Coding Module 1 Quiz
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Coding Module 1 Quiz

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Questions and Answers

A condition that arises during the hospital stay that prolongs the length of stay is?

comorbidity

In ICD-10-PCS coding, it is the coder's responsibility to interpret the provider's documentation in alignment with PCS definitions for the character values.

True

Which of the following statements is not true regarding clinical documentation in a patient's medical record?

  • Treatment or services provided that are documented may be billed
  • Treatment or services provided that are not documented may still be billed (correct)
  • Clinical documentation must always be complete
  • None of the above

    • CMS is an organization that oversees private insurance companies.

    <p>False</p> Signup and view all the answers

    Following the coding process, the next step in the revenue cycle flow is?

    <p>billing</p> Signup and view all the answers

    ICD-10-PCS codes contain how many characters (either letters or numbers) in the code?

    <p>7</p> Signup and view all the answers

    The annual update for ICD-10 code books and official coding guidelines is effective for dates of service and discharge on or after __________.

    <p>October 1</p> Signup and view all the answers

    The Root Operation is a character value in which coding classification system?

    <p>ICD-10-PCS</p> Signup and view all the answers

    In CPT coding, the term 'procedure' describes services which include diagnostic tests.

    <p>True</p> Signup and view all the answers

    The coding classification system used for inpatient procedures is?

    <p>ICD-10-PCS</p> Signup and view all the answers

    The Uniform Hospital Discharge Data Set (UHDDS) definition of principal diagnosis does not apply to hospital-based outpatient services and provider-based office visits.

    <p>True</p> Signup and view all the answers

    CAHIIM is an organization that oversees what type of programs?

    <p>Health Information higher education programs</p> Signup and view all the answers

    The Admissions Department determines strategic goals and is accountable for operational efficiency and effectiveness.

    <p>True</p> Signup and view all the answers

    The term for chart readiness so that it can be forwarded to a coding specialist is __________.

    <p>legal</p> Signup and view all the answers

    Standardized terminology of patient information is created by?

    <p>SNOMED-CT</p> Signup and view all the answers

    Adherence to official coding guidelines is optional in the coding process.

    <p>False</p> Signup and view all the answers

    A request for payment of services submitted to a third-party payer or the patient is called __________.

    <p>claim</p> Signup and view all the answers

    Which statement is not true regarding the use of Encoders and Computer-Assisted Coding Software Systems?

    <p>Coding software can assign codes more effectively than a skilled coding professional.</p> Signup and view all the answers

    Accurate data in the revenue cycle begins with which of the following?

    <p>Accurate entry of patient demographic and insurance information when the patient registers for services</p> Signup and view all the answers

    Software or forms that contain itemized lists of charges for every service and supply a facility provides for their patients is called __________.

    <p>CDM</p> Signup and view all the answers

    The principal procedure is performed for diagnostic or exploratory purposes.

    <p>True</p> Signup and view all the answers

    Which coding classification system is used for diagnosis coding for both inpatient and outpatient coding?

    <p>ICD-10-CM</p> Signup and view all the answers

    The ICD-10-CM coding system is used for coding both inpatient and outpatient diagnosis codes?

    <p>True</p> Signup and view all the answers

    Hospital accreditation is a voluntary process.

    <p>True</p> Signup and view all the answers

    How many characters are in the CPT code?

    <p>5</p> Signup and view all the answers

    The health information staff responsible for assigning numeric or alphanumeric codes to clinical documentation is the __________.

    <p>coding specialist</p> Signup and view all the answers

    The Clinical Documentation Specialist is responsible for maintaining the charge description master on an annual basis.

    <p>False</p> Signup and view all the answers

    Which of the following would be important to revenue cycle management?

    <p>All of the above.</p> Signup and view all the answers

    Coding with integrity involves which of the following aspects?

    <p>All of the above.</p> Signup and view all the answers

    An APC Grouper is used for inpatient coding.

    <p>False</p> Signup and view all the answers

    Clinical Services includes all individuals or departments providing treatment or services for the patient.

    <p>True</p> Signup and view all the answers

    Important components of the ICD-10-PCS coding classification system include:

    <p>All of the above.</p> Signup and view all the answers

    In the CPT code book, where would a coder find general guidelines?

    <p>at the beginning of each section</p> Signup and view all the answers

    Which of the following is not an expectation for revenue cycle performance?

    <p>Individuals and departments working independently without collaboration.</p> Signup and view all the answers

    Which statement is true regarding coding?

    <p>All of the above.</p> Signup and view all the answers

    Revenue Cycle workflow collaborations include all of the following except:

    <p>Human resources and clinical documentation improvement.</p> Signup and view all the answers

    The coding classification system that provides codes for outpatient procedure coding is:

    <p>CPT</p> Signup and view all the answers

    Which job titles represent career options in coding and billing?

    <p>All of the above</p> Signup and view all the answers

    Coding guidelines are a set of 'rules' intended to provide official direction for the interpretation, assignment, and code build process.

    <p>True</p> Signup and view all the answers

    The Principal Diagnosis in inpatient coding is?

    <p>The condition, after study, which occasioned the admission (as an inpatient) to the hospital</p> Signup and view all the answers

    Study Notes

    Comorbidity and Coding Basics

    • Comorbidity refers to a condition that arises during a hospital stay, extending the length of that stay.
    • In ICD-10-PCS coding, coders must interpret provider documentation in accordance with PCS definitions for character values.

    Clinical Documentation and Coding Standards

    • Accurate clinical documentation is crucial; unrecorded treatments may not be billed.
    • Adherence to official coding guidelines is mandatory in the coding process to ensure compliance.
    • CAHIIM oversees health information higher education programs, ensuring educational standards.

    Revenue Cycle Management

    • The next step in the revenue cycle following coding is billing.
    • Accurate demographic and insurance information during patient registration is vital for seamless revenue cycle management.

    Coding Systems and Terminology

    • ICD-10-PCS codes consist of 7 characters, while CPT codes have 5 characters.
    • ICD-10-CM coding system is utilized for both inpatient and outpatient diagnosis coding.
    • SNOMED-CT standardizes patient information terminology across the healthcare industry.

    Coding Roles and Responsibilities

    • Coding specialists are responsible for assigning numeric or alphanumeric codes to clinical documentation.
    • Clinical documentation specialists do not maintain the charge description master annually.

    Important Guidelines and Updates

    • The annual update for ICD-10 code books and guidelines comes into effect on October 1.
    • General guidelines in CPT code books can be found at the beginning of each section.

    Clinical Services and Efficient Workflow

    • Clinical services encompass all individuals and departments involved in patient treatment.
    • Effective revenue cycle performance relies on collaborative efforts between all departments, avoiding isolated work.

    Coding Ethics and Integrity

    • Coding with integrity includes understanding legal and ethical aspects, as well as applying official coding guidelines.

    Job Opportunities in Coding and Billing

    • Career options in coding and billing include Claims Specialist, Educator/Trainer, and Inpatient Auditor.

    Key Concepts to Remember

    • The principal diagnosis in inpatient coding is defined as the condition leading to a patient's admission to the hospital.
    • An APC Grouper is designed for outpatient coding, not inpatient.

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    Description

    Test your knowledge with the Coding Module 1 Quiz. This quiz covers essential terms and concepts related to coding, including definitions and responsibilities in healthcare documentation. Perfect for students looking to strengthen their understanding of coding principles.

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