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Glossary Terms

Chapter 3

QuestionAnswer
Acute A condition with a rapid and short course.
Anatomical Body site.
And Can mean either and or or when it is in the code description.
BMI Body mass index
Brackets [] Symbol to enclose synonyms, alternate wording, or explanatory phrases in the Tabular List. Brackets are used in the ICD-10-CM Alphabetic Index to identify manifestation codes in which multiple coding and sequencing rules will apply.
Chronic A condition that develops slowly and lasts a long time.
Code First Note in the Tabular List written in italics requiring the underlying disease be reported first.
Colon : Used in the Tabular List after an incomplete term that needs one or more of the modifiers that follow to make it assignable to a given category.
Combination Code Single code used to classify two diagnoses.
COPD Chronic Obstructive Pulmonary Disease
Default Code The code listed next to the main tem and represents the condition most commonly associated with the main term.
Etiology Cause of the disease
Eponymn Disease or syndrome named after a person.
Essential Modifiers Subterms that are listed below the main term in the alphabetical order and are indented.
Excludes 1 Note in the Tabular List to indicate the terms listed are to be reported with a code from another category and are not to be reported with the current selected code.
Excludes 2 note in the Tabular List to indicate the terms listed are to be reported with the current selected code.
Includes Note in the Tabular List under a three-character code title to define further, or to give an example of the contents of the category.
Index to Disease and injuries Diagnosis codes organized by main term in an alphabetic index
Main Term The key word to reference the disease, condition, or symptom in the ICD-10-CM Alphabetic Index. Main terms are bolded in the ICD-10-CM Alphabetic Index.
NEC Not elsewhere classified
Nonessential Modifiers Subterms that follow the main term and are enclosed in parentheses used to clarify the diagnosis but are not required.
NOS Not otherwise specified
Parentheses () Symbol to enclose supplementary words that may be present or absent in the statement of a disease or procedure, without affecting the code number to which it is assigned.
Point Dash This symbol is found in the ICD-10-CM Alphabetic Index after certain codes. It indicates that the code is incomplete and go to that category or subcategory of codes to complete that code.
Rubrics Three-character categories
See also Note in the ICD-10-CM Alphabetic Index that indicates additional information is available that may provide an additional diagnostic code.
See Note in the ICD-10-CM Alphabetic Index that directs you to a more specific term under which the correct code can be found.
Septicemia A systemic disease associated with microorganisms or toxins in the blood. These toxins are caused by bacteria, viruses, fungi, or other organisms.
Sepsis Whole body inflammatory state. It generally refers to SIRS that is due to an infection.
Sequela (late effect) An inactive, residual effect or condition produced after the acute portion of an injury or illness has passed.
Severe Sepsis Sepsis with associated acute organ dysfunction
Subterms These terms are indented under the main term to describe differences in site, etiology, or clinical type. Subterms add specificity to the main term.
Tabular List Diagnosis codes organized in numerical order.
Unspecified Codes are used when the information in the medical record is not available for coding more specificity.
Use Additional Code Note in the Tabular List instructing you to report a second code, if the information is available , to provide a more complete picture of the diagnosis.
Z Codes Codes used to describe circumstances or conditions that could influence patient care.
With Means associated with or due to in a code title in the ICD-10-CM Alphabetic Index or an instructional note in the Tabular List.
Created by: MissMeeMee