Overview of coding

The coding system that is used to classify dental procedures and services is called the

Current Dental Terminology (CDT) Example Patient underwent incision and drainage of intraoral soft tissue abscess. CDT code D7510 is assigned.

The American psychiatric association published a standard classification of mental disorders called the _____ -5

DSM

Which is a standard classification of mental disorders used by mental disorder used by mental health professionals in the United States

DSM

Medical necessity requires providers to document procedures, services, and supplies that are proper and needed for the A) convenience of the physician or health care facility B) diagnosis or treatment of a patients medical condition

Diagnosis or treatment of a patients medical condition

The health insurance portability and accountability act of 1996 (HIPPA) requires two types of code sets, large code sets and small code sets, to be adopted for the purpose of _____ data elements A) decrypting B) encoding C) interpreting D) translating

Encoding

A progress note contains documentation that the EKG showed elevated T-wave changes. This statement would be located in the _____ portion of the POR progress note

objective

Reporting codes for signs and symptoms in addition to the established diagnosis code is called:

overcoding

A progress note contains documentation that the patient is to be followed up with in the physician's office two weeks after discharge from the hospital. This statement would be located in the __________ portion of the POR progress note.

plan

Continuity of patient care is considered a ______ purpose of the patient record. a. primary b. secondary

primary

Coders should always avoid assumption coding, and can do so by generating a physician ________ when documentation needs clarification prior to the assignment of codes.

query

Which is used to capture paper record images onto storage media

scanner

When a multi-hospital system provides physician office services along with traditional inpatient, outpatient, and emergency department hospital care, the concept of ______ coding is adopted to facilitate professional and institutional billing.

single path

Reporting multiple codes to increase reimbursement when a single combination code should be reported is called _____

unbundling

Reporting codes that are not supported by documentation in the patient record for the purpose of increasing reimbursement is called _______

upcoding

The purpose of adopting standard code sets was to

improve data quality and simplify claims submissions for providers

Claims are denied if ________ necessity of procedures or services is not established.

medical

The requirement that patient diagnoses justify diagnostic and/or therapeutic procedures or services provided is called

medical necessity

Which type of clinical terminologies and clinical vocabularies are used by health care providers to document patient care?

medical nomenclature

Which is the business record for a patient encounter (inpatient or outpatient) that documents health care services provided to a patient?

medical record

A medical assistant usually joins the American medical technologists (AMT) or the ____

AAMA (American association of medical assistants)

A coder usually joins either the American Health Information Management Association (AHIMA) or the ________

AAPC (previously called the American Academy of Professional Coders)

The system that classifies services not included in the CPT manual to describe the service, supply, or therapy provided and may also be assigned to report nursing services and alternative medicine procedures is called

ABC codes (alternative billing codes)

Hospital coders and abstractors use automated case _____ software to collect and report inpatient and outpatient data for statistical analysis and reimbursement purposes

Abstracting

Software that automatically generates medical codes by analyzing clinical documentation in the electronic health record or electronic medical record is called ____

CAC (computer assisted coding)

The system that provides a new standardized framework and a unique coding structure for assessing, documenting, and classifying home health and ambulatory care is called the _____ system

CCC (clinical care classification)

Which is a code set adopted by HIPPA for use by clearinghouses, health plans, and providers?

CDT

Physicians offices submit data to third-party payers on the ____ claim

CMS-1500

Which is the standard claim submitted by physicians offices to third-party payers

CMS-1500

Which classifies outpatient hospital and physician office procedures and services

CPT

A public or private entity that processes or facilitates the processing of health information and claims from a nonstandard format is called a health care _____

Clearinghouse

A medical nomenclature that is organized according to similar conditions, diseases, procedures, and services and contains codes for each is called a ____ (or classification) system

Coding

Specific sets of patient characteristics (or case-mix groups) on which payment determinations are made under several prospective payment systems is represented by the

Health Insurance Prospective Payment System (HIPPS) Rate Codes Example: The home health prospective payment system (HHPPS) requires entry of the Outcome and Assessment Information Set (OASIS) data set into grouper software, which generates the five-digit alphanumeric HIPPS code that is entered on the UB-04 claim. For example, HIPPS code HAEJ1 is entered on the UB-04 claim.

According to HIPPA, health plans that do not accept standard code sets are required to modify their systems to accept all valid codes or to contract with a

Health care clearinghouse

The classification of neoplasms used by cancer registries throughout the world to record incidence of malignancy and survival rates is called _____

ICD-0-3

All diseases, injuries, and reasons for an encounter, whether patients are treated as inpatients or outpatients, are coded using the ____ classification system

ICD-10-CM

A coder is required to have a working knowledge of the CPT, HCPCS Level II, ICD-10-CM, and _____ coding systems

ICD-10-PCS

Inpatient hospital procedures and services are coded using the ____ classification system

ICD-10-PCS

The system that classifies health and health-related domains to describe body functions and structures, activities, and participation is called the ____

ICF (international classification of functioning, disability and health)

Attending professional association conferences and meetings provides opportunities to ______ (or interact) with other professionals, which can facilitate being placed for internship or job placement.

Network

Which is a benefit of joining a professional association

Opportunities to network with other members

The intensity of services and severity of illness associated with inpatient care and captured as part of ____ (or facility) coding

Institutional

A profession that is closely related to that of a coder is health ____ specialist (or claims examiner) who review health related claims to determine whether the costs are reasonable and medically necessary based on the patient's diagnosis reported for procedures performed and services provided

Insurance

Which is an electronic database and universal standard used for clinical care and management

LOINC

An electronic database and universal standard that is used to identify medical laboratory observations and for the purpose of clinical care and management is called the

LOINC (logical observation identifiers names and codes)

An internet-based discussion forum that covers a variety of professional topics and issues is called an online discussion board or ____

Listserv

Appointment scheduling and claims processing are processes associated with medical ____ software

Management

To whom does the student report at the professional practice experience (or internship) site?

PPE or internship supervisor

Which is the business record for a patient encounter (inpatient or outpatient) that documents health care services provided to a patient? A) demographic data collected on admission B) patient record housed in the facility

Patient record housed in the facility

Students who become members of ____ associations usually pay a reduced membership fee and receive most of the same benefits as active members

Professional

The complexity and intensity of procedures performed and services provided during an outpatient or physician office encounter are captured as part of _____ coding

Professional

Which is considered to be a small code set according to HIPPA? A) actions taken to prevent, diagnose, treat, and manage disease and injury B) causes of injury, disease, impairment, or other health-related problems C) disease, injuries, impairments, and other health-related problems D) race, ethnicity, type of facility, and type of unit

Race, ethnicity, type of facility, and type of unit

The nomenclature that provides normalized names for clinical drugs and links it's name to many of the drug vocabularies commonly used in the pharmacy management and drug interaction software is called

RxNORM

Evaluating quality of patient care is considered a _____ purpose of patient record A) primary B) secondary

Secondary

Which type of medical record format store's documentation in labeled sections

Source-oriented record

Which processes health care claims and performs related business functions for a health plan

Third Party Administrator

Hospitals submit data to third-party payers on the ______ (or CMS-1450) claim.

UB-04 Hospitals and other health care facilities use automated case abstracting software to collect and report inpatient and outpatient data for statistical analysis and reimbursement purposes.

The set of flies and software that allows many health and biomedical vocabularies and standards to enable interoperability among computer systems is called the

UMLS (unified medical language system)

Which is an example of patient demographic data? A) date of birth B) discharge diagnosis

a. date of birth (Patient identification information that is collected according to facility policy (e.g., patient's name, date of birth, mother's maiden name, and SSN)

A progress note contains diagnoses of muscle strain and weakness. This statement would be located in the _____ portion of the POR progress note.

assessment

To provide the maximum benefit to students, internships are typically _____ work experiences that are arranged by academic program faculty

b. nonpaid

Which is a secondary purpose of the medical record that does not relate directly to patient care?

clinical research

Hospitals and other health care facilities use automated case abstracting software to

collect and report data for statistical analysis and reimbursement purposes

The primary purpose of the patient record is _____ , which involves documenting patient care services so that others who treat the patient have a source of information on which to base additional care and treatment

continuity of care

Which is documented in the progress notes section of the POR to summarize the patients care, treatment, response to care, and condition on release from the facility

discharge note

Routinely assigning lower-level CPT codes for convenience instead of reviewing patient record documentation and the coding manual to determine the proper code to be reported is called _______

downcoding