CDIP DOMAIN 1 CLINICAL CODING PRACTICE EXAM QUESTIONS AND ANSWERS.

Principal Diagnosis The disease or condition that was present on admission, was the principal reason for admission, and received treatment or evaluation during the hospital stay or visit for the reason established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care First Listed Diagnosis Used in the outpatient setting, this term is used (instead of the inpatient setting's principal diagnosis), and it is determined in accordance with ICD-10-CM's coding conventions (or rules) as well as general and disease-specific coding guidelines. Secondary Diagnosis A statement of those conditions coexisting during a hospital episode that affect the treatment received or the length of stay Where to find pertinent Diagnoses H&P, Progress Notes, Clinic Notes, Operative & Pathology reports, Procedure Notes, Lab/Radiology Findings, Discharge Summary Value of Utilizing Coding Software Accurate Coding, increase in productivity, Grouping, Edits, and Resources. 7 Characteristics of High Quality Documentation 1. clear 2. consistent 3. complete 4. precise 5. legible 6. timely 7. reliable Complication Conditions that develop in a patient already suffering from a disease - prolongs the length of stay by at least 1 day in about 75% of the cases Comorbidity a pre-existing condition which of its presence with the principal diagnosis will increase the length of stay by at least 1 day in 75% of the cases Medicare CMS- Establish rules MS-DRG - is used for reimbursement Medicaid is handle by individual states primary insurance own rules and regulations per plan MS- DRG Medicare Severity Diagnosis Related Group PPS (Prospective Payment System) fixed payment scale/schedule based o your DRG, effected Medicare Part A, resulted in shorter hospital stays MS-DRG Reimbursement Calculation MS-DRG Relative Weight X Hospital Specific Adjusted base rate = Payment APR - DRG All Patient Refined Diagnosis-Related Group SOI Severity of Illness ROM Risk of Mortality APR-DRG Four Levels 1. Minor 2. Moderate 3. Major 4. Extreme Hospital outpatient Prospective Payment Systems (OPPS) Ambulatory Payment Classifications (APC) Home Health Prospective Payment Systems (HH PPS) Outcome and Assessment Information Set (OASIS) Skilled Nursing Facility Prospective Payment Systems (SNF PPS ) Minimum Data Set (MDS) Inpatient Rehabilitation Facility Prospective Payment Systems (IRF PPS) Patient Assessment Instrument (PAI) (IRF-PAI) What impacts MS-DRG assignment MS-DRG Regulations CC MCC Principal Diagnosis Secondary Diagnosis Principal Procdure Secondary Procedure Gender Discharge Status MS- DRG System Hiararchy MDC Major Diagnostic Category - Surgical - MS DRG Group A & B medical - MS DRG Group C & D HCPCS Healthcare Common Procedure Coding System CPT Current Procedural Terminology - Maintained by AMA 6 Sections of CPT Evaluation, Anesthesia, Surgery, Radiology, Medicine & Pathology & Laboratory. X Placeholder for ICD-10 NEC Not Elsewhere Classifaible - other specified NOS Not otherwise specified - unspecified Brackets [ ] tabular list to enclose synonyms, alternative wording or explanatory phrases, also manifestation codes Parenthesis both alpha and tab list to enclose supplementary word that may be present or absent in the statement of a disease or procedure without affecting the code number to which it is assigned Colon incomplete terms which needs one or more of the modifiers following the colon Other when the information in the medical record provides detail for which a specific code does not exist unspecified information in the medical record is insufficient to assign a more specific code includes further define, or give examples of the content of the category inclusion terms list of terms is included under some codes Excludes 1 note NOT CODED HERE- the code excluded should NEVER be used at the same time as the code above the note exclude 2 not included here - the condition excluded is not part of the condition represented by the code but a patient may have both condition at the same time Use additional code / code first Used for Sequencing And and/or with or in, associated with or due to see/ see also alpha index stating another code should be referenced default code represent that condition is most commonly associates with the main term or is the unspecified code for the condition signs and symptoms are acceptable for reporting purposes when a related definitive diagnosis has not been established Acute and Chronic code both and sequence the acute code first combination code a single code to classify two diagnosis, a diagnosis with associated secondary process/associated complication Sequela late effect Impending or Threatened Condition 1. If it occurred, code as confirmed; 2. If it didn't occur, see if Impending or Threatened is in index; 3. If nothing in index, code underlying conditions and omit coding Impending or Threatened condition DX from documentation other than the patient provider is accepted for BMI Depth of non-pressure ulcer Pressure ulcer state coma scale HIS Stoke Scale Social Determination of Health Laterality Blood Alcohol Level