Flashcards in Test 1 Deck (44):
What does ICD-10 CM stand for?
International Classification of Diseases, Tenth Revision, Clinical Modification.
What does ICD-10 PCS stand for?
International Classification of Diseases, Tenth Revision, Procedure Coding System.
What is the Tabular List?
A chronological list of codes divided into chapters based on the body system or condition.
What is the index?
An alphabetical list of terms and their corresponding code.
What is a section?
Groups of three-character categories. Ex: L00-L08
What is a Category?
Three-character code numbers. Ex: L02
What is a subcategory?
Four-character code numbers. Ex: L02.2
What is a subclassification?
Five, six, or seven character code numbers. Ex: L02.211
What is the placeholder character in ICD-10?
What is the UHDDS?
Used for reporting inpatient data in acute care, short-term, and long-term care hospitals.
What is a Principal Diagnosis?
The condition established after study to be chiefly responsible for admission of the patient to the hospital for care.
What is a Secondary Diagnosis?
Those conditions that coexist at the time of admission or develop subsequently or affect patient care for the current hospital episode.
What does UHDDS stand for?
Uniform Hospital Discharge Data Set.
What are General Notes?
They provide information on usage in a specific section.
What are Inclusion Notes?
Notes used to further define, or give examples of, the content of the chapter, section, or category.
What does excludes1 mean?
"NOT CODED HERE" It instructs that the code excluded should never be used at the same time as the code above the note.
What does exludes2 mean?
"NOT INCLUDED HERE" It instructs that the condition excluded is not part of the condition represented by the code. Under certain conditions, it is OK to use an exculdes2 code.
What does Code First mean?
The underlying condition should be sequenced first.
What does Use Additional Code mean?
Identify the manifestations commonly associated with a disease.
What does Code Also mean?
Two codes may be required to fully describe a condition.
What does NEC stand for?
Not Elsewhere Classifiable.
What does NEC mean?
A code or condition is not found in the codebook.
What does NOS stand for?
Not Otherwise Specified.
What does NOS mean?
Information can not be found in the medical record.
What does "see" mean?
The coder must refer to an alternative term.
What does "see also" mean?
There is another place in the index where a code can be found if one is not found where you originally looked.
What does "see category" mean?
Provides the coder with a category number.
What does "see condition" mean?
Refer to the main term of a condition.
What do parenthesis mean?
They are used to enclose supplementary words or explanatory information. They are nonessential modifiers.
What do square brackets mean?
They are used to enclose synonyms, alternative wordings, abbreviations, and explanatory phrases that provide additional information.
What do colons mean?
They are used after an incomplete term that needs one or more modifiers.
What is a Principal Procedure?
One which was performed for definitive treatment. Usually related to the principal diagnosis.
What is a Secondary Procedure?
All other significant procedures.
Who are the cooperating parties for ICD-10?
AHIMA, AHA, CMS, NCHS
What does AHIMA, AHA, CMA and NCHS stand for?
American Health Information Management Association, American Hospital Association, Centers for Medicare and Medicaid Services, the National Center for Health Statistics.
Who is responsible for the development of the diagnosis side of ICD-10?
CMS and NCHS.
Who is responsible for the development of the procedure side of ICD-10?
When is the compliance date for ICD-10?
October 1, 2014
What do Z codes represent?
Factors influencing health status and contact with health services that may be recorded as diagnosis.
What do you search for first in the index?
The main term
What does a dash at the end of an index entry mean?
Additional characters are required.
The word "and" can be interpreted as what?
"And" or "or"
The word "with" should be interpreted to mean?
"Associated with" or "due to"