Medical Terminology Modifiers & Medical Decision Making Levels

Modifier Type	Code/Prefix/Suffix	Meaning	Clinical Application or Example
E/M Modifier	24	Unrelated Evaluation and Management (E/M) service by the same physician during a postoperative period.	Used for an E/M visit during a global period for a reason unrelated to the original surgery, such as managing chemotherapy or treating a kidney stone after a prostatectomy.
E/M Modifier	25	Significant, separately identifiable E/M service by the same physician or other qualified health care professional on the same day of a procedure or other service.	Used when an E/M service (e.g., for chronic sinusitis or a new diagnosis in a fellow eye) is distinct from a minor procedure (0 or 10-day global) or diagnostic test performed on the same day.
E/M Modifier	57	Decision for surgery.	An E/M service provided the day before or the day of a major procedure (90-day global) that results in the initial decision to perform the surgery (e.g., initial consultation for a vasectomy).
E/M Modifier	26	Professional Component.	Used to indicate only the professional services (physician’s interpretation) provided for imaging or diagnostic tests, such as an obstetrical ultrasound.
E/M Modifier	TC	Technical Component.	Used to indicate the technical portion of a test (equipment and facility use), such as the algorithmic classification of a burn injury or portable X-ray.
MDM Level	Straightforward	Minimal complexity of problems, data review, and risk of morbidity.	Associated with CPT codes 99202, 99282, or 99211 (minimal); involves 1 self-limited or minor problem, such as a simple sprain or a foreign body in a child’s nostril.
MDM Level	Low	Low complexity of establishing a diagnosis or selecting management based on low problem complexity, limited data, and low risk.	Associated with CPT codes 99203 or 99283; involves 2 or more self-limited problems or 1 stable chronic illness, such as well-controlled hypertension or non-purulent cellulitis.
MDM Level	Moderate	Moderate complexity of establishing a diagnosis or selecting management based on moderate problem complexity, moderate data, and moderate risk.	Associated with CPT codes 99204 or 99284; involves chronic illness with exacerbation (e.g., COPD), prescription drug management, or decisions regarding minor surgery with risk factors.
MDM Level	High	High complexity of establishing a diagnosis or selecting management based on high problem complexity, extensive data, and high risk.	Associated with CPT codes 99205 or 99285; involves illnesses that pose a threat to life or bodily function (e.g., Acute MI) or decisions regarding emergency major surgery.
Global Period	090 Days	Major surgical procedure global period.	Includes 1 day before surgery, the day of surgery, and 90 days following. Examples include hip replacement, coronary artery bypass, or spinal fusion.
Global Period	010 Days	Minor surgical procedure global period.	Includes the day of surgery and 10 days following. Examples include acne surgery, simple abscess incision and drainage, or certain endoscopic sinus procedures.
Global Period	000 Days	Zero-day global period; minor surgical procedure or endoscopy.	The end of the procedure is the end of the global period; includes diagnostic urology procedures and intravitreal eye injections.
Global Period	XXX	The global concept does not apply to this code.	Used for procedures with inherent pre-, intra-, and post-work performed each time, such as fine needle aspiration or diagnostic tests.
Global Period	ZZZ	Add-on code; related to another service and included in the global period of the primary service.	Used for codes like 10004 (each additional lesion) which follow the global rules of the primary procedure.
Global Period	MMM	Maternity global period.	Covers antepartum, delivery, and postpartum care packages.
Global Period	YYY	Unlisted code or contractor priced; global period determined by the local carrier.	Used for unlisted procedures where the global period is established by individual carriers or MACs.
Global Period	90 Days	Post-operative tracking window for patient visual function improvement.	Used specifically in the context of the Cataracts: Improvement in Patient’s Visual Function measure (OP-31/ASC-11).
Global Period	29 days	Standard refill/replacement cycle for inFlow device.	One inFlow device (A4341) may be covered no more than once every 29 days.
Global Period	Month	Standard maintenance cycle for indwelling catheters.	No more than one catheter per month is covered for routine maintenance.
Global Period	3 months	Standard replacement cycle for external urethral clamps.	One external urethral clamp (A4356) is covered every 3 months.
Global Period	4 weeks (28 days)	Duration defining acute or subsequent myocardial infarction.	Used to differentiate between acute (I21) or subsequent (I22) myocardial infarction.
Global Period	Peripartum	Defined as the last month of pregnancy to five months postpartum.	Used to describe conditions like pregnancy-associated cardiomyopathy (O90.3).
Global Period	Postpartum	Begins immediately after delivery and continues for six weeks.	Used for conditions arising within 6 weeks following delivery.
Prefix	a-, an-	Without, lack of, absence, or not.	Examples include arrhythmia (without rhythm), anemia (lack of blood), atypical, and anoxia.
Prefix	ab-	From, away from, or negative.	Examples include abduction (moving away), abnormal, and abdominal.
Prefix	ad-	Toward, at, increase, or on.	Examples include adduction (moving toward) and addiction.
Prefix	anti-	Against or opposed to.	Examples include antipsychotic and antibacterial protection.
Prefix	brady-	Slow.	Examples include bradycardia (abnormally slow heart rate).
Prefix	dys-	Bad, abnormal, difficult, or painful.	Examples include dysphagia (difficulty swallowing), dyspnea, and dysrhythmia.
Prefix	endo-	Within or inside.	Examples include endotracheal, endocarditis (inner lining of heart), and endocrine.
Prefix	epi-	Upon, over, above, on top, or around.	Examples include epicardium and epigastric (area above stomach).
Prefix	hyper-	Excessive, increased, abnormally high, or above.	Examples include hyperthyroidism and hypertension (high blood pressure).
Prefix	hypo-	Deficient, decreased, abnormally low, or below.	Examples include hypotension (low blood pressure), hypoglycemia, and hypogastric.
Prefix	peri-	Around or surrounding.	Examples include pericarditis (membrane surrounding the heart), perirenal (around kidney), and perinatal.
Prefix	tachy-	Rapid or fast.	Example: tachycardia (heart rate exceeding 100 beats per minute).
Prefix	sub-	Under, less, or below.	Examples include subcutaneous (under skin) and subcostal (below a rib).
Prefix	ambi-	Both.	Example: Ambidextrous.
Prefix	ante-	Before.	Example: Antepartum.
Prefix	apo-	Off, away from.	Example: Apophysis.
Prefix	auto-	Self.	Example: Autograph.
Prefix	bi-	Two or twice.	Example: Bilateral.
Prefix	inter-	Between or among.	Example: Interstitial (between tissue parts).
Prefix	intra-	Within or inside.	Example: Intramuscular.
Prefix	poly-	Excessive, over, or many.	Example: Polyarteritis (inflammation of many arteries).
Prefix	pre-	Before.	Example: Prenatal.
Prefix	post-	After or behind.	Example: Postnatal.
Prefix	super-, supra-	Above or excessive.	Example: Supracostal (above the ribs).
Prefix	neo-	New.	Example: Neonate.
Prefix	erythr/o-	Red.	Example: Erythrocyte.
Prefix	achillo-	Relating to the Achilles tendon.	Example: Achillorrhaphy (repair of tendon).
Prefix	acromio-	Relating to the acromion (scapula).	Example: Acromionectomy.
Prefix	adreno-	Relating to the adrenal gland.	Example: Adrenalectomy.
Prefix	blepharo-	Relating to the eyelid.	Example: Blepharectomy.
Prefix	cholecyst-	Relating to the gallbladder.	Example: Cholecystectomy.
Prefix	colp-	Relating to the vagina.	Example: Colpectomy.
Prefix	cyst-	Relating to the bladder.	Example: Cystectomy.
Prefix	kerato-	Pertaining to the cornea.	Example: Keratoconjunctivitis.
Prefix	ana-	Back, again, or up.	Example: Anaplasia.
Prefix	para-	Side.	Example: Paranasal sinuses.
Suffix	-ectomy	Excision, surgical removal, or cutting out.	Examples include mastectomy, gastrectomy, appendectomy, and partial nephrectomy. Includes incision and opening of the organ.
Suffix	-itis	Inflammation or infection.	Examples include tonsillitis, arthritis, gastritis, and otitis.
Suffix	-plasty	Surgical repair, restoration, reconstruction, or replacement.	Examples include rhinoplasty, myoplasty, vertebroplasty, and acetabuloplasty.
Suffix	-otomy	Incision, cutting, or surgical opening of an organ.	Examples include adenoidotomy, nephrotomy, and colotomy. Often performed as part of an -ectomy.
Suffix	-orrhaphy	Surgical repair, suturing, or repair by sutures.	Examples include adrenalorrhaphy, myorrhaphy, and neurorrhaphy.
Suffix	-scopy	Process of visual examination.	Examples include gastroscopy, arthroscopy, and cystoscopy.
Suffix	-algia	Pain or painful condition.	Examples include myalgia, arthralgia, and fibromyalgia.
Suffix	-oma	Tumor, mass, fluid collection, or benign tumor.	Examples include angioma, melanoma, and adenoma.
Suffix	-osis	A condition, disease, process, abnormal hardening, or increase.	Examples include psychosis, osteoporosis, gastrosis, and angiostenosis.
Suffix	-rrhaphy	Surgical suturing.	Examples include hymenorrhaphy and neurorrhaphy.
Suffix	-rrhage	Burst forth, bleeding, or abnormal excessive fluid discharge.	Example: Hemorrhage (rapid flow of blood).
Suffix	-rrhea	Flow or discharge.	Examples include diarrhea and flowing discharge.
Suffix	-rrhexis	Rupture.	Examples include karyorrhexis and myorrhexis (muscle rupture).
Suffix	-sclerosis	Abnormal hardening.	Examples include atherosclerosis and arteriosclerosis.
Suffix	-megaly	Abnormal enlargement.	Examples include splenomegaly, atriomegaly, and hepatomegaly.
Suffix	-malacia	Abnormal softening.	Examples include osteomalacia and arteriomalacia.
Suffix	-plegia	Paralysis.	Examples include paraplegia, hemiplegia, and cardiovascular paralysis.
Suffix	-centesis	Surgical puncture for aspiration or to remove fluid.	Examples include amniocentesis and thoracentesis.
Suffix	-ac	Pertaining to; one afflicted with.	Examples include cardiac and celiac.
Suffix	-al, -ary	Pertaining to.	Examples include abdominal, femoral, biliary tract, and coronary.
Suffix	-ase	Enzyme.	Example: Lactase.
Suffix	-asthenia	Weakness.	Example: Myasthenia gravis.
Suffix	-ation	Process.	Examples include medication and eburnation.
Suffix	-cele	Pouching or hernia.	Examples include hydrocele and varicocele.
Suffix	-cidal	Killing or destroying.	Examples include bacteriocidal and suicidal.
Suffix	-clast	Break.	Example: Osteoclast.
Suffix	-crine	To secrete.	Example: Endocrine.
Suffix	-cyte	Cell.	Example: Leukocyte.
Suffix	-desis	Binding.	Example: Arthrodesis.
Suffix	-dipsia	Condition of thirst.	Examples include dipsomania and oligodipsia.
Suffix	-ectasia	Expansion or dilation.	Example: Bronchiectasis.
Suffix	-edema	Swelling.	Examples include lymphedema and lipedema.
Suffix	-emesis	Vomiting condition.	Example: Hematemesis.
Suffix	-emia, -aemia	Blood condition.	Examples include anemia and anaemia.
Suffix	-genic	Pertaining to producing or forming; originates from.	Examples include cardiogenic shock and cardiogenic symptoms.
Suffix	-geusia	Taste.	Examples include ageusia and dysgeusia.
Suffix	-gram	Record or picture.	Examples include angiogram and sonogram.
Suffix	-graph	Instrument used to record data or picture.	Example: Electrocardiograph.
Suffix	-graphy	Process of recording.	Example: Angiography.
Suffix	-ia	Indicates a disease, abnormal condition, or state of.	Examples include anemia and ischemia (holding back blood flow).
Suffix	-iasis	Condition, formation, or presence of.	Example: Mydriasis.
Suffix	-iatry	Denotes a field in medicine emphasizing a certain body component.	Examples include podiatry and psychiatry.
Suffix	-logy	Denotes the academic study or practice of a certain field.	Examples include hematology and urology.
Suffix	-paresis	Slight paralysis.	Example: Hemiparesis.
Suffix	-pathy	Disease or disorder.	Examples include neuropathy, arteriopathy, and keratopathy.
Suffix	-penia	Deficiency.	Example: Osteopenia.
Suffix	-pepsia	Relating to digestion or the digestive tract.	Example: Dyspepsia.
Suffix	-pnea	Air, breath, or lung.	Example: Apnea.
Suffix	-stomy, -ostomy	Creation of an opening or artificial opening to the body surface.	Examples include colostomy and forming an artificial opening.
Suffix	-trophy	Nourishment or development.	Example: Pseudohypertrophy.
Suffix	-acusis	Hearing.	Example: Hyperacusis.
Suffix	-ad	Toward or in the direction of.	Examples include dorsad and ventrad.
Suffix	-dynia	Condition of pain.	Example: Cardiodynia (chest pain).
Suffix	-spasm	Sudden involuntary muscle contraction.	Example: Angiospasm (contraction of vessel walls).
Suffix	-lysis	Destruction or dissolution.	Example: Lysis of adhesions (destruction of scar tissue).
Suffix	-genesis	Production.	Example: Keratogenesis (production of horny cells).
Suffix	-necrosis	Tissue death.	Example: Arterionecrosis.
Suffix	-stenosis	Abnormal narrowing.	Example: Arteriostenosis.
Suffix	-pexy	Surgical fixation.	Not in source.
Surgical Modifier	50	Bilateral Procedure.	Used for procedures performed on both sides of the body in the same session, such as bilateral knee replacements or bilateral mastectomy.
Surgical Modifier	51	Multiple Procedures.	Used when multiple procedures (other than E/M) are performed at the same session by the same provider; identifies second and subsequent procedures.
Surgical Modifier	58	Staged or related procedure or service by the same physician during the postoperative period.	Used when a subsequent procedure was planned prospectively, is more extensive than the original, or follows a diagnostic procedure (e.g., diagnostic endoscopy leading to open procedure).
Surgical Modifier	59	Distinct Procedural Service.	Used to identify procedures/services that are performed at different anatomic sites or different encounters on the same day to bypass NCCI unbundling edits.
Surgical Modifier	78	Unplanned return to the operating/procedure room by the same physician for a related procedure during the postoperative period.	Used for treating complications (e.g., controlling postoperative hemorrhage or repairing a CSF leak) resulting from the original surgery.
Surgical Modifier	79	Unrelated procedure or service by the same physician during the postoperative period.	Used when performing a completely unrelated surgical service during the recovery period of a prior surgery (e.g., surgery on the opposite eye).
Surgical Modifier	22	Increased Procedural Services.	Used when the work required is substantially greater than typically required due to intensity, technical difficulty, or time (e.g., heavily scarred sinuses).
Surgical Modifier	52	Reduced Services.	Used when a procedure is partially reduced, eliminated, or aborted at the physician’s discretion (e.g., a partial polypectomy).
Surgical Modifier	53	Discontinued Procedure.	Termination of a procedure due to extenuating circumstances that threaten the well-being of the patient.
Surgical Modifier	62	Two Surgeons.	Two surgeons work together as primary surgeons performing distinct parts of a single procedure (e.g., ENT and Neurosurgeon for skull base surgery).
Surgical Modifier	66	Team Surgery.	Used for complex procedures requiring the skills of more than two surgeons of different specialties working together (e.g., complex kidney transplant).
Surgical Modifier	80	Assistant Surgeon.	Identifies that a surgical assistant (a second surgeon in a non-resident setting) was involved in the case.
Surgical Modifier	82	Assistant surgeon when a qualified resident surgeon is not available.	Used when a faculty surgeon assists another because no qualified resident is available in a teaching setting.
Surgical Modifier	AS	Non-physician provider (PA, NP, or CNS) serving as assistant at surgery.	A non-physician professional assisting during a surgical procedure and billing under their own NPI.
Global Period Split	54	Surgical Care Only.	Reported by the surgeon when they perform the intra-operative portion of the global package but not the postoperative care.
Global Period Split	55	Postoperative Management Only.	Reported by the provider furnishing only the outpatient postoperative management portion following a formal transfer of care.
Global Period Split	56	Pre-operative Care Only.	Reported by the provider who furnishes only the pre-operative care when a formal transfer of care is agreed upon.
NCCI Modifier	XE	Separate Encounter.	A distinct service that occurred during a separate encounter on the same date of service.
NCCI Modifier	XP	Separate Practitioner.	A distinct service performed by a different practitioner on the same date of service.
NCCI Modifier	XS	Separate Structure.	A distinct service performed on a separate organ/structure (e.g., unbundling medically distinct sinus surgery codes).
NCCI Modifier	XU	Unusual Non-Overlapping Service.	A distinct service that does not overlap usual components of the main service, used when two bundled procedures are performed.
Functional Level	K0	Level 0: Does not have the ability or potential to ambulate or transfer safely.	Patient who does not benefit from a prosthesis for mobility.
Functional Level	K1	Level 1: Has ability/potential for transfers or fixed cadence ambulation.	Household ambulator.
Functional Level	K2	Level 2: Has ability/potential to traverse low-level environmental barriers.	Limited community ambulator (curbs, stairs).
Functional Level	K3	Level 3: Has ability/potential for ambulation with variable cadence.	Community ambulator who can traverse most barriers and has vocational/exercise needs.
Functional Level	K4	Level 4: Has ability/potential for prosthetic ambulation exceeding basic skills.	Active adult or athlete requiring high-impact use.
Patient Status	P1 (ASA I)	A normal healthy patient.	Standard physical status classification for surgical fitness.
Patient Status	P2 (ASA II)	A patient with mild systemic disease.	Classification for pre-operative assessment of surgical fitness.
Patient Status	P3 (ASA III)	A patient with severe systemic disease.	May require specific clearance for procedures in ambulatory surgery centers.
Patient Status	P4 (ASA IV)	A patient with severe systemic disease that is a constant threat to life.	Used in risk stratification to determine hospital vs. ambulatory setting for surgery.
Patient Status	P5 (ASA V)	A moribund patient who is not expected to survive without the operation.	Extreme risk or last-resort surgical classification.
Patient Status	P6 (ASA VI)	A declared brain-dead patient whose organs are being removed for donor purposes.	Categorization for organ procurement procedures.
MDM Level	Stage 1	Earliest severity level.	Includes Stage 1 necrotizing enterocolitis without pneumatosis, Stage 1 pressure ulcers (focal edema), or Stage 1 Chronic Kidney Disease.
MDM Level	Stage 2	Mild severity level.	Includes Stage 2 necrotizing enterocolitis with pneumatosis, Stage 2 pressure ulcers (blister/abrasion), or Stage 2 Chronic Kidney Disease.
MDM Level	Stage 3	Moderate severity level.	Includes Stage 3 necrotizing enterocolitis with perforation, Stage 3 pressure ulcers (subcutaneous damage), or Stage 3 Chronic Kidney Disease.
MDM Level	Stage 4	Severe severity level.	Includes Stage 4 pressure ulcers (necrosis through muscle/bone) or Stage 4 Chronic Kidney Disease.
MDM Level	Grade I - IV	Hemorrhoid severity levels.	Grade I (no prolapse) through Grade IV (cannot be manually replaced).
MDM Level	Stage F1 - F4	Hepatic fibrosis and cirrhosis levels.	F1/F2 (early fibrosis), F3 (advanced fibrosis), and F4 (cirrhosis/sclerosis).
MDM Level	Stage D	End stage heart failure.	Clinical diagnosis level for heart failure (I50.84).
MDM Level	E16.A1-E16.A3	Hypoglycemia levels 1, 2, and 3.	Clinical diagnosis level for non-diabetic hypoglycemia.
MDM Level	D89.831-D89.835	Cytokine release syndrome grades 1 through 5.	Categorizes the severity level of cytokine release syndrome.
Suffix	E10.A1-E10.A2	Presymptomatic Stage 1 and 2.	Modifies the stage of Type 1 diabetes mellitus in medical documentation.
7th Character	A	Initial encounter.	Used while the patient is receiving active treatment for a condition, such as a traumatic fracture or periprosthetic fracture.
7th Character	D	Subsequent encounter.	Used for encounters after active treatment is completed, during the routine healing/recovery phase.
7th Character	S	Sequela.	Used for complications or late effects (e.g., scar formation) that arise as a direct result of a condition.
7th Character	B, C	Initial encounter for open fractures.	B (Type I or II) and C (Type IIIA, IIIB, or IIIC).
7th Character	E, F, G, H, J	Subsequent encounters with varying healing.	Includes routine healing (E, F) or delayed healing (G, H, J) for open/closed fractures.
7th Character	K, M, N	Subsequent encounter for fractures with nonunion.	Used when the bone has failed to heal properly.
7th Character	P, Q, R	Subsequent encounter for fractures with malunion.	Used when a fracture has healed in an incorrect position.
7th Character	0, 1	Gout status.	0 (without tophus) and 1 (with tophus).
7th Character	0 - 4	Glaucoma staging.	0 (unspecified), 1 (mild), 2 (moderate), 3 (severe), 4 (indeterminate).
7th Character	0 - 4	Glasgow Coma Scale timing.	0 (unspecified), 1 (in the field), 2 (emergency department), 3 (hospital admission), 4 (24+ hours after admission).
7th Character	1 - 4	Glasgow Coma Scale Eye Opening.	1 (never), 2 (to pain), 3 (to sound), 4 (spontaneous).
Laterality	1, 2, 3, 9	Eye Designation (7th character).	1 (Right), 2 (Left), 3 (Bilateral), 9 (Unspecified).
Anatomical Modifier	LT, RT	Left side and Right side.	Used to identify procedures performed on the left (LT) or right (RT) side of the body, such as an intravitreal injection.
Medicaid level	U1 - UD	Medicaid levels of care 1 through 13.	State-specific care intensity reporting as defined by each state.
Severity Level	F01.5, F01.A-C	Vascular Dementia severity.	F01.5 (unspecified), F01.A (mild), F01.B (moderate), F01.C (severe).
Retinal Severity	0, 1, 2	Retinal Vein Occlusion (7th character).	0 (with macular edema), 1 (with neovascularization), 2 (stable).
Macular Stage	0 - 4	Macular Degeneration Stage (7th character).	Stages from 0 (unspecified) to 4 (advanced dry with subfoveal involvement).
Placeholder	X	Placeholder character.	Used for codes less than 6 characters that require a 7th character; must be assigned for all positions less than 6.
Code Extension	.8	Overlapping lesion.	Used for primary malignant neoplasms that overlap two or more contiguous sites.
CMS Modifier	PN, PO	Off-campus provider-based departments.	PN (Nonexcepted items/services) and PO (Excepted/grandfathered services).
CMS Modifier	JG, TB	340B Drug program modifiers.	JG (Discount acquired) and TB (Acquired for informational purposes/rural hospitals).
CMS Modifier	FB, FC	Device credit modifiers.	FB (Item provided without cost/full credit) and FC (Partial credit received for replacement device).
CMS Modifier	JW, JZ	Drug waste modifiers.	JW (Discarded drug amount from single-dose container) and JZ (Zero drug amount discarded).
CMS Modifier	GA, GX, GY, GZ	Liability and exclusion modifiers.	GA (ABN on file), GX (Voluntary notice), GY (Statutorily excluded), GZ (Expected denial/no ABN).
CMS Modifier	AA, QX, QZ	Anesthesia service modifiers.	AA (Personally performed by anesthesiologist), QX (CRNA with medical direction), QZ (CRNA without direction).
CMS Modifier	QM, QN	Ambulance service modifiers.	QM (Provided under arrangement) and QN (Furnished directly by provider).
CMS Modifier	Q0, Q1	Clinical research modifiers.	Q0 (Investigational service) and Q1 (Routine clinical service in study).
CMS Modifier	NU, RR	Equipment ownership modifiers.	NU (New equipment) and RR (Rental).
CMS Modifier	FX, CT	Technology reduction modifiers.	FX (Traditional film X-rays) and CT (Sub-standard CT technology).
CMS Modifier	GC, AI	Teaching and record modifiers.	GC (Resident under teaching physician) and AI (Principal physician of record).
CMS Modifier	FS, FT	Shared and unrelated visit modifiers.	FS (Split/shared E/M visit) and FT (Unrelated E/M during global period/same day).
CMS Modifier	SG	Ambulatory Surgical Center (ASC) modifier.	Required to indicate facility services provided by an ASC.
Operation	0 - Y	PCS Root Operation modifiers.	Categorizes surgical intent: 0 (Alteration), 1 (Bypass), 5 (Destruction), B (Excision), T (Resection), Y (Transplantation), etc.
Instruction	Includes, Excludes 1, Excludes 2	ICD-10 Coding Notations.	Define category content or clarify when codes cannot be used together (Excludes 1) or can be used together (Excludes 2).
Coding Convention	Code First, Use Additional Code, Code Also	Sequencing Instructions.	Mandate the order of etiology and manifestation codes or allow discretionary sequencing.
Nonessential	Parentheses ( )	Supplementary words.	Enclose words that may be present without affecting the code assignment.
Essential	Comma ,	Verbiage indicators.	Used in the Alphabetic Index to indicate alternate verbiage or essential details.