Introduction to Coding Flashcards
coding
the transformation of verbal descriptions (written or spoken) into numbers; these numbers are part of a classification system
diagnosis
a word or phrase used by a physician to identify a disease from which an individual suffers or a condition for which the patient needs, seeks, or receives medical care
physician
a person who is qualified to practice medicine
procedure
any single, separate, systematic process done on the body that is complete in itself; procedures can be performed with or without instruments and can be used to heal the body or do further tests to aid in diagnosis
NCHS
acronym for: National Center for Health Statistics; a federal agency that uses statistics to guide actions and policies that improve the American public’s overall health
CMS
acronym for: Centers for Medicare and Medicaid Services; they are the federal agency that runs Medicare; they also work with local states to administer Medicaid and CHIP; they also help determine health information standards
Medicare
a national health insurance program usually provided to people 65 and older, but also occasionally provided to younger people with disabilities
Medicaid
a combination state and federal health insurance program that provides healthcare to people with low incomes
CHIP
acronym for Children’s Health Insurance Program; a program administered by the United States Department of Health and Human Services; it helps provide health insurance for children who belong to families that are too rich for Medicaid, but too poor to get health insurance
classification system
in the context of medical coding, a system of organizing diseases and procedures for easy retrieval of information
registrar
an official responsible for keeping a register or official records
register
an official list or record, for example of births, marriages, and deaths, of shipping, or of historic places
APHA
acronym for: American Public Health Association; founded in 1872, it is an organization of public health professionals; they played a role in starting the ICD system
WHO
acronym for: World Health Organization; founded in 1948, they are an agency within the United Nations that is responsible for international health
HHS
acronym for: United States Department of Health and Human Services; a federal agency that provides health services to the American people while also protecting the public health
Official Addendum
A reference source that documents the annual changes made to ICD-10-CM and ICD-10-PCS; it can be found on the NCHS website. NCHS is responsible for ICD-10-CM and CMS is responsible for ICD-10-PCS. AHIMA and AHA (American Hospital Association) assist.
The changes in the Official Addendum are effective April 1 and October 1 of each year.
ICD-10-CM Coordination and Maintenance Committee
a committee, made up of people from the NCHS and CMS, that holds two meetings a year to discuss modifying the ICD-10-CM and the ICD-10-PCS
ICD-10-CM
a modification of the ICD-10, authorized by the World Health Organization, used as a source for diagnosis codes in the United States of America; it replaces the earlier ICD-9-CM; it is used universally by all healthcare providers
the CM stands for “clinical modification”, in reference to its modification for use in the USA
ICD-10-PCS
a resource created by the joint efforts of 3M and CMS; it is used as a source of procedure codes in the USA; it replaces the procedure section that used to be in ICD-9-CM; it is used for inpatient hospital encounters
diagnosis codes
a tool to group and identify diseases, disorders, symptoms, poisonings, adverse effects of drugs and chemicals, injuries and other reasons for patient encounters
procedure codes
a sub-type of medical classification used to identify specific surgical, medical, or diagnostic interventions
intervention codes
another word for procedure codes
ICD
acronym for: International Statistical Classification of Diseases and Related Health Problems; a medical classification list created by the World Health Organization; it contains codes for diseases, signs and symptoms, abnormal findings, complaints, social circumstances, and external causes of injury or diseases.
ICD-10
the 10th revision of the ICD, used as the basis for the ICD-10-CM
ICD-11
the 11th and most recent revision of the ICD
CPT
acronym for: Current Procedural Terminology; it is a resource used for coding outpatient encounters and office procedures.
HCPCS
pronounced “hick pics”; acronym for: Healthcare Common Procedure Coding System; there are two levels: Level 1 is the CPT code book; Level 2 deals with items, supplies and non-physician services which are not covered by Level 1
inpatient care
care that requires the patient to stay overnight
outpatient care
care that allows the patient to come in for care and leave
aggregate deductible vs embedded deductible
Embedded deductible involves both an individual deductible and a family deductible. If an individual family member gets really sick and meets their own personal deductible, they start getting medical expenses paid at the post-deductible rate, but the rest of the family does not get that benefit. The money they pay also contributes to the family deductible. If enough family members get sick and pay, they will meet the family deductible and then everyone on the plan can get post-deductible healthcare.
With aggregate deductibles, everyone must contribute to pay the family deductible before any family member gets the post-deductible rate.
encopresis
Encopresis (en-ko-PREE-sis), sometimes called fecal incontinence or soiling, is the repeated passing of stool (usually involuntarily) into clothing.
Typically it happens when impacted stool collects in the colon and rectum: The colon becomes too full and liquid stool leaks around the retained stool, staining underwear. Eventually, stool retention can cause stretching (distention) of the bowels and loss of control over bowel movements.
What is the difference between assigning a number to a verbal description such as for a zip code and the activity of assigning a diagnosis or procedure code to medical documentation?
Assigning a zip code is a simple activity.
Assigning diagnostic and procedural codes requires a detailed thought process supported by thorough knowledge of medical terminology, anatomy, and pathophysiology.
What questions do the ICD-10-CM and CPT manuals answer?
ICD-10-CM answers the question, “WHY did the patient seek healthcare services?”
CPT answers the question, “WHAT services were performed?”
technical component
the portion of a medical procedure that concerns only the technical aspect of the procedure, but not the interpretive, or professional, aspect
For example, the technical component might include the administration of a chest X-ray but not the assessment of that X-ray for disease or abnormality.
crosswalking
the mapping of equivalent, identical, or similar information across two or more distinct data sets; typically, this is done with two different versions of the same data set, e.g. ICD-9 vs ICD-10
What is the main rule of crosswalking?
When crosswalking, you can code from a specific condition to a general one but you cannot code from a general condition to a specific one.
allowed amount
the amount an insurance company will pay to reimburse a healthcare service or procedure
appeal (health insurance)
the process by which a patient or provider attempts to persuade an insurance payer to pay for more (or any) of a medical claim
occurs only after a claim has been denied or rejected
Applied to Deductible (ATD)
the amount of money a patient owes a healthcare provider that goes to paying their annual deductible
Assignment of Benefits (AOB)
Insurance payments paid directly to the healthcare provider for medical services administered to the patient. The assignment of benefits occurs after a claim has been successfully processed.
capitation
An arrangement between a healthcare provider and an insurance payer that pays the provider a fixed sum for every patient they take on. This usually happens in HMOs.
clean claim
a claim received by an insurance payer that is free from errors and processed in a timely manner
clearinghouse (health insurance)
A third party organization in the billing process, separate from the healthcare provider and insurance payer, that receives, reviews, and edits claims before sending them to insurance companies. The act of receiving, reviewing, and editing claims is sometimes called scrubbing.
COBRA
The Consolidated Omnibus Budget Reconciliation Act (COBRA) gives workers and their families who lose their health benefits the right to choose to continue group health benefits provided by their group health plan for limited periods of time under certain circumstances such as voluntary or involuntary job loss, reduction in the hours worked, transition between jobs, death, divorce, and other life events. Qualified individuals may be required to pay the entire premium for coverage up to 102% of the cost to the plan.
Electronic Remittance Advice (ERA)
A digital version of the EOB that describes how much of a claim the insurance company will pay and, in the case of a denied claim, explains why the claim was returned.
Utilization Limit
Medicare places a yearly limit on certain medical services. If a patient passes this threshold, known as the utilization limit, they may be ineligible for Medicare coverage for that procedure.
NPI (National Provider Index)
a 10-digit number used to identify health care providers
rejected claims vs denied claims
A rejected claim is one that contains one or many errors found before the claim is processed. It is returned to the biller in order to be corrected.
Denied claims are claims that the payer has processed and deemed unpayable.
