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首页 Chapter 4 ICD-9-CM Coding Guidelines第四章ICD-9编码指南…

Chapter 4 ICD-9-CM Coding Guidelines第四章ICD-9编码指南-厘米.doc

Chapter 4 ICD-9-CM Coding Guide…

章鱼miko
2017-11-25 0人阅读 举报 0 0 暂无简介

简介:本文档为《Chapter 4 ICD-9-CM Coding Guidelines第四章ICD-9编码指南-厘米doc》,可适用于高等教育领域

ChapterICDCMCodingGuidelines第四章ICD编码指南厘米Chapter:ICDCMCodingGuidelinesTRUEFALSEICDCMdiagnosiscodeshavebeenadoptedunderHIPAAforallhealthcaresettingsANS:TPTS:DIF:EasyTheICDCMOfficialGuidelinesforCodingandReportingisorganizedintofoursectionsANS:TPTS:DIF:EasyICDCMprocedurecodeshavebeenadoptedforinpatientproceduresbyhospitalsANS:TPTS:DIF:EasyAviolationofthecodingguidelinesisaHIPAAviolationANS:TPTS:DIF:EasyTheconditionornatureofalateeffectshouldbereportedasthesecondarycodeANS:FPTS:DIF:ModerateThecodefortheacutephaseofanillnessthatledtothelateeffectshouldalwaysbereportedwithacodeforthelateeffectANS:FPTS:DIF:EasyAlateeffectissynonymouswithcomplicationANS:FPTS:DIF:EasyWhencodingbothanacuteandchroniccondition,sequencetheacuteconditionfirstANS:TPTS:DIF:EasyThecodershoulduseboththeICDCMIndextoDiseasesandtheTabularListofDiseaseswhenlocatingandassigningcodesANS:TPTS:DIF:EasySignsandsymptomsthatareintegraltothediseaseprocessshouldbeassignedasadditionalcodesANS:FPTS:DIF:ModerateWhena“codefirst”noteispresentandanunderlyingconditionisdocumentedinthepatientrecord,theunderlyingconditionisreportedfirstANS:TPTS:DIF:EasyThereisnotimelimitonwhenalateeffectorresidualcodecanbereportedANS:TPTS:DIF:EasyWhenalateeffectiscoded,thelateeffectcodeissequencedfirstANS:FPTS:DIF:EasyICDCMprocedurecodesconsistofalphanumericcodesANS:FPTS:DIF:EasyTheICDCMcodingsystemwasdevelopedinthesANS:FPTS:DIF:EasyIfthephraseomitcodeisfoundafterthemaintermorsubterm,donotassignacodetotheoperativeapproachANS:TPTS:DIF:EasyProcedurecodesshouldalwaysbeassignedforanoperativeapproachANS:FPTS:DIF:EasyAssignmentofacombinationcodeshouldtakeprecedenceoverassignmentofmultiplecodesANS:TPTS:DIF:EasyAcolonoscopyisanexampleofanopenprocedureANS:FPTS:DIF:EasyWhencodingendoscopicprocedures,iftheendoscopeispassedthroughmorethanonebodycavity,assignthecodeforthemostdistantsiteANS:TPTS:DIF:EasyWhenacoderfindstheICDcodeinthealphabeticindex,heorshedoesn’tneedtolookitupinthetabularlistalsoANS:FPTS:DIF:EasyCOMPLETIONAsinglecodethatisusedtoclassifytwodiagnosesorproceduresisreferredtoasa(n)ANS:combinationcodePTS:DIF:EasyAssigningtwoormorecodestocompletelyclassifytheelementsofacomplexdiagnosisorprocedurestatementisreferredtoasANS:multiplecodesmultiplecodingPTS:DIF:EasyTheresidualconditionthatdevelopsaftertheacutephaseofanillnessorinjuryhasendedisreferredtoasa(n)ANS:lateeffectPTS:DIF:EasyCompleteandaccuratecodeassignmentandreportingofdiagnosesandproceduresistheresponsibilityoftheANS:coderPTS:DIF:EasyTheICDCMOfficialGuidelinesforCodingandReportingisorganizedintosectionsANS:fourPTS:DIF:EasyThetermusedtomean“physicianoranyqualifiedhealthcarepractitionerwhoislegallyaccountableforestablishingthepatient’sdiagnosis”isANS:providerPTS:DIF:EasyThestructureoftheICDCMTabularListofProceduresisbasedonANS:anatomyPTS:DIF:EasySurgicalproceduresindexedaseponymsarelistedunderthemaintermandthentheeponymANS:operationPTS:DIF:EasyICDCMprocedurecodescontainordigitsANS:three,four,PTS:DIF:EasyWhenapatientundergoesbothabiopsyandsubsequentremovalofadditionaltissue,assigncodesANS:twoPTS:DIF:ModerateApatientwasscheduledforbiopsyofthebladderviacystoscopyThescopewasunabletoadvanceduetoblockageThecodershouldassignacodeforANS:cystoscopyPTS:DIF:ModerateTheconditionestablishedafterstudytobechieflyresponsibleforoccasioningtheadmissionofthepatienttothehospitalforcareisthedefinitionofANS:principaldiagnosisPTS:DIF:EasyAnoutcomeofdeliverycode(VV)wouldbelocatedontherecordANS:mother’smom’sPTS:DIF:EasyThefourthdigitsubcategoryofamyocardialinfarctioncodedescribestheofthemyocardialinfarctionANS:locationsitePTS:DIF:ModerateNeoplasmsshouldbecodeddirectlyfromthereportANS:pathologyPTS:DIF:EasyIfaneoplasmisidentifiedbuttheresultsofpathologyexaminationarenotavailable,theneoplasmissaidtobeofnatureANS:unspecifiedPTS:DIF:EasyWhentheoriginofatumorinvolvestwoadjacentsites,thelocationissaidtobeoverlapping,orANS:contiguousPTS:DIF:ModerateThetypeofdiabetesmellituswherebythepatient’sbodyisunabletoproduceinsulinistypeANS:IPTS:DIF:EasyApatientwasbroughttotheemergencyroomatamandleftagainstmedicaladviceat:amwithoutbeingexaminedReportcodeANS:VPTS:DIF:DifficultMrDoddwasdiagnosedwithtumorofthesacralspineReportcodeANS:PTS:DIF:DifficultSHORTANSWERDescribethestructureofanICDCMdiagnosiscodeANS:AnICDCMdiagnosiscodecontainsthree,four,orfivedigitsthatmaybefurthersubdividedbyassigningfourthandorfifthdigitstoprovidegreaterdetailPTS:DIF:ModerateWhattwoorganizationsprovideofficialcodingguidelinesforcodingandreportingusingtheInternationalClassificationofDiseases,thRevision,ClinicalModificationANS:TheCentersforMedicareandMedicaidServices(CMS)andtheNationalCenterforHealthStatistics(NCHS)provideofficialcodingguidelinesforcodingandreportingusingtheInternationalClassificationofDiseases,thRevision,ClinicalModificationPTS:DIF:ModerateWhywerethecodingguidelinesdevelopedANS:CodingguidelinesweredevelopedtoassistboththehealthcareproviderandthecoderinidentifyingdiagnosesandproceduresthataretobereportedPTS:DIF:ModerateHowarethemaintermsintheIndextoProceduresorganizedANS:ThemaintermsintheIndextoProceduresareorganizedinalphabeticalorderaccordingtotypeofprocedure,commonnameoftheprocedure,andeponymsPTS:DIF:ModerateAsurgeonmakesanincisiontostartahysterectomy,butthesurgeryisstoppedafterthefirstincisionHowshouldthecodercodetheprocedureANS:ThecodershouldassignacodefortheincisionofthesitePTS:DIF:ModerateApatientistreatedforanHIVrelatedconditionHowshouldthisbereportedonthehealthinsuranceclaimANS:ThecodershouldreportICDCMcodefirstonthehealthinsuranceclaimandassignadditionaldiagnosiscodesforalldocumentedHIVrelatedconditionsandinfectionsPTS:DIF:ModerateWhena“codefirst”noteispresentandanunderlyingconditionisdocumentedinthepatientrecord,whichconditionshouldbereportedfirstANS:TheunderlyingconditionshouldbereportedfirstPTS:DIF:ModerateAyearoldmalepatientwithsymptomaticHIVdiseaseisadmittedfortreatmentofamyocardialinfarctionWhichconditionshouldbesequencedfirstANS:TheconditionofmyocardialinfarctionshouldbesequencedfirstPTS:DIF:DifficultWhatismalignanthypertensionANS:ItisasevereformofhypertensionwithvasculardamageandadiastolicpressurereadingofmmHgorgreaterPTS:DIF:ModerateWhatismeantbyuncontrolledhypertensionANS:UncontrolledhypertensionisuntreatedhypertensionorhypertensionnotrespondingtocurrenttherapeuticregimenPTS:DIF:ModerateWhattermsareusedtorefertoacerebralinfarctionANS:Thetermsstroke,CVA,andcerebrovascularaccidentareusedtorefertoacerebralinfarctionPTS:DIF:ModerateWhatismeantbythetermstatusasthmaticusANS:Thetermreferstoapatient’sfailuretorespondtotherapyadministeredduringanasthmaticepisode,whichisalifethreateningcomplicationthatrequiresemergencycarePTS:DIF:ModerateChronicrenalfailureisnowreferredtoaswhatANS:ChronicrenalfailureisnowreferredtoaschronickidneydiseasePTS:DIF:EasyWhatconditionsareclassifiedunderChapter:ComplicationsofPregnancy,Childbirth,andthePuerperiumANS:Diseasesanddisordersthatoccurduringpregnancy,childbirth,andtheweeksimmediatelyfollowingchildbirthareclassifiedunderChapterPTS:DIF:ModerateAyearoldpregnantfemalefellandfracturedherwristWhichconditionshouldbesequencedfirstANS:ThefractureofwristshouldbesequencedfirstPTS:DIF:ModerateWhatisalatestageofHIVdiseaseANS:Acquiredimmunedeficiencysyndrome(AIDS)isalatestageofHIVdiseasePTS:DIF:EasyWhatismeantbythetermidiopathicANS:Thetermidiopathicmeans“hasanunknownetiology”PTS:DIF:EasyWhenmaycodesfromChapter:CongenitalAnomaliesbeassignedANS:CodesfromChaptermaybeassignedthroughoutthelifeofthepatientPTS:DIF:ModerateWhatistheperinatalperiodANS:Theperinatalperiodistheintervaloftimeoccurringbefore,during,anduptodaysfollowingbirthPTS:DIF:ModerateApatiententerstheemergencyroomwithabdominalpainandundergoesemergencyappendectomyforacuteappendicitisWhatconditionisreportedastheprincipaldiagnosisANS:AcuteappendicitisisreportedastheprincipaldiagnosisPTS:DIF:ModerateMULTIPLECHOICEApatientsufferedafractureoftheradiusandulnaduetoafallontheiceayearagoThepatientpresentstodaywithpainduetononunionofthefractureWhichshouldbecodedasalateeffectafractureofradiuscpainbfractureofulnadnonunionANS:DPTS:DIF:DifficultWhichofthefollowingdiagnosticstatementsisanexampleofalateeffectafractureofankleduetofalloutofbedbinfectedburnofhandcpostoperativewoundinfectiondtraumaticarthritisofthekneeANS:DPTS:DIF:DifficultAmalignantneoplasmthatislocalized,circumscribed,encapsulated,andnoninvasivebuthasnotspreadtodeeperoradjacenttissuesororgansisaatumorcmetastaticbbenigndinsituANS:DPTS:DIF:ModerateGiventhediagnosis“metastaticcarcinomafrombreasttolung,”breastwouldbecodedasamalignantprimarycinsitubmalignantsecondarydbenignANS:APTS:DIF:DifficultAdenocarcinomaofprostateglandSquamouscellcarcinoma,bronchogenic,leftlungReportcodesa,M,,Mc,M,,Mb,M,,Md,M,,MANS:APTS:DIF:DifficultYungLeewasdiagnosedwithanginapermanentcardiacpacemakerinsertedyearago,functioningwellReportcodesa,Vc,Vb,Vd,VANS:APTS:DIF:ModerateAyearoldmalepatientsufferedanmissile(open)fractureoftibialshaft,uppersectionReportcode(s)ac,bdANS:BPTS:DIF:DifficultHypertensivecardiovasculardiseasewithcongestiveheartfailurebenignessentialhypertensionReportcodesa,c,,b,,d,ANS:DPTS:DIF:DifficultFivehouroldinfant,prematureatweeks,spontaneousbirth,istransferredtogeneralhospitalfortreatmentintheneonatalintensivecareunitFinaldiagnosis:malenewborn,suspectedrespiratorydistresssyndromeduetoprematurityReportcodesforthegeneralhospitalinpatientstayaV,,c,Vb,,dV,,ANS:BPTS:DIF:DifficultPeritonitisduetocatheterinsertedintoabdomenforambulatoryperitonealdialysisRemovalofcatheterReportcodesa,,c,b,d,ANS:APTS:DIF:DifficultAcutegangrenousappendicitisPostoperativeparalyticileusAppendectomyReportcodesa,,c,,b,,d,,ANS:DPTS:DIF:ModerateHemiplegiasecondarytocerebralarterythrombosisyearagoReportcode(s)a,cb,d,ANS:CPTS:DIF:DifficultInfectedseconddegreeburnsofthehandfromboilingwaterReportcodesa,,Ec,,Eb,,Ed,,EANS:DPTS:DIF:DifficultUremiacardiomegalymalignanthypertensionReportcode(s)a,,c,bd,ANS:DPTS:DIF:DifficultSuspectedmyocardialinfarction,ruledoutReportcode(s)acVbVdANS:BPTS:DIF:ModerateGramnegativesepticemiaduetobacteroidesReportcodeacbdANS:APTS:DIF:EasyDisplacementofcardiacpacemakerelectrodeReportcodeacbdANS:BPTS:DIF:DifficultAyearoldpatientwastreatedasaninpatientfor“feverofunknownorigin”Reportcode(s)ac,Vb,dVANS:APTS:DIF:DifficultMalunionoffracture,rightanklePatientfelldownstairsmonthsagoandfracturedherankleitwashealinguntilrecently,whenthepatientcomplainedofpainandthephysiciannotedthemalunionReportcodesa,,E,Ec,,E,Eb,,E,Ed,,E,EANS:APTS:DIF:DifficultArterioscleroticcardiovasculardiseaseAcutemyocardialinfarctionReportcodesa,c,b,d,,ANS:CPTS:DIF:DifficultMATCHINGMatcheachdiagnosticstatementwiththetypeofcodeassignmentlistedbelowaMcodebEcodecVcodeburnoffootduetobonfireincidentnormalnewbornfemalecarbonmonoxidepoisoningcarcinomaofthelungfamilyhistoryofbreastcancerANS:BPTS:DIF:DifficultANS:CPTS:DIF:DifficultANS:BPTS:DIF:DifficultANS:APTS:DIF:DifficultANS:CPTS:DIF:DifficultMatcheachdiagnosticstatementwithaneoplasmdescriptionlistedbelowamalignantprimarybmalignantsecondarycbenignduncertainbehavioreunspecifiedbraintumortesticularadenomaneuroastrocytomaadenocarcinomaofthelungmetastaticcarcinomatothebrainANS:EPTS:DIF:DifficultANS:CPTS:DIF:DifficultANS:DPTS:DIF:DifficultANS:APTS:DIF:DifficultANS:BPTS:DIF:DifficultMatcheachdiagnosticstatementwithanepisodeofcarelistedbelowaunspecifiedbdeliveredwithwithoutantepartumcomplicationcdeliveredwithpostpartumcomplicationdantepartumcomplicationepostpartumcomplicationpreeclampsia,weeks,pregnancyundeliveredIUPdelivered,firstdegreeperineallacerationIUPdelivered,postpartumhemorrhageinfectedepisiotomy,weekafterpreviousdeliverypatientreadmittedweeksafterdeliverywithseverehemorrhageANS:DPTS:DIF:DifficultANS:BPTS:DIF:DifficultANS:CPTS:DIF:DifficultANS:EPTS:DIF:DifficultANS:APTS:DIF:DifficultMatcheachdiagnosticstatementwithatypeofconditionlistedbelowapoisoningbadverseeffectcpoisoninglateeffectdadverseeffectlateeffectallergytoamoxicillintoxiceffectofcarbonmonoxidesequelaeofprevioushypersensitivitytoDarvonbraindamageduetopreviousdrugoverdosestuporduetocombinationofNyquilandValiumANS:BPTS:DIF:DifficultANS:APTS:DIF:DifficultANS:DPTS:DIF:DifficultANS:CPTS:DIF:DifficultANS:APTS:DIF:Difficult

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Chapter 4 ICD-9-CM Coding Guidelines第四章ICD-9编码指南-厘米

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