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Billing and Coding
Chapter 5 Terms
| Question | Answer |
|---|---|
| Add-on code | Procedure that is performed and reported only in addition to a primary procedure; indicated in CPT by a plus sign (+). |
| Bundled payment | An experimental Medicare payment method by which an entire episode of care is paid for by a predetermined single payment. |
| bundling | Using a single procedure code that covers a group of related procedures. |
| Category I codes | Procedure codes found in the main body of CPT (Evaluation and Management, Anesthesia, Surgery, Pathology and Laboratory, Radiology, and Medicine). |
| Category II codes | Optional CPT codes that track performance measures for a medical goal such as reducing tobacco use. |
| Category III codes | Temporary codes for emerging technology, services, and procedures that are used instead of unlisted codes when available. |
| consultation | Service performed by a physician to advise a requesting physician about a patient’s condition and care; the consultant does not assume responsibility for the patient’s care and must send a written report back to the requestor. |
| Current Procedural Terminology (CPT) | Publication of the American Medical Association containing the HIPAA- mandated standardized classification system for reporting medical procedures and services performed by physicians. |
| Durable Medical Equipment (DME) | Medicare term for reusable physical supplies such as wheelchairs and hospital beds that are ordered by the provider for use in the home; reported with HCPCS Level II codes. |
| E/M codes (evaluation and management codes) | Procedure codes that cover physicians’ services performed to determine the optimum course for patient care; listed in the Evaluation and Management section of CPT. |
| Fragmented Billing | Incorrect billing practice in which procedures covered under a single bundled code are unbundled and separately reported. |
| Global period | The number of days surrounding a surgical procedure during which all services relating to the procedure—preoperative, during the surgery, and postoperative—are considered part of the surgical package and are not additionally reimbursed. |
| Global surgery rule (Surgical Package) | |
| Healthcare Common Procedural Coding System (HCPCS) | Procedure codes for Medicare claims, made up of CPT codes (Level I) and national codes (Level II). |
| Key component | Factor required to be documented for various levels of evaluation and management services. |
| Level II | HCPCS national codes. |
| Level II modifiers | HCPCS national code set modifiers. |
| modifiers | A number that is appended to a code to report particular facts. CPT modifiers report special circumstances involved with a procedure or service. HCPCS modifiers are often used to designate a body part, such as left side or right side. |
| Never event | Preventable medical error resulting in serious consequences for the patient; Medicare policy is never to pay the healthcare provider for these conditions. |
| Outpatient | A patient who receives healthcare in a hospital setting without admission; the length of stay is generally less than twenty-three hours. |
| Panel | In CPT, a single code grouping laboratory tests that are frequently done together. |
| Physical Status modifier | Code used in the Anesthesia Section of CPT with procedure codes to indicate the patient’s health status. |
| Primary Procedure | The most resource-intensive (highest paid) CPT procedure done during a patient’s encounter. |
| Professional Component (PC) | The part of the relative value associated with a procedure code that represents a physician’s skill, time,Page G-13 and expertise used in performing it; contrast with the technical component. |
| Resequenced | CPT procedure codes that have been reassigned to another sequence, or CPT range of codes. |
| Section guidelines | Usage notes provided at the beginnings of CPT sections. |
| Separate procedure | Descriptor used in the Surgery Section of CPT for a procedure that is usually part of a surgical package but may also be performed separately or for a different purpose, in which case it may be billed. |
| Special report | Note explaining the reasons for a new, variable, or unlisted procedure or service; describes the patient’s condition and justifies the procedure’s medical necessity. |
| Surgical package | Combination of services included in a single procedure code for some surgical procedures in CPT. |
| Technical Component (TC) | The part of the relative value associated with a procedure code that reflects the technician’s work and the equipment and supplies used in performing it; in contrast to the professional component. |
| Unbundling | The incorrect billing practice of breaking a panel or package of services/procedures into component parts and reporting them separately. |
| Unlisted procedure | A service that is not listed in CPT; it is reported with an unlisted procedure code and requires a special report when used. |
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t_talks
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