insurance-ch5-diagnostic coding
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27 terms
Terms | Definitions |
|---|---|
 adverse affect | unexpected, undesired, potentially harmful side effects. |
| benign tumor | a tumor that is not cancerous |
| chief complaint | Patient's statement describing symptoms, problems, or conditions as the reason for seeking health care services from a physician. |
| combination code | single ICD 9 CM code used to identify etiology and manifestation of a disease |
| complication | a development that complicates a situation |
| conventions | Typographic techniques or standard practices that provide visual guidelines for understanding printed material. |
| E codes | located in the Tabular list of Diseases, describe external causes of injury, poisoning, or other adverse reactions affecting a pt's health. |
| eponym | the name of a person for whom something is supposedly named |
| etiology | study of the cause of disease |
| in situ | in the original or natural place or site |
| international classification of diseases, ninth revision, clinical modification | ICD-9-Cm used to code inpatient and outpatient diagnosis and inpatient procedures |
| international classification of diseases, tenth revision, clinical modification | ICD-10-CM used to code death certificates in the US now, but will be used to code inpatient and outpatient diagnosis |
| intoxication | the physiological state produced by a poison or other toxic substance |
| italicized code | an ICD-9-CM code that can never be sequenced as the principal or primary diagnosis... |
| late effect | residual problem after the acute phase of an illness or injury has terminated |
| malignant tumor | a tumor that is malignant and tends to spread to other parts of the body |
| metastasis | the spreading of a disease to another part of the body |
| neoplasm | tissue that grows more rapidly than normal and continues to grow even after the stimuli that initiated the growth cease, and that serves no useful function |
| not elsewhere classified | not elsewhere classified (NEC) A designation used in the ICD-9-CM coding manual that indicates a more specific code is not available to describe the condition, even though there is more detailed information in the medical record. |
| not otherwise specified | (NOS) not otherwise specified A designation used in the ICD-9 CM coding manual that indicates there is lack of sufficient details in the medical record to assign a more specific code. |
| physicans fee profile | fiscal agent which keeps an continous recored of the usual charges summited for specific service and when thes fees have be compiled and averaged over a given period the physicians fee profile is established |
| primary diagnosis | The condition considered to be the major health problem for the patient for the submitted claim. |
| principal diagnosis | the condition that after study is established as chiefly responsible for a patient's admission to a hospital |
| secondary diagnosis | A second reason for an office or hospital encounter that may contribute to the condition or defines the need for a higher level of care but is not the underlying cause. |
| slanted brackets | ( [ ] ) used to indicate the need for another code. |
| syndrome | a group of symptoms or signs that collectively characterize or indicate a disease, disorder, abnormality, etc. |
| V codes | Numeric designations in the ICD-9-CM preceded by the letter "V"; used to classify persons who are not currently sick when they encounter health services |
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