D521-Introduction to Medical Coding

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

How long have you had the sore throat? (duration)

What part of your throat hurts? (location)

Is the pain continuous? Does it become better or worse? (timing)

How does it compare to other sore throats you have had? (severity)

Do you also have other symptoms? (associated signs and symptoms)

What are you doing when it hurts? (context)

How would you describe the pain? (quality)

What have you done to obtain relief? Did it work? (modifying factors)

Common Diagnosis coding process errors

Illegible physician handwriting

Illogical physician diagnosis documentation

Lack of physician documentation

Transcription errors by typist or voice-recognition systems

Content of the rest of the patient's medical record does not support the diagnosis documented

Lack of specificity

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

a procedure that is surgical in nature, carries a surgical risk or anesthesia risk, and 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
Extraction

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
Creation
Fusion

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

Issues payments to healthcare providers on the basis of the charges assigned to each of the separate services that were performed for the patient

reasonable cost system of reimbursement

relies on an annual cost report to compile data used to determine periodic interim payments.

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