CCS-P Medical Coding flashcards

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

Excludes1 note

A note in ICD-10-CM indicating two codes cannot be reported together because the conditions are mutually exclusive.

Seventh character placeholder

In ICD-10-CM, the character X is used as a placeholder when a code requires a seventh character but has fewer than six characters before it.

Combination code

A single ICD-10-CM code that reports both an underlying condition and a related manifestation or complication.

Laterality in ICD-10-CM

ICD-10-CM injury and neoplasm codes often require a right, left, or bilateral designation; unspecified laterality is used only when documentation does not specify.

Z code use

ICD-10-CM Z codes report factors influencing health status or encounters for reasons other than disease, such as status, history, or aftercare.

Principal diagnosis inpatient

The condition established after study to be chiefly responsible for the inpatient admission; it is sequenced first on the UB-04 claim.

Outpatient suspected diagnosis

In outpatient coding, do not assign a diagnosis documented as suspected, probable, or rule out; code the signs or symptoms that prompted the visit instead.

Diabetes coding sequence

When a diabetic complication is documented as due to diabetes, assign the diabetes combination code first and then code the manifestation if a separate code is required.

Modifier 25

A CPT modifier appended to an E/M service indicating it was significant, separately identifiable, and beyond the usual preoperative or postoperative work of a same-day procedure.

Global surgical package

The services included in a surgical CPT code: preoperative evaluation, intraoperative care, and postoperative follow-up for the code's global period.

Add-on code

A CPT code designated with a plus sign that is always reported with a primary procedure and never alone.

Modifier 59

A modifier used to identify a distinct procedural service not ordinarily reported together with another service on the same day.

HCPCS Level II

A national alphanumeric code set used for supplies, drugs, durable medical equipment, and services not represented in CPT.

NCCI edit

A national correct coding initiative edit pair identifying two codes that should not be billed together unless a qualifying modifier is appropriate.

Multiple procedure reduction

Under Medicare, when multiple surgical procedures are performed, the highest-valued procedure is paid at 100% and additional procedures at 50%.

Nonfacility versus facility

Place-of-service setting affects CPT payment: nonfacility claims include practice expense for supplies and staff, while facility claims do not.

Medical necessity

The documented reason a service or item is reasonable and necessary for the diagnosis or treatment of a patient's condition.

Incident-to billing

Billing a service performed by auxiliary personnel under a physician's direct supervision as if the physician performed it.

Teaching physician rule

The teaching physician must personally document or verify key portions of care and be present during key procedures for services billed under their name.

Advance beneficiary notice

A written notice, required before certain noncovered Medicare services, informing the beneficiary of potential financial responsibility.

Physician query

A formal communication asking the provider to clarify or add documentation when the record is ambiguous, inconsistent, or insufficient to support a code.

HIPAA minimum necessary

A privacy rule standard requiring covered entities to limit use or disclosure of protected health information to the minimum needed.

Local coverage determination

A local coverage determination issued by a Medicare Administrative Contractor that states coverage conditions for a service in its jurisdiction.

Late entry

A documentation addition made after the original note, clearly dated and timed as an addendum, without altering the original entry.

Clean claim rate

The number of claims accepted on first submission divided by total claims submitted, expressed as a percentage.

Days in accounts receivable

Total accounts receivable divided by average daily charges, showing how many days of revenue are outstanding.

First-pass denial rate

The number of claims denied on first submission divided by total claims submitted, expressed as a percentage.

Charge capture

The process of recording patient services and supplies in the billing system so they can be coded and billed.

DRG payment

A prospective payment classification grouping inpatient stays by diagnosis, procedures, and complications to determine Medicare payment.

APC payment

An outpatient prospective payment classification grouping services by clinical and cost similarity for facility payment.

Coding audit

A review of medical records and assigned codes to measure accuracy, compliance, and documentation support.

Recovery Audit Contractor

A Recovery Audit Contractor reviews Medicare claims for improper payments and seeks recovery or refunds.