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Vocab & Important Info

organizes a medical nomenclature according to similar conditions, diseases, procedures, & services & it contains codes for each Coding System
Coding System AKA Classification System
ICD-9-CM arranges these elements of coding/classification system into appropriate __ & __ chapters; sections
called the United States Postal Service ZIP Code system, which classifies addresses as numbers nonmedical "coding system"
adopted in 1979 to classify diagnoses (Volumes 1 & 2) & procedures (Volume 3) International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM)
developed by the National Center for Health Statistics (NCHS) to replace Volume 3 of ICD-9-CM International Classification of Diseases, Tenth Revision, Procedure Coding System (ICD-10-PCS)
when ICD-10-PCS implemented it will be used to classify __ __ & __ inpatient procedures; services
originally published by the American Medical Association (AMA) in 1966; considered Level I of the Healthcare Common Procedure Coding System (HCPCS) Current Procedural Terminology (CPT)
; includes Level II (national codes), called HCPCS level II (or HCPCS national codes); managed by the Centers for Medicare & Medicaid (CMS) Healthcare Common Procedure Coding System (HCPCS)
classifies medical equipment, injectable drugs, transportation services, & other services not classified by CPT HCPCS Level II
use HCPCS Level II to report procedures & services Physicians & ambulatory care settings
discontinued in 2004 HCPCS Level III codes
collection of words/phrases with their meanings vocabulary
example of a vocabulary is SNOMED CT
system that is clinically descriptive & arranges/organizes like/related entities classification
example of a classification as classify nephrolithiasis, renal calculi, & kidney stone within the same category ICD-9-CM
system of names used as preferred terminology nomenclature
listing of the proper name for each disease entity with its specific code number disease nomenclature
Nephrolithiasis, Renal Calculi, & Kidney stone all refer to the same disease/medical condition example of nomenclature
refers to a set of terms representing the system of concepts of a particular subject field terminology
refers to a set of standardized terms & their synonyms that record patient findings, circumstances, events, & interventions with sufficient detail to support clinical care, decision support, outcomes research, & quality improvement clinical terminology
clinical terminology can be efficiently mapped to __ __ for administrative, regulatory, oversight, & fiscal requirements broader classifications
set of concepts & relationships that provides a common consultation point for comparison & aggregation of data about the entire healthcare process, recorded by multiple individuals, systems,/institutions reference terminology
acute care facilities (hospitals), behavioral healthcare facilities, hospice inpatient care, long-term care facilities are all inpatient health care settings
process of converting medical diagnoses & medical procedures to code # contained within code set that best/most accurately describes diagnosis & medical procedure medical coding
used for patient care, research, reimbursement, & evaluation of services coded medical information
central premise was that deaths from plague needed to be examined in the context of all other causes of mortality in order to understand effects of all diseases (deductive reasoning) Reflections on the Weekly Bills of Mortality
London merchant who published Reflections on the Weekly Bills of Mortality 1665 James Graunt
sixty disease categories in the Bills constituted the FIRST __ __ to analyze incidences of disease systematic attempt
first medical statistician for the General Register Office of England; standardized terminology and utilized primary diseases for a UNIFORM classification system Dr. William Farr
recognized need for a UNIFORM classification of causes of death in 1853 & requested Dr. Farr prepare a classification for consideration at its next meeting in Paris in 1855 International Statistical Congress in Brussels
Dr. Farr's classification was based primarily on __ __ & consisted of 138 __ anatomical site; rubrics
adopted in 1864 and revised at four subsequent International Statistical Congresses Dr. Farr's classification list
chief statistician of the city of Paris, prepared a revised list that was adopted by the International Statistical Institute in 1893; known as the Bertillion Classification Jacques Berillion
FIRST standard system actually implemented internationally Bertillion Classification
recommended use of Bertillion Classification in United States, Canada, & Mexico in 1898 American Public Health Association
has working knowledge standardized medical coding systems, coding guidelines, principles/rules, government reg., & 3rd-party payer requirements to ensure all diagnoses, medical services, & procedures as documented in medical records are coded accurately medical information coding specialist
American Academy of Professional Coders (AAPC): certifications: CPC, CPC-A, CPC- H, and CPC-P; American Health Information Management (AHIMA): certifications CCA, CCS, CCS-P Medical Coding Specialist
career associated with American Medical Billing Association (AMBA) Health Insurance Specialist
Medical Association of Billers (MAB) certification for career in Health Insurance Specialist Certified Medical Billing Specialist (CMBS)
National Association of Claims Assistance Professionals (NACAP) certification for career in Health Insurance Specialist Certified Claims Assistance Professional (CCAP) & Certified Electronic Claims Professional (CECP)
ICD-9-CM codes are assigned to inpatient cases to __ __ __ for education and research, determine third-party payer reimbursement, and facilitate institutional financial planning collect statistical data
once entered into a facility's database, the ICD-9-CM codes are transmitted to the facility's billing department, which generates the __ __ for submission to 3rd-party payers UB-04 claim
hospital inpatient cases usually have multiple __ & __ documented diagnoses; procedures
once ICD-9-CM codes are assigned to hospital inpatient cases, the coder must __ them according to principal diagnosis, other diagnoses, principal procedure, and other significant procedures as defined by the __ sequence; UHDDS
responsible for documenting and authenticating legible, complete, and timely patient records in accordance with federal regulations & accrediting agency standards health care providers
patient's medical record MUST __ the codes assigned & submitted on claims for third-party reimbursement support
patient's diagnosis MUST __ diagnostic and therapeutic procedures or services provided justify
patient's diagnosis justifies diagnostic & therapuetic procedures/services provided medical necessity
founded 1988; provide education & professional certification to physician-based medical coders & elevate standards of medical coding; proven mastery of all code sets, Evaluation & Management principles & documentation guidelines American Association of Professional Coders (AAPC)
adherence to accepted standards Compliance
American Health Information Management Association (AHIMA)
electronic health record EHR
Certified Claims Assistance Professional (CCAP)
Certified coding associate (CCA)
Certified coding specialist (CCS)
Certified coding specialist-physician based (CCS-P)
Certified Professional Coder(CPC)
Centers for Medicare & Medicaid Services (CMS)
official daily publication for rules, proposed rules, & notices of US federal agencies & organizations Federal Register
Central Office on ICD-9-CM of the American Hospital Association
payment for health care services Reimbursement
Closed classification system
coding software that is used to assign diagnosis & procedure codes Encoder
Coding Clinic
combination of formats producing similar results i.e. paper & electronic records hybrid record
degree/certificate/award that recognizes course of study taken in specific field & that acknowledges competency required Credential
Certified Professional Coder, Apprentice status (CPC-A)
reason in patient's own words for presenting to hospital chief complaint
Certified Professional Coder, Hospital (CPC-H)
condition established after study to be chiefly responsible for occasioning admission of patient to hospital for care Principal Diagnosis
Certified Professional Coder, Payer (CPC-P)
procedure performed/definitive treatment, rather than diagnostic or exploratory purposes, or one necessary to take care of complication Principal Procedure
Certified Electronic Claims Professional (CECP)
criteria/guidelines for what is determined to be reasonable/necessary for particular medical service medical necessity
Certified Medical Billing Specialist (CMBS)
other diagnoses
Medical Association of Medical Billers (MAB)
patient's reason for visit (PRV)
condition that requires patient to be hospitalized admitting diagnosis
indicator to differentiate between condition developed during particular hospital encounter & condition present at time of admission present on admission (POA)
preexisting diagnosis/condition (present on admission) which may lead to increased resource use comorbidities
daily recordings by health care providers of patient progress progress notes
condition arising during during patient's hospitalization which may lead to increased resource use complication
question-&-answer period that occurs between patient & health care provider during which any healthcare issues are reviewed review of systems
healthcare provider asked to see patient to provide expert opinion outside expertise of requestor consultant
considered if surgical in nature, carries procedural/anesthetic risk, &/or requires specialized training significant procedure
Uniform Hospital Discharge Data Set (UHDDS)
diagnosis-related groups DRGs
DRGs are now known as MS-DRGs
amyotrophic lateral sclerosis (ALS) or Lou Gehrig disease can also be called motor neuron disease