Ch. 6: CPT/HCPCS

Question 1

What are category 1 codes in CPT?

Answer 1

• most commonly performed procedures and services.
• five-digit numeric codes
• these are the codes in the six main sections of CPT.
• when coders refer to CPT, they usually mean the Category I codes

Question 2

what are category II codes?

Answer 2

• track the quality of care, helping collect performance measurements, used for research
• five-character alphanumeric codes, with four numbers followed by the letter “F” for “facilitate”
• optional
• you can’t substitute Category II codes for Category I codes

Question 3

what are category III codes?

Answer 3

• temporary codes for new and emerging technology
• five-character alphanumeric codes, with four numbers followed by the letter “T” (Think of “T” for “temporary.”)
• if they don’t become Category I codes, they’ll be retired.

Question 4

What are the 4 categories of the “main term”?

Answer 4

1. Procedure or service
2. Organ or anatomic site
3. Condition
4. Eponyms, and abbreviations

Question 5

Bullet (•)

Answer 5

alerts you to new code or addition

Question 6

Triangle (▴)

Answer 6

signifies a change in a code’s description; see Appendix B

Question 7

Facing triangles (▶text◀)

Answer 7

indicate new/revised CPT section guideline information as well as changed descriptions

Question 8

Plus sign (+)

Answer 8

means an add-on code that you must use with the related procedure code; see Appendix D

Question 9

Circle (∘)

Answer 9

indicates a recycled/reinstated code

Question 10

Circled Bullet (⊙)

Answer 10

signifies moderate (conscious) sedation; see Appendix G

Question 11

Universal No Code (∅ or ⦰)

Answer 11

alerts you to codes you can’t use with modifier -51; see Appendix E

Question 12

Flash Symbol

Answer 12

identifies products pending FDA approval; see Appendix K

Question 13

Number Symbol (#)

Answer 13

indicates codes out of numeric order; see Appendix N

Question 14

What are the 3 key components of the E/M that are required for most E/M codes?

Answer 14

history
examination
medical decision making

Question 15

In the history component what do the following stand far? CC, HPI, ROS

Answer 15

CC-chief complaint
HPI-history of present illness
ROS-review of systems

Question 16

What are the 4 levels of both history and examination?

Answer 16

1. problem focused
2. expanded problem focused
3. detailed
4. comprehensive

Question 17

Go through each of the 4 levels in regards to the history component

Answer 17

1. problem focused
   Chief Complaint (CC)
   Brief History of Present Illness (HPI)
2. expanded problem focused
   CC
   HPI (brief)
   Problem-related review of systems (ROS)3

3.  detailed
CC
HPI (Extended)
Extended ROS
Pertinent Past, Family, Social History

4. comprehensive
CC
HPI (Extended)
Complete ROS
Complete Past, Family, Social History

Question 18

Go through each of the 4 levels in regards to the examination component

Answer 18

1. problem focused
   - Limited exam of affected body area/organ system
   - Document result of assessing 1-5 structures/functions of affected part
2. expanded problem focused
   - Limited exam of affected body area/organ system and related systems
   - Document result of assessing at least 6 structures/functions of affected parts
3. detailed
   - Extended exam of affected body areas and related organ systems
   - Document results of assessing at least 2 structures/functions in 6 organ systems—or 12 structures/functions in 2+ organ systems
4. comprehensive
   - General, multisystem exam
   - Document results of assessing at least 2 structures/functions in 9 organ systems—or all structures/functions in affected organ system, plus at least 1 structure/function of remaining organ systems

Question 19

What are the 4 levels of medical decision making (MDM)? Describe each.

Answer 19

1. Straightforward
   - Diagnosis of a self-limited problem
   - Minimal risk of complications
   - Minimal amount of clinical data to review
2. Low complexity
   - 2+ self-limited problems, stable chronic condition, or acute uncomplicated illness/injury
   - Low risk for complications
   - Limited amount of clinical data to review
3. Moderate complexity
   - Multiple problems/diagnoses, chronic illnesses w/mild progression, uncertain new diagnoses requiring additional tests, or acute illness affecting several body systems
   - Moderate risk for complications
   - Moderate amount of clinical data to review
4. High-complexity
   - Extensive problems/diagnoses, chronic illness w/severe progression, or life-threatening illness/injury (acute or chronic)
   - High risk for complications or death
   - Extensive amounts of clinical data to review
   - May result in major surgery, poor prognosis

Question 20

What is included in Pre-Op within a surgical package?

Answer 20

• After doctor and patient decide on surgery, the doctor can do one related E/M encounter (history and physical) on the date immediately prior to or on the date of the procedure.
• Local infiltration
• Metacarpal/metatarsal/digital block
• Topical anesthesia

Question 21

What is included in Intraoperative within a surgical package?

Answer 21

Actual performance of the surgical procedure

Question 22

What is included in Post-Op within a surgical package?

Answer 22

• Immediate post-op care (post-op notes, dictation, talking with the family or other physicians)
• Writing orders
• Evaluating the patient in the post-anesthesia care unit (PACU)
• Other typical uncomplicated post-operative follow-up care

Question 23

What is a surgical package called in Medicare?

Answer 23

global surgical package

Question 24

What is another name for HCPCS level II codes?

Answer 24

HCPCS national codes

Question 25

What does SOAP stand for?

Answer 25

Subjective Objective Assessment Plan