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