Medical Coding Chapters 1&2
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University of Texas, El Paso *
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Medicine
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Apr 3, 2024
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Chapter 1: The Business of Medicine
Exercise 1
1.What type of profession, other than coding, might a skilled coder enter? Skilled coders may become consultants, educators, or medical auditors.
2.What is the difference between outpatient and inpatient coding? Outpatient are provider services and interact with providers daily. Outpatient coding utilizes: CPT®, HCPCS Level II, and ICD-10-CM codes as well as Ambulatory Payment Classifications (APCs). Inpatient on the other hand have limited access to the provider. Inpatient coding utilizes: ICD-10-CM and ICD-10-PCS codes and MS-DRGs for reimbursement.
3.What is a mid-level provider? Mid-level providers include physician assistants (PA) and nurse practitioners (NP). Mid-level providers typically need oversight from a physician.
4.Discuss the different parts of Medicare and what each program covers. There are four different part of
Medicare A-D. Medicare Part A helps to cover inpatient hospital care, as well as care provided in skilled nursing facilities, hospice, and home health.
Medicare Part B covers two types of services:
1) Medically necessary provider services needed to diagnose or treat a medical condition and that meet accepted standards of medical practice, and
2) Preventive services to prevent illness or detect it at an early stage. Medicare Part B is an optional benefit for which the patient pays a monthly premium, an annual deductible, and generally has a 20 percent co-insurance, except for preventive services covered under healthcare law.
Medicare Part C, also called Medicare Advantage, combines the benefits of Medicare Part A, Part B, and sometimes Part D. The plans are managed by private insurers approved by Medicare and may include Preferred Provider Organizations (PPOs), Health Maintenance Organizations (HMOs), and others. The plans may charge different copayments, coinsurance, or deductibles for services. Accurate and thorough
diagnosis coding is important for Medicare Advantage claims because reimbursement is tied to the patient’s health status. The CMS hierarchical condition category (CMS-HCC) risk adjustment model provides adjusted payments based on a patient’s diseases and demographics. If a coder doesn’t include all pertinent diagnoses and co-morbidities (associated illnesses), there may be loss of additional reimbursement to which the provider is entitled.
Medicare Part D is a prescription drug program available to all Medicare beneficiaries for a fee. Private companies approved by Medicare provide the coverage.
5.Evaluation and management (E/M) services are often provided in a standard format. One such format is SOAP notes. What does SOAP represent?
S—Subjective — The patient’s statement about his or her health, including symptoms.
O—Objective — The provider’s examination and documentation of the patient’s illness using observation, palpation, auscultation, and percussion. Tests and other services performed may be documented here as well.
A—Assessment — Evaluation and conclusion made by the provider. This is usually where you find the diagnosis(es) that supports the services rendered.
P—Plan — Course of action. Here the provider will list the next steps for the patient, whether it’s ordering additional tests, taking over-the-counter medications, etc.
6.What are five tips for coding operative (OP) reports?
1.Highlight unfamiliar words — Research for understanding.
2.Diagnosis code reporting — Use the post-operative diagnosis for coding unless there are further defined diagnoses or additional diagnoses found in the body of the operative report. If a pathology report is available, use the findings from the pathology report for the diagnosis.
3.Start with the procedures listed — One way of quickly starting the research process is by focusing on the procedures listed in the header. Read the note in its entirety to verify the procedures performed. Although procedures listed in the header may not be listed correctly and procedures documented within
the body of the report may not be listed in the header at all, it is a place to start.
4.Look for key words — Key words may include locations and anatomical structures involved, surgical approach, procedure method (debridement, drainage, incision, repair, etc.), procedure type (open, closed, simple, intermediate, etc.), size and number, and the surgical instruments used during the procedure.
5.Read the body — All procedures reported should be documented within the body of the report. The body may indicate a procedure was abandoned or complicated, possibly indicating the need for a different procedure code or reporting of a modifier.
7. What is medical necessity and what tool can you refer to for the medical necessity of a service? Medical necessity relates to whether a procedure or service is considered appropriate in each circumstance. CMS has developed policies regarding medical necessity based on regulations found in title XVIII, §1862(a)(1) of the Social Security Act.
8.What are common reasons Medicare may deny a procedure or service? Non-covered items are deemed not reasonable and necessary, this is the Medicare reimbursement rule.
9.Under the Privacy Rule, the minimum necessary standard does NOT apply to what type of disclosures?
Disclosures to or requests by a healthcare provider for treatment purposes.
Disclosures to the individual who is the subject of the information.
Uses or disclosures made pursuant to an individual’s authorization.
Uses or disclosures required for compliance with the HIPAA Administrative Simplification Rules.
Disclosures to the US Department of Health & Human Services (HHS) when disclosure of information is required under the Privacy Rule for enforcement purposes.
Uses or disclosures required by other law.
10.What are seven key components of an internal compliance plan?
1.Conducting internal monitoring and auditing through the performance of periodic audits. This ongoing evaluation includes not only whether the provider practice’s standards and procedures are current and accurate, but also whether the compliance program is working (for example, whether individuals are properly carrying out their responsibilities and claims are being submitted appropriately).
2.Implementing compliance and practice standards through the development of written standards and procedures. After the internal audit identifies the practice’s risk areas, the next step is to develop a method for dealing with those risk areas through the practice’s standards and procedures. Written standards and procedures are a central component of any compliance program. Those standards and procedures help to reduce the prospect of erroneous claims and fraudulent activity by identifying risk areas for the practice and establishing tighter internal controls to counter those risks, while also helping to identify any aberrant billing practices.
3.Designating a compliance officer or contact(s) to monitor compliance efforts and enforce practice standards. Ideally, one member of the staff needs to accept the responsibility of developing a corrective action plan, if necessary, and oversee adherence to that plan. This person can either oversee all compliance activities for the practice or play a limited role merely to resolve the current issue.
4.Conducting appropriate training and education on practice standards and procedures. Education is important to any compliance program. Ideally, education programs are tailored to the provider practice’s needs, specialty, and size, including both compliance and specific training.
5.Responding appropriately to detected violations through the investigation of allegations and the disclosure of incidents to appropriate government entities. It’s important that the compliance contact or
another practice employee look into possible violations and, if so, take decisive steps to correct the problem. As appropriate, such steps may involve a corrective action plan, the return of any overpayments, a report to the government, and a referral to law enforcement authorities.
6.Developing open lines of communication, such as: (1) discussions at staff meetings regarding how to avoid erroneous or fraudulent conduct; and (2) community bulletin boards, to keep practice employees updated regarding compliance activities. The OIG believes that all practice employees, when seeking answers to questions or reporting potential instances of erroneous or fraudulent conduct should know whom to turn to for assistance in these matters and should be able to do so without fear of retribution.
7.Enforcing disciplinary standards through well-publicized guidelines. The OIG recommends that a provider practice’s enforcement and disciplinary mechanisms ensure that violations of the practice’s compliance policies will result in consistent and appropriate sanctions, including the possibility of termination, against the offending individual.
Quiz 1
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Question 1
Select the TRUE statement regarding ABNs.
Correct Answer:
a.
ABNs may not be recognized by non-Medicare payers.
Response Feedback:
Rationale: ABNs may not be recognized by non-Medicare payers. Providers should review their contracts to determine which payers will accept an ABN for services not covered.
Question 2
Which act was enacted as part of the American Recovery and Reinvestment Act of 2009 (ARRA) and affected privacy and security?
Correct Answer:
b.
HITECH
Response Feedback:
Rationale: The Health Information Technology for Economic and Clinical Health Act (HITECH) was enacted as a part of the American Recovery and Reinvestment Act of 2009 (ARRA) to promote the adoption and meaningful
use of health information technology. Portions of HITECH strengthen HIPAA
rules by addressing privacy and security concerns associated with the electronic transmission of health information.
Question 3
According to the example LCD from Novitas Solutions, which of the following conditions is considered a systemic condition that may result in the need for routine foot care?
Correct Answer:
b.
Chronic venous insufficiency
Response Feedback:
Rationale: According to the LCD, Chronic venous insufficiency is a systemic condition that may result in the need for routine foot care.
Question 4
Who would NOT be considered a covered entity under HIPAA?
Correct Answer:
d.
Patient
s
Response Feedback:
Rationale: Covered entities in relation to HIPAA include Health Care Providers, Health Plans, and Health Care Clearinghouses. The patient is not considered a covered entity although it is the patient’s data that is protected.
Question 5
When presenting a cost estimate on an ABN for a potentially noncovered service, the cost estimate should be within what range of the actual cost?
Correct Answer:
c.
$100 or 25 percent
Response Feedback:
Rationale: CMS instructions stipulate, “Notifiers must make a good faith effort to insert a reasonable estimate…the estimate should be within $100 or 25 percent of the actual costs, whichever is greater.”
Question 6
Which statement describes a medically necessary service?
Correct Answer:
b.
Using the least radical service/procedure that allows for effective treatment of the patient’s complaint or condition.
Response Feedback:
Rationale: Medical necessity is using the least radical services/procedure
that allows for effective treatment of the patient’s complaint or condition.
Question 7
What document is referenced to when looking for potential problem areas identified by the government indicating scrutiny of the services?
Correct Answer:
c.
OIG Work Plan
Response Feedback:
Rationale: Twice a year, the OIG releases a Work Plan outlining its priorities for the fiscal year ahead. Within the Work Plan, potential problem areas with claims submissions are listed and will be targeted with special scrutiny.
Question 8
Under HIPAA, what would be a policy requirement for “minimum necessary”?
Correct Answer:
a.
Only individuals whose job requires it may have access to protected health information.
Response Feedback:
Rationale: It is the responsibility of a covered entity to develop and implement policies, best suited to its particular circumstances to meet HIPAA requirements. As a policy requirement, only those individuals whose job requires it may have access to protected health information.
Question 9
What form is provided to a patient to indicate a service may not be covered by Medicare
and the patient may be responsible for the charges?
Correct Answer:
d.
ABN
Response Feedback:
Rationale: An Advanced Beneficiary Notice (ABN) is used when a Medicare
beneficiary requests or agrees to receive a procedure or service that Medicare may not cover. This form notifies the patient of potential out of pocket costs for the patient.
Question 10
What document assists provider offices with the development of Compliance Manuals?
Correct Answer:
a.
OIG Compliance Program Guidance
Response Feedback:
Rationale: The OIG has offered compliance program guidance to form the basis of a voluntary compliance program for physician offices.
Assessment 1
Question 1
What type of profession, other than coding, might skilled coders enter?
Correct Answer:
c.
Consultants, educators, medical auditors
Question 2
What is the difference between outpatient and inpatient coding?
Correct Answer:
d.
Inpatient coders use ICD-10-CM and ICD-10-PCS.
Question 3
What is a mid-level provider?
Correct Answer:
c.
Mid-level providers include physician assistants (PA) and nurse practitioners (NP).
Question 4
What are the different parts of Medicare?
Correct Answer:
b.
Part A, B, C, D
Question 5
Evaluation and management (E/M) services are often provided and documented in a standard format. One such format is SOAP notes. What does SOAP represent?
Correct Answer:
a.
Subjective, Objective, Assessment, Plan
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Response Feedback:
S -
Subjective - The patient's statement about his or her health, including symptoms.
O -
Objective - The provider assesses and documents the patient's illness using observation, palpation, auscultation and percussion. Tests and other performed services may be documented here as well.
A -
Assessment - Evaluation and conclusion made by the provider. This is usually where the diagnosis(es) for the services are found.
P -
Plan - Course of action. Here, the provider will list the next steps for the patient, whether ordering additional tests, taking over the counter medications, etc.
Question 6
What are five tips for coding operative (op) reports?
Correct Answer:
b.
Diagnosis code reporting, Start with the procedures listed, Look for key words, Highlight unfamiliar words, Read the body
Question 7
What is medical necessity?
Correct Answer:
d.
Relates to whether a procedure or service is considered appropriate in a given circumstance.
Question 8
What is not
a common reason Medicare may deny a procedure or service?
Correct Answer:
c.
Covered service
Question 9
Under the Privacy Rule, the minimum necessary standard does NOT
apply to what type of disclosures?
Correct Answer:
c.
Disclosures to the individual who is the subject of the information.
Response Feedback:
Under the Privacy Rule, the minimum necessary standard does not apply
to the following:
Disclosures to or requests by a health care provider for treatment
purposes.
Disclosures to the individual who is the subject of the information.
Uses or disclosures made pursuant to an individual's authorization.
Uses or disclosures required for compliance with the HIPAA Administrative Simplification Rules.
Disclosures to the U. S. Department of Health & Human Services (HHS) when disclosure of information is required under the Privacy Rule for enforcement purposes.
Uses or disclosures required by other law.
Question 10
Which is not
one of the seven key components of an internal compliance plan?
Correct Answer:
b.
Conduct training but not perform education on practice standards and procedures
Chapter 2: Medical Terminology and Anatomy Review
1.Diagnosis: Calcification left basal ganglia
Where are the basal ganglia located?
2.Diagnosis: Vesicoureteral reflux
What is this a reflux of?
3.Documentation: The posterior vaginal fornix and outer cervical os were prepped with a cleansing solution.
In this statement, what does “os” stand for?
4.Hysterosalpingogram report: “Right cornual contour abnormality.”
Where is the cornua found anatomically for this case?
5.Surgical procedure: Myringotomy
What anatomic location is being operated on?
6.Documentation: There was no cleft of the uvula or submucosal palate by visual and palpable exam.
What is being examined?
7.Documentation: Recession of left inferior rectus muscle, 5 mm
What anatomic location is being operated on?
8.Diagnosis: Kyphosis
What anatomic location does this diagnosis most often refer to?
9.Documentation: Suprapatellar recess showed no evidence of loose bodies or joint pathology.
What anatomic location does this refer to?
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10.Colles’ fracture
What anatomic location does this refer to?