![]() Conditions that are an integral part of the disease process Signs and symptoms that are associated routinely with a disease process should not be assigned a additional codes unless otherwise instructed by the classifications Conditions that are NOT an integral part of the disease process Additional signs an symptoms that may not be associated routinely with a disease process should be coded when present. Signs and symptoms Codes that describe symptoms and signs, as opposed to diagnosis, are acceptable for reporting purposes when a related definitive diagnosis has not been established (confirmed) by the provider. In the absence of Alphabetic Index guidance, assign codes for the documented manifestations of the syndromes. Syndromes Follow the Alphabetic Index guidance when coding syndromes. Example, appendicitis, w/o any additional information, such as acute or chronic, the default code should be assigned. The default code represents that condition that is most commonly associated with the main term, or is the unspecified code for the condition. ![]() Default codes A code listed next to a main term in the ICD-10-CM Alphabetic Index is referred to as a default code. "Code also note" A "code also" note instructs that two codes may be required to fully describe a condition, but this note does not provide sequencing direction. "See Also" A "see also" instruction following a main term in the Alphabetic Index instructs that there is another main term that may also be referenced that may provide additional Alphabetic Index entries that may be useful. It is necessary to go to the main term referenced with the "see" note to locate the correct code. "See" The "see" instruction following a main term in the Alphabetic Index indicates that another term should be referenced. "With" The word "with" should be interpreted to mean "associated with" or "due to" when it appears in a code title, the Alphabetic Index, or and instructional not in the Tabular List. It is acceptable to use both the code and the excluded code together, when appropriate. An excludes 2 note indicates that the condition excluded is not part of the condition represented y the code but a patient may have both conditions at the same time. Excludes 2 A type 2 excludes note represents "Not included here". It means "NOT CODED HERE!" An Exclude 1 note indicates that the code excluded should never be used at the same time as the code above the Exclude 1 note. Excludes 1 A type 1 Exclude note is a pure exclude note. These terms are the conditions for which that code is to be used. Inclusion Terms List of terms is included under some codes. ![]() Includes Notes This note appears immediately under a three character code title to further define or give examples of, the content of the category. "Unspecified" codes Codes titled "unspecified" are for use when the information in the medical record is insufficient to assign a more specific code. "Other" codes Codes titled "other" or "other specified" are for use when the information in the medical record provides detail for which a specific code does not exist. ![]()
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