What does ICD-10-CM stand for?
ICD-10-CM stands for International Classification of Diseases, 10th Revision, Clinical Modification, used for diagnostic coding in the U.S.
When coding a diagnosis, which should be reported first?
The principal diagnosis is always listed first. It reflects the main reason for the healthcare encounter.
What symbol in ICD-10-CM indicates that another code is needed to fully describe the condition?
The 'code first' instruction or the use of slashes (/) may indicate that multiple codes are required for specificity.
Which section of the CPT manual contains evaluation and management codes?
The E/M codes are used to bill for patient encounters and are found at the beginning of the CPT manual.
How should a coder handle a diagnosis described as 'probable' or 'suspected' in outpatient coding?
In outpatient coding, uncertain diagnoses (e.g., 'probable') should not be coded as confirmed conditions; instead, code the symptoms.
Which of the following is a placeholder character used in ICD-10-CM?
The letter 'X' is used as a placeholder when a code requires a 7th character but there are fewer than six characters before it.
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What is the correct sequence if both acute and chronic conditions are coded?
According to ICD-10-CM guidelines, when both acute and chronic versions of a condition are documented, the acute condition is listed first.
What does the term 'code also' mean in coding guidelines?
'Code also' means a second code may be required to give a full picture of the condition or procedure.
Which coding convention is used to indicate a condition that should not be coded together with another?
The 'Excludes1' note means the two conditions cannot be coded together, as the excluded condition is not part of the coded condition.