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Apply coding guidelines

If a patient has an excision of a malignant lesion of the skin, the CPT code is determined by the body area from which the excision occurs and which of the following?

Diameter of the lesion as well as the margins (margins is ab normal-looking) excised as described in the operative report.

According to CPT, a repair of a laceration that includes retention sutures would be considered what type of closer?

A complex repair, this type of repair is goes beyond layer closure and requires scar revision, debridement, extensive undermining, stents, or retention sutures.

The patient was admitted with nausea, vomiting and abdominal pain. The physician documents the following on the discharge summary: acute cholecystitis, nausea, vomiting, and abdominal pain. What is the correct coding and sequencing for this case.

Acute cholecystitis because signs and symptoms integral to the disease process should not be coded.

A patient is admitted with spotting. She had been treated two weeks previously for a miscarriage with sepsis. The sepsis had resolved and she is afebrile at this time. She is treated with an aspiration dilation and curettage.

Miscarriage because patient's sepsis has resolved before being admitted to the hospital.

An 80 year old femail is admitted with fever, lethargy, hypotension, tachycardia, oliguria, and elevated WBC. The patient has more than 100,000 organisms of Escherichia coli per cc or urine

Query the physician to ask if the patient has septicemia because of the symptomatology.

The practice of using a code that results in a higher payment to the provider than the code that actually reflects the service or item provided is known as:

Upcoding

A 65 year old patient, with a history of lung cancer, is admitted to a healthcare facility with ataxia and syncope and a fractured arm as a result of falling. The patient undergoes a closed reduction of the fracture in the emergency department and undergoes a complete workup for metastatic carcinoma of the brain. The patient is found to have metastatic carcinoma of the lung to the brain and undergoes radiation therapy to the brain. what is the principal diagnosis in the case.

Metastatic carcinoma of the brain, which is a condition established after study to chiefly(important) responsible for occasioning the admission of the patient to the hospital for care.

A patient was admitted for abdominal pain with diarrhea and was diagnosed with infectious gastroenteritis. The patient also had angina and chronic obstructive pulmonary disease. what is the correct coding and sequencing for this case?

Infectious gastroenteritis: chronic obstructive pulmonary disease, and angina. abdominal pain is a symptom of gastroenteritis NOT code.

A Patient is admitted with a history of prostate cancer and with mental confusion. The patient completed radiation therapy for prostatic carcinoma three years ago and is status post a radical resection of the prostate. A CT scan of the brain during the current admission reveals metastasis. what is the correct coding and sequencing for the current hospital stay?

Metastatic carcinoma of the Brain and V code for prostate cancer. No code for mental confusion b/c is a symptom of cancer. If patient have history of a primary site of malignancy but later develop a secondary neoplasm or a metastatic site at another location, treatment is directed to the secondary site (code first) then V code as an additional code.

A Patient is admitted w/abdominal pain. Dr. states that the discharge diagnosis is pancreatitis versus noncalculus cholecystitis. Both diagnoses are equally treated. What is the correct coding and sequencing for this case.

Sequence either the pancreatitis or noncalculus cholecystitis as principal diagnosis. When it equally meet the definition of principal diagnosis as determined by the circumstances of admission, diagnostic workup, an/or the therapy provided except direct it by coding guideline.

According to the UHDDS, what is the definition of "other diagnoses"?

Is considered all condition that coexist at the time of admission, or develop subsequently, which affect the treatment received and/or the length of stay.

A 7 year-old was admitted to ER for treatment of shortness of breath. The patient is given epinephrine and nebulizer treatments. the shortness of breath and wheezing are unabated(reduce) following treatment. No documentation of diagnosis what is a diagnosis should be suspected.

Asthma with status asthmaticus, Dr should be queried.

Coder might find patient's problem list if the medication list contains the drug Procardia?

Hypertension. This drug is use to relieves angina/stable angina pectoris(chest pain), is anti-anginal, anti-hypertensive. it also treat vasospastic angina.

Dr orders a chest x-ray for an office patient who presents with fever, productive cough and shortness of breath. Dr. indicates in the progress notes "Rule out Pneumonia" what should the coder report for that visit when the results have not ye been received?

Signs, symptoms, abnormal test results or other reasons for the outpatient visit are used when Dr. qualifies a diagnostic statement as "possible", "probable", "suspected", "questionable", "rule out", or "working diagnosis" which is uncertainty term.

What is the promotes uniform used reporting and statistical data collection for medical procedures, supplies, products, and services?

HCPCS Healthcare Common Procedure Coding System is used to report the healthcare procedures, supplies, products, and services by Medicare.

What system provides a detailed classification system for coding the histology, topography, and behavior of neoplasms?

ICD-O-3 International Classification of Diseases for Oncology, Third Edition is a classify incidences of malignant disease. In Hospital use it for develop cancer registries which is a list of all cancer diagnosed and treated in facility.

What standard provides the most comprehensive controlled vocabulary for coding the content of a patient record?

SNOMED CT creates a standardized vocabulary to make it easy to gather and retrieve information in EHR.

What diagnostic manual provides a set of codes used for collecting data about substance abuse and mental health disorders?

DSM-IV-TR is Diagnostic and Statistical Manual of Mental Disorders, Fourth Revision, Text Revision and it updated and published by APA the american Psychiatric Association. DSM is contains a list of the criteria for diagnosis each mental disorder and diagnosis code.

What is planned to replace ICD-9-CM Volumes 1 and 2?

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

What organization originally published ICD-9?

WHO World Health Organization

What organization is responsible for updating the procedure classification of ICD-9-CM?

CMS Centers for Medicare and Medicaid Services

List of four organizations parties that helps maintained ICD-9-CM

NCHS responsible for update diagnosis classification V 1 and V2, CMS responsible for update the procedure classification V3, AHIMA works to help provide training and certification, and AHA maintains the central office and publishes coding clinic that contains coding guidelines.

Which level of the classification system are the most specific ICD-9-CM codes found?

Subclassification level. which is five-digit code numbers

What is a four-digit ICD-9-CM diagnosis codes referred to as?

Subcategory codes is four-digit code. which is divided from Categories have 3 digit number codes

Which is ICD-9-CM codes are always alphanumeric?

E codes, External causes of injury and poisoning. it's classify environmental events and circumstances as the causes of an injury, poisoning, or other adverse effect?

Which volume of ICD-9-CM contains the tabular and alphabetic lists of procedures?

Volume 3. Tabular list contains chapters organized according to anatomical system, except for the last chapter, Miscellaneous Diagnostic and Therapeutic Procedures.

What is the purpose of CPT Current Procedural Terminology developed by AMA

To provides a system for coding the clinical PROCEDURES and SERVICES provided by physicians and other clinical professionals not with Medicare patient they use HCPCS.

How many level of HCPCS used and monitored by CMS.

There are two sets of codes. The first set, HCPCS Level I, are based on and identical to CPT codes, the codes developed by the American Medical Assocation. Level II HCPCS codes are used by medical suppliers other than physicians, such as ambulance services or durable medical equipment.

Which is elements of coding quality represent the degree to which codes accurately reflect the patient's diagnoses and procedures?

Validity

A patient is admitted to the hospital with acute lower abdominal pain. The principal diagnosis is acute appendicitis. The patient also has a diagnosis of diabetes. The patient undergoes an appendectomy and subsequently develops two wound infections. In the DRG system, what is considered a comorbid condition?

Diabetes because it is a condition that existed at admission and is thought to increase the patient stay at least one day at hospital.

What is GPCI

GPCI Geographic practice cost indices is the number used to multiply each relative value (RVU)

What is a nomenclature

is a system that lists preferred medical terminology, or call "naming" system, or refer to clinical terminology, such as CPT.

What is Classification systems?

is a systems that group together similar diseases and procedures. ICD-9-CM is a example of a classification system.

what is purpose of Clinical vocabularies

It developed to create a list of clinical words or phrases with their meanings.

what is Geometric and arithmetic?

Geometric mean LOS which is a total days of service, excluding any outliers or transfers, divided by the total number of patients. Arithmetic mean LOS is defined as the total days of service divided by the total number of patients. the number of Arithmetic mean is all way higher than Geometric.

What is call for the condition established after study to be the reason for hospitalization?

Principal diagnosis

which payment system that the a prospective payment system (PPS) implemented for payment of inpatient services?

DRGs diagnosis-related groups is a system that CMS implemented a PPS for inpatient hospital care provided to MEDICARE beneficiaries. PPS implemented in 1983.

In the Inpatient Prospective Payment System assignment to a DRG begins with the_____.

Principal diagnosis, which is determines the MDC assignment. MDC is Major diagnostic categories that MS-DRG classified or organized into 25 MDC or groups.

NCCI edits prevent improper payments where?

Incorrect code combinations are on the claim. The NCCI is a predefined set of edits created by Medicare.

Medicare inpatient reimbursement levels are based on:

MS-DRG calculated for the encounter

Coding and billing documentation must be based on the_____.

Provider's documentation mush support the billing and coding.

Unbundling refers to____.

Failure to use a comprehensive code to inappropriately maximize reimbursement. It's occur when use multiple procedures code for a group/or single code that describes all steps of procedures performed.

MS-DRGs may be split into a maximum of _____ payment tiers based on severity as determined by the presence of a major complicatio and comorbidities MCC, a Complications and comorbidities CC; or no CC.

Three, one is with MCC, second is with CC, and third w/o CC/MCC. A complication is a secondary condition that arises during hospitalization; a comorbidity is one that exists at the time of admission. Case with CC, or MCC is represent a higher severity level and higher payment.

What is complications or comorbidities?

Complications are conditions that arise during the hospitalization such as postoperative wound infection. Comorbidities are coexisting conditions, such as hypertension.

Different type of hospital that are Excluded from Medicare PPS and still paid on the basis of reasonable cost, subject to payment limits per discharge or under a separate PPS.

Psychiatric and rehabilitaiton facilities, Logn-term care hospital (ALS of 25 days or more, children's hospitals, cancer hospitals, and Critical assess hospitals.

The purpose of the present on admission (POA) indicator is to____.

Differentiate between conditions present on admission and conditions that develop during an inpatient admission

The National correct Coding Initiative (NCCI) was developed in 1996 by CMS to control improper coding leading to inappropriate payment for_____.

Part B Medicare claims which is identify procedures and services cannot be billed together on the same day of service for a patient which is a main NCCI edits function.

NCCI edit files contain code pairs called mutually exclusive edits which prevent payment for____.

Services that cannot reasonable be billed together. The matually exclusive edit applies to improbable or impossible combinations of codes.

Why coders should be evaluated at least quarterly maybe with training?

Data quality and integrity which is a data accurately and ensured the correct code.

what is Haldol prescribed for?

To treat certain mental/mood disorder. behavior or mental conditions

Mary Patient presented to the emergency department with chest pains and shortness of breath. She was treated for congestive heart failure and returned home. Two days later, her symptoms had worsened. She presented again to the emergency department and was admitted to the hospital for inpatient treatment of congestive heart failure. The hospital will bill Medicare for_____.

One inpatient visit under MS-DRGs. There is a 72-hour window for Medicare patients. So outpatient and inpatient visits w/in 72-hour period need to be reviewed before complete and accurate coding and assigning MS-DRG.

Most chief financial officers view the HIM department's most essential role in the revenue cycle management to be_____.

Coding of the record.

[ ] Brackets are used?

Used in the tabular list to enclose synonyms, alternative wording or explanatory phrases. In the index to identify manifestation codes.

( ) Parentheses are used?

Used in both the index and tabular list to enclose supplementary words that may be present or absent in the statement with out affected the code. The Term refer to Nonessential modifiers.

: Colons are used?

Used in Tabular list after an incomplete term which needs one or more of the modifiers following the colon to make it assignable to a given category.

When multiple burns are present, the first sequenced diagnosis is the____.

Highest-degree burn.

A coding professional may assume a cause-and-effect relationship between hypertension and which of the following complications?

Hypertension and chronic kidney disease

A patient which know AIDS is admitted to the hospital for treatment of Pneumocystis carinii pneumonia. Assign the principal diagnosis for this patient.

When patient is treated for a complication associated with HIV infection, the 042 code (HIV) is assigned as the principal diagnosis to identify the HIV disease and additional codes to identify other diagnoses. Minimum two codes case of patient admitted for HIV related illness.

Coding productivity is measured by:

Quantity and quality: check type of error and how fast they can code

The___ is responsible for issuing official coding guidelines for ICD-9-CM, whereas the ____ is responsible for issuing official guidelines for CPT.

AHA American Hospital Association issuing ICD-9, AMA. American Medical Association AMA maintains CPT nomenclature system and publishes CPT assistant.

Medicare outpatients are grouped by:

APC, Ambulatory Payment Classification. Medicare reimburses hospital for outpatient services based on Outpatient Prospective Payment System (OPPS), which categorizes patients into groups. groups know as APC.

How DRG and APC groupings work?

Coders enter the codes that have been selected ito a computer program called a grouper. The grouper then assigns the patient's case to the correct group bases on the ICD-9-CM and/or CPT/HCPCS codes.

What is the reason to establishing a coding quality program?

Proactively identify variations in coding practices among staff member. Determine the cause and scope of identified problems. Set priorities for resolving identified problems.

A patient is seem as an outpatient to receive radiation and chemotherapy for distal esophageal carcinoma. What is the appropriate principal diagnosis.

V58.11, Encounter for antineoplastic chemotherapy.

When Dr does not specify the method used to remove a lesion during an endoscopy, what is the appropriate procedure?

Query the physician as to the method used.

Chemical dependency services inpatient & outpatient service for substance use (addiction) have their own series of codes in which US coding system?

HCPCS procedure codes and it much be filed on a CMS 1500 claim form

A coding professional needs to code an ambulatory record, but the procedure code performed is not in the CPT Manual. What would the coder use to code the procedure?

HCPCS level II code. HCPCS divided into two code levels/groups: levels I codes are most referred to merely as CPT but levels II codes were developed to code medical services, equipment, and supplies that are not included in CPT but most people when refer to HCPCS mean levels II.

A 30 year old femail has a vaginal delivery with single liveborn female with episiotomy and repair ( surgical incision of perineum during childbirth to facilitate delivery)

650 normal delivery, V27.0 Single liveborn, 73.6 Episiotomy (with subsequent repair)

A patient is scheduled for an outpatient colonoscopy, but due to a sudden drop in blood pressure, the procedure is cancelled just as the scope is introduced into the rectum. Because of moderately severe mental retardation, the patient is given general anesthetic prior to the procedure. How should this procedure be coded?

assign the code for colonoscopy with modifier -74, Discontinued outpatient procedure.

Providers should be queried regarding information in the health record for all of the following, except:

Insignificant information. (not important/ or small not worse it to bring it up.

The purpose of the POA present on admission indicator is to identify:

Hospita-acquired conditions. Acquired mean ability.

Present on Admission POA defined as:

a condition present at the time the order for inpatient admission occurs. conditions that develop during an outpatient encounter, including ER, observation or outpatient surgery. POA indicator is assigned to principal and secondary diagnoses and the external cause of injury codes.

CMS identified hospital-acquired condition (not present on admission? as?

a reasonably preventable and hospitals do not receive additional payment for cases for example foreign object retained after surgery, state III and IV pressure ulcers, falls and trauma, Surgical site infection, air embolism, blood incompatibility.

The ____ operates in the systems of Medicare Administrative Contractors (MACs) and provide a series of flags that can affect APC payments because it identifies coding errors in claims.

OCE outpatient code editor.

The main purpose of Correct Coding Initiative (CCI) edits is to prohibit:

Unbundling of procedures. Use multi-code instated one code to claim appropriate procedures. CCI edits also apply to the APC system and updated quarterly.

When assigning evaluation and management codes for hospital outpatient services, the coder should follow:

The hospital's own internal guidelines.
For the most part, APCs follow the CPT coding rules, However hospitals can develop their own criteria for assigning E/M codes that determine the level of the visit and hospital do not follow the same guidelines as physicians.

Which of the following is not one of the components that make up the total relative value unit (RVU) for a given procedure?

Staff work. the components of RVU is physician work, practice expense, and Malpractice expense.

what is neoplasm types is correct for sympathicoblastoma

Malignant because the sympathicoblastoma is refer to Neoplasm, by site, Malignant in alphabetic index.

In CPT, if a patient has two lacerations of the arm that are repaired with simple closures, what would apply for correct coding?

One CPT code, adding the lengths of the lacerations together. The length of multiple laceration repairs located in the same classification are added together and one code assigned.

A patient had a placenta previa with delivery of twins. The patient had two prior cesarean sections. this was an emergent C-Section due to hemorrhage. The appropriate principal diagnosis would be?

[Placenta previa] in case of a cesarean delivery, the selection of the principal diagnosis should correspond to the reason the cesarean delivery was performed.

In order to clarify documentation, the preferred method of contact between a coder and a physician is___

Face-to-face communication in order for coder to be able to modified, changed, or deleted only after, or when the physician documents in the medical record.

Coding accuracy is best determined by_____

[A predefined audit process] coders should be evaluated at least quarterly, with appropriate training needs identified, facilitated(to make easier), and reassessed over time. Only through this continuous process of evaluation can data quality and integrity be accurately measured and ensured.

What is different between APR DRG grouper and DRG grouper?

MS-DRGs have three levels of severity for a given diagnosis grouping w/CC or w/MCC, and w/o a CC/MCC. APR-DRG have four levels the result is that there are more than 1,200. MS-DRGs have only 700 group. Also MS-DRG system, the number of CCs does not affect the severity level; for example a case with seven CCs can fall into the same DRG as a case w/only one CC. In addition the grouper logic for APR-DRGs is much more complex, involving multiple steps to determine severity and sometimes rerouting to a different MDC based on codes other than the principal diagnosis.

What is the most likely to impair(make worse) an experienced coder's productivity?

Hybrid record b/c they are not used to and it slow the productive at first.

An inpatient, acute-care coder must follow official ICD-9-CM coding guidelines established by the____

[Cooperating Parties]; NCHS, AHA, AHIMA, and CMS. serve as a clearing house to answer questions, develop educational materials and programs, work cooperatively in maintaining the integrity and recommend revisions and modification to current and future revisions.

A patient was admitted to the hospital with symptoms of a stroke and secondary diagnoses of COPD and hypertension. The patient was subsequently discharged from the hospital w/ a principal diagnosis of CVA cerebral vascular accident and 2nd diagnoses of catheter-associated UTI, COPD, and hypertension. which diagnoses should NOT be reports as POA

[catheter-associated UTI] because it didn't occur when patient at the time of patient admitted. POA present on admission is defined as present at the time the order for inpatient admission occurs including the condition that develop during an outpatient encounter such as in emergency department, observation, or outpatient surgery.

A patient was admitted to the hospital on September 15, 2011 and discharged on October 5, 2011. In order to code this record correctly, the coder must use the version of ICD-9-CM updated on:

[October first] The ICD-9-CM updated biannual. The effective for discharges after October 1 and April 1. For a patent discharged on October 5, 2011, The October 1 version should be used to code the record correctly.

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