CONVENTIONS
What are NEC and NOS considered in the ICD-10-CM code book?
a. Abbreviations
b. Essential modifiers
c. Eponyms
d.Qualifiers
a. Abbreviations
When is it appropriate to use history of malignancy from category Z85?
a. Once the malignancy is removed from that site but the patient is still receiving chemotherapy.
b. When the patient cancels treatment for that site.
c. It has been excised, no evidence of any existing primary malignancy, and there is no further treatment directed to the site.
d. When five years has passed after surgery.
ANS: C
Rationale: ICD-10-CM guideline 1.C.2.m indicates that when a primary malignancy has been previously excised or eradicated from its site and there is no further treatment directed to that site and there is no evidence of any existing primary malignancy at that site, a code from category Z85 Personal history of malignant neoplasm is used to indicate the former site of the malignancy.
What does the 4th character in diabetes mellitus diabetes codes indicate?
a. The condition as controlled or uncontrolled.
b. Any complication associated with diabetes.
c. Type of diabetes (type 1, type 2, secondary).
d. If the diabetes is primary or secondary diabetes.
ANS: B
Rationale: The 4th character in diabetes mellitus codes indicates the complication associated with diabetes. For example, subcategory code E10.2 indicates a person that has renal (kidney) complications due to diabetes.
Three-character ICD-10-CM codes represent what level of code in the ICD-10-CM?
A. Section
B. Category
C. Subcategory
D. Subclassification
B. Category
What type of code is assigned when the provider documents the reason for a patient seeking healthcare services that is not for an injury or disease?
a. External cause code (V00-Y99)
c. Non-specific code
b.ICD-10-PCS code
d. Z code (Z00-Z99)
d. Z code (Z00-Z99)
What is the sequencing order when coding a sequela (late effect)?
a. The cause of the late effect is coded first and the residual condition is coded second.
b. The symptom is coded first followed by the residual condition and the late effect code.
c. The cause of the late effect is coded first; the residual condition is coded second followed by the symptoms.
d. The residual condition is coded first, and the code(s) for the cause of the late effect are coded as secondary.
ANS: D
Rationale: Per ICD -10-CM guideline 1.B.10 coding of sequela (late effects) generally requires two codes sequenced in the following order: The condition or nature of the late effect is sequenced first and the late effect code is sequenced second. Exceptions to this guideline are those instances where the code for the late effect is followed by a manifestation code in the Tabular List and title or the late effect code has been expanded to include the manifestation.
If a diabetic patient uses insulin, and the type of diabetes is not documented, what type of diabetes would be coded according to ICD-10-CM guidelines?
a. Secondary diabetes
b. The use of insulin does not specify that a patient is a certain type of diabetes
c. Type 1
d. Type 2
ANS: D
Rationale: Some patients with type 2 diabetes mellitus are unable to control their blood sugar through diet and oral medication alone and do require insulin. If the documentation in a medical record does not indicate the type of diabetes but does indicate that the patient uses insulin, the diabetes is reported as type 2. Refer to ICD-10-CM guidelines I.C.4.a.3.
Referencing ICD-10-CM guideline I.B.10, what is the time limit when assigning codes as sequela?
A. At least six months beyond the injury or illness causing the sequela.
B. At least two years beyond the injury or illness causing the sequela.
C. There is no time limit on sequelae.
D. There is a sliding scale of time limits on sequelae in the ICD-10-CM appendix.
C. There is no time limit on sequelae.
In the ICD-10-CM Alphabetic Index what is the code next to the main term called?
a. Category Code
c. Default Code
b. Subcategory Code
d. Unspecified Code
c. Default Code
In the ICD-10-CM Alphabetic Index next to Hypertension, what do the terms in parentheses indicate?
a. Hypertension cannot be coded unless one of those words is documented with hypertension in the diagnosis.
b. Hypertension needs two codes assigned.
c. Supplementary words that can be present or absent with the diagnosis hypertension and does not affect the code to which it is assigned.
d. Look at another main term to find that type of hypertension.
ANS: C
Rationale: ICD-10-CM guideline I.A.7 states parentheses are used to enclose supplementary words that may be present or absent in the statement of disease or procedure, without affecting the code number to which it assigned.
In ICD-10-CM what condition is reported as the default code when the provider documents urosepsis?
a. Urinary tract infection (UTI)
b. Sepsis
c. Severe Sepsis
d. The provider must be queried before an ICD-10-CM code can be applied.
ANS: D
Rationale: ICD-10-CM guideline I.C.1.d.1.a.(ii) indicates urosepsis is a nonspecific term. It is not to be considered synonymous with sepsis. Urosepsis does not have a default code. If the provider documents urosepsis without additional information, the provider must be queried before an ICD-10-CM code can be applied.
Name an example of when a problem caused by diabetes is NOT sequenced after the code for diabetes.
A. When a patient’s insulin pump malfunctions
B. When the patient has type 2 diabetes
C. When the patient has type 1 diabetes
D. When the patient has end-stage renal disease caused by diabetes
Refer to ICD-10-CM guideline I.C.4.a.5.a.
A. When a patient’s insulin pump malfunctions
What is an example of an eponym?
a. Neuropathy
c. Salpingo-oophoritis
b. Paget’s disease
d. Xanthoma
b. Paget’s disease
Which of the following statements is TRUE in reference to reporting body mass index (BMI) codes?
a. BMI codes should be reported as primary codes only.
b. BMI codes should be reported as a secondary code only.
c. BMI codes should never be reported in ICD-10-CM.
d. BMI codes are only reported with the ICD-10-CM code E66.3 for overweight.
ANS: B
Rationale: ICD-10-CM guideline I.B.14 indicates that BMI codes are reported as secondary diagnoses. In the Tabular List, BMI codes can be reported with any code in subcategory E66.-, not just code E66.3.
According to ICD-10-CM guidelines, what is the maximum length of time for a myocardial infarction to be considered acute?
a. One week
c. Eight weeks
b. Four weeks (28 days)
d. Only at the time of occurrence
ANS: B
Rationale: In ICD-10-CM guideline I.C.9.e.1, myocardial infarctions are classified as acute if the duration is four weeks (28 days) or less from onset. In the Tabular List the Includes note also lists this under category code I21.
Which of the following does NOT require documentation for a cause-and-effect relationship to be coded? (Reference
guidelines I.C.9.a and I.C.9.a.3)
A. Cerebrovascular hemorrhage due to an operation
B. Hypertension and chronic kidney disease
C. Hypertension and encephalopathy
D. All require cause and effect to be documented
Answer: B. Hypertension and chronic kidney disease Rationale:
ICD-10-CM guideline 1.C.9.a.2 - Section I.C.9.a.3, state that hypertension has a presumed cause-and-effect relationship with CKD.
When a patient has a condition that is both acute and chronic and there are separate entries for both, how is it reported?
a. Code only the acute code
b. Code both sequencing the chronic first
c. Code both sequencing the acute first
d. Code only the chronic code
ANS: C
Rationale: According to the ICD-10-CM guideline 1.B.8 if the same condition is described as both acute (subacute) and chronic and separate entries exist in the ICD-10-CM Alphabetic Index at the same indentation level, code both and sequence the acute (subacute) first.
According to ICD-10-CM guidelines, when a patient is seen for management of anemia due to malignancy, how is it reported?
a. Anemia is the only condition reported.
b. The malignancy is the only condition reported.
c. The malignancy is reported first, followed by the code for the anemia.
d. Anemia is reported first, followed by the code for the malignancy.
ANS: C
Rationale: ICD-10-CM guideline I.C.2.c.1, when the patient is being seen for management of the anemia associated with malignancy, the code for the malignancy is reported first, followed by the appropriate code for the anemia (for example D63.0 Anemia in neoplastic disease).
When it is documented that the patient is both using tobacco and has a dependence on tobacco, how is this reported in ICD-10-CM?
a. The use of tobacco is the only code reported because it is considered acute.
b. The dependence on tobacco is the only code reported based on the hierarchy in the ICD-10-CM guidelines.
c. The use of tobacco and the dependence on tobacco are both reported.
d. The use of tobacco is reported with a code for history of tobacco use to report the dependence on tobacco.
ANS: B
Rationale: In ICD-10-CM guideline I.C.5.b.2, there are codes for use, abuse, and dependence. Only one code is assigned to identify the pattern of use. This is based on the following hierarchy, listed in order of priority: dependence, abuse, use. If the documentation shows both use and dependence, only dependence is reported.
If an ST elevation myocardial infarction converts to a non-ST elevation myocardial infarction in the course of thrombolytic therapy, how is it coded? (Reference ICD-10-CM guideline I.C.9.e.1)
A. Sequence STEMI first, then NSTEMI
B. Sequence NSTEMI first, then STEMI
C. Code only STEMI
D. Code only NSTEMI
Answer: C. Code only STEMI
Rationale: ICD-10-CM guideline 1.C.9.e.1, states that if STEMI converts to NSTEMI due to thrombolytic therapy, it is still coded as STEMI.