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1995 Documentation Guidelines  Code selection guidelines developed by the AMA and the Health Care Financing Administration (HCFA, now CMS) to make E/M codes more consistent.
1997 Documentation Guidelines  Refinement of 1995 Documentation Guidelines for single-specialty and multisystem exams.
abnormal finding  Out of normal range; often refers to a finding based on a laboratory or radiology test.
abuse  Action that improperly uses another person's resources.
acute  Illness or condition with severe symptoms and short duration; can also refer to a sudden exacerbation of a chronic condition.
addenda  Updates to the ICD-9-CM diagnostic coding system.
add-on code  CPT code preceded by + that is always performed along with another primary procedure and that is reported with the primary code.
administration  Means or method by which a drug or chemical is introduced into the body.
admitting physician  Physician who orders the patient to be admitted to the hospital.
advance beneficiary notice (ABN)  Medicare form used to inform a patient that a service, item, or supply is not likely to be reimbursed by the Medicare program.
AHA Coding Clinic® for ICD-9-CM  Quarterly publication of the American Hospital Association (AHA) that offers coding advice, guidelines, and practical information and that gives correct code assignments for new diseases and technologies.
AHIMA  See American Health Information Management Association.
Alphabetic Index  ICD-9-CM section that contains an index of the disease descriptions in the Tabular List, an index of drugs and chemicals that cause poisoning in table format, and an index of external causes of injury, such as accidents; officially Volume 2, but often appears first in the ICD-9-CM book.
Alphabetic Index and Tabular List of Procedures (Volume 3)  The HIPAA-mandated inpatient procedure code set.
Alphabetic Index to Diseases and Injuries  A main section of the ICD-9-CM Alphabetic Index that contains main terms used to classify diseases.
Alphabetic Index to External Causes of Disease and Injury  A section of the ICD-9-CM Alphabetic Index that includes terms that identify causes and circumstances of injuries, poisonings, and adverse effects.
ambulatory  Able to be treated as an out-patient; not bedridden.
Ambulatory Payment Classifications (APC)  Prospective payment system used by Medicare for reimbursement of hospital outpatient services.
ambulatory surgery  Services provided on an outpatient basis.
American Academy of Professional Coders (AAPC)  National association that fosters the establishment and maintenance of professional, ethical, educational, and certification standards for medical coding.
American Health Information Management Association (AHIMA)  National association of health information management professionals that promotes valid, accessible, yet confidential health information.
American Hospital Association (AHA)  National organization that represents all types of hospitals, health care networks, and their patients and communities; advocates for members in national health policy development, legislative and regulatory debates, and judicial matters.
American Medical Association (AMA)  Member organization for physicians that aims to promote the art and science of medicine, improve public health, and promote ethical, educational, and clinical standards for the medical profession; maintains the CPT code set.
American Society of Anesthesiologists  Professional organization of anesthesiologists that publishes the annual Relative Value Guide.
analgesia  Absence of pain by use of a medication or agent without loss of consciousness.
analgesic  Medication or agent that reduces pain or inhibits the ability to feel pain without loss of consciousness.
analyte  A chemical or substance being measured or analyzed.
ancillary services  Services provided by a laboratory, radiology facility, pharmacy, pathology facility, physical therapy facility, or speech therapy facility.
anesthesia  The loss of the ability to feel pain caused by the administration of a drug or other medical intervention; partial or complete loss of sensation with or without loss of consciousness.
anesthesia modifiers  HCPCS Level II modifiers that identify the provider of anesthesia services.
anesthesiologist  Physician who specializes in providing anesthesia and pain management services.
anesthesiology  Practice of medicine dealing with providing anesthesia and maintaining respiratory and cardiac functions and pain relief during surgical procedures.
anesthetist  Critical care nurse with additional training in anesthesiology; also known as CRNA (certified registered nurse anesthetist).
anteroposterior  From front to back.
assay  To test drug purity or the drug's ability to be absorbed by the body.
attending physician  Physician responsible for patient care during hospitalization.
authorization  (1) Document signed by a patient to permit release of particular medical information under stated specific conditions. (2) A health plan's system of approving payment of benefits for services that satisfy the plan's requirements for coverage.
automated  Performed using a machine or computer (such as an automated lab test).
biofeedback  Treatment modality in which people are trained to improve their current state of health by recognizing signals from their own bodies.
braces  ICD-9-CM punctuation mark used to enclose a series of terms, each of which is modified by the statement to the right of the brace. The terms to both the left and the right of the brace must be present in order to assign the code.
brachytherapy  Internal radiation therapy that involves inserting a radioactive substance into the patient via tubes, wires, seeds, needles, or other small containers.
brackets  ICD-9-CM punctuation mark used to enclose synonyms or explanatory notes.
bundle  Use of a single procedure code to cover a group of related procedures.
bundled code  A single procedure code that covers a group of related procedures.
capitation  Payment method in which a prepayment covers the provider's services to a plan member for a specified period of time.
cardiac catheterization  Procedure that involves passing a catheter into the heart through a vein or artery to withdraw samples of blood, measure pressures in the heart's chambers or great vessels, and inject contrast media.
carryover line  Line indented six character spaces from the term above to denote a continuation of the line in the ICD-9 CM indexes.
category  (1) In ICD-9-CM, a three-digit code used to represent a disease or injury or a two-digit code used to represent a procedure. (2) Methodology used by CPT to classify the sections of E/M services.
Category I codes  Procedure codes found in the main body of CPT (Evaluation and Management, Anesthesia, Surgery, Pathology and Laboratory, Radiology, and Medicine).
Category II codes  Optional or supplemental CPT codes that track performance measures for a medical goal such as reducing tobacco use.
Category III codes  Temporary CPT codes for emerging technology, services, and procedures that are used instead of unlisted codes when available.
catheterization  Introduction of a catheter into a vein, artery, or vessel. Catheters are thin tubes that allow drainage or injection of fluids or access by surgical instruments.
causal condition  The medical illness that brought on the documented condition.
CCI column 1/column 2 code pair edit  Medicare code edit under which CPT codes in column 2 will not be paid if reported for the same patient on the same day of service by the same provider as the column 1 code.
CCI modifier indicator  Number that shows whether the use of a modifier can bypass a CCI edit.
CCI mutually exclusive code (MEC) edit  CCI edit for codes for services that could not have reasonably been done during a single patient encounter, so both will not be paid by Medicare. Only the lower-paid code is reimbursed.
Centers for Disease Control (CDC)  Federal agency in the Department of Health and Human Services (HHS) that administers national programs for the prevention and control of communicable and vector borne diseases and for implementing programs for dealing with environmental health problems.
Centers for Medicare and Medicaid Services (CMS) (formerly HCFA)  Federal agency in the Department of Health and Human Services (HHS) that runs Medicare, Medicaid, clinical laboratories (under the CLIA program), and other government health programs. CMS promotes health care services and delivery for its beneficiaries and maintains payment processes that pay claims for covered medically necessary services only, at correct payment amounts, and in a timely manner.
certificate of medical necessity (CMN)  Signed certificate from a physician to a supplier of medical equipment that contains information about medical necessity.
certification  Process of earning a credential through a combination of education and experience followed by successful performance on a national certification exam. Certified individuals must maintain their credentials by meeting annual continuing education requirements.
chapter  A section of the ICD-9-CM Tabular List that covers diseases and injuries to a specific body system.
chapter-specific guidelines  Section 1C of the ICD-9-CM Official Guidelines for Coding and Reporting, which provides detailed instructions for coding conditions and situations that are specific to certain ICD-9-CM chapters.
charge capture  Administrative procedures that ensure that billable services are recorded and reported for payment.
charge description master (CDM) or charge master  In a facility, a computerized list of all billable services, procedures, devices, medications, and supplies that can be provided to inpatients and outpatients.
chief complaint (CC)  Patient's description of the symptoms or other reasons for seeking medical care.
chronic  Of long duration (referring to an illness or condition).
CLIA-waived test  Simple laboratory test often performed in a physician office that does not require CLIA certification to conduct; the provider must comply with the test manufacturers' exact instructions.
Clinical Laboratory Improvement Amendments (CLIA)  1988 federal law establishing standards for laboratory testing performed in hospital-based facilities, physician office laboratories, and other locations; administered by CMS.
closed procedure  Surgery that does not involve making an incision and surgically opening the site of an injury or area in need of repair or treatment.
CMS HCPCS Workgroup  Federal government committee that maintains the Level II HCPCS code set.
CMS-1491  Claim form used to submit ambulance charges to Medicare.
CMS-1500 (08/05)  Medicare-mandated paper billing form for physician services.
code first notes  ICD-9-CM instructional notations directing the coder to list particular disease codes before other codes.
code first underlying disease  ICD-9-CM instructional notation directing the coder to code both the cause and the manifestation of the disease, coding the manifestation second.
code range  Numerical code sequence list with a beginning and end point; the coder must evaluate each code in the sequence before selecting the most appropriate one.
code set  Alphabetic and/or numeric representations for data. Medical code sets are systems of medical terms that are for HIPAA transactions. Administrative (nonmedical) code sets, such as taxonomy codes and ZIP codes, are also used in HIPAA transactions.
coding  Process of assigning codes to diagnoses and procedures or services.
coexisting condition  Additional illness that either has an effect on the patient's primary illness or is also treated during the encounter.
colon  ICD-9-CM punctuation mark placed after an incomplete term that needs one or more of the modifiers that follow in order to be assigned.
combination code  Single ICD-9-CM code that classifies both the etiology and the manifestation of an illness or injury.
comorbidity  Admitted patient's coexisting condition that affects the length of the hospital stay or the course of treatment.
comorbidity/complication (CC)  A condition in addition to the basic diagnosis that is likely to cause a longer hospitalization period.
comparative or contrasting condition  Usually two separate conditions that may or may not be related to one another.
complete blood count (CBC)  The most common blood test, which includes white blood cell (WBC) count, red blood cell (RBC) count, hemoglobin, hematocrit, and platelet count.
complete lab test  The entire procedure for a lab test, including ordering the procedure or test, obtaining the sample or specimen, handling the specimen, performing the procedure or test, and analyzing and interpreting the results.
complete procedure  Procedure in which one physician provides the supervision and interpretation and also performs the actual procedure.
compliance  Actions that satisfy official guidelines and requirements.
compliance plan  Written plan created by a health care provider or health care plan for the following: the appointment of a compliance officer and committee; a code of conduct for physicians' business arrangements and employees' compliance; training plans; properly prepared and updated coding tools such as job reference aids, encounter forms, and documentation templates; rules for prompt identification and refunding of overpayments; and ongoing monitoring and auditing of claim preparation.
complication  Condition a patient develops after hospital admission that affects the recovery and discharge period.
computer assisted coding (CAC)  Use of a product that examines documents electronically and suggests codes for the medical coder to validate.
computerized axial tomography scan (CT or CAT scan)  Type of radiographic imaging that can produce cross-sectional views and three-dimensional images of soft tissues such as the internal organs as well as other parts of the body.
conscious sedation (CS)  Sedative and/or analgesic injected to relieve patient anxiety and control pain during a diagnostic or therapeutic procedure while not putting the patient to sleep.
consultation  Service performed by a physician to advise a requesting physician about a patient's condition and care; the consultant does not assume responsibility for the patient's care and must send a written report back to the requestor.
consulting physician  Physician who provides a consultation.
continuous positive airway pressure (CPAP)  Use of air pressure to push the tongue forward and open the throat to prevent sleep apnea.
contraindication  Something (such as a symptom or condition) that makes a particular treatment or procedure inadvisable.
contrast material (media)  In imaging, a substance that helps provide a clearer image. It can be administered, or introduced, with an injection, rectally, or orally.
contributory components  The last four E/M components: counseling, coordination of care, nature of the presenting problem, and time.
convention  Typographic techniques or standard practices that provide visual guidelines for understanding printed material, specifically, all punctuation, symbols, abbreviations, instructions and cross references applicable to ICD-9-CM coding.
cooperating parties  Committee of representatives from NCHS, CMS, AHIMA, and AHA that maintains the ICD-9-CM coding system.
coordination of care  The component of a physician's work that involves coordinating patient's care with other providers or agencies.
Correct Coding Initiative (CCI)  Medicare's official listing of each CPT code and what services are bundled or considered an inherent part of another service.
counseling  Physician's discussion with a patient and/or family about diagnostic results, risks and benefits of management options, instructions for management, importance of compliance, and patient and family education.
covered entity (CE)  Under HIPAA, health plan, clearinghouse, or provider that transmits any health information in electronic form in connection with a HIPAA transaction; does not specifically include workers' compensation programs, property and casualty programs, or disability insurance programs.
CPT modifier  Characters that may be appended to a CPT code to show that the base code is in some way different from the code descriptor.
critical care  Medical care provided to a patient who is critically ill or critically injured. Both the illness or injury and the care must meet the definition of critical in order for services to be reported as critical care services.
cross-references  Directions in printed material that tell a coder where to find additional information.
crosswalk  A comparison connecting two sets of items, such as a list of deleted codes and the current correct codes that replace them.
Current Dental Terminology (CDT)  HIPAA-mandated code set for procedures performed in a dental office.
Current Procedural Terminology (CPT)  HIPAA-mandated procedural code set developed and maintained by the American Medical Association.
decubitus  Lying down (refers to sores that result from long periods of lying down).
definitive diagnosis  The actual medical condition rather than its signs or symptoms.
de-identified health information  Medical data from which individual identifiers have been removed.
descriptor  Narrative part of a CPT code that identifies the procedure or service.
diagnosis code  Number assigned to a diagnosis in ICD-9-CM.
diagnosis-related group (DRG)  Medicare payment category for inpatients.
diagnostic procedure  Procedure performed to confirm a physician's working diagnosis or to assist in determining a course of treatment, but not specifically to treat the problem.
direct care  In-person, face-to-face care.
discharge summary  a progress note of a patient's condition upon discharge including disposition or arrangements (such as returning home, died, or moving to another facility).
disposition  The place or circumstance of patient discharge.
DME Medicare Administrative Contractors(DME MACs)  DME suppliers that have contracts with Medicare. Each DMEMAC covers a specific geographical region of the country and is responsible for processing durable medical equipment and prosthetic and orthotic supplies claims.
documentation  Systematic, logical, and consistent recording of a patient's health status—history, examinations, tests, results of treatments, and observations—in chronological order in a patient medical record.
dosimetry  Process of determining the amount of radiation needed during treatment.
durable medical equipment (DME)  Equipment that is primarily and customarily used to serve a medical purpose, can withstand repeated use, and is appropriate for use in the home.
Durable Medical Equipment Regional Carriers (DMERCs)  Medicare contractors that process claims for durable medical equipment, prosthetics, orthotics, and supplies.
durable medical equipment, prosthetic and orthotic supplies (DMEPOS)  DMEPOS dealers provide patients with durable medical equipment and supplies.
837I  HIPAA-mandated electronic format for claims for institutional (facility) services.
837P  HIPAA-mandated electronic format for claims for professional services.
E code  Alphanumeric ICD-9-CM code for an external cause of injury or poisoning.
E/M components  Seven factors—history, examination, medical decision making, counseling, coordination of care, nature of the presenting problem, and time—used in the selection of the level of service.
echocardiography  Ultrasound procedure used to examine the cardiac chambers and valves, the great vessels, and the pericardium.
edits  Computer processes that review submitted information against certain criteria.
electrocardiogram (ECG or EKG)  Test that records the electrical activity of the heart.
electronic health record or electronic medical record (EHR or EMR)  Collection of health information that is immediately electronically accessible by authorized users.
encoder  Computer software that assists coders in assigning medical codes.
encounter  Visit of a patient and a medical professional.
encounter form  Form that contains a provider's most frequent or major services. Also called a superbill, the services are checked off after a patient's encounter, and the form is used as a receipt and in billing.
endoscope  Viewing instrument made up of hundreds of tiny light-transmitting glass fibers bundled tightly together with a camera on the end that is inserted into a joint, a natural orifice, or an artificially created puncture site to guide surgery without large incisions.
enteral  Via the intestine (such as in the administration of substances).
eponym  Name or phrase formed from or based on a person's name; usually describes a condition or procedure associated with that person.
established patient  Patient who has received a professional service from the physician or another physician of the same specialty in the same group within three years.
ethics  Standards of conduct based on moral principles.
etiology  Cause or origin of a disease.
evaluation and management (E/M)  The part of a physician's work that includes assessing the nature of a patient's condition and devising a plan to treat it.
examination  Face-to-face inspection and investigation by a physician for the purpose of diagnosis and management.
excludes  ICD-9-CM coding convention that lists terms that are excluded or are to be coded elsewhere.
face sheet  Cover sheet of a facility's medical record that contains patient identification data.
face-to-face time  Direct time a physician spends with a patient obtaining history, examining the patient, and discussing plans.
facility  Health care institution.
facility modifier  CPT modifier used in coding hospital outpatient services and procedures.
family history  Medical events in a patient's family.
Federal Register  Official publication for federal government rules, proposed rules, and notices.
fee schedule  List of charges for services performed.
fee-for-service  Method of charging in which a provider's payment is based on each service performed.
first-listed diagnosis  ICD-9-CM code reported first, which represents the reason for the outpatient visit.
fluoroscopy  Imaging technique that uses a continuous low-level X-ray beam to view the body in motion.
Food and Drug Administration (FDA)  Federal agency that protects against public health hazards by ensuring the safety and in most cases the quality and effectiveness of products and services.
fraud  Intentional deceptive act to obtain a benefit.
freestanding facility  Hospital-owned medical center that provides outpatient services.
frontal  Facing forward.
general anesthesia  Anesthesia that renders the patient unconscious, pain-free, and pharmacologically paralyzed for the entire surgical procedure. Constant attendance of anesthesia personnel and monitoring are required.
global period  Specific time period assigned by a payer to a CPT code that groups payment for any services provided to a patient relative to the surgical procedure performed. Time frames range from ten to ninety days surrounding a procedure.
global surgery days  Global period surrounding surgery during which a single fee is paid for all related services furnished by the surgeon before, during, and after the procedure.
grouper  Software used to assign DRGs based on inpatients' diagnoses and procedures during hospitalization.
HCFA  See Centers for Medicare and Medicaid Services.
HCPCS Level I  CPT codes used to report physician services.
HCPCS Level II  Coding system for identifying medical services and supplies for government payers.
HCPCS modifiers  Modifiers required on claims for government payers such as Medicare.
health care claim  Electronic transaction or a paper document filed with a health plan to receive benefits.
health information management (HIM)  Hospital department that organizes and maintains patient medical records; also profession devoted to managing, analyzing, and utilizing data vital for patient care and making the data accessible to health care providers.
Health Insurance Portability and Accountability Act (HIPAA) of 1996  Federal act that sets forth guidelines for standardizing the electronic data interchange of administrative and financial transactions, exposing fraud and abuse in government programs, and protecting the security and privacy of health information.
health plan  Under HIPAA, an individual or group plan that either provides or pays for the cost of medical care; group health plan, health insurance issuer, health maintenance organization, Medicare, Medicaid, TRICARE, and other government and nongovernmental plan.
Healthcare Common Procedure Coding System (HCPCS)  Two-level coding system comprising CPT procedure codes and the HCPCS supply code set.
hemodialysis  Dialysis in which blood is circulated through an artificial kidney machine to be cleaned.
HIPAA Electronic Health Care Transactions and Code Sets (TCS)  HIPAA rule governing the electronic exchange of health information.
HIPAA Privacy Rule  Law that regulates the use and disclosure of patients' protected health information (PHI).
HIPAA Security Rule  Law that requires covered entities to establish administrative, physical, and technical safeguards to protect the confidentiality, integrity, and availability of health information.
history  Subjective information about illness and symptoms provided by a patient to a physician.
history codes  ICD-9-CM V codes that represent past conditions or status affecting medical care.
history of present illness  Documentation of a patient's response to a physician's questions about the patient's chief complaint.
Hospital Outpatient Prospective Payment System (HOPPS)  See Outpatient Prospective Payment System.
hospital-based facility  Health care outpatient facility owned by a hospital.
hospital-based outpatient services  Services provided by a hospital in which the patient is not formally admitted (such as in an emergency room, an ambulatory surgery center, or for outpatient testing).
hybrid record  Medical record that is made up of both electronic and paper documents.
ICD-10-CM  International Classification of Diseases, Tenth Revision, Clinical Modification.
ICD-9-CM  See International Classification of Diseases, Ninth Revision, Clinical Modification.
ICD-9-CM Alphabetic Index and Tabular List of Procedures (Volume 3)  Official title of Volume 3 of ICD-9-CM.
ICD-9-CM Alphabetic Index to Disease and Injuries (Volume 2)  Official title of Volume 2 of ICD-9-CM.
ICD-9-CM Coordination and Maintenance Committee  Federal group that considers and adopts changes to the ICD-9-CM code set.
ICD-9-CM Official Guidelines for Coding and Reporting  Written by NCHS and CMS and approved by the cooperating parties, it provides rules for selecting and sequencing diagnosis codes in both the inpatient and the outpatient environments.
ICD-9-CM Tabular List of Disease and Injuries (Volume 1)  Official title of Volume 1 of ICD-9-CM.
ill-defined condition  Medical condition that is vague and is often described by a sign or symptom.
immunotherapy  Process by which an allergic patient can become desensitized to antigens that trigger allergic responses.
impending  Medical condition that is considered as threatened at the time of discharge.
incidental procedure  Related procedure that is performed with a more complex primary procedure at an operative session and that would not usually be reported alone.
includes  ICD-9-CM coding convention that further defines or gives examples of terms that are included in a code or code section.
informed consent  Process by which a patient authorizes medical treatment after discussion with a physician about the nature, indications, benefits, and risks of a recommended treatment.
inhalant (INH)  Substance introduced or administered into the body by inhaling it through the nose or mouth.
injection (INJ)  Introduction or administration of a substance into the body via a needle.
inpatient  Person admitted to a medical facility for services that require an overnight stay.
Inpatient Prospective Payment System (IPPS)  Medicare payment system for hospitals and other inpatient facilities.
integral  In diagnosis coding, a symptom that is part of the process of an underlying disease.
International Classification of Diseases Adapted for Indexing of Hospital Records and Operation Classification (ICDA)  Diagnosis classification system used before ICD-9-CM.
International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM)  HIPAA-mandated standardized code set for diseases and injuries developed by the World Health Organization and modified for use in the United States.
interventional radiology  Radiology subspecialty that uses CT, ultrasound, and fluoroscopy to guide procedures such as percutaneous stent placement, biopsy, and catheterization.
intra-arterial or intra-arterially (IA)  Administered directly into an artery.
intramuscular (IM)  Administered directly into the muscle.
intrathecal (IT)  Administered directly into the spinal canal.
intravenous (IV)  Administered directly into a vein.
The Joint Commission  Formerly called the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), an organization that reviews hospitals, other organizations and programs for accreditation"?
key components  The essential parts of an E/M service, including history, examination, and medical decision making.
late effect  Condition that remains after an acute illness or injury has completed its course.
lateral  At the side (the view of a body part being examined).
LCD  See local coverage determination.
Level I  Current Procedural Terminology (CPT), one of the two main parts of the HCPCS code set.
Level II  Coding system that covers products, supplies, and services not included in the CPT codes; one of the two main parts of the HCPCS code set.
level of service (LOS)  One of four types of E/M services provided by a physician: problem-focused (PF), expanded problem-focused (EPF), detailed (DET), or comprehensive (COMP).
local anesthesia  Anesthesia administered by injection, topical anesthesia, or spray to a very specific body area.
local coverage determination (LCD)  Notice sent to providers with detailed and updated information about the coding and medical necessity of a specific Medicare service.
lozenge  ICD-9-CM symbol denoting a code unique to ICD-9-CM and not part of ICD-9.
magnetic resonance imaging (MRI)  Type of imaging that uses radio frequency waves and a strong magnetic field rather than X-rays to provide detailed pictures of internal organs and tissues.
main term  Word in boldface type that denotes a disease, injury, or condition in the ICD-9-CM Alphabetic Index.
major CC (MCC)  Secondary diagnosis classified by the IPPS as severe when assigning the DRG.
mammography  Low-dose X-ray system for the examination of breasts.
mandatory multiple coding  Single condition that must be represented by two or more codes.
manifestation  Characteristic sign or symptom of a disease.
manual  Without the use of machines (such as performing a laboratory test and analyzing the specimen without the use of a machine).
medical coder  Medical office staff member with specialized training who handles the diagnostic and procedural coding of medical records.
medical coding  Process of assigning diagnosis and procedure codes to patients' records in medical documentation.
medical decision making (MDM)  Complex process that a physician uses to establish a diagnosis and determine how to treat or manage the condition.
medical insurance  Financial plan that covers the cost of hospital and medical care.
medical necessity  Payment criterion that requires medical treatments to be appropriate and to be provided in accordance with generally accepted standards of medical practice. To be medically necessary, the reported procedure or service must match the diagnosis, be provided at the appropriate level, not be elective, not be experimental, and not be performed for the convenience of the patient or the patient's family.
medical observation  Medical services for hospital outpatients that provide close monitoring before potential admission.
medical standards of care  State-specified performance measures for the delivery of health care by medical professionals.
medically unlikely edits (MUEs)  CMS unit-of-service edits that check for clerical or software-based coding or billing errors, such as anatomically related mistakes.
Medicare Carrier Manual (MCM)  Manual on coverage of and payment for services reported with HCPCS codes.
Medicare-Severity DRG (MS-DRG)  Medicare Inpatient Prospective Payment System revision that takes into account whether certain conditions were present on admission.
minimum necessary standard  Principle that individually identifiable health information should be disclosed only to the extent needed to support the purpose of the disclosure.
modality  Method, technique, or protocol used to treat or diagnose a disease or injury.
modifier  Character that is appended to a code to report special circumstances involved with a procedure or service.
monitored anesthesia care (MAC)  Heavy IV sedation administered by a CRNA or MD that is deeper than conscious IV sedation.
morbidity  Rate of incidence of disease.
mortality  Death rate.
National Center for Health Statistics (NCHS)  Division of the Centers for Disease Control that tracks health care statistics and participates as a member of the cooperating parties.
national coverage determination (NCD)  Policy stating whether and under what circumstances a service is covered by the Medicare program.
negligence  Failure to perform duties according to the state-required standard of care.
Neoplasm Table  Table in the ICD-9-CM Alphabetic Index that points to codes for neoplasms, referring to anatomical location and behavior.
new patient  Patient who has not received a professional service from the physician or another physician of the same specialty in the same group within a three-year period.
nonoutpatient  Inpatient.
nonscheduled admission  admission to a hospital without prior arrangements (as from the ED).
not elsewhere classified (NEC)  ICD-9-CM abbreviation indicating the code to be used when an illness or condition cannot be placed in any other category.
not otherwise specified (NOS)  ICD-9-CM abbreviation indicating the code to be used when no information is available for assigning a more specific code; unspecified.
notes  Explanations located throughout all volumes of ICD-9-CM to define terms or to provide coding instructions.
Notice of Exclusions from Medicare Benefits (NEMB)  CMS form—given by a participating provider to a Medicare patient before providing a noncovered service—that provides written notification that Medicare will not pay and estimates the charge for which the patient will be responsible.
nuclear medicine  Branch of medicine that uses radioactive elements for either diagnostic imaging or radiopharmacological treatment.
oblique  Slanted (view of object being X-rayed).
observation  Monitoring in a hospital to see if the patient will need to be admitted or will require further treatment.
observation unit  Hospital unit set up to treat patients on an outpatient basis. Typically, patients stay in this special unit for monitoring for eight to forty-eight hours.
Office for Civil Rights (OCR)  Federal agency that enforces the HIPAA Privacy Act.
Office of the Inspector General (OIG)  Federal agency that investigates and prosecutes fraud against government health care programs such as Medicare.
omit code  Instruction in the ICD-9-CM Alphabetic Index to Procedures instructing the coder to not report an incision performed for completion of additional surgery.
open procedure  Procedure that involves making an incision and surgically opening the body at the site of the injury or ailment.
OPPS APC status indicators  Letters assigned to each CPT/HCPCS code identifying the payment rules established by the Centers for Medicare and Medicaid Services (CMS) for that code.
other (OTH) routes  Suppository or catheter injections aside from routine methods of administration.
outpatient (OP)  Patient who receives health care in a medical setting without admission.
outpatient code editor (OCE)  Medicare computer program that checks claims from the outpatient departments of hospitals and other facilities.
outpatient procedure  Services for patients who are not formally admitted, which are usually provided in a specialty unit (such as a cardiac catheterization lab or physical therapy).
Outpatient Prospective Payment System (OPPS)  System used by Medicare to pay providers for services to patients who are not admitted.
panel  Group of lab tests commonly performed together.
parenteral  Administered into the body other than through the digestive tract.
parentheses  ICD-9-CM punctuation mark used to enclose supplemental words or nonessential modifiers. The absence or presence of terms in parentheses does not affect code assignment.
past history  Patient's personal medical history.
patient's reason for visit  Patient's stated purpose for an encounter, which is used to provide the equivalent of a principal diagnosis in the outpatient setting.
payer  Health plan or program.
payment-for-performance (P4P)  Health plan financial incentives program to encourage providers to follow recommended care management protocols.
peritoneal dialysis  Dialysis that uses a filtration process in which fluid is placed into the peritoneal cavity through a catheter and is cycled or drained several times a day, cleaning the blood inside the body rather than in a machine.
permanent codes  Type of HCPCS codes maintained by the CMS HCPCS Workgroup that are available for use and change only if a majority of Workgroup members agree.
physical status modifier  Code used in the Anesthesia Section of CPT with procedure codes to indicate the patient's health status.
place of service (POS) code  HIPAA administrative code that indicates where medical services were provided.
POA exempt from reporting  Conditions that do not require a POA (present on admission) indicator.
port  Site where the treatment beam will enter the skin and focus on a malignant area.
positron emission tomography (PET)  Type of imaging that produces high energy three-dimensional computer reconstructed images of the metabolic function of an organ such as thyroid, liver, spleen, bone, cardiovascular, or kidney.
posteroanterior  From back to front.
postoperative observation  Special services that provide close monitoring of surgical patients in a designated unit.
postoperative period  Period after surgery during which visits relating to the surgery are reimbursed (generally ten days for minor procedures and ninety days for major surgery).
present on admission (POA)  Indicator required by Medicare that identifies whether a coded condition was present at the time of hospital admission.
presenting problem  Reason for the patient's encounter with a physician, such as an injury or illness.
preventive medicine  Medical services such as annual physicals that aim to prevent disease and/or detect problems early.
primary procedure  The most comprehensive, complex, and resource-intensive procedure, which according to the ICD-9-CM Official Guidelines is listed first, before any other procedures.
principal diagnosis  Condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care.
problem-oriented  Relating to an encounter in which the patient has a condition, symptom, or diagnosis that will be evaluated or treated during the visit.
procedure code  Code that identifies medical treatment or diagnostic services.
professional  (1) Person trained (and often certified or licensed) to practice medicine or work in other areas of health care.(2) Appropriate to the standards of a profession.
professional component (PC)  The part of a charge that represents the physician's time and skill in performing the procedure.
professional service  Face-to-face service(used for E/M coding).
protected health information (PHI)  Individually identifiable health information that is transmitted or maintained by electronic media.
provider  Person or entity that supplies medical or health services and bills for oris paid for the services in the normal course of business. A provider may be a professional member of the health care team, such as a physician, or a facility, such as a hospital or skilled nursing home.
qualifying circumstance  Anesthesia services provided under particularly difficult circumstances such as extraordinary condition of the patient, notable operative conditions, and/or unusual risk factors.
query  Written communication with a physician asking for clarification of documentation to support code assignment.
radiation oncology  Subspecialty of radiology that utilizes high-energy ionizing radiation to treat malignant neoplasm sand certain nonmalignant conditions.
radiology  Subspecialty of medicine that concentrates on medical imaging to prevent, diagnose, and treat diseases and injuries.
radiology report  Written report signed by the interpreting physician that accompanies all diagnostic or therapeutic radiological services.
radiotherapy  Treatment of disease by radiation and/or X-ray.
real-time  Immediate imaging results.
red blood cell (RBC) count  Blood test for the number of red blood cells.
referral  Transfer of a patient's care from one physician to another for either a specific diagnosis or for total care.
referring physician  Physician who refers the patient to another physician for treatment.
regional anesthesia  Numbing of a region or part of the body without inducing unconsciousness.
Relative Value Guide  Annual publication of the American Society of Anesthesiologists that lists anesthesia guidelines, modifiers, and common procedures performed by anesthesiologists and elements used in calculating anesthesia fees.
release of information (ROI)  Transmission of a patient's information.
residual condition  Condition that remains after the acute phase of an illness or injury has terminated.
resource-based relative value system(RBRVS)  System of Medicare reimbursement that sets physicians' fees for providing care to Medicare patients based on the physician's work, overhead, and the cost of malpractice insurance.
revenue cycle  Process of providing services, billing, collecting payments, and using the funds for the cost of operations.
review of systems  Physician's review of the major functions of the body's systems in the examination of a patient.
roll-up rule  Payment concept that direct show to code an office visit that turns into hospital observation for a patient. The office care is coded together with the observation care, thereby being "rolled-up" into one set of codes.
S&I  See supervision and interpretation.
scheduled admission  admission to a hospital of a patient for whom prior arrangements were made.
screening procedure  Procedure performed to detect a disease or condition in the absence of signs and symptoms.
secondary diagnosis  Diagnosis that is reported in addition to a principal diagnosis; must meet the UHDDS guidelines.
secondary diagnosis code  Code that is listed after the principal diagnosis; also called "additional diagnosis code" or" other diagnosis code."
secondary procedure  Procedure that is less extensive or resource-intensive and is listed in addition to the primary procedure.
section guidelines  Notes and coding instructions that appear at the beginning of each of the six sections of Category I codes in CPT.
section mark  In ICD-9-CM, a punctuation mark located to the left of the code to signify a footnote.
semicolon  In ICD-9-CM, punctuation used to identify and divide the common portion and the unique portion of the code.
separate procedure  Status of some CPT codes indicating that the procedure can be billed only if it was performed alone, for a specific purpose, and independent of any other related service provided; the procedure is usually part of another procedure and not separately reported.
sequence  Put in order; the order in which multiple diagnoses or procedure codes are listed on health care claims.
sequenced  Ordering the codes reported.
sign  Objective indication that can be evaluated by the physician, such as weight loss.
significant procedure  Incision, excision, repair, manipulation, amputation, endoscopy, destruction, suturing, or introductions.
single proton emission computerized tomography (SPECT)  Type of diagnostic imaging that provides three-dimensional computer-reconstructed images of an organ.
social history  Patient's age, employment, marital status, and other factors relating to social environment as documented during the physician's examination.
special report  Documentation that meets the payer's requirement to describe the nature, extent, need for the procedure, time involved, effort, and equipment necessary.
specificity  Use of additional ICD-9-CMdigits to provide more detail.
specimen  Tissue submitted for individual examination and pathologic diagnosis.
spirometry  Pulmonary function test that measures volume of air in the lungs by measuring how much air is expelled from the lung and how quickly.
standby  Category of physician service meaning at the ready, referring to a physician who is asked by another physician to wait in case special services are needed, such as an obstetrician asking a pediatrician to stand by in the case of a difficult delivery.
Statistical Analysis Durable Medical Equipment Regional Carriers (SADMERC)  CMS contractors who provide assistance in determining which HCPCS codes describe DMEPOS items for Medicare billing purposes.
subcategory  In ICD-9-CM, a four-digit code.
subclassification  In ICD-9-CM, a five-digit code.
subcutaneous (SC)  Beneath the skin.
subterm  Term indented under a main term in the ICD-9-CM Alphabetic Index that modifies the disease, condition, or procedure.
supervision and interpretation (S&I)  Physician's work in supervising a technician who is performing a procedure and in preparing a report based on the findings.
supplemental classification system  Group of codes used to classify events or circumstances; they identify factors influencing health status and contact with health services (V codes) or external causes of injury and poisoning (E codes).
surgery modifier  Modifier that can be appended to a surgical procedure code only, not to an E/M code; includes HCPCS Level II anatomic modifiers.
surgical package  Services routinely carried out in conjunction with a surgical procedure, including one pre-op office visit after the decision for surgery is made, infiltration of anesthesia, the actual surgical procedure, writing orders, and typical postoperative follow-up care.
symptom  Subjective statement by the patient that cannot be confirmed during an examination, such as pain.
Table of Drugs (and Chemicals)  Reference listing of drugs and chemicals in theICD-9-CM Alphabetic Index.
Tabular List  Section of ICD-9-CM in which diagnosis codes are presented in numerical order; officially called Volume 1.
technical component (TC)  The part of the charge associated with a procedure code that reflects the technician's work and the equipment and supplies used in performing it; in contrast to the professional component.
temporary codes  HCPCS codes that can be added, changed, or deleted on a quarterly basis. Once established and approved, temporary codes are usually implemented within ninety days.
therapeutic procedure  Surgical treatment or correction of a confirmed disease, condition, or injury.
therapeutic services  Restorative procedures to repair or cure a disease or condition.
threatened  Likely to occur.
time  Length of time a physician spends with a patient; one of the contributory E/M components.
time (tm) units  Intervals of anesthesia time, ranging from ten to twenty minutes, used to calculate anesthesia reimbursement.
transitional pass-through payments  Temporary payments (in addition to the APC payment) made for certain medical devices, drugs, and biologicals provided exclusively to Medicare patients.
treatment plan.  The documented steps of patient care and treatment.
treatment, payment, and health care operations (TPO)  Under HIPAA, patients' protected health information may be shared without authorization for the purposes of treatment, payment, and operations.
UB-04 (CMS-1450)  Paper billing form completed for hospital services.
UHDDS  See Uniform Hospital Discharge Data Set.
ultrasound  Imaging technique that uses ultra-high-frequency sound waves for diagnostic scanning.
unbundle  To take apart and report codes that are included in a bundled code.
unbundling  Breaking apart an "all-inclusive "or "comprehensive package" into its component parts or less-extensive individual services.
uncertain diagnosis  Conditions documented as possible, probable, suspected, or ruled out.
unclassified HCPCS code  Code assigned to services or items without a specific Level II HCPCS code or CPT code until a new code can be implemented.
Uniform Hospital Discharge Data Set (UHDDS)  Uniform set of data definitions applied to inpatient health care settings; the minimum data set collected on each inpatient.
unit/floortime  Care provided to the patient in a facility setting (such as a hospital or nursing home), including bedside care and services, reviewing the patient's medical record, writing orders, and reviewing films or test results.
unlisted code  CPT code located in each section and subsection that ends in 9 and is used when a code does not completely describe the service provided.
unscheduled outpatient visit  Visit in which the facility is not expecting the patient, such as an emergency room encounter.
unspecified  Incompletely described condition that must be coded with an unspecified ICD code.
upcoding  Use of a procedure code that provides a higher payment than the code for the service actually provided.
use additional code  In ICD-9-CM, an instruction to assign an additional code providing more information, if known.
usual fee  Charge for a physician's particular services that is billed to most patients most of the time under typical conditions.
V code  Alphanumeric code in ICD-9-CM that identifies factors that influence health status and encounters that are not due to illness or injury.
various routes/variously, into joint, cavity tissue, or topical (VAR)  Indication that various routes are available and used for a drug, such as intra-articularly or into cavities, or topical application.
visit  Seeing a health care provider or obtaining health care services in person.
white blood cell (WBC) count  Blood test that counts the number of white blood cells.
World Health Organization (WHO)  United Nations agency concerned with global health issues; publishes revisions of the International Classification of Diseases.

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