A
When a specific code is documented, but that level of specificity is not available in the alphabetic index, what type of code would be assigned?
What is "NEC"?
What does the term "NOS" mean?
What is "Not otherwise specified"?
__________ are used to enclose synonyms, alternative wording, abbreviations and explanatory phrases.
What are "Brackets"?
This is used to enclose supplementary words or explanatory information which are considered "nonessential modifiers".
What is "Parentheses"?
This appears immediately under three-character code titles to further define and provide examples of the diagnoses found in that section.
What are "Includes Notes"?
A threatened condition can be code if it is documented at this time
What is "discharge"?
These appear under some codes to include conditions that the code may be used for-these could be synonyms or "other specified" codes
What are "Inclusion Terms"?
This means "NOT CODED HERE!" and indicates that the two conditions should never be coded together with the exception if the 2 conditions are completely unrelated to each other.
What is "Excludes1"?
This means "Not included here", indicating that the condition excluded is not part of the condition represented by the code and a patient can have both at the same time.
What is "Excludes2"?
A ______ note indicates that the code is a manifestation code and the etiology code should be coded first.
What is a "code first" note?
A ________ indicates that the code is an etiology code and needs an additional code to capture the manifestation.
What is "use additional code"?
In order to assign a code that is documented by other clinician's who are not the patient's provider, we must have this documented by the MD
What is an "associated diagnosis"?
This type of code may also have "in diseases classified elsewhere" noted in the title and can NEVER be used as the principal diagnosis.
What is "manifestation code"?
The word "and" should be interpreted to mean what when it appears in the title of a code?
What ins "and" or "or"
A causal relationship between conditions is assumed when these words appear in either the code title, Alphabetic Index, or an instructional note in the Tabular List.
What is "with" or "in"?
This instruction in the Alphabetic Index indicates that another term must be referenced
What is "see"?
This instruction in the Alphabetic Index indicates that another term may also be referenced
What is "See Also"?
There must be a cause-and-effect relationship between the care provided and the condition in order to assign this type of code
What is a "Complication Code"?
This note indicates that two codes may be required to fully capture a condition, but does not provide sequencing guidance
What is "Code Also"?
This is the code listed next to a main term in the Alphabetic Index and would be assigned if the condition is documented without any further specificity
What is "Default Code"?
In order to locate a code in the ICD-10-CM, it is important to start here
What is the "Alphabetic Index"?
As coders, we should always code to the highest level of this
What is "specificity"?
Assigning a code for this is acceptable when a related definitive diagnosis has not been established
What are "Signs and Symptoms"?
Use of this type of code may be assigned to further explain the reasons for presenting for healthcare services and includes transfers between facilities or provides additional information relevant to the encounter
What is "Z code"?
Unless otherwise instructed by the classification, we not code conditions that are ______ to a disease process
What is "integral"?
This note indicates that a secondary code should be added
What is "use additional code"?
This type of note may be found with conditions that are due to an underlying condition
What is "Code First"?
A41.51 Sepsis due to Escherichia coli [E.coli] is an example of this type of code, indicating that no other code is needed to fully capture the clinical picture.
What is "Combination Code"?
This type of code can be used when the condition occurs after the acute phase of an illness:
Example: scar formation after a burn
What is "sequela"?
The condition that is responsible for the admission to the hospital for care
What is the "Principal Diagnosis?