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| 2875938178 | medical coding process | requires the review of patient record documentation to identify diagnoses, procedures, and services for the purpose of assigning ICD-10-CM/PCS, HCPCS level 2, and/or CPT codes | 0 | |
| 2875953654 | code of ethics | AAPC - code of ethics publication AHIMA - standards for ethical coding publication serves as guidelines for ethical coding conduct | 1 | |
| 2875970958 | steps to accurate coding | 1. review entire patient record 2. select diagnoses, procedures, services 3. assign codes - depending on setting, retrospective or concurrent or both | 2 | |
| 2875976777 | retrospective coding | the review of records to assign codes after the patient is discharged from the health care facility or released from same-day outpatient care most common with inpatient hospital stays | 3 | |
| 2875993657 | concurrent coding | the review of records and/or use of encounter forms and chargemasters to assign codes during an inpatient stay or an outpatient encounter most common with outpatient encounters because encounter forms and chargemasters are completed in real time | 4 | |
| 2876037809 | encounter forms | used to record data about office procedures and services provided to patients | 5 | |
| 2876042408 | chargemasters | contain a computer-generated list of procedures, services, and supplies and corresponding revenue codes along with charges for each | 6 | |
| 2876056758 | AHA's measures for coding accuracy | adherence to ICD-10-CM/PCS coding principles and instructions attention to specificity in code selection where indicated by physician documentation in the patient record grasp of medical terminology absence of clerical-type errors | 7 | |
| 2876114646 | assumption coding | the assignment of codes based on assuming, from a review of clinical evidence in the patient's record, that the patient has certain diagnoses or received certain procedures/services even though the provider did not specifically document those diagnoses or procedures/services avoid this by implementing the physician query process | 8 | |
| 2876583237 | physician query process | used to obtain clarification about patient record documentation from physicians EHR has an automated physician query process, which results in better and more timely responses query should not lead the physician to a desired outcome utilization managers, aka case managers, can be a liaison for coders and physicians | 9 | |
| 2876619190 | physician query process guidelines | indicators that trigger coders to send a query 1. legibility 2. completeness 3. clarity 4. consistency 5. precision 6. clinical indicators of a diagnosis but the diagnosis is not documented 7. clinical evidence for a higher degree of specificity or severity but not documented 8. cause-and-effect relation between 2 conditions but relation not documented 9. underlying cause when a patient is admitted with symptoms 10. treatment is documented without a corresponding diagnosis for medical necessity 11. lack of present on admission (POA) indicator status determine whether the query will generate concurrently or retrospectively coders do not make clinical assumptions, ask open-ended questions query forms may be either part of the official patient record or considered an administrative form | 10 | |
| 2876781423 | Clinical Documentation Improvement (CDI) Program | to help health care facilities comply with government programs and other initiatives with the goal of improving health care quality CDI Specialist initiates concurrent and retrospective reviews of inpatient records for the purpose of: - implementing documentation clarification and specificity processes (as part of physician query process) - using and interpreting clinical documentation improvement statistics - conducting research and providing education to improve clinical documentation - ensuring compliance with initiatives that serve to improve the quality of health care (complying with fraud and abuse regulations, enforcing privacy and security of patient info, monitoring a health info exchange [HIE]) | 11 | |
| 2876832852 | coding compliance program | ensures that the assignment of codes to diagnoses, procedures, and services follows established coding guidelines found in orgs' policies & procedures | 12 | |
| 2879690539 | coding compliance - detection | the process of identifying potential coding compliance problems | 13 | |
| 2879696211 | coding compliance - correction | based on the review of patient records that contain potential coding compliance problems, during which specific compliance issues are identified and problem-solving methods are used to implement necessary improvements | 14 | |
| 2879717334 | coding compliance - prevention | involves educating coders and providers so as to prevent coding compliance problems from reoccuring | 15 | |
| 2879726071 | coding compliance - verification | provides an audit trail that the detection, correction, and prevention functions of the coding compliance program are being actively preformed | 16 | |
| 2879740661 | coding compliance - comparison | requires the analysis of internal coding patterns over specified periods of time as well as the analysis of external coding patterns by using external benchmarks (trends) | 17 | |
| 2879759795 | coding compliance - completeness | ensures that codes are assigned to all reportable diagnoses, procedures, and services documented in the patient record | 18 | |
| 2879770799 | coding compliance - reliability | allows for the same results to be consistently achieved | 19 | |
| 2879777910 | coding compliance - validity | confirms that assigned codes accurately reflect the patient's diagnoses, procedures, and services | 20 | |
| 2879789376 | coding compliance - timeliness | means the patient records are coded in accordance with established policies and procedures to ensure timely reimbursement | 21 | |
| 2879803644 | Computer-Assisted Coding (CAC) | uses software to automatically generate medical codes by reading transcribed clinical documentation provided by health care practitioners uses natural language processing theories to generate codes that are reviewed and validated by coders for reporting on third-party payer claims | 22 |
