Chapter 3 - Intro to ICD-10-CM Flashcards
Acute
Condition with a rapid and short course
And
Can mean either “and” or “or” when it is in a code description
BMI
Body mass index
Brackets [ ]
Symbol to enclose synonyms, alternate wording or explanatory phrases int he Tabular List. Used to identify manifestation codes in which multiple coding and sequencing rules will apply
Chronic
Condition that develops slowly and lasts a long time
Code First
Note in the Tabular List written in Italics requiring the underlying disease 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
Combination Code
Single code used to classify two diagnosies
COPD
Chronic Obstructive Pulmonary Disease (look-up “Obstruction/Pulmonary”)
Default Code
The code listed next to the main term and represents the condition most commonly associated with the main term
Etiology
Cause of the disease
Eponym
Disease or syndrome named after a person
Essential Modifiers
Subterms that are listed below the main term in 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 Diseases and Injuries
AKA Alphabetic Index. Diagnosis codes organized by main term.
Main Term
The key word to reference the disease, condition, or symptom in the Alphabetic Index
NEC
Not elsewhere classified
Nonessential Modifiers
Subterms that follow the main term and are enclosed in parentheses used to clarify the diagnosis but are not required.
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 . -
This symbol is found in the Alphabetic Index after certain codes. It indicated that the code is incomplete and to go to that category/subcategory to complete the code
Rubrics
Three character categories
See Also
Indicated additional information is available that may provide an additional diagnostic code
See
Note that directs you to a more specific term under which that correct code can be found
Septicemia
Systemic disease associated with microorganisms in the blood
Sepsis
Whole body inflammatory state. Generally refers to SIRS that is due to an infection
Sequela (late effect)
An inactive, residual effect produced after the acute portion of an injury/illness has passed
Severe Sepsis
Sepsis with associated acute organ dysfunction
Subterms
Terms indented under the main term to describe differences in site, etiology or clinical type. Add specificity to the main terml
Tabular List
Diagnosis codes organized in numerical order
Unspecified
Codes are used when the information in the medical record is not available for coding more specificity
Use Additional Code
Note in the Tabular List instructing you to report a second code, if the info is available, to provide a more complete picture of the diagnosis
Z Codes
Used to describe circumstances that could influence patient care
With
Means “associated with” or”due to”
Bruise in ICD-10-CM
Contusion
Pre-Operative Coding
- Code the examination/preoperative
- Code the condition for which the patient is having the surgery
- Code the results of the pre-operative exam
When a patient presents for outpatient surgery and develops complications requiring observation, how do you code?
- The reason for the surgery is the primary diagnosis
- The complications is the secondary diagnosis
Sickle cell anemia (CPT lookup)
Look up disease/sickle cell
