Medical Coding

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NOS Not otherwise specified

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equivalent of unspecified and is used only when you lack the information necessary to code to a more specific diagnosis.

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NEC Not elsewhere classifiable

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provide a code specific for the patient’s condition. Selecting a code with the NEC classification means that the provider documented more specific information regarding the patient’s condition, but there is not a code in ICD-10-CM to report the condition accurately.

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[ ]Brackets

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used in the Tabular List to enclose synonyms, alternate wording, or explanatory phrases.

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( )Parentheses

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enclose supplementary words that may be present or absent in the statement of a disease or procedure, without affecting the code number to which it is assigned

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: COLON

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used in the Tabular List after an incomplete term that needs one or more of the modifiers that follow to make it assignable to a given category.

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"Other" codes

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(usually with an 8 or a 9 as the last character) are used when the information in the medical record provides detail for which a specific code does not exist.

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"Unspecified " code

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(usually with a 9 or a 0 as the last ­character) are used when the information in the medical record is not available for coding more specifically.

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"Includes" note

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appears immediately under a three-character code title to define further, or to give an example of the contents of the category.

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"excludes 1" note

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represents not coded here. This note indicates that the code excluded should not be used at the same time as the code above the Excludes1

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excludes 2 note

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represents “Not included here.” A type 2 excludes note indicates that the condition excluded is not part of the condition represented by the code, but a patient may have both conditions at the same time. When a type 2 excludes note appears under a code, it is acceptable to use both the code and the excluded code together when both conditions exist

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additional code

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should be used after a primary code, if the information is available, to provide a more complete picture of the diagnosis.

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"Code first" note

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the note indicates two codes are needed to report a condition and requires that the underlying disease (etiology) be recorded first

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additional code

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causal condition note indicates that this code may be assigned as a diagnosis when the causal condition is unknown or not applicable.

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eponym

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is a disease or syndrome named after a person. An example is Lou Gehrig’s disease, which also is known as amyotrophic lateral sclerosis (ALS)

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Modifiers

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modifiers are subterms indented two spaces and listed in alphabetical order below the main term

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Nonessential modifiers

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are subterms that follow the main term and are enclosed in parentheses

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Notes

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Used to define terms, clarify information, or list choices for additional characters in the Tabular List

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Default Code

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default code represents that condition is the most commonly associated with the main term or is the unspecified code for the condition

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.- Point Dash

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after certain codes. This indicates that the code is incomplete, and you must go to that category or subcategory of codes to complete that code.

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Acute and Chronic

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acute and a chronic condition are documented, and there is a separate code for each, report both codes. The acute code is sequenced first.

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Combination Code

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used to fully identify an instance in which two diagnoses, or a diagnosis with an associated secondary process (manifestation) or complication, are included in the description of a single code

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sequela

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is the residual effect (condition produced) after the acute portion of an illness or injury has terminated. There is no time limit on when a sequela code can be used.

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Impending or Threatened Condition

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subterm impending or threatened under the main term of the condition. If a subterm does not exist, reference Impending or Threatened as the main term, with the condition as a subterm. If a suitable code does not exist, report the signs and symptoms that led the provider to suspect an impending or threatened condition

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Laterality

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If no bilateral code is provided and the condition is bilateral, assign separate codes for both the left and right side.

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Complications of Care

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condition changes the course of the surgery, then it would be appropriate to report a complication code. If you are uncertain as to the relationship between the condition and the surgery or medical care, query the provider.

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Borderline Diagnosis

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not the same as uncertain diagnoses. Borderline diagnoses are coded as confirmed diagnoses unless there is an index entry of borderline for that classification.

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Use of Sign/Symptom/Unspecified Codes

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When sufficient clinical information is not known or available about a particular health condition to assign a more specific code, report the appropriate unspecified code.

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Hurricane Aftermath

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The appropriate injury code should be reported first, followed the external cause code

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Chronic diseases

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treated on an ongoing basis may be coded and reported as many times as the patient receives treatment and care for the condition(s).

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Diagnostic Services Only

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sequence first the diagnosis, condition, problem, or other reason for encounter/visit shown in the medical record to be chiefly responsible for the outpatient services provided during the encounter/visit.

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Therapeutic Services Only

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sequence first the diagnosis, condition, problem, or other reason for encounter/visit shown in the medical record to be chiefly responsible for the outpatient services provided during the encounter. Codes for other diagnoses (for example, chronic conditions) may be sequenced as additional diagnoses

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Preoperative Evaluations Only

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Encounter for pre-procedural examinations to describe the pre-operative consultations. Assign a code for the condition to describe the reason for the surgery as an additional diagnosis. Code also any findings related to the pre-operative evaluation.

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Ambulatory Surgery

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code the diagnosis for which the surgery was performed. If the postoperative diagnosis is known to be different from the preoperative diagnosis at the time the diagnosis is confirmed, select the postoperative diagnosis for coding because it is the most definitive.

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Outpatient Prenatal Visits

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For routine outpatient prenatal visits when no complications are present, a code from category Z34 Encounters for supervision of normal pregnancy should be used as a principal diagnosis

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Encounters for General Medical Examinations with Abnormal Findings

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code identifying general exam with abnormal findings as the primary code. The abnormal findings are reported as additional codes.

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Avascular

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—A lack in blood supply, devitalized, necrotic, and nonviable. Specific types include slough and eschar.

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Clean Wound

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—Wound is free of devitalized tissue, purulent drainage, foreign material, or debris.

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Closed Wound Edges

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—Edges of top layers of epidermis have rolled down to cover lower edge of epidermis, so epithelial cells cannot migrate from wound edges; also described as epibole. Presents clinically as sealed edge of mature epithelium; may be hard/thickened; may be discolored (for example, yellowish, gray, white).

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Full-thickness

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—Tissue damage involving total loss of epidermis and dermis and extending into the subcutaneous tissue and possibly into muscle or bone.

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Granulation Tissue—

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The pink/red, moist tissue comprised of new blood vessels, connective tissue, fibroblasts, and inflammatory cells, that fills an open wound when it starts to heal; it typically appears deep pink or red with an irregular, berry-like surface

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Healing Ridge

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—Palpatory finding is indicative of new collagen synthesis. Palpation (feeling or touching) reveals induration (hardening) beneath the skin extending to about one centimeter on each side of the wound

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Nongranulating

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—Absence of granulation tissue, wound surface appears smooth as opposed to granular.

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Sinus Tract—

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Course of tissue destruction. It occurs in any direction from the surface or edge of the wound; and, it results in dead space with potential for abscess formation. It’s also called tunneling

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Slough—

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Soft, moist avascular (devitalized) tissue may be white, yellow, tan, or green; may be loose or firmly adherent

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Undermining—

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Area of tissue destruction extends under the intact skin along the periphery of a wound; commonly seen in shear injuries

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Avascular

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A lack in blood supply, devitalized, necrotic, and nonviable. Specific types include slough and eschar.

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Colles’ Fracture

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A fracture of the wrist at the distal radius. Sometimes the ulnar styloid also is involved.

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Smith’s Fracture

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Similar to a Colles’ fracture, except the bones are displaced toward the palm

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Jones Fracture

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A stress fracture of the fifth metatarsal of the foot.

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Salter-Harris Fracture—

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An epiphyseal plate fracture; a common injury seen in children.

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Dupuytren’s Fracture—

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Fracture of the distal fibula with rupture of the distal tibiofibular ligaments and lateral displacement of the talus.

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Monteggia’s Fracture

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Fracture of the proximal third of the ulna with associated dislocation of the radial head.

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calcaneal fracture

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Heel fracture

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Subluxation

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is a partial or incomplete dislocation of the joint.

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Dislocation

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is a complete dislocation of the joint.

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Comminuted

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The bone is crushed or splintered into several pieces.

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Compression

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The bone is compressed onto another bone caused by trauma or osteoporosis and common in vertebrae

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Depressed

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Fracture typically resulting from blunt force trauma to the skull. There is a portion of the bone that is pushed in.

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Type of fracture

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Greenstick

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The bone is broken on one surface and bent on the other

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Torus / Incomplete

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Torus or Incomplete—One side of the bone buckles. This is mostly common in children because of their softer bones.

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Fracture

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Terms that may indicate an open fracture:

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Compound InfectedMissilePunctureWith foreign body

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Impacted

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One part of a bone is driven forcefully into another.