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Blesi8e Ch28 Terms
[MO2] Coding [Tier 01]
| Term | Definition |
|---|---|
| add-on-code | procedure codes that indicate additional work associated with another primary procedure; never reported as a stand-alone code |
| alphabetic index | index arranged in alphabetic order by disease |
| bundle | putting multiple healthcare services under one billing code. |
| bundled code | any code that includes more than one procedure in its description |
| carrier | the company that provides the insurance policy |
| category | the first three characters of an ICD_1-CM code designate the category of a diagnosis |
| chief complaint (CC) | the main reason for the patient's visit |
| combination code | a diagnosis with an associated complication |
| comorbidity | a condition that exists along with the primary diagnosis of a patient |
| concurrent care | when similar care is being provided to a patient by more than one provider |
| consultation | when a patient visits with another provider at the request of the health care provider |
| contributory factors | additional components that can be considered when selecting an evaluation and management code |
| conventions | a list of abbreviations, punctuations, symbols, typefaces and instructional notes |
| counseling | discussion with a patient and/or family concerning results, prognosis, treatment, risk factor reduction and patient/family education |
| critical care | when constant bedside attention is required to a patient who is critically ill or unstable |
| cross-reference | referencing from one part of the code book to another part containing related information |
| current procedural terminology (CPT) | a numerical listing of procedures performed in medical practice |
| diagnosis | the identification of the illness or problem by the provider upon examination of the patient |
| downcoding | a practice of third-part payers in which the benefits code has been changed to a less complex or lower-cost procedure than was reported |
| E/M code | related to medical services as opposed to surgical services |
| established patient | patient who has received professional services from a provider who belongs to the same group practice, within the past three years |
| etiology | the cause, set of causes or manner of causation of a disease or condition |
| global period | the period of time that is covered for follow-up care |
| HCPCS Level II codes | codes that identify products, supplies and services not included in CPT |
| healthcare common procedure coding system (HCPCS) | comprised of two levels; CPT codes and National codes.developed to identify products and supplies for which there are no CPT codes |
| index | terms listed in alphabetic order with categories and subcategories listed along with code range |
| international classification of diseases (ICD) | a comprehensive listing of diseases and disorders of the human body |
| key components | the major factors to be considered when selecting an evaluation and management code: history, exam and medical decision making |
| laterality | specifying whether the condition occurs on the left, right or bilaterally |
| modifiers | coding markers that inform third-party payers that circumstances for that particular code have been altered |
| morbidity | the frequency of the appearance of complications following a surgical procedure or other treatment |
| mortality | a fatal outcome |
| neoplasm | medical term for new growth; can be benign or malignant |
| new patient | a patient who has not received services from the provider within the past three years |
| panel | an organ or disease-oriented laboratory procedure frequently ordered together |
| primary diagnosis | the main reason a patient is seen or cared for during an encounter |
| procedure code | code that represents a medical procedure such as surgery or diagnostic tests and medical services |
| reimbursement | a payback or compensate for money spent or for losses or damages incurred |
| secondary diagnosis | diagnosis other than the primary diagnosis for other condition affecting a patient during the same visit and the principal diagnosis |
| sequela | a pathological condition resulting from prior injury, disease or attack |
| sequenced | order of succession |
| specificity | something specially suited for a given use or purpose |
| subcategory | describes the digit that comes after the decimal point. This digit further describes the nature of the illness or injury, and gives additional information as to its location or manifestation. |
| surgical package | procedures found in CPT that may include preoperative exam and testing |
| tabular list | A chronological list of ICD-10-CM codes divided into chapters based on body system or condition. |
| unbundling | reporting multiple codes for a service when there is one code that will report the entire service; considered fraudulent billing and could results in stiff penalties and fine |
| upcoding | reporting a higher-level code than is appropriate for the service that was rendered |
| world health organization (WHO) | an agency of the United Nations concerned with health on an international level |
Created by:
MaesterRay
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