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NHA CBCS Module 3: Coding And Coding Guidelines questions and answers rated A+ 2024/2025
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NHA CBCS Module 3: Coding AndCoding Guidelines
Abstracting - ANSReviewing scientific report documentation to find out medical ideas that
help assigning codes to the highest degree of specificity.
Scientific documentation - ANSInformation recorded inside the scientific record relating the
health reputation of a patient as determined by a fitness care provider.
CPT - ANSCurrent Procedural Terminology. Codes for services and tactics.
Electronic fitness file (EHR) - ANSA virtual version of a patient's chart that consists of
information documented by means of more than one providers at distinct centers concerning
one patient.
HCPCS - ANSHealthcare Common Procedural Coding System.
ICD-10-CM - ANSInternational Classification of Diseases - 10th Revision - Clinical
Modification. Codes for sicknesses, accidents, and statuses.
Clinical coding - ANSProcess of abstracting diagnoses, techniques, and offerings from the
scientific document and changing them to numeric and/or alphanumeric codes for claims
submission.
Clinical necessity - ANSProcess of presenting diagnosis codes that guide the offerings
rendered to the affected person; coding for clinical necessity entails associating relevant
prognosis codes to carrier/manner codes in the billing software program, that is known as
linking/linkage.
Clinical file - ANSDocuments fitness care services provided to a patient.
Query - ANSContacting the accountable issuer to request explanation about documented
diagnoses or methods.
Declare denial - ANSUnpaid clinical claim back by payer because of coding mistakes,
lacking statistics, preauthorization necessities, or health plan insurance troubles.
Downcoding - ANSUnpaid scientific claim back by using payer due to coding mistakes,
missing records, preauthorization requirements, or health plan coverage issues.
Encounter shape - ANSFinancial file supply record used by companies to document handled
diagnoses and services furnished to a patient for a single come across.
, Modifier - ANSProvides additional data approximately a process or carrier without altering
the definition of the code description.
Preauthorization - ANSPrior acclaim for services granted by payer after health plan
overview.
History of Present Illness (HPI) - ANSBrief description of the patient's gift contamination or
different motive for an encounter, along with such information as places, length, severity, and
associated symptoms and symptoms.
Unbundling - ANSSubmitting multiple CPT codes while a unmarried code is to be had to
document offerings in complete.
Upcoding - ANSAssignment of ICD-10-CM code this is greater intense than analysis
supported with the aid of the documentation inside the medical report.
Every affected person come upon have to encompass _________________. - ANSEvery
affected person encounter must include the motive for the come upon and supported
medical necessity.
Documentation for every encounter includes the reason for the stumble upon, history,
physical exam, diagnostic or laboratory exams, and a remedy plan to aid each CPT,
ICD-10-CM, or HCPCS code mentioned at the claim.
What does SOAP stand for and what is it used for? - ANSSubjective, Objective,
Assessment, Plan
Used to summary statistics and details required for code assignments.
Explain the "S" in SOAP. - ANSSubjective - symptoms or history of the condition the use of
the patient's own words, defined development or decline of the circumstance for the reason
that closing remedy, causes for any gaps in remedies, and the patient's compliance with
issuer pointers.
Explain the "O" in SOAP. - ANSObjective - crucial symptoms, bodily exam findings,
laboratory and other diagnostic information, and imaging outcomes and documentation from
different clinicians which have been reviewed and taken into consideration.
Explain the "A" in SOAP. - ANSAssessment - the diagnostic influence or operating diagnoses
primarily based at the subjective court cases and objective findings.
Explain the "P" in SOAP. - ANSPlan - method or plan for remedy which includes remedy
frequency, length, and predicted outcomes and goals of remedy. The plan regularly includes
medicinal drugs, referrals, and patient schooling or counseling.
Match the documentation kind with the appropriate statistics.
Documentation kind: Assessment; Plan; Subjective; Objective
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