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Vocabulary > Main terms > Flashcards

Main terms Flashcards

1
Q

emergency department services, physician direction of advanced life support

A

emergency - cpt code 99288

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2
Q

intertochanteric femoral fracture (closed treatment)

A

fracture, femur, intertrochanteric, closed treatment - cpt code 27238

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3
Q

removal of gallbladder calculi by means of an open procedure

A

removal, caliculi (stone) - cpt code 47480

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4
Q

lung, bullae resection

A

resection, lung, bullae - cpt code 32141

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5
Q

providers are reimbursed for the procedures and services rendered based on what code

A

cpt/hcpcs

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6
Q

what organization first published the cpt coding system

A

AMA

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7
Q

a common, concise coding system is required by what law

A

HIPAA

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8
Q

name the box location on the CMS-1500 form for cpt/hcpcs codes

A

24D

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9
Q

what symbol indicates that the description for a code has changed

A

triangle

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10
Q

what appendix are modifiers located in

A

six

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11
Q

how many sections are in the cpt manual

A

six

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12
Q

guidelines that are applicable to all codes are found at the beginning of what

A

each section

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13
Q

before assigning an indented code, refer to the preceding

A

stand-alone

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14
Q

what appendix are clinical examples located in

A

appendix C

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15
Q

a procedure or service not found in the cpt manual may be coded as what

A

unlisted procedure

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16
Q

reporting a category III code requires a

A

special report

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17
Q

what type of cpt codes have 4 numbers followed by a letter

A

category III codes

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18
Q

single codes displayed in the cpt index should be verified in the _______portion of the cpt manual to ensure accuracy

A

tabular

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19
Q

coding system devloped by the american medical association

A

CPT

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20
Q

special guides that help the coder compare codes and descriptors with the previous edition of cpt

A

symbols

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21
Q

provides specific instruction about coding for each section of the cpt manual

A

guidelines

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22
Q

supplemental codes used for performance measurements

A

category II

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23
Q

temporary cpt codes

A

category III

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24
Q

existing from birth

A

congenital

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25
Q

period of time a surgical procedure is being performed

A

intraoperative

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26
Q

after childbirth

A

postpartum

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27
Q

pertaining to the cervix of the uterus

A

cervical

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28
Q

expansion of the cervix

A

dilation

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29
Q

the perinatal period starts before birth through how many days after birth

A

28 days

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30
Q

exclude and include notes are only referenced where

A

tabular

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31
Q

pressure ulcers are graded and reported based on the stage of the ulcer and

A

depth

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32
Q

when a disease is documented as a portion of the bone at the joint, which site designation should be reported

A

bone

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33
Q

fx due to a bone disease

A

pathological fx

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34
Q

concentration of mineral salts also known as a stone

A

calculus

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35
Q

what main term in the index should you lacate first to find teh causative organism

A

infection

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36
Q

when a pt presents for management of anemia associated with a malignancy and the encounter is for the anemia only, what is sequenced as the primary dx for this encounter

A

malignancy

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37
Q

name 2 types of anemia due to blood loss located as subterms in the index

A

chronic and acute

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38
Q

whay type of code is applied for dementia with parkinsonism

A

combination code

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39
Q

new tumor growth that can be benign or malignant

A

neoplasm

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40
Q

study of the structures, composition, and function of the tissues

A

histology

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41
Q

infalmmatory condition in response to microorganisms in the tissue, blood, lungs, skin, or urinary system

A

sepsis

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42
Q

medical condition that is present in conjunction with another medical condition, potentially hidden at first

A

underlying condition

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43
Q

what condition is reported as the first listed diagnosis when otitis media is the result of an underlying disease

A

underlying desease

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44
Q

2 codes are required for reporting secondary HTN, sequencing of these codes is based on what?

A

reason for the encounter

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45
Q

causative organism is also known as etiology, what is the disease process also described as

A

manifestation

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46
Q

a dash (-) at the end of an alphabetic index entry indicates what requirement

A

additional characters

47
Q

instructional notes are included in what list

A

tabular

48
Q

section IV of the ICD-10 official guidelines for coding and reporting is for what type of coding

A

outpatient

49
Q

dehydration with pneumonia is not considered an ______ part of a disease process

A

integral

50
Q

when a code first note is indicated and the patient has an underlying condition documented, which is listed as teh principle or first list diagnosis

A

underlying condition

51
Q

when a condition is described as both acute and chronic with separate subentries in the alphabetic index at the same indention level, which is coded first

A

acute

52
Q

when one code can identify 2 diagnoses or a diagnosis with an associated complication it is considered what type of code

A

combination

53
Q

what type of diagnosis codes do you report when the acute phase of an illness or injury has passed but residual remains

A

late effects

54
Q

laterality refers to what type of organs

A

paired

55
Q

use of more than one ICD 10 code to fully describe a condition

A

multiple coding

56
Q

single ICD 10 code used to classify 2 diagnoses

A

combination code

57
Q

sudden onset and short duration

A

acute

58
Q

a condition that follows an illness

A

sequela

59
Q

occuring on 2 sides

A

bilateral

60
Q

in the outpatient setting, the term first listed diagnosis is used in lieu of what diagnosis

A

principle

61
Q

what diagnosis is used when the documented condition is not confirmed in the oupatient setting

A

signs and symptoms

62
Q

what is the first listed diagnosis when a patient presents for outpatient surgery

A

reason for surgery

63
Q

is is important to code all the conditions or problems that are being managed during an encounter to support what

A

data integrity

64
Q

z codes are used more frequently in what setting

A

outpatient

65
Q

what 2 code categories are used to report the 1st listed diagnosis for medical observation for suspected conditions and conditions ruled out

A

Z03 and Z04

66
Q

additional diagnosis codes are used to report what conditions

A

coexisting

67
Q

in what setting are uncertain diagnoses reported

A

inpatient

68
Q

what type of condition may be reported as many times as the patient receives care or treatment for

A

chronic

69
Q

what code is assigned for encounters for routine lab/radiology testing in the absence of any signs, symptoms, or associated diagnosis

A

Z01.89 - encounter for other specified special examinations

70
Q

when the primary reason for therapeutic services is chemotherapy or radiation therapy, what code category is assigned as the first listed diagnosis

A

Z codes

71
Q

what code is assigned as an additional diagnosis for patients receiving preoperative evaluations

A

condition that describes the reason for the surgery

72
Q

for routine outpatient prenatal visits when no complications are present, what code category is assigned

A

Z34

73
Q

when the postoperative diagnosis is different than the preoperative diagnosis at the time the diagnosis is confirmed, which diagnosis is reported

A

postoperative diagnosis

74
Q

type of codes used to classify persons who are not currently sick

A

Z codes

75
Q

section of the official guidelines for coding and reporting that includes selection of principal diagnosis for non outpatient settings

A

section II

76
Q

assigned to indicate a patient has the sequelae or residual of a past disease or condition

A

status code

77
Q

classification of health condition due to external cause, never reported as a first listed diagnosis

A

external cause code

78
Q

a diagnosis that is documented at the time of discharge as probable, suspected, possible or rule out are what

A

uncertain diagnosis

79
Q

how many alphanumeric positions do level II codes hold

A

5

80
Q

what code grouping reports temporary codes assigned by CMS

A

Q codes

81
Q

what code group is use by state medicaid agencies

A

T codes

82
Q

where are level II modifers found in the HCPCS manual

A

after the table of drugs section or preceding the A codes

83
Q

what name are J codes referred to in the table of drugs

A

generic

84
Q

which A code would you report for a surgical tray

A

A4550

85
Q

collection of codes that represents procedures, supplies, products, and services

A

HCPCS healthcare common procedure coding system

86
Q

codes no longer available since the implementation of HIPAA

A

level III or local codes

87
Q

reported when no existing level II code adequately describes the service or item being billed

A

miscelaneous codes

88
Q

introduction of fluid into a tissue, vessel, or cavity

A

injection

89
Q

equipment used by a patient with a chronic disabling condition

A

DME

90
Q

what part of the cpt manual lists a full description for all modifiers

A

appendix A

91
Q

when a cpt code does not fully explain an unusual procedure, what should be added to the code

A

modifier

92
Q

what a modifier is applied to a surgical procedure to indicate increased physician work was performed

A

-22

93
Q

what modifier is applied to indicate a service for which general anesthesia was used when normally normally local anesthesia would be iundicated

A

-23

94
Q

what modifier is applied to indicate and E&M encounter was performed and not related to a current global period

A

-24

95
Q

when a pt comes into the office twice in one day for different medical reasons, the -25 modifier should be applied to which visit

A

second E&M

96
Q

what modifier indictes the professional component of a diagnostic test

A

-26

97
Q

third-party payers require this modifier for a mandated service

A

-32

98
Q

modifier -33 indicates a covered preventive service, what organization grades preventive services

A

US preventative services task force (USPSTF)

99
Q

modifier -47 anesthesia by the surgeon, is never added to what cpt code

A

anesthesia codes

100
Q

how many units of service may be billed when reporting the -50 modifier to medicare

A

one unit

101
Q

when reporting -51 modifier to indicate multiple procedures performed, which procedure should be reported first on the claim

A

primary procedure

102
Q

some payers may decrease thepayment on a procedure when this modifier is applied

A

-52

103
Q

modifier -53, discontinued procedure, is never reported with E&M codes or codes based on what

A

time

104
Q

when the surgeon transfers postoperative care to another physician, report with what modifier

A

-54

105
Q

modifier -55 is used for services provided to the pt after what disposition

A

discharge from the hospital

106
Q

medicare considers what service to be part of the surgery and bundled payment not allowing the -56 modifier

A

preoperative

107
Q

E/M services provided the day before or the day of a major surgery are included in what package

A

global days

108
Q

a planned procedure intended to include the original procedure plus one or more subsequent procedures is indicated by what modifier

A

-58

109
Q

modifier -59 is applicable to all cpt codes except what type of codes

A

E/M codes and weekly radiation management

110
Q

period of time a surgical procedure is being performed

A

intraoperative

111
Q

inform third party payers of circumstances that may affect the way payment is made

A

modifiers

112
Q

describing a physicians services in radiology or pathology

A

professional component

113
Q

describing the services provided by the facility

A

technical component

114
Q

bundling together of time, effort, and services for a specific procedure into one code instead of reporting each component separately

A

surgical package

Vocabulary (13 decks)

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