Abnormal findings alone on a report can be coded.
False
Z codes can be coded only as principal diagnosis.
False
To indicate birth status for a newborn, use a:
code
A symptom is:
subjective evidence of a disease or of a patient’s condition as perceived by the patient
Signs and symptoms that are integral to the disease process:
should not be coded
Fever is an example of a sign/symptom.
True
Prophylactic means:
medication used to prevent a disease from occurring
A Z code is used to indicate a history of a certain condition, even if the patient currently has the condition.
False
A screening examination is:
an examination of an asymptomatic individual to detect a given disease
Threatened or impending conditions should never be coded as confirmed
False
The infant was seen in the ER for fever. Physician documented fever due to vaccination.
R50.83
A(n) ____ code is used to explain continuing surveillance following completed treatment of a disease, condition, or injury.
follow-up code
Which of the following is a category of Z codes?
a. Contact/exposure
b. Inoculations and vaccinations
c. Status
d. All of the above (correct answer)
b. Inoculations and vaccinations
c. Status
d. All of the above (correct answer)
Patient is admitted to hospice care for treatment of terminal ESRD.
N18.6, Z51.5
Which of the following is NOT true of status codes?
a. A status code is informative because the status may affect the course of treatment and its outcome.
b. A status code is distinct from a history code.
c. A status code should not be used with a diagnosis code from one of the body system chapters if the diagnosis code includes the information provided by the status code.
d. None of the above are correct. (correct answer)
b. A status code is distinct from a history code.
c. A status code should not be used with a diagnosis code from one of the body system chapters if the diagnosis code includes the information provided by the status code.
d. None of the above are correct. (correct answer)
Signs and symptoms are not often correlated with a definitive diagnosis in the health record.
True
Patient was seen in the clinic. Final diagnosis is RUQ rebound abdominal tenderness.
R10.811
Patient has been taking Lipitor for hypercholesterolemia for one year. A hepatic function laboratory test was performed to assess any adverse effects on the patient’s liver function. A fasting lipid profile was also done to assess the effectiveness of the Lipitor.
Z51.81, Z79.899, E78.0
A Z code for long-term use of antibiotics should not be assigned when antibiotics are taken for a short period of time for an acute illness.
True
The patient was admitted for prophylactic breast removal. The patient has a strong family history of breast cancer and the patient has severe fibrocystic disease in both breasts, making breast examination difficult. The patient was taken to the OR, and a bilateral simple mastectomy was performed. The patient recovered with no problems. The pathology report showed no evidence of malignancy.
Final Diagnosis: Family history of breast cancer; severe fibrocystic disease.
Procedure: Bilateral simple mastectomy.
Final Diagnosis: Family history of breast cancer; severe fibrocystic disease.
Procedure: Bilateral simple mastectomy.
Z40.01, Z80.3, N60.11, N60.12, 0HTV0ZZ
The patient was admitted for biopsy of an enlarged lymph node in the area of the left axilla. The patient has a past medical history of breast cancer with a mastectomy of the left breast 1 year ago. The patient is no longer receiving any therapy for her cancer. A needle biopsy was done. The pathology report showed normal lymphatic tissue with no evidence of metastatic spread.
Final Diagnosis: Lymphadenopathy left axilla; metastasis ruled out.
Procedure: Needle core biopsy axillary lymph node.
Final Diagnosis: Lymphadenopathy left axilla; metastasis ruled out.
Procedure: Needle core biopsy axillary lymph node.
R59.0, Z85.3, Z90.12, 07B63ZX
In ICD-10-CM there are Excludes1 notes that are helpful in determining whether a symptoms code should be assigned.
True
A person who has had an allergic episode related to a substance or food in the past should always be considered allergic to the substance.
True
The patient is admitted to the hospital with fever and dehydration resulting from pneumonia.
J18.9, E86.0
Observation codes are to be used if an injury or illness, or any signs or symptoms related to the suspected condition, are present.
False
ICD-10-CM provides codes to deal with encounters for circumstances other than a disease or injury.
True
A screening code may be listed first if the reason for the visit is specifically a screening exam.
True
A 6-month-old infant was admitted with a febrile seizure. The patient had a temperature of 103 and had been started on antibiotics the day before for an acute bilateral otitis media. The patient was discharged to the care of the parents on the following day.
Final Diagnosis: Febrile seizure; fever due to acute bilateral otitis media.
Final Diagnosis: Febrile seizure; fever due to acute bilateral otitis media.
R56.00, H66.93
The patient was admitted with abdominal pain in the right upper quadrant. Workup included an EGD that showed some mild gastritis, and abdominal ultrasound was positive for gallstones in the gallbladder.
Final Diagnosis: Abdominal pain due to gastritis versus cholelithiasis.
Procedure: Esophagogastroduodenoscopy with biopsy of the stomach.
Final Diagnosis: Abdominal pain due to gastritis versus cholelithiasis.
Procedure: Esophagogastroduodenoscopy with biopsy of the stomach.
K29.70, K80.20, 0DB68ZX
The patient is admitted to the hospital with right lower quadrant pain and nausea and vomiting. The patient had a low-grade fever. A diagnosis of acute appendicitis is made, and the patient is taken to the OR for removal of the appendix via open approach.
K35.80, 0DTJ0ZZ