CPT - E/M Key Terms

Question 1

An evaluation and management service provided at the request of another physician to recommend care for a patient’s specific condition or problem. The consultant’s opinion and any services that were performed must be communicated back to the requesting physician in the form of a written report.

Answer 1

Consultation

Question 2

A patient who has been seen within the past 3 years by the physician or another physician of the same specialty who belongs to the same group.

Answer 2

Established patient

Question 3

Medical decision making refers to the complexity of establishing a diagnosis and/or selecting a management option. Four types of MDM are recognized: Straightforward, Low complexity, Moderate complexity, and High complexity.

Answer 3

Medical Decision Making (MDM)

Question 4

The presenting problem is the reason for the encounter. The E/M codes recognize five types of presenting problems: Minimal, Self-limited or minor, Low severity, Moderate severity, High severity.

Answer 4

Nature of Presenting Problem

Question 5

Past history includes a review of the patient’s past experiences with illnesses/injuries and prior operations/hospitalizations.

Answer 5

Past History

Question 6

A patient who has not been seen within the past 3 years by the physician or another physician of the same specialty who belongs to the same group.

Answer 6

New patient

Question 7

is a review of marital status; occupation; drug, alcohol, and tobacco use; sexual history; hobbies, and educational level.

Answer 7

Social history

Question 8

history includes a review of the significant medical diseases of family members.

Answer 8

Family History

Question 9

An inventory of body systems gathered through a series of questions.

Answer 9

Review of Systems (ROS)

Question 10

is defined as the total time the physician spends on the date of the encounter. This includes both face-to-face (time spent with the patient or family) and non-face-to-face work done on that day.

Answer 10

Time

Question 11

These codes describe encounters in which healthcare providers evaluate a patient’s health status and create a plan of care.

Answer 11

“E/M” codes

Question 12

section that is located in the very front of the CPT code book because these codes describe the services that physicians most frequently provide.

Answer 12

The E/M Section

Question 13

refers to assessing a patient’s health status.

Answer 13

Evaluation

Question 14

refers to putting into place a plan of care.

Answer 14

Management

Question 15

is to verify that the level of code chosen by the provider is supported by the documentation in the patient’s medical record.

Answer 15

The primary role of a coder in E/M coding

Question 16

Purpose of “upcoding” E/M codes is to

Answer 16

obtain higher reimbursements is

Question 17

considered coding fraud.

Answer 17

“upcoding” E/M codes

Question 18

This type of qualifier are terms that provide more information about the CPT code. They can occur in the middle of a code description or after the semicolon. They may or may not be enclosed in parentheses. Be sure to read all code descriptions very carefully before assigning a CPT code to make sure descriptive qualifiers are not overlooked.

Answer 18

Descriptive qualifiers

Question 19

What are the six main sections in the order they appear in the CPT codebook.

Answer 19

Evaluation and Management (E/M)
Anesthesia
Surgery
Radiology
Pathology and Laboratory
Medicine

Question 20

How many sections of Category I codes.

Answer 20

six or 6

Question 21

This (95115-95125) is an example of a

Answer 21

code range

Question 22

Cannot stand alone is what type of code

Answer 22

Add-on code

Question 23

A symbol that Indicates a revised code description

Answer 23

Triangle

Question 24

Includes instructions for using the CPT codebook

Answer 24

Introduction

Question 25

Organized alphabetically by main terms

Answer 25

CPT Index

Question 26

Listed under a main term

Answer 26

Modifying term

Question 27

“See” and “See also” notes

Answer 27

Cross-references

Question 28

Placed before the code number, the bullet alerts you to an entirely new code and description.

Answer 28

Bullet ( * )

Question 29

Placed before the code number, a triangle identifies a revised code description.

Answer 29

Triangle (▴)

Question 30

Surrounding text, facing triangles indicate that typographical errors have been corrected and stylistic improvements have been made to guidelines and notes.

Answer 30

Facing triangles ( ▶text◀ )

Question 31

Placed before the code number, a plus sign means an add-on code, which identifies additional procedures commonly associated with the main procedure.

Answer 31

Plus sign (+)

Question 32

Codes identified with a _________ sign are never reported as stand-alone codes and are only reported in addition to a primary procedure.

Answer 32

plus

Question 33

What are the Main terms categories:

Answer 33

Procedure or service
Organ or anatomic site
Condition
Synonyms, eponyms, and abbreviations

Question 34

Main terms come in how many categories:

Answer 34

four or 4

Question 35

The CPT codebook has how many components:

Answer 35

six or 6

Question 36

What are the components of the CPT codebook

Answer 36

I. Introduction
II. The Main Body (Category I codes), with six sections:
III. Category II codes
IV. Category III codes
V. Appendices
VI. Alphabetic Index

Question 37

codes that are temporary codes for new and emerging technologies.

Answer 37

Category III Codes

Question 38

codes that are supplemental codes used to track the quality of care the provider is giving.

Answer 38

Category II Codes

Question 39

codes represent the procedures and services that healthcare professionals nationwide most commonly perform.

Answer 39

Category I Codes

Question 40

What are the the two levels of HCPCS and the three categories of Level I.

Answer 40

Level I: CPT and HCPCS Level II

Question 41

What area the three categories of Level I.

Answer 41

Category I Codes, Category II Codes, Category III Codes