Chapter 25: Procedural and Diagnostic Coding

Question 1

Add-on codes

Answer 1

a code that is always assigned in addition to the primary procedure or service; codes are designated with the + symbol and are found in Appendix D of the CPT code book; they are never reported as a stand-alone code

Question 2

Alphabetic index

Answer 2

the index arranged in alphabetic order by disease (specific illness, injury, eponym abbreviation, or other descriptive diagnostic term); includes diagnostic terms for other reasons for the encounter.

Question 3

bundle

Answer 3

to “bundle” is the arbitrary practice of some insurance carriers to group codes together, by which they either ignore additional codes reported on a claim and reimburse one of the lesser codes, or they ignore modifiers through edits built into their claims processing system

Question 4

bundled code

Answer 4

any code that includes more than one procedure in its description

Question 5

category

Answer 5

the first three characters of an ICD-10-CM code designate the category of the diagnosis

Question 6

combination code

Answer 6

a single code used to classify (a) two diagnoses; (b) a diagnosis with an associated secondary process (manifestation); (c) a diagnosis with an associated complication

Question 7

comorbidity

Answer 7

a condition that exists along with the primary diagnosis of a patient

Question 8

concurrent care

Answer 8

when similar care is being provided to a patient by more than one provider

Question 9

consultation

Answer 9

when a patient visits with another provider at the request of the health care provider

Question 10

contributory factors

Answer 10

additional components that can be considered when selecting an evaluation and management code: time, nature of presenting problem, counseling, and coordination of care

Question 11

conventions

Answer 11

a list of abbreviations, punctuations, symbols, typefaces, and instructional notes; provide guidelines for using the code set

Question 12

coordination of care

Answer 12

defined as the time a licensed provider spends coordinating patient care with other health care agencies, for example, home care or nursing home care

Question 13

critical care

Answer 13

when constant bedside attention is required to a patient who is critically ill or unstable

Question 14

cross-reference

Answer 14

referencing from one part of the code book to another part containing related information (e.g., cross-referencing from the index to the Tabular List)

Question 15

Current Procedural Terminology (CPT)

Answer 15

a numerical listing of procedures performed in medical practice; a standardized identification of procedures. Published by the American Medical Association

Question 16

diagnosis

Answer 16

the reason the patient is receiving care; the identification of the illness or problem by the provider upon examination of the patient

Question 17

downcoding

Answer 17

a practice of third-party payers in which the benefits code has been changed to a less complex or lower-cost procedure than was reported; another payer practice in which a reported evaluation and management service is reduced to a lower level based strictly on the diagnosis code required

Question 18

E/M codes

Answer 18

CPT codes relating to the evaluation and management of the patient; related to medical services as opposed to surgical services

Question 19

established patient

Answer 19

patient who has received professional services from a provider of the exact same specialty and subspecialty who belongs to the same group practice, within the past three years

Question 20

global period

Answer 20

the period of time that is covered for follow-up care

Question 21

HCPCS Level II codes

Answer 21

codes that identify products, supplies, and services not included in CPT

Question 22

Healthcare Common Procedure Coding System (HCPCS)

Answer 22

The HCPCS is compromised of two levels: Level I: Current Procedural Terminology (CPT) codes; and Level II: National codes. The National codes are approved and maintained jointly by the Centers for Medicare and Medicaid Services (CMS), the Health Insurance Association of America, and the Blue Cross Blue Shield Association. Health care professionals such as dentists, orthodontists, and some technical support services such as ambulance services cannot report their services with CPT codes because there are no codes in that coding system that properly report them. Thus, HCPCS Level II codes were developed to identify products and supplies for which there are no CPT codes.

Question 23

index

Answer 23

located at the end of the CPT manual; terms listed in alphabetic order with categories and subcategories listed along with code range.

Question 24

International Classification of Disease (ICD)

Answer 24

a comprehensive listing of diseases and disorders of the human body. Effective October 1, 2015, ICD-9 was replaced with ICD-10. ICD-10-CM codes describe the disease or condition presented by the patient; use of these codes establishes the medical necessity for the services and procedures provided to the patient.

Question 25

key components

Answer 25

the major factors to be considered when selecting an evaluation and management code: history, exam, medical decision making.

Question 26

laterality

Answer 26

specifying whether the condition occurs on the left, right, or bilaterally

Question 27

modifiers

Answer 27

coding markers that inform third-party payers that circumstances for that particular code have been altered

Question 28

morbidity

Answer 28

the frequency of the appearance of complications following a surgical procedure or other treatment

Question 29

mortality

Answer 29

a fatal outcome

Question 30

new patient

Answer 30

for CPT purposes, a patient who has not received services from the provider within the past three years

Question 31

panel

Answer 31

an organ or disease-oriented laboratory procedure frequently ordered together

Question 32

primary diagnosis

Answer 32

the main reason a patient is seen or cared for during an encounter (synonymous with principal diagnosis).

Question 33

principal diagnosis

Answer 33

the main reason for the patient’s visit (synonymous with primary diagnosis)

Question 34

procedure code

Answer 34

code that represents a medical procedure such as a surgery or diagnostic tests, and medical services, such as evaluating a patient’s condition by physical examination; often used interchangeably with CPT

Question 35

reimbursement

Answer 35

to pay back or compensate for money spent, or losses or damages incurred; payment for provider services (from insurance company)

Question 36

secondary diagnosis

Answer 36

diagnosis is other than the primary diagnosis for other conditions affecting a patient during the same visit and the principal diagnosis

Question 37

sequela

Answer 37

a pathological condition resulting from prior injury, disease, or attack

Question 38

sequences

Answer 38

order of succession

Question 39

specificity

Answer 39

something specially suited for a given use or purpose; a remedy regarded as a certain cure for a particular disease; detailed, providing more specifics

Question 40

subcategories

Answer 40

either four of five characters (ICD-10-CM) and includes either letters or numbers; codes may be from three to seven characters in length; each level of subdivision after a category is a subcategory.

Question 41

surgical package

Answer 41

procedures found in CPT that may include preoperative exam and testing, the surgical procedure itself (including local or regional anesthesia if used), and routine follow-up care for a set period of time

Question 42

Tabular List

Answer 42

when the code description is located in the Alphabetic Index, the code or codes should be verified by looking in the Tabular List (alphanumeric order); contains categories, subcategories, and valid codes; in ICD-10-CM a sequential, alphanumeric list of codes divided into chapters based on the body system or condition.

Question 43

unbundling

Answer 43

reporting multiple codes for a service when there is one code that will report the entire service; reporting multiple procedure codes for services when only one code is appropriate; is considered fraudulent billing and could result in stiff penalties and fines if found to have been done intentionally

Question 44

upcoding

Answer 44

reporting a higher-level code than is appropriate for the service that was rendered, resulting in higher reimbursement; when a facility coder assigns a diagnosis code that does not match patient documentation, with the intention of increasing reimbursement to the facility through the DRG system, serious penalties and fines will be levied against the facility for submitting fraudulent claims

Question 45

World Health Organization’s (WHO)

Answer 45

established in 1948, an agency of the United Nations concerned with health on an international level; monitors disease outbreaks and assesses health system performance around the world