38 Questions
What is the impact of Ambulatory Payment Classifications (APCs) on physicians' services?
They are not affected by APCs
How are Ambulatory Payment Classifications (APCs) adjusted?
According to geographical location for the hospital
What is the purpose of ICD-10-CM codes in relation to APCs?
To determine medical necessity
What happens when a CPT code and a Diagnosis code do not match?
The claim is automatically denied
What is a characteristic of combination codes?
They represent two disease processes or one disease with associated symptoms or complications
Where can Ambulatory Payment Classifications (APCs) be found?
On the CMS website, under Medicare fee-for-service payment, under addendum A and B
What is the primary purpose of Medical Coding Classification Systems?
To capture clinical data for reporting and reimbursement
Which of the following is NOT a component of the International Classification of Diseases (ICD)?
ICD-10-DSM: Diagnostic and Statistical Manual of Mental Disorders
What is the purpose of the Uniform Hospital Discharge Data Set?
To establish a minimum common core data set for insurance claims
What is the correct way to code diagnostic services from radiology and pathology?
Based on the validation by the treating physician
What is the consequence of not following the correct order of codes in a claim submission?
Negative financial impact, and potential fraud prosecution
Which classification system is used for reporting care delivered by physicians?
CPT
What is the main difference between ICD-10-CM and ICD-10-PCS?
ICD-10-CM is used for clinical modification, ICD-10-PCS is used for procedural coding system
What is the UB-04 form used for?
To submit insurance claims
What is the primary purpose of a Master Patient Index (MPI)?
To locate patient records and prevent duplicates and overlays
What is the minimum duration for which medical records must be retained according to the retention policy?
10 years
What is the primary goal of data mining in healthcare?
To retrieve health information data from various systems
Why is patient identification crucial in medical records?
To prevent medical errors and deaths
What happens to physical documents after they are scanned and uploaded to an Electronic Healthcare Record (EHR)?
They are shredded to maintain confidentiality
What is the primary characteristic of big data in healthcare?
All of the above
What is the purpose of health data standards?
To standardize data elements and units with values
What is required for the release of information (ROI) process?
Government-issued ID and authorization of disclosure
What is the primary purpose of the Principal Diagnosis in inpatient coding?
To identify the condition that is the 'driver' behind the DRG
What is the significance of the 7th character in ICD-10-CM codes?
It is a placeholder character
What is the purpose of ICD-10-PCS?
To code inpatient procedures
What is the significance of the first character in an ICD-10-PCS code?
It is a letter that indicates the procedure section
What is the purpose of the notes and definitions in the ICD-10-CM book?
To provide additional information about the codes
What is the difference between the Principal Diagnosis and the Primary Diagnosis?
The Principal Diagnosis is used for inpatient coding, while the Primary Diagnosis is used for outpatient coding
What is the significance of the 9th edition of ICD-CM?
It was used for 36 years before being replaced by ICD-10-CM
What is the purpose of code sequencing in inpatient coding?
To sequence the codes in the order of their highest level of specificity
What is the primary purpose of data abstraction?
To extract relevant information from medical records for statistics and compliance
What is the significance of the midpoint in time measurement?
It is the basis for unit of time measurement
What is the primary goal of data cleanliness?
To maintain up-to-date and accurate data
Which of the following is an official source for coding complicated procedures?
All of the above
What is the importance of documenting procedures and diagnostics?
To prevent denials, win appeals, and prevent accusations of fraud
What is the primary method of ensuring data integrity?
Patient identification of inaccuracies or data anomalies
What is included in health record data for abstraction?
All of the above
What is the significance of time in relation to drug administration?
It is relevant to the timing of drug administration
Study Notes
Clinical Classification Systems
- Time is a measure of the amount of time spent by a healthcare provider face-to-face with a patient, with the unit of time based on when the midpoint has passed, and is relevant to drug administration.
Data Integrity
- Relies on patient identification to eliminate inaccuracies or data anomalies, ensuring data is up-to-date and accurate.
- Data cleanliness is maintained through duplicate matching algorithms, data integrity teams, governance policies, education, and training.
Official Sources for Coding
- Official sources, such as the American Hospital Association (AHA) coding clinic for ICD-10, American Medical Association's (AMA's) CPT Assistant, and Coders desk reference, are recommended for coding complicated procedures and uncertain situations.
Health Record Data for Abstraction
- Elements include patient admit/discharge dates, discharge matching management notes, attending physician matching admit orders, and specific data points for newborn accounts, consulting information, and cause of death.
Data Abstraction
- Extracting relevant information from medical records for statistics, compliance, referrals, discharge information, and more.
Medical Coding Classification Systems
- Definition: a system that captures clinical data for reporting and reimbursement.
- International Classification of Diseases (ICD) identifies morbidity and mortality statistics (current version 10th), with 2 components: ICD-10-CM: Clinical Modification and ICD-10-PCS: Procedural coding system.
- Current Procedural Terminology (CPT) is used for the reporting of care delivered by physicians.
- Healthcare Common Procedure Coding (HCPC) and Diagnostic and Statistical Manual of Mental Disorders (DSM) are also part of the classification systems.
Uniform Data Collection Process
- Uniform Hospital Discharge Data Set (established in 1974 by Health and Human Services HHS) establishes a minimum common core data set, abstracted during discharge for insurance claims.
- Elements include personal identification, admission/discharge dates, types of admission, attending physician ID, operating physician, diagnosis, procedures with dates, patient's disposition, and the expected payer.
ICD-10-CM
- History: traced back to the 16th century, with the 9th edition used for 36 years, and the 10th edition being the current version.
- Changes: new combination codes, added 7th character, expanded codes, trimesters in OB codes, time frames changed, and definitions in notes.
- Needed a procedure book, so ICD-10-PCS was created, with codes ranging from 3-7 characters.
Inpatient Coding
- Principal Diagnosis (PDX): the "driver" behind the DRG, condition established after, and why they are admitted, does not get assigned to outpatient services.
- Code sequencing: PDX must be highest level of specificity, followed by secondary, to find the sequence, coder must review whole document and stay.
Outpatient Coding
- Primary Diagnosis: the reason that the patient is at the hospital, assigned to outpatient services.
- Conventions: knowing general differences, why you need them, what needs a modifier, where to find them, etc. is beneficial for coding.
Ambulatory Payment Classifications (APCs)
- Packaging of items and services found within the Outpatient Prospective Payment System (OPPS), including supplies, anesthesia, operating & recovery room, ancillary services, devices/implants, drugs, lab tests, and imaging services.
- Can be located on CMS.gov, updated annually, under Medicare fee-for-service payment.
CPT & Diagnosis Codes
- Both have to match up, otherwise, it will be denied.
- One Dx coder can support multiple CPT codes.
Medical Record
- Has a personal ID number to differentiate all patients apart.
- Contains full history, surgical history, family history, demographics, shots, drug allergies, and medical directives.
- Patient Identification is number one key because it prevents deaths, errors.
Electronic Healthcare Record (EHR)
- A record of the patient's journey electronically, must be able to maintain meaning for a lifetime.
- Items are assembled by scanning, or manual entry, and then processed through coding and deficiency management.
Big Data and Health Data Standards
- Big Data refers to the sheer volume of data available, the frequency that it is used, and has many forms.
- Health Data standards involve standardization of data elements, units with values.
This quiz covers clinical classification systems, time management in healthcare, and ensuring data integrity in patient records. Topics include time tracking, data accuracy, and anomaly detection.
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