Coding Chapter 1 Flashcards

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

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

Centers for Medicare and Medicaid Services.

<p>Public or private entity that processes or facilitates the processing of health information and claims from a nonstandard to a standard format.</p> Signup and view all the answers

<p>Documenting patient care services so that others who treat the patient have a source of information on which to base additional care and treatment.</p> Signup and view all the answers

<p>Current Procedural Terminology.</p> Signup and view all the answers

<p>Patient identification information that is collected according to facility policy.</p> Signup and view all the answers

<p>Routinely assigning lower-level CPT codes as a convenience instead of reviewing patient record documentation and the coding manual to find the proper code to be reported.</p> Signup and view all the answers

<p>Collection of patient information documented by a number of providers at one or more facilities regarding one patient.</p> Signup and view all the answers

<p>Created on a computer, using various input devices, records are created using vendor software, which also assists in provider decision making regarding patient care and treatment.</p> Signup and view all the answers

<p>Process of standardizing data by assigning numeric values to text or other information.</p> Signup and view all the answers

<p>5 digit CPT codes developed and published by the American Medical Association.</p> Signup and view all the answers

<p>Provisions that protect the security and privacy and confidentiality of health information.</p> Signup and view all the answers

<p>Routinely assigning an unspecified ICD9 or 10 disease code instead of reviewing the coding manual to select the appropriate code number.</p> Signup and view all the answers

<p>Determination that a service or procedure rendered is reasonable and necessary for the diagnosis or treatment of an illness or injury.</p> Signup and view all the answers

<p>Observations about the patient, such as physical findings or lab results.</p> Signup and view all the answers

<p>Reporting codes for signs and symptoms associated, in addition to an established diagnosis code.</p> Signup and view all the answers

<p>Diagnostic, therapeutic, and education plans to resolve the problem.</p> Signup and view all the answers

<p>Systematic method of documentation that consists of four components: database, problem list, initial plan, and progress notes.</p> Signup and view all the answers

<p>Report organized according to documentation source, each of which is located in a labeled section of the record.</p> Signup and view all the answers

<p>Patient's statement about how he feels.</p> Signup and view all the answers

<p>Entity that processes health care claims and performs related business functions for a health plan.</p> Signup and view all the answers

<p>Insurance company.</p> Signup and view all the answers

<p>The process of coding multiple codes to describe multiple services using one code.</p> Signup and view all the answers

<p>Assignment of an ICD-9-CM diagnosis code that does not match patient record documentation for the purpose of illegal increasing reimbursement.</p> Signup and view all the answers

<p>Certification for individuals proficient in medical coding.</p> Signup and view all the answers

<p>Organization providing certifications in medical coding including CPC, CPC-A, CPC-H, and CIRCC.</p> Signup and view all the answers