Coding and Coding Guidelines Flashcards

In CPT E/M coding for office visits, which three key components determine the level of service for new patients?

Answer: History, physical exam, and medical decision making — all three must meet or exceed the level

For new patients, all three key components (history, physical examination, and medical decision making) must meet or exceed the requirements for the selected level of service.

What is a principal diagnosis in inpatient hospital coding?

Answer: The condition established after study to be chiefly responsible for the admission of the patient to the hospital

The principal diagnosis is defined as the condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care.

What does the ICD-10-CM Alphabetic Index instruct you to do when you see 'see also'?

Answer: Also look up the referenced main term if your current search does not produce a complete code

'See also' in the Alphabetic Index directs the coder to look up an additional main term if the current index entry does not provide complete coding information.

What is the correct coding sequence for a patient admitted for sepsis caused by MRSA pneumonia?

Answer: Code the sepsis first (A41.02 Sepsis due to MRSA), then the pneumonia as the underlying infection

When sepsis and a localized infection (like pneumonia) are present, ICD-10-CM guidelines direct coders to sequence the sepsis code first, followed by a code for the localized infection.

What is the function of CPT Category III codes?

Answer: Temporary codes for emerging technology, services, and procedures used to collect data for FDA approval or coverage decisions

CPT Category III codes (four digits + letter T) are temporary codes for new and experimental services. They are used to collect data and track utilization to support FDA approval or payer coverage decisions.

When coding a fracture in ICD-10-CM, what information is needed to select the correct 7th character?

Answer: The encounter type (initial, subsequent, sequela), healing status for subsequent encounters, and for open fractures, the Gustilo classification

Fracture coding requires the 7th character to reflect: (1) whether it is an initial encounter (A=closed, B=open type I/II, C=open type IIIA/B/C), (2) subsequent encounter healing status (D=routine, G=delayed, K=nonunion, P=malunion), or (3) sequela (S).