Key Medical Terminologies Every Coder Should Know

 

1. ICD (International Classification of Diseases)

  • ICD-10-CM: Used for diagnosis coding.

  • ICD-10-PCS: Used for inpatient procedure coding.

🔹 2. CPT (Current Procedural Terminology)

  • Maintained by the AMA.

  • Used to report outpatient and physician services.

🔹 3. HCPCS (Healthcare Common Procedure Coding System)

  • Level I: CPT codes.

  • Level II: National codes for supplies, equipment, and non-physician services.

🔹 4. E/M (Evaluation and Management)

  • Codes for services like office visits, consultations, and hospital visits.

  • Documentation depends on time, complexity, and medical decision-making.

🔹 5. DRG (Diagnosis Related Groups)

  • Used in inpatient hospital billing to classify hospital cases.

🔹 6. Modifiers

  • Add-ons to CPT/HCPCS codes to provide additional details (e.g., -25 for a significant, separately identifiable E/M service).

🔹 7. Medical Necessity

  • Justification that a service is needed based on clinical standards.

  • Must be supported by diagnosis codes.

🔹 8. ABN (Advance Beneficiary Notice)

  • A notice given to Medicare patients when a service might not be covered.

🔹 9. NCD/LCD (National/Local Coverage Determinations)

  • Guidelines that help determine what Medicare will cover.

🔹 10. Coding Guidelines

  • Official rules and conventions set by CMS and AHA for accurate coding.

🔹 11. POA (Present on Admission)

  • Indicates if a condition was present at the time of inpatient admission.

🔹 12. HCC (Hierarchical Condition Category)

  • Risk adjustment model used for Medicare Advantage and ACA plans.

🔹 13. NOS & NEC

  • NOS: Not Otherwise Specified.

  • NEC: Not Elsewhere Classified.

  • Common in ICD coding when details are missing or non-specific.

🔹 14. Bundling/Unbundling

  • Bundling: Combining services into a single code.

  • Unbundling: Separating bundled codes (often considered improper).

🔹 15. Denial Codes (CARC & RARC)

  • Codes explaining why a claim was denied.

  • CARC: Claim Adjustment Reason Codes.

  • RARC: Remittance Advice Remark Codes.

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