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Coding Principles
ICD-9 Cpt-4 HCPCS
| Question | Answer |
|---|---|
| ICD-9-CM | international classification of diseases 9th revision clinical modification |
| ICD-9-cm | published by WHO world health organization |
| ICD-9-cm | codes have 3 to 5 digits the more digits the more specific |
| The category | first 3 digits of icd-9-cm code |
| the sub category | 4th digit of icd-9-cm code |
| sub classification | 5th digit of icd-9-cm code |
| primary dx | first listed diagnosis chief complaint reason pt was seen |
| qualified dx | working diagnosis qualifying symptoms |
| adverse effect | unfavorable reaction (to a medication) |
| benign | noncancerous no properties of cancer |
| malignant | cancerous having properties of cancer |
| CA in situ | cancer is still at site of origin has not spread |
| morbidity | a diseased condition of the body |
| mortality | the death rate number of deaths in a given time |
| comorbidity | an underlying disease or condition contributes to the pt's present condition |
| familial | inherited from ones family |
| acute | a condition that runs a short but severe course |
| NOS | not otherwise specified |
| NEC | not elsewhere classifiable |
| chronic | "recurrent" condition that runs over a longer period of time |
| eponym | a procedure or disease named after the physician who discovered it |
| V codes | non sickness or injury codes |
| E codes | external causes of injury never used as primary dx |
| slanted brackets | indicate the need for a second code listed as dx in the same order |
| italicized codes | never used as primary dx |
| main terms | appear in bold |
| icd-9 volume 2 | alphabetical guide code listed by pts condition |
| icd-9 volume 1 | numerical real deal codes |
| icd-9 volume 2 section 2 | table of drugs and chemicals |
| icd-9 volume 2 section 3 | index to external causes of injury |
| cogenital | born with, present at birth |
| volume 1 v codes | located after the systems |
| volume 1 e codes | located after the v codes |
| sub terms | indented 2 spaces |
| sub sub terms | indented 4 spaces |
| non-essential modifiers | in parenthesis after main terms included with main term |
| personal history | a pt's history |
| family history | a pt's family history |
| fitting of | equipment |
| history of | icd-9 vol 2 codes for family and personal history |
| hypertension | section of icd-9 vol2 |
| neoplasm | new growth section of icd-9 vol2 benign malignant or unspecified |
| connecting words | with, without,due to associated with, in with mention of |
| colon : | needs one or more of the following modifiers |
| brace } | modifies all in bracket |
| excludes | indicative that terms are to be coded elsewhere |
| ICD-9-cm volume 3 | procedure codes located here used in hospital setting for inpatients not used in dr offices |
| see | explicit directions to look elsewhere |
| see also | directs coder to look under another term for specifics |
| see category | directs coder to look in volume 1 |
| notes | define and give instruction |
| modifiers | added to codes to supply more specific information |
| and | means and or |
| with | 2 conditions must be present to use code |
| brackets ] | enclose synonyms or alternate words |
| italics | exclusion notes or diagnosis not to be used as primary |
| includes | further defines or explains content |
| parenthesis | supplementary words that do not change the code |
| X | used during guide to remember that code needs a 5th digit |
| late effect | residual effect from previous injury or surgery |
| combination code | use 1 code to diagnose 2 separate dx |
| burns | needs 2 codes (at least) first code is site and degree 2nd code is % of body surface |
| primary neoplasms | first site of cancer |
| secondary neoplasms | another site (other than 1st) that cancer has spread to |
| uncertain behavior | the pathology report must state this in order to use these codes |
| unspecified | code used when neoplasm destroyed while biopsy report still pending |
| metastasis | spread of a tumor from one site to other sites |
| morphology | tissue typing of a neoplasm could be benign or malignant |
| CPT-4 | current procedural terminology 4th edition published by the ama American medical association |
| CPT-4 | six sections : E&M ,anesthesiology surgery, radiology, pathology & laboratory, and medicine |
| anesthesia | all codes require a physical status modifier |
| consultation | one physician asking another physician for advice in writing |
| + add on codes | these codes are not to be used without another code in front of them |
| review of systems | inventory of the body obtained thru a mini-exam series of questions |
| history of present illness | information about a pt's condition from onset to present |
| past family social history | questions used to get clear understanding of pt's background |
| convert inches to cm | 2.54 x # of inches |
| chief complaint (cc) | reason for the visit reason pt is being seen |
| integumentary system | 3 types of closures simple , intermediate, complex |
| modifiers | 2 digits used after the 5 digit code |
| open fractures | bones stick out of skin |
| closed fractures | bones do not stick out of skin |
| manipulation attempted reduction | maneuvering the bone back into place |
| radiology | when coding for xray look in xray |
| pathology panels | a whole series of tests on a specific subject |
| principle diagnosis | reason to admit pt in hospital |
| principle procedure | performed for definitive treatment not diagnostic or exploratory |
| outpatient coding | if no dx code for signs and symptoms |
| inpatient coding | if no dx code as if dx was present |
| cpt-4 | level 1 |
| hcpcs | level 2 |
| hcpcs | healthcare common procedural codes dme injections transportation |
| dme | durable medical equiptment |
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