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CBCS Vocab Review
Hodgson Certification Review Chapters 1-2
| Term | Definition |
|---|---|
| ambulatory | care that does not require an overnight stay |
| attending physician | physician who has graduated from a college |
| biopsy | removal of a sample of tissue from a living person for laboratory |
| central nervous system | divided into 2 parts; brain and spinal cord; responsible for conducting sensory information from the peripheral nervous system to the brain |
| circulatory/lymphatic systems | responsible for the overall balance of body system functions |
| digestive system | responsible for ingesting and digesting food, absorbing nutrients, and eliminating wastes |
| endocrine system | glands that produce and secrete hormones |
| health maintenance organization | managed health care system consisting of health care providers that offer services to members for fixed payments, utilized PCPs |
| inpatient | person who has been admitted to a hospital |
| integumentary system | responsible for regulating body temperature, |
| LPN (licensed practical nurse | care for patients under the direction of registered nurses and and other health care providers |
| MA (medical assistant) | heatlh care provider who performs administrative and clinical tasks to support the work of physicians and other health professionals |
| morphology | study of the form and structure of living things |
| medical billing and coding specialist | administrative support staff member with specialized training responsible for health insurance claim billing, coding and patient financial accounting |
| musculoskeletal system | responsible for giving the human body form, stability, and enabling movement; bones, muscles, tendons, ligaments, joints, cartilage, and other connective tissue are the major parts of the integumentary system |
| nervous system | responsible for receiving information and interpreting it via electrical signals carried by the nerves; consists of the central nervous system and peripheral nervous system |
| outpatient | person who has not been admitted by the hospital and receives outkpatient services from the hospital |
| peripheral nervous system | connects the central nervous system to the limbs and organs |
| physician orders | written, telephone, fax, or consultation orders for new or altered treatment |
| primary care physician | physician in a HMO who directs all aspects of a patient's care, including routine services, referrals to specialists within the system, and supervision of hospital admissions |
| referral | authorization issued by a PCP to a referred provider |
| referring physician | physician who refers a patient for a service or supply that they cannot directly provide |
| registered nurse | graduate nurse who has been legally authorized (registered to practice; licensed by a state board of nurse examiners |
| reproductive system | system responsible for human reproduction in both males and females |
| resident physician | physician who has finished medical school and his internship and is receiving training in a specialized area |
| urea | nitrogen-containing substance normally cleared from the blood by the kidney into the urine |
| urinalysis | group of tests performed on a urine sample |
| urinary system | system responsible for aiding in the process of secreting and eliminating urine |
| urology | study of conditions related to the urinary tract |
| venipuncture | puncturing of a vein for any medical purpose |
| abstract | collect data from a medical record |
| acronyms | word formed from the initial letters of other words |
| alphabetic index to diseases and injuries | volume 2 of the ICD-9-CM; lists called main terms, that describe illnesses, injuries, conditions, drugs, and diseases |
| benign | abnormal growths that are stable, treatable, and generally not life-threatening; when referred to in relation to hypertension, refers to essential hypertension progressing at a slow pace, possibly symptomless |
| bilateral | having two sides or on both sides of the body |
| cancer | malignant neoplasms; tissues with uncontrolled growth that can spread and invade other parts of the body |
| categories | 3 digit ICD-9-CM codes representing a single disease or condition |
| chapter | main division of the ICD-9-CM tabular list |
| chapter specific coding guidelines | coding guidelines for specific diagnoses or conditions |
| coding conventions | general coding rules that are independent of the guidelines and are incorporated within the alphabetic index and tabular list of ICD-9-CM as instructional notes |
| covered entities | health care providers required by law to obey HIPAA regulations |
| CPT Category I codes | permanent CPT codes consisting of six sections and comprised of five numeric characters |
| CPT Category II codes | used for performance measurement; comprised of four digits followed by the letter "F" |
| CPT Category III codes | Temporary codes for emerging technology, services, and procedures; comprised of four digits followed by the letter "T" |
| CPT modifiers | 2 digit alpha, numeric or alphanumeric characters added to CPT codes with additional information needs to be communicated pertaining to a procedure or service |
| CPT section guidelines | contain definitions of terms, explanation of notes that appear in that section, and other related information |
| CPT unlisted codes | codes that may be used when no existing CPT code describes the procedure performed |
| CPT | listing of codes for reporting services and procedures performed by providers and other health care professionals |
| diagnosis | identifying or determining a disease or injury by medical evaluation |
| documentation | written account of all health care services provided to a patient during the health care encounter or admission |
| e codes | classify the cuases of injury, poisoning, and adverse effects and are used for statistial purposes |
| eponyms | a word or name derived from the name of a person |
| HIPAA | federal act that sets guidelines for standardizing electronic interchange, exposing fraud and abuse and protecting privacy and security of health information |
| ICD 9 CM Official Guidelines for Coding and Reporting | Guidelines that assist with coding and sequencing instructions in situations when the ICD 9 CM does not provide direction; coding and sequencing take precedence over any guidelines |
| in situ | classification for a neoplasm that is localized to the site or origin and has not spread to adjacent tissue or other areas of the body |
| main terms | words that describe illnesses, injuries, conditions, drugs, and diseases; appearing in bold print in the alphabetic index to diseases |
| malignant | tissues with uncontrolled growth, also called cancer, that can spread and invade other parts of the body; when referred to in relation to hypertension, refers to severe hypertension (extremely high blood pressure) |
| medical necessity | third party payer requirement that all health care services provided are necessary for the care of the patient according to accepted standards |
| mortality | frequency of deaths in a specific population |
| neoplasm | new and abnormal growths, particularly when the growth is uncontrolled and does not behave normally |
| nonessential modifiers | words that do not affect code assignment |
| notice of privacy practices (NPP) | written notice to patients of the use and disclosure of PHI and the patient's rights and covered entity's legal duties with respect to the patient's PHI |
| office for civil rights (OCR) | department of health and human services designated office responsible for investigating health information privacy and patient safety confidentiality complaints and, if necessary, taking corrective actions |
| primary malignancy | the original site of a malignant neoplasm |
| privacy officer | individual appointed by a covered entity to be responsible for the development, implementation, and oversight of the HIPAA Privacy Rule within the organization |
| primary malignancy | spread of a neoplasm from the primary or original site to an adjacent or remote area of the body |
| section | comprised of a group of three-digit ICD-9-CM categories representing a group of conditions or related conditions |
| semicolons | punctuation marks used in the CPT manual to conserve space and to separate the common part of a description from the unique portion |
| specificity | highest level of definition |
| subcategories | 4-digit ICD-9-CM codes that are more specific than the category code in terms of cause, site, or manifestation of the condition |
| subclassifications | 5-digit ICD-9-CM codes that provide the highest level of specificity to describe the condition; use of the fifth-digit subclassification is mandatory if available |
| subterms | words indented under the main term in the ICD-9-CM coding manual |
| tabular list of diseases | Volume 1 of the ICD-9-CM; contains the numerical listing of diagnosis codes transmitted or maintained in electronic media or any other form or medium |
| uncertain behavior | describes tumors whose behavior cannot be predicted; only a pathologist can designate neoplasms as uncertain |
| unspecified behavior | describes tumors that are not clearly identified in the medical record |
| V codes | ICD-9-CM codes that report factors influencing health status and encounters with the health system for reasons other than injury or illness |
| World Health Organization (WHO) | United Nations health coordination and direction authority |
Created by:
tina.reynolds
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