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Chapter 5

Apply Knowledge Of Coding

TermDefinition
Volume 1 tabular list of diseases and injuries
Volume 2 the alphabetic index to diseases and injuries
Volume 3 classification for procedures for reporting hospital procedures
V-codes codes used to classify visits when circumstances other than diseases or injury
E-codes codes used to classify environmental events, such as the cause of injury, positioning and other adverse events
encounter a direct, professional meeting between a patient and a health care professional
mortality the incidence of death in a specific population
morbidity the number of cases of diseases in a specific population
category I CPT code codes that covers physicians services and hospital outpatient coding
category II CPT code code designed to serve as supplement tracking codes that can be used for performance measurement
category III CPT code code used for temporary coding for new technology and services that have not met the requirements needed to be added to the main section of the CPT book
encounter form form that includes information about past history, current history, inpatient record, discharge information, and insurance information
abstracting the extraction of specific data from a medical record, often for use in a external database.
encoder software that suggests codes based on documentation or other input
MS-DRG grouper software that helps coders assign the appropriate Medicare severity diagnosis-related group bases on the level of services provided
APC grouper helps coders determine the appropriate ambulatory payment classification (APC) for a outpatient encounter
computer assisted coding software that scans the entire patients electronic record and codes the encounter based on record
coronal, frontal vertical plane dividing the body into front and back surfaces
transverse horizontal plane dividing the body into top and bottom
sagittal vertical plane dividing the body into right and left sides
medial middle of the body surface
lateral pertaining to the side
inferior below
distal far from origin away from
superior above
proximal near the origin, closer.
coronal,frontal vertical plane dividing the body into front and back surfaces
transverse horizontal plane dividing the body into top and bottom
sagittal vertical plane dividing the body into right and left sides
medial middle of the body structure
lateral pertaining to the side
inferior below
distal far from the origin, away from
anterior,ventral front of the body surface
posterior,dorsal back of the body surface
superior above
proximal near the origin closer
Created by: K.Lindsey