| Question | Answer |
| 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 |
