Coding & Coding Guidelines

Question 1

What does Documentation include?

Answer 1

The reason for encounter, history, physical exam, diagnostic/lab tests, and a treatment plan. It should also validate the appropriateness of the medical services.

Question 2

What is Medical Necessity?

Answer 2

The process of providing diagnosis codes that support the services rendered to the patient; coding for medical necessity involves associating applicable diagnosis codes to service/procedure codes within the billing software, which is referred to linking/linkage.

Question 3

What must each patient encounter have?

Answer 3

The reason for visit and medical necessity.

Question 4

What does SOAP stand for?

Answer 4

Subjective, Objective, Assessment, Plan

Question 5

What does the Subjective in SOAP mean?

Answer 5

Symptoms or history of the condition using the patient’s own words, describes improvement or decline of the condition since the last visit, explanations for any gaps in treatment, and the patient’s compliance with the provider’s recommendations.

Question 6

What does the Objective in SOAP mean?

Answer 6

Vital signs, physical examination findings, laboratory, and other diagnostic data, imaging results, and documentation from other clinicians.

Question 7

What does the Assessment in SOAP mean?

Answer 7

The diagnostic impression or working diagnoses based on the subjective complaints and objective findings.

Question 8

What does the Plan in SOAP mean?

Answer 8

Procedure or plan for treatment including treatment frequency, duration, and expected outcomes and goals of treatment. the plan often includes medication, referrals, and patient education and counseling.

Question 9

What does the Medical Record consist of?

Answer 9

Administrative data and clinical documentation

Question 10

What is Clinical Documentation?

Answer 10

Information recorded in the medical record pertaining to the health status of a patient as determined by a health care provider.

Question 11

What is the key to coding?

Answer 11

Clinical Documentation

Question 12

What are some typical types of documentation?

Answer 12

History & Physical, Progress Notes, Consultation Report, Orders, Operative Reports, Radiology/Nuclear Medicine Reports, and Discharge Summary

Question 13

What is a History & Physical(H&P)?

Answer 13

Information pertaining to the patient’s health history and current condition.

Question 14

What is a Progress Note?

Answer 14

Documentation of a patient encounter which includes history, exam, and medical decision-making.

Question 15

What is a Consultation Report?

Answer 15

This type of report includes physical examination and test results, along with the consultant’s expert opinion about the patient’s condition.

Question 16

What are Orders?

Answer 16

A request made by the provider to receive services, labs, diagnostic tests, therapy, or medication. The order includes a diagnostic statement to indicate why the order is needed. Without an order these services cannot be performed.

Question 17

What is an Operative Report?

Answer 17

Surgeon dictated report containing details about the procedure performed, why it was necessary, operative findings, and the condition of the patient at the end of the procedure.

Question 18

What is a Radiology/Nuclear Report?

Answer 18

A report written by the radiologist which describes the findings and assessment of radiology films or nuclear medicine tests.

Question 19

What is a Discharge Summary?

Answer 19

A summary of an inpatient or surgical encounter which includes the last face-to-face encounter, a physical exam, review of medication, and any discharge orders for home health or physical therapy, and any other instructions for the patients. This summary report is often used by the primary care provider(PCP).

Question 20

What are the Standard Code Sets used for Billing?

Answer 20

Terminology Standards

Question 21

What are Code Sets used for?

Answer 21

To classify medical treatments, tests, procedures, supplies, and equipment, and diagnoses identified in the medical records.

Question 22

Other than billing, what are code sets used for?

Answer 22

Research and Population Health Management

Question 23

Who regulates Code Sets?

Answer 23

HIPAA Administrative Simplification

Question 24

What are the different Code Sets?

Answer 24

ICD-10, CPT, HCPCS, CDT, and NDC

Question 25

What is the ICD-10 Code Set?

Answer 25

Includes both ICD-10-CM for diagnosis codes and ICD-10-PCS for inpatient procedure codes.

Question 26

What is the CPT Code Set?

Answer 26

Outpatient services/procedures

Question 27

What is the HCPCS Code Set?

Answer 27

Services not included in CPT

Question 28

What is the CDT Code Set?

Answer 28

Dental Procedures

Question 29

What is the NDC Code Set?

Answer 29

Drug Products

Question 30

What is the RBRVS?

Answer 30

Resource-Based Relative Value Scale. This scale is used to calculate payment for professional services. It assigns value to CPT & HCPCS Level II Codes.

Question 31

What is HCC?

Answer 31

Hierarchical Condition Category. This model adjusts reimbursement for patients who have an increased risk.

Question 32

What Code Set is SNOMED-CT?

Answer 32

Systemized Nomenclature of Medicine-Clinical Terms. This code set allows data to be abstracted regardless of different terms or phrases used by mapping sets of clinical phrases together by like terms.

Question 33

What are Modifiers?

Answer 33

This is a two-digit code that can include letters, numbers, or both and is used to add information or change the description of service in order to improve accuracy or specificity.

Question 34

What is Unbundling?

Answer 34

Using multiple CPT codes to report individual components of the documented procedure.(Using multiple codes when only one should have been used)

Question 35

What is Upcoding?

Answer 35

Reporting a higher-level service/procedure or more severe diagnosis than what is supported in the provider’s documentation. (Patient had a cold, but it was billed as Pneumonia)

Question 36

What is Downcoding?

Answer 36

This is when a lower-level code is used due to the provider’s documentation lacking detailed information. This will result in lower reimbursement.

Question 37

What is a query?

Answer 37

Contacting the responsible provider to request clarification about documented diagnoses or procedures.

Question 38

What is Telehealth?

Answer 38

Using electronic information and telecommunication technology to provide care to patients, including education for patients and providers.

Question 39

What is the Quality Payment Program(QPP)?

Answer 39

This is a type of payer-specific coding requirement. This program shifts the focus from revenue-based care to value-based care.

Question 40

What are other programs that help improve patient health and costs?

Answer 40

Merit-Based Incentive Payment System(MIPS) & Advanced Alternative Payment Models(APMs)

Question 41

What are providers who participate in MIPS required to do?

Answer 41

Report Quality Measures