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ICD-10 Terminology

ICD-10 Terminology


Acute condition – Medical condition that is characterized by sudden onset, short duration, and/or severe change. 

Additional diagnosis – A secondary diagnosis code that is used to provide a better description of the primary diagnosis. 

Alphabetic Index – A list of possible diagnosis codes to use for locating an ICD-10-CM diagnosis code. 

Applied mapping – Use of a reference mapping to adapt to the needs of a particular application, such as quality, data, or research. 

Approach – The use of the fifth character in the code structure to define the technique used to reach the body site. 

Backward mapping – Mapping that proceeds from a newer code set to one that is much older (going from ICD-10-CM to ICD-9-CM). 

Body part – The anatomical site or region represented by the fourth character in the code structure. 

Body system – The use of the second character to define the general physiological system or anatomical region where the procedure was performed. 

Brackets – Punctuation used in the Alphabetic Index to indicate manifestation codes, which must be listed after the disease code. 

Category – The three-digit diagnosis code classifications used to define various conditions. 

Causal properties – Factors that specify various causes of diseases, such as disabilities and genetics. 

Character – One of the seven components that comprise an ICD-10-PCS procedure code. 

Chronic condition – A medical condition that is characterized by frequent recurrence, long duration, and/or slow progression. 

Code also – Instruction that directs the coder to assign more than one code. 

Code first – Instruction that directs the coder to assign the code for the underlying disease first and the manifestation second. 

Combination code – A single code used to classify two diagnoses, a diagnosis with an associated secondary manifestation, or a diagnosis with complication. 

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Conventions – The general rules for use of the classification, which are independent of guidelines and are incorporated within the Alphabetic Index and Tabular List of ICD-10-CM as instructional notes. 

Demographic – Statistical data related to the patient, such as race, gender, age, and location. 

Device – Equipment used for a specific purpose, which is represented by the sixth character of an ICD-10-PCS code in sections 0, 1, 2, and 4. 

Diagnosis – The conclusion reached by a healthcare provider based on diagnostic testing and clinical findings (why it was done). 

Encounter – Patient visit for treatment or procedure in an outpatient setting. 

Forward mapping – Mapping that proceeds from an older code set to a newer one (ICD-9-CM to ICD-10-PCS). 

GEMs – Reference mapping, called General Equivalence Maps, which includes all valid relationships between the codes in ICD-9-CM and those of ICD-10-CM. 

Guidelines – Instructions listed in the front of the ICD-10 manuals that are needed to report codes. 

In situ – Confined to the site of origin and non-invasive. 

Main term – The key word/phrase used in the Alphabetic Index of ICD-10 to find the appropriate diagnosis code. 

Manifestation codes – Codes used to report conditions that have both an underlying cause and multiple body system manifestations due to that cause. 

Medical necessity – Supplies or services that are necessary for the diagnosis and treatment of a medical condition, meet the standards of acceptable practice, and are not for convenience. 

Morbidity – The disease rate or number of cases of a particular disease in a given age range, occupation, gender, or other population or group. 

Mortality – The death rate demonstrated by the population in a given age range, region, gender, or other relevant grouping. 

Multiaxial code – One of the six main attributes of the ICD-10-PCS code structure, in which the characters are independent yet have consistency within defined sections. 

Nonessential modifier – A term that coexists with the main term, does not affect the code assignment, and is indicated by parentheses. 

Not Elsewhere Classifiable (NEC) – Code assigned when there is not code to use for the level of specificity. 

Not Otherwise Specified (NOS) – Code assigned when more specific codes exist but the documentation does not support specificity. 

Parentheses – Punctuation in the Alphabetic Index and Tabular List that encloses nonessential modifiers. 

Placeholder – The use of "X" into the code to indicate unused digits or when the code needs a seventh digit to convey specific information. 

Principle diagnosis – The first-listed diagnosis code that defines the primary reason for the encounter. 

Qualifier – The seventh character of an ICD-10-PCS code which is unique to individual procedures or treatments. 

Root operation/type – The third character of the code structure that defines the objective of a procedure. 

Secondary diagnosis – Diagnosis that affects patient care because it requires clinical assessment, treatment, diagnostic testing, procedures, and an extended length of stay. 

Section – The first character of the code structure that defines the general type of procedure. 

See also – An instructional term that directs coders to another term. 

Sequalae – A residual effect (condition-produced) that occurs after the acute stage of illness or injury. 

Subterm – A term listed below the main term in the Alphabetic Index that gives more specificity. 

Table – A component of ICD-10-PCS that is used along with the index to finish building a procedure code. 

Tabular List – An essential list of codes, which include laterality and any applicable seventh characters. 

Use additional code – Instruction to assign a secondary code after the disease code. 

Value – Individual units represented by a letter or number and that define each character of ICD-10-PCS.


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