Exam 8: Symptoms, Signs, and Abnormal Clinical and Laboratory Findings Not Elsewhere Classified, and Z Codes

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 the following terms to the correct definition. -Done in the absence of any signs or symptoms

List one reason why a screening code would not be necessary.

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.

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.

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

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

Match the following terms to the correct definition. -Subjective evidence of a disease or of a patient's condition as perceived by the patient

Ascites due to cirrhosis of liver: __________

What does BMI stand for?

Patient was seen in the clinic.Final diagnosis is RUQ rebound abdominal tenderness.

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.

A(n) ____ code is used to explain continuing surveillance following completed treatment of a disease,condition,or injury.

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.

Patient is admitted to hospice care for treatment of terminal ESRD.

Principal diagnosis is documented as right upper quadrant abdominal pain due to cholecystitis versus peptic ulcer disease: __________

A screening code may be listed first if the reason for the visit is specifically a screening exam.

Outpatient Encounter: Patient has been taking Lipitor for hypercholesterolemia for 1 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.

Where can documentation of a patient's medical and surgical history be found?

Encounter for admission examination for prisoner: __________