Final answer:
In cases where a medical record provides detail but no specific ICD 10 CM code exists for a condition, a 'code also' note is used to provide additional detail. This allows for comprehensive documentation and is important for treatment, billing, and statistical purposes in healthcare.
Step-by-step explanation:
The coding convention used in the description of an ICD 10 CM code when the information in the medical record provides detail, but no specific code exists is referred to as a 'code also' note according to Guideline I.A.6. This means that if the specific condition is not represented by its own unique ICD-10-CM code, the coder may have to use an additional code to provide more detail about the case.
For example, the ICD-10-CM contains codes for various viral infections, and when clinicians suspect a particular virus is the cause of a patient's illness, they would use that specific ICD code to prescribe appropriate treatments or order the necessary laboratory tests.
Medical laboratories, health-care management systems, medical coders, medical billers, vital-records keepers, and epidemiologists all rely on ICD codes for a variety of purposes related to treatment, billing, record keeping, and statistical analysis.