Procedural Coding Basics Flashcards
Common Procedural Terminology (CPT)
● CPT puts procedures into numerical codes.
● Contains 5 numbers and no letters.***
● Updates every January 1st
● Start at the Tabular Index (the back), then the Alphabetic Index (the front)
● Managed by the American Medical Association (AMA)***
● Used for tracking, insurance claims submission, and keeping confidentiality safe.
CPT Codes can be found: FEE SLIP
● In the Encounter Form
● Also known as the Fee Slip.
● It’s a form/document that allows the provider to check off what he/she has done
so they can get paid for their service.
This form then gets sent off to get billed.
● Pathology Reports and Radiology Reports are also included
CPT Coding Index Only (Opposite of ICD-10)
● The Alphabetic Index is located in the back of the book.
● The Tabular Index is located in the front of the back.
E/M codes
● Codes that reflect what the provider does during the time spent with the patient.
● Charges go by the level of medical decision-making (MDM), the level of
knowledge that the physician may have, and if there new or an established
patient.
6 Sections of Tabular Index:
- Evaluation and Management (E/M)
- Anesthesia
- Surgery
- Radiology
- Pathology and Laboratory
- Medicine
Upcoding
- use of a higher-level procedure code than is supported in the*****
documentation of medical necessity. (the use of a higher charge to get more money, but
there is no proof. could be fraudulent)
Downcoding ( losing money)
- use of a lower-level procedure code than is justified. (losing money for
professional courtesy, fraudulent)
Fraud ( billing for a service that was never provided)
- an intentional deception to gain something for your benefit (billing for a service
that was never provided)
ABUSE ( taking advance at a higher level)
- knowingly taking advantage/overcharging at a higher level than was never
needed. (abusing the power to charge them)
CPT Modifiers ( 2 digit numerical code ended of a copy )
● A 2-digit numerical code that is added to the end of a CPT code gives it more
detail.
● Ex: 91234 -50
Conventions
● Symbols used to provide more information about specific codes.
● Explanation of codes located at the bottom of the Tabular Index
New Patient -
- Has not received any professional services from the provider (or another
of the practice’s providers with the same specialty and subspecialty) in the last 3 years
Established Patient -
Has received professional services from the provider (or another
of the practice’s providers with the same specialty and subspecialty) in the last 3 year
POS - Place of Service
● Healthcare facility where the provider delivers care to the patient.
○ Ex: provider’s office, hospital emergency department, skilled nursing
facility, patient’s home
CPT Coding - Surgical Section
Coded for the size of the wound in centimeters
CPT Coding - Pathology and Laboratory Section
- Panel - all tests listed under code selected are performed (blood draw procedure)
- Ex: lipid panel, thyroid panel.
DME - Durable Medical Equipment covered under B Medicare
- Equipment the patient uses at home
- Covered under Medicare part B***
- Includes crutches, wheelchairs, walkers, glucometers, bp cuffs etc.
ON RMA - Bundled Codes
A charge for one prize
Global period
Limited time for bundle codes
○ (ex: limited combo lasting until April 30th)
CPT Code Categories
- Category I
- Includes regular CPT Codes
- (ex: 99215 contains no letter, 5 digits) - Category II
- Also known as HCPCS Codes
- (ex: A8790 contains a letter, 5 code*
- Codes for Durable Medical Equipment (DME)
- Codes that help measure performance
- Codes for medical supplies - Category III
- Codes for Emerging Technology
- (ex: 8763T contains a letter, T, 5 digit)
CPT Modifier
Modifer 50 = bilateral
- Ex: 69210 - one side of the ear
- Ex: 69210-50 - both sides of the ear
Modifer 26
-professional component
- More than one doctor is involved.
Claim Form
● A document that goes to the insurance company to request payment
● Must be error-free, denial will occur if errors are seen
● No one wants claims denied because payment will not be processed
Group Number
● a code assigned to your employer’s insurance plan
Insurance Card
- Make sure to scan BOTH SIDES of the pt’s insurance card
- On the back of the card has numbers (insurance resources)
DME is covered
- under Medicare part B
Cpt code contains ..
letter, 5 code
sections of CPT books
ELM
RADIOLOGY
PATHLOGY
DRUG TESTING
ANESTHESIA
MEDCINE
SURGERY
tubular index
has six sections
paper claim form**
is known a cms
medcial sulppies
hcpcs A codes
dme
hcpcs e codes
np- NP IS WITH A ZERO
99202***
99201
99203
99204
99205
when does Common Procedural Terminology (CPT) updated
January 1st
RMA which is a detail charge for a new pt*****
99023
what is a high expensive charge for a new pt**
99205
Codes for Emerging Technology***
8763T
EP- IS WITH A 1
99211
99212***
99213
99214
99215
T OR FLASE if a claim is rejected CAN IT BE SENT BACK
T they send it back and it can be resimmited
WHAT DOES CMS ASK FOR
INSURANCE COVERAGE
Audit
opinion about whether the financial statements are fairly presented in accordance with applicable accounting standards.
How many sections are in the cpt manual
Six
True or class revised codes are highlighted in the cpt manual
FLASE
What information is needed in block #1 of a cms-1500 form?
Item 1 - Show the type of health insurance coverage applicable to this claim by checking the appropriate box,
what is the physician’s office place of service code
11
What is clearing house
an independent, centralized service available to healthcare providers for the purpose of simplifying medical insurance claims submission for multiple carriers.
What are the steps in filling a claim with a third party?
Exchange information with the other driver involved in the accident.
Take as many pictures and record as many details related to the accident as you can.
File a claim against their insurance company.
File a police report and get a copy of it.
What does dirty claim mean?
an insurance claim submitted with errors or one that requires manual processing to resolve problems or is rejected for payments. electronic claim.
What information is found on an explanation of benefits?
payment details, covered charges, write offs, and patient responsibilities and deductibles.
What is used in the alphabetic index portion of cpt book?
Eponym
Code range 70000-79999 belongs to
Radiology
are used to help measure performance outcome
category 2 cpt
what code number represents an urgent care facility as in pos
20
what is the meaning of electronic data interchanging
transfer information electronically
on a cms-1500 form
12 amount of codes that can be used
what section of cms-1500 you would find information about the patient and the insured
section two
a patients billing records should have
insurance billing
which block on the cms-1500 form would you find the patients name
block 12
what code is for new patient exp problem focused
99202
what code would be for ESTABLISHED PATIENT PROBLEM FOCUSED
99212
WHAT INFORMATION IS NEEDED FOR BLOCK 1 OF CMS-1500 FORM
INSURANCE
ARE REVISED CODES HIGHLIGHTED IN CPT MANUAL?
YES
