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A comprehensive guide to the icd-10-pcs and cpt coding systems for various medical conditions and procedures. It includes codes for diseases such as anaphylaxis, carcinoma of the vagina, and ovarian vein syndrome, as well as codes for procedures like endotracheal intubation, biopsy, and carpal tunnel release. It also covers topics like critical care coding, incident reports, and urinalysis results.
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You have been asked to recommend time-limited documentation standards for inclusion in the Medical Staff Bylaws, Rules, and Regulations. The committee documentation standards must meet the standards of both the Joint Commission and the Medicare Conditions of Participation. The standards for the history and physical exam documentation are discussed first. You advise them that the time period for completion of this report should be set at 24 hours after admission or prior to surgery The patient is diagnosed with congestive heart failure. A drug of choice is Digoxin In the past, Joint Commission standards have focused on promoting the use of a facility-approved abbreviation list to be used by hospital care providers. With the advent of the Commission's national patient safety goals, the focus has shifted to the use of prohibited or "dangerous" abbreviations According to the UHDDS, a procedure that is surgical in nature, carries a procedural or anesthetic risk, or requires special training is defined as a significant procedure CMS adjusts the Medicare Severity DRGs and the reimbursement rates every fiscal year beginning October 1
What is the root operation main term? Total left knee replacement replacement What is the root operation main term? Gastric lap band for treatment of morbid obesity restriction What main term would be used? Percutaneous angioplasty right coronary artery using a balloon-tipped catheter to expand the vessel dilation A patient with Medicare is seen in the physician's office. The total charge for this office visit is $250.00. The patient has previously paid his deductible under Medicare Part B. The PAR Medicare fee schedule amount for this service is $200.00. The non-PAR Medicare fee schedule amount for this service is $190.00. If this physician is a participating physician who accepts assignment for this claim, the total amount the physician will receive is $200. Vaginal delivery with episiotomy of full-term liveborn infant. Patient undergoes repair of delivery episiotomy and postdelivery elective vaginal endoscopic ligation of fallopian tubes bilaterally. (Code the diagnoses using ICD-10-CM and procedures using ICD-10-PCS.) O80, Z37.0, Z30.2, 10E0XZZ, 0W8NXZZ, 0UL74ZZ
Codes from category O36, known or suspected fetal abnormality affecting the mother, should be assigned when they affect the management of the mother HCPCS codes beginning with the letter J represent __________________. drugs NDC codes represent __________________. drug products Medicare covers which of the following scenarios? People over 65, People under 65 with certain disabilities, and ESRD _________________________ means that providers work together to ensure that the patient receives the best care and providers in different locations are not duplicating care. Coordination of care __________________ means that providers work toward the same treatment goal for the patient. Continuity of care The information the patient gives to the provider belongs to ____________________. The patient State laws require providers to keep medical records for patients discharged, no longer seen or deceased for a minimum period of _______________. Seven years
An advantage of an electronic health record is _________________. Providers can simultaneously access the same patient's record What is the major disadvantage for providers who do not participate with Medicare or Medicaid? They may suffer financial distress The federal government will pay Medicare and Medicaid participating providers to implement EHRs, because it will ________________________. Improve coordination and continuity of patient care _________________ is the term used to classify the presence of an illness, disease, or injury. Morbidity A coder should never code inpatient procedures directly from the Alphabetic Index without cross-referencing the codes to the ____________________. Tabular List _______________ represent reasons for encounters, other than a disease, condition, or injury, with some exceptions. Z codes
__________________ provide additional information about the patient's injury or poisoning but do not represent the patient's actual condition. V-Y codes When should a coder assign an unspecified code? When a more specific code is not available A morphology fifth-digit code of /9 means that the neoplasm is _________________. Malignant, uncertain whether primary or metastatic site The American Psychiatric Association created the ________________ to classify mental disorders and help diagnosis and research various mental conditions. DSM- The ______________________ section of the Alphabetic Index contains an alphabetical list of external causes of accidents and injuries, along with their corresponding V-Y codes. Index to External Causes of Injury A main term may be one word or a phrase, but a main term is not a ______________. carryover line, body site, subterm
The Health Insurance Portability and Accountability Act requires coders to
Follow the guidelines established by the NCHS and CMS when coding You need to analyze data on the types of care provided to Medicare patients in your geographic area by DRG. Which of the following would be most helpful? MEDPAR Litholapaxy, 3 cm calculus Which code would it be? 50590= Lithotripsy, extracorporeal shock wave 52317= Litholapaxy: crushing or fragmentation of calculus by any means in bladder and removal of fragments; simple or small (< 2.5 cm) 52318= Litholapaxy: crushing or fragmentation of calculus by any means in bladder and removal of fragments; complicated or large (over 2.5 cm) 52353= Cystourethroscopy, with ureteroscopy and/or pyeloscopy; with lithotripsy (ureteral catheterization is included) 52318
A Medicare Summary Notice (MSN) is sent to ________ as their EOB. patients (beneficiaries) Patient presents to the operating room for fulguration of bladder tumors. The cystoscope was inserted and entered the urethra, which was normal. Bladder tumors measuring approximately 1.5 cm were removed. Which code would it be? 50957= Ureteral endoscopy through established ureterostomy, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service; with fulguration and/or incision, with or without biopsy 51530= Cystotomy; for excision of bladder tumor 52214= Cystourethroscopy, with fulguration (including cyrosurgery or laser surgery) of trigone, bladder neck, prostatic fossa, urethra, or periurethral glands 52234= Cystourethroscopy, with fulguration (including cryosurgery or laser surgery) and/or resection of small bladder tumor(s) (0.5 up to 2. cm) 52234
A patient is admitted to the hospital for a coronary artery bypass surgery. Postoperatively, he develops a pulmonary embolism. The present on admission (POA) indicator is N = not present at the time of inpatient admission In assigning E/M codes, three key components are used. These are history, examination, and medical decision making Under APCs, payment status indicator "X" means ancillary services A coworker complained of sudden onset of chest pain and went to the emergency room. A myocardial infarction was ruled out. You would code only the chest pain The special form that plays the central role in planning and providing care at nursing, psychiatric, and rehabilitation facilities is the interdisciplinary patient care plan The _______________ are the organizations that contract with Medicare to perform reviews of medical records with the corresponding Medicare claims to detect and correct improper payments. recovery audit contractors (RACs)
This document is published by the Office of Inspector General (OIG) every year. It details the OIG's focus for Medicare fraud and abuse for that year. It gives health care providers an indication of general and specific areas that are targeted for review. It can be found on the Internet on CMS's website. the OIG's Work Plan ____ is knowingly making false statements or representation of material facts to obtain a benefit or payment for which no entitlement would otherwise exist. Fraud Before a user is allowed to access protected health information, the system confirms that the patient is who he or she says he or she is. This is known as authentication ____ are errors in medical care that are clearly identifiable, preventable, and serious in their consequences for patients. Never events or sentinel events Which of the following can be released without consent or authorization? de-identified health information Based on CMS's DRG system, other systems have been developed for payment purposes. The one that classifies the non-Medicare population, such as HIV patients, neonates, and pediatric patients, is known as APR-DRGs
Under which of the following conditions can an original paper-based patient health record be physically removed from the hospital? when the director of health records is acting in response to a subpoena duces tecum and takes the health record to court You want to review the one document in your facility that will spell out the documentation requirements for patient records, designate the time frame for completion by the active medical staff, and indicate the penalties for failure to comply with these record standards. Your best resource will be medical staff rules and regulations The PQRS is a reporting system established by the federal government for physician practices that participate in Medicare for quality measure reporting The best resource for checking out specific voluntary accreditation standards and guidelines for a rehabilitation facility is the CARF manual What does CARF manual means? Commission on Accreditation of Rehabilitation Facilities When health care providers are found guilty under any of the civil false claims statutes, the Office of Inspector General is responsible for negotiating these settlements and the provider is placed under a
Corporate Integrity Agreement What is ANSI ASC X12N 837 format? The ANSI ASC X12 837 is the claim/encounter format. It is important to note all X12 formats are messaging standards developed for the sole purpose of transmitting data between two entities referred to as trading partners in the HIPAA legislation The Health Insurance Portability and Accountability Act (HIPAA) requires the retention of health insurance claims and accounting records for a minimum of ____ years, unless state law specifies a longer period. 5 This initiative was instituted by the government to eliminate fraud and abuse and recover overpayments, and involves the use of ______________. Charts are audited to identify Medicare overpayments and underpayments. These entities are paid based on a percentage of money they identify and collect on behalf of the government. Recovery Audit Contractors (RAC) When a provider, knowingly or unknowingly, uses practices that are inconsistent with accepted medical practice and that directly or indirectly result in unnecessary costs to the Medicare program, this is called abuse Your hospital is required by the Joint Commission and CMS to participate in national benchmarking on specific disease entities for quality of care measurement. This required collection and reporting of disease-specific data is considered
a series of core measures This law prohibits a physician from referring Medicare patients to clinical laboratory services where the doctor or a member of his family has a financial interest. the Stark I Law What is the Stark I Law? Stark Law is a set of United States federal laws that prohibit physician self- referral, specifically a referral by a physician of a Medicare or Medicaid patient to an entity providing designated health services ("DHS") if the physician (or an immediate family member) has a financial relationship with that entity CMS delegates its daily operations of the Medicare and Medicaid programs to the Medicare administrative contractor (MAC) In determining your acute care facility's degree of compliance with prospective payment requirements for Medicare, the best resource to reference for recent certification standards is the Federal Register Accreditation by Joint Commission is a voluntary activity for a facility, and it is required for reimbursement of certain patient groups
Stage I of meaningful use focuses on data capture and sharing. Which of the following is included in the menu set of objectives for eligible hospitals in this stage? use CPOE for medication orders What does CPOE means? Computerized physician order entry, sometimes referred to as computerized provider order entry or computerized provider order management, is a process of electronic entry of medical practitioner instructions for the treatment of patients under his or her care The federally mandated resident assessment instrument used in long-term care facilities consists of three basic components, including the new care area assessment, utilization guidelines, and the MDS Engaging patients and their families in health care decisions is one of the core objectives for achieving meaningful use of EHRs The method of calculating errors in a coding audit that allows for benchmarking with other hospitals, and permits the reviewer to track errors by case type, is the record-over-record method The abstract completed on the patients in your hospital contains the following items: patient demographics, prehospital interventions, vital
signs on admission, procedures and treatment prior to hospitalization, transport modality, and injury severity score. The hospital uses these data for its trauma registry Which of the following is least likely to be identified by a deficiency analysis technician? discrepancy between postoperative diagnosis by the surgeon and pathology diagnosis by the pathologist A participating (PAR) physician is one who signs an agreement to participate in the Medicare program and agrees to accept whatever Medicare pays for a provider or service
Before making recommendations to the Executive Committee regarding new physicians who have applied for active membership, the Credentials Committee must query the National Practitioner Data Bank When developing a data collection system, the most effective approach first considers the end user's needs As part of Joint Commission's National Patient Safety Goal initiative, acute care hospitals are now required to use a preoperative verification process to confirm the patient's true identity and to confirm that necessary documents such as X-rays or medical records are available. They must also develop and use a process for marking the surgical site Under ASC-PPS, the patient is responsible for paying the coinsurance amount based upon ____ of the national median charge for the services rendered 20% There are times when documentation is incomplete or insufficient to support the diagnoses found in the chart. The most common way of communicating with the physician for answers is by using established physician query protocols Your job description includes working with agents who have been charged with detecting and correcting overpayments made to your hospital in the
Medicare Fee for Service program. You will need to develop a professional relationship with recovery audit contractors During a retrospective review of Rose Hunter's inpatient health record, the health information clerk notes that on day 4 of hospitalization, there was one missed dose of insulin. What type of review is this clerk performing? qualitative review The hospital implemented an electronic query system to allow more effective communication with physicians and other health practitioners to improve clinical documentation in the patient record. This query system was implemented as part of a __________________________program. clinical documentation improvement (CDI) Ultimate responsibility for the quality and completion of entries in patient health records belongs to the attending physician Joint Commission does not approve of auto authentication of entries in a health record. The primary objection to this practice is that evidence cannot be provided that the physician actually reviewed and approved each report Currently, the enforcement of HIPAA Privacy and Security Rules is the responsibility of the Office for Civil Rights
The patient sees a participating (PAR) provider and has a procedure performed after meeting the annual deductible. If the Medicare-approved amount is $200, how much is the patient's out-of-pocket expense? $ The committee that is responsible for establishing the quality improvement priorities of the cancer program and for monitoring the effectiveness of quality improvement activities is the Cancer Committee To monitor timely claims processing in a hospital, a summary report of "patient receivables" is generated frequently. Aged receivables can negatively affect a facility's cash flow; therefore, to maintain the facility's fiscal integrity, the HIM manager must routinely analyze this report. Though this report has no standard title, it is often called the DNFB (discharged, not final billed) The health care providers at your hospital do a very thorough job of periodic open record review to ensure the completeness of record documentation. A qualitative review of surgical records would likely include checking for documentation regarding the presence or absence of such items as preoperative and postoperative diagnosis, description of findings, and specimens removed The Correct Coding Initiative (CCI) edits contain a listing of codes under two columns titled "comprehensive codes" and "component codes." According to the CCI edits, when a provider bills Medicare for a procedure that appears in both columns for the same beneficiary on the same date of service they should
code only the comprehensive code The coding supervisor notices that the coders are routinely failing to code all possible diagnoses and procedures for a patient encounter. This indicates to the supervisor that there is a problem with completeness The Cancer Committee at your hospital requests a list of all patients entered into your cancer registry in the last year. This information would be obtained by checking the accession register In compiling statistics to report the specific cause of death for all open- heart surgery cases, the quality coordinator assists in documenting patient care outcomes To gather statistics for surgical services provided on an outpatient basis, which of the following codes are needed? CPT codes In preparation for an EHR, you are working with a team conducting a total facility inventory of all forms currently used. You must name each form for bar coding and indexing into a document management system. The unnamed document in front of you includes a microscopic description of tissue excised during surgery. The document type you are most likely to give to this form is pathology report
You need to retrieve information on a particular physician in your facility. Specifically, you need to know how many cases he saw during the month of May. What would be your best source of information? physician index The chargemaster relieves the coders from coding repetitive services that require little, if any, formal documentation analysis. This is called hard coding While performing routine quantitative analysis of a record, a medical record employee finds an incident report in the record. The employee brings this to the attention of her supervisor. Which best practice should the supervisor follow to deal with this situation? Refer this record to the Risk Manager for further review and removal of the incident report There are seven criteria for high-quality clinical documentation. All of these elements are included EXCEPT covered (by third-party payer) You are looking at statistics for your facility that include average length of stay (ALOS) and discharge data by DRG. What type of data are you reviewing? aggregate data The performance of qualitative analysis is an important tool in ensuring data quality. These reviews evaluate
the overall quality of documentation The utilization review coordinator reviews inpatient records at regular intervals to justify necessity and appropriateness of care to warrant further hospitalization. Which of the following utilization review activities is being performed? continued stay review Health care claims transactions use one of three electronic formats, including which one of those listed below? ANSI ASC X12N 837 format Which feature is a trademark of an effective PI program? a continuous cycle of improvement projects over time In regard to quality of coding, the degree to which the same results (same codes) are obtained by different coders or on multiple attempts by the same coder refers to reliability The Recovery Audit Contractor (RAC) program was developed to identify and reduce improper payments for collection of overpayments Surgical case review includes all of the following EXCEPT
cases with elements missing in the preoperative anesthesia consultation Under APCs, the payment status indicator "N" means that the payment is packaged into the payment for other services The physician's office note states: "Counseling visit, 15 minutes counseling in follow-up with a patient newly diagnosed with diabetes." If the physician reports code 99214, which piece of documentation is missing to substantiate this code? total length of visit Under the RBRVS, each HCPCS/CPT code contains three components, each having assigned relative value units. These three components are physician work, practice expense, and malpractice insurance expense Which of the following statements is FALSE regarding the use of modifiers with the CPT codes? All modifiers will alter (increase or decrease) the reimbursement of the procedure When coding multiple wound repairs in CPT all wound repairs are grouped and coded, with the most complex reported first. The diagnosis reads "first-, second-, and third-degree burns of the right arm." You would code
the third degree only According to the American Medical Association, medical decision making is measured by all of the following except the specialty of the treating physician According to CPT, antepartum care includes all of the following EXCEPT monthly visits up to 36 weeks When appropriate, under the outpatient PPS, a hospital can use this CPT code in place of, but not in addition to, a code for a medical visit or emergency department service. CPT Code 99291 (critical care) All of the following items are "packaged" under the Medicare ASC payments, EXCEPT for brachytherapy In general, all three key components (history, physical examination, and medical decision making) for the E/M codes in CPT should be met or exceeded when a new patient is seen in the office In order to use the inpatient CPT consultation codes, the consulting physician must
document his findings in the patient's medical record The code structure for ICD-10-CM differs from the code structure of ICD-9- CM. An ICD-10-CM code consists of three to seven characters CMS identified Hospital-Acquired Conditions (HACs). Some of these HACs include foreign objects retained after surgery, blood incompatibility, and catheter-associated urinary tract infection. The importance of the HAC payment provision is that the hospital will not receive additional payment for these conditions when they are not present on admission ICD-10-PCS was implemented in the United States to code hospital inpatient procedures A complete redo of a knee replacement requiring a new prosthesis is coded to which root operation(s)? removal; replacement Extraction of retained products of conception after a vaginal birth. Identify the approach via natural or artificial opening In ICD-10-CM, the final character of the code indicates laterality. An unspecified side code is also provided should the site not be identified in
the medical record. If no bilateral code is provided and the condition is bilateral, the ICD-10-CM Official Coding Guidelines direct the coder to assign separate codes for both the left and right side The following coding system(s) is/are utilized in the MS-DRG prospective payment methodology for assignment and proper reimbursement. ICD-10-CM/ICD-10-PCS codes Of the following, which is a hospital-acquired condition (HAC)? air embolism Mappings between ICD-9-CM and ICD-10-CM were developed and released by the National Center for Health Statistics (NCHS) to facilitate the transition from one code set to another. They are called GEMS (General Equivalency Mappings) CMS-identified "hospital-acquired conditions" mean that when a particular diagnosis is not "present on admission," CMS determines it to be reasonably preventable When coding free skin grafts, which of the following is NOT an essential item of data needed for accurate coding? Donor site Left common carotid endarterectomy, open
extraction Which of the following contains a list of coding edits developed by CMS in an effort to promote correct coding nationwide and to prevent the inappropriate unbundling of related services? National Correct Coding Initiative (NCCI) The physician listed the diagnoses as congestive heart failure with acute pulmonary edema. You will code ____________. the CHF only Which of the following is coded as a late effect in ICD-10-CM? tinnitus due to allergic reaction after administration of eardrops A document that acknowledges patient responsibility for payment if Medicare denies the claim is a(n) advance beneficiary notice The purpose of the Correct Coding Initiative is to _____. detect and prevent payment for improperly coded services When is it appropriate to use category Z85, history of malignant neoplasm? Primary malignancy has been eradicated and no adjunct treatment is being given at this time.