Chapter 12 Coding and Clinical Documentation Integrity
Management Test.
1. benchmarking The process of comparing performance with a preestablished
standard or
performance of another facility or group.
2. cc/mcc capture rate Using the MS-DRG system, it is the percent of admissions
within an MS-DRG
family assigned to an MS-DRG with CC, MCC, or both.
3. clean claim rate A measure of the coding unit's or organization's ability to comply
with billing
edits.
4. CDI (Clinical Program that strives to initiate concurrent and retrospective reviews of
Docu- mentation
med- ical records to improve the quality of provider
integrity)
documentation.
5. codding
A component of a health information management compliance
compliance plan
plan or a corporate compliance plan that focuses on the unique
regulations and guidelines with which coding professionals
6. CAC (computer must comply.
as- sisted
coding) Coding tool which uses a process of extracting and translating free-
text data and electronic health record data into medical codes for
billing and coding purposes.
7. denial rate A measure of how well a facility or practice complies with billing
rules and
regulations for all payers. Specific to coding management, it is a
metric used to determine if the coding unit complies with coding
requirements.
8. Discharge 9. DNFB (discharged, not final billed)
status code
1/
9
, Chapter 12 Coding and Clinical Documentation Integrity
Management Test.
Code reported on an inpatient or transferred to at the end of their stay.
claim to identify where the
patient is being discharged A measure of the health of the claims generation process. The
measure can be displayed in days or in dollars.
10. encoder Software program used to facilitate the assignment of diagnostic and
proce-
dure codes according to the rules of the coding system.
11.
2/
9
Management Test.
1. benchmarking The process of comparing performance with a preestablished
standard or
performance of another facility or group.
2. cc/mcc capture rate Using the MS-DRG system, it is the percent of admissions
within an MS-DRG
family assigned to an MS-DRG with CC, MCC, or both.
3. clean claim rate A measure of the coding unit's or organization's ability to comply
with billing
edits.
4. CDI (Clinical Program that strives to initiate concurrent and retrospective reviews of
Docu- mentation
med- ical records to improve the quality of provider
integrity)
documentation.
5. codding
A component of a health information management compliance
compliance plan
plan or a corporate compliance plan that focuses on the unique
regulations and guidelines with which coding professionals
6. CAC (computer must comply.
as- sisted
coding) Coding tool which uses a process of extracting and translating free-
text data and electronic health record data into medical codes for
billing and coding purposes.
7. denial rate A measure of how well a facility or practice complies with billing
rules and
regulations for all payers. Specific to coding management, it is a
metric used to determine if the coding unit complies with coding
requirements.
8. Discharge 9. DNFB (discharged, not final billed)
status code
1/
9
, Chapter 12 Coding and Clinical Documentation Integrity
Management Test.
Code reported on an inpatient or transferred to at the end of their stay.
claim to identify where the
patient is being discharged A measure of the health of the claims generation process. The
measure can be displayed in days or in dollars.
10. encoder Software program used to facilitate the assignment of diagnostic and
proce-
dure codes according to the rules of the coding system.
11.
2/
9
