Medical Coding Guidelines & Compliance Flashcards
6 cards from real CCS practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 6 Medical Coding Guidelines & Compliance flashcards as text
According to the ICD-10-CM Official Guidelines, what is the definition of the principal diagnosis for inpatient coding?
Answer: The condition established after study to be chiefly responsible for occasioning the admission
Per UHDDS and ICD-10-CM Guidelines, the principal diagnosis is 'the condition established after study to be chiefly responsible for occasioning the admission to the hospital for care.'
Under ICD-10-CM Official Coding Guidelines, when two or more diagnoses meet the definition of principal diagnosis, how should the coder proceed?
Answer: Either condition may be sequenced first
When two or more conditions equally meet the definition of principal diagnosis, the Official Guidelines state that either may be sequenced first as principal diagnosis.
What is the ICD-10-CM coding guideline for signs and symptoms that are integral to a confirmed disease?
Answer: Do not code signs and symptoms routinely reported with the confirmed disease
Per ICD-10-CM Guidelines, signs and symptoms that are routinely associated with a disease process (integral to the disease) should not be assigned as additional codes.
Under the ICD-10-CM Official Guidelines, the term 'code also' means:
Answer: An additional code should be reported if applicable and present
'Code also' is an instructional note indicating that an additional code may be assigned if the condition is present and applicable - it is not always mandatory.
A patient is treated for a fractured femur resulting from a fall from a ladder at a construction site. In addition to the fracture code, what additional code type is required by ICD-10-CM?
Answer: An external cause code (V00-Y99) for the mechanism and place of injury
ICD-10-CM Guidelines require external cause codes (Chapter 20, V00-Y99) to capture the mechanism of injury (fall from ladder) and place of occurrence (construction site) when injuries are coded.
What does the ICD-10-CM guideline state about coding 'probable' or 'suspected' diagnoses in the outpatient setting?
Answer: Do not code the probable diagnosis; code the signs, symptoms, or condition documented
In outpatient settings, ICD-10-CM Guidelines prohibit coding probable, suspected, or 'rule out' diagnoses. Code the documented sign, symptom, or finding instead.