OP Course 4: Billing & Coding Flashcards
What are ICD codes?
International classification of diseases
Diagnosis
What part of the SOAP notes should support the ICD diagnosis?
HPI’s 8 elements
What does the first letter or number of a procedure code correlate to?
Specific area of medicine
What is the function of modifiers? Examples?
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
T/F: Every word on the ICD diagnosis must be supported by your documentation.
True
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?
HPI (onset, location, timing)
PE findings (TM erythema, bulging, etc)
What is the phrase that describes a complaint ICD code?
Specific and supported
Your provider chose a clinical impression that is unsupported by your documentation. What is the correct way to address this discrepancy?
Ask for clarification on the diagnosis after exiting the pt room
What is the difference between a new and established pt?
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.
T/F: Established patients typically have longer visits and a more detailed chart?
False. They are typically shorter and concise.
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?
No. She’s established
What do evaluation & management (E&M) levels evaluate? How many levels are there?
Level of service for a visit which determines the amount of eligible reimbursement
5 levels
What do the 5 E&M levels correspond to? Which ones are important for an outpatient clinic?
Level 1: Minimal
Level 2: Problem-focused visit
Level 3: Expanded problem visit
Level 4: Detailed
Level 5: Comprehensive
How many elements are required for an E&M level 4 for a new patient?
HPI:
ROS:
PHx:
PE:
Assessment:
HPI: 4
ROS: 10 (all)
PHx: 3 (PMHx/PSHx & FHx & SHx)
PE: 9 (2 findings per system)
Assessment: 1
How many elements are required for an E&M level 4 for an established patient?
HPI:
ROS:
PHx:
PE:
Assessment:
HPI: 2
ROS: 2
PHx: 1
PE: 2
Assessment: 2
Decipher the following E&M code:
99201
992 = OP
0 = New pt
1 = Level 1 visit
Decipher the following E&M code:
99214
992 = OP
1 = Established pt
4 = Level 4 visit
What should be included in the Assessment & Planning billing subsection?
Data (labs, imaging, PMHx, etc)
Diagnoses
Health risk (overall complexity)
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.
True
T/F: In Outpatient clinics, a level 4 chart would be very thorough.
True
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
Level 3
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.
50%
Risk adjustment factor (RAF) is used for what?
To predict healthcare costs and determines hierarchal condition categories (HCC)
What happens to reimbursement to the provider when risk for treatment increases?
Reimbursement increases due to complexity of care provided.
What criteria constitute a low-risk patient?
2 or more minor problems
1 stable chronic illness
Acute uncomplicated illness or injury
What criteria constitute a moderate-risk patient?
- 1 or more chronic illness with mild exacerbation or progression
- 2 or more stable chronic illnesses
- Undiagnosed new problem with uncertain prognosis
- Acute illness with systemic symptoms
- Acute complicated injury
- Prescription drug management
What criteria constitute a high-risk patient?
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)
What risk level would the following patient be?
No PMHx, here for an ankle sprain
Low
What risk level would the following patient be?
Check-up for HTN and DM
Moderate
What risk level would the following patient be?
Asthma with recent exacerbation
Moderate
What risk level would the following patient be?
HTN well controlled and UTI symptoms
Low
What risk level would the following patient be?
No PMHX. Recently their Blood pressure has been high
Moderate
If a pt is given an HCC diagnosis, they are considered_____.
High risk
What demographics could cause a pt to be considered high risk?
Age
Sex
Disability
What health factors could cause a pt to be considered high risk?
- FHx
- New or continuation of old Rx
- Chronic illnesses (exacerbation, etc)
- 2+ Stable chronic illnesses
- Undiagnosed problem with an uncertain prognosis
- Acute illness with systemic symptoms
- Acute complicated injury
What phrase can you use to make sure your A&P documentation is complete?
MEAT
Monitored
Evaluated
Addressed
Treated
What is a superbill?
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.
In a superbill, ICD codes bill for ______. Is it required?
Diagnosis
Required
In a superbill, E&M codes bill for ______. Is it required?
Level of service for visit
Required
In a superbill, HCC/RAF bills for ______. Is it required?
Level of health risk
Not required
In a superbill, procedure codes bill for ______. Is it required?
Procedures performed
Not required
In a superbill, counseling codes bill for ______. Is it required?
Counseling from provider
Not required
