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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
Created by: tina.reynolds