Documentation and Coding Flashcards
What are the reasons for coding? (3)
- Keep track of pts health
- Keep track of what you are doing
- Keep pts info in one place
True or false: everything you do, or consider doing for a patient, must be written in their chart
True
True or false: even simple accidents may be interpreted as fraud and is punishable with monetary restitution and/or jail time
True
True or false: In a case of false or fraudulent claims, the OIG may seek a penalty of up to $10,000 for each item or service improperly claimed
True
In a kickback case, the OIG may seek a penalty of up to $(__) for each improper act and damages of up to three times the amount of remuneration at issue
$50,000
What is E and M coding?
Evaluation and management–The process by which physician-pt encounter are translated into a 5 digit code
What are the three components of EM coding?
- History
- PE
- MDM
What is CPT coding?
Current procedural terminology
–Tells the insurance company what you did for the patient, including the E and M, lab tests, and procedures
OMT is considered a procedure. Thus what code must be used when documenting care?
CPT codes
What are the questions that must be answered for a CPT codes? (3)
- Indications
- Description of procedure and outcome
- Description of areas treated
Are you paid on how many regions you treat, or how many styles of treatment it took you to resolve the dysfunction?
Only on the region treated
When coding, does the number of SDs affect the coding? Does the number of treatments count?
No–only counts the region treated and only once
What are ICD-10 codes?
International classification of disease codes, used to define a diagnosis
True or false: there is no right/wrong way of performing a superbill, as long as all of the information is captured, and is presented appropriately
True
True or false: OMT gets more money treating one patient every half hour than two patients in the same timeframe
True
