Term
| The ___ and ___ of the ___ take precedence over ___. |
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Definition
conventions
instructions
classification
guidelines |
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Term
| These conventions are incorporated within the ___ ___ and ___ ___ of the ICD-10-CM as ___ ___. |
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Definition
Alphabetic Index
Tabular List
instructional notes |
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Term
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Definition
| conventions incorporated within the Alphabetic Index and Tabular List of the ICD-10-CM |
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Term
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Definition
| an alphabetical list of terms and their corresponding code |
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Term
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Definition
| the general rules for use of the classification independent of the guidelines |
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Term
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Definition
| a structured list of codes divided into chapters based on body system or condition |
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Term
|
Definition
|
|
Term
| category that has no further subdivison |
|
Definition
|
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Term
| each level of subdivision after a category |
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Definition
|
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Term
|
Definition
| final level of subdivision |
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Term
| A code that has an applicable 7th character is considered ___ without the 7th character. |
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Definition
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Term
| A three-character category that has no further subdivision is equivalent to a ___. |
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Definition
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Term
| Where a placeholder exists, the _ must be used in order for the code to be considered a ___ ___. |
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Definition
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Term
| Examples of the etiology/manifestation convention notes: |
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Definition
Code first
use additional code
in diseases classified elsewhere |
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Term
|
Definition
|
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Term
|
Definition
| note at manifestation code |
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Term
| in diseases classified elsewhere |
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Definition
|
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Term
|
Definition
|
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Term
|
Definition
| another term should be referenced |
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Term
|
Definition
| two codes may be required to fully describe a condition |
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Term
| Codes for symptoms, signs, and ill-defined conditions from Chapter 18 are not to be used as principal diagnosis when a related ___ diagnosis has been established. |
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Definition
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Term
| The principal diagnosis is defined in the UHDDS as |
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Definition
| That condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care. |
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Term
| For reporting purposes the definition for "other diagnoses" is interpreted as additional conditions that affect patient care in terms of requiring: |
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Definition
Clinical evaluation
Therapeutic treatment
Diagnostic procedures
Extended length of hospital stay
Increased nursing care
Monitoring |
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Term
| Codes that describe ___ ___ ___, as opposed to ___, are acceptable for reporting when a ___ ___ ___ has not been established (confirmed) by the provider. |
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Definition
symptoms and signs
diagnoses
related definitive diagnosis |
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Term
| ___ and ___ that are ___ ___ with a disease process should ___ be assigned as ___ ___, unless otherwise instructed by the ___. |
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Definition
Signs
symptoms
associated routinely
not
additional codes
classification |
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Term
| If the provider documents a "___" diagnosis at the ___ ___ ___, the diagnosis is coded as ___, unless the classification provides a ___ entry (e.g. borderline diabetes). |
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Definition
borderline
time of discharge
confirmed
specific |
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Term
| The ___ of inpatient admission ___ govern the ___ of ___ diagnosis. |
|
Definition
circumstances
always
selection
principal |
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Term
| In determining principal diagnosis, ___ ___ in the ICD-10-CM, the Tabular List and Alphabetic Index ___ ___ over these ___ ___ ___. |
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Definition
coding conventions
take precedence
official coding guidelines |
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Term
| In the ___ ___ when two or more diagnoses ___ meet the ___ for principal diagnosis as determined by the ___ __ ___, ___ ___ and/or ___ ___, and the Alphabetic Index, Tabular List, or another coding guidelines does not provide ___ ___, ___ ___ of the diagnosis may be sequenced ___. |
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Definition
unusual instance
equally
criteria
circumstances of admission
diagnostic workup
therapy provided
sequencing direction
any one
first |
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Term
| Sequence as the ___ ___ the condition, which ___ ___ occasioned the ___ to the hospital even though treatment ___ ___ have been ___ ___ due to ___ ___. |
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Definition
principal diagnosis
after study
admission
may not
carried out
unforeseen circumstances |
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Term
| If the diagnosis documented __ __ ___ __ ___ is qualified as "___", "___", "___", "___", "___", or "___ __ __ ___ ___", or other similar terms indicating ___, code the condition as if it existed or was established. |
|
Definition
at the time of discharge
probable
suspected
likely
questionable
possible
still to be ruled out
uncertainty |
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Term
| Diagnoses that relate to an ___ ___ which have __ ___ on the ___ hospital stay are to be ___. |
|
Definition
earlier episode
no bearing
current
excluded |
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Term
| If the provider has included a diagnosis in the final diagnostic statement, such as the discharge summary or the face sheet, it should ___ be coded. Some providers include the diagnostic statement ___ ___ or diagnoses and ___-___ ___ from ___ admission that have no bearing on the current stay. ___ ___ are ___ __ __ ___ and are coded only if required by hospital policy. |
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Definition
| ordinarily resolved conditions status-post procedures previous Such conditions not to be reported |
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Term
| ___ findings (___, x-ray, ___ and other diagnostic results) are ___ ___ and reported unless the provider ___ ___ ___ ___. |
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Definition
| Abnormal laboratory pathologic not coded indicates their clinical significance |
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