CCA (ASA) cheat sheet

ICD-10-CM diagnosis codes are 3 to 7 characters; the first character is a letter, characters 2 through 7 may be numeric or alphabetic, and alpha characters appear only in later positions.

ICD-10-PCS procedure codes are always exactly 7 alphanumeric characters, each position carrying a fixed meaning: section, body system, root operation, body part, approach, device, qualifier.

An Excludes1 note in ICD-10-CM means the two conditions are mutually exclusive and cannot be coded together; an Excludes2 note means the conditions are not included in the code but may be reported together.

The principal diagnosis is the condition established after study to be chiefly responsible for occasioning the inpatient admission and is sequenced first.

Seventh-character encounter values: A = initial encounter, D = subsequent encounter, S = sequela.

CPT Category I codes are 5 digits; Category II codes are 5 digits ending in F (performance measures); Category III codes are 5 digits ending in T (emerging technology).

HCPCS Level II codes consist of one letter followed by four digits; HCPCS and CPT modifiers are two characters (alphanumeric or numeric).

Modifier 25 indicates a significant, separately identifiable E/M service by the same physician on the same day as a procedure or other service.

Evaluation and management level is determined by the key components of history, examination, and medical decision making, or by time when counseling dominates.

Prefixes: hyper- (above normal), hypo- (below normal), tachy- (fast), brady- (slow), dys- (difficult or painful), poly- (many), leuko- (white).

Suffixes: -itis (inflammation), -ectomy (surgical removal), -otomy (incision), -ostomy (creation of an opening), -plasty (repair), -megaly (enlargement), -emia (blood condition), -uria (urine condition).

Anatomical position is standing erect, face forward, arms at the sides with palms forward; all directional terms assume this posture.

Planes: sagittal divides the body into right and left, frontal (coronal) divides anterior from posterior, transverse divides superior from inferior.

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

Ventral cavity contains the thoracic cavity (heart, lungs) and abdominopelvic cavity; the dorsal cavity contains the cranial and spinal cavities.

Blood flow: right atrium, tricuspid valve, right ventricle, pulmonary valve, pulmonary artery, lungs, pulmonary veins, left atrium, mitral valve, left ventricle, aortic valve, aorta.

The adult skeleton has 206 bones: 80 axial (skull, vertebral column, rib cage) and 126 appendicular.

GI tract order: mouth, esophagus, stomach, duodenum, jejunum, ileum, cecum, ascending/transverse/descending/sigmoid colon, rectum, anus.

The medical record must be complete, accurate, timely, legible, authenticated, and confidential, with every entry attributable to its author.

Correction of an error requires a single line drawn through the entry, the corrected information, and the date, time, and initials or signature; the original entry is never obliterated.

Late entries are labeled 'late entry' and show both the date of the actual entry and the date of the event being documented.

UHDDS defines the minimum data set for inpatient discharges, including principal diagnosis, other diagnoses, procedures, and discharge disposition.

A discharge summary documents the reason for admission, diagnoses, procedures, significant findings, discharge medications, discharge condition, and follow-up plan.

SOAP note structure: Subjective (patient complaint), Objective (exam findings and data), Assessment (diagnosis or impression), Plan (treatment).

An operative report includes pre- and postoperative diagnoses, the procedure performed, surgeon and assistants, findings, complications, and estimated blood loss.

An addendum supplements a previously completed entry; the original entry remains intact, and the addendum is dated and authenticated by its author.

Medicare Conditions of Participation require hospitals to retain medical records for at least 5 years.

The HIPAA Privacy Rule permits use and disclosure of protected health information without authorization for treatment, payment, and health care operations.

The minimum necessary standard limits PHI to the least amount reasonably needed for the purpose; disclosures for treatment are exempt from the standard.

Breach notification: individuals must be notified within 60 days of discovery; HHS is notified within 60 days (annually if fewer than 500 individuals); media notice is required when 500 or more residents of a state are affected.

The Stark Law prohibits physician self-referral of Medicare patients for designated health services to entities with which the physician has a financial relationship.

The Anti-Kickback Statute prohibits knowingly offering, paying, soliciting, or receiving remuneration to induce referrals of items or services reimbursed by federal programs.

The OIG compliance program elements include written standards, a designated compliance officer, training, open communication, auditing and monitoring, enforcement, and corrective action.

EMTALA requires Medicare-participating hospitals with emergency departments to provide a medical screening examination and stabilizing treatment regardless of ability to pay.

A valid authorization must include a description of the information, the purpose, an expiration date, the individual's signature, a right-to-revoke statement, and a redisclosure statement.

42 CFR Part 2 imposes stricter confidentiality requirements on substance use disorder treatment records than HIPAA does.

Medicare inpatient payment under IPPS = DRG weight multiplied by the hospital base rate, adjusted for wage index, indirect medical education, disproportionate share, and outliers.

MS-DRG assignment depends on the principal diagnosis, the procedures performed, and the presence of a CC (complication/comorbidity) or MCC (major CC).

Medicare hospital outpatient services are paid under OPPS using Ambulatory Payment Classifications (APCs).

Physician payment under RBRVS = [(work RVU x work GPCI) + (practice expense RVU x PE GPCI) + (malpractice RVU x MP GPCI)] x conversion factor.

The CMS-1500 paper form and X12 837P electronic transaction are used for professional claims; the UB-04 and X12 837I are used for institutional claims.

NCCI consists of Procedure-to-Procedure edits (column one/column two) and Medically Unlikely Edits (MUEs) that set maximum units per code per patient per day.

DRG weight expresses relative resource consumption; case mix index is the average DRG weight of a hospital's discharges and increases with severity.

Medicare Part A covers inpatient hospital, skilled nursing facility, hospice, and some home health; Part B covers physician and outpatient services.

Capitation is a fixed payment per enrollee per period; per diem is a fixed payment per patient day; case rate is a fixed payment per episode or case.

An EMR is a record within a single organization; an EHR is designed for information sharing across multiple organizations.

HL7 defines clinical messaging standards, FHIR provides web-based interoperability APIs, and DICOM governs medical imaging data.

X12 837 is the health care claim transaction; X12 835 is the electronic remittance advice; X12 270/271 is eligibility inquiry and response.

Data quality characteristics include accuracy, accessibility, comprehensiveness, consistency, currency, definition, granularity, precision, relevancy, and timeliness.

The master patient index uniquely identifies each patient and links all encounters and records belonging to that patient across the organization.

The HIPAA Security Rule requires administrative, physical, and technical safeguards to protect electronic protected health information.

Audit trails capture who accessed or modified data and when, supporting security monitoring and data integrity.

Computer-assisted coding uses natural language processing to generate candidate codes from clinical text; the coder must review and validate every result.

A data dictionary defines the attributes, permitted values, and format of each data element in a database.