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