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CBCS Vocab Review

Hodgson Certification Review Chapters 1-2

TermDefinition
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