Chapter 3: Introduction To ICD-10-CM

Question 1

NEC

Answer 1

Not elsewhere classifiable. Means provider documented more specific info about patient’s condition but no code for the specific condition.

Question 2

NOS

Answer 2

Not otherwise specified. Used only when you lack info to code a more specific diagnosis.

Question 3

Brackets [ ] - Tabular list

Answer 3

Used in tabular list to enclose synonyms, alternate wordings, or explanatory phrases.

Question 4

Brackets [ ] - Alphabetical list

Answer 4

Used in alphabetical index to identify manifestation codes where multiple coding and sequencing rules will apply. Code in bracket always follows the code before the bracket

Question 5

Parentheses ( )

Answer 5

Supplementary words that may or may not be present, without affecting the code to which it is assigned. Non-essential modifiers

Question 6

Colon :

Answer 6

Used in tabular list after an incomplete term that needs one or more modifier to make it assignable to a given category.

Question 7

Other codes

Answer 7

(Usually has an 8 or 9 at the end) Used when medical record provides detail for which no code exists. NEC entries point to other codes where this NEC is included

Question 8

Unspecified

Answer 8

(Usually with a 9 or 0 at the end) Used when the medical record doesn’t allow for more specific codes. Only used where no other option is available.

Question 9

Includes

Answer 9

Immediately after a 3 code title to define further or give an example of the category.

Question 10

Excludes1

Answer 10

Type 1 Excludes should not be used at the same time as the code above the Excludes1 when the two diagnosis are related. Includes when two conditions cannot occur together. IE congenital form vs acquired form of the same condition.

Question 11

Excludes2

Answer 11

A type 2 Excludes notes that a condition excluded is not part of the condition represented by the code, but a patient may have both conditions at the same time. Acceptable to use both codes when both conditions exist.

Question 12

Use additional code

Answer 12

Additional code(s) should be used after a primary code to provide a more complete picture of the diagnosis.

Question 13

Code first

Answer 13

Only appears in tabular list. Notes that two codes are needed to report a condition. Requires underlying condition first and the particular manifestation second.

Question 14

Use additional code, if applicable

Answer 14

A second code to be used in addition to the first code if the condition is met

Question 15

Eponym

Answer 15

Disease or syndrome named after a person.

Question 16

Modifiers

Answer 16

Essential modifiers are Sub terms indented two spaces and in alphabetical order. Non essential modifiers are in parentheses. They clarify the diagnosis but are not required.

Question 17

And

Answer 17

“And” in a code description can mean “and” or “or”

Question 18

With

Answer 18

“With” or “in” can mean associated with or due to. Terms below “with” in the alphabetical index are presumed to have causal relationship between the two conditions. Only if documentation specifically state two conditions are unrelated would they be reported separately.

Question 19

See

Answer 19

Directs you to a more specific code

Question 20

See also

Answer 20

Indicates additional info is available that may provide an additional code

Question 21

Default code

Answer 21

Code listed next to a main term. Condition most commonly associated with that term or is the unspecific code for that condition.

Question 22

.- (Point dash)

Answer 22

Incomplete code and you must go to that category or subcategory to complete the code.

Question 23

Signs and symptoms

Answer 23

Do not code a diagnosis unless it’s certain in the outpatient setting. Examples: Probable, suspected, questionable, rule out, differential, working.

Question 24

Z Code

Answer 24

Do not code conditions previously treated. Z codes indicate history of a previous condition that affects patients care or provides the need for a patient to seek medical care.

Question 25

Sequelae(late effects)

Answer 25

Residual effect of the acute portion of an illness or injury. Two codes usually required. Residual is coded first and the sequelae are coded second.

Question 26

Borderline diagnosis

Answer 26

Not the same as uncertain diagnosis. Borderline diagnosis are coded as confirmed diagnosis unless there is an index entry of borderline for that classification

Question 27

Use of sign/symptom/unspecified codes

Answer 27

Signs and symptoms are reported unless a definitive diagnosis has been reported. When sufficient clinical info is unavailable to assign a specific code report the unspecified code.

Question 28

Trauma

Answer 28

Injury related