• Shuffle
    Toggle On
    Toggle Off
  • Alphabetize
    Toggle On
    Toggle Off
  • Front First
    Toggle On
    Toggle Off
  • Both Sides
    Toggle On
    Toggle Off
  • Read
    Toggle On
    Toggle Off
Reading...
Front

How to study your flashcards.

Right/Left arrow keys: Navigate between flashcards.right arrow keyleft arrow key

Up/Down arrow keys: Flip the card between the front and back.down keyup key

H key: Show hint (3rd side).h key

A key: Read text to speech.a key

image

Play button

image

Play button

image

Progress

1/81

Click to flip

81 Cards in this Set

  • Front
  • Back
ADVANCE BENEFICIARY NOTICE (ABN)
document that acknowledges patient responsibility for payment if Medicare denies the claim.
ADVERSE EFFECT
also called adverse reaction; the appearance of a pathologic condition due to ingestion or exposure to a chemical substance properly administered or taken.
AXIS OF CLASSIFICATION
organizes entities, diseases, and othe conditions according to etiology, anatomy, or severity.
BENIGN
not cancerous
CARCINOMA (CA) IN SITU
a malignant tumor that is localized, circumscribed, encapsulated, and noninvasive (has not spread to deeper or adjacent tissues or organs)
CLASSIFICATION OF DRUGS BY AHFS LIST
Appendix C of ICD-9-CM that contains the American Hospital Formulary Services list number and its ICD-9-CM equivalent code number; organized in numerical order according to AHFS list number
CLASSIFICATION OF INDUSTRIAL ACCIDENTS ACCORDING TO AGENCY
Appendix D of ICD-9-CM; based on employment injury statistics adopted by the tenth International Conference of Labor Statisticians
CODING CONVENTIONS
rules tha apply to the assignment of ICD-9-CM codes
COMPLICATION
condition that develops subsequent to inpatient admission.
CONGENITAL ANOMALY
disorder diagnosed in infants at birth
CONTIGUOUS SITE
also called overlapping site; occurs when the origin of the tumor (primary site) involves two adjacent sites.
DIAGNOSTIC CODING AND REPORTING GUIDLINES FOR OUTPATIENT SERVICES: HOSPITAL-BASED AND PHYSICIAN OFFICE
developed by the federal government for use in reporting diagnoses for claims submission
E CODE
located in the ICD-9-CM Tabular List, describes external causes of injury, poisoning, or other adverse reactions affecting a patient's health.
ENCODER
automates the coding process using computerized or Web-based software; instead of manually looking up conditions (or procedures) in the coding manual's index, the coder uses the software's search feature to locate and verify diagnosis and procedure codes.
FIRST-LISTED DIAGNOSIS
reported on outpatient claims (instead of inpatient principal diagnosis); it is determined in accordance with ICD-9-CM's coding conventions (or rules) as well as general and disease-specific coding guidelines
IATROGENIC ILLNESS
illnes that results from medical intervention (e.g., adverse reaction to contrast material injected prior to a scan)
CODE IN SLANTED BRACKETS
always reported as secondary codes because they are manifetations (results) of other conditions.
EPONYM
disease (or procedure) named for an individual (e.g., physician who originally discovered the disease, first patient diagnosed with the disease).
ESSENTIAL MODIFIERS
subterms that are indented below the main term in alphabetical order (except for "with" and "without"); clarifies the main term and must be contained in the diagnostic statement for the code to be assigned
MAIN TERMS
condition printed in boldface type and followed by the code number
NEC (NOT ELSEWHERE CLASSIFIABLE)
identifies codes to be assigned when information needed to assign a more specific code cannot be located in the ICD-9-CM coding book
NONESSENTIAL MODIFIERS
subterms enclosed in parentheses following the main term that clarify code selection, but do not have to be present in the provider's diagnostic statement
NOTES
contained in boxes to define terms, clarify index entries, and list choices for additional digits (e.g., fourth and fifth digits)
SEE
directs the coder to a more specific term under which the code can be found
SEE ALSO
refers the coder to an index entry that may provide additional information to assign the code.
SEE ALSO CONDITION
directs the coder to the condition in the index (because the coder referenced an anatomic site, etc.)
SEE CATEGORY
directs the coder to a specific three-digit category code in the Tabular List of Diseases for code assignment
SUBTERM
essential modifiers that qualify the main term by listing alternate sites, etiology, or clinical status.
CODE ALSO ANY SYNCHRONOUS PROCEDURES
refers to operative procedures that are to be coded to completely classify a procedure.
OMIT CODE
term that identifies procedures or services that may be components of other procedures; this instruction means that the procedure or service is not coded.
AND
when two disorders are separated by the word "and", it is interpreted as "and/or" and indicates that either of the two disorders is associated with the code number
BOLD TYPE
all category and subcategory codes and descriptions are printed in bold type
BRACES
enclose a series of terms, each of which modifies the statement located to the right of the brace
BRACKETS
enclose synonyms, alternate wording, or explanatory phrases
CATEGORY
printed in bold upper-and lowercase type and are preceded by a three-digit code
CODE FIRST UNDERLYING DISEASE
appears when the code referenced is to be sequenced as a secondary code; the code, title, and instructions are italicized
COLON
used after an incomplete term and is followed by one or more modifiers (additional terms)
EXCLUDES
directs the coder to another location in the codebook for proper assignment of the code
FORMAT
all subterms are idented below the term to which they are linked; if a definition or disease requires more than one line, that text is printed on the next line further indented
FOURTH AND FIFTH DIGITS
create ICD-9-CM subcategory and subclassification codes, respectively. (In the ICD-9-CM Tabular List of Procedures, third and fourth digits create ICD-9-CM subcategory and subclassification codes, respectively
INCLUDES
includes notes appear below a three-digit category code description to further define, clarify, or provide an example.
MAJOR TOPIC HEADING
printed in bold uppercase letters and followed by a range of codes enclosed in parentheses.
NOT OTHERWISE SPECIFIED (NOS)
indicates that the code is unspecified; coders should ask the provider for an more specific diagnosis before assigning the code.
PARENTHESES
enclose supplementary words that may be present or absent in the diagnostic statement, without affecting assignment of the code number
SUBCATEGORY
indented and printed in the same fashion as the major category headings
SUBCLASSIFICATION
requires the assignment of a fifth digit
USE ADDITIONAL CODE
indicates that a second code is to be reported to provide more information about the diagnosis
WITH
when codes combine one disorder with another (e.g., code that combines primary condition with a complication), the provider's diagnostic statement must clearly indicate that both conditions are present and that a relationship exists between the conditions
INDE TO PROCEDURE AND TABULAR LIST OF PROCEDURES (VOLUME 3) (ICD-9-CM)
included only in the hospital version of commercial ICD-9-CM; is a combined alphabetical index and numerical listing of inpatient procedures
INDEXING
cataloging diseases and procedures by code number
INJURY
traumatic wound or damage to an organ
LATE EFFECT
residual effect or sequela of a previous acute illness, injury, or surgery
LESION
any discontinuity of tissue (e.g., skin or organ) that may or may not be malignant.
LIST OF THREE-DIGIT CATEGORIES
found in Appendix E of ICD-9-CM; contains a breakdown of three-digit category codes organized beneath section headings.
MALIGNANT
cancerous
METASTASIZE
the spread of cancer from primary to secondary sites
METASTATIC
descriptive term that indicates a primary cancer has spread to another part of the body
MORBIDITY
pertaining to illness or disease
MORPHOLOGY
indicates the tissue type of a neoplasm; though M codes are not reported on provider office claims, they are reported to state cancer registries
MORPHOLOGY OF NEOPLASMS (M CODES)
Appendix A of ICD-9-CM; contains a reference to the World Health Organization publication entitled International Classification of Diseases for Oncology (ICD-O)
MORTALITY
pertaining to death
NATIONAL CENTER FOR HEALTH STATISTICS (NCHS)
one of the U.S. Department of Health and Human Services agencies responsible for overseeing all changes and modifications to the ICD-9-CM
NEOPLAMS
new growth, or tumor, in which cell reproduction is out of control
OUTPATIENT
person treated in one of three settings; health care provider's office; hospital clinic, emergency department, hospital same-day surgery unit, or ambulatory surgical center (ASC) where the patient is released within 23 hours; or hospital admission solely for observation where the patient is released after a short stay
PERINATAL CONDITION
occurs before birth, during birth, or within the perinatal period
PERINATAL PERIOD
first 28 days of life
POISONING
occurs as the result of an overdose, wrong substance administered or taken, or intoxication (e.g., combining prescribed drugs with nonprescribed drugs or alcohol)
PREADMISSION TESTING (PAT)
completed prior to an inpatient admission or outpatient surgery to facilitate the patient's treatment and reduce the length of stay
PRIMARY MALIGNANCY
original cancer site
PRINCIPAL DIAGNOSIS
condition determined, after study, that resulted in the patient's admission to the hospital
PRINCIPAL PROCEDURE
procedure performed for definitive treatment rather than diagnostic purposes; one performed to treat a complication; or that which is most closely related to the principal diagnosis
QUALIFIED DIAGNOSIS
working diagnosis that is not yet proved or established
RE-EXCISION
occurs when the pathology report recommends that the surgeon perform a second excision to widen the margins of the original tumor site
SECONDARY DIAGNOSES
also called concurrent condiotion or comorbidity; coexists with the primary condition, has the potential to affect treatment of the primary condition, and is an active condition ofr which the patient is treated or monitored
SECONDARY MALIGNANCY
tumor has metasized to a secondary site, either adjacent to the primary site or to remote region of the body
SECONDARY PROCEDURE
additional procedure performed during the same encounter as the principal procedure
SEQUELAE
late effects of injury or illness
TABULAR LIST OF DISEASES (VOLUME 1)
contains 17 chapters that classify diseases and injuries, two supplemental classifications, and five appendices
UNCERTAIN BEHAVIOR
it is not possible to predict subsequent morphology or behavior from the submitted specimen
UNSPECIFIED NATURE
neoplasm is identified, but no further indication of the histology or natur of the tumor is reflected in the documented diagnosis
V CODE
located in the Tabular List of Diseases and assigned for patient encounters when a circumstance other than a disease or injury is present.