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Medical Coding

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Term
Definition
Default Code   a code listed next to the main term in the Alpha Index that represents that condition that is most commonly associated with the main term, or is the unspecified code for the condition  
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Code Also Note   a note that instructs that two coders may be required to fully describe a condition - note does NOT provide sequencing direction  
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See Note   an instruction following the main term in the Alphabetic Index that indicates that another term should be referenced - for correct coding it is necessary to go to the main term referenced with this note.  
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See Also   an instruction following a main term in the Alphabetic Index that instructs that there is another main term that may also be referenced that may provide additional Alphabetic Index entries that may be useful.  
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With   interpreted to mean "associated with" or "due to" when it appears in a code title, Alphabetic Index, or an instruction note in the Tabular List - sequenced immediately after the main term  
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And   interpreted to mean either "and" or "or" when it appears in a title  
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Etiology/Manifestation Convention   When a condition has both an underlying etiology and multiple body system manifestations due to the underlying etiology, the underlying condition is sequenced first  
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In Diseases Classified Elsewhere   Found in the title of most manifestation codes; These codes are never sequenced first.  
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Use Additional Code   Note at the etiology code to alert the coder that a manifestation code is needed.  
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Code First   Note at the manifestation code to alert the coder that there is an underlying condition that should be sequenced before the manifestation code.  
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Etiology and Manifestation Structure in the Alphabetic Index   Both conditions are listed together with the etiology code listed first followed by the manifestation code in brackets - codes in brackets are always sequenced second.  
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Excludes1   a pure excludes note - means NOT CODED HERE - indicates that the listed code and the excluded code should never be used together  
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Excludes2   represents "not included here" - the excluded code is not part of the condition represented by the code - both conditions can be coded at the same time when appropriate  
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includes Notes   appears immediately under a three character code title to further define, or give examples of, the content of the category  
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Inclusion Terms   list of terms is included under some codes - conditions for which that code is to be used - maybe synonyms of the code title or in the case of "other specified" codes  
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"Other" Codes   codes titled "other" or "other specified" are for use when information in the medical record provides details for which a specific code does not exist - NEC in the Alphabetic Index designated "other" codes in the Tabular List  
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"Unspecified" Codes   codes titled "unspecified" are for use when the information in the medical record is insufficient to assign a more specific code  
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Brackets [ ]   used in the Tabular List to enclose synonyms, alternative words, or explanatory phrases used in the Alphabetic Index to identify manifestation codes  
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Parentheses ()   used in the Tabular List and the Alphabetic Index to enclose supplementary words - AKA nonessential modifiers  
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Colons :   used in the Tabular List after an incomplete term which needs one or more modifiers following the colon to make it assignable to a given category  
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NEC   an Alphabetic Index abbreviation meaning not elsewhere classified - represents "other specified"  
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NOS   an Alphabetic Index abbreviation meaning not otherwise specified- equivalent of unspecified  
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