certified professional coder Interview Questions and Answers

1. What is the role of a Certified Professional Coder (CPC)?

   • Answer: A CPC is a healthcare professional who translates medical diagnoses, procedures, and services into standardized codes used for billing and reimbursement by insurance companies and other payers. They ensure accurate and compliant coding practices, maximizing reimbursement while adhering to regulatory guidelines.

2. Explain the difference between ICD-10 and CPT codes.

   • Answer: ICD-10 codes (International Classification of Diseases, 10th Revision) classify diagnoses and reasons for encounters. CPT codes (Current Procedural Terminology) describe medical, surgical, and diagnostic procedures and services performed by physicians and other healthcare providers.

3. What is HCPCS Level II?

   • Answer: HCPCS Level II codes are alphanumeric codes used to report medical supplies, equipment, and services not included in CPT or other standardized coding systems. They're often used for durable medical equipment (DME) and other supplies.

4. Describe the importance of medical record review in accurate coding.

   • Answer: Medical record review is crucial for accurate coding because it ensures the coder has access to all relevant information to select the appropriate codes. Incomplete or inaccurate documentation can lead to incorrect coding and subsequent reimbursement issues.

5. What are modifiers in CPT coding? Give examples.

   • Answer: Modifiers are two-digit codes appended to CPT codes to provide additional information about the circumstances of a service. Examples include -22 (increased procedural services), -50 (bilateral procedure), and -59 (distinct procedural service).

6. Explain the concept of unbundling and why it's problematic.

   • Answer: Unbundling is the practice of billing separately for individual components of a procedure that are normally included in a single code. It's problematic because it results in inflated billing and is considered fraudulent.

7. What is the role of the Official Coding Guidelines?

   • Answer: The Official Coding Guidelines provide instructions and conventions for using coding systems, ensuring consistent and accurate coding practices across healthcare providers.

8. Describe the process of auditing codes for accuracy.

   • Answer: Code auditing involves a systematic review of coded medical records to identify errors, inconsistencies, and areas for improvement. This process may involve comparing coded data to documentation, checking for compliance with coding guidelines, and using specialized audit software.

9. What are some common coding errors and how can they be avoided?

   • Answer: Common errors include misinterpretation of documentation, incorrect code selection, missing or incorrect modifiers, and upcoding/downcoding. Avoiding these requires careful review of documentation, thorough understanding of coding guidelines, and regular updates on coding changes.

10. Explain the importance of staying updated on coding changes.

    • Answer: Coding systems are regularly updated (e.g., annual ICD-10 updates). Staying current ensures compliance, accurate coding, and optimal reimbursement. Failure to stay updated can lead to rejected claims and financial penalties.

11. What is the difference between a principal diagnosis and a secondary diagnosis?

    • Answer: The principal diagnosis is the condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care. Secondary diagnoses are all other conditions that coexist at the time of admission, develop subsequently, or that affect the treatment received and the length of hospital stay.

12. How do you handle a situation where the medical documentation is unclear or incomplete?

    • Answer: When documentation is unclear or incomplete, I would first attempt to clarify the information by querying the physician or other relevant healthcare provider. If clarification is not possible, I would code to the highest degree of certainty based on the available information, documenting the uncertainty and the rationale for the code selection in my notes.

13. Explain the concept of "present on admission" (POA) indicators.

    • Answer: POA indicators are used in inpatient coding to indicate whether a diagnosis or condition was present at the time of admission to the hospital. This impacts reimbursement, particularly for Medicare, as conditions not present on admission may not be fully reimbursed.

14. What is the significance of compliance in medical coding?

    • Answer: Compliance in medical coding is crucial to avoid legal and financial penalties. It ensures adherence to all relevant laws, regulations, and coding guidelines, reducing the risk of audits, fines, and legal actions.

15. What resources do you use to stay current with coding updates and changes?

    • Answer: I regularly consult resources such as the AMA's CPT Assistant, the AHA's coding clinics, official coding guidelines from CMS and other payers, and professional coding journals and websites. I also participate in continuing education courses to maintain my CPC certification.

16. How do you handle challenging or complex medical cases?

    • Answer: I approach complex cases systematically. I thoroughly review all documentation, research the relevant codes and guidelines, consult with other coders or supervisors if needed, and document my coding rationale clearly. I may use coding resources, such as coding books and online databases, to guide my code selection.

17. Describe your experience with different types of healthcare settings (e.g., hospital, physician's office).

    • Answer: *(This answer should be tailored to the applicant's actual experience. If they have no experience, they should honestly state that and explain their understanding of the differences)*

18. What software or tools are you proficient in using for coding?

    • Answer: *(This answer should be tailored to the applicant's actual experience. Examples include various Electronic Health Record (EHR) systems, coding software, and claim submission portals.)*

19. Explain your understanding of the concept of medical necessity.

    • Answer: Medical necessity refers to whether a healthcare service or procedure is appropriate and necessary for a patient's medical condition based on current standards of medical practice. It’s a critical factor in determining if a claim will be reimbursed.

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