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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.
|The patient receives feeding or medication into the small intestine.
|The patient receives feeding or medication by injection route such as intravenously, subcutaneously, etc., not through the alimentary canal.
|The patient receives through the artery system.
|The patient receives through the venous system.
|The patient receives an injection into the muscular system. This is the most common method of administration.
|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.
|The patient receives the medication using various, often multiple means.
|The patient receives any other method not listed.
|The patient receives medication through the mouth, (orally).
|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.
|Required alphanumeric codes for emerging technology instead of unlisted codes.
|Optional alphanumeric codes for quality measures statistical data research and development purposes.
|Within the CPT code book, the guidelines are the pages or paragraphs prior to a series of codes.
|To identify or investigate for purposes of determining a condition or diagnosis.
|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.
|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.
|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.
|A critical inspection and investigation, usually following a particular method, performed for diagnostic or investigational purposes.
|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.
|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.