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321 code it chapter 1

Terms in this set (75)

Unbundling
Reporting multiple codes to increase reimbursement when a single combination code should be reported.
Upcoding
Reporting codes that are not supported by documentation in the patient record for the purpose of increasing reimbursement
overcoding
Reporting codes for signs and symptoms in adition to tge establushed diagnosis cide
Jamming
Routinely assigning an unspecific ICD-10-CM disease code instead of reviewing the code manual to select the appropiate code
Downcoding
Routinely assigning lowe level CPT coses as convenience instead of reviewing patient record documentation and the coding manual to determine the proper code to be reported
Medical coding process
Requieres the review of patient tecord documemtation to identify diagnoses, procedures and services for tge purpose of assigning ICD-10-CM, ICD-10PCS, HCPcS level II, or CPT codes
Concurrent coding
Is the review of records ir use of encounter forms and changemaster to assign codes during inpatient stay or outpatient encounter
Endcoding
Process of standardizing data by assigning alphanumeric values
Coding
Assignment of codes to diagnoses services and procedures based on patient record documentation
Code
Includes numeric and alphanumeric characters that are reported to health plans
Medical nomenclature
Is a vocabulary and medical terms
Coding system
Organizes a medical nomenclature according to similar conditions diseases procedures and services
Intership
Benefits the student and the facility that acepta the student for placement
Internship supervisor
The person who the student reports at the site
Application service provider (ASP)
Third party entity that manages and distributes software based services and solutions to costumers across wide area network from a central data center
Online discussion board or listserv
Internet based or email discussion forum that cover a variety of topics and issues
Assumption coding
Codes based on assuming, from a review of clinical evidence in the patients record, that the patient has certain diagnoses or received certain procedures/ services even though the provider did not specifically documented those diagnoses or procedures.
Physician query process
Is used when coders have questions about document diagnoses and procedures or services they use the query to contact the responsable physician to request clarification about a document
Computer-assisted coding (CAC)
Uses software to automatically generate codes by reading transcribe clinical documentation provide by health care practitioners.
Evidence based coding
Involves clicking on codeas that CAC software generates to review electronic health records used to generate that code.
Alternative billing codes (ABC codes)
Classify services not included in the CPT manual to describe the service supply or therapy provide, they might also be assigned to report nurses services or alternative medicine.
Clinical care classification system (CCC)
Provides a new standardized framework and unique coding structure for assessing documenting and classifying home health and ambulatory care.
Current Dental Terminology (CDT)
It classifies dental procedure and services
Diagnostic and statistical manual of mental disorders (DSM)
Classification of mental disorders use by mental health professionals
Health insurance prospective payment system (HIPPS)rate codes
Alphanumerical codes consisting on five digits
International classification of diseases for oncology third edition (ICD-O-3)
This was implemented in 2001 as a classification of neoplasms used by cancer registries throughout the world to record incidence of malignancy and survival rates.
ICD morphology codes
Indicate the type of cell that has become neoplastic and it's biological activity in order words, the kind of tumor that developed and how behaves
International classification of functioning, disability and health (ICF)
Classifies health and health related domains that describe body functions and structure, activities and participation.
Logical observation identifiers names and codes (LOINC)
Electronic data beard and universal standard that is use to identify medical laboratory observations and for the purpose of clinical care management.
National drug codes (NDC)
Is managed by the FDA is established as part of an out of hospital drug reimbursement program under Medicare services as a universal product identifier for human drugs
Rx Norm
Provides names for clinical drugs and links it's names to many of the drug vocabularies
Unified medical language system (UMLS)
Is a set of files and software that allows many health and biomedical vocabularies and standard to enable interoperability among computer systems.
Medical record
Is the business record for a patient encounter that documents health care services provided to a patient
Demographic data
Patient identification information such as name, date of birth,
Continuity of care
Serve as a communication tool for physicians and other patient care professionals. Assist planning and documenting patient illness and treatment
Primary purpose of the record
To provide continuity of care
Secondary purpose of the record
Evaluating the quality of patient care
Secondary propuse of the record
Provide data for clinical research
Secondary propuse of the record
Provide information to third party payers for reimbursement
Secondary propuse of the record
Serving the médico legal interest of the patient facility and providers of care
Documentation
Notes and reports in the patients records by a health care professional
Teaching hospital
An approved graduate medical education residency program in medicine, osteopathy, dentistry or podiatry
Teaching physician
A physician who supervises residents during patient care
Resident physician
Individual who participates in an approved GME program
Hospitalist
A physician who provides care for hospital inpatients
Medical necessity
Patient s diagnosis must also justify diagnostic and therapeutic procedures or services provided
Manual record
Paper based
Automated record
Uses computer technology
Hybrid record
Consist of both paper based and computer generated documents
Source oriented record
Are organized according to documentation source
Problem oriented record
Systematic method consisting of database problem list initial plan progress notes
POR database
Contains patient information including chief complaint, present conditions and diagnosis, social data, past personal medical and social history, review of systems, physical examination, baseline laboratory data
Problem list
Table of contents for the patient record, contains patients problems
Initial plan
Contains the strategy for managing patient care and any actions taken to investigate the patient condition and to treat and educate the patient.
Diagnostic/management plans
Plans to learn more about the patients condition and the management of the conditions
Therapeutic plans
Specific medications goals procedures therapies and treatment used to treat the patient
Patient education plans
Plans to educate the patient about conditions for which the patient is being treated
Progress notes
Documents for each problem assigned to the patient
Subjective
Patient statement about how he/she feels including symptomatic information
Objective
Observations about a patient, such as physical findings or lab or x Ray results
Assessment
Judgment, opinion or evaluation made by health care providers
Plan
diagnostic, therapeutic and education plans to resolve the problems
Discharge note
Progress note section of the POR to summarized the patient s care treatment response to care and condition on discharge
Transfer note
It summarizes the reason for admission current diagnosis and medical information and reason for transfer
Integrated record
Reports arranged in strict chronological date order which allows for observation of how patient is progressing based on test results
Electronic health record (EHR)
Is a collection of information documented by a number of providers at different facilities regarding one patient
Electronic medical record (EMR)
Is created on a computer using keyboard a mouse an optical pen device a voice recognition system a scanner of touch screen
Optical disk imaging
Microfilm or remote storage system because patient records are converted to an electronic image and saved on storage media
Scanner
is use to capture paper record images onto the storage media
Jukebox
Storages large number of optical disk resulting in a huge storage capabilities
Health data collection
Use with the purpose of administrative planning submitting statistics to state and federal government agencies and reporting health claims data to third party
Automated case abstracting software
Collect and report inpatient and outpatient data for statistical analysis and reimbursement purposes
CMS-1500
Standard claim submitted by physicians office to third party payers
Medical management software
combination of practice management and medical billing software Appointment scheduling claims processing patient invoicing patient management report generation
UB-04 or CMS -145
Claim for submission to third party payers
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