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HIM 140 Glossary
A-C
| Term | Definition |
| Abbreviation-NEC (not elsewhere classified) | means "other specified" and identifies codes that are to be assigned when information needed to assign a more specific code cannot be located in the code book |
| Abbreviation-NOS (not otherwise specified) | is equivalent of "unspecified". It identifies codes that are to be assigned when information needed to assign a more specific cod cannot be obtained from the provider |
| And | interpreted as meaning and/or when it appears in category titles and code descriptions in the Tabular List of Diseases and Tabular List of Procedures |
| Application service provider (ASP) | third-party entity that manages and distributes software-based services and solutions to customers across a wide area network (WAN) from a central data center |
| Assessment (A) | judgement, opinion, or evaluation made by the heath care provider; consider part of the problem-oriented record |
| Automated record | a type of record that is created using computer technology |
| Benign | non canceroius |
| boxed note | define terms, provide coding instruction, and list fifth digit subclassification for those categories that use the same fifth digits. |
| cross reference see | instruction afte a main term directs the coder to refer to another term in the index to disease or index to procedures to locate the code. |
| Category Code | three-digit ICD-9-CM disease code or two-digit ICD-99-CM procedure code within a section |
| Centers for Medicare & Medicaid Services (CMS) | administrative agency in the federal Department of Health & Human Services |
| Claims Examiner | (is the same as a health insurance specialist) employed by the third-party payers to review health-related claims to determine whether the costs are reasonable and medically necessary based on the patients diagnosis |
| Classification system | (is the same as coding system) organizes a medical nomenclature according to similar conditions, diseases, procedures, and services; it contains codes for each |
| Classification of drugs by AHFS List | located in ICD-9-CM Appendix C; contains the American Hospital formulary services (AHFS) list number and its ICD-9-CM equivalent code number. |
| Classification of Industrial Accidents According to Agency | located in ICD-9-CM Appendix D; based on employment injury statistics adopted by the Tenth International Conference of labor statisticians. |
| Clearinghouse | public or private entity that processes or facilitates the processing of health information and claims from a nonstandard to a standard format |
| CMS-1450 | Standard claim submitted by health care institutions to payers for inpatient and outpatient services. |
| CMS- 1500 | Standard claim submitted by physicians' offices to third-party payers. |
| Codes | Numeric and alphanumeric characters that are reported to health plans for health care reimbursement and to external agencies for data collection, in addition to being reported internally for education and research. |
| Coding | Assignment of codes to diagnoses, services, and procedures based on patient record documentation. |
| Coding specialist | Acquires a working knowledge of coding system, coding principles and rules, government regulations, and third-party payer requirement to ensure that all diagnoses, services, and procedure documented in patient records are coded accurately for reimbursement, research, and statistical purpose. |
| Coding system | Organizes a medical nomenclature according to similar conditions, diseases, procedures, and services; it contains codes for each. |
| computer base patient record (CPR) | It addresses many paper based health record problems with new capabilities to include collection of clinical , administrative, and financial info at the encounter of care, move data among providers to facilitate continuity of care. It measures clinical process improvements and outcomes, report data to public health,regulatory and accreditation agencies. Also contains alerts and remainders which enables health care providers to give better care and decrease errors. |
| Continuity of Care | Documenting patient care services so other providers who treat the patient has a source of information on which to base further treatment and care |
| Current Procedural Terminology | The classification of procedures and services, and is used by physicians and health care settings |
| Cross Reference see also | See also instruction is located after a main term or subterm in the index and directs the coder to another term (or subterm) that may provide additional useful index entries. If the original main term (or subterm) provides the correct code, then the see also instruction does not have to be followed. |
| Cross Reference see condition | This instruction directs the coder to the main term for a condition found in the Index to Diseases. The see condition is only found in the Index to Disease |
D-G
| Term | Definition |
| Database | The initial care plan and progress notes. Each problem oriented health record contains a database which contains: chief complaints, present illness. social history, diagnosis, test results, physical examinations and medical history. |
| Demographic data | Pt identification information that's collected to the facility to include patients name, date of birth, ssn, address, emergency contacts insurance info etc. This collection of info may vary between facilities. |
| Diagnostic/management plans | One of the three categories that consist of the POR problem list. The diagnostic/management plan assist in management of the condition. |
| Discharge note | Located in the progress note section of the POR to summarize the patient's care, treatment, response to care and condition upon discharge.All problems are documented here |
| Due to | Is located in the Index to Diseases as a subterm that is listed in alphabetical order. It indicates the presence of a cause and effect relationship between two conditions. When the Index fo Diseases includes due to as a subterm, the code is assigned only if the physician documented the causal relationship between the two conditions. Although the due to phrase is included in the Tabular List of Diseases code descriptions, it is not a coding instruction |
| E Codes | E codes are classifications of external causes of injury and poisonings. They are 4 digit codes that are added to another but not necessarily apart of it, to establish medical necessity or medications, E codes include environment events such as vehicluar accidents,machinery or other injuries. |
| Eponym | Eponyms are diseases or syndromes that are named for people. |
| Essential Modifier | see subterm (which says qualifying word listed below the main term in the ICD-9-CM Index to Diseases; list alternate sites, etiology or clinical status. |
| Etiology | cause of disease |
| Etiology and manifestation rules - code first underlying disease | When looking up a diagnosis that has the note 'code first underlying disease', use an additional diagnosis code to list the underlying disease, and make sure it is listed first; as the cause of or contributor to the manifestation. |
| Etiology and Manifestation rules- code, if applicable, any casual condition first | In this case you would code the casual condition first then code the manifestation. |
| Etiology and Manifestation rules- in diseases classified elsewhere | These must be used in conjunction with an underlying condition code and they must be listed following the underlying condition. |
| Etiology and Manifestation rules- use additional code | This means that there is an unerlying condition that needs an additional code. |
| Excludes Notes | appears below an ICD-9-CM Tabular List of Diseases or Tabular list of Procedures code to direct the coder to another location in the tabular list to classify conditions or procedures that are excluded from the code. Depending on the coding instructions, codes for the excluded conditions or procedures may or may not be reported with the code from which the condition or procedure is excluded. |
| Format | The ICD-9-CM uses an indented format for ease of use. All index to Diseases subterms associated with an index entry's main term are indented two spaces, with any 2nd and 3rd qualifiers associated the main term further indented by two and four spaces, respectively. In addition, if an index entry requires more than one line, the additional text is printed on the next line and indented five spaces. |
H-L
| Term | Definition |
| HCPCS national codes | see HCPCS Level II (which says Coding system managed by CMS that classifies medical equipment, injectable drugs, transportation services and other services not classified by CPT. |
| Health care clearinghouse | see clearinghouse (which says: public or private entity that processes or facilitates the processing of health information and claims from a nonstandard to a standard format. |
| Healthcare Common Procedure Coding System | includes level I codes (CPT) and level II codes (HCPCS level II National codes) |
| (HCPCS) | includes level I codes (CPT) and level II codes (HCPCS level II national codes) |
| HCPCS Level II temporary codes | maintained by the CMS and other members of the HCPCS National Panel, independent of permanent level II codes, and allow payers the flexibility to establish codes that are needed beffore the next january 1 annual update. |
| Health care provider | see provider (which says: physician or other health care professional who performs procedures or provides services to patients. |
| Health data collection | performed by health care facilities to do administrative planning, to submit statistics to state and federal government agencies and other organizations, and to report health claims data to third party payers for reimbursement purposes. |
| Health Insurance Portability and Accountability Act of 1996 (HIPAA) | federal legislation that amended the Internal revenue code of 1986 to improve portability and continuity of health insurance coverage in the group and individual markets; combat waste, fraud and abuse in health insurance and health care delivery. HIPAA is intended to promote the use of medical savings accounts, improves access to long-term care services and coverage, simplify the administration of health insurance by creating unique identifiers for providers, health plans and employers; create standards for electronic health information transactions and create privacy / security standards for health information. |
| Health insurance specialist | employed by third party payers to review health-related clams to determine whether the costs are reasonable and medically necessary based on the patient's diagnosis. |
| Health Plan | Insurance company that establishes a contract to reimburse health care facilities and patients for procedures and services provided. |
| Hospitalist | Physician who is authorized to practice only in a hospital setting; some facilities also call the residents. |
| Hybrid Record | Record that consists of both paper-based and computer-generated documents. |
| ICD-9-CM Official Guidelines for Coding and Reporting | These guidelines are a set of rules that have been developed to accompany and compliment the official conventions and instructions provided within the ICD-9-CM itself. These guidelines are based on the coding and sequencing instructions in volumes I,II, and III of ICD-9-CM, but provide additional instruction. |
| In | Appears in the Index to Diseases, located in alphabetical order below the main term. To assign a code from the list of 2nd and/or 3rd qualifiers below the word in, the physician must document both conditions in the patient's record. For example, "pneumonia in candidiasis." |
| Includes note | Found in the Tabular List of Diseases or Tabular List of Procedures. Appears immediately below the codes to further define or provide examples. |
| Inclusion term | Listed below certain 4- and 5-digit codes in the Tabular List of Diseases and Tabular List of Procedures. They include conditions or procedures for which that code is to be assigned. Can be synonyms of the code title or, for "other" codes, a list of conditions assigned to that code. Includes terms that do not appear in the Tabular List. |
| Index to Diseases | An alphabetical listing of main terms or conditions printed in boldfaced type that may be expressed as nouns, adjectives, or eponyms |
| Index to Procedures and Tabular List of Procedures | Included in the hospital version of comercial ICD-9-CM coding manuals as a combined alphabetical index and tabular list of inpatient procedures and services. |
| Indexed | Identified according to a unique identification number. |
| Initial Plan | Documentation of the strategy for managing patient care and actions taken to investigate the patient's condition and to treat / educate the patient; the initial plan consists of three categories: diagnostic / management plans, therapeutic plans, and patient education plans; considered part of the problem-oriented record (POR). |
| Integrated Record | Arranged in strict chronological date order (or in reverse order), which allows for observation of how the patient is progressing according to test results and how the patient responds to treatment based on test results. |
| International Classification of disease (ICD) | Published by the World Health Organization and used to classify mortality data from death certificates. |
| Internship | Student placement in a health care facility to provide on-the-job experience prior to graduation. |
| Jamming | Routinely assigning a 0 or 9 as a fourth and/or fifth place digit position of an ICD-9-CM disease code instead of reviewing the coding manual to select the appropriate code number. |
| Jukebox | Equipment that stores large numbers of optical disks, resulting in huge storage capabilities. |
| laser | device filled with a gas, liquid or solid substance that is stimulated to emit light to a specific wavelength, for the purpose of burning, cutting or disolving tissue. |
| List of Three-Digit Categories | Located in Appendix E of ICD-9-CM and contains a list of three-digit category disease codes organized beneath section headings. |
| Listserv | see online discussion board : Internet-based or e-mail discussion forum that covers a variety of topics and issues. |
M-Q
| Term | Definition | ||
| Main term | ICD-9-CM Index to Diseases (and Index to Procedures) main terms are printed in boldfaced type and followed by the code number. | ||
| Malignant | A neoplasm that is cancerous | ||
| Manifestation | The manifestation rules are that the multiple body systems, which are considered secondary, be sequenced after the underlying condition (etiology). In most cases, the manifestation code will have in its title an "in diseases classified elsewhere" note, which indicates that the manifestation codes are a component of the etiology/manifestation coding convention. A manifestation code that does not contain "in diseases classified elsewhere" in its title will contain a "use additional code" note. NOTE: Make sure you sequence the manifestation code after the etiology code. | ||
| Manual Record | Paper-based record that includes handwritten progress notes and physician orders, graphic charts, and so on. | ||
| Medical Assistant | Health care professional employed by a provider to perform administrative and clinical tasks. | ||
| Medical Management Software | Combination practice management and medical billing software that automates the daily work flow and procedures of a physician's office or clinic. | ||
| Medical Necessity | Determination that a service or procedure rendered is reasonable and necessary for the diagnosis or treatment of an illness or injury. | ||
| Medical Nomenclature | Vocabulary of clinical and medical terms (e.g., arthritis, gastritis, and pneumonia) used by health care providers to document patient care. | ||
| Medical Record | Business record for an inpatient or outpatient encounter that documents health care services provided to a patient; stores patient demographic data and documentation that supports diagnoses and justifies treatment; and contains results of treatment provided. | ||
| Medicare Prescription Drug, Improvement, and Modernization Act (MMA) | A law of the United States which was enacted in 2003. It produced the largest overhaul of Medicare in the public health program's 38-year history | ||
Morphology |
Indicates the tissue type of a neoplasm such as adenocarcinoma or sarcoma. | ||
| Morphology of Neoplasm (M codes) | are found in Appendix A of the ICD-9-CM code book and contain references to the World Health Organization publication entitled International Classification of Disease for Oncology (ICD-O). | ||
| Mortality | The state or condition of being mortal or susceptible to death. The relative frequency or measure of the number of deaths in a specific population (death rate) | ||
| National Center for Health Statistics (NCHS) | Along with the Centers for Medicare and Medi-caid Services (CMS), these are the U.S. Department of Health & Human Services (DHHS) agencies responsible for overseeing all changes and modifications to ICD-9-CM. The NCHS works with the World Health Organization (WHO) to coordinate official disease classification activities for ICD-9-CM, Volumes 1(Tabular List of Diseases) and 2(Index to Diseases). Activities include the use, interpretation and periodic revision of the classification system. | ||
| Neoplasm | New growth, or tumor, in which cell reproduction is out of control | ||
| Nonessential Modifier | qualifying word contained in parentheses after the main term in the ICD-9-CM Index to Diseases that does not have to be included in the diagnostic or procedural statement for the code number listed after the parentheses to be assigned. | ||
| Objective (O) | Observation about the patient, such as physical findings, or lab or x-ray results. [e.g., chest x-ray results] | ||
| Online Discussion Board | An Internet-based or e-mail discussion forum that covers a variety of topics and issues | ||
| Optical Disk Imaging | Provides an alternative to traditional microfilm or remote storage systems because patient records are converted to an electronic image and saved and a scanner is used to capture paper record images onto the storage media(e.g. optical disk). It allows for rapid automated retrieval of records. | ||
| Other and other specified codes | Assigned when patient record documentation provides detail for which a specific code does not exist in ICD-9-CM. The abbreviation NEC (not elsewhere classifiable) is used to direct the coder to the "other specified" code in the Tabular List of Diseases and Tabular List of procedures. | ||
| Overcoding | Reporting codes for signs and symptoms in addition to the established diagnosis code. | ||
| Physician Query Process | A process to use when a coder has questions about documented diagnoses and/or procedures/services. | ||
| Plan (P) | Diagnostic, therapeutic, and education plans to resolved the problems [e.g., patient to take Tylenol as needed for pan.] | ||
| Problem List | Acts as a table of contents for a patient record using the POR format. It is filed at the beginning of the record and contains all of the patient's problems in a numbered list. | ||
| Problem-oriented record (POR) | A type of format that consist of four components: database, problem list, initial plan and progress notes. | ||
| Progress Notes | The portion of a POR that documents each problem assigned to a patient, using the SOAP structure. | ||
| Provider | Physician or other health care professional who performs procedures or provides services to patients | ||
| Punctuation – Colon | Is used after an incomplete term in the Tabular List of Diseases and Tabular List of Procedures when one or more modifiers (additional terms) included after the colon are to be included in the diagnostic statement to classify a condition or procedure. The colon is not used in the Index to Diseases or the Index to Procedures. | ||
| Punctuation - Parenthesis | Are used in both the ICD-9-CM indexes and the tabular listings to enclose nonessential modifiers, whichar e supplementary words that may be present in or absent from the physicians's statement of a disease or preceure without affecting the code number to whihc it is assigned. | ||
| Punctuation - Slanted Brackets | Are used in the Index of Disease to identify manifestation codes. A manifestation is a conditon that occurs as the result of another condition, and manifestation codes are always reported as secondary codes. | ||
| Punctuation - Square Brackets | Are used in the Tabular List of Diseases and Tabular List of Procedures to enclose synoynms, alternatative wording and explanatory phrases. |
R-Z
| Residential Physician | A person who participates in an approved graduate medical education (GME) program. | ||
| Removal | procedures performed to eliminate tissue (for example: amputations) or take something out (such as removal of implants) | ||
| Scanner | A piece of equipment that is used to transfer paper record images into a digital medium to be stored electronically. | ||
| Section | Group of ICD-9-CM three-digit disease categories within a chapter | ||
| Sectionalized Record | This is another term for Source Oriented Record(SOR) *see below | ||
| Source Oriented Record | Reports are organized according to documentation source. Each documentation is located in a labeled section. | ||
| Subcategory code | Four-digit ICD-9-CM disease code or three-digit ICD-9-CM procedure code within a category; each subcategory code contains a decimal followed by one number | ||
| Subclassification code | Five-digit ICD-9-CM disease code or four-digit ICD-9-CM code within a subcategory; each subclassification code contains a decimal followed by two numbers | ||
| Subjectives | This represents the "S" in the SOAP structure of progress notes. It stands for the patient's statement about how he feels, including symptomatic information such as "headache". | ||
| Subterm | Qualifying word listed below the main term in the ICD-9-CM Index to Diseases; list alternate sites, etiology, or clinical status | ||
| Tables | are found in the ICD-9-CM Index to Diseases and is a way in which subterms, 2nd qualifiers, and 3rd qualifiers and their codes are organized intocolumns and rows to make it easier to select an properly code. | ||
| Tabular List of Diseases | Arranges ICD-9-CM codes and descriptions in numerical order; contains 17 chapters, 2 supplemental classifications, and 4 appendices | ||
| Teaching Hospital | A hospital engaged in an approved graduate medical education, residency program in medicine, osteopathy, dentistry or podiatry. | ||
| Teaching Physician | A physician who supervises residents during patient care. | ||
| Therapeutic Plans | One of 3 categories of initial plans serving as a table of contents for the patient record which includes specific medications, goals, procedures, therapies and treatments used to treat a patient | ||
| Third-party administrator (TPA) | entity that processes health care claims and performs related business functions for a health plan, might contract with a clearing house to standardize data for claims processing. | ||
| Third-party payer | health plan/ health insurance | ||
| Transfer note | documented when a patient is transferred to a different facility, summary of admission, current diagnoses, medical info and the reason for transfer | ||
UB-04 |
Standard claim submitted by health care institutions to payers for both inpatient and outpatient services. | ||
| Unbundling | reporting multiple codes to increase reimbursement when a single combo code should be used | ||
| Unlisted service or procedure | a service or procedure for which there is no assigned CPT or HCPCS code | ||
| Unspecified code | are assigned when patient record documentation provides detail for which a specific code does not exist in ICD-9-CM. | ||
| Upcoding | reporting codes that are not supported by documentation in the patient record for the purpose of increasing reimbursement | ||
| V codes | Reported for patient encounters when a circumstance other than disease or injury is documented; V codes are located in a supplementary classification in the ICD-9-CM Tabular List of Diseases | ||
| With | When the word "with" appears in the Index to Diseases or Index to Procedures, it is located immediately below the main term, not in alphabetical order. To assign a code from the list of 2nd and/or 3rd qualifiers below the word "with", the physician must document the presence of both conditions (or procedures) in the patient's record. | ||
sreehill |
Latest page update: made by sreehill
, Oct 25 2008, 1:10 AM EDT
(about this update
About This Update
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41 words added view changes - complete history) |
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