Module 1: Introduction to the ICD-10-CM
IN THIS LESSON
Speaking the Coding Language
"Speaking the coding language" means understanding and correctly applying the specific terminology and conventions of ICD-10-CM to accurately translate medical diagnoses into standardized codes.
ICD-10-CM Key Terminology – Speaking the Coding Language
Understanding the specific language used in ICD-10-CM is essential for accurate coding. It's like learning the vocabulary of a new subject. Here are some key terms and definitions you'll need to know:
1. Diagnosis:
Definition: The identification of a disease, condition, or injury based on its signs, symptoms, and other diagnostic procedures.
Importance: ICD-10-CM codes are assigned to diagnoses.
2. Principal Diagnosis:
Definition: The condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care.
Importance: This is the main reason for the patient's encounter and is crucial for inpatient coding.
3. Secondary Diagnosis:
Definition: All conditions that coexist at the time of admission, that develop subsequently, or that affect the treatment received and/or the length of stay.
Importance: These are additional conditions that impact patient care.
4. Code:
Definition: A combination of letters and numbers that represents a specific diagnosis or condition in the ICD-10-CM system.
Importance: Codes are the core of the ICD-10-CM system.
5. Alphabetic Index:
Definition: An alphabetical listing of diagnoses, conditions, and reasons for encounters in the ICD-10-CM manual.
Importance: Used to locate potential codes.
6. Tabular List:
Definition: A numerical listing of ICD-10-CM codes, organized by chapters, with detailed descriptions and instructions.
Importance: Used to verify and confirm codes.
7. "Includes" Notes:
Definition: Notes in the Tabular List that further define or provide examples of the content of a code category.
Importance: Helps ensure accurate code selection.
8. "Excludes" Notes:
Definition: Notes in the Tabular List that indicate conditions that are not coded to the current code.
Importance: Prevents incorrect code assignment.
9. "Code Also" Notes:
Definition: Instructions in the Tabular List indicating that another code should be assigned in conjunction with the primary code.
Importance: Ensures all relevant conditions are coded.
10. "Use Additional Code" Notes:
Definition: Instructions in the Tabular List indicating that an additional code should be used to provide a more complete picture of the diagnosis.
Importance: Provides additional specificity.
11. "See" and "See Also" References:
Definition: Directives in the Alphabetic Index that guide the coder to other terms or locations within the index.
Importance: Helps locate the correct code when the initial search is unsuccessful.
12. "NEC" (Not Elsewhere Classifiable):
Definition: Used when a specific code does not exist for a condition that is documented in the medical record.
Importance: Indicates that the condition is coded to a general category.
13. "NOS" (Not Otherwise Specified):
Definition: Used when the medical record lacks the information needed to assign a more specific code.
Importance: Indicates that the condition is unspecified.
14. Laterality:
Definition: The specification of whether a condition affects the right, left, or bilateral side of the body.
Importance: Many ICD-10-CM codes require laterality to be specified.
Why These Terms Matter:
Understanding these terms will help you navigate the ICD-10-CM manual more effectively and ensure you're assigning accurate codes. It's like learning the building blocks of the coding language.
Practical Application:
As you work with the ICD-10-CM manual, you'll see these terms used frequently. Pay close attention to them, and don't hesitate to look them up if you're unsure of their meaning.