CCS-P Study Set 2023
According to AMA medical decision making is measured by - Answer-1. number of dx or management
options
2. amount and complexity
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3. risk of complications
CPT Assistant - Answer-provides official guidance in CPT coding
published by the AMA
A barrier to wide spread use of automated code assignments is - Answer-poor quality of documentation
When should coders assign codes from lab reports alone - Answer-Never. If findings are out of normal
range and the physician has ordered additional testing or treatment; consult with the physician as to
whether the Dx should be added or if an abnormal finding should be listed.
4 cooperating parties of ICD-9 and responsibilities of each - Answer-NCHS (national center for health
statistics): maintaines dx classifications in Vol 1&2
CMS: maintains procedural classification in Vol 3
AHIMA & AHA: give advice & assistance on coding guidelines in conjunction with health information
management practitioners, physicians, & other users of ICD-9
When can code 99291 (E/M critical care) be used in place of a medical visit or ER code - Answer-When the
patient meets the definition of critical care and receives outpatient care on the same day
limiting charge - Answer-this is the amount a NON PAR Medicare provider can collect from a patient in
excess of 15% over the NON PAR Medicare approved amount.
When does CMS send the payment directly to the patient - Answer-when a NON PAR provider does not
accept assignment
hard coding - Answer-refers to CPT/HCPCS codes that appear in the hospitals chargemaster and will be
included automatically on the patient's bill.
CAC- computer assisted coding - Answer-AHIMA defines as the use of computer software that
automatically generates a set of medical codes for review , validation, and use based upon the
documentation provided by the various providers of healthcare.
modifier: A1-principle physical of record - Answer-required for patients covered by Medicare when reporting
Initial Hospital Service codes
POMR- PROBLEM ORIENTED MEDICAL RECORD - Answer-Organized by problem number
Database: history and physical
Problem List: titles, numbers, dates of problems..."Table of Contents" of the record
Initial Plan: describes diagnostic, therapeutic, and patient education plans
Progress Note: documents the progress of a patient throughout the episode of care
Discharge Note/ Transfer Note: summarizes episode of care and current status of patient
Cost Sharing Provision of Health Ins. - Answer-formulary for drugs
co-pay
benefit limitations
Common Complication of Labor and Delivery - Answer-forceps or vacuum extractor delivery without
mention of indication
renal sphincter tear, not associated with 3rd degree peritoneal laceration
trauma to perineum and vulva during delivery
HIPAA law in regards to children under 18 - Answer-defers to state law on matters that concern minors
disease index - Answer-list diagnostic codes in order
physician index - Answer-lists cases in order by physician name or number
master patient index - Answer-cross reference patient name and medical record number
operation index - Answer-list medical records by operative procedures
Point of Care Service - Answer-when clinical documentation is entered in computer at the same time and
location of service
Federal Register - Answer-published by CMS. Contains both proposed and final notes for Conditions of
Participation for hospitals
NEC - Answer-Books fault> Doctor has detail documented, book does not contain matching detail
NOS - Answer-Doctors fault> Doctor lacks specific documentation although ICD has detailed options
V codes - Answer-supplemental classification
Problem based include: need for vaccine
Fact based include: history of, outcome of delivery
Service based: dialysis, chemo, therapy
When is an interval H&P permitted - Answer-when a patient is readmitted for the same or related problem
with-in 30 days
Required data for Acute Care and ER records - Answer-physical findings
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