Exam 5: General Coding Guidelines for Diagnosis

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

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?

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

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?

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

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

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

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

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

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

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.

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.

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

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

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

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

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.

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

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.

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.