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TERMS-CHAPTER 5
Medical Office Proc.-CPT Coding
| Question | Answer |
|---|---|
| Current Procedural Terminology | CPT- a publication of the American Medical Assoc. |
| Procedure codes found in the main body of CPT- Evaluation & Management. Anesthesia, surgery, pathology & laboratory, radiology and medicine | Category I Codes |
| Optional CPT codes that track performance measures for a medical goal such as reducing tobacco use | Category II Codes |
| temporary codes for emerging technology, services, and procedures that are used instead of unlisted codes when available | Catergory III Codes |
| the narrative part of a CPT code that identifies the procedure or service | descriptor |
| usuage notes provided at the beginning of CPT sections | section guidelines |
| a service that is not listed in CPT; it is reported w/ an unlisted procedure code and requires a special report when used | unlisted procedure |
| note explaining the reasons for a new variable or unlisted procedure or service; describes the patients condition and justifies the procedures medical necessity | special report |
| procedure that is performed and reported only in addition to a primary procedure; indicated in CPT by a plus sign (+) | Add-on code |
| procedure performed in addition to the primary procedure | secondary procedure |
| the most resource-intensive (highest) paid CPT procedure done during a patient's encounter. | primary procedure |
| moderate, drug-induced depression of consciousness | conscious sedation |
| a number that is appended to a code to report particular facts. CPT modifers report special circumstances involved with a procedure or service. HCPC's modifers are often used to designate a body part, such as left side or right side. | modifier |
| the part of the relative value associated with a procedure code that reflects the technician's work and the equipment and supplies used in performing it; in contrast to the professional component | technical component |
| the part of the relative value associated with a procedure code that represents a physician's skill, time, and expertise used in performing it; contrast w/ the technical component | professional component (PC) |
| service performed by a physician to advise a requesting physician about a patient's condition and care; the consult does not assume responsibility for the patient's care and must send a written report back to the requestor | consultation |
| factor req'd to be documented for various levels of evaluation and management services | key components |
| a patient who receives health care in a hospital setting without admission; the length of stay is generally less than 23 hrs | outpatient |
| combination of services included in a single procedure code for some surgical procedures in CPT | Surgical Package |
| Global Surgery Rule | Surgical Package |
| the number of days surrounding a surgical procedure during which all services relating to the procedure- preoperative, during the surgery, and postoperative are considered part of the surgical package and are not additionally reimbursed | Global Period |
| descriptor used in the surgery section of CPT for a procedure that is usually part of a surgical package but may also be performed separately or for a different purpose, in which case it may be billed | seperate procedure |
| the incorrect billing practice of breaking a panel or package of services/procedures into component parts and reporting them separately | unbundling |
| incorrect billing practice in which procedures covered under a single bundled code are unbundled and separately reported | fragmented billing |
| supplemental medical services such as diagnostic services and occupational therapy that supports the diagnosis and treatment of patient's conditions | ancillary services |
| a bullet(a solid circle) indicates what | a new procedure code. It appears only next to the code only the year that it it listed |
| a triangle indicates what | indicates that the descriptor has changed. it only appears the year the descriptor is revised |
| facing triangles indicate what | enclose a new or revised text other than the code's descriptor |
| the 3 Rs Coders should remember | Request opinion, Render service, report back |
| PMH- Abbreviation for... | Past Medical History |
| FH- Abbreviation for... | Family History |
| SH- Abbreviation for... | Social History |
Created by:
Tina Everett