diagnosis of severe sepsis must include a(n):

organ dysfunction Signup and view all the answers

There are times when a fifth, sixth, or seventh character is required, yet there are no fourth, fifth, or sixth characters. In these cases, ICD-10-CM uses a placeholder character, the letter ____, so the following characters will fall into their correct locations.

X Signup and view all the answers

In the ICD-10-CM Alphabetic Index turn to Pneumoconiosis. What punctuation(s) do you find?

Parentheses Signup and view all the answers

AMR stands for:

Antimicrobial Resistance Signup and view all the answers

What section of the ICD-10-CM code book would provide you with a suggested code to describe how a patient was injured?

External Cause of Injuries Index Signup and view all the answers

The ______ notation is a reminder that you are going to need another code to identify the underlying disease that caused the diagnosed condition.

Code first Signup and view all the answers

Tuberculosis is transmitted by:

Air Signup and view all the answers

Once you have a suggested code from the Alphabetic Index, Neoplasm Table, Table of Drugs and Chemicals, and/or the Index to External Cause Codes, you will need to find that code in the:

Tabular List of Diseases and Injuries Signup and view all the answers

Study Notes

ICD-10-CM Coding Fundamentals

Principal diagnosis for HIV patients with unrelated conditions is the unrelated condition itself.
ICD-10-CM Tabular List organizes codes in alphanumeric order with complete descriptions.
Equal severity diagnoses should be reported in head-to-toe anatomical order.

Official Guidelines Overview

Section II pertains to the selection of principal diagnosis in ICD-10-CM.
Inflammation is a tissue reaction to infection or injury, leading to pain, swelling, and redness.
The Table of Drugs and Chemicals outlines drugs and chemicals that may cause poisoning or adverse reactions.

Exposure Types and Guidelines

Touch exposure involves interaction with blood and bodily fluids, facilitating pathogen transmission.
Codes should never be reported directly from the Alphabetic Index without verification from the Tabular List.
Symbols in the Tabular List indicate the requirement for additional characters.

Screening and Diagnosis

Screening involves testing seemingly well individuals for early disease detection.
First step in code lookup is to find the main term in the Alphabetic Index.
Influenza cases require coding for the condition and its manifestations.

Infectious Agents and Conditions

Fungi include mushrooms, yeast, and mold, while Staphylococcus aureus indicates a bacterial infection.
Salmonella poisoning should be coded as salmonella.
Specific pathogens must be identified to appropriately code severe sepsis cases.

Neoplasm and Infection Definitions

The Neoplasm Table categorizes tumorous conditions by anatomical location and features.
Acute conditions are severe, while chronic conditions continue over long periods.
Principal diagnosis reflects the primary reason for a patient’s hospital admission.

Diagnostic Notations and Coding Practices

NEC represents "not elsewhere classifiable," while differential diagnosis refers to uncertain diagnoses.
Excludes notations signal the need for code verification, while Includes notation elaborates associated terms.
Codes for septic shock require multiple entries to reflect the underlying conditions accurately.

Infection Transmission and Signs

Infections can spread through droplet, touch, and all forms of exposure.
Symptoms like fever and chills without identified pathogens can be indicated as SIRS (Systemic Inflammatory Response Syndrome).
Community-acquired pneumonia applies to cases not recently exposed to healthcare facilities.

Specific Pathogen Considerations

Tuberculosis transmission occurs via air, while dysentery is linked to contaminated water consumption.
Bacteremia diagnoses identify the presence of bacteria in the bloodstream.
The condition necessitating the greatest hospital resources characterizes the principal diagnosis.

Important Punctuation and Coding Knowledge

Slanted brackets in the Alphabetic Index specify related conditions, while parentheses indicate relevant diagnoses.
A hyphen in the Alphabetic Index highlights the need for additional characters.
The coding for conditions developed in healthcare settings is labeled as nosocomial.

Coding Guidelines and Requirements

The correct coding sequence for SIRS requires identification of the underlying cause and acute organ dysfunction.
Placeholder character "X" is used when additional characters are necessary but unavailable.
AMR stands for Antimicrobial Resistance, impacting treatment strategies in healthcare.

Conclusion

Understanding the layout and guidelines of the ICD-10-CM codebook is essential for accurate medical coding.
Awareness of common infectious diseases and their coding conventions assists in proper documentation and billing.

Studying That Suits You

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Description

This quiz covers key concepts from Chapters 4 and 5 of the Medical Coding curriculum, focusing on the ICD-10-CM guidelines. Study the rules for coding principal diagnoses and other important coding procedures. Perfect for students preparing for exams in medical coding and billing.

Medical Coding Chapter 4-5 Study Guide

Questions and Answers

If a patient with HIV disease is admitted for an _____ condition, the code for the ______ condition should be the principal diagnosis.

The Tabular List section of the ICD-10-CM book lists every code and its complete description in ______ order by code.

If two (or more) diagnoses are of equal severity, then report them in order of anatomical site— ______.

According to the ICD-10-CM Official Guidelines, section ____ corresponds to Selection of Principal Diagnosis.

_____ is the reaction of tissues to infection or injury; characterized by pain, swelling, and erythema.

The section of the ICD-10-CM code book listing drugs, chemicals, and other biologicals that may poison a patient or result in an adverse reaction is known as the:

Exposure due to physical interaction with blood, bodily fluids, nonintact skin, and mucous membranes can enable a long list of bloodborne pathogens to make their way from one person to another. This type of exposure is known as:

The coder reports a code directly from the Alphabetic Index without checking it in the Tabular List.

A _____ located to the left of a code in the Tabular List is a symbol that notifies you that an additional character is required.

According to the ICD-10-CM Official Guidelines, I.C.21.c.5: ______ is the testing for disease or disease precursors in seemingly well individuals so that early detection and treatment can be provided for those who test positive for the disease.

What is the first step in looking up an ICD-10-CM diagnosis code?

Mushrooms, yeast, and mold are edible forms of:

Staphylococcus aureus is what type of infection?

Janie was diagnosed with salmonella poisoning. The coder should assign code(s) for:

In order to code a diagnosis of meningitis, you have to know the specific virus or bacterium at the core of the inflammation. This can typically be found in the ______ report.

A patient complains of dizziness. The physician states that she has hypertension. The coder should assign a code for:

Debbie Simmons is diagnosed with influenza with respiratory manifestations. The main term is _____; the correct diagnosis code is ______.

Signs and symptoms of an existence of infection include all except a(n): rash.

In the ICD-10-CM Alphabetic Index turn to Disease>Alzheimer's. What punctuation(s) do you find?

_______ will show you alternate terms, alternate phrases, and/or synonyms to provide additional detail or explanation to the description.

George Honker is diagnosed with acute hepatitis B without delta-agent with hepatic coma. The main term is _____; the correct diagnosis code is ______.

Outpatient coders cannot assign a diagnosis code for a diagnosis documented as: All of these.

Lice and mites are examples of:

Tetanus is an infection of the nervous system and is caused by the entry of _______ into the body through a break in the skin.

ICD-10-CM code range V00-Y99 identifies:

Malaria, a disease spread by mosquitoes, is an example of a:

______ is severe; serious.

The physician's notes state, 'Chest congestion, possible pneumonia.' The coder in the physician's office should code:

The word or phrase _____ means the same thing as NEC: The physician specified additional information that the ICD-10-CM book doesn't have in any of the other codes in the category.

The diagnosis of severe sepsis must include:

If one code exists with a description that includes two or more diagnoses identified in one patient at the same time, you must choose the code that includes as many conditions as available. These codes are known as:

An infection can spread through:

When an infection or virus spreads throughout the entire body it is known as:

In your ICD-10-CM turn to code L03.211 in the Tabular List. What notation is found under the code?

The correct sequence for coding SIRS is:

The ______ notation provides you with additional terms and diagnoses that are included in the above code (this code's description).

A condition that affects the entire body and virtually all body systems, therefore requiring the physician to consider this in his or her medical decision-making for any other condition is known as a:

One disease that affects or encourages another condition is known as a:

A breakout section of the Alphabetic Index listing the suggested codes for benign and malignant neoplasms is known as the:

Refer to the ICD-10-CM Official Guidelines Section I. How many parts does Section I have?

ICD-10-CM code range J00-J99 identifies the Diseases of the:

The code description that states 'diseases classified elsewhere' means that:

The diagnosis of sepsis must include:

Which of the following punctuation is found in the Alphabetic Index?

Which of the following are named by their shape?

Which of the following embed themselves in host cells and can be difficult to isolate?

The Neoplasm Table is set up as a seven-column table organized by the information in column 1—the anatomical location of the tumor, in alphabetic order. Moving to the right, what information is found in column four?

Coding for septic shock will require:

Refer to the ICD-10-CM Official Guidelines Section IV.C. This guideline concerns:

When the physician indicates that the patient's signs and symptoms may closely lead to two different diagnoses and using the word versus or or between two diagnostic statements this is known as a/an:

Throughout the ICD-10-CM code book you will find which of the following to help guide you to the most accurate code for a patient encounter?

What are hookworms, pinworms, and tapeworms examples of?

The condition, after study, that is the primary, or main, reason for the admission of a patient to the hospital for care; the condition that requires the largest amount of hospital resources for care is known as the:

____ is/are any agent that causes disease; a microorganism such as a bacterium or virus.

Chickenpox is a:

Primary immunodeficiency disorders include all of the following except: AIDS.

Refer to the ICD-10-CM Official Guidelines I.C.1.d.2.a which states: _______ generally refers to circulatory failure associated with severe sepsis, and therefore, it represents a type of acute organ dysfunction.

Exposure due to some diseases, such as influenza, can be transmitted by coughing, spitting, talking, and sneezing. This type of exposure is known as:

____ identifies that pneumonia has developed in a patient who has not recently been in the hospital or another health care facility.

NEC stands for:

The ______ notation identifies codes that cannot be used together on the same health claim form with the originally listed code.

_____ is of long duration; continuing over an extended period of time.

The coder report a code for HIV infection or illness without a specific physician diagnostic statement-a confirmed diagnosis.

The Table of Drugs and Chemicals' first column shows a list of substances. Moving to the right, the sixth column identifies which of the following?

Which of the following can lay dormant for long periods of time?

When a patient acquires a condition that develops as a result of being in a health care facility it is known as a(n) _____ condition.

A/An ____________ notation is a warning to stop and double-check the documentation so you don't report the code above the notation when a code shown in the notation may be more accurate.

A physical reaction, such as fever and chills, to an unspecified pathogen is a diagnosis referred to by the acronym:

The presence of unknown bacteria in the blood may be diagnosed as:

The rules for coding uncertain diagnoses for patients of an inpatient facility are different from those for outpatients. You will find the guideline in which section?

When there are no symptoms or manifestations this is known as:

Signs of Cellulitis include all of the following except:

All of the following are types of pneumonia except:

Dysentery is transmitted by:

A _____ is used in the Alphabetic Index to indicate that additional characters are required.

What is the most common nail fungus infection?

In the ICD-10-CM Tabular List turn to code G04.01. What notation do you find under this code?

The diagnosis of severe sepsis must include a(n):

If a patient with HIV disease is admitted for an _ condition, the code for the __ condition should be the principal diagnosis.

Debbie Simmons is diagnosed with influenza with respiratory manifestations. The main term is _; the correct diagnosis code is __.

George Honker is diagnosed with acute hepatitis B without delta-agent with hepatic coma. The main term is _; the correct diagnosis code is __.