study set Flashcards
ARF (urinary)
acute renal failure
BPH (urinary)
benign prostatic hypertrophy
BUN (urinary)
blood, urea, nitrogen
CRF(urinary)
chronic renal failure
C&S (urinary)
culture and sensitivity
cysto
cystoscopy
ESRD
end stage renal disease
ESWL (urinary)
extracorporeal shock-wave lithotripsy
IVP (urinary)
intravenous pyelogram
IVU
intravenous urography
KUB (urinary)
kidneys, ureters, bladder
PD (urinary)
peritoneal dialysis
RP (urinary)
retrograde pyelogram
TURP (urinary)
transurethral resection of the prostate
U/A (urinary)
urinalysis
UTI (urinary)
urinary tract infection
VCUG (urinary)
voiding cystourethrogram
The Structures found in the urinary system include ?
bilateral kidneys, bilateral ureters, the urinary bladder, and the urethra.
The external sphincter controls the release of ?
the urine from the bladder
The kidneys are located in the back of?
the body on either side of the vertebral column
The ureters are?
muscular tubes that transport urine from the kidneys to the bladder.
where is The urinary bladder located?
The urinary bladder is located in the pelvic cavity
what does the urinary bladder serves as?
and serves as a temporary reservoir for the urine
T OR F: The urethra is a mucous membrane-lined tube that transports urine from the bladder to be excreted from the body
TRUE
A ___________ is an incision made into the renal pelvis
pyelotomy
Endoscopy codes for ureteral procedures completed through an established ureterostomy are reported with codes _____ to _______
50951 to 50961
Code range _______ to _______ is used to report ureteral endoscopy through a ureterotomy.
50970 to 50980
An alternate method of catheterizing the bladder for drainage is completed by performing a _________
cystostomy
Code range ____-______is used for male patients to report procedures completed on the vesical neck and prostate
52400-52700
BPH (male)
benign prostatic hyperplasia
TRUS (male)
transrectal ultrasound
TUIP (male)
transurethral incision of the prostate
DRE (male)
digital rectal exam
TUMT (male)
transurethral microwave thermotherapy
Fluoroscopy
immediate serial images produced using roentgen rays. allows for examination of function of body part or organ
echocardiography
ultrasound used to study heart structures
CT/CAT Scan
cross-sectional images produced, usually diagnostic
extension
movement that increases angle of joint
eversion
turning outward
decubitus
one position for prolonged period, produces localization of fluid that leads to skin breakdown
Axial
referencing axis of structure or part of body
Radiologic technician
person specially trained to use equipment that generates pictures or studies
Radiologist
doctor whos specialty is radiology
Radiology
study of x-rays, high-frequency soundwaves, and high-strength magnetic fields to diagnose and or treat diseases or injuries.
Inversion
turning inward or inside out.
oblique
different angles
Angiography
contrast used for imaging vessels
Arteriography
contrast used for imaging arteries
Arthrograhpy
X-ray of inside joint
the 5 Organs of urinary system include
kidneys, renal pelvis, ureters, bladder, urethra
Function of the urinary system
organs and structures that remove waste from body
why would a physician order a culture and sensitivity (c&s)
if suspected a UTI in patient.
primary purpose of the organs of urinary system
filter blood and create urine as a waste by-product
Blood, urea, nitrogen (BUN)
blood test thats performed on patients who are suspected to have kidney dysfunction, very common and reveals important info. about how well the kidneys and liver are working in a patient
Benign Prostatic Hypertrophy (BPH)
unusual enlargement of the prostate glans; very common diagnosis
BAL (respristory)
Bronchial alveolar lavage
COPD (respristory)
Chronic obstructive pulmonary disease
COLD (respiratory)
Chronic obstructive lung disease
DOE (respiratory)
Dyspnea on exertion
what are the 4 sinus cavities
- maxillary sinus
- ethmoid sinus
- sphenoid sinus
- Frontal sinus
what are the Maxillary sinus also called?
maxillary antrum
pharyngolaryngectomy
surgical excision of hypopharynx and larynx
Endotracheal intubation
tube inserted to keep trachea open
Ethmoidectomy
removal of ethmoid sinus
Maxillectomy
removal of maxillary sinus
Diagnostic
when the physcian is just exploring there looking around, they’re trying to arrive at a diagnosis
Therapeutic
is actually TREATING the condition
what is another term we USE for THERAPEUTIC?
surgical
Direct laryngoscopy
direct viewing of larynx and adjacent structure by use of laryngoscope
Indirect laryngoscopy
view of larynx by use of laryngeal mirror placed in back of throat, with second mirror held outside of mouth.
Tracheostomy
planned, emergency, or fenestration procedure
Bronchoscopy
examination of bronchi using flexible or rigid to line for endoscope
Core needle biopsy
typically performed with a needle that is designed to obtain a core sample of tissue for histopathologic evaluation
a fine needle aspiration biopsy
performed when material is aspirated with a fine needle and the cells are examined sciocally
thoracentesis
fluid accumulated in the space between the ribs and physician will use a syringe and needle to remove that fluid
pleurectomy
removal of intra plural from body
pleurectomy (excision/resection/removal)
surgical removal of pleura
Maxillary sinus
located below eye and lateral to nasal cavity
T or F
are ALL the 4 sinus cavities Bilateral?
TRUE
How many codes are there for repairs on lungs?
four
Pneumonectomy
removal of lung
Pneumocentesis
surgical puncturing of lung
what are the two types of nasal endoscopies
diagnostic and surgical
surgical repairs of the ______ are known as rhinoplasty
nose
Index main terms organized by
- produce or service
- organ or other anatomic site
- condition
- synonyms, eponyms and abbreviations
The narrowing of the nasal vestibule is called?
stenosis
Secondary rhinoplasty is also known as ___________rhinoplasty
revision
Rhinotomy
a surgical procedure in which an incision is made along one side of the nose
a primary rhinoplasty is also known as an_______
initial
Sinus
cavity located in skull close to paranasal area
Trachea
tube-shaped structure in neck extending from larynx to bronchi
PFT (respiratory)
pulmonary function testing
RLL (respiratory)
right lower lobe
Pharynx
tubular structure that extends from base of skull to esophagus
Frontal sinus
located within frontal bone behind eyebrows
Ethmoid sinus
located between eyes
LUL (respiratory)
left upper lobe
CXR
chest X-ray
LLL (respiratory)
left lower lobe
Sphenoid sinus
located directly behind nose
Lungs
pair of organs located in thorax , constitute main organs of respiratory system
ARF (respiratory)
acute respiratory failure
ARD (respiratory)
acute respiratory disease
V/Q scan
Ventilation/perfusion scan
TLC (respiratory)
total lung capacity
SOB
shortness of breath
RUL (respiratory)
right upper lobe
CPT
current procedural terminology
add-on code symbol (+)
used within cpt to list procedures that are completed in addition to the primary procedure or service performed
Larynx
voice organ that connects pharynx with trachea
Bronchi
large air passages in lungs through which air is inhaled and exhaled
Laryngectomy
surgical removal of larynx
Real-time scanning
provides two-dimensional image of both structures and movement
M-mode
takes measurements of velocity and amplitude of moving echo-producing structures. allows for one-dimensional viewing
B-scan
two-dimensional image
A-mode
one-dimensional measurement
Follow-up/repeat study
completed, documented study that must be done again
Limited study
partial scan or exam of body area or quadrant
Complete study
encompasses entire body
U/S (radiology)
ultrasound
SPECT
single-photon emission computer tomography
Rad Onc
radiation oncology
Rad
radiation absorbed dose
PET
positron emission tomography
MRI (abbre)
magnetic resonance imaging
KUB
kidneys, ureter, baldder
FX
fracture
ECHO
echocardiogram
CXR
chest x-ray
CT
computed tomography
CAT
computed axial tomography
AP
anteroposterior
Ultarsonography
sound waves passed over body structures to send signal to computer, computer turns signal into picture for examination
Mammography
process used to examine soft breast tissue for benign or malignant growths
MRI
radio frequency signals used to examine soft tissue and bony structures of body without radiation
T or F
CPT codes tell the insurance carrier what brought the patient to the physician’s office
false
T or F?
text, symbols, and the history of CPT are found in the introduction of the book
true
T or F
the cpt code book is updated annually on july 1?
False; updated on january 1 by AMA
T or F?
the surgery section of codes begins with code 10004-69990
True
T or F?
(triangle) is the symbol for a revised code
TRUE
The cpt coding system was first published in 1966 by the _____ ______ ____
american medical association
A complete and detailed description of ALL modifiers used in CPT is found in Appendix ___
A
The cpt manual contains ______ main sections (how many?)
6
The ______ separates the common portion of the code description from additional portions of the code
semicolon
The_____ is organized by main terms
index
A document that clearly explains why a physician feels the patient needs durable medical equipment or a service and it must be filled in the patients medical record for certain supplies. this document is known as a certificate of __________ necessity
medical
HCPCS codes that are used to report transportation services are ____ codes
A
A written notice to the patient that identifies a provided service that might not be covered by CMS is known as an ________ ________ _________
Advance, Beneficiary , notice
A postural drainage board is reported with code ______
E0606
T or F?
Appendix 2 identifies modifier’s used with category 1 and category 2 codes
False
T or F?
Appendix 2 identifies modifiers used with HCPCS codes
TRueee
T or F?
the route of administration involving the gastrointestinal tract is called the parenteral.
False
T or F?
Parenteral refers to a route of administration
TRue
T or F?
When coding for ambulance services, the point of pickup and the destination must both be identified
TRUE
T or F?
Level I codes are published by the CMS
false
T or F?
Level II are published by the CMS?
true
T or F?
The american medical association (AMA) maintains the Level I codes?
True
T or F?
Codes related to the senses, such as speech and hearing, are located in the Q code series
false
T or F?
the Q codes are temporary codes used to report various supplies, drugs, and biologicals in instances when no permanent code has been assigned
TRUE
HCPCS Level II codes are published _____ by _____ _________ _____ ______ ______ ______
annually, centers, for medicare, and , medicaid , services
A cpt modifier is an ___ digit modifier appended to a cpt code to indicate that a service or procedure has been altered.
2
A complete listing of Level I modifiers commonly found in the CPT coding book can be found in appendix ____
A
when billing physician services, place modifier’s in item ______ of the CMS-1500 form.
24d
statistical modifiers, also known as ________ modifiers’, are used for informational purposes and affect the processing or payment of the code billed but do not affect the fee/
informational
Modiffer 99 indicates that _____modiered are needed for an individual cpt code
multiple
a mandated service is reported using modifier ____
32
when a surgeon completes only the surgical care, modifier _____ should be appended to the cpt procedure code.
54
what is the 1st section of CPT?
Evaluation and Management (E/M)
Evaluation and Management (E/M)
codes that reflect the evaluation by a provider and also the management portion of the patient’s care
Evaluation and Management means exactly what it says:
The patient is first evaluated by a physician, nurse practitioner, physician assistant, or in some cases a nurse. After the evaluation is completed, a management plan is implemented and recorded in the patient’s medical record. The evaluation of the patient, along with the management plan, are considered billable services, and the CPT codes are used to delineate the type of service given to the patient, thus determining the revenue amount generated by the service provided.
what are the 3 major questions that you must ask when you are identifying an Evaluation and Management code:
- Is the patient a new or an established patient?
- Where was the service provided?
- What was the level of the service rendered?
T or F
New Patient codes—99202–99205
True
T or F
Established Patient codes—99211–99215
true
secretes insulin
pancreas
secretes hormone that regulates serum calcium levels
parathyroid
regulates electrolytes, helps with glucose metabolism, and helps with heart and lung function
adrenal gland
what is the code range for the endocrine system ?
60000-60699
new patient
A patient who has not received professional services within the past three years from a physician or another physician of the same specialty who belongs to the same group practice
Established patient
a patient who has received professional services from a physician or another physician of the same specialty within the past three years in the same group setting
thymus gland
secretes thymosin
T or F?
the pancreas functions in the endocrine and digestive system
true
T or F
the cardiovascular system….
pumps blood through body VIA heart and blood vessels
True
T or F?
the cardiovascular system ….
oxygen and nutrients carried through body by blood
true
T or F?
the cardiovascular system…
waste products transported for disposal from body
True
T or F?
the heart is enclosed in pericardium?
True
where is the heart located?
between lungs in thoracic cavity
the ________ is a large muscle that acts like a pump
heart
CC
cardiac catheterization
CCU
coronary care unit
CHD
coronary heart disease
CHF
congestive heart failure
DVT
deep vein thrombosis
MVP
mitral valve prolapse
AS
aortic stenosis
ASD
atrial septal defect
ASHD
arteriosclerotic heart disease
BBB
bundle-branch block
CABG
coronary artery bypass graft
CAD
coronary artery disease
code range for cardiovascular
33016-33141
cardiac pacemaker
correct and manage heart dysrhythmias
pulse generator
source of power for pacemaker
electrodes
attach to pulse generator to conduct power
pacing cardioverter- defibrillator
emits defibrillating shocks that stimulate heart
_____ valve is between aorta and Lt. ventricle
aortic
_______ valve is between the Lt. atrium and Lt. ventricle
mitral
what is the mitral valve also known as?
bicuspid valve
the removal of the synovial membrane of a joint is an
synovectomy
T or F
a tendon comprises fibers and cells that cause movement and are able to contract
F
The examination of the interior of a joint by using an arthroscope
artroscopy
the surgical fixation of a joint
artrodesis
the displacement of a bone
dislocation
a surgical incision made into a joint
arthrotomy
a sheet of fibrous tissue
fascia
the process of suturing or fastening a structure in place
fixation
thin sheets of fibrous connective tissue
cartilage
the reduction of a dislocation or fracture
manipulation
the destruction of multiple lesions or complicated lesions would justify the selection of an extensive destruction code
true
DR pan completed a complete radical vulvectomy with bilateral inguinofemoral lymphadenectomy. the appropriate code to report this procedure is
56637
colpocleisis
surgical closure of the vagina
colpopexy
suturing of the vagina to the abdominal wall
conization of the cervix
use of a cold knife to cut a cone-shaped portion of the cervical tissue for examination
colpocentesis
aspiration of fluid through the vaginal wall via the use of a syringe
Trachelectomy
removal of the cervix uteri
The male genital system is primarily for reproduction, but it also functions as part of the urinary system.
TRue
Diagnostic procedures are always included in surgical procedures in the laparoscopic section of prostate procedures.
true k
If the code does not state unilateral or bilateral, it is assumed that the procedure is bilateral.
false
Laparoscopic repair of a hernia performed at the same time as the orchiopexy would be reported with two repair codes, one indicating the hernia repair and one for the orchiopexy.
TRue
The distal end of the penis is also known as the ____ _____
glans penis
The erectile tissue of the penis is called the_____ _____
corpora cavernosa
The structure that is located below the urinary bladder and on the upper end of the urethra is the _____ _____
prostate gland
The germ cell secretion of the testicles is called
sperm
An elective procedure used to remove the foreskin completely from the glans penis is called
circumcision
Local anesthetics are injected into the carpal tunnel area to relieve pain.
true
An osteotomy is the completion of plastic surgery on a bone.
FALSEEE
osteoplasty is the completion of plastic surgery on a bone.
TRUEEEEE
The term
introitus refers to an opening or space
true
The use of an electric current to destroy living tissue, usually used to control bleeding, is known as a(n)
fulguration
an ________is an abnormal passage.
fistula
Another term for small bowel prolapse is _______
enterocele
The nasopharynx is part of the pharynx and contains the tonsils.
true
Cheiloplasty refers to repair of the lips.
true
The digestive system aids the body in eliminating waste.
true
The mouth, throat, intestines, and anus are all structures of the digestive system.
true
The abdomen is the area of the body that lies between the thorax and the ______
pelvis
A type of hernia that pushes the stomach upward into the mediastinal cavity through the diaphragm is called a(n)_________
hernia.
hiatal
The anatomical structure that is positioned at the base of the esophagus on one end and connects to the duodenum on the other end is the ____________
stomach
An examination of the entire colon, from the rectum to the cecum, is known as a(n)______
colonoscopy
Antepartum care is the care rendered during the time prior to childbirth.
TRUE
A spontaneous abortion can be elective or therapeutic and is induced by medical personnel working within the law.
FALSE
Services such as fetal monitoring during labor, delivery of the placenta, and episiotomy are not included in most delivery services and should be coded separately.
false
During the second week through the eighth week of pregnancy, the embryo grows and develops into a fetus.
true
Delivery services include any workup performed relative to the admission and management of labor, as well as ultrasounds performed before the mother goes home from the hospital.
false; ultrasounds billed separately
VBAC stands for vaginal
birth after cesarean .
Another term for placenta is _________
chorionic villus
services that include hospital care and office visits immediately following birth, up to six weeks are called ______ services
postpartum
A procedure in which one or more fetuses are removed from the uterus in order to increase the chances of the survival of the strongest one is ______ ______ ______ abbreativted ________
multifetal, pregnancy, reduction, MPR
After a patient is evaluated, a management plan is implemented and recorded in the medical record.
True
A new patient is one who has not received face-to-face care from their provider within two years.
False
The ROS is the part of the note in which the provider documents any body system(s) that might be affected by the chief complaint.
TRue
An incorrect place of service can result in a rejection by insurance carriers.
true
To code a preventive physical exam, the coder must first determine the level of history the provider has recorded.
false
The location where care was rendered is called the
____ _____ ____ abbreviated _____
.
place of service, POS
services provided to a patient who is presenting for a well visit are called
________ _______ _____
preventive medicine
services.
Critical care codes are
time -based codes.
true
A patient who has not received face-to-face services from a provider of the same specialty within the same group practice would be considered a ________
patient.
new
A patient who has received face-to-face services from a provider of the same specialty within the same group practice would be considered a ______________
patient.
established
A service rendered by a provider when their opinion or expertise is requested by another provider or appropriate source is called a __________
consultation
An organized hospital-based facility that renders unscheduled episodic services to patients who require immediate attention is known as a
emergency department
, abbreviated ED
.
true
For services to a neonate in the intensive care unit to be coded with a 99479, the birth weight of the infant must fall between _________ grams and _____
grams.
1,500 and 2,500
