CHAPTER 1

Question 1

Assumption coding

Answer 1

nappropriate assignment of codes based on assuming, from a review of clinical evidence in the patient’s record, that the patient has certain diagnoses or received certain procedures/services even though the provider did not specifically document those diagnoses or procedures/services.

Question 2

CMS

Answer 2

Centers for Medicare & Medicaid Services

administrative agency in the federal Department of Health & Human Services.

Question 3

classification system

Answer 3

see coding system

Question 4

Clinical documentation improvement

Answer 4

helps ensure accurate and thorough patient record documentation and identifies discrepancies between provider documentation and codes to be assigned.

Question 5

clinical documentation integrity

Answer 5

see clinical documentation improvement

Question 6

CMS-1450

Answer 6

see UB-04

Question 7

CMS-1500

Answer 7

claim submitted by physicians’ office to third-party payers

Question 8

Code

Answer 8

numerical and alphanumerical characters that are reported to health plans for health care reimbursement and to external agencies (e.g. state departments of health) for data collection, in addition to being reported internally (e.g. acute care hospital) for education and research).

Question 9

coder

Answer 9

acquires a working knowledge of coding systems (e.g., CPT, HCPCS Level II, ICD-10-CM, and ICD-10-PCS), coding principles and rules, government regulations, and third-party payer requirements to ensure that all diseases, injuries, reasons for an encounter, services (e.g. office visit), and procedures (e.g. surgery and x-ray) documented in patient records are coded accurately for reimbursement, research, and statistical purposes.)

Question 10

coding

Answer 10

assignment of codes to diagnoses, services, and procedures based on patient record documentation.

Question 11

coding system

Answer 11

organizes a medical nomenclature according to similar conditions, diseases, procedures, and services; it contains codes for each.

Question 12

Computer-assisted coding (CAC)

Answer 12

uses computer software to automatically generate medical codes by “reading” transcribed clinical documentation; uses “natural language processing theories to generate codes that are reviewed and validated by codes for reporting on third-party payer claims.

Question 13

UMLS

Answer 13

Unified Medical Language System

Question 14

CPT

Answer 14

Current Procedural Terminology

Question 15

HCPCS

Answer 15

Healthcare Common Procedure Coding System

Question 16

AMA

Answer 16

American Medical Association

Question 17

Current Procedural Terminology (CPT) explained

Answer 17

coding system used by physicians and outpatient health care settings to assign CPT codes for reporting procedures and services on health insurance claims;
considered Level I of the Healthcare Common Procedure Coding System (HCPCS);
published and updated by the AMA to classify procedures and services;
listing of descriptive terms and identifying codes for reporting medical services and procedures;
provides a uniform language that describes medical, surgical, and diagnostic services to facilitate communication among providers, patients, and third-party payers.)

Question 18

DSM

Answer 18

Diagnostic and Statistical Manual of Mental Disorders

Question 19

Diagnostic and Statistical Manual of Mental Disorders explained:

Answer 19

manual published by the American Psychiatric Association that contains diagnostic assessment criteria used as tools to identify psychiatric disorders;

DSM includes psychiatric disorders and codes, provides a mechanism for communicating and recording diagnostic information, and is used in areas of research and statistics).

Question 20

Downcoding

Answer 20

routinely assigning lower-level CPT codes for convenience instead of reviewing patient record documentation and the coding manual to determine the proper code to be reported.

Question 21

Encoder

Answer 21

software that automates the coding process; software search features facilitate the location and verification of diagnosis and procedure codes.

Question 22

Encoding

Answer 22

process of standardizing data by assigning numeric values (codes or numbers to text or other information).

Question 23

Evidence-based coding

Answer 23

clicking on codes that CAC software generates to review electronic health record documentation (evidence) used to generate the code;
when it is determined that documentation supports the CAC-generated code, the coding auditor clicks to accept the code;
when documentation does not support the CAC-generated code, the coding auditor replaces it with an accurate code.

Question 24

evidence-verification coding

Answer 24

see evidence-based coding

Question 25

HCPCS Level II

Answer 25

coding system managed by the Centers for Medicare and Medicaid Services (CMS) that classifies medical equipment, injectable drugs, transportation services, and other services not classified in the CPT.

Question 26

HCPCS national codes

Answer 26

see HCPCS Level II

Question 27

Healthcare Common Procedure Coding System (HCPCS)

Answer 27

includes Level I codes (CPT) and Level II codes (HCPCS Level II national codes).

Question 28

HIPAA explained

Answer 28

federal legislation that amended the Internal Revenue Code of 1986 to improve portability and continuity of health insurance coverage in the group of individual markets, combat easte/fraud/abuse in health insurance and health care delivery, promote the use of medical savings accounts, improve access to long-term care services and coverage, simplify the administration of health insurance by creating unique identifiers for providers/health plans/ employers, create standards for electronic health information transactions, and create private/security standards for health information.

Question 29

HIPAA

Answer 29

Health Insurance Portability and Accountability Act of 1996

Question 30

Institutional coding

Answer 30

captures severity of illness (ICD-10-CM) and intensity of services (ICD-1–PCS), both of which are used to justify an inpatient facility admission.

Question 31

International Classification of Diseases for Oncology, Third Edition (ICD-O-3):

Answer 31

implemented in 2001 to classify a tumor according to primary site (topography) and morphology (histology, behavior, and aggression of tumor).

Question 32

International Classification of Diseases, 11th Revision (ICD-11):

Answer 32

developed by the World Health Organization (WHO) and released in 2018 for a planned implementation by member states on January 1, 2022, ICD-11 contains improved usability, which contains more clinical detail and requires less training time, classification of all clinical detail, eHealth readiness for the electronic health record, linkage to other classifications and terminologies (e.g. SNOMED-CT), multilingual support, and updated scientific content).

Question 33

International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM)

Answer 33

developed by the Centers for Medicaid & Medicaid Services (CMS) to classify all diseases and injuries.

Question 34

NCHS

Answer 34

National Center for Health Statistics

Question 35

International Classification of Diseases, Tenth Revision, Procedure Coding System (ICD-10-PCS)

Answer 35

developed by the National Center for Health Statistics (NCHS) to classify inpatient procedures and services.

Question 36

ICF

Answer 36

International Classification of Functioning, Disability and Health

Question 37

International Classification of Functioning, Disability and Health (ICF):

Answer 37

classifies health and health-related domains that describe body functions and structures, activities, and participation; complements ICD-10, looking beyond mortality and disease.

Question 38

Jamming:

Answer 38

routinely assigning an unspecified ICD-10-CM disease code instead of reviewing the coding manual to select the appropriate code number.

Question 39

Logical Observation Identifiers Names and Codes (LOINC®):

Answer 39

electronic database and universal standard used to identify medical laboratory observations and for the purpose of clinical care management.

Question 40

Medical necessity:

Answer 40

determination that a service or procedure rendered is reasonable and necessary for the diagnosis or treatment of an illness or injury.

Question 41

Medical nomenclature:

Answer 41

includes clinical terminologies and clinical vocabularies that are used by healthcare providers to document patient care; clinical terminologies include designations, expressions, symbols, and terms used in the field of medicine, and clinical vocabularies include clinical phrases or words along with their meanings.

Question 42

MMA

Answer 42

Medicare Prescription Drug, Improvement, and Modernization Act

Question 43

Medicare Prescription Drug, Improvement, and Modernization Act explained:

Answer 43

federal legislation that requires all code sets to be valid at the time services are provided; eliminated carriers, fiscal intermediaries, and durable medical equipment regional carriers, and created Medicare administrative contractors.

Question 44

NDC

Answer 44

National Drug Codes

Question 45

National Drug Codes (NDC) explained

Answer 45

contains prescription drugs and a few selected over-the-counter (OTC) products, which pharmacies use to report transactions and some health care professionals use for reporting claims.

Question 46

overcoding

Answer 46

reporting codes for signs and symptoms associated, in addition to an established diagnosis code.

Question 47

Physician Query Process:

Answer 47

contacting the responsible physician to request clarification about documentation and codes to be assigned; the process is activated when the coder notices a problem with documentation quality.

Question 48

Professional Coding:

Answer 48

captures the complexity and intensity of procedures performed and services provided (CPT and HCPCS Level II) during an outpatient or physician office encounter.

Question 49

RxNorm

Answer 49

provides normalized names for clinical drugs and links its names to many of the drug vocabularies commonly used in pharmacy management and drug interaction software, including those of First Databank, Micromedex, MediSpan, Gold Standard Drug Database, and Multum; by providing links among these vocabularies, RxNorm can mediate messages among systems that do not use the same software and vocabulary.

Question 50

Single-Path coding:

Answer 50

combines professional and institutional coding to improve productivity and ensure the submission of clean claims, leading to improved reimbursement.

Question 51

Specialty coders

Answer 51

individuals who have obtained advanced training in medical specialties (e.g. anesthesia, obstetrics) and who are skilled in that medical specialty’s compliance and reimbursement areas.

Question 52

SNOMED CT

Answer 52

Systematized Nomenclature of Medicine Clinical Terms

Question 53

SNOMED CT (Systematized Nomenclature of Medicine Clinical Terms)

Answer 53

comprehensive and multilingual clinical terminology of body structures, clinical findings, diagnoses, medications, outcomes, procedures, specimens, therapies, and treatments.

Question 54

Unbundling

Answer 54

reporting multiple codes to increase reimbursement when a single combination code should be reported.

Question 56

Unified Medical Language System (UMLS) explained:

Answer 56

set of files and software that allows many health and biomedical vocabularies and standards to enable interoperability among computer systems; used to enhance or develop applications, including electronic health records, classification tools, dictionaries and language translators; used to link health information, medical terms, drug names, and billing codes across different computer systems.