Overview of Coding

Question 1

Acquires a working knowledge of coding systems (CPT. HCPCS level II, ICD-10-CM, ICD-10-PCS), coding conventions and guidelines, government regulations, and third-party payer requirements to ensure that all diagnoses (conditions), services (office visits), and procedures (surgery, xrays), documented in patient records are coded accurately for reimbursement, research, and statistical purposes.

Answer 1

Coder

Question 2

Benefits the student and the facility that accepts the student for placement. Students receive on-the-job experience prior to graduation and assistance in obtaining permanent employment.

Answer 2

coding internship

Question 3

The person to whom the student reports at the site.

Answer 3

internship supervisor

Question 4

Certified Coding Associate (CCA)
Certified Coding Specialist (CCS)
Certified Coding Specialist–Physician-based (CCS-P)

Answer 4

credentials available from AHIMA include the following

Question 5

Certified Professional Coder (CPC)
Certified Inpatient Coder (CIC)
Certified Outpatient Coder (COC)
Certified Risk Adjustment Coder (CRC)
Certified Professional Coder--Payer (CPC-P)

Answer 5

credentials available from AAPC

Question 6

AAPC also offers specialty certifications in response to a demand for those who have obtained advanced training in medical specialties and who are skilled in compliance and reimbursement areas such as the Certified Ambulatory Surgical Center Coder (CASCC) credential.

Answer 6

specialty coders

Question 7

An internet based third party entity that manages and distributes software based services and solutions to customers across a wide area network from a central data center. This allows coders to work from home.

Answer 7

application service provider (ASP)

Question 8

organizes a medical nomenclature according to similar conditions, diseases, procedures, and services; it contains codes for each.

Answer 8

coding system/classification system

Question 9

vocabulary of clinical and medical terms (e.g., arthritis, gastritis, and pneumonia) used by health care providers to document patient care.

Answer 9

medical nomenclature

Question 10

numerical and alphanumerical characters that are reported to health plans for health care reimbursement and to external agencies (e.g., state departments of health) for data collection, in addition to being reported internally (e.g., acute care hospital) for education and research.

Answer 10

code

Question 11

assignment of codes to diagnoses, services, and procedures based on patient record documentation.

Answer 11

Coding

Question 12

adopted in 1979 to classify diagnoses (Volumes 1 and 2) and procedures (Volume 3); all health care facilities assigned ICD-9-CM codes to report diagnoses, and hospitals reported ICD-9-CM procedure codes for inpatient procedures and services; replaced by ICD-10-CM and ICD-10-PCS in 2015.

Answer 12

International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM)

Question 13

developed by the Centers for Medicare and Medicaid Services (CMS) to classify all diseases and injuries. Replaced ICD-9-CM on October 1, 2015 to classify all diagnoses.

Answer 13

International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM)

Question 14

developed by the National Center for Health Statistics (NCHS) to classify inpatient procedures and services. It was developed by the National Center for Health Statistics (NCHS) to classify inpatient procedures and services, and it was implemented on October 1, 2015 (replacing Volume 3 of ICD-9-CM).

Answer 14

International Classification of Diseases, Tenth Revision, Procedure Coding System (ICD-10-PCS)

Question 15

coding system used by physicians and outpatient health care settings to assign CPT codes for reporting procedures and services on health insurance claims; considered level I of the Healthcare Common Procedure Coding System (HCPCS); published and updated by the American Medical Association (AMA) to classify procedures and services; listing of descriptive terms and identifying codes for reporting medical services and procedures; provides a uniform language that describes medical, surgical, and diagnostic services to facilitate communication among providers, patients, and third-party payers.

Answer 15

Current Procedural Terminology (CPT)

Question 16

includes level I codes (CPT) and level II codes (HCPCS level II national codes). HCPCS level II classifies medical equipment, injectable drugs, transportation services, and other services not classified in CPT. Physicians and ambulatory care settings use HCPCS level II to report procedures and services.

Answer 16

Healthcare Common Procedure Coding System (HCPCS)

Question 17

includes comprehensive coverage of diseases, clinical findings, therapies, procedures, and outcomes; combines the content and structure of a previous revision of SNOMED with medical nomenclatures titled the United Kingdom’s National Health Service’s Clinical Terms Version 3 (formerly called Read Codes, developed in the early 1980s by Dr. James Read to record and retrieve primary care data in a computer).

Answer 17

SNOMED Clinical Terms/SNOWMED-CT

Question 18

federal legislation that amended the Internal Revenue Code of 1986 to improve portability and continuity of health insurance coverage in the group and individual markets, combat waste/fraud/abuse in health insurance and health care delivery, promote the use of medical savings accounts, improve access to long-term care services and coverage, simplify the administration of health insurance by creating unique identifiers for providers/health plans/employers, create standards for electronic health information transactions, and create privacy/security standards for health information.

Answer 18

Health Insurance Portability and Accountability Act of 1996 (HIPAA)

Question 19

process of standardizing data by assigning numeric values (codes or numbers) to text or other information.

Answer 19

Encoding

Question 20

entity that processes health care claims and performs related business functions for a health plan; the TPA might contract with a health care clearinghouse to standardize data for claims processing.

Answer 20

third-party administrator (TPA)

Question 21

public or private entity that processes or facilitates the processing of health information and claims from a nonstandard to a standard format.

Answer 21

health care clearinghouse

Question 22

contract established by an insurance company to reimburse health care facilities and patients for procedures and services provided.

Answer 22

third-party payer

Question 23

reporting multiple codes to increase reimbursement when a single combination code should be reported.

Answer 23

Unbundling

Question 24

reporting codes that are not supported by documentation in the patient record for the purpose of increasing reimbursement.

Answer 24

Upcoding

Question 25

reporting codes for signs and symptoms associated, in addition to an established diagnosis code.

Answer 25

Overcoding

Question 26

routinely assigning an unspecified ICD-10-CM disease code instead of reviewing the coding manual to select the appropriate code number.

Answer 26

Jamming

Question 27

routinely assigning lower-level CPT codes as a convenience instead of reviewing patient record documentation and the coding manual to determine the proper code to be reported.

Answer 27

Downcoding

Question 28

requires the review of patient record documentation to identify diagnoses, procedures, and services for the purpose of assigning ICD-10-CM/PCS, HCPCS level II, and/or CPT codes.

Answer 28

medical coding process

Question 29

the review of records to assign codes after the patient is discharged from the health care facility (e.g., hospital inpatient) or released from same-day outpatient care (e.g., hospital outpatient surgery unit). It is most commonly associated with inpatient hospital stays because accurate coding requires verification of diagnoses and procedures by reviewing completed face sheets, discharge summaries, operative reports, pathology reports, and progress notes in the patient records.

Answer 29

Retrospective coding

Question 30

review of records and/or use of encounter forms and chargemasters to assign codes during an inpatient stay or an outpatient encounter; typically performed for outpatient encounters because encounter forms and chargemasters are completed in “real time” by health care providers as part of the charge-capture process.

Answer 30

Concurrent coding

Question 31

used to record data about office procedures and services provided to patients.

Answer 31

Encounter forms

Question 32

contain a computer-generated list of procedures, services, and supplies and corresponding revenue codes along with charges for each.

Answer 32

Chargemasters

Question 33

inappropriate assignment of codes based on assuming, from a review of clinical evidence in the patient’s record, that the patient has certain diagnoses or received certain procedures/services even though the provider did not specifically document those diagnoses or procedures/services.

Answer 33

assumption coding

Question 34

contacting the responsible physician to request clarification about documentation and codes to be assigned; the process is activated when the coder notices a problem with documentation quality.

Answer 34

physician query process

Question 35

Legibility (e.g., illegible handwritten patient record entries)
Completeness (e.g., abnormal test results but clinical significance of results is not documented)
Clarity (e.g., signs and symptoms are present in the patient record, but a definitive diagnosis is not documented)
Consistency (e.g., discrepancy among two or more treating providers regarding a diagnosis, such as a patient who presents with shortness of breath and the consulting physician documents pneumonia as the cause while the attending physician documents congestive heart failure as the cause)
Precision (e.g., clinical documentation indicates a more specific diagnosis than is documented, such as a sputum culture that indicates bacterial pneumonia and the diagnosis does not indicate the cause of the pneumonia)

Answer 35

Establish a policy to indicate when a coder should generate a physician query, such as when documentation in the patient’s record fails to meet one of the following five criteria (according to AHIMA’s practice brief, entitled Managing an Effective Query Process):

Question 36

Clinical indicators of a diagnosis (e.g., lab, x-ray) but the diagnosis is not documented
Clinical evidence for a higher degree of specificity or severity (e.g., progress notes) but specificity or severity is not documented in the diagnosis
Cause-and-effect relationship between two conditions or an organism but the relationship is not documented in the diagnosis (e.g., due to, with)
An underlying cause when a patient is admitted with symptoms (e.g., shortness of breath is documented instead of diagnosed pneumonia)
Treatment is documented without a corresponding diagnosis for medical necessity (e.g., antibiotics for a secondary diagnosis of UTI, which is not documented as a diagnosis)
Lack of present on admission (POA) indicator status (e.g., history did not indicate diagnoses that were present on admission, such as chronic asthma) (The POA indicator status is discussed in textbook Chapter 19.)
Determine whether the query will be generated concurrently (during inpatient hospitalization) or retrospectively (after patient discharge).

Answer 36

Query the physician when the following are noted by the coder and when provider documentation in the patient record is not present (according to AHIMA’s practice brief, entitled Managing an Effective Query Process):

Question 37

That means that coders should ask physicians open-ended questions to avoid leading the physicians by indicating a preference for a particular response.

Answer 37

Who, What, When, Why, and How

Question 38

the process of identifying potential coding compliance problems. For example, a coder notices that some patient records contain insufficient or incomplete documentation, which adversely impacts coding specificity. The coder brings these records to the attention of the coding compliance officer (e.g., coding supervisor), who implements the next stage of the coding compliance program.

Answer 38

Detection

Question 39

based on the review of patient records that contain potential coding compliance problems, during which specific compliance issues are identified and problem-solving methods are used to implement necessary improvements (corrections). For example, the coding compliance officer conducts a careful review of the patient records that contain insufficient or incomplete documentation. She determines that all of them are the responsibility of a physician new to the practice, and she prepares educational material specific to documentation issues noted during her review of the patient records.

Answer 39

Correction

Question 40

involves educating coders and providers so as to prevent coding compliance problems from recurring. For example, the coding compliance officer schedules a meeting with the physician responsible for insufficient or incomplete documentation, and educates the physician about the specific areas of insufficient or incomplete documentation that adversely impact medical coding. This meeting is conducted in a nonconfrontational manner, with education and correction as its goals.

Answer 40

Prevention

Question 41

provides an “audit trail” that the detection, correction, and prevention functions of the coding compliance program are being actively performed. For example, the coding compliance officer maintains a file that contains the following:

Original codes assigned based on insufficient and incomplete documentation
Educational materials prepared specific to the documentation issues
Minutes of the educational meeting with the responsible physician
Final codes assigned based on sufficient and complete documentation
Remittance advice from third-party payer, which contains adjudication (decision about reimbursement, including possible claims denial)

Answer 41

Verification

Question 42

requires the analysis of internal coding patterns over specified periods of time (e.g., quarterly) as well as the analysis of external coding patterns by using external benchmarks (trends). For example, the coding compliance officer reviews reports of quarterly medical audits to determine whether the new physician’s documentation has improved. Such reports contain the results of claims submission, which indicate the number of claims denials based on nonspecific codes submitted as a result of insufficient and incomplete documentation. In addition, the coding compliance officer obtains benchmark data (reports) from third-party payers and compares the coding practices in her facility with those of similar providers; if reimbursement to similar providers is significantly higher (or lower) than that paid to her provider, she initiates the detection process in an attempt to identify related coding compliance problems.

Answer 42

Comparison

Question 43

ensures that codes are assigned to all reportable diagnoses, procedures, and services documented in the patient record. For example, coders review the entire patient record to assign the most specific codes possible.

Answer 43

Completeness

Question 44

allows for the same results to be consistently achieved. For example, when the same patient record is coded by different coding professionals, they assign identical diagnosis and procedure/service codes.

Answer 44

Reliability

Question 45

confirms that assigned codes accurately reflect the patient’s diagnoses, procedures, and services. For example, coders do not assign codes to diagnoses that were not medically managed or treated during an encounter.

Answer 45

Validity

Question 46

means that patient records are coded in accordance with established policies and procedures to ensure timely reimbursement.

Answer 46

Timeliness

Question 47

uses computer software to automatically generate medical codes by “reading” transcribed clinical documentation; uses “natural language processing” theories to generate codes that are reviewed and validated by coders for reporting on third-party payer claims.

Answer 47

Computer-assisted coding (CAC)

Question 48

clicking on codes that CAC software generates to review electronic health record documentation (evidence) used to generate the code; when it is determined that documentation supports the CAC-generated code, the coding auditor clicks to accept the code; when documentation does not support the CAC-generated code, the coding auditor replaces it with an accurate code.

Answer 48

evidence-based coding

Question 49

manual published by the American Psychiatric Association that contains diagnostic assessment criteria used as tools to identify psychiatric disorders; DSM includes psychiatric disorders and codes, provides a mechanism for communicating and recording diagnostic information, and is used in the areas of research and statistics.

Answer 49

Diagnostic and Statistical Manual of Mental Disorders (DSM)