Chapter 18-19 vocab

Terms in this set (49)

an outline or summary of the diagnostic statement and/or procedures and services preformed. in procedural coding, the outline or summary assists in ensuring that all procedures and services are included in an insurance claim submission and that nothing was omitted or added to the encounter form or change ticket.

alphabetic index

it list conditions, injuries, illnesses, and diseases in alphabetical order by main terms, modifying terms, and subterms.

ancillary diagnostic services

services that support patient diagnoses

in the contex of the ICD-10-CM, 'and' should be interrupted as "and/or"

the physician's determination of what is or may be wrong with the patient based on findings from the history and physical examination(H&P). the assessment includes a preliminary, interim, or final diagnosis.

chief complaint(CC)

the reason the patient has sought medical care.it is recorded in the history documentation in the medical record, proceeded by the abbreviation CC.

used when more than one code is necessary to identify a given condition; 'code also' or 'use additional code' is used.

converting verbal or written descriptions into numeric and alphanumeric designations.

abbreviations, punctuations, symbols, instructional notations, and related entities that provide guidance to the medical assistant or order in the selection of an accurate, specific code.

the concise, technical description of the cause, nature or manifestations of a condition or problem. (initial diagnosis, working diagnosis, differential diagnosis, clinical diagnosis,)

diagnostic statement

information about a patient's diagnosis or diagnoses that has been extracted from the medical documentation.

the causes of a disorder; a claim may be classified according to the etiology.

exclusion terms are always written in italics, and the word 'excludes' often is enclosed in a box to draw particular attention to these instructions. exclusion terms may apply to a chapter, section, a category, or subcategory.

history and physical examination (H&P,HPE)

at the patient's first visit with a new physician or provider or upon admission to a hospital, the history and physical examination(H&P) are documented.

an assessment is the physicians determination of what is or may be wrong with the patient based on findings from the history and physical examination.

International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Clinical Modification(ICD-10-CM)

the current ICM rules manual, which contains the greatest numbers of changes in the ICD-CM system in ICD history. to allow more specific reporting of diseases and newly recognized conditions, the ICD-10-Cm contains aproximally 5,500 more codes than the ICD-9-CM.

signs and symptoms of a disease.

found in both the Alphabetic Index and the Tabular Index, notations are instructions or guidelines in classification assignments, defining category content or the use of subdivision codes; also called 'instructional notions'.

principal diagnosis

initial identification of the condition or complaint that the patient expresses in the outpatient medical setting.

a direction to the coder to look in another place

a direction to the coder to look elsewhere if the main term or subterm for the entry are not sufficient or coding the information.

a direction to the coder to see a specific category

a system of charting comprising the subjective findings, objective findings, assessment, and plan for treatment.

volume 1 of the ICD-10-CM coding manual: it contains all diagnosis codes which are grouped into 21 chapters of disease and injury.

use additional code

term only appears in the Tabular Index

In context ICD-10-CM, terms 'with', 'with mention of', and 'associated with' in a title dictate that both parts of the title must be present in the diagnostic statement to allow assignment of the particular code.

a code that indicates additional or supplemental procedures carried out in addition to the primary procedure.

codes designating procedures or services that are grouped together and paid for as one procedure or service.

indented one level below a subsection in the CPT coding manual

a change in the code submitted for reimbursement, usually preformed by the preformed by the insurance company.

procedures, services, or diagnoses named after people.

the guidelines are found at the beginning of each of the 6 sections of main text of the CPT.

Health Care Common Procedural Coding system (HCPCS)

Level II codes created to supplement procedures and services not covered in the CPT

the primary or key word or words abstracted from a medical record that are used to begin the code search in the Alphabetic Index.

see Tabular Index

2 characters code additions that explain circumstances that alter a provider services or provide additional clarification of detail about a procedure or service.

a key word selected after the main term has been chosen r or help further define or describe the procedure or service.

new patient (NP)

patient who is new and visiting a physician for the 1st time

patient status (PS)

state of patient as either new or established

physical status

physical condition of a patient.

place of service (POS)

the place where a procedure or service was preformed, which has a specific code.

one of the 6 divisions of the CPT manual

a term indented one level below a category

term indented one level below a section

unbundles codes

the deliberate upgrading of a CPT code to the next highest reimbursable code, despite a lack of documentation, so as to receive higher reimbursement.

...October 1, 2015

ICD 10 has 7 characters. what are the first 3 characters called?

ICD has 7 characters. what is the middle 3 characters called?

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