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coding chapter 3

medical coding

TermDefinition
NEC Not elsewhere classified. Used in 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.
ICD 10 CM conventions include the following Instructional notes; abbreviations; cross reference notes; punctuation marks; relational terms (and, with, without, due to)
Examples of instructional notes Inclusion and exclusion notes; general notes; code first notes; use additional code notes; code also notes.+
Exclusion notes are introduced by what word? Excludes. Excluded conditions are listed in alphabetical order with the code number or code range in parentheses. Exclusion notes are opposite of inclusion notes. They indicate a particular condition is not assigned to the code to which the note applies.
Excludes 1 Not coded here. This instructs that the code should never be used at the same time as the code above the excludes note. This is used when 2 conditions cannot occur together. for example congenital hydrocephalus and acquired hydrocephalus.
Excludes 2 Means NOT INCLUDED HERE. This instructs that the condition excluded is not part of the condition represented by the code. However, a patient may have both conditions at the same time. When an excludes 2 note appears under a code it is acceptable to use
Excludes 2 NOT INCLUDED HERE MEANS WHAT? Means NOT INCLUDED HERE. This instructs that the condition excluded is not part of the condition represented by the code. However, a patient may have both conditions at the same time. When an excludes 2 note appears under a code it is acceptable to use
Code first and Use additional code This indicates proper sequencing order. etiology followed by manifestation
Code also Code also indicates that 2 codes may be required to fully describe a condition
NEC there is no separate code for condition even if the diagnostic statement is specific.In the tabular, (Not elsewhere classified) these conditions are ordinarily classified to a code with a fourth or sixth character "8" or a fifth character "9"
NOS NOS means unspecified. It is used in Alphabetic index and tabular list. This is to be used when neither the diagnostic statement nor the medical records provide information that permits classification to a more specific code.
Cross reference notes These notes advise the coder to look elsewhere before assigning a code. The cross reference instructions will say, "See" "See also" "See category" "See condition"
SEE This cross reference instruction indicates that you MUST refer to an alternative term. You must follow this advice.
See category This is a variation of SEE cross reference. This provides the coder with a category number. The coder MUST refer to that number in the tabular list and select a code from the options provided there.
See condition this cross reference appears when the coder has referenced the adjective instead of the term in noun form. Example:Arterial - thrombosis
Parentheses enclose supplementary words or explanatory information that may be present or absent in the statement of diagnosis
Parenthesis Used to ensure coder. Nonessential modifiers are in parenthesis
Square brackets Used in tabular to enclose synonyms, alternative wording. To also provide additional information. Similar to parenthesis in that they are not required for the statement of diagnosis.
Square brackets Information inside brackets can never be assigned as the principal diagnosis.
Colons Used in the Tabular List in both inclusion and exclusion notes after an incomplete term that needs one or more of the modifiers following the colon in order for the term to apply.
And The word "and" should be interpreted to mean "and or or"
With The word with should be interpreted to mean associated with or due to when it appears in a code title,alphabetic index, or instructional note in the tabular list.
Due to The words due to in either the alphabetic index or the tabular list indicate that a causal relationship between 2 conditions is present.
Created by: beanpod
 

 



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