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MBC Final Exam

Chapter's 13-22

Words that follow a code number in the CPT manual are called: Procedure/Service Descriptor
Code that has all of the words that describe the code that follows is what type of code? Stand Alone
CPT symbol ~ Hyphen Range of Codes
CPT Symbol ~ Comma Multiple codes
CBT Symbol ~ Triangle Revised Code
CBT Symbol ~ Bullet New Code
CPT Symbol ~ Bullseye Moderate Sedation
CPT Symbol ~ <.........> Revised Text
Where is specific coding information about each section located? Guidelines
Unlisted procedures for use in a specific section of the CPT manual is contained in: Guidelines
A procedure or service not found in the CPT manual, is located at the end of a subsection or subheading Unlisted Procedure
Additions,deletions,and revisions can be found? Appendix B
Modifiers can be found? Appendix A
CPT Current Procedural Terminolgoy
AMA American Medical Association
Format of a CPT Code 5 digits
The universal health insurance form for submission of outpatient services CMS 1500
Identifies a code that is never used alone Add on code
How many main sections are in the CPT manual? 6
Provides additional information to the third-party payer Modifier
This may affect the way payment is made by a third-party payer Modifier
Past History includes surgeries, drug allergies, etc
Family History includes any disorders that may be hereditary or genetic; ie: diabetes, cancer, etc.
Social History includes marital status, current employment, occupational history, use of drugs, level of education, sexual history
HPI History of Present Illness
Different Elements of HPI Location, Duration, Timing, Modifiying Factors, Associated Signs and Symptoms, Context, Quality, Severity
Level of E/M Service Based on Documentation, Key Components, Contributing factors
What is the objective portion of the E/M Service? Examination
MDM Medical Decision Making
MDM is based on: The number of diagnoses, Amount of data, and risk of mobidity the physican must consider about the management of patient's condition
When is time calculated for anesthesia services? The time begins when the anesthesiologist begins preparing the patient for anesthesia
CRNA Certified Registered Nurse Anesthesiologist
CRNA is Type of nurse who can administer anesthesia under the direction of an anesthesiologist
Qualifiying Circumstances = Used when the administration of the anesthesia is more difficult
Physical Modifiers The anesthesia status modifier that indicates the patient's condition at the time anesthesia was administered
The type of sedation that allows a procedure to be performed without pain to the patient, but the patient is not completely alseep Conscious or Moderate Sedation
The Anesthesia Formula is: B+T+M
What accompanies an unlisted code? Special Report
Is general anesthesia included in the surgical package? No
What is the global period for Major Surgery Procedures? 90 days
What is the global period for Minor Surgery Procedures? 10 days
Placed afer some codes in the CPT manual and contains helpful information Parenthical Information
Division of the Surgery section are based on: Body System
"Margins" refer to: the narrowest margin required to adequatley excise the lesion based on tghe physican's judgement
Rule of Nines
Info needed to correctly code for local treatment of burns Percentage of body surface and depth of burn
What Modifier is this? - Same physican performs an unrelated procedure on the same patient whithin global period -79
What modifer is this? Staged Procedure -58
To properly code a lesion excision, you must know the following Behavior, the narrowest margin, Site, Number and Diameter
The method used by the physician to obtain a lesion biopsy depends on the size and type
Reduction aka Manipulation
What is manuipulation Restoration of a fracture or dislocation to its normal anatomic alignment by the application of manually applied force
Types of fracture treatment Open, Closed, Percutaneous
Fracture Codes are based on Treatment Type
Skeletal Treatment Use of force applied to internal device inserted into bone
Skin Traction Traction by use of strapping, elastic wraps, or tape
Cranial Halo is a form of External Fixation
Advantages of endoscopy/arthoscopy 1. Less Risky 2. Less Room for infection 3. Faster Healing Time
A bunionectomy is a Hallux Calgus Correction
A diagnostic endoscopic procedure is reported only when no surgical procedure is performed during the same operative session
This is key in documentation in the respiratory system Medical Necessity
Methods that a physician uses to control a nosebleed Packing, Cauterization, Ligation
Lavage Washing
Thoracentesisis performed to withdraw fluid from the pleural space usually due to respiratory failure
Scope placed into a body cavity Endoscopy
Surgical procedure is performed to reshape the nose Rhinoplasty
Surgical procedure for the rearrangement of the nasal septum Septoplasty
incision made over the laryx Laryngotomy
Establishment of an airway Intubation
Creation of an opening into the trachea Tracheostomy
Repair of a damaged trachea Tracheoplasty
Free flow or withdrawal of fluids from a wound or cavity Drainage
Invasive Break in Skin
Non-invasive Non break in skin
The correct order from largest to smallest division of the CPT hierarchy in the CPT manual is Section, Subsection, _____, Category Subheading
Appendix C of the CPT Manual contains examples of______ Codes E/M
There are two types of codes, but only _____ codes have the full description Stand Alone
The index of the CPT Manual is in alphabetic order with the ______ listed first and then further divided by subterm Main Term
These codes are Category I procedure codes that are considered unusual, experimental, or new and do not have a specific code to be assigned Unlisted Procedure
A code that has all of the words that describe the code that follows is what type of code? Stand Alone
Which puncuation mark between codes in the index of the CPT manual indicated a range of codes is available? Hyphen
Which puncuation mark between codes in the index of the CPT manual indicates two codes are available? Comma
In which CPT appendix would additions, deleation, and revisions be found? Appendix B
In which CPT appendix would all modifiers be found? Appendix A
This act mandated the adoption of national uniform standards for eletronic transmission of financial and administrative health information HIPAA
Who publishes CPT? AMA
What is the function of an add-on code? indentifies a code that is never used alone
<.......> Revised text
^ Revised Code
Bullet New Code
+ Add-on Code
Circle with a line thru it Modifier -51 modifier
CPT Current Procedural Terminology
HCPCS Healthcare Common Procedure Coding System
AMA American Medical Association
CMS Centers for Medicare and Medicaid Services
What are the four elements of history? 1. Chief Complaint 2. History of Present Illness 3. Review of Systems 4. Past, Family, Social History
Complexity of Medical Decision Making is based on what three elements? 1. Diagnosis 2. Data 3. Risk
What are the three key components that are present in every patient case, except counseling encounters or time-based codes, and enable the coder to choose the appropriate level of services? 1. History 2. Examination 3. Meidcal Decsion Making
The words that follow a code number in the CPT manual are called Procedure/ Service Descriptor
A code that has all of the words that describe the code that follows is what type of code? Stand Alone
A list of unlisted procedures for use in a specific section of the CPT manual is contained in Guidelines
CPT Codes have how many digits? 5
The universal health insurance form for submission of outpatient services is CMS 1500
How many main sections are in the CPT Manual 6
A modifier Provides additional information to the third-party payer
These elements would be part of what kind of history? Employment, education, use of drugs Social
The level of E/M service is based on Documentation, Key Components, Contributing Factors
The examination is what portion of the E/M Service Objective
MDM is based on Number of diagnoses, risk of morbidity, amount of data
The request for advice or opinion from one physician to another physician is this type of service Consultation
Whan a physcian performs a preventative care service, the extent of the exam is determined by the Age
The ____ section Guidelines contain the definition of the chief complaint E/M
Appendix C of the CPT manual contains examples of what type of codes E/M
An established patient is one who has received face to face professional services from the physician or another physican of the same specialty in the same group within the past how many years 3
The term used to describe a patient who has NOT been formally admitted to a health care facility is outpatient
The four types of patient status are 1. New 2. Established 3. Inpatient 4. Outpatient
A statement describing the reason for the encounter and is a history element Chief Complaint
Modifiers may affect the way payment is made by a third party payer
Modifier -57, decision for surgery, is used on what type of service E/M
Modifier -51, multiple procedure, is used on what type of services Surgery
Modifier -32 is used to indicate a service is mandated. What is an example of when a service is mandated? An insurance company REQUIRES a second opionion
Modifier -25, significant, seperately idendifiable E/M service by the same physician on the same day of procedure or other service, is used to report an E/M service that was Provided on the same day as a minor procedure performed by the same physician
Modifier -58, staged or related procedure or service by the same physician during the postoperative period is used to indicate that a subsequent surgery was planned at the time of the first surgery
Modifier -52, reduced services, is used to indicate a service was reduced without changing the definition of the code
The modifier that indicates only the professional componet of the service was provided is -26
Example of HPI Location Chest
Example of HPI Modifiying Factor Some relief with rest
Example of HPI Severity Worst I've ever had
Example of HPI Duration Since Last Night
Example of HPI Timing Continuous
To remedy, replace or heal Repair
suffix for molding or surgically forming -plasty
Free flow or withdrawal of fluids from a wound or cavity Drainage
Cutting or taking away Excision
To unite parts by stiching them togehter Suture
Inspection of body organs or cavities by the use of a lighted scope that may be placed through an existing opening or through a small incision Endoscopy
Scraping of a cavity using a spoon-shaped instrument Curettage
Forcing a fluid into a vessel or cavity Injection
Suffix for suturing -rrhaphy
suffix for puncture of a cavity -centesis
suffix for removal of part of all of an organ of the body -ectomy
Removal of a small piece of living tissue for diagnostic examination Biopsy
Surgically cutting into Incision
Binding or typing off, as in constricting blood flow Ligation
suffix for incision into -otomy
99100 is an example of a Qualifiying Circumstance
In the Anesthesia Section of the CPT manual, the codes are usually divided FIRST by Anatomic Site
The society that publishes the Relative Value Guide for anesthesia services is the American Society of Anesthesiologists
Which codes begin with the number 99 and are used to indicate anesthesia services provided during sitations that make the administration of the anesthesia more difficult? Qualifying Circumstances
The anesthesia status modifier that indicates the patient's condition at the time anesthesia was administered is Physical
The global surgery period includes All routine preoperative and postoperative care
What are the divisions of the Surgery section based on Body System
Represents the contents of a surgical package Preoperative, intraoperative, and postoperative services
Using the Rule of Nines, two adult Legs are what percentage 36 (18 on each leg; 9 front, 9 back each)
What two items are needed to correctly code for local treatment of burns percentage of body surface and depth of burn
There is no tissue remaining for pathological examination after this method has been used Destruction
Which treatment of a fracture requires the fracture to be exposed to view or opened at a remote site for nailing across the fracture Open
Which of the following terms describes traction by use of strapping, elastic wrap, or tape Skin Traction
This type of graft is often taken from the upper thigh area Fascia Lata
Insertion of a device into the muscle to measure the pressure within the muscle is monitoring of Interstitial Fluid Pressure
Fast becoming the treatment of choice for many orthopedic surgical procedure is what type of procedure Endoscopy/Arthroscopy
Open TREATMENT of a fracture is when the fracture site is surgically opened and visualized or opened remotely
Endoscopic procedures are reported on the ____ place to which the scope is advanced Farthest
Because most third party payers do not pay for cosmetic surgery, the physician must carefully document ____ to ensure reimbursement for non cosmetic procedures Medical Necessity
If the physican performs a lavage of the maxillary sinus, what is he/she doing? washing the maxillary sinus
Thoracentesis is performed to withdraw fluid from the pleural space for a variety of conditions including respirator failure
In what surgery subsection would you find the code for the incision and drainage of a nasal abscess using an EXTERNAL approach to the abcess Integumentary System
Incision made over the larynx Laryngotomy
Establishment of an airway Intubation
Removal by cutting Ablation
Destruction of tissue by burning Cauterization
Fixation of a joint Arthodesis
Bone is displaced from the normal joint Dislocation
____ cardiology is entering the body to make a correction or for examination Invasive
Supervision and interpretation codes for angiography are located where in the CPT manual? Radiology Section
An example of a non-invasive cardiology procedure service is Cardiovascular Stress Test
The device that can be inserted into the body to electrically shock the heart into regular rythm Cardioverter-Defibrillator
Pacemaker insertion codes are divided based on the surgical Approach
What is the name of the eletrodes that are placed into the atrium and/or ventricle of the heart when a pacemaker is inserted Leads
What are the three sections of the CPT Manual that you use to code many cardiovascular services 1. Surgery 2. Radiology 3. Medicine
The number of postoperative days usually assigned for the global period following implantation of a pacemaker is 90
A mass of undissolved matter that is present in blood and is transported by the blood Embolus
Cardiovascular stress test codes are used for Excercise-induced studies and Pharmacologically-induced studies
If the clinic physicain performs the catherization procedure at the hospital, which modifier would you append to the catherization code -26
If a clinic owns its own x-ray equipment, what modifier would be used when coding the supervision and interpretation of a cardiac catherization No modifier
Manufactures most blood cells Bone Marrow
The spleen is composed of this material that also surrounds veins and arteries Lymph Tissue
A malignant disease of the bone marrow in which excesive white blood cells are producced Leukemia
Mediastinum codes are identified by which factor Surgical Approach
This type of lymphadenectomy is the removal of the lymph nodes, glands, and surrounding tissues Radical
The lymph node excision category codes are based on what two things 1. method 2. location
How many categories are located in the Mediastinum subheading 4
A diaphragmatic hernia is also known as a Esophageal hiatal hernia
This bone marrow is taken from a close relative, so there is a genetic similarity Allogenic
This bone marrow is collected from the patient and later transplanted or reinfused back into the patient from whom it came Autologenic
What word describes a lymphadenectomy in which only thhe lymph nodes are removed Limited
What is it called when the diaphragm is out of normal position and has moved up farther into the thoracic cavity Eventration
A procedure in which fluid is withdrawn from the space around the heart through a needle and a catheter is left in to allow for continued drainage Pericariocentesisis
Created by: iamamandataylor