Glossary of Coding Conventions and Rules

Terms	Definitions
see also	instructional term in the index that is located after a main term or subterm and directs the coder to another main term (or subterm) that may provide additional useful index entries.
see	instructional term in ICD–9–CM and ICD–10–CM/PCS that directs the coder to refer to another term in the indexes the code.
see category	instructional term in the index that directs the coder to the tabular list, where a code can be selected from the options provided.
see condition	instructional term in the index that directs the coder to the main term for a condition.
abbreviation	use of NEC (not elsewhere classifiable) and NOS (not otherwise specified). (NEC and NOS abbreviations do not appear in ICD–10–PCS.)
abbreviations	use of NEC (not elsewhere classifiable) and NOS (not otherwise specified). (NEC and NOS abbreviations do not appear in ICD–10–PCS.)
and	interpreted as meaning “and/or.”
boxed note	defines terms, provides coding instruction, and lists fifth–digit subclassifications for categories that use the same fifth digits; Index to Procedures boxed notes also provide coding instruction and list fourth–digit subclassifications for categories that use the same fourth digits. (Boxed notes do not appear in ICD–10–CM or ICD–10–PCS.)
code first underlying disease	tabular list instructional note that assists with proper sequencing of codes.
code, if applicable, any causal condition first	tabular list instructional note requires causal conditions to be sequenced first, if present.
coding conventions (ICD–10–CM)	general rules used in the ICD–10–CM classification system that are independent of coding guidelines.
coding conventions (ICD–9–CM)	general rules used in the ICD–9–CM classification systems that are independent of coding guidelines.
colon	used after an incomplete term in the tabular list when one or more additional terms (called modifiers) after the colon must be documented in the diagnostic or procedural statement to classify a condition or procedure.
cross–reference	instruction to refer to another entry in the index (e.g., see, see also, see condition) or tabular list (e.g., see category) to assign the correct code.
due to	index subterm (in alphabetical order) that indicates the presence of a cause–and–effect (or causal) relationship between two conditions.
eponym	disease, syndrome, or procedure named after a person.
etiology and manifestation rules	include the following in the tabular list: code first underlying disease; code, if applicable, any causal condition first; use additional code; and in diseases classified elsewhere.
excludes note	appears below codes in the tabular list to direct the coder to another location in the tabular list to classify conditions (or procedures) that are excluded from the code.
excludes1 note	appears below codes in the ICD–10–CM tabular list to direct the coder to another location in the tabular list to classify conditions that are excluded from the code – code either the original code or the code to which the excludes1 note directs you.
excludes2 note	appears below codes in the ICD–10–CM tabular list to direct the coder to another location in the tabular list to classify conditions that are excluded from the code – both the original code and the code to which the excludes2 note directs you can be reported if documentation supports both conditions.
format	index subterms are indented two spaces below a main term; second, third, and fourth qualifiers are indented two, four, and six spaces, respectively, below the subterm.
in	Index to Diseases subterm (in alphabetical order) that indicates the presence of a cause–and–effect (or causal) relationship between two conditions.
in (due to)	index subterm (in alphabetical order) that indicates the presence of a cause–and–effect (or causal) relationship between two conditions.
in diseases classified elsewhere	phrase that indicates that manifestation codes are a component of the etiology/manifestation coding convention.
includes note	appears immediately below tabular list codes to further define terms or provide examples.
inclusion term	listed below certain codes in the tabular lists; includes conditions or procedures for which that code number is to be assigned; can be synonyms of the code title or, for “other” codes, a list of conditions or procedures assigned to that code.
manifestation	condition that occurs as the result of another condition; a manifestation code is always reported as a secondary code.
modifier	additional term included after the colon in the ICD–9–CM tabular lists that is to be included in the statement to classify a condition or procedure.
NEC (not elsewhere classifiable)	equivalent of “other specified”; identifies codes that are to be assigned when information needed to assign a more specific code cannot be located in the coding manual.
NOS (not otherwise specified)	the equivalent of “unspecified”; identifies codes that are to be assigned when information needed to assign a more specific code cannot be obtained from the provider.
other and other specified codes	assigned when patient record documentation provides detail for which a specific code does not exist in the coding manual.
parentheses	used in the indexes and tabular lists to enclose nonessential modifiers, which are supplementary words that may be present in or absent from the physician’s statement of a disease or procedure without affecting the code number to which it is assigned.
punctuation	slanted brackets, square brackets, parentheses, and colons.
slanted brackets	used in the index to identify manifestation codes. (Square brackets are used in ICD–10–CM for this purpose.)
square brackets	used in the tabular lists to enclose synonyms, alternative wording, or explanatory phrases. (Used in ICD–10–CM index to enclose manifestation codes, which are always sequenced second.)
table	index feature that organizes subterms, second qualifiers, and third qualifiers and their codes in columns and rows to make it easier to select the proper code. (Tables also appear in ICD–10–PCS, instead of a tabular list, to facilitate assignment of values to create the seven–character code.)
trust the index	concept that inclusion terms listed in the Tabular List of Diseases are not meant to be exhaustive and that additional terms found only in the Index to Diseases (but not in the Tabular List of Diseases) may also be assigned to a code.
unspecified code	assigned when patient record documentation is insufficient to assign a more specific code.
use additional code	instructional note that assists in proper sequencing of the codes.
with	located below an index main term or subterm in alphabetical order. Read More  ">http://training.velanhcs.com/courses</a>