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MED 112
Chapter 4 Terms
| Question | Answer |
|---|---|
| HIPAA Health Care Transactions and Code Sets | ICD-10-CM mandated code set for diagnosis |
| ICD-10-CM | 3-4-5-6-7-digit character used to represent a disease, injury, or symptom - International Classification of Diseases 10th Revision |
| Clinical Modifications | Used to code and classify morbidity data from patient medical records |
| NCHS | National Center for Health Statistics |
| WHO | World Health Organizations |
| CDC | U.S. Center for Disease and Prevention |
| Code (also called an ICD code) | three- to seven-digit characters alphanumeric representation of a disease or condition |
| Seventh character extension | a requirement contained in the note at the start of the code it covers; seventh character must be in position 7 of the alphanumeric code |
| 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 |
| Subterm | Word or phrase that describes a main term in the Alphabetic Index |
| Main term | Word that identifies a disease or condition in the Alphabetic Index |
| Chief complaint | Patient’s description of the symptoms or other reasons for seeking medical care |
| Eponym | A name or phrase formed from or based on a person’s name |
| Etiology | A cause or origin of a disease or condition |
| Acute | An illness or condition with severe symptoms and a short duration |
| Chronic | An illness or condition with a long duration |
| Sequelae | Conditions that remain after an acute illness or injury has been treated and resolved |
| ICD-10-CM | HIPAA-mandated diagnosis code set as of October 1, 2015 |
| SODH (Social determinants of health) | Z codes that capture the social determinants of health of a patient that are documented in the medical record |
| Convention | A typographic technique that provides visual guidance for understanding information |
| Two major parts of ICD-10-CM | 1. Index to Diseases and Injuries 2. Tabular list diseases and injuries |
| Tabular List | Lists the diagnosis codes, descriptions, and notes in chapter alphanumerically |
| Alphanumeric Index | Lists diseases and injuries alphabetically with corresponding diagnosis codes |
| Neoplasm Table | Table of code numbers for neoplasms by anatomical site and divided by the description of the neoplasm |
| Table of Drugs and Chemicals | An index in table format of drugs and chemicals to identify poisoning status and external causes of adverse effects |
| Index to external causes | An index of the external cause-of-injury codes used to classify injury incidents by mechanism and intent |
| Diagnostic statement | provider's description of the main reason for a patient's encounter |
| Default term | Listed next to the main term in the alphabetic index that is most often associated with a particular disease or condition |
| Nonessential modifier | Supplementary terms that are not essential to the selection of the code. |
| NEC (not elsewhere classified) | Code to use when a disease or condition cannot be placed in any other category |
| NOS (not otherwise specified) | Code to use when no information is available for assigning the disease or condition to a more specific code; unspecified |
| Manifestation | The disease's typical signs, symptoms, or secondary processes. |
| First-listed code | Code for diagnosis that is the patient's main condition. For cases with underlying condition and manifestation, first listed code is underlying condition |
| Placeholder x (dummy placeholder) | when a fifth,-sixth-, or seventh digit character is required but the digit space to the left of that character is empty. |
| Category | A three-digit code that covers single disease or related condition |
| Subcategory | A four-or five character alphanumeric subdivision of a category - shows disease's etiology, site, or manifestation |
| Inclusion notes | Notes headed by the word "includes" and refine the content of category appearing above them. |
| Colon | : indicates incomplete term |
| Parentheses | ( ) are used around descriptions that do not affect the code |
| Brackets | [ ] used around synonyms, alternative wordings, or explanations |
| Laterality | captures the side of the body that is documented; the fourth, fifth, or sixth character of a code specify the affected side(s) |
| Official Guidelines for coding and reporting | The general rules, inpatient (hospital), and outpatient coding guidance from the four cooperating parties (CMS advisors, AHA, AHIMA, and NCHS) |
| Primary diagnosis | The first listed diagnosis |
| Section IV | Code primary diagnosis - code to highest level of certainty - code to highest level of specificity |
| Coexisting Conditions | May be related to the primary diagnosis, or involve separate illness that the provider diagnoses and treats during encounter |
| Seventh-Character Extension (2) | A= Initial encounter D= subsequent encounter S = Sequela |
| External Cause Code | reports the cause of injury from various environmental events like transportation accidents, falls, and fires |
| Chief Complaint (CC) | medical reason that the patient presents for the particular visit |
| GEM | General Equivalence Mappings - a tool to help find corresponding diagnosis codes between two code sets |
Created by:
Felicia26