ICD-10 Diagnosis Code D48.0

Neoplasm of uncertain behavior of bone/artic cartl

Diagnosis Code D48.0

ICD-10: D48.0
Short Description: Neoplasm of uncertain behavior of bone/artic cartl
Long Description: Neoplasm of uncertain behavior of bone and articular cartilage
This is the 2019 version of the ICD-10-CM diagnosis code D48.0

Valid for Submission
The code D48.0 is valid for submission for HIPAA-covered transactions.

Code Classification
  • Neoplasms (C00–D48)
    • Neoplasms of uncertain behavior, polycythemia vera and myelodysplastic syndromes (D37-D48)
      • Neoplasm of uncertain behavior of other and unsp sites (D48)
Version 2019 Billable Code Neoplasm Uncertain Behavior

Information for Medical Professionals

Diagnostic Related Groups
The diagnosis code D48.0 is grouped in the following Diagnostic Related Group(s) (MS-DRG V35.0)

  • 456 - SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE OR MALIGNANCY OR INFECTION OR EXTENSIVE FUSIONS WITH MCC
  • 457 - SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE OR MALIGNANCY OR INFECTION OR EXTENSIVE FUSIONS WITH CC
  • 458 - SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE OR MALIGNANCY OR INFECTION OR EXTENSIVE FUSIONS WITHOUT CC/MCC

Convert to ICD-9
  • 238.0 - Unc behav neo bone

Synonyms
  • Giant cell neoplasm of bone of pelvis
  • Giant cell neoplasm of clavicle
  • Giant cell neoplasm of long bone of lower limb
  • Giant cell neoplasm of mandible
  • Giant cell neoplasm of sacrum
  • Giant cell tumor of bone
  • Giant cell tumor of bone and articular cartilage
  • Giant cell tumor of craniofacial bones
  • Giant cell tumor of long bone of upper limb
  • Giant cell tumor of short bone of lower limb
  • Giant cell tumor of short bone of upper limb
  • Mass of parietal bone of skull
  • Neoplasm of acromion
  • Neoplasm of calcaneus
  • Neoplasm of clavicle
  • Neoplasm of coccyx
  • Neoplasm of cuboid
  • Neoplasm of ethmoid bone
  • Neoplasm of first cuneiform bone of foot
  • Neoplasm of frontal bone
  • Neoplasm of hamate bone
  • Neoplasm of ilium
  • Neoplasm of ischium
  • Neoplasm of lunate bone
  • Neoplasm of maxilla
  • Neoplasm of nasal bone
  • Neoplasm of navicular bone of foot
  • Neoplasm of occipital bone
  • Neoplasm of palatine bone
  • Neoplasm of parietal bone
  • Neoplasm of patella
  • Neoplasm of phalanx of foot
  • Neoplasm of phalanx of hand
  • Neoplasm of pisiform bone of hand
  • Neoplasm of pubis
  • Neoplasm of radius
  • Neoplasm of rib
  • Neoplasm of scaphoid bone
  • Neoplasm of second cuneiform bone of foot
  • Neoplasm of sphenoid bone
  • Neoplasm of sternum
  • Neoplasm of talus
  • Neoplasm of third cuneiform bone of foot
  • Neoplasm of trapezium
  • Neoplasm of trapezoid bone
  • Neoplasm of ulna
  • Neoplasm of uncertain behavior of acromion
  • Neoplasm of uncertain behavior of articular cartilage
  • Neoplasm of uncertain behavior of bone
  • Neoplasm of uncertain behavior of bone and articular cartilage
  • Neoplasm of uncertain behavior of bone of face
  • Neoplasm of uncertain behavior of bone of hand
  • Neoplasm of uncertain behavior of bone of lower limb
  • Neoplasm of uncertain behavior of bone of skull
  • Neoplasm of uncertain behavior of bone of upper limb
  • Neoplasm of uncertain behavior of calcaneus
  • Neoplasm of uncertain behavior of carpal bone
  • Neoplasm of uncertain behavior of cervical vertebral column
  • Neoplasm of uncertain behavior of chest wall
  • Neoplasm of uncertain behavior of chest wall
  • Neoplasm of uncertain behavior of clavicle
  • Neoplasm of uncertain behavior of coccyx
  • Neoplasm of uncertain behavior of cuboid
  • Neoplasm of uncertain behavior of ethmoid bone
  • Neoplasm of uncertain behavior of femur
  • Neoplasm of uncertain behavior of first cuneiform bone of foot
  • Neoplasm of uncertain behavior of forearm
  • Neoplasm of uncertain behavior of forearm
  • Neoplasm of uncertain behavior of frontal bone
  • Neoplasm of uncertain behavior of hamate bone
  • Neoplasm of uncertain behavior of ilium
  • Neoplasm of uncertain behavior of ischium
  • Neoplasm of uncertain behavior of long bone of lower limb
  • Neoplasm of uncertain behavior of long bone of upper limb
  • Neoplasm of uncertain behavior of lumbar vertebral column
  • Neoplasm of uncertain behavior of lunate bone
  • Neoplasm of uncertain behavior of mandible
  • Neoplasm of uncertain behavior of maxilla
  • Neoplasm of uncertain behavior of metacarpal bone
  • Neoplasm of uncertain behavior of metatarsal bone
  • Neoplasm of uncertain behavior of nasal bone
  • Neoplasm of uncertain behavior of navicular bone of foot
  • Neoplasm of uncertain behavior of nose
  • Neoplasm of uncertain behavior of nose
  • Neoplasm of uncertain behavior of occipital bone
  • Neoplasm of uncertain behavior of palate
  • Neoplasm of uncertain behavior of palatine bone
  • Neoplasm of uncertain behavior of parietal bone
  • Neoplasm of uncertain behavior of patella
  • Neoplasm of uncertain behavior of pelvic bone
  • Neoplasm of uncertain behavior of phalanx of foot
  • Neoplasm of uncertain behavior of phalanx of hand
  • Neoplasm of uncertain behavior of pisiform bone of hand
  • Neoplasm of uncertain behavior of pubis
  • Neoplasm of uncertain behavior of radius
  • Neoplasm of uncertain behavior of rib
  • Neoplasm of uncertain behavior of sacrum
  • Neoplasm of uncertain behavior of scaphoid bone
  • Neoplasm of uncertain behavior of scapula
  • Neoplasm of uncertain behavior of second cuneiform bone of foot
  • Neoplasm of uncertain behavior of septum of nose
  • Neoplasm of uncertain behavior of short bone of lower limb
  • Neoplasm of uncertain behavior of short bone of upper limb
  • Neoplasm of uncertain behavior of shoulder
  • Neoplasm of uncertain behavior of skeletal system
  • Neoplasm of uncertain behavior of sphenoid bone
  • Neoplasm of uncertain behavior of sternum
  • Neoplasm of uncertain behavior of talus
  • Neoplasm of uncertain behavior of tarsal bone
  • Neoplasm of uncertain behavior of temporal bone
  • Neoplasm of uncertain behavior of thigh
  • Neoplasm of uncertain behavior of third cuneiform bone of foot
  • Neoplasm of uncertain behavior of thoracic vertebral column
  • Neoplasm of uncertain behavior of trapezium
  • Neoplasm of uncertain behavior of trapezoid bone
  • Neoplasm of uncertain behavior of ulna
  • Neoplasm of uncertain behavior of vertebral column
  • Neoplasm of uncertain behavior of vomer
  • Neoplasm of uncertain behavior of zygomatic bone
  • Neoplasm of zygomatic bone
  • Synovial osteochondromatosis of 1st metatarsophalangeal joint
  • Synovial osteochondromatosis of acromioclavicular joint
  • Synovial osteochondromatosis of ankle
  • Synovial osteochondromatosis of elbow
  • Synovial osteochondromatosis of interphalangeal joint of toe
  • Synovial osteochondromatosis of knee
  • Synovial osteochondromatosis of lesser metatarsophalangeal joint
  • Synovial osteochondromatosis of shoulder
  • Synovial osteochondromatosis of subtalar joint
  • Synovial osteochondromatosis of talonavicular joint

Index to Diseases and Injuries
References found for the code D48.0 in the Index to Diseases and Injuries:

  • - Tumor - See Also: Neoplasm, unspecified behavior, by site;
    • - giant cell - See Also: Neoplasm, uncertain behavior, by site;

Tabular List of Diseases and Injuries
References found for the code D48.0 in the Tabular List of Diseases and Injuries:

  • Type 1 Excludes Notes:
    • neoplasm of uncertain behavior of cartilage of ear (D48.1)
    • neoplasm of uncertain behavior of cartilage of larynx (D38.0)
    • neoplasm of uncertain behavior of cartilage of nose (D38.5)
    • neoplasm of uncertain behavior of conNEC tive tissue of eyelid (D48.1)
    • neoplasm of uncertain behavior of synovia (D48.1)

Table of Neoplasms

The code D48.0 is included in the table of neoplasms by anatomical site. For each site there are six possible code numbers according to whether the neoplasm in question is malignant, benign, in situ, of uncertain behavior, or of unspecified nature. The description of the neoplasm will often indicate which of the six columns is appropriate.

Where such descriptors are not present, the remainder of the Index should be consulted where guidance is given to the appropriate column for each morphological (histological) variety listed. However, the guidance in the Index can be overridden if one of the descriptors mentioned above is present.

The Tabular must be reviewed for the complete diagnosis code.

Neoplasm, neoplastic Malignant
Primary
Malignant
Secondary
CaInSitu Benign Uncertain
Behavior
Unspecified
Behavior
»alveolar
  »ridge or process
C41.1C79.51D16.5D48.0D49.2
»alveolar
  »ridge or process
    »lower
C41.1C79.51D16.5D48.0D49.2
»alveolar
  »ridge or process
    »upper
C41.0C79.51D16.4D48.0D49.2
»atlas
C41.2C79.51D16.6D48.0D49.2
»bone (periosteum)
C41.9C79.51D16.9D48.0D49.2
»bone (periosteum)
  »acetabulum
C41.4C79.51D16.8D48.0D49.2
»bone (periosteum)
  »atlas
C41.2C79.51D16.6D48.0D49.2
»bone (periosteum)
  »axis
C41.2C79.51D16.6D48.0D49.2
»bone (periosteum)
  »back NEC
C41.2C79.51D16.6D48.0D49.2
»bone (periosteum)
  »calvarium
C41.0C79.51D16.4D48.0D49.2
»bone (periosteum)
  »cartilage NEC
C41.9C79.51D16.9D48.0D49.2
»bone (periosteum)
  »clavicle
C41.3C79.51D16.7D48.0D49.2
»bone (periosteum)
  »clivus
C41.0C79.51D16.4D48.0D49.2
»bone (periosteum)
  »coccygeal vertebra
C41.4C79.51D16.8D48.0D49.2
»bone (periosteum)
  »coccyx
C41.4C79.51D16.8D48.0D49.2
»bone (periosteum)
  »costal cartilage
C41.3C79.51D16.7D48.0D49.2
»bone (periosteum)
  »costovertebral joint
C41.3C79.51D16.7D48.0D49.2
»bone (periosteum)
  »cranial
C41.0C79.51D16.4D48.0D49.2
»bone (periosteum)
  »cuneiform
C41.9C79.51D16.9D48.0D49.2
»bone (periosteum)
  »ethmoid (labyrinth)
C41.0C79.51D16.4D48.0D49.2
»bone (periosteum)
  »face
C41.0C79.51D16.4D48.0D49.2
»bone (periosteum)
  »frontal
C41.0C79.51D16.4D48.0D49.2
»bone (periosteum)
  »hip
C41.4C79.51D16.8D48.0D49.2
»bone (periosteum)
  »hyoid
C41.0C79.51D16.4D48.0D49.2
»bone (periosteum)
  »ilium
C41.4C79.51D16.8D48.0D49.2
»bone (periosteum)
  »innominate
C41.4C79.51D16.8D48.0D49.2
»bone (periosteum)
  »intervertebral cartilage or disc
C41.2C79.51D16.6D48.0D49.2
»bone (periosteum)
  »ischium
C41.4C79.51D16.8D48.0D49.2
»bone (periosteum)
  »jaw (lower)
C41.1C79.51D16.5D48.0D49.2
»bone (periosteum)
  »malar
C41.0C79.51D16.4D48.0D49.2
»bone (periosteum)
  »mandible
C41.1C79.51D16.5D48.0D49.2
»bone (periosteum)
  »mastoid
C41.0C79.51D16.4D48.0D49.2
»bone (periosteum)
  »maxilla, maxillary (superior)
C41.0C79.51D16.4D48.0D49.2
»bone (periosteum)
  »maxilla, maxillary (superior)
    »inferior
C41.1C79.51D16.5D48.0D49.2
»bone (periosteum)
  »nose, nasal
C41.0C79.51D16.4D48.0D49.2
»bone (periosteum)
  »occipital
C41.0C79.51D16.4D48.0D49.2
»bone (periosteum)
  »orbit
C41.0C79.51D16.4D48.0D49.2
»bone (periosteum)
  »parietal
C41.0C79.51D16.4D48.0D49.2
»bone (periosteum)
  »pelvic
C41.4C79.51D16.8D48.0D49.2
»bone (periosteum)
  »pubic
C41.4C79.51D16.8D48.0D49.2
»bone (periosteum)
  »rib
C41.3C79.51D16.7D48.0D49.2
»bone (periosteum)
  »sacral vertebra
C41.4C79.51D16.8D48.0D49.2
»bone (periosteum)
  »sacrum
C41.4C79.51D16.8D48.0D49.2
»bone (periosteum)
  »sella turcica
C41.0C79.51D16.4D48.0D49.2
»bone (periosteum)
  »skull
C41.0C79.51D16.4D48.0D49.2
»bone (periosteum)
  »sphenoid
C41.0C79.51D16.4D48.0D49.2
»bone (periosteum)
  »spine, spinal (column)
C41.2C79.51D16.6D48.0D49.2
»bone (periosteum)
  »spine, spinal (column)
    »coccyx
C41.4C79.51D16.8D48.0D49.2
»bone (periosteum)
  »spine, spinal (column)
    »sacrum
C41.4C79.51D16.8D48.0D49.2
»bone (periosteum)
  »sternum
C41.3C79.51D16.7D48.0D49.2
»bone (periosteum)
  »temporal
C41.0C79.51D16.4D48.0D49.2
»bone (periosteum)
  »turbinate
C41.0C79.51D16.4D48.0D49.2
»bone (periosteum)
  »vertebra (column)
C41.2C79.51D16.6D48.0D49.2
»bone (periosteum)
  »vertebra (column)
    »coccyx
C41.4C79.51D16.8D48.0D49.2
»bone (periosteum)
  »vertebra (column)
    »sacrum
C41.4C79.51D16.8D48.0D49.2
»bone (periosteum)
  »vomer
C41.0C79.51D16.4D48.0D49.2
»bone (periosteum)
  »xiphoid process
C41.3C79.51D16.7D48.0D49.2
»bone (periosteum)
  »zygomatic
C41.0C79.51D16.4D48.0D49.2
»calvarium
C41.0C79.51D16.4D48.0D49.2
»cartilage (articular) (joint) NEC [See Also: Neoplasm, bone]
C41.9C79.51D16.9D48.0D49.2
»cartilage (articular) (joint) NEC [See Also: Neoplasm, bone]
  »costal
C41.3C79.51D16.7D48.0D49.2
»cartilage (articular) (joint) NEC [See Also: Neoplasm, bone]
  »ensiform
C41.3C79.51D16.7D48.0D49.2
»cartilage (articular) (joint) NEC [See Also: Neoplasm, bone]
  »intervertebral
C41.2C79.51D16.6D48.0D49.2
»cartilage (articular) (joint) NEC [See Also: Neoplasm, bone]
  »rib
C41.3C79.51D16.7D48.0D49.2
»cartilage (articular) (joint) NEC [See Also: Neoplasm, bone]
  »semilunar (knee)
C40.2C79.51D16.2D48.0D49.2
»clavicle
C41.3C79.51D16.7D48.0D49.2
»clivus
C41.0C79.51D16.4D48.0D49.2
»coccygeal
  »vertebra
C41.4C79.51D16.8D48.0D49.2
»coccyx
C41.4C79.51D16.8D48.0D49.2
»costal cartilage
C41.3C79.51D16.7D48.0D49.2
»costovertebral joint
C41.3C79.51D16.7D48.0D49.2
»disc, intervertebral
C41.2C79.51D16.6D48.0D49.2
»ensiform cartilage
C41.3C79.51D16.7D48.0D49.2
»ethmoid (sinus)
  »bone or labyrinth
C41.0C79.51D16.4D48.0D49.2
»frontal
C41.0C79.51D16.4D48.0D49.2
»frontal
  »bone
C41.0C79.51D16.4D48.0D49.2
»ilium
C41.4C79.51D16.8D48.0D49.2
»intervertebral cartilage or disc
C41.2C79.51D16.6D48.0D49.2
»ischium
C41.4C79.51D16.8D48.0D49.2
»jaw
  »bone
C41.1C79.51D16.5D48.0D49.2
»joint NEC [See Also: Neoplasm, bone]
C41.9C79.51D16.9D48.0D49.2
»joint NEC [See Also: Neoplasm, bone]
  »costovertebral
C41.3C79.51D16.7D48.0D49.2
»joint NEC [See Also: Neoplasm, bone]
  »sternocostal
C41.3C79.51D16.7D48.0D49.2
»joint NEC [See Also: Neoplasm, bone]
  »temporomandibular
C41.1C79.51D16.5D48.0D49.2
»malar
C41.0C79.51D16.4D48.0D49.2
»mandible
C41.1C79.51D16.5D48.0D49.2
»mandible
  »alveolar
    »ridge or process
C41.1C79.51D16.5D48.0D49.2
»mastoid (air cells) (antrum) (cavity)
  »bone or process
C41.0C79.51D16.4D48.0D49.2
»maxilla, maxillary (superior)
C41.0C79.51D16.4D48.0D49.2
»maxilla, maxillary (superior)
  »alveolar
    »ridge or process (carcinoma)
C41.0C79.51D16.4D48.0D49.2
»meniscus, knee joint (lateral) (medial)
C40.2C79.51D16.2D48.0D49.2
»nose, nasal
  »bone
C41.0C79.51D16.4D48.0D49.2
»nose, nasal
  »turbinate (mucosa)
    »bone
C41.0C79.51D16.4D48.0D49.2
»nucleus pulposus
C41.2C79.51D16.6D48.0D49.2
»occipital
C41.0C79.51D16.4D48.0D49.2
»occipital
  »bone
C41.0C79.51D16.4D48.0D49.2
»orbit
  »bone
C41.0C79.51D16.4D48.0D49.2
»parietal
C41.0C79.51D16.4D48.0D49.2
»parietal
  »bone
C41.0C79.51D16.4D48.0D49.2
»pelvis, pelvic
  »bone
C41.4C79.51D16.8D48.0D49.2
»pubic bone
C41.4C79.51D16.8D48.0D49.2
»rib
C41.3C79.51D16.7D48.0D49.2
»sacrococcyx, sacrococcygeal
C76.3C79.51D16.8D48.0D49.2
»sacrum, sacral (vertebra)
C41.4C79.51D16.8D48.0D49.2
»sella turcica
  »bone
C41.0C79.51D16.4D48.0D49.2
»semilunar cartilage (knee)
C40.2C79.51D16.2D48.0D49.2
»sinus (accessory)
  »bone (any)
C41.0C79.51D16.4D48.0D49.2
»skeleton, skeletal NEC
C41.9C79.51D16.9D48.0D49.2
»skull
C41.0C79.51D16.4D48.0D49.2
»sphenoid
  »bone
C41.0C79.51D16.4D48.0D49.2
»spine, spinal (column)
C41.2C79.51D16.6D48.0D49.2
»spine, spinal (column)
  »coccyx
C41.4C79.51D16.8D48.0D49.2
»spine, spinal (column)
  »lumbosacral
C41.2C79.51D16.6D48.0D49.2
»spine, spinal (column)
  »sacrum
C41.4C79.51D16.8D48.0D49.2
»sternum
C41.3C79.51D16.7D48.0D49.2
»symphysis pubis
C41.4C79.51D16.8D48.0D49.2
»temporal
C41.0C79.51D16.4D48.0D49.2
»temporal
  »bone
C41.0C79.51D16.4D48.0D49.2
»turbinate (bone)
C41.0C79.51D16.4D48.0D49.2
»vertebra (column)
C41.2C79.51D16.6D48.0D49.2
»vertebra (column)
  »coccyx
C41.4C79.51D16.8D48.0D49.2
»vertebra (column)
  »sacrum
C41.4C79.51D16.8D48.0D49.2
»vomer
C41.0C79.51D16.4D48.0D49.2
»xiphoid process
C41.3C79.51D16.7D48.0D49.2

Information for Patients


Bone Diseases

Your bones help you move, give you shape and support your body. They are living tissues that rebuild constantly throughout your life. During childhood and your teens, your body adds new bone faster than it removes old bone. After about age 20, you can lose bone faster than you make bone. To have strong bones when you are young, and to prevent bone loss when you are older, you need to get enough calcium, vitamin D, and exercise. You should also avoid smoking and drinking too much alcohol.

Bone diseases can make bones easy to break. Different kinds of bone problems include

  • Low bone density and osteoporosis, which make your bones weak and more likely to break
  • Osteogenesis imperfecta makes your bones brittle
  • Paget's disease of bone makes them weak
  • Bones can also develop cancer and infections
  • Other bone diseases, which are caused by poor nutrition, genetics, or problems with the rate of bone growth or rebuilding

NIH: National Institute of Arthritis and Musculoskeletal and Skin Diseases

  • ALP - blood test (Medical Encyclopedia)
  • ALP isoenzyme test (Medical Encyclopedia)
  • Blount disease (Medical Encyclopedia)
  • Bone lesion biopsy (Medical Encyclopedia)
  • Bone pain or tenderness (Medical Encyclopedia)
  • Bone tumor (Medical Encyclopedia)
  • Bowlegs (Medical Encyclopedia)
  • Fibrous dysplasia (Medical Encyclopedia)
  • Osteomalacia (Medical Encyclopedia)
  • Osteopenia - premature infants (Medical Encyclopedia)

[Read More]

Cartilage Disorders

Cartilage is the tough but flexible tissue that covers the ends of your bones at a joint. It also gives shape and support to other parts of your body, such as your ears, nose and windpipe. Healthy cartilage helps you move by allowing your bones to glide over each other. It also protects bones by preventing them from rubbing against each other.

Injured, inflamed, or damaged cartilage can cause symptoms such as pain and limited movement. It can also lead to joint damage and deformity. Causes of cartilage problems include

  • Tears and injuries, such as sports injuries
  • Genetic factors
  • Other disorders, such as some types of arthritis

Osteoarthritis results from breakdown of cartilage.

NIH: National Institute of Arthritis and Musculoskeletal and Skin Diseases

  • Costochondritis (Medical Encyclopedia)
  • Meniscus tears -- aftercare (Medical Encyclopedia)
  • Pectus carinatum (Medical Encyclopedia)
  • Pectus excavatum (Medical Encyclopedia)
  • Perichondritis (Medical Encyclopedia)

[Read More]

ICD-10 Footnotes

General Equivalence Map Definitions
The ICD-10 and ICD-9 GEMs are used to facilitate linking between the diagnosis codes in ICD-9-CM and the new ICD-10-CM code set. The GEMs are the raw material from which providers, health information vendors and payers can derive specific applied mappings to meet their needs.

  • Approximate Flag - The approximate flag is on, indicating that the relationship between the code in the source system and the code in the target system is an approximate equivalent.
  • No Map Flag - The no map flag indicates that a code in the source system is not linked to any code in the target system.
  • Combination Flag - The combination flag indicates that more than one code in the target system is required to satisfy the full equivalent meaning of a code in the source system.

Index of Diseases and Injuries Definitions

  • And - The word "and" should be interpreted to mean either "and" or "or" when it appears in a title.
  • 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.
  • Code first - Certain conditions have both an underlying etiology and multiple body system manifestations due to the underlying etiology. For such conditions, the ICD-10-CM has a coding convention that requires the underlying condition be sequenced first followed by the manifestation. Wherever such a combination exists, there is a "use additional code" note at the etiology code, and a "code first" note at the manifestation code. These instructional notes indicate the proper sequencing order of the codes, etiology followed by manifestation.
  • Type 1 Excludes Notes - A type 1 Excludes note is a pure excludes note. It means "NOT CODED HERE!" An Excludes1 note indicates that the code excluded should never be used at the same time as the code above the Excludes1 note. An Excludes1 is used when two conditions cannot occur together, such as a congenital form versus an acquired form of the same condition.
  • Type 2 Excludes Notes - A type 2 Excludes note represents "Not included here". An excludes2 note indicates that the condition excluded is not part of the condition represented by the code, but a patient may have both conditions at the same time. When an Excludes2 note appears under a code, it is acceptable to use both the code and the excluded code together, when appropriate.
  • Includes Notes - This note appears immediately under a three character code title to further define, or give examples of, the content of the category.
  • Inclusion terms - List of terms is included under some codes. These terms are the conditions for which that code is to be used. The terms may be synonyms of the code title, or, in the case of "other specified" codes, the terms are a list of the various conditions assigned to that code. The inclusion terms are not necessarily exhaustive. Additional terms found only in the Alphabetic Index may also be assigned to a code.
  • NEC "Not elsewhere classifiable" - This abbreviation in the Alphabetic Index represents "other specified". When a specific code is not available for a condition, the Alphabetic Index directs the coder to the "other specified” code in the Tabular List.
  • NOS "Not otherwise specified" - This abbreviation is the equivalent of unspecified.
  • See - The "see" instruction following a main term in the Alphabetic Index indicates that another term should be referenced. It is necessary to go to the main term referenced with the "see" note to locate the correct code.
  • 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 not necessary to follow the "see also" note when the original main term provides the necessary code.
  • 7th Characters - Certain ICD-10-CM categories have applicable 7th characters. The applicable 7th character is required for all codes within the category, or as the notes in the Tabular List instruct. The 7th character must always be the 7th character in the data field. If a code that requires a 7th character is not 6 characters, a placeholder X must be used to fill in the empty characters.
  • 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 an instructional note in the Tabular List. The word "with" in the Alphabetic Index is sequenced immediately following the main term, not in alphabetical order.

Present on Admission
The Present on Admission (POA) indicator is used for diagnosis codes included in claims involving inpatient admissions to general acute care hospitals. POA indicators must be reported to CMS on each claim to facilitate the grouping of diagnoses codes into the proper Diagnostic Related Groups (DRG). CMS publishes a listing of specific diagnosis codes that are exempt from the POA reporting requirement.

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