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CBCS: Module 3 Vocab
| Term | Definition |
|---|---|
| Abstracting | Reviewing medical record documentation to discover clinical concepts that assigning codes to the highest level of specificity |
| Clinical Documentation | Information recorded in the medical record pertaining to the health status of a patient as determined by a health care provider |
| CPT | Current Procedural Technology. Codes for services and procedures |
| Electronic Health Record (EHR) | A digital version of a patient's chart that includes information documented by multiple providers at different facilities regarding one patient |
| HCPCS | Healthcare Common Procedure Coding System |
| ICD-10-CM | International Classification of Diseases 10th Revision Clinical Modification. This codes for diseases/injuries/statuses |
| Medical Coding | Process of abstracting diagnoses, procedures, and services from the medical record and converting them to alphanumeric codes for claims submission's |
| Medical Necessity | Process of providing diagnosis codes that support the services rendered to the patient; coding for medical necessity involves associating applicable diagnosis codes to service/procedure codes within the billing software a.k.a. linking/linkage |
| Medical Record | Documents health care services provided to a patient |
| Query | Contacting the responsible provider to request clarification about documented diagnoses or procedures |
| Claim Denial | Unpaid medical claim returned to payer due to coding errors, missing information, preauthorization requirements, or health plan coverage issues |
| Downcoding | Unpaid medical claim returned by payer due to coding errors, missing information. preauthorization requirements, or health plan coverage issues |
| Encounter Form | Financial record source document used by providers to record treated diagnoses and services provided to a patient for a single encounter |
| Modifier | Provides additional information about a procedure or service without altering the definition of the code description |
| Preauthorization | Prior approval for services granted by payer after health pan review |
| (HPI) History of Present Illness | Brief description pf the patient's present illness or other reason for an encounter, including details about location, duration, severity, and associated signs and symptoms |
| Unbundling | Submitting multiple CPT codes when a single code is available to report services in full |
| Upcoding | Assignment of ICD-10-CM code that is more severe then diagnosis supported by the documentation in the medical record |
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almestica.nashia
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