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22 terms

Medical Coding Key Terms -Test 1

<p>Medical Coding</p>
STUDY
PLAY
acute
occurring now; of short-term duration.
appendices
additional information segments.
chief complaint
statement in the patient's own words that describes the reason for the visit; should be documented in the patient's own words.
chronic
occurring over the long term or reoccurring frequently.
concurrent condition
condition that occurs at the same time as the primary diagnosis and affects the patient's treatment or recovery from the primary condition.
consultation
service provided by the health care provider at the request of another physician.
contributory factors
issues that affect a decision.
conventions
ways of identifying special instructions through the use of abbreviations, symbols, and other short descriptions.
coordination of care
approach to managing a patient's care when a provider asks other health care providers to assist.
counseling
discussion with the patient or family conducted by a health care provider concerning the patient's diagnosis, test results, and other approaches to medical care.
diagnosis
determination of the nature of a disease based on signs, symptoms, and laboratory findings.
E codes
ICD-9 CM supplementary codes for external causes of injury and poising.
eponym
person or persons for whom something (e.g., disease, procedure) has been named, or the name so derived (e.g., a simple urethropexy is known as the Marshall-Marchetti-Kravitz procedure).
established patient
person who has been treated by a member of the health care team in the past 3 years.
examination
physical review of the body system or systems.
greatest specificity
coding to the highest level of documentation available; not using only a three-digit when a four-or five-digit code exits to better describe the disease or procedure.
guidelines
rules that define items necessary to interpret and report procedures and services appropriately (e.g., for CPT codes).
history
information about past events.
history of present illness (HPI)
chronological description of the patient's present illness from the first sign or symptom to the present.
inpatient
person who has been admitted to the hospital for continued care.
instructional terms
words or phrases that have a special meaning to provide needed information.
key components
three main factors (history, examination, and medical decision making) taken into account when selecting a level of E/M service in CPT coding.