CCS Master Flashcards - Day 1 Foundations

Vocabulary based on CCS Master Flashcards covering Day 1 Official Coding Guidelines and CCS Foundations including UHDDS, ICD-10-CM/PCS, and CPT.

Principal Diagnosis

The condition established after study to be chiefly responsible for the patient's admission in the inpatient setting.

Reportable Secondary Diagnosis (UHDDS)

A condition affecting care by requiring clinical evaluation, therapeutic treatment, diagnostic studies, increased nursing care/monitoring, or affecting patient management.

Coding H&P Diagnoses

Diagnoses listed in the H&P should only be coded if they meet UHDDS reporting criteria.

Abnormal Laboratory Values

Should not be coded unless the provider documents a corresponding diagnosis.

Symptoms in Coding

Symptoms are not coded when a definitive diagnosis explains them.

Excludes1

A coding convention meaning never code the two conditions together.

Excludes2

A coding convention meaning both conditions may be coded together if documented.

Hypertension + Heart Failure Coding

Code I11.0 first, then an additional code for the type of heart failure.

Hypertension + CKD Coding

Assume a causal relationship unless documentation states otherwise.

Z79.4

Code for long-term use of insulin; assigned for Type 2 diabetes using insulin, but not for Type 1 diabetes.

DKA (Diabetic Ketoacidosis) Coding

If documented, do not also code uncontrolled diabetes.

Z51.11

The principal diagnosis code for an admission solely for chemotherapy.

Metastasis (Primary Colon Cancer Removed)

Coded using a history code for the primary site plus the metastatic site.

G89 Sequencing

Sequenced first when the encounter is primarily for pain control or pain management.

Arthroscopy CPT (298xx family)

Indicated if the operative report repeatedly says arthroscopy.

Orthopedic CPT Selection

Requires determining if the procedure was open, percutaneous, or arthroscopic.

Root Operation

The most difficult part of PCS, based on the objective of the procedure actually performed.

CABG PCS Coding

Codes are based on the number of coronary artery sites bypassed.

PTCA with Stent Root Operation

Dilation.

96365

CPT code for initial IV infusion.

96366

CPT code for each additional hour of the same infusion.

96367

CPT code for sequential infusion of a different substance.

96368

CPT code for concurrent infusion.

Modifier -25

Represents a significant, separately identifiable E/M service on the same day as a procedure.

Inpatient Chart Reading Order

H&P → Operative reports → Consults → Progress notes → Discharge summary.

Abstraction Priority

Diagnoses should be abstracted first, rather than codes.