Flash Cards for Diagnostic Coding for MBC notes
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| coding | the assignment of numeric or alphanumeric digits and characters to specific diagnostic and procedural phrases
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| The World Health Organization (WHO) | in 1948, assumed responsibility for preparing and publishing the revisions to the ICD every 10 years. Thus, with every 10-year revision, the name of the current ICD changes.
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| An abbreviation for the International Classification of Diseases, Tenth Revision, Clinical Modification | ICD-10-CM
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| ICD-10-CM | an arrangement of classes or groups of diagnoses by systematic division that is used in the United States
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| mortality | the rate or frequency of deaths
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| morbidity | the rate or frequency of disease
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| National Center for Health Statistics (NCHS) | in the United States, is responsible for maintaining the ICD-10-CM diagnostic codes.
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| The Centers for Medicare and Medicaid Services (CMS) | responsible for maintaining the procedure codes of ICD-10-PCS.
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| Health Insurance Portability and Accountability Act (HIPAA) | passed by Congress in 1996 to improve the portability and continuity of health care coverage
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| Administrative Simplification | developed standards for the electronic exchange of health care data by administrative and financial transactions
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| The American Health Information Management Association (AHIMA) | represents health information professionals who manage, organize, process, and manipulate patient data.
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| The American Academy of Professional Coders (AAPC) | was founded to elevate the standards of medical coding.
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| The Certified Professional Coder (CPC) certification | validates a coder’s proficiency in the physician office setting
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| the Certified Inpatient Coder, (CIC) certification | validates proficiency in the inpatient hospital setting
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| Certified Outpatient Coder (COC) certification | validates coding proficiency in outpatient hospital and outpatient facility coding.
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| Certified Risk Adjustment Coder (CRC) certification | validates that a coder can read a medical chart and assign the correct diagnosis (ICD-10-CM) codes for a wide variety of clinical cases and services for risk adjustment models.
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| The Tabular List of Diseases and Injuries | an alphanumerical list of codes, commonly referred to as the Tabular.
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| divided into chapters based on body system (anatomical site) or condition (etiology) | The Tabular List
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| Conventions | instructional notes, punctuation marks, abbreviations, and symbols
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| Instructional notes | appear in both the Tabular List and Alphabetic Index of ICD-10-CM.
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| Includes note | used to define, give examples, or both, of the content of a category of ICD-10-CM or of a block of category codes.
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| Excludes notes | used to signify that the conditions listed are not assigned to the category or block of category codes.
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| How many types of Excludes Notes are there? | Two
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| Excludes1 note | easy to understand and apply.
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| Excludes2 note | used to signify that the diagnostic terms listed after the note are not part of the condition(s) represented by the code or code block.
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| See note | used in the Alphabetic Index of ICD-10-CM and instructs the coder to cross-reference the term or diagnosis that follows the notation.
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| See Also note | refers the coder to another location in the Alphabetic Index when the initial listing does not contain all the necessary information to accurately select a code.
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| Code First note | instructs the coder to select a code to represent the etiology that caused the manifestation.
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| Use Additional Code note | instructs the coder to use an additional code to identify the manifestation that is present.
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| In Diseases Classified Elsewhere Note | applies to the etiology/manifestation conventions.
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| Code Also note | is used in ICD-10-CM to instruct the coder that two codes may be needed to fully code a diagnostic phrase.
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| The terms found within the parentheses are referred to as | nonessential modifiers.
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| Parentheses | are used in both the Tabular List and Alphabetic Index. Parentheses are used around terms that provide additional information about the main diagnostic term.
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| Brackets | are used in the Tabular Listing and in the Alphabetic Index.
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| A colon | is used in the Tabular listing after a term that is modified by one or more of the terms following the colon
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| What does NEC stand for? | not elsewhere classifiable
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| What does NOS Stand for? | not otherwise specified.
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| The point dash symbol (.–) | tells the coder that the code contains a list of options at a level of specificity past the three-character category.
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| Granularity | the level of detail.
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| Laterality | for bilateral sites ICD-10-CM indicates the specific site.
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