ICD 10 CM CONVENTIONS PART 1
TLDRThe transcript discusses ICD-10-CM conventions, focusing on the format and structure of codes, including categories, subcategories, and the use of placeholder characters and abbreviations. It explains the importance of the seventh character in codes, the use of 'NOS' (Not Otherwise Specified) and 'NEC' (Not Elsewhere Classifiable), and the role of punctuation in the ICD-10-CM system. The video aims to educate viewers on the intricacies of medical coding, emphasizing the need for accurate and detailed documentation for proper code assignment.
Takeaways
- 📚 ICD-10-CM conventions are the general rules for classification independent of guidelines.
- 🗂️ ICD-10-CM is divided into two parts: Alphabetic Index and Tableau List, each with specific functions.
- 🔢 Categories in ICD-10-CM are three-character codes, with possible further subdivisions into subcategories and quotes.
- 🌟 The final level of subdivision in ICD-10-CM is referred to as a quote, and codes with a seventh character are valid only with that character.
- 📈 Subcategories can be 3, 4, 5, 6, or 7 characters long, each level representing a deeper level of specificity.
- 🔄 The 'X' character is used as a placeholder in certain codes to allow for further expansion, particularly in poisoning and adverse effect codes.
- 📌 Abbreviations such as 'NOS' (Not Otherwise Specified) and 'NEC' (Not Elsewhere Classifiable) are used for unspecified or detailed conditions without a specific code.
- 🔖 Punctuation in ICD-10-CM, including brackets, parentheses, and colons, serve specific purposes in coding, such as indicating manifestation codes or non-essential modifiers.
- 🏥 For conditions with detailed descriptions but no specific code, 'Other Specified' codes are used, while 'Unspecified' codes are for insufficient documentation.
- 📋 When reporting, only codes are permissible, not categories or subcategories, and any applicable 7th character is required.
- 🔍 Examples provided in the script illustrate the structure and application of ICD-10-CM codes in various medical scenarios.
Q & A
What are the two main components of ICD-10-CM?
-The two main components of ICD-10-CM are the Alphabetic Index and the Tabular List.
What is the purpose of the Alphabetic Index in ICD-10-CM?
-The Alphabetic Index is a list of terms and their corresponding codes, categorized into types such as diseases and injuries, external causes of injury, neoplasms, and drugs and chemicals.
How is the Tabular List structured in ICD-10-CM?
-The Tabular List is structured into chapters based on body systems or conditions, containing categories, subcategories, and codes.
What is the significance of the seventh character in ICD-10-CM codes?
-The seventh character in ICD-10-CM codes provides additional detail about the condition, and its absence makes the code invalid if the seventh character is applicable.
What is the role of the placeholder character 'X' in ICD-10-CM?
-The placeholder character 'X' is used in certain codes to allow for further expansion and is required for the code to be considered valid.
What are the two types of abbreviations used in ICD-10-CM and what do they represent?
-The two types of abbreviations are NEC (Not Elsewhere Classifiable) and NOS (Not Otherwise Specified). NEC is used when a specific code is not available, directing the coder to another specified code, while NOS is used when the information is insufficient to assign a more specific code.
How are punctuations like brackets, parentheses, and colons used in ICD-10-CM?
-Brackets are used to enclose synonyms, alternative wordings, or manifestation codes. Parentheses enclose non-essential modifiers or supplemental words. Colons are used after incomplete terms needing modifiers to make them assignable or in cases like 'use additional code' scenarios.
What is the difference between 'Other Specified' and 'Unspecified' codes in ICD-10-CM?
-Other Specified codes are used when the medical record provides a detailed description of a condition for which no specific code exists. Unspecified codes are used when there is insufficient documentation to assign a more specific code, and these codes can represent both 'other' and 'unspecified' scenarios for categories without a provided unspecified code.
How do you identify when to use a placeholder 'X' or a seventh character in ICD-10-CM?
-If a code requires a seventh character and it is not a six-character code, a placeholder 'X' must be used to fill in the empty characters. For codes with an applicable seventh character, this character must always be the seventh character in the data field.
What is the final level of subdivision in ICD-10-CM coding?
-The final level of subdivision in ICD-10-CM coding is referred to as a 'code', which can be a 3, 4, 5, 6, or 7-character term, depending on the level of detail required.
Can you provide an example of a code with a seventh character and its significance?
-An example of a code with a seventh character is S42.001D, which indicates a fracture of the unspecified part of the right clavicle with a subsequent encounter. The seventh character 'D' signifies that it is a subsequent encounter.
How are 'Other Specified' codes identified in the Alphabetic Index?
-In the Alphabetic Index, entries with 'NEC' in the line designate other specified codes, which represent specific disease entities for which no specific code exists.
Outlines
📚 Introduction to ICD-10-CM: Format, Structure, and Conventions
This paragraph introduces the ICD-10-CM coding system, emphasizing its conventions and structure. It explains the division of ICD-10-CM into an alphabetic index and a tabular list, with the former being an alphabetical list of terms and codes, and the latter organized by body system or condition. The importance of categories, subcategories, and codes is highlighted, with categories being three-character codes. The paragraph also details the significance of the seventh character in codes, which is essential for validity and further categorization. An example of typhoid fever coding is provided to illustrate the hierarchy and structure of ICD-10-CM codes.
🔢 Understanding ICD-10-CM Codes: Length and Placeholder Characters
This section delves into the specifics of ICD-10-CM codes, discussing the varying lengths of codes (3, 4, 5, 6, or 7 characters) and the use of placeholder characters (such as 'x') to allow for further expansion and specificity. Examples are given for 6-character codes related to malignant neuroendocrine tumors and 7-character codes for fractures, including the use of the seventh character to indicate subsequent encounters. The paragraph also addresses the use of placeholder characters for codes requiring additional characters, as seen in poisoning and adverse effect codes.
📝 Abbreviations and Punctuations in ICD-10-CM Coding
This paragraph discusses the use of abbreviations such as NEC (Not Elsewhere Classifiable) and NOS (Not Otherwise Specified) in ICD-10-CM coding. It explains how these abbreviations are used when a specific code is not available or when a condition is not clearly defined. The paragraph also covers the role of punctuation marks like brackets, parentheses, and colons in the coding system. Brackets are used to denote manifestation codes and synonyms, while parentheses enclose non-essential modifiers. The use of colons to complete incomplete terms and the concept of 'use additional code' are also explained with examples.
💡 Coding Examples and Conventions: Other Specified and Unspecified Codes
This section provides examples of other specified and unspecified codes in ICD-10-CM. It clarifies the use of these codes when a medical record provides detailed information that does not correspond to a specific code or when there is insufficient documentation to assign a more specific code. Examples are given for conditions like other viral enteritis, other specified anemias, other specified sepsis, and other specified cough. The importance of using the correct code to represent both other and unspecified scenarios when an unspecified code is not provided is emphasized.
👨🏫 Conclusion and Encouragement for Further Learning
The final paragraph concludes the video script by thanking the viewers for watching and encouraging them to subscribe for more videos on medical coding and CPC training. It serves as a call to action for viewers to continue their education on ICD-10-CM coding and related topics.
Mindmap
Keywords
💡ICD-10-CM
💡Format and Structure of Codes
💡Seventh Character
💡Placeholder Character
💡Abbreviations
💡Punctuations
💡Other Specified Codes
💡Unspecified Codes
💡Alphabetic Index
💡Tabular List
Highlights
ICD-10-CM conventions are the general rules for the use of classification independent of the guidelines.
ICD-10-CM is divided into two parts: Alphabetic Index and Tableau List.
The Alphabetic Index is a list of terms and their corresponding codes, while the Tableau List is structured by body system or condition.
The ICD-10-CM categories, subcategories, and codes can be represented by either a letter or a number.
All categories in ICD-10-CM are three-character codes, and a category with no further subdivision is equivalent to a code.
Subcategories can be 3, 4, 5, 6, or 7 characters long, with each level of subdivision after a category being referred to as a subcategory.
The final level of subdivision is a code, and codes with an applicable 7th character are still referred to as codes, not subcategories.
A code that requires an applicable 7th character is considered invalid without it.
For reporting purposes, only codes are permissible, not categories or subcategories, and any applicable 7th character is required.
The ICD-10-CM utilizes a placeholder character 'X' at certain codes to allow further expansion.
Abbreviations in ICD-10-CM include 'NOS' (Not Otherwise Specified) and 'NEC' (Not Elsewhere Classifiable).
Punctuations in ICD-10-CM include brackets, parentheses, and colons, each serving a specific purpose in the classification system.
Brackets are used in the Tableau List to enclose synonyms, alternative wordings, or explanatory phrases, and in the Alphabetic Index to identify manifestation codes.
Parentheses are used in both the Alphabetic Index and Tableau List to enclose non-essential modifiers.
Colons are used in the Tableau List after an incomplete term which needs one or more of the modifiers following the colon to make it assignable.
Other Specified codes are used when the medical record provides detailed information for a condition for which no specific code exists.
Unspecified codes are used when there is insufficient documentation in the medical record to assign a more specific code.
For categories where an unspecified code is not provided, other specified codes may represent both other and unspecified scenarios.
Examples of Other Specified codes include A08.39 for other specified enteritis, D64.89 for other specified anemias, and B33.8 for other specified viral diseases.
Examples of Unspecified codes include I63.9 for cerebral infraction unspecified, B34.0 for adenovirus infection unspecified, and A41.9 for sepsis unspecified organism.
Transcripts
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