53 terms

MRT-108 ICD-9

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.
Are composed of a group of three-digit categories representing a group of conditions or related conditions
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.
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
not elsewhere classifiable; use this code only if a more specific code is not availiable.
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
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.
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.
the cause of a disease
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.
a number of symptoms occurring together and characterizing a specific disease or condition
remedy that prevents or slows the course of an illness or disease
bold type
typeface used for all ocdes and titles in Volume I
indented under main term and effects code selection
Persons with Potential Health Hazards Related to Personal and Family History.
This code indicates the patient has tested positive for the HIV virus but has not manifested symptoms of HIV or AIDS.
Persons encountering health services in circumstance related to reproduction and development. Normal Pregnancy, Supervision of High-Risk Pregnancy and Postpartum care and examination
includes codes for contraceptive management, such as general contraception, counseling and advice.
Outcome of delivery, should be included on every maternal record when a delivery has occurred.
Liveborn Infants According to Type of birth, These codes are only used once in a livetime.
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.
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.
(medicine) any objective evidence of the presence of a disorder or disease observed by the physician.
is any subjective evidence of disease reported by the patient to the physician.
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
is responsible for maintaining Volumes 3
the cause of a disease
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
Classification of Diseases and Injuries, cantins 17 chapters that classify conditions according to etiology (cause of disease) or be specific anatomical 9Body) system.