The steps to diagnosis coding are as follows:

  1. The steps to diagnosis coding are as follows 1. Identify the main term(s) in the diagnostic statement.

    2. Locate the main term(s) in the Alphabetic Index (referred to in this material as the Index).

    3.Review any subterms under the main term in the Index.

    4. Follow any cross-reference instructions (i.e., see, see also).

    5. Verify the code(s) selected from the Index in the Tabular List (referred to in the material as the Tabular)

    6. Refer to any instructional notations in the Tabular.

    7. Assign codes to the highest level of specificity.

    8. Code the diagnosis until all elements are completely identified.Don't take shortcuts.

    Always follow these steps when assigning a code.
  2. Which government organization was formerly the Health Care Financing Administration and is a member of the Cooperating Parties?

    D. Centers for Medicare and Medicaid Services
  3. Always follow the instructional notations that appear in both the Index and the Tabular List.

    A. TrueB. False
  4. In the I-10 Index, a dash will always follow the end of an Index entry when additional characters are required.

    A. TrueB. False
  5. Section I.B.8. Acute and Chronic Conditions directs the coder to place the ________ code first and the ________ code second.

    A. chronic; acute
    B. acute; chronic
    B. acute; chronic
  6. Laterality

    Some ICD-10-CM codes indicate laterality,specifying whether the condition occurs on the left, right or is bilateral.

    If no bilateral code is provided and the condition is bilateral, assign separate codes for both the left and right side. 

    If the side is not identified in the medical record, assign the code for the unspecified side.
  7. Reporting Same Diagnosis Code More than Once

    Each unique ICD-10-CM diagnosis code may be reported only once for an encounter.

    This applies to bilateral conditions when there are no distinct codes identifying laterality or two different conditions classified to the same ICD-10-CM diagnosis code.
  8. According to Section I.B.10. in the textbook, a sequela is the residual effect after the acute phase of an illness or injury has terminated.

    A. Yes
    B. No
  9. When two or more interrelated conditions exist and either could be the first-listed diagnosis, which is sequenced first?

    D. either
  10. Can you report shortness of breath as an additional code when reporting pneumonia as the first-listed condition?

    A. Yes
    B. No
  11. With the use of the ICD-10-CM manual, correctly code the disease/disorder.

    Scenario 1


    Acute and chronic Stage 5 renal failure

    HOSPITAL COURSE: The patient was admitted due to unstable creatinine levels. Patient ultimately ended up needing a dialysis catheter placed and did undergodialysis treatment. For now the patient will undergo hemodialysis 3 days a week. Nurses will check creatinine level during dialysis run. Nephrology specialist will be primary for the renal failure.

    DISCHARGE PLAN: The patient will be going home today. He will continue with hemodialysis as an outpatient. We will schedule the patient to see me in two weeks.
    N17.9, N18.5, Z99.2
Card Set
The steps to diagnosis coding are as follows:
chapter 4