Medical Coding Basics
This type of code identifies why a service was provided.
What is a diagnosis code?
ICD-10-CM codes contain this many characters.
What is 3 to 7 characters?
Knowingly billing for services that were never provided is called this.
What is fraud?
For chemical burns, this main term is used in the Index.
What is Corrosion?
CPT codes are how many characters long?
What is five characters?
This type of code describes services performed for a patient.
What is a procedure code?
This section must always be used to verify a code after using the Index.
What is the Tabular List?
Improper billing practices that are not intentional but result in improper payment.
What is abuse?
Diabetes codes are combination codes that include the type and this.
What is the complication?
CPT codes are required on this claim form.
What is the CMS-1500?
HIPAA mandates the use of these approved code sets for covered entities.
What are ICD-10-CM and CPT?
This placeholder character is used in certain 6- and 7-character codes.
What is the letter X?
Coding at a higher level than what was provided is known as this.
What is upcoding?
When coding fractures, you must include the anatomic site, laterality, and this.
What is the episode of care?
Before assigning a CPT code, you must abstract this from the medical record.
What are the procedures/services performed?
The primary diagnosis chiefly responsible for the services provided is called this.
What is the first-listed diagnosis?
An Excludes1 note means this.
What are mutually exclusive conditions that cannot be coded together?
Coding at a lower level than what was provided is called this.
What is downcoding?
These codes identify factors influencing health status and well visits.
What are Z-codes?
Each CPT code must be linked to this type of code.
What is a diagnosis code (ICD-10-CM)?
Coding begins and ends with this document.
What is the patient’s medical record?
This character often identifies the episode of care for injuries.
What is the seventh character?
This federal office investigates fraud and abuse in Medicare and Medicaid.
What is the Office of Inspector General (OIG)?
When coding poisonings, you must identify the substance and this factor.
What is intent (accidental, self-harm, assault, undetermined)?
“If it isn’t charted, it wasn’t done” emphasizes the importance of this.
What is proper documentation?