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<p>Medical Coding</p>


occurring now; of short-term duration.


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.


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.


service provided by the health care provider at the request of another physician.

contributory factors

issues that affect a decision.


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.


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.


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.


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.


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.


rules that define items necessary to interpret and report procedures and services appropriately (e.g., for CPT codes).


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.


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.

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