Competency 2: Healthcare Classification Systems

When did HCFA (now CMS) implement the National Correct Coding Initiative for physician claims?

1996 - The Medicare National Correct Coding Initiative (NCCI) (also known as CCI) was implemented to promote national correct coding methodologies and to control improper coding leading to inappropriate payment.

Coding accuracy is best determined by:

A predefined audit process

The period of time between discharge and claim submission, which a facility defines by policy, is called the:

Bill Hold - A bill hold is a situation where a claim is put on hold due to missing or incorrect information, such as a missing diagnosis code or incorrect patient information.

A coding audit shows that an inpatient coder is using multiple codes that describe the individual components of a procedure rather than using a single code that describes all the steps of the procedure performed. Which of the following should be done in this case?

Counsel the coder to stop the practice immediately

At Medical Center Hospital, HIM professionals are located in the nursing stations, where they are responsible for all aspects of health record processing. While the patient is in the facility, the HIM professional does a daily review of the record to ensure complete documentation. This approach is called a _____.

Concurrent review

All of the following are goals for a clinical documentation improvement program:

a. Promoting record completion during the patient's stay b. Identifying missing, conflicting, or nonspecific documentation c. Improving communication between the physician and the care team

The primary responsibility of a coder is to:

Ensure accuracy of coded data

A patient who was admitted for treatment of an intervertebral disk injury developed a urinary tract infection and fever several days after undergoing surgery. In this situation the urinary tract infection would be classified as:

Healthcare-associated infection

Community Hospital implemented a clinical document improvement (CDI) program six months ago. The goal of the program was to improve clinical documentation to support quality of care, data quality, and HIM coding accuracy. Which of the following would be best to ensure that everyone understands the importance of this program?

Include ancillary clinical staff and medical staff in the process

Coding compliance programs focus on preventing accusations of fraud and abuse in healthcare. Which organization from the Department of Health and Human Services provides guidance for healthcare organizations in developing compliance programs?

Office of the Inspector General (OIG)

You are the coding manager and are completing a review of a new coder's work. The case facts are that the patient was treated in the emergency department for two forearm lacerations that were both repaired with simple closure. The new coder assigned one CPT code for the largest laceration. Which of the following would be the correct CPT code assignment for this case?

One CPT code adding the lengths of the lacerations together

Which of the following elements is found in a charge description master?

Procedure or service charge

Which of the following is the principal goal of internal auditing programs for billing and coding?

Protect providers from sanctions or fines

In reviewing a patient chart, the coder finds that the patient's chest x-ray is suggestive of chronic obstructive pulmonary disease (COPD). The attending physician mentions the x-ray finding in one progress note, but no medication, treatment, or further evaluation is provided. Which of the following actions should the coder take in this case?

Query the attending physician and ask him to validate a diagnosis based on the chest x-ray results

A patient is admitted to the hospital with shortness of breath and congestive heart failure. The patient undergoes intubation with mechanical ventilation. The final diagnoses documented by the attending physician are: Congestive heart failure, mechanical ventilation, and intubation. Which of the following actions should the coder take in this case?

Query the attending physician as to the reason for the intubation and mechanical ventilation to add as a secondary diagnosis

Carolyn works as a coder in a hospital inpatient department. She sees a lab report in a patient's health record that is positive for staph infection. However, there is no mention of staph in the physician's documentation. What should Carolyn do?

Query the physician - A medical coding query is a formal request for more information or clarification from a healthcare provider about something written in a patient's medical record. Queries are an important part of the medical coding process and are used to ensure accurate documentation, billing, and reimbursement.

An 80-year-old female is admitted with fever, lethargy, hypotension, tachycardia, oliguria, and elevated WBC. The patient has more than 100,000 organisms of Escherichia coli per cc of urine. The attending physician documents "urosepsis." How should the coder proceed to code this case?

Query the physician to ask if the patient has septicemia because of the symptomatology.

Which of the following is the definition of revenue cycle management?

The coordination of all administrative and clinical functions that contribute to the capture, management, and collection of patient service revenue

Why is it important to have a CDI physician champion or advisor?

To allow for peer-to-peer physician communication and education

A physician performed a total abdominal hysterectomy with bilateral salpingo-oophorectomy on his patient at Community Hospital. His office billed the following:

Unbundled procedures

The coder assigned separate codes for individual tests when a combination code exists. This is an example of which of the following?

Unbundling -is a type of medical billing fraud that occurs when a medical provider bills complex procedures separately instead of as one coded procedure. This allows the provider to recover more reimbursement for the same services, which can illegally increase their profits. Unbundling is also known as "fragmentation"

The practice of using a code that results in a higher payment to the provider than the code that actually reflects the service or item provided is known as:

Upcoding - is a type of healthcare fraud that occurs when a provider submits inaccurate billing codes to Medicare, Medicaid, or private insurers for a procedure or treatment that is more serious or expensive than what was actually performed.