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HCPCS Level 2

Understanding Medical Coding

Healthcare Common Procedure Coding System Level 2 (HCPCS Level II) The second level of the coding system created by CMS for reporting of procedures, services, supplies, medications, equipment, and items.
Table of Drugs A comprehensive list of non-oral drugs by both technical and brand names that include the route of administration and dose information for reporting purposes.
Enteral The patient receives feeding or medication into the small intestine.
Parenteral The patient receives feeding or medication by injection route such as intravenously, subcutaneously, etc., not through the alimentary canal.
Intra-arterial (IA) The patient receives through the artery system.
Intravenous (IV) The patient receives through the venous system.
Intramuscular (IM) The patient receives an injection into the muscular system. This is the most common method of administration.
Intrathecal (IT) The patient receives through the membrane.
Inhaled Solution (INH) The patient inhales the medication, may use respiratory equipment commonly known as the Intermittent Positive Pressure Breathing treatment.
Injection Not Otherwise Specified (INJ) The patient receives an injection other than the options listed, such as intradermal or an injection directly into anatomy.
Various (VAR) The patient receives the medication using various, often multiple means.
Other (OTH) The patient receives any other method not listed.
Orally (ORAL) The patient receives medication through the mouth, (orally).
Modifier A 2 digit number placed after the usual procedural code, which represents a particular explanation to further describe the procedure/service or circumstances involved with the procedure.
Category 3 Required alphanumeric codes for emerging technology instead of unlisted codes.
Category 2 Optional alphanumeric codes for quality measures statistical data research and development purposes.
CPT Guidelines Within the CPT code book, the guidelines are the pages or paragraphs prior to a series of codes.
Diagnostic To identify or investigate for purposes of determining a condition or diagnosis.
Therapeutic To achieve a therapeutic result or to treat a condition or diagnosis.
Evaluation and Management Service (E/M) The first section of the CPT coding manual that describes office visits, hospital visits, nursing facility visits, and consultations.
Professional Services A face-to-face service rendered by a physician and reported by a specific CPT code.
Nature of Presenting Problem (NPP) A presenting problem may be a complaint, disease, illness, condition, sign or symptom, injury, finding or other reason for an encounter.
History A record of past events; a systematic account of the medical emotional, and psychosocial occurrences in a patient's life and of factors in the family, ancestors, and environment that may have a bearing on the patient's condition.
Medical Decision Making The complexity of establishing a diagnosis and/or selection a management option.
Chief Complaint (CC) A subjective statement made by a patient describing his or her most significant or serious symptoms or sign of illness or dysfunction.
History of Present Illness (HPI) Inquiry from the first sign or symptom through today of the patient's experiences that associate to the chief complaint and reason fort the visit.
Review of Systems(ROS) Inquiry of the signs or symptoms that define the problem affecting the body systems.
Past, Family, and Social History (PFSH) Pertinent inquiry of the patient's history of the illness, family history, and social history with specific documentation required.
Examination A critical inspection and investigation, usually following a particular method, performed for diagnostic or investigational purposes.
Counseling The act of providing advice and guidance to a patient and his or her family.
Coordination of Care The arrangement and/or organization of patent care to include all health care providers.
Consultation A type of service provided by a physician (usually a specialist) whose opinion or advice regarding evaluation and management of a specific problem is requested by another physician or other appropriate source.
Created by: jeffypop