aapc crc exam 10

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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

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

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 _____.

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?

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

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

Burns due to a chemical such as lye is coded to corrosion.

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

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

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

Code Q03.9 and Code G91.9 can be used together if both are present.

Code Z33.2 is assigned for elective termination of pregnancy without complication.

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

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

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

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

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

subsequent encounter for fracture with delayed healing

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

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

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)

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

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

Nurse Practicianer

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

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

Only code N40.1 is assigned for enlarged prostate with nocturia.

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

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

Physical Therapist

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

**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?

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

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?

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?

When coding a neoplasm, the first step is to go to the Neoplasm Table.

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.

When mechanical ventilation is used during a surgical procedure, it is normally coded as a procedure.

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

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

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)

All conditions that occur postoperatively are classified as complications.

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

Code C50.811 is assigned for one carcinoma of the breast located at the spot where the right upper and lower quadrants join/overlap.

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

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)

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

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

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?

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?

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

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