CCA high-yield HIM coding drill

The rule

Classification follows the record and the official guidelines. Queries clarify. They do not coach a paying code.

Next step

Hold an incomplete record. Do not code a procedure you cannot see.

Never miss

• Inpatient procedures use ICD-10-PCS. Diagnoses use ICD-10-CM.
• PCS is seven characters. Root operation is the high-yield miss.
• Excision is a portion. Resection is the whole body part.
• MS-DRG rests on principal diagnosis, procedures, CC/MCC, and discharge status.
• UHDDS principal diagnosis is the condition established after study to be chiefly responsible for admission.
• ROI is minimum necessary and purpose-limited.

Traps

• Sequencing a secondary diagnosis as principal to raise weight.
• A leading query that names the hoped-for MCC.
• Coding from the booking slip when the operative report is missing.
• Releasing the whole chart because letterhead looked official.

Shortcuts

• Setting first: inpatient versus outpatient classification.
• Abstraction follows the measure specification.
• Unique user IDs and audit logs on every release.

Terms

• ICD-10-PCS. Inpatient hospital procedure classification. Seven characters.
• Root operation. The objective of the procedure in PCS, such as Excision or Resection.
• MS-DRG. Medicare inpatient grouping from documented facts, not from the chargemaster.
• APC. Ambulatory Payment Classification. Hospital outpatient prospective payment.
• UHDDS. Uniform Hospital Discharge Data Set. Defines principal diagnosis.
• Non-leading query. Points at documented facts and asks for clarification without handing the code.

Memory hooks

• PORTION vs WHOLE. Excision versus Resection The PCS pair people swap.