CPT defines a separate procedure as - Procedure considered an integral part of a more major service
No combination code available - Use separate codes
... [Show More] for hypertension and acute renal failure
Documentation from the nursing staff or other allied health professionals' notes can be used to provide specificity for code assignment for which of the following diagnoses? - Body Mass Index (BMI)
POA Indicator - Y - Y-Yes, present at the time of inpatient admission
POA Indicator - N - N-No, not present at the time of inpatient admission
POA Indicator - U - U-Unknown, documentation is insufficient to determine if condition is present on admission and you cannot speak to the physician to figure it out
POA Indicator - W - W-Clinically undetermined, provider is unable to clinically determine whether condition was present on admission or not
POA Indicator - E - E-Exempt, unreported/not used, some facilities will leave these blank, others will use the letter "E"
Present on Admission Indicator (POA) - A Present On Admission (POA) indicator is required on all diagnosis codes for the inpatient setting except for admission. The indicator should be reported for principal diagnosis codes, secondary diagnosis codes, Z-codes, and External cause injury codes.
The use of the outpatient code editor (OCE) is designed to: - Identify incomplete and incorrect claims
Medicare's identification of medically necessary services is outlined in: - Local Coverage Determinations (LCDs)
Medically unlikely edits are used to identify: - Maximum units of service for a HCPCS code
National Correct Coding Initiative (NCCI) Edits are released how often? - Quarterly
In 2000, CMS issued the final rule on the outpatient prospective payment system (OPPS). The final rule: - Divided outpatient services into fixed payment groups
Diagnostic-related groups (DRGs) and ambulatory patient classifications (APCs) are similar in that they are both: - Prospective payment systems
What are APCs? - APCs or "Ambulatory Payment Classifications" are the government's method of paying facilities for outpatient services for the Medicare program.
How do APCs work? - The payments are calculated by multiplying the APCs relative weight by the OPPS conversion factor and then there is a minor adjustment for geographic location.
APC Status Indicator - C - Inpatient Procedures, not paid under OPPS
APC Status Indicator - N - Items and Services Packaged into APC Rates
APC Status Indicator - S - Significant Procedure, Not Discounted When Multiple
APC Status Indicator - T - Significant Procedure, Multiple Reduction Applies
APC Status Indicator - V - Clinic or Emergency Department Visit
APC Status Indicator - X - Ancillary Services
APC Status Indicator - Y - Non-Implantable Durable Medical Equipment
Medicare exerts control of provider reimbursement through adjustment of this component of the resource-based relative value scale (RBRVS) - Conversion factor
The process of collecting data elements from a source document is known as: - Abstracting
What piece of claims data from hospital A alerts a payer that the patient was transferred to hospital B? - Discharge disposition
Admission source code used to identify a patient admitted to the facility from home: - Non-Healthcare Facility
Admission source code used to identify a patient admitted to the facility from hospice care: - Transfer from hospice
When a patient is transferred from an acute care facility to a skilled nursing home facility, what abstracted data element can impact the DRG assignment? - Discharge disposition
A complication or comorbidity - Hypernatremia - A high concentration of sodium in the blood. Hypernatremia most often occurs in people who don't drink enough water.
A major complication comorbidity: - Acute diastolic congestive heart failure
MCC - major complication or comorbidity
increases the use of medical and hospital expenses
CC - complication or comorbidity
Which condition meets the definition of comorbidity? - Hypertension
Myocardial Infarction - CPK elevation with MB enzymes elevated and the EKG ST changes denote MI (myocardial infarction)
Coding a Cardiac Catheterization - Include:
the approach
the side of the heart into which catheter was inserted
note if any additional procedures were performed
Coding a Wound Closure - Include:
the site and length of the closure
the repair type: simple, intermediate, or complex
CHF - Congestive Heart Failure
Query - POA - Yes/No queries are permissible to establish POA status
Compliant queries include - Relevant clinical indicators
Query must: - Provide a concise presentation of facts and clinical indicators
Acute Bronchiolitis - Bronchiolitis is a common lung infection in young children and infants. It causes inflammation and congestion in the small airways (bronchioles) of the lung. Bronchiolitis is almost always caused by a virus.
Gram-negative Pneumonia - Clinical indicators include:
infiltrate in the lungs
shortness of breath
fever
chest pain
Authentication of health record entries - Prove authorship of documents
Medical Staff Bylaws - Include requirements for documentation and record completion, as well as penalties for nonadherence
Data Quality - Ensuring the accuracy and completeness of an organization's data
Information Management - Supports decision making
According to Medicare requirements, a history and physical must: - Be completed for each patient no more than 30 days before or 24 hours after admission or registration, but prior to surgery
Revenue Code - Revenue codes are 4-digit numbers that are used on hospital bills to tell the insurance companies either where the patient was when they received treatment, or what type of item a patient might have received as a patient. A medical claim will not be paid if this is missing from a bill. The revenue code tells an insurance company whether the procedure was performed in the emergency room, operating room or another department.
PSI - The Patient Safety Indicators (PSIs) provide information on potentially avoidable safety events that represent opportunities for improvement in the delivery of care. More specifically, they focus on potential in-hospital complications and adverse events following surgeries, procedures, and childbirth.
The UHDDS definition of principal diagnosis does not apply to the coding of outpatient encounters because - Short duration of the evaluation does not allow enough time to make an "after study" determination
The UHDDS definition of principal diagnosis does not apply in the: - Provider Office (Outpatient Services)
UHDDS - Uniform Hospital Discharge Data Set - A defined set of data that give a minimum description of a hospital episode or admission; recommended upon discharge for all hospital stays reimbursed under Medicare and Medicaid.
APC Codes (Ambulatory Payment Classifications) - APCs or Ambulatory Payment Classifications are the United States government's method of paying for facility outpatient services for the Medicare (United States) program. APCs are an outpatient prospective payment system applicable only to hospitals.
MS-DRGs - Medicare Severity Diagnosis Related Groups - Defined by a particular set of patient attributes which include principal diagnosis, specific secondary diagnoses, procedures, sex and discharge status.
What is difference between a DRG and a MS-DRG? - Medicare Severity-Diagnosis Related Groups (MS-DRG) is a severity-based system. So the patient might have five CCs, but will only be assigned to the DRG based on one CC. In contrast to MS-DRGs, full severity-adjusted systems do not just look at one diagnosis.
All Patients Refined Diagnosis Related Groups (APR DRG) - a classification system that classifies patients according to their reason of admission, severity of illness and risk of mortality.
All APR DRGs have 4 severity levels.
All Patient DRGs (AP-DRGs) - an expansion of the basic DRGs to be more representative of Non-Medicare populations such as pediatric patients. The All Patient Refined DRGs (APR-DRG) incorporate severity of illness subclasses into the AP-DRGs.
Prolonged Pregnancy - 42 weeks +
Cardiac Lead - use of a guide wire - percutaneous approach
CPT - an endoscopy that is undertaken to the level of the midtransverse colon - colonoscopy
A patient admitted with pneumococcal pneumonia and severe pneumococcal sepsis - Assign codes for sepsis, pneumonia and severe sepsis
Code three codes
A code for the systemic infection is sequenced first followed by the code for the localized infection and a code from category R65.2
Patient admitted with insulin dependent diabetes (type of diabetes not specified) - If not specified, the default is E11.- Type 2 diabetes mellitus
Patient admitted with unstable angina & congestive heart failure. What is the coding sequence? - Assign both codes (unstable angina & CHF), sequence either first
Facilities use X modifiers in place of which modifier - 59
Patient admitted with SOB & CHF - develops respiratory failure - Respiratory Failure is listed as a secondary Dx - does not meet the definition of a primary Dx
Congestive Heart Failure & Respiratory Failure
The Outpatient Code Editor (OCE) has all of the following types of edits except - valid diagnosis edits
The Outpatient Code Editor looks for invalid entries: - Sex & procedure edits
Invalid revenue edits
Diagnosis & age edits
The National Correct Coding Initiative (NCCI) Edits apply tp services billed by - The same provider, for the same beneficiary, on the same date of service
Medicare payment to physicians for services rendered is made under the - Resource-based Relative Value Scale
Inpatient procedures are coded with - ICD-10_PCS
Under the Inpatient Prospective Payment System (IPPS), what can be used to measure the cost of care for inpatients? - Case-mix index
The abstracting of this data element has an impact on the DRG reimbursement - Discharge disposition
Which of the following is a data element that coders typically are tasked with abstracting? - Date of surgery
When a patient goes home with an order for home health to start one week after an inpatient admission, this is categorized as a - discharge
Major complications & comorbidities (MCCs) are determined to require the greatest degree of resources with a payment group and also reflect the greatest - SOI - Severity of Illness
Major complications & comorbidities (MCCs) - Type 2 Myocardial Infarction
Asthma with status asthmaticus - An acute asthmatic attack in which the degree of bronchial obstruction is not relieved by the usual treatment, such as epinephrine and aminophylline
Patient discharged with Dx acute pulmonary edema due to congestive heart failure - Code: Congestive Heart Failure
Diagnosis listed as "possible" or "rule out" - Outpatient coding does not permit the use of "possible" or "rule out" diagnoses.
The most challenging type of provider query is issued for - Establishing clinical validation
When creating a compliant query to clarify conflicting information from the surgeon and the attending physician, to whom should the query be directed - attending physician
Verbal queries - Must have a written response in the record for coding purposes
Most hospitals require a medical record to be completed within - 30 days
A completed and signed operative report needs clarification of the size of the skin lesions that were removed. What process is used for that clarification? - Amendment
Conditions on the hospital-acquired condition list: - Stage 3 & 4 pressure ulcers are on the HAC list
What is the term used for applying the HIPAA privacy rule over state rule(s) which are less strict? - Preemption
According to the UHDDS, section 3, the definition of other diagnoses is all conditions that: - Coexist at the time of admission, that develop subsequently, or that affect the treatment received or the length of stay
Which patient specific UHDDS items also have the potential to an impact on MS-DRG assignment? - Sex and discharge disposition
Inpatient setting - "Rule Out" Dx - In this setting, "rule out" Dx are coded as if they exist
Open biopsy for a frozen section immediately before definitive surgery - Code both: Open Biopsy & Definitive Surgery
Exploratory surgery not coded when definitive surgery is performed
The "code if applicable, any causal condition first" note in the ICD-10-CM Tabular list indicates that this code may be assigned when the causal condition is unknown or not applicable. When the causal condition is known, the code for that condition may be reported as which type of diagnosis? - Principal
Functions of the Outpatient Code Editor (OCE) - Editing the data on the claim for accuracy
Specifying the action the FI should take when specific edits occur
Assign APCs to the claim (for hospital outpatient services)
Determining payment-related conditions that require direct reference to HCPCS codes and modifiers
Units of service - Number of body parts
NOT a function of the Outpatient Code Editor (OCE) - Determining payment-related conditions that require direct reference to ICD-10-CM codes
Medicare reimburses inpatient stays based on - MS-DRGs
Esophageal varices - Often associated with Cirrhosis of the liver
Neurogenic claudication - Leg pain, tingling & cramping when present with lumbar stenosis
A discrepancy in the record while the patient is still on the floor - who is responsible for obtaining clarity on the information? - Clinical document specialist
Morbid obesity - Coder cannot assign without physician documentation of the condition
Compliant multiple choice queries can: - provide a new diagnosis with supporting clinical indicators
Sepsis/Septic Shock - Fever, chills, tachycardia, tachypnea, lactic acidosis (signs of sepsis) when you add respiratory issues requiring mechanical ventilation & circulatory failure (vasopressers) - points to septic shock
Under which of the following circumstances does a facility lose a potential increase in reimbursement when a hospital acquired condition (HAC) is coded with POA indicator "Y" - When the HAC is the only CC/MCC on the account
HAC & POA indicators were implemented by Medicare to address - Quality issues
Under HIPAA, every organization must have - Privacy & Security Officers
According to the UHDDS, the definition of a secondary diagnosis is a condition that: - Receives clinical evaluation, therapeutic treatment, further evaluation, extends the length of stay, increases nursing monitoring and care
The UHDDS definition of principal procedure indicates that the principal procedure can be assigned for which of the following? - Ad [Show Less]