study set Flashcards by Abihail Castillo

ARF (urinary)

acute renal failure

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BPH (urinary)

benign prostatic hypertrophy

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BUN (urinary)

blood, urea, nitrogen

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CRF(urinary)

chronic renal failure

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C&S (urinary)

culture and sensitivity

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cysto

cystoscopy

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ESRD

end stage renal disease

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ESWL (urinary)

extracorporeal shock-wave lithotripsy

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IVP (urinary)

intravenous pyelogram

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IVU

intravenous urography

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KUB (urinary)

kidneys, ureters, bladder

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PD (urinary)

peritoneal dialysis

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RP (urinary)

retrograde pyelogram

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TURP (urinary)

transurethral resection of the prostate

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U/A (urinary)

urinalysis

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UTI (urinary)

urinary tract infection

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VCUG (urinary)

voiding cystourethrogram

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The Structures found in the urinary system include ?

bilateral kidneys, bilateral ureters, the urinary bladder, and the urethra.

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The external sphincter controls the release of ?

the urine from the bladder

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The kidneys are located in the back of?

the body on either side of the vertebral column

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The ureters are?

muscular tubes that transport urine from the kidneys to the bladder.

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where is The urinary bladder located?

The urinary bladder is located in the pelvic cavity

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what does the urinary bladder serves as?

and serves as a temporary reservoir for the urine

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T OR F: The urethra is a mucous membrane-lined tube that transports urine from the bladder to be excreted from the body

TRUE

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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

1. maxillary sinus 2. ethmoid sinus 3. sphenoid sinus 4. 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

1. produce or service 2. organ or other anatomic site 3. condition 4. 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

fracture

ECHO

echocardiogram

CXR

chest x-ray

computed tomography

CAT

computed axial tomography

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 ___

The cpt manual contains ______ main sections (how many?)

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 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.

A complete listing of Level I modifiers commonly found in the CPT coding book can be found in appendix ____

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 ____

when a surgeon completes only the surgical care, modifier _____ should be appended to the cpt procedure code.

what is the 1st section of CPT?

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:

1. Is the patient a new or an established patient? 2. Where was the service provided? 3. 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

cardiac catheterization

CCU

coronary care unit

CHD

coronary heart disease

CHF

congestive heart failure

DVT

deep vein thrombosis

MVP

mitral valve prolapse

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

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