Practical Applications Flashcards

A patient had breast cancer excised two years ago, has no evidence of disease, and receives no treatment. How is this reported?

Answer: Z85.3

When the primary malignancy has been excised or eradicated with no further treatment and no evidence of disease, a personal history Z85 code is used.

A patient presents only to receive an influenza vaccination. Which code is first-listed?

Answer: Z23

Z23 is encounter for immunization, reported with the appropriate procedure code for the vaccine.

A stage 3 pressure ulcer of the sacral region is documented. Which code is correct?

Answer: L89.153

L89.153 is pressure ulcer of sacral region, stage 3 (the last digit indicates stage).

A dietitian documents a BMI of 38, and the physician documents obesity. Can the BMI code be reported?

Answer: Yes, BMI may come from other clinicians but the associated diagnosis must be provider-documented

BMI can be taken from clinicians other than the provider, but the associated diagnosis such as obesity must be documented by the provider.

At inpatient discharge, the attending documents 'suspected pneumonia' and it remains uncertain. How does a hospital coder report it?

Answer: Code it as if it existed

For inpatient admissions to short-term acute care hospitals, uncertain diagnoses at discharge are coded as if established.

A patient stopped taking an antihypertensive because of cost, resulting in uncontrolled hypertension. Which sixth character in the T46 code identifies underdosing?

Answer: 6

Underdosing codes use the character 6 (for example T46.5X6A), with a Z91.12-/Z91.13- code for the reason.

A patient is documented as nicotine dependent on cigarettes with no complications. Which code is correct?

Answer: F17.210

F17.210 is nicotine dependence, cigarettes, uncomplicated; Z72.0 is for tobacco use without dependence.