CPC Exam ICD conventions & guidelines
latest 2022 100% pass
Precedence ✔✔Instructions and Guidelines of the classification take precedence over guidelines.
Section I ✔✔general coding guidelines and chapter specific gu
...
CPC Exam ICD conventions & guidelines
latest 2022 100% pass
Precedence ✔✔Instructions and Guidelines of the classification take precedence over guidelines.
Section I ✔✔general coding guidelines and chapter specific guidelines
Section II ✔✔selection of principal diagnosis for non outpatient settings
Section III ✔✔Additional diagnoses in non-outpatient settings
Section IV ✔✔Outpatient coding and reporting
E&M ✔✔physicians' work
New Patient ✔✔one who has not received any medical services by same physician or physician
of the same specialty in the practice within the last 3 yrs.
Established Patient ✔✔someone who has received medical services with in the last 3 yrs from the
physician or another physician of the same specialty who belongs to the same group practice
Chief Complaint ✔✔a brief statement describing the symptom, problem, diagnosis, or condition
that is the reason a patient seeks medical care
Volume 1 ✔✔aka Tabular, contains the disease and condition codes and the descriptions with the
V codes and E codes
Volume 2 ✔✔this is the alphabetic index of volume 1
Volume 3 ✔✔NOT USED ON CPC EXAM contains codes for surgical, therapeutic, and
diagnostic procedures; used primarily by hospitals
Volume 1 & Volume 2 ✔✔used in the inpatient and outpatient settings by physicians
V codes ✔✔used to identify health care encounters that occur for other reasons other than illness
or injury or to identify patients whose illness is influenced by special circumstances or problems
E codes ✔✔used to describe the reason or external cause of injury, poisoning and other adverse
effects.
ICD updates ✔✔Yearly usually in October
Tabular List ✔✔aka Volume I Consists of 17 chapters based on either body system or cause or
type of disease. The codes range from 001-999.
Alphabetic Index ✔✔aka Volume II, look here first for codes
Chapters ✔✔are the main division in the ICD-9-CM
Sections ✔✔are composed of a group of three-digit codes representing a group of conditions or
related conditions
Categories ✔✔Composed of three-digit codes representing a single disease or condition. The
three-digit code is used only if it is not further subdivided.
Subcategories ✔✔Provide a 4th digit which is more specific then a category code in terms of
cause, site, or manifestation of the condition. This must be used if available.
Subclassification ✔✔Provides a 5th digit which gives the highest specificity of description to a
condition. Use of it is mandatory if it is available. A code not reported to the full number of digits
required is invalid
nonessential modifiers ✔✔Terms in parenthesis who's presence/absences has no effect on the
code.
essential modifiers ✔✔are not enclosed in parentheses and are SUB TERMS that DO affect the
selection of appropriate code
Malignant hypertension ✔✔severe form of hypertension w/vascular damage and a diastolic
pressure of 130 mmHg or greater
Benign Hypertension ✔✔Mild or controlled hypertension and no damage to the vascular system
or organs
Unspecified Hypertension ✔✔this is not specified as benign or malignant in the diagnosis or
medical record
Malignant Neoplasm ✔✔further classified as to primary, secondary, or carcinoma in situ
Primary malignancy ✔✔the original cancer site. malignant tumors are considered primary unless
documented as secondary or metastatic
Secondary malignancy ✔✔cancer that has metastasized(spread) to a secondary site either adjacent
or remote region of the body
Carcinoma in situ ✔✔IN CELL - cancer that is localized and has not spread to adjacent tissues or
distant parts of the body
Benign Neoplasm ✔✔noninvasive, non-spreading, nonmalignant
Uncertain behavior ✔✔uncertain whether benign or malignant; borderline malignancy
Unspecified Nature ✔✔a neoplasm is identified; however, no nature of the tumor is documented
in the diagnosis or medical record
Table of Drugs and Chemicals ✔✔contains a list of drugs and chemicals with the corresponding
poisoning codes and E codes; part of Volume I
NEC ✔✔not elsewhere classified; represents other specified; when code is not available for a
condition the tabular includes an NEC entry
NOS ✔✔not otherwise specified; equivalent of unspecified
Other codes ✔✔usually with a 4th digit 8 or fifth digit 9; use when the medical record provides
detail for which a specific code does NOT exist; NEC index entries; means "other"
unspecified ✔✔usually with 4th digit 9 or 5th digit 0; when info does not give enough information
to assign specific code, NOS; means "not specified"
AND ✔✔means AND or OR in a title
WITH ✔✔means associated with or due to
SEE ✔✔another term should be referenced; go to the main term referenced with the "see" not to
locate the correct code
SEE ALSO ✔✔another main term that may also be referenced that may provide additional index
entries that may be useful; not necessary if original main term provides the necessary code; might
indicate a different way to look it up
Guidelines ✔✔Guidelines are a set of rules developed to accompany and complement official
conventions and instructions provided within the ICD9CM.
when can you code 388.xx first ✔✔See I.C.6
How do you code hypertension with heart disease? ✔✔Code 402.xx followed by the type of heart
failure is mentioned; See I.C.7.a.2 for the answer.
How do you code hypertension with ESRD. ✔✔First code is 403.xx followed by the ESRD
How do you code poisonings? ✔✔Poisonings - see guidelines I.C.17.e.2
trephination ✔✔drilling a hole in the skull to expose the dura mater
tentorium cerebelli ✔✔an extension of the dura mater, separates the cerebrum from the cerebellum
F wave ✔✔voltage change after electrical stimulation above the distal region of a nerve; used to
measure NCV
H reflex ✔✔hoffman reflex; reaction of muscles after electrical stimulation sensory fibers; used
to dx proximal disease
slanted brackets ✔✔in the alpha listing indicate mandatory additional codes and the order in which
to list them
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