ICD Flashcards

In ICD-10-CM, what does the letter that begins each code generally represent?

Answer: The category of disease or body system

The first character is always a letter that broadly indicates the chapter or category of the condition.

What is the maximum number of characters an ICD-10-CM diagnosis code can contain?

Answer: 7

ICD-10-CM codes can be up to seven characters long for full specificity.

Which character position in an ICD-10-CM code is reserved for the seventh-character extension such as encounter type?

Answer: Seventh

The seventh character captures details like initial encounter, subsequent encounter, or sequela.

The seventh-character 'A' in an injury code most commonly indicates which encounter type?

Answer: Initial encounter

The letter 'A' designates the initial encounter while the patient receives active treatment.

What does the seventh-character 'S' designate in ICD-10-CM injury coding?

Answer: Sequela

The 'S' character identifies a sequela, a condition that arises as a direct result of a prior injury.

When a code requires a seventh character but only has three to five characters, what must be used as a placeholder?

Answer: The letter X

The dummy placeholder 'X' fills empty character positions so the seventh character lands in the correct spot.

ICD-10-CM is primarily used in the United States for which purpose?

Answer: Diagnosis coding and reporting

ICD-10-CM is the U.S. clinical modification used for reporting diagnoses across healthcare settings.

In the ICD-10-CM coding convention, what does the abbreviation 'NOS' mean?

Answer: Not otherwise specified

NOS means 'not otherwise specified' and corresponds to an unspecified code.

What does the abbreviation 'NEC' indicate in ICD-10-CM?

Answer: Not elsewhere classifiable

NEC means 'not elsewhere classifiable,' used when no specific code exists for a documented condition.

An 'Excludes1' note in ICD-10-CM means what?

Answer: The excluded code should never be used with the code above it

Excludes1 is a pure exclusion meaning the two conditions cannot be reported together.

An 'Excludes2' note in ICD-10-CM indicates what?

Answer: The condition is not part of the code but may be coded together if present

Excludes2 means the excluded condition is separate, and both codes may be assigned if both are present.

In the Alphabetic Index, what do brackets [ ] around a code or term typically enclose?

Answer: Synonyms, alternative wording, or explanatory phrases

Brackets enclose synonyms, alternative terms, or explanatory phrases in the index and tabular list.

The instructional note 'Code first' in ICD-10-CM directs the coder to do what?

Answer: Sequence the underlying condition before the manifestation

'Code first' indicates an underlying etiology must be sequenced before the manifestation code.

What does a 'Use additional code' note instruct the coder to do?

Answer: Add a secondary code to fully describe the condition

This note signals that an additional code is needed to capture more detail, such as an infectious agent.

A patient returns for routine follow-up during the healing phase of a fractured wrist. Which seventh character is most appropriate?

Answer: D (subsequent encounter)

The 'D' character is used for subsequent encounters during the routine healing or recovery phase.

When laterality is required but the affected side is not documented, what should the coder do?

Answer: Assign the unspecified-side code

If documentation does not state the side, an unspecified laterality code is assigned.

For a patient seen for an injury caused by a fall, which type of code captures how the injury happened?

Answer: An external cause code (V–Y)

External cause codes (V00–Y99) describe the circumstances, like a fall, that led to the injury.

A patient comes in solely for a routine general health checkup with no complaints. The appropriate first-listed code is most likely from which series?

Answer: Z codes (encounter for exam)

A Z code for an encounter for a general examination is reported when there is no active disease.

When coding a suspected condition documented as 'rule out' in the outpatient setting, what does ICD-10-CM guidance direct?

Answer: Code the signs, symptoms, or reason for the visit instead

In outpatient coding, unconfirmed diagnoses are not coded; the documented signs and symptoms are reported instead.

A combination code in ICD-10-CM is best described as a single code that does what?

Answer: Classifies two diagnoses or a diagnosis with an associated complication

A combination code captures two diagnoses, or a diagnosis with a manifestation or complication, in one code.