Medical Billing and Coding Certificate Exam Already Passed

Medical Billing and Coding Certificate Exam Already Passed Chief Complaint (element 1 of history) History of present illness, Review symptom, Past, Family, and Social history History Levels (Element 2 of history) and Examination Levels (Element 3 of History) Problem focused, expanded problem focused, detailed, Comprehensive Medical Decision Making Complexity Levels (element 4 of history) Straightforward, Low, Moderate, High straightforward Minimal diagnosis Minimal risk Minimal complexity of data Low Limited diagnosis Limited/low risk to patient Limited data Moderate Multiple diagnosis Moderate risk to patient Moderate amount and complexity of data high Extensive diagnosis high risk to patient extensive amount and complexity of data truncated coding (error in coding) using diagnosis codes that are not as specific as possible assumption coding (fraudulent coding) reporting items of services that are not actually documented errors of the coding process -altering documentation after services are reported -coding without documentation -reporting services provided by unlicensed or unqualified clinical personnel -coding a unilateral service twice instead of choosing the bilateral -not satisfying the condition of coverage for a particular service -codes that report more than one diagnosis with one code is a combination code Unbundling codes when multiple codes are used to code a procedure when a single code should be used Upcoding using a procedural code that provides a higher reimbursement rate than the correct code Downcoding the document does not justify the level of service Most common billing errors Billing non-covered services Billing over limit services Upcoding Downcoding Billing without signatures Using outdated codes External Audits Internal Audits Retrospective audits Types of Audits done