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