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Basic Medical Coding Chapter 1-5 Flashcards

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2889040498AHIMAAmerican Health Management Association0
2889040499CMSCenters for Medicare and Medicaid Services1
2889045659WHOWorld Health Orginization2
2889644394AHAAmerican Hospital Association3
2889646256APHAAmerican Public Health Association4
2889650816HHSDepartment of Health and Human Services5
2889652899ICDInternational Classification of Diseases6
2889655483NCHSNational Center for Health Statistics7
2889660212WHAWorld Health Assembly8
3014151533London Bill of mortalitySystem used to track deaths in the early 1600s9
3014151534American public health associationAssociation of public health professionals focused on improving public health since 1872; recomended that America adopt the bertillon system in 1898 and revise it every 10 years.10
3014151535World health organizationOrganization within the United nations that coordinates and provides authority regarding global health issues, identifies health research priorities, sets standards, develops evidence-based policy, provides support to nations in need and tracks trends in global health11
3028187845Consultation Reportreport completed by the consulting physician if an attending physician requests a specialist to see patient and provide an opinion or coverage for an aspect of care related to the consulting physician;s area of specialization12
3028204167operative reportreport that provides details of a surgical procedure13
3028206675pathology reporton record if speciemns are removed during a surgical procedure and re sent to thelaboratory for pathological examination. type size summary of gross and mircroscopic findings detailed findings and a pathological diagnosis14
3031757094Clinical modificationmodification of the ICD developed by the US providing a more specific descripition of the clinical presentation of disease processes which aids in statistical analaysis15
3031771543World Health AssemblyDecision making body of the world health organization16
3032302720National Center for Health (NCHS)A division of the Centers for disease control and prevention that gathers and analyzes a broad array of data about the health of Americans.17
3032323535Centers for Medicare and Medicaid Service (CMS)Agency within the United State Department of Health and Human services that administers the Medicare, Medicaid and children's health insurance programs.18
3032336301Department of Health and Human Services (HHS)United States government agency that administers federal health programs, including the Food and Drug Administration and the Centers for Disease Control and Prevention.19
3032344468American Hospital Association (AHA)National organization that represents and serves hospitals , healthcare networks, patients, and communities; one of the cooperating parties that maintain official guidelines and official advice on using ICD-9-CM.20
3032373003American Health Information Management Association (AHIMA)Professional organization for health information management professionals including coders; one of the cooperating parties that maintain offical coding guidelines and official advice on using ICD-9-CM21
3032386336Coding ClinicQurterly publication by the AHA in which official ICD-9-CM coding advice is disseminated, with a special edition to present guidelines for new codes each year.22
3032393713Title XVIIIPortion of the Social Security Act the established coverage for he elderly and disabled.23
3032398507Social Security ActLegal act that led to the creation of he Medicare and Medicaid programs.24
3032405053MedicarePortion of the Social Security act that established healthcare services for low income individuals25
3032410666Title XIXPortion of the Social Security Act that established healthcare services for low income individuals.26
3032417200MedicaidProgram in which the federal and state governments work together to provide healthcare services to low income individuals27
3032424911Prospective Payment System (PPS)System in which payment is made based on a predetermined fixed amount28
3032428992Commercial InsuranceInsurance provided by a party other than the federal government29
3032435249Inpatient Prospective Payment SystemProspective payment system used to reimburse acute care hospital admissions.30
3032439975Medicare SeverityDiagnosis related groups (MS-DRG) groupings of diagnosis and procedures that are associated with fixed payment amounts, based on the average cost for each specified grouping.31
3032450228Uniform Hospital Discharge Date Sets (UHDDS)Standard data set for Medicare and Medicaid32
3032455644Ambelatory Payment Classifications (APCS)Categories into which hospital outpatient services are classified for reimbursement33
3032460848Resource Based Relative Value Scale (RBRVS)Physician fee schedule34
3032464059Outcome and Assessment Information Set (OASIS)Instrument used to document assessment of a patients condition, which is then used to determine the case mix adjustment to the standard payment rate.35
3032470315Home Health Resource Groups (HHRGs)Case-mix groups available for patient classification based on clinical presentation functional factors and service utilization.36
3032476999Data Elements for Emergency Department Systems (DEEDS)Data set used to promote increased uniformity among data elements documented by Emergency department physicians and for reporting trauma registry data.37
3032487675National Hospital Ambulatory Medical Care Survey (NHAMCS)Survey providing data that reflects the use and provision of ambulatory care services in hospital emergency and outpatient department.38
3032496244National Electronic Disease Surveillance System (NEDSS)Data set for disease trends and/or outbreaks which public health personel use to protect the nations health.39
3032508486Uniform Ambulatory Care Data Sets (UACDS)Data set that is pertinent to the ambulatory care or outpatient setting.40
3032512361Federal REgisterOfficial daily publication of the US government; it communicates information about proposed rules, final rules and regulations, changes to existing rules, notices of meetings and adjudicatory proceedings, notices of federal agencies and organizations executive orders and presidential documents.41
3032521456UsesTerm used to describe the 3 distinct versions of ICD-II42
3032530080ParametersFactors that define the content model for classification categories for ICD-II.43
3032532174LinearizationIn ICD-II reference to lists established for statistical reporting of mortality, morbidity, and other circumstances.44
3032536764Textual definitionsKey descriptions of and guidance on meanings to assist with translation for codes based on WHO definitions, which describe underlying physiology, along with signs and symptoms of each disorder.45
3032542678TermsWords or phrases that have been assigned standard meanings to reflect the underlying concepts used in the ICD context, such as "includes", "excludes", and other directional phrases.46
3032552601Body System/Structure DescriptionsTthe atributes of ICD-II that identifies physiological groupings .47
3032556201Temporal Propertiescharacteristics of the patients condition. ex. are onset characteristics and the duration or courseof a disease or health condition48
3032560992Severity of Subtypes PropertiesCharacteristics that describe the extent, magnitude or severity of a condition.49
3032566285Manifestation PropertiesSigns, symptoms, and clinical findings50
3032569237Casual propertiesFactors, such as genetics, that specify causes of disease entities.51
3032571565Functioning PropertiesCharacteristics that identify disabilities or the functional impact of disease entities.52
3032576722Specific Condition PropertiesProperties of conditions that may require monitoring according to public health indicators53
3032579748Life Cycle PropertiesCategories that are pertinent to specific age groups54
3032580918Treatment PropertiesPertinent interventions relted to a diagnosis entity such as insulin treatment for a diabetic patient55
3032583731Diagnostic criteriaLogical Standards for coding specific disease entities.56
3032589069Electronic Health Records (EHRs)Automated health record documentation that includes digital images, point of care documentation by providers, clinical decision report and the ability to be accessed by multiple users at some time.57
3032598933Face SheetDocumentation that contains patient info found on inpatient, outpatient and longterm care records.58
3032602583DemographicCharacteristics of individuals such as age gender and address which are used for statistical purposes.59
3032605219Physician OrdersDocumentation of prescribed medications, therapies, consultation requests and other treatments.60
3032608610Progress NotesNotes that physicians and other providers write in the records to document pertinent info during hospital or long term care stay, usually in a SOAP note format.61
3032617987SOAP noteA subjective, objective, assessment and plan note62
3032623069SubjectiveComponent of a SOAP note that is a statement generally in patients own words about why the patient is seeking care or how the patient feels.63
3032626729ObjectiveComponent of a a SOAP note such as preservice of abnormal lung sounds that is based on the observations of a healthcare professional.64
3032631460AssessmentComponent of a SOAP note containing diagnosis information.65
3032634514PlanComponent of a soap note that includes info about meds to be ordered surgical procedures to be performed or other treatment information.66
3032644925Nursing NotesDocumentation by nursing staff67
3032646889Medication Administration RecordsRecords that provide a record of medications that have been ordered for the patient.68
3032652352Parenthesis ()Punctuation found both in the tabular list and the alphabetic index that surrounds non essential modifiers69
3032655103Non-Essential ModifiersTerms that may co-exist with the main term but do not change the code assignment for the condition.70
3032658515Colon :Punctuation found in the tabular list when a term must be modified by the addition of another term in order to qualify it for assignment of another term in order to qualify it for assignment of a specific code or to a category71
3032667447Not Elsewhere Classifiable (NEC)May be interpreted as "other specified"' codes with this abbreviation are assigned when there is more specific documentation but no code exists for the appropriate level of specificity.72
3032674704Not Otherwise Specified (NOS)Another way of stating "unspecified", codes with this abbreviation are assigned when more specific codes may exist but the documentation lacks specificity.73
3032685491ConventionsGuidelines for how codes are selected and sequenced.74
3032695732GuidelinesInstructions in the code book the provide helpful notes about how to assign codes in certain cases75
3032699220Alphabetic IndexAlphabetic list of diagnosis and their associated codes76
3032702221Tabular ListChronological list of codes77
3032703129SectionsGroupings of several categories of codes created by subdivisions of chapter classifications78
3032704878CategoryFirst of three characters of both ICD - 9-CM and ICD-10-CM diagnosis codes79
3032708327PlaceholderThe character X is inserted to hold the places of the 5th or 6th character in codes with six or seven characters if there is not a 5th or 6th character80
3032712254andmeans and/or when it appears in a title or narrative statement81
3032713977withterm used in the alphabetic index immediately following the main term, but not necessarily in alphabetic order.82
3032716087includesterm that is accompanied by conditions that are examples of what may be included in a specific category.83
3032718468seeterm used to instruct the coder to refer to another term84
3032720391see alsoterm used to instruct the coder to refer to another term85
3032723033Code alsoInstruction that tells the coder that more than one code must be assigned but it does not imply any sequencing guidance86
3032725885Code firstInstructs the coder to assign the code for the underlying disease before the code for the manifestation of the disease and generally accompanies a manifestation code87
3032730940Use additional CodeInstructs the order to also assign a secondary code, following the disease code it generally accompanies,for any manifestations that exist for the case.88
3032734503ExcludesTerm unique to ICD-9-CM used to communicate to the coder that the code should not be assigned, as a different code may be more appropriate.89
3032738398Excludes 1Term unique to ICD-10-CM used to indicate that the excluded code should not be assigned in conjunction with the code under which it is listed as the two conditions do not occur together.90
3032745363Excludes 2Unique to ICD-10-CM used to indicate that the condition being excluded is not considered part of the condition for the code under which it is listed; rather another code should also be assigned.91
3032760817bracketsPunctuation found in both the tabular list and alphabetic index surrounding manifestation codes to indicate that the manifestation should be sequenced after the disease code.92
3032764995DiagnosisA disease or other medical condition93
3032766272PocedureMedical care administered during a patient encounter, ex. eam, tests, therapeutic treatment or surgery.94
3032769999Medical NecessityTerm used by Medicare and other payers to define the need for each procedure code to be justified by at least one diagnosis code95
3032775730Continuing Education Units (CEUs)Credits that are required to maintain credentials for coders who have successfully passed a coding credential examination96
3032779204QueryAsking a physician a question regarding documentation for coding purposes97
3032781203MaintermTerm searched for in the alphabetic index to locate the necessary corresponding code98
3032783618SubtermTerm used to modify the main term when looking up codes99
3032785466ChapterOrganizational unit of the code book dedicated to a group of diagnosis100
3032786894SectionGroup of categories that include similar conditions101
3032788101CategoryFirst 3 characters of an ICD-10-CM code102
3032792657Late EffectICD-9-CM effect of medical conditions or injuries that may require additional treatment or impact other conditions later in life103
3032796086SequelaTerm used to refer to late effect - ICD-10-CM104
3032800194Principal diagnosisCondition established after the study to be chiefly responsible for occasioning the admission of the patient to the hospital for care.105
3032807231Differential diagnosesTwo or more contrasting or comparative diagnosis106
3032808088Secondary diagnosesDiagnoses that impact patient care because they extend the length of stay or require, clinical evaluation, therapeutic treatment, diagnostic procedures, or increased care or monitoring107
3032818785EncounterWhen a patient presents for care in the outpatient setting108
3032821619First Listed DiagnosisTerm used in outpatient setting instead of "principal diagnosis".109
3033357317why the 1985 revision meeting was postponedneed for restructuring due to extensive expansion110
3033359622final draft of the icd11 submitted2014111
3033360680intended use for classification of diagnoses in early1600tracking deaths112
3033361891wht does abbreviation CM meanclinical modification113
3033363197organizations are cooperating parties for maintaing official coding guidlines for icd9cmaha, ahima, cms, nchs114
3033364792how many parameters are included in the content model for icd1113115
3033365989how often is it recommened that the icd classification system be revised by WHOevery 10 yrs116
3033366624in the 1800sthe need to track medical records became more widely recognized117
3033367863development of a procedure coding systemresult of the clnical modification of the ICD118
3033368750four (quarterly)number of editions each yr of coding clinic icd9cm119
3033369965London bill of mortalityroots of med. coding traced back to this120
3033371213until 1985 ICD was updated every10yrs121
3033372846icd10 indorsed in 1990 by 43rdWHA122
3033373515PCS in icd10pcsprocedure coding system123
3033374744proposed and final rulings for changes icd in US are published inFederal Register124
3033375524coding changes additions deletions are effective every yr onOct. 1125
3033377010best explains organization of icd9cm and icd10cm manualslayout of book and method of looking up diagnosis codes are very similar126
3033378408symbol identifies terms may coexist with main term but do not change code assignmentparenthesis127
3033378741how many volumes in icd9cm3128
3033379518how many volumes in icd10cm2129
3033380668which statement is correct relative to outpatient prospective payment systemhospitals may be paid for more than one APC per encounter130
3033382331basis for reimbursemtn of skilled nursing facilityresource utilization groups (RUG-III)131
3033383940basis of inpatient perspective payment systemMS-DRG medicare severity diagnosis related groups132
3033386679part of UHDDSpatient sex, secondary diagnosis, identifction of the surgeon133
3033388809was developed before medicaid medicare and group health insuranceBluecross/blueshield134
3033389538software used for reporting skilled nursing dataraven resident assessment validation and entry135
3033391464relative to inpatient prospective payment systemwage index is used to adjust the payment according to the location of the facility136
3033394298data set specific to inpatient settinguhdds uniform hospital discharge data set137
3033395521in 1983when first prospective payment system was implemented138
3033397788outcome and assessment information setinstrument used to document assessment of home health patients139
3033399004pps for skilled nursing facilitiesrug-III resource utilization groups140
303340179180case mix groups are that are available for patient classification based on clinical presentation functional factors and service utilization is calledHHRGs home health resource groups141
3033407868pps reimbursement involves payment made based on predetermined fixed amount is forMedicare142

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