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