ICD 10 Coding Guidelines 1 — Questions and Answers
Question 1: What should you code first in an outpatient encounter?
- The most severe condition
- The reason for the encounter or visit (Correct answer)
- The chronic conditions
- Symptoms only
Correct answer: The reason for the encounter or visit
In outpatient settings, the first-listed diagnosis is the condition chiefly responsible for the services provided during the encounter.
Question 2: When should you use an acute and chronic code together?
- Never
- When a condition has both an acute exacerbation and an underlying chronic condition, code both with the acute code first (Correct answer)
- Only for respiratory conditions
- Only in inpatient settings
Correct answer: When a condition has both an acute exacerbation and an underlying chronic condition, code both with the acute code first
When a patient has both acute and chronic forms of a condition, both should be coded, with the acute condition sequenced first.
Question 3: What is the 'code first' convention?
- Always code alphabetically
- Certain codes must be sequenced before others; the underlying condition is coded first followed by the manifestation (Correct answer)
- Code the first condition diagnosed
- An obsolete rule
Correct answer: Certain codes must be sequenced before others; the underlying condition is coded first followed by the manifestation
The 'code first' note indicates a manifestation code that requires the underlying disease to be coded first, establishing the etiology/manifestation relationship.
Question 4: Can you code a suspected or probable diagnosis in outpatient settings?
- Yes, always
- No, code only confirmed conditions or the signs/symptoms in outpatient settings (Correct answer)
- Only with physician approval
- Only for cancer
Correct answer: No, code only confirmed conditions or the signs/symptoms in outpatient settings
In outpatient settings, do not code suspected, probable, or rule-out diagnoses. Instead, code the signs, symptoms, or conditions to the highest degree of certainty.
Question 5: What is sequencing in ICD-10-CM?
- Putting codes in alphabetical order
- The order in which diagnosis codes are listed, with the principal/first-listed diagnosis sequenced first (Correct answer)
- Numbering codes
- A random arrangement
Correct answer: The order in which diagnosis codes are listed, with the principal/first-listed diagnosis sequenced first
Sequencing determines which diagnosis is listed first (principal diagnosis for inpatient, first-listed for outpatient) followed by additional diagnoses in order of relevance.
Question 6: What does 'code also' mean in ICD-10-CM?
- An optional instruction
- An instruction that two codes may be needed together to fully describe a condition, with either code potentially sequenced first (Correct answer)
- Code again in another system
- An error message
Correct answer: An instruction that two codes may be needed together to fully describe a condition, with either code potentially sequenced first
'Code also' indicates that both codes should be reported. Unlike 'code first,' sequencing depends on the circumstances of the encounter.
ICD 10 Coding Guidelines 1
What should you code first in an outpatient encounter?