Appendix C — The Encounter Workbook
This is Account 10-4471, blank.
The book follows one office visit through forty chapters — from a patient checking in on a Tuesday
morning to a zero balance one hundred days later. Each chapter's 🗂️ The Encounter checkpoint adds
the piece that chapter's material produces: a code, a form field, a document, a decision, a number, or
a lens. This appendix is the same file with the answers taken out, so that you can build it yourself
instead of watching somebody build it.
That is the single highest-value thing you can do with this book, and it is worth saying why. You can read a chapter on modifiers and understand every sentence in it. Deciding, on your own, whether a particular modifier belongs on a particular line of a particular claim is a different act, and it is the act you will be paid for. The gap between the two is exactly the width of this appendix.
C.1 How to use this workbook
Copy it, or rebuild it in whatever you actually work in — a notebook, a spreadsheet, a folder of files. Nobody will grade it. It is a file you keep.
The rhythm, forty times:
- Read the chapter. All of it, up to but not including its
🗂️ The Encountersection. - Stop there and work this appendix's worksheet for that chapter. Write the answer down. Writing it down is not a formality — an answer you have not written is usually an answer you have not finished.
- Then read the chapter's checkpoint and compare. Where you agree, you have confirmed something. Where you differ, find out which of you is right and why, because the reasoning is the part that transfers. A right answer with no path behind it expires on the next update cycle.
Two practical notes.
A few checkpoints hand you a document — a remittance advice, a decision letter, an audit worksheet. Where that happens, copy the document into your workbook first, cover the analysis that follows it, and do the analysis yourself. Reading somebody's reading of a remittance teaches you very little; reading the remittance teaches you the job.
Do not guess a code. If you are not certain a code exists with the meaning you need, write the category instead — "a code in the subcategory for pain in a specified joint" — and go look it up. That habit is the whole discipline of Chapter 8 §8.1, and this workbook is a place to practice it where a wrong answer costs nothing. Assign from the current year's code book or encoder, never from a textbook. ICD-10-CM changes every October 1, CPT every January 1, HCPCS Level II quarterly, and NCCI edits quarterly (Appendix A §A.1).
Start the tracker in §C.3 now, before Chapter 1. It is three grids — the open questions, the money, and the calendar — and you will add one line to each every few chapters for the rest of the book.
And the honest promise. A reader who works all forty of these will finish with a complete claim file: an eligibility response, a clinical note read line by line, four diagnosis codes and four service lines with the reasoning behind each, a completed CMS-1500, a submission trail and its acknowledgments, two remittance advices, a denial classified to a root cause, an appeal letter and the decision it won, an aging history, a patient statement, and an audit worksheet scoring the whole thing. That is not a study aid. That is the artifact a hiring manager asks to see when you have no experience, and Chapter 40 says so in its own words.
C.2 The case file as given
Everything below was known on day one. Nothing else in this appendix is filled in for you.
ACCOUNT 10-4471 — THE FILE, AS IT ARRIVES [constructed teaching example]
PRACTICE Northgate Family Medicine. Five physicians, independent,
mid-size metropolitan area. Six front-office staff, two
medical assistants per provider, one coder, one biller,
one practice manager. Roughly 19,000 encounters a year.
PATIENT Established patient, age 58. Seen twice already this
calendar year.
COVERAGE Northfield Mutual Health Plan, a commercial PPO. In network.
$1,500 individual deductible ....... MET on February 28
primary care office visit copay .... $30.00
coinsurance on other services ...... 20%
out-of-pocket maximum .............. $4,000.00
DATE OF Day 0 — Tuesday, March 14.
SERVICE
PRESENTING Six weeks of right knee pain, worsening — a new complaint.
Plus a scheduled follow-up of three chronic conditions:
type 2 diabetes mellitus, essential hypertension, and
hyperlipidemia, all documented as stable.
ORDERS Hemoglobin A1c and a lipid panel. Blood drawn in the office
by venipuncture.
PROCEDURE Right knee intra-articular injection, methylprednisolone
acetate 40 mg, performed the same day.
THE NOTE Signed electronically on day 0 at 6:42 p.m., with an
attestation.
THE ARC The claim is submitted, denied once on one line, appealed
once, paid twice, and closed at a zero balance on day 100.
The note itself is printed in full at Chapter 4 §4.10, as Figure 4.2. Do not work from the summary above once you have reached Chapter 4 — work from the note. Everything this file becomes is an inference from a document somebody signed, and the summary is not that document.
⚠️ What is deliberately not here. No codes. No allowed amounts. No modifier decisions. No denial reason. No dates between day 0 and day 100. Those are the forty worksheets, and if you find yourself wanting them now, that impatience is the correct instinct being applied at the wrong moment — it is what makes coders guess.
Your first act, before Chapter 1. Read the block above the way this book reads every document, and fill in the four fields it leaves open.
THE DOCUMENT A referral summary and benefit record, day 0.
THE CONTEXT One encounter, not yet coded, not yet billed.
WHAT IT SHOWS _________________________________________________
WHAT IT DOESN'T _________________________________________________
THE DECISION _________________________________________________
THE LESSON _________________________________________________
Chapter 1 — The account is opened
The whole file at a glance, and the six places its money can leak.
What this chapter contributes — your task. Two grids. First, map the arc: you know the file starts on day 0 and reaches a zero balance on day 100, and you know it is denied once, appealed once, and paid twice. Lay out every stage you expect between those two points and mark which ones you cannot yet date. Second, name the six moments where money can be lost on this encounter — not in general, on this one — and say which chapter will check each.
WHERE THIS FILE CAN LOSE MONEY — six, one per stage of the cycle
# THE STAGE WHAT COULD GO WRONG, ON THIS FILE CHECKED IN
-- --------------------- ------------------------------------ ----------
1 access, registration ____________________________________ Ch ____
2 the encounter and
charge capture ____________________________________ Ch ____
3 documentation ____________________________________ Ch ____
4 coding ____________________________________ Ch ____
5 claim submission ____________________________________ Ch ____
6 remittance, follow-up ____________________________________ Ch ____
What it settles, and what it does not. In one sentence each: what do you actually know about this account right now, and what have you assumed because it sounded reasonable? Be strict with the second list; it is longer than it feels.
Open questions. Two questions are visible from the case file alone and neither can be answered yet. Write them down, in your own words, in §C.3.
Check yourself against: Chapter 1's 🗂️ The Encounter section, and §1.8 for the six leaks.
Chapter 2 — The benefit design, read forward
The patient's share of this encounter was knowable at check-in. Prove it.
What this chapter contributes — your task. Predict the adjudication before the claim goes out. Use the benefit design in §C.2 and the money grid in §C.3. Fill in every cell you can defend, leave blank every cell that needs a number you do not have, and then write down what you would have to obtain to fill each blank and who has it.
What it settles, and what it does not. Which of the four numbers — charge, allowed amount, contractual adjustment, patient responsibility — can you produce from the benefit design alone? Which one requires the contract? And state plainly: does a benefit prediction tell you what the plan will actually pay? Answer that one in writing; the rest of Part V and all of Part VI turn on it.
Open questions. One of your two questions from Chapter 1 got sharper here without getting answered. Note how, and why "sharper but unanswered" is progress.
Check yourself against: Chapter 2's 🗂️ The Encounter section; §2.7 for reading a benefit design
before you bill.
Chapter 3 — The Medicare counterfactual
Same patient, same knee, same note — a different payer.
What this chapter contributes — your task. Rebuild the encounter as though the patient were 68 and enrolled in Original Medicare, everything clinical identical. Then set the two results side by side.
THE SAME ENCOUNTER, TWO PAYERS
COMMERCIAL PPO ORIGINAL MEDICARE
charges ................. 367.00 367.00
allowed ................. ________ ________
contractual adjustment .. ________ ________
patient ................. ________ ________
payer ................... ________ ________
CHECK charges − allowed = adjustment, both columns
CHECK allowed − patient = payer, both columns
What it settles, and what it does not. Answer three: does the practice collect more or less, and by how much? Does the patient pay more or less — and is that the direction you expected? What document does a Medicare beneficiary receive that this commercial patient does not, and what does it tell them (Chapter 3 §3.9)?
Open questions. Unchanged. Say so explicitly in the tracker; a chapter that changes nothing about the open questions is still worth recording as such.
Check yourself against: Chapter 3's 🗂️ The Encounter section.
Chapter 4 — The note itself
Everything from here forward is an inference from one document.
What this chapter contributes — your task. Work from Figure 4.2 at Chapter 4 §4.10, not from any summary. Find the elements in the note that will support billing the office visit as a service separate from the procedure — there are several, and the useful ones are the ones with nothing to do with the knee. Then find the sentence the assessment does not contain.
READING THE NOTE FOR THE SEPARATELY IDENTIFIABLE ARGUMENT
# THE ELEMENT WHERE IT IS IN THE NOTE
-- ----------------------------------- ---------------------------------
1 _________________________________ _______________________________
2 _________________________________ _______________________________
3 _________________________________ _______________________________
4 _________________________________ _______________________________
WHICH OF THESE ARE INDEPENDENT OF THE KNEE? ____________________
THE SENTENCE THAT IS MISSING FROM THE ASSESSMENT
_____________________________________________________________________
Where does that information appear instead? ________________________
Why does the difference matter to a reviewer? ______________________
ONE THING YOU NOTICE ON THE PROBLEM LIST AND DO NOT ACT ON
_____________________________________________________________________
What it settles, and what it does not. The note settles what was documented. It does not settle a single code. Write one sentence on why those are different statements — it is the sentence the rest of the book is built on.
Open questions. The note explicitly declines to answer one of your questions. That is a documented fact, not an omission. Record it that way.
Check yourself against: Chapter 4's 🗂️ The Encounter section.
Chapter 5 — The compliance reading of the same note
The same page, read by an auditor and then by a prosecutor.
What this chapter contributes — your task. Two passes.
PASS 1 — THE AUDITOR: is each line supported, and on what?
LINE / SERVICE SUPPORTED? ON WHAT, SPECIFICALLY
---------------------- ---------- ------------------------------------
the office visit ________ ____________________________________
the injection ________ ____________________________________
the drug ________ ____________________________________
the blood draw ________ ____________________________________
PASS 2 — THE COUNTERFACTUAL
Rewrite the assessment as two flat lines that acknowledge the
conditions rather than evaluating them. Everything clinical is
unchanged. Now build, step by step, the chain a reviewer would
assert against that version of the claim.
1 _________________________________________________________
2 _________________________________________________________
3 _________________________________________________________
4 _________________________________________________________
5 _________________________________________________________
Your last step should name the mental state the statute requires
(Chapter 5 §5.3). Notice whether anyone in your chain had to
intend anything.
What it settles, and what it does not. Does this claim's defensibility rest on the care that was given, or on the sentences that were written about it? Answer in one line, and then say whether that answer makes you comfortable.
Open questions. A new one is now visible even though this chapter does not ask it properly. Add it to the tracker and mark where you expect it to be raised.
Check yourself against: Chapter 5's 🗂️ The Encounter section.
Chapter 6 — The toolkit, routed
Which reference answers which question, and in what order.
What this chapter contributes — your task. Build the routing table for this specific file. Work forward through the encounter and list every question it will raise, in the order it will come up. For each, name the source that answers it — and be specific: not "the code book" but which book, which part of it, and whether the answer is in the index, the tabular, the guidelines, a parenthetical, or a policy.
ACCOUNT 10-4471 — WHICH REFERENCE ANSWERS WHICH QUESTION
ORDER THE QUESTION THE SOURCE CH
----- --------------------------------- --------------------------- --
1 _________________________________ ___________________________ __
2 _________________________________ ___________________________ __
3 _________________________________ ___________________________ __
4 _________________________________ ___________________________ __
5 _________________________________ ___________________________ __
6 _________________________________ ___________________________ __
7 _________________________________ ___________________________ __
8 _________________________________ ___________________________ __
9 _________________________________ ___________________________ __
10 _________________________________ ___________________________ __
11 _________________________________ ___________________________ __
12 _________________________________ ___________________________ __
13 _________________________________ ___________________________ __
Then, for each open question in §C.3: which source resolves it,
and which chapter does the work?
What it settles, and what it does not. Mark which rows in your table name a reference book and which name the record. Then say what follows from the ratio. And note which of your questions are really the same question asked three ways with three different sources — a coder who conflates them will confidently answer the wrong one.
Open questions. All still open. You now know where each will be answered, which is a different kind of knowledge and worth having.
Check yourself against: Chapter 6's 🗂️ The Encounter section; §6.6 for the free authoritative
sources.
Chapter 7 — The first diagnosis, located
Where the knee complaint lives in the structure of ICD-10-CM.
What this chapter contributes — your task. Take the diagnosis that describes the knee as the note describes it and drill it down, character by character. Do not start from the code you think it is; start from the classification's chapter and work down.
LOCATING THE KNEE DIAGNOSIS
CHAPTER ............ ______ ______________________________________
|
BLOCK .............. ______ ______________________________________
|
CATEGORY ........... ______ ______________________________________
|
4th CHARACTER ...... ______ ______________________________________
|
5th CHARACTER ...... ______ ______________________________________
|
6th CHARACTER ...... ______ ______________________________________
CHARACTER COUNT ......................... ______
SEVENTH CHARACTER REQUIRED? ............. ______ how do you know?
IS A PLACEHOLDER CHARACTER NEEDED? ...... ______
WHICH CHARACTER CARRIES LATERALITY? ..... ______
WHERE IS LATERALITY DOCUMENTED IN THE NOTE? _______________________
What it settles, and what it does not. Two questions. Did the code land in the chapter you would have predicted from the word the patient used? And: how many independent places in the note support the laterality character — count them, because most notes are not like this one.
Open questions. This chapter touches none of them. Say so.
Check yourself against: Chapter 7's 🗂️ The Encounter section; §7.4 for reading a code character
by character.
Chapter 8 — The same diagnosis, found the long way
Chapter 7 showed where it lives. This one is how you get there.
What this chapter contributes — your task. Reproduce the lookup as a path somebody else could follow — and record the wrong turns, because the wrong turns are where the learning is.
THE PATH
WRONG TURN 1 what a reasonable person looks up first ______________
what the index gives them ______________________
why it stops there __________________________________
WRONG TURN 2 the main term's own code, taken without reading the
subterms: _______________
why it is valid, payable, and wrong: ________________
STEP ONE — ALPHABETIC INDEX
main term ______________
subterm ______________
subterm ______________ → ______________
What did the index give you that you cannot bill? ____________
STEP TWO — TABULAR LIST
category notes say ______________________________
Excludes notes say ______________________________
laterality options are ______________________________
documentation supports ______________________________
ASSIGN: ______________
What it settles, and what it does not. How many of your step-two findings were negative — that is, confirmed that nothing changed? Write the number down, then write down the one finding that was not available from the index at all. That single item is the entire argument for step two.
Open questions. Unchanged. What the Tabular's instructions cannot tell you is whether a guideline sitting above them changes the answer. Note that as the next chapter's job.
Check yourself against: Chapter 8's 🗂️ The Encounter section; §8.10 for five lookups worked
start to finish.
Chapter 9 — The Guidelines applied
The rules that sit above the conventions, on this file.
What this chapter contributes — your task. Three decisions, each written out with its reasoning.
1 FIRST-LISTED DIAGNOSIS
This encounter had two purposes. Which condition is chiefly
responsible for the services? ______________
Is there a defensible alternative sequence? ______________
What is NOT free about the sequencing? __________________________
2 THE SYMPTOM CODE
The provider declined to name a disease. Is coding the symptom a
failure of specificity, a documentation gap, or the classification's
correct answer? ______________
Cite the guideline: ______________
3 THE "WITH" CONVENTION AND THE CHRONIC KIDNEY DISEASE ENTRY
What does the convention PERMIT? _______________________________
What PRIOR question governs whether that permission is even
reached? _______________________________________________________
Which conditions does the assessment actually address? __________
So what is reported for the diabetes on this claim, and why? ____
What it settles, and what it does not. Decision 3 answers one half of a question and leaves the other half standing. State both halves in one sentence each: what is being asked, and what is not.
Open questions. One question moves from open to partially resolved here. Record which half closed and which chapter owns the other.
Check yourself against: Chapter 9's 🗂️ The Encounter section; §9.3, §9.6, and §9.7.
Chapter 10 — The diabetes line
The same decision, now in the endocrine chapter's own terms.
What this chapter contributes — your task. Put the diabetes diagnosis through the structure the chapter teaches, and be precise about what the code asserts versus what it assumes.
THE DIABETES LINE
What the assessment says, verbatim: ______________________________
What the medication list says: ____________________________________
What the problem list says: _______________________________________
The category structure — which category, and why? ________________
The 4th character is the ______________ axis.
The code you assign: ______________
WHAT IT ASSERTS ________________________________________________
WHAT IT ASSUMES ________________________________________________
IS THAT ASSUMPTION TRUE OF THIS ENCOUNTER? ______________
"Stable" — is that a codeable axis? ______________
What two things DOES the classification ask about specifically?
______________ and ______________. Is either documented? ________
Is there anything here to query? ______________ Why or why not?
What it settles, and what it does not. Does the record need to change, or does the code? Those are different findings and only one of them is a coding error.
Open questions. Note the status-code question this chapter raises and deliberately leaves to the current Tabular instruction. Write down how you would resolve it rather than what the answer is.
Check yourself against: Chapter 10's 🗂️ The Encounter section; §10.6.
Chapter 11 — The hypertension line
The third time one structure decides a code on this file.
What this chapter contributes — your task. Run the circulatory conventions against the note.
THE HYPERTENSION LINE
What the assessment says: _________________________________________
What the cardiac examination documents: ___________________________
What the problem list carries: ____________________________________
THE QUESTION THE CHAPTER FORCES: is there organ involvement?
HEART? documented? ______ what does the convention require
for the heart, specifically? ___________________________
KIDNEY? on the problem list? ______
does the convention presume a relationship here? ______
so why is the code what it is? ___________________________
ASSIGN: ______________
What it settles, and what it does not. Write the general rule this file has now demonstrated three times, in one sentence, in your own words. It is a sentence about what a linkage convention is for — and about what it is never permission to do.
Open questions. Unchanged. But note that a second convention would also have supported a fuller code and did not get to. Whether that makes the point softer or sharper is worth a line of your own.
Check yourself against: Chapter 11's 🗂️ The Encounter section; §11.1 and §11.8.
Chapter 12 — What is not on this claim
Four diagnoses, and three categories of code that are absent on purpose.
What this chapter contributes — your task. Account for the absences. Each one is a decision.
THE CODES THAT ARE NOT THERE
NO SEVENTH CHARACTER
why not: ______________________________________________________
WHAT WOULD HAVE CHANGED IT: ___________________________________
which clause in the note closes the question? _________________
NO EXTERNAL CAUSE CODE
why not: ______________________________________________________
NO Z-CODE
why not: ______________________________________________________
WHAT WOULD HAVE ADDED ONE: ____________________________________
would it be first-listed or secondary? ______________
NO SYMPTOM CODE FROM THE SIGNS-AND-SYMPTOMS CHAPTER
but the claim carries a symptom code. Explain. _______________
What it settles, and what it does not. Part II's work on this file is finished when you can defend all four diagnosis codes and the three absences. Can you? Then say what remains entirely uncoded.
Open questions. Unchanged. Note the four-word clause in the note that did more work in this analysis than any other sentence, and what kind of sentence it is.
Check yourself against: Chapter 12's 🗂️ The Encounter section; §12.7 and §12.9.
Chapter 13 — Three procedure codes, located
Where they live in CPT, and which guideline governs the injection.
What this chapter contributes — your task. Locate each of the three CPT services in the structure — and notice that one of them will not be in CPT at all.
WHERE THE PROCEDURE CODES LIVE
the office visit SECTION ______________ SUBSECTION ______________
CATEGORY ______________
the injection SECTION ______________ SUBSECTION ______________
HEADING ______________ SUBHEADING ______________
Does the section name match your intuition? ______
the blood draw SECTION ______________ SUBSECTION ______________
HEADING ______________
Does THAT one match your intuition? ______
the drug ______________________________________________
THE GUIDELINE THAT GOVERNS THE INJECTION — two layers
section guidelines: ___________________________________________
subsection notes and the parenthetical: _______________________
THE PARENTHETICAL POINTS AT A SECOND CODE. Which clause in the
procedure note decides between them? _________________________
What it settles, and what it does not. Locating a code is not assigning one. Name the two things still required before the office visit line is defensible, and the chapter that supplies each.
Open questions. Unchanged. But you have now met the second documented negative in this note. Note what a documented negative is and why a coder should notice one.
Check yourself against: Chapter 13's 🗂️ The Encounter section; §13.4 and §13.6.
Chapter 14 — The two modifiers
What each one asserts, who reads it, and what happens if it is missing.
What this chapter contributes — your task. For each modifier on this claim, three answers — and then the question the book has been building toward since Chapter 5.
THE MODIFIERS
LINE 1 modifier ______
ASSERTS ......... _____________________________________________
READ BY ......... _____________________________________________
IF MISSING ...... _____________________________________________
and what is the dollar consequence? __________
is it appealable? ______ why or why not? ____
LINE 2 modifier ______
ASSERTS ......... _____________________________________________
READ BY ......... _____________________________________________
IF MISSING ...... _____________________________________________
THE TEST: where in the documentation is the thing the modifier says?
THE MODIFIER ASSERTS THE NOTE SAYS
------------------------------ ----------------------------
______________________________ ____________________________
______________________________ ____________________________
______________________________ ____________________________
______________________________ ____________________________
Is the global period of the procedure relevant to WHICH modifier is
correct? ______ Which two modifiers are you choosing between, and
what decides it? ______________________________________________
What it settles, and what it does not. Answer the modifier question yes or no, then state the qualifications honestly — a flat answer with no qualifications is usually an answer that has not been tested. In particular: if the documentation supports the modifier, does that guarantee the line is paid?
Open questions. One closes here, or nearly. Record your answer and note what would have to happen for you to call it confirmed rather than answered.
Check yourself against: Chapter 14's 🗂️ The Encounter section; §14.4 and §14.8; Appendix B §B.3.
Chapter 15 — Leveling the office visit
The level has to stand on the documentation, and the note tells you which road is closed.
What this chapter contributes — your task. Level the visit from Figure 4.2. Find the sentence in the note that removes one of the two selection methods before you start.
LEVELING THE VISIT
WHICH METHOD IS AVAILABLE? ______________
What sentence in the note decides that? _______________________
PROBLEMS ADDRESSED
the assessment items, listed: ________________________________
how many stable chronic illnesses? ______ threshold? ______
the new problem — what is its prognosis, per the note? ________
LEVEL: ______________ reached how many independent ways? ____
DATA REVIEWED AND ANALYZED
unique tests ordered: ______________
category 1 count: ______ threshold for the next level up: ____
external records? independent interpretation? discussion? _____
LEVEL: ______________
RISK
what in the plan carries it? ________________________________
LEVEL: ______________
DETERMINATION
____________ / ____________ / ____________
two of three at ______________ → code ______________
Does the element that fell short change the answer? ______ Why?
What it settles, and what it does not. Two things this section must not do: it must not code a definitive knee diagnosis, and it must not re-open the modifier. Say why not, in one line each. Then answer the harder question: how many separate jobs is one set of sentences in that assessment doing?
Open questions. Unchanged. The knee question stays open, and the note is the reason.
Check yourself against: Chapter 15 §15.13; §15.4 and §15.8 for the elements and the time alternative.
Chapter 16 — The same knee, in the emergency department
A counterfactual. Nothing below happened; the encounter was an office visit.
What this chapter contributes — your task. Suppose the pain worsened on a Sunday and the patient went to the emergency department instead of waiting for Tuesday.
THE SUNDAY COUNTERFACTUAL
What does an emergency department actually DO with this knee?
________________________________________________________________
Does it inject the knee? ______ So does the ED visit REPLACE
the March 14 encounter, or precede it? ______________
THE PROFESSIONAL CLAIM
problems ______ data ______ risk ______ → level ______
Which three conditions score NOTHING here, and why? __________
Is time an option in this family? ______
THE FACILITY CLAIM
Does one exist? ______ Whose is it? ______________
THE COMPARISON
MARCH 14, OFFICE THE COUNTERFACTUAL
claims ................. ______ ______
charges ................ 367.00 ______
allowed ................ ______ ______
patient ................ ______ ______
knee injected? ......... ______ ______
If one prescription had been an over-the-counter recommendation
instead, what changes? _______________________________________
What it settles, and what it does not. Write two sentences: one on what this comparison is an argument for, and one on what it is emphatically not an argument for. A billing office that gets the second sentence wrong will be both unkind and wrong.
Open questions. Unchanged.
Check yourself against: Chapter 16 §16.10; §16.6 for the emergency department levels.
Chapter 17 — The procedure's package
A minor procedure has a global period, and the package decides what may never appear on the claim.
What this chapter contributes — your task. Trace the surgical package for this specific injection.
THE PACKAGE
GLOBAL PERIOD OF THE PROCEDURE: ______ How many postoperative
days does that carry? ______
INCLUDED, therefore NOT separately billable:
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
NOT INCLUDED:
______________________________________________________________
______________________________________________________________
THE DRUG NAMED IN THE PROCEDURE NOTE THAT IS INSIDE THE PACKAGE:
______________ Where does it appear on the claim? __________
WHY THIS PROCEDURE AND NOT THE HIGHER-VALUED ALTERNATIVE
the two candidate codes describe: ____________________________
the clause in the note that decides: _________________________
what would the alternative additionally require documented? ___
If the patient returns in three weeks for a look at the knee, is
that visit inside any package? ______ What does that follow from?
What it settles, and what it does not. Two student questions fall out of the global period. Answer both: why one modifier rather than another on the visit line, and why the local anesthetic is not a billable line.
Open questions. Unchanged.
Check yourself against: Chapter 17 §17.2 and §17.7; §17.1 for the package itself.
Chapter 18 — Why there is no multiple-procedure reduction
A claim with four lines and one procedure.
What this chapter contributes — your task. Decide whether the multiple-procedure reduction applies here, line by line, and then run the counterfactual the chapter sets up.
IS A MULTIPLE-PROCEDURE REDUCTION APPLIED?
LINE 1 what kind of service is it? ______________ subject? ____
LINE 2 ______________ subject? ____
LINE 3 ______________ subject? ____
LINE 4 ______________ subject? ____
HOW MANY SURGICAL PROCEDURES ARE ON THIS CLAIM? ______
ANSWER, WITH THE REASON IN ONE SENTENCE: ______________________
THE COUNTERFACTUAL — BOTH KNEES
Which lookup comes FIRST, before any convention question? ______
Three ways a payer might want it reported:
A ____________________________________________________________
B ____________________________________________________________
C ____________________________________________________________
What happens to the drug line, and why is it a units question
rather than a second line? ___________________________________
Which payment mechanism applies to a bilateral procedure — and is
it the same one you were just asked about? __________________
What it settles, and what it does not. Say what a practice that guesses the convention risks, and say how it would find out it had been guessing. The second half is the harder half.
Open questions. Unchanged.
Check yourself against: Chapter 18 §18.12; §18.8 and §18.9.
Chapter 19 — The lab lines, and the two that are not here
Two tests were ordered. Neither is on this claim, and that is correct.
What this chapter contributes — your task. Account for every ordered service.
THE ORDERS AND THE CLAIM
ORDERED ON THIS CLAIM? WHOSE CLAIM, IF NOT?
-------------------------- -------------- ---------------------
hemoglobin A1c ______ ______________________
lipid panel ______ ______________________
blood drawn in office ______ ______________________
THE RULE THAT DECIDES: ________________________________________
Who is listed as the referring provider on the other claim? _____
THE COUNTERFACTUAL — PERFORMED IN HOUSE
Three questions that would arise and do not now:
1 __________________________________________________________
2 __________________________________________________________
3 __________________________________________________________
What does the practice earn from the lab orders as things stand?
$__________
Is in-house testing obviously better? ______ List what it
would require: ___________________________________________
AND ONE MORE LINE THAT IS NOT THERE
the specimen handling code: ______ Is it payable? __________
How would the practice find out? ____________________________
Which of two situations is it in — correctly not billing
something unpayable, or not billing something payable? ________
What it settles, and what it does not. One sentence on why "a code you never report can never be denied" is a warning rather than a comfort.
Open questions. Unchanged.
Check yourself against: Chapter 19 §19.12; §19.4, §19.5, and §19.6.
Chapter 20 — The drug line
A descriptor, a dose, a unit count, and an attestation the claim does not make.
What this chapter contributes — your task. Report the drug from the record.
THE DRUG LINE
What the procedure note documents: ______________________________
The descriptor's stated amount: ______________
UNITS: ______ ÷ ______ = ______
What would a note saying only "steroid injected" support? _______
THE WASTE QUESTION
Was anything discarded? ______ On what evidence? ___________
Which attestation modifier does the record support? __________
Which one would be wrong here, and why? _______________________
Is it on the claim as originally built? ______
Is that a coding error, an overpayment, or something else?
______________________________________________________________
What does a coder DO about it? _______________________________
What does a coder NOT do? ____________________________________
AND THE LOCAL ANESTHETIC
It has a J-code family. Does that make it separately payable?
______ Give the reason, and name the chapter that established it.
What it settles, and what it does not. Write the general rule in one line: what does it take for a drug to be reportable, as opposed to merely codeable?
Open questions. Unchanged.
Check yourself against: Chapter 20 §20.4; §20.3 and §20.10.
Chapter 21 — The edit, run
The office visit against the injection, through the procedure-to-procedure edit table.
What this chapter contributes — your task. Run the edit in order and stop at the first step that ends the analysis. Then notice what happens anyway.
RUNNING THE EDIT
Does the pair exist? ______
Column One ______________ Column Two ______________
MODIFIER INDICATOR ______
STEP 1 what does that indicator permit? ______________________
Continue or stop? ______
STEP 2 the Policy Manual's language on this pair:
______________________________________________________
How does it compare to the modifier's own definition?
______________________________________________________
STEP 3 does the documentation establish the circumstance? ____
on what evidence? ____________________________________
STEP 4 is there a MORE SPECIFIC modifier? ______ why not? ____
IS THE OVERRIDE CORRECT? ______
AND WHAT HAPPENED ANYWAY, ON DAY 17? __________________________
What does that tell you about the relationship between a correct
override and a payment? _______________________________________
What it settles, and what it does not. Set this override beside the unbundled shoulder claim from Account 31-2245. They differ at exactly one step. Which one, and what is the difference made of?
Open questions. Unchanged. Note that this chapter bears on the modifier question from a different direction than Chapter 14 did — permission versus support — and say why they are not the same question.
Check yourself against: Chapter 21 §21.9; §21.2, §21.3, and §21.5.
Chapter 22 — Medical necessity
Was the injection covered, and was any advance notice owed?
What this chapter contributes — your task. Three pieces of work.
1 FIND THE POLICY
Which payer's policy governs this claim? ______________________
Where would you find it? ______________________________________
What does it list among supporting diagnoses? __________________
2 LINK THE DIAGNOSIS TO THE SERVICE
Which diagnosis supports the procedure line? ______________
Does the note document a failure of conservative therapy? ______
WHERE in the note is that information? ______________________
Where would a reviewer look? ________________________________
Is the difference an error, or something else? ________________
3 THE ADVANCE BENEFICIARY NOTICE QUESTION
Is the patient a Medicare beneficiary? ______
So does the form apply at all? ______ What applies instead? ___
AND SEPARATELY: even if she were, would one have been proper?
______ What does the notice require that this case lacks? _____
What would a routine, collect-from-everyone version of it be?
________________________________________________________________
Was the day-17 denial a medical necessity denial? ______
Would a notice have addressed it? ______
What it settles, and what it does not. Two of your open questions can close in this chapter. Write each answer in a single sentence, then write the sentence they have in common — it is a sentence about reasoning backward from what happened later, and it applies to both.
Open questions. Update the tracker. Note that a later diagnosis does not reach backward and change a code assigned from an earlier record; say why that is a rule and not a preference.
Check yourself against: Chapter 22 §22.8 and §22.11; §22.5 and §22.6.
Chapter 23 — Where the money comes from
The allowed amount, the charge, and the difference between having a number and having a method.
What this chapter contributes — your task. Two derivations, one of which will fail.
1 WHERE THE ALLOWED AMOUNT COMES FROM
work RVU ______ × work GPCI ______ = ______
PE RVU ______ × PE GPCI ______ = ______
MP RVU ______ × MP GPCI ______ = ______
TOTAL = ______
× conversion factor ______ = $______
Label every figure you used. Are any of them current? __________
2 WHERE THE CHARGE CAME FROM
Can anyone at the practice derive it? ______
Is it a multiple of the fee schedule? ______
line-by-line ratios: ______ ______ ______ ______
is there a consistent multiple? ______
Is it a computed figure of any kind? ______
SO WHAT IS THE CHARGE ACTUALLY DOING ON THIS CLAIM?
______________________________________________________________
Is it above every contracted rate? ______ Does it cap anything?
______ Is that by design or by accident? ______
What it settles, and what it does not. One of your open questions closes here, and the answer is uncomfortable. Write it in one sentence and then write what a practice that wanted a better answer would need to have — not a number, a thing.
Open questions. Update the tracker.
Check yourself against: Chapter 23 §23.7; §23.2 and §23.4 for the arithmetic.
Chapter 24 — Rewind to check-in
The front end did almost everything right, and the encounter still produced a surprise.
What this chapter contributes — your task. Reconstruct the morning of day 0.
WHAT THE FRONT DESK DID
eligibility verified for the date of service? ______
what did the response return? _______________________________
asked whether anything had changed? ______
referral required? ______ determined how? ________________
prior authorization required for the visit? ______
amount collected at check-in: $______
WHAT IT MISSED
What did the schedule say the appointment was for? ____________
What did the patient intend to raise? ________________________
So which question was never asked? ___________________________
And which check was therefore never run? _____________________
Was the answer to that check favorable? ______ Was that
process, or luck? ______
COLLECTED AT CHECK-IN ............ $______
ACTUAL PATIENT RESPONSIBILITY .... $______
---------
BILLED AFTER THE FACT ............ $______
WHAT A BETTER FRONT END WOULD HAVE DONE — three things, all cheap
1 ______________________________________________________________
2 ______________________________________________________________
3 ______________________________________________________________
What it settles, and what it does not. The hard sentence in this chapter is that the front desk did nothing wrong. Write your own version of it, then say what category of failure this is if it is not an error.
Open questions. A question is raised here that this chapter deliberately does not answer, and it is the last one the book will close. Add it to the tracker now.
Check yourself against: Chapter 24 §24.11; §24.3, §24.5, and §24.8.
Chapter 25 — The claim form, item by item
Everything the book has established so far, on one page.
What this chapter contributes — your task. Build the CMS-1500 for this encounter. Every field you complete should be traceable to a chapter; where you cannot name one, mark the field and come back.
CMS-1500 (02/12) — ACCOUNT 10-4471 [complete from the record]
1 ______________________ 1a __________________
2 ______________________ 3 ______ / ______ sex ______
4 ______________________ 6 relationship ______
9 ______________________ 11 group ______ 11d ______
10a ______ 10b ______ 10c ______
12 ______________________ 13 ______________________
14 ______________________ 17 ______________________
19 ______________________ 20 ______ why? ________________
21 ICD indicator ______
A ____________ B ____________ C ____________ D ____________
22 ______ 23 ______
24 A: DOS B: POS D: CODE / MOD E: PTR F: CHARGE G: UNITS
1 ______ – ______ ______ ______ ______ ______ 185.00 ______
2 ______ – ______ ______ ______ ______ ______ 150.00 ______
3 ______ – ______ ______ ______ ______ ______ 18.00 ______
4 ______ – ______ ______ ______ ______ ______ 14.00 ______
27 accept assignment ______
28 TOTAL CHARGE $______
29 AMOUNT PAID $______ why does this field matter? ______
31 ______ 32 ______ 33 ______________________
33a ______ (whose NPI?) 24J ______ (whose NPI?)
THREE THINGS THAT ARE CORRECTLY ABSENT FROM THIS FORM
1 ____________________________________________________________
2 ____________________________________________________________
3 ____________________________________________________________
What it settles, and what it does not. For each diagnosis pointer, say what the pointer asserts. One line on this claim points at a diagnosis that is not the knee — find it and defend it, because pointing it anywhere else would assert something clinically false.
Open questions. Unchanged. Note where on this form one of the partially resolved questions is quietly sitting.
Check yourself against: Chapter 25 §25.10; §25.4 and §25.5; Appendix D §D.2 and §D.3.
Chapter 26 — The same encounter as a facility claim
A second counterfactual: the practice acquired and converted, everything else identical.
What this chapter contributes — your task. Build the institutional claim that would appear, and then price the difference.
IF NORTHGATE WERE A PROVIDER-BASED DEPARTMENT
WHAT CHANGES ON THE PROFESSIONAL CLAIM
the codes: ______________
place of service: ______ → ______
the allowed amounts: ______ Why? ____________________________
WHAT APPEARS THAT DID NOT EXIST BEFORE
FL 4 TYPE OF BILL ......... ______ digit by digit: ________
FL 6 STATEMENT COVERS ..... ______ through ______
FL 42 REVENUE FL 44 HCPCS FL 46 UNITS FL 47 CHARGES
______________ ____________ ___________ _____________
______________ ____________ ___________ _____________
______________ ____________ ___________ _____________
0001 TOTAL _____________
FL 67 PRINCIPAL DIAGNOSIS ... ______ others ______________
FL 76 ATTENDING ............. ______
THE COMPARISON
INDEPENDENT PROVIDER-BASED
professional allowed ______ ______
facility allowed ______ ______
TOTAL ALLOWED ______ ______
PATIENT ______ ______
On which claim does the drug sit, and is that a coding question or
an ownership question? _______________________________________
What it settles, and what it does not. State clearly what this comparison is not an argument for. Then state the one thing about it the patient can see. That second answer is the point of the section.
Open questions. Unchanged.
Check yourself against: Chapter 26 §26.9; §26.3 and §26.4; Appendix D §D.8.
Chapter 27 — The claim as a transaction
Three days from a signed note to an acknowledged claim, and nothing in the pipeline can catch what is coming.
What this chapter contributes — your task. Walk days 0 through 3 and record what exists at the end of each one.
CHECKOUT TO ACKNOWLEDGMENT
DAY 0 ____________________________________________________
What has been SUBMITTED at the end of this day? ______
DAY 1 ____________________________________________________
Who does this day's work? ______________
DAY 2 ____________________________________________________
The claim stops being a form and becomes a ______.
Item 24E has become ______. Item 21 has become ______.
DAY 3 ____________________________________________________
Which acknowledgment says the FILE is valid? ______
Which says the PAYER took the claim? ______
Does either say the claim will be paid? ______
THEN NOTHING HAPPENS FOR ______ DAYS.
FOUR THINGS TO NOTICE
1 __________________________________________________________
2 __________________________________________________________
3 __________________________________________________________
4 __________________________________________________________
What it settles, and what it does not. Answer directly: could a scrubber, a clearinghouse, or an acknowledgment have caught the denial that is coming? For each of the three, say what it actually checks — and then say what kind of decision the denial is instead.
Open questions. Unchanged.
Check yourself against: Chapter 27 §27.10; §27.4 and §27.6.
Chapter 28 — Posting the first remittance
Day 17. Three lines pay and one does not, and the account does not look broken.
What this chapter contributes — your task. Chapter 28 §28.11 prints the remittance. Copy its four lines into the grid below before reading the analysis that follows it, run the checks, and post it yourself.
POSTING THE REMITTANCE
LINE CHARGE GROUP/CARC AMOUNT RARC PAID
---- ------- ---------- ------- ----- -------
1 185.00 ______ ______ _____ ______
______ ______
2 150.00 ______ ______ _____ ______
______ ______
3 18.00 ______ ______ _____ ______
______ ______
4 14.00 ______ ______ _____ ______
______ ______
LINE CHECKS charge − adjustments = paid, every line
1 185.00 − ______ − ______ = ______
2 150.00 − ______ − ______ = ______
3 18.00 − ______ − ______ = ______
4 14.00 − ______ − ______ = ______
TOTAL PAID ______ + ______ + ______ = ______ matches the EFT? ___
PATIENT RESP ______ + ______ + ______ = ______
LINE 1 CARRIES TWO ADJUSTMENTS. What does each one do?
the first: ____________________________________________________
the second: ___________________________________________________
SO WHAT IS THE APPEALABLE AMOUNT? $______ Why not the charge?
THE POSTING DECISION
Is the denied amount a contractual adjustment or something else?
______ What happens to the account if you post it as an
adjustment? __________________________________________________
AND THE COPAY COLLECTED ON DAY 0
Does this remittance touch it? ______ Why not? _____________
Do you bill the patient today? ______ Why not? _____________
What it settles, and what it does not. Write the sentence that explains why a posting process that recorded "payment received" and moved on would have been telling the truth — and would still have lost the money.
Open questions. Unchanged. The denial has now been read and priced. What it costs to resolve is not this chapter's arithmetic.
Check yourself against: Chapter 28 §28.11; §28.3, §28.4, §28.5, and §28.6; Appendix E §E.2 and §E.3.
Chapter 29 — Classifying the denial
A person reaches the denial on day 20. What they do first is not appeal.
What this chapter contributes — your task. Work the denial in order, and log it.
TOUCH 1 — READ, CLASSIFY, PULL THE NOTE
STEP 1 read the codes
the group code means ______________________________________
the reason code means _____________________________________
the remark code names _____________________________________
In one sentence, what has the payer asserted? _____________
STEP 2 triage
Which of the four reasons a valid code does not pay? ________
Does that ordinarily end the analysis? ______
Is there a branch? ______ What is the edit's indicator? ____
Does the documentation support the override? ______ on what?
BRANCH: ______________________________________________________
STEP 3 classify the root cause BEFORE acting
ROOT CAUSE ......... _____________________________________
HARD OR SOFT ....... ______
PREVENTABLE? ....... ______
STEP 4 the decision: ______________
MINUTES SPENT ON THIS TOUCH: ______
THE LOG ENTRY — every field, including the two practices leave out
DOS ______ DENIED ______ PAYER ______________
CODE ______ CHG ______ ALLOWED ______
CARC ______ RARC ______
ROOT CAUSE ______________________________
HARD / SOFT ______ PREVENTABLE ______
ACTION ______________ OUTCOME ______________ RESOLVED ______
What it settles, and what it does not. The hardest idea here: a claim can be correct at every step, win its appeal, and still be logged as preventable. Explain what "preventable" means in that sentence, and why misreading it as blame causes practices to under-report the category.
Open questions. The last open question is raised again here and stopped at deliberately. Say what this chapter supplied toward it, and what it withheld.
Check yourself against: Chapter 29 §29.10; §29.3, §29.4, and §29.7; Appendix E §E.5 and §E.7.
Chapter 30 — Writing the appeal
The argument, the evidence, the deadline, and why this one was won.
What this chapter contributes — your task. Draft the letter. One page is enough, and a page that puts three documents side by side beats three pages of insistence.
APPEAL LETTER — SKELETON
TO / attention ..............................................
RE: patient · account · claim number · date of service · the line
THE DECISION BEING APPEALED
group ______ reason ______ remark ______ amount $______
1 WHAT WE ARE ASKING FOR, in one sentence
__________________________________________________________
2 WHAT THE RECORD SHOWS — each element tied to a place in the note
element ____________________ located at ____________________
element ____________________ located at ____________________
element ____________________ located at ____________________
element ____________________ located at ____________________
Which of these have nothing to do with the procedure? ________
Why is that the spine of the argument? _____________________
3 THE GAP, AND HOW YOU HANDLE IT
The note never states one thing the argument would like it to
state. What? ______________________________________________
You may not quote a sentence that does not exist and you may
not ask for an addendum after a denial. So: lay documented
facts in a row and let the reviewer draw the conclusion.
fact 1 ___________________________________________________
fact 2 ___________________________________________________
fact 3 ___________________________________________________
fact 4 ___________________________________________________
fact 5 ___________________________________________________
4 THE RULES YOU RELY ON — all published BEFORE the claim was filed
the manual language: _______________________________________
the payer's own policy: ____________________________________
5 WHAT IS ENCLOSED — and nothing else
__________________________________________________________
Why is "and nothing else" a rule and not a style? __________
6 THE CALENDAR
filed on day ______ of a ______-day window
the payer's own response commitment: ______ days
your own status-check rule: ______ days → check on day ______
What it settles, and what it does not. Nothing in the packet was created for the appeal. Say what follows from that, in the form of an instruction to yourself about the next claim you code.
Open questions. One closes its last loop here. Which, and what changed — the answer, or who agrees with it?
Check yourself against: Chapter 30 §30.11; §30.2, §30.3, §30.4, and §30.10.
Chapter 31 — The line that stood still
One claim moving forward is Chapter 30's story. One line standing still is this one.
What this chapter contributes — your task. Follow the denied line through the aging report.
ONE LINE IN ACCOUNTS RECEIVABLE
DAY WHAT THE LINE IS DOING BUCKET
---- ------------------------------------------ --------
____ ________________________________________ ________
____ ________________________________________ ________
____ ________________________________________ ________
____ ________________________________________ ________
____ ________________________________________ ________
DENIED ON DAY ______, RESOLVED ON DAY ______
DAYS IN THE AGING AS A DENIED RECEIVABLE: ______ − ______ = ______
WHAT THE AGING REPORT SAW ...... _______________________________
WHAT IT DID NOT SEE ............ _______________________________
Would the aging report ever have flagged this line? ______
Around what day? ______ Would that have been in time? ______
WHAT ACTUALLY SURFACED IT, TWICE: _____________________________
WHAT THE DELAY COST — in three currencies
staff attention .... ______ minutes across ______ touches
the loaded rate published in this chapter:
$______ per hour = $______ per minute
► write both down. Do not multiply them here.
time value ......... $______ arrived ______ days late.
Did any prompt-pay remedy attach? ______
anything else ...... timely filing risk? ______ re-aging? ______
write-off pressure? ______
THE PATIENT SIDE OF THE SAME ACCOUNT
responsibility created on day ______, billed on day ______
aged from date of service, how old was it when paid? ______
How long after the first statement did the patient pay? ______
So which party's sequencing did that aging number measure? ______
What it settles, and what it does not. Every aging number is an answer to the question "aged from when?" Demonstrate that twice on this account, once on each side of the ledger.
Open questions. The last of the capstone's inputs is now published. List all four in the tracker, with the chapter each came from — and stop there.
Check yourself against: Chapter 31 §31.12; §31.2, §31.5, and §31.7.
Chapter 32 — The statement, and the estimate that could have preceded it
What it says, when it goes, and what could have been said in advance.
What this chapter contributes — your task. Two documents: one that exists and one that does not.
1 THE STATEMENT
responsibility ................. $______
payment received on day 0 ...... $______
BALANCE DUE .................... $______
Issued on day ______. Why not earlier? _______________________
Paid on day ______. Account balance ______.
Why must the statement show the credit rather than the net? ____
2 RUN THE TAPE BACKWARD — what could have been known, and when
AT SCHEDULING
office visit copay ................ $______
blood draw, coinsurance ........... $______
what must be said about the labs? ____________________________
ESTIMATE .......................... $______
plus the sentence: ____________________________________________
IN THE ROOM, BEFORE CONSENT
the procedure and the drug, coinsurance ...... $______
RUNNING TOTAL ................................ $______
Checks: ______ + ______ = ______ · ______ + ______ = ______
Could an estimate at scheduling have included the procedure? ____
Why not? _____________________________________________________
Was the running total knowable before the needle was uncapped?
______ By whom? ____________________________________________
Was a good faith estimate in the statute's sense owed here? ____
Why or why not? _____________________________________________
Does the answer to that question change what the practice should
have done? ______
What it settles, and what it does not. The file closes here on the money. Reconcile every figure from your Chapter 2 prediction to this statement and show both checks. Then answer the one thing it does not settle — whether the hundred days had to happen at all.
Open questions. One remains.
Check yourself against: Chapter 32 §32.11; §32.2 and §32.6.
Chapter 33 — The same patient, admitted
A lens, not a change to the file. The real account is an office encounter and stays one.
What this chapter contributes — your task. Suppose the same patient fell at home, fractured a hip, was admitted through the emergency department, and had it repaired the next morning. Re-read the same record under inpatient rules.
THE INPATIENT COUNTERFACTUAL
PRINCIPAL DIAGNOSIS
which condition, and on what test? __________________________
what category would you look in? ____________________________
does it need a seventh character? ______
which two codes from the special chapters now have a home? ____
SECONDARY DIAGNOSES
which of the three chronic conditions are reportable, and why?
______________________________________________________________
the problem-list entry — does the same test apply? ______
may any linkage be assumed here? ______ who owns that? ______
POA indicators: ______________
THE PROCEDURE
which code set reports it? ______________
what determines the root operation? _________________________
THE GROUPING
does the procedure change the partition? ______
do the secondaries reach the higher severity split? ______
what family does the stay land in? __________________________
THE MONEY
can a coder derive the payment here? ______ Why not? ________
What it settles, and what it does not. One sentence: what is the same about coding an inpatient record and coding this office claim, and what is genuinely different? The honest answer is shorter than students expect.
Open questions. Unchanged; the counterfactual adds none, which is itself worth noting.
Check yourself against: Chapter 33's 🗂️ The Encounter section; §33.2, §33.4, and §33.7.
Chapter 34 — The same injection in a hospital outpatient department
The facility claim from Chapter 26, now read from the inside.
What this chapter contributes — your task. Take the institutional claim you built for Chapter 26 and run each line through this chapter's method: a line meets a status indicator before it meets a price.
THE FACILITY CLAIM, LINE BY LINE
THE VISIT LINE
separately payable? ______ indicator type ______
under Medicare specifically, what does the facility report, and
why is it not the physician's code? __________________________
THE PROCEDURE LINE
separately payable? ______ indicator type ______
subject to discounting? ______ Is there a second one? ______
THE DRUG LINE
what happens to a low-cost drug on a facility claim? ________
indicator ______ what does the facility get paid for it? ____
does the patient owe coinsurance on it? ______
should the line still appear on the claim? ______ Why? _____
THE BLOOD DRAW AND THE LAB HANDLING
packaged or payable? ______ conditional on what? ___________
what happens to the reference laboratory's own claims? _______
WHY THE PATIENT PAYS MORE — mechanically, not rhetorically
which lines pull cost sharing OUT of the patient's bill? ______
which put it IN? ____________________________________________
net effect on this account: $______ → $______
What it settles, and what it does not. The reader who stared at a hospital bill in Chapter 1 has now read its last unexplained line. Write, in your own words, the sentence you would say to that person about why the same injection costs different amounts in different rooms.
Open questions. Unchanged.
Check yourself against: Chapter 34's 🗂️ The Encounter section; §34.4 and §34.5.
Chapter 35 — The same knee, in orthopedics
Same patient, same joint, same six weeks — a different practice.
What this chapter contributes — your task. Referred to an orthopedic group instead. Five things about the claim change, and none of them is the knee. Find them.
THE ORTHOPEDIC COUNTERFACTUAL
1 THE E/M CATEGORY
new or established? ______ on what rule? ________________
which code family? ______________
2 THE RAW MATERIAL OF THE SEPARATELY IDENTIFIABLE ARGUMENT
which of your four elements survive? ______________________
which do not, and why? ____________________________________
So the argument must now be built from what? ______________
Is it stronger or weaker? ______ Say why in one sentence.
3 THE PROCEDURE CODE
what does an orthopedic practice have in the room that a family
practice may not? ______________
which code does that make more likely? ______________
what must the note then say, and with what behind it? _______
4 THE DIAGNOSIS
films obtained at the visit — what could that support? ______
does that make the original code wrong? ______ Why not? ___
5 A LINE THAT DISAPPEARS
which one, and why? _______________________________________
four lines become ______ — or ______, if what happens? ______
ONE THING THAT DOES NOT CHANGE
____________________________________________________________
What it settles, and what it does not. "Specialty coding" is not a separate rulebook. Write the one-sentence version of what it actually is, using this comparison as the evidence.
Open questions. Unchanged.
Check yourself against: Chapter 35's 🗂️ The Encounter section; §35.3.
Chapter 36 — The revisit
The book has told you thirty times that this chapter comes back for one line. Here it is.
What this chapter contributes — your task. Five steps, in order, and the first one takes nothing back.
1 MEAT, APPLIED TO THE ACTUAL NOTE
CONDITION M E A T REPORTABLE?
---------------------- --- --- --- --- -------------
____________________ ___ ___ ___ ___ ___________
____________________ ___ ___ ___ ___ ___________
____________________ ___ ___ ___ ___ ___________
____________________ ___ ___ ___ ___ ___________
____________________ ___ ___ ___ ___ ___________
How many pass on all four? ______ How many fail on all four?
______ Is that a marginal call? ______
2 THE SENTENCE THAT IS MISSING, AND WHY IT IS PROBABLY TRUE
Read two frozen facts of the record together: ________________
and ________________. What does an ordinary clinician do with
that pairing? ______________________________________________
Does the note say so? ______
May a coder say it? ______ State the rule. _______________
3 THE QUERY
Write the WRONG query first — the obvious one:
____________________________________________________________
Why is it both leading and the wrong question? ______________
Now write the defensible one:
____________________________________________________________
Does it quote only the relevant excerpt? ______
Does it offer the negative answer with equal weight? ______
Does it ask about THIS encounter? ______
Does it name a code, suggest a diagnosis, or mention payment?
______
IF THE ANSWER IS YES: what may be added, and how? ___________
IF THE ANSWER IS NO: what changes? ______ What is the real
remedy, and is it retrospective or prospective? _____________
4 THE CONSEQUENCE, WHICH IS NOT ABOUT THIS CLAIM
Does any money on this account change? ______
What changes instead? ______________________________________
What question can the practice's own data no longer answer? __
5 WHAT IT IS WORTH — as a lens, not as this file's money
Say first why the arithmetic below is a lens: _______________
RAF as coded ......... ______ RAF as the patient is ... ______
difference ........... ______ × a stated benchmark ... ______
Label every coefficient you use. Are any of them current? ___
Where does that money go — to the practice or to the plan? ____
What, then, is the argument that actually matters? __________
What it settles, and what it does not. Two statements must both be true and neither may cancel the other: the code was correct, and it was insufficient as a description of the patient. Write both, and then say which one needs to change — the coder or the record.
Open questions. One closes here. One remains, and it is the last.
Check yourself against: Chapter 36 §36.11; §36.7 for the criteria.
Chapter 37 — Auditing the file
Thirty-seven chapters built this claim. Now read it the way a stranger would.
What this chapter contributes — your task. You are an external auditor. No relationship to the practice, no access to anyone who was in the room, no interest in anybody's interpretation. You have the claim, the remittance, and the record. Score it.
AUDIT WORKSHEET — ACCOUNT 10-4471
LINE CODE MOD PTR CHG SCORED AGAINST WHAT STANDARD
---- ----- --- ---- ------- --------------------------------
1 _____ ___ ____ 185.00 ________________________________
2 _____ ___ ____ 150.00 ________________________________
3 _____ ___ ____ 18.00 ________________________________
4 _____ ___ ____ 14.00 ________________________________
For each line: SUPPORTED or NOT, and the sentence in the record
that carries it.
1 ______ __________________________________________________
2 ______ __________________________________________________
3 ______ __________________________________________________
4 ______ __________________________________________________
THE SIGNATURE ______ date and attestation present? ______
SOMETHING THAT IS CORRECTLY NOT THERE
____________________ and the ______ independent reasons for it
THE THREE DOCUMENTED GAPS — what does an auditor DO with each?
gap 1 _______________________________________________________
error, or organization problem? ______ score it ______
gap 2 _______________________________________________________
error, or the finding? ______
what was its real-world consequence on this file? ______
gap 3 _______________________________________________________
relevant to THIS audit? ______ to a different one? ____
THE SCORE
code-level accuracy ........ ______ of ______ lines supported
chart-level ................ ______
financial variance ......... $______ direction: ___________
documentation findings ..... ______
THE PROSPECTIVE CORRECTION
what changes? ______________________________________________
does it change THIS note? ______ Why absolutely not? ______
What it settles, and what it does not. Then the sentence to carry out of the chapter, which you should write before you read it: the claim that scores highest is the claim that was denied. What does that tell you about the relationship between an audit and a payer's decision — and what has a practice confused if it expects a clean audit to prevent denials?
Open questions. Only one is still open, and this chapter deliberately does not touch it. Say why scoring a claim's defensibility and deciding what a denial was worth are different questions.
Check yourself against: Chapter 37 §37.11; §37.3 for scoring a chart.
Chapter 38 — The note through a coding engine
The same note, read by software.
What this chapter contributes — your task. Run Figure 4.2 through computer-assisted coding — on paper, by predicting what an engine would produce — and then grade the engine.
THE ENGINE'S OUTPUT, PREDICTED
WHAT IT ALMOST CERTAINLY GETS RIGHT
_____________________________________________________________
_____________________________________________________________
Why are these the easy ones? ______________________________
WHAT IT PLAUSIBLY GETS WRONG OR MISSES
_____________________________________________________________
_____________________________________________________________
For each, say WHAT KIND of judgment the miss required:
a rule? a lookup? a reading of a negative? a decision
about what was ADDRESSED? __________________________________
THE DOCUMENTED NEGATIVES IN THIS NOTE
Would an engine treat "no imaging guidance used" as evidence,
or as an absence? ______ Why does that distinction decide a
code here? ________________________________________________
THE THREE GAPS
Which of the three gaps in this note could software detect?
______ Which requires knowing what the payer will do? ______
Which requires knowing what the ENCOUNTER addressed, as opposed
to what the record mentions? ______________________________
MEASURING THE ENGINE
Which error is more expensive on this file — a code suggested
that should not have been, or a code missed? ________________
What does that asymmetry imply about where the human sits? ___
What it settles, and what it does not. Answer the question the chapter is named for: on this file, specifically, what is the coder still there for? Give three concrete answers drawn from work you actually did in this workbook, not from a general belief about judgment.
Open questions. One remains.
Check yourself against: Chapter 38, which runs the same note through the same machinery.
Chapter 39 — Three credentials, one file
What a CPC, a CCS, and a CPB each own on this account.
What this chapter contributes — your task. Divide the file three ways.
WHO OWNS WHICH PART OF ACCOUNT 10-4471
CPC — professional coding
pieces of the file: ________________________________________
the chapters where that work was done: _____________________
CCS — facility coding
pieces of the file: ________________________________________
► Why is this credential's version of this file necessarily a
counterfactual? _________________________________________
CPB — billing
pieces of the file: ________________________________________
the chapters where that work was done: _____________________
THE THREE COLUMNS TOGETHER
Do they reconcile to the account totals? ______
Show both checks: ______ − ______ = ______
______ − ______ = ______
THE ONE THING NONE OF THE THREE COULD HAVE FINISHED ALONE
___________________________________________________________
What does that say about what a credential actually
certifies? ________________________________________________
What it settles, and what it does not. Which credential would you sit for, and — separately — which one describes the work you actually want? Those are not always the same answer, and writing both down is more useful than picking one.
Open questions. One remains, and the next chapter is where it goes.
Check yourself against: Chapter 39, which divides the same file the same three ways.
Chapter 40 — The capstone
Everything in the file is on the page except one thing, and this is where it happens.
⚠️ Work this one before you read Chapter 40. It is the only worksheet in this appendix where the comparison at the end tells you something about your judgment rather than about your arithmetic. If you read the chapter first, you will find its conclusion persuasive and you will not find out whether you would have reached it.
What this chapter contributes — your task. Three parts, in this order, and do not skip ahead to the third.
Part one — assemble the file. Put every document in order and confirm that nothing is missing. Use the checklist in §C.3. A file with a gap in it is not a capstone; it is a draft.
Part two — gather the inputs. Four numbers, each already published somewhere in this book, each one you have already written down in this workbook. Find them again, and record where each came from. Do not compute anything in this part.
THE INPUTS
staff time spent on the denial, across all touches
______ minutes from Chapter ______
the practice's fully loaded cost of that staff time
$______ per ______ from Chapter ______
the amount at issue on the denied line
$______ from Chapter ______
the practice's measured appeal overturn rate
______ % from Chapter ______
► Check each one against the chapter you took it from. An input
you cannot source is an input you should not use.
Part three — answer the question, and then the larger one behind it.
Q4 — COULD THIS DENIAL HAVE BEEN PREVENTED?
What, specifically, would have stopped it? ____________________
______________________________________________________________
What would that cost to build, once? $______
What does it cost each time a claim goes out afterward? $______
(Those are two different numbers. Answer both.)
Would you build it? ______ Say why in one sentence: __________
WAS THIS APPEAL WORTH WORKING?
Write the METHOD before you write a number. What do you do with
the inputs above, in what order, and what does each step tell
you that the one before it did not?
step 1 ______________________________________________________
step 2 ______________________________________________________
step 3 ______________________________________________________
step _ ______________________________________________________
Now run it, showing the arithmetic:
____________________________________________________________
____________________________________________________________
Your answer, in one sentence: ________________________________
AND THE QUESTION THE BOOK HAS BEEN CIRCLING SINCE CHAPTER 1
Which denials are worth fighting, and which ones should never
have happened?
Is the answer for THIS line the answer for every denied line in
this practice? ______
If not, what makes the difference? __________________________
______________________________________________________________
How would a practice test that against its own denial log?
______________________________________________________________
______________________________________________________________
And whatever your answer turns out to be — what should the
practice DO with it? ________________________________________
YOUR THIRTY-DAY PLAN
The capstone has a second half that is about you rather than the
account. Write it before you read the chapter's version:
weeks 1–2 ___________________________________________________
weeks 3–4 ___________________________________________________
what you will be able to show someone at the end __________
What it settles, and what it does not. The file is closed and the last question is answered. Then say what the account did not settle — about this practice, about this payer, and about the difference between the work you just did and the work that would have made it unnecessary.
Open questions. None. Write the date you finished, because you will want it later.
Check yourself against: Chapter 40, which assembles the same file and answers the same question. Read your answer beside the book's before you decide which one you believe — and if you disagree, work out whether you differ on the arithmetic, on an input, or on what the answer means. Those are three different disagreements and only one of them has a right answer.
C.3 The running tracker
Three grids. Start them at Chapter 1 and add to them as you go. They are what turn forty worksheets into one file.
The open questions
Six questions run through this book. Each is raised somewhere and answered somewhere else, sometimes many chapters later. Fill in the last three columns as they close — and where a question closes in two halves, record both.
# THE QUESTION RAISED ANSWERED THE ANSWER
--- --------------------------------------- ------- --------- -----------
Q1 Was the modifier on the visit line
correctly applied? Ch ____ Ch ____ __________
Q2 Is the diabetes code right? Ch ____ Ch ____ __________
__________
Q3 Should an advance beneficiary notice
have been obtained? Ch ____ Ch ____ __________
Q4 Could the denial have been prevented? Ch ____ Ch ____ __________
Q5 What is actually wrong with the knee? Ch ____ Ch ____ __________
Q6 Why did the practice charge $185.00
for the office visit? Ch ____ Ch ____ __________
⚠️ A question that closes in two halves is not a bookkeeping curiosity. At least one of these does, and if you record only the second half you will have lost the more useful of the two answers. When you find it, write both halves and the chapter for each.
The money
The charges are given; everything else you derive. Update it whenever a chapter supplies a figure, and run the checks every time — a grid that does not foot is a grid with an error in it, and finding the error is the exercise.
ACCOUNT 10-4471 — THE MONEY [constructed teaching example]
LINE SERVICE CODE CHARGE ALLOWED CONTRACTUAL PATIENT PLAN
ADJUSTMENT
---- -------------------- ------- ------- ------- ----------- ------- -------
1 the office visit _______ 185.00 _______ ___________ _______ _______
2 the knee injection _______ 150.00 _______ ___________ _______ _______
3 the drug injected _______ 18.00 _______ ___________ _______ _______
4 the blood draw _______ 14.00 _______ ___________ _______ _______
---- -------------------- ------- ------- ------- ----------- ------- -------
TOTAL 367.00 _______ ___________ _______ _______
CHECK 1 charge − allowed = contractual adjustment
367.00 − _______ = _______
CHECK 2 allowed − patient = plan
_______ − _______ = _______
CHECK 3 the patient column, added down
______ + ______ + ______ + ______ = ______
AND THE TWO NUMBERS THAT ARE NOT ON THIS GRID
collected from the patient at check-in ......... $______
billed to the patient after the fact ........... $______
► Why is the second one not the same as the patient column
total? ______________________________________________
The calendar
Day 0 is Tuesday, March 14, and the account reaches a zero balance on day 100. Everything between is yours to fill in as the chapters supply it. Record the weekday as well as the date — several things in this file happen on a Friday, and at least one deadline is counted in business days.
ACCOUNT 10-4471 — 100 DAYS
DAY DATE WHAT HAPPENED CHAPTER
---- ------------- ----------------------------------- -------
0 Tue, Mar 14 date of service; note signed ____
____ _____________ ___________________________________ ____
____ _____________ ___________________________________ ____
____ _____________ ___________________________________ ____
____ _____________ ___________________________________ ____
____ _____________ ___________________________________ ____
____ _____________ ___________________________________ ____
____ _____________ ___________________________________ ____
____ _____________ ___________________________________ ____
____ _____________ ___________________________________ ____
100 _____________ account balance $0.00 ____
ELAPSED, SERVICE TO ZERO BALANCE: 100 days on a clean,
correctly coded, in-network claim that was denied once.
► Two federal holidays fall inside this window. Find them,
and say whether either one mattered.
The file itself
The documents you should hold when the workbook is finished. Check each off when it is in your file and you can explain every line on it to somebody who was not there.
[ ] the eligibility response, and what it returned
[ ] the clinical note, read line by line, with the elements marked
[ ] four diagnosis codes, each with its lookup path written out
[ ] four service lines, each with the guideline that governs it
[ ] the modifier analysis for both modifiers
[ ] the edit run, step by step, with its outcome
[ ] the coverage policy and the diagnosis linkage
[ ] the pricing derivation, and the charge that cannot be derived
[ ] the completed CMS-1500
[ ] the submission trail and both acknowledgments
[ ] the first remittance, posted, with every line check shown
[ ] the denial classified to a root cause, and the log entry
[ ] the appeal letter, its enclosures, and its calendar
[ ] the decision letter and the second remittance
[ ] the aging history of the denied line
[ ] the patient statement, and the estimate that could have preceded it
[ ] the audit worksheet and its score
[ ] the capstone: the inputs, the method, the answer, and the plan
C.4 Handing off
When the last worksheet is done, you will have something most people entering this field do not have: one complete claim file that you can explain end to end. Not forty summaries — one account, from an eligibility response on a Tuesday morning to a zero balance in late June, with the reasoning written down at every point where a decision was made.
That is worth saying out loud in an interview, and Chapter 40 says how. A candidate who can walk a hiring manager through a denied line — what the reason code asserted, why the documentation answered it, what the appeal enclosed and what it deliberately left out, how long the money sat and where it sat — has demonstrated the job. A candidate who can name the credential they are studying for has demonstrated an intention.
Two honest warnings before you close the file.
Everything perishable in it is perishable. The codes, the fee schedule figures, the edit files, the coverage policies, and the notice requirements all change on schedules that have nothing to do with your convenience. What does not expire is the path — main term, subterm, verify, read the conventions, read the guidelines, check the edits, read the policy, then decide. Keep the paths. Let the numbers go.
And this account was the easy one. It was in network, the deductible was met, the eligibility was verified, the documentation was better than most, the coding was right, the denial was wrong, and the appeal was won. It still took a hundred days, three touches, and an argument that had to be constructed rather than quoted. Hold on to that when you read a denial rate.
The last question is Chapter 40's, and it is the only one this workbook deliberately leaves you to answer alone: which denials are worth fighting, and which ones should never have happened. Work it before you read the answer. You have every input you need, and you have had them for several chapters.