Chapter 14: Procedural Coding Essentials

bilaterally

Pertaining to, involving, or affecting two or both sides.

certified registered nurse anesthetist (CRNA)

A nursing healthcare professional who is certified to administer anesthesia.

chief complaint

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

CPT Assistant

An online CPT coding journal, supported by the AMA, that addresses subjects such as appealing insurance denials, validating coding to auditors, training staff members, and answering day-to-day coding questions.

debridement

The surgical removal of dead, damaged, or infected tissue to improve the function of healthy tissue.

eponym

In medical terms, a medical diagnosis or procedure named for the person who discovered it.

global services

For purposes of CPT coding, medical services and procedures performed for the patient before, during, and after a surgical procedure that are included with the assigned CPT code.

performance measurement

The regular collection of data to assess whether the correct processes are being performed and the desired results are being achieved.

ROS: review of systems

A list of questions answered by the patient related to each organ system, designed to uncover potential disease processes.

special report

Additional medical documentation required to confirm the need for the use of an unlisted, unusual, or newly adopted medical procedures code.

specificity

The quality or state of being specific.

downcoding

The use of a lower-level procedure code than is justified.

modifiers

Two-digit numeric codes that report or indicate specific criteria, specific condition, or special circumstance.

upcoding

The use of a higher-level procedure code than is supported in the documentation or by medical necessity.

abstract

The process of collecting pertinent medical information needed to assign the correct code.

morbidity

The relative incidence of disease.

conventions

Special symbols used to provide additional information about specific codes.

mortality

Relates to the number deaths from a given disease.

quantitative

Determine the amount of drug present.

unbundled code

Each step of the procedure is listed separately.

qualitative

Based on the type of drug found.

bundled code

Include services related to prepping the patient for the procedure, performing the procedure, and suturing to complete the procedure.