Domain 1 : Coding Basics and Abstracting Documentation - Terms and Concepts to Know

Cengage eTextbook: Professional Review Guide for CCA Examination 2025 Domain 1: Part 1 - Coding Basics and Abstracting Documentation Terms and concepts to know pg 36

Abstracting

The process of extracting relevant clinical details from physician documentation to assign accurate diagnosis (IDC-10-CM) codes and procedure (CPT or ICD-10-PCS) codes

Ambiguous

Having two meanings

Assume

Non-specific details that are considered to be true; filling in missing details with one's own knowledge

Co-Morbidities

A pre-existing medical condition not related to the patient's current condition, but should be considered when providing treatment. For example, the patient has a fractured ankle and is also pregnant.

Contradictory

Notations that disagree with each other

Demographics

Data used to identify an individual, such as name, address, and date of birth

Documentation

Written and electronic healthcare findings, procedures, services, treatments, as other pertinent details related to care provided to a patient for the purposes of communicating with others on the healthcare team

Diagnosis

The identification of why the patient needs, seeks, or received medical care

Diagnostic

Tests and examinations used to determine why the patient needs healthcare intervention

Encounter

Time spent by the patient with a physician to discuss healthcare concerns

Facility

A healthcare building, such as a hospital, physician's office, or clinic

Interpretation

Identifying meanings of terms in a different language. For example, malignant is interpreted as cancer.

Manifestations

Signs or symptoms of an underlying disease or injury. For example, neuropathy is a sign/symptom of diabetes; numbness in fingers and toes is a sign/symptom of a traumatic brain injury

Patient

The individual receiving care from a healthcare provider

Physician

The healthcare provider, typically with an MD license

Preventative

Treatments provided to keep a healthy patient healthy. For example, flu shot.

Procedure

What the physician does for or to the patient in treatment

Query

To ask; used to request clarification or additional details from a physician with regard to a diagnosis or procedure

Sequela

Late effect; a condition that results from another condition. For example, aphasia resulting after a patient has experienced a stroke

Signs

Measurable anomaly of health. For example, fever can be measured by a thermometer.

Source Documents

Reports included in the patient record, such as pathology test results

Symptoms

Non-measurable anomalies of health, as described by the patient. For example, a headache.

Therapeutic

A procedure, service, or treatment provided to a patient to correct or heal a healthcare concern