- Acute Conditions –
The medical conditions characterized by sudden onset, severe
change, and/or short duration.
- Additional Diagnosis –
The secondary diagnosis code used, if available, to provide
a more complete picture of the primary diagnosis.
- Bilateral – For bilateral
sites, the final character of the codes in the ICD-10-CM
indicates laterality. An unspecified side code is also provided
should the side not be identified in the medical record.
If no bilateral code is provided and the condition is bilateral,
assign separate codes for both the left and right side.
- Category – The three-digit
diagnosis code classifications that broadly define each
condition (e.g., 250 for diabetes mellitus).
- Centers for Disease Control and Prevention
(CDC) – A federal health data organization
that helps maintain several code sets included in the HIPAA
standards, including the ICD-9-CM codes. A division of the
Department of Health and Human Services responsible for
monitoring, researching and developing public health policies
for the prevention of disease, injury and disability and
the promotion of healthy behaviors. The National Center
for Health Statistics is the part of the CDC that maintains
health related statistics including the coordination with
World Health Organization (WHO) on use of International
Classification of Diseases (ICD) in North America.
- Chronic Conditions –
Medical conditions characterized by long duration, frequent
recurrence over a long period of time, and/or slow progression
- Combination Codes –
A single code used to classify any of the following: two
diagnoses; a diagnosis with an associated secondary process
(manifestation); or a diagnosis with an associated complication.
- Conventions of ICD-10 –
The general rules for use of the classification independent
of guidelines. These conventions are incorporated within
the Index and Tabular of the ICD-10-CM as instructional
notes. Possible conventions to include with code are:
• Notes – Extra information to
define or clarify code choice.
• Includes Notes – This note appears
immediately under a three character code title to further
define, or give examples of, the content of the category.
• Not otherwise specified (NOS) –
This abbreviation is the equivalent of unspecified.
• Excludes Notes – A type 1 Excludes
note is a pure excludes note. It means “NOT CODED
HERE!” An Excludes1 note indicates that the code excluded
should never be used at the same time as the code above
the Excludes1 note. An Excludes1 is used when two conditions
cannot occur together, such as a congenital form versus
an acquired form of the same condition. A type 2 excludes
note represents “Not included here.” An excludes2
note indicates that the condition excluded is not part of
the condition represented by the code, but a patient may
have both conditions at the same time. When an Excludes2
note appears under a code, it is acceptable to use both
the code and the excluded code together, when appropriate.
• Not elsewhere classifiable (NEC) –
This abbreviation in the Tabular List represents “other
specified.” When a specific code is not available
for a condition the Tabular List includes an NEC entry under
a code to identify the code as the “other specified”
- Crosswalk/mapping –
A new test is determined to be similar to an existing test,
multiple existing test codes, or a portion of an existing
test code. The new test code is then assigned to the related
existing local fee schedule amounts and resulting national
limitation amount. In some instances, a test may only equate
to a portion of a test, and, in those instances, payment
at an appropriate percentage of the payment for the existing
test is assigned.
- Centers for Medicare & Medicaid
Services (CMS) – The federal agency that
runs the Medicare program. In addition, CMS works with the
States to run the Medicaid program. CMS works to make sure
that the beneficiaries in these programs are able to get
high quality healthcare.
- Current Procedural Terminology (CPT
)Codes – This is the procedural coding system
that is currently used in America primarily to report physician
professional services. Frequently called “CPT”,
the Current Procedural Terminology, is a code set, developed
in 1966 and maintained by the American Medical Association
(AMA), used to describe what healthcare professional services
were provided or utilized by healthcare professionals. CPT
codes are also known as “Level I” codes. Additional
codes to describe use of healthcare facilities and services
provided by healthcare professionals are known as “Level
II” or “Healthcare Common Procedure Coding System”
(HCPCS). Level II codes were developed are maintained by
- Federal Register –
The “Federal Register” is the official daily
publication for rules, proposed rules and notices of federal
agencies and organizations, as well as Executive Orders
and other Presidential documents.
- GEMs - This reference mapping
attempts to include all valid relationships between the
codes in the ICD-9-CM diagnosis classification and the ICD-10-CM
- Healthcare Common Procedure Coding
System (HCPCS) – A medical code set that
identifies healthcare procedures, equipment, and supplies
for claim submission purposes. It has been selected for
use in the HIPAA transactions. HCPCS Level I contains numeric
CPT codes which are maintained by the AMA. HCPCS Level II
contains alphanumeric codes used to identify various items
and services that are not included in the CPT medical code
set. These are maintained by Health Care Financing Administration
(HCFA), Blue Cross and Blue Shield Association (BCBSA),
and the Health Insurance Association of America (HIAA).
HCPCS Level III contains alphanumeric codes that are assigned
by Medicaid state agencies to identify additional items
and services not included in levels I or II. These are usually
called "local codes", and must have "W",
"X", "Y", or "Z" in the first
position. HCPCS Procedure Modifier Codes can be used with
all three levels, with the WA - ZY range used for locally
assigned procedure modifiers.
- Health Insurance Portability &
Accountability Act (HIPAA) – A law passed
in 1996 which is also sometimes called the “Kassebaum-Kennedy”
law. This law expands healthcare coverage for patients who
have lost or changed jobs, or have pre-existing conditions.
HIPAA does not replace the states' roles as primary regulators
of insurance. The HIPAA legislation has the following broad
goals, to provide: 1) a way to uniquely identify providers,
employers and health plans, 2) a uniform level of protection
of health information, known as the "Security Rule,"
3) a uniform level of protection of the privacy of health
data associated with patients, known as the "Privacy
Rule" and 4) a simpler healthcare electronic transaction
process by describing standards by which all healthcare
administrative entities would use, which is known as the
“Transactions and Code Sets Rule”.
- HIPAA 4010 – The original
healthcare transactions version of HIPAA (officially known
as Version 004010 of the ASC X12 transaction implementation
guides) named as part of HIPAA’s Electronic Transaction
Standards regulation. Version 4010 was required to be used
by HIPAA covered healthcare entities by Oct. 16, 2003.
- HIPAA 5010 – Required
by Jan. 1, 2012 to be the new version of the HIPAA healthcare
transactions. Officially known as Version 005010 of the
ASC X12 transaction Technical Report Type 3. This new version
was required as a result of Department of Health and Human
Services (HHS) final rules published on Jan. 6, 2009.
- International Classification of Diseases
(ICD) – A medical code set maintained by
the World Health Organization (WHO). The primary purpose
of this code set is to classify both causes of death or
mortality and diseases or morbidity. A U.S. extension, known
as ICD-CM, “Clinical Modification,” is maintained
by the NCHS within the CDC to more precisely define ICD
use in the U.S.
- ICD-9 – The mortality
and morbidity classification coding system that is currently
used throughout most of the world, including the United
States. The ICD-9 classification of death and disease is
based a series of classifications systems first adopted
- ICD-9-CM – The “clinical
modification” to the ICD-9 code set that is currently
used in America to report medical diagnoses. The “Clinical
Modification” refers to the base WHO defined ICD-9
code set that has been defined for use in United State by
the National Center for Health Statistics (NCHS) division
of the Centers for Disease Control (CDC).
- ICD-9-PCS – The procedural
coding system currently used in America primarily for hospital
inpatient services. It is contained in Volume 3 of ICD-9-CM.
- ICD-10 – The mortality
and morbidity classification coding system implemented by
WHO in 1993 to replace ICD-9.
- ICD-10-CM – The updated
version of the clinical modification coding set defined
by the National Center for Health Statistics that will replace
ICD-9-CM no sooner than Oct. 1, 2015.
- ICD-10-PCS – The updated
procedural coding system defined by CMS that will replace
Volume 3 of ICD-9-CM for hospital inpatient services.
- Index (to diseases) –
The ICD-10-CM is divided into the Alphabetic Index, an alphabetical
list of terms and their corresponding code, and the Tabular
List, a chronological list of codes divided into chapters
based on body system or condition. The Alphabetic Index
consists of the following parts: the Index of Diseases and
Injury, the Index of External Causes of Injury, the Table
of Neoplasms and the Table of Drugs and Chemicals.
- Manifestation Codes –
Certain conditions have both an underlying etiology and
multiple body system manifestations due to the underlying
etiology. For such conditions, the ICD-10-CM has a coding
convention that requires the underlying condition be sequenced
first followed by the manifestation. Wherever such a combination
exists, there is a “use additional code” note
at the etiology code, and a “code first” note
at the manifestation code. These instructional notes indicate
the proper sequencing order of the codes, etiology followed
- Medical Necessity –
Services or supplies that: are proper and needed for the
diagnosis or treatment of a medical condition; are provided
for the diagnosis, direct care, and treatment of a medical
condition; meet the standards of good medical practice in
the local area; and are not mainly for the convenience of
the patient or doctor.
- Morbidity – Term refers
to the disease rate or number of cases of a particular disease
in a given age range, gender, occupation, or other relevant
population based grouping.
- Mortality –Term refers
to the death rate reflected by the population in a given
region, age range, or other relevant statistical grouping
- National Center for Health Statistics
(NCHS) – A federal organization within the
CDC that collects, analyzes, and distributes healthcare
statistics. The NCHS helps maintain the ICD-CM codes.
- Principle Diagnosis –
First-listed/primary diagnosis code. The code sequenced
first on a medical record defines the primary reason for
the encounter as determined at the end of the encounter.
- Signs/Symptoms – Codes
that describe symptoms and signs, as opposed to diagnoses,
are acceptable for reporting purposes when a related definitive
diagnosis has not been established (confirmed) by the provider.
- Sequelae – A late
effect is the residual effect (condition produced) after
the acute phase of an illness or injury has terminated.
There is no time limit on when a late effect code can be
used. The residual may be apparent early, such as in cerebral
infarction, or it may occur months or years later, such
as that due to a previous injury.
- Tabular List – It
is essential to use both the Alphabetic Index and Tabular
List when locating and assigning a code. The Alphabetic
Index does not always provide the full code. Selection of
the full code, including laterality and any applicable 7th
character can only be done in the Tabular List. A dash (-)
at the end of an Alphabetic Index entry indicates that additional
characters are required. Even if a dash is not included
at the Alphabetic Index entry, it is necessary to refer
to the Tabular List to verify that no 7th character is required.
- Uniform Hospital Discharge Data Set
(UHDDS) – The UHDDS definitions are used
by hospitals to report inpatient data elements in a standardized
manner. These data elements and their definitions can be
found in the July 31, 1985, Federal Register (Vol. 50, No,
147), pp. 31038-40.
- Volume I – The detailed,
tabular list of diagnosis codes in the ICD-9-CM manual.
- Volume II – The alphabetical
index to diseases in the ICD-9-CM diagnosis coding manual.
- Volume III – The ICD-9/ICD-10
list of procedure codes, used in inpatient settings.
- World Health Organization (WHO)
– An organization that maintains the International
Classification of Diseases (ICD) medical code set.
2011 Official Draft Coding Guidelines – http://www.cdc.gov/nchs/icd/icd10cm.htm#10update
Centers for Medicare & Medicaid Services
Medpac – http://medpac.gov/