Chapter 6 - Intro to CPT, Surgery Guidelines, HCPCS & Modifiers Flashcards
Add-on Code
CPT® code used to report a supplemental or additional procedure appended to a primary procedure (stand-alone) code. Add-on codes are recognized by the CPT® symbol + used throughout the CPT® code book.
The Centers for Medicare & Medicaid Services (CMS)
Agency within the United States Department of Health and Human Services that administers the Medicare program and works in partnership with state governments to administer Medicaid and State Children’s Health Insurance Programs.
Current Procedural Terminology (CPT®)
A code set copyrighted and maintained by the American Medical Association (AMA).
Diagnosis Pointer Field
A field on the medical claim form (CMS 1500) that relates the line item to the diagnosis on the base claim.
Global Package
The period (0–90 days as determined by the health plan) and services provided for a surgery inclusive of preoperative visits, intraoperative services, post-surgical complications, postoperative visits, post-surgical pain management by the surgeon, and several miscellaneous services as defined by the health plan, regardless of setting (for example, in a hospital, an ambulatory surgical center (AMC), or physician office).
Global Surgery Status Indicator
An assigned indicator, which determines classification for a minor or major surgery, based on RVU calculations.
Healthcare Common Procedure Coding System (HCPCS) Level II
HCPCS Level II is the national procedure code set for healthcare practitioners, providers, and medical equipment suppliers when filing insurance claims for medical devices, medications, transportation services, and other items and services.
Locum Tenens
Substitute physician who takes over the professional practice of a physician who is absent for reasons such as illness, pregnancy, vacation, or continuing medical education. When a locum tenens fills in, the regular physician submits the claim with modifier Q6 appended to the services.
Major Surgery
Surgeries classified as major have a global surgical period that includes the day before the surgery, the day of surgery, and any related follow-up visits with/by the physician 90 days after the procedure.
Minor Surgery
Surgeries classified as minor have a global surgical period that includes the preoperative service the day of surgery, surgery, and any related follow-up visits with/by the physician 0–10 days after the surgery.
National Correct Coding Initiative (NCCI)
Used by professional coder to determine codes considered by CMS to be bundled codes for procedures and services deemed necessary to accomplish a major procedure. This is to promote correct coding methodologies and to control improper assignment of codes that results in inappropriate reimbursement.
Resource-Based Relative Value Scale (RBRVS)
Physician payment schedule established by Medicare.
Relative Value Units (RVU)
CMS reimburses physicians for Medicare services using a national payment schedule based upon the resources used in furnishing physician services. RVUs are configured using work based on specialties, practice expense, and physician liability insurance.
