CBCS: Module 3 Vocab
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| Abstracting | Reviewing medical record documentation to discover clinical concepts that assigning codes to the highest level of specificity
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| Clinical Documentation | Information recorded in the medical record pertaining to the health status of a patient as determined by a health care provider
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| CPT | Current Procedural Technology. Codes for services and procedures
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| Electronic Health Record (EHR) | A digital version of a patient's chart that includes information documented by multiple providers at different facilities regarding one patient
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| HCPCS | Healthcare Common Procedure Coding System
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| ICD-10-CM | International Classification of Diseases 10th Revision Clinical Modification. This codes for diseases/injuries/statuses
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| Medical Coding | Process of abstracting diagnoses, procedures, and services from the medical record and converting them to alphanumeric codes for claims submission's
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| Medical Necessity | Process of providing diagnosis codes that support the services rendered to the patient; coding for medical necessity involves associating applicable diagnosis codes to service/procedure codes within the billing software a.k.a. linking/linkage
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| Medical Record | Documents health care services provided to a patient
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| Query | Contacting the responsible provider to request clarification about documented diagnoses or procedures
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| Claim Denial | Unpaid medical claim returned to payer due to coding errors, missing information, preauthorization requirements, or health plan coverage issues
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| Downcoding | Unpaid medical claim returned by payer due to coding errors, missing information. preauthorization requirements, or health plan coverage issues
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| Encounter Form | Financial record source document used by providers to record treated diagnoses and services provided to a patient for a single encounter
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| Modifier | Provides additional information about a procedure or service without altering the definition of the code description
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| Preauthorization | Prior approval for services granted by payer after health pan review
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| (HPI) History of Present Illness | Brief description pf the patient's present illness or other reason for an encounter, including details about location, duration, severity, and associated signs and symptoms
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| Unbundling | Submitting multiple CPT codes when a single code is available to report services in full
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| Upcoding | Assignment of ICD-10-CM code that is more severe then diagnosis supported by the documentation in the medical record
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