Coding Guidelines Study deck Flashcards
(34 cards)
What is ICD-10-CM used for in healthcare?
ICD-10-CM is used to classify and code diagnoses, symptoms, and external causes of injury. It helps in categorizing diseases, conditions, and medical incidents.
What is HCPCS, and what are its two levels?
HCPCS (Healthcare Common Procedure Coding System) includes CPT codes (Level I) and codes for services, supplies, and durable medical equipment not covered in CPT (Level II).
What does CPT stand for, and what is it used for?
CPT stands for Current Procedural Terminology. It is used to describe medical, surgical, and diagnostic services to standardize billing and coding.
What is the structure of ICD-10-CM codes?
ICD-10-CM codes can be 3-7 characters long, with the first three characters representing the category, and additional characters providing more specificity, such as laterality or anatomic site.
What are the three categories of CPT codes?
Category I: Procedures and services.
Category II: Performance measurement.
Category III: Emerging technologies and services.
What is the role of CMS in healthcare coding?
CMS (Centers for Medicare & Medicaid Services) provides guidelines on billing, coding, and documentation for services to be reimbursed by Medicare and Medicaid.
What is the National Correct Coding Initiative (NCCI)?
NCCI edits are used by CMS to prevent improper coding that can lead to overpayment by identifying and correcting coding errors.
What are some CMS programs healthcare providers should be familiar with?
Providers should be familiar with CMS programs like Medicare Access and CHIP Reauthorization Act (MACRA), Merit-based Incentive Payment System (MIPS), and Promoting Interoperability (formerly Meaningful Use).
Why is it important to understand facility-specific coding protocols?
Facility-specific coding protocols ensure compliance with local regulations, payer requirements, and internal policies, impacting documentation and reimbursement.
What is the significance of Local Coverage Determinations (LCDs) and National Coverage Determinations (NCDs)?
LCDs and NCDs provide guidance on what services are covered by Medicare in specific regions or nationally, affecting coding decisions and coverage.
How does HIPAA affect health record management and coding?
HIPAA focuses on patient privacy, ensuring the confidentiality, integrity, and availability of health records, impacting the handling and transmission of codes and billing.
What is the purpose of the HITECH Act in healthcare?
The HITECH Act promotes the adoption and meaningful use of health information technology (HIT), particularly EHRs, and strengthens HIPAA regulations.
How do state regulations impact coding and record management?
State regulations may have additional or stricter guidelines regarding patient privacy, data retention, and access, influencing coding, billing, and compliance.
Why is it important to stay current with CMS regulations?
CMS regulations determine coding and documentation requirements for reimbursement, ensuring correct billing and preventing claim denials.
How can regional payer policies impact coding?
Regional payer policies, such as bundled services or procedure limitations, can affect coding decisions and the reimbursement process.
What is the purpose of the Medicare Physician Fee Schedule?
The Medicare Physician Fee Schedule outlines the reimbursement rates for healthcare services under Medicare, guiding coding and billing practices.
What should you understand about HIPAA when studying federal regulations?
HIPAA compliance ensures the protection of patient data and governs the exchange of health information, impacting the coding process and electronic health record (EHR) management.
What are key compliance requirements under the HITECH Act?
The HITECH Act mandates meaningful use of EHR systems, imposes penalties for non-compliance, and reinforces HIPAA’s privacy and security rules.
NEC - Alpha
“Not elsewhere classifiable”
This abbreviation in the Alphabetic Index represents “other specified.”
When a specific code is not available for a condition, the Alphabetic
Index directs the coder to the “other specified” code in the Tabular List.
NOS - Alpha/Tabular
“Not otherwise specified”
This abbreviation is the equivalent of unspecified.
NEC -Tabular
Not elsewhere classifiable”
This abbreviation in the Tabular List represents “other specified”. When
a specific code is not available for a condition, the Tabular List includes
an NEC entry under a code to identify the code as the “other specified”
code.
[ ] -Brackets
Brackets are used in the Tabular List to enclose synonyms, alternative wording or
explanatory phrases. Brackets are used in the Alphabetic Index to identify
manifestation codes.
( ) - Parentheses
Parentheses are used in both the Alphabetic Index and Tabular List to enclose
supplementary words that may be present or absent in the statement of a disease or
procedure without affecting the code number to which it is assigned. The terms
within the parentheses are referred to as nonessential modifiers. The nonessential
modifiers in the Alphabetic Index to Diseases apply to subterms following a main
term except when a nonessential modifier and a subentry are mutually exclusive,
the subentry takes precedence. For example, in the ICD-10-CM Alphabetic Index
under the main term Enteritis, “acute” is a nonessential modifier and “chronic” is a
subentry. In this case, the nonessential modifier “acute” does not apply to the
subentry “chronic”.
: - colons
Colons are used in the Tabular List after an incomplete term which needs one or
more of the modifiers following the colon to make it assignable to a given
category.
