Podcast
Questions and Answers
The CPT coding process applies to all sections of the CPT manual, except for which sections?
The CPT coding process applies to all sections of the CPT manual, except for which sections?
- Anesthesia (correct)
- E/M (correct)
- Radiology
- Surgery
What are the two basic steps to start the procedural coding process?
What are the two basic steps to start the procedural coding process?
Analyze and abstract the procedural statement documented in the health record; compare it with the encounter form, operative report, or other documentation.
Why is it not possible to assign a code only using the alphabetic system?
Why is it not possible to assign a code only using the alphabetic system?
Because the Alphabetic Index does not provide code descriptions, the Tabular List must be used to ensure code accuracy.
Name and describe the four primary classifications used in the Alphabetic Index.
Name and describe the four primary classifications used in the Alphabetic Index.
What does a semicolon at the end of a main description indicate?
What does a semicolon at the end of a main description indicate?
What are stand-alone codes?
What are stand-alone codes?
What is the next step after finding a stand-alone code in the Alphabetic Index?
What is the next step after finding a stand-alone code in the Alphabetic Index?
What does assigning the correct E/M code include?
What does assigning the correct E/M code include?
What are the first two steps in choosing an E/M code?
What are the first two steps in choosing an E/M code?
How do you identify the Place of Service (POS)?
How do you identify the Place of Service (POS)?
How do you determine the level of service for E/M coding?
How do you determine the level of service for E/M coding?
Name the four levels of history taking.
Name the four levels of history taking.
What are the different levels of examination?
What are the different levels of examination?
Name the different factors that contribute to E/M complexity.
Name the different factors that contribute to E/M complexity.
What are CPT-4 codes and who assigns them?
What are CPT-4 codes and who assigns them?
Anesthesia services are provided based on what?
Anesthesia services are provided based on what?
What does the term 'global service' mean when referring to surgical package definition?
What does the term 'global service' mean when referring to surgical package definition?
What is the difference between a bundled code and an unbundled code?
What is the difference between a bundled code and an unbundled code?
In the integumentary system, what are the levels of closure (repair)?
In the integumentary system, what are the levels of closure (repair)?
In the musculoskeletal system, name and describe the types of fractures.
In the musculoskeletal system, name and describe the types of fractures.
Name and describe normal services in maternity care and delivery.
Name and describe normal services in maternity care and delivery.
In CPT coding guidelines for Radiology, how is the section divided?
In CPT coding guidelines for Radiology, how is the section divided?
What are HCPCS code sets?
What are HCPCS code sets?
How many coding conventions does HCPCS use?
How many coding conventions does HCPCS use?
HCPCS modifiers do not change the description, but rather what?
HCPCS modifiers do not change the description, but rather what?
Study Notes
CPT Coding Process
- CPT uses the Alphabetic Index and Tabular List, except for the E/M and Anesthesia sections.
- Determining procedures begins with analyzing health records and comparing them with documentation such as encounter forms and operative reports.
Alphabetic Index Limitations
- The Alphabetic Index does not include code descriptions; thus, the Tabular List is necessary to ensure accurate code assignment.
Main and Modifying Term Classifications
- Four primary classifications guide searches in the Alphabetic Index:
- Procedure or service: Examples include examination and excision.
- Organ or anatomic site: Examples include clavicle and liver.
- Condition, illness, or injury: Includes terms like cholelithiasis and fracture.
- Eponym, synonym, abbreviation, or acronym: Examples are MRI and TURP.
E/M Code Assignment Criteria
- Assigning E/M codes involves identifying relevant sections, reviewing reporting instructions, determining service levels, and assessing history, examination, and medical decision complexity.
Levels of History
- Four levels of history reflect the depth of patient evaluation:
- Problem-focused: Addresses chief complaints with minimal history.
- Expanded problem-focused: Tightened review with related system input.
- Detailed: Involves extended history and related system reviews.
- Comprehensive: Covers extensive history with a complete review of all body systems.
E/M Exam Levels
- Examination levels consist of:
- Problem-focused: Targeted to a single area.
- Expanded problem-focused: Addresses related areas.
- Detailed: Comprehensive related area review.
- Comprehensive: Full multisystem or detailed single system review.
Contributing Factors to E/M Complexity
- Factors influencing E/M complexity include counseling, nature of presenting problems, coordination of care, and time involved, affecting service code selection.
CPT-4 Codes in Anesthesia
- Anesthesia services use CPT-4 codes assigned by anesthesiologists and CRNAs, starting with 0 and indicate surgery sites.
Anesthesia Service Units
- Anesthesia services are categorized into Basic Unit Value (B), Time Units (T), and Modifying Units (M), indicating the complexity, time spent, and special circumstances during procedures.
Global Services in Surgical Packages
- Global services combine patient prep, surgical care, and postsurgical care under a single code, reflecting the surgical package's total cost.
Bundled vs. Unbundled Codes
- Bundled codes represent entire procedure stages as a single code, while unbundled codes separately detail each step in major procedures.
Levels of Closure in Integumentary System
- Closure levels include:
- Simple repair: Superficial wounds without deeper structure involvement.
- Intermediate repair: Layered closure with deeper tissues included.
- Complex repair: Requires extensive techniques beyond layered closure.
Fracture Types in Musculoskeletal System
- Fractures are classified into:
- Closed: Bone does not pierce the skin.
- Open: Bone cuts through skin layers.
- Treatment methods include closed and open treatments, with distinct approaches based on visibility.
Maternity Care and Delivery Services
- Services include antepartum care (initial and ongoing visits), delivery (hospital admission, labor management), and postpartum care (follow-up visits).
Radiology Coding Guidelines
- The Radiology section is subdivided into anatomical areas and specific categories related to various procedures performed.
HCPCS Code Sets
- HCPCS comprises five-digit alphanumeric codes starting with a letter followed by four numbers for healthcare procedure coding.
HCPCS Coding Conventions
- HCPCS employs five coding conventions for specific code instructions without altering the code description, but adding relevant details or conditions.
Studying That Suits You
Use AI to generate personalized quizzes and flashcards to suit your learning preferences.
Description
Test your knowledge of procedure coding with these flashcards from Chapter 15. The quiz covers essential concepts and the CPT coding process, focusing on the use of the Alphabetic Index and the Tabular List. Perfect for anyone studying medical coding.
