chptr 1 intro Flashcards
(13 cards)
classification systems
the term used in health care to identify ICD10 CM ICD10 PCS and HCPCS level II code sets
condition
the state of abnormality or dysfunction
diagnosis
a physicians determination of a patients condition, illness, or injury
eponym
a disease or condition named for a person
external cause
an event, outside the body, that causes injury, poisoning, or an adverse reaction
inpatient
an individual admitted for an overnight or longer stay in a hospital
medical necessity
the assessment that the provider was acting according to standard practices in providing a procedure or service for an individual with a specific diagnosis.
nonessential modifiers
descriptors whose inclusion in the physicians notes are not absolutely necessary and that are provided simply to further clarify a code description; optional terms
outpatient
a patient who receives services for a short amount of time (less than 24 hours) in a physicians office or clinic, without being kept overnight. an outpatient facility includes a hospital er, ambulatory care center, same day surgery, walk in clinic
procedure
action taken, in accordance with the standards of care, by the physician to accomplish a predetermined objective (result) ; a surgical operation
reimbursement
the process of paying for health care services after they have been provided
services
spending time with a patient and/or family about health care situations
treatment
the provision of medical care for a disorder or disease