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CBCS: Module 3 Vocab

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Term
Definition
show Reviewing medical record documentation to discover clinical concepts that assigning codes to the highest level of specificity  
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Clinical Documentation   show
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show Current Procedural Technology. Codes for services and procedures  
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show 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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HCPCS   show
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show International Classification of Diseases 10th Revision Clinical Modification. This codes for diseases/injuries/statuses  
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show Process of abstracting diagnoses, procedures, and services from the medical record and converting them to alphanumeric codes for claims submission's  
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Medical Necessity   show
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show Documents health care services provided to a patient  
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Query   show
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Claim Denial   show
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Downcoding   show
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show 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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show Provides additional information about a procedure or service without altering the definition of the code description  
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Preauthorization   show
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show 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  
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Unbundling   show
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show Assignment of ICD-10-CM code that is more severe then diagnosis supported by the documentation in the medical record  
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