Ch 13 Test SG Flashcards
A category of the CPT manual
Located in the tabular list and arranged by sections
Each code as a description of the service for procedure performed
Category I codes
A category of the CPT manual
A set of supplemental tracking codes that providers use for performance management; 5th digit is F
Optional codes and are not reported as part of the insurance billing process
Located in appendix H And are listed in alphabetical order by condition
Category II Codes
A category of the CPT manual
Temporary codes assigned for emerging and new technology, services and procedures that have not been officially added to the Tabular list of the CPT manual.
These codes are intended to be used for data collection purposes, to substantiate widespread use, or as part of the approval process of the US FDA
5th digit is the letter T.
They have no reimbursement value and are listed in their own section of the CPT manual
Category III Codes
This can include any or all of the following:
- Encounter form
- history and physical reports
- progress notes
- discharge summary
- operative report
- pathology report
- anesthesia record
- radiology report
Types of medical documentation for CPT coding
These codes can only be used when no category I or Category III Code exactly matches the medical documentation
Use of this code results was a special report that must be sent with the insurance claim and describes the procedure or service in detail.
Unlisted procedures or services codes
These are two digit, alpha numeric codes that reports or indicate specific criteria, a specific condition, or a special circumstance.
They are used with CPT codes to indicate that a service or procedure performed was altered by specific circumstances
List is found in appendix A
Modifiers
A part of the CPT coding manual separated and organized by main terms; these terms represent the type of surgery, the anatomic site, or eponym
Alphabetic index
This part of the CPT manual is divided into six sections, with codes listed in numeric order in each section.
These codes include definitions, guidelines, notes, which enable the coder to select the most specific code based on the procedural statement and service descriptions documented in the health record
The Tabular List
The use of this type of punctuation indicates that modifying terms and descriptions follow.
;
Semicolon
A level of history
Concentrates on the chief complaint; it looks up the symptoms, severity, and duration of the problem it usually does not include a review of systems or the family and social history’s.
Problem -focused history
A level of history
Includes a review of systems that relate to the chief complaint usually the past, family, and social histories are not included.
Expanded problem focused history
A level of history
Consists of the chief complaint; extended history of present illness is; ROS that is directly related to the problem or problems identified in the history of the present illness, a review of a limited number of additional systems; and the pertinent past, family, and or social history is directly related to the patients problems.
Detailed history
A level of history
This includes the chief complaint; extended history of present illness; ROS that is directly related to the problem or problems identified in the history of the present illness plus a review of all additional body systems; and complete past, family, and social history.
Comprehensive history
A level of examination
Examination is limited to the single body area or single system mentioned in the chief complaint.
Problem focused examination
A level of examination
Includes limited body area or system and body areas or organ systems are examined
Expanded problem focused examination
