Unit 4 Glossary

For inpatient coding, the condition established after study to be chiefly responsible for the hospital admission (UHDDS definition). The outpatient equivalent of principal diagnosis — condition chiefly responsible for services rendered during the encounter. A pre-existing condition that affects the patient's treatment or length of stay during the current hospitalization. A late effect or residual condition resulting from a prior disease, injury, or treatment; coded with 7th character S. A diagnosis described as 'possible,' 'probable,' or 'suspected'; coded AS IF confirmed for inpatient, as symptom for outpatient. ICD-10-CM codes (V–Y) that classify the environmental event or circumstance causing an injury or adverse effect. Codes from Z42–Z49 used when a patient returns for care after the initial condition has resolved. Indicator required for inpatient diagnoses showing whether the condition was present when the patient was admitted.