2889040498 | AHIMA | American Health Management Association | 0 | |
2889040499 | CMS | Centers for Medicare and Medicaid Services | 1 | |
2889045659 | WHO | World Health Orginization | 2 | |
2889644394 | AHA | American Hospital Association | 3 | |
2889646256 | APHA | American Public Health Association | 4 | |
2889650816 | HHS | Department of Health and Human Services | 5 | |
2889652899 | ICD | International Classification of Diseases | 6 | |
2889655483 | NCHS | National Center for Health Statistics | 7 | |
2889660212 | WHA | World Health Assembly | 8 | |
3014151533 | London Bill of mortality | System used to track deaths in the early 1600s | 9 | |
3014151534 | American public health association | Association 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 | |
3014151535 | World health organization | Organization 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 health | 11 | |
3028187845 | Consultation Report | report 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 specialization | 12 | |
3028204167 | operative report | report that provides details of a surgical procedure | 13 | |
3028206675 | pathology report | on 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 diagnosis | 14 | |
3031757094 | Clinical modification | modification of the ICD developed by the US providing a more specific descripition of the clinical presentation of disease processes which aids in statistical analaysis | 15 | |
3031771543 | World Health Assembly | Decision making body of the world health organization | 16 | |
3032302720 | National 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 | |
3032323535 | Centers 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 | |
3032336301 | Department 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 | |
3032344468 | American 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 | |
3032373003 | American 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-CM | 21 | |
3032386336 | Coding Clinic | Qurterly 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 | |
3032393713 | Title XVIII | Portion of the Social Security Act the established coverage for he elderly and disabled. | 23 | |
3032398507 | Social Security Act | Legal act that led to the creation of he Medicare and Medicaid programs. | 24 | |
3032405053 | Medicare | Portion of the Social Security act that established healthcare services for low income individuals | 25 | |
3032410666 | Title XIX | Portion of the Social Security Act that established healthcare services for low income individuals. | 26 | |
3032417200 | Medicaid | Program in which the federal and state governments work together to provide healthcare services to low income individuals | 27 | |
3032424911 | Prospective Payment System (PPS) | System in which payment is made based on a predetermined fixed amount | 28 | |
3032428992 | Commercial Insurance | Insurance provided by a party other than the federal government | 29 | |
3032435249 | Inpatient Prospective Payment System | Prospective payment system used to reimburse acute care hospital admissions. | 30 | |
3032439975 | Medicare Severity | Diagnosis 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 | |
3032450228 | Uniform Hospital Discharge Date Sets (UHDDS) | Standard data set for Medicare and Medicaid | 32 | |
3032455644 | Ambelatory Payment Classifications (APCS) | Categories into which hospital outpatient services are classified for reimbursement | 33 | |
3032460848 | Resource Based Relative Value Scale (RBRVS) | Physician fee schedule | 34 | |
3032464059 | Outcome 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 | |
3032470315 | Home Health Resource Groups (HHRGs) | Case-mix groups available for patient classification based on clinical presentation functional factors and service utilization. | 36 | |
3032476999 | Data 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 | |
3032487675 | National 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 | |
3032496244 | National Electronic Disease Surveillance System (NEDSS) | Data set for disease trends and/or outbreaks which public health personel use to protect the nations health. | 39 | |
3032508486 | Uniform Ambulatory Care Data Sets (UACDS) | Data set that is pertinent to the ambulatory care or outpatient setting. | 40 | |
3032512361 | Federal REgister | Official 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 | |
3032521456 | Uses | Term used to describe the 3 distinct versions of ICD-II | 42 | |
3032530080 | Parameters | Factors that define the content model for classification categories for ICD-II. | 43 | |
3032532174 | Linearization | In ICD-II reference to lists established for statistical reporting of mortality, morbidity, and other circumstances. | 44 | |
3032536764 | Textual definitions | Key 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 | |
3032542678 | Terms | Words 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 | |
3032552601 | Body System/Structure Descriptions | Tthe atributes of ICD-II that identifies physiological groupings . | 47 | |
3032556201 | Temporal Properties | characteristics of the patients condition. ex. are onset characteristics and the duration or courseof a disease or health condition | 48 | |
3032560992 | Severity of Subtypes Properties | Characteristics that describe the extent, magnitude or severity of a condition. | 49 | |
3032566285 | Manifestation Properties | Signs, symptoms, and clinical findings | 50 | |
3032569237 | Casual properties | Factors, such as genetics, that specify causes of disease entities. | 51 | |
3032571565 | Functioning Properties | Characteristics that identify disabilities or the functional impact of disease entities. | 52 | |
3032576722 | Specific Condition Properties | Properties of conditions that may require monitoring according to public health indicators | 53 | |
3032579748 | Life Cycle Properties | Categories that are pertinent to specific age groups | 54 | |
3032580918 | Treatment Properties | Pertinent interventions relted to a diagnosis entity such as insulin treatment for a diabetic patient | 55 | |
3032583731 | Diagnostic criteria | Logical Standards for coding specific disease entities. | 56 | |
3032589069 | Electronic 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 | |
3032598933 | Face Sheet | Documentation that contains patient info found on inpatient, outpatient and longterm care records. | 58 | |
3032602583 | Demographic | Characteristics of individuals such as age gender and address which are used for statistical purposes. | 59 | |
3032605219 | Physician Orders | Documentation of prescribed medications, therapies, consultation requests and other treatments. | 60 | |
3032608610 | Progress Notes | Notes 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 | |
3032617987 | SOAP note | A subjective, objective, assessment and plan note | 62 | |
3032623069 | Subjective | Component 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 | |
3032626729 | Objective | Component of a a SOAP note such as preservice of abnormal lung sounds that is based on the observations of a healthcare professional. | 64 | |
3032631460 | Assessment | Component of a SOAP note containing diagnosis information. | 65 | |
3032634514 | Plan | Component of a soap note that includes info about meds to be ordered surgical procedures to be performed or other treatment information. | 66 | |
3032644925 | Nursing Notes | Documentation by nursing staff | 67 | |
3032646889 | Medication Administration Records | Records that provide a record of medications that have been ordered for the patient. | 68 | |
3032652352 | Parenthesis () | Punctuation found both in the tabular list and the alphabetic index that surrounds non essential modifiers | 69 | |
3032655103 | Non-Essential Modifiers | Terms that may co-exist with the main term but do not change the code assignment for the condition. | 70 | |
3032658515 | Colon : | 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 category | 71 | |
3032667447 | Not 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 | |
3032674704 | Not 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 | |
3032685491 | Conventions | Guidelines for how codes are selected and sequenced. | 74 | |
3032695732 | Guidelines | Instructions in the code book the provide helpful notes about how to assign codes in certain cases | 75 | |
3032699220 | Alphabetic Index | Alphabetic list of diagnosis and their associated codes | 76 | |
3032702221 | Tabular List | Chronological list of codes | 77 | |
3032703129 | Sections | Groupings of several categories of codes created by subdivisions of chapter classifications | 78 | |
3032704878 | Category | First of three characters of both ICD - 9-CM and ICD-10-CM diagnosis codes | 79 | |
3032708327 | Placeholder | The 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 character | 80 | |
3032712254 | and | means and/or when it appears in a title or narrative statement | 81 | |
3032713977 | with | term used in the alphabetic index immediately following the main term, but not necessarily in alphabetic order. | 82 | |
3032716087 | includes | term that is accompanied by conditions that are examples of what may be included in a specific category. | 83 | |
3032718468 | see | term used to instruct the coder to refer to another term | 84 | |
3032720391 | see also | term used to instruct the coder to refer to another term | 85 | |
3032723033 | Code also | Instruction that tells the coder that more than one code must be assigned but it does not imply any sequencing guidance | 86 | |
3032725885 | Code first | Instructs the coder to assign the code for the underlying disease before the code for the manifestation of the disease and generally accompanies a manifestation code | 87 | |
3032730940 | Use additional Code | Instructs the order to also assign a secondary code, following the disease code it generally accompanies,for any manifestations that exist for the case. | 88 | |
3032734503 | Excludes | Term 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 | |
3032738398 | Excludes 1 | Term 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 | |
3032745363 | Excludes 2 | Unique 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 | |
3032760817 | brackets | Punctuation 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 | |
3032764995 | Diagnosis | A disease or other medical condition | 93 | |
3032766272 | Pocedure | Medical care administered during a patient encounter, ex. eam, tests, therapeutic treatment or surgery. | 94 | |
3032769999 | Medical Necessity | Term used by Medicare and other payers to define the need for each procedure code to be justified by at least one diagnosis code | 95 | |
3032775730 | Continuing Education Units (CEUs) | Credits that are required to maintain credentials for coders who have successfully passed a coding credential examination | 96 | |
3032779204 | Query | Asking a physician a question regarding documentation for coding purposes | 97 | |
3032781203 | Mainterm | Term searched for in the alphabetic index to locate the necessary corresponding code | 98 | |
3032783618 | Subterm | Term used to modify the main term when looking up codes | 99 | |
3032785466 | Chapter | Organizational unit of the code book dedicated to a group of diagnosis | 100 | |
3032786894 | Section | Group of categories that include similar conditions | 101 | |
3032788101 | Category | First 3 characters of an ICD-10-CM code | 102 | |
3032792657 | Late Effect | ICD-9-CM effect of medical conditions or injuries that may require additional treatment or impact other conditions later in life | 103 | |
3032796086 | Sequela | Term used to refer to late effect - ICD-10-CM | 104 | |
3032800194 | Principal diagnosis | Condition established after the study to be chiefly responsible for occasioning the admission of the patient to the hospital for care. | 105 | |
3032807231 | Differential diagnoses | Two or more contrasting or comparative diagnosis | 106 | |
3032808088 | Secondary diagnoses | Diagnoses that impact patient care because they extend the length of stay or require, clinical evaluation, therapeutic treatment, diagnostic procedures, or increased care or monitoring | 107 | |
3032818785 | Encounter | When a patient presents for care in the outpatient setting | 108 | |
3032821619 | First Listed Diagnosis | Term used in outpatient setting instead of "principal diagnosis". | 109 | |
3033357317 | why the 1985 revision meeting was postponed | need for restructuring due to extensive expansion | 110 | |
3033359622 | final draft of the icd11 submitted | 2014 | 111 | |
3033360680 | intended use for classification of diagnoses in early1600 | tracking deaths | 112 | |
3033361891 | wht does abbreviation CM mean | clinical modification | 113 | |
3033363197 | organizations are cooperating parties for maintaing official coding guidlines for icd9cm | aha, ahima, cms, nchs | 114 | |
3033364792 | how many parameters are included in the content model for icd11 | 13 | 115 | |
3033365989 | how often is it recommened that the icd classification system be revised by WHO | every 10 yrs | 116 | |
3033366624 | in the 1800s | the need to track medical records became more widely recognized | 117 | |
3033367863 | development of a procedure coding system | result of the clnical modification of the ICD | 118 | |
3033368750 | four (quarterly) | number of editions each yr of coding clinic icd9cm | 119 | |
3033369965 | London bill of mortality | roots of med. coding traced back to this | 120 | |
3033371213 | until 1985 ICD was updated every | 10yrs | 121 | |
3033372846 | icd10 indorsed in 1990 by 43rd | WHA | 122 | |
3033373515 | PCS in icd10pcs | procedure coding system | 123 | |
3033374744 | proposed and final rulings for changes icd in US are published in | Federal Register | 124 | |
3033375524 | coding changes additions deletions are effective every yr on | Oct. 1 | 125 | |
3033377010 | best explains organization of icd9cm and icd10cm manuals | layout of book and method of looking up diagnosis codes are very similar | 126 | |
3033378408 | symbol identifies terms may coexist with main term but do not change code assignment | parenthesis | 127 | |
3033378741 | how many volumes in icd9cm | 3 | 128 | |
3033379518 | how many volumes in icd10cm | 2 | 129 | |
3033380668 | which statement is correct relative to outpatient prospective payment system | hospitals may be paid for more than one APC per encounter | 130 | |
3033382331 | basis for reimbursemtn of skilled nursing facility | resource utilization groups (RUG-III) | 131 | |
3033383940 | basis of inpatient perspective payment system | MS-DRG medicare severity diagnosis related groups | 132 | |
3033386679 | part of UHDDS | patient sex, secondary diagnosis, identifction of the surgeon | 133 | |
3033388809 | was developed before medicaid medicare and group health insurance | Bluecross/blueshield | 134 | |
3033389538 | software used for reporting skilled nursing data | raven resident assessment validation and entry | 135 | |
3033391464 | relative to inpatient prospective payment system | wage index is used to adjust the payment according to the location of the facility | 136 | |
3033394298 | data set specific to inpatient setting | uhdds uniform hospital discharge data set | 137 | |
3033395521 | in 1983 | when first prospective payment system was implemented | 138 | |
3033397788 | outcome and assessment information set | instrument used to document assessment of home health patients | 139 | |
3033399004 | pps for skilled nursing facilities | rug-III resource utilization groups | 140 | |
3033401791 | 80case mix groups are that are available for patient classification based on clinical presentation functional factors and service utilization is called | HHRGs home health resource groups | 141 | |
3033407868 | pps reimbursement involves payment made based on predetermined fixed amount is for | Medicare | 142 |
Basic Medical Coding Chapter 1-5 Flashcards
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