Ch. 3 Glossary Flashcards
Acute
A condition with a rapid and short course
Anatomical
Body site
And
Can mean either “and” or “or” when it is in the code description
BMI
Body mass index
Brackets
[ ]
Symbol to enclose synonyms, alternate wording, or explanatory phrases in the Tabular List.
Used in the ICD-10-CM Alphabetic Index to identify manifestation codes in which multiple coding and sequencing rules will apply.
Brackets
[ ]
Symbol to enclose synonyms, alternate wording, or explanatory phrases in the Tabular List.
Used in the ICD-10-CM Alphabetic Index to identify manifestation codes in which multiple coding and sequencing rules will apply.
Chronic
A condition that develops slowly and lasts a long time
Code First
Note in the Tabular List written in italics requiring the underlying disease to be reported first
Colon
:
Used in the Tabular List after an incomplete term that needs one or more of the modifiers that follow to make it assignable to a given category
Colon
:
Used in the Tabular List after an incomplete term that needs one or more of the modifiers that follow to make it assignable to a given category
Combination Code
Single code used to classify two diagnoses
COPD
Chronic Obstructive Pulmonary Disease
Default Code
The code listed next to the main term and represents the condition most commonly associated with the main term
Etiology
Cause of a disease
Eponym
Disease or syndrome named after a person
Essential Modifiers
Subterms that are listed below the main term in the alphabetical order and are indented
Excludes1
Note in the Tabular List to indicate the terms listed are to be reported with a code from another category and are not to be reported with the current selected code
Excludes2
Note in the Tabular List to indicate the terms listed are to be reported from another category and may be reported with the current selected code if both conditions exist
Includes
Note in the Tabular List under a three-character code title to define further, or to give an example of the contents of the category
Index to Disease and Injuries
Diagnosis codes organized by main term in an alphabetic index
Main Term
The key word to reference the disease, condition, or syndrome in the ICD-10-CM Alphabetic Index. These are bolded in the ICD-10-CM Alphabetic Index.
NEC
Not elsewhere classified
Nonessential Modifiers
Subterms that follow the main term and are enclosed in parentheses to clarify the diagnosis, but are not required
Nonessential Modifiers
Subterms that follow the main term and are enclosed in parentheses to clarify the diagnosis, but are not required
NOS
Not otherwise specified
NOS
Not otherwise specified
Parentheses
( )
Symbol to enclose supplementary words that may be present or absent in the statement of a disease or procedure, without affecting the code number to which it is assigned
Point Dash
.—
Symbol found in the ICD-10-CM Alphabetic Index after certain codes
Indicates that the code is incomplete and to go to that category or subcategory of codes to complete that code
Point Dash
.—
Symbol found in the ICD-10-CM Alphabetic Index after certain codes
Indicates that the code is incomplete and to go to that category or subcategory of codes to complete that code
Rubrics
Three-character categories
See Also
Note in the ICD-10-CM Alphabetic Index that indicates additional information is available that may provide an additional diagnosis code
See
Note in the ICD-10-CM Alphabetic Index that directs you to a more specific term under which the correct code can be found
Septicemia
A systemic disease associated with microorganisms or toxins in the blood; these toxins are produced by bacteria, viruses, fungi, or other organisms
Sepsis
Whole body inflammatory state
Generally refers to SIRS that is due to an infection
Sequela
Late effects
An inactive, residual effect or condition produced after the acute portion of an injury or illness has passed
Severe Sepsis
Sepsis with associated acute organ dysfunction
Subterms
Terms that are indented under the main term to describe differences in site, etiology, or clinical type
Add specificity to the main term
Tabular List
Diagnosis codes organized in numerical order
Unspecified
Codes used when the information in the medical record is not available for coding for specificity
Use Additional Code
Note in the Tabular List instructing you to report a second code, if the information is available, to provide a more complete picture of the diagnosis
Z Codes
Codes used to describe circumstances or conditions that could influence patient care
With
Means “associated with” or “due to” in a code title in the ICD-10-CM Alphabetic Index or instructional note in the Tabular List