ICD-10-CM Diagnosis Coding Flashcards

A patient presents for a follow-up visit for a displaced fracture of the right radial styloid process. The fracture is healing as expected, and the patient is receiving routine care for the healing fracture, such as a cast check. The initial encounter occurred two weeks ago. How should this encounter be coded?

Answer: S52.511D, Displaced fracture of right radial styloid process, subsequent encounter for fracture with routine healing

The ICD-10-CM guidelines for injury coding require a 7th character to indicate the episode of care. The character 'D' is used for a subsequent encounter when the patient has completed active treatment and is in the routine healing or recovery phase. Since the patient is in a follow-up visit for a healing fracture, 'D' is the correct 7th character.

In the ICD-10-CM Tabular List, what does an "Excludes1" note signify?

Answer: The excluded code should never be used at the same time as the code above the Excludes1 note, as the two conditions are mutually exclusive.

An Excludes1 note means "NOT CODED HERE!" and is used when two conditions cannot occur together. The code mentioned in the Excludes1 note should not be reported with the code under which the note appears, with a rare exception for when the two conditions are completely unrelated.

A patient with End-Stage Renal Disease (ESRD) on dialysis is diagnosed with anemia due to their kidney disease. According to ICD-10-CM Official Guidelines, how should this be coded and sequenced?

Answer: N18.6, D63.1

ICD-10-CM guidelines for anemia associated with chronic kidney disease (CKD) instruct the coder to sequence the code for the underlying CKD first, followed by the code for the anemia. Under code D63.1 (Anemia in chronic kidney disease), there is a "Code first" instructional note for the underlying chronic kidney disease (N18.-). Therefore, N18.6 (End stage renal disease) is sequenced first, followed by D63.1.

A patient presents for a routine annual exam. The patient had breast cancer treated with a mastectomy five years ago and there is no evidence of recurrence and no ongoing treatment for the cancer. Which code category best represents the patient's resolved cancer status?

Answer: Z85.- (Personal history of malignant neoplasm)

When a primary malignancy has been excised or eradicated and the patient is no longer receiving active treatment for it, a code from category Z85, Personal history of malignant neoplasm, is used to indicate the former site of the cancer. Using a code for active cancer (C50.-) would be incorrect as the condition is resolved.

Which of the following best describes the primary purpose of External Cause of Morbidity codes (V00-Y99) in ICD-10-CM?

Answer: To provide supplemental information about the cause, intent, and place of an injury or health condition.

External Cause codes are intended to be used as secondary codes to provide additional information. They describe how an injury or health condition occurred (cause), whether it was intentional or accidental (intent), where it happened (place), and what the patient was doing (activity). They should never be sequenced as the principal diagnosis.

A 28-year-old patient, who is pregnant for the first time, presents for a routine prenatal visit at 22 weeks gestation. The examination is normal and there are no complaints or complications. How should this encounter be coded?

Answer: Z34.02, Encounter for supervision of normal first pregnancy, second trimester

For routine outpatient prenatal visits for a normal pregnancy without any complications, a code from category Z34 is used. The 5th character '0' indicates a first pregnancy, and the 6th character '2' specifies the second trimester. Since the patient is at 22 weeks and has a normal exam, Z34.02 is the most accurate code.