CPT Coding 2014

Axillary nodes
lymph nodes located in the armpit
splenectomy
excision of the spleen
splenoportography
radiographic procedure to allow visualiztion of the splenic and portal veins of the spleen
allogenic
of the same species, but genetically different
thoracic duct
collection and distribution point for lymph and the largest lymph vessel located in the chest
retroperitoneal
behind the sac holding the abdominal organs and viscera (peritoneum)
jugular nodes
lymph nodes located next to the large vein in the neck
cystic hygroma
congenital deformity or benign tumor of the lymphatic system
Cloquet’s node
also called a gland; it is the highest of the deep groin lymph nodes
Inguinofemoral
term that refers to the groin and thigh
Cannulation
insertion of a tube into a duct or cavity
Abscess
localizaton of pus
Autologous, autogenous
from oneself
aspiration
use of a needle and syringe to withdraw fluid
stem cell
immature blood cells
transplantation
grafting of tissue from one source to another
lymph node
station along the lymphatic system
lymphadenitis
inflammation of a lymph node
lymphangiotomy
incision into a lymphatic vessel
lymphadenectomy
excision of a lymph node ( or nodes )
Mediastinum
The area between the lungs that contains the heart, aorta, trachea, lymph nodes, thymus gland, esophagus, and bronchial tubes.
diaphragm
muscular wall that separates the thoracic and abdominal cavities.
mediastinotomy
cutting into the mediastinum
fundoplasty
repair of the bottom of an organ or muscle
pyloroplasty
incision and repair of the phyloric channel
diaphragmatic hernia
hernia of the diaphragm
mediastinoscopy
use of an endoscope inserted through a small incision to view the mediastinum.
imbrication
overlapping
transthoracic
across the thorax
transabdominal
across the abdomen
paraesophageal hiatus hernia
hernia that is near the esophagus
gastroplasty
operation on the stomach for repair or reconfiguration.
vagotomy
surgical separation of the vagus nerve.
Gloss-
prefix meaning tongue
gastro-
prefix meaning stomach
anastomosis
surgical connection of two tubular structures, such as two pieces of the intestine.
hernia
organ or tissue protruding through the wall or cavity that usually contains it.
gastrointestinal
pertaining to the stomach and intestine.
ostomy
artifical opening
colostomy
artificial opening between the colon and the abdominal wall.
ileostomy
artificial opening between the ileum and the abdominal wall
jejunostomy
artificial opening between the jejunum and the abdominal wall.
gastrostomy
artificial opening between the stomach and the abdominal wall.
proctosigmoidoscopy
endoscopic examination of the sigmoid colon and rectum
sigmoidoscopy
endoscopic examination of the entire rectum and sigmoid colon that may include a portion of the descending colon.
colonoscopy
endoscopic examination of the entire colon that may include part of the terminal ileum.
cholangiography
radiographic recording of the bile ducts
chole-
prefix meaning bile
hepa-
prefix meaning liver
incarcerated
regarding hernias, a cnostricted, irreducible hernia that may cause obstruction of an intestine.
reducible
able to be corrected or put back into a normal position
spleen
initiates an immune response, filters and removes bacteria from the bloodstream and destroys worn out blood cells.
marrow or blood cell transplant
is a treatment for patients with blood disease, such as leukemia or lymphoma
bone marrow aspiration
a procedure in which a sample of bone marrow is taken by means of a needle that is inserted into the marrow cavity.
limited lymphadenectomy
is the removal of the lymph nodes only
phrenic nerve
another name for the diaphragmatic nerve
endoscope
is use to performed to view the esophagus and stomach are performed with this instrument
diagnostic endoscopy
type of endoscopy is always included in a surgical endoscopy and would therefore never be reported separately
surgical approach
The difference between the mediastinum incision codes is the _________ __________
bacteria
The spleen initiates an immune response, filters and removes _________from the bloodstream and destroys worn out blood cells.
Separate
Total or partial splenectomy codes are designed in the CPT manual as __________procedures.
Blood Cell
A marrow or _________ __________ transplant is a treatment for patients with blood diseases, such as leukemia or lymphoma.
Aspiration
A bone marrow ___________ is a procedure in which a sample of bone marrow is taken by means of a needle that is inserted into the marrow cavity.
Allogenic
A(n) ____________bone marrow comes from a close relative.
Autologous
A(n) ____________bone marrow comes from the patient, is processed, and later transplanted or reinfused.
Limited
A(n) _____________ lymphadenectomy is the removal of the lymph node only.
surgical approach
The Mediastinum category of codes is based on the _____________ ______________ taken to perform the mediastinotomy.
Phrenic
Another name for the diaphragmatic nerve is the _________nerve.
What are the two subheadings within the Cardiovascular System subsection?
Heart and Pericardium, Arteries and veins
The subspecialty of internal medicine that is concerned with the diagnosis and treatment of the heart is
Cardiology
In Chapter 16 you learned about coding from which three sections of he CPT?
Surgery, medicine, and radiology
Procedures that break the skin for correction or examination are known as________ procedures
invasive
Procedures that do not break the skin are known as_________ procedures
noninvasive
The study of the heart’s electrical system is known as
electrophysiology
The use of radioactive radiologic procedures to aid in the diagnosis of cardiologic conditions is termed ________ _________ Cardiology
nuclear medicine
A catheter that is inserted into an artery and manipulated to a further order is termed ________ placement
selective
A catheter that is inserted into an artery and not manipulated to a further order is termed _______________ Placement
non selective
Surgocal procedures on the Heart and Pericardium subheading contain procedures that are performed through both open surgical sites and
percutaneous
Anatomic
The Respiratory System subsection is arranged by_________site.
endoscopy
The procedure in which a scope is placed through a small incision and into a body cavity is called a/an?
extent
When coding endoscopic procedures you must be certain to code to the fullest ________ of the procedure and to code the correct approach for the procedure.
-51
If more than one distinct procedure was performed during an endoscopic procedure, what modifier would you add to the lesser-priced service?
diagnostic
What type of endoscopy is always bundled into a surgical endoscopy?
Indirect
A(n) _________ laryngoscopy is performed when a physician uses a tongue depressor to hold the tongue down and view the epiglottis with a mirror.
direct
A(n) ___________laryngoscopy is performed when the endoscrope is passed into the larynx and the physician can look at the larynx through a scope.
Ear, Nose, Throat
An otorhinolaryngologist is a physician who specializes in treating condtions of the __________, _____________, and _________
integumentary
When coding a nasal abscess or a nasal biopsy of the skin using the external approach, you use codes from the _____________System subsection.
Respiratory
When coding a nasal abscess or a nasal biopsy using the internal approach, you use codes from the __________System subsection
Superior, Middle, Inferior
What are the three sections of turbinates? ____________, ______________, and _____________
Displacement (30210)
What is the name of the therapy in which the physician flushes saline solution into the sinuses to remove mucus or pus?
ligation, exploration, debridement
What are the three things that are considered components of wound repair?
length, complexity, site of repair
Wound repair codes are determined by what three criteria?
simple, intermediate, complex
What are the three classifications of wound repair?
multiple procedures
modifier -51
guidelines
What is the title for the information that preceeds each section?
debridement
What is the term for cleansing of an area or wound?
punch
What type of biopsy may be performed to excise a disc of tissue?
tissue expander
What is the term for the elastic material formed into a sac that is then filled with fluid or air?
autograft
What is the name of the graft that is taken from the patient’s body?
benign or malignant
What is the major distinction in coding destruction of lesions?
site and size
The division of malignant lesion excision is based on _______ and _______.
dermabrasion
What is the procedure used to treat acne or wrinkles by means of sanding?
pathologist
In order to report Mohs surgery, the physician would act as the surgeon and the __________.
excisional
In what kind of biopsy is the entire lesion removed for biopsy?
11200
Shirley Peters, age 80, an established patient, presents to the office for removal of 12 skin tags?
false
Dermatologists are the only providers who utilize the codes in the integumentary system? T or F
False
In the excision of a lesion, the size is taken from the pathology report. True or False
What is the largest section of the six CPT manual sections?
Surgery
Does Medicare reimburse for every surgical tray?
NO
The subsections in the Surgery section are usually divided according to ________.
medical specialty or body system or anatomical site.
These are found at the beginning of each section and contain information specific to the section: ________.
guidelines
Information within parentheses is referred to as ________ expression or phrase.
Parenthetical
Before assigning this type of code, you must be certain that a more specific Category I or a Category III code is not available: ________.
UNLISTED
This report contains the nature, extent, need, time, effort, and at times equipment necessary to provide a service: ________.
SPECIAL
This designation within the CPT manual indicates a procedure that is only reported when it is performed as the only procedure or when another procedure performed at the same time is unrelated to this procedure. This is a ________ procedure.
SEPARATE
When time, effort, and services are bundled together, they form a ________ package.
SURGICAL
________ anesthesia is defined as local infiltration, metacarpal/digital block, or topical anesthesia.
LOCAL
According to Medicare guidelines, ________ complications of a surgical procedure are usually included in the reimbursement for a major surgical procedure.
ROUTINE
Code ________ is a CPT code that can be assigned to report a surgical tray.
99070
Code ________ is a HCPCS code that can be assigned to report a surgical tray.
A4550
This code reports a postoperative follow-up visit that is included in the global service: ________.
99024
What are the three things that are considered components of wound repair?
Ligation
Exploration
Debridement
Wound repair codes are determined by what three criteria?
Length
Complexity
Site of repair
What are the three classifications of wound repair?
Simple
Intermediate
Complex
Modifier-51 indicates what?
MULTIPLE PROCEDURES
Shirley Peters, age 80, an established patient, presents to the office for removal of 12 skin tags.
CPT Code
Removal of 180-cm2 strawberry nevus of left cheek, autograft with split-thickness skin graft of 180-cm2.
CPT Codes
Nipple reconstruction.
CPT Code
Destruction of 0.4-cm malignant lesion of the neck.
CPT Code
Simple repair of a superficial wound of the genitalia; 2.4 cm.
CPT Code
Adjacent tissue transfer of chin defect; 9 cm2.
CPT Code
What are the three things that are considered components of wound repair?
(1)_____________________
(2)_____________________
(3)_____________________
(1) Ligation
(2) Exploration
(3) Debridement
Wound repair codes are determined by what three criteria?
(4)____________________
(5)____________________
(6)____________________
(4) Length
(5) Complexity
(6) Site of repair
What are the three classifications of would repair?
(7)____________________
(8)____________________
(9)____________________
(7) Simple
(8) Intermediate
(9) Complex
(10) Modifier -51 indicates what?
(10) MULTIPLE PROCEDURES
(11)What is the title for the information that precedes each section?
(11) GUIDELINES
(12)__________is the cleansing of an area or wound.
(12) DEBRIDEMENT
(13)A(n)___________biopsy may be performed to excise a disc tissue.
(13) PUNCH
(14)What is the term for the elastic material formed into a sac that is then filled with fluid or air?
____________________ ____________________
(14) TISSUE EXPANDER
(15)What is the name of the graft that is taken from the patient’s body?____________________
(15) AUTOGRAFT
(16)The major distinction in coding destruction of lesions is whether the lesion is ____________or ___________
(16) BENIGN OR MALIGNANT
(17)The division of malignant lesion excision is based on ___________and______________
(17) SITE AND SIZE
(18)What is the procedure used to treat acne or wrinkles by means of sanding?_____________
(18) DERMABRASION
(19)In order to report Mohs’ surgery, the physician would act as the surgeon and the ________________.
(19) PATHOLOGIST
(20)In a(n)______________biopsy, the entire lesion is removed for biopsy.
(20) EXCISIONAL
Removal of 37 skin tags by electrosurgical destruction:
11200, 11201 x 3 units
The removal of a lesion by transverse incision that did not require sutured closure is reported using codes from which subsection?
Shaving of Epidermal or Dermal Lesions
Using the “Rule of Nines,” adult legs are what percentage of the human body?
18%
The correct code for repairing the following lacerations: 4.2 simple repair of the trunk, 1.3 simple repair of the arm, and 2.8 intermediate repair of the scalp:
12032, 12002-51
Fine needle aspiration of the breast without imaging:
10021
Where is the bimalleolar bone located?
ankle
Surgical and fracture repair codes in the musculoskeletal subsection:
include the application and removal of the initial casts, splints, or strapping applied by the treating physician.
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 procedures is what type of procedure?
arthroscopy
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
T/F The codes for wound exploration can be reported for exploration of any type of wound.
False
The application of a cranial halo is a form of:
external fixation
Open treatment of a fracture is when the:
fracture is surgically opened and visualized or opened remotely
A ____ arthroscopy is always included in a surgical arthroscopy.
diagnostic
Which term describes a reduction?
manipulation
Excision defined as full thickness would be through the:
dermis
T/F
A needle biopsy is a way of obtaining a piece of tissue out of the body, using a tiny incision, so the tissue can be examined under a microscope by a pathologist. Because this biopsy is performed through the skin, it is called a percutaneous biopsy.
False
This type of graft is often taken from the lower thigh area.
fascia lata
Fast becoming the treatment of choice for many orthopedic surgical procedures is what type of procedure?
endoscopy/arthroscopy
Surgical and fracture repair codes in the musculoskeletal subsection:
include the application and removal of the initial casts, splints, or strapping applied by the treating physician.
T/F Codes for arthrodesis include the bone graft and instrumentation, and these cannot be coded separately.
False
Wound exploration codes have the following service(s) bundled into the codes:
exploration, including enlargement; debridement, removal of foreign body(ies), minor vessel ligation, repair
The restoration of a fracture or dislocation to its normal anatomic alignment by the application of manually applied force is known as:
manipulation
T/F You cannot report codes for open wound exploration (20100-20103) if the wound is sufficient in size to accomplish the repair and the wound does not need to be enlarged.
True
Wound closure requiring the use of adhesive strips as the sole repair material should be coded with:
an E/M code
T/F An orthopedic surgeon cannot report the service of ultrasonic guidance because this is a radiologic procedure, and only a radiologist can report services represented in the Radiology section.
False
What two items are needed to correctly code for local treatment of burns?
percentage of body surface and depth of burn
The method used by the physician to obtain a lesion biopsy depends on which set of factors?
size and type
Endoscopic plantar fasciotomy.
CPT: ________
29893
Rationale: The coder should start in the Index of the CPT manual. The coder should locate the main term ” Fasciotomy” and then the subterm “Plantar” and the sub-subterm “Endoscopic” and the coder is given 298293. After verifying the code in the tabular this is the correct choice.
Costochondral cartilage graft.
CPT: ________
20910
Rationale: The coder should begin by locating the CPT manual index and referring to the main term “Graft and then the subterm “Cartilage” then locate the sub-subterm “Costochondral” the code given 20910. The coder should refer to the CPT tabular list to verify the code.
Closed treatment of a pelvic rim fracture, without manipulation.
CPT: ________
Rationale: The coder should refer to the CPT manual index and locate the main term “Fracture” then the subterm of body site “Pelvic Ring” and the type of treatment “Closed treatment”. The coder is given a code range 27193-27194. The coder should refer to the CPT tabular list to and locate the first listed code 27193 which is the correct choice.
What code would be used to report Mr. Jones’ visit to Dr. Green 2 weeks after major surgery?
CPT: ________
99024
Rationale: In the CPT manual the coder should locate the index and reference the main term “Surgical”, then the subterm Services. Located beneath that the coder will find the subterm of the subterm “Post-op Visit.” The coder should then verify the coder by refering to the CPT tabular list. The coder would find the code in the “Medicine Section of the CPT manual under “miscellaneous services”
Aspiration of shoulder joint.
CPT: ________
20610
Rationale: The coder should refer to the CPT manual Index and locate the main term “Aspiration” and then the body site “Joint.”
Initial, local treatment, first-degree burn, of back of hand, 5% body surface. The burn was caused by steam from a pipe at his home that accidentally was connect improperly.
CPT: _________
CPT 16000
Rationale: The coder should begin by referencing the CPT manual index. The coder should locate the main term “Burns”, then the subterm “Initial Treatment” The coder should refer to the CPT manual tabular list to verify the code 16000.
Excision of 2.5 cm malignant lip lesion and two malignant lesions of the chest, each 1.5 cm in diameter.
CPT: _______, CPT_______-Modifier___*__
11643 11602-51 * 2
The coder should refer to the index in the CPT manual. Locate the main term “Excision”, then locate the subterm “Skin”, then the subterm of the subterm “Lesion”. Then the coder would select the code range for next the sub-sub term “Malignant” which is “11600-11646.” The coder would then reference the CPT manual tabular list. The coder should then locate the base code that includes the location of the lip lesion (11640) then underneath the coder needs to locate the size of the lesion the was 2.5 cm so the correct code would be 11643 2.1-3.0cm. Then the coder must locate the base code that includes location of the second lesion on the chest this code is 11600, underneath there the coder would be directed to 11602 because each one measured 1.5 cm. The coder would then add a Modifier -51 because multiple procedures where done during the same surgical session. and the coder would also indicate how many lesions where excised by adding x 2.
Destruction of 4.0 cm malignant lesion of the eyelid.
CPT: _______
17284
Rationale: The coder should refer to the CPT manual index. Locate the main term “Destruction” then the subterm “Skin Lesion”, then the sub-subterm “malignant” The coder is given the code range 17260-17286. The coder should then reference the CPT tabular list and find the base code that includes the defect site in this case “eyelids” (17280) the coder should then look to the indented codes and locate 17284 because of the size of the lesion.
Provide the CPT-4 procedure code for the following:
Rita, an established patient, has a 16.2 cm simple repair of the cheek. A surgical tray is used.
CPT: _______; CPT_______
12016; 99070
Rationale: The coder would start by locating the main term ” Repair” in the index of the CPT manual. Then locate the subterm “Wound”. The case states it was a “simple repair”, so the coder would selectthe code range (12001-12021) , then refer to the tabular list. Because this wound is located on the face the code must first find that base code that includes the facial area, which is 12011, then the coder must select from the indented codes below based on the size of the repair. The size is 16.2, which falls in between 12.6 cm and 20.0 cm, so the correct choice would be 12016. The physician also used a surgical tray. The code must reference the index for the main term “Special Services” then the subterm “Supply of Materials. The coder is given the code 99070, then coder should then refer to the CPT tabular list, which states supplies and material provided by a physician over and above……..office visit.
You do not report the E/M code because this is an established patient and the treatment constitutes the main service provided to the patient.
Use a Modifier if necessary?
John is returning to the physician’s office 2 weeks post-surgery for an application of a new long leg cast. The patient required surgery due to a traumatic fracture of the lower leg.
CPT:_______- Modifier ______
29345-58
Rationale: The coder should refer to the CPT manual index and locate the main term ” Cast” and the subterm “Long leg.” A modifier -58 should be appended to this because the patient is still within his post-operative (90-day) period.
DEBRIDEMENT
The removal of infected, contaminated, damaged, devitalized, necrotic, or foreign tissue from a wound
THE GOAL OF DEBRIDEMENT
Is to cleanse the woundm reduce bacterial contaminationm and provide an optimal enviroment for wound healing or possible surgical intervention
THE USUAL ENDPOINT OF DEBRIDEMENT
Is removal of pathological tissue and/ or foreign material until healthy tissue is exposed
DEBRIDEMENT TECHNIQUES
Include sharp and blunt dissection, curettement, scrubbing, and forceful irrigation.
DEBRIDEMENT OF BURNED SURFACES
CPT CODES OF 16000-16036 ARE REPORTED
types of treatment for lesions
include paring(peeling or scraping), shaving(slicing) excision( cutting, removal) and destruction ( ablation)
Macule
flat area of color change; no elevation or depression
Papule
solid elevation; less than 0.5 cm in diameter
Nodule
solid elevation 0.5-1 cm in diameter; extends deeper into dermis than papule
Tumor
solid mass; larger than 1cm
Plaque
Flat elevated surface foung where papules, nodules, or tumors cluster
Wheal
Type of plaque; result is transient edema in dermis
Vescle
small blister; greater than 0.5 cm
Scales
Flakes of cornified skin layer
Crust
Dried exudate on skin
Fissure
Cracks in skin
Erosion
Loss of epodermis that does not extend into dermis
Ulcer
Area of destruction of entire epidermis
Scar
Excess collagen production following area
Atrophy
Loss of some portion of the skin
IF MULTIPLE LESIONS ARE TREATED
Code the MOST COMPLEX LESION (highest $ amount) PROCEDURE FIRST FOLLOWED BY THE OTHERS USING MODIFIER -51 to indicate that multiple procedures were performed
Simple excision
is a full thickness (through the dermis) excision
Simple closure
is nonlayered closure
Paring of 3 common warts
CPT code: 11056 ( lesin, skin, paring/curettement); ICD-9 code: 078.19 (wart, common)
Removal of 15 skin tags
CPT code:11200 ( lesion, skin tags, removal) ICD-9 code: 701.9 (tag, skin)
shaving of 1-cm dermal lesion of face
CPT code: 11311 (lesion, skin, shaving) ICD-9 709.9 (lesion, dermal)
Reporting wound repair
following factors must be considered:
1.Length of the wound in cm
2.Complexity of the repair
3.Site of the wound
3 types of repai
1.Simple
2.Intermediate
3.Complex
abscess
localized collection of pus that will result in the disentegration of tissure over time
allogenic
graft that is from the same species, but genetically different
allograft
tissue graft between individuals who are not of the same genotype
allotransplantation
transplantation between individuals who are not of the same genotype
anomaly
abnormality
autogenous
for oneself; autotogous
axillary nodes
lymph nodes located in the armpit
benign
not progressive or recurrent
biopsy
removal of small piece of living tissure for diagnostic purposes
cryosurgery
destruction of lesions using extrene cold
dermis
second layer of skin, holding blood vessels, nerve endings, sweat glands and hair follicles
destruction
killing of tissure by means of laser, electrocautery . chemicals and other means
electrodesiccation
destruction of lasion by the use of electric current radiated through a needle
excision
full thickness removal of lesion that may include simple closure
incision
cut into
lesion
abnormal or altered tissure, wound, abcess, cyst or boil
seperate procedure
minor procedure that when done by themselves are coded as a procedure
seperate procedure
when performed at same time as a major procedure are considered incidental and not coded seperately
shaving
horizontal or transvere removal of dermal or epidermal lesions, without full thickness graft
skin graft
transplantation of tissue to repair a defect
soft tissue
tissues; fascia, connective tissue, muscle and so forth
suture
to unite parts by stitching them together
tissue transfer
piece of skin for grafting thats still part of the original blood supplyu
wound repair, complex
involves complicated wound closure including revision, debridement, extansive undermining
wound repair, intermediate
require closure of one or more subcutaneous tissues and superficial fascea, in addition to skin closure
wound repair, simple
superficial wound repair, involving epidermis, dermis and subcutaneous tissure, requiring only simple one layer suturing
19 subsections
surgery is divided in how many sections
anatomic site
body system; subsections are usually devided according to this in surgery
arrow beginning and end
indicate that the information is new or has been revised for current edition
metric
meaurement in the cpt manual is in what system
length
1rst criteria for wound repair
complexity
2nd criterai for wound repair
site of repair
3rd criteria for wound repair
simple
1rst classification of wound repair (complexity)
intermediate
2nc classification of wound repair(complexity)
complex
3rd classification of wound repair(complexity)
modifier 51
most complex lesion procedure first and other using this; indicates multiple procedures
modifier 50
bilateral procedure modifier
same procedure
performed on a different site; 1rst time multiple procedures are coded
multiple procedure
performed during same operation; 2nd time multiple procedures are coded
procedure performed
multiple times; 3rd time multiple procedures are coded
general
first subsection in surgery section
special report
must accompany submission of unlisted code
preoperative
surgery package and surgical gobal fee are terms to describe what 1
intraoperative
surgery package and surgical global fees are terms to describe what 2
postoperative
surgical package and surgical fees are terms to describe what3
99024
five digit code used for documentaion purposes to report non billed postoperative services provided to the patient under the umbrella of surgical package
benign or malignant
major distinction in coding destruction of whether the lesion is
site and size
division of malignant lesion excision is base on what
global or singular
kind of package was developed by third party payers and may go beyond the package described in the ct manual
seperate procedure
two words follow a procedure discription alert you to the fact that you can code the procedure only if it is not done as part of a more extensive procedure
preoperative
first thing bundled in a surgery package
intraoperative
second thing bundled in a surgery package
postoperative
third thing bundled in a surgery package
modifier 27
multiple outpatient hospital e/m encounters on same date
abcess
localized collection of pus that will result in disintegration over time
cyst
closed sac containing fluid or matter
lesion
abnormal or altered tissue
tumor
swelling or enlargement; sponataneous growth or tissue that forms ans abnormal mass
epidermis
outer layer of skin
dermis
second layer of skin holding blood vessel nerve endings, sweat glands and hair follicles
repair
pertains to suturing a wound
modifier 58
stage or related procedure or service by same physician during the postoperative period
modifier 59
distinct procedural service
modifier 76
repeat procedure by same physician
modifier 77
repeat procedure by another physician
modifier 78
return to the operating room for a related procedure during the postoperative period
modifier 79
unrelated procedure or service by the same physician during the postoperative period
modifier 91
repeat clinical diagnostic labratory test
skin grafts, flaps
measurement area in square cm
lesion removal
measurement of diameter in cm
wound repair
measurement of length in cm
repairs
group together same anatomic site
repairs
group together the same classification such as simple or intermediate
hcpcs
modifiers used for indication of finger or toe
fee for surgery
surgery package and surgical global fee are terms to describe what 4
aphakia
absence of the lens of the eyes
echography
ultrasound procedure in which sound waves are bounced off an internal organ and the resulting image is recorded
gonioscopy
use of a scope to examine the angles of the eye
hemodialysis
cleansing of the blood outside the body
modality
treatment method
nystagmus
rapid involuntary eye movements
optokinetic
movement of the eye to objects moving in the visual field
percutaneous
through the skin
phlebotomy
cutting into a vein
retrograde
moving backward or against the usual direction of flow
subcutaneous
tissue below dermis, primarily fat cells that insulate the body
tonometry
measurement of pressure or tension
transcutaneous
entering by way of the skin
tympanometry
procedure for evaluation of middle ear disorders
OTH
other routes
IT
inhalant solution
IV
intravenous
IM
intramuscular
SC
subcutaneous
INH
intrathecul
VAR
various routes
oscillating
to swing backward and forward
audiometry
hearing test
tympanometry
procedure for evaluating middle ear disorders
electrocochleography
stimulation of the cochea to measure electial activity
orthoptic
corrective, in the correct place
angioscopy
studing the capillaries of the eyes
electroretinography
recording electrical activity in the retina
anomaloscope
a device for detecting color blindness
aphakia
absence of the lens of the eye
corneosclera
cornea and sclera together forming one organ
cornea
the transparent part of the coat of the eyeball that covers the iris and pupil and admits light to the interior
sclera
the think outer coat of the eye, mostly white and opique
Removal of 37 skin tags by electrosurgical destruction:
11200, 11201 x 3 units
The removal of a lesion by transverse incision that did not require sutured closure is reported using codes from which subsection?
Shaving of Epidermal or Dermal Lesions
Using the “Rule of Nines,” adult legs are what percentage of the human body?
18%
The correct code for repairing the following lacerations: 4.2 simple repair of the trunk, 1.3 simple repair of the arm, and 2.8 intermediate repair of the scalp:
12032, 12002-51
Fine needle aspiration of the breast without imaging:
10021
Where is the bimalleolar bone located?
ankle
Surgical and fracture repair codes in the musculoskeletal subsection:
include the application and removal of the initial casts, splints, or strapping applied by the treating physician.
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 procedures is what type of procedure?
arthroscopy
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
T/F The codes for wound exploration can be reported for exploration of any type of wound.
False
The application of a cranial halo is a form of:
external fixation
Open treatment of a fracture is when the:
fracture is surgically opened and visualized or opened remotely
A ____ arthroscopy is always included in a surgical arthroscopy.
diagnostic
Which term describes a reduction?
manipulation
Excision defined as full thickness would be through the:
dermis
T/F
A needle biopsy is a way of obtaining a piece of tissue out of the body, using a tiny incision, so the tissue can be examined under a microscope by a pathologist. Because this biopsy is performed through the skin, it is called a percutaneous biopsy.
False
This type of graft is often taken from the lower thigh area.
fascia lata
Fast becoming the treatment of choice for many orthopedic surgical procedures is what type of procedure?
endoscopy/arthroscopy
Surgical and fracture repair codes in the musculoskeletal subsection:
include the application and removal of the initial casts, splints, or strapping applied by the treating physician.
T/F Codes for arthrodesis include the bone graft and instrumentation, and these cannot be coded separately.
False
Wound exploration codes have the following service(s) bundled into the codes:
exploration, including enlargement; debridement, removal of foreign body(ies), minor vessel ligation, repair
The restoration of a fracture or dislocation to its normal anatomic alignment by the application of manually applied force is known as:
manipulation
T/F You cannot report codes for open wound exploration (20100-20103) if the wound is sufficient in size to accomplish the repair and the wound does not need to be enlarged.
True
Wound closure requiring the use of adhesive strips as the sole repair material should be coded with:
an E/M code
T/F An orthopedic surgeon cannot report the service of ultrasonic guidance because this is a radiologic procedure, and only a radiologist can report services represented in the Radiology section.
False
What two items are needed to correctly code for local treatment of burns?
percentage of body surface and depth of burn
The method used by the physician to obtain a lesion biopsy depends on which set of factors?
size and type
Endoscopic plantar fasciotomy.
CPT: ________
29893
Rationale: The coder should start in the Index of the CPT manual. The coder should locate the main term ” Fasciotomy” and then the subterm “Plantar” and the sub-subterm “Endoscopic” and the coder is given 298293. After verifying the code in the tabular this is the correct choice.
Costochondral cartilage graft.
CPT: ________
20910
Rationale: The coder should begin by locating the CPT manual index and referring to the main term “Graft and then the subterm “Cartilage” then locate the sub-subterm “Costochondral” the code given 20910. The coder should refer to the CPT tabular list to verify the code.
Closed treatment of a pelvic rim fracture, without manipulation.
CPT: ________
Rationale: The coder should refer to the CPT manual index and locate the main term “Fracture” then the subterm of body site “Pelvic Ring” and the type of treatment “Closed treatment”. The coder is given a code range 27193-27194. The coder should refer to the CPT tabular list to and locate the first listed code 27193 which is the correct choice.
What code would be used to report Mr. Jones’ visit to Dr. Green 2 weeks after major surgery?
CPT: ________
99024
Rationale: In the CPT manual the coder should locate the index and reference the main term “Surgical”, then the subterm Services. Located beneath that the coder will find the subterm of the subterm “Post-op Visit.” The coder should then verify the coder by refering to the CPT tabular list. The coder would find the code in the “Medicine Section of the CPT manual under “miscellaneous services”
Aspiration of shoulder joint.
CPT: ________
20610
Rationale: The coder should refer to the CPT manual Index and locate the main term “Aspiration” and then the body site “Joint.”
Initial, local treatment, first-degree burn, of back of hand, 5% body surface. The burn was caused by steam from a pipe at his home that accidentally was connect improperly.
CPT: _________
CPT 16000
Rationale: The coder should begin by referencing the CPT manual index. The coder should locate the main term “Burns”, then the subterm “Initial Treatment” The coder should refer to the CPT manual tabular list to verify the code 16000.
Excision of 2.5 cm malignant lip lesion and two malignant lesions of the chest, each 1.5 cm in diameter.
CPT: _______, CPT_______-Modifier___*__
11643 11602-51 * 2
The coder should refer to the index in the CPT manual. Locate the main term “Excision”, then locate the subterm “Skin”, then the subterm of the subterm “Lesion”. Then the coder would select the code range for next the sub-sub term “Malignant” which is “11600-11646.” The coder would then reference the CPT manual tabular list. The coder should then locate the base code that includes the location of the lip lesion (11640) then underneath the coder needs to locate the size of the lesion the was 2.5 cm so the correct code would be 11643 2.1-3.0cm. Then the coder must locate the base code that includes location of the second lesion on the chest this code is 11600, underneath there the coder would be directed to 11602 because each one measured 1.5 cm. The coder would then add a Modifier -51 because multiple procedures where done during the same surgical session. and the coder would also indicate how many lesions where excised by adding x 2.
Destruction of 4.0 cm malignant lesion of the eyelid.
CPT: _______
17284
Rationale: The coder should refer to the CPT manual index. Locate the main term “Destruction” then the subterm “Skin Lesion”, then the sub-subterm “malignant” The coder is given the code range 17260-17286. The coder should then reference the CPT tabular list and find the base code that includes the defect site in this case “eyelids” (17280) the coder should then look to the indented codes and locate 17284 because of the size of the lesion.
Provide the CPT-4 procedure code for the following:
Rita, an established patient, has a 16.2 cm simple repair of the cheek. A surgical tray is used.
CPT: _______; CPT_______
12016; 99070
Rationale: The coder would start by locating the main term ” Repair” in the index of the CPT manual. Then locate the subterm “Wound”. The case states it was a “simple repair”, so the coder would selectthe code range (12001-12021) , then refer to the tabular list. Because this wound is located on the face the code must first find that base code that includes the facial area, which is 12011, then the coder must select from the indented codes below based on the size of the repair. The size is 16.2, which falls in between 12.6 cm and 20.0 cm, so the correct choice would be 12016. The physician also used a surgical tray. The code must reference the index for the main term “Special Services” then the subterm “Supply of Materials. The coder is given the code 99070, then coder should then refer to the CPT tabular list, which states supplies and material provided by a physician over and above……..office visit.
You do not report the E/M code because this is an established patient and the treatment constitutes the main service provided to the patient.
Use a Modifier if necessary?
John is returning to the physician’s office 2 weeks post-surgery for an application of a new long leg cast. The patient required surgery due to a traumatic fracture of the lower leg.
CPT:_______- Modifier ______
29345-58
Rationale: The coder should refer to the CPT manual index and locate the main term ” Cast” and the subterm “Long leg.” A modifier -58 should be appended to this because the patient is still within his post-operative (90-day) period.
Fractures are coded by treatment
Open, closed, or percutaneous
Open Treatment
is made when a surgery is performed in which the fracture is exposed by an incision made over the fracture and the fractured bone is visualized
Closed treatment
is performed when the physician repairs the fracture without visualizing the fracture
Percutaneous skeletal fixation
describes fracture treatment that neither open nor closed. In this procedure, the fracture is not open to view,but fixation is placed across the fracture site, usually under x-ray imaging
Greenstck fracture
A greenstick, buckle or torus fracture is a fracture in a young, soft bone in which the bone bends and partially breaks
Avulsion fracture
is a bone fracture which occurs when a fragment of bone tears away from the main mass of bone as a result of physical trauma.
Spiral fracture
is a bone fracture occurring when torque is applied along the axis of a bone.
Impacted fracture
is a type of fracture in which one of broken fragments of bone wedges into another
Transverse fracture
A fracture in which the break is across the bone
Comminuted fracture
A fracture in which bone is broken, splintered or crushed into a number of pieces. …
Oblique factor
A fracture that is diagonal to a bone’s long axis
Simple (closed) fracture
is a broken bone when the skin over the fracture site is in tact
Compound (open) fracture
A fracture in which the bone is sticking through the skin
Colles’ fracture
is a distal fracture of the radius in the forearm with dorsal (posterior) displacement of the wrist and hand. …
Nasal bone fracture, closed treatment
cpt code: 21310
Unclomplicated, closed treatment of one fractured rib
cpt code: 21800
Interphalangeal joint dislocation of toe, open treatment with internal fixation
cpt code: 28675
Open distal fibula fracture repair with internal fixation
27792
Femoral shaft fracture repair using closed treatment
27500
Percutaneous skeletal fixation of impact fracture of proximal end, femoral neck
27235
Open treatment of shoulder dislocation with closed frcture of the greater humeral tuberosity, non- dispaced
cpt code: 23670
icd9: 812.03
closed treatment of closed mandibular fracture, including interdental fixation
cpt: 21453
icd9: 802.20
Percutaneous skeletal fixation of a closed distal radius fracture
cpt: 25606
icd9: 813.81
Closed ankle dislocation, closed treatment
cpt: 27840
icd9: 837.0
Penetrating woulnd elploration may be coded from the musculoskeletal system, Integumentary system, or the appropriate______ site.
Anatomic
Which physician subspecialty can report the codes from the muscloskeletal system subsection
any physician
It is the _______ of the fracture that determines the method treatment
Extent or type
___________is the applicatin of pulling force to hold a bone in place
Traction
What term is used to mean “put the bone back into place”
REDUCTION
what is the term that describes the physicians actions of bending, manipulating, rotating, pulling or guiding the bone back into place
manipulation
what term describes the cleaning of a wound
debridement
what term describes a bone that is not in its normal location
dislocation or dislocated
this is a hollow needle that is often used to withdraw samples of fluid from a joint
trocar
Incision of a superficial soft tissue abscess, secondary to osteomyelitis
cpt code: 20000
Radical resection of a 2.7 cm malignant neoplasm of the soft tissue of the upper back
cpt code: 21935
closed treatment of 3 vertebral process fractures
cpt code: 22305
under general anesthesia, manipulation of a right shoulder joint with external fixation
23700-RT
Lengthening of four tendons of elbow
24305×4
Incision and drainage of bursa of elbow
23931
Open treatment of carpal scaphoid fracture with internal fixation applied
25628
arthroscopy of 2 metacarpophalangeal joints
26530×2
Tenotomy of 2 flexor tendons of a finger using an open procedure
26455×2
amputation lower arm using krukenberg procedure
25915
open treatment of radial and ulnar shaft fracture with internal fixation of both radius and ulna
25575
Osteoplasty for shortening of both of radius and ulna for adult kienbock’s disease
cpt: 25392
icd9: 732.8
Percutaneous lateral tenetomy for tennis elbow (lateral epicondylitis)
cpt: 24357
icd9: 726.32
replantation of right arm, including the neck of the humerus through the elbow joint, following a complete traumatic amputation
cpt: 20802-RT
ICD9: 887.2
exploration of a penetrating wound of the left leg
20103 wound, exploration, penetrating extremity
replantation
replantation of right foot after a completet, traumatic amputation
20838 replantation, foot
radical resection of malignant neoplasm of cheek, less than 2 cm
21015 tumor, resection, face
nonoperative, electrical stimulationof nonhealing femur fracture
20974 electrical stimulation,bone healing, noninvasive
percutaneous needle biopsy of muscle of upper arm in a patient with congenital myotonic muscular dystrophy
20206 biopsy, muscle
icd-9-cm 359.22 dystrophy, muscular, congenital, myotonic
intra-articular aspiration and injection of finger joint arthritis
20600 aspiration, joint
icd-9-cm 716.94 arthritis, hand
replacement of fiberglass shoulder to hand (long-arm) cast for a 54-yr old patient
29065 cast,long arm
99070 supply materials
initial application of a walking type short leg cast for a sprain
29425 cast walking
removal of a full leg cast by a physician who didnt apply the cast
29425 cast removal
strapping of a 46 yr old patirents knee
29530 strapping, knee
replacement of a thigh to toes cast on the right leg of a 35 yr old female patient
29345 cast long leg 99070 supply, materials
SURGICAL ARThroscopy of ankle, which included extensive debridement
29898 arthroscopy surgical ankle
diagnostic knee arthroscopy with synovial biopsy
29870 arthroscopy diagnostic knee
the musculoskeletal system subsection is formatted according to what type of sites?
anatomic
which physician subspecialty can report the codes from the musculoskeletal system subsection?
any physician
list the three types of fracture treatments and briefly describe each
closed: the fracture site is not opened to view; open: the fracture site is
opened to the surgeon’s view or remotely opened; and percutaneous
skeletal fi xation: neither open nor closed but where pins, screws, or
other fi xation is placed into the bone through the skin
it is the______________ of the fracture that determines the method of treatment.
extent or type
_______________is the application of pulling force to hold a bone in place.
traction
what is the term that describes the physician’s actions of bending, rotating, pulling, or guiding the bone back into place?
manipulation
what term is used to mean “put the bone back in place”?
reduction
what term describes a bone that is not in its normal location?
dislocation
what term describes the cleaning of a wound?
debridement
this is a hollow needle that is often used to withdraw samples of fluid from a joint?
trocar
would a biopsy code usually include the administration of any necessary local anesthesia?
yes
Closed treatment
fracture treatment when site is not surgically opened and visualized or reduction
Open treatment
fracture site that is surgically opened and vusualized
Percutaneous
reshaping or reconstructing a jiont
Fracture
break in a bone
Dislocation
displacement of a bone from its normal location in a joint
Manipulation
word used interchangeably with reduction to mean the attempted restoration of a fracture or joint dislocation to its normal anatomic position
Fixation
the application of pins, wires, screws, and so on to immobilize; these can be placed externally or internally
Skeletal traction
application of force to a limb with the used of a pin, screw, wire, or clamp attached to the bone
Soft tissue
tissues (fascia, connective tissue, muscle, etc..)surrounding organs and other structures
Arthroplasty
reshaping or reconstructing a joint
Arthrodesis
surgical immobilization of a joint
Would a biopsy code usually include the administration of any necessary local anesthesia?
Yes
What is arthrocentesis?
Aspiration of a joint
What is a uniplane fixation device?
Device that has 2 or more pins inserted above a fracture & 2 or more pins below a fracture on only 1 surface & is used to stabilize the fracture
What is the name of the graft that is taken from the lower thigh area where the fascia is the thickest?
Fascia lata graft
What type of stimulation often is used to promote healing of a slow healing fracture?
Electrical or ultrasound
What is fast becoming the surgical method of choice for many musculoskeletal procedures today?
Arthroscopy
What is the term that describes the use of tape applied to the body to provide support or limit motion?
Strapping
Do you bill for the removal of a cast that your physician applied?
No-removal is part of cast service
What 2 words describe when elastic wrap or take is fastened to the skin or wrapped around a limb and weights are then attached to the wraps or tape?
Skin traction
What is the primary difference between the excision codes found in the musculoskeletal system subsection and the excision codes found in the integumentary system subsection?
Musculoskeletal applies to muscle and Integumentary applies to skin & subcutaneous tissue. The primary difference is extent.
fasciectomy
excision of fascia
joint movement abduction
movement of a limb away from the midline of the body
adduction
movement of limb toward midline of body
circumduction
circular movement of limb
extension
movement by which two parts are drawn away from each other
hyperextension
excessive extension of a limb
pronation
applied to hand, the act of turning palm down
ligament
band of fibrous tissues that connect cartilage or bone and supports a joint
lysis
releasing
manipulation or reduction
mean the attempted restoration of a fracture or joint dislocation to its normal anatomic position
tenorrhaphy
together tow parts of tendon
traction
application of force to limb
tocar needle
needle with tube on the end; used to puncture and withdraw fluid from cavity
anatomic site
muscoskeletal system subsection is formated according to what type of sites
any physician
which physicans subspecialty can use the codes from the muskoskeletal subsection
local anesthesia
biopsy code usually includes the administration of this
arthrocentisis
aspiration of a joint
uniplane fixation device
device that has two or more pins
fascia lata graft
name of graft that is takent from lower thigh area where fascia is thickest
electric or ultrasound
type of stimulation often used to promote healing of slow healing fracture
arthroscopy
becoming the surgical method of choice for many muscoskeletal procedures
strapping
use of tape applied to the body to provide support or limit motion
no
removal of cast that physician applied is part of service
skin traction
elastic wrap or tape is fastened to the skin or wrapped around a limb and weights are attached to wraps of tape
type of biopsy
excision category based on this first
depth of biopsy
excision category based on this second
method of obtaining biopsy
excision category based on this third
wound exploration
used for traumatic wounds that result from penetrating trauma
incision
code used when abscess is associated with soft tissue and possibly down to the bone that underlies the abscess area
open
fractures are coded by 1 treatment
closed
fracture are coded by 2 treatement
orif
open reduction with internal fixation uses pins wires screws to stabilize a fracture
keller type procedure
in which a wire is inserted through the bone of a toe to hold bones in correct alignment
hallux
great toe
valgus
angulation of toe toward midline
body area
arthroscopy codes are divided according to1
type of procedure
arthroscopy codes are divided according to2
extent of procedure
arthtroscopy codes are dividing according to 3
removal codes
used to report removal of foreign bodies that are lodged in the muscle
injection codes
used to report injections made into tendon,ligament or ganglion cyst
spinal instrumentation
used to stabilize the spinal column in some repair procedures
segmental
instrumentation is attached of a fixated device at each end of area being repaired, at least on other attachement in spinal area being fixed
nonsegmental
instrumentation is application of fixative device at each end of area being repaired
major
shoulder or hip
small
finger or toe
intermediate
ankle or elbow
CPT
current procedural terminology
Revisions
are terms that reflectd the tchnologic advances made in medicine and are incorpated into the CPT manual
Solid dot
new code
+
add-on code
( )
encloses additional information
arrow facing up
revised code
O with a line through it
modifier -51 exempt
Appendix A
modifiers are found
Appendix B
where they have additions, deletions, and revisions
Guidelines
a list of the unlisited procedures for use in a specific section of the CPT manual
Third-party payers
requires a special report with the use of unlisted codes
Nature, extent, and need
represent three of the six elements that a special report must contain
Hyphen
punctuation mark between codes in the index of the CPT mannual indicate two codes are available
Comma
punctuation mark between codes in the index of the CPT mannual indicating 2 codes are available
Largest to smallest division of the CPT
category is the largest
section is the second category
subsection is the third category
subheading is the smallest division
Procedure/service descriptor
words that follow a code number in the CPT manual
stand alone
are codes that has all the words that describe the codes
Unlisted/Category III
procedures that are experimental, newly approved, or seldom used are reported
scoliosis
abnormal condition of lateral curvature of the spine
pyrexia
fever
podagra
pain in big toe
ischium
upper part of hip bone
ethmoid bone
cranial bone supports nasal cavity
colles fracture
bone break at the wrist
myelopoiesis
formation of bone marrow
bone occipital
forms the back and base of skull
talipes
clubfoot
trochanter
large process below the neck of the femur
calcaneus
heel bone
olecranon
elbow bone
communited fracture
bone is splintered or crushed
acetabulum
hip socket
sphenoid bone
bat-shaped cranial bone behind the eye
1.the more the complex subsection referred to in the text were Integ, Musculo, resipratory, Cardio, Digestive, and
Female genital
2. The info in the ___ contains info that is necessary to correctly code in the section, & the info is not repeated elsewhere
Guidelines
3.Notes may appear before subsec, subhead, ___ & subcategories
Categories
4. when a note is present, that note must be read and ___ if the coding is to be accurate
Followed
5. w/in the surgery Guidelines the ___ procedure codes are presented in a list by anatomic site
Unlisted
6. according to the CPT maunal “Pertinent info [in the ___ report] should include an adequate def. or description of the nature, extent, need, time, effort, and equip. necessary to provide the service
Special
7. there are minor and ___ procedure designations for the purposes of a surgical package
Major
8. the breast biopsy and mastectomy of the left breast were preformed during the same operative session would both procedures be reported
Yes
9. if a breast and right knee operation were preformed during the same operative session would both procedures be reported
Yes
10. The CPT manual describes the surg. pkg as including one related preop E/M service the operative procedure, and immediate ____ care
Follow up care
11. Local infiltration is considered ___ anesthesia
Local
12. this term means a worsening as described in the text
Exacerbations
13. this type of anesthesia is not part of the surgical package
General anesthesia
14. the predeifined number of days before and after a surgical package
Global Period
15. what is the CPT code that reports a surgical tray
99070
16. what is the HCPCS code that reports a surgical tray
A4550
17. according to the medicare guidlines a surg, pkg includes the treatment of complications by the ___ physician
Same
18. At an off. visit a decision for surgery was made. the surgical procedure was scheduled 21 days later. would the office visit service be
A. reported separtely
19. Splitting open of the wound is
Dehiscence
20. Inclusion or exclusion of a procedure in the cpt manual implies health insurance coverage or no health insurance coverage
True
21. the code range in the surgical section is
10021-69990
22. the subsection that follows the digestive system is the ___ system
Urinary
23. what type of microscope has a section of the surgery section
Operating scope
24.the difference between 10021 and 10022 is that one is with ___ ____ and one is without
Imaging guidance
25. according to the parenthetical info following the code 10022 for a precutaneousneedle biopsy other than fine needle aspiration, see ____ for salivary gland
42400
26. according to the surgery guidelines codes designated as ____ _____ should not be reported in addition to the code for the totao procedure or service of which it is considered an integral component
Separate procedure
27. according to the surgery guidelines follow up care for ____ surgical procedures includs only that care which is usually a part of the surgical procedure
Therapeutic
28. according to the surgery guidelines the code range for maternity care and delivery is
59000-59899
29. according to the surgery guidelines this is the code for unlisted procedures of the lip
40799
30. according to the surgery guidelines this is the code for unlisted procedures of the urinary system
53899
What is the largest section of the six CPT manual section?
Surgery section
Does Medicare reimburse for every surgical tray?
NO
The subsections in the Surgery section are usually divided according to _______.
Medical specialty or body system.
This symbol indicates new or revised text within the current edition of the CPT manual
Triangle
These are found at the beginning of each section and contain information specific to the section :
Guidelines
Information within parentheses is referred to as _____ expression or phrase.
parenthetical
Before assigning this type of code, you must be certain that a more specific Category I or Category III code is not available
Unlisted procedure
This report contains the nature, extent, need, time, effort, and at times equipment necessary to provide a service :
Special reports
This designation within the CPT manual indicates a procedure that is only reported when it is preformed as the only procedure or when another procedure performed at the same time is unrelated to this procedure. this is a ________ procedure.
Separate
When time, effort, and service are bundled together, they form a ________ package.
surgical
_______ anesthesia is defined as local infiltration, metacarpal/ dital block, or topical anesthesia
Local

CHART NOTE

CC: This established patient presents to the office today with complaints of rectal bleeding and itching of 2 weeks’ duration.

OBJECTIVE: This is a 50-year-old male in apparent good health. His BP is 119/78. Rectal examination showed a Grade I hemorrhoid in the 2 o’clock position approximately 2 cm across. The area around the hemorrhoid was slightly inflamed and a small amount of blood was noted.

ASSESSMENT: Hemorrhoid.

PLAN: Discussed conservative treatment options with the patient and explained surgical option. He wants to try the more conservative approach of stool softeners, warm and sitz baths. I discussed with him the importance of improved bowel habits. He is to return for a recheck in 2 months. The medical decision making was of straightforward complexity.

CPT Code:

CPT CODE 99212

DIALYSIS PROGRESS NOTE

LOCATION: Inpatient, Hospital

PATIENT: Gloria Baxter

ATTENDING PHYSICIAN: Ronald Green, MD

This patient is continuing on CAPD. Her weight has fluctuated to some extent dependent on some GI losses. She has not been ultrainfiltrating aggressively, but she has not been eating well either. Over the last day or so she has had problems with hypotension, related to perhaps initially bradycardia and then subsequently to recurrence of atrial fibrillation with a more rapid rate. She did drop her weight to 154, and we have given her some saline boluses through the night. This morning she is reasonably stable. Her weight is 158 pounds. She has no congestive failure and no pain. Her abdomen is soft. Fluid clear. Cultures have remained negative. She had been on Unasyn coverage because of an elevated white count and suspected sepsis but that has not materialized.

The management plan at this time is to discuss a different drug management plan with cardiology to see whether or not she is a candidate for a class III drug in view of the patient’s intolerance to digoxin and/or quinidine. She may well tolerate digoxin at a lower dose, but the problem is it is not effectively blocking her ventricular response.

The other component of her management will be to interrupt the antibiotic and observe her, and then thirdly she will get esophagogastroduodenoscopy today and a CT of her abdomen tomorrow to try to investigate the true core problem that she has. Finally, we are going to increase her Epogen slightly to try to push her hemoglobin up a little faster and try to keep her over 12. This will be a substitute for her hypoalbuminemia and hopefully will maintain her blood pressure and her organ perfusion a little bit better.

This illness is still serious. She is not thriving. She is not eating well, and her prognosis at this point is still extremely guarded. Code level II reaffirmed. (MDM is high complexity.)

CPT Code

99233
This patient is seen in the clinic at the request of Dr. Jones for evaluation of suprapubic pain. Patient is a 22-year-old black female G1 P0, LMP 12/20/xx, EDC 10/16/xx by 14-week ultrasound taken on 4/16/xx, 18 weeks with twin gestation. Presents with complaint of suprapubic sharp to mild pain with onset 2 months ago. Pain has become progressively worse. Patient has been seen by Dr. Jones for this pregnancy and has also been seen by Dr. Smith for this current complaint 2 weeks ago. Patient denies urgency and frequency of nocturia, denies hematuria, and denies discharge.
Labs: CBC and urinalysis performed.
Allergies: none. Past medical history: genital wart 1986.
Past surgical history: wart removed by laser 1986.
Social history: no smoking, illicit drugs, or alcohol.PE: During an expanded problem-focused examination, the HEENT was found to be normal.
FHT: A 148, B 146.
Heart: normal.
Lungs: CTA.
Abdomen: gravid 20 cm. Slight tender suprapubic region.
Vaginal exam: closed cervix, thick, long; no discharge.
Extremities: negative for edema; UA loaded with bacteria and WBC.
Impression: 1. IUP at 18 weeks with twin gestation. 2. Acute UTI (the MDM was straightforward).

Recommendation: Keflex, 500 mg, and follow-up with Dr. Jones

99242
4. The level of E/M service is based on:
Documentation
Key components
Contributing factors
All of the above
all of the above
According to E/M guidelines, a(n) ________ exam encompasses a complete single-specialty exam or a complete multisystem exam.
Problem-focused
Expanded problem focused
Detailed
Comprehensive
Comprehensive
What are the four levels of medical decision making complexity?
Low Complexity High Complexity Moderate Complexity Straightforward
The code range for Home Services is ________.
99341-99350
What are the four levels of history type?
problem-focused, expanded problem-focused, detailed, comprehensive
What CPT code is assigned to an ED service that has a detailed history and exam with a moderate level of MDM?99284
99291
99283
99220
99284
Mr. Smith presents to the Emergency Department at the local hospital for chest pain and is seen by the ED physician on duty. The physician obtains an extended HPI, an extended ROS, and a pertinent PFSH. What is the level of history? Problem-focused
Expanded problem focused
Detailed
Comprehensive
detailed
An initial inpatient consultation with a detailed history, detailed exam and MDM of low complexity
99253
The physician performs an extended exam of the affected body areas and related organ systems. What is the level of the examination?
Problem-focused
Expanded problem focused
Detailed
Comprehensive
detailed
Dr. Martin provided 1 hour and 20 minutes of critical care services to Jack Smithton (age 64), who is in the Intensive Care Unit with acute respiratory distress syndrome. (Separate the codes with a comma in your response as follows: XXXXX, XXXXX.)
99291, 99292
Counseling, coordination of care, nature of presenting problem, and time are considered:
Levels of E/M service
Key components
Contributory factors
Medical decision-making process
Contributory factors
These elements would be part of the ________ history: employment, education, use of drugs.
Past
Social
Family
Any of above
Social
The HPI must be documented in the medical record by:
The physician
Any office staff member
The patient
Any of the above
The physician
When a physician performs a preventive care service, the extent of the exam is determined by the:
Age
Gender
Gender and age
Length of time elapsed since last exam
Age
The definition of low birth weight can be found in the notes for subheading ________.
Continuing intensive care

LOCATION: Emergency Room

SUBJECTIVE: This is a 38-year-old female who presents to the emergency room with a history of currently being under treatment for a right corneal abrasion that occurred on Sunday. She states she was seen by the “eye doctor earlier today” and now has a bandage over her eye. Apparently her eye is opened underneath the bandage and she is unable to close her eyelid. She feels her eyelid is stuck to the bandage.

OBJECTIVE: She is afebrile with stable vital signs. The patch was removed and there was a folded piece of Telfa that had slipped down and her upper eyelid was unable to close over the top of this. The Telfa was removed and a wet patch was placed. This did provide significant comfort. Her eye patch was reinforced.

ASSESSMENT: 1. Right corneal abrasion under treatment. 2. Eye patch replaced as described above.

PLAN: She has a follow up visit tomorrow morning with ophthalmology. I told her she needs to keep that appointment. She is to return here sooner if she is having increasing problems.

CPT Code:

99281
The term used to describe a patient who has NOT been formally admitted to a health care facility is ________.
outpatient
The ________ is a statement describing the reason for the encounter and is a history element.
Chief Complaint
Modifier ________ is used to indicate that a separately identifiable E/M service was performed by the physician on the same day as the preventive medicine service.
-25

Donald Mayors is a homebound patient who is experiencing some new problems with managing his diabetes. Dr. Martin, who has never seen this patient before, drives to Donald’s residence and spends 20 minutes examining the patient and explaining the adjustments that are to be made in the insulin dosage. The medical decision making is straightforward.

CPT Code:

99341

CHART NOTE

CC: Dizziness

SUBJECTIVE: This 46-year-old female established patient presents today reporting feeling ill yesterday, and she has developed some dizziness. She feels like things stick in her throat and that her throat is “sticky.” She has a past history of hypothyroidism and taking Synthroid 0.125 mg q day. Her last TSH was last year and the level appeared to be normal at 0.49.

OBJECTIVE: The patient appears to be in good health and in good spirits. Her BP is 120/81. Afebrile. HEENT normal. Neck is supple. No palpable masses are noted. No thyromegaly, tenderness, or nodes. TSA is elevated at 9.9.

ASSESSMENT: Hypothyroidism (MDM was low).

PLAN: Increase Synthroid to 0.15 mg q day. Recheck in 2 months.

CPT Code:

99213

CAPD CYCLER DIALYSIS PROGRESS NOTE

LOCATION: Inpatient, Hospital

PATIENT: Mandy Horton

ATTENDING PHYSICIAN: Ronald Green, MD

This patient was reasonably stable overnight. She was evaluated empty . She was in no cardiorespiratory distress. Clear lungs, dullness at the bases. A few crackles but otherwise a somewhat irregular heart rhythm this morning. Echocardiogram pending. Abdomen soft. Exit site okay. She was going to be put on CAPD today. This is being done to facilitate some of her studies as we can work this around them. CT is planned for this morning. The CT will be a critical study since we do have significantly abnormal liver function and the question is what could be possibly going on there. She has an esophagitis consistent with herpes or CMV, and the situation could turn ominous depending on the CT results. We are also doing a calorie count to see whether or not we need to consider supplementing her if everything else works out.

The dialysis plan today will be to use five 2.5-liter exchanges, three of them being 2.5% and two of them 1.5%. (MDM is moderate complexity.)

CPT Code:

99232
Subjective: This 17-year-old patient presents to the emergency department after racing motorcycles earlier today. He had his helmet on as well as all of his racing gear. He actively races motorcycles and has done this all summer long, winning a number of times. He came over a jump and lost control of the bike, going over the handlebars. He denies hitting his head but landed on his left elbow and his left knee and has had some discomfort in these areas since. He tells me that he was not going fast, approximately 30 mph. He denies any loss of consciousness. The main complaints center only on the left knee and the left elbow.
Objective: The patient is in no acute distress, nontoxic appearing. During an expanded problem-focused examination, he is alert and oriented.
Eyes: PERL, EOMI conjugate without nystagmus. Funduscopic exam reveals the discs to be sharp and the TMs normal. Throat: clear with teeth intact. Neck: nontender. No palpable discomfort or adenopathy. He has intact clavicles. Lungs: clear. Heart: regular rate and rhythm. Abdomen: soft; no hepatosplenomegaly, rebound, or guarding. He has good upper- and lower-extremity strength. His right arm is nontender to palpation. The left arm has a small amount of tenderness around the elbow joint, but there is no obvious deformity and he does have good, active motion. He has no tenderness with movement of the hips and no tenderness down the long bones of the lower extremities. There is mild tenderness at the left knee. The knee is intact with negative drawer sign and minimal tenderness along the lateral collateral ligament region. There is no real tenderness along the joint line or over the mediocollateral ligament. Both of these ligaments are intact with stress. X-rays of the left knee and left elbow are negative for fracture.
Assessment: Contusion, left elbow and left knee (the MDM was of low complexity).
Plan: Ice, Tylenol; recheck if not improving over the next few days, otherwise on a prn basis.
CPT Code: ____________________
99282

This patient is seen in the clinic at the request of Dr. Jones for evaluation of suprapubic pain. Patient is a 22-year-old black female G1 P0, LMP 12/20/xx, EDC 10/16/xx by 14-week ultrasound taken on 4/16/xx, 18 weeks with twin gestation. Presents with complaint of suprapubic sharp to mild pain with onset 2 months ago. Pain has become progressively worse. Patient has been seen by Dr. Jones for this pregnancy and has also been seen by Dr. Smith for this current complaint 2 weeks ago. Patient denies urgency and frequency of nocturia, denies hematuria, and denies discharge. Labs: CBC and urinalysis performed. Allergies: none. Past medical history: genital wart 1986. Past surgical history: wart removed by laser 1986. Social history: no smoking, illicit drugs, or alcohol.

PE: During an expanded problem-focused examination, the HEENT was found to be normal. FHT: A 148, B 146. Heart: normal. Lungs: CTA. Abdomen: gravid 20 cm. Slight tender suprapubic region. Vaginal exam: closed cervix, thick, long; no discharge. Extremities: negative for edema; UA loaded with bacteria and WBC.
Impression: 1. IUP at 18 weeks with twin gestation. 2. Acute UTI (the MDM was straightforward).
Recommendation: Keflex, 500 mg, and follow-up with Dr. Jones.
CPT Code: ____________________

99242
This is a 79-year-old right-handed married female, who I am now hospitalizing for evaluation of recurrent episodes of numbness and weakness of left upper extremity.
This patient relates to having two episodes occurring during the last week of June; both of these occurred while she was eating breakfast around 7:30 AM. She developed sudden onset, without warning, of complete paralysis as well as numbness of the left arm, which lasted for 10 to 15 minutes. There was no speech impairment, no involvement of the face or leg, and no associated headache. These symptoms completely returned to normal. She denies associated chest pain, shortness of breath, or tachycardia with these spells, and there was no jerking of the extremities. About 2 days later, she again had a similar spell. She has not had any further episodes since that time.Patient’s history is significant for hypertension since age 35. She had no previous history of heart disease or diabetes. Two years ago she was seen by Dr. Smith for left putamen hemorrhage. Patient was also found to have right meningioma arising near the petrous region. She describes about 8 episodes over the past 10 years when her right peripheral vision blacked out briefly. She could not recall whether either eye was affected or if this was the right peripheral vision. The last such episode was about 4 months ago.
This past winter she also had about a 2-week period when the right foot seemed to drag. There has been no recent head injury, and there is no prior history of seizures.
Recent carotid Doppler study performed showed moderate calcified plaque in the right carotid bulb but no significant lesion. No flow could be found in the left internal carotid artery, suggesting left internal carotid artery occlusion. Calcified plaque was also noted in the left carotid bulb. Repeat CT scan of the head again showed the old area of infarction involving the left basal ganglia. There was an enhancing lesion starting in the right tentorial region and extending upward into the right parietal area, having the appearance of a meningioma. This is basically unchanged from the previous scan.

Past Medical History: No serious illnesses.
Operations: 1. Hysterectomy and bladder repair
2. Bilateral blepharoplasty
3. D&C times 4
Allergies: None
Medications: 1. Hytrin, 5 mg, one daily
2. Lozol, 2.5 mg, one daily
Tobacco: Does not smoke
Alcohol: Occasional
Education: Bachelor’s degree
Review of Systems: No recent head trauma, blackout spells, or seizures; no recent problems with headaches
Eyes: As noted
ENT: Negative
Respiratory: Negative
Cardiovascular: Negative except for hypertension
GI/GU: Negative
Endocrine: No diabetes or thyroid problems
Musculoskeletal: Some arthritis, both hands
Psychological: Negative
Family history: Mother deceased from heart disease; father had multiple strokes; two brothers, one with polio; three children whose health is good
Physical Examination: Very pleasant elderly female, in no distress at this time
Vitals: Blood pressure is 140/84; pulse, 90; 150/90
Left arm sitting position
Weight: 115
Skin: No skin lesions present
Nodes: No lymphadenopathy
Chest: Clear to auscultation
Cardiac: Reveals a regular rhythm; I did not hear any murmurs or gallops
Abdomen: Soft, no masses
Back: Negative
Extremities: Negative
Higher cortical function: Intact; speech is fluent
Cranial nerves II-XII: Intact; pupils are equal, reactive to light both direct and consequently; confrontation fields are intact; funduscopic exam was normal; ocular sensation is intact; there is no facial paresis or droop
Reflexes: 1/1 throughout; plantar responses are downgoing bilaterally
Motor/tone/strength: Felt to be normal throughout with particular attention paid to the left upper extremity
Sensory: Reveals no sensory deficits, again with attention paid to the left upper extremity
Coordination: Normal
Gait: Reveals no abnormalities; she is able to walk on heels and toes without difficulty; tandem walk is normal; Romberg is negative
Impression: (1) recurrent episodes of left upper-extremity paralysis and numbness; subclavian steal syndrome (Moderate MDM)
Plan: Extensive neurological workup

CPT Code: ____________________

99222
This is a 15-year-old girl, never seen at this clinic. During a problem-focused history, she states that she noticed a lump on the back of her right wrist yesterday.
P/E: There is a 2-cm freely movable, rubbery, round swelling on the dorsal surface of the right wrist. Distal neurovascular and tendon exam intact. This is not painful to palpation. (The MDM was of straightforward complexity.)
Impression: Ganglion cyst, right wrist.
Treatment: Refer to Dr. Andrews for further treatment.
CPT Code: ____________________
99201
A new patient presents to the physician’s office at which time the physician provides a comprehensive history and exam with a high complexity MDM.
CPT Code: ____________________
99205
An initial inpatient consultation with a detailed history, detailed exam and MDM of low complexity.
CPT Code: ____________________
99253
A 40-year-old established patient presents to the physician office for a preventive care exam.
CPT Code: ____________________
99396
History and exam of the normal newborn infant born in a hospital setting.
CPT Code: ___________________
99460
A 7-year-old female established patient presents to the pediatrician complaining of ear pain x 3 days. A detailed history is then taken. She had associated fever of 101° F yesterday. Mom treated her with Tylenol. The fever this AM is 99° F. She has had some chills and cough as well as some difficulty breathing. No nausea or vomiting. No prior history of Otitis. Brother was sick earlier this week. The physician performed a detailed exam of the ENT as well as a limited exam of GI, Lungs, and Heart. Vital signs were taken in the office. The physician diagnosed the patient with Otitis Media and an Upper Respiratory Infection and prescribed an antibiotic. The MDM is stated to be moderate.
CPT Code: ____________________
99214

CLINIC NOTE

CC: Patient presents for routine examination

SUBJECTIVE: Sally is a 42-year-old female patient who presents today for a routine physical examination

OBJECTIVE: BP 120/80. Pelvic exam: normal external genitalia. Vagina without discharge except for a scant amount of white discharge that appears normal. Cervix: Multiparous, clear. Bimanual exam is unremarkable. All systems are within normal limits.

ASSESSMENT:
1. Normal BP.
2. Normal pelvic exam.

PLAN: Return in 1 year or as needed.

CPT Code: ____________________

99396
Donald Mayors is a homebound patient who is experiencing some new problems with managing his diabetes. Dr. Martin, who has never seen this patient before, drives to Donald’s residence and spends 20 minutes examining the patient and explaining the adjustments that are to be made in the insulin dosage. The medical decision making is straightforward.
CPT Code: ____________________
99341
Location: Emergency Room
SUBJECTIVE: This is a 38-year-old female who presents to the emergency room with a history of currently being under treatment for a right corneal abrasion that occurred on Sunday. She states she was seen by the “eye doctor earlier today” and now has a bandage over her eye. Apparently her eye is opened underneath the bandage and she is unable to close her eyelid. She feels her eyelid is stuck to the bandage.
OBJECTIVE: She is afebrile with stable vital signs. The patch was removed and there was a folded piece of Telfa that had slipped down and her upper eyelid was unable to close over the top of this. The Telfa was removed and a wet patch was placed. This did provide significant comfort. Her eye patch was reinforced.
ASSESSMENT: 1. Right corneal abrasion under treatment. 2. Eye patch replaced as described above.PLAN: She has a follow up visit tomorrow morning with ophthalmology. I told her she needs to keep that appointment. She is to return here sooner if she is having increasing problems.

CPT Code: ____________________

99281
Location: Emergency Room
SUBJECTIVE: A 32-year-old female who presents to the emergency department with chief complaint of increased postoperative swelling. This patient had right neck lymph node biopsy done 3 days ago. Patient has a dressing in place ever since then. For the past 24 hours, she feels like she has increased swelling and she presents now because of it. She denies any accompanying fever, chills, or sweats.
PAST MEDICAL HISTORY: No known drug allergies. Only surgery was wisdom tooth extraction 1 month ago and then the recent lymph node biopsy. Medically, she has a history of depression.
REVIEW OF SYSTEMS: Respiratory: She denies dyspnea.
OBJECTIVE: This is an alert 32-year-old female who appears to be in no acute distress. Temperature is 35.7, pulse 90, respirations 18, blood pressure 144/105, oxygen saturation 99%. HEENT: Conjunctivae and lids normal. Mouth well hydrated. Pharynx normal. Neck is supple. I have removed the dressing. There is a Pen Rose drain in place. The wound seems to be healing well. There is some soft tissue swelling which extends about 3 cm from the wound itself. There is no erythema and no warmth to the area.
ASSESSMENT: Postoperative swelling.
PLAN: I have discussed the case with the ENT surgeon. We have redressed the area. Patient is reassured and will be following up with her doctor tomorrow for drain removal.
CPT Code: ____________________
99282
Location: Hospital
PROGRESS NOTE
The patient is seen today. She has been transferred from the ICU to the floor. She has essentially stabilized. Again, she is having some type of seizure activity.
PHYSICAL EXAMINATION: Her vitals overall are fairly well stabilized. Her postoperative dressings are in place. She did have a significantly elevated INR so
the dressings have been kept in place to minimize the risk of bleeding. She was sleeping when I saw her so I did not wake her. Her toes are pink and warm. Calves are soft.
IMPRESSION: Seizure, status post left hip bipolar hemiarthroplasty.
PLAN: I will continue to follow. From my standpoint, she can mobilize and weight bear as tolerated on the left side. We will change her dressings and place TED hose on the left. We will continue to follow her INR and hemoglobin. Of note, she has been made code status II.CPT Code: ____________________

99231
Anesthesia for diagnostic arthroscopic procedure of the knee joint.
CPT Code: ____________________
01382
Anesthesia for bilateral vasectomy.
CPT Code: ____________________
00921
Anesthesia for tracheobronchial reconstruction.
CPT Code: ____________________
00539
Anesthesia for burr holes.
CPT Code: ____________________
00214
Anesthesia for radical hysterectomy.
CPT Code: ____________________
00846
Daily hospital management of epidural, continuous drug administration.
CPT Code: ____________________
01996
Assign a CPT anesthesia code for debridement of third-degree burns of right arm, 6% body surface area.
CPT Code: ____________________
01952
Assign a CPT anesthesia code for percutaneous liver biopsy.
CPT Code: ____________________
00702
Assign a CPT anesthesia code for total hip replacement, open procedure.
CPT Code: ____________________
01214
Assign a CPT anesthesia code for repair of cleft palate.
CPT Code: ____________________
00172
Assign a CPT anesthesia code for Strayer procedure.
CPT Code: ____________________
01474
2 Examples of Place of Service
Office
Hospital
ED
Nursing Home
4 Examples of Type of Service
Consultation
Admission
Newborn Care
Office Visit
4 Examples of Patient Status
New/Established
Outpatient/Inpatient
New Patient
Patient who has not received professional services from physician or another physician of same specialty/subspecialty in same group within past 3 years
Inpatient
Patient who has been formally admitted to health care facility.
3 Key Components to E/M Level of Service
History
Examination
Medical Decision Making Complexity
4 Contributory Factors to E/M Level of Service
Counseling
Coordination of Care
Nature of Presenting Problem
Time
4 Elements of History
Chief Complaint
History of Presenting Illness
Review of Symptoms
Past/Family/Social History
CC
Chief Complaint abbreviation
ROS
Review of Symptoms abbreviation
HPI
History of Present Illness abbreviation
PFSH
Past/Family/Social History abbreviation
Chief Complaint
Patient’s statement describing symptoms, problems, or conditions as the reason for seeking health care services from a physician.
History of Present Illness
description of current problem, includes location, quality, severity, duration, timing, context, modifying factors, and associated signs and symptoms
Context
Under what circumstances a symptom occurs
Modifying Factors
What circumstances make symptom better or worse
Associated Signs and Symptoms
What other symptoms occur when main symptom occurs
Review of Symptoms
An inventory of body systems obtained through a series of questions in which the patient reports signs or symptoms they are currently having or has had in past
Constitutional Symptoms
Usual weight, weight changes, fever, weakness, fatigue
Cardiovascular Symptoms
Chest pain
rheumatic fever
tachycardia
palpitation
high blood pressure
edema
vertigo
faintness
varicose veins
thrombophlebitis
Respiratory Symptoms
Chest Pain
wheezing
cough
dyspnea
sputum (color and quantity)
hemoptysis
asthma
bronchitis
emphysema
pneumonia
tuberculosis
pleurisy
last chest xray
shortness of breath
Gastrointestinal Symptoms
appetite
thirst
nausea
vomiting
hematemesis
rectal bleeding
change in bowel habits
diarrhea
constipation
indigestion
food intolerance
flatus
hemorrhoids
jaundice
Musculoskeletal symptoms
joint pain/stiffness
arthritis
gout
backache
muscle pain
cramps
swelling
redness
limitation in motor activity
Integumentary symptoms
rashes
eruptions
dryness
cyanosis
jaundice
changes in skin/hair/nails
breast lumps/dimpling/discharge
Neurological Symptoms
faintness
blackouts
seizures
paralysis
tingling
tremors
memory loss
Endocrine Symptoms
thyroid trouble
heat/cold intolerance
excessive sweating/thirst/hunger/urination
blood sugar levels
Hematologic/Lymphatic Symptoms
Anemia
easy bruising/bleeding
past transfusions
Past History
Pt’s past experience with illness/operations/injuries/treatments
Social History
Age-appropriate review of past/current activities including:
employment/occupational history
marital status/sexual history
use of drugs/alcohol/tobacco
education level
Family History
health status/cause of death of parents/siblings/children
Specific diseases related to CC, HPI, or ROS
hereditary diseases of family members
4 History Levels
Problem focused
Expanded problem focused
Detailed
Comprehensive
Problem Focused History
Brief HPI (1-3)
ROS- none
PFSH- none
Expanded Problem Focused History
Brief HPI (1-3)
Problem pertinent ROS (1 organ system)
PFSH – none.
Detailed History
Extended HPI (4+)
Extended ROS (2-9 organ systems)
Pertinent PFSH (1+)
Comprehensive History
Extended HPI (4+)
Complete ROS (10+ organ systems)
Complete PFSH. (2-3 elements depending on service)
How many elements are required to qualify for a given level of History?
3 of 3. (Lowest level is the level choice.)
4 Examination Levels
Problem focused
Expanded problem focused
Detailed
Comprehensive
Problem Focused Exam
(1997)
Exam level with 1-5 bullets
Expanded Problem Focused Exam (1997)
Exam level with 6+ bullets
Detailed Exam (1997)
Exam level with 9+ bullets (eye specific)
Comprehensive Exam (1997)
Exam level with all 14 bullets
3 Elements of Medical Decision Making Complexity
Number of Problems
Amount of Data
Risk
4 Levels of Medical Decision Making
Straightforward
Low
Moderate
High
Straightforward
MDM Level with
Minimal dx/mgt options (1 problem point)
Minimal/no data (1 data point)
Minimal risk
Low-complexity
MDM Level with
limited dx/mgt options (2 problem points)
limited data (2 data points)
low risk
Moderate-complexity
MDM Level with
multiple dx/mgt options (3 problem points)
moderate data (3 data points)
moderate risk
High-complexity
MDM Level with
extensive dx/mgt options (4+ problem points)
extensive data (4+ data points)
high risk
What type of problem as the highest number of MDM points?
new problem, additional followup planned
Do you get multiple points if labs or xrays are ordered and/or reviewed?
No. One data point regardless of number of tests.
Do you get multiple points if labs are ordered AND reviewed?
Yes. One point for an ordered test, one point for a reviewed test.
How many elements are required to qualify for a given level of medical decision making?
2 of 3 (Majority is the choice.)
Counseling
One of 3 Contributing Factors
Discussion of diagnosis, test results, impressions, and/or recommendations, prognosis, treatment options, follow-up, etc.
Coordination of Care
One of 3 Contributing Factors
For example, arranging admission to rehabilitation hospitals and nursing facilities.
Nature of the Presenting Problem
One of 3 Contributing Factors
Severity of Chief Complaint
Name the two types of time that a physician spends in the care of the patient
1. Direct/face to face
2. Unit/floor time
What are the two instances that time is considered for E/M services?
1. Time based codes (eg. Hospital D/C)
2. When 50% or more of time is spent in counseling/coordinating care.
How many key components must be present to code a given level of Office/Other Outpatient Services, New Patient?
3 of 3
How many key components must be present to code a given level of Office/Other Outpatient Services, Established Patient?
2 of 3
If a patient was seen in the office by his physician on Monday and during the appointment the physician decided to admit the patient to the Observation Unit of the local hospital, would you code both the office service and the observation service?
No. Services immediately prior to admission are bundled into the observation service and therefore not coded separately.
attending physician
The physician who admits the patient and is responsible for the patient during the stay in the inpatient facility.
consultant
A physician whose opinion and advice is requested by another physician, but does not take responsibility for the patient.
concurrent care
The care given to the patient by more than one physician at the same time. For example, a pulmonologist and a cardiologist both treating the patient for different conditions at the same time.
Give two examples of physicians who can admit patients to a hospital
1. PCP
2. Hospitalist
Hospitalist
Hospital-based physician who only sees patients in the hospital and assumes the responsibility of the PCP for hospitalized patients.
Can Critical care and other E/M servcies may be provided to the same pt on the same day by the same physician?
Yes.
True or False: Services for a pt who is not critically ill but is in a critical care unit are reported using Critical Care codes.
False. Use other appropriate E/M codes.
What is the determining factor in assigning a level of Critical Care Service?
Time per day
Subtract non-critical service time
If less than 30 minutes, use other E/M code
True or False: Many Critical Care codes have other services bundled into the code.
True.
What modifier is used, per payer request, when reporting non-bundled services into the Critical Care codes
-25
Nursing Facility
Not a hospital, but has inpatient beds and professional health care staff. Lowest level of nursing facility
Skilled Nursing Facility (SNF)
Staffed with physicians/nurses. Patients require more care than in standard nursing facility.
True or False: Prolonged service of less than 30 minutes total duration on a given date is not separately reported.
True. The work involved is included in the total work of the E/M code.
Three subheadings under the Prolonged Services subsection.
1. Prolonged Physician Service With Direct Patient Contact
2. Prolonged Physician Service Without Direct Patient Contact
3. Physician Standby Services
True or False: While reporting standby services for a patient, a physician may provide care/services to other patients.
False.
Standby service may be coded for time spent by a physician proctoring another physician.
False.
The codes within this subsection are used to report physician supervision of a patient under the care of a home health agency in a home, domiciliary, or equivalent environment and supervision of care for patients in a hospice or nursing facility.
Care Plan Oversight Services
The codes within this subsection are used to report services when the patient is not currently ill but receives services.
Preventive Medicine Services
This subsection is used to report coordination of care with other health professionals or in warfarin therapy management and coordination of care with other health care professionals
Case Management Services
Codes from this subsection are for care provided in the patient’s home.
Home Services
This subsection is used by non-hospital settings with a professional staff that provides continuous health care services to patients who are not acutely ill.
Nursing Facility Services
Codes from this subsection are used to report the length of time the physician spends providing care to a critically ill patient.
Critical Care Services
Codes from this subsection are used by a hospital-based departments that are open 24 hours a day. They are often combined with Critical Care Services.
Emergency Department Services
Codes from this subsection are used when one physician asks another physician for an opinion about a patient
Consultation Services
Initial hospital care, Subsequent hospital care, and
Discharge services are all types of what E/M Service?
Hospital Inpatient Services.
If the physician thinks the patient is not ill enough to be formally admitted but still needs to be observed, this code subsection will be used.
Hospital Observation Services.
This subsection of codes could be the physician’s office or other ambulatory facility, such as the outpatient surgery center at a hospital. These codes cannot be used once the patient has been admitted to a health care facility.
Office and Other Outpatient Services
This type of Preventive Medicine Services code is used when a patient is seen specifically to promote health, for example a diet/exercise program.
Counseling Risk Factor Reduction and Behavior Change Intervention.
True or False: If a significant problem is encountered during a preventive examination, additional E/M codes are used to report further services
True.
Coding Preventive Medicine Services is largely based on what factor?
Age of the patient.
The 2 types of Non-Face-To-Face Physician Services
1. Telephone Services
2. On-line Medical Evaluation
Codes from this subheading cannot originate from an E/M service that was provided within the previous seven days and cannot lead to an E/M service within the next 24 hours or the next available appointment. The services are reported based on the time documented in the medical record.
Non-Face-To-Face Physician Services
Use codes from this subheading to report evaluation and management services provided to a normal newborn infant. These services may be provided in a hospital or in a birthing center. The services are reported on a per day basis of initial or subsequent service.
Newborn Care Services
Inpatient neonatal and pediatric critical care codes are based on what factor?
The age of the patient. Neonate = 28 days or younger. Pediatric = 29 days through 24 months or 2-5 years.
What subsection is used when a neonate or infant is not considered critically ill but still needs intensive observation?
Initial and Continuing Intensive Care Services
VLBW
Very Low Birth Weight (less than 1500 grams)
LBW
Low Birth Weight (1500-2500 grams)
This subsection has one code, 99499, that is used to indicate that there is no other code that accurately represents the services provided to the patient.
Other Evaluation and Management Services
What must always accompany an unlisted E/M service code?
Special report
A patient comes into your physician’s office for a physical examination for a life insurance policy. What group of codes would you use to report this service?
Special evaluation and management services
Which government group is responsible for the Medicare program?
Centers for Medicare and Medicaid Services
The Documentation Guidelines apply only to this group of codes.
E/M Codes
What are the three years that Documentation Guidelines were published?
1995
1997
2000
E/M services represent which percent of all services provided to Medicare and Medicaid patients?
50%
CMS stands for
Centers for Medicare and Medicaid Services
Key component of medical decision making is based on what criteria?
Complexity of the decision the physician must make about the patient’s diagnosis and care.
Complexity of Medical Decision Making (MDM) is based on what 3 components?
1.) # of diagnoses or management options (minimal, limited, multiple, or extensive), 2.) Amount or complexity of data to review (minimal, none, limited, moderate, or extensive), 3.) Risk of complication or death if the condition goes untreated (minimal, low, moderate, or high).
Medical decision making complexity levels
Straightforward, Low, Moderate, and High
Straightforward medical decision making consists of what criteria?
Minimal diagnosis & management options, minimal or non for amount and complexity of data to be reviewed, and minimal risk to patient of complications or death if untreated.
Low-complexity medical decision making consists of what criteria?
Limited # of diagnosis & management options, limited data to be reviewed and low risk to patient of complications or death if untreated.
Moderate-complexity medical decision making consists of what criteria?
Multiple diagnoses and management options, moderate amount and complexity of data to be reviewed, & moderate risk to patient of complications of death if untreated.
High-complexity medical decision making consists of what criteria?
Extensive diagnosis & management options, extensive amount and complexity of data to be reviewed & high risk to patient for complications of death if the problem is untreated.
Levels of risk
1.) Minimal or Level 1 (self-limited or minor problem). 2.)Low or Level 2 (2 or more minor problems, one stable chronic illness, or Acute, uncomplicated illness or injury) 3.) Moderate or Level 3 (1 or more chronic illnesses

CHART NOTE

CC: This established patient presents to the office today with complaints of rectal bleeding and itching of 2 weeks’ duration.

OBJECTIVE: This is a 50-year-old male in apparent good health. His BP is 119/78. Rectal examination showed a Grade I hemorrhoid in the 2 o’clock position approximately 2 cm across. The area around the hemorrhoid was slightly inflamed and a small amount of blood was noted.

ASSESSMENT: Hemorrhoid.

PLAN: Discussed conservative treatment options with the patient and explained surgical option. He wants to try the more conservative approach of stool softeners, warm and sitz baths. I discussed with him the importance of improved bowel habits. He is to return for a recheck in 2 months. The medical decision making was of straightforward complexity.

CPT Code:

CPT CODE 99212

DIALYSIS PROGRESS NOTE

LOCATION: Inpatient, Hospital

PATIENT: Gloria Baxter

ATTENDING PHYSICIAN: Ronald Green, MD

This patient is continuing on CAPD. Her weight has fluctuated to some extent dependent on some GI losses. She has not been ultrainfiltrating aggressively, but she has not been eating well either. Over the last day or so she has had problems with hypotension, related to perhaps initially bradycardia and then subsequently to recurrence of atrial fibrillation with a more rapid rate. She did drop her weight to 154, and we have given her some saline boluses through the night. This morning she is reasonably stable. Her weight is 158 pounds. She has no congestive failure and no pain. Her abdomen is soft. Fluid clear. Cultures have remained negative. She had been on Unasyn coverage because of an elevated white count and suspected sepsis but that has not materialized.

The management plan at this time is to discuss a different drug management plan with cardiology to see whether or not she is a candidate for a class III drug in view of the patient’s intolerance to digoxin and/or quinidine. She may well tolerate digoxin at a lower dose, but the problem is it is not effectively blocking her ventricular response.

The other component of her management will be to interrupt the antibiotic and observe her, and then thirdly she will get esophagogastroduodenoscopy today and a CT of her abdomen tomorrow to try to investigate the true core problem that she has. Finally, we are going to increase her Epogen slightly to try to push her hemoglobin up a little faster and try to keep her over 12. This will be a substitute for her hypoalbuminemia and hopefully will maintain her blood pressure and her organ perfusion a little bit better.

This illness is still serious. She is not thriving. She is not eating well, and her prognosis at this point is still extremely guarded. Code level II reaffirmed. (MDM is high complexity.)

CPT Code

99233
This patient is seen in the clinic at the request of Dr. Jones for evaluation of suprapubic pain. Patient is a 22-year-old black female G1 P0, LMP 12/20/xx, EDC 10/16/xx by 14-week ultrasound taken on 4/16/xx, 18 weeks with twin gestation. Presents with complaint of suprapubic sharp to mild pain with onset 2 months ago. Pain has become progressively worse. Patient has been seen by Dr. Jones for this pregnancy and has also been seen by Dr. Smith for this current complaint 2 weeks ago. Patient denies urgency and frequency of nocturia, denies hematuria, and denies discharge.
Labs: CBC and urinalysis performed.
Allergies: none. Past medical history: genital wart 1986.
Past surgical history: wart removed by laser 1986.
Social history: no smoking, illicit drugs, or alcohol.PE: During an expanded problem-focused examination, the HEENT was found to be normal.
FHT: A 148, B 146.
Heart: normal.
Lungs: CTA.
Abdomen: gravid 20 cm. Slight tender suprapubic region.
Vaginal exam: closed cervix, thick, long; no discharge.
Extremities: negative for edema; UA loaded with bacteria and WBC.
Impression: 1. IUP at 18 weeks with twin gestation. 2. Acute UTI (the MDM was straightforward).

Recommendation: Keflex, 500 mg, and follow-up with Dr. Jones

99242
4. The level of E/M service is based on:
Documentation
Key components
Contributing factors
All of the above
all of the above
According to E/M guidelines, a(n) ________ exam encompasses a complete single-specialty exam or a complete multisystem exam.
Problem-focused
Expanded problem focused
Detailed
Comprehensive
Comprehensive
What are the four levels of medical decision making complexity?
Low Complexity High Complexity Moderate Complexity Straightforward
The code range for Home Services is ________.
99341-99350
What are the four levels of history type?
problem-focused, expanded problem-focused, detailed, comprehensive
What CPT code is assigned to an ED service that has a detailed history and exam with a moderate level of MDM?99284
99291
99283
99220
99284
Mr. Smith presents to the Emergency Department at the local hospital for chest pain and is seen by the ED physician on duty. The physician obtains an extended HPI, an extended ROS, and a pertinent PFSH. What is the level of history? Problem-focused
Expanded problem focused
Detailed
Comprehensive
detailed
An initial inpatient consultation with a detailed history, detailed exam and MDM of low complexity
99253
The physician performs an extended exam of the affected body areas and related organ systems. What is the level of the examination?
Problem-focused
Expanded problem focused
Detailed
Comprehensive
detailed
Dr. Martin provided 1 hour and 20 minutes of critical care services to Jack Smithton (age 64), who is in the Intensive Care Unit with acute respiratory distress syndrome. (Separate the codes with a comma in your response as follows: XXXXX, XXXXX.)
99291, 99292
Counseling, coordination of care, nature of presenting problem, and time are considered:
Levels of E/M service
Key components
Contributory factors
Medical decision-making process
Contributory factors
These elements would be part of the ________ history: employment, education, use of drugs.
Past
Social
Family
Any of above
Social
The HPI must be documented in the medical record by:
The physician
Any office staff member
The patient
Any of the above
The physician
When a physician performs a preventive care service, the extent of the exam is determined by the:
Age
Gender
Gender and age
Length of time elapsed since last exam
Age
The definition of low birth weight can be found in the notes for subheading ________.
Continuing intensive care

LOCATION: Emergency Room

SUBJECTIVE: This is a 38-year-old female who presents to the emergency room with a history of currently being under treatment for a right corneal abrasion that occurred on Sunday. She states she was seen by the “eye doctor earlier today” and now has a bandage over her eye. Apparently her eye is opened underneath the bandage and she is unable to close her eyelid. She feels her eyelid is stuck to the bandage.

OBJECTIVE: She is afebrile with stable vital signs. The patch was removed and there was a folded piece of Telfa that had slipped down and her upper eyelid was unable to close over the top of this. The Telfa was removed and a wet patch was placed. This did provide significant comfort. Her eye patch was reinforced.

ASSESSMENT: 1. Right corneal abrasion under treatment. 2. Eye patch replaced as described above.

PLAN: She has a follow up visit tomorrow morning with ophthalmology. I told her she needs to keep that appointment. She is to return here sooner if she is having increasing problems.

CPT Code:

99281
The term used to describe a patient who has NOT been formally admitted to a health care facility is ________.
outpatient
The ________ is a statement describing the reason for the encounter and is a history element.
Chief Complaint
Modifier ________ is used to indicate that a separately identifiable E/M service was performed by the physician on the same day as the preventive medicine service.
-25

Donald Mayors is a homebound patient who is experiencing some new problems with managing his diabetes. Dr. Martin, who has never seen this patient before, drives to Donald’s residence and spends 20 minutes examining the patient and explaining the adjustments that are to be made in the insulin dosage. The medical decision making is straightforward.

CPT Code:

99341

CHART NOTE

CC: Dizziness

SUBJECTIVE: This 46-year-old female established patient presents today reporting feeling ill yesterday, and she has developed some dizziness. She feels like things stick in her throat and that her throat is “sticky.” She has a past history of hypothyroidism and taking Synthroid 0.125 mg q day. Her last TSH was last year and the level appeared to be normal at 0.49.

OBJECTIVE: The patient appears to be in good health and in good spirits. Her BP is 120/81. Afebrile. HEENT normal. Neck is supple. No palpable masses are noted. No thyromegaly, tenderness, or nodes. TSA is elevated at 9.9.

ASSESSMENT: Hypothyroidism (MDM was low).

PLAN: Increase Synthroid to 0.15 mg q day. Recheck in 2 months.

CPT Code:

99213

CAPD CYCLER DIALYSIS PROGRESS NOTE

LOCATION: Inpatient, Hospital

PATIENT: Mandy Horton

ATTENDING PHYSICIAN: Ronald Green, MD

This patient was reasonably stable overnight. She was evaluated empty . She was in no cardiorespiratory distress. Clear lungs, dullness at the bases. A few crackles but otherwise a somewhat irregular heart rhythm this morning. Echocardiogram pending. Abdomen soft. Exit site okay. She was going to be put on CAPD today. This is being done to facilitate some of her studies as we can work this around them. CT is planned for this morning. The CT will be a critical study since we do have significantly abnormal liver function and the question is what could be possibly going on there. She has an esophagitis consistent with herpes or CMV, and the situation could turn ominous depending on the CT results. We are also doing a calorie count to see whether or not we need to consider supplementing her if everything else works out.

The dialysis plan today will be to use five 2.5-liter exchanges, three of them being 2.5% and two of them 1.5%. (MDM is moderate complexity.)

CPT Code:

99232
T/F- Findings observed by M.D. about Pt. complaint is known as review of systems:
False
T/F- Patients recieving care in the Neonatal Intensive Care Unit (NICU) of a hospital are typicaly suffering very low birth rate:
True
T/F- Is it acceptable for a M.D. rendering standby care to one hospital Pt. while treating another so long as both Pt’s are on the same floor:
False
TF- Inventory of body systems obtained through questioning to identify signs or symptoms that the Pt. may be experiencing is known as ROS:
True
CPT stands for:
Current Procedure Terminology
Category I CPT codes have ___ digits:
5
Examination is limited to the affected body area or organ system identified by the chief complaint:
Problem focused
M.D. performs a preventive care sevice the extent of the exam is determined by the:
Age of the Pt. and the risk factors identified
Hospital inpatient services subsection is used for Pt’s admitted to:
Acute Care
Which CPT appendix would modifiers be found:
Appenix A
Term used to describe a Pt. who has NOT been formally admitted to the health care facility is:
Out Patient
HPI must be documented in the medical record by:
Physician
Examination is the ____ portion of the E/M service:
Objective
Final code selection for determining the level of E/M service is based on:
Key components, Contributary factors
Examination limited to the affected body area or organ system and other related organ systems:
Expanded problem focus
According to CPT guidelines a ___exam encompasses a complete single-specialty exam or a complete multi-system exam:
Comprehensive
Managment of a Pt.’s condition, the M.D.’s level of medical decision making (MDM) is based on:
Overall
The act mandated to adoption of national uniform standards for electronic transmission of financial and administrative health information:
HIPAA
Critical care codes are reported based on:
Time physician spends with a Pt.
Established Pt. is one who has recieved professional service from the M.D. within the ____years:
3- face to face professional service
Codes from the E/M subsection Nursing Facilities Service are used to reprt services provided in this type of facitlity:
Initail , Subsequent, Other Nursing facility or Skilled Intermediate care, Long-term care
The M.D. who had primary responsibility of the Pt. in the hospital is called:
Attending physician
Amniocentesis is:
Puncture of the amniocentesis sac using a needle to withdraw amniotic fluid to be evaluatted and tested
X-ray record of the spinal cord:
Myelogram
Extended exam of the affected body area or areas and related organ systems:
Detailed
BA or OS=> Neck:
BA
BA or OS=> Skin:
OS
BA or OS=> Eyes:
OS
BA or OS=> Back:
BA
BA or OS=> Respiratory:
OS
Spelling->Both sides:
Bilateral
Spelling-> Without oxygen:
Anoxia
Spelling-> Slow heartbeat:
Bradycardia
Spelling-> Lack of water:
Dehydration
Malignant tumor of bone:
Myeloma
For an M.D. to bill CPT code 99213 he is required to document which of the following key components:
A: Expanded problem focused history,
B: Expanded problem focused exam
C: MDM Low complexity
Tachy, as in tachycardia, means:
Swift, fast,abnormal heart action
Endo. as in endoscopy, means:
Within- Visually examine organs, cavity with an endoscope
Domiciliary:
No health services or medical services offered in site, facility includes lodging, meals. supervision, personal care, leisure activities. independently
Concurrent care:
More than one physician provides service to a Pt. on the same day for a different condition
Systemic:
Pertaining to whole body
Preventive medicine services:
Routine physical evaluation and management of a Pt. who is healthy and has no complaints
Observation status:
Classification of a Pt. who does not have an illness severe enough to meet acute inpatient criteria and does not require as intensive as an inpatient but does require hospitalization for a short period of time
Critical care:
Pt. over 24 months of age may either be critically ill or injured, Requires a physician to be constantly available to the Pt. and providing services exclusively to a Pt.
Inpatient status:
One who has been formally admitted to an acure health care facility
These elements would be part of the ____ history: employment, education, use of drugs.
social
Bruising would be an element of review of this organ system
Hematologic
The level of E/M service is based on
documentation
key components
contributing factors
The HPI must be documented in the medical record by:
the physician
The examination is the ____ portion of the E/M service
objective
Medical decision making (MDM) is based on the ____ the physician must consider about the management of a patient’s condition.
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
8. If the number of diagnoses or management options and the amount of data to be reviewed is extensive, and there is a high risk of complications, the medical decision-making level is considered:
Highly complex
When a patient is receiving extensive care from more than one physician during the same period of time, it is considered:
Concurrent care
No differentiation is made as to patient status (new or established) when assigning hospital observation codes.
True
The three factors that the coder must consider in the assignment of an E/M code are: 1. Place of Service 2. _____________ of Service 3. Patient Status
Type
Gladys Swain slipped from the sidewalk curb and twisted her right ankle. Because of her severe pain; she was suffering and because of the inability to bear weight on the foot, she sought treatment at her neighborhood hospital emergency department. The treating physicians were fairly confident that Ms. Swain had an ankle injury. The physician completed a problem-focused history regarding the injury and a problem-focused examination of her right foot and ankle. The MDM complexity was straightforward. The patient was immediately sent to radiology department for an X-ray. A two-view x-ray of the right ankle was completed. The radiologist confirmed a simple closed fracture of the medial malleolus. The patient then returned to the emergency department, where the physician immobilized the ankle. The patient was referred to an Orthopedic surgeon for follow up
What is the body system, body cavity, Subjective statement, diagnosis and treament
what are the reasons for the CPT coding system?
1) Comparative Analysis
2) data for research
3) improved communication
what is the function of an add-on code?
identifies a code that is never to be used alone…
rules that govern coding in various health care settings.
variabe…
how many sections are in the CPT manual?
6…
when will unclear terminology CPT be replaced with more precise definitions?
upon publications of CPT-5…
what does a modifier do?
provide additional information to the third-party payer…
the words that follow a code number in the CPT manual are called?
procedure/ service descriptions…
what is a type of code that has all of the words that describe the code that follows
stand alone code…
this is the type of code used to report procedures that are experimental, newly approved, or seldom used
unlisted/ cateogory 3 code…
what group(s) require a special report with the use of unliste codes
third-party payers…
is an act that mandate the adoption of national uniform standards for electronic transmission of financial and administrative health information
HIPAA…
what year was the CPT first developed and published?
1966…
who publishes the CPT book?
American Medical Association (AMA)…
health care providers are ______ based on the codes submitted on a claim form for procedures an services rendered
Reimbursed…
category I CPT codes have how many digits?
5…
the universal health insurance form for submission of outpatient is called?
CMS-1500…
what are the 6 elements that a special report must contain?
1) nature
2) extent
3) need
4) time
5) effort
6) equipment used
7) photos and medical journal…
what is the punctuation mark between codes in the index of the CPT manual that indicates that a range of codes is available?
a hyphen…
what is the punctuation mark between codes in the index of the CPT manual that indicates two codes are available?
a comma…
what part of the CPT manual would you find a list of the unlisted procedures for use in a specific section of the CPT manual?
guidelines…
which CPT appendix would you find additions, deletions, and revision?
B…
which CPT appendix would you find all modifiers?
A…
what does CPT stand for?
Current Procedural Terminology
is a term that reflects the technological advances made in medicine that are incorporated into the CPT manual.
Revision…
where in the CPT book is specific coding information about each section located?
Guidlines…
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
Procedures that are experimental, newly approved, or seldom used are reported with what type of code?
unlisted/Category III
Who requires a special report with the use of unlisted codes?
third-party payers
Which of the following represents three of the six elements that a special report must contain?
nature, extent, need
Which punctuation mark between codes in the index of the CPT manual indicates a range of codes is available?
hyphen
Which punctuation mark between codes in the index of the CPT manual indicates two codes are available?
comma
A list of unlisted procedures for use in a specific section of the CPT manual is contained in:
Guidelines
In which CPT appendix would additions, deletions, and revisions be found?
Appendix B
In which CPT appendix would all modifiers be found?
Appendix A
CPT stands for:
Current Procedural Terminology
Which terms reflects the technological advances made in medicine that are incorporated into the CPT manual?
revisions
Where is specific coding information about each section located?
Guidelines
This act mandated the adoption of national uniform standards for electronic transmission of financial and administrative health information.
HIPAA
What year was CPT first developed and published?
1966
Who publishes CPT?
AMA
Health care providers are ___ based on the codes submitted on a claim form for procedures and services rendered.
reimbursed
Category I CPT codes have ___ digits
5
The universal health insurance form for submission of outpatient services is the:
CMS-1500
Which of the following is NOT a reason for the CPT coding system?
increased reimbursement
What is the function of an add-on code?
identifies a code that is never used alone
The rules that govern coding in various health care settings are:
nationally established
How many main sections are in the CPT manual?
6
A modifier:
provides additional information to the third-party payer
An unlisted procedure code:
ALL OF THE ABOVE: is a procedure or service not found in the CPT manual, is located in the Section Guidelines, is located at the end of a subsection or subheading
How often are Category III codes released?
twice a year
According to the notes preceding the Category III codes in the CPT manual, the digits of the Category III codes are not intended to reflect the placement of the code in the Category I section of the CPT:
nomenclature
According to the CPT manual, modifier -91 is not to be used when test are __ to confirm inertial results.
rerun
According to the E/M guidelines, time is not a descriptive component for the ___ department levels of E/M service.
emergency
According tothe Radiology Guidelines, these are the methods that qualify as “with contrast.”
intavascularly, intra-articularly, intrathecally
Level II codes are not used in which setting?
inpatient
Which of the following would be used to code drugs?
J codes
Name the six basic location methods to locate main terms in the index of CPT.
procedure/service
synonym
eponymous
anatomic site
condition of disease
abbreviations
What 2 words describe a decreased level of consciousness that does not put patients completely to sleep and that allows the patient to breathe on their own during surgical procedure?
Moderate sedation
What do the initials CRNA stand for?
Certified Registered Nurse Anesthetist
CMS publishes an annual list of _____ ______ values for anesthesia codes
Base unit
The “M” in the anesthesia formula stands for ____ unit.
Modifying
What is the term that describes the services provided to a patient by the physician before surgery?
preoperative
What is another term for the time after the surgery when the physician provides services to the patient?
postoperative
The ___ factor for the locale is multipled by the number of base units in the procedure plus the time units to determine the price of the anesthesia service.
Conversion
The modifier indicates that a CRNA service with medical direction by a physician was provided.
-Qx
Patient with severe systemic disease that is a constant threat to life
P4
Normal healthy patient
P1
patient with a severe systemic disease
P3
Declared brain-dead patient whose organs are being removed for donor purposes
P6
Patient with mild systemic disease
P2
Moribound patient who is not expected to survive without the operation
P5
Diagnostic arthroscopic procedure of knee joint
Knee.. 01382
Radical hysterectomy
Anesthesia, Hysterectomy, Radical; 00846
Cesarean delivery only
Anesthesia, Cesarean delivery; 01961
Transurethral resection of the prostate
Anesethesia, Transurethral Procedures; 00914
Anesthesia for a myringotomy on a healthy 5-year-old patient.
Anesthesia, Myringotomy; 00120-P1 or 00126-P1
Repeat procedure or service by same physician:
76
Two surgeons:
62
Professional component:
26
Multiple modifiers:
99
Distinct procedural service:
59
Mandated service:
32
Significant identifiable E/M service provided by the same physician on the same day as another service or procedure:
25
Minimum assistant surgeon:
81
Repeat procedure by another physician:
77
Unrelated procedure or service by the same physician during the postoperative period:
79
Unusual anesthesia:
23
Unplanned return to the operating room for a related procedure during the postoperative period:
78
Surgical care only:
54
Reduced service:
52

Anesthesia for tendon repair of the shoulder, normal, healthy patient:

Anesthesia Code: ________.

01610-P1

Anesthesia for a cesarean hysterectomy following neuraxial labor anesthesia, normal, healthy patient:

Anesthesia Codes: ________.

01967-P1, 01969-P1

Anesthesia for a missed abortion procedure in which the mother is in grave danger of death:

Anesthesia Code: ________.

01965-P5

Cranioplasty for a depressed skull fracture, simple, extradural, for a patient with mild diabetes, well-controlled:

Anesthesia Code: ________.

00215-P2

Total hip replacement in a 75-year-old patient with hypertension that is well controlled with medication:

Anesthesia Codes: ________.

00214-P2, 99100

Burn excision of 5% of the total body surface with skin grafting of the abdomen. Patient is 9 months old and in stable condition:

Anesthesia Codes: ________.

01952-P1, 99100

Hospital management of a continuous epidural drug delivery system for 5 days:

Anesthesia Code: ________.

01996×5

Arthroscopic total wrist replacement in a normal, healthy patient:

Anesthesia Code: ________.

01832-P1
Is examination of the back an organ system or body area examination?
Body Area
What are the four types of patient status?
New, Established, Outpatient and Inpatient
The first outpatient visit is called the ________ visit, and the second visit is called the ________ visit.
Initial, subsequent
The first three factors a coder must consider when coding are patient? .
Patient status, type of service, place of service
How many types of histories are there?
Four
Which history is more complex: the problem focused history or the expanded problem focused history?
Expaneded Problem Focused
List the four types of examinations, in order of difficulty from least difficult to most difficult.
Problem focused, expanded problem focused, detailed, and comprehensive
The examination that is limited to the affected body area is the ________.
Problem Focused
What does VLBW stand for?
Very Low Birth Weight
What medical decision making involves a situation in which the diagnosis and management options are minimal, data amount and complexity that must be reviewed are minimal/none, and there is a minimal risk to the patient of complications or death?
Straightforward
What term is used to describe a patient who has been formally admitted to a hospital?
Inpatient
The physician provides initial intensive care service for the evaluation and management of a critically ill newborn (5 days old) inpatient for one day.
CPT Code: ________.
99468
A 55-year-old man is seen by the dermatologist for the first time and complains of two cystic lesions on his back. Considering that the patient is otherwise healthy and has a primary care physician caring for him, the dermatologist focuses the history of the present illness on the skin lesions (problem focused history) and focuses the problem focused physical examination on the patient’s trunk. The physician concludes with straightforward decision making that the lesions are sebaceous cysts. The physician advises the patient that the lesions should be monitored for any changes, but that no surgical intervention is warranted at this time.
CPT Code: ________.
99201
A 68-year-old woman visits her internist again complaining of angina that seems to have worsened over the past 3 days. The patient had had an acute anterior wall myocardial infarction (MI) 2 months earlier. One month after the acute MI, she began to have angina pectoris. The patient also states that she thinks the medications are causing her to have gastrointestinal problems while not relieving her symptoms. She had refused a cardiac catheterization after her MI to evaluate the extent of her coronary artery disease. The physician performs a detailed history and a detailed physical examination of her cardiovascular, respiratory, and gastrointestinal systems. The physician indicates that the decision making process is moderately complex, given the number of conditions it is necessary to consider.
CPT Code: ________.
99214
A 22-year-old woman visits the gynecologist for the first time since relocating from another state last year. The patient wants a gynecologic examination and wants to discuss contraceptive options with the physician (think Preventive Medicine Services!). The physician collects pertinent past and social history related to the patient’s reproductive system and performs a pertinent systems review extended to a limited number of additional systems. The physician completes the history with an extended history of her present physical state. A physical examination includes her cardiovascular and respiratory systems with an extended review of her genitourinary system. Given the patient’s history of not tolerating certain types of oral contraceptives in the past, the physician’s decision making involves a limited number of management options, all with low risk of morbidity to the patient.
CPT Code: ________.
99385

An established patient is admitted on observation status for influenza symptoms and extreme nausea and vomiting. The patient is severely dehydrated and has been experiencing dizziness and mental confusion for the past 2 days. Prior to this episode the patient was well but became acutely ill overnight with these symptoms. Given the abrupt onset of these symptoms, the physician has to consider multiple possible causes and orders a variety of laboratory tests to be performed. The patient is at risk for a moderate number of complications. The MDM complexity is moderate. A comprehensive history is collected, and a comprehensive head-to-toe physical examination is performed.

CPT Code: ________.

99219
A physician visits another patient on observation status who has severe influenza. The decision is made to admit the patient, whose condition has worsened and who is not responding to the therapy initiated on the observation unit. The physician performs a detailed history and a detailed physical examination to reflect the patient’s current status. The patient’s problem is of low severity but requires ongoing active management, with possible surgical consultation. The MDM complexity is low.
CPT Code: ________.
99221
An 8-month-old infant, who is a new patient, is brought in by her mother for diaper rash. The physician focuses on the problem of the diaper rash for the problem focused history and examination. The MDM complexity is straightforward.
CPT Code: ________.
99201
A 33-year-old man is brought to his private physician’s office by his wife. The man, who is an established patient, has been experiencing severe leg pain of 2 weeks’ duration. In the past 2 days, the patient has experienced fainting spells, nausea, and vomiting. The patient has had multiple other vague complaints over the past month that he dismissed as unimportant, but his wife is not so sure, and she describes his general health as deteriorating. The physician performs a comprehensive multisystem physical examination after performing a complete review of systems and a complete past medical, family, and social history, with an extended history of the present illness (comprehensive history). The physician has to consider an extensive number of diagnoses, orders a variety of tests to be performed immediately, and indicates the MDM complexity to be high.
CPT Code: ________.
99215
A 42-year-old woman, who is an established patient, visits her family practitioner with the chief complaint of a self-discovered breast lump. She describes a feeling of fullness and tenderness over the mass that has become more pronounced in the past 2 weeks. Because the patient is otherwise healthy and has had a physical within the past 6 months, the physician focuses his attention on the breast lump during the taking of a problem focused history and the performance of a problem focused physical examination. The physician orders an immediate mammography to be performed and a follow-up appointment in 5 days. The physician has given the patient no other options and indicates that the MDM complexity is straightforward.
CPT Code: ________
99212
May affect the way payment is made by 3rd party payers
Modifiers
Modifiers are used to indicate
Bilateral procedure, Multiple Procedures, Service greater than required
Modifier -57
Decision for surgery can be used with an E/M code
Modifier -79
Unrelated procedure or service by the same physician during the past.
Op period
Can only be used with a surgery code
Modifier -51
Multiple procedure, can only be used with a surgery code
Modifier -80
Assistant Surgeon, is used when a 2nd surgeon provides assistance to primary surgeon
Modifier -32
Indicates a service is mandated. Ex- an insurance company requires a 2nd opinion prior to surgery
Modifier -59
Distinct procedure service indicates services that are usually bundled into one payment were provided as separate
services
Modifier -25
Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service is used to report an E/M service 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 post op period indicates a subsequent surgery was planned at the time of the 1st surgery
Modifier -52
Reduced services- a service was reduced without changing the definition of the code
Modifier -AA
Is a HCPCS modifier- is used to report anesthesia services performed personally by anesthesiologist or when an anesthetist assists a physician …
Modifier- 99
Multiple Modifiers
Modifier- 26
Professional component
Modifier- 51
Indicates multiple procedures
Apendix A
Lists some HCPCS modifiers
TC
Tecchnical component of a diagnostic procedure
Modifier- 90
Used to indicate services of an outside laboratory
When two or more physicians, with technicians and specialized equipment, work together to complete a complicated procedure and each physician has a specific portion to complete.
Surgical Team
This modifier indicates an increased service and is overused and results in an increase in payment of 20%-30%. As such, assignment of this modifier comes under scrutiny by 3rd party payers.
Modifier -22
When modifier -54 is assigned payment for the ___________ portion of the surgical procedure is being requested.
Inoperative
Joan assigned modifier -32 to an E/M consultation code 99244. Medical records shows request was made by patient’s spouse. Is Joan correct?
No, this modifier is NOT to be used to report 2nd opinion requested by a patient, spouse or another physician
It is only appended to other than E/M codes
Modifier -59
What is the weight in pounds of a 4-kilogram infant?
8.8
Which two statements are not true about modifier -53?
Describes circumstances based on the patients preoperative condition
describes circumstances in which the patient cancelled the procedure
Modifier -57 can be added to Surgery section codes?
False
When adding multiple CPT modifiers to a code, you would list the modifiers from
Highest to lowest
What appendix in the CPT manual contains a complete list of all modifiers?
Appendix A
What is the word that means assigning multiple codes when one code would do?
Unbundling
Do all third party payers recognize all modifiers as listed in the CPT manual?
No
What is the term that describes two physicians working together in the completion of a procedure when each has the same level of responsibility
Co-surgeons
CPT stands for ________.
Current Procedural Terminology
The CPT manual often reflects the technological advances made in medicine with these codes:
Category III Codes
The CPT manual is ever changing and is updated annually to reflect technological advances and editorial ________.
Revisions
What type of code ends with 99?
Unlisted
Coding information that pertains to an entire section is located in the ________.
Guidelines
These codes provide supplemental information and do not substitute for a Category I code:
Category II Codes
What is the name of the two-digit number or a digit and a number that is located after the CPT code number and provides more detail about the code?
modifier
Where is the list of all the modifiers located?
Appendix A
When using an unlisted or Category III code, third-party payers usually require the submission of what?
Special Report
Additions, deletions, and revisions are listed in which Appendix?
B
A listing of all add-on codes is located in which Appendix?
D
The symbol used between two code numbers to indicate that a range is available is a ________.
Hyphen
Repeat procedure by the same physician:
76
Surgical care only:
54
Anesthesia by the surgeon:
47
Bilateral procedure:
50
Orbit: Code:
67599
Rectum: Code:
45999
Lips: Code:
40799
General musculoskeletal: Code:
20999
T4 Total:
Thyroxine, Total
SHBG:
Sex Hormone Binding Globulin
Radius:
Arm, Lower; Elbow; Ulna
Modifier -22
Increased Procedural Services
Modifier -23
Unusual Anesthesia Modifier
Modifier -24
Unrelated E/M Services by the Same Physician During a Postoperative Period
Modifier -25
Significant Separately Identifiable E/M Service by the Same Physician on the Same Day of the Procedure or Other Service
Modifier -26
Professional Component
Modifier -32
Mandated Services
Modifier -47
Anesthesia by Surgeon
Modifier -50
Bilateral Procedure
Modifier -51
Multiple Procedures
Modifier -52
Reduced Services
Modifier -53
Discontinued Procedure
Modifier -54
Surgical Care Only
Modifier -55
Postoperative Management Only
Modifier -56
Preoperative Management Only
Modifier -57
Decision for Surgery
Modifier -58
Staged or Related Procedure or Service by the Same Physician During the Postoperative Period
Modifier -59
Distinct Procedural Service
Modifier -62
Two Surgeons
Modifier -63
Procedure Performed on Infants Less than 4 kg
Modifier -66
Surgical Team
Modifier -76
Repeat Procedure or Service by Same Physician
Modifier -77
Repeat Procedure by Another Physician
Modifier -78
Unplanned Return to the Operating/Procedure Room by the Same Physician Following Initial Procedure for a Related Procedure During the postoperative Period
Modifier -79
Unrelated Procedure or Service by the Same Physician During the Postoperative Period
Modifier -80
Assistant Surgeon
Modifier -81
Minimum Assistant Surgeon
Modifier -82
Assistant Surgeon (When Qualified Resident Surgeon Not Available)
Modifier -90
Reference (Outside) Laboratory
Modifier -91
Repeat Clinical Diagnostic Laboratory Test
Modifier -92
Alternative Laboratory Platform Testing
Modifier -99
Multiple Modifiers
Surgical Team
When more than two physicians, with technicians and specialized equipment, work together to complete a complicated procedure and each physician has a specific portion of the surgery to complete, they are term what?
Modifier -22
This modifier indicates an increased service and is overused and results in an increase in payment of 20% to 30%. As such, the assignment of this modifier comes under particularly close scrutiny by third-party payers. What is this modifier?
Modifier -54
Payment for the intraoperative or surgery portion of the surgical procedure is being requested.
Modifier -59
Only to other than E/M codes
What is the weight in pounds of a 4-kilogram infant?
8.8 lbs.
Modifier -55
(Postoperative Management Only) should be assigned when a provider other than the surgeon is responsible for postoperative management.
NCCI
National Correct Coding Initiative
National Correct Coding Initiative (NCCI)
Implemented by the American Medical Association
Modifier -52
A service that has been partially reduced at the physician’s discretion is reflected by the modifier
Modifiers -23, -52, and -73
When the provider performs a procedure or service for which there is no CPT code, the coder should assign
National Correct Coding Initiative (NCCI)
Automated edits that identify pairs of services that normally should not be billed by the same physician for the same patient on the same day are part of the
What is a functional modifier
It is a pricing modifier, which means that the third-party payer considers it when determining reimbursement
Modifier -62
When two primary surgeons are required during an operative, each performing distinct parts of a reportable procedure, modifier ___________ should be assigned.
Modifier -76
When a procedure was repeated because of special circumstances involving the original service and the same physician performed the repeat procedure, modifier ____ should be recorded.
Modifier -32
Workers’ Compensation referred a patient to a physician for a mandatory examination to determine the legitimacy of a claim (insurance certification). What modifier would be added to the code for the examination service?
Modifier -47
Dr. Ramus administers regional anesthesia by intravenous injection (also known as Bier’s local anesthesia) for a surgical procedure on the patient’s lower arm. Dr. Ramus then performs the surgical procedure. What modifier would be added to the surgical code.
Modifier -25
A patient came to the office twice in one day to see the same physician for unrelated problems. What modifier would be added to the code for the second office visit?
Modifier -51 – There are three significant times when multiple procedures are reported:
1. Same Operation, Different Site
2. Multiple Operation(s), same Operative Session
3. Procedure Performed Multiple Times
Modifier -54, -55, and -56
When reporting his or her own individual services, each physician would use the same procedure code for the surgery, letting the modifier indicate to the third-party payer the part of the surgical package that each personally performed.
Appendix A
What appendix in the CPT manual contains a complete list of all modifiers?
Preoperative Services
What is the term that describes the services provided to a patient by the physician before surgery?
When listing multiple CPT modifiers, you would list them from:
Highest to lowest
Which of the following statements is true about modifier?
may be used to describe those times when the physician elects to terminate a procedure due to the well-being of the patient
Dr. Wells began surgery on an 86-year-old female with severe hypertension. The patient was satisfactorily anesthetized and the site opened to view. Shortly thereafter, the patient’s blood pressure dropped significantly, and the physician was unable to stabilize the patient. The procedure was discontinued.
Modifier -53
The patient is a 10-month-old boy who fell while trying to walk. He cut the bottom of his lip open. Sutures are necessary, but due to the patient’s age and excessive movement, general anesthesia is needed.
Modifier -23
A patient has a hernia repair and 2 days later must be returned to the operating room for a dehiscence of the incision. When coding the secondary hernia repair, which modifier would you add onto the surgical codes?
Modifier -78
A surgeon performed a repair of an enterocele using an abdominal approach and reported the service with 57270. Then patient was morbidly obese with a BMI of 42, and due to this circumstance, the procedure took a significant amount of additional time to perform.
Modifier -22
During a radical right descended orchiectomy for an extensive malignant tumor (54435), the patient began to hemorrhage. After considerable time and effort, the hemorrhage was controlled.
Modifier -22
The modifier -RT and LT are:
Right and Left, Never used with Modifier -50, and HCPCS modifiers
Which group of modifier, are most likely NOT to be recognized by insurance carriers?
Modifiers -63, -53, -54, -55, and -56
Modifiers -54 and -55 most likely would be used.
By two different physicians, on separated claims
Modifier -TC means:
Technical Component
Adding modifier ______________, Unusual Services modifier, indicates “additional effort or time”:
Modifier -22; May still not be compensated at a higher rate, even with a report, if the carrier doesn’t agree.
The modifier -23, ____________ would not be appropriate for the use of a accupuncture
Unusual anesthesia
Modifier -24 should always be used with:
Evaluation and Management codes.
Modifier -25
Used for the initial evaluation of a problem for which a procedure is performed.
If general anesthesia is applied, modifier -23 should be used when your CPT manual notes under the CPT code:
Procedure “usually performed without anesthesia or under local anesthesia.”
Some CPT codes are “Technical Service only”. This means:
Only the “facility”, most often a hospital, would bill for services (use of the equipment.)
The use of a magnifying surgical loupe qualifies the use of modifier -20, microsurgery:
Modifier -20 has been deleted from CPT and can no longer be used.
Which of the following modifiers are considered informational only (will not impact reimbursement)?
Modifiers -24, -32, and -57
What the percentage amounts allocated for Modifier -54, -55, and -56, respectively?
70%, 20%, 10%
What the percentage amounts for modifier -54?
Intraoperative: 70%
What the percentage amounts for modifier -55?
Postoperative: 20%
What the percentage amounts for modifier -56?
Preoperative: 10%
What is the word that means assigning multiple codes when one code would do?
Unbundling
What is the term that describes the services provided to a patient by the physician after surgery?
Postoperative Services
A patient is admitted and has bilateral arthroscopy of the knees due to Baker’s cysts.
Modifier -50
A radiological examination of the gastrointestinal tract was ordered by a third-party payer for a confirmation of Crohn’s disease (regional enteritis) of the large bowel.
Modifier -32
Anesthesia provided by the ENT physician during a tympanoplasty for repair of a tympanic membrane perforation.
Modifier -47
A patient is seen at the direction of Workers’ Compensation for a complete physical examination for insurance certification.
Modifier -32
The patient returns to the operating room for removal of deep pins during the postoperative period, due to complication (dislodged) after an open repair of a humerus fracture.
Modifier -78
A patient has a surgical procedure on Tuesday, and later that day the physician must take the patient back to the operating room to repeat (redo) a coronary bypass, due to complications of initial procedure.
Modifier -76
The patient underwent a bilateral tympanoplasty.
Modifier -50
If you must use two or more modifiers to describe a service, you would use which modifier to indicate this circumstance?
Modifier -99
A surgeon performs a procedure on a neonate weighing 9kg; the procedure was extremely complicated. What modifier would you use to indicate this service, which has an increased level of complexity?
Modifier -22
Dr. Storely performed cataract surgery on 10/31/2008 and Dr. Jones provided postoperative care following discharge. What modifier would you use to indicate the postoperative care following discharge?
Modifier -55
Dr. Merideth serves as an assistant surgeon to Dr. Taylor. What modifiers; would you add to the procedure code to indicate Dr. Merideth’s status during the procedure?
Modifier -80
The third-party payer requires the use of HCPCS/National modifiers; the surgeon performed a surgical procedure on the patient’s left thumb. What Level II modifier would indicate the left thumb?
Modifier -FA
What Level II modifier indicates the upper left eyelid?
Modifier -E1
Which modifier is requests payment for the full fee of the subsequent service because it was unassociated with the first procedure. A new global period should start when modifier _____ is submitted
Modifier -79
The CPT manual was developed by the
American Medical Association (AMA)
CPT stands for
Current Procedural Terminology
Providers of health care are paid based on the codes submitted for _____________ or procedures provided to the patient.
services
The first CPT was published in this year
1966
In which year were CPT codes incorporated as Level I codes into the Healthcare Procedure Coding Sytem (HCPCS)?
1983
The CPT manual often reflects the technologic advances made in medicine with these codes:
Category 3 Codes
The CPT manual is ever changing and is updated annually to reflect technologic advances and editorial _______.
Revisions
What type of codes end with 99?
Unlisted Procedure
Coding information that pertains to an entire section is located in the ___________.
Guidelines
These codes provide supplemental information and do not substitute for a Category 1 Code:
Category 2 Codes
What is the name of the two-digit number or a digit and a number that is located after the CPT code number and provides more detail about the code?
Modifier
When using an unlisted or Category 3 Code, third-party payers usually require the submission of what?
Special Report
Appendix A
lists all modifiers that are used to alter or modify codes.
Appendix B
additions to, deletions from, and revisions of the CPT manual.
Appendix C
clinical examples of many of the Evaluation and Management (E/M) codes.
Appendix D
lists all add-on codes.
Appendix E
complete list of Modifier -51 exempt codes.
Appendix F
summary of CPT codes that are Modifier -63 exempt.
Modifier -51 indicates what?
More than one procedure was performed.
Modifier -63 identifies what?
Procedures that are performed on infants who weigh less than 4 kg or 8.8 pounds and represents a significant increase in the physician’s works and complexity of service/procedure.
Appendix G
Summary of Moderate Sedation Codes.
(Procedure that requires conscious sedation.)
Appendix H
Category 2 Codes.
Category 2 codes
optional tracking codes that are used to identify performance measures of clinical components that may be typically included in evaluation and management services. (Removed)
Category 1 codes
for the most part, define professional services.
Appendix I
Genetic Testing Code Modifiers
Appendix J
Electrodiagnostic Medicine Listing of Sensory, Motor, and Mixed Nerves.
Appendix K
Product Pending FDA Approval
Appendix L
Vascular Families
Appendix M
Summary of crosswalked deleted CPT codes.
Appendix N
Resequenced CPT codes
Modifiers
provide additional information to the third-party payer about services provided to the patient. At times a five digit code may not reflect completely the service or procedure provided.
CPT modifiers are listed in descending or ascending numeric order?
Descending.
Definition of a chief complaint using the E/M Guidelines:
Chief Complaint is a concise statement describing the symptom, problem, condition, diagnosis, or other factor that is the reason for the encounter, usually stated in the patient’s words.
According to the Surgery Guidelines, surgical destruction is a part of a surgical procedure and ____________ methods of destruction are not ordinarily listed separately.
different
According to the Radiology Guidelines, who must sign a written report to have the report considered part of the radiologic procedure?
the interpreting individual
Under whose supervision are the Pathology and Laboratory services provided?
Physician
What is the code listed in the Medicine Guidelines that is to be used to identify materials supplied by the physician that are beyond those ordinarily included in the service provided?
99070
Describe a stand-alone code.
They have the full description.
Describe an intended code.
They are listed under associated stand-alone codes.
Words following the semicolon in stand-alone codes can indicate the following three things:
Alternative anatomical sites, alternative procedures, or a description of the extent of the service.
What is the two-digit modifier that indicates two primary surgeons?
-62
If the CPT code is 43820 (gastrojejunostomy without vagotomy) and two primary surgeons performed the services, the service could be stated this way:
43820-62
Bilateral inguinal herniorrhaphy:
-50
A postoperative ureterotomy patient has to be returned to the operating room (unplanned) for a complication related to the initial procedure during the postoperative period:
-78
A decision to perform surgery is made during an evaluation and management service on the day before or the day of surgery:
-57
A surgical team is required:
-66
Physician A actively assists physician B during a surgical procedure:
-80
Symbols with definitions are located at the bottom of the page in the CPT manual; True or False?
True
A category III code would be reported rather than a Category I __________ code.
unlisted
Special reports must be submitted with claims for procedures that are unusual, new, seldom used, or use Category I ____________ codes or Category _______ codes.
unlisted; III
The symbol used between two code numbers to indicate that a range is available is a _________?
hyphen (-)
Using figure 13-31 (bottom of page) Identify, in this order, #13, #14, #15, #16
Subsection, Section, Subheading, Category
The symbol that indicates a product is pending FDA approval is the __________________?
Lightening bolt
A complete list of the codes disgnated with the symbol that indicates a product is pending FDA approval is listed in this appendix of the CPT manual ____________.
Appendix K
The Genetic Testing Code Modifiers are listed in this appendix of the CPT manual. ____________.
Appendix I
total
Anesthesia services are based on ____________time the patient is under the anesthesiologist’s care. Calculation of units of time is determined by the third-party payer.
begins preparing the patient to receive anesthesia, continues through the procedure, and ends when the patient is no longer under the personal care of the anesthesiologist.
Anesthesia time begins when the anesthesilogist ___________________and continues ______________ the procedure, and ends when ______________________________________________
-47
According to the Anesthesia Guidelines, what is the one modifier that is not used with anesthesia procedures? _______
physical status
“P1” is an example of what type of modifier? ___________ _____________
moribund
What word means “in a dying state”?
systemic
What word means “affecting the body as a whole”?
6
The letter “P” in combination with what number indicates a brain-dead patient?
qualifying
What type of circumstance identifies a component of anesthesia service that affects the character of the service?
anatomic
Anesthesia procedures are divided by what type of site?
complex, combined total (or total time)
According to the Anesthesia Guidelines, the Separate or Multiple Procedures section, when multiple surgical procedures are performed during a single anesthetic administration, the anesthesia code representing the most ____________ procedure is reported and the time reported is the ________________ or _________________ for all procedures.
No
Is it true that a physician who personally administers the anesthesia to the patient upon whom he or she is operating cannot bill the third-party payer? (if True, why; if False, why, AND is there any additional information you might want to add?)
Relative Value Guide (RVG)
What is the name of the guide that is published by the American Society of Anesthesiologists and provdides the weights of various anesthesia services?
body area
Is the examination of the back an organ system or body area examination?
new, established, outpatient, inpatient
The four types of patient status are?
initial, subsequent
The first outpatient visit is called the ________visit, and the seond visit is called the _________visit.
status, place of service, type of service
The first three factors a coder must consider when coding are patient ______, ________ __ ________, and _________ __ ________.
4
How many types of histories are there?
expanded problem focused history
Which history is more complex: The problem focused history or the expanded problem focused history?
problem focused, expanded problem focused, detailed, comprehensive
The four types of examinations, in order of difficulty (from least difficult to most difficult) are as follows:
problem focused
The examination that is limited to the affected body area is the ___________ ____________ .
very low birth weight
What does VLBW stand for?
straightforward
What medical decision making involves a situation in which the diagnosis and management options are minimal, data amount and complexity that must be reviewed are minimal/none, and there is a minimal risk to the patient of complications or death?
inpatient
What term is used to describe a patient who hs been formally admitted to a hospital?
surgical team, 66
When more than two physicians, with technicians and specialized equipment, work together to complete a complicated procedure and each physician has a specific portion of the surgery to complete, they are termed what ____________ ___________, and the modifier is -_______.
No, because it states in the notes for modifier 22 that this modifier should not be appended to an E/M Service
Can modifier -22 be assigned to 99291, 99292 codes ( which are E/M service codes)
-22
This modifier indicates an increased service and is overused and results in an increase in payment of 20% to 30%. As such, the assignment of this modifier comes under particularly close scrutiny by third-party payers. What is this modifier?
intraoperative or surgery
When modifier -54 is assigned, payment for the __________________ portion of the surgical procedure is being requested.
She is incorrect because modifier 32 is only assigned for mandated services, such as police and Workers Compensation and not for requests made by patient, family member, or another physician.
Joan is a new coder at the local clinic. You have been assigned to review her coding before it is submitted to the third-party payer. You note that she assigned modifier -32 to E/M consultation code 99244. The medical record indicates that the request for the second opinion was made by the patient’s spouse. Is Joan correct in modifier -32 assignment? Why or why not?
b
Which of these statements is true about modifier -59? a. It is only appended to E/M codes
b. It is only appended to other than E/M codes.
8.8 lbs.
What is the weight in pounds of a 4-kilogram infant?
c
Which of the following statemtns is NOT true about modifier -53?
a. describes circumstances based on the patient’s condition.
b. may be used to describe those times when the physician elects to terminate a procedure due to the well-being of the patient.
c. describes circumstances in which the patient cancelled the procedure.
d. may be used to describe ASC reporting of previously scheduled procedure that is partially reduced as a result of extenuating circumstances.
False
True or False: Modifier -57 can be added to Surgery section codes?
a
When adding multiple CPT modifiers to a cdoe, you would list the modifiers from:
a. highest to lowest
b. lowest to highest
c. makes no difference which is listed first.
-76
Modifier used to repeat procedure or service by same physician?
-62
Modifier for Two surgeons?
-26
Modifier for Professional component?
-99
Modifier for Multiple modifiers?
-59
Modifier for Distinct Procedural Service?
-32
Modifier for Mandated Service
-25
Modifier for Significant identifiab le E/M service provided by the same physician on the same day as another service or procedure?
-81
Modifierfor Minimum Assistant Surgeon?
-77
Repeat procedure by another physician?
-79
Unrelated procedure or service by the same physician during the postoperative period
-23
Unusual anesthesia
-78
Unplanned return to the operating room for a related procedure during the postopeative period.
-54
Surgical care only.
-52
Reduced service.
-66
Surgical Team
When more than two physicians, with technicians and specialized equipment, work together to complete a complicated procedure and each physician has a specific portion of the surgery to complete, they are termed what?
Surgical Team
Can modifier -22 be assigned to 99291, 99292 codes?
no
This modifier indicates an increased service and is overused and results in an increase in payment of 20% to 30%. As such, the assignment of this modifier comes under particularly close scrutiny by third-party payers. What is this modifier?
-22
When modifier -54 is assigned, payment for the _________ portion of the surgical procedure is being requested.
surgery
Joan is a new coder at the local clinic. You have been assigned to review her coding before it is submitted to the third-party payer. You note that she assigned modifier -32 to E/M consultation code 99244. The medical record indicates that the request for the second opinion was made by the patient’s spouse. Is Joan correct in modifier -32 assignment? Why or why not?
no
Which of these statements is true about modifier -59?
It is only appended to other than E/M codes.
What is the weight in pounds of a 4-kilogram infant?
8.8
Modifier -57 can be added to Surgery section codes?
False
When adding multiple CPT modifiers to a code, you would list the modifiers from:
Highest to lowest.
The four types of medical decision making, in order of complexity from most to least complex are:
High, moderate, low, straightforward
Complexity of medical decision making is based on three
elements
List the five types of presenting problems from the most risk and least recovery to least risk and most recovery:
High severity, moderate severity, low severity, self-limited/minor severity, minimal severity
Counseling and coordination of care are what kind of factors in most cases?
contributory
Time that is used as a guide for outpatient services is what kind of time? _____
face-to-face or direct time
Inpatient time spent at the bedside or nursing station during or after the visit is what kind of time? ____
unit/floor time
The patient’s _____ _____ will reflect the number of systems examined by a brief statement of the findings.
medical record or health record
A discussion with a patient and/or family concerning one or more of the following areas: diagnostic results, impressions, and/or recommended diagnostic studies; prognosis; risks and benefits of treatment; instructions for treatment; importance of compliance with treatment; risk factor reduction; and patient and family education is ___
counseling
The history is the ____ information the patient tells the physician.
subjective
There is no distinction made between the new and established patients in this service department of a hospital:
emergency department
Those services rendered by a physician whose opinion or advice is requested by another physician or agency in the evaluation and/or treatment of a patient is a ______, whereas the physician who has primary responsibility for the patient in the hospital is called the _____.
consultation, attending
When critically ill patients in medical emergencies require constant attendance of the physician (e.g., cardiac arrest, shock, bleeding, and respiratory failure) to stabilize them, what kind of care is needed?
critical care
When care is provided for similar services (e.g., hospital visits) to the same patient by more than one physician on the same day for different conditions, the care is _____.
concurrent
What is the name for the transfer of the total or specific care of a patient from one physician to another that does not constitute a consultation?
referral or request
An inventory of body systems obtained through questioning to identify signs and/or symptoms that the patient may be experiencing is a _______
review of systems
If the physician who is standing by does so for 25 minutes, can he or she round the time up to 30 minutes for reporting purposes?
no
One who has not been formally admitted to a health care facility
Outpatient
Advice or opinion from one physician to another physician
Consultation
Evaluation and determination of care for a newborn infant
Newborn care
One who has been formally admitted to an acute health care facility
Inpatient
Attention to an acute illness or injury that results in hospitalization
Admission
One who has received services from the physician or another physician in the same group within the last 3 years
Established patient
One who has not received services from the physician or another physician in the same group within the last 3 years
New Patient
A face-to-face encounter in an office between the physician and patient
Office Visit
Which code is an example of an add-on code?
11301
Match the Codes to the correct section in which they are used:
Medicine- 95199
Radiology- 78999
Pathology/Laboratory- 81099
Anesthesia- 00144
Using Appendix A of the CPT manual, match the correct two-digit modifiers to the correct name of the modifier:
-76 Repeat procedure by the same physician
-51 Multiple procedures
-54 Surgical care only
-50 Bilateral procedure
Using the Surgery guidelines, match the unlisted surgery procedure codes to the correct code description.
eyelid- 67999
cardiac- 33999
inner ear- 69949
nervous system- 64999
Using the index of your CPT manual, locate the following terms and match the terms with the correct “See” note.
UFR – See Uroflowmetry
Stenger Test – See Audiologic Function Test; Ear, Nose, and Throat
VLDL – See Lipoprotein
An established patient is one who has received professional services from the physician or another physician of the same specialty in the same group within the past _____ years?
3
According to Medicare guidelines, ____________ complications of a surgical procedure are usually included in the reimbursement for a major surgical procedure.
Routine
Code ________ is a CPT code that can be assigned to report a surgical tray.
99070
Code ________ is a HCPCS code that can be assigned to report a surgical tray.
A4550
This code reports a postoperative follow-up visit that is included in the global service.
99024
_________ destruction is a part of a surgical procedure and different methods of destruction are not ordinarily listed separately.
Surgical
Care of the condition for which a diagnostic procedure was performed or of other ______ conditions is not included and may be listed separately.
concomitant
There are “Notes” in Burns, _________ Treatment subsection.
local
The only code in the Operating Microscope subsection is __________.
69990
Folow-up care for therapeutic surgical procedures includes only that care which is usually part of the ___________.
Surgical services
The four codes for radiological supervision and interpretation are ________, ________, ________, ________.
76942, 77002, 77012, 77021
For evaluation of fine needle aspirate, see _______, _________, ______________.

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