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International Classification of Diseases 9th Revision Clinical Modification
What does ICD 9 CM stand for?
classification of diseases and injuries, supplementary classifications, appendices
What are the subdivisions of volume 1?
Used in both exclusion/inclusion notes to indicate that one of the modifiers from the list below must be present in order for statement to apply.
This is used in volume 2 to enclose a code number that must be used with the code preceding it.
This is used when documentation indicates a specific condition but there is no separate code for the condition.
This is used when the diagnostic statement and medical record does not provide specific information that would permit classification to a specific code.
Directs coder to look under another term if all information is not found under the first term
chapter, section, category, subcategory, subclassfication
List the order in which codes are organized.
Terms listed in the alphabetic index in boldface type all the way to the left are known as
documentation, specific condition
Codes containing the abbreviation NOS are to be used when _____ doesn't provide enough information to point you to a ______
London Bills of Mortality
This was the first documentation of the proportion of children who died before age six.
Final Rule of the HIPAA Administrative Simplification Modifications
Implementation of ICD 10 was established in the
Medicare Prescription Drug Improvement and Modernization Act
Which act included the possibility that code changes could occur twice a year?
These have 4 digits and provide more specificity of information regarding etiology, site, and manifestations.
chapter, section, category, subcategory
5 digit assignments and instructions appear at the beginning of a ______, _____, _____, or _____.
This is a type of specific condition that is not otherwise classified to preceding fourth digits in same category.
This describes a condition that has not been described as specific enough to assign it to another 4th digit in same category.
Supplementary classification of factor influencing health status and contact with health services.
index to diseases and injuries, table of drugs and chemicals, index to e codes
Three major sections of the alphabetic index (volume 2).
associated condition, present
For exclusion notes, codes under consideration cannot be assigned if the _______ specified in the exclusion note is _____.
additional code, explain the condition
Exclusion notes may indicate that an ______ may be required to fully _____.
5th digit, additional coding instructions, definition of terms
ICD 9 Notes describe needed ______, provide ______, and provide _____.
underlying condition, manifestation
Mandatory multiple coding indicates the need for two codes. One for _____ and the other for _____.
underlying condition, manifestation
When multiple coding is needed, the first code is the _____ and the second code is the _____.
once the cause is identified
Signs and symptoms that are characteristic of an illness are not coded _____.
These are indented two standard indentations from level of preceding line and used only when the complete entry cannot fit on a single line
main term, subterm
Subterms preceded by "with" or "without" are not listed in alpha order but appear immediately below ____ or appropriate _____ entries.
These notes indicate that a particular condition is not assigned to the code to which the note applies.
code first underlying condition
This identifies a code for a condition that is a manifestation of an underlying disease and that a specific condition must be sequenced first.
code any causal condition first
Indicate that if a causal condition were present, it would be sequenced before the code.
Indicates that both elements in the title must be present in the diagnostic or procedural statement. Do not indicate cause/effect relationship, but may occur together frequently.
index, tabular list
The condition or procedure to be coded must first be located in the _____ and the code provided must then be verified in the _____.
A single code to classify either two diagnoses, or a diagnosis with a secondary condition.
When no combination code is provided, _____ should be assigned as needed to fully code condition.
The required assignment of two codes to provide information about both a manifestation and underlying disease.
Probable or rule out conditions may be coded on _____ side but not _____ side.
symptoms, signs, abnormalities
For patients seen in an outpatient setting, only ____, ____, and ______ may be reported to the highest degree of certainty.
personal consequences, unconfirmed diagnoses
Incorrect reporting of epilepsy, AIDS, and MS can have serious _______ and therefore caution should be used in coding _____.
possible, not possible
Rule out indicates that a diagnosis is considered ______. Ruled out indicates that a diagnosis is ______.
If the physician indicates a borderline condition, the coder should ask for _____.
With a borderline condition, if the disease is not clarified by provider, code for _____.
both codes, indentation level, acute
If a condition is described as acute and chronic, _____ are assigned, if they are at the same ______, with the code for the ____ condition listed first.
For acute and chronic conditions, if "acute" is following by "chronic" in parentheses, code only ____.
impending or threatening condition
If an impending or threatening condition actually occurs, code _______.
impending, threatened, subterm, impending, threatened
If neither the threatened/impending condition nor a related condition occurred, the coder must answer whether: (1) the condition is indexed under ______ or _____; (2) and if there is a _____ for _____ or ____ under main term.
precursor condition, impending, threatened
When neither threatened or impending terms are indexed, ______ is coded. Code is not assigned for _____ or _____ condition.
A residual condition that remains after the termination of the acute phase of illness or injury.
residual condition, cause of late effect
With late effects, _____ is sequenced first followed by ____.
cause of late effect
In the case of late effect, when the residual effect is not stated, ______ is used alone.
In the case of late effect, when no late effect code is provided in ICD 9, but the condition is described as being a late effect, only _____ is coded.
history, complication of previous surgery
Conditions described as due to previous surgery are coded as ____ or _____ rather than late effects.
cause of late effect code
When the late effect code has been expanded at the fourth or fifth digit level to include the residual condition, only _____ code is assigned.
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