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Kinn's Chapter 17

Abstract Outline or summary of the diagnostic statement and/or procedures and services performed.
Alphabetic Index Volume 2 of the ICD-9-CM coding manual; it lists conditions, injuries, illnesses, and diseases in alphabetical order by main terms, modifying terms, and subterms. It also contains the Classification of Factors Influencing Health Status and Contact with He
Ancillary diagnostic services Services that support patient diagnoses (e.g., laboratory or radiologic services).
And In the context of the ICD-9-CM, ____ should be interpreted as and/or
Assessment The physician's determination of what is or may be wrong with the patient based on the findings from the history and physical examination (H&P). It includes a preliminary, interim, or final diagnosis.
Chief Complaint (CC) The reason that patient has sought medical care, usually taken down in the patient's own words. It is recorded in the history documentation in the medical record, preceded by the abbreviation CC.
Code first When more than one code is necessary to identify a given condition, ____ or use additional code is used. Is found at a manifestation code.
Coding Converting verbal or written descriptions into numeric and alphanumeric designations.
Conventions Abbreviations, punctuation, symbols, instructional notations, and related entities that help guide the medical assistant or coder in the selection of an accurate specific code.
Diagnosis The concise, technical description of the cause, nature, or manifestations of a condition or problem.
Diagnostic statement Information about a patient's diagnosis or diagnoses that has been extracted from the medical documentation.
Etiology The science and study of the causes of disease. The cause of a disorder; a claim may be classified according to this.
Excludes Are always written in italics, and the word is often enclosed in a box to draw particular attention to these instructions. May apply to a chapter, a section, a category, or a subcategory.
History and physical examination (H&P/HPE) Normally includes the chief complaint (CC), a review of systems (ROS), the patients personal and family medical history, a physical examination, and assessment of the findings from the history and physical exam, and a treatment plan for the patient.
Includes When this term appears under a subdivision, such as a category (3 digit code) or two-digit procedure code title, it indicates that the code and title include these terms.
International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) Manual that establishes the system for classifying disease to facilitate collection of uniform and comparable health information for statistical purposes, for indexing medical records for data storage and retrieval, and to facilitate payment.
International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) Current ICM rules manual, which contains the greatest number of changes in the ICD-CM system in ICD history.
Manifestation An indication of the existence, reality, or presence of something, especially an illness.
Notations Found in both the Alphabetic Index and the Tabular Index, notations are instructions or guide in classification assignments, defining category content or the use of subdivision codes
Notes Used to define codes and give coding instructions; often used to list the fifth-digit sub-classification for certain categories
Principal diagnosis The initial identification of the condition or complaint the patient expresses in the outpatient medical setting based on the physician's assessment as documented in the medical record.
See A direction to the coder to look in another place; this instruction must always be followed. It is found in the Alphabetic Index, volumes 2 and 3.
See also A direction to the coder to look elsewhere if the main term or subterm(s) for the entry are not sufficient for coding the information.
See category A direction to the coder to see a specific category (three-digit-code); this instruction must always be followed
SOAP notes A system of charting comprising the SUBJECTIVE, OBJECTIVE, ASSESSMENT, and PLAN.
Tabular Index Volume 1 of the ICD-9-CM coding manual; it contains all the diagnostic codes in numeric order, which are grouped into 17 chapters of diseases and injuries.
Use additional code Note that is found at the etiology code when the underlying condition is sequenced first, followed by the manifestation.
With A title dictate that both parts of the title must be present in the diagnostic statement to allow assignment of the particular code.
Created by: mrsdancona