Ch01 - Answer Key PDF

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Check Your Understanding Answer Key Chapter 1 Check Your Understanding 1.1 1. Breast Mass 2. Primary hydronephrosis 3. Deviation of nasal septum 4. Inguinal adenopathy 5. Gastric pouch 6. Tension headache 7. Acute pancreatitis 8. Mild persistent asthma 9. Otitis Externa 10. Major Depressive Disorder

Check Your Understanding 1.2 Using the Alphabetic Index, underline the subterm in each of the following diagnoses. 1. Atrial septal defect 2. Reflux esophagitis 3. Blood loss anemia 4. High arch, of foot 5. Bullous impetigo 6. Lactose intolerance 7. Spontaneous Delivery 1 Copyright ©2020 by the American Health Information Management Association. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, photocopying, recording or otherwise without prior permission from the publisher.

8. Cerebrospinal meningitis 9. Nausea with vomiting 10. Capillary nevus 11. Aortoiliac occlusion 12. Accessory nerve paralysis 13. Low basal metabolic rate 14. Q fever with pneumonia 15. Congenital scoliosis 16. Traumatic shock 17. Venous stasis 18. Pulmonary tuberculosis 19. Giant urticaria (example of either word in diagnostic phrase could be main term or subterm) 20. Joint xanthoma

Check Your Understanding 1.3 1. Chronic alcoholism 2. Angina pectoris 3. Animal bite to hand 4. Benign hypertension 5. Congestive systolic heart failure 6. Acquired deafness 7. Diabetes mellitus 8. Tropical dysentery 9. Pulmonary emphysema 10. Fever of unknown origin 2 Copyright ©2020 by the American Health Information Management Association. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, photocopying, recording or otherwise without prior permission from the publisher.

11. Dry gangrene 12. Recurrent hernia 13. Large-for-dates infant 14. Malignant mesothelioma 15. Blindness, both eyes 16. Pericarditis with effusion 17. Background retinopathy 18. Generalized sepsis 19. Secondary Polycythemia 20. Migratory Pneumonia

Check Your Understanding 1.4 1. Huntington’s disease G10 2. Sprengel’s deformity Q74.0 3. Stokes-Adams syndrome I45.9 4. Briquet’s disorder F45.0 5.

Costen’s complex, M26.69

6. Christmas disease D67 7. Cushing’s syndrome E24.9 8. Colle’s fracture of right radius, S52.531 9. Bell’s palsy G51.0 10. Aarskog’s syndrome Q87.19

Check Your Understanding 1.5 1. Subacute endomyometritis 3 Copyright ©2020 by the American Health Information Management Association. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, photocopying, recording or otherwise without prior permission from the publisher.

See Endometritis, subacute N71.0 2. Rheumatic Pneumonia I00 3. Osteoarthrosis, both hips See also Osteoarthritis, hip, bilateral M16.0 4. Cervical intervertebral disc prolapse See Displacement, intervertebral disc, cervical M50.20 5. Stenosis of cerebral artery See Occlusion, artery, cerebral I66.9 6. Early-onset Alzheimer’s disease Disease, Alzheimer’s, early onset G30.0 and F02.80 7. Meningitis in bacterial disease Meningitis, in, bacterial disease NEC A48.8 and G01 8. Aspiration pneumonia Pneumonia, aspiration J69.0 9. Nutritional polyneuritis Polyneuritis, nutritional E63.9 and G63 10. Ankylosing spondylitis with lung involvement Spondylitis, ankylosing, with lung involvement M45.9 and J99 11. Acute Sigmoiditis See also Enteritis K52.9 12. Abdominal Hernia Hernia, abdomen, abdominal K46.9 13. Cholesteatoma, left ear Cholesteatoma (ear)(middle)(with reaction) H71.92 14. Idiopathic Dystonia 4 Copyright ©2020 by the American Health Information Management Association. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, photocopying, recording or otherwise without prior permission from the publisher.

Dystonia, idiopathic G24.1 15. Acute necrotizing myopathy Myopathy, acute, necrotizing G72.81

Check Your Understanding 1.6 1. a. Category code .

b. Chapter 1: Certain Infectious and Parasitic Diseases Viral Infections characterized by skin and mucous membrane lesions (B00–B09) c. Manifestations d. Complications that can occur with measles, such as encephalitis, meningitis, pneumonia, otitis

media, intestinal complication, and other complications e. B05.9 Measles without complications 2. a. Category code b. Chapter 10: Diseases of the Respiratory System Other acute lower respiratory infections (J20–J22) c. Etiology (due to specific organisms) d. The codes identify the infectious organism that caused the acute bronchitis, such as Mycoplasma pneumoniae, Haemophilus influenzae, Streptococcus, coxsackievirus, and others. e. J20.9, Acute bronchitis, unspecified 3. a. Subcategory code b. Chapter 12: Diseases of the Skin and Subcutaneous Tissue Other disorders of the skin and subcutaneous tissue (L80–L99) c. Site of ankle and severity identified by stage d. The codes identify the site of the pressure ulcer as right ankle and the current stage of 1, 2, 3, 4, or unspecified. 5 Copyright ©2020 by the American Health Information Management Association. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, photocopying, recording or otherwise without prior permission from the publisher.

e. L89.519, Pressure ulcer of right ankle, unspecified stage 4. Unspecified trimester (of pregnancy), first trimester, second trimester, third trimester 5. Right shoulder, left shoulder, unspecified shoulder 6. A for initial encounter, D for subsequent encounter, and S for sequelae 7. Yes, the placeholder of X would be placed in the sixth position in order to add the seventh character of A. The complete code would be S00.01XA. 8. No, a placeholder of X would not be required as the code is already six characters long and the seventh character of A is added to it. The complete code would be S62.185A. 9. Chapter 7 - Diseases of the eye and adnexa and Chapter 8 - Diseases of the ear and mastoid process. 10. The letter U has been reserved by the World Health Organization for future use.

Check Your Understanding 1.7 1. a. Poxvirus, B08.8 (NEC) b. Enterovirus enteritis, A08.39 (NEC) c. Pyrexia, R50.9 (NOS) 2. a. Repeated falls, R29.6 b. Chronic respiratory disease, J98.9 (NOS) c. Dental caries, K02.9 (unspecified) 3. The word in brackets is “German measles,” and it is alternative wording for the diagnosis of Rubella. 4. The two codes are G31.09 (Underlying disease, Frontotemporal dementia) and F02.80 (Manifestation, dementia in other diseases classified elsewhere without behavioral disturbance). 5. NOS stands for Not Otherwise Specified and it is equivalent to “unspecified”. NOS codes are available when the documentation of the condition identified by the provider in the health record does not provide enough information to assign a more specific code.

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Check Your Understanding 1.8 1. Broad- or floating-betalipoproteinema, Combined hyperlipidemia NOS, Elevated cholesterol with elevated triglycerides NEC, Fredrickson’s hyperlipoproteinemia type IIb or III, Hyperbetalipoproteinema with prebetalipoproteinemia, Hypercholesteremia with endogenous hyperglyceridemia, Hyperlipidemia group C, Tubo-eruptive xanthoma, and Xanthoma tuberosum would be considered inclusion terms for code E78.2 2. Rapidly progressive glomerular disease Rapidly progressive glomerulonephritis Rapidly progressive nephritis 3. The three terms are considered inclusion terms. 4. The three terms are considered an includes note. 5. Chapter 16 note states “Codes from this chapter are for use on newborn records only, never on maternal records”. These codes are assigned for conditions that have their origin in the fetal or perinatal period (before birth through the first 28 days after birth) even if morbidity occurs later. These codes are not to be used on the materal records. 6. The excludes note indicates that codes excluded from each other are independent of each other. In ICD-10-CM, there are two types of excludes notes designated as either Excludes1 or Excludes2 in their title. Either or both may appear under a category, subcategory, or code. 7. The Excludes1 note indicates that the conditions listed after it cannot ever be used at the same time as the code above the Excludes1 note. The conditions listed in the code and in the Excludes1 note are mutually exclusive. A patient cannot have both conditions at the same time. 8. The Excludes2 note means that two codes are applied when both conditions are present. The conditions that appear as an Excludes2 note are not part of the code that is listed above it. A patient may have both conditions at the same time. 9. No, code N28.1 cannot be used with a code from category Q61 because of the Excludes1 note that 7 Copyright ©2020 by the American Health Information Management Association. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, photocopying, recording or otherwise without prior permission from the publisher.

appears under category Q61 and lists N28.1 as well as code Q60.6. Cystic kidney disease is a congenital condition included in Chapter 17: Congenital Malformations, Deformations and Chromosomal Abnormalities (Q00–Q99), and code N28.1 is an acquired cyst of the kidney meaning it developed during the person's lifetime but was not a congenital condition. 10. Yes, I51.7 can be coded with a code from category I42 because there is an Excludes2 note under category I42 that would indicate a patient may have both conditions at the same time. One code does not include both conditions. When both conditions are present, two codes are applied.

Check Your Understanding 1.9 1. In ICD-10-CM, there is a coding convention that requires two codes for situations when one disease produces another condition. The first disease is considered the etiology, and the second condition that it produces is called the manifestation. The etiology or the first disease must be coded first. The manifestation(s) are listed as additional codes. 2. The coding convention used in ICD-10-CM that directs the coder that two codes may be required to fully describe a condition is known as a “Code also note”. It does not, however, provide sequencing direction. 3. The manifestation codes also appear in italicized fonts. This instruction makes sure the coder follows the proper sequencing of codes, that is, the etiology condition is coded first, followed by the manifestation code. 4. Code G20 would be considered the etiology code and F02.80 would be considered the manifestation code. In the Alphabetic Index, both conditions may be listed on one line with the etiology code listed first and the manifestation code appearing in slanted brackets after it. The code in the brackets is never listed first or used as a single code. The manifestation code must be listed second. 5. The “use additional code” note appears with the code for toxic shock syndrome because it is an 8 Copyright ©2020 by the American Health Information Management Association. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, photocopying, recording or otherwise without prior permission from the publisher.

infectious disease code that does not identify the specific bacterial or viral organism that caused it, but that organism can be identified with another code from B95 or B96. 6. The “code first” note instructs the coders to code first the associated diagnosis of AIDS (B20). The second note states the coder should use an additional code for any associated manifestation, such as endocarditis (I39), meningitis (G02), pericarditis (I32), or retinitis (H32). 7. “Code, if applicable, a causal condition first” note indicates that a code from category R35 may be assigned as a first-listed or principal diagnosis when the causal condition is unknown or not applicable. If a causal condition is known, for example, an enlarged prostate, then the code for the enlarged prostate should be sequenced as the principal or first-listed diagnosis. 8. A note exists under S04, Injury of cranial nerve, which identifies that the selection of side should be based on the side of the body being affected. A “code first” note also identifies to code any associated intracranial injury, S06.-, first. A “code also” note indicates that two codes may be required to fully describe a condition, that is, S01.- for an associated open wound of head or S02.- for any associated skull fracture. The code first note provides sequencing directions for coding this condition. A note also exists to identify the appropriate 7th character. 9. The “code first” note instructs the coder to code first the complication of transplanted organ (T86.-). The second note states to “use additional code” to identify the specific malignancy that is present in the organ, for example, malignant neoplasm of the kidney. 10. There is a “use additional code” note to include a code that identifies the stage of the chronic kidney disease (N18.1-N18.6).

Check Your Understanding 1.10 1.Cross-references are used as directions for the coder to look elsewhere in the Alphabetic Index before assigning a code. 2. The term “and” is interpreted to mean “and” or “or” when it appears in a code title. The term “and” 9 Copyright ©2020 by the American Health Information Management Association. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, photocopying, recording or otherwise without prior permission from the publisher.

means the patient may have one or the other of the statements included in the code title. 3. The term “with” in a diagnosis statement is used to acknowledge two conditions exist. The term “with” may be used by the physician to include the two conditions, but the physician may also use other phrases such as “associated with” or “due to” to describe the two conditions. The ICD-10-CM phrase of “with” also applies in the Alphabetic Index or in the Tabular List in an instructional note. In the Alphabetic Index, the term “with” will appear immediately following the main term. The term “with” does not appear necessarily with other subterms starting with the letter “W.” In the Tabular List, the term “with” appearing in a code title means that two conditions (condition A with condition B) must be present in the patient to use that particular code. 4. Two conditions must be present, asthma with chronic obstructive bronchitis, and included in the diagnostic statement to assign code J44.9. 5. In ICD-10-CM, the “see” direction is used to instruct the coder to reference another term in the Alphabetic Index that provides more complete information about the condition to be coded. The “see” note also appears with an anatomical site main term to direct the coder to locate the disease present at that anatomic site in the Alphabetic Index The cross-reference note “see also” in the Alphabetic Index follows a main term if the coder should reference another term in the Index for additional information. The instruction is intended to help the coder find the most information available in the Alphabetic Index when the coder may not identify all the options that could be used. However, it is not necessary to follow the “see also” note when the original main term provides all the necessary information to assign a complete code. 6. Under the term Buttonhole deformity, the cross-reference of see “Deformity, finger boutonnier” appears to direct the coder to find the most appropriate main term (deformity) and code of the condition. 7. The cross-reference note “see also” in the Alphabetic Index follows a main term if the coder should reference another term in the Index for additional information. The instruction is intended to help the coder find the most information available in the Alphabetic Index when the coder may not identify all the 10 Copyright ©2020 by the American Health Information Management Association. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, photocopying, recording or otherwise without prior permission from the publisher.

options that could be used. However, it is not necessary to follow the “see also” note when the original main term provides all the necessary information to assign a complete code. With this diagnosis, the complete entry of “perinatal bronchopulmonary dysplasia” is found under the main term of dysplasia with the available code included and, for this reason, the coder is not obligated to refer to the main term of “anomaly” in the Alphabetic Index in order to code this condition. 8. Under the main term of enchondroma, the coder finds the cross-reference note of “see also—neoplasm, bone, benign.” No code is provided next to the term “enchondroma,” so the coder is obligated to refer to the main term of neoplasm, bone, benign to locate the appropriate code. The coder will note that the location of the enchondroma, that is, the specific bone, is needed to code the condition most accurately. 9. Connecting words or connecting terms are subterms in the Alphabetic Index that appear after a main term to indicate a relationship between the main term and an associated condition or etiology. The connecting words “with” and “without” appear in both the Alphabetic Index and in the Tabular List in code titles. “With” and “without” connecting terms are sequenced before all other subterms in the Alphabetic Index but may also appear with the other subterms in alphabetic order. 10. Under the main term of infertility and the subterm of female, the following connecting terms are included: age-related, associated with, due to, nonimplantation, and origin. The connecting terms allow the coder to find the most appropriate code for female infertility when it is associated with another condition.

Check Your Understanding 1.11 1. The first step in coding is to locate the main term and applicable subterms in the Alphabetic Index. Then, the code found in the Alphabetic Index is verified in the Tabular List. The coder must read and be guided by the instructional notations that appear in both the Alphabetic Index and the Tabular List. The coder must use both the Alphabetic Index and Tabular List when locating and assigning a code. 2. A three-character code is to be used only if it is not further subdivided, that is, there are no applicable 11 Copyright ©2020 by the American Health Information Management Association. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, photocopying, recording or otherwise without prior permission from the publisher.

fourth, fifth, sixth, or seventh characters to be used. 3. a. K80.8, Other cholelithiasis No, the diagnosis code of K80.8 is invalid as a fifth character is required to identify whether obstruction was present or not with the condition. b. O82, Encounter for cesarean delivery without indication Yes, the code O82 is a valid code. c. P05.0, Newborn light for gestational age No, the diagnosis code of P05.0 is invalid as a fifth character is required to describe the weight range of the newborn in grams. d. B20, Human immunodeficiency virus [HIV] disease Yes, the diagnosis code of B20 is a valid code. e. I63.21, Cerebral infarction due to unspecified occlusion or steno...