CPC Medical Coding key terms

A diagnosis coding system used in the United States to report diseases, injuries, and health conditions with alphanumeric codes up to seven characters. It supports accurate billing, statistics, and clinical documentation.

The alphabetical list in the ICD-10-CM manual that helps coders find diagnosis codes by condition, symptom, or reason for visit before verifying the code in the Tabular List.

The numeric and alphanumeric organized section of ICD-10-CM that presents code categories, subcategories, and full code descriptions along with instructional notes and conventions.

An ICD-10-CM instruction meaning the two conditions cannot be coded together because the excluded condition is entirely unrelated to the code being reviewed; coders should report the more specific condition.

An ICD-10-CM instruction indicating that the excluded condition is not part of the condition represented by the code, so both conditions may be coded if documented.

A single ICD-10-CM code that captures two diagnoses, a diagnosis with a complication, or a diagnosis with a manifestation, eliminating the need to report separate codes.

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

The diagnosis reported first on an outpatient or physician claim, representing the main reason for the encounter in the order required by payer and coding guidelines.

The process of deciding the order in which multiple diagnosis or procedure codes are reported, following official guidelines so that the most significant condition or procedure appears first.

An ICD-10-CM character used mainly in injury, poisoning, and obstetric codes to show the episode of care, such as initial encounter, subsequent encounter, or sequela.

An ICD-10-CM character used to fill empty positions so a code reaches the required length or seventh character, ensuring the code is valid and complete.

Current Procedural Terminology, a standardized code set maintained by the American Medical Association that describes medical, surgical, and diagnostic services for physician and outpatient billing.

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

A two-character code added to a CPT or HCPCS code to clarify that a service was performed differently, under distinct circumstances, or by a different provider than the basic code describes.

Evaluation and management codes report cognitive services such as office visits, hospital visits, and consultations, selected by history, examination, and medical decision making or by time.

The patient's main reason for the encounter, usually stated in the patient's own words, which guides history taking and supports the medical necessity of the visit.

A chronological description of the patient's current problem, including elements such as location, quality, severity, duration, timing, context, modifying factors, and associated signs or symptoms.

An inventory of the patient's body systems that asks about symptoms the patient may be experiencing, used to build the history portion of an evaluation and management service.

The patient's prior illnesses, surgeries, medications, family health patterns, and social habits such as occupation and tobacco use, documented to complete the history for E/M leveling.

The complexity of establishing a diagnosis and choosing a management plan, based on number and type of problems, amount of data reviewed, and risk of complications.

Selecting an evaluation and management code by the total time the physician spends on the date of the encounter in face-to-face or non-face-to-face activities, when counseling or coordination dominates.

A patient who has not received any professional services from the physician or same-specialty group within the previous three years, which affects E/M code selection.

A patient who has received professional services from the physician or same-specialty group within the past three years, allowing use of established patient E/M codes.

A payment bundle that includes preoperative, intraoperative, and postoperative services routinely performed with a surgical procedure, with postoperative days varying by procedure.

A two-digit code on a claim identifying where the service was provided, such as office, hospital outpatient, or ambulatory surgical center, which affects payment.

A payment distinction where facility billing includes the use of hospital or ASC resources, while non-facility billing includes practice overhead and supplies in the physician's office.

A visit focused on health promotion and disease prevention, such as a well-child exam or annual physical, coded differently from problem-oriented E/M visits.

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

A modifier added to an E/M code when the visit results in the decision to perform surgery, distinguishing the decision from the surgical procedure itself.

The National Correct Coding Initiative, a Medicare program that publishes edits identifying code pairs that should not be billed together because they are components of the same service.

The payment practice of combining services that are integral to a primary procedure into one payment, so separate codes for the components are not reimbursed.

Reporting components of a single procedure as separate codes to obtain higher payment, which is improper when the services are integral to the primary procedure.

The requirement that a service be reasonable and necessary for the diagnosis or treatment of illness or injury, meeting accepted standards of care and payer coverage rules.

A written notice from a Medicare provider to a beneficiary stating that a service may not be covered and that the patient may be responsible for payment.

A claim submitted with complete, accurate, and valid information that can be processed by the payer without additional review or correction.

A payer document sent to the patient or provider explaining how a claim was processed, including allowed amounts, payments, adjustments, denials, and patient responsibility.

Intentional deception or misrepresentation that a person knows could result in unauthorized benefit, such as billing for services never provided.

Practices that directly or indirectly cause unnecessary costs to the health program, inconsistent with sound business or medical practice, but without intent to deceive.

Billing a service at a higher level or with a more complex code than the documentation supports, which can be fraudulent if done intentionally.

A systematic review of medical records and claims to verify that documentation supports the codes billed and that payer rules were followed.