Chapter 4. Layout-General guidlines

Question 1

excludes 1

Answer 1

A code with this may not be used in conjunction with certain other codes

Question 2

Etiology

Answer 2

the underlying cause of a disease or condition

Question 3

Disease classification system

Answer 3

system of identifying diseases conditions, injury, and illness into a universally recognized code

Question 4

: colon

Answer 4

used in tabular list after an incomplete description that needs one or more of the modifiers following the colon to make it assignable to a given category

Question 5

code first

Answer 5

a code with this note should be sequenced first as the principle or first-listed diagnosis

Question 6

code also

Answer 6

a code with this note should be coded in addition to another code or codes

Question 7

chapter

Answer 7

section in the ICD-10_CM code book of related conditions, such as obstetrics or cardiovascular conditions

Question 8

category

Answer 8

describes similar or closely related conditions that are grouped together by a three character code

Question 9

[ Brackets]

Answer 9

used in the tabular list to enclose synonyms, alternative wording, or explanatory phrases

Question 10

‘and’

Answer 10

means either AND or OR

Question 11

alphabetic index

Answer 11

used to help search for a diagnosis, condition, illness, and injuries by name

Question 12

excludes 2

Answer 12

a code with this note normally is not used in addition to certain other codes, but it is not completely restricted from use

Question 13

extensions

Answer 13

adds detail pertinent to the encounter with the provider of care and is the seventh character in an ICD-10_CM code

Question 14

First-listed diagnosis

Answer 14

used by health care providers in a non-hospital setting to identify the main or chief reason why a patient is being treated or receiving care

Question 15

ICD-10-CM

Answer 15

International classification of diseases, tenth revision, clinical modification. Provides diagnostic codes for diseases, injuries, and other conditions

Question 16

Manifestation

Answer 16

the outward symptoms and signs of a disease or condition

Question 17

NEC

Answer 17

Not elsewhere classified. The category number for a code including the description NEC can only be used when the code lacks information necessary to code the term to a more specific category

Question 18

NOC

Answer 18

not otherwise specified; the diagnostic statement does not provide more specificity or definition

Question 19

parentheses

Answer 19

parentheses are used in both the index and tabular list to enclose supplementary words which may be present or absent in the statement of a disease or procedure without affecting the code number to which it is assigned

Question 20

placeholders

Answer 20

the letter x is used to fill in an empty space between the end of a code and the seventh character extension

Question 21

principle diagnosis

Answer 21

that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care

Question 22

see also

Answer 22

directs the coder to additional main terms in the alphabetic index

Question 23

see

Answer 23

refers the coder to a different location in the alphabetic index

Question 24

sequela

Answer 24

late effects or complications

Question 25

subcategory

Answer 25

adds additional detail or specificity to the category code

Question 26

tabular list

Answer 26

contains all codes, in alphanumeric order, and code descriptions, subdivided by chapters

Question 27

with/ without a code description

Answer 27

indicates whether there is an additional problem associated with the codes