Medical Coding: ICD-10 Coding Fundamentals and Practice, Exams of Medicine

Download Medical Coding: ICD-10 Coding Fundamentals and Practice and more Exams Medicine in PDF only on Docsity! Medical Coding 300+ questions with answers to study ICD-10 coding Coding is - ANS the process of translating this written or dictated medical record into a series of numeric or alpha-numeric codes Proper code assignment is determined by - ANS content of the medical record and by the unique rules that governs each code set What are 3 things that Coder must master - ANS 1. anatomy 2. medical terminology 3. must be detail-oriented Medical coders assign a code to what - ANS 1. Each diagnosis 2. Service/procedure 3. Supply, using the classification system when applicable The classification system determines ______ - ANS the amount health care providers will be reimbursed if the patient is covered by Medicare, Medicaid, or other insurance programs using the system A coder must evaluate the medical record for - ANS 1. completeness and accuracy 2. communicate regularly with physicians and the health care professional to clarify DX or obtain additional PT info. Techicians who speciallize in coding inpatient hospital services are referred as - ANS 1. Health information coders 2. medical record coders 3. Coder/abstractors 4. Coding Specialist What is MS-DRGs and what does it do? - ANS 1. Medicare Severity-Diagnosis Related Groups 2. Determines the amt the hospital will be reimbursed if the PT is covered by Medicare or other insurance programs What is EHR - ANS Electronic health record Skilled coders may become - ANS consulatants, educators or medical auditors What is the difference between Hospital and Physican Services - ANS 1. Outpatient coding (physician services)- learning CPT, HCPCS, LEVEL II, ICD-9 CM codes Volume 1 and 2 2. Inpatient coding (Hospital services)- Learning CPT, ICD-9 CM codes Volumes 1,2,3 and MS-DRGS What is APC and who uses it - ANS Ambulatory Payment Classification- outpatient facility coders (physician services What is the coder's role in a physician's office - ANS Extremely important for the proper reimbursement of services and the livelihood of the physician What is a physican degree of education - ANS 4 years of college, 4 years of medical school plus 3 to 5 years of residency. What are mid-level providers and who can be classified as one? - ANS 1. Mid-level providers are know as physician extenders 2. Physician assistants (PA) and Nurse Practitioners (NP) What does the CMS-HCC provide - ANS Risk adjument model provides adjusted payment based on a patient's disease and demographic factors. If a coder does not include all pertinent diagnoses and co-morbidities, the provider may lose out on what - ANS additional reimbursement for which he/she is entitled. What is Medicare Part D - ANS Prescription drug coverage program available to all Medicare beneficiaries. Private companies approved by Medicare provide the coverage. What is Medicaid - ANS A health insurance assistance program for some low income people (especially children and pregnant women) sponsored by federal and state governments Medicaid is administered on___________ - ANS a state-by-state basis and coverage varies- although each of the state programs adheres to certain federal guidelines When is a physican considered a "participating physician" - ANS When contracted with a insurance carrier whether that be a private insurance company or a governmental. Participating Providers (Par Providers) are required to accept__________________ - ANS the allowed payment amount determined by the insurance carrier as the fee for payment and follow all other guidelines stipulated by the contract The difference between the physican's fee and the insurance carriers allowed amount is - ANS adjusted by the participating provider Non-participating Providers (non par) are? - ANS 1. providers not contracted with the insurance carriers 2. not required to make the adjustment What is limiting charge - ANS Limits set on what can be charged for each CPT code, no matter if the physican is Par or Non-Par What is a medical record - ANS Documentation or the recording of pertinent facts and observation about an individual's health history, including past and present illness, tests, treatments and outcomes Medical record chronologically - ANS documents patient care to assist in continuity of care between providers, facilitate claims review and payment Can a Medical record serve as legal document - ANS YES All services provided to a patient are_______ - ANS supported and documented in the medical record What are coders required to do with the medical records? - ANS Read and understand the documentation in the medical record in order to accurately code the services rendered. What are some different types of services documented in a medical record? - ANS Evaluation and management Operative reports X-Rays Evaluation and Management services are provided in what standard format - ANS SOAP What is SOAP documentation? - ANS S- Subjective O-Objective A- Asssessment P-Plan What is the definition of O in SOAP? - ANS objective-The provider assesses and documents the patient's illness using observation, palpation, auscultation and percussion. Test and other services performed may be documented here as well What is the definition of A in SOAP? - ANS Assessment-Evaluation and conclusion made by the provider. This is usually where the diagnosis(es) for the services are found What is the definition of P in SOAP? - ANS Plan-Course of Action. Here, the provider will list eh next steps for the patient, whether it is ordering additional test, or taking over the counter medication What is a operative report - ANS a document the detail of a procedure performed on a patient What will most operative notes have - ANS Header and Body what are some of things that operative header note might include? - ANS 1. Date and time of procedure 2. Name of surgeon, co-surgeon, assistant surgeon 3. Typer of anethesia and anestheiology provider name 4. Pre-operative and post-operative diagnoses 5. Procedures performed 6. Complications What are some of things that operative body note might include? - ANS 1. indication for surgery 2. details of the procedure (s) 3. Findings 2. MAC is responsible for interpreting national policies into regional policies. The LCDs further define what codes are needed and when an item or service will be covered . LCD have jurisdiction only with their regional area What is MAC? - ANS Medical Administrative Contractor If a NCD does not exist what are CMS guidelines? - ANS Where coverage of an item or service is provided for specified indications or circumstances but is not explicitly excluded for others, or where the item or service is not mentioned at all in the CMS Manual System, the Medicare contractor is to make the coverage decision, in consultation with its medical staff and with CMS when appropriate, based on the laws, regulations, ruling and general program instructions. How often should Practices check policies to maintain compliance? - ANS Quarterly What does ABN stand for - ANS Advance Beneficiary Notice of Noncoverage, or Advance Beneficiary Notice What is an ABN? - ANS A standardized form that explains to the patient why medicare may deny a particular service or procedure. What does ABN protect? - ANS The provider's financial interest by creating a paper trail that CMS requires before a provider can bill the patient for payment if Medicare denies coverage for the stated service or procedure What must the provider complete (in regards to ABN)? - ANS 1. Complete one-page form in full 2. giving the patient an explanation as to why Medicare is likely to refuse coverage for proposed procedure or service What are some of the common reasons why Medicare may deny a procedure and service? - ANS 1. Medicare does not pay for the procedure/service for the patient's condition 2. Medicare does not pay for the procedure/service as frequently as proposed 3. Medicare does not pay for experimental procedure/services What must the provider present to the patient on the ABN for a proposed procedure or service? - ANS Cost Estimate What do CMS instructions stipulate on Cost estimate? - ANS Notifiers must make a good faith effort to insert a reasonalble estimate...the estimate should be within $100 or 25% of the actual costs, whichever is greated. When do CMS rules require the provider to present the ABN to patient? - ANS Far enough in advance that the beneficiary or representative have time to consider the options and make an informed choice. What must be done BEFORE the patient signs the ABN - ANS 1. ABN must be verbally received with beneficiary or his/her representative 2. Any questions raised during that review must be answered After the ABN is signed, What are some choices the patient has? - ANS 1. Proceed with procedure/service and assume financial responsibility. If the patient chooses to proceed, he may request the charge be submitted to Medicare for consideration (with the understanding that it will probably be denied 2. Elect to fore go the procedure or service. What must go to the patient and to the provider - ANS 1. Copy of completed signed form must be given to beneficiary or representative 2. The provider must retain the original notice on file What action can the provider take if the patient refuses to sign the ABN? - ANS If the patient still requests the procedures or services but refuses to sign a properly-presented ABN, the provider should document the patient's refusal. The provider and a witness should then sign the form. When is a ABN never required and WHY? - ANS 1. Emergency and urgent care situation 2. CMS prohibits giving an ABN to a patient who is "under duress," including patients who need Emergency Department service before stabilization What is HIPAA - ANS Health Insurance Portability and Accountability Act of 1996 How many Acts are under HIPAA - ANS 5 Which is the most important Title concerning the position of a medical coder? - ANS Title II-Preventing Health care Fraud and Abuse; Administrative Simplication; Medical Liability Reform What is Title II of HIPAA known as? - ANS Administration Simplification Administration Simplification speaks to ________ - ANS the increasing use of technology in the health care industry Administration Simplification (HIPAA) addresses the need for - ANS 1. National standards for electronic health care tranaction and code sets 2. National unique indentifiers for providers, health plans and employers 3. Privacy and Security of health data Who is under the covered entity - ANS 1. health care providers 2. Health plans 3. Health care Clearinghouse Who is under the "health care providers covered entity"? - ANS 1. Doctors When will ICD-10-CM be effective? - ANS October 1, 2013 What does the acronym NDC stand for? - ANS National Drug codes What does the acronym NPI stand for and who uses it? - ANS 1. National Provider Indentifier 2. indentifier for providers required on the transactions What does the acronym EIN and who uses it? - ANS 1. Employer Indentification Number 2. Issued to employers by the Internal Revenue Services (IRS) Who enforces the HIPAA privacy rule? - ANS OCR (Office of Civil Rights) What does the acronym OCR stand for? - ANS Office of Civil Rights What does the OCR do? - ANS Protects the privacy of individually identifiable health information; HIPAA Security Rule Patient Safety Rule What is the HIPAA Security Rule according to the OCR? - ANS Sets national standards for the security of electronic protected health information and the confidentiality provision of the patient Safety Rule What is the Patient Safety Rule according to the OCR? - ANS Protects identifiable information being used to analyze patient safety events and improve patient safety What is the acronym PHI stand for? - ANS Protected health information What does acronym TPO stand for? - ANS Treatment Payment and Health Care Operations When and who can a covered entity disclose health information to? - ANS 1. A covered entity may use or disclose protected health information for its own treatment,payment or health care operations 2. A covered entity may disclose protected health information for treatment activities of a health care provider 3. A covered entity may disclose protected health information to another covered entity or a health care provider for the payment activities of the entity that receives the information 4 A covered entity may disclose to another covered entity for health care operation activities of the entity that receives the information, if each entity either has or had a relationship with the individual who is the subject of the protected health information 5. A covered entity that participates in an organized health care arrangement may disclose protected health information about an individual to another covered entity that participates in the organized health care arrangement for any health care operations activities of the organized health care arrangement What is the HIPAA minimum necessary requirement? - ANS The minimum necessary protected health information should be provided to satisfy a particular purpose. if the information is not required to satisfy a particular purpose, it must be withheld. Under the Privacy rule the minimum necessary standards does not apply to the following________ - ANS 1. Disclosures to or requests by a health care provider for treatment of purposes 2. Disclosures to the individual who is the subject of the information 3. Uses or disclosures made pursuant to an individual's authorization 4. Uses or disclosures required for compliance with the HIPAA Administrative Simplification Rules 5. Disclosures to the U.S. Department of Health and Human Services when disclosure of the information is required under the Privacy Rule for enforcement purposes 6. Uses or disclosures that are required by other laws What does the acronym HITECH stand for? - ANS Health Information Technology for Economic and Clinical Health Act What does the acronym ARRA stand for? - ANS American Recovery and Reinvestment Act of 2009 HITECH was enacted as part of what? - ANS American Recovery and Reinvestment Act of 2009 (ARRA) What does ARRA and HITECH promote? - ANS The adoption and meaningful use of health information technology Portions of HITECH strengthen HIPAA rules by_______ - ANS addressing the privacy and security concerns assoicated with the electronic transmission of health information HITECH has how many categories of violation - ANS Four What do the categories of ARRA depend on? - ANS The covered entity's level of culpability for releasing protected information and minimum and maximum penalties. HITECH lowers ________ for what constitutes a violation but provides ________ during which any violation not due to willful neglect may be corrected without a penalty. - ANS 1. Lowers the Bar 2. 30-Day window HITECH allows patients to do what? - ANS 1. request an audit trail showing all disclosures of their health information made through an electronic record 2. requires an individual to be notified if there is an unauthorized disclosure or use of his or her health information What should all physician's office and health care facilities have and actively use? - ANS A compliance plan Identify the following prefix of location : Dia- - ANS Through; complete Identify the following prefix of location : Per- - ANS Through Identify the following prefix of location : Trans- - ANS through; across Identify the following prefix of time : Ante- - ANS before; forward Identify the following prefix of time : Pre- - ANS Before, in front of Identify the following prefix of time : Pro- - ANS Before, in front of Identify the following prefix of time :Post- - ANS after, behind Identify the following prefix of number : Mon/o - ANS one; single Identify the following prefix of number : Bi- - ANS two, twice Identify the following prefix of number :Tri- - ANS Three Identify the following prefix of number : Quadri- - ANS Four Identify the following prefix of number : Poly- - ANS Many, much What does the term "suffix" mean and where does come from? - ANS 1. to fasten underneath 2. Latin word subfigure What are some of the common suffixes for diseases and meaning? - ANS 1. -itis-inflammation 2. -oma-tumor 3. -pathy- disease of identify the following suffix :-gram - ANS a record of data identify the following suffix: -graph - ANS instrument for recording data identify the following suffix: -graphy - ANS act of recording data Identify the following suffix: -meter - ANS Instrument of measuring Identify the following suffix: -scope - ANS instrument for viewing or examining identify the following suffix: -scopy - ANS examination of identify the following suffix: -centesis - ANS puncture, tap identify the following suffix: -desis - ANS binding, fusion identify the following suffix: -ectomy - ANS excision, surgical removal identify the following suffix: -pexy - ANS surgical fixation identify the following suffix: -plasty - ANS plastic repair, plastic surgery, reconstruction identify the following suffix: -rraphy - ANS surgical repair, suture identify the following suffix: -stomy - ANS surgical creation of an opening identify the following suffix: -tome - ANS Instrument for incising (cutting) identify the following suffix: -tomy - ANS incision, cutting Identify the following suffix: - tripsy - ANS crushing What is the standard body position and what is it? - ANS 1. anatomical position 2. an upright, face-forward position with the arms by the side and palms facing forward. The feet are parallel and slightly apart What does Anterior or Ventral mean? - ANS toward the front of the body What does Posterior or Dorsal mean? - ANS toward the back of the body What does Medial mean? - ANS Towards the mid line of the body What does Lateral mean? - ANS Toward the side of the body What does Proximal mean? - ANS nearer to the point of attachment or to the given reference point What is mitosis? - ANS Cells divide and multiply to form two cells How many cavities does the body have? - ANS 5 What are the 5 types of body cavities and what is in the space? - ANS 1. cranial cavity- inside the skull, or cranium, containing the brain 2. Spinal (Vertebral canal)- inside the spinal column containing the spinal cord 3. Thoracic or chest cavity- the space containing the heart, lungs, esophagus, trachea, bronchi, and thymus 4. Abdominal cavity- the space containing the lower portion of the esophagus, the stomach, intestines (excluding the sigmoid colon and rectum) kidneys, liver, gallbladder, pancreas, spleen and ureters 5. Pelvic cavity- the space containing the urinary bladder, certain reproductive organs, part of the large intestine, and the rectum How many types of membranes are there in the human body? - ANS 5 What are 5 types of membranes in the human body? - ANS 1. Mucous Membrane 2. Serous Membrane 3. Synovial Membrane 4. Meninges What is the mucous membrane composed of? - ANS Epithelium overlaying a layer of connective tissue called Lamina Propria What is the job of epithelium in mucous membranes? - ANS It is involved in absorption and secretion Where do mucous membranes line? - ANS The interior walls of the organs and tubes opening to the outside of the body What is the serous membrane composed of? - ANS A layer of simple squamous epithelium overlaying a layer of loose connective tissue. What does the serous membrane support? - ANS internal organs What does the serous membrane compartmentalize? - ANS The large cavities to hinder spread of infection What does the serous membrane line? - ANS Cavities including the thoracic cavity and internal organs What is synovial membrane composed of? - ANS Connective tissue What do synovial membranes line? - ANS Joint cavities What do synovial membranes do? - ANS 1. secrete synovial fluid into the joint cavity 2. lubricates the ends of of bones so they move freely What are meninges composed of? - ANS 3 connective tissue membranes Where are meninges found? - ANS Located within the dorsal cavity What do the meninges do? - ANS They serve as a protective covering what does the cutaneous membrane consist of - ANS a thin outer layer of stratified squamous epithelium attached to a thicker underlying layer of connective tissue. What does the cutaneous membrane form? - ANS the outer covering of the body What is another term for cutaneous membrane? - ANS skin What is connective tissue? - ANS A number of different tissues with common features. What is the purpose of connective tissue? - ANS Provides a framework to support the entire body by cartilage and bones What are the four general groups of connective tissue? - ANS 1. Bone 2. Adipose tissue 3. Cartilage 4. Blood The largest organ system in the body is comprised of what 3 structures? - ANS 1. skin 2. hair 3. Nail What is largest organ system called? - ANS integumentary system The integumentary system structures work together to provide what functions within the body? - ANS 1. Protection from injury, fluid loss, and microorganism 2. Temperature regulation 3. Fluid balance-excretion 4. Sensation Subcutaneous tissue is mostly composed of __________ - ANS fatty or adipose tissue plus some areolar tissue What is areolar tissue? - ANS loose connective tissue consisting of a meshwork of collagen, elastic tissue and reticular fibers. The hypodermis serves to _________ - ANS 1. protect the underlying structures 2. prevent the loss of body heat 3. anchor the skin to the underlying musculature What is the fibrous connective tissue that is included in the hypodermis? - ANS superficial fascia Define cutaneous - ANS Pertaining to the skin Define dermatology - ANS the study of the skin Define dermatologist - ANS Physician specializing in diseases of the skin and subcutaneous tissue Define decubitus - ANS Pressure ulcer/bedsore Define ecchymosis - ANS Condition in which blood seeps into the skin causing discoloration Define hypodermic - ANS Pertaining to under the skin Define intradermal - ANS Pertaining to within the skin Define jaundice - ANS Yellowness of skin Define melanin - ANS Pigment giving color to the skin Define melanoma - ANS Pigmented tumor of the skin Define pediculosis - ANS Infestation with lice Define subcutaneous - ANS Pertaining to below the skin Define tinea - ANS Ringworm; a fungal infection of the skin By which week does a developing fetus have its lifetime supply of hair follicles? - ANS By 22 weeks On average a human body has how many follicles - ANS 5 million follicles Where is greatest concentration of hair follicles? - ANS head Hair on the scalp grows approximately how much per day and per year - ANS 1) .3 to .4 mm/day 2) @ 6 inches per year What are 2 structures of hair? - ANS 1. follicle 2. shaft The shaft is composed of keratin in what 3 layers? - ANS 1. medulla 2 cortex 3. cuticle Pigment cells are in what layer of the shaft? - ANS The cortex What layer gives hair its charactertistic color? - ANS The medulla What is a fingernail made of? - ANS keratin What is the purpose of keratin on the fingernail? - ANS 1. protective plate 2. counterforce to the finger tip to increase sensory input of touch Nails grow all the time but the rate of growth slow with _____ - ANS Age and poor circulation Fingernails grow at an approximate rate of _______ - ANS of 3mm per month Toenails grow at an approximate rate of _______ - ANS 1 mm per month What are the 6 specific parts of the nail? - ANS 1. root 2. nail bed 3. nail plate 4. eponychium (cuticle) 5. perionychium 6. hyponychium Where are tubular bones found? - ANS Long tubular bones are found in the extremities. Short tubular bones are found. Short tubular bones are found in the hands and feet. Define the classification of SHORT bones. - ANS Roughly cube shaped bones located in the foot and wrist. Define the classification SESAMOID of bone - ANS Bones that develop in specific tendons What is the largest sesamoid bone - ANS the patella Define the classification CUBOIDAL of bone - ANS referred to as short bones Define the classification of FLAT of bone - ANS Consists of a layer of spongy bone between two thin layers of compact bones; Cross-section is flat not round. Flat bones have marrow but lack what? - ANS The lack a bone marrow cavity Define the classification of an irregular bone - ANS Bones in the body not fitting into and specified classification Vertebrae are considered what? - ANS They are considered irregular bones What is cartilage? - ANS It is a type of flexible connective tisssue (T/F) Cartilage is nonvascular or has no blood vessels - ANS True What is cartilage is made of? - ANS It is made of a matrix of chondrocytes, collagen, cells called proteoglycans depending on the type of cartilage Joints and articulating surfaces provide what? - ANS A connection between two or more parts of skeleton Joints are classified according to what? - ANS They are classified according to the type of connective tissue at the articulating surfaces What are the 3 types of joints? - ANS 1. fibrous 2. cartilaginous 3. Synovial What are the characteristics of synovial joints? - ANS 1. Articular cartilage that covers the bone ends 2. Joint cavity lined with synovial membrane 3. Joint capsule of fibrous connective tissue that surrounds and provides stability of the joint 4. Accessory ligament that give reinforcement The human skeleton is divided in which 2 parts - ANS 1. Axial 2. Appendicular What does the axial skeleton consist of? - ANS It consists of the skull, hyoid/cervical spine, ribs, sternum, vertebrae, sacrum What does the appendicular skeleton consist of - ANS It consistes of the shoulder girdle, pelvic girdle, extremities Define closed fracture - ANS A fracture that does not involve a break in the skin. Define compound fracture - ANS A fracture that projects through the skin increasing th possibility of infection Define comminuted fracture - ANS A fracture shattered into bony fragments Define transverse fracture - ANS A fracture that breaks the shaft of a bone across the longitudinal axis Define greenstick fracture - ANS A fracture where only one side of the shaft is broken, and the other is bent. Common in children Define spiral fracture - ANS A fracture spread along the length of a bone and produced by twisting stress Define Colles' fracture - ANS A fracture of the distal radius in the forearm with dorsal (posterior) displacement of the wrist and hand Define compression fracture - ANS It is a collapse of a vertebra. It may be due trauma, tumor or osteoporosis Define epiphyseal fracture - ANS It iss a fracture at one of the ends of a long bone that involves the bone's growth plate What are 3 types of muscles found in the body - ANS 1. Skeletal Muscle 2. Cardiac Muscle 3. Smooth Muscle