CDIP Domain 1: Clinical Coding Practice, Questions & Answers, 100% Accurate, Graded A

CDIP Domain 1: Clinical Coding Practice, Questions & Answers, 100% Accurate, Graded A Coding Clinic - -Valuable reference tool for coders that is published by AHA each quarter CPT - -Current Procedural Terminology MS-DRGs - -Medicare Severity-Diagnosis Related Groups CPT Assistant - -Monthly publication by the AMA that provides coding advice for CPT coding scenarios Encoder Nosology - -Provides coding professionals from the encoder company that are available to help answer tough coding questions History & Physical - -Provides the initial chief complaint and initial impressions of the provider when the patient is first admitted. It also has a comprehensive physical review of the patient's body systems and vital signs, and provides the initial treatment plan, medications, and tests that are being ordered to treat the patient. Progress Notes - -Provide information about what is going on with the patient on a day-to-day basis; they should include the diagnoses that are being treated as well as any information about any changes in the patient's well-being and tests/procedures being performed. Operative and Pathology Reports - -Summarize the invasive procedures performed and any samples that are removed from the patient's body Pathology report - -Provides detailed information from the pathologist of the facility as to the status of the tissues or organs removed from the patient's body Encoder - -Specialty software used to facilitate the assignment of diagnostic and procedural codes according to the rules of the coding system What is the value of utilizing coding software? - -It facilitates accurate coding by providing links to coding resources, groups diagnosis and procedure codes to the correct MS-DRG, and provides edits with additional information for the coder to consider when placing codes into the encoder Principal diagnosis - -Diagnosis that, after study, is the reason for the patient's admission to the hospital. Secondary diagnoses - -Additional supporting information for the conditions the patient is being cared for MCC - -Major Complication or Comorbidity CC - -Complication or Comorbidity CMI - -Case Mix Index LOS - -Length of Stay Complication - -A condition arising during the hospital stay that prolongs the LOS by at least one day in approximately 75% of the cases Comorbidity - -A pre-existing condition which because of its presence with the principal diagnosis will increase the LOS by at least one day in 75% of the cases Primary procedures - -Procedure codes that best represent the procedure that has been performed Secondary procedures - -Do not typically impact the MS-DRG; however, they are important for capturing the details of the care the patient has received while in the hospital. Coding conventions for ICD-10-CM - -General rules for the use of the classification independent of the guidelines Letter that ICD-10 utilizes as a placeholder for certain codes - -X Excludes1 - -Indicates that the code excluded should never be used with the code above the Excludes1 note. Excludes2 - -Indicates that, when appropriate, it is acceptable to use both the code and the excluded code together. Inclusion terms - -List of terms that are included under some codes. They are the conditions for which the code should be used. CMS - -Centers for Medicare & Medicaid Services Medicare patients are reimbursed by - -MS-DRGs Medicaid has it's rates set by - -each individual st