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EHR & I-10

QuestionAnswer
ICD-10-CM International Classification of Diseases, Tenth Edition, Clinical Modification
WHO (World Health Organization Developed ICD-10
morbidity the rate or frequency of disease
mortality the rate or frequency of death
NCHS (National Center for Health Statistics) responsible for maintaining the diagnostic codes in volumes 1 and 2 of the ICD-CM manuals
CMS (Centers for Medicare and Medicaid Services responsible for maintaining the procedure codes of ICD-CM found in volume 3
AAPC (American Academy of Professional Coders) Founded to elevate standards of medical coding.
CPC Certified Professional Coder
CPC-H Certified Professional Coder, hospital based
AAMA American Association of Medical Assistants
CMA Certified Medical Assistant
AMT American Medical Technologists
RMA Registered Medical Assistant
Tabular List of Diseases and injuries alphanumeric list of codes that is divided into chapters based on body system or condition.
Instructional Notes Appear in Tabular Notes and the Alphabetic Index
Includes notes used to define or give examples of the content in the category.
Conventions Instructional Notes, punctuation marks, abbreviations and symbols used as guides for coders in the ICD-10-CM.
Excludes notes used to signify that conditions listed are not assigned to the category.
Excludes 1 Note used to indicate that the diagnostic terms listed are not coded to the category.
Excludes 2 Note used to indicate that the diagnostic terms listed after the note are not part of the condition represented after the note and another code may be required.
See note instructs the coder to cross reference the term that follows.
See Also note refers the coder to another location when the initial listing does not contain the necessary information to accuratley select a code.
Use Additional Code not instructst the coder to use an additional code to identify the manifestation that is present.
Code First note instructs the coder to select a code to represent the etiology that caused the manifestation and sequence it first.
Code Also note instructs the coder that two codes may be needed to properly code the diagnostic phrase. No order given.
Parenthesis Used around terms providing additional information. Nonessential modifiers.
Brackets Used around synonyms, alternative wording, abbreviations or explainitory phrases. Does not affect code assignment.
Colon used after a term that is modified by one or more of the terms following the colon.
NEC Not elsewhere classifiable
NOS Not otherwised specified.
Point dash symbol .- tells the coder that the code contains a list of options to further specify.
granularity greater level of detail
laterality defining left or right side.
embryo developing child through 8th week of pregnancy
fetus developing child from 9th week until birth
uterus part of the female anatomy that houses the fetus until birth
Antepartum the time before child birth
Childbirth the delivery of one or more infants
labor and delivery the delivery of one or more infants
puerperium postpartum period- begins immediately after childbirth and lasts 6 weeks
Postpartum after childbirth
Molar pregnancy a blighted ovum in the uterus developes into a mole or benign tumor
missed abortion fetus has died before 22 weeks of gestation with retention of the dead fetus up to four weeks after demise
legally induced abortion an abortion that is legally induced by medical personnel working within the law
abruptio placentae premature sudden separation of the placenta from the uterus prior to or during labor
placentia previa abnormal position of placenta in lower uterus so that cervical OS is partially or completey covered.
Created by: ashliemarie21
 

 



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