Medical Coding Vocabulary and Keywords
Medical coding is the process of allocating digits or alphanumeric codes to the diseases, injuries, treatments, and procedures that medical care providers use to document every detail correctly of the patient.
There is a long list of keywords and vocabulary used by coders when working with medical coding when talking about medical coding. It is crucial for medical coders to become very familiar with these terms. Those who have excellent knowledge about the keywords will be able to provide an effective job performance. Here I mention some keywords and vocabulary that every medical coder should consider.
Let’s look at those.
Category codes are three-digit codes that follow a specific condition. For example, a situation like COPD (Chronic Pulmonary Obstructive Disease) is for category code 496.
Subcategory codes are four-digit codes, which serve the purpose of describing the code in much detail. These codes represent the digit that comes after the decimal point. This digit further defines the nature of the illness or injury and gives additional information as to its location or manifestation.
For example, a subcategory code of HTD 401.9 provides much detail of the hypertension disorder.
The sub-classification codes stick to the subcategory in ICD codes. This code further expands on the subcategory and details the injury or disease’s manifestation, severity, or location. For example, in ICD-10-CM, a sub-classification also describes which encounter is for the doctor.
These codes require five digits because of the intricate detail included. Numerous sub-classification codes end with two zeros, which have three numbers and a decimal point like 180.00.
Symbols represent a single code used to classify a diagnosis with complications or associated secondary manifestations.
ICD- International Classification of Diseases
The ICD is a set of medical diagnostic codes initiated over a very long time. Maintained today by the WHO, ICD codes make a global language for documenting diseases and injury. Currently, the US uses ICD-10-CM. ICD codes are numeric or alphanumeric. They include a three-character category, which describes the illness, usually followed by a decimal point, and two to four more characters, depending on the code set, which gives more detail about the manifestation and place of the disease.
The Category describes the basic details of the injury or illness and the Category related to the first three characters of the ICD code. In some cases, the Category describes the patient’s condition correctly. However performed, the coder should list a more detailed explanation of the injury or illness in some cases. For example, in ICD-10-CM, categories are three numbers.
ICD-9 consists of three alphanumeric codes, except CME and V codes. In ICD-10-CM, all categories are alphanumeric. ICD-10 system used for classifying codes of sicknesses.
Clinical Modification- CM
Clinical modification, created by the National Center for Health Statistics, is added to the ICD codes sets made in the United States. Many countries enlarge and explain ICD code sets for their national use; The United States, for example developed ICD-10 from 14,000 codes to over 68,000 unique codes. The term “-CM” adds to the end of the ICD code title. For example, ICD-10-CM means International Classification of Diseases, Tenth Revision, Clinical Modification.
CPT- Current Procedural Terminology
American Medical Association published, patent, and managed CPT codes. In addition, it describes services of the surgical, medical, and diagnostic varieties performed in some cases on a patient.
CPT codes play an essential role in the reimbursement process. These codes have five characters and can be numeric or alphanumeric.
The CPT codes have three Categories. The largest and most widely used category I describes medical procedures, technologies, and services. Category II is about performance management and extra detail—category III codes for emerging and experimental medical procedures and services.
This CPT manual section covers surgical procedures performed on patients. The most extensive and most complex area of CPT’s first Category, the Surgery section, is divided into sections based on which part of the body the surgery is performing. Then, further subdivided according to the type of procedure is being fulfilled. For example, there is a section for removing the hand and fingers, part of the wide section of surgical procedures performed on the musculoskeletal system. The code range for surgery is 10021 – 69990.
CPT code set also includes a section for anesthesia codes. These codes range from 00100 – 01999, including the anesthetized body’s area and the type of procedure performed. For example, many codes for anesthesia of the shoulder and axilla are also for radiological procedures.
This section of the CPT manual covers radiologic tests and procedures like X-rays, ultrasounds, and oncology. The codes for Radiology are 70010-79999.
Pathology and Laboratory (CPT)
Pathology and Laboratory of Category I CPT codes concerns lab testing and pathological analysis. This section includes codes for procedures to decide the status and principal reason for a patient’s illness or condition. Pathology and Laboratory codes have the range of 80047-89398.
Evaluation and Management/ E&M Codes
E&M is a part of CPT codes that describe assessing a patient’s health and their care management. Doctors often use these codes to refer to a specialty.
E&M is at the beginning of the CPT manual, even with being out of numerical order. The E&M codes are 99201 – 99499.
The Medicine section is the final section of the first Category of CPT. Medicine (CPT) codes describe procedures directly related to applying the medication, medical techniques, and medical equipment to the patient. This section does not have primary patient considerations or surgical processors, which have their units. Medicine codes have the range of 90281 – 99199 and 99500-99607.
Healthcare Common Procedure Codes (HCPCS)
HCPCS codes recognize services, supplies, and products not covered in CPT coding. These codes are for services not provided by a doctor, but ambulance services and other parts can fulfill.
HCPCS is the main procedural code set for reporting procedures to Medicare, Medicaid, and other third-party payers. Maintained by CMS, HCPCS has two levels. Level I is similar to CPT, and usage is also the same way. Level II is about the equipment, medication, and outpatient services not covered in CPT.
The primary term is the term that has to look at a medical coder’s book index. So, for example, if a person has chronic bronchitis, the coder would look up the code for bronchitis.
Default Code / Unspecified Code
Default codes are listed next to the primary term, and default codes are available when there is no particular code for the condition.
A modifier is a two-character code that adds to a procedure code to display an essential difference in the procedure. For example, CPT codes include numeric modifiers, and HCPCS codes include alphanumeric modifiers. Modifiers are put down at the end of a legend with a hyphen and give details about the procedure itself, that’s the procedure’s Medicare suitability and a host of other essential features.
For example, the CPT modifier -51 informed the payer that this procedure was one of the multiple procedures. In addition, the HCPCS modifier –LT, describes a bilateral process performed only on the left side of the body.
Modifier Exempt (CPT)
Specific codes in CPT cannot have modifiers added to them. Modifier exempt is a shortlist that is included additionally in the CPT manual.
These are the subterms that come after the primary term, and they are writing in parenthesis. Again, these are not mandatory but serve the function of providing more clarity to the diagnosis.
New and Established Pts
These codes are about new or usual patients. The further distinction is about patients who have not received services from a doctor or the same specialty doctor in the previous three years. The established credit is about the patients who have received assistance during the last three years.
These reports are requested from health insurance to explain why service was performed or discontinued. Supplemental records mostly have, in some cases, CPT modifiers.
When there are only six available characters for a code and a seventh needs to be added, it is complete with the character of X.
These codes are for various kinds of emerging technologies. So whenever that happens, these codes end with the letter T.
V codes discover any situations which can impact the care of a patient. In addition, these codes identify conditions that are not considered an injury or illness.
V codes include live-born infants, people with risk or disease because of family history, people encountering health services for sure or mandated evaluation or aftercare, and a host of other not easily classifiable situations. Therefore, V-codes have been replacing ICD-10- CM with Z-codes.
E-codes consist of a set of ICD-10-CM codes that include external causes of injury, such as auto accidents, poisoning, and homicide. E Codes also have the location of the damage.
These codes describe situations outside of injury or disease that reasoned a patient to visit a health professional. For example, Z-codes can include a patient visiting a doctor because of family medical history.
Z-codes are much similar to the V-codes in ICD-9-CM.
Here I mention some keywords that a medical coder should be aware of when working as a professional.
Relative Value Unit (RVU)
This term describes formulas produced by Medicare.
American Medical Association
American Medical Association is the group entrusted with establishing and modifying any changes to the medical coding system.
Advanced Beneficiary Notice (ABN)
ABN is part of Medicare and is issued when a patient agrees to undergo a service that Medicare may not cover. It is a way that makes patients aware of that fact.
An eponym describes an illness that has taken its name from a natural person.
Principle diagnosis refers to the diagnosis code that is listed first. It explains the main reason for the medical visit and is used very often by coders.
CMS – Center for Medicare and Medical Services
CMS is one of the most critical organizations in healthcare today. It updates and maintains the HCPCS code set.
NCHS – National Center for Health Statistics
The NCHS is a government organization that traces medical information. In addition, NCHS is responsible for making and publishing the clinical updates to ICD codes and their annual modifications.
Pathology is about the science of the chain of events about the disease.
The technical component is about covering only the technical part of the process but not the professional role. So, for example, a technical feature includes conducting a chest X-ray but would not assess that X-ray for disease or abnormality.
WHO- World Health Organization
WHO is an international organization, which is an agency of the United Nations. WHO administers the creation of ICD codes and is one of the most critical organizations in global health.
Medical Essentiality is about rationalizing medical services as logical, required, or relevant. Medical Essentiality is an excellent example of ICD codes. A coder may use the ICD code for a broken arm, for example, to illustrate the medical Essentiality of an X-ray and the application of a cast.
Morbidity is about a specific illness that a patient or population has. ICD codes report morbidity. Heart diseases, obesity, and diabetes are examples of morbidity.
The mortality rate is the death rate in a particular population. The mortality rate has two types, cause-specific mortality rate and age-specific mortality rate.
A sequel is a pathological condition that can result from a previous injury or illness. Medical coders can experience this term in ICD-10-CM in the code’s subclassifications.
In CPT, a professional component is about the services performed by a fully licensed medical professional. For example, professional services include evaluating a radiologic test but not administering it, a technical component.