Deck 5: General Coding Guidelines for Diagnosis

Question 1

A patient is admitted to the hospital with vomiting, diarrhea, and an inability to eat or drink. IV fluids are administered, and the patient is put on bowel rest. The following day, the patient is discharged with a diagnosis of gastroenteritis and dehydration. What is the principal diagnosis?

Answer 1

Either gastroenteritis or dehydration could be the principal diagnosis.

Question 2

A patient comes to the hospital with unstable angina. Serial cardiac enzymes and EKGs are performed, and anterolateral myocardial infarction is confirmed. The patient develops congestive heart failure on day 2 of the hospital stay. What is the principal diagnosis?

Answer 2

Anterolateral myocardial infarction (angina is a symptom of an MI)

Question 3

List one reason when it is NOT acceptable to code a symptom code from Chapter 18.

Answer 3

When a definitive diagnosis has been established or when the symptom is an integral part of the disease process.

Question 4

What is/are the diagnosis code(s) for acute and chronic cholecystitis?

Question 5

If a diagnosis is documented as possible at the time of discharge from an inpatient stay, code the condition as if it exists.

Question 6

A(n) ____ is a residual effect (condition produced) after the acute phase of an illness or injury has terminated.

A)combination effect
B)acute effect
C)sequela
D)chronic effect

Question 7

When a coder notices on a laboratory test result that a patient's sodium is below normal, it is acceptable to code hyponatremia.

Question 8

Conditions that are routinely associated with a disease or condition should not be coded as additional diagnoses unless instructed by the classification or unless they affect the patient's condition or treatment given.

Question 9

A patient who is a known diabetic is admitted for treatment of pneumonia. What is the principal diagnosis?

Question 10

When the patient is admitted for a complication due to a surgical procedure, the complication is the principal diagnosis.

Question 11

In the inpatient setting, it is not acceptable to code diagnoses that have not yet been confirmed and are questionable or suspected at the time of discharge.

Question 12

A patient is admitted to the hospital with Crohn's disease, hypertension, and rheumatoid arthritis for bowel resection. In the OR before incision, the patient develops tachycardia, and the procedure is canceled. What is the principal diagnosis?

Question 13

When you assign separate codes that are used to identify acute and chronic conditions, the acute code is sequenced first.

Question 14

The selection of codes A00.0 through T88.9, Z00-Z99.8 is NOT used frequently to describe the reason for the admission/encounter.

Question 15

A(n) __________ code is a single code used to classify two diagnoses, a diagnosis with an associated secondary process, or a diagnosis with an associated complication.

Question 16

If a patient is admitted for a complication due to a surgical procedure, the reason for the surgical procedure is the principal diagnosis.

Question 17

If the principal diagnosis was abdominal pain due to acute appendicitis, the abdominal pain would be coded as a secondary diagnosis.

Question 18

Codes for symptoms, signs, and ill-defined conditions are NOT to be used as a principal diagnosis when a related definitive diagnosis has been established.

Question 19

Principal diagnosis is defined in the Uniform Hospital Discharge Data Set (UHDDS) as that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care.

Question 20

Etiology/manifestation convention requires ____ code(s) to fully describe a single condition that affects multiple body systems.

A)one
B)two
C)three
D)zero

Question 21

What is/are the diagnosis code(s) for acute and chronic respiratory failure?

Question 22

What is/are the diagnosis code(s) for posttraumatic osteoarthritis due to previous left femoral neck fracture (hip)?

Question 23

What is/are the diagnosis code(s) for thoracolumbar scoliosis (neuromuscular) due to past history of poliomyelitis?

Question 24

What is/are the diagnosis code(s) for acute and chronic renal failure?

Question 25

What is/are the diagnosis code(s) for acute and chronic bronchitis?

Question 26

What is/are the diagnosis code(s) for acute and chronic pancreatitis?

Question 27

What is/are the diagnosis code(s) for memory deficit due to previous cerebral infarction?