Successfully navigating the transition
to ICD- 10 terminology
by Sarah Kurusz
V100 No 12 BULLETIN American College of Surgeons
44 |
WHAT SURGEONS SHOULD KNOW ABOUT...
The 10th revision of the International Classification of Diseases (ICD- 10) took
effect October 1 in the U.S.
The change to ICD- 10 allows
you and your coders to capture
more details about the health
status of patients and sets the
stage for improved patient care
and public health surveillance
across the country. As with any
new government policy, law,
standard, or code, questions
are sure to arise. The American
College of Surgeons (ACS) is
taking steps to ease the transition
to ICD- 10 from ICD- 9.
Glossary of terms
Besides the task of transitioning
to ICD- 10, surgeons and their
staff should become familiar
with new terminology to
properly code with the expanded
code set. Following is a useful
glossary of ICD- 10 terms to help
ensure a smooth transition.
•Alphabetic Index: An alphabetical
list of ICD-10-CM (Clinical
Modification) terms and their
corresponding codes, which helps
to determine which section to
refer to in the Tabular List. It does
not always provide the full code.
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.
•Acute conditions: 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 also is
provided in instances where the
side may be unidentified 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
(for example, 250 for diabetes
mellitus).
•Character “x”: Used as a
placeholder in ICD-10-CM in
certain codes to allow for future
expansion and to fill in empty
characters when a code that is
less than six characters in length
requires a seventh character.
•Chronic conditions: Medical
conditions characterized by long
duration, frequent recurrence
over a long period of time, and/or
slow progression over time.
• Combination codes: Single codes
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 List of the ICD-10-CM
as instructional notes. Possible
conventions to include with codes
include the following:
Ȗ Notes: Extra information to
define or clarify code choice.
Ȗ Includes notes: This note
appears immediately under a
three-character code title to
further define or give examples
of the content of the category.
Ȗ Not otherwise specified (NOS):
This abbreviation is the
equivalent of “unspecified.”
