CEHRS - Certified Electronic Health Records Specialist Medical Coding in EHR Questions and Answers 1 — Questions and Answers
Question 1: A physician documents a patient's diagnosis as 'Type 2 diabetes mellitus with hyperglycemia' and the procedure as a 'comprehensive metabolic panel'. Within the EHR, what is the MOST critical relationship the CEHRS must ensure is established for proper claim submission?
- The CPT code for the procedure is from the most recent publication year.
- The patient's insurance information is verified and active.
- The ICD-10-CM code for the diagnosis demonstrates medical necessity for the CPT code of the service provided. (Correct answer)
- The physician's digital signature is applied within 24 hours of the patient encounter.
Correct answer: The ICD-10-CM code for the diagnosis demonstrates medical necessity for the CPT code of the service provided.
For a claim to be paid, the diagnosis code (ICD-10-CM) must justify the reason a procedure or service (CPT) was performed. This relationship is called 'medical necessity'. An EHR helps facilitate this by allowing the linkage of diagnosis codes to procedure codes, but the CEHRS must understand this principle to ensure accurate claims are generated.
Question 2: A healthcare facility implements Computer-Assisted Coding (CAC) software integrated with its EHR. Which of the following best describes the primary function of CAC in the workflow of a coding professional?
- To automatically assign and submit final codes for billing without human review.
- To replace the need for certified coders by using artificial intelligence for all coding tasks.
- To analyze clinical documentation and suggest appropriate codes for review and validation by a human coder. (Correct answer)
- To exclusively audit previously submitted claims for errors and compliance issues.
Correct answer: To analyze clinical documentation and suggest appropriate codes for review and validation by a human coder.
Computer-Assisted Coding (CAC) software analyzes unstructured clinical documentation within the EHR using Natural Language Processing (NLP) and suggests relevant diagnosis and procedure codes. However, it is a tool to aid, not replace, the coder. The coding professional must review, validate, and finalize the suggested codes to ensure accuracy and compliance before billing.
Question 3: A CEHRS is working in the EHR to finalize an encounter form (superbill). The physician performed a standard office visit (CPT 99213) and a separate, significant procedure on the same day. To ensure both services are billed correctly, the CEHRS should verify that the physician has linked which of the following to the CPT codes?
- A referral from another physician.
- The time spent on each service.
- A specific diagnosis for each procedure and an appropriate modifier. (Correct answer)
- The patient's consent form for the procedure.
Correct answer: A specific diagnosis for each procedure and an appropriate modifier.
When multiple procedures are performed, each must be supported by a diagnosis demonstrating medical necessity. Additionally, a modifier (like modifier 25 for a significant, separately identifiable E/M service on the same day of a procedure) is often required to indicate to the payer that the services were distinct. The EHR must be capable of capturing both the linked diagnosis and the necessary modifier.
Question 4: Which feature within an EHR system is specifically designed to help prevent coding and billing errors, such as unbundling or using incorrect code combinations, before a claim is submitted?
- Patient portal messaging
- Clinical decision support alerts
- Claims scrubbing and edits (Correct answer)
- Electronic prescribing functionality
Correct answer: Claims scrubbing and edits
EHR and practice management systems often include 'claims scrubbers' or built-in edits, such as the National Correct Coding Initiative (NCCI) edits. These tools automatically check claims for common errors, such as mutually exclusive procedures being billed together (unbundling) or invalid diagnosis/procedure links, before they are sent to the payer, thereby reducing denial rates.
Question 5: A CEHRS notices that a provider frequently uses a pre-populated EHR template for documenting patient visits for 'chronic hypertension'. The template automatically includes extensive review of systems and physical exam details, often leading to a higher-level E/M code being suggested by the EHR. This practice poses a significant compliance risk related to:
- HIPAA privacy violations.
- Lack of medical necessity. (Correct answer)
- Inaccurate patient demographic data.
- Failure to obtain informed consent.
Correct answer: Lack of medical necessity.
While EHR templates can improve efficiency, using them to auto-populate extensive documentation that doesn't reflect the actual, specific service performed for that visit can lead to upcoding. Billing is based on the medical necessity of the services provided, not just the volume of documentation generated by an EHR. Payers can deny these claims and audit the provider for potential fraud if the documentation doesn't accurately support the level of service billed.
Question 6: When a CEHRS enters diagnosis and procedure codes into the EHR for a Medicare patient, the system should be able to check these codes against which of the following to verify that the service is covered for the given diagnosis?
- The hospital's internal charge description master (CDM).
- The American Medical Association (AMA) CPT codebook.
- National and Local Coverage Determinations (NCDs/LCDs). (Correct answer)
- The patient's previous billing history.
Correct answer: National and Local Coverage Determinations (NCDs/LCDs).
National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs) are policies developed by Medicare and its regional contractors that specify the circumstances under which a particular service or procedure is considered medically necessary and therefore covered. Modern EHRs can integrate these rules to provide real-time feedback on the likelihood of a service being covered for a specific diagnosis code.
CEHRS - Certified Electronic Health Records Specialist Medical Coding in EHR Questions and Answers 1
A physician documents a patient's diagnosis as 'Type 2 diabetes mellitus with hyperglycemia' and the procedure as a 'comprehensive metabolic panel'.
Within the EHR, what is the MOST critical relationship the CEHRS must ensure is established for proper claim submission?