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ICD-9
Faye Brown Ch 1-4
105
Medical
Undergraduate 2
10/03/2012

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Cards

Term
Terms
Definition
Definitions
Term
health record
Definition
principal repository for data and information about the healthcare services provided to a patient
Term
primary purpose of health record
Definition
associated directly with the provision of patient care services - patient care delivery, patient care mgmt, patient care support processes, financial & other administrative processes
Term
secondary purpose of health record
Definition
related to the environment in which healthcare services are provided - education, research, regulation & policy making
Term
IOM definition of users of healthcare records
Definition
those individuals who enter, verify, correct, analyze or obtain information from the record, either directly or indirectly through an intermediary
Term
quality domains
Definition
data applications, data collections, data warehousing & data analysis
Term
quality characteristics
Definition
accuracy, accessibility, comprehensiveness, consistency, currency, definition, granularity, precision, relevancy, timeliness
Term
paper based record system
Definition
source oriented, problem oriented, integrated
Term
clinical data
Definition
documents the patient's medical condition, diagnosis, treatment & services provided
Term
administrative data
Definition
demographic & financial info and consents & authorizations
Term
care plan
Definition
summary of the patient's problems with a detailed plan for intervention
Term
operative reports
Definition
surgical procedures performed on the patient
Term
recovery room report
Definition
postanesthesia note, nurses' notes regarding the patient's condition & surgical site, vital signs, intravenous fluids & other medical monitoring
Term
pathology report
Definition
dictated by the pathologist after examination of tissue received for evaluation
Term
consultation report
Definition
documents the clinical opinion of a physician other than the primary/attending physician
Term
discharge summary
Definition
a concise account of the patient's illness, course of treatment, response to treatment & condition at the time the patient is discharged
Term
demographics
Definition
the study of statistical characteristics of human populations
Term
authorization
Definition
permission granted by the patient or representative to release info for other than treatment, payment or healthcare operations
Term
consent
Definition
used when the permission is for treatment, payment or healthcare operations
Term
advance directive
Definition
written document that names the patient's choice of legal representative for healthcare purposes - (living wills)
Term
Patient Self Determination Act
Definition
requires healthcare facilities to provide written information on the patient's right to execute advance directives & to accept or refuse medical treatment
Term
OASIS
Definition
standardized patient assessment insturment used for home health care
Term
every 60 days
Definition
physician reviews & renews the home health certification/plan of care
Term
every 30 days
Definition
documentation of a care plan review is required
Term
personal health record
Definition
an electronic, universally available, lifelong resource of health information needed by individuals to make health decisions
Term
health record formats
Definition
paper, electronic & hybrid
Term
types of paper based records
Definition
source oriented (grouped together), problem oriented (itemized), integrated(chronological order)
Term
medical nomenclature
Definition
vocabulary of clinical & medical terms used by healthcare providers to document patient
Term
large code sets
Definition
diseases, injuries& impairments, causes of injuries, disease or impairments, actions taken to prevent, diagnose, treat or manage diseases, substances, equipment & supplies
Term
small code set
Definition
race, ethnicity, type of facility, type of unit
Term
unbundling
Definition
reporting multiple codes to increase reimbursement when a single combination code should be used
Term
upcoding
Definition
reporting codes that are not supported by documentation in the patient record
Term
overcoding
Definition
reporting codes for signs & symptoms in addition to the established diagnosis code
Term
jamming
Definition
assigning 0 ir 9 as the 4th or 5th digit instead of reviewing the coding manual for the appropriate code
Term
downcoding
Definition
assigning lower level CPT codes instead of reviewing patient record documentation & coding manual to determine the proper code
Term
first listed diagnosis
Definition
diagnosis, condition, problem or other reason for the encounter documented in the record to be chiefly responsible for the services provided
Term
principal diagnosis
Definition
condition established after study to be chiefly responsible for the admission of the patient to the hospital
Term
principal procedure
Definition
performed for definitive treatment rather than dagnostic or exploratory purposes, necessary to treat complications
Term
qualified diagnosis
Definition
diagnoses documented as probable, suspected, questionable, rule out or working diagnosis
Term
E-Codes
Definition
Codes used to indicate the external circumstances for injuries.
Term
V-Codes
Definition
Codes used to indicate the conditions not included in the main classification but may be recorded as diagnoses.
Term
ICD-9-CM (stands for)
Definition
International Classification of Diseases, Ninth Revision, Clinical Modification
Term
ICD-9-CM (definition)
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.
Term
When are modifications made and who makes them?
Definition
Yearly modifications are made by the ICD-9-CM Co-cordination and Maintenance Committee (C&M).
Term
Who is on the C&M Committee?
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).
Term
What does Clinical Modification (CM) mean?
Definition
More precise codes to describe illnesses.
Term
Definition of diagnosis
Definition
Identification of a disease based on signs and symptoms. They can be listed as eponyms, nouns, syndromes or adjectives. Not by anatomical site.
Term
Eponyms
Definition
Diseases named after an individual
Term
Syndrome
Definition
A group of symptoms that collectively indicate or characterize a disease, psychological disorder, or other abnormal condition.
Term
How many volumes in ICD-9-CM for Hospitals?
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.
Term
Volume 1 Tabular List
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.
Term
Volume 2 Alphabetic Index
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.
Term
Volume 3 Procedures
Definition
Alphabletic Index to Procedures; Procedures Tablular List
Term
What are Headings?
Definition
Headings are listed as mainterms from left to right and are in bold type in the alphabetic indices and tabular lists.
Term
Chapters
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.
Term
Sections
Definition
The division of each chapter.Consists of groups of 3 digit categories within that chapter i.e. 001-009.
Term
Category
Definition
A basic code or one code made up of 3 digits are represents one condition i.e. 003 Other Salmonella Infections.
Term
Subcategory
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
Term
Subclassification
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.
Term
Conventions
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.
Term
Alphabetic Index Abbreviation "NEC"
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.
Term
Tabular Abbreviations "NEC"
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.
Term
Tabular Abbreviations "NOC"
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.
Term
Types of Punctuation used in Alphabetic and Tabular Lists
Definition
Brackets, Parentheses, and Colon. (In some older volumes Braces).
Term
Brackets
Definition
Enclose synonyms, alternative terminology and explanatory phrases.
Term
Colon
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.
Term
Parentheses
Definition
Enclose supplementary words, non-essential modifiers that may be present or absent, in the disease description without affecting the code assignment.
Term
Instructional Notes
Definition
These include general notes, inclusion and exclusion notes, code first notes, and use additional code notes.
Term
General Notes
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.
Term
Inclusion Notes
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
Term
Inclusion Terms
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.
Term
Uniform Hospital Discharge Data Set (UHDDS)
Definition
Is used for reporting impatient data in acute care, short term care, and long term care hospitals
Term
The UHDDS requiere the following items
Definition
Principal diagnoses, other diagnoses that have significance for the specific hospital episode, and all significant procedures
Term
Other items of general information regarding the patient and the specific episode of care
Definition
age, sex, and race of the patient, expected payer and hospital identification.
Term
UHDDS application
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.
Term
Principal diagnosis- definition
Definition
The condition established after study to be chiefly responsible for admission of the patient to the hospital.
Term
Importance of correct selection of Principal Diagnosis
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.
Term
Principal Diagnosis and after study.
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.
Term
Selection of Principal Diagnosis
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.
Term
Admission Following Medical Observation
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
Term
Admission Following Postoperative Observation
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-
Term
Admission from Outpatient Surgery
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.
Term
Two or more conditions
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 .
Term
Comparable or contrasting conditions
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.
Term
Symptom Followed by contrasting/comparative diagnoses
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.
Term
UHDDS definition of other diagnoses
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.
Term
Reporting Guidelines for other diagnoses
Definition
Previous conditions stated as diagnoses, other diagnoses with no documentation supporting reportability
Term
Chronic conditions that are not the thrust of treatment
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.
Term
Conditions that are an integral part of a disease process
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.
Term
Condition that are not an integral part of a disease process.
Definition
Should be coded when present.
Term
Abnormal Finding
Definition
codes should never be assigned on the basis of an abnormal finding alone.
Term
Admitting Diagnosis
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.
Term
Procedures
Definition
The UHDDS requires that all significant procedures be reported.
Term
Relationship of UHDDS to outpatient reporting
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.
Term
Ethical coding and reporting
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.
Term
Ethical coding and reporting (cont)
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.
Term
Documentation
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.
Term
Documentation (Cont..)
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.
Term
Medical Records Reports
Definition
Test performed and their findings, therapies provided, descriptions of surgical procedures, and daily records of the patient's progress.
Term
Documentation of final diagnoses
Definition
A physician may list final diagnoses on a variety of reports, including:Admission record (face sheet) -progress note, or discharge summary.
Term
Review of the inpatient medical record
Definition
The coder do not have to assume a diagnosis solely on the basis of medication administration or abnormal findings in diagnostic reports.
Term
Coding specificity
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.
Term
Physician documentation
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.)
Term
Mid-level provider documentation
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)
Term
present on admission (POA) indicator
Definition
Data element approved by the National Uniform Billing Committee (NUBC) for inpatient reporting.
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