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MedCodingWk1
Vocab & Important Info
| Question | Answer |
|---|---|
| organizes a medical nomenclature according to similar conditions, diseases, procedures, & services & it contains codes for each | Coding System |
| Coding System AKA | Classification System |
| ICD-9-CM arranges these elements of coding/classification system into appropriate __ & __ | chapters; sections |
| called the United States Postal Service ZIP Code system, which classifies addresses as numbers | nonmedical "coding system" |
| adopted in 1979 to classify diagnoses (Volumes 1 & 2) & procedures (Volume 3) | International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) |
| developed by the National Center for Health Statistics (NCHS) to replace Volume 3 of ICD-9-CM | International Classification of Diseases, Tenth Revision, Procedure Coding System (ICD-10-PCS) |
| when ICD-10-PCS implemented it will be used to classify __ __ & __ | inpatient procedures; services |
| originally published by the American Medical Association (AMA) in 1966; considered Level I of the Healthcare Common Procedure Coding System (HCPCS) | Current Procedural Terminology (CPT) |
| ; includes Level II (national codes), called HCPCS level II (or HCPCS national codes); managed by the Centers for Medicare & Medicaid (CMS) | Healthcare Common Procedure Coding System (HCPCS) |
| classifies medical equipment, injectable drugs, transportation services, & other services not classified by CPT | HCPCS Level II |
| use HCPCS Level II to report procedures & services | Physicians & ambulatory care settings |
| discontinued in 2004 | HCPCS Level III codes |
| collection of words/phrases with their meanings | vocabulary |
| example of a vocabulary is | SNOMED CT |
| system that is clinically descriptive & arranges/organizes like/related entities | classification |
| example of a classification as classify nephrolithiasis, renal calculi, & kidney stone within the same category | ICD-9-CM |
| system of names used as preferred terminology | nomenclature |
| listing of the proper name for each disease entity with its specific code number | disease nomenclature |
| Nephrolithiasis, Renal Calculi, & Kidney stone all refer to the same disease/medical condition | example of nomenclature |
| refers to a set of terms representing the system of concepts of a particular subject field | terminology |
| refers to a set of standardized terms & their synonyms that record patient findings, circumstances, events, & interventions with sufficient detail to support clinical care, decision support, outcomes research, & quality improvement | clinical terminology |
| clinical terminology can be efficiently mapped to __ __ for administrative, regulatory, oversight, & fiscal requirements | broader classifications |
| set of concepts & relationships that provides a common consultation point for comparison & aggregation of data about the entire healthcare process, recorded by multiple individuals, systems,/institutions | reference terminology |
| acute care facilities (hospitals), behavioral healthcare facilities, hospice inpatient care, long-term care facilities are all | inpatient health care settings |
| process of converting medical diagnoses & medical procedures to code # contained within code set that best/most accurately describes diagnosis & medical procedure | medical coding |
| used for patient care, research, reimbursement, & evaluation of services | coded medical information |
| central premise was that deaths from plague needed to be examined in the context of all other causes of mortality in order to understand effects of all diseases (deductive reasoning) | Reflections on the Weekly Bills of Mortality |
| London merchant who published Reflections on the Weekly Bills of Mortality 1665 | James Graunt |
| sixty disease categories in the Bills constituted the FIRST __ __ to analyze incidences of disease | systematic attempt |
| first medical statistician for the General Register Office of England; standardized terminology and utilized primary diseases for a UNIFORM classification system | Dr. William Farr |
| recognized need for a UNIFORM classification of causes of death in 1853 & requested Dr. Farr prepare a classification for consideration at its next meeting in Paris in 1855 | International Statistical Congress in Brussels |
| Dr. Farr's classification was based primarily on __ __ & consisted of 138 __ | anatomical site; rubrics |
| adopted in 1864 and revised at four subsequent International Statistical Congresses | Dr. Farr's classification list |
| chief statistician of the city of Paris, prepared a revised list that was adopted by the International Statistical Institute in 1893; known as the Bertillion Classification | Jacques Berillion |
| FIRST standard system actually implemented internationally | Bertillion Classification |
| recommended use of Bertillion Classification in United States, Canada, & Mexico in 1898 | American Public Health Association |
| has working knowledge standardized medical coding systems, coding guidelines, principles/rules, government reg., & 3rd-party payer requirements to ensure all diagnoses, medical services, & procedures as documented in medical records are coded accurately | medical information coding specialist |
| American Academy of Professional Coders (AAPC): certifications: CPC, CPC-A, CPC- H, and CPC-P; American Health Information Management (AHIMA): certifications CCA, CCS, CCS-P | Medical Coding Specialist |
| career associated with American Medical Billing Association (AMBA) | Health Insurance Specialist |
| Medical Association of Billers (MAB) certification for career in Health Insurance Specialist | Certified Medical Billing Specialist (CMBS) |
| National Association of Claims Assistance Professionals (NACAP) certification for career in Health Insurance Specialist | Certified Claims Assistance Professional (CCAP) & Certified Electronic Claims Professional (CECP) |
| ICD-9-CM codes are assigned to inpatient cases to __ __ __ for education and research, determine third-party payer reimbursement, and facilitate institutional financial planning | collect statistical data |
| once entered into a facility's database, the ICD-9-CM codes are transmitted to the facility's billing department, which generates the __ __ for submission to 3rd-party payers | UB-04 claim |
| hospital inpatient cases usually have multiple __ & __ documented | diagnoses; procedures |
| once ICD-9-CM codes are assigned to hospital inpatient cases, the coder must __ them according to principal diagnosis, other diagnoses, principal procedure, and other significant procedures as defined by the __ | sequence; UHDDS |
| responsible for documenting and authenticating legible, complete, and timely patient records in accordance with federal regulations & accrediting agency standards | health care providers |
| patient's medical record MUST __ the codes assigned & submitted on claims for third-party reimbursement | support |
| patient's diagnosis MUST __ diagnostic and therapeutic procedures or services provided | justify |
| patient's diagnosis justifies diagnostic & therapuetic procedures/services provided | medical necessity |
| founded 1988; provide education & professional certification to physician-based medical coders & elevate standards of medical coding; proven mastery of all code sets, Evaluation & Management principles & documentation guidelines | American Association of Professional Coders (AAPC) |
| adherence to accepted standards | Compliance |
| American Health Information Management Association (AHIMA) | |
| electronic health record | EHR |
| Certified Claims Assistance Professional (CCAP) | |
| Certified coding associate (CCA) | |
| Certified coding specialist (CCS) | |
| Certified coding specialist-physician based (CCS-P) | |
| Certified Professional Coder(CPC) | |
| Centers for Medicare & Medicaid Services (CMS) | |
| official daily publication for rules, proposed rules, & notices of US federal agencies & organizations | Federal Register |
| Central Office on ICD-9-CM of the American Hospital Association | |
| payment for health care services | Reimbursement |
| Closed classification system | |
| coding software that is used to assign diagnosis & procedure codes | Encoder |
| Coding Clinic | |
| combination of formats producing similar results i.e. paper & electronic records | hybrid record |
| degree/certificate/award that recognizes course of study taken in specific field & that acknowledges competency required | Credential |
| Certified Professional Coder, Apprentice status (CPC-A) | |
| reason in patient's own words for presenting to hospital | chief complaint |
| Certified Professional Coder, Hospital (CPC-H) | |
| condition established after study to be chiefly responsible for occasioning admission of patient to hospital for care | Principal Diagnosis |
| Certified Professional Coder, Payer (CPC-P) | |
| procedure performed/definitive treatment, rather than diagnostic or exploratory purposes, or one necessary to take care of complication | Principal Procedure |
| Certified Electronic Claims Professional (CECP) | |
| criteria/guidelines for what is determined to be reasonable/necessary for particular medical service | medical necessity |
| Certified Medical Billing Specialist (CMBS) | |
| other diagnoses | |
| Medical Association of Medical Billers (MAB) | |
| patient's reason for visit (PRV) | |
| condition that requires patient to be hospitalized | admitting diagnosis |
| indicator to differentiate between condition developed during particular hospital encounter & condition present at time of admission | present on admission (POA) |
| preexisting diagnosis/condition (present on admission) which may lead to increased resource use | comorbidities |
| daily recordings by health care providers of patient progress | progress notes |
| condition arising during during patient's hospitalization which may lead to increased resource use | complication |
| question-&-answer period that occurs between patient & health care provider during which any healthcare issues are reviewed | review of systems |
| healthcare provider asked to see patient to provide expert opinion outside expertise of requestor | consultant |
| considered if surgical in nature, carries procedural/anesthetic risk, &/or requires specialized training | significant procedure |
| Uniform Hospital Discharge Data Set (UHDDS) | |
| diagnosis-related groups | DRGs |
| DRGs are now known as | MS-DRGs |
| amyotrophic lateral sclerosis (ALS) or Lou Gehrig disease can also be called | motor neuron disease |
Created by:
lfrancois
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