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ICD-10-CM Convention

Medical Coding

Default Code a code listed next to the main term in the Alpha Index that represents that condition that is most commonly associated with the main term, or is the unspecified code for the condition
Code Also Note a note that instructs that two coders may be required to fully describe a condition - note does NOT provide sequencing direction
See Note an instruction following the main term in the Alphabetic Index that indicates that another term should be referenced - for correct coding it is necessary to go to the main term referenced with this note.
See Also an instruction following a main term in the Alphabetic Index that instructs that there is another main term that may also be referenced that may provide additional Alphabetic Index entries that may be useful.
With interpreted to mean "associated with" or "due to" when it appears in a code title, Alphabetic Index, or an instruction note in the Tabular List - sequenced immediately after the main term
And interpreted to mean either "and" or "or" when it appears in a title
Etiology/Manifestation Convention When a condition has both an underlying etiology and multiple body system manifestations due to the underlying etiology, the underlying condition is sequenced first
In Diseases Classified Elsewhere Found in the title of most manifestation codes; These codes are never sequenced first.
Use Additional Code Note at the etiology code to alert the coder that a manifestation code is needed.
Code First Note at the manifestation code to alert the coder that there is an underlying condition that should be sequenced before the manifestation code.
Etiology and Manifestation Structure in the Alphabetic Index Both conditions are listed together with the etiology code listed first followed by the manifestation code in brackets - codes in brackets are always sequenced second.
Excludes1 a pure excludes note - means NOT CODED HERE - indicates that the listed code and the excluded code should never be used together
Excludes2 represents "not included here" - the excluded code is not part of the condition represented by the code - both conditions can be coded at the same time when appropriate
includes Notes appears immediately under a three character code title to further define, or give examples of, the content of the category
Inclusion Terms list of terms is included under some codes - conditions for which that code is to be used - maybe synonyms of the code title or in the case of "other specified" codes
"Other" Codes codes titled "other" or "other specified" are for use when information in the medical record provides details for which a specific code does not exist - NEC in the Alphabetic Index designated "other" codes in the Tabular List
"Unspecified" Codes codes titled "unspecified" are for use when the information in the medical record is insufficient to assign a more specific code
Brackets [ ] used in the Tabular List to enclose synonyms, alternative words, or explanatory phrases used in the Alphabetic Index to identify manifestation codes
Parentheses () used in the Tabular List and the Alphabetic Index to enclose supplementary words - AKA nonessential modifiers
Colons : used in the Tabular List after an incomplete term which needs one or more modifiers following the colon to make it assignable to a given category
NEC an Alphabetic Index abbreviation meaning not elsewhere classified - represents "other specified"
NOS an Alphabetic Index abbreviation meaning not otherwise specified- equivalent of unspecified
Created by: dbshort