CEMC Exam Questions with 100% Correct Answers | Verified | Updated 2024, Exams of Advanced Education

Download CEMC Exam Questions with 100% Correct Answers | Verified | Updated 2024 and more Exams Advanced Education in PDF only on Docsity! CEMC Exam Questions with 100% Correct Answers | Verified | Updated 2024 __________________ are not a consideration when choosing the right answer. - Correct Answer-Individual payer rules Follow the CPT coding guidelines unless... - Correct Answer-It is specifically stated in the case note or exam question that Medicare covers the patient. Example of reporting additional signs and symptoms attributable to a definitive Dx - Correct Answer-The patient presents with shortness of breath. The next day, the MD determines the patient has pneumonia ; but, feels that the shortness of breath may be due to a cardiac condition. In such a case, you may still report the shortness of breath as a sign and symptom with the pneumonia because the MD has documented reason to believe that the conditions are unrelated. pg. 1 professoraxe l Do NOT ___________ or _____________ information - Correct Answer-Extrapolate or assume Select codes ONLY from what is apparent in the available documentation The ___________ makes the determination as to whether a condition becomes chronic - Correct Answer-Doctor Healthcare providers must begin using the most recent ICD- 10-CM code revisions on ________ of each year, with no ______. - Correct Answer-October 1st grace period to transition to the changes. Coders will select an appropriate code for ______ or _________ (primary) versus _________ (secondary) based on the available documentation. - Correct Answer-Acute Sub-acute Chronic pg. 2 professoraxe l Section IV: Dx Coding and Reporting Guidelines for Outpatient Services Uniform Hospital Discharge Data Set - Correct Answer- (UHDDS) : Defines the principle Dx as "that condition established after study to be chiefly responsible for the admission of the patient to the hospital for care." Rules for Reporting Additional Dx - Correct Answer-Diagnoses, in addition to the principal Dx, that affect the patient's care Diagnostic Coding and Reporting Guidelines for Outpatient Services - Correct Answer-This includes information about coding signs and symptoms, when to report chronic Dx, ambulatory surgery, routine output prenatal visits, and more. What should the coder use to determine the correct code? - Correct Answer-Use the Alphabetic Index, and Tabular List of the ICD-10-CM code book pg. 5 professoraxe l When attempting to select an ICD-10-CM Dx code, begin by..... - Correct Answer-Searching for the main term - such as lesion, burn, etc. In the Alphabetic Index Follow all cross-references and "see also" entries. When you have located the code you are seeking, turn to that code in the Tabular List. Be sure to read each code's - Correct Answer-Disease definition Footnotes Color-coded prompts, and other instructions Read all supplemental information completely to be certain you are choosing the correct code. Always select a diagnosis - Correct Answer-To the highest specificity supported by the available documentation pg. 6 professoraxe l The first listed diagnosis should describe the...... - Correct Answer-most significant reason for the procedure or visit Generally, the first-listed Dx will be reflective of..... - Correct Answer-The patient's chief complaint Secondary diagnoses.. - Correct Answer-Relevant diseases and conditions, and Related patient or family hx conditions When coding pre-existing conditions, make sure... - Correct Answer-The assigned Dx code identifies the current reason for medical management. Do NOT report conditions - Correct Answer-That no longer exist, or Do not pertain to the visit pg. 7 professoraxe l Only after testing confirms cancer should you report the cancer Dx. Outpatient encounters with diagnostic tests which have been interpreted by a physician and the final report is available at the time of coding - Correct Answer-Report confirmed or definitive Dx documented in the interpretation If a definitive Dx is known, do NOT code.... - Correct Answer- Related signs and symptoms as additional dx If the test is positive, - Correct Answer-you code the findings. For tests interpreted as normal, code the - Correct Answer- Condition, symptom(s), or sign(s) that necessitated the diagnostic study. If a diagnostic test is ordered without a clear indication of the reason, and the ordering physician is not available to gather enough information prior to treating the patient,.... - Correct Answer-You will want to confirm the order for the physician's reason(s) that the test was ordered. pg. 10 professoraxe l When provided with both a preoperative and postoperative Dx, always report the - Correct Answer-Postoperative Dx code(s) if the pre- and postoperative Dx differ. ______ and ______ attributable to a definitive Dx should NOT be reported separately. - Correct Answer-Signs and symptoms Cite additional signs and symptoms beyond the primary Dx only when - Correct Answer-Those signs and symptoms are not interrelated to the disease process. Report only additional conditions that - Correct Answer-Affect treatment, and that the provider documents for the current visit. Examples of multiple conditions reported with a single code - Correct Answer-Code category 112 describes hypertension with chronic kidney disease. Category K81.2 describes acute and chronic cholecystitis pg. 11 professoraxe l **Two (2) separate codes are not necessary to describe these concurrent conditions. When selecting multiple conditions reported with a single code, be careful to read all - Correct Answer-Inclusion, Excludes 1, and Excludes 2 notes to help guide your decision. Reporting a single condition with multiple codes: More than one (1) ICD-10-CM code may be necessary to describe a single condition accurately. - Correct Answer-The ICD-10-CM code book uses Notes, Brackets, and Italics to identify these situations. Reporting a single condition with multiple codes - Correct Answer-Be on the lookout for "code first", "use additional", pg. 12 professoraxe l Combination codes for diabetes mellitus are broken down as... - Correct Answer-3-character categories from E08 - E13, which specify the type of diabetes Diabetes mellitus codes require.... - Correct Answer-*a 4th character to describe the general complication category (ex. - renal or ophthalmologist complication) *and a 5th character to specify the type of complication (ex. - mononeuropathy, chronic kidney disease) Diabetes mellitus codes are combination codes that include... - Correct Answer-the type of DM, The body system affected, and the complications affecting that body system Type I diabetes is the result of - Correct Answer-autoimmune destruction of the pancreatic beta cells, which cause insulin to cease. pg. 15 professoraxe l Regular insulin injections are necessary for the patient to survive. Type I DM is referred to as - Correct Answer-Juvenile-type or insult-dependent diabetes because the onset is typically discovered at a young age. Type 2 diabetes is caused by . - Correct Answer-the body's inability to respond to insulin that is produced, and is referred to as insulin resistant Gestational diabetes occurs only - Correct Answer-Because of pregnancy, and is reported in Chapter 15, under subcategory O24. 4-, rather than E08 - E13. **Documentation for diabetes should be specific and indicate : - Correct Answer-1) Type I, Type II, or gestational, not just NIDDM (Non-Insulin-Dependent Diabetes Mellitus) or IDDM (Insulin-dependent Diabetes Mellitus). 2) Body system affected with specific complication(s) of that body system. pg. 16 professoraxe l 3) Whether the patient is receiving insulin if they are a non- traditional 1 diabetic. Some patients have multiple complications of diabetes. - Correct Answer-The Guidelines state to code as many codes as necessary from a category. Sequencing would be dependent upon the main reason for the particular encounter. Additionally, _____ or _______ should be reported for patients who routinely use insulin in non-Type-1 diabetes - Correct Answer-Z79.4, Long term (current) use of insulin Z79.84 Long term (current) use of oral hypoglycemic drugs Do NOT report Z79.4 or Z79.84 if.... - Correct Answer-Insulin is given temporarily to bring a patient's blood sugar under control during the encounter. Z79.4 or Z79.84 is not reported with a gestational diabetic patient The code descriptors in the subcategory for pg. 17 professoraxe l "use additional codes", and "code first" for code order. Example of sequencing of diabetes as a secondary manifestation - Correct Answer-Under category E09, Drug or chemical induced diabetes mellitus, it indicates that if the diabetes is due to poisoning, first code the poisoning code. But if it is due to an adverse effect, the adverse effect code would be reported second. There is also a specific guideline for secondary diabetes due to a pancreatectomy. Code E89.1 first, followed by code from category E13, followed by code from subcategory Z90.41- (acquired absence of pancreas). Guidelines indicate that the late effects of cerebrovascular disease include - Correct Answer-neurologic deficits caused by cerebrovascular diasese and may be present from the onset or may arise at any time after the onset of the condition. - classifiable to categories I60 - I67 pg. 20 professoraxe l Example: A code(s) from category I69 may be assigned on a health case record with codes from I60 - I67 if - Correct Answer-the patient has a current Cerebrovascular Accident (CVA) and deficits from an old CVA. Some codes in category I69 that specify hemiplegia, hemiparesis and monoplegia also identify whether the dominant or nondominant side is affected. - Correct Answer-If the dominance is not stated (right-handed, left-handed, or ambidextrous), and the classification does not indicate a default, the following applies: * For ambidextrous patients, the default is always dominant; * If the left side is affected, the default is nondominant; * If the right side is affected, the default is dominant The Table of Neoplasms (Alphabetic Index) lists neoplasms by anatomic sites and is divided into 6 columns: - Correct Answer-* Malignant Primary; * Malignant Secondary; * Ca in situ; pg. 21 professoraxe l * Benign; * Uncertain Behavior; * Unspecified Behavior The first 3 columns of the Neoplasm Table describe - Correct Answer-Malignant Neoplasms. A Dx of maligant should be - Correct Answer-confirmed by pathology *It is recommended that you select a Dx code after the pathology report becomes available. A ________ malignancy is the site of origin of the neoplasm. A _______ malignancy is the site to which the primary tumor has spread, or to which _________ tumor has spread, or to which ________ tumor has metastasized by lymphatic spread, invasion of blood vessels, or implantation as tumor cells are shed into body cavities. - Correct Answer-Primary secondary; Primary pg. 22 professoraxe l The ICD-10-CM code set generally classifies neoplasms by ________________, ________________, or ____________________. - Correct Answer-System (example, respiratory); Organ (example, intrathoracic organs, or Site (example, tract, upper) Exceptions: Lymphatic neoplasms; hematopoietic neoplasms, malignant melanoma of the skin; and some common tumors of the bone, uterus, and ovary. For correct coding of a Neoplasm, ..... - Correct Answer-1) First check the Alphabetic Index to see if a specific code is assigned to a list morphologic type (example: sarcoma, adenoma, melanoma); 2) Then turn to the Tabular List to be sure that there are no "inclusion" or "exclusion" notes for the selected code. ICD-10-CM does not break down codes for hypertension by ____________________. - Correct Answer-severity (benign or malignant) pg. 25 professoraxe l If a patient has hypertension with no systemic issue of kidney disease or heart disease, the code assigned is _______. - Correct Answer-I10, Essential (primary) hypertension. Certain heart conditions (I51.4 - I51.9) with hypertension are assigned a code from - Correct Answer-category I11 ICD-10-CM coding guidelines presumes a causal relationship between hypertension and heart disease as the two conditions are linked by the term "with" in the ICD-10-CM Alphabetic Index A causal relationship is reported unless the documentation specifically states the conditions are unrelated. If the patient also has heart failure, an additional code from category I50 should be reported. Select a code from _____________________________ when both hypertensive heart disease and hypertensive renal disease are stated in the Dx. - Correct Answer-combination category I13, Hypertensive Heart and chronic kidney disease. pg. 26 professoraxe l **Assume a causal relationship between the hypertension, heart disease and renal disease, unless documentation specifically states the conditions are unrelated. Assign codes from category _________________________ when conditions are classified to codes N18.1 - N18.9 are present. - Correct Answer-I12, Hypertensive chronic kidney disease ICD-10-CM presumes a cause and effect relationship and classifies chronic kidney disease with hypertension as hypertensive renal disease. **Acute renal failure is reported as an additional code when it is with hypertensive chronic kidney disease. _______ (late effect) codes are usually reported as secondary Dx, with the _______ (reason for the visit) as primary. - Correct Answer-Sequela Effect pg. 27 professoraxe l When coding for asthma, the ____ of the asthma should be documented as - Correct Answer-severity intermittent,' mild persistent, moderate persistent, servere persitent _________ indicates that the patient is not responding to treatment. - Correct Answer-Status asthmaticus Acute bronchitis (category ____) and acute bronchiolitis (category ____) are common diagnoses when a patient presents with symptoms of ____________. - Correct Answer- Acute Bronchitis = category J20 Acute bronchiolitis = category J21 a servere productive cough Pneumonia codes are based on the ______________________, and may require you to report an additional code to describe pg. 30 professoraxe l the _______________________________. - Correct Answer- causative agent underlying disease. Influenza is a viral infection and coding is based on the influenza strain: - Correct Answer-Avian (J09.X2) H1N1/novel influenza A (J10.1) unspecified with pneumonia or other respiratory manifestations. Code only confirmed cases of ____________ flu. - Correct Answer-avian Injury codes are in chapter ______ - Correct Answer-19 (Fractures, burns, lacerations, etc) When reporting injury codes, be sure to code to the highest possible degree of specificity allowed by the documentation. - Correct Answer-Example: If there is a laceration: How big is it? pg. 31 professoraxe l How deep is it? Location on body How patient got the lacertaion Communicate with physician to let them know what details you will need to achieve appropriate specificity for these codes. Most codes in Chapter 19 require _____ character to indicate the "episode of care" for the patient's injury - Correct Answer- a 7th character. Time for E/Ms - Correct Answer-Time in the office setting is face-to-face time with the patient Time in the inpatient setting is unit/floor time 7th character choices for injuries are: - Correct Answer-"A" (Initial encounter) "D" (Subsequent encounter) pg. 32 professoraxe l "S82" fractures of the lower leg, including the ankle "S92" fractures of the calcaneus (heel bone/ os calcis) ________ or ________ fracture is one in which there is a break in the integument at the fracture site or fracture hematoma. - Correct Answer-"open" or "compound" The bony fragment went through the skin, or there is an opening between the skin and the fracture Words in the MR that will be a clue to an "open" or "compound" fracture - Correct Answer-"puncture" "missile" "with foreign body" "debridement of..." "cleaning the wound" In a _______ fracture, the skin remains intact overlying the fracture and its hematoma. There is no protruding bone and the skin is not broken - Correct Answer-"closed fracture" pg. 35 professoraxe l Words used in the MR to identify a "closed" fractures: - Correct Answer-"comminuted" "depressed" "elevated" "fissured" "greenstick" "impacted" "linear" "march" "simple" "transverse" ICD-10-DM Guidelines give the following defaults for fractures: - Correct Answer-* A fracture not indicated as closed or open should be classified as "closed". *A fracture that is not indicated as displaced or nondisplaced should be classified as "displaced" Use these ICD-10-CM Guidelines for assign the most specific fracture code: - Correct Answer-*Whether the fracture is traumatic or pathologic; pg. 36 professoraxe l *Whether the fracture is opened or closed; *The location of the fracture, including specific site; *The type of fracture; *The laterality of the fracture; *Whether the fracture is displaced or nondisplaced; *How the fracture is healing; *If there is a nonunion or malunion present; *and the episode of care. If the patient has multiple fractures, - Correct Answer-the fractures should be coded separately by site. The codes should be sequenced according to severity of the fractures ICD-10-CM makes a distinction between burns and ________. - Correct Answer-corrosions Burns are from a heat source Corrosions are from a chemical source pg. 37 professoraxe l Category T31 and T32 codes require both ______ and _____ code characters, which describe the percent of the body burned and the percentage of the body affected by 3rd-degree burns, respectively. - Correct Answer-4th and 5th Example: Code T31.21 indicates burns involving 20-29% of the body surface with 10-19% third degree burns Categories T31 and T32 are based on the "rule of nines". The first question you should ask when selecting a code for poisoning/adverse effect/underdosing by drugs, medicinal, and biological substances should always be________ - Correct Answer-How did it happen? That is, was the substance properly or improperly administered? A patient may have an adverse reaction to a properly administered drug, which requires different coding than if a drug was given in error. pg. 40 professoraxe l Poising / adverse effect / underdosing by drugs, medicinal, or biological substances includes codes from category _______ - Correct Answer-T36 - T50 Sequencing rule for poisoning: - Correct Answer-Assign appropriate "poisoning code" first Assign manifesttion code(s) next. This indicates improper use of a medication which includes overdose, wrong substance given, or taken in error, wrong route of administration Sequencing of codes for adverse effect: - Correct Answer- Assign code(s) for the nature of the adverse effect(s) (vomiting, hives, renal failure, etc) first Assign the adverse code next. This is when a patient had an adverse effect of a drug that was CORRECTLY prescribed and administered. Sequencing for underdosing: - Correct Answer-Assign code(s) for the nature of the underdosing first. pg. 41 professoraxe l Assign the underdosing code next. This refers to taking less of a medication than is prescribed by a provider or a manufacturer's instruction. For a Dx of drug abuse or dependence to the substance, report ______________ as an additional diagnosis. - Correct Answer- the abuse or dependence code Toxic effect codes are from category: - Correct Answer-T51 - T56 How are Toxic Effects different from poisonings? - Correct Answer-Toxic effects are different from poisoning in that they refer to substances that are chiefly non-medical in source. These codes exclude burns from chemical agents, localized toxic effects indexed elsewhere, and respiratory conditions due to external agents. When reporting toxic effects, you should also ___________________________, to specify the nature of the pg. 42 professoraxe l Z code for Inoculations/Vaccinations - Correct Answer-Used when a patient is being seen to receive a prophylactic inoculation against a disease. It may be used as a secondary code if the immunization is given during a preventive medicine encounter. Z Codes for History (of) - Correct Answer-This can include either personal history (Z85 - Z92, a past medical condition that no longer exists and for which the patient is not receiving treatment, but that has a potential for recurrence) or family history (Z80 - Z84, a patient has a family member(s) who has had a particular disease that causes the patient to be at higher risk of contracting the disease). Z codes for screening - Correct Answer-Codes Z11 - Z13, Z36 describe testing for disease in seemingly well individuals so that early detection and treatment can be provided for those who test positive for the disease; Conditions discovered during a screening visit may be assigned a secondary code. pg. 45 professoraxe l Z codes for observation - Correct Answer-Z03, Encounter for medical observation for suspected diseases and conditions ruled out Z04, Encounter for examination and observation for other reasons Z05, Encounter for observation and evaluation of newborn for suspected diseases and conditions ruled out DO NOT use an observation Z code if an injury or illness or any sign or symptom(s) related to the suspected condition are present Z Codes for Aftercare - Correct Answer-These codes are reported when the initial treatment of a disease or injury has been performed and the patient requires continued care during the healing or recovery phase, or for the long-term consequences of the disease. Z Codes for Follow-up - Correct Answer-Codes under categories Z08 - Z09 and Z39 pg. 46 professoraxe l Explain continuing surveillance following completed treatment of a disease, condition, or injury They imply that the condition has been fully treated and no longer exists. Z Codes for Specific Encounters for Care - Correct Answer- Situations when the initial treatment of a disease or injury has been performed and the patient required continued care during the healing or recovery phase, or for long consequences of the disease. Examples include Z49.01, Encounter for fitting and adjustment of extracorporeal dialysis catheter, Z43.3, Encounter for attention to colostomy, and Z44.11, Encounter for fitting and adjustment of complete right artificial leg. Z Codes for Counseling - Correct Answer-When a patient or family member receives assistance in the aftermath of illness or injury; Or support is required to cope with family or social problems pg. 47 professoraxe l Activity - These codes indicate the activity the patient was involved in when injured (like, playing tennis, running, building houses). These codes do NOT have a 7th character and are reported only once, at the initial encounter for treatment. External Cause Status - these codes indicate the patient's work status at the time of injury (like, injured at work, while doing volunteer activity, or on active duty). These codes do not have a 7th character extension and are reported only once, at the initial encounter for treatment. There are three (3) general principles regarding documentation and to ensure credit can be thoroughly verified (It is important to follow these rules of thumb): - Correct Answer-1) Documentation should be legible to someone other than the documenting physician or provider and their staff 2)The date of service, name of the patient, and the name of the provider should be easily demonstrated by the documentation. pg. 50 professoraxe l 3) The documentation should support the nature of the visit and the medical necessity of the services rendered. There are three (3) key components which are used to measure the level of E/M: - Correct Answer-History Exam Medical Decision Making There are additional components which include analysing the necessity of the service comparative to the nature of the presenting problem and crediting time spent in counseling and coordination of care when the needs of the patient are not reflected by a standard history and physical: - Correct Answer- Example: When a patient is given a new diagnosis of cancer, "time" drives the level of service. Time and activities must be documented to support the variation from component base leveling. pg. 51 professoraxe l Since coding relies on counting subjective elements, the correct interpretation requires ____________. - Correct Answer-consistency citable references, a logical argument, and ultimately - medical necessuty For certification exam purposes, you are required to assign the E/M coide based on the - Correct Answer-The three (3) key components, or time when appropriately documented. AAPC does not expect examinees to select the E/M code based on _______________________ for exam purposes. - Correct Answer-medical necessity **However, when selecting E/M codes for payers, medical necessity is the overarching requirement. **Although a high level service may be supported by documentation of the three (3) key components, it may not be medically necessary to perform all E/M elements required for a high level service. pg. 52 professoraxe l indicate the new status of the history and to leave an audit trail regarding where the original documentation is stored. Physicians should be cautioned that although a comprehensive history may be performed, _______ - Correct Answer-a comprehensive history is not always medically necessary or billable. Don't confuse the ____________ with the History of Present Illness (scoring) - Correct Answer-Chief Complaint. The _____________ is a chronological description of the development of the patient's present illness from the first sign or symptom or from the previous encounter to the present. - Correct Answer-HPI or History of Present Illness **The HPI must be documented by the provider If completed by ancilliary staff, must be signed as viewed and agreed by the physician There are _____ elements of the HPI - Correct Answer-eight (8) pg. 55 professoraxe l Location, Quality, Severity, Duration, Timing, Context, Modifying factors, and Associated signs and symptoms Locations - Correct Answer-The patient's statements regarding the anatomical place, position, or site of the chief complaint (ear pain; abdominal pain, cut foot, etc) Quality: - Correct Answer-The patient's statements regarding characteristics about the problem: How it looks or feels Example: Green phlegm; itchy ear; metallic taste; throbbing pain; whistling sound pg. 56 professoraxe l Severity - Correct Answer-The patient's statements regarding a degree or measurement of how bad it is. Example: improved; extreme pain; feeling better; intolerable pain. In some cases, the patient may rank the pain on a scale of 1 - 10 Duration - Correct Answer-The patient's statements regarding how long the complaint has been occurring or the time when the complaint first occurred. Example: It occurred fin childhood; he noticed it two weeks ago; for several years; the symptoms have been present for 3 days; woke up with it this morning Timing: - Correct Answer-The patient's statements regarding a measuresment of when or at what frequency he noticed the complaint. Example: that it is intermittent; constant; comes on in the morning; lasts for 5-minutes and then goes away pg. 57 professoraxe l Both the 1995 and 1997 DGs define the Review of Systems (ROS) as - Correct Answer-an account of body systems obtained through a series of questions seeking to spot signs and/or symptoms that the patient my be experiencing or has experienced. This query is made by the MD and/or staff verbally or via a patient intake form to best define the patient's total problem. Even though there are four (4) levels of history, there are only three (3) types of ROS The ROS defines the need for - Correct Answer-an extended examination; testing; and possible effective management options ROS elements reference - Correct Answer-signs and symptoms of which both positive and negative comments are considered There are 14 systems of the ROS - Correct Answer- Consitutional Eyes Ears, nose, throat Cardiovascular pg. 60 professoraxe l Respiratory Gastrointestinal Genitourinary musculoskeletal Integumentary Neurological Psychiatric Endocrine Hematologic/Lymphatic allergic/Immunologic The three(3) types of ROS - Correct Answer-Problem pertinent: Review of one or more components of one (1) system. Can have multiple components of one (1 system): Example: Respiratory: Cough, phlegm, chest pain on deep inspiration, wheezing, shortness of breath, etc Extended ROS: a review of two (2) to nine (9) systems Complete ROS: review of 10 or more systems. pg. 61 professoraxe l For most payers, if there is a separate documentation of at least one of the review of system elements and the provider states that the remaining systems were reviewed and negative, - Correct Answer-credit should be given for a complete ROS Example: The ROS in a patient visiting a pediatrician may read, "Denies fevers, chills, congestion, or cough. The remaining systems were reviewed and were negative." The ROS is complete. The provider documents the Constitutional and Respiratory along with stating that the other systems were also reviewed and were negative. PFSH - Correct Answer-May be obtained by the provider asking the patient by the office staff asking patient or byy patient completing a form Allergies - Correct Answer-Can be counted in the ROS or in the Past medical history Can only be counted in one (1) of them pg. 62 professoraxe l gray aread associated, and only with the __________ DGs - Correct Answer-1995 Limited and extended: It is the "amount of information documented" that determine the difference between expanded problem focused verses detailed exam. Single System exam should be "complete" Limited: If there are only brief statements, the exam would be considered expanded problem focused Extended: If there is elaboration of findings for at least two (2) of the areas and/or systems, then the exam would be detailed. Complete exam 1995 DGs: An eight-system exam; does not allow for body areas, only the organ systems (Constitutional, respiratory, cardiovascular, HEENT (includes ears, nose, mouth and throat), gastrointestinal, genitourinary, musculoskeletal, skin, neurologic, psychiatric, hematologic/lymphatic/immunologic) When speaking to a physician about how s/he conducts a physical exam: - Correct Answer-"What would make you want pg. 65 professoraxe l to perform a more detailed exam for one patient versus another?" and "Would the majority of your peers agree with you that this additional bullet was necessay?" Both the 1995 and the 1997 have these things in common for the Physical exam: - Correct Answer-1) Both have 4 levels of exams 2) Both recognize the same body areas including head and face, neck, chest including breast and axilla, the abdomen, genitalia, groin, buttocks, back including spine, and each extremity. 3) Both recognize the same organ systems 4) The DGs both require the MD to elaborate on abnormal findings as well as to describe unexpected finding and each allows brief note of "negative" or "normal" to to document normal findings or unaffected areas or systems. pg. 66 professoraxe l If a provider uses the 1997 DGs, the auditor must use the - Correct Answer-Single organ system exam and the general multisystem example to determine which provides the best results for the provider. For a Detailed Exam, there should be documentation to support two (2) bullets in at least six organ systems, or body areas, or a total of 12 bullets in two or more organ systems or body areas. For 1997 DGs, if the provider states "cardiovascular normal, respiratory normal", - Correct Answer-a bullet cannot be assigned because we do not know which of the elements of the exam were performed. Medical Decision Making - Correct Answer-The nature of the presenting problem(s) and the medical necessity of the encounter are the coder's best guide with regards to this component of the DGs The number of diagnosis and management options is based on the relative level of difficulty in making a diagnosis and the status of the problem such as whether it is controlled versus worsening. pg. 67 professoraxe l A ____________________ is counted as four (4) points - Correct Answer-New problem with additional workup Workup is defined as: - Correct Answer-Anything that the physician plans to do to make or confirm a Dx. If a physician suspects a Dx and sends the pt. on for a diagnostic test to confirm that suspicion, that diagnostic test would count as workup. If the patient is scheduled for routine blood work to monitor side effects of medication, this would not be considered additional workup. There are four (4) levels of number os diagnosis and treatment options in MDM: - Correct Answer-Mimimal = 1 point Limited = 2 points Multiple = 3 points and Extensive = 4 points The amount and complexity of data to be reviewed is measure by the need to order and review tests and the need to gather information and data - Correct Answer-Planning, scheduling, pg. 70 professoraxe l performing and reviewing clinical labs and tests from the medicine section and radiology sections are indications of data collected. There may be a need to request old records or to obtain additional history from someone other than the patient. Discussions with the performing MD about unusual or unexpected patient results are documented and can be given credit. If a MD needs to make an independent visualization and interpretation with an MRI film or a Gram stain and he or she is not billing separately for that service, it would be credited in this component of code selection (This would not be the review of someone else's summary and interpretation; but an independent review of the actual film or stain. Under MDM, discussing a patient's results with the performing or consulting MD is worth ______ point, IF it is captured in the documentation. - Correct Answer-one (1) point _________ points are given for the review and summary of data from old records or additional history gathered from someone other than the patient. pg. 71 professoraxe l _________ points are given for the independent or 2nd interpretation of an image tracing or specimen. (This is NOT just the review of the report, but the actual film image or tracing. - Correct Answer-Two (2) Medical Decision Making: Overall Risks (how measured) - Correct Answer-Risk is measured based on the physician's determination of the patient's probability of becoming ill or diseased, having complications, or dying between this encounter and the next planned encounter. The nature of the presenting problem and the urgency of the visit, comorbid conditions, and diagnostic tests for surgery are indications of risk. The 3 columns of Overall Risk (Medical Decision Making) - Correct Answer-Presenting problems Diagnostic procedures ordered Management options CMS does NOT reimburse for consultations. - Correct Answer- Bill as a new or established patient office and outpatient codes; or initial and subsequent hospital care codes pg. 72 professoraxe l ____________ can be used by all providers to report the visits that occur while the patient is admitted. - Correct Answer- Subsequent hospital care codes (99231 - 99233) If the patient is seen in the morning and then later the physician returns to discharge the patient, ____________ - Correct Answer-Only report the discharge code. It is inappropriate to code more than one E/M code per DOS. Any services performed on the same date, when related to admission, should be - Correct Answer-Included in the initial hospital care codes and NOT reported separately. This includes office visits, observation visits, and nursing facility visits if provided by the same provider on the same date of service. According to CMS, any provider can use the emergency department codes (________), as long as the service is provided in ________. - Correct Answer-(99281 - 99285) the Emergency Department (ED) setting pg. 75 professoraxe l **There is no requirement for the provider to be "assigned" to the ED to use these codes. When an ED physician requests another physician to see the patient in the ED, _________ - Correct Answer-BOTH physicians should report an ED code unless the patient is admitted. If the patient is admitted, the ED physician chooses a code from 99281-99285 and the physician admitting the patient through the ED will report an initial hospital care codes (99221 - 99223). If the patient is seen by both the ED physician and his or her personal physician in the ED, - Correct Answer-Both providers report the ED service unless one of the physicians admits the patient. In that case, the admitting physician will report the initial hospital care codes. Emergency department codes cannot be reported forrt - Correct Answer-Services rendered in the physician's office. pg. 76 professoraxe l The patient must be registered to the ED to use code (99281 - 99285). ICD-10-CM Guidelines section I - Correct Answer-The structure and Conventions of the classification and general guidelines that apply to the entire classification. ICD-10-CM Guidelines section II: - Correct Answer-Guidelines for selection of Principal diagnosis for NON-outpatient settings. ICD-10-CM Guidelines section III: - Correct Answer-Guidelines for reporting additional diagnoses in NON-outpatient settings. ICD-10-CM Guidelines section IV: - Correct Answer-Outpatient coding and reporting. Signs and symptoms that are associated routinely with a disease process should..... - Correct Answer-Not be assigned as additional codes, unless otherwise instructed by the classification. ICD-10-CM Guidelines section I, B., 5 pg. 77 professoraxe l Ventilatory management (94002-94004, 94660, 94662), Vascular access procedures (36000, 36410, 36415, 36591, 36600). Examples of vital organ failure include - Correct Answer- central nervous system failure, circulatory failure, shock, renal, hepatic, metabolic, and/or respiratory failure Inpatient critical care services provided to iinfants 29 days through 71 months of age are reported with - Correct Answer- pediatric critical care codes 99471 - 99476. Inpatient critical care services provided to neonates (28 days of age or younger) are reported with - Correct Answer- neonatal critical care codes 99468 and 99469.. The reporting of the pediatric and neonatal critical care services is not based on time or the type of unit, and is not dependent upon the type of physician or other qualified health care professional delivering the care. To report critical care services provided in the outpatient setting (i.e., the emergency department or office), - Correct pg. 80 professoraxe l Answer-for neonates and pediatric patients up through 71 months of age, use critical care codes 99291, 99292. If the same individual provides critical care services for a neonatal or pediatric patient in both the outpatient and inpatient settings on the same day, report - Correct Answer- only the appropriate neonatal or pediatric critical care code 99468-99472 for all critical care services provided on that day. Also report ______________ for neonatal or pediatric critical care services provided by the individual providing critical care at one facility but transferring the patient to another facility. - Correct Answer-99291-99292 Services for a patient who is not critically ill but happens to be in a critical care unit are rreported using - Correct Answer- other appropriate E/M codes. ___________ and ________________ may be provided to the same patient on the same date by the same individual. - Correct Answer-Critical care and other E/M services pg. 81 professoraxe l Codes __________, ______ should be reported fo the attendance during the transport of critically ill or critically injured patients older than 24 months of age to or from a facility or hospital - Correct Answer-99291, 99292 For transport services of critically ill or critically injured pediatric patients 24 months of age or young, use codes - Correct Answer-99466, 99467. Codes 99291, 99292 are used to report the _____________ of time spend in providing critical care services to a critically ill or injured patinet, even if the time spent providing the care_________. - Correct Answer-total duration of time providing care on that date is not continuous. For any given period of time spent providing critical care services, the provider must - Correct Answer-devote his/her full attention to the patient, and therefore cannot provides services to any other patient during the same period of time. The physician cannot work on any other patient during this time pg. 82 professoraxe l It should be used only once per date even if the time spent by the individual is not continuous on that date. Critical care of less than 30 minutes total duration on a given date should be reported with the - Correct Answer- appropriate E/M code. Code 99292 is used to report - Correct Answer-additional blocks of time of up to 30-minutes each beyond the first 74- minutes Example: 135-164 minutes (2hr 15 min - 2h 45 min) 99291 x1 and 99292 x3 Oberservation services: - Correct Answer-When a provider admits a patient to observation, he is evaluating a patient's condition to see if it resolves (in which case the patient can go home) or worsens (in which case the patient my be admitted). To qualify for observation, the service must be medically necessary. The physician must date and timestamp the admission orders to observation; there much be periodic pg. 85 professoraxe l assessments on the patient's condition, including nurses' notes and provider progress notes. Observation usually lasts 24 hours or less, and rarely exceeds 48 hrs. There are four (4) different code categories for observation encounters: - Correct Answer-Initial observation care (99218- 99220): Used only by the MD ordering the observation care; Discharge from Observation (99217): Used when discharge from observation occurs on a DIFFERENT date of service than the admission date. Observation or Inpatient services (Including Admission and Discharge on the same day) - 99234 - 99236: If the patient is admitted and discharge on the same day Subsequent Observation care (99224 - 99226): Dates of service which occur subsequent to the admission and prior to discharge. Usually the patient is admitted to observatioin during an ER (ED) encounter or clinic/office visit. In this case, we report - Correct Answer-only the observation code when the care in both sites is performed by the same provider and same group on the same date of service. pg. 86 professoraxe l You do NOT report an ED and observation visit if the same provider/same group physician admits the patient to observation care on the same DOS If an observation encounter spans three (3) days, here is how it is to be coded: - Correct Answer-The provider would code an initial observation code for the first date; A subsequent observation code (99224 - 99226) for the second day; and 99217 for the discharge the third day. When the patient's condition requires an inpatient admission on the same date as observation was initiated, you report - Correct Answer-the initial hospital care code (99221 - 99223) only. **If the services occur on different dates of service, both services can be coded. Nursing facility services are subcategorized into - Correct Answer-Initial Nursing Facility Visit (99304 - 99306), Subsequent Nursing Facility Visit (99307 - 99310), pg. 87 professoraxe l Prolonged service codes can only be reported in addition to other E/M codes having...... - Correct Answer-time stated in the description. Prolonged services canNOT be reported when the prolonged service is - Correct Answer-less than 30 minutes. Prolonged services that will be reported by clinical staff that is being supervised may not be reported for services of fewer than 45 minutes. ________________ describe E/M services provided for a patient without a sign, symptom, condition or illness. - Correct Answer-Preventive medicine services (99381 - 99397) Comprehensive Exam that is age-appropriate The codes are based on the age of the patient, and whether the patient is New or Established; pg. 90 professoraxe l If during the preventive medicine exam an abnormality is discovered, or a condition that already exists is addressed, - Correct Answer-A significant amount of work, above what is normally performed, the additional work can be reported with a separate E/M service code Use the modifier -25 with the additional E/M code When modifier -25 is appended to an E/M code, - Correct Answer-see if you can separate the documentation into two (2) distinct notes, one to support each service. Other preventive medicine services include - Correct Answer- Counseling Risk Factor Reduction, and Behavior Change Intervention services (provided to patients who have already developed the risky behavior) Preventive Medine Counseling is a service provided to patients to - Correct Answer-prevent a risky behavior from developing or to prevent injury from occurring. pg. 91 professoraxe l The counseling occurs to address issues such as drug abuse, family problems, diet and exercise etc. These services may NOT be reported in addition to preventive medicine visits (99381-99397) They are bundled in. Code selection is based on face-to-face time spent with the patient, and according to whether the counseling is provided to an individual or in a group setting. Smoking cessation counseling, and alcohol and substance abuse counseling are found in - Correct Answer-the behavior change intervention codes (99406; 99407 - Smoke cessation) (99408; 99409 - Alcohol and substance abuse screening and intervention) Patient returning to the office on the same DOS - Correct Answer-When a patient is seen earlier in the office and then returns later the same DOS for a refill of Rx, to receive injection or a blood pressure check -- a 2nd E/M should not be reported for the second visit If the patient returns with a "different" complaint from the earlier visit and the MD documents the key elements in the pg. 92 professoraxe l Medicare requires the physician to be on site to bill - Correct Answer-incident-to services If the requirements for incident-to billing are met, the claim is submitted - Correct Answer-under the physician's name as if he personally performed the service reimbursement is at 100% Services performed by NPPs that are not incident-to are billed - Correct Answer-under the NPPs own NPI numbers, and reimbursed at 85% Examples of incident-to and compared with NPPs billing on their own NPI - Correct Answer-1) If a patient comes for a follow up as part of the physician's treatment plan and is seen by the NPP, the service is billed under the physician's NPI number paid at 100% 2) If the patient comes in for a new problem (not seen as part of the physician's treatment plan for an established problem), pg. 95 professoraxe l this service would be billed by the NPP and paid at 85% of the fee schedule Standby Services: Code 99360 is reported when.... - Correct Answer-a physician or other qualified healthcare professional is requested by another physician/individual to be available and in the same room in case his services are needed to provide care for the patient. (A time of 30-minutes or beyond must be documented to report this code.) **If the physician or other qualified healthcare professional DOES provide care for the aptient, you CANNOT code 99360. You code the service provided, ONLY Shared/Split Visits: - Correct Answer-Occurs when an NPP and physician are involved in the same patient case. 1) In an office setting: Incident-to requirements must be met. Service can be billed by the physician. If not, it is billed by the NPP 2) In the hospital setting, if the physician performs a face-to- face encounter, the service can be billed by the physician or the NPP. If the physician only reviews the chart and discusses the case with the NPP, the service is billed by the NPP. pg. 96 professoraxe l Teaching Physician Guidelines: Services provided by teaching physicians in conjunction with resident services can be billed to Medicare if the physician is - Correct Answer-1) involved in the key or critical portions of the services that are performed by the resident. 2) The physician also needs to participate in the patient's management 3) The documentation must include the services provided by the resident was well as the services provided by the teaching physician. 4)It must be clear in the documentation that the physician performed a face-to-face encounter with the patient, or the service cannot be billed. *When the above requirements are met, combine the resident's note and the teaching physician's note to select the appropriate E/M code **For procedures, the physician must be physically there supervising the procedure being performed by the resident pg. 97 professoraxe l