NHA CBCS Module 3 Coding And Coding Guidelines
Questions and Answers () (Verified
Answers)
abstracting
Reviewing medical record documentation to discover clinical concepts that support assigning codes to
the highest level of specificity.
clinical documentation
Information recorded in the medical record pertaining to the health status of a patient as determined
by a health care provider.
CPT
Current Procedural Terminology. Codes for services and procedures.
electronic health record (EHR)
A digital version of a patient's chart that includes information documented by multiple providers at
different facilities regarding one patient.
HCPCS
Healthcare Common Procedural Coding System.
ICD-10-CM
International Classification of Diseases - 10th Revision - Clinical Modification. Codes for diseases,
injuries, and statuses.
medical coding
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
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
Documents health care services provided to a patient.
query
Contacting the responsible provider to request clarification about documented diagnoses or
procedures.
claim denial
Unpaid medical claim returned by payer due to coding errors, missing information, preauthorization
requirements, or health plan coverage issues.
, downcoding
Unpaid medical claim returned by payer due to coding errors, missing information, preauthorization
requirements, or health plan coverage issues.
encounter form
Financial record source document used by providers to record treated diagnoses and services
provided to a patient for a single encounter.
modifier
Provides additional information about a procedure or service without altering the definition of the
code description.
preauthorization
Prior approval for services granted by payer after health plan review.
History of Present Illness (HPI)
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
Submitting multiple CPT codes when a single code is available to report services in full.
upcoding
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 _________________.
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?
Subjective, Objective, Assessment, Plan
Used to abstract information and details required for code assignments.
Explain the "S" in SOAP.
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.
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.
Questions and Answers () (Verified
Answers)
abstracting
Reviewing medical record documentation to discover clinical concepts that support assigning codes to
the highest level of specificity.
clinical documentation
Information recorded in the medical record pertaining to the health status of a patient as determined
by a health care provider.
CPT
Current Procedural Terminology. Codes for services and procedures.
electronic health record (EHR)
A digital version of a patient's chart that includes information documented by multiple providers at
different facilities regarding one patient.
HCPCS
Healthcare Common Procedural Coding System.
ICD-10-CM
International Classification of Diseases - 10th Revision - Clinical Modification. Codes for diseases,
injuries, and statuses.
medical coding
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
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
Documents health care services provided to a patient.
query
Contacting the responsible provider to request clarification about documented diagnoses or
procedures.
claim denial
Unpaid medical claim returned by payer due to coding errors, missing information, preauthorization
requirements, or health plan coverage issues.
, downcoding
Unpaid medical claim returned by payer due to coding errors, missing information, preauthorization
requirements, or health plan coverage issues.
encounter form
Financial record source document used by providers to record treated diagnoses and services
provided to a patient for a single encounter.
modifier
Provides additional information about a procedure or service without altering the definition of the
code description.
preauthorization
Prior approval for services granted by payer after health plan review.
History of Present Illness (HPI)
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
Submitting multiple CPT codes when a single code is available to report services in full.
upcoding
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 _________________.
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?
Subjective, Objective, Assessment, Plan
Used to abstract information and details required for code assignments.
Explain the "S" in SOAP.
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.
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.
