Medical Coding Vocabulary and Key Terms

Posted by Dave Cowley on Nov 28, 2017 2:51:49 PM

Medical coding can be full of unknown terminology and TLA's (three letter acronyms). It can be daunting and often times overwhelming to have a slew of words coming at you that might sound like Mandarin to an unfamiliar ear.  Our staff’s experience combined would probably equal centuries of medical coding knowledge, yet at times we will still hear a word that we are not familiar with.  We thought it would be useful for industry peers to create this resource full of medical coding vocabulary and key terms. Without further ado let’s get started: 
Medical Coding Vocabulary and Key Terms


Clinical Modification

This designation, created by the National Center for Health Statistics, is added to the ICD code sets when they are implemented in the United States. The ICD-10 code set went from 14,000 codes to over 68,000+ codes with the transition to ICD-10-CM. The term "CM" added to the end stands for "clinical modification". 


The center for medicare and medicaid services. This federal agency updates and maintains the HCPCS code set and is considered one of the most important organizations in healthcare today. 



Current Procedural Terminology. Published, copyrighted, and maintained by the American Medical Association, CPT codes describe what procedure or service was performed on a patient. 

CPT Coding is divided into three different levels. 

Category 1: This is the largest and most frequently used. Category 1 describes medical services, technologies and procedures. 

Category 2: This is used for performance management and additional data.

Category 3: This is reserved for emerging and expiremental procedures. 



The Healthcare Common Procedure Coding System. This is the main procedural code set for reporting procedures to Medicare, Medicaid, and a large number of other third party payers. Similar to CPT, there are different levels with HCPCS. 

Level 1: Identical to CPT. Used when reporting to medicare or medicaid. 

Level 2: Describes equipment, medication, and outpatient services not included in CPT



E-codes are a set of ICD-9-CM Codes that include codes for external causes for injury, such as auto accidents, poisoning, and homicide. 


Evaluation and Management (CPT)

E&M is a section of CPT codes used to describe the assessment of a patients health and management of their care. Example: Codes for visits to doctor's office and trips to the emergency room. 



The first topic is "ICD" which stands for International Classification of Disease. In ICD the first three characters of the code describes the basic manifestation of the injury or sickness. More often than not coders will need to identify more than just the first few characters. In recent years here in the US we have moved from ICD-9 to ICD-10. ICD-10 codes are all alphanumeric, whereas with ICD-9 most of the codes were just three numbers. This transition from ICD-9 to ICD-10 increased complexity for providers and requires increased specificity when coding. 



A two character code added to a procedure code to demonstrate an important variation of the procedure. These are added at the end of the code with a hyphen and may provide information about the procedure itself, medicare eligibility, and a host of other things. 


Modifier Exempt

Certain codes in CPT cannot have modifiers added to them. This is a fairly short list that can be found in the appendices of the CPT Manual. 



The national Center for Health Statistics. A government agency that tracks health information, and is responsible for creating and publishing both the clinical modifications to ICD codes and their annual updates. 



The science of the causes and effects of disease. 



In ICD codes the subcategory describes the digits that come after the decimal point. This digit further describes the nature of the illness or injury and gives additional information to its location or manifestation. 



The sub classification follows the subcategory in ICD codes. The sub classification further expands about the manifestation, severity, or location of the injury or disease. in ICD-10-CM there is a sub classification that describes which encounter this is for the doctor. Example: first treatment for the ailment, follow-up, assessment of a condition that is the result of a previous injury or disease. There may be as many as three sub classifications. 


Technical Component

The portion of a medical procedure that concerns only the technical aspect of the procedure, but not the interpretive, or professional aspect. Example: Administration of a chest X-ray, but Not assessment of that X-ray for disease or abnormality. 



The World Health Organization. This international body, which is an agency of the United Nations, oversees the creation of ICD codes and is one of the most important organizations in international health. 



Describes patient visits related to circumstances other than disease or injury that cause a patient to visit a health professional. This includes live-born infants, people with risk or disease due to family history, people encountering health services for specific mandated evaluation or aftercare, and a host of other not easily classifiable situations. 



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Topics: education, ICD-10, medical coding, ICD 10 CM