Chapter 25: Procedural and Diagnostic Coding Flashcards
Add-on codes
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
Alphabetic index
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.
bundle
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
bundled code
any code that includes more than one procedure in its description
category
the first three characters of an ICD-10-CM code designate the category of the diagnosis
combination code
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
comorbidity
a condition that exists along with the primary diagnosis of a patient
concurrent care
when similar care is being provided to a patient by more than one provider
consultation
when a patient visits with another provider at the request of the health care provider
contributory factors
additional components that can be considered when selecting an evaluation and management code: time, nature of presenting problem, counseling, and coordination of care
conventions
a list of abbreviations, punctuations, symbols, typefaces, and instructional notes; provide guidelines for using the code set
coordination of care
defined as the time a licensed provider spends coordinating patient care with other health care agencies, for example, home care or nursing home care
critical care
when constant bedside attention is required to a patient who is critically ill or unstable
cross-reference
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)
Current Procedural Terminology (CPT)
a numerical listing of procedures performed in medical practice; a standardized identification of procedures. Published by the American Medical Association
diagnosis
the reason the patient is receiving care; the identification of the illness or problem by the provider upon examination of the patient
downcoding
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
E/M codes
CPT codes relating to the evaluation and management of the patient; related to medical services as opposed to surgical services
established patient
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
global period
the period of time that is covered for follow-up care
HCPCS Level II codes
codes that identify products, supplies, and services not included in CPT
Healthcare Common Procedure Coding System (HCPCS)
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.
index
located at the end of the CPT manual; terms listed in alphabetic order with categories and subcategories listed along with code range.
International Classification of Disease (ICD)
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.
