Final exam m101

Why is accurate and precise coding important?

It Improves the chance to getting your money back and increases the chance the insurance carrier will accept the claim

What can coding mistakes cause for the provider and patient?

Mistakes cost the provider a fee and may result in services not being covered for the patient.

What types of formats can codes be?

Numeric or alphanumeric.

ICD

International classification of delivery

What classification system does the U.S. currently use?

ICD‑10.

How many digits did ICD‑9 codes use?

Three digits. Example: 250 = diabetes mellitus

What does HCPCS allow billing for?

Non‑medical services like hospital beds, walkers, and vaccines.

Where does HCPCS originate from?

Medicare applanumeric

What does CPT stand for?

Current Procedural Terminology.

What did the provider do for the patient?

surgery, consult or treat.

How long are CPT codes?

Five digits, with possible two‑digit modifiers.

What section includes office visit codes?

Evaluation & Management (E/M)

What do CPT codes describe?

like whatt the provider did—surgery, consult, or treatment.

What are the Evaluation and Management codes for new patients?

99202–99205.

What are CPT designated as?

as levels of service to the patient.

What are the E/M codes for established patients?

99211–99215.

what does the new cpt code started with?

started 99201.

What does a higher E/M number indicate?

It indicates the provider did more work, requiring higher reimbursement

A new patient E/m- 99204 will reimburse?

more than a 99202.

An established patient e/m will reimburse- 99215?

more than a 99213.

What is the last E/M code used in the office?

99215. Anything higher occurred outside the office, hospital, long term facility.

Who are third‑party payers?

Medicare, Medicaid, commercial insurance.

Who is not a third‑party payer?

Spouse, child, employer.

What are CPT modifiers?

Two‑digit codes added to CPT codes to give claim examiners more information.

How are CPT modifiers written?

With a dash before the number (e.g., -25, -50).

What is the purpose of a CPT modifier?

A: To provide additional information using numbers instead of words so claims can be processed accurately.

How many digits does a standard CPT code have?

Five digits.

How many digits can a CPT code have when a modifier is added?

Up to seven digits.

What does modifier -50 indicate?

Bilateral procedure.

What do insurance companies require in order to pay for care?

They only pay for care that is medically necessary, supported by CPT and ICD documentation

What must CPT and ICD documentation support?

Medical necessity for the services provided.

When is a Special Report filed?

When no appropriate CPT code can be located.

What is the purpose of a Special Report?

To allow the insurance company to determine proper payment.

What is upcoding?

Billing for a more expensive procedure than what was performed; it is illegal and fraud.

What is an example of upcoding?

Treating a blister with a band aid but billing for draining the blister.

What is downcoding?

Billing for a lower service than performed; results in loss of revenue and it’s considered fraud.

Can insurance companies downcode a claim?

Yes — if CPT and ICD documentation do not support each other.

What is unbundling?

Billing separately for procedures that the insurance company requires to be billed together as one claim. ex: pre-op-post

Why is unbundling considered fraud?

It causes overpayment and can lead to a fraud suit under the False Claims Act.

What does the False Claims Act penalize?

Claims the provider knew or should have known were improper; penalties often around $10,000 per claim.

Can a provider blame the biller or coder for a false claim?

No — the provider is responsible for the accuracy of the claim.

What is concurrent care?

Multiple providers caring for the same hospitalized patient at the same time. 24/7 bedside attention.

What is critical care?

Care requiring continuous, 24/7 bedside attention.

What is a consultation in medical care?

When one provider asks another to assist in diagnosing or caring for a patient; the patient remains under the requesting provider.

What is counseling in a medical encounter?

The provider discusses issues such as treatment options, test results, or the importance of following the care plan.

What defines a new patient?

No services from the provider/group in the last 3 years.

What defines an established patient?

A patient who has received the same services from the provider or group within the last three years.

Why does new vs. established patient status matter?

It affects the CPT code and the reimbursement amount.

What is the chief complaint?

The main reason for the visit or encounter.

What are the four levels of patient history?

Problem‑focused, expanded problem‑focused, detailed, and comprehensive.

What determines the level of service for a visit?

The level of decision‑making or the time spent with the patient.

What is the degree of medical decision‑making?

A measure of how complex the provider’s clinical judgment must be for the encounter.

What does the integumentary system include?

Hair, nails, skin, and glands.

What does the musculoskeletal system include?

Bones, tendons, cartilage, ext.

What does the cardiovascular system include?

The heart and blood vessels.

What is the function of the urinary system?

Waste removal.

What is a panel in medical testing?

disease‑oriented lab tests, such as CBG and urine tests.

What is required for CPT coding?

A procedure must be documented in the medical record; if it isn’t documented, it cannot be coded.

What is HCPCS used for?

Coding services not covered by CPT, such as walkers, canes, and drugs.

What was ICD‑9?

The International Classification of Diseases, Ninth Revision; formerly used in the U.S. and used for millions of claims.

How many digits were ICD‑9 disease codes?

Three digits.

What three books did ICD‑9 use?

Tabular(number), alphabetic, and hospital.

What were ICD‑9 E codes used for?

External causes — events that caused the medical issue., M‑codes (cancer/).

What were ICD‑9 V codes used for?

Wellness care and factors influencing health status (e.g., physical exams, flu or COVID shots).

How were modifiers shown in ICD‑9?

As decimal points — one or two digits depending on the medical condition.

What ICD code set is currently used in the United States?

ICD‑10.

What did ICD‑10 combine into one book?

The tabular and alphabetic code.

What is the purpose of ICD codes?

To track morbidity (illness) and mortality (death).

What does NEC mean in ICD‑10?

Not Elsewhere Classified — the disease has not been made part of the ICD‑10.

What does NOS mean?

Not otherwise specified —physician has not provided enough information to provide a definite ICD-10code.

How do insurance carriers view NEC and NOS codes?

They frown upon their use.

How many disease codes are in ICD‑10 compared to ICD‑9?

ICD‑9 had about 14,000; ICD‑10 has about 69,000.

How many spaces did ICD‑9 allow for each disease code?

Three spaces.

How many spaces can ICD‑10 codes have?

Up to seven spaces.

What do the first three characters of an ICD‑10 code represent?

The disease category.

What do the last four characters of an ICD‑10 code represent?

Modifiers that add detail and specificity.

Why is ICD‑10 considered more precise?

It allows more characters and greater detail in coding.

What replaced ICD‑9 V codes in ICD‑10?

Z codes.

What replaced ICD‑9 E codes in ICD‑10?

V, W, X, and Y codes (cause‑of‑injury codes).

What do ICD‑10 S and T codes represent?

External causes of injury or conditions.

What is laterality?

can tell the claim examiner that exact part off the body treated, example right arm or left leg.

Why do encounter forms need to be rewritten for ICD‑10?

Some Terminology has changed with ICD-10.

Does ICD‑10 still use an alphabetic and tabular index?

Yes — codes are still looked up and verified the same way.

What is a DRG?

Diagnosis‑related group — determines hospital stay length based on age, sex, and condition.

What can insurers do with coding accuracy?

The idea that insurers may bundle or ignore legitimate codes or downgrade claims even when documentation is correct.

What does it mean when an insurer downgrades a claim?

They reimburse less money than appropriate, despite proper documentation.

What is a Medicare audit?

A review of a provider’s charts to verify that submitted claims were legitimate.

What is revenue cycle management?

Managing the financial side of a medical practice as a result of the patient encounter.

What does the revenue cycle include?

Billing, coding, claim submission, collections, and payments.

When does the revenue cycle begin?

At patient registration with insurance information and verification of coverage.

What happens at patient check‑in?

Insurance can be re‑verified and any copay can be collected.

What coding systems may be assigned after the provider encounter?

CPT, ICD, and HCPCS codes.

What is a fee schedule?

The provider’s charge for a particular service.

What does adjudication of a claim mean?

Determining whether the claim will be covered and how much will be paid.

Why did the provider go to medical school?

To practice medicine — not to manage an office.

Who may handle management functions in a small medical office?

Staff such as MAs, billers/coders, ultrasound techs, or nurses.

Who may handle management in a large medical office?

A practice manager or non‑office manager who runs the business side.

Front: What is absentee management?

When a provider tries to run the office without being physically present, using another provider/NP/PA to treat patients.

What is remittance advice (RA)?

An explanation of benefits for multiple claims paid with the same check.

What is an Explanation of Benefits (EOB)?

A report from the insurance company explaining how a claim was processed, including what was allowed, denied, copays, deductibles, and what the patient owes.