Basic Medical Coding Terminology — Medical Coding Terms

Basic Medical Coding Terminology — Medical Coding Terms

November 2, 2019 10 By Jose Scott


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. Get more cpc exam tips, coding certification
training and ceu credits. Go to www.codingcertification.org