Step-By-Step Vocab & Notes
Step-By-Step Vocab & Notes Medical Coding
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Step-By-Step Vocab & Notes Chapter 8: An Overview of ICD-9-CM Codes are used to o Facilitate Payment of Health Services o Evaluate patients’ use of Health Care Facilities (Utilization Patterns) o Study Health Care Costs o Research the Quality of Health Care o Predict Health Care Trends o Plan for Future Health Care Needs ICD-9-CM Manual o Volume 1: Diseases – Tabular List o Volume 2: Diseases – Alphabetic Index o Volume 3: Procedures – Tabular List and Alphabetic Index Classification of Diseases and Injuries o Chapter: Main division in the ICD-9-CM manual. o Section: A section is a group of three-digit categories that represent a group of conditions or related conditions. o Category: A three-digit Category is a code that represents a single condition or disease. There are approximately 100 codes at the category level; most others require a fourth or fifth digit. If you look at the footnote area of your ICD-9-CM Manual, you will see there is a symbol that is used to direct the coder to assign further digits. o Sub-Category: A four-digit Sub-Category code provides more info or specificity as compared to the three-digit code in terms of the cause, site or manifestation of the condition. You must assign the fourth digit if it is available. Always code to the highest level of specificity based on the documentation in the medical record. o Sub-Classification: A five-digit Sub-Classification code adds even more info and specificity to a condition’s description. You must assign the fifth digit if it is available. Instructions on the use of fifth digits may appear at the beginning of a chapter, a section or third/fourth digit Category Bold type is used for all codes and titles in the Tabular List in Volume 1 Italicized type o is used for all exclusion notes and to identify those codes that are not usually sequenced as the first-listed diagnosis o Italicized type CANNOT be assigned as a first-listed diagnosis because they always follow another code o Italicized codes are to be sequenced in the order specified in the Alphabetic Index, Volume 2, or according to specific coding instructions in the Tabular List Volume 1 Fourth & Fifth-Digit Specificity o The addition of the fourth & fifth digits to the basic three-digit code provides greater specificity to the numeric designation of the patient’s condition and reduces third-party payer returns of claims for further clarification of the diagnosis codes o When four digits are used, they are called Sub-Category Codes o When five digits are used, they are called Sub-Classification o Not all codes have fourth or fifth digits, but when a fourth or fifth digit is available IT MUST BE USED Appendixes o Appendix A: Morphology of Neoplasms o Appendix B: Glossary of Mental Disorders (Deleted in 2004) o Appendix C: Classification of Drugs by American Hospital Formulary Service List Number and Their ICD-9-CM Equivalents o Appendix D: Classification of Industrial Accidents According to Agency o Appendix E: List of Three-Digit Categories Appendix A: Morphology of Neoplasms o Morphology is the study of the form and structure of Neoplasms o The World Health Organization (WHO) published an adaptation of the International Classification of Diseases for Oncology (ICD-O) o The ICD-O contains codes for the location (Topography) and the Morphology of tumors o Morphology codes consist of five-digits: the first four identify the Histologic (Morphologic) type of the Neoplasm and the fifth indicates the behavior of the Neoplasm Appendix B: Glossary of Mental Disorders o DELETED IN 2004 Appendix C: Drugs o This alphabetized sub-section is entitled Classification of Drugs by American Hospital Formulary Services List Number and Their ICD-9-CM Equivalents o A division of the American Hospital Formulary Services (AHFS) regularly publishes a coded listing of drugs o These AHFS codes have as many as six digits with each beginning with a number, then a colon and then up to four additional digits to provide specificity Appendix D: Industrial Accidents o The subsection Classification of Industrial Accidents According to Agency contains three-digit codes to identify occupational hazards. The subsection is divided into categories o These categories are: Machines Means of Transport and Lifting Equipment Other Equipment Materials, Substances and Radiations Working Environment Other Agencies, Not Elsewhere Classified (NEC) Agencies Not Classified for Lack of Sufficient Data o The identification of occupational hazards is especially important in coding injury or death that is job-related o Statisticians analyze the data and make statements about the risks involved in various occupations based on the data collected from the forms completed by health care workers o Occupational hazard codes are not placed on the insurance or billing forms o Instead these specialized codes are used by state and federal organizations to summarize data concerning industrial accidents Appendix E: Three-Digit Categories o Appendix E is a list of all the three-digit categories in the ICD-9-CM, presented by chapter o The categories are labeled 1 through 17, V01-91 and E000-E-999 o Reviewing Appendix E is a good way to get a quick overview of all of the codes in the ICD-9-CM Manual Alphabetic Index, Volume 2 o As a coder, you reference the Index FIRST and THEN locate the code identified in the Index in the Tabular List, Volume 1 o Everything in the Index is listed by condition o The Alphabetic Index consists of three sections: Index to Diseases Table of Drugs and Chemicals Index to External Causes of Injury (E-Codes) o There are 2 tables located within the Index to Diseases. These tables are used to better list the sub-terms under the main term entries of Hypertension and Neoplasms o The ICD-9-CM Index utilizes three levels of indentation in the Alphabetic Index. They are: Main Terms Sub-Terms Carryover Terms o The main terms are identified by bold print and are flush with the left margin of each column o Alphabetization rules apply in locating main terms and sub-terms in the Alphabetic Index o Numerical entries appear first under the main term or subterm. Each term is followed by the code(s) that apply to the term o The sub-terms under the main terms are indented to the right. They begin with a lowercase letter and are not bolded. These sub-terms modify the main term and are called essential modifiers. These sub-terms provide greater specificity for proper code assignment o Certain sub-terms are called connecting words. These define a relationship between a main term or a sub-term and an associated condition or etiology o Carryover lines are used when there is not enough space on a single line for an entry. They are indented to the right even further that a sub-term to avoid confusion o The two main abbreviations NEC and NOS are often used and are very important NEC (Not Elsewhere Classified): NEC is used in both the Alphabetic Index and the Tabular List. In the Alphabetic Index, NEC represents “Other Specified”. When a specific disease or condition is documented and there is not a specific code available, the Index will direct the coder by using the abbreviation NEC to an “Other Specified” Code. The NEC abbreviation in the Tabular List also means “Other Specified” and it often is classified to the final digit 8. The code may not fully describe the disease process or medical condition NEC can be used in two ways: NEC directs the coder to other classifications, if appropriate. Other Sub- Terms or Exclude Notes may provide hints as to what the other classifications may be NEC is used when the ICD-9-CM does not have any codes that provide greater specificity NOS (Not Otherwise Specified): NOS is the equivalent of “Unspecified”. It is used when the info at hand does not permit a more specific code assignment. The coder should query the physician for more specific info so that a more specific code assignment can be made Punctuation o Brackets: [ ] Brackets enclose synonyms, alternative wording or explanatory phrases Are found in the Tabular List o Slanted Brackets: [ ] Slanted Brackets used in the Alphabetic Index, Volume 2 Are used to enclose the manifestation of the underlying condition Sequence the code INSIDE the slanted brackets AFTER the underlying condition code o Parentheses: ( ) Parentheses enclose supplementary words (Non-Essential Modifiers) that may be present or absent in the statement of a disease or procedure without affecting code assignment Parentheses are located in both the Alphabetic Index and the Tabular List o Colon: : Colons 0are located in the Tabular List AFTER an incomplete term that needs one or more of the modifiers that follow in order to make the condition assignable to a given category o Brace: } A Brace is used in some publications to enclose a series of terms, each of which is modified by the statement appearing at the right of the Brace o Includes Notes Includes notes appear in the Tabular List, Volume 1 They further define or provide examples and may apply to the chapter, section or category The notes at the beginning of the chapter apply to the entire chapter The notes at the beginning of the category apply to that entire category You HAVE to refer to the beginning of the chapter or section for any Includes Notes that refer to an entire chapter or section because the Includes notes are not repeated within the chapter or section Includes Notes may also be located before or after category codes o Excludes Notes Excludes notes appear in the Tabular List, Volume 1 and indicate terms that are to be coded elsewhere Excludes Notes can be located at the beginning of a section or below a Category or Sub-Category o Sub-Categories Sub-Categories consist of four-digit codes that provide more info or specificity. The specificity may provide insight to the etiology of the disease as well as the location of the disease or to manifestation o AND and WITH Although the two words “AND” and “WITH” have similar meanings in everyday language, in ICD-9-CM terminology they have special significance and meanings “AND” means and/or “WITH” indicates that two conditions are included in the code and both conditions MUST be present to report the code o Cross-References Cross-References provide the coder with possible alternatives or synonyms for a term There are three types of Cross-References: See See is an explicit direction to look elsewhere It is used for anatomic sites and many modifiers not normally used in the Alphabetic Index The See cross-reference is also used to reference the appropriate main term under which all the info concerning a specific disease will be located See Also See Also directs the coder to reference another main term if all the info being searched for cannot be located under the first main term entry See Category See Category directs you to Volume 1, Tabular list for important info governing the use of the specific code o Use Additional Code You add info by assigning an additional code to provide a more complete picture of the diagnosis or procedure The use of an additional code is MANDATORY when supporting physician documentation is located in the record o Code First Underlying Disease The phrase “Code First Underlying Disease” is used in the categories in the Tabular List, Volume 1 In some cases, the code, title and instructions appear in italics to indicate that the underlying disease be sequenced first o Code, If Applicable, Any Casual Condition This instructional note appears in the Tabular List The note instructs the coder to sequence the casual condition (Etiology) first Unlike the instructional note “Code First Underlying Disease”, if no casual condition is present or documented, then the code may be sequenced first o Notes Certain main terms are followed by notes that are used to define terms and give coding instructions o Eponyms Eponyms are diseases, procedures or syndromes named for people Eponyms are listed both as main terms in their appropriate alphabetic sequence in the Index and under the main terms “Disease” or “Syndrome” A description of the disease or syndrome is usually included in parentheses following the Eponym o Tabular List, Volume 3 Volume 3 has abbreviations, punctuation, symbols and terms similar to those used in volumes 1 & 2 The following are the conventions that are the same in all volumes: Abbreviations of NEC and NOS Punctuation, Symbols, Brackets, Parentheses, Colons and Braces Bold type for all codes and titles Italicized type for all exclusion notes Instructional notations of Includes and Excludes The term “Code Also” has two purposes in Volume 3: To allow the coding of each component of a procedure To allow the coding of the use of special adjunctive (at the same time) procedures or equipment These instructions are NOT MANDATORY but they serve as a reminder to code these additional procedures if they were performed o Alphabetic Index, Volume 3 Procedures are 2 digit codes Diseases are 3 digit codes Numbers are all placed in numeric sequence BEFORE alphabetic characters (Numbers come BEFORE Letters) “As”, “By”, “With” IMMEDIATELY follow the main term to which they refer When multiple prepositional references are present, they are listed alphabetically CH. 8 DONE (48 PAGES) Chapter 8: An Overview of ICD-9-CM Chapter 9: ICD-9-CM Outpatient Codes and Reporting Guidelines First-Listed Diagnosis o In the outpatient setting, the term first-listed diagnosis is used in lieu of principal diagnosis o If a patient has an unconfirmed diagnosis, code for the symptoms as there is no confirmed diagnosis o When a patient presents for outpatient surgery, code the reason for the surgery as the first-listed diagnosis, EVEN IF NO SURGERY IS PERFORMED o When a patient is admitted for observation for a medical condition, assign a code for the medical condition as the first-listed diagnosis o In some cases, additional diagnoses would be reported to describe manifestations, complications, reasons for canceled procedures and other coexisting conditions o Accurate reporting of ICD-9-CM codes require that the documentation should describe the patient’s condition o Codes that describe symptoms & signs, as opposed to diagnoses, are acceptable for reporting purposes when a diagnosis has not been established/confirmed by the provider V-Codes o Used to deal with encounters for circumstances other than a disease or injury o Used for people who are not currently sick, people with chronic illnesses, circumstances that are not illnesses or injuries but still affect people’s health, and newborns or multiple gestation status o Terms that indicate V-Codes: Admission Dialysis Maladjustme Test nt Aftercare Dissatisfactio Observation Transplant n with Attention to Donor Problem Unavailabilit y of medical facilities Boarder, Examination Procedure Vaccination hospital (Surgical) Care (of) Fitting of Prophylactic Carrier Follow-up Replacement Checking Health, Screening Healthy Contraceptio History Status n Counseling Maintenance Supervision (of) TH TH o IF A CODE HAS A 4 or 5 DIGIT IT MUST BE ASSIGNED o DO NOT CODE diagnoses documented as “Probable” “Suspected” “Questionable” or “Rule Out” o Code the conditions that are certain and the symptoms of the conditions that are uncertain o Chronic diseases can be coded and reported as many times as the patient receives care for the condition o Code all documented conditions that coexist at the time of the encounter/visit o DO NOT code conditions that were previously treated and no longer exist o For therapeutic or diagnostic services code the diagnosis, condition or problem first Chapter 10: Using ICD-9-CM o Steps to Accurate Coding: 1. Identify the main term(s) in the diagnostic statement 2. Locate the main term(s) in the Alphabetic Index (Volume 2) 3. Review any subterms under the main term in the index 4. Follow any cross-reference instructions 5. Verify the code(s) selected from the Index (Volume 2) in the Tabular List (Volume 3) 6. Refer to any instructional notations in the Tabular 7. Assign codes to the highest level of specificity 8. Code the diagnosis until all elements are completely identified o ALWAYS USE BOTH THE ALPHABETIC INDEX AND TABULAR LIST o Locate each term in the Alphabetic Index o CODE TO THE HIGHEST LEVEL OF SPECIFICITY o If the same condition is both acute and chronic, and separate subentries exist in the Alphabetic Index at the same indentation level, code both and sequence the acute code first o A combination code is a single code used to classify: Two diagnoses A diagnosis with an associated secondary process A diagnosis with an associated complication o Residual is always coded before a late effect o A late effect is the residual effect after the acute phase of an illness or injury has terminated. THERE IS NO TIME LIMIT ON WHEN A LATE EFFECT CODE CAN BE USED o Code any condition described at the time of discharge as “impending” or “threatened” as follows: If it did occur, code as confirmed diagnosis If it did not occur, reference the Alphabetic index to determine if the condition has a subentry term for it and also reference main term entries for “Impending” and “Threatened” If the subterms are listed, assign the given code If the subterms are not listed, code the existing underlying conditions and not the condition described as impending or threatened Chapter 11: Chapter Specific Guidelines (ICD- 9-CM Chapters 1-8) o Combination coding applies when one code fully describes the condition o Multiple coding applies when it takes more than one code to fully describe the condition o Neoplasms are STAGED, which means that they are evaluated for placement on a common grading scale based on level of invasion o To assign a diagnosis code to a neoplasm is a 2 step process: 1. Locate the morphology or histologic type of the neoplasm in the index of the ICD-9-CM 2. Review all modifiers and subterms and then follow the instructions or verify the code listed o M-Codes are NOT assigned in the outpatient setting. M-Codes are alphanumeric codes and are listed in Appendix A of the ICD-9 Manual. The alphanumeric structure of the morphology codes starts with M, followed by 4 digits that indicate the histologic type of neoplasm and a slash, followed by a fifth digit that indicates behavior o When sequenced, neoplasm codes would go in the order of which neoplasm the treatment was directed towards. If treatment was directed and the secondary neoplasm, it would be coded first Chapter 12: Chapter Specific Guidelines (ICD- 9-CM Chapters 9-17) CHECK THE TABULAR LIST IN CASE OF INCLUDE/EXCLUDE NOTES Chapter 2: An Overview of ICD-10-CM o ICD-10-CM was issued in 1993 by the WHO o ICD-10-CM does NOT include Volume 3 (procedure classification) o I-10 was developed by the National Center for Health Statistics (NCHS) o Improvements in the content and format of the I-10 include: Addition of information relevant to ambulatory and managed care encounters Expansion of injury codes Extensive expansion of the injury codes, allowing for greater specificity Creation of combination diagnosis/symptom codes to reduce the number of codes needed to fully describe a condition Addition of a sixth character Incorporation of common fourth- and fifth-character subclassifications Updating and greater specificity of diabetes mellitus codes Facilitation of providing greater specificity when assigning codes o Use GEMs to translate from ICD-9 to ICD-10 and ICD-10 to ICD-9 Chapter 4: Using ICD-10-CM o Steps to accurate coding in ICD-10: 1. Identify the main term(s) in the diagnostic statement 2. Locate the main term(s) in the Alphabetic Index 3. Review any subterms under the main term in the Index 4. Follow any cross-reference instructions 5. Verify the code(s) selected from the index in the tabular list 6. Refer to any instructional notations in the Tabular 7. Assign codes to the highest level of specificity 8. Code the diagnosis until all elements are completely identified Chapter 13: Introduction to the CPT and Level 2 National Codes (HCPCS) o Current Procedural Terminology (CPT) is a coding system developed by the American Medical Association (AMA) to convert widely accepted, uniform descriptions of medical, surgical and diagnostic services rendered by health care providers into 5 digit numeric codes o Appendices of the CPT Manual: Appendix A Modifiers Appendix B Summary of Additions, Deletions & Revisions Appendix C Clinical Examples Appendix D Summary of CPT Add-On Codes Appendix E Summary of CPT Codes Exempt from Modifier 51 Appendix F Summary of CPT Codes Exempt from Modifier 63 Appendix G Summary of CPT Codes That Include Moderate (Conscious) Sedation Appendix H Alphabetic Index of Performance Measures by Clinical Condition or Topic Appendix I Genetic Testing Code Modifiers Appendix J Electrodiagnostic Medicine Listing of Sensory, Motor and Mixed Nerves Appendix K Product Pending FDA Approval Appendix L Vascular Families Appendix M Deleted CPT Codes Appendix N Summary of Resequenced CPT Codes Appendix O Multianalyte Assays with Algorythmic Analyses Chapter 14: Modifiers o Modifiers inform third-party payers of circumstances that may affect the way payment is made o Modifiers indicate the following types of information: Altered service Bilateral procedure Multiple Procedure Professional part of the service/procedure only More than one physician/surgeon -22 Increased Procedural Services -23 Unusual Anesthesia -24 Unrelated Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional During a Postoperative Period -25 Significant Separately Identifiable E/M Service -26 Professional Component -32 Mandated Services -33 Preventative Service -47 Anesthesia by Surgeon -50 Bilateral Procedures -51 Multiple Procedures -52 Reduced Services -53 Discontinued procedure -54, -55, -56 Surgical Package (If done by separate physicians/surgeons) -54 Surgical Care Only -55 Postoperative Management Only -56 Preoperative Management Only -57 Decision for Surgery -58 Staged or Related Procedure or Service by the Same Physician or Other Qualified Health Care Professional During the Postoperative Period -59 Distinct Procedural Service -62 Two Surgeons -63 Procedure Performed on Infants Less than 4 Kg -66 Surgical Team -76 Repeat Procedure or Service by the Same Physician or Other Qualified Health Care Professional -77 Repeat Procedure by Another Physician or Other Qualified Health Care Professional -78 Unplanned Return to the Operating/Procedure Room by the Same Physician or Other Qualified Health Care Professional Following Initial Procedure for a Related Procedure During the Postoperative Period -79 Unrelated Procedure or Service by the Same Physician or Other Qualified Health Care Professional During the Postoperative Period -80 Assistant Surgeon -81 Minimum Assistant Surgeon -82 Assistant Surgeon (When Qualified Resident Surgeon Not Available -90 Reference (Outside) Lab -91 Repeat Clinical Diagnostic Lab Test -92 Alternative Lab Platform Testing -99 Multiple Modifiers Medical Coding CPT Coding is The process of translating written or dictated medical record into a series of numeric or alpha-numeric codes Proper Code assignment is Content of the medical record determined by and by the unique rules that govern each code set 3 things a Coder must 1. Anatomy 2. Medical Terminology master 3. Detail Orientation Medical Coders assign a 1. Each diagnosis code to what? 2. Service/Procedure 3. Supply (Using the Classification system when applicable) The Classification System The amount healthcare determines providers will be reimbursed if the patient is covered by Medicare, Medicaid or other insurance programs using the system A Coder must evaluate the 1. Completeness and medical record for accuracy 2. Communicate regularly with physicians and healthcare professionals to clarify DX or obtain additional PT info Technicians who specialize 1. Health Information Coders in Coding inpatient hospital 2. Medical Record Coders services are referred to as 3. Coders/Abstractors 4. Coding Specialists What is MS-DRGs and what 1. Medicare Severity- does it do? Diagnosis Related Groups 2. Determines the amount the hospital will be reimbursed it the PT is covered by Medicare or other insurance programs What is EHR? Electronic Health Record Skilled coders may become Consultants, Educators or Medical Auditors What is the difference 1. Outpatient Coding between Hospital and (physician services) Physician Services? learning CPT, HCPCS, LEVEL II, ICD-9, CM Codes Volumes 1,2,3 and MS- DRGS What is APC and who uses Ambulatory Payment it? Classification Outpatient Facility Coders What is the Coder’s role in Extremely important for the a Physician’s Office? proper reimbursement of services and the livelihood of the physician What is a Physician’s 4 yrs college, 4 yrs Med school, degree of education? 3-5 yrs Residency What are mid-level 1. Mid-level providers are providers and who can be known as physician can be classified as one? extenders 2. Physician Assistants (PA) & Nurse Practitioners (NP) What are the requirements 1. 26 ½ month program for a PA and what can they 2. Licensed to practice do? NP must have Master’s Degree in Nursing In simplest terms, how 2 many players are there? Private insurance plans and government insurance plans Commercial carriers are Private payers that offer both considered what? group and individual plans Private payers contracts Hospitalization, basic and may vary but include what? major medical coverage What is the most significant Medicare government insurer? What is Medicare? Federal health insurance program Administered by the Center for Medicare & Medicaid Service (CMS) What is CMS and what does Center for Medicare & Medicaid it provide? Services (CMS) provides coverage for people over the age of 65, blind or disabled individuals, people with end- stage renal disease CMS regulations often Last serve as the ____ word in coding requirement for Medicare and Non-Medicare payers alike What are the parts of Medicare A Medicare Medicare B Medicare C Medicare D What is Medicare Part A? Covers in-patient hospital care, care provided in skilled nursing facilities, hospice care and home healthcare What is Medicare Part B? Covers medically necessary doctors’ services, outpatient care, other medical services (Including some preventative service not covered under Medicare Part A) Medicare part B is An optional benefit that the considered what? patient must pay a premium and generally requires a yearly co-pay Where is Medicare Part B Physicians’ offices (Outpatient usually used? Facility) What is Medicare Part C? Combines the benefits of Medicare Part A, B & sometimes D What is Medicare Part C Medicare Advantage also called? What is PPO? Preferred Provider Organizations What is HMO? Health Maintenance Organizations Which plan covers PPO and Medicare Part C HMO? What is the CMS-HCC? Center for Medicare & Medicaid Services-Hierarchical Condition Category What does the CMS-HCC Risk adjustment model provide? provides adjusted payment based on a patient’s disease and demographic factors If a Coder does not include Additional reimbursement that all pertinent Diagnoses and he/she is entitled to Co-Morbidities, the provider may lose out on what? Medicare Part D Prescription drug coverage program available to all Medicare beneficiaries Private companies approved by Medicare provide the coverage What is Medicaid? A health insurance assistance program for low income people (especially children and pregnant women) Sponsored by federal & state governments Medicaid is administered on A state-by-state basis and coverage varies Each state program adheres to certain federal guidelines When is a physician When contracted with an considered a “Participating insurance carrier whether that Physician” be a private insurance company or governmental Participating Providers are The allowed payment amount required to accept what? determined by the insurance carrier as the fee for payment and follow all other guidelines stipulated by the contract The difference between the Adjusted by the participating physician’s fee and the provider insurance carrier’s allowed amount is? Non-Participating Providers 1. Providers not contracted are? with insurance carriers 2. Not required to make the adjustment What is Limiting Charge? Limits set on what can be charged for each CPT code, no matter if the physician is Par or Non-Par What is a Medical Record? Documentation or the recording of pertinent facts and observation about an individual’s health history including past & present illnesses, tests, treatments and outcomes Medical Records Documents patient care to chronologically______ assist in continuity of care between providers, facilitate claims, review and payment Can a Medical Record serve YES as a legal document? All services provided to a Supported and documented in patient are ________ the Medical Record What are Coders required Read and understand the to do with the Medical documentation in the medical Records? record in order to accurately code the services rendered What are some different Evaluation & Management types of services Operative Reports documented in a Medical X-Rays Record? Evaluation and SOAP Management Services are provided in what standard format? What is SOAP S - Subjective documentation? O - Objective A – Assessment P – Plan What is the definition of O Objective in SOAP? The provider assesses and documents the patient’s illness using observation, palpation, auscultation and percussion. Tests and other services performed may be documented here as well What is the definition of A Assessment in SOAP? Evaluation and conclusion made by the provider. Usually where the diagnosis(es) for the services are found What is the definition of P Plan in SOAP? Course of action. Provider lists the next steps for the patient, whether it’s ordering additional test, or taking over-the-counter medication What is an Operative A document detailing a Report? procedure performed on a patient What will most Operative Header & Body notes have? What are some of the 1. Date & Time of Procedure 2. Name of Surgeon, Co- things that an Operative Header Note might include? Surgeon, etc 3. Type of anesthesia and Anestheiology provider name 4. Pre-Operative & Post- Operative diagnoses 5. Procedures performed 6. Complications What are some things that 1. Indication for surgery the Operative Body Note 2. Details of the might include procedure(s) 3. Findings What is the approximate 20% percentage of an Operative Report that contains words less important to a Coder? What is the task for a Coder To break down the information with an Operative Report? and applying the correct code What are the 5 most 1. Diagnosis Code Reporting important Coding tips for 2. Start with the procedures Operative Reports for a listed Coder? 3. Look for key words 4. Highlight unfamiliar words 5. Read the body What does the first coding Diagnosis code reporting: tip mean for the Operative Use the post-operative Report for a Coder? diagnosis for coding unless there are further defined diagnoses or additional diagnoses found in the body or finding the operative report What does the second Start with procedures listed: coding tip mean for the For the coder who is new to Operative Report for a Coding a procedure, 1 way of Coder? quickly starting the research process is by focusing on the procedures listed in the header. Read the note in its entirety to verify the procedures performed. Procedures listed in the header may not be listed correctly and procedures documented with the body of the report may not be listed in the header at all. It will help a coder with a place to start What does the third coding Look for key words: tip mean for the Operative Key words may include Report for a Coder? locations and anatomical structures involved, surgical approach, procedure method, procedure type, size & number and surgical instruments used during the procedure What does the fourth Highlight unfamiliar words: coding tip mean for the Words you aren’t familiar with Operative Report for a should be highlighted and Coder? researched for understanding What does the fifth coding Read the body: tip mean for the Operative All procedures reported should Report for a Coder? be documented with the body of the report. The body may indicate a procedure was abandoned or complicated, possibly indicating the need for a different procedure code or reporting of a modifier What is Medical Necessity Whether a procedure or service related to? is considered appropriate in a given circumstance Generally what is a The least radical Medically-Necessary service/procedure that allows Service? for effective treatment of the patient’s complaint or condition Under what regulations is Title XVIII 1862 of the Social “Medically Necessity” Security Act found under? What is the National Describes whether specific Coverage Determinations medical items, services, Manual? treatment procedures or technologies can be paid under Medicare What is the difference 1. Covered items- Services between Covered and Non- and procedures are Covered Items? covered only when linked to designated, approved diagnosis 2. Non-Covered items are deemed not reasonable or necessary Medicare and many Not reasonable or necessary insurance plans may deny according to the Medicare payment for a service that reimbursement rules is What is NCD and what does 1. National Coverage it do? Determinations 2. Explains when Medicare will pay for items or services What is LCD and what does 1. Local Coverage it provide? Determinations 2. MAC is responsible for interpreting national policies into regional policies. The LCDs further define what codes are needed and when an item or service will be covered. LCD have jurisdiction only within their regional area What is MAC? Medical Administrative Contractor If a NCD does not exist Where coverage of an item or what are CMS guidelines? service is provided for specified indications or circumstances but is not explicitly excluded for others, or where the item or service is not mentioned at all in the CMS Manual System, the Medicare contractor is to make the coverage decision, in the consultation with its medical staff and with CMS when appropriate, based on the laws, regulations, ruling and general program instructions How often should practices Quarterly check policies to maintain compliance? What does ABN stand for? Advance Beneficiary Notice of Non-coverage, or Advance Beneficiary Notice What is an ABN? A standardized form that explains to the patient why Medicare may deny a particular service or procedure What does ABN protect? The provider’s financial interest by creating a paper trail that CMS requires before a provider can bill the patient for payment if Medicare denies coverage for the stated service or procedure What must the provider 1. Complete one-page form complete in regards to in full ABN? 2. Giving the patient an explanation as to why Medicare is likely to refuse coverage for proposed procedure or service What are some of the 1. Medicare does not pay for common reasons why the procedure/service for Medicare may deny a the patient’s condition procedure and service? 2. Medicare doesn’t pay for the procedure/service as frequently as proposed 3. Medicare does not pay for experimental procedures/services What must the provider Cost Estimate present to the patient on the ABN for a proposed procedure or service? What doe CMS instructions Notifiers must make good faith stipulate on Cost Estimate? effort to insert a reasonable estimate The estimate should be within $100 or 25% of the actual costs, whichever is greater When do CMS rules require Far enough in advance that the the provider to present the beneficiary or representative ABN to the patient? have time to consider the options and make an informed choice What must be done BEFORE 1. ABN must be verbally the patient signs the ABN? received with beneficiary or his/her representative 2. Any questions raised during that review must be answered After the ABN is signed, 1. Proceed with What are some choices the procedure/service and patient has? assume financial responsibility. If the patient chooses to proceed, he may request the charge be submitted to Medicare for consideration (With the understanding that it will probably be denied) 2. Elect to forego the procedure or service What must go to the 1. Copy of completed, patient AND the provider? signed form must be given to the beneficiary or representative 2. The provider must retain the original notice on file What action can the If the patient still requests the provider take if the patient procedures or services but refuses to sign the ABN? refuses to sign a properly- presented ABN, the provider should document the patient’s refusal. The provider and a witness then sign the form When is an ABN never 1. Emergency and urgent required? care situation And Why? 2. CMS prohibits giving an ABN to a patient who is “under duress” including patients who need Emergency Department service before stabilization What is HIPAA? Health Insurance Portability and Accountability Act of 1996 How many Acts are under 5 HIPAA? Which is the most Title 2-Preventing Healthcare important Title concerning Fraud and Abuse; the position of a Medical Administrative Simplification; Coder? Medical Liability Reform What is Title 2 of HIPAA Administration Simplification known as? Administration The increasing use of Simplification speaks to technology in the healthcare _____ industry Administration 1. National standards for Simplification (HIPAA) electronic healthcare addresses the need for transaction and code sets what? 2. National unique identifiers for providers, health plans and employers 3. Privacy and Security of health data Who is under the covered 1. Healthcare Providers entity? 2. Health Plans 3. Healthcare Clearinghouse Who is under the 1. Doctors 2. Clinics “healthcare providers covered entity”? 3. Psychologists 4. Nursing Home 5. Pharmacies Who is under the “health 1. Health Insurance plan covered entity”? Companies 2. HMO 3. Company Health Plans The definition of a Health Any policy, plan or program Plan in the HIPPA that provides or pays for the regulations excludes _______ cost of excepted benefits What do Excepted benefits 1. Coverage only for an include? accident, or disability income insurance, or any combination thereof 2. Coverage issued as a supplement to liability insurance 3. Liability insurance, including general liability insurance and automobile liability insurance 4. Worker’s compensation or similar insurance 5. Credit-only insurance 6. Coverage for on-site medical clinics 7. Other similar insurance coverage, specified in regulation, under which benefits for medical care are secondary or incidental to other insurance benefits What is included in the Entities that process Healthcare Clearinghouse nonstandard health information covered entity? they receive from another entity into standard format or vice versa Why is there a need for According to CMS “transactions National Standard for are electronic exchanges Electronic Healthcare involving transfer of Transaction and Code Set? information between 2 parties for a specific purpose. National standards for electronic healthcare transaction are designed to improve the efficiency and effectiveness of the healthcare system by standardizing the formats used for electronic transactions What Transactions are used 1. Health claims & in the National Standard for equivalent encounter Electronic Care Transaction information and Code Set? 2. Enrollment and Disenrollment in a health plan 3. Eligibility for a health plan 4. Healthcare payment and remittance advice 5. Health plan premium payments 6. Health claim status 7. Referral certification and authorization 8. Coordination of benefits Which Code Sets within the 1. HCPCS Transactions have been 2. CPT 3. CDT designated for standard 4. ICD-9-CM use? 5. NDC What does the acronym Healthcare Common Procedure HCPCS stand for? Coding System What does the acronym CPT Current Procedural Terminology stand for? What does the acronym Common Dental Terminology CDT stand for? When will ICD-10-CM be October 1, 2013 effective? What does the acronym National Drug Codes NDC stand for? What does the acronym NPI 1. National Provider stand for? Identifier Who uses it? 2. Identifier for providers required on the transactions What does the acronym EIN 1. Employer Identification stand for? Number Who uses it? 2. Issued to employers by the Internal Revenue Services (IRS) Who enforces the HIPAA OCR (Office of Civil Rights) Privacy Rule? What does the acronym Office of Civil Rights OCR stand for? What does the OCR do? Protects the privacy of individually identifiable health information; HIPAA Security Rule Patient Safety Rule What is the HIPAA Security Sets national standards for the Rule according to the OCR? security of electronic protected health information and the confidentiality provision of the Patient Safety Rule What is the Patient Safety Protects identifiable Rule according to the OCR? information being used to analyze patient safety events and improve patient safety What does the acronym PHI Protected Health Information stand for? What does the acronym Treatment Payment and Health TPO stand for? Care Operations When and Who can a 1. A covered entity may use Covered Entity disclose or disclose protected health information to? health information for its own treatment, payment or healthcare operations 2. A covered entity may disclose protected health information for treatment activities of a health care provider 3. A covered entity may disclose protected health information to another covered entity or a healthcare provider for the payment activities of the entity that receives the information 4. A covered entity may disclose to another covered entity for health care operation activities of the entity that receives the information, if each entity either has or had a relationship with the individual who is the subject of the protected health information 5. A covered entity that participates in an organized health care arrangement may disclose protected health information about an individual to another covered entity that participates in the organized health care arrangement for any health care operations activities of the organized health care arrangement What is the HIPAA Minimum The minimum necessary Necessary Requirement? protected health information should be provided to satisfy a particular purpose. if the information is not required to satisfy a particular purpose, it must be withheld. Under the Privacy Rule the 1. Disclosures to or requests by Minimum Necessary a health care provider for Standards do not apply to treatment of purposes _______ 2. Disclosures to the individual
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