Medical Coding Vocabulary and Key Terms

Medical Coding Vocabulary and Key Terms

When applying for medical coding jobs, recruiters expect you to be well-versed with at least the basic terminology and concepts associated with the field. Being a technical field, a career opportunity in medical coding depends on a rich vocabulary to demonstrate your knowledge and skills to prospective employers.

In this article, we will help you approach and understand medical coding vocabulary and important terms right from the basics, so that they do not intimidate you anymore.

What is Medical Coding

Medical coding is the process of representing various aspects of healthcare using abbreviated alphanumeric codes, such as diagnoses, treatments, and medical equipment. These codes make it easier to read and comprehend critical information about a patient’s condition and treatment, and they establish a consistent system that medical professionals and others may use to figure out what services a patient has received and why.

Medical or clinical coders classify a patient’s condition and treatment in medical records for examination by healthcare and finance specialists. Medical billing, which includes “preparing billing claims and submitting them to insurance providers,” is intimately related to medical coding. It is critical to ensure that the interaction was categorized appropriately in order to receive proper payment and have an accurate patient medical history.

Key Medical Coding Terminology You Should be Familiar With

Current Procedural Terminology (CPT)

The Current Procedural Terminology (CPT) code classification is a valuable sort of medical code categorization. The CPT covers some of the most regularly used by healthcare professionals and provides codes that can be used to report various medical services and procedures, such as operations and diagnostic tests. To understand CPT codes, you should be familiar with the following terms:

  • Category I codes: Because it contains so many services, Category I codes are one of the larger code collections that medical professionals utilize regularly. Medical procedures, health technology services, and other therapies are all covered under these codes.
  • Category II codes: Knowing how to use category II codes allows you to keep track of a patient’s progress after they’ve been diagnosed and treated. Patient history, such as recent levels of nutrients or chemicals in their blood work, and immunization status are examples of category II code phrases.
  • Category III codes: CPT category III codes are often newer and refer to experimental and trial-phase services. Medical coding terminology in this area frequently refers to a patient’s health issues and how the services help manage their care.
  • E/M Codes: E/M codes, which stand for “evaluation and management,” describe what a healthcare expert considers to be a patient’s treatment needs in order to manage their condition. These codes frequently reflect common services such as outpatient therapy or consultations.
  • Fee Schedule: The cost of each therapy described with CPT codes in various categories is referred to by the fee schedule for CPT codes. Understanding the pricing schedule can aid you in double-checking billing information and ensuring that each patient or their insurance is only billed for what they owe.

Electronic Health Records (EHR)

International Classification of Diseases

The International Classification of Diseases (ICD) is another frequent medical code classification that represents the basic condition of a patient’s disease or injury. For healthcare providers, billing and insurance staff, these codes can be used with others to completely explain a patient’s diagnosis, condition, and treatment. The following are some medical phrases that can help you understand ICD codes:

  • E-Codes: For medical records, you can use e-codes to identify injuries caused by exterior sources rather than internal illnesses or diseases. Car accidents, consuming poisonous drugs, and falling are examples of external causes.
  • V-Codes: A v-code is another ICD code that can be used to indicate that a patient obtained healthcare for reasons other than being sick or injured. These causes include preventative care at yearly checkups or a family history of cancer.
  • NOS: When a healthcare expert is unable to provide a particular diagnosis for a patient, a NOS code is displayed. Despite the lack of specificity in the diagnosis, the doctor may nevertheless treat and diagnose depending on the outcomes of those services.
  • NEC: When you don’t have the codes to classify a condition, you can utilize the NEC code, which stands for “not elsewhere classifiable.” This might happen when doctors give thorough diagnoses but billing and insurance personnel only require the basic diagnosis number.
  • Dx: Diagnose codes are abbreviated as Dx, which is useful to know when reporting ICD codes for a patient’s history or billing information. When determining a patient’s past treatment or distinguishing ICD diagnoses from CPT treatments, you can look for Dx information in their records.

International Classification of Functioning, Disability, and Health (ICF)

The WHO’s International Classification of Functioning, Disability, and Health is a book/online database that is used to categorize health and disability on a personal and population level. It is the international standard for measuring health and disability.

Revenue Value Units (RVU)

The Medicare reimbursement system uses revenue value units as a value measurement. The payment formula for each service includes three RVUs: one for practice expense, one for malpractice expense, and one for physician effort. This formula and the RVUs it contains are used to determine how much Medicare should pay the care provider.

Signature on File (SOF)

When a patient or a family member signs a paper, the care practitioner is able to make required treatment or diagnosis decisions without the need for prior consultation. Payment of any health insurance benefits to the supplier, physician, or patient is usually allowed under a SOF agreement.

Uniform Hospital Discharge Data Set (UHDDS)

The UHDDS is a collection of information gathered following inpatient hospital discharges. It provides standard demographic and identifying information about the patient, with the primary purpose of ensuring that all discharges have uniform data.

Why is Learning Medical Coding Terminology Important?

Many healthcare providers utilize medical coding terminology to comprehend medical codes and ensure that a patient’s experience with health services is as pleasant as possible. Medical coding terminology is required of all billing and insurance staff as well, apart from medical coders themselves.

Now get ahead of your competitors and give a kickstart to your career by learning about the basics of medical coding vocabulary and key terminology and secure the best opportunities this field has to offer.

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Nicolas Desjardins

Hello everyone, I am the main writer for SIND Canada. I've been writing articles for more than 10 years and I like sharing my knowledge. I'm currently writing for many websites and newspapers. All my ideas come from my very active lifestyle, every day I ask myself hundreds of questions to doctors, specialists, and physicians. I always keep myself very informed to give you the best information. In all my years as a computer scientist made me become an incredible researcher. I believe that any information should be free, we want to know more every day because we learn every day. Most of our medical sources come from Canada.ca and government research. You can contact me on our forum or by email at info@sind.ca.

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