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ICD-9 Vocabulary
| Term | Definition |
|---|---|
| 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. |
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