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ICD-10 Terms to Know
Basic terms to know for ICD-10-CM & ICD-10-PCS
| Term | Definition |
|---|---|
| ICD-10-CM | INTERNATIONAL CLASSIFICATION OF DISEASES, TENTH REVISION, CLINICAL MODIFICATION, CONSISTS OF DIAGNOSIS CODES |
| ICD-10-PCS | INTERNATIONAL CLASSIFICATION OF DISEASES, TENTH REVISION, PROCEDURE CODING SYSTEM; CONSISTS OF PROCEDURE CODES |
| NEC | NOT ELSEWHERE CLASSIFIED; USED IN THE ALPHABETIC INDEX TO INDICATE THAT THERE IS NO SEPARATE CODE FOR THE CONDITION EVEN THOUGH THE DIAGNOSTIC STATEMENT IS SPECIFIC |
| NOS | NOT OTHERWISE SPECIFIED; EQUIVALENT TO THE TERM "UNSPECIFIED" |
| MS-DRG SYSTEM | MEDICARE SEVERITY-ADJUSTED DIAGNOSIS-RELATED GROUPS SYSTEM; A PATIENT CLASSIFICATION SYSTEM USED IN HOSPITAL INPATIENT REIMBURSEMENT |
| OTHER REPORTABLE DIAGNOSESS | CONDITIONS THAT COEXIST AT THE TIME OS ADMISSION, DEVELOP SUBSEQUENTLY, OR AFFECT PATIENT CARE DURING THE HOSPITAL STAY |
| PRINCIPAL DIAGNOSIS | THE CONDITION ESTABLISHED AFTER STUDY THAT IS CHIEFLY RESPONSIBLE FOR ADMISSION OF THE PATIENT TO THE HOSPITAL |
| UHDDS | UNIFORM HOSPITAL DISCHARGE DATA SET; INFORMATION USED FOR REPORTING INPATIENT DATA |
| POA INDICATOR | PRESENT ON ADMISSION INDICATOR; A DATA ELEMENT THAT APPLIES TO DIAGNOSIS CODES FOR CLAIMS INVOLVING INPATIENT CARE |
| PROVIDER | A PHYSICIAN OR ANY QUALIFIED EALTH CARE PRACTITIONER (SUCH AS A NURSE PRACTITIONER OR PHYSICIAN ASSISTANT)WHO IS LEGALLY ACCOUNTABLE FOR ESTABLISHING THE PATIENT'S DIAGNOSIS |
| ALPHABETIC INDEX OF DISEASES AND INJURIES AND THE INDEX TO EXTERNAL CAUSES | INCLUDE ENTRIES FOR MAIN TERMS (DISEASES, CONDITIONS, OR INJURIES) AND SUBTERMS (SITE, TYPE, OR ETIOLOGY). THE NEOPLASM TABLE, AND THE TABLE OF DRUGS AND CHEMICALS |
| NEC | NOT OTHERWISE CLASSIFIED |
| NOS | NOT OTHERWISE SPECIFIED |
| "RULE OUT" | INDICATES THAT A DIAGNOSIS IS STILL POSSIBLE |
| "RULED OUT" | INDICATES THAT A DIAGNOSIS ONCE CONSIDERED LIKELY IS NO LONGER POSSIBLE |
| CHARACTER | AN AXIS OF CLASSIFICATION THAT SPECIFIES INFORMATION ABOUT THE PROCEDURE PERFORMED |
| VALUE | ONE OF THE 34 LETTERS OR NUMBERS THAT CAN BE SELECTED TO REPRESENT ONE OF THE CHARACTERS IN AN ICD-10-PCS CODE |
| APPROACH | THE FIFTH CHARACTER IN THE CODE IN THE MEDICAL AND SURGICAL SECTION; IT CARRIES ADDITIONAL INFORMATION FOR THAT PARTICULAR PROCEDURE |
| ROOT OPERATION | THE THIRD CHARACTER IN THE CODE IN THE MEDICAL AND SURGICAL SECTION CORRESPONDING TO THE OBJECTIVE OFF THE PROCEDURE; IN THIS SECTION ALONE THERE ARE 31 POSSIBLE OBJECTIVES |
| PRINCIPAL PROCEDURE | PRODEDURE PERFORMED FOR DEFINITIVE TREATMENT (RATHER THAN FOR DIAGNOSTIC OR EXPLORATORY PURPOSES) |
| ROOT OPERATION | THE THIRD CHARACTER IN AN ICD-10-PCS CODE, WHICH REFERS TO THE OBJECTIVE OF THE PROCEDURE |
| AFTERCARE MANAGEMENT | CONTINUED CARE DURING THE HEALING PHASE OR LONG-TERM CARE DUE TO THE CONSEQUENCES OF A DISEASE |
| EXTERNAL CAUSE OF MORBIDITY CODES | CODES FOR EXTERNAL CAUSES TO PROVIDE INFORMATION FOR INJURY RESEARCH AND EVALUATION OF INJURY PREVENTION STRATEGIES |
| PALLIATIVE CARE | CARE FOCUSED ON THE MANAGEMENT OF PAIN AND OTHER SYMPTOMS OF PATIENTS WHO ARE IN THE TERMINAL PHASE OF AN ILLNESS |
| Z CODES | CODES FOR FACTORS INFLUENCING HEALTH STATUS AND CONTACT WITH HEALTH SERVICES |
| SIGN | OBJECTIVE EVIDENCE OF DISEASE OBSERVED BY THE EXAMINING PHYSICIAN |
| SYMPTOM | SUBJECTIVE OBSERVATION REPORTED BY THE PATIENT |
| BACTEREMIA | PRESENCE OF BACTERIAL IN THE BLOOD-STREAM AFTER A TRAUMA OR AN INFECTION |
| SEPSIS | SIRS DUE TO INFECTION; A SEVERE CASE INDICATES ORGAN DYSFUNCTION |
| SEPTIC SHOCK | CIRCULATORY FAILURE ASSOCIATED WITH SEVERE SEPSIS |
| SEPTICEMIA | A SYSTEMIC DISEASE ASSOCIATED WITH PATHOLOGICAL MICROOORGANISMS OR TOXINS IN THE BLOODSTREAM |
| SIRS | SYSTEMIC INFLAMMATORY RESPONSE SYNDROME; A SYSTEMIC RESPONSE TO INFECTION OR TRAUMA WITH SUCH SYMPTOMS AS FEVER AND TACHYCARDIA |
| DIABETES MELLITUS | A CHRONIC DISORDER OF IMPAIRED CARBOHYDRATE, PROTEIN, AND FAT METABOLISM |
| TYPE 1 DIABETES | ALSO KNOWN AS JUVENILE TYPE; CHARACTERIZED BY THE BODY'S FAILURE TO PRODUCE INSULIN |
| TYPE 2 DIABETES | CHARACTERIZED BY THE BODY'S PRODUCTION OF INSULIN IN AN INSUFFICIENT QUANTITY OR THE BODY'S INABILITY TO UTILIZE SUCH INSULIN |
| ABUSE | PROBLEMATIC USE OF DRUGS OR ALCOHOL BUT WITHOUT DEPENDENCE |
| DEPENDENCE | INCREASED TOLERANCE TO DRUGS OR ALCOHOL WITH A COMPULSION TO CONTINUE TAKING THE SUBSTANCE DESPITE THE COST; WITHDRAWAL SYMPTOMS OFTEN OCCUR UPON CESSATION |
| ANEMIA | A CONDITON IN WHICH BLOOD IS DEFICIENT IN THE AMOUNT OF HEMOGLOBIN IN RED BLOOD CELLS OR IN THE VOLUME OF RED BLOOD CELLS |
| APLASTIC ANEMIA | A CONDITION IN WHICH THERE IS A DEFICIENCY OF RED BLOOD CELLS BECAUSE THE BONE MARROW IS FAILING TO PRODUCE THEM |
| PANCYTOPENIA | A TYPE OF APLASTIC ANEMIA IN WHICH RED BLOOD CELLS, WHITE BLOOD CELLS, AND PLATELETS ARE ALL DEFICIENT |
| SICKLE-CELL ANEMIA | A HEREDITARY DISEASE OF THE RED BLOOD CELLS PASSED TO A CHILD WHEN BOTH PARENTS CARRY THE GENETIC TRAIT |
| SICKLE-CELL TRAIT | A CONDITION THAT OCCURS WHEN A CHILD RECEIVES THE TRAIT FROM ONLY ONE PARENT |
| THROMBOCYTOPENIA | A DEFICIENCY IN PLATELETS, THE CELLS THAT ARE IMPORTANT IN BLOOD CLOTTING |
| CENTRAL NERVOUS SYSTEM | THE BRAIN AND SPINAL CHORD |
| CONDUCTIVE HEARING LOSS | HEARING LOSS DUE TO A PROBLEM WITH A PART OF THE EAR |
| PERIPHERAL NERVOUS SYSTEM | ALL ELEMENTS OF THE NERVOUS SYSTEM EXCEPT THE BRAIN AND SPINAL CORD |
| SENSORINEURAL HEARING LOSS | HEARING LOSS DUE TO A PROBLEM WITH THE SENSORY PART OF THE EAR OF THE NERVES ASSOCIATED WITH HEARING |
| ACUTE PULMONARY EDEMA | EXCESSIVE FLUID IN THE TISSUE AND ALVEOLAR SPACES OF THE LUNG |
| ATELECTASIS | A COLLAPSE OF LUNG TISSUE; AN INTEGRAL PART OF PULMONARY DISEASE |
| BRONCHOSPASM | A SUDDEN CONSTRICTION OF THE MUSCLES IN THE WALLS OF THE BRONCHIOLES |
| COPD | CHRONIC OBSTRUCTIVE PULMONARY DISEASE; A GENERAL TERM DESCRIBING CONDITIONS THAT RESULT IN AN AIRWAY OBSTRUCTION |
| PLEURAL EFFUSION | ACCUMULATION OF FLUID WITHIN THE PLEURAL SPACES |
| CENTRAL NERVOUS SYSTEM | THE BRAIN AND SPINAL CHORD |
| CONDUCTIVE HEARING LOSS | HEARING LOSS DUE TO A PROBLEM WITH A PART OF THE EAR |
| PERIPHERAL NERVOUS SYSTEM | ALL ELEMENTS OF THE NERVOUS SYSTEM EXCEPT THE BRAIN AND SPINAL CORD |
| SENSORINEURAL HEARING LOSS | HEARING LOSS DUE TO A PROBLEM WITH THE SENSORY PART OF THE EAR OF THE NERVES ASSOCIATED WITH HEARING |
| ACUTE PULMONARY EDEMA | EXCESSIVE FLUID IN THE TISSUE AND ALVEOLAR SPACES OF THE LUNG |
| ATELECTASIS | A COLLAPSE OF LUNG TISSUE; AN INTEGRAL PART OF PULMONARY DISEASE |
| BRONCHOSPASM | A SUDDEN CONSTRICTION OF THE MUSCLES IN THE WALLS OF THE BRONCHIOLES |
| COPD | CHRONIC OBSTRUCTIVE PULMONARY DISEASE; A GENERAL TERM DESCRIBING CONDITIONS THAT RESULT IN AN AIRWAY OBSTRUCTION |
| PLEURAL EFFUSION | ACCUMULATION OF FLUID WITHIN THE PLEURAL SPACES |
| BILLIARY SYSTEM | A NETWORK INCLUDING THE GALLBLADDER AND BILE DUCTS |
| CALCULUS | A STONE COMPOSED OF MINERALS THAT FORMS IN AN ORGAN OR DUCT OF THE BODY |
| DIVERTICULITIS | THE INFLAMMATION OF EXISTING DIVERTICULA |
| DIVERTICULOSIS | THE PRESENCE OF ONE OR MORE DIVERTICULA OF THE DESIGNATED SITE |
| DIVERTICULUM | A SMALL POUCH OR SAC OPENING FROM A TUBULAR OR SACCULAR ORGAN; CONSIDERED A MEDICAL CONDITION; THE PLURAL TERM IS DIVERTICULA |
| ESOPHAGITIS | AN INFLAMMATION OF THE LINING OF THE ESOPHAGUS |
| ESOPHAGEAL VARICES | ABNORMALLY ENLARGED VEINS IN THE LOWER PART OF THE ESOPHAGUS |
| GI | GASTROINTESTINAL; OF THE STOMACH AND/OR INTESTINES |
| ACUTE KIDNEY FAILURE | SUDDEN FAILURE OF RENAL FUNCTION FOLLOWING A SEVERE INSULT TO THE KIDNEYS |
| CHRONIC KIDNEY DISEASE | LONG-TERM INDICATING THAT RENAL DISEASE IS PRESENT |
| URETER | CARRIES URINE FROM THE KIDNEYS TO THE BLADDER |
| URETHRA | CARRIES URINE FROM THE BLADDER TO THE OUTSIDE OF THE BODY |
| NEPHROPATHY | GENERAL TERM INDICATING THAT RENAL DISEASE IS PRESENT |
| CELULITIS | AN INFECTION OF THE SKIN AND SOFT TISSUES RESULTING FROM SOME SORT OF BREAK IN THE SKIN |
| DEBRIDEMENT | REMOVAL OF DEAD, DAMAGED, OR INFECTED TISSUE |
| ANTEPARTUM | THE PERIOD OF PREGNANCY FROM CONCEPTION TO CHILDBIRTH |
| PERIPARTUM | THE PERIOD INVOLVING THE LAST MONTH OF PREGNANCY TO FIVE MONTHS POSTPARTUM |
| POSTPARTUM | THE PERIOD BEGINNING RIGHT AFTER DELIVERY AND INCLUDING THE NEXT SIX WEEKS |
| PUERPERIUM | THE CLINICAL TERM FOR THE POSTPARTUM PERIOD |
| ABORTION | THE EXPULSION OR EXTRACTION OF ALL OR PART OF THE PLACENTA WITH OR WITHOUT AN IDENTIFIABLE FETUS WITH LESS THAN AN ESTIMATED 20 WEEKS GESTATIONAL AGE |
| BIOCHEMICAL PREGNANCY | A PREGNANCY THAT IS TOO EARLY TO CONFIRM EXCEPT THROUGH BIOCHEMICAL MEANS; CONSIDERED THE EARLIEST FORM OF MISCARRIAGE |
| ECTOPIC PREGNANCY | A PREGNANCY IN WHICH A FERTILIZED OVUM IMPLANTS AND DEVELOPS OUTSIDE THE UTERUS |
| MOLAR PREGNANCY | A CONDITION IN WHICH AN OVUM WITHIN THE UTERUS DEVELOPS INTO A MOLE OR BENIGN TUOR |
| CONGENITAL ANOMALY | ABNORMAL CONDITION PRESENT AT BIRTH, WHICH MAY NOT BE RECOGNIZED UNTIL LATER IN LIFE |
| NEWBORN IMMATURITY | IMPLIES A BIRTH OF LESS THAN 37 WEEKS GESTATION |
| NEWBORN POSTMATURITY | A GESTATIONAL PERIOD OF MORE THAN 40 WEEKS |
| NEWBORN LOW BIRTH WEIGHT | IMPLIES A BIRTH WEIGHT OF 1000-2499 GRAMS |
| NEWBORN EXTREMELY LOW BIRTH WEIGHT | IMPLIES A BIRTH WEIGHT OF LESS THAN 500-999 GRAMS |
| DIASTOLIC HEART FAILURE | OCCURS WHEN THE HEART HAS A PROBLEM RELAXING BETWEEN CONTRACTIONS TO ALLOW ENOUGH BLOOD INTO THE VENTRICLES |
| SYSTOLIC HEART FAILURE | OCCURS WHEN THE ABILITY OF THE HEART TO CONTRACT DECREASES |
| THROMBOPHLEBITIS OF A VEIN | A CONDITION INDICATED BY A CLOT THAT HAS BECOME INFLAMED |
| THROMBOSIS OF A VEIN | A CONDITION INDICATED BY THE FORMING OF A CLOT |
| DIRECT EXTENSION | THE INVASION OF ADJACENT SITES BY A MALIGNANT NEOPLASM |
| INVASIVE | THE EXTENSION OF TUMOR CELLS TO OTHER ADJACENT SITES |
| METASTASIS | THE RESULTING SPREAD OF INVASIVE TUMOR CELLS |
| NEOPLASM | A NEW OR ABNORMAL GROWTH |
| EXTERNAL CAUSE CODES | INDICATE EXTERNAL CAUSE OF MORBIDITY; USED WITH INJURY AND POISONING CODES |
| PATHOLOGICAL FRACTURE | A FRACTURE CAUSED BY BONE WEAKENING ASSOCIATED WITH CONDITIONS SUCH AS OSTEOPOROSIS OR NEOPLASTIC DISEASES |
| RULE OF NINES | A TOOL TO HELP PHYSICIANS ESTIMATE THE AMOUNT OF BODY SURFACE INVOLVED IN A BURN |
| ADVERSE EFFECT | CLASSIFICATION OF A CONDITION CAUSED BY A DRUG OR ANOTHER SUBSTANCE WHEN USED CORRECTLY |
| POISONING | CLASSIFICATION OF A CONDITION CAUSED BY A DRUG OR ANOTHER SUBSTANCE WHEN USED INCORRECTLY |
| TOXIC EFFECT | CLASSIFICATION OF A CONDITION CAUSED BY INGESTION OR CONTACT WITH A HARMFUL SUBSTANCE |
| UNDERDOSING | CLASSIFICATION OF A CONDITION CAUSED BY TAKING LESS OF A MEDICATION THAN IS PRESCCRIBED BY A PROVIDER OR A MANUFACTURER'S INSTRUCTIONS |
| LATROGENIC CONDITION | CONDITION RESULTING FROM THE TREATMENT OF ANOTHER CONDITION |
| TABULAR LIST | CONTAINS CATEGORIES, SUBCATEGORIES, AND VALID CODES |
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