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DIAGNOSTIC CODING

Medical Assistant: DIAGNOSTIC CODING ICD-10CM

QuestionAnswer
Diagnosis codes are used to report patients’ conditions on claims. Physicians determine the diagnosis, and medical coders assign the codes for those diagnose
Code Makeup three- to seven-character alphanumeric representation of a disease or condition. Category, Subcategory, Code
ICD-10-CM HIPAA-mandated October 1, 2015
Alphabetic Index part of ICD-10-CM listing diseases and injuries alphabetically with corresponding diagnosis codes
Tabular List part of ICD-10-CM listing diagnosis codes in chapters alphanumerically
Neoplasm Table summary table of code numbers for neoplasms by anatomical site and divided by the description of the neoplasm
Table of Drugs and Chemicals index in table format of drugs and chemicals that are listed in the Tabular List
Index to External Causes index of all external causes of diseases and injuries classified in the Tabular List
diagnostic statement physician’s description of the main reason for a patient’s encounter
convention typographic technique that provides visual guidance for understanding information
main term word that identifies a disease or condition in the Alphabetic Index
default code ICD-10-CM code listed next to the main term in the Alphabetic Index that is most often associated with a particular disease or condition
subterm word or phrase that describes a main term in the Alphabetic Index
etiology cause or origin of a disease or condition or describe a particular type or body site for the main term
nonessential modifier supplementary word or phrase that helps define a code in ICD-10-CM
eponym name or phrase formed from or based on a person’s name
not elsewhere classifiable NEC -- abbreviation indicating the code to use when a disease or condition cannot be placed in any other category
not otherwise specified NOS -- term that indicates the code to use when no information is available for assigning the disease or condition a more specific code; unspecified
manifestation characteristic sign or symptom of a disease
first-listed code code for diagnosis that is the patient’s main condition; in cases involving an underlying condition and a manifestation, the underlying condition is the first-listed code
connecting words such as due to, during, following, and with, may also indicate the need for two codes or for a single code that covers both conditions
combination code single code describing both the etiology and the manifestation(s) of a particular condition
placeholder character character “x” inserted in a code to fill a blank space
seventh-character extension necessary assignment of a seventh character to a code; often for the sequence of an encounter
category three-character code for classifying a disease or condition
subcategory four- or five-character code number
inclusion notes Tabular List entries addressing the applicability of certain codes to specified conditions
exclusion notes Tabular List entries limiting applicability of particular codes to specified conditions
excludes 1 exclusion note used when two conditions could not exist together, such as an acquired and a congenital condition; means “not coded here”
excludes 2 exclusion note meaning that a particular condition is not included here, but a patient could have both conditions at the same time
colon (:) indicates an incomplete term.
Parentheses ( ) are used around descriptions that do not affect the code—that is, nonessential, supplementary term. For example, “Idiopathic (torsion) dystonia NOS.”
Brackets [ ] are used around synonyms, alternative wordings, or explanations. For example, “Niacin deficiency [pellagra].”
NEC and NOS are used in the Tabular List with the same meanings as in the Alphabetic Index.
laterality use of ICD-10-CM classification system to capture the side of the body that is documented; the fourth, fifth, or sixth characters of a code specify the affected side(s)
Official Guidelines general rules, inpatient (hospital) coding guidance, and outpatient (physician office/clinic) coding guidance from the four cooperating parties (CMS advisers and participants from the AHA, AHIMA, and NCHS)
Section I Conventions, general coding guidelines, and chapter-specific guidelines
Section II Selection of Principal Diagnosis, and Section III, Reporting Additional Diagnoses, explain the guidelines for establishing the diagnosis or diagnoses for inpatient cases.
Section IV Diagnostic Coding and Reporting Guidelines for Outpatient Services, explains the guidelines for establishing the diagnosis or diagnoses for all outpatient encounters
primary diagnosis first-listed diagnosis; in inpatient coding, the condition established after study to be chiefly responsible for the admission of the patient
Diagnostic Statement Patient is an elderly female complaining of back pain
coexisting condition additional illness that either has an effect on the patient’s primary illness or is also treated during the encounter
Chart Note Mackenzie, whose previous encounter was for her regularly scheduled blood pressure check to monitor her hypertension, presents today with a new onset of psoriasis
Sequelae conditions that remain after an acute illness or injury has been treated and resolved -- followed by subterms that list the causes. Two codes are usually required
Malignant Primary main diagnosis is found at the site of origin
Malignant Secondary main diagnosis metastasized (spread) to an additional body site from the original location.
Carcinoma in situ neoplasm is restricted to one site (a noninvasive type); this may also be referred to as preinvasive cancer
Uncertain behavior not classifiable when the cells were examined
Unspecified behavior no documentation of the nature of the neoplasm
Adverse effects unintentional, harmful reactions to a proper dosage of a drug properly taken
poisoning refers to the medical result of the incorrect use of a substance
underdosing taking less of a medication than is prescribed by a provider or the manufacturer.
external cause code ICD-10-CM code for an external cause of a disease or injury
encounter A = initial, D = subsequent, or S = sequela
general equivalence mappings GEM -- tables of related ICD-10-CM and ICD-9-CM codes
Created by: baybro9933