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Procedural coding
Vocab
| Term | Definition |
|---|---|
| number of digits in a code | five |
| current procedural terminology | a reference manual published by the American medical Association that contains procedural codes |
| January 1st | codes are updated every year on this date |
| number of main sections in the manual | 6 |
| procedural code | codes that represents a medical procedure, such as surgery and diagnostic tests, and medical services, such as an examination to evaluate a patient condition |
| evaluation and management | the section that is used frequently, and is therefore listed at the beginning of the manual |
| introduction section | in this section of the manual, you will find helpful information regarding common prefixes, suffixes, and root words |
| indented description | this description means that you refer back to the previous code description |
| add-on codes | a plus sign (+) is used to describe procedures done in addition to a main procedure |
| third party payer | a health plan that agrees to carry the risk of paying for patient services |
| appendix D | this appendix in the manual contains a complete listing of all add-on codes in the manual |
| instructional symbols | these are used to give repetitive information without adding multiple pages |
| blue triangle | this symbols tells the user that the code description has been revised in some way from last year |
| CMS | a Congressional agency designed to handle Medicare and Medicaid insurance claims |
| modifier | the use of this shows that one or more special circumstances apply to the service or procedure the physician performed |
| red dot | this symbols denotes a new code for this edition of the CPT |
| lightening bolt | this symbols denotes vaccines pending FDA approval |
| pound sign | this symbol is used to denote codes that are out of numeric sequence |
| bundled codes | any code that included more than one procedure in its description |
| bull's eye | this symbols denotes moderate sedation and means it is understood that conscious sedation is necessary for the procedure performed, so it is included; it cannot be billed separately |
| concurrent codes | similar care being provided by more than one physician |
| critical care | care provided to unstable, critically ill patients |
| consultation | patient visits or appointments provided at the request of other healthcare providers |
| counseling | considered part of the evaluation and management services, but if a complete history and physical exam does not take place, this code can be used |
| reimbursement | the payment that the health care provider or facility receives for providing a medical service |
| downcoding | a term used when the insurance carrier bases reimbursement on a code level lower than the one submitted by the provider |
| unbundling | is defined as breaking a bundled code into its component parts for higher reimbursement and is not allowed |
| up-coding | refers to coding a procedure or service at a higher level than that provided to receive a higher level of reimbursement |
| fraud | an act of deception that is used to take advantage of another person or entity |
| new patient | a patient that has not been seen in the practice within the last three years |
| patient history | this includes the chief complaint, history of present illness, review of systems, and social history |
| physical examination | an evaluation of the body and its function using inspection, palpation, percussion, and auscultation |
| established patient | a patient that has been seen by a practitioner of the same speciality in the same practice within 3 years |
| surgical package | grouped together, includes the preoperative exam and testing; the surgical procedure itself; including local and regional anesthesia if used; and routine follow-up for a set period of time |
| global period | period of time covered for follow-up care following surgery |
| superbill | a form that combines the charges for services rendered, an invoice for payment or insurance co-payment |
| CMS-1500 | the uniform professional health care insurance claim form in the United States |
| primary procedural | the principle reason for the patient encounter, this is listed first |
| clean claims | refers to claims in which each reported service is connected to a diagnosis that supports the procedure as necessary to investigate or treat the patient condition |
| claim fraud | occurs when physicians or other practitioners falsely represent their services or charges to payees |
| compliance plans | a process for finding, correcting, and preventing illegal medical office practices |
Created by:
dyturner-13
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