Coding Guidelines Study deck

Question 1

What is ICD-10-CM used for in healthcare?

Answer 1

ICD-10-CM is used to classify and code diagnoses, symptoms, and external causes of injury. It helps in categorizing diseases, conditions, and medical incidents.

Question 2

What is HCPCS, and what are its two levels?

Answer 2

HCPCS (Healthcare Common Procedure Coding System) includes CPT codes (Level I) and codes for services, supplies, and durable medical equipment not covered in CPT (Level II).

Question 2

What does CPT stand for, and what is it used for?

Answer 2

CPT stands for Current Procedural Terminology. It is used to describe medical, surgical, and diagnostic services to standardize billing and coding.

Question 3

What is the structure of ICD-10-CM codes?

Answer 3

ICD-10-CM codes can be 3-7 characters long, with the first three characters representing the category, and additional characters providing more specificity, such as laterality or anatomic site.

Question 4

What are the three categories of CPT codes?

Answer 4

Category I: Procedures and services.
Category II: Performance measurement.
Category III: Emerging technologies and services.

Question 5

What is the role of CMS in healthcare coding?

Answer 5

CMS (Centers for Medicare & Medicaid Services) provides guidelines on billing, coding, and documentation for services to be reimbursed by Medicare and Medicaid.

Question 6

What is the National Correct Coding Initiative (NCCI)?

Answer 6

NCCI edits are used by CMS to prevent improper coding that can lead to overpayment by identifying and correcting coding errors.

Question 7

What are some CMS programs healthcare providers should be familiar with?

Answer 7

Providers should be familiar with CMS programs like Medicare Access and CHIP Reauthorization Act (MACRA), Merit-based Incentive Payment System (MIPS), and Promoting Interoperability (formerly Meaningful Use).

Question 8

Why is it important to understand facility-specific coding protocols?

Answer 8

Facility-specific coding protocols ensure compliance with local regulations, payer requirements, and internal policies, impacting documentation and reimbursement.

Question 9

What is the significance of Local Coverage Determinations (LCDs) and National Coverage Determinations (NCDs)?

Answer 9

LCDs and NCDs provide guidance on what services are covered by Medicare in specific regions or nationally, affecting coding decisions and coverage.

Question 10

How does HIPAA affect health record management and coding?

Answer 10

HIPAA focuses on patient privacy, ensuring the confidentiality, integrity, and availability of health records, impacting the handling and transmission of codes and billing.

Question 11

What is the purpose of the HITECH Act in healthcare?

Answer 11

The HITECH Act promotes the adoption and meaningful use of health information technology (HIT), particularly EHRs, and strengthens HIPAA regulations.

Question 12

How do state regulations impact coding and record management?

Answer 12

State regulations may have additional or stricter guidelines regarding patient privacy, data retention, and access, influencing coding, billing, and compliance.

Question 13

Why is it important to stay current with CMS regulations?

Answer 13

CMS regulations determine coding and documentation requirements for reimbursement, ensuring correct billing and preventing claim denials.

Question 14

How can regional payer policies impact coding?

Answer 14

Regional payer policies, such as bundled services or procedure limitations, can affect coding decisions and the reimbursement process.

Question 15

What is the purpose of the Medicare Physician Fee Schedule?

Answer 15

The Medicare Physician Fee Schedule outlines the reimbursement rates for healthcare services under Medicare, guiding coding and billing practices.

Question 16

What should you understand about HIPAA when studying federal regulations?

Answer 16

HIPAA compliance ensures the protection of patient data and governs the exchange of health information, impacting the coding process and electronic health record (EHR) management.

Question 17

What are key compliance requirements under the HITECH Act?

Answer 17

The HITECH Act mandates meaningful use of EHR systems, imposes penalties for non-compliance, and reinforces HIPAA’s privacy and security rules.

Question 18

NEC - Alpha

Answer 18

“Not elsewhere classifiable”
This abbreviation in the Alphabetic Index represents “other specified.”
When a specific code is not available for a condition, the Alphabetic
Index directs the coder to the “other specified” code in the Tabular List.

Question 19

NOS - Alpha/Tabular

Answer 19

“Not otherwise specified”
This abbreviation is the equivalent of unspecified.

Question 20

NEC -Tabular

Answer 20

Not elsewhere classifiable”
This abbreviation in the Tabular List represents “other specified”. When
a specific code is not available for a condition, the Tabular List includes
an NEC entry under a code to identify the code as the “other specified”
code.

Question 21

[ ] -Brackets

Answer 21

Brackets are used in the Tabular List to enclose synonyms, alternative wording or
explanatory phrases. Brackets are used in the Alphabetic Index to identify
manifestation codes.

Question 22

( ) - Parentheses

Answer 22

Parentheses are used in both the Alphabetic Index and Tabular List to enclose
supplementary words that may be present or absent in the statement of a disease or
procedure without affecting the code number to which it is assigned. The terms
within the parentheses are referred to as nonessential modifiers. The nonessential
modifiers in the Alphabetic Index to Diseases apply to subterms following a main
term except when a nonessential modifier and a subentry are mutually exclusive,
the subentry takes precedence. For example, in the ICD-10-CM Alphabetic Index
under the main term Enteritis, “acute” is a nonessential modifier and “chronic” is a
subentry. In this case, the nonessential modifier “acute” does not apply to the
subentry “chronic”.

Question 23

: - colons

Answer 23

Colons are used in the Tabular List after an incomplete term which needs one or
more of the modifiers following the colon to make it assignable to a given
category.

Question 24

What are the main parts of the ICD-10-CM?

Answer 24

The ICD-10-CM is divided into the Alphabetic Index and the Tabular List. The Alphabetic Index includes the Index of Diseases and Injury, Index of External Causes of Injury, Table of Neoplasms, and Table of Drugs and Chemicals. The Tabular List contains codes organized by body system or condition.

Question 25

What is the purpose of the placeholder character “X” in ICD-10-CM?

Answer 25

The “X” is used as a placeholder in certain ICD-10-CM codes to allow for future expansion. It ensures codes are valid when fewer than seven characters are available.

Question 26

What is the 7th character used for in ICD-10-CM?

Answer 26

The 7th character is used in certain ICD-10-CM categories to identify details such as the encounter type (initial, subsequent, or sequela). It is required where applicable, and if a code is less than six characters, a placeholder “X” must be used.

Question 27

What is the difference between NEC and NOS in ICD-10-CM?

Answer 27

NEC stands for “Not Elsewhere Classifiable” and is used when a more specific code is not available. NOS stands for “Not Otherwise Specified” and is used when the documentation does not provide enough detail for a more specific code.

Question 28

How should codes be reported for ambulatory surgery?

Answer 28

The diagnosis code for which the surgery was performed should be used. If the postoperative diagnosis differs from the preoperative one, the postoperative diagnosis should be coded.

Question 29

When should you use a sequela code in ICD-10-CM?

Answer 29

A sequela code is used for residual effects (conditions that persist) after the acute phase of an illness or injury has ended. The sequela condition is coded first, followed by the code for the original illness or injury that caused the sequela.

Question 30

What is the guideline for coding chronic diseases in ICD-10-CM?

Answer 30

Chronic diseases treated on an ongoing basis may be coded and reported as often as the patient receives treatment and care for the condition.

Question 31

What should you do when coding for uncertain diagnoses in inpatient settings?

Answer 31

If a diagnosis is documented as “probable,” “suspected,” “likely,” or other similar terms, code it as if it were confirmed. This guideline only applies to inpatient settings, not outpatient.

Question 32

What is the guideline for coding “impending” or “threatened” conditions?

Answer 32

If the condition occurred, it is coded as a confirmed diagnosis. If it did not occur, reference the Alphabetic Index for a specific entry under “impending” or “threatened.” If no entry exists, code the underlying condition(s) instead

Question 33

How is laterality coded in ICD-10-CM?

Answer 33

Codes in ICD-10-CM often specify laterality (right, left, bilateral). If the condition affects both sides and a bilateral code is available, use it. If no bilateral code is available, assign separate codes for left and right.