Internship Notes

Front 1

NEC

Back 1

Not elsewhere classified: when in the Alphabetic index to indicate that there is no specific code for the condition even though the diagnostic statement is specific

-used in the alphabetic index and the tabular list

-indicates there is NO separate code for the condition even though the diagnostic statement may be very specific

-OTHER SPECIFIED

-

Front 2

NOS

Back 2

NOT Otherwise Specified; "unspecified"

Front 3

Includes notes

Back 3

"includes"

-the beginning of a chapter

-conditions may be synonyms or conditions similar enough to be classified the same code

Front 4

Excludes notes:

Back 4

"excludes"

-a condition is not assigned to the code to which the note applies or is listed after

"code this condition elsewhere"

Front 5

Excludes 1:

Back 5

NOT CODED HERE

-the code listed should never be used at the same time as the code listed above the note

Front 6

Excludes 2:

Back 6

NOT INCLUDED HERE

-the condition excluded is not part of the condition represented by the code

-the two conditions CAN exist at the same time but the condition should be coding using a different code if they do

Front 7

etiology

Back 7

underlying condition (followed by the manifestation)

Front 8

USe additional code

Back 8

a clue to identify the manifestations commonly associated with the disease

Front 9

Code also

Back 9

indicates that two codes may be required to fully describe a condition but does not provide sequencing direction

Front 10

Cross reference notes:

Back 10

see, see also, see category, see condition

Front 11

See

Back 11

-indicates that the coder must refer to an alternative term

Front 12

see also

Back 12

indicates that there is another place in the alphabetic index to which the coder must refer when the entries under consideration do not provide a code for the specific condition or procedure

Front 13

see category

Back 13

means see category and the coder must go to the tabular list and select a code from the options provided there

Front 14

see condition

Back 14

-refers to the main term of a condition

-example: If a coder references the main term Arterial for arterial thrombosis, the index advice is to "see condition", and the coder should then go to the main term Thrombosis

-usually occurs when the coder has accidentally referenced the adjective, rather than the term for the condition itself

Front 15

Parentheses

Back 15

-nonessential modifiers that are used to suggest that the terms in the parentheses are included in the code but need not be stated in the diagnosis

-the words in the parentheses do not impact the code assignment in any way; they serve only as reassurance that the correct code has been located

Front 16

essential modifiers

Back 16

are listed in the subterms in the Alphabetic index, not in parentheses, and they DO affect code assignment

Front 17

square brackets

Back 17

-often used in the tabular list to enclose synonyms, alternative wordings, abbreviations, and explanatory phrases that provide additional information

-example human immunodeficiency [HIV]

Front 18

Colons

Back 18

:

-used in the tabular list in both inclusion notes and exclusion notes after an incomplete term that needs one or more of the modifiers following the colon in order for the term to apply

Front 19

and

Back 19

means either "and" or "or"