5 Written questions
5 Matching questions
- Modifier 22, Unusual procedural services
- HCPCS Level II - National Codes
- Billing based on time
- a 2-digit numeric code
Used to indicate that a procedure has been altered by some specific circumstance, but not changed in its definition
- b Time is only a factor in determining the level of service if > 50% of the time spent is spent in counseling/coordination of care.
You must document the total amount of time spent and indicate that >50% of that time was spent in counseling/coordination of care
- c Many procedure codes also include procedures and supplies that are routinely necessary to perform the procedure
Only services not typically performed, or materials not typically used, should be billed separately
Charging for these items separately, known as "unbundling" or "fragmenting," is against the law.
- d Created by CMS
Services and supplies not found in the CPT code set
Ambulance services and durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS)
Alpha-numeric (one letter plus 4 numbers)
- e When the service provided is > that usually required for the listed procedure (E/M - 21)
A provider excises a lesion from the crease of the neck of a very obese person. The obesity makes the excision more difficult. The provider indicates the complexity of the removal by adding 22 modifier to code. It may be helpful to include copy of operative report.
5 Multiple choice questions
- *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.
- Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service.
Pt is seen for fever, h/a, vomiting, and stiff neck. A spinal tap is performed as well as the E&M services consistent with 99214.
62270 Spinal puncture, lumbar, diagnostic
Indicates that same provider did both procedures at the same visit.
- It's how we get paid.
Avoid denials/delay in payment
Avoid audit by coding properly
Documentation must support code
"If it isn't documented, you didn't do it"
- 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)
- a physician is prohibited from making any referral to a provider of designated health services if the physician has a "financial relationship" with the provider. a healthcare provider is prohibited from submitting for services rendered to patients referred in violation of the statute
5 True/False questions
Complex repairs → Automatically running a test based on a previous test result w/o the MD/PA requesting the second test
Reflex Testing → Automatically running a test based on a previous test result w/o the MD/PA requesting the second test
Medical Necessity → it is improper to bill medicare for services or treatment that is not medically necessary. To knowingly do so is a violation of the false claims act.
NPI (National Provider Identifier) → Means Unspecified (don't know yet)
Used when the coder does not have enough information to select a more definitive diagnosis (ie. Cultures are pending)
NEC - Not Elsewhere Classifiable → 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