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ICD-10 Terminology & Definitions
July 17, 2015
Acute Conditions - The medical conditions characterized by sudden onset, severe and/or short duration.
Additional Diagnosis - The secondary diagnosis code used, if available, to provide a more complete picture of the primary diagnosis.
And - Means "and/or" when it appears in a title or narrative statement. Example: S33 says “Dislocation and sprain”, which can mean either sprain and/or dislocation.
Bilateral - For bilateral sites, the final character of the codes in the ICD-10-CM indicates laterality. An unspecified side code is also provided should the side not be identified in the medical record. If no bilateral code is provided and the condition is bilateral, assign separate codes for both the left and right side.
Brackets [ ] - Punctuation found in both the Tabular List and the Alphabetic Index surrounding manifestation codes to indicate that the manifestation should be sequenced after the disease code.
Chronic Conditions - Medical conditions characterized by long duration, frequent recurrence over a long period of time, and/or slow progression over time.
Code Also - Instruction that tells the coder that more than one code could be assigned, but it does not imply any sequencing guidance. Generally the most serious condition should be listed first.
Code First - Instructs the coder to assign the code for the underlying disease before the code for the manifestation of the disease and generally accompanies a manifestation code. This note is not common for musculoskeletal codes.
Colon : - Punctuation found in the Tabular List when a term must be modified by the addition of another term in order to qualify it for assignment of a specific code or to a category.
Combination Codes - A single code used to classify any of the following: two diagnoses; a diagnosis with an associated secondary process (manifestation); or a diagnosis with an associated complication.
Crosswalk/mapping - Moving from one code set to another. This is generally done with GEMs, but can be customized.
Excludes - "Excludes" as used in ICD-9-CM indicates that the code should not be used, because another code may be more appropriate. "Excludes" notes usually include suggestions of more appropriate codes or code ranges. ICD-10-CM introduces two types of excludes: "Excludes1" and "Excludes2".
Codes/conditions listed in the "Excludes1" notes should not be used because the two conditions do not occur together. It may be helpful to think of the “Excludes1” list to be codes that might be suggested instead.
Codes/conditions listed in the "Excludes2" notes indicate that the conditions being excluded are not considered part of the subject condition, but that another code should also be assigned. It may be helpful to think of “Excludes2” codes to those that might need to be added to provide full detail.
Codes may have both, either or neither Excludes1 and Excludes2 notes.
GEMs - Generated by the National Center for Health Statistics, this reference mapping attempts to include all valid relationships between the codes in the ICD-9-CM diagnosis classification and the ICD-10-CM diagnosis classification. CMS warns not to code directly from GEMs, as they only provide approximations. Note that GEMs frequently point to “unspecified” ICD-10 codes, which may lead to denied claims.
Includes - Term that is accompanied by conditions that are examples of what may be included in a specific category.
NEC - “Not elsewhere classified” or “other specified” is used when the information in the medical record provides detail for which a specific codes does not exist. Example M53.86 Other specified dorsopathies, lumbar region might be used for “facet syndrome”. The code does not name the condition, but the documentation does.
Nonessential Modifiers - Terms that may coexist with the main term but do not change the code assignment for the condition. These are generally contained within parentheses.
NOS - “Not otherwise specified” or “unspecified” Used when the information in the medical record is insufficient to assign a more specific code. Example: M54.9 Dorsalgia unspecified. The code is vague, but so is the documentation.
Manifestation Codes - Certain conditions have both an underlying etiology and multiple body system manifestations due to the underlying etiology. For such conditions, the ICD-10-CM has a coding convention that requires the underlying condition be sequenced first followed by the manifestation. Wherever such a combination exists, there is a "use additional code" note at the etiology code, and a "code first" note at the manifestation code. These instructional notes indicate the proper sequencing order of the codes, etiology followed by manifestation. However, these are uncommon for musculoskeletal diagnoses that are most likely to be used by chiropractors.
Medical Necessity - Services or supplies that: are proper and needed for the diagnosis or treatment of a medical condition; are provided for the diagnosis, direct care, and treatment of a medical condition; meet the standards of good medical practice in the local area; and are not mainly for the convenience of the patient or doctor. Diagnosis codes convey this information.
Parentheses ( ) - Punctuation found in both the Tabular List and the Alphabetic Index that surrounds nonessential modifiers. Example: M99.1- subluxation complex (vertebral). The word “vertebral” is not essential to the code description.
Principle Diagnosis - First-listed/primary diagnosis code. The code sequenced first on a medical record defines the primary reason for the visit as determined at the end of the encounter.
Signs/Symptoms - Codes that describe symptoms and signs, as opposed to diagnoses, are acceptable for reporting purposes when a related definitive diagnosis has not been established (confirmed) by the provider.
See - Term used in the Alphabetic Index to instruct the coder to refer to another term.
See Also - Term used in the Alphabetic Index to instruct the coder to refer to another term if desired.
Sequelae - A late effect is the residual effect (condition produced) after the acute phase of an illness or injury has terminated. There is no time limit on when a late effect code can be used. The residual may be apparent early, such as in cerebral infarction, or it may occur months or years later, such as that due to a previous injury.
With - Term used in the alphabetic index immediately following the main term, but not necessarily in alphabetic order in the Alphabetic Index. It is defined as “associated with” or “due to”. If not specified in the documentation, the default is “without”.