Chapter 17 Medical Billing and coding vocabulary 2

System for classifying disease tofacilitate collection of uniform and comparable health information, for statistical purposes and indexing medical records for data storage and retrieval

System containing the greater number of changes in ICD history. To allow more specific reproting of disease and newly recigbuzed conditions, the ICD-10-CM contains approximately 5500 more codes than ICD-9

The signs and symptoms of a disease

Notations, also known as instructional notations, are found in both the Alphabetic Index and the
Tabular Index as instructions or guides in classification assignments, defining category content or the use of subdivision codes.

Initial identification of the condition or complaint that the patient expresses in the outpatient medical setting

In the context of ICD-9_CM, the term "with," "with mention of," and "associated with" in a title dictate that both parts of the title be present in the statement of the diagnosis order to asign the particular code.

a direction given to the coder to look in another place. This term must always be followed and is found in the Alphabetic Index, Volume 2 and 3

A direction given to the coder to look elsewhere if the main term or subterm (or subterms) for that entry are not sufficient for coding the information. If a code number follows, "see also" is enclosed in parentheses. If ther is no code number, "see also" is preceded by a dash

A direction given to the coder to see a specific category (three digit code). This must always be followed

This term appears only in Volume 1 in thoe subdivisions in which the user should add further information by means of an additional code to give a more complete picture of the diagnosis.