Practice Quiz

Medical Coding

Category - Compliance and Regulatory

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What are the correct steps to coding for the best payment outcome?
  1. Identify the reason for the encounter based on what the physician documented as the diagnosis without reviewing the medical record. Find the diagnosis in the Tabular List and choose the code with the highest specificity. Assign the code and submit to insurance.
  2. Identify the reason for the encounter based on the diagnosed reason and confirmation within the medical record. Find the diagnosis in the Tabular List, confirm it in the Alphabetic Index, assign the code without regard to the specificity and submit to insurance.
  3. Identify the reason for the encounter based on the diagnosed reason and confirmation within the medical record. Find the diagnosis in the Alphabetic Index, review entries for modifiers, choose the best code and locate it in the Tabular List, then determine whether the code is the highest level of specificity. If so, assign that code to the encounter. Sequencing is very important, so review this prior to final billing submission.
  4. Identify the reason for the encounter based on what the physician documented as the diagnosis after reviewing the medical record. Find the diagnosis in the Alphabetic Index, find it in the Tabular List, and use the first code available without regard to modifiers or specificity.
Explanation
Answer: C - The proper way to code is to identify the reason for the encounter using the documentation for support. Then to consult the Alphabetic Index, review stipulations for modifiers, and confirm with the Tabular List. Using the Tabular List, specificity can be coded at its highest level, based on documentation. Assign the code, making sure that the sequence is correct before submitting to the insurances.

Always remember to consult the Alphabetic List, reading all options, cross references, abbreviations, and/or modifiers before moving onto the Tabular List. The Tabular List will allow the highest specificity by referring to the number of characters required in the code and prompting this change before sequencing and submitting to the insurance company for payment.
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