Show:
Structure - DX/PCS
Dx Guidelines - Pt 1
Dx Guidelines - Pt 2
Dx Guidelines - Pt 3
PCS Guidelines
100
The character "X" is used for future expansion.
What is true?
100
In the absence of Alphabetical Index guidance, assign codes for the documented manifestations of this . Additional codes for manifestations that are not an integral part of the disease process may also be assigned when the condition does not have a unique code.
What is Syndromes?
100
There are chapter specific coding guidelines, such as in obstetrics, poisoning, HIV and NB that take precedent in sequencing when Acute Respiratory Failure is a principal dx.
What is true?
100
Cast change or removal, removal of external or internal fixation device, or medication adjustment are examples of this 7th character.
What is "D"? Subsequent Encounter (aka aftercare)
100
The procedure codes in these body systems should only be used when the procedure is performed on an anatomical region rather than a specific body part.
What is general anatomical regions?
200
This note indicates that the condition is not part of the condition represented by the code, but the patient may have both conditions at the same time.
What is Excludes2?
200
Certain infections are classifed in chapters other than Chapter 1 and no organism is identified as part of the infection code. In these instances, it is not necessary to use an additional code from category B95, B96 and B97.
What is false? It is necessary to use an additional code from these categories to code to describe the infection.
200
Code only confirmed cases of influenza due to certain identified viruses. Confirmation requires documentation of a positive laboratory finding.
What is false? Coding should be based on the provider's diagnostic statement for the patient that has Avian Flu or other Novel Influenza A. H1N1 or H3N2 not identified as novel or variant also qualify.
200
When a fracture is not specified using these two indicators, the fracture should be coded to this.
What is closed and displaced?
200
Lower body parts specifics body parts located above and below the diaphragm.
What is false? Lower body parts are below the diaphragm.
300
This code represents the condition most commonly associated with the main term, or is the unspecified code for the condition.
What is the default code?
300
A cause and effect relationship is presumed for hypertension and heart disease.
What is false? A causal relationship must be 'stated' or 'implied' in order to assign a code from I11.
300
In NB coding, the default is due to community acquired when a NB has a condition that can be due to either the birth process or community acquired - and there is no definitive documentation.
What is false? The default is due to the birth process.
300
Encounters for Rehab: The first code to be sequenced first should represent this condition.
What is the condition for which the service is being performed? Such as hemiplegia.
300
Intended procedures that are discontinued should be coded to the root operation performed. If the procedure is discontinued before any root operation is performed, do not code anything.
What is false? If a procedure is discontinued before any other root operation is performed, code the root operation Inspection of the body part or anatomical region.
400
These tables should always be consulted to find the most appropriate valid code.
What is the PCS tables?
400
A primary malignant neoplasm that overlaps two or more contiguous sites should be classified to the subcategory / code .8 unless the combination is specifically indexed elsewhere. Tumors in different quadrants of the same breast is an example.
What is false? Tumors in the different quadrants of the same breast should have individual codes assigned for each site.
400
A malformation/deformation/or chromosomal abnormality may be the principal / first listed diagnosis on a record?
What is true? It can also be a secondary diagnosis.
400
Z79 - Long term drug therapy can be assigned for medications administered for a brief period of time.
What is false? This category should be assigned for medication received for an extended period of time for prophylactic, chronic or a disease requiring a lengthy course of treatment.
400
When a diagnostic Excision, Extraction or Drainage (biopsy)procedure is performed, followed by a more definitive procedure, do not code the biopsy. Code only the definitive treatment.
What is false? Both the biopsy and definitive treatment are coded.
500
It is the coder's responsibility to determine what the documentation in the medical record equates to in the PCS definitions.
What is true?
500
These two chapters do not have any specific coding guidelines.
What are Chapters 8 and 11 (Diseases of the Ear and Mastoid Process and Diseases of the Digestive System)?
500
When both the birthweight and gestational age information is available, two codes should be assigned with the gestational age sequenced before the birthweight.
What is false? The birthweight should be sequenced before the gestational age.
500
If a non prescribed drug is taken in combination w/ a correctly prescribed and properly administered drug, any toxicity or reaction resulting from the interaction of the two drugs would be classified as an adverse effect.
What is false? The interaction between a non prescribed and prescribed, would be classified as a poisoning.
500
When a mixture of autologous and nonautologous bone graft is used to render the joint immobile, code the procedure with no device value.
What is false? Code the device value to Autologous Tissue Substitute.