Medical Coding Quiz 1

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The risk factors for type 1 diabetes include all of the following except:

Type 2 diabetes accounts for approximately what percentage of all cases of diabetes in adults?

Excessive thirst and volume of very dilute urine may be symptoms of:

Among female children and adolescents, the first sign of type 1 diabetes may be:

What does the "ICD" in ICD 10 Coding stand for?

Patient is 1 month status post TURP. Patient presents to physician's office with acute abdominal p

Patient has a mature senile cataract

Patient has acute allergic serous otitis media, right ear:

What code should you report for minimal brain dysfunction (MBD)?

What does the acronym HIT stand for?

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Vascular Catheterization - Coding

Vascular system anatomy and terminology to make reporting these procedures less challenging. A thorough understanding of the anatomy and medical terminology of the vascular system is required to accurately code arterial vessel procedures. Here’s a quick run-through of clinical information and coding guidance to show you how order affects coding. Order Matters Please refer to Appendix L of the CPT® code book for the vascular families. The aorta is the major artery. Each main vessel branching off the aorta is a first order vessel (e.g., left common carotid). First order vessels have several vessels branching off them, designated as second order vessels (e.g., right subclavian and axillary). Second order vessels have several vessels branching off them, designated as third order vessels (e.g., right internal carotid). Third order vessels have several smaller vessels branching off them, designated as beyond the third order (e.g., left deep palmar arch). Catheterization Can Ei...

Fracture Treatments & Cast application

Correctly coding casts, splints, and strapping can be confusing. Much of the confusion is related to what type of materials are classified as casts, splints, or strapping; whether the CPT application codes or the HCPCS level II codes should be assigned; and whether the work performed is included in E/M codes. This article provides general guidance and suggested best practices for sorting out these issues. Defining Treatment Modality A cast is a “rigid dressing, molded to the body while pliable and hardening as it dries,” that provides firm support; it does not allow movement. 1 A splint is any stiff device attached to a limb in order to discourage movement. There are two types of splints: static or dynamic. 2 Static splints provide full immobilization, while dynamic splints allow some movement. 3 Strapping refers to the application of overlapping strips of adhesive plaster or tape to a body part to exert pressure and hold a structure in place. 4 Basic Rules ...

Place Holder X

The letter " x ” serves as a placeholder when a code contains fewer than six characters and a seventh character applies. The " x ” also allows for future expansion of the codes. When reporting ICD - 10 - CM codes, coders must add a placeholder so the seventh character is in the correct position. Not every ICD-10-CM code with a seventh character has a sixth character—or even a fifth or fourth character for that matter. This frequently occurs with poisonings and injuries. The letter "x” serves as a placeholder when a code contains fewer than six characters and a seventh character applies. The "x” also allows for future expansion of the codes. When reporting ICD-10-CM codes, coders must add a placeholder so the seventh character is in the correct position. Without this placeholder to ensure characters appear in the correct positions, codes are invalid. For example, a patient presents with an accidental poisoning by an antiallergic drug. For the initial ...

Glossary of Coding Conventions and Rules

Terms Definitions see also instructional term in the index that is located after a main term or subterm and directs the coder to another main term (or subterm) that may provide additional useful index entries. see instructional term in ICD–9–CM and ICD–10–CM/PCS that directs the coder to refer to another term in the indexes the code. see category instructional term in the index that directs the coder to the tabular list, where a code can be selected from the options provided. see condition instructional term in the index that directs the coder to the main term for a condition. abbreviation use of NEC (not elsewhere classifiable) and NOS (not otherwise specified). (NEC and NOS abbreviations do not appear in ICD–10–PCS.) abbreviations use of NEC (not elsewhere classifiable) and NOS (not otherwise specified). (NEC and NOS abbreviations do not appear...

Burns and Corrosions

Chemicals, such as lye or acid, can cause corrosion upon contact with a person's skin. As a professional coding specialist, you may need to code the diagnosis of a burn or corrosion. A chemical burn occurs when living tissue is exposed to a corrosive substance such as a strong acid or base. Chemical burns follow standard burn classification and may cause extensive tissue damage. Burns from a heat source are classified by depth (first, second, third, unspecified), extent, and agent. For multiple burns, sequence the highest degree burn first. Multiple burns of the same three-character category are coded to the highest degree. Non-healing burns are coded as acute burns. The extent of injury is best described using the percentage of the total body surface area (%TBSA) that is affected by a burn. The measurement of burn surface area is important during the initial management of people with burns for estimating fluid requirements and determining need for transfer to a burns service T...

DRG – Diagnosis related grouping

Medicare and many health insurance companies pay hospitals using DRGs, or diagnostic related groupings. This means the hospital gets paid based on the admitted patient’s diagnosis rather than based on what it actually spent caring for the hospitalized patient. If a hospital can treat a patient while spending less money than the DRG payment for that illness, the hospital makes a profit. If, while treating the hospitalized patient, the hospital spends more money than the DRG payment, the hospital will lose money on that patient’s hospitalization. This is meant to control health care costs by encouraging the efficient care of hospitalized patients. Why You Should Care How a DRG Is Determined If you’re a patient, understanding the basics of what factors impact your DRG assignment can help you better understand your hospital bill, what your health insurance company or Medicare is paying for, or why you’ve been assigned a particular DRG. If you’re a physician rather than a p...

Systemic vs. Pulmonary Circulation

What Does the Heart Do? The heart is a pump, usually beating about 60 to 100 times per minute. With each heartbeat, the heart sends blood throughout our bodies, carrying oxygen to every cell. After delivering the oxygen, the blood returns to the heart. The heart then sends the blood to the lungs to pick up more oxygen. This cycle repeats over and over again. What Does the Circulatory System Do? The circulatory system is made up of blood vessels that carry blood away from and towards the heart. Arteries carry blood away from the heart and veins carry blood back to the heart. The circulatory system carries oxygen, nutrients, and hormones to cells, and removes waste products, like carbon dioxide. These roadways travel in one direction only, to keep things going where they should. What Are the Parts of the Heart? The heart has four chambers — two on top and two on bottom: · ...

Anemia Coding

Guidelines: CKD : When the patient has anemia due to chronic kidney disease (CKD) you must report a code from N18 (CKD) in addition to D63.1 (Anemia in chronic kidney disease). Codes from N18- indicate the stage of the illness Example: Patient presented for treatment of stage 3 CKD. The provider also addresses the CKD caused anemia during the encounter. You should report N18.3 – CKD stage 3 – moderate followed by D63.1 for the anemia. Neoplastic Disease: In cases where the patient has anemia due to a neoplasm, you should report the proper neoplasm code alongside D63.0 (Anemia in neoplastic disease) However if a patient has anemia caused by his chemotherapy, immunotherapy, or radiotherapy and he presents for the treatment of the anemia only your first listed code should be an adverse effect code. Then report the anemia and neoplasm codes. Drug Induced Anemias: Autoimmune hemolytic anemia is caused by auto antibody induced hemolysis. It is usually idiop...

Sepsis Coding

Small differences in sepsis and SIRS guidelines can result in major differences in reimbursement. Sepsis, systemic inflammatory response syndrome (SIRS), and septicemia have historically been difficult to code. ICD-10-CM has introduced lots of changes to sepsis and SIRS coding. It’s critical to code sepsis properly due to the impact the diagnosis has on reimbursement. For example, consider the following case study: A 39-year-old patient was admitted with the diagnosis of community-acquired pneumonia in the setting of presumptive influenza and concurrent sepsis. In the history and physical exam, it was documented that the patient had sepsis and SIRS, meeting the criteria of leukocytosis, fever, and tachypnea, with pneumonia as the source. The sputum culture was positive for pseudomonas pneumonia. The patient had a six-day stay. The discharge diagnoses were influenza with pneumonia bacterial superinfection, positive for pseudomonas, as well as acidosis, asthma exa...

How to apply ICD-10-CM Codes

Basically the ICD-10-CM book is divided into 2 sections: Alphabetical Index and Tabular List. You will be coding diagnoses, illness, conditions, injury and external causes using ICD-10 You need to check the disease/illness in the Alphabetical Index first. It will direct you to the correct code. Once you go to the code in Tabular list read all the rules for that code and then carefully choose the correct code. Quite a simple process but just needs some attention! ICD-10-CM Guidelines for Coding and Reporting Guidelines for coding and reporting with ICD-10-CM are provided by the Centers for Medicare and Medicaid Services (CMS) and the National Center for Health Statistics (NCHS). These guidelines have been approved by the four organizations that make up the Cooperating Parties for the ICD-10-CM: the American Hospital Association (AHA), the American Health Information Management Association (AHIMA), CMS, and NCHS. The conventions of ICD-10-CM take precedence over these guide...

Medical Coding Simplified

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