Ch 4 ICD 10 Flashcards
Lists diagnosis code in chapters alphanumerically.
Tabular list
Lists diseases and injuries alphabetically with appropriate diagnosis codes.
Alphabetic index
Physician’s description of the main reason for the patient encounter. Begins the process of assigning ICD-10-CM code.
Diagnostic statement
Technique providing visual guidance for understanding coding information.
Conventions
Listed next to main term
Default code
Supplementary word or phrase helping to define a code
Nonessential modifier
Are indented farther to the right than subterms. They are used when the main term or subterm is too long to fit on one line.
Turnover lines
Disease’s typical signs symptoms or secondary process- need second code indicated by brackets after the term
Manifestation
Diagnoses that is the main condition
First-listed code
Single code describing etiology and manifestations of a particular condition
Combination code
What is the necessary assignment of the seventh character to a code; often for the sequence of an encounter?
Seven-character extension
Three-character code for classifying disease or condition
Category
Four or five character code number
Subcategories
Entries addressing applicability of certain codes to express specified conditions
Inclusion notes
Entries limiting applicability of particular codes to specified conditions
Exclusion notes
Used when two conditions could not exist together such as an acquired and a congenital condition means “not coded here”
Excludes 1
Means a particular condition is not included here but a patient could have both conditions at the same time
Excludes 2
Used around descriptions that do not affect the code
Parentheses ()
Used around synonyms, alternative wordings, or explanations
Brackets [ ]
Document side of the body being classified with the fourth, fifth, or sixth characters of a code
Laterality
Additional illness that either has an effect on the patient’s primary illness or is also treated during the encounter
Coexisting condition
Conditions that remain after an acute illness or injury has been treated and resolved in ICD 10 CM
Sequelae
In inpatient coding the condition established after study to be chiefly responsible for the admission of the patients
Principal diagnosis
Codes used by pathologists
M codes