Chapter 5

Question 0

What does ICD–9–CM stand for?

Answer 0

International classification of diseases, ninth revision, clinical modification

Question 1

Nomenclature

Answer 1

System that lists preferred medical terminology,

• a.k.a. naming system and clinical terminology
• example CPT

Question 2

Why are these classification systems developed?

Answer 2

Development of these systems has helped to standardize terminology for collection, processing, and retrieval of medical terminology

Question 3

Who developed the first medical nomenclature and what was it called?

Answer 3

New York Academy of Medicine

-“standard nomenclature of disease and operations”

Question 4

Who are the users of clinical vocabulary and classification?

Answer 4

1) Clinical users: ex- physician uses ICD-9-CM codes to track a patient’s diagnostic history
2) Administrative users: ex- CPT codes are used to report physician services to Medicare program for reimbursement

Question 5

What are the medical coding sets established by HHS in accordance with HIPPA?

Answer 5

1) ICD-9-CM
2) HCPCS-health care financing administration procedure coding system( includes CPT-current procedural terminology)
3) CDT-current dental terminology
4) NDC-national drug codes

Question 6

Who published ICD-9-CM and where?

Answer 6

Published by WHO in Geneva Switzerland

Question 7

ICD-9-CM is maintained by what organizations a.k.a. cooperating parties?

Answer 7

1) National Center for Health Statistics NCHS
2) American Hospital Association AHA
3) American Health Information Management Association AHIMA
4) Centers for Medicare and Medicaid Services CMS

Question 8

What are the responsibilities of the cooperating parties?

Answer 8

1) answer questions on ICD-9-CM
2) develop programs on ICD-9- CM
3) maintain the integrity of ICD-9-CM
4) recommend modifications to current and future versions of ICD

Question 9

What is the duty of each cooperating body in ICD-9-CM?

Answer 9

1) NCHS: responsible for updating the diagnosis classification
2) CMS: responsible for updating the procedure classification
3) AHIMA: provides training and certification
4) AHA: maintains the central office on ICD-9-CM and publishes the coding clinic for ICD-9-CM (coding guidelines and usage)

Question 10

What are some of the uses of ICD-9-CM?

Answer 10

-classifying morbidity and mortality info for statistical purposes
-starring and retrieving data
-reporting diagnosis by physician
-determining patterns of care
-conducting clinical research
-analyzing payments
-reporting healthcare data for evaluation
-

Question 11

What is the structure of ICD-9-CM?

Answer 11

It is divided into three volumes:

1) volume one- tabular list:
2) volume two- alphabetical index
3) volume three- tabular list and alphabetical index (only in US, not international version)

Question 12

Explain volume one of ICD-9-CM?

Answer 12

It is divided into three subdivision:
1) classification of diseases and injuries:
(17 chpts -> sections (3 digit codes) -> categories -> subcategories (4 digit codes)

2) supplementary classifications:
-V codes:
when circumstances other, than disease or injury, are the reason for patient encounter with the healthcare provider
-E codes:
classify conditions as the cause of injury and other effects

3) appendixes:
Appendix A, B, C, D, E

Question 13

Describe the difference in coding of V and E codes?

Answer 13

alphanumeric codes

V codes: begin with the V letter then numbers: V15.04

E codes: begin with the E letter then numbers: E925.0

Question 14

Explain volume two of ICD-9-CM?

Answer 14

The main terms are alphabetically in the index by the type of disease, injury, or illness; with sub terms indented under the main term

Question 15

What are some of the new enhancements of ICD-10-CM?

Answer 15

• combination codes (a single code may be used to for two diagnosis)
• provides expanded codes for more detail
• decreased cross-referencing (by writing out the full title for all codes)
• provides laterally codes (for left and right side)

Question 16

Describe the difference of the specificity of codes in ICD-9-CM and ICD-10-CM?

Answer 16

ICD-9: most specific five digit code numbers

ICD-10: six digit code level with seven digit extension

Question 17

Why was ICD-10-PCS established?

Answer 17

ICD-10-CM does not include a procedure volume; therefore CMS developed a separate procedure code system to replace ICD-9-CM Volume 3

Question 18

What does ICD-10-PCS stand for?

Answer 18

International Classification of Diseases, 10th Revision, Procedure Coding System

Question 19

What was the purpose for updating the procedure section of ICD-9-CM or (what are the goals of ICD-10-PCS)

Answer 19

1) improve accuracy of coding
2) reduce training effort
3) improve communication with physicians

Question 20

Describe the structure of ICD-10-PCS?

Answer 20

• Divided into 16 sections according to general type of procedure
• Then each procedure has seven characters

Question 21

What are the seven characters in ICD-10-PCS?

Answer 21

1- section where the code is
2- body system
3- room operation
4- specific body part
5- approach used
6- device used for procedure
7- any additional information about the procedure

Question 22

What are some of the transition issues from ICD-9 to ICD-10?

Answer 22

• understanding the general structure of the system
• impact to workflow
• conduct an inventory
• software changes

Question 23

What is ICF?

Answer 23

International Classification of Functioning, Disability, and Health
Broad components:
1) body functions and structures
2) activities and participation
3) additional info on environmental factors

Question 24

Explain ICD-O-3?

Answer 24

International Classification of Diseases for Oncology, 3rd Edition

Purpose:
A system for classifying malignant diseases (cancer)

Structure:
A dual axis classification to code the:

1) topography: uses same code as ICD-10

2) morphology: identifies the type of tumor and it’s behavior ex- M9891/3
- the letter M
- four digits identify the histology type
- last digit identifies the behavior of tumor

3) alphabetical index

Question 25

Why is HCPCS?

Answer 25

Healthcare Common Procedure Coding System.

used to report physicians’ services to Medicare for reimbursement

Question 26

Why did HCPCS change it’s name?

Answer 26

It was called the HCFA Common Procedure Coding System.

Why? Health Care Financing Administration changed its name to Centers for Medicare and Medicaid Services

Question 27

Explain the 2 code levels for HCPCS?

Answer 27

Level I: AMA’s CPT codes.

Level II: aka National Codes are maintained by CMS.

Question 28

What is CPT?

Answer 28

A listing of terms and codes for reporting diagnostic and therapeutic and medical services

Question 29

Who is the CPT advisory committee and what are their objectives?

Answer 29

They advise the Editorial pPanel who revise, modify and update the CPT.
objectives:
1) to serve as a resource to the editorial panel by giving advice
2) to provide documentation
3) to suggest revisions

Question 30

What are the eight sections of the CPT code book?

Answer 30

• evaluation and management services
• anesthesia
• surgery
• radiology
• pathology and lab
• medicine
• category II codes
• catagory III codes

Question 31

What is the structure of the CPT book?

Answer 31

Introduction, eight sections, appendixes, and index

Question 32

What is the purposes of category II and III codes?

Answer 32

Category II: supplement tracking codes for performance measurement (optional)

Category III: to allow temporary record coding for new technology (that do not meet requirements to be added to main section of CPT book)
(not optional)

Question 33

What is the relationship between category I and III codes?

Answer 33

As category I codes are created, the temporary category three codes are deleted

Category III codes are added every six months.

If category III codes have not been utilized within five years, they will be removed

Question 34

The appendixes provide information to help the colder in coding. Describe each appendix.

Answer 34

Appendix A: a list of modifiers (two digit code that follow the main CPT code)

Appendix B: a summary of additions and revisions

Appendix C: clinical examples for codes

Appendix D: list of CPT add on codes (must be preceded by primary code)

Appendix E: summary of CPT codes except from modifier 51

Appendix F: summary of CPT codes except from modifier 63

Appendix G: codes for conscious sedation

Appendix H: index of performance measures by clinical condition

Appendix I: genetic testing code modifiers

Appendix J: list of sensory, motor, & mixed nerves

Appendix K: CPT codes not approved by FDA

Appendix L: reference of vascular families

Appendix M: deleted CPT codes and crosswalk to current codes

Appendix N: resequenced codes

Question 35

What are the main term entries of the index for the CPT book?

Answer 35

1) procedure or service
2) organ
3) condition
4) synonym or abbreviation

Question 36

What is SNOMED CT?

Answer 36

Systematized Nomenclature of Medicine Clinical Terminology

It is a systemized nomenclature of medically useful turns (standardized vocabulary)

Created by the American College of Pathologist ACP

Question 37

What is the purpose for SNOMED CT?

Answer 37

Because two physicians may use to terms for the same medical condition

Question 38

What are the main areas of SNOMED CT?

Answer 38

• concept
• descriptions
• relationship: between two concepts
• history: changes to concept

8 fields, 2 classification field( disease/diagnosis D and P procedures), one modifier and linkage term field(G)

Question 39

What is DSM-IV-TR?

Answer 39

Diagnostic and Statistical Manual of Mental Disorders, fourth edition, Text Revision

published by American Psychiatric Association

Develop because ICD was not detailed for clinical and research use in mental disorders

Question 40

What is the structure of DSM-IV-TR and purpose?

Answer 40

Axis I: clinical disorders
Axis II: personality disorder
Axis III: general medical conditions
Axis IV: psychosocial and environmental problems
Axis V: global assessment of functioning

Purpose of these axes is to establish an evaluation of patient symptoms for diagnosis

Question 41

Why should coding processes be monitored?

Answer 41

1) reliability: different people code the same codes
2) validity: code reflects patient’s diagnosis and procedure
3) completeness: codes capture all diagnoses and procedures documented
4) timeliness:

Question 42

What are the steps in the coding process?

Answer 42

1) the coder must have a complete health record on the patient
2) coder reviews documents to verify diagnosis and procedure
3) coder selects what diagnosis and procedure needs to be coded, and assigns appropriate codes according to you UHDDS guideline
4) then codes are entered into facility’s database

Question 43

Define encoder.

Answer 43

The type of tool used to aid in the coding process

Question 44

Define interface.

Answer 44

The total component of screens navigations and mechanisms used to help the end-user operate the encoding software

Question 45

What is CAC?

Answer 45

Computer – assisted coding

a technology for complete computerization of coding

Question 46

What is a NLP?

Answer 46

Natural language processing.

A form of CAC

Question 47

What is the UMLS project

Answer 47

Unified Medical Language System

Established by National Library of Medicine NLM

Question 48

What are UMLS’s knowledge resources?

Answer 48

1) metathesaurus: uniform collection of healthcare related vocabularies, coding, etc
2) specialist lexicon: syntactic information
3) semantic network: characterizes and identifies relationships between concepts

Question 49

What is nosology?

Answer 49

It is a branch of medical science that deals with classification systems