KEY TERMS : Billing

Study Notes

Chief Complaint (CC)

Patient's description of symptoms or reason for seeking medical care.
If a diagnosis is not established, codes are assigned for the patient's symptoms.

Diagnostic Statement (DX)

Physician's description of the patient's encounter.
May include a specific diagnosis or list of symptoms/related conditions.

Acute Condition

Symptoms are sudden, severe, and short in duration.
Can result from a chronic disease causing sudden, severe symptoms.

Eponym

Diagnosis named after the physician or scientist who established the syndrome or group of symptoms.
Example: Angelman's syndrome, named after Dr. Harry Angelman.

Laterality

Diagnosis or injury of one side of the body (right or left).
Diagnosis codes can be specific to laterality, identifying the affected side.

Combination Code

Single diagnosis code identifying both the etiology (cause) and manifestation of a condition.
Example: Diabetes (etiology) causing retinopathy and macular edema (manifestations).
Used instead of separate codes when available.

First-Listed Code (Primary Diagnosis/Principal Diagnosis)

Main reason for patient's encounter.
Listed first on the claim form when multiple diagnosis codes are assigned.
Primary Diagnosis is used for outpatient claims.
Principal Diagnosis is used for inpatient claims.

External Cause Code

Assigned for the situation that caused the injury.
Example: Codes for vehicle accidents to support a broken leg diagnosis.

GEMS (General Equivalence Mappings)

Used during the transition from ICD-9-CM to ICD-10-CM to translate codes between the sets.
This conversion was the responsibility of CMS (Centers for Medicare & Medicaid Services).

Description

This quiz covers fundamental concepts in medical coding, including chief complaints, diagnostic statements, acute conditions, eponyms, laterality, and combination codes. Test your knowledge on these essential topics that are crucial for accurate patient documentation and coding.