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Domain II – Coding (18%)

Domain II – Coding (18%). RHIT Prep Workshop Test Year 2014. Purposes For Coding. Research Reimbursement Trend Analysis Resource Utilization Analysis Cost Analysis. CDI. CDI = Clinical Documentation Improvement Accurate reimbursement requires accurate coding

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Domain II – Coding (18%)

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  1. Domain II – Coding (18%) RHIT Prep Workshop Test Year 2014

  2. Purposes For Coding Research Reimbursement Trend Analysis Resource Utilization Analysis Cost Analysis

  3. CDI • CDI= Clinical Documentation Improvement • Accurate reimbursement requires accurate coding • Accurate coding requires documentation that is: • Complete • Accurate • Timely

  4. If it is not documented, it didn’t happen If it didn’t happen, you cannot code it!

  5. Nomenclature Proper names for diseases and procedures SNDO = Standard Nomenclature of Disease and Operations SNOMED = Standard Nomenclature of Medicine SNOMEDCT = Standard Nomenclature of Medicine Clinical Terminology

  6. Classifications System for assigning a code to a disease or procedure • ICD-9-CM =International Classification of Diseases – 9th revision – Clinical Modification ….as of October 1, 2014 • ICD-10-CM replaces ICD-9-CM vol 1 & 2 • ICD-10-PCS replaces ICD-9-CM vol 3 • ICD-O = International Classification of Diseases – Oncology

  7. Classifications DSM-IV = Diagnostic and Statistical Manual of Mental Disorders CPT = Current Procedural Terminology HCPCS Level II = Health Care Procedural Coding System

  8. Classifications DRG= Diagnosis Related Groups APC = Ambulatory Payment Classification MS-DRG = Medicare Severity – Diagnosis Related Groups OPPS = Outpatient Prospective Payment Systems

  9. Practice Question #1 Which of the following provides the most comprehensive controlled vocabulary for coding the content of a patient record? CPT HCPCS ICD-9-CM SNOMEDCT

  10. Practice Question #2 Which of the following classifications is used exclusively for classifying cases of malignant disease? CPT ICD-O HCPCS ICD-10-CM

  11. Practice Question #3 Which of the following provides a set of codes used for collecting data about substance abuse and mental health disorders? CPT HCPCS Level II DSM-IV SNOWMED

  12. Approves Official Coding Guidelines American Hospital Association (AHA) American Health Information Management Association (AHIMA) Centers for Medicare and Medicaid Services (CMS) National Center for Health Statistics (NCHS)

  13. ICD-10-CM Originally published by WHO (World Health Organization) NCHS and CMS are responsible for overseeing changes and modifications to the ICD-10-CM.

  14. Guidance Official ICD-10-CM Guidelines for Coding and Reporting [within ICD-10-CM book] and http://www.cdc.gov/nchs/icd/icd10cm.htm#icd2014 Guidelines[within CPT book] Coding Clinic – published by the AHA [American Hospital Association] CPT Assistant – published by the AMA [American Medical Association]

  15. Practice Question #4 Which organization originally published ICD-10? American Hospital Association World Health Organization Centers for Disease Control American Medical Association

  16. Practice Question #5 Which of the following organizations is responsible for updating the procedure classification ICD-10-PCS? National Center for Health Statistics Centers for Medicare and Medicaid Svs. American Hospital Association D. Centers for Disease Control

  17. ICD-10-CM Diagnosis Codes (both Tabular List andAlphabetic Index) Used in all types of healthcare facilities Interprets clinical data into numerical codes for disease, conditions, injuries, signs, and symptoms

  18. ICD-10-PCS Inpatient procedure codes (both Tabular List and Index) Interprets clinical data into numerical codes for procedures, services, and treatments provided to an inpatient (admitted into an acute care facility)

  19. ICD-10-CM Diagnosis Codes • 21 Chapters of up to 7 characters • Example: A23.4567 • Additional digits provide more specific detail about condition • Code Category = 3 characters • Sub-category = 4 – 5 characters • Sub-classification = 6 -7 characters

  20. ICD-10-CM Diagnosis Codes A00 –T88 report disease, injury, and other conditions currently in the patient Z00-Z99 report circumstances other than disease or injury as a reason for health care services V01-Y99 report the external causes of poisoning, injury, or adverse effects

  21. ICD-10-PCS Procedure Codes • 7 characters built from tables • Example: 0JQ63ZZ • Alphabetic Index • Tables Section • Numerals 0 thru 9then, letters B thru J • Each of the seven characters means something depending upon the section

  22. ICD-10-PCS – Medical/Surgical Section Character Place Means • Section of Book • Body System • Root Operation • Body Part • The Approach • The Device • The Qualifier

  23. HCPCS • CPT = Current Procedural Terminology • Level I, Category I of HCPCS • Example: 12345 • Developed, maintained, published by AMA (American Medical Association) • Used to report • Physician Services in any location • Outpatient facility services

  24. HCPCS Level I, Category II Example: 1234F • CPT codes used to track physician performance of specific measures Level I, Category III Example: 1234T • CPT codes used to track emerging technology, services, and procedures

  25. HCPCS • Level II • Example: A1234 • Codes used to report the provision of services, procedures, and supplies that are not accurately represented in CPT • Examples: Ambulance, DME (durable medical equipment), Orthotics, Prosthetics, Supplies, and Medication administered by professional

  26. Practice Question #6 At which level of the classification system are the most specific ICD-10-CM codes found? Category level Section level Subcategory level Sub-classification level

  27. Practice Question #7 Which of the following ICD-10-CM codes classify environmental events and circumstances as the cause of an injury, poisoning, or other adverse effect? Category codes E codes Subcategory codes V thru Y codes

  28. Practice Question #8 Which of the following is used to report the healthcare supplies, procedures, and services provided to patients by healthcare professionals? CPT HCPCS ICD-10-CM SNOMEDCT

  29. Practice Question # 9 Which code set contains those used to report inpatient procedures? ICD-10-CM CPT HCPCS Level II ICD-10-PCS

  30. Practice Question #10 Which of the following would be classified in ICD-10-CM with an W code? Echocardiogram Fall from curb Adenocarcinoma Admission for plastic surgery

  31. UHDDS Terms UHDDS = Uniform Hospital Discharge Data Set • Admitting diagnosis • Principle diagnosis (inpatient) • First-listed diagnosis (outpatient) • Other diagnoses • CC = Co-morbidities/Complications • MCC = Major Complication and Comorbidity

  32. UHDDS Terms Principle procedure Other procedures

  33. UHDDS Terms • POA = Present On Admission Y = Yes U = Unknown N = No W = Clinically undetermined • HAC = Hospital-Acquired Conditions

  34. Practice Question #11 The purpose of the present on admission (POA) indicator is to: Differentiate between conditions present on admission and conditions that develop during an inpatient admission Track principal diagnoses Distinguish between principal and primary diagnoses Determine principal diagnosis

  35. Practice Question #12 The present on admission (POA) indicator is a requirement for: Inpatient Medicare claims submitted by all hospitals Inpatient Medicare and Medicaid claims submitted by hospitals Medicare claims submitted by all entities Inpatient skilled nursing facility Medicare claims

  36. Practice Question #13 Patient admitted into hospital with acute lower abdominal pain. Principal diagnosis is acute appendicitis. Patient also has diabetes mellitus. Patient undergoes an appendectomy. Post-operative wound infections develop. In DRG, which is considered a co-morbidity? Acute appendicitis C. Diabetes Appendectomy D. Wound infection

  37. Practice Question #14 6-year old patient was admitted to ED for treatment of shortness of breath. The patient is given epinephrine and nebulizer treatments. The SOB (shortness of breath) and wheezing are unabated following treatment. What diagnosis is suspected? Acute bronchitis Acute bronchitis with COPD Asthma with status asthmaticus Chronic obstructive asthma

  38. Practice Question #15 UHDDS definition of “other diagnoses” is: Recorded in patient record Documented by the attending physician Considered all conditions that coexist at the time of admission or develop subsequently, which affect the treatment and/or length of stay Documented by at least 2 physicians or nursing staff

  39. Coding Edits NCD = National Coverage Determination LCD = Local Coverage Determination NCCI = National Correct Coding Initiative OCE = Outpatient Code Editor

  40. Illegal Practices Upcoding Unbundling Mutually exclusive codes Coding for coverage Lack of supporting documentation

  41. Practice Question #16 NCCI edits prevent improper payments where: Medical necessity has not been justified by a diagnosis The account is potentially upcoded The claim contains any of a variety of errors Incorrect code combinations are on the claim

  42. Practice Question #17 Unbundling refers to: Failure to use a comprehensive code to inappropriately maximize reimbursement Failure to use multiple procedure codes to inappropriately maximize reimbursement Combined billing for pre- and post-surgery physician services Using and incorrect DRG code

  43. Practice Questions #18 The function of the NCCI editor is to : Report poor performing physicians Identify procedures and services that cannot be billed together on the same day of service for a patient Identify poor performing coders Identify problems in the national coding system

  44. Practice Question #19 The practice of using a code that results in a higher payment to the provider than the code that actually reflects the service or item provided is known as: Unbundling Upcoding Medically unnecessary services Billing for services not provided

  45. Query Process: When A Query should be posed to the physician when a patient’s record fails to meet one of the five criteria: Legibility Completeness Clarity Consistency Precision

  46. Query Process: Who The query should be directed to the provider who originated the progress note, operative report, or other documentation in question.

  47. Query Process: How In writing Using precise language Includes clinical indications from the record ASK the provider to make a clinical interpretation of the facts May NOT lead the provider toward a particular response

  48. Practice Question #20 When documentation in the health record is not clear, the coding professional should: Submit the question to Coding Clinic Refer to dictation from other encounters for the patient to get clarification Query the physician who originated the progress note or other report in question Query the physician that consistently responds to queries in a timely manner

  49. Practice Question #21 Which of the following information would generally be found in a query to a physician? Health record number and demographic data Name and contact number of the individual initiating the query and account number Date query initiated and date query must be completed by Demographic information and name and contact of individual initiating the query

  50. Practice Question #22 Providers should be queried regarding information in the health record for all of the following, except: Conflicting documentation Ambiguous documentation Incomplete documentation Insignificant documentation

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