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Chapter 5 Diagnostic coding

Terms in this set (22)

Appropriate diagnosis coding can mean
The financial success or failure of a medical practice.
A physician's fee profile
Is a compilation of each physician's charges and the payments made to him or her over a given period of time for each specific professional service rendered to a patient.
Diagnosis that relate to a patient's previous medical problem but have no bearing on the patient's present condition are not
CODED
Primary Diagnosis
(First listed condition) is the main reason for the encounter
Secondary Diagnosis
Listed subsequently, may contribute to the condition or define the need for a higher level of care but is not the underlying cause.
Principle Diagnosis
Used in inpatient hospital coding, is the diagnosis obtained after study that prompted the hospitalization .
Admitting Diagnoses
Some diagnostic codes are considered questionable when used as the first diagnosis on admission of a patient to the hospital ( For example Obesity, Benign Hypertension, Controlled Diabetes)
Diagnosis coding for office and outpatient services provided after October 1, 2014, is performed using the
ICD-10-CM
In 1948, the WHO developed the official version of the
ICD in Geneva, Switzerland
Crosswalks
To facilitate the coding process between ICD-9-CM and ICD-10-CM systems, a common translation tool referred to as the general equivalence mappings (GEMs)
GEM
Is a comprehensive translation tool that can be used to accurately and effectively translate codes.
ICD-10-CM is updated
Annually and contains a Tabular List of Diseases
Conventions
Are rules or principles for determining a diagnostic code when using diagnostic code books such as each space, typefaces, indentations, punctuation marks, symbols, instructional notes, abbreviations, cross reference notes, and specific usage of the words and, with and due to.
NEC
Not elsewhere classifiable
NOS
Not otherwise specified
Brackets [ ]
Are used in the Tabular List to enclose synonyms, alternative wording, or provide explanatory phrases.
Parenthesis ( )
Are used in the Alphabetic Index and the Tabular List to enclose supplementary words that may further define the condition but do not affect the code number assigned.
Colons
Are used in the Tabular List after an incomplete term that requires additional modifiers to appropriately assign the code.
Combination Code
Is a situation in which a single code is used to classify two diagnoses or a diagnosis with an associated secondary process ( manifestation) or a diagnosis with an associated complication.
Sequela
Is a LATE EFFECT or condition produced after the acute phase of an illness.
Syndromes
Is another name for a symptom complex, which is a set of complex signs, symptoms, or other manifestations resulting from a common cause or appearing in combination, presenting a distinct clinical picture of a disease or inherited abnormality.
Neoplasms
Is a spontaneous new growth of tissue froming an
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