Coding is - ✔✔the process of translating this written or dictated medical record into a series of numeric or alpha-numeric codes Proper code assignment is determined by - ✔✔content of the medical record and by the unique rules that governs each code set What are 3 things that Coder must master - ✔✔1. anatomy 2. medical terminology 3. must be detail-oriented Medical coders assign a code to what - ✔✔1. Each diagnosis 2. Service/procedure 3. Supply, using the classification system when applicable The classification system determines ______ - ✔✔the amount health care providers will be reimbursed if the patient is covered by Medicare, Medicaid, or other insurance programs using the system A coder must evaluate the medical record for - ✔✔1. completeness and accuracy 2. communicate regularly with physicians and the health care professional to clarify DX or obtain additional PT info. Techicians who speciallize in coding inpatient hospital services are referred as - ✔✔1. Health information coders 2. medical record coders 3. Coder/abstractors 4. Coding Specialist What is MS-DRGs and what does it do? - ✔✔1. Medicare Severity-Diagnosis Related Groups 2. Determines the amt the hospital will be reimbursed if the PT is covered by Medicare or other insurance programs What is EHR - ✔✔Electronic health record Skilled coders may become - ✔✔consulatants, educators or medical auditors What is the difference between Hospital and Physican Services - ✔✔1. Outpatient coding (physician services)- learning CPT, HCPCS, LEVEL II, ICD-9 CM codes Volume 1 and 2 2. Inpatient coding (Hospital services)- Learning CPT, ICD-9 CM codes Volumes 1,2,3 and MS-DRGS What is APC and who uses it - ✔✔Ambulatory Payment Classification- outpatient facility coders (physician services What is the coder's role in a physician's office - ✔✔Extremely important for the proper reimbursement of services and the livelihood of the physician What is a physican degree of education - ✔✔4 years of college, 4 years of medical school plus 3 to 5 years of residency. What are mid-level providers and who can be classified as one? - ✔✔1. Mid-level providers are know as physician extenders 2. Physician assistants (PA) and Nurse Practitioners (NP) What are the requirement for a PA and what - ✔✔1. 26 1/2 month program to complete 2. Licensed to practice medicine under physician supervision NP must have - ✔✔A Master's Degree in Nursing