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Coding Terms

TermDefinition
NEC not elsewhere classified; used in the Alpha Index to indicate that there is no separate code for the condition even though the diagnostic statement is specific
NOS not otherwise specified; equivalent to the term "unspecified"
Excludes1 NOT CODED HERE
Excludes2 NOT INCLUDED HERE
Parentheses used to enclose supplementary words or explanatory info that may be either present or absent in the statement of diagnosis without affecting the code to which it is assigned.
Non-Essential Modifiers are used to suggest the terms in the parentheses are included in the code but need to be stated in the diagnosis
Square Brackets used in the Tabular List to enclose synonyms, alternative wordings, abbreviations and explanatory phrases that provide additional info; never be assigned as principal diagnosis
Colons used in the Tabular List in both inclusion and exclusion notes after an incomplete term that needs one or more of the modifiers following the colon in order for the term to apply
"And" should be interpreted to mean either "and" or "or"
"With" should be interpreted to mean "associated with" or "due to"
MS-DRG System Medicare Severity-Adjusted Diagnosis-Related Groups system; a patient classification system used in hospital inpatient reimbursement
Other Reportable Diagnoses conditions that coexist a the time of admission, develop subsequently, or affect patient care during the hospital stay
Principal Diagnosis the condition established after study that is chiefly responsible for admission of the patient to the hospital
UHDDS Uniform Hospital Discharge Data Set; info used for reporting inpatient data in acute care, short-term care and long-term care hospitals
POA Indicator present on admission indicator; a data element that applies to diagnosis codes for claims involving inpatient care
Provider a physician or any qualified health care practitioner, who is legally accountable for establishing the patient's diagnosis
Tabular List contains categories, subcategories and valid codes
"Rule Out" indicates that a diagnosis is still possible
"Ruled Out" indicates that a diagnosis once considered likely is no longer possible
Character an axis of classification that specifies information about the procedure performed
ValueApproach the 5th character in the code in the Medical and Surgical Section; the way the procedure site is reached
Qualifier the 7th character in the code in the Medical and Surgical Section; it carries additional info for that particular procedure
Root Operation the 3rd character in ICD-10-PCS code, which refers to the objective of the procedure
Principal Procedure procedure performed for definitive treatment (rather than for the diagnostic or exploratory purposes)
Z Codes codes for factors influencing health status and contact with health services
External Cause of Morbidity Codes codes for external causes to provide info for injury research and evaluation of injury prevention strategies
Aftercare Management continued care during the healing phase or long-term care due to the consequences of a disease
Sign objective evidence of disease observed by the examining physician
Symptom subjective observation reported by the patient
Created by: wallace263