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Basics of Diagnostic Coding Terminology

A review of terms for medical assistants to learn when working with coding in financial management

AB
ancillaryservices that support patient diagnoses
ancillary therapeutic servicesservices that support patient treatment available from specialists or surgery
"and"should be interpreted as "and/or" in ICD-9-CM
"code also"when more than one code is necessary to fully identify a given condition.
codingconverting verbal or written descriptions into numerical and alphanumerical designations
"code if applicable"notation meaning that the designated code may be principal if no casual condition is applicable or known
comorbiditiespreexisting conditions that will, because of their presence with a specific principal diagnosis, cause an increase in length of an inpaitent hospital stay by at least one day in approximately 75% of cases
complicationswith respect to coding, conditions that arise during a hospital stay that prolong the length of stay by at least one day in approximately 75% of cases
"diagnosis"determination of the nature of a disease
etiologywhat caused a disorder
"excludes"terms that are written in italics, to draw particular attention to those instructions.
"includes"appear under a subdivision and indicates that the code and title include those terms
ICD-9-CMsystem for classifying disease to facilitate the collection of information for statistical purposes
mandatedrequired by law
"omit code"primarily used in volume 3 when procedure is the way of approaching for an operation
preexisting conditionsome physical condition that existed before insurance was issued
primary diagnosisinitial identification of the condition or complaint that the patient complains of in medical setting
prinicpal diagnosiscondition for patient chiefly being admitted to hospital
"see"direction given to the coder to look somewhere else
"see also"direction given to the coder to look somewhere else if the main term or subterm entry are not sufficient
"see category"direction that is given to a coder to look in a specific category. This must always be followed.
superbillfomr on which list of procedures and ICD-9-CM codes that are most frequently used are listed and marked off in order to check out of a medical setting


Coastal Bend College
Beeville, TX

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