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ICD Coding Vocabular

Vocabulary for ICD 9 and 10

adverse effect development of a pathologic condition that results from a drug or chemical substance that was intentional or accidental
benign not cancerous
carcinoma in situ a malignant tumor that is localized, circumscribed, encapsulated, and noninvasive (has not spread to deeper or adjacent tissues or organs)
comorbidity concurrent condition that coexists with the first-listed diagnosis, has the potential to affect treatment of the first-listed diagnosis, and is an active condition for which the patient is treated and/or monitored
complication condition that develops after outpatient care has been provided or during an inpatient admission
computer assisted coding (CAC) uses a natural language processing engine to "read" patient records and generate ICD-10-CM and HCPCs/CPT codes
contiguous sites AKA; overlapping sites. occurs when the origin of the tumor (primary site) involves two adjacent sites
Cooperating Parties organizations/agencies that approve official guidelines for coding and reporting ICD-CM and ICD-PCS; AHA, AMA, CMS, NCHS
encoder automates the coding process using computerized or web-based software
essential modifier qualifies the main term by listing alternative sites, etiology, or clinical status; it is indented two spaces under the main term
first listed diagnosis reported on outpatient claims to reflect the reason for the encounter, and it is often a sign or symptom
general equivalence mapping (GEM) translation dictionaries or crosswalks of codes that can be used to roughly identify ICD-10-CM/PCS codes for their ICD-9-CM equivalent codes
iatrogenic illness illness that results from medical intervention
eponym disease or medical condition named after a person
etiology cause or origin of a disease
manifestation resulting symptoms or conditions due to the underlying etiology
legacy classification system system that is no longer supported or updated, such as ICD-9 when ICD-10 replaces it
lesion any discontinuity of tissue (skin or organ) that may or may not be malignant
main term bold-faced term located in the ICD-10-CM index; listed in alphabetical order with subterms and qualifiers indented below each main term
malignant Cancerous
metastasis spread of cancer from the primary to secondary site
morbidity Pertaining to illness or disease
morphology Indicates the tissue type of a neoplasm; morphology codes are reported to state cancer registries
mortality Pertaining to death
neoplasm New growth, or tumor, in which cell reproduction is out of control
nonessential modifier Supplementary words located in parentheses after an ICD– 10 – CM main term that do not have to be included in the diagnostic statement for the code number to be assigned
outpatient 1 of 3 settings:healthcare office; hospital clinic, emergency department, hospital same-day surgery unit, or ambulatory surgical center the patient is released within 23 hours;for hospital admissions for observation or patient released after short stay
overlapping sites Occurs when the origin of the tumor(primary site) involves two adjacent sites
physician query process When coders have questions about documented diagnoses or procedures/services they contact the responsible physician to request clarification about documentation and the codes to be a assigned
poisoning: accidental poisoning that results from an inadvertent overdose, wrong substance administered/ taken, or intoxication that includes combining prescription drugs with nonprescription drugs or alchohol
poisoning: assault poisoning inflicted by another person who intended to kill or injure the patient
poisoning: intentional self-harm poisoning that results from a deliberate overdose, such as a suicide attempt, of substance(s)administered/taken or intoxication that includes purposely combining prescription drugs with nonprescription drugs or alcohol
poisoning: undetermined subcategory used if the patient record does not document whether the poisoning was intentional or accidental
primary malignancy Original cancer site
principal diagnosis Condition determined, after study, that resulted in the patient admission to the hospital
qualified diagnosis Working diagnosis that is not yet proven or established; reported for inpatient cases only
qualifiers Supplementary terms in the ICD–10–CM index two diseases and injuries that further modify sub terms and other qualifiers
secondary diagnosis Coexists with the primary condition, has the potential to affect treatment of the primary condition, and is an active condition for which the patient is treated for monitored
secondary malignancy Cancer has metastasized to a secondary site, either adjacent to the primary site or to a remote region of the body
sequela Residual late effects of injury or illness
subterm Qualifies the main term by listing alternative sites, etiology, or clinical status; it is indented two spaces under the main term
trust the index Concept that inclusion terms listed below codes in the tabular list are not meant to be exhaustive, and additional terms found only in the index may also be associated to a code
uncertain behavior Is not possible to predict subsequent morphology or behavior from the submitted specimen
underdosing Taking less of a medication that is prescribed by a provider or a manufacturer's instructions
Created by: tina.reynolds