ICD-10-CM Key Terms
used in the Tabular Listing and Alphabetic Index to enclose synonyms, alternative wording, abbreviations, or explanatory phrases.
Brackets
used to signify that the diagnostic terms listed are not coded to the category or subcategory; therefore, the two conditions are mutually exclusive.
Excludes 1
the level of detail.
Granularity
an object that is supposed to remain in the body after the completion of a procedure, such as a pacemaker.
Device
modifying the anatomical structure of a body part without affecting its function.
alteration
instructs the coder that two codes may be needed to fully code the diagnostic phrase being coded; no sequencing directions are provided.
Code Also
the terms found in the parentheses that do not change code assignment.
Nonessential Modifiers
for bilateral sites ICD-10-CM indicates the specific site.
Laterality
the complete specification of the seven characters to identify what service was performed.
Procedure
eradicating all or a portion of a body part.
Destruction
notes appearing in the Tabular section of ICD-10-CM and identifying for the coder the sequence of the code assignment.
Code First
used in both Tabular List and Alphabetic Index around terms providing additional information about the main diagnostic term.
Parenthesis
For inpatient records, diagnoses are typically recorded where?
facesheet
additional information unique to the individual procedure being performed.
Qualifier
pulling or stripping out or off all or a portion of a body part.
Extraction
indicates that the term excludes 1, or excludes 2, or includes are incomplete phrases and need the words listed after this to be complete
Colon
a signal to the coder that the code contains a list of options at a level of specificity past the three-character category.
Point Dash
To begin coding you first go to the _____ section?
Alphabetic Index
the objective of the procedure, such as bypass, drainage, fluoroscopy, and the like.
Root Operation
entry, by puncture or minor incision, of instrumentation through the skin or mucous membrane and/or any other body layers necessary to reach the site of the procedure.
Percutaneous
a group of instructional notes, punctuation marks, abbreviations, and symbols.
Conventions
used in the Alphabetic Index and instructs the coder to cross-reference the term or diagnosis following the notation.
See
The main term is the condition that is found to be why the patient is being treated.
true
Inpatient procedures
cutting out or off, without replacement, all of a body part.
Resection