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ICD Coding Vocabular
Vocabulary for ICD 9 and 10
| Term | Definition |
|---|---|
| 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
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