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CPT Chapter 01
| Term | Definition |
|---|---|
| medical coding | The process of assigning standardized alphanumeric identifiers to the diagnoses and procedures documented in a health record. |
| diagnosis | A statement or conclusion that describes a patient’s illness, disease, or health problem. |
| procedure | An activity performed on an individual to improve health, treat disease or injury, or identify a diagnosis. |
| health record | A legal document that contains descriptions of all the products and services provided to a patient. Also known as medical record. |
| third-party payer | An entity contracted to pay the medical provider on behalf the policyholder. |
| self-pay patients | Patients who pay for the entire visit themselves. |
| morbidity | Statistics regarding illness. |
| mortality | Statistics regarding death. |
| abstract | To take away. |
| electronic health record (EHR) | A record that collects patient data in a computerized format designed to facilitate sharing across a continuum of healthcare entities. |
| operative report | A report that presents diagnoses, names of healthcare personnel, findings, a procedure description, details of specimens, and blood loss. |
| practice management system (PMS) | The software used by physician practices to store, organize, bill, and reconcile patient financial accounts. |
| nomenclature | A system of naming things. |
| classification system | A system used to organize like medical conditions, procedures, or concepts into categories and assign them codes that, when deciphered, describe each item in detail. |
| Systematized Nomenclature of Medicine (SNOMED) | A nomenclature that contains the names of diseases, bacteria, anatomic sites, procedures, and other medical terms, as well as the corresponding medical codes. |
| SNOMED-CT | A nomenclature that is designed to improve the accuracy of information entered into EHR systems and improve communication between EHR systems, improving the quality of patient care. CT stands for clinical terminology. |
| MEDCIN | A medical nomenclature used in EHR systems that enables the system to index, store, and combine medical data. |
| Health Insurance Portability and Accountability Act of 1996 (HIPAA) | Federal legislation enacted to provide continuing health coverage, reduce healthcare costs, and guarantee the security and privacy of health information. |
| International Classification of Diseases (ICD) | A statistical classification system maintained by the World Health Organization (WHO). |
| ICD-9 | A diagnosis and procedure classification system used in the United States. |
| inpatient procedures | Medical procedures performed in the hospital. |
| ICD-10-CM | A diagnosis classification system that is scheduled to replace the ICD-9 diagnosis classification system in October 2015. |
| ICD-10-PCS | A classification system used to report procedures performed in an inpatient setting. |
| ICD-O-3 | A neoplasm classification system that categorizes neoplasms by their anatomical site, histology, behavior, and grading. Its codes are also known as morphology codes. |
| neoplasm | A tumor. |
| morphology codes | Codes that describe the form and structure of tumors. |
| histology | The study of microscopic anatomy. Also known as morphology. |
| morphology | The study of microscopic anatomy. Also known as histology. |
| grading | The cell stage. |
| cancer registries | A registry that keeps track of statistical information regarding cancer behaviors and characteristics and supplies this information to physicians, hospitals, and researchers. |
| International Classification of Functioning, Disability, and Health (ICF) | A classification system used to categorize the health and disability functionality of individuals and the general population. |
| Diagnostic and Statistical Manual of Mental Disorders (DSM) | A standard classification system developed by the American Psychiatric Association and used by mental health professionals to categorize mental illnesses. |
| Healthcare Common Procedure Coding System (HCPCS) | The standards used to report medical, surgical, and diagnostic procedures as well as products and drugs. |
| Outpatient providers | Providers who are not employees of a hospital, but who may bill for their professional services performed in the hospital or in the medical office. |
| Current Procedural Terminology (CPT®) | HCPCS Level I codes that are used to report medical services and procedures performed by outpatient providers. |
| American Medical Association (AMA) | An organization that develops, revises, and licenses CPT® codes for publication. |
| Current Dental Terminology (CDT) | The common language used when describing dental procedures. Also known as the Code on Dental Procedures and Nomenclatures. |
| American Dental Association (ADA) | An organization that maintains CDT codes. |
| health information management (HIM) | The practice of analyzing, maintaining, and protecting traditional and digital confidential patient information. |
| inpatient coders | Hospital coders who use ICD-10 codes to report diagnoses and procedures. |
| physician coders | Coders in physician offices who use ICD-10-CM to report diagnoses, and CPT® and HCPCS codes to report procedures and services. |
| revenue cycle | A process that consists of the steps necessary to receive reimbursement for services or procedures provided to a patient. |
| chargemaster | A comprehensive listing maintained by a hospital that contains all the services, procedures, and even medicines they provide, along with the price they charge for each one. |
| professional organization | An association of people who have the same occupation. |
| AAPC | A group that offers its members education and training programs, certifications, and networking and job opportunities. Formerly known as the American Academy of Professional Coders. |
| certified professional coder (CPC) | An AAPC member who successfully passes the certification examination in medical coding for physician offices and is awarded a certificate. |
| Continuing education (CE) | Education that typically comprises courses, webinars, workshops, and other offerings that allow professionals to stay up-to-date with changes and innovations in their field. |
| American Health Information Management Association (AHIMA) | An organization that developed a core data set for physician practices with elements for history and physicals, problem lists, and other data elements used by physicians. |
| Commission on Accreditation for Health Informatics and Information Management Education (CAHIIM) | An organization that promotes and enforces accreditation standards for health information and health informatics education programs |
| medical compliance | The process of meeting the regulations, recommendations, and expectations of federal and state agencies that pay for medical services and procedures. |
| professionalism | The process of conducting oneself with responsibility, integrity, accountability, and excellence in the workplace; also communicating effectively and appropriately and maintaining a high level of productivity. |
| communication skills | The ability to convey information in a way that your audience can easily understand. |
| technical skills | The knowledge and ability to work efficiently with technology. |
| critical thinking skills | Skills that include the ability to formulate ideas, solve problems, analyze situations, and think creatively. |
| healthcare provider | An individual who has completed the required education and is licensed to practice medicine, provide medical care, and/or perform procedures in a medical facility. |
| healthcare practitioner | Another name for a person who practices medicine. |
| internship | A type of job that allows medical students to practice medicine in a medical setting under the supervision of a teaching physician. |
| residency | A process that typically takes place in a hospital setting, allowing graduates to apply their new knowledge and skills to a medical specialty of their choosing. |
| nonphysician practitioner (NPP) | A medical provider who has completed undergraduate studies in a specific scope of patient care. Also known as a mid-level. |
| mid-level | A medical provider who has completed undergraduate studies in a specific scope of patient care. Also known as a nonphysician practitioner (NPP). |
| allied health professional | A person that provides ancillary and support services to assist in the care of patients. |
| ethics | A generally accepted standard of moral conduct. |
| coding ethics | The standards that medical coders are expected to follow as they perform their daily tasks. |
| compliance plan | An internal process that allows the medical facility to identify incidents that may result in the violation of federal or state regulations. |
| fraud | The act of intentionally submitting false information to benefit yourself or others. |
| upcoding | The process of reporting a service or procedure that is more extensive than what the documentation supports. Also known as overcoding. |
| abuse | Incidents or practices (usually considered fraudulent) that are inconsistent with accepted sound medical business or fiscal practices. |
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