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Coding
| Question | Answer |
|---|---|
| CPT codes are maintained by who? | AMA - American Medical Association |
| APCs are based on what codes? | HCPCS Level 1 (CPT) and Level 2 Codes |
| What does APC stand for? | Ambulatory Payment Classifications |
| Which of the following can influence MS-DRG assignment? Choices: CPT&HCPCS codes, ICD-10-PCS Codes, UB-92 | ICD-10-PCS Codes |
| What does MS-DRG stand for? | Medicare Severity Diagnosis Related Groups |
| What is an MS-DRG level of severity? | |
| When do updated CPT codes go into effect? | January |
| Medicare Reimbursement for outpatient surgery performed at a local hospital is based on: | APCs |
| When do ICD-10-CM and ICD-10-PCS changes go into effect? | October |
| What healthcare service does not use a Prospective Payment System? | Physician Office |
| What does PPS stand for? | Prospective Payment System |
| What does RBRVS stand for? | Resource-Based Relative Value Scale |
| What does AHIMA stand for? | The American Health Information Management Association |
| What does UHDDS stand for? | Uniform Hospital Discharge Data Set |
| What does OPPS stand for? | Outpatient Prospective Payment System |
| What are Status Indicators? | Status Indicators denote what type of service was provided. |
| What are a few status indicators? | X=Ancillar V= Clinic or Emergency Room T=Significant procedure that is discounrted S=sifnificant procedure paid at 100% P= Partial Hospitalization |
| In CPT Reduction means what? | Manipulation |
| Tubal Ligation is what? | The procedure of Cutting and tying or blocking the fallopian tubes, as a form of contraceptive |
| What does fulgration mean? | A procedure that uses heat from electric current to destroy abnormal tissue. (Tumor/Lesion). Or control bleeding during surgery or after an injury |
| How are the 3 trimesters broken up? | 1st trimester- week 1 -week 12 2nd trimester- week 13 - week 26 3rd trimester- week 26 to end of pregnancy |
| What makes a compliant query? | Providing concise presentation of facts and clinical indicators. |
| What is the most challenging type of provider query used for? | Establishing Clinical Validation |
| A compliant queries includes what? | Relevant clinic indicators |
| Multiple choice queries must supply how many choices in order to be compliant? | No specific number |
| Compliant multiple-choice querie Can provide a new diagnosis with supporting clinical indicators | |
| Verbal queries Must have a written response in the health record for coding purposes | |
| When creating compliant queries coding professionals should | Query once with additional follow up if necessary |
| When a compliant query remains unanswered, what is the next step for the coding professional? | Refer to the internal escalation policy and follow the process outlined therein |
| Medically unlikely edits are used to identify what? | Maximum units of services for a HCPCS code |
| Medicae's identification of medically necessary services is outline d in what? | Local Coverage Determinations |
| The use of the outpatient code editor (OCE) is designed for what? | To identify incomplete or incorrect claims |
| National Correct Coding Initiative (NCCI) edits are released how often? | Quarterly |
| What is Present on Admission (POA) classified as? | A condition that occurs prior to an inpatient admission |
| What stage of pressure sores are on the HAC list for hospital aquaired conditions? | Stage 3 and 4 pressure ulcers |
| Can internal policies conflict with requirements provided in coding guidelines, conventions, and so on. | No they cannot. |
| A contract coding professional works for a hospital and, in the course of daily work, routinely accesses protected patient health information. Under HIPAA, what should be in place to permit access and protect patient privacy? | Business associate agreement |
| Under the Inpatient Prospective Payment System (IPPS), what can be used to measure the cost of care for inpatients? | Under the Inpatient Prospective Payment System (IPPS), what can be used to measure the cost of care for inpatients? |
| Which patient-specific UHDDS items also have the potential to have an impact on MS-DRG assignment? | Sex and discharge disposition |
| The outpatient code editor (OCE) has all of the following types of edits except | Valid diagnosis code edits |
| When a POA indicator for a HAC that is the only CC/MCC condition on the record is listed as N, what happens to the reimbursement for that account? | The reimbursement is not eligible for increase, since the condition was not present on admission and should have been prevented using best practices |
| According to CPT, an endoscopy that is undertaken to the level of the midtransverse colon would be coded as a | Colonoscopy |
| Determining medical necessity for outpatient services includes all the following except: | Requiring new HCPCS codes be developed to replace codes in the CPT code book |
| The abstracting of this data element has an impact on the DRG reimbursement. | Discharge disposition |
| A coding professional has noted that a particular nurse practitioner is sending orders for outpatient testing with the diagnosis listed as “possible” or “rule out” without any accompanying signs or symptoms or abnormal findings suggestive of the possible | Ask for outpatient CDI specialist to educate the NP on the guidelines for outpatient coding which do not permit the use of “possible” or “rule out” diagnoses |
| Major complications and comorbidities (MCCs) are determined to require the greatest degree of resources with a payment group and also reflect the greatest _____. | SOI |
| According to the UHDDS, section III, the definition of other diagnoses is all conditions that: | Coexist at the time of admission, that develop subsequently, or that affect the treatment received or the length of stay |
| Which of the following is a data element that coding professionals typically are tasked with abstracting? | Date of surgery |
| The National Correct Coding Initiative (NCCI) Edits apply to services billed by: | The same provider, for same beneficiary, on same date of service |
| A completed and signed operative report needs clarification of the size of the skin lesions that were removed. What process is used for that clarification? | Amendment |
| What is the term used for applying the HIPAA Privacy Rule over state rule(s) that are less strict? | Preemption |
| Which of the following statements best describes how the retention of records should be determined? | Unless state law requires longer periods of time, specific patient health information should be retained for HIPAA-established minimum time periods. |
| Facilities may use X modifiers in place of which modifier? | 59 |
| Which type of conditions are always considered present on admission? | Congenital |
| Medicare payment to healthcare providers for services rendered is made under the: | Resource-based Relative Value Scale |
| When a patient leaves an acute inpatient prospective payment system (IPPS) facility against medical advice, and is then admitted into a different IPPS facility on the same day, the initial facility should categorize this as a(n): | Transfer |
| Is long term use of Insulin coded for Type 1 Diabetics? | NO |
| What does HCPCS stand for? | Healthcare Common Procedure Coding System |
| When are HCPCS updated? | Quarterly * Not yearly |
| What year was the Balance Budget Refinement Act put into place? | 1999 |
| What is a clinically significant diagnosis? | If it requires clinical evaluation, therapeutic treatment, diagnostic procedures, extended length of stay, increased nursing care or monitoring or has implications for future healthcare needs |
| What does MCC stand for? | Major Complication/Comorbidity |
| What does CC stand for? | Complication/Comorbidity |
| What does HAC stand for? | Hospital Acquired Conditions |
| What does IPPS stand for? | Inpatient Prospective Payment System |
| As a part of Medicare Value-Based Purchasing program CMS implemented what? | Paying for Value Program entitled Hospital Acquired Conditions (HACs). |
| If a patient is identified as having a HAC what happens to the payment? | It can be reduced, due to the HAC not being prevented through best practice. |
| What does CMS-HCC stand for? | CMS Hierarchical Condition Categories |
| What dos the CMS-HCC do? | It is used to risk adjust within the Medicare Advantage capitation payment system. Used to predict the average costs for a predetermined set of factors. |
| Inpatient Medicare Claims are paid under what system? | IPPS |
| Who pays out the Inpatient Medicare Claims. | Medicare Administrative Contractor (MAC) |
| Inpatient Medicare Claims are processed through what kind of editor? | MCR- Medicare Code Editor |
| What are two edit conflicts on Medicare claims? | Age and Sex |
| What does POA stand for? | Present on Admission |
| What are the POA indicators? | Y for Yes N for No U for Unknown W for Clinically undetermined lastly unreported/not used |
| What does NCHS stand for? | National Center for Health Statistics |
| What does AHA stand for? | American Hospital Association |
| Alteration | Modifying the natural anatomic structure of a body party without affecting the function of the body part. ( To improve appearance, face lift, breast augmentation.) |
| Bypass | Altering the route of passage of the contents of a tubular body part. (Coronary artery bypass, colostomy formation) (A to C but going around B) |
| Change | Taking out or off a device from a body part and putting back an identical or similar device in or on the same body part w/o cutting or puncturing the skin or mucous membrane. (Uses external approach- Cath Change) |
| Control | Stopping, or attempting to stop, post-procedural or other acute bleeding. (Control of bleeding duodenal ulcer) |
| Creation | Putting in or on biological or synthetic material to form a new body part that to the extent possible replicates the anatomic structure or function of an absent body part. (Gender reassignment surgery, correct congenital anomalies- creating of vagina) |
| Destruction | Physical eradication of all or a portion of a body part by the direct us of energy force or a destructive agent ( No body part is physically taken out- cautery of skin lesion) |
| Detachment | Cutting off all or party of the upper or lower extremities (below-Knee amputation) |
| Dilation | Expanding an orifice or the lumen of a tubular body part (Natural or artificial orifice- done by stretching or cutting to expand- pyloromyotomy, angioplasty) |
| Division | Cutting into a body part without draining fluids and or gases from the body part in order to separate or transect the body part ( made into multiple portions- osteotomy) |
| Drainage | Taking or letting out fluids and or gases from a body part (Thoracentesis, incision&drainage) |
| Excision | Cutting out or off, without replacement, a portion of a body part (Cutting out a small chunk - partial nephrectomy, liver biopsy) |
| Extirpation | Taking or cutting out solid matter from a body part (can be an abnormal byproduct or foreign body- Taking out clots, choledocholithotomy) |
| Extraction | Pulling or stripping out or off all or portion of a body part by the use of force. (D&C, vein stripping) |
| Fragmentation | Breaking solid matter in a body part into pieces. (Physical Force manual or ultrasonic- Pieces or not taken out but eliminated- Extracorporeal shockwave lithotripsy) |
| Fusion | Joining together portions of an articular body part, rendering the articular body part immobile. (Done by fixation device, bone graft or other- Spinal fusion, ankle arthrodesis) |
| Insertion | Putting in a non-biological appliance that monitors, assis, performs or prevents a physiological function but does not physically take place of a body part. (Radioactive implant, central venous catheter) |
| Inspection | Visually/Manually exploring a body part (with/without optical instruments- diagnostic arthroscopy, exploratory laparotomy) |
| Map | Locating the route of passage of electrical impulses and or locating functional areas in a body part. (on to cardiac conduction mechanism and the central nervous system) |
| Occlusion | Completely closing an orifice or lumen of a tubular body part. (Fallopian tube ligation) |
| Reattachment | putting back in or on all or a portion of a separated body part to its normal location or other suitable location(Reattachment of hand) |
| Release | Freeing a body part from an abnormal physical constraint. Some of the restraining tissues may be taken out but none of the body part is. (Carpel Tunnel Release) |
| Removal | Taking out or off a DEVICE from a body part (Taken out with no exchange- drain tube removal, removing pacemaker) |
| Repair | Restoring, to the extent possible, a body part to its normal anatomic structure and function. Use only when the method to accomplish the repair is not another root operation. (Colostomy takedown, suture of laceration) |
| Replacement | Putting in or on a biological or synthetic material that physically takes the place and or function of all or a portion of a body part. ( Total Hip replacement- free skin graft) |
| Reposition | Moving to its normal locations or other suitable locations all or portion of a body part (Reposition of undescended testis- fracture reduction) |
| Resection | Cutting out or off, without repalcement, all of of a body part. (total Nephrectomy, total lobectomy of lung) |
| Restriction | Partially closing an orifice or the lumen of a tubular body part (Esophagogastric fundoplication, cervical cerclage) |
| Revision | Correcting, to the extent possible, a portion of a malfunction device or the position of a displaced device. ( Adjustment of pacemaker lead, Adjust of hip prostesis) |
| Supplement | Putting in or on biological or synthetic material that physically reinforces and or augments the function of a portion of a body part. (Herniorrhaphy using mesh) |
| Transfer | Moving, without taking out, all or a portion of a body part to another location to take over the function of all or a portion of a body part. (Tendon Transfer, Skin pedicle flap transfer) |
| Transplantation | Puttin in or on all or a portion of a living body part taken from another individual or animal to physically take the place and or function of all or a portion of a smaller body part. (Kidney Transplant, heart transplant) |
| Abortion | Artificially terminating a pregnancy. |
| delivery | assisting the passage of the products of conception from the genital canal. |
| Compression | putting pressure on a body region |
| Dressing | putting material on a body region for protection (sterile dressing to a wound) |
| Immobilization | limiting or preventing motion of a body region. (splint on a finger) |
| Packing | Putting material in a body region or orifice (packing of nasal canal) |
| Traction | Exerting a pulling force on a body region in a distal direction. (Lumbar traction using motorized split-traction table) |
| Introduction | Putting in or on a therapeutic, diagnostic, nutritional, physiological or prophylactical substance. except blood or blood products. (Nerve block injection to median nerve) |
| irrigation | putting in or on a cleansing solution (flushing of eye) |
| Transfusion | Putting in blood or blood products or stem cell substance. |
| Measurement | Determining the level of a physiological or physical function at a point in time. EKG, TEMP |
| Monitoring | Determining the level of a physiological or physical function |
| Assistance | Taking over a portion of a physiological function by extracorporeal means. (Assist a normal function but does not take control of.- Hyperbaric oxygenation of a wound) |
| Performance | Completely taking over a physiological function by extracorporeal means. ( Cardiopulmonary bypass in conjunction with CABG- Cardiac pacing- Total mechanical ventilation) |
| Restoration | Returning or attempting to return a physiological function to its original state by extracorporeal means. (Only Cardioversion and defibrillation procedures- Failed ones are still coded as restoration) |
| Atmospheric Control | Extracorporeal control of atmospheric pressure and composition. (Antigen-free air condition, series treatment) |
| Decompression | Extracorporeal elimination of undissolved gas from body fluids. A single type of procedure-treatment for decompression sickness (the bends) in a hyperbaric chamber, (Hyperbaric decompression treatment, single) |
| Electromagnetic Therapy | Extracorporeal treatment by electromagnetic rays. TMS(Transcranial magnetic stimulation, series treatment. |
| Hyperthermia | Extracorporeal raising of body temperature. To treat temperature imbalance, and as an adjunct radiation treatment for cancer. When performed to treat temperature imbalance, its hyperthermia. When performed for cancer treatment, it is a modality qualifier. |
| Hypothermia | Extracorporeal lowering of body temp. Treatment for temperature imbalances, series. |
| Pheresis | Extracorporeal separation of blood products. Treat diseases wheres too much of one blood component is produced such as leukemia. or to remove blood products like platelets from donor for another patient. |
| Phototherapy | Extracorporeal treatment by light rays. Exposing blood to light rays outside of the body. |
| Ultrasound Therapy | Extracorporeal treatment by ultrasound. (Therapeutic ultrasound of peripheral vessels, single treatment.) |
| Ultraviolet Therapy | Treatment by Ultraviolet light. Ultraviolet phototherapy, series treatment |
| Shock Wave Therapy | Treatment by shockwaves. Shockwave therapy of plantar fascia, single treatment. |
| Perfusion | Treatment by diffusion of therapeutic fluid. Perfusion of donor lungs prior to successful transplantation |
| Treatment | Manual treatment to eliminate or alleviate somatic dysfunction and related disorder. Fascial release of abdomen, osteopathic treatment |
| Other procedures | Methodologies that attempt to remediate or cure a disorder or a disease. For nontraditional whole body therapies including acupuncture and meditation |
| Manipulation | Manual procedure that involves a directed thrust to move a joint past the physiological range of motion, without exceeding the anatomical limit. Chiropractic treatment for cervical spine, short lever specific contact. |
| Speech Assessment | Measurement of speech and related functions |
| Motor and/or Nerve Function Assessment | Measurements of motor, nerve and related functions. |
| ADL Assessment | Measurement of functional level for activities of daily living |
| Hearing Assessment | Measurement of hearing and related functions |
| Hearing Aid Assessment | Measurement of the appropriateness and/or effectiveness of a hearing device |
| Vestibular | Measurement of the vestibular and related functions |
| Speech Treatment | Application of techniques to improve, augment, or compensate for speech and related function impairment |
| Motor Treatment | Exercise or activities to increase or facilitate motor function |
| ADL Treatment | Exercise or activities to facilitate functional competence for activities of daily living |
| Hearing Treatment | Application of techniques to improve, augment, or compensate for hearing and related functional impairment |
| Hearing Aid Treatment | Application of techniques to improve the communication abilities of individuals with cochlear implants. |
| Vestibular Treatment | Application of techniques to improve, augment, or compensate for vestibular and related functional impairment. |
| Device Fitting | Fitting for a device designed to facilitate or support achievement of a higher level of function. |
| Caregiver Training | Training in activities to support patient's optimal level of function |
| Plain Radiography | Planar display of an image developed from the capture of external ionizing radiation on photographic of photoconductive plate |
| Fluoroscopy | Single plane of bi-plane real time display of an image developed from the capture of external ionizing radiation on a fluorescent screen. The image may also be stored by either digital or analog means |
| CT Scan | Computer-Reformatted digital display of multi-planar images developed from the capture of external ionizing radiation on a fluorescent screen. The image may also be stored by either digital or analog means. |
| MRI | Computer-reformatted digital display of multi-planar images developed from the capture of radio-frequency signals emitted by nuclei in a body site excited within a magnetic field. |
| Planar Nuclear Medicine Imaging | Introduction of radioactive materials into the body for single plane display of images developed from the capture of radioactive emissions |
| Non-Imaging Nuclear Medicine Uptake | Introduction of radioactive materials into the body for measurements of organ function, from the detection of radioactive emissions. |
| Open Approach | Cutting through skin or mucous membrane, expose sight of procedure. |
| Percutaneous Approach | Skin or Mucous Membrane. Puncture or minor incision. WITHOUT Visualizatons |
| Percutaneous Endoscopic Approach | Skin or Mucous Membrane, puncture or minor incision. With Visualization. Ex with scope |
| Via natural or artificial opening appraoch | Through an opening, direct entry, WITHOUT visualization- Catheter placement. endotracheal tube |
| Via natural or artificial opening endoscopic approach | Through an opening, direct entry, WITH visualization- EGD |
| Via Natural or artificial opening with percutaneous endoscopic assistance | One way throat an opening and visualization throat a small incision or puncture. WITH visualization. |
| External Approach | Done directly on skin or mucous membrane. No cutting or visualization aid- Tonsil removal, fracture reduction |
| Medicare part A covers what? | Inpatient hospital stays |
| Medicare part B covers what? | Services and preventative care rendered by a physician, outpatient care, and medical supplies. |
| Medicare part C covers what? | (Medicare Advantage Plan) This bundles Part A and Part B into one plan. dispensed by a privates insurance carrier contracted with Medicare. |
| Medicare Part D covers what? | Prescription Drugs |
| What does Medicare Medigap cover? | It helps to offset the out-of-pocket expenses. |
Created by:
orrkate90