ICD 10 – Space – Flashcards
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ICD stands for:
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international classification of diseases
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lists diseases and codes according to a system copyrighted by the World Health Organization of the United Nations. is used to code and classify morbidity data from patient medical records, physician offices, and surveys conducted by the National Center for Health Statistics.
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ICD
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an ICD-10-CM diagnosis code has between _____ and _____ alphanumeric characters. the system is built on categories for diseases, injuries, and symptoms.
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three and seven
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an acronym that stands for general equivalence mappings.
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GEMs
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addenda to codes are released:
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regularly and must be followed as of the date they go into effect.
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ICD-10-CM has to major parts that are used in medical practices:
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the tabular list and the alphabetic index
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the alphabetic index has three additional sections:
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the neoplasm table, the table of drugs and chemicals, and the index to external causes.
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contains all the medical terms in the tabular list classifications, for some conditions it also lists common terms that are not found in the tabular list, is organized by condition.. not by the anatomical site.
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the alphabetic index
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the assignment of the correct code begins with looking up the ____________ term that describes the patients condition based on the diagnostic statement.
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medical term/ the main term first ( what is bolded)
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a word that identifies a disease or condition in the alphabetic index. each term appears in boldface type and is followed by its default code.
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main term
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a word or phrase that describes a main term in the alphabetic index. it may show etiology of the disease, describe a particular type or body site for the main term.
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sub term
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are for main terms or subterms shown in parentheses on the same line, they are supplementary terms that are essential to the selection of the correct code. they help point to the correct term.
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nonessential modifiers
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example: when there is a entry for flu, with a cross reference to influenza.
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common terms
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condition or procedure named for a person such as the physician who discovered or invented it; some are named for patients. usually listed both under that name and under the main term disease or syndrome. EXAMPLE hodgkins disease appears as a subterm under disease and as a key term.
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eponyms
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a guide for coding other syndromes.
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alphabetic index
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are used when many nonessential modifiers appear, they are always indented farther to the right than are sub terms, it is important to read carefully to distinguish from a sub term line.
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turnover lines
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an example of this is if "see" appears after a main term, the coder must look up the term that follows the word "see" in the index. the "see" reference means that the main term where the coder first looked is not correct; another category must be used.
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cross reference
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another type of cross reference, points the coder to additional, related index entries. with the word category added to it, it indicates that the coder should review the additional categories that are mentioned.
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see also
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what does NEC mean?
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not elsewhere classifiable
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means that there is no code that is specific for the condition, this abbreviation means that no code matches the exact situation.
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NEC
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abbreviation meaning unspecified, indicates that the code to be located in the tabular list should be used when a condition is not completely described in the medical record.
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NOS
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some conditions may require two codes, one for the ________ and a second for the ________.
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etiology, manifestation
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the disease's typical signs , symptoms, or secondary processes. this requirement is indicated when two codes, the second in brackets, appear after a term.
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manifestation
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the use of this in the alphabetic index around a code means that it cannot be the first listed code in coding a diagnostic statement; these codes are listed after the codes or the etiology.
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brackets
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may indicate the need for two codes or for a single code that covers both conditions.
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the use of connecting words such as due to, during, following, with
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when the alphabetic index indicates the possible need for two codes, the tabular list entry is used to determine:
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whether in fact they are needed.
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describing both the etiology and the manifestation is available instead of two codes. may also exist that classify two diagnoses or a diagnosis with an associated complication.
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combination code
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what type of term is Pompe's disease ?
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eponym, because it is named after a person.
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word meaning to count, record, or list systematically.
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tabulate
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the diseases in the tabular list are organized into chapters according to:
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etiology, body system, or purpose
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a three character alphanumeric code that covers a single disease or related condition.
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category
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a four or five character alphanumeric subdivision of a category. shows the diseases etiology, site, or manifestation.
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sub category
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a code, the smallest division, has how many alphanumeric characters?
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3, 4, 5, 6, or 7
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the first character in a code is always a ________
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letter
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a valid code has to have at least ________. each character beyond the category level provides greater specificity to the codes meaning.
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three characters
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used in some codes when a fifth, sixth, or seventh digit character is required but the digit space to the left is empty.
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place holder, dummy character designed as "X"
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is usually required to specify the sequence of the visit. must always be in the position of the number it is of the alphanumeric code, so if the code is not at least six characters long, the placeholder character must"X" must be used to fill that empty space.
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seventh character
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are headed by the word includes and refine the content of the category appearing above them.
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inclusion notes
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are headed by the word excludes and indicate conditions that are not classifiable to the code above. two types of exclusion notes are used.
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exclusion notes
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is used when two conditions could not exist together, such as an acquired and a congenital condition; it means ' not coded here'
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excludes 1
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means ' not included here' but a patient could have both conditions at the same time.
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excludes 2
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indicates an incomplete term. one or more of the entries following it is required to make a complete term. when it is used the diagnostic statement must include one of the terms after the colon to be assigned a code from the particular category. HAS TO BE DIAGNOSIS
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colon (:)
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are used around descriptions that do not affect the code- that is, nonessential, supplementary terms. DOES NOT HAVE TO BE IN A DIAGNOSES
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parentheses ( )
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are used around synonyms, alternative wordings, or explanations. they have the same meaning as parentheses.
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brackets
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addresses multiple codes for conditions that have both an underlying etiology and manifestations is indicated I the tabular list by some phrases that contain instructions about the need for additional codes. the phrase point to situations in which more than one code is required.
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convention
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may be followed by the instruction use an additional code or a note saying the same thing. the order of the codes must be the same as shown in the alphabetic index: it comes first, followed by the manifestation code.
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etiology code
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appears below a manifestation code that must not be used as a first listed code. these codes are for symptoms only, never for causes.
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code first underlying disease
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appears when ICD 10 CM requires assignment of codes for health factors such as tobacco used and alcohol use.
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"use additional code "note
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provides a coding structure based on the concept of laterality. it is the idea that the classification system should capture the side of the body that is documented for a particular condition.
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tabular lists
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means a preference for one side of the body, like left handedness. when the affected side of the condition is not known, an unspecified code is assigned.
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laterality
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if condition is documented this way, but there is no appropriate code for it (that is, both) two codes for the left and right sides are assigned.
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bilateral
