Please enable JavaScript.
Coggle requires JavaScript to display documents.
DConvention.2: Instructional notes (Instructional 'Notes' are used…
DConvention.2: Instructional notes
Instructional 'Notes' are used within the Tabular list at a chapter level, block level, 3 character and 4 character levels.
They describe the general content of the succeeding categories, give instruction regarding the use of categories and provide 5th character sub-classifications.
Inclusion Notes (inclusion terms, 'Incl.:'
Inclusion notes clarify the content an dintended use of the chapter, block, category or subcategory to which the notes apply.
They give examples of the conditions and diagnoses classified at the chapter, block, category or code.
The listed inclusion terms are not exhaustive and alternative diagnoses are listed in the Alphabetical Index.
Inclusion notes appearing under chapter and block titles usually give a general definition of the content of the section to which they apply.
these inclusion notes apply to ALL categories within the chapter block.
inclusion notes appearing under character code level are note preceded by the abbreviation Incl.:
Exclusion notes (exclusions terms, 'Excl.:')
Exclusion notes are used to prevent a category or code from being used incorrectly :red_flag:
They inform the coder that, although the category or code description my suggest the term could be classidied here, it is in fact classified elsewhere.
However they do not always prevent the use of the code from the category the exclusion note appears in; they can indicate that a code from a different category should be assigned in addition to fully reflect the patient's diagnoses.
Use notes :pencil2:
Is a specific instruction to use an additional code in order to describe a condition more completely and, just like other types of notes, can be found at chapter, block, three character category and fourth character subcategory levels.
The 'use' note is NEVER optional and must ALWAYS be adhered to where the information is available in the medical record. :fire:
IF DESIRED notes :pencil2:
Where a notes states to 'Use an additional code, IF DESIRED to add further information about the disorder, where that information is present in the medical record the additional code MUST be assigned.
ARE FOR USE WITH :pencil2:
This instruction is mandatory, and the 4 character subdivisions referred to MUST BE USED.