Terms and abbreviations

The US code set for diagnoses: diseases, symptoms, injuries and other reasons for a healthcare encounter. A new release takes effect each October 1.

Source: National Center for Health Statistics (NCHS, part of CDC) and CMS · Browse ICD-10-CM

The US code set for procedures performed during a hospital inpatient stay. Each code is seven characters. A new release takes effect each October 1.

Source: CMS · Browse ICD-10-PCS

Codes for supplies, equipment, drugs and services that CPT does not describe, such as walkers, wheelchairs, ambulance services and injected drugs. Updated quarterly.

Source: CMS · Browse HCPCS Level II

The code set for physician and outpatient procedures and services. It is owned and licensed by the American Medical Association; MedCoder does not publish CPT codes or CPT-keyed edits.

Source: American Medical Association · Scope and limitations

The identifier for a drug product and its package, in labeler-product-package form.

Source: US Food and Drug Administration (FDA) · Search NDCs

A two-character code added to a procedure or supply code to give more information, such as which side of the body or that a service was distinct from another.

Source: CMS (HCPCS Level II modifiers) · Look up modifiers

The group a Medicare hospital inpatient stay is assigned to, from its diagnoses, procedures and other claim data. Medicare’s inpatient payment is built on it. MedCoder’s grouping is an independent implementation of CMS’s published logic, not CMS-certified.

Source: CMS · MS-DRG reference

A category in a CMS risk-adjustment model (CMS-HCC, RxHCC). Models map diagnosis codes to categories used to estimate expected cost. A code may map to no category, one, or more than one model.

Source: CMS · Read the guide

Groupings of ICD-10-CM and ICD-10-PCS codes into clinically meaningful categories, used for research and reporting rather than for claims.

Source: Agency for Healthcare Research and Quality (AHRQ)

CMS edits that detect errors and inconsistencies in the codes on a hospital inpatient claim, for example a diagnosis that conflicts with the patient’s age or sex.

Source: CMS · Claim Check

The CMS program of edits that flag code pairs and quantities that are not normally reported together. It publishes two kinds of edit: PTP and MUE.

Source: CMS · NCCI PTP edits on MedCoder

A pair of codes that is not normally reported together for the same patient, on the same date, by the same provider. Some pairs allow a modifier when the services were distinct.

Source: CMS (NCCI) · Read the guide

An MUE is the maximum units of service CMS publishes for a code on the vast majority of appropriately reported claims by the same provider or supplier, for the same beneficiary, on the same date of service.

Source: CMS (NCCI) · MUE on MedCoder

A CMS decision on whether, and when, Medicare covers an item or service nationwide, published in the Medicare National Coverage Determinations Manual.

Source: CMS · Search NCDs

A coverage policy a Medicare Administrative Contractor publishes for the states it serves, stating when an item or service is reasonable and necessary there.

Source: Medicare Administrative Contractors, through the CMS Medicare Coverage Database · Search LCDs

A private company CMS contracts to process Medicare claims for a group of states. MACs publish LCDs and their billing and coding articles.

Source: CMS

A code carried to its full number of characters, so it can be reported. A category or subcategory with more specific codes beneath it is a heading, not reported on its own.

Source: Official Guidelines, Section I.B.2 (Level of Detail in Coding)

Some categories need a 7th character, such as the one for an initial encounter, a subsequent encounter or a sequela. When a code is shorter than six characters, a placeholder “X” fills the empty positions.

Source: Official Guidelines, Sections I.A.4 (Placeholder character) and I.A.5 (7th Characters) · Read the guide

A condition listed under a code as one the code is used for: a synonym of the title, or one of the conditions an “other specified” code covers. The list is not exhaustive.

Source: Official Guidelines, Section I.A.11 (Inclusion terms)

“Not coded here.” The excluded condition is not reported together with this code, except when the two conditions are unrelated to each other.

Source: Official Guidelines, Section I.A.12.a (Excludes1) · Read the guide

“Not included here.” The excluded condition is not part of this code, but a patient may have both, and both codes may be reported together when appropriate.

Source: Official Guidelines, Section I.A.12.b (Excludes2) · Read the guide

Paired notes for a condition with an underlying cause and a manifestation: the underlying condition is listed first, if applicable, followed by the manifestation.

Source: Official Guidelines, Section I.A.13 (Etiology/manifestation convention) · Read the guide

Two codes may be needed to describe the condition fully. The note gives no order; the order depends on the circumstances of the encounter.

Source: Official Guidelines, Section I.A.17 (“Code also” note) · Read the guide

An indicator on a hospital inpatient claim stating whether each diagnosis was present when the patient was admitted.

Source: CMS · Read the guide

Health information that identifies a person, such as a name, date of birth, address or record number. Do not enter it into MedCoder; Claim Check works from codes.

Source: HIPAA Privacy Rule (US Department of Health and Human Services) · Privacy policy