Marcy's CPT fundementals Final review

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final exam reveiw

CPT stands for

Current Procedural Terminology

How many sections is the CPT manual divided into?

6

Where is specific coding information about each section located?

guidelines

In which CPT Appendix would modifiers be found

A) Appendix A

Which punctuation mark between codes in the index of the CPT manual indicates that a range of codes are available?

hyphen

A code that has all of the words that describe the code following it, is called what type of code?

stand-alone

Procedures that are experimental, newly approved, or seldom used are reported with what type of code?

unlisted

According to the Surgery Guidelines is surgical destruction part of a surgical procedure

yes

The updated manual of the CPT is published in what month?

November

What type of code has only a portion of the code description

indented

Current procedural terminology , (CPT) also known as CPT-4 is a coding system developed by the AMA to convert widely accepted , uniform descriptions of medical, surgical, and diagnostic services rendered by health care providers into five-digit numeric codes.

True

CPT codes into the Healthcare common Procedural Coding System HCPCS to provide a uniform system of reporting services, procedures, and supplies

True

Per CPT guidelines, a seperate procedure

Is considered to be an integral part of another, larger service

CPT was developed and is maintained by

AMA

CPT is updated:

Annually for the main body of codes and every 6 months for category III codes

The Alphabetic Index to CPT includes listings for

Procedures/services
Examinations/tests
Anatomic sites

The use of the term "for" followed by a diagnosis in CPT means that:

The procedure can only be reported for that diagnosis

When an excision is being performed, the "margins" refer to the ____ required to adequately excise the lesion based on the physician's judgment

narrowest margin

Excision defined as full thickness would be through the

dermis

Mohs micrographic surgery requires a single physician to act in two integrated but separate and distinct capabilities of a surgeon and a(n):

pathologist

When reporting a staged procedure what modifier is added to the CPT code

-58

A patient who has been treated within the past 2 years by the physician or a member of his/her practice who has the same specialty is considered

an established patient

The MDM is based on the

complexity of the medical decision

What are the three factors Of E/M code assignments?

Place of service, type of service, patient status

Often, finding the correct E/M code begins with knowing

Where the patient met with the physician

A consultation is expected to be a (an) ______ relationship with the patient

temporary

Physicians are required to use the documentation guidelines developed by the AMA and CMS, formerly the HCFA

False

A referral is the same as a consultation

False

An eponym should not be used when a comparable anatomic term can be used in its place

True

A medical report is a

permanent legal document.
progress note

Reasons for documentation are

defense of a professional liability claim.
insurance carriers require accurate documentation that supports procedure and diagnostic codes

The SOAP in patient medical record charting may be defined as

S-subjective, O-objective, A-assessment, P-plan

A concise statement describing the symptom, problem, condition, diagnosis, physician-recommended return, or other factor that is the reason for the encounter is abbreviated as

CC

A triangle in front of a code in the updated CPT manual means

the description has been changed

What does comorbidity mean?

Underlying diseases or other conditions present at the time of the visit

Radiology codes designated as a "separate procedure" should be reported in addition to the code for the total procedure or service

False

The modifier reported when a physician component is reported separately is

-26

A ____ procedure is one that is performed independently of, and not immediately related to, another service

separate

What is the modifier used to identify the technical component of a radiologic procedure

-TC

A service that is rarely provided, unusual, variable, or new would always require a special report in determining medical appropriateness of the service

True

When reporting organ or disease-oriented panels, if all but one of the tests within the panel is substantiated by the physician's documentation, it is acceptable to assign the code with modifier -52 to the code used to report the service

False

What type of drug test measures the presence of a drug in the specimen?

qualitative

Quantitative analysis is defined as

. determining the amounts and proportions of chemical constituents

Psychiatric diagnostic interview examination includes

history
mental status
disposition and communication with family or other sources

If an established patient is given an immunization during an office visit, and the only service provided was the immunization, what type of codes would you use to report the service?

a Medicine section immunization code and an administration code

Outpatient dialysis services are usually reported on this basis

monthly

The Cardiovascular subsection contains many diagnostic/therapeutic procedures and services that are primarily divided as to whether the procedures or services are invasive or

noninvasive

What does the abbreviation EMG stand for

electromyography

Level II national codes are not used in which setting?

inpatient

A cardiovascular surgeon begins to perform a percutaneous transcatheter placement of an intracoronary stent, but stops the procedure because of the patients respiratory distress.
A) 92982
B) 92980
C) 92980-52
D) 92980-53

92980-53

Introduction of catheter into the aorta

36200

A thyroid-stimulating hormone (TSH) test.

84443

A patient has an office encounter for removal of five skin tags on her hand (10 day global). During the visit she asks the physician to evaluate swelling and heat in her left knee. The physician performs an expanded history and examination with low medical decision making.

99213-25, 11200

ORIF humerus shaft fracture with cast application (Open Reduction Internal Fixation)

24515

What is the correct code for a home visit with an established patient that required a detailed history of what has occurred since the physician;s previous visit, a detailed examination, and moderately complex medical decision making?

99349

Percutaneous gastrostomy tube placement

43246

A needle with a suture attached is passed through an incision into the stomach. The needle is snared and removed via the mouth. A gastrostomy tube is connected to the suture and passed through the mouth into the stomach and out the abdominal wall. What is the correct code for this procedure?
A) a. 74230
B) b. 74340
C) c. 49440
D) d. none of the above

none of the above

Anesthesia for ORIF of fracture of the distal tibia and fibula
Anesthesia for ORIF of fracture of the distal tibia and fibula

01480

A qualitative screening for methamphetamine

80101

Codes 76801 and 76802 include determination of the number of gestational sacs and fetuses, gestational sac/fetal measurements appropriate for gestation <14 weeks 0 days, and:
A) a. survey of visible fetal and placental anatomic structure
B) b. qualitative assessment of amniotic fluid/gestational sac shape
C) c. examination of the maternal uterus and adnexa
D) d. all of the above

all of the above

A 39-year-old man, new to the area, obtains a referral from a local hospital to Dr. Tanner, an internist. The man reports he feels well, exercises regularly, and has no particular complaints, but wants to establish himself with a physician for ongoing medical care. The physician performs a comprehensive history and physical examination, discusses risk factor reduction with the patient, and orders a series of laboratory and electrocardiographic tests as appropriate for the man's age. All test results are returned with normal findings, and the patient is advised to return in 1 year for another annual examination or earlier if any problems arise. What is the CPT code for this visit?

99385

SMR of nasal turbinates

30140

Radiologic examination, nasal bones, complete, minimum of three views

70160

The physician ordered a hemogram, hepatitis B surface antigen, antibody rubella, qualitative syphilis test, antibody screen, blood typing ABO, and a blood-typing RhD on a pregnant woman.
CPT Code panel: ____________________

80055

A wet mount to determine a vaginal yeast infection using a KOH prep.
CPT Code: ____________________

92082

A routine ECG with 12 leads, tracing only was performed

93005

Postoperative follow-up visit 4 weeks after a surgery that has a 90-day global period.
CPT Code: ____________________

99024

Patient has many things going on. First, he's had no difficulties following the feral cat bite, and the cat was normal on quarantine. He seemed to be recovering from the flu but is plagued with a very persisting cough and pain down the center of his chest without fever or grossly discolored phlegm. Physical exam shows expiratory rhonchi and gross exacerbation of his cough on forced expiration. Spirometry before and after bronchodilator was remarkably good; nonetheless, it is improved and he is symptomatically improved with a Proventil inhaler, which he is given a sample. I don't think other antibiotics would help. His reflux is under good control with proprietary antacids with a clear exam. He has several areas of seborrheic keratoses on his face and head that need attention. Finally, in follow-up of the above, he needs a complete physical exam.


Which of the following is not required for correctly linked codes?
A) the diagnosis and procedure codes present a logical clinical relationship
B) the diagnosis and procedure codes are from the same data set
C) the procedures are necessary and effective, and are not elective or experimental
D) the treatment is provided at an appropriate level for the presenting problem

B

The subjective findings are:
A) expiratory ronchi
B) persistent cough
C) persistent cough and pain down center of chest
D) seborric keratosis on face and head that need attention

c

The objective findings are:
A) persistent cough
B) expiratory ronchi, gross exacerbation of cough on forced expiration
C) cough, pain,seborreic keratosis
D) expiratory ronchi, gross exacerbation of cough on forced expiration, seborrheic keratosis on face and head

d

The patients diagnosis(es) to be coded are:
A) cough, pain, keratosis, cat bite
B) influenza, keratosis, cat bite
C) influenza, acute bronchitis, seborrheic keratosis on face and head, cat bite
D) seborrheic keratosis, influenza, bronchitis, cat bite

influenza, acute bronchitis, seborrheic keratosis on face and head, cat bite

Procedures/services to be coded are:
A) level 4 new pt E/M,Spirometry
B) established pt level 5 E/M office visit, Spirometry before and after bronchodilator
C) E/M,Spirometry, Proventil inhaler,excision of seborrheic keratosis
D) complete physical exam

B

Now provide the ICD-9 and CPT codes for the above scenario for Roy A Takashima

487.1;
466.0;
702.19;
E906.3;
99215, or 99214;
94060

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