billing and coding
Terms in this set (26)
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
what is the patient tell you
what is the diagnosis
after test is done
how to treat
Consist of 3 volumes
includes a tabular numerical listing of diagnosis
consists of alphabetic listings of diagnosis
includes a tabular and alphabetic listing of procedures
world health organization
American hospital association
National center of health statistics
Centers for medicare and medicaid services
the American health information management association
not otherwise specified
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.