ICD 10 – Space – Flashcards

Unlock all answers in this set

Unlock answers
question
ICD stands for:
answer
international classification of diseases
question
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.
answer
ICD
question
an ICD-10-CM diagnosis code has between _____ and _____ alphanumeric characters. the system is built on categories for diseases, injuries, and symptoms.
answer
three and seven
question
an acronym that stands for general equivalence mappings.
answer
GEMs
question
addenda to codes are released:
answer
regularly and must be followed as of the date they go into effect.
question
ICD-10-CM has to major parts that are used in medical practices:
answer
the tabular list and the alphabetic index
question
the alphabetic index has three additional sections:
answer
the neoplasm table, the table of drugs and chemicals, and the index to external causes.
question
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.
answer
the alphabetic index
question
the assignment of the correct code begins with looking up the ____________ term that describes the patients condition based on the diagnostic statement.
answer
medical term/ the main term first ( what is bolded)
question
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.
answer
main term
question
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.
answer
sub term
question
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.
answer
nonessential modifiers
question
example: when there is a entry for flu, with a cross reference to influenza.
answer
common terms
question
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.
answer
eponyms
question
a guide for coding other syndromes.
answer
alphabetic index
question
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.
answer
turnover lines
question
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.
answer
cross reference
question
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.
answer
see also
question
what does NEC mean?
answer
not elsewhere classifiable
question
means that there is no code that is specific for the condition, this abbreviation means that no code matches the exact situation.
answer
NEC
question
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.
answer
NOS
question
some conditions may require two codes, one for the ________ and a second for the ________.
answer
etiology, manifestation
question
the disease's typical signs , symptoms, or secondary processes. this requirement is indicated when two codes, the second in brackets, appear after a term.
answer
manifestation
question
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.
answer
brackets
question
may indicate the need for two codes or for a single code that covers both conditions.
answer
the use of connecting words such as due to, during, following, with
question
when the alphabetic index indicates the possible need for two codes, the tabular list entry is used to determine:
answer
whether in fact they are needed.
question
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.
answer
combination code
question
what type of term is Pompe's disease ?
answer
eponym, because it is named after a person.
question
word meaning to count, record, or list systematically.
answer
tabulate
question
the diseases in the tabular list are organized into chapters according to:
answer
etiology, body system, or purpose
question
a three character alphanumeric code that covers a single disease or related condition.
answer
category
question
a four or five character alphanumeric subdivision of a category. shows the diseases etiology, site, or manifestation.
answer
sub category
question
a code, the smallest division, has how many alphanumeric characters?
answer
3, 4, 5, 6, or 7
question
the first character in a code is always a ________
answer
letter
question
a valid code has to have at least ________. each character beyond the category level provides greater specificity to the codes meaning.
answer
three characters
question
used in some codes when a fifth, sixth, or seventh digit character is required but the digit space to the left is empty.
answer
place holder, dummy character designed as "X"
question
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.
answer
seventh character
question
are headed by the word includes and refine the content of the category appearing above them.
answer
inclusion notes
question
are headed by the word excludes and indicate conditions that are not classifiable to the code above. two types of exclusion notes are used.
answer
exclusion notes
question
is used when two conditions could not exist together, such as an acquired and a congenital condition; it means ' not coded here'
answer
excludes 1
question
means ' not included here' but a patient could have both conditions at the same time.
answer
excludes 2
question
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
answer
colon (:)
question
are used around descriptions that do not affect the code- that is, nonessential, supplementary terms. DOES NOT HAVE TO BE IN A DIAGNOSES
answer
parentheses ( )
question
are used around synonyms, alternative wordings, or explanations. they have the same meaning as parentheses.
answer
brackets
question
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.
answer
convention
question
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.
answer
etiology code
question
appears below a manifestation code that must not be used as a first listed code. these codes are for symptoms only, never for causes.
answer
code first underlying disease
question
appears when ICD 10 CM requires assignment of codes for health factors such as tobacco used and alcohol use.
answer
"use additional code "note
question
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.
answer
tabular lists
question
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.
answer
laterality
question
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.
answer
bilateral
Get an explanation on any task
Get unstuck with the help of our AI assistant in seconds
New