Questions and Answers
What does 'Assessment' refer to in healthcare?
Judgment, opinion, or evaluation made by the health care provider; considered part of the problem-oriented record SOAP note.
What is 'assumption coding'?
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.
What does 'CMS' stand for?
Centers for Medicare and Medicaid Services.
What is a clearinghouse in healthcare?
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What does 'continuity of care' mean?
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What does 'CPT' stand for?
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What is demographic data?
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What is 'downcoding'?
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What is an electronic health record?
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What is an electronic medical record?
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What is the definition of 'encoding'?
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What does 'Healthcare Common Procedure Coding System' represent?
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What is the Health Insurance Portability Accountability Act of 1996?
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What does 'jamming' refer to in coding?
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What is 'medical necessity'?
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What does 'Objective' mean in medical documentation?
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What is 'overcoding'?
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What does 'Plan' refer to in a medical context?
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What is a Problem-oriented record?
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What is a Source-oriented record?
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What does 'Subjective' mean in medical documentation?
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What is a third-party administrator?
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What is a third-party payer?
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What does 'unbundling' refer to?
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What is 'upcoding'?
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What does 'Certified Professional Coder (CPC)' refer to?
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What is the American Academy of Professional Coders (AAPC)?
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Study Notes
Coding Terminology
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Assessment: Evaluation made by a healthcare provider, part of the SOAP note documentation process.
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Assumption Coding: Involves incorrectly assigning codes based on assumptions from clinical evidence instead of documented diagnoses or procedures.
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CMS: Centers for Medicare & Medicaid Services; an administrative agency within the federal Department of Health and Human Services.
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Clearinghouse: An entity (public or private) that processes health information and claims, converting them from a nonstandard to a standard format.
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Continuity of Care: Refers to the documentation of patient services to ensure subsequent caregivers have access to relevant information.
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CPT (Current Procedural Terminology): A coding system used in outpatient healthcare settings for reporting procedures and services on insurance claims.
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Demographic Data: Patient identification information collected according to facility policy.
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Downcoding: The practice of assigning lower-level CPT codes without reviewing necessary documentation, often for convenience.
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Electronic Health Record (EHR): A comprehensive collection of patient information documented by multiple providers across different facilities.
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Electronic Medical Record (EMR): Computerized records created using various input methods, supported by vendor software for medical decision-making.
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Encoding: The process of standardizing data by assigning numeric values to textual or other types of information.
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Healthcare Common Procedure Coding System (HCPCS): A set of five-digit CPT codes developed by the American Medical Association for procedural coding.
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HIPAA (Health Insurance Portability and Accountability Act of 1996): Legislation that protects the privacy, security, and confidentiality of health information.
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Jamming: Incorrectly assigning unspecified ICD-9 or 10 codes instead of using the coding manual to determine the correct code.
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Medical Necessity: The evaluation that determines if a service or procedure is appropriate for the diagnosis or treatment of a patient’s condition.
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Objective: Documented observations about a patient, including physical findings and lab results.
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Overcoding: The practice of reporting additional codes for signs and symptoms alongside an established diagnosis.
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Plan: The outlined diagnostic, therapeutic, and educational strategies created to address a patient’s issues.
Documentation Methods
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Problem-Oriented Record: A systematic documentation method featuring four components: database, problem list, initial plan, and progress notes.
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Source-Oriented Record: Organized documentation based on the source of information, with sections labeled accordingly.
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Subjective: Patient's self-reported feelings or experiences regarding their health.
Healthcare Administration
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Third Party Administrator: An entity responsible for processing healthcare claims and related functions for health plans.
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Third Party Payer: Typically refers to insurance companies that pay for healthcare services.
Coding Practices
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Unbundling: The coding practice of assigning multiple codes for different services instead of using a single code.
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Upcoding: The illegitimate practice of assigning an incorrect ICD-9-CM diagnosis code to increase reimbursement rates contrary to patient documentation.
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Certified Professional Coder (CPC): A professional certification indicating expertise in medical coding.
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American Academy of Professional Coders (AAPC): A professional organization providing certification such as CPC, CPC-A, CPC-H, and CIRCC for coding specialists.
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Test your knowledge on key terms from Coding Chapter 1. This flashcard quiz will help you familiarize yourself with important definitions and concepts relevant to coding in healthcare. Perfect for students and professionals alike!