DIABETES
What documentation is required to support the diagnosis of Nephropathy?
What is a renal biopsy?
What reduces the risk of disease progression and disability in RA?
What are DMARDs?
What are the 3 categories / levels for cancer?
(think order of occurrence)
What are Primary, Secondary, History of?
Where are the criteria for Major Depression defined?
What is DSM-V?
Documentation of how many drinks of alcohol are considered “moderate”?
What are:
MALES: </= 2/day
FEMALES: 1/day
(unless contraindicated)
When diagnosing
DM w/CKD,
what other ICD-10 code must be documented?
What is the CKD Stage?
(N18.1–N18.6)
In RA,
joint involvement is characteristically
unilateral or bilateral?
What is bilateral?
What category / level of Cancer does
Active treatment
belong with?
What is Primary or Secondary?
Documentation of what 3 conditions are required to diagnose Major Depression
(DSM-V criteria)?
DAILY DOUBLE
What are:
1. 5 of 9 specific symptoms,
2. occurring in the same
2-week period,
3. with change in previous
function (not d/t another
reason)?
DAILY DOUBLE
Documentation of how many drinks are considered
Hazardous or Risky for people >65 y/o?
DAILY DOUBLE
What are:
FEMALES:
>7 drinks / week OR
>3 drinks / occasion
MALES:
14 drinks / week OR
>4 drinks / occasion
DAILY DOUBLE
Ophthalmic, Renal, Circulatory, Skin, Neurological Comorbidities
What are types of Diabetic Secondary Complications?
Name 3 organs/systems
(other than joints)
that RA inflammation can affect
DAILY DOUBLE
What are:
Heart (pericardial sac), lungs, eyes, mouth,
blood vessels (WBCs), nerves, spleen (Felty’s)?
DAILY DOUBLE
What category / level of Cancer does
Prophylactic treatment belong with?
What is History of?
What Depression screening tools are commonly used?
What are:
PHQ-2 ,PHQ-3, PHQ-9?
(Also other screening tools or Clinical Interview are acceptable)
What screening tools are commonly used for Alcohol Use / Abuse / Dependence?
What are:
CAGE
T-ACE
AUDIT
Single Question ?
What additional documentation is needed for Insulin-Dependent DM patients?
What is
Document patient is taking Long-Term (current) Use of Insulin in note and assign code Z79.4 ?
What 3 factors should be documented to reach the specific RA diagnosis
ICD-10 code?
What are:
1. W/ or W/O Rheumatoid
Factor (sero+/sero-)
2. Site
3. Laterality
What levels of specificity should be documented for Breast Cancer?
What are
Laterality and Gender? (ICD-10 codes
5th and 6th characters)
How often can the PHQ-9 test be administered?
What is every 2 weeks?
What are the 3 categories for documenting
Alcohol consumption?
What are Alcohol Use, Abuse, Dependence?
“Uncontrolled DM”
in ICD-9 is now called what in ICD-10?
What is Type 2 DM with Hyperglycemia? (E11.65)
What is the only condition that
does NOT require an
ICD-10 code 6th character
in RA?
What is “Unspecified site?”
(M06.00,
M05.00 – M05.90)
What is the
difference in documentation between Active Cancer and History of Cancer?
What is Active has current treatment stated (C Code), History of has no active treatment stated (Z Code)?
How long can a
Single Episode of Depression last?
What is a lifetime?
If Alcohol Use, Abuse and Dependence are documented, what ICD-10-CM code should be assigned?
What is Alcohol Dependence?