[Music] this is part one of the icd-10-cm coding convention series today we're going to be talking about main terms and subterms it's a little difficult to understand the difference between main terms and sub terms at first but the more you practice the easier it will get if you have any questions at all please do not hesitate to ask icd-10-cm identifying the main term and sub-term let's start with what is a main term a main term is a noun and you may be asking what is a noun a noun names something such as a person place or thing a main term is the noun that describes the patient's diagnosis or the reason for the encounter and an example of this would be appendicitis the main term should be abstracted from the documentation for the encounter and to do this the medical coder must review the medical record find the provider's documentation for that specific encounter and then abstract the diagnoses conditions or other reasons for the encounter and then after that they're going to locate those codes for those specific reasons the diagnoses conditions or other reasons and then those codes are going to be entered onto the claim form and that is how the physician is going to get reimbursed sub terms are adjectives that describe the noun subterms are indented under the main term and this indicates that they pertain to the main term and they also help identify variations of the main term an example of this would be that there are many different types of pain so the subterms indented under the main term pain would describe the various types of pain another example would be mass there are many different types of masses so the subterms indented under the main term mass would describe the various types or sites of mass and as you can see on this example which i also had on the previous slide there is a picture on the right hand side and this is what it would look like in your icd-10 cm code book mass is the main term it's bolded boldfaced in the code book it may even be a different color it also starts with a capital letter then you go down to breast you can tell that it's indented to the right and this would be considered the sub term there are many different types of masses there's abdominal and then you have epigastric generalized left lower quadrant and so on you could also have a mass in your chest ear kidney or localized it is a good idea to scan the entire list of subterms when you're coding to understand how they are listed under the main term there are subterms and then there are sub terms of sub terms it can get confusing so make sure to take your time when you're reviewing the sub terms just to make sure you are selecting the correct one and because of the complexity of icd-10-cm codes many publishers of the codebook will include lines down each column of the index and this will help coders navigate through all the different sub-terms it's also helpful to use a ruler or something with a straight edge to help keep track of the subterms essential versus non-essential modifiers subterms are considered essential modifiers because they impact the code that is selected the location of the pane is an essential modifier that leads the coder to assign a code different than the code for an alternate site of pain non-essential modifiers are words located in parentheses next to the main term of a sub term in the index they offer additional information but do not impact code selection so on this example you can see pneumonia it is about halfway down the page and this is taken from the icd-10-cm code book in parentheses next to ammonia you'll see acute double migratory purulent septic and unresolved these are non-essential modifiers so what that means is the provider could document acute pneumonia double pneumonia purulent unresolved pneumonia any of the above and they're all going to be that same code j18.9 or the provider stating any of those words in those parentheses does not change the code selection now something that is not listed on this example is parentheses next to a sub term however a sub term is an essential modifier so that's something that you need to know so if the physician was to document allergic pneumonia or anthrax pneumonia or aspiration pneumonia that would change the code selection so as you can see we will go with anthrax it's a 22.1 versus aspiration which is j 69.0 so those essential modifiers the sub terms do change the code selection default codes are the codes for the unspecified version of a condition that can be easy to overlook for example if the coder is looking for pneumonia unspecified then it is not necessary to look any further than the first entry which would be j18.9 default codes are always listed next to the main term and represent the least specified version of that code so this is going to be a little exercise that we do on the next few slides so the diagnosis is acute appendicitis what would be the noun the main term appendicitis acute is a descriptive term so acute is very unspecific it would never be the main term acute and chronic will never be the main term another example this diagnosis is bipolar disorder what would be the main term disorder bipolar is describing the type of disorder diabetic neuropathy what's the main term neuropathy because there are different types of neuropathy so for this example diabetic is describing neuropathy inguinal hernia what is the main term the main term is hernia because there is umbilical hernia hiatal hernia inglenol hernia and so on it is describing the type of hernia intervertebral disc degeneration this one's a little bit tricky because there are three words but think about it what words are describing the noun degeneration so intervertebral disc is describing the type of degeneration thanks for joining me today make sure to watch part two