Mod 5: med ins coding procedures

what term defines a malignant neoplasm as being absent invasion of surrounding tissues

in situ

reimbursement

to make repayment from expense or loss incurred

medically necessary

accept healthcare services appropriate for the evaluation and treatment of a disease,condition,illness, or injury and consistent with the applicable standard of care

abstract

collection important information from the health record

specificity

the quality or state of being specific

etiology

the study of the causes or origin of diseases

how many characters are used for an ICD-10-CM

3-7

in ICD10-CM codes longer than 3 characters always have a decimal point between the

3rd and 4th characters

a…note is an instructional notation that indicates the underlying condition

code first

the abbreviation that means unspecified

NOS

encoder software

a tool commonly used by coders to assist in medical coding. The software performs computer aided coding to assign the most accurate code possible

……appears in bold font

Main terms

the SOAP notes system of documentation divides the info into what 4 areas?

subjective, objective, assessment, plan

SOAP note system

clinical documentation

what letter has been reserved to assign to new disease of uncertain etiology

U

the……is the determination of the disease or condition that is causing the pts signs and symptoms

diagnosis

when are updates for the ICD-10-CM publishes

yearly in on October 1st

…..modify the main term by describing different sites or etiology found intended under the main term

essential modifiers

the……also called the superbill can be viewed in the EHR or as a paper document

encounter form

if the provider has documented “rule out” in the diagnostic statement what must the MA code

signs/symptoms

….follow the main term and are enclosed in parenthesis provide supplementary words or explanatory information

nonessential modifiers

in the ICD-10-CM coding system an X is used as

a placeholder character

can the medical coder assign a code from the alphabetic index?

no