Exam 1 Review

Who is responsible for maintaining ICD-10-CM?

National Center for Health Statistics (NCHS)

Who is responsible for maintaining ICD-10-PCS?

Centers for Medicare & Medicaid Services (CMS)

When was ICD-10 implemented in the U.S.?

October 1, 2015

Which legislation mandates the use of standardized coding systems like ICD-10?

Health Insurance Portability and Accountability Act (HIPAA)

Where is ICD-10-PCS used?

Hospital inpatient procedures only

What are the four cooperating parties responsible for coding guidelines?

• American Hospital Association (AHA)

• American Health Information Management Association (AHIMA)

• Centers for Medicare & Medicaid Services (CMS)

• National Center for Health Statistics (NCHS)

What is the first character of every ICD-10-CM code?

A letter

How many characters can an ICD-10-CM code have?

3 to 7 characters

What does the placeholder "X" in ICD-10-CM represent?

A placeholder for future expansion

What is the purpose of the 7th character in ICD-10-CM codes?

To indicate the episode of care (initial, subsequent, sequela)

What does "NEC" stand for?

Not Elsewhere Classifiable

What does "NOS" stand for?

Not Otherwise Specified

What is the difference between Excludes 1 and Excludes 2 notes?

• Excludes 1: The two conditions cannot be coded together.

• Excludes 2: The conditions can be coded together if applicable.

What is the DSM?

The Diagnostic and Statistical Manual of Mental Disorders (DSM) is a classification system for psychiatric disorders.

Who publishes the DSM?

The American Psychiatric Association (APA) publishes the DSM.

How does DSM relate to ICD-10-CM?

The DSM lists mental health conditions, but ICD-10-CM provides codes for reporting these conditions in medical records.

When can the "personal history of malignant neoplasm" be used?

When a patient no longer has active cancer but has a history of a malignant neoplasm that may affect treatment or monitoring.

What is the correct ICD-10-CM code for "personal history of malignant neoplasm"?

Z85.XX series (Personal history of malignant neoplasm, site-specific).

How do you sequence an admission for primary vs. secondary neoplasm sites?

• If a patient is admitted for treatment of a primary neoplasm, code the primary neoplasm first.

• If a patient is admitted for treatment of a secondary neoplasm, code the metastasis (secondary site) first and then the primary neoplasm.

What is an overlapping malignant neoplasm?

A cancer that involves two or more adjacent sites but is not classified elsewhere.

What is MRSA?

Methicillin-Resistant Staphylococcus Aureus (MRSA) is an antibiotic-resistant bacterial infection.

When do you use combination codes for MRSA?

When MRSA is the cause of a specific condition, such as pneumonia (J15.212) or sepsis (A41.02).

When do you NOT use a combination code for MRSA?

When MRSA is documented but no specific condition is coded. Instead, use:

• B95.62 (MRSA as the cause of other diseases).

• Z16.11 (Resistance to penicillins).

When is HIV coded as the principal diagnosis?

If the patient is admitted for an HIV-related condition, use B20 (HIV Disease) first, followed by the specific condition.

When is HIV NOT the principal diagnosis?

If the patient is admitted for a condition unrelated to HIV, that condition is coded first, with B20 as a secondary diagnosis.

What code is used for an HIV-positive patient without symptoms?

Z21 (Asymptomatic HIV status).

What code is used for an inconclusive HIV test result?

R75 (Inconclusive laboratory evidence of HIV).

Can Z21 be used if a patient has an HIV-related illness?

No. If a patient has an HIV-related condition, B20 must be assigned instead.

What is the POA (Present on Admission) indicator?

A code used to identify whether a condition was present at the time of hospital admission.

What is the POA indicator used for?

It affects reimbursement and helps identify hospital-acquired conditions (HACs).

What are the POA indicator options?

• Y = Yes, condition was present on admission.

• N = No, condition developed after admission.

• U = Unknown.

• W = Clinically undetermined.

What is the Principal Diagnosis?

The main reason for the inpatient hospital admission, as defined by UHDDS (Uniform Hospital Discharge Data Set).

Is the Principal Diagnosis the same as the First-Listed Diagnosis?

No. Principal Diagnosis applies only to inpatient settings, while First-Listed Diagnosis is used in outpatient settings.

What does UHDDS stand for, and why is it important?

Uniform Hospital Discharge Data Set – It defines key inpatient coding requirements, including Principal Diagnosis.

What was the effect of the Medicare Modernization Act (MMA) on coding?

• Introduced Medicare Part D (prescription drug coverage).

• Required more detailed medication coding for reimbursement.

• Encouraged Electronic Health Records (EHRs), affecting coding workflow.

When was the MMA enacted?

2003.

What are essential modifiers?

Words indented under the main term in the Alphabetic Index that change the meaning of the diagnosis.

What are nonessential modifiers?

Words in parentheses ( ) in the Alphabetic Index that do not change the meaning of the diagnosis.

Example of an essential modifier?

• Bronchitis, acute (J20.9) vs.

• Bronchitis, asthmatic (J45.909).

Example of a nonessential modifier?

Anemia (nutritional) (deficiency) → Words in parentheses do not change the code.

What does a "See" note in the Index mean?

It requires the coder to look at another term for the correct code.

What does a "See Also" note mean?

It suggests checking another term if additional information is needed, but it's not mandatory

What does a "Code Also" note mean?

It instructs coders to assign multiple codes when both conditions are documented.