HCPCS, Coding, compliance & Auditing Exam
Questions With Answers
Source Documening
Actual Pt health records, office noes, consultation report, progress note, operative report, or
diagnosis evaluation
its imperative to become familiar with what constitutes correct documentation because
reimbursement for the physician's services is based on WHAT IS DOCUMENTED
Sound Health records should be chronologically documented because these records serve the
following function
They enable the physician and other healthcare professionals to plan and
evaluate the patient's treatment.
• They enhance communications and promote continuity of care among
physicians and other healthcare professionals involved in the patient's care.
• They facilitate claims review and payment.
• They reduce hassles related to medical review.
• They serve as a legal document to verify the care provided, which can be
helpful in defending against an alleged professional liability claim.
The physician should read, sign, and date all dictated medical records
before they're placed in the patient's chart. A signature alongside the note indicates that the
physician read the transcription and approved the information
When Medicare audits a medical record and the record can't be read by at least two people
considered illegible, and the services won't be reimbursed.
CMS
administers Medicare, doesn't specify whether a full
signature is required or whether initials are permitted.
documentation of each patient encounter should include
date, reason for the encounter, appropriate history and physical exam, review of lab and/or x-ray
data, assessment, and plan for care.
The CPT and ICD-9 codes reported on the health insurance claim form
should reflect the documentation in the medical
record and support the medical necessity. An important phrase to remember in the insurance world
is, "if it wasn't documented, it wasn't done!"
medically necessary services
as those that adhere to standards of good medical practice, match up with the diagnosis, and provide
the most appropriate level of care in the most appropriate
setting (may or may not be covered depending on plan)
It's important to understand medical necessity because it determines (1) whether how patients are
being treated is appropriate and (2) whether the services or
procedures are reimbursable.
, Choosing the primary diagnosis and then linking the diagnosis to the procedure are critical steps
for proper reimbursement
codelinkage edits (ICD-9/CPT matching)
built into their claims-processing systems
Coding from operative reports can be difficult
You must have a good understanding of medical terminology as well as a correct idea of the actual
procedure performed. Effective communication with the physician is essential for accurate coding.
Evaluation and Management (E/M) codes
cover those services generally considered to be the office visit, hospital visit, consultation, or ER visit.
EX (pediatric or family practice,)
HCPCS (pronounced HIC-pics)
is the Healthcare Common Procedure Coding System
stands for Healthcare Common Procedure Coding System. HCPCS was established in the 1980s to
provide a standardized coding system for describing the specific procedures and services in health
care
Level II codes (national codes)
used mainly to identify products, supplies, and services not included in the CPT-4 codes. These can
include
• Ambulance services
• Durable medical equipment
Prosthetics
• Orthotics
• Nonphysician supplies
created to provide reporting and billing mechanisms
for codes not covered under CPT.
Level II HCPCS codes consist of four digits preceded by an alphabetical character ranging from A
through V
Level I codes
consist of five-digit codes, CPT level
HCPCS originally stood for
HCFA Common Procedure Coding System. HCFA was the acronym for the Health Care Financing
administration, which is now known as the Centers for Medicare and Medicaid (CMS), thus the coding
system was named after that organization.
Today, Medicare, Medicaid, as well as private health insurers all use HCPCS codes for billing and
claims processing.
HHS
In 2003 gave authority to the CMS to maintain and distribute HCPCS Level II codes under HIPAA.
They're updated on January 1 of each year, just like
CPT (Level I) codes.
Questions With Answers
Source Documening
Actual Pt health records, office noes, consultation report, progress note, operative report, or
diagnosis evaluation
its imperative to become familiar with what constitutes correct documentation because
reimbursement for the physician's services is based on WHAT IS DOCUMENTED
Sound Health records should be chronologically documented because these records serve the
following function
They enable the physician and other healthcare professionals to plan and
evaluate the patient's treatment.
• They enhance communications and promote continuity of care among
physicians and other healthcare professionals involved in the patient's care.
• They facilitate claims review and payment.
• They reduce hassles related to medical review.
• They serve as a legal document to verify the care provided, which can be
helpful in defending against an alleged professional liability claim.
The physician should read, sign, and date all dictated medical records
before they're placed in the patient's chart. A signature alongside the note indicates that the
physician read the transcription and approved the information
When Medicare audits a medical record and the record can't be read by at least two people
considered illegible, and the services won't be reimbursed.
CMS
administers Medicare, doesn't specify whether a full
signature is required or whether initials are permitted.
documentation of each patient encounter should include
date, reason for the encounter, appropriate history and physical exam, review of lab and/or x-ray
data, assessment, and plan for care.
The CPT and ICD-9 codes reported on the health insurance claim form
should reflect the documentation in the medical
record and support the medical necessity. An important phrase to remember in the insurance world
is, "if it wasn't documented, it wasn't done!"
medically necessary services
as those that adhere to standards of good medical practice, match up with the diagnosis, and provide
the most appropriate level of care in the most appropriate
setting (may or may not be covered depending on plan)
It's important to understand medical necessity because it determines (1) whether how patients are
being treated is appropriate and (2) whether the services or
procedures are reimbursable.
, Choosing the primary diagnosis and then linking the diagnosis to the procedure are critical steps
for proper reimbursement
codelinkage edits (ICD-9/CPT matching)
built into their claims-processing systems
Coding from operative reports can be difficult
You must have a good understanding of medical terminology as well as a correct idea of the actual
procedure performed. Effective communication with the physician is essential for accurate coding.
Evaluation and Management (E/M) codes
cover those services generally considered to be the office visit, hospital visit, consultation, or ER visit.
EX (pediatric or family practice,)
HCPCS (pronounced HIC-pics)
is the Healthcare Common Procedure Coding System
stands for Healthcare Common Procedure Coding System. HCPCS was established in the 1980s to
provide a standardized coding system for describing the specific procedures and services in health
care
Level II codes (national codes)
used mainly to identify products, supplies, and services not included in the CPT-4 codes. These can
include
• Ambulance services
• Durable medical equipment
Prosthetics
• Orthotics
• Nonphysician supplies
created to provide reporting and billing mechanisms
for codes not covered under CPT.
Level II HCPCS codes consist of four digits preceded by an alphabetical character ranging from A
through V
Level I codes
consist of five-digit codes, CPT level
HCPCS originally stood for
HCFA Common Procedure Coding System. HCFA was the acronym for the Health Care Financing
administration, which is now known as the Centers for Medicare and Medicaid (CMS), thus the coding
system was named after that organization.
Today, Medicare, Medicaid, as well as private health insurers all use HCPCS codes for billing and
claims processing.
HHS
In 2003 gave authority to the CMS to maintain and distribute HCPCS Level II codes under HIPAA.
They're updated on January 1 of each year, just like
CPT (Level I) codes.
