Certified Professional Coding Test 2022 COMPLETE SOLUTIONS, Graded A+

Certified Professional Coding Test 2022 COMPLETE SOLUTIONS, Graded A+ Document Content and Description Below Certified Professional Coding Test 2022 COMPLETE SOLUTIONS Coding is - the process of translating this written or dictated medical record into a series of numeric or alpha-numeric codes Prop er code assignment is determined by - content of the medical record and by the unique rules that governs each code set What are 3 things that Coder must master - 1. anatomy 2. medical terminology 3. must be detail-oriented Medical coders assign a code to what - 1. Each diagnosis 2. Service/procedure 3. Supply, using the classification system when applicable The classification system determines ______ - the amount health care providers will be reimbursed if the patient is covered by Medicare, Medicaid, or other insurance programs using the system A coder must evaluate the medical record for - 1. completeness and accuracy 2. communicate regularly with physicians and the health care professional to clarify DX or obtain additional PT info. Techicians who speciallize in coding inpatient hospital services are referred as - 1. Health information coders 2. medical record coders 3. Coder/abstractors 4. Coding SpecialistWhat is MS-DRGs and what does it do? - 1. Medicare Severity-Diagnosis Related Groups 2. Determines the amt the hospital will be reimbursed if the PT is covered by Medicare or other insurance programs What is EHR - Electronic health record Skilled coders may become - consulatants, educators or medical auditors What is the difference between Hospital and Physican Services - 1. Outpatient coding (physician services)- learning CPT, HCPCS, LEVEL II, ICD-9 CM codes Volume 1 and 2 2. Inpatient coding (Hospital services)- Learning CPT, ICD-9 CM codes Volumes 1,2,3 and MS-DRGS What is APC and who uses it - Ambulatory Payment Classification- outpatient facility coders (physician services What is the coder's role in a physician's office - Extremely important for the proper reimbursement of services and the livelihood of the physician What is a physican degree of education - 4 years of college, 4 years of medical school plus 3 to 5 years of residency. What are mid-level providers and who can be classified as one? - 1. Mid-level providers are know as physician extenders 2. Physician assistants (PA) and Nurse Practitioners (NP) What are the requirement for a PA and what - 1. 26 1/2 month program to complete 2. Licensed to practice medicine under physician supervision NP must have - A Master's Degree in NursingIn simplest terms, how many payers are there? - 2 Private insurance plans and government insurance plans Commercial carriers are considered what - Private payers that offer both group and individual plans. Private Payers contracts may vary but may include _____ - hospitalization, basic, and major medical coverage. What is the most significant government insurer - Medicare What is Medicare - Federal health insurance program- Administered by the Center for Medicare & Medicaid Services (CMS) What is CMS and what does it provide - Center for Medicare & Medicaid Services (CMS) provides coverage for people over the age of 65, blind, or disabled individuals, people with end -stage renal disease CMS regulations often serves as the____ word in coding requirement for Medicare and Non-Medicare payers alike - Last What are the parts of Medicare - Medicare A Medicare B Medicare C Medicare D What is Medicare Part A? - Covers inpatient hospital care, as well as care provided in skilled nursing facilites, hospice care, and home health care What is Medicare Part B? - Covers medically necessary doctors' services, outpatient care, other medical services (including some preventive service not covered under Medicare Part A)Medicare Part B is considered what? - A optional benefit for which the patient must pay a premium and which generally requires a yearly copay Where is Medicare Part B usually used - Physician offices (Outpatient Facility) What is Medicare Part C - Combines the benefits of Medicare Part A, Part B, and sometimes Part D. What is Medicare Part C also called - Medicare Advantage What is PPO - Preferred Provider Organizations What is HMO - Health Maintenace Organizations Which plan covers PPO and HMO - Medicare Part C What is the CMS-HCC - Center for Medicare & Medicaid Services-Hierarchical condition category What does the CMS-HCC provide - Risk adjument model provides adjusted payment based on a patient's disease and demographic factors. If a coder does not include all pertinent diagnoses and co-morbidities, the provider may lose out on what - additional reimbursement for which he/she is entitled. What is Medicare Part D - Prescription drug coverage program available to all Medicare beneficiaries. Private companies approved by Medicare provide the coverage. What is Medicaid - A health insurance assistance program for some low income people (especially children and pregnant women) sponsored by federal and state governmentsMedicaid is administered on___________ - a state-by-state basis and coverage varies- although each of the state programs adheres to certain federal guidelines When is a physican considered a "participating physician" - When contracted with a insurance carrier whether that be a private insurance company or a governmental. Participating Providers (Par Providers) are required to accept__________________ - the allowed payment amount determined by the insurance carrier as the fee for payment and follow all other guidelines stipulated by the contract The difference between the physican's fee and the insurance carriers allowed amount is - adjusted by the participating provider Non-participating Providers (non par) are? - 1. providers not contracted with the insurance carriers 2. not required to make the adjustment What is limiting charge - Limits set on what can be charged for each CPT code, no matter if the physican is Par or Non-Par What is a medical record - Documentation or the recording of pertinent facts and observation about an individual's health history, including past and present illness, tests, treatments and outcomes Medical record chronologically - documents patient care to assist in continuity of care between providers, facilitate claims review and payment Can a Medical record serve as legal document - YES All services provided to a patient are_______ - supported and documented in the medical record What are coders required to do with the medical records? - Read and understand the documentation in the medical record in order to accurately code the services rendered.What are some different types of services documented in a medical record? - Evaluation and management Operative reports X-Rays Evaluation and Management services are provided in what standard format - SOAP What is SOAP documentation? - S- Subjective O-Objective A- Asssessment P-Plan What is the definition of O in SOAP? - objective-The provider assesses and documents the patient's illness using observation, palpation, auscultation and percussion. Test and other services performed may be documented here as well What is the definition of A in SOAP? - Assessment-Evaluation and conclusion made by the provider. This is usually where the diagnosis(es) for the services are found What is the definition of P in SOAP? - Plan-Course of Action. Here, the provider will list eh next steps for the patient, whether it is ordering additional test, or taking over the counter medication What is a operative report - a document the detail of a procedure performed on a patient What will most operative notes have - Header and Body what are some of things that operative header note might include? - 1. Date and time of procedure 2. Name of surgeon, co-surgeon, assistant surgeon 3. Typer of anethesia and anestheiology provider name4. Pre-operative and post-operative diagnoses 5. Procedures performed 6. Complications What are some of things that operative body note might include? - 1. indication for surgery 2. details of the procedure (s) 3. Findings What is the approximate percentage of an operative report that contains words less important to a coder? - 20 % What is the task for a coder with an operative report? - to break down the information and applying the correct code. What are the 5 most important Coding Tips for operative reports for a coders - 1. Diagnosis code reporting 2. Start with the procedures listed 3. Look for key words 4. Highlight unfamiliar words 5. Read the body What does the first coding tip mean for the operative report for a coder ? - Diagnosis code reporting- Use the post-operative diagnosis for coding unless there are further defined diagnoses or additional diagnoses found in the body or finding of the operative report. What does the second coding tip mean for the operative report for a coder? - Start with the procedures listed- For the coder who is new to coding a procedure , one way of quickly starting the research process is by focusing on the procedures listed in the header. Read the note in its entirety to verify the procedures performed. Procedures listed in the header may not be listed correctly and procedures documented with the body of the report may not be listed in the header at all. It will help a coder with a place to startWhat does the third coding tip mean for the operative report for a coder? - Look for key words- Key words may include locations ana anatomical structures involved, surgicial approach, procedure method, procedure type, siiz and number and the surgical instruments used during the procedure What does the fourth coding tip mean for the operative report for a coder? - Highlight unfamiliar words- Words you are not familiar with should be highlighted and researched for understanding What does the fifth coding tip mean for the operative report for a coder? - Ready the body- All procedures reported should be documented with the body of the report. The body may indicate a procedure was abandoned or complicated, possibly indicating the need for a different procedure code or reporting of a modifier What is medical necessity related to? - whether a procedure or service is considered appropriate in a given circumstance Generally what is a medically-necessary service? - the least radical service/procedure that allows for effective treatment of the patient's complaint or condition Under what regulations is medically necessity found under - Title XVIII 1862 (a) (1) of the Social Security Act What is the National Coverage Determinations Manual - Describes whether specific medical items, services, treatment procedures or technologies can be paid under Medicare What is the difference between Covered and Non-covered items - 1. Covered items-services and procedures are covered only when linked to designated, approved diagnosis 2. Non-covered items are deemed "not reasonable or necessary Medicare and many insurance plan may deny payment for a service that is - not reasonable or necessary according to the Medicare reimbursement rules. What is NCD and what does it do? - 1. National Coverage Determinations2. Explains when Medicare will pay for items or services What is LCD and What does it provide? - 1. Local Coverage Determinations 2. MAC is responsible for interpreting national policies into regional policies. The LCDs further define what codes are needed and when an item or service will be covered . LCD have jurisdiction only with their regional area What is MAC? - Medical Administrative Contractor If a NCD does not exist what are CMS guidelines? - Where coverage of an item or service is provided for specified indications or circumstances but is not explicitly excluded for others, or where the item or service is not mentioned at all in the CMS Manual System, the Medicare contractor is to make the coverage decision, in consultation with its medical staff and with CMS when appropriate, based on the laws, regulations, ruling and general program instructions. How often should Practices check policies to maintain compliance? - Quarterly What does ABN stand for - Advance Beneficiary Notice of Noncoverage, or Advance Beneficiary Notice What is an ABN? - A standardized form that explains to the patient why medicare may deny a particular service or procedure. What does ABN protect? - The provider's financial interest by creating a paper trail that CMS requires before a provider can bill the patient for payment if Medicare denies coverage for the stated service or procedure What must the provider complete (in regards to ABN)? - 1. Complete one-page form in full 2. giving the patient an explanation as to why Medicare is likely to refuse coverage for proposed procedure or serviceWhat are some of the common reasons why Medicare may deny a procedure and service? - 1. Medicare does not pay for the procedure/service for the patient's condition 2. Medicare does not pay for the procedure/service as frequently as proposed 3. Medicare does not pay for experimental procedure/services What must the provider present to the patient on the ABN for a proposed procedure or service? - Cost Estimate What do CMS instructions stipulate on Cost estimate? - Notifiers must make a good faith effort to insert a reasonalble estimate...the estimate should be within $100 or 25% of the actual costs, whichever is greated. When do CMS rules require the provider to present the ABN to patient? - Far enough in advance that the beneficiary or representative have time to consider the options and make an informed choice. What must be done BEFORE the patient signs the ABN - 1. ABN must be verbally received with beneficiary or his/her representative 2. Any questions raised during that review must be answered After the ABN is signed, What are some choices the patient has? - 1. Proceed with procedure/service and assume financial responsibility. If the patient chooses to proceed, he may request the charge be submitted to Medicare for consideration (with the understanding that it will probably be denied 2. Elect to fore go the procedure or service. What must go to the patient and to the provider - 1. Copy of completed signed form must be given to beneficiary or representative 2. The provider must retain the original notice on file What action can the provider take if the patient refuses to sign the ABN? - If the patient still requests the procedures or services but refuses to sign a properly-presented ABN, the provider should document the patient's refusal. The provider and a witness should then sign the form.When is a ABN never required and WHY? - 1. Emergency and urgent care situation 2. CMS prohibits giving an ABN to a patient who is "under duress," including patients who need Emergency Department service before stabilization What is HIPAA - Health Insurance Portability and Accountability Act of 199 Show Less