Term
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Definition
| International Classification of Diseases, 10th Revision, Clinical Modification |
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Definition
| Oct 1, 2020 to Sept 30, 2021 |
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Term
| 4 approving organizations are |
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Definition
the Cooperating Parties for the ICD-10-CM
The American Hospital Association (AHA)
The American Health Information Management Assocation (AHIMA)
Centers for Medicare and Medicaid Services (CMS)
National Center for Health Statistics (NCHS) |
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| "The ________ and ______ take precedence over the guidelines."* |
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Definition
| instructions and conventions |
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| Adherence to guidelines is required under _________ |
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Definition
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| "The conventions, general guidelines and chapter-specific guidelines are applicable to all health care settings unless otherwise indicated."* |
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Definition
| guidelines for selection of principal dx for non-outpatient settings |
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Definition
| guidelines for reporting additional dx in non-outpatient settings |
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Definition
| outpatient coding and reporting |
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| "The conventions are general rules for use of the classification, independent of the ____."* |
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Definition
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| How many characters do categories have? |
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Definition
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| How many characters do subcategories have? |
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Definition
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Term
| Codes may have __ to __ characters |
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Definition
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| The X character is considered a ____ |
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Definition
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| If the category requires a 7th character, a code without the 7th character is ____ |
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Definition
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| If a code that requires a 7th character is not 6 characters, a ______ must be used to fill the empty characters |
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Definition
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Term
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Definition
| Not elsewhere classifiable |
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Term
| When the Alphabetic Index doesn't provide a code to match the provider's specificity, the coder is directed the coder to the ________ ________code in the Tabular List."* |
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Definition
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Term
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Definition
Not otherwise specified
equivalent of unspecified |
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Term
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Definition
Brackets
Tabular use: "enclose synonyms, alternative wording or explanatory phrases"*
alphabetic index use:
identifies manifestation codes |
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Term
| ( ) used in Alphabetic Index |
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Definition
called nonessential modifiers
enclose supplementary words not required in provider's statement
For example, in the ICD-10-CM Alphabetic Index
under the main term Enteritis, “acute” is a nonessential modifier and
ICD-10-CM Official Guidelines for Coding and Reporting
FY 2021
Page 9 of 126
“chronic” is a subentry. In this case, the nonessential modifier “acute”
does not apply to the subentry “chronic”. |
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Definition
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Term
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Definition
"Colons are used in the Tabular List after an incomplete term which needs
one or more of the modifiers following the colon to make it assignable to
a given category."* |
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Term
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Definition
other or other specified codes
when medical record gives specificity that does not exist
For those
categories for which an unspecified code is not provided, the “other
specified” code may represent both other and unspecified. |
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Term
| Alphabetic Index entries with NEC |
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Definition
designates uses of "other" in Tabular List
These Alphabetic Index
entries represent specific disease entities for which no specific code
exists, so the term is included within an “other” code. |
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Term
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Definition
Codes titled “unspecified” are for use when the information in the
medical record is insufficient to assign a more specific code. For those
categories for which an unspecified code is not provided, the “other
specified” code may represent both other and unspecified. |
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Term
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Definition
| gives examples of diagnoses coded under the 3 character code title, not an exhaustive list |
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Term
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Definition
Pure excludes note
NOT CODED HERE!
The code in the excluded list should never be used at the same time as the code above the Excludes1 note.
Exception: when the 2 conditions are documented as unrelated to each other. |
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Term
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Definition
Not included here
the condition excluded is not part of the condition represented by the code, but the pt may have both at the same time. |
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Term
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Definition
an etiology/manifestation convention which will appear as instruction under the manifestation code
code the underlying condition first, before the manifestation.
The etiology code will have "use additional code" to refer coder to the manifestation code |
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Term
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Definition
an etiology/manifestation convention which will appear on an etiology code.
This code is sequenced first, then coder adds the manifestation codes |
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Definition
are sequenced after the corresonding etiology
will include "in diseases classified elsewhere" in the code title |
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Term
| "in disease classified elsewhere" |
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Definition
| indicates this code is a manifestation code, and an etiology code is required |
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Definition
(Dictionary.com)
The cause or origin of a disease |
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Definition
(Oxford Language Dictionary)
a symptom or sign of an ailment |
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Term
| manifestations without "in diseases classified elsewhere" in the title |
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Definition
*"For such codes, there is a “use additional code” note at
the etiology code and a “code first” note at the manifestation code, and the
rules for sequencing apply" |
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Term
| Name the 2 departments of the U.S. Federal Government's Department of Health and Human Services (DHHS) that provide the guidelines for coding and reporting in the ICD-10-CM |
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Definition
The Centers for Medicare and Medicaid Services (CMS)
National Center for Health Statistics (NCHS) |
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Term
| sections or passages in " " followed by an * |
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Definition
| are directly quoted from the ICD-10-CM FY2021 document. |
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Term
Etiology/manifestation codes have a specific structure in the Alphabetic index, with the etiology code listed first, followed by the manifestation in brackets.
What in the listing, G20, [F02.80] which is the etiology, which is the manifestation? |
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Definition
G20 is the etiology
F02.80 is the manifestation |
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Term
T/F
All "code first" and "use additional code" notes are etiology/manifestation combinations |
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Definition
| No, sometimes they are used as sequencing rules only. |
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Term
| "and" should be interpreted to mean |
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Definition
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Term
"with" or "in" should be interpreted to mean _____________
in either the Alphabetic Index or the Tabular List. |
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Definition
| "associated with" or "due to" |
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Term
| Which terms presume a causal relationship and can be coded as such without specific documentation of the linkage? |
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Definition
"with"
"in"
unless a guideline requires the linking documentation, as in sepsis and organ failure |
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Term
| What terms in the Alphabetic Index tells the coder that another main term may provide useful entries? |
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Definition
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Term
| What term tells the coder that 2 codes might be necessary to describe the condition, without sequencing direction? |
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Definition
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Term
| What type of code is the unspecified code for a condition? |
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Definition
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Term
| Is a provider's documentation that a patient has a condition sufficient to code it, or must there be clinical criterion met in the encounter? |
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Definition
| The provider's statement is enough |
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| How should a condition documented as acute (subacute) and chronic when there are separate subentries in the Alphabetic Index at the same indentation level? |
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Definition
| Code both, sequence acute (subacute) first |
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| The residual effect after an acute phase of an illness is called a ___ or ___ __. |
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Definition
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| What is the time limit for when sequelas may be coded? |
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Definition
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| Is a code for the acute phase of the illness or injury coded along with the sequela? (I63.9 with I69.351?) |
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Definition
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Term
| At discharge, impending or threatened conditions should not be coded unless __ or __. |
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Definition
the condition occurred,
or
the alphabetic index has a listing for impending or threatened for that condition |
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Term
| If there is no code for bilateral, how do you code a bilateral condition? |
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Definition
| By coding both the left and right side codes |
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Term
| How do you code a bilateral condition in where it no longer exists on the treated side, and is not being treated in the current encounter? |
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Definition
| Code only the side being treated which still exists |
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Term
| Some chart metrics are documented by unacceptable providers such as a nurse or MA. When can these be used for coding? |
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Definition
The associated dx must be documented by the provider (Nurse's documentation of a BMI 43 is not coded without the provider documenting a weight related dx in the same encounter.
Other examples include :
depth of pressure ulcers
pressure ulcer stage
coma scale
NIH stroke scale |
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Term
| Is it required for social determinants of health to be documented only by the acceptable provider of the encounter? |
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Definition
| No, as this is social information, not medical diagnosis. |
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Term
| Can patient reported information be used to assign codes for social determinants of health? |
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Definition
| Yes, when it is signed-off and incorporated into the record by the acceptable provider. |
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Term
| How do we code syndromes, when there is no alphabetic index guidance? |
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Definition
| Code the manifestations that are documented. |
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Term
| When is it appropriate to code a condition as a complication of other medical care or surgery? |
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Definition
| When the provider documents a cause-and-effect relationship. |
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Term
| How are "borderline" diagnoses coded? |
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Definition
If documented as borderline at time of discharge, the diagnosis is coded as confirmed UNLESS there is a code for "borderline" in the Alphabetic index (borderline diabetes).
borderline is NOT an uncertain dx, and so there is no distinction between inpatient and outpatient settings for this guideline. |
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Term
| How should external cause of morbidity codes be used for injuries directly caused by cataclysmic events, such as a hurricane? |
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Definition
| the injury is sequenced first, then the cataclysmic event sequenced as the first listed external cause of morbidity code. |
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