AMCA-MCBC Study Guide PDF

Be aware that word roots, prefixes and suffixes may have the same definition 1.01 Anesthesia Anesthesia located before the surgery section is a section of its own. These services include general and regional anesthesia. When coding anesthesia services, be careful to look for the service for which g...

Be aware that word roots, prefixes and suffixes may have the same definition 1.01 Anesthesia Anesthesia located before the surgery section is a section of its own. These services include general and regional anesthesia. When coding anesthesia services, be careful to look for the service for which general anesthesia was performed under the Anesthesia in the CPT index, followed by the body site. Terms to be familiar with in this CPT section include: Physical status Modifiers: These modifiers are used only in the Anesthesia section with procedure codes to indicate the patients' health status before Anesthesia is provided. Qualifying Circumstances: These modifiers are used only in the Anesthesia section with the procedure code in the case of difficult or extraordinary circumstances as extreme age (under 1 and over 70). Basic Value: Each Anesthesia code, published by the American Society of Anesthesiologists, has a basic value also referred to as the relative value, which include services bundled into the anesthesia procedure code in addition to the value of work associated with the anesthesia service. Preoperative Visit- History and exam performed by the Anesthesiology staff. Intraoperative Care- including the administration of fluids, monitoring vitals, body temperature, blood pressure and pulse, in addition to the administration of anesthesia Postoperative Visit- also known as the post anesthesia recovery period. Time Units: Time is used to help determine reimbursement for Anesthesia services. It defines the actual time spent providing the service. Typically, time is documented in minutes converted to units. 15 mins = 1 Unit The time starts when the provider prepared the patient or the induction of anesthesia to the time ending in which the provider is no longer in attendance ant patient is sent to the surgery recovery area. Modifying Unit: Modifying units are determined by the Physical status and any qualifying circumstances. These both can be found in the Anesthesia Guidelines and have an impact on Anesthesia reimbursement. Qualifying Circumstances 99100 – Anesthesia for Patient of Extreme Age, Under 1 Year and Over 70 – 1 unit 99116 – Anesthesia Complicated By Utilization of Total Body Hypothermia – 5 units 99135 – Anesthesia Complicated By Utilization of Controlled Hypotension – 5 units 99140 – Anesthesia Complicated – 1 unit AMCA, Medical Coder and Biller Certification Study Guide (MCBC) This document is the property of the AMCA. The document and any of its contents cannot be reproduced, shared or disseminated for any reason without written consent of the AMCA. ©  Physical Status Modifiers P1 - A normal healthy patient 0 units P2 - A patient with mild systemic disease 0 units P3 - A patient with severe systemic disease 1 units P4 - A patient with severe systemic disease that is a constant threat to life 2 units P5 - A moribund patient who is not expected to survive without the operation 3 units P6 - A declared brain-dead patient whose organs are being removed for donor purposes 0 units 1.02 Surgery The Surgery section is the largest in the CPT coding manual and arranged by body system. It is important for coders to become familiar with the guidelines related to the surgery section. Becoming familiar with the arrangement of subsections within the CPT allows for easier code selection. Surgical Guidelines Include: Physician Services- Alerts coders that Physician Services are found in the E/M section CPT surgical package definition- o Evaluation and Management (E/M) service(s) subsequent to the decision o for surgery on the day before and/or day of surgery (including history and physical) o Local infiltration, metacarpal/metatarsal/digital block, or topical anesthesia o Immediate postoperative care, including dictating operative notes, talking with the family and other physicians or other qualified health care professionals o Writing orders o Evaluating the patient in the post anesthesia recovery area o Typical postoperative follow-up care Follow-up care for diagnostic and therapist procedures- This care includes only the care related to the recovery from the procedure. Materials supplied by the physician- If the provider supplied additional materials over what is typically used for the procedure, the provider can bill drugs, trays, supplies and the other materials. Reporting more than one procedure/service- More than one procedure/service is completed on the same date, session, or during the postoperative period, codes should be appended with CPT modifiers. Separate procedure- Following some code descriptions are the words ’separate procedure’. These codes report procedures that are typically part of a larger service or procedure and therefore are not reported if the larger procedure is performed. However, if the code description designed as a ‘separate procedure’ is completed alone, then the AMCA, Medical Coder and Biller Certification Study Guide (MCBC) This document is the property of the AMCA. The document and any of its contents cannot be reproduced, shared or disseminated for any reason without written consent of the AMCA. ©  code is reported. Unlisted service or procedure- These codes should be used only when a more specific code is not available for use. When these codes are used, it is common for payers to request a special report that outlines the description of the following Special report- A service that is rarely provided, unusual, variable, or new may require a special report. Pertinent information should include an adequate definition or description of the nature, extent, and need for the procedure, and the time, effort, and equipment necessary to provide the service. Surgical destruction - Surgical destruction is a part of a surgical procedure and different methods of destruction are not ordinarily listed separately unless the technique substantially alters the standard management of a problem or condition. Exceptions under special circumstances are provided for by separate code numbers. 1.03 Radiology Radiology is a branch of medicine which uses x-rays, magnetic resonance imaging (MRI), computerized axial tomography (CAT), and ultrasounds to diagnose and treat disease. Being familiar with the terminology used in the positioning of a patient as the radiological procedure is performed, helps the coder in code assignment. Anterior At or near the front of the body (front view) Posterior At or near the back of the body (back view) Midline An imaginary vertical line that divides the body equally (right down the middle) Lateral Farther from midline (side view) Medial Nearer to midline (side view) Superior Toward the head/upper part of a structure (bird’s- eye view, looking down) Inferior Away from the head/lower part of a structure (bottom view, looking up) Superficial Close to the surface of the body Deep Away from the surface of the body Proximal Nearer to the origination of a structure Distal Farther from the origination of a structure AMCA, Medical Coder and Biller Certification Study Guide (MCBC) This document is the property of the AMCA. The document and any of its contents cannot be reproduced, shared or disseminated for any reason without written consent of the AMCA. © Other Anatomical Directional Terms Dorsal: Near the upper surface, toward the back Ventral: Toward the bottom, toward the belly Lateral: Toward the side, away from the mid-line Medial: Toward the mid-line, middle, away from the side Rostral: Toward the front Caudal: Toward the back, toward the tail Bilateral: Involving both sides of the body Unilateral: Involving one side of the body Ipsilateral: On the same side of the body Contralateral: On opposite sides of the body Parietal: Relating to a body cavity wall Visceral: Relating to organs within body cavities Axial: Around a central axis Intermediate: Between two structures Radiology Guidelines and Terms: Separate Procedure However, when a procedure or service that is designated as a ‘separate procedure’ is carried out independently or considered to be unrelated or distinct from other procedures/services provided at the time, it may be reported by itself, or in addition to other procedures/services by appending modifier 59 to the specific ‘separate procedure’ code to indicate that the procedure is not considered to be a component of another procedure, but is distinct, independent procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injury). AMCA, Medical Coder and Biller Certification Study Guide (MCBC) This document is the property of the AMCA. The document and any of its contents cannot be reproduced, shared or disseminated for any reason without written consent of the AMCA. © Unlisted Procedure A service or procedure may be provided that is not listed in this edition of the CPT ® codebook. When reporting such a service, the appropriate "Unlisted Procedure" code may be used to indicate the service, identifying it by "Special Report" as discussed below. The "Unlisted Procedures" and accompanying codes for Radiology (Including Nuclear Medicine and Diagnostic Ultrasound). Supervision and Interpretation Imaging may be required during the performance of certain procedures or certain imaging procedures may require surgical procedures to access the imaged area. Many services include image guidance, which is not separately reportable and is so stated in the descriptor or guidelines. When imaging is not included in a surgical procedure or procedure from the Medicine section, image guidance codes or codes labeled "radiological supervision and interpretation" may be reported for the portion of the service that requires imaging. Both services require image documentation and radiological supervision, interpretation, and report services require a separate interpretation. Administration of Contrast Material(s) The phrase "with contrast" used in the codes for procedures performed using contrast for imaging enhancement represents contrast material administered intravascularly, intra- particularly, or intrathecally. For intra-articular injection, use the appropriate joint injection code. If radiographic arthrography is performed, also use the arthrography supervision and interpretation code for the appropriate joint (which includes fluoroscopy). If computed tomography (CT) or magnetic resonance (MR) arthrography are performed without radiographic arthrography, use the appropriate joint injection code, the appropriate CT or MR code ("with contrast" or "without followed by contrast"), and the appropriate imaging guidance code for needle placement for contrast injection. For spine examinations using computed tomography, magnetic resonance imaging, magnetic resonance angiography, "with contrast" includes intrathecal or intravascular injection. For intrathecal injection, use also 61055 or 62284. Injection of intravascular contrast material is part of the "with contrast" CT, computed tomographic angiography (CTA), magnetic resonance imaging (MRI), and magnetic resonance angiography (MRA) procedures. Oral and/or rectal contrast administration alone does not qualify as a study "with contrast." Written Report(s) A written report (e.g., handwritten, or electronic) signed by the interpreting individual should be considered an integral part of a radiologic procedure or interpretation. AMCA, Medical Coder and Biller Certification Study Guide (MCBC) This document is the property of the AMCA. The document and any of its contents cannot be reproduced, shared or disseminated for any reason without written consent of the AMCA. © 1.04 Pathology and Laboratory The Pathology and Laboratory is divided into 18 sections that describe services that apply to all parts of the body and disease processes. Tests of specimen provide information for to diagnose, treat or prevent conditions. Laboratories also called clinical labs, use terminology specific to the field which could serve as useful to coders. Qualitative Testing: Determines the presence or absence of a drug only. Quantitative Testing: Determines the presence and amount of a drug. Hematology: The studies of the components and behavior of blood. Immunology: The study of the immune system and its components and function. Microbiology: The study of microorganisms. It includes four subspecialties; bacteria, fungi, parasites and viruses. Gross Examination: The inspection of the entire specimen without examining under a microscope. Semi Quantitative: Tests describe an amount within a specified range or over a certain amount. Pathology: Study of the causes and effects of a disease or injury. Necropsy: The surgical examination of a dead body to determine cause of death, i.e., and autopsy Forensics- Studies used or applied in the investigation and establish of facts or evidence in a court of law. 1.05 Psychiatry The Psychiatry subsection if found in the Medicine Section of the CPT. Psychiatry services include diagnostic services, psychotherapy, and other services to an individual, family, or group. Terms to know when coding for Psychiatric services: Interactive Complexity: Specific communication factors that complicate the delivery of a psychiatric procedure. Psychiatric Diagnostic procedures: An integrated biopsychosocial assessment including history, mental status and recommendations including communication with the family or other sources. AMCA, Medical Coder and Biller Certification Study Guide (MCBC) This document is the property of the AMCA. The document and any of its contents cannot be reproduced, shared or disseminated for any reason without written consent of the AMCA. ©  Psychotherapy: Treatment of mental illness and behavioral disturbances in which the physician or other qualified health care professional, through definitive therapeutic communication, attempts to alleviate the emotional disturbances, reverse, or change maladaptive patterns of behavior and encourage personality growth and development. Pharmacologic Management: Pharmacologic management, including prescription and review of medication, when performed with psychotherapy services. Narcosynthesis: Intravenous injections of sodium amytal or sodium pentothal to induce a state in which the patient is more relaxed and communicative. Narco-suggestion, narcosynthesis, and narcoanalysis are therapeutic processes using these drug adjuncts. Therapeutic Repetitive transcranial magnetic stimulation (TMS): A noninvasive form of brain stimulation in which a changing magnetic field is used to cause electric current at a specific area of the brain through electromagnetic induction. An electric pulse generator, or stimulator, is connected to a magnetic coil, which in turn is connected to the scalp. Electroconvulsive Therapy: Electroconvulsive therapy (ECT) is a procedure, done under general anesthesia, in which small electric currents are passed through the brain, intentionally triggering a brief seizure. ECT seems to cause changes in brain chemistry that can quickly reverse symptoms of certain mental health condition. Hypnotherapy: A form of psychotherapy that uses relaxation, extreme concentration, and intense attention to achieve a heightened state of consciousness or mindfulness. Environmental intervention: The idea that a great deal of illness and poor health in the contemporary world results from environmental toxins. People who study environmental medicine identify these conditions as often resulting from an amorphous complex of toxins, allergens, stress, processed food, and other types of stimuli for which evolution has not prepared the human body. It consists of recommendations for specific changes in the patient's physical or extrafamilial environments. These recommendations attempt to reduce factors that are contributing to the patient's problems. The primary means by which environmental therapy attempts to treat these conditions is detoxification. 1.06 Immunizations and Vaccines Immunizations and Vaccines is in the medicine section and have a major impact on codes and payer guidelines. The following terms within this section, are important to know. Serum Globulins: Identify the serum globulins extracted from the blood is used to diagnose the various conditions such as certain cancer type, liver disease, autoimmune disorders and nutritional issues. With the help of the serum globulin test, serious health issues can be identified. Diphtheria: Diphtheria is a potentially fatal, contagious disease that usually involves the nose, throat, and air passages, but may also infect the skin. Its most striking feature is the formation of a grayish membrane covering the tonsils and upper part of the throat. Anthrax vaccine: Cell protein extract of cultures of Bacillus anthracis, used for immunization against anthrax. AMCA, Medical Coder and Biller Certification Study Guide (MCBC) This document is the property of the AMCA. The document and any of its contents cannot be reproduced, shared or disseminated for any reason without written consent of the AMCA. ©  Typhoid: A type of killed vaccine used for active immunity production; made from killed typhoid bacillus (Salmonella Typhi). Pneumococcal: A nonmotile, gram positive bacterium (Streptococcus pneumoniae) that is the most common cause of bacterial pneumonia and is a cause of meningitis and other infectious Diseases. Influenza: An acute contagious viral infection of humans, characterized by inflammation of the respiratory tract and by fever, chills, muscular pain, and prostration. Also called grippe. Cholera: An acute infectious disease of the small intestine, caused by the bacterium Vibrio cholerae and characterized by profuse watery diarrhea, vomiting, muscle cramps, severe dehydration, and depletion of electrolyte. Vaccines: A preparation of killed microorganisms, living attenuated organisms, or living fully virulent organisms that is administered to produce or artificially increase immunity to a disease. Toxoids: A bacterial toxin that has been chemically changed to lose its poisonous properties but retain its ability to stimulate antibody production. Tetanus: An acute, often fatal disease characterized by spasmodic contraction of voluntary muscles, especially those of the neck and jaw, and caused by the toxin of the bacterium Clostridium tetani, which typically infects the body through a deep wound. Also called lockjaw. Yellow fever: Also known as sylvatic fever and viral hemorrhagic fever or VHF, is a severe infectious disease caused by a type of virus called a Flavivirus. Yellow fever epidemics may also occur after flooding caused by earthquakes and other natural disasters. They result from a combination of new habitats available for the vectors of the disease and changes in human behavior (spending more time outdoors and neglecting sanitation precautions). Yellow fever's incubation period (the amount of time between the introduction of the virus into the host and the development of symptoms) is three to six days. During this time, there are generally no symptoms identifiable to the host. The period of invasion lasts two to five days, and begins with an abrupt onset of symptoms, including fever and chills, intense headache and lower backache, muscle aches, nausea, and extreme exhaustion. The patient's tongue shows a characteristic white, furry coating in the center, surrounded by a swollen, reddened margin. While most other infections that cause a high fever also cause an increased heart rate, yellow fever results in an unusual finding, called Faget's sign. 1.07 Biofeedback Biofeedback is a subsection in the Medicine section. Biofeedback: Biofeedback therapy provides visual, auditory, or other evidence of the status of AMCA, Medical Coder and Biller Certification Study Guide (MCBC) This document is the property of the AMCA. The document and any of its contents cannot be reproduced, shared or disseminated for any reason without written consent of the AMCA. © certain body functions so that a person can exert voluntary control over the functions, and thereby alleviate an abnormal bodily condition. Biofeedback therapy often uses electrical devices to transform bodily signals indicative of such functions as heart rate, blood pressure, skin temperature, salivation, peripheral vasomotor activity, and gross muscle tone into a tone or light, the loudness or brightness of which shows the extent of activity in the function being measured. A technique used to learn to control some of your body's functions, such as your heart rate. Common Conditions that use the codes from this subsection is Intrinsic (urethral) sphincter deficiency [ISD] Stress incontinence, female Muscular wasting and disuse atrophy Incontinence of feces Urinary incontinence, unspecified Stress incontinence, male Mixed incontinence, (male) (female) Mechanical and motor 1.08 Dialysis Dialysis: A treatment that filters and purifies the blood using a machine. This helps keep your fluids and electrolytes in balance when the kidneys can’t properly function. Properly functioning kidneys prevent extra water, waste, and other impurities from accumulating in your body. They also help control blood pressure and regulate the levels of chemical elements in the blood. Hemodialysis: Hemodialysis is the most common type of dialysis. This process uses an artificial kidney (hemodialyzer) to remove waste and extra fluid from the blood. The blood is removed from the body and filtered through the artificial kidney. The filtered blood is then returned to the body with the help of a dialysis machine. AMCA, Medical Coder and Biller Certification Study Guide (MCBC) This document is the property of the AMCA. The document and any of its contents cannot be reproduced, shared or disseminated for any reason without written consent of the AMCA. ©  Peritoneal dialysis: Peritoneal dialysis involves surgery to implant a peritoneal dialysis (PD) catheter into your abdomen. The catheter helps filter your blood through the peritoneum, a membrane in your abdomen. Continuous renal replacement therapy (CRRT): This therapy is used primarily in the intensive care unit for people with acute kidney failure. It is also known as hemofiltration. A machine passes the blood through tubing. A filter then removes waste products and water. The blood is returned to the body, along with replacement fluid. End Stage Renal Disease: Also called end-stage renal disease (ESRD), is the final stage of chronic kidney disease. It means the kidneys no longer function well enough to meet the needs of daily life. A patient with end-stage renal failure must receive dialysis or a kidney transplantation to survive for more than a few weeks. Diabetes: A disease in which the body’s ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of glucose in the blood and urine. 1.09 Health and behavior assessment This subsection of the Medicine Section includes health and behavioral assessment procedures that are used to identify the psychological, behavioral, emotional, cognitive, and social factors important to the prevention, treatment, or management of physical health problems. Psychological factors: Psychological factors refer to thoughts, feelings and other cognitive characteristics that affect the attitude, behavior, and functions of the human mind. Behavioral Factors: Any particular behavior or behavior pattern which strongly yet adversely affects health. It increases the chances of developing a disease, disability, or syndrome. Examples of these factors include tobacco use, alcohol consumption, smoking, obesity, physical activity, and sexual activity. Cognitive Factors: Cognitive factors refer to characteristics of the person that affect performance and learning. Cognitive factors are internal to each person and serve to modulate behavior and behavioral responses to external stimuli like stress. Social Factors: These are the factors that affect thought and behavior in social situations. 1.10 Body planes and directional terms Body Structure and Directional Terminology Positional and Directional Terms Anterior (ventral) – front surface of the body Posterior (dorsal) – back side of the body Deep – away from the surface Proximal –near the point of attachment to the trunk or near the beginning of a structure. Distal – far from the point of attachment to the trunk or far from the beginning of a structure. AMCA, Medical Coder and Biller Certification Study Guide (MCBC) This document is the property of the AMCA. The document and any of its contents cannot be reproduced, shared or disseminated for any reason without written consent of the AMCA. ©  Inferior – below another structure Superior – above another structure Superficial – toward or on the surface Medial – pertaining to the middle or nearer the medial plane of the body Lateral – pertaining to the side Supine – lying on the back Prone – lying on the belly Transverse – divides the body into top and bottom halves 1.11 Integumentary systems and structures The integument is an organ and is an alternative name for skin. The integumentary system includes the skin and the skin derivatives: hair, nails, and endocrine glands. Glands: participate in regulating body temperature. Sebaceous - Oil glands. Located in the dermis and secrete sebum. Sudoriferous - Sweat gland Epidermis – The Epidermis is the thinner more superficial layer of the skin. Dermis – The deeper, thicker layer of the skin, composed of connective tissue, blood vessels, nerves, glands, and hair follicles. Stratum corneum: The outermost layer, made of 25-30 layers of dead flat keratinocytes. Lamellar granules provide water repellent action and are continuously shed & replaced. Stratum lucidum: Only found in the fingertips, palms of hands, & soles of feet. Stratum granulosum: Made up of 3-5 layers of keratinocytes, site of keratin formation, keratohyalin gives the granular appearance. Stratum spinosum: Appears covered in thorn like spikes, provide strength & flexibility to the skin. Stratum Basale: The deepest layer of the five layers of the dermis. Musculoskeletal system and structures AMCA, Medical Coder and Biller Certification Study Guide (MCBC) This document is the property of the AMCA. The document and any of its contents cannot be reproduced, shared or disseminated for any reason without written consent of the AMCA. ©  Types of Muscle: Types of Bones: Long Bone- Legs and Arms Short Bone- Hand, Fingers, Feet, Flat Bone- Skull, Ribs, Patella, Hip Bone, Nasal Bone Irregular Bone- Cervical, Thoracic, Lumbar Vertebra Appendicular skeleton: all bones of the upper and lower limbs, plus the girdle bones that attach each limb to the axial skeleton. Axial skeleton: central, vertical axis of the body, including the skull, vertebral column, and thoracic cage. Coccyx: small bone located at inferior end of the adult vertebral column that is formed by the fusion of four coccygeal vertebrae; also referred to as the “tailbone”. Ear ossicles: three small bones located in the middle ear cavity that serve to transmit sound vibrations to the inner ear. AMCA, Medical Coder and Biller Certification Study Guide (MCBC) This document is the property of the AMCA. The document and any of its contents cannot be reproduced, shared or disseminated for any reason without written consent of the AMCA. © Hyoid bone: small, U-shaped bone located in upper neck that does not contact any other bone. Ribs: thin, curved bones of the chest wall. Types of Fractures Type of fracture Description Transverse Occurs straight across the long axis of the bone Oblique Occurs at an angle that is not 90 degrees Spiral Bone segments are pulled apart because of a twisting motion Comminuted Several breaks result in many small pieces between two large segments Impacted One fragment is driven into the other, usually because of compression Greenstick A partial fracture in which only one side of the bone is broken Open (or compound) A fracture in which at least one end of the broken bone tears through the skin; carries a high risk of infection Closed (or simple) A fracture in which the skin remains intact AMCA, Medical Coder and Biller Certification Study Guide (MCBC) This document is the property of the AMCA. The document and any of its contents cannot be reproduced, shared or disseminated for any reason without written consent of the AMCA. ©  1.13 Respiratory system and organs Pulmonary Pertaining to the lungs and respiratory system. Pharyngeal Pertaining to the pharynx. Pharynx The pharynx is located behind the nasal cavities. It extends down to the larynx. The pharynx is particularly important because it is the only passage from the mouth and the nasal cavities to the lung. Thorax Thoraxes and thoraces are plural for thorax. The upper part of the chest containing the organs of respiration. Trachea The trachea extends from the cricoid cartilages to about midway of the chest around the 5th or 6th thoracic vertebrae. The windpipe is another name for the trachea. Alveolar Little hollow; Pertains to the alveolus. Alveolus also means little hollow. Bronchus Windpipe Bronchioles Little windpipe; Airways that extend from the bronchi. Diaphragm A dome-shaped muscle that separates the thoracic cavity and the abdominal cavity. Epiglottis A leaf-like structure that covers the larynx that prevents food from entering the larynx. AMCA, Medical Coder and Biller Certification Study Guide (MCBC) This document is the property of the AMCA. The document and any of its contents cannot be reproduced, shared or disseminated for any reason without written consent of the AMCA. © 1.14 Cardiovascular system and organs Arteries: The blood vessels that take blood away from the heart. Veins: Blood vessels that return blood to the heart. Capillaries: Small vessels that lie between the arteries and veins. Systemic circulation: Takes oxygen-rich blood to the tissues and organs of the body Pulmonary circulation: Takes oxygen-depleted blood to the lungs and oxygen-rich blood back to the heart again. Atherosclerosis – A disease process that leads to the buildup of a waxy substance, called plaque, inside blood vessels. Atrium (right and left) – The two upper or holding chambers of the heart (together referred to as atria). Carotid artery – A major artery (right and left) in the neck supplying blood to the brain. Cerebral embolism – A blood clot formed in one part of the body and then carried by the bloodstream to the brain, where it blocks an artery. Cerebral hemorrhage – Bleeding within the brain resulting from a ruptured blood vessel, aneurysm, or head injury. Cerebral thrombosis – Formation of a blood clot in an artery that supplies part of the brain. Cerebrovascular – Pertaining to the blood vessels of the brain. Pulmonary – Refers to the lungs and respiratory system. Pulmonary embolism – A condition in which a blood clot that has formed elsewhere in the body travels to the lungs. Pulmonary valve – The heart valve between the right ventricle and the pulmonary artery that controls blood flow from the heart into the lungs. Pulmonary vein – The blood vessel that carries newly oxygenated blood from the lungs back to the left atrium of the heart. AMCA, Medical Coder and Biller Certification Study Guide (MCBC) This document is the property of the AMCA. The document and any of its contents cannot be reproduced, shared or disseminated for any reason without written consent of the AMCA. © 1.15 Gastrointestinal system and organs Anus: The opening at one end of the digestive tract from which waste is expelled. Appendectomy: Surgical removal of the appendix to treat appendicitis. Appendicitis: Inflammation of the appendix that requires immediate medical attention. Appendix: A small, finger-like tube located where the large and small intestine join. It has no known function. Colon: The last three or four feet of the intestine (except for the last eight inches, which is called the rectum). Synonymous with the "large intestine" or "large bowel." Diaphragm: Thin, dome-shaped muscle that separates the abdomen from the chest. When the muscle contracts, the dome flattens, increasing the volume of the chest. Gallbladder: A small pear-shaped organ located beneath the liver on the right side of the abdomen. The gallbladder’s primary functions are to store and concentrate bile and secrete bile into the small intestine to help digest food. Large intestine: This digestive organ is made up of the ascending (right) colon, the transverse (across) colon, the descending (left) colon, and the sigmoid (end) colon. The appendix is also part of the large intestine. The large intestine receives the liquid contents from the small intestine and absorbs the water and electrolytes from this liquid to form feces, or waste. Liver: One of the most complex and largest organs in the body, which performs more than 5,000 life-sustaining functions AMCA, Medical Coder and Biller Certification Study Guide (MCBC) This document is the property of the AMCA. The document and any of its contents cannot be reproduced, shared or disseminated for any reason without written consent of the AMCA. © 1.16 Genitourinary system and organs Urinary system removes a type of waste called urea from your blood. Urea is produced when foods containing protein, such as meat, poultry, and certain vegetables, are broken down in the body. Urea is carried in the bloodstream to the kidneys. Kidneys are bean-shaped organs about the size of your fists. They are near the middle of the back, just below the rib cage. The kidneys remove urea from the blood through tiny filtering units called nephrons. Urine travels down two thin tubes called ureters to the bladder. The ureters are about 8 to 10 inches long. Muscles in the ureter walls constantly tighten and relax to force urine downward away from the kidneys. Bladder is a hollow muscular organ shaped like a balloon. It sits in your pelvis and is held in place by ligaments attached to other organs and the pelvic bones. Sphincter muscles close tightly like a rubber band around the opening of the bladder into the urethra, the tube that allows urine to pass outside the body. AMCA, Medical Coder and Biller Certification Study Guide (MCBC) This document is the property of the AMCA. The document and any of its contents cannot be reproduced, shared or disseminated for any reason without written consent of the AMCA. © 1.17 Central nervous system and structures Somatic nervous system (SNS) is responsible for conscious perception and voluntary motor responses. Voluntary motor response means the contraction of skeletal muscle, but those contractions are not always voluntary in the sense that you must want to perform them. Autonomic nervous system (ANS) is responsible for involuntary control of the body, usually for the sake of homeostasis (regulation of the internal environment) Cerebrum is the largest part of the brain. It sits on top of the brain stem. The cerebrum controls functions that we are aware of, such as problem-solving and speech. It also controls voluntary movements, like waving to a friend. Whether you are doing your homework or jumping hurdles, you are using your cerebrum. Cerebellum is the next largest part of the brain. It lies under the cerebrum and behind the brain stem. The cerebellum controls body position, coordination, and balance. Whether you are riding a bicycle or handwriting, you are using your cerebellum Brain stem is the smallest of the three main parts of the brain. It lies directly under the cerebrum. The brain stem controls basic body functions, such as breathing, heartbeat, and digestion. Spinal cord is the long, tube-shaped bundle of neurons that runs from the brain stem to the lower back. It carries nerve impulses back and forth between the body and brain. AMCA, Medical Coder and Biller Certification Study Guide (MCBC) This document is the property of the AMCA. The document and any of its contents cannot be reproduced, shared or disseminated for any reason without written consent of the AMCA. © 1.18 Metabolic/endocrine system and organs Hypothalamus. While some people don’t consider it a gland, the hypothalamus produces multiple hormones that control the pituitary gland. It is also involved in regulating many functions, including sleep-wake cycles, body temperature, and appetite. It can also regulate the function of other endocrine glands. Pituitary. The pituitary gland is located below the hypothalamus. The hormones it produces affect growth and reproduction. They can also control the function of other endocrine glands. Pineal. This gland is found in the middle of your brain. It is important for your sleep- wake cycles. Thyroid. The thyroid gland is in the front part of your neck. It is important for metabolism. Parathyroid. Also located in the front of your neck, the parathyroid gland is important for maintaining control of calcium levels in your bones and blood. Thymus. Located in the upper torso, the thymus is active until puberty and produces hormones important for the development of a type of white blood cell called a T cell. Adrenal. One adrenal gland can be found on top of each kidney. These glands produce hormones important for regulating functions such as blood pressure, heart rate, and stress response. Pancreas. The pancreas is in your abdomen behind your stomach. Its endocrine function involves controlling blood sugar levels. AMCA, Medical Coder and Biller Certification Study Guide (MCBC) This document is the property of the AMCA. The document and any of its contents cannot be reproduced, shared or disseminated for any reason without written consent of the AMCA. © 1.19 Hematologic/lymphatic system Lymph nodes also destroy invading cells and particles in a process known as phagocytosis. Thoracic duct, there is only one, is the largest vessel of the lymph system. It collects lymph from the body below the diaphragm and from left side of body above the diaphragm. The spleen, tonsils, and thymus are accessory organs of this system. The spleen enlarges with infectious diseases and decreases in size in old age. Some phagocytosis takes place in the spleen. The tonsils filter out bacteria and foreign matter. The thymus produces cells that destroy foreign substances. AMCA, Medical Coder and Biller Certification Study Guide (MCBC) This document is the property of the AMCA. The document and any of its contents cannot be reproduced, shared or disseminated for any reason without written consent of the AMCA. © 1.20 Immunologic system Bone marrow: The soft tissue in the hollow center of bones, is the ultimate source of all blood cells, including white blood cells destined to become immune cells. The thymus is an organ that lies behind the breastbone; lymphocytes known as Lymph: Lymph is a fluid that circulates throughout the body in the lymphatic system. It forms when tissue fluids/blood plasma (mostly water, with proteins and other dissolved substances) drain into the lymphatic system. It contains a high number of lymphocytes (white cells that fight infection). Lymph that forms in the digestive system called chyle, this contains higher levels of fats, and looks milky white. Lymph vessels: Walled, valve structures that carry lymph throughout the body Lymph nodes: Small bean-shaped glands that produce lymphocytes, filter harmful substances from the tissues, and contain macrophages, which are cells that digest cellular debris, pathogens, and other foreign substances. Major groups of lymph nodes are in the tonsils, adenoids, armpits, neck, groin, and mediastinum. Thymus: The thymus is a specialized organ of the immune system, located between the breastbone and heart. It produces lymphocytes, is important for T cell maturation (T for thymus-derived). It plays an important function in both the immune and endocrine systems. Spleen: The spleen is an organ in the upper left abdomen, which filters blood, disposes of worn-out red blood cells, and provides a 'reserve supply' of blood. It contains both red tissue, and white lymphatic tissue. Different parts of the spleen specialize in different kinds of immune cells. Types of Immunity Cells The immune system has cells that perform specific functions. These cells are found in the blood stream and are called white blood cells. AMCA, Medical Coder and Biller Certification Study Guide (MCBC) This document is the property of the AMCA. The document and any of its contents cannot be reproduced, shared or disseminated for any reason without written consent of the AMCA. ©  B cells - B cells are also called B lymphocytes. These cells produce antibodies that bind to antigens and neutralize them. Each B cell makes one specific type of antibody. For example, there is a specific B cell that helps to fight off the flu. T cells - T cells are also called T lymphocytes. These cells help to get rid of good cells that have already been infected. Helper T cells - Helper T cells tell B cells to start making antibodies or instruct killer T cells to attack. Killer T cells - Killer T cells destroy cells that have been infected by the invader. Memory cells - Memory cells remember antigens that have already attacked the body. They help the body to fight off any new attacks by a specific antigen. 1.21 Ophthalmology Sclera: The white outer layer of the eyeball. Cornea: The front transparent part of the sclera is called cornea. Light enters the eye through the cornea. Iris: A dark muscular tissue and ring-like structure behind the cornea are known as the iris. The color of iris indicates the color of the eye. The iris also helps regulate or adjust exposure by adjusting the iris. Pupil: A small opening in the iris is known as a pupil. Its size is controlled by the help of iris. It controls the amount of light that enters the eye. Lens: Behind the pupil, there is a transparent structure called a lens. By the action of ciliary muscles, it changes its shape to focus light on the retina. It becomes thinner to focus distant objects and becomes thicker to focus nearby objects. Retina: It is a light-sensitive layer that consists of numerous nerve cells. It converts images formed by the lens into electrical impulses. These electrical impulses are then transmitted to the brain through optic nerves. Optic nerves: Optic nerves are of two types. These include cones and rods. Cones: Cones are the nerve cells that are more sensitive to bright light. They help in detailed central and color vision. AMCA, Medical Coder and Biller Certification Study Guide (MCBC) This document is the property of the AMCA. The document and any of its contents cannot be reproduced, shared or disseminated for any reason without written consent of the AMCA. © 1.22 Otolaryngology (i.e., ears, nose, mouth, and throat) o External or outer ear, consisting of: ▪ Pinna or auricle. This is the outside part of the ear. ▪ External auditory canal or tube. This is the tube that connects the outer ear to the inside or middle ear. o Tympanic membrane (eardrum). The tympanic membrane divides the external ear from the middle ear. o Middle ear (tympanic cavity), consists of: ▪ Ossicles. Three small bones that are connected and transmit the sound waves to the inner ear. The bones are called: Malleus Incus AMCA, Medical Coder and Biller Certification Study Guide (MCBC) This document is the property of the AMCA. The document and any of its contents cannot be reproduced, shared or disseminated for any reason without written consent of the AMCA. ©  Stapes o Eustachian tube. A canal that links the middle ear with the back of the nose. The eustachian tube helps to equalize the pressure in the middle ear. Equalized pressure is needed for the proper transfer of sound waves. The eustachian tube is lined with mucous, just like the inside of the nose and throat. Inner ear, consisting of: o Cochlea. This contains the nerves for hearing. o Vestibule. This contains receptors for balance. o Semicircular canals. This contains receptors for balance. Maxillary sinus: This sinus is in the body of the maxilla behind the cheek just above the roots of the premolar and molar teeth. It is shaped like a pyramid. It opens into the nasal cavity via the semilunar hiatus. Frontal sinuses: Found within the frontal bone, each of these sinuses is triangular and runs above the medial end of the eyebrow and backward to the orbit. They open into the nasal cavity via the semilunar hiatus. Sphenoid sinuses: These sinuses are found in the sphenoid bone. Each open into the sphenoethmoid recess. Ethmoid sinuses: The anterior, middle, and posterior ethmoid sinuses are in the ethmoid bone between the nose and the eye. The anterior sinus opens into the nasal cavity by the infundibulum, the middle sinus opens into the ethmoidal bulla, and the posterior sinus opens into the superior meatus. Voice box (larynx). The larynx is a cylindrical grouping of cartilage, muscles, and soft tissue that contains the vocal cords. The vocal cords are the upper opening into the windpipe (trachea), the passageway to the lungs. Epiglottis. A flap of soft tissue located just above the vocal cords. The epiglottis folds down over the vocal cords to prevent food and irritants from entering the lungs. Tonsils and adenoids. They are made up of lymph tissue and are located at the back and the sides of the mouth. They protect against infection. No real function after childhood 1.1 Constitutional symptoms (e.g., fever, weight loss, etc.) AMCA, Medical Coder and Biller Certification Study Guide (MCBC) This document is the property of the AMCA. The document and any of its contents cannot be reproduced, shared or disseminated for any reason without written consent of the AMCA. ©  Fever is a common symptom of illness and is called constitutional because it affects the entire body through the immune system producing a high temperature. Weight loss is a vague indicator of disease, although severe weight loss is an obvious focus for serious disease diagnosis Weakness is a general symptom that can signal the presence of a variety of diseases, from influenza to heart conditions 2. Physicians’ Current Procedural Terminology (CPT)/Health Care Common Procedural Coding System (HCPCS) 2.01 CPT code interpretation and terminology Current Procedural Terminology (CPT) The Current Procedural Terminology (CPT) used by physicians and other healthcare providers. It is considered Level I of the HCPCS. The CPT is made up of the main text – sections of codes – followed by appendixes and an index. 2.02 Evaluation and Management (E/M) codes In selecting an E/M code the three key factors that need to be considered are history, examination and medical decision making. Patient Examination and Documentation History is documented in the patient’s medical file. History is typically taken by the assistant or the doctor and could be used as a reference for certain diseases or symptoms. There are 4 different types of histories that could be taken: History of Present Illness – description of its development from the first sign or symptom that the patient experienced to the present time. The abbreviation PFSH stands for the following: Past Medical, Family and Social History. Past Medical History – the history explains the patient’s experiences with illnesses, injuries, and treatments in addition to operations, injuries, and hospitalizations. It also covers current medications, allergies, immunization status and diet. Family History – reviews the medical history of the patient’s family. Social History – patient’s age, marital status, employment, etc. History: Four elements of a history 1. Chief complaint a. Of present illness(s) b. Review of symptom(s) c. Past, Family and or Social History 2. History Levels a. Problem Focused AMCA, Medical Coder and Biller Certification Study Guide (MCBC) This document is the property of the AMCA. The document and any of its contents cannot be reproduced, shared or disseminated for any reason without written consent of the AMCA. ©  b. Expanded problem focused c. Detailed d. Comprehensive 3. Examination Levels a. Problem focused b. Expanded problem focused c. Detailed d. Comprehensive 4. Medical Decision-Making Complexity Levels a. Straightforward b. Low c. Moderate d. High i. Straightforward 1. Minimal diagnosis 2. Minimal risk 3. Minimal complexity of data ii. Low 1. Limited diagnosis 2. Limited/low risk to patient 3. Limited data iii. Moderate 1. Multiple diagnoses 2. Moderate risk to the patient 3. Moderate amount and complexity of data iv. High 1. Extensive diagnoses 2. High risk to patient 3. Extensive amount and complexity of data 2.03 Anesthesia codes Anesthesia CPT Code range 00100- 01999 Anesthesia is administered to patients to relive pain during surgery. Anesthesia can be administered by a board-certified anesthesiologist or a CRNA (certified registered Nurse anesthetist who administers the medication to help achieve loss of sensation during procedures or surgeries. Anesthesia requires an evaluation of the patient which includes documenting the history and physical examination and answering any questions from the patient, to minimize the risk of adverse reactions. Billing and coding of anesthesia services depend on the payer and the state the service was performed. It is imperative for coders to be aware of coding requirements of the payer as codes AMCA, Medical Coder and Biller Certification Study Guide (MCBC) This document is the property of the AMCA. The document and any of its contents cannot be reproduced, shared or disseminated for any reason without written consent of the AMCA. © submitted can differ. The anesthesia section, the smallest section in the CPT coding manual is grouped by the body site. Index; Anesthesia, corneal transplant, 00144 To code for Anesthesia services there are important elements to consider such as Physical Status Modifiers (as mentioned earlier), Qualifying circumstances, Anesthesia Modifiers, and CPT Modifiers. Physical Status Modifiers P1 - A normal healthy patient P2 - A patient with mild systemic disease P3 - A patient with severe systemic disease P4 - A patient with severe systemic disease that is a constant threat to life P5 - A moribund patient who is not expected to survive without the operation P6 - A declared brain-dead patient whose organs are being removed for donor purposes HCPCS Anesthesia Modifiers AA -Anesthesia services personally performed by the anesthesiologist AD- Supervision, more than four procedures QK- Medical direction of two, three, or four concurrent anesthesia procedures QS- Monitored Anesthesia Care (MAC) services (can be billed by a qualified nonphysician anesthetist or physician) QX- Qualified non-physician anesthetist with medical direction by a physician QY-Medical direction of one CRNA/AA by an anesthesiologist QZ -Certified Registered Nurse Anesthetist (CRNA) without medical direction by a physician CPT Modifiers for Anesthesia Codes 23- Unusual Anesthesia 53- Discontinued Procedure 59- Distinct procedural service 74- Discontinued outpatient after anesthesia administered 99- Multiple modifiers Qualifying Circumstances 99100 – Anesthesia for Patient of Extreme Age, Under 1 Year and Over 70 99116 – Anesthesia Complicated By Utilization of Total Body Hypothermia 99135 – Anesthesia Complicated By Utilization of Controlled Hypotension 99140 – Anesthesia Complicated by Emergency Conditions AMCA, Medical Coder and Biller Certification Study Guide (MCBC) This document is the property of the AMCA. The document and any of its contents cannot be reproduced, shared or disseminated for any reason without written consent of the AMCA. © 2.04 Surgery codes Surgery CPT Code range 10004- 69990 The Surgery Section of the CPT is organized by body system. Each subsection is then subdivided into categories specific to organ or anatomic site. Then further subdivided by procedure subcategories in the following order based on the anatomical site and body system. When coding from the surgery section, coders must carefully read the procedure, and ask what body system, anatomic site and procedure performed. Subsections within the surgery section: 1. 10004-10021 Fine Needle Aspiration Biopsy Procedures 2. 10030-19499 Surgical Procedures on the Integumentary System 3. 20100-29999 Surgical Procedures on the Musculoskeletal System 4. 30000-32999 Surgical Procedures on the Respiratory System 5. 33016-37799 Surgical Procedures on the Cardiovascular System 6. 38100-38999 Surgical Procedures on the Hemic and Lymphatic Systems 7. 39000-39599 Surgical Procedures on the Mediastinum and Diaphragm 8. 40490-49999 Surgical Procedures on the Digestive System 9. 50010-53899 Surgical Procedures on the Urinary System 10. 54000-55899 Surgical Procedures on the Male Genital System 11. 55920 Reproductive System Procedures 12. 55970-55980 Intersex Surgery 13. 56405-58999 Surgical Procedures on the Female Genital System 14. 59000-59899 Surgical Procedures for Maternity Care and Delivery 15. 60000-60699 Surgical Procedures on the Endocrine System 16. 61000-64999 Surgical Procedures on the Nervous System 17. 65091-68899 Surgical Procedures on the Eye and Ocular Adnexa 18. 69000-69979 Surgical Procedures on the Auditory System 19. 69990 Operating Microscope Procedures Procedures include, but not limited to, depending on body system, the following: Incision Excision Introduction and removal Incision and Drainage Repair Endoscopy Repair, revision, or Reconstruction Destruction Replantation AMCA, Medical Coder and Biller Certification Study Guide (MCBC) This document is the property of the AMCA. The document and any of its contents cannot be reproduced, shared or disseminated for any reason without written consent of the AMCA. © When coding from this section, Billers and Coders must keep in mind the surgical package (global surgery). Because the surgical package includes a variety of services provided by a surgeon, the surgical package includes three types of procedures: Simple Procedures (Zero Global Period) o There is no preoperative/postoperative period, so the global period is only the day of the procedure. o Unless special circumstances exist, a visit on the same day as surgery is not payable. o Services are generally simple minor procedures and some endoscopic procedures. Minor surgical procedures (10-day global period) o There is no preoperative period, so the global period starts the day of the procedure. o Unless special circumstances exist, a visit on the same day as surgery is not payable. o There are 11 days in the global surgical package beginning the day of the procedure and then the 10-days following it. Major surgical procedures (90-day global period) o There is one day of preoperative care, so the global period starts the day prior to the surgery. o Care on the day of the surgery is included in the global period unless the decision to perform the surgery was made during the visit on this day. (See modifier -57). o There are 92 days in the global surgical period beginning the day before the procedure, the day of the procedure, and the 90 days following it. The Surgical package includes: The following services are included in the surgical service payment and are not separately reimbursed: Pre-operative visits–one day prior for major surgeries and on the same day a major or minor surgery is performed Intra-operative services. Post-operative visits. Post-surgical pain management by the surgeon. Supplies, except for those identified as exclusions. Miscellaneous services—items such as dressing changes; local incisional care; removal of operative pack; removal of cutaneous sutures and staples, lines, wires, tubes, drains, casts, and splints; insertion, irrigation and removal of urinary catheters, routine peripheral intravenous lines, nasogastric and rectal tubes; and changes and removal of tracheostomy tubes. AMCA, Medical Coder and Biller Certification Study Guide (MCBC) This document is the property of the AMCA. The document and any of its contents cannot be reproduced, shared or disseminated for any reason without written consent of the AMCA. ©  Complications following surgery, all additional medical or surgical services required of the surgeon during the post-operative period which do not require an additional trip to the operating room. It is essential that coders are aware that unbundling is not allowed. Unbundling mean assigning multiple codes to procedures when just one comprehensive code should be reported. There are billable services not included in the surgical package. Examples are: Services of other physicians related to the surgery, except where the surgeon and the other physician(s) agree on the transfer of care. This agreement may be in the form of a letter or an annotation in the discharge summary, hospital record, or ASC record. Visits unrelated to the diagnosis for which the surgical procedure is performed, unless the visits occur due to complications of the surgery Treatment for the underlying condition or an added course of treatment which is not part of normal recovery from surgery Diagnostic tests and procedures, including diagnostic radiological procedures Clearly distinct surgical procedures that occur during the post-operative period which are not re-operations or treatment for complications Treatment for post-operative complications requiring a return trip to the Operating Room (OR). An OR, for this purpose, is defined as a place of service specifically equipped and staffed for the sole purpose of performing procedures. The term includes a cardiac catheterization suite, a laser suite, and an endoscopy suite. It does not include a patient’s room, a minor treatment room, a recovery room, or an intensive care unit (unless the patient’s condition was so critical there would be insufficient time for transportation to an OR). If a less extensive procedure fails, and a more extensive procedure is required, the second procedure is payable separately. Immunosuppressive therapy for organ transplants Critical care services (CPT codes 99291 and 99292) unrelated to the surgery where a seriously injured or burned patient is critically ill and requires constant attendance of the physician As codes are selected and assigned, it is important to read the coding rules and guidelines surrounding them (e.g., after the heading and subheading and in parentheses) for coding accuracy. 2.05 Radiology codes Radiology Procedures CPT Code range 70010- 79999 Diagnostic Radiology: This subsection is used to report a procedure or service rendered during the assessment for a disease for a more definitive diagnosis. AMCA, Medical Coder and Biller Certification Study Guide (MCBC) This document is the property of the AMCA. The document and any of its contents cannot be reproduced, shared or disseminated for any reason without written consent of the AMCA. ©  Diagnostic Ultrasound: This subsection is used to establish a diagnosis based on the extent of the study. The extent is indicated by complete, limited or follow-up/complete. A complete study is a study the examines the body area. Limited study is a partial examination of a body area or quadrant. Follow-up/repeat study is a study performed on an area that requires an additional completed study or exam. Radiologic Guidance: These services are to be used to report fluoroscopic guidance, computed tomography (CT), magnetic resonance guidance and other radiologic guidance. To properly code the numerous instruction notes must be read and followed. Breast Mammography: This code range reports mammographic procedures based on the imaging device, screening for diagnostic, and whether it is unilateral or bilateral. Screening mammograms are always bilateral. Diagnostic mammograms may be unilateral or bilateral and is usually performed with the focus on a sign or symptom. Bone and joint studies: Classify bone and joint studies 77071-77086. Radiation Oncology: Uses high energy ionizing radiation to treat malignant neoplasms and certain nonmalignant conditions. Therapeutic modalities directed at malignant and benign lesions include brachytherapy, hyperthermia, stereotactic radiation, teletherapy. Nuclear Medicine: Use of ratio active elements for diagnostic imaging and radiopharmaceutical therapy. Nuclear medicine codes do not include the provision of radium, which means that the nuclear medicine report must be reviewed to identify the diagnostic or therapeutic radiopharmaceutical provided. 2.06 Pathology and Laboratory codes Pathology and Laboratory Procedures CPT Code range 80047- 89398 The Pathology and medicine section of the CPT coding manual is divided into 18 sections that apply to all parts of the body. Specimen are sent to the Laboratory to assess and diagnose a medical condition. 80047-80081 Organ or Disease Oriented Panels Reported to describe panels of tests often ordered together. These codes are used when all the tests listed under the panel are performed. If one or more is not performed, the panel code cannot be used. Each test must be reported separately. 80145-80377 Therapeutic Drug Assays Report for laboratory test performed to determine how much of a specific prescribed drug is in the patient blood. Report for monitoring the response to know, prescribed medications. The tissue most observed is blood and the codes may be used for assays on any source (sputum, urine). 80400-80439 Evocative/Suppression Testing Procedures Report for laboratory test when substances are injected for the purpose of confirming or ruling out a specific disorder. AMCA, Medical Coder and Biller Certification Study Guide (MCBC) This document is the property of the AMCA. The document and any of its contents cannot be reproduced, shared or disseminated for any reason without written consent of the AMCA. © Evocative suppressing tests describe how well various endocrine glands are functioning. 80500-80502 Clinical Pathology Consultations Reported by pathologists who perform clinical pathology consultations requested by attending physicians when a test result requires additional medical interpretive judgement. 81000-81099 Urinalysis Procedures Reported for laboratory tests performed on body fluids (urine, blood). Tests are ordered by physicians and performed by technologists under the supervision of a physician. 81105-81408 Molecular Pathology Procedures Molecular pathology procedures are medical laboratory procedures involving the analysis of nucleic acid (DNA)) to detect variant in genes that may be indicative of germline or somatic conditions or to test for histocompatibility antigens. 81410-81479 Genomic Sequencing Procedures and Other Molecular Multianalyte Assays Reported for GSP’s performed on nucleic acids from germline or neoplastic samples. To report these codes all components of the descriptors must be performed. 81490-81599 Multianalyte Assays with Algorithmic Analyses Multianalyte Assays with Algorithmic Analysis are procedures that utilize multiple results derived from panes of analysis of various types including molecular pathology assays, fluorescent in sit hybridization assays, acid-based assays. 82009-84999 Chemistry Procedures The sources or specimens can be blood, stool, urine, or blood. In this section the coder may encounter the term analyte, which refers to the substance being tested. 85002-85999 Hematology and Coagulation Procedures Reported for Hematology and Coagulation including blood count and other counts of blood components. Hematology is the study of blood and coagulation is the clotting of the blood. 86000-86849 Immunology Procedures Antibodies are elements the human body creates to deal with antigens. Antigens may be viruses, bacteria, or other immune triggers the body fights off by creating antibodies. 86850-86999 Transfusion Medicine Procedures These codes also can be used to describe the same work when transfusion is not involved. 87003-87999 Microbiology Procedures AMCA, Medical Coder and Biller Certification Study Guide (MCBC) This document is the property of the AMCA. The document and any of its contents cannot be reproduced, shared or disseminated for any reason without written consent of the AMCA. © These codes include presumptive identification of microorganisms grown on selective media. Include microbiology on bacteriology, mycology, parasitology, and virology. 88000-88099 Postmortem Examination Procedures Reported for postmortem examination (also called autopsy or necropsy). Codes in this section vary based on whether the study is gross only or gross and microscopic. 88104-88199 Cytopathology Procedures Cytopathology is an examination of cervical and /or vaginal cells. Pap smear results are reported by two methods. Bethesda and Non-Bethesda. 88230-88299 Cytogenetic Studies Reported for pathology screening tests and for tissue cultures and chromosome analysis studies. Molecular pathology procedures should be reported with the appropriated cod from Tier 1 and Tier 2. 88300-88399 Surgical Pathology Procedures Reported when specimens removed during surgery require pathology diagnosis. These codes are arranged by levels and associated procedures. 88720-88749 In Vivo (e.g., Transcutaneous) Laboratory Procedures Reported for codes in In Vivo procedures. These codes are reported for noninvasive laboratory procedures that are permed transcutaneous which means the measurement is obtained by pressing a laboratory instrument against the patient skin to obtain a laboratory value. 89049-89240 Other Pathology and Laboratory Procedures Report these codes for miscellaneous laboratory procedures, not elsewhere classified in the Path/Lab section. 89250-89398 Reproductive Medicine Procedures These services are related to invitro fertilization and storage of various reproductive tissues. These codes can be used alone or used in combination when appropriate. 2.07 Medicine Codes Medicine Services and Procedures CPT Code range 90281- 99756 The Medicine section of the CPT manual follows Pathology and Laboratory. It lists a variety of services that are not classified in any of the other 5 sections of the CPT that include invasive (includes incisional access), and noninvasive procedures (does not require a surgical incision or excision). Many codes reported from this section apply to various medical specialists (e.g., ophthalmology, psychiatry) and different types of healthcare providers (occupational and physical therapists). AMCA, Medical Coder and Biller Certification Study Guide (MCBC) This document is the property of the AMCA. The document and any of its contents cannot be reproduced, shared or disseminated for any reason without written consent of the AMCA. © 90281-90399 Immune Globulins, Serum, or Recombinant Products Immune globulins are substances produced from immunoglobulins in human blood. Immunoglobulins (antibodies) travel in the blood or lymph and provide protection against certain diseases. Immune globulin products are individually listed with the appropriate CPT codes. They may be administered by the following routes: Intramuscular (IM)—into a muscle. Subcutaneous (SQ)—into subcutaneous tissue. Intravenous (IV)—into a vein. The coder must assign a code from 90765 to 90779 for the specific administration route in addition to coding the specific immune globulin product (90281–90399). This code range is reported in addition to administration codes (90460-90474). 90460-90474 Immunization Administration for Vaccines/Toxoids Reported for intradermal, intramuscular, percutaneous and subcutaneous injections. As well as intranasal and/or oral administration. 90476-90756 Vaccines, Toxoids Immunity is acquired when the body produces antibodies in response to antigen exposure. Immunity can be acquired from having the active disease or receiving a vaccination. An antigen is a foreign substance that can attack the body and cause illness. Antigens may be bacteria, viruses, fungi or other types of germs. Vaccines (viruses) and toxoids (bacteria) that are attenuated (weakened) can be injected in small amounts to enable the body to form antibodies, resulting in an immune (antigen/antibody) response. The immune response provides protection against the antigen if a subsequent exposure occurs. Vaccination and toxoid administration codes are divided by route of administration, age of patient, and number of administrations. Routes include Percutaneous—through the skin (absorption). Intradermal— into the skin. Intramuscular—into a muscle. Subcutaneous—into subcutaneous tissue (beneath the skin). Intranasal—into the nasal cavity. Oral—into the mouth. Vaccination codes are specific for patients younger than 8 years of age and for age 8 and older. Add-on codes are provided for each additional administration. The coder should remember that each additional means the add-on code will be assigned for each additional injection or administration after the initial one. 90785-90899 Psychiatry Services and Procedures: Psychiatry is the medical specialty concerned with the diagnosis and treatment of mental disorders. Psychiatric codes are provided for inpatient and outpatient services. The patient’s primary care provider may request psychiatric consultations. This service requires a thorough review of the patient’s history and a lengthy psychiatric examination. Results are then reported back to the requesting physician and a written report is completed. An appropriate code from the Evaluation and Management (E/M) section of CPT is assigned for this service. Psychotherapy is the treatment of emotional, behavioral, personality, and psychiatric disorders based primarily on verbal or nonverbal communication and interventions with the patient. Medical E/M services for a health assessment and medication monitoring can be provided in conjunction with psychotherapy visits. AMCA, Medical Coder and Biller Certification Study Guide (MCBC) This document is the property of the AMCA. The document and any of its contents cannot be reproduced, shared or disseminated for any reason without written consent of the AMCA. © 90901-90913 Biofeedback Services and Procedures: Reported for Biofeedback services, including review of the patient's history preparation of biofeedback equipment, placement of electrodes on patient reading and interpreting responses, monitoring the patient and control of muscle responses. There are only two codes from this subsection. 90935-90999 Dialysis Services and Procedures: Reported for hemodialysis, miscellaneous dialysis procedures, and end stage renal disease services and other dialysis procedures. 91010-91299 Gastroenterology Procedures: Reported for gastric physiology services and other diagnostic procedures performed on the gastrointestinal system. 92002-92499 Ophthalmology Services and Procedures: Reported for general ophthalmological services such as contact lens, and spectacle services. CPT provides specific codes for services provided to new and established ophthalmologic patients. If the services provided are less than those described in codes 92002–92014, the coder should assign an appropriate code from the E/M section of CPT. Intermediate and comprehensive are the levels of service reported. The selection is determined by whether the patient is new or established and whether the service was intermediate or comprehensive. 92502-92700 Special Otorhinolaryngologic Services and Procedures Reported for special diagnostic services typically performed by an ENT specialist. 92920-93799 Cardiovascular Procedures Reported for therapeutic services and procedures, cardiograph cardiovascular monitoring services, implantable and wearable cardiac device evaluations, intracardiac electrophysiological procedures/studies, noninvasive physiologic studies and procedures and other vascular studies. 93880-93998 Non-Invasive Vascular Diagnostic Studies Reported for cerebrovascular arterial studies, extremity arterial and venous studies, visceral and penile vascular studies, extremity arterial-venous studies, and noninvasive vascular diagnostic studies. 94002-94799 Pulmonary Procedures Reported for ventilator management and pulmonary diagnostic testing and therapies. AMCA, Medical Coder and Biller Certification Study Guide (MCBC) This document is the property of the AMCA. The document and any of its contents cannot be reproduced, shared or disseminated for any reason without written consent of the AMCA. © 95249-95251 Endocrinology Services Reported for the continuous glucose monitoring of interstitial tissue fluid via subcutaneous interstitial sensor placement. Hookup of the sensor to the transmitter is for up to 72 hours. 95700-96020 Neurology and Neuromuscular Procedures Reported for neurology and neuromuscular diagnostic and therapeutic services that do not require surgical procedures (e.g., sleep testing, EEG, EMG, motion analysis). This subsection includes: Sleep Testing Routine Electroencephalography Muscle and the Range of Motion testing Electromyography and Nerve Conduction Tests Intraoperative Neurophysiology Autonomic Function Test Evoked Potentials and Reflex Test Special EEG Tests Neuro-stimulator analysis Motion Analysis Functional Brain Mapping 96040 Medical Genetics and Genetic Counseling Services Reported for counseling of an individual, couple, of family to investigate family genetic history and assess the risks associated with genetic defects in offspring. 96105-96146 Central Nervous System Assessments/Tests (e.g., Neuro-Cognitive, Mental Status, Speech Testing) Reported for tests performed to measure cognitive function of the central nervous system (neuro-cognitive, mental status, Speech testing). 96150-96171 Health and Behavior Assessment/Intervention Procedures Reported for tests that identify the psychological behavioral, emotional, cognitive, and social elements involved in the prevention, treatment, or management of physical health problems. AMCA, Medical Coder and Biller Certification Study Guide (MCBC) This document is the property of the AMCA. The document and any of its contents cannot be reproduced, shared or disseminated for any reason without written consent of the AMCA. © 96360-96549 Hydration, Therapeutic, Prophylactic, Diagnostic Injections and Infusions, and Chemotherapy and Other Highly Complex Drug or Highly Complex Biologic Agent Administration Reported for hydration IV infusion that consists of prepackage fluid and electrolytes. Codes include the administration local anesthesia, intravenous insertion, access to catheter, IV or ports. 96567-96574 Photodynamic Therapy Procedures Reported for the administration of light therapy to destroy premalignant/malignant lesions or ablate abnormal tissue using photosensitive drugs. Physicians use this therapy to treat lesions. 96900-96999 Special Dermatological Procedures Reported for special dermatological procedures for actinotherapy, examination of hair, photochemotherapy and laser treatment for skin disease. Laser treatments codes are divided according to the total areal involved in the treatment. 97151-97158 Adaptive Behavior Services Report of Behavior identification assessments is conducted by the physician and may include analysis of pertinent date, a detailed behavior history, patient observation. Behavioral identification supporting assessment 97152 is administered by a technical under the direction of physician other qualified heath professional. 97161-97799 Physical Medicine and Rehabilitation Evaluations Reported for services that focus on the prevention, diagnosis, and treatment of disorders of the musculoskeletal, cardiovascular, and pulmonary systems that may produce temporary or permanent impairment. 97802-97804 Medical Nutrition Therapy Procedures Reported for medical nutrition therapy, which is classified according to the type of assessment, individual or group therapy and length of time. Codes 97802 and 97803 are reported for the face-to-face interaction with the patient, per 15 minutes increments, 97810-97814 Acupuncture Procedures 97810-97814 are reported for acupuncture service with or without electric stimulation. The provider is face to face with the patient and reported in 15 minute increments. 98925-98929 Osteopathic Manipulative Treatment Procedures Reported for the application of manual manipulation to improve somatic and related disorders. Code selection is based on the number of body regions manipulated. AMCA, Medical Coder and Biller Certification Study Guide (MCBC) This document is the property of the AMCA. The document and any of its contents cannot be reproduced, shared or disseminated for any reason without written consent of the AMCA. © 98940-98943 Chiropractic Manipulative Treatment Procedures Chiropractic manipulative treatment (CMT) is a form of manual treatment to influence joint and neurophysiological function. This treatment may be accomplished using a variety of techniques. 98960-98962 Education and Training for Patient Self-Management Reported for educational and training service prescribed by a physician or other qualified health care professional and provided by a qualified, nonphysician health care professional using a standardize curriculum to an individual or group of patients for the treatment of established illness or disease or to delay comorbidities. 98966-98968 Non-Face-to-Face Nonphysician Services Reported for telephone services provided to an established patient, parent or guardian, and online medical evaluation. 99000-99091 Special Services, Procedures and Reports Reported for special services, procedures, and reports (not elsewhere classified in the CPT). Code 99000 is reported for transfer of a laboratory specimen from a provider's office to a laboratory. For transfer of a specimen from the patient in a site other than a provider's office 99001. 99100-99140 Qualifying Circumstances for Anesthesia Many anesthesia services are provided under particularly difficult circumstances, depending on factors such as extraordinary conditions, and or unusual risk factors. These anesthesia ‘modifiers’ list 4 add-on codes that indicate the circumstance that significantly affect the character of the anesthesia service provided. 99151-99157 Moderate (Conscious) Sedation Reported for a drug induced depression of consciousness that requires no interventions o maintain airway patency of ventilation. Moderate conscious sedation is the administration of a moderate sedation or analgesia which result in drug induced depression of consciousness. The codes are not used to report administration of medications for pain control, minimal sedation, deep sedation, or monitored anesthesia care (00100-01999). 99170-99199 Other Medicine Services and Procedures Reported for services and procedures that cannot be classified in another subsection of the Medicine section (hypothermia treatment). 99500-99602 Home Health Procedures and Services Reported by nonphysician healthcare professionals who perform procedures and provide services to the patient at their residence (patient’s home, assisted living, or group home). AMCA, Medical Coder and Biller Certification Study Guide (MCBC) This document is the property of the AMCA. The document and any of its contents cannot be reproduced, shared or disseminated for any reason without written consent of the AMCA. © 99605-99607 Medication Therapy Management Services Reported when a pharmacist provides individual management of medication therapy with assessment and intervention. Medication therapy management service (MTMS) describe a face- to-face patient assessment and intervention as appropriate by a pharmacist, upon request. 2.08 Modifiers Modifiers are essential to Billers/Coders, as they are a communication to payers that indicate the service or procedure has been altered, without changing the description of the code itself. Modifiers allow healthcare professionals to provide more information describing the encounter to ensure and maximize reimbursement. Listings of modifiers can be found on the front cover page of the CPT Level l coding manual. There you will find a quick ‘at a glance’ view of the CPT Level 2 Modifiers with a small listing of HCPCS modifiers commonly used for CPT services procedures. Appendix A of the CPT manual provides a complete listing of Level I CPT Modifiers and descriptions. It is important to become familiar with Modifiers and how they are used. Modifiers can be used to indicate many circumstances, including: Report Technical and Professional Components of a Service A Decision was surgery was made during and E/M Service was for Pre/Post/Surgery only Service was Discontinued due to circumstances that threaten the well-being of patient Service was Reduced at the Physician’s discretion Procedure was performed Bilaterally Service provided is increased Modifiers are placed in Field 24d of the CMS 1500 claim form. More than one modifier can be reported. In fact, as many that fit the circumstance of the encounter should be reported. It should be considered that third party payers have different instructions for the use of modifiers. Billers should be aware of the modifier instructions used for the Payer claims are submitted to. When more than one modifier is reported, the modifier that most affect pricing should be reported first. 2.09 CPT Category II codes Category II Codes contain a set of supplemental tracking codes that can be used for performance measurement. It is anticipated that the use of Category II codes for performance measurement will decrease the need for record abstraction and chart review and thereby minimize administrative burden on physician other healthcare professional hospitals and entities seeking to measure the quality of patient care. This care is not required for coding and describe clinical components that may be included in evaluation and management services Category II CPT Codes have been developed for nine clinical conditions (including complete performance measurements sets) and five screening measures. AMCA, Medical Coder and Biller Certification Study Guide (MCBC) This document is the property of the AMCA. The document and any of its contents cannot be reproduced, shared or disseminated for any reason without written consent of the AMCA. © These codes are grouped within categories based on established clinical documentation methods (e.g., history, physical findings, assessment, plan). Each code identifies the specific clinical condition and performance measured. The categories are defined as follows: Category II CPT Codes are used for reporting purposes only and therefore do not have values assigned on the Medicare physician fee schedule (Resource-Based Relative Value Scale or RBRVS). The reporting of Category II CPT Codes is optional, and these codes are not used in place of Category I CPT Codes. As a result, these codes should not be sent on the CMS 1500 form for fee-for-service reimbursement. However, these codes may be beneficial to a practice because they allow internal monitoring of performance, patient compliance and outcomes and may be needed for Payer Incentivized Programs. 2.10 CPT Category III codes Category III contains a set of temporary codes for emerging technology, services, and procedures. Category III codes are 4 numerical digits followed by T: Temporary codes are intended to support the wide utilization and data collection, with and/or without reimbursement, and are required for AMA approval of Category 1 codes. Many commercial Payers typically wait until codes have Category I approval to begin reimbursement. Category III codes allow data collection for these services or procedures. Use of unlisted codes (Category I at the end of each subsection codes ending in 99; Ex: 60699 Unlisted procedure, endocrine system) does not offer the opportunity for the collection of specific data. If a Category III code is available, this code must be reported instead of a Category I unlisted code. Should a Category 1 unlisted service be assigned, a special report must be provided to the payer that indicates the pertinent information and should include an adequate definition or description the nature, extent, and need for the procedure, along with the time, effort, and equipment necessary to provide the service. This is an activity that is critically important in the evaluation of health care delivery and the formation of public and private policy. The use of the codes in this section allows physicians and other qualified health care professionals, insurers, health services researchers, and health policy experts to identify emerging technology, services, and procedures for clinical efficacy, utilization, and outcomes. These codes are intended to be used for data collection to substantiate widespread usage or to provide documentation for the Food and Drug Administration (FDA) approval process. Codes in this section may eventually receive a Category I CPT code. In general, a given Category III code will be archived five years from the date of initial publication or extension unless a modification of the archival date is specifically noted at the time of a revision or change to a code (e.g., addition of parenthetical instructions, reinstatement). As the development of new procedures and technologies emerge, temporary codes are assigned as additional codes to tract their usage and see whether the procedure can be considered for a permanent code (Category I) in the upcoming year. The CPT Category III codes AMCA, Medical Coder and Biller Certification Study Guide (MCBC) This document is the property of the AMCA. The document and any of its contents cannot be reproduced, shared or disseminated for any reason without written consent of the AMCA. © may not conform to one or more of the following CPT Category I code requirements: All devices and drugs necessary for performance of the procedure or service have received FDA clearance or approval when such is required for performance of the procedure or service. The procedure or service is performed by many physicians or other qualified health care professionals across the United States. The procedure or service is performed with frequency consistent with the intended clinical use (i.e., a service for a common condition should have high volume, whereas a service commonly performed for a rare condition may have low volume). The procedure or service is consistent with current medical practice. The clinical efficacy of the procedure or service is documented in literature that meets the requirements set forth in the CPT code change application 2.11 HCPCS level II codes HCPCS pronounced ‘Hick-picks' stand for the Healthcare Common Procedure Coding System. This system is a uniform method maintained by the Centers for Medicare and Medicaid Services. It reports professional services, procedures, supplies and equipment not listed in the CPT coding manual. HCPCS has two levels of code Level I: CPT Codes: These include Category I, II, III codes in addition to Appendix A-P. Level I and CPT codes are synonymous. When asked to assign a level I Code, the coder will automatically refer to their CPT coding manual. Level II: HCPCS National Codes: Level II Codes are required for reporting most medical services and supplies provided to Medicare and Medicaid patients and by most commercial payers. National Level II Codes are maintained by the HCPCS National Panel which include Blue Cross Blue Shield (BCBS) the Health Insurance Association of America (HIAA), and CMS. These national codes provide a standardized coding system that provides a set of uniform codes. CMS is responsible for the maintenance of HCPCS codes which include: Meeting the operational needs of Medicare/Medicaid Coordinate with government programs by a uniform application of CMS policies Allow providers and suppliers to communicate their services in a consistent manner Ensure the validity of profiles and fee schedules through standardization of such code Enhance medical education and research by providing a vehicle for local regional and national cost comparison AMCA, Medical Coder and Biller Certification Study Guide (MCBC) This document is the property of the AMCA. The document and any of its contents cannot be reproduced, shared or disseminated for any reason without written consent of the AMCA. © HCPCS Level II codes are organized by type depending on the purpose of the codes. The four types are: Permanent National Code: These Permanent codes are maintained by the CMS Workgroup and are responsible for making unanimous decisions about additions, revisions, and deletions to the permanent national alphanumeric codes. Miscellaneous Codes: These codes include miscellaneous and not otherwise specified codes that are reported when a DMEPOS Dealer submits a claim for a product or service for which there is not an existing HCPCS code. With miscellaneous codes DMEPOS dealers can submit a claim for the product or service as soon as it is approved by the Food and Drug Administration (FDA). Claims containing miscellaneous codes are manually reviewed and must include, completer description of the product/service, pricing information, supporting documentation that explains why the service is necessary. Temporary Codes: These codes allow payers the flexibility to establish codes that are needed before the next Jan. 1 annual update. Although, the HCPCS National Panel may decide to replace temporary codes with permanent codes, if permanent cares are not established, they may remain temporary indefinitely. Categories of Temporary codes include the following: G-codes identify professional healthcare procedures and services that do not have codes in CPT; used for all payers. H-codes are reported to state Medicaid agencies are mandated by the state law to establish separate codes identifying mental health services. K-codes are reported to MAC’s when existing permanent codes do not include codes needed to implement a medical review coverage policy. Q-codes identify services that would not ordinarily be assigned a CPT Code (e.g., medical equipment and services). S-codes are used when no HCPCS Level II codes exist to report drugs, services and supplies but are needed to implement private payer policies and programs for claims processing. Modifiers: HCPCS Modifiers are identified with two alphabetic or alpha-numeric codes added to the CPT level I or Level II codes Modifiers are listed inside the front and back covers or as a separate appendix depending on the publisher. These modifiers provide how the reporting physician or provider can indicate that a