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Medical Coding and Clinical Coding Specialist, Exams of Advanced Education

West Virginia University (WVU)Advanced Education

An overview of medical coding and clinical coding, including the role of a medical coding or clinical coding specialist, the key coding systems used (cpt-4 and icd-10), and the guidelines for reporting diagnoses and procedures. It covers topics such as the structure and organization of the icd-10 coding system, the rules for code assignment, and the criteria for selecting the principal diagnosis. The document also discusses the differences between inpatient and outpatient coding, highlighting the importance of accurate coding for patient care, reimbursement, and data reporting. Overall, this document serves as a comprehensive guide to understanding the fundamentals of medical coding and the responsibilities of a clinical coding specialist.

Typology: Exams

2023/2024

Available from 10/15/2024

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ICD 10 (Actual) Exam Solved 100% Correct
What is coding? - ANS-Transformation of verbal descriptions of diseases, injuries, and
procedures into numeric or alphanumeric designations.
What was coding originally done for? And now? - ANS-performed to classify mortality
(cause of death) data on death certificates. Done to classify morbidity and procedural
data.
What is a Classification System? - ANS-an arrangement of elements into groups
according to established criteria
What is a medical coding or clinical coding specialist? - ANS-is an individual who
reviews and analyzes health records to identify relevant diagnoses and procedures for
distinct patient encounters. The medical coding specialist is responsible for translating
diagnostic and procedural phrases utilized by healthcare providers into coded form. The
translation process requires interaction with the healthcare provider to ensure that the
terms have been translated correctly. The coded information that is a product of the
coding process is then utilized for reimbursement purposes, in the assessment of
clinical care, to support medical research activity and to support the identification of
healthcare concerns critical to the public at large." (AHIMA)
What is ICD-10 CM? - ANS-Used to report diagnoses by all; Used by hospitals to report
inpatient procedures
What is CPT-4? - ANS-Current Procedural Terminology (AMA) - Used by physicians to
report all procedures; used by hospitals to report outpatient procedures
What is ICD 10th? - ANS-• Developed and maintained by WHO (1993 release date)
• Currently in use worldwide by most developed countries
• Contains diagnosis information only
• Currently in use in U.S. in very limited capacity: coding cause of death (death
certificate)
ICD 10 CM and PCS: - ANS-• Maintained and updated by the 'four cooperating parties':
CMS, NCHS, AHIMA, AHA
• Implemented on October 1, 2015
• ICD-10-CM - International Classification of Disease, 10th Revision, Clinical
Modification contains diagnosis codes
• ICD-10-PCS - International Classification of Diseases, 10th Revision, Procedural
Coding System contains procedure codes
Who is ICD PC and CM updated by? - ANS-CMS, NCHS, AHIMA, AHA
When was the ICD 10 CM PCS implemented on? - ANS-October 1, 2015
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ICD 10 (Actual) Exam Solved 100% Correct

What is coding? - ANS-Transformation of verbal descriptions of diseases, injuries, and procedures into numeric or alphanumeric designations. What was coding originally done for? And now? - ANS-performed to classify mortality (cause of death) data on death certificates. Done to classify morbidity and procedural data. What is a Classification System? - ANS-an arrangement of elements into groups according to established criteria What is a medical coding or clinical coding specialist? - ANS-is an individual who reviews and analyzes health records to identify relevant diagnoses and procedures for distinct patient encounters. The medical coding specialist is responsible for translating diagnostic and procedural phrases utilized by healthcare providers into coded form. The translation process requires interaction with the healthcare provider to ensure that the terms have been translated correctly. The coded information that is a product of the coding process is then utilized for reimbursement purposes, in the assessment of clinical care, to support medical research activity and to support the identification of healthcare concerns critical to the public at large." (AHIMA) What is ICD-10 CM? - ANS-Used to report diagnoses by all; Used by hospitals to report inpatient procedures What is CPT-4? - ANS-Current Procedural Terminology (AMA) - Used by physicians to report all procedures; used by hospitals to report outpatient procedures What is ICD 10th? - ANS-• Developed and maintained by WHO (1993 release date)

  • Currently in use worldwide by most developed countries
  • Contains diagnosis information only
  • Currently in use in U.S. in very limited capacity: coding cause of death (death certificate) ICD 10 CM and PCS: - ANS-• Maintained and updated by the 'four cooperating parties': CMS, NCHS, AHIMA, AHA
  • Implemented on October 1, 2015
  • ICD-10-CM - International Classification of Disease, 10th Revision, Clinical Modification contains diagnosis codes
  • ICD-10-PCS - International Classification of Diseases, 10th Revision, Procedural Coding System contains procedure codes Who is ICD PC and CM updated by? - ANS-CMS, NCHS, AHIMA, AHA When was the ICD 10 CM PCS implemented on? - ANS-October 1, 2015

What does the ICD 10 CM 10th revision contain? - ANS-Contains diagnosis codes What does ICD 10 PCS contain? - ANS-Procedure codes What is an alphabetic index? - ANS-• Main terms in bold and capitalized- represent conditions or injuries

  • Subterms indented ~two spaces
  • More specific subterms indented under subterm
  • Carryover lines indented ~four spaces; complete entry couldn't fit on one line
  • Alphabetization Rules
  • With and Without appear immediately below the main term or appropriate subterm entries
  • Other connecting words (e.g. due to, following, in) appear in alpha order
  • Tables for: 1) Neoplasms and 2) Drugs and Chemicals
  • Separate Index for External Cause Codes
    • (dash) and/or √ (check) at end of Index entry indicates additional characters required
  • See Tabular Alphabetic Index: Main terms? - ANS-Main terms in bold and capitalized- represent conditions or injuries Alphabetic Index: Subterms? - ANS-indented ~two spaces
  • More specific subterms indented under subterm Alphabetic Index: Carryover line? - ANS-four spaces; complete entry couldn't fit on one line Alphabetization Rules: - ANS-With and Without appear immediately below the main term or appropriate subterm entries Other connecting words (e.g. due to, following, in) appear in alpha order Separate index for? - ANS-External Cause Codes What indicates additional characters requires? - ANS-- (dash) and/or √ (check) at end of Index entry. See the tabular. Sections - ANS-Groups of related categories Categories - ANS-3-character codes Sub-categories - ANS-4-character codes 5th, 6th, or seventh-character - ANS-Digit sublcassifications

Use Additional Code - ANS-Identifies a second code is needed to completely classify a condition which needs to be sequenced after the 'code first' code NOS - ANS-Not otherwise specified-• Interpret as 'unspecified'; indicates limitation of documentation

  • The statement being coded is not further specified (acute, chronic, etc.). Verify that documentation does not contain more specific information NEC - ANS-Not Elsewhere Classified. • Used to indicate that no separate code for the condition exists even though there the diagnostic statement is very specific
  • Search code book carefully for code before assigning See - ANS-The instruction must be followed to locate a code Gastrodynia —see Pain, abdominal Femur, femoral —see condition See Also - ANS-Not necessary to follow the note if the entry provides the necessary code Gastrojejunitis (see also Enteritis) K52. Enteritis (acute) (diarrheal) (hemorrhagic) K52. adenovirus A08. aertrycke infection A02. allergic K52. Parenthesis ( ) - ANS-- used to enclose nonessential modifiers; the term may be either present or absent in the documentation; the term does not impact on code assignment
  • Used in Tabular and Alphabetic Lists Essential Modifiers - ANS-must be present in the statement you are coding and impact on code assignment. These are listed as subterms Example Asthma, asthmatic (bronchial) (catarrh) (spasmodic) J45. cough variant J45. detergent J69. Asthma J45. Bronchial asthma J45. Detergent bronchial asthma J69. Cough variant asthma J45. Square Brackets [ ] - ANS-used in the Tabular and Index to enclose synonyms, abbreviations and alternative wordings that provide additional information.

H49.02 Third [oculomotor] nerve palsy, left eye J05.0 Acute obstructive laryngitis [croup] Colons - ANS-used in inclusion and exclusion notes; indicates that one modifier in the list that appears after the colon must be present for the statement to apply. Excludes1: acoustic neuritis (in): herpes zoster (B02.29) syphilis (A52.15) With term - ANS-is to be interpreted as 'associated with' or 'due to' when it appears in a code title, the Alphabetic Index, or an instructional note in the Tabular List. The classification presumes a causal relationship between the two conditions linked by these terms in the Alphabetic Index or Tabular List.

  • These conditions should be coded as related even in the absence of provider documentation explicitly linking them, unless the documentation clearly states the conditions are unrelated.
  • The word "with" in the Alphabetic Index is sequenced immediately following the main term, not in alphabetical order. And term - ANS-to be interpreted as and/or when appearing in a title
  • Examples 035 Maternal care for known or suspected abnormality and damage Interpreted as - Maternal care for known or suspected abnormality and/or damage A18.0 Tuberculosis of bones and joints Interpreted as - Tuberculosis of bones and/or joints Combination Code Guidelines: - ANS-Assign only the combination code when that code fully identifies the diagnostic conditions involved or when the Alphabetic Index so directs. When the combination code lacks necessary specificity in describing the manifestation or complication, an additional code should be used as a secondary code Laterality - ANS-Many codes in ICD-10-CM specify whether the condition occurs on the left, right or is bilateral. *****If no bilateral code is provided and the condition is bilateral, assign separate codes for both the left and right side*** Coding steps: CM - ANS-1. Locate the main term in the Alphabetic Index.
  1. Verify the code number in the tabular list.
  2. Continue coding diagnostic statement until all the components are fully identified.

When a subterm for both acute and chronic are listed at the same indentation level what do you list? - ANS-List the code for both acute and chronic;sequence the acute code first. What are conditions described as subacute coded as? - ANS-Code them as acute if there is not a separate subterm for subacute. Complications of care coding? - ANS-Code assignment must be based upon the provider's documentation of the relationship between the condition and the medical care/procedure performed to code a condition as a complication of care. Impending or Threatened Conditions Coding? - ANS-• If the condition actually occurred, code as confirmed

  • If the condition didn't occur, look under Main Term Threatened or Impending or look under condition as main term with threatened or impending as subterm. If the condition is listed, assign code.
  • If the condition is not listed, assign a code for the precursor condition that actually did occur.
  • Impending gangrene. Gangrene did not occur. Would code condition that was actually present; such as, cellulitis. UHDDS is mandated by who? - ANS-is a minimum data set (MDS) mandated for Medicare and Medicaid reporting and used by many other private payers. -inpatient hospitalization data set -provides definitions for several data elements -purpose: uniformity and comparability of data -definitions related to coding are presented below what is a principal diagnosis? - ANS-the condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital. AFTER STUDY -Not the admitting diagnosis or chief complaint -not the differential diagnosis. (which is the all related diseases to the symptoms) With an elective admission it is likely that the: - ANS-chief complaint/reason for admission is the PD. Ex-patient admitted for a total hip replacement. Guidelines for Selection of PD: 1

Two or more diagnoses equally meeting the definition for principal diagnosis: - ANS-- either may be sequenced first unless coding rule specifies otherwise -'equally' determined by circumstances of admission, work-up and therapy provided -example: trauma admission with two serious problems Guidelines for Selection of PD: 2 Two or more contrasting (either or; vs.) conditions - this is somewhat rare occurrence - ANS--after study still considering more than one diagnosis -code both diagnoses as confirmed -if cannot determine which diagnosis more closely meets definition for principal dx., either may be sequenced first Guidelines for Selection of PD: 3 Original treatment plan not carried out: - ANS--criteria for designation of principal diagnosis do not change. Other Diagnoses - conditions that coexist at the time of admission or develop subsequently and affect patient care for the current hospital episode -do not report diagnoses that have no impact on patient care during current hospital stay UHDDS considers a diagnosis to have 'affected the episode of hospital care' in terms of any of the following: - ANS-• Clinical evaluation (testing, consultations, close observation) -just noting on physical exam is not enough

  • Therapeutic treatment (medications, surgery, therapy, etc.)
  • Further evaluation by diagnostic studies, procedures or consultation
  • Extended length of hospital stay
  • Increased nursing care and/or other monitoring Reporting Guidelines for other Diagnoses:
  1. Previous conditions stated as diagnosis: - ANS--do not report historical information or status post procedures that have no bearing on the current stay -history of asthma in childhood that has resolved; patient now age 40 and presenting for a hernia repair (don't code) -patient status post hysterectomy in 1982; patient now admitted for AMI; (don't code) -caution: sometimes a still existing chronic condition is reported as a history; for example, 'patient with a 10 year history of hypertension;' -HTN still present and should be coded Reporting Guidelines for other Diagnoses:
  2. Other diagnosis with no documentation supporting reportability: - ANS--diagnosis noted in final diagnoses by physician should have supporting documentation within the body of the medical record