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ICD-9-CM Conventions
The ICD-9-CM Coding conventions - Section I A of the coding guidelines
Question | Answer |
---|---|
Give the meaning for the abbreviation NEC | Not Elsewhere classified. This abbreviation in the index represents "other specified" - in plain English it means the doc gave you a specific diagnosis, but the book does not get that specific |
Give the meaning for the abbreviation NOS | Not Otherwise SpecifiedThis is equivalentto "unspecified" - In other words - the book goes into specificty, but the provider did not get into specifics. An example would be the simple diagnosis of hypertension, which codes to 401.9 |
What do parentheses () signify in the index and tabular? | They enclose supplementary words "non-essential modifiers". If you see words in parentheses it means that those words may or may not be present in the providers documentation, it does not matter, either way this is the code you use. |
What does an excludes not signify? | An excludes note under code indicates that the terms excluded from the code are to be coded elsewhere. |
When would you use an "other" code (usually a code with a 5th digit of 8 or a fifth digit of 9) | When the information in the medical record provides detail for which a specific code does not exist. They are labeled NEC |
When would you use an "unspecified" code (usually a code with a 4th digit of 9 or a fifth digit of 0) | When the information in the medical record is insufficient to assign a more specific code. |
What is meant by "manifestation of disease" coding? | Certain conditions have both an underlying etiology and multiple body system manifestations due to the underlying etiology. For these conditions, ICD-9 requires the underlying condition to be sequenced first followed by the manifestation |
What do slanted brackets (or italicized) brackets signify when you see them in the index? | They mean that the code in the brackets is the manifestation of the underlying disease. When you see this in the index you code both codes - the code within the brackets go second. |
What does "And" mean? | The word "and" should be interpreted to mean either "and" or "or" when it appears in the title |
What does the term "see" mean? | The "see" instruction following a main term in the index indicates that another term should be referenced. It is necessary to go to the main term referrnced with the "see" note to locate the correct code |
What does the term "see also" mean? | A "see also" instruction following a main term in the index instructs that there is another term that may also be referenced that may provide additional index entries hat may be useful. |