Introduction to medical coding Shay

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103 Terms

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Diagnosis

identification of a disease by a licensed provider

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Morbidity

Refers to ill health in an individual and the levels of ill health in a population or group.

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Mortality

the state of being subject to death

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Comorbidity

a secondary condition that is present on admission and causes an increase in length of stay (LOS)

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Complication

a secondary condition that arises during hospitalization and causes an increase in length of stay (LOS)

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Principal diagnosis

that condition established after study, which is found to be primarily responsible for admission of the patient to the hospital

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What is a characteristic of ICD-6?

The first version of ICD used for both death classification and disease indexing

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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.

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Which characteristic of ICD-10-PCS represents a difference from ICD-9-CM?

No diagnostic information is included.

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American Health Information Management Association (AHIMA)

a professional organization for health information management (HIM) professionals

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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

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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.

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History of Present Illness (HPI)

eight categories that constitute a chronological description of an illness.

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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

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Common Diagnosis coding process errors

Poor physician handwriting, diagnosis, or documentation

Transcription errors

Lack of specificity

Patient’s medical record does not support diagnosis

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Hybrid Record

A combination of paper and electronic records; a health record that includes both paper and electronic elements

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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

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The Joint Commission

an independent organization that accredits healthcare organizations in the United States based on performance standards

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Longitudinal health record

a single complete health record that combines data from a variety of sources within a healthcare system

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Source-oriented health record

a system of health record organization where information is organized according to the patient care department that provided the care

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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.

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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.

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significant procedure

Surgical in nature

Surgical risk

Anesthesia risk

Requires specialized training

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Uniform Hospital Discharge Data Set (UHDDS)

an organization that defines data sets for reporting procedures performed

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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

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evaluation and management (E&M)

a section of CPT codes used to report services provided by a physician or other qualified healthcare professional

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modifiers

two characters appended to a CPT code to provide additional information about the procedure without changing the meaning of the code

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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

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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.

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facility billing

the hospital's charge for technical services provided in an outpatient department of a hospital

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place of service codes

the two-digit codes added to professional claims to indicate the setting where services were provided

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professional billing

a physician's charge for medical services provided in an outpatient setting

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Root operations that take out some or all of a body part

Excision

Resection

Detachment

Destruction

Exrtaction

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Root operations that take out solids/fluids/gases from a body part

Drainage

Extirpation

Fragmentation

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Root operations that involve cutting or separation only

Division

Release

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Root operations that put or put back or move some or all of a body part

Transplantation

Reattachment

Transfer

Reposition

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Root operations that alter the diameter or route of a tubular body part

Restriction

Occlusion

Dilation

Bypass

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Root operations that always involve a device

Insertion

Replacement

Supplement

Change

Removal

Revision

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Root operations involving examination only

Inspection

Map

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Root operations that include other repairs

Control

Repair

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Root operations that include other objectives

Alteration

Fusion

Creation

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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.

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Inpatient Prospective Payment System (IPPS)

a system of categorizing inpatient cases into a group based on average resources used for one inclusive payment

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Outpatient Prospective Payment System (OPPS)

a system used to determine outpatient reimbursement based on CPT codes assigned

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revenue cycle

the process of tracking and analyzing data that includes patient registration, medical coding, and patient billing processes for accurate reimbursement

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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)

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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)

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Episode-of-care reimbursement

payments are made for all services provided for a specific time period or illness

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Retrospective payment system

When the exact amount of the payment is determined after the service has been delivered

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Prospective payment system (PPS)

When the exact amount of the payment is determined before the service is delivered

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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

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claim adjudication

the process used by payers to evaluate a medical claim for reimbursement

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claim denial

the refusal of a payer to reimburse the healthcare provider for services billed

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medical necessity

guidelines developed by payers to ensure treatment meets accepted medical standards necessary to treat the condition or to diagnose a disease

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advanced beneficiary notice (ABN)

a waiver of liability for the patient to sign if the provider deems Medicare will not pay for a service

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charge description master (CDM)

a database of all billable items, revenue codes, and CPT/HCPCS codes that describe a service provided within a hospital

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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

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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

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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

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Prospective payment inpatient hospitals

Medicare reimburses based on DRGs

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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.

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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

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Prospective payment home health agency

Receives a lump sum every 60 days based on patient needs

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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

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What does the OIG stand for and investigate?

Office of the Inspector General

They investigate healthcare fraud and are backed up by laws

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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

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Start Law

Legislation stating that providers cannot refer patients to organizations in which they or a family member has financial interest

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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.

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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

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What is the maximum civil monetary penalty?

10,000 per item or service, with the responsibility of triple penalties in some instances

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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

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How much can a whistleblower receive of recovered monies in a fraud case?

25 percent of the money the government recovers

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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

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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

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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

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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.

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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.

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When would you code signs and symptoms

When there is no definitive diagnosis or a symptom is not typical for the condition

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When would you not code signs and symptoms?

When there is a definitive diagnosis and if the symptoms are typical for the condition

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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.

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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.

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Excludes type I

used when two conditions cannot occur together and should not be coded together

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Code also

two codes may be needed to describe one condition fully, but the sequence of those codes is not defined

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Use additional code

etiology listing to remind coders that the manifestation should also be coded

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Code first

underlying cause of the condition must be coded first, then the manifestationS

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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.

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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.

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With

Also means associated with/due to

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And

Also means and/or

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NEC

not elsewhere classifiable or other specified. Documentation in the medical record provides detail for a specific code does not exist

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NOS

Not otherwise specified or unspecified. Documentation in the medical record is not enough to assign a more specific code

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Colons

used in tabular list to add words to an incomplete term so it is assignable to a specific category

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Parentheses

used to enclose supplementary words that can be present or absent I the statement of a disease without affecting the code number

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Brackets

used in tabular list to enclose symptoms, alternative working, or explanatory phrases

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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

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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

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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

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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

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ICD-10-PCS codes must have how many characters

7

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ICD-10-CM must have how many characters

3-7