AAPC - Chapter 1: Practical Application

What are five tips for coding operative (op) reports?

Diagnosis code reporting, Start with the procedures listed, Look for key words, Highlight unfamiliar words, Read the body

Under the Privacy Rule, the minimum necessary standard does NOT apply to what type of disclosures?

Disclosures to the individual who is the subject of the information.

What is a mid-level provider?

Mid-level providers include physician assistants (PA) and nurse practitioners (NP).

Which is not one of the seven key components of an internal compliance plan?

Conduct training but not perform education on practice standards and procedures.

What type of profession, other than coding, might skilled coders enter?

Consultants, educators, medical auditors

What is not a common reason Medicare may deny a procedure or service?

Covered service. Medicare doesn't pay for the procedure/service to treat the patient's condition, the procedure/service as frequently as proposed or for experimental procedures/services.

What is the difference between outpatient and inpatient coding?

Outpatient coding focuses on physician services. Outpatient coders focus on assigning CPT, HCPCS Level II, and ICD-10-CM codes. They work in provider offices, outpatient clinics and facility outpatient departments. Outpatient facility coders also work with ambulatory payment classifications (APCs). Inpatient hospital coding focuses on a different subset of skills, where coders work with ICD-10-CM and ICD-10-PCS. These coders also assign Medicare severity-diagnosis related groups (MS-DRGs) for reimbursement. Outpatient coders usually will have more interaction throughout the day and must communicate well with providers; inpatient coders tend to have less interaction throughout the day.

What are the different parts of Medicare?

Part A, B, C, D

What is medical necessity?

Relates to whether a procedure or service is considered appropriate in a given circumstance.

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?

Subjective, Objective, Assessment, Plan