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ICD-10-CM Coding Conventions
General ICD-10-CM Guidelines
Steps To Correct Coding
True or False
Miscellaneous
100
It has 2 uses- 1)as the fifth character for certain character codes 2) it provides for future expansion without disturbing the 6th character structure.
What is Placeholder "X"
100
If no bilateral code is provided, code left and right.
What is true?
100

Identify the reason for the visit or encounter (i.e., a sign, symptom, diagnosis and/or condition).

What is Step I?

100

 Uncertain diagnoses may be reported if documented at the time of discharge.

What is true?

100
It stands for Clinical Modification.
What is the CM in ICD-10-CM?
200
This character provides further specificity about the condition being coded.
What is the 7th character?
200
In ICD-10-CM, any condition that arises during or after surgery should be considered a complication.
What is false. The code should be assigned based on the providers documentation of a causal relationship.
200

Locate the main term entry

What is "step 3"?

200

Always turn to the tabular list first

What is false?

200

_________ enclose manifestation codes that can be used only as secondary codes to the underlying condition code immediately preceding

What are Brackets?

300
When this note appears, it is acceptable to code both conditions.
What is "Excludes 2" note?
300
The letters "I" and "O" are only used in the first character.
What is true? This is so that the letters I and O will not be confused with the numbers 1 and 0.
300

Choose a potential code and locate it in the tabular list.

What is step 6?

300

Nonessential modifiers, terms that are supplementary words or explanatory information affect the code selection 

What is 'false"?

300
Use this when the information in the medical record provides detail for a specific code that?does not exist.
What is “other” or “other specified?"
400
It is a "pure excludes" note.
What is "Excludes 1" note.
400
The patient presents for revision of a scar due to a burn. This is coded with the _______ sequenced first followed by the ________ code.
What is scar,burn(injury)
400

Consult the alphabetic index.

What is step II?

400

The  Alphabetic Index does not include the important instructional notes found in the tabular list.

What is "true"?

400

______________ are listed next to the main term and represent the condition most commonly associated with the main term or the unspecified code for the main term.

What are "default codes"?

500
In ICD-10-CM all inclusion notes ?contain all conditions for which a particular code number is to be used and are considered to be “exhaustive.”
What is false? Inclusion notes contain terms that are the condition for which that code number is to be used. The terms may be synonyms of the code title, or in the case ?of “other specified” codes, the terms are a list of various conditions assigned to that code. The inclusion terms ?are not necessarily exhaustive.
500

“See also” cross-references, identified by italicized type, provide alternative terms that you must look up 

What is false?

500

Sequence codes correctly

What is step 10? 

500

Choosing the main term that best describes the reason chiefly responsible for the service provided is the most important step in coding.

What is True

500

_______subterms are listed out of alphabetic order and identify a presumed causal relationship between the two conditions they link.

What is "with"?