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ICD-9-CM

Adopted in 1979 to classify diagnoses, Used to report hospital diagnoses and procedures

CPT

originally published by the AMA in 1966, currently AMA publishes annual revisions which are used by physicians and outpatient healthcare settings

HCPCS

also includes level II, managed by Medicare CMS, this system is used to classify medical equipment, injectable drugs, transportaiton services, and other services not classified in Level I

Small code set

Reace, ethnicity, type of facility and type of unit

Large code set

substances, equipemnt, supplies, diseases, injury, impairments, or other health-related problems, actions taken to preven, diagnose, treat or manage diseases, injuries and impairments

medical nomenclature

national health service's clinical terms version 3, read codes, and SNOMED

overcoding

reporting codes for signs and sympotms in addition to the established diagnosis code

unbundling

reporting multiple codes to increase reimbursement when a single combination should be reported

downcoding

routinely assigning lower-level CPT codes as a convenience instead of reviewing patient record documentation and the coding manual to determine the proper code to be reported

upcoding

reporting codes that are not supported by documentation in the patent record for the purpose of increasing reimbursement

jamming

routinely assigning a 0 or 9 as the fourth or fifth digit position of an ICD-9-CM disease code instead of reviewing the coding manual to select the appropriate code number

primary purpose of a patient record

continuity of care

secodnary purpose

evaluating quality of patient care, providign data for use in clinical research, serving medicolegal interests of patien, facility and providers

patient/medical record

the business record for a patient encounter that documents health care services provided to a patient

medical necessity

the patient's diagnosis must justify diagnostic and/or therapeutic procedures or services provided

integrated

when reports are arranged iin strict chronological order or ( reverse date order)

demographic information

patient identification information collected according to facility policy, which includes the patient's name, date of birth, and so on.

ICD-9-CM code book hierarchy

chapter, section, category, sub category

Volume 3 includes

tabular list of procedures and Index to procedures

ICD-9-CM tabular list of procedures chapters are arragnged

according to anatomic site (body systems)

to initially locate an E code, go to the?

alphabetic indext ot external cause of injury and poisoning

essential modifiers

terms which are located below main terms and indented two spaces

omit code

considered an integral part of the procedure and is not coded

hyptersion table

located in volume 2 index to disease

adhering to the ICD-9-CM coding guidlines is

mandated by the cooperating parties for the ICD-9-CM and required by HIPAA

NCHS and CMS

work together to prepare official ICD-9-CM disease classification for coding and reporting

volume 1

arrages codes and description in numerical order and it contains 17 chapter that classify diseases and injuries, 2 supplemental classifications and 4 appendices

v codes

supplementary codes that are reported for patient encounters when a circumstance other than disease or injury is documented

e codes

supplementary codes located in the ICD-9-CM tabular list of diseases that describes external causes of injury, posioning, or other adverse reactions affecting a patient health

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