Chapter 25: Procedural and Diagnostic Coding Flashcards
Add-on codes
a code that is always assigned in addition to the primary procedure or service; codes are designated with the + symbol and are found in Appendix D of the CPT code book; they are never reported as a stand-alone code
Alphabetic index
the index arranged in alphabetic order by disease (specific illness, injury, eponym abbreviation, or other descriptive diagnostic term); includes diagnostic terms for other reasons for the encounter.
bundle
to “bundle” is the arbitrary practice of some insurance carriers to group codes together, by which they either ignore additional codes reported on a claim and reimburse one of the lesser codes, or they ignore modifiers through edits built into their claims processing system
bundled code
any code that includes more than one procedure in its description
category
the first three characters of an ICD-10-CM code designate the category of the diagnosis
combination code
a single code used to classify (a) two diagnoses; (b) a diagnosis with an associated secondary process (manifestation); (c) a diagnosis with an associated complication
comorbidity
a condition that exists along with the primary diagnosis of a patient
concurrent care
when similar care is being provided to a patient by more than one provider
consultation
when a patient visits with another provider at the request of the health care provider
contributory factors
additional components that can be considered when selecting an evaluation and management code: time, nature of presenting problem, counseling, and coordination of care
conventions
a list of abbreviations, punctuations, symbols, typefaces, and instructional notes; provide guidelines for using the code set
coordination of care
defined as the time a licensed provider spends coordinating patient care with other health care agencies, for example, home care or nursing home care
critical care
when constant bedside attention is required to a patient who is critically ill or unstable
cross-reference
referencing from one part of the code book to another part containing related information (e.g., cross-referencing from the index to the Tabular List)
Current Procedural Terminology (CPT)
a numerical listing of procedures performed in medical practice; a standardized identification of procedures. Published by the American Medical Association
diagnosis
the reason the patient is receiving care; the identification of the illness or problem by the provider upon examination of the patient
downcoding
a practice of third-party payers in which the benefits code has been changed to a less complex or lower-cost procedure than was reported; another payer practice in which a reported evaluation and management service is reduced to a lower level based strictly on the diagnosis code required
E/M codes
CPT codes relating to the evaluation and management of the patient; related to medical services as opposed to surgical services
established patient
patient who has received professional services from a provider of the exact same specialty and subspecialty who belongs to the same group practice, within the past three years
global period
the period of time that is covered for follow-up care
HCPCS Level II codes
codes that identify products, supplies, and services not included in CPT
Healthcare Common Procedure Coding System (HCPCS)
The HCPCS is compromised of two levels: Level I: Current Procedural Terminology (CPT) codes; and Level II: National codes. The National codes are approved and maintained jointly by the Centers for Medicare and Medicaid Services (CMS), the Health Insurance Association of America, and the Blue Cross Blue Shield Association. Health care professionals such as dentists, orthodontists, and some technical support services such as ambulance services cannot report their services with CPT codes because there are no codes in that coding system that properly report them. Thus, HCPCS Level II codes were developed to identify products and supplies for which there are no CPT codes.
index
located at the end of the CPT manual; terms listed in alphabetic order with categories and subcategories listed along with code range.
International Classification of Disease (ICD)
a comprehensive listing of diseases and disorders of the human body. Effective October 1, 2015, ICD-9 was replaced with ICD-10. ICD-10-CM codes describe the disease or condition presented by the patient; use of these codes establishes the medical necessity for the services and procedures provided to the patient.
key components
the major factors to be considered when selecting an evaluation and management code: history, exam, medical decision making.
laterality
specifying whether the condition occurs on the left, right, or bilaterally
modifiers
coding markers that inform third-party payers that circumstances for that particular code have been altered
morbidity
the frequency of the appearance of complications following a surgical procedure or other treatment
mortality
a fatal outcome
new patient
for CPT purposes, a patient who has not received services from the provider within the past three years
panel
an organ or disease-oriented laboratory procedure frequently ordered together
primary diagnosis
the main reason a patient is seen or cared for during an encounter (synonymous with principal diagnosis).
principal diagnosis
the main reason for the patient’s visit (synonymous with primary diagnosis)
procedure code
code that represents a medical procedure such as a surgery or diagnostic tests, and medical services, such as evaluating a patient’s condition by physical examination; often used interchangeably with CPT
reimbursement
to pay back or compensate for money spent, or losses or damages incurred; payment for provider services (from insurance company)
secondary diagnosis
diagnosis is other than the primary diagnosis for other conditions affecting a patient during the same visit and the principal diagnosis
sequela
a pathological condition resulting from prior injury, disease, or attack
sequences
order of succession
specificity
something specially suited for a given use or purpose; a remedy regarded as a certain cure for a particular disease; detailed, providing more specifics
subcategories
either four of five characters (ICD-10-CM) and includes either letters or numbers; codes may be from three to seven characters in length; each level of subdivision after a category is a subcategory.
surgical package
procedures found in CPT that may include preoperative exam and testing, the surgical procedure itself (including local or regional anesthesia if used), and routine follow-up care for a set period of time
Tabular List
when the code description is located in the Alphabetic Index, the code or codes should be verified by looking in the Tabular List (alphanumeric order); contains categories, subcategories, and valid codes; in ICD-10-CM a sequential, alphanumeric list of codes divided into chapters based on the body system or condition.
unbundling
reporting multiple codes for a service when there is one code that will report the entire service; reporting multiple procedure codes for services when only one code is appropriate; is considered fraudulent billing and could result in stiff penalties and fines if found to have been done intentionally
upcoding
reporting a higher-level code than is appropriate for the service that was rendered, resulting in higher reimbursement; when a facility coder assigns a diagnosis code that does not match patient documentation, with the intention of increasing reimbursement to the facility through the DRG system, serious penalties and fines will be levied against the facility for submitting fraudulent claims
World Health Organization’s (WHO)
established in 1948, an agency of the United Nations concerned with health on an international level; monitors disease outbreaks and assesses health system performance around the world
