Chapter 29- Procedural Coding Basics Flashcards
Lesson #1:
Which statements describe how the tabular index of the CPT manual is organized?
- Sections are subdivided into subsections.
- Subsections are subdivided into categories.
- Categories are subdivided into subcategories.
How is the subsection within the tabular index of the CPT manual formatted?
Below the section and indented two spaces.
In which order are the codes within the tabular index of the CPT manual organized?
Numeric order within each section
What do the terms used in the alphabetic index of the CPT manual represent?
Eponym, Diagnosis, Anatomic Site
What does the alphabetic index of the CPT manual list instead of page numbers?
Code or code ranges.
Which is true regarding the alphabetic index of the CPT manual?
The “see” statement points to another location in the alphabetic index to find the code or code range.
When extracting data from medical documentation, what must providers do?
Assign the CPT code with the description that most closely resembles the medical document.
Which documents can be used to extract data for procedural coding?
Progress notes
Encounter form
Radiology report
Operative report
When reviewing medical documentation for procedural coding, which statement best describes the order in which coding occurs?
The patient’s health record is analyzed, and then the CPT code is assigned.
Place the steps in order for CPT coding for a surgery.
The first step for CPT coding for a surgery is to abstract the procedure/services from the procedural statement in the surgical report and determine the main term. Once the main term is determined, it must be located in the alphabetic index. Select any modifying terms, if required. Once a code has been determined from the alphabetic index, write it down. Locate the code in the tabular index and compare the code with the procedural statement. Read the coding guidelines to ensure that the code may be used and there are no contradictions. Next, determine if any add-on codes, modifiers, and/or special reports are needed. The last step is to record the CPT code selected on the health record documentation and on the insurance claim form.
Place the steps in order for using the CPT alphabetic index when coding for procedures.
The first step in using the CPT alphabetic index is to abstract the procedures and/or services performed from the medical documentation and determine the main and modifying terms. Select the most appropriate main term and begin searching the alphabetic index. If the main term does not produce a code, then use a different main term. Once the main term has been located, select one or more modifying terms, if needed. Finally, find the code or code range that includes all or most of the description of the procedure or service found in the medical record.
Place the steps in order for using the CPT tabular index when coding for procedures.
The first step for using the CPT tabular index is to turn to the main text and find the first code or code range from the alphabetic index search. Next, compare the description of the code with the medical documentation, ensuring that the code description matches the documentation. Once everything matches, then read the guidelines and notes for the section and subsection to ensure that there are no contraindications to using the code, then evaluate the conventions, add-on codes, and modifier-51 exempt. Then determine the need to use a modifier or special report. The last step is to record the selected CPT code in the health record documentation next to the procedure or service and on the insurance claim form.
What places of services for patient care are identified most frequently when coding procedures?
Office and hospital
Match the code with the corresponding name for places of service in procedure coding.
For procedure coding, who is considered a new patient?
A patient who has not received any services from the provider within the past three years.
