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Billing and Coding
Chapter 4 Terms
| Term | Definition |
|---|---|
| Acute | Description of an illness or condition having severe symptoms and a short duration; can also refer to a sudden exacerbation of a chronic condition. |
| Alphabetic Index | A part of ICD-10-CM and of ICD-9-CM that lists disease and injuries alphabetically with corresponding diagnosis codes. |
| Category | A three-digit code used for classifying a disease or condition. |
| Chief Complaint (CC) | A patient’s description of the symptoms or other reasons for seeking medical care from a provider. |
| Chronic | Description of an illness or condition with a long duration. |
| Code | In ICD-10-CM, three-, four-, five-, six-, or seven-digit characters used to represent a disease, injury, or symptom. |
| Coexisting Condition | Additional illness that either has an effect on the patient’s primary illness or is also treated during the encounter. |
| Combination Code | A single code that classifies both the etiology and the manifestation(s) of an illness or injury. |
| Convention | Agreement to use typographic techniques or standard practices that provide visual guidelines for understanding printed material. |
| Default Code | ICD-10-CM code listed next to the main term in the Alphabetic Index that is most often associated with a particular disease or condition. |
| Diagnostic statement | A physician’s description of the main reason for a patient’s encounter; may also describe related conditions or symptoms. |
| Eponym | A name or phrase that is formed from or based on a person’s name; usually describes a condition or procedure associated with that person. |
| Etiology | The cause or origin of a disease. |
| Excludes 1 | A type of exclusion note that is used when two conditions could not exist together. |
| Excludes 2 | A type of exclusion note that is used when a condition is “not included here,” but a patient could have both conditions at the same time. |
| Exclusion Notes | Tabular List entries limiting applicability of particular codes to specified conditions. |
| External Cause Code | Diagnosis code that reports the cause of injuries from various environmental events. |
| First-listed code | Code for diagnosis that is the patient’s main condition; in cases involving an underlying condition and a manifestation, the underlying condition is the first-listed code. |
| GEMs | n acronym that stands for general equivalence mappings, which are prepared by the federal government to aid coders in selecting codes for ICD-10-CM. |
| ICD-10-CM | Abbreviated title of International Classification of Diseases, Tenth Revision, Clinical Modification, the HIPAA-mandated diagnosis code set as of October 1, 2015. |
| ICD-10-CM Official Guidelines for Coding and Reporting | The general rules, inpatient (hospital), and outpatient coding guidance from the four cooperating parties (CMS advisers and participants from the AHA, AHIMA, and NCHS). |
| Inclusion Notes | Notes that are headed by the word includes and refine the content of the category appearing above them. |
| Index to External Causes | An index of all the external causes of diseases and injuries that are listed in the related chapter of the Tabular List. |
| Laterality | Use of ICD-10-CM classification system to capture the side of the body that is documented; the fourth, fifth, or sixth characters of a code specify the affected side(s). |
| main term | A word that identifies a disease or condition in the Alphabetic Index. |
| Manifestation | A disease’s typical signs, symptoms, or secondary processes. |
| NEC (not elsewhere classifiable) | An abbreviation indicating the code to use when a disease or condition cannot be placed in any other category. |
| Neoplasm Table | A summary table of code numbers for neoplasms by anatomical site and divided by the description of the neoplasm. |
| Nonessential Modifier | Supplementary terms that are not essential to the selection of the correct code, and which are shown in parentheses on the same line as a main term or subterm. |
| NOS (not otherwise specified) | An abbreviation indicating the code to use when no information is available for assigning the disease or condition to a more specific code; unspecified. |
| Placeholder character (x) | Designated as “x” in some codes when a fifth-, sixth-, or seventh-digit character is required but the digit space to the left of that character is empty. |
| Primary Diagnosis | The first-listed diagnosis. |
| Principle Diagnosis (PDX) | In inpatient coding, the condition that after study is established as chiefly responsible for a patient’s admission to a hospital. |
| Sequelae | Conditions that remain after a patient’s acute illness or injury has ended. |
| Seventh-character extension | A requirement contained in the note at the start of the code it covers; a seventh character must always be in position 7 of the alphanumeric code. |
| subcategory | A four- or five-character code number. |
| Subterm | Word or phrase that describes a main term in the Alphabetic Index. |
| Table of Drugs and Chemicals | An index in table format of drugs and chemicals that are listed in the Tabular List. |
| Tabular List (TL) | The part of ICD 10-CM that lists diagnosis codes in chapters alphanumerically. |
| Z code | Abbreviation for code from the twenty-first chapter of the ICD-10-CM that identify factors that influence health status and encounters that are not due to illness or injury. |
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