Chapter 3 Outpatient and Reporting
Principal Diagnosis
Tabular
Instructional notes are included in what list?
New tumor growth can be benign or malignant.
Malignant
True or False
Modifiers complete the story for the insurance carriers to determine reimbursement.
True
True or False
You will always code External codes as the first listed.
False.
External codes are never coded as the first listed.
Signs and Symptoms
What diagnosis is used when the documented condition is not confirmed in the outpatient setting?
Seven characters
How many characters are possible in the ICD-10 coding?
What is the Study of the structures, composition, and function of the tissues?
Histology
-51
What is bilateral procedures?
Anesthesia Coding
Repair of cleft palate
Index location: ____________________
Code: ____________________
Index Location: Anesthesia
Code: 00172 Cleft palate Repair
Reason for surgery
What is the first listed dx when a patient presents for an outpatient setting?
Integral
What is called when signs and symptoms are due to a diagnosed condition?
Code:
Pneumonia due to Klebsiella pheumoniae
J15.0 Pneumonia due to Klebsiella pneumoniae
-32
What is mandated services?
A 53-year-old new patient presents for an initial office visit to discuss a surgical vasectomy for sterilization. The history and examination are detailed and the MDM is of low complexity.
CPT Code: ___________________
ICD-10-CM Code: ________________
E/M: 99203
ICD:10 Z30.09, Counseling, contraceptive
Chronic diseases
What type of conditions may be reported as many times as the patient receives care or treatment for?
Combination Coding
What is the term called when Two diagnoses, or a dx with an associated secondary process, or a dx with an associated complication?
Code: Metastatic Bone Cancer
C79.51 Metastatic bone cancer,
C80.1 Malignant neoplasm, unspecified
Less than 3 years
What is an established patient?
An established 48-year-old woman has had diarrhea for the past 5 days. Her temperature is 101° F. An expanded problem focused history and examination are done. MDM complexity is low. CPT Code: ___________________
ICD-10-CM Code: ________________
E/M: 99213 Established patient
Dx: R19.7 Diarrhea
Postoperative diagnosis
When the postoperative diagnosis is different than the preoperative diagnosis at the time the diagnosis is confirmed, which diagnosis is reported?
Late Effect (Sequela)
What is the residual and cause of this case:
Leg pain resulting from old fracture of the femur
Residual: Leg Pain
Cause: Old Fracture Femur
Code:
Acutel maxillary sinustitis due to Hemophilus influenzae
J01.00, B96.3
Acute maxillary sinusitis due to Hemophlius influenzae
-History
-Examination
-MDM
What are the key components of E/M services?
Under the initial Hospital Care:
Which code has a time component of 70 minutes?
99223 Hospital Services, Inpatient Services, Initial Hopsital Care.