Chapter 6 Flashcards
adverse effect
taking less of a medication than is prescribed by a provider or a manufacturer’s instruction.
Benign
not cancerous.
carcinoma (Ca) in situ
a malignant tumor that is localized, circumscribed, encapsulated, and noninvasive (has not spread to deeper or adjacent tissues or organs).
Comorbidity
concurrent condition that coexists with the first-listed diagnosis (outpatient care) (or principal diagnosis for inpatient care), has the potential to affect treatment of the first-listed diagnosis (outpatient care) (or principal diagnosis for inpatient care), and is an active condition for which the patient is treated and/or monitored.
Complication
condition that develops after outpatient care has been provided or during an inpatient admission.
computer-aided coding (CAC)
see computer-assisted coding (CAC).
computer-assisted coding (CAC)
uses a natural language processing engine to “read” patient records and generate ICD-10-CM and HCPCS/CPT codes.
contiguous sites
also called overlapping sites; occurs when the origin of the tumor (primary site) involves two adjacent sites.
Cooperating Parties for ICD-10-CM/PCS
AHA, AMA, CMS, and NCHS organizations and agencies that approve official guidelines for coding and reporting ICD-10-CM and ICD-10-PCS.
Encoder
automates the coding process using computerized or web-based software; instead of manually looking up conditions (or procedures) in the coding manual’s index, the coder uses the software’s search feature to locate and verify diagnosis and procedure codes.
Encounter
face-to-face contact between a patient and a health care provider (e.g., physician, nurse practitioner) who assesses and treats the patient’s condition.
essential modifier
see subterm.
evidence-based coding
coding auditor clicks on codes that CAC software generates to review electronic health record documentation (evidence) used to generate the code.
first-listed diagnosis
reported on outpatient claims (instead of inpatient principal diagnosis); it reflects the reason for the encounter, and it is often a sign or symptom.
general equivalence mapping (GEM)
translation dictionaries or crosswalks of codes that can be used to roughly identify ICD-10-CM/PCS codes for their ICD-9-CM equivalent codes (and vice versa). See also legacy coding system.
iatrogenic illness
illness that results from medical intervention (e.g., adverse reaction to contrast material injected prior to a scan).
ICD-10-CM coding conventions and brackets
general coding rules that apply to the assignment of codes, independent of official coding guidelines.
code first underlying disease
appears when the code referenced is to be sequenced as a secondary code; the code, title, and instructions are italicized.
code first underlying disease, such as
see code first underlying disease.
code, if applicable, any causal condition first
requires causal condition to be sequenced first if present; a causal condition is a disease that manifests (or results in) another condition.
Colon
used after an incomplete term and is followed by one or more modifiers (additional terms).
due to
located in the index in alphabetical order to indicate the presence of a cause-and-effect (or causal) relationship between two conditions.
Eponym
disease or syndrome named for a person; listed in appropriate alphabetical sequence as main terms in the index.
etiology and manifestation rules
include the following notes in the ICD-10-CM Tabular List of Diseases and Injuries: Code first underlying disease; Code first underlying disease, such as; Code, if applicable, any causal condition first; Use additional code; and In diseases classified elsewhere.
Excludes1 note
a “pure” excludes, which means “not coded here” and indicates mutually exclusive codes; in other words, two conditions that cannot be reported together.
Excludes2 note
means “not included here” and indicates that although the excluded condition is not classified as part of the condition it is excluded from, a patient may be diagnosed with all conditions at the same time; therefore, it may be acceptable to assign both the code and the excluded code(s) together if supported by medical documentation
In
located in alphabetical order below the main term; to assign a code from the list of qualifiers below the word “in,” the provider must document both conditions in the patient’s record; ICD-10-CM classifies certain conditions as if there were a cause-and-effect relationship present because they occur together much of the time, such as pneumonia in Q fever.
in diseases classified elsewhere
indicates that the manifestation codes are a component of the etiology/manifestation coding convention.
includes note
appear below certain tabular list categories to further define, clarify, or provide examples.
Manifestation
condition that occurs as the result of another condition; manifestation codes are always reported as secondary codes.
NEC (not elsewhere classifiable)
means “other” or “other specified” and identifies codes that are assigned when information needed to assign a more specific code cannot be located.
parentheses
enclose supplementary words that may be present or absent in the diagnostic statement, without affecting assignment of the code number.
See
directs the coder to refer to another term in the index to locate the code.
see also
located after a main term or subterm in the index and directs the coder to another main term (or subterm) that may provide additional useful index entries.
see category
instruction directs the coder to the ICD-10-CM tabular list, where a code can be selected from the options provided there.
see condition
directs the coder to the main term for a condition, found in the index.
Table of Drugs and Chemicals
alphabetical index of medicinal, chemical, and biological substances that result in poisonings, adverse effects, and underdosing.
Table of Neoplasms
alphabetical index of anatomic sites for which there are six possible codes according to whether the neoplasm in question is malignant, benign, in situ, of uncertain behavior, or of unspecified nature.
unspecified codes
assigned because patient record documentation is insufficient to assign a more specific code.
use additional code
indicates that a second code is to be reported to provide more information about the diagnosis.
With
when codes combine one disorder with another (e.g., code that combines primary condition with a complication), the provider’s diagnostic statement must clearly indicate that both conditions are present and that a relationship exists between the conditions.
ICD-10-CM Diagnostic Coding and Reporting Guidelines for Outpatient Services—Hospital-Based Outpatient Services and Provider-Based Office Visits
developed by the federal government, outpatient diagnoses that have been approved for use by hospitals/providers in coding and reporting hospital-based outpatient services and provider-based office visits.
ICD-10-CM Index to Diseases and Injuries
an alphabetical listing of terms and their corresponding codes, which include specific illnesses, injuries, eponyms, abbreviations, and other descriptive diagnostic terms.
ICD-10-CM Index to External Cause of Injuries
arranged in alphabetical order by main term indicating the event; are secondary codes for use in any health care setting; capture how the injury or health condition happened (cause), the intent (unintentional or accidental; or intentional, such as suicide or assault), the place where the event occurred, the activity of the patient at the time of the event, and the person’s status.
ICD-10-CM Official Guidelines for Coding and Reporting
prepared by CMS and NCHS and approved by the cooperating parties for ICD-10-CM/PCS; contain rules that were developed to accompany and complement coding conventions and instructions provided in ICD-10-CM; adherence when assigning diagnosis codes is required under HIPAA.
ICD-10-CM Tabular List of Diseases and Injuries
arranged in alphabetical order by main term indicating the event; are secondary codes for use in any health care setting; capture how the injury or health condition happened (cause), the intent (unintentional or accidental; or intentional, such as suicide or assault), the place where the event occurred, the activity of the patient at the time of the event, and the person’s status.
ICD-10-CM/PCS Coordination and Maintenance Committee
responsible for overseeing all changes and modifications to ICD-10-CM (diagnosis) and ICD-10-PCS (procedure) codes; discusses issues such as the creation and update of general equivalence mappings (GEMs).
ICD-10-PCS Official Guidelines for Coding and Reporting
prepared by CMS and NCHS and approved by the cooperating parties for ICD-10-CM/PCS; contain rules that were developed to accompany and complement official conventions and instructions provided in ICD-10-PCS; adherence when assigning procedure codes is required under HIPAA.
International Classification of Diseases, 10th Revision (ICD-10)
developed by the World Health Organization (WHO) and released in 2018 to begin the implementation proces (e.g., translation into languages other than English).
legacy classification system
see legacy coding system.
legacy coding system
system that is no longer supported or updated, such as ICD-9-CM once ICD-10-CM/PCS replaced it effective October 1, 2015. (See also general equivalence mapping.)
lesion
any discontinuity of tissue (e.g., skin or organ) that may or may not be malignant.
main term
bold-faced term located in the ICD-10-CM index; listed in alphabetical order with sub terms and qualifiers indented below each main term.
Malignant
Malignantcancerous
Metastasis
spread of cancer from primary to secondary site(s).
morbidity
pertaining to illness or disease.
morphology
pertaining to death.
Neoplasm
growth, or tumor, in which cell reproduction is out of control
nonessential modifier
supplementary words located in parentheses after an ICD-10-CM main term that do not have to be included in the diagnostic statement for the code number to be assigned.
Outpatient
person treated in one of three settings: health care provider’s office; hospital clinic, emergency department, hospital same-day surgery unit, or ambulatory surgical center (ASC) where the patient is released within 23 hours; or hospital admission solely for observation where the patient is released after a short stay.
overlapping sites
see contiguous sites.
physician query process
when coders have questions about documented diagnoses or procedures/services, they contact the responsible physician to request clarification about documentation and the code(s) to be assigned.
poisoning: accidental (unintentional)
poisoning that results from an inadvertent overdose, wrong substance administered/taken, or intoxication that includes combining prescription drugs with nonprescription drugs or alcohol.
poisoning: assault
poisoning inflicted by another person who intended to kill or injure the patient.
poisoning: intentional self-harm
poisoning that results from a deliberate overdose, such as a suicide attempt, of substance(s) administered/taken or intoxication that includes purposely combining prescription drugs with nonprescription drugs or alcohol.
poisoning: undetermined
subcategory used if the patient record does not document whether the poisoning was intentional or accidental.
preadmission testing (PAT)
completed prior to an inpatient admission or outpatient surgery to facilitate the patient’s treatment and reduce the length of stay.
primary malignancy
original cancer site.
principal diagnosis
condition determined, after study, that resulted in the patient’s admission to the hospital.
qualified diagnosis
working diagnosis that is not yet proven or established; reported for inpatient cases only.
Qualifiers
supplementary terms in the ICD-10-CM Index to Diseases and Injuries that further modify subterms and other qualifiers.
re-excision
occurs when the pathology report recommends that the surgeon perform a second excision to widen the margins of the original tumor site.
secondary diagnosis
coexists with the primary condition, has the potential to affect treatment of the primary condition, and is an active condition for which the patient is treated or monitored.
secondary malignancy
tumor has metastasized to a secondary site, either adjacent to the primary site or to a remote region of the body.
sequela
residual late effects of injury or illness
subterm
qualifies the main term by listing alternative sites, etiology, or clinical status; it is indented two spaces under the main term.
trust the index
concept that inclusion terms listed below codes in the tabular list are not meant to be exhaustive, and additional terms found only in the index may also be associated to a code.
uncertain behavior
it is not possible to predict subsequent morphology or behavior from the submitted specimen.
underdosing
taking less of a medication than is prescribed by a provider or a manufacturer’s instruction.
unspecified nature
neoplasm is identified, but no further indication of the histology or nature of the tumor is reflected in the documented diagnosis.
