5 Written questions
5 Matching questions
- History component levels
- Phantom Billing
- Complex repairs
- ICD-9 volumes
- a Billing for tests not performed
- b Problem Focused= HPI: Brief (1-3); ROS & PFSF N/A
Expanded Problem Focused= HPI: Brief (1-3); ROS:Problem pert (1); PFSH: N/A
Detailed= HPI: Extended (4-3 chronic); ROS Extended (2-9); PFSH: Pertinent (at least 1)
Comprehensive= HPI: Extended (4 or 3 chronic); ROS: Complete (10+); PFSH: Complete (2 established) (3 new/consult)
- c Pronounced "hick picks"
Health Care Financing Administration's Common Procedural Coding System
HCFA (Health Care Financing Administration) Now CMS (Centers for Medicare and Medicaid Services) was/is the governing agency of Medicare and Medicaid
CPT (Common Procedural Terminology)
National Codes or alpha-numeric codes
Local codes (phased out in 2003)
- d Vol 1= "Diseases- Tabular List"
Vol 2= "Diseases- Alphabetical Index"
Vol 3= Listing of procedure codes and an index to the procedures.
- e repairs requiring more than layered closure (ie: scar revision, debridement, etc.)
5 Multiple choice questions
- Problem focused= 1-5 elements
Expanded problem focused= >6
Comprehensive= 18+ or 2 bullets in 9 systems
- *Code to the highest level of certainty at that visit.
*Only code the reason for the encounter, and those conditions that affect the care delivered
*Use the most specific code available (4th=complications of the disease; 5th=clarifies condition)
*Do not use "rule out" or "suspected" diagnosis (codes as a pre-existing condition to insurance co)
Instead use a code from the "symptoms, signs, and ill-defined conditions" chapter.
*Make sure the ICD-9 code supports the CPT code.
- • A Medicare billing provision that enables services provided by NNPs (non-physician providers) in an office or clinic setting to be reimbursed at 100% of the physician fee schedule by billing using the physician's NPI (otherwise reimbursed 85%)
- • When a physician has previously diagnosed and has established care and a management plan for the Medicare patient, and the NPP is providing the follow up care.
• When any physician is on the premises and available if the NPP needs assistance.
• In any clinic not associated with hospitals.
- "A consultation is a type of service provided by a physician whose opinion or advice regarding evaluation and/or management of a specific problem is requested by another physician or other appropriate source."
5 True/False questions
Medical Necessity → "Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT code. It would not be medically necessary to bill a higher level of evaluation and management service when a lower level of service is warranted. The volume of documentation should not be the primary influence upon which a specific level of service is billed."
Parentheses ( ) → Used to enclose supplementary words which may or may not be present in the disease statement and which do not affect code selection per se.
Mod 57, Decision for surgery → An E/M service that resulted in the initial decision to perform surgery
A practitioner is consulted to determine whether surgery is necessary for a pt with abd pain. The services meet the criteria to report consultation*. The requesting MD agrees w/ consult and surgeon takes over case. Later that day surgery to repair perf ulcer is done.
99244-57 office consultation for a new or established pt
44602 suture of small intestine for perf ulcer...
Starred procedures → Suturing of superficial tissues where wound requires simple one layer closure
Local anesthetic included in charge
If wound is closed with adhesive strips, use E/M code instead (regular office visit)
However use of dermabond or staples would be procedural codes
Heavily contaminated wounds requiring extensive cleaning and simple closure may be coded as Intermediate repair
3types of repairs: Simple, Intermediate, Complex
NOS - Not Otherwise Specified → can be used in two instances:
1) not enough info available to determine which specific diagnosis code should be used in situations where ICD-9 provides very specific diagnoses.
2) The coder has specific information about the diagnosis that is not an option in the choice of ICD-9 codes