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Ch.3 3-2-1
| Question | Answer |
|---|---|
| Coding conventions | General rules used in the ICD-10-CM classification system that are independent of coding system |
| Abbreviations | To save space |
| NEC | Not elsewhere classification |
| NOS | Not otherwise specified |
| And | Meaning/or |
| Boxed notes | Defines terms and provide coding instructions |
| Code also | Alerts the coder that more then one code may be required to fully describe the condition |
| cross-references | Instruct the coder to refer to another entry in the index |
| See | Instruction after a main term directs the coder to refer to another term in the ICD-10_CM and ICD-10-PCS indexes to locate the code |
| See also | Instruction is located after a main term or subterm in the ICD-10-CM indexes and directs the coder to another main term or subterm that may provide additional useful index entires |
| See category | Instruction directs the coder to the ICD-10-CM tabular list, where a code can be selected from the options provided there |
| See condition | Instruction directs the coder to the main term for a condition, found in the ICD-10-CM disease index |
| default code | A code listed next to a main term in the ICD-10-CM indexes |
| due to | Located in the ICD-10CM index to Diseases and Injuries in alphabetical order to indicate the presence of a cause-and-effect relationship between two condition |
| eponym | Diseases or syndromes that are named for the people |
| etiology and manifestation rules | Following notes in the ICD-10-CM Tabular List of Diseases and Injuries: Code first underlying disease, code, if applicable, any causal conditions first, use additional code, and in diseases classified elsewhere |
| code first underlying disease | Instructional notes assist coders in the proper sequencing of the codes |
| code, if applicable, any causal condition | Requires the causal condition to be sequenced first if present |
| in diseases classified elsewhere | Indicates that the manifestation codes are a component of the etiology/manifestation coding convention |
| use additional code | Etiology and manifestation combination codes exists |
| excludes1 notes | Not coded here and indicates mutually exclusive codes, two or more conditions that cannot be coded together |
| excludes2 notes | Not included here and indicates that although the excluded condition is not classified as part of the condition it is excluded from, a patient may be diagnosed with all conditions at the same time |
| format | ICD-10-CM and ICD-10-PCS uses an indented format for ease in reference |
| in | Appears in the ICD-10-CM disease index |
| includes note | Appears in the ICD-10-CM tabular list below certain categories to further define, clarify, or give examples about the content below a code category |
| inclusion term | Indicates some of the conditions for which that code may be assigned |
| manifestation | A condition that occurs as the result of another condition |
| modifier | Following the colon is needed to make the condition assignable to a given category |
| other | See other specified |
| other specified | Appears in a code description, the code is assigned when patient record documentation provides detail for which a specific code does not exist in ICD-10-CM |
| punctuation | Brackets, Colons, Parentheses |
| brackets | Used to identify manifestation codes in the ICD-10-CM Index to Diseases and Injuries |
| colon | Used after an incomplete term or phrase in the ICD-10-CM diseases and injuries |
| parentheses | Used in both the ICD-10CM indexes and tabular list and ICD-10-PCS index to enclose nonessential modifiers, which are supplementary words that may be present in or absent from the physician's statement of a disease or procedure without affecting the code |
| syndrome | Which is an association of clinically recognizable features such as signs, symptoms, and/or characteristics that often occur together |
| tables | Organize subterms, 2nd qualifiers, and 3rd qualifiers and their codes in columns and rows to make it easier to select proper code |
| trust the index | When you find a term in the disease index that is not repeated in the tabular list, the code can still be assigned |
| typeface | ICD-10-CM and ICD-10-PCS also makes use of the boldface and italic typeface for ease in reference |
| unspecified code | Assigned because patient record documentation is insufficient to assign a more specific code |
| use | the action of using something or the state of being used for some purpose. |
| with | Appears in the ICD-10-CM Index to Diseases and Injuries, it is located immediately below the main term, not in alphabetical order |
Created by:
alth1445