Week 1 Lab - Marketa Benedetti - HIT 103

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Apr 3, 2024

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Marketa Benedetti January 28, 2024 HIT 103: Basic ICD-10-CM/PCS Coding Lab – Week 1 Student Learning Outcomes • Apply ICD-10-CM Official Coding Guidelines and Conventions for diagnostic coding. • Apply ICD-10-CM current regulations and established policies in code assignments. • AHIMA Competencies – Explain the use of classification systems, clinical vocabularies, and nomenclatures. 1. What is the definition of a "procedure"? A procedure refers to a medical or surgical activity performed by a healthcare provider on a patient to diagnose, treat, or prevent a medical condition. Procedures are often coded using specific codes to facilitate billing, record-keeping, and statistical analysis. 2. What is the definition of a diagnosis? Diagnosis refers to the identification of a disease, condition, or injury through a systematic process of examining symptoms, medical history, and diagnostic tests. In medical coding, diagnoses are assigned specific codes, from the International Classification of Diseases (ICD) system, to represent the patient’s health condition for billing and documentation purposes. 3. According to the HIPAA Electronic Transactions and Coding Standards Rule, what are the medical coding standards that are mandated for use in the United States? The Health Insurance Portability and Accountability Act (HIPAA) Electronic Transactions and Code Sets Rule mandates the use of certain medical coding standards in the United States. These include: • ICD-10-CM (International Classification of Diseases, 10th Edition, Clinical Modification) for diagnosis coding • CPT (Current Procedural Terminology) for outpatient & professional services coding

Marketa Benedetti January 28, 2024 • HCPCS (Healthcare Common Procedure Coding System) for procedures, services, and supplies not covered by CPT 4. What is the definition of a "Nonessential Modifier"? A nonessential modifier is an additional descriptor that provides extra information about a procedure or service but is not required for the code assignment. It does not affect the code's meaning or reimbursement but may offer additional details for clarification or specificity. 5. What is the definition of an Eponym? An eponym is a term derived from the name of a person, often a physician or scientist, who first identified a particular disease, medical condition, surgical procedure, or anatomical part. Eponyms are commonly used in medicine to honor individuals who made significant contributions to the field. 6. What is the difference between an "Excludes 1" Note and an "Excludes 2 Note"? • Excludes 1 Note: Indicates that the excluded code should never be used with the code from which it is excluded. The two conditions cannot occur together. • Excludes 2 Note: Indicates that the excluded code should not be used with the code from which it is excluded unless both conditions are present. They may coexist under certain circumstances. 7. What is the difference between a "Code First" and a "Use Additional Code" instructional note? • Code First: Instructs the coder to sequence the primary code first, followed by the code(s) mentioned in the note. It indicates that the primary condition should be coded before any associated secondary conditions. • Use Additional Code: Instructs the coder to add one or more additional codes to provide a more complete picture of the patient's condition. These codes are supplemental and should be used in addition to the primary code.

Marketa Benedetti January 28, 2024 8. Refer to code category B58 in the ICD-10-CM coding book. What condition is excluded from this category? Code category B58 = Toxoplasmosis What is excluded? Congenital Toxoplasmosis (P37.1) 9. Refer to code C73 in the ICD-10-CM coding book. What additional direction is given to a coder for the use of this code? C73 = Malignant neoplasm of thyroid gland What additional direction is given?  Use additional code to identify any functional activity 10. Refer to code G90.4 in the ICD-10-CM coding book. List two of the conditions that are included under the "Use additional code" note. G90.4 = Autonomic dysreflexia Conditions listed under the “Use additional code” note:  fecal impaction (K56.41)  pressure ulcer (pressure area) (L89.-)  urinary tract infection (N39.0) 11. Refer to code K62.89 in the ICD-10-CM coding book. What additional direction is given to a coder for the use of this code? K62.89 = Other specified diseases of anus and rectum Proctitis NOS  Use additional code for any associated fecal incontinence (R15.-) 12. Refer to subcategory N39.4 in the ICD-10-CM coding book. List the names and titles of three of the subdivision codes included in this section. N39.4 = Other specified urinary incontinence Subdivision codes included in this section are as follows: • N39.41 – Urge incontinence • N39.42 – Incontinence without sensory awareness

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Marketa Benedetti January 28, 2024 • N39.43 – Post-void dribbling • N39.44 – Nocturnal enuresis • N39.45 – Continuous leakage • N39.46 – Mixed incontinence 13. What is the definition of the term "sequela"? Sequela refers to a condition that is the residual effect or aftereffect of a previous disease or injury. In medical coding, sequela codes are used to indicate the chronic or residual nature of a condition resulting from a past illness or injury. 14. When coding for impending or threatened conditions, if the condition did not occur, what direction should the coder follow in order to accurately code the condition? If the condition did not occur , the coder should use the appropriate code for the specific signs and symptoms or abnormal findings associated with the impending or threatened condition. This allows for accurate coding even if the condition did not fully manifest. 15. What is the difference between a 'See' and a 'See Also' instructional note? • 'See' – Directs the coder to refer to another term or code for additional information, clarification, or the correct code assignment. • 'See Also' – This indicates that there may be additional, related terms or codes worth considering for a more comprehensive understanding. 16. What is the difference between the abbreviations 'NEC' and 'NOS'? • NEC (Not Elsewhere Classified): Indicates that the code does not fit into any other category and provides a specific code for an unspecified condition within a broader category. • NOS (Not Otherwise Specified): Indicates that the information available does not provide enough detail to assign a more specific code, and a general code is used to represent the condition.

Marketa Benedetti January 28, 2024 17. As it pertains to ICD-10-CM, what is a 'connecting word' and list four examples of connecting words. Connecting words in ICD-10-CM help link essential modifiers or terms. Examples include: • And • With • In • Of 18. Refer to category code S31 in your CPT coding book. Based on the information in this category, what does the placeholder character 'D' represent? S31 = Open wound of abdomen, lower back, pelvis and external genitals Placeholder characters are as follows: A = initial encounter D = subsequent encounter S = sequela 19. Refer to the chapter-specific guidelines for Tabular List Chapter 20. Based on the guidelines, what is the definition of a 'non-traffic' accident? In medical coding, a non-traffic accident refers to incidents that don't involve motor vehicles on public roads. These are categorized in Chapter 20: External Causes of Morbidity, specifically in the V00-V99 series. Accurate coding requires attention to detail in documenting the circumstances. Examples of non-traffic accidents include: • Falls • Home accidents • Workplace injuries • Recreational incidents Proper coding ensures an accurate representation of the patient's condition, serving billing, statistical, and research purposes effectively. 20. Refer to code Z71.3. List an instructional note that provides additional information for the use of this code?

Marketa Benedetti January 28, 2024 Z71.3 = Dietary counseling and surveillance Instructional note that provides additional information for the use of code : - Use additional code for any associated underlying medical condition - Use additional code to identify body mass index (BMI), if known (Z68.-)

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