Coding Guidelines and Conventions Flashcards
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Read the first 7 Coding Guidelines and Conventions flashcards as text
According to ICD-10-CM obstetric coding guidelines, which Z code must be reported as an additional code to indicate the outcome of delivery?
Answer: Z37 – Outcome of delivery
A Z37 code (Outcome of delivery) is required as an additional code on the mother's delivery record to specify the number of liveborns and stillborns.
When a patient undergoes an amniocentesis for diagnostic purposes, which CPT code category is appropriate?
Answer: 59000 – Amniocentesis, diagnostic
CPT 59000 is specifically designated for diagnostic amniocentesis, while therapeutic amniocentesis has a separate code (59001).
The ICD-10-CM instruction 'Use additional code' means:
Answer: An additional code should be assigned to provide more detail or specify an associated condition
A 'Use additional code' instruction directs the coder to assign a secondary code to provide more complete information about the patient's condition, such as an organism or causal substance.
In CPT, Category III codes are used for:
Answer: Emerging technologies, services, and procedures that do not yet have Category I codes
CPT Category III codes are temporary codes assigned to emerging technologies and procedures that lack sufficient data for permanent Category I status.
When a cesarean delivery is performed due to a failed trial of labor after previous cesarean (TOLAC), which ICD-10-CM code category applies?
Answer: O66.41 – Failed attempted vaginal birth after previous cesarean delivery
O66.41 specifically identifies a failed attempted VBAC (TOLAC) that results in cesarean delivery, making it the most precise code for this scenario.
Which ICD-10-CM coding convention indicates that a note applies to all codes in a section, not just the code under which it appears?
Answer: Section-level instructional note
Section-level (or block-level) instructional notes in ICD-10-CM apply to all codes within the specified section or block, not merely the individual code where they are printed.
A patient at 32 weeks gestation is seen in the office for supervision of a high-risk pregnancy due to advanced maternal age. Which code set applies?
Answer: O09.523 – Supervision of elderly multigravida, third trimester
At 32 weeks gestation (third trimester), supervision of elderly multigravida is coded O09.523, which specifies the third trimester for a patient with advanced maternal age who has had prior deliveries.