FREE Certified Coding Associate Clinical Questions and Answers
The coder records that the patient is taking Haldol as directed. The ultimate diagnoses listed on the progress notes are acute pharyngitis, malnutrition, and diabetes mellitus. What illness would the coder be suspicious the patient has and should ask the doctor about?
Schizophrenia is a serious mental disorder that can have a significant impact on a person's thoughts, emotions, and behavior. It often requires specialized treatment and care. If the patient is taking Haldol as directed, it suggests that they might have a history of or ongoing mental health concerns that require further attention and assessment by the healthcare provider.
What is the name of the federal initiative to identify and address erroneous payments made through Medicare's Fee-for-Service (FFS) programs?
The RAC program aims to detect and correct improper payments, including both overpayments and underpayments, in the Medicare FFS system. RACs are third-party entities contracted by the Centers for Medicare & Medicaid Services (CMS) to review claims and identify payment discrepancies. They play a role in improving the accuracy and integrity of Medicare payments.
What kind of company carries out Medicare and Medicaid certification surveys for hospitals under contract with the CMS?
These state agencies are responsible for conducting surveys and inspections to ensure that healthcare providers, including hospitals, meet the required standards to participate in the Medicare and Medicaid programs. The surveys assess various aspects of patient care, safety, facility conditions, and regulatory compliance to determine if the provider is eligible for Medicare and Medicaid reimbursement.
The Joint Commission's ORYX program and HEDIS are both made to gather data for .
The Joint Commission's ORYX program and HEDIS (Healthcare Effectiveness Data and Information Set) are designed to gather data for performance improvement programs in the healthcare industry. The data collected through these programs is used to assess and enhance the quality of care provided by healthcare organizations, identify areas for improvement, and drive overall healthcare quality improvement efforts.
The creation of standards for electronic medical records was required by the .
The creation of standards for electronic medical records was required by the Health Insurance Portability and Accountability Act (HIPAA) of 1996.
Written or oral authorization to move forward with caution is categorized as:
Informed consent refers to the process where an individual is provided with all the necessary information about a medical procedure, treatment, or intervention, including potential risks, benefits, alternatives, and possible outcomes.
In a doctor's progress note, a diabetic patient is noted as having "FBS 110 mg%, urine sugar, no acetone." Where would this notation be placed in a POMR progress note?
The notation "FBS 110 mg%, urine sugar, no acetone" would be placed in the "Objective" section of a POMR progress note.
Determine the punctuation mark that is used to augment any additional words or explanatory information that may or may not be included in the ICD-9-CM coding statement of diagnosis or procedure. The case's code number is unaffected by the punctuation. The punctuation is used in all three volumes of ICD-9-CM and is regarded as a nonessential modifer.
In the ICD-9-CM coding system, parentheses ( ) are used to enclose additional words or explanatory information that may or may not be included in the coding statement of diagnosis or procedure. The case's code number is indeed unaffected by the punctuation. This punctuation convention helps provide additional context or clarification for the coding while maintaining the integrity of the primary code.
The following entities have established messaging standards for electronic data interchange in healthcare:
HL7 (Health Level 7) is an international organization that develops standards for the exchange, integration, sharing, and retrieval of electronic health information. Their standards facilitate the interoperability of healthcare information systems and the seamless exchange of data between different healthcare entities and systems. HL7's messaging standards play a crucial role in electronic data interchange in the healthcare domain.
what are the names of the four-digit icd9cm diagnostic codes
The four-digit codes in ICD-9-CM are referred to as "Subcategory Codes."
What's the most procedure codes that can be included on a paper UB-04 claim form for a hospital inpatient?
These codes represent the treatments, procedures, surgeries, or other medical interventions performed during the inpatient stay. It's important to accurately code and document the procedures to ensure proper billing and reimbursement. Keep in mind that the specific requirements and limitations for procedure code reporting may vary depending on the healthcare provider's location, payer, and any updates to billing regulations.
what are the names of the five-digit icd9cm diagnostic codes
The "newborn period" according to ICD-9-CM is the time period from birth to the ___ day after birth.
This period is significant in medical coding and classification as it helps categorize conditions and diagnoses that specifically pertain to newborns within this timeframe.
what standard language is used to code medical procedures and services?
CPT codes are developed and maintained by the American Medical Association (AMA). These codes provide a uniform system for describing medical, surgical, and diagnostic services, including procedures, treatments, and other healthcare services provided by healthcare professionals. CPT codes play a crucial role in accurately documenting and billing for medical services, as well as facilitating communication and data exchange within the healthcare industry.
How are codes assigned when categorizing a selective catheterization in CPT?
The code selected should represent the highest order of vessel or branch catheterized during the procedure.