CCC cheat sheet

ICD-10-CM is the U.S. clinical modification for diagnosis coding; ICD-10-PCS is used only for inpatient procedure coding.

ICD-10-CM codes are 3-7 characters: category, etiology, anatomic site, severity, and encounter type; a 7th character is required for injuries and most obstetrics.

ICD-10-PCS has 7 alphanumeric characters, each a defined axis (section, body system, root operation, body part, approach, device, qualifier).

CPT is maintained by the AMA; Category I codes are 5 digits, Category II are 4 digits plus F, Category III are 4 digits plus T.

HCPCS Level II codes begin with a letter (A-V) and cover drugs, supplies, and equipment not described in CPT.

The ICD-10-PCS root operation defines the objective of the procedure; the same body part with different root operations yields different codes.

The Alphabetic Index must be consulted first for diagnosis coding, then the Tabular List to confirm specificity and excludes notes.

ICD-10-CM conventions include 'code first', 'use additional code', 'see also', and Excludes1 (not coded together) vs Excludes2 (may be coded together).

Anatomical position: body erect, face forward, palms forward; all directional terms reference this position.

Prefixes alter meaning (brady- slow, tachy- fast, hyper- excessive, hypo- deficient); suffixes denote condition or procedure (-itis inflammation, -ectomy removal, -otomy incision).

Body planes: sagittal divides left/right, coronal (frontal) divides anterior/posterior, transverse divides superior/inferior.

The four abdominal quadrants are RUQ, LUQ, RLQ, LLQ; the liver and gallbladder sit in the RUQ, the appendix in the RLQ.

Directional pairs: proximal/distal (limbs), superior/inferior, medial/lateral, anterior/posterior, superficial/deep.

The integumentary system layers are epidermis, dermis, and subcutaneous tissue; the skin is the largest organ system.

The cardiovascular system circulates blood: right heart to lungs (pulmonary), left heart to body (systemic); arteries carry blood away from the heart.

Cranial nerves number 12 pairs; spinal nerves 31 pairs; the autonomic nervous system divides into sympathetic and parasympathetic.

The ICD-10-CM Official Guidelines for Coding and Reporting are organized by section (conventions, neoplasms, diabetes, injuries, obstetrics, etc.) and are updated annually.

Principal diagnosis is the condition chiefly responsible for admission after study; it is not always the condition present on admission.

The principal procedure is the procedure most related to the principal diagnosis, or the most significant procedure performed for treatment.

Signs and symptoms that are integral to a confirmed diagnosis are not coded separately; if no definitive diagnosis is documented, code the signs/symptoms.

Sequela coding requires two codes: the residual condition first and the cause of the sequela second.

External cause codes (V, W, X, Y) are used with injury and poisoning codes to identify how and where the event occurred; they are never principal diagnosis.

Combination codes that fully describe a condition should be used instead of multiple separate codes when available in the Tabular List.

When documentation is unclear or conflicting, the coder must query the provider rather than assume a diagnosis or procedure.

MS-DRG assignment uses the principal diagnosis, secondary diagnoses (CC/MCC), procedures, discharge status, and age/sex; the base rate times the DRG weight yields payment.

Inpatient prospective payment (IPPS) pays per discharge by DRG; outpatient prospective payment (OPPS) pays per service by APC.

The physician fee schedule uses relative value units (work, practice expense, malpractice) multiplied by a conversion factor and adjusted by geographic index.

The NCCI edits (Column 1/Column 2 and MUE) define code pairs that cannot be billed together without an appropriate modifier.

Medical necessity requires that services be reasonable and necessary for the diagnosis or treatment of illness or injury.

The False Claims Act prohibits knowingly submitting false claims; the Anti-Kickback Statute prohibits remuneration for referrals of federally payable services.

The OIG Work Plan and RAC audits target high-risk coding areas; compliance programs should include monitoring, auditing, and education.

The HIPAA Privacy Rule permits use/disclosure for treatment, payment, and operations; the Minimum Necessary standard limits other disclosures.

The health record must contain identification, consent, history and physical, progress notes, orders, results, operative reports, and discharge summary.

Data quality dimensions include accuracy, completeness, consistency, timeliness, validity, and granularity.

The four data quality characteristics used in coding review are relevance, completeness, accuracy, and timeliness.

Documentation must be legible, authenticated, and contemporaneous; late entries are appended with date, time, and reason.

The legal health record is the record the facility designates as its official business record for disclosure purposes.

The MPI (master patient index) is the facility's index of patient identifiers; duplicate records cause data integrity and patient safety risks.

Retention schedules are set by state law and facility policy; Medicare requires records be retained at least 5 years for cost reports.

Quantitative analysis checks for required signatures, dates, and completeness; qualitative analysis reviews clinical accuracy and consistency.

HIPAA Privacy Rule covers protected health information (PHI); Security Rule covers electronic PHI (ePHI) confidentiality, integrity, and availability.

The minimum necessary standard applies to uses and disclosures except treatment, and disclosures to the individual or authorized by law.

Breach notification: individual notice within 60 days of discovery; HHS notice within 60 days for breaches affecting 500+ individuals.

The AHIMA Code of Ethics requires coding professionals to uphold accuracy, confidentiality, and the integrity of the record.

Coding professionals must not alter documentation; they may query the provider but cannot change the record themselves.

The Stark Law prohibits physician self-referral for designated health services paid by Medicare/Medicaid unless an exception applies.

The OIG compliance program guidance for hospitals includes written policies, a compliance officer, training, auditing, and discipline for violations.

Release of PHI for research generally requires authorization or an IRB-approved waiver; psychotherapy notes require specific authorization.