Comorbidity

Tabular list

A numerical list of diagnosis codes presented in a format similar to a table

Frenotomy

Release of tongue tie by clipping the lingual frenulum. Often preformed without anesthesia with few complications

RBRVS

Resource Based Relative Value Scale.... the prospective payment system used by Medicare to pay phycians. it considers the CPT code in relations to Geographic adjustment is then made to account for cost-of-living differences throughout the nation

Acute

Short term A condition with a rapid onset with a short course. New, usually of rapid onset and of concern, opposite of chronic

Diagnosis

Statement naming the cause of a condition

Downcoding

assigning lower-level codes than documented in the record.

Regurgitation

backward flowing, as in the return of solids or fluids to the mouth from the stomach

Subcutaneous

beneath the skin

Nonessential

type of information that should be set apart from the rest of the sentence with commas

Synchronous

(adj.) occurring at the same time, simultaneous

Thoracoscopic

- exploration and biopsie

Subcategory

4-digit diagnosis codes in the ICD-9-CM system

V-code

A billing code for preventative care

Modifiers

A modifier provides descriptive information mainly in the form of adjectives and adverbs.

CPC, CCS-P

Certified coding specialist

CPC, CPC-H

Certified professional coder

Eponym

Disease/syndrome named for a person

Synchronous

Happening at the same time; occurring at the same rate and thus happening together repeatedly

ICD-9-CM

International Classification of Disease, 9th Clinical Modification

ICD

International Classification of Diseases

Subclassification

Provides a 5th digit which gives the highest specificity of description to a condition. Use of it is mandatory if it is available. A code not reported to the full number of digits required is invalid

Sections

Related groups of code within a chapter in the tabular list

Hypertension table

Table to aasist with codes choices for hypertension

Neoplasm table

Table to assist with Cole selection for neoplasm

Table of drugs and chemicals

Table to assist with code selection that identify drugs and other chemicals

Procedure code

The services the doctor provides to a patient are called procedures that are identified by a procedure code number. Typical procedures include office visits, injections, radiographs, appendectomy sutures, and other services.

Main term

The word that identifies a disease or condition in the Alphanumeric index.

Otoscopy

Visual examination of the ear

Procedure

a series of actions that are done in a certain way or order, a medical treatment or operation11

Thoracotomy

a surgical treatment of lung cancer by removing all or part of a lung

Essential

absolutely necessary

Comorbidity

co-occurrence of two or more diagnoses within the same person

Morbidity

concern with death and disease

Mortality

incidence of death

Excludes

indicates terms that are to be coded elsewhere

Bullae

large blisters.

Upcoding

A code is chosen for a more severe condition or for a more extensive procedure then is document in the patient medical records

E-code

A code representing an external cause of injury or poisoning codes for External causes of injury

Situ

An outcome that turns out to be very different from what was expected

Includes

Appears under a three-digit code title to further define or explain category content

Principal diagnosis

Condition that is chiefly responsible for admission to the hospital

Chronic

Continuing over a long period of time.

Secondary diagnosis

Diagnosis other than the primary diagnosis for other conditions that are also affecting the patient at the time of the visit

See category

Directs the coder to Volume 1 for important information

Subterms

LOCATED UNDER THE MAIN TERMS AND INDENTED TO THE RIGHT

Status post

Means the client has had the procedure or event in the past

See condition

The "see condition" note found in the Alphabetic Index to Diseases instructs the coder to refer to a main term for the condition. This note will follow index terms that are nouns for anatomical sites or adjectival forms of disease term. In the example below, the index terms "Cervix" and "Diffuse" are followed by the - see condition. Coders should search the index using a condition term such as atrophy or prolapse The "see condition" note found in the Alphabetic Index to Diseases instructs the coder to refer to a main term for the condition. This note will follow index terms that are nouns for anatomical sites or adjectival forms of disease term. In the example below, the index terms "Cervix" and "Diffuse" are followed by the - see condition. Coders should search the index using a condition term such as atrophy or prolapse

Greatest level of specificity

The code with the greatest level of detail that matches the patient medical record with the greatest accuracy.

Primary diagnosis

The condition considered to be the major health problem for the patient for the submitted claim. OUTPATIENT

Pigeonholing

The practice of using a short list of diagnosis codes and using those codes for all patients regardless of whether the cole matches actual diagnosis and conditions