Term
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Definition
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Term
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Definition
| principal repository for data and information about the healthcare services provided to a patient |
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Term
| primary purpose of health record |
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Definition
| associated directly with the provision of patient care services - patient care delivery, patient care mgmt, patient care support processes, financial & other administrative processes |
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Term
| secondary purpose of health record |
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Definition
| related to the environment in which healthcare services are provided - education, research, regulation & policy making |
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Term
| IOM definition of users of healthcare records |
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Definition
| those individuals who enter, verify, correct, analyze or obtain information from the record, either directly or indirectly through an intermediary |
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Term
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Definition
| data applications, data collections, data warehousing & data analysis |
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Definition
| accuracy, accessibility, comprehensiveness, consistency, currency, definition, granularity, precision, relevancy, timeliness |
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Term
| paper based record system |
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Definition
| source oriented, problem oriented, integrated |
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Term
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Definition
| documents the patient's medical condition, diagnosis, treatment & services provided |
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Definition
| demographic & financial info and consents & authorizations |
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Definition
| summary of the patient's problems with a detailed plan for intervention |
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Definition
| surgical procedures performed on the patient |
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Definition
| postanesthesia note, nurses' notes regarding the patient's condition & surgical site, vital signs, intravenous fluids & other medical monitoring |
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Definition
| dictated by the pathologist after examination of tissue received for evaluation |
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Definition
| documents the clinical opinion of a physician other than the primary/attending physician |
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Definition
| a concise account of the patient's illness, course of treatment, response to treatment & condition at the time the patient is discharged |
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Definition
| the study of statistical characteristics of human populations |
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Definition
| permission granted by the patient or representative to release info for other than treatment, payment or healthcare operations |
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Term
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Definition
| used when the permission is for treatment, payment or healthcare operations |
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Definition
| written document that names the patient's choice of legal representative for healthcare purposes - (living wills) |
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Term
| Patient Self Determination Act |
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Definition
| requires healthcare facilities to provide written information on the patient's right to execute advance directives & to accept or refuse medical treatment |
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Definition
| standardized patient assessment insturment used for home health care |
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Term
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Definition
| physician reviews & renews the home health certification/plan of care |
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Term
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Definition
| documentation of a care plan review is required |
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Term
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Definition
| an electronic, universally available, lifelong resource of health information needed by individuals to make health decisions |
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Term
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Definition
| paper, electronic & hybrid |
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Term
| types of paper based records |
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Definition
| source oriented (grouped together), problem oriented (itemized), integrated(chronological order) |
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Term
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Definition
| vocabulary of clinical & medical terms used by healthcare providers to document patient |
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Term
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Definition
| diseases, injuries& impairments, causes of injuries, disease or impairments, actions taken to prevent, diagnose, treat or manage diseases, substances, equipment & supplies |
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Term
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Definition
| race, ethnicity, type of facility, type of unit |
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Term
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Definition
| reporting multiple codes to increase reimbursement when a single combination code should be used |
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Term
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Definition
| reporting codes that are not supported by documentation in the patient record |
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Term
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Definition
| reporting codes for signs & symptoms in addition to the established diagnosis code |
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Term
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Definition
| assigning 0 ir 9 as the 4th or 5th digit instead of reviewing the coding manual for the appropriate code |
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Term
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Definition
| assigning lower level CPT codes instead of reviewing patient record documentation & coding manual to determine the proper code |
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Term
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Definition
| diagnosis, condition, problem or other reason for the encounter documented in the record to be chiefly responsible for the services provided |
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Term
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Definition
| condition established after study to be chiefly responsible for the admission of the patient to the hospital |
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Term
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Definition
| performed for definitive treatment rather than dagnostic or exploratory purposes, necessary to treat complications |
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Term
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Definition
| diagnoses documented as probable, suspected, questionable, rule out or working diagnosis |
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Term
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Definition
| Codes used to indicate the external circumstances for injuries. |
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Term
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Definition
| Codes used to indicate the conditions not included in the main classification but may be recorded as diagnoses. |
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Term
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Definition
| International Classification of Diseases, Ninth Revision, Clinical Modification |
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Term
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Definition
| A medical classification system used for the collection of information regarding disease and injury (mortality and morbidity) for medical record indexing and medical care review. Based on the Word Health Organization official version of ICD-9 and what is currently used in the U.S. |
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Term
| When are modifications made and who makes them? |
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Definition
| Yearly modifications are made by the ICD-9-CM Co-cordination and Maintenance Committee (C&M). |
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Term
| Who is on the C&M Committee? |
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Definition
| Members of C&M Committee are composed of individuals from: American Medical Association (AMA), the National Center for Heath Statistics (NCHS), Centers for Medicare and Medicaid (CMS) {formerly known as HCFA}, and the American Health Information Management Association (AHIMA). |
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Term
| What does Clinical Modification (CM) mean? |
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Definition
| More precise codes to describe illnesses. |
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Term
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Definition
| Identification of a disease based on signs and symptoms. They can be listed as eponyms, nouns, syndromes or adjectives. Not by anatomical site. |
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Term
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Definition
| Diseases named after an individual |
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Term
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Definition
| A group of symptoms that collectively indicate or characterize a disease, psychological disorder, or other abnormal condition. |
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Term
| How many volumes in ICD-9-CM for Hospitals? |
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Definition
| ICD-9-CM for Hospitals consists of 3 volumes: Volume 1 the Tabular List, Volume 2 the Alphabetic Index of Diseases and Volume 3 Procedures. |
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Term
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Definition
| Consists of 17 chapters, numeric list of codes and their descriptors by chapter; Supplementary classification of factors influencing health status and contact with health services which at the V-CODES (V01-V91); Supplementary classification of external causes of injury and poisoning which are the E-CODES (E000-E999); Appendix A (Morphology of Neoplasms- histological type and behavior); Appendix C classification of drugs by the American Hospital Fomulary Service List number and their ICD-9-CM equivalents. |
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Term
| Volume 2 Alphabetic Index |
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Definition
| Alphabetic Index to Diseases and Injuries; Table of Drugs and Chemicals; Index to External Causes of Injury - E-Codes; Hypertension table; and Neoplasm table. |
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Term
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Definition
| Alphabletic Index to Procedures; Procedures Tablular List |
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Term
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Definition
| Headings are listed as mainterms from left to right and are in bold type in the alphabetic indices and tabular lists. |
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Term
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Definition
| Have the page number on the top left of the tabular list, followed by descriptors; then number range for each i.e. 001-139 The number ranges identify a group of related or similar diseases that affect similar body organs. |
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Term
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Definition
| The division of each chapter.Consists of groups of 3 digit categories within that chapter i.e. 001-009. |
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Term
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Definition
| A basic code or one code made up of 3 digits are represents one condition i.e. 003 Other Salmonella Infections. |
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Term
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Definition
| A more specificied disease or condition that is indented under a 3 digit category. It's the fourth digit. i.e. 003.0 Salmonella gastroenteritis |
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Term
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Definition
| A more specific disease or condition indented under the subcategory. The fourth digit has been expanded to a fifth digit. i.e. 003.21 Salmonella Meningitis. |
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Term
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Definition
| Consists of abbreviations, symbols, footnotes, boldface and italacized type, and punctuation marks. The following are boldface: Main terms in the Index; Category titles; Subcategory titles; and Code numbers. |
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Term
| Alphabetic Index Abbreviation "NEC" |
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Definition
| Means not elsewhere classified In the Index when a code is not available for a specific condition, the coder is directed to other or other specified condition. Ex: Pneumoconiosis dust NEC 504. |
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Term
| Tabular Abbreviations "NEC" |
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Definition
| Not elsewhere classified in tabular represents other specified and has a NEC entry under the code to identify it as an other specified condition. Ex: Influenza 487.1 with other respiratory manifestations Influenza NEC. NOTE: Use when there really is no other code only. |
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Term
| Tabular Abbreviations "NOC" |
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Definition
| NOC is not otherwise specified. This abbreviation is equivalent to unspecified. Ex: Influenza NOC. NOTE: You will see this with an ill defined diagnostic statement, meaning if you had more information you could get a better code. Can query doctor for better code. |
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Term
| Types of Punctuation used in Alphabetic and Tabular Lists |
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Definition
| Brackets, Parentheses, and Colon. (In some older volumes Braces). |
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Term
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Definition
| Enclose synonyms, alternative terminology and explanatory phrases. |
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Term
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Definition
| Used in the tabular list after an incomplete term that needs one or more of the modifiers that follows in order to make it assignable to a given category. Allso used in both inclusion and exclusion notes. |
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Term
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Definition
| Enclose supplementary words, non-essential modifiers that may be present or absent, in the disease description without affecting the code assignment. |
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Term
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Definition
| These include general notes, inclusion and exclusion notes, code first notes, and use additional code notes. |
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Term
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Definition
| Most general notes in the Tabular List of diseases provide information regarding the 5th digits that must be used; a few provide general information on usage in a specific section that explains the 4th and 5th digits (see cod 250). In the Alphabetic Index general information notes are usually enclosed in boxes and printed in italic type. |
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Term
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Definition
| Appears in the Tabular List and is introduced by the word includes at the beginning of a chapter or section. The word includes is not used when the note applies to a category or subcategory. Section Ex: 001-139; Category Ex: 007 or 216 |
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Term
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Definition
| List of terms included under certain 4 or 5 digit codes. These terms are the condition for which that code number is to be used. The terms may be synonyms of the code title, or in the case of other specified codes the terms are a list of various conditions assigned to that code. They are not necessarily exhaustive. Additional terms found only in the index may also be assigned to a code. |
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Term
| Uniform Hospital Discharge Data Set (UHDDS) |
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Definition
| Is used for reporting impatient data in acute care, short term care, and long term care hospitals |
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Term
| The UHDDS requiere the following items |
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Definition
| Principal diagnoses, other diagnoses that have significance for the specific hospital episode, and all significant procedures |
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Term
| Other items of general information regarding the patient and the specific episode of care |
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Definition
| age, sex, and race of the patient, expected payer and hospital identification. |
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Term
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Definition
| Definition and guidelines for selection of principal diagnosis and other ( secondary)diagnoses apply to: Acute care short-term hospitals, long-term care hospitals, psychiatric hospitals, home health agencies, rehabilitation facilities, nursing homes. |
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Term
| Principal diagnosis- definition |
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Definition
| The condition established after study to be chiefly responsible for admission of the patient to the hospital. |
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Term
| Importance of correct selection of Principal Diagnosis |
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Definition
| Significant in cost comparisons, in care analysis, and in utilization review.Crucial for reimbursement because many third-party payers ( including Medicare) base reimbursement primarily on principal diagnosis. |
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Term
| Principal Diagnosis and after study. |
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Definition
| The principal diagnosis is not the admitting diagnosis, but the diagnosis found after workup or even after surgery that proves to be the reason for the admission, is ordinary listed first in the physician diagnostic statement, but this is not always the case. |
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Term
| Selection of Principal Diagnosis |
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Definition
| The circumstances of inpatient admission always govern the selection of the principal diagnosis, coding directives manuals volumes 1,2 and 3, take precedence over all other guidelines. Complete documentation is important without it the application of all coding guidelines is very difficult. |
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Term
| Admission Following Medical Observation |
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Definition
| Principal diagnosis: If the condition of the patient either worsen or doesn't improve, the physician may decide to admit the patient as an impatient. Report the medical condition that led to the hospital admission |
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Term
| Admission Following Postoperative Observation |
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Definition
| If the patient doesn't improve, the physician may admit the patient to the same hospital as an inpatient.Principal Diagnosis: Apply UHDDS definition of principal diagnosis- |
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Term
| Admission from Outpatient Surgery |
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Definition
| If no complication or other condition is documented as the reason for the inpatient admission, assign the reason for the outpatient surgery as the principal diagnosis- If the reason is for another condition unrelated to the surgery, assign the unrelated condition as the principal diagnosis. |
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Term
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Definition
| In the unusual situation in which two or more diagnoses equally meet the criteria for principal diagnosis as determined by the circumstances of the admission and the diagnostic workup and/or therapy provided, either may be sequenced first . |
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Term
| Comparable or contrasting conditions |
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Definition
| Two or more comparable or contrasting conditions, both diagnoses are coded as though confirmed and the principal diagnoses is designated according to the circumstances of the admission or when no further determination can be made as to which diagnosis more closely meet the criteria for principal diagnosis, either may be sequenced first. |
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Term
| Symptom Followed by contrasting/comparative diagnoses |
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Definition
| The symptom code is sequenced first. However, if the symptom code is integral to each of the condition listed, no additional code for the symptom is reported. |
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Term
| UHDDS definition of other diagnoses |
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Definition
| Includes only those conditions that affect the episode of hospital care in terms of any of the following: Clinical evaluation-therapeutic treatment-further evaluation by diagnostic studies, procedures, or consultation-extended length of hospital stay-increased nursing care and/or monitoring. |
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Term
| Reporting Guidelines for other diagnoses |
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Definition
| Previous conditions stated as diagnoses, other diagnoses with no documentation supporting reportability |
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Term
| Chronic conditions that are not the thrust of treatment |
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Definition
| Criteria for selection of these chronic conditions to be reported as other diagnoses include: the severity of the condition, the use or consideration of alternative measures, an increase in nursing care, the use of diagnostic or therapeutic services, the need for close monitoring, and modifications of nursing care plans. |
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Term
| Conditions that are an integral part of a disease process |
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Definition
| should not be reported as additional diagnoses, unless otherwise instructed by the classification Example: a patient was admitted with nausea and vomiting due to infectious gastroenteritis. Nausea and vomiting are common symptoms of infectious gastroenteritis and are therefore not reported. |
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Term
| Condition that are not an integral part of a disease process. |
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Definition
| Should be coded when present. |
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Term
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Definition
| codes should never be assigned on the basis of an abnormal finding alone. |
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Term
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Definition
| The admitting diagnosis is not an element of the UHDDS. It must be reported for some payers and may be useful in quality-of-care studies. Ordinarily, only one admitting diagnosis can be reported. |
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Term
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Definition
| The UHDDS requires that all significant procedures be reported. |
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Term
| Relationship of UHDDS to outpatient reporting |
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Definition
| The UHDDS definition of principal diagnosis does not apply to outpatient encounters, if the physician does not identify a definite condition or problem at the conclusion of a visit or encounter, report the document chief complaint as the reason for the encounter/visit. |
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Term
| Ethical coding and reporting |
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Definition
| Medicare reimbursement depends on: the correct designation of the principal diagnosis, the presence or absence of additional codes that represent complications, comorbidities, or major complications as defined by MSDRG system, and procedures performed. |
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Term
| Ethical coding and reporting (cont) |
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Definition
| Accurate and ethical ICD-9-CM coding- depends on correctly following all instructions in the coding manuals, official guidelines and coding clinic for ICD-9-CM and has to meet the criteria set by the UHDDS. |
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Term
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Definition
| It is inappropriate for coders to assign a diagnosis based solely on physician orders for prescribed medications without the physician's documentation of the diagnosis being treated.No diagnosis should be added without the approval of the physician. |
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Term
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Definition
| Physicians may not be aware of coding and reporting guidelines and may not always list the principal diagnosis first in the diagnosis statement. Medical record documentation must support the designation of principal diagnosis. |
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Term
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Definition
| Test performed and their findings, therapies provided, descriptions of surgical procedures, and daily records of the patient's progress. |
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Term
| Documentation of final diagnoses |
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Definition
| A physician may list final diagnoses on a variety of reports, including:Admission record (face sheet) -progress note, or discharge summary. |
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Term
| Review of the inpatient medical record |
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Definition
| The coder do not have to assume a diagnosis solely on the basis of medication administration or abnormal findings in diagnostic reports. |
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Term
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Definition
| do not always contain sufficient information for providing the required specificity in coding.Examples of reports to provide further specificity: Lab report for the organism responsible for infection. X-ray or operative report for the specific bone fractured. The physician should indicate confirmation by documentation in the medical record. |
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Term
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Definition
| Code assignment is generally based on the attending physician's documentation however code assignment may be based on the documentation of other physician's (e.g., consultants, residents, anesthesiologists, etc.) |
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Term
| Mid-level provider documentation |
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Definition
| such as nurse practitioners and physician assistants, who are involved in the care of the patient and who document diagnoses on the health record. (code assignment has to check if they are considered legally accountable for establishing a diagnoses) |
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Term
| present on admission (POA) indicator |
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Definition
| Data element approved by the National Uniform Billing Committee (NUBC) for inpatient reporting. |
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