CDIP Domain 1: Clinical Coding Practice Exam 2023

Coding Clinic - Answer- Valuable reference tool for coders that is published by AHA each quarter CPT - Answer- Current Procedural Terminology MS-DRGs - Answer- Medicare Severity-Diagnosis Related Groups CPT Assistant - Answer- Monthly publication by the AMA that provides coding advice for CPT coding scenarios Encoder Nosology - Answer- Provides coding professionals from the encoder company that are available to help answer tough coding questions History & Physical - Answer- 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 - Answer- 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 - Answer- Summarize the invasive procedures performed and any samples that are removed from the patient's body Pathology report - Answer- 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 - Answer- 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? - Answer- 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 - Answer- Diagnosis that, after study, is the reason for the patient's admission to the hospital. Secondary diagnoses - Answer- Additional supporting information for the conditions the patient is being cared for MCC - Answer- Major Complication or Comorbidity CC - Answer- Complication or Comorbidity CMI - Answer- Case Mix Index LOS - Answer- Length of Stay Complication - Answer- A condition arising during the hospital stay that prolongs the LOS by at least one day in approximately 75% of the cases Comorbidity - Answer- 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 - Answer- Procedure codes that best represent the procedure that has been performed Secondary procedures - Answer- 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 - Answer- General rules for the use of the classification independent of the guidelines Letter that ICD-10 utilizes as a placeholder for certain codes - Answer- X Excludes1 - Answer- Indicates that the code excluded should never be used with the code above the Excludes1 note. Excludes2 - Answer- Indicates that, when appropriate, it is acceptable to use both the code and the excluded code together. Inclusion terms - Answer- List of terms that are included under some codes. They are the conditions for which the code should be used. CMS - Answer- Centers for Medicare & Medicaid Services Medicare patients are reimbursed by - Answer- MS-DRGs Medicaid has it's rates set by - Answer- each individual state PPS - Answer- Prospective Payment System Prospective Payment System - Answer- Payment method based on a predetermined amount that results from a particular service APR-DRG - Answer- All Patient Refined Diagnosis Related Groups All Patient Refined DRGs - Answer- Incorporate severity of illness as a part of assigning DRGs to determine the complexity of the patient and the need for an increased utilization of resources as the patient moves to a higher level of severity of illness based on additional diagnoses. APG - Answer- Ambulatory Patient Group Ambulatory Patient Group - Answer- Provides fixed reimbursement to a facility for outpatient procedures or visits and includes data regarding the reason for the visit and patient data Each individual MS-DRG has these components - Answer- title, geometric mean length of stay, arithmetic mean length of stay, relative weight, and ICD code range. Formula used to calculate payment for a specific case - Answer- The hospital's payment rate per case X the weight of the MS-DRG to which the case is assigned = Payment SOI - Answer- Severity of Illness Severity of Illness - Answer- Extent of physiologic decomposition or organ system loss of function ROM - Answer- Risk of Mortality Risk of Mortality - Answer- The likelihood of dying Levels of SOI and ROM - Answer- 1=Minor, 2= Moderate, 3=Major, and 4= Extreme OPPS - Answer- Hospital Outpatient Prospective Payment System APCs - Answer- Ambulatory Payment Classifications HH PPS - Answer- Home Health Prospective Payment System OASIS - Answer- Outcome and Assessment Information Set SNF PPS - Answer- Skilled Nursing Facility Prospective Payment System MDS - Answer- Minimum Data Set The Hospital Outpatient Prospective Payment System utilizes - Answer- Ambulatory Payment Classifications (APCs) Home Health Prospective Payment System utilizes - Answer- A case-mix methodology based on data elements from OASIS Skilled Nursing Facilitates Prospective Payment System utilizes - Answer- Minimum Data Set Minimum Data Set - Answer- A standardized screening and assessment tool that gives a multidimensional view of the patients functional capability. IRF PPS - Answer- Inpatient Rehabilitation Facility Prospective Payment System Inpatient Rehabilitation Facility prospective payment system utilizes - Answer- The patient assessment instrument (PAI) to assign patients to case-mix groups according to their clinical status and resource requirements. The final MS-DRG assignment is based on factors such as - Answer- Principal and secondary diagnoses, principal and secondary procedures, patient gender, and discharge status Communication between the coders and the CDI specialist should be - Answer- Open and supportive Level 1-CPT codes are maintained by - Answer- American Medical Association (AMA) Level II National Codes are maintained by - Answer- CMS The six sections within category one of Level 1 CPT are - Answer- Evaluation and Management, Anesthesia, Surgery, Radiology, Pathology/Laboratory, and Medicine How many categories are under Level 1 CPT? - Answer- 3 HCPCS - Answer- Healthcare Common Procedure Coding System