CCS-P Study Set (latest updated)

According to AMA medical decision making is measured by - ANSWER 1. number of dx or management options 2. amount and complexity of data review 3. risk of complications CPT Assistant - ANSWER provides official guidan ...

According to AMA medical decision making is measured by - ANSWER 1. number of dx or management options 2. amount and complexity of data review 3. risk of complications CPT Assistant - ANSWER provides official guidance in CPT coding published by the AMA A barrier to wide spread use of automated code assignments is - ANSWER poor quality of documentation When should coders assign codes from lab reports alone - ANSWER Never. If findings are out of normal range and the physician has ordered additional testing or treatment; consult with the physician as to whether the Dx should be added or if an abnormal finding should be listed. 4 cooperating parties of ICD-9 and responsibilities of each - ANSWER NCHS (national center for health statistics): maintaines dx classifications in Vol 1&2 CMS: maintains procedural classification in Vol 3 AHIMA & AHA: give advice & assistance on coding guidelines in conjunction with health information management practitioners, physicians, & other users of ICD-9 When can code 99291 (E/M critical care) be used in place of a medical visit or ER code - ANSWER When the patient meets the definition of critical care and receives outpatient care on the same day limiting charge - ANSWER this is the amount a NON PAR Medicare provider can collect from a patient in excess of 15% over the NON PAR Medicare approved amount. When does CMS send the payment directly to the patient - ANSWER when a NON PAR provider does not accept assignment hard coding - ANSWER refers to CPT/HCPCS codes that appear in the hospitals chargemaster and will be included automatically on the patient's bill. CAC- computer assisted coding - ANSWER AHIMA defines as the use of computer software that automatically generates a set of medical codes for review , validation, and use based upon the documentation provided by the various providers of healthcare. modifier: A1-principle physical of record - ANSWER required for patients covered by Medicare when reporting Initial Hospital Service codes POMR- PROBLEM ORIENTED MEDICAL RECORD - ANSWER Organized by problem number Database: history and physical Problem List: titles, numbers, dates of problems..."Table of Contents" of the record Initial Plan: describes diagnostic, therapeutic, and patient education plans Progress Note: documents the progress of a patient throughout the episode of care Discharge Note/ Transfer Note: summarizes episode of care and current status of patient Cost Sharing Provision of Health Ins. - ANSWER formulary for drugs co-pay benefit limitations Common Complication of Labor and Delivery - ANSWER forceps or vacuum extractor delivery without mention of indication renal sphincter tear, not associated with 3rd degree peritoneal laceration trauma to perineum and vulva during delivery HIPAA law in regards to children under 18 - ANSWER defers to state law on matters that concern minors disease index - ANSWER list diagnostic codes in order physician index - ANSWER lists cases in order by physician name or number master patient index - ANSWER cross reference patient name and medical record number operation index - ANSWER list medical records by operative procedures Point of Care Service - ANSWER when clinical documentation is entered in computer at the same time and location of service Federal Register - ANSWER published by CMS. Contains both proposed and final notes for Conditions of Participation for hospitals NEC - ANSWER Books fault> Doctor has detail documented, book does not contain matching detail NOS - ANSWER Doctors fault> Doctor lacks specific documentation although ICD has detailed options V codes - ANSWER supplemental classification Problem based include: need for vaccine Fact based include: history of, outcome of delivery Service based: dialysis, chemo, therapy When is an interval H&P permitted - ANSWER when a patient is readmitted for the same or related problem with-in 30 days Required data for Acute Care and ER records - ANSWER physical findings lab and diagnostic test results follow-up instructions subpeona duces tecum - ANSWER ONLY reason that warrants the original patient chart to leave the premisses of the hospital OBRA - ANSWER Omnibus Budget Reconciliation Act of 1987 MDS - ANSWER Minimum Data Set- used to collect assessment data elements on Nsg home episodes facility data dictionary - ANSWER includes security levels for each form field and definitions for all entities Consultation Report - ANSWER used for obscure diagnoses. patients that physicians are not sure of the best therapeutic action and / or question of criminal activity o patient. Medical Staff By Laws, Rules, and Regulations - ANSWER H&P Exam completed documentation is due within 24 hours after admission prior to surgery. integrated health record - ANSWER arranged in strict chronological order SOMR-Source Oriented Health Record - ANSWER organized by subject matter, then chronologically within each subject; labs together, progress notes together etc. methicillin-resistant staphyllococus - ANSWER SUPERBUG, a major source of hospital-acquired infections Prion Disease - ANSWER family of rare progressive neuro-degenerative disorders. Including: Creutzfeldt-Jakob disease (human) Varient Creutzfeld-Jakob disease (human) Gertsmann-Straussler-Scheinker Syndrome (human) Fatal Familial Insomnia Kuru, aka TSE's transmissible spongiform encephalopathies Synthroid - ANSWER Rx prescribed to replace small levels of thyroid hormone criteria for assigning CPT preventative medicine codes - ANSWER age Fetal Death - ANSWER state law determines weight and weeks of gestation, normal parameters are 500 + grams or 22 + weeks of gestation missed abortion - ANSWER fetal death prior to completion of 22 weeks gestation Unlisted codes in CPT - ANSWER only use when there is actually no code for the procedure DO NOT USE when the coder does not understand the procedure or document additional information MUST be submitted with the claim including; description of procedure, time/ effort necessary to preform procedure, type of equipment required, medical reason for procedure Superbill - ANSWER Aka; charge ticket Data Quality Analysis - ANSWER accuracy accessibility comprehensives consistency currency definition granularity integrity precision relevancy timeliness NON PAR Medicare reimbursement - ANSWER 95% of the PAR Medicare allowed. Providers can bill up to 115% of the NON PAR allowed amount. CPT Key components - ANSWER history exam medical decision making CPT contributing Components - ANSWER counseling coordination of care nature of presenting problem time HCPCS Modifies A1 - ANSWER required for initial hospital service codes when billing Medicare Psychotherapy codes are assigned based on - ANSWER time discounted charges - ANSWER provider charges full rate to insurance carrier but has an arrangement with the insurance carrier to pay at a discounted rate. Physicians usually write off the discount but may bill the patient for all of the portion of remaining balance. Usual Customary Fee profile - ANSWER based on usual fee submitted by that provider combined with the customary fee for that code insurance pays the lowest of; the physician amount, area customary fee, or schedule of benefits negotiated fee schedule - ANSWER created between physician and insurance company agreed flat rate per procedure, visit, or service negotiations based on supply and demand negotiations normally mandate agreed rate are considered payment in full and not allowed to balance bill the patient RBRVS: resource-based relative value scale - ANSWER national fee system used to calculate the approved amount for Medicare payments value assigned to each CPT code based on work involved, cost, and malpractice expenses conversion factors published Federal Register each December Management of a Fee Schedule requires - ANSWER How the practice is reimbursed for services basic value of services provided going rates of services in the market place signals indicating fees need adjustment DO NOT charge less than the payer will pay. Fee Evaluations - ANSWER should occur at least annually unless practice has 100% negotiated and / or capitated rates evaluate codes that provide 80% of revenue for the practice Freedom Information Unit - ANSWER send letter to request answers to questions regarding coding policies payment rates, or payment policies from Medicare only 1 specific request per letter for a quick and accurate response Where are payor specific guidelines found - ANSWER procedure manuals, newsletters, and bulletins published by the payor Local and National coverage Determinations - ANSWER provide guidelines that cover medical necessity Klebsiella - ANSWER gram negative pneumonia clinical data - ANSWER relates to diagnosis and treatment documentation in the health record Radiology reports can be used for coding when - ANSWER used to clarify an outpatient diagnosis or reason for service contraceptive sterilization - ANSWER V25.2 ABN: advanced beneficiary notice - ANSWER waiver required by Medicare for all physician office procedures when there is a question as to whether or not the service will be paid for by Medicare issued each time each questionable service is provided linking - ANSWER explains medical necessity of a procedure on a claim Medicare Prescription Drug, Improvement and Modernization Act of 2003 - ANSWER stipulates that IC-9-CM diagnosis and procedure codes will be issued twice a year April 1st October 1st Effective ways to select an audit sample - ANSWER random sample of records for all physicians in a group all services provided on a randomly selected day all rejected claims during a specific time period Spreadsheet software - ANSWER application that will allow facilitate data collection and analysis