Chapter 3: ICD-10-CM Introduction

ICD-10-CM Vocabulary Flashcards

ICD-10

International standard diagnostic classification for epidemiology, health management, and clinical use.

Alphabetic Index

Diagnostic terms organized in alphabetic order for diseases in the Tabular List.

Tabular List

Diagnosis codes organized in numerical order, divided into chapters by body system or condition.

Medical Necessity

Establishing medical need is the first step in third-party reimbursement; payers require knowledge of the emergent nature, severity, and signs/symptoms of a patient's condition.

ICD-10-CM

International Classification of Diseases, Tenth Revision, Clinical Modification, developed by the NCHS.

Etiology

The cause of a disease or condition.

Anatomical Site

The location on the body of a disease or injury.

Category Codes

Three-character codes in the Tabular List.

Subcategories

Categories further subdivided with the addition of a decimal point and additional characters.

Extension

The 7th character added to a subcategory.

NEC (Not Elsewhere Classifiable)

Used when ICD-10-CM does not provide a specific code for the patient's condition, but the provider documented more specific information.

NOS (Not Otherwise Specified)

Equivalent to 'unspecified,' used when the coder lacks the information to report a more specific code.

Brackets []

Used in the Tabular List to enclose synonyms, alternate wording, or explanatory phrases; in the Alphabetic Index to indicate multiple codes are required.

Parentheses ()

Used to enclose supplementary words that may be present or absent without affecting the code number (nonessential modifiers).

Boldface

Used for all codes and titles in the Tabular List and main terms in the Alphabetic Index.

Excludes1

Indicates that the condition is not coded here and should not be used at the same time as the code above the note if the conditions are related.

Excludes2

Indicates that the condition is not included here but a patient may have both conditions at the same time.

Includes

Note that appears after a three-character code title to further define or clarify the category.

Use additional code

Signals that an additional code should be used to provide a more complete picture of the diagnosis.

Code first

Instruction used in categories not intended to be the principal diagnosis, requiring the underlying disease (etiology) be recorded first.

Combination code

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

Eponym

A disease or syndrome named after a person.

Essential modifiers

Subterms listed in the Alphabetic Index below the main term in alphabetical order and are indented two spaces.

Nonessential modifiers

Subterms that follow the main term and are enclosed in parentheses; they can clarify the diagnosis but are not required.

Other

Used when the information provides detail for which a specific code does not exist; index entries with NEC in the line designate other codes in the Tabular List.

See

Instruction that directs you to a more specific term under which the correct code can be found.

See also

Indicates additional information is available that may provide an additional diagnosis code.

See category

Indicates that you should review the category specified before assigning a code.

Unspecified

Codes used when the information is not available for coding more specifically and should only be selected when there is no other option.

Laterality

Specifies the side of the body that is affected (right, left, or bilateral).

Sequela (Late Effect)

The residual effect (condition produced) after the acute phase of an injury or illness has terminated. There is no time limit on when a sequela code can be used.

Impending or Threatened Condition

When a patient is discharged with a condition described as impending or threatened, review the Alphabetic Index for the subterm of impending or threatened under the main term of the condition.

CMS

Centers for Medicare & Medicaid Services.

NCHS

National Center for Health Statistics.

DSM-V

Diagnostic and Statistical Manual, Fifth Edition, published by the American Psychiatric Association.

Myocardial Infarction

Heart attack that occurs when blood flow to the heart is blocked.

Overdosing

Taking more of a medication than instructed by a provider.

SDOH

Social Determinants of Health.

VAP

Ventilator-associated pneumonia.