ICD 10 Diagnostic Coding

What is the minimum/maximum number of characters an ICD-10-CM code can have?

3-7 character

What does a category code represent? How many characters are in that code?

Represent a single disease/ condition. 3 Characters 

What does a subcategory code represent? How many characters are in that code?

Codes that provided more specificity than 3 digit codes. 4 character

What does a subclassification code represent? How many characters can be in that code?

Codes that add the most specificity that the manual allows. 5-7 Character. 

What are Main Terms

Identify disease conditions or injuries. Are set flush with the left hand margin and are Pirnted in bold type and begin with a capital letter. 

Subterms

Indicate site, type or etiology.  Are indented one standard indentation to the right of  the main term and are printed in regular type and begin with a lowercase.  

What are More specific sub terms

Are indented farther and farther  right as needed and always indentd by one standard indention from the preceding subterm  

What are Carry over lines

are used only when the complete entry cannot fit on a single line. They are idented two standard indentations from the level of the preceding line.  

What does the convention NEC stand for?  

Not Elsewere Coded. Meaning the manual does  not have a code for the documented condition.( 4^th or 6^th code is ususaly a 8) 

What does the convention [ ] brackets stand for? 

 Its a number in the square bracket that can be a manifestation and must be used as a secondary code.  

What does the convention parenthetical terms refer to?  

Words  in parenthesis after a main term in the index which have no effect on the selection of code

What does the convention essential modifier mean? 

it is a main term tha can be followed  by an indented subterm that does have an effect on the selection of appropriate codes. 

. What does the convention nonessential modifier mean? 

are supplementary terms that are NOT essential to the selection of the correct term. They help point to the correct term,

What does the convention cross-references stand for? Name the different cross references and their 
meanings. 

are used in the alphabetical index to advise the coding professional to look elsewhere before assigning a code. 

What are the different type of cross references ?

See, See also, See category and see condition.

What does see mean in cross reference

indicates that the user must refer to an alternative term 

What does see also mean in cross reference

advise that there is another place in the alphabetic index that must be checked when the entries under consideration do not provide a code for the specific condition or procedure

What does see category mean in cross reference

Provides the three character alpha-numeric identifier for the category  

What does see condition mean

occasionally the index advises the user to refer to the main term of a condition. 

What are eponyms? 

They are diseases, syndromes or procedures that are named after a specific person. Usualy the first person who discovered it. 

What does the convention NOS stand for?  

Not otherwise Specified. Is used when the docuementation  does not supply more specific info in the diagnosis or record to go by. ( 4 or 6^th character is usualy a 9) 

What does the convention : (colon) stand for?  

It is used in the tabular list after an incomplete term that needs one or more of the modifiers folllowing the colon in order for the term to apply. 

What does the convention code first underlying disease mean?

if a condition is a manifestation of another, underlying disease the underlying cause must be coded first

What does the convention includes mean?

It is used to further define or give examples of the content  of the chapater or category.  

What does the convention excludes 1 mean?  

It means not coded here. This means that the coded excluded should never be used at the same time as the code above the exclude 1 note. 

What does the convention excludes 2 mean?

This means not included here. Thuis note instructs that the condition excluded is not part of the condition represented by the code. 

What does the convention use additional code mean? 

This is used as a clue to identify the manifestation disease and the sequencing depens on the circumstances 

In relational terms, how should the terms “and”, “with” and “due to” be interpreted? 

These codes are used to express the relationship betwen the main term and subterm. These words indicate an assoicated condition/ etiology. 

What do Z codes represent; why are they used?  

represent factors infleucing health status and are connected with health serivces that may be recorded as diagnoses

What do V, W, X, Y codes represent; why are they used? 

These codes are used to indicate the external circunmstantes that are responsible for injuries and certain conditions.  

Describe the steps to locating a code in the ICD manual. 

Identify the main term in the diagnostic statement, Locate the main term in the alpa index, Review any suber term under the main term, Follow any cross- reference instructions, Verify the code selected from the alpha index in the tabular listing, Assign the cod to the highest level of specificity and code the diagnosis until all elements are complete identified. 

Should a ruled out condition be coded? 

No it should not be coded because it is no longer probable if it is documented that it has already been ruled out.