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Questions and Answers
A condition that arises during the hospital stay that prolongs the length of stay is?
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.
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 (A)
Which of the following statements is not true regarding clinical documentation in a patient's medical record?
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.
CMS is an organization that oversees private insurance companies.
Following the coding process, the next step in the revenue cycle flow is?
Following the coding process, the next step in the revenue cycle flow is?
ICD-10-PCS codes contain how many characters (either letters or numbers) in the code?
ICD-10-PCS codes contain how many characters (either letters or numbers) in the code?
The annual update for ICD-10 code books and official coding guidelines is effective for dates of service and discharge on or after __________.
The annual update for ICD-10 code books and official coding guidelines is effective for dates of service and discharge on or after __________.
The Root Operation is a character value in which coding classification system?
The Root Operation is a character value in which coding classification system?
In CPT coding, the term 'procedure' describes services which include diagnostic tests.
In CPT coding, the term 'procedure' describes services which include diagnostic tests.
The coding classification system used for inpatient procedures is?
The coding classification system used for inpatient procedures is?
The Uniform Hospital Discharge Data Set (UHDDS) definition of principal diagnosis does not apply to hospital-based outpatient services and provider-based office visits.
The Uniform Hospital Discharge Data Set (UHDDS) definition of principal diagnosis does not apply to hospital-based outpatient services and provider-based office visits.
CAHIIM is an organization that oversees what type of programs?
CAHIIM is an organization that oversees what type of programs?
The Admissions Department determines strategic goals and is accountable for operational efficiency and effectiveness.
The Admissions Department determines strategic goals and is accountable for operational efficiency and effectiveness.
The term for chart readiness so that it can be forwarded to a coding specialist is __________.
The term for chart readiness so that it can be forwarded to a coding specialist is __________.
Standardized terminology of patient information is created by?
Standardized terminology of patient information is created by?
Adherence to official coding guidelines is optional in the coding process.
Adherence to official coding guidelines is optional in the coding process.
A request for payment of services submitted to a third-party payer or the patient is called __________.
A request for payment of services submitted to a third-party payer or the patient is called __________.
Which statement is not true regarding the use of Encoders and Computer-Assisted Coding Software Systems?
Which statement is not true regarding the use of Encoders and Computer-Assisted Coding Software Systems?
Accurate data in the revenue cycle begins with which of the following?
Accurate data in the revenue cycle begins with which of the following?
Software or forms that contain itemized lists of charges for every service and supply a facility provides for their patients is called __________.
Software or forms that contain itemized lists of charges for every service and supply a facility provides for their patients is called __________.
The principal procedure is performed for diagnostic or exploratory purposes.
The principal procedure is performed for diagnostic or exploratory purposes.
Which coding classification system is used for diagnosis coding for both inpatient and outpatient coding?
Which coding classification system is used for diagnosis coding for both inpatient and outpatient coding?
The ICD-10-CM coding system is used for coding both inpatient and outpatient diagnosis codes?
The ICD-10-CM coding system is used for coding both inpatient and outpatient diagnosis codes?
Hospital accreditation is a voluntary process.
Hospital accreditation is a voluntary process.
How many characters are in the CPT code?
How many characters are in the CPT code?
The health information staff responsible for assigning numeric or alphanumeric codes to clinical documentation is the __________.
The health information staff responsible for assigning numeric or alphanumeric codes to clinical documentation is the __________.
The Clinical Documentation Specialist is responsible for maintaining the charge description master on an annual basis.
The Clinical Documentation Specialist is responsible for maintaining the charge description master on an annual basis.
Which of the following would be important to revenue cycle management?
Which of the following would be important to revenue cycle management?
Coding with integrity involves which of the following aspects?
Coding with integrity involves which of the following aspects?
An APC Grouper is used for inpatient coding.
An APC Grouper is used for inpatient coding.
Clinical Services includes all individuals or departments providing treatment or services for the patient.
Clinical Services includes all individuals or departments providing treatment or services for the patient.
Important components of the ICD-10-PCS coding classification system include:
Important components of the ICD-10-PCS coding classification system include:
In the CPT code book, where would a coder find general guidelines?
In the CPT code book, where would a coder find general guidelines?
Which of the following is not an expectation for revenue cycle performance?
Which of the following is not an expectation for revenue cycle performance?
Which statement is true regarding coding?
Which statement is true regarding coding?
Revenue Cycle workflow collaborations include all of the following except:
Revenue Cycle workflow collaborations include all of the following except:
The coding classification system that provides codes for outpatient procedure coding is:
The coding classification system that provides codes for outpatient procedure coding is:
Which job titles represent career options in coding and billing?
Which job titles represent career options in coding and billing?
Coding guidelines are a set of 'rules' intended to provide official direction for the interpretation, assignment, and code build process.
Coding guidelines are a set of 'rules' intended to provide official direction for the interpretation, assignment, and code build process.
The Principal Diagnosis in inpatient coding is?
The Principal Diagnosis in inpatient coding is?
Flashcards
Comorbidity
Comorbidity
A condition that arises during a hospital stay, extending the length of that stay.
ICD-10-PCS
ICD-10-PCS
A system used for coding procedures in hospitals, using 7 characters.
Clinical Documentation
Clinical Documentation
Detailed medical records that accurately reflect patient treatment and services.
Coding Guidelines
Coding Guidelines
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CAHIIM
CAHIIM
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Billing
Billing
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Demographics
Demographics
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ICD-10-CM
ICD-10-CM
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CPT
CPT
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SNOMED-CT
SNOMED-CT
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Coding Specialists
Coding Specialists
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ICD-10 Update
ICD-10 Update
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CPT General Guidelines
CPT General Guidelines
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Clinical Services
Clinical Services
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Collaborative Efforts
Collaborative Efforts
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Coding Integrity
Coding Integrity
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Inpatient Auditor
Inpatient Auditor
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Principal Diagnosis (Inpatient)
Principal Diagnosis (Inpatient)
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APC Grouper
APC Grouper
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Documentation and Billing
Documentation and Billing
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Adhering to Coding Guidelines
Adhering to Coding Guidelines
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Revenue Cycle Management
Revenue Cycle Management
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Demographics and Revenue Cycle
Demographics and Revenue Cycle
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Coding Specialists' Role
Coding Specialists' Role
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Clinical Documentation Specialists' Responsibilities
Clinical Documentation Specialists' Responsibilities
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Coding and Billing Job Opportunities
Coding and Billing Job Opportunities
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Billing after Coding
Billing after Coding
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Coding Ethics
Coding Ethics
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Importance of Coding Integrity
Importance of Coding Integrity
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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.
