TCC HIM Students - Recently Updated Pages

ePortfolio

cgore — Wed, 18 Nov 2009 17:41:59 CST

Creating an ePortfolio is an essential part for your future employment.
Watch this presentation to walk through setting up your electronic portfolio.

Check out this sample ePortfolio

Give us your ePortfolio site

Char	http://goreeportfolio.wetpaint.com

Access the following documents to help you start your ePortfolio:

What is an ePortfolio

Sections of an ePortfolio

Signing up for and using Scribd

HIM 175

cgore — Wed, 18 Nov 2009 16:26:26 CST

There is no abstract available for this page revision.

TCC HIM Students Home

DianeBrowning — Tue, 17 Feb 2009 19:19:13 CST

Hey I think I got it now!!!!!!!!! Yipeeeeeeeee
Hello To All,
It is Elizabeth. Here's hoping that this is not mistaken attempt at the activity...
I live in Tacoma Washington and it is finally clearing up for the morning here...
have a great day

Name	Hometown	Birth Place
Merri Van Houte	Taoma, WA	Britt, IA
Char Gore	Tacoma, WA	El Paso, TX
Lola Broussard	Tacoma WA	Beaumont, TX
Amy Teaford	Tacoma, WA	Lakewood, WA
Pat Carmack	Tacoma, WA	Augusta, GA
Susan R	Tacoma, WA	Jersey City, NJ
Jaime Clark	Poulsbo, Wa.	Bremerton, Wa.
Igor Beschieru	Tacoma, WA	Moldova
Laura Womack	Tacoma, WA	Brewster, WA
Sheryl Taylor	Olympia, WA	California
Rachael DeGarmo	Suquamish, WA	Kansas
Tina Wyatt	Ravensdale, WA	Renton, WA
Anita Tolbert	Tacoma WA	Weisbaden, Germany
Melvin Moore	Tacoma WA	Charlotte, North Carolina
Kelly Alvarez	Des Moines, WA	San Jose, CA
Jaime Scott	Auburn,WA	Phoenix, AZ
Silvia Hogan	wet palm beach, FL	Ft. Polk, LA
Sarah Bailey	Tacoma, WA	Leicester, England
Nicole Freeman	Tucson, AZ	Chandler, AZ
Haley Jauregui	Roy, WA	Tacoma, WA
Gina Shelton	Ellensburg, WA	Modesto, CA
Les Sandusky	Lakewood, WA	Windecken, FRG
Julie Ciaravella	Tacoma, WA	Alameda, CA
Geoff Cain	Tacoma, WA	Santa Maria, CA
Vicky Willis	Tacoma, WA	Pasadena, CA
Heidi Johnson	Kent, WA	Linton, ND
Juiles Smith	Federal Way, WA	Spokane, WA
Frank Rocha	Los Angeles,CA	Los Angeles,CA
Sandra Keys	Macomb, MI	Detroit, MI
Brenda Granberry	Lufkin, TX	Leesville, LA
Lemuel Harden	Tacoma, WA	Lakewood, WA
Aiisha Agustin	Tacoma, WA	Guam
Vince Ryan	Poulsbo, WA	Niagara Falls, NY
Kristina Murray	Tacoma, WA	Auburn, WA
Cara Eaton	Tacoma, WA	Levittown, NY
Amy Tevis	Chehalis, WA	Tacoma, WA
Stephanie Delegard	Tacoma, WA	Evansville, IN
Teresa Palmer	Port Orchard, WA	Paso Robles, CA
Robert Hibbs	Tacoma, WA	Everett, WA
Helen Lew	Tacoma, WA	Tacoma, WA
Jason Thrasher	Lakewood WA	Lewisport KY

Mary Vickers	Olympia, WA	Texarkana, AR
Diane Forrester	Tacoma, WA	Tacoma, WA
Kimberly Cates	Port Orchard, WA	Santa Rosa, CA
Jerri Peckham	Elma, WA	Portsmouth, VA
Elizabeth Coggin	Tacoma, Wa	Portsmouth, VA
Rose Ralson	Tacoma, WA	Seattle, WA
Cynthia Zinakova	Tacoma, WA	St. Louis, MO
Kim Lee	Federal Way, WA	Spokane, WA
Debi Watson	Tacoma ,WA	Tacoma, WA
Diane Browning	Tacoma, WA	Tacoma, WA

HIM 110

tccklee — Tue, 02 Dec 2008 13:01:55 CST

There is no abstract available for this page revision.

Books for Sale

tccklee — Tue, 02 Dec 2008 12:48:28 CST

If you have a book you want to sell please post the book here. Please list contact information such as an email address so that individuals may contact you.

170 Glossary

frocha04020 — Tue, 25 Nov 2008 02:48:05 CST

Glossary

Add your glossary terms to the table below. Make sure you are putting them in correct alpha order. This is a collborative project. At the end you will all have a printable glossary to take with you. As a group, you will want to police this glossary to make sure the definitions being inserted are correct and that things are in alphabetical order so they are easy to find.

To insert a new row in the table:

Put your cursor in the row BELOW where you want to add the new row
Right click on the table
Click - Add Row

A-C

Term

Definition

Ablation

destruction (or removal) of benign,premalignant or malignant tissue by any method

Acellular dermal replacement

Is a bioengineered artifical skin

Actinic keratosis

common sun-induced skin lesion of the epidermis that has the potential to become skin cancer

Add-on code

reported when another procedure is performed in addition to the primary procedure during the same operative session; modifier -51 (multiple procedures) is NOT used with add-on codes

Adenoids

located at the rear of the nose; contain lymphoid tissue that helps fight infections

Ambulatory Health Care

The care given to patients who are not confined to an institutional bed as inpatients at the time care is given. Ambulatory care is given and after a recovery time the patient is discharge without going to an inpatient status.It is subdivided into the care providing by freestanding medical organizations and care provided by hospital settings or at hospital direction. The key to understanding ambulatory care is that the patient travels to and from either the freestanding medical organization or to the hospital setting on the same day without being admitted as an inpatient. An example would be someone presenting at the hospital for a colonoscopy, normally this type of patient would be discharged the same day of the procedure.

Aneurysm

Bulge in an artery that can weaken the arterial wall and eventually burst, resulting in hemorrhage.

angiogenesis

growth of new capillaries

angioscopy

microscopic visualization of substances as they pass through capillaries

Anoscopy

diagnostic procedure during which anal mucosa and the lower rectum are visualized using an anoscope

Advance Beneficiary Notice (ABN)

Form completed and signed by a Medicare beneficiary each time a provider believes a normally covered service will not be covered and the provider wants to bill the beneficiary directly for the service.

Appendix A of CPT

contains a list of CPT modifiers and detailed descriptions

Appendix B of CPT

contains annual CPT coding changes that include added, deleted, and revised CPT codes; it serves as teh basis for updating interoffice documents and billing tools

Appendix G of CPT

Contains a summary of CPT codes that include moderate(conscious) and that are identified throughout CPT with a bulls-eye symbol.

Appendix H of CPT

Contains an alphabetic index of performance measures by clinical condition or topic.

Appendix I of CPT

Contains genetic testing modifiers.

Appendix J of CPT

contains an electodiagnostic medicine listing of senory,motor and mixed nerves that are reported for motor and nerve studies 95900.95903 and 95904, respectively. There is also a table that indicates the "type of study and maximum number of studies" generally performed for needle electromyogram (EMG), nerve conduction studies and other EMG studies. The AMA's CPT Changes 2006:An Insider's View calls this table a "... tool to detect outliers."

Appendix K of CPT

Contains a list of products that are pending FDA approval but that have been assigned CPT codes. In the CPT manual, these codes are preceded by the flash symbol

Appendix L of CPT

Contains a list of vascular families that is intended to assist in the selection of first-, second-,third- and beyond third order branch arteries.

Arteriovenous fistula

Abnormal passageway between an artery and a vein, which allows blood to flow directly into a vein.

Arthoscopy

Visual examination of the inside of a joint

Arthrodesis

Surgical fixation of a joint.

Artificial ankylosis

Same as arthrodesis, surgical fixation of a joint.

Arytenoidectomy

Excision of an arytenoid cartilage, which is located in the bilateral vocal fold.

Arytenoidopexy

surgical fixation of arytenoidal cartilage and/or surrounding muscles. It is done to improve a patient's breathing.

Augmentation

process of enlarging or increasing

Auricle

the projecting shell-like structure on the side of the head constituing the external ear; also, called pinna.

Autogenous

Originating in the patient's body

Autograft

transplantation of tissue from the same individual

Benign

a not malgnant tumor,which does not invade surrounding tissues or spread to other parts of the body.

Bipolar cautery

Technique that uses an electric current that flows from one tip or the forceps to the other and does not require a grounding pad.

Blepharoplasty

Any surgical repair of an eyelid.

Blood

tissue that consists of plasma, red blood cells, white blood cells, and platelets (or thrombocytes)

Bone Marrow

spongy material that fills large bones cavities; consists of red marrow and yellow marrow

Bone marrow aspiration

a procedure in which marrow tissue is obtained by application of suction through a needle attached to a syringe.

Bone marrow biopsy

Boring a small hole into a long bone and using a large hollow needle to remove bone marrow for examination under a microscope

Bronchoscopy

examination of the bronchi through a bronchoscope

Bullet symbol (in CPT)

Located to the left of a code number, this identifies new procedures and services added to CPT.

Bull's-eye symbol (in CPT)

This indicates a procedure that includes moderate (conscious) sedation; Appendix G of the CPT lists all codes with the bull's-eye symbol.

Bunion

caused by bone inflammation and swelling and results in the medial deviation and axial rotation of the first metatarsophalangeal (MTP) joint.

Cancer Staging

determination that cancer has or has not spread anatomically from its point of origin.

Cardiac ablation

stops atrial or ventricular fibrilation by using radio frequency waves (modified electrical energy) to create small scars on the heart's surface.

Cardiac valves

flap of tissue that keeps blood flowing in one direction to allow for the efficient one-way flow of blood through the hearts chambers

Category 1 codes in CPT

Procedures/services identified by a five-digit CPT code and descriptor nomenclature; these are codes traditionally associated with CPT and organized into six sections.

Category II codes

These are optional CPT "performance measurements" tracking code that is assigned an alphanumeric identifier with a letter in the last field; this type of code is located after the CPT Medicine section.

Category III codes

"Emerging technology" temporary CPT code assigned for data collection purposes that are assigned an alphanumeric identifier with a letter in the last field; this type of code is located after the Medicine section, and it will be archieved after five years if it is not accepted for placement within Categrry I section of CPT

Cellulitis

A spreading bacterial infection of the skin and subcutaneous tissues, usually caused by streptococcal or staphococcal infections in adults.

Certificate of Medical Necessity (CMN)

Prescription for durable medical equipment, services, and supplies.

Cheiloplasty

plastic surgery of the lips

Chemical peel

Use of chemical agents to remove wrinkles and abnormal pigmentation.

Chemosurgery

The use of chemicals to destroy diseased tissue, such as is used for skin cancer.

Cholecystectomy

surgical removal of the gallbladder

Chyle

Digestive fluid that contains proteins and fats.

Closed Fracture Treatment

Fracture site that is not surgically opened or exposed.

Closed Laparoscopy

Insufflation of the abdominal cavity using a percutaneously placed needle; performed to examine peritoneal contents using a laparoscope.

Cold biopsy forceps

technique that does not use electrocoagulation; the polyp is simply pulled from the colon wall

Colectomy

removal of part or all of the large intestine

Colostomy

removal of a portion of colon or rectum' remaining colon is broughtto the abdominal wall

commissurotomy

narrowed valve leaflets are widened by carefully opening the fused leaflets with a scalpel

Complex Fistulectomy

excision of multiple fistulas.

Complex repair

Requiring more than a layered closure. For example, revision, debridement, creation of a defect, or preparation of the site.

composite graft

vein and synthetic graft material or segments of veins from two or more locations.

Comprehensive/component edits

These are code pairs that should not be billed together because one service inherently includes the other.

Conscious sedation

Moderate (conscious) sedation or analgesia that results in a drug-induced depression of consciousness.

Coronary artery by pass graft (CABG)

A procedure performed to improve the flow of blood to the heart.

Coronary endarterectomy

removal of the inner layer of coronary arteries that contain cholesterol plaques

Continent ileostomy

Surgical variation of an ileostomy where a reservoir pouch is created inside the abdoment using a portion of the terminal ileum, a valve is constructed in the puch, and the stoma is brought through the abdominal wall.

Cross-over vein graft

making an incision to expose the vein's incompetent valve, dividing that section of the vein and connecting it to a nearby vein that has functioning valves.

Cryosurgery

An application of extreme cold, such as liquid nitrogen, to destroy abnormal tissue cells, such as warts or small skin tumors.

Cutdown

1.the surgical insertion of a catheter into a vein, as for the administration of intravenous medication.2. reduction, or decrease.

Cystometrogram

records urinary bladder pressure at various volumes; useful in diagnosing bladder outlet obstruction and other voiding dysfunctions

Cystourethroscopy

Allows for the direct visual examination of the urinary bladder and urethra.

D-G

*Term*	*Definition*
Decubitus ulcer	An ulceration of the skin and the underlying tissue that occurs over a bony prominence.
Destruction	Ablation of benign, premalignant,or malignant tissues by any method.
Diagnostic endoscopy	Use of instrumentation for surgical visualization to determine extent of disease.
Diagnostic Procedure	Laboratgory, radiographic, and other tests performed to evaluatge the patient's complaints or symptoms and to establish the diagnosis.
Digestive system	Begins at the mouth and extends to the anus.
Diaphragm	thin muscle below the heart and lungs that separates the chest from the abdomen
Diverticula	small pouches (herniations) in the colon that bulge outward through weak spots
Diverticulosis	presence of diverticula in the mucosa and submucosal, through or between fibers of the colon's major muscle layer.
DME MAC Medical Review Policies	DMEPOS claims are submitted to the DME Medicare administration Contractors(MAC) that were awarded contracts by CMS. Each DME MAC covers a specific geographic region of the country and is responsible for processing DMEPOS claims for its specific region.
Durable medical equipment, prosthetics, orthotics and supplies (DMEPOS)	Items used by a patient such as artificial limbs, braces, surgical dressings and wheelchairs. They are items that can generally be used more than once, are used for medical purposes, in a patient's home, and would not be used if the patient were not ill or injured.

DMEPOS dealer	A DMEPOS dealer supplies patients with DME, and reports HCPCS level II codes to identify equipment reported on claims submitted to insurers.
direct laryngoscopy	insertion of a flexible or rigid laryngoscope to visualize throat structures.
dislocation	total displacement of a bone from its joint
Dual Chamber	Contains two electrodes; one is placed in the right atrium, and the other is placed in the right ventricle
Electrophysiology	study of heart arrythmias
Electrosurgery	the use of an electrical device to destroy abnormal tissue
embolus	blood clot that circulates throughout the bloodstream
Endocardium	Inner lining of the heart.
Endorectal pull-through(ileoanal anastomosis)	common alternative to conventional ileostomy, and is not considered an ostomy because there is no stoma
Endoscopic Retrograde Cholangiopancreatography (ERCP)	Passing and endoscope through the esophagus, stomach, and duodenum to the ducts of the biliary tree and pancreas.

esophagogastroscopy	direct visualization of the esophagus and the stomach
Enterectomy	Resection of small bowel segments.
Enterolysis	freeing of intestinal adhesions
Esophagpgastroduodenoscopy EGD	Use of a fiberoptic endoscope to visualize the esophagus, stomach and proximal duodenum.


Excisional biopsy	removal of a lump or suspicious area in its entirety
Embolectomy	surgical removal of an embolus
Extensor tendons	Tendons that serve to straightens the fingers.
External fixation device	hardware inserted through bone and skin that is held rigid with cross braces outside of the body; it is always removed after the fracture has healed
Femur	long bone of the thigh, articulates with the hip bone, tibia and patella
Fine-needle aspiration (FNA)	Involves the removal of fluid from a cyst or cells from a solid mass. Suction is applied as the needle is withdrawn to obtain strands of single cells for cytologic diagnosis.
First order vessels	extend as primary arterial branches from the aorta


Flail chest	the loss of stability of the thoracic cage following multiple fractures of the ribs with or without accompanying fracture of the sternum.
Flexor tendons

Forbidden (or prohibitory) symbol	symbol (a circle with a front slash inside) located to the left of the CPT codes that identify codes exempt from modifier -51
Free skin Graft	Completely seperated from the donor site before being transferred to the recipient site.
Full-thickness graft	removal (harvesting) of epidermis and dermis
Functional modifier	pricing modifier that a third-party payer considers when determining reimbursement
Gastrectomy	removal of all or a portion of the stomach
Global period	Postoperative catergory for major or minor surgeries 0 to 90 days for postoperative care
Guidelines	define terms and explain the assignment of codes for procedures and services located in a specific section of CPT
Graft	procedures involve moving healthy tissue from one site to another to replace diseased or defective tissue.

H-L

*Term*	*Definition*
Harvesting	to obtain samples or remove bacteria or other microorganism from a culture. removal of donor organs for transplantation
HCPCS level I	Codes which are composed of AMA's Current Procedural Terminology (CPT) codes and modifers.

HCPCS level II modifiers	two-digit alpha or alphanumeric codes added to any HCPCS level I (CPT) or II (national) code to provide additional information about the product or service reported

HCPCS level II permanent national codes	maintained by the HCPCS National Panel which it makes their decisions about addition, revisions, and deletions of codes.
HCPCS level II temporary codes	HCPCS Level II temporary codes are maintained by 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 before the next January 1 annual update.
Heart murmur	extra heart sound
Hemic system	Blood- producing system.
Hepatotomy	Open dranage of abscess or cyst.
Hernia	protusion of internal organs through a weakening in the musculature

Hot biopsy Forceps	technique that uses tweezer-like forceps connected to a monopolar electrocautery unit and a grounding pad to remove lesions or polyps.
Horizontal triangles	used to indicate new and revised text
Ileostomy	Removal of the colon and rectum with the small intestines brought to the abdominal wall.
Incision	a cut made with a knife, electrosurgical unit or laser especially for surgical purposes (eg body tissue)
Incision and drainage (I&D)	(I&D) is a form of tissue removal that involves cutting open a lesion (abnormal tissue, such as an abscess) and draining its contents (e.g., pus) [I am not sure who did this definition, but thanks! This one was actually assigned to me, but when I arrived her to complete it, it was already done for me! -Nicole Freeman]

Immobilize	secure bone in a fixed position.
Inferred words	used to save space in the CPT index when referrencing subterms
J-pouch (see also) ileoanal anastomosis	Common alternative to conventional ileostopmy, and it is not considered an ostomy because there is not stoma.


Informational modifiers	clarify aspects of the procedure or service provided for the payer
Intermediate repairs	Wound repair where one of the deeper layers of subcutaneous tissue and fascia are involved.
Kidney	filters and cleans blood, producing urine that carries waste
Knee	"Hinged" joint comprosed of bones, cartilage, ligaments, and tendons.
Lapascopy	Examination of the peritoneal contents using a laparoscope that is inserted through the abdoninal wall.
laryngoscopy	visualization of the back of the throat including the larynx and vocal cords
larynx	voice box
Laser-assisted uvulopalatoplasty	procedure that uses a laser technique to remove tissue from the uvula, soft palate, and pharynx.
laser technique	Technique that is most suitable for treatment of rectal lesions and uses a waveguide to deliver the laser beam through the endoscope to the lesion
Lithotripsy	See percutaneous lithotomy.

Lobectomy	Removal of a single lobe of the lung
Local Coverage Determinations (LCDs)	LCD's define coverage criteria, payment rules, adn documentation required as applied to DMEPOS claims processed by DME MACs for frequently ordered DMEPOS equipment, services, and supplied; formerly called local medical review policies (LMRPs).
Lumpectomy	partial mastectomy

Luxation	displacement or organs or articular surfaces; complete discoloration of a joint
Lymph	clear fluid that contains chyle, some red blood cells, and lymphocytes, which help fight infection and disease
Lymph nodes	the bean-shaped masses of lymphatic tissues that help to protect against infections, also called lymph glands.
lymphatic system	consists of the spleen, thymus, tonsils, adenoids, vessels that carry lymph and lymph nodes

M-Q

Medicare Carriers Manual (MAC)

provides direction about services and procedures to be reimbursed by the MAC (Medicare Administrative Contractor)

Manipulation

realignment of bones.

malignant

(Sorry could not get this row in the right spot!) malignant is cancerous

Mastectomy, modified radical

Is a total mastectomy that includes removal of the breast and nipple, axillary lymph nodes, and pectoralis minor muscle

Mastectomy, radical

Total mastectomy that includes removal of the breast and nipple, pectoralis muscles (major and/or minor,) axillary lymph nodes, and internal mammary lymph nodes.

Meckel's diverticulum

common congenital abnormality of the gastrointestinal tract that results in a pouch in the wall of the small bowel that contains remnants of fetal gastrointestinal tissue

Mediastinum

space in the thoracic cavity between the lungs that contain the aorta, the esophagus, the heart and other structures.

Maze procedure

Stops atrial fibrillation or atrial flutter by using incisions in heart tissue to stop abnormal heart rhythm

Microdermabrasion

Not classifed in CPT. This is a skin freshening technique used to repair facial skin that is damaged by the sun and the effects of aging. A sandblaster device is used to spray tiny cystals across the face, mixing gentle abrasion with suction to remove the outer layer of skin.

Modified maze procedure

(cardiac ablation) stops atrial or ventricular fibrillation by using radiofrequency waves (modified electrical energy) to create small scars on the heart's surface.

Moderate Sedation (conscious)

Moderate sedation or analgesia that results in a drug-induced depression of consciousness.

Mohs micrographic surgery

It is a minor surgical procedure and special method of removing skin cancer using local anesthesia. Also, it is a very precise and highly detailed technique whereby small layers of skin are sequentially removed and immediatelly examined under microscope. The name 'Mohs', this surgery got after his inventor, Dr. Frederic Mohs, who first described this technique in 1941.

Mutually excluse edits

code pairs that, for clinical reasons, are unlikely to be performed on the same patients on the same day; two different types of testing that yield equivalent results.

Myocardium

muscle layer of the heart.

National Correct Coding Initiative (NCCI)

to promote national correct coding methodologies and control improper assignment of codes that results in inappropriate reimbursement of Medicare Part B claims.

National Coverage Determination

An NCD sets forth the extent to which Medicare will cover specific services, procedures, or technologies on a national basis. Medical contractors are required to follow NCDs.

Needle core biopsy

is obtained using a hand-operated needle or stereotactic localization.

Nephrectomy

surgical removal of kidney

Nissen fundoplasty

Mobilizing the lower end of the esophagus by suturing the fundus of the stomach around the circumference of teh lower esophagus at the esoohagogastric junction.

nonselective vascular catheterization

introduction of a catheter into a vessel and then inserting the catheter into lesser- (or first) order vessels

Notes

should be considered similar to guideliness in that they give guidance , by explaining and defining the contents of susection, and individual code.

Open biopsy

can be an incisional or excisional, depending on the amount of lesion removed.

Open Fracture Treatment

Fracture site that is surgically opened or exposed so that treatment can be provided.

Open transluminal arterectomy

Insision is made in the skin overlying the artery, and the artery is punctured with a large needle.

Orthotics

branch of medicine that deals with the design and fitting of orthopedic (related to bonde disorders) devices

Oropharynx

area between the soft palate and the upper portion of the epiglottis, including the tonsils

Osteogensis

Bone growth

osteotomy

surgical incision into bone

pacemaker

regulates the patient's heartbeat to prevent arrhythmias and includes a pulse generator and electrodes

Open laparoscopy

Insufflation of the abdomen using a trocar,which is placed under direct vision (using a laparoscope) after making a small celiotomy incision.

Pacing cardioverter-defibrillator (PCD)

similar to a pacemaker in that it includes a pulse generator and electrodes, but it uses a combination of antitachycardia pacing and low-energy cardioversion or defibrillating shocks to regulate the patient's heartbeat and prevent arrhythmias.

Palatopharynogplasty

Surgical resection of xcess tissue from the uvula, sold palate, and pharynx to open the airway.

Patency

Open and unblocked status of a blood vessel or another tube in the body.

Pedicle skin graft

portion of skin graft is transferred to the recipient area and a remaining portion ( the base) is attached to the donor site so there is a vasculature and nerve supply to the recipient area.

Percutaneous lithotomy

Two-stage procedure that requires a percutaneous nephrostomy and dilation of the nephrostomy tract.

Percutaneous myocardial revascularization

catheter with a laser inside is inserted through an artery into the left ventricle of the heart

Percutaneous needle biopsy

Insertion of a long needle through the skin and into other tissue (e.g., chest wall, lung, or mediastinum) to obtain tissue for diagnostic evaluation.

Percutaneous skeletal fixation

use of an external or internal fixation device to stabilize and immobilize a fracture; types include external fixation and internal fixation

Percutaneous transluminal angioplasty (PTA)

puncturing and artery and inserting a sheath, guidewire, and guiding catheter (after removing the guidewire)

pericardium

membrane that surrounds the heart; also called pericardial sac

Percutaneous transluminal artherectomy

The management of coronary artery occlusion by any of various catheter-based techniques; a non-surgical procedure to open blocked coronary arteries by using a device on the end of a catheter to cut or shave away atherosclerotic plague.

Pericardiocentesis

insertion of a needle to withdraw fluid from the pericardial sac.

Pericardiectomy

removal of part of the pericardium (to treat chronic pericarditits)

Pericardial sac (Pericardium)

Membrane that surrounds the heart; also called pericardial sac

Peristalsis

wavelike motions that propel urine.

Peritoneoscopy

See laparoscopy

Pilonidal cyst

Entrapped epithelial tissue and hair located in the sacral area at the top of the crease between the buttocks, which can become infected.

Pleura

membrane that envelopes the lungs and lines the wall of the pleural cavity

Pleural effision

too much fluid collected in the pleural space;also called 'water in the lungs.'

Pneumocentesis

Puncture if the pleural space with a transthoracic needle to drain fluid or to obtain material for diagnostic study

Premalignant

Pertaining to tissue that is not yet malignant, but is poised to become malignant.

Pressure Ulcer

ulceration of the skin and underlying tissue that occurs over a bony prominence

Prosthetics

branch of medicine that deals with the design, production, and use of artificial bodyparts

Plus symbol

Identifies add-on codes procedures that are commonly, but not always, performed at the same time and by the same surgen as the primary procedure. [**Once again, thank you to whoever did this definition for me...it was already completed when I came to do it. -Nicole Freeman**]

Protectomy

surgical removal of the rectum

Protosigmoidoscopy

visual examination of the rectum and sigmoid colon

Pyramidal Fracture

(lefort II) surgical fracture of the midfacial skeleton at an apex near the superior aspect of the nasal bones.

Notice of Exclusion from Medicare Benifits (NEMB)

is a form completed and signed by a Medicare beneficiary before items, procedures, and services excluded from Medicare does not cover certain items and services because they do not meet the definition of a Medicare benefit or because they are specifically excluded by law.

R-Z

Term

Definition

Reconstruction

The surgical rebuilding of a body part, such as the breast or the knee joint.

Removal

procedures performed to eliminate tissue (for example: amputations) or take something out (such as removal of implants)

Reduction

realignment of bones.

Repair

Procedures performed to surgically improve improperly functioning parts of the body.

Research

(n) an investigation into a subject in order to discover or revise facts or theories
(v) to make researches or investigate carefully

Revision

surgical modification of a previous procedure or a device

Range of Codes

index code numbers for specific procedures may be represented as a single code number, a range of codes seperated by a dash, a series of codes separated by commas, or a combintion of single codes and a range of codes

Rhytidectomy

excision of section of skin to eliminate wrinkles

SADMERC

statistical analysis durable medical equipment regional carrier
assists suppliers and manufactures in determining HCPCS codes to be used.

Second-order vessels

Branches from first -order vessels

Second Stage

use of a seton to cut through the fistula; teh seton is left in place until later removal.

Segmentectomy

Removal of one segment of a lobe.

Selective vascular catheterization

insertion and manipulation or guidance of a catheter into the branches of the arterial system (other than the aorta or the vessel punctured) for the purpose of performing diagnostic or therapeutic procedures

Semicolon

; symbol used to save space in CPT code descriptions.

Separate Procedure

Cpt code descriptions that contain the term separate procedure in parentheses are commonly performed as an integral component of a total service or procedure.

Septal defect

occurs when the tissue doesn't completely close between the heart's chambers

Septum

Tissue that separates the heart's left and right sides.

Seton

Large silk suture or rubber bands.

Rhinoplasty

repair of skin defect of the nose using harvested tissue or plastic surgery to change the nose's shape

Sigmoidoscopy

visual examination of the entire rectum and sigmoid colon and may include a portion of the descending colon

Simple Closure

Same as simple repair, a one-layer closure, non-layered closure, or single-layer closure of a superficial wound involving the epidermis, dermis or subcutaneous tissues. Involves the use of staples, sutures, and/or tissue adhesives.

Simple Repair

Superficial, only simple one layer primary suturing required

Single chamber

contains a single electrode that is positioned in the heart's right atrium or right ventricle

skeletal traction

exerts a pulling force on th affected limb to realign bone or joint

Special Report

a report that must accompany the claim to describe the nature, extent, and need for the procedure or service when an unlisted procedure or service code is reported.

spleen

produces mature lymphocytes, destroys worn-out red blood cells and serves as a reservoir for blood

stab phlebectomy

excision of a segment of a vein with a pointed instrument; also called venectomy.

stabilize

secure bone in a fixed position

Staged procedure or service

additional procedure that is planned prospectively at the time of the original procedure.

Stem cells

Contained in bone marrow

Stented Valve

includes framework on which the replacement heart valve is mounted to provide support for the valve's leaflets.

Stereotactic Localization

use of specialized three-dimensional imaging to target a nonpalpable lesion

Stentless valve

an actual heart valved obtained from either a human donor (homograft) or a pig:it does not contain framework.

Subcutaneous fistulectomy

Removal of an anal fistula, without division of the sphincter muscle.

Subglottic stenosis

Narrowing of the airway below the vocal cords, adjacent to the cricoid cartilage.

Submuscular fistulectomy

Removal of an anal fistula,including division of the sphincter muscle

Subsection information

Unique instructions called notes which are located just beloe the title.

Surgical destruction

ablation (or removal) of tissues by any method, including chemical treatment, cryosurgery, electrosurgery, or laser.

Surgical endoscopy

performed when anything in addition to visualization is performed, such as the removal of a foreign body

Surgical Package

services performed that are integral to the standard of medical /surgical services, such as the cleansing, shaving, and prepping of skin ad the insertion of intravenous access for medication.

Suture

Is the surgical closure of a wound, using catgut, glue, silk tread, wire, or other materials.

sympathectomy

excision of a segment of the symphathetic nerve

Therapeutic apheresis

Removal of blood components, cells, or plasma solute and retransfusion of the remaining components into the patient.

Therapeutic surgical procedure

Performed to treat specific conditions or injuries, they include the procedure itself and normal, uncomplicated follow up.

thoracentesis

surgical puncture of the chest wall with a needle to obtain fluid from the pleural cavity

Third-order (and beyond) vessels(sorry out of order)

branch from second-order vessels

Thorascopy

the insertion of an endoscope through a very small incision in the chest wall.

thrombectomy

surgical removal of a thrombus

Thromboendarterectomy

Surgical excision of a thrombus and atherosclerotic inner lining from an obstructed artery.

Thymus

produces T lymphocytes, which are important to the body's immune function

Tibia

Larger of the two lower leg bones

Tibial Plateau

lower portion of the femur that articulates with the tibia.

Tissue-cultured autograft

it is an autograft that was supplied by the laboratory. An autograft is the transplantation of tissue from the same individual.

tonsils

located at the back of the throat; help fight infections

Total Mastectomy

Surgical removal of the entire breast, including the pectoral fascia and a sampling of axillary lymph nodes.

Trachea

Windpipe.

Tracheobronchoscopy

visual examinatino of the interior of the trachea and bronchus

Transposition of great vessels

congenital reversal of the aorta and pumonary artery.

Transitional pass-through payments

Temporary additonal payments(over and above the OPPS payments) made for certain innonvative medical devices, drugs,and biologicals provided to Medicare beneficiaries.

Transluminal angioplasty

a procedure used to widen vessels narrowed by stenoses or occlusions through or across a vessel lumen.

Transluminal atherectomy

excision of plaque from inside a blood vessel

Transmyocardial Revascularization

procedure that uses a high-powered laser to create small channels in the heart muscle to increase blood supply to the myocardium

Transurethral resection of the prostate (TURP)

Resection of the prostate gland via transurethral approach using an electrosurgical device

Transurethral ureteroscopic lithotripsy

procedure in which a cystoscope is inserted through the urethra into the bladder and a ureteroscopic is passed into the ureters

Triangle symbol

Located to the left of a code number identifies a code ddescription that has been revised.

truncus arteriosus

congenital malformation in which just one artery arises from the heart to form the aorta and pulmonary artery

Tunneled

Implanted

Unlisted procedure

A code that is assigned to a procedure that the provider performs for which there is no CPT Code.

Unlisted Service

A code that is assigned to a service that the provider performs for which there is no CPT Code.

Unlisted service or procedure

a service or procedure for which there is no assigned CPT or HCPCS code

Upper GI Endoscopy

direct visualization of the esophagus and stomach

Urethra

Muscular tube that discharges urine from the bladder to the outside fo the body.

Urinary System

Consists of the kidneys, ureters, urinary bladder and urethra.

Urinary Bladder

Hollow organ that serves as a resevoir for urine until it passes from the body (via urination).

Ureterolithotomy

surgical removal of stones from the ureter

Urethroplasty

Surgical repair of the urethra.

Uroflowmetry

measures the amount of urine that flows from the urinary bladder per second

valvular atresia

valve fails to develop properly and is completely closed at birth

Valvular heart disease

abnormality or dysfunction of one or more of the heart's four valves (aortic, mitral, pulmonary and/or tricuspid)

Valvular prolapse

Two valvular flaps do not close properly, resulting in backflow of blood.

Valvulotomy

Open heart surgery in which an incision is made into a valve to repair valvular damage

Valvular stenosis

** Sorry could not get a row to add in the correct alphabetical spot! **

narrowing of one or more of the cardiac valves

Valvular regurgitation

backflow of blood because one or more cardiac valves closes improperly

Valvuloplasty

plastic surgery to repair a valve, especially a cardiac valve, also called valvoplasty.

Vascular Family

group of vessels that is accessed by the same first-order vessel and is supplied by the same primary branch from the aorta.

Wedge resection

surgical removal of a portion of lung that is less than a segment

Venous valve transposition

surgical procedures performed to treat chronic deep venous insufficiency.

Visceral arteries

Supply blood to the intestines, liver, and spleen.

Volvulus

twisting or displacement of intestine causing obstruction

Xenograft

surgical transplantation of tissue from a different species

145 Glossary

tacomawomack — Mon, 24 Nov 2008 19:46:21 CST

Put your cursor in the row BELOW where you want to add the new row
Right click on the table
Click - Add Row

A-C

*Term*	*Definition*
Accuracy	A characteristics of data that are free from significant error, up-to-date, and representative of relevant facts.
Ambulatory Care Facilities	Facilities who give care to patients who are not confined to an institutional bed as inpatients at the time care is rendered. It is provided in an outpatient setting which can be provided by freestanding medical organizations or care can be provided in a hospital setting or at hospital direction. Examples are emergency room, outpatient departments and ambulatory surgical centers.
Autopsy Rate	The proportion or percentage of deaths in a healthcare organization that are followed by the performance of autopsy.
Average daily census	Is the mean number of hospital inpatients present in the hospital each day for a given period of time.
Average Duration of Hospitalization	Length of stay for hospital inpatients discharged during a given period of time.
Average length of stay (ALOS)	The mean length of stay for hospital inpatients discharged during a given period of time
Average Length of Stay	Average number of days that inpatients discharged during the period under consideration stayed in the hospital.
Bar Chart	A graphic technique used to display frequency distribution of nominal or ordinal data that fall into categories; also called bar graph
Bar Graph	A method used to present the frequency of data through the use of horizontal and vertical axes. Typically, the horizontal axis (x-axis) shows discrete categories, and the vertical axis (y-axis) shows the number of frequency.
Bed count	The number of inpatient beds set up and staffed for use on a given day; also called bed complement.
Bed Occupancy Ratio	The proportion of beds occupied, defined as the ratio of inpatient service days to bed count days during a specified period of time.
Bed turnover rate	The average number of times a bed changes occupants during a given period of time.
Cancer mortality rate	The proportion of patients that die from cancer


CDC Centers for Disease Control and Prevention	A group of federal agencies that oversees health promotion and disease control and prevention activities in the US.

Census	A count of a particular population
Census Day (Inpatient Service Day)	A unit of measure equivalent to the services received by one inpatient during one 24-hour period
Chronic	Of long duration.
Clean surgical case	A surgical case in which no infection existed prior to surgery
CMS (Centers for Medicare and Medicaid Services)	The division of the Department of Health and Human Services that is responsible for developing health care policy in the United States and for administering the Medicare program and the federal portion of the Medicaid program; called the Health Care Financing Administration (HCFA) prior to 2001.
Complete Master Census	A total census for a facility showing names and locations of patients present in the hospital at a particular point of time.
Concomitant	To take place at the same time as another condition
Continuous Data	Data that represent measurable quantities but are not restricted to certain specified values.
Coroner	A public officer whose principal duty is to inquire via an inquest into the cause of any death that there is reason to suppose is not due to natural causes.
Correlation	Measures the extent of a linear relationship between two variables.
Crude Death Rate	The total number of deaths in a given population for a given period of time divided by the estimated population for the same period of time.
Daily Inpatient Cenus	The number of patients who were present on a PCU at the census taking time each day and any inpatients who were both admitted after the previous census taking and discharged before the next census taking time.
Dead on arrival (DOA)
Decile	The tenth equal part of a distribution.
Descriptive statistics	Statistics that describe populations
Bed Capacity	The number of beds that a facility has been designated and constructed to house.
Disposition	The healthcare practitioner's status of the patient at discharge (outpatients). (Inpatients) A core data health element that identifies the circumstances under which the patient left the hospital.


Early Fetal Death	The death of a product of human conception that is fewer than 20 weeks gestation and 500 g or less in weight before its complete expulsion or extraction from the mother.
Encounter	The direct personal contact between a patient and a physician or other person authorized by state licensure law and, if applicable, by medical staff bylaws to order or furnish health care services of the diagnosis or treatment of the patient.

D-G

*Term*	*Definition*
Data	Raw facts and Figures
Dead on Arrival (DOA)	The condition of a patient who arrives at a healthcare facility with no signs of life and who was pronounced dead by a physician.
Decimal	Numbered or proceeding by tens; based on the number 10; expressed in or utilizing a decimal system, especially with a decimal point
Delivery	The process of delivering a live born infant or dead fetus (and placenta) by manual, insrumental or surgical means
Descriptive statistics	The statistics used to characterize or summarize given population.
Discharge	When a patient leaves the hospital after medical treatment has been completed
Discharge Days	are days complied on the patient after he or she has been discharged from the hospital.
Discharge Date (inpatient)	The year, month and day that an inpatient was formally released from the hospital and room,board. and continuous nursing services were terminated.
Discrete Data	Data that represent separate and distinct values or observations; that is, data tat contain only finite numbers and have only specified values.
Fetal Autopsy Rate
Fetal Death	The death of a product of human conception before its complete expulsion or extraction from the mother regardless the duration of pregnancy. Also referred to as still born
Fetal Autopsy Rate	The number of autopsies performed on intermediate and late fetal deaths for a given time period divided by the total number of intermediate and late fetal deaths for the same time period.
Fetal Death Rate	A proportion that compares the number of intermediate and or late fetal deaths to the total number of live births and intermediate or late fetal deaths during the same period of time.
Frequency Distribution	List of values that a variable takes in a sample.
Frequency Distribution Table	A summary of data. Frequency distribution tables can be used for both categorical and numeric variables.
Frequency Polygon	Type of line graph that represents a frequency distribution
Gross Autopsy Rate	Is the ratio during any given period of time of all inpatients autopsies to all inpatients deaths

Gross Death Rate	The number of inpatient deaths that occurred during a given time period divided by the total number of inpatient discharges, including deaths for the same period of time.

Ou
H-L

*Term*	*Definition*
Health information department	That area of an organization responsible for managing appropriate use of and access to patient-specific health information.
Histogram	A graphic technique used to display the frequency distribution of continuous data (interval or ratio data) as either numbers or percentages in a series of bars.
Home Health	Refers to medical and non-medical services provided by patients' family members at their place of residence.

Hospice	Managed Care Organization (MCO), a lodging facility or program for those with fatal illnesses
Hospitals	A healthcare entity with an organized medical staff and appropriate facilities that provide inpatient 24 hour care including sleeping accommodations and nutritional services as well as providing diagnostic and therapeutic services at all times.
Hospital Autopsy Rate	the total number of autopsies performed by a hospital pathologist for a given time period divided by the number of deaths of hospital patients (inpatients and outpatients) whose bodies were available for autopsy for the same time period.
Hospital Inpatient Autopsy	A postmortem examination performed on the body of a patient who died during an inpatient hopitalization by a hospital pathologist or a physician of the medical staff who has been delegated the responsibility.
Hospitalization	The confinement of a patient in a hospital.
Iatrogenic	Induced inadvertently by a physician or surgeon or by medical treatment or diagnostic procedures.
Indirect Obstetric Death	Death of a woman that resulted from a previously existing disease that was not due to obstetric causes, although the physiological effects of pregnancy were partially responsible for the death.
Inpatient bed count	The number of available inpatient beds, both occupied and vacant, on any given day. Also referred to as bed count
Infant mortality rate	The number of deaths of individuals under one year of age during a given time period divided by the number of live births reported for the same time period
Inferential Statistics	Inferences that are made about populations based upon the behavior of samples.
Information	Organized and classified data put into context; so-called "meaningful" data
Inpatients	A patient who is provided with room, board, and continuous general nursing services in an area of an acute care facility where patients generally stay at least overnight.
Inpatient Admission	An acute care facility's formal acceptance of a patient who is to be provided with room, board, and continuous nursing service in an area of the facility where patients generally stay at least overnight.
Inpatient Census	The count of patients present at a specific time and in a particular place.
Inpatient Service Day	A unit of measure denoting the services received by one inpatient in one 24-hour period.
Institutional death rate (Net death rate)	The total number of inpatient deaths minus the number of deaths that occured less than fourty-eight hours after admission for a given period divided by the total number of inpatient discharges minus the number of deaths that occured less than fourty-eight hours after admission for the same period of time\
inter-hospital transfer	transfers in and out of the hospital
Intermediate Fetal Death	A death of a product of human conception before its complete expulsion or extraction from the mother that is twenty completed weeks of gestation (but less than 28 weeks) and weighs 501 to 1,000 grams.
Interval data	The type of data that represents observations than can be measured on an evenly distributed scale beginning at a point other than true zero. The most important characteristic is that the intervals between values are equal. An example is time which is measured in terms of 24 hrs in a day. The time between each hr is the same (60 mins)
Late Fetal Death	The death of a product of human conception that is twenty-eight weeks or more of gestation and weighs 1,001 grams or more before its complete expulsion or extraction from the mother.
Leave of absence	The authorized absence of an inpatient from a hospital or other facility for a specified period of time occurring after admission and prior to discharge.
Line Graph	A graphic technique used to illustrate the relationship between continuous measurements; consists of a line drawn to connect a series of points on an arithmetic scale and is often used to display time trends.
LOS (length of stay)	The number of calendar days a patient stays in the hospital, from admission to discharge.

Length of stay	the number of calendar days a patient stays in the hospital, from admissions to discharge.

M-Q

*Term*	*Definition*
Maternal death	Is defined as the death of any woman from any cause related to or aggravated by pregnancy or its management (regardless of duration or site of pregnancy, but not from accidental or incidental causes).
Managed Care Organization (MCO)	Is a type of healthcare organization that delivers medical care and manages all aspects of the care or the payment for care by limiting providers of care, discounting payment to providers of care, and/or limiting access to care
Mean	A measure if central tendency that is determined by calculating the arithmetic average of the observations in frequency distribution
Median	A measure of central tendency that shows the midpoint of a frequency distribution when the observations have been arranged in order from lowest to highest.
Medical Examiner	A public officer whose principal duty is to inquire via an inquest into the cause of any death that there is reason to suppose is not due to natural causes.
Measures of central tendency	A single typical or average number that is representative of the entire collection of data or specific population. Three measures of central tendency commonly used are mean, median, and mode.
Mode	A score that happens with the greatest frequency.
Morgue	The place where the bodies of persons who have died are kept until identified and claimed by relatives or are released for burial.
Mortality	Refers to the incidence of death in a specific population. the loss of subjects during the course of a clinical research study
Necropsy	see autopsy; Postmortem examination of organs and tissues of a body to determine the cause of death of pathalogical conditions.
Neonatal Death	The death of a liveborn infant within the first the first twenty-seven days, twenty-three hours, and fifty-nine minutes following the moment of birth.
Neonatal Period	The period of an infant's life from the hour of birth through the first 27 days, 23 hours, and 59 minutes of life.
Net Autopsy Rate	Is the ratio of inpatient autopsies compared to inpatient deaths calculated by dividing the total number of inpatient autopsies performed by the hospital pathologist for a given time period by the total number in inpatient deaths minus unautopsied coroners' or medical examiners' cases for the same time period.
Newborn	An inpatient who was born in a hospital at the beginning of the current inpatient hospitalization.
Newborn Autopsy Rate	The number of autopsies performed on newborns who died during a given time period divided by the total number of newborns who died during the same time period.
Newborn Bassinet Count	The number of available hospital newborn bassinets, both occupied and vacant, on any given day.
Newborn mortality rate	Statistical tabulations for vital events related to pregancy and newborns can provide valuable information on reproductive health. The formula is: total number of newborn deaths for a period x 100 divided by total number of newborn discharges for the period
Normal Distribution of Data	Means that most of the values in a set of data are close to the "average" and relatively few values tend to one extreme or the other.
Nominal data	A type of data that represents values or observations that can be labeled or named and where the values fall into unordered categories; also caled dichotomous data



Nosocomial Infection	An infection acquired by a patient while receiving care or services in a healthcare organization; also called hospital-acquired infection.
Observation Patient	A patient who presents with a medical condition with a significant degree of instability and disability and who needs to be monitored, evaluated, and assessed to determine whether he or she should be admitted for inpatient care or discharged for care in another setting.
Occupancy Percent (Bed Occupancy Ratio)	The proportions of beds occupied, defined as the ration of inpatient service days to bed count days during a specified period of time
Occupancy Ratio (Bed Occupancy Ratio)	The proportion of beds occupied, defined as the ratio of inpatient service days to bed count days during a specified period of time -- the ration looks like this: Total inpatient service days in a period X 100 Total bed count days in the period (Bed count X Number of days in the period)
Ordinal data	A type of data that represents values or observations that can be ranked or ordered.
Outpatient	A patient who receives ambulatory care services in a hospital-based clinic or department.
Patient Day (inpatient service day)	A unit of measure equivalent to the services received by one inpatient during one 24-hour period.
Patient Care Unit (PCU)	An organizational entity of a healthcare facility organized both physically and functionally to provide care.
Percentage	A value computed on the basis of the whole divided into 100 parts.
Percent of occupancy (aka-Inpatient bed occupancy rate)	The total number of inpatient service days for a given time period divided by the total number of inpatient bed count days for the same time period.
Percentile	The value of a variable below which a certain percent of observations fall.
Perinatal Death	An all-inclusive term that refers to both stillborn infants and neonatal deaths.
Pictogram	A graphic technique in which pictures are used in the display of data
Pie chart	A graphic technique in which the proportions of a category are displayed as portions of a circle (like pieces of a pie).
Pie Graph	Also known as pie chart; a method used to present the frequency of data through the use of a circle drawn and divided into sections that correspond to the frequency in each category.
Postmortem	done, occurring, or collected after death.
Postneonatal Death	the death of a liveborn infant from twenty-eight days to the end of the first year of life (three hundred sixty-four days, 23 hours, and fifty-nine minutes from the moment of birth)
Postoperative Death Rate	The ratio of deaths within ten days after surgery to the total number of operations performed during a specified period of time
Postoperative Infection Rate	The number of infections that occur in clean surgical cases for a given time period divided by the total number of operations within the same time period.
Postpartum	Occurring after childbirth
Preexisting condition	Any injury, disease, or physical condition occurring prior to an arbitrary date.

Prepartum	Is a period of time occuring prior to childbirth
Proportion	a part, share, or number considered in comparative relation to a whole
Numerator	The part of a fraction that is above the line and signifies the number of parts of the denominator taken.

NCHS	National Center for Health Statistics
Quartile	The fourth equal part of a distribution.

R-Z

*Term*	*Definition*
Range	Distance or extent between possible extremes
Rank	This is where the observations are first arranged from highest to lowest, according to magnitude and then assigned numbers that correspond to each observation's place in the sequence
Rate	A measure used to compare an event over time; a comparison of the number of times an event did happen (numerator) with the number of times an event could have happened (denominator).
Ratio	A calculation found by dividing one quantity by another; also, a general term that can include a number of specific measures such as proportion, percentage, and rate.
Ratio data or scale	The highest level of measurement. On the ratio scale, there is a defined unit of measure, a real 0 point, and the intervals between successive vlaues are equal. ratio data may be displayed by units of equal size placed on a scale starting with 0, and thus can be manipulated mathematically. eg (0, 5, 10, 15, 20).
Recapitulation	The hypothetical occurrence in an individual organism's development of successive stages resembling the series of ancestral types from which it has descended so that the ontogeny of the individual retraces the phylogeny of its group, A Concise Summary

Semiannual	occurring every six months or twice a year.
Scatter Diagram	A graph that visually displays the linear relationships among factors.
Skewness	The horizontal stretching of a frequency distribution to one side or the other so that one tail is longer than the other.
Standard Deviation	A measure of variability that describes the deviation from the mean of frequency distribution in the orginal units of measurement; the square root of the variance.
Stillbirth	The birth of a fetus, regardless of gestational age, that shows no evidence of life (such as heartbeats or respirations) after complete expulsion or extraction from the mother during childbirth.
Surgical Operation	one or more surgical procedures performed at one time for one patient via a common approach or for a common purpose.
Surgical Procedure	Any single, separate, systematic process upon or within the body that complete in itself; is normally performed by a physician, dentist or other licensed practitioner; can be performed with or without instruments; and is performed to restore disunited or deficient parts, remove disease or injured tissues, extract foreign matter, assist in obstetrical delivery, or aid in diagnosis.
Table	An organized arrangement of data, usually in columns and rows.
Total Bed Count Days	The sum off inpatient bed count days for each of the days during a specified period of time.

Total Inpatient Service Days	The sum of all inpatient service days for each of the days during a specified period of time.
Utilization Management	A program that evaluates the healthcare facility's effeciency in providing necessary care to patients in the most effective manner.
Variability	The difference between each score and every other score in a frequency distribution.
Variables	Those things that may vary or change and therefore can be manipulated or measured.
Variance	a disagreement between two parts; the square of standard deviation
Vital Statistics	Data related to births, deaths, marriages, divorces and fetal deaths. All states have laws that require this information to be submitted to the National Vital Statistics System which is part of the CDC/National Center for Health Statistics.







Whole Numbers	The set of counting numbers or natural numbers including 0 (zero).

220 Glossary

DianeBrowning — Mon, 10 Nov 2008 23:10:13 CST

Put your cursor in the row BELOW where you want to add the new row
Right click on the table
Click - Add Row

A-C

*Term*	*Definition*
Acute Care Hospital	An acute care facility (ACF) is a hospital that provides health care services to patients who have serious, sudden, or acute illnesses or injuries and/or who need certain surgeries.
Additional diagnosis	additional conditions that affect patient care by requiring one or more of the following: clinical or therapeutic evaluation diagnostic procedures entended length of hospital stay increased nursing care &/or monitoring
Anomaly	Irregularity,. Deviation from normal.

Benign Hypertension	hypertension of prolonged or chronic duration; this type of hypertension is usually controlled by medication
Boxed Notes	Defines the terms, provides coding instructions and lists 5th digit classifications for categories that uses 5th digits.

Combination Code	Single code used to classify two diagnoses (or Procedures), a diagnosis with an associated secondary process (manifestation), or a diagnosis with an associated complication.
Comorbidity	A coexisting condition that is treated during the same encounter as or impacts the medical management of another condition.
Complete Abortion	an induced or spontaneous abortion in which all fetal and placental material has been expelled from the uterus before 20 weeks' gestation.
Complication	Conditon that develops after patient admission
Compound Fracture	A fracture in which the broken bone is sticking through an open wound in the skin (also called an open fracture).
Communicable	Capable of being trasmitted from a person or animal, either throught direct or indirect contact, transmission or by insect or other vectors.
Congenital	Present at birth

D-G

*Term*	*Definition*
DRG	Diagnosis-Related Group classifies inpatient hospital cases into groups that are expected to consume similar hospital resources; each DRG has a payment weight assigned to it that is based on the average resources used to treat Medicare patients in that DRG
Ectopic pregnancy	Implantation of the fertilized ovum outside of the uterine cavity.
Elective Surgery	Surgery that is subject to choice. The choice may be made by the patient or the physician

Excludes note	Appears below an ICD-9-CM Tabular List of Disease 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

Fracture	A breach (break) in continuity of a bone resulting in an injury
Fracture - Nonunion	Failure of the ends of a fractured bone to unite
Gestational Diabetes	Pregnant women who have never had diabetes before but who have high blood sugar levels during pregnancy.

H-L

*Term*	*Definition*
HIV	Human immunodeficienty virus. A retrovirus of the subfamily lentivirus that causes acquired immunodeficiency syndrome (AIDS).
Immunity Disorder	Immune system disorders occure when the immune system does not fight tumors or harmful substances like it should. The immune respone may be over or under active.
Includes note	appears immediately below ICD-9-CM tabular list codes to further define or provide examples.
Incomplete abortion	Miscarriage in which part, but not all, of the uterine contents are expelled.
Inpatient	Someone who stays overnight in a medical facility for 24 or more hours and is provided with room and board and nursing services.

M-Q

*Term*	*Definition*
Malignant hypertension	Accelerated, severe hypertensive disorder with progressive cardiovascular damage and a poor prognosis; characterized by rapidly rising blood pressure greater than 140 diastolic.
Malunion	Failure of the ends of a fractured bone to heal (unite).
Manifestation	An indication of the existence, reality, or presence of something, especially an illness or sign or symptom of illness.
Maximizing Reimbursement	One form of "DRG Creep", this is considered a no-no and if discovered, could result in sanctions and/or fines! (selection of a principal diagnosis based solely on reimbursement value, whether or not that diagnosis meets the criteria for selection or not). The other form of "DRG Creep" is upcoding (assignment of a higher-paying diagnosis or procedure code even if not supported by documentation in the patient record) - also a no-no and if discovered, could be subjected to same penalties as maximizing.


Metabolic Disease	Disease due to abnormal biochemistry, usually as a result of an absent or deficient enzyme.
Molar Pregnancy	An abnormality during pregnancy; chorionic villi around the fetus degenerate and form clusters of fluid-filled sacs; usually associated with the death of the fetus
Normal Delivery	Patient admitted for a full-term normal delivery of a single healthy infant without complications in either the antepartum period, during delivery or postpartum period during the delivery episode.
Obstetrics	The medical specialty that studies anatomy and physiology of the female reproductive system and uses diagnostic tests, medical and surgical procedures and drugs to monitor normal pregnancy and childbirth and treat diseases.
Open Fracture	type of fracture that has an associated open wound
Optimizing Reimbursement	determining which of several diagnosis to report as the principal diagnosis when multiple diagnoses equally meet the criteria for selection as the principal diagnosis.
Opportunistic infection	Takes advantage of the body's weakened defenses, such as in an HIV-positive patient.
Other significant procedure	Carry an operative or anesthetic risk, require highly trained personnel, or require special facilities or equipment.
Parasitic Disease	Disease in which the primary axis is organism responsible.
Perinatal Period	The interval of time occurring before, during, and up to 28 days following birth.
Peripartum Period	occuring during the last 10% of the gestation period or the first few weeks, pertaining to the mother
puerperium	Or postpartum stage begins at the end of the third stage of labor and continues for six weeks.
Postpartum period	The period just after delivery.
Principal Diagnosis	Condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care.
Principal Procedure	is: performed for definitive treatment rather than for diagnostic or exploratory purposes; necessary to treat a complication; and most closely related to the principal diagnosis
Prophylaxis	A measure taken for the prevention of a disease or condition
Pre-eclampsia	Is a medical condition where hypertension arises in pregnancy (pregnancy-induced hypertension) in association with significant amounts ofprotein in the urine.

R-Z

*Term*		*Definition*
Sequelae		A condition following as a consequence of a disease.
simple fracture		A type of fracture that is contained beneath the skin and has intact ligaments and skin.

Sign		Comment coming from the patient's(or patient's guardian) mouth; when a symptom has a physical manifestation that can be detected by others, it is known as a sign.
Symptom		Any subjective evidence of disease or of a patient's condition. (see also sign)
trust the index		Concept that inclusion terms listed in the Tabular List of Diseases are not meant to be exhaustive and that additional terms found only in the Index to Diseases (but not in the Tabular List of Diseases) may also be assigned to a code.
type 1 diabetes mellitus		a chronic condition in which the pancreas produces little or no insulin; formerly known as juvenile diabetes or insulin-dependent diabetes.
type 2 diabetes mellitus		occurs when a patient's body is unable to to properly use the insulin produced by the body.
Secondary Procedure (or other significant procedure)		Carry an operative or anesthetic risk, require highly trained personnel, or require special facilities or equipment
Unspecified Hypertension		is an ICD-9-CM subcategory assigned when the provider does not document benign or malignant.
V29 Category Usage		Category V29 - Observation and Evaluation of Newborns for Suspected Conditions Not Found - should be used for newborns, within the neonatal period (first 28 days of life), who are suspected of having an abnormal condition resulting from exposure from the mother or the birth process, but without signs or symptoms, and, which after examination and observation, is found not to exist.
V30 Category Usage		Category V30 - Liveborn infants according to type of birth - these categories are intended for the coding of iveborn infants who are consuming healthcare (e.g., crib or bassinet occupancy)
Viruses		Submicroscopic parasites that cause disease. Contain DNA or RNA, are surrounded by protein, and use host cells to replicate. Include varicella (chickenpox virus), cold viruses, hepatitis viruses, herpes viruses, and human immunodeficiency virus (HIV).
Spontaneous Abortion		Miscarriage or spontaneous abortion is the natural or spontaneous end of a pregnancy at a stage where the embryo or fetus is incapable of surviving, generally defined in humans at prior to 20 weeks of gestation. Miscarriage is the most common complication of early pregnancy.

HIM 101

verafyde — Tue, 04 Nov 2008 01:05:09 CST

Let's practice using our wiki.
First - Click the EasyEdit Button above(looks like this ).

Next - Enter your contact information below. When you are done click SAVE in the EasyEdit Toolbar at the top of the page.

FALL 2008

Student	LiveJournal username	Twitter username	Windows Live IM username	Delicious username	Google username
Char Gore	tccchar	tccchar	WL - tccchar@hotmail.com Yahoo - Tccchar2000 AIM - Tccchar2000	tccchar	cgore@tacomacc.edu
Jason Thrasher	jlt1975	jlt1975	jthrasher93@yahoo.com		jthrasher93@yahoo.com
Amy Everson	Amersrd5	Amersrd5	Ifibersol@hotmail.com Windows Live		AEverson3 amy@myspeedline.com
Cindi Sonich	sonichtcchim	sonipeeps	Cindi (csonich)		tcccindi@yahoo.com
Elizabeth Bingham	elizabeth200815	elizabeth200815	softassilk73@hotmail.com
Tiffany M. Fortune	Mrs_lil_momma	Mrs_lil_momma	Mrs_lil_momma@hotmail.com		Mrs_lil_momma@hotmail.com
Mary Vickers	vicktcchim	maryvtcc	Yahoo - maryvtcc AIM - jamms8441		maryvtcc@yahoo.com
Rose Ralson	ralsontcchim	rralson	rosieralson@hotmail.com WL		rosieralson@hotmail.com
Stephanie Delegard	steph_delegard	sdelegard	steph.delegard@gmail.com
Sarah Emery	emery123	sarahe123	sarahaemery@hotmail.com		sarahaemery@hotmail.com
Rick Mounce	RMounce RandBme	RandBme	Yahoo - RandBme
Crystal Cowan	ccowan84324	ccowan84324	crystal.jazzy@hotmail.com		crystal.jazzy@hotmail.com
Jennifer Mikami	tutucutie12	tutucutie12	tutucutie@hotmail.com		tutucutie12@hotmail.com
Kimberly Cates	CatesCutiePie	Kcates4995	WL:Kcates49925@tacomacc.edu yahoo: pure_addiction_05@yahoo.com		Kcates49925@tacomacc.edu
Debbie Stokes	stokesdeb	stokesdeb	stokesdeb@comcast.ent
Jerri Peckham	peckham67	jerrij123	jerrij123@yahoo.com		jerrij123@hotmail.com
Cassandra Starks	starkstcchim	CMS615253	CDS093@live.com		Cassandra0809@gmail.com
Lola Broussard	Lbroussard02031 Degaut33	DoresA52$$	lolambroussard@comcast.net		lb8014@gmail.com
Yvonne Curry	bunny2_kids	kids2love	WL:bunny.2love@live.com		ycurry37815@tacomacc.edu
Lyn Rossman	rossmantcchim	LynMR	WL TCClynr		Lrossman@clearwire.net
Elizabeth Coggin	verafyde	verafyde	verafyde@hotmail.com		verafyde@hotmail.com
Merri Van Houte	vanhomerri	merrirae	helena-rae@hotmail.com		merrivh0972@gmail.com
Diane Forrester	didee123	didee123	dfor572002-Yahoo
Annette Tyler	tatyler7	tatyler7	tatyler7@comcast.net		tatyler7
Khanh Julie Mai	kmai90019	kmai90019	kmai90019@hotmail.com	none	kmai90019@tacomacc.edu
Ashley DeVaney	devaneytcchim	adevaney62316	ashdevaney11@live.com		ashdevaney11@yahoo.com
Melissa May	maymelissa	mmay72	google: mmay72@gmail.com		mmay72@gmail.com
Randy Stiffler	wstiffler12920	wstiffler12920	wstiffler12920		wstiffler12920@tacomacc.edu
Geoff Cain	caintcchim	him101	geoff-cain@hotmail.com	geoffcain	javatology@gmail.com
Debi Watson	dwatac	him101	dwatac@yahoo.com
Joyce Garrett	JGarrettTCCHIM	JGarrettTCCHIM	yahoo: qwertybertyz		qwertybertyz@yahoo.com
Cynthia Zinakova	cynzin	cynzin	cynzin@live.com		cynzin4@gmail.com

SUMMER 2008

Student Name	Google Name	Windows Live IM User Name	Liverjournal User Name	Wiki User Name	Twitter User Name	Delicious User Name
Charlene Gore	cgore@tacomacc.edu	Tccchar@hotmail.com	Tcchar	Tccchar	Tccchar	TCCchar
Nicole Freeman	nfreeman8@cox.net	nfreeman8@cox.net	blondesoprano	blondesoprano	blondesoprano8	blondesoprano
Silvia Hogan		ihogan88@yahoo.com	silvizzy	silverhead	silverhead00	silverehad
Jaime Scott	jscott88419@tacomacc.edu	jscott88419@hotmail.com	jscott88419	jscott88419	jscott88419	jscott88419
Sandra Keys	keymedicalcliams@live.com	keymedicalcliams@live.com	keystcchim	Keys2	SKeys2	sankeys
Anita Tolbert	atolbert20523@tacomacc.edu	anita_tolbert@hotmail.com	tolberttcchim	TolbertA	atolbert	tolberta
Frank Rocha	rocha_frank@yahoo.com	rocha_frank@live.com	frank_rocha	frocha04020	frankrocha	frank_rocha
Beschieru, Igor	shreky3@gmail.com	Messenger: iggorb3@hotmail.com email me @: shreky3@gmail.com	igorbeschieru Messenger	ibeschieru	igorbeschieru	shreky3
Hulene Donovan			donovantcchim	donovantcchim	donovantcchim
Sarah Bailey	Sbailey88707@tacomacc.edu	secretrecipe1@hotmail.com	sarahtcchim	sarahxke	xke	sarahxke
Heidi Johnson	heidij6181@hotmail.com	heidij6181@hotmail.com	heidij2	heidij2	heidij2	heidij2
Amie Rhoads		pennys_mama@live.com	rhoadstcchim	rhoadstcchim	penys_mama	rhoadstcchim
Juiles Smith	JYSMITH4808@GMAIL.COM	jysmith4808@msn.com	jysmith4808	jysmith4808@msn.com	jysmith4808	JYSMITH4808
Vincent Ryan	VRyan26318@tacomacc.edu	Vincentryan@live.com	ryantcchim	Vincentryan	Vinceryan	Niagarason
Les Sandusky		jimmy3988@yahoo.com	jimmy3988	jimmy3988	jimmy3988
			Ciaravelltcchim	JCiaravella40831	JCiaravella
Melvin Moore	blueboysc29@aol.com	mm101677@hotmail.com	Carlosmi42	Carlosmi42	Carlosmi42	Carlosmi
Geoff Cain		Geoff-Cain@hotmail.com	caintcchim	geoffcain	him101 or geoffcain	tcc_multimedia
Kristina Murray	kmurray53719@tacomacc.edu	Kmurray4197@msn.com kmurray53719@tacomacc.edu	murraytcchim	Kmurray53719	KristiMurray	kmurray53719
BrendaGranberry	rmharris11@aol.com	BGranberry48814@live.com	bgranberry51	bgranberry51	bgranberry50	bgranberry51
Lemuel Harden	workonly1@yahoo.com	lpharden@live.com	lpharden	lpharden	lhhardenlpharden
Aiisha Agustin	AAgustin06510@tacomacc.edu	asagustin@live.com	asagustin	asagustin	AAgustinasagustin
Haley Jauregui		Poeta.HJ@gmail.com	poetahj	poetahj	poetahj	poetahj
Abril Mitchell	abriltcc@gmail.com	Mzabril@live.com	abriltcc	abriltcc	abriltcc	AbrilTcc.delicious.com
Elizabeth Bingham	elizabeth200815@yahoo.com	elizabeth200815@live.com

HEY CHAR:		ARE WE ALLOWED TO	ADD OUR SCRIBD	USERNAMES TO	THIS WIKI? THX!	-NICOLE

SPRING 2008

Active lII	Reflective lIllII	Both IIlllllllII
Sensing llllilllIllII	Intuitive I	Both lIII
Visual IIllllllI	Verbal llI	Both lIlIII
Sequential lIIllll	Global lllIlII	Both l lIII

The wiki page keeps track of who has participated and at exactly what time so you don't need to email me that you have completed this assignment.

HIM 140 Glossary

sreehill — Sat, 25 Oct 2008 00:10:19 CDT

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

Modifier

Morphology

Additional term included after the colon in the ICD-9-CM tabular lists that is to be included in the statement to classify a condition or procedure

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

Trust the index

UB-04

Concept that inclusion terms listed in the Tabular List of Diseases are not meant to be exhaustive and that additional terms found only in the Index to Diseases(but not in the Tabular List of Diseases) may also be assigned to a code.

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.

HIM 145

merrirae — Sun, 19 Oct 2008 22:05:47 CDT

Nursing Facility - A comprehensive term for long-term care facilities that provide nursing care and related services on a 24-hour basis for residents requiring medical, nursing, or rehabilitative care.

Vital Statistics - Data related to births, deaths, marriages and fetal deaths. All states have laws that require this information to be submitted to the National Vital Statistics System which is part of the CDC/National Center for Health Statistics.

Annual - Yearly

Conferences

tccklee — Wed, 01 Oct 2008 11:51:35 CDT

AHIMA National Conference In Seattle

Check out the student price!

AHIMA 2008 National Conference In Seattle!

Fun Stuff

chargore — Wed, 03 Sep 2008 11:58:37 CDT

Check out the awesome cook book put together by the HIM 101 class Summer 2008.

HIM 170

chargore — Wed, 13 Aug 2008 18:37:24 CDT

There is no abstract available for this page revision.

HIM 220

chargore — Wed, 13 Aug 2008 18:36:36 CDT

There is no abstract available for this page revision.

Glossary

chargore — Wed, 13 Aug 2008 18:30:39 CDT

Put your cursor in the row BELOW where you want to add the new row
Right click on the table
Click - Add Row

A-C

*Term*	*Definition*

D-G

*Term*	*Definition*

H-L

*Term*	*Definition*

M-Q

*Term*	*Definition*

R-Z

*Term*	*Definition*

HIM 195

chargore — Wed, 13 Aug 2008 18:12:41 CDT

SU08

Assessment of Learning Styles

kmurray53719 — Thu, 17 Jul 2008 16:37:17 CDT

Let's practice using our wiki.
First - Click the EasyEdit Button above(looks like this ).

Next - put a tick mark (just use the letter l) in the appropriate table box reflecting the type of learner you are.

Summer 2008 (HIM 140 and HIM 195)

Active IIII	Reflective	Both III
Sensing III	Intuitive	Both II
Visual II	Verbal I	Both II
Sequential I	Global I	Both III

Tutorials

geoffcain — Tue, 08 Jul 2008 19:12:27 CDT

Hey gang! Here is a link to a brief video on creating a links list in Live Journal: See it here!