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CPT and ICD Coding
Business Practice Coding Exams
| Question | Answer |
|---|---|
| WHAT IS THE ABBREVIATION FOR CPT Sections | A SPIDER RAN PAST ME Ewww |
| A spider ran past me ewww stands for | anesthesia, surgery, radiology, path/lab, medication, eval and management |
| ICD Code Breakdown | first 3=category, 4=etiology, 5=severity, 6=anatomical position, 7=duration |
| what factors determine the level of service for lacerations | anatomical location, type of laceration (cm), severity of repair |
| what factors determine the level of service for burns | degree of burn, body surface area, agent |
| what factors determine the level of service for fractures | is it closed or open, manipulation |
| what do you need in order to determine the level of service for doctors visits | POS, TOS, PATIENT STATUS |
| ICD ( International Classification of Diseases) is the same as | American nomenclature of disease |
| The CPT manual is broken into | 2 volumes |
| volume 1 of the CPT book is | tabular list (description) |
| volume 2 of the CPT book is | instruction manual (index) |
| updates or changes to the CPT manual take place | every January |
| an automated system that uses language processing software and can assign codes to clinical procedures and services is called | computer assisted coding (CAC) |
| for coding purposes, the definition of new patient is | one who has not received any professional services from physician, or another physician of same specialty who belongs to the same group practice in the past 3 years |
| explain the difference between a consult and a patient referral | consult: gives (2nd opinion) regarding a condition or need for surgery and may initiate diagnostic or therapeutic services Referral; the transfer of the total or specific care of a patient from one physician to another |
| CPT Symbols= plus sign, dark dot, dark triangle | add-on code, new code, revised code |
| in what section of CPT are office visits and hospital visits found? | E/M Section |
| To code from the evaluation and management (E/M) section of CPT, what three things must be determined | POS, TOS, Patient Status |
| when coding lesion removals on male or female genitalia, always select codes from the integumentary subsection of the surgery section in CPT | False |
| the documentation required in a patient medical record when an injection is given includes the following | record name of the med, amount of substance to be injected (cubic cm, grams, units), the lot number from the bottle, route and site |
| A two-digit code used in addition to the procedure code to indicate circumstances in which the procedure differs in some way from that described is called | a modifier |
| A five digit code that can't stand alone but is designed to be used with primary procedure codes, known as "parent codes" are | add-on codes |
| the first classification of causes of death was introduced by the French physician Jacques Bertillon in the year | 1893 |
| what was the compliance implementation date for using ICD-10-CM codes | 2013 |
| what does computerized assisted coding use to read and analyze the medical record | natural language intelligence, and clinical language intelligence |
| what guidelines does the medical assistant need to become familiar with to assign correct diagnostic codes | ICD-10 |
| each service performed needs to be linked to a reason why it was done. (connects procedure codes to diagnostic codes) | Code Linkage |
| what is the abbreviation for the coding edits that were implemented by the Centers for Medicare and Medicaid Services (CMS) to promote correct coding and control inappropriate reimbursement | NCCI (National Correct Coding Initiative) |
| NCCI (National Correct Coding Initiative) | inappropriate reimbursement |
| A single code used to describe two diagnoses is called a | |
| qualified diagnosis | a code that is set and qualified for use based on codes like signs, symptoms, abnormal test results, or other reasons for the encounter. You would not code instead rule out, suspects, suspicion, likely probable as a diagnosis |
| NEC | not-elsewhere classifiable, can't find the right description to code diagnosis |
| NOS | not-otherwise specified, not enough clinical evidence to code diagnosis |
| when coding an underlying cause of a disease, along with the disease that resulted you would follow what rule? | etiology and manifestation rule |
| what is coded first according to the etiology and manifestation rule | underlying condition (etiology)=cause |
| what is coded second according to the etiology and manifestation rule | manifestations (disease that resulted) =effect |
| to caode diagnoses, you must start where an go where to verify | start in volume 2 and then go to volume 1 to verify |
| Diagnotic codes using ICD-10-CM can vary from what to what digits | 3 to 7 digits |
| "x" used in the fourth, fifth, or sixth digit with certain character codes to allow for future expansion is call ed a | place holder |
| primary malignant | original site of tumor |
| secondary malignant | additional tumor that appears at site of metastasize |
| carcinoma in citu | a tumor that is localized or confined to site of origin |
| neoplasm uncertain behaviour | properties of tumor is not recognized as benign or malignant , status of tumor not documented by MD or pathologist |
| unspecified neoplasm | monitor a skin tag or area to see if it is benign, malignant, etc |
| routine postoperative pain should not be coded | true |
| a coding compliance program is | voluntary |
| CPT codes are revised each | January |
| care of an unstable, acutely ill, or injured patient requiring constant bedside attention by a physician is referred to as | critical care |
| The "three R's" to remember when coding consultation services are | request, record, and report |
| consultation codes are no longer used by | medicare |
| how many sections are there in CPT | 6 |
| when coding evaluation and management services, first determine | place of service, type of service, patient status |
| three key components needed to code evaluation and management services are | history, physical examination, medical decision making |
| when coding from the surgery section of CPT, the first thing you should do is | go to the index |
| according to CPT, a surgical package | includes the operation, certain types of anesthesia, and normal uncomplicated postoperative care within designated follow-up days |
| the sums of multiple laceration repairs can be added together if | they are in the same body area, as defined in CPT and the are the same "type" of wound |
| in CPT, descriptions for "indented codes" always relate back to the | parent code |
| starting at the beginning of the following subsections in the surgery section, codes are arranged by | anatomic site |
| ICD-10-CM has replaced ICD-9-CM on | October 1st, 2013 or 2015 |
| coexisting medical conditions are referred to as | comorbidity |
| when coding diagnoses, start by looking | in volume 2 |
| in an inpatient setting, the condition established after study that prompted the hospitalization is called the | primary diagnosis , first-listed diagnosis |
| checking a diagnostic code against a procedure code to ensure medical necessity is referred to as | code linkage |
| when a single code exists that can classify two diagnoses, a diagnosis with a secondary process, or a diagnosis with an associated complication, it is referred to as a | double code |
| a qualified diagnosis is a | condition coded as if it existed but has not been proven |
| all categories in ICD-10-CM | have 3 alphanumeric digits |
| tables listed in ICD-10-CM are | neoplasm table and table of drugs and chemicals |
| when a patient presents with influenza, the type of flu documented in the medical record | does not have to be verified by positive laboratory serology |
| if documentation in a patients medical record does not state "open fracture" code it as | closed |
| burns are classified by | depth, extent, agent |
| a disease or condition that has a rapid onset and a short severe course is said to be | acute |
| a disease or condition that progresses slowly and has a long duration is said to be | chronic |
| a disease or condition that develops more slowly than acute but more rapidly then chronic condition | sub-acute |
| a correlating procedure found in the same section would be called a | code bundle |
| consultation codes | not used by medicare , medicare uses time intervals for appointments |
| v,w,x,y,z | external morbidities |
| wellness diagnostic code | z |
Created by:
shosho1994
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