Chapter 3: Introduction To ICD-10-CM Flashcards
NEC
Not elsewhere classifiable. Means provider documented more specific info about patient’s condition but no code for the specific condition.
NOS
Not otherwise specified. Used only when you lack info to code a more specific diagnosis.
Brackets [ ] - Tabular list
Used in tabular list to enclose synonyms, alternate wordings, or explanatory phrases.
Brackets [ ] - Alphabetical list
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
Parentheses ( )
Supplementary words that may or may not be present, without affecting the code to which it is assigned. Non-essential modifiers
Colon :
Used in tabular list after an incomplete term that needs one or more modifier to make it assignable to a given category.
Other codes
(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
Unspecified
(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.
Includes
Immediately after a 3 code title to define further or give an example of the category.
Excludes1
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.
Excludes2
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.
Use additional code
Additional code(s) should be used after a primary code to provide a more complete picture of the diagnosis.
Code first
Only appears in tabular list. Notes that two codes are needed to report a condition. Requires underlying condition first and the particular manifestation second.
Use additional code, if applicable
A second code to be used in addition to the first code if the condition is met
Eponym
Disease or syndrome named after a person.
Modifiers
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.
And
“And” in a code description can mean “and” or “or”
With
“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.
See
Directs you to a more specific code
See also
Indicates additional info is available that may provide an additional code
Default code
Code listed next to a main term. Condition most commonly associated with that term or is the unspecific code for that condition.
.- (Point dash)
Incomplete code and you must go to that category or subcategory to complete the code.
Signs and symptoms
Do not code a diagnosis unless it’s certain in the outpatient setting. Examples: Probable, suspected, questionable, rule out, differential, working.
Z Code
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.
Sequelae(late effects)
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.
Borderline diagnosis
Not the same as uncertain diagnosis. Borderline diagnosis are coded as confirmed diagnosis unless there is an index entry of borderline for that classification
Use of sign/symptom/unspecified codes
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.
Trauma
Injury related
