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HIT 73A
CHAPTER 4 - 6
| Question | Answer |
|---|---|
| NEC | Not elsewhere classified |
| NOS | Not otherwise specified |
| Rule out | Indicates that a diagnosis is still possible |
| Ruled out | Diagnosis is set |
| Assign a three-digit code | Only when there are no four-digit codes within the category |
| Assign a four-digit code | Only where there is no fifth-digit subclassification for that category |
| Assign a fifth digit code | When the category for which a fifth-digit subclassification is provided |
| When assign code | No two-digit code. Assign a three-digit when there is no 4th digit. Assign a four-digit code when there is no 5th digit. Assign a 5th subclassification code is provided |
| When coding | All digits must be used. None can be omitted and none can be added |
| One exception when you code | The one exception to this rule is that a 0 should be added as a 4th digit when the 5th digit is required when there is no 4th digit present |
| Assign residual code | The residual NOS code should never be assigned when a more specific code is available |
| To complete coding of Late Effects | There 2 codes required: Residual condition or nature of the late effect OR the cause of the late effect |
| Late Effect due to injury | If the late is due to injury, a late effect E code should also be assigned. |
| Signs (Objective) | Are what the doctor sees |
| Symptoms (Subjective) | Are what you experience |
| V codes | Are used for continued care after the initial treatment of an injury or disease |
| E codes | Are for external causes of injury and poisoning |
| Palliative (relieving without curing) care | Are cares focused on the management of pain and other symptoms of patients who are in the terminal phase of an illness |
| Adverse effect 不利影响 | A result of drug therapy that is neither intended nor expected in normal therapeutic use and that causes significant, sometimes life-threatening conditions. |
| Tremors | Shaking |
| V codes as a principal diagnosis | When a person with a resolving disease or injury or a chronic condition is being seen for specific aftercare. radiation, Chemo,or dialysis |
| V Codes is also use for | After care visits |
| Ascites 腹水 | Is an abnormal accumulation of fluid in the abdomen. |
| sense organs 感觉器官 | A specialized organ or structure, such as the eye, ear, tongue, nose, or skin, where sensory neurons are concentrated and which functions as a receptor. Also called sensor. |
| Consultation notes | Sometimes in progress notes rather than on separate reports |
| Final diagnoses | May be find in the admission record (face sheet), progress notes, or discharge summary |
| 3 steps in locating the codes to be assigned | 1 Locate the main term. 2 Verify the code number in the Tabular List. 3 Assign the verified code or codes |
| Locate the main term in the Alpha Index | 1 Review and nonessential modifiers related to the main term. 2 Follow any cross-reference instructions. 3 Refer to any notes in the Alpha Index |
| Verify the code number in the Tabular List | 1 Read the code title. 2 Read and be guided by any instructional notes. Refer to other codes as instructed. 3 Determine whether a fifth digit must be added. |
| Assign the verified code or codes | It is imperative that these steps be followed without exception; the condition or procedure to be coded must first be located in the Alpha Index and then verified in the Tabular List. |
| Dual Classification | Is used to describe the required assignment of 2 codes |
| manifestation code | Is in italics 斜体(the letters usually slope to the right)and can not be assigned as the principal diagnosis |
| A code in brackets in the Alpha Index | Can be used as a secondary code |
| Residual | Is a Late effect (sequela of a previous illness or injury |
| Residual or late effect terms | Old, Late, Due to previous injury or illness, Traumatic, unless there is evidence of current injury |
| Complete coding of late effects requires 2 codes: | 1 Residual condition or nature of the late effect. 2 Cause of the late effect |
| Sequence coding of the 2 late effects | 1st. The residual condition. 2nd The cause of the late effect |
| Late effects due to a injury | A late effect injury E code should also be assigned beside the late effect code |
| Traumatic | Also known as Late Effect |
| Palpitation P. 213 | 785.1 |
| Edema P. 98 | 782.3 |
| Hemoptysis P. 130 | 876.3 |
Created by:
Lilyn Ta
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