clinical vocabulary Flashcards
Alphabetic index
A content list for a reference work organized by the first letter of each entry
ICD-10-CM
Tenth revision of the ICD code set
Insurance reimbursement
The process of receiving payment from an insurance company for a covered benefit
Nomenclature
An organized system of words used in a particular field
Tabular list
A category grouping of items
International Classification of Diseases-10th Revision-Procedure Classification System (ICD-10-PCS)
A separate procedure code system in the ICD-10 clinical vocabulary system
Procedure code
A code assigned to a particular medical service or procedure
International Classification of Diseases for Oncology (ICD-O)
An extension of the ICD for use in classifying neoplasms
Oncology
The medical specialty that focuses on cancer
Neoplasm
An abnormal growth that may or may not form a tumor and may or may not be malignant/cancerous
Health Care Procedure Coding System (HCPCS)
A diagnosis and procedure code nomenclature used for outpatient billing in the US
HCPCS Level I
A clinical coding system used to describe medical and surgical procedures performed by healthcare providers that is identical to the Current Procedural Terminology (CPT) system of the American Medical Association.
HCPCS Level II
A collection of codes for services that are not found in the CPT system, including, for example, non-physician services
Systemized Nomenclature of Medicine Clinical Terminology (SNOMED CT)
A multinational, multilingual, comprehensive medical nomenclature covering all aspects of medicine
Diagnostics and Statistical Manual of Mental Disorders-5th Edition (DSM-5)
The current version of the DSM, a publication of the American Psychiatric Association (APA) used as the primary resource in the US to classify and diagnose mental disorders
Mental disorder
A condition in which a person’s thoughts, feelings, and/or behaviors cause distress or impair the ability to function
Substance abuse
A pattern of use of medications or substances that are not part of an approved medical plan or treatment
Nursing vocabulary
A nomenclature system used to communicate nursing strategies, protocols, and procedures
Medical transcriptionist
A specialist who creates text-based medical records from a voice recording
Medical coding
The process of assigning nomenclature codes to patient data obtained by examining medical records
Medical coder
A specialist in medical coding
Medical billing
The process of generating claim forms that list diagnosis and procedure codes, charges and patient demographic information for reimbursement purposes.
Medical biller
A professional who prepares and submits insurance claims for a provider based on a medical coder’s work
Medical claims examiner
A health insurance professional who examine submitted medical claims to ensure that they are valid and qualify for payment
