Chapter's 13-22
Quiz yourself by thinking what should be in
each of the black spaces below before clicking
on it to display the answer.
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| Words that follow a code number in the CPT manual are called: | Procedure/Service Descriptor
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| Code that has all of the words that describe the code that follows is what type of code? | Stand Alone
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| CPT symbol ~ Hyphen | Range of Codes
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| CPT Symbol ~ Comma | Multiple codes
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| CBT Symbol ~ Triangle | Revised Code
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| CBT Symbol ~ Bullet | New Code
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| CPT Symbol ~ Bullseye | Moderate Sedation
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| CPT Symbol ~ <.........> | Revised Text
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| Where is specific coding information about each section located? | Guidelines
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| Unlisted procedures for use in a specific section of the CPT manual is contained in: | Guidelines
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| A procedure or service not found in the CPT manual, is located at the end of a subsection or subheading | Unlisted Procedure
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| Additions,deletions,and revisions can be found? | Appendix B
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| Modifiers can be found? | Appendix A
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| CPT | Current Procedural Terminolgoy
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| AMA | American Medical Association
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| Format of a CPT Code | 5 digits
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| The universal health insurance form for submission of outpatient services | CMS 1500
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| Identifies a code that is never used alone | Add on code
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| How many main sections are in the CPT manual? | 6
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| Provides additional information to the third-party payer | Modifier
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| This may affect the way payment is made by a third-party payer | Modifier
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| Past History | includes surgeries, drug allergies, etc
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| Family History | includes any disorders that may be hereditary or genetic; ie: diabetes, cancer, etc.
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| Social History | includes marital status, current employment, occupational history, use of drugs, level of education, sexual history
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| HPI | History of Present Illness
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| Different Elements of HPI | Location, Duration, Timing, Modifiying Factors, Associated Signs and Symptoms, Context, Quality, Severity
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| Level of E/M Service | Based on Documentation, Key Components, Contributing factors
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| What is the objective portion of the E/M Service? | Examination
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| MDM | Medical Decision Making
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| MDM is based on: | The number of diagnoses, Amount of data, and risk of mobidity the physican must consider about the management of patient's condition
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| When is time calculated for anesthesia services? | The time begins when the anesthesiologist begins preparing the patient for anesthesia
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| CRNA | Certified Registered Nurse Anesthesiologist
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| CRNA is | Type of nurse who can administer anesthesia under the direction of an anesthesiologist
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| Qualifiying Circumstances = | Used when the administration of the anesthesia is more difficult
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| Physical Modifiers | The anesthesia status modifier that indicates the patient's condition at the time anesthesia was administered
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| The type of sedation that allows a procedure to be performed without pain to the patient, but the patient is not completely alseep | Conscious or Moderate Sedation
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| The Anesthesia Formula is: | B+T+M
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| What accompanies an unlisted code? | Special Report
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| Is general anesthesia included in the surgical package? | No
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| What is the global period for Major Surgery Procedures? | 90 days
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| What is the global period for Minor Surgery Procedures? | 10 days
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| Placed afer some codes in the CPT manual and contains helpful information | Parenthical Information
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| Division of the Surgery section are based on: | Body System
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| "Margins" refer to: | the narrowest margin required to adequatley excise the lesion based on tghe physican's judgement
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| Rule of Nines |
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| Info needed to correctly code for local treatment of burns | Percentage of body surface and depth of burn
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| What Modifier is this? - Same physican performs an unrelated procedure on the same patient whithin global period | -79
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| What modifer is this? Staged Procedure | -58
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| To properly code a lesion excision, you must know the following | Behavior, the narrowest margin, Site, Number and Diameter
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| The method used by the physician to obtain a lesion biopsy depends on | the size and type
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| Reduction aka | Manipulation
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| What is manuipulation | Restoration of a fracture or dislocation to its normal anatomic alignment by the application of manually applied force
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| Types of fracture treatment | Open, Closed, Percutaneous
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| Fracture Codes are based on | Treatment Type
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| Skeletal Treatment | Use of force applied to internal device inserted into bone
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| Skin Traction | Traction by use of strapping, elastic wraps, or tape
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| Cranial Halo is a form of | External Fixation
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| Advantages of endoscopy/arthoscopy | 1. Less Risky
2. Less Room for infection
3. Faster Healing Time
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| A bunionectomy is a | Hallux Calgus Correction
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| A diagnostic endoscopic procedure is reported only when | no surgical procedure is performed during the same operative session
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| This is key in documentation in the respiratory system | Medical Necessity
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| Methods that a physician uses to control a nosebleed | Packing, Cauterization, Ligation
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| Lavage | Washing
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| Thoracentesisis performed to | withdraw fluid from the pleural space usually due to respiratory failure
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| Scope placed into a body cavity | Endoscopy
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| Surgical procedure is performed to reshape the nose | Rhinoplasty
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| Surgical procedure for the rearrangement of the nasal septum | Septoplasty
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| incision made over the laryx | Laryngotomy
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| Establishment of an airway | Intubation
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| Creation of an opening into the trachea | Tracheostomy
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| Repair of a damaged trachea | Tracheoplasty
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| Free flow or withdrawal of fluids from a wound or cavity | Drainage
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| Invasive | Break in Skin
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| Non-invasive | Non break in skin
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| The correct order from largest to smallest division of the CPT hierarchy in the CPT manual is Section, Subsection, _____, Category | Subheading
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| Appendix C of the CPT Manual contains examples of______ Codes | E/M
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| There are two types of codes, but only _____ codes have the full description | Stand Alone
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| The index of the CPT Manual is in alphabetic order with the ______ listed first and then further divided by subterm | Main Term
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| These codes are Category I procedure codes that are considered unusual, experimental, or new and do not have a specific code to be assigned | Unlisted Procedure
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| A code that has all of the words that describe the code that follows is what type of code? | Stand Alone
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| Which puncuation mark between codes in the index of the CPT manual indicated a range of codes is available? | Hyphen
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| Which puncuation mark between codes in the index of the CPT manual indicates two codes are available? | Comma
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| In which CPT appendix would additions, deleation, and revisions be found? | Appendix B
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| In which CPT appendix would all modifiers be found? | Appendix A
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| This act mandated the adoption of national uniform standards for eletronic transmission of financial and administrative health information | HIPAA
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| Who publishes CPT? | AMA
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| What is the function of an add-on code? | indentifies a code that is never used alone
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| <.......> | Revised text
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| ^ | Revised Code
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| Bullet | New Code
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| + | Add-on Code
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| Circle with a line thru it | Modifier -51 modifier
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| CPT | Current Procedural Terminology
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| HCPCS | Healthcare Common Procedure Coding System
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| AMA | American Medical Association
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| CMS | Centers for Medicare and Medicaid Services
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| What are the four elements of history? | 1. Chief Complaint
2. History of Present Illness
3. Review of Systems
4. Past, Family, Social History
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| Complexity of Medical Decision Making is based on what three elements? | 1. Diagnosis
2. Data
3. Risk
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| What are the three key components that are present in every patient case, except counseling encounters or time-based codes, and enable the coder to choose the appropriate level of services? | 1. History
2. Examination
3. Meidcal Decsion Making
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| The words that follow a code number in the CPT manual are called | Procedure/ Service Descriptor
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| A code that has all of the words that describe the code that follows is what type of code? | Stand Alone
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| A list of unlisted procedures for use in a specific section of the CPT manual is contained in | Guidelines
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| CPT Codes have how many digits? | 5
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| The universal health insurance form for submission of outpatient services is | CMS 1500
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| How many main sections are in the CPT Manual | 6
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| A modifier | Provides additional information to the third-party payer
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| These elements would be part of what kind of history? Employment, education, use of drugs | Social
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| The level of E/M service is based on | Documentation, Key Components, Contributing Factors
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| The examination is what portion of the E/M Service | Objective
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| MDM is based on | Number of diagnoses, risk of morbidity, amount of data
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| The request for advice or opinion from one physician to another physician is this type of service | Consultation
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| Whan a physcian performs a preventative care service, the extent of the exam is determined by the | Age
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| The ____ section Guidelines contain the definition of the chief complaint | E/M
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| Appendix C of the CPT manual contains examples of what type of codes | E/M
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| An established patient is one who has received face to face professional services from the physician or another physican of the same specialty in the same group within the past how many years | 3
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| The term used to describe a patient who has NOT been formally admitted to a health care facility is | outpatient
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| The four types of patient status are | 1. New
2. Established
3. Inpatient
4. Outpatient
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| A statement describing the reason for the encounter and is a history element | Chief Complaint
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| Modifiers may affect | the way payment is made by a third party payer
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| Modifier -57, decision for surgery, is used on what type of service | E/M
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| Modifier -51, multiple procedure, is used on what type of services | Surgery
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| Modifier -32 is used to indicate a service is mandated. What is an example of when a service is mandated? | An insurance company REQUIRES a second opionion
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| Modifier -25, significant, seperately idendifiable E/M service by the same physician on the same day of procedure or other service, is used to report an E/M service that was | Provided on the same day as a minor procedure performed by the same physician
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| Modifier -58, staged or related procedure or service by the same physician during the postoperative period is used to indicate | that a subsequent surgery was planned at the time of the first surgery
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| Modifier -52, reduced services, is used to indicate | a service was reduced without changing the definition of the code
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| The modifier that indicates only the professional componet of the service was provided is | -26
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| Example of HPI Location | Chest
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| Example of HPI Modifiying Factor | Some relief with rest
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| Example of HPI Severity | Worst I've ever had
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| Example of HPI Duration | Since Last Night
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| Example of HPI Timing | Continuous
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| To remedy, replace or heal | Repair
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| suffix for molding or surgically forming | -plasty
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| Free flow or withdrawal of fluids from a wound or cavity | Drainage
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| Cutting or taking away | Excision
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| To unite parts by stiching them togehter | Suture
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| Inspection of body organs or cavities by the use of a lighted scope that may be placed through an existing opening or through a small incision | Endoscopy
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| Scraping of a cavity using a spoon-shaped instrument | Curettage
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| Forcing a fluid into a vessel or cavity | Injection
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| Suffix for suturing | -rrhaphy
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| suffix for puncture of a cavity | -centesis
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| suffix for removal of part of all of an organ of the body | -ectomy
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| Removal of a small piece of living tissue for diagnostic examination | Biopsy
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| Surgically cutting into | Incision
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| Binding or typing off, as in constricting blood flow | Ligation
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| suffix for incision into | -otomy
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| 99100 is an example of a | Qualifiying Circumstance
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| In the Anesthesia Section of the CPT manual, the codes are usually divided FIRST by | Anatomic Site
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| The society that publishes the Relative Value Guide for anesthesia services is the | American Society of Anesthesiologists
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| Which codes begin with the number 99 and are used to indicate anesthesia services provided during sitations that make the administration of the anesthesia more difficult? | Qualifying Circumstances
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| The anesthesia status modifier that indicates the patient's condition at the time anesthesia was administered is | Physical
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| The global surgery period includes | All routine preoperative and postoperative care
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| What are the divisions of the Surgery section based on | Body System
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| Represents the contents of a surgical package | Preoperative, intraoperative, and postoperative services
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| Using the Rule of Nines, two adult Legs are what percentage | 36 (18 on each leg; 9 front, 9 back each)
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| What two items are needed to correctly code for local treatment of burns | percentage of body surface and depth of burn
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| There is no tissue remaining for pathological examination after this method has been used | Destruction
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| Which treatment of a fracture requires the fracture to be exposed to view or opened at a remote site for nailing across the fracture | Open
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| Which of the following terms describes traction by use of strapping, elastic wrap, or tape | Skin Traction
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| This type of graft is often taken from the upper thigh area | Fascia Lata
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| Insertion of a device into the muscle to measure the pressure within the muscle is monitoring of | Interstitial Fluid Pressure
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| Fast becoming the treatment of choice for many orthopedic surgical procedure is what type of procedure | Endoscopy/Arthroscopy
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| Open TREATMENT of a fracture is when the | fracture site is surgically opened and visualized or opened remotely
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| Endoscopic procedures are reported on the ____ place to which the scope is advanced | Farthest
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| Because most third party payers do not pay for cosmetic surgery, the physician must carefully document ____ to ensure reimbursement for non cosmetic procedures | Medical Necessity
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| If the physican performs a lavage of the maxillary sinus, what is he/she doing? | washing the maxillary sinus
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| Thoracentesis is performed to withdraw fluid from the pleural space for a variety of conditions including | respirator failure
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| In what surgery subsection would you find the code for the incision and drainage of a nasal abscess using an EXTERNAL approach to the abcess | Integumentary System
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| Incision made over the larynx | Laryngotomy
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| Establishment of an airway | Intubation
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| Removal by cutting | Ablation
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| Destruction of tissue by burning | Cauterization
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| Fixation of a joint | Arthodesis
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| Bone is displaced from the normal joint | Dislocation
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| ____ cardiology is entering the body to make a correction or for examination | Invasive
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| Supervision and interpretation codes for angiography are located where in the CPT manual? | Radiology Section
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| An example of a non-invasive cardiology procedure service is | Cardiovascular Stress Test
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| The device that can be inserted into the body to electrically shock the heart into regular rythm | Cardioverter-Defibrillator
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| Pacemaker insertion codes are divided based on the surgical | Approach
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| What is the name of the eletrodes that are placed into the atrium and/or ventricle of the heart when a pacemaker is inserted | Leads
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| What are the three sections of the CPT Manual that you use to code many cardiovascular services | 1. Surgery
2. Radiology
3. Medicine
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| The number of postoperative days usually assigned for the global period following implantation of a pacemaker is | 90
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| A mass of undissolved matter that is present in blood and is transported by the blood | Embolus
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| Cardiovascular stress test codes are used for | Excercise-induced studies and Pharmacologically-induced studies
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| If the clinic physicain performs the catherization procedure at the hospital, which modifier would you append to the catherization code | -26
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| If a clinic owns its own x-ray equipment, what modifier would be used when coding the supervision and interpretation of a cardiac catherization | No modifier
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| Manufactures most blood cells | Bone Marrow
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| The spleen is composed of this material that also surrounds veins and arteries | Lymph Tissue
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| A malignant disease of the bone marrow in which excesive white blood cells are producced | Leukemia
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| Mediastinum codes are identified by which factor | Surgical Approach
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| This type of lymphadenectomy is the removal of the lymph nodes, glands, and surrounding tissues | Radical
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| The lymph node excision category codes are based on what two things | 1. method
2. location
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| How many categories are located in the Mediastinum subheading | 4
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| A diaphragmatic hernia is also known as a | Esophageal hiatal hernia
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| This bone marrow is taken from a close relative, so there is a genetic similarity | Allogenic
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| This bone marrow is collected from the patient and later transplanted or reinfused back into the patient from whom it came | Autologenic
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| What word describes a lymphadenectomy in which only thhe lymph nodes are removed | Limited
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| What is it called when the diaphragm is out of normal position and has moved up farther into the thoracic cavity | Eventration
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| A procedure in which fluid is withdrawn from the space around the heart through a needle and a catheter is left in to allow for continued drainage | Pericariocentesisis
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