Chapter 47 Exam Flashcards
What does the American Medical Association have to do with coding?
- they are the ones who publish CPT codes
What are uses for procedure codes (3)?
- to justify medical services to insurance companies by correlating procedures to diagnosis
- to collect statistics about the outcome and effectiveness of treatment
- to help physicians and hospitals set fees based on the amount of time and skill required to provide a specific service
How often are new code books or computer code sets purchased by the medical office?-
Must purchase updated versions of code books/computer files containing all the codes used for insurance billing EVERY YEAR
What are modifiers?
-An addition to the procedure code that indicates unusual circumstances related to the procedure, such as more extensive procedure or two procedures performed in the same session
What is the format of most CPT codes?
5 character numeric codes
What is the Evaluation and Management section of the CPT manual?
- contains codes for office visits provided by primary care practioners and specialists. Cover service oriented parts of medical care.
What is it used for?
they are used to attempt to link reimbursement to the completeness of the examination and the amount of skill required to manage the patient’s problem(s).
What factors determine the level of service used in this section?
- the extent of the medical history
- the extent of the physical examination
- the complexity of decision making
Problem focused history
addresses chief complaint with a brief history of the illness/problem. Used for a straightforward problem.
Expanded problem focused history
addresses chief complaint, brief history of present illness/problem, and review of systems that have to do with chief complaint. Used for more complicated problem or single diagnosis w/more than one body system involved.
Detailed history
addresses chief complaint , extended history of present illness, and review of body systems (beyond relating to chief complaint), and family history as it relates to present problem. Used w/ more complicated medical problems or multiple.
Comprehensive history
Chief complaint, extended history of present illness, a review of all body systems, complete family history. Used when patient has severe, acute medical condition or serious changes in a long-term condition.
Straightforward complexity
minimal diagnosis, minimal complexity, minimal risk of complications
Low complexity
limited number of diagnosis, limited complexity, low risk of complications
Moderate complexity
multiple diagnoses, moderate complexity, moderate risk of complications
High complexity
extensive diagnoses, extensive complexity, high risk of complications
What defines an established patient?
-one who has been seen in the previous 3 years
What type of anesthesia that does not receive a separate code?
Local anesthesia by infiltration
In anesthesia, what do standard modifiers indicate?
Used throughout the CPT code manual
What do physical status modifiers indicate?
The patient’s condition at the time the anesthesia was administered
In relation to anesthesia, what is included in the code for a surgery?
local or topical anesthesia or a digital nerve block
What diagnostic tests are included in the Radiology section of the CPT manual?
- Plain x-ray films
- computed tomography (CT or CAT)
- magnetic resonance imaging (MRI)
- magnetic resonance angiography (MRA)
- standard angiography
What is a panel in diagnostic testing?
-a group of laboratory tests, usually ordered together for diagnosis or screening, such as a cardiac panel
Which types of specimens can the office charge for collection even if the specimen is sent to a laboratory for testing?
Pathology testing, such as PAP tests or biopsies
What does HCPCS stand for?
Healthcare common procedure coding system
level II HCPCS codes…..
five-digit alphanumeric coding system and designates specific services and equipment. Primarily used for items/services that do not have level 1 codes.
What does ICD-9-CM stand for?
International Classification of Disease, 9th Revision, Clinical Modification
What does ICD-10-CM stand for?
International Classification of Disease, 10th Revision, Clinical Modification
Why were diagnosis codes originally developed?
Fulfill 4 purposes:
-track disease processes, classify causes of death, collect data for medical research, and evaluate hospital service utilization
What does the WHO have to do with ICD codes?
published the first edition of the International Classification of Diseases, which assigned numbers to specific diseases and has revised it several times since 1948
What do E and M codes stand for?
-Evaluation and management codes
What are V codes?
Codes that begin with the letter V
-Identify factors influencing health status or an encounter with health services when there is no disease or injury, such as to receive an immunization.
when are v codes used?
Used primarily for physical exams, well baby and well-child visits, and visits during pregnancy
What does NOS stand for?
not otherwise specified
what does NOS mean with respect to codes?
it is used when there is not enough information given to select a more specific code
What does NEC stand for?
-not elsewhere classified
what does NEC mean in respect to codes?
it is used when a more specific code for the condition is not available
what is upcoding?
Using a code to 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.
what is downcoding?
Codes do not reflect a high enough level of service, resulting in lower levels of reimbursement than are justified
