Billing & Coding - Section 2: ICD10 Coding Basics Flashcards
1
Q
In 1996, the administrative simplification section of HIPAA approved ____ sets, along with other data standards, to be used in the electronic submissionof health information between covered entities.
A
Code
2
Q
In ____, the administrative simplification section of HIPAA approved code sets, along with other data standards, to be used in the electronic submissionof health information between covered entities.
A
1996
3
Q
What are the 2 procedural code sets that report surgical procedures, diagnostic services, physician services, therapy services, and other medical supplies and services.
A
CPT
HCPCS level II
4
Q
What are CPT codes also known as?
A
HCPCS level I
5
Q
What is the diagnostic code set known as?
A
ICD-10-CM
6
Q
True or False:
The origin of the CPT, HCPCS, and ICD-10 code sets predates the adoption of HIPAA but they were officially accepted as part of the act
A
True
7
Q
CPT is a registered trademark of the ____
A
AMA
8
Q
CPT codes was were first created by the ____ in 1966 with subsequent versions and revisions
A
AMA
9
Q
CPT codes were first created by the AMA in ____ with subsequent versions and revisions
A
1966
10
Q
In ____, the code set was included in the CMS healthcare common procedure coding system (HCPCS)
A
1983
11
Q
In 1983, the code set was included in the ____
A
CMS HCPCS
12
Q
How often are CPT codes updated?
A
At least annually
13
Q
When is the most comprehensive CPT code update published?
A
Each fall
14
Q
When is the most comprehensive CPT code update implemented?
A
At the first of the new calendar year
15
Q
Other CPT code updates, which can include vaccine products, can occur when?
A
Mid-year
16
Q
The CPT code set is maintained by the ____
A
AMA
17
Q
The CPT code set is copyrighted by the ____
A
AMA
18
Q
CPT codes are ____ numeric characters in length and are organized by the ____ of service
A
5
Type
19
Q
Used to report supplies, equipment, and drugs, as well as services and devices which have been assigned temporary or new codes
A
HCPCS codes
20
Q
Medicare codes start with ____
A
G
21
Q
Medicaid services can also be reported with ____ codes
A
HCPCS
22
Q
HCPCS level II codes are typically referred to as what?
A
HCPCS codes
23
Q
Includes codes used to report certain Medicare and Medicaid services which are not reported with CPT codes
A
HCPCS codes
24
Q
How often are HCPCS codes updated?
A
At least annually but as often as quarterly
25
Who updates HCPCS codes?
CMS
26
HCPCS codes are ____ characters in length beginning with a ____ followed by ____ numbers
5
Letter
4
27
What do J codes represent?
Injectible drugs
28
The International Classification of Disease (ICD) originates with the ____ and is maintained in the US by the ____ in collaboration with the National Center for Health Statistics
World Health Organization (WHO)
| Center for Disease Control and Prevention (CDC)
29
What does the "10" in ICD-10 represent?
The 10th revision of the ICD code set
30
What does the "CM" indicate in ICD-10-CM?
That a clinical modification has been made by the US
31
These codes are used to report diseases, conditions, manifestations, and signs and symptoms.
ICD-10-CM
32
These codes can be used to report the reason for an encounter or service
ICD-10-CM
33
When did ICD-10-CM replace ICD-9-CM?
On October 1, 2015
34
When ICD-10-CM replaced ICD-9-CM, the new code set required more specific code assignment, which resulted in what?
A larger code set and new guidelines
35
True or False:
ICD 11 is out but it will be a while before the US adopts this
True
36
With ICD-10-CM codes, what should the code assignment match?
The specificity of the clinical documentation
37
The ICD-10-CM code is structured:
1st character - ____
2nd character - ____
3rd-7th characters - ____ or ____
Alpha
Numeric
Alpha or numeric
38
What is the added code extension within ICD-10-CM codes (7th character) used for?
Obstetrics, injuries, and external causes of injury
39
What do you need to watch for in the 5th or 6th charcater position for ICD-10-CM codes?
"Dummy" placeholder
40
What is the "first-listed" diagnosis used when sequencing ICD-10 codes?
The condition which occasioned the visit (chief complaint)
41
With ICD-10 codes, rule out or differential diagnoses are NOT used in ____ coding
Outpatient
42
True or False:
With ICD-10 codes, co-existing conditions which are present at the time of the visit and effect care of treatment cannot be listed
False; can be listed
43
With ICD-10 codes, ____ conditions are listed above chronic, stable conditions
Acute
44
With ICD-10 codes, signs and symptoms which are integral to the diagnosis SHOULD or SHOULD NOT be listed
Should not
45
Some EHRs require a problem to be reported for each treatment plan. What problem can this cause?
This can overstate the E&M level in some cases
46
With ICD-10 codes, signs and symptoms which are integral to the diagnosis should not be listed. Using the below example, which signs/symptoms would not be listed and why?
Cough, fever, pneumonia
Cough and fever because they are always present with pneumonia
47
With ICD-10 codes, signs and symptoms which are integral to the diagnosis should not be listed. When should signs and symptoms be listed?
If there is no definitive diagnosis during the encounter
48
With ICD-10 codes, conditions which have been resolved or do not affect current treatment ARE or ARE NOT coded
Are not
49
True or False:
Inpatient and outpaitent guidelines are different but never overlap
False; may overlap in some cases
50
If more than one condition was responsible for the visit, which condition should be first listed?
Either can be coded as the first-listed
51
If an acute problem and a chronic problem exist, which problem is listed first?
The acute is listed before the chronic
52
If there is a diagnosis related to a procedure and the procedure is the reason for the visit, which is first-listed?
The diagnosis
53
If other diagnoses contribute to the treatment plan, where are they listed?
Below the reason for the visit
54
If co-existing conditions are present and equally responsible for the reason for the visit, which may be coded as the first-listed diagnosis?
Either may be coded as the first-listed diagnosis
55
Coding example:
Patient presents for continued care of both diabetes and hypertension. Both are stable, chronic codition. Which should be first-listed?
Either can be listed 1st or 2nd
56
Coding example:
Patient presents for continued care of both diabetes and hypertension. The hypertension is stable, but the patient's blood sugar is not controlled causing other manifestations. Which should be coded as first-listed?
The diabetes would be coded as the first-listed and the hypertension would be coded as the second-listed
57
Coding example:
Patient presents for continued care of diabetes, hypertension, and is having a skin lesion removed. Both chronic conditions are stable. Which should be coded as first-listed?
The diagnosis related to the skin procedures would be coded as first-listed and then the other 2 diagnoses would be in either the 2nd or 3rd positions
58
Coding example:
Patient presents for a sinus infection but is also under our treatment for diabetes and hypertension. The chronic conditions are stable, but we need to consider those comorbidities and other drugs in the decision on how to treat the infection. What should be coded as first-listed?
The sinusitis would be the first-listed (reason for the visit and acute) and the chronic conditions would be coded 2nd or 3rd
59
To properly select a code in the classification that corresponds to a diagnosis or reason for the patient encounter, locate the term in the ____ index - carefully follow indentations and "see also" terms. It is not always a straightforward journey; some IT tootls can lead you down the wrong path!
Alphabetic
60
To properly select a code in the ICD-10 classification that corresponds to a diagnosis or reason for the patient encounter, verify the code in the ____ list. Always consult the instructional notations that appear in both the Index and Tabular list
Tabular
61
Some EHRs will only show truncated code descriptions or will map ICD-9 codes to ICD-10 codes automatically. What problem can this cause?
Errors in code assignment can occur
62
What is the most accurate method of ICD-10 code assignment?
Being able to verify a diagnosis using the code set
63
The CPT evaluation and management code descriptions DO or DO NOT give enough guidance for knowing how to correctly assign the C&M levels of service
Do not
64
Providers generally have developed their own way of deciding on a level of service since CPT E&M code descriptions do not give enough guidance for knowing how to correctly assign the E&M levels of service. What can this cause?
Improper code assignment
65
Even though RHCs get an all-inclusive rate, the correct level of E&M service should always be reported. Why is this?
We report the service that we actually perform
66
For Medicare RHC encounters, the patient is responsible for a co-insurance that is equal to ____% of the total charges. Assuming the correct level can affect the ____ amounts and the total ____. Also, the ____ reponsibility will be higher if we charge more.
20%
Coinsurance
Reimbursement
Patient
67
____ should be correctly reported in order to evaluate productivity, allocation of resources, and other areas of practice management.
Utilization
68
The clinic should report the correct level of service to ensure that the RHC is reimbursed correctly by what type of payer?
Fee-for-service
69
Effective January 1, 2021, CMS is aligning E&M coding changes with changed adopted by the ____ CPT Editorial Panel for office/outpatient E&M visits
AMA
70
Effective January 1, 2021, CMS is aligning E&M coding changes with changed adopted by the AMA CPT Editorial Panel for office/outpatient E&M visits, which retains ____ levels of coding for established patients and reduces the number of levels to ____ for office/outpatient E&M visits for new patients and revises the code descriptions.
5
| 4
71
Effective January 1, 2021, CMS is aligning E&M coding changes with changed adopted by the AMA CPT Editorial Panel for office/outpatient E&M visits, revises the time and medical decision making process for all of the codes and requires performance of history and exam only as ____ ____
Medically appropriate
72
The 2021 changes to E&M coding allows clinicians to choose the E&M visit level based on either ____ or ____
Medical decision making or time
73
As of January 1, 2021, the ____ of ____ is determined either by medical decision making or total of provider time spent on the date of service
Level of service
74
____ ____ should support the level of service
Clinical documentation
75
History (chief complaint, HPI, ROS, and PSFH) and exam should be documented to support ____ ____
Medical necessity
76
99211 code does exist but IS or ISN'T qualified as an RHC encounter
Isn't
77
```
For E&M code 99202 (new patient):
History - ____ appropriate
Exam - ____ appropriate
Medical Decision Making - ____
Time - ____-____ minutes
```
Medically
Medically
Straightforward
15-29 minutes
78
```
For E&M code 99203 (new patient):
History - ____ appropriate
Exam - ____ appropriate
Medical Decision Making - ____
Time - ____-____ minutes
```
Medically
Medically
Low
30-44 minutes
79
```
For E&M code 99204 (new patient):
History - ____ appropriate
Exam - ____ appropriate
Medical Decision Making - ____
Time - ____-____ minutes
```
Medically
Medically
Moderate
45-59 minutes
80
```
For E&M code 99205 (new patient):
History - ____ appropriate
Exam - ____ appropriate
Medical Decision Making - ____
Time - ____-____ minutes
```
Medically
Medically
High
60-74 minutes
81
```
For E&M code 99212 (established patient):
History - ____ appropriate
Exam - ____ appropriate
Medical Decision Making - ____
Time - ____-____ minutes
```
Medically
Medically
Straightforward
10-19 minutes
82
```
For E&M code 99213 (established patient):
History - ____ appropriate
Exam - ____ appropriate
Medical Decision Making - ____
Time - ____-____ minutes
```
Medically
Medically
Low
20-29 minutes
83
```
For E&M code 99214 (established patient):
History - ____ appropriate
Exam - ____ appropriate
Medical Decision Making - ____
Time - ____-____ minutes
```
Medically
Medically
Moderate
30-39 minutes
84
```
For E&M code 99215 (established patient):
History - ____ appropriate
Exam - ____ appropriate
Medical Decision Making - ____
Time - ____-____ minutes
```
Medically
Medically
High
40-54 minutes
85
A ____-____ evaluation and management service is the assessment and treatment of a presenting problem. The patient has a chief complaint.
Problem-oriented
86
A ____ service is a defined service, or a group of services, periodically performed to aid in screening for or early detection of potential health threats
Preventive
87
The services and frequency of preventive screenings are usually defined by who?
Health plan or payer
88
____ determine how the preventive services are performed
Payers
89
Preventive services are reporting using either ____ codes 99381-99397 (age specific) or the Medicare-specific level II ____ codes.
CPT
| G
90
A ____ service is being performed if the patient is asymptomatic for a screening and does not have a chief complaint
Preventive
91
A preventive service is being performed if the patient is ____ for a screening and does not have a chief complaint
Asymptomatic
92
A preventive service is being performed if the patient is asymptomatic for a screening and does not have a ____ complaint
Chief
93
A new patient is a patient who has not been seen in the clinic (or by any group using the same EIN) by a provider of the same specialty within the last ____ years
3
94
A patient is not a new patient to a new individual provider but to the ____ or ____
Clinic or EIN
95
The ____ code registered to the individual provider's NPI number is used to determine specialty
Taxonomy
96
A problem-oriented evaluation and management service may include a problem that may be an ____ illness, an injury, or an ongoing ____ condition
Acute
| Chronic
97
Beginning in April 2016, CMS began requiring that procedural code detail be included on the ____ institutional bill types submitted by RHCs
UB-04
98
True or False:
It is important to report all RHC services performed during the face-to-face encounter
True
99
CMS introduced the -CG modifier in October ____
2016
100
The -CG modifier is appended to the E&M ____ code or an ____-____ ____ code to report an RHC encounter and to trigger payment of the AIR rate
Service
| In-office procedure
101
The -CG modifier is appended to the E&M service code or an in-office procedure code to report an ____ encounter and to trigger payment of the ____
RHC
| All-inclusive rate
102
True or False:
The 25 modifier is used more than the 59
False; 59 is used more than 25
103
The 25 or 59 modifier ARE or ARE NOT used on Medicare claims in the same way they are used on other payer claims
Are not
104
What are the 25 and 59 modifiers used for?
To report 2 separate and unrelated RHC encounters occurring on the same date of service
105
Revenue codes are used when submitting ____ claims
Institutional (UB-04)
106
Revenue codes are maintained by who annually?
The National Uniform Billing Committee
107
At what frequence are revenue codes maintained by the National Uniform Billing Committee?
Annually
108
What are revenue codes used to report?
The location or setting in which a service was provided or a type of service
109
Billing edits and denials can occur if a revenue code and ____ code are deemed a mismatch
Procedural
110
True or False:
There are certain CPT codes that would not be performed in certain places of service
True
111
Condition codes report ____ information needed for correct claim processing
Supplemental
112
Category ____ codes are used to report supplemental information, such as patient data, patient status, and quality measure
II
113
Category II codes CAN or CANNOT be reported on the UB-04 claim
Cannot
114
How can category II codes be reported for Medicaid and other payers?
On the 1500 format
115
The process of clarifying both diagnoses and medical services using nationally approved code sets
Coding
116
What is the primary purpose of coding?
To allow the standardization of health data
117
Coding IS or IS NOT a reimbursement methodology by design
Is not
118
Coding is not a reimbursement methodology by design even though codes are used by payers to establish what?
Payment terms
119
True or False:
If a code exists, a payer will recognize it as a payable service
False; just because a cost exists doesn't mean that a payer will recongize it as a reimbursable service
120
Not all valid codes are ____ codes
Payable
121
Not all valid codes represent ____ services
Allowable
122
The process of reporting medical services to a payer for the purpose of being reimbursed
Billing
123
True or False:
Billing guidelines are the same from payer to payer
False; may vary from payer to payer
124
This service occurs when other related services are provided subsequent to an intial service
Incident to
125
What is the below an example of?
A bandage change is performed by nursing staff several days after a physician has provided wound care
Incident to service
126
A bandage change is performed by nursing staff several days after a physician has provided wound care. This type of service is "incident to" the first encounter and ARE or ARE NOT reported as another billable encounter
Are not
127
NPs or PAs can also be "incident to" a ____'s service if certain conditions are met
Physician's
128
What are the 4 "incident to" criteria?
1) The patient is an established patient who was initially seen by the physician
2) The problem is an existing problem for which the physician initiated treatment
3) The physician is in the office or clinic suite at the time the "incident to" service was performed by the NP or PA
4) The documentation establishes a relationship between the initial service and the subsequent "incident to" service
129
In what type of clinic is there an incentive to bill NP and PA services as incident to a physician because the full fee schedule is paid?
Fee-for-service
130
Why is there no financial benefit for billing NP and PA services as incident to in an RHC?
Because the AIR or encounter rate is paid for all qualified provider types
131
True or False:
Most commerical plans follow the Medicare guidelines for incident to billing
True
132
Co-signing the note does not waive the incident to ____ requirements
Billing
133
All providers should be ____, obtain ____ provider numbers, and be linked to contract appropriately even if it means a payment reduction under some plans
Credentialed
| Individual
134
Use ____ when choosing to bill NP or PA services as incident to the supervising or collaborating physician
Caution
135
True or False:
All plans, including MCOs, recognize "incident to" bill
False; some plans, including MCOs, do not recognize incident to billing at all
136
Health insurance companies provide coverage only for health-realted services that they define or determine to be ____ necessary
Medically
137
Most health plans will not pay for healthcare services that they deem as not medically necessary. These include:
____ surgical procedures
____ testing (lab and imaging) not indicated for patient's signs and symptoms
____ tests performed at more frequent intervals than recommeded
Elective
Diagnostic
Screening
138
Many health insurance companies also will not cover procedures, devices, or drugs that they consider to be ____ or not proven to work
Experimental
139
National or local coverage determinations and health plan benefits also determine medical necessity. ____ of services may be required
Preauthorization
140
True or False:
If treating for a hospice ailment, you can bill for this visit as long as it is medically necessary
False; cannot bill for visit even if medically necessary and must look to hospice company for payment or write-off
141
Treatment for hopice ailment cannot be billed where?
To Medicare Part B
