Major complication and comorbitity
MCC stands for
Medicare outpatients are grouped by:
Hypertension and chronic kidney disease
A coding professional may assume a cause-and-effect relationship between hypertension and which of the following complications?
When multiple burns are present, the first sequenced diagnosis is the:
Nonessential modifiers are enclosed in:
warranted by the actual service/resource intensity of the facility.
The practice of undercoding can affect a hospital's MS-DRG case mix b/c It makes it lower than
MS-DRG calculated for the encounter
Medicare inpatient reimbursement levels are based on:
Incorrect code combinations are on the claim
NCCI edits prevent improper payments where
MDC: Major diagnostic categories
Diagnosis-related groups are organized into:
_____ is a prospective payment system implemented by CMS in 1983 for payment of inpatient services as a way to control Medicare spending. It reimburses hospitals a predetermined amount for each medicare InPt stay. Payments are determined by the _____ to which each case is assigned according to the patient's principal Dx.
-The body area from which the excision occurs
- Diameter of the lesion as well as the margins excised as described in the OPERATIVE report.
CPT code determination for a malignant lesion excision is determined by...
According to CPT, a repair of a laceration that includes retention sutures would be considered what type of closure?
A _____ repair of a wound goes beyond layer closure and requires scar revision, debridement, extensive undermining, stents, or retention sutures.
Signs and symptoms
_____ are not coded when they are integral to the disease process. Consider: Fever, nausea, influenza
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:
_____ is designated and defined as the condition established after study to chiefly responsible for occasioning the admission of the patient to the hospital for care.
Secondary Site Code (metastatic)
The _____ is assigned first with a category V10 code (Hx of cancer) used as an additional Dx
Any one of the Dx may be sequenced first
In the unusual instance when two or more diagnoses equally meet the definition for prinicipal Dx, as determined by the circumstances of admission, diagnostic workup, and/or therapy provided, and the Alpha Index, Tabular, or another coding guideline does not provide sequencing direction in such cases _____.
____ are designated and definted (by DHHS) as all conditions that coexist at the time of admission, that develop subsequently, or that affect the treatment received and/or the LOS.
no bearing on the current hospital stay
Diagnoses are to be excluded that are related to an earlier episode that has _____.
Signs, symptoms, abnormal test results, or other reasons for the _____ visit are used when a physician qualifies a diagnostic statement with terms indicating uncertainty.
HCPCS (Healthcare Common Procedure Coding System
promotes uniform reporting and statistical data collection for medical procedures, supplies, products, and services
ICD-O-3: International Classification of Diseases for Oncology, 3rd Ed
a detailed classification system for classifying incidences of malignant disease and coding the histology, topography, and behavior of neoplasms
provides the most comprehensive controlled vocabulary for coding the content of a patient record
SNOMED CT: Systematized Nomenclature of Medicine Clinical Terms
a comprehensive clinical vocabulary designed to encompass all the terms used in medicine, including procedures and diagnoses
DSM-IV-TR: Diagnostic and Statistical Manual of Mental Disorders, 4th Ed
the American Psychiatric Association's _____, updated as a 2000 "text revision"; a widely used system for classifying psychological disorders.
ICD-10-CM: International Classification of Diseases, 10th Revision, Clinical Modification
The planned replacement for ICD-9-CM Volumes 1 & 2
ICD-9-CM Volume 1
Tabular List of Diseases, used by all health care facilities , used to report diagnoses
ICD-9-CM Volume 2
Alphabetic Index to Diseases, used by all health care facilities, used to report diagnoses. Contains Alphabetical Index of Diseases and Injuries, Table of Drugs and Chemicals, and Index to External Causes of Injury and Poisoning.
ICD-9-CM Volume 3
Combined alphabetical index and numerical listing of inpatient procedures
WHO: World Health Organization
Which organization originally published ICD-9?
CMS: Centers for Medicare & Medicaid Services
Which organization is responsible for updating the procedure classification of ICD-9-CM?
The Cooperating Parties
Responsible for maintaining ICD-9. NCHS, AHA, AHIMA & CMS.
Responsible for maintaining the diagnosis classifciation (Volumes 1 & 2) of ICD-9.
Responsible for maintaining the the procedure classification (Volume 3) of ICD-9
_____ works to help provide training and certification for ICD-9
AHA: American Hospital Association
_____ maintains the central office on ICD-9-CM & publishes 'Coding clinic for ICD-9-CM,' which contains the official coding guidelines and official guidance on the usage of ICD-9-CM codes
The most specific codes in the ICD-9-CM system are found at the _____ level. Five-digit codes represent this level.
4-digit diagnosis codes in the ICD-9-CM system
E-Codes (External cause of injury codes)
_____ provide a means to classify environmental events, circumstances, and conditions as teh cause of injury, poisoning, and other adverse effects. These codes must be used in addition to codes from the main chapters of ICD-9-CM.
CPT: Current Procedural Terminology
The purpose of _____ is to provide a system for standard terminology and coding to report medical procedures and services provided by physicians and other clinical professionals.
_____ is the degree to which codes accurately reflect the patient's diagnoses and procedures.
_____ is a condition that existed at admission and is thought to increase the patient stay at least one day for approximately 75% of the patients. Example; a patient admitted with appendicits & has diabetes
MDC: Major diagnostic categories
To determine the appropriate MS_DRG, a claim for a healthcare encounter is first classified into one of 25 _____. The principal Dx determines the MDC assignment.
Failure to use a comprehensive code to inappropriately maximize reimbursement
MS-DRG: Medicare Severity Diagnosis Related Groups
Medicare implemented _____ in 2007 to classify inpatient hospital cases into groups according to similar resource utilization. Hospitals receive a predetermined payment according to _____ for treating Medicare patients.
MS-DRGs may be split into a maximum of _____ payment tiers based on severity as determined by the presence of a Major Complication/Comorbidity (MCC), a Complication/Comorbiditiy (CC), or no CC at all.
POA: Present on Admission
____ is defined as a condition present at the time the order for inpatient admission occurs- conditions that develop during an ouptatient encounter, including the ED, observation or outpt surgery are considered as _____
POA: Present on Admission
The purpose of the _____ indicator is to differentiate between conditions present on admission and conditions that develop during an inpatient admission.
Inpatient Medicare claims submitted by all hospitals
The present on admission (POA) indicator is a requirement for _____
Medicare Part B claims
The National Correct Coding Initiative (NCCI) was developed to control improper coding leading to inappropriate payment for:
The function of the _____ is to identify procedures and services that cannon be billed together on the same day of service for a patient.
Services that cannot be billed together
NCCI edit files contain code pairs called mutually exclusive edits which prevent payment for _____
Data quality and integrity
The authors recommend evaluation of coders at least quarterly for the purpose of measurement and assurance of:
as close to 100% as possible
Quality standards for coding accuracy should be:
makes it lower than warranted by the actual service/resource intensity of the facility
The practice of undercoding can affect a hospital's MS-DRG case mix how?