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Scribe America > OP Course 4: Billing & Coding > Flashcards

OP Course 4: Billing & Coding Flashcards

1
Q

What are ICD codes?

A

International classification of diseases

Diagnosis

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2
Q

What part of the SOAP notes should support the ICD diagnosis?

A

HPI’s 8 elements

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3
Q

What does the first letter or number of a procedure code correlate to?

A

Specific area of medicine

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4
Q

What is the function of modifiers? Examples?

A

Specify something unique about the patient visit in the ICD

ex:

  • pt has a procedure on bilateral extremities
  • Pt is visiting for pre-op management
  • Pt requires a repeat procedure by the same provider
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5
Q

T/F: Every word on the ICD diagnosis must be supported by your documentation.

A

True

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6
Q

The doctor assigns a diagnosis of H65.06 - Acute otitis media, recurrent, left ear. What are some items that you must document in the HPI and PE in order to support this diagnosis?

A

HPI (onset, location, timing)

PE findings (TM erythema, bulging, etc)

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7
Q

What is the phrase that describes a complaint ICD code?

A

Specific and supported

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8
Q

Your provider chose a clinical impression that is unsupported by your documentation. What is the correct way to address this discrepancy?

A

Ask for clarification on the diagnosis after exiting the pt room

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9
Q

What is the difference between a new and established pt?

A

New pts have not had care by any member of the billing physician’s specialty or practice within 3 years. Established patients have had care within 3 years.

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10
Q

T/F: Established patients typically have longer visits and a more detailed chart?

A

False. They are typically shorter and concise.

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11
Q

Alice has an orthopedic visit with Dr. Jackson whose partner, Dr. Tran, saw Alice 18 months ago for a wrist sprain. Is Alice considered a new patient during her appointment with Dr. Jackson?

A

No. She’s established

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12
Q

What do evaluation & management (E&M) levels evaluate? How many levels are there?

A

Level of service for a visit which determines the amount of eligible reimbursement

5 levels

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13
Q

What do the 5 E&M levels correspond to? Which ones are important for an outpatient clinic?

A

Level 1: Minimal

Level 2: Problem-focused visit

Level 3: Expanded problem visit

Level 4: Detailed

Level 5: Comprehensive

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14
Q

How many elements are required for an E&M level 4 for a new patient?

HPI:

ROS:

PHx:

PE:

Assessment:

A

HPI: 4

ROS: 10 (all)

PHx: 3 (PMHx/PSHx & FHx & SHx)

PE: 9 (2 findings per system)

Assessment: 1

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15
Q

How many elements are required for an E&M level 4 for an established patient?

HPI:

ROS:

PHx:

PE:

Assessment:

A

HPI: 2

ROS: 2

PHx: 1

PE: 2

Assessment: 2

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16
Q

Decipher the following E&M code:

99201

A

992 = OP

0 = New pt

1 = Level 1 visit

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17
Q

Decipher the following E&M code:

99214

A

992 = OP

1 = Established pt

4 = Level 4 visit

18
Q

What should be included in the Assessment & Planning billing subsection?

A

Data (labs, imaging, PMHx, etc)

Diagnoses

Health risk (overall complexity)

19
Q

T/F: Most patient’s charts will be a level 3 or 4, due to the amount of detail that providers typically get when questioning the patient.

A

True

20
Q

T/F: In Outpatient clinics, a level 4 chart would be very thorough.

A

True

21
Q

Mrs. Smith is a new patient and her note contains the items below. Is this a level 3 or level 4 visit?

3 elements of the HPI
9 ROS systems
Only PMHx and SHx
9 PE systems
Dx of HTN in the assessment

A

Level 3

22
Q

If at least ___% of the pt encounter is spent with face-to-face counseling, it should be billed for counseling time. Should be calculated accordingly.

A

50%

23
Q

Risk adjustment factor (RAF) is used for what?

A

To predict healthcare costs and determines hierarchal condition categories (HCC)

24
Q

What happens to reimbursement to the provider when risk for treatment increases?

A

Reimbursement increases due to complexity of care provided.

25
Q

What criteria constitute a low-risk patient?

A

2 or more minor problems

1 stable chronic illness

Acute uncomplicated illness or injury

26
Q

What criteria constitute a moderate-risk patient?

A
  1. 1 or more chronic illness with mild exacerbation or progression
  2. 2 or more stable chronic illnesses
  3. Undiagnosed new problem with uncertain prognosis
  4. Acute illness with systemic symptoms
  5. Acute complicated injury
  6. Prescription drug management
27
Q

What criteria constitute a high-risk patient?

A

1 or more chronic illness with severe exacerbation or progression

Acute or chronic illness or injuries that pose a threat to life or bodily function (e.g., acute MI)

28
Q

What risk level would the following patient be?

No PMHx, here for an ankle sprain

A

Low

29
Q

What risk level would the following patient be?

Check-up for HTN and DM

A

Moderate

30
Q

What risk level would the following patient be?

Asthma with recent exacerbation

A

Moderate

31
Q

What risk level would the following patient be?

HTN well controlled and UTI symptoms

A

Low

32
Q

What risk level would the following patient be?

No PMHX. Recently their Blood pressure has been high

A

Moderate

33
Q

If a pt is given an HCC diagnosis, they are considered_____.

A

High risk

34
Q

What demographics could cause a pt to be considered high risk?

A

Age

Sex

Disability

35
Q

What health factors could cause a pt to be considered high risk?

A
  1. FHx
  2. New or continuation of old Rx
  3. Chronic illnesses (exacerbation, etc)
  4. 2+ Stable chronic illnesses
  5. Undiagnosed problem with an uncertain prognosis
  6. Acute illness with systemic symptoms
  7. Acute complicated injury
36
Q

What phrase can you use to make sure your A&P documentation is complete?

A

MEAT

Monitored

Evaluated

Addressed

Treated

37
Q

What is a superbill?

A

A bill that details the services provided to the patient during a single visit, generated by the healthcare provider; submitted to insurance company or pt for reimbursement.

38
Q

In a superbill, ICD codes bill for ______. Is it required?

A

Diagnosis

Required

39
Q

In a superbill, E&M codes bill for ______. Is it required?

A

Level of service for visit

Required

40
Q

In a superbill, HCC/RAF bills for ______. Is it required?

A

Level of health risk

Not required

41
Q

In a superbill, procedure codes bill for ______. Is it required?

A

Procedures performed

Not required

42
Q

In a superbill, counseling codes bill for ______. Is it required?

A

Counseling from provider

Not required

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