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Alphabetic Index of the ICD-10-CM - .....ANSWER
...✔✔ referenced first to identify the diagnostic term
or condition to be coded
provide the first few characters for the code to then use
to locate the appropriate section within the Tabular List
to complete the code.
Tabular List - .....ANSWER ...✔✔ provide additional
information needed to code the condition correctly such
as Excludes 1 notes (not coded here), Excludes 2 notes
(not included here), Code First, Code Also, and so forth
Excludes 1 notes - .....ANSWER ...✔✔ not coded here
Excludes 2 notes - .....ANSWER ...✔✔ (not included
here)
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Coding clinics - .....ANSWER ...✔✔ published
quarterly by the American Hospital Association (AHA).
These provide clarification and advice on how to
implement and interpret the Official Guidelines for
Coding and Reporting. Any person can submit a question
to the AHA for assistance. All questions will receive a
response and those deemed most beneficial to the
industry will be published.
CPT® codebook - .....ANSWER ...✔✔ copyrighted
and published by the American Medical Association
(AMA)
encoder nosology - .....ANSWER ...✔✔ platform for
the CDI professional to seek guidance and ask specific
questions regarding the correct coding and sequencing
for various scenarios
Principal diagnosis: - .....ANSWER ...✔✔ "that
condition established after study to be chiefly
responsible for occasioning the admission of the patient
to the hospital for care"
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Secondary (Other) diagnosis - .....ANSWER ...✔✔ "all
conditions that coexist at the time of admission, that
develop subsequently, or that affect the treatment
received and/or the length of stay" (p. 107). In other
words, to meet this definition, the condition must have
received one or more of the following:
Clinical evaluation; or
Therapeutic treatment; or
Diagnostic procedures; or
Extended length of hospital stay; or
Increased nursing care and/or monitoring.
approved by the four organizations that make up the
Cooperating Parties for the ICD-10-CM - .....ANSWER
...✔✔ American Hospital Association (AHA), the
American Health Information Management Association
(AHIMA), CMS, and NCHS.
The Alphabetic Index consists of the following parts -
.....ANSWER ...✔✔ the Index of Diseases and Injury,
the Index of External Causes of Injury, the Table of
Neoplasms and the Table of Drugs and Chemicals.
The ICD-10-CM Tabular List contains - .....ANSWER
...✔✔ categories, subcategories and codes
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"X" - .....ANSWER ...✔✔ used as a placeholder at
certain codes to allow for future expansion.
NEC - .....ANSWER ...✔✔ "Not elsewhere classifiable"
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.
NOS - .....ANSWER ...✔✔ "Not otherwise specified"
This abbreviation is the equivalent of unspecified.
NEC - .....ANSWER ...✔✔ Not elsewhere classifiable"
This abbreviation in the Tabular List represents "other
specified". When a specific code is not available for a
condition, the Tabular List includes an NEC entry under a
code to identify the code as the "other specified" code.
[ ] - .....ANSWER ...✔✔ Brackets 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.