ICD 10 Coding Basics 2 — Questions and Answers
Question 1: What are 7th character extensions used for in ICD-10-CM?
- Error codes
- Providing additional information such as initial encounter, subsequent encounter, or sequela (Correct answer)
- Billing amounts
- Provider identification
Correct answer: Providing additional information such as initial encounter, subsequent encounter, or sequela
The 7th character often indicates the encounter type: A (initial), D (subsequent), or S (sequela), particularly for injury and fracture codes.
Question 2: What does 'laterality' mean in ICD-10-CM coding?
- The direction of a procedure
- Specifying which side of the body (right, left, or bilateral) is affected (Correct answer)
- The severity of illness
- The duration of disease
Correct answer: Specifying which side of the body (right, left, or bilateral) is affected
ICD-10-CM includes laterality to identify whether a condition affects the right side, left side, or both sides, adding clinical specificity.
Question 3: What is a combination code in ICD-10-CM?
- Two codes combined into one
- A single code that classifies both the diagnosis and a common symptom, manifestation, or complication together (Correct answer)
- A code for multiple patients
- A merged billing code
Correct answer: A single code that classifies both the diagnosis and a common symptom, manifestation, or complication together
Combination codes classify two diagnoses or a diagnosis with a complication in a single code, reducing the need for multiple codes.
Question 4: What does 'unspecified' mean in an ICD-10-CM code?
- The code is invalid
- The documentation does not provide enough detail to assign a more specific code (Correct answer)
- The disease is unknown
- The patient refused diagnosis
Correct answer: The documentation does not provide enough detail to assign a more specific code
Unspecified codes are used when clinical documentation lacks the detail needed for a more specific code. They should be avoided when more specific information is available.
Question 5: What is the Excludes1 note in ICD-10-CM?
- A list of included conditions
- A note indicating two conditions cannot occur together, so the codes should never be reported together (Correct answer)
- A list of related codes
- An obsolete notation
Correct answer: A note indicating two conditions cannot occur together, so the codes should never be reported together
Excludes1 means 'not coded here.' The excluded condition and the code cannot be used together because the two conditions cannot coexist.
Question 6: What is the principal diagnosis?
- The most expensive diagnosis
- The condition established after study to be chiefly responsible for the patient's admission to the hospital (Correct answer)
- The first diagnosis listed
- The most severe condition
Correct answer: The condition established after study to be chiefly responsible for the patient's admission to the hospital
The principal diagnosis is determined after evaluation and is the condition that prompted the inpatient admission, which may differ from the admitting diagnosis.
ICD 10 Coding Basics 2
What are 7th character extensions used for in ICD-10-CM?