question

Name the 4 Cooperating Parties for ICD-9-CM

answer

1) AHIMA, 2) AHA-American Hospital Association, 3) CMS-Centers for Medicare and Medicaid, and 4) NCHS-National Center for Health Statistics

question

What is a POA Indicator?

answer

The POA-Present on Admission Indicator is used to differentiate between conditions present at the time of admission and conditions that develop during an inpatient admission. The POA Indicator applies to diagnosis codes for claims involving inpatient admissions to acute care hospitals and other facilities. POA - developed by the Cooperating Parties.

question

What organization is responsible for updating the diagnosis classification (Volumes 1 & 2) for ICD-9-CM?

answer

Volumes 1 & 2 of the ICD-9-CM are updated by NCHS-National Center for Health Statistics.

question

What organization is responsible for updating the procedure classification (Volume 3) for ICD-9-CM?

answer

Volume 3 of the ICD-9-CM is updated by CMS-Centers for Medicaid and Medicare.

question

Which classification level of ICD-9-CM codes is the most specific?

answer

The "sub-classification" level is the most specific level of coding in ICD-9-CM (5-digit codes).

question

What are the levels of ICD-9-CM codes called?

answer

Category>Subcategory (4-digit)>Sub-classification (5-digit)

question

How many digits are in the Subcategory Level of ICD-9-CM codes?

answer

There are 4 digits at the Subcategory Level of ICD-9-CM codes.

question

Please describe E Codes.

answer

E Codes classify environmental events and circumstances as the cause of an injury, poisoning, or other adverse effect.

question

Please describe V Codes.

answer

V Codes are diagnosis codes that indicate a REASON for the healthcare encounter.

question

Please give brief description of Volume I of the ICD-9-CM Volumes.

answer

Volume I of the ICD-9-CM contains the TABULAR INDEX - a numerical listing of codes that represent diseases and injuries.

question

Please give a brief description of Volume 2 of the ICD-9-CM Volumes.

answer

Volume 2 of the ICD-9-CM contains the ALPHABETIC INDEX to Diseases and Injuries (You should always trust this index).

question

Please give a brief description of Volume 3 of the ICD-9-CM Volumes.

answer

Volume 3 of the ICD-9-CM contains the TABULAR and ALPHABETIC INDEX to Procedures.

question

Which item is not a purpose of the ICD-9-CM: A)-used in the evaluation of medical care planning for healthcare delivery systems, B)-used in the collection of data about nursing care, C)-used to facilitate data storage and retrieval, or D)-used as the basis of epidemiological research

answer

Collection of data about nursing care is not a purpose of the ICD-9-CM.

question

Which item is not one of the purposes of ICD-9-CM: A)-reporting of diagnoses by physicians, B)-classification of mortality for statistical purposes, C)-the identification of supplies, products & services provided to patients, or D)-classification of morbidity for statistical purposes

answer

The identification of supplies, products & services provided to patients is NOT on of the purposes of ICD-9-CM.

question

Please define "complication".

answer

A complication is a secondary condition that arises during hospitalization and is thought to increase the LOS-Length of Stay by at least one day for approximately 75% of patients.

question

Please define "comorbidity".

answer

Comorbidity is a pre-existing condition that because of its presence with a specific diagnosis will likely cause an increase in the patient's length of stay in the hospital.

question

Please define "principal diagnosis".

answer

Principal diagnosis is the condition established, after study, to be chiefly responsible for occasioning the admission to the patient for the hospital. The principal diagnosis is NOT the admitting diagnosis, but the diagnosis found after workup, or even after surgery that proves to the be reason for admission.

question

State the criteria of a "Significant Procedure".

answer

1- Surgical in Nature, 2-Carries a procedural risk, 3- Carries an anesthetic risk, 4- Requires specialized training

question

Which volume of ICD-9-CM contains the numerical listing of codes that represent diseases and injuries?

answer

Volume I - the Tablular List contains the numerical listing of codes that represent diseases and injuries.

question

What ICD-9-CM codes are always alphanumeric?

answer

V Codes are always alphanumeric.

question

Which volume of ICD-9-CM contains the Tabular and Alphabetic Index of Porcedures?

answer

Volume 3 of the ICD-9-CM contains the Tabluar LIst and Alphabetic Index of Procedures.

question

What is the standard terminology used to code medical procedures and services?

answer

CPT is a comprehensive listing of terms and codes for reporting diagnostic and therapeutic procedures and medical services.

question

According to CPT, a repair of a laceration that includes retention sutures would be considered what type of closure?

answer

Complex Closure would describe the repair of wounds requiring more than layered closure, namely, scar revision, debridement, extensive undermining, stents, or retention sutures.

question

A 7-year old patient was admitted to ER for treatment of shortness of breath. Patient was give epinephrine and nebulizer treatments. The shortness of breath and wheezing are unabated following treatment. What diagnosis should be suspected? [epineprhine-adrenaline hormone secreted by the medulla of the adrenal glands - when injected treats vasoldilation by increasing blood flow]

answer

Status Asthmaticus: fails to respond to therapy administered during an asthmatic attack. This is a life-threatening conditions that requires emergency care and likely hospitalization. (Schraffenberger)

question

How is the CPT code determined for an excision of a malignant lesion of the skin?

answer

The CPT code for an excision of a malignant lesion of the skin by the body area from which the excision occurs and by measuring the greatest clinical diameter of the apparent lesion plus that margin required for complete excision (lesion diameter + the most narrow margins required = the excised diameter).

question

Patient admitted for spotting. Patient had been treated 2 weeks prior for a miscarriage with sepsis. Sepsis has resolved and she is afrebrile [having no fever] at this time. Patient is treated with an aspiration dilation and curettage. Products of conception are found. What is the principal diagnosis?

answer

Miscarriage: subsequent [later] admissions for retained products of conception following a spontaneous or legally induced abortion are assigned the appropriate code from Catogory 634, spontaneous abortion, or 635, legally induced abortion, with a fifth digit of "1" (incomplete). This advise is appropriate even when the patient was discharged previously with a discharge diagnosis of complete abortion.

question

What is a condition that arises during hospitalization?

answer

Complication

question

What codes are used to assign a diagnosis to a patient who is seeking healthcare services but is no necessarily sick?

answer

V Codes are diagnosis codes and indicate a reason for healthcare encounter.

question

What is the 2-digit modifier that may be reported to indicate a physician performed the postoperative management of a patient, but another physician performed the surgical procedure?

answer

Modifier -55 is used to identify the physician provided ONLY postoperative care services for a particular procedure. [modifiers are appended to the code to provide more information or to alert the payer that a payment change is required.]

question

What does an encoder do for a coder?

answer

An encoder takes a coder through a series of questions an choices called a logic based encoder. The logic based encoder prompts the user through a variety of questions and choices based on the terminology entered. The coder selects the most accurate colde for a service or condition (and any possible complications or comorbidities).

question

Patient admitted for abdominal pain with diarrhea and diagnosed with infectious gastroenteritis. Patient also has angina and chronic obstruction pulmonary disease. What is the correct coding and sequence for this case?

answer

Infectious gastroenteritis; chronic obstructive pulmonary disease; angina - Patients can have several chronic conditions that co-exist at the time of their admision and qualify as additional disgnoses. [the codes for the symptoms "abdominal pain", "diarrhea", "vomiting", or "abdominal cramps" - signs, symptoms, and ill-defined conditions are not to be used as the Principal Diagnosis when a related definitive diagnosis has been established. *Chapter 16 CPT Codebook*

question

Patient admitted with history of prostate cancer and with mental confusion. Patient completed radiation therapy for prostatic carcinoma 3 years prior and is status post a radical resection of the prostate. A CT Scan of the brain during the current admission reveals metastasis. What is the correct coding and sequencing for this case?

answer

Metastastic carcinoma of the brain; History of carcinoma of the prostate - for a FORMER malignancy a code from Category V10, personal history of a malignant neoplasm should be used to indicate the former site of malignancy [when a primary malignancy has been previously excised or eradicated from its site and there is NO further treatment directed to that site & no evidence of any existing primary malignancy]. The mention of extension, invasion, or metastatic to another site is coded as a secondary malignant neoplasm to that site. The secondary site may be the principal, with the V10 code used as a secondary code. (Shcraffenberger)

question

Patient admitted with abdominal pain. Physician states that the discharge diagnosis is pancreatitis versus noncalculus cholecystitis. Both diagnoses are equally treated. What is the correct coding and sequencing for this case?

answer

Unusual Instance: Sequence EITHER the pancreatitis OR noncalculus cholecystitis as the principal diagnosis - two or more diagnoses equally meet the criteria for the principal diagnosis as determined by the circumstances of admission, diagnostic workup, and the therapy provided. ALSO the Alphabetic Index, Tabular List, or another coding guideline does not provide sequencing direction. In such cases any one of the diagnoses may be sequenced first.

question

80-year old female frebrile, lethargy, hypotension, tachycardia, oliguria, and elevated WBC. Patient has has >100K organisms of Escherichia coli per cc of urine. Attending physician documents: "urosepsis". How should the coder proceed in this case?

answer

NEED TO STUDY THIS BEFORE ADDING THE ANSWER

question

65-year old patient with history of lung cancer is admitted to a healthcare facility with ataxia (without coordination) and syncope (fainting) and a fractured arm-result of a fall. Treatment is a closed reduction of the fracture in the ER department and undergoes a complete workup for metastatic carcinoma of the brain. Patient is found to have metastatic carcinoma of the lung to the brain and undergoes radiation therapy to the brain. What is the principal diagnosis in this case?

answer

Metastatic carcinoma of the brain. If treatment is directed at the malignancy, designate the malignancy as the principal diagnosis. The ONLY EXCEPTION to this guideline is if a patient admission or encounter is SOLELY for the administration of chemotherapy, immunotherapy, or radiation therapy which would prompt the coder to assigne the appropriate V Code as the 1st listed or principal diagnosis and diagnosis or problem for which the service is being peformed as the secondary diagnosis.

question

What is the definition of "other diagnoses"? [according to the UHDDS-Uniform Hospital Discharge Data Set

answer

For reporting purposes "other diagnoses" is interpreted as ADDITIONAL CONDITIONS that affect patient care in terms of requiring: clinical evaluation or therapeutic treatement or diagnostic procedures or extends the length of stay or increases nursing care and monitoring.

question

What is the UHDDS?

answer

Uniform Hospital Discharge Data Set is a minimum set of items based on standard definitions to provide consistent data for multiple users. UHDDS is required for reporting Medicare and Medicaid patients and many other health care payers also use most of the UHDDS for the uniform billing system.

question

What are the required data items of UHDDS?

answer

1- Principal Diagnosis 2- Other Diagnoses that have a significance for the specific hospital episode 3- All significant procedures 4- Age, Sex, Race of patient 5- Expected Payer 5- Hospital's Identification

question

Patient in the ER for chest pain. Evaluation reveals suspicion of GERD [gastroesophageal reflux disease]. Final diagnosis was "Rule out chest pain versus GERD". What is correct ICD-9-CM code?

answer

786.50, Chest pain NOS: The condition should be coded to the highest degree of certainty - such as the sign or symptom the patient exhibits. In the outpatient setting, the condition [here-GERD] in the statement should NOT BE CODED AS IF it existed. Signs, symptoms, abnormal test results, or other reasons for the outpatient visit are used when a physician qualifies a diagnostic statement as "rule out" or other similar terms indicating uncertainty.

question

A skin lesion is removed from a patient's cheek in the dermatologist's office. Physician documents "skin lesion" in the health record. Before billing the pathology report returns with a diagnosis of basal cell carcinoma. What actions should the coder take for this claim submission?

answer

Code: Basal Cell Carcinoma: In the OUTPATIENT setting, when diagnostic tests have been interpreted by the physician and the final report is available at the time of coding, code any CONFIRMED or DEFINITIVE diagnosis(es) that are documented in the record. Do NOT code related signs and symptoms as addtional diagnoses. ******NOTE this differs from the coding practive in the hospital inpatient setting regarding abnormal findings on test results. *********

question

Epidural given during labor. Subsequently determined the patient would require a C-section for cephalopelvic disproportion [baby's head too large for mother's pelvis] because of obstructed labor [failure of the fetus to descend through the birth canal]. What it the correct ICD-9-CM diagnostic and the CPT anesthesia codes?

answer

NEED TO LOOK UP THIS ANSWER

question

Physician correctly prescribes Coumadin [anticoagulant-blood thinner]. Patient takes the Coumadin as prescribed but develops hematuria [blood in the urine] as a result of taking the medication. What the correct way to code this case?

answer

Hematuria; adverse reaction to Coumadin. An adverse effect can occur when everything is done correctly. Adverse effects can occur in situations where medications are administered properly and prescribed correctly in both therapeutic and diagnostic procedures. The first listed diagnosis is the MANIFESTATION or the nature of the adverse drug effect - in this case HEMATURIA. Locate the drug in the SUBSTANCE colum of the Table of Drugs and Chemicals in the Alphabetic Index to Diseases. Select the E Code for the drug from the Therapeutic Use column of the Table of Drugs and Chemicals. Use of the E Code is MANDATORY when coding adverse effects.

question

What is the procedure for locating a DRUG?

answer

Locate the drug in the SUBSTANCE colum of the Table of Drugs and Chemicals in the Alphabetic Index to Diseases. Select the E Code for the drug from the Therapeutic Use column of the Table of Drugs and Chemicals. Use of the E Code is MANDATORY when coding adverse effects.

question

Briefly describe MS-DRG

answer

MS-DRG (Medical-Severity-Diagnosis-Related Group). It is system to classsify hospital cases in groups. DRG's are used to determine how much Medicare pays the hospital for each "product" [i.e. "appendectomy"] since patients within each group are clinically similar and are expected to use the same level of hospital resources. Each DRG was a payment weight assigned to it based on the average resources used to treat Medicare patients in that DRG. Payment weights are affected by geographic location (cost of living), number of low income patietns in that location, whether the facility is a teaching facility, and if the case is an outlier case (a particularly costly case). Claim information is gathered: ICD diagnoses, procedures, age, sex, discharge status, and the presence of complication or comorbidities. Examples: Normal Newborn, Psychoses, Major Joint Replacement, Chest Pain, Cesarean Section, Simple pneumonia, Heart Failure. DRG's were developed to monitor quality of care and resource use, cost efficiency, and use the indicators to improve quality. Only ONE DRG can be assigned and reimbursed for a single admission. The payment provided for the DRG is intended to cover the costs of all hospital services performed during the patient's stay. Under the PPS, hospitals are paid a set fee for treating patients in a single DRG category, regardless of the acutal cost of care for the individual.

question

Patient admitted to the hospital for shortness of breath and congestive heart failure. Patient subsequently develops respiratory failure. Patient undergoes intubation with ventilator management. What is the correct sequencing and coding of this case?

answer

Congestive Heart Failure, Respiratory Failure, Ventilator Management, Intubation: Acute Respiratory Failure [518.81] may be assigned as a principal or secondary diagnosis depending upon the circumstances of the inpatient admission. {chapter specific coding guidelines provide specific sequencing direction-obstetrics, poisoning, HIV, newborn}. Respiratory failure may be listed as a secondary diagnosis. If respiratory failure occurs AFTER admission, it may be listed as a secondary diagnosis.

question

Patient admitted to the hospital with abdominal pain. Principal diagnosis is cholecystitis. Patient has a history of hypertension and diabetes. In the DRG [Diagnosis Related Group] prospective payment system, which of following determines the MDC [Major Diagnostic Category] assignment for this patient? a-abdominal pain, b-cholecystitis, c-hypertension, or d-diabetes

answer

Cholecystitis - The principal diagnosis determines the MDC.

question

Patient is admitted to the hospital with symptoms of a stroke and secondary diagnoses of COPD and hypertension. Patient was subsequently discharged with a principal diagnosis of cerebral vascular accident and secondary diagnosis of catheter-associated urinary tract infection, COPD, and hypertension. Which of the following diagnoses should NOT be tagged as POA? A) catheter-associated UTI, B) CVA, C) COPD, or D-Hypertension

answer

A) Catheter-Associated UTI: POA-Present on Admission is defined as present at the time the order for inpatient admission occurs. [All claims involving inpatient admissions to general acute care hospitals or other facilities that are subject to law or regulation mandating collection of present on admission information.] Conditions that develop during an outpatient encounter, including the ER Department, observation, or outpatient surgery, are considered POA. Any condition that occurs after admission is NOT considered a POA condition.

question

Patient returns during a 90-day postoperative period from a ventral hernia repair, now complaining of eye pain. What modifier would a physician setting use with the E&M [Evaluation and Management] code?

answer

-24: Unrelated evaluation and management service by the same physician during a postoperative period. NOTE: -79: Unrelated procedure or service by the same physician during the postoperative period... would NOT be used as the question made mention of E&M, not service or procedure.

question

Identify the 2-digit modifier that may be reported to indicate a physician performed the postoperative management of a patient, but another physician performed the surgical procedure.

answer

-55: postoperative management only {Modifiers are appended to code the provide more information to alert the payer that payment change is required.

question

An encoder that takes a coder through a series of questions and choices is called:

answer

A logic-based encoder: prompts the user through a variety of questions and choices based on the clinical terminology entered. The coder selects the most accurate code for a service or condition and any possible complications or co-morbidities.

question

A HIT-Health Information Technician is processing payments for hospital outpatient services to be reimbursed by Medicare for a patient who had 2 physician visits, underwent radiology examinations, clinical laboratory test, and who received take-home surgical dressings. Which of the following services is reimbursed under the outpatient prospective payment system? A) Clinical Laboratory Tests, B) Physician Office Visits, C) Radiology Examinations, or D) Take-Home Surgical Dressings

answer

Radiology Examinations: Radiology procedures are identified under the prospective payment system with a status indicator X. Status indicator X identifies ancillary services that are separately paid. ******JOHNS BOOK*****RE-READ this

question

Which of the following types of hospitals are excluded from the Medicare inpatient prospective payment system? A) Children's, B) Rural, C) State Supported, or D) Tertiary (major hospital)

answer

Children's: psychiatric ad rehabilitation hospitals, long-term care hospitals, children's hospitals, cancer hospitals, and critical access hospitals are pain on the basis of reasonable cost, subject to payment limits per discharge under separate PPS ********JOHNS BOOK*********RE-READ this

question

How are Diagnosis-related groups organized?

answer

DRG's are organized into MDC's - DRG's are classified by one of 25 major diagnostic categories.

question

In processing a Medicare payment for outpatient radiology examinations, a hospital outpatient services department would receive payment under which of the following? A) DRGs, B) HHRGS, C) OASIS, or D) OPPS

answer

OPPS - Radiology procedures performed as outpatients are paid under the Medicare prospective payment system and are identified with a status indicator X for ancillary services.

question

Which of the following is NOT reimbursed according to the Medicare outpatient prospective payment system? A) CMHC (community mental health center) partial hospitalization services, B) Critical access hospitals, C) Hospital outpatient departments, or D) Vaccines provided by CORFs (comprehensive outpatient rehabilitation facility)

answer

Critical Access Hospitals are paid on a cost-based payment system and are not part of the prospective payment system. *********JOHNS********RE-READ

question

How often are fee schedules updated by third-party payers?

answer

Third-Party Payers who reimburse providers on a fee-for-service basis generally update fee schedules on an annual basis.

question

What billing form is used by a health record technician to perform the billing functions for a physician's office?

answer

Physicians submit claims via the electronic format via the CMS-1500 billing form.

question

What does it mean when a provide accepts assignment?

answer

To accept assignment means the provider or supplier accepts, as payment in full, the allowed charge from the fee schedule.

question

A coding audit shows that an inpatient coder is using multiple codes that describe the individual components of a procedure rather than using a single code that describes all the steps of the procedure performed. What should be done in this case?

answer

Counsel the coder and stop the practice immediately and review the elements of the hospital compliance program with the coder.

question

Why were prospective payment systems developed by the federal government?

answer

Prospective payment systems were developed to manage the costs of Medicare and Medicaid. Since 1983, PPS have been used to manage the costs of the Medicare and Medicaid systems.

question

What is the goal of a coding compliance program?

answer

The goal of a coding compliance program is to prevent accusations of fraud and abuse.

question

If a patient's total outpatient bill is $500.00 and the patient's healthcare insurance plan pays 80% of the allowable charges, what is the amount the patient is responsible for?

answer

$100.00 to the patient

question

In a managed fee-for-service arrangement, which of the following would be used as a cost-control process for inpatient surgical services? A) prospectively pre-certify the necessity of inpatient services, B) Determine what services can be bundled, C) pay only 80% of the inpatient bill, or D) require the patient to pay 20% of the inpatient bill

answer

A) Pre-certify - managed FFS reimbursement is similar to traditional FFS reimbursement except that managed FFS care plans control costs primarily by managing their members' use of healthcare services.

question

In processing a bill under the Medicare outpatient prospective payment system (OPPS) in which a patient had 3 surgical procedures performed during the same operative session, which of the following would apply? A) bundling of services, B) outlier adjustment, C) pass-through payment, or D) discounting of procedures

answer

Discounting applies to multiple surgical procedures furnished during the same operative session. The full rate will be paid to the surgical procedure with the highest rate and the additional procedures with be discounted 50% of their APC (Ambulatory Payment Classification) rate.

question

What is a request for reconsideration of a denied claim for insurance coverage for healthcare services called?

answer

An appeal

question

Can a claim be denied for not meeting medical necessity?

answer

Yes

question

Can a claim be denied for billing too many units of a specific service?

answer

Yes

question

Can a claim be denied for unbundling?

answer

Yes

question

Can a claim be denied for "Approved Pre-certification"?

answer

No

question

What is NCCI?

answer

National Correct Coding Initiative

question

Timely and correct reimbursement is dependent on: A) Adjudication, B) Clean claims, C) Remittance advice, D) Actual Charge

answer

Clean claims are essential for correct reimbursement.

question

Common errors that delay, rather than prevent payment, include all of the following EXCEPT? A) patient name or certificate number, B) Claims out of sequence, C) Illogical demographic data, or D) Inaccurate or deleted codes

answer

A patient name or certificate number is required for filing claims.

question

Which of the following is NOT an essential data element for a healthcare insurance claim? A) revenue code, B) procedure code, C) Provider name, or D) Procedure name

answer

A procedure name is not a required element on an insurance claim.

question

What is the electronic format for hospital technical fees?

answer

837I. Effective 10/16/2003, under the Administrative Simplification Compliance section of HIPAA [Health Insurance Portability and Accountability Act of 1996], all healthcare providers must electronically submit claims to Medicare. 837I is for hospitals. 837P is for professional claims. UB-04 are for hospital (technical) claims and 1500 is for clinic (professional) claims.

question

What is the process that determines how a claim will be reimbursed based on the insurance benefit?

answer

Adjudication is the process that determines reimbursement based on the member's benefits.

question

Which statement is NOT one of the outcomes that can occur as part of auto-adjudication? [when clean claims are submitted, they can be adjudicated in many ways through computer software automatically]

answer

Auto-Calculate. Claims that automatically process through computer software either auto-pay, auto-suspend, or auto-deny.

question

What system assigns each service a value representing the true resources involved in producing it, including the time and intensity of work, the expenses of the practice and the risk of malpractice?

answer

RVUs - Relative value units are assigned to each service to provide a value that corresponds to payment.

question

Which statement is NOT reflective of meeting medical necessity requirements? A) A service or supply provided for the diagnosis, treatment, cure, or relief of a health condition, illness, injury, or disease, B) A service or supply provided that is not experimental, investigational, or cosmetic in purpose, C) A service provided that is necessary for and appropriate to the diagnosis, treatment, cure, or relief of a health condition, illness, injury, disease, or its symptoms, or D) A service provided solely for the convenience of the insured, the insured's family, or the provider.

answer

A service provided solely for the convenience of the insured, the insured's family, or the provider.

question

Patient has 2 health insurance policies: Medicare and a Medicare supplement. Which of the following statements is true? A) Patient receives any monies paid by the insurance companies over and above the charges, B) Coordination of benefits is necessary to determine which policy is primary and which is secondary so that there is no duplication of payments, C) the decision on which company is primary is based on remittance advice, or D) patient should not have a Medicare supplement

answer

Coordination of benefits is necessary to determine which policy is primary and which is secondary so that there is no duplication of payments.

question

Which system reimburses hospitals a predetermined amount for each Medicare inpatient admission? A) APR-DRG, B) DRG, C) APC, or D) RUG

answer

A DRG is a predetermined amount of reimbursement for each Medicare inpatient.

question

What does Medicare Part D pay for?

answer

Medicare Part D pays for prescription drugs for beneficiaries.

question

Medicaid is a government-sponsored healthcare insurance program that became effective in 1966 as Title 19 of the Social Security Act. Medicaid is administered by: A) the federal government, B) the state government, C) the federal and state government, or D) third-party administrators

answer

Medicaid is administered by federal and state government and is designed to offer assistance to low income people.

question

The MS-DRG system creates a hospital's case mix index (type or categories of patients treated by the hospital) based on the relative weights of the MS-DRG. The case mix can be figured by multiplying the relative weight of each MS-DRG by the number of _______________ within the MS-DRG? A) Admissions, B) Discharges, C) CCs, or D) MCCs

answer

Discharges

question

Under the Medicare hospital outpatient perspective payment system (OPPS), services are paid according to: A) fee for service schedule basis that varies according to the MPFS, B) a rate per service basis that varies according to the APC (Ambulatory Payment Classification) group to which the service is assigned C) A cost to charge ratio based on the hospital cost report, or D) a rate pre service basis that varies according to the DRG group

answer

B) a rate per service basis that varies according to the APC

question

Under the OPPS (Outpatient Perspective Payment System), on which code set is the APC (Ambulatory Payment Classification) system primarily based for outpatient procedures and services including devices, drugs, and other covered items?

answer

CPT/HCPCS (Healthcare Common Procedural Coding System)

question

Sometimes hospital departments must work together to solve claims issue errors to prevent them from happening over and over again. What departments would need to work together if an audit found that the claim did not contain the procedure code or charge for a pacemaker insertion?

answer

Health Information, Business Office and Cardiac Department

question

What are Medicare's newest claims processing payment contract entities referred to as:

answer

MAC's - Medicare Administrative Contractors are replacing the claims payment contractors known as FIs and carriers.

question

Which of the following best describes the type of coding utilized when a CPT/HCPCS code is assigned directly through the charge description master for claim submission and bypasses the record review and code assignment by the facility coding staff? A) Hard Coding, B) Soft Coding, C) Encoder coding, or D) Natural language processing coding

answer

HCPCS codes that are assigned in the charge description master that flow directly to the claim and bypass facility coding staff is a process known as hard coding.

question

What is guarantor?

answer

The person is who responsible for the bill. In the case of a child patient, the parent is the guarantor.

question

What are the 2 major types of coding edits with respect to NCCI (The National Correct Coding Initiative)?

answer

1) the comprehensive/component edit [pertains to HCPCS codes that should not be used together] and 2) the mutually exclusive edit [applies to improbable or impossible combinations of codes]

question

Describe the NCCI (National Correct Coding Initiative):

answer

A list of coding edits has been developed by CMS in a effort to promote correct coding nationwide and to prevent the inappropriate unbundling of related services. NCCI helps CMS to detect inappropriate codes submitted on claims. NCCI edits are included in most encoding computer software packages.

question

Given NCCI edits, if the placement of a catheter is billed along with the performance of an infusion procedure for the same date of service for an outpatient beneficiary, Medicare will pay for:

answer

Medicare will pay for the infusion procedure. Access to an indwelling IV or insertion of a subcutaneous catheter or port for the purpose of a therapeutic infusion is considered part of the procedure and not separately billed. {Physicians often infuse medications such as nitroglycerine during cardiac catheterization procedures. CPT Assistant states that infusion of medication should be considered an intrinsic part of the catheterization procedure.

question

Which of the following actions would best to determine whether POA [present on admission] indicators for the conditions selected by CMS are having a negative impact on the hospital's Medicare reimbursement? A) Identify all records for a period having these conditions and determine if these conditions are the only secondary diagnoses present on the claim that will lead to higher payment B) Identify all records for a period that have these indicators for these conditions, C) Take a random sample of records for a period of time for records having these indicators for these conditions and extrapolate the negative impact on Medicare reimbursement.

answer

Any secondary diagnoses assigned present on admission status will have a negative impact on reimbursement if no other code on the claim is assigned as a complication or co-morbidity or a major complication or co-morbidity.

question

The sum of a hospital's total relative DRG weights for a year was 15,192 and hospital had 10,471 total discharges for the year. Given this information, what would be the hospital's case mix index for that year? A) 0.689, B) 1.59, C) 1.45 x 100, or D) 1.45

answer

The case-mix index is 1.45 for the total case-mix index of the hospital. The sum all total weights 15,192 divided by the sum of total patient discharges 10,471 = the case mix index.

question

How is the total weight for each MS-DRG calculated?

answer

An individual MS-DRG case mix can be figured by multiplying the relative weight of each MS-DRG by the #of discharges within that MS-DRG.

question

Promoting correct coding and control of inappropriate payments is the basis of NCCI claims processing edits that help identify claims not meeting medical necessity. The NCCI automated prepayment edits used by payers is based on all of following EXCEPT: A) coding conventions defined in the CPT book, B) national and local policies and coding edits, C) analysis of standard medical and surgical procedures, or D) clinical documentation in the discharge summary

answer

D) clinical documentation in the discharge summary. Edits are predetermined based on coding conventions defined in the CPT codebooks, national and local policies and coding edits, analysis of standard medical and surgical practice, and review of current coding practices.

question

The NCCI editing system used in processing OPPS claims is referred to as:

answer

OCE-Outpatient Code Editor: portions of the NCCI are incorporated into the outpatient code editor (OCE) against which all ambulatory claims are reviewed. The OCE, also applies a set of logical rules to determine whether various combinations of codes are correct and appropriately represent services provided.

question

Denials of outpatient claims are often generated from all of the following edits EXCEPT: A) NCCI (National Correct Coding Initiative, B) OCE (Outpatient Code Editor, C) OCE (Outpatient Claims Editor, or D) national and local policies

answer

OCE - Outpatient Claims Editor Does Not Exist - the correct terminology is OCE Outpatient Code Editor

question

What new generation/design of consumer-directed healthcare will be driven by a design where co-payments are set based on the value of the clinical services rather than the traditional practices that focus only on the costs of clinical services [i.e. it will focus on both the benefit and cost]?

answer

VBID - Value Based Insurance Design calculates both the benefit and costs of clinical services.

question

A national dollar amount that Congress designates to convert relative value units into dollars (on an annual basis) is called:

answer

Conversion Factor

question

IPPS

answer

Inpatient Prospective Payment System Inpatient Acute Care Hospital IPPS is the Medicare reimbursement system for inpatient services provided in an acute care setting. Payment to facilities, not payment for professional services. DRG/MS-DRG

question

IPF PPS

answer

Inpatient psychiatric facility prospective payment system Inpatient psychiatric facility Per Diem

question

SNF PPS

answer

Skilled Nursing Facility Prospective Payment System RUG - Resource Utilization Group

question

HHPPS

answer

Home Health Prospective Payment System Home Health Agency HHRG - Home Health Resource Group

question

IRF PPS

answer

Inpatient Rehabilitation Facility Prospective Payment System Inpatient Rehabilitation Facility CMG: Case-Mix Group

question

LTCH PPS

answer

Lont-Term Care Hospital Prospective Payment System Long-Term Care Hospital LTC-DRG MS-LTC-DRG

question

OPPS

answer

Outpatient Prospective Payment System Outpatient Hospital Service APC Group - Ambulatory Payment Classification Group

question

ASC

answer

Ambulatory Surgery Center Payment Method ASC Group

question

RBRVS

answer

Resource-Based Relative Value Scale Physician Offices and practice groups RBRVS - Relative Value Scale

question

Name examples of Fee-For-Service Reimbursement

answer

Self-Pay Traditional retrospective Payment Managed Care

question

Name examples of Episode of Care Reimbursement

answer

Capitated Payment Global Payment Prospective Payment

question

UCR

answer

Usual Customary, and Reasonable

question

CPR

answer

Customary, Prevailing, and Reasonable

question

Define Capitated Payment/Capitation:

answer

A method of payment for health services in which the 3rd Party Payer reimburses providers a FIXED, per capita (per head/per person) amount. A common phrase is PMPM - per member per month. Capitation is characteristic of HMOs.

question

HCPCS

answer

Healthcare Common Procedure Coding System a two-tiered system of procedural codes used primarily for ambulatory care and physician services.

question

CPT

answer

Current Procedural Terminology (CPT-HSPCS LEvel I) CPT reports diagnostic and surgical services and procedures. Created and Published by the AMA. Category I, II and III

question

CPT Category I

answer

CPT Category 1 Code that represents a procedure or service that is consistent with contemporary medical practice and is performed by many physicians in clinical practice in multiple locations. Category I is 6 Sections: Evaluation and Management Anesthesia Surgery Radiology Pathology and Laboratory Medicine

question

CPT Category II

answer

Category II codes represent services and/or test results that contribute to positive health outcomes and quality patient care. This category of codes is a set of optional tracking codes for performance measurement. Use of Category II codes is OPTIONAL and they may NOT be used as substitutes for Category I codes. Category II codes are represented by a 5-digit alphanumeric code with the alpha character F in the last position.

question

CPT Category III

answer

Represent emerging technologies. 5-digit alphanumeric code ending with T.

question

CPT Modifiers

answer

CPT contain modifiers for use by physicians and other healthcare providers to give additional information needed to process a claim. Common reasons to use modifiers: 1) a service was increased or reduced, 2) only part of a service was performed, 3) a bilateral procedure was performed, 4) an unusual event occurred during a procedure or service. Modifiers also make note of LT-Left Side, RT-Right Side, E1-upper left eyelid, and F1-left hand, second digit

question

MDC

answer

Major Diagnostic Category - represents the body systems treated by medicine. (There are 25 MDCs). Examples: 1) diseases and disorders of the nervous system, 2) diseases and disorders of the eye, 3) infectious and parasitic diseases, 4) HIV, 5) endocrine & metabolic disorders, 6) pregnancy, childbirth, and the puerperium, etc...

question

CC

answer

Complication or Co-Morbidity (refinements of the MS-DRG system)

question

MCC

answer

Major Complication or Co-Morbidity (refinements of the MS-DRG system)

question

Medicare Part A

answer

Inpatient Hospital Insurance (includes: inpatient hospitalization, long term care hospitalization, skilled nursing, home health, and hospice care)

question

Medicare Part B

answer

Supplemental Medical Insurance - optional. Covers Physician Services, Medical Services, and Medical Supplies not covered by Medicare Part A. $99.00 per month.

question

Medicare Part C

answer

Medicare Advantage covers services excluded from Parts A and B. (includes: long-term nursing care, custodial care, dental, vision, routine exams, health and wellness education, acupuncture, hearing aids)

question

Medicare Part D

answer

Medicare drug benefit

question

Medigap

answer

Medicare beneficiaries who purchase private insurance to supplement their Part A and Part B

question

MCO

answer

Managed Care Organization (Disease management, primary care physician, high quality and affordable care, pre-auth, 2nd opinions, HMOs, EPOs, PPO)

question

Case Mix Index

answer

Case Mix Index is an average of the sum of the RWs (relative weights) of all patients treated during a specific time period. It is a single number that compares the overall complexity of the healthcare organization's patients with the complexity of the average of all hospitals. Typically, CMI is for a specific period and is derived from the sum of all diagnosis-related group (DRG) weights, divided by the number of Medicare patients.

question

DRG and RW

answer

DRG and RW (Relative Weight): Each DRG is assigned a RW (Relative Weight) that is intended to represent the resource intensity of the clinical group.

question

Steps to Assigning MS-DRG:

answer

Step 1: Pre-MDC Assignment Step 2: Major Diagnostic Category Determination (Principal Diagnosis) Step 3: Medical/Surgical Determination (determine if a procedure was performed) Step 4: Refinement (refinement questions to isolate the correct MS-DRG assignment - Is an MCC present, Is a CC present, what is the patient's sex, birth weight for neonates, patient's discharge disposition (dead, alive)

question

What is an outlier?

answer

Outliers are cases in prosprctive payment systems with unusually long lengths of stay (day outlier) or exceptionally high costs (cost outlier).

question

What is Medicare's 4-step methodology for calculating total MS-DRG payment?

answer

MACs (Medicare Administrative Contractors) use grouper and pricer software to calculate the MS-DRG and payment for each hospital encounter. STEPS: 1) the hosptial submits an electronic claim to their designated MAC. MAC performs a claim audit to ensure the claim is a clean claim. Once the claim is clean, the grouper software assigns an MS-DRG based on the demographic and coded data submitted; 2) A base payment rate is established for each Medicare-particpating hospital for each fiscal year (FY). The base payment is a per encounter rate that is based on historic claims data. The RW for MS-DRG 293 (Congestive Heart Failure) is 0.6756. The fully adjusted hospital specific base rate is $7325.00. The RW is multiplied by the hospital base rate to calculate the initial payment rate. ($7235 x 0.6756 = $4948.77); 3) Add-on are added for high cost outliers; 4) Add-on for new medical service or new technology are added at 50%.

question

What entity is responsible for updating the MS-DRG?

answer

CMS

question

What are RBRVSs?

answer

Resource-Based Relative Value Scale: for physician services, the ambulance fee schedule, and the hospital outpatient payment system. A relative value scale permits comparisons of the resources needed or appropriate prices for various units of service. It takes into account labor, skill, supplies, equipment, space, and other costs for each service or procedure.

question

What is included in ASC payment system?

answer

ASC- Ambulatory Surgical Center payment system? End-stage renal disease payment system, safety net provider payments, and hospice services payment system

question

What are the 3 components of the structure of payment to physicians?

answer

1) RVU (relative value unit-to measure resource) Each RVU has 3 elements (physician work (WORK), physician practice expense (PE), malpractice (MP). Each is adjusted to the local costs. WORK has aspects of intensity (mental, technical, physical effort, stress). PE costs are overhead. 2) geographic adjustment (GPCI-geographic practice cost indexes) 3) CF (conversion factor) which is a constant that applies to the entire RVU.

question

What is the payment to nonparticipating physicians (Medicare)?

answer

Medicare payments to nonparticipating physicians are reduced by 5%. They receive 95% of what participating physicians receive.

question

How is Anesthesia billed?

answer

Base Units and Time Units with CF (conversion factor) for locality.

question

Define OPPS

answer

OPPS - Hospital Outpatient Prospective Payment System: OPPS requires hospitals/facilities to use Levels 1 and II HCPCS codes. Packaging and bundling concepts are used in OPPS.

question

What is the "two-times rule" under APC (Ambulatory Payment Classification)?

answer

The "two-times rule" states that median cost of the most expensive item or service within a group cannot be more than 2 times greater than the median cost of the least expensive item or service within the same group.

question

What are the 4 reimbursement methods used by OPPS?

answer

1) APC, 2) Fee Schedule, 3) Reasonable Cost, and 4) Average sale of price of Drugs

question

What is ASC?

answer

Ambulatory Surgical Center

question

What is ESRD PPS?

answer

End Stage Renal Disease Prospective Payment System

question

What are safety net providers?

answer

AKA "Essential Community Providers" and "Providers of Last Resort". These are providers that deliver a significant level of healthcare services either by legal mandate or they adopted an open door policy and a substantal share of their patient mix is uninsured. (rural health clinics, public health department clinics, ER department of public hospitals)

question

What are the 4 setting of PAC (Post Acute Care)?

answer

1) SNF- skilled nursing facility, 2) LTCH-long term care hospital, 3) IRF-inpatient rehabilitation facility, 4) HHA-home health agency. EACH PAC has a PPS.

question

What is an RUG?

answer

Resource Utilization Group - Classification for resources used in a nursing home. Patients are classified into 1 of 44 possible RUGs based on data.

question

What is OASIS?

answer

Outcome Assessment Information Set: an instrument by which data is collected in a Home Health agency. OASIS data includes: sociodemographic, environment, support status, health status, functional status, and behavioral status. OASIS uses ICD-9-CM codes to represent the health status of patients.

question

Provide a description of RCM (revenue cycle management):

answer

Preclaims Submission Activities: patient's responsbile parties, copayments, deductibles Claims Processing Activities: capture of billable services - charge capture; order entry; CDM-charge descrption master>>hard coding. Auditing and Submitting the claim Accounts Receivable: who receives what payments Claims Reconciliation and Collections: reviews, collections, write-offs

question

What is the AHA Coding Clinic for HSPCS?

answer

Official coding guidance for Healthcare Common Procedure Coding System (HCPCS) Level II procedure, service and supply codes.

question

What is the AHA Coding Clinic for ICD-9-CM?

answer

A publication issued quarterly by the AHA and approved by CMS to give coding advice and direction for ICD-9-CM.

question

What are the AHIMA Standard of Ethical Coding?

answer

Standard developed by the Council on Coding and Classification by the AHIMA (American Health Information Management Association) to give health informtion coding professionals ethical guidelines for performing their coding and grouping tasks.

question

Name some ancillary services:

answer

radiology, laboratory, or physical therapy

question

What is benchmarking?

answer

Benchmarking is the process of comparing performance with a pre-established standard or performance of another facility or group.

question

What is block grant?

answer

A fixed amount of money given or allocated for a specific purpose, such as a transfer of governmental funds to cover health services.

question

What is bundling?

answer

The combination of supply and pharmaceutical costs or medical visits with associated procedures or services for 1 lump sum payment.

question

What is a carve-out?

answer

Contracts that separate out services or populations of patients or clients to decrease risk and costs.

question

Define Charge Capture:

answer

The process of collecting all services, procedures, and supplies provided during patient care.

question

Describe CDM-Charge description master:

answer

This is the database used by healthcare facilities to house the price list for all services provided to patients.

question

Define Clean Claim:

answer

Request for payment that contains only accurate information.

question

Describe "grouper":

answer

Computer program that uses specific data elements to assign patients, clients, or residents to groups, categories, or classes.

question

Describe "hard coding":

answer

The use of the charge description master to code repetitive services.

question

Describe unbundling:

answer

The fradulent process in which individual component codes are submitted for reimbusement rather than one comprehensive code.

question

Describe upcoding:

answer

The fradulent process of submiting codes for reimbursement that indicates more complex or higher-paying services than those the patient actually received.

question

Which of the following is NOT a component of most patient records? A) Patient identification, B) Clinical history, C) Financial Information, or D) Test results

answer

C-Financial Information

question

Identify where the following information would be found in the acute-care record: Following induction of an adequate general anesthesia, and with the patient supine on the padded table, the left upper extremity was prepped and draped in the standard fashion. A) in the anesthesia report, B) in the physician progess notes, C) in the operative report, or D) in the recovery room record

answer

C- in the operative report

question

Identify where the following information would be found in the acute-care record: "CBC: WBC: 12.0, RBC 4.65, HGB 14.8, HCT 43.3, MCV 93." A) in the medical lab report, B) in the pathology report, C) in the physical examination, D) in the physicians orders

answer

A-in the medical laboratory report

question

Identify where the following information would be found in the acute-care record: "PA and Lateral Chest: The lungs are clear. The heart and mediastinum are normal in size and configuration. There are minor degenerative changes of the lower thoracic spine." A) in the medical lab report, B) in the physical examination, C) in the physician progress notes, or D) in the radiology report

answer

D-the radiology report

question

The following is documented in an acute-care record: "HEENT: Reveals the tympanic membrances, nares, and pharynx to be clear. No obvious head trauma. CHEST: Good bilateral chest counds." In which of the following would this documentation appear? A) History, B) pathology report, C) physical examination, or D) Operation report

answer

C-physical examination

question

The following is documented in an acute care record: Microscopic: Sections are of squamous mucosa with no atypia." In which document would this appear? A) history, B) pathology report, C) physical examination, or D) operation report

answer

B-pathology report

question

The following is documented in the acute care record: "Admit to 3C. Diet: NPO. Meds: Compazine 10mg IV Q 6 PRN." In which document would this appear: A) admission order, B) history, C) physical exam, or D) progress notes

answer

A-admission order

question

The following is doucmented in an acure-care record: "38 weeks gestation, Apgars 8/9, 6#9.8oz, good cry." In which document would this appear? A) admission note, B) clinical laboratory, C) newborn record, D) physician order

answer

C-newborn record

question

The following is documented in an acute-care record: "Atrial fibrillation with rapid ventricular response, left axis deivation, left bundle branch block." In which document would this appear? A) Admission order, B) Clinical laboratory report, C) ECG report, or D) Radiology Report

answer

C-ECG report

question

The following is documented in an acute-care record:"I was asked to evaluate this Level I trauma patient with an open left humeral epicondylar fracture. Recommendations: proceed with urgent surgery for debridement, irrigation, and treatment of open fracture." In which document would this appear: A) Admission note, B) Consultation Report, C) Discharge Summary, or D) Nursing Progress Notes

answer

B-Consultation Report

question

The following is documented in an acute-care record: "Spoke to the attending re: my assessment. Provided adoption and counseling information. Spoke to CPS re: referral. Case manager to meet with patient and family. In which document would this appear? A) Admission note, B) Nursing Note, C) Physician Progress Note, or D) Social work note

answer

D-Social work note

question

Mary Smith, RHIA, has been charged with the responsibility of designing a data colelction form to be used on admission of a patient to the acute-care hospital in which she works. The first resource she sould use is: A) UHDDS, B) UACDS, C) MDS, or D) ORYX

answer

A-UHDDS (Uniform Hospital Discharge Data Set) - In 1974 the federal government adopted UHDDS as the standard for collecting data for Medicare and Medicaid. The others are: UACDS: Uniform Ambulatory Care Data Set MDS: Minimum Data Set ORYX: performance measurement for healthcare organizations

question

Both HEDIS and the Joint Commission's ORYX programs are designed to collect data to be used for: A) performance-improvement programs, B) billing and claims data processing, C) developing hospital discharge abstracting systems, or D) developing individual care plans for residents

answer

A-performance improvement programs HEDIS-Healthcare Effectiveness Data and Information Set (collects data to measure physician performance) ORYX-collects quality data for hospitals and long term care organizations

question

A notation for a diabetic patient in a physician progress note reads: "Occasionally gets hungry. No insulin reactions. Says she is following her diabetic diet." In which part of the POMR progress note would this notation be written? A) subjective, B) Objective, C) Assessment, or D) Plan

answer

A-subjective: subjective information includes symptoms and actions reported by the patient and not observed or measured by the healthcare provider.

question

A notation for a diabetic patient in a physican progress note reads: "FBS 110mg%, urine sugar, no acetone". In which part of the POMR progress note would this notation be written? A) subjective, B) objective, C) assessment, or D) plan

answer

B-objective: objective information is measured or observed by the healthcare provider

question

A notation for a hypertensive patient in a physican ambulatory care progess note reads: "Continue with Diuril, 500mgs once daily. Return in 2 weeks." In which part of the POMR progress note would this notation be written? A) subjective, B) objective, C) assessment, or D) plan

answer

D-plan: the plan lays out a road map for the patient

question

A notation for a hypertensive patient in a physician ambulatory care progress note reads: "Blood pressure adequately controlled." In which part of the POMR progress note would this notation be written? A) subjective, B) objective, C) assessment, or D) plan

answer

C-assessment: Professional conclusions reached from evaluation of the subjective or objective information make up the assessment.

question

Reviewing the health record for missing signatures, missin medical reports, and ensuring that all document belong in the health record is an example of what type of review? A) Quantitative, B) Qualitative, C) Statistical, or D) Outcomes

answer

A-Quantitative Analysis

question

Dr. Jones entered a progress note in a patient's health record 24 hours after he visited the patient. Which quality element is missin from the progress notes? A) Data Completeness, B) Data relevancy, C) Data currency, or D) Data precision

answer

C-Data Currency: timeliness - should be recorded near or at the time of the event

question

The admitting data of Mrs. White's health record indicated that her birthdate was March 21, 1948. On the discharge summary, her birthdate was recorded as July 21, 1948. Which quality element is missing from Mrs. White's health record? A) Data completeness, B) Data consistency, C) Data accessibility, or D) Data comprehensiveness

answer

B-Data consistency

question

Which of the following is an example of clinical data? A) Admitting diagnosis, B) Date and time of admission, C) Insurance information, or D) Health record number

answer

A-Admitting Diagnosis: clinical data document the patient's medical condition, diagnosis, and procedures performed as well as the healthcare treatment provided.

question

Documentation of aides who assist a patient with activities of daily living, bathing, laundry, and cleaning would be found in what type of specialty record? A) Home Health, B) Behavioral Health, C) End Stage renal disease, or D) Rehabilitative Care

answer

A-Home health

question

Which of the following materials is NOT documented in and Emergency Care Record? A) Patient's instruction as discharge, B) time and means of the patient's arrival, C) patient's complete medical history, or D) emergency care administered before arrival at the facility

answer

C-Patient's complete medical history. The emergency care record includes a pertinent history of the illness or injury and physical findings.

question

What is the defining characteristic of an integrated health record format? A) each setion of the record is maintained by the patient care department that provided the care, B) integrated health records are intended to be used in ambulatory settings, C) Integrated health records include both patper and computer printouts, or D) Integrated health record components are arranged in strict chronological order

answer

D-integrated health record components are arranged in strict chronological order

question

Which of the following represents documentation of the patient's current and past health status? A) physical examination, B) medical history, C) physicians orders, or D) patient consent

answer

B-medical history

question

Which of the following contains the physician's findings based on an examination of the patient? A) physical examination, B) discharge summary, C) medical history, or D) patient instructions

answer

A-physical examination report represents the attending physician's assessment of the patient's current health status

question

What is the function of the consulation report?

answer

The consulation report documents opinions about the patient's condition from the perspective of a physician not previously involved in that patient's case

question

What is the function of the physician's orders?

answer

To document the physician's instructions to other parties involved in providing care to the patient

question

Which type of patient care record includes documentation of a family bereavement period?

answer

A hospice record.

question

In a joint effort of the DHHS (Department of Health and Human Services), OIG (Office of Inspector General), CMS (Centers for Medicare and Medicaid Services, and AOA (Administration on Aging, which program was released in 1995 to target fraud and abuse among healthcare providers? A) Operation Restore Trust, B) Medicare Integrity Program, C) Tax Equity and Fiscal Responsibilty Act (TERFA), and D) Medicare and Medicaid Patient and Program Protection Act

answer

A-Operation Restore Trust

question

All of the following should be part of the core areas of a coding compliance plan EXCEPT: A) physician query process, B) Correct us of encoder software, C) Coding diagnoses supported by medical record documentation, and D) Tracking lenght of stay

answer

D-tracking length of stay

question

Common forms of fraud and abuse include all of the following except: A) Upcoding, B) Unbundling or "exlploding" charges, C) Refiling Claims after denials, or D) Billing for services not furnished to patients

answer

C) Refiling claims after denial is not possible becuase denied claims must be appealed and is not a factor in controlling fraud and abuse

question

What is the primary use of the case-mix index? A) benchmark of ER room levels, B) Defines how a hosptial compares to peers and whether the facility is at risk, C) Audit of APCS and the comparison to same-size hospitals, or D) a tool for the coding manager to compare coder productivity

answer

B-peer comparison or benchmarking helps a manager to know how his or her team has performed compared to peers.This includes whether the case-mix index level puts the facility at risk.

question

What resource can managers use to discover current, hot areas of compliance? A) policies and procedures, B) National Coverage Determination, C) Official Coding Guidelines, or D) OIG Workplan

answer

D-OIG Workplan is published every year to provide insight into the directions the OIG is taking, as well as highlights of hot areas of compliance. Coding managers should review this document every year.

question

What is the program that was unveiled in 1998 by the OIG that encourages healthcare providers to report fradulent conduct affecting Medicare, Medicaid and other federal healthcare programs? A) WHO-World Health Organization, B) Voluntary Disclosure Program, C) Compliance Disclosure Program, or D) Fraud and Abuse Program

answer

B-Voluntary Disclosure Program

question

What is the process used to transform text into an unintelligible string of characters that can be transmitted via communicaiton media with a high degree of security and then decrypted when it reaches a secure destination?

answer

Encryption

question

Using uniform terminology is a way to improve:

answer

data reliability-a method at looking at data consistency, sometimes referred to as data reliability. Reliability is frequently checked by having more than one person abstract data for the same case and compare the results for any discrepancies.

question

What law mandated the development of standards for electronic medical records? A) Medicare and Medicaid legislation of 1965, B) Prospective Payment Act of 1983, C) HIPAA of 1996, or D) Balanced Budget Act of 1997

answer

HIPAA

question

Messaging standards for electronic data interchange in healthcare have been developed by: A) HL7, B) IEE, C) The Joint Commission, or D) CMS

answer

HL7-HL7 Electronic Health Record System (EHR-S) Functional Mode.

question

What is the incentive to improve the quality of clinicial outcomes using the electronic health record that could result in additional reimbursement or eligibilty for grants or other subsidies to support further HIT efforts? A) Pay for performance and quality, B) Patient referrals, C) Payer of last resort, D) Performance evaluations

answer

A-Pay for performance and quality

question

A threat to data security is: A) encryption, B) malware, C) audit trail, or D) data quality

answer

B-malware

question

Data Security refers to: A) guaranteeing privacy, B) controlling access, C) using uniformed terminology, or D) transparency

answer

B-controlling access

question

A record of all transcations in the computer system that is maintained and reviewed for unauthorized access is called: A) Audit Trail, B) security breach, C) unauthorized access, or D) privacy trail

answer

A-Audit Trail

question

Which of the following is a true statement about data stewardship? A) HIM Professionals are not qualified to address data stewardship, B) Data stewardship addresses the needs of the healthcare organization but not the patient, C) HIM professionals have worked with many data stewardship issues for years, or D) Data stewardship does not include privacy issues

answer

C-HIM professionals have worked with many data stewardship issues for years

question

A coding audit shows that an inpatient coder is using multiple codes that describe the individual components of a procedure rather than using a single code that describes all the steps of the procedure performed. Which of the following should be done in this case? A) Require all coders to use this practice, B) Report the practice to the OIG, C) Counsel the coder and stop the practice immediately, or D) Put the coder or an unpaid leave of absence

answer

C-counsel the coder and stop the practice immediately-perform training

question

A HIT (Health Information Technician) is hired as the chief compliance officer for a large group practice. In evaluating the current program, the HIT learns that there are written standards of conduct and policies and porcedures that address specific areas of potential fraud as well as audits in place to monitor compliance. Which of the following should the compliance officer also ensure are in place? A) Compliance program education and training programs for all employees in the organization, B) Establishment of a hotline to receive complaints and adoption of procedures to protect whistleblowers from retaliation, C) Adopt procedures to adequately identify individuals who make complaints so that appropriate follow-up can be conducted, or D) Establish a corporate compliance committee who report directly to the CFO

answer

B-Establishment of a hotline to receive complaints and adoption of procedures to protect whistleblowers from retaliation

question

In developing a coding compliance program, which of the following would not be ordinarily included as participants in coding compliance education? A) Current coding personnel, B) Medical Staff, C) Newly hired coding personnel, or D) Nursing staff

answer

D-Nursing Staff

question

Which of the following issues compliance program guidance? A) AHIMA, B) CMS, C) Federal Register, or D) HHS Office of Inspector General (OIG)

answer

D-HHS Office of Inspector General (OIG)

question

The practice of assigning a diagnosis or procedure code sprcifically for the purpose of obtaining a higher level of payment is called: A) billing, B) Unbundling, C) Upcoding, or D) Unnecessary Service

answer

C-Upcoding

question

This person designs, implements, and maintains a program that ensures conformity to all types of regulatory and voluntary accreditation requirements governing the provision of healthcare products or services: A) General Counsel, B) Health Information Director, C) Privacy Officer, or D) Compliance Officer

answer

D-Compliance Officer

question

The HIM department is planning to scan nonelectronic medical record documentation. The project includes the scanning of health record documentation such as history and physicals, physician orders, operative reports, and nursing notes. Which of the following methods of scanning would be best to help HIM professionals monitor the completeness of health records during a patient's hospitalization? A) Ad hoc, B) Concurrent, C) Retrospective, D) Post discharge

answer

B-Concurrent review occurs on a continuing basis during a patient's stay

question

Which of the following laws created the Healthcare Integrity and Protection Data Bank? A) HIPAA, B) American Recovery and Reinvestment Act, C) Consolidate Omnibus Budget Reconciliation Act, or D) Healthcare Quality Improvement Act

answer

A-HIPAA

question

HIT Professionals must have knowledge of: A) Security issues with regard to the management of healthcare reform, B) Laws affecting the physician malpractice insurance, C) AMA's professional ethical principles of practice regarding physician assistants, or D) Laws affecting the use of disclosure of health information

answer

D-Laws affecting the use of disclosure of health information

question

The HIPAA Privacy Rule: A) applies to certain states, B) applies only to healthcare providers operated by the federal government, C) applies nationally to healthcare providers, or D) serves to limt access to an individual's own health information

answer

C-applies nationally to healthcare providers

question

An accounting of disclosures must include disclosures: A) for use in law enforcement requests, B) to any patient family member who makes a request, C) to any individual who requested the information, or D) made for public health reporting purposes

answer

D-made for public health reporting purposes

question

Notices of privacy practices must be available at the site where the individual is treated and: A) must be posted next to the entrance, B) must be posted in a prominent place where is it reasonable to expect that patients will read them, C) may be posted anywhere at the site, or D) do not have to posted at the site

answer

B-must be posted in a prominent place where is it reasonable to expect that patients will read them

question

Calling out patient names in a physician's office is: A) an incidental disclosure, B) not subject to the "minimum necessary" requirement, C) A disclosure for payment purposes, or D) a HIPAA violation

answer

A-an incidental disclosure occurs as part of the permitted use of disclosure.

question

Which of the following is NOT an element of data quality? A) Accessibility, B) Data Backup, C) Precision, or D) Relevancy

answer

B-Data Backup/Data Quality includes the following characteristics: accuracy, accessibility, comprehensiveness, consistency, currency, definition, granularity, precision, relevancy, and timeliness

question

The protection measures and tools for safeguarding information and information systems is a definition of: A) Confidentiality, B) Data Security, C) Information privacy or D) Informational access control

answer

B-Data Security

question

Computer software programs that assist in the assignment of codes used with diagnostic and procedureal classifications are called: A) natual language processing systems, B) montoring/audit programs, C) encoders, D) concept, description, and relationship tables

answer

C-Encoders

question

A special webpage that offers secure access to data is called a: A) access control, B) Home Page, C) Intranet, or D) Portal

answer

D-Portal: a portal is a special application to provide secure remote access to specific applications

question

One form of _________________ uses software to aid the physician in selecting the correct code with processes such as drop-down boxes or the use of touch-screen terminals. A) Integrated workflow processes, B) Computer-Assisted Coding, C) Electronic Document management syste, or D) Speech recognition system

answer

B-Computer Assisted Coding (CAC)

question

One form of __________________ computer-assisted coding (CAC) may use, which means that digital text from online documents stored in the information system is read directly by the software, which then suggests codes to match the documentation. A) Encoded Vocabulary, B) natural-language processing, C) Data exchange standards, or D) structured reports

answer

B-Natural language processing (NLP) is an artifical intelligence software that reads digital text from online documents and suggests codes to match the documents

question

Which of the following tasks may NOT be performed in an electronic health record system? A) Document Imaging, B) Analysis, C) Assembly, or D) Indexing

answer

C-Assembly In an EHR, reports are indexed, similar to filing in the paper record, and ensure that the documents are placed in the correct location with the correct record. Record analysis and completion is done via computer. Document imaging converts paper documents into digitized electronic versions.

question

Electronic systems used by nurses and physicians to doucment assessments and findings are called: A) Computerized provider order entry, B) electronic document management systems, C) electronic medication administration records, or D) electronic patient care charting

answer

D-Electronic Patient Care Charting

question

Data definition refers to: A) Meaning of Data, B) Completeness of Data, C) Consistency of Data, or D) Detail of Data

answer

A-Meaning of Data: Data Definition means that the data and information documented in the health record are defined; users of the data must understand what the data means and represents

question

An encoder that is built using system techniques such as reul-based systems is a: A) encoder interface, B) logic based encoder, C) automated code book encoder, or D) grouper

answer

B-Logic Based Encoder

question

Good encoding software should include ______________ to ensure quality: A) edit checks, B) voice recognition, C) reimbursement techonology, or D) passwords

answer

A-edit checks

question

The key data element for linking data about an individual who is seen in a variety of care setting is the: A) facility medical record number, B) facility identification number, C) unique patient identifier, or D) patient date of birth

answer

C-Unique patient identifer which a unique number assigned by a healtcare provider to a patient that distinguishes the patient's medical record from all others

question

Which of the following make data entry easier by may harm data quality? A) use of templates, B) copy and paste, C) drop-down boxes, or D) structured data

answer

B-copy and paste

question

A transition technology used by many hospitals to increase access to medical record content is: A) EHR-Electronic Health Record, B) EDMS-Electronic Document Mangagement System, C) ESA-Electronic Signature Authentication, or D) PACS (Picture Archving and Communication System

answer

B-EDMS-Electronic Document Management System For hospitals that do not have all EHR components, the result is a hybrid record that is part electronic and part paper. Some hospitals overcome hybrid record issues by scanning all paper documents into an EDMS, thereby making everything available online.

question

This system will require the author to sign onto the system using a user ID and Password to complete the entries made: A) Digitial Dictation, B) Electronic Signature Authentication, C) Single Sign on Technology, or D) Clinical Data Respository

answer

B-Electronic Signature Authentication system requires the AUTHOR to sign onto the system using a USER ID and Password, review the document to be signed, and indicate approval.

question

Coders will assign codes that have been selected into a computer program called a ______________ to assign the patient's case to the correct group based on ICD-9-CM and/or CPT/HCPCS codes. A) Encoder, B) Computer-Assisted Coding, C) Natural-Language Processor, or D) Grouper

answer

D-Grouper In both the MS-DRG and APC groupings, coders enter the codes that have been selected in a computer program called a grouper. The grouper then assigns the patient' case to the correct group based on the ICD-9-CM and/or CPT/HCPCS codes.

question

What is the legal term used to define the protection of health information in a patient-provider relationship? A) Access, B) Confidentiality, C) Privacy, or D) Security

answer

B-Confidentiality: is a legal ethical concept that establishes the healthcare provider's responsibility for protecting the health records and other personal and private information from unauthorized use or disclosure.

question

The Uniform Health Care Decisions Act ranks the next of kin in the following order for medical decision-making purposes: A) Adult sibling; adult child; spouse; parent, B) Parent; spouse; adult child; adult sibling, C) Spouse; parent; adult sibling; adult child, or D) Spouse; adult child; parent; adult sibling

answer

D-Spouse, Adult Child, Parent, Adult Sibling: UHCDA suggest this order of decision making for an individual's next of kin. If no one is available who is so related to the individual, authority may be granted to "an adult who exhibited special care and concern for the individual"

question

Which of the following is a direct command that requires an individual or a representative of an organization to appear in court or to present an object to the court? A) judicial decision, B) subpoena, C) credential, or D) regulation

answer

B-subpoena

question

Exceptions to the consent requirement include: A) Medical Emergencies, B) Provider Discretion, C) Implied Consent, or D) Informed Consent

answer

A-Medical Emergencies: the law permits a presumption of consent during emergency situations, regardless of whether the patient is an adult or a minor

question

The term "minimum necessary" means that healthcare providers and other covered entities must limt use, access, and disclosure to the minimum necessary to: A) satify one's curiosity, B) accomplish the intended purpose, C) treat an individual, or D) perform research

answer

B-accomplish the intended purpose: The Privacy Rule introduced the standard of minimum necessary to limit the amount of PHI (Protected Health Information) used, disclosed, and requested. This mean that healthcare providers and other covered entities must limut uses, disclosures, and requests to only the amount needed to accomplish the intended purposes.

question

What is PHI?

answer

Protected Health Information

question

A well-informed patient will know that the HIPAA Privacy Rule requires that individuals be able to: A) Request restrictions on certain uses and disclosures of PHI, B) Remove their record from the facility, C) Deny provider changes to their PHI, or D) Delete portions of the record they think are incorrect

answer

A-Request restrictions on certain uses and disclosures: HIPAA provides patients with rights that allow them to have some control over their health information: right of access, right to request amendment of PHI, right to acounting of disclosures, right to request restrictions of PHI, right to request confidential communications, and right to complain of Privacy Rule violations

question

Written or Spoken permission to proceed with care is classified as: A) An Advance Directive, B) Formal Consent, C) Expressed Consent, or D) Implied Consent

answer

C-Expressed Consent (can be written or spoken)

question

The number that has bee proposed for use as a unique patient identification number but is controversial because of confidentiality and privacy concerns is:

answer

A-Social Security Number

question

Deidentified information: A) does identify an individual, B) Is information from which personal characteristics have been stripped, C) Can be later constituted or combined to re-identify an individual, or D) Pertains to a person that is identified within the information

answer

B-De-identified information is information from which personal characteristics have been stripped (doesn't identify the person)

question

Which of the following is NOT true of notices of privacy practices? A) they must be made available at the site where the individual is treated, B) they must be posted in a prominent place, C) they must contain content that may not be changed, or D) they must be prominently posted on the covered entity's website when the entity has one

answer

C-The Notice Of Privacy includes a statment that reserves the right to change the terms of its notice and make the new provisions effective for all PHI that is maintains.

question

With regard to training in PHI policies and procedures, the following statement is TRUE: A) every member of the covered entity's workforce must be trained, B) only individuals employed by the covered entity must be trained, C) training only need to occur when there are material changes to the policies and procedures, or D) documentation of training is not required

answer

A-Every member of the covered entity's workforce must be trained.

question

ICD-9-CM are the __________ the patient saw the provider.

answer

"why" - The ICD-9-CM code(s) placed onto a healtcare claim specifically describe the reason(s) the individual has come to see the health care provider on a given day. As a coder, you are only concerned with the diagnosis as determined by the health care provider. The patient's chief complaint is usually a key element in properly coding this explanation.

question

Is payment for determined by diagnosis or procedure?

answer

Procedure(s) performed. Medical necessity is tied to the procedure.

question

Are Volume 3 of ICD-9-CM typically for hospital or physician procedures?

answer

Hospital

question

Memory Tip: V in VCode stands for _________________

answer

Memory Tip - Prevention: V codes cover screenings, such as mammograms or colonoscopy; preventative medicinces such as vaccines, fertility testing and treatments; prenatal checkups; and well-baby exams. A V Code can be listed as a principal or first-listed code.

question

Memory Tip: C in ECode stands for ___________________

answer

Memory Tip - External Cause: E codes explain HOW an enjury or poisoning happened, and/or WHERE it happened. E Codes are important because the event or element that caused the inhury may require a different insurance company to pay. (i.e. - work/worker's comp, auto/auto insurance, slip at home/homeowner's insurance). In some circumstances you need 2 E codes to tell the whole story - the how and where. An E COde can NEVER be a principal or first-listed code.

question

What is an underlying condition?

answer

One disease that affects or encourages another condition. (Example: diabetes, hypertension). Foot ulcer due to diabetes - Code Foot ulcer first and then diabetes.

question

What does CC stand for in the IDC-9-CM book?

answer

complication/comorbidity - the CC is there to remind you to code the underlying case.....i.e. diabetes with foot ulcer

question

What does MC stand for in the ICD-9-CM book?

answer

MC means that this diagnosis code is a major complication of another diagnosis.

question

For OutPatient coding: the coder should not code those conditions described as:

answer

probable, suspected, rule out, or working - this rule changes for inpatient treatments

question

What do SLANTED brackets represent: [ ]

answer

these surround additional codes/secondary codes that MUST be included with the initial code.

question

Hypertension Table; Malignant, Benign, Unspecified

answer

Malignant 5% of all patients (high blood pressure plus swelling of the optic nerve - typically associated with organ damage, such as heart or kidney failure); Benign - 95% of all cases - BUT if record is not specific - code as Unspecified

question

Neoplasm Primary

answer

Primary indicates the anatomical site where the neoplasm originated.

question

Neoplams Secondary

answer

Identifies an anatomical site to which the malignant neoplams has spread or metastasized

question

Neoplams Ca in Site

answer

Indicates the tumor has undergone malignant changes but is still limted to the originating site and has not spread.

question

Poisoning

answer

Poisoning indicates that the patient's body reacted negatively to a drug or chemical - this is the first code you will use to identify the cause of the poisoning

question

E Code Accident

answer

This E Code will be added to the poisoning code to indicate that the adverse reaction was caused by an accidental overdose, an accidental taking of the wrong substance, or an accident that happened during the use of drugs and chemical substances. UNINTENTIONAL ingestion or exposure.

question

E Code Therapeutic Use

answer

This E Code is used when the RIGHT drug is taken in the RIGHT dose by the RIGHT person, but an UNEXPECTED reaction occurred.

question

E Code Suicide attempt

answer

This code indicates that the overdose or incorrect substance was taken with the full intent of causing one's own death.

question

E Code Assault

answer

This code specifies taht one person casued the poisoning on purpose to inflict illness, injury, or death upon another person. This code implies murder.

question

E Code Undetermined`

answer

This code is to be used only when the record does not state what caused the poisoning.

question

Define POA and when are POA indicators required?

answer

POA is defined as present at the time the order for inpatient admission occurs - conditions that deveopl during an outpatient encounter, including ER, observation, or outpatient surgery, are considered POA. The POA Indicator is required for all claims involving Medicare inpatient admission to general IPPS acute care hospitals or other facilites.

question

When are signs and symptoms codes reported?

answer

Codes that describe symptoms and signs are reported when a related definitive diagnosis has not been established (or confirmed) by the provider. ICD-9-CM (Symptoms, Signs and Ill-Defined Conditions 780.0-799.9. **some others can be found in other chapters - i.e. 536.8 stomach pain found in chapter 9, diseases of the digestive system.

question

Explain what is done with signs and symptoms that an integral part of a disease process?

answer

Conditions that are an integral part of a disease process (signs and symptoms) should NOT be assigned as additional codes because they are included in the disease process. Example: Patient in ER complaint of shortness of breath. X-Ray reveals pneumonia. Assign 486 for pnemonia, but DO NOT assigne a code for shortness of breath because it is a symptom of pnemonia.

question

Explain what is done with signs and symptoms that are NOT an integral part of a disease process?

answer

Conditions that ARE NOT integral should BE coded when present. Example: Patient is seen for follow-up of her controlled hypertension. During encounter she describes insomnia. Dr. prescribes Aluma. Assign 401.9 to the Hypertension, and 780.52 to the insomnia because it is NOT a symptom of hypertension and it was medically managed during the visit.

question

When are multiple codes required?

answer

The etiology/manifestation coding convention requires that 2 codes be reported to completely describe a single condition that affects multiple body systems. Multiple codes may also be needed to report late effects, complications, and obstetrical cases to more fully describe the patient's condition. Example: amyloid neuritis - 277.39 and 357.4

question

"Use additional Code"

answer

Use additional code notes are found in the tabular list. Example: Infections in Chapter 1 may be required to identify the bacterail organism causing the infection. UTI due to e Coli - Report: 599.0 and 041.4

question

Code First - Underlying condition

answer

When a "code first" note is present and an underlying condition is documented in the patient record, the underlying condition is reported first. Example: Dr. documents rheumatic pneumonia - upon review in ICD-9-CM index and tabular - assign codes 390 and 517.1 for the condition

question

Code if applicable any causal condition first

answer

indicate that this code may be assigned as a 1st listed diagnosis when the causal condition is unknown or not applicable. If the causal condition IS known, then the it should be reported as the 1st listed diagnosis. Example: Urinary Incontinence and Cogential Ureterocele: Code 753.23 and 788.30

question

How to code Acute and Chronic Conditions:

answer

Example: Acute Gastritis and Chronic Gastritis are diagnosed. Assign 535.00 and 535.10 in that order. Sequence acute or subacute first.

question

What is a combination code?

answer

A combination code is a single code that is used to classify. A) 2 diagnoses or procedures, B) a diagnosis with an associated 2nday process (manifestation), or C) a diagnosis with an associated complication. Example: 574.00 is a combination code: acute cholecystitis and cholelithiasis - 574.0 includes both conditions.

question

What is a late effect?

answer

A late effect is the residual condition (long-term condition) that develops after the acute phase of an illness or injury has ended. There is NO TIME LIMIT on when a late effect can be reported.

question

Example of a late effect:

answer

Can be apparent early - i.e. hemiparesis due to CVA, painful scar following a sever burn. OR it may occur months or years later: traumatic arthritis elbow due to prior fracture. The Residual Condition or Nature of the Late Effect is reported FIRST and The Late Effect is reported SECOND. Example:

question

When is the code for an acute phase of an illness or injury that led to the late effect reported?

answer

Never - because the treatment for the acute phase has ended.

question

Tabular List of Procedures in ICD-9-CM (INPATIENT SETTINGS):

answer

The tablular list of procedures is based on anatomy rather than surgical specialty and it contains numeric codes only. Based on body systems except for 3 chapters - Chapter 00 - procedures and interventions NEC, Chapter 13 - Obstetrical Procedures, or Chapter 16 - Miscellaneous Diagnostic and Therapeutic Procedures.

question

Organisms

answer

Bacteria; Chlamydia; Fungi; Helminth (worm); Mycoplasmas; Protozoans; Rickettsias; Viruses

question

Supplemental V Code Classification Factors

answer

V01 - contact with or exposure to communicable disease V02 - carrier or suspected carriers of infectious diseases V03 - V06 - Need for prophylactic vaccination and inoculation against bacterial, viral and single and combination diseases V07 - Need for isolation V08 - asymptomatic HIV infection status V09 - infection with drug-resistant microorganisms

question

HIV Rules

answer

Code ONLY CONFIRMED Cases of HIV. When a patient is treated for an HIV-Related Condition, report code 042 first on the health insurance claim and assign diagnosis codes for all documented HIV-related conditions and opportunistic infectins (i.e. candidiasis, Kaposi's sarcoma).

question

Describe Septicemia:

answer

Septicmia generally refers to a systemic disease associated with the presence of pathological microorganisms ot toxins in the blood, which include bacteria, viruses, fungi.

question

SIRS

answer

Systemic inflammatory response syndrome (SIRS) generally refers to the system response to infectin, trauma/burns, or other insult (such as cancer) with symptoms including fever, tachycardia, tachypnea, and leukocytosis. Sepis generally refers to SIRS due to infection. Severe Sepsis generally refers to sepsis with associated acute organ dysfunction.

question

How do you code SIRS, Sepsis, and Severe Sepsis?

answer

Requires a minimum of 2 codes: 1) a code for the underlying cause (such as infection or trauma) and a code from subcategory 995.9 Systemic inflammaatory resonse syndrome (SIRS). The underlying cause is sequenced 1st, then the code from 995.9. [Sepsis and Severe Sepsis require a code for the systemic infection and either code 995.91-Sepsis, or 995.92-Severe Sepsis. If the causal organism is not documented code 038.9, Unspecified septicemia.

question

MRSA

answer

Methicillin-Resistant Staphylococcus aureus

question

Coding Neoplasms:

answer

1-read all notes in table that apply 2-never assign a code form the table 3-report only codes for current status of neoplasm 4-assign a neoplasm code if the tumor has been excised and patient is STILL undergoing radiation or chemo 5-assign a V-Code if the tumor is NO LONGER present OR patient is not receiving treatment only follow-up care 6-the classification documented on a pathology report ovverides the morpholoby classification entry in the Index to Diseases

question

STEMI and NSTEMI

answer

Non-ST elevation myocardial infarction is a less severe, partial block. A NSTEMI can evolve to a STEMI (large portion of heart damage)

question

Puerperium - Define

answer

the 6 weeks immediately following childbirth **Complications of Pregnancy, Childbirth, and the Puerperium are NEVER reported on the Baby's record.

question

Normal Delivery

answer

Code 650 is for a normal delivery, which required minimal or no assistance. An episotomy is permitted, but fetal manipulation is NOT (i.e. use of forceps). V27.0 Single Liveborn is the only outcome of delivery code appropriate for use with 650

question

Pregnancy V-Codes

answer

V22.0 - routine outpatient pre-natal no complications present V22.1 - supervision of normal first pregnancy V23 category - supervision of high risk pregnancy V27.0 - V27.9 - outcome of delivery should be included on every maternal record when a delivery has occurred. [do not use on newborn record]

question

Long Term Insulin Use

answer

V58.67 - long term (current) use of insulin.

question

Coding Pressure Ulcers:

answer

Two codes are needed to completely describe a pressure ulcer: a code from subcategory 707.0, Pressure Ulcer (site) and 707.2 Pressure Ulcer (stage)

question

Fractures

answer

Newly Diagnosed Fracture 733.1 and subcategories of this may be used while the patient is receiving active treatment for the fracture - surgical treatment, emergency department encounter, evaluation and treatment by a new physician. For Aftercare: V-Codes are used (cast changes or removal; removal of external or internal fixation deivce, medication adjustment, follow-up)

question

Perinatal Period

answer

The perinatal period is the interval of time occurring before, during, and up to 28 days following birth. Codes here are NEVER reported on the mother's record - only the infant record. V30-V39 are only coded once - the birth of an infant

question

When are codes for Signs, Symptoms, and Ill-Defined Conditions used?

answer

When there are no other, more specific diagnoses classifiable elsewhere. Codes from this chapter are use to report symptoms, signs, and ill-defined conditions that point with equal suspicion to 2 or more diagnoses or represent important problems in medcal care that may affect management of the patient. Example: patient admitted right lower quad abdominal pain; pelvic ultrasound negative - Assigne code 789.03 - Abdominal pain, right lower quadrant

question

Burns

answer

1st Degree - erythema 2nd Degree - blistering 3rd Degree - full thickness involvement Extent - percentage of body surface involved Agent - chemical, fire, sun - Assigned an E Code Highest Degree is coded first when more than one burn is present.

question

V Code Terms in the Alphabetic Index:

answer

Absence, Admission for, Aftercare, Attention to, Encounter for, Fitting of, History of, Long-term, Resistance, Status (post), Carrier of, checkup, counseling, dialysis, donot, exposure, newborn, outcome of delivery, removal, vaccination, routine

question

When are codes in slanted brackets listed?

answer

Codes in slanted brackets are always listed as secondary codes because the are manifestations (results) of other conditions.

question

CPT Appendix

answer

Appendix A - Detailed description of each CPT Modifier Appendix B - Annual CPT Coding changes (added, deleted, revised) Appendix C - Clinical examples for Evaluation and Management Appendix D - Add-on Codes (+ symbol) Appendix E - Codes exempt from Modifier -51 reporting rules

question

CPT Modifiers (listed)

answer

-24: Unrelated Evaluation & Management Service Same Dr -25: Significant Separate E&M Service -57: Decision for Surgery -22: Increased Procedural Service -52: Reduced Services -53: Discontinued Procedure -73: Discontinued Prior to Anesthesia -74: Discontinued After Anesthesia -54: Surgical Care Only -55 Postoperative Management -56: Preoperative Management -50: Bilateral -59: Distinct Procedural Service -62: Two Surgeons

question

Evaluation & Management

answer

E/M services provided in a Dr's office, hospital outpatient department, or another ambulatory care facility Observation Services: furnished in hospital outpatient setting-patient is an outpatient Hosptial Inpatient Services: E/M services provided to hosptial inpatients, including partial hospitalization services Consultations: a consultaiton is an exam of a patient by a provider for the purpose of advising the referring Dr in the E&M Emergency Dept Services Critical Care Services Nursing Facility Services Rest Home Assisted Living Prolonged Services Case Management Newborn Care Preventative Care

question

To comply with HIPAA, under usual circumstances, a covered entity, must act on a patient's request to review or copy his/her health information with _______ days.

answer

30 days

question

The HIPAA Privacy Rule requires that covered entities must limit use, access, and disclosure of PHI to only the amount needed to accomplish the intended purpose. What concept is this an example of? A) Minimum Necessary, B) Notice of Privacy Practices, C) Authorization, or D) Consent

answer

The Standard of Minimun Necessary

question

Which of the following statements is false? A) A notice of privacy practices must be written in plan language, B) Consent for use and disclosure of information must be obtained from every patient, C) An authorization does not have to be obtained for uses and disclosures for treatment, payment and operations, D) A notice of privacy must give an example of a use or disclosure for healthcare operations.

answer

B) Under the Privacy Rule, healthcare providers are not required to obtain patient consent to use or disclose personally identifiable information for treatment, payment or healthcare operations.

question

Which of the following statements is NOT true about a business associate agreement? A) It prohibits the business associate from using or disclosing PHI for any purpose other than that described in the contract with the covered entity, B) It allows the business associate to maintain PHI indefinitely, C) It prohibits the business associate from using or disclosing PHI in any way that would violate the HIPAA Privacy Rule, or D) It requires the business associate to make available all of its books and records relating to PHI use and disclosure to the DHHS (Dept of Health & Human Services) or its agents

answer

B

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