Chapter 5 Flashcards

Question

modifiers that are specific to anesthesia codes An-Es-Thee-Sha

Answer 1

*P1–P6 are physical status modifiers that designate the general health status of the patient.

Answer 2

*extreme age 99100 *total body hypothermia 99116 *controlled hypotension 99135 *emergency conditions 99140 **if the qualifying circumstance is part of the CPT code description, the qualifying circumstance is NOT reported. EXAMPLE: 00834 - Anesthesia for hernia repairs in the lower abdomen not otherwise specified, younger than 1 year of age.

Answer 3

Modifiers - To report circumstances surrounding the various methods of anesthesia. *did anesthesiologist perform the anesthesia. *or provided medical direction

Answer 4

Anesthesiologist is a physician licensed to practice medicine and has completed anesthesiology program. CRNA: Certified RN Anesthesiologist who has completed an accredited anesthesia training program. Anesthesiologist Assistant: (should be spelled out bcuz AA already taken) has completed accredited program. may only be directed by an anesthesiologist. Anesthesia Resident: completed medical degree. In a Residency program. SRNA: Student Registered Nurse Anesthetist

Answer 5

AA - Anesthesia by Anesthesiologist AD - Medical supervision by a physician. QK- Medical direction of 2,3, or 4 concurrent procedures. (concurrent means all current ongoing cases) QY- Medical direction of one CRNA GC- Resident QX- CRNA w/ medical direction. QZ-CRNA w/o medical direction. State scope of practice may prohibit claims w/ a non-medical direction modifier.

Answer 6

are reported in the first position after the CPT code bcuz payment is related to the modifier. Other modifiers are reported second position after medical direction modifiers.

Answer 7

the most complex procedure (highest unit value) is reported.

Answer 8

*Local (nerve blocks) *One E/M *Post Op *talking w/ fam & other physicians *Post Op follow up.

Answer 9

Medicare: *0 days, *10 days (minor surgery) *90 days (major surgery) Many payers adopt Medicare global periods. (this used in the CPB exam)

Answer 10

the Medicare Physician Fee Schedule can be referenced. MPFS

Answer 11

000 - is for ... Minor procedure w/ PreOp PostOp. E/M on day of procedure NOT payable.

Answer 12

*Minor procedures *Pre-Op Day of *10 day Post-op. *E/M NOT paid on day of and 10 day f/u

Answer 13

*Major procedure. *One day Pre-Op *90 Days Post-Op *E/M NOT paid for day of, day prior and day of surgery.

Answer 14

Maternity codes *global period does NOT apply

Answer 15

Global... Does NOT apply. E/M, Anesthesia, Lab & Radiology.

Answer 16

these are unlisted codes, and subject to individual pricing.

Answer 17

These are add-on codes. They are related to another service and included in the global period.

Answer 18

may be separately reported.

Answer 19

complications that result in a return to the OR.

Answer 20

*Report major procedure w/ CPT code *Additional procedures use modifiers *Modifier 51 TIP: Some payers request modifier 51 not be appended as the payers processing system is programmed to automatically append modifier 51 to subsequent procedures. It is necessary for a medical biller to know the policies of their payers.

Answer 21

care related to recovery from the procedure. Care for underlying condition is not included in follow up.

Answer 22

add-on codes. Add-on codes should never be reported without a parent code.

Answer 23

15260Full thickness graft, free, including direct closure of donor site, nose, ears, eyelids, and/or lips; 20 sq cm or less +15261each additional 20 sq cm, or part thereof (List separately in addition to code for primary procedure)

Answer 24

*Does NOT mean bill separately. *if the procedure.... is performed as part of another procedure .... that typically includes the "separate procedure" then separate reporting of the "separate procedure" code is INCORRECT.

Answer 25

The code for a liver biopsy can be found in the CPT® Index under Biopsy/Liver which directs you to 47000, 47001, 47100, 47700. Biopsy Liver 47000, 47001, 47100, 47700 You can also look under Liver/Biopsy

Answer 26

bcuz they give guidance on correct coding procedures.

Answer 27

separately while the length of multiple repairs within the same anatomic section are added together.

Answer 28

is always included when performed w/ a surgical endoscopy or arthroscopy respectively.

Answer 29

29800Arthroscopy, temporomandibular joint, diagnostic, with or without synovial biopsy (separate procedure) 29804Arthroscopy, temporomandibular joint, surgical CPT® code 29800 is inclusive to CPT® code 29804 and is not reported separately.

Answer 30

supervision and interpretation included in the procedure. the imaging codes are NOT reported in addition to the procedure code.

Answer 31

is included in the section guidelines.

Answer 32

parenthetic instructions

Answer 33

Answer: B. 01464 Rationale: Look in the CPT® Index for Anesthesia/Arthroscopic Procedures/Ankle and you are directed to 01464. Verify code selection in numeric section of the CPT® code book.

Answer 34

Answer: D. 00832 with the time units for both procedures Rationale: When reporting multiple anesthesia procedures during one surgical session, the anesthesia code with the most anesthesia base units is reported with the time units for both procedures.

Answer 35

Answer: A. 45300 Rationale: Look in the CPT® Index for Proctosigmoidoscopy/Diagnostic which directs you to 45300. Verify code selection in the numeric section of the CPT® code book.

Answer 36

Answer: D. Use 64492 in conjunction with 64490, 64491 Rationale: In the CPT® code book, code 64492 has a parenthetic instruction to assist in coding: (Use 64492 in conjunction with 64490, 64491)

Answer 37

Answer: A. 69424-50 Rationale: In the CPT® code book, code 69424 has two parenthetic instructions to assist in coding: (For bilateral procedure, report 69424 with modifier 50.) (Do not report 69424 in conjunction with 69205, 69210, 69420, 69421, 69433–69676, 69710–69745, 69801–69930.)

Answer 38

Radiological services

Answer 39

radiological supervision and interpretation. *If single provider performs the interventional procedure and radiological services, that provider may submit both codes.

Answer 40

*Technical Component use TC modifier *Professional component designated with modifier 26.

Answer 41

TC Technical Component. Professional interpreting the image claims the Professional Component.

Answer 42

The global service is reported without a modifier.

Answer 43

HCPCS Code with Modifiers *72020-26 Interpretation Only *72020-TC Performed the x-ray

Answer 44

also found in X-ray, CT Scan, Magnetic Resonance Imagin MRI

Answer 45

need to know which views and how many views are taken. many codes are based on views.

Answer 46

code options for contrast, without contrast, and without contrast followed by with contrast.

Answer 47

contrast administered *Intravascular (artery or vein) *intra-articular (joint) *Intrathecally (spinal cord)

Answer 48

do not qualify as a study "with contrast"

Answer 49

*for panels *do NOT include collection *Sometimes the collection is considered inclusive to office visit.

Answer 50

*if not exact match in the panel *additional tests reported individually

Answer 51

be divided into technical and professional components.

Answer 52

Owner of lab equipment claims the technical component, while provider interpreting results of test claims the professional component. Codes for this section can be found in the CPT Index under Pathology and Lab

Answer 53

*immunization *pshychiatric *dialysis *cardiovascular (catheterization, angioplasties stent placement. implantable devices *allergy tx *neurological testing *intravenous infusion *physical medicine *rehab services

Answer 54

*to report specific circumstances, service, medical equipment w/o changing definition of code.

Answer 55

two-digit codes Appendix A

Answer 56

are in Appendix B of HCPCS code book

Answer 57

*list functional or pricing modifiers in the first position. *next informational modifiers; these clarify aspects of procedure/service

Answer 58

*Procedures w/ professional & technical (but only one inc. in the claim) *more than one provider performed the procedure. *Procedures that were increased or decreased from usual procedure *multiple different procedures during same session *single procedure performed more than once during same session *single procedure performed bilaterally

Answer 59

The service provided is greater than usually required for the procedure. Documentation must support the substantial work and reason for additional work "above and beyond" and there is no other code.

Answer 60

appended to E/M codes.

Answer 61

*Excessive blood loss during procedure *Excessive large surgical specimen. *Trauma complicated procedure. *Other pathologies, tumors, malformation that interferes with procedure.

Answer 62

*Increased time provider variation *Another code exists that covers the increased work. key words: extended time, took longer than normal, extenuating circumstances.

Answer 63

Use For: *E/M unrelated service to the surgical procedure. *E/M service performed during Post-Op period ... reasons unrelated to original procedure. *Insurance Carrier Specific. Some Ins. allow the use of Mod24 due to a complication of the surgical procedure.

Answer 64

*Immunosuppressive therapy *Chemotherapy *Critical care services unrelated to the surgery.

Answer 65

On the day of procedure or service... patient's condition required a significant, separately E/M service "above & beyond" the other service.

Answer 66

*With E/M codes for initial service... on the same day... a separate service, such as dialysis, that would NOT require E/M services. *When significant, separately E/M service performed, on same day as a preventive care visit, the E/M must be for a NON preventive reason and documented.

Answer 67

*E/M resulted in decision to perform a major surgery (see Modifier 57) *On surgical code.. it's added to the E/M code when both are performed together. *Office visit E/M code when primary reason for visit is for minor surgery.

Answer 68

Keywords: unrelated outside of not related to Mod 25 is commonly misused. Work w/ coder ... to determine if documentation supports an E/M visit separate from the surgical procedure performed.

Answer 69

Appropriate uses: *Imaging Co use TC Technical Component *Professional services interpretation of images.

Answer 70

Using TC and Professional together. If same provider performs both services it's considered global. Using modifier when re-reading a study interpreted by another provider. Most insurances only pay for a single interpretation.

Answer 71

Bilateral Procedures some insurances require the cpt code be reported twice w/ Mod50 added to one of the codes. Not all procedures can be reported w/ Mod50. Some codes say "unilateral or bilateral" indicating the code is used only once even if procedure performed on both sides.

Answer 72

*exact same service bilaterally *MPFS Medicare Physician fee Schedule indicate CPT can be reported w/ Mod 50 *Medicare recognizes Mod 50 on Radiology when study performed on each side. NOT all insurances allow this modifier combo.

Answer 73

*Bilateral on different areas of the body *on bilateral procedure ... if it's part of description of code used. *on unilateral ... if it's in the description of code used.

Answer 74

is for multiple procedures, other than E/M, Physical Medicine & Rehab, or provision of supplies are performed at the same session, same provider.

Answer 75

for multiple instances of the same service ... each service on separate line and does not require Modifier 59

Answer 76

*separating procedures *unbundling procedures into its components *appending Mod 51 to add-on codes that are Mod51 exempt *appending to E/M code

Answer 77

*for reduced or eliminated services associated with the code to which modifier is appended.

Answer 78

*Indicate terminated procedure (Mod53) *Appended to E/M services *Appended to time-based services, such as psychotherapy, anesthesia, critical care.

Answer 79

Discontinued Procedure. *Procedure started, but d/c bcuz of extenuating circumstances, threaten well-being of patient such as uncontrollable bleeding, hypotension, physiologic changes, unexpected findings, anesthesia complications.

Answer 80

Elective cancellation of a procedure prior to anesthesia.

Answer 81

To indicate different providers provided Preoperative (Mod 56) Intraoperative (Mod 54) Postoperative (Mod 55) Only appended to codes that have a global period. For procedures w/o global period (zero days), pre and post op are reported separately w/o modifiers.

Answer 82

*Provider performed only surgical procedure. *If provider didn't do the Pre-Op, then only append Mod 54 and 55

Answer 83

*Appending mod 54 w/o global period *Appending mod 55 Post-Op by a provider of a different specialty. *Appending mod 54, 55 ,56 to an E/M code.

Answer 84

Modifier 54 Keywords: only performed the surgical procedure, no pre or post-op management, etc. Modifier 55 Keywords: post-op follow-up only, postoperative care turned over to, transfer of care, etc. Modifier 56 Keywords: pre-op evaluation only, covering for surgeon, etc.

Answer 85

*When E/M done the day before or day of surgery results in the decision to perform surgery, append Mod 57. *Medicare and most Ins only recognize modifier 57 "day before or day of" which has a 90-day global period.

Answer 86

append both Modifier 24 and Modifier 57 to the E/M code.

Answer 87

To indicate a procedure or service during the Post-Op period was *Planned at the time of original (staged) *More extensive than the original procedure *For therapy following a diagnostic procedure (related)

Answer 88

Inappropriate use of Mod 58 when a patient is returned to the operating room for a complication. Keyword: return or will proceed with additional services in next procedure etc.

Answer 89

Procedure or service distinct or independent from other non E/M services.

Answer 90

Used with code pairs listed in the NCCI National Correct Coding Initiative for a different *session *encounter *procedure *surgery *site *organ *incision/excision *lesion

Answer 91

*Not listed in the NCCI *Do NOT use w/ E/M codes *Medicare: do NOT use w/ code pair that has a CCM (correct coding modifier) restricting the use of a modifier or if on eof the X-ESPU is appropriate. *Documentation does not support services were separate and distinct. *another modifier exists to describe service. *Do NOT append w/ modifier 51 on the same procedure code.

Answer 92

represents the separate Encounter Structure Practitioner Unusual service

Answer 93

*During Post-op *Unrelated to the original procedure *Performed during global period of first procedure. *Do NOT use Mod 79 if second procedure is related to the first.

Answer 94

*Used for Assistant Surgeon *Provider assisted the surgeon *MPFS relative files can be found on CMS website.

Answer 95

Medicare Physician Fee Schedule

Answer 96

Answer: B. 70551 Rationale: Look in the CPT® Index for Magnetic Resonance Imaging (MRI)/Diagnostic/Brain which directs you to 70551–70555. In the numeric section of CPT®, 70551 indicates without contrast.

Answer 97

Answer: B. 80061, 85027 Rationale: The lipid panel by CPT® definition includes total cholesterol (82465), HDL cholesterol (83718), and triglycerides (84478). The CBC (85027) is reported separately, in addition to, the lipid panel (80061).

Answer 98

Answer: A. 90460, 90474 Rationale: Read the parenthetical instructions in this section. Under 90474, there is a parenthetic instruction stating 90474 can be reported in conjunction with codes 90460, 90471, or 90473. 90461, 90472, and 90474 are all add-on codes and require a primary code be reported in addition.

Answer 99

Answer: A. 19318-50 Rationale: There is guidance under the Integumentary System/Breast/Repair and/or Reconstruction heading that states to append modifier 50 when the procedures are performed bilaterally. 36251 is a unilateral procedure but there is an option for the same procedure to be performed bilaterally (36252). 36252 is a bilateral procedure and therefore should not have modifier 50 appended. 69801 has a parenthetic instruction stating not to report it more than once per day, using modifier 50 would equate to performing the procedure twice in one day.

Answer 100

Answer: B. 99213-25 Rationale: Modifiers 22, 54, 55, 56 and 59 are not appended to office visit codes. Modifier 25 indicates the office visit is separately identifiable from another procedure and is correct to append to an office visit code.

Answer 101

The period (0–90 days as determined by the health plan) and services provided for a surgery inclusive of preoperative visits, intraoperative services, post-surgical complications not requiring a return trip to the operating room.

Answer 102

An assigned indicator, which determines classification for a minor or major surgery, based on relative value unit (RVU) calculations.

Answer 103

*Global surgical period includes day before, the day of, and follow-up 90 days after procedure.

Answer 104

*Global preop the day of surgery, surgery follow-up 0-10 days after.

Answer 105

National Correct Coding Initiative *To determine codes *Considered by CM to be bundled for major procedure.