B&C Chapter 7: CPT Coding

Question 1

care plan oversight services

Answer 1

cover the provider’s time supervising a complex and multidisciplinary care treatment program for a specific patient who is under the care of a home health agency, hospice, or nursing facility.

Question 2

case management services

Answer 2

process by which an attending physician coordinates and supervises care provided to a patient by other providers.

Question 3

Category I codes

Answer 3

procedures/services identified by a five-digit CPT code and descriptor nomenclature; these codes are traditionally associated with CPT and organized within six sections.

Question 4

Category II codes

Answer 4

optional evidence-based performance measurement tracking codes that are assigned an alphanumeric identifier with a letter in the last field (e.g., 1234A); these codes will be located after the Medicine section; their use is optional.

Question 5

Category III codes

Answer 5

temporary codes for data collection purposes that are assigned an alphanumeric identifier with a letter in the last field (e.g., 0075T)

Question 6

comprehensive assessment

Answer 6

must include an assessment of the patient’s functional capacity, identification of potential problems, and a nursing plan to enhance, or at least maintain, the patient’s physical and psychosocial functions.

Question 7

concurrent care

Answer 7

provision of similar services, such as hospital inpatient visits, to the same patient by more than one provider on the same day.

Question 8

consultation

Answer 8

examination of a patient by a health care provider, usually a specialist, for the purpose of advising the referring or attending physician in the evaluation and/or management of a specific problem with a known diagnosis.

Question 9

contributory components

Answer 9

include counseling, coordination of care, nature of presenting problem, and time.

Question 10

coordination of care

Answer 10

provider makes arrangements with other providers or agencies for services to be provided to a patient.

Question 11

counseling

Answer 11

discussion with a patient and/or family concerning one or more of the following areas: diagnostic results, impressions, and/or recommended diagnostic studies; prognosis; risks and benefits of management (treatment) options; instructions for management (treatment) and/or follow-up; importance of compliance with chosen management (treatment) options; risk factor reduction; and patient and family education.

Question 12

boldface type

Answer 12

highlights main terms in the CPT index and categories, subcategories, headings, and code numbers in the CPT manual.

Question 13

cross-reference terms (See, See also)

Answer 13

direct coders to a different CPT index entry because no codes are found under the original entry.

Question 14

descriptive qualifier

Answer 14

terms that clarify assignment of a CPT code.

Question 15

guidelines

Answer 15

define terms and explain the assignment of codes for procedures and services located in a particular section.

Question 16

inferred words

Answer 16

used to save space in the CPT index when referencing subterms.

Question 17

instructional notes

Answer 17

appear throughout CPT sections to clarify the assignment of codes.

Question 18

italicized type

Answer 18

used for the cross-reference term, See, in the CPT index.

Question 19

bullet symbol

Answer 19

bullet located to the left of a code number identifies new CPT procedures and services.

Question 20

triangle symbol

Answer 20

triangle located to the left of a code number identifies a revised code description.

Question 21

horizontal triangles symbol

Answer 21

horizontal triangles surround revised guidelines and notes. This symbol is not used for revised code descriptions.

Question 22

semicolon

Answer 22

semicolon saves space in CPT so that some code descriptions are not printed in their entirety next to a code number; the entry is indented and the coder refers back to the common portion of the code description located before the semicolon.

Question 23

plus symbol

Answer 23

plus symbol identifies add-on codes for procedures that are commonly, but not always, performed at the same time and by the same surgeon as the primary procedure.

Question 24

forbidden (or prohibitory) symbol

Answer 24

forbidden symbol identifies codes that are not to be appended with modifier -51.

Question 25

flash symbol

Answer 25

indicates that a code is pending FDA approval but that it has been assigned a CPT code.

Question 26

number symbol

Answer 26

number symbol precedes CPT codes that appear out of numerical order.

Question 27

star symbol

Answer 27

star symbol precedes CPT codes that are reported for synchronous telemedicine services and require addition of modifier -95.

Question 28

green reference symbol

Answer 28

green reference symbol indicates that the coder should refer to the CPT Assistant monthly newsletter.

Question 29

blue reference symbol

Answer 29

blue reference symbol indicates that the coder should refer to the CPT Changes: An Insider’s View annual publication, which contains all coding changes for the current year.

Question 30

red reference symbol

Answer 30

red reference symbol indicates that the coder should refer to the Clinical Examples in Radiology quarterly newsletter.

Question 31

duplicate PLA symbol

Answer 31

PLA symbol identifies duplicate proprietary laboratory analyses (PLA) tests.

Question 32

double arrow symbol

Answer 32

double arrow symbol identifies CPT Category I PLA codes.

Question 33

critical care services

Answer 33

reported when a provider directly delivers medical care for a critically ill or critically injured patient.

Question 34

direct patient contact

Answer 34

refers to face-to-face patient contact (outpatient or inpatient).

Question 35

emergency department services

Answer 35

services provided in an organized, hospital-based facility, which is open on a 24-hour basis, for the purpose of “providing unscheduled episodic services to patients requiring immediate medical attention.”

Question 36

established patient

Answer 36

one who has received professional services from the provider, or from another provider of the same specialty who belongs to the same group practice, within the past three years.

Question 37

Evaluation and Management Documentation Guidelines

Answer 37

federal (CMS) guidelines that explain how E/M codes are assigned according to elements associated with comprehensive multisystem and single-system examinations.

Question 38

Evaluation and Management (E/M) section

Answer 38

located at the beginning of CPT because these codes describe services (e.g., office visits) that are most frequently provided by physicians and other health care practitioners (e.g., nurse practitioner, physician assistant).

Question 39

extent of examination (CPT)

Answer 39

includes comprehensive, detailed, expanded problem focused, and problem focused levels, based on physician documentation.

Question 40

comprehensive examination

Answer 40

general multisystem examination or a complete examination of a single organ system.

Question 41

detailed examination

Answer 41

extended examination of the affected body area(s) and other symptomatic or related organ system(s).

Question 42

expanded problem focused examination

Answer 42

limited examination of the affected body area or organ system and other symptomatic or related organ system(s).

Question 43

problem focused examination

Answer 43

limited examination of the affected body area or organ system.

Question 44

extent of history (CPT)

Answer 44

includes comprehensive, detailed, expanded problem focused, and problem focused levels, based on physician documentation.

Question 45

comprehensive history

Answer 45

chief complaint, extended history of present illness, review of systems directly related to the problem(s) identified in the history of the present illness, plus a review of all additional body systems and complete past/family/social history.

Question 46

detailed history

Answer 46

chief complaint, extended history of present illness, problem-pertinent system review extended to include a limited number of additional systems, pertinent past/family/social history directly related to patient’s problem.

Question 47

expanded problem focused history

Answer 47

chief complaint, brief history of present illness, problem-pertinent system review.

Question 48

problem focused history

Answer 48

chief complaint, brief history of present illness or problem.

Question 49

face-to-face time

Answer 49

amount of time the office or outpatient care provider spends with the patient and/or family.

Question 50

global period

Answer 50

includes all services related to a procedure during a period of time (e.g., 10 days, 30 days, 90 days, depending on payer guidelines).

Question 51

global surgery

Answer 51

also called package concept or surgical package; includes the procedure, local infiltration, metacarpal/digital block or tropical anesthesia when used, and normal, uncomplicated follow-up care.

Question 52

history

Answer 52

interview of the patient that includes the following components: history of the present illness (HPI) (including the patient’s chief complain), a review of systems (ROS), and a past/family/social history (PFSH).

Question 53

home services

Answer 53

health care services provided in a private residence.

Question 54

hospital discharge services

Answer 54

includes the final examination of the patient; discussion of the hospital stay with the patient and/or caregiver; instructions for continuing care provided to the patient and/or caregiver; and preparation of discharge records, prescriptions, and referral forms.

Question 55

indented code

Answer 55

CPT code that is indented below a stand-alone code, requiring the coder to refer back to the common portion of the code description that is located before the semicolon.

Question 56

initial hospital care

Answer 56

covers the first inpatient encounter the admitting/attending physician has with the patient for each admission.

Question 57

key components

Answer 57

extent of history, extent of examination, and complexity of medical decision making (except for Office or Other Outpatient Services).

Question 58

level of E/M service

Answer 58

use of last number of each CPT evaluation and management services code to represent level of service provided.

Question 59

medical decision making

Answer 59

refers to the complexity of establishing a diagnosis and/or selecting a management option as measured by the number of diagnoses or management options, amount and/or complexity of data to be reviewed, and risk of complications and/or morbidity or mortality.

Question 60

moderate (conscious) sedation

Answer 60

administration of moderate sedation or analgesia, which results in a drug-induced depression of consciousness.

Question 61

modifier

Answer 61

provide additional information about a procedure or service (e.g., left-sided procedure).

Question 62

monitored anesthesia care (MAC)

Answer 62

provision of local or regional anesthetic services with certain conscious-altering drugs when provided by a physician, anesthesiologist, or medically directed CRNA; monitored anesthesia care involved sufficiently monitoring the patient to anticipate the potential need for administration of general anesthesia, and it requires continuous evaluation of vital physiologic functions as well as recognition and treatment of adverse changes.

Question 63

multiple surgical procedures

Answer 63

two or more surgeries performed during the same operative session.

Question 64

nature of the presenting problem

Answer 64

defined by CPT as a disease, condition, illness, injury, symptom, sign, finding, complaint, or other reason for the encounter, with or without a diagnosis being established at the time of the encounter.

Question 65

new patient

Answer 65

one who has not received any professional services from a provider, of from another provider of the same specialty who belongs to the same group practice, within the past three years.

Question 66

newborn care

Answer 66

covers examinations of normal or high-risk neonates in the hospital or other locations, subsequent newborn care in a hospital, and resuscitation of high-risk babies.

Question 67

nursing facility services

Answer 67

performed at the following sites: skilled nursing facilities (SNFs), intermediate care facilities (ICFs), and long-term care facilities (LTCFs).

Question 68

observation or inpatient care services

Answer 68

CPT codes used to report observation or inpatient hospital care services provided to patients admitted and discharged on the same date of service.

Question 69

observation services

Answer 69

furnished in a hospital out-patient setting to determine whether further treatment or inpatient admission is needed; when a patient is placed under observation, the patient is categorized as an outpatient; if the duration of observation care is expected to be 24 hours or more, the physician must order an inpatient admission (and the date the physician orders the inpatient stay is the date of inpatient admission).

Question 70

organ- or disease-oriented panel

Answer 70

series of blood chemistry studies routinely ordered by providers at the same time to investigate a specific organ (e.g., liver panel) or disease (e.g., thyroid panel).

Question 71

partial hospitalization

Answer 71

short-term, intensive treatment program where individuals who are experiencing an acute episode of an illness (e.g., geriatric, psychiatric, or rehabilitative) can receive medically supervised treatment during a significant number of daytime or nighttime hours; this type of program is an alternative to 24-hour inpatient hospitalization and allows the patients to maintain their everyday lives without the disruption associated with an inpatient hospital stay.

Question 72

physical examination

Answer 72

assessment of the patient’s body areas (e.g., extremities) and organ systems (e.g., cardiovascular).

Question 73

physical status modifier

Answer 73

indicates the patient’s condition at the time anesthesia was administered.

Question 74

place of service (POS)

Answer 74

the physical location where health care is provided to patients (e.g., office or other outpatient settings, hospitals, nursing facilities, home health care, or emergency departments); the two-digit location code is required by Medicare.

Question 75

preoperative clearance

Answer 75

occurs when a surgeon requests that a specialist or other physician (e.g., general practice) examine a patient and gives an opinion as to whether that patient can withstand the expected risks of a specific surgery.

Question 76

preventive medicine services

Answer 76

routine examinations or risk management counseling for children and adults exhibiting no overt signs or symptoms of a disorder while presenting to the medical office for a preventive medical physical; also called “wellness visits.”

Question 77

professional component

Answer 77

supervision of procedure, interpretation, and writing of the report.

Question 78

prolonged services

Answer 78

assigned in addition to other E/M services when treatment exceeds by 30 minutes or more the time included in the CPT description of the service.

Question 79

qualifying circumstances

Answer 79

CPT Medicine Section codes reported in additional to Anesthesia Section codes when situations or circumstances make anesthesia administration more difficult (e.g., patient of extreme age, such as under one year or over 70).

Question 80

radiologic views

Answer 80

studies taken from different angles.

Question 81

referral

Answer 81

a patient who reports that another provider referred them.

Question 82

resequenced code

Answer 82

CPT codes that appear out of numerical order and are preceded by the # symbol (so as to provide direction to the out-of-sequence code).

Question 83

separate procedure

Answer 83

follows a CPT code description to identify procedures that are an integral part of another procedure or service.

Question 84

special report

Answer 84

must accompany the claim when a CPT unlisted procedure or service code is reported to describe the nature, extent, and need for the procedure or service.

Question 85

stand-alone code

Answer 85

CPT code that includes a complete description of the procedure or service.

Question 86

standby services

Answer 86

cover providers who spend prolonged periods of time without direct patient contact, until provider’s services are required.

Question 87

subsequent hospital care

Answer 87

includes review of patient’s chart for changes in the patient’s condition, the results of diagnostic studies, and/or reassessment of the patient’s condition since the last assessment performed by the physician.

Question 88

surgical package

Answer 88

see global surgery.

Question 89

technical component

Answer 89

use of equipment and supplies for services performed.

Question 90

telemedicine

Answer 90

provision of remote medical care an interactive audio and video telecommunications system that permits real-time communication between you, at the distant site, and the beneficiary, at the originating site; an alternative to in person face-to-face encounters.

Question 91

transfer of care

Answer 91

occurs when a physician who is managing some or all of a patient’s problems releases the patient to the care of another physician who is not providing consultative services.

Question 92

type of service (TOS)

Answer 92

refers to the kind of health care services provided to patients; a code required by Medicare to denote anesthesia services.

Question 93

unit/floor time

Answer 93

amount of time the provider spends at the patient’s bedside and managing the patient’s care on the unit or floor (e.g., writing orders for diagnostic tests or reviewing test results).

Question 94

unlisted procedure

Answer 94

also called unlisted service; assigned when the provider performs a procedure or service for which there is no CPT code.

Question 95

unlisted service

Answer 95

see unlisted procedure.