ICD-10-CM Quiz 1

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Format & Structure
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Terms in this set (32)
Parentheses are used in both the Alphabetic Index and Tabular List to enclose supplementary words that may be present or asent in the statement of a disease or procedure without affecting the code number to which it assigned. The terms within the parentheses are referred to as nonessential modifiers.
"Other" codesCodes titled "other" or "other specified" are for use when the information in the medical record provides detail for which a specific code does not exist."Unspecified" codesCodes titled "unspecified" are for use when the information in the medical record is insufficient to assign a more specific code.Includes NotesThis note appears immediately under a three character code title to further define or give examples of, the content of the category.Inclusion TermsList of terms is included under some codes. These terms are the conditions for which that code is to be used.Excludes 1A type 1 Exclude note is a pure exclude note. It means "NOT CODED HERE!" An Exclude 1 note indicates that the code excluded should never be used at the same time as the code above the Exclude 1 note.Excludes 2A type 2 excludes note represents "Not included here". An excludes 2 note indicates that the condition excluded is not part of the condition represented y the code but a patient may have both conditions at the same time. It is acceptable to use both the code and the excluded code together, when appropriate."With"The word "with" should be interpreted to mean "associated with" or "due to" when it appears in a code title, the Alphabetic Index, or and instructional not in the Tabular List."See"The "see" instruction following a main term in the Alphabetic Index indicates that another term should be referenced. It is necessary to go to the main term referenced with the "see" note to locate the correct code."See Also"A "see also" instruction following a main term in the Alphabetic Index instructs that there is another main term that may also be referenced that may provide additional Alphabetic Index entries that may be useful."Code also note"A "code also" note instructs that two codes may be required to fully describe a condition, but this note does not provide sequencing direction.Default codesA code listed next to a main term in the ICD-10-CM Alphabetic Index is referred to as a default code. The default code represents that condition that is most commonly associated with the main term, or is the unspecified code for the condition. Example, appendicitis, w/o any additional information, such as acute or chronic, the default code should be assigned.SyndromesFollow the Alphabetic Index guidance when coding syndromes. In the absence of Alphabetic Index guidance, assign codes for the documented manifestations of the syndromes.Signs and symptomsCodes that describe symptoms and signs, as opposed to diagnosis, are acceptable for reporting purposes when a related definitive diagnosis has not been established (confirmed) by the provider.Conditions that are an integral part of the disease processSigns and symptoms that are associated routinely with a disease process should not be assigned a additional codes unless otherwise instructed by the classificationsConditions that are NOT an integral part of the disease processAdditional signs an symptoms that may not be associated routinely with a disease process should be coded when present.Multiple coding for a single conditionIn addition to the etiology/manifestation convention that requires two codes to fully describe a single condition that affects multiple body systems, there are other single conditions that also require more than one code.Acute or Chronic ConditionsIf the same condition is described as both acute (subacute) and chronic, and separate subentries exist in the Alphbetic Index at the same indentation level, code both and sequence the acute (subacute) code first.Combination CodeA combination code is a single code used to classify Two diagnoses, or A diagnosis with an associated secondary process (manifestation) A diagnosis with an associated complicationLate Effects (Sequela)A late effect is the residual effect (condition produced) after the acute phase of an illness or injury has terminated.Impending or Threatened ConditionCode any condition described at the time of discharge a s "impending" or "threatened" as follows: If it did occur, code as confirmed diagnosis. If it did NOT occur, reference the Alphabetic Index to determine if the condition has a subentry term for "impending" or "threatened" and also reference main term for "Impending and for "Threatened".Reporting Same DX code more than OnceEach unique ICD-10-CM diagnosis code may be reported only once for an encounter. This applies to bilateral conditions when there are no distinct codes identifying laterally or two different conditions classified to the same ICD-10-CM diagnosis code.LaterallyFor bilateral sites, the final character of the codes in the ICD-10-CM indicates laterally.