Kinns Ch. 18 Billing and Coding
Terms in this set (111)
an outline or summary
volume 2 of the ICD-9-CM coding manual
ancillary diagnostic services
services that support patient diagnoses
should be interpreted as and/or
the physician's determination of what is or may be wrong with the patient based on the findings from the history and physical examination (includes a preliminary, interim, or final diagnosis)
known as (CC). The reason the patient has sought medical care. It is recorded in the history documentation in the medical record.
used when more than one code is necessary to identify a given condition
converting verbal or written descriptions into numeric and alphanumeric designations
abbreviations, punctuation, symbols, instructional notations, and related entities that provide guidance to the medical assistant or coder in the selection of an accurate, specific code.
technical description of the cause, nature of, or manifestations of a condition or a problem
the physician's temporary impression, sometimes called a working diagnosis
a comparison of two or more diseases with similar signs and symptoms
the conclusion the physician reaches after evaluating all findings, including lab and other test results
info about a patient's diagnosis that has been extracted from the medical documentation
the cause of a disorder
always written in italics. may apply to a chapter, a section, a category, or a subcategory.
history and physical examination
known as (H&P, HPE) normally includes the CC, medical history, physical examination, an assessment of the findings from the history and physical exam, and a treatment plan for the patient.
an assessment is the physicians determination of what is or may be wrong with the patient based on the findings from the history and physical examination. appears under a subdivision such as a category.
International Classification of Diseases, Ninth Revision, Clinical Modification
The manual that established the system for classifying disease to facilitate collection of uniform and comparable health information, for statistical purposes, and for indexing medical records for data storage and retrieval.
International Statistical Classifications of Diseases and Related Health Problems, Tenth Revision, Clinical Modification (IDC-10-CM)
The current IM rules manual, which contains the greatest number 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 approximately 5,500 more codes than the ICD-9-CM.
the signs and symptoms of a disease
fouond in both the alphabetic index and the tabular index, notations are instructions or guides in classifaction assignments, defining category content or the use of subdivision codes; also called intrumental notations
initial identification of the condition or complaint that the patient expresses in the outpatient medical setting.
a direction to the coder to look in other place; this instruction must always be followed. it is found in the alphabetic index, volumes 2 and 3.
a direction to a coder to look elsewhere in the main term or subterm for that entry are not sufficient for coding the information. if a code number follows, see also is enclosed in parentheses. if there is no code number, see also is preceded by a dash.
a direction to the coder to see a specific category (three digit code) this instruction must always be followed.
a system of charting compromising the Subjective findings, Objective findings, Assessment, and Plan for the treatment
volume 1 of the icd-9-cm coding manual; it contains all the diagnostic codes, which are grouped into 17 chapters of disease and injury.
use additional code
a term that appears only in the tabular index (volume 1) in subdivisions in which the user should add further information, by means of an additional code, to give a more complete picture of the diagnosis. for the purpose of coding, the if desired phrase will not be used. when the term use additional code if desired appears, disregard "if desired" and assign the appropriate additional code.
in the context of the ICD-9-CM, the terims with, with mention of, and assiciated 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 determination of the nature of a condition, illness, disease, injury, or congenital defect.
synonyms of assessment and diagnostic statement
diagnostic findings and procedures and services
used to determine the charges for an encounter to generate an insurance claim.
describes conditions, illnesses, diseases, and injuries.
used to locate codes in the tabular index based on diagnosis provided in the medical record.
found in operative reports, discharge summaries, history and physical reports (H&P), and reports on ancillary diagnostic services.
ancillary diagnosis services
include radiology, pathology, and laboratory service reports. used by healthcare providers to code and report clinical information.
used to track healthcare statistics
the translation or transformation of written descriptions of diseases, illnesses, or injuries into written codes.
identification of the disease
a three, four, or five digit code
standardize a system of diagnostic coding accepted and understood by all parties in the reimbursement cycle
create a more convenient method of data storage and retrieval
help maximize reimbursement to the provider
shortening the claims processing time
facilitate the assess regulatory compliance through the use of guidelines and other instructions
help evaluate the appropriateness and timeliness of medical care
the first to group data by disease processes
updated quarterly to reflect any changes, deletions or additions from the previous year.
three digit code
represents a specific disease, illness, condition or injury
four digit code
represents a subcategory
five digit code
made up of three volumes
volumes 1 and 2
used for diagnostic coding by hospitals, physicians, and all other providers of service.
tabular index.contains all the diagnostic codes (grouped into 17 chapters of disease and injury)
alphabetic index. refers to the user back to the category codes in the tabular index, rather than to page numbers.
used by hospitals to code inpatient procedures and services formed in the hospital environment. (most physician providers do not use this)
17 chapters that classify diseases and injuries
two sections containing supplementary classification codes V and E
a group of three digit code numbers that describe general category
a three digit code that represents a specific disease, illness, condition, or injury within a section or chapter
adds additional information or description to the category code. generally used to assign a fourth digit.
adds the highest level of detail to the illness or injury. the subclassification is used to assign a fifth digit when appropriate.
describe factors that influence health status and contact with health services that cannot be classified elsewhere.
describe external causes of injury or poisoning
used when patient is not currently ill or to explain problems that influence a patients current illness, condition, or injury.
classified environmental or external causes of injury, poisoning, or other adverse effects on the body.
morphology of neoplasms
glossary of mental disorders
classification of drugs
classification of industrial accidents
list of three digit categories
abbreviations, punctuation, symbols, instructional notations, and related entities that help the medical assistant or coder select an accurate, specific code.
not otherwise specified
not elsewhere classifiable
brackets, parentheses, colon, and braces
four basic forms of puncuation
used to designate the requirement of a fourth or fifth digit (or both), new entries, and revised text or codes.
enclose synonyms, alternative wording, or explanatory phrases
used to enclose supplementary words, may be present or absent in the statement of disease or procedure. do not usually affect the code number selected, but provide further definition or specificity to the code description
used in the tabular index after an incomplete term that needs one or more of the modifiers or adjectives to follow to make it assignable to a given category
enclose a series of terms, each of which is modified by the statement appearing to the right of the brace
lozenge or circle symbol
found to the left of a disease code. will contain the number 4 or 5 to indicate the use of a fourth or fifth digit is required
section mark symbol
only used when in the tabular index of diseases and precedes a code denoting a footnote on the page
indicates a new entry
indicates a revision in the tabular index and a code change in the alphabetic index
notation indicating that under a category or other subdivision, separate terms can be found that will serve to further define, give examples of or provide modifying adjectives and sites of conditions.
enclosed within a box and printed in italics. indicated some code classifications cannot be used with the code selected
used to define terms and give coding classification for certain categories
follows a main term that indicated that a different term should be referenced
variation of the see instruction
generally found following a main term in the alphabetic index and directs the coder to another area with additional index entries that may be useful.
directs the use of codes that are not normally intended to be used as a principal diagnosis or are not to be sequences before the underlying disease
use additional code
indicates that a supplement code should be used in addition to the one selected. helps create a more complete picture of the diagnosis.
should be interpreted to mean either and or or
sequenced immediately after a main term. provides additional definition or specificity to the code description
three supplementary sections
what is the section name of the hypertension table, neoplasm table, and table of drugs and chemicals
appear in bold type
indented two spaces to the right under the main term
are always indented two additional spaces from the level of the preceding line
words that further describe the main term
found in the alphabetic index indented below main terms
two types of modifiers
essential and nonessential modifiers
indented under the main term. affect code selection and are used in the coding process only if they are specified in the diagnostic statement
shown in parentheses after the term. modifies and adds further info about the term. do not effect code selection.
also known as a superbill, fee slip, or charge ticket
second most common medical document from which diagnostic info can be obtained
used for extracting procedure and diagnostic info for patients who were hospitalized rather than seen in the physicians office.
used to extract procedure and diagnostic info for patients who underwent surgery as an outpatient or patient
radiology, laboratory, or pathology report
not used to obtain diagnostic statements. must be documented in the treatment notes in medical record to be used for diagnostic coding, change entry, or insurance billing purposes.
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