Cbcs Study Guide 2.1 Chapter 5: Vocabulary

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MORBIDITY:

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THE NUMBER OF CASES OF DISEASE IN A SPECIFIC POPULATION

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MORTALITY:

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THE INCIDENCE OF DEATH IN A SPECIFIC POPULATION

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DIAGNOSIS-RELATED GROUP:

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IS A SYSTEM TO CLASSIFY HOSPITAL CASES

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VOLUME 1:

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TABULAR LIST OF DISEASES AND INJURIES

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V CODES:

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CODES USED TO CLASSIFY VISITS WHEN CIRCUMSTANCES OTHER THAN DISEASE OR INJURY ARE THE REASON FOR THE APPOINTMENT (SPECIFIC TO ICD-9-CM)

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E CODES:

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CODES USED TO CLASSIFY ENVIRONMENTAL EVENTS, CIRCUMSTANCES, AND CONDITIONS (SPECIFIC TO ICD-9-CM)

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APPENDIX A:

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MORPHOLOGY OF NEOPLASMS

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APPENDIX B:

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CLASSIFICATION OF DRUGS

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MORPHOLOGY OF NEOPLASM:

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IDENTIFIES THE TYPE OF NEOPLASM (TUMOR) WHETHER IT’S BEHAVIOR IS BENIGN OR IN SITU, AND WHETHER IT IS PRIMARY OR SECONDARY TUMOR

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VOLUME 2:

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THE ALPHABETIC INDEX OF DISEASES AND INJURIES

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VOLUME 3:

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THE CLASSIFICATION FOR PROCEDURES FOR REPORTING HOSPITAL PROCEDURES

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SECTIONS:

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ARE GROUPS OF 3 DIGIT CODE NUMBERS

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CATEGORIES:

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A GROUP OF CLOSELY RELATED CONDITIONS, OR A SINGLE DISEASE ENTITY

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SUB CATEGORIES:

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IS REPRESENTED BY A 4 DIGIT CODE NUMBER

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SUB-CLASSIFICATION:

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IS REPRESENTED BY 5 DIGIT CODE NUMBER

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IN SITU:

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HAS NOT SPREAD TO ANOTHER AREA

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ENCOUNTER:

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A DIRECT, PROFESSIONAL MEETING BETWEEN PATIENT AND A HEALTH CARE PROFESSIONAL WHO IS LICENSED TO PROVIDE MEDICAL SERVICES

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HEALTHCARE COMMON PROCEDURE CODING SYSTEM (HCPCS):

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IS A GROUP OF CODES AND DESCRIPTIONS USED TO REPRESENT HEALTH CARE PROCEDURES, SUPPLIES, PRODUCTS AND SERVICES

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HCPCS LEVEL I:

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THE CURRENT PROCEDURAL TERMINOLOGY (CPT-4) CODES

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HCPCS LEVEL II:

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ALSO CALLED NATIONAL CODES

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CATEGORY I CPT CODE:

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CODE THAT COVERS PHYSICIANS SERVICES AND HOSPITAL OUTPATIENT CODING; THESE CODES ARE 5 DIGIT CODES WITH 2 DIGIT MODIFIERS

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MODIFIERS:

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USE BOTH LEVEL I AND LEVEL II HCPCS TO CHANGE THE CODE DESCRIPTION

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MODIFIER 50:

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USED TO DESCRIBE A BILATERAL PROCEDURE

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MODIFIER 22:

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USED TO INDICATE THAT A PROCEDURE WAS DECREASED OR LIMITED

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APPENDIX A:

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HAS A COMPLETE LIST OF MODIFIERS AND THEIR DESCRIPTIONS (2 DIGIT CODES THAT FOLLOW THE CPT CODE)

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APPENDIX B:

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IS A SUMMARY OF THE ADDITIONS, DELETIONS, AND REVISIONS THAT HAVE BEEN PUT INTO USE IN THE CURRENT CPT EDITION

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APPENDIX C:

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HAS CLINICAL EXAMPLES FOR CODES IN THE EVALUATION AND MANAGEMENT SECTION OF THE CPT

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APPENDIX D:

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IS A LISTING OF CPT ADD-ON CODES (NEVER REPORT ALONE, PRIMARY CODE GOES 1ST)

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APPENDIX E:

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SUMMARY OF CPT CODES THAT ARE EXEMPT FOR MODIFIER 51

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APPENDIX F:

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SUMMARY OF CODES EXEMPT FROM MODIFIER 63

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APPENDIX G:

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HAS CODES THAT INCLUDE CONSCIOUS/MODERATE SEDATION

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APPENDIX H:

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AN ALPHABETIC INDEX OF PERFORMANCE MEASURE BY CLINICAL CONDITION OR TYPE BUT WAS REMOVED FROM THE CPT

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APPENDIX I:

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HAS GENERIC TESTING CODE MODIFIERS USED FOR REPORTING WITH LAB PROCEDURES RELATED TO GENERIC TESTING

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APPENDIX J:

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INCLUDES A LIST OF SENSORY, MOTOR, AND MIXED NERVES THAT ARE USEFUL FOR NERVE CONDUCTION STUDIES

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APPENDIX K:

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LISTS PROCEDURES INCLUDED IN THE CPT CODEBOOK THAT ARE NOT YET APPROVED

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APPENDIX L:

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IS A REFERENCE OF THE VASCULAR FAMILIES, INCLUDING WHICH ARE CONSIDERED FIRST, SECOND OR THIRD ORDER VESSELS

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APPENDIX M

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SHOWS A TABLE OF DELETED CPT CODES AND CROSSWALKS TO CURRENT CODES

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APPENDIX N:

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IS A LISTING OF CODES THAT HAVE BEEN RE-SEQUENCED

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CPT INDEX:

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LISTS MAIN TERMS IN ALPHABETICAL ORDER

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SUB-TERM:

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MODIFIES THE MAIN TERM AND ARE INDENTED UNDER THE MAIN TERM.

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NOMENCLATURE:

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A SYSTEM OF NAMES USED IN A PARTICULAR DISCIPLINE, AS IN MEDICINE AND SURGERY, ANATOMY AND BIOCHEMISTRY, ETC. A STANDARD SYSTEM OF NOMENCLATURE PRESUPPOSES THE EXISTENCE OF AN ORGANIZED CLASSIFICATION OF THE ENTITIES WITHIN THAT FIELD.

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HCPCS A CODES:

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AMBULANCE AND TRANSPORTATION SERVICES, MEDICAL AND SURGICAL SUPPLIES, ADMINISTRATIVE, MISCELLANEOUS AND INVESTIGATIONAL SERVICES AND SUPPLIES

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HCPCS B CODES:

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ENTERAL AND PARENTERAL THERAPY

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HCPCS D CODES:

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DENTAL

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HCPCS E CODES:

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DURABLE MEDICAL EQUIPMENT

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HCPCS G CODES:

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PROCEDURES/PROFESSIONAL SERVICES (TEMPORARY)

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HCPCS J CODE:

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DRUGS THAT ARE USUALLY NOT SELF-ADMINISTERED

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HCPCS L CODES:

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ORTHOTIC AND PROSTHETIC PROCEDURES AND DEVICES

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HCPCS M CODES:

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OFFICE SERVICES AND CARDIOVASCULAR AND OTHER MEDICAL SERVICES

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HCPCS P CODES:

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PATHOLOGY AND LABORATORY SERVICES

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HCPCS Q CODES:

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TEMPORARY CODES

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HCPCS R CODES:

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DOMESTIC RADIOLOGY SERVICES

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HCPCS V CODES:

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VISION, HEARING, AND SPEECH-LANGUAGE PATHOLOGY SERVICES

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HCPCS CODE AA MODIFIER:

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ANESTHESIA SERVICES PERFORMED PERSONALLY BY ANESTHESIOLOGIST

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HCPCS CODE E1 MODIFIER:

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UPPER LEFT EYELID

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HCPCS CODE E2 MODIFIER:

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LOWER LEFT EYELID

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HCPCS CODE E3 MODIFIER:

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UPPER RIGHT EYELID

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HCPCS CODE E4 MODIFIER:

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LOWER RIGHT EYELID

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HCPCS CODE NU MODIFIER:

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NEW EQUIPMENT

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HCPCS CODE QC MODIFIER:

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SINGLE CHANNEL MONITORING

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ENCOUNTER:

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TERM USED TO DESCRIBE A DIRECT, PROFESSIONAL VISIT BETWEEN A PATIENT AND A HEALTH CARE PROFESSIONAL SUCH AS A PHYSICIAN WHO IS LICENSED TO PROVIDE MEDICAL SERVICES INCLUDING DIAGNOSIS AND TREATMENT

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ENCOUNTER FORM:

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FORM THAT INCLUDES INFORMATION ABOUT PAST HISTORY, CURRENT HISTORY, INPATIENT RECORD, DISCHARGE INFORMATION AND INSURANCE INFORMATION

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ABSTRACTING:

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THE EXTRACTION OF SPECIFIC DATA FROM A MEDICAL RECORD, OFTEN FOR USE IN AN EXTERNAL DATABASE

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ENCODER:

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SOFTWARE THAT SUGGESTS CODES BASED ON DOCUMENTATION OR OTHER INPUT

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MS-DRG GROUPER:

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SOFTWARE THAT HELPS CODERS ASSIGN THE APPROPRIATE MEDICARE SEVERITY DIAGNOSIS-RELATED GROUP BASED ON THE LEVEL OF SERVICES PROVIDED, SEVERITY OF THE ILLNESS OR INJURY AND OTHER FACTORS

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APG GROUPER:

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HELPS CODERS DETERMINE THE APPROPRIATE AMBULATORY PAYMENT CLASSIFICATION (APC) FOR AN OUTPATIENT ENCOUNTER

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COMPUTER-ASSISTED CODING:

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SOFTWARE THAT SCANS THE ENTIRE PATIENT’S ELECTRONIC RECORD AND CODES THE ENCOUNTER BASED ON THE DOCUMENTATION IN THE RECORD

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DIGESTIVE SYSTEM:

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RESPONSIBLE FOR INGESTING AND DIGESTING FOOD, ABSORBING NUTRIENTS, AND ELIMINATING WASTE

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RESPIRATORY SYSTEM:

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RESPONSIBLE FOR DELIVERING OXYGENATED BLOOD TO ALL PARTS OF THE BODY

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MUSCULOSKELETAL SYSTEM:

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GIVES THE HUMAN BODY FORM AND STABILITY AND ENABLES MOVEMENT

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CONNECTIVE TISSUE:

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MADE UP OF ELASTIC FIBERS AND COLLAGEN

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ORTHOPEDIC SURGEONS:

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SPECIALIST IN PHYSICAL MEDICINE AND REHABILITATION

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INTEGUMENTARY SYSTEM:

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REGULATES THE BODY TEMPERATURE, ACTS AS A SENSORY RECEPTOR TO INTERNAL AND EXTERNAL STIMULI, SECRETES WASTE FROM THE BODY THROUGH SWEAT AND ABSORBS VITAMIN D AND CALCIUM FROM SUNLIGHT TO NOURISH THE BODY.

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CARDIOVASCULAR SYSTEM:

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DELIVERS NUTRIENTS AND OXYGEN TO EVERY CELL WITHIN THE BODY AND REMOVES WASTE PRODUCTS

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CORONARY HEART DISEASE:

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NARROWING OF THE SMALL BLOOD VESSELS THAT SUPPLY OXYGEN TO THE HEART MUSCLE

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CIRCULATORY AND LYMPHATIC SYSTEM:

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RESPONSIBLE FOR THE OVERALL BALANCE OF THE BODY SYSTEM FUNCTIONS

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ARTERIES:

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TRANSPORTS OXYGEN RICH BLOOD TO ALL PARTS OF THE BODY

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PULMONARY VEIN:

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CARRIES BLOOD TO THE LUNGS WHERE CARBON DIOXIDE IS EXCHANGED FOR OXYGEN

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LYMPHATIC SYSTEM:

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DISTRIBUTES FLUIDS AND NUTRIENTS THROUGHOUT THE BODY AND DRAINS EXCESS FLUIDS AND PROTEIN TO PREVENT EDEMA

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EDEMA:

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RETENTION OF EXCESS FLUID IN THE BODY

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LYMPH:

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FLUID THAT CONTAINS WHITE BLOOD CELLS, PROTEINS, AND FATS

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URINARY SYSTEM:

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AIDS IN THE PROCESS OF SECRETING AND ELIMINATING URINE

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URETERS:

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ARE THE ROUTE BY WHICH URINE EXITS THE KIDNEYS AND CONNECTS TO THE BLADDER

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BLADDER:

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WHERE URINE IS STORED UNTIL IT IS EXPELLED VIA THE URETHRA

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EXCRETION:

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THE ELIMINATION OF WASTE FROM THE BODY

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RENAL INSUFFICIENCY:

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THE REDUCED ABILITY OF THE KIDNEYS TO PERFORM THEIR NECESSARY FUNCTIONS

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RENAL FAILURE:

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IS THE COMPLETE FAILURE OF KIDNEY FUNCTION

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ENDOCRINE SYSTEM:

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A SYSTEM OF GLANDS THAT PRODUCES AND SECRETES HORMONES

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HORMONES:

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REGULATE THE BODY’S GROWTH, METABOLISM, SEXUAL DEVELOPMENT, AND FUNCTION. RELEASED INTO THE BLOODSTREAM AND ACT AS CHEMICAL MESSENGERS IN THE BODY

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THE NERVOUS SYSTEM:

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CONSISTS OF THE CENTRAL NERVOUS SYSTEM (CMS) AND THE PERIPHERAL NERVOUS SYSTEM (PNS). IT RECEIVES INFORMATION AND INTERPRETS IT VIA ELECTRICAL SIGNALS CARRIED BY THE NERVES

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SPINAL CORD:

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CONDUCTS SENSORY INFORMATION FROM THE PERIPHERAL NERVOUS SYSTEM TO THE BRAIN AND INFORMATION FROM THE BRAIN TO THE SKELETAL MUSCLES, CARDIAC MUSCLE, SMOOTH MUSCLE, AND GLANDS

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THE REPRODUCTIVE SYSTEM:

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THE SYSTEM BY WHICH HUMAN REPRODUCE

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OUTPATIENT CARE:

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SERVICES THAT DO NOT REQUIRE AN OVERNIGHT STAY, ALSO CALLED AMBULATORY CARE

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HOSPITAL DEPARTMENTS:

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DESIGNED TO ADDRESS SPECIFIC HEALTH CARE NEEDS

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DEPARTMENT OF PEDIATRICS:

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IS RESPONSIBLE FOR MEETING THE MEDICAL NEEDS OF INFANTS, CHILDREN, AND TEENAGERS

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DEPARTMENT OF INTERNAL/FAMILY MEDICINE:

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RESPONSIBLE FOR MEETING THE NEEDS OF PATIENTS OF ALL AGES AND ADDRESSING A WIDE RANGE OF PATIENT HEALTH CONCERNS, REFERS THE PATIENT TO A SPECIALITY DEPARTMENT FOR FURTHER TREATMENT, ADVANCED SCREENING, AND CARE

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DEPARTMENT OF UROLOGY:

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TREATS PATIENTS FOR ILLNESSES AND CONDITIONS RELATED TO THE URINARY SYSTEM

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DEPARTMENT OF DERMATOLOGY:

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TREATS PATIENTS WHO HAVE MEDICAL CONDITIONS THAT AFFECT THE INTEGUMENTARY SYSTEM OR SKIN. HAIR AND NAILS. THE DEPARTMENT SEE PATIENTS WHOSE SKIN CONDITIONS RANGE FROM MILD TO SEVERE

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DEPARTMENT OF CARDIOLOGY:

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RESPONSIBLE FOR TREATING PATIENTS WHO HAVE CONDITIONS RELATED TO THE HEART

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DEPARTMENT OF CARDIOVASCULAR MEDICINE:

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RESPONSIBLE FOR TREATING PATIENTS WHO HAVE CONDITIONS RELATED TO THE VASCULAR SYSTEM

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DEPARTMENT OF PATHOLOGY:

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SPECIALIZES IN THE STUDY OF DISEASES

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RESULT OF GROSS AND MICROSCOPIC EXAMINATION:

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ASSISTS PATHOLOGISTS IN DETERMINING THE BEHAVIOR OR MORPHOLOGY OF THE CELLS

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LABORATORY DEPARTMENT:

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RESPONSIBLE FOR PROCESSING BLOOD, BODY FLUID, AND TISSUE SPECIMENS FROM PATIENTS AND PERFORMING A VARIETY OF ANALYTICAL TESTS OR EXAMINATIONS REQUESTED BY A LICENSED MEDICAL PRACTIONER

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CLINICAL STAFF:

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INVOLVED IN DIRECT MEDICAL PATIENT CARE

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ADMINISTRATIVE:

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SUPPORTS PATIENT CARE

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ATTENDING/STAFF PHYSICIANS:

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RESPONSIBLE FOR DIAGNOSING CONDITIONS IN PATIENTS, PERFORMING PROCEDURES NECESSARY TO TREAT PATIENTS, FOR DIRECTING ANY FOLLOW UP CARE OR REFERRALS NECESSARY TO PROMOTE A HEALTHY PROGNOSIS FOR THE PATIENT, ISSUE ORDERS FOR PATIENTS, AND HAVE FINAL RESPONSIBILITY BOTH LEGAL AND OTHERWISE FOR THE CARE OF PATIENTS ADMITTED TO THE HOSPITAL

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REFERRING PHYSICIAN:

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REFER PATIENTS FOR SERVICES OR SUPPLIES THAT THEY CANNOT DIRECTLY PROVIDE

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RESIDENT PHYSICIAN:

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HAVE FINISHED MEDICAL SCHOOL, THEIR INTERNSHIP, AND ARE CURRENTLY RECEIVING IN A SPECIALIZED AREA

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FELLOW PHYSICIANS:

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ENTER INTO A TRAINING PROGRAM IN A MEDICAL SPECIALITY AFTER COMPLETING RESIDENCY

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REGISTERED NURSE:

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RESPONSIBLE FOR CARRYING OUT VERBAL AND WRITTEN ORDERS.

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LICENSED PRACTICAL NURSE:

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ABLE TO PERFORM FUNCTIONS SIMILAR TO AN REGISTERED NURSE, BUT UNDER THE DIRECT SUPERVISION OF AN REGISTERED NURSE

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MEDICAL ASSISTANTS:

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PERFORMS ADMINISTRATIVE AND CLINICAL TASKS TO KEEP PROVIDERS’ OFFICES RUNNING SMOOTHLY, AND SOME BASIC MEDICAL BILLING AND CODING. THEY ARE AN INTEGRAL PART OF THE HEALTH CARE SYSTEM

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MEDICAL ADMINISTRATIVE ASSISTANTS:

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ARE RESPONSIBLE FOR PROVIDING ADMINISTRATIVE SUPPORT TO HEALTH CARE PROVIDERS AND OTHER HEALTH CARE PROFESSIONALS

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MEDICAL CODING AND BILLING:

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RESPONSIBLE FOR OBTAINING THE MAXIMUM REIMBURSEMENT FOR PROCEDURES FOR REIMBURSEMENT