Registered Health Information Administrator / Technician (RHIA / RHIT) Medical Coding and Reimbursement Methodologies Syllabus

Medical Coding and Reimbursement Methodologies syllabus — full chapter and topic list

Expand any chapter to see its topics and sub-topics. This is the whole examinable outline for Medical Coding and Reimbursement Methodologies in Registered Health Information Administrator / Technician (RHIA / RHIT), not a summary of it.

1. 1

   ICD-10-CM Diagnosis Coding

   3 topics

   • ICD-10-CM Structure and Conventions
     • Alphabetic Index and Tabular List
     • Code structure, placeholders, and 7th characters
     • Includes, excludes1/excludes2, and instructional notes
   • Official Coding Guidelines
     • Principal versus secondary diagnosis selection
     • Combination codes and manifestation coding
     • Signs, symptoms, and uncertain diagnoses
   • Coding by Body System and Condition
     • Neoplasms and infectious diseases
     • Pregnancy, perinatal, and external causes
     • Z codes and status conditions
2. 2

   ICD-10-PCS Procedure Coding

   3 topics

   • PCS Structure and Character System
     • Seven-character code construction
     • Root operations and approaches
   • PCS Coding Guidelines
     • Body part and device selection
     • Multiple and discontinued procedures
   • Procedure Documentation Interpretation
     • Operative report analysis
     • Identifying objective of the procedure
3. 3

   CPT and HCPCS Coding

   3 topics

   • CPT Category I, II, and III Codes
     • Evaluation and management coding
     • Surgery, radiology, pathology, and medicine sections
     • Modifiers and their application
   • HCPCS Level II Coding
     • Supplies, drugs, and durable medical equipment
     • National versus local coverage
   • Outpatient Coding Conventions
     • First-listed diagnosis rules
     • Coding from outpatient documentation
4. 4

   Reimbursement Systems

   4 topics

   • Prospective Payment Systems
     • MS-DRGs and inpatient PPS
     • APCs and outpatient PPS
     • RBRVS and physician fee schedule
   • Payers and Coverage
     • Medicare parts A through D
     • Medicaid and commercial payers
     • Managed care and value-based payment
   • Revenue Cycle Management
     • Charge capture and chargemaster (CDM)
     • Claims, remittance, and denials management
     • Case mix index and reimbursement impact
   • Coding Compliance and Quality
     • Coding audits and accuracy review
     • Computer-assisted coding and NLP
     • Fraud, abuse, and the False Claims Act

Medical Coding and Reimbursement Methodologies flashcards for Registered Health Information Administrator / Technician (RHIA / RHIT)

24 of 54 cards from the Medical Coding and Reimbursement Methodologies deck — real questions with worked answers.

1. What is the maximum number of characters in an ICD-10-CM code, and what is the structure of the first three positions?

   Up to 7 characters. The first character is always a letter, the second is numeric, characters 3-7 can be letters or numbers; a decimal point is placed after the third character (category).

2. In ICD-10-CM, what is the function of the 7th character extension, and what placeholder is used to fill empty positions before it?

   The 7th character adds information such as episode of care (e.g., A=initial, D=subsequent, S=sequela). The placeholder 'X' fills empty character positions so the 7th character lands in the correct position.

3. What is the difference between the ICD-10-CM conventions 'Excludes1' and 'Excludes2'?

   Excludes1 means 'NOT CODED HERE'—the two conditions can never be reported together. Excludes2 means 'NOT INCLUDED HERE'—the condition is separate, so both codes may be reported together if the patient has both.

4. In ICD-10-CM, what do the conventions 'NEC' and 'NOS' indicate?

   NEC (Not Elsewhere Classifiable) means the code is used when the documentation is specific but no distinct code exists ('other specified'). NOS (Not Otherwise Specified) is the equivalent of 'unspecified'—documentation lacks detail.

5. In the ICD-10-CM Alphabetic Index, what do brackets, parentheses, and the colon convention signify?

   Brackets [ ] enclose synonyms/explanatory phrases (in Tabular) or manifestation codes. Parentheses ( ) enclose nonessential modifiers that do not affect code assignment. A colon in the Tabular List indicates an incomplete term that needs a modifier to be assignable.

6. What do the ICD-10-CM instructional notes 'Code first' and 'Use additional code' direct the coder to do?

   They identify etiology/manifestation sequencing: 'Code first' the underlying condition, then 'Use additional code' for the manifestation. The etiology code is sequenced first and the manifestation code second.

7. Per ICD-10-CM Official Guidelines, when is a condition designated as the principal diagnosis for inpatient coding?

   The principal diagnosis is the condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital.

8. What is the ICD-10-CM guideline for coding signs and symptoms when a definitive diagnosis has been established?

   Signs/symptoms that are integral to (routinely associated with) a confirmed disease process are NOT coded separately. Symptoms that are NOT routinely associated with the disease should be coded additionally.

9. Per the ICD-10-CM guideline on 'uncertain diagnoses,' how is a condition documented as 'probable,' 'suspected,' or 'rule out' handled in the inpatient vs. outpatient setting?

   Inpatient (short-term/acute): code the uncertain diagnosis as if it exists. Outpatient: do NOT code uncertain diagnoses—instead code the documented signs, symptoms, or test findings to the highest level of certainty.

10. What is the ICD-10-CM definition and coding rule for 'sequela' (late effect)?

    A sequela is a residual condition produced after the acute phase of an illness/injury has ended (no time limit). Code the residual/current condition first, then the sequela code; the original acute injury is never coded with the sequela.

11. In ICD-10-CM, how are 'combination codes' defined and when are they used?

    A combination code is a single code that classifies two diagnoses, a diagnosis with an associated manifestation, or a diagnosis with an associated complication. Use it when the classification provides it; do not assign multiple codes if a combination code fully describes the condition.

12. In ICD-10-CM Chapter 2 (Neoplasms), how is the principal/first-listed diagnosis determined when treatment is directed at the malignancy itself?

    When treatment is directed at the malignancy, the malignancy is sequenced as the principal/first-listed diagnosis. (Exception: if the encounter is solely for chemotherapy, radiation, or immunotherapy, the Z51.- code is sequenced first.)

13. What sequencing does ICD-10-CM require for diabetes mellitus with an associated condition (e.g., diabetic chronic kidney disease)?

    Diabetes codes (categories E08-E13) are combination codes that include the type, body system affected, and complication. Assign as many codes as needed to describe all complications; the diabetes code is sequenced first, followed by additional codes where instructed (e.g., the stage of CKD).

14. In ICD-10-CM obstetric coding, which chapter codes take sequencing priority, and what does the 7th character on many Chapter 15 codes indicate?

    Chapter 15 (Pregnancy, Childbirth, and the Puerperium / O codes) take sequencing priority over codes from other chapters. The 7th character identifies the fetus to which the code applies in multiple gestations (e.g., 0=single, 1=fetus 1).

15. How many characters are in every ICD-10-PCS code, and what value set may each character take?

    Every ICD-10-PCS code is exactly 7 characters. Each character can be one of 34 possible values: digits 0-9 and letters A-H, J-N, P-Z (the letters I and O are excluded to avoid confusion with 1 and 0).

16. What does each of the 7 characters represent in an ICD-10-PCS code from the Medical and Surgical section?

    1: Section, 2: Body System, 3: Root Operation, 4: Body Part, 5: Approach, 6: Device, 7: Qualifier.

17. In ICD-10-PCS, what value is the first character (Section) for the Medical and Surgical section, and name three other sections.

    Medical and Surgical = '0'. Others include: 1=Obstetrics, 2=Placement, 3=Administration, 4=Measurement and Monitoring, B=Imaging, F=Physical Rehabilitation, etc.

18. Define the ICD-10-PCS root operations 'Excision' vs. 'Resection.'

    Excision = cutting out/off, without replacement, a PORTION of a body part. Resection = cutting out/off, without replacement, ALL of a body part. The key distinction is partial (Excision) vs. whole (Resection).

19. In ICD-10-PCS, distinguish the root operations 'Bypass,' 'Dilation,' and 'Occlusion.'

    Bypass = altering the route of passage of contents of a tubular body part. Dilation = expanding an orifice or the lumen of a tubular body part. Occlusion = completely closing an orifice or the lumen of a tubular body part.

20. What are the seven ICD-10-PCS approach values' general categories?

    Open; Percutaneous; Percutaneous Endoscopic; Via Natural or Artificial Opening; Via Natural or Artificial Opening Endoscopic; Via Natural or Artificial Opening with Percutaneous Endoscopic Assistance; External.

21. In ICD-10-PCS, what is required for a device to be coded in the 6th character?

    A device is coded only if it remains in/on the patient after the procedure is completed. Instruments used to perform the procedure are not coded as devices. If no device is used, the value 'Z' (No Device) is used.

22. Per ICD-10-PCS Guideline B3.2, when are multiple procedures coded during the same operative episode?

    Multiple procedures are coded if: (1) the same root operation is performed on different body parts with distinct values; (2) the same root operation is repeated at different body sites; (3) multiple root operations with distinct objectives are performed on the same body part; or (4) the same root operation is performed via a different approach.

23. In ICD-10-PCS, how is the body part coded when a procedure is performed on a tubular body part involving a portion (Guideline B4.1c / continuous structure)?

    For a procedure performed on a continuous tubular body part, the body part value coded is the one that specifies the most distal portion of the procedure site (or as the guidelines direct). General rule: code to the most specific body part value available for the site treated.

24. In ICD-10-PCS, what is the difference between the root operations 'Inspection' and 'Drainage'?

    Inspection = visually and/or manually exploring a body part. Drainage = taking or letting out fluids and/or gases from a body part. If a diagnostic drainage is for fluid sampling, the qualifier 'X' (Diagnostic) is used.

See more Medical Coding and Reimbursement Methodologies flashcards →

Planning Medical Coding and Reimbursement Methodologies for Registered Health Information Administrator / Technician (RHIA / RHIT)

Medical Coding and Reimbursement Methodologies (Registered Health Information Administrator / Technician (RHIA / RHIT)) FAQ