Chapter 25: Procedural and diagnostic coding

How often is the CPT manual updated?

Annually

Which appendix in the CPT manual lists deleted, revised, and added codes each year?

Appendix B

How many characters long are CPT codes?

5 characters

Which CPT code category includes the most common and widely used codes?

Category I

Category II CPT codes are primarily used for:

Performance management and tracking

Category III codes represent:

Temporary codes for emerging technologies

What symbol in the CPT manual indicates an add-on code?

+

Add-on codes in the CPT manual:

Are listed in Appendix D

What does Modifier 25 indicate?

A separately identifiable E/M service was provided on the same day as another procedure

When should Modifier 26 be used?

To report the professional component of radiology services

What must be included when submitting an unlisted procedure code?

A copy of the operative note

Which coding practice involves using multiple codes when one inclusive code exists?

Unbundling

Assigning a higher-level CPT code than documentation supports in order to increase reimbursement is called:

Upcoding

Which practice occurs when an insurer reduces a service level code strictly based on the diagnosis code reported?

Downcoding

When multiple specialists are caring for a hospitalized patient, this is called:

Concurrent care

What are the requirements for coding critical care?

At least 30 minutes of constant bedside attention, documented explicitly

The “three Rs” of consultation documentation are:

Request, Reason, Report

Counseling, as part of E/M services, may include:

Prognosis, treatment risks/benefits, and patient education

Which CPT codes are for Office or Other Outpatient E/M services effective January 1, 2021?

99202–99215

For CPT purposes, a new patient is one who:

Has not received services from a provider in the same specialty/subspecialty in the past 3 years

What are the key components of E/M coding?

History, examination, and medical decision making (MDM)

Which of the following is a contributory factor in E/M coding?

Time, counseling, and coordination of care

Which type of patient history includes a complete past, family, and social history plus a review of all body systems?

Comprehensive

A limited exam of the affected body area or organ system only is called:

Problem-focused exam

What is the minimum time requirement for critical care coding?

30 minutes

Counseling may be used to determine the E/M level if:

The physician spends at least 50% of the encounter on counseling/coordination of care

Which presenting problem is considered self-limited or minor?

Runs a definite course, transient, not likely to alter health status

Which level of MDM involves minimal diagnoses, minimal or no data, and minimal risk?

Straightforward

Craig W. Smith, a 35-year-old new patient, had a CPE (annual physical) and 1 skin tag removed. Which is correct?

99385-25, 11200

Jane Morgan, 67, an established patient, received an E/M sick visit, EKG, pulse ox, and flu vaccine with administration. Which is correct?

99213, 93000, 94760, Q2037, G0008

A surgical package usually includes all of the following except:

Hospital room and board

Which CPT code is used for total hip replacement (left side)?

27130-LT

27447-LT

22554

The integumentary system includes which of the following under CPT?

Skin, hair, nails, glands, and breast

Which CPT system section covers pacemaker insertion?

Cardiovascular

Coding fracture treatment assumes:

Casting and strapping are included

Which section includes codes for thyroidectomy?

Endocrine

Which CPT section uses modifiers 26 (professional component) and TC (technical component) most frequently?

Radiology

When coding for a diagnostic test or study, which of the following is correct?

A specific CPT code must be used in addition to the E/M code

What is the correct first step in assigning a CPT code?

Review the encounter form/progress note

Why should you never code directly from the CPT Alphabetic Index?

It contains incomplete descriptions

What is the purpose of a modifier in CPT coding?

Provide additional clarification about the procedure performed

A provider performed a CPE for a new PPO patient, a sick visit for a Medicare patient with nausea/vomiting, and a sick visit for an established PPO patient with a laceration requiring stitches. Which tool should be used to determine the correct CPT codes?

The CPT manual

Why were HCPCS Level II codes developed?

To report products, supplies, and services not included in CPT

What is the structure of a HCPCS Level II code?

Five alphanumeric characters

The correct process for finding a HCPCS Level II code is:

Start with the Alphabetic Index, then verify in the Tabular List

Which of the following is a HCPCS Level II code for basic life support ambulance service, emergency transport?

A0429

A patient received an influenza vaccine (fluviron) in the office. Which HCPCS Level II codes are correct?

G0008, Q2037

A Medicare patient receives a flu shot in the office. Which HCPCS Level II code is used for the administration of the vaccine?

G0008

Which HCPCS code range is used for Durable Medical Equipment (DME)?

E0100–E8002

Which code represents oxygen administration during ambulance transport?

A0422

Which HCPCS Level II section would include a breast prosthesis?

L5000–L9900

Which HCPCS code is for injection, adrenaline (epinephrine), 0.1 mg?

J0171

What does ICD-10-CM primarily code for in the U.S.?

Diseases and conditions presented by the patient

What is the purpose of ICD-10-CM codes on a claim?

To justify the medical necessity of services or procedures

Which of the following is the correct structure of an ICD-10-CM code?

Three to seven characters, using letters and numbers

What is the role of the seventh character in ICD-10-CM codes?

Indicates encounter type (e.g., initial, subsequent, sequela)

If a code requires a seventh character but has fewer than six characters, what must be used

Placeholder “X”

Which encounter does the seventh character “A” represent?

Initial encounter

How many chapters does the ICD-10-CM Tabular List contain?

21

In the ICD-10-CM manual, the Alphabetic Index contains all of the following EXCEPT:

CPT procedure descriptions

What does the abbreviation NOS stand for in ICD-10-CM coding?

Not Otherwise Specified

What does an “Excludes 1” note mean in ICD-10-CM?

Condition not coded here (mutually exclusive)

What does an “Excludes 2” note mean in ICD-10-CM?

The condition may be coded separately if present

What is the function of brackets [ ] in the Tabular List?

Enclose synonyms or explanatory phrases

Which abbreviation means “Not elsewhere classified”?

NEC

In ICD-10-CM, the instruction “Code Also” means:

An additional code may be required to fully describe the condition

What is the main difference between morbidity and mortality?

Morbidity is complications or disease frequency; mortality is death

What is the main rule for sequencing ICD-10-CM codes during an encounter?

Code the reason for the visit (primary diagnosis) first

When is the main coding rule (primary diagnosis first) NOT applied?

When a condition discovered after examination requires more effort than the original complaint

If a condition is documented as both acute and chronic, and both have subentries in the Alphabetic Index, how should it be coded?

Code both, sequencing the acute condition first

What is a combination code in ICD-10-CM?

A single code that captures two diagnoses, or a diagnosis with a manifestation/complication

Which of the following is an example of a combination code?

E11.321—Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy, with macular edema

What does CMS define as multiple coding?

Assigning more than one code to describe a single condition fully

When a combination code fully describes a diagnosis, how should multiple coding be used?

Do not use multiple coding

What does laterality in ICD-10-CM coding refer to?

The side of the body affected (left, right, bilateral)

If a condition is bilateral but no bilateral code exists, what should the coder do?

Assign separate codes for left and right

What should a coder do if the provider documents “rule out” without a definitive diagnosis?

Code only the symptoms documented

In the scenario where a patient presents with fever, chills, and shortness of breath, “rule out bacterial pneumonia,” what should be coded?

Fever (R50.9) and shortness of breath (R06.02)

How does Medicare define medical necessity under Title XVIII of the Social Security Act?

Services that are reasonable and necessary for diagnosis, treatment, or to improve a malformed body member

According to the AMA, which of the following is NOT part of medical necessity?

Services for the convenience of the patient, provider, or health plan

What is the main purpose of computer-assisted coding software?

To ensure accuracy and reduce claim denials

What feature do many encoder programs include to help coders select the most accurate code?

Decision support screens

What is “unbundling” in coding?

Reporting multiple codes when one inclusive code should be used

What is the practice of assigning a code that increases reimbursement but is not supported by documentation?

Upcoding

Which of the following best describes downcoding?

A payer or provider assigns a lower-level service code than what was documented

What is the penalty under the Stark Law for improper physician self-referrals (2019)?

$25,372 per claim

Which law imposes penalties of $102,522 per violation for kickbacks related to federal health care programs?

Federal Anti-Kickback Statute

Under the False Claims Act, what is the 2019 penalty for knowingly submitting false or fraudulent claims to the federal government?

$10,461 per claim

Under the False Claims Act, what is the penalty for making or using a false record related to a fraudulent claim?

$52,308

Why is documentation especially critical during a Medicare audit?

To provide evidence that services were appropriate and rendered

What phrase should coders remember when documenting patient encounters?

“If it is not documented, it was never done.”

Which of the following is NOT a required component of proper documentation?

Patient’s insurance copay