Appendix A Glossary of Coding Terms

Access Location

Specifies the external site through which the internal organ is reached: skin or mucous membrane and external orifices

Advance Beneficiary Notice (ABN)

A statement signed by the patient when he or she is notified by the provider, prior to a service or procedure being done, that Medicare may not reimburse the provider for the service, wherein the patient indicates that he will be responsible for any charges

Aftercare

Aftercare visit Z codes are used to classify patient care encounters when the initial treatment of a disease has been performed and the patient requires continued care during the healing or recovery period, or for the long term consequences of a disease. The aftercare codes should not be used when the patient continues to receive a current active illness when the diagnosis code is used instead

Alphabetic Index:

Divided into two parts—the Index to Diseases and Injury and the Index to External Causes of Injury.

Within the Index of Diseases and Injury there is a Neoplasm with main terms set in boldface are listed in alphabetical order. Main terms are entries printed in boldface type and flush with the left margin of each column in the Alphabetic Index.

And

the term “and” should be interpreted to mean “and” or “or” when it appears in a code title. The term “and” means the patient may have one or the other of the statements includes in the code title.

Bilateral procedure

A surgical or other procedure that was performed on two sides of the body, that is, on mirror images of the body such as two kidneys, two radial bones, and so on.

It impact ICD-10-PCS procedure coding. If a ___ body part value exists for a particular body part, a single procedure code is assigned using the ___ body part value. If no ____ body part value exists, each procedure is coded separately using the appropriate body part value for right and left.

Body Part

Specific anatomical site where the procedure was performed.

Body part key

List of anatomical terms with the corresponding PCS description that is used for the body part values in the ICD-10-PCS codes

Body system

The second character of a code defines the body system which is the general physiological system or anatomical region involved

Brackets

A punctuation mark ___ found only in the Tabular List of ICD-10-CM to enclose synonyms, alternative wording, or explanatory phrases.

Canceled or Discontinued Surgery

A surgical or other procedure that was started but not completed due to unforeseen circumstances; ___ procedures impacts PCS procedure coding. A procedure may be ___ or ____ b/c of the patient’s deteriorating medical condition during surgery, due to the patient’s choice, due to malfunctioning equipment or the unavailability of staff

Carryover lines

carryover lines appear in the Alphabetic Index to Diseases and are needed on occasion when the number of words that can fit on a single line of print is limited. They are two indents from the preceding line. Code must be careful to avoiding confusing the ___ line with the subterm entries.

Category:

A three-character ICD-10-CM code that represents a single disease entity or a group of similar or closely-related conditions

Centers for Medicare and Medicaid Services (CMS)

The division of the Department of Health and Human Services that is responsible for developing healthcare policy in the United States and for administering the Medicare Program and the federal portion of the Medicaid program maintaining the procedure portion of the ICD-10-PCS

Characters

The seven digits or letters of a code

Classification

a clinical vocabular, terminology, or nomenclature that lists words or phrases with their meanings, provides for the proper use of clinical words as names or symbols, and facilitates mapping standardized terms to broader classifications for administrative, regulatory, oversight, and fiscal requirements

Classification system:

A system for grouping similar diseases and procedures and organizing related information for easy retrieval. A system for assigning numeric or alphanumeric code numbers to represent specific diseases or procedures

“Code Also” note

Note appearing in ICD-10-CM, meaning that two codes may be required to fully describe a condition but this notes does not provide sequencing direction

Code first

An instruction notation found in the ICD-10-CM for categories in which primary tabulation (or first listing of the code) is not intended.

The code, title and instructions are set in italic type to serve as notice not to assign that code as the principal or first listed code.

The note provides sequencing direction and requires listing code for the underlying disease (etiology) first and the code for the manifestation second.

The note will suggest underlying diseases but it is not all-inclusive.

The manifestation codes appear in italicized fonts

Code, if applicable, a causal condition first note

A note indicates that this code may be assigned as a first-listed or principal diagnosis when the cause condition is unknown or not applicable. If the causal condition is known, then the code for that condition should be sequenced as the first-listed or principal diagnosis

Coding

the transformation of verbal descriptions into numbers. The process of assigning numeric or alphanumeric representations to clinical documentation

Coding clinic

A publication issued quarterly by the American Hospital Association and approved by the CMS to give coding advise and direction for ICD-10-CM

Colon

A punctuation mark __ that is used in the Tabular List of ICD10CM after an incomplete term that needs one or more additional terms or modifiers in order to be assigned to a given category or code

Combination codes

One code that describes both the etiology and manifestation of the disease, such as streptococcal pharyngitis, ICd-10-CM code J02.0.

The underlying disease is the streptococcal infection and the manifestation is the pharyngitis

Comorbidity

Defined within the Uniform Hospital Discharge Data Set and within the scope of the Medicare Acute Care Inpatient Prospective Payment System-

an additional dx that describes a pre-existing condition that, because of its presence with a specific principal dx, will cause an increase in the patient’s length of stay

Completeness

In the ICD-10-PCS system, there should be a unique code for all substantially different procedures

Complication

Defined within the UHDDS and within the scope of Medicare Acute Care Inpatient Prospective Payment System-

an additional dx that describes a condition arising after the beginning of hospital observation and treatment and then modifies the course of the patient’s illness or the medical care required

Complication/comorbidities

Illnesses or injuries that coexist with the condition for which the patient is primarily seeking healthcare.

In the new Medicare-severity diagnosis-related groups (MS-DRGs), certain conditions that reflect more serious, resource intensive conditions are described as major complications/comorbidities (MCCs)

Connecting Words:

Subterm in the Alphabetic Index that appear after a main term to indicate a relationship between the main term and an associated condition or etiology

Cooperating Parties for the ICD-10-CM

A group of organizations (American Health Information Management Association, the American Hospital Association, the Centers for Medicare and Medicaid Services, and the National Center for Health Statistics) that collaborates in the development and maintenance of the ICD-10-CM

Current Procedural Terminology, Fourth Edition (CPT)

A comprehensive, descriptive list of terms and numeric codes used for reporting diagnostic and therapeutic procedures and other medical services performed by physicians; published and updated annually by the American Medical Association

Default Code:

the ___ ___ represents the condition that is most commonly associated with the main term, or is the unspecified code for the condition.

If a condition is documented in the medical record without an additional information, such as whether it is acute or chronic, the default code should be assigned

Department of Health and Human Service (HHS)

The cabinet-level federal agency that oversees all the health- and human-services-related activities of the federal government and administers federal regulations

Device

A graft, prostheses, implant, simple, mechanical, or electronic appliance that remains in the patient’s body at the conclusion of the procedure

Device Aggregation Table:

Table in ICD-10-PCS that crosswalks particular device character value definitions for specific root operations in a specific body part to the more general device character value to be used when the root operation covers a wide range of body parts and the device character represents an entire family of devices

Device Keys

Key in ICD-10-PCS that includes brand names and generic names of devices to help the coder determine the PCS device description by referencing the name of the device used during a procedure

Diagnosis

A word or phrase used by a physician to identify a disease from which an individual patient suffers or a condition for which the patient needs, seeks, or receives medical care. All diagnoses affecting the current hospital stay must be reported as part of UHDDS

Diagnosis-related groups (DRGs)

A unit of case-mix classification adopted by the federal government and some other payers as a prospective payment mechanism for hospital inpatients in which disease are placed into groups b/c related diseases and treatments tend to consume similar amounts of healthcare resources and incur similar amounts of cost; in the Medicare and Medicaid programs, one of more than 500 diagnostic classifications in which cases demonstrate similar resource consumption and LOS patterns.

Under the prospective payment system (PPS), hospitals are paid a set fee for treating patients in a single DRG category, regardless of the actual cost of care for the individual.

For fiscal year 2008, Medicare adopted a severity-adjusted diagnosis-related group system called Medicare Severity Diagnosis-Related Groups (MS-DRGs)

Diagnostic and Statistical Manual of Mental Disorders, 5th Edition, Text Revision (DSM-5-TR)

A nomenclature developed by the American Psychiatric Association to standardize the diagnostic process for patients with psychiatric disorders.

Most recent was published in 2022

Disposition of Patient

The destination of the patient upon leaving the hospital

Disproportionate share hospital (DSH)

Healthcare organizations that meet governmental criteria for percentages of indigent patients or hospitals that serve a disproportionate share of low-income patients

Electronic Appliances

materials that assist, monitor, or take the place of or prevent a physiological function

Eponym

A name for a disease, organ, procedure, or body function that is derived from the name of a person, usually a physician or scientist who first identified the condition or devised the object bearing the name. An ___ is capitalized when it is a proper name.

Etiology and Manifestation

A coding convention that requires two codes for situations when one disease produces another condition.

The first disease is considered the etiology and the second condition that it produces is called ___

Excision

Cutting out or off, without replacement, a portion of a body part

Excludes notes

indicates that certain codes ____ from each other are independent of each other.

There are two types of ___ notes designed as Excludes 1 & and Excludes 2 in ICD-10-CM

Excludes1

note that indicates that the conditions listed after it cannot ever be used at the same time as the code above the ___ note

Excludes2

Note that means that two codes are applied when both conditions are present

Expandability

The structure of the ICD-10-PCS codes allows for changes to be made easily by adding values as needed or using existing values to identify new procedures

Expected Payer

The single major source expected by the patient to pay for this bill

Example: Blue Cross/Blue Shield, Medicare, Medicaid, workers’ compensation

External Approach

An approach used when procedures are performed directly on the skin or mucous membrane

Family history

A family history is the identification of a medical condition that is currently or formerly present in a patient’s family member that puts the patient at higher risk of contracting the same condition. The possibility of the patient contracting the same condition may alter the type of treatment the patient receives.

Federal Register

The daily publication of the US Government Printing Office that reports all changes in regulations and federally-mandated standards, including HCPCS and ICD-10-CM codes

Follow-up code:

idenfies the reason for healthcare sergices when the treatment of the patient’s condition is completed, and the patient is undergoing surveillance or a “checkup” to determine if his or her disease-free status continues.

A ____ code means the condition has been fully treated and no longer exists

Grafts and prostheses

Biological or synthetic material that takes the place of all or a portion of a body part

Health Insurance Portability and Accountability Act of 1996 (HIPAA)

The federal legislation enacted to provide continuity of health coverage, control fraud and abuse in healthcare, reduce healthcare costs, and guarantee the security and privacy of health information; limits exclusion for preexisting medical conditions, prohibits discrimination against employees and dependents based on health status, guarantees availability of health insurance to small employers, and guarantees renewability of insurance to all employees regardless of size; also known as Public Law 104-191 and the Kassebaum-Kennedy Law

Histology

The study of cell structures under a microscope. Certain neoplasms are identified by the histologic name of the cell structures, for example, oat cell carcinoma of the lung

Hospital Identification

The unique number assigned to each institution

ICD-10-CM Coordination and Maintenance (C&M) Committee:

Composed of representatives from the National Center for Health Statistics (NCHS) and the CMS that is responsible for maintaining the United States’ clinical modification version of the ICD-10-CM code sets; holds open meetings that serve as a public forum for discussing (but not making decisions about) proposed revisions to ICD-10-CM

Implant

Therapeutic material that is not absorbed, eliminated, or incorporated into a body part

Includes note

used throughout the ICD-10-CM, the Tabular List, to further define or provide an example of a three character code.

They are not exhaustive; that is, not every synonym or similar condition may be listed.

They appear at the beginning of a chapter, section or directly below a category or subcategory code

Inclusion terms:

they are lists of medical diagnoses under some codes in the tabular list.

These are conditions for which the code is to be used. These terms may be synonyms of the code title or the terms are a list of various conditions assigned to “other specified” codes.

The inclusion terms are not an exhaustive list of terms. Additional terms found only in the Alphabetical Index may also be assigned to the code

Index

Provides an alphabetic listing of procedure titles in ICD-10-PCS

Indiscriminate multiple coding rules

coding guidelines and rules that identify when multiple codes should or should not be used

ICD-9-CM

A coding and classification system used in the US to report dx in all healthcare settings and inpatient procedures and services as well as morbidity and mortality information

ICD-10-CM

The replacement for ICD-9-CM vol 1 & 2, developed to contain more codes and allow greater specificity.

Will be used for dx coding in all types of healthcare facilities and ambulatory settings

International Classification of Diseases, 10th Revision, Procedure Coding System

A separate procedure coding system taht replaces ICD-9-CM vol 3, intended to improve coding accuracy and efficiency, reduce training effort, and improve communication with physicians.

Will be used for inpatient hospital procedures coding

Instrumentation

Specialized equipment used to perform a procedure on an internal body part

Laterality

Right or left side

Main Terms

Entries printed in boldface type and flush with the left margin of each column with Vol 2, the Alphabetic Index to Diseases and Injuries

Represents: (1) diseases (2) conditions (3) nouns and (4) adjectives

The first place in ICD-10-CM that the coder uses to locate the ICD-10-CM code for the patient’s disease, condition, or procedure to be classified. Within ICD-10-PCS, the Index to Procedures, main terms identify the type of procedure performed

Medical Necessity

1. the likelihood that a proposed healthcare service will have a reasonable beneficial effect on the patient’s physical condition and quality of life at a specific point in his or her illness or lifetime

2. Healthcare services and supplies that are proven or acknowledged to be effective in the dx, txt, cure, or relief of a health condition, illness, injury, disease, or its sx and to be consistent with the community’s accepted standard of care. Only those services, procedures, and patient care warranted by the patient’s condition are provided.

3. The concept that procedures are only reimbursed as a covered benefit when they are performed for a specific dx or at a specified frequency

Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003

The federal legislation that includes language concerning the timeliness of data collection and contains information about the updating of ICD-10-CM twice a year, if needed, on April 1, as well as the traditional Oct 1st for ICD-10-CM code changes

Medicare-Severity Diagnosis-Related Groups (MS-DRGs)

For fiscal year 2008, Medicare adopted this system.

This was the most drastic revision to the DRG system in 24 years.

Medicare’s goal with the new MS-DRG system was to significantly improve Medicare’s ability to recognize severity of illness in its inpatient hospital payments.

The new system is projected to increase payments to hospitals for services provided to the sicker patients and decrease payments for treating less severely ill patients

Method of Approach

The surgical technique used to reach the operative site

Morphology

The study of the physical shape or size of a specimen, plant, or animal.

In medicine the term morphology is also used to describe neoplasms, that is, the form and structure of the tumor in the organ.

Multiaxial

The ability of a nomenclature to express the meaning of a concept across several axes as is true in ICD-10-PCS

National Center for Health Statistics (NCHS)

The federal agency responsible for collecting and disseminating information on health service utilization and the health status of the population in the United States; responsible for the use of ICD-10 in the US and developed the clinical modification to the ICD-10 and is responsible for updating the dx portion of the ICD-10-CM

National Uniform Billing Committee (NUBC)

The national group responsible for identifying data elements and designing the CMS-1450 claim form or the Uniform Bill-04 (UB-04)

NEC

An abbreviation of “not elsewhere classified” this abbreviation in the Alphabetic Index represents “other specified”

When a specific coe is not available for a condition, the Alphabetic Index directs the coder to the “other specified” code in the Tabular List.

Nonessential modifiers

A series of terms in parentheses that sometimes directly follow main terms and subterms in the Alphabetic Index to Diseases of ICD-10-CM.

The presence or absence of these parenthetical terms in the diagnosis has no effect on the selection of the codes listed for that main terms or subterm

NOS

An abbreviation of “not otherwise specified”

The equivalent of unspecified. It is used in the Alphabetic Index and the Tabular list. Codes describing “not otherwise specified” conditions or procedures are assigned only when the diagnostic statement, as well as the health record, does not provide enough information to assign a more specific code.

Official Addendum to ICD-10-CM

The official document that notes the changes made to ICD 10 CM at least on an annual basis, traditionally on Oct 1st of every year but could be updated on April 1st each year as included in MMA 2003.

The NCHS publishes the addendum for the diagnosis classification. The Center for Medicare and Medicaid Services publishes the addendum for the procedure classification

Other diagnoses

Defined in UHDDS as all conditions that coexist at the time of admission, that develop subsequently, or that affect the treatment received or the length of stay.

May also be referred to as additional diagnoses

“Other” and “Other Specified” codes

Codes used in ICD-10-CM when the information in the health record is more descriptive than the available codes in ICD-10-CM

Usually the Alphabetic Index entries with NEC in the line designate “other” codes in the Tabular List

Overlapping lesion:

A primary malignant neoplasm that overlaps two or more sites

Parentheses

A punctuation mark that encloses supplementary words or explanatory information that may or may not be present in the statement of a diagnosis or procedure.

The words within the ___ do not affect the code number assigned to the case.

Terms in ____ are considered nonessential modifiers

Personal history

a ___ is a description of the patient’s past medical condition that no longer exists and for which the patient is not receiving any treatment.

However, the fact that the patient had the condition is important because the condition has the potential for recurrence and the patient may require continued monitoring

Personal identification

The unique number assigned to each physician within the hospital

Place of occurrence code:

a code used to identify the place where an injury occurred.

This code describes the physical location or place where the event occurred, not the patient’s activity at the time of the event

Placeholder

ICD 10 CM uses a ____ character, which is always the letter X, in two ways.

First, the X provides for future expansion without disturbing the overall code structure.

Second, it is used when a coder has fewer than six characters and a seventh character is required to be used with the code.

Present on Admission (POA)

A data element required on the CMS 1450 claim form or the Uniform Bill-04 to be linked with all ICD 10 CM diagnosis codes according to _____ reporting guidelines.

The purpose of the POA indicator is to differentiate between conditions that were present in the patient at the time of admission and the conditions that develop during the inpatient stay

Principal Diagnosis

Defined in UHDDS as the condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care.

The definition is used with ICD 10 CM coding to determine the first-reported dx code

Principal Procedure

The ___ performed for definitive treatment rather than for diagnostic or exploratory purposes or for treatment of a complication.

Definition is included in the UHDDS and used when applying ICD-10-PCS procedure codes.

When more than one procedure meets the criteria for _______, the one most closely related to the principal diagnosis should be selected.

Procedure (surgical or therapeutic)

Any single, separate, systemic process upon or within the body that can be complete in itself; is normally performed by a physician, dentist, or other licensed practitioner; can be performed either with or without instruments; and is performed to restore disunited or deficient parts, remove diseased or injured tissues, extract foreign matter, assist in obstetrical delivery, or aid in dx.

Quality Improvement Organization (QIO)

CMS contracts with one or more organizations in each state or region to serve as that area’s ____.

____ are not-for-profit private organizations staffed by health quality experts, clinicians, and consumers organized to improve the care delivered to people with Medicare.

____ focus is on improving the quality of healthcare by working with medical providers through quality improvement activities.

CMS contracts with a _____ for a five-year period of time with an agreement called a scope of work as to what services the QIO will provide to Medicare beneficiaries or on their behalf

Qualifier

The seventh character of ICD 10 PCS that specifies an additional attribute of the procedure, if applicable

Recovery Audit Contractors (RACs)

Organizations that contract with Medicare to perform reviews of medical records with the corresponding Medicare claim to (1) detect Medicare improper payments, including both underpayments and overpayments; and (2) correct Medicare improper payments

The examination of the ICD 10 CM coding is a major area of focus for the ____ as the dx and procedure codes create the MS-DRG that is the basis of payment for acute care hospitals

ICD 10 CM and CPT coding is other health care organizations—rehab hospitals and units, physician offices— determine reimbursement to the providers and therefore, are a focus of attention during these providers’ review.

Release

freeing a body part from an abnormal physical constraint by cutting or by use of force.

Coded to the body part being freed in ICD 10 PCS

Repair

Restoring, to the extent possible, a body part to its normal anatomical structure and function

It also functions as the “not elsewhere classified (NEC)” root operation and is to be used when the procedure performed does not meet the definition of one of the other root operations in ICD 10 PCS

Reposition

Moving all or a portion of a body part to its normal location or other suitable location in ICD 10 PCs