Ch. 3 ICD-10 Coding Conventions Key Terms

Question 1

Brackets [ ]

Answer 1

Used in Tabular and Alpha Index to enclose synonyms, alternative wording, abbreviations, or explanatory phrases

Question 2

Code also

Answer 2

Instructs the coder that 2 codes may be needed to fully code the diagnostic phrase being coded. No sequencing directions are provided.

Question 3

Code first

Answer 3

Notes appearing in the Tabular section of I-10. Identifies for the coder the sequence of code assignment.

Question 4

Colon :

Answer 4

USED IN TABULAR after a term that is modified by one or more terms following the colon. The colon is the completer.

Ex/ female infertility associated with:
Disease E23.0
Disease E28.3

Question 5

Convention

Answer 5

A group of instructional notes, punctuation marks, abbreviations, and symbols

Question 6

Excludes1

Answer 6

ASSIGN ONE
NOT CODED HERE
ONE OR THE OTHER

The diagnostic terms listed are not coded to the category or subcategory; therefore, the 2 conditions are mutually exclusive (can’t be used together. This is a pure excludes note meaning NOT CODED HERE

Question 7

Excludes2

Answer 7

ASSIGN TWO CODES

Used to signify that the diagnostic terms listed after the note are not part of the condition(s) represented by the code or code block. This excludes note means NOT INCLUDED HERE

Question 8

in diseases classified elsewhere

Answer 8

Applies to the etiology/manifestation conventions

Question 9

Includes

Answer 9

Defining term or note
Governs that chapter, section, category etc

Note used to define and/or give examples of the content of a particular category or a block of category codes

Question 10

Instructional notes

Answer 10

Appear in both the TABULAR LIST AND ALPHA INDEX of I-10 and provide instruction to the coder

Question 11

NEC (NOT ELSEWHERE SPECIFIED)

Answer 11

.8
IN THE MANUAL
The secondary condition is specified but NOT FOUND in the subcategory of the main condition

Used to signal coders that the term being coded is considered a general term. The manual provides no more specificity for the coding classification of this disease, conversion, etc

Question 12

Nonessential modifiers

Answer 12

USE IT OUT LOSE IT

The terms found in parentheses that do not change code assignment. We coders cam choose to lose or use these terms when making code selection

Question 13

NOS (NOT OTHERWISE SPECIFIED)

Answer 13

.9
DOCUMENTOR ISSUE DID NOT PROVIDE ANY OTHER SUPPORTING DOCUMENTATION

Codes that are not specified and should be used only after the coder has clarified (queried) with the physician that a more specific code is not available. This is an opportunity to educate physicians on documentation practices

Question 14

Parentheses ( )

Answer 14

USE IT OR LOSE IT

Used in the Tabular List and Alphabetic Index around terms providing additional information about the main diagnosis term

Question 15

Point dash .__

Answer 15

A signal to the coder that the code contains list of options at a level of specificity past the 3- digit character category

Question 16

See

Answer 16

MANDATORY

Used in the Alpha Index and instructs the coder to cross-reference the term or diagnosis following the notation

Question 17

See also

Answer 17

OPTIONAL

Refers the coder to another location in the Alpha Index when the initial listing does not contain all the necessary information to select an accurate code

Question 18

Use additional code

Answer 18

Instructs the coder to use an additional code to identify the manifestation that is present