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CRHCP Course & Test > Billing & Coding - Section 2: ICD10 Coding Basics > Flashcards

Billing & Coding - Section 2: ICD10 Coding Basics Flashcards

1
Q

In 1996, the administrative simplification section of HIPAA approved ____ sets, along with other data standards, to be used in the electronic submissionof health information between covered entities.

A

Code

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2
Q

In ____, the administrative simplification section of HIPAA approved code sets, along with other data standards, to be used in the electronic submissionof health information between covered entities.

A

1996

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3
Q

What are the 2 procedural code sets that report surgical procedures, diagnostic services, physician services, therapy services, and other medical supplies and services.

A

CPT

HCPCS level II

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4
Q

What are CPT codes also known as?

A

HCPCS level I

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5
Q

What is the diagnostic code set known as?

A

ICD-10-CM

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6
Q

True or False:

The origin of the CPT, HCPCS, and ICD-10 code sets predates the adoption of HIPAA but they were officially accepted as part of the act

A

True

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7
Q

CPT is a registered trademark of the ____

A

AMA

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8
Q

CPT codes was were first created by the ____ in 1966 with subsequent versions and revisions

A

AMA

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9
Q

CPT codes were first created by the AMA in ____ with subsequent versions and revisions

A

1966

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10
Q

In ____, the code set was included in the CMS healthcare common procedure coding system (HCPCS)

A

1983

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11
Q

In 1983, the code set was included in the ____

A

CMS HCPCS

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12
Q

How often are CPT codes updated?

A

At least annually

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13
Q

When is the most comprehensive CPT code update published?

A

Each fall

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14
Q

When is the most comprehensive CPT code update implemented?

A

At the first of the new calendar year

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15
Q

Other CPT code updates, which can include vaccine products, can occur when?

A

Mid-year

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16
Q

The CPT code set is maintained by the ____

A

AMA

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17
Q

The CPT code set is copyrighted by the ____

A

AMA

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18
Q

CPT codes are ____ numeric characters in length and are organized by the ____ of service

A

5

Type

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19
Q

Used to report supplies, equipment, and drugs, as well as services and devices which have been assigned temporary or new codes

A

HCPCS codes

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20
Q

Medicare codes start with ____

A

G

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21
Q

Medicaid services can also be reported with ____ codes

A

HCPCS

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22
Q

HCPCS level II codes are typically referred to as what?

A

HCPCS codes

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23
Q

Includes codes used to report certain Medicare and Medicaid services which are not reported with CPT codes

A

HCPCS codes

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24
Q

How often are HCPCS codes updated?

A

At least annually but as often as quarterly

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25
Q

Who updates HCPCS codes?

A

CMS

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26
Q

HCPCS codes are ____ characters in length beginning with a ____ followed by ____ numbers

A

5
Letter
4

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27
Q

What do J codes represent?

A

Injectible drugs

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28
Q

The International Classification of Disease (ICD) originates with the ____ and is maintained in the US by the ____ in collaboration with the National Center for Health Statistics

A

World Health Organization (WHO)

Center for Disease Control and Prevention (CDC)

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29
Q

What does the “10” in ICD-10 represent?

A

The 10th revision of the ICD code set

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30
Q

What does the “CM” indicate in ICD-10-CM?

A

That a clinical modification has been made by the US

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31
Q

These codes are used to report diseases, conditions, manifestations, and signs and symptoms.

A

ICD-10-CM

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32
Q

These codes can be used to report the reason for an encounter or service

A

ICD-10-CM

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33
Q

When did ICD-10-CM replace ICD-9-CM?

A

On October 1, 2015

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34
Q

When ICD-10-CM replaced ICD-9-CM, the new code set required more specific code assignment, which resulted in what?

A

A larger code set and new guidelines

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35
Q

True or False:

ICD 11 is out but it will be a while before the US adopts this

A

True

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36
Q

With ICD-10-CM codes, what should the code assignment match?

A

The specificity of the clinical documentation

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37
Q

The ICD-10-CM code is structured:

1st character - ____
2nd character - ____
3rd-7th characters - ____ or ____

A

Alpha
Numeric
Alpha or numeric

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38
Q

What is the added code extension within ICD-10-CM codes (7th character) used for?

A

Obstetrics, injuries, and external causes of injury

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39
Q

What do you need to watch for in the 5th or 6th charcater position for ICD-10-CM codes?

A

“Dummy” placeholder

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40
Q

What is the “first-listed” diagnosis used when sequencing ICD-10 codes?

A

The condition which occasioned the visit (chief complaint)

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41
Q

With ICD-10 codes, rule out or differential diagnoses are NOT used in ____ coding

A

Outpatient

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42
Q

True or False:

With ICD-10 codes, co-existing conditions which are present at the time of the visit and effect care of treatment cannot be listed

A

False; can be listed

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43
Q

With ICD-10 codes, ____ conditions are listed above chronic, stable conditions

A

Acute

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44
Q

With ICD-10 codes, signs and symptoms which are integral to the diagnosis SHOULD or SHOULD NOT be listed

A

Should not

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45
Q

Some EHRs require a problem to be reported for each treatment plan. What problem can this cause?

A

This can overstate the E&M level in some cases

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46
Q

With ICD-10 codes, signs and symptoms which are integral to the diagnosis should not be listed. Using the below example, which signs/symptoms would not be listed and why?

Cough, fever, pneumonia

A

Cough and fever because they are always present with pneumonia

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47
Q

With ICD-10 codes, signs and symptoms which are integral to the diagnosis should not be listed. When should signs and symptoms be listed?

A

If there is no definitive diagnosis during the encounter

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48
Q

With ICD-10 codes, conditions which have been resolved or do not affect current treatment ARE or ARE NOT coded

A

Are not

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49
Q

True or False:

Inpatient and outpaitent guidelines are different but never overlap

A

False; may overlap in some cases

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50
Q

If more than one condition was responsible for the visit, which condition should be first listed?

A

Either can be coded as the first-listed

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51
Q

If an acute problem and a chronic problem exist, which problem is listed first?

A

The acute is listed before the chronic

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52
Q

If there is a diagnosis related to a procedure and the procedure is the reason for the visit, which is first-listed?

A

The diagnosis

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53
Q

If other diagnoses contribute to the treatment plan, where are they listed?

A

Below the reason for the visit

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54
Q

If co-existing conditions are present and equally responsible for the reason for the visit, which may be coded as the first-listed diagnosis?

A

Either may be coded as the first-listed diagnosis

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55
Q

Coding example:

Patient presents for continued care of both diabetes and hypertension. Both are stable, chronic codition. Which should be first-listed?

A

Either can be listed 1st or 2nd

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56
Q

Coding example:

Patient presents for continued care of both diabetes and hypertension. The hypertension is stable, but the patient’s blood sugar is not controlled causing other manifestations. Which should be coded as first-listed?

A

The diabetes would be coded as the first-listed and the hypertension would be coded as the second-listed

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57
Q

Coding example:

Patient presents for continued care of diabetes, hypertension, and is having a skin lesion removed. Both chronic conditions are stable. Which should be coded as first-listed?

A

The diagnosis related to the skin procedures would be coded as first-listed and then the other 2 diagnoses would be in either the 2nd or 3rd positions

58
Q

Coding example:

Patient presents for a sinus infection but is also under our treatment for diabetes and hypertension. The chronic conditions are stable, but we need to consider those comorbidities and other drugs in the decision on how to treat the infection. What should be coded as first-listed?

A

The sinusitis would be the first-listed (reason for the visit and acute) and the chronic conditions would be coded 2nd or 3rd

59
Q

To properly select a code in the classification that corresponds to a diagnosis or reason for the patient encounter, locate the term in the ____ index - carefully follow indentations and “see also” terms. It is not always a straightforward journey; some IT tootls can lead you down the wrong path!

A

Alphabetic

60
Q

To properly select a code in the ICD-10 classification that corresponds to a diagnosis or reason for the patient encounter, verify the code in the ____ list. Always consult the instructional notations that appear in both the Index and Tabular list

A

Tabular

61
Q

Some EHRs will only show truncated code descriptions or will map ICD-9 codes to ICD-10 codes automatically. What problem can this cause?

A

Errors in code assignment can occur

62
Q

What is the most accurate method of ICD-10 code assignment?

A

Being able to verify a diagnosis using the code set

63
Q

The CPT evaluation and management code descriptions DO or DO NOT give enough guidance for knowing how to correctly assign the C&M levels of service

A

Do not

64
Q

Providers generally have developed their own way of deciding on a level of service since CPT E&M code descriptions do not give enough guidance for knowing how to correctly assign the E&M levels of service. What can this cause?

A

Improper code assignment

65
Q

Even though RHCs get an all-inclusive rate, the correct level of E&M service should always be reported. Why is this?

A

We report the service that we actually perform

66
Q

For Medicare RHC encounters, the patient is responsible for a co-insurance that is equal to ____% of the total charges. Assuming the correct level can affect the ____ amounts and the total ____. Also, the ____ reponsibility will be higher if we charge more.

A

20%
Coinsurance
Reimbursement
Patient

67
Q

____ should be correctly reported in order to evaluate productivity, allocation of resources, and other areas of practice management.

A

Utilization

68
Q

The clinic should report the correct level of service to ensure that the RHC is reimbursed correctly by what type of payer?

A

Fee-for-service

69
Q

Effective January 1, 2021, CMS is aligning E&M coding changes with changed adopted by the ____ CPT Editorial Panel for office/outpatient E&M visits

A

AMA

70
Q

Effective January 1, 2021, CMS is aligning E&M coding changes with changed adopted by the AMA CPT Editorial Panel for office/outpatient E&M visits, which retains ____ levels of coding for established patients and reduces the number of levels to ____ for office/outpatient E&M visits for new patients and revises the code descriptions.

A

5

4

71
Q

Effective January 1, 2021, CMS is aligning E&M coding changes with changed adopted by the AMA CPT Editorial Panel for office/outpatient E&M visits, revises the time and medical decision making process for all of the codes and requires performance of history and exam only as ____ ____

A

Medically appropriate

72
Q

The 2021 changes to E&M coding allows clinicians to choose the E&M visit level based on either ____ or ____

A

Medical decision making or time

73
Q

As of January 1, 2021, the ____ of ____ is determined either by medical decision making or total of provider time spent on the date of service

A

Level of service

74
Q

____ ____ should support the level of service

A

Clinical documentation

75
Q

History (chief complaint, HPI, ROS, and PSFH) and exam should be documented to support ____ ____

A

Medical necessity

76
Q

99211 code does exist but IS or ISN’T qualified as an RHC encounter

A

Isn’t

77
Q 
For E&M code 99202 (new patient):
History - \_\_\_\_ appropriate
Exam - \_\_\_\_ appropriate
Medical Decision Making - \_\_\_\_
Time - \_\_\_\_-\_\_\_\_ minutes
A

Medically
Medically
Straightforward
15-29 minutes

78
Q 
For E&M code 99203 (new patient):
History - \_\_\_\_ appropriate
Exam - \_\_\_\_ appropriate
Medical Decision Making - \_\_\_\_
Time - \_\_\_\_-\_\_\_\_ minutes
A

Medically
Medically
Low
30-44 minutes

79
Q 
For E&M code 99204 (new patient):
History - \_\_\_\_ appropriate
Exam - \_\_\_\_ appropriate
Medical Decision Making - \_\_\_\_
Time - \_\_\_\_-\_\_\_\_ minutes
A

Medically
Medically
Moderate
45-59 minutes

80
Q 
For E&M code 99205 (new patient):
History - \_\_\_\_ appropriate
Exam - \_\_\_\_ appropriate
Medical Decision Making - \_\_\_\_
Time - \_\_\_\_-\_\_\_\_ minutes
A

Medically
Medically
High
60-74 minutes

81
Q 
For E&M code 99212 (established patient):
History - \_\_\_\_ appropriate
Exam - \_\_\_\_ appropriate
Medical Decision Making - \_\_\_\_
Time - \_\_\_\_-\_\_\_\_ minutes
A

Medically
Medically
Straightforward
10-19 minutes

82
Q 
For E&M code 99213 (established patient):
History - \_\_\_\_ appropriate
Exam - \_\_\_\_ appropriate
Medical Decision Making - \_\_\_\_
Time - \_\_\_\_-\_\_\_\_ minutes
A

Medically
Medically
Low
20-29 minutes

83
Q 
For E&M code 99214 (established patient):
History - \_\_\_\_ appropriate
Exam - \_\_\_\_ appropriate
Medical Decision Making - \_\_\_\_
Time - \_\_\_\_-\_\_\_\_ minutes
A

Medically
Medically
Moderate
30-39 minutes

84
Q 
For E&M code 99215 (established patient):
History - \_\_\_\_ appropriate
Exam - \_\_\_\_ appropriate
Medical Decision Making - \_\_\_\_
Time - \_\_\_\_-\_\_\_\_ minutes
A

Medically
Medically
High
40-54 minutes

85
Q

A ____-____ evaluation and management service is the assessment and treatment of a presenting problem. The patient has a chief complaint.

A

Problem-oriented

86
Q

A ____ service is a defined service, or a group of services, periodically performed to aid in screening for or early detection of potential health threats

A

Preventive

87
Q

The services and frequency of preventive screenings are usually defined by who?

A

Health plan or payer

88
Q

____ determine how the preventive services are performed

A

Payers

89
Q

Preventive services are reporting using either ____ codes 99381-99397 (age specific) or the Medicare-specific level II ____ codes.

A

CPT

G

90
Q

A ____ service is being performed if the patient is asymptomatic for a screening and does not have a chief complaint

A

Preventive

91
Q

A preventive service is being performed if the patient is ____ for a screening and does not have a chief complaint

A

Asymptomatic

92
Q

A preventive service is being performed if the patient is asymptomatic for a screening and does not have a ____ complaint

A

Chief

93
Q

A new patient is a patient who has not been seen in the clinic (or by any group using the same EIN) by a provider of the same specialty within the last ____ years

A

3

94
Q

A patient is not a new patient to a new individual provider but to the ____ or ____

A

Clinic or EIN

95
Q

The ____ code registered to the individual provider’s NPI number is used to determine specialty

A

Taxonomy

96
Q

A problem-oriented evaluation and management service may include a problem that may be an ____ illness, an injury, or an ongoing ____ condition

A

Acute

Chronic

97
Q

Beginning in April 2016, CMS began requiring that procedural code detail be included on the ____ institutional bill types submitted by RHCs

A

UB-04

98
Q

True or False:

It is important to report all RHC services performed during the face-to-face encounter

A

True

99
Q

CMS introduced the -CG modifier in October ____

A

2016

100
Q

The -CG modifier is appended to the E&M ____ code or an ____-____ ____ code to report an RHC encounter and to trigger payment of the AIR rate

A

Service

In-office procedure

101
Q

The -CG modifier is appended to the E&M service code or an in-office procedure code to report an ____ encounter and to trigger payment of the ____

A

RHC

All-inclusive rate

102
Q

True or False:

The 25 modifier is used more than the 59

A

False; 59 is used more than 25

103
Q

The 25 or 59 modifier ARE or ARE NOT used on Medicare claims in the same way they are used on other payer claims

A

Are not

104
Q

What are the 25 and 59 modifiers used for?

A

To report 2 separate and unrelated RHC encounters occurring on the same date of service

105
Q

Revenue codes are used when submitting ____ claims

A

Institutional (UB-04)

106
Q

Revenue codes are maintained by who annually?

A

The National Uniform Billing Committee

107
Q

At what frequence are revenue codes maintained by the National Uniform Billing Committee?

A

Annually

108
Q

What are revenue codes used to report?

A

The location or setting in which a service was provided or a type of service

109
Q

Billing edits and denials can occur if a revenue code and ____ code are deemed a mismatch

A

Procedural

110
Q

True or False:

There are certain CPT codes that would not be performed in certain places of service

A

True

111
Q

Condition codes report ____ information needed for correct claim processing

A

Supplemental

112
Q

Category ____ codes are used to report supplemental information, such as patient data, patient status, and quality measure

A

II

113
Q

Category II codes CAN or CANNOT be reported on the UB-04 claim

A

Cannot

114
Q

How can category II codes be reported for Medicaid and other payers?

A

On the 1500 format

115
Q

The process of clarifying both diagnoses and medical services using nationally approved code sets

A

Coding

116
Q

What is the primary purpose of coding?

A

To allow the standardization of health data

117
Q

Coding IS or IS NOT a reimbursement methodology by design

A

Is not

118
Q

Coding is not a reimbursement methodology by design even though codes are used by payers to establish what?

A

Payment terms

119
Q

True or False:

If a code exists, a payer will recognize it as a payable service

A

False; just because a cost exists doesn’t mean that a payer will recongize it as a reimbursable service

120
Q

Not all valid codes are ____ codes

A

Payable

121
Q

Not all valid codes represent ____ services

A

Allowable

122
Q

The process of reporting medical services to a payer for the purpose of being reimbursed

A

Billing

123
Q

True or False:

Billing guidelines are the same from payer to payer

A

False; may vary from payer to payer

124
Q

This service occurs when other related services are provided subsequent to an intial service

A

Incident to

125
Q

What is the below an example of?

A bandage change is performed by nursing staff several days after a physician has provided wound care

A

Incident to service

126
Q

A bandage change is performed by nursing staff several days after a physician has provided wound care. This type of service is “incident to” the first encounter and ARE or ARE NOT reported as another billable encounter

A

Are not

127
Q

NPs or PAs can also be “incident to” a ____’s service if certain conditions are met

A

Physician’s

128
Q

What are the 4 “incident to” criteria?

A

1) The patient is an established patient who was initially seen by the physician
2) The problem is an existing problem for which the physician initiated treatment
3) The physician is in the office or clinic suite at the time the “incident to” service was performed by the NP or PA
4) The documentation establishes a relationship between the initial service and the subsequent “incident to” service

129
Q

In what type of clinic is there an incentive to bill NP and PA services as incident to a physician because the full fee schedule is paid?

A

Fee-for-service

130
Q

Why is there no financial benefit for billing NP and PA services as incident to in an RHC?

A

Because the AIR or encounter rate is paid for all qualified provider types

131
Q

True or False:

Most commerical plans follow the Medicare guidelines for incident to billing

A

True

132
Q

Co-signing the note does not waive the incident to ____ requirements

A

Billing

133
Q

All providers should be ____, obtain ____ provider numbers, and be linked to contract appropriately even if it means a payment reduction under some plans

A

Credentialed

Individual

134
Q

Use ____ when choosing to bill NP or PA services as incident to the supervising or collaborating physician

A

Caution

135
Q

True or False:

All plans, including MCOs, recognize “incident to” bill

A

False; some plans, including MCOs, do not recognize incident to billing at all

136
Q

Health insurance companies provide coverage only for health-realted services that they define or determine to be ____ necessary

A

Medically

137
Q

Most health plans will not pay for healthcare services that they deem as not medically necessary. These include:
____ surgical procedures
____ testing (lab and imaging) not indicated for patient’s signs and symptoms
____ tests performed at more frequent intervals than recommeded

A

Elective
Diagnostic
Screening

138
Q

Many health insurance companies also will not cover procedures, devices, or drugs that they consider to be ____ or not proven to work

A

Experimental

139
Q

National or local coverage determinations and health plan benefits also determine medical necessity. ____ of services may be required

A

Preauthorization

140
Q

True or False:

If treating for a hospice ailment, you can bill for this visit as long as it is medically necessary

A

False; cannot bill for visit even if medically necessary and must look to hospice company for payment or write-off

141
Q

Treatment for hopice ailment cannot be billed where?

A

To Medicare Part B

CRHCP Course & Test (14 decks)

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