ICD-10-CM Guidelines 2023 I.A. Conventions Flashcards
NEC
- Not elsewhere classifiable
- ‘Other specified’
NOS
- Not otherwise specified
- equivalent of unspecified
Brackets [ ]
- enclose synonyms, alternative wording or explanitory phrases
- identifies manifestation codes
Parenthesis ( )
- enclose supplementary words
- nonessential modifiers
“Other” codes
- “other” or “other specified
- info provides greater detail for a code that doesn’t exist
“unspecified” codes
information is insufficient to assign a more specific code
Includes Notes
appears immediately under a 3-character code to further define or give examples
Inclusion terms
terms of conditions for which the code is to be used or synonyms of the code title
Excludes 1
- NOT coded here
- code pairs should never be used together
- Ex. a congenital form vs. an acquired form of the same condition
- EXCEPTION: when two conditions are clearly unrelated to each other
Excludes 2
- Not Included here
- the condition excluded is not part of the condition represented by the code
- both codes may be used when appropriate
Etiology/manifestion
“code first”, “use additional code” and “in diseases classified elsewher
- conditions with an underlying etiology and manifestations due to the etiology
- sequence underlying condition first, followed by manifestation
- manifestations = “in diseases classified elsewhere”
- “In diseases classified elsewhere” may NEVER be used as first listed or principal diagnosis
- manifestion code in [brackets]
G20, [F02.80/1] Parkinson’s, with dementia (with or without behavioral d
And
interpreted to mean either “and” or “or” in a code title
With
- “with” or “in” means “associated with” or “due to”
- classification presumes a causal relation b/w two codes even in abscence of provider documentation unless another guideline requires documented linkage
- EXCEPTION - sepsis guideline for “acute organ dysfunction that is not clearly associated with sepsis”
See
Index instruction; it is necessary to go to the main term referenced
See Also
Index instruction; not necessisary to follow but may provide additional Inded entries that may be useful
Code Also
Index instruction; two codes may be required to fully describe a condition. Does NOT provide sequencing direction; sequencing depends on the circumstances of the encounter
Default code
The code listed next to the main term in the Index; the most commonly associated condition or the unspecified code for the condition.
Code assignment and Clinical Criteria
Assignment of a diagnosis code is based on the provider’s diagnostic statement the condition exists. Code assignment is not based on clinical criteria used by the provider to establish the diagnosis. If there is conflicting documentation, query the provider.
