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Coding

ICD-9-CM

international classification of diseases, 9th revision, clinical modification

Volume 1

Disease: Tabular list. Contains the disease and condition codes and the descriptions also contains the V codes and E codes

Volume 2

Diseases: Alphabetic Index. This is the alphabetic index of volume 1 and contains table of drugs and chemicals and index of external causes of injury ( E codes )

Volume 3

Procedures: Tabular list and Alphabetic index. Contains codes for surgical, therapeutic, and diagnostic procedures; used primarily by hospitals.

Supplementary Classifications

There are (2)TWO supplemental classifications included in the TABULAR LIST (Volume 1): V Code(s): Supplemental Classification of Factors Influencing Health Status and Contact with Health Services (V01-V91). E Code(s): Supplemental Classification of External Causes of Injury and Poisoning (E000-E999.

Sections

Are composed of a group of three-digit categories representing a group of conditions or related conditions

Categories

Composed of three-digit codes representing a single disease or condition. The three-digit code is used only if it is not further subdivided. There are about a 100 of these codes.

Subcategories

Provide a 4 digit code ( one after the decimal point ) which is more specific then a category code in terms of cause, site, or manifestation of the condition. This must be used if available.

Fifth-Digit Subclassifications

Provide greater detail

NEC

not elsewhere classifiable; use this code only if a more specific code is not availiable.

NOS

Not otherwise specified:

Residual Subcategories

cods with titles "other" and "unspecified"

Nonessential Modifers

their presence or absence does not have an effect on the selection of the code listed for the main term

Eponyms

Terms derived from the name of a person, often a physician or scientist who was the first to identify a condition or technique such as Parkinson disease.

Cross-Reference Terms

directs the coder to look elsewhere in the code book before assigning a code.

See

This mandatory instruction must be followed to ensure accurate ICD-9-CM code assignment.

See also

The _ _ cross reference directs you to look under another main term if all the information being searched for cannot be located under the first main term entry.

See Category

a direction to the coder to see a specific category (three-digit code), this instruction must always be followed

Instructional Notations

clarify information or provide additional information

Includes Notes

further defines or provide example of a category or section

Excludes Notes

Indicates conditions that are to be coded/listed elsewhere.

Etiology

the cause of a disease

Manifestations

Display or disclosure of characteristics signs or symptoms of an illness; allow diagnosis to occur

Use additional Code

notes that indicate an additional code needs to be assigned to provide a more complete picture of the diagnosis or procedure.

Parenthesis ()

enclose supplementary words or explanatory information tht may or may not be present i the statement of a diagnosis or procedure

Square Brackets [ ]

used to enclose synonyms. alternative wording, abbreviations and explanatory phrases

Slanted Brackets

Enclose the manifestiation of the underlying condition, when a cose is listed inside you must sequence that code after the underlying condition code.

Colon :

is used in the Tabular list after an incomplete term that need one or more modifiers in order to be assigned to a given category or code

Brace }

simplifies tabular entries and saves printing space by reducig repetitive wording.

Syndromes

a number of symptoms occurring together and characterizing a specific disease or condition

Prophylactic

remedy that prevents or slows the course of an illness or disease

bold type

typeface used for all ocdes and titles in Volume I

Subterm

indented under main term and effects code selection

V10-V19

Persons with Potential Health Hazards Related to Personal and Family History.

V8

This code indicates the patient has tested positive for the HIV virus but has not manifested symptoms of HIV or AIDS.

V22-V24

Persons encountering health services in circumstance related to reproduction and development. Normal Pregnancy, Supervision of High-Risk Pregnancy and Postpartum care and examination

V25

includes codes for contraceptive management, such as general contraception, counseling and advice.

V27

Outcome of delivery, should be included on every maternal record when a delivery has occurred.

V30-V39

Liveborn Infants According to Type of birth, These codes are only used once in a livetime.

V58

includes codes for admissions or encounters for radiotherapy, antieoplastic chemotherapy, antineoplastic immunotherapy, attention to surgical dressings and sutures, other after care following surgery, and long-term drug use. therapeutic drug monitoring, and so forth.

V64

code used if procedure is not fully carried out

Nonspecific V Codes

are unlikely to be used in inpatient settings because they are to nonspecific or vague, or generic.

Sign

(medicine) any objective evidence of the presence of a disorder or disease observed by the physician.

Symptom

is any subjective evidence of disease reported by the patient to the physician.

With

should be interpreted to mean "associated with" or "due" to when it appears in a code title.

Other and Unspecified codes

usually a code with a 4th digit 8 or fifth-digit 9 for diagnosis codes, are for use when the information in the medical record provides detail for which a specific code does not exist.

National Center for Health statistics (NCHS)

is resposible for maintaining Volumes 1 & 2

CMS

is responsible for maintaining Volumes 3

etiology

the cause of a disease

Morphology

The tissue or body system or organ involved where cancer is prevelant

E codes

used to diagnose the environment of injury (the letter e followed by 3 numeric digits, a decimal, and a fourth digit

Connecting words

sub-terms that indicate a relation ship between the main terms and an associated condition or etiology in alphabetic index

Chapter

Classification of Diseases and Injuries, cantins 17 chapters that classify conditions according to etiology (cause of disease) or be specific anatomical 9Body) system.

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