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KINNS Ch 18 Key Term

KINNS Ch 18

Question	Answer
abstract	An outline or summary of the diagnostic statement and/or procedures and services performed.
Alphabetic Index	Volume 2 of the ICD-9-CM coding manual; it lists conditions, injuries, illnesses, and diseases in alphabetical order by main terms, modifying terms, and subterms.
ancillary diagnostic services	Services that support patient diagnoses (e.g., laboratory or radiologic services).
and	In the context of the ICD-9-CM, and should be interpreted as and/or.
assessment	The physician's determination of what is or may be wrong with the patient based on the findings from the history and physical examination (H&P). The assessment includes a preliminary, interim, or final diagnosis.
chief complaint (CC)	The reason the patient has sought medical care. It is recorded in the history documentation in the medical record, preceded by the abbreviation CC.
code also	Used when more than one code is necessary to identify a given condition; code also or use additional code is used.
coding	Converting verbal or written descriptions into numeric and alphanumeric designations.
conventions	Abbreviations, punctuation, symbols, instructional notations, and related entities that provide guidance to the medical assistant or coder in the selection of an accurate, specific code.
diagnosis	The concise, technical description of the cause, nature, or manifestations of a condition or problem.
diagnostic statement	Information about a patient's diagnosis or diagnoses that has been extracted from the medical documentation.
etiology	The cause of a disorder; a claim may be classified according to the etiology.
excludes	Exclusion terms are always written in italics, and the word excludes often is enclosed in a box to draw particular attention to these instructions.
history and physical examination (H&P, HPE)	At the patient's first visit with a new physician or provider or upon admission to a hospital, the history and physical examination (H&P) are documented.
includes	An assessment is the physician's determination of what is or may be wrong with the patient based on the findings from the history and physical examination.
International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM)	The manual that establishes the system for classifying disease to facilitate collection of uniform and comparable health information, for statistical purposes, and for indexing medical records for data storage and retrieval.
International Statistical Classifications of Diseases and Related Health Problems, Tenth Revision, Clinical Modification (ICD-10-CM)	The current ICM rules manual, which contains the greatest number of changes in the ICD-CM system in ICD history.
manifestation	The signs and symptoms of a disease.
notations	Found in both the Alphabetic Index and the Tabular Index, notations are instructions or guides in classification assignments, defining category content or the use of subdivision codes; also called instructional notations.
principal diagnosis	Initial identification of the condition or complaint that the patient expresses in the outpatient medical setting.
see	A direction to the coder to look in another place; this instruction must always be followed. It is found in the Alphabetic Index, volumes 2 and 3.
see also	A direction to the coder to look elsewhere if the main term or subterm (or subterms) for that entry are not sufficient for coding the information.
see category	A direction to the coder to see a specific category (three-digit code); this instruction must always be followed.
SOAP notes	A system of charting comprising the subjective findings, objective findings, assessment, and plan for treatment.
Tabular Index	Volume 1 of the ICD-9-CM coding manual; it contains all the diagnostic codes, which are grouped into 17 chapters of disease and injury.
use additional code	A term that appears only in the Tabular Index (volume 1) in subdivisions in which the user should add further information, by means of an additional code, to give a more complete picture of the diagnosis.
with	In the context of the ICD-9-CM, the terms with, with mention of, and associated with in a title dictate that both parts of the title must be present in the diagnostic statement to allow assignment of the particular code.

Created by: curriculum

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