Chapter 1 - Introduction to ICD-10-CM Flashcards
flush (documents) [3 terms]
(adj) Aligned along a margin.
For example, text that is flush left is aligned along the left margin. Flush-right text is aligned along the right margin.
The opposite of flush is ragged.
Text that is both flush left and flush right is said to be justified.
main terms
ICD-10-CM entries printed in boldface and flush with the left margin of each column; they are located in the ICD-10-CM indexes.
What are the two indices and two tables in ICD-10-CM, located before the Tabular List?
Index to Diseases and Injuries
External Causes of Injuries Index
Table of Neoplasms
Table of Drugs and Chemicals
What are the four types of main terms in ICD-10-CM?
Diseases such as influenza or bronchitis
Conditions such as fatigue, fracture, or injury
Nouns such as disease, disorder, or syndrome
Adjectives such as double, kink, or large
What is the first and second place that a coder goes to locate ICD-10-CM codes for a patient’s disease or condition?
First place: The two indices of ICD-10-CM, also called the Alphabetic Index.
Second place: The Tabular List.
subterms
Also called essential modifiers.
They are in regular type and begin with a lowercase letter. They are indented one standard indentation to the right under the main term and are listed in alphabetic order.
They describe essential differences in the site, cause, or clinical type of the condition.
More specific subterms (sub-subterms) are indented farther to the right as needed and are also listed in alphabetic order. They are also lowercase and regular.
(Note: Eponyms do not start with a lowercase letter, as they are proper nouns.)
carryover lines
They are basically a form of word wrap used when the number of words cannot fit on a single line. Example below:
Delivery (childbirth) (labor)
cesarean (for)
occurring after 37 completed weeks of gestation but before 39 completed
weeks of gestation due to (spontaneous) onset of labor (O75.82)
The last two lines, starting with “occurring after”, are the carryover lines.
nonessential modifiers
Also called supplementary terms.
They are a term or series of terms that appear in parenthesis and that follow a main term or subterm. These parenthetical terms are not considered important descriptors of the diagnosis or condition in the ICD-10-CM system.
Nonessential modifiers apply to the main term and to subterms following the main term. However, there is an exception: When a nonessential modifier term and a subterm are mutually exclusive, the subterm takes precedence.
For example: “Enteritis (acute)” also has a subterm called “chronic (noninfectious)”; the chronic in the subterm overrides the acute in the main term.
“see” and “see also” (ICD-10-CM)
The “see” note is a cross-reference term that tells the coder to look elsewhere in the index before assigning a code. It points to an alternative term.
The “see also” note tells the coder to look elsewhere in the index, but only if all the needed information cannot be found under the first main term. It is not necessary to follow the “see also” note when the original main term provides the necessary code.
Note: “see” and “see also” are called cross-reference terms.
Examples below:
rheumatoid arthritis–see
Rheumatoid, polyneuropathy
Aberrant (congenital)–see also Malposition, congenital
“code also” (ICD-10-CM)
The “code also” note means that two codes may be required to fully describe a condition, but this note does not provide sequencing directions. The sequencing depends on the circumstances of the encounter.
default code (ICD-10-CM)
It is the code listed next to a main term. It represents the condition that is most commonly associated with the main term.
Example:
Pancake heart R93.1
(Note: Pancake heart appears to be a very uncommon term for a chest problem that causes a compression of the heart.)
Tabular List (ICD-10-CM)
A structured list of codes divided into 21 chapters based on body system or condition. It makes up the bulk of the ICD-10-CM book.
What is the ICD-10-CM code format?
The first three characters are called the category. They represent a single disease or a group of similar or closely related conditions. A three-character category that has no further subdivision is equivalent to a code.
The fourth character is called the subcategory. The fifth and sixth characters are called the sub-classification. Together these three characters give information about the etiology (cause of the disease), site (anatomic location), severity, or manifestation of the disease.
The seventh character is called the extension code. It adds more information, such as whether it is an initial or subsequent encounter.
placeholder character (ICD-10-CM)
ICD-10-CM utilizes a placeholder character, which is always the letter X, and it has two uses:
- The X provides for future expansion without disturbing the overall code structure
(e. g. T42.3X1A, Poisoning by barbiturates, accident, initial encounter) - It is also used when a code has fewer than six characters and a seventh character extension is required. The X is assigned for all characters less than six in order to meet the requirement of coding to the highest level of specificity.
(e. g. T58.11XA, Toxic effect of carbon monoxide from utility gas, accidental, initial encounter)
not elsewhere classifiable (NEC)
NEC appears when a more specific code is not available and you are only able to use the more general code provided.
not otherwise specified (NOS)
It is the equivalent of unspecified. This is used when the documentation provided by the provider does not provide enough information to assign a more specific code.
square brackets vs slanted brackets
Square brackets are a punctuation mark used to enclose synonyms, abbreviations, alternative wording, or explanatory phrases. In other words, they provide information.
(e.g. B20, Human immunodeficiency virus [HIV] disease)
Slanted brackets are used to identify manifestation codes. Manifestation codes represent the secondary condition that is present in addition to the underlying or primary disease that caused the secondary condition. Two codes are required when the patient has both the underlying disease and the secondary condition.
The use of the slanted bracket in the Alphabetic Index provides sequencing directions. You must code the slanted bracket second.
(e.g. Amyloid heart (disease) E85.4 [I43]
First code: E85.4 Organ-limited amyloidosis
Second code: I43 Cardiomyopathy in diseases classified elsewhere)
colon (:) (ICD-10-CM)
The colon is a punctuation mark used after an incomplete term that needs one or more additional terms to be coded. Some versions have “includes” and “excludes” notes included with it.
Example:
F02 Dementia in other diseases classified elsewhere
Code first the underlying physiological condition, such as:
Alzheimer’s (G30.-)
cerebral lipidosis (E75.4)
Creutzfeldt-Jakob disease (A81.0-)
“other” or “other specified”
“other” and “other specified” are used when the information in the health record is more descriptive than the available codes in ICD-10-CM. Often seen with NEC.
(e.g. R93.89 Abnormal finding on diagnostic imaging of other specified body structures)
“unspecified”
a term used when the information in the health record is insufficient to assign a more specific code
(e.g. J45.909 Unspecified asthma, uncomplicated)
inclusion terms
a list of conditions for which a code is to be used
Example:
I51.7 Cardiomegaly
Cardiac dilatation
Cardiac hypertrophy
Ventricular dilatation
“includes” note
A type of inclusion term that appears immediately under a three-character code to further define, or give examples of, the content of the category.
Example: J44 Other chronic obstructive pulmonary disease Includes: asthma with chronic obstructive pulmonary disease chronic asthmatic (obstructive) bronchitis chronic bronchitis with airways obstruction
Excludes1
Excludes1 indicates that the condition after it cannot ever be used at the same time as the code above the Excludes1 note. In other words, a patient cannot have both conditions at the same time. The coder must determine which condition the patient actually has in order to code correctly.
Example:
E06 Thyroiditis
Excludes1: postpartum thyroiditis (O90.5)
In this example, a patient who is in the postpartum period and has thyroiditis would have the diagnosis code O90.5 assigned. Other patients who have thyroiditis and are not in the postpartum period would have the disease coded as E06. This is an either/or situation. Both codes cannot be used on the same patient during the same episode of care.
Excludes2
Excludes2 means that two codes are applied when both conditions are present. The conditions that appear as an Excludes2 note are not part of the code that is listed above it.
Example:
G47 Sleep disorders
Excludes2: nightmares (F51.5)
nonorganic sleep disorders (F51.-)
sleep terrors (F51.4)
sleepwalking (F51.3)
In this example, a patient can have sleep disorders and nightmares at the same time. The Excludes2 note means that code G47 for sleep disorders does not include the condition of nightmares. When the patient has both a sleep disorder and nightmares, two codes must be used: a code from the category G47 and the code F51.4.
