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Medical Coding Basics

Instructions:

Answer 50 questions in 15 minutes.
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Match each statement with the correct term.
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This is a study tool. The 3 wrong answers for each question are randomly chosen from answers to other questions. So, you might find at times the answers obvious, but you will see it re-enforces your understanding as you take the test each time.

1. What is the National Correct Coding Initiative (NCCI)?
Initiative developed by CMS to promote national correct coding methods and control improper coding that leads to wrong payments of Part B health claims.
Strong - broad and have large surfaces for muscles to attach to.
When a person who is not sick/injured seeks health services for a specific thing (immunizations - organ donors) -When a person with a chronic condition presents for specific treatment of that condition (diabtetes) -When a circumstance influences the
Before - in front of

2. Vomer
Slow
Near the point of attachment to the trunk.
Bone that forms the wall between the nostrils
Under

3. Lumbar
Free moving joints that are surrounded by joint capsules.
Lower Back
In front of the temporal bones
Forms the sides of the cranium

4. -plasty
Surgical Repair
Disease Condition
Nose
Karatin

5. How long should Medical Records be retained?
Near the point of attachment to the trunk.
A break at the distal end of the bone - usually when someone tries to break their fall.
Governed by State and Local laws; should be retained indefinitely. For deceased patients - they should be kept at least 5 years.
Opening

6. Ulna
All
A Federal law that prohibits submitting a false claim or making a false statement or representation in connection with a claim.
Lower medial arm bone
1. Malignant (Accelerated and severe) 2. Benign (Mild or controlled) 3. Unspecified (Not specified in the Medical Record)

7. Occipital Bone
Bursting forth blood
Forms the back of the skull
1. For treatment (discussing the case with another professional)2.Payment (When providers submit claims on the patient's behalf).3. Operations: Staff training and Quality Improvement.
Date of Service (DOS) -Place of Service (POS) -Type of Service (TOS) -Diagnosis -Procedure(s)

8. -oma
Standards of conduct based on moral principals.
Enlargement
Mass
Discharge - Flow

9. How long should Medical Records be retained?
Discharge - Flow
Governed by State and Local laws; should be retained indefinitely. For deceased patients - they should be kept at least 5 years.
Osseous
1. Insurance Reform 2. Administrative Simplification

10. Frontal Bone
Before - in front of
Forms the front part of the skull and the forehead.
5
Discharge - Flow

11. supra
Suture
Shin
1. Volume 1; Tabular List 2. Volume 2; Diseases - Alphabetic Index 3. Volume 3; Procedures - tabular list and index
Above

12. What is hair made of?
Birth
Wrist bones
Karatin
Four

13. What are the 2 types of glands on the skin?
Horizontal plane dividing the upper and lower parts of the body.
1. Sebaceous (oil) glands 2. Suddiferous (sweat) glands
Lower medial arm bone
Date of Service (DOS) -Place of Service (POS) -Type of Service (TOS) -Diagnosis -Procedure(s)

14. Parietal Bones
Through
Ovary
1. The provider's usual charge for the service 2. The average charge of all the other providers in the same geographical area 3. The actual charge submitted on the claim The lowest amount is used as basis for the payment.
Forms the sides of the cranium

15. stomat/
Disease Condition
A working diagnosis that has not yet been established.
Mouth
Surgical Puncture

16. What is Carcinoma in situ?
Cancer that has localized and not spread at all.
Near the point of attachment to the trunk.
Opening
Office of Inspector General (OIG)

17. Short Bones
Small with irregular shapes (ie wrist and ankle)
CMS-1500
Upper Back
Upper Arm bone

18. What is Employee Liability Insurance?
Active - retired - survivors and their families of the Armed Forces.
1. Epidermis (Top layer) 2. Dermis (Middle layer) 3. Subcutaneous Layer
Under
Protection against loss of money caused by failure through error or unintentional omission of the individual or service submitting the claim.

19. para
Beside
Shoulder - collar - pelvic - arms and legs.
Upper Arm bone
Karatin

20. When can a provider share PHI without specific permission from the patient?

21. anti
1. For treatment (discussing the case with another professional)2.Payment (When providers submit claims on the patient's behalf).3. Operations: Staff training and Quality Improvement.
1. The provider's usual charge for the service 2. The average charge of all the other providers in the same geographical area 3. The actual charge submitted on the claim The lowest amount is used as basis for the payment.
A Federal law that prohibits submitting a false claim or making a false statement or representation in connection with a claim.
Against

22. Lateral
Breast
MM/DD/YY
Vertical plane dividing the body into Anterior and Posterior sections.
Side

23. -tomy
Before - in front of
1996
To cut into
Absence of hair

24. What are bones connected together with?
Blood Condition
Intestine
Before - in front of
Fibrous bands of ligaments

25. hemi
Half
Finger Bones
To cut into
1. The provider's usual charge for the service 2. The average charge of all the other providers in the same geographical area 3. The actual charge submitted on the claim The lowest amount is used as basis for the payment.

26. What are bones made of?
Cancer that has localized and not spread at all.
Osseous
Vertical plane dividing the body into Anterior and Posterior sections.
Surgical Repair

27. -pathy
Breast
A break at the distal end of the bone - usually when someone tries to break their fall.
Disease Condition
Surgical Fixation

28. How many bones are in the spine?
Half
Structural protein found in skin and connective tissue.
No.
26

29. Parietal Bones
Forms the sides of the cranium
Above
Bacterial inflammatory skin disease with lesions - pustules and vesicles
1. History -Chief complaint -History of Present illness -Review of Symptoms -Past - Family and Social History 2. Physical Exam 3.Medical Decision Making Complexity

30. Collagen
Social and Medical History -Family History -Physical Exam Findings -Progress Notes -Lab/Rad Results -Consultation Reports -Correspondence to the patient
Structural protein found in skin and connective tissue.
Ankle
Reimbursement is sent directly from payer to the provider.

31. When are V codes used?
Shoulder - collar - pelvic - arms and legs.
1. History -Chief complaint -History of Present illness -Review of Symptoms -Past - Family and Social History 2. Physical Exam 3.Medical Decision Making Complexity
The original cancer site. Malignant tumores are considered primary unless documented as secondary or metastatic.
When a person who is not sick/injured seeks health services for a specific thing (immunizations - organ donors) -When a person with a chronic condition presents for specific treatment of that condition (diabtetes) -When a circumstance influences the

32. What does a Surgical Package (aka Global Surgery) include?
Surgical Procedure Performed -Local infiltration/metatarsal/digit block/anesthesia -Pre-Op E/M services on day before surgery -Immediate Post-Op care -Normal - uncomplicated Post-Op care
Movement away from the midline
Free moving joints that are surrounded by joint capsules.
Major skin pigment

33. What does a triangle in the CPT book next to a code mean?
Wrist bones
Out - out of
A change in the code description since the last edition.
Bones the palm of the hand

34. How is Usual - Customary and Reasonable pricing calculated?

35. oophor
CMS-1500
No.
A change in the code description since the last edition.
Ovary

36. pseudo
Upper Arm bone
Hind foot bone
False
Sacrum

37. Melanin
1996
Muscle
Major skin pigment
Fallopian tubes

38. -itis
Inflammation
Head
Far from the point of attachment of the trunk.
MM/DD/YY

39. What are the key components of E/M?
Record
1. History -Chief complaint -History of Present illness -Review of Symptoms -Past - Family and Social History 2. Physical Exam 3.Medical Decision Making Complexity
Small - rounded bones that resemble sesame seeds that are found near joints. (ie knee cap)
Lower medial arm bone

40. hepato/
Turning the palm or foot upward
Without
Heart
Liver

41. hyster/
Uteris
Smaller - lateral leg bone
Sacrum
Turning the palm or foot upward

42. What is CHAMPVA
Noninvasive - non-spreading - nonmalignant.
Provides medical benefits to spouses and children of veterans with total - permanent - service related disabilities- or have died.
Far from the point of attachment of the trunk.
Visual Examination

43. -sclerosis
Hardening
Fat cell
Wrist bones
The fractured area of the bone collapses on itself.

44. epi
The Axial Skeleton and the Appendicular Skeleton
1. History -Chief complaint -History of Present illness -Review of Symptoms -Past - Family and Social History 2. Physical Exam 3.Medical Decision Making Complexity
Above
Hardening

45. Fibula
Bones at the corner of each eye that cradle the tearducts
Neck Bones
Governed by State and Local laws; should be retained indefinitely. For deceased patients - they should be kept at least 5 years.
Smaller - lateral leg bone

46. Lipocyte
Fat cell
The bone is broken and pierces an organ.
A break at the distal end of the bone - usually when someone tries to break their fall.
1. Volume 1; Tabular List 2. Volume 2; Diseases - Alphabetic Index 3. Volume 3; Procedures - tabular list and index

47. What are the two types of edits that the NCCI implements?
Half
Upper roof of the mouth
1. Column 1/ Column 2; identified unbundled codes.2. Mutually Exclusive Edits: Codes that are unlikely to be performed on the same patient in the same day.
No.

48. tetra
Karatin
Head
Four
Below - deficient

49. What does a triangle in the CPT book next to a code mean?
Upper Arm bone
1. The amount of time - intensity of effort and medical skill required for the service 2.Overhead; the practice costs related to performing the service 3. Cost of Medical Malpractice insurance
A change in the code description since the last edition.
Lower Back

50. ante
Blood Condition
Before
Fibrous bands of ligaments
Bones at the corner of each eye that cradle the tearducts