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Workbook Chap 6

CPT Coding

The coding system used for billing professional medical services and procedures is found in a book titled Current Procedural Terminology
The Medicare program uses a system of coding composed of two levels, and this is called Healtcare Common Procedure Coding System (HCPCS)
A medical service or procedure performed that differs in some way from the code description may be shown by using a CPT code with a Modifier
A relative value scale or schedule is a listing of procedure codes indicating the relative value of services performed, which is shown by unit values
Name three methods for basing payments adopted by insurance companies and by state and federal programs 1. Fee schedules 2. UCR - usual, customary and reasonable 3. Relative value scale
Name 4 situations that can occur in a practice when referring to charges and payments from a fee schedule 1. Medicare Par physician paid from Medicare fee schedule 2. Non-par physician paid based on limiting fee schedule 3. Managed care paid on basis of the fee schedule written into negotiated contract 4. Work related injuries paid using a WC fee schedule
Name the six sections of Category I in the CPT book 1. E/M 2. Anesthesiology 3. Surgery 4. Radiology, Nuc. Medicine, Ultrasound 5. Pathology and Lab 6. Medicine
Name five hospital departments where critical care of a patient takes place 1. Coronary care unit 2. Intensive care unit 3. Pediatric ICU 4. Respiratory care unit 5. Emergency care facility
A surgical package includes what? The operation Anesthesia (local infiltration, topical, metacarpal, metatarsal or digital block) E/M encounter day before or same day as surgery Immediate post-op care writing orders evaluating patient post-anesthesia recovery Post-op follow-up care
Medicare global surgery policy includes: Pre-operative visit (day before or of surgery) Intraoperative services that are usual and necessary part of the procedure and also includes: Complications of surgery that don't require added trips Post-op visits - variable post-op periods range from 0, 10, 30 or 90 day. Writing orders; evaluating patient in recovery & normal post-op pain mgmnt
A function of computer software that performs online checking of codes on an insurance claim to detect improper code submission is called code edits; code editing
A single code that describes two or more component codes bundled together as one unit is known as a comprehensive code
To group related codes together is commonly referred to as bundling
Use of many procedural codes to identify procedures that may be described by one code is termed unbundling
A code used on a claim that does not match the code system used by the third-party payer and is converted to the closest code rendering less payment is termed downcoding
Intentional manipulation of procedural codes to generate increased reimbursement is called upcoding
Some reasons for using modifiers on insurance claims include: To report either a professional or technical component of a service/procedure To report a service/procedure performed > one doc or in > one location To report a service has been increased or reduced Service provided >once Only part of service was performed Adjunctive service was performed Bilateral procedure was performed Unusual events occurred
What modifier is usually used when billing for an assistant surgeon who is not in a teaching hospital? -80
When is modifier -99 used? If a procedure requires more than one modifier code; -99 goes after the CPT code and added modifiers on separate lines
Unusual anesthesia modifier -23
Increased service modifier -22
Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service modifier -25
Professional component modifier -26
multiple procedures modifier -51
Reduced service modifier -52
Decision for surgery modifier -57
Staged or related procedure modifier - 58
Bilateral procedures modifier -50
Assistant surgeon modifier -80
Outside Lab modifier -90
Multiple modifiers modifier -99
The codes used to bill ambulance services, surgical supplies and durable medical equipment are Level II HCPCS national codes
A complex reimbursement system in which three fees are considered in calculating payment is known as Usual, customary and reasonable (UCR)
Medicare defines the postoperative global periods as 0, 10, 30 or 90 days
To code a bilateral procedure as two separate codes that include the same surgical approach may be referred to as unbundling
When two surgeons work together as primary surgeons performing distinct parts of a procedure and each doctor bills for performing their distince part of the procedure, the CPT surgical code is listed with modifier -62
True or False: Procedure coding is the transformation of written descriptions of procedures and professional services into numeric designations (code numbers) True
True or False: Category II codes describe clinical components that may be typically included in E/M services or clinical services True
True or False: When multiple lacerations have been repaired using the same technique and are in the same anatomic category, each repair should be assigned a code when billing an insurance claim False
True or False: When listing a steril tray for an in-office surgical procedure, the tray is bundled with the procedure unless additional supplies are needed in addition to those usually used. True
True or False: HCPCS Level II modifiers consist of only two alphanumeric characters False
I & D incision and drainage
IM intramuscular
Pap papanicolau smear
ER emergency
EEG electroencephalogram
DPT diphtheria, pertussis, tetanus
ECG electrocardiogram
IUD intrauterine device
OB obstetrics
D & C dilation and curettage
OV office visit
KUP kidney, ureter, bladder
GI gastrointestinal
Hgb hemoglobin
new pt new patient
rt right
UA urinalysis
est pt established patient
ASHD arteriosclerotic heart disease
tet.tox. tetanus toxoid
CBC complete blood count
E/M evaluation and management
CPT Current Procedural Terminology
Ob-Gyn Obstetrics Gynecology
TURP Transurethral resection of the prostate
cm centimeter
T & A tonsillectomy and adnoidectomy
mL milliliter
inj injection
hx history
NC no charge
Created by: mpeoples