CHAPTER 4 - 6
Quiz yourself by thinking what should be in
each of the black spaces below before clicking
on it to display the answer.
Help!
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| NEC | Not elsewhere classified
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| NOS | Not otherwise specified
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| Rule out | Indicates that a diagnosis is still possible
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| Ruled out | Diagnosis is set
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| Assign a three-digit code | Only when there are no four-digit codes within the category
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| Assign a four-digit code | Only where there is no fifth-digit subclassification for that category
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| Assign a fifth digit code | When the category for which a
fifth-digit subclassification is provided
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| 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
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| When coding | All digits must be used. None can be omitted and none can be added
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| 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
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| Assign residual code | The residual NOS code should never be assigned when a more specific code is available
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| 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
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| Late Effect due to injury | If the late is due to injury, a late effect E code should also be assigned.
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| Signs (Objective) | Are what the doctor sees
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| Symptoms (Subjective) | Are what you experience
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| V codes | Are used for continued care after the initial treatment of an injury or disease
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| E codes | Are for external causes of injury and poisoning
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| 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
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| 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.
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| Tremors | Shaking
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| 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
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| V Codes is also use for | After care visits
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| Ascites 腹水 | Is an abnormal accumulation of fluid in the abdomen.
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| 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.
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| Consultation notes | Sometimes in progress notes rather than on separate reports
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| Final diagnoses | May be find in the admission record (face sheet), progress notes, or discharge summary
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| 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
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| 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
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| 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.
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| 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.
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| Dual Classification | Is used to describe the required assignment of 2 codes
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| manifestation code | Is in italics 斜体(the letters usually slope to the right)and can not be assigned as the principal diagnosis
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| A code in brackets in the Alpha Index | Can be used as a secondary code
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| Residual | Is a Late effect (sequela of a previous illness or injury
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| Residual or late effect terms | Old, Late, Due to previous injury or illness, Traumatic, unless there is evidence of current injury
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| Complete coding of late effects requires 2 codes: | 1 Residual condition or nature of the late effect. 2 Cause of the late effect
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| Sequence coding of the 2 late effects | 1st. The residual condition. 2nd The cause of the late effect
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| Late effects due to a injury | A late effect injury E code should also be assigned beside the late effect code
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| Traumatic | Also known as Late Effect
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| Palpitation P. 213 | 785.1
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| Edema P. 98 | 782.3
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| Hemoptysis P. 130 | 876.3
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Created by:
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