Chapter 13

Diagnostic Coding Essentials

abstract

collecting important information from the health record.

cataract

progressive loss of transparency of the lens of the eye.

chronic

developing slowly and lasting for a long time, generally 3 or more months.

contraindicate

to specify that an agent or procedure should not be used.

dementia

a mental disorder in which the individual experiences a progressive loss of memory, personality alterations, confusion, loss of touch with reality, and stupor (seeming unawareness of, and disconnection with, one’s surroundings.)

diagnosis

determining the cause of a condition, illness, disease, injury, or congenital defect.

diagnostic statement

information about a patient’s diagnosis or diagnoses that have been taken from the medical documentation.

encoder

software that will apply diagnostic or procedure codes to medical conditions or procedures.

encounter form

a document used to capture the services/procedures and diagnoses for a patient visit. the fees for the services/procedures are usually included on the encounter form.

epidemiology

the branch of medicine dealing with the incidence, distribution, and control of disease in a population. It also involves the prevalence of disease in large populations, in addition to detection of the source and cause of epidemics of infectious disease.

etiology

the study of the causes or origin of diseases.

histologic

pertaining to the study of body tissues.

impending

a term used in the diagnosis of a condition that can be imminently threatening. For example, a patient showing signs of prediabetes may in the near future develop diabetes; therefore, in this case, diabetes is an impending condition.

medically necessary

accepted healthcare services that are appropriate for the evaluation and treatment of a disease, condition, illness, or injury and are consistent with the applicable standard of care.

mortality

the relative frequency of deaths in a specific population.

myxedema

advanced hypothyroidism in adulthood.

reimbursement

the make repayment for an expense of a loss incurred.

sequela

( or sequelae for plural) an abnormal condition resulting from a previous disease.

specificity

the quality or state of being specific.

encounter

any meeting between a patient and a health provider.

ancillary diagnostic services

radiology, pathology, and laboratory reports

subjective findings

patient’s chief complaint or statements about why the patient is seeking medical care.

conventions

abbreviations, punctuation, symbols, instructional notations, and related entities.

chief complaint

a statement in the patient’s own words that describes the reason for the visit.

manifestation

the signs and symptoms of a disease.

peripartum

the period from the last month of pregnancy to 5 months postpartum.

postpartum

first 6 weeks after delivery.

objective findings

any measurable indicators found during the physical examination.

antepartum

pregnancy

ICD-10-CM

International Classification of Diseases, Tenth Revision, Clinical Modification

CMS

Centers for Medicare and Medicaid Services

WHO

World Health Organization

EHR

electronic health record

HPI

history of present illness

H&P

history and physical exam

CC

chief complaint

HIV

human immunodeficiency virus

AIDS

acquired immunodeficiency syndrome

DM

diabetes mellitus