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Coding Terms
| Term | Definition |
|---|---|
| NEC | not elsewhere classified; used in the Alpha 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" |
| Excludes1 | NOT CODED HERE |
| Excludes2 | NOT INCLUDED HERE |
| Parentheses | used to enclose supplementary words or explanatory info that may be either present or absent in the statement of diagnosis without affecting the code to which it is assigned. |
| Non-Essential Modifiers | are used to suggest the terms in the parentheses are included in the code but need to be stated in the diagnosis |
| Square Brackets | used in the Tabular List to enclose synonyms, alternative wordings, abbreviations and explanatory phrases that provide additional info; never be assigned as principal diagnosis |
| Colons | used in the Tabular List in both inclusion and exclusion notes after an incomplete term that needs one or more of the modifiers following the colon in order for the term to apply |
| "And" | should be interpreted to mean either "and" or "or" |
| "With" | should be interpreted to mean "associated with" or "due to" |
| MS-DRG System | Medicare Severity-Adjusted Diagnosis-Related Groups system; a patient classification system used in hospital inpatient reimbursement |
| Other Reportable Diagnoses | conditions that coexist a the time of 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; info used for reporting inpatient data in acute care, short-term care and long-term care hospitals |
| 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 health care practitioner, who is legally accountable for establishing the patient's diagnosis |
| Tabular List | contains categories, subcategories and valid codes |
| "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 |
| ValueApproach | the 5th character in the code in the Medical and Surgical Section; the way the procedure site is reached |
| Qualifier | the 7th character in the code in the Medical and Surgical Section; it carries additional info for that particular procedure |
| Root Operation | the 3rd character in ICD-10-PCS code, which refers to the objective of the procedure |
| Principal Procedure | procedure performed for definitive treatment (rather than for the diagnostic or exploratory purposes) |
| Z Codes | codes for factors influencing health status and contact with health services |
| External Cause of Morbidity Codes | codes for external causes to provide info for injury research and evaluation of injury prevention strategies |
| Aftercare Management | continued care during the healing phase or long-term care due to the consequences of a disease |
| Sign | objective evidence of disease observed by the examining physician |
| Symptom | subjective observation reported by the patient |
Created by:
wallace263
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