chapter 6 icd coding Flashcards
ADVERSE EFFECT
DEVELOPMENT OF A PATHOLOGIC CONDITION THAT RESULTS FROM A DRUG OR CHEMICAL SUBSTANCE THAT WAS PROPERLY ADMINISTERED OR TAKEN
BENIGN
NOT CANCEROUS
CARCINOMA CA IN SITU
A MALIGNANT TUMOR THAT IS LOCALIZED CIRCUMSCRIBED ENCAPSULATED AND NONINVASIVE
COMORBIDITY
CONCURRENT CONDITIONS THAT COEXISTS WITH THE FIRST LISTED DIAGNOSIS HAS THE POTENTIAL TO AFFECT TREATMENT OF THE FIRST LISTED DIAGNOSIS AND IS AND ACTIVE CONDITION FOR WHICH THE PATIENT IS TREATED AND MONITORED
COMPLICATION
CONDITION THAT DEVELOPS AFTER OUTPATIENTS CARE HAS BEEN PROVIDED OR DURING AN INPATIENT ADMISSION
COMPUTER AIDED CODING CAC
ARE COMPUTER ASSISTED CODING CAC
COMPUTER ASSISTED CODING CAC
USES A NATURAL LANGUAGE PROCESSING ENGINE TO READ PATIENT RECORDS AND GENERATE ICD 10 CM AND HCPS/CPT CODES
CONTIGUOUS SITES
ALSO CALLED OVERLAPPING SITES OCCURS WHEN THE ORIGIN OF THE TUMOR INVOLVES TWO ADJACENT SITES
COOPERATING PARTIES FOR ICD 10 CM/PCS
AHA, AMA,CMS AND NCHS ORGANIZINGTIONS AND AGENCIES THAT APPROVE OFFICIAL GIDELINES FOR CODING AND REPORTING ICD 10 CM
ENCODER
AUTOMATES THE CODING PROCESS USING COMPUTERIZED OR WEDB BASESED SOFTWARE LOOKING UP CONDITIONS USES THE SOFTWARE SEARCH FEATURE TO LOCATE AND VERIFY DIAGNOSIS AND PROCEDURE CODES
ENCOUNTER
FACE-TO-FACE CONTACT BETWEEN A PATIENT AND A HEALTH CARE PROVIDER WHO ASSES AND TREATS THE PATIENT’S CONDITION
ESSENTIAL MODIFIER
SUBTERM
EVIDENCE-BASED CODING
CODING AUDITOR CLICKS ON CODES THAT CAC SOFTWARE GENERATES TO REVIEW ELECTRONIC HEALTH RECORD DOCUMENTATION USED TO GENERATE THE CODE
FIRST LISTED DIAGNOSIS
REPORTED ON OUTPATIENT CLAIMS IT REFKEFCTS THE REASON FOR THE ENCOUNTER AND IT IS OFTEN A SIGN OR SYMPTOM
GENERAL EQUIVALENCE MAPPING GEM
TRANSLATION DICTIONARIES R CROSSWALK OF CODES THAT CAN BE USED TO ROUGHLY IDENTIFY ICD 19 CM CODES FOR THEITH ICD 9 CM EQUIIVALENT CODES
IATROGENIC ILLNESS
ILLNESSS THAT RESULTS FROM MEDICAL INTERVENTION
ICD-10-CM CODING CONVENTIONS
GENERAL CODING RULES THAT APPLY TO THE ASSIGNMENT OF CODES INDEPENDENT OF OFFICIAL CODING GUIDELINES
AND
WHEN TWO DISORDERS ARE SEPARATED BY TEH WORD AND IT IS INTERPRETED AS AND OR AND INDICATES THAT EITHER OF THE TWO DISORDERS IS ASSOCIATED WITH THE CODDE NUMBER
BRACKETS
USED IN THE INDEX TO IDENTIFY MANIFESTATAION CODES AND IN THE INDEX AND TABULAR LIST TO ENCLOSE ABBREVITATIONS SYNONYMS ALTERNATIVE WORDING OR EXPLANATORY PHRASES
CODE ALSO
ICD 10 CM TABULAR LIST INSTRUCTION THAT INDICATES TWO CODES MAY BE REQUIRED TO FULLY DESCRIBE A CONDITION WITH SEQUENCING DEPENDING ON THE CIRCUMSTANCES OF THE ENCOUNTER
CODE FIRST UNDERLYING DISEASE
APPERARS 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 PRESENTA CAUSAL CONDITION IS A DISEASE THAT MANIFESTS ANOTHER CONDITION
COLON
USED AFTER AN INCOMPLETE TERM AND IS FIOLLOWED BY INE OR MORE MODIFIERS
DEFAULT CODE
LISTED NEXT TO A MAIN TERM IN THE ICD 10 CM ALPHABETIC INDEX AND REPRESENTS THE CONDITION TAHT IS MOST COMMONLY ASSOCIATED WITH THE MAIN TERM OR IS THE UNSPECIFIED CODE FOR THE CONDITION
DUE TO
LOCATED IN THE INDEX IN ALPHABETICAL ORDER TO INDICATE THE PRESENCE OF A CAUSE-AND-EFFECT RELATIONSHIP BETWEEN TWO CONDITIONS
EPONYM
DISEASE AND PROCEDURES NAMED FOR PEOPLE SUCH AS BARLOWS DISEASE
ETIOLOGY AND MANIFESTION RULES
INCLUDE THE FOLLOWING NOTES IN ICD-10-CM TABULARE 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
EXCLUDES 1 NOTE
A PURE EXCLUDES WHICH MEANS NOT CODED HERE AND INDICATES MUTUALLY EXCLUSIVE CODES IN OTHER WORDS TWO CONDITIONS THAT CANNOT BE REPORTED TOGETHER
EXCLUDES 2 NOTE
MEANS NOT INCLUDED HERE AND INDICATES THAT ALTHOUGH THE EXCLUDED CONDITION IS NOT CLASSIFIED AS PART OF THE CONDITION IT IS EXCLUDED FROM
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 PATIENTS RECORD
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 PROVIDED EXAMPLES
MANIFESTATION
CONDITION THAT OCCURS AS THE RESULT OF ANOTHER CONDITION MANIFESTION 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
NOS NOT OTHERWISE SPECIFIED
INDICATES THAT THE CODE IS UNSPECIFIED CODDERS SHOULD ASK THE PROVIDER FOR A MORE SPECIFIC DIAGNOSIS BEFORE ASSIGNING THE CODE
OTHER AND OTHER SPECIFIED CODE
ASSIGNED WHEN PATIENT RECORD DOCUMENTATION PROVIDES DETAIL FOR WHICH A SPECIFIC CODE DOES NOT EXIST IN ICD 10 CM
PARENTHESES
ENCLOSE SUPPLEMENTARY WORDS THAT MAY BE PRESENT PR 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 CODE TO THE ICD 10CM 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 POISONING 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 THE PROVIDERS 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 OUTPATIENT SERVICES AND PROVIDER-BASED OFFICE VISITS
DEVELOPED BY THE FEDERAL GOVERNMENT OUTPATIENT DIAGNOSES THAT HAVE BEEN APPROVED FOR USE BY HOSPITAL PROVIDERS IN CODING AND REPORTING HOSPITAL-BASED OUTPATIENT SERVICES AND PROVIDER-BASED OFFICE VISITS
ICD-`10-CM INDEX OF DISEASES AND INJURIES
AND 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 CAUSES OF INJURY
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 THE INTENT THE PLACE WHERE THE EVENT OCCURRED THE ACTIVITY OF THE PATIENT AT THE TIME OF THE EVENT AND THE PERSONS STATUS
ICD 10 CM OFFICIAL GUIDELINES FOR CODING AND REPORTING
PREPARED BY CMAS AND NCHS AND APPROVED BY THE COOPERATING PARTIES FOR ICD 10 CM CONTAIN RULES THAT WERE DEVELOPED TO ACCOMPANY AND COMPLEMENT CODING CONVENTIONS AND INSTRUCTIONS PROVIDED IN ICD 10 CM
ICD 10 CM TABULAR LIST OF DISEASES AND INJURIES
CHRONOLOGICAL LIST OF CODES CONTAINED WITHIN 22 CHAPTERS WHICH ARE BASED ON BODY SYSTEM OR CONDITION
ICD 10 CM COORDINATION AND MAINTENANCE COMMITTEE
RESPONSIBLE FOR OVERSEEING ALL CHANGES AND MODIFICATIONS TO ICD 10 CM AND ICD 10 PCS CODES AND 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 OCS CONTAIN RULES THAT WERE DEVELOPED TO ACCOMPANY AND COMPLEMENT OFFICIAL CONVENTIONS AND INSTRUCTIONS PROVIDED ON ICD 10 PCS ADHERENCE WHEN ASSIGNING PROCEDURE CODES IS REQUIRED UNDER HIPAA
INTERNATION CLASSIFICATION OF DISEASE 11TH REVISION ICD 11
DEVELOPED BY THE WORLD HEALTH ORGANIZATION AND RELEASED IN 2018 TO BEGIN THE IMPLEMENTATION PROCESS
LEGACY CLASSIFICATION SYSTEM
LEGACY CODING SYSTEM
LEGACY CODING SYSTEM
SYSTEM THAT IS NO LONGER SUPPORTED OR UPDATED SUCH AS ICD 9 CM ONCE ICD 10 CM REPLACED IT EFFECTIVE OCTOBER 1, 2015
LESION
ANY DISCONTINUITY OF TISSUE THAT MAY OR MAY NOT BE MALIGNANT
MAIN TERM
BOLD FACED TERM LOCATED IN THE ICD 10 CM INDEX LISTED IN ALPHABETICAL ORDER WITH SUBTERMS AND QUALIFIERS INDENTED BELOW EACH MAIN TERM
MALIGNANT
CANCEROUS
METASTASIS
SPRED OF CANCER FROM PRIMARY TO SECONDRAY SITES
MORBIDITY
PERTAINING TO ILLNESS OR DISEASE
MORPHOLOGY
INDICATES THE TISSUE TYE OF A NEOPLASM MORPHOLOGY CODES ARE REPORTED TO STATE CANCER REGISTRIES
MORTALITY
DEATH
NEOPLASM
NEW 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 TEH CODE NUMBER TO BE ASSIGNED
OUTPATIENT
PERSON TREATED IN ONE OF THREE SETTINGS HEALTH CARE PROVIDER OFFICE HOSPITAL CLINIC EMERGENCY DEPARTMENT HOSPITAL SAME DAY SURGERY UNIT OR AMBULATORY SURGICAL CENTER WHERE TEH PATIENT IS RELEASED WITHIN 23 HOURS OR HOSPITAL ADMISSION SOLELY FOR OBSERVATION WHERE THE PATIENT IS RELEASED AFTER A SHORT STAY
OVERLAPPING SITES
CONTIGUOUS SITES
PHYSICIAN QUERY PROCESS
WHEN CODERS HAVE QUESTIONS ABOUT DOCUMEBTED DIAGNOSES OR PROCEDURES THEY CONTACT THE RESPONSIBLE PHYSICIAN TO REQUEST CLARIFICATION ABOUT DOCUMENTATION AND THE CODES TO BE ASSIGNED
PLACEHOLDER
CHARACTER X AS A PLACEHOLDER TP ALLOWS FOR FUTURE EXPANSION OF CERTAIN CODES USED WHEN A CODE CONTAINS FEWER THAN SIX CHARACTERS AND A SEVENTH CHARACTER APPLIES
POISONING ACCIDENTAL UNINTENTIONAL
POISONING THAT RESULTS FROM AN INADVERTENT OBERDOSE WRONG SUBSTANCE ADMINISTERED OR INTOXICATION THAT INCLUDES COMBINING PRESCRIPTION DRUGS WITH NONPRESCRIPTION DRUGS OR ALCHOL
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 OR SUBSTANCES ADMINISTERED TAKEN OR INTOXICATION THAT INCLUDES PUROSELY COMBINING PERSCRIPTION DRUGS WITH NONPRESSCRPTION DRUGS OR ALCOHOL`
POISONING UNDETERMINED
SUBCATEGORY USED IF THE PATIENT RECORD DOES NOT DOCUMENT WHETHER THE POISONING WAS INTENTIONAL OR ACCIDENTAL
PREDMISSION TESTING PAT
COMPLETED PRIOR TO AN INPATIENT ADMISSION OR OUTPATIENT SURGERY TO FACILIATE THE PATIENTS TREATMENT AND REDUCE THE LENGTH OF STAY
PRIMARY MALIGNANCY
ORIGINLAL CANER SITE
PRINCIPAL DIAGNOSIS
CONDITION DETERMINED AFTER STUDY THAT RESULTED IN TEH PATIENTS ADMISSION OT 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 QULIFERS
RE EXCISION
OCCURS WHEN THE PATHOLOGY REPORT RECOMMENTDS 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 METASTAIZED TO A SECONDARY SITE EITHER ADJECENT TO THE PRIMARY SITE OR TO A REMOTE REGION OF THE BODY
SEQUELA
RESIDUAL LATE EFECTS OF INJURY OR ILLNESS
subterm
QUALIFIES THE MAIN TERM BY LISTING ALTERNATIVE SITES ETILIOGY 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 TH EINDEX MAY ALSO BE ASSOCIATED TO A CODE
UNCERTAIN BEHAVIOR
IT IS NOT POSSIBLE TO PREDICT SUBSEQUENT MORPHOLOGY OR BEHAVIOR FORM THE SUBMITTED SPECIMEN
UNDERDOSING
TAKING LESS OF A MEDICATION THAN IS PRESCRIBED BY A PROVIDER OR A MANUFACTURERS INSTRUCTION
UNSPECIFIED NATURE
NEOPLASM IS IDENTIFIED BUT NO FUTHER INDICATION OF THE HISTOLOGY OR NATAURE OF THE TUMOR IS REFLECTED IN THE DOCUMENTED DIAGNOSIS
GENERAL EQUIVALENCE MAPPINGS GEMS
TRANSLATION DICTIONARIES OR CROSSWALKS OF CODES THAT CAN BE USED TO ROUGHLY IDENTIFY ICD 10 CM CODES FOR THEIE RICD 9 CM EQUIVALENT CODES
ENCODERS
AUTOMATES THE CODING PROCESS USING COMPUTERIZED OR WEB BASED SOFTWARE INSTEAD OF MANUALLY LOOKING UP A CONDITIONS IN THE CODING MAUALS INDEX THE CODER USES THE SOFTWARES SEARCH FEATURE TO LOCATE AND VERIFY DIAGNOSIS AND PROCEDURE CODES
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 TERM MAIN TERM OR SUBTERM THAT MAY PROVIDE ADDITIONAL USEFUL INDEX ENTRIES
SEE CATEGORY
INSTRUCTION DIRECTS THE CODER TO THE ICD 10 TABULAR LIST WHERE A CODE CAN BE DELETED FORM THE OPTIONS PROVIDED THERE
SEE CONDITION
DIRECTS THE CODER TO TEH MAIN TERM FOR A CONDITION FOUND IN THE INDEX
ICD 10 CM INDEX TO DISEASES AND INJURIES\
ALPHABETICAL LISTING OF TERNS AND THEIR CORRESPONDING CODES WHICH INCLUDE SPECIFIC ILLNESSES INJURIES EPONUMS ABBREVIATIONS AND OTHER DESCRIPTIVE DIAGNOSTIC TERMS
MAIN TERMS
BOLD FACED TERM LOCATED IN THE ICD 10 INDEX LISTED IN ALPHABETICAL ORDER WITH SUBTERMS AND QUALIFIERS INDENTED BELOW EACH MAIN TERM
NONESSNETIAL MODIFIERS
SUPPLEMENTARY WORDS LOCATED IN PARENTHESES AFTER AN ICD 10 MAIN TERM THAT DO NOT HAVE TO BE INCLUDED IN ATHE DIAGNOSTIC STATEMENT FOR ATHE CODE NUMBER TO BE ASSIGNED
SUBTERMS
QUALIFIES THE MAIN TERM BY LISTING ALTERNATIVE SITES ETIOLOGY OR CLINICAL STATUS IT IS INDENTED TWO SPACES UNDER THE MAIN TERM
ESSENTIAL MODIFIERS
SEE SUBTERMS
NEOPLASMS
NEW GROWHT OR TUMOR IN WHICH CELL REPRODUCTION IS OUT OF CONTROL
ICD 10 CM INDEX OF EXTERNAL CAUSES OF INJURY
ARRANGED IN ALPHABETICAL ORDER BY MAIN TERM INDICATING THE EVENT AND SECONDARY CODES FOR USE IN ANY HELTH CARE SETTING CAPTURE HOW THE INJURY OR HEALTH CONDITION HAPPENED CAUSE AND INTENT UNINTENTIONAL OR ACIDENTAL 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 PERSONS STATUS
QUALIFIED DIAGANOSES
WORKING DIAGNOSIS THAT IS NOT YET PROVEN OR ESTABLISHED REPORTED FOR INPATIENT CASES ONLY
SECONDARY DIAGNOSES
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
