CH # 47: Medical Coding

Question 1

A patient who has been seen by 1 of the physicians in the practice in the same speciality w/in the last 3 years

Answer 1

Established patient

Question 2

A patient who has been formally admitted 2 a healthcare facility

Answer 2

Inpatient

Question 3

Healthcare that is reasonable and necessary 4 a patient based on evidence-based clinical standards of care

Answer 3

Medical necessity

Question 4

An addition 2 a Current Procedural Terminology(CPT) code that indicates unusual circumstances related 2 the procedure(s)

All codes r listed in Appendix A and is added 2 the main code after a hyphen

Answer 4

Modifiers and 2-digit modifiers

Question 5

The study of function and form

Answer 5

Morphology

Question 6

A diagnosis code that is not elsewhere classified. It is used when a more specific code 4 the condition is not available

Answer 6

NEC

Not Elsewhere Classifiable

Question 7

Abnormal growth or tumor

Answer 7

Neoplasm

Question 8

4 billing purposes, a patient who has not received services during the previous 3 years from a physician in a medical practice in the same speciality

Answer 8

New patient

Question 9

A diagnosis code that is not otherwise specified. It is used when there is not enough information given 2 select a more specific code

Answer 9

NOS

Not Otherwise Specified

Question 10

A patient who has not been admitted 2 a healthcare facility

Answer 10

Outpatient

Question 11

A group of diagnostic tests done in 1 machine all at the same time

Answer 11

Panel

Question 12

Any condition the results from disease, injury or treatment 4 a disease or injury

Answer 12

Sequela

Question 13

Surgical services covered by a single procedure code that includes a preoperative visit, postoperative care and local anesthesia(if applicable)

Answer 13

Surgical package

Question 14

Using a code 2 obtain a higher level of reimbursement than is justified by medical procedures performed as documented in the medical record. This can result in serious fines and penalties

Answer 14

Upcoding

Question 15

HCPCS codes(95%-98%) r used 4 Medicare Part B) include the current CPT codes which r updated annually by the AMA. All medical offices must buy an updated book every year

Used primarily 4 items and services that do not have Level I (CPT) codes. Also includes additional HCPCS codes 4 procedures, injections and durable medical equipment not covered by Medicare Part B that r not included in the CPT system. There used 2 b Medicaid codes but have been phased out

Answer 15

HCPCS level 2 procedure codes

Question 16

Optional codes that may b used 2 track performance but not reported 2 insurance carriers

Last character of the codes is always “F” instead of a digit

Found after the 6 main sections of the CPT

Codes r updated twice a year and can b found on the AMA website

Answer 16

CPT category 2 codes

Question 17

1st publisher of codes in 1869 and called it the American Nomenclature of Disease

This book was a dictionary of diseases

Answer 17

AMA

American Medical Association

Question 18

This book contains codes and provides a narrative description and a 5 digit code 4 each procedure or service or physician or other licensed provider may perform 4 a patient

These codes r used 4 billing purposes

Last digit of code indications:
0: anesthia
1-6: surgeries
1: surgeries 4 skin
2: surgeries 4 musclear/skeletal system
3: surgeries 4 respiratory and cardiovascular systems
4: surgeries 4 digestion system
5: surgeries 4 urinary/ reproductive system
6: surgeries 4 endocrine system, nervous system, some opthamology,
auditory system
7: radiology/nuclear medicine
8: pathology, well woman examination
9: medicine section, psychiatry, dialasis, gastrointerology,
ophthalmology

Answer 18

CPT codes

Question 19

These codes cover the service-oriented part of medical care. They attempt 2 link reimbursement 2 the completeness of the examination and the amount of skill required 2 manage the patient’s problems causing the physician 2 limit time w/patients

Factors when determining the proper code

1) establish patient or new patient, inpatient or outpatient
2) location of service, primary or consultant
3) level of service

Answer 19

Evaluation and management

Question 20

Depends on 3 key factors:
1) extent of medical history: number of body systems
discussed
2) extent of the physical examination: number of body systems
examined
3) complexity of medical decision making

Answer 20

Levels of service

Question 21

-coordination of care(time spent arranging other services 4  
  the patient)
-counseling
-the nature of the patients proble
-the amount of time spent w/the patient

Answer 21

Secondary factors 4 choosing an E/M code

Question 22

These codes r included w/the procedure and is not given a separate code

Steps 4 choosing CPT codes

1) anatomic region affected
2) type of procedure

Reimbursed services r based on a formula: B+T+M

Answer 22

Anesthesia codes

Question 23

2 types:
-standard: those used throughout the CPT manual
-physical status: indicates the patient’s condition at the time
medication was administered

Answer 23

Anesthesia modifiers