The Webinar Will Start Momentarily……. Coding Certification Exam Review Jennifer Lame’, MPH,...

The Webinar Will Start Momentarily……

Coding Certification Exam Review

Jennifer Lame’, MPH, RHIT AHIMA Approved ICD-10-CM/PCS Trainer

October 12, 2012

Today’s AgendaO 6 CCA CompetenciesO Key Features from Each CompetencyO Sample Questions from Each

CompetencyO Q&A

ObjectivesO Review the 6 Domains covered on

CCA examO Highlight Key aspects from each

domainO Explore exam format and question

structureO Provide practice activities to explore

CCA readiness

6 CCA DomainsO Domain I – Clinical Classification Systems

(32%)O Domain II – Reimbursement Methodologies

(23%)O Domain III – Health Record and Data Content

(15%)O Domain IV – Compliance (14%)O Domain V – Information Technologies (8%)O Domain VI – Confidentiality & Privacy (8%)

Clinical Classification Systems

O Approximately 32 questions; largest portion of the exam

O CPTO ICD-9O HCPCS

Coding StepsO Determine service you are coding forO Read through the entire record and

documentation to determine diagnosis and procedure, if any.

O Select the appropriate diagnosis and procedures to code

O Sequence codes according to UHDDS guidelines

O Enter codes into facility’s database

Official Coding Guidelines

O Highest level of specificityO E-codesO Signs/symptomsO Probable/likely/suspectedO V-codes

Check PointO A 65- year old male was admitted for N/V and

abd. Pain. Dr. Smith admits the patient for work up and finds he has acute cholecystitis. Dr. Smith’s discharge summary’s discharge diagnosis states: acute cholecystitis with nausea, vomiting and abdominal pain. What is the correct coding sequence:

O A. Acute cholecystitis, N/V, abd painO B. Abd pain, N/V acute cholecystitisO C. N/V, cholecystitis, adb. PainO D. Acute cholecystitis

Check PointO Mary Smith is a 76-year old female patient

who presents to the ER with difficulty breathing. After the ER physician conducts the exam he determines the she is experiencing Acute bronchitis with bronchospams. What codes are assigned?O A. 466.0O B. 466.0, 519.11O C. 519.11O D. 466.19

Check PointO When a procedure is completed on

the same day as another procedure, that is not typically reported together on the same day, but in this instance are appropriate what modifier is appended to indicate that the procedure was distinct from the other one?

Check PointO A 56-year old male is admitted for

SDS of a needle bx of a cervical lymphnode for lympahdenopathy. Pathology report reveals Hodgkin’s sarcoma what codes are assigned?O A. 201.21, 38505O B. 201.91, 38505O C. 201.21, 38500O D. 785.6, 38510

CheckpointO A 35-year old female is seen by Dr.

Smith in the ER for chest pain. After Dr. Smith examines the pt. he suspects she has GERD. His final diagnosis is suspected GERD. What is the correct ICD-9 code assignment?O A. Admission for suspected

cardiovascular diseaseO B. Chest pain, nosO C. Esophageal painO D. GERD

CheckpointO A patient is seen in the ER for

seizures. The physician does a workup for epilepsy and diagnosis is rule out epilepsy. What is the correct code assignmentO A. 780.39O B. 345.90O C. 780.39, 345.80O D. 345.80

Reimbursement Methodologies

O Approximately 23 questionsO Medicare

O Part A, Part B, Part C, Part DO 65 or older or some disabilities

O MedicaidO Low Income

O TricareO Healthcare for active duty service members

O Champ-VAO For dependents and survivors of disabled veterans

O Blue Cross and Blue ShieldO Now plans in all 50 states

Reimbursement Methodologies

O Fee for serviceO Episode of careO CapitationO Global paymentO Global surgery paymentO Prospective payment

NCCIO National Correct Coding Initiative

Policies based offO Coding Conventions defined in the

CPT codebooksO National and local policies and coding

editsO Analysis of standard medical and

surgical practiceO Review of current coding practices

CheckpointO Fee Schedules are updated by Third-

Party PayersO AnnuallyO MonthlyO SemiannuallyO Weekly

CheckpointO Dr. Smith saw a patient in the

outpatient radiology department for a mammogram. Which type of payment system would the hospital be reimbursed under?O A. DRGsO B. HHRGsO C. OASISO D. OPPS

Health Records & Data Content

O Approximately 15 questionsO Purpose of Health Record

O Primary PurposeO Secondary Purpose

O Function of the Health RecordO Quality of the Health Record

O AHIMA Data Quality Management Model

Data Quality Management Model

O Data applications: the purposes for which data are collected

O Data collection: the processes by which data are collected

O Data warehousing: the processes and systems by which data are archived

O Data analysis: the processes by which data are translated into information that can be used for designated application

Characteristics of Data Quality

O AccessibilityO AccuracyO ConsistencyO ComprehensivenessO CurrencyO DefinitionO GranularityO RelevancyO PrecisionO Timeliness

Content of the Health Record

O Clinical O AdministrativeO Types

O Acute care, emergency care, behavioral health, rehabilitation, ambulatory, correctional facilities, long-term care, home health, hospice, end-stage renal disease, personal

Clinical DocumentsO Medical historyO Physical examinationO Physicians ordersO Clinical observationsO Results of proceduresO ConsultationsO Discharge summaryO Final instructions

Format of the Health Record

O EHRO HybridO Paper-Based

O Source-oriented health recordO Problem-oriented health record

O SOAP noteO Integrated health record

Check PointO Use of the health record by Dr. Smith

to facilitate patient care is considered which of the following:O A. Primary purposeO B. Patient care supportO C. Secondary purposeO D. Policy making

Check PointO From the following list, which one

does not represent a characteristic of high-quality health record data?O A. Data accountabilityO B. Data consistencyO C. Data currencyO D. Data relevancy

Health Information Requirements and Standards

O Data SetO A recommended set of data with

uniform definitions utilized for a specific purpose

O PurposeO Identify elements that should be

collected from each patientO Provide uniform definitions for

common terms

HIT Common Data SetsO UHDDSO UACDSO MDSO OASIS-CO HEDISO DEEDSO ORYXO NHIN

Check PointO Federal law and Medicare require

which of the following for the inpatient data set?O UACDSO UHDDSO MDSO HEDIS

ComplianceO Approximately 14 questionsO OIG’s 7 elements for a compliance plan

O Development/distribution of written standards of conduct

O Designation of a chief compliance officerO Implementation of effective education/training for

all employeesO Maintenance of a process to receive complaintsO A system to respond of allegations of illegal activityO Evaluation techniques to monitor complianceO Investigation/remediation of identified systemic

problems

HIM Compliance PlanO Code of conductO Policies and proceduresO Education and trainingO CommunicationO AuditingO Corrective actionO reporting

AHIMA’s Standards of Ethical Coding

O Coding professionals should: Apply accurate, complete, and consistent coding practices for the production of high-quality healthcare data.

O Report all healthcare data elements (e.g. diagnosis and procedure codes, present on admission indicator, discharge status) required for external reporting purposes (e.g. reimbursement and other administrative uses, population health, quality and patient safety measurement, and research) completely and accurately, in accordance with regulatory and documentation standards and requirements and applicable official coding conventions, rules, and guidelines.

O Assign and report only the codes and data that are clearly and consistently supported by health record documentation in accordance with applicable code set and abstraction conventions, rules, and guidelines.

O Query provider (physician or other qualified healthcare practitioner) for clarification and additional documentation prior to code assignment when there is conflicting, incomplete, or ambiguous information in the health record regarding a significant reportable condition or procedure or other reportable data element dependent on health record documentation (e.g. present on admission indicator).

O Refuse to change reported codes or the narratives of codes so that meanings are misrepresented. O Refuse to participate in or support coding or documentation practices intended to inappropriately increase

payment, qualify for insurance policy coverage, or skew data by means that do not comply with federal and state statutes, regulations and official rules and guidelines.

O Facilitate interdisciplinary collaboration in situations supporting proper coding practices. O Advance coding knowledge and practice through continuing education.O Refuse to participate in or conceal unethical coding or abstraction practices or procedures.O Protect the confidentiality of the health record at all times and refuse to access protected health information

not required for coding-related activities ( examples of coding-related activities include completion of code assignment, other health record data abstraction, coding audits, and educational purposes).

O Demonstrate behavior that reflects integrity, shows a commitment to ethical and legal coding practices, and fosters trust in professional activities.

Information TechnologiesO Approximately 8 questionsO HL7 EHR Systems Functional Model

O Direct CareO Care managementO Clinical decision supportO Operations management and communication

O SupportiveO Clinical supportO Measurement, analysis, research & reportO Administrative & financial

O Information InfrastructureO SecurityO Health record information & managementO Registry & directory servicesO Standard terminologiesO Standards-based interoperabilityO Business rules managementO Workflow management

Stage of EHRO Clinical Data RepositoryO Point of Care ChartingO Transition State

CheckpointO All of the following functions can be

completed by an EHR except?O A. AnalysisO B. AssemblyO C. Document imagingO D. indexing

CheckpointO Which of the following technologies

would allow a hospital to get as much medical record information online quickly?O A. Clinical data repositoryO B. Picture archiving systemO C. Electronic document management

systemO D. Speech recognition system

Confidentiality & Privacy

O Approximately 8 questionsO Court System

O State – 3 tier systemO Federal – 3 tier system

O Source of LawO ConstitutionO StatutesO AdministrativeO Judicial

Legal ProceedingsO LawsuitO Discovery periodO TrialO Malpractice

Form and Content of the Health Record

O Primary purposeO Guidelines for form and content

O OrganizedO Authorized personnelO Entries documented/identifiable/permanentO Use approved abbreviationsO Correct errors with a single line,

initials/date/timeO Addendums made as a patient wishO Any requirements outlined in state

law/regulation

Retention of the Health Record

O Comply with local/state/federal statutes and regulations

O Depends on the type of facility ie. Acute care will differ from long-term care

O AHIMA publishes retention guidelines that are a good resource to review

HIPAAO HIPAA Privacy Rule is the key law that

governs confidentiality and patient information and PHI

O HIPAA Contains five titlesO I- health care access, portability and

renewabilityO II – preventing health care fraud & abuseO III – tax- related health provisionO IV – group health plan requirementsO V- revenue offsets

Check PointO What should a hospital do when the

state law requires more stringent privacy protection than HIPAA?O Ignore the state law and follow HIPAAO Follow the state law and ignore HIPAAO Comply with both state law and HIPAAO Ignore both state law and HIPAA

CheckpointO You work in a HIM department and

received a subpoena duces tecum for the records of Mrs. Jane Doe. To respond to this subpoena what do you do?O A. Review the subpoena to determine what

documents must be producedO B. Review the subpoena and notify your CEOO C. Review the subpoena and consult your

lawyerO D. Review the subpoena and contact your

risk manager

CCA FormatO Three types of questions

O RecallO Tests your memory skills/facts

O ApplicationO Tests your ability to interpret data

O AnalysisO Tests your ability to solve specific problems

O 100 questionsO Multiple-choice 90 scored/10 not scored

AHIMA CCA ResourcesO Content outline:

O http://md20.quartz.synacor.com/service/home/~/CCA_Content_Outline.pdf?auth=co&loc=en_US&id=47701&part=2

O Candidate Guide:O http://md20.quartz.synacor.com/service/hom

e/~/CCA_Candidate_Guide.pdf?auth=co&loc=en_US&id=47701&part=4

O Recommended resources:O http://md20.quartz.synacor.com/service/hom

e/~/CCA_Recommended_Resources.pdf?auth=co&loc=en_US&id=47701&part=3

Study TipsO Purchase a CCA Review guide

O AHIMA or PRG/Cengage learning O Compile a list of resources

O Previous books, medical dictionary, coding manualO Determine a study schedule

O Allow a set time each week/day to studyO Practice with sample questions

O Start with a practice test to determine your strengths weaknesses/focus study time on weaknesses

O Review AHIMA’s WebsiteO Ensure you have correct material for exam,

registration, sample questions, other pertinent data

Other ResourcesO www.merckmanual.comO http://www.bcbstx.com/pdf/druglist.pdfO www.aafp.comO www.ahima.orgO www.cdc.govO http://

stedmansonline.com/webFiles/Dict-Stedmans28/APP06.pdf

O http://ahima.org/certification/cca.aspxO http://ahima.org/certification/ccs.aspxO http://ahima.org/certification/ccsp.aspx

Thank You!www.HIMageConsulting.com