Ch. 3 Glossary

Question 1

Acute

Answer 1

A condition with a rapid and short course

Question 2

Anatomical

Answer 2

Body site

Question 3

And

Answer 3

Can mean either “and” or “or” when it is in the code description

Question 4

BMI

Answer 4

Body mass index

Question 5

Brackets

Answer 5

[ ]
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.

Question 6

Brackets

Answer 6

[ ]
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.

Question 7

Chronic

Answer 7

A condition that develops slowly and lasts a long time

Question 8

Code First

Answer 8

Note in the Tabular List written in italics requiring the underlying disease to be reported first

Question 9

Colon

Answer 9

:
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

Question 10

Colon

Answer 10

:
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

Question 11

Combination Code

Answer 11

Single code used to classify two diagnoses

Question 12

COPD

Answer 12

Chronic Obstructive Pulmonary Disease

Question 13

Default Code

Answer 13

The code listed next to the main term and represents the condition most commonly associated with the main term

Question 14

Etiology

Answer 14

Cause of a disease

Question 15

Eponym

Answer 15

Disease or syndrome named after a person

Question 16

Essential Modifiers

Answer 16

Subterms that are listed below the main term in the alphabetical order and are indented

Question 17

Excludes1

Answer 17

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

Question 18

Excludes2

Answer 18

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

Question 19

Includes

Answer 19

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

Question 20

Index to Disease and Injuries

Answer 20

Diagnosis codes organized by main term in an alphabetic index

Question 21

Main Term

Answer 21

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.

Question 22

NEC

Answer 22

Not elsewhere classified

Question 23

Nonessential Modifiers

Answer 23

Subterms that follow the main term and are enclosed in parentheses to clarify the diagnosis, but are not required

Question 24

Nonessential Modifiers

Answer 24

Subterms that follow the main term and are enclosed in parentheses to clarify the diagnosis, but are not required

Question 25

NOS

Answer 25

Not otherwise specified

Question 26

NOS

Answer 26

Not otherwise specified

Question 27

Parentheses

Answer 27

( ) 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

Question 28

Point Dash

Answer 28

.— 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

Question 29

Point Dash

Answer 29

.— 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

Question 30

Rubrics

Answer 30

Three-character categories

Question 31

See Also

Answer 31

Note in the ICD-10-CM Alphabetic Index that indicates additional information is available that may provide an additional diagnosis code

Question 32

See

Answer 32

Note in the ICD-10-CM Alphabetic Index that directs you to a more specific term under which the correct code can be found

Question 33

Septicemia

Answer 33

A systemic disease associated with microorganisms or toxins in the blood; these toxins are produced by bacteria, viruses, fungi, or other organisms

Question 34

Sepsis

Answer 34

Whole body inflammatory state Generally refers to SIRS that is due to an infection

Question 35

Sequela

Answer 35

Late effects An inactive, residual effect or condition produced after the acute portion of an injury or illness has passed

Question 36

Severe Sepsis

Answer 36

Sepsis with associated acute organ dysfunction

Question 37

Subterms

Answer 37

Terms that are indented under the main term to describe differences in site, etiology, or clinical type Add specificity to the main term

Question 38

Tabular List

Answer 38

Diagnosis codes organized in numerical order

Question 39

Unspecified

Answer 39

Codes used when the information in the medical record is not available for coding for specificity

Question 40

Use Additional Code

Answer 40

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

Question 41

Z Codes

Answer 41

Codes used to describe circumstances or conditions that could influence patient care

Question 42

With

Answer 42

Means “associated with” or “due to” in a code title in the ICD-10-CM Alphabetic Index or instructional note in the Tabular List