CCS (AHIMA) flashcards

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

Principal Diagnosis Definition

In inpatient coding, the condition established after study to be chiefly responsible for occasioning the admission, even when the patient presents with another condition.

First-Listed Diagnosis

In outpatient and physician coding, the condition, symptom, or reason documented by the provider as the primary reason for the encounter on that date.

ICD-10-PCS Code Structure

Seven alphanumeric characters, each a defined axis: section, body system, root operation, body part, approach, device, and qualifier, read in that fixed order.

Root Operation Resection

An ICD-10-PCS root operation that cuts out or removes all of a body part without replacement, distinguishing it from excision, which removes only some.

Modifier 25 Purpose

Reports a significant, separately identifiable evaluation and management service provided by the same physician on the same day as a procedure or other service.

CPT Category II Codes

Four-digit codes followed by the letter F, used for performance measurement and tracking; they are not used to bill or reimburse physician services.

Seventh Character Encounter

An ICD-10-CM character indicating the encounter stage, such as A for initial encounter, D for subsequent encounter, and S for sequela of a healed condition.

Medical Necessity Documentation

Record content that supports why a service was reasonable and necessary; coders may not assign a diagnosis that the treating provider did not document.

History and Physical Timing

CMS requires the history and physical be completed no more than 30 days before admission and updated within 24 hours after inpatient admission by the responsible provider.

Late Entry Requirements

A late entry must be labeled, dated and timed when written, and authenticated by its author, while the original record content remains visible and retrievable.

Cloned Documentation Risk

Copying text from another encounter or patient creates unsupported diagnoses and potential false claims, because documentation must reflect that patient's actual clinical course.

Provider Authentication

Signing of a record entry by the provider who performed or documented the service using a unique identifier; auto-authentication through default credentials is not permitted.

Ambiguity Query Trigger

Documentation that is unclear, inconsistent, or conflicting, such as a diagnosis named in nursing notes but not by the physician, is a trigger for a provider query.

Non-Leading Query

A query that presents clinical evidence and asks for clarification without suggesting or directing the provider toward a particular diagnosis or reimbursement outcome.

Query Elements

A compliant query states the clinical indicators from the record, asks a clear question, and offers multiple-choice answers including an option for other or unable to determine.

Query Retention

The query and the provider's response become part of the health record and must be retained and retrievable according to the organization's record retention policy.

Open-Ended Query

A query phrased as please clarify or please specify, allowing the provider to supply the diagnosis in their own words and reducing the risk of leading.

Unanswered Query Action

If the provider does not respond to a query, the coder assigns only codes supported by existing documentation and does not assume the queried condition.

Query for Specificity

A query may be sent when a documented diagnosis is unspecified and the record contains clinical details that could support a more specific code.

Minimum Necessary Standard

A HIPAA Privacy Rule requirement to limit uses and disclosures of protected health information to the least amount reasonably needed to accomplish the purpose.

Breach Notification Deadline

Affected individuals must be notified without unreasonable delay and within 60 days of discovery; breaches affecting 500 or more people also require prompt HHS notice.

NCCI Column One Code

In a procedure-to-procedure edit pair, the comprehensive code that is payable; the Column Two code is bundled and denied unless a valid modifier applies.

LCD Versus NCD

A national coverage determination is issued by CMS and applies to all Medicare contractors; a local coverage determination is issued by a Medicare Administrative Contractor for its jurisdiction only.

Medical Necessity Requirement

Services must be reasonable and necessary for diagnosis or treatment, and the diagnosis reported on the claim must be supported by and consistent with the record.

RAC Lookback Period

Recovery Audit Contractors may review Medicare claims for up to three years from the date the claim was paid to identify overpayments and underpayments.

False Claims Act Damages

A defendant who knowingly submits a false claim is liable for three times the government's damages plus civil monetary penalties for each separate claim filed.

MS-DRG Grouper Inputs

The grouper uses the principal diagnosis, secondary diagnoses acting as CC or MCC, performed procedures, age, sex, and discharge disposition to assign a DRG.

Computer-Assisted Coding Validation

CAC software uses natural language processing to suggest codes from the record, but a credentialed coder must review and confirm every assignment before finalizing.

Encoder Edit Checks

Encoder software applies NCCI edits, medical-necessity edits, and age or sex conflict warnings as codes are entered, prompting review before the claim is released.

SNOMED CT Role

A comprehensive clinical terminology used to capture detailed findings in the electronic health record, mapped to classification systems such as ICD-10-CM for reporting.

Audit Trail Requirement

A HIPAA Security Rule control that records who accessed or changed electronic protected health information and when, supporting accountability and breach investigation.

HIPAA Risk Analysis

A required Security Rule activity: an accurate and thorough assessment of potential risks and vulnerabilities to electronic protected health information, documented and periodically updated.