Chapter 3 - The Coding Process Flashcards
Terminology
Alphabetic Index
The section of a code book showing all codes, from A to Z by the short description.
Alphanumeric
Containing both letters and numbers
Coding Process
The sequence of actions required to interpret physician documentation into the codes that accurately report what occurred during a specific encounter between Health care professional and patient.
Linking
Confirming medical necessity by pairing at least one a diagnosis code to at least one procedure code.
• multiple procedure codes can link to one diagnosis code, and multiple diagnosis codes can link to one procedure code. But there must be at least one of each to support the encounter. (P. 47)
Main section
The section of the CPT code book listing all of the coded in numeric order.
Notations
Alerts and warnings that support more accurate use of codes in a specific code set.
Official Guidelines
A listing of rules and regulations instructing how to use a specific code set accurately.
Symbols
Mark, similar to emojis, that provide additional direction to use codes correctly and accurately.
Tables
The section of the ICD-10-PCS code book listing all of the codes in alphanumeric order, based on the first three characters of the code.
Tabular list of diseases and injuries
The section of the ICD-10-CM code book listing all of the codes in alphanumeric order.
The coding process
The sequence of actions required to interpret physician documentation into the codes that accurately report what occurred during a specific encounter between Healthcare professional and patient
ACTION 1
Abstract the documentation
- Read completely through the documentation for the encounter, from beginning to end.
- re-read the documentation and identify the main words regarding the diagnoses (why) and procedures (what) of the encounter.
- if the patient was injured, you will need to identify the external causes (how and where) as well.
ACTION 2
Query, if necessary
- Make a list of questions you have regarding:
* unclear
* missing
* contradictory - information necessary to code.
- query the healthcare provider who cared for the patient.
- never assume or guess.
- use non leading questions.
ACTION 3
Code the diagnosis or diagnoses
Code each diagnosis and/or appropriate signs or symptoms describing why the health care provider treated this patient during this encounter, as documented in the notes, to tell the whole story.
Use the best, most accurate code or codes available based on that documentation.
ACTION 4
Code the procedure or procedures
Determine for whom you are reporting: physician, outpatient facility, or inpatient facility. This way, you will know which code set to use: CPT or ICD-10-PCS.
Code each procedure, service, or treatment, as stated in the notes, describing what the provider did for the patient during this encounter.
ACTION 5
Confirm medical necessity
Ensure that each and every procedure code is supported by at least one diagnosis code to verify medical necessity.
ACTION 6
Double-check your codes
Begin to build the Habit, right now, of reading slowly, carefully, and completely.
There are so many times, when reviewing a coding error, we have heard, “Oh, I can’t believe I didn’t see that!”
It is better for you to find and correct your own mistakes then have anyone else find your mistakes and suffer the consequences.
The Alphabetic Indexes
Diagnoses (why)
ICD-10-CM code set
The Alphabetic Indexes
Physicians services (what)
CPT code set
The Alphabetic Indexes
Outpatient facility Services (what)
CPT code set
The Alphabetic Indexes
Inpatient (hospital) facility Services (what)
ICD-10-PCS code set
The Alphabetic Indexes
Transportation, Equipment, drugs (what)
HCPCS Level II code set
Conventions
Notations and symbols in the Tabular List (ICD-10-CM) and Main Section (CPT) that include tips and hints pointing you toward the correct code.
“Use additional code”
Notation reminds you that you will need to include a second code reporting the detail identified in the notation. This notation helps you ensure you are reporting complete information about a patient’s diagnosis that will support medical necessity for the appropriate treatment.
A “check mark” symbol in the HCPCS Level II book
Alerts you that this code description includes a specific quantity
The “star” symbol in front of the CPT book
Informs you, the coder, that if this service was provided using audio, video/ synchronous equipment, you will need to append modifier 95 to this code.
there are six specific actions that you should take as part of the coding process:
Action 1. Abstract the documentation
Action 2. Query, if necessary
Action 3. Code the diagnosis or diagnoses
Action 4. Code the procedure or procedures
Action 5. Confirm medical necessity
Action 6. Double-check your codes
What is the number one consideration when coding?
Accuracy
You cannot report a code from the alphabetic index until you have confirmed it is correct and complete by using…..
- CPT’s Main Section
- ICD-10-CM’s Tabular List
- ICD-10-PCS’s Tables Section
- HCPCS Level II’s Alphanumeric Section
When abstracting information regarding a patient’s injury, what should you identify to determine external causes?
The how and where
What are included in the Tabular List (ICD-10-CM) and Main Section (CPT) to provide tips and hints to point you towards the correct code?
Conventions
What rules and regulations must be referred to every time you are working to determine a code?
Official Guidelines
The code that identifies the reasons why the patient was seen by a healthcare professional ___________what the physician or Healthcare professional did to the patient only when they are in accordance with the standards of care.
justify
After abstracting the main terms, a coder will go next to the ________________.
Alphabetic index
Where can you find The Official Guidelines?
- ICD-10-CM; in the front of this code book
- CPT; in front of each individual main section
- ICD-10-PCS; in the front of this code book
____________ codes are composed of seven characters.
ICD-10-PCS
ICD-10-CM Official Guidelines: Section I
Conventions, General coding guidelines and chapter specific guidelines.
ICD-10-CM Official Guidelines: Section II
Selection of Principal Diagnosis.
ICD-10-CM Official Guidelines: Section III
Reporting Additional Diagnoses.
ICD-10-CM Official Guidelines: Section IV
Diagnostic Coding and Reporting Guidelines for Outpatient Services.
ICD-10-CM Official Guidelines: Sequela (Late Effects)
Section 1.B.10
ICD-10-CM Official Guidelines: Format and Structure
Section 1.A.2
ICD-10-CM Official Guidelines: Abbreviations - Tabular List abbreviations
Section 1.A.6.b
ICD-10-CM Official Guidelines: Etiology/Manifestations Convention
(“code first”, “use additional code” and “in Diseases classified elsewhere “ notes)
Section 1.A.13
ICD-10-CM Official Guidelines: “Code Also” note
Section 1.A.17
ICD-10-CM Official Guidelines: Conditions that are an integral part of a disease process
Section 1.B.5
ICD-10-CM Official Guidelines: Placeholder character “X”
Section 1.A.4
ICD-10-CM Official Guidelines: Conditions that are NOT an integral part of a disease process
Section 1.B.6
ICD-10-CM Official Guidelines: Signs and Symptoms
Section 1.B.4
ICD-10-CM Official Guidelines: Laterality
Section 1.B.13
Conventions
(notations and symbols) in the Tabular List (ICD-10-CM) and Main Section (CPT) that include tips and hints pointing you toward the correct code.
