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Glossary Terms
Chapter 3
Question | Answer |
---|---|
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. |