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Terms in this set (...)

Cross reference notes
These types of notes are located in the alphabetic indexes to instruct the coder to look elsewhere before assigning a final code.
Four types include:
See Also: Its followed by a main term. It indicates that another main term maybe checked that may provide additional useful index entries
See Category
See Condition
Coding for complications of pregnancy, childbirth, and the puerperium
Peripartum: The period from the last month of pregnancy to 5 months postpartum
Treatment or progress notes
the second most common medical document from which diagnostic information can be obtained
*often used for SOAP notes
Coding complications of care
2 requirements must be met: A cause and effect relationship must be established between the care provided and the condition; and the documentation must indicate that the condition is a complication
• not all conditions that occur during or after medical care or surgery are classified as complications
•If it's not documented it didn't happen
Coding for burns and corrosions
Because burned are coded by sight and degree and by the extent of body surface involvement
•At least two coats and a third if the wound is infected
ICD-10-CM Uses all letters except which one?
U- It's used to put new diseases
Subjective findings
Include the patient's chief complaint or statement about why the patient is seeking medical care
General Equivalence Mappings (GEMs)
provide forward and backward mapping between the ICD-9 and ICD-10 coding systems

To create a useful, practical,Code to code,translation reference dictionary for both code sets, And to offer acceptable translation alternatives whenever possible.
To look up allergy
L/U shock main term
-due too
-combined code

Or a patient who is allergic to a certain food
Ca in situ (malignant neoplasm sites)
- Carcinoma in situ is defined as the absence of invasion of surrounding tissues
- In Situ is only used when diagnostic statements contains the exact phrase

* The Ca in situ column is used ONLY if the provider documents that precise terminology
The alphabetic index
SUBTERMS - these terms are in dented one space to the right under at is sensual modifier (two spaces to the right under the main term)
-two spaces
- to gray lines in the index
Clode 1st/use additional code
- Etiology goes FIRST " use a secondary additional quote"
- manifestations goes SECOND " code 1st etiology"
One of six steps for coding neoplasms
6. Check the code in the tabular list to make sure it complies with the guidelines, conventions, and instructional notations in the tabular list
Newborn coding
The para Nadel. Extends from just before the birth through 28 days after birth,

Z 38,

only wants to a newborn at the time of birth
Updating the ICD-10-CM
EVERY YEAR the CMS reviews the ICD-10-CM coding manual, and the update is publish on October 1
Seventh character for fetus identification
Identify the fetus
Assign the seventh character O
Not only A, D, S
Coding the etiology and manifestation
- Etiology refers to the underlying cause or origin of a disease
- Manifestation describes the signs and symptoms of the disease
Coding for injuries
The code for the most serious injury, as determined by the provider and the focus of treatment, is sequenced first
What cost the most?
Coding for drug toxicity
Underdosing - patient takes less of a medication that is prescribed by the provider or by the manufactures instructions
Coding for Diabetes Mellitus
Type 1
Type 2
-If insulin is documented in the health record a second code is required
Coding for skin ulcers
L89{ pressure ulcer}
-are combination code is that identify the Site of the pressure ulcer and the stages of the ulcer
One, two, three, four
human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS)
HIV - indicates that only the virus is present
AIDS- a syndrome, Manifestation of signs and/or symptoms that can occur as a result of HIV infection
Coding guidelines
-set of rules that have developed a complement the official
• section I
• section II
•Section III-Reporting Additional Diagnosis; this section includes guidelines for reporting additional diagnosis is non-outpatient settings
• section IV
The history of medical coding
-in 1946 the international Commission of the world health organization WHO establish his code to define specific infectious diseases, parasites, symptoms, and cause of death.

Dash this coats that was called the manual of international Step to Stickel classification of diseases, injuries and causes of death ICD
History and physical exam
What is the most important preoperative evaluation performed by the surgical team?

History and physical exam H&P are the starting point of the patients narrative medical evaluation

Statement, called chief complaint, is often abbreviated in the history documentation in the health record

After the cc, the provider document any other Pertinent history about medical, behavioral, and social factors, such as smoking, drinking, drug use, family history, previous surgeries, and hospitalizations