18 Basics of Diagnostic Coding 2026/2027

18 Basics of Diagnostic Coding 2026/2027

diagnosis - ANS-in medical coding, assessment and diagnostic statement are
synonyms with
encounter - ANS-any contact between a patient and a provider of service
assessment - ANS-the physician's determination of what is or may be wrong with the
patient based on the findings from the H&P
chief complaint - ANS-the abbreviation CC is a statement in the patient's own words that
describes why the person sought medical attention
manifestation - ANS-the signs and symptoms of a disease
alphabetic index - ANS-lists conditions, injuries, and diseases in alphabetical order by
main terms, modifying term, and subterms
ancillary diagnostic services - ANS-services that support patient diagnoses (e.g.,
laboratory or radiology services)
and/or - ANS-in the context of the ICD-9-CM, the word and should always be interpreted
as
chapters - ANS-are broad sections of the ICD-9-CM coding manual grouped by disease
or illness
code also - ANS-is used when one or more codes are necessary to identify a given
condition; also know as use additional code
coding - ANS-converting verbal or written descriptions into numeric and alphanumeric
designations
conventions - ANS-the abbreviations, punctuation, symbols, instructional notations, and
related entities that provide guidance to the medical assistant or coder in selecting an
accurate and specific code
diagnosis - ANS-the determination of the nature of a disease, injury, or congenital
defect
diagnosis statement - ANS-the information about the diagnosis or diagnoses of the
patient which have been extracted from the medical documentation
etiology - ANS-the cause of the disorder; a claim may be classified according to this