ICD-10-CM Coding Basics
LPN / LVN
Other IDT Member
1. Who of the following can diagnose for ICD-10-CM coding purposes: Speech Therapist, Dietitian, Physician Assistant or Director of Nursing? Please name all that apply.
2. Your speech therapist documented that the resident had oropharyngeal dysphagia in her notes. You can add the diagnosis code for oropharyngeal dysphagia to the resident’s medical record from that documentation.
3. The physician documented “Urosepsis” as the primary diagnosis. You should:
A. Code Sepsis as the primary diagnosis
B. Code UTI as the primary diagnosis
C. Query the physician
D. Find a different diagnosis from the resident’s diagnosis list
4. Your dietitian documented that the resident had a BMI of 40 which falls within the guidelines for morbid obesity. The physician has not documented the diagnosis of morbid obesity in the medical record. It is acceptable to code morbid obesity on the MDS.
5. Your resident’s hospital discharge summary listed hip fracture of unspecified hip as the primary diagnosis. You should:
A. Query the physician to specify which hip had been fractured
B. Determine which hip has been surgically repaired and document in the medical record so it can be coded
C. Contact the hospital to get more specific information
D. Append the hip fracture of unspecified hip code to the medical record
E. A or B
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