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NEC Not elsewhere classified
NOS Not otherwise specified
Rule out Indicates that a diagnosis is still possible
Ruled out Diagnosis is set
Assign a three-digit code Only when there are no four-digit codes within the category
Assign a four-digit code Only where there is no fifth-digit subclassification for that category
Assign a fifth digit code When the category for which a fifth-digit subclassification is provided
When assign code No two-digit code. Assign a three-digit when there is no 4th digit. Assign a four-digit code when there is no 5th digit. Assign a 5th subclassification code is provided
When coding All digits must be used. None can be omitted and none can be added
One exception when you code The one exception to this rule is that a 0 should be added as a 4th digit when the 5th digit is required when there is no 4th digit present
Assign residual code The residual NOS code should never be assigned when a more specific code is available
To complete coding of Late Effects There 2 codes required: Residual condition or nature of the late effect OR the cause of the late effect
Late Effect due to injury If the late is due to injury, a late effect E code should also be assigned.
Signs (Objective) Are what the doctor sees
Symptoms (Subjective) Are what you experience
V codes Are used for continued care after the initial treatment of an injury or disease
E codes Are for external causes of injury and poisoning
Palliative (relieving without curing) care Are cares focused on the management of pain and other symptoms of patients who are in the terminal phase of an illness
Adverse effect 不利影响 A result of drug therapy that is neither intended nor expected in normal therapeutic use and that causes significant, sometimes life-threatening conditions.
Tremors Shaking
V codes as a principal diagnosis When a person with a resolving disease or injury or a chronic condition is being seen for specific aftercare. radiation, Chemo,or dialysis
V Codes is also use for After care visits
Ascites 腹水 Is an abnormal accumulation of fluid in the abdomen.
sense organs 感觉器官 A specialized organ or structure, such as the eye, ear, tongue, nose, or skin, where sensory neurons are concentrated and which functions as a receptor. Also called sensor.
Consultation notes Sometimes in progress notes rather than on separate reports
Final diagnoses May be find in the admission record (face sheet), progress notes, or discharge summary
3 steps in locating the codes to be assigned 1 Locate the main term. 2 Verify the code number in the Tabular List. 3 Assign the verified code or codes
Locate the main term in the Alpha Index 1 Review and nonessential modifiers related to the main term. 2 Follow any cross-reference instructions. 3 Refer to any notes in the Alpha Index
Verify the code number in the Tabular List 1 Read the code title. 2 Read and be guided by any instructional notes. Refer to other codes as instructed. 3 Determine whether a fifth digit must be added.
Assign the verified code or codes It is imperative that these steps be followed without exception; the condition or procedure to be coded must first be located in the Alpha Index and then verified in the Tabular List.
Dual Classification Is used to describe the required assignment of 2 codes
manifestation code Is in italics 斜体(the letters usually slope to the right)and can not be assigned as the principal diagnosis
A code in brackets in the Alpha Index Can be used as a secondary code
Residual Is a Late effect (sequela of a previous illness or injury
Residual or late effect terms Old, Late, Due to previous injury or illness, Traumatic, unless there is evidence of current injury
Complete coding of late effects requires 2 codes: 1 Residual condition or nature of the late effect. 2 Cause of the late effect
Sequence coding of the 2 late effects 1st. The residual condition. 2nd The cause of the late effect
Late effects due to a injury A late effect injury E code should also be assigned beside the late effect code
Traumatic Also known as Late Effect
Palpitation P. 213 785.1
Edema P. 98 782.3
Hemoptysis P. 130 876.3
Created by: Lilyn Ta