CCS-P Study Guide Questions and Answers Rated A+

CCS-P Study Guide Questions and Answers Rated A+ According to AMA medical decision making is measured by 1. number of dx or management options 2. amount and complexity of data review 3. risk of complications CPT Assistant provides official guidance in CPT coding published by the AMA A barrier to wide spread use of automated code assignments is poor quality of documentation When should coders assign codes from lab reports alone Never. If findings are out of normal range and the physician has ordered additional testing or treatment; consult with the physician as to whether the Dx should be added or if an abnormal finding should be listed. 4 cooperating parties of ICD-9 and responsibilities of each NCHS (national center for health statistics): maintaines dx classifications in Vol 1&2 CMS: maintains procedural classification in Vol 3 AHIMA & AHA: give advice & assistance on coding guidelines in conjunction with health information management practitioners, physicians, & other users of ICD-9 When can code 99291 (E/M critical care) be used in place of a medical visit or ER code When the patient meets the definition of critical care and receives outpatient care on the same day limiting charge this is the amount a NON PAR Medicare provider can collect from a patient in excess of 15% over the NON PAR Medicare approved amount. When does CMS send the payment directly to the patient when a NON PAR provider does not accept assignment hard coding refers to CPT/HCPCS codes that appear in the hospitals chargemaster and will be included automatically on the patient's bill. CAC- computer assisted coding AHIMA defines as the use of computer software that automatically generates a set of medical codes for review , validation, and use based upon the documentation provided by the various providers of healthcare. modifier: A1-principle physical of record required for patients covered by Medicare when reporting Initial Hospital Service codes POMR- PROBLEM ORIENTED MEDICAL RECORD Organized by problem number Database: history and physical Problem List: titles, numbers, dates of problems..."Table of Contents" of the record Initial Plan: describes diagnostic, therapeutic, and patient education plans Progress Note: documents the progress of a patient throughout the episode of care Discharge Note/ Transfer Note: summarizes episode of care and current status of patient Cost Sharing Provision of Health Ins. formulary for drugs co-pay benefit limitations Common Complication of Labor and Delivery forceps or vacuum extractor delivery without mention of indication renal