coding chapter 1-4
with
"with mention of" ," associated with" , and " in" indicate that both elements in the title must be present in the diagnostic or procedural statement.
Coding certification is offered by the following professional organization
AHIMA
Which of the following is NOT a coding credential
AHIMA
AHIMA
American Health Information Association
AHA
American hospital association
when translating a disease or a procedure to an ICD-9-CM code, one must have knowledge of
Anatomy, Terminology, Coding rules and guidelines
DS
Data system, sheet
DHHS
Department of health and human services
DRGs
Diagnosis related groups
HIPAAk
Health Insurance Portability and Accountability Act
The current coding system used in the US is known as
ICD-9-CM International classification of diseases, 9th revision, clinical modification codes
WHO
International classification of causes of death World Health Organization
nonessential modifier
Is a term that is enclosed in parenthesis following a main term or a subterm, whose presence or absence has no effect on the code assignment
cooperating parties
NCHS,CMS- federal organization AHA, AHIMA - professional organizations
Symptom
Subjective evidence of a disease or of a patients condition as perceived by the patient
TJC
The joint commission
TPR
Third party reimbursement
What appendix is a complete listing of all three-digit code categories in ICD-9-CM
V-codes
Only A and B are used
Which of the code book volumes are used in a physician's office
see category
a cross-reference that gives directions to go to a specific code category in the tabular list, Volume 1
provider
a physician or any qualified health care practitioner (such as a nurse practitioner or physician assistant
Acute
a short and relatively severe course
neoplasm
abnormal growth
coding conventions
addressed by the ICD-9-CM official guidelines for coding and reporting
compliance
adhering to accepted standards
"code, if applicable, any causal condition"
an instruction an instruction to code the causal condition if it is known
other codes
are used when the information in the medical record provides detail for which a specific code does not exist
ICD-9-CM may be updated
biannually
discharge summary
brief report written by a healthcare provider that summarizes a patients hospital stay
CMS
centers for medicare and medicaid services
CCS
certified code specialist
ICD-9-CM, Appendix D
classification of industrial accidents according to agency contains a complete list of all the three digit code categories
specificity
coding to the highest level of detail
CBC
complete blood count
CC
complication or cormobidity- chief complaint admission note
encoder
computer software to assist in code selection and MS-DRG
When a compliance plan for coding is constructed, the following steps are crucial
conduct audits, develop coding policies and procedures, cultivate a relationship with billing dept,
CEUs
continuing education units
CPT
current procedural terminology
DOB
date of birth
Credential
degree, certificate, or award that recognizes a course of study taken in a specific field
etiology
describes the cause or origin of a disease or condition
Eponym
diagnosis or procedure named for a person
procedure
diagnostic or therapeutic process performed on a patient
ER
emergency room
Integral
essential part of a disease process
Abstracting
extracting data from the health record
brackets
form of punctuation; are used in the index to identify manifestation codes in the alphabetic index
conventions
general rules for the use of the ICD-9-CM classification that must be followed for accurate coding
classification
grouping together, as with items for storage and retrieval
consultant
healthcare provider who is asked to see the patient and provide expert opinion
HPI
history of present illness
HAC
hospital acquired conditions
diagnosis
identification of disease by signs, symptoms, or tests
alphabetic index
index of disease conditions listed in alphabetic order
see and see also
instruction following a main term in the index indicates that another term should be referenced. It is necessary to go to the main term referenced with "See" note to locate the correct code
parentheses
is (are) used in both the index and tabular list to enclose supplementary words that may be present or absent in the statement of a disease or procedure, without affecting the code assignment
see condition
is a reference that instructs coders to look up another term to locate a code for a particular condition. is used in the alphabetic index to provide guidance when two conditions are related or have a causal relationship
principal diagnosis
is defined as the condition established after study to be chiefly responsible for admission of the patient to the hospital
UHDDS
is used for reporting inpatient data in acute care, short term care, and long term care hospitals. developed in 1985. Condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care
MRI
magnetic resonance imaging
MRN
medical record number
coded data are not used for the following reason
medical terminology
MS-DRG
medicare severity adjusted diagnosis-related groups
subterm
modifier of a main term
NCHS
national center for health statistics
NEC
not elsewhere classified- when a specific code is not available for a condition in the index or tabular list for the coder to code "other specified"
NOS
not otherwise specified
OIG
office of inspector general
OGCR
official guidelines for coding and reporting
OR
operating room-operative report
disposition
place a patient goes upon discharge from the hospital
Cormobidity
preexisting secondary diagnosis
POA
present on admission
POA indicator
present on admission indicator; a data element that applies to diagnosis codes for claims involving inpatient care
why is it important for the coder to understand coding convention?
proper conventions will lead to efficient and accurate coding and sequencing
review of systems
question and answer period between healthcare provider and patient regarding healthcare issues
RHIA
registered health information administrators
and
should be interpreted to mean either "and" or "or" when it appears in the title
coding clinic articles
some books are updated with replacement pages quarterly and may include references
SOAP
subjective objective assessment plan
essential modifier
subterms used in the alphabetic index that affect code assignment
manifestation
symptom or condition that is the result of a disease
nomenclature
system of names used as preferred terminology
Main term
term used to identify a disease condition or injury
inclusion terms
terms may be included under certain four and five digit codes; conditions for which that code number is to be used; inclusion terms are not necessarily exhaustive.
diabetes mellitus
the most commonly used etiology/manifestation combinations are the codes
instructional notes
these include general notes, inclusion, and exclusion notes, code first notes, and use additional code notes.
the purpose of a classification system is
to group like items for storage and retrieval
excludes note
under a code indicates that the terms excluded from the code are to be coded elsewhere
parenthesis ( )
used both in the index and tabular list to enclose supplementary words that may be present or absent in the statement of a disease or produce without affecting the code number to which it was assigned
colons
used in both inclusion and exclusion notes to indicate that one of the modifiers from the list indented below the entry must be present in order for the statement to apply
due to
used in the alphabetic index is sequenced immediately following the main term, not in alphabetical order
brackets [ ]
used in the tabular list to enclose synonyms, alternative wording, or explanatory phrases
unspecified codes
usually a code with a four digit or fifth digit "0" for diagnosis that is used when the information in the medical record is insufficient to assign a more specific code
which volume of the ICD-9-CM book contains the alphabetic index of diseases and injuries?
volume 2
asymptomatic
without any symptoms
terminology
words or phrases that apply to a particular field
connecting words
words such as "with" "in" "due to" and "associated with" are used to express the relationship between the main term or a subterm indicating an associated condition of etiology
Documentation
written or typed information supplied by the healthcare provider to communicate patient data and activity