CIC (National Alliance) key terms

A national minimum data set collected on inpatient discharges that standardizes data elements, including the definition of principal diagnosis that coders apply when selecting the first-listed diagnosis on a claim.

The condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care; it is sequenced first on the inpatient claim.

Any condition other than the principal diagnosis that is documented and affects patient care during the stay, including conditions that raise severity or resource use.

The federal rules issued by the cooperating parties that govern how diagnoses are selected and sequenced, including chapter-specific instructions coders must follow for inpatient records.

A note stating two codes cannot be reported together because the conditions are mutually exclusive; the coder selects the single code that best represents the documented condition.

A note meaning the excluded condition is not part of the condition represented by the code; both may be coded separately when each is documented and clinically relevant.

A single code that classifies two diagnoses, or a diagnosis with its associated manifestation or complication, used instead of reporting each element with separate codes.

Instructional notes that establish sequencing when one condition is due to another, requiring the underlying cause to be coded first and the manifestation or added detail coded second.

A code used when documentation does not support a more specific diagnosis; frequent use reduces data quality and may lower severity, so coders query when clarification is possible.

A reporting flag showing whether a condition was present when the inpatient admission occurred, reported with values such as Y, N, U, and W for quality and payment purposes.

A condition that develops during hospitalization and meets criteria for reduced or denied payment because it was not present on admission and was reasonably preventable.

A Medicare payment policy under which inpatient admission is generally appropriate when the physician expects the stay to span at least two midnights, supporting Part A payment.

The determination that services provided were reasonable and necessary for diagnosing or treating illness or injury, a fundamental requirement for Medicare payment of a claim.

A Medicare-contracted entity that reviews claims for improper payments and recovers overpayments or returns underpayments, concentrating on high-risk coding and billing issues.

A federal statute imposing liability on entities that knowingly submit false or fraudulent claims, including claims unsupported by documentation; violations carry civil penalties and treble damages.

A hospital's structured set of written policies, training, monitoring, auditing, and enforcement activities designed to prevent and detect violations of coding and billing requirements.

Medicare Severity Diagnosis Related Groups, the inpatient prospective payment classification that assigns each stay to a group based on principal diagnosis, procedures, and secondary diagnoses reflecting severity.

Complication or comorbidity and major complication or comorbidity; secondary diagnoses designated by the grouper as raising severity, which can move a case into a higher-paying DRG.

Software that applies MS-DRG logic to coded diagnoses and procedures, producing the final DRG assignment and its relative weight for payment calculation.

A value assigned to each MS-DRG reflecting its average resource cost compared with the national average; it is multiplied by the standardized payment amount to calculate base payment.

The average relative weight of all discharges in a hospital or unit during a period, used to measure patient acuity and resource intensity.

Additional Medicare payment made when a case's estimated costs exceed a fixed threshold above the DRG payment, reflecting an unusually costly or lengthy stay.

A reduced DRG payment applied when a patient is discharged to a post-acute care provider before the geometric mean length of stay, because the hospital did not bear full expected costs.

The average length of stay calculated using logarithms, published for each MS-DRG and used to set thresholds for transfer and outlier payment adjustments.

The inpatient procedure classification system using seven-character alphanumeric codes built from tables that define section, body system, root operation, body part, approach, device, and qualifier.

The third character of an ICD-10-PCS code that defines the objective of the procedure, such as excision, resection, drainage, or bypass.

The fourth character of an ICD-10-PCS code specifying the anatomical site on which the root operation is performed, selected from the values listed in the applicable table.

The fifth character of an ICD-10-PCS code identifying how the operative site was reached, such as open, percutaneous, percutaneous endoscopic, or via natural or artificial opening.

The sixth character of an ICD-10-PCS code indicating the device left in place at the end of the procedure, with the value Z meaning no device remains.

The seventh character of an ICD-10-PCS code providing extra attribute information about the procedure, such as diagnostic versus therapeutic intent or a specific technique used.

An ICD-10-PCS root operation meaning cutting out or off all of a body part without replacement, distinguished from excision, which removes only a portion of the body part.

A root operation creating a new route for contents to flow around a blocked or diseased area, coded with a qualifier identifying the destination of the flow.

The grid in the ICD-10-PCS codebook listing valid character combinations for a body system and root operation; coders build a code by choosing one value in each applicable column.

A written or electronic communication asking the provider to clarify, specify, or add documentation needed for accurate code assignment, written in a non-leading manner.

A program of concurrent record review, querying, and provider education intended to ensure the medical record clearly and completely reflects the patient's severity of illness and care provided.

The extent of physiologic decompensation or organ system loss of function, a concept used by DRG and risk-adjustment systems to explain resource use and outcomes.

Documentation of coding and query activity, including who changed what and when, that supports compliance review and defends the final coded record.

Agency for Healthcare Research and Quality measures built from coded data that flag potentially preventable complications and adverse events for quality reporting and comparison.