CCC key terms

A standardized code set used in the United States to assign alphanumeric codes to diagnoses, symptoms, and reasons for healthcare encounters for reporting and reimbursement purposes.

A seven-character alphanumeric code set used in U.S. inpatient hospital settings to describe surgical, medical, and therapeutic procedures performed on patients.

A code set maintained by the American Medical Association that describes medical, surgical, and diagnostic services and is used primarily to report physician and outpatient services for reimbursement.

A national code set used to report supplies, drugs, durable medical equipment, and services not described by CPT, often required by Medicare and other payers.

A two-character code appended to a procedure code to provide additional detail about the service, such as a distinct site, laterality, or a reduced or increased service.

The condition established after study to be chiefly responsible for occasioning the patient's admission to the hospital for care.

The procedure performed for definitive treatment that is most closely related to the principal diagnosis, or the procedure most related to the reason for admission.

The guideline-driven process of determining which diagnosis or procedure code is listed first on a claim or record, based on the reason for the encounter and official conventions.

Official rules published with a code set that direct how codes are selected, combined, and reported, including conventions for etiology, manifestation, and combination codes.

A coding convention in which the underlying cause of a condition is coded first, followed by the code for the resulting sign or condition it produces.

A single code that reports two diagnoses together, such as an underlying condition and its manifestation, eliminating the need for a separate secondary code.

The category of evaluation and management service selected based on documented medical decision making or time, determining the intensity and payment of the visit.

The determination that a service or item is reasonable and required for the diagnosis or treatment of a patient's condition, supporting payment and defending against denial.

Billing edits that identify code pairs not reportable together because one service is bundled into another, used to prevent improper separate payment.

The process of reviewing, appealing, and correcting claims that payers have refused to pay, including root-cause analysis to prevent repeat denials.

A claim submitted with all required data elements accurate and complete so that a payer can process it without requesting additional information or correction.

A two-digit code on a claim identifying where a service was rendered, such as a physician office, outpatient hospital, or inpatient facility, which affects payment.

A written notice given to a Medicare beneficiary before a service likely to be denied as not medically necessary, allowing the patient to accept financial responsibility.

Rules determining when Medicare pays after another insurer, such as an employer group health plan or auto policy, is the primary payer.

The process of determining which of two or more health plans pays first on a claim and how the remaining balance is handled by the other plans.

A payer statement showing services billed, amounts allowed, amounts paid, and patient responsibility, used to reconcile claims and verify payment accuracy.

A formal written request from a coder or clinical documentation specialist to a provider seeking clarification of ambiguous or incomplete documentation before code assignment.

A program that works with providers to improve the accuracy, completeness, and specificity of medical record documentation so it fully reflects patient severity and care.

The accuracy, completeness, timeliness, and consistency of documentation in a patient's record, supporting quality care, coding accuracy, and legal defensibility.

The degree to which health data are accurate, complete, consistent, timely, and reliable for clinical, administrative, and reporting purposes.

A systematic review of records and claims against documentation and coding rules to measure accuracy, identify errors, and support compliance and education.

An organization's structured set of policies, training, monitoring, and enforcement activities designed to prevent and detect violations of billing and healthcare laws.

A federal law imposing liability on entities that knowingly submit false or fraudulent claims to government payers, with penalties and whistleblower provisions.

A federal law prohibiting knowingly offering or receiving remuneration to induce referrals for items or services payable by federal healthcare programs.

A federal law prohibiting physician self-referral for designated health services payable by Medicare when the physician has a financial relationship with the entity, absent an exception.

Reporting a service or diagnosis at a higher level of complexity or payment than documented, which is a form of fraudulent billing.

Billing separately for components of a service that should be reported with a single comprehensive code, resulting in improper additional payment.

Federal regulations governing the use and disclosure of protected health information and establishing patient rights over their health information.

Individually identifiable health information created or received by a covered entity that relates to a person's health, care, or payment for care.

The HIPAA principle requiring that only the least amount of protected health information needed for a purpose be used or disclosed.

A patient's documented permission allowing use or disclosure of protected health information for purposes not otherwise permitted by the privacy rule.

The standard reference posture with the body upright, face forward, arms at the sides, and palms facing forward, used to describe locations and directions.

Imaginary flat surfaces, including sagittal, coronal, and transverse, used to divide and describe the body for anatomical reference and documentation.

Directional terms describing position along a limb, with proximal meaning closer to the body's point of attachment and distal meaning farther away.

The side of the body on which a condition or procedure occurs, such as right or left, which must be documented and captured in coding.