Chapter 8 — Key Takeaways
The rule
Alphabetic Index first. Tabular List second. Always. For your entire career.
Step one finds it — the index knows synonyms, eponyms, and lay terms you do not. Step two governs it — and everything that governs a code is in the Tabular:
| Only in the Tabular |
|---|
| the complete code (the index prints a dash) |
| seventh character requirements, at category level |
| Excludes1 / Excludes2 notes |
| code first / use additional code / code also |
| laterality options and which character carries them |
| inclusion terms; block- and chapter-level notes |
You are not looking it up for the code. You are looking it up for the path — the thing you must reproduce two years from now for someone who was not there.
The index
Main terms are CONDITIONS, not body parts.
Knee — see condition is the index catching you.
- Indentation is meaning. Each level narrows the one above.
- A trailing dash = more characters required, only the Tabular has them.
- Main terms also include: encounter nouns (Screening, Aftercare, History, Examination), eponyms, abbreviations.
| Appearance | Changes the code? | Must be documented? | |
|---|---|---|---|
| Nonessential modifier | in ( parentheses ) | No | No |
| Essential modifier | indented subterm | Yes | Yes |
Parentheses are permission to ignore. Indentation is a requirement to document.
Excludes1 vs. Excludes2
| Excludes1 | Excludes2 | |
|---|---|---|
| Means | "NOT CODED HERE" | "NOT INCLUDED HERE" |
| The conditions | cannot occur together | can occur together |
| Report both? | No | Yes, when both documented |
| If your patient has it | you have the wrong code | you may need both codes |
Excludes1 — ONE of them. Excludes2 — you may need TWO.
The exception: where the two conditions are genuinely unrelated in this patient, both may be reported. Where unclear, query the provider — relatedness is a clinical determination and not yours to make.
Companion-code instructions
| Appears on | Sequencing | |
|---|---|---|
| Code first | the manifestation | fixed — underlying first |
| Use additional code | the etiology | fixed — this code first |
| Code also | either | not fixed — depends on the encounter |
"Code first" and "use additional code" are the same relationship from opposite ends and usually appear as a matched pair. "Code also" is not optional — it requires two codes and declines to order them.
NEC vs. NOS
| Means | What is limiting you | Fixable by a query? | |
|---|---|---|---|
| NOS | not otherwise specified | the record | Yes |
| NEC | not elsewhere classifiable | the code set | No |
NEC blames the book. NOS blames the note.
Descriptors containing "other" are usually NEC; "unspecified" is usually NOS.
Punctuation and conventions
| Tabular | Index | |
|---|---|---|
| [ ] | synonyms, explanatory phrases | manifestation codes — sequenced second |
| ( ) | nonessential modifiers | same |
| : | incomplete term; a modifier is required | — |
- "And" means and/or. "Bones and joints" covers either or both.
- "With" means associated with or due to — and can create an assumed causal relationship. Chapter 9 §9.7.
- "See" is mandatory. "See also" is advisory.
The three tables
| Table | Organized by | You must know first |
|---|---|---|
| Neoplasms | site × six behavior columns | the behavior |
| Drugs and Chemicals | substance × six circumstance columns | poisoning, adverse effect, or underdosing |
| External Causes | the event | what happened |
All three answers are clinical facts the record must supply — a coder may not. And all three are starting points: you still verify in the Tabular.
Key terms
Alphabetic Index · Tabular List · main term · subterm · essential modifier · nonessential modifier · dash · Excludes1 · Excludes2 · code first · use additional code · code also · NEC · NOS · Table of Neoplasms · Table of Drugs and Chemicals · External Cause Index
Monday morning
You should be able to:
- Find any condition in the index in under a minute, starting from the right kind of word.
- Recognize a dash and know it means you are not finished.
- Tell an essential modifier from a nonessential one at a glance.
- Apply Excludes1 and Excludes2 correctly, and know that one of them is permission.
- Document a lookup path someone could audit two years from now.
- Use all three specialty tables, and know what question each asks you first.
The Encounter: diagnosis A is now found, not just located.
Main term Pain, subterm joint, subterm knee, dash → Tabular, no seventh character, no Excludes applied, laterality in the sixth character, documentation supports right in three places → M25.561.
Three of step two's four findings were negative. That is what step two usually looks like — and the fourth one, the laterality character, was not available from the index at all.