& ExamCoding
Review.pdf
I Chapter 01 _ Study Guide & Exam Review.pdf Page 1 of 41
Medical Coding I Chapter 01 | Study
Guide & Exam Review
Medical Coding I Chapter 01 _ Study GuideMedical
& ExamCoding
Review.pdf
I Chapter 01 _ Study Guide & Exam Review.pdf Page 1 of 41
,Medical Coding I - Chapter 01.pdf Medical Coding I - Chapter 01.pdf Page 2 of 41
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
Centers for Medicare & Medicaid Services (CMS)
administrative agency in the federal Department of Health & Human Services
clinical documentation improvement (clinical documentation integrity)
helps ensure accurate and thorough patient record documentation and identifies
discrepancies between provider documentation and codes to be assigned
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CMS-1450 (UB-04)
Standard claim submitted by health care institutions to third-party payers for inpatient and
outpatient services
CMS-1500
claim submitted by physicians' offices to third-party payers
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code
numerical and alphanumerical characters that are reported to health plans for health care
reimbursement and to external agencies for data collection, in addition to being reported
internally for education and research
coder
acquires a working knowledge of coding systems, CPT, HCPCS Level II, ICD-10-CM, ICD-10-
PCS, coding principles and rules, govt regulations nad third-party payer requirements to
ensure that all diseases, injuries, reasons for an encounter, services, and procedures
documented in patient records are coded accurately for reimbursement, research, and
statistical purposes
coding
assignment of codes to diagnoses, services, and procedures based on patient record
documentation
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