Intro into Coding

Question 1

What is coding?

Answer 1

“Coding” is a general term used for the application of a number of systems used to uniformly document and track health care services delivered.

Question 2

What are the different ways coding is used?

Answer 2

They are used in a number of ways, including:

• Billing and reimbursement,
• Practice profiling, and
• Quality measurement.

Question 3

Remember, the chart is a _____ document & the writing must be _______. HIPAA clarified that every patient has a right to see their medical record, and to ______ corrections.

Answer 3

• Legal
• Legible
• Append

Question 4

The multiple types of codes fall into 2 general categories:

Answer 4

1) Diagnosis

2) Service

Question 5

What coding system is typically used for Dx codes?

Answer 5

the International Classification of Diseases, 9th revision (ICD-9).

Question 6

What are ICD-9’s used for?

Answer 6

To record the diagnoses for which a patient was seen/treated.

Question 7

What’s the format of the ICD-9 codes?

Answer 7

Their format is 3 digits, followed by a decimal point and up to 2 more digits. The more digits used, the more specifically the diagnosis is defined. Ideally, coding should always be as specific as possible. Unfortunately, that can be more easily said than done!

Question 8

Explain the significance of the 5 digits in this ICD-9 code for Diabetes? 250.01

Answer 8

• 250 = Diabetes
• .0x = W/o complication
• .x1 = Type 1, controlled

Question 9

Many practices include a list of their most ______ diagnosis codes on their billing form. In the past, these often included only the most ______ code (e.g., 250 for diabetes), to avoid too long a list. This is not advisable, as 4th and 5th digits may be required for ________.

Answer 9

• Common
• General
• Payment

Question 10

Use _____ and _______ if you’re not certain of the diagnosis. Don’t ______ people with diagnoses they don’t have. This can _______ affect them in getting jobs, insurance, and other things in the future.

Answer 10

• Signs & Symptoms
• Label
• Adversely
  (i. e.,An outpatient seen with epigastric pain suspected to be peptic ulcer disease should NOT be coded with PUD unless the diagnosis is confirmed radiographically or endoscopically.
  789. 06 = abdominal pain, epigastric is appropriate)

Question 11

The diagnoses coded should _____ include all problems the patient has, just those ___________ in the specific visit. Diagnoses should be listed in order of priority, with the ______ reason for the visit being first.

Answer 11

• NOT
• Adressed
• Primary

Question 12

For patients with multiple chronic problems, code all documented conditions that _____ the care delivered. Do not code stable problems that are not _________.

Answer 12

• Affect
• Addressed
  (i. e., A 56 year old is seen with URI symptoms and facial pain of 3 days duration. She is a type 1 diabetic in good control who also suffers from chronic pain due to arthritis. Her exam is consistent with acute sinusitis. Because of her diabetes, antibiotics are prescribed & her Diabetes should be coded as well as sinusitis.)

Question 13

What’s the second category (service codes)?

Answer 13

Coding for services rendered

Question 14

All of these (service) codes come from the Health Care Financing Agency’s _______ _______ Coding System (HCPCS). There are several levels of these codes.

Answer 14

Common Procedural (HCPCS)

Question 15

What are the three levels of HCPCS service codes?

Answer 15

I: Current Procedural Terminology
II: National HCPCS codes
III: Local

Question 16

Describe Level I, the Current Procedural Terminology, or CPT-4?

Answer 16

Is a system of codes for services delivered designed by the American Medical Association (AMA). This includes codes for evaluation and management services, surgical procedures, and other types of services.

Question 17

The _______ HCPCS codes were designed by the Centers for Medicare and Medicaid Services (CMS, formerly HCFA), to cover ________ and some ________ not included in level I. [G, J, and Q codes]

Answer 17

• National
• Supplies
• Services

Question 18

_____ codes, which have been commonly in use, are being phased out as part of the uniform billing procedures mandated by ______.

Answer 18

• Local codes

- HIPPA

Question 19

While all of these are technically HCPCS codes, in common parlance we generally refer to 3 types of codes for services:

Answer 19

1) Evaluation and Management (E&M codes) – for visits
2) CPT codes – for procedures
3) HCPCS codes – for materials and supplies

Question 20

HCPCS codes for Supplies and materials are coded with _______ codes specific to each ____.

Answer 20

-5-digit
-Item
(Examples: Carpal tunnel splint (prefab wrist splint) = S8451; Self adherent bandage, elastic, width less than 3 inches, per yard = A6453 & Minor surgical tray = A455)

Question 21

CPT assigns a 5-digit code to every _______.
As in ICD-9, there may be multiple codes that vary based on small differences, such as the length of the wound repaired, the method used to remove a lesion, etc.

Answer 21

-Procedures

Question 22

Many of the procedure codes (CPT) also include subordinate procedures and the supplies that are routinely necessary to perform the procedure – a custom known as _______.

Answer 22

-Bundling

Question 23

__________ and _______ codes are 5-digit codes beginning with 99, used to define the degree of services provided in a patient-provider encounter.

Answer 23

Evaluation & Management

Question 24

Categories of E & M codes include:

Answer 24

• Office or other outpatient services
• Hospital/inpatient services
• Consultations
• Emergency department services
• Critical care services
• Nursing facility services
• Home services

Question 25

The level of evaluation and management services is defined by what 3 major criteria, that together determine the level of service given?

Answer 25

1) History (extent - focused vs. comprehensive)
2) Physical Exam (amount - how many systems)
3) Medical Decision Making (complexity)
- Documentation of EMRs must justify code.

Question 26

ICD-10 codes manual contains what 3 volumes, and what does each contain?

Answer 26

• Volume I = Tabular/Alphanumeric listing of diseases.
• Volume 2 = Instruction manual
• Volume 3 = Alphabetical listing of diseases.