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Coding Skills Assessment

To complete the Coding Skills Assessment, complete the following steps.

  • Click here to download the Coding Skills Assessment Worksheet.
  • Use the ICD-10-CM Codebook to assign codes to each of the given scenarios.
  • Sequence codes according to the UHDDS definition of principal diagnosis.
  • Add additional diagnoses as appropriate.

Be sure to proofread your answer sheet before submitting, you do not want to lose points for typographical errors.

For a review of how to use your coding textbook, please view this guide.

Step 1 – Find a Diagnosis in the Alphabetic Index

See if you can locate the term Acne. To find this term, you need to turn to the Alphabetic Index to Diseases – which is after the guidelines near the beginning of your book. In the index, the main term acne links to the code L70.9

But what if the doctor states the diagnosis as Acne rosacea? Now review the indented list below the main term acne (called subterms) and find the subterm rosacea. Acne rosacea is coded as L71.9.

Step 2 – Verify the Code in the Tabular List of Diseases

Once you find a code in the Alphabetic Index, the very important next step is to verify the code in the tabular. Coders have to be very careful in assigning a code because what seems like a simple thing to do (linking a name of a disease to a number) isn’t always so simple. There are many rules involved in coding and by checking the Tabular, coders verify that they are assigning the correct code.

Find the code L71.9. It’s not too difficult, because this section is in alpha-numerical order. L71.9 Rosacea is the main term in the Tabular List. Notice what else is mentioned below it. Other names for the same disease are listed, and also a definition of the term acne is given. In this case, there are no coding rules involved, and you can assign the code L71.9.

Giving it Another Try

Step 1 – Find the Diagnosis in the Alphabetic Index

Let’s try coding another disease, postmenopausal osteoporosis. We know that step one is to find the disease in the Alphabetic Index – easy enough. But wait a minute – what is the main term of the disease? Do we look up the word postmenopausal or osteoporosis?

This is where courses like Medical Terminology and Pathophysiology are going to help you. Osteoporosis is the actual disease, while postmenopausal is a subterm that applies to this disorder.

As you practice identifying the main term, if you can’t find it under one word, try another. Remember, the main term will be a disease, injury or condition that the patient has. Do not try to find codes by anatomic site.

Look up Osteoporosis and scan down the subterms to find postmenopausal. The code for postmenopausal osteoporosis is M81.0

Step 2 – Verify the Code in the Tabular List of Diseases

Notice that M81.0 links to the main term Senile Osteoporosis in the Alphabetic Index. Reading just below the code, Postmenopausal Osteoporosis is listed as another term for the same disorder. Hooray! You found the correct code. Or did you?

Take a look at the M81.0 section just above the code you found, and read the coding rules in red. These rules apply to any codes beginning with M81.0. There is a rule telling you to use an additional code if other conditions are going on at the same time. In this case, you won’t need to use an additional code, but in the real world, this is a reminder to the coder to add other codes if the patient has other related disorders.

Also, check the M81 category just above Osteoporosis. These rules apply to any codes beginning with M81. Notice there is an Excludes note, where if any of the listed diseases occur at the same time as osteoporosis, they can’t be coded.

Congratulations! You found the correct code M81.0. As a rule of thumb, remember to always double check your code and carefully read information the Tabular List tells you.

TermsDefinitions
1. Principal diagnosisThe condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care.
2. Principal procedureProcedure performed for definitive treatment, rather than for diagnostic or exploratory purposes, or one that was necessary to take care of a complication.
3. Instructional notesProvide additional information regarding proper code assignment; examples are: Includes; Excludes; Code First; Use Additional Code; and Code, If Applicable, Any Causal Condition First.
4. Main termTerm that identifies disease conditions or injuries; it is identified in bold print and set flush with the left margin of each column in the Alphabetic Index.
5. SubtermsGive more specific information about a main term; listed below and indented to the right of the main term.
6. CategoryIn the Tabular List, a single three-digit code that describes a disease or similarly related group of conditions.
7. SubcategoryIn the Tabular List, a fourth-digit code that provides additional information or specificity.
8. SubclassificationIn the Tabular List, a fifth, sixth or seventh characters that provides even greater specificity.
9. SectionConsists of a group of three-digit categories that represent diseases or conditions that are similar.
10. SpecificityCoding to the greatest detail possible for a code.

 

Last Updated on February 11, 2019

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