NHA CBCS Module 3: Coding And Coding Guidelines Questions with Detailed Verified Answers

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NHA CBCS Module 3: Coding And Coding
Guidelines Questions with Detailed Verified
Answers

Question: abstracting

Ans✅ ✅: Reviewing medical record documentation to discover clinical concepts that
support assigning codes to the highest level of specificity.

Question: clinical documentation

Ans✅ ✅: Information recorded in the medical record pertaining to the health status
of a patient as determined by a health care provider.

Question: CPT

Ans✅ ✅: Current Procedural Terminology. Codes for services and procedures.

Question: 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.

Question: HCPCS

Ans✅ ✅: Healthcare Common Procedural Coding System.

Question: ICD-10-CM

Ans✅ ✅: International Classification of Diseases - 10th Revision - Clinical
Modification. Codes for diseases, injuries, and statuses.

Question: medical coding

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Ans✅ ✅: Process of abstracting diagnoses, procedures, and services from the
medical record and converting them to numeric and/or alphanumeric codes for claims
submission.

Question: 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.

Question: medical record

Ans✅ ✅: Documents health care services provided to a patient.

Question: query

Ans✅ ✅: Contacting the responsible provider to request clarification about
documented diagnoses or procedures.

Question: claim denial

Ans✅ ✅: Unpaid medical claim returned by payer due to coding errors, missing
information, preauthorization requirements, or health plan coverage issues.

Question: downcoding

Ans✅ ✅: Unpaid medical claim returned by payer due to coding errors, missing
information, preauthorization requirements, or health plan coverage issues.

Question: encounter form

Ans✅ ✅: Financial record source document used by providers to record treated
diagnoses and services provided to a patient for a single encounter.

Question: modifier

Ans✅ ✅: Provides additional information about a procedure or service without
altering the definition of the code description.

Question: preauthorization