CCS-P Medical Coding key terms

The condition established after study to be chiefly responsible for the patient's admission or encounter, used as the first-listed diagnosis for inpatient coding.

An additional condition that coexists at the time of the encounter and affects patient care, treatment, or management, reported after the principal diagnosis.

An ICD-10-CM note showing that two codes cannot be reported together because the conditions are mutually exclusive; only the more specific condition is coded.

An ICD-10-CM note meaning the condition is not part of the code's description but may be reported separately when both conditions are present and documented.

A single ICD-10-CM code that reports two diagnoses together, or a diagnosis with an associated complication or manifestation, reducing the need for multiple codes.

A late effect or residual condition resulting from an earlier injury or illness; the residual is typically coded first, followed by the cause code.

An ICD-10-CM code describing factors influencing health status or contact with health services, such as screening, history, or aftercare, rather than a current illness.

An ICD-10-CM index table that classifies tumors by anatomical site and behavior, including malignant primary, malignant secondary, benign, uncertain, and unspecified.

Taking less medication than prescribed, or not taking prescribed medication, when documented as a reason for the encounter or affecting care.

An ICD-10-CM designation showing whether a condition affects the right, left, or both sides, or is unspecified, required for certain diagnoses.

A two-character code appended to a CPT or HCPCS code to clarify the service performed, such as laterality, distinct service, reduced service, or professional component.

A CPT code for evaluation and management services, selected by place and type of service, patient status, and level based on medical decision making or time.

The number of days before and after a surgical procedure during which routine preoperative and postoperative care is included in the surgical code's payment.

Reporting component services together under one inclusive code when they are integral to a primary service, rather than billing each component separately.

A pair of procedure codes that generally cannot be billed together because one is a component of the other; an appropriate modifier may sometimes override the edit.

A national alphanumeric code set for supplies, drugs, durable medical equipment, and services not described by CPT, used mainly by Medicare and other payers.

A two-digit code on the claim identifying where a service was furnished, such as physician office, hospital outpatient, inpatient, or ambulatory surgical center.

Services included in payment for a surgical procedure, such as local anesthesia, incision, closure, and routine follow-up care during the global period.

A CPT code describing an additional service or procedure that is always performed with a primary procedure and cannot be reported alone.

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

A modifier indicating that a procedure or service was distinct or independent from other services performed on the same day, often used to override bundling edits.

Services that are reasonable and necessary to diagnose or treat an illness or injury and that meet accepted standards of medical care.

A written communication to the provider asking for clarification of documentation that affects diagnosis code assignment, quality reporting, or reimbursement.

A systematic review of medical records and claims to verify coding accuracy, documentation support, and compliance with payer and regulatory rules.

A formal set of policies, training, monitoring, and corrective actions designed to prevent and detect coding, billing, and regulatory violations.

A federal law that protects the privacy and security of protected health information and sets standards for electronic healthcare transactions and identifiers.

A form given to a Medicare beneficiary before a service that may not be covered, explaining possible financial responsibility and obtaining the patient's agreement to proceed.

A Medicare billing rule allowing services furnished by auxiliary personnel to be billed under the supervising physician's NPI when specific supervision and documentation requirements are met.

Copying documentation from a previous encounter into the current record without confirming it accurately describes the current visit, creating accuracy and compliance risks.

The process of recording services, supplies, and drugs provided to a patient and converting them into billable charges with correct codes and quantities.

A claim with complete and accurate data that passes payer edits and requires no manual correction before it can be processed for payment.

The process of reviewing rejected or denied claims, correcting errors, filing appeals, and identifying root causes to prevent repeat denials.

A program that improves provider documentation so it accurately reflects patient severity, diagnoses, and services, supporting correct coding, quality reporting, and reimbursement.

A Medicare contractor that audits claims for improper payments, recovers overpayments, and identifies underpayments, with providers able to appeal findings.

An indicator on inpatient claims showing whether a condition was present when the patient was admitted, used for quality reporting and payment adjustments.

A payer's decision about whether a service is covered and under what conditions, often based on medical necessity criteria and policy.