PROCEDURAL AND DIAGNOSTIC CODING
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| When completing health insurance claims electronically, list the types of codes required on the claim according to the Standard Code Set. | (1) International Classification of Disease (2) CPT Current Procedural Terminology (3) HCPCS Level 2
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| To code from the Evaluation and management section of CPT, What three things must be determined? | (1) Place of service (2) Type of service (3) Patient Status
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| Surgical package rules are established by? | AMA
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| Global package rules are established by? | CMS
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| Repairs of lacerations are coded according to? | (1) Type of repair (2) Location (3) Length
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| When coding fractures name two things that need to be determined? | (1) Closed or Open (2) Manipulation
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| Endoscopes should always reflect the __________ are of visualization? | Furthest
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| What is the less invasive surgical approach called when coding abdominal procedures? | Laproscopy
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| The documentation required in a patients medical record when an injection is given includes? | (1) Name of Medication (2) amount in cubic centimeters (3) Route
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| Diagnostic codes using ICD-10-CM can vary from? | 3 to 7 digits
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| What is a qualified diagnosis? | any terms suspected, suspicion of, questionable, likely \, probably, or possible do not code these conditions as if they existed or were established instead code signs, symptoms, abnormal test results or other reasons.
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| What is NEC? | Not elsewhere classifiable
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| What is NOS? | Not otherwise specified
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| When coding an underlying cause of a disease, along with the disease that resulted, name the rule to follow and state which is coded first and second | Rule: Etiology/manifestation
Code first: Etiology
Code Second: Manifestation
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| When coding neoplasms, name the five titles that codes are listed under and give a brief defintion of each term | Primary, Secondary, Carcinoma in situ, Uncertain behavior, Unspecified neoplasm
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| When coding burns, name three elements in which burns are classified | Depth, Extent, Agent
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| Co Morbidity | The simultaneous presence of 2 or more chronic diseases or conditions in a pt
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| Morbidity | Presence of 1 disease in pt or population
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| Mortality Rate | The number of deaths in a place or a group compared with the total number of people in that place or group
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| A | Anesthesia - 00
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| S | Surgery - 10
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| R | Radiology - 70
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| P | Pathology and Laboratory - 80
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| M | Medicine - 90
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| E & M | Evaluation and Management - 99
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| A coding compliance program is? | Voluntary
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| The standard code set is? | Mandated by HIPAA, Provides tracking of morbidity, Provides tracking of mortality, provides tracking of comorbidity
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| Natural language processing (NLP) is? | Used in CAC
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| How many sections are there in Current Procedural Terminology? | 6
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| When coding from surgery section of CPT, the first thing you should do is? | Go to the index
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| Medicare? | Does not use consultation codes
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| Three key components needed to code evaluation and management services are? | Place of service, type of service, and patient status
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| According to CPT, a surgical package includes? | The operation, Certain types of anesthesia, and the postoperative visits within designated follow up days
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| The sums of multiple laceration repairs can be added together if? | They are in the same body area, as defined in CPT and they are the same "type" of wound
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| Checking a diagnostic code against a procedure code is referred to as? | Code linkage
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| When coding diagnoses, start by looking in ? | Volume 2
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| ICD-10-CM will replace (or has replaced) ICD- 9-CM by? | October 1 2013
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| In diagnostic coding, the following symbol is used as a placeholder when a subcategory does not have a 4th 5th or 6th digit and 7th digit needs to be applied | x (ex)
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