Term
| What are the two types of coding systems used? |
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Definition
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Term
| What is a classification system? |
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Definition
| An arrangement of elements into groups according to established criteria |
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Term
| What does it mean when ICD-9-CM is stated as being a closed classification system? |
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Definition
| It provides one and only one place to classify each condition and procedure. |
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Term
| How is the ICD-9-CM used by the hospital? |
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Definition
| Codes required only for hospital inpt services. Inpt procedures are coded in range of procedure codes in categories 00-86. Chapter 16 codes (87-99) may be used selectively for inpt procedure coding according to hospital and procedures. |
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Term
| How is the ICD-9-CM used for outpt services? |
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Definition
| Outpt departments, physician's offices and other ambulatory care facilities used CPT-4 and HCPCS codes for procedures. HCPCS and CPT required for physician coding and procedures performed in other healthcare settings, such as hospital outpt departments. |
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Term
| How are the main terms identified in the Alphabetic index? |
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Definition
1. Listed in boldface type
2. ID the type of procedure performed with subterms indented in alphabetic order
3. Main terms can inclue: Titles of operations, procedure names, nouns, verbs
4. Main terms for procedures indicate an action performed, not a Dx or reason for procedure |
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Term
| What do subterms indicate? |
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Definition
| Described difference in condition |
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Term
| What do 4th and 5th digits provide? |
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Definition
-Subcategories (4-digit code #'s): provide more specificity or info regarding the condition's etiology, site, or manifestation
-5th digit subclasses add greater specificity to certain 4th digit codes |
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Term
| What types of conditions are the reporting of E-codes mandatory? |
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Definition
| Supplementary classification of external causes of injury and poisoning. Cannot be used in place of a Dx code |
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Term
| What do codes in brackets signify? |
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Definition
| Used with mandatory multiple coding. The 1st code is the underlying condition and the 2nd code, in brackets, is the manifestation |
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Term
| What does the abbreviation "NEC" mean? |
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Definition
-Not Elsewhere Classified
-Used with ill-defined terms in the Tabular List to warn coder that specified forms of the condition are coded differently |
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Term
| NEC codes are typically classified to which final digit? |
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Definition
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Term
| What does the abbreviation "NOS" mean? |
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Definition
| Not Otherwise Specified (equivalent of "unspecified") |
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Term
| NOS codes are typically classified to which final digit? |
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Definition
| Usually included with .9 codes |
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Term
| If the codes do not make a distinction between unilateral or bilateral major procedures, how do we handle coding bilateral major procedures? |
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Definition
-ICD-9-CM may provide a single code to identify that a bilateral procedure was performed (A bilateral procedure code is used only once)
-However, when ICD-9-CM does not provide a code for a "bilateral" procedure, the code for the procedure is listed twice |
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Term
| How do you coe cancelled procedures? |
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Definition
1. When a procedure was started but not completed, the procedure is coded to the extent it was performed
2. Coding rule = "Code as far as it goes"
3. Cavity entered - "code exploratory procedure"
4. Incision made - "code incision only"
5. No procedure = add V64 Dx code for the reason the procedure was not completed |
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Term
| What is the definition of principal Dx? |
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Definition
| The condition established after study to be chiefly responsible for occasioning the admission of the pt to the hospital for care |
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Term
| What is the definition of Principal Procedure? |
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Definition
| That which was performed for definitive Tx rather than for diagnostic or exploratory purposes or for Tx of a complication |
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Term
| Why do we need to code MCCs and CCs? |
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Definition
-Codes that are identified as Major Complications and Comorbidities (MCC) and Complications/Comorbidities (CC) will affect DRG assignment
-DRG group determines reimbursement; based on the DRG is how much money we get (higher the wt, the more money we get back) |
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Term
| What is the implementation date for ICD-9-CM and ICD-10-PCS? |
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Definition
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Term
| How is the ICD-10-CM code structure different from the ICD-9-CM? |
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Definition
-Changed slightly to accommodate code expansion and classification improvements
-Has alphanumeric structure, with all codes starting with an alphabetic character
-The basic code structure consists of three digits
-A decimal point is used to separate the basic three-digit category code from its subcategory and subclassifications
-The first character in ICD-10-CM codes is alpha; characters two and three are numeric, while characters four through seven are alpha or numeric
-Alpha characters are not case sensitive
-Most codes contain a maximum of six characters, with a few chapters having a seventh character code extension |
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Term
| ID the purposes and uses of CPT |
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Definition
-Serves as a method of communication between insurance carriers and medical professionals
-Enables comparisons of reimbursement amounts
-Speeds the processing of claims
-Provides data on trending and planning |
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Term
| Define and list components of HCPCs |
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Definition
-A 2-part system developed by CMS to standardize the coding system used to process Medicare claims. It is used for all services
-Level I: CPT Codes. 80% of HCPCS can be coded using CPT
-Level II: National Codes (for supplies). Developed by CMS to identify other servies not in CPT |
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Term
| Compare and contrast CPT with ICD-9-CM |
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Definition
-Copyrighted and published by AMA since 1966
-Developed as a method of communication between MDs and 3rd party payers
-Intended to be used for reimbursement (unlike ICD-9-CM)
-Nomenclature
-Must use new edition by January 1
-Official publication: CPT Assistant |
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Term
| Specify the conditions that must be met before a procedure or service is included in the CPT manual |
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Definition
-Commonly performed by physicians across the country
-Consistent with contemporary medical practice |
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Term
| Describe Category I, II, and III CPT codes |
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Definition
-Category I: Comprised of 5 numbers
-Category II: 4 numbers followed by the letter "F". Performance measures
-Category III: 4 numbers followed by the letter "T". Emerging technology |
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Term
| Interpret conventions and characteristics of CPT |
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Definition
1. Bullet: Indicated a new code for the current year. Listed in Appendix B
2. Plus sign: Designed as an add-on code. Must be used in addition to the primary procedure code. Summary of codes in Appendix D
3. Circled bullet: Indicated that CPT code includes conscious sedation as an inherent part of providing the procedure
4. Null Symbol: Exemption to modifier 51 (multiple procedures). Alerts coders to the fact that the code cannot be appended with modifier 51. Applies to physician coding only. All exempt codes listed in Appendix E
5. Pending FDA Approval Symbol (Bolt): IDs codes for vaccines that are pending FDA approval |
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Term
| Be able to ID what is included within a surgical package |
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Definition
1. General Definition: A combo of individual servies provided during one surgical operation. Treated as one single service for purposes of reimbursement. A single payment is issued for each package of related surgical services
2. CPT Definition: Includes the actual procedure, local, digital, or topical anesthesia, one related E/M code on the date prior to or on date of the procedure, immediate post-op care, writing orders, and typical post-op follow-up care
3. Medicare Definition: depends on if it is a major or minor Sx. Allows for post-op global periods; 90 days for major surgeries and 0-10 days for minor surgeries |
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Term
| Define unlisted procedure, separate procedure and unbundling |
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Definition
1. Unlisted procedure: allows us to assign a code to a procedure not listed in CPT. Assigned at a last resort. The Alphabetic index lists all unlisted procedures
2. Separate procedure: One that, when performed in conjunction with another service, is considered an integral part of the major service. Should NOT be coded separately. May be coded when performed independently and not in conjunction with the major procedure
3. Unbundling: The practice of using multiple codes that describe the individual components of a procedure rather than as appropriate single code that describes all the steps in the procedure performed |
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Term
| How are coding decisions regarding debridement determined? |
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Definition
| -Coding decision is based on the deepest level and documented size |
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Term
| How do we handle the coding of the debridement of multiple wounds? |
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Definition
| Add the surface areas of wounds of the documented size |
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Term
| How do we handle the coding of the debridement of multiple wounds? |
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Definition
| Add the surface areas of wounds of the same depth. Do not add if different depths. |
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Term
| What removal methods are considered according to CPT to be coded as destruction? |
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Definition
| Electrosurgery, cryosurgery, laser, chemical Tx |
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Term
| Differentiate between simple, intermediate and complex wound repairs |
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Definition
1. Simple: Superficial repairs. This is the most common. Read the operative note for use of sutures, staples, and adhesive. Does not include Steri-strips
2. Intermediate: Closure of one or more deeper layers. Single layer closure can be coded as intermediate if the wound is heavily contaminated
3. Complex: more than layer. Least common. Look for a more involved procedure. Wounds will be described as angular, jagged, irregular. Requires scar revision, debridement, stents, extensive undermining or retention sutures |
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Term
| How do we handle the coding os multiple wound repairs? |
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Definition
| Only add wound repairs if it is the same repair classification and the same anatomical site. Then add the lengths. Never add lesions |
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Term
| How do we handle the coding of a diagnostic endoscopy when performed with a surgical endoscopy? |
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Definition
| Since a surgical endoscopy always includes a diagnostic component, it should not be reported separately |
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Term
| Differentiate between the types of laryngoscopies |
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Definition
1. Direct: inserts a laryngoscope and uses general anesthesia. If an operating microscope is used, do not separately code
2. Indirect: Simplest way. uses a laryngeal mirror
3. Flexible fibrotic: Stoboscopy? |
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Term
| When coding colonoscopies, what will the different colonoscopy codes identify? |
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Definition
| The different codes will identify the technique used to remove the tumor or polyp. You can use multiple codes if different techniques were performed. |
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Term
| Two codes are needed when coding CABGs, what do they ID? |
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Definition
| One code IDs the # of venous grafts and one code IDs the # of arterial grafts |
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Term
| Interventional Radiology catheter placement is described interms of selective and non-selective. What do these indicate? |
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Definition
1. Nonselective: Catheter is not advanced any further than the puncture site
2. Selective: Catheter is moved beyond vessel punctured or beyond the aorta. Coding descriptions reference "order" such as 1st order, 2nd order, etc... |
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Term
| ID the purpose of modifiers |
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Definition
-Appended to CPT code to provide more info
-May increase payment
-May decrease payment
-May prevent denial |
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Term
| Which set of guidelines should physicians utilize when determining the selection of the E/M codes? |
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Definition
| Physicians may use either set of guidelines, whichever is more advantageous to the individual physician |
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Term
| What do E/M codes describe? |
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Definition
The describe services given to a pt, which include:
1. Type of service
2. Location where a service is provided
3. Extent of Hx, exam and medical decision making
4. Select the code that matches the service |
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Term
| Provide the definition of new and established pt |
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Definition
1. New: a pt who has not received any professional services within the past 3 years from the physician or another physician of the same specialty who belongs to the same group practice
2. Established: a pt who has received professional services within the past 3 years from the physician or another physician of the same specialty who belongs to the same group practice |
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Term
| Can multiple E/M codes be used on the same day? |
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Definition
1. Concurrent care: Two or more physicians provide similar services to the same patient on the same day
2. Reimbursement is limited to one physician per day unless from different specialties and is medically necessary |
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Term
| Be able to ID E/M components and contributory elements |
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Definition
-Key components include: Hx, exam, medical decision making
-Contributory Elements include: Counseling, coordination or care, nature of presenting problem, time |
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Term
| Typically a new pt must meet or exceed __ of __ key components. |
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Definition
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Term
| Typically an established pt must meet __ of __ key components. |
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Definition
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Term
| What are the two measures fo time and their definitions? |
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Definition
1. Direct face-to-face time: Outpt visits are measured as direct face-to-face time. Direct face-to-face time is the time a physician spends directly with a pt during an office visit obtaining the Hx, performing an exam, and discussing the results
2. Unit/floor time: Inpt time is measured as unit/floor time and is used to describe the time a physician spends in the hospital setting dealing with the pt's care. Unit/floor time includes care given to the pt at the bedside as well as at other settings on the unit or floor |
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Term
| If a physician sees a pt in his/her office and then admits the pt to the hospital, can the physician submit both an E/M code for the office visit and the hospital admission? |
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Definition
| Bundled into the admission are services that were provided in another location, such as the physician's office, nursing facility or ED. This means that the services provided in these other locations are considered when assigning a code from the 99234-99236 range. So, do not report office visit code if the physician admits the pt to the hospital or nursing facility during the course of events |
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Term
| What are the different categories of E/M codes for hospital inpt services? |
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Definition
1. Initial Hospital Care: the physician's first inpt hospital visit
2. Subsequent hospital care: recorded for each subsequent day that the physician visits
3. Hospital D/C services: recorded on the day the pt is discharged |
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Term
| If a consulting physician sees a pt several times over the course of their Tx, how are consultation E/M codes handled? |
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Definition
-Office or Other Outpt Consultations: Consultation code and then any other visits are reported as office visit codes
-Inpt Consultations: a consultant can report only one consultation code per admission |
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Term
| What factor is key in determining the appropriate E/M code for critical care? |
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Definition
| Time, or the total duration of critical care time, is the key factor in determining the correct code |
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Term
| What are the two categories for non-face to face services? |
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Definition
1. Telephone services: differentiated by time
2. Online medical evaluations: Pt's inquiry and physician's response must be maintained in permanent storage (electronic or hard copy) |
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Term
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Definition
-A false representation of fact
-A failure to disclose a fact that is material (relevant) to a healthcare transaction
-Damage to another party that reasonably relies on the misrepresentation or failure to disclose
-To purposely bill for services that were never given or to bill for a service that has a higher reimbursement than the service produced |
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Term
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Definition
-Inconsistent handling of sound fiscal, business, or medical practices resulting in:
-Unnecessary costs to the program
-Improper payment
-Services that fail to meet professionally recognized standards of care or are medically unnecessary, or
-Services that directly or indirectly result in adverse pt outcomes or delays in appropriate Dx or Tx
-Payment for items or services that are billed by mistake by providers, but should not be paid for by Medicare |
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Term
| What is the definition of corporate compliance and what are its goals? |
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Definition
-A mechanism to assure compliance with federal and state laws; accreditation standards
-Goals: to prevent violations of laws, reduce penalties (liability) for violations, and to avoid government-imposed "corporate integrity agreement" |
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Term
| Be able to ID the healthcare entities that should implement corporate compliance programs |
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Definition
| -Hospitals, clinical labs, home health agencies, third-party medical billing companies, DME providers, hospices, Medicare+Choice organizations, nursing facilities, ambulance suppliers, individual and small group physician practices, pharmaceutical manufacturers, recipients of US public health services research awards, Part D plan sponsors |
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Term
| What are the elements of the corporate compliance program? |
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Definition
-Code of conduct or standards of conduct that should contain the: mission, vision, philosophy, core values or similar corporate statements
-Policies and procedures
-Corporate compliance officer and staff
-Open lines of communication
-Auditing and monitoring
-Offense detection and corrective action initiatives
-Enforcing disciplinary standards |
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Term
| Be able to ID high-risk areas in which the corporate compliance program should be monitoring? |
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Definition
-Billing for Non-covered services
-Altered claim forms
-Duplicate billing
-Misrepresentation of facts on claim form
-Failing to return overpayments
-Unbundling
-Billing for medically unnecessary services
-Overcoding or upcoding
-Billing for items or services not rendered
-False cost reports |
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Term
| What is the role of the Office of the Inspector General (OIG)? |
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Definition
1. Overview of OIG office:
-Mission is to protect the integrity of DHHS programs as well as the health and welfare of program beneficiaries
-Since its 1976 establishment, the OIG has been at the forefront with fighting waste, fraud and abuse in Medicare, Medicaid and more than 300 other HHS programs
2. Investigations: conducts criminal, civil and administrative investigations of fraud and misconduct related to HHS programs, operations and beneficiaries |
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Term
| Be able to ID the range of penalties that can result |
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Definition
| -These include: Civil monetary penalties, exclusion from participating in the Medicare/Medicaid program, repayment of fees received and prison time |
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Term
| What is Revenue Cycle Management? |
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Definition
| -All administrative and clinical fxns that contribute to the capture, mgmt, and collection of pt service revenue |
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Term
| What is the difference between hard and soft coded diagnostic/procedural data? |
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Definition
1. Hard coding: a change description master; computerized
2. Soft coding: each record is coded by a trained coding profession in the health info mgmt department |
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Term
| Be able to ID errors that may cause a claim to be rejected or denied |
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Definition
-Incompatible dates of service
-Nonspecific or inaccurate Dx and procedure codes
-Lack of medical necessity
-Inaccurate revenue code assignment
-Failure to follow contract-specific requirements |
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Term
| Be able to ID the causes of payment delays and lost revenue |
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Definition
-Poor clinical documentation
-Poor coding
-Need for better contract negotiations
-Out of date chargemaster
-Inadequate precertification/eligibility processes
-Numerous denials and appeals |
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