Chapter One Flashcards
Assumption coding
Inappropriate assignment of codes, based on assuming from a review of clinical evidence in the patient’s record, that the patient has certain diagnoses, or receive certain procedures/services, even though the provider did not specifically document those diagnosis or procedures/services.
Centers for Medicare and Medicaid services (CMS)
Administrative agency in the federal department of health and human services.
Classification system
see coding system
Clinical documentation improvement
Helps ensure accurate and thorough. Patient record documentation and identifies discrepancies between provider documentation and codes to be assigned.
Clinical documentation integrity
See clinical documentation improvement
CMS – 1450
See UB – 04
CMS – 1500
Claim submitted by physicians offices to third-party payers
Code
Numerical and alpha numerical characters that are reported to health plans for healthcare reimbursement and to external agencies (e.g., state departments of health) for data collection, in addition to being reported internally (e.g., acute care hospital) for education and research.
Coder
Acquires a working knowledge of coding systems (e.g., CPT, HCPCS,Level II, ICD-10-CM, and ICD-10-PCS), coding principles and rules, government regulations, and third-party payer requirements to ensure that all diseases, injuries, reasons for an encounter, services (e.g., office visit), and procedures (e.g., surgery and x-ray) documented in patient records are coded accurately for reimbursement, research, and statistical purposes.
Coding
Assignment of codes to diagnosis, services and procedures, based on patient record documentation
Coding system
Organizes and medical nomenclature , according to similar conditions, diseases, procedures, and services it contains codes for each
Computer assisted coding CAC
Uses computer software to automatically generate medical codes by reading transcribed clinical documentation uses natural language processing theories to generate codes that are reviewed and validated by codes for reporting on third-party payer claims
Concurrent coding
Review of records and use of encounter forms and charge masters to assign codes during an inpatient stay, or an outpatient encounter typically performed for outpatient encounters because encounter forms and charge masters are completed in real time by healthcare providers is part of the charge capture process
Current procedural terminology CPT
Codeine system used by physicians and outpatient healthcare settings to assign CPT codes for reporting procedures and services on health. Insurance claims considered level one of the healthcare, common procedure coding system, HCP, C,S, and published and updated by the American medical association, AMA to classify procedures and services, listing of descriptive terms and identifying codes for reporting medical services and procedures provides uniform language that describes medical surgical and diagnostic services to facilitate communication among providers patients and third-party payers.
Diagnostic and statistical manual of mental disorders, DSM
Manual, published by the American psychiatric Association that contains diagnostic assessment criteria used as tools to identify psychiatric disorders. DSM includes psychiatric disorders and codes provides a mechanism for communicating and recording diagnostic information and is used in the areas of research and statistics statistics.
