LessonLesson 04: Guidance Terms-Excludes 1 – means “not coded here” think “one best code is needed”-Excludes 2 – means “not included here”. Think “two codes are needed”-“Code first" and "Use additional code" are guidance terms to help the coder do the following:oRecognize that two codes should be assigned to fully report a diagnosisoRemember the sequence in which the codes should be reported.oAlways code etiology first then manifestation codeo“Use additional code” will appear under etiology code while “Code first underlying disease” will appear under manifestation code-“code first" also appears under some non-italicized codes to indicate that two codes should be assignedto fully report a condition, but only if the instruction pertains to the diagnosis.-“code also” means that two codes are needed but the sequence of the codes do not matter-Brackets are meant to enclose synonyms-Parentheses enclose nonessential modifiers. These nonessential modifiers do not affect the main term diagnosis and will be chosen whether the nonessential modifiers are there or not-Colons are followed after diagnostic terms that are incomplete and must need a companion term in order to be a complete code-Not Elsewhere Classifiable (NEC) - A convention that denotes that a specific diagnosis was documented but there is no corresponding code for that specific diagnosis-Not Otherwise Classifiable (NOS) - A specific diagnosis is not documented. The documentation is not specific enough to assign a specific code.Lesson 05: Steps to Coding-The basic steps in coding1.Locate the main term in the alphabetic index.2.Review any subterms.3.Check for notes in the alphabetic index.4.Reference the code number selected in the tabular list.5.Check for notes in the tabular list.6.Assign the code.-A dash (-) at the end of an alphanumeric index code indicates that an additional code is required. A code without the dash means an additional code is not required but must still be looked up into the Tabular list to verify that no additional code is needed-Combination codes use one code to specify two diagnoses such as a diagnosis with an associated secondary process (manifestation), a diagnosis with an associated sign or symptom, or a diagnosis with an associated complication-When a certain underlying condition has an etiology followed by multiple manifestations, then there needs to be multiple codes. The etiology is coded first
followed by the manifestation. You will see a code followed by another code in brackets, which both need to be coded to fully code for the diagnosis. -Multiple codes may be required to fully describe a condition for many types of situations, including the following: late effects, complication codes, obstetric codes.