Medical Coding and Claims Flashcards
abuse
an unreasonable and generally unacceptable departure from precedent and custom with one person taking advantage of another person or set of circumstances; abuse may or may not be unlawful
adverse effect
a pathologic reaction to a drug that occurs when appropriate doses are given
appeal
a request to a authority for a decision
benign tumor
a nonmalignant lesion that is not invasive or metastatic
chief complaint
a patient’s statement describing symptoms and conditions that are the reason for seeking health-care services
claim
a bill sent to the insurance carrier for payment related to patient care
clean claim
completed insurance claim form submitted to a carrier without deficiencies or errors
CMS 1500
universal health insurance claim form used in the physician’s office
comorbidity
a condition that exists along with the condition for which the patient is receiving treatment
concurrent use
similar services provided to the patient on the same day by a different physician
consultation
services rendered by a physician whose opinion or advice is requested by another physician or agency in the evaluation or treatment of a patient’s problem
counseling
discussion with patient or family concerning diagnosis, recommendations, risks, benefits, prognosis, and necessary condition-related education
critical care
intensive care in acute life-threatening conditions requiring constant beside attention by the physician
Current Procedural Terminology (CPT)
coding system first published by the American Medical Association in 1966; a manual, updated annually, that contains the codes for procedures and services preformed by doctors and other select medical personnel
dirty claim
a claim held or rejected by the insurance carrier due to problems or errors
E code
a supplementary classification of ICD-9 coding that denotes the external cause of an injury rather than a disease
eponym
the name of a disease or procedure derived from the name of a place or person
established patient
a person who has received care from the physician or another physician of the same specialty in the same group practice within 3 years
etiology
the cause of a disease
explanation of benefits (EOB)
synonymous with remittance advice (RA); a correspondence by the insurance company informing the patient and medical office the amount paid for a claim and why
fraud
intentional and unlawful deception for gain that results in harm to another person or organization
gang visits
billing for individual visits when not all the patients present during the visit received services
General Equivalency Mapping (GEM)
a crosswalk between the ICD-9 and the ICD-10
Healthcare Common Procedure Coding System (HCPCS - hicpics)
a method developed by the Health Care Finance Administration for coding procedures and other services delivered to Medicare patients
in situ
neoplasm confined to the site of origin
International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9 or ICD-9-CM)
a coding system published by the US Department of Health and Human Services to classify diseases and injuries
International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM)
diagnostic coding system to replace the ICD-9
International Classification of Diseases, Tenth Revision, Procedural Coding System (ICD-10-PCS)
procedural coding system to replace the CPT system in hospitals
late effect
a residual condition occurring after the acute phase is over
malignant tumor
a neoplasm with invasive and metastatic properties
new patient
a person who has not received care from the physician or another physician of the same specialty in the same group practice within 3 or more years
Not elsewhere classified (NEC)
a term used in ICD-9 coding when information is not available to code the term in a more specific category
Not otherwise specified (NOS)
a term used in ICD-9 coding for unspecified diagnosis
phantom billing
billing for services or supplies not provided
ping-ponging
unnecessary or excessive referrals of patients to other providers and back to primary office
point of service (POS)
facility where the health-care service took place
primary diagnosis
the symptoms, conditions, and initial impressions, diagnosed as the cause for the patient seeking health-care services
principal diagnosis
the definitive diagnosis
remittance advice (RA)
synonymous with explanation of benefits (EOB), correspondence by the insurance company informing the patient and medical office the amount paid for a claim and why
split billing
charging for several visits when services were performed during one visit
superbill
also called an encounter form; a charge form custom-designed for the specific medical practice; lists the ICD-9 and CPT codes common to the services of that practice
unbundling
using several CPT codes to identify procedures normally covered by a single code
upcoding
deliberately using an incorrect code to bill at a higher rate
V codes
ICD-9 codes identifying health care visits for reasons other than illness
yo-yoing
scheduling the patient for unnecessary follow-up visits
