Week 1 Lab - Marketa Benedetti - HIT 103

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City Colleges of Chicago, Malcolm X *

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103

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Mechanical Engineering

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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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