Your FREE CCA Flashcards 2026 – 200+ Cards

The U.S. diagnosis code set (Clinical Modification), maintained by NCHS; used to report diagnoses in all care settings. Codes are 3–7 characters.

The procedure code set for inpatient hospital procedures, maintained by CMS. Every code is exactly 7 characters.

Current Procedural Terminology — the AMA code set (HCPCS Level I) for physician and outpatient procedures and services; 5-digit codes.

An alphanumeric CMS code set (one letter + four digits) for drugs, supplies, DME, and ambulance — items not in CPT.

The condition established after study to be chiefly responsible for occasioning the patient's admission to the hospital (UHDDS definition).

The outpatient counterpart to the principal diagnosis — the main reason, established at that encounter, for the visit or service.

The diagnosis is selected based on the complete workup during the stay, not the admitting impression — so it may differ from the admitting diagnosis.

An ICD-10-CM note meaning 'not coded here' — the two conditions are mutually exclusive and can never be reported together.

An ICD-10-CM note meaning 'not included here' — the conditions are separate, so both may be coded when each is documented.

A single ICD-10-CM code that classifies two diagnoses, or a diagnosis with an associated manifestation or complication.

Code the underlying condition (etiology) first, then the manifestation. A manifestation code can never be sequenced first.

An ICD-10-CM instruction to sequence the underlying condition (etiology) before the current code.

An ICD-10-CM instruction to assign an additional code, usually sequenced after the underlying condition, to fully describe it.

Signals a manifestation code that is never sequenced first; the underlying etiology must be coded and sequenced before it.

Initial encounter — the patient is receiving active treatment for the injury.

Subsequent encounter — routine care during the healing or recovery phase.

Sequela — a residual late effect of an injury or its treatment.

Holds an empty character position so a required 7th character lands in the correct slot.

Not elsewhere classifiable — the condition is specified but the classification lacks a more precise code.

Not otherwise specified — equivalent to 'unspecified' in the Tabular List.

Find the term in the Alphabetic Index, then verify the code in the Tabular List — never code from the Index alone.

CMS, NCHS, AHA, and AHIMA — the four parties that develop and approve the Official Guidelines.

The Tabular List and Alphabetic Index instructions (conventions) take precedence over the general coding guidelines.

Never code a 'probable,' 'suspected,' or 'rule out' condition as confirmed — code the signs, symptoms, or reason for the visit.

A diagnosis documented as 'suspected' but not ruled out at discharge may be coded as if it existed.

Not coded separately when they are routinely associated with the established underlying condition.

A mandatory instruction in the Alphabetic Index to refer to the alternative term indicated.

Diagnostic coding and reporting guidelines for outpatient services, including first-listed diagnosis selection.

Section — e.g., 0 = Medical and Surgical.

Body System — the general body system.

Root Operation — the objective of the procedure; the most-tested PCS character.

Body Part — the specific anatomical site.

Approach — the technique used to reach the site (open, percutaneous, etc.).

Device — any device left in place at the end of the procedure.

Qualifier — additional distinguishing detail about the procedure.

Cutting out or off, without replacement, a PORTION of a body part.

Cutting out or off, without replacement, ALL of a body part.

Excision removes part of a body part; Resection removes all of a defined body part (e.g., a whole lung lobe).

Never used — to avoid confusion with the digits 0 and 1.

The grids from which each of the 7 characters of an ICD-10-PCS code is selected and built.

CPT is the AMA code set for physician/outpatient procedures; HCPCS Level II covers what CPT does not.

Leveled by Medical Decision Making (MDM) OR total time on the encounter date; history and exam no longer set the level.

Problems addressed, amount/complexity of data reviewed, and risk of complications.

A patient not seen by the provider — or same-specialty provider in the group — within the prior 3 years.

A patient seen by the provider or same-specialty group within the prior 3 years.

99202–99215 (99202–99205 new, 99211–99215 established).

A significant, separately identifiable E/M service by the same provider on the same day as a procedure.

Distinct procedural service — flags a procedure not normally reported together that is appropriate here.

Bilateral procedure — performed on both the left and right sides in one operative session.

Professional component — the physician's interpretation and report only.

Technical component — the equipment, supplies, and technician only.

Repeat clinical diagnostic laboratory test performed the same day to obtain a new result.

Report injectable and infusion drugs by dosage amount.

Report durable medical equipment (DME), such as a wheelchair.

Report ambulance/transportation and medical & surgical supplies.

One alphabetic letter followed by four numeric digits.

Code the resulting condition first, then the sequela code with 7th character S.

When no guideline directs otherwise, either condition may be sequenced as principal.

Codes are 3 to 7 characters, with a decimal placed after the 3rd character.

The category — the broad disease or condition group.

Altering the route of passage of the contents of a tubular body part.

Putting in a nonbiological device that monitors, assists, performs, or prevents a physiological function.

Taking out or off a device from a body part.

Cutting off all or part of an extremity (amputation).

Cutting through the skin or mucous membrane to expose the procedure site.

Entry by puncture or minor incision to reach the procedure site.

Entry by puncture/minor incision plus visualization with an endoscope.

A code that describes a manifestation of an underlying disease and can never be sequenced first.

The code listed next to a main term in the Index, representing the condition most commonly associated with that term.

Terms linked by 'with' in the Index or Tabular are assumed related unless documentation indicates otherwise.

Many codes specify right, left, or bilateral; assign the correct side from documentation.

Optional performance-measure tracking codes that end in the letter F.

Temporary codes for emerging technology, services, and procedures, ending in the letter T.

99291 reports the first 30–74 minutes; +99292 each additional 30 minutes.

Report encounters for reasons other than disease/injury, such as exams, screenings, and aftercare.

Capture how an injury happened (cause, intent, place, activity); never sequenced as principal/first-listed.

Reimburses a provider a predetermined, fixed amount tied to the case or service, rather than the provider's actual charges.

Because payment is fixed regardless of actual cost, facilities are incentivized to manage resources efficiently.

Medicare Severity Diagnosis-Related Group — the inpatient payment group based on clinically and resource-similar cases, refined by severity.

The principal and secondary diagnoses, procedures, sex, and discharge status.

A secondary diagnosis that can raise a case to a higher-weighted MS-DRG.

A more severe secondary diagnosis that can raise a case to an even higher-weighted MS-DRG.

Represents the relative resource intensity of cases in that group compared with the average case.

MS-DRG relative weight multiplied by the hospital's base payment rate.

The average of a facility's MS-DRG relative weights; a higher CMI means a more complex, resource-intensive patient mix.

Captured CCs/MCCs raise MS-DRG weights, which raises the average (the CMI).

The Medicare inpatient prospective payment system — pays a fixed amount per inpatient discharge using MS-DRGs.

Ambulatory Payment Classification — the outpatient prospective payment grouping under OPPS, paying per service or procedure.

The Medicare hospital outpatient prospective payment system — pays per outpatient service using APCs.

MS-DRGs pay per inpatient discharge (IPPS); APCs pay per outpatient service/procedure (OPPS).

Pays a single all-inclusive amount for a primary service plus its associated adjunctive services.

Tells how a service is paid — e.g., packaged into another service's payment rather than paid separately.

An additional PPS payment for an unusually costly case far exceeding the typical cost of its group.

A broad clinical category under which DRGs are organized, generally by body system or etiology.

A facility's master list of billable items and services, each with a charge code, description, amount, and CPT/HCPCS code.

A charge code, item description, charge amount, and associated CPT or HCPCS code.

To keep CPT/HCPCS codes current and prevent claim denials or incorrect payment; ideally at least annually.

Hard-coded services flow through the CDM automatically; soft-coded services are assigned by a coder reviewing documentation.

CMS edits that prevent improper payment: procedure-to-procedure (PTP) edits and Medically Unlikely Edits (MUEs).

A procedure-to-procedure edit that stops unbundling of code pairs that should be reported together.

Caps the maximum units of a HCPCS/CPT code reportable for one patient on one day.

No modifier can override the edit — the codes cannot be unbundled.

A modifier (such as 59) may bypass the edit when clinically justified and documented.

It helps determine the MS-DRG, which drives the inpatient payment amount.

The Resource-Based Relative Value Scale underlying the Medicare Physician Fee Schedule (work + practice-expense + malpractice RVUs).

The institutional/facility claim form used to bill for hospital and facility services (CMS-1450).

The claim form used to bill for physician and other professional (non-institutional) services.

The set of administrative and clinical functions that capture, manage, and collect patient-service revenue, from registration to final payment.

Claims using the deleted code may be denied or rejected.

One had a documented complication or comorbidity that shifted it to a higher-severity group.

A charge is what a facility lists for a service; reimbursement is what the payer actually pays (often a set PPS amount).

A fixed payment amount per day of care, regardless of the actual services delivered that day.

A fixed payment per member per month to cover a defined set of services, regardless of utilization.

Payment for each individual service provided — the opposite of a bundled/prospective amount.

The payer's explanation accompanying payment, detailing how each claim line was adjudicated.

A claim with no errors or missing information that can be processed without additional data.

A payer's refusal to pay a claim, often due to coding, coverage, or documentation issues.

A coverage decision made by a Medicare Administrative Contractor for its region.

A nationwide Medicare coverage decision made by CMS.

The principle that a service must be reasonable and necessary; the diagnosis must support the procedure billed.

A notice to a Medicare patient before a likely-noncovered service, shifting financial responsibility to the patient.

The permanent database that links a unique identifier to each patient and all of their encounters — the backbone of the HIS.

To prevent creating a duplicate entry for a patient who already exists in the system.

Two or more records created for the same patient — fragments care and creates billing and patient-safety risk.

Unique to one patient and stable across all encounters.

Uniform Hospital Discharge Data Set — standard data elements reported for hospital inpatients; source of the principal-diagnosis definition.

A procedure that carries a procedural or anesthetic risk, requires special training, or is surgical in nature.

Uniform Ambulatory Care Data Set — standardizes data collection for outpatient/ambulatory care visits.

Every facility reports the same defined elements the same way, making the data comparable across facilities.

Data are raw, unprocessed facts; information is data organized and interpreted to be meaningful and useful.

Verification by the author who is responsible for the entry — e.g., a signature; one author cannot sign for another.

Must clearly state it is a late entry and reflect when the information was actually documented.

Enter an addendum or amendment that links to the original while preserving (never obscuring) the original content.

Obscuring original content destroys the record's integrity and its value as legal and clinical evidence.

Documents the chief complaint and establishes the patient's baseline condition.

The preoperative and postoperative diagnoses, the procedure performed, and the surgeon's findings.

The reason for admission, significant findings, procedures/treatment, condition at discharge, and follow-up.

The defined set of documents an organization would produce as its official record for legal purposes.

Organizes patient records by the diagnosis codes assigned during their care.

A registry collects more detailed clinical data on a specific population or condition than an index does.

Defines characteristics such as accuracy, completeness, consistency, and timeliness for health data.

The data-quality characteristic that data are correct and free of error.

Capture each data element once at its source and reuse it to reduce duplicate, inconsistent entry.

Must uniquely identify the author and be applied under that author's control.

The date the entry was made (plus authentication by its author).

Nearly every other system relies on it to correctly identify and link a patient's information.

Using standard categories lets disposition data be compared reliably across facilities.

The group of records a covered entity uses to make decisions about a patient; subject to access and amendment rights.

Patient identifying information such as name, address, date of birth, and sex.

Documentation of the patient's health condition, care, and treatment within the record.

The data-quality characteristic that all required data elements are present.

The data-quality characteristic that data are recorded and available when needed.

A collection of detailed data on patients with a specific diagnosis or condition (e.g., a cancer registry).

Knowing and intentional deception or misrepresentation to obtain an unauthorized benefit, such as billing for services not rendered.

Practices inconsistent with sound fiscal or medical practice that cause unnecessary cost, without the same proven intent.

Intent. Fraud requires knowing, intentional deception; abuse does not.

Assigning a code that reflects a more severe diagnosis or more expensive service than the documentation supports.

Billing component codes separately when a single comprehensive code should be reported, to obtain higher payment.

Routinely selecting the highest-level E/M code on every chart regardless of documentation.

A federal law imposing liability on anyone who knowingly submits, or causes to be submitted, false claims to Medicare.

Includes actual knowledge, deliberate ignorance, and reckless disregard of the truth — not just intent to defraud.

A whistleblower lawsuit allowing a private individual to sue on the government's behalf and share in any recovery.

Report and return it within the required timeframe to avoid False Claims Act liability.

Prohibits knowingly offering, paying, soliciting, or receiving remuneration to induce referrals of covered items or services.

Generally restricts a physician from referring Medicare patients to an entity with which they have a financial relationship, unless an exception applies.

Identifies the areas the HHS Office of Inspector General intends to review or audit — signals compliance-risk focus.

A designated compliance officer/committee, training, auditing/monitoring, and a confidential reporting hotline, among others.

Lets employees report concerns and protects good-faith reporters from retaliation.

The OIG List of Excluded Individuals and Entities — check it before employing or contracting with anyone.

The excluded party's claims are no longer paid by Medicare/Medicaid, and others may face penalties for using them.

Reviews Medicare claims to identify and correct improper payments — both overpayments and underpayments.

Direct coders to assign codes based on provider documentation in the record and applicable coding guidelines.

A compliant, non-leading request to a provider to clarify conflicting, incomplete, or ambiguous documentation before coding.

When documentation is conflicting, incomplete, ambiguous, or imprecise and the missing detail affects code assignment.

Generally requires provider documentation — query the provider before coding it.

Refuse to assign it and report the concern through the established compliance channel.

It produces payment not supported by documentation, which can constitute fraud.

Report a colleague viewing records they have no business reason to access through the facility's privacy/compliance process.

To prevent, detect, and correct violations of law and improper coding/billing within an organization.

A periodic review of coded records against documentation to find and correct errors before claims go out.

A query that asks the provider to clarify without suggesting a specific answer that would increase payment.

The improvement in behavior that results from knowing one's work is being monitored or audited.

Protects electronic PHI (ePHI) through administrative, physical, and technical safeguards.

Software that scans clinical documentation and suggests candidate codes for a coder to review and validate.

Natural language processing (NLP), which extracts clinical concepts from free-text documentation.

Validate each suggested code against the documentation and edit or delete as needed — suggestions are not final.

A confirmation workflow is safer because NLP suggestions still require coder review before finalizing.

Audit a sample of CAC-assisted charts against documentation for accuracy.

Helps a coder select and validate diagnosis and procedure codes during the coding process.

Prompts the coder with sequencing edits and questions that mirror the coding guidelines.

Assigns coded data to a payment group, such as an MS-DRG, based on the codes entered.

An encoder helps select/validate codes; a grouper assigns the case to a payment group.

Verify that all relevant secondary diagnoses and their POA status were coded.

Records who accessed or modified a patient record, and when.

Limits each user's access to the record functions appropriate to that person's job role.

Helps a coder quickly locate terms across the record, reducing search time.

Look to provider documentation such as the operative report and the discharge summary.

Initiate a physician query to resolve the conflict before coding.

Standardized data elements and code sets that ease retrieval and improve data quality.

Shows whether a diagnosis was present at the time of inpatient admission; it affects MS-DRG payment and is grouper input.

Technology that interprets human (free-text) language so software can extract clinical concepts for coding.

A program that works with providers to ensure documentation accurately reflects severity and supports coding.

The accuracy, completeness, and consistency of data over its entire lifecycle.

The ability of different health IT systems to exchange and use data with one another.

The Health Insurance Portability and Accountability Act — its Privacy and Security Rules protect protected health information.

Individually identifiable health information held or transmitted by a covered entity in any form — electronic, paper, or oral.

Limit the use, disclosure, and request of PHI to the least amount needed to accomplish the intended purpose.

Does not apply to disclosures for treatment, or to disclosures made under the patient's authorization.

A permitted secondary exposure of PHI when reasonable safeguards and the minimum necessary standard are followed.

Kept separate from the rest of the record; generally require a specific authorization to disclose, even for routine purposes.

A person with legal authority to make health care decisions for the patient, such as a health-care proxy.

Continues for 50 years after the date of death under the HIPAA Privacy Rule.

A patient's right to obtain a copy of their own record, generally within 30 days (with one possible 30-day extension).

A patient's right to request a correction to PHI in the designated record set.

A patient's right to be contacted by a chosen method or at a chosen location.

A list of certain PHI disclosures; it generally excludes treatment, payment, and health care operations disclosures.

Must be done in writing; after revocation, further disclosures under it are not permitted.

Confirm the identity and authority of the requester before disclosing any PHI.

Requires satisfactory assurances (patient notice or a protective order) before PHI is disclosed.

A patient may be charged a reasonable, cost-based fee limited to copying, supplies, and labor for the copy.

Penalties applied against workforce members who fail to comply with the entity's privacy policies.

A data set stripped of most direct identifiers, shareable for research under a data use agreement.

An agreement committing a recipient of a limited data set to safeguard the information and limit its use.

Carry more stringent consent requirements and limits on redisclosure than general HIPAA PHI.

Disclose only the information reasonably needed for the public-health purpose.

A health plan, health care clearinghouse, or health care provider that transmits health information electronically — bound by HIPAA.

A person/entity that performs functions involving PHI on behalf of a covered entity; bound by a BAA.

A contract requiring a business associate to safeguard PHI per HIPAA.

An impermissible use or disclosure of unsecured PHI that compromises its security or privacy.

Health data stripped of identifiers so it is no longer PHI and falls outside HIPAA restrictions.

The core uses/disclosures of PHI permitted without separate authorization.