Chapter 3 The Coding Process

Where can you find conventions that offer tips and hints in selecting the correct code?

-CPT Main Section -ICD-10-CM Tabular List

Which of the following uses alpha numeric or numeric order for code selection?

-CPT Main Section -ICD-10-PCS Tables -ICD-10-CM Tabular List

You cannot report a code from the Alphabetic Index until you have confirmed it is correct and complete by using which one of the following code books?

-CPT's Main Section -ICD-10-CM's Tabular List -ICD-10-PCS's Tables section

The _____ book includes official guidelines within the sections, subsections, with advice and direction for accurate coding or just those procedures, services, and treatments.

CPT

What are included in the Tabular List (ICD-10-CM) and Main Section (CPT) to provide tips and hints to point you toward the correct code?

Conventions

Where are the guidelines located in the ICD-10-CM book?

Front of book

Where would you find the guidelines in the ICD-10-PCS book?

Front of book

Select the title used for the ICD-10-CM Guidelines.

ICD-10-CM Official Guidelines for Coding and Reporting

Which of the following is the title used for the ICD-10-PCS Guidelines?

ICD-10-PCS Official Guidelines for Coding and Reporting

Where would you locate most of the guidelines in the CPT coding book?

In front of each main section

What is used to review any diagnosis coding rules with which you must comply?

Official Guidelines

What rules and regulations must be referred to every time you are working to determine a code?

Official Guidelines

To select the best, most accurate code(s) a coder should base the selection on

Official Guidelines. documentation.

Which of the following is a term seen in the ICD-10-CM Alphabetic Index?

Shock

When abstracting information regarding a patient's injury, you should identify which of the following to determine external causes?

The how and where

Which of the following is the number one consideration when coding?

Accuracy

When coding each procedure, service, or treatment,

code only those that were provided to the patient during the encounter.

When creating a query to determine the most accurate code or codes, what should you use when asking the physician to amend the documentation?

nonleading questions

As a professional coding specialist, it is your responsibility to submit ____​_ accurate, truthful information, supported by the physician's documentation.

only

If you are unclear or are missing information necessary to code an encounter, you should

query the health care provider who cared for the patient.

There are ____​_ specific actions that you should take as part of the coding process.

six

Once you read the documentation, you should reread and identify the main words regarding the _____ and _____ of the encounter.

why; what

What actions should be taken when double-checking codes?

-Go back into the code books to reread the full description. -Check for typos.

When coding a procedure, for whom might you be reporting?

-Inpatient facility -Outpatient facility -Physician

Which of the following are acceptable places to confirm a code in the CPT or ICD-10 books?

-Main Section -Tables -Tabular List

With so many code sets and codes, the process to get from ____​_ to ____​_ is more complicated than simply finding a word here and a code there.

documentation; code