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MBC2025

Flash Cards for Diagnostic Coding for MBC notes

TermDefinition
coding the assignment of numeric or alphanumeric digits and characters to specific diagnostic and procedural phrases
The World Health Organization (WHO) in 1948, assumed responsibility for preparing and publishing the revisions to the ICD every 10 years. Thus, with every 10-year revision, the name of the current ICD changes.
An abbreviation for the International Classification of Diseases, Tenth Revision, Clinical Modification ICD-10-CM
ICD-10-CM an arrangement of classes or groups of diagnoses by systematic division that is used in the United States
mortality the rate or frequency of deaths
morbidity the rate or frequency of disease
National Center for Health Statistics (NCHS) in the United States, is responsible for maintaining the ICD-10-CM diagnostic codes.
The Centers for Medicare and Medicaid Services (CMS) responsible for maintaining the procedure codes of ICD-10-PCS.
Health Insurance Portability and Accountability Act (HIPAA) passed by Congress in 1996 to improve the portability and continuity of health care coverage
Administrative Simplification developed standards for the electronic exchange of health care data by administrative and financial transactions
The American Health Information Management Association (AHIMA) represents health information professionals who manage, organize, process, and manipulate patient data.
The American Academy of Professional Coders (AAPC) was founded to elevate the standards of medical coding.
The Certified Professional Coder (CPC) certification validates a coder’s proficiency in the physician office setting
the Certified Inpatient Coder, (CIC) certification validates proficiency in the inpatient hospital setting
Certified Outpatient Coder (COC) certification validates coding proficiency in outpatient hospital and outpatient facility coding.
Certified Risk Adjustment Coder (CRC) certification validates that a coder can read a medical chart and assign the correct diagnosis (ICD-10-CM) codes for a wide variety of clinical cases and services for risk adjustment models.
The Tabular List of Diseases and Injuries an alphanumerical list of codes, commonly referred to as the Tabular.
divided into chapters based on body system (anatomical site) or condition (etiology) The Tabular List
Conventions instructional notes, punctuation marks, abbreviations, and symbols
Instructional notes appear in both the Tabular List and Alphabetic Index of ICD-10-CM.
Includes note used to define, give examples, or both, of the content of a category of ICD-10-CM or of a block of category codes.
Excludes notes used to signify that the conditions listed are not assigned to the category or block of category codes.
How many types of Excludes Notes are there? Two
Excludes1 note easy to understand and apply.
Excludes2 note used to signify that the diagnostic terms listed after the note are not part of the condition(s) represented by the code or code block.
See note used in the Alphabetic Index of ICD-10-CM and instructs the coder to cross-reference the term or diagnosis that follows the notation.
See Also note refers the coder to another location in the Alphabetic Index when the initial listing does not contain all the necessary information to accurately select a code.
Code First note instructs the coder to select a code to represent the etiology that caused the manifestation.
Use Additional Code note instructs the coder to use an additional code to identify the manifestation that is present.
In Diseases Classified Elsewhere Note applies to the etiology/manifestation conventions.
Code Also note is used in ICD-10-CM to instruct the coder that two codes may be needed to fully code a diagnostic phrase.
The terms found within the parentheses are referred to as nonessential modifiers.
Parentheses are used in both the Tabular List and Alphabetic Index. Parentheses are used around terms that provide additional information about the main diagnostic term.
Brackets are used in the Tabular Listing and in the Alphabetic Index.
A colon is used in the Tabular listing after a term that is modified by one or more of the terms following the colon
What does NEC stand for? not elsewhere classifiable
What does NOS Stand for? not otherwise specified.
The point dash symbol (.–) tells the coder that the code contains a list of options at a level of specificity past the three-character category.
Granularity the level of detail.
Laterality for bilateral sites ICD-10-CM indicates the specific site.
Created by: Chlamelt
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