Chapter 6 Flashcards
adverse effect
taking less of a medication than is prescribed by a provider or a manufacturer’s instruction.
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).
Comorbidity
concurrent condition that coexists with the first-listed diagnosis (outpatient care) (or principal diagnosis for inpatient care), has the potential to affect treatment of the first-listed diagnosis (outpatient care) (or principal diagnosis for inpatient care), and is an active condition for which the patient is treated and/or monitored.
Complication
condition that develops after outpatient care has been provided or during an inpatient admission.
computer-aided coding (CAC)
see computer-assisted coding (CAC).
computer-assisted coding (CAC)
uses a natural language processing engine to “read” patient records and generate ICD-10-CM and HCPCS/CPT codes.
contiguous sites
also called overlapping sites; occurs when the origin of the tumor (primary site) involves two adjacent sites.
Cooperating Parties for ICD-10-CM/PCS
AHA, AMA, CMS, and NCHS organizations and agencies that approve official guidelines for coding and reporting ICD-10-CM and ICD-10-PCS.
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.
Encounter
face-to-face contact between a patient and a health care provider (e.g., physician, nurse practitioner) who assesses and treats the patient’s condition.
essential modifier
see subterm.
evidence-based coding
coding auditor clicks on codes that CAC software generates to review electronic health record documentation (evidence) used to generate the code.
first-listed diagnosis
reported on outpatient claims (instead of inpatient principal diagnosis); it reflects the reason for the encounter, and it is often a sign or symptom.
general equivalence mapping (GEM)
translation dictionaries or crosswalks of codes that can be used to roughly identify ICD-10-CM/PCS codes for their ICD-9-CM equivalent codes (and vice versa). See also legacy coding system.
iatrogenic illness
illness that results from medical intervention (e.g., adverse reaction to contrast material injected prior to a scan).
ICD-10-CM coding conventions and brackets
general coding rules that apply to the assignment of codes, independent of official coding guidelines.
code first underlying disease
appears when the code referenced is to be sequenced as a secondary code; the code, title, and instructions are italicized.
code first underlying disease, such as
see code first underlying disease.
code, if applicable, any causal condition first
requires causal condition to be sequenced first if present; a causal condition is a disease that manifests (or results in) another condition.
Colon
used after an incomplete term and is followed by one or more modifiers (additional terms).
due to
located in the index in alphabetical order to indicate the presence of a cause-and-effect (or causal) relationship between two conditions.
Eponym
disease or syndrome named for a person; listed in appropriate alphabetical sequence as main terms in the index.
etiology and manifestation rules
include the following notes in the ICD-10-CM Tabular List of Diseases and Injuries: Code first underlying disease; Code first underlying disease, such as; Code, if applicable, any causal condition first; Use additional code; and In diseases classified elsewhere.