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.
For procedure coding, who is an established patient?
A patient who is seeing a different family practitioner in the same practice within three years
Place the steps in order for performing CPT coding for an evaluation and management code.
The first step for performing CPT coding for an evaluation and management code is to identify the place of service, and then identify the patient status. Then identify the subsection, category, or subcategory of service in the E/M section. Next, determine the level of service by determining the level of history obtained, the extent of the examination performed, and the complexity of medical decision making. If necessary, compare the medical documentation against examples in Appendix C. Then select the appropriate level of E/M service code and document it in the patient’s health record.
Which factors can contribute to the complexity of E/M procedure coding?
Counseling, Coordination of care and Nature of presenting problem
Place the steps in order for procedure coding for an office visit.
The first step for performing CPT coding for an office visit is to identify the place of service and then identify the patient status. Then identify the subsection, category, or subcategory of service in the E/M section. Next, determine the level of service by determining the level of history obtained, the extent of the examination performed, and the complexity of medical decision making. If necessary, compare the medical documentation against examples in Appendix C. Then select the appropriate level of E/M service code and document it in the patient’s health record.
Which items are used in the anesthesia CPT billing formula?
Time units, modifying units, base unit values
With which number do anesthesia codes begin?
0
Which type of sedation requires CPT-4 codes?
Unconscious
Which statement describes how the basic unit value is used in anesthesia coding?
A numeric value assigned to each service based on the level of complexity.
Board work:
What records are used for CPT coding?
Eponym:
in medical terms, a medical diagnosis or procedure named for the person who discovered it.
Alphabetical index:
Tabular index= 6 sections
What is the humerus?
Sections of the CPT book?
Elm
Radiology’
Pathology
-Drug testing
Anesthesia
Medicine
Surgery
Problem focus charge:
99212
Which code will bring in the most $$?
99215, 99205
Which code will bring in the most money between 99215 or 99205?
99215 b/c it’s an existing pt.
Being overcharged?
over coding
Being undercharged?
under coding
2 CPT:
1 labor code and 1 medicine code
