CCA (ASA) key terms

The U.S. coding system used to report diagnoses and reasons for visits on health care claims, organized by body system and containing codes for diseases, injuries, and symptoms.

The U.S. inpatient procedure coding system used by hospitals to report surgical and medical procedures, built from seven characters describing the procedure's section, body system, root operation, and other details.

A set of five-character procedure codes maintained by the American Medical Association and used mainly for outpatient and physician services to report tests, surgeries, and evaluations.

A national coding system for supplies, drugs, durable medical equipment, and some services not represented in CPT, using a letter followed by four digits.

A two-character code added to a procedure or service code to show that a service was altered by a specific circumstance without changing the underlying procedure.

The condition established after study to be chiefly responsible for the patient's admission to inpatient care, sequenced first on the claim.

The payment practice of combining services that are typically performed together into one payment, so separate charges for the components are not paid.

A word root joined to a vowel, usually 'o,' that links to a suffix or another root to build medical terms such as cardiology.

A word part attached to the end of a root or combining form that changes meaning, often indicating a condition, procedure, or specialty.

A word part attached to the beginning of a term that modifies its meaning, such as 'hyper-' meaning above normal.

A medical term named after a person, such as a disease or sign named for the physician who first described it.

The standard reference posture in anatomy: standing upright, facing forward, arms at the sides with palms forward, and feet flat.

Imaginary flat surfaces used to divide the body for anatomical description, including the sagittal, coronal, and transverse planes; they help locate organs and describe movement.

A directional term meaning closer to the point of attachment or to the trunk of the body; the opposite of distal.

The body's ability to maintain stable internal conditions, such as temperature and pH, through ongoing physiological adjustments that keep cells functioning properly.

Four sections created by crossing two imaginary lines at the navel, used to describe the location of abdominal pain, organs, and findings.

The patient's main reason for seeking care, usually recorded in the patient's own words at the start of the encounter.

A dated entry in the health record describing the patient's condition, care given, and response during an episode of treatment.

A report prepared when a patient leaves a hospital that summarizes the admission, key findings, treatment, and follow-up instructions.

A detailed record of a surgical procedure describing the preoperative diagnosis, findings, technique used, and postoperative condition; it is written by the surgeon.

The process of verifying that a health record entry was made by the person who claims to have written it, often by signature or secure electronic sign-on.

An addition to the health record made after the original note was completed, clearly dated and timed to show when it was actually written.

The requirement that a service be reasonable and necessary for the diagnosis or treatment of a patient's condition to be covered by payers.

Federal regulations that protect individually identifiable health information and set rules for its use and disclosure by covered entities.

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

A national set of coding edits that identify pairs of services that should not normally be billed together, helping prevent improper separate payment.

Assigning a higher-paying code than the documentation supports, which is a form of fraudulent billing and a compliance risk.

A form given to a Medicare beneficiary before a service that may not be covered, allowing the patient to choose to receive it and accept financial responsibility.

The federal office within the Department of Health and Human Services that investigates fraud, waste, and abuse in Medicare and Medicaid programs.

The full process of managing patient accounts from scheduling and registration through coding, billing, payment posting, and collections.

A document from a payer explaining how a claim was processed, including paid, denied, or adjusted amounts and any patient responsibility.

A Medicare inpatient payment classification that groups hospital stays by diagnosis, procedures, and complications to set a fixed payment amount.

A Medicare outpatient prospective payment category that groups similar outpatient services and assigns a predetermined payment rate to each group.

A payment model in which a provider receives a fixed amount per patient for a set period, regardless of how many services are used.

A payment model that pays providers separately for each service delivered, based on a fee schedule or charge.

A digital record of a patient's health information that can be shared across care settings and updated in real time.

Software that converts clinical documentation into coded data by suggesting codes based on terms entered, which a coder then reviews.

Technology that analyzes clinical text and proposes diagnosis and procedure codes to support, but not replace, human coding decisions.

An intermediary that receives electronic claims from providers, checks them for format and data errors, and transmits them to payers.

A system-generated record that tracks who accessed or changed health information and when, supporting security and compliance reviews.