There are so many basic coding terms you need to know early on.
Here are a few with simple explanations.
I get questions on these when people start the first couple chapters of the coding.
The books tend to make them much harder than they have to be.
Itís actually very simple.
When they say category, subcategory, subclassification or truncated codes or main terms, what theyíre
really meaning is for category codes.
Thatís a 3 digit code.
So like COPD is 496 and you donít need any other digits to explain COPD, itís 496.
So thatís a category code.
Now even if a code like hypertension which is 401.9, thatís just like essential hypertension,
that has a subcategory which is 9.
But the category would be 401, the 3 digits but it has an additional subcategory which
is 9, which explains the code a little bit more.
And as a general rule, if something ends in 9, itís unspecified.
Thatís the way it is in ICD 9.
In ICD 10, itíll be different.
But then, you can extend that out.
ICD 9 codes go up to 5 digits.
The last digit is called a subclassification.
So thatís a 5th digit.
Diabetes, 250.00.
One of the mostÖ I think, well known subclassification code because everybody knows, if youíve been
coding for very long and you will note this for your exams because theyíll tend to do
this to make sure youíre paying attention, I guessÖ that if a diabetic code does not
have 5 digits, itís not a valid code.
If you accidentally leave off that last 0 or the 1 or the 2 you would put there then
youíre not going to get paid because itís not a valid code.
It has a subclassification.
And what it ultimately means is diabetes is so expandable, they canít fit everything
that is involved with diabetes into those 4 digits or 3 digits.
Now if a code is not taken to the highest level or the last digit thatís available
like a subclassification is called truncated.
And so you always want to be as specific as you can in your classifications.
Remember, youíll hear that again and again, go to the highest specificity.
Thatís why you never see the DM code without 5 digits.
Thatís an automatic giveaway that that is not a valid code.
Now when you hear the term ëmain termí this isÖ theyíre talking about whatís the main
term youíre going to go look up in the index.
So when youíre looking up in your manuals, your ICD9 you know, you have the index and
you have the tabular.
You look up the main term in your index and then you look up that code and say itís diabetes.
And it says 250 and then you go and you find 250 in the tabular and then you find out if
it needs additional digits and it does.
So some of the books that I used at the college would give you lists of different diagnostic
terms to show you or help you practice what is the main term that you would look up.
Because Iím telling you, if you look up the wrong main term, youíre going to take more
time because youíre not going to be able to find it.
So in this first one, senile dementiaÖ and I underlined all of the main terms there in
that list that you would use.
So senile dementia, what does the person have?
They donít have senile, they have dementia.
Thatís the main term.
Allergic enteritis.
Enteritis is what they have, they donít have allergic.
Renal hypertension.
Now renal is a main term but hypertension is the type ofÖ itís what type of hypertension
they have.
Chronic bronchitis is bronchitis.
Chronic and acute is not a main term.
Acquired deformity of the ankle ñ youíre going to look up deformity.
Nasal packing due to severe epistaxis ñ and if you donít know epistaxis, it just means
theyíve got a bloody noseÖ so itís epistaxis.
Hepatic infarct, the hepatic would be the liver and an infarct is a blockage.
And so you can have you know, like a myocardial infarct of the heart.
Itís a blockage someplace and that one just happens to be in the liver.
Now thisÖ I may not pronounce this right, this Reynaudís gangrene.
Thatís kind of a tricky one because you would normally say gangrene.
But if it is named after somebody and that letter is capitalized, you can usually look
it up by that name as well in the index.
So thatís kind of a tricky one.
Acute cholecystitis with obstruction, itís cholecystitis.
They have an obstruction but where is the obstruction?
Itís in the gallbladder so they have cholecystitis.
So thatís just kind of like a basic overview of when you first start coding, how to find
the highest specificity.
Be aware that most coding manuals will have a little dot or a little stop sign we call
themÖ it depends whether you have a color coded book.
Itís usually red that tells you, you know, stop, you need more digits.
Be aware of that when youíre taking your exam.
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