According to the Code of Federal Regulations, what constitutes a clean claim?
- A claim with no defect, impropriety or lack of documentation that prevents timely payment. 2. The claim otherwise conforms to the clean claim requirements under original medicare.
During an annual general medical examination an abnormal finding is identified, how should it be coded?
A code from subcategory Z00.0 should be the primary followed by the codes for the abnormal findings.
External cause codes always come after diagnosis, but sometimes there are multiple. What is the priority order (5) for external causes?
- Child and adult abuse 2. Terrorism events 3. Cataclysmic events 4. Transport accidents 5. All other external cause and activity codes.
How do you code a bilateral condition when each side is treated in separate encounters?
Assign the bilateral code for the first encounter, then use a unilateral code for the second assuming the treatment fixed the issue on that side. If the condition persists on both sides even after the first treatment, then the bilateral code can still be used.
How do you code for a borderline diagnosis?
Code it as confirmed unless there is an index entry of borderline for that classification.
How do you determine a patients primary and secondary insurance?
If the patient is the subscriber on their insurance plan, that is their primary, if they are also covered under another insurance (spouse) that would be secondary.
If a code has less than six characters but has an applicable 7th character, what must be done?
Add “X” for every missing character up to the 7th. (EX: R86XXX8)
If a patient is diagnosed with arteriosclerosis with chronic total occlusion of the coronary artery, what do you look up in the alphabetic index?
Arteriosclerosis. The main term, not body part or region, comes first and the rest of the specific information is coded as far as it can be past that term.
If a patient is seen solely for the administration of chemotherapy, immunotherapy or radiation therapy, what is the proper coding?
The appropriate Z code should be the primary reported code followed by the code for the malignancy being treated on the date of service.
If a patient lists a P.O box for their mail address what should you do?
Ask for a cross street or mile marker.
Is it acceptable to code from the alphabetic index of the ICD-10?
No, the code must always be looked up in the tabular list for specificity.
Should you code for symptoms when a diagnosis has been established.
No. Unless they are distinct from the diagnosis as indicated by the provider.
What 6 instances qualify as poisoning?
- Accidental drug overdose 2. Wrong substance taken or given 3. Drug taken inadvertently 4. Accident in usage of drug 5. Suicide attempt 6. Assault
What are “Z” codes used for?
Radiation therapy or chemotherapy encounters for neoplasms.
What are the 4 divisions of the ICD-10 alphabetic index?
- Index to diseases and injuries 2. Table of Neoplasms 3. Table of drugs and chemicals 4. External cause of injuries index
What are the four additional guidelines to the birthday rule?
- If both parents have the same birthday, primary coverage goes to the oldest policy. 2. When one parent has regular coverage and the other has COBRA, regular coverage takes priority. 3. In divorce, if the custodial parent has not remarried, the custodial parents plan is primary and non-custodial is secondary. If one parent has a group plan and the other an individual, the group plan is primary. 4. In divorce, when the custodial parent has remarried, custodial parent is primary and stepparent is secondary. Non-custodial parent is payer of last resort. *These are not law and may not be followed by all payers. Check with payers and state law to be sure.
What are the four patient types?
- Self-pay 2. Medicare 3. Medicade 4. Commercial Carrier
What are the four stages of a claim cycle?
- Claims submission and electronic data interchange (EDI). 2. Claims processing 3. Claims adjudication 4. Payment or denial
What do brackets [ ] contain in the alphabetic index?
Manifestation codes that are used when two codes are required to accurately report a condition.
What do parenthesis ( ) contain?
Nonessential modifiers. These are supplementary words that may be present or absent in the statement of a disease or procedure that don’t affect the code number to which it is assigned.
What do you do if a patient has a syndrome that is not listed in the ICD-10?
Code the patients documented manifestations of the syndrome.
What does “NOS” stand for in the ICD-10?
Not otherwise specified. This is the equivalent of unspecified.
What does carcinoma in situ (Ca in situ) mean?
A neoplasm that is contained within the original site or location.
What does NEC mean in the ICD-10?
Not elsewhere classifiable. Means a provider documented more specific information regarding the patients condition but there is not a code to report the condition accurately.
