CAMC Part 1 Exam cheat sheet

Prefixes alter meaning without changing the root: brady- = slow, tachy- = fast, hypo- = below/deficient, hyper- = above/excess, dys- = painful/difficult/abnormal.

Suffixes determine word class: -itis = inflammation, -ectomy = surgical removal, -otomy = incision, -ostomy = creation of an opening, -plasty = repair, -megaly = enlargement, -oma = tumor.

Directional terms: proximal = closer to the point of attachment; distal = farther; superior = above; inferior = below; anterior/ventral = front; posterior/dorsal = back; medial = toward midline; lateral = away from midline.

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

Body cavities: cranial and spinal are dorsal; thoracic, abdominal, and pelvic are ventral. The diaphragm separates thoracic from abdominal cavities.

Cellular injury: hypoxia is the most common cause of cell injury and leads to ATP depletion, failure of the Na+/K+ pump, and cell swelling.

Inflammation hallmarks: rubor (redness), calor (heat), tumor (swelling), dolor (pain), and functio laesa (loss of function).

Neoplasia terminology: benign tumors are non-invasive and well-differentiated; malignant tumors invade and metastasize; carcinoma arises from epithelium, sarcoma from connective tissue.

The ICD-10-CM Tabular List is organized by chapter, section, category (3 characters), subcategory (4-5 characters), and code (6-7 characters); the Alphabetic Index is arranged by main term, then subterm.

The Alphabetic Index must never be used alone to assign a code; always verify the code in the Tabular List and follow any instructional notes there.

Instructional notes: 'Includes' lists conditions that belong to a code; 'Excludes1' means the two codes cannot be reported together; 'Excludes2' means the conditions are not included but may be reported together if both are present.

The 'code first' note indicates the underlying etiology should be sequenced before the manifestation; 'use additional code' indicates a secondary code is required to fully describe the condition.

Laterality is required for many musculoskeletal and neoplasm codes; unspecified laterality should be avoided when documentation supports a side.

Seventh characters are used for certain codes: in Chapter 19 (injury/poisoning) the 7th character indicates encounter type (A initial, D subsequent, S sequela); in Chapter 15 (pregnancy) it indicates the fetus and trimester.

The 'code also' note indicates an additional code may be needed to fully describe the condition, but the sequencing is not mandated.

Signs and symptoms are coded when a definitive diagnosis has not been established; do not code a symptom that is an integral part of a confirmed diagnosis.

ICD-10-PCS codes are 7 characters with no decimals; each character position has a defined meaning: Section, Body System, Root Operation, Body Part, Approach, Device, Qualifier.

In ICD-10-PCS the root operation defines the intent of the procedure (e.g., Excision = cutting out without replacement; Resection = cutting out with replacement; Bypass = rerouting; Dilation = expanding).

ICD-10-PCS is used for inpatient hospital procedures in the U.S.; CPT is used for outpatient and physician services.

CPT code categories: Category I = standard procedures with five digits; Category II = performance measurement (four digits plus F); Category III = emerging technology (four digits plus T).

CPT modifiers communicate altered service: -25 = significant, separately identifiable E/M service by the same physician on the same day; -59 = distinct procedural service; -26 = professional component; -TC = technical component.

Surgical package (global surgery): the surgical code includes the operation, local anesthesia, and typical pre- and post-operative care; E/M services on the same day as a major procedure are generally not separately billable unless a -25 modifier applies.

Anesthesia coding: use the anesthesia code plus the base units and time units; physical status modifiers (P1-P6) and qualifying circumstances may add units.

Radiology coding: split into professional (interpretation, -26) and technical (equipment, supplies, -TC) components; global service includes both.

Office/outpatient E/M (99202-99215) is selected by either medical decision making (MDM) or total time on the date of the encounter; both methods are not required.

MDM is determined by three elements: number and complexity of problems addressed, amount and/or complexity of data reviewed, and risk of complications/morbidity/mortality.

Total time includes pre-visit review, the visit itself, and post-visit documentation; it excludes time spent by clinical staff, prolonged services unless separately reported, and travel.

The 2021+ office/outpatient E/M guidelines eliminated the history and physical exam as key components for code selection; they remain documented but are not scored.

Hospital inpatient E/M (99221-99223, 99231-99233, 99234-99236) still uses the key components of history, exam, and MDM, or time for some codes.

Prolonged services: 99417 is used with office/outpatient E/M for each 15 minutes beyond the highest-level code; 99418 is used for inpatient prolonged services.

Documentation must support the level of service: for MDM-based coding, the record must show the problems addressed, data reviewed, and risk; for time-based coding, the record must show the total time.

Critical care (99291-99292) requires direct delivery of care for a critically ill or injured patient; 99291 is the first 30-74 minutes, 99292 is each additional 30 minutes.

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

Medicare Part C (Medicare Advantage) is a managed care alternative; Part D covers prescription drugs.

The CMS-1500 form is used for physician/outpatient claims; the UB-04 (CMS-1450) is used for institutional claims.

The claim filing process: patient registration, eligibility verification, coding, charge entry, claim scrubbing, submission, payer adjudication, remittance advice, and payment posting.

The Explanation of Benefits (EOB) and Electronic Remittance Advice (ERA) explain payer payment decisions and adjustments.

Common denial reasons: missing/invalid diagnosis or procedure code, no prior authorization, eligibility issues, and bundling edits (NCCI).

NCCI edits: Column 1/Column 2 pairs indicate that the Column 2 code is bundled into the Column 1 code; modifier -59 or appropriate X modifier may bypass if the services are distinct.

The Medicare Physician Fee Schedule uses relative value units (RVUs) multiplied by a conversion factor and adjusted by geographic practice cost indices (GPCI).

The False Claims Act prohibits knowingly submitting false or fraudulent claims to government payers; penalties include treble damages and per-claim fines.

The Anti-Kickback Statute prohibits offering or receiving remuneration to induce referrals for items or services covered by federal healthcare programs.

The Stark Law (Physician Self-Referral Law) prohibits physicians from referring Medicare patients to entities with which they (or immediate family) have a financial relationship, unless an exception applies.

The Civil Monetary Penalties Law and Exclusion Statute allow HHS-OIG to impose penalties and exclude providers from federal healthcare programs.

HIPAA Privacy Rule protects individually identifiable health information; the Security Rule protects electronic PHI; the Breach Notification Rule requires notification of breaches.

A compliance program typically includes written policies, a compliance officer, training, communication lines, internal monitoring, and enforcement/discipline.

Audit types: internal audits, external audits, payer audits (RAC, MAC, UPIC), and OIG reviews; sampling and extrapolation may be used to estimate overpayments.

The 60-day overpayment rule requires providers to report and return identified overpayments within 60 days of identification.

The legal health record is the record that would be released in response to a legal request; it includes documents created at or near the time of care by authorized personnel.

HIPAA requires a valid authorization for uses and disclosures not otherwise permitted; authorizations must include the purpose, expiration, and right to revoke.

The minimum necessary standard requires limiting PHI use/disclosure to the minimum needed for the purpose.

Record retention: Medicare requires retention of records for at least 7 years; state laws may require longer periods.

Documentation must be timely, accurate, complete, and legible; late entries should be clearly labeled as such and not alter the original record.

Corrections to the record should be made via addendum or strike-through with initials, date, and reason; never obliterate or delete original entries.

Release of information: patient consent is generally required except for treatment, payment, operations, or as required by law; psychotherapy notes require separate authorization.

Data quality characteristics include accuracy, completeness, consistency, timeliness, and validity; the medical record is the primary source for coding.

When coding from a case, first identify the main term in the Alphabetic Index, then verify the code in the Tabular List, and check for additional codes required by notes.

Sequence the principal diagnosis as the condition established after study to be chiefly responsible for the encounter; for outpatient, sequence the first-listed diagnosis as the reason for the visit.

If a patient presents with a symptom and a definitive diagnosis is made during the encounter, code the definitive diagnosis, not the symptom.

For multiple injuries, code each injury and sequence the most severe condition first; use the injury codes with the appropriate 7th character.

When a patient has multiple chronic conditions, code all that are relevant to the encounter; do not code conditions that are not addressed unless required by a 'code also' note.

Data quality: query the provider when documentation is ambiguous, inconsistent, or incomplete; never assign a code based on assumption.

For procedures, verify the root operation and approach in ICD-10-PCS; for CPT, check bundling edits (NCCI) and modifiers before submission.

Case application: read the entire note, identify the reason for the visit, any procedures performed, and the final diagnoses; then assign codes in the correct sequence.