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Procedural Coding

What is counseling? A discussion between the physician and a patient, family, or both concerning the diagnosis, recommended studies or tests, prognosis, risks, and benefits of treatment, treatment options, patient and family education, etc.
What is a modifier? In CPT coding, a two-digit add-on number placed after the usual procedure code number to indicate a procedure or service has been altered by specific circumstances.
What is preventative medicine? Services provided to prevent the occurence of illness, injury, and disease
How is preventative medicine categorized? Codes are categorized by a patient's age
What is an observation status? Not formally admitted, on hold while a decision is made to admit or discharge based on the patient's condition observed
What is a follow-up consult? When the doctor is asked to follow up while the patient is admitted. Does not assume management of the patient's condition
How do you code a consult or a follow-up? After consult is complete and the physician assumes management of all the patient's conditions. Do not use follow-up codes. The patient becomes established and these codes are used
What are the contributory factors? Counseling, coordination of care, time, and nature of the presenting problem
What is a confirmatory consult? When the consulting doctor offers an opinion about the treatment plan after a diagnosis has been made
What is a referral and what way can they be used? The transfer of a specific or total care of a patient from one doctor to another for known problems. It is not a consult because a second opinion is not being requested. Also, an authorization for a patient to receive service.
What are E/M services? Services the physician provides to evaluate patients that were previously referred to as office, hospital, home visits
How many key components need to be present to assign a code? 3 of 3 for a new patient and 2 of 3 for an established patient
What are the key components used to I.D. the correct level of service? History, examination, and medical decision making
What is a consult? Services are rendered by a doctor who's opinion or advice is requested by another doctor to evaluate or treat a patient's illness
What is a consultation? Services rendered by a physician whose opinion or advice is requested by another physician or agency in the evaluation or treatment of a patient's illness or suspected problem
What is an office/outpatient consult? When the patient is seen in the office by a specialist
What is an initial new patient consult? The first visit by the consulting doctor
What is outpatient? Services received in an office, clinic, urgent care center, ER, or surgery center
What is a follow-up? When a patient comes back for a return visit
What are bundled services? Services grouped together that are related to a procedure
What is an inpatient? Someone who has been formerly admitted to the hospital or other health care facility for an overnight stay
What is emergency care? Health care services provided to prevent serious impairment of bodily functions or serious dysfunction to any body organ or part. Advanced life support may be necessary. Not all care provided in an emergency dept. can be termed emergency care
What is critical care? In reference to coding professional services, this phrase relates to intensive care provided in a variety of acute life-threatening conditions requiring constant bedside attention by a physician
What is an established patient? Someone who has received professional services within 3 years
What is a new patient? Someone who has no received any professional service in 3 years
What criteria needs to be met in order to bill 99211? (office visit) face-to-face contact with patient; physician must be in office; separate service must be provided; must have proper documentation
Created by: sanzijessica