Vocab & Important Info
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| organizes a medical nomenclature according to similar conditions, diseases, procedures, & services & it contains codes for each | Coding System
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| Coding System AKA | Classification System
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| ICD-9-CM arranges these elements of coding/classification system into appropriate __ & __ | chapters; sections
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| called the United States Postal Service ZIP Code system, which classifies addresses as numbers | nonmedical "coding system"
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| adopted in 1979 to classify diagnoses (Volumes 1 & 2) & procedures (Volume 3) | International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM)
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| 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)
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| when ICD-10-PCS implemented it will be used to classify __ __ & __ | inpatient procedures; services
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| 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)
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| ; 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)
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| classifies medical equipment, injectable drugs, transportation services, & other services not classified by CPT | HCPCS Level II
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| use HCPCS Level II to report procedures & services | Physicians & ambulatory care settings
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| discontinued in 2004 | HCPCS Level III codes
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| collection of words/phrases with their meanings | vocabulary
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| example of a vocabulary is | SNOMED CT
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| system that is clinically descriptive & arranges/organizes like/related entities | classification
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| example of a classification as classify nephrolithiasis, renal calculi, & kidney stone within the same category | ICD-9-CM
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| system of names used as preferred terminology | nomenclature
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| listing of the proper name for each disease entity with its specific code number | disease nomenclature
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| Nephrolithiasis, Renal Calculi, & Kidney stone all refer to the same disease/medical condition | example of nomenclature
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| refers to a set of terms representing the system of concepts of a particular subject field | terminology
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| 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
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| clinical terminology can be efficiently mapped to __ __ for administrative, regulatory, oversight, & fiscal requirements | broader classifications
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| 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
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| acute care facilities (hospitals), behavioral healthcare facilities, hospice inpatient care, long-term care facilities are all | inpatient health care settings
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| process of converting medical diagnoses & medical procedures to code # contained within code set that best/most accurately describes diagnosis & medical procedure | medical coding
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| used for patient care, research, reimbursement, & evaluation of services | coded medical information
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| 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
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| London merchant who published Reflections on the Weekly Bills of Mortality 1665 | James Graunt
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| sixty disease categories in the Bills constituted the FIRST __ __ to analyze incidences of disease | systematic attempt
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| first medical statistician for the General Register Office of England; standardized terminology and utilized primary diseases for a UNIFORM classification system | Dr. William Farr
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| 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
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| Dr. Farr's classification was based primarily on __ __ & consisted of 138 __ | anatomical site; rubrics
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| adopted in 1864 and revised at four subsequent International Statistical Congresses | Dr. Farr's classification list
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| 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
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| FIRST standard system actually implemented internationally | Bertillion Classification
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| recommended use of Bertillion Classification in United States, Canada, & Mexico in 1898 | American Public Health Association
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| 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
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| 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
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| career associated with American Medical Billing Association (AMBA) | Health Insurance Specialist
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| Medical Association of Billers (MAB) certification for career in Health Insurance Specialist | Certified Medical Billing Specialist (CMBS)
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| National Association of Claims Assistance Professionals (NACAP) certification for career in Health Insurance Specialist | Certified Claims Assistance Professional (CCAP) & Certified Electronic Claims Professional (CECP)
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| 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
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| 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
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| hospital inpatient cases usually have multiple __ & __ documented | diagnoses; procedures
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| 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
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| responsible for documenting and authenticating legible, complete, and timely patient records in accordance with federal regulations & accrediting agency standards | health care providers
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| patient's medical record MUST __ the codes assigned & submitted on claims for third-party reimbursement | support
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| patient's diagnosis MUST __ diagnostic and therapeutic procedures or services provided | justify
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| patient's diagnosis justifies diagnostic & therapuetic procedures/services provided | medical necessity
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| 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)
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| adherence to accepted standards | Compliance
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| American Health Information Management Association (AHIMA)
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| electronic health record | EHR
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| Certified Claims Assistance Professional (CCAP)
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| Certified coding associate (CCA)
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| Certified coding specialist (CCS)
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| Certified coding specialist-physician based (CCS-P)
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| Certified Professional Coder(CPC)
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| Centers for Medicare & Medicaid Services (CMS)
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| official daily publication for rules, proposed rules, & notices of US federal agencies & organizations | Federal Register
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| Central Office on ICD-9-CM of the American Hospital Association
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| payment for health care services | Reimbursement
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| Closed classification system
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| coding software that is used to assign diagnosis & procedure codes | Encoder
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| Coding Clinic
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| combination of formats producing similar results i.e. paper & electronic records | hybrid record
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| degree/certificate/award that recognizes course of study taken in specific field & that acknowledges competency required | Credential
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| Certified Professional Coder, Apprentice status (CPC-A)
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| reason in patient's own words for presenting to hospital | chief complaint
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| Certified Professional Coder, Hospital (CPC-H)
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| condition established after study to be chiefly responsible for occasioning admission of patient to hospital for care | Principal Diagnosis
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| Certified Professional Coder, Payer (CPC-P)
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| procedure performed/definitive treatment, rather than diagnostic or exploratory purposes, or one necessary to take care of complication | Principal Procedure
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| Certified Electronic Claims Professional (CECP)
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| criteria/guidelines for what is determined to be reasonable/necessary for particular medical service | medical necessity
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| Certified Medical Billing Specialist (CMBS)
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| other diagnoses
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| Medical Association of Medical Billers (MAB)
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| patient's reason for visit (PRV)
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| condition that requires patient to be hospitalized | admitting diagnosis
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| indicator to differentiate between condition developed during particular hospital encounter & condition present at time of admission | present on admission (POA)
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| preexisting diagnosis/condition (present on admission) which may lead to increased resource use | comorbidities
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| daily recordings by health care providers of patient progress | progress notes
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| condition arising during during patient's hospitalization which may lead to increased resource use | complication
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| question-&-answer period that occurs between patient & health care provider during which any healthcare issues are reviewed | review of systems
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| healthcare provider asked to see patient to provide expert opinion outside expertise of requestor | consultant
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| considered if surgical in nature, carries procedural/anesthetic risk, &/or requires specialized training | significant procedure
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| Uniform Hospital Discharge Data Set (UHDDS)
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| diagnosis-related groups | DRGs
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| DRGs are now known as | MS-DRGs
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| amyotrophic lateral sclerosis (ALS) or Lou Gehrig disease can also be called | motor neuron disease
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