NHA CBCS Module 3: Coding And Coding Guidelines Exam Questions And Answers

NHA CBCS Module 3: Coding And Coding Guidelines Exam Questions And Answers abstracting - ANS Reviewing medical record documentation to discover clinical concepts that support assigning codes to the highest level of specificity. clinical documentation - ANS Information recorded in the medical record pertaining to the health status of a patient as determined by a health care provider. CPT - ANS Current Procedural Terminology. Codes for services and procedures. electronic health record (EHR) - ANS A digital version of a patient's chart that includes information documented by multiple providers at different facilities regarding one patient. HCPCS - ANS Healthcare Common Procedural Coding System. ICD-10-CM - ANS International Classification of Diseases - 10th Revision - Clinical Modification. Codes for diseases, injuries, and statuses. medical coding - ANS Process of abstracting diagnoses, procedures, and services from the medical record and converting them to numeric and/or alphanumeric codes for claims submission. medical necessity - ANS Process of providing diagnosis codes that support the services rendered to the patient; coding for medical necessity involves associating applicable diagnosis codes to service/procedure codes within the billing software, which is referred to as linking/linkage. medical record - ANS Documents health care services provided to a patient. query - ANS Contacting the responsible provider to request clarification about documented diagnoses or procedures. claim denial - ANS Unpaid medical claim returned by payer due to coding errors, missing information, preauthorization requirements, or health plan coverage issues. downcoding - ANS Unpaid medical claim returned by payer due to coding errors, missing information, preauthorization requirements, or health plan coverage issues. encounter form - ANS Financial record source document used by providers to record treated diagnoses and services provided to a patient for a single encounter. modifier - ANS Provides additional information about a procedure or service without altering the definition of the code description. preauthorization - ANS Prior approval for services granted by payer after health plan review. History of Present Illness (HPI) - ANS Brief description of the patient's present illness or other reason for an encounter, including such details as locations, duration, severity, and associated signs and symptoms. unbundling - ANS Submitting multiple CPT codes when a single code is available to report services in full. upcoding - ANS Assignment of ICD-10-CM code that is more severe than diagnosis supported by the documentation in the medical record. Every patient encounter must include _________________. - ANS Every patient encounter must include the reason for the encounter and supported medical necessity. Documentation for each encounter includes the reason for the encounter, history, physical exam, diagnostic or laboratory tests, and a treatment plan to support each CPT, ICD-10-CM, or HCPCS code reported on the claim. What does SOAP stand for and what is it used for? - ANS Subjective, Objective, Assessment, Plan Used to abstract information and details required for code assignments. Explain the "S" in SOAP. - ANS Subjective - symptoms or history of the condition using the patient's own words, described improvement or decline of the condition since the last treatment, explanations for any gaps in treatments, and the patient's compliance with provider recommendations. Explain the "O" in SOAP. - ANS Objective - vital signs, physical examination findings, laboratory and other diagnostic data, and imaging results and documentation from other clinicians that have been reviewed and considered. Explain the "A" in SOAP. - ANS Assessment - the diagnostic impression or working diagnoses based on the subjective complaints and objective findings.