CCA (ASA) flashcards

32 cards. Read the term and the definition here. The deck at the top of this page is optional.

Excludes1 note

An ICD-10-CM instruction indicating that two codes are mutually exclusive and may not be reported together; the excluded code should never be assigned at the same time as the code carrying the note.

Principal diagnosis

The condition established after study to be chiefly responsible for occasioning the inpatient admission; it is sequenced first on the claim per UHDDS requirements.

Placeholder X

In ICD-10-CM, the character X fills the sixth position when a seventh character is required but no sixth character exists for that code.

Modifier 25

A modifier appended to an E/M code to show a significant, separately identifiable evaluation and management service by the same physician on the same day as a procedure.

ICD-10-PCS structure

Seven alphanumeric characters, each with a defined meaning: section, body system, root operation, body part, approach, device, and qualifier.

CPT Category III codes

Five-character alphanumeric codes ending in T that report emerging technology, services, and procedures; they are temporary and are replaced when Category I codes are established.

7th character S

In ICD-10-CM, the seventh character S identifies a sequela, which is a condition that is the late or residual effect of a prior injury or disease.

First-listed diagnosis

In outpatient coding, the diagnosis sequenced first on the claim, representing the condition chiefly responsible for the services provided on that date.

-ostomy

Suffix meaning the surgical creation of an artificial opening between two structures or between a structure and the body surface, as in a colostomy.

Sagittal plane

An anatomical plane that divides the body vertically into right and left portions; the midsagittal plane divides the body into equal halves.

Proximal

A directional term meaning closer to the point of attachment of a limb to the trunk, or closer to the origin of a structure.

Tricuspid valve

The heart valve located between the right atrium and right ventricle that prevents backflow of blood into the atrium during ventricular contraction.

-megaly

Suffix meaning abnormal enlargement of an organ or structure, as seen in hepatomegaly (enlarged liver) or cardiomegaly (enlarged heart).

Anatomical position

The standard reference posture of standing erect, face forward, arms at the sides, and palms facing forward; all directional terms are based on it.

Duodenum

The first and shortest segment of the small intestine, extending from the pyloric sphincter of the stomach to the jejunum, and a major site of chemical digestion.

Homeostasis

The body's maintenance of a stable internal environment, including temperature, pH, and electrolyte balance, through continuous physiological regulatory processes.

UHDDS

The Uniform Hospital Discharge Data Set defines the minimum core data elements collected on every inpatient discharge, including principal diagnosis, procedures, and discharge disposition.

Late entry

A documentation entry recorded after the fact, labeled late entry and containing the actual date and time of entry plus the date of the original event.

Addendum

A supplement added to an existing, completed record entry to provide additional information; the original entry remains unchanged and the addendum is dated and authenticated.

Discharge summary

A concise account of a hospitalization covering the reason for admission, diagnoses, procedures, significant findings, discharge medications, discharge condition, and follow-up plan.

SOAP format

A documentation style structured as Subjective (patient statements), Objective (observable findings and data), Assessment (diagnosis or impression), and Plan (treatment).

Minimum necessary

A HIPAA principle requiring covered entities to limit protected health information use and disclosure to the least amount reasonably needed to accomplish the intended purpose.

Breach notification

The HIPAA requirement to notify affected individuals within 60 days of discovering a breach of unsecured PHI, with HHS notification and media notice when 500 or more residents are affected.

Stark Law

A federal statute prohibiting physicians from referring Medicare patients for designated health services to entities with which the physician or an immediate family member has a financial relationship.

EMTALA

The Emergency Medical Treatment and Labor Act requires Medicare-participating hospitals with emergency departments to provide a medical screening examination and stabilizing treatment regardless of ability to pay.

MS-DRG

Medicare Severity Diagnosis Related Group: the inpatient prospective payment classification based on principal diagnosis, procedures performed, and the presence of complications or comorbidities.

Case mix index

The average DRG weight of a hospital's discharges; higher values indicate greater resource intensity among patients and increase overall payment.

RBRVS

The Resource-Based Relative Value Scale prices physician services using work, practice expense, and malpractice relative value units, adjusted by geographic indices and a conversion factor.

NCCI MUE

A Medically Unlikely Edit that sets the maximum number of units of a single code a provider would reasonably report for one patient on one date of service.

Master patient index

A database that assigns a unique identifier to each patient and links all encounters and records belonging to that patient across the organization.

FHIR

Fast Healthcare Interoperability Resources: a standards framework using web-based application programming interfaces to exchange health care data between systems.

Audit trail

A chronological record of system activity showing who accessed or modified data and when, supporting security monitoring and data integrity.