Conventions

_______________________codes are never permitted to be used as first-listed or principal diagnosis codes.

"In diseases classified elsewhere" Manifestation

A ________________ note instructs that two codes may be required to fully describe a condition, but this note does not provide sequencing direction.

"code also"

The ________________ is the terms in ( ) after the main term. According to the updated guidelines, when a ________________________ and a subentry following a main term in the ICD-10-CM Alphabetic Index are mutually exclusive, the subentry takes precedence.

nonessential modifiers

The _______________ represents that condition that is most commonly associated with the main term, or is the unspecified code for the condition.

default code

A ______________ instruction following a main term in the Alphabetic Index instructs that there is another main term that may also be referenced that may provide additional Alphabetic Index entries that may be useful. It is not necessary to follow the ______________ note when the original main term provides the necessary code.

"see also"

The____________ instruction following a main term in the Alphabetic Index indicates that another term should be referenced. It is necessary to go to the main term referenced with the ____________ note to locate the correct code.

"see"

Codes titled _______________ are for use when the information in the medical record is insufficient to assign a more specific code.

"unspecified"

The word _________ should be interpreted to mean "associated with" or "due to" when it appears in a code title, the Alphabetic Index, or an instructional note in the Tabular List.

"with"

The classification presumes a causal relationship between the two conditions linked by these terms in the Alphabetic Index or Tabular List. These conditions should be coded as related even in the absence of provider documentation explicitly linking them, unless the documentation clearly states the conditions are unrelated. For conditions not specifically linked by these relational terms in the classification, provider documentation must link the conditions in order to code them as related.

"with" "due to" "associated with"

_______________ is an alphabetical list of terms and their corresponding code.

Alphabetic Index

If the same condition is described as both acute (subacute) and chronic, and separate subentries exist in the Alphabetic Index at the same indentation level......

Code both conditions with the acute condition coded first.

______________ are the general rules for use of the classification independent of the guidelines.

Conventions

_________________ are incorporated within the Alphabetic Index and Tabular List of the ICD-10-CM as instructional notes.

Conventions

An ____________ note indicates that the condition excluded is not part of the condition represented by the code, but a patient may have both conditions at the same time.

Excludes2

An ___________ note indicates that the code excluded should never be used at the same time as the code above the __________ note.

Exludes1

This note appears immediately under a three character code title to further define, or give examples of, the content of the category.

Includes notes

The terms may be synonyms of the code title, or, in the case of "other specified" codes, the terms are a list of the various conditions assigned to that code.

Inclusion terms

Alphabetic Index entries with _______ in the line designate "other" codes in the Tabular List. These Alphabetic Index entries represent specific disease entities for which no specific code exists so the term is included within an "other" code.

NEC

This abbreviation in the Alphabetic Index represents "other specified." When a specific code is not available for a condition, the Alphabetic Index directs the coder to the "other specified" code in the Tabular List.

NEC Not Elsewhere Classifiable

When a specific code is not available for a condition, the Tabular List includes an__________________

NEC entry

This abbreviation is the equivalent of unspecified.

NOS Not Otherwise Specified

_________________ is a structured list of codes divided into chapters based on body system or condition.

Tabular list

Code assignment and clinical criteria

The assignment of a diagnosis code is based on the provider's diagnostic statement that the condition exists. The provider's statement that the patient has a particular condition is sufficient. Code assignment is not based on clinical criteria used by the provider to establish the diagnosis.

_____________are used in the Tabular List to enclose synonyms, alternative wording or explanatory phrases.

brackets [ ]

____________are used in the Alphabetic Index to identify manifestation codes.

brackets [ ]

_____________ are used in the Tabular List after an incomplete term which needs one or more of the modifiers following the ___________ to make it assignable to a given category.

colons :

ICD- 10-CM has a coding convention that requires the underlying ____________ be sequenced first, if applicable, followed by the __________________ .

etiology manifestation

________________are used in both the Alphabetic Index and Tabular List to enclose supplementary words that may be present or absent in the statement of a disease or procedure without affecting the code number to which it is assigned.

parenthesis ( ) nonessential modifiers