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ICD-9 Vocabulary

TermDefinition
Abstract Outline or summary of a diagnostic statement or procedures and services performed.
Alphabetic Index Volume 2 of the ICD 9 code manual. Lists conditions, injuries, illnesses, and diseases in alphabetical order by main terms and subterms
Ancillary diagnostic services Services that support patient diagnoses (lab,or radiologic services)
Assessment Physicians determination of what is or may be wrong with the patient based on the findings from the history and physical examinations.
Chief complaint (CC) Reason the patient has sought medical care
Code also Used when more than one code is necessary to identify a given conditions; code also or use additional code is used.
Coding converting verbal or written descriptions into numeric and alphanumeric designations
Conventions Abbreviations, punctuation, symbols, instructional notations and related entities that provide guidance to the coder in the selection of an accurate specific code
Diagnosis Concise, technical description of the cause, nature, or n=manifestations of a condition or problem
Diagnostic statement Information about a patient's diagnoses or diagnoses that has been extracted from the medical documentation
Etiology The cause of the disorder
Excludes Exclusion terms are always written in italics, and the word excludes often is enclosed in a box. The applicable code number usually follows the exclusion.
Includes This term appearing under a subdivision, such as a category indicates that the code includes these terms.
International Classification of Diseases, Ninth Revision, Clinical Modification ()ICD-9-CM) Manual that establishes the system for classifying disease for collection of uniform health information, for statistical purposes, and for indexing medical records for data storage and retrieval.
ICD-10_CM Current ICM rules manual, which contains the greatest number of changes in the ICD-CM system in the ICD history. Allows more specific reporting of diseases and newly recognized conditions.
Manifestations Signs and symptoms of a disease
Notations Instructions or guides in classification assignments, defining category content; also called instructional notations. Found in both the Alphanumeric and Tabular Index
Principal diagnosis Initial identification of the condition or complaint that the patient expresses in the outpatient setting.
See To look in another place in the book. This instruction must always be followed.
See also Directions to the coder to look elsewhere if the main term or subterm for that entry is not sufficient for coding the information .
See Category Direction to see a specific category (three digit code)
SOAP notes system of charting comprising the subjective, objective findings, assessment and plan for treatment
Tabular Index Volume 1 of the ICD-9 coding manual; it contains all the diagnostic codes which are grouped into 17 chapters of disease and injury
Use additional code Term that appears only in the Tabular Index in subdivisions in which the user should add further information, by means of an additional code, to give a complete picture of the diagnosis
With Term with, with mention of and associated with in a title dictate that both parts of the title must be present in the diagnostic statement to allow assignment of the particular code.
Created by: charndoug