CHAPTER 14 PROCEDURAL CODING ESSENTIALS

certified registered nurse anesthetist (CRNA)

A nursing healthcare professional who is certified to administer anesthesia.

chief complaint

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

CPT Assistant

An online CPT coding journal, supported by the AMA, that addresses subjects such 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

performance measurement

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

review of systems (ROS)

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 procedure code.

specificity

The quality or state of being specific.

bilaterally

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