Chapter 46 Medical Coding

Diagnosis-related groups (DRGs)

a system for grouping hospital inpatient who are expected to utilize a similar amount of hosiptal resources as a basis for Medicare reimbursements

Downcoding

using procedure codes that do not reflect a high enough level of service

Established Patient

a patient who has been seen by one of the physicians in the practice within the past 3 years

Inpatient

a patient who has been admitted to a healthcare facility for at least one overnight stay

medical necessity

healthcare that is reasonable and necessary for patient based on evidence clinical standards of care

modifier

an addition to a current procedural terminology (CPT) code that indicated unusual circumstances related to the procedure, such as a more extensive procedure or two procedures performed in the same session

NEC (not elsewhere classified)

a diagnosis code that is used when a more specific code for the condition is not available

New Patient

for biling purposes, a patient who has not received services during the previous 3 years from any physician in a medical practice

NOS

a diagnosis code that is not otherwise specified. It is used when there is not enough information given to select a more specific code

Outpatient

a patient who has not been admitted to a healthcare facility

Panel

a group of diagnostic tests done simultaneously in one machine

Relative value unit (RVU)

a number that quantifies the amount of physician labor, resources, and expertise necessary to provide the service represented by a CPT code

Sequela

any conditions that results from a disease, injury or treatment for a disease or injury

Surgical Package

surgical services usually covered by a single procedure code that includes a preoperative visit, postoperative care, and local anesthesia (if applicable)

Upcoding

using a code to obtain higher level of reimbursement that is justified by medical procedures performed as documented in the medical record. This can result in serious fines and penalties