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CBCS_Coding_2
Term | Definition |
---|---|
consultation | service provided by a physician whose opinion or advice regarding an evaluation and/or advice regarding evaluation and/or management of a specific problem is requested by another physician or appropriate resource |
medical decision making, history, and exam | the three components of evaluation & management coding |
history | information about the patient's previous health care encounters, family health, and lifestyle |
medical decision making | the complexity of establishing a diagnosis and/or selecting a management or treatment option |
upcoding | selecting codes at a higher level than the level substantiated by the patient's record |
body system | what the cpt surgery section is organized by |
unbundling | billing for services that are a part of a surgical package individually |
modifiers | provide additional information about a service or procedure and are expressed as a two-digit number added on to the cpt code |
professional | component of radiology services done by radiologists, includes reading & interpreting & reading results of a radiology film |
technical | component of radiology services done by radiology technicians, includes expenses for supplies and equipment |
level II/national codes | healthcare common procedure coding system (hpcs) |
cpt alphabetic index | key to locating codes in cpt main sections |
triangle | placed before a cpt code, identifies a narrative description revision |
circled bullet | placed in front of a cpt code, indicates that the procedure includes moderation section |
separate procedures | often part of a more comprehensive procedure |