The Webinar Will Start Momentarily……

1. The Webinar Will Start Momentarily……

2. Coding Certification Exam Review Jennifer Lame’, MPH, RHIT AHIMA Approved ICD-10-CM/PCS Trainer October 12, 2012

3. Today’s Agenda • 6 CCA Competencies • Key Features from Each Competency • Sample Questions from Each Competency • Q&A

4. Objectives • Review the 6 Domains covered on CCA exam • Highlight Key aspects from each domain • Explore exam format and question structure • Provide practice activities to explore CCA readiness

5. 6 CCA Domains • Domain I – Clinical Classification Systems (32%) • Domain II – Reimbursement Methodologies (23%) • Domain III – Health Record and Data Content (15%) • Domain IV – Compliance (14%) • Domain V – Information Technologies (8%) • Domain VI – Confidentiality & Privacy (8%)

6. Clinical Classification Systems • Approximately 32 questions; largest portion of the exam • CPT • ICD-9 • HCPCS

7. Coding Steps • Determine service you are coding for • Read through the entire record and documentation to determine diagnosis and procedure, if any. • Select the appropriate diagnosis and procedures to code • Sequence codes according to UHDDS guidelines • Enter codes into facility’s database

8. Official Coding Guidelines • Highest level of specificity • E-codes • Signs/symptoms • Probable/likely/suspected • V-codes

9. Check Point • A 65- year old male was admitted for N/V and abd. Pain. Dr. Smith admits the patient for work up and finds he has acute cholecystitis. Dr. Smith’s discharge summary’s discharge diagnosis states: acute cholecystitis with nausea, vomiting and abdominal pain. What is the correct coding sequence: • A. Acute cholecystitis, N/V, abd pain • B. Abd pain, N/V acute cholecystitis • C. N/V, cholecystitis, adb. Pain • D. Acute cholecystitis

10. Check Point • Mary Smith is a 76-year old female patient who presents to the ER with difficulty breathing. After the ER physician conducts the exam he determines the she is experiencing Acute bronchitis with bronchospams. What codes are assigned? • A. 466.0 • B. 466.0, 519.11 • C. 519.11 • D. 466.19

11. Check Point • When a procedure is completed on the same day as another procedure, that is not typically reported together on the same day, but in this instance are appropriate what modifier is appended to indicate that the procedure was distinct from the other one?

12. Check Point • A 56-year old male is admitted for SDS of a needle bx of a cervical lymphnode for lympahdenopathy. Pathology report reveals Hodgkin’s sarcoma what codes are assigned? • A. 201.21, 38505 • B. 201.91, 38505 • C. 201.21, 38500 • D. 785.6, 38510

13. Checkpoint • A 35-year old female is seen by Dr. Smith in the ER for chest pain. After Dr. Smith examines the pt. he suspects she has GERD. His final diagnosis is suspected GERD. What is the correct ICD-9 code assignment? • A. Admission for suspected cardiovascular disease • B. Chest pain, nos • C. Esophageal pain • D. GERD

14. Checkpoint • A patient is seen in the ER for seizures. The physician does a workup for epilepsy and diagnosis is rule out epilepsy. What is the correct code assignment • A. 780.39 • B. 345.90 • C. 780.39, 345.80 • D. 345.80

15. Reimbursement Methodologies • Approximately 23 questions • Medicare • Part A, Part B, Part C, Part D • 65 or older or some disabilities • Medicaid • Low Income • Tricare • Healthcare for active duty service members • Champ-VA • For dependents and survivors of disabled veterans • Blue Cross and Blue Shield • Now plans in all 50 states

16. Reimbursement Methodologies • Fee for service • Episode of care • Capitation • Global payment • Global surgery payment • Prospective payment

17. NCCI • National Correct Coding Initiative Policies based off • Coding Conventions defined in the CPT codebooks • National and local policies and coding edits • Analysis of standard medical and surgical practice • Review of current coding practices

18. Checkpoint • Fee Schedules are updated by Third-Party Payers • Annually • Monthly • Semiannually • Weekly

19. Checkpoint • Dr. Smith saw a patient in the outpatient radiology department for a mammogram. Which type of payment system would the hospital be reimbursed under? • A. DRGs • B. HHRGs • C. OASIS • D. OPPS

20. Health Records & Data Content • Approximately 15 questions • Purpose of Health Record • Primary Purpose • Secondary Purpose • Function of the Health Record • Quality of the Health Record • AHIMA Data Quality Management Model

21. Data Quality Management Model • Data applications: the purposes for which data are collected • Data collection: the processes by which data are collected • Data warehousing: the processes and systems by which data are archived • Data analysis: the processes by which data are translated into information that can be used for designated application

22. Characteristics of Data Quality • Accessibility • Accuracy • Consistency • Comprehensiveness • Currency • Definition • Granularity • Relevancy • Precision • Timeliness

23. Content of the Health Record • Clinical • Administrative • Types • Acute care, emergency care, behavioral health, rehabilitation, ambulatory, correctional facilities, long-term care, home health, hospice, end-stage renal disease, personal

24. Clinical Documents • Medical history • Physical examination • Physicians orders • Clinical observations • Results of procedures • Consultations • Discharge summary • Final instructions

25. Format of the Health Record • EHR • Hybrid • Paper-Based • Source-oriented health record • Problem-oriented health record • SOAP note • Integrated health record

26. Check Point • Use of the health record by Dr. Smith to facilitate patient care is considered which of the following: • A. Primary purpose • B. Patient care support • C. Secondary purpose • D. Policy making

27. Check Point • From the following list, which one does not represent a characteristic of high-quality health record data? • A. Data accountability • B. Data consistency • C. Data currency • D. Data relevancy

28. Health Information Requirements and Standards • Data Set • A recommended set of data with uniform definitions utilized for a specific purpose • Purpose • Identify elements that should be collected from each patient • Provide uniform definitions for common terms

29. HIT Common Data Sets • UHDDS • UACDS • MDS • OASIS-C • HEDIS • DEEDS • ORYX • NHIN

30. Check Point • Federal law and Medicare require which of the following for the inpatient data set? • UACDS • UHDDS • MDS • HEDIS

31. Compliance • Approximately 14 questions • OIG’s 7 elements for a compliance plan • Development/distribution of written standards of conduct • Designation of a chief compliance officer • Implementation of effective education/training for all employees • Maintenance of a process to receive complaints • A system to respond of allegations of illegal activity • Evaluation techniques to monitor compliance • Investigation/remediation of identified systemic problems

32. HIM Compliance Plan • Code of conduct • Policies and procedures • Education and training • Communication • Auditing • Corrective action • reporting

33. AHIMA’s Standards of Ethical Coding • Coding professionals should: Apply accurate, complete, and consistent coding practices for the production of high-quality healthcare data. • Report all healthcare data elements (e.g. diagnosis and procedure codes, present on admission indicator, discharge status) required for external reporting purposes (e.g. reimbursement and other administrative uses, population health, quality and patient safety measurement, and research) completely and accurately, in accordance with regulatory and documentation standards and requirements and applicable official coding conventions, rules, and guidelines. • Assign and report only the codes and data that are clearly and consistently supported by health record documentation in accordance with applicable code set and abstraction conventions, rules, and guidelines. • Query provider (physician or other qualified healthcare practitioner) for clarification and additional documentation prior to code assignment when there is conflicting, incomplete, or ambiguous information in the health record regarding a significant reportable condition or procedure or other reportable data element dependent on health record documentation (e.g. present on admission indicator). • Refuse to change reported codes or the narratives of codes so that meanings are misrepresented. • Refuse to participate in or support coding or documentation practices intended to inappropriately increase payment, qualify for insurance policy coverage, or skew data by means that do not comply with federal and state statutes, regulations and official rules and guidelines. • Facilitate interdisciplinary collaboration in situations supporting proper coding practices. • Advance coding knowledge and practice through continuing education. • Refuse to participate in or conceal unethical coding or abstraction practices or procedures. • Protect the confidentiality of the health record at all times and refuse to access protected health information not required for coding-related activities ( examples of coding-related activities include completion of code assignment, other health record data abstraction, coding audits, and educational purposes). • Demonstrate behavior that reflects integrity, shows a commitment to ethical and legal coding practices, and fosters trust in professional activities.

34. Information Technologies • Approximately 8 questions • HL7 EHR Systems Functional Model • Direct Care • Care management • Clinical decision support • Operations management and communication • Supportive • Clinical support • Measurement, analysis, research & report • Administrative & financial • Information Infrastructure • Security • Health record information & management • Registry & directory services • Standard terminologies • Standards-based interoperability • Business rules management • Workflow management

35. Stage of EHR • Clinical Data Repository • Point of Care Charting • Transition State

36. Checkpoint • All of the following functions can be completed by an EHR except? • A. Analysis • B. Assembly • C. Document imaging • D. indexing

37. Checkpoint • Which of the following technologies would allow a hospital to get as much medical record information online quickly? • A. Clinical data repository • B. Picture archiving system • C. Electronic document management system • D. Speech recognition system

38. Confidentiality & Privacy • Approximately 8 questions • Court System • State – 3 tier system • Federal – 3 tier system • Source of Law • Constitution • Statutes • Administrative • Judicial

39. Legal Proceedings • Lawsuit • Discovery period • Trial • Malpractice

40. Form and Content of the Health Record • Primary purpose • Guidelines for form and content • Organized • Authorized personnel • Entries documented/identifiable/permanent • Use approved abbreviations • Correct errors with a single line, initials/date/time • Addendums made as a patient wish • Any requirements outlined in state law/regulation

41. Retention of the Health Record • Comply with local/state/federal statutes and regulations • Depends on the type of facility ie. Acute care will differ from long-term care • AHIMA publishes retention guidelines that are a good resource to review

42. HIPAA • HIPAA Privacy Rule is the key law that governs confidentiality and patient information and PHI • HIPAA Contains five titles • I- health care access, portability and renewability • II – preventing health care fraud & abuse • III – tax- related health provision • IV – group health plan requirements • V- revenue offsets

43. Check Point • What should a hospital do when the state law requires more stringent privacy protection than HIPAA? • Ignore the state law and follow HIPAA • Follow the state law and ignore HIPAA • Comply with both state law and HIPAA • Ignore both state law and HIPAA

44. Checkpoint • You work in a HIM department and received a subpoena ducestecum for the records of Mrs. Jane Doe. To respond to this subpoena what do you do? • A. Review the subpoena to determine what documents must be produced • B. Review the subpoena and notify your CEO • C. Review the subpoena and consult your lawyer • D. Review the subpoena and contact your risk manager

45. CCA Format • Three types of questions • Recall • Tests your memory skills/facts • Application • Tests your ability to interpret data • Analysis • Tests your ability to solve specific problems • 100 questions • Multiple-choice 90 scored/10 not scored

46. AHIMA CCA Resources • Content outline: • http://md20.quartz.synacor.com/service/home/~/CCA_Content_Outline.pdf?auth=co&loc=en_US&id=47701&part=2 • Candidate Guide: • http://md20.quartz.synacor.com/service/home/~/CCA_Candidate_Guide.pdf?auth=co&loc=en_US&id=47701&part=4 • Recommended resources: • http://md20.quartz.synacor.com/service/home/~/CCA_Recommended_Resources.pdf?auth=co&loc=en_US&id=47701&part=3

47. Study Tips • Purchase a CCA Review guide • AHIMA or PRG/Cengage learning • Compile a list of resources • Previous books, medical dictionary, coding manual • Determine a study schedule • Allow a set time each week/day to study • Practice with sample questions • Start with a practice test to determine your strengths weaknesses/focus study time on weaknesses • Review AHIMA’s Website • Ensure you have correct material for exam, registration, sample questions, other pertinent data

48. OtherResources • www.merckmanual.com • http://www.bcbstx.com/pdf/druglist.pdf • www.aafp.com • www.ahima.org • www.cdc.gov • http://stedmansonline.com/webFiles/Dict-Stedmans28/APP06.pdf • http://ahima.org/certification/cca.aspx • http://ahima.org/certification/ccs.aspx • http://ahima.org/certification/ccsp.aspx

49. Thank You!www.HIMageConsulting.com