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MED112 Chapter 4
| Question | Answer |
|---|---|
| Two parts of the ICD-10-CM | Index and Tabular list |
| Index that contains tabular List Classifications and conditions and terms not found on the tabular list | Alphabetic index |
| Length of ICD-10-CM codes | 3-7 digits |
| Help point to the correct term but doesn't appear in the physician's diagnostic statement for the coder to correctly select the code | Nonessential Modifiers |
| Many Terms appear more than once in the Alphabetic index | Common Terms |
| First additional resource sections for researching codes | ICD-10-CM Neoplasm table, |
| Second additional resource sections for researching codes | ICD-10-CM Table of drugs and chemicals |
| Third additional resource sections for researching codes | ICD-10-CM Index to External Causes |
| Eponym | Condition or procedure named after a patient, or the physician who invented or discovered it, |
| When main term or sub-term is too long to fit one line what is used | Turnover/Carryover lines |
| First step in assigning the correct code is to look up the | Medical term |
| What term is cross-referenced with the accepted medical term if in the Alphabetic Index | Common Term |
| If the cross-reference term appears after the main term | Look up the term that follows the Cross-reference term |
| Listed under both that name and the main term disease or syndrome | Ephonym |
| Abbreviation means that no code matches the exact situation | NEC |
| Abbreviation means not otherwise specified not completely described | NOS |
| Category | Three-character Alphanumeric code that covers a single disease or related condition |
| Subcategory | A four-or- five character alphanumeric subdivision of a category |
| Some conditions that may require two codes | Etiology & Manifestation |
| Inclusion Notes use the word | Includes |
| Tabular List are organized by | Etiology and body system and purpose |
| Letter never used as the first character of an ICD-10-CM | U |
| Excludes 1 | used when two conditions could not exist together |
| Etiology Code may include instructions to | use an additional code |
| Received it's name for the means of count record or list systematically | Tabular List |
| Idea that the classification system should capture the side of the body documented for a condition | Laterality |
| Four Cooperating parties that follow the ICD-10-CM Official Guidelines for coding and reporting | CMS, AHA, AHIMA, NCHS |
| Excludes 2 | Not Included here |
| ICD-10-CM Code for the primary diagnosis is listed | First |
| Acute Symptoms are | Sudden and Severe in nature |
| No appropriate code for ICD-10-CM Codes for bilateral but | Two Codes are Assigned |
| Conditions that remain after acute illness or injury has ended | Sequelae |
| Coexisting Conditions | May be related to primary diagnosis may involve separte illness that is diagnosed and treated during the encounter |
| Classified in Chapter 1 of ICD-10-CM Tabular list | Infectious and parasitic diseases |
| First step in outpatient diagnosis coding | Review complete medical documentation |
| Second step in outpatient diagnosis coding | Abstract the medical condition from visit documentation |
| Third step in outpatient diagnosis coding | Identify the main term of each condition |
| Forth step in outpatient diagnosis coding | Locate the main term in the alphabetic Index |
| Fifth step in outpatient diagnosis coding | Verify the code in the tabular list |
| Sixth step in outpatient diagnosis coding | Check compliance with any applicable official guidelines and list codes in appropriate order |
| Used when coding in Physician practice | Reported Symptoms |
| GEM General Equivalence mappings | Used for Pre-2015 code reviews or audits |
| Z codes | used to report patient encounters for circumstances other than a specific disease, injury, or external cause. |
| Typographic technique that provides visual guidance for understanding information | Conventions |
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