CAMC Part 1 Exam key terms

The determination that a service or supply is reasonable, necessary, and appropriate for diagnosing or treating a patient's condition, based on accepted standards of care and supported by documentation in the record.

The condition established after study to be chiefly responsible for the patient's admission to the hospital for inpatient care, sequenced first in the inpatient coding of the encounter.

The diagnosis reported first on an outpatient or physician claim, representing the condition chiefly responsible for the services provided that day; it is not always the most severe condition coded.

A late effect: a residual condition that remains after the acute phase of an illness or injury has ended. The residual condition is coded first, followed by the code for the original cause.

An ICD-10-CM instruction meaning the two conditions cannot be reported together because they are mutually exclusive; the excluded code is never used with the code bearing the note.

An ICD-10-CM instruction meaning the excluded condition is not part of the condition represented by the code; if both conditions exist, both may be reported separately.

An ICD-10-CM instruction directing the coder to report the underlying cause or etiology code before the manifestation code, so the causal condition is sequenced first.

An ICD-10-CM instruction telling the coder that a secondary code is required to fully describe the condition, such as a manifestation, organism, or cause not captured by the primary code.

A flag reported on inpatient claims showing whether a condition was present when the patient was admitted, developed during the stay, or was unable to be determined; used for quality and payment purposes.

A condition that develops during a hospital stay and was not present on admission. Certain HACs trigger reduced payment in Medicare's quality programs.

Medicare Severity Diagnosis-Related Group: the inpatient prospective payment classification that groups stays by principal diagnosis, procedures, complications, and severity to set a fixed payment per stay.

The outpatient prospective payment system grouping that assigns hospital outpatient services with similar clinical and cost characteristics to a single payment rate.

A unit weighting physician services by work, practice expense, and malpractice cost; multiplied by a geographic adjustment and a conversion factor to produce the Medicare allowed amount.

A published list of payment rates for services, such as the Medicare Physician Fee Schedule, used to determine the allowed amount before coinsurance and deductible are applied.

The maximum amount a payer will recognize as payable for a covered service under its contract or fee schedule; patient cost-sharing and payer payment together make up this amount.

A statement from the payer to the patient and provider showing services processed, the allowed amount, payments made, adjustments, and the patient's remaining responsibility.

The electronic transaction a payer sends with claim payment details, including paid, denied, and adjusted amounts plus reason codes used to post payments and manage denials.

A claim submitted with all required data elements complete, accurate, and free of errors that would cause the payer to reject or return it for correction before adjudication.

A payer's refusal to pay a claim or line item, often due to missing authorization, ineligibility, bundling edits, or insufficient documentation; denials require appeal or correction and resubmission.

The end-to-end financial process from patient scheduling and registration through coding, billing, payment posting, and collections, aimed at accurate and timely reimbursement.

The process of recording services, supplies, and procedures provided to a patient so they can be billed; incomplete capture causes lost revenue and inaccurate claims.

The specific code selected within an E/M category, chosen using the required level of medical decision making or total time on the date of the encounter, per current guidelines.

One of the two permitted bases for selecting an E/M level, reflecting the number and complexity of problems addressed, the data reviewed, and the risk of complications or morbidity.

For E/M selection, the entire time on the date of the encounter spent on the patient's care, including chart review, counseling, documentation, and care coordination, whether or not the patient is present.

The rules specifying what must be recorded in the medical record to support the codes reported, including the elements of history, examination, assessment, and the basis for the level selected.

A record structure organizing documentation around the patient's identified problems, with progress notes written in subjective, objective, assessment, and plan format for each problem.

A chronological record of who accessed or changed a health record and when, used to detect unauthorized access, verify documentation integrity, and support compliance investigations.

The HIPAA principle that uses and disclosures of protected health information should be limited to the least amount needed to accomplish the intended purpose.

Individually identifiable health information held or transmitted by a covered entity or business associate, in any form, relating to the patient's past, present, or future health or payment.

The three core activities for which HIPAA permits use or disclosure of protected health information without patient authorization, covering care delivery, billing, and administrative functions.

Reporting a service or diagnosis at a higher level of complexity or severity than the documentation supports, in order to increase payment; a form of fraudulent billing.

Billing components of a single procedure separately when they are properly reported as one combined code, producing improper additional payment; an integrity risk in procedure coding.

A two-character code appended to a procedure code to indicate a significant circumstance, such as a distinct service, laterality, or a reduced service, that changes how the claim is processed.

Medicare's edit system identifying code pairs that should not be billed together, including procedure-to-procedure edits and medically unlikely units, used to prevent improper payment.

A federal law imposing civil liability on parties who knowingly submit or cause submission of false or fraudulent claims for government payment, with whistleblower provisions and treble damages.

The inpatient procedure classification system built from seven characters describing the section, body system, root operation, body part, approach, device, and qualifier.

The third character of an ICD-10-PCS code defining the objective of the procedure, such as excision, drainage, or insertion, and the key driver of code selection.

Current Procedural Terminology: the AMA-maintained code set used to report medical services and procedures for outpatient and physician billing, organized into categories including surgery, radiology, and E/M.

The designation of which side of the body a condition or procedure involves (right, left, bilateral, or unspecified), required in many ICD-10-CM and procedure codes for accurate reporting.

The standard reference posture for describing the body: standing upright, face forward, arms at the sides, and palms facing forward, used to define directional terms in anatomy.

The study of how disease processes alter normal body function, linking structural and functional changes to the signs, symptoms, and diagnoses that coders must translate into codes.