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Medical Coding

ACUTE Refers to the condition that is the primary reason forthe current encounter
ADVERSE Any response to a drug that is noxious and unintended and occurs with proper dosage
AFTERCARE An encounter for something planned in advanceexample-cast removal
Alphabetic Portion of the of the ICD9-CM that lists definitions and codes in alphabetic order.example-also called Volume @2
Carry-Over Lines- Are always indented more than two spaces from the level of the preceding line
Category Refers to diagnoses coded listed within a specific three-digit categoryExample-category 250, Diabetes Mellitus
Cause- That which brings about any condition or produces any effect
Chronic Continuing over a long period of time or reoccuring frequently
Coding The process of transferring written or verbal descriptions of diseases, injuries and procedures into numerical designations
Combination A code that combines a diagnosis with an associated secondary process or complication
Complication The Occurrence of two or more diseases in the same patient at the same time
Concurrent When a patient is being treated by more than one provide for different conditions at the same time
CPT Current Procedural Terminology Listing of codes and descriptions for procedures, services and supplies published by the American Medical Association. Use to bill insurance carriers.
Diagnosis A written descrpition of the reason (s) for the procedure, service, or encounter (signs, symptons, complaints)
Down Coding- The process where the insurance carriers reduce the value of a procedure and the resulting reimbursement due to either 1)a mismatchof CPT code and description or 2) ICD9-CM code does not justify the procedure or level of service
E Codes Specific ICD9-CM codes used to identify the cause of injury , poisoning, and other adverse affects(never primary, always eternalexamples-car accident.
Eponyms- Medical procedures or conditions named after a person or place
Etiology The cause (s) or origin of a disease.
ICD-9 International Classifications of Diseases, 9th revision
ICD-10 International Clasifications of Diseases, 10th revision
Late Effec A residual effect (condition produced after the acute phase of an illness or injury has ended
Main Term Refers to listing in the Alphabetic Index appearing BOLD FACE type
Mainfestions Characteristsics signs of symptons of an illness
Multiple Refers to the need to use more than one ICD 9 CM code to fully identify a coding condition
Primary Code The ICD-9-CM code that defines the main reason for the current encounter
Residual The long term condition (s) resulting from a previous acute illness or injury
Rule Out Refers to a method used to indicate that a condition is probable, suspected or questionable but unconfirmed.
Secondary Code Listed after the primary code that further indicate the cause (s) code for the current encounter of define the need for higher levels of care.
Sequencing The process of listing ICD 9CM codes in the proper order
Specificity Refers to requirement to code to the highest number of digits possible, 3, 4, or 5 when chosing an ICD 9-CM code
Sub term refers to listing appearing in the Alphabetic Index under Main Term and always indented two spaces to the right
SubCategories Refers to the groupings of four digits codes listed under three-digit categories
Tabular list is the portion of the icd 9 cm that lists codes and definitions in numeric order. also referred to as volume 1
V Codes Specific ICD 9 cm code used to identify encounters for reasons other than illness or injury, for example, immunization
volume 1 see tabular list
volume 2 see alpha list
Created by: d.holifield