chapter 7 cpt coding Flashcards
care plan oversight services
cover the providers time supervising a complex and multidisciplinary care treatment program for a specific patient who is under the care of a home health agency hospice or nursing facility
case managemnt services
process by which an attending physician coordinates and supervise care provided to a patient by other providers
category 1 codes
procedurze service identified by a five digit cpt code and descriptor nomenclature these code are traditionally associated with cpt and organized within six sections
category II codes
optional evidence based performance measurement tracking codes that are assigned an alphanumeric identifier with a letter in the last field
category III codes
temporary codes for data collection purposes that are assigned an alphanumeric identifier with a letter in t he last field
comprehensive assessment
must include an assessment ofthe patients functional capacity identification of potential problems and a nursing plan to enhance or at least maintain the patients physical and psychosocial functions
concurrent care
provision of similar services such as hosptial inpatient visits to the same patient by more than one provider on the same day
consultation
examination of a patient by a health care provider usually a specialist for purpose of advising the referring or attending physician in the evaluation and or management of a specific problem with a know diagnosis
contributory components
include conseling coordination of care nature of presenting problem and time
coordination of care
provider makes arrangements with other providers or agencies for services to be provided to apatient
counseling
discussion with a patient and or family concerning one or more of the following areas diagnostic results impression and or recommended diagnostic studies prognosis risk and benefits of management options instructions for management and or follow up importance of compliance with chosen management options risk factor reduction and patient and family education
boldface type
highlights main terms in the cpt index and categories subcategories headings and code numbers in the cpt manual
cross reference terms see, see also
direct coders to a different cpt index entry because no code are found under the original entry
descriptive qualifier
terms that clarify assignment of a cpt code
guidelines
define terms and explain the assignment of codes for procedures and services located in a particular section
inferred words
used to save space in the cpt index when referencing subterms
instructional notes
appear throughout cpt sections to clarify the assignment of codes
italicized type
used for teh cross reference term
bullet symbol
bullet located to the left of a code number identifies new cpt procedures and services
triangle symbol
triangle located to teh left of a code number identifies a revised code description
horizontal triangles symbol
surround revised guidelines and notes this symbol is not used for revied code description
semicolon
saves space in cpt so that some code descriptions are not printed in their entirety next to a code number the entry is indented and the coder refers back to the common portion of the code description located before the semicolon
plus symbol
identifies add on codes for procedures that are commonly but not always performed at the same time and buy the same surgeon as the primary procedure
forbidden symbol
identifies codes that are not to be appended with modifier -51
flash symbol
indicates that a code is pending d=fda approval but that it has been assigned a cpt code
number symbol
precedes cpt codes that appear out of numerical order
star symbol
cpt codes that rae reported for synchronous telemedicine services and require addition of modifier -95
green reference symbol
that the coder should refer to the cpt assistance monthly newsletter
blue reference symbol
that the coder should refer to the cpt changes
red reference symbol
that the coder should refer to the clinical examples in radiology quarterly newsletter
duplicate pla symbol
identifies duplicate proprietary laboratiry analyses PLA test
double arrow symbol
double arrow symbol identifies cpt catory 1 PLA codes
critical care services
reparted when a provider directly delivers medical care for critically ill injured patient
direct patient contact
face to face patient contract outpatient or inpatient
emergency department services
services provided in an organixed hispital based facility which is open on a 24 hour basis for the purpose of providing unscheduled episodic services to patients requiring immediate medical attention
established patient
one who has recived professional services from the provider or from another provider of the same specialty who belongs to the same group practice within the past three years
evaluation and management documetation guidelines
federal cms guidelines that explain how e/m codes are assigned according to elements associated with comprehensive multisystem and single system examination
evaluation and management e/m section
located at eh beginning of cpt because there codes describe services that are most frequently provided by physicians and other health care practitioners
extent of examination cpt
includes comprehensive detailed expanded problem focused and problem focused levels based on physician documentation
comprehensive examination
general multisystem examination or a complet examination of a single organ system
detailed examination
affected body areas and other symptomatic or related organ systems
expanded problem focused examination
limited examination of the affected body area or organ system and other symptomic or related organ systems
problem focused examination
limited examination of the affected body area or organ system
extent of history cpt
includes comprehensive detalied expanded problem focused and problem focused levels based on physician documentation
comprehensive history
cheif complaint extended history of present illness review of systems directly related to the problems identified in the history of the present illness plus a review of a;; additional body systems and complete past family social history
detailed history
chief complaint extended history of present illness problem pertinent system review extended to include a limited number of additional systems pertinent past family social history directly related to patients problem
expanded problem focused history
chief complaint brief history of present illness problem pertinent system review
problem focused history
chief complaint brief history of present illness or problem
face to face time
amount of time the office or outpatient care provider spends with the patient and or family
global period
includes all services related to a procedure during a period of time
global surgery
package concept or surgical package includes the procedure local infiltration metacarpal digital block or topical anesthesia when used and normal uncomplicated follow up care
history
interview of the patient that includes the following components history of present illness a review of systems and past family social history
hospital discharge services
includes the final examination of the patient discussion of the hospital stay with the patient and or caregiver instructions for continuing care provided to the patient and or caregiver and preparation of discharge records prescription and referral forms
home services
health care sevices provided in a private residence
indented code
cpt code that is indented below a stand alone code requiring the coder to refer back to the common portion of the code description that is located before the semicolon
initial hospital care
covers the first inpatient encounter ther admitting attending physician has with the patient for each admission
key components
extent of history exten of examination and complexity of medical decision making
level of E/M service
use of last number of each cpt evaluation and management services code to represent level of service provided
medical decision making
refers to the complexiity of establishng a diagnosis and or selecting a management option as measured by the nume=ber of diagnoses of=r management options amount and or complexity of data to be reviewed and risk of complications and or morbidity or mortality
moderate sedation
administration of moderate sedation or analgesia which results in a drug induced depression of consciousness
modifier
provide additional information about a procedure or service
monitored anesthesia care MAC
provision of local or regional anesthetic services with certain conscious a;tering drugs when provided by a physician anesthesiologist or medically directed crna monitored anesthesia care incolces sufficiently monitoring the patient to anticipate the potential need for administration of general anesthesia and it requires continuous evaluation of vital physiologic functions as well as recognition and treatment of adverse changes
multiple surgical procedures
two or more surgeries performed during the same operative session
nature of the presenting problem
defined by cpt as a disease condition illness injury symptom sign finding complaint or other reason or other reason for the encounter with or without a diagnosis being established at the time of the encounter
new patient
one who has not recived any professional services from the provider or form another provider of the same specialty who belongs to the same group practice within the past three years
newborn care
covers examinations of normal or high riskk neonates in the hospital or other locations subsequent newborn care in a hospital and resuscitation of high risk babies
nursing facility services
performed at the following sites
observation or inpatient care services
cpt codes used to report observation or inpatient hospital care services provided to patients admitted and discharged on the same data of service
observation services
furnished in a hospital out patient setting to determine whether further treatment or inpatient admission is needed when a patient is placed under observation the patient os categorized as an outpatient if the duration of observation care is expected to be 24 hours or more the physician must order an inpatient admission
organ or disese oriented panel
series of blood chemisty studies routineluy ordered by providers at the same time to investigate a specific organ
partial hospitalization
short term intensive treatment program where individuals who are experiencing an acute episode of an illness
physical examination
assessmetn of the patients bofy areas
physical status modifier
indicates the patients condition at eh time anesthesia was adminustered
place of service pos
physical location where health care is provied to patients
preoperative clearance
occurs when a surgeon request that a specialist or other physician examine patient and give an option as to weather that patient can with stand the expected risks of a specific surgery
preventive medicine services
routtoms of a disorder while presemtomg pine examinations or risk managemtn counseling for children and adults exhibiting no over signs orsymp
