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ch.3 key terms

3-2-1! code it

QuestionAnswer
coding conventions general rules used in the ICD-10-cm classification system that are independent of coding guideline.
abbreviations use NEC (not elsewhere classifiable)and NOS (not otherwise specified). (NEC and NOS abbreviation do not appear in ICD-10-PCS).
NEC(not elsewhere classifiable) equivalent of "other specified"; identifies codes that are to be assigned when formation needed to assigned a more specific code cannot be located in the coding manual.
NOS (not otherwise specified) equivalent of "unspecified"; identifies codes that are to be assigned when information needed to assign a more specific code cannot be located be obtained from the provider.
and interpreted as meaning "and/or".
boxed note defines terms, provides coding instructions, and lifts fifth-digit subclassifications for categories that use the same fifth digits;
code also ICD-10-CM note that provides instruction that two codes may be required to fully describe a condition; this note does not provide sequencing direction.
crossed -references instruction to refer to another entry in the index or tabular list to assign the correct code.
see instructional term that directs the coder to refer to another term in the indexes.
see also instructional term that located after a main term or subterm in the index and directs the coder to another main term (or subterm) that may provide additional useful index entries.
see category instructional term that directs the coder to the tabular list, where a code can be selected from the option provided there.
see condition instructional term that directs the coder to the main term in the index for a condition.
default code ICD-10-CM code listed next to a main term in the index; represents that condition that is most commonly associated with the main term, or is the unspecified code for the condition.
due to index subterm (in alphabetical order) that indicates the presence of a cause-and-effect (or casual) relationship between two conditions.
eponym disease, syndrome, or procedure named for a person
etiology and manifestation rules include the following in the tabular list: code first underlying disease; code, if applicable, any casual condition first; use additional code; and in disease classified elsewhere.
code, if applicable, any case condition first tabular list instructional note that requires casual conditions to be sequenced first, if present.
in diseases classified elsewhere indicates that manifestation codes are a component of the etiology/manifestation coding convention.
use additional code instructional note that assists in proper sequencing of the codes.
excludes1 note appears below codes in the ICD-10- CM tabular list to direct the coder to another location in the tabular list to classify conditions that are excluded from the code-code either the original code or the code to which excludeds1 note directs you.
excludes 2 note appears below codes in the ICD-10-CM tabular list to direct the coder to another location in the tabular list to classify conditions that are excluded from the code: both the original code and the code which the excludes2 note .
format for ease of reference, index sub terms are indented two spaces below a main term; second, third, and fourth qualifiers are indented two ,four, and six spaces , respectively, below the subterm.
in index subterm (in alphabetical order) that indicates the presences of cause -and- effect (or causal) relationship between two conditions.
includes note appears immediately below tabular list codes further define term or provides examples.
inclusion term listed below certain codes in the tabular list; includes conditions or procedures for which that codes number is to be assigned; can be synonyms of the code tittle or, for "other codes, a list of conditions or procedures assigned to that code.
manifestation condition that occurs as the result of another condition; a manifestation code is always reported as a second code.
modifier additional term included after the colon in the ICD-10-CM tabular list that is to be included in the statement to classify a condition or procedure.
other when this word appears in an ICD-10-CM code description, the code is assigned when patient record documentation provides detail for which a specific code does no exist.
other specified when the phrase appears in an ICD-10-CM code description , the code is assigned when patient record documentation proves detail for which specific code doesn't exist.
punctuation brackets, parenthesis , and colons.
brackets used in the index to enclose manifestation codes; used in the tabular list to encose synonyms, alternative wording, and explanatory phrases.
colon used after an incomplete sentence term in the tabular list when one or more additional term (called modifiers) after the colon must be documented in the diagnostic or procedural statement to classify a condition or procedure.
parenthesis used in the index and tabular list to enclose modifiers , which are supplementary words that may be present in or absent from physician's statement of a disease or procedure without affecting the code number to which it is assigned.
syndrome association of clinically recognizable features such as signs, symptoms, and characteristics that often occur together, so that the presence of one or more feature alerts health care providers as to the possible presence of others.
tables index feature that organizes subterms, second qualifiers, and third qualifiers and their codes in columns and rows to make it easier to select the proper code.
trust the index concept that inclusion terms listed in the tabular list of diseases are not meant to be exhaustive and that additional terms found only in the index to diseases may also be signed to a code.
typeface for ease of reference, index main terms are boldface and manifestation codes in italicized.
unspecified code assigned when patients records documentation is insufficient to assigned a more specific code.
use directs the coder to a body part or a device in the ICD-10-PCS index.
with index term that is located immediately below the main term, not in alphabetical order.
Created by: mariaparra
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