Week 7 highlights Flashcards
Bolded or highlighted (34 cards)
Medical coding is the transformation of healthcare diagnoses, procedures, medical services, and equipment into _______________ medical alphanumeric codes.
universal
Codes are assigned based on your ________________ documentation.
medical record
Codes are applied during the ____________________ process, which includes reviewing your documentation, assigning the appropriate codes, and creating a claim,
medical billing
Define coding
(highlighted)
A # assigned to a dx, a procedure, a service, and equipment
True or false: They can tell if a patient developed the illness while under your care based on your coding
True
The Department of Health and Human Services (HHS) has mandated that all entities covered by the___________________________ must all transition to a new set of codes for electronic health care transactions onOctober 1, 2015.
Health Insurance Portability and Accountability Act External(HIPAA)
What is ICD-10 for?
Diagnosis coding
World Health Organization (WHO) authorized the publication of the______________________________, which was implemented for mortality coding and classification from death certificates in the U.S. in 1999.
International Classification of Diseases External10th Revision (ICD-10)
ICD-10-CM improves the quality of _______ necessary to achieve other healthcare initiatives with specificity Internationally
data
The U.S. developed a_____________________(ICD-10-CM) for medical diagnoses based on WHO’s ICD-10
Clinical Modification
1) ICD-10-CMS90.453ASuperficial foreign body, unspecified ________ toe(s), initial encounter
2) ICD-10-CMS90.456ASuperficial foreign body, unspecified _________ toe(s), initial encounter
1) great
2) lesser
True or false: If it’s not documented, it didn’t happen
True
True or false: Your templates cannot be the same for Q pt
True
What does CPT coding include?
Office visit level, procedures, and time
What is the universal language that accurately describes medical, surgical and diagnostic services?
CPT
Describe the ICD-10 and CPT (visit and procedure) for an I&D of abscess, gluteal cleft, simple, one
1) ICD-10: LO5.01=dx
2) CPT: 99213 or 99214=office visit level code (“level 3 or level 4”)
AND
10060=procedure code
CPT category 1: What are the codes for eval and management (office visit)?
99201 – 99499
99214 is what CPT code?
Office visit, established pt, moderate complexity
(very common code)
If you see a 1 in a CPT code, what does it mean?
The patient is already established (not a new pt)
Ex: 99214 vs 99204
99213 means what?
Level 3 service provided for evaluation and management of an established patient
(Medical Decision Making of Low Complexity)
Is there a level 1 code for a new patient?
(important)
No; 99201 has been deleted
E/M Levels recognize _______ types of medical decision making
four
E/M Levels recognize four types of medical decision making; what are they?
2 = straight-forward
3 = low complexity
4 = moderate complexity
5= high complexity
To qualify for a given type of decision making _______ of the ________ elements in the table must be either met or exceeded
two of the three
