NCE PRACTICE EXAM

Per ICD-10CM guidelines do not code signs and symptoms. Edema is a symptom of both hypertension and CKD. ICD-10CM guidelines state there is a casual relationship assumed between CKD and hypertension unless the provider specifically states that the hypertension is not related to the CKD, giving this patient hypertensive chronic kidney disease instead of regular hypertension.

1997 E/M guidelines state that the provider must reach 12 bullet points for a detailed level of exam. Although the patient's chart has a detailed history and moderate medical decision making, the provider only reached 11 bullet points, making this level a 99202. N39.0 is not the most specific code for this chart.

The provider performs an excision, not an incision, completely removing the cyst. The excision is intermediate because it involves subcutaneous extensions and the repair is included with the procedure.

Pediatric vaccines with counseling are coded per component. Each first component of a vaccine (Measles and Diphtheria in this case) are coded as one unit of 90460. Each additional component to the vaccine (mumps, rubella, tetanus and acellular pertussis) receive another 90461 for an additional component code.

ICD-10 PCS are used as procedure codes for inpatient visits. DRGs use similar ICD-10CM weights for facility reimbursement and ICD-10CM are used as diagnosis codes for all healthcare settings.

According to ICD-10CM guidelines, urosepsis is a nonspecific term and has no tabular position. The provider must be queried for clarification.

According to chapter guidelines, if a patient is seen for an HIV-related condition, (which oral hairy leukoplakia is), then B20 is coded first, then the complications. Only the provider's statement is needed that the patient has HIV, not a positive lab test. F17.200 is to be assigned when the provider documents "smoker", but gives no further clarification (AHA: 2016, 1Q, 36)

Cystitis is an infection of the bladder. The provider must specifically state that the infection or condition is not affecting the pregnancy for an incidental code. The patient is experiencing blood in her urine, which gives us the hematuria portion of the diagnosis.

16025 covers whole face burns and includes debridement.

Anesthesia for all closed procedures on humerus and elbow. The 99100 code is only used for patients under 1 year old or over 70 years old. 01744 is for open procedures, not closed.

The Omnibus Rule established HITECH and the AARA of 2009 and finalized the Breach Notification Rule, mandating that covered entities who have more than 10 individuals with outdated contact information involved in a data breach must be notified by posting a notice on their website or creating a local ad in the newspaper. For breaches over 500 individuals, major news outlets must be contacted and the Secretary of HHS immediately.

HIPAA Privacy Rule Section 164.510(b)(3) allows providers to discuss PHI with family members if they determine it is in the patient's best interest for coordination of treatment or payment, unless the patient has expressed wishes that their information is not shared with family.

HIPAA HITECH requires that covered entities take reasonable action to protect electronically transmitted information. Removing protected health information, encrypting email and creating confidentiality notices are a multi-layered security approach that is best-practice to prevent breaches of data.

The Inpatient Prospective Payment System drives value-based care by paying inpatient stays based on DRGs (Diagnosis-Related Group(s)) which are groups of diagnoses with similar weights in order to determine "how much" a patient's stay ought to cost. These drivers force hospitals to work to be most efficient in their use of resources to come in under what they will be paid in order to avoid losing money.

RVUs are based off work for each HCPCS. RVUs are multiplied by Geographic Practice Cost Indices (GPCI), which account for physician work, cost of malpractice and practice expenses. A conversion factor, which is a national number that changes annually, is multiplied by the sum of RVUs that are multiplied by the GPCI to calculate payment for professional fee schedules.

The HAC-POA (Hospital acquired condition, present on admission) program was created by the Deficit Reduction Act of 2005--any of these conditions which are not present on admission and could have reasonably been prevented by following accepted standards of care will not be reimbursed. Usually, adding the DRG weight would have increased the facility's reimbursement, but this forces hospitals to avoid hospital acquired conditions, rather than profit from them.

RVUs multiplied by conversion factor gives you the amount payable for a provider's fee schedule.

The Balanced Budget Act mandated that SNF-PPS be paid per diem for all costs, which is based on a case-mix of diagnoses.

Payment status indicator C indicates that the HCPCS is only performed in an in-patient setting.

CMS conditions of participation require that the patient's history and physical be completed and documented within the patient's record within 24 hours of admission, but not greater than 30 days prior to admission.

CC, HPI, ROS and PFSH are the components of a patient history. ROS is performed to make sure the provider did not miss any relevant complaints and can be pulled from the HPI if needed.

Rubber stamps were prohibited by CMS in 2015 for provider authentication

An open-record review takes place when a qualitative analysis of the patient's record is done while the patient is in active treatment. The Joint Commission requires these reviews to ensure that documentation standards are met while the patient is still under care.

There are 18 unique identifiers protected by HIPAA. Only the first 3 digits of a patient's zip code is not PHI, as long as there are more than 20,000 people in the group that forms all zip codes. E.g. 123XX+123XY+123XZ have more than 20,000 people. Otherwise the zip code must be changed to 00000.

EHRs are defined by NAHIT as able to communicate and exchange data with multiple systems. EMRs do not have this capacity.

Systemized Nomenclature of Medicine--Clinical Terminology (SNOMED CT) is the global standard for clinicians and is used to define terms in EHRs around the world.

Under Administrative Simplification, HIPAA standard 5010, using ASC X12, was created and implemented. HIPAA standard 4010 was no longer accepted as of June 30, 2012

The OIG states that billing companies who submit fraudulent claims (as well as the person who submitted them!) are just as responsible as the provider who rendered the services. Both undercoding and overcoding are examples of fraudulent claims, the claim submitted must accurately represent the services rendered.

Procedures include a minor evaluation and management service. If the patient complains of an abscess and a I&D is performed, only the procedure should be reported. If the patient comes in complaining of hypertension and an abscess is discovered, then it would be acceptable to report an evaluation and management service.

Physician queries must be non-leading, not based on reimbursement, for the purpose of improving patient care and open-ended, or Yes/No questions. Providers must not add documentation solely for the purpose of being reimbursed and it must be within a reasonable time frame.