ICD-10-CM Guidelines Chapter 1-3

HIV

100

What is the code for a confirmed case of HIV/AIDS?

B20

200

What is the code for HIV counseling after HIV testing, when the result is POSITIVE?

Z21 with no symptoms; B20 if there are symptoms

300

How do you code for an inconclusive laboratory report for HIV testing?

R75

400

TRUE/FALSE - If the patient previously had symptoms and was diagnosed with B20 (HIV), but has been symptom free for 25 years, if he goes to the doctor, it is ok to code Z21 asymptomatic HIV

FALSE - Once the patient is diagnosed with B20, the coder MAY NEVER USE ANY OTHER HIV related code for this patient

500

If the person is pregnant, and the HIV disease is complicating the pregnancy, how do you code for the encounter?

O98.7, B20

Sepsis

100

Code for Severe Sepsis

R65.2

200

Urosepsis is synonymous with Sepsis

False. See guideline d.1.a(ii) Urosepsis

300

There is an implied causal relationship between all post procedural complications and sepsis.

False. Code assignment is based on provider's documentation of the relationship between the infection and the procedure.

400

TRUE or FALSE: Septic shock generally refers to circulatory failure associated with severe sepsis, and thus represents a type of acute organ dysfunction

TRUE

500

Sepsis with organ failure is considered severe sepsis

TRUE

Sequencing

100

When trying to determine sequencing, the first question you should ask is?

What is the reason for the encounter.

200

Codes from Chapter ____ take sequencing priority.

15 (Pregnancy)

300

A code from R65.2 can be coded first (first listed diagnosis)?

FALSE

400

Carol goes to the doctor to discuss a lump she felt in her breast. She tells the doctor that there is a history of breast cancer in the family, as well as a history of diabetes and colon cancer. What do you code (in general, not specific codes)

Code for the lump in the breast, then history of breast cancer in the family. Some would argue that the history of diabetes and history of colon cancer are not pertinent to the encounter, so they would not be coded.

500

Patient with diagnosed AIDS comes to the physician because he fell and hurt his wrist. The doctor diagnoses a fractured left wrist. How do you code for this encounter?

(1) Code the fractured wrist, (2) B20 because he has AIDS

Neoplasms

100

The "first" cancer is considered the ___________ cancer.

PRIMARY

200

You can have more than one primary cancers, and more than one secondary cancers.

FALSE. You can have 1 primary cancer; you can have multiple secondary cancers.

300

Neoplasm is another name for ____________

Cancer/Tumor

400

Personal history of malignant neoplasm is Z58

FALSE. Z85

500

When does a cancer become part of the persons personal history of malignant neoplasm?

When there is no further treatment directed to that site and there is no evidence of any existing primary malignancy. (see guideline d in Chapter 2: Neoplasms)

MRSA

100

What does MRSA stand for?

Methicillin Resistant Staphylococcus Aureas

200

When a person has HIV, and the encounter is for an unrelated HIV condition, how do you code for the encounter? (in general terms, not exact ICD-10-CM codes)

First code for the unrelated HIV condition, then code for HIV/AIDS

300

MRSA and MSSA are the same thing

FALSE - MRSA = Methicillin RESISTANT Staphylococcus Aureus; MSSA = Methicillin SUSCEPTIBLE Staphylocuccus Aureas

400

If the reason for admission is both sepsis or severe sepsis and a localized infection, how should this be coded?

Code first the underlying systemic infection, and then code for the localized infection. If patient has severe sepsis, R65.2 should also be assigned as a secondary diagnosis.

500

What is SIRS?

Systemic Inflammatory Response Syndrome