Chapter 18&19 MEAS108

Terms in this set (39)

The notation within ICD using directions like see or see also after the main terms in the index; notes that another term maybe appropriate when coding the referenced diagnosis

Cross-reference

Code set based on a system maintained by WHO whose use is mandated by HIPAA for reporting diseases, conditions, signs, and symptoms

The patient's primary reason for seeking care

Chief complaint

The alphanumeric designation used to communicate the diagnosis to third-party payers o the healthcare claim form

One of two ways diagnoses are listend in IDC; diagonses appear in alpha order wit their corresponding diagnoses codes

Alphabetic Index

Type of ICD-9 code set that identifies external causes of injuries and illnesses

One of two ways diagnoses are listed in ICD; diagnoses codes are listed in numeric order with additional instructions regarding the use of the code for each diagnosis

The first diagnosis listed for OUTpatient claims as the PRIMARY reason for the patient's visit

Primary diagnosis

Analysis of the connection between diagnostic and procedural information in order to evaluate the medical necessaity of the reported charges

Another term for the physician's assessment of the patient's condition

The first diagnosis listed for INpatient claims as the PRINCIPAL reason found, after study, for the patient's hospitalization

Principal diagnosis

An ICD-9 code used to identify healthcare encounters for reasons other than illness or injury, such as annual exams and immunization

The list of abbreviation, punctuation, symbols, typefaces, and instructional notes providing guidelines for using the ICD code set

Causes and severity of illness

Subdivisions of the alpha index for ICD-10 chapters containing clinical descriptions of the code range for coding

The cause of a disease or condition

The 3-digit code subdivision in ICD-10

The organization that maintain and updates ICD

Divisions of ICD-10 named for a body system or specific disease type

Causes of death

Similar care being provided by more than one physician

Concurrent care

A reference with the most commonly used systems of codes

The period of time after many procedures for follow-up care that is considered included in the payment for that procedure

One or more two-digit alphanumeric codes assigned in addition to the CPT code to show that some special circumstances applies to the service or procedure

Any CPT code that includes more than one procedure in its description

Codes that represent medical procedures, diagnostic tests, and examinations to evaluate patient's condition

Codes used when discussing questions or concerns regarding test results, prognosis, risks, options, treatments instructions, importance of compliance, risk factor reduction, and patient/family education

Lab test frequently ordered together that are organ- or disease- orientated

Codes used to describe the wide range of time, effort, skill, and locations used by physicians for different patients to diagnose conditions and plan treatment

Codes that cover many supplies and DME; also referred to as nation codes; services and procedures may not be found in CPT

HCPCS Level 2 codes

CPT codes that is only reported in addition to primary code

The act of separately listing services or procedures instead of using available codes that includes all services provided

Care provided to unstable, critically ill patients; constant bedside attention is needed with explicit information as to time spent

Purposely choosing a code of higher level than that of the service provided

Patient who has not received professional services from physician within the last 3 years

Analysis of the connection between diagnostic and procedural information in order to evaluate medical necessity

Term used when the insurance carrier bases reimbursement on a code level lower than the one submitted by the provider

Care provided at the request of another healthcare provider

Patient who has been seen by the physician within the last 3 years

Established patient

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