aapc crc exam 10
CMS HCC Interaction
is the combination of multiple diagnoses or a diagnosis with disabled status that results in an additional relative factor added to the risk score calculation
ACO Concept
is a response to fee-for-service payment, which has contributed to rapidly rising cots and poorly coordinated care
HHS HRADV
is an annual requirement of all plans
Function of risk adjustment
is to identify all current diagnoses to their highest specificity
CMS RADV
is typically typically two to three years after payment
yellowness of skin
jaundice
movement
kin/o
movement
kinesi/o
lip
labi/o
tear, lacrimal apparatus
lacrim/o
larynx
laryng/o
toward side of body
lateral
IVA Process
occurs during the summer and fall months; the fall and winter months involve the Secondary Validation Auditor (SVA) selected by HHS/CMS HHS calculates error rates for payment adjustments and for potential adjustments to payments and charges.
HHS HRADV
occurs typically six months after year-end
HRADV
of the 200 selected, 80% 4/5 or 2/3 will have one or more HCCs, while 20% 1/5 or 1/3 will have no suspected HCCs Tens strata are used in the statistically valid sample based on age, risk score, with strata 10 being those with no HCCs
HRADV
is conducted annually on the data submitted to the Edge server. It differs from the CMS RADV, in that health plans are not "selected." Is an annual requirement. Sampling takes place from April-June of a calendar year for the prior year's DOS, based on Edge server submissions.
Highest Ranking Subcategory
is listed first in the overall HCC chronological list, therefore the lower the number the higher the rank within that category HCC8 trumps HCC12
Initial Review
is performed to determine which medical records contain documentation required to substantiate the HCCs that have been captured in the CMS system for these patients
Signs and symptoms that are associated routinely with a disease process _____________, unless otherwise instructed by the classification.
should not be coded
saliva, salivary gland, salivary duct
sial/o
RADV primary objectives
*verify enrollee CMS-HCCs used for payment *identify risk adjustment discrepancies *calculate enrollee-level payment error *estimate national and contract-level payment errors *implement contract-level payment adjustments
spread through contact with an infected person's blood, semen, or other body fluid and causes swelling of the liver and can cause liver damage that can lead to cancer. Chronic condition that can lead to death.
Hepatitis C (HCV)
unique in that patient can contract only if they are already infected with Hepatitis B via contact through infected blood, dirty needles, or unprotected sex.
Hepatitis D (HDV)
infectious hepatitis spread through drinking water, or oral-anal contact, and causes swelling of liver with no long-term damage.
Hepatitis E (HEV)
weakened wall of stomach protrusion
Hiatal Hernia
sweat/perspiration
Hidr/o
HCC
Hierarchical Condition Category
O09
High risk patient prenatal
Probably Forever/Almost ALLS
Is this condition a Probably Forever/Almost ALLS (still has condition even though mediation or device is covering up symptoms), Forever/ALLS, or a Chronic condition? Alcoholism in Remission
Probably Forever/Almost ALLS
Is this condition a Probably Forever/Almost ALLS (still has condition even though mediation or device is covering up symptoms), Forever/ALLS, or a Chronic condition? Amputations, Organ Transplant, History of MI
Probably Forever/Almost ALLS
Is this condition a Probably Forever/Almost ALLS (still has condition even though mediation or device is covering up symptoms), Forever/ALLS, or a Chronic condition? Osteomyelititis, Periostitis an Infections involving Bone (Category 730)
0GTK0ZZ
The patient was diagnosed with carcinoma of the left lobe of the thyroid gland and underwent an open total thyroidectomy. Code the procedure.
1. Early detection of chronic conditions 2. Coordination of care 3. Accurate reporting of conditions 4. Improvement of health conditions
What are the 4 focal points of a MA Plan?
risk score (5 demographic factors)
calculate risk score: age, sex, medicaid status, disability and original reason for medicare entitlement
ACO
can choose one of two payment models one sided or two sided based on the degree of risk and potential savings they prefer
National RADV Audit
a. Selection of patients using "stratified sample" methodology, where a percentage of patients are selected randomly from high risk, medium risk, and low risk, based on HCC risk scores. b. Selection of MA plan and/or contracts is random
Targeted RADV Audit
a. Targeted contract of those who have had problematic past audit findings. b. Plans with higher risk scores when compared to traditional FFS (Fee-For Service Medicare).
away from
ab-
space containing lower portion of esophagus, the stomach, intestines (excluding sigmoid colon and rectum), kidneys, liver, gallbladder, pancreas, spleen, and ureters
abdominal cavity (ventral cavity)
If the same condition is described as both acute (subacute) and chronic, and separate subentries exist in the Alphabetic Index at the same indentation level, code both and sequence the _________________.
acute (subacute) code first
acute is sequenced first
acute and chronic
A code from subcategory R65.2, Severe sepsis, should not be assigned unless severe sepsis or an associated __________________ is documented
acute organ dysfunction
toward; near
ad-
In the Chronic-illness Disability Payment System, weights are ? across major categories
additive
muscles that contract to bring a body part (limb) toward the median line of the body
adductor muscles
loss of hair
alopecia
standard body position; upright, face-forward with arms by the side and palms facing forward; feet parallel and slightly apart.
anatomical position
vessel
angi/o
before; forward
ante-
toward front of body
anterior (ventral)
aorta
aort/o
Accountable Care Organizations
are a payment and delivery model designed to improve healthcare and lower costs that also use risk adjustment
Risk Score Adjustments
are applied to only the benchmark because it was developed based on historical data and is being used to establish expected levels of per capita spending in the ACO, and attempts to ensure that the expected levels are reasonable based on the actual composition of the ACOs assigned population.
Diagnosis Within Hierarchies (Categories)
are inclusive of one another, while any additional diagnoses from other hierarchies or stand-alone diagnoses are additive and increase each patient's overall risk score
artery
arter/o
artery
arteri/o
joint
arthr/o
RA HCC Model
assigns a value to each diagnosis code that is included in the model each code carries a value through a RAF that can be thought of in similar terms to the RVU assigned to procedure codes
atrium
atri/o
CMS only allows own specific attestation form to be used where signatures or credentials are missing to attest treatment during RADV process
attestation form
permitted for signature and/or credentials on outpatient documentation only. CMS forms only
attestation form (CMS)
Extremely low blood pressure that doesn't respond adequately to simple fluid replacement.
be diagnosed with septic shock, you must have signs and symptoms of severe sepsis, plus......
RA proration payments
begin after issuers have paid charges and funds are collected for each risk pool/market. The charges collected will be distributed monthly based on the amount collected within the monthly payment cycle in the same risk pool/market.
two, twice
bi-
first listed code to identify artery additional code to report it is bilateral
bilateral occlusion and stenosis
eyelid
blephar/o
bronchus
bronch/o
cheek
bucc/o
bursa, sac of fluid near joint
burs/o
Codes titled "Other or other specified" are for use when the information in the medical record provides detailed for which a specific code does not exist.
"Other or other specified" codes
Codes titled "Unspecified" are for use when the information in the medical records is insufficient to assign a more specific code.
"Unspecified" codes
not otherwise specified (NOS)
"unspecified"
Parentheses are used to enclose supplementary words that may be present or absent in the statement of a disease or procedure. They do not affect the code (nonessential modifiers)
( )
The principal or first-listed code for an encounter due to an insulin pump malfunction resulting in an overdose of insulin, should also be ___________________________ followed by code ___________________________.
* T85.6-, Mechanical complication of other specified internal and external prosthetic devices, implants and grafts. * T38.3X1, Poisoning by insulin and oral hypoglycemic [antidiabetic] drugs, accidental (unintentional). 6
MRR findings/contract level payment adjustments
*CMS provides MA of RADV findings
puncture; tap
-centesis
binding, fusion
-desis
excision, surgical removal
-ectomy
a record of data
-gram
instrument for recording data
-graph
act of recording data
-graphy
instrument for incising (cutting)
-tome
incision, cutting
-tomy
ra data processing time
1 to 2 days
Financial Impacts Occur in Two Main Areas
1) The initial submission of specific diagnosis codes which relay certain HCC values 2) within the constraints of a risk adjustment audit where funding may need to be returned if HCC-valued diagnosis codes are unsupported
there a total of ? Clinical Risk Groups?
1,080 categories/groups
ACA Risk Programs
1. Permanent RA Program, shifting healthcare dollars from health plans that enroll healthier patients to those health plans that enroll less healthy patients 2. Transitional Reinsurance Program, provides additional funding to health plan that enroll patients with especially costly medical needs. 3. 3-Year Transitional Risk Corridor Program, to mitigate risks associated with mis-pricing premiums when the estimated medical costs of patients are uncertain. Government will provide funding in the health plan's losses exceed a certain threshold and a health plan will pay the government if the health plan's gains exceed a certain threshold.
CMS HCC Model Interactions
2) Disabled: this is a combination of certain diseases and the disabled status of an enrollee; a diagnosis with disabled status that results in an additional relative factor added to the risk score calculation
The coding of severe sepsis requires a minimum of ____ codes: first a code for the _________________, followed by a code from subcategory _________________________.
2, underlying systemic infection, R65.2Severe sepsis
how many base Clinical Risk Groups are there
272
mechanism of the injury, soft tissue damage, degrees of skeletal involvement
3 categories of Gustilo classifications of open fractures
site, laterality, severity
3 components of ulcer coding
specificity of site, inclusion of laterality, nature of fracture (oblique vs segmental) and 7th character extender additions
4 components of fracture coding
proper, cartilage, bone and blood
4 groups of connective tissue
how many severity of illness levels are included in the Clinical Risk Group model?
4-6
disable interactions
5 in community; 4 institutional
stratum corneum; stratum lucidum (palms and soles); stratum granulosum; stratum spinosum; stratum basale (stratum germinativum)
5 layers of epidermis
The lower outer quadrant (Inferior ateral)
5 o'clock on the left breast would be...
mucous, serous, synovial, meninges, and cutaneous
5 types of membranes
How many categories are included in Chronic-illness Disability Payment System? How many major categories?
58 categories; 20 major categories
disease interactions
6 in community model; 5 in institutional model
how many health categories of included in the Clinical Risk Group
9
99XXX codes
99XXX codes are E&M (Evaluation and Management) codes 99385, 99386, 99387, 99395, 99396, 99397
Colon is used in the Tabular List after an incomplete term that needs one or more of the modifiers that follow to make it assignable to a given category
:
initial encounter for fracture
A
O20.0
A 26-year-old female is admitted with bleeding and a threatened abortion. She is at 18 weeks. Drugs were given and the abortion is averted. What is the principal diagnosis?
excision
A breast lumpectomy is an example of which root operation in ICD-10-PCS?
Adverse Selection
A concept in economics, insurance, and risk management, which captures the idea of a "rigged" trade. When buyers and sellers have access to different information (asymmetric information), traders with better private information about the quality of a product will selectively participate in trades which benefit them the most (at the expense of the other trader). A textbook example is Akerlof's market for lemons. Buyers sometimes have better information about how much benefit they can extract from a service in which case the "bad" customers are more likely to apply for the service. For example, an all-you-can-eat buffet restaurant which sets one price for all customers risks being adversely selected against by high appetite (and hence least profitable) customers.
Refers to an earlier surgery injury illness no significance for the episode of care no code for the condition is assogn
A diagnostic expressed status post
1. false information due to lack of adequate chart documentation or incomplete and/or inaccurate ICD coding 2. Patients not seen 3. Indicative of insufficient claims data submission
A lower RAF Score may indicate (3 things)?
poisoning
A patient accidently picked up her husband's medication and mistook it for her hypertension medication. She had a reaction and was taken to the ER. This is coded as _____.
1
A patient had a CABG performed using harvested saphenous vein to bypass four blockages in the coronary arteries. In addition to the excision code for the saphenous vein harvesting, how many bypass codes are assigned?
F
A patient is admitted to the hospital because he suffers a subsequent AMI after discharge for care of an initial AMI (two weeks prior). A code from category I21 is sequenced as the principal diagnosis
either pyelonephritis or diverticulitis listed first
A patient is admitted with severe abdominal pain, nausea and vomiting due to acute pyelonephritis and diverticulitis. Both underlying conditions are treated, and the physician believes both equally meet the criteria for principal diagnosis. How is this coded?
R11.2 (combines the nausea and vomiting conditions)
A patient visits the primary care physician for complaints of nausea and vomiting. Which option is appropriate to report a diagnosis of nausea and vomiting? Apply the coding concept from ICD-10-CM guidelines, section I.B.9.
I25.110
A patient was admitted to the hospital because of unstable angina, and a percutaneous transluminal angioplasty was carried out quickly to abort an impending myocardial infarction. The results of the angioplasty showed arteriosclerotic blockage of the native coronary artery. What is the principal diagnosis?
R11.0, T46.2x5A, I48.91
A patient was prescribed Amiodarone to control his atrial fibrillation. The patient quit taking his prescribed medication on his own one week ago, because he said the medication made him nauseous. He is now admitted for control of atrial fibrillation and medication adjustment.
F10.229
A patient with acute alcohol intoxication, abuse, and dependence was admitted for treatment and underwent alcohol abuse detoxification. Code the principal (first-listed) diagnosis.
HZ2ZZZZ
A patient with acute alcohol intoxication, abuse, and dependence was admitted for treatment and underwent alcohol abuse detoxification. Code the procedure
O23.12
A pregnant patient at 20 weeks gestation has a chronic cystitis and has recurrent bouts of acute cystitis during her pregnancy, with an acute episode at time of admission. Code the principal (first-listed) diagnosis.
Factor analysis
A statistical method used to describe variability among observed, correlated variables in terms of a potentially lower number of unobserved variables called factors.
O32.1xx0, Z37.0, Z3A.38, 10D07Z6
A term pregnancy, liveborn was delivered; breech presentation; 38 weeks gestation; delivery by partial breech vacuum extraction.
Two code one for the removal uterus and for cervix
A total hysterectomy remove the whole uterus and cervix
Excludes2
A type 2 Excludes note represents "Not included here." An excludes2 note indicates that the condition excluded is not part of the condition represented by the code, but a patient may have both conditions at the same time. When an Excludes2 note appears under a code, it is acceptable to use both the code and the excluded code together, when appropriate.
A myocardial infarction associated with a CABG
A type 5 MI is.....
A 22-year-old female is admitted to ICU for acute renal (kidney) failure due to sepsis (causal organism unknown). Applying the coding concept from ICD-10-CM guideline I.C.1.d.1.b, what ICD-10-CM codes are reported (in the correct sequencing)?
A41.9, R65.20, N17.9
A 22-year-old female is admitted to ICU for acute renal (kidney) failure due to sepsis (causal organism unknown). Which ICD-10-CM codes are reported in the correct sequencing?
A41.9, R65.20, N17.9
Affordable Care Act
ACA
Adjusted Clinical Groups
ACGs
American Hospital Association
AHA
Published by American Hospital Association
AHA coding clonics
Retrovir, AZT, Videx
AIDS
ANSI 835
ANSI Health Care Claims and Remittance Format
Using extreme heat freezing chemical (cryoablation) microwaves radiofrequency under the root destruction
Ablation
Assign only code for dependence
Abuse and dependence
is not equivalent to an infection superimposed on a chronic condition, although an exacerbation may be triggered by an infection.
According to guideline I.C.10.a.1 an acute exacerbation....
problem or condition that is usually short-lived, a current new problem, or a new instance of a known problem that occurs in intervals
Acute
results in dilatation (stretching) of the walls
Acute Cor Pulmonale
If the same condition is described as both acute (subacute) and chronic, and separate subentried exist code both and sequence the acute first.
Acute and Chronic Conditions
May occur following surgery but not necessarily a complication of the procedure and should not be coded as a postoperative complication unless the physician identifies it as such
Acute blood loss anemia
T
Acute pulmonary edema is included in codes I50.- and no additional code is assigned.
To the root release should not be coded unless is required before operation
Adhesion of lysis
model developed by John Hopkins in 1992
Adjusted Clinical Groups
ACG
Adjusted Clinical Groups (outpatient)
Code treatment then code complication.
Admitted for treatment and develop complication
Is not an element of the UHDDS (uniform hospital discharge data set
Admitting diagnosis
the patient had an adverse effect of a drug that was correctly prescribed and properly administered
Adverse effect
Allergic reaction Cumulative effect Hypersensitivity Idiosyncratic reaction Paradoxical reaction Synergistic
Adverse effect of a drug
ACA
Affordable Care Act
Should not be used for aftercare injuries
After care code
Z42-Z51
After care visit
Claritin, Phenergan, Allegra, Zyrtec, Benadryl
Allergies
ACHP
Alliance of Community Health Plans
To locate the appropriate table that contains all information necessary to construct a procedure code
Alphabetic Index PCS
AAPC
American Academy of Professional Coders
AHA
American Hospital Association
ANSI
American National Standards Institute
AHIMA
American health Information Management Association
ANOVA
Analysis of Variance
Interpret as either and or Or
And
Means either "and" or "or" when it appears in the title.
And
When used in a code description means and/or
And
can mean "and" or "or"
And
Code also the cause Code first the poisoning and under-dosing of medications If associated with malignancy, code malignancy first
Anemia
Code first the underlying condition follow by anemia code
Anemia
Feosol, Feriron, Fergom, Procrut, Epigen, Neupogen
Anemia
Code first the underlying kidney disease N18 follow by anemia code D63.1
Anemia chronic kidney disease
Code the neoplasm C00-D49
Anemia in neoplastic
Code first the underlying chronic disease
Anemia of other chronic disease
Anemia code sequence first follow by the adverse effect
Anemia with adverse effect of chemotherapy and the trea men is for anemia
If the anemia is caused by chemotherapy or radiotherapy, the _______ code is reported first, followed by the appropriate codes for the _____________________.
Anemia, neoplasm and the adverse effect
Verpamil, diltiazem, nifedipine
Angina pectoris
Ativan, Xanax, Valium, lorazepam, diazepam
Anxiety
What does the 4th character in diabetes mellitus diabetes codes indicate?
Any complication associated with diabetes.
Caused by failure of the bone marrow to produce red blood cells
Aplastic anemia
Failure of the bone marrow to produce red blood cell maybe congenital but usually idiopathic or acquired
Aplastic anemia
Always consult the Alphabetic Index first. Refer to the Tabular List to locate the selected code.
Applying the coding concept from ICD-10-CM guidelines, section 1.B.1, which of the following is the recommended method for using your ICD-10-CM codebook?
Categories
Are unique and additive, meaning that any condition belonging to a particular category will carry a value that is included in Risk Score Calculation in addition to conditions in any other category.
Verapamil, digoxin Lanoxin, quinidine,
Arrhythmia
abnormal connection or passageway between an artery and a vein, and may result from surgical creation or acquired due to pathological processes (trauma or erosion of arterial aneurysm).
Arteriovenous (AV) Fistula
Tubular graft used to connect the artery and vein( creation of arteriovenous graft root operation is bypass
Arteriovenous graft
Ibuprofen, Lodine, naproxen, prednisone, Deltasone, Relafen
Arthritis
Z38.00
Assign the code for a newborn, delivered vaginally (born in the hospital) with tetralogy of Fallot. Code the principal (first-listed) diagnosis.
Q21.3
Assign the code for a newborn, delivered vaginally (born in the hospital) with tetralogy of Fallot. Code the secondary diagnosis.
M80.08xA
Assign the code for a patient being seen in the emergency room for a compression fracture due to senile osteoporosis (initial encounter).
D64.81
Assign the code for anemia due to antineoplastic chemotherapy.
H40.10X1
Assign the code for bilateral open-angle glaucoma, mild stage.
K95.01
Assign the code for infection due to gastric band procedure.
Z51.11
Assign the codes to this case. The patient has carcinoma of the ascending colon with prior resection and was admitted for his first chemotherapy treatment. Code the principal (first-listed) diagnosis.
C18.2
Assign the codes to this case. The patient has carcinoma of the ascending colon with prior resection and was admitted for his first chemotherapy treatment. Code the secondary diagnosis
0UF58ZZ
Assign the procedure code for a hysteroscopy with an intraluminal lithotripsy of the right fallopian tube calcification.
inflammatory disease of the airways, usually tightening/narrowing of the bronchioles, making it difficult for air to pass through normally. Combo of genetics and environmental exposures. Comorbidities include GERD, sinusitis, anxiety, depression, and OSA
Asthma
Z21
Asymptomatic HIV infection is coded as...
ACO QA Measures Domain 5
At-Risk Population/ Frail Elderly Health
Alveoli are deflated
Atelectasis
irregular impulses reaching the AV node and only some are being transmitted. Placement of P, QRS, and T waves are out of rhythm from intense "shaking" or "churning" of the ventricles from the atrial hyperactivity or rapid firing of impulses. Managed through blood thinning medications to prevent clots from churning activity. A-Fib can be treated with pacemaker, rarely, and unless other conduction disorders exists, do not code A-fib.
Atrial Fibrillation
A separate procedure is coded
Autograph obtained from a different body part
For all positive diagnosis HIV positive Or HIV related is sufficient
B20
If a patient test results come back positive for HIV and the patient is symptomatic, what code should be used?
B20
When a patient is admitted for an HIV related condition, _____ is sequenced first followed by additional diagnoses codes for all reported HIV related conditions.
B20
Known prior diagnosis of HIV related illness should always be Coded B20. *patient previously diagnosed B20 should never be assigned to R75 or Z21.
B20 (HIV)
Balanced Budget Act of 1997
BBA
Bone Density Measurement
BDM
Presence of bacteria in the bloodstream after a trauma or an infection
Bacteremia
CASE 1 Operative Report PREOPERATIVE DIAGNOSES: Splenic abscesses and multiple intra-abdominal abscesses, related to HIV, AIDS, and hepatitis C. POSTOPERATIVE DIAGNOSES: Splenic abscesses and multiple intra-abdominal abscesses, related to HIV, AIDS, and hepatitis C. (Postoperative diagnoses are reported.) OPERATIVE PROCEDURE: 1. Exploratory laparotomy with drainage of multiple intra-abdominal abscesses. 2. Splenectomy. 3. Vac Pak closure. FINDINGS: This is a 42-year-old man who was recently admitted to the medical service with a splenic defect and found to a splenic vein thrombosis. He was treated with antibiotics and anticoagulation. He returned and was admitted with a CT scan showing mass of left upper quadrant with abscesses surrounding both sides of the spleen(The location of the abscesses are on both sides of the spleen.), as well as, multiple other intra-abdominal abscesses below the left lobe of the liver in both lower quadrants and in the pelvis. The patient has a psychiatric illness and was difficult to consent and had been anticoagulated with an INR of 3. Once those issues were resolved by psychiatry consultation and phone consent from the patient's father, he was brought to the operating room. OPERATIVE PROCEDURE: The patient was brought to operating room, a time-out procedure was performed. He was already receiving parenteral antibiotics. He was placed in the supine position and then given a general endotracheal anesthetic. Anesthesia started multiple IVs and an arterial line. A Foley catheter was sterilely inserted with some difficulty requiring a Coude catheter. After the abdomen was prepped and draped in the sterile fashion, a long midline incision was made through the skin. This was carried through the subcutaneous tissues and down through the midline fascia using the Bovie. The fascia was opened in the midline. The entire left upper quadrant was replaced with an abscess peel separate from the free peritoneal cavity. This was opened, and at least 3 to 4 L of foul smelling crankcase colored fluid were removed. Once the abscess cavity was completely opened, it was evident that the spleen was floating within this pus(Confirms the location of the abscess.) as had been predicted by the CT. This was irrigated copiously and the left lower quadrant subhepatic and pelvic abscesses (Location of abscesses.) were likewise discovered containing the same foul smelling dark bloody fluid. All of these areas were sucked out, irrigated, and the procedure repeated multiple times. We thought it reasonable to go ahead with the splenectomy. The anatomic planes were obviously terribly distorted. There was no clear margin between stomach spleen, colon spleen, etc., but most of the dense attachments were to the abscess cavity peel. Using this as a guide, the spleen was eventually rotated up and out to the point where the upper attachments presumably where the short gastric used to reside were taken via Harmonic scalpel. The single fire of a 45 mm stapler with vascular load was taken across the lower pole followed by two firings of the echelon stapler across the hilum. This controlled most of the ongoing bleeding. Single bleeding site below the splenic artery was controlled with two stitches, one of 3-0 Prolene and the other of 4-0 Prolene. Because of diffuse ooze in the area and the fact that the patient would be scheduled for a return visit to the operating room tomorrow to reinspect the abscess cavities, it was elected to leave two laparotomy pads in the left upper quadrant and Vac Pak the abdomen. The Vac Pak was created using blue towels and Ioban dressings in the usual fashion with 10 mm fully perforated flat Jackson-Pratt drains brought out at the appropriate level. The patient was critical throughout the procedure and will be taken directly to the intensive care unit, intubated, with a plan for reexploration and removal of the packs tomorrow. The patient received four units of packed cells during the procedure, as well as albumin and a large volume of crystalloid. There were no intraoperative complications noted and the specimen sent included the spleen. Cultures from the abscess cavity were also taken. What diagnosis code(s) are reported?
B20, D73.3, K65.1, B19.20
Root operation drainage (fluid removal)or excision (removal of a mass or lump) Seventh character X for diagnostic
Biopsies of breast
Excision
Biopsies to the root
Both are coded
Biopsy + more definitive procedures
Coded using; excision, extraction, or drainage + the qualifier diagnostic (qualifier diagnostic is used only for biopsies)
Biopsy procedure
diabetics should check 1-4 times a day
Blood Sugar Levels
Device value no autologous tissue substitute or autologous tissue substitute
Bone graft
If the provider documents a "borderline" diagnosis at the time of discharge, the diagnosis is Coded as confirmed, unless the classification provides an specific entry.
Borderline Diagnosis
Should code only as confirm unless the classification provide a specific index entry
Borderline condition
Without further provider should be assign a code R73.0 abnormal glucose
Borderline diabetes
Used in the alphabetic index to identify manifestation codes.
Brackets [ ]
Slow heart rate
Bradycardia
general defects in the electrical conduction system of the heart between the atrial and ventricle portions of the heart
Bundle Branch Block
depth, extent, agent
Burns are classified by
T
Burns due to a chemical such as lye is coded to corrosion.
T
Burns of the same site are coded to the highest degree only.
Use only the degree of greatest severity along with the additional codes for burns of other anatomic sites
Burns on different body parts
The body part bypassed from and to. The fourth character is the from and the qualifier is the to
Bypass procedures
Chronic Condition SNP
C-SNP
What diagnosis code is reported for secondary neoplasm of the descending colon?
C78.5
F
C78.7 + C18.7 is correct sequencing for the diagnoses in the following case: Carcinoma of sigmoid colon with small metastatic nodules on the liver; sigmoid resection of the colon carried out.
hardening and narrowing of arteries that supply blood to the muscle of the heart
CAD
relationship maybe assumed unless documented angina is due to another cause
CAD (atherosclerosis) and angina
coordinated care plans
CCP
Chronic-Illness Disability Payment System
CDPS
Code of Federal Regulations
CFR
The severity of CKD is designated by stages 1-5. Stage 2, code N18.2, equates to mild CKD; stage 3, code N18.3, equates to moderate CKD; stage 4, code N18.4, equates to severe CKD. Code N18.6, End stage renal disease (ESRD), is assigned when the provider has documented end-stage-renal disease (ESRD). If both a stage of CKD and ESRD are documented, assign code N18.6 only.
CKD Types
Centers for Medicare and Medicaid Services
CMS
when electrical impulses have problems or difficulties some patients can experience problems intermittently, while others may persist for a chronic-period or be life-long. Only coded when current or malfunction with an implant. -common disorders include 1. supraventricular tachycardia 2. AV blocks 3. sick sinus syndrome 4. atrial/ventricular fibrillation 5. atrial/ventricular flutter
Cardiac Conduction Disorders
disease that weakens and enlarges the heart muscle and makes it more difficult for the heart to pump blood and deliver it to the rest of the body. Closely associated as major cause of heart failure. 3 main types: 1. dilated 2. hypertrophic 3. restrictive
Cardiomyopathy
ACO QA Measures Domain 2
Care Coordination
Is the overall health status and risk of a provider panel of member, which utilizes combined data from the following areas and provides a depiction of member heath risk profile for a plan, which is used to predict future costs and payments.
Case Mix/Risk Adjustment
Treatment to the cellulitis is code first treatment to the open wound open wound is code first
Cellulitis
CCIIO
Center for Consumer Information & Insurance Oversight
CMS
Centers for Medicare and Medicaid Services
emergent loss of brain function due to lack of blood circulation to the brain. Causes include blockage such as thrombosis (clot), embolism, or a break in a vessel, such as a hemorrhage. Affected area of the brain is unable to function and the patient may be unable to move 1 or both sides of the body, unable to speak, or unable to see, depending on side of brain affected. Urgent treatment necessary. Risk factors include age, long-term HTN, diabetes, uncontrolled high cholesterol, smoking, A-Fib, and history of stroke or TIA
Cerbrovascular Accident (CVA)
Cerner
Cerner for IHC = iCentra EDW data
CNM
Certified Nurse Midwife
CRNA
Certified Registered Nurse Assistant
Extraction root operation
Cesarean deliver
21 chapterwaa
Chapter
Infection and parasites disease and Take precedence over other chapter for the same condition
Chapter 1
ICD-10-CM _______ ______ codes always take sequencing priority and should be listed first.
Chapter 15
Can be designated followed by two or more contrasting comparative condition
Chapter 18
Seen place holder X
Chapter 19
naturally occurring substance in the body that is necessary for cell growth.
Cholesterol
problem or condition that is more permanent, that can be long-term or life-long in nature
Chronic
suffer from an increase in the mucous in the airway passages, with a thickening of the walls of the bronchioles with inflammation, which narrows those airways and limits the airflow. "Blue Bloaters" for the bluish color/tint to skin and lips.
Chronic Bronchitis
CC
Chronic Condition
CCRR
Chronic Condition Re-Evaluation Rate
results in RT ventricular hypertrophy (RVH) (thickening of the walls placing extra stress on the right ventricle)
Chronic Cor Pulmonale
CDS
Chronic Disease Score
CDPS
Chronic Illness and Disability Payment Systems
Code to N18.6 (ESRD) and dialysis status Z99.2
Chronic kidney disease stage 5
model developed by University of California, San Diego in 1996
Chronic-illness Disability Payment System
EDGE Claims/Enrollment
Claims per enrollee ratio EDGE Claims/Enrollment Percent of enrollees without claims Percent of claims without enrollees Percent of medical claims that are institutional claims Percent of pharmacy claims
CRG
Clinical Risk Group
model developed by 3M Health Information Systems in 2000
Clinical Risk Groups
Note instructs that two codes may be required to fully describe a condition, but this note does not provide sequence directions.
Code Also Note
F
Code Q03.9 and Code G91.9 can be used together if both are present.
T
Code Z33.2 is assigned for elective termination of pregnancy without complication.
T
Code Z79.4 should be assigned to code E10.22 when the patient has been put on long-term insulin.
Indicate two code may be require
Code also
1. chemotherapy 2. radiotherapy 3. hormonal therapy 4. watchful waiting (monitoring and deciding course of action) 5. patient refused and considered too frail
Code cancer as active
T
Code category Z85 is used only when a primary neoplasm has been excised or eradicated and is no longer under treatment with no existing evidence of the existing primary malignancy.
CDPS
Coders may not use diagnosis codes from lab or radiology or other diagnostic studies because many of these dx are rule-out or suspected dx. All other face to face encounters may be used.
Used to identify diagnosis, symptoms, conditions, problems, complaints or other reason for the encounter/visit.
Codes
T
Codes from category J09 should only be assigned for confirmed cases.
do not code if provider does not state word "hemiparesis" if late effect of stroke: must be documented clearly a cause and effect relationship
Coding Clinic ICD 9 (hemiparesis)
First determine if benign, in-situ, malignant, or of uncertain histologic behavior.
Coding Neoplasm
Require two codes one for root operation reposition and another for root supplement same for arcuplasty, kyphoplasty, skyphoplasty, spineoplasty
Coding for percutaneous vertebroasty or percutaneous vertebral augmentation
Are used in the tabular list in both inclusion note and exclusion note after an incomplete
Colon
Means that MRSA and MSSA is present on or in the body without necessarily causing illness. Z22.322 MRSA Z22.321 MSSA
Colonization
artificial opening created surgically where a stoma (mouth) is formed in from the large intestine or colon through the abdomen and the stoma is sutured in place providing a channel for waste to leave the body. May be reversible/irreversible dependent upon needs. Placed on the lower left side of abdomen, just below waistline. Cecostomy is another example.
Colostomy
Single code used to classify two diagnosis.
Combination Code
Combination Code includes type of infection and MRSA organism.
Combination Code for MRSA infection
bone breaks into many fragments; typically seen in crush injuries ; common in elderly
Comminuted fracture
1. Aphasia (inability to speak) 2. Dysphasia (difficulty speaking) (recall "s" for speaking) 3. Dysphagia (difficulty swallowing) (recall "g" for GI tract) 4. Ataxia (lack of muscle coordination) 5. Hemiparesis/Hemiplegia (weakness on 1 side of the body)
Common late effects related to CVA, TIA, and cerebrovascular disese
diagnoses in addition to the primary problem(s) that the patient has while being treated for another condition simultaneously.
Comorbidities
There must be a cause and effect relationship between the care provided and the condition, and an indication in the documentation that it is a complication.
Complication of Care
Are found under complication
Complication of medical or surgical
Require additional codes
Complications of ectopic pregnancy and abortions
broken bone fragments lacerate soft tissue and protrude through an open wound in the skin
Compound fracture
CWV
Comprehensive Wellness Visit
CCs
Condition Categories
Categories and Multiple Diagnosis
Condition categories will each represent a RAF When 1 category has more than one diagnosis with a risk value again only the most significant risk value from each category will factor into the overall risk score.
Are found under delivery, pregnancy, puerperal
Condition that complicate pregnancy, childbirth
Are often grouped together in residual code labeled not elsewhere classified
Condition that occur infrequently or low importance
rounded project on the end of a bone usually at the point of articulation
Condyle
Code only _____ cases of HIV. Lab work is not required only the physician documents.
Confirmed
Under the main anomaly
Congenital condition
occurs when the heart cannot pump enough blood to meet the body's need, and develops after other conditions have weakened or damaged the heart muscle. Causes blood/fluid to back up into liver, abdomen, lower extremities, and lungs. Backup leads to coughing from an overload of fluid in the lungs (pulmonary edema), fluid around the lungs (pleural effusion), swelling of fluid in the abdomen (ascites), and swelling in the feet and ankles.
Congestive Heart Failure
CAHPS
Consumer Assessment of Healthcare Providers and Systems
Classified by number of distinct sites treated
Coronary arteries
CSR
Cost Sharing Reduction
Health Insurance Claim Number (Beneficiary Medicare ID#)
Correctly answered Correctly answeredIncorrectly answered Incorrectly answeredMissed correct multiple choice option Missed correct multiple choice option Question 1 of 10 MARx distributes the Model Output Report (MOR) to MA sponsors at the contract level? Correct answer: A) You chose: A) Correct answerA) True B) False Points: 1 out of 1 Feedback: Rationale: The MOR documents the demographics and HCCs used to determine risk scores for each beneficiary in each model run. Because the new risk adjustment model has a revised set of HCCs, CMS is providing plan sponsors with an additional Part C MOR detail record type for PY2014. Question 2 of 10 The MOR file format changes help MA plans understand how CMS determines risk adjustment scores? Correct answer: A) You chose: A) Correct answerA) True B) False Points: 1 out of 1 Feedback: Rationale: The MOR file format changes help MA plans understand how CMS determines risk adjustment scores for each beneficiary. As a result, MA plans must make appropriate changes to properly receive the additional detail record type on the MOR. Question 3 of 10 The only beneficiary information that can change on a monthly basis is The Beneficiary's HICN and _____________. Please select the correct choice below: Correct answer: C) You chose: C) A) The beneficiarie's PCP B) The beneficiarie's deductible Correct answerC) The beneficiarie's contract they are enrolled in D) None of the above Points: 1 out of 1 Feedback: Rationale: The final MOR states the final risk adjustment HCC indicators used to determine the final risk scores for the previous payment year. Since the MOR HCC indicators are only updated after each model run, the demographic and disease factors remain the same for each beneficiary on the MOR until the next model run is performed. The only beneficiary information that can change on a monthly basis is: The Beneficiary's HICN The Contract The Beneficiary Is Enrolled In Question 4 of 10 The ESRD status of a beneficiary, as reported on the MOR, can only change in a model run? Correct answer: A) You chose: A) Correct answerA) True B) False Points: 1 out of 1 Feedback: Rationale: The ESRD status of a beneficiary, as reported on the MOR, can only change in a model run. To assess the ESRD status of a beneficiary used for purposes of payment in a specific month, the plan should refer to the MMR (Monthly Membership Report). Question 5 of 10 MA Plans receive separate MOR files for both Medicare Part C (CMS HCC) and ___________. Please select the answer below that best fits the blank. Correct answer: B) You chose: B) A) Medicare Part B Correct answerB) Medicare Part D C) Medicare Part A D) None of the above Points: 1 out of 1 Feedback: Rationale: The MOR file contains a series of flags indicating which demographic factors (age, sex and entitlements for Medicaid and disability) and disease factors (HCCs and disease interactions) are used to calculate the risk score for each non-hospice beneficiary enrolled in the plan. Plans receive separate MOR files for the Part C (CMS-HCC) and Part D (RxHCC) risk adjustment models. Question 6 of 10 What is the name of the new CMS HCC Risk Adjustment Model for 2014? Correct answer: C) You chose: C) A) V12 B) V25 Correct answerC) V22 D) None of the above Points: 1 out of 1 Feedback: Rationale: One key change for PY2014 is the implementation of a new CMS-hierarchical condition category (HCC) risk adjustment model, V22. The Risk scores calculated using this new model are blended with risk scores calculated using the CMS-HCC model from 2013. Question 7 of 10 What does the acronym MOR stand for? Correct answer: B) You chose: B) A) Medicare Output Report Correct answerB) Model Output Report C) Medicaid Output Report D) Medical Output Report Points: 1 out of 1 Feedback: Rationale: The Monthly Model Output Report (MOR) for Additional Part C Risk Adjustment Model, is in effect for 2014. The Payment Notice published on April 1, 2013 outlines all of the key changes effective for Payment Year (PY) 2014. Question 8 of 10 If a beneficiary is ESRD at the time the Midyear model is performed, the beneficiary will be reported as ESRD on the July - December MORs? Correct answer: A) You chose: A) Correct answerA) True B) False Points: 1 out of 1 Feedback: Rationale: If a beneficiary is ESRD at the time the Midyear model is performed, the beneficiary will be reported as ESRD on the July - December MORs, even though the payment for previous months will be retroactively adjusted to reflect the appropriate ESRD risk score. Question 9 of 10 If a beneficiary is ESRD at the time the Final Model run is performed, the beneficiary will be reported as ESRD on the Final MOR? Correct answer: A) You chose: A) Correct answerA) True B) False Points: 1 out of 1 Feedback: Rationale: If a beneficiary is ESRD at the time the Final Model run is performed, the beneficiary will be reported as ESRD on the Final MOR. If the beneficiary is non-ESRD at the time the Final Model run is performed, the beneficiary will be reported as non-ESRD on the Final MOR. Question 10 of 10 The MOR HCC indicators are updated after each model run is complete by the following system: Correct answer: D) You chose: D) A) The CMS HCC system B) FERAS C) RADV Correct answerD) RAS Points: 1 out of 1 Feedback: Rationale: The MOR HCC indicators are updated after each model run is completed by the Risk Adjustment System (RAS). The initial model run produces a monthly MOR for January - June payment months. The mid-year model run produces a monthly MOR for July - December payments months. ?
D70.4, R50.81
Cyclic neutropenia is coded with D70.0 Cyclic neurtopenia. There are additional coding instructions for this code listed under the category D70 Neutropenia. Using those instructions, how would you report a patient with cyclic neutropenia with an associated fever?
Via natural or artificial opening endoscopic
Cystoscopic approach
artificial opening created surgically between the urinary bladder and the skin as a method to drain urine from the bladder, aka suprapubic (above pubic bone) cystostomy, epicystostomy, or vesicostomy (2 main types: 1. cutaneious-vesicostomy; 2. appendico-vesicostomy)
Cystostomy
subsequent encounter for fracture with routine healing
D
Dual Eligible SNP
D-SNP
A 32 year-old male was seen in the ASC for removal of two lipomas. One was located on his back and the other was located on the right forearm. Both involved subcutaneous tissue. What ICD-10-CM code(s) is/are reported?
D17.21, D17.1
A 45-year-old female with ovarian cancer visits her oncologist to receive an injection of Procrit®. The Procrit® has been prescribed to her for treatment of her anemia resulting from antineoplastic chemotherapy treatment. Applying the coding concept from ICD-10-CM guidelines I.C.2.c.2. What ICD-10-CM codes should be reported?
D64.81, C56.9, T45.1X5A
DIAGNOSIS_DATE
DIAGNOSIS_DATE does not represent when the member was diagnosed with the condition. It is the most recent date that the member was seen for that diagnosis.
DOS
Date of Service
thrombosis (blood clot) in a deep vein. Signs include pain, swelling, redness, warmness, and engorged superficial veins in the leg. Most serious complication is when a thrombosis (clot) dislodges (embolizes) and travels to the lungs, becoming life-threatening pulmonary embolism (PE). Challenging b/c many instances of DVT prophylaxis or measures to avoid formation of DVT and require confirmation.
Deep Vein Thrombosis (DVT)
If a condition is documented in a medical record (for example, appendicitis) without any additional information, such as acute or chronic, the default Code should be assigned.
Default Code
A payment arrangement for health care service providers such as physicians or nurse practitioners. It pays a physician or group of physicians a set amount for each enrolled person assigned to them, per period of time, whether or not that person seeks care.
Define Capitation
One or more chronic illnesses with severe exacerbation, progression or side effects of treatment Acute or Chronic illnesses or injuries that pose a threat to life or body function
Define High Risk
80/20 rule. Requires health insurance companies in the individual and small group markets to spend at least 80 percent of premium dollars they collect on medical care or activities to improve health care quality, and 85 percent in the large group market.
Define MLR Rule
Medical Numerator divided by the premium denominator
Define MLR calculation defined as:
One or more chronic illnesses with mild exacerbation, progression or side effects of treatment Two or more chronic stable illnesses
Define Moderate Risk
Incurred claims and expenses for activities that improve health care quality
Define medical numerator
The 5th digit of 4
Delivery and Pregnancy Dx - what digit is only used for a postpartum complication?
5th or 6th digit represents trimester
Delivery and pregnancy
a) Delivery diagnosis code b) Outcome of delivery c)Weeks of gestation d) Procedure code
Delivery chart codes should include
serious loss of overall cognitive ability in a previously unimpaired person, beyond normal-aging expectations. Static, result of unique brain injury, or progressive, results in long-term decline due to damage or disease in the body.
Dementia
general term to mean temporary or transient state of low mood, sometimes accompanied by low self-esteem or a loss of interest in normal daily living activities. Patients with more advanced mental disorder, or who require ongoing antidepressant medication are diagnosed with major depression. Coding Clinic, 2011 Volume 28, No. 3, when documentation links depression with anxiety, dysthymic disorder (F34.1) is reported
Depression
HHS
Dept. of Health and Human Services
skin
Derm/o
skin
Dermat/o
Admission/encounter to determine the extent of malignant is Coded first even if treatment is administered.
Determine extent of malignant
-type 1, patient cannot produce their own insulin and must take insulin injections. -type 2, patient does not make enough insulin, or is unable to use the insulin the body makes -high risk racial groups include American Indians, African Americans, Latinos, Asian American, and Pacific Islanders
Diabetes
DRG
Diagnosis Related Group
DRG
Diagnosis Related Groups (inpatient)
F31.0 Bipolar disorder, current episode hypomanic
Diagnosis: Axis 1: BPAD I, severe, current episode hypomanic
helps support many (not all) functions of the kidney. When on dialysis, has an irreversible kidney disease and usually awaiting kidney transplant. Two types: 1. hemodialysis 2. peritoneal dialysis
Dialysis
shaft of a long bone
Diaphysis
referred to as a 'working diagnosis' and found in a list of diagnoses the provider is considering during the evaluation of the patient. Eace of the differential diagnoses is ruled out over time and testing, until one fianl diagnosis remains as the problem condition.
Differential Diagnosis
thinner myocardium (heart wall)
Dilated Cardiomyopathy
Usually recorded on the face sheet, final progress sheet or discharge summary
Discharge diagnoses
a complete dislocation of the joint and is also known as luxation of the joint
Dislocation
when the bone breaks into two or more parts and the bone moves so that it is no longer aligned in its normal position
Displaced fracture
DDC
Distributed Data Collection for RI, RA
Separating or transecting a body part
Division
As if they were established
Do not Code unconfirmed condition such as HIV, multiple sclerosis, epilepsy
If the pain is specified as acute chronic post thoracotomy postpocedural or neoplasm related or the underlying diagnosis is known
Do not assign code G89
With chapter 15
Do not use Z34
DO
Doctor of Osteopathy - a form of drug-free non-invasive manual medicine that focuses on total body health by treating and strengthening the musculoskeletal framework, which includes the joints, muscles and spine. Its aim is to positively affect the body's nervous, circulatory and lymphatic systems.
Two code that provide info about both a manifestation and the associate underlying condition the first code identifies the underlying condition and the second identifies the manifestation
Dual coding
Casual relationship between condition is present
Due to
Dunning
Dunning is also the process of methodically communicating with individuals to ensure certain requested action is taken. It follows a similar process of progressive moving from gentle reminders to firmer communications as due dates approach or pass.
Shows diagnosis clusters submitted with information that duplicates a stored cluster.
Duplicate Diagnosis Cluster Report
DMEMACS
Durable Medical Equipment Medicare Administrative Contracts
A lab screening shows congenital iodine-deficiency hypothyroidism for an infant with identified intellectual disability. What ICD-10-CM code(s) is/are reported?
E00.9, F79
Patient presents to this clinic with palpitations, weight loss, bulging eyes and extreme nervousness. The tests ordered come back positive with Graves' disease. Select the ICD-10-CM code(s) to report.
E05.00
A patient with type 2 diabetes presents with diabetic macular edema and proliferative diabetic retinopathy in the right eye. What ICD-10-CM code(s) is/are reported?
E11.3511
CEFR
EDGE Server Claim and Enrollee Frequency Report
EDI
Electronic Data Interchange
patients suffer from inflammation of the alveoli (air sacs where oxygen exchange occur on a cellular level) and reduces the elasticity of the lung. "Pink Puffers" for pink complexion.
Emphysema
EDS
Encounter Data Submission
Is code to destruction
Endometrial ablation
scope to diagnose and monitor GERD conditions
Endoscopic Gastric Dilation (EGD)
ECS
Enrollee (Without) Claims Summary
EDW
Enterprise Data Warehouse
end of the shaft of a long bone
Epiphysis
This report is distributed monthly and quarterly. Provides an overview of all errors associated with files submitted in test and production.
Error Frequency Report
Section 1343 of the ACA
Establishes a permanent Risk Adjustment (RA) program which is intended to provide payments to health insurance issuers that attract higher-risk populations.
Certain conditions have both an underlying etiology and multiple body system manifestations due to the underlying etiology. For such conditions, the ICD10-CM has a coding convention that requires the underlying condition be sequenced first, if applicable, followed by the manifestation. Wherever such a combination exists, there is a "use additional code" note at the etiology code, and a "code first" note at the manifestation code. These instructional notes indicate the proper sequencing order of the codes, etiology followed by manifestation.
Etiology/manifestation convention
E&M codes (E/M)
Evaluation and Management - 99385, 99386, 99387, 99395, 99396, 99397 are part of the list indicating an AWV
Versajet and ultrasonic debridements
Example of nonexcisional debridements
Cutting out of a less specific body part
Excision
To the root excision
Excisional debridements
Not include here but patient may have both condition
Exclude2
"Not Coded Here" Notes indicates that the code excluded should never be used at the same time as the code above the excludes 1 note.
Excludes 1
"Not included here" Note includes that the condition excluded is not part of the condition represented by the code, but a patient might have both conditions.
Excludes 2
Note means not code here two condition cannot occur together
Excludes1
contract to straighten a body part at the joint
Extensor muscle
EDGE
External Data Gathering Environment server
Used T36-T65
External code are not used to report the intent for poisoning toxic effect adverse effect underdosing of drug
Are assigned as additional code
External codes
V00-Y99
External codes
Destroy biliary stones root fragmentation approach external
Extracorporeal shock wave lithotripsy
Code first underlying condition
F01-F09
The provider sees a 70 year-old patient with documented history of being combative and aggressive in the nursing home. The provider diagnoses the patient with dementia and refers the patient to a neurologist for further evaluation. What ICD-10-CM code(s) is/are reported?
F03.91
A mother brings her son into the doctor because he has been getting in trouble in school for his behavior. He is not paying attention or following the instructions. He is constantly losing his pencil and forgetting to bring in his homework. After evaluating the child, the provider diagnoses him with attention deficit hyperactivity disorder (ADHD), predominately inattentive type, and sends the patient for a consultation with a psychiatrist to see if medication can help. Select the diagnosis code.
F90.0
False Claims Act
FCA
Rejected data after it has been processed through FERAS is recorded in this report.
FERAS Response Report.
FFM
Federally-Facilitated Marketplace - will operate in states that have chosen not to build their own Marketplace
If a patient with HIV disease is admitted for an unrelated condition such as a fracture, the code for the unrelated condition is coded _______. B20 is used as an additional diagnosis.
First
PR interval is greater than 0.20 sec
First Degree AV Block
superficial burns through only the epidermis
First degree burns
FDR Oversight Committee
First tier, Downstream, and Related Entities
abnormal connection or passageway between 2 epithelium (skin) - line organs or vessels that normally do not connect. May be acquired as disease, congenital, or surgically created connection for therapeutic reasons.
Fistula
strong, flat plates of bone; protect the bodies vital organs
Flat bones
contract to bend a body part at the joint
Flexor muscle
-Simple-the patient remains conscious, but experiences sensations and feelings that are abnormal -Complex-the patient has a change in or loss of consciousness
Focal seizures include
The index provides Subterms for both but the Subterms for the organism takes precedence over the Subterms chronic
For a chronic cystitis due to gonococcus
Public-Facing Form 1095
Form 1095-A is a tax form that will be sent to consumers that have been enrolled in health insurancethrough the Marketplace in the past year.
Treatment to fracture first treatment to neoplasm neoplasm first
Fracture sequence
Classified by the level of the spine
Fusion of spine
subsequent encounter for fracture with NONunion
G
subsequent encounter for fracture with delayed healing
G
Initial AWV visit
G0438 is a code for?
Subsequent AWV visit
G0439 is a code for?
A 58 year-old patient sees the provider for confusion and loss of memory. The provider diagnoses the patient with early onset stages of Alzheimer's disease with dementia. What ICD-10-CM codes are reported?
G30.0, F02.80
A 32 year-old patient with an ophthalmoplegic migraine is not responding to medication and is admitted to the observation unit. What ICD-10-CM code is reported?
G43.B1
Mr. Timmins fell off a roof and suffered a spinal injury. As a result of the injury, he has been suffering from chronic pain in his lower back for several years. Today, he presents for insertion of a neurostimulator for pain control. Applying the coding concept from ICD-10-CM guideline I.C.6.b.1.a and I.C.6.b.1.b.ii, what ICD-10-CM codes should be reported for the pain? Do not code the external cause codes (discussed later in the curriculum).
G89.21, M54.5
Mrs. Johnson is here today to receive an intercostal nerve block to mitigate the debilitating pain of her malignancy. Her cancer has metastasized to her bones in her thoracic spine. Primary cancer is unknown. What ICD-10-CM codes are reported?
G89.3, C79.51, C80.1
indicates how well the kidneys are filtering creatinine (waste produced by the muscles)
GFR
stomach acid, and sometimes, bile flows backward (reflux) into the esophagus and backwash of acid destroys the lining of the esophagus causing heartburn.
Gastroesophageal Reflux Disease (GERD)
Means gastritis, duodenitis, diverticulosis, diverticulitis
Gastrointestinal term bleeding
Assessing the degree of consciousness 3 factors amout of eye opening, verbal responsiveness motor responsiveness
Glasgow coma scale
__________ is a condition when the optic nerve is damaged, causing vision loss.
Glaucoma
Page 54
Go over sequencing for neoplasm complications
Good
Good
Form of arthritis caused by high levels of uric acid in the blood
Gout
caused by the accumulation of uric acid crystals below the skin
Gouty tophi
Always code first if present
Grangrene code
incomplete break; common in children
Greenstick
A patient presents with pigmentary glaucoma bilaterally, moderate stage on the right, mild stage on the left. Reference ICD-10-CM guideline I.C.7.a.3. What ICD-10-CM code(s) is/are reported?
H40.1312, H40.1321
After referral from the ED, patient is seeing the ophthalmologist to examine an old injury with retained magnetic iron metal foreign body in his posterior wall within the right eye with the possibility of infection. What ICD-10-CM codes are reported?
H44.641, Z18.11
cancer codes
HCC varies depending on whether cancer is primary site or secondary site
Healthy form of cholesterol
HDL
HRADV
HHS/CMS identifies a similar sample of patients; however, the dates of service only come from those that were submitted on claims through the Edge servers. There is a requirement to tie any diagnoses identified to an active claim that was submitted. Additional diagnoses that are documented as current in those dates of service on claims for the year, but not included on the original claim, may also be approved. The submission of all HCCs are cumulative, so there may be a negative or positive outcome overall from a financial perspective in such an audit.
Code only confirmed cases.. the providers diagnostic statement that the patient is HIV positive, or has an HIV related illness is sufficient.
HIV codes (A00-B99)
Code 098.7 HIV complicated pregnancy, B20 HIV, then code for the HIV related illness.
HIV in pregnancy, childbirth or puerperium
Code only confirmed cases (diagnosis sufficient)
HIV infections
B20
HIV related illness is coded as....
HHS HCC
Health Human Services Hierarchical Condition Category
HIOS
Health Information Oversight System
HIX
Health Insurance Exchange
HIOS
Health Insurance Oversight System
HOS
Health Outcome Survey
HCPCS
Healthcare Common Procedure Coding System
HEDIS
Healthcare Effectiveness Data and Information Set
Approved Provider Documentation
Healthcare professionals who are at least Master's degree prepared, licensed as a provider, and who diagnose conditions in their daily work. Any provider may validate any diagnosis, as diagnoses are not dependent upon the specialty. Diagnosis may be collected from that provider, even if he or she is not treating the diagnosis, if an approved provider validates any diagnosis as current, it will be accepted. It is not about the provider treating or attending to the diagnosis, but rather validating the diagnosis as part of his or her medical decision-making.
_________ is paralysis on one vertical half of the body.
Hemiplegia
Paralysis of one side of the body. What side is dominant or nondominant. For ambidextrous patient default should be dominant, left side is affected non dominant, right side dominant
Hemiplegia/hemiparesis
Is coded to extracorporeal assistance and performance
Hemodialysis
Classified to hernia with gangrene
Hernia with both grangrene and obstruction
HPI
History of Present Illness
4
How degrees of hemorrhoids are there?
Do not code it unless there is documention that the excis debridement was performed. Check AHA CC.
How do you code an excisional debridement?
T40.1x1A, R40.20
How is coma due to poisoning by heroin, initial encounter coded?
51 or more total employees
How many employees are in a Large Group?
1-50 total employees
How many employees are in a Small Group?
Audits are done annually on selected plans that may have to request medical record documentation from the providers to support the submitted diagnoses.
How often does CMS conduct data validation audits and for what purpose?
Illnesses always assumed related to HIV -Kaposi's sarcoma, or lymphoma -Cryptoccal meningitis -Pneumocystis carinii pneumona (PCP) Cytomegalovirus
Human Immunodeficiency Virus (HIV)
elevated levels of cholesterol in the blood, and a type of hyperlipidemia. Cholesterol measured through blood analysis, and can be affected by diet.
Hypercholesterolemia
high levels of lipids in the blood
Hyperlipidemia
chronic elevated blood pressure of arteries making the muscle work harder than normal. Measured when the heart is contracting (systole) or relaxing between beats (diastolic). Constant reading of 140/90 mmHG or above is diagnosed as HTN.
Hypertension (HTN)
T
Hypertensive heart disease with congestive heart failure is coded I11.0 + I50.9.
Institutional SNP
I-SNP
Codes for type 1 STEMI are _________________________.
I21.0-I21.2 and code I21.3
Are closed classification provide one and only one place to classify condition and procedure
ICD-10-CM/PCS
When a primary malignancy has been excised but further treatment, such as an additional surgery for the malignancy, radiation therapy or chemotherapy is directed to that site, the primary malignancy code should be used until treatment is completed.
IMP Point Malignancy
This note appears directly under a there-character code title to define further
INCLUDES
**improper elimination & recovery improvement act **legislative act that requires the reporting of the error rate.
IPERIA
no underlying cause can be determined in healthy young adults
Idiopathic osteoporosis
Query the provider to as even though CHF is considered to be chronic, it can be broken down by acute, chronic, or acute on chronic.
If CHF is listed in the problem list, the CDEO should....
Then assign the appropriate code to identify the condition along with code for MRSA B95.62.
If NO combination Code for MRSA
Assign code for abuse
If use and abuse
artificial opening created surgically where a stoma (moth) is formed from the loop end of the small instestine (ileum) through the abdomen, and the stoma is sutured in place. May be reversible or irreversible dependent upon needs. Usually located on right side of abdomen. Common diseases necessitating ileostomy include Crohn's disease, ulcerative colitis, and colorectal cancer. Jejunostomy and duodenostomy are other small intestine artificial openings. Small intestine: 1. Duodenum 2. Jejunum 3. Ileum
Ileostomy
R99 patient who has already died is brought into an emergeny
Ill-defined condition
Require two code one for insertion and another one for insertion of reservoir
Implantable venous access device
Risk Score, which is determined through diagnosis coding
In HCC coding the payment to the Health Plan is based on?
Full Part A and Part B Medicare expenditures
In Predictive Modeling, CMS-HCC predicts?
Expenditures for which Part D sponsors are responsible, i.e., drug costs excluding cost sharing amounts for which the enrollee or the government is responsible for paying.
In Predictive Modeling, the RxHCC predicts?
Never permitted to be used as first- listed or principal diagnosis code.
In diseases classified elsewhere
Classified as obstructed
Incarcerated or strsngulated
Classified as a ventral hernia
Incisional hernia
Note appears immediately under a three character code title to further define, give examples.
Includes Notes
List of terms included under some codes. They are conditions for which the code is to be used.
Inclusion Terms
ICE
Industry Collaboration Effort
the end of the humerus is forced against the acromion causing the arm to lock in an upward and backward position
Inferior dislocation
IPPE
Initial Preventive Physical Examination
IVA
Initial Validation Audit
IVC
Initial Validation Contractor
Use code from ch. 20 to indicate cause of injury
Injuries and burns
Not coded separately if used to achieve the objective of the procedure
Inspection
If using a different approach the inspection is coded seperately
Inspection and another procedure performed at the same time
code first code, if applicable, any causal condition first code also use additional code
Instructional notes that indicated when to use more than one code:
enables the body to use consumed sugars as energy
Insulin
Code the procedure to the root operation performed
Intended procedure discontinued
IRR
Inter-Rater Reliability - measures the degree of agreement among reviewers (coders)
Coded with the device value inter-body device
Interbody fusion
IMG
Intermountain Group
Performance
Invasive mechanical ventilation
loss of bone due to age; aka primary osteoporosis
Involutional osteoporsis
nonuniform in shape
Irregular bones
Probably Forever/Almost ALLS
Is this condition a Probably Forever/Almost ALLS (still has condition even though mediation or device is covering up symptoms), Forever/ALLS, or a Chronic condition? Enteris and Ulcerative Colitis (Categories 555-557)
Probably Forever/Almost ALLS
Is this condition a Probably Forever/Almost ALLS (still has condition even though mediation or device is covering up symptoms), Forever/ALLS, or a Chronic condition? Intestinal Obstruction without mention of Hernia (Category 560)
Probably Forever/Almost ALLS
Is this condition a Probably Forever/Almost ALLS (still has condition even though mediation or device is covering up symptoms), Forever/ALLS, or a Chronic condition? CHF (compensated)
Probably Forever/Almost ALLS
Is this condition a Probably Forever/Almost ALLS (still has condition even though mediation or device is covering up symptoms), Forever/ALLS, or a Chronic condition? Disease of Pulmonary Circulation (Categories 415-47) -Regional
Probably Forever/Almost ALLS
Is this condition a Probably Forever/Almost ALLS (still has condition even though mediation or device is covering up symptoms), Forever/ALLS, or a Chronic condition? Heart Failure (Category 428)
Forever/ALLS
Is this condition a Probably Forever/Almost ALLS (still has condition even though mediation or device is covering up symptoms), Forever/ALLS, or a Chronic condition? Lower limb amputation status (including toe)
Forever/ALLS
Is this condition a Probably Forever/Almost ALLS (still has condition even though mediation or device is covering up symptoms), Forever/ALLS, or a Chronic condition? Malignant Neoplasm (except skin and lip) but including melanoma
Forever/ALLS
Is this condition a Probably Forever/Almost ALLS (still has condition even though mediation or device is covering up symptoms), Forever/ALLS, or a Chronic condition? Residual Late Effects of Stroke
As long as there is no conflict information between from the information from the attending if conflict queried the the attending physician
It is appropriate to base Code assignment on the documentation of other physician
Excludes 1
It means "NOT CODED HERE!" An Excludes1 note indicates that the code excluded should never be used at the same time as the code above the Excludes1 note. An Excludes1 is used when two conditions cannot occur together, such as a congenital form versus an acquired form of the same condition. If two conditions are not related to one another, it is possible to report both codes despite the presence of an Exclude note 1. Ex: Mental disorder (F01-F99) cannot be assigned with the R40-R46 codes but if dizziness (R42) is not component if mental health condition then we can code it separately.
Pneumonia due to adenovirus. What ICD-10-CM code is reported?
J12.0
A patient is admitted to the hospital with pneumonia. Testing indicates the patient's pneumonia is due to Staphylococcus aureus and is methicillin resistant (MRSA). What ICD-10-CM code(s) is/are reported?
J15.212
requires signatures be dated and timed
Joint Commission
keratin, horny layer of skin
Kerat/o
infectious bacterium that can cause destructive changes to human lungs including inflammation/hemorrhage with cell death (necrosis) that sometimes produces thick, bloody, mucoid sputum (currant jelly sputum). Also cause infection in lower biliary tract and surgical wound sites.
Klebsiella Pneumoniae
procedure where fractured bone is rebuilt, however, it only strengthens the vertebrae affected and can often lead to another fractured vertebra above or below the one repaired
Kyphoplasty
Local coverage determinations
LCDs
bad form of cholesterol
LDL
Has a unique category
Labor pneumonia
according to AAPC's Code of EThics, a member shall use only ____ and ____ means in all professional dealings and shall refuse to cooperate with, or condone by silence, the actions of those who engage in fraudulent, deceptive or illegal acts
Legal and ethical
LCSW
Licensed Clinical Social Worker
tough cords that connect bone to bone
Ligaments
Is coded to the root operation extirpation
Lithotripsy with removal of fragments
Admission, examination, history, observation, aftercare, problem, status
Locate z code & external
Admission. Examination history observation aftercare problem status
Locating Z codes and external cause
Code as a subenocardial MI
MI documented as nontransmural or subendocardial with a site provided
Medical Loss Ratio Rule and Reports
MLR
EMPI
MMI (Intermountain member identifier)
Identify disease condition or injuries
Main term
When the patient develops anemia because of the neoplasm and presents for treatment of the anemia, the code for the ________ is listed first, followed by the code for the ______.
Malignancy, anemia
Code to the site of origin mentioned.
Malignant of ectopic tissue
Two or more overlapping sites should be Coded. 8 (overlapping lesion).
Malignant overlapping sites
faulty union of the fragments of a fractured bone
Malunion
MCO
Managed Care Organization
Usually have the phrase in disease classified elsewhere never use as first listed or principal diagnosis
Manifestation code
Supplemental Diagnoses
May be approved if they are documented as current diagnoses in the record. The submission of all diagnoses (with HCCs) are cumulative; therefore, there may be a negative or positive financial outcome in such an audit.
"P" is the SA node's (RT atrium) electical impulse for the heart to pump/beat "QRS" is the ventricular (RT & LT ventricles) response (heartbeat) "T" is the repolarization of electrical energy for the process to repeat itself "PR" Interval "PR" Segment "QRS" Complex "ST" Segment "QT" Interval
Measurement of Heart Rate
An underdose of insulin due to an insulin pump failure should be assigned to a code from subcategory _________________________.,
Mechanical complication of other specified internal and external prosthetic devices, implants and grafts
Classifies to the extracorporeal assistant and performance
Mechanical ventilation non invasive
CDPS
Medicaid Chronic Illness and Disability Payment Systems
MRX
Medicaid RX prescription drug risk adjustment model developed using CDPS information based on combining the CDS and the RxRisk Model
UCSD
Medicaid Rx
Prescription Based Program Risk Adjustment Examples:
MedicaidRx (UCSD) RxGroups (DxCG) Medicare Hierarchical Condition Category, Part D (RxHCC) Health and Human Services Hierarchical Condition Category (HHS HCC)
MRA
Medical Risk Adjustment
Assign only sickle cell disease
Medical record both sickle cell disease and sickle cell trait
MA
Medicare Advantage
MAO
Medicare Advantage Organization
Processes payments to plans and issues the MMR (Monthly Membership Report) and MOR (Model Output Report).
Medicare Advantage Prescription Drug System (MARx)
HCC-C
Medicare Hierarchical Condition Category Part C
Diagnoses reported in the prior year and demographic information are utilized to "predict" future costs and adjust payments accordingly
Medicare risk adjustment model is prospective. This means?
Is code to F01-F09
Mental disorders
growth plate region
Metaphysis
Code with device value autologous tissue subsitute
Mixture of autologous and non autologous bone graft
MEAT
Monitor, Evaluate, Assess/Address, Treat
progression from long-term mononeuropathy beginning to radiate to other nearby nerves
Mononeuritis Multiplex
compression of single nerve, with 1 location numb/tingling
Mononeuropathy
__________ is paralysis of one limb.
Monoplegia
Anxiety disorder, bipolar disorder, and depression, among others
Mood affective disorders include
For example: renal cell carcinoma arises in the kidney
Morphology can lead to primary site
A separate procedure is coded for each coronary artery site that uses a different device and/or qualifier
Multiple coronary artery sites bypassed
documentation includes number of gestations, number of amniotic sacs, and number of placentae
Multiple gestation
Same site that are not contiguous (tumors in different quadrant of the same breast) code for each site.
Multiple malignant
Body part that specifies the entire area inspected is coded
Multiple non-tubular parts inspected in a region
a) if the same root operation is performed on different body parts b) the same root operation is repeated at different body sites that are included in the same body part value c) multiple root operations with distinct objectives are performed on the same body part d) the intended root operation is attempted using one approach, but is converted to a different approach.
Multiple procedures during the same operative episode
Code the most distal part inspected
Multiple tubular parts inspected
Separate procedure is coded for each vertebral joint that uses a different device and/or qualifier
Multiple vertebral joints fused
heart attack, blockage occurred in the normal pathway of the heart, different from cardiac arrest, meaning the heart stopped beating due to an electrical conduction problem
Myocardial Infarction (MI)
A patient sees the nephrologist for a B-12 injection to treat erythropoietin resistant anemia due to stage 3 chronic kidney disease. What ICD-10-CM codes are reported?
N18.3, D63.1
An elderly male patient presents to the ED complaining of a high fever the day prior to the encounter and of extreme lethargy. He has a history of benign hypertension which has been elevated. On arrival he was examined by his primary care physician and admitted, with possible septic urinary tract infection and concern for his elevated blood pressure. He was noted to have hematuria and a urine culture performed. Positive UTI and pseudomonas showed in the urine culture and IV antibiotics were administered. During the course of the day, his fever decreased and his lethargy improved. As the IV fluids were decreased, he resumed a benign hypertensive state. On the next hospital day, his primary care physician noted the urine was clear and he was discharged on oral antibiotics, with septicemia ruled out. What ICD-10-CM codes should be reported?
N39.0, B96.5, I10
CMS National Coverage Determinations
NCDs
Not elsewhere classifiable - ICD-10-CM system does not provide a code specific for patient's condition
NEC
Not elsewhere classified
NEC
Not elsewhere specified - equivalent to "unspecified"
NOS
Not otherwise specified
NOS
plaque or blockage only partially occludes the coronary artery and only a portion of the heart muscle being supplied by the affected artery dies.
NSTEMI
1. Encourage patients to go to the doctor for AWV/HRA annually 2. Periodic chart audits with payback of reimbursement associated with unsupported coding 3. Audit your diagnosis codes
Name 3 ways to maximize Risk Scores?
NCQA
National Committee for Quality Assurance
NDC
National Drug Codes
Fracture together
Never code traumatic and pathological
Code left and right No side identified assign the code for unspecified
No bilateral
convulsions, new-onset seizure, single seizure, seizures (w/o mention of disorder/recurrent), febrile seizure, and hysterical seizure
Non-Epileptic Seizures
break in a bone due to weakening of the bone from a disease or condition without trauma
Non-Traumatic Pathological Fracture
To the extraction or to the root irrigation when perform by irrigating
Non-excisional debridements
failure of the ends of a fractured bone to unite
Nonunion
all complexes are normal, evenly spaced, with a rate of 60-100 beats per minute
Normal Sinus Rhythm (NSR)
O80
Normal delivery code
Z34 no code from chapter 15
Normal routine pregnancy
MedicAl treatment develop during hospitALIZation
Nosocomial infection
Additional code of Y95
Nosocomial infections
When a specific code is not available for a condition the alphabetic index directs the coder to the other specified code in tabular list.
Not elsewhere classified
Unspecified code
Not otherwise specified
Used to define terms, clarify information, or list choices for additional characters in the Tabular List
Notes
NP
Nurse Practicianer
NP
Nurse Practitioner
sever form of malnutrition with sever, overall wasting from lack of nutrients and common in underdeveloped countries.
Nutritional Marasmus
Always first diagnosis no complication can be present
O80
Embolization to completely close a vessel
Occlusion
OT
Occupational Therapist
OIG
Office of Inspector General
RADV
Only Part C HCCs are audited here health plans submit up to five best records from an acceptable treating provider, demonstrating those diagnoses as current in the year being audited that support the HCC values that were paid
F
Only code N40.1 is assigned for enlarged prostate with nocturia.
F
Only one code is reported for anemia of chronic disease.
When coding septic shock, first code the systemic infection followed by R65.21 or
Organ function
integumentary, musculoskeletal, cardiovascular, lymphatic, respiratory, digestive, urinary, reproductive, nervous, organs of sense, endocrine, hematologic, immune
Organ systems
OREC
Original Reason for Entitlement
Low bone mass; t score -1.0 to -2.5
Osteopenia
very low bone mass; t score -2.5 or lower
Osteoporosis
are used when the information in the medical record provides detail for which a specific code does not exist
Other
________________ is any inflammation of the middle ear without reference to etiology or pathogenesis.
Otitis media (OM)
The body part with the deepest layer is coded
Overlapping layers
subsequent encounter for fracture with MALunion
P
a) Present at the time the order for inpatient admission occurs b) Develop during outpatient encounter (emergency, observation, surgery)
POA
Y= present at time of inpatient admission N= not present at the time of admission U= documentation is insufficient to determine if condition is present on admission W= provider is unable to clinically determine whether condition was present on admission or not
POA Definitions
Patient Protection and Affordable Care Act
PPACA
Maybe used in conjunction with pain other pain code maybe used as principal diagnosis
Pain in category G89
Type of aplastic anemia that represent a deficiency of all three elements of the blood
Pancytopenia
_________ is the paralysis of both lower limbs.
Paraplegia
Are used to enclosed supplementary words or explanatory information that may either present or absent without affecting the code (non essential
Parentheses
Enclose supplementary terms. Terms within the parentheses are referred to as nonessential modifiers.
Parentheses ( )
Bones that are weakened by disease
Pathological fracture
PMH
Patient Medical History
ACO QA Measures Domain 3
Patient Safety
Code for non-related condition should be principal diagnosis, B20 HIV, then code all reported HIV related conditions.
Patient admitted for HIV non-related condition
The principal diagnosis should be B20, HIV followed by additional diagnosis codes for all reported related conditions.
Patient admitted for HIV related condition
1/3 Core Principles of ACOs
Payments are linked to quality improvements that also reduce overall costs and use
PMPM
Per Member Per Month
Is coded to the root operation extirpation
Per cutaneous nephrostomy
EDGE server Data Evaluation Metrics
Percent of all enrollees with at least one HCC1 Risk Adjustment - Average number of conditions per enrollee with at least one HCC Issuer average risk score Reinsurance - Percent of individual market enrollees with reinsurance payments Average reinsurance payment per enrollee receiving reinsurance payments
dislocations of certain joints are further classified by the extent based upon percentage of the dislocation
Percentage
If using per cutaneous approach it is coded as bypass
Peritoneal
external bag of ingredients is attached to the patient's abdomen and an exchange occurs through osmosis to pull out waste and fluid from te patient
Peritoneal Dialysis
PT
Physical Therapist
PA
Physician Assistant
PLRS
Plan Average Liability Risk Score
Accumulation of fluid within the pleural may principal diagnosis if treatment is for pleural effusion
Pleural effision
Administered, taken or prescribed incorrectly Alcohol in conjunction with a drug Street drugs resulting in overdose Street drugs in addition to OTC or prescription meds. Two OTC drugs used together
Poisoning
improper use of a medication including overdose, wrong substance given or taken in error, wrong route of administration, interaction of drug(s) and alcohol
Poisoning
involves 2 or more locations, usually symmetrical (both hands, both arms, both feet, both legs)
Polyneuropathy
Condition should be code as established diagnosis
Possible, probable, suspected, likely, questionable or rule out
the end of the bone is displaced posterior to the joint and its normal anatomic position
Posterior dislocation
due to the lack of estrogen, leading to bone resorption at a faster rate than the production of new bone (type 1 osteoporosis)
Postmenopausal osteoporosis
The prospective application of risk measures along with statistical techniques to identify "high risk" individuals who greatly would benefit from targeted care management interventions, such as being moved to a SNP. It provides a potential RAF score for each claim, which can in turn be used to target claims which indicate a "suspect" patterns.
Predictive Modeling
abnormal condition in pregnancy that involves high blood pressure and a high level of protein in the urine
Preeclampsia
PDP
Prescription Drug Plan
injuries to skin and underlying tissues that result from prolonged pressure on the skin
Pressure ulcers
ACO QA Measures Domain 4
Preventative Health
PCP
Primary Care Physician
Previously excised and no further treatment or existing malignant code Z85 personal history of malignant.
Primary malignant previously excised
Is where the cancer arises
Primary site of neoplasm
PFFS
Private Fee for Service
Approach is via natural or artificial opening
Procedure describe as transurethral
Code the root operation inspection of the body part or anatomical region inspected
Procedure discontinued before root operation is performed
PACE
Programs for All inclusive Care for the Elderly
PHI
Protected Health Information
form of malnutrition characterized by lack of protein, can be life-threatening, and a complication of AIDS, CKD< inflammatory bowel disorders, and other illnesses
Protein Calorie Malnutrition (PCM) "Protien Energy Malnutrition (PEM)"
blockage of the main artery of the lung or one of its branches by an embolism
Pulmonary Embolism (PE)
increase in pressure of the pulmonary artery, veins, or capillaries
Pulmonary Hypertension
_________ is paralysis of all four limbs.
Quadriplegia
QHP
Qualified Health Plan
Edge Servers
Qualified health plans participating in the Health Exchange (HIE) under the ACA had to set up and Edge server for sharing data with the CMS. The Edge servers offer detailed data on the health plans while protecting patients through de-identification. The servers are secure, and are walled off from all other health plan data with data flowing in one direction; from the health plan to HHS.
QBP
Quality Bonus Payment
A patient is brought in by the ambulance with seizures. After examination and workup is complete, it is determined the seizures were due to alcohol abuse with intoxication. What ICD-10-CM code(s) is/are reported?
R56.9, F10.129
Can never be assigned principal diagnosis
R65.2
Code ____ can never be used as principal diagnosis.
R65.2
Severe sepsis is associated with acute organ dysfunction. A minimum of two codes are required. Code underlying condition first, followed by a code from subcategory ______ depending on what is documented.
R65.2
If a patient has sepsis and an acute organ dysfunction, but the medical record documentation indicates that the acute organ dysfunction is related to a medical condition other than the sepsis, do not assign a code from subcategory ____________________. An acute organ dysfunction must be associated with the sepsis in order to assign the severe sepsis code.
R65.2, Severe sepsis
When a patient has a blood test for HIV that is inconclusive, what ICD-10-CM code is assigned
R75
Inconclusive labortory evidence of human immunodeficiency virus (HIV)
R75 (HIV)
Risk Adjustment
RA
**face to face encounters **approved provider **provider signature/authentication **provider printed name & credential **date of service **documentation supports diagnosis **diagnosis part of medical decision making
RA Coding Steps
determines if diagnosis codes are supported by medical documentation
RADV
risk adjustment data validation
RADV
2 types **medical record review **payment error calculation
RADV appeals
one best medical record submitted and audited by RADV/IVC (initial validation contractor) 30 days to appeal from date of RADV report
RADV appeals: medical record review
additional documentation allowed 30 days to appeal from date of RADV report 3rd party that was not involved in initial audit will review hearing can be requested
RADV appeals: payment error calculation
**beneficiary must be enrolled in MA plan from January of data collection year through January of payment year **enrollment must be continuous **non-ESRD beneficiaries **non hospice status **must have atleast one HCC **must also be enrolled in Medicare part B
RADV eligibility
**face to face **approved provider **correct dos **signed and credentialed **inpatient record must have admission and discharge date (full record) **outpatient record (one dos)
RADV one best record
**one best record for each HCC being validated --replacement record can be submitted up until the deadline. --CMS will audit last record submitted
RADV record submission
**2 year lag --year one: data collection year --year two: payment year --year three: RADV conducted error rate reported **12 weeks to complete (from time selected members revealed) **retrospective (after payment made)
RADV timeline
2 types of RADV: **national **targeted
RADV types
Provides a summary of all diagnoses stored for a given time period.
RAPS Monthly Plan Activity Report and Cumulative Plan Activity Report
This is a daily report that shows all records approved and where errors occurred.
RAPS Return File
Daily reports that shows all records approved and where errors occurred.
RAPS Return file
Displays records on which errors occurred.
RAPS Transaction Error Report
A report sent to the MA organization daily and identifies data that have been finalized in RAPS database
RAPS Transaction Summary Report
Stores all finalized diagnosis clusters
RAPS database
contained within nucleus, transcribed from DNA by enzymes and plays crucial role in protein synthesis
RNA (ribonucleic acid)
RBIS
Rates and Benefits Information System
a) Of displaced fracture; coded to the root operation b) reposition and the application of a cast or splint; reposition is not coded separately c) non displaced fracture is coded to the root operation immobilization in the placement section
Reduction
There is no time limit on sequelae
Referencing ICD-10-CM guidelines, section I.B.10, what is the time limit when assigning codes as "sequela?"
Check the ICD-10-CM Index to Diseases and Injuries to see if there are listings under "threatened" or "impending" and if not, code the existing underlying condition(s) rather than the condition described as impending.
Referencing ICD-10-CM guidelines, section I.B.11, what is the appropriate action with a physician documents an impending condition that had not occurred by the time of discharge?
Code the acute condition first, followed by the chronic condition
Referencing ICD-10-guidelnes, section I.B.8, when a patient presents with an acute and chronic condition, and no single code captures both the chronic and acute nature of the illness, how are the codes sequenced?
RI
Reinsurance
Freeing a body part without cutting
Relaease
Body part being freed is coded not the tissue being manipulated
Release procedure
1/3 Core Principles of ACOs
Reliable and progressively more sophisticated performance measurements to support improvement, and provide confidence that savings are achieved through improvements of care.
Root operation extirpation
Removal of biliary ducts
Only report code once if no distinct codes identifying laterality.
Reporting same diagnosis code more than once
All of a specific body part is cut out or off
Resection
Confirm patient dependence and do not report b/c of a planned procedure/surgery
Respirator/Ventilator Status
Code exposure to tobacco
Respiratory condition
Coded to the lower anatomic location
Respiratory condition occurring in more than one place
Embolization to narrow the lumen of a vessel
Restriction
cerebrovascular infarction that lasts more than 24 hours, but less than 72 hours
Reversible Ischemic Neurologic Deficit (RIND)
antibody in the blood that is present for most people with RA
Rheumatoid factor (RF)
Three R's
Risk Adjustment Risk Corridor Reinsurance
RADV
Risk Adjustment Data Validation
RADVI
Risk Adjustment Diagnosis Validation
RAF
Risk Adjustment Factor
Calculates risk scores for all beneficiaries with available data
Risk Adjustment Model
RAPS
Risk Adjustment Processing System
Executes the risk adjustment model and calculates the risk score using the SAS model.
Risk Adjustment System (RAS)
RAUF
Risk Adjustment User Fees
noted elements about a patient's known medical history or social habits that may place the patient at risk to develop a condition.
Risk Factors
Measures individual beneficiaries' relative risk and are used to adjust payments for each beneficiary's expected expenditures.
Risk Scores.
Progressive prolongation of PR interval with dropped beats (the PR interval gets longer and longer, and finally 1 beat drops
Second Degree AV Block ("Mobitz I," "Type I," "Wenkebach")
PR interval remains unchanged prior to the P wave, which suddenly fails to conduct to the ventricles
Second Degree AV Block ("Mobitz II," "Type II," "Hay")
burns involved the epidermis and dermis, typically blisters
Second degree burns
health problems which damage, injur, interfere with, or destroy the pancreas -chronic pancreatitis (occurs when digestive enzymes attack and destroy the pancreas. Main cause is alcoholism, blocked or narrow pancreatic duct due to some form of trauma or cyst, and heredity) -Cushing's disease (hormonal disorder caused by prolonged exposure of the body's tissues to high levels of hormone cortisol spontaneously produced by the adrenals, or by excessive use of cortisol or other similar steroid hormones (steroids to treat asthma, RA, lupus, inflammatory bowel disease, etc) -Cystic fibrosis - genetic disease that causes the incapacitation of the pancreas by fibrosis and can lead to the development of DM 2 -Adenocarcinomas - cancers that begin in cells that line the inside of organs. Almost all pancreatic cancers are of this type -Drugs (chemically induced diabetes)
Secondary Diabetes
SVA
Secondary Validation Audit
_______________ is a type of diabetes caused by something other than genetics or environmental factors. It is always caused by another condition or event.
Secondary diabetes
Codes under categories E08, Diabetes mellitus due to underlying condition, E09, Drug or chemical induced diabetes mellitus, and E13, Other specified diabetes mellitus, identify complications/manifestations associated with secondary diabetes mellitus. Secondary diabetes is always caused by another condition or event (e.g., cystic fibrosis, malignant neoplasm of pancreas, pancreatectomy, adverse effect of drug, or poisoning).
Secondary diabetes mellitus
When cancer leaves the original site
Secondary neoplasm
directs you to a more specific term where correct code can be found
See
indicates additional information is available that may provide an additional diagnostic code
See also
Instruction for See" is mandatory you cannot code without following
See"
fracture in which the bone breaks into two or more large pieces at the fracture site
Segmental fracture
SH
Select Health
SSD
Selected Significant Disease Model
T
Selection of "in remission" for categories F10-F19 requires the provider's clinical judgement.
The employer or other plan sponsor pays the cost of health benefits from its own assets.
Self-funded plans
thinning of both the cortical and trabecular bone typically occurs after age 70 (type II osteoporosis)
Senile osteoprosis
SIRS due to infection a severe case indicates organ dysfunction
Sepsis
Sepsis For a diagnosis of sepsis, assign the appropriate code for the underlying systemic infection. If the type of infection or causal organism is not further specified, assign code A41.9, Sepsis, unspecified organism.
Sepsis
If the type of infection or causal organism is not further specified, assign code A41.9. Sepsis, unspecified organism.
Sepsis A41.9
Code first localized infection follow if severe sepsis develop after admission code it second
Sepsis and severe sepsis with a localized not present on admission
Code first underlying condition follow by localized followed by localized infection,
Sepsis and severe sepsis with a localized on admission
Systemic infection sequenced first, followed by code R65.21, severe sepsis with septic Shock or, T81.12, postprocedural septic shock. *septic shock can not be assigned as a principal diagnosis.
Septic Shock Code
Refers to circulatory failure associated with severe sepsis, and therefore, it represents a type of acute organ dysfunction.
Septic Shock def
Circulatory failure associated with severe sepsis
Septic shock
Underlying infection + R65.1
Septic shock
Systemic disease associate with pathological microorganism or toxins in the bloodstream
Septicemia
Conditions or complications that arise as a direct result of the injury; osteonecrosis ,posttraumatic osteoarthritis, necrosis of bone
Sequela of fractures
The residual condition (sequela) is coded first, and the code(s) for the cause of the sequela are coded secondary.
Sequelae (Late Effects)
A residual effect (condition produced) after the acute phase of an illness or injury has terminated.
Sequelae (late effects)
May occur at any time require two code, condition or nature of late effect or late effect code (second second)
Sequelae or late effect
Admitted for HIV- B20 A/D unrelated- unrelated first then B20 Asymptomatic HIV- Z21 Inconclusive HIV- R75 Previously diagnosed- B20 HIV in pregnancy- O98.7 Asymptomatic HIV in pregnancy- O98.7 + Z21 Encounters for testing of HIV- Z11.4 Return visit for negative test results- Z71.7
Sequencing HIV codes
Respiratory illness caused by a corona virus begin with fever may include chills headache malaise Z20.828,B97.21, J12.81
Severe acuterespiratory syndrome (SARS)
Coding require a minimum of two code underlying infection first followed by a code from subcategory R65.2 severe sepsis additional code for the organisms should be code
Severe sepsis
Coding severe sepsis requires a minimum of 2 codes: first a code for the underlying systemic infection, followed by a code for the subcategory R65.2, severe sepsis.
Severe sepsis
Underlying infection + R65.2
Severe sepsis
approximately as wife as they are long; carpals and tarsals
Short bones
extremely slow, or persistently-below-normal heart rate due to a malfunctioning SA node. Repairable by pacemaker placement
Sick Sinus Syndrome (SSS)
The disease is passed to a child when both parents carry the genetic trait
Sickle cell anemia or disease
Do not generally develop sickle cell disease they carry the trait
Sickle cell trait
The disease is passed to a child when one parent carry the genetic trait
Sickle cell trait
Chapter 18
Sign and symptom
Should a patient with signs and symptoms is being seen for HIV testing, what should be coded while waiting on the results?
Signs and symptoms
Manifestation
Signs and/or symptoms of an underlying disease, not the disease itself, and therefore, cannot be a principal diagnosis.
located in upper right quadrant of heart and is the pacemaker of the heart. Sends electric signal that prompts the heart to contract/pump. When signal is blocked/interrupted/sent too frequently or infrequently/ventricular response is out-of-sync, conduction disorders occur
Sino Atrial (SA) Node
...... Family or personal history of skin cancers should always be documented and reported.
Some forms of cancer are prone to recur or have a familial predominance....
a fracture in which the bone has been twisted apart
Spiral fracture
Are always pathological
Spontaneous fracture
Tear or stretch of the ligament
Sprains
To enclosed synonyms , alternative wording, abbreviation and explanatory that provide additional information or can also be used to indicate that the number in the bracket can only be a manifestation
Square brackets
occurs with physical exertion, lasts for short time, is relieved by rest and/or medicine, and does not present as a surprise to the patient as all episodes tend to be alike in presentation and the pain is always the same level Symptoms: -occurs when the heart must work harder (physical exertion) -doesn't come as a surprise, and episodes of pain tend to be alike -usually lasts a short time (5 min or less) -relieved by rest/medicine -may feel like gas/indigestion -may feel like chest pain that spreads to the arms, back, or other areas
Stable Angina
intact skin with nonblanchable redness
Stage 1 pressure ulcer
partial thickness skin loss involving epidermis, dermis, or both
Stage 2 pressure ulcer
full thickness tissue loss with visible fat
Stage 3 pressure ulcer
Full-thickness tissue loss with exposed bone, muscle, or tendon
Stage 4 pressure ulcer
ANSI 837
Standard format used by industry to transmit electronic health care claims
varicose veins of the lower extremities
Stasis Ulcers
SADMERCS
Statistical Analysis Durable Medical Equipment Regional Carriers
acute severe exacerbation or not responding to normal treatments
Status Asthmaticus
1. Look up morphology 2. No primary site code- use neoplasm table 3. If the term metastatic is used assume these are secondary sites: Bones, brain, diaphragm, heart, liver, lymph nodes, mediastinum, meninges, peritoneum, pleura, retroperitoneum, spinal cord, and sites from C76
Steps for coding neoplasms
presence of a stoma may be an indicator that there is an artificial opening. Derivative from Greek word meaning mouth and have suffix of "-ostomy" and begin w/prefix to identify the organ site or area where stoma connected
Stoma
injury to the muscle and/or tendon
Strains
result of a major lack of blood flow due to blockage or hemorrhage
Stroke
SOAP Notes
Subjective: describes patient problem/illness Objective: physician observation Assessment: patient's current conditions and status Plan: treatment, referrals, prescriptions, referrals, education
partial or incomplete dislocation of joint
Subluxation
receiving routing care for the fracture during the healing or recovery phase; routine cast changes or removal, removal of external or internal fixation device, medication adjustment, other aftercare and follow-up visits
Subsequent Encounter
Code from I22 and I21
Subsequent MI within 4 weeks of initial
Indicate site, type, or etiology
Subterms
Unacceptable Types of Medical Record Documentation
Superbills Physician-Signed Attestations Lists of Patient Conditions Outside of Medical Record Documentation Diagnostic Reports That Have Not been Interpreted Any Documentation For Dates of Service Outside the Data Collection Period
They do not affect code assignment
Supplementary words enclosed in parentheses in the ICD-10-CM codebook have what effect on the coding? Refer to ICD-10-CM guidelines, section I.A.7.
Acute life threatening upper respiratory infection
Supraglottitis
faster than normal heart rate originates at or above the atrioventricular node (AV). Atrial Fibrillation and paroxysmal supraventricular tachycardia (PSVT) are types of SVT.
Supraventricular Tachycardia (SVT)
It is customary to perform a biopsy first before the definitive surgery. Definitive surgery is sequence first follow by biopsie
Surgery of breast is performed for neoplasm
Identifies members with suspected and undocumented conditions. Suspected conditions are based on prescribed medications, previously reported conditions, DME, lab tests, therapy, etc. Undocumented conditions are diagnosis codes that link to an HCC, but for which there is no M.E.A.T. that supports reporting it in the chart.
Suspect Generation
The symptom code is code first
Symptoms followed by contrasting / comparative diagnoses
Sepsis and severe sepsis require a code to identify the ________ _________. If documentation does not include the casual organism, report A41.9 Sepsis, unspecified organism.
Systematic infection
reaction to infection, trauma, burns, or other bodily assault or severe dx and presence of known or suspected infection
Systemic Inflammatory Response Syndrome (SIRS)
Condition is due to poisoning (T36-T65) is sequence first if for adverse effect (T36-T65) sequence second
T36-T65
Four years post hepatic transplant, the patient is diagnosed with combined hepatocellular carcinoma and cholangiocarcinoma of the liver. What ICD-10-CM codes are reported?
T86.49, C80.2, C22.0
Chronic-illness Disability Payment System is a Medicaid program used to make health-based capitated payments for
TANF and disabled Medicaid beneficiaries
Fast heart rate
Tachycardia
TANF
Temporary Assistance for Needy Families
strong cords that attach muscle to bone at the point of insertion
Tendons
F
The codes for hypertension with chronic kidney disease stage 4 are I10, N18.4.
F
The coding of late effects (or sequela) always requires two codes.
F
The correct sequencing for severe sepsis with MRSA and acute respiratory failure is: R65.20 + J96.00 + A41.02.
T
The correct sequencing of early onset Alzheimer's disease with dementia is G30.0 followed by F02.80
Middle
The ear has three main portions, otitis media occurs in the _________ ear
CDPS
The goal is to capture all current diagnoses, but also to include all known status codes, to include family history codes, when appropriate (these are often used in their model suspect logic.)
According to ICD-10-CM guidelines, when a patient is seen for management of anemia due to malignancy, how is it reported?
The malignancy is reported first, followed by the code for the anemia.
J96.01
The patient arrived to the hospital in acute respiratory failure and hypoxia. The patient was intubated, and the physician documents that the patient is being admitted to the hospital for treatment of the acute respiratory failure with hypoxia. The patient also has congestive heart failure. Mechanical ventilation was provided for 48 consecutive hours. Code the principal (first-listed) diagnosis.
5A1945Z
The patient arrived to the hospital in acute respiratory failure and hypoxia. The patient was intubated, and the physician documents that the patient is being admitted to the hospital for treatment of the acute respiratory failure with hypoxia. The patient also has congestive heart failure. Mechanical ventilation was provided for 48 consecutive hours. Code the procedure for the mechanical ventilation.
I50.9
The patient arrived to the hospital in acute respiratory failure and hypoxia. The patient was intubated, and the physician documents that the patient is being admitted to the hospital for treatment of the acute respiratory failure with hypoxia. The patient also has congestive heart failure. Mechanical ventilation was provided for 48 consecutive hours. Code the secondary diagnosis.
K81.2
The patient has acute and chronic cholecystitis and underwent a laparoscopic total cholecystectomy. Code the principal (first-listed) diagnosis.
0FT44ZZ
The patient has acute and chronic cholecystitis and underwent a laparoscopic total cholecystectomy. Code the procedure.
F
The presence of CKD in a patient that has had a kidney transplant indicates that there is the complication of rejection.
Causality
The relationship between cause and effect. - the principle that everything has a cause - the relation between one process (the cause) and another (the effect), where the first is understood to be partly responsible for the second. In general, a process has many causes, which are said to be causal factors for it, and all lie in its past.
Risk Corridor
The risk corridor provision protects insurers against the uncertainty in rate-setting in the first three years by limiting large losses or profits.
T
The stage of a pressure ulcer may be assigned based on nursing documentation.
Reinsurance
The transitional reinsurance provision will stabilize premiums for coverage in the individual and small employer group markets by protecting health plans that experience unpredictable, high-cost conditions during the first three years of the Exchange.
F
There are a minimum of three codes reported for an underdose of insulin due to insulin pump failure.
1/3 Core Principles of ACOs
They are provider-led organizations with a s strong base of primary care that are collectively accountable for quality and total per capita across the continuum of care for a population of patients
No association between P waves and QRS complexes
Third Degree AV Block (Complete)
0B5J4ZZ
This 58-year-old male patient has carcinoma of the left lower lung lobe. A thoracoscopic ablation of the left lower lung lobe was performed. Code the procedure.
NCQA's Committee on Performance Measurement
This is a broad spectrum collaborative effort that combines folks from various employer groups, consumers, health plans and more, to analyze, review and collectively decide on what content make the grade for HEDIS. Together, the group governs which HEDIS measures will be included annually and delineates what field tests will determine the measures matrix.
Illegally Induced (636)
This type of Abortion is not performed in a accordance w/provisions of state law or not meeting regulartory requirements . Performed outside of the hospital.
Failed (638)
This type of Abortion is one in which an elective abortion px has failed to evacuate or expel the fetus and the patient is sitll pregnant.
Spontaneous (634)
This type of Abortion occurs wo any instrument or chemical intervention.
Legally induced (635)
This type of Abortion performed for either therapeutic or elective termination of pregnancy (elective abortion, induced, artificial, termination of pregnancy)
No entry in the index code the presenting condition if there is an entry code it
Threatened / impending
Category
Three-character ICD-10-CM codes represent what level of code in the ICD-10-CM?
Should a condition originate in the perinatal period, and continue throughout the life of the patient, should the Perinatal code be used throughout the life of the patient of or should the perinatal code be discontinued after delivery.
Throughout life of the patient
1. Body temperature is above 101 F or below 96.8 F 2. Heart rate higher than 90 beats per minute 3. Respiratory rate higher than 20 breaths per minute
To be diagnosed with sepsis, two of the following symptoms must be present:
a harmful substance is ingested or a person comes in contact with it
Toxic effects
Caused by bacteria infection, symptoms include high fever vomiting watery diarrhea myalgia hypotension
Toxic shock syndrome
surgically created opening into the trachea (windpipe) to establish an airway or remove secretions
Tracheostomy
temporary loss of blood flow without any infarction (cell death), aka mini-strokes. Possible to experience silent TIA, where damage/losses of blood flow occur with no noticeable symptoms
Transient Ischemic Attack (TIA)
a) Putting in a mature and functioning living body part taken from another individual or animal b) putting in autologous or non-autologous cells is coded to the administration section
Transplantation
Is code to via natural or artificial opening endoscopic
Transurethral endoscopic
complete fracture that is straight across the bone at right angles to the long axis of the bone
Transverse fracture
If the treatment is directed at the malignant, designate the malignant as the principal diagnosis.
Treatment at the malignant
Patient admission/encounter is solely for chemotherapy, immunotherapy, or radiation therapy.
Treatment at the malignant (exception)
Caused by Mycobacterium tuberculosis and mycobacterium bovis spread through the air A15-A19
Tuberculosis
To a group of serious life threatening metabolic, can occur after antineoplastic therapy leukemia and lymphomas when cancer cell is destroy they can release intra cellular ions and metabolic into the circulation
Tumor lysis syndrome
A combination code is a single code used to classify: ____________________________, , or _________________________, and _______________________.
Two diagnoses, A diagnosis with an associated secondary process (manifestation), A diagnosis with an associated complication
CMS HCC Model Interactions
Type 1 Interaction Disease Interaction: Disease combinations can increase an individual's medical costs; may be 2 or 3 diseases in an interaction.
spontaneous MI related to ischemia due to a primary coronary event such as plaque erosion and/or rupture fissuring, or dissection. Prototypic heart atk.
Type 1 MI
secondary to ischemia due to decreased supply or increased demand (i.e. coronary artery spasm, coronary embolism, anemia, arrhythmias, HTN, hypotension)
Type 2 MI
If the type of diabetes mellitus is not documented in the medical record the default is E11.-, _________________.
Type 2 diabetes mellitus
If the documentation in a medical record does not indicate the type of diabetes but does indicate that the patient uses insulin, code E11-, _____________________. An additional code should be assigned from category ____________________ to identify the long-term (current) use of insulin or oral hypoglycemic drugs.
Type 2 diabetes mellitus, should be assigned, Z79
sudden unexpected cardiac death including cardiac arrest often with symptoms of ischemia accompanied by new ST elevation or new LBBB or evidence of fresh thrombus in a coronary artery
Type 3 MI
MI associated with revascularization procedures
Type 4a-4c MI
MI associated with coronary artery bypass graft surgery
Type 5 MI
Code first underlying condition (gangrene etc)
Ulcer
pathologist reviewed cancer sample and is not sure benign/malignant. Only code when documented by pathology
Uncertain
1. Aggregate premiums 2. Claims experience 3. Quality improvement expenditures 4. Non-claims costs incurred in the Large Group, Small Group and Individual markets
Under MLR, for each state in which health insurers write coverage, they must submit data on 4 elements. They are:
taking less of a medication than is prescribed by a provider or a manufacturer's instruction
Underdosing
UHDDS
Uniform Hospital Discharge Data Set
Does not apply to the coding of outpatient
Uniform hospital discharge data set
are used when the information in the medical record is not available for coding more specifically
Unspecified
working diagnosis and not yet defined
Unspecified
caused/complicated by CAD and associated with increased risk of MI. Considered an acute condition with life-threatening consequences and American College of Cardiology and the American Heart Association guidelines recommend initial treatment in ED. Some orgs have rule that unless patient evaluated in office prior to being sent to ER for treatment, unstable angina should not be coded in office setting. Some providers document as ongoing chronic condition b/c occurs 'at rest' or document b/c of seriousness and historical complications for the patient Symptoms: -oft occurs while you may be resting, sleeping, or with little physical exertion -comes as a surprise -may last longer than stable angina -rest/medicine usually do not relieve it -may get worse over time -can lead to heart attack
Unstable Angina
Specifies body parts above or below the diaphragm respectively
Upper and lower body parts
An additional code should be used after a primary code to provide a more complete picture of the diagnosis
Use additional code
Note is found at the etiology code or underlying condition
Use additional code
This code may be assigned as a diagnosis when the causal condition is unknown or not applicable
Use additional code, if applicable
Each healthcare encounter should be Coded to the level of certainty known for that encounter.
Use sign/Symptoms and unspecified Codes
Assign code for dependence
Use, dependence
Assign code for dependence
Use, dependence, abuse
Extraction
Vaginal delivery assistance with forceps vacuum internal version
VRP
Value Recognition Program (IH program)
result of deformed valves in the veins which leave affected veins engorged and painful
Varicose Veins
uncoordinated contraction of the cardiac muscle of the ventricles in the heart, making them "quiver" rather than contract properly and is life-threatening condition requiring immediate attention. Treatable with cardioversion (shock treatment), medication, and Automatic Internal Cardiac Defibrillator (AICD), which is special pacemaker that can monitor for problem rhythms and shock the patient when necessary.
Ventricular Fibrillation (V-Fib)
arrhythmia, tachycardia, that affects the ventricles with a rate of over 200 beats per minute and considered a transition between ventricular tachycardia and fibrillation. Considered a critically unstable arrhythmia that can result in sudden cardiac death. Treatable with cardioversion (shock treatment), medication, and Automatic Internal Cardiac Defibrillator (AICD), which is special pacemaker that can monitor for problem rhythms and shock the patient when necessary.
Ventricular Flutter (V-Flutter)
bones of the spine become broken due to trauma
Vertebral compression fracture
One code supplement root code
Vertebroasty
Z3A
Weeks of gestation code
Bite of mosquitos fever, headache, body ache elderly patient or those weakened immune system the virus may cause encephalitis meningitis or permanent neurological damage A92.3
West Nile virus fever
Delivery Dx code (6xx) Outcome of Delivery (V2x.xx) Px code (73.59 if not other px was performed)
What 3 codes do delivery patients always have to have?
1. Retrospective and concurrent utilization review 2. Most fraud prevention activities (beyond those that recover incurred claims) 3. Provider network contracting and management costs 4. Provider credentialing 5. Costs associated with calculating and administering enrollee/employee incentives 6. Clinical data collection without data analysis 7. Claims adjudication expenses 8. Marketing expenses 9. Broker commissions
What 9 items are not considered part of medical costs, and are considered administrative costs:
1. HCC Description 2. Last rendering provider name 3. Last rendering provider specialty 4. Last DOS 5. Suspect Provider Name 6. Suspect Provider Specialty 7. Last Suspect provider visit 8. Current Year HCC 9. Projected Next Year Dropped 10. Projected Next Year New 11. Reoccurring
What are the 11 key components on a Suspect Generation List that MA plans rely on their coders to look for when reviewing charts?
Annual Wellness Visit
What does AWV stand for?
Model Output Report
What does MOR stand for?
National Association of Insurance Commissioners
What does NAIC stand for?
National Committee for Quality Assurance
What does NCQA stand for?
Office of Inspector General
What does OIG stand for?
Preferred Provider Organizations
What does PPO stand for?
F
When a patient with AIDS is admitted for treatment, code B20 is always listed as the principal diagnosis.
the condition is reported as a diagnosis and doe snot fall under the "probably" or "rule-out" guideline
When a provider documents "evidence of".....
a higher return on their premium dollars
When an MA Plan directs a smaller amount of premium dollars to administrative costs, generally members receive the following on their premium dollars ?
Review definition of 5th digits in category; Understand the difference between type 1 & 2 and the patho of each type.
When assigning Diabetes Diagnosis remember what 2 things?
Specific type of Pneu Know criteria for recognizing gram negative and other types of pneu; review the various types of COPD and how ACUTE exacerbation of each is coded. (AHA coding Clinic); Review criteria for coding respiratory failure and when it is sequenced.
When coding Respiratory what things should you look for?
F
When coding a neoplasm, the first step is to go to the Neoplasm Table.
F
When coding fractures, if documentation is not present, nondisplaced and closed are considered the default classifications.
When do you code acute respiratory failure as a secondary diagnosis?
When it occurs after admission.
F
When mechanical ventilation is used during a surgical procedure, it is normally coded as a procedure.
F
When no intent for a poisoning is provided, the code for undetermined poisoning should be assigned.
percutaneous endoscopic
Which approach in ICD-10-PCS is defined as "entry, by puncture or minor incision, of instrumentation through the skin or mucous membrane and/or any other body layers necessary to reach and visualize the site of the procedure?"
NEC
Which coding convention is used in the description of an ICD-10-CM code when the information in the medical record provides detail, but no specific code exists? Refer to ICD-10-CM guidelines, section I.A.6.
Mean as associate with or due to
With
Means "associated with" or "due to".
With
can mean "associated with" or "due to"
With
shorter urethra then men, allowing bacteria quicker access to the bladder
Women are more prone to UTIs due to
What is an acute exacerbation of asthma or COPD? (Reference ICD-10-CM guideline I.C.10.a.1)
Worsening or decompensation of asthma or COPD
Factor influencing Heath status and contact (Z codes: Z00-Z99)
Z code
Encounter, admission , examination
Z code section
Some can be used as principal or fist listed diagnosis
Z codes
For specific after care such as removal of internal fixation, sole purpose of special therapy radiotherapy chemotherapy
Z codes are used as principal
When a primary malignancy has been previously excised or eradicated from its site and there is no further treatment directed to that site and there is no evidence of any existing primary malignancy, a code from category _________________________________. * Any mention of extension, invasion, or metastasis to another site is coded as a secondary malignant neoplasm to that site. The secondary site may be the ______________________ with the Z85 code used as a secondary code.
Z codes should be given. Z85, Personal history of malignant neoplasm, should be used to indicate the former site of the malignancy. * principal or first-listed
When coding an encounter for chemotherapy, immunotherapy, and radiotherapy, report the ___________ first, followed by the active code for the ___________________________, even if that neoplasm has already been removed.
Z codes, malignant neoplasm
Encountered for medical observation for suspected disease and condition ruled out
Z03
Encountered for examination and observation for other disease and c
Z04
Only as principal not secondary
Z04, Z03
ACO
a minimum of 5,000 patients must be enrolled in an ACO to be eligible under the Patient Protection and Affordable Care Act (ACA) passed by Congress in 210.
CDPS + Rx
a model developed using Medicaid data, diagnostic and pharmacy data. Data was supplied by CMS from Medicaid Analytic eXtract (MAX) data system.
Fee For Service
a payment model where services are paid for separately, payment based on quantity or care vs. quality of care
calyx
cali/o
calyx
calic/o
ACO
clinicians are held accountable for the quality of care they provide and for the health costs for a defined patient population
cochlea of inner ear
cochle/o
cancer coding
code only most severe and costly form of cancer.
"history of" error
coding past condition as active; coding active condition as history of; impacts ra
vagina
colp/o
CMS
compares benchmarks and payments in ACOs to the actual Part A and Part B FFS costs for beneficiaries assigned to the ACO in each performance year in contract with them
**faster, more accurate payment of claims **fewer billing mistakes **diminished chances of a payer audit **less chance of running afoul of self-referral and anti-kickback statutes
compliance benefits
written set of instructions outlining process for coding and submitting accurate claims, and what to do if mistakes are found
compliance plan
If the provider documents a "borderline" diagnosis at the time of discharge, the diagnosis is coded as ___________, unless the classification provides a specific entry (e.g., borderline diabetes). If a borderline condition has a specific index entry in ICD-10-CM, it should be coded as such. Since borderline conditions are not uncertain diagnoses, no distinction is made between the care setting (inpatient versus outpatient).
confirmed
connects and supports various body structures
connective tissue
support and connect tissues of body
connective tissues
authoratative
conservative, official, and factual; perfect grammar, spelling, and punctuation.
consistent
consistent messages, right the first time and every time
cornea
corne/o
referred as atherosclerosis
coronary artery disease (CAD)
CMS HCC Model
correlates all diagnoses, care, and related healthcare costs between it FFS member and its HMO members some diagnoses are not used to calculate payment, but are used to distinguish variable between members with different categories
cerebral cortex, outer portion
cortic/o
space inside the skull, or cranium, containing the brain
cranial cavity (dorsal cavity)
Stage 1 Groups
created by mapping build the CDPS identification, then they are combined into Major Categories
pertaining to the skin
cutaneous
forms outer covering of body; skin
cutaneous membrane
urinary bladder
cyst/o
study of cells including formation, structure, and function of cells
cytology
makes up body of cells
cytoplasm
lacrimal sac
dacryocyst/o
pressure ulcer/bedsore
decubitus
closer to center of body
deep (internal)
physician specializing in diseases of skin and subcutaenous tissue
dermatologist
study of skin
dermatology
located under epidermis; stratum papillare and stratum reticulare
dermis 2 types
Advanced Payment ACO Model
designed for physician based and rural providers who are already in, or are interested in, the Shared Savings Program and re proving high-quality coordinated care to Medicare patients. allows providers to receive upfront monthly payments that can be used for coordination of care efforts, such as EMR purchasing, hiring diabetic educators, obtaining clinical equipment
Error Rate
determined during annual audits and applied to the premiums for the entire patient population for that health plan
CMS
determines which health plans will be audited along with which patients are included in the audit
HHS HCC Model
developed using commercial claims data within the commercial risk adjustment population
CMS center for beneficiary choices
develops and implements ra payment methodology for MM program. monitors plans to improve data quality
right
dextr/o
through; complete
dia-
ra data requirements diagnosis
diagnosis codes must be reported at least once per enrollee within data collection period
required diagnosis
diagnosis codes required to be submitted for the CMS-HCC model and future model development
DxG's
diagnosis groups < filtered by ICD codes
medical record request: enrollee list
displays: *organizations name, enrollee ID, current contract ID, previous contract ID
farther from point of attachment or from given reference point
distal
conditions treated/cured
do not code conditions previously treated or no longer exist
symptoms/signs
do not code if part of an integral underlying condition
DO
doctor of osteopathy
dx codes importance to ra
drives risk scores, which drives ra reimbursement from CMS to MA organizations
accessible communication
easy accessibility
brain
encephal/o
in; within
end/o-
endocrine glands or system
endocrin/o
RADV purpose
ensure risk adjusted payment integrity and accuracy
intestine
enter/o
collection of eosinophil's in the esophagus
eosinophilic esophagitis
epididymis
epididym/o
vulva
episi/o
found in skin and lining of blood vessels, respiratory, intestinal, urinary tracts, and other body body systems
epithelial tissue
work
erg/o
red blood cell
erythr/o
red blood cell
erythrocyt/o
results of RADV audit are extrapolated across all members of audited plan
extrapolated
Reviews
fall into 3 main categories, Retrospective Concurrent Prospective Based on the current DOS compared to the treatment DOS being reviewed.
CDPS
far more diagnosis codes identified than are included in the Medicare HCC model Also rate as high, medium, and low risk rating is used in hierarchical value setting (low overruled by medium, medium overruled by high) The more severe condition in any family or hierarchy overrules other conditions in the same family.
fascia
fasci/o
thin membrane surrounding the muscles, tendons, bones and other organs and tissues; projects tissues around muscles during movement
fascia
inflammation of the fascia
fascitis
ACO
federal government in the form of Medicare, is the primary payer of an ACO; other payers include private insurances or employer-purchased insurance
FFS
fee for service; physician pay based on specific services provided to each patient
Trumping
final definition that is applied (superseded in rank ,value, or importance)
If the patient is admitted with a localized infection, such as pneumonia, and sepsis/severe sepsis doesn't develop until after admission, the localized infection should be assigned _________, followed by the appropriate sepsis/severe sepsis codes.
first
If the reason for admission is both sepsis or severe sepsis and a localized infection, such as pneumonia or cellulitis, a code(s) for the underlying systemic infection should be assigned ____________ and the code for the localized infection should be assigned as a _____________________.
first, secondary diagnosis
For such cases, the postprocedural infection code, such as T80.2, Infections following infusion, transfusion, and therapeutic injection, T81.4, Infection following a procedure, T88.0, Infection following immunization, or O86.0, Infection of obstetric surgical wound, should be coded ________, followed by the code for the ______________. If the patient has severe sepsis, the appropriate code from subcategory _________ should also be assigned with the additional code(s) for any acute organ dysfunction.
first, specific infection, R65.2
neuroglia cells
gli/o
glomerulus
glomerul/o
tongue
gloss/o
woman
gyn/o
woman
gynec/o
sacs holding the root of hair fibers
hair follicles
knoblike indentation at bottom of hair follicle containing the blood supply to hair root
hair papilla
Platinum
have higher monthly premiums, but pay more for costs of care. Ideal for those with regular DR visits and/or lots of prescriptions
Bronze
have the lowest premium monthly patient cost but he highest deductibles and other out of pocket costs
ra data requirements
health insurance claim (HIC) #, diagnosis code, service date from, service date through, provider type
HPMS
health plan management system; CMS MA information system that contains health plan-level data
blood
hem/o
blood
hemat/o
weakness on one side of body.
hemiparesis
liver
hepat/o
HCC
hierarchies or families of conditions placed to gain an HCC numeric code, which translates RAF
acceptable data sources
hospital inpatients, hospital outpatient facilities, and physicians
high calcium which can increase acid production
hypercalcemia
pertaining to under the skin
hypodermic
subcutaneous tissue; not considered layer of skin; composed of fatty or adipose tissue
hypodermis
pituitary gland, hypophysis
hypophys/o
uterus
hyster/o
Gold
ideal for those with more expected DR visits and or prescriptions
New Enrollees
identified as as newly eligible disabled or aged-in beneficiaries with less than 12 months of Medicare Part B entitlement during the data year collection, which is the calendar year
HCC-C Model
identifies conditions that are not only chronic to manage, but also that may be especially complex when paired with another co-morbidity/condition
cause is unknown
idiopathic
cancer guidelines
if malignant status not specified, code to primary site except for: bone, brain, diaphragms, heart, liver, lymph nodes, mediastinum, meninges, peritoneum, pleura, retro peritoneum, and spinal cord
immunity, immune system
immun/o
Final Scores
in risk adjustment models are always affected by known diagnoses
ACO
in some models the organization is at risk for a portion of any spending that exceeds the target
CDPS Disabled Model
includes patient ages and conditions and coders are encouraged to code all conditions- because a in Medicare HCC model- diagnosis values in this model are additive, and the desire is to accurately gain the appropriate total risk score for each patient.
below; toward lower end of the supine
inferior (caudal)
use additional code
informs coder that more than one code is needed to fully described condition
exclude notes
informs coder which dx codes are not included in code selection
pancreatic islets
insul/o
If the patient is treated with both oral medications and insulin, only the code for long-term (current) use of _____________ should be assigned.
insulin
largest organ system in body; skin, hair, nails
integumentary
If no bilateral code is provided and the condition is bilateral, assign separate codes for both the ______________. If the side is not identified in the medical record, assign the code for the _______________.
left and right side, unspecified side
white blood cell
leuk/o
white blood cell
leukocyt/o
tongue
lingu/o
little moon area of nail
lunula
lymph, lymphatic system
lymph/o
lymph node
lymphaden/o
lymphatic vessel
lymphangi/o
common UI
maintains medicare beneficiary eligibility data
When a patient is admitted for the purpose of insertion or implantation of radioactive elements (e.g., brachytherapy) and develops complications such as uncontrolled nausea and vomiting or dehydration, the principal or first-listed diagnosis is the appropriate code for the ______________________ followed by any codes for the complications.
malignancy
mixed services model
managed care org. use a combination of contractual arrangements
palmetto government benefits admin (palmetto gba)
manages front-end ra system (FERAS) and customer service and support center (CSSC)
CDPS
maps over 16,461 ICD codes and to 58 categories, which lead up to 20 major categories related to major body systems (cardiovascular) and type of disease (diabetes)
MRX
maps over 56,236 NDC codes from patient utilization to 45 Medicaid Rx categories for the Part D model values in Medicaid
breast, mammary gland
mast/o
risk scores
measure individual beneficiaries' relative risk and are used to adjust payments for each beneficiary's expected expenditures
toward midline of body
medial
assessment and plan: information contained that relates to medical decision making and diagnosis treatment and management. history and exam may also contain information
medical decision making
medulla oblongata, medulla (inner section), middle, soft, marrow
medull/o
dark, black, melanin
melan/o
pigment giving color to skin
melanin
pigmented malignant tumor of skin, most dangerous form of skin cancer
melanoma
line internal spaces of organs and tubes opening to outside, and lining body cavities
membranes
menstruation
men/o
meninges
mening/o
meninges
meninge/o
composed of three connective tissue membranes found within dorsal cavity and serve as protective covering of brain and spinal cord.
meninges
menstraution
mens
middle
mes/o
uterus
metr/o
uterus
metri/i
cuts through midline of body from front to back and divides body into equal right and left sections
midsagittal plane
ACO
might contract with out of network providers who agree to abide by its requirements because it is responsible for the cost and quality of care provided by specialists outside of the it
providers should develop safeguards to prevent unauthorized access
minimum necessary rule is based on sound current practice that protected health information should not be used or disclosed when it is not necessary to satisfy a particular purpose or carry out a function:
cells divide and multiply to form two cells
mitosis
one; single
mon/o
Within major categories in the Chronic-illness Disability Payment System, only the ? diagnosis counts
most severe
ACOs
move providers away from traditional FFS methods and toward more capitated and risk-adjusted budgets
line interior walls of organs and tubes opening to outside of body; lined with epithelium, and involved in absorption and secretion
mucous membranes
produces movement
muscle tissue
muscle
muscul/o
muscle
my/o
bone marrow, spinal cord
myel/o
tympanic membrane
myrin/o
visible part of nail
nail bed
visible part of nail
nail body
root, nail bed, nail plate, eponychium (cuticle), perionychium, hyponychium
nail divided into 6 parts
stupor, numbness, sleep
narc/o
random selection
national RADV
**eligible enrollees from each contract will be ranked from lowest to highest score **201 total beneficiaries selected from each contract **67 from each group selected randomly ---1/3 or 67 highest risk scores --1/3 or 67 middle risk scores --1/3 or 67 lowest risk scores
national RADV audit
individual born with.
native artery (CAD)
kidney
nephr/o
conducts impulses to and from the brain
nerve tissue
nervous system, nervous tissue, nerve
neur/i
ovum, egg cell
o/o
Silver
offer the best value for saving on out of pocket costs. Those who qualify for cost-sharing reductions based on income can have a lower deductible and pay lower out of pocket cots. Best for those who don't expect to use regular medical services and don't take regular prescriptions
After the IVA
once completed with chart review, an identified senior official from the health plan is identified as primary user, to handle communications from the health plan to CMS/HHS through the provided audit tool.
Adjusting Historical Benchmark
one of the adjustments made to the historical benchmark each performance year relates to the risk score of beneficiaries assigned to the ACO for that year
nail
onych/o
inflammation of nail matrix
onychitis
ovary
oophor/o
reviewing the documentation in the detail of the procedure to further clarify or define both procedures and diagnoses
operative report coding:
mouth
or/o
testis
orchi/o
testis
orchid/o
tow or more kinds of tissue, together performing special body functions
organs
scrotum
osche/o
bone
oste/o
ear
ot/o
Continuously Assigned
other enrollees are assigned in the current performance year and either assigned in the most recent prior calendar year, or received a primary care service from any of the ACO providers in the prior year CMS determines the risk score with both demographic and health status components, and will adjust the risk score downward if the risk score declines. If the risk score stays the same or increases, CMS makes an adjustment using demographic factors only.
ovum, egg cell
ov/o
"history of"
patient no longer has the condition and dx often indexes to V code not in HCC models
Newly Assigned Beneficiary
patient who is neither assign to the ACO in the most recent prior calendar year, nor is receiving primary care services from any of the ACO participants in the prior year CMS makes risk score adjustments to reflect both a demographic component and a health status component.
HHS HCC Model
patients are classified in this model by platinum, gold, silver, bronze, or catastrophic
infestation with lice
pediculosis
space containing urinary bladder, certain reproductive organs, part of the large intestine, and rectum
pelvic cavity (ventral cavity)
PMPM
per member per month
through
per-
lens
phac/o
many, much
poly-
after, behind
post-
toward back of body
posterior (dorsal)
before, in front of
pre-
attached to beginning of word to modify or alter its meaning. Not all terms contain prefix. Indicats location, time or number
prefix
If the treatment is directed at the malignancy, designate the malignancy as the ______________.
principal diagnosis
When a patient is admitted because of a primary neoplasm with metastasis and treatment is directed toward the secondary site only, the secondary neoplasm is designated as the _____________________ even though the primary malignancy is still present.
principal diagnosis
before, in front of
pro-
rectum and anus
proct/o
PACE
program of all-inclusive care for the elderly:
**done before chart submitted **problems can be fixed before submitting **coding errors can be identified **can query provider **identify missed HCC's
prospective audit
prostate
prostat/o
CMS regional office
provide assistance to ra organization and beneficiaris
timely
provide information when needed and meeting deadlines
final risk score calculation
providers may request recalculation of payment once error of inaccurate diagnosis submitted for calculating risk scores have been discovered and have an effect on final payment
ACO One-Sided Model
providers no longer assume any financial risk throughout the three years and continued to have the opportunity to share in cost savings above 2%
ACO Two-Sided Model
providers will assume some financial risk, but will be able to share in savings that occur with no 2% benchmark before provider savings accrue
nearer to point of attachment or a given reference point
proximal
mind
psych/o
lungs
pulm/o
lungs
pulmon/o
renal pelvis
pyel/o
four
quadri-
ra data
ra data must be submitted at least quarterly; processed through RAPS
date span
ra; it is important to determine if reported dx cluster falls within data reporting period
spinal nerve root
radicul/o
current communication
recent
kidney
ren/o
V codes
represent factors that influence health status or describe contact with health services
medical record request once sampling completed
request defined by 3 segments: *request: initial notice of RADV selection; enrollee list, official request instructions *submission: MA response to request *receipt: process used by MRRC for receiving, logging and tracking of records
Health Plan
required to obtain all relevant medical records for the patients selected
HCC Model
requires any data elements used should come from face to face encounters
Premium Stabilization Final Rule
requires the states, or HHS on behalf of the states to: - Validate a statistically valid sample of data for all issuers and submit for risk adjustment every year and - Provide an appeals process
**done after chart submitted **ID and submit additional codes **ID and submit deleted codes **conducted by the MAP or an organization on behalf of MAP
restrospective audit
retina
retin/o
IVA
reviews the sample to identify DOS that support HCCs through diagnoses codes for the chosen patients in the sample is handled by a 3rd party vendor, chosen by the health plan, who has no conflicts of interest and can provide both a coding review and the enrollment verification portions of the HRADV as well as claims system accuracy verification
The Shared Savings Program
rewards ACOs that reduce their growth in healthcare costs, while placing patients first in quality of care measures. One version of the model, the organization share in any "cost savings" with CMS, and there is no penalty if the target is not met. In another version of the model, the organization shares in the "potential savings" and is at risk for losses, as well.
nose
rhin/o
multiple chronic diseases
risk adjusted payment based on assignment of dx to disease groups, HCC. most influenced by medicare costs associated with chronic diseases
RAPS
risk adjustment processing system
RAPS
risk adjustment processing system; process ra data
RAS
risk adjustment system; calculates risk score
Commercial Risk Adjustment Population
risk for individual and small group plans inside and outside of the exchange marketplace
word part holding fundamental meaning of medical term; medical term at least one root or base word
root
cuts through body from front to back and divides into right and left sections
sagittal plane
oviduct, tube
salping/o
tube, eustachian tube
salping/o
HRADV
sample audited is 200 enrollees per issuer, per state where plans re eligible
sclera
scler/o
RAF
scores have changing values based on where the diagnoses was established, and if the patients has other including factors such as ESRD, hospice, or are dual eligible and may vary patient to patient
sebum, sebaceous gland
seb/o
HHS HCC Model
selected different set of HCCs to reflect the population differences HCCs may be excluded from this RA model if they are not predictive of costs; or, if the diagnoses are too vague, discretionary in treatment or coding, or not medically significant.
semen
semin/o
If a patient admission/encounter is for the insertion or implantation of radioactive elements (e.g., brachytherapy) the appropriate code for the malignancy is ________________________.
sequenced as the principal or first-listed diagnosis. Code Z51.0 should not be assigned
When the admission/encounter is for management of dehydration due to the malignancy and only the dehydration is being treated (intravenous rehydration), the dehydration is ____________________, followed by the code(s) for the malignancy.
sequenced first
When an encounter is for a pathological fracture due to a neoplasm, and the focus of treatment is the fracture, a code from subcategory M84.5, Pathological fracture in neoplastic disease, should be _______________________, followed by the code for the neoplasm. *If the focus of treatment is the neoplasm with an associated pathological fracture, the neoplasm code should be ___________________,, followed by a code from M84.5 for the pathological fracture.
sequenced first, sequenced first
line cavities, including thoracic cavity and internal organs; support internal organs and compartmentalize large cavities.
serous membranes
If a patient has sepsis and associated acute organ dysfunction or multiple organ dysfunction (MOD), follow the instructions for coding ________________.
severe sepsis
semen, spermatozoa
sperm/o
semen, spermatozoa
spermat/o
space inside the spinal column containing spinal cord
spinal cavity (vertebral canal) (dorsal cavity)
breathing
spir/o
spleen
splen/o
Premium Stabilization Final Rule Allows
states or HHS on behalf of states to: -Adjust average actuarial risk for each plan based on the error rate found in validation (audit) and -Adjust payments and charges based on the changes to average actuarial risk
mouth
stoma
mouth
stomat/o
deepest of 5 layers, made of basal cells
stratum basale (stratum germinativum)
horny layer; outermost layer
stratum corneum
granular layer of cells; keratohyaline granules and lamellated granules
stratum granulosum
clear layer
stratum lucidum (palms and soles)
thin superficial layer interlocked with epidermis
stratum papillare
thick layer of dense, irregular connective tissue
stratum reticulare
composed of prickle cells that are interwoven for protection
stratum spinosum
Per coding clinic: do not report 433.1 for patient diagnosed with stroke and carotid artery disease unless documented carotid artery caused the stroke
stroke and carotid artery disease
cells, tissues, organs, systems
structure of human body
vessels carrying blood and lymph; nerves and nerve endings, glands, hair follicles
structures of dermis nourishing and innervevating skin
pertaining to below the skin
subcutaneous
If an AMI is documented as nontransmural or subendocardial, but the site is provided, it is still coded as a _________________.
subendocardial AMI
E codes
supplemental classification used for reporting external causes of injuries and poisonings
synovial fluid, joint, or membrane
synov/i
line joint cavities and are composed of connective tissue; secretes synovial fluid into joint cavity; lubricates ends of bones so they can move freely
synovial membranes
groups of organs working together to perform complex body functions.
systems
past data validation problems plan is reporting higher risk scores than national average noticeable changes in reporting from previous years
targeted RADV
tendon
ten/o
tendon
tendin/o
ACO
term coined by Elliott Fisher, Director of the Dartmouth Institute of Health Policy and Clinical Practice in 2006.
testis, testicle
test/o
New Enrollee
the beneficiarie's correct risk score will be determined during the next year
Coding of sequela generally requires two codes sequenced in the following order: _____________________________________________.
the condition or nature of the sequela is sequenced first. The sequela code is sequenced second.
Three types of Reviews
these various medical documentation reviews are used to forecast future healthcare needs, while explaining current needs and expenses
ACO Two-Sided Model
they participate in both shared savings and losses for all three years at a maximum sharing rate of 60%, provided that the minimum shared savings threshold rate of 2% is reach with a shared loss cap that increases every year
ACO One-Sided Model
they participate in shared savings for the first two years and assume shared losses in addition to the shared savings for the third year, at a maximum 50% sharing rate with a shared loss cap that increases each year
space containing the heart, lungs, esophagus, trachea, bronchi, and thymus
thoracic/chest cavity (ventral cavity)
New Enrollee
those beneficiaries with less than 12 months of Medicare Part B entitlement during the data collection year
blood clot
thromb/o
platelet, thrombocyte
thrombocyt/o
Maintaining Health Care Costs ACOs
through care delivery focusing on reducing unnecessary hospital admissions and re admissions, eliminating unnecessary ER visits, improving continuity of care, and improving at-home-care
thymus gland
thym/o
thyroid gland
thyr/o
thyroid gland
thyroid/o
ringworm (a fungal infection of skin)
tinea
group of similar cells performing specific task
tissue
ACO Quality Measures
to address the goal of improving healthcare quality CMS has established five domains in which the evaluate the quality of an ACOs performance
Realizing Savings
to realize savings, the actual expenditures must be lower than the updated benchmark. If expenditures are higher than the updated benchmark, and if the ACO selected the two-sided risk payment model, they may have to share losses with CMS
tone; pressure
ton/o
tonsil
tonsil/o
trachea
trache/o
through; across
trans
cuts horizontally through body and separates body into upper (superior) and lower (inferior) sections
transverse (horizontal) (axial)
three
tri-
hair
trich/o
tympanic cavity (middle ear), tympanic membrane
tympan/o
CMS RADV
typically involves approximately 30 health plans
capturing codes
unique diagnoses at least once during risk adjustment data-reporting period
base of ulcer covered by slough and/or eschar in the wound bed preventing clinician from determining accurate stage
unstageable pressure ulcer
urine, urinary tract
ur/o
ureter
ureter/o
urethra
urethr/o
urine
urin/o
The term _____________ is a nonspecific term. It has no default code in the Alphabetic Index. It is not to be considered synonymous with sepsis.
urosepsis
risk adjustment models
use to calculate risk scores which predicts healthcare expenditures.
HCC-C Model
used by Medicare Advantage plans (Medicare HMOs) began using in 2004, with a full financial impact occurring in 2007
not elsewhere classified (NEC)
used when medical record documents a condition to a level of specificity not identified by specific ICD 9 or ICD 10 code.
HHS HRADV
uses 10 strata 80% of Members Adult -low,med,high Child " Infant " 20% of members - No HCCs
CMS RADV
uses a stratified sample of three strata (high, mediu, low risk)
Prospective Model
uses base year to predict the cost for the following year
uvula
uvul/o
medical record review
validate risk adjusted payments *service provided by an acceptable ra provider type and physician specialty *dos within collection period *provider signature and credentials on each note *acceptable documentaiton based on documentation guidance *dx supported by medical record documentation
valve
valv/o
valve
valvul/o
Hybrid Model
vary greatly and may be models created without influence from HCC or CDPS examples, most being a combination of HCC and CDPS models, with variation by health plan preferences.
vessel, duct
vas/o
vessel, duct
vascul/o
vein
ven/i
vein
ven/o
cavity, ventricle
ventricul/o
What are the severity levels within the Chronic-illness Disability Payment System
very high, medium, low, and very low
HCC RA Approved Providers
MD DO NP PA CRNA LCSW OT PT CNM
ra errors
*unacceptable provider type and physician specialty *dos submitted does not fall within ra data collection period *missing provider signature and credentials *incomplete: diagnosis code cannot be assigned for dos if documentation is insufficient or incomplete *never sent: no medical record documentation was received *diagnosis code does not match ra diagnosis at teh 3rd, 4th, or 5th digit level
physician documentation/communication tips
**document and report co-existing diagnoses **communicate issues regarding inadequate documentation **adhere to proper methods for appending (late entries) or correcting inaccurate data entries: lab/radiology results, strike through, initial, and date. **use only standard abbreviations **identify patient and date on each page of record
ra data flow
**hospital/physician submits data to MA organization **MA organization submits data at least quarterly to Palmetto GBA **MA organization submits data via Direct Data Entry or in RAPS format **data sent to FERAS for processing where file-level data, batch-level data, and first and last detail records are checked **any data rejected, report on FERAS Response Report **passing FERAS checks, file submitted to RAPS where detail editing performed **RAPS return file is returned daily ; shows approved and errors **RAPS transaction error report displays records on errors **RAPS distributed monthly and quarterly **RAPS database stores all finalized diagnosis clusters **RAS calculates RAF by executing the CMS-HCC model
documentation guidelines
**reported diagnoses must be supported with medical record documentation **medical records and codes subject to CMS validation **characteristics of acceptable documentation: clear, concise, consistent, complete, legible
appeal stage
*CMS will implement formal appeal process facilitated by CMS office of Hearings.
medical record receipt
*administrative check: confirms beneficiary demographic information, name, HIC number and service date within or outside of collection period *clinical check:verify record dated and signed, appropriate provider type, consist of pertinent components
medical record request: information in beneficiary list
*coversheet ID number, enrollee last name, first name, enrollee date of birth, enrollee HIC number, validation HCC, ICD9CM/ICD10CM codes related to validation HCC
document dispute/appeal process
*does not accept first time submission of medical record *does not accept missing medical records *medical record resulted in coding discrepancy *clearly document reason for disagreement
CMS reimbursement
*each medical record submitted per beneficiary HCC *if one record supports more than one beneficiary HCC, will receive reimbursement for one record *rule applies regardless of method chosen for medical record submission
nursing home resident medical records
*encounter must be face to face *provider rendering services must be an acceptable provider *medical record must clearly document provider's signature and credentials *beneficiary in minimum data set (MDS) as long term institutional resident
documentation disputes/appeal
*enrollee HCC level discrepancy findings will be allowed for dispute *MA may dispute for particular medical record dos submitted during medical record request stage *MA organizations will be given 60 days to submit a documentation dispute *expert coding panel reviews every dispute; panel consists of senior medical reviewer, senior coder, physician
RADV submitted code guideline
*face to face encounter *code accordance to ICD 9 CM/ICD 10 CM *dos within collection period *acceptable RA provider type and physician specialty
inpatient medical record documentation
*fact sheet *history and physcial exam *physician orders *progress notes *operative/pathology reports *consultation reports *diagnostic testing reports *discharge summary
outpatient medical record documentation
*fact sheet *history and physical exam *physician orders *progress notes *diagnostic reports (to support documentation) *consultation reports
payment adjustment
*findings will be recalculated based on findings and payment error will be re-estimated. *MA will be notified of revised payment error estimate resulting in payment adjustment
medical record request: initial letter
*inform contract was selected for data validation *request primary and secondary points of contact *compliance officer is given approx 5 days to respond to initial request
sampling selection
*national sample: estimate national annual payment error. consists of continuously and non-continuously enrolled beneficiaries with at least one ra codes (CMS-HCC) *contract specific sample: estimate annual payment error at contract level; CMS will target or randomly select contracts;
unacceptable types of dx (outpatient hospital/physician settings)
*probable, suspected, questionable, rule out, working
unacceptable sources of medical records
*skilled nursing facility (SNF) *diagnostic readiology *freestanding ambulatory surgical center (ASC) *alternative data sources *unacceptable physician extenders *durable medical equipment (DME)
RADV core process
*stage 1: sampling and medical record request *stage 2: medical record review (MRR) *stage 3: MRR findings and cotract-level payment adjustments *stage 4: documentation dispute *stage 5: post documentation dispute payment adjustments *stage 6: appeals
unacceptable types of medical rec documentation
*superbill *physician-signed attestation *list of patient conditions *diagnostic report that has not been interpreted *documentation for dos outside the data collection period
instrument for measuring
-meter
surgical fixation
-pexy
plastic repair, plastic surgery, reconstruction
-plasty
surgical repair, suture
-rraphy
instrument for viewing or examining
-scope
examination of
-scopy
surgical creation of an opening
-stomy
crushing
-tripsy
indicates the code is incomplete
.- Point Dash
S82.891A (right ankle), S82.892A (left ankle)
A patient is brought to the ED with right and left ankle fractures. Applying the coding concepts from ICD-10-CM guidelines, section I.B.12, which ICD-10-CM code selection should you report?
Z3A.20
A pregnant patient at 20 weeks gestation has a chronic cystitis and has recurrent bouts of acute cystitis during her pregnancy, with an acute episode at time of admission. Code the secondary diagnosis.
F
Aftercare Z codes (Z42-Z51) are used to show that continued care is provided for injuries.
Risk Adjustment Elements
Age Gender Socioeconomic Status Disability Status Insurance Status (Medicare, Medicaid, dual-eligible, etc.) Claims Data Elements such as procedure codes, place of service codes, etc. Special Patient Specific Conditions (for ex: enrollment in hospice or being an ESRD patient)
F
All conditions that occur postoperatively are classified as complications.
F
All intraoperative and postprocedural complications are classified to categories T80-T88.
"chest pain," though not clinically accurate b/c is specifically a heart-related pain. Ongoing, chronic condition that flares up from time-to-time; or a sudden, unexpected symptom which may be related to an impending heart attack
Angina
AWV
Annual Wellness Visit - These are the CPT codes that we use to identify annual well visits: G0439, G0438. E&M codes (99385, 99386, 99387, 99395, 99396, 99397)
the end of the bone is displace to the anterior, media, and slightly inferior to its normal anatomic position
Anterior dislocation
The ICD-10-CM codes for type 1 acute myocardial infarction (AMI) identify the site, such as _________________________.
Anterolateral wall or true posterior wall
infers that an opening was made to the outside of the body and is replacing/bypassing a normal body function (colostomy, ileostomy, tracheostomy, etc) and may affect the patient care decisions as they place patient at risk for infection, require continual monitory for patency, and DME supplies are costly to purchase for patients. Nasogastric (NG) tubes, Port-A-Caths, indwelling urinary catheters, and chest tubes are NOT artificial openings
Artificial Openings
Risk Adjustment
As a permanent program, risk adjustment scores will be used to avoid adverse selection by transferring funds from plans that enroll lower risk individuals to plans with higher risk populations.
when SA Node sends its electrical impulse downward through the heart, the electrical impulse runs along a normal pathway. These bundles (electrical lines) can become blocked for various reasons, causing "bundle branch block," blocking the normal flow of the signal. Disruption of the elctrical message between atrium (top of hear) and ventricles (bottom of heart).
Atrioventricular (AV Block)
inflammation of the liver, acute when less than 6 months, chronic when persists beyond 6 months. Can last 30 or more days outside human body and carriers can have no signs or symptoms
Hepatitis
BMI is tool oft used to measure patient weight as it relates to height, and may be accepted from any clinician and does not have to be stated by the treating provider to code for. Obesity, however, is dx that must be stated by treating provider.
BMI (Body Mass Index) and Obesity
continual GERD not responsive to treatment which leads to a form of intestinal metaplasia, precursor for cancer.
Barrett's Esophagus
spread through contact with an infected person's blood, semen, or other body fluid and classified an STD. Chronic condition that may cause liver cancer and death.
Hepatitis B (HBV)
air embolism, PE which arises from complications from a procedure
Iatrogenic
adjusting payment plans
CMS able to make appropriate and accurate payments for enrollees with differences in expected costs
RADV
CMS identifies a random stratified sample of patients to audit. 1/3 or patients with a high risk factor + 1/3 of patients with a medium risk factor + 1/3 of patients with a low risk factor
CASE 2 Dear Dr. Smith, Mr. Martin was seen in the office for continued management of his breast cancer.(This indicates the patient's main reason for the office visit.) He's having some increasing pain in his breast which is due to the cancer.(Pain related to the neoplasm.) He is also complaining of neck pain. It does not seem to be worse at night; it seems to be worse with activity. He has no other symptoms. Otherwise his review of systems is unremarkable. He's had no constitutional symptoms. On physical exam, he is alert and oriented. Eyes: EOMI, PERLA, no icterus. The heart had a regular rate and rhythm; S1, S2 within normal limits. The lungs are clear to auscultation and percussion. The abdomen was soft, without masses or organomegaly. He was tender to palpation over the left anterior iliac crest. Otherwise he had no point tenderness over his musculoskeletal system. Neck: Supple. No tenderness, no enlarged lymph nodes in the neck. ASSESSMENT: Adenocarcinoma of the left breast, positive estrogen receptor status. Neck pain. (This is the definitive diagnosis that is reported.) PLAN: The plan is to continue the Tamoxifen at this time. His laboratory studies were reviewed and were essentially unremarkable; however we'll obtain a bone scan to ascertain the extent of his disease.(This is a male patient.) Sincerely, John Smith, M.D. What diagnosis code(s) are reported?
C50.922, G89.3, M54.2, Z17.0, Z79.810
Mr. McFarland visits his oncologist for prostate cancer. He is reporting more fatigue than usual. Lab tests determine the patient has anemia due to the cancer. Applying the coding concept from ICD-10-CM guideline I.C.2.c.1., what ICD-10-CM codes should be reported for the visit?
C61, D63.0
Coding Intensity Adjustment
CMS makes adjustments to reflect "difference in coding patterns between MA plans and providers under Part A & B" CMS uses the results of this anaysis to devlop a factor that is applied to the risk score to account for these differences. MA risk scores increase faster than FFS scores. The goal of the MA coding adjustment is to maintain MA risk scores at the level they would be if MA plans coded similarly to FFS providers (not necessarily at 1.0 avg.) CMS adopted the minimum coding intensity increase requirement set by Congress- 5.66% in 2017
new enrollee
CMS uses medicare FFS up to 12 months of data collected within collection period to calculate risk score. If data is submitted via RAPS, CMS uses those too.
Centers for Medicare and Medicaid Services-Hierarchal Condition Category
CMS-HCC
Monthly payments to Medicare Advantage plans and PACE organizations.
CMS-HCC model adjusts standardized payments for?
99213-Mid-level, face to face visit (this is not AWV code). If E/M service provided must be a separate service and use modifier -25.
CPT code for provider's reimbursement for AWV?
Clinical Risk Groups
CRGs
wasting syndrome, loss of weight, muscle atrophy, fatigue, weakness, a significant reduced appetite in someone not actively trying to lose weight
Cachexia
Capitation Rate
Capitation is a payment arrangement for health care service providers such as physicians or nurse practitioners. It pays a physician or group of physicians a set amount for each enrolled person assigned to them, per period of time, whether or not that person seeks care.
decrease in the function of the kidneys and their ability to filter waste from the body and a progressive illness that occurs over a period of many months, even years. Risk factors include HTN, diabetes, and family history of CKD. CKD can lead to cardiovascular disease problems, anemia (low blood iron), and pericarditis (inflammation, bacterial or viral, of the sac surrounding the heart)
Chronic Kidney Disease (CKD)
catch-all phrase oft used to describe many conditions such as emphysema, chronic bronchitis, and sometimes obstructive asthma. AKA Chronic Obstructive Lung Disease (COLD) and Chronic Obstructive Respiratory Disease (CORD). Permanent and worsens over lifetime and many patients suffer from hypoxia (low oxygen levels in blood). Most cases associated with smoking. Can lead to additional comorbidity such as pulmonary HTN, cor pulmonale (right sided heart failure), cachexia (weight loss and muscle wasting), osteoporosis, heart disease, and depression.
Chronic Obstructive Pulmonary Disease (COPD)
Are systemic disease that are ordinarily should be coded even in the absence of documented intervention
Chronic condition such as hypertension, Parkinson's disease, chronic obstructive pulmonary disease, diabetes mellitus
T
Code C50.811 is assigned for one carcinoma of the breast located at the spot where the right upper and lower quadrants join/overlap.
T
Code G81.91 is assigned with code I66.9 for cerebral thrombosis with transient right hemiplegia that has cleared by the time the patient is discharged.
Note is found at the manifestation code to provide instruction that the underlying condition should sequenced first
Code first
This note indicates two codes are needed to report a condition and requires that the underlying disease (etiology) be coded first, and the manifestation be coded second
Code first
Only confirm diagnosis do not code if stat men indicate suspected possible likely
Code influenza to category J09
Layer of excision
Code only the deepest
-transmural vs non-transmural -Q wave vs-non-Q-wave -ST (STEMI) vs Non-ST elevations (NSTEMI) -Acute MI (AMI) -RT Ventricular or LT Ventricular -Anterior (Front), posterior (back), lateral (side), inferior (under) -Apical, Septal, Subendocardial -Anterolateral (Anterior and Lateral) -Anteroseptal (Anterior and Septal) -Extensive Anterior
Common Wording for MI
"pulmonary heart disease" is an enlargement of the right ventricle of the heart as a response to increased resistance or high blood pressure in the lungs (pulmonary HTN). Caused by chronic lung disease and 2 major causes are vascular changes b/c of tissue dmg (disease, hypoxic injury, chemical agents, etc) and chronic hypoxic pulmonary vasoconstriction. Lead to RT heart failure and death.
Cor Pulmonale
CPT
Current Procedural Terminology - CPT codes can be used to identify annual wellness visits
aka infectious hepatitis is caused by eating food or drinking water infected with virus HAV or caused by anal-oral contact during sex. Not chronic or lifelong and almost every patient whom contracts has full recovery
Hepatitis A
The completion of the implementation of payments with CMS calculating final risk adjustment factors and beneficiary stats based on complete data. Necessary adjustments for institutional status and demographic data for enrollees is considered. CMS continues to allow a period (approximately 13 months after the data collection year) for submitting final RAPS data for the appropriate data collection period.
Define Reconciliation
Premium revenue less federal and state taxes, licensing and regulatory fees, with adjustment for risks, risk corridors and reinsurance
Define premium denominator
CASE 3 SUBJECTIVE: Low-grade fever at home. She has had some lumps in the abdominal wall and when she injects her insulin; it does seem to hurt there. She stopped four of her medications including Neurontin, Depakote, Lasix, and Premarin, and overall she feels quite well. Unfortunately, she has put on 20 pounds since our last visit. OBJECTIVE: HEENT: Tympanic membranes are retracted but otherwise clear. The nose shows significant green rhinorrhea present. Throat is mildly inflamed with moderate postnasal drainage. Neck: No significant adenopathy. Lungs: Clear. Heart: Regular rate and rhythm. Abdomen: Soft, obese, and nontender. Multiple lipomas are palpated. ASSESSMENT 1. Diabetes mellitus, type 1. 2. Diabetic neuropathy. 3. Acute sinusitis. (The definitive diagnoses are reported.) PLAN: At this time, I have recommended the addition of some Keflex for her acute sinusitis.(Provider treated the acute sinusitis.) I have given her a chair for the shower. They will not cover her Glucerna anymore so a note for that will be required. What diagnosis code(s) are reported?
E10.40, J01.90
CASE 9 Follow-up Visit: The patient has some memory problems. She is hard of hearing. She is legally blind. Her pharmacist and her family are very worried about her memory issues. She lives at home, family takes care of laying out her medications and helping with the chores, but she does take care of her own home to best of her ability. Exam: Pleasant elderly woman in no acute distress. She has postop changes of her eyes. TMs are dull. Pharynx is clear. Neck is supple without adenopathy. Lungs are clear. Good air movement. Heart is regular. She had a slight murmur. Abdomen is soft. Moderately obese. Non-tender. Extremities; no clubbing or edema. Foot exam shows some bunion deformity but otherwise healthy. Light touch is preserved. There is no ankle edema or stasis change. Examination of the upper arms reveal good range of motion. There is significant pain in her shoulder with rotational movements. It is localized mostly over the deltoid. There is no other deformity. There is a very slight left shoulder discomfort and slight right hip discomfort. Impression: 1. Dementia 2. Right shoulder pain. 3. Benign hypertensive cardiovascular disease. 4. Type 2 diabetes good control. Most recent AlC done today 5.9%. Liver test normal. Cholesterol 199, LDL a little high at 115. Plans: 1. I offered her and her family neuropsychological evaluation to evaluate for dementia. Her system complex is consistent with dementia, whether it be from small vascular disease or Alzheimer's is unknown. At this point, they would much rather initiate treatment than go through an exhaustive neuropsychological test. 2. For the shoulder we decided on right deltoid bursa aspiration injection. She has had injection for bursitis in the past and prefers to go this route. She will ice and rest the shoulder after injection. 3. Follow up in 3 months. Procedure: Aspiration injection right deltoid bursa. The point of maximal tenderness was identified, skin was prepped with alcohol. A 25-gauge, 1 ½-inch needle was advanced to the humerus and then aspirated. 1 cc of 0.25% Marcaine mixed with 80 mg Depo Medrol was deposited. Needle was withdrawn. Band-aid was applied. Post injection she had marked improvement; increased range of motion consistent with good placement of the medication. She was started on Cerefolin, plus NAC and Aricept starter pack was given with email away script. Follow-up in 3 months and we will reassess her dementia at that time. What diagnosis code(s) are reported?
E11.9, M25.511, I11.9, F03.90
A 12-year-old's diabetes mellitus is well controlled with oral antidiabetic medications. The patient has no complications. Applying the coding concept from ICD-10-CM guidelines I.C.4.a.1., I.C.4.a.2., and I.C.4.a.3, what ICD-10-CM code(s) is/are reported?
E11.9, Z79.84
Episode Risk Groups
ERGs
"Not coded here" This note indicates that the code should not be used at the same time as the code above (two conditions that cannot occur together)
EXCLUDES1
"Not included here" This note indicates that the condition excluded is not part of the condition represented by the code (patient may have both conditions at the same time)
EXCLUDES2
RADV Check List
Each record must be clear, consistent, concise, complete and legible. 1. Is the record the correct enrollee? 2.Is the Record the correct calendar year for the payment year being audited? 3. Is the date of service present for the face-to-face visit? 4. Is the record legible? 5. Are there valid credentials and/or is there a valid physician specialty documented on the record? 6. If the outpatient/physician record does not contain a valid credential and/or signature, is there a completed CMS-Generated Attestation for this date of service? 7. Is there a diagnosis on the record? 8. Does the diagnosis support an HCC? 9. Does the diagnosis support the requested HCC?
hyperactivity of the neurons in the brain caused by brain disorders, brain trauma, stroke, brain cancers, and drug/alcohol abuse, and other conditions. Manifested through seizure activity. Symptom-related seizure should not be coded for seizure disorder, where seizures are recurrent per the Coding Clinic, 2008, Q1 publication.
Epilepsy & Convulsions
model developed by Ingenix in 2001
Episode Risk Groups
Means ulcers
Gastrointestinal term hemmorrhage
artificial opening created for nutritional support or gastrointestinal compression. Feeding tube may be called a G-tube or PEG tube depending on procedure used. Can be a surgical procedure, percutaneous (puncture through the skin) procedure, or a percutaneous endoscopic gastrostomy (PEG).
Gastrostomy
patient is connected to a machine (dialyzer) through a surgically created AV (arteriovenous) fistula so that blood can be pumped from the patient, cleansed through the machine, and then pumped back into the patient
Hemodialysis
gives a blood sugar average for the past 3 months and is the gold standard used by physicians to monitor the control of the diabetic's blood sugar. 7 or less is controlled and over 7 require changes to meds or insulin dosing or both.
Hemoglobin (A1C)
CASE 6 PREOPERATIVE DIAGNOSIS: Cataract, left eye POSTOPERATIVE DIAGNOSIS: Cataract eye Presbyopia PROCEDURE: 1 Cataract extraction with IOL implant 2 Correction of presbyopia with lens implantation PROCEDURE DETAIL: The patient was brought to the operating room under neuroleptic anesthesia monitoring. A topical anesthetic was placed within the operative eye and the patient was prepped and draped in usual manner for sterile ophthalmic surgery. A lid speculum was inserted into the right infrapalpebral space. A 6-0 silk suture was placed through the episclera at 12 o'clock. A subconjunctival injection of non-preserved lidocaine was given. A peritomy was fashioned from 11 o'clock to 1 o'clock with Westcott scissors. Hemostasis was achieved with the wet-field cautery. A 3-mm incision was made in the cornea and dissected anteriorly with a crescent blade The anterior chamber was entered at 12 o'clock and 2 o'clock with a Supersharp blade. Non-preserved lidocaine was instilled into the anterior chamber. Viscoelastic was instilled in the anterior chamber and using a bent 25-guage needle, a 360-degree anterior capsulotomy was performed using Utrata forceps. The capsulotomy was measured and found to be 5.5 mm in diameter. Using an irrigating cannula, the lens nucleus was hydrodissected and loosened. Using the phacoemulsification unit, the lens nucleus was divided and emulsified. The irrigating/aspirating tip was used to remove the cortical fragments from the capsular bag, and the posterior capsule was polished. Using a curette to polish the anterior capsule, cortical fragments were removed from the anterior lens capsule for 270 degrees. The irrigating/aspirating tip was used to remove the capsular fragments. The anterior chamber and capsule bag were inflated with viscoelastic and using a lens inserter, a Cystalens was then placed within the capsular bag and rotated to the horizontal position. The viscoelastic was removed with the irrigating/aspirating tip and the lens was found to be in excellent position with a slight posterior vault. The wound was hydrated with balanced salt solution and tested and found to be watertight at a pressure of 20 mmHg. Topical Vigamox was applied The conjunctiva was repositioned over the wound with a wet field cautery. The traction suture and lid speculum were removed. A patch was applied. The patient tolerated the procedure well and left the operating room in good condition. What diagnosis code(s) are reported?
H26.9, H52.4
A patient sees her provider for spontaneous episodes of vertigo lasting 30 minutes each, fluctuating hearing loss, and tinnitus. The provider performs a hearing test and confirms hearing loss in the right ear. The provider documents the patient has Meniere's disease in the right ear. What ICD-10-CM code(s) is (are) reported?
H81.01
CASE 5 PREOPERATIVE DIAGNOSIS: Bilateral profound sensorineural hearing loss. POSTOPERATIVE DIAGNOSIS: Bilateral profound sensorineural hearing loss.(Report the postoperative diagnosis.) PROCEDURES PERFORMED: 1. Placement of left Nucleus cochlear implant. 2. Facial nerve monitoring for an hour. 3. Microscope use. ANESTHESIA: General. INDICATIONS: This is a 69-year-old woman who has had progressive hearing loss (The diagnosis is documented as the indication for the surgery.) over the last 10-15 years. Hearing aids are not useful for her. She is a candidate for cochlear implant by FDA standards. The risks, benefits, and alternatives of procedure were described to the patient, who voiced understanding and wished to proceed. PROCEDURE: After properly identifying the patient, she was taken to the main operating room, where general anesthetic was induced. The table was turned to 180 degrees and a standard left-sided post auricular shave and injection of 1% lidocaine plus 1:100,000 epinephrine was performed. The patient was then prepped and draped in a sterile fashion after placing facial nerve monitoring probes, which were tested and found to work well. At this time, the previously outlined incision line was incised and flaps were elevated. A subtemporal pocket was designed in the usual fashion for placement of the device. A standard cortical mastoidectomy was then performed and the fascial recess was opened exposing the area of the round window niche. The lip of the round window was drilled down exposing the round window membrane. At this time, the wound was copiously irrigated with bacitracin containing solution, and the device was then placed into the pocket. A 1-mm cochleostomy was made, and the device was inserted into the cochleostomy with an advance-off stylet technique. A small piece of temporalis muscle was packed around the cochleostomy, and the wound was closed in layers using 3-0 and 4-0 Monocryl and Steri-Strips. A standard mastoid dressing was applied. The patient was returned to anesthesia, where she was awakened, extubated, and taken to the recovery room in stable condition. What diagnosis code(s) are reported?
H90.3
The percentage of members 18-75 years of age with diabetes (type 1 and type 2) who had each of the following: -Hemoglobin A1c testing -Eye exam (retinal) -Medical attention for nephropathy (includes attention to any one of the following: diabetic nephropathy, end stage renal disease. chronic renal failure, chronic kidney disease, renal insufficiency. proteinuria, albuminuria, renal dysfunction. acute renal failure, dialysis. hemodialysis or peritoneal dialysis) -Blood pressure measurement for control (< 140/90)
HEDIS measure for Diabetes management includes:
**health and human recourses **reports annual Medicare Advantage payment error rate. if diagnosis not validated by the medical documentation, it contributes to payment error rate
HHS
Diagnosis-Based Risk Adjustment Examples
HHS HCC- Commercial, Individual, and Small Group CDPS Medicare HCC-C DRG-Inpatient ACG- Outpatient
The Department of Health and Human Services - Hierarchical Condition Category
HHS-HCC
RADV
HHS-RADV -- Risk Adjustment Data Validation
Which of the following does NOT require documentation for a cause-and-effect relationship to be coded? (Reference guideline I.C.9.a.2 and I.C.9.a.3)
Hypertension and chronic kidney disease
1) Hypertension with Heart Disease ( I50.- or I51.4I51.9) 2) Hypertensive Chronic Kidney Disease ( I12 and type of Kidney disease N18) 3) Hypertensive Heart and Chronic Kidney Disease ( I13, Type of Kidney disease and type of heart failure) 4) Hypertensive Cerebrovascular Disease ( I60-I69) 5) Hypertensive Retinopathy 6) Hypertension, Secondary 7) Hypertension, Transient 8) Hypertension, Controlled (I10-I15) 9) Hypertension, Uncontrolled (I10-I15) 10) Hypertensive Crisis (I16) 11) Pulmonary Hypertension (I27.1, I27.2-)
Hypertension coding
thickened myocardium (heart wall)
Hypertrophic Cardiomyopathy
thyroid gland does not make enough thyroid hormone
Hypothyroidism
CASE 10 CC: HTN INTERVAL HISTORY: No new complaints. EXAM: NAD. 130/80, 84, 22. Lungs are clear. Heart RRR, no MRGs. Abdomen is soft, non-tender. No peripheral edema. IMPRESSION: Stable HTN on current meds. PLAN: No changes needed. RTC in six months with labs. What diagnosis code(s) are reported?
I10
A patient is coming in for follow up of his essential hypertension and cardiomegaly. Both conditions are stable and he is told to continue with his medications. The two conditions are unrelated. What ICD-10-CM code(s) is/are reported?
I10, I51.7
For encounters occurring while the myocardial infarction is equal to, or less than, four weeks old, including transfers to another acute setting or a postacute setting, and the myocardial infarction meets the definition for "other diagnoses" codes from category _______ may continue to be reported.
I21
Type 1 myocardial infarctions are assigned to codes
I21.0-I21.4
If only type 1 STEMI or transmural MI without the site is documented, assign code ________, ST elevation (STEMI) myocardial infarction of unspecified site.
I21.3
Codes for type 1 non ST elevation myocardial infarction (NSTEMI) and nontransmural MIs
I21.4
Acute myocardial infarction, unspecified, is the default for unspecified acute myocardial infarction or unspecified type.
I21.9
What ICD-10-CM code is used for the first episode of an acute myocardial infarction?
I21.9
Type 2 myocardial infarction, and myocardial infarction due to demand ischemia or secondary to ischemic balance, is assigned to code _____________________.
I21.A1, Myocardial infarction type 2 with a code for the underlying cause
Acute myocardial infarctions type 3, 4a, 4b, 4c and 5 are assigned to code ___________________.
I21.A9, Other myocardial infarction type
When a patient who has suffered a type 1 or unspecified AMI has a new AMI within the 4 week time frame of the initial AMI.
I22 (Subsequent ST elevation (STEMI) and non-ST elevation (NSTEMI) myocardial infarction)
Patient with coronary arteriosclerosis disease (CAD) sees his cardiologist to discuss a coronary artery bypass graft (CABG). This will be the patient's first CABG. What ICD-10-CM code is reported?
I25.10
CASE 4 S: The patient presents today for reevaluation and titration of carvedilol for his coronary artery disease and hyperlipidemia.(Patient returns for treatment of CAD and hyperlipidemia.) His weight is up 7 pounds. He has quit smoking. He has no further cough and he states he is feeling well except for the weight gain. He states he doesn't feel he's eating more, but his wife says he's eating more. We've been attempting to titrate up his carvedilol to 25mg twice a day from initially 6.25mg. He has tolerated the titration quite well. He gets cephalgias on occasion. He states he has a weak spell but this is before he takes his morning medicine. I updated his medical list here today. I gave him samples of Lipitor. O: Weight is 217, pulse rate 68, respirations 16, and blood pressure 138/82. HEENT examination is unchanged. His heart is a regular rate. His lungs are clear. A: 1. CAD 2. Hyperlipidemia (Select the codes for the definitive diagnoses.) P: 1.The plan is samples of Lipitor using the two months' supply that I have given him. 2. We've increased his Coreg to 25mg bid. He'll recheck with us in six months. What diagnosis code(s) are reported?
I25.10, E87.5, Z87.891, Z79.899
For old or healed myocardial infarctions not requiring further care, code _________, Old myocardial infarction, may be assigned.
I25.2
CASE 8 Subjective: Here to follow up on her atrial fibrillation. No new problems. Feeling well. Medications are per medication sheet. These were reconstituted with the medications that she was discharged home on. 0bjective: Blood pressure is 110/64. Pulse is regular at 72. Neck is supple. Chest is clear. Cardiac normal sinus rhythm. Assessment: Atrial fibrillation, currently stable Plan: 1. Prothrombin time to monitor long term use of anticoagulant. 2. Follow up with me in one month or sooner as needed if she has any other problems in the meantime. Will also check a creatinine and potassium today. What diagnosis code(s) are reported?
I48.91, Z79.01, Z51.81
A patient presents to the ED with weakness on the left side and aphasia. Tests are ordered and the patient is admitted with a cerebrovascular accident (CVA). What ICD-10-CM code(s) is/are reported?
I63.9
combination codes with or without angina pectoris.
ICD 10 CM CAD
two codes not required because code includes anatomic site and laterality
ICD 10 CM codes for occlusion and stenosis
**left side: default non-dominant **right side: default is dominant **ambidextrous: default is dominant
ICD 10 hemiparesis
accurate reimbursement contains
ICD 9 CM & ICD 10 CM basis of ra models accurate dx codes are a result of clear, consistent, and complete documentation CMS verifies accuracy
Coding of sequela generally requires 2 codes sequenced in following order 1. condition or nature of the sequela sequence first 2. sequela code is sequenced second Exceptions is never to code acute phase of illness/injury that led to the sequela
ICD Guidelines Sequela (late effects)
Code assignment may be based on medical record documentation from clinicians not the patient's provider; however, associated obesity must be documented by the patient's provider. -adult is defined as persons 21 years of age or older -pediatrics are defined as persons 2-20 years of age and not based on height/weight ratio, but instead on percentile based on the growth charts published by the Centers for Disease Control and Prevention (CDC) -Only document code for BMI when it has been documented in the record and never make calculation to obtain undocumented BMI. -although BMI establishes standard numeric values that correlate with obesity, coders should never code for obesity or morbid obesity based off a BMI measurement. The treating provider must document to code for them.
ICD-10 BMI Coding Guidelines
treating provider must document the stage, never infer from the lab results based on creatinine and GFR (glomerular filtration rate). -when provider documents between stages, such as stage 1-2, or 2-3, always choose the lower of the 2 stages. Can code stage based off descriptors (mild, moderate, severe) in lieu of stage number.
ICD-10 CKD Coding Guidelines
If the same condition is described as both acute (subacute) and chronic, and separate subentries exist in the Alphabetic Index at the same indentation level, code both and sequence the acute (subacute) code first
ICD-10 Guideline Acute/Chronic Conditions
-patient has bilateral conditoin and each side is treated during separate encounters, assign "bilatera" code (as condition still exists on both sides) including encounter to treat 1st side -second encounter for treatment, after 1 side has previously been treated, and the condition no longer exists on that side, code the appropriate unilateral code for the side where the conditions still exists
ICD-10 Laterality Coding Guidelines
V codes; ex: V64.41 ( Laparoscopic surgical procedure converted to open procedure )
If a patient goes in for surgery and planned having a laparoscopic px but has to an open px, what type of code would you assign?
Code infection following procedure T81.4
If a person is read mitt because
dependence
If drug or alcohol use, abuse and dependence are all documented, assign the code for _____.
Often clear quickly code from categoryG81 event without treatment
If hemiplegia occurring with cerebrovascular accident(CVA)
T
If laterality is not identified in the medical record, assign the code for the unspecified side.
dominant
If the affected side is documented, but not specified as dominant or non-dominant, ambidextrous patients would have which coded as the default in category G81?
Y84.2 - Radiological procedure and radiotherapy as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure.
If the anemia is caused by the radiotherapy and the treatment is focused on the anemia, the anemia is coded first, followed by a code for the neoplasm, and then...
Go to infection
If the organic is specified but not indexed under main term
Z16.11 - Resistance to penicillin...... as an additional diagnosis.
If there is no combo code available, do not assign......
Probably Forever/Almost ALLS
Is this condition a Probably Forever/Almost ALLS (still has condition even though mediation or device is covering up symptoms), Forever/ALLS, or a Chronic condition? Septicemia (Category 380)
Probably Forever/Almost ALLS
Is this condition a Probably Forever/Almost ALLS (still has condition even though mediation or device is covering up symptoms), Forever/ALLS, or a Chronic condition? Acute Kidney Failure, Chronic Kidney Disease (Categories 584-585)
Probably Forever/Almost ALLS
Is this condition a Probably Forever/Almost ALLS (still has condition even though mediation or device is covering up symptoms), Forever/ALLS, or a Chronic condition? Perforated Gastric, Duodenal, Peptic, and Gastrojejunal Ulcers (Categories 531-534)
Probably Forever/Almost ALLS
Is this condition a Probably Forever/Almost ALLS (still has condition even though mediation or device is covering up symptoms), Forever/ALLS, or a Chronic condition? Pathologic Fractures of Vertebrae, Neck of Femur, other specified part of Femur (Category 733)
Probably Forever/Almost ALLS
Is this condition a Probably Forever/Almost ALLS (still has condition even though mediation or device is covering up symptoms), Forever/ALLS, or a Chronic condition? Schizoprenia
Forever/ALLS
Is this condition a Probably Forever/Almost ALLS (still has condition even though mediation or device is covering up symptoms), Forever/ALLS, or a Chronic condition? Upper Limb Amputation status
CASE 7 PROGRESS NOTE This patient is a 50 year-old female who began developing bleeding, bright red blood per rectum, approximately two weeks ago. She is referred by her family physician. She states that after a bowel movement she noticed blood in the toilet. She denied any prior history of bleeding or pain with defecation. She states that she has had an external hemorrhoid that did bleed at times but that is not where this bleeding is coming from. She is presently concerned because a close friend of hers was recently diagnosed with rectal carcinoma requiring chemotherapy that was missed by her primary doctor. She is here today for evaluation for a colonoscopy. Physical examination, she appears to be a well appearing 50 year-old, white female. Abdomen is soft, non-tender, non-distended. ASSESSMENT: 50 year-old female with rectal bleeding PLAN: We'll schedule the patient for an outpatient colonoscopy. The patient was made aware of all the risks involved with the procedure and was willing to proceed. What diagnosis code(s) are reported?
K62.5
residual condition produced from the acute phase of another illness or injury and there is no time limit to use a late effect code, as it may occur immediately, or months/years later. Phrases to indicate include "result of," "due to," "because of," "secondary to," "related to," etc
Late Effect
Found under Sequelae
Late effect
Specifying whether the condition occurs on the left, right and bilateral. If no code is available bilateral code both sides, if medical records don't identify code unspecified side.
Laterality
the end of the bone is displaced outwardly (laterally) to the joint and its normal anatomic position
Laterally dislocation
Merkel Cell Carcinoma
MCC
bones that are longer than they are wide
Long bones
prostate cancer
Lupron treats
A patient returns to the provider for an injection to relieve low back pain from a car accident. What ICD-10-CM code(s) is/are reported?
M54.5
medical record submission:
MA request from providers: *attach HIPAA fact sheet, org contact, and CMS signed sample provider letters *ONE best medical record to submit with completed coversheet *dos may include consecutive range of dates for inpatient record; one dos if outpatient or physician provider *one coversheet for each HCC being validated
local coverage determinations (LDC) are administered by MAC. each region MAC is responsible for interpreting national policies into regional policies
MAC (Medicare Administrative Contractor
The Medicare Access and CHIP Reauthorization Act of 2015
MACRA
Medicare Advantage Prescription Drug
MAPD
1. Be designed to improve health quality 2. Enhance health information technology in a way that improves quality, transparency, or outcomes. 3. Be designed to increase the likelihood of desired health outcomes in ways that can be objectively measured and produce verifiable results 4. Be directed toward individual health plan members, incurred for the benefit of specified member segments or provide health improvements to the general population 5. Be grounded in evidence-based medicine, widely accepted best clinical practice or criteria established by recognized health care quality organizations 6. Programs to help individuals manage serious conditions such as cancer or heart disease 7. Hospital discharge planning designed to reduce hospital readmission. 8. Activities to improve patient safety and reduce medical errors 9. Health assessments and wellness coaching designed to manage a health condition or achieve measurable health improvements 10. Arranging and managing transitions 11. Medication and care compliance 12. Prospective medical and drug utilization review 13. Programs to support shared decision-making with patients, their families, and the patient's representatives 14. Use of medical homes (as defined in the ACA) 15. Nurse-line (with some exceptions) 16. Comprehensive discharge planning.
MLR provision calls for health insurers to report annually to HHS on the percent of total premium revenue spent on activities that improve health care quality. These activities must meet 16 requirements. Name them.
MMP
Medicare Medicaid Plans
RxHCC
Medicare part D
Stopping or attempt to stop post-procedural bleeding; if unsuccessful and another more definitive root operation is performed code that instead of control
Root operation Control
paraoxysmal means sudden burst, or display of the tachycardia in portions or waves where there is a great intensity, which calms and then bursts forth in display again. Supraventricular tachycardia is a rapid atrial rhythm, while a ventricular tachycardia is a rapid ventricular rhythm.
Paroxysmal Supraventricular Tachycardia (PSVT)
ACO QA Measures Domain 1
Patient / Caregiver Experience
Indicate that a diagnosis is still possible code as confirmed
Rule out
Indicates that a diagnosis once considered likely is no longer possible never code
Ruled out
DxCG
Rx Groups
Monthly Part D direct subsidy
RxHCC model adjusts standardized payments for?
sequela of fracture
S
A patient is admitted to the hospital for repair of an open fracture, type 1, of the head of the left femur. The patient has been previously diagnosed with symptomatic HIV. What ICD-10-CM code(s) is/are reported for the admission?
S72.052B, B20
A 23 year-old patient presents to the Emergency Department with a cut on his leg. He is a confirmed AIDS patient as documented in the record. What ICD-10-CM codes should be reported?
S81.819A, B20
Systemic inflammatory response syndrome a systemic response to infection or trauma with such symptoms as fever and tachycardia
SIRS
Social Security Disability Insurance
SSDI
coronary artery is completely blocked and virtually all the heart muscle being supplied by the affected artery starts to die
STEMI
Types of MI
STEMI and NSTEMI
If a type 1 NSTEMI evolves to STEMI, assign the _______ code. If a type 1 STEMI converts to NSTEMI due to thrombolytic therapy, it is still coded as ________.
STEMI, STEMI
Report when a related definitive diagnosis has not been established or confirmed by the provider.
Signs/Symptoms
C73
The patient was diagnosed with carcinoma of the left lobe of the thyroid gland and underwent an open total thyroidectomy. Code the principal (first-listed) diagnosis.
S72.012A
The patient is treated for an intracapsular fracture of the neck of the left femur (initial treatment). An open reduction with insertion of nail was done. Code the principal (first-listed) diagnosis.
0QS704Z
The patient is treated for an intracapsular fracture of the neck of the left femur (initial treatment). An open reduction with insertion of nail was done. Code the procedure.
TPA
Third Party Administrators
involve the epidermis, dermis and varying levels of the subcutaneous and underlying structures
Third degree burns
C34.32
This 58-year-old male patient has carcinoma of the left lower lung lobe. A thoracoscopic ablation of the left lower lung lobe was performed. Code the principal (first-listed) diagnosis.
I69.354
This patient had an acute cerebral infarction with left-sided hemiparesis. She was transferred to the LTC facility with a diagnosis of acute CVA. What code is assigned in the long term care facility?
Admitted for treatment of secondary site solely is the principal diagnosis.
Treatment for secondary site
1- less than 14 wks 2- less than 28 wks, more than 14 3- 28 wks thru delivery
Trimesters
wound is greater than 1 cm with moderate soft tissue injury; typically simple transverse, short oblique fracture, or with minimal comminution
Type II Gustilo Classification
F
When a patient is admitted with respiratory failure and another acute condition (such as AMI or CVA) the principal diagnosis is always respiratory failure.
1. Accurate coding and capture of all chronic conditions 2. Only the physician or NPP can document in the patient chart. 3. At minimum, diagnosis/HCC codes should be captured every 6 months. 4. CMS "drops" the codes from the prior year every December 31 and starts over again with each member's conditions for the new year.
What are the 4 key components (combination of measures) of a RAF Score?
1. Provider Performance Assessment 2. Patient Outcome Monitoring
What are the combined data areas used to depict member health risk profiles for Case Mix and Risk Adjustment?
1. First Friday in September = Initial Risk Score 2. First Friday in March = Mid-year Update 3. January 31 after the payment year = Final reconcilation
What are the three submission deadlines?
1. Billing for services not provided 2. Billing for a higher reimbursed diagnosis code when a less costly diagnosis code is the most specific and appropriate for the service performed.
What are two categories that are defined by Predictive Modeling that indicate aberrant behavior?
K29.00
What code is assigned for acute gastritis without bleeding?
MA organization
What does Batch-level information identify?
Consumer Assessment of Healthcare Providers and Systems
What does CAHPS stand for?
Clinical Nurse Specialist
What does CNS (medical professional) stands for?
Committee for Public Comment
What does CPM stand for?
Beneficiary
What does Detail-level information identify?
Submitter
What does File-level information identified?
Healthcare Effectiveness Data and Information Set
What does HEDIS stand for?
Health Organization Questionairre
What does HOQ stand for?
Health Plan Organizations
What does HPO stand for?
Health Risk Assessment
What does HRA stand for?
Interactive Data Submission System
What does IDSS stand for?
Initial Preventive Physical Exam
What does IPPE stand for?
Key Performance Indicators
What does KPI stand for?
Personalized Prevention Plan Services
What does PPPS stand for?
Risk Adjustment Data Validation
What does RADVs stand for?
A patient with chronic conditions
What does a risk score above 1.00 suggest?
Additional characters are needed.
What does the dash (-) mean in ICD-10-CM?
1.00
What if the average risk score CMS suggest for an average healthy senior?
To provide purchases and consumers with the information they need to reliably compare the performance of health care plans.
What is HEDIS purpose?
J44.9 Chronic obstruction pulmonary disease, unspecified
What is ICD-10-CM code for COPD?
The code that represents the condition most commonly associated with the main term
What is a default code? Refer to ICD-10-CM guidelines, section 1.A.18.
Prevents multiple diagnoses in the same disease group from skewing the risk score with a higher score. The more severe diagnoses "trumps" the lower diagnoses within the same disease group.
What is diagnostic hierarchies?
It is a list of providers who we think we might be able to obtain a HCC
What is the "Suspect Generation List"?
To indicate whether the abortion is complete or incomplete.
What is the 5th digit sub classification used for when coding an abortion?
S80-02XA
What is the ICD-10-CM code for a bruised left knee?
I10
What is the ICD-10-CM code for essential hypertension?
N40.1, R33.8 (listed as an additional code to report urinary retention)
What is the ICD-10-CM code for prostate hyperplasia with urinary retention?
V70.0 - Preventative Medicine
What is the ICD-9 code for AWV?
Ensures that a minimum percent of premiums are used to pay claims. This limits the amount of insurance companies can spend on administrative expenses and profits.
What is the MLR Provision?
It contains a series of red flags indicating which demographic factors and disease factors are used to calculate the risk score for each non-hospice beneficiary enrolled in the plan.
What is the MOR?
Plan Liability Model
What is the another name for the RxHCC model?
T16.2XXA
What is the correct code for an initial encounter for a foreign body in the left ear?
Code 650; Delivery is entirely normal w/single liveborn outcome; No postpartum complications, and any antepartum comp experienced during pregnancy must have been resolved before the time of delivery.
What is the definition of a Normal Delivery?
V22
What is the new CMS-HCC RA model?
To allow for adjustments in capitated (set amount for each enrolled person assigned to them, per period of time, whether or not that person seeks care) payment amounts so that MA plans pay out fairly and accurately and minimize questionable incentives in order to avoid enrolling sicker beneficiaries.
What is the point of risk adjustment?
All HCCs are dropped.
What is the significance of December 31 in HCC coding?
M25.551 (right hip pain), M25.552 (left hip pain)
What is/are the ICD-10-CM code(s) for bilateral hip pain?
A
What seventh character is assigned to code S82.62x for a patient who broke his left lateral malleolus two weeks ago? He was initially seen in the emergency room, and is now coming to the hospital to have an ORIF done for his displaced fracture.
Additive and Hierarchical. Allows for more than one disease to impact the final risk score.
What two models are used to calculate a RAF score properly? What do these models allow to happen to the final risk score?
File-level, batch-level and first and last detailed records
What types of data are checked in FERAS?
T
When a cystoscopy is performed to visualize the bladder and no other procedure is performed, code 0TJB8ZZ is assigned.
Use a combination code whenever available that incorporates a hemorrhage and the specific disorder. Use the 578.x category as an additional code when no combo code has been created or when the cause of the hemorrhage is unknown.
When a dx of Gastrointestinal is aparent, what rule should you follow?
Only for encounter for rape if no physical finding if physical finding is found do not assigned Z04.41
Z04.41 cover collection of specimen advice given & counseling
Is assigned principal diagnosis when the reason is admitted for the purpose of surveillance after the initial treatment has been completed
Z08,Z09, Z39
Being seen to determine HIV status.
Z11.4
Asymptomatic human immunodeficiency virus (HIV) infection is applied when the patient is HIV positive and does not have any documented symptoms of an HIV related illness. What is the code?
Z21
Tested HIV positive, but no signs or symptoms of the condition.
Z21 (HIV)
What code should be used to report weeks of gestation?
Z38
Having signs or symptoms is being seen for HIV testing... Patient returns and is informed HIV negative.
Z71.7
Are assigned for long termed of a condition not to treat acute illness or brief period
Z79
For patients with secondary diabetes mellitus who routinely use insulin or oral hypoglycemic drugs, an additional code from category _______________ should be assigned to identify the long-term (current) use of insulin or oral hypoglycemic drugs.
Z79
Code ___________ should not be assigned if insulin is given temporarily to bring a type 2 patient's blood sugar under control during an encounter.
Z79.4
If the patient is treated with both oral medications and insulin, only the code for long-term (current) use of insulin should be assigned. Code ____________ should not be assigned if insulin is given temporarily to bring a secondary diabetic patient's blood sugar under control during an encounter.
Z79.4
When a primary malignancy has been previously excised or eradicated from its site, there is no further treatment (of the malignancy) directed to that site, and there is no evidence of any existing primary malignancy, a code from category ____________________________.
Z85, Personal history of malignant neoplasm, should be used to indicate the former site of the malignancy
pancreatic tumor which increases acid production
Zollinger-Ellison Syndrome
Brackets are used in the Tabular List to enclose synonyms, alternate wording, or explanatory phrases. Brackets are used in the Index of Diseases and Injuries to identify manifestation codes in which multiple coding and sequencing rules will apply
[ ]
Secondary Review
additional analysis is performed to determine the medical records that should be submitted to CMS that support the HCC values sampled, for additional review and analysis
adrenal gland, epinephrine
adren/o
adrenal gland, epinephrine
adrenal/o
adrenal cortex
adrenocortic/o
For encounters after the 4 week time frame and the patient is still receiving care related to the myocardial infarction, the appropriate ___________ should be assigned, rather than a code from category I21.
aftercare code
ra rule
all ra diagnosis codes submitted must be supported by medical record documentation
interactions
allow for additive factors based on chronic conditions and disabled status to increase payment accuracy
hierarchies
allow for payment based on most serious conditions when less serious conditions exist
purpose of risk adjustment
allows CMS to pay plans for the risk of the beneficiaries they enroll, instead of an average amount for Medicare beneficiaries
risk scores
allows CMS to use standardized bids as base payments to plans
CMS RADV
allows any fact-to-face encounter for audit support
HHS HRADV
allows for as many DOS submissions as the health plan would like to submit provided they were all processed on the Edge server
CMS RADV
allows for up to five best records to support an HCC
HHS HRADV
allows only those DOS that were submitted on the Edge server with an exception to allow encounters that would normally be accepted on the Edge server
Concurrent Reviews
are performed ongoing; as patient's are seen and maybe after or prior to reporting; in RA, these are typically the current year, combined with the prior year's DOS
Reviews & Audits
are performed within health plans and other organizations, while some work is accomplished using trusted vendors to achieve
Retrospective Reviews
are preformed after the information has been reported; in RA these are typically the prior year's DOS
Categories
are subdivided into 79 HCC's where certain categories have several subcategories. The subcategories make the Hierarchies in the term Hierarchical Condition Categories.
heart
cardi/o
***first-listed code for artery (i.e. basilar artery), carotid artery, vertebral artery ***additional code reported for multiple and bilateral precerebral artery disease
carotid stenosis guideline (bilateral occlusion and stenosis of precerebral arteries
Hierarchies of CDPS
carry the same rule of thumb, with those diagnoses that are less serious being overridden by a higher value condition in the same family or hierarchy
tough flexible tissue found in many places throughout the body; covers and protects the end of the bone at the joint
cartilage
cell membranes forms boundary of cell; surrounds and protects individual cell
cell membranes
cerebrum
cerebr/o
bile, gall
chol/e
bile, gall
chol/o
bile duct
cholangi/o
gallbladder
cholecyst/o
common bile duct
choledoch/o
cartilage
chondr/o
located in nucleus of cell; contain genes that determine hereditary characteristics
chromosomes
Septic shock generally refers to ______________________ associated with severe sepsis, and therefore, it represents a type of acute organ dysfunction
circulatory failure
New Beneficiary Calculations
during the payment year CMS assigns a new enrollee factor to any beneficiary who does not have 12 months of diagnoses to support a risk score
out; outside
ec-
condition in which blood seep sinto the skin causing discoloration
ecchymosis
out; outside
ecto-
Disease Interactions
enable an added value to conditions that are not only chronic to manage, but also that may be especially complex when paired with another co-morbidity/condition
specialized structures required for hair growth
follicles
PACE
frail and elderly individuals eligible for nursing home placement based on state medicaid criteria
outpatient and physicians dos
from date and through date may be the same
inpatient dos
from date and through date must be different; reflects dates of admission to and discharge from a facility
FERAS
front-end risk adjustment system; ra submitters sends data to palmetto through FERAS
cuts at right angle to midline; from side to side, and divides body into front (anterior) and back (posterior) sections
frontal (coronal)
serves to protect the underlying structures, prevent loss of body heat, anchor skin to underlying musculature
functions of hypodermis
Commercial Plan
funding is allocated based on the current year's known diagnoses
Medicare
funding is allocated based on the previous year's known diagnoses (or medical problems)
ganglion
gangli/o
ganglion
ganglion/o
stomach
gastr/o
specific segment of base pairs in chromosomes; functional unit of heredity
gene
protection from injury, fluid loss, and microorganism; temperature regulation; fluid balance; sensation
integumentary functions
pertaining to within the skin
intradermal
HHS HRADV
involves all participating plans
CMS RADV
involves choosing health plans by random sampling or targeting efforts
nervous system, nervous tissue, nerve
neur/o
practical relevant and well organized communication
no background noise, clear and easy to read/understand
small, round structure in center of cell
nucleus
CDPS Plan payment is calculated based on the ? , versus in CMS-HCC Model, plan payment is calculated directly from risk scores of
overall risk score of the population; individual enrollees
A primary malignant neoplasm that overlaps two or more contiguous (next to each other) sites should be classified to the subcategory/code .8 ('overlapping lesion'), unless the combination is specifically indexed elsewhere. For multiple neoplasms of the same site that are not contiguous such as tumors in different quadrants of the same breast, codes for each site should be assigned.
overlapping malignant lesion
ovum, egg cell
ovul/o
parathyroid gland
parathyr/o
parathyroid gland
parathyroid/o
HCC Model
pathology is allowed from HI facilities, HO facilities, and physicians, and that the encounter is within an approved provider
ADLs
patient functional abilities Activities of Daily Living
Annual Risk Adjustment Audits
performed by CMS on risk adjustment data submitted by, or on behalf of, health plans to ensure program integrity
according to OIG, internal monitoring and auditing should be performed .
periodic audits
ongoing evaluations includes not only whether the physician practice's standrds and procedures are in fact current and accurate, but also whether the compliance program is working, i.e., whether individuals are properly carrying out their responsibilities and claims are submitted appropriately.
periodic audits
lens
phak/o
pharynx
pharyng/o
vein
phleb/o
diaphragm
phren/o
phrenic nerve
phrenic/o
staff model
physician are paid employees managed care plan; phyisicans generally provide services in clinic setting
capitated
physician pay is fixed amount per patient per month, regardless of types of services provided
co-existing/related conditions
physicians should code all documented conditions that co-exist at time of visit, and require or affect patient care
pituitary gland, hypophysis
pituitar/o
HHS HCC Model
plans are adjusted by plan metal level geographical rating area induced demand age rating so that transfers reflect health risk and not other cost differences
Catastrophic
plans available to those under 30 years or those over 30 years with a qualifying hardship
Payers
play several roles in helping ACOs achieve higher quality of care and lower expenditures, and may collaborate with one another to align incentives for ACOs and to create financial incentives for providers to improve health-care quality.
pleura
pleur/o
ae
plural ending -a
ina
plural ending -en
ices
plural ending -ex, -ix, -yx
es
plural ending -is
mata
plural ending -ma
nges
plural ending -nx (anx, inx, ynx)
a
plural ending -on
a
plural ending -um
i
plural ending -us
air, gas; respiration, lung
pneum/o
air, gas; respiration, lung
pneumat/o
lung
pneumon/o
Additional signs and symptoms that may not be associated routinely with a disease process _____________ when present.
should be coded
Prospective Reviews
similar to concurrent, because when considering the current year's encounters, these will affect the next year and not the current year, where payment is concerned risk assessments to include home assessments are often called ....
sleep
somn/i
sleep
somn/o
medical records
submit via electronic media, fax, hardcopy. do not email
attached at end of word to modify its meaning; not all terms have suffix. frequently indicates procedure, condition, disorder, or disease
suffix
closer to surface of body
superficial (external)
fibrous connective tissue located in hypodermis
superficial fascia
above; toward head
superior (cranial)
urinary bladder
vesic/o
seminal vesicle
vesicul/o
sinking of abdominal organs below normal position
viceroptosis
documentation of weakness cannot be use to code hemiparesis. weakness is considered symptom code and maybe used for other conditions
weakness
Newly Assigned Beneficiary
when beneficiaries are assigned to an ACO for the first year they become entitled to Medicare, they are newly assigned, but CMS has not diagnosis data for those patients prior to their Medicare entitlement. These patients receive new enrollee risk score without any adjustment for health conditions
Greatest Hierarchical Rank
while there may be two or more valid conditions with Risk Adjustment Value only the one with the greatest hierarchical rank will be included in the risk score for the patient
CDPS & MRX
work by mapping diagnoses and their pharmaceutical use to a group (vector) of disease categories
