-2-1 CODE IT! FINAL EXAM KEY TERMS
Application service provider - answer-A third-party entity that manages and distributes
software-based services and solutions to customers across a wide area network (WAN) from a
central data center.
Assessment (A) - answer-Judgement, opinion, or evaluation made by a healthcare provider;
considered part of the problem-oriented record (POR) SOAP note.
Assumption coding - answer-inappropriate assignment of codes based on assuming, from a
review of clinical evidence in the patient's record, that the patient has certain diagnoses or
received certain procedures/ services even though the provider did not specifically document
those diagnoses or procedures/ services
Automated case abstracting software - answer-software program that is used to collect and
report inpatient and outpatient data for statistical analysis and reimbursement purposes.
Automated record - answer-type of record that is created using computer technology
Centers for Medicare & Medicaid Services (CMS) - answer-Administrative agency in the
federal Department of Health & Human Services.
Claims examiner - answer-employed by third-party payers to review health-related claims to
determine whether the charges are reasonable and medically necessary based on the patient's
diagnosis.
Classification system - answer-Organizes a medical nomenclature according to similar
conditions, diseases, procedures, and services; it contains codes for each.
Clearinghouse - answer-a public or private entity that processes or facilitates the processing of
health information and claims from a nonstandard to a standard format.
CMS-1450 - answer-UB-04; standard claim submitted by health care institutions to payers for
inpatient and outpatient services.
CMS-1500 - answer-standard claim submitted by physicians' offices to third-party payers.
Code - answer-Numerical and alphanumerical characters that are reported to health plans for
health care reimbursement and to external agencies (e.g., state departments of health) for data
collection, in addition to being reported internally (e.g., acute care hospital) for education and
research.
Coder - answer-acquires a working knowledge of coding systems (e.g., CPT, HCPCS level II,
ICD-10-CM, and ICD-10-PCS), coding principles and rules, government regulations, and third-
party payer requirements to ensure that all diagnoses (conditions), services (e.g., office visit),
,and procedures (e.g., surgery and x-ray) documented in patient records are coded accurately for
reimbursement, research, and statistical purposes.
Coding - answer-Assignment of codes to diagnoses, services, and procedures based on patient
record documentation.
Coding system - answer-Organizes medical nomenclature according to similar conditions,
diseases, procedures, and services; it contains codes for each.
Computer-assisted coding (CAC) - answer-uses computer software to automatically generate
medical codes by "reading" transcribed clinical documentation; uses "natural language
processing" theories to generate codes that are reviewed and validated by coders for reporting on
third-party payer claims.
Concurrent coding - answer-review of records and/or use of encounter forms and chargemasters
to assign codes during an inpatient stay or an outpatient encounter; typically performed for
outpatient encounters because encounter forms and chargemasters are completed in "real time"
by health care providers as part of the charge-capture process.
Continuity of care - answer-documenting patient care services so that others who treat the
patient have a source of information on which to base additional care and treatment
Current Procedural Terminology (CPT) - answer-coding system used by physicians and
outpatient health care settings to assign CPT codes for reporting procedures and services on
health insurance claims; considered level I of the Healthcare Common Procedure Coding
System (HCPCS); published and updated by the American Medical Association (AMA) to
classify procedures and services; listing of descriptive terms and identifying codes for reporting
medical services and procedures; provides a uniform language that describes medical, surgical,
and diagnostic services to facilitate communication among providers, patients, and third-party
payers.
Database - answer-contains a minimum data set of patient information collected on each patient,
including chief complaint; present conditions and diagnoses; social data; past, personal, medical,
and social history; review of systems; physical examination; and baseline laboratory data;
considered part of the problem-oriented record (POR).
Demographic data - answer-patient identification information that is collected according to
facility policy (e.g., patient's name, date of birth, mother's maiden name, and Social Security
number).
Diagnostic and Statistical Manual of Mental Disorders (DMS) - answer-manual published by the
American Psychiatric Association that contains diagnostic assessment criteria used as tools to
identify psychiatric disorders; DSM includes psychiatric disorders and codes, provides a
mechanism for communicating and recording diagnostic information, and is used in the areas of
research and statistics.
, Diagnostic/management plans - answer-information about the patient's condition and the
planned management of conditions; considered part of the problem-oriented record (POR).
Discharge note - answer-documented in the progress note section of the problem-oriented record
(POR) to summarize the patient's care, treatment, response to care, and condition on discharge.
Documentation - answer-includes dictated and transcribed, typed or handwritten, and computer-
generated notes and reports recorded in the patient's records by a health care professional.
Document imaging - answer-converting paper records to an electronic image and saved on
storage media.
Downcoding - answer-routinely assigning lower-level CPT codes for convenience instead of
reviewing patient record documentation and the coding manual to determine the proper code to
be reported.
Electronic health record (EHR) - answer-collection of patient information documented by a
number of providers at one or more facilities regarding one patient; multidisciplinary and
multienterprise approach to record keeping because it has the ability to link patient information
created at different locations according to a unique patient identifier; provides access to
complete and accurate health problems, status, and treatment data; contains alerts and reminders
for health care providers.
Electronic medical record (EMR) - answer-created on a computer, using a keyboard, a mouse,
an optical pen device, a voice recognition system, a scanner, or a touch screen; records are
created using vendor software, which also assists in provider decision making regarding patient
care and treatment.
Encoder - answer-software that automates the coding process; software search features facilitate
the location and verification of diagnosis and procedure codes.
Encoding - answer-process of standardizing data by assigning numeric values (codes or
numbers) to text or other information.
Evidence-based coding - answer-clicking on codes that CAC software generates to review
electronic health record documentation (evidence) used to generate the code; when it is
determined that documentation supports the CAC-generated code, the coding auditor clicks to
accept the code; when documentation does not support the CAC-generated code, the coding
auditor replaces it with an accurate code.
Evidence-verification coding - answer-clicking on codes that CAC software generates to review
electronic health record documentation (evidence) used to generate the code; when it is
determined that documentation supports the CAC-generated code, the coding auditor clicks to
accept the code; when documentation does not support the CAC-generated code, the coding
auditor replaces it with an accurate code.
