Week 7: coding Flashcards
(38 cards)
Codes report the story to the ______
payer
Codes are applied during the medical billing process, which includes reviewing your documentation, assigning the appropriate codes, and creating a claim; “_________________” to be paid by insurance carriers.
Picture of Health
Your Documentation has an Impact on Everything; give examples
Coding and sequencing
Quality measures / Quality of Care
Reimbursement (Accepted vs. Denied)-more specific the better
Severity-level profiles / Risk adjustment profiles
Compliance
Present on admission reporting / Hospital-acquired conditions
Medical Necessity
Specialty Referrals
Continuum of Care
What occurs before and after coding?
Pt encounter
Documentation
Coding
Then billing
A coder/(provider) can figure out the number (s) by reading your __________; the better you ______, the more the practice gets paid/reimbursed
chart; chart
List the 3 types of code used
1) ICD-10
2) CPT-current procedural terminology
3) HCPCS-health care common procedure code (Medicare & Medicaid
Define ICD-10-CM diagnosis code
International Classification of Diseases
CM=clinical modification
-used by 27 countries
Explain the importance of ICD-10-CM codes
1) ICD-10-CM improves the quality of data necessary to achieve other healthcare initiatives with specificity Internationally
-“Condition, Status (and Plan) for all DX”
2) ICD-10 paints a picture of health to the payers/CMS
-If it’s NOT documented, it didn’t happen.
-No assumptions, info can not be implied, no clinical indicators can be coded as a diagnosis
Explain the development of ICD-10-CM
1) The U.S. developed aClinical Modification(ICD-10-CM) for medical diagnoses based on WHO’s ICD-10
2) and CMS developed a new Procedure Coding System
(ICD-10-PCS) for inpatient procedures
-ICD-10-CM replaces ICD-9-CM, volumes 1 and 2, and ICD-10-PCS replaces ICD-9-CM, volume 3
-ICD-11 as of January 1, 2022 (NOT adopted by US yet)
List the 2 main social determinants of health
psychosocial
socioeconomic circumstances
List the different groups of COVID19 infections as far as ICD codes go
confirmed infection
probable infection
possible infection
inconclusive infection
w/sequalae ie sepsis
Give some examples of new ICD10 codes
1) Non-insulin DM injectables: Victoza, Byetta; Glucagon (generic approved 2020)
2) Vaping related disorders
The FY 2025 ICD-10-CM updates introduce over _______ code changes, including252 new codes, 13 revisions, and 36 deletions, reflecting ongoing advancements in clinical documentation and disease specificity.
These code changes will go into effect with October 1, 2024.
300
List some new 2025 code changes
1) Cancer in remission
2) Expanded detail
3) Specific locations
4) New codes for presymptomatic T1DM
Describe how documentation relates to codes
Codes tell the story
Why do you have to document???
Prove your “Medical Decision Making”
must be written by you to be coded and submitted
If it’s NOT documented, it didn’t happen
No assumptions, info can not be implied, no clinical indicators can be coded as a diagnosis
For accurate reporting of ICD-10-CM diagnosis codes, the documentation should describe what?
The patient’s condition, using terminology which includes specific diagnoses as well as symptoms, problems, or reasons for the encounter meet a stated diagnosis
ICD-10:
1) Proper _____________ is the key to accurate payment and successful data validation
2) Therefore, risk adjusted payment accuracy also relies on “________” Progress Note documentation for each DOS*
3) Your templates __________ be the same for Q pt
1) documentation
2) unique
3) cannot
In all cases, the documentation must support and substantiate what?
support the code selected and substantiate that the proper coding guidelines were followed.
In all cases, the documentation must support the code selected and substantiate that the proper coding guidelines were followed.
_____________________ validation ensures that both are appropriate. Code/Diagnosis to Documentation
Risk Adjustment Data
_______________ or ____________ a diagnoses to reflect a higher specificity without supporting source documentation is fraudulent.
Up coding or changing
Give an example of ICD-10 using “Cyst on finger”=dx/ICD-10
1) NOT GOOD, not specific
2) The coder may query the provider for questions:
Which digit on the hand? Which hand? Size? Simple or complicated cyst?
-Dx/ICD-10=Cyst; R 1st digit, anterior lateral, <1cm, simple, no tendon or muscle involvement
CPT Coding:
1) What is fee for service?
2) CPT & HCPCS Codes tell the story of what?
3) What abt ICD-10?
1) service to the patient for reimbursement
2) what you have done for your patient
3) ICD-10-CM codes paint a picture of health via diagnosis codes
Why do you have to document?
Prove your “Medical Decision Making”
What is CPT? Describe
It’s how you bill for your services provided
CPT – Universal language that accurately describes: medical, surgical and diagnostic services
communication among physicians, patients and third parties such as payers.
