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ICD-10 Terms to Know

Basic terms to know for ICD-10-CM & ICD-10-PCS

TermDefinition
ICD-10-CM INTERNATIONAL CLASSIFICATION OF DISEASES, TENTH REVISION, CLINICAL MODIFICATION, CONSISTS OF DIAGNOSIS CODES
ICD-10-PCS INTERNATIONAL CLASSIFICATION OF DISEASES, TENTH REVISION, PROCEDURE CODING SYSTEM; CONSISTS OF PROCEDURE CODES
NEC NOT ELSEWHERE CLASSIFIED; USED IN THE ALPHABETIC INDEX TO INDICATE THAT THERE IS NO SEPARATE CODE FOR THE CONDITION EVEN THOUGH THE DIAGNOSTIC STATEMENT IS SPECIFIC
NOS NOT OTHERWISE SPECIFIED; EQUIVALENT TO THE TERM "UNSPECIFIED"
MS-DRG SYSTEM MEDICARE SEVERITY-ADJUSTED DIAGNOSIS-RELATED GROUPS SYSTEM; A PATIENT CLASSIFICATION SYSTEM USED IN HOSPITAL INPATIENT REIMBURSEMENT
OTHER REPORTABLE DIAGNOSESS CONDITIONS THAT COEXIST AT THE TIME OS ADMISSION, DEVELOP SUBSEQUENTLY, OR AFFECT PATIENT CARE DURING THE HOSPITAL STAY
PRINCIPAL DIAGNOSIS THE CONDITION ESTABLISHED AFTER STUDY THAT IS CHIEFLY RESPONSIBLE FOR ADMISSION OF THE PATIENT TO THE HOSPITAL
UHDDS UNIFORM HOSPITAL DISCHARGE DATA SET; INFORMATION USED FOR REPORTING INPATIENT DATA
POA INDICATOR PRESENT ON ADMISSION INDICATOR; A DATA ELEMENT THAT APPLIES TO DIAGNOSIS CODES FOR CLAIMS INVOLVING INPATIENT CARE
PROVIDER A PHYSICIAN OR ANY QUALIFIED EALTH CARE PRACTITIONER (SUCH AS A NURSE PRACTITIONER OR PHYSICIAN ASSISTANT)WHO IS LEGALLY ACCOUNTABLE FOR ESTABLISHING THE PATIENT'S DIAGNOSIS
ALPHABETIC INDEX OF DISEASES AND INJURIES AND THE INDEX TO EXTERNAL CAUSES INCLUDE ENTRIES FOR MAIN TERMS (DISEASES, CONDITIONS, OR INJURIES) AND SUBTERMS (SITE, TYPE, OR ETIOLOGY). THE NEOPLASM TABLE, AND THE TABLE OF DRUGS AND CHEMICALS
NEC NOT OTHERWISE CLASSIFIED
NOS NOT OTHERWISE SPECIFIED
"RULE OUT" INDICATES THAT A DIAGNOSIS IS STILL POSSIBLE
"RULED OUT" INDICATES THAT A DIAGNOSIS ONCE CONSIDERED LIKELY IS NO LONGER POSSIBLE
CHARACTER AN AXIS OF CLASSIFICATION THAT SPECIFIES INFORMATION ABOUT THE PROCEDURE PERFORMED
VALUE ONE OF THE 34 LETTERS OR NUMBERS THAT CAN BE SELECTED TO REPRESENT ONE OF THE CHARACTERS IN AN ICD-10-PCS CODE
APPROACH THE FIFTH CHARACTER IN THE CODE IN THE MEDICAL AND SURGICAL SECTION; IT CARRIES ADDITIONAL INFORMATION FOR THAT PARTICULAR PROCEDURE
ROOT OPERATION THE THIRD CHARACTER IN THE CODE IN THE MEDICAL AND SURGICAL SECTION CORRESPONDING TO THE OBJECTIVE OFF THE PROCEDURE; IN THIS SECTION ALONE THERE ARE 31 POSSIBLE OBJECTIVES
PRINCIPAL PROCEDURE PRODEDURE PERFORMED FOR DEFINITIVE TREATMENT (RATHER THAN FOR DIAGNOSTIC OR EXPLORATORY PURPOSES)
ROOT OPERATION THE THIRD CHARACTER IN AN ICD-10-PCS CODE, WHICH REFERS TO THE OBJECTIVE OF THE PROCEDURE
AFTERCARE MANAGEMENT CONTINUED CARE DURING THE HEALING PHASE OR LONG-TERM CARE DUE TO THE CONSEQUENCES OF A DISEASE
EXTERNAL CAUSE OF MORBIDITY CODES CODES FOR EXTERNAL CAUSES TO PROVIDE INFORMATION FOR INJURY RESEARCH AND EVALUATION OF INJURY PREVENTION STRATEGIES
PALLIATIVE CARE CARE FOCUSED ON THE MANAGEMENT OF PAIN AND OTHER SYMPTOMS OF PATIENTS WHO ARE IN THE TERMINAL PHASE OF AN ILLNESS
Z CODES CODES FOR FACTORS INFLUENCING HEALTH STATUS AND CONTACT WITH HEALTH SERVICES
SIGN OBJECTIVE EVIDENCE OF DISEASE OBSERVED BY THE EXAMINING PHYSICIAN
SYMPTOM SUBJECTIVE OBSERVATION REPORTED BY THE PATIENT
BACTEREMIA PRESENCE OF BACTERIAL IN THE BLOOD-STREAM AFTER A TRAUMA OR AN INFECTION
SEPSIS SIRS DUE TO INFECTION; A SEVERE CASE INDICATES ORGAN DYSFUNCTION
SEPTIC SHOCK CIRCULATORY FAILURE ASSOCIATED WITH SEVERE SEPSIS
SEPTICEMIA A SYSTEMIC DISEASE ASSOCIATED WITH PATHOLOGICAL MICROOORGANISMS OR TOXINS IN THE BLOODSTREAM
SIRS SYSTEMIC INFLAMMATORY RESPONSE SYNDROME; A SYSTEMIC RESPONSE TO INFECTION OR TRAUMA WITH SUCH SYMPTOMS AS FEVER AND TACHYCARDIA
DIABETES MELLITUS A CHRONIC DISORDER OF IMPAIRED CARBOHYDRATE, PROTEIN, AND FAT METABOLISM
TYPE 1 DIABETES ALSO KNOWN AS JUVENILE TYPE; CHARACTERIZED BY THE BODY'S FAILURE TO PRODUCE INSULIN
TYPE 2 DIABETES CHARACTERIZED BY THE BODY'S PRODUCTION OF INSULIN IN AN INSUFFICIENT QUANTITY OR THE BODY'S INABILITY TO UTILIZE SUCH INSULIN
ABUSE PROBLEMATIC USE OF DRUGS OR ALCOHOL BUT WITHOUT DEPENDENCE
DEPENDENCE INCREASED TOLERANCE TO DRUGS OR ALCOHOL WITH A COMPULSION TO CONTINUE TAKING THE SUBSTANCE DESPITE THE COST; WITHDRAWAL SYMPTOMS OFTEN OCCUR UPON CESSATION
ANEMIA A CONDITON IN WHICH BLOOD IS DEFICIENT IN THE AMOUNT OF HEMOGLOBIN IN RED BLOOD CELLS OR IN THE VOLUME OF RED BLOOD CELLS
APLASTIC ANEMIA A CONDITION IN WHICH THERE IS A DEFICIENCY OF RED BLOOD CELLS BECAUSE THE BONE MARROW IS FAILING TO PRODUCE THEM
PANCYTOPENIA A TYPE OF APLASTIC ANEMIA IN WHICH RED BLOOD CELLS, WHITE BLOOD CELLS, AND PLATELETS ARE ALL DEFICIENT
SICKLE-CELL ANEMIA A HEREDITARY DISEASE OF THE RED BLOOD CELLS PASSED TO A CHILD WHEN BOTH PARENTS CARRY THE GENETIC TRAIT
SICKLE-CELL TRAIT A CONDITION THAT OCCURS WHEN A CHILD RECEIVES THE TRAIT FROM ONLY ONE PARENT
THROMBOCYTOPENIA A DEFICIENCY IN PLATELETS, THE CELLS THAT ARE IMPORTANT IN BLOOD CLOTTING
CENTRAL NERVOUS SYSTEM THE BRAIN AND SPINAL CHORD
CONDUCTIVE HEARING LOSS HEARING LOSS DUE TO A PROBLEM WITH A PART OF THE EAR
PERIPHERAL NERVOUS SYSTEM ALL ELEMENTS OF THE NERVOUS SYSTEM EXCEPT THE BRAIN AND SPINAL CORD
SENSORINEURAL HEARING LOSS HEARING LOSS DUE TO A PROBLEM WITH THE SENSORY PART OF THE EAR OF THE NERVES ASSOCIATED WITH HEARING
ACUTE PULMONARY EDEMA EXCESSIVE FLUID IN THE TISSUE AND ALVEOLAR SPACES OF THE LUNG
ATELECTASIS A COLLAPSE OF LUNG TISSUE; AN INTEGRAL PART OF PULMONARY DISEASE
BRONCHOSPASM A SUDDEN CONSTRICTION OF THE MUSCLES IN THE WALLS OF THE BRONCHIOLES
COPD CHRONIC OBSTRUCTIVE PULMONARY DISEASE; A GENERAL TERM DESCRIBING CONDITIONS THAT RESULT IN AN AIRWAY OBSTRUCTION
PLEURAL EFFUSION ACCUMULATION OF FLUID WITHIN THE PLEURAL SPACES
CENTRAL NERVOUS SYSTEM THE BRAIN AND SPINAL CHORD
CONDUCTIVE HEARING LOSS HEARING LOSS DUE TO A PROBLEM WITH A PART OF THE EAR
PERIPHERAL NERVOUS SYSTEM ALL ELEMENTS OF THE NERVOUS SYSTEM EXCEPT THE BRAIN AND SPINAL CORD
SENSORINEURAL HEARING LOSS HEARING LOSS DUE TO A PROBLEM WITH THE SENSORY PART OF THE EAR OF THE NERVES ASSOCIATED WITH HEARING
ACUTE PULMONARY EDEMA EXCESSIVE FLUID IN THE TISSUE AND ALVEOLAR SPACES OF THE LUNG
ATELECTASIS A COLLAPSE OF LUNG TISSUE; AN INTEGRAL PART OF PULMONARY DISEASE
BRONCHOSPASM A SUDDEN CONSTRICTION OF THE MUSCLES IN THE WALLS OF THE BRONCHIOLES
COPD CHRONIC OBSTRUCTIVE PULMONARY DISEASE; A GENERAL TERM DESCRIBING CONDITIONS THAT RESULT IN AN AIRWAY OBSTRUCTION
PLEURAL EFFUSION ACCUMULATION OF FLUID WITHIN THE PLEURAL SPACES
BILLIARY SYSTEM A NETWORK INCLUDING THE GALLBLADDER AND BILE DUCTS
CALCULUS A STONE COMPOSED OF MINERALS THAT FORMS IN AN ORGAN OR DUCT OF THE BODY
DIVERTICULITIS THE INFLAMMATION OF EXISTING DIVERTICULA
DIVERTICULOSIS THE PRESENCE OF ONE OR MORE DIVERTICULA OF THE DESIGNATED SITE
DIVERTICULUM A SMALL POUCH OR SAC OPENING FROM A TUBULAR OR SACCULAR ORGAN; CONSIDERED A MEDICAL CONDITION; THE PLURAL TERM IS DIVERTICULA
ESOPHAGITIS AN INFLAMMATION OF THE LINING OF THE ESOPHAGUS
ESOPHAGEAL VARICES ABNORMALLY ENLARGED VEINS IN THE LOWER PART OF THE ESOPHAGUS
GI GASTROINTESTINAL; OF THE STOMACH AND/OR INTESTINES
ACUTE KIDNEY FAILURE SUDDEN FAILURE OF RENAL FUNCTION FOLLOWING A SEVERE INSULT TO THE KIDNEYS
CHRONIC KIDNEY DISEASE LONG-TERM INDICATING THAT RENAL DISEASE IS PRESENT
URETER CARRIES URINE FROM THE KIDNEYS TO THE BLADDER
URETHRA CARRIES URINE FROM THE BLADDER TO THE OUTSIDE OF THE BODY
NEPHROPATHY GENERAL TERM INDICATING THAT RENAL DISEASE IS PRESENT
CELULITIS AN INFECTION OF THE SKIN AND SOFT TISSUES RESULTING FROM SOME SORT OF BREAK IN THE SKIN
DEBRIDEMENT REMOVAL OF DEAD, DAMAGED, OR INFECTED TISSUE
ANTEPARTUM THE PERIOD OF PREGNANCY FROM CONCEPTION TO CHILDBIRTH
PERIPARTUM THE PERIOD INVOLVING THE LAST MONTH OF PREGNANCY TO FIVE MONTHS POSTPARTUM
POSTPARTUM THE PERIOD BEGINNING RIGHT AFTER DELIVERY AND INCLUDING THE NEXT SIX WEEKS
PUERPERIUM THE CLINICAL TERM FOR THE POSTPARTUM PERIOD
ABORTION THE EXPULSION OR EXTRACTION OF ALL OR PART OF THE PLACENTA WITH OR WITHOUT AN IDENTIFIABLE FETUS WITH LESS THAN AN ESTIMATED 20 WEEKS GESTATIONAL AGE
BIOCHEMICAL PREGNANCY A PREGNANCY THAT IS TOO EARLY TO CONFIRM EXCEPT THROUGH BIOCHEMICAL MEANS; CONSIDERED THE EARLIEST FORM OF MISCARRIAGE
ECTOPIC PREGNANCY A PREGNANCY IN WHICH A FERTILIZED OVUM IMPLANTS AND DEVELOPS OUTSIDE THE UTERUS
MOLAR PREGNANCY A CONDITION IN WHICH AN OVUM WITHIN THE UTERUS DEVELOPS INTO A MOLE OR BENIGN TUOR
CONGENITAL ANOMALY ABNORMAL CONDITION PRESENT AT BIRTH, WHICH MAY NOT BE RECOGNIZED UNTIL LATER IN LIFE
NEWBORN IMMATURITY IMPLIES A BIRTH OF LESS THAN 37 WEEKS GESTATION
NEWBORN POSTMATURITY A GESTATIONAL PERIOD OF MORE THAN 40 WEEKS
NEWBORN LOW BIRTH WEIGHT IMPLIES A BIRTH WEIGHT OF 1000-2499 GRAMS
NEWBORN EXTREMELY LOW BIRTH WEIGHT IMPLIES A BIRTH WEIGHT OF LESS THAN 500-999 GRAMS
DIASTOLIC HEART FAILURE OCCURS WHEN THE HEART HAS A PROBLEM RELAXING BETWEEN CONTRACTIONS TO ALLOW ENOUGH BLOOD INTO THE VENTRICLES
SYSTOLIC HEART FAILURE OCCURS WHEN THE ABILITY OF THE HEART TO CONTRACT DECREASES
THROMBOPHLEBITIS OF A VEIN A CONDITION INDICATED BY A CLOT THAT HAS BECOME INFLAMED
THROMBOSIS OF A VEIN A CONDITION INDICATED BY THE FORMING OF A CLOT
DIRECT EXTENSION THE INVASION OF ADJACENT SITES BY A MALIGNANT NEOPLASM
INVASIVE THE EXTENSION OF TUMOR CELLS TO OTHER ADJACENT SITES
METASTASIS THE RESULTING SPREAD OF INVASIVE TUMOR CELLS
NEOPLASM A NEW OR ABNORMAL GROWTH
EXTERNAL CAUSE CODES INDICATE EXTERNAL CAUSE OF MORBIDITY; USED WITH INJURY AND POISONING CODES
PATHOLOGICAL FRACTURE A FRACTURE CAUSED BY BONE WEAKENING ASSOCIATED WITH CONDITIONS SUCH AS OSTEOPOROSIS OR NEOPLASTIC DISEASES
RULE OF NINES A TOOL TO HELP PHYSICIANS ESTIMATE THE AMOUNT OF BODY SURFACE INVOLVED IN A BURN
ADVERSE EFFECT CLASSIFICATION OF A CONDITION CAUSED BY A DRUG OR ANOTHER SUBSTANCE WHEN USED CORRECTLY
POISONING CLASSIFICATION OF A CONDITION CAUSED BY A DRUG OR ANOTHER SUBSTANCE WHEN USED INCORRECTLY
TOXIC EFFECT CLASSIFICATION OF A CONDITION CAUSED BY INGESTION OR CONTACT WITH A HARMFUL SUBSTANCE
UNDERDOSING CLASSIFICATION OF A CONDITION CAUSED BY TAKING LESS OF A MEDICATION THAN IS PRESCCRIBED BY A PROVIDER OR A MANUFACTURER'S INSTRUCTIONS
LATROGENIC CONDITION CONDITION RESULTING FROM THE TREATMENT OF ANOTHER CONDITION
TABULAR LIST CONTAINS CATEGORIES, SUBCATEGORIES, AND VALID CODES
Created by: alli805