Billing & Coding - Section 2: ICD10 Coding Basics Flashcards
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.
Code
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.
1996
What are the 2 procedural code sets that report surgical procedures, diagnostic services, physician services, therapy services, and other medical supplies and services.
CPT
HCPCS level II
What are CPT codes also known as?
HCPCS level I
What is the diagnostic code set known as?
ICD-10-CM
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
True
CPT is a registered trademark of the ____
AMA
CPT codes was were first created by the ____ in 1966 with subsequent versions and revisions
AMA
CPT codes were first created by the AMA in ____ with subsequent versions and revisions
1966
In ____, the code set was included in the CMS healthcare common procedure coding system (HCPCS)
1983
In 1983, the code set was included in the ____
CMS HCPCS
How often are CPT codes updated?
At least annually
When is the most comprehensive CPT code update published?
Each fall
When is the most comprehensive CPT code update implemented?
At the first of the new calendar year
Other CPT code updates, which can include vaccine products, can occur when?
Mid-year
The CPT code set is maintained by the ____
AMA
The CPT code set is copyrighted by the ____
AMA
CPT codes are ____ numeric characters in length and are organized by the ____ of service
5
Type
Used to report supplies, equipment, and drugs, as well as services and devices which have been assigned temporary or new codes
HCPCS codes
Medicare codes start with ____
G
Medicaid services can also be reported with ____ codes
HCPCS
HCPCS level II codes are typically referred to as what?
HCPCS codes
Includes codes used to report certain Medicare and Medicaid services which are not reported with CPT codes
HCPCS codes
How often are HCPCS codes updated?
At least annually but as often as quarterly
Who updates HCPCS codes?
CMS
HCPCS codes are ____ characters in length beginning with a ____ followed by ____ numbers
5
Letter
4
What do J codes represent?
Injectible drugs
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
World Health Organization (WHO)
Center for Disease Control and Prevention (CDC)
What does the “10” in ICD-10 represent?
The 10th revision of the ICD code set
What does the “CM” indicate in ICD-10-CM?
That a clinical modification has been made by the US
These codes are used to report diseases, conditions, manifestations, and signs and symptoms.
ICD-10-CM
These codes can be used to report the reason for an encounter or service
ICD-10-CM
When did ICD-10-CM replace ICD-9-CM?
On October 1, 2015
When ICD-10-CM replaced ICD-9-CM, the new code set required more specific code assignment, which resulted in what?
A larger code set and new guidelines
True or False:
ICD 11 is out but it will be a while before the US adopts this
True
With ICD-10-CM codes, what should the code assignment match?
The specificity of the clinical documentation
The ICD-10-CM code is structured:
1st character - ____
2nd character - ____
3rd-7th characters - ____ or ____
Alpha
Numeric
Alpha or numeric
What is the added code extension within ICD-10-CM codes (7th character) used for?
Obstetrics, injuries, and external causes of injury
What do you need to watch for in the 5th or 6th charcater position for ICD-10-CM codes?
“Dummy” placeholder
What is the “first-listed” diagnosis used when sequencing ICD-10 codes?
The condition which occasioned the visit (chief complaint)
With ICD-10 codes, rule out or differential diagnoses are NOT used in ____ coding
Outpatient
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
False; can be listed
With ICD-10 codes, ____ conditions are listed above chronic, stable conditions
Acute
With ICD-10 codes, signs and symptoms which are integral to the diagnosis SHOULD or SHOULD NOT be listed
Should not
Some EHRs require a problem to be reported for each treatment plan. What problem can this cause?
This can overstate the E&M level in some cases
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
Cough and fever because they are always present with pneumonia
With ICD-10 codes, signs and symptoms which are integral to the diagnosis should not be listed. When should signs and symptoms be listed?
If there is no definitive diagnosis during the encounter
With ICD-10 codes, conditions which have been resolved or do not affect current treatment ARE or ARE NOT coded
Are not
True or False:
Inpatient and outpaitent guidelines are different but never overlap
False; may overlap in some cases
If more than one condition was responsible for the visit, which condition should be first listed?
Either can be coded as the first-listed
If an acute problem and a chronic problem exist, which problem is listed first?
The acute is listed before the chronic
If there is a diagnosis related to a procedure and the procedure is the reason for the visit, which is first-listed?
The diagnosis
If other diagnoses contribute to the treatment plan, where are they listed?
Below the reason for the visit
If co-existing conditions are present and equally responsible for the reason for the visit, which may be coded as the first-listed diagnosis?
Either may be coded as the first-listed diagnosis
Coding example:
Patient presents for continued care of both diabetes and hypertension. Both are stable, chronic codition. Which should be first-listed?
Either can be listed 1st or 2nd
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?
The diabetes would be coded as the first-listed and the hypertension would be coded as the second-listed
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?
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
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?
The sinusitis would be the first-listed (reason for the visit and acute) and the chronic conditions would be coded 2nd or 3rd
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!
Alphabetic
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
Tabular
Some EHRs will only show truncated code descriptions or will map ICD-9 codes to ICD-10 codes automatically. What problem can this cause?
Errors in code assignment can occur
What is the most accurate method of ICD-10 code assignment?
Being able to verify a diagnosis using the code set
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
Do not
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?
Improper code assignment
Even though RHCs get an all-inclusive rate, the correct level of E&M service should always be reported. Why is this?
We report the service that we actually perform
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.
20%
Coinsurance
Reimbursement
Patient
____ should be correctly reported in order to evaluate productivity, allocation of resources, and other areas of practice management.
Utilization
The clinic should report the correct level of service to ensure that the RHC is reimbursed correctly by what type of payer?
Fee-for-service
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
AMA
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.
5
4
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 ____ ____
Medically appropriate
The 2021 changes to E&M coding allows clinicians to choose the E&M visit level based on either ____ or ____
Medical decision making or time
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
Level of service
____ ____ should support the level of service
Clinical documentation
History (chief complaint, HPI, ROS, and PSFH) and exam should be documented to support ____ ____
Medical necessity
99211 code does exist but IS or ISN’T qualified as an RHC encounter
Isn’t
For E&M code 99202 (new patient): History - \_\_\_\_ appropriate Exam - \_\_\_\_ appropriate Medical Decision Making - \_\_\_\_ Time - \_\_\_\_-\_\_\_\_ minutes
Medically
Medically
Straightforward
15-29 minutes
For E&M code 99203 (new patient): History - \_\_\_\_ appropriate Exam - \_\_\_\_ appropriate Medical Decision Making - \_\_\_\_ Time - \_\_\_\_-\_\_\_\_ minutes
Medically
Medically
Low
30-44 minutes
For E&M code 99204 (new patient): History - \_\_\_\_ appropriate Exam - \_\_\_\_ appropriate Medical Decision Making - \_\_\_\_ Time - \_\_\_\_-\_\_\_\_ minutes
Medically
Medically
Moderate
45-59 minutes
For E&M code 99205 (new patient): History - \_\_\_\_ appropriate Exam - \_\_\_\_ appropriate Medical Decision Making - \_\_\_\_ Time - \_\_\_\_-\_\_\_\_ minutes
Medically
Medically
High
60-74 minutes
For E&M code 99212 (established patient): History - \_\_\_\_ appropriate Exam - \_\_\_\_ appropriate Medical Decision Making - \_\_\_\_ Time - \_\_\_\_-\_\_\_\_ minutes
Medically
Medically
Straightforward
10-19 minutes
For E&M code 99213 (established patient): History - \_\_\_\_ appropriate Exam - \_\_\_\_ appropriate Medical Decision Making - \_\_\_\_ Time - \_\_\_\_-\_\_\_\_ minutes
Medically
Medically
Low
20-29 minutes
For E&M code 99214 (established patient): History - \_\_\_\_ appropriate Exam - \_\_\_\_ appropriate Medical Decision Making - \_\_\_\_ Time - \_\_\_\_-\_\_\_\_ minutes
Medically
Medically
Moderate
30-39 minutes
For E&M code 99215 (established patient): History - \_\_\_\_ appropriate Exam - \_\_\_\_ appropriate Medical Decision Making - \_\_\_\_ Time - \_\_\_\_-\_\_\_\_ minutes
Medically
Medically
High
40-54 minutes
A ____-____ evaluation and management service is the assessment and treatment of a presenting problem. The patient has a chief complaint.
Problem-oriented
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
Preventive
The services and frequency of preventive screenings are usually defined by who?
Health plan or payer
____ determine how the preventive services are performed
Payers
Preventive services are reporting using either ____ codes 99381-99397 (age specific) or the Medicare-specific level II ____ codes.
CPT
G
A ____ service is being performed if the patient is asymptomatic for a screening and does not have a chief complaint
Preventive
A preventive service is being performed if the patient is ____ for a screening and does not have a chief complaint
Asymptomatic
A preventive service is being performed if the patient is asymptomatic for a screening and does not have a ____ complaint
Chief
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
3
A patient is not a new patient to a new individual provider but to the ____ or ____
Clinic or EIN
The ____ code registered to the individual provider’s NPI number is used to determine specialty
Taxonomy
A problem-oriented evaluation and management service may include a problem that may be an ____ illness, an injury, or an ongoing ____ condition
Acute
Chronic
Beginning in April 2016, CMS began requiring that procedural code detail be included on the ____ institutional bill types submitted by RHCs
UB-04
True or False:
It is important to report all RHC services performed during the face-to-face encounter
True
CMS introduced the -CG modifier in October ____
2016
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
Service
In-office procedure
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 ____
RHC
All-inclusive rate
True or False:
The 25 modifier is used more than the 59
False; 59 is used more than 25
The 25 or 59 modifier ARE or ARE NOT used on Medicare claims in the same way they are used on other payer claims
Are not
What are the 25 and 59 modifiers used for?
To report 2 separate and unrelated RHC encounters occurring on the same date of service
Revenue codes are used when submitting ____ claims
Institutional (UB-04)
Revenue codes are maintained by who annually?
The National Uniform Billing Committee
At what frequence are revenue codes maintained by the National Uniform Billing Committee?
Annually
What are revenue codes used to report?
The location or setting in which a service was provided or a type of service
Billing edits and denials can occur if a revenue code and ____ code are deemed a mismatch
Procedural
True or False:
There are certain CPT codes that would not be performed in certain places of service
True
Condition codes report ____ information needed for correct claim processing
Supplemental
Category ____ codes are used to report supplemental information, such as patient data, patient status, and quality measure
II
Category II codes CAN or CANNOT be reported on the UB-04 claim
Cannot
How can category II codes be reported for Medicaid and other payers?
On the 1500 format
The process of clarifying both diagnoses and medical services using nationally approved code sets
Coding
What is the primary purpose of coding?
To allow the standardization of health data
Coding IS or IS NOT a reimbursement methodology by design
Is not
Coding is not a reimbursement methodology by design even though codes are used by payers to establish what?
Payment terms
True or False:
If a code exists, a payer will recognize it as a payable service
False; just because a cost exists doesn’t mean that a payer will recongize it as a reimbursable service
Not all valid codes are ____ codes
Payable
Not all valid codes represent ____ services
Allowable
The process of reporting medical services to a payer for the purpose of being reimbursed
Billing
True or False:
Billing guidelines are the same from payer to payer
False; may vary from payer to payer
This service occurs when other related services are provided subsequent to an intial service
Incident to
What is the below an example of?
A bandage change is performed by nursing staff several days after a physician has provided wound care
Incident to service
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
Are not
NPs or PAs can also be “incident to” a ____’s service if certain conditions are met
Physician’s
What are the 4 “incident to” criteria?
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
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?
Fee-for-service
Why is there no financial benefit for billing NP and PA services as incident to in an RHC?
Because the AIR or encounter rate is paid for all qualified provider types
True or False:
Most commerical plans follow the Medicare guidelines for incident to billing
True
Co-signing the note does not waive the incident to ____ requirements
Billing
All providers should be ____, obtain ____ provider numbers, and be linked to contract appropriately even if it means a payment reduction under some plans
Credentialed
Individual
Use ____ when choosing to bill NP or PA services as incident to the supervising or collaborating physician
Caution
True or False:
All plans, including MCOs, recognize “incident to” bill
False; some plans, including MCOs, do not recognize incident to billing at all
Health insurance companies provide coverage only for health-realted services that they define or determine to be ____ necessary
Medically
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
Elective
Diagnostic
Screening
Many health insurance companies also will not cover procedures, devices, or drugs that they consider to be ____ or not proven to work
Experimental
National or local coverage determinations and health plan benefits also determine medical necessity. ____ of services may be required
Preauthorization
True or False:
If treating for a hospice ailment, you can bill for this visit as long as it is medically necessary
False; cannot bill for visit even if medically necessary and must look to hospice company for payment or write-off
Treatment for hopice ailment cannot be billed where?
To Medicare Part B
