ICD-10-CM Guidelines Section 1 B. General Coding Guidelines

When selecting an ICD-10-CM code, what is the correct procedure to ensure the full and accurate code is assigned?

• Choose the code directly from the Alphabetic Index as it usually provides the complete code

• Verify the code in the Tabular List only if the Alphabetic Index entry includes a dash (-)

• Locate the term in the Alphabetic Index and verify the full code, including laterality and any 7th character, in the Tabular List

• Use the Alphabetic Index for code assignment and reference the Tabular List only for complex cases

What is the correct approach when assigning ICD-10-CM diagnosis codes to ensure compliance with the level of detail required?

• A three-character code can always be used if it describes the diagnosis

• Codes must be reported with the highest number of characters available and specificity documented in the medical record

• Codes with fewer than seven characters are invalid, even if the diagnosis is fully represented by three characters

• Only fourth and fifth characters are necessary for a valid code; sixth and seventh characters are optional

Which of the following correctly identifies when codes from A00.0 through T88.9, Z00-Z99.8, and U00-U85 should be used?

• Only when documenting chronic conditions

• Only when documenting symptoms or complaints

• These codes must be used to identify diagnoses, symptoms, conditions, problems, complaints, or other reasons for the encounter

• These codes are only used for identifying infectious diseases and injuries

When is it appropriate to report codes that describe signs and symptoms rather than a definitive diagnosis?

• Only when the symptoms are severe and require immediate treatment

• When a definitive diagnosis has not been established or confirmed by the provider

• Only if the symptoms are related to chronic conditions.

• When the signs and symptoms are found in Chapter 18 (R00.0 - R99)

When should signs and symptoms that are routinely associated with a disease process be coded?

• Always code signs and symptoms separately to provide more detail

• Only code signs and symptoms if they occur frequently during the disease process

• Do not assign codes for signs and symptoms routinely associated with the disease process, unless instructed otherwise by the classification

• Code signs and symptoms separately only if they occur before the disease diagnosis is confirmed

A patient is diagnosed with pneumonia and also presents with chest pain and shortness of breath. The physician confirms that the chest pain and shortness of breath are not typically associated with pneumonia. How should the coding be handled in this case?

• Only the pneumonia diagnosis should be coded, as the primary condition covers all associated symptoms

• The pneumonia should be coded, and additional codes should be assigned for the chest pain and shortness of breath, since they are not routinely associated with pneumonia

• The chest pain and shortness of breath should be ignored, as they are part of the patient's overall condition

• Only the symptoms should be coded, without specifying the pneumonia diagnosis

When encountering a "use additional code" note in the Tabular List, what does this indicate regarding the coding process?

• The primary code is sufficient and no further codes are necessary

• The secondary code should only be used if the patient has multiple conditions

• A secondary code is needed to fully describe the condition, such as identifying the organism causing an infection

• The secondary code should only be added if the primary diagnosis is unclear

Which of the following statements is correct when using a "code first" note in the Tabular List?

• The "code first" note means that this code must always be used as the principal diagnosis

• The "code first" note indicates that the underlying condition should be sequenced before the current code, if the underlying condition is known

• The "code first" note only applies if there is no specific etiology/manifestation relationship

• A "code first" note means that no additional codes are needed to fully describe the condition

A patient is diagnosed with both acute and chronic bronchitis during the same visit. The Alphabetic Index provides separate subentries for both acute and chronic bronchitis. How should the coding be sequenced for this patient?

• Only the acute bronchitis code should be assigned, as it represents the more urgent condition

• Only the chronic bronchitis code should be assigned, since it reflects the long-term condition

• Both the acute and chronic bronchitis codes should be assigned, with the chronic code sequenced first

• Both the acute and chronic bronchitis codes should be assigned, with the acute code sequenced first

Under which circumstances should a combination code be used instead of multiple codes, according to ICD-10-CM guidelines?

• When a combination code is available but lacks specificity in describing the complication or manifestation, assign only the combination code

• Use both a combination code and additional codes if the classification does not fully describe each element of the diagnosis or its associated condition

• Assign the combination code only when it fully captures the diagnosis, along with any associated secondary process or complication, and the Alphabetic Index directs its use

• Use multiple codes instead of a combination code whenever there are more than two diagnostic conditions involved