Introduction to Medical Coding
Expert-defined terms from the Professional Certificate in Medical Coding and Billing course at LearnUNI. Free to read, free to share, paired with a globally recognised certification pathway.
Introduction to Medical Coding #
Introduction to Medical Coding
Medical coding is the process of translating healthcare services and procedures… #
These codes are used for billing purposes, insurance claims, data analysis, and reimbursement. Medical coders play a crucial role in ensuring accurate documentation and coding to support healthcare providers and facilities. This glossary will provide an in-depth look at key terms and concepts related to medical coding in the context of the Professional Certificate in Medical Coding and Billing.
Alphabetical Glossary of Terms #
Alphabetical Glossary of Terms
1 #
ABN (Advanced Beneficiary Notice)
- Explanation: An ABN is a form given to Medicare patients in advance to… #
By signing the ABN, the patient agrees to pay for the service out of pocket if Medicare denies coverage.
2 #
AMA (American Medical Association)
- Explanation: The AMA is a professional organization that publishes the… #
The AMA also provides guidance on coding practices and updates to ensure accurate coding.
3 #
Audit
- Explanation: An audit is a review process conducted to assess the accur… #
Audits can be internal (conducted within the organization) or external (conducted by a third party).
4 #
Bundling
- Explanation: Bundling refers to the practice of combining multiple serv… #
Bundling rules are established by payers to prevent overbilling and ensure appropriate reimbursement.
5 #
CMS (Centers for Medicare & Medicaid Services)
- Explanation: CMS is a federal agency that administers the Medicare and… #
It sets regulations and guidelines for healthcare providers, including coding and billing requirements.
6 #
CPT (Current Procedural Terminology)
- Explanation: CPT is a standardized code set published by the AMA for re… #
It is used by healthcare providers, coders, and payers to communicate information about the services provided.
7 #
Denial
- Explanation: A denial occurs when a claim for reimbursement is not acce… #
Providers can appeal denials to request reconsideration and payment.
8 #
E/M (Evaluation and Management)
- Explanation: E/M codes are used to report patient encounters for evalua… #
These codes reflect the complexity of the visit based on factors such as history, exam, and medical decision-making.
9. ICD #
10-CM (International Classification of Diseases, 10th Revision, Clinical Modification)
- Explanation: ICD-10-CM is a diagnostic code set used to report patient… #
It provides a standardized system for classifying diseases, injuries, and other health conditions.
10 #
Modifier
- Explanation: A modifier is a two-digit code used to provide additional… #
Modifiers may indicate a specific circumstance, such as a bilateral procedure or a separate service performed on the same day.
11 #
NCCI (National Correct Coding Initiative)
- Explanation: NCCI is a set of coding edits developed by CMS to promote… #
NCCI edits identify code pairs that should not be reported together in most circumstances.
12 #
Payer
- Explanation: A payer is an entity that pays for healthcare services on… #
Payers establish reimbursement rates and guidelines for coding and billing.
13 #
Revenue Cycle
- Explanation: The revenue cycle encompasses the entire process of genera… #
Effective revenue cycle management is essential for financial sustainability.
14 #
Superbill
- Explanation: A superbill is a document used by healthcare providers to… #
It typically includes codes for procedures, diagnoses, and other billable items.
15 #
Unbundling
- Explanation: Unbundling refers to the practice of billing separately fo… #
Unbundling can result in overpayment and is considered fraudulent coding.
16 #
V Code
- Explanation: V codes are used in ICD-10-CM to report factors influencin… #
These codes are typically used when a patient's condition or encounter does not fit into a specific disease category.
17 #
Z Code
- Explanation: Z codes are used in ICD-10-CM to report encounters for iss… #
These codes capture information about preventive services, screenings, and follow-up care.
18. 72 #
Hour Rule
- Explanation: The 72-hour rule requires that certain outpatient services… #
This rule impacts coding and reimbursement for hospital services.
19 #
95 Guidelines
- Explanation: The 95 guidelines refer to the guidelines for reporting E/… #
These guidelines outline the documentation requirements and coding considerations for virtual encounters.
20 #
99214
- Explanation: 99214 is a specific E/M CPT code used to report an establi… #
This code corresponds to a specific level of service based on documentation criteria.
21 #
99291
- Explanation: 99291 is a CPT code used to report the first 30-74 minutes… #
This code is time-based and may be reported in addition to other E/M services.
22 #
99490
- Explanation: 99490 is a CPT code used to report chronic care management… #
This code covers non-face-to-face services such as care coordination and remote monitoring.
23 #
3M Encoder
- Explanation: The 3M Encoder is a software tool used by medical coders t… #
It provides coding guidance based on official coding guidelines and regulations.
24 #
7th Character Extension
- Explanation: The 7th character extension is used in ICD-10-CM to provid… #
This extension helps specify the stage of treatment or recovery.
25 #
80/20 Rule
- Explanation: The 80/20 rule, also known as the Pareto principle, states… #
In medical coding, this principle can be applied to focus on the most common diagnoses and procedures for efficient coding.
26 #
835 File
- Explanation: An 835 file is an electronic remittance advice file that p… #
This file is used by providers to reconcile payments and denials.
27 #
AHA (American Hospital Association)
- Explanation: The AHA is a professional organization that provides guida… #
It publishes coding clinics and updates to help facilities stay compliant with regulations.
28 #
AHIMA (American Health Information Management Association)
- Explanation: AHIMA is a professional association for health information… #
It offers certifications, educational programs, and resources to support coding and data integrity.
29 #
ANSI (American National Standards Institute)
- Explanation: ANSI is a nonprofit organization that oversees the develop… #
ANSI standards ensure interoperability and consistency in code sets and data exchange.
30 #
ARRA (American Recovery and Reinvestment Act)
- Explanation: ARRA is a federal legislation enacted in 2009 to stimulate… #
The HITECH Act, a component of ARRA, incentivizes the meaningful use of electronic health records.
31 #
Audit Trail
- Explanation: An audit trail is a chronological record of system activit… #
In medical coding, audit trails are used to track changes and ensure data integrity.
32 #
Charge Description Master (CDM)
- Explanation: The CDM is a database that contains information about bill… #
It serves as a reference for coding, billing, and pricing of services to ensure accurate reimbursement.
33 #
Claim Scrubber
- Explanation: A claim scrubber is a software tool that automatically rev… #
This helps improve claim acceptance rates and reduce denials.
34 #
Clinical Documentation Improvement (CDI)
- Explanation: CDI is a process focused on improving the quality and accu… #
CDI specialists work with providers to ensure thorough and specific documentation.
35 #
Compliance Plan
- Explanation: A compliance plan is a set of policies and procedures desi… #
The plan addresses areas such as coding, billing, privacy, and fraud prevention.
36 #
Concurrent Review
- Explanation: Concurrent review is a process of assessing the medical ne… #
This review helps ensure that services are provided efficiently and meet quality standards.
37 #
CPT Assistant
- Explanation: CPT Assistant is a publication by the AMA that provides of… #
It offers explanations, examples, and case studies to assist coders in accurate code assignment.
38 #
Credentialing
- Explanation: Credentialing is the process of verifying a healthcare pro… #
Credentialing is required for providers to participate in insurance networks.
39 #
Data Analytics
- Explanation: Data analytics involves the use of statistical analysis an… #
In healthcare, data analytics can be used to identify trends, improve outcomes, and optimize operations.
40. DRG (Diagnosis #
Related Group)
- Explanation: DRGs are a classification system used to group inpatient s… #
DRGs determine reimbursement rates for hospitals under the prospective payment system.
41 #
EHR (Electronic Health Record)
- Explanation: An EHR is a digital record of a patient's health informati… #
EHRs allow for real-time access to patient data and enhance communication among providers.
42 #
Encoder
- Explanation: An encoder is a software tool used by medical coders to se… #
Encoders provide coding suggestions, guidelines, and references to support code selection.
43 #
EOB (Explanation of Benefits)
- Explanation: An EOB is a document sent to patients by insurance compani… #
The EOB details what the insurance covered, denied, and what the patient owes.
44 #
Fraud and Abuse
- Explanation: Fraud and abuse in healthcare involve intentional deceptio… #
Examples include upcoding, unbundling, kickbacks, and billing for services not provided.
45 #
HCC (Hierarchical Condition Category)
- Explanation: HCCs are a risk adjustment model used by Medicare to predi… #
HCCs are derived from ICD-10-CM diagnosis codes reported by providers.
46 #
HHS (Department of Health and Human Services)
- Explanation: HHS is a federal agency responsible for protecting the hea… #
HHS oversees healthcare programs, enforces HIPAA regulations, and provides guidance on healthcare policy.
47 #
HIPAA (Health Insurance Portability and Accountability Act)
- Explanation: HIPAA is a federal law that establishes standards for the… #
HIPAA regulations govern the use, disclosure, and protection of PHI by healthcare providers and entities.
48. ICD #
10-PCS (International Classification of Diseases, 10th Revision, Procedure Coding System)
- Explanation: ICD-10-PCS is a procedure code set used to report inpatien… #
It provides a detailed system for classifying and reporting medical interventions and treatments.
49 #
LCD (Local Coverage Determination)
- Explanation: LCDs are coverage policies developed by Medicare Administr… #
LCDs outline medical necessity, coding guidelines, and documentation requirements.
50 #
MAC (Medicare Administrative Contractor)
- Explanation: MACs are private organizations contracted by CMS to proces… #
MACs play a key role in administering Medicare benefits and ensuring compliance with regulations.
51 #
Meaningful Use
- Explanation: Meaningful use refers to the utilization of certified elec… #
The EHR incentive program incentivizes providers to demonstrate meaningful use of EHRs.
52 #
Medical Necessity
- Explanation: Medical necessity refers to the requirement that healthcar… #
Payers use medical necessity criteria to determine coverage.
53 #
Medicare Fraud Waste and Abuse (FWA