Diagnostic coding
Diagnosis codes on an insurance claim explain
the patient's condition that was treated during the visit
In locating a diagnosis, look up the main term, which is the
disease and injury
Diagnoses that relate to a patient's previous medical problem and that have no bearing on the patient's present condition should be ____ when coding.
excluded
Codes that are used principally by tumor or cancer registries are
neoplasm codes
Primary diagnosis
The diagnosis listed first in submitting insurance claims for patients seen in a physician's office is the
primary diagnosis
Terms enclosed in parentheses following the main term are referred to as
non-essential modifiers
External cause codes are used
to show cause of injury
A ___ is a late effect or condition produced after the acute phase of an illness
sequela
Underlying cause of the disease
etiology
NEC stands for?
"not elsewhere classifiable"
What is an eponym?
The name of a disease, structure, operation, or procedure, usually derived from the name of a place or a person who discovered or described it first.
What is the table that contains a classification of substances for identifying poisoning states and external causes of adverse effects?
Table of Drugs and Chemicals
Cancer confined to one site
Carcinoma in situ
The diagnosis that prompted hospitalization
principal diagnosis
NOS means?
"not otherwise specified"
ICD-10-CM was published by the WHO in
1992
In ICD-10-CM, a code with a fourth digit 9 or fifth digit 0 for diagnosis codes means
information in the health record is unspecified.
In ICD-10-CM, a placeholder for future code expansion is shown as
X character
Why is the correct sequence of codes on an insurance claim important?
to make the chronology of patient care events understood and to make the severity of disease understood.
The _________________ is a set of rules developed to accompany and complement the official conventions and instructions provided in the ICD-10-CM coding manual.
Official Guidelines for Coding and Reporting
The first three characters of an ICD-10-CM code are composed as
Character 1 (alpha), Character 2 (numeric), Character 3 (numeric)
Annual updates to the ICD-10-CM coding system are published in the ___.
federal register
The sixth character of an ICD-10-CM code can signify
trimester of pregnancy
May contribute to the condition or define the need for a higher level of care but is not the underlying cause
secondary diagnosis