- Root operation
- The third character of an ICD-10-PCS code — the objective of the procedure (e.g., Excision, Resection, Bypass).
- ICD-10-CM
- The U.S. clinical-modification code set for reporting diagnoses in all health-care settings.
- ICD-10-PCS
- The 7-character code set used to report inpatient hospital procedures.
- CPT
- Current Procedural Terminology — the AMA code set for physician and outpatient procedures and services.
- HCPCS Level II
- Codes for supplies, drugs, equipment, and services not covered by CPT.
- Principal diagnosis
- The condition established after study to be chiefly responsible for the patient's admission to the hospital (UHDDS definition).
- First-listed diagnosis
- In outpatient coding, the diagnosis or reason chiefly responsible for the services provided, sequenced first.
- 'After study' (principal dx)
- Means the principal diagnosis is the condition the workup confirms caused the admission — not the admitting diagnosis or chief complaint.
- Secondary diagnosis
- An additional condition that affects patient care during the encounter (a comorbidity or complication).
- Sequencing
- The order codes are listed: the principal/first-listed diagnosis first, then secondary diagnoses and procedures.
- ICD-10-PCS code length
- Always exactly 7 characters; each position has a fixed meaning that is independent of the others.
- PCS character 1
- Section — where the procedure is performed (e.g., 0 = Medical and Surgical).
- PCS character 2
- Body system — the general body system involved.
- PCS character 3
- Root operation — the objective of the procedure (most-tested PCS character).
- PCS character 4
- Body part — the specific anatomical site.
- PCS character 5
- Approach — the technique used to reach the site (Open, Percutaneous, etc.).
- PCS character 6
- Device — any device that remains after the procedure (Z = no device).
- PCS character 7
- Qualifier — additional detail unique to the procedure (Z = none).
- Excision (PCS root operation)
- Cutting out or off, without replacement, a PORTION of a body part.
- Resection (PCS root operation)
- Cutting out or off, without replacement, ALL of a body part.
- Excision vs Resection
- Excision removes part of a body part; Resection removes all of it (e.g., total nephrectomy = Resection).
- Destruction (PCS root operation)
- Eradicating all or a portion of a body part by direct energy, force, or a destructive agent.
- Extraction (PCS root operation)
- Pulling or stripping out all or a portion of a body part by force.
- Detachment (PCS root operation)
- Cutting off all or a portion of an extremity — i.e., amputation.
- Bypass (PCS root operation)
- Altering the route of passage of the contents of a tubular body part.
- Drainage (PCS root operation)
- Taking or letting out fluids and/or gases from a body part.
- Insertion (PCS root operation)
- Putting in a non-biological device that monitors, assists, performs, or prevents a function but does not take the place of a body part.
- Replacement (PCS root operation)
- Putting in biological or synthetic material that physically takes the place of all or a portion of a body part.
- PCS approach: Open
- Cutting through skin or mucous membrane and any other layers to fully expose the procedure site.
- PCS approach: Percutaneous
- Entry by puncture or minor incision of instrumentation to reach the procedure site.
- PCS approach: Percutaneous Endoscopic
- Entry by puncture or minor incision of instrumentation AND visualization to reach and see the site.
- Modifier
- A two-character CPT/HCPCS addition that gives extra detail about a service (e.g., bilateral, distinct, repeat).
- Modifier -59
- Distinct procedural service — indicates a procedure was separate and distinct from others performed the same day.
- Modifier -50
- Bilateral procedure — the same procedure was performed on both sides.
- Modifier -26
- Professional component — reports only the physician's interpretation portion of a service.
- MS-DRG
- Medicare Severity Diagnosis-Related Group — the inpatient classification that pays a fixed amount per admission.
- CC
- Complication or comorbidity — a secondary condition that increases resource use and can raise the DRG tier.
- MCC
- Major complication or comorbidity — a secondary condition that increases resource use even more, often shifting to a higher DRG.
- MCC vs CC
- An MCC raises the DRG (and payment) more than a CC; both depend on complete documentation of secondary diagnoses.
- APC
- Ambulatory Payment Classification — the payment unit under Medicare's hospital Outpatient PPS.
- IPPS
- Inpatient Prospective Payment System — pays acute hospitals a fixed amount per MS-DRG.
- OPPS
- Outpatient Prospective Payment System — pays hospitals for outpatient services using APCs.
- DRG vs APC
- DRGs pay for inpatient admissions (IPPS); APCs pay for hospital outpatient services (OPPS).
- POA indicator
- Present on Admission — a value (Y, N, U, W) reported with each inpatient diagnosis showing whether it was present at admission.
- POA value Y
- The condition was present at the time of inpatient admission.
- POA value N
- The condition was not present at the time of inpatient admission.
- POA value U
- Documentation is insufficient to determine whether the condition was present on admission.
- POA value W
- The provider is unable to clinically determine whether the condition was present on admission.
- NCCI edits
- National Correct Coding Initiative edits — automated checks that prevent improper code pairs and unbundling.
- Abstracting
- Extracting and recording the relevant data (diagnoses, procedures, demographics) from the record for coding and reporting.
- ICD-10-CM conventions
- Rules in the code book — Alphabetic Index, Tabular List, includes/excludes notes, 'code first' and 'use additional code.'
- 'Code first' note
- An ICD-10-CM instruction to sequence an underlying condition before the manifestation code.
- 'Use additional code' note
- An ICD-10-CM instruction to add a secondary code to fully describe a condition.
- Excludes1 note
- ICD-10-CM convention meaning the two conditions cannot be coded together (a 'not coded here' rule).
- Excludes2 note
- ICD-10-CM convention meaning the condition is not part of the code but both may be reported together if present.
- Combination code
- A single ICD-10-CM code that classifies two diagnoses, or a diagnosis with a manifestation or complication.
- Laterality
- ICD-10-CM specificity for the side of the body (right, left, bilateral) required for many conditions.
- Code set for inpatient procedures
- ICD-10-PCS.
- Code set for outpatient procedures
- CPT and HCPCS Level II.
- Code set for diagnoses (all settings)
- ICD-10-CM.
- MS-DRG drivers
- The principal diagnosis, procedures, and the presence of any CC or MCC.
- RBRVS
- Resource-Based Relative Value Scale — the basis of the Medicare physician fee schedule, paying per relative value unit (RVU).
- PDPM
- Patient-Driven Payment Model — the case-mix-adjusted per-diem payment system for skilled nursing facilities.
- E/M coding
- Evaluation and Management coding — CPT codes for office, hospital, and other patient-management visits.
- Encoder vs code book
- An encoder is software that helps assign codes; the code book is the printed reference — both must follow the Official Guidelines.
- Sequencing an MCC
- An MCC is a secondary diagnosis, so it is never the principal diagnosis — but it can move the case to a higher DRG.
- Why POA matters
- It drives the Hospital-Acquired Condition payment policy: a complication not present on admission may not raise the DRG.
- Coding documentation rule
- Every code must be supported by documentation in the body of the health record.
- Coder's response to conflicting docs
- Query the provider — never choose one diagnosis or assume which is correct.
- Verify and validate documentation
- Confirm that the documentation in the record actually supports each assigned code.
- Clinical documentation integrity (CDI)
- Efforts to ensure the record accurately and completely reflects the patient's clinical status to support correct coding.
- Ambiguous documentation
- Documentation that is unclear; the coder queries for clarification rather than guessing.
- Incomplete documentation
- Documentation missing the detail needed to assign a code; the coder queries for specificity.
- Clinically inconsistent documentation
- Documentation where clinical indicators don't match the stated diagnosis; the coder queries.
- Conflicting documentation
- Two providers (or notes) state different diagnoses, admission types, or laterality; resolved only by clarification.
- Can a coder infer a diagnosis?
- No — a coder cannot assign a diagnosis the provider has not documented; the record must be clarified.
- Legal health record
- The official business record of patient care; codes must be supported by, and queries documented in, this record.
- Documentation source for inpatient procedures
- The operative or procedure report — coders read it to assign the correct ICD-10-PCS code.
- Discharge summary
- A summary of the inpatient stay used to confirm diagnoses, procedures, and the principal diagnosis.
- History and physical (H&P)
- The admission documentation of the patient's history and exam; part of the record the coder reviews.
- Coding from query response
- Only after the provider's clarification is entered into the record can the coder assign the code.
- Documentation 'in the body' of the record
- Required documentation must appear in the record itself, not only on a cover sheet or claim.
- Admission type conflict
- When documentation disagrees on admission type, the coder queries to resolve it before coding.
- Laterality conflict
- When the side of the body is documented inconsistently, the coder queries to clarify before coding.
- Role of the coder vs provider
- The provider documents the diagnosis; the coder ensures the documentation supports the assigned code.
- When documentation is clear and complete
- The coder assigns the code with confidence — no query is needed.
- Why documentation quality matters
- Incomplete documentation can cause missed CCs/MCCs, wrong DRGs, denials, and compliance risk.
- Amending the record
- Only the provider may amend or clarify clinical documentation — never the coder.
- Supporting medical necessity in docs
- The documentation must show why a service was needed so the diagnosis can support the procedure billed.
- Provider query
- A communication asking a provider to clarify ambiguous, incomplete, conflicting, or clinically inconsistent documentation.
- Compliant query
- A non-leading query supported by clinical indicators that does not suggest a diagnosis solely to increase reimbursement.
- Leading query
- A non-compliant query that steers the provider toward a particular answer, usually to maximize payment.
- Clinical indicators
- Documented signs, symptoms, lab values, treatments, or findings that justify and support a query or diagnosis.
- When to query
- When documentation is ambiguous, incomplete, conflicting, or clinically inconsistent.
- Query options
- A compliant query offers balanced, clinically supported choices plus 'other' and 'clinically undetermined.'
- Is a query allowed to increase payment?
- A query may only clarify the record; writing it to increase payment makes it leading and non-compliant.
- Where does a query response go?
- Into the legal health record — it must be documented there before the code is assigned.
- Purpose of a query
- To clarify documentation so the correct code can be assigned — not to question clinical judgment.
- Verbal vs written query
- Both are acceptable if compliant; a verbal query and its response must still be documented.
- Identifying query opportunities
- Analyzing current documentation to spot where indicators support a diagnosis the provider hasn't stated.
- Example: query trigger
- Low serum sodium plus hypertonic saline but no stated diagnosis — query for possible hyponatremia.
- Non-leading wording
- Presents the clinical facts neutrally and asks the provider to interpret, rather than naming the answer.
- Query and clinical validation
- When indicators don't support a documented diagnosis, a query can also confirm whether it should stand.
- Coder's limit on queries
- A coder cannot add, change, or assume a diagnosis — only the provider can resolve the query.
- Ethical query standard
- Queries must follow AHIMA/industry guidance: compliant, non-leading, and clinically supported.
- HIPAA
- The Health Insurance Portability and Accountability Act, protecting health information via its Privacy and Security Rules.
- Protected health information (PHI)
- Individually identifiable health information protected under HIPAA.
- Minimum necessary
- The HIPAA principle of using or disclosing only the least PHI needed to accomplish the purpose.
- HIPAA Privacy Rule
- Limits how PHI is used and disclosed and gives patients rights to access and control their information.
- HIPAA Security Rule
- Sets standards to protect electronic PHI (ePHI) through administrative, physical, and technical safeguards.
- Permitted HIPAA disclosures
- Treatment, payment, and health-care operations (TPO) are permitted; most other uses require authorization.
- UHDDS
- Uniform Hospital Discharge Data Set — standardized inpatient data elements, including the principal-diagnosis definition.
- AHIMA Standards of Ethical Coding
- Professional principles requiring accurate, complete, honest coding that reflects the documentation — never upcoding.
- Upcoding
- Assigning a code for a more severe or expensive condition or service than the documentation supports — fraud.
- Unbundling
- Reporting components of a service separately for higher payment when one combined code applies.
- PSI
- Patient Safety Indicator — an AHRQ measure that screens coded data for potentially preventable in-hospital complications.
- HAC
- Hospital-Acquired Condition — a reasonably preventable condition acquired during the stay.
- HAC payment impact
- Under CMS policy, a HAC that was not present on admission can reduce Medicare payment.
- HAC examples
- Certain surgical-site infections, falls with injury, and catheter-associated urinary tract infections.
- Medical necessity
- A service must be reasonable and necessary to diagnose or treat a condition; the diagnosis must support the procedure billed.
- Payer-specific guidelines
- Individual payers have their own coverage and coding rules a coder must follow beyond the Official Guidelines.
- Fraud vs abuse
- Fraud is intentional deception for gain (e.g., upcoding); abuse is improper practices that result in unnecessary cost.
- Compliance program
- An organizational system of policies, audits, and education designed to prevent coding fraud and abuse.
- Ensuring record completeness
- A regulatory-compliance task: confirming the record is complete and accurate before final coding.
- Why ethical coding matters
- It protects patients, the organization's integrity, and reimbursement accuracy, and avoids audits and penalties.
- Coder's stance on revenue vs accuracy
- Code only what the documentation supports; never choose an option just because it pays more.
- OIG
- Office of Inspector General — investigates health-care fraud and publishes compliance guidance and work plans.
- Patient right to access PHI
- Under HIPAA, patients have the right to access and obtain a copy of their own health information.
- Breach of PHI
- An impermissible use or disclosure of PHI; HITECH added breach-notification requirements.
- EHR
- Electronic Health Record — a digital version of a patient's chart maintained over time by providers.
- Encoder
- Software that helps a coder find and assign correct ICD-10/CPT/HCPCS codes, often with built-in references and edits.
- Grouper
- Software that classifies a coded case into a payment group such as an MS-DRG or APC.
- Encoder vs grouper
- An encoder helps assign codes; a grouper turns the assigned codes into a payment classification.
- Computer-assisted coding (CAC)
- Software using natural-language processing to suggest codes from documentation; a coder must validate every code.
- CAC limitation
- CAC suggestions can be wrong or incomplete, so a credentialed coder must review, correct, and finalize them.
- HITECH
- The Health Information Technology for Economic and Clinical Health Act — promoted EHR adoption and strengthened HIPAA.
- HITECH vs HIPAA
- HIPAA sets the privacy and security rules; HITECH strengthened their enforcement and pushed EHR adoption.
- Natural-language processing (in coding)
- Technology that reads free-text documentation to identify codable concepts for CAC.
- Does technology replace the coder?
- No — encoders, groupers, and CAC assist, but the credentialed coder's judgment remains essential.
- Types of EHR data
- Structured (coded fields) and unstructured (free-text notes); CAC works on the unstructured text.
- Business associate (HITECH)
- A vendor handling PHI for a covered entity; HITECH extended HIPAA obligations to business associates.
- Breach notification (HITECH)
- HITECH requires notifying affected individuals (and HHS) when unsecured PHI is breached.
- Role of CAC in productivity
- CAC can speed coding and improve consistency, but accuracy still depends on coder validation.
- EHR and documentation source
- The EHR is the source documentation the coder reviews to assign and validate codes.
- Interoperability
- The ability of different health IT systems to exchange and use information, supported by EHR standards.
- Etiology/manifestation convention
- ICD-10-CM rule to code the underlying condition (etiology) first, then the manifestation, often with paired codes.
- Sign/symptom coding rule
- Codes for signs and symptoms are not assigned when a related definitive diagnosis has been established.
- Acute vs chronic (same condition)
- When both acute and chronic forms are documented and indexed separately, code both, sequencing the acute first.
- Impending or threatened condition
- If it occurred, code it as a confirmed diagnosis; if it did not, follow the index for 'impending' or 'threatened.'
- Inpatient 'probable/suspected' rule
- For inpatients, an uncertain diagnosis (probable, suspected, likely) documented at discharge is coded as if it exists.
- Outpatient 'probable/suspected' rule
- For outpatients, uncertain diagnoses are NOT coded; code the documented signs, symptoms, or reason for the visit.
- Z code
- An ICD-10-CM code for factors influencing health status and contact with health services (not a disease).
- External cause code (V–Y)
- ICD-10-CM codes describing how an injury or condition happened; never sequenced as a principal diagnosis.
- Sepsis sequencing
- Code the underlying systemic infection first; severe sepsis requires a code for sepsis plus the associated organ dysfunction.
- Principal procedure
- The procedure performed for definitive treatment, or most related to the principal diagnosis, sequenced first among procedures.
- Present-on-admission exempt codes
- Certain ICD-10-CM codes (e.g., some Z codes) are exempt from POA reporting per the official list.
- CPT category I codes
- Five-digit CPT codes for widely performed procedures and services with FDA approval where applicable.
- CPT category II codes
- Optional CPT tracking codes for performance measurement (alphanumeric, ending in F).
- CPT category III codes
- Temporary CPT codes for emerging technology, services, and procedures (alphanumeric, ending in T).
- Modifier -25
- Significant, separately identifiable E/M service by the same provider on the day of a procedure.
- Modifier -51
- Multiple procedures performed at the same session by the same provider.
- Modifier -76
- Repeat procedure or service by the same physician on the same day.
- Global surgical package
- A single CPT payment covering the procedure plus normal pre- and post-operative care for a defined period.
- HCPCS J codes
- HCPCS Level II codes for drugs administered other than orally (e.g., injectables).
- Severity of illness / risk of mortality
- APR-DRG concepts that adjust inpatient classification based on how sick the patient is and mortality risk.
- Case mix index (CMI)
- The average DRG relative weight for a facility — reflects the resource intensity of its patients.
- Relative weight (DRG)
- A number reflecting the average resources to treat cases in a DRG relative to the average inpatient case.
- Default code
- The ICD-10-CM code listed next to the main term in the Alphabetic Index, representing the most common form.
- Eponym
- A condition or procedure named after a person (e.g., a disease name); look it up under the eponym or the condition.
- NEC vs NOS
- NEC = not elsewhere classifiable (specific info exists but no code); NOS = not otherwise specified (unspecified).
- Placeholder character 'X'
- An ICD-10-CM placeholder (X) used to fill empty positions so a required 7th character lands correctly.
- 7th character (ICD-10-CM)
- An extension required for certain categories (e.g., injuries) indicating encounter type: initial, subsequent, or sequela.
- Sequela (late effect)
- A residual condition produced after the acute phase of an illness or injury has ended; code the condition, then the sequela code.
- Body Part Key (PCS)
- An ICD-10-PCS resource that maps anatomical terms to the correct PCS body-part value.
- Device Key (PCS)
- An ICD-10-PCS resource that maps device terms to the correct PCS device value (character 6).
- Query for specificity
- Used when documentation lacks the detail (e.g., type, acuity, site) needed to assign the most specific code.
- Coding from nursing notes
- Generally diagnoses are coded from provider documentation; some clinical details (e.g., BMI, stage) may come from other clinicians if the provider documents the condition.
- Abnormal findings
- Abnormal lab or test findings are not coded unless the provider documents their clinical significance.
- Documentation integrity vs reimbursement
- CDI aims for an accurate record; any resulting reimbursement change must follow from accuracy, not the other way around.
- Reviewing the full record
- Coders review the entire record (H&P, progress notes, op reports, diagnostics, discharge summary) before final coding.
- Conflicting attending vs consultant
- When the attending and a consultant disagree, query the attending (the provider responsible for the diagnosis).
- Documentation timeliness
- Records must be completed timely; coding waits for required documentation rather than guessing.
- Multiple-choice query format
- A compliant format offering reasonable, clinically supported options plus 'other' and 'unable to determine.'
- Open-ended query format
- A compliant format asking the provider to document the diagnosis in their own words, prompted by clinical indicators.
- Query retention
- Queries and their responses are part of the documentation/compliance trail and are retained per policy.
- Querying for present on admission
- A query may be needed to clarify whether a condition was present on admission for POA reporting.
- Querying clinical validity
- A query can address whether a documented diagnosis is clinically supported by the indicators in the record.
- Covered entity (HIPAA)
- Health plans, health-care clearinghouses, and providers who transmit health information electronically.
- TPO
- Treatment, Payment, and health-care Operations — the HIPAA-permitted disclosures that do not require authorization.
- De-identified data
- Health information stripped of identifiers so it is no longer PHI and falls outside HIPAA restrictions.
- RAC
- Recovery Audit Contractor — reviews Medicare claims to identify and recover improper payments.
- False Claims Act
- A federal law imposing liability for knowingly submitting false or fraudulent claims to the government.
- Compliance with UHDDS
- Following UHDDS definitions and data elements is a Regulatory Compliance task for inpatient reporting.
- Medical necessity denial
- A claim denied because the diagnosis did not support the medical necessity of the service billed.
- Coder's duty under ethical standards
- Apply accurate codes, query when needed, refuse to misrepresent conditions, and report compliance concerns.
- Audit
- A review of coded records against documentation to verify accuracy and compliance; supports the compliance program.
- CAC workflow
- Documentation → NLP suggests codes → credentialed coder reviews/validates → final codes assigned.
- EHR meaningful use / Promoting Interoperability
- CMS programs that incentivized EHR adoption and data exchange under HITECH.
- Structured data entry
- Coded, discrete EHR fields (e.g., problem lists) that support reporting and analytics.
- Master patient index (MPI)
- A database that maintains a unique identifier for each patient across an organization's systems.
- Clinical decision support
- EHR tools that provide alerts and guidance to clinicians at the point of care.
- Audit trail (EHR)
- A record of who accessed or changed the EHR and when — supports HIPAA security and accountability.