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18 Cards in this Set

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Application Service Provider (ASP)
third-party entity that manages & distributes software-based services & solutions to customers across a wide area network (WAN) fr. a central data center.
medical nomenclature
vocabulary of clinical & medical terms used by healthcare providers to document patient care (e.g. arthritis, gastritis).
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.
Physician Query Process
contacting the responsible physician to request clarification about documentation & codes to be assigned; the process is activated when the coder notices a problem w/documentation quality.
hybrid record
record that consists of both paper-based & computer-generated documents.
optical disk imaging
alternative to traditional microfilm or remote storage systems because patient records are converted to an electronic image & saved on storage media.
benign
not cancerous.
essential modifiers
qualifying word listed below the main term in the ICD-9-CM Index to Diseases, list alternate sites, etiology, or clinical status.
etiology
cause of disease.
malignant
cancerous.
morphology
indicates the tissue type of a neoplasm.
nonessential modifiers
qualifying word contained in parentheses after the main term in the ICD-9-CM Index to Diseases that does not have to be included in the diagnostic or procedural statement for the code number listed after the parentheses to assigned.
eponym
diseases or syndromes that are named for people.
carcinoma (CA) in situ
malignant tumor that is localized, circumscribed, encapsulated, & noninvasive, but has not spread to deeper or adjacent tissues or organs.
lexicon
glossary.
beveavement
grief.
co morbidity
coexisting condition that is treated during the same encounter as/or impacts the medical management of another condition.
curative
therapeutic.