Icd-10-Cm

Front 1

Medical neccesity

Back 1

1 knowledge of emergent nature or severity of complaint or condition. 2 all signs,symptoms, complaints, background facts reason for care. 3 facts substantiated by patient's medical record

Front 2

Index to diseases and injuries

Back 2

Alphabetic. Divided into sections organized by main terms: Index to Diseases and Injuries+Neoplasm Table+Table of Drugs and Chemicals+Index to External Causes of Injuries.

Front 3

Main terms

Back 3

In bold. Code listed next to main term is considered default code. Always verify default code in Tabular List.

Front 4

Subterms

Back 4

Add specificity to the main term.

Front 5

Default code

Back 5

Represents the condition most commonly associated with the main term. Always verify in the Tabular List, as with all code assignments.

Front 6

Tabular List

Back 6

Contains 21 chpts and contain categories, subcategories, and codes.

Front 7

Characters

Back 7

The first character of a category is a letter. The second and third may be either numbers or letters.

Front 8

Subcategories

Back 8

Are either four or five characters,letters or numbers.

Front 9

Codes

Back 9

Are either 3,4,5 or 6 characters and the final character may be a letter or number. Some categories have a 7th character.

Front 10

Symbols

Back 10

Throughout Tabular List to identify when a code requires an additional character.

Front 11

Excludes,Includes at beginning of chapters.

Back 11

Apply to entire chapters.

Front 12

Fourth character in code

Back 12

Further defines the site,etiology, and manifestation of the disease or condition. Three characters plus a decimal followed by an additional character to identify condition to the highest level of specificity.

Front 13

5th or 6th character

Back 13

Subclassifications represent the most accurate level of specificity regarding the patient's condition or diagnosis.

Front 14

Applicable 7th character

Back 14

Required for all codes within the category, or as notes in the Tabular List instruct. X,as a placeholder, must be used to fill empty character spaces. Ie: M48.40XA.

Front 15

NEC

Back 15

Not elsewhere classified. Used when system doesn't provide a code specific for patient's condition. Means that provider documented more specific information, but there is no corresponding code.

Front 16

NOS

Back 16

Not otherwise specified = unspecified, used only when Coder lacks information necessary to code to a more specific diagnosis.

Front 17

Brackets

Back 17

Used in Tabular List to enclose synonyms,alternate wording, or explanatory phrases. Used in Index to Diseases and Injuries to identify manifestation codes in which multiple Coding and sequencing will apply.

Front 18

Code in brackets

Back 18

Always sequenced after the code that appears before the brackets.

Front 19

Parentheses

Back 19

Used to enclose supplementary words that may be present orabsent in the statement of a disease or procedure, without affecting the code # to which it is assigned. Nonessential modifiers.

Front 20

: Colon

Back 20

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

Front 21

Other,other unspecified

Back 21

Used when the information in the medical record provides detail for which a specific code does not exist.(8or9 as last character)

Front 22

Unspecified

Back 22

Used when information in medical record is not available for Coding more specifically. Should be selected only when there is no other option. (9 or 0 as last character)

Front 23

Includes note

Back 23

Appears immediately after a 3 character code title to define further,or give an example of the contents of the category.

Front 24

Excludes 1

Back 24

Represents "Not coded here". Indicates that code excluded should not be used at the same time as the code above the note when the two diagnoses are related or can't occur together.

Front 25

Excludes 2

Back 25

Represents "Not included here". Indicates that the condition excluded is not part of the condition represented by the code, but a patient may have both conditions. It is acceptable both the code and the excluded code when both conditions exist.