Week 2 Assignment Worksheet

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Fortis College *

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MOA - 115

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Feb 20, 2024

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MOA115 Medical Records and Insurance Week 2 Assignment Section A: Coding Accuracy Section B: ICD Coding Concepts Section A: Coding Accuracy Directions: • Using reliable internet resources, research the questions. Type your answers below the questions. • Your answers should be at least 5 sentences. 1. Describe the importance of coding medical charges accurately. Medical billing and coding serve as a bridge between healthcare providers and insurance companies as well as patients. It helps all parties involved understand the costs that have been incurred, the coverage that will be provided by insurance, and the amount that the patient is required to pay out of pocket . Coding is utilized for appropriate patient treatment, reimbursement, research, the basis of financial and clinical decision making and worldwide comparative trending . 2. Describe two of the most common ways medical charges can be coded inaccurately. The two primary coding systems used in medical billing are the Current Procedural Terminology (CPT) and the International Classification of Diseases (ICD) coding systems . CPT codes are used to describe medical, surgical, and diagnostic services and procedures performed by healthcare providers. CPT codes are assigned based on the specific procedure or service rendered during a patient's visit. ICD codes are used to represent diagnoses, symptoms, and reasons for seeking medical care. The current version is ICD- 10, which replaced ICD-9. ICD codes are assigned based on the patient's medical condition as documented by the healthcare provider . 3. Describe the impact of inaccurate coding on the healthcare facility. If wrong diagnoses are entered, then it can prove to be risky for that patient. Even a problem in the modifier can change the location of the procedure performed. Sometimes, extra CPT codes can lead to an increase in the bill which the patient does not expect. Inaccuracy in coding and billing is not only bad for the care providers but is also hazardous for the patients.

MOA115 Medical Records and Insurance Week 2 Assignment Section A: Coding Accuracy Section B: ICD Coding Concepts 4. Describe the impact of inaccurate coding on the patient. Inaccurate coding can lead to the wrong procedure. If wrong diagnoses are entered, then it can prove to be risky for that patient. Even a problem in the modifier can change the location of the procedure performed. Sometimes, extra CPT codes can lead to an increase in the bill which the patient does not expect. 5. Describe an encoder for medical coding. In the realm of healthcare revenue cycle management (RCM), an encoder refers to a software tool or system that assists in the accurate and efficient coding of medical procedures and diagnoses . It plays a crucial role in ensuring that healthcare providers receive appropriate reimbursement for the services they provide. 6. Discuss accuracy in coding when using an encoder. Encoder accuracy is a measure of the error between the value read out by the encoder and the actual physical value being measured . For rotary encoders it is usually expressed in arcseconds or degrees. The most common unit for indicating the accuracy of linear encoders is µm per unit of length of the scale (µm/m). Section B: ICD Coding Concepts . Getting to Know the ICD-10-CM (Answer #1-5) 1. Fill in the blanks in the following statements with terms from the word bank to describe how to use the most current diagnostic coding classification system. Word Bank: Code Coding guidelines Character Convention Diagnostic Diagnostic statements Essential modifier Exclusion ICD-10-CM Main term Tabular List a. Abstract the correct diagnosis from the __CODE_____________________ found in the patient health record.

MOA115 Medical Records and Insurance Week 2 Assignment Section A: Coding Accuracy Section B: ICD Coding Concepts b. Use the _TABULAR LIST______________________ to look up the diagnosis in the Alphabetic Index. c. Review the _ESSENTIAL MODIFIER______________________ under the main term. d. Choose the correct code based on the ___DIAGNOSTIC ____________________ statement. e. Look up the code from the Alphabetic Index in the _TUBLAR LIST______________________. f. Check for any _CODING GUIDLINES_____________________, _CONVENTION______________________, inclusion notes, _EXCLUSION_____________________ notes, or additional CHARACTER_______________________ symbol. g. Assign the final _ICD-10-CM______________________ diagnosis code. 2. ICD-10-CM codes can have up to _3-7_____ characters. A(n) _PLACEHOLDER______________________ “x” is used to fill in for positions that don’t have characters. 3. What are the seventh characters used for encounter types and what do they indicate? _______________________________________________________________________ ________________________________________________________________________ THE TYPE OF ENCOUNTER OR PHASE OF TREATMENT. INITIAL AND SUBSEQUENT ENCOUNTER OR SEQUELA 4. Four basic forms of punctuation are used in the Tabular Index. List them and what they are used for. ________________________________________________________________________ ________________________________________________________________________ brackets, parentheses, commas, and braces . Symbols are used to designate the requirement of a fourth or fifth digit, new entries, and revised text or codes . 5. Match the following terms. __B___ Main terms __A___ Subterms __D___ Nonessential modifiers _C____ Essential modifiers a. These terms are indented under the main c. Are found after the main term and are term; they change the description of the enclosed in parentheses diagnosis in bold type

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MOA115 Medical Records and Insurance Week 2 Assignment Section A: Coding Accuracy Section B: ICD Coding Concepts d. Indented under the essential modifier b. Appear in bold C. Preparing for Diagnostic Coding 1. The SOAP notes system of documentation divides the information into what four areas? a. _SUBJECTIVE______________________________________________________ __________ b. OBJECTIVEFINDINGS ________________________________________________________________ c. ASSESSMENT______________________________________________________ ___________ d. PLANFORTREATMENT _________________________________________________________________ 2. To prepare for medical coding, the coder must analyze the patient’s health record and ABSTRACT_______________________ the diagnostic statement. 3. Information pertinent to code selection can be abstracted from a variety of medical documents. List the documents where the diagnostic statement may be found. Encounter forms, treatment notes, discharge summary, operative reports, and radiology, pathology, and laboratory reports . ________________________________________________________________________ ________________________________________________________________________ 4. The HISTORY AND PHYSICAL EXAM_______________________ is the provider’s health history evaluation and physical assessment of the patient. 5. The CHIEF COMPLAINT_______________________ is a statement in the patient’s own words that describes why the person is seeking medical attention. 6. The _OPERATIVEBREPORT______________________ is used for extracting procedure and diagnostic information for patients who underwent surgery.

Week 2 Assignment Worksheet

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