Understanding Medical Coding
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| Healthcare Common Procedure Coding System Level 2 (HCPCS Level II) | The second level of the coding system created by CMS for reporting of procedures, services, supplies, medications, equipment, and items.
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| Table of Drugs | A comprehensive list of non-oral drugs by both technical and brand names that include the route of administration and dose information for reporting purposes.
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| Enteral | The patient receives feeding or medication into the small intestine.
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| Parenteral | The patient receives feeding or medication by injection route such as intravenously, subcutaneously, etc., not through the alimentary canal.
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| Intra-arterial (IA) | The patient receives through the artery system.
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| Intravenous (IV) | The patient receives through the venous system.
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| Intramuscular (IM) | The patient receives an injection into the muscular system. This is the most common method of administration.
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| Intrathecal (IT) | The patient receives through the membrane.
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| Inhaled Solution (INH) | The patient inhales the medication, may use respiratory equipment commonly known as the Intermittent Positive Pressure Breathing treatment.
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| Injection Not Otherwise Specified (INJ) | The patient receives an injection other than the options listed, such as intradermal or an injection directly into anatomy.
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| Various (VAR) | The patient receives the medication using various, often multiple means.
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| Other (OTH) | The patient receives any other method not listed.
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| Orally (ORAL) | The patient receives medication through the mouth, (orally).
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| Modifier | A 2 digit number placed after the usual procedural code, which represents a particular explanation to further describe the procedure/service or circumstances involved with the procedure.
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| Category 3 | Required alphanumeric codes for emerging technology instead of unlisted codes.
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| Category 2 | Optional alphanumeric codes for quality measures statistical data research and development purposes.
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| CPT Guidelines | Within the CPT code book, the guidelines are the pages or paragraphs prior to a series of codes.
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| Diagnostic | To identify or investigate for purposes of determining a condition or diagnosis.
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| Therapeutic | To achieve a therapeutic result or to treat a condition or diagnosis.
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| Evaluation and Management Service (E/M) | The first section of the CPT coding manual that describes office visits, hospital visits, nursing facility visits, and consultations.
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| Professional Services | A face-to-face service rendered by a physician and reported by a specific CPT code.
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| Nature of Presenting Problem (NPP) | A presenting problem may be a complaint, disease, illness, condition, sign or symptom, injury, finding or other reason for an encounter.
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| History | A record of past events; a systematic account of the medical emotional, and psychosocial occurrences in a patient's life and of factors in the family, ancestors, and environment that may have a bearing on the patient's condition.
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| Medical Decision Making | The complexity of establishing a diagnosis and/or selection a management option.
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| Chief Complaint (CC) | A subjective statement made by a patient describing his or her most significant or serious symptoms or sign of illness or dysfunction.
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| History of Present Illness (HPI) | Inquiry from the first sign or symptom through today of the patient's experiences that associate to the chief complaint and reason fort the visit.
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| Review of Systems(ROS) | Inquiry of the signs or symptoms that define the problem affecting the body systems.
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| Past, Family, and Social History (PFSH) | Pertinent inquiry of the patient's history of the illness, family history, and social history with specific documentation required.
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| Examination | A critical inspection and investigation, usually following a particular method, performed for diagnostic or investigational purposes.
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| Counseling | The act of providing advice and guidance to a patient and his or her family.
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| Coordination of Care | The arrangement and/or organization of patent care to include all health care providers.
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| Consultation | A type of service provided by a physician (usually a specialist) whose opinion or advice regarding evaluation and management of a specific problem is requested by another physician or other appropriate source.
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