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ICD-10-CM Guidelines Exam/21 Complete Questions and Answers
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ICD-10-CM Guidelines Exam/21 Complete Questions and Answers
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ICD-10-CM Guidelines Exam/21Complete Questions and Answers
Section I.A 15. "With" - -The word with or in should be interpreted to mean
associated with or due to when it appears in a code title, the alphabetic
index (either under a main term or subterm), or an instructional note in the
tabular list. This classification presumes a casual relationship between the
two conditions liked by these terms in the alphabetic index or tabular list.
These conditions should be coded as related even in the absence of provider
documentation explicitly linking them, unless the documentation clearly
states the conditions are unrelated or when another guideline exists that
specifically requires a documented linkage between two conditions(e.g.,
sepsis guideline for "acute organ dysfunction that is not clearly associated
with the sepsis"). For conditions not specifically linked by these relational
terms in the classification or when a guideline requires that a linkage
between two conditions be explicitly documented, provider documentation
must link the conditions in order to code them as related.
The word "with" in the alphabetic index is sequenced immediately following
the main term, not in alphabetical order.
-Section I.A. 12.a. Excludes1 (paragraph 2) - -An exception to the Excludes1
definition is the circumstance when the two conditions are unrelated to each
other. If it is not clear whether the two conditions involving an Excludes1
note are unrelated or not, query the provider.
-Section I.A. 18. Default Codes - -A code listed next to a main term in the
icd-10-cm alphabetic index is referred to as a default code. The default code
represents that condition that is most commonly associated with the main
term, or is the unspecified code for the condition. If a condition is
documented in a medical record without any additional information, such as
acute or chronic, the default code should be assigned.
-Section I.A. 19. Code assignment and clinical criteria - -The assignment of a
diagnosis code is based on the providers diagnostic statement that the
condition exists. The providers statement that the patient has a particular
condition is sufficient. Code assignment is not based on clinical criteria used
by the provide4r to establish the diagnosis.
-Section IV - Diagnostic Coding and Reporting Guidelines for Outpatient
Services - -These coding guidelines for outpatient diagnoses have been
approved for use by hospitals/providers in coding and reporting hospital-
based outpatient services and provider- based office visits. Guidelines in
Section I, Conventions, general coding guidelines and chapter- specific
, guidelines, should also be applied for outpatient services and office visits.
Information about the use of certain abbreviations, punctuation, symbols,
and other conventions used in the ICD-10-CM Tabular List (code numbers
and titles), can be found in Section IA of these guidelines, under
"Conventions Used in the Tabular List." Section I. B. contains general
guidelines that apply to the entire classification. Section I. C. contains
chapter-specific guidelines that correspond to the chapters as they are
arranged in the classification. Information about the correct sequence to use
in finding a code is also described in Section I. The terms encounter and visit
are often used interchangeably in describing outpatient service contacts and,
therefore, appear together in these guidelines without distinguishing one
from the other. Though the conventions and general guidelines apply to all
settings, coding guidelines for outpatient and provider reporting of diagnoses
will vary in a number of instances from those for inpatient diagnoses,
recognizing that:
The Uniform Hospital Discharge Data Set (UHDDS) definition of principal
diagnosis does not apply to hospital-based outpatient services and provider-
based office visits. Coding guidelines for inconclusive diagnoses (probable,
suspected, rule out, etc.) were
developed for inpatient reporting and do not apply to outpatients.
A. Selection of first-listed condition
In the outpatient setting, the term first-listed diagnosis is used in lieu of
principal diagnosis.
In determining the first-listed diagnosis
-Section IV.A Outpatient Surgery - -When a patient presents for outpatient
surgery (same day surgery), code the reason for the surgery as the first-
listed diagnosis (reason for the encounter), even if the surgery is not
performed due to a contraindication.
-Section IV.B Codes from A00.0 through T88.9, Z00-Z99 - -The appropriate
code(s) from A00.0 through T88.9, Z00-Z99 must be used to identify
diagnoses, symptoms, conditions, problems, complaints, or other reason(s)
for the encounter/visit.
-Section IV.C Accurate reporting of ICD-10-CM diagnosis coded - -For
accurate reporting of ICD-10-CM diagnosis codes, the documentation should
describe the patient's condition, using terminology which includes specific
diagnoses as well as symptoms, problems, or reasons for the encounter.
There are ICD-10-CM codes to describe all of these.
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