Medical Billing Module 12: Part One

ICD-10-CM Coding

abbreviations

adverse effect

development of a pathologic condition that results from a drug or chemical substance that was properly administered or taken.

and

when two disorders are separated by the word “and,” it is interpreted as “and/or” and indicates that either of the two disorders is associated with the code number.

benign

not cancerous.

boxed notes

defines terms, provides coding instruction, and lists seventh characters as needed.

brackets

used in the index to identify manifestation codes and in the index and tabular list to enclose abbreviations, synonyms, alternative wording, or explanatory phrases.

carcinoma (Ca) in situ

malignant tumor that is localized, circumscribed, encapsulated, and noninvasive (has not spread to deeper or adjacent tissues or organs).

coding conventions (ICD-10-CM)

general coding rules that apply to the assignment of codes, independent of official coding guidelines.

code also

tabular list instruction that indicates two codes may be required to fully describe a condition, and sequencing depends on the circumstances of the encounter.

code first

tabular list instructional note that assists with proper sequencing of codes.

colon

used after an incomplete term and is followed by one or more modifiers (additional terms).

comorbidity

concurrent condition that coexists with the first-listed diagnosis (outpatient care) or principal diagnosis (inpatient care), has the potential to affect treatment of the first-listed diagnosis or principal diagnosis, and is an active condition for which the patient is treated and/or monitored.

complication

condition that develops after outpatient care has been provided or during an inpatient admission.

computer-aided coding (CAC)

see computer-assisted coding (CAC): uses a natural language processing engine to “read” patient records and generate ICD-10-CM and HCPCS/CPT codes.

computer-assisted coding (CAC)

uses a natural language processing engine to “read” patient records and generate ICD-10-CM and HCPCS/CPT codes.

contiguous sites

also called overlapping sites; occurs when the origin of the tumor (primary site) involves two adjacent sites.

Cooperating Parties for ICD-10-CM/PCS

AHA, AMA, CMS, and NCHS organizations and agencies that approve official guidelines for coding and reporting ICD-10-CM and ICD-10-PCS.

cross references

default code

listed next to a main term in the ICD-10-CM index and represents the condition that is most commonly associated with the main term or is the unspecified code for the condition.

due to

index subterm that indicates the presence of a cause-and-effect or causal relationship between two conditions.

encoders

automates the coding process using computerized or web-based software; instead of manually looking up conditions or procedures in the coding manual’s index, the coder uses the software’s search feature to locate and verify diagnosis and procedure codes.

Eponyms

diseases, syndrome, and procedures named for a person.

essential modifiers

see subterm: qualifies the main term by listing alternative sites, etiology, or clinical status; it is indented two spaces under the main term.

etiology and manifestation convention

classification of conditions that have both an underlying etiology and multiple body system manifestations due to the underlying etiology (e.g., code first underlying disease).

evidence-based coding

coding auditor clicks on codes that CAC software generates to review electronic health record documentation (evidence) used to generate the code.

Excludes1 note

appears below codes in the tabular list to direct the coder to another location to classify conditions that are excluded from the code; code either the original code or the code to which the excludes1 note directs you except when the provider documents the existence of both conditions.

Excludes2 note

means “not included here” and indicates that although the excluded condition is not classified as part of the condition it is excluded from, a patient may be diagnosed with all conditions at the same time; therefore, it may be acceptable to assign both the code and the excluded code(s) together if supported by medical documentation.

first-listed diagnosis

reported on outpatient claims (instead of inpatient principal diagnosis); it reflects the reason for the encounter, and it is often a sign or symptom.

in

located in alphabetical order below the main term; to assign a code from the list of qualifiers below the word “in,” the provider must document both conditions in the patient’s record; ICD-10-CM classifies certain conditions as if there were a cause-and-effect relationship present because they occur together much of the time, such as “pneumonia in Q fever.”

in diseases classified elsewhere

indicates that manifestation codes are a component of the etiology/manifestation coding convention.

includes note

appear below certain tabular list categories to further define, clarify, or provide examples.

laterality

ICD-10-CM specifically classifies conditions that occur on the left, right, or bilaterally.

manifestation

condition that occurs as the result of another condition; manifestation codes are always reported as secondary codes.

NEC (not elsewhere classifiable)

equivalent of “other specified”; identifies codes that are to be assigned when information needed to assign a more specific code cannot be located in the coding manual.

NOS (not otherwise specified)

equivalent of “unspecified”; identifies codes that are to be assigned when information needed to assign a more specific code cannot be obtained from the provider.

Other codes

when this word appears in an ICD-10-CM tabular list code description, the code is assigned when patient record documentation provides detail for which a specific code does not exist.

other specified codes

when this phrase appears in an ICD-10-CM code description, the code is assigned when patient record documentation provides detail for which a specific code does not exist.

parentheses

enclose supplementary words that may be present or absent in the diagnostic statement, without affecting assignment of the code number.

placeholder

use of character “X” as a placeholder to allow for future expansion of certain codes; used when a code contains fewer than six characters and a seventh character applies.

see

instructional term that directs the coder to refer to another term in the index.

see also

instructional term that is located after a main term or subterm in the index and directs the coder to another main term (or subterm) that may provide additional useful index entries.

see category

instructional term that directs the coder to the tabular list, where a code can be selected from the options provided there.

see condition

instructional term that directs the coder to the main term in the index for a condition.

Table of Drugs and Chemicals

alphabetical index of medicinal, chemical, and biological substances that result in poisonings, adverse effects, and underdosings.

Table of Neoplasms unspecified codes

when patient record documentation is insufficient to assign a more specific code, this (unspecified) code is assigned.

use additional code

instructional note that assists in proper sequencing of the codes.

with

when codes combine one disorder with another (e.g., code that combines primary condition with a complication), the provider’s diagnostic statement must clearly indicate that both conditions are present and that a relationship exists between the conditions.

ICD-10-CM Diagnostic Coding and Reporting Guidelines for Outpatient Services

developed by the federal government, outpatient diagnoses that have been approved for use by hospitals/providers in coding and reporting hospital-based outpatient services and provider-based office visits.

ICD-10-CM Index to Diseases and Injuries

an alphabetical listing of terms and their corresponding codes, which include specific illnesses, injuries, eponyms, abbreviations, and other descriptive diagnostic terms.

ICD-10-CM Index of External Causes of Injury

arranged in alphabetical order by main term indicating the event; are secondary codes for use in any health care setting; capture how the injury or health condition happened (cause), the intent (unintentional or accidental; or intentional, such as suicide or assault), the place where the event occurred, the activity of the patient at the time of the event, and the person’s status.

ICD-10-CM Official Guidelines for Coding and Reporting

prepared by CMS and NCHS and approved by the cooperating parties for ICD-10-CM/PCS; contain rules that were developed to accompany and complement coding conventions and instructions provided in ICD-10-CM; adherence when assigning diagnosis codes is required under HIPAA.

ICD-10-CM Tabular List of Diseases and Injuries

chronological list of codes contained within 22 chapters, which are based on body system or condition.

ICD-10-CM/PCS Coordination and Maintenance Committee

responsible for overseeing all changes and modifications to ICD-10-CM (diagnosis) and ICD-10-PCS (procedure) codes; discusses issues such as the creation and update of general equivalence mappings (GEMs).

ICD-10-PCS Official Guidelines for Coding and Reporting

prepared by CMS and NCHS and approved by the cooperating parties for ICD-10-CM/PCS; contain rules that were developed to accompany and complement official conventions and instructions provided in ICD-10-PCS; adherence when assigning procedure codes is required under HIPAA.

International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)

coding system to be implemented on October 1, 2015, and used to report diseases, injuries, and other reasons for inpatient and outpatient encounters.

International Classification of Diseases, 11th Revision (ICD-11)

developed by the World Health Organization (WHO) and released in 2018 to begin the implementation process (e.g., translation into languages other than English).

International Classification of Diseases, 10th Revision, Procedure Classification System (ICD-10-PCS)

coding system to be implemented on October 1, 2015, and used to report procedures and services on inpatient claims.

Main terms

bold-faced term located in the ICD-10-CM index; listed in alphabetical order with subterms and qualifiers indented below each main term.

medically managed

diagnosis not directly treated during an encounter but considered when determining a plan of care for other conditions treated during the encounter.

Nonessential modifiers

supplementary words located in parentheses after an ICD-10-CM main term that do not have to be included in the diagnostic statement for the code number to be assigned.

overlapping sites

see contiguous sites: also called overlapping sites; occurs when the origin of the tumor (primary site) involves two adjacent sites.

poisoning: accidental (unintentional)

poisoning that results from an inadvertent overdose, wrong substance administered/taken, or intoxication that includes combining prescription drugs with nonprescription drugs or alcohol.

poisoning: assault

poisoning inflicted by another person who intended to kill or injure the patient.

poisoning: intentional self-harm

poisoning that results from a deliberate overdose, such as a suicide attempt, of substance(s) administered/taken or intoxication that includes purposely combining prescription drugs with nonprescription drugs or alcohol.

poisoning: undetermined

subcategory used if the patient record does not document whether the poisoning was intentional or accidental.

primary malignancy

original cancer site.

principal diagnosis

condition determined, after study, that resulted in the patient’s admission to the hospital.

qualified diagnoses

working diagnosis that is not yet proven or established; reported for inpatient cases only.

qualifiers

supplementary terms in the ICD-10-CM Index to Diseases and Injuries that further modify subterms and other qualifiers.

Secondary diagnoses

coexists with the primary condition, has the potential to affect treatment of the primary condition, and is an active condition for which the patient is treated or monitored.

secondary malignancy

tumor has metastasized to a secondary site, either adjacent to the primary site or to a remote region of the body.

sequela

residual effects of illness, injury, or trauma.

Subterms

qualifies the main term by listing alternative sites, etiology, or clinical status; it is indented two spaces under the main term.

trust the index

uncertain behavior

it is not possible to predict subsequent morphology or behavior from the submitted specimen.

underdosing

taking less of a medication than is prescribed by a provider or a manufacturer’s instruction.

unspecified nature

neoplasm is identified, but no further indication of the histology or nature of the tumor is reflected in the documented diagnosis.