Week 5 Medical Assistant Chap 45-48: Basics of Health Insurance and the Health Insurance Claim; Basics of Procedural and Diagnostic Coding; Financial Management
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348 Terms
What was the first comprehensive disease classification system published in the U.S.?
The American Nomenclature of Disease in 1869.
What is the purpose of a coding system in medical care?
To standardize information and facilitate its use by computers.
What does HCPCS stand for?
Healthcare Common Procedure Coding System.
What are the two levels of HCPCS codes?
Level I (CPT codes) and Level II (additional codes for procedures, injections, and durable medical equipment).
When was the first edition of the Current Procedural Terminology (CPT) system published?
In 1966.
What percentage of HCPCS Level I codes are used for Medicare Part B?
95%-98%.
What is the main use of procedure codes in medical coding?
To justify medical services and collect statistics about treatment outcomes.
What is the significance of Relative Value Units (RVUs) in CPT coding?
RVUs quantify the amount of physician labor, resources, and expertise needed for a service.
How many sections is the CPT Manual divided into?
Six sections.
What is the range of codes for the Evaluation and Management section in the CPT Manual?
99201-99499.
What does a new code symbol () indicate in the CPT Manual?
The code has been added since the last edition.
What does the revised code symbol () indicate?
The code has been changed since the last edition.
What does the modifier exempt symbol () signify?
The code cannot be used with modifier -51 (multiple procedures).
What is an add-on code () in the CPT Manual?
A code that must be used with another code and cannot be used with modifier -51.
What is the purpose of the CPT Manual?
To provide narrative descriptions and five-digit codes for procedures or services.
What is required to support the need for any procedure performed?
Documentation of a diagnosis in the medical record.
What is the role of HCPCS Level II codes?
To provide additional codes for procedures, injections, and durable medical equipment covered by Medicare Part B.
When was the fourth edition of the HCPCS first published?
In 1977.
What is the primary focus of the CPT system?
Primarily surgical procedures.
What does the term 'abate' mean in the context of medical coding?
To reduce or lessen, often referring to the frequency or complexity of procedures.
What is the significance of the CPT coding system for insurance billing?
It became the standard for insurance billing in the 1980s.
What does the term 'abduct' refer to in medical terminology?
To take by force, often used in the context of patient care or procedures.
What is the purpose of Category II Codes?
They are optional codes used to track performance and are not reported to insurance carriers.
What character denotes Category II Codes?
The last character is the letter 'F'.
What do Category III Codes represent?
They report services that represent emerging technology and consist of four digits followed by the letter 'T'.
How often are Category III Codes updated?
They are updated twice a year.
What is included in Appendix A of the CPT manual?
Modifiers.
What is a modifier in medical coding?
An addition to a procedure code indicating unusual circumstances related to the procedure.
What is the first step in looking up CPT codes?
Look up the procedure in the alphabetic index or online code system.
What factors should be considered when selecting a specific CPT code?
Location, size of lesion, method of performing the procedure, and complexity.
What are Evaluation and Management (E/M) codes used for?
They are used for service-oriented parts of medicine, such as patient examinations.
What primary factors determine the level of service for E/M codes?
Extent of history, extent of physical examination, and complexity of medical decision making.
What is a problem-focused history?
A brief history addressing the chief complaint.
What does a comprehensive history include?
Extended history of the current illness and review of all body systems, especially those related to the chief complaint.
What is the definition of anesthesia?
Administration of a medication that causes total or partial loss of sensation.
What are the three types of anesthesia?
General, regional, and local.
What does the surgical package include?
All services related to a surgery, including pre-operative and post-operative care.
What is the radiology section of the CPT manual?
It includes most standard radiologic procedures like CT scans and MRIs.
How are pathology and laboratory tests organized in the CPT manual?
By type of tests, panels, or assays.
What is the Healthcare Common Procedure Coding System (HCPCS) Level II used for?
It is used for Medicare and Medicaid, covering items and services not included in CPT codes.
What is the format of HCPCS Level II codes?
An alphanumeric format consisting of one letter followed by four digits.
What should be done if a procedure is performed infrequently?
The medical assistant should look up the code before entering the charge in the computer.
What is the significance of modifiers in anesthesia coding?
They relate specifically to patient condition when anesthesia is used.
What is the role of documentation in E/M coding?
It must support the level of service billed.
What is a detailed history in medical documentation?
It includes an extended history of the current illness and a review of most body systems.
What is the difference between stand-alone and indented CPT codes?
Stand-alone codes contain semicolons, while indented codes provide text to replace words after the semicolon.
What is the importance of the Tabular List in coding?
It helps choose the best code based on various factors about the procedure.
What is included in the surgical package regarding evaluation/management visits?
One evaluation/management visit that occurs after the decision for surgery has been made.
What is a Category II code?
Not reported to insurance carriers, found after main sections of CPT, and ends with the letter F.
What is a Category III code?
Consists of four digits followed by the letter T and is used to report services representing emerging technology.
What is the purpose of modifiers in CPT coding?
Modifiers indicate unusual circumstances related to a procedure.
What is the primary focus of Evaluation and Management (E/M) codes?
Codes for service-oriented parts of medicine, such as patient examinations.
What factors determine the correct E/M code?
Factors include whether the patient is new or established, type of service, and where the service was provided.
What is the difference between a problem-focused history and a comprehensive history?
A problem-focused history addresses the chief complaint, while a comprehensive history includes an extended history and review of all body systems.
What does a detailed physical examination include?
It includes the affected body system and other related body systems.
What is included in a surgical package?
All services related to a surgery, including preoperative and postoperative care.
What is the role of the radiology section in CPT coding?
It includes most standard radiologic procedures such as CT scans and MRIs.
How are pathology and laboratory tests organized in CPT?
By type of tests, panels, or assays.
What is a panel in laboratory coding?
A group of laboratory tests that are usually ordered together.
What should be considered when selecting an E/M code?
Coordination of care, counseling, nature of the patient's problem, and amount of time spent with the patient.
What is the significance of documentation in E/M coding?
Documentation must support the level of service billed.
What is the purpose of modifiers listed in Appendix A?
To provide additional information about the procedure code.
What does the term 'medical decision making' refer to?
The complexity of medical decisions made during patient care.
What are the four levels of medical decision making complexity?
Straightforward, low complexity, moderate complexity, and high complexity.
What does a comprehensive physical examination entail?
A multisystem or complete examination of the patient.
What is the role of the medical assistant in coding?
To review medical records and determine the correct E/M code.
What is the significance of the superbill?
It is used to check the correct E/M code and bill for services rendered.
What must be done if a procedure is performed infrequently?
The MD writes the name of the procedure on the superbill for lookup.
What is the purpose of the ICD-10-CM codes?
To provide a standardized coding system for diseases and health conditions.
What is the primary focus of the medicine section in CPT coding?
Codes for noninvasive diagnostic procedures and treatments.
What types of procedures are included in the medicine section?
Electrocardiograms, spirometry, and immunizations.
What modifier cannot be used with modifier -51?
Modifier -51 cannot be used with multiple procedures.
What does the code 97811 represent?
Acupuncture without electrical stimulation, each additional 15 minutes.
What does 'FDA approval pending' indicate?
The code is used for medications that have not yet received FDA approval.
What are Category II codes?
Codes not reported to insurance carriers, found after main sections of CPT, and used to track performance.
What are Category III codes used for?
To report services that represent emerging technology.
What is a problem-focused medical history?
A history that addresses the chief complaint and provides a brief history of the current illness.
What factors determine the correct Evaluation and Management (E/M) code?
New vs. established patient, type of service, and location of service.
What is the difference between a detailed history and a comprehensive history?
A detailed history includes an extended history of the current illness and review of most body systems, while a comprehensive history includes all body systems.
What types of anesthesia exist?
General, regional, and local anesthesia.
What is the significance of the Tabular List in CPT coding?
It is used to choose the best code based on factors about the procedure.
What is the purpose of the Healthcare Common Procedure Coding System (HCPCS) Level II codes?
To provide additional codes for equipment and services covered by Medicare that most insurance does not cover.
What is a comprehensive physical examination?
A multisystem or complete examination.
What is the primary factor determining the level of service in E/M coding?
The extent of the history and physical examination.
What does a low complexity medical decision making involve?
Usually one problem with low complexity.
What is a panel in laboratory testing?
A group of laboratory tests that are usually ordered together.
What does the code for blood specimen collection represent?
It is a specific code for blood specimen collection by venipuncture or capillary puncture.
What is the role of the superbill in medical coding?
It is used to record procedures performed and their corresponding codes.
What is the importance of reviewing guidelines at the beginning of the CPT manual?
To ensure correct coding based on specific procedures and circumstances.
What does 'synchronous telemedicine services' refer to?
CPT codes that may be used for real-time patient-provider interactions.
What is a straightforward medical decision making?
Involves usually one problem with low complexity.
What is the purpose of the appendices in the CPT manual?
To provide additional information and summaries related to coding.
What is the purpose of diagnosis coding?
To track diseases, classify causes of disease, collect data for research, and evaluate hospital service utilization.
When was the first edition of the International Classification of Diseases published?
In 1948.
Who manages the International Classification of Diseases?
The World Health Organization.
What are some new features of ICD-10-CM compared to ICD-9-CM?
More extensive information related to ambulatory care, an expansion of injury codes, new combination diagnosis and symptom codes, and added sixth and seventh digits for some conditions.
What are the two parts of the ICD-10-CM manual?
The Index and the Tabular List.
What does the first character of an ICD-10-CM code represent?
A letter indicating the category of the condition.
How many characters can a valid ICD-10-CM code have?
Up to 7 characters.
What is the purpose of Z codes in ICD-10-CM?
To indicate individuals who do not have a disease or injury, such as for immunizations.