Exam 5: General Coding Guidelines for Diagnosis

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?

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

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

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.

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.

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

The selection of codes A00.0 through Z99.89 will NOT be used frequently to describe the reason for the admission/encounter.

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

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

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

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

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

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

What is the diagnosis code(s) for cognitive deficits due to previous cerebral infarction?

A patient who is a known diabetic is admitted for treatment of an ulcer of the left great toe.What is the principal diagnosis?

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

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

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?

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?

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