Chapter 3 ICD-10-CM Coding Conventions

Question 1

Brackets [ ]

Answer 1

Used in the Tabular Listing and Alphabetic Index to enclose synonyms, alternative wording, abbreviations, or explanatory phrases.

Question 2

Code Also

Answer 2

Instructs the coder that two 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 ICD-10-CM and identifying for the coder the sequence of the code assignment

Question 4

Colon :

Answer 4

Used in the Tabular listing after a term that is modified by one or more terms following the colon.

Question 5

Conventions

Answer 5

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

Question 6

Excludes

Answer 6

Notes used to signify that the conditions listed are not assigned to the category or block of category codes.

Question 7

Excludes1

Answer 7

Used to signify that the diagnostic terms listed are not coded to the category or subcategory; therefore, the two conditions are mutually exclusive. Means “NOT CODED HERE”

Question 8

Excludes2

Answer 8

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. Means “NOT INCLUDED HERE”

Question 9

In Diseases Classified Elsewhere

Answer 9

Applies to the etiology/manifestation conventions

Question 10

Includes

Answer 10

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

Question 11

Instructional

Answer 11

Appears in both the Tabular List and Alphabetic Index of ICD-10-CM and provide further instruction for the coder.

Question 12

NEC

Answer 12

“Not elsewhere classifiable” used to signal coders that the term being coded is considered a general term. used in both the Alphabetic Index and the Tabular List.

Question 13

NOS

Answer 13

“Not otherwise specified” codes are not specific and should be used only after the coder has clarified with the physician that a more specific code is not available.

Question 14

Nonessential modifiers

Answer 14

The terms found in the parentheses that do not change code assignment

Question 15

Parentheses ( )

Answer 15

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

Question 16

Point dash .-

Answer 16

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

Question 17

See

Answer 17

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

Question 18

See Also

Answer 18

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

Question 19

Use Additional Code

Answer 19

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