Neoplasm Table

summary table of code numbers for neoplasms by anatomical site and divided by the description of the neoplasm

Table of Drugs and Chemicals

index in a table format of drugs and chemicals that are listed in the Tabular List

Index of External Causes

index of all external causes of disease and injuries classified in the Tabular List

diagnosis statement

physician's description of the main reason for a patient's encounter

convention

typographic technique that provides visual guidance for understanding information

main term

word the identifies a disease of condition in the Alphabetic table

default code

ICD-10-CM code listed next to the main term in the Alphabetic index that is most often associated with a particular disease or condition

subterm

word of phrase that describes a main term in the Alphabetical index

etiology

cause or origin of a disease of condition

nonessential modifyer

supplementary word of phrase that helps define a code in ICD-10-CM

eponym

name of phrase formed from or based on a person's name

NEC (not elsewhere classifiable)

abbreviation indication the coded to use when a disease of condition cannot be placed in any other category

NOS (not otherwise specified)

term that indicates the coded to used when no information is available for assigning the disease of condition a more specific code; unspecified

manifestation

characteristic sign of symptom of a disease

first-listed code

code for diagnosis that is the patient's main condition; in cases involving an underlying condition and a manifestation, the underlying condition is the first-listed code

combination code

single code describing both the etiology and the manifestation(s) of a particular condition

placeholder character (x)

character "x" inserted in a code to fill a blank space

seventh-character extention

necessary assignment of a seventh character to a code; often for the sequence of an encounter

category

three-character code for classifying a disease of condition

subcategory

four- or five- character code number

inclusion notes

Tabular List entries addressing the applicability of certain codes to specified conditions

exclusion notes

Tabular List entries limiting applicability of particular codes to specified conditions

excludes 1

exclusion note used when two conditions could not exist together, such as an acquired and a congenital condition; means "not coded here"

excludes 2

exclusion note meaning that a particular condition is not included here, but a patient could have both conditions at the same time

laterality

use of ICD-10-CM classification system to capture the side of the body that is documented; the fourth, fifth, and sixth characters of a code specify the affected side(s)

ICD-10-CM Official Guidelines for Coding and Reporting

general rules, inpatient (hospital) coding guidance, and outpatient (physician's office/clinic) coding guidance from the four cooperating parties (CMS advisers and partiipants from the AHA, AHIMA, and NCHS)

primary diagnosis

first-listed diagnosis

coexisting condition

additional illness that either has an effect on the patient's primary illness or is also treated during the encounter

acute

illness or condition with severe symptoms and a short duration

chronic

illness or condition with a long duration

sequelae

conditions that remain after an acute illness or injury has been treated and resolved

principal diagnosis

in inpatient coding, the condition is established after study to be chiefly responsible for the admission of the patient

external cause code

ICD-10-CM code for an external cause of a disease or injury

Z code

abbreviation for codes from the 21st chapter of the ICD-10-CM that identify factors that influence health status and encounters that are not due to illness or injury

chief complaint (CC)

patient's description of the symptoms or other reasons for seeking medical care

ICD-9-CM

previous HIPAA mandated diagnosis code set

GEMs

acronym for general equivalence mappings, reference tables or related ICD-10-CM and ICD-9-CM codes