Medical Coding — ICD-10-PCS, Compliance & Reimbursement flashcards
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ICD-10-PCS structure, root operations, body part, approach and device rules (FY 2027), then HIPAA, the False Claims Act, Anti-Kickback and Stark laws, NCCI edits, ABNs, NCDs and LCDs, MS-DRGs, APCs, RBRVS, claim forms, the NPI and compliant queries.
Learn deck · part of Medical coding: AAPC CPC and AHIMA CCA · written against: ICD-10-CM Official Guidelines and code set FY 2027 (effective 1 October 2026); CPT structure and E/M guidelines described in our own words; HCPCS Level II, NCCI and ICD-10-PCS per CMS. Updated 2026-10-10.
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In which setting is ICD-10-PCS the required procedure code set?Hospital inpatient procedures.ICD-10-PCS › Structure and Conventions
Physicians, hospital outpatient departments and other settings report procedures with CPT and HCPCS instead. -
How many characters does an ICD-10-PCS code have, and which values may each character take?Seven characters, each a digit 0–9 or a letter other than I and O, for 34 possible values.ICD-10-PCS › Structure and Conventions
I and O are left out because they are easily confused with 1 and 0 (Guideline A2). -
In the Medical and Surgical section, what does each of the seven characters stand for?Section, body system, root operation, body part, approach, device and qualifier.ICD-10-PCS › Structure and Conventions
The meaning of a value depends on its position and on the values before it (Guidelines A1 and A4). -
Which first character marks the Medical and Surgical section, and which marks New Technology?0 for Medical and Surgical; X for New Technology.ICD-10-PCS › Structure and Conventions
Other sections include 1 Obstetrics, 3 Administration, B Imaging and D Radiation Therapy. -
Must the ICD-10-PCS Index be consulted before building a code?No: a valid code may be chosen directly from the Tables.ICD-10-PCS › Structure and Conventions
The Index only points to a Table, and the Table must always be used to complete the code (Guidelines A6–A7). -
Which three kinds of organizations are HIPAA covered entities?Health plans, health care clearinghouses, and health care providers that transmit health information electronically in standard transactions.Compliance and Reimbursement › HIPAA
Business associates that handle PHI for them are bound through business associate agreements. -
Which HIPAA code sets report diagnoses and inpatient hospital procedures?ICD-10-CM for diagnoses in all settings, and ICD-10-PCS for inpatient hospital procedures.Compliance and Reimbursement › HIPAA
CPT and HCPCS cover physician and other services, CDT dental services, and NDC drugs in retail pharmacy transactions. -
Which X12 transactions carry a professional claim and an institutional claim?The 837P for professional claims and the 837I for institutional claims.Compliance and Reimbursement › HIPAA
The 835 is the electronic remittance advice that explains how the claim was paid. -
What are the X12 270/271 and 276/277 transactions?270/271: eligibility and benefit inquiry and response; 276/277: claim status inquiry and response.Compliance and Reimbursement › HIPAA
The 278 carries referral and prior authorization requests. -
Does HIPAA's minimum necessary standard apply when a physician shares PHI with another provider for treatment?No: disclosures for treatment are exempt, as are disclosures to the patient and those made with the patient's authorization.Compliance and Reimbursement › HIPAA
It does apply to most payment and operations uses, such as giving records to an auditor.
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About these cards
Review status: Second-reader reviewed, with corrections applied.
Checked against:
- ICD-10-PCS items checked against the ICD-10-PCS Official Guidelines for Coding and Reporting 2027 and the FY 2027 code tables and definitions (CMS, public domain).
- NCCI, ABN, coverage and payment items checked against the Medicare NCCI Policy Manual (2026) and other CMS publications (public domain). No yearly-changing payment amounts are given.
- CPT® is a registered trademark of the American Medical Association. No CPT descriptors are reproduced.
- CPC® is a registered trademark of AAPC, and CCA is a credential of AHIMA; neither is affiliated with, or endorses, this product.
These are independent study notes written for Willys. They are not official exam material, may contain mistakes, and are no substitute for your course, your teacher or the exam owner's own publications. Found an error? Tell us — corrections ship as a new version of the deck.
Not coding, billing or compliance advice. These cards prepare you for a certification exam. Code sets change every year, so code real claims from the current ICD-10-CM, CPT® and HCPCS books and your payers' policies. No CPT descriptors are reproduced here.
CPT® is a registered trademark of the American Medical Association; no CPT descriptors are reproduced. CPC® is a registered trademark of AAPC, and CCA is a credential of AHIMA; neither is affiliated with, or endorses, this product.
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