NHA CBCS Module 3 Coding And Coding
Guidelines Questions & Answers
1. abstracting
Answer Reviewing medical record documentation to discover clinical con- cepts
that support assigning codes to the highest level of specificity.
2. clinical documentation
Answer Information recorded in the medical record pertaining to the health status
of a patient as determined by a health care provider.
3. CPT
Answer Current Procedural Terminology. Codes for services and procedures.
4. electronic health record (EHR)
Answer A digital version of a patient's chart that includes information documented by
multiple providers at different facilities regarding one patient.
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5. HCPCS
Answer Healthcare Common Procedural Coding System.
6. ICD-10-CM
Answer International Classification of Diseases - 10th Revision - Clinical
Modification. Codes for diseases, injuries, and statuses.
7. medical coding
Answer Process of abstracting diagnoses, procedures, and services from the medical
record and converting them to numeric and/or alphanumeric codes for claims
submission.
8. medical necessity
Answer Process of providing diagnosis codes that support the ser- vices rendered to
the patient; coding for medical necessity involves associating applicable diagnosis
codes to service/procedure codes within the billing software, which is referred to as
linking/linkage.
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9. medical record
Answer Documents health care services provided to a patient.
10. query
Answer Contacting the responsible provider to request clarification about docu-
mented diagnoses or procedures.
11. claim denial
Answer Unpaid medical claim returned by payer due to coding errors, missing
information, preauthorization requirements, or health plan coverage issues.
12. downcoding
Answer Unpaid medical claim returned by payer due to coding errors, missing
information, preauthorization requirements, or health plan coverage issues.
13. encounter form
Answer Financial record source document used by providers to record treated
diagnoses and services provided to a patient for a single encounter.
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