clinical coder Interview Questions and Answers

1. What is the difference between ICD-10 and ICD-9 coding?

   • Answer: ICD-10 is a more detailed and specific coding system than ICD-9. It uses alphanumeric codes with more characters, allowing for a greater number of diagnoses and procedures to be coded. ICD-10 also incorporates laterality (left/right) and etiology (cause) in its coding structure, offering a higher level of specificity and improved data analysis capabilities. ICD-9 used a simpler, less detailed numeric coding system. This improved specificity in ICD-10 leads to better tracking of diseases and improved healthcare analytics.

2. Explain the concept of medical necessity.

   • Answer: Medical necessity refers to whether a service or procedure is appropriate and necessary for the diagnosis or treatment of a patient's condition. It's based on evidence-based medicine, standards of care, and the patient's individual circumstances. Services must be reasonable and necessary to improve the patient's health or prevent further complications. Unnecessary services are not covered by insurance.

3. What are some common coding compliance challenges?

   • Answer: Common challenges include staying updated with coding changes (ICD-10 updates, CPT changes), ensuring accurate code selection, managing upcoding and downcoding, handling incomplete or unclear documentation from physicians, understanding payer-specific guidelines, and preventing fraud and abuse.

4. Describe your experience with electronic health records (EHRs).

   • Answer: [This requires a personalized answer based on the candidate's experience. Example: "I have extensive experience with Epic, Cerner, and Meditech EHR systems. I am proficient in using their coding functionalities, querying the systems for patient data, and identifying relevant information for accurate coding. I understand the importance of data integrity within the EHR and adhere to strict data privacy regulations."]

5. How do you handle conflicting information in medical records?

   • Answer: When conflicting information exists, I carefully review all documentation to understand the context and identify the most accurate and reliable information. I may query the physician for clarification if necessary. My approach prioritizes using the most complete and consistent information available, documenting my query and resolution process.

6. Explain the importance of proper documentation in medical coding.

   • Answer: Proper documentation is crucial because it provides the basis for accurate coding. Without clear and complete documentation, it's impossible to assign the correct codes, potentially leading to inaccurate reimbursement, delayed payments, compliance issues, and poor quality of care reporting. The documentation must support the codes assigned.

7. What are CPT codes?

   • Answer: CPT (Current Procedural Terminology) codes are a set of medical codes used to report medical, surgical, and diagnostic procedures and services performed by physicians and other healthcare providers. They're essential for billing and reimbursement purposes.

8. What are HCPCS codes?

   • Answer: HCPCS (Healthcare Common Procedure Coding System) codes are used to report supplies, products, and services that aren't covered by CPT codes. Level I HCPCS codes are identical to CPT codes, while Level II codes are alphanumeric and cover things like medical supplies, ambulance services, and durable medical equipment.

9. What is the difference between principal diagnosis and 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 other conditions that coexist at the time of admission, develop during the stay, or affect the care received.

10. How do you stay updated on coding changes and guidelines?

    • Answer: I stay current through continuous professional development, including attending webinars and conferences, subscribing to industry journals and newsletters (like those from AHIMA), and participating in online learning platforms focused on medical coding. I also utilize official resources from organizations such as the AMA and CMS.

11. What is your experience with auditing medical records?

    • Answer: [Personalize this answer based on experience. Example: "I have experience in auditing medical records to ensure coding accuracy and compliance with regulations. I'm familiar with various auditing techniques and software and can identify areas where documentation or coding may need improvement."]

12. Describe your knowledge of HIPAA regulations.

    • Answer: I understand HIPAA's importance in protecting patient health information (PHI). I'm familiar with the Privacy Rule, Security Rule, and Breach Notification Rule. I know the importance of confidentiality and adhering to strict procedures to protect patient data.

13. How do you handle a high volume of charts?

    • Answer: I prioritize charts based on urgency and deadlines. I use efficient workflows, time management techniques, and prioritization methods to manage large workloads effectively. I also focus on maintaining accuracy while working quickly.

14. Explain your understanding of Outpatient Coding guidelines.

    • Answer: Outpatient coding involves assigning ICD-10 codes for diagnoses and CPT/HCPCS codes for procedures. It differs from inpatient coding in that it focuses on the reason for the visit rather than the reason for admission. I'm familiar with E/M coding guidelines in the outpatient setting and understand the differences in documentation requirements.

15. How do you handle pressure and meet deadlines?

    • Answer: I manage pressure by prioritizing tasks, breaking down large projects into smaller, manageable steps, and utilizing time management techniques. I'm proactive in communicating potential delays and work collaboratively to meet deadlines.

16. What software and tools do you use for medical coding?

    • Answer: [List specific software and tools. Example: "I am proficient in using various coding software such as 3M 360 EnCoder, Codify, and AAPC's official coding resources. I also utilize Microsoft Office Suite for documentation and data analysis."]

17. Explain your understanding of E/M coding.

    • Answer: E/M (Evaluation and Management) coding involves assigning codes based on the physician's documentation of the patient's history, physical examination, medical decision-making, and level of effort. I understand the different levels of E/M codes and the documentation requirements for each level.

18. What is your experience with quality assurance and improvement in medical coding?

    • Answer: [Personalize this answer. Example: "I've participated in quality assurance reviews, identifying areas for improvement in coding accuracy and efficiency. I am familiar with various quality metrics and actively seek ways to improve my coding performance."]

19. How do you handle denials and appeals?

    • Answer: When denials occur, I analyze the reason for the denial and identify the necessary steps for appeal. I thoroughly review the documentation and coding to ensure accuracy and identify any missing information. I then prepare and submit a well-supported appeal, following the payer's guidelines.

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