Question

can someone help me answer these 5 questions please. this book is Let's Code It! ICD-10-CM

Let's Check It! Rules and Regulations Please answer the following questions from the knowledge you have gained after reading this chapter 1. LO 3.1 List the six Actions of the coding process and explain each action in your own words. 2. LO 3.2 Discuss the Alphabetic Index and the role it plays in the coding process. 3. LO 3.3 Explain the ICD-10-CM Tabular List, how the codes are listed, and why it is important. 4. LO 3.4 Describe what the Official Guidelines are, why they are important, where they are located, and if you are required to comply with these guidelines. 5. LO 3.5 Discuss the importance of linking a diagnosis code to a procedure code. 52 PARTI I MEDICAL CODING FUNDAMENTALS

Answer 1

The purpose of code linkage is to prove medical necessity and give insurance companies a reason to pay a medical provider. Code linkage connects a diagnosis code with a procedure code. ... A lack of code linkage or codelinkage that does not demonstrate medical necessity will prevent a medical practice from getting paid.

list of fees. Most try to set fees that are in line with patients’ expectations so as • to be competitive in attracting patients Medical insurance spets update the practice’s fee schedules when new codes are released. When new or altered CPT codes are among those the practice reports, the fees related to them must be updated, too Payers, too, must establish the rates they pay providers. There are two main methods: charge-based and resource-based. Charge-based fee structures are based on the fees that providers of similar training and experience have charged for similar services. Resource-based fee structures are built by comparing three factors: (1) how difficult it is for the provider to do the procedure, (2) how much office overhead the procedure involves, and (3) the relative risk that the procedure presents to the patient and to the provider. In addition to setting various fee schedules, payers use one of three main methods to pay providers: 1. Allowed charges 2. Contracted fee schedule 3. Capitation

Without a doubt provider coding errors are a top reason for rejected claims at Community Health Centers (CHCs). This shouldn’t be surprising. We all know that CHC providers are insanely busy and creating and presenting quality coding training is next to impossible. Hiring a certified coder is another option but that can be costly and finding/ retaining qualified people can be a challenge.

PMG’s coding team reviews client claim data to find patterns indicating denials caused by coding errors. When they identify the coding error they communicate with the client so the code can be corrected and the claim resubmitted for payment. If it seems like a training is needed, our team builds a presentation based on that CHC’s particular challenges and coordinates to present the training either online or in person at the center.

I spent some time with our coding team and we chatted about Code Linkage and Medical Necessity, which is definitely high on the list for coding errors that cause claim rejections. You know payers love to reject claims for that! Fortunately, they have trained quite a few CHC providers on this topic and today I will be sharing a quick ‘cheat sheet’ version of their wisdom!

Code Linkage

Code linkage is the verification that the diagnosis code and procedure code match up to support medical necessity for the procedure. Failure to link the codes can result in claim denials.

Medical Necessity

Medical necessity is used to describe care that is reasonable, necessary, and/or appropriate, based on evidence-based clinical standards of care. The way to provide proof of medical necessity is to indicate with the proper CPT code and ICD code.

Bringing it All Together

Every CPT code must be supported by a corresponding ICD diagnosis code that supports medical necessity for the procedure that was performed; connecting the procedure codes to diagnosis codes that indicate that the procedure was medically necessary. The CPT codes tell what the provider did and the ICD code supports why the service was done.

Examples

If the patient came in with a fever and sore throat, and your office billed for a urinalysis, then insurance may not pay for it. Payers would consider a urinalysis for a sore throat and fever mismatched. Payers may consider performing a urinalysis on a patient who is not having any urinary symptoms or problems not medically necessary

A claim for a chest X-ray might be denied if the only diagnosis listed is diabetes because that diagnosis does not indicate a medically necessary or valid reason for the X-ray.

Our Two Cents

As the healthcare landscape continues to transform and we further explore alternative payment methodologies the importance of documentation and coding will grow. Accurate and compliant coding with will have an ever-increasing effect on reporting and without a doubt, your bottom line. As PMG Co-Founder, Ray Jorgensen often says, “Get paid when you can as much as you can so you can give it away when you want to.”