26 terms

billing and coding

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is the condition after study that brought the patient to the hospital for care.
Principal diagnosis ( inpatient)
is the main reason for the visit.
Primary diagnosis (outpatient)
subjective, objective, assessment, plan
SOAP
what is the patient tell you
Subjective
what is the diagnosis
objective
after test is done
Assessment
how to treat
Plan
ICD-9-CM
Consist of 3 volumes
includes a tabular numerical listing of diagnosis
Volume 1
consists of alphabetic listings of diagnosis
Volume 2
includes a tabular and alphabetic listing of procedures
Volume 3
world health organization
WHO
American hospital association
AHA
National center of health statistics
NCHS
Centers for medicare and medicaid services
CMS
the American health information management association
AHIMA
categories
3 digits
subcategories
4 digits
subclassification
5 digits
not otherwise specified
NEC
brackets that appear beneath a code indicate the fifth digit that are considered valid digits for the code.
[ ]
slanted brackets that appear in the alphabetic index indicate mandatory multiple coding.
/ /
parentheses enclose supplementary word called nonessential modifiers, that maybe present in the narrative description of a disease without affecting the code assignment.
( )
colons are used in the tabular list after an incomplete term that needs one or more of the modifiers that follow in order to make it assignable to a given category.
:
a bullet at the code or line of text indicate that the entry is new
.
a triangle in the tabular list indicates that the code tittle is revised. In alphabetic index the triangle indicates that the code has been change.
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