Chapter 6 ICD-10 Coding

IDC-10-CM Terms and Definitions

adverse effect

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

carcinoma in situ

a malignant tumor that is localized, circumscribed, encapulated, and has not spread to deeper or adjacent tissues or organs

coding conventions (IDC-10-CM)

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

“and”

indicates that either of the two disorders is associated with a particular code number

brackets

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

code also

tabular list: indicates two codes may be required to fully describe a condition with sequencing depending on circumstances of the encounter

code first underlying disease

appears when the code referenced is to be sequenced as a secondary code; the underlying disease that necessitates the manifestation code should be listed first in the coding sequence.

code, if applicable, any casual condition

requires casual condition to be sequenced first if present; a casual condition is a disease that manifests another condition

colon

used after an incomplete term and is followed by one or more modifiers

default code

listed next to a main term in the ICD-10-CM alphabetic index and represents the condition most commonly associated with that term.

due to

located in the index in alphabetical order to indicate the presence of a cause-and-effect relationship between two conditions

eponyms

diseases and procedures named for people, such as Barlow’s disease.

Excludes1 note

a “pure” excludes, which means “not coded here” and indicates that the excluded condition is not part of the condition being coded and should not be reported together.

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 excluded codes together if supported by medical documentation

“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 patients record. ICD-10-CM classifies certain conditions as if there was a cause and effect relationship present because they occur together much of the time

“in” diseases classified elsewhere

indicates that the 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)

means “other” or “other specified” and identifies codes that are assigned when information needed to assign a more specific code cannot be located.

NOS (not otherwise specified)

indicates that the code is unspecified; coders should ask the provider for a more specific diagnosis before assigning the code.

“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.

parentheses

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

placeholder

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

“see”

cross reference that provides direction to a different index main term or mainterm and subterm

Table of Drugs and Chemicals

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

Table of Neoplasms

alphabetical index of anatomic sites for which there are six possible codes according to whether the neoplasm in question is malignant, benign, in situ, of uncertain behavior, or of unspecified nature

unspecified codes

when patient record documentation is insufficient to assign a more specific code, this is assigned

use additional code

indicates that a second code is to be reported to provide more information about the diagnosis

with

when codes combine one disorder with another, the provider’s diagnostic statement must clearly indicate that both conditions are present and that a relationship exists between the conditions

comorbidity

concurrent condition that coexists with first listed diagnosis, has the potential to affect treatment of the first-listed 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

CAC

computer aided coding

computer-assisted coding

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 involves two adjacent sites

Cooperating Parties for ICD-10-CM

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

encoder

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

essential modifier

“see subterm”

evidence-based coding

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

first-listed diagnosis

reported on outpatient claims; it reflects the reason for the encounter, and is often a sign or symptom

Diagnostic Coding and Reporting Guidelines for Outpatient Services

outpatient diagnoses that are approved for coding hospital based outpatient services or provider based office visits

Index to Diseases and Injuries

listing of terms and corresponding codes for illnesses or injury, eponyms, etc.

Index of External Causes of Injury

secondary codes that capture how the injury or health condition happened, intent, and environment of the patient.

Guidelines for Coding and Reporting

rules made to accompany and complement coding conventions and instructions provide, HIPPA mandates adherence to this

Tabular List of Diseases and Injuries

Chronological List of codes contained within 22 chapters, which are based on body system or condition

main term

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

nonessential modifier

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

primary malignancy

original cancer site

principal diagnosis

condition determined, after study, that resulted in the patients 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 diagnosis

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 late effects of injury or illness

subterm

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

trust the index

concept that inclusion terms listed below codes in the tabular list are not meant to be exhaustive, and additional terms found only in the index may also be assigned to a code

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 manufacturers instruction

unspecified nature

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