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Medical Billing & Coding Module 3

Terms in this set (30)

Encounter
is a face-to-face contact between a patient and a health care provider (e.g., physician, nurse practitioner) who assesses and treats the patient's condition.
Eponyms
diseases or syndromes that are named for people. They are listed in appropriate alphabetical sequence as main terms in the index.
Parentheses
used in the index and tabular list to enclose nonessential modifiers, which are supplementary words that may be present in or absent from the physician's statement of a disease or procedure without affecting the code number to which it is assigned.
Brackets
used in the index to identify manifestation codes and in the index and tabular list to enclose abbreviations, synonyms, alternative wording, or explanatory phrases.
Manifestation
is a condition that occurs as the result of another condition, and manifestation codes are always reported as secondary codes.
Table of Neoplasms
is an alphabetic index of anatomic sites for which there are six possible code numbers according to whether the neoplasm in question is malignant primary, malignant secondary, malignant in situ, benign, of uncertain behavior, or of unspecified nature.
Table of Drugs and Chemicals
is an alphabetic index of medicinal, chemical, and biological substances that result in poisonings and adverse effects.
Other and Other Specified Codes
assigned when patient record documentation provides detail for which a specific code does not exist in ICD-10-CM.
Unspecified Codes
are assigned when patient record documentation is insufficient to assign a more specific code.
Main Terms
in the index are boldfaced and listed in alphabetical order, which means hyphens within main terms are ignored, but a single space within a main term is not ignored.
Nonessential Modifiers
are supplementary words located in parentheses after a main term that do not have to be included in the diagnostic statement for the code to be assigned.
Qualifiers
are supplementary terms that further modify subterms and other qualifiers.
Subterms
qualify the main term by listing alternative sites, etiology, or clinical status.
Neoplasms
are new growths, or tumors, in which cell reproduction is out of control.
Lesion
defined as any discontinuity of tissue (e.g., skin or organ) that may or may not be malignant.
Benign
A noninvasive, nonspreading, nonmalignant tumor
Contiguous Sites
occur when the origin of the tumor (primary site) involves two adjacent sites.
Morphology
indicates the tissue type of a neoplasm (e.g., adenocarcinoma and sarcoma); and while they are not reported on insurance claims, they are reported to state cancer registries.
Metastasis
spread of cancer from primary to secondary sites
Secondary Diagnosis
include comorbidities and complications.
Comorbidity
is a concurrent condition that coexists with the first-listed diagnosis (outpatient care) (or principal diagnosis, for inpatient care), has the potential to affect treat- ment of the first-listed diagnosis (outpatient care) (or principal diagnosis for inpatient care), and is an active condition for which the patient is treated and/ or monitored.
Complication
is a condition that develops after outpatient care has been provided.
Legacy Coding System
it will be used to archive data but will no longer be supported or updated by the ICD- 9-CM Coordination and Maintenance Committee.
General Equivalence Mappings (GEMs)
which are translation dictionaries or crosswalks of codes that can be used to roughly identify ICD-10-CM codes for their ICD-9-CM equivalent codes (and vice versa).
ICD-10-CM Coding Conventions
are general rules used in the classification, and they are independent of coding guidelines
Colon
is used after an incomplete term or phrase in the index and tabular list when one or more modifiers (additional terms) is needed to assign a code.
Diseases Classified Elsewhere
which indicates that the manifestation code is a component of the etiology/ manifestation coding convention.
Malignant
cancerous, invasive, capable of spreading to other parts of the body
Re-excision
of a tumor occurs when the pathology report recommends that the surgeon perform a second excision to widen the margins of the original tumor site.
Iatrogenic Illness
can result from a medical intervention, such as an adverse reaction to contrast material injected prior to a scan, and is classified within individual ICD-10-CM chapters.
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