Chpt 15

Question 1

Abuse

Answer 1

A practice that is inconsistent with sound fiscal , business or medical practices, and results in unnecessary costs to the Medicaid or Medicare program, or in reimbursement of services that are not medically necessary, improper behavior and billing practices that result in financial gain but are not fraudulent

Question 2

Eponym

Answer 2

A disease or condition named after an individual

Question 3

Etiology

Answer 3

Cause of a disease or an illness

Question 4

Evaluation and Management (E&M) codes

Answer 4

Codes that describe patient encounters with a physician for evaluation and management of a health problem

Question 5

Fraud

Answer 5

An intentional deception or misrepresentation made by a person with the knowledge that the deception could result in a benefit to oneself ir another

Question 6

Global period

Answer 6

The period of time, both before and after a surgical procedure, included in the surgical procedure fee
Insurance companies determine the number of days

Question 7

Healthcare Common Procedure Coding System (HCPCS)

Answer 7

A set of codes developed and maintained by CMS for the reporting of professional services, nonphysician services, supplies, DME and injectable drugs
3 levels: CPT (use COT code if there is also a HCPCS code), HCPCS, 3rd is being phased out - developed by regional Medicare carriers- HIPAA simplicity mandate is phasing out

Question 8

Modifier

Question 9

Tabular index

Question 10

Upcode

Answer 10

To code and bill for a higher level of service than what was actually provided

Question 11

Usual, customary, and reasonable (UCR)

Answer 11

The reimbursement method in which insurance companies compare providers’ charges to other providers in the same geographic area
Before mid-1960s
Average of charges in the area

Question 12

Relative value unit system

Answer 12

Developed by US Congress in 1992

Question 13

Current Procedural terminology (CPT)

Answer 13

All procedures approved by FDA
1966
Updated annually- last is 4th in 1977
Originally focused mainly on surgical procedures

Question 14

CPT for Medicare

Answer 14

1980s Congress requires providers to use CPT codes for all services rendered

Question 15

CPT codes

Answer 15

5 digits
Must appear on CMS-1500 insurance claim forms

Question 16

CPT publisher

Answer 16

American Medical Association (AMA)
Provides a uniform language

Question 17

CPT Effective date

Answer 17

January 1
Updated annually
Use the edition in effect at the time of the service

Question 18

Most important tool in determining procedure code

Answer 18

Patient’s medical record

Question 19

11 coding steps

Answer 19

1. Identify primary and secondary procedures performed ; quantities performed
2. Locate the main term in the alphabetic index: service name, condition name, name of organ or anatomical site, or eponym
3. Review modifying terms or notes associated with the main term
4. Identify the tentative code associated with the appropriate modifying term
5. Locate the tentative code in the tabular index
6. Interpret the conventions used in the tabular index
   Conventions: formatting, punctuation, instructional notes, symbols
7. Select the code with the highest level of specificity. Check chart notes
8. Review the code for appropriate bundling, add-on codes and quantity
9. Determine if modifiers are required
10. Verify the final code against the documentation
11. Assign the final code

Question 20

Circle around a dot

Answer 20

Moderate sedation is automatically included in this code description

Question 21

Circle with a diagonal line from top left to bottom right

Answer 21

This code is modifier 51 exempt

Question 22

Plus sign

Answer 22

Add-on code must be used with this code

Question 23

Lightening bolt

Answer 23

FDA approval is pending for this code

Question 24

Parentheses

Answer 24

Used to enclose synonyms, eponyms, or other descriptions that do not affect the code assignment

Question 25

Bullet

Answer 25

New code in this edition of the CPT manual

Question 26

Triangle

Answer 26

Revised code; the number is the same, the descriptor has been updated

Question 27

Two horizontal triangles

Answer 27

Contains new or revised text

Question 28

E/M code’s information

Answer 28

Begin with 99 but at front of code book Based on category of service, may be location or type New or established patient

Question 29

Elements of E&M codes

Answer 29

History and Examination (problem focused, expanded problem focused, detailed, comprehensive) & medical decision making (The number of possible diagnoses, amount of complexity of the medical records, the risk of significant complications)

Question 30

Anesthesia codes

Answer 30

Before surgery Section General, regional and supplementation of local anesthesia

Question 31

Surgery codes

Answer 31

Broken down into body systems Then further into anatomical sections Each surgical code is a bundled code: one E/M visit prior to surgery, prepping the patient, performing operation with all elements, immediate postoperative includes talking to family, writing orders, evaluate patient in postanesthesia recovery are, typical postoperative care

Question 32

Radiology codes

Answer 32

The technical component and the professional component

Question 33

Pathology and laboratory codes

Answer 33

A complete procedure includes ordering the test, taking and handling the sample, performing the actual test, analyzing and reporting in the test results 80000 codes report the performance of tests only and do not include collection

Question 34

Medicine codes

Answer 34

May be used with codes from any section Services provided by physicians and non physician practitioners Immunizations require 2 codes- immunization itself and the particular vaccine

Question 35

Cardiac catheterization

Answer 35

Most commonly performed surgical procedure 3 codes: code for procedure, code for the injection procedure , code for the imaging supervision and interpretation Each if these codes has a technical component and a professional component

Question 36

Best method for timely, proper reimbursement

Answer 36

Proper documentation of services provided in the EHR, with extenuating circumstances: needed a translator, multiple complaints, extensive health history

Question 37

American Public Health Association (APHA)

Answer 37

Adopted Bertillion’s 1893 Bertillion Classification of Causes if Death, in 1898 APHA recommended it be updated every 10 years 1901 APHA published ICD-1, used until 1910 then ICD-2, etc. ICD-9-CM published in1979

Question 38

ICD-10-CM coding

Answer 38

Completed in 1999 for all major countries except US US was slated for October 1 2013 for implementation but was delayed until October 1, 2015 Expanded code structure to incorporate updated terminology. Allows coding to higher specificity

Question 39

ICD-10-CM

Answer 39

21 chapters Diagnostic codes describe the need for the medical visit Updated annually and take effect October 1 each year Use edition in effect for date of service WHO has updated codes since 1948; code changes published by the National Center for Health Statistics, CMS and WHO Introductory material, alphabetic index, tabular list (alphanumeric list of diseases and injuries) Each chapter organized according to areas of the body

Question 40

Finding the correct code in ICD-10-CM

Answer 40

Begins with medical chart All relevant information in the chart should be coded

Question 41

Office-based or outpatient coding

Answer 41

Refer to patient registration form Encounter form Visit notes Lab and radiology reports Operative reports for outpatient procedures

Question 42

Inpatient coding

Answer 42

Refer to Admitting history and physical Daily progress notes Operative reports Lab and radiology reports Discharge summary

Question 43

Dx coding

Answer 43

Dx must describe the reasons the specific service was provided and related medical conditions that may affect the specific service Do not repeat the patient’s problem list

Question 44

Order of Dx coding

Answer 44

1. Identify the first-listed Dx as stated in the record Reason chiefly responsible for visit. Secondary Dx are additional conditions or complaints 2. Locate the main term in the alphabetic index: condition, disease or reason for visit (ie. Screening), eponym, abbreviation, nontechnical term 3. Review any modifiers or subterms associated with the main term Subterms indented 2 spaces-further describe the condition; modifiers appear in parentheses 4. Identify the tentative code associated with the most appropriate subterm 5. Locate the tentative code in the tabular list 6. Select the code with the highest level of specificity 7. Verify the final code against the documentation 8. Assign the code 9. Repeat the process for any additional codes required

Question 45

Coding more than 1 Dx

Answer 45

Up to 4 Dx codes can be entered on the CMS-1500 form. The main reason for the visit is the first-listed Dx