Chapter 46 Key Terms

NEC

A diagnosis code that is not elsewhere classified. It is used when a more specific code for the condition is not available

NOS

A diagnosis code that is not otherwise specified. It is used when there is not enough information given to select a more specific code

Panel

A group of diagnostic tests done in one machine at the same time

RVU (Relative Value Unit)

A number that quantifies the amount of physician labor, resources, and expertise necessary to provide the service represented by a CPT code

Inpatient

A patient who has been formally admitted to a health care facility

Established patient

A patient who has been seen by one of the physicians in the practice in the same specialty within the past 3 years

Outpatient

A patient who has not been admitted to a health care facility

New patient

A patient who has not received services during the previous 3 years from a physician in a medical practice in the same specialty

DRG (Diagnosis Related Groups)

A system for grouping hospital inpatients who are expected to utilize a similar amount of hospital resources as a basis for Medicare reimbursement

Modifier

An addition to a CPT code that indicates unusual circumstances related to the procedure

Sequela

Any condition that results from a disease, injury, or treatment for a disease or injury

Medical necessity

Health care that is reasonable and necessary for a patient based on evidence-based clinical standards of care

Surgical package

Surgical services usually covered by a single procedure code that includes a preoperative visit, postoperative care, and local anesthesia

Upcoding

Using a code to obtain a higher level of reimbursement than is justified by medical procedures performed as documented in the medical record. This can result in serious fines and penalties.

Downcoding

Using procedure codes that do not reflect a high enough level of service