Procedure Coding Quiz: Four Classifications of Terms

Questions and Answers

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?

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?

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.

Procedure or service; organ or anatomic site; condition, illness, or injury; eponym, synonym, abbreviation, or acronym. Signup and view all the answers

What does a semicolon at the end of a main description indicate?

It indicates that modifying terms and descriptions follow. Signup and view all the answers

What are stand-alone codes?

Codes that include one main term but may have several modifying terms associated with complex medical procedures. Signup and view all the answers

What is the next step after finding a stand-alone code in the Alphabetic Index?

Look up each code in the Tabular List and select the one that most closely matches the medical documentation. Signup and view all the answers

What does assigning the correct E/M code include?

Identifying the section, subsection, category, subcategory, reviewing reporting instructions, examining the level of E/M service, history obtained, and complexity of decision making. Signup and view all the answers

What are the first two steps in choosing an E/M code?

Identify the place of service and identify the patient status. Signup and view all the answers

How do you identify the Place of Service (POS)?

The POS is the healthcare facility where the patient-provider encounter occurred. Signup and view all the answers

How do you determine the level of service for E/M coding?

By evaluating the history, examination, and medical decision making. Signup and view all the answers

Name the four levels of history taking.

Problem-focused, expanded problem-focused, detailed, comprehensive. Signup and view all the answers

What are the different levels of examination?

Problem-focused examination, expanded problem-focused examination, detailed examination, comprehensive examination. Signup and view all the answers

Name the different factors that contribute to E/M complexity.

Counseling, nature of the presenting problem, coordination of care, time. Signup and view all the answers

What are CPT-4 codes and who assigns them?

Codes used by anesthesiologists and CRNAs that start with a zero (0) and identify the anatomic location of surgery. Signup and view all the answers

Anesthesia services are provided based on what?

Based on anatomic region, basic unit value, time units, and modifying units. Signup and view all the answers

What does the term 'global service' mean when referring to surgical package definition?

It refers to patient prep, surgical care, and postsurgical care included in a single code. Signup and view all the answers

What is the difference between a bundled code and an unbundled code?

Bundled codes include all services of a procedure in one code, while unbundled codes separate each step. Signup and view all the answers

In the integumentary system, what are the levels of closure (repair)?

Simple repair, intermediate repair, complex repair. Signup and view all the answers

In the musculoskeletal system, name and describe the types of fractures.

Closed fracture: bone does not protrude; open fracture: bone cuts through skin; closed treatment: not surgically opened. Signup and view all the answers

Name and describe normal services in maternity care and delivery.

Antepartum care, delivery, postpartum care. Signup and view all the answers

In CPT coding guidelines for Radiology, how is the section divided?

Divided into subsections: head and neck; chest, spine, pelvis; extremities; abdomen; gynecologic procedures. Signup and view all the answers

What are HCPCS code sets?

Codes with five alphanumeric digits, beginning with one letter followed by four numerals. Signup and view all the answers

How many coding conventions does HCPCS use?

Five coding conventions. Signup and view all the answers

HCPCS modifiers do not change the description, but rather what?

Provide additional information or describe extenuating circumstances. Signup and view all the answers

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.

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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.

Assignment 2 Chapter 15 Procedure Coding