Coding Flashcards

Assessment

Judgment, opinion, or evaluation made by the health care provider; considered part of the problem-oriented record SOAP note.

Assumption Coding

Inappropriate assignment of codes based on assuming, from a review of clinical evidence in the patient's record, that the patient has certain diagnoses or received certain procedures/services even though the provider did not specifically document those diagnoses or procedures/services.

CMS

Administrative agency in the federal Department of Health and Human Services.

clearinghouse

Public or private entity that processes or facilitates the processing of health information and claims from a nonstandard to a standard format.

Continuity of Care

Documenting patient care services so that others who treat the patient have a source of information on which to base additional care and treatment.

CPT

Coding system used by physicians and outpatient health care settings to assign CPT codes for reporting procedures and services on health insurance claims.

Demographic Data

Patient identification information that is collected according to facility policy.

Downcoding

Routinely assigning lower-level CPT codes as a convenience instead of reviewing patient record documentation and the coding manual the proper code to be reported.

Electronic Health Record

Collection of patient information documented by a number of providers at one or more facilities regarding one patient.

Electronic Medical Record

Created on a computer, using a keyboard, a mouse, an optical pen device, a voice recognition system, a scanner or a touch screen. records are created using vendor software, which also assists in provider decision making regarding patient care and treatment.

Encoding

Process of standardizing data by assigning numeric values to text or other information.

Healthcare Common Procedure Coding System (HCPCS)

5 digit CPT codes developed and published by the American Medical Association

Health Insurance Portability Accountability Act of 1996 (HIPAA)

Provisions that protect the security and privacy and confidentiality of health information.

Jamming

Routinely assigning an Unspecified ICD9 or 10 disease code instead of reviewing the coding manual to select the appropriate code number.

Medical Necessity

Determination that a service or procedure rendered is reasonable and necessary for the diagnosis or treatment of an illness or injury.

Objective

Observations about the patient, such as physical findings or lab results

overcoding

reporting codes for signs and symptoms associated, in addition to an established diagnosis code.

Plan

Diagnostic, therapeutic, and education plans to resolve the problem.

Problem-Oriented Record Charting

Systematic method of documentation that consists of four components: Database, Problem List, Initial Plan / Plan of Care, and Progress Notes.

Source-Oriented Record

Report organized according to documentation source, each of which is located in a labeled section of the record.

Subjective

A patient's statement about how they feel or family history.

Third-party Administrator

Entity that processes health care claims and performs related business functions for a health plan.

Third-party Payer

Insurance companies.

Unbundling

The process of coding multiple codes to describe multiple services instead of using one code.

Upcoding

Assignment of an ICD-10-CM diagnosis code that does not match patient record documentation for the purpose of illegal increasing reimbursement.

Certified Professional Coder

CPC

American Academy of Professional Coders AAPC

CPC, CPC A, CPC H, CIRCC