Coding Guidelines

Understanding Punctuation and Abbreviations in Medical Coding Dictionaries

This section outlines the specific meanings and uses of various punctuation marks and abbreviations encountered in medical coding references, such as the Tabular List and Alphabetic Index. Understanding these conventions is crucial for accurate code selection and diagnosis validation.

Brackets

• Regular Brackets ( [] ): These are commonly found in the Tabular List.
  • Purpose: They indicate alternate terms or synonyms that can be used interchangeably with the main description.
  • Function: They provide additional detail or explanation to clarify the description of a code.
  • Example: If a diagnosis is listed as "Appendicitis [Inflammation of Appendix]", the brackets clarify that "Inflammation of Appendix" is a synonym for Appendicitis.
• Slanted Brackets ( // ): These are specifically used in the Alphabetic Index.
  • Purpose: They surround an additional code(s) that must be included with the initial code selected.
  • Significance: The code(s) within slanted brackets are mandatory co-codes, meaning they are an integral part of the complete diagnostic coding for that entry.
  • Example: If an entry in the Alphabetic Index leads to a code for a primary condition, and then shows // an additional code // for a manifestation or associated condition, both codes must be assigned.

Parentheses

• Parentheses ( () ): These are used to enclose optional terms.
  • Purpose: They provide additional descriptors that may or may not be present in the patient's documentation but do not change the code's validity nor are required for its assignment.
  • Function: They offer supplementary information or nonessential modifiers.
  • Example: "Diabetes (mellitus) without complication" - "mellitus" is an optional term that further specifies the type of diabetes but is not strictly necessary to validate the code if the patient has diabetes without further specified types.

Colon

• Colon ( : ): This punctuation mark is found exclusively in the Tabular List.
  • Purpose: It emphasizes that one or more of the following descriptors are required to make the code valid for the diagnosis.
  • Significance: If the descriptors following a colon are not present in the patient's documentation, the code cannot be used as presented; further specificity or a different code pathway may be needed.
  • Example: A code entry might state: "Chronic kidney disease: Stage 3, requiring dialysis." The colon indicates that both "Stage 3" AND "requiring dialysis" are essential components for assigning that specific code.

Abbreviations

• NES (Not Elsewhere Specified):
  • Meaning: This abbreviation indicates that the documentation provides insufficient information to assign a more specific code.
  • Implication: It's typically used when the coder has looked for a more specific option but couldn't find one that precisely matches the available detail.
• NOS (Not Otherwise Specified):
  • Meaning: Similar to NES, NOS signifies that the medical record lacks the specific details needed for a more precise code.
  • Implication: The presence of NOS often leads to a query to the provider. This is because NOS suggests that while a general category is known, critical descriptive details are missing, and obtaining these details would lead to a more accurate and specific code assignment.
    • Action for Coder: When NOS is encountered, it often signals a necessity to seek clarification from the healthcare provider to enhance the specificity of the diagnosis, leading to improved data quality and appropriate reimbursement.