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Diagnosis
identification of a disease by a licensed provider
Morbidity
Refers to ill health in an individual and the levels of ill health in a population or group.
Mortality
the state of being subject to death
Comorbidity
a secondary condition that is present on admission and causes an increase in length of stay (LOS)
Complication
a secondary condition that arises during hospitalization and causes an increase in length of stay (LOS)
Principal diagnosis
that condition established after study, which is found to be primarily responsible for admission of the patient to the hospital
What is a characteristic of ICD-6?
The first version of ICD used for both death classification and disease indexing
What was the first ICD revision for which an alternate was made due to disagreements?
The United States developed its own version of ICD-8 based on disagreements over the circulatory section.
Which characteristic of ICD-10-PCS represents a difference from ICD-9-CM?
No diagnostic information is included.
American Health Information Management Association (AHIMA)
a professional organization for health information management (HIM) professionals
American Hospital Association (AHA)
Non profit group or alliance of member hospitals and health care organizations that promote the interests of hospitals. It is an advocacy group for health care organizations, particularly hospitals
World Health Organization (WHO)
A group within the United Nations responsible for human health, including combating the spread of infectious diseases and health issues related to natural disasters.
History of Present Illness (HPI)
eight categories that constitute a chronological description of an illness.
History of Present Illness (HPI) eight categories
Off: what provides relief (modifying factors)
Location: where
Duration: when did it start
Context: what are you doing when it hurts
Associated signs and symptoms
Radiating, burning: how would you describe pain, quality
Timing: how long does it last, does it get worse or better
Severity: how does this compare to other sore throats
Common Diagnosis coding process errors
Poor physician handwriting, diagnosis, or documentation
Transcription errors
Lack of specificity
Patient’s medical record does not support diagnosis
Hybrid Record
A combination of paper and electronic records; a health record that includes both paper and electronic elements
Integrated health record
A system of health record organization in which all the paper forms are arranged in strict chronological order and mixed with forms created by different departments
The Joint Commission
an independent organization that accredits healthcare organizations in the United States based on performance standards
Longitudinal health record
a single complete health record that combines data from a variety of sources within a healthcare system
Source-oriented health record
a system of health record organization where information is organized according to the patient care department that provided the care
ICD-10-PCS
ICD-10-PCS is a system of medical classification used for procedural coding. It is a US system that is used in hospital settings to report inpatient procedures. ICD-10-PCS codes support data collection, payment and electronic health records.
principal procedure
A procedure performed for definitive treatment, one that is necessary for treating a certain condition. It is usually related to the primary diagnosis.
significant procedure
Surgical in nature
Surgical risk
Anesthesia risk
Requires specialized training
Uniform Hospital Discharge Data Set (UHDDS)
an organization that defines data sets for reporting procedures performed
Current Procedural Terminology (CPT)
coding system is published and maintained by the American Medical Association (AMA). the standardized classification system for reporting medical procedures and services. It consists of five characters that report outpatient procedures, including anesthesia, surgery, radiology, pathology and laboratory, Evaluation and management, medicine services
evaluation and management (E&M)
a section of CPT codes used to report services provided by a physician or other qualified healthcare professional
modifiers
two characters appended to a CPT code to provide additional information about the procedure without changing the meaning of the code
resource-based relative value scale (RBRVS)
a scale that provides a value to each CPT code based on physician work effort, practice expense, and malpractice expense
Healthcare Common Procedure Coding System (HCPCS)
A group of codes and descriptors used to represent health care procedures, supplies, products, and services. Consists of Level I (CPT codes) and Level II (HCPCS codes). The AMA manages the Level I codes, and the Centers for Medicare and Medicaid Services (CMS) publishes annual updates to the Level II codes. The Level II codes consist of five alphanumeric characters used to report durable medical equipment, prosthetics, medications, orthotics, and other provider services that are not found in CPT. HCPCS codes allow for more accurate reporting of services rendered during a patient encounter.
facility billing
the hospital's charge for technical services provided in an outpatient department of a hospital
place of service codes
the two-digit codes added to professional claims to indicate the setting where services were provided
professional billing
a physician's charge for medical services provided in an outpatient setting
Root operations that take out some or all of a body part
Excision
Resection
Detachment
Destruction
Exrtaction
Root operations that take out solids/fluids/gases from a body part
Drainage
Extirpation
Fragmentation
Root operations that involve cutting or separation only
Division
Release
Root operations that put or put back or move some or all of a body part
Transplantation
Reattachment
Transfer
Reposition
Root operations that alter the diameter or route of a tubular body part
Restriction
Occlusion
Dilation
Bypass
Root operations that always involve a device
Insertion
Replacement
Supplement
Change
Removal
Revision
Root operations involving examination only
Inspection
Map
Root operations that include other repairs
Control
Repair
Root operations that include other objectives
Alteration
Fusion
Creation
ICD-10-CM
a standardized classification system of diagnosis codes used for medical claim reporting in all healthcare settings. It is a set of diagnosis codes used in the United States of America, developed by a component of the U.S.
Inpatient Prospective Payment System (IPPS)
a system of categorizing inpatient cases into a group based on average resources used for one inclusive payment
Outpatient Prospective Payment System (OPPS)
a system used to determine outpatient reimbursement based on CPT codes assigned
revenue cycle
the process of tracking and analyzing data that includes patient registration, medical coding, and patient billing processes for accurate reimbursement
fee-for-service reimbursement
Payments to healthcare providers on the basis of the charges assigned to each of the separate services that were performed for the patient (physicians, labs, and ambulances)
reasonable cost system of reimbursement
facilities submit and annual cost report, receive periodic interim payments. (inpatient hospitals, skilled nursing facilities, hospices, and critical access hospitals)
Episode-of-care reimbursement
payments are made for all services provided for a specific time period or illness
Retrospective payment system
When the exact amount of the payment is determined after the service has been delivered
Prospective payment system (PPS)
When the exact amount of the payment is determined before the service is delivered
Revenue management life cycle
Front-end process: Patient access, including scheduling, preauthorization, insurance verification, point-of-service collection, and financial counseling
Middle process: Charge capture, chargemaster, case management, clinical documentation, and coding
Back-end process: Claims processing and payment posting, follow-up, collections, and denial management
claim adjudication
the process used by payers to evaluate a medical claim for reimbursement
claim denial
the refusal of a payer to reimburse the healthcare provider for services billed
medical necessity
guidelines developed by payers to ensure treatment meets accepted medical standards necessary to treat the condition or to diagnose a disease
advanced beneficiary notice (ABN)
a waiver of liability for the patient to sign if the provider deems Medicare will not pay for a service
charge description master (CDM)
a database of all billable items, revenue codes, and CPT/HCPCS codes that describe a service provided within a hospital
discharged not final billed (DNFB)
a measure of patient accounts that are held up due to either coding delays or other issues that prevent claim submission
explanation of benefits (EOB)
a statement from the payer that summarizes the costs of healthcare services billed, what is covered by the insurance plan, and how much is the patient's responsibility to pay
National Correct Coding Initiative (NCCI)
an insurance rating and data collection bureau developed by CMS to promote national coding methodologies to help reduce improper coding that may result in inappropriate payments of Medicare and Medicaid claims
Prospective payment inpatient hospitals
Medicare reimburses based on DRGs
Prospective Payment Ambulatory surgical centers
Payments based on procedure, if more than one is done ASC receives full payment for highest rated procedure, all others are payed at 50 percent. Payment to physician doing surgery is billed separately.
Prospective payment skilled nursing facility
patient must be hospitalized for 3 days before being admitted, and must be admitted within 30 days after being discharged from hospital
Prospective payment home health agency
Receives a lump sum every 60 days based on patient needs
What are the approaches used in the 5th character of the ICD-10-PCS code
Open
Percutaneous
Percutaneous endoscopic
7- Via natural or artificial opening
8- Via natural or artificial opening endoscopic
F- via natural or artificial opening with percutaneous endoscopic assistance
X- External: procedures performed directly on the skin or mucous membrane and procedures performed directly by the application of external force through the skin or mucous membrane
What does the OIG stand for and investigate?
Office of the Inspector General
They investigate healthcare fraud and are backed up by laws
What is the OCR, what do they investigate?
Office for Civil Rights, investigates compliance with HIPPA regulations and non- discrimination in programs that receive federal funds
Start Law
Legislation stating that providers cannot refer patients to organizations in which they or a family member has financial interest
Anti-kickback statute
Legislation stating that providers cannot be paid for referring patients to an orgaization
Anti-kickback statute states that a physician/facility cannot be given remuneration (money) in exchange for referrals.
EMTALA/ Antidumping statute (1986)
Created because poor or uninsured patients would be placed back in ambulances and sent to a public hospital
This states that any patient needing emergency care be given screening to determine if they have an emergency condition, if a condition exists the patient must be stabilized before being discharged or transferredW
What is the maximum civil monetary penalty?
10,000 per item or service, with the responsibility of triple penalties in some instances
What is a qui-tam lawsuit?
OIG receives whistleblower claims to get information. Allows private citizens to act on government behalf in filing lawsuits against an organization of individual that has violated the federal False Claims Act.H
How much can a whistleblower receive of recovered monies in a fraud case?
25 percent of the money the government recovers
What is DRG creep and how does it happen?
Is when a hospital every year, deliberately increases its case mix index or an average of the total values assigned to all DRGs is used to increase reimbursement
Can also increase the incidence of high-severity codes is found at a higher level than the incidence of that severity of disease is found in the population
Happens when there is fraudulent coding
How can a coding manager proactively prevent DRG creep?
Compare DRG, APC, or other payment category results to national or regional norms. Use outside auditors to review coding practices and patterns is recommended to increase objectivity
What are the sections of the ICD-10-PCS code book?
Section 0: Medical and surgical
Section 1: Obstetrics
Section 2: Placement
Section 3: Administration
Section 4: Measurement and monitoring
Section 5: Extracorporeal assistance and performance
Section 6: Extracorporeal therapies
Section 7: Osteopathic
Section 8: Other procedures
Section 9: Chiropractic
Should you code acute, chronic, or both when a diagnosis is documented as both acute and chronic? Which do you code first?
You should code both, but sequence acute first.
When should you use a combination code?
Used for a combination of two diagnosis, or a diagnosis associated with a manifestation or complication.
Do not use multiple codes if a combination code describes all elements.
When would you code signs and symptoms
When there is no definitive diagnosis or a symptom is not typical for the condition
When would you not code signs and symptoms?
When there is a definitive diagnosis and if the symptoms are typical for the condition
Should you first look up a diagnosis in the alphabetic or tabular index? Which one is more detailed?
Look up each term in the alphabetic index and verify the code selected in the tabular list. The alphabetic index does not always provide the full code, so it is mandatory to reference the tabular list as well, read and be guided by instructional notations.
Excludes type II
Excluded condition is not part of the condition represented by the code, but the two codes may be used together, if appropriate.
Excludes type I
used when two conditions cannot occur together and should not be coded together
Code also
two codes may be needed to describe one condition fully, but the sequence of those codes is not defined
Use additional code
etiology listing to remind coders that the manifestation should also be coded
Code first
underlying cause of the condition must be coded first, then the manifestationS
See also
another main term that may have useful additional index entries, but it is not mandatory to follow “see also” if the necessary code is found under the original main term.
See
following a main term in the alphabetic index, means that another term should be referenced. The correct code will not be used unless this instruction is followed.
With
Also means associated with/due to
And
Also means and/or
NEC
not elsewhere classifiable or other specified. Documentation in the medical record provides detail for a specific code does not exist
NOS
Not otherwise specified or unspecified. Documentation in the medical record is not enough to assign a more specific code
Colons
used in tabular list to add words to an incomplete term so it is assignable to a specific category
Parentheses
used to enclose supplementary words that can be present or absent I the statement of a disease without affecting the code number
Brackets
used in tabular list to enclose symptoms, alternative working, or explanatory phrases
ICD-9-CM
14,000 Diagnosis codes
3-5 characters
Decimal after 3rd character
The first character is a letter (E or V) or a number
Characters 2-5 are numbers
Laterality not addressed
Initial versus subsequent encounters not addressed
Combination codes for commonly associated conditions are limited
Injuries grouped by type of injury
Some clinical concepts not represented, such as underdosing, blood alcohol level
ICD-10-CM
69,000 diagnosis codes
3-7 characters
Decimal after 3rd character
1st character letter
2nd character number
Characters 3-7 are alpha or numeric
Separate codes for laterality
Separate codes for initial and subsequent encounters in some chapters
Many combination codes available
Injuries grouped by anatomic site
Additional concepts available
ICD-9- Procedure codes
4,000 procedure codes
4 digits all numbers
Decimal after 2nd digit
Procedure codes often contain diagnostic concepts
Eponymic (named after a person) terms were common
Involves finding procedure in the index and verifying it in the tabular list
ICD-10-PCS
72,000 procedure codes
7 letter and number characters (I and O not used because they can be confused with 1 and 0)
No decimals
Descriptive of the body system, body part, root operation, approach, device, and certain additional qualifying characters, no diagnostic information is included
No eponyms
The coding process is directly from body system/root operation tables, each row in a table defines a valid combination of code values
ICD-10-PCS codes must have how many characters
7
ICD-10-CM must have how many characters
3-7