Chapter 1

Classification Systems

The term used in health care to identify ICD-10-CM, CPT, ICD-10-PCS, and HCPCS Level II code sets.

Diagnosis

A physician’s determination of a patient’s condition, illness, or injury.

Procedure

Action taken, in accordance with the standards of care, by the physician to accomplish a predetermined objective (result); a surgical operation.

Medical Necessity

The assessment that the provider was acting according to standard practices in providing a procedure or service for an individual with a specific diagnosis.

Reimbursement

The process of paying for health care services after they have been provided.

Condition

The state of abnormality or dysfunction

Eponym

A disease or condition named for a person.

Nonessential Modifiers

Descriptors whose inclusion in the physician’s notes are not absolutely necessary and that are provided simply to further clarify a code description; optional terms.

External Cause

An event, outside the body, that causes injury, poisoning, or an adverse reaction.

Procedures

Actions, or a series of actions, taken to accomplish an objective (resut)

Services

Spending time with a patient and/or family about health care situations.

Treatments

The provision of medical care for a disorder or disease.

Diagnostic tests or procedures

Performed to provide the physician with additional information required to determined a confirmed diagnosis

Preventive procedures and services

Are provided to keep a healthy patient healthy. Also include early detection tests, known as screenings.

Therapeutic procedures

Are performed with the intention of removing, correcting, or repairing an abnormality or condition

Outpatient

A patient who receives services for a short amount of time (less than 24 hours) in a physician’s office or clinic, without being kept overnight.

Inpatient

An individual admitted for an overnight or longer stay in a hospital.