ICD-10-CM CODING CONVENTIONS

Question 1

and

Answer 1

when two disorders are seperated by the word and it is interpreted as “and/or” and indicates that either of the two disorders is associated withthte code number.

Question 2

brackets

Answer 2

used in the index to identify manifestation codes and in the index and tabular list to enclose abbreviations, synonyms, alternate wording, or explanatory phrases.

Question 3

code also

Answer 3

ICD-10-CM tablulsr list instruction that indicates two codes may be required to fully describe a condition with sequencing depending on circumstances of the encounter.

Question 4

code first underlysing disease

Answer 4

appears when the code refrenced is to be sequenced as a secondary code; the code, title, and instructions are italicized.

Question 5

code is applicable, any casual condition first

Answer 5

requires casual condition to be sequenced first if present; a casual condition is a disease that manifests (or results in) another condition.

Question 7

colon :

Answer 7

used after an incomplete term and id followed by one or more modifiers (additional terms).

Question 8

default code

Answer 8

listed next to a main term in the ICD-10-CM condition that is most commonly associated with the main term or is the unspecified code for the condition.

Question 9

due to

Answer 9

located in the index in alphabetical order to indicate the presence of a cause-and-effect (or casual) relationship between two cnditions.

Question 10

eponyms

Answer 10

diseases and procedures named for people, such as BArlow’s disease.

Question 11

Excludes1 note

Answer 11

a “pure” excludes which means”not coded here” and indicates mutually exclusive codes: in other words, two conditions that cannot be reported togeteher.

Question 12

Excludes2 note

Answer 12

means “not included here” and indicates that although the excluded condition is not classified as pat of the 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.

Question 13

in

Answer 13

located in alphabetical order below the main term; to assign a code from the list of qulaifiers below the word “in,” the provider must document both coditions in the patient’s record: ICD-10-CM classifies certain conditions as if there were a cause-and-effect relationship present becasue they occur together much fo the time, such as pneumonia in Q fever.

Question 14

in disease classified elsewhere

Answer 14

indicates that the manifestation code are a component of the etiology/manidestation coding convention.

Question 15

includes note

Answer 15

appear below certain tabular list categories to further define, clarify, or provide examples.

Question 16

laterality

Answer 16

ICD-10-CM specifically classifies that occur on the left, right, or bilaterally.

Question 17

manifestation

Answer 17

condition that occurs as the result of another condition;manifestation codes are always reported as secondary codes.

Question 18

NEC (not elsewhere classifiable)

Answer 18

means “other” or “other specified” and identifies codes that are assigned when informatin needed to assign a more specfic code cannot be located.

Question 19

NOS (not otherwise specified)

Answer 19

indicates tha the code is unspecified; coders should ask the provider for a more specific disgnosis before assigned the code.

Question 20

other codes

Answer 20

when this word appears in an ICD-10-CM tabular list code description, the code is assigned when patient record documentation provides detail for which a specific code does not exist.

Question 21

other specfied codes

Answer 21

when this phrase appears in an ICD-10-CM code description, the code is assigned when patient record documentation provides detail for which a specific code does not exist.

Question 22

parentheses

Answer 22

enclose supplementary words that may be present or absent in the diagnotic statement, without affecting assignment of the code number.

Question 23

placeholder

Answer 23

use of character “X” as a placeholder to allow for future expansion of certain codes; used when a code contains fewer than six characters and a seventh character applies

Question 24

see

Answer 24

cross-refernce that provides direction to different index main term or main term and subterm

Question 25

see also

Answer 25

cross-refernce that provides direction to an additional main term.

Question 26

see category

Answer 26

instruction directs the coder to the ICD-10-CM tabular list, where a code can be selected from the options provided there.

Question 27

see condition

Answer 27

directs the coder to the main term for a condition, dound in the index.

Question 28

Tbale of Drugs and Chemicals

Answer 28

alphabteical index of medicinal, chemical, and biological substances that result in poisoning, adverse effects, and over and/or underdosings.

Question 29

Table of Neoplasms

Answer 29

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 unspecified nature.

Question 30

unspecified codes

Answer 30

when patient record documentation is insufficient to assign a more specific code, this (unspecified) code is assigned.

Question 31

use additional code

Answer 31

indicates that a second code is to be reported to provide more information about the diagnosis

Question 32

with

Answer 32

when codes combine one disorder with another (e.g. code that combines primary condition with a complication), the provider’s diagnostic statement must clealry indicate that both conditions are preset and that a relationship exsists between the conditions

Question 33

subterm

Answer 33

qualifies the main term by listing alternativ sites, etiology, or clinical status; it is indented two spaces under the main term.