Main Term

“What’s wrong”, not a body part or adjective

Essential Modifier/subterm

Under the main term, indented two places to the right, MUST be in the documentation to use that code

Non-Essential Modifier

Located in parentheses – NOT required to be in your documentation for you to use the code

NOS

the Medical Record is lacking data for you to assign a better code “Query the provider”

NEC

The ICD book is lacking data for you to assign a better code.. (wait for ICD-10?? ;0)

Codes in Slanted Brackets

You must use both codes and in the order given

Brackets

[ ] – surround synonyms, explanatory phrases, examples

Parentheses

 non-essential modifiers, nice to have but not a need to have in the medical documentation

Colon

Space saver, so the book doesn’t have to repeat itself.

Stop sign

You are not done coding-the found code requires 4^th and or 5^th digits.

Brace

space saver- usually used for lists of similar items

Includes

A list in the tabular of other terms that match the code that you have found

Excludes

The Alpha has directed you to the incorrect code, so they give you the correct code under the term _______. Terms that are to be coded elsewhere (Note- they are given)

Category

The first three digits of every code

Subcategory

The fourth digit if needed

Subclassification

The fifth digit if needed

Eponym

Something named after someone who suffered from it or discovered it- CAN be the main term

AND

 the documentation must have one of the terms but does not need both terms to use that code

With

(Restrictive) You must have both terms in the dictation for you to use that code

S&S

Signs and Symptoms- 780-799.Know when to code them AND when not to code them

DD

Definitive Dx. (Diagnosis)

Principal diagnosis

The diagnosis found after study to be chiefly responsible for the admission of a patient

Comorbidity

Two diseases exist at the same time. Usually both DD’s

Qualified Diagnosis

Rule out MI, questionable Heart Attack, suspected Neoplasm, Observe for arrhythmia

Diagnoses that are not yet fully proven

DO CODE the S&S J

Volume 1

Tabular (numerical)

Volume 2

Alpha (Index)

Volume 3

Procedures- used by inpatient

See condition

“You looked up the wrong word!!” (e.g. body part or adjective)

See category

Go directly to the tabular and find the given category

See also condition

Could mean you looked up the wrong word- review back to medical record for Main Term

See also

Suggestion- go see other provided term

Notes

Disease Definition or

Box- 4^th or 5^th digits or

Coding instructions

See

Command- you must go to the given term

Code First Underlying Disease

  1.    You need to code the underlying (causing) condition first

2.       Then you code the diagnosis you were seeking

Use Additional Code

1.       You found your first code But you are not done

2.       Go find another code

Late effect/sequelae

Current condition/illness or injury caused from a previously healed condition

V Code

Reason the patient is seeking healthcare, not necessarily for a current illness. E.g. pregnancy, immunizations, lab tests, infusions, follow-up, chemotherapy, radiation tx.

E-Code

External cause of injury or illness- poisoning, injuries, cancer, terrorism,

Italics

Typeface used for all exclusion notes and codes that are never listed first

Combo codes

One code that includes two conditions (more than 1 thing)

Multiple Coding

Required that you use more than 1 code