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ch 6.Documentation and Coding Standards
Documentation and Coding Standards
220
Health Care
Not Applicable
03/17/2017
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Term
the medical record chronologically documents patient care to
 Definition
1. enable the physician and other healthcare professionals to plan and evaluate the patient's immediate treatment, and to monitor his/her healthcare.
2. Enhance communication and promote continuity of care among physicians and other healthcare professionals involved in the patients care.
3. facilitate claims review and payment.
4. Assist in utilization review and quality of care evaluations.
5. Reduce complicated medical review.
6. Provide clinical data for research and education.
7. serve as a legal document to verify the services provided, (in a liability claim)
Term
What is the Supplemental Compliance Program Guidance for Hospitals and who publishes it?
 Definition
published by OIG and its a document that addresses the need for timely, accurate, and complete documentation.
Term
Payers may request additional documentation to validate that services provided were
 Definition
1 appropriate to the treatment of the patients condition
2 medically necessary for the diagnosis and/or treatment of an illness or injury
3. coded correctly
4. reported correctly for the site of service.
Term
Who sets the standards in CoP/CfC?
 Definition
The federal register
Term
The standards in CoP/CfC include
 Definition
guidelines for documentation and apply to both hospitals and ASCs and must be met to participate in Medicare and Medicaid programs.
Term
ASCs guidelines for CoP/CfC
 Definition
in accordance with 42 CFR 416
Term
CAH guidelines for CoP/CfC
 Definition
in accordance with 42 CFR 485 subpart F
Term
Hospitals guidelines for CoP/CfC
 Definition
in accordance with 42 CFR 482
Term
regulation 42 cfr 482.24 outlines
 Definition
the CoP for medical records services. The conditions include that each patient should have a mr, the mr must be organized to allow for pronpt completion, filing, and retrieval, must be retained for at least five years, and patient confidentiality should be protected.
Term
a facility may be accredited for Medicare participation purposes through
 Definition
one of the CMS recognized national accreditation organizations.
Term
Among those recognized as organizations for ASCs and hospitals are
 Definition
American Association for Accreditation of Ambulatory Surgery Facilities and the Joint Commission.
Term
The Joint Commission
 Definition
accredits many hospitals. governed by a board of physicians, administrators, nursess, employers, a labor representative, health plan leaders, quality experts, ethicists, a consumer advocate and educators.
Term
What does a hospital have to do to become accredited by the Joint Commission
 Definition
It must undergo an extensive on-site review by a Joint Commission and in addition they will have unannounced surveys after its previous full survey.
Term
Survey by the Joint Commission evaluates
 Definition
the hospitals performance in areas that affect patient care including the hospital mr. The hospital is evaluated, scored and awarded accreditation based on how well the hospital meets the standards.
Term
Joint Commission accreditation confirms
 Definition
the facility has demonstrated compliance in all areas based on the Joint Commission standards
Term
Standards are broken down
 Definition
by elements of performance EPs
Term
For mr documentation the EPs
 Definition
are found in the record of care, treatment and services RC chapter of each accreditation manual
Term
The Joint Commission EPs and standards can be found
 Definition
in the accreditation manual for the specific type of facility. CAMAC and CAMH.
Term
documentation standards are classified into two categories
 Definition
patient-specific data and information
Additional standards for specific patient populations, such as operative/invasice procedures, ambulatory care, emergency, clinical trials, addictions, emotional, or behavioral disorders.
Term
patient specific data applies to
 Definition
all patients whether they are admitted as inpatients or outpatients, and where the additional standards apply to patients who fit the specific criteria.
Term
To meet the specific documentation requirements, the following general information must be documented.
 Definition
patient demographics
reason for care, treatment, or service
evidence of informed consent
evidence of known advance directives
legal status of pts receiving behavioral healthcare services.
emergency care, Tx, services provided to pt before arrival
documentation of findings and assessments
diagnostic and therapeutic orders
reassessments and plan of care revisions, if indicated
response to care, Tx, services provided
every dose of meds administered and any adverse reactions
meds dispensed or prescribed at discharge
relevant dx/conditions est during course of care, Tx, and services.
Term
Assessment of patients
 Definition
assessment to include physical, psychological, social, nutrition, hydration status, and functional status.
Medical history and physical within 24 hours of admission.
Comprehensive pain assessment approopriate to patients condition and scope of care, tx, and service provided
assessment or impression derived from history and exam.
Initial nursing assessment of inpatient admission within 24 hours
Diagnosis, diagnostic impression, or condition
Sufficient information in mr
Identify nutritional screenings, if justified
Identify allergies to medicines and foods.
Complete functional status screening, when warranted
any specialized assessment and reassessment information for various populations
discharge plan or transfer of care
periodic reassessment of patient, as needed
integrated information from all staff members from various assessments to develop a plan for care, tx, and services
Term
Under the assessment of patient sufficient information in the mr to
 Definition
identify the patient
support dx/condition
justify care, tx, and service
document course and results of care, tx, services
promote continuity of care among its providers.
Term
Every mr entry is
 Definition
dated, author identified, and authenticated
Term
For documentation of care the signature can be
 Definition
written, electronic, or rubber-stamped (based on state regulations and carrier requirements).
Term
For documentation of care the History and PE contains
 Definition
consultations, operative reports, and discharge summaries.
Term
for documentation of care when verbal orders are given what needs to be documented
 Definition
a date and identification of the individual who gave the order, who received it, and who implemented the order.
Term
verbal orders authenticated
 Definition
within given timeframe(defined by state, federal law, or regulation).
Term
Goals of tx and tx plans should be
 Definition
documented
Term
Relevant observations should be
 Definition
documented
Term
Progress notes should be
 Definition
documented and authenticated
Term
Consultation reports should be
 Definition
documented as applicable
Term
All diagnostic test, therapeutic procedures, and results should beq
 Definition
documented
Term
Hospital must have policies and procedures in place regarding
 Definition
entry of information in pts mr
timeframe not to exceed 30 days in which the record must be completed after discharge.
Term
Hospital measurement of mr delinquency should be
 Definition
no less frequently than three months
Term
patient is educated in
 Definition
safe and effective use of meds
understanding of plan of care, tx, and services
nutritional intervention, diets, and oral health
safe and effective use of medical equipment or supplies provided by organization.
rehab tech to help reach maximum independence.
understand pain, risk for pain, importance and effective pain mgmt process
arrangement for services needed to meet pts medical needs after discharge, if applicable.
specific academic educational needs of children, if applicable.
Term
Discharge summary should have the following documented
 Definition
reason for hospitalization or care.
significant findings.
procedure, care, and/or tx provided.
patients condition at discharge.
meds and/or the services prescribed.
instructions to pt and/or family for immediate care when discharged and follow up care, when necessary.
Term
Pre-operative monitoring and documentation includes
 Definition
provisional dx recorded prior to performance of procedure.
completed informed consent for procedure.
Pre-anesthesia assessment prior to administration.
reevaluation of pt immediately before anesthesia
appropriate methods to continuously monitor oxygenation, ventilation, circulation during the procedure.
Term
Informed consent for procedure should
 Definition
identify benefits, risks, side effects, and potential difficulties related to recovery.
Term
Post op monitoring and documentation includes
 Definition
physiological status.
mental status.
meds including iv fluids.
blood and blood components, if administered.
vital signs and loc
pain level, pre- and post-administration of prescribed medication for pain.
complications, unusual events, and mgmt of those events.
Use of approved discharge criteria to determine pts readiness for discharge appropriately documented.
Operative report authenticated by surgeon and available in the mr.
Term
The operative report documentation must include
 Definition
1. indications for the procedure (supports medical necessity).
2. findings.
3. procedure performed.
4. description of procedure.
5. specimen removed.
6. post op dx
7. primary surgeon and assistants identified.
8. complications.
( the first 8 elements is required in the immediate post op note)
9. unusual service.
10. estimated blood loss.
11. Op progress note dictated immediately after procedure.
12. post op documentation record including pt discharge from post-sedation or post-anesthesia care according to discharge criteria and name of responsible physician.
Term
When should the op reports be done after the procedure and what method can they be in?
 Definition
should be dictated or handwritten immediately or within 24 hours following procedure.
Term
Records of pts who have received emergency care, tx, and services should contain the following detail
 Definition
1. time and means of arrival.
2. If the pt left against medical advice.
3. final disposition, condition, and instructions for follow-up care, tx, and services.
4. communication btw organization or provider to which pt is transferred or discharged.
5. reason for transfer or discharge.
6. pts physical and psychosocial status.
7. summary of care, tx, and services provided, and progress towards goals.
8. community resources or referrals provided to pt.
Term
ambulatory care records should contain, at the minimum, the following documentation
 Definition
1. summary of all significant dx., procedures, drug allergies, and meds.
2. known significant medical dx and conditions.
3. documentation of significant operative and invasive procedures.
4. known adverse and allergic drug reactions.
5. documented meds, including otc and herbal preparations
Term
ambulatory records should be stored
 Definition
in the same location to assist the provider in quick access of the medical information
Term
some diagnostic test include
 Definition
laboratory services, diagnostic x-rays, EKGs, pulmonary function studies, psychological tests, thyroid function test, and other test to diagnose an illness or injury.
Term
diagnostic serve may include the services of
 Definition
nurses, technicians, psychologists, and drugs and biologicals necessary for diagnostic study including the use of supplies and equipment.
Term
all hospital outpatient diagnostic services follow
 Definition
the physician supervision requirements for individual tests as though they were furnished in a physicians office.
Term
for outpatient hospital facilities direct supervision means
 Definition
immediately available.
Term
hospitals may furnish diagnostic services without direct supervision if
 Definition
if diagnostic services are outside the hospitals premises.
Term
outpatient therapeutic services include
 Definition
clinic services, emergency department services, and observation services.
Term
therapeutic services and supplies must be
 Definition
furnished as an integral part of the physician services in the diagnosis or treatment of an illness or injury. Order must be written by physician. And the physician must see pt periodically to assess the pt, record progress, and change or adjust treatment regimens.
Term
incident-to for the physicians offices
 Definition
means that the physician can bill for services provided by qualified employees as though he or she personally performed the services. physician bills under his provider number. Must be physically present in the office, and must have seen the pt in the past for condition being treated.
Term
incident -to a physician or NPPs service
 Definition
all services and supplies furnished to hospital or CAH outpatients that are not diagnostic services and that aid the physician or NPP in the treatment of the patient.
Term
define incident to
 Definition
services that are performed per the direction of a physician's treatment plan during the course of a professional service. This means the services or supplies are furnished as an integral, although incidental part of the physicians personal professional services in the course of diagnosis or treatment of an injury or illness where the physician remains actively involved in the treatment. ie. the services must be integral and incidental part of the physicians treatment plan.
Term
define direct supervision for services in the hospital main building or on campus departments
 Definition
means that the qualified supervisor must be on the same hospital campus during the service.
Term
rules to follow for incident to
 Definition
the service must be an integral, although an incidental part of the physician's professional services.
1. physician must have provided a previous e/m service, determined a dx, and documented a plan-of care.
2. physician must be present in the office suite (direct supervision) and immediately available.
3. physician doesn't need to see pt each time but must see the pt subsequently for services of a frequency that reflects active participation in the course of tx for the specific problem.
4. availability by phone doesn't meet direct supervision.
5. must be billed under the supervising physician;s NPI
6.when there is a change in the POC it is no longer considered incident to.
7. services are furnished by ancillary personnel under the direct supervision of the physician.
8. services are in a non-institutional setting.
9. there are no incident to services in a hospital, in-patient, outpatient, or snf.
Term
medical necessity as defined by payers
 Definition
services or supplies that are
in accordance with standards of good medical practice.
consistent with the diagnosis.
the most appropriate level of care provided in the most appropriate setting.
Term
medically necessary services often depend
 Definition
on the benefits plan
Term
critical questions a coder should ask about the standards of documentation are?
 Definition
1. is the reason for the pt encounter documented in the mr?
2. are all services provided documented?
3. does the mr clearly explain why support services, procedures, and supplies were provided?
4. is the assessment of the pts condition apparent in the mr?
5. does the mr contain information on the pts progress and the results of tx.?
6. does the mr include the physicians poc?
7. does the information in the mr provide a reasonable medical rationale for the setting and services to support billing?
8. does the information in the mr support the care given when another healthcare professional must assume care or perform medical review?
Term
The patients name and id should be on what pages in the mr?
 Definition
every page.
Term
past and present diagnosis should be accessible to
 Definition
the treating and/or consulting physicians.
Term
the documentation of each patient encounter should include
 Definition
the date
the reason for the encounter,
an appropriate history, physical exam,
review of lab, x-ray data and other ancillary services
if appropriate assessment, care plan (including discharge plan if appropriate
and legible identity of the observer.
Term
the reasons for and results of X-rays, lab tests, and other ancillary services should be documented or included in the
 Definition
mr
Term
relevant health and risk factors should be identified. meds, allergies and adverse reactions should be prominently noted in
 Definition
the mr
Term
the pts progress, including response to tx, change in tx, change in dx,, and pt noncompliance should
 Definition
all be documented.
Term
the documentation for each encounter needs to be
 Definition
complete to avoid relying on prior chart entries.
Term
the written plan of care should include, when appropriate
 Definition
treatments and medications, specifying frequency and dosage, referrals and consultations, patient/family education, and specific instructions for follow up.
Term
the codes reported on the claim form or billing statement should reflect
 Definition
the documentation in the mr for each date of service.
Term
when a consultation is requested there should be a what in the mr?
 Definition
a confirmed note from the consultant.
Term
Administrative Simplification provisions of HIPAA were designed
 Definition
to improve health care quality and reduce costs by simplifying the administration and management of health information.
Term
Administrative Simplification provisions addresses
 Definition
electronic transmission of medical claims, which is required for all Medicare claims submitted by covered entities , standardized code sets, and privacy regulations that give the pt greater voice in the release of pHI.
Term
under transmission standards the physician must
 Definition
take steps to secure electronically transmitted pt information from unauthorized disclosure and interception, including establishing policies and safeguards governing the gathering, storing, use, and disclosure of identifiable pt information.
Term
Any state is free to adopt laws that give more privacy, but it cannot
 Definition
take away the basic rights given by HIPAA (minimum standards).
Term
National standards (privacy regulations)include
 Definition
the right of patients to see, copy and request an amendment to their own mr. providers can charge for copies of mr but HIPAA sets limits on the fees.
Term
Are providers required to make exceptions to the way medical information is conveyed?
 Definition
Yes a pt can say they want telephone calls about treatment to go to a particular phone number.
Term
Does the provider have to give the patient the notice of HIPAA privacy rule?
 Definition
Yes. it explains pts rights under the rule and what to do if their rights have been violated.
Term
disclosures
 Definition
when instances of the pts PHI being released for reasons other than treatment, payment, healthcare operations, or information releases specifically authorized by the patient. the provider must keep an accounting of all disclosures.
Term
The HIPAA standards office is responsible for
 Definition
transactions and code sets, security, and identifiers for providers, insurers, and employers for use in electronic transactions.
Term
the HHS office of civil rights(OCR) is responsible for for what regulations?
 Definition
implementation and oversight of privacy regulations.
Term
What must the hospital do with regards to patients records?
 Definition
must have a procedure for ensuring the confidentiality of patient records. information from copies of records may only be released to authorized individuals, and the hospital must ensure that unauthorized individuals cannot gain access to or alter patient records.
Term
original medical records must be released by the hospital only in accordance with
 Definition
federal or state laws, court orders, or subpoenas.
Term
the professional coder's greatest liability is
 Definition
a lack of familiarity with anatomy, physiology, and terminology.
Term
some procedures if billed inappropriately will
 Definition
invoke penalties.
Term
deliberate ignorance is never an excuse when there is
 Definition
a breach of the rules, policies, or guidelines. the facility staff is expected to stay up to date.
Term
Many private insurers employ their own
 Definition
rules and additional restrictions may apply when participating in a network.
Term
To monitor reimbursement and coding patterns
 Definition
prepayment(prospective) and post-payment (retrospective) reviews and audits are performed. These audits should be included in the compliance plan.
Term
Whats the old saying for coders?
 Definition
if it isn't documented, it wasn't done.
Term
if mr record shows no evidence of the performed test, procedure, or service that was billed and paid for
 Definition
the reimbursement must be returned and an overpayment interest penalty paid.
Term
overutilization, overcharging, and suspect billing practices can also result in
 Definition
an audit
Term
if abuse or fraud is suspected in the Medicare or Medicaid programs, the government may
 Definition
call an investigation and, in cases of guilt, levy monetary penalties.
Term
When should information be entered in the pts chart?
 Definition
at the time of service,or immediately following the service.
Term
dictation for documentation should
 Definition
be an efficient, thorough, and organized method for recording pt information.
Term
physicians dictating their pts notes in the hospital or ASC must take precautions such as
 Definition
It may take several days for the transcriptionist to transcribe the recorded information and return to the physician to review for accuracy. So during this time its necessary for the physician to enter into the chart a written summary of the services rendered on that date.
Term
according to Medicare guidelines, the physician must sign dictated notes when?
 Definition
before they are placed in the patient's chart.a signature indicates the provider has read the transcription and approved the information.
Term
for basic documentation date and time should
 Definition
accompany all entries.
Term
what are the various signature methods
 Definition
handwritten, electronic, signature stamp, rubber stamp
Term
CMS only allows rubber stamps under what condition?
 Definition
permits the use of rubber stamp in accordance with the rehabilitation Act of 73 in the case of an author with physical disability, after approval of disability by the CMS contractor.
Term
What are the problems that can occur with the use of alternate signature stamps?
 Definition
potential of misuse or abuse and less secure. The individual whose name is on the alternate signature method bears the responsibility for the authenticity of the information being attested. physicians should check with their attorneys and malpractice insurers on the use of alternate signature methods.
Term
an order or other medical record documentation for medical review purposes for Medicare in determining coverage must have what?
 Definition
a legible signature, whether handwritten or electronic
Term
can payers deny a claim on the sole basis of type of signature submitted?
 Definition
no they have been cautioned against doing this.
Term
Many payers don't require a signature or initials what is generally the best practice?
 Definition
a full signature is generally the best practice because mr can and often do become legal documents.
Term
How does the electronic signature system work?
 Definition
There is a code or other means to uniquely identify each physician having access to the system. The physician signs an electronic record by entering their code into the system. Congress included provisions addressing security and electronic signature but they are not finalized.
Term
Is the electronic signature acceptable in the hospital setting to meet documentation requirements?
 Definition
yes
Term
who can make entries in the mr
 Definition
only individuals specified in hospital and medical staff policies . and all entries must be dated and authenticated. and a method established to identify the author.
Term
What are the rules regarding the use of rubber stamps in the hospital?
 Definition
The individual whom the stamp belongs to must sign a statement to the effect that they are the only one that uses the stamp and place this in the administrative office of the hospital. No one else is allowed to use the stamp. and there are sanctions if you do.
Term
What parts of the mr must the physician authenticate?
 Definition
The parts of the mr that are the physicians responsibility. If Non physicians document the physician has to authenticate that information.
Term
What systems meet the authentication requirements
 Definition
1. computerized systems that require physician to review the document online and indicated that it has been approved by entering a computer code.
2. a system in which the physician signs off against a list of entries that must be verified in the individual record.
3. a mail system in which transcripts are sent to the physician for review, and then they sign it and returns a postcard identifying the record and verifying its accuracy.
Term
acronyms in the mr are okay as long as they
 Definition
are commonly recognized.
Term
There is a list of dangerous abbreviations, acronyms, and symbols that is published by
 Definition
The Joint Commission
Term
Do not use U, u (unit)
 Definition
write unit instead
Term
Do not use IU (international unit)
 Definition
write international unit instead
Term
Do not use Q.D., QD, q.d., qd (daily)
 Definition
write daily instead
Term
Do not use Q.O.D., QOD, q.o.d., qod (every other day
 Definition
write every other day instead
Term
Trailing zeros can only be used where
 Definition
required to demonstrate the level of precision of the value being reported. ie. lab results, size of lesions, or catheter/tube sizes
Term
do not use lack of leading zero (.x mg)
 Definition
write 0.x mg instead
Term
Do not use MS
 Definition
because it can mean two different things so write it out.
Term
Do not use MSO4 or MgSO4
 Definition
write magnesium sulfate instead
Term
false claims act
 Definition
prohibits making a false record or statement to get a false or fraudulent claim paid by the government and conspiring to have a false or fraudulent claim paid by the government.
Term
what are the penalties for a person found in violation of the false claims act?
 Definition
Person must repay three times the amount of damages suffered by the government and a mandatory civil penalty of at least 10,781.40 and no more than 21,562.80 per claim.
Term
what is a whistleblower?
 Definition
is a person who knows about a person or entity who is submitting false claims.
Term
Under the false claims act it allows the whistleblower to?
 Definition
bring a suit on behalf of the government and to share in the damages recovered as a result of the suit.
Term
another name for a whistleblower is?
 Definition
qui tam relator
Term
key to effective operative report dictation and coding is?
 Definition
to identify, describe, and code each separate procedure performed.
Term
The summary in the operative report must
 Definition
contain enough information about the surgical procedure that it could be used to recreate the operative report in the event of the loss of the transcription.
Term
When coding procedures for operation it is important to?
 Definition
read the body of the operative report, and not to code from the procedure title at the top of the note.
Term
The body of the operative report must support?
 Definition
the procedure title as well as the postoperative diagnosis.
Term
are all elements of the op report necessary for every operation?
 Definition
No. because different procedures require different levels of detail.
Term
what should be reported for Anesthesia and Anesthesiologist on the operative report?
 Definition
The type of anesthesia(MAC, general, local) used should be reported with the name of the anesthesiologist or nurse anesthetist. It is often helpful to note the anesthesia time as well.
Term
Indications on the operative report
 Definition
Noting indications helps establish the medical necessity of the procedure and gives a good foundation for coding. Include a brief history or summary of the cause for the surgical intervention.
Term
What should be reported for Procedure in Detail (Body of report) in the operative report?
 Definition
The procedure in detail constitutes the ultimate source of documentation for the procedure, and payers consider it the final resource for payment decisions. It should read like a step-by-step report of the operation and be as descriptive as possible, using phrases that reflect CPT' terminology. Include the structures and layers of tissues involved, as well as the length of all incisions and the size of all pertinent normal or abnormal structures. The description should include a report of any abnormalities or special circumstances, and most importantly, any complications or differences in approach.
Term
Complications element of the operative report
 Definition
The nature of the complication should be reported, as well as the amount of time taken, in relation to the length of the surgery. Any intraoperative misadventure should be summarized in the complications section of the operative report. Specific information about the complications and the steps taken to deal with them belong in the body of the report.
Term
Unusual Services element of the operative report
 Definition
Any time a procedure involves services that are unusual or unique, they should be documented in the patient record with an explanation of why the procedure was unusual. If the unusual circumstance involved a nonstandard approach or unique way of accomplishing the procedure, that information should be documented. When dictating unusual services, the physician should state the procedure was unusual and explain how it compares to the same procedure under normal circumstances. Usually this is documented in a separate paragraph in the body of the operative report, so that you or the payer can identify it.
Term
Postoperative Condition element of the operative report
 Definition
The condition of the patient at the completion of the surgery, as well as the disposition (postoperative location of the patient), should be documented in the operative report such as, ccTie patient is stable in a recovery room," or "The patient is critical in the intensive care unit").
Term
Additional Information of the operative report
 Definition
The following elements should be included in the documentation where applicable: estimated blood loss (compared to the normal range), type and quantity of intraoperative fluids given such as, blood, saline, catheters, tubes or drains left in the patient, such as, intravenous lines, urinary catheters, or drainage systems. Also, include any foreign bodies intentionally left in the operative site.
Term
Preoperative diagnosis of the operative report
 Definition
the preoperative diagnosis is often a presumed diagnosis, as findings during and after surgery can lead to a different postoperative diagnosis.
Term
Postoperative diagnosis of the operative report
 Definition
is a more definitive diagnosis, based on intraoperative findings. this diagnosis is the basis for ICD-10 code selection and must be supported in the body of the report.
Term
Title of procedure of the operative report
 Definition
the operative report must include a listing of all procedures performed, usually in chronological order. if eponyms are used, add a technical description to ensure proper understanding for anyone who may see the chart. Procedures performed by the anesthesiologist are also listed here. Do not code from this section but use it as a guide when reading the body of the procedure.
Term
what is an eponym
 Definition
a name given to a diagnosis or procedure based on the name of a person.
Term
surgeons of the operative report
 Definition
all surgeons involved with the procedure should be listed, including primary surgeon, co-surgeons, and assistant surgeons.
Term
What surgeon is responsible for the procedural note when there is more than one surgeon involved in the operation?
 Definition
the primary surgeon. A resident, intern or assistant can dictate the note, but the primary surgeon must indicate agreement by reading and signing it.
Term
co-surgeons
 Definition
usually called in to handle a particular area of expertise, have shared responsibility in the procedure and must record their involvement. The must dictate their own operative note showing their specific involvement in the procedure. They should make clear at what point they became involved.
Term
assistant surgeons
 Definition
provide assistance when needed under the guidance of the surgeon. They do not dictate a separate note.
Term
how to handle the dictation of surgeons when there several co-surgeons involved
 Definition
Best to place one surgeon in charge of the overall dictation. That surgeon gives and overview of the entire procedure describing each surgeons role and how that role fits into the procedure as a whole. each surgeon then dictates their involvement in the procedure in descriptive terms.
Term
Alternative therapies in the operative report
 Definition
The report must indicate the patient was given adequate information to sign an informed consent, including information on alternative therapies. The therapies should be named individually in the consent form and state the risks and benefits of each one, along with a statement outlining the risks and benefits of the current surgery.
Term
Dictation for the operative report
 Definition
surgeon must read it, make any changes before making it official by signing it. A copy should also go into the patients clinic chart so that two separate copies are maintained, for cross reference. And it should be done asap after the procedure.
Term
Which surgeon can dictate the operative report?
 Definition
Prefer the primary surgeon but the assistant or resident may provide the dictation. If they do then the primary must be involved and read the report then sign.
Term
what should the coder use to code from for operative reports
 Definition
always use a copy so you can mark it up.
Term
Highlight unfamiliar words in the operative report and
 Definition
research them for better understanding.
Term
coding tips for coding procedures in the operative report
 Definition
first focus on the procedures listed in the title of the report. Then you need to read the body of the report as all procedures must be documented here and may not be in the title of the report and make sure additional procedures are not part of the main procedure.
Term
you should only code the operations documented in the
 Definition
body of the operative report.
Term
a separate procedure is
 Definition
a service that is performed as part of a larger procedure and it is not coded separately. However if the separate procedure is the only surgical procedure performed, or is unrelated to the major procedure performed at the same time, it may be a reportable service. think they are not performed when a more extensive procedure is performed through the same incision.
Term
Diagnosis code reporting for the operative report
 Definition
The postoperative diagnosis is the primary diagnosis and if any additional diagnostic statements are present, they should be reported as secondary diagnosis.
Term
To ensure the correct diagnosis code for the procedure performed was chosen you should reference other parts
 Definition
of the pts chart by examining the pathology report(outpt only), history, etc.
Term
when coding operative reports look for key words because
 Definition
they may include locations and anatomical structures involved, surgical approach, procedure method(debridement, drainage, incision, repair) procedure type (open simple etc), size and number and surgical instruments used, position of pt
Term
certain terms are part of major surgical procedures and are not coded separately such as
 Definition
undermining, take down, or lysis of adhesions
Term
what should you do if there is a discrepancy between the operative report and the procedure listed in the procedure title?
 Definition
consult with the physician who performed the service.
Term
what is the term for two hollow oegans joined together surgically?
 Definition
anastomosis
Term
which act imposes civil liability on any person or entity who submits a false claim?
 Definition
false claims act
Term
when reviewing the operative notes and before selecting a CPT code for a procedure, it is important to note the () that was used by the surgeon?
 Definition
approach
Term
how are skin grafts measured?
 Definition
in square centimeters
Term
Excision
 Definition
the act of cutting out; the surgical removal of all or part of a structure or organ.
Term
incision
 Definition
a surgical cut made into skin.
Term
resection
 Definition
surgical removal of a section or segment of an organ or body structure.
Term
transection
 Definition
a cutting or section made across the long axis of a structure.
Term
bisection
 Definition
division by cutting into two parts
Term
blunt dissection
 Definition
separating tissue with a finger or blunt instrument without cutting.
Term
sharp dissection
 Definition
a separation of tissues using a sharp instrument for cutting, such as a scalpel.
Term
anastomosis
 Definition
joining together, such as two hollow organs, two arteries, or two veins.
Term
when documenting procedures involving lesions, it is important to record
 Definition
the size of each lesion. If size is not documented then you must code to the smallest size.
Term
How are lacerations and nerve grafts measured for coding purposes?
 Definition
by total length in centimeters.
Term
How are skin grafts and destruction codes measured for coding purposes?
 Definition
by area in square centimeters. calculated my multiplying length by width.
Term
How are neoplasms measured for coding purposes?
 Definition
measured across the greatest dimension, including the smallest margin for excision multiplied by 2.
Term
How is tattooing measured for coding purposes?
 Definition
by sq centimeters.
Term
In coding lesions its is also important to know what in addition to the size?
 Definition
if the lesion is benign or malignant. Refer to pathology report if physician did not document this in the note.
Term
What is the appropriate documentation for destruction of a lesion?
 Definition
consists of the following; diagnosis, anatomic diagram indicating the site,size and number of lesions treated, the method of destruction, and any extenuating circumstances.
Term
skin grafting is reported in?
 Definition
sq centimeters. skin grafts and substitutes may be used to cover the burn site.
Term
burns are often documented by
 Definition
percentage of total body surface area.
Term
documentation involving repair of lacerations should indicate the following;
 Definition
the depth of laceration, such as subcutaneous. Should also describe whether there were any complications, such as foreign body removal from the wound, debridement required, or undermining repaired.
Term
For lesions excisions how are they measured for coding purposes?
 Definition
specify the diameter of the lesion plus the smallest margin multiplied by 2.
Term
Outpatient therapy services include
 Definition
physical therapy, occupational therapy, and speech-language pathology services.
Term
When are outpatient therapy services covered
 Definition
services required b/c the individual needed therapy services.
a poc has been est. and is periodically reviewed.
services were furnished while under the care of a physician.
the physician or non physician practitioner certifies the poc.
Term
documentation requirements for therapy services include:
 Definition
evaluation and poc
certification and recertification
progress reports
treatment notes for each tx day
length of therapy session. should be recorded in minutes.
Term
therapy can't start until
 Definition
the initial poc is established. must be established for each type of therapy.
Term
the plan of care for therapy services in outpatient must contain;
 Definition
dx
lt tx goals
type of rehab, including specific interventions, procedure or modality
amt of therapy # tx sessions/day
duration of therapy-#of wks or # of tx sessions.
frequency of therapy - # of tx sessions in wk.
Term
some additional elements for the poc for therapy are
 Definition
short-term goals
long-term goals
expected duration for current episode of care
specific tx interventions, procedures, modalities or techniques and the amt of each
beginning date for the plan
Term
for outpatient therapy if the poc is established by physician, NPP, clinical nurse specialist, or physician assistant it must be signed by
 Definition
the person who established the care.
Term
if the poc is established by a physical therapist or speech-language pathologist, the certification must be signed by
 Definition
physician, NPP, clinical nurse specialist, or physician assistant who has knowledge of the case.
Term
the initial certification for outpatient therapy should be obtained
 Definition
asap after the plan is established.
Term
Medicare's comprehensive error rate testing review process is used
 Definition
to identify errors in outpatient therapy services. such as missing poc, signatures etc.
Term
recertification for outpatient therapy
 Definition
is required at least every 90 days
Term
when therapy is recertified the plan must indicate
 Definition
the continuing need for the therapy. the person who reviews the plan must re-certify by signing the mr.
Term
for radiology services the person who performs the radiology services must
 Definition
sign reports of his or her interpretations
Term
How long must the hospital maintain reports, printouts, films, scans, and other image records as appropriate for radiology
 Definition
for at least 5 years
Term
The hospital must maintain copies of nuclear medicine reports for
 Definition
least 5 years.
Term
Condition of participation: Nuclear medicine services says the hospital must maintain signed and dated reports of
 Definition
nuclear medicine interpretations, consultations, and procedures.
Term
Nuclear medicine services. The practitioner approved by the medical staff to interpret diagnostic procedures must
 Definition
sign and date the interpretation of these tests.
Term
Nuclear medicine services must be ordered only
 Definition
by practitioner whose scope of Federal or State licensure and whose defined staff privileges allow such referrals.
Term
The hospital must do what with regards to radiopharmaceuticals
 Definition
the hospital must maintain records of the receipt and disposition
Term
For radiation oncology, the report should include
 Definition
clinical indications and precise anatomical and radiological terminology. The patient's chart also should include information regarding the need for custom treatment devices such as, standard or custom shielding blocks and the physician's participation in their design, supervision, and construction
Term
The following list identifies the elements to document in support of medical necessity and complexity for radiology services
 Definition
Detailed description of imaging performed and interpreted
Number of views (when an exam does not meet the criteria of the code, it may have to be reported with an unlisted procedure code)
Unilateral or bilateral views (bilateral views performed for comparison are coded as a single procedure) Limited or complete
Diagnostic or therapeutic (nuclear medicine)
3-D rendering
With or without KUB (Kidney, Ureter, Bladder), a type of single abdominal view
With or without contrast material (type and amount)
With or without duplex scans (ultrasound studies)
Complete or limited follow up
Indication for procedure or service
Findings (if known)
Term
Condition of participation: Radiologic services
 Definition
(1) The radiologist or other practitioner who performs radiology services must sign reports of his or her interpretations.
(2) The hospital must maintain the following for at least 5 years:
(i) Copies of reports and printouts.
(ii) Films, scans, and other image records, as appropriate
Term
If a combination of services (radiology) is performed in the same session for the patient, each service should be
 Definition
separately documented in the written report, either delineated in the same report or described in separate reports the radiologist generates from each of the services provided.
Term
for a diagnostic mammogram the physician must
 Definition
order the exam. (this is when there are signs or symptoms for doing the test). medicare covers as often as is medically necessary.
Term
rule out dx(mammograms) is insufficient for
 Definition
determining medical necessity and documentation must include a physician's interpretation of the results. If there are no significant findings, the diagnosis code will be assigned for the signs and symptoms that led to the order for the diagnostic mammogram
Term
Screening mammography refers to a
 Definition
a radiographic procedure for the early detection of breast cancer in an asymptomatic woman. The exam includes a physician's interpretation of the results of the procedure and Medicare covers a mammography provided to a woman at her direct request, without a physician's order.
Term
To qualify for Medicare coverage of a bone mass measurement study, one of the following must apply:
 Definition
Determined by provider to be estrogen-deficient and at clinical risk for osteoporosis based on medical history and other findings
Vertebral abnormalities demonstrated by an X-ray to be indicative of osteoporosis, osteopenia, or vertebral fracture Glucocorticoid therapy equivalent to 5.0 mg of prednisone, or greater, per day, for more than three months Primary hyperparathyroidism
To assess response to, or effcacy of, a FDA-approved osteoporosis drug therapy
Term
Staging Breast Cancer medicare covers
 Definition
positron emission tomography (PET) for staging of breast cancer, including PET full and partial ring scanners as an adjunct to standard imaging modalities for staging patients with distant metastasis or restaging patients with recurrence or metastasis, and for monitoring treatment response for patients with locally advanced and metastatic breast cancer.
Term
What does medicare cover as a primary or initial diagnostic study for determining myocardial perfusion(viability) prior to revascularization of coronary vessels ?
 Definition
Medicare covers SPECT and FDG PET
Term
Medicare covers PET following an inconclusive
 Definition
SPECT
Term
Based on findings from a routine X-ray exam, a radiologist may feel further studies are warranted. The documentation must indicate
 Definition
the medical necessity for further studies
Term
when the radiologist elect to due further studies based on finding they are not usually required
 Definition
to check with the ordering provider before proceeding with additional studies, except when Medicare is the primary payer; Medicare does require going back to the ordering/treating physician.
Term
lnvasive or interventional radiology procedures are
 Definition
radiological studies accompanied by an invasive surgical procedure
Term
The following format is suggested for documenting invasive radiology procedures:
 Definition
Date and time of report
Title of operation or procedure
Clinical indication or reason for procedure
Monitoring (optional)
Sedation
Detailed account of procedure
Radiology modality used for imaging (CT, MRI, Fluoroscopy, Ultrasound, etc.)
The procedure note must show performance of each procedure listed in the report heading
For vascular procedures, include the access route(s), each nonselective and selective vessel catheterized, and any deviation from normal anatomy
Injections (including type and amount of contrast material)
Findings
Complications
Postprocedure patient status
Impression or short description of the findings
Term
BBA
 Definition
The Balanced Budget Act of 1997
Term
BBA) mandated the use of a
 Definition
negotiated rulemaking committee to develop national coverage and administrative policies for clinical diagnostic laboratory services payable under Medicare Part B by January 1, 1999
Term
Each NCD outlines the requirements that must be met to submit a claim (laboratory and pathology)
 Definition
A physician's order for the lab test
The medical condition for which a laboratory test is reasonable and necessary
The appropriate use of procedure codes in billing for a laboratory test. Do not unbundle the CPT@ codes for laboratory services (Example: a basic metabolic panel includes seven individual tests. Do not report all seven tests separately, report the basic metabolic panel with one CPT' code.)
The medical documentation that is required by a Medicare contractor at the time a claim is submitted for a laboratory test
Record-keeping requirements in addition to any information required to be submitted with a claim, including all physician's documentation requirements as outlined in each NCD in Pub 100-03 National Coverage Determinations Manual Limitations on frequency of coverage for the same services performed on the same individual
Term
In March 2000, a proposed rule published in the Federal Register
 Definition
set forth uniform national coverage and administrative policies for clinical diagnostic laboratory services.
Term
The final rule, published in the Federal Register on November 23, 2001, established the national coverage and administrative policies for clinical diagnostic laboratory services payable under Medicare Part B. It promotes
 Definition
Medicare program integrity and national uniformity, and simplifies administrative requirements for clinical diagnostic services
Term
for radiology services the person who performs the radiology services must
 Definition
sign reports of his or her interpretations
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