Exam 9: Symptoms, Signs, and Abnormal Clinical and Laboratory Findings Not Elsewhere Classified, and Z Codes

A(n) ______________ is objective evidence of a disease or of a patient's condition as perceived by the patient's examining physician.

The NIHSS is a clinical assessment tool used to evaluate and monitor the neurologic status in acute-stroke patients.

Exposure to syphilis: __________

ICD-10-CM provides codes to deal with encounters for circumstances other than a disease or injury.

Patient is admitted with an acute cerebrovascular accident. The NIHSS score on admission is 35: _____________________________

Which of the following is NOT true of status codes?

Outpatient Encounter: Patient has been taking Lipitor for hypercholesterolemia for 1 year. A hepatic function lab 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.

Observation codes are to be used if an injury or illness or any signs or symptoms related to the suspected condition is present.

Urethral discharge: __________

On physical exam, the physician noted that the patient had hepatosplenomegaly. Further testing was ordered, and the patient will return in 2 weeks.

The patient was admitted for a takedown of colostomy. The patient underwent a colostomy 3 months ago after colon resection was performed for perforated diverticulitis. The patient was taken to the OR for open colostomy reversal with end-to-end anastomosis. No excision of the colon was performed. The patient still has a few diverticula of the large intestine and should follow a diverticulosis diet.Final Diagnosis: Diverticulosis Procedure: Colostomy takedown

In ICD-10-CM, there are Excludes1 notes that are helpful in determining whether a symptom's code should be assigned.

What is meant by screening exam or test?

Which of the following is NOT a specific Z code category?

Where are Z codes located in the Tabular List of the coding book?

In the inpatient setting, when a Z code is used as a diagnosis for a given procedure or a reason for the encounter, a procedure code is not necessary to identify that the procedure was performed.

Match each definition to one of the following items. -A person who is not currently sick encounters health services for some specific reason, such as to act as an organ donor; to receive prophylactic care, such as inoculations or health screenings; or to receive counseling on health-related issues

Counseling on the initiation of contraceptive foam use: __________

Oral phase dysphagia: __________

A 6-month-old infant was admitted with a febrile seizure. The patient had a temperature of 103° F. The patient was discharged to the care of the parents on the following day.Final Diagnosis: Febrile seizure