Icd-9-Cm Coding

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ADVANCE BENEFICIARY NOTICE (ABN)

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document that acknowledges patient responsibility for payment if Medicare denies the claim.

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ADVERSE EFFECT

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also called adverse reaction; the appearance of a pathologic condition due to ingestion or exposure to a chemical substance properly administered or taken.

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AXIS OF CLASSIFICATION

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organizes entities, diseases, and othe conditions according to etiology, anatomy, or severity.

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BENIGN

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not cancerous

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CARCINOMA (CA) IN SITU

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a malignant tumor that is localized, circumscribed, encapsulated, and noninvasive (has not spread to deeper or adjacent tissues or organs)

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CLASSIFICATION OF DRUGS BY AHFS LIST

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Appendix C of ICD-9-CM that contains the American Hospital Formulary Services list number and its ICD-9-CM equivalent code number; organized in numerical order according to AHFS list number

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CLASSIFICATION OF INDUSTRIAL ACCIDENTS ACCORDING TO AGENCY

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Appendix D of ICD-9-CM; based on employment injury statistics adopted by the tenth International Conference of Labor Statisticians

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CODING CONVENTIONS

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rules tha apply to the assignment of ICD-9-CM codes

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COMPLICATION

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condition that develops subsequent to inpatient admission.

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CONGENITAL ANOMALY

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disorder diagnosed in infants at birth

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CONTIGUOUS SITE

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also called overlapping site; occurs when the origin of the tumor (primary site) involves two adjacent sites.

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DIAGNOSTIC CODING AND REPORTING GUIDLINES FOR OUTPATIENT SERVICES: HOSPITAL-BASED AND PHYSICIAN OFFICE

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developed by the federal government for use in reporting diagnoses for claims submission

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E CODE

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located in the ICD-9-CM Tabular List, describes external causes of injury, poisoning, or other adverse reactions affecting a patient's health.

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ENCODER

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automates the coding process using computerized or Web-based software; instead of manually looking up conditions (or procedures) in the coding manual's index, the coder uses the software's search feature to locate and verify diagnosis and procedure codes.

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FIRST-LISTED DIAGNOSIS

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reported on outpatient claims (instead of inpatient principal diagnosis); it is determined in accordance with ICD-9-CM's coding conventions (or rules) as well as general and disease-specific coding guidelines

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IATROGENIC ILLNESS

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illnes that results from medical intervention (e.g., adverse reaction to contrast material injected prior to a scan)

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CODE IN SLANTED BRACKETS

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always reported as secondary codes because they are manifetations (results) of other conditions.

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EPONYM

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disease (or procedure) named for an individual (e.g., physician who originally discovered the disease, first patient diagnosed with the disease).

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ESSENTIAL MODIFIERS

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subterms that are indented below the main term in alphabetical order (except for "with" and "without"); clarifies the main term and must be contained in the diagnostic statement for the code to be assigned

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MAIN TERMS

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condition printed in boldface type and followed by the code number

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NEC (NOT ELSEWHERE CLASSIFIABLE)

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identifies codes to be assigned when information needed to assign a more specific code cannot be located in the ICD-9-CM coding book

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NONESSENTIAL MODIFIERS

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subterms enclosed in parentheses following the main term that clarify code selection, but do not have to be present in the provider's diagnostic statement

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NOTES

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contained in boxes to define terms, clarify index entries, and list choices for additional digits (e.g., fourth and fifth digits)

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SEE

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directs the coder to a more specific term under which the code can be found

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SEE ALSO

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refers the coder to an index entry that may provide additional information to assign the code.

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SEE ALSO CONDITION

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directs the coder to the condition in the index (because the coder referenced an anatomic site, etc.)

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SEE CATEGORY

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directs the coder to a specific three-digit category code in the Tabular List of Diseases for code assignment

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SUBTERM

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essential modifiers that qualify the main term by listing alternate sites, etiology, or clinical status.

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CODE ALSO ANY SYNCHRONOUS PROCEDURES

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refers to operative procedures that are to be coded to completely classify a procedure.

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OMIT CODE

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term that identifies procedures or services that may be components of other procedures; this instruction means that the procedure or service is not coded.

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AND

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when two disorders are separated by the word "and", it is interpreted as "and/or" and indicates that either of the two disorders is associated with the code number

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BOLD TYPE

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all category and subcategory codes and descriptions are printed in bold type

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BRACES

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enclose a series of terms, each of which modifies the statement located to the right of the brace

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BRACKETS

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enclose synonyms, alternate wording, or explanatory phrases

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CATEGORY

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printed in bold upper-and lowercase type and are preceded by a three-digit code

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CODE FIRST UNDERLYING DISEASE

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appears when the code referenced is to be sequenced as a secondary code; the code, title, and instructions are italicized

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COLON

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used after an incomplete term and is followed by one or more modifiers (additional terms)

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EXCLUDES

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directs the coder to another location in the codebook for proper assignment of the code

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FORMAT

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all subterms are idented below the term to which they are linked; if a definition or disease requires more than one line, that text is printed on the next line further indented

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FOURTH AND FIFTH DIGITS

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create ICD-9-CM subcategory and subclassification codes, respectively. (In the ICD-9-CM Tabular List of Procedures, third and fourth digits create ICD-9-CM subcategory and subclassification codes, respectively

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INCLUDES

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includes notes appear below a three-digit category code description to further define, clarify, or provide an example.

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MAJOR TOPIC HEADING

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printed in bold uppercase letters and followed by a range of codes enclosed in parentheses.

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NOT OTHERWISE SPECIFIED (NOS)

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indicates that the code is unspecified; coders should ask the provider for an more specific diagnosis before assigning the code.

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PARENTHESES

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enclose supplementary words that may be present or absent in the diagnostic statement, without affecting assignment of the code number

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SUBCATEGORY

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indented and printed in the same fashion as the major category headings

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SUBCLASSIFICATION

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requires the assignment of a fifth digit

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USE ADDITIONAL CODE

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indicates that a second code is to be reported to provide more information about the diagnosis

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WITH

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when codes combine one disorder with another (e.g., code that combines primary condition with a complication), the provider's diagnostic statement must clearly indicate that both conditions are present and that a relationship exists between the conditions

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INDE TO PROCEDURE AND TABULAR LIST OF PROCEDURES (VOLUME 3) (ICD-9-CM)

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included only in the hospital version of commercial ICD-9-CM; is a combined alphabetical index and numerical listing of inpatient procedures

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INDEXING

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cataloging diseases and procedures by code number

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INJURY

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traumatic wound or damage to an organ

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LATE EFFECT

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residual effect or sequela of a previous acute illness, injury, or surgery

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LESION

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any discontinuity of tissue (e.g., skin or organ) that may or may not be malignant.

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LIST OF THREE-DIGIT CATEGORIES

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found in Appendix E of ICD-9-CM; contains a breakdown of three-digit category codes organized beneath section headings.

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MALIGNANT

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cancerous

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METASTASIZE

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the spread of cancer from primary to secondary sites

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METASTATIC

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descriptive term that indicates a primary cancer has spread to another part of the body

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MORBIDITY

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pertaining to illness or disease

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MORPHOLOGY

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indicates the tissue type of a neoplasm; though M codes are not reported on provider office claims, they are reported to state cancer registries

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MORPHOLOGY OF NEOPLASMS (M CODES)

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Appendix A of ICD-9-CM; contains a reference to the World Health Organization publication entitled International Classification of Diseases for Oncology (ICD-O)

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MORTALITY

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pertaining to death

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NATIONAL CENTER FOR HEALTH STATISTICS (NCHS)

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one of the U.S. Department of Health and Human Services agencies responsible for overseeing all changes and modifications to the ICD-9-CM

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NEOPLAMS

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new growth, or tumor, in which cell reproduction is out of control

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OUTPATIENT

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person treated in one of three settings; health care provider's office; hospital clinic, emergency department, hospital same-day surgery unit, or ambulatory surgical center (ASC) where the patient is released within 23 hours; or hospital admission solely for observation where the patient is released after a short stay

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PERINATAL CONDITION

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occurs before birth, during birth, or within the perinatal period

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PERINATAL PERIOD

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first 28 days of life

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POISONING

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occurs as the result of an overdose, wrong substance administered or taken, or intoxication (e.g., combining prescribed drugs with nonprescribed drugs or alcohol)

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PREADMISSION TESTING (PAT)

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completed prior to an inpatient admission or outpatient surgery to facilitate the patient's treatment and reduce the length of stay

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PRIMARY MALIGNANCY

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original cancer site

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PRINCIPAL DIAGNOSIS

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condition determined, after study, that resulted in the patient's admission to the hospital

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PRINCIPAL PROCEDURE

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procedure performed for definitive treatment rather than diagnostic purposes; one performed to treat a complication; or that which is most closely related to the principal diagnosis

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QUALIFIED DIAGNOSIS

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working diagnosis that is not yet proved or established

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RE-EXCISION

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occurs when the pathology report recommends that the surgeon perform a second excision to widen the margins of the original tumor site

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SECONDARY DIAGNOSES

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also called concurrent condiotion or comorbidity; coexists with the primary condition, has the potential to affect treatment of the primary condition, and is an active condition ofr which the patient is treated or monitored

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SECONDARY MALIGNANCY

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tumor has metasized to a secondary site, either adjacent to the primary site or to remote region of the body

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SECONDARY PROCEDURE

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additional procedure performed during the same encounter as the principal procedure

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SEQUELAE

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late effects of injury or illness

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TABULAR LIST OF DISEASES (VOLUME 1)

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contains 17 chapters that classify diseases and injuries, two supplemental classifications, and five appendices

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UNCERTAIN BEHAVIOR

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it is not possible to predict subsequent morphology or behavior from the submitted specimen

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UNSPECIFIED NATURE

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neoplasm is identified, but no further indication of the histology or natur of the tumor is reflected in the documented diagnosis

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V CODE

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located in the Tabular List of Diseases and assigned for patient encounters when a circumstance other than a disease or injury is present.