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.
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.
- ICD-10-CM Coding Guidelines - Pregnancy, Childbirth, and the Puerperium (Chapter 15) and Certain Conditions Originating in the Perinatal Period (Chapter 16)
- ICD-10-PCS Coding in the Medical and Surgical-Related Subsection
- ICD-10-CM Coding Guidelines - Factors Influencing Health Status and Contact with Health Services (Chapter 21)
- ICD-10-CM Coding Guidelines - External Causes of Morbidity (Chapter 20)
- ICD-10-CM: Translating Documentation to Codes
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