Business Practices Chp 17
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| when completing health insurance electronically, list the three types of codes required on the claim | ICD, CPT, HCPCS
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| what does the symbol + mean | add-on code
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| what does the symbol . (dot) mean | new code
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| what does the symbol (triangle) mean | revised code/changed
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| what is a bundled code | contains a group of one or more services that are related to a procedure
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| to code from the E&M (evaluation and management) section of CPT what 3 things must be deteremined | POS (place of service), TOS (type of service), patient status (new/est)
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| repairs of lacerations are coded according to what three things | length in cm, location, type of repair (simple, intermediate, severe)
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| when coding fractures, name 2 things that need to be determined | if it's open or closed, if it can be manipulated
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| surgical package rules are established by | AMA
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| global package rules are established by | centers for Medicaid and Medicare services
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| the documentation required in a pt's medical record when an injection is given includes | name of medication, amount of injection (in cc or grams), route of administration
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| ICD-10 replaced ICD-9 on what date | 10/1/13
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| qualified diagnosis | a condition coded as if it existed but has not been proven - qualified by "suspected, suspicion of, questionable, likely, probably or possible, rule out" - do not get coded
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| rule out (R/O) coding rule | cannot code something that says R/O - code instead actual diagnosis or sign and symptoms
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| to code diagnoses start in | volume 2 (index)
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| to verify the code refer to | volume 1 (description)
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| NEC | not elsewhere classifiable - used when medical record indicates more info avail but more specific code cannot be found
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| NOS | not otherwise specified - unspecified by physician - when more specific code cannot be identified
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| when coding burns name 3 elements in which burns are classified | degree of burn, extent - how much service in %, agent - what caused? oil, fire, etc.
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| when coding neoplasms name the 5 titles that codes are listed under | primary malignancy - original site of tumor, secondary malignancy -additional tumor (metastasis), carcinoma in situ - site of origin, neoplasm of uncertain behavior -not recognizable as benign or malignant, unspecified neoplasm - status not documented
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| major uses of procedures codes | justifies medical services, collects statistics about outcome & effectiveness of treatment, set fees depending on procedure, complexity, skill & length
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| Medicare modernization act of 2004 states | any new, revised and deleted codes must be implemented every January 1st
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| CPT manual provides | a five digit code and description for each procedure
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| how many sections of the CPT manual | six
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| what section of CPT is 99's | E&M evaluation and management - pt status, location, complexity of visit
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| what section of CPT is 00's | anesthesia - smallest section of the book
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| what section of CPT is 10-69 | Sx surgery - largest section & only section broken down into body system &/or organs
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| what section of CPT is 70 | radiology
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| what section of CPT is 80 | pathology & laboratory - all blood work, cultures, microbiology, etc
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| what section of CPT is 90 | medicine - includes ECG, physical therapy
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| how many digits are modifiers | two
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| how many digits are ICD codes | 3-7 digits
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| reasons for development of diagnosis codes | track disease, classify causes, collect data for research, evaluation of hospital service utilization
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| nonessential modifiers | ICD - in parentheses - words that may occur in the diagnosis but are not required
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| ICD breakdown | first three digits (alpha-numerical) = category, all digits thereafter = subcategory. After category - etiology, severity, anatomical location, duration (ESAD)
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| when coding from the surgery section of CPT the first thing you should do is | go to the index
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| NLP is used in | CAC
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| does not use consultation codes | Medicare
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| according to CPT a surgical package includes | the operation, certain types of anesthesia & postoperative visits within designated follow-up days
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| the sum of multiple laceration repairs can be added together if | they are in the same body area and are the same type of wound
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| code linkage | checking a diagnostic code against a procedure code
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| coding rule for etiology and manifestations is to | code the etiology in the first position and the manifestation in the second position
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| in diagnostic coding which symbol is used as a placeholder | an X
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| the two tables listed in ICD-10 are | neoplasm and table of drugs and chemicals
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| what is the ICD-10 code for hypothyroidism | E03.9
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| what is the ICD-10 code for DMII | E11.9
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| what is the ICD-10 code for HTN | I10
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| what is the ICD-10 code for hypercholestermia | E78.0
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| what is the ICD-10 code for hyperlipidemia | E78.5
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| HCPCS I & HCPCS II | additional coding books for CPT - both have temporary and permanent codes
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| RBRVS | Medicare are only ones to use this system
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| morbidity | presence of one disease
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| co-morbidity | presence of two or more diseases
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| mortality | cause of death
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| benign | neoplasms that are noninvasive and do not metastasize - noncancerous
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| malignant | harmful neoplasm that has the capability of spread and invading other tissues = cancer
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| acute | a disease that has a rapid onset and a short, severe course
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| chronic | a disease that progresses slowly and has a long duration
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| subacute | a disease that develops more slowly than acute but more rapidly than chronic
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| categories listed in V-Z are | external morbidities
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| referral | the transfer of pt care from one physician to another
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