321 code it chapter 1

Unbundling - answer-Reporting multiple codes to increase reimbursement when a single combination code should be reported. Upcoding - answer-Reporting codes that are not supported by documentation in the patient record for the purpose of increasing reimbursement overcoding - answer-Reporting codes for signs and symptoms in adition to tge establushed diagnosis cide Jamming - answer-Routinely assigning an unspecific ICD-10-CM disease code instead of reviewing the code manual to select the appropiate code Downcoding - answer-Routinely assigning lowe level CPT coses as convenience instead of reviewing patient record documentation and the coding manual to determine the proper code to be reported Medical coding process - answer-Requieres the review of patient tecord documemtation to identify diagnoses, procedures and services for tge purpose of assigning ICD-10-CM, ICD-10PCS, HCPcS level II, or CPT codes Concurrent coding - answer-Is the review of records ir use of encounter forms and changemaster to assign codes during inpatient stay or outpatient encounter Endcoding - answer-Process of standardizing data by assigning alphanumeric values Coding - answer-Assignment of codes to diagnoses services and procedures based on patient record documentation Code - answer-Includes numeric and alphanumeric characters that are reported to health plans Medical nomenclature - answer-Is a vocabulary and medical terms Coding system - answer-Organizes a medical nomenclature according to similar conditions diseases procedures and services Intership - answer-Benefits the student and the facility that acepta the student for placement Internship supervisor - answer-The person who the student reports at the site Application service provider (ASP) - answer-Third party entity that manages and distributes software based services and solutions to costumers across wide area network from a central data center Online discussion board or listserv - answer-Internet based or email discussion forum that cover a variety of topics and issues Assumption coding - answer-Codes based on assuming, from a review of clinical evidence in the patients record, that the patient has certain diagnoses or received certain procedures/ services even though the provider did not specifically documented those diagnoses or procedures. Physician query process - answer-Is used when coders have questions about document diagnoses and procedures or services they use the query to contact the responsable physician to request clarification about a document Computer-assisted coding (CAC) - answer-Uses software to automatically generate codes by reading transcribe clinical documentation provide by health care practitioners. Evidence based coding - answer-Involves clicking on codeas that CAC software generates to review electronic health records used to generate that code. Alternative billing codes (ABC codes) - answer-Classify services not included in the CPT manual to describe the service supply or therapy provide, they might also be assigned to report nurses services or alternative medicine. Clinical care classification system (CCC) - answer-Provides a new standardized framework and unique coding structure for assessing documenting and classifying home health and ambulatory care. Current Dental Terminology (CDT) - answer-It classifies dental procedure and services Diagnostic and statistical manual of mental disorders (DSM) - answer-Classification of mental disorders use by mental health professionals Health insurance prospective payment system (HIPPS)rate codes - answer-Alphanumerical codes consisting on five digits International classification of diseases for oncology third edition (ICD-O-3) - answer-This was implemented in 2001 as a classification of neoplasms used by cancer registries throughout the world to record incidence of malignancy and survival rates. ICD morphology codes - answer-Indicate the type of cell that has become neoplastic and it's biological activity in order words, the kind of tumor that developed and how behaves International classification of functioning, disability and health (ICF) - answer-Classifies health and health related domains that describe body functions and structure, activities and participation. Logical observation identifiers names and codes (LOINC) - answer-Electronic data beard and universal standard that is use to identify medical laboratory observations and for the purpose of clinical care management. National drug codes (NDC) - answer-Is managed by the FDA is established as part of an out of hospital drug reimbursement program under Medicare services as a universal product identifier for human drugs Rx Norm - answer-Provides names for clinical drugs and links it's names to many of the drug vocabularies Unified medical language system (UMLS) - answer-Is a set of files and software that allows many health and biomedical vocabularies and standard to enable interoperability among computer systems. Medical record - answer-Is the business record for a patient encounter that documents health care services provided to a patient Demographic data - answer-Patient identification information such as name, date of birth, Continuity of care - answer-Serve as a communication tool for physicians and other patient care professionals. Assist planning and documenting patient illness and treatment Primary purpose of the record - answer-To provide continuity of care Secondary purpose of the record - answer-Evaluating the quality of patient care Secondary propuse of the record - answer-Provide data for clinical research Secondary propuse of the record - answer-Provide information to third party payers for reimbursement Secondary propuse of the record - answer-Serving the médico legal interest of the patient facility and providers of care Documentation - answer-Notes and reports in the patients records by a health care professional Teaching hospital - answer-An approved graduate medical education residency program in medicine, osteopathy, dentistry or podiatry Teaching physician - answer-A physician who supervises residents during patient care Resident physician - answer-Individual who participates in an approved GME program Hospitalist - answer-A physician who provides care for hospital inpatients Medical necessity - answer-Patient s diagnosis must also justify diagnostic and therapeutic procedures or services provided Manual record - answer-Paper based Automated record - answer-Uses computer technology Hybrid record - answer-Consist of both paper based and computer generated documents Source oriented record - answer-Are organized according to documentation source Problem oriented record - answer-Systematic method consisting of database problem list initial plan progress notes POR database - answer-Contains patient information including chief com