ICD-10-CM Coding Fundamentals Flashcards

Vocabulary terms and definitions based on an introductory lecture on ICD-10-CM coding conventions, general guidelines, and chapter-specific rules.

Computer Assisted Coding (CAC)

Software, often called encoders, utilized to assist in the coding process.

Encoder

A common computer tool used to assist in coding; however, a coder must know how to code manually first to identify errors in its output.

Documentation

The essential record that provides all details about a patient, location, and facility; in coding, if it was not documented, it did not happen.

Granularity

The level of detail in a code, referring to coding to the highest level of specificity.

Laterality

The specification of which side of the body is affected, such as right, left, or bilateral.

Category Code

The main three-digit level of a code which provides specific guidelines, notes, and instructional terms for a group of codes.

Placeholder X

A convention used to fill empty character spaces to allow for the placement of a seventh character when a code does not have six characters.

Excludes 1

A coding convention meaning 'not coded here,' representing that one code is used or the other, but never both.

Excludes 2

A coding convention meaning 'not included here,' indicating the patient may have both the condition identified by the code and the condition in the note.

Main Term

The word used to begin a search in the Alphabetic Index, usually representing the patient's condition or disease rather than an anatomical site.

Default Code

The code listed directly next to the main term in the Alphabetic Index, representing the condition most commonly associated with that term.

See

An instructional term in the index indicating that another term must be referenced to find the correct code.

See Also

An instructional term in the index suggesting that another term may provide a better option for the specific condition documented.

Brackets [ ]

Punctuation used in the Tabular List to include synonyms or alternative wording, and in the Alphabetic Index to identify manifestation codes.

Dual Code Assignment

The requirement to use two codes to fully describe a condition, often involving an underlying disease and a resulting manifestation.

Sequela

A late effect or residual condition that remains after the acute phase of an illness or injury has ended.

Z codes

Codes found in Chapter 21 used for factors influencing health status and contact with health services, such as homelessness or history of a disease.

Combination Code

A single code used to classify two diagnoses, or a diagnosis with an associated secondary process or complication.

Code First

An instructional note at the manifestation code indicating that the underlying condition must be sequenced as the principal diagnosis.

B20

The ICD-10-CM code for Human Immunodeficiency Virus [HIV] disease, assigned only when the condition is documented as confirmed.