Medical Coding Lecture Notes

Flashcards based on medical coding lecture notes.

Introduction to Medical Coding

Provides students with the foundation for translating medical terminology into correct diagnosis and procedure codes.

Code sets introduced in the Introduction to Medical Coding course

CPT, ICD-10-CM, ICD-10-PCS, and HCPCS

Second character in an ICD-10-PCS code

Body system

Fifth character in an ICD-10-PCS code

Qualifier

Character in an ICD-10-PCS code indicates the device

Device

Section indicated by the character 0 in an ICD-10-PCS code

Medical and surgical

Root operation grouping for the medical and surgical section contains removing solids, fluids, or gases from a body part

Extirpation

Root operation in ICD-10-PCS coding categorized as moving or putting back some or all of a body part

Reattachment

Main section that is part of the Current Procedural Terminology (CPT) classification structure

Administration and placement

HCPCS modifier that indicates a repeat clinical lab

91

Characteristic of the fee-for-service system of reimbursement

Involves periodic interim payments to facilities

Characteristic of the prospective payment system of reimbursement

Uses an annual report to reconcile payment

Event that occurs when a coder misinterprets documentation and assigns an incorrect MS-DRG code

The facility will receive an under reimbursement

Data used to identify the relevant diagnosis-related group for a patient discharge

Principal diagnosis

Factor used to assign a patient discharge into a DRG

Gender

Component included in the front-end process of the revenue management life cycle

Scheduling

Component included in the middle process of the revenue management life cycle

Financial counseling

Event that occurs when a coder forgets to code a major complication

The facility will receive an under reimbursement

Used to specify explanatory phrases, according to diagnosis coding conventions

Parentheses, ( )

Punctuation used to specify words for category assignment in diagnosis coding

Square brackets, [ ]

General guideline for diagnosis coding with ICD-10-CM

Only use a code with fewer than seven characters if it is not further subdivided

Guideline for sequencing for inpatients

Sequence a complication code first if admission is for treatment of the complication

Square brackets, [ ], are used for in coding diagnoses with ICD-10-CM

Alternative wordings

Category assessed when gathering the history of present illness (HPI)

Location

Primary category addressed in the history of present illness (HPI)

Timing

What a complete diagnostic statement should always include

Site

Common problem in the diagnosis coding process explains why computers cannot conduct the entirety of the process

A lack of patient contact

Characteristic of ICD-10-CM represents a difference from ICD-9-CM

Code characters are included to indicate the condition's duration

Characteristic of ICD-10-PCS as compared to ICD-9-CM

There is a focus on describing procedure objectives

Term that matches the definition: a diseased condition or the occurrence of disease in a population

Morbidity

Characteristic of ICD-10-CM represents a difference from ICD-9-CM

There are many combination codes for commonly associated conditions

Response for a coder when a coworker indicates that adding a comorbidity would result in a higher-weighted DRG

Code the diagnosis originally supported with documentation

Ethical response for a coder instructed to determine the sequence of codes that results in the highest-weight DRG assignment

Use the sequence that follows coding guidelines

Benefits associated with an effective compliance program

Increased reimbursement rates

Challenge faced by those implementing effective revenue integrity programs

Convincing patients of the need for transparency

Demonstrated top ethical challenge for leaders in healthcare

Ethical Violation Severity

Defined disciplinary action of AHIMA that refers to a disapproval of conduct through a written reprimand

Censure

What providers that underperform in revenue integrity risk

Net revenue leakage