CH # 47: Medical Coding Flashcards
A patient who has been seen by 1 of the physicians in the practice in the same speciality w/in the last 3 years
Established patient
A patient who has been formally admitted 2 a healthcare facility
Inpatient
Healthcare that is reasonable and necessary 4 a patient based on evidence-based clinical standards of care
Medical necessity
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
Modifiers and 2-digit modifiers
The study of function and form
Morphology
A diagnosis code that is not elsewhere classified. It is used when a more specific code 4 the condition is not available
NEC
Not Elsewhere Classifiable
Abnormal growth or tumor
Neoplasm
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
New patient
A diagnosis code that is not otherwise specified. It is used when there is not enough information given 2 select a more specific code
NOS
Not Otherwise Specified
A patient who has not been admitted 2 a healthcare facility
Outpatient
A group of diagnostic tests done in 1 machine all at the same time
Panel
Any condition the results from disease, injury or treatment 4 a disease or injury
Sequela
Surgical services covered by a single procedure code that includes a preoperative visit, postoperative care and local anesthesia(if applicable)
Surgical package
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
Upcoding
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
HCPCS level 2 procedure codes
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
CPT category 2 codes
1st publisher of codes in 1869 and called it the American Nomenclature of Disease
This book was a dictionary of diseases
AMA
American Medical Association
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
CPT codes
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
Evaluation and management
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
Levels of service
-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
Secondary factors 4 choosing an E/M code
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
Anesthesia codes
2 types:
-standard: those used throughout the CPT manual
-physical status: indicates the patient’s condition at the time
medication was administered
Anesthesia modifiers
