Coding Hodge-Podge
The process of accurately assigning codes to verbal (written) descriptions of a patient's condition(s) and healthcare services provided to treat those conditions?
What is coding?
This encounter occurs when a patient has been formally admitted to a healthcare facility, such as an acute-care hospital, long-term care facility, or rehabilitation facility.
What is an inpatient encounter?
What is this outpatient patient's Dx?
CC: Low back pain that started a month ago
Assessment: Patient was last seen 6 months ago for annual checkup.
Exam: Lumbar region tight to palpation. Limited ROM on flexion, extension and rotation.
Plan: Schedule MRI
What is low back pain?
This code set was developed by the NCHS and based on the WHO's code set and is used for diagnoses.
What is ICD-10-CM?
This is the primary certification of the AAPC.
What is the CPC?
These are used to describe patient illnesses, diseases, conditions, injuries, or other reasons for seeking healthcare services.
What are diagnosis codes?
Ancillary services are known as this type of encounter.
What is an outpatient encounter?
What is this outpatient patient's Dx?
Reason for encounter: Follow up on MRI and lab results
Assessment: Bloodwork negative for arthritis. MRI shows dispalcement of L4-5 disc.
What is disc displacement?
This code set was developed by the CMS and 3M for hospital inpatient procedures.
What is ICD-10-PCS?
This is the primary coding certification of AHIMA.
What is the CCS?
HIPAA allows for the use of several distinct systems of medical codes for different purposes. These distinct systems are known as these.
What are code sets?
This healthcare provide oversees and coordinates all aspects of the patient's care in an inpatient encounter.
Who is the attending physician?
What is this inpatient patient's Dx?
CC: SOB
Assessment: Chronic combined systolic and diastolic heart failure, due to hypertension.
What is ccombined systolic and diastolic heart failure, due to hypertension?
This code set was developed by the AMA and used for hospital outpatient and physician procedures and services.
What is CPT?
This is the minimum average expectation for coding accuracy.
What is 95%?
These are used to describe the services healthcare professionals provide to patients, such as evaluation, consultation, testing, treatments, and surgery.
What are procedure codes?
While each encounter is unique to the patient's situation, it generally involves these 3 steps.
What are diagnosis, treatment, and documentation?
What is/are this outpatient patient's dx?
CC: Polydipsia, polyuria, and difficulty sleeping.
Assessment: Type 2 diabetes, possible sleep apnea
What are type 2 diabetes and difficulty sleeping?
This code set was developed by CMS for supplies, items, and services not covered by CPT, physician and nonphysician services, Medicare services, supplies.
What is HCPCS?
Coders are expected to meet this, a specific number of cases each day determined by their organization and type of record.
What is case production?
This term has two meanings: 1) An action taken by a coder to identify the appropriate information to code. 2) A task in health information management in which inpatient coders review the medical record and cull data required for reporting, such as patient demographics and lengths of stay.
What is abstracting?
When documentation is not clear, coders do not make assumptions about missing information. Coders send this to the physician asking for more information.
What is a query?
What is/are this outpatient patient's diagnosis?
CC: Extreme nervousness and irritability
Assessment: R/O hyperthyroidism
Plan: Thyroid workup
What are extreme nervousness and irritability?
This code set was developed by HHS and provided identification of the manufacturer, product, and package size of all drugs and biologics recognized by the FDA.
What is NDC?
Coders are expected to have mastered these 3 skills.
What is abstracting, assigning, and arranging?