Chapters 1 & 2 Flashcards
Classification Systems
The term used in health care to Identify ICD- 10- CM, CPT, ICD-10-PCS, and HCPC level code sets
What are the 4 Aspects of the Health Care system that Classification Systems Communicate?
Medical Necessity
Statistical Analyses
Reimbursement
Resource Allocation
Diagnosis-Diagnostic Statement
Explains WHY the patient requires the attention of a healthcare Provider
Medical Necessity
The assessment that the provider was acting according to standard practices in providing a procedure or service for an individual with a specific diagnosis.
Procedure
Explains WHAT the physician or health care provider did for that patient.
Actions, or a series of actions, taken to accomplish an objective (result) ex: surgically removing a mole or sectioning the small intestine
Statistical Analyses
Research organizations and govn’t agencies statistically analyze the data provided by codes to develop programs, identify research areas, allocate funds, and write public health policies that will best address areas of concern for the health of our nation
Reimbursement
The process of paying for health care services after they have been provided
What might the Physicians notes Explain
The reasons why the encountered occurred- such as specific condition or illness, the signs or symptoms of a yet- unnamed problem, or another reason for the encounter such as preventive service
What Three Parties are involved in reimbursement?
The health care provider – 1ST Party
The patient – 2nd party
The insurance company or other organization financially responsible – 3rd Party Payer
What is an Alphabetic Index A.K.A
Index to Diseases and Injuries
Resource Allocations
Deciding how to efficiently and effectively distribute funds, equipment, and staff members to the patients and locations who need them most
Condition
State of abnormality or dysfunction
Ex- infection, fracture and wound
Eponym
A disease or condition named for a person
Ex- Epstien-Barr Syndrom and Cushings Disease
Includes Note Directly below the Term you are coding means?
What are they know as in the ICD-10 CM book?
Provides you with the alternative words or phrases that the physician might use that mean the same condition. In English they are known as Synonyms.
In the ICD-10-CM book they are known as Non Essential Modifiers
What are Diagnostic descriptions listed by?
three things
Condition
Eponym
Other descriptors (ex- personal history, family history)
Nonessential Modifiers
Descriptors whose inclusion in the physician’s notes are not absolutely necessary and that are provided simply to further clarify a code description; optional terms
Simply put – a descriptor used to clarify a code description but isn’t necessary
How Does the Tabular List organize all ICD-10-CM codes (2 Ways)
First in Alphabetic Order, Then in numeric order
A00 through Z99.89
Purpose of a Neoplasm Table
Itemizes all the anatomical sites in the human body that may develop a tumor
Table of Drugs and Chemicals
Lists pharmaceuticals and chemicals that may cause poisoning of adverse effects in the human body
What is the format of ICD-10- CM Codes?
(how are they listed?)
When an additional character is needed to complete the code- How might that look?
3- character code category
A letter of the alphabet followed by
A minimum of 2 characters (either letters or numbers
An extra symbol is added such as a bullet or a box with a check mark
External Causes
An event, outside the body, that causes injury, poisoning, or an adverse reaction
Services
Spending time with a patient and or family about health care situations
Actions that will most often involve counseling, educating, and advising the patient, such as discussing test results or sharing recommendations for risk reduction
Index to External Causes Lists what?
Causes of injury and poisoning to explain HOW a patient got injured and WHERE
Treatments
The provision of medical care for a disorder or disease
Are typically an application of a health care service, such as radiation treatments for tumor reduction or acupuncture
Diagnostic Test
Procedures are performed to provide the with additional information required to determine a confirmed diagnosis
What three code sets are available for you to use to translate health care procedures, services, and treatments into codes.
CPT- Current Procedural Terminology
ICD-10-CM PCS- International Classification of Diseases-10th Revision-Procedure Coding Systems
HCPCS Level II - Healthcare Common Procedure Coding Systems
Preventive
Procedures and services are provided to keep a healthy patient healthy—to avoid illness or injury, including early detection testing known as screenings
CPT used to describe what?
For what kind of Patient?
Procedures performed by a physician in any location
Services range from speaking with a patient about test results to performing surgery or determining a treatment plan.
CPT codes are used to report the contribution made by OUTPATIENT Facilities. Ex- physician’s office, a clinic, an ambulatory surgical center, or the emergency department of a hospital such as a sterile procedure room, trained nursing and support staff
Therapeutic
Procedures, treatments, and services are performed with the intention of removing, correcting, or repairing an abnormality or condition
How many parts and Sections does the CPT Code Book have?
List them.
How are they organized?
Are there exceptions?
2 parts and 6 Sections
Evaluation and Management Anesthesia Surgery Radiology Pathology and Laboratory Medicine
Generally presented in numeric order by code number
Some Exceptions so read carefully
ICD- 10-CM PCS Codes Describe What?
The contribution made by the hospital to a procedure provided to an INPATIENT
List the CPT sections and their structures
CPT Codes (Category I) 5 didget codes. They all have no letters, no punctuation.) Ex: 51100 Aspiration of the bladder, by needle.
Category II codes- 5 character codes, with four numbers followed by the letter F. Ex: 20001F Weight recorded. (used for supplemental tracking of performance measurements. Not reimbursable but support research on specific physician actions taken on behalf of the patient’s health)
Category III codes- are 5 character codes. These codes also have 4 numbers; however these codes are follwed by the letter T. Ex: 0208T ure ton Audiometry (threshold), automated: air only temporary codes used to report emerging technological procedures. These codes enable tracking physician adoption and the frequency of the use to identify what should stay and what will be deleted
Modifiers are listed in appendix A and are 2 character: two numbers: 2 letters, or one letter and one number. Used under special circumstances such as the use of unusual anesthesia, 2 surgeons working on the same patient at the same time.
Inpatient
An individual admitted for an overnight or longer stay in a hospital in an acute care facility.
How are CPT codes organized?
What four Types of Entries are there? Explain.
Alphabetical order by code description, presented in four types of entries
Procedures or Services such as bypass,decompression,insertion
Anatomical site or organ, such as brain stem, spinal cord, lymph nodes
Condition, such as pregnancy, fracture, abscess
Eponyms, synonyms, or abriev. Such as potts- smith procedure or EEG
How does the Table Section of the ICD-10-CM code-book differ from the others?
Rather than a listing of the codes in numeric or alphanumeric order, you will find Tables listing various characters and their meanings. Then you will build the code, according to the physician’s documentation.
How are ICD-10-CM PCS codes made up?
7 characters and are alphanumeric (both letters and numbers) Each of the seven positions in the code represents a specific piece of info relation to a procedure, service or treatment provided.
ICD-10-CM Make up (Part 2)
- Section of the ICD-10-CM-PCS code set
- Body system upon which the procedure or service was performed
- Root Operation, which explains the category or type of procedure
- Body part, which identifies the specific anatomical site involved in the procedure
- Approach, which reports which method was used to perform the service or treatment
- Device, which reports, when applicable, what type of device was involved in the service or procedure
- Qualifier, which adds any additional detail
Ex- ODQ48ZZ Repair of the esophagogastric junction, via natural opening endoscopic
What do HCPCS Level II codes cover?
Specific aspects of health care services including
Medical Equipment (wheel chairs or humidifier)
Pharmaceuticals (saline solution, chemo drug
Medical Supplies provided for the patients home (eye patch or compression stockings)
Dental Services (provided by dental profesh)
Transportation Services (ambulance)
Vision and Hearing (trifocal spectacles or aid)
Orthotic and Prosthetic Procedures (scoliosis brace or prosthetic arm)
HCPCS (pronounced Hick-Picks)
AKA?
CPT codes
How is HCPCS Level II organized?
Listed in sections, grouped by the type of service, the type of supply item, or the type of equipment they represent. Use Alphabetic Index to direct you to the correct section or subsection in the Alphanumeric Listing of the code book. One type of service or procedure might be located under several different categories depending upon the details
When do you use HCPCS Level II codes?
If the CPT code set does not contain a code that accurately and completely reports a procedure or service.
Note-For the most part, healthy care services are listed in the HCPCS Levell II section titled Procedures/ Professional Sercies (Temporary) but not exclusively so be certain to check the Alphabetic Index
Do all 3rd party payers accept HCPCS Levell II codes?
No. You must find out whether each third party payer with which you facility works will permit the reporting of HCPC Level II codes on a claim form. If not, you should ask for the payers policies on reporting the services and supplies covered by HCPCS level II so you don’t have a claim delayed or denied
What is the Format of an HCPCS Level II Code?
They are all structured the same way; 1 letter followed by 4 numbers. No dots, no dashes
Ex- A0225 Ambulance service, neonatal transport, base rate, emergency transport, one way
Facility
WHERE the service was provided
Patient
WHO is provided with care
What is the first question that you ask as a professional coder?
For whom are you reporting?
ex- cardiologist? Endocrinologist? The facility?
Physician
WHO is the health care provider you are representing
Abstracting
The process of identifying the relevant words or phrases in health care documentation in order to determine the best, most appropriate code
Professional Coding Specialists’ Motto
If it isn’t documented, it didn’t happen. If it didn’t happen, you can’t code it!
Patient’s Registration Form Includes?
Patients demographic info, health insurance policy numbers and the name of the individual who will be financially responsible
Assume
Suppose to be the case, without proof, guess the intended details
Demographic
Details including the patients name, address, DOB, and other personal details, not specifically related to health
Interpret
Explain the meaning of, convert a meaning from one language to another
Referral Authorization Form
If another physician or health care provider referred this patient
Physicians Notes/ Operative Reports
Written documentation of what occurred during the encounter between physicians and patient is also known as clinical documentation MOST IMPORTANT SOURCE FOR DETAILS required to determine the most accurate code or codes
Medication Logs
If the facility is residential, such as an acute care hospital, skilled nursing facility etc, the nursing staff must record every time they administer a medication to a patient, including the drug name, dosage, time administered, and route used for administration. All data must be reported.
Pathology and Laboratory Reports
Results of testing performed on blood, tissue, and other specimens hold important keys to the patient’s condition.
Allergy List
Included for the patient’s safety so health care professionals can avoid giving the patient any substance to which he or she may be allergic
Imaging Reports
Similar to pathology reports; these are reports written by a radiologist containing his or her interpretation of images take of the patients x ray, CT scan MRI ect
History and Physical (H&P)
This document, written by admitting physicians, explains the background and current issues used to make the decision to admit the patient into the hospital
Consultations Reports
Specialist is asked by an attending physician to evaluate a patient’s condition, a report is written and sent over to be included in the patients’ medical record in the requesting physicians files, as well as, those belonging to the consulting physician
Discharge Summary
At the time a patient is released from a facility, such as a hospital, the discharge summary provides the conclusions and results of the patient’s stay in the facility in addition to the follow-up advice
What does every professional/patient encounter must have?
One report able (code able) reason why and at least one report able (code able) explanation of what
Symptoms
Subjective sensation or departure from the norm as related by the patient
In an outpatient encounter if there is no confirmed diagnostic statement what do you code?
The patient’s signs and symptoms that led the physician’s decision for the next step in care.
Signs
Measurable indicators of a patient’s health status
When an inpatient is admitted into the hospital is being discharged without a confirmed diagnosis, what do you code?
The suspected conditions listed on the discharge summary as if they were confirmed. You will not code the signs and symptoms
Main Term
Word identifies the disease, illness, condition, or primary reason for the visit
This sign + that symptom =
This diagnosis
Etiology
The original source or cause for the development of a disease or condition
Aka underlying condition
Underlying Conditions
Diseases that cause patients to develop other conditions
Query
To Ask the physician who wrote the documentation to provide clarification or additional specifics
You must ask for the details in a non-leading manner. Asking open-ended questions or providing multiple options for the answer are the best approaches
It should be accompanied by the pertinent clinical information from the patient’s chart
Manifestation
A condition that develops as the result of another, underlying condition
Co- Morbidity
A separate diagnosis existing in the same patient at the same time as an unrelated diagnosis
Only those conditions that the physician has specifically evaluated, treated, or ordered additional testing (ect.) for should be reported with a code
Code the reason for the encounter with the physician first
Sequela
A cause and effect relationship between an original condition that has been resolved with a current condition also known as a late effect
Scarring
Nonunion of a fracture
Malunion of a fracture
When the connection is specifically documented by the physician or health care professional confirming the new condition as a sequela (late effect) of a previous condition
How many codes does a sequela require?
Two
- The sequela condition, which is the condition that resulted and is being treated, such as scar or paralysis
- The sequela(late effect) or original-condition code with the seventh character “S”
Outpatient
patient who receives services for a short amount of time (less than 24 hours) in a physician’s office or clinic, without being kept overnight
Non essential Modifiers
descriptors whose inclusion in the physicians notes are not absolutely necessary and that are provided simply to further clarify a code description optional terms
Outpatient Facility
includes a hospital emergency room, ambulatory care center, same-day surgery center, or walk in clinic.
inpatient facility
an establishment that provides health care services to individuals who stay overnight on the premises
Includes
alternative words or phrases that the physicians might use that mean the same condition aka Nonessential modifiers
Preventative
keep a healthy patient healthy/ avoid illness or injury /also includes early detection testing/screenings
Therapeutic Procedures, Treatments and Services
intention of removing correcting or repairing an abnormality or condition
assume
suppose to be the case, with out proof guess the intended details
Demographic
Demographic details include the patients name, address, date of birth and other personal details, not specifically related to health
If there is no confirmed diagnostic statement in and outpatient situation what will you code?
signs and symptoms that led the physician’s decision for the next steps in care
If a patient admitted to the hospital is being discharged without a confirmed diagnosis what will you code?
suspected conditions
