History and physical examination (H&P, HPE) At the patient’s first visit with a new physician or an established provider or upon admission to a hospital, the history and physical examination (H&P) are documented. The term Excludes means “DO NOT CODE HERE.” An excludes note under a code indicates that the terms excluded from the code are to be coded elsewhere. The applicable code number usually follows the exclusion term. Exclusion terms may apply to a chapter, a section, a category, or a subcategory. The cause of a disorder a claim may be classified according to the etiology.Įxcludes Exclusion terms are always written in italics, and the word excludes often is enclosed in a box to draw particular attention to these instructions. Clinical diagnosis: The conclusion the physician reaches after evaluating all findings, including laboratory and other test results.ĭiagnostic statement Information about a patient’s diagnosis or diagnoses that has been extracted from the medical documentation.Įtiology The science and study of the causes of disease. Differentiated diagnosis: A comparison of two or more diseases with similar signs and symptoms. Initial diagnosis: The physician’s temporary impression, sometimes called a working diagnosis. A use additional code note is found at the etiology code when the underlying condition is sequenced first followed by the manifestation.Ĭoding Converting verbal or written descriptions into numeric and alphanumeric designations.Ĭonventions Abbreviations, punctuation, symbols, instructional notations, and related entities that help guide the medical assistant or coder in the selection of an accurate, specific code.ĭiagnosis The concise, technical description of the cause, nature, or manifestations of a condition or problem. A code first note is found at a manifestation code. It is recorded in the history documentation in the medical record, preceded by the abbreviation CC.Ĭode first When more than one code is necessary to identify a given condition, code first or use additional code is used. The assessment includes a preliminary, interim, or final diagnosis.Ĭhief complaint (CC) The reason the patient has sought medical care, usually taken down in the patient’s own words. It also contains the Classification of Factors Influencing Health Status and Contact with Health Service (V Codes) and the index for Supplemental Classification of External Causes of Injury and Poisoning (E Codes).Īncillary diagnostic services Services that support patient diagnoses (e.g., laboratory or radiologic services).Īnd In the context of the ICD-9-CM, and should be interpreted as and/or.Īssessment The physician’s determination of what is or may be wrong with the patient based on the findings from the history and physical examination (H&P). In procedural coding, the outline or summary helps ensure that all procedures and services are included in an insurance claim submission and that nothing is omitted from or added to the encounter form or charge ticket as a verb form, abstract means to compile this outline or summary for use in procedural coding.Īlphabetic Index Volume 2 of the ICD-9-CM coding manual it lists conditions, injuries, illnesses, and diseases in alphabetical order by main terms, modifying terms, and subterms. Correctly use instructional terms and symbols as defined in the ICD-9-CM.Ībstract An outline or summary of the diagnostic statement and/or procedures and services performed. Explain the importance of the Tabular Index.Ĩ. Demonstrate the use of the Alphabetic Index in the selection of main and modifying terms and the appropriate code (or codes) or code ranges.ħ. Explain where diagnostic information can be found and demonstrate how to abstract the diagnostic statement from the medical record.Ħ. Explain and apply the basic coding rules in the use of the ICD-9-CM.ĥ. Describe how to use the most current diagnostic coding system.Ĥ. Identify three purposes of the most current diagnostic coding system.ģ. Define, spell, and pronounce the terms listed in the vocabulary.Ģ.
0 Comments
Leave a Reply. |
AuthorWrite something about yourself. No need to be fancy, just an overview. ArchivesCategories |