Coding Chapter 2

Front 1

NEC

Back 1

Not Elsewhere Classifiable: a specific code for this has not been created yet

Front 2

NOS

Back 2

Not Otherwise Specified: not enough information has been given to the coder to assign a more specific code.

Front 3

braces }

Back 3

encloses several terms found in the tablular index, which are modified by the statement to the right of the brace

Front 4

brackets [

Back 4

]

Hint 4

contain explainatory phrases or terms. OR the may enclose specific fifth digits that are valid only with the code above it.

Front 5

parentheses ( )

Back 5

encloses nonessential modifiers or describe words that do not affect the code assignment.

Front 6

colon :

Back 6

incomplete terms

Front 7

italics

Back 7

identify codes that may not be used as primary diagnosises.

Front 8

includes

Back 8

code can be used

Front 9

excludes

Back 9

code is located elsewhere

Front 10

use additional code

Back 10

must use a supplemental code if the information is avalible

Front 11

code first underlying disease

Back 11

can never be used as a stand alone code or as a primary dignosis code

Front 12

omit code

Back 12

means no code should be assigned

Front 13

see also

Back 13

is a manditory instruction to cross reference another main term.

Front 14

appendix a

Back 14

morphology of neoplasims

Front 15

appendix b

Back 15

deleted in 2005

Front 16

appendix c

Back 16

classification of drugs

Front 17

appendix d

Back 17

classification of industrial accidents

Front 18

appendix e

Back 18

list of 3 digit catagories

Front 19

v codes

Back 19

factors influencing health status and contact with health services ( obgyn visits, immunizations, physical, pre-op, and counseling)( are procedure codes can stand alone for coding)

Front 20

e codes

Back 20

external causes of injury and poisonings (accident, injury, posioning, suicide, and assualt)( is a supporting code not a stand alone code)

Front 21

morbirity

Back 21

sickness

Front 22

mortality

Back 22

death

Front 23

volume I

Back 23

tabular/numerical list of diseases

Front 24

volume II

Back 24

alphabetic index of diseases

Front 25

Volume III

Back 25

tabular and alphabetic index of procedures

Front 26

addenda

Back 26

an addition made to book or publication (at the end of a document, revision, or a change)

Front 27

adverse affect

Back 27

an undesired condition that results from use of a medication or drug given in the correct dosage.

Front 28

combination code

Back 28

a single code that classifies more than one condition

Front 29

complication code

Back 29

secondary code on the claim form, not primary reason for visit

Front 30

conventions

Back 30

formatting used in coding books that is exclusive to each volume and publisher

Front 31

cross walk

Back 31

reference aid that compares information in one system to another

Front 32

diagnosis

Back 32

the process of determining by examination the nature and circumstances of a diseased condition

Front 33

diagnostic statement

Back 33

main reason for the patient encounter along with description of additional condtions or symptoms that are treated or related

Front 34

eponym

Back 34

a procedure or diagnosis name derived from the name of a person

Front 35

etiology

Back 35

cause of origin of a disease

Front 36

ICD9CM

Back 36

internation classification of diseases, ninth edition revision clinical modification; a coding system used to code signs, symptoms, injuries, diseases, and conditions.

Front 37

late effect/ reisdual effect

Back 37

a condtion that remains after a patients acute illness or injury.

Front 38

main term

Back 38

the term used when searching for a specific diagnosis code usually the chief complaint

Front 39

manifestation

Back 39

related to the patients condition

Front 40

morphology

Back 40

the study of the structure of words

Front 41

primary diagnosis

Back 41

the patients main reason for the visit or encounter

Front 42

principle diagnosis

Back 42

the condition established after all tests and procedures are completed.

Front 43

rule out r/o

Back 43

a designation for an uncertain diagnosis that the provider orders tests or studies for an attempt to eliminate it as a cause of the patients complaint.

Front 44

secondary

Back 44

a procedure that is performed in addition to the primary procedure

Front 45

sign

Back 45

an indication of a particular disorder that can be observed or measured by a physician

Front 46

subterm

Back 46

coding terms that provide more specific information than the main term; provides the anotomic site affected by the disease or injury.

Front 47

supplementary term

Back 47

nonessential word or phrase that help define a code usually in () or []

Front 48

symbols

Back 48

show changes, alerts reader to new codes, deletions or alterations.

Front 49

symtoms

Back 49

an indication of a disorder or disease that the patient reports to the physician but can not be observed or measured

Front 50

definition of diagnosis coding

Back 50

describes services, procedures and supplies

Front 51

ICD10CM

Back 51

replaces volume I and II of the ICD9CM; uses alphanumeric codes; is much more detailed than the ICD9CM. Includes ambulatory and managed care encounters. contains injury codes; combines codes to provide a more detailed description of the injury or illness.

Front 52

instructional terms

Back 52

assist coders to find most specific term

Front 53

WHO

Back 53

world health organization

Front 54

NCHS

Back 54

national center for health statistics

Front 55

what year was the cause of death given?

Back 55

1629

Front 56

when did they start to include the age of death?

Back 56

in the early 18th century

Front 57

what year was the plague in the bills of mortality?

Back 57

1665

Front 58

in what year did the icd come under the world health organization?

Back 58

1948

Front 59

what year was a committee convened by the national center for health statistics?

Back 59

1977

Front 60

what year did the medicare catastrophic coverage act happen?

Back 60

1988

Front 61

the who finished the 10th revision of the icd in what year?

Back 61

1992