Practical Applications Flashcards

In the outpatient setting, a physician documents 'probable pneumonia.' How should the coder report the visit?

Answer: Code the signs and symptoms documented

Outpatient guidelines prohibit coding uncertain diagnoses (probable, suspected), so signs and symptoms are coded instead.

A patient has an annual physical exam and an abnormal finding is discovered during the exam. Which code is correct?

Answer: Z00.01

Z00.01 is encounter for general adult medical examination with abnormal findings, with the finding coded additionally.

Which statement about external cause codes (V00–Y99) is correct?

Answer: They are never sequenced first

External cause codes are secondary codes and are never reported as the first-listed or principal diagnosis.

Why does code T36.0X1A include the letter X in the fifth position?

Answer: It is a placeholder so the seventh character stays in position seven

The X placeholder fills unused character positions so that the 7th character is in the correct place.

A pregnant patient is seen for a urinary tract infection and the provider does not state the pregnancy is incidental. Which codes are sequenced first?

Answer: Chapter 15 (O) codes

Chapter 15 codes have sequencing priority over other chapters unless the provider documents the pregnancy is incidental.

A patient has COPD with an acute exacerbation. Which code is most specific?

Answer: J44.1

J44.1 is chronic obstructive pulmonary disease with (acute) exacerbation.

A manifestation code has a 'code first underlying condition' note. How can it be reported?

Answer: Only as a secondary diagnosis after the etiology code

Manifestation codes cannot be first-listed; the underlying condition is sequenced first.