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Ch 1 Key Terms
3-2-1 Code It!
| Question | Answer |
|---|---|
| Application Service Provider (ASP) | 3rd-party entity that manages and distributes software-based services and solutions to customers across a wide area network (WAN) from a central data center. |
| Assessment (A) | judgment, opinion, or evaluation made by the health care provider; considered part of the problem-oriented record (POR) SOAP note. |
| Assumption coding | inappropriate assignment of codes based on assuming, from a review of clinical evidence in the patient's record, that the patient has certain diagnoses or received certain procedures without doctor approval |
| Automated case abstracting software | software program that is used to collect and report inpatient and outpatient data for statistical analysis and reimbursement purposes |
| automated record | type of record that is created using computer technology |
| Centers for Medicare & Medicaid Services (CMS) | administrative agency in the federal Department of Health and Human Services |
| claims examiner | basically a health insurance specialist |
| classification system | basically a coding system |
| clearinghouse | public or private entity that processes or facilitates the processing of health information and claims from a nonstandard to a standard format. |
| CMS-1450 | same as UB-04 |
| CMS-1500 | standard claim submitted by physicians' offices to third-party payers |
| code | numerical and alphanumerical characters |
| coder | acquires a working knowledge of coding systems |
| coding | assignment of codes to diagnoses, services, and procedures based on patient record documentation |
| computer-assisted coding (CAC) | uses computer software to automatically generate medical codes by "reading" transcribed clinical documentation |
| concurrent coding | review od recodes and/or use of encounter forms and chargemasters to assign codes during an inpatient stay or outpatient encounter |
| continuity of care | documenting patient care services so that others who treat the patient have a source of information on which to base additional care and treatment. |
| Current Procedural Terminology (CPT) | coding system used by health care professionals to assign CPT codes for reporting procedures and services on health insurance claims |
| database | contains a minimum set of patient information collected on each patient, including chief complaint; present conditions and diagnoses; social data; part, personal, medical history |
| demographic data | patient identification information that is collected according to facility policy |
| Diagnostic and Statistical Manual of Mental Disorders (DSM) | manual published by the American Psychiatric Association that contains diagnostic assessment criteria used as tools to identify psychiatric disorders |
| diagnostic/management plan | information about the patient's condition and the planned management of conditions; considered part of the problem-oriented record |
| discharge note | documented in the progress note section of the problem-oriented record (POR) to summarize the patient's care, treatment, response to care, and condition on discharge |
| documentation | includes dictated and transcribed, typed or handwritten, and computer-generated notes and reports recorded in the patient's records by a health care professional |
| document imaging | same as optical disk imaging |
| downcoding | routinely assigning lower-level CPT codes as a convenience instead of reviewing patient record documentation and the coding manual to determine the proper code to be reported |
| electronic health record (EHR) | collection of patient info documented by a number of providers at one or more facilities regarding one patient |
| electronic medical record (EMR) | created on a computer, using a keyboard, a mouse, an optical pen device, a voice recognition system, a scanner, or a touch screen |
| encoding | process of standardizing data by assigning numeric values (codes or number) to text or other info |
| evidence-based coding | clicking on codes that CAC software generates to review electronic health record documentation (evidence) used to generate the code; |
| HCPCS level II | coding system managed by Centers for Medicare & Medicaid Services (CMS) that classifies medical equipment, injectable drugs, transportation services, and other services not classified in the CPT |
| HCPCS national codes | same as HCPCS level II |
| health care clearinghouse | same as clearinghouse |
| Healthcare Common Procedure Coding System (HCPCS) | includes level I codes (CPT) and level II codes (HCPCS level II national codes) |
| health data collection | performed by health care facilities to do administrative planning, to submit statistics to state and federal government agencies (and other organizations) and to report health claim data to third-party payers for reimbursement purposes |
| Health Insurance Portability and Accountability Act of 1996 (HIPAA) | federal legislation that amended the Internal Revenue Code of 1986 to improve portability and continuity of health insurance coverage in the group and individual markets, combat waste/fraud/abuse in health insurance and healthcare delivery... |
| health insurance specialist | employed by 3rd-party payers to review health-related claims to determine whether the costs are reasonable and medically necessary based on the patient's diagnosis |
| health plan | contract established by a n insurance company to reimburse healthcare facilities and patients for procedures and services provided |
| hospitalist | physician who provides care for hospital inpatients |
| hybrid record | combined paper-based and computer-generated documents |
| indexed | identified according to a unique identification number |
| initial plan | documentation of the strategy for managing patient care and actions taken to investigate the patient's condition and to treat/educate the patient |
| integrated record | arranged in strict chronological date order (or in reverse date order), which allows for observation of how the patient is progressing according to test results and how the patient responds to treatment based on test results |
| International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) | adopted in 1979 to classify diagnoses (VOL 1&2) and procedures (VOL3) |
| International Classification of Diseases, Tenth Revision, Clinical Modification/Procedure Coding System (ICD-10-CM/PCS) | shortened name the Centers for Medicare and Medicaid Services uses to identify the classification systems |
| International Classification of Diseases, Tenth Revision, Procedure Coding System (ICD-10-PCS) | developed by the National Center for Health Statistics (NCHS) to classify inpatient procedures and services |
| International Classification of Diseases for Oncology, Third Edition (ICD-O-3) | implemented in 2001 to classify a tumor according to primary site (topography) and morphology (histology, behavior, and aggression of tumor) |
| International Classification of Functioning, Disability and Health (ICF) | classifies health and health-related domains that describe body functions and structures, activities, and participation |
| internship | student placement in a health care facility to provide on-the-job experience prior to graduation |
| internship supervisor | person to whom a student reports at an internship site |
| jamming | routinely assigning an unspecified ICD-10-CM disease code instead of reviewing the coding manual to select the appropriate code number |
| juxebox | equipment that store large numbers of optical disks, resulting in huge storage capabilities |
| listserv | see online discussion board |
| Logical Observation Identifiers Name and Codes (LOINC) | electronic database and universal standard used to identify medical laboratory observation and for the purpose of clinical care and management |
| manual record | paper-based record that includes handwritten progress notes and physician orders, graphic charts, and so on |
| Medical assistant | health care professional employed by a provider to perform administrative and clinical tasks |
| medical coding process | requires the review of patient record documentation to identify diagnoses, procedures, and services for the purpose of assigning ICD-10-CM/PCS, HCPCS level II, and/or CPT codes |
| medical management software | combination practice management and medical billing software that automates the daily workflow and procedures of a physician's office or clinic |
| medical necessity | determination that a service or procedure rendered is reasonable and necessary for the diagnosis or treatment of an illness or injury |
| medical record | same as a patient record |
| medical nomenclature | vocabulary of clinical and medical terms used by health care providers to document patient care |
| National Drug Codes (NDC) | contains prescription drugs and few selected over-the-counter (OTC) products, which pharmacies use to report transactions and some health care professional use for reporting on claims |
| Objective (O) | observations about the patient, such as physical findings or lab or x-ray results; considered part of the problem-oriented record (POR) SOAP note |
| online discussion board | internet-based or e-mail discussion forum that covers a variety of topics and issues |
| optical disk imaging | alternative to traditional microfilm or remote storage systems because patient records are converted to an electronic image and saved on storage media |
| overcoding | reporting codes for signs and symptoms associated, in addition to an established diagnosis code |
| patient education plan | program to educate the patient about conditions for which the patient is being treated |
| patient record | business record for an inpatient or outpatient encounter that documents health care services provided to a patient |
| physician query process | contacting the responsible physician to request clarification about documentation and codes to be assigned |
| Plan (P) | diagnostic, therapeutic, and education plans to resolve the problems |
| problem list | serves as a table of contents for the patient record because it is files at the beginning of the record and contains a numbered list of the patient's problem |
| problem-oriented record (POR) | systematic method of documentation that consists of four components; database, problem list, initial plan, and progress notes |
| progress notes | narrative notes documented by the provider to demonstrate continuity of care and the patient's response to treatment |
| provider | physician or other health care professional who performs procedures or provides services to patients |
| resident physician | individual who participates in an approved graduate medical education (GME) program |
| RxNorm | provides normalized names for clinical drugs and links its names to man of the drug vocabularies commonly used in pharmacy management and drug interaction software, including those of First Databank, Micromedex, MediSpan, etc. |
| scanner | equipment that captures paper record images onto the storage media |
| sectionalized record | see source-oriented record |
| SNOMED CT | includes comprehensive coverage of diseases, clinical findings, therapies, procedures, and outcomes |
| source-oriented record (SOR) | reports organized according to documentation source, each of which is located in a labeled section of the record |
| specialty coders | individuals who have obtained advanced training in medical specialties and who are skilled in that medical specialty's compliance and reimbursement areas |
| Subjective (S) | patient's statement about how he or she feels, including symptomatic information; considered part of the problem-oriented record (POR) SOAP note |
| teaching hospital | hospital engaged in an approved graduate medical education (GME) residency program in medicine, osteopathy, dentistry, and podiatry |
| teaching physician | physician who supervises residents during patient care |
| therapeutic plan | specific medication, goals, procedures, therapies, and treatments used to treat the patient; considered part of the problem oriented record |
| third-party administrator (TPA) | entity that processes health care claims and performs related business functions for a health plan |
| third-party payer | see health plan |
| transfer note | documentation when a patient is transferred to another facility; summarize reason for admission |
| UB-04 | standard claim submitted by health care institutions to payers for inpatient and outpatient services |
| unbundling | reporting multiple codes to increase reimbursement when a single combination code should be reported |
| Unified Medical Language System (UMLS) | set of files and software that allows many health and biomedical vocabularies and standards to enable interoperability among computer systems |
| upcoding | reporting codes that are not supported by documentation in the patient record for the purpose of increasing reimbursement |
| coding system | organizes a medical nomenclature according to similar conditions, diseases, procedures, and services; it contains codes for each. |
Created by:
Cristinacholi
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