Lesson 6 Flashcards
ICD-10-PCS
Is a coding system developed by centers for Medicare and Medicaid services for coding procedures in inpatient hospital settings only.
Index to diseases and injuries
An alphabetic list of terms and their corresponding codes. It also includes a table of neoplasms, table of drugs and chemicals, and an index to external clauses of injuries.
Known also as alphabetical Index
Tabular list
A list of codes and code descriptions divided into chapters
Main terms
In the index are boldfaced, capitalized, flush with the left margin and in alphabetical order.
Nonessential modifiers
Sometimes next to the main term. Which are supplementary words located in parentheses after a main term and do not have to be Included in the diagnostic statement for the code to be assigned.
Sub terms
Are indented underneath main terms and they further describe the condition.
Qualifiers
Are terms that are indented under subterms and provide additional i formation.
Neoplasm
Means new growth and refers to an abnormal mass of tissue that results when cel reproduction is out of control. It is also called a tumor.
Malignant primary
A malignant tumor is cancerous and capable of spreading to other parts of the body. A primary malignancy is the original tumor site. All malignant tumors are considere primary unless otherwise documented as metastatic or secondary.
Secondary malignancy
The tumor has metastasized (spread) to a secondary site, either adjacent to the primary site or to a remote region of the body. For example a patient who has prostate cancer that has metastasized to the bone has a primary prostate cancer and a secondary bone cancer.
Carcinoma (Ca) in situ
A malignant tumor that is contained at the original site. (Has not spread)
Benign
A non cancerous neoplasm that is not life threatening
Uncertain behavior
The pathologist will not be able to make a definite diagnosis about the behavior of the neoplasm
Unspecified behavior
The documentation doesn’t support a more specific code or results are pending.
Laterality
A term that indicates whether a condition affects one side of the body or the other
Encounter
The face to face contact between a patient and a healthcare provider who assesses and treats the patients condition.
Neoplasm
Means “new growth”, and refers to ah abnormal mass of tissue that results when cell reproduction is out of control
Eponym
A disease or condition names after the person who identified it
Etiology
The cause of a disease
Manifestation
A condition or complication caused by another condition or disease
Excludes1
Indicates that two specific conditions cannot be coded Togethor for the same encounter
Excludes2
Indicates that a specific condition is not included here, but the two conditions can be coded separately
Combination code
A single code used to classify two diagnoses
GEMs
General equivalence mappings. Are translation dictionaries or crosswalks of codes that can be used to roughly identify icd-10-cm codes from their icd-9-cm codes and vice versa
Mortality
Death
Morbidity
Disease
What are the two current outpatient coding systems
- Icd-10-cm for diagnoses.
Internacional classification of diseases, tenth revision, clinical modification
2.hcpcs (healthcare common procedure coding system )
-hcpcs level 1, called current procedural terminology (cpt) got procedures and services.
-hcpcs level 2 for services and supplies not listen in cpt
Icd-10-pcs
Is a coding system developed by centers for Medicare and Medicaid services for coding procedures in inpatient hospital settings only.
WHO
World health organization
NCHS
The national center for health statistics
Benefits of icd-10-cm
-It provided greater coding accuracy and specificity.
-it contains a multitude of descriptions relevant to out patient care
-It’s / flexible enough to allow for expansion
-It’s up to date with current standard
-it meets hippa’s EDI standards and the need of current payment systems
-it aligns the u.s. goring system with those worldwide
Icd-10-cm has key features to be aware of
Codes may be 3, 4, 5, 6, or 7 characters in length.
First character is always a letter. All letters are used except “u”
Additional characters Can be numbers or letters
Codes include laterality, or specific side of body (right shoulder, left eye), where applicable
