Chapter 13 Health Insurance Today

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Category

Codes in the tabular section of CPT are formatted using four classifications: section, subsection, subheading, and category. "Category" is the most definitive classification and aids in selecting the applicable code.

Category III codes

Established by AMA as a set of temporary CPT codes for emerging technologies, services, and procedures where data collection is needed to substantiate widespread use or for the Food and Drug administration's approval process.

Centers for Medicare and Medicaid Services (CMS)

Agency responsible for administering the Medicare and Medicaid programs. Developed the CPT codes to establish a more uniform payment schedule for Medicare carriers to use when reimbursing providers. Formerly called the Health Care Financing Administration.

Chief complaint

The reason why the patient is seeing the physician.

Concurrent care

when a patient receives similar services (e.g., hospital visits) by more than one healthcare provider on the same day

Consultation

When the primary care provider sends a patient to another provider, usually a specialist, for the purpose of the consulting physician rendering his or her expert opinion regarding the patient's condition. The primary care provider does not relinquish the care of the patient to the consulting provider.

Counseling

A service provided to the patient and his or her family that involves impressions and recommended diagnostic studies, discussion of diagnostic results, prognosis, risks and benefits or treatment, and instructions.

Critical Care

The constant attention (either at bedside or immediately available) by a physician in a medical crisis.

Crosswalks

The process of matching one set of data elements or catergory of codes to their equivalents within a new set of elements or codes.

Emergency Care

Care given in a hospital emergency department.

Established Patient

A person who has been treated previously by the healthcare provider, regardless of location of service, within the past 3 years.

Evaluation and Management (E&M) codes

Codes found at the beginning of the CPT manual that represent the services provided directly to the patient during an encounter that do not involve an actual procedure.

Face-to-face time

The time that the healthcare provider spends in direct contact with a patient during an office visit, which includes taking a history, performing an examination, and discussing results.

HCFA's Common Procedure Coding System (HCPCS)

Developed by the Health Care Financing Administration to provide a uniform language that accurately describes medical, surgical, and diagnostic services, serving as an effective means for reliable nationwide communication among physicians, insurance carriers, and patients.

HCPCS codes

Descriptive terms with letters or numbers or both used to report medical services and procedures for reimbursement. Provides a uniform language to describe medical, surgical, and diagnostic services. HCPCS codes are used to report procedures and services to government and private health insurance programs, and reimbursement is based on the codes reported.

Health Care Financing Administration (HCFA)

see: Centers for Medicare and Medicaid.

History of present illness

elements of a physical examination that include location, quality, severity, duration, timing, context, modifying factors, and associated signs and symptoms of a patient's current illness or injury.

Indented code

codes that refer back to the common portion of the procedure listed in the preceding entry

Inpatient

A patient who has been formally admitted to a hospital for diagnostic tests, medical care and treatment, or a surgical procedure, typically staying overnight.

Key components

the main elements that establish the level in evaluation and management coding (history, examination, and complexity in medical decision making).

Level I (codes)

American Medical Association (AMA) Physicians' CPT codes. Five-digit codes accompanied by descriptive terms, used for reporting services performed by healthcare professionals developed and updated annually by the AMA.

Level II (codes)

HCPCS National Codes used to report medical services, supplies, drugs, and durable medial equipment not contained in the Level l codes. Codes that begin with a single letter, followed by 4 digits. Level ll code supersede Level l codes for similar encounters, Evaluation and Management services, or other procedures and represent the portion of procedures involving supplies and materials. Level ll codes are developed and updated annually by the Centers for Medicare and Medicaid Services and their contractors.

Level III (codes)

codes and descriptors developed by local Medicare contractors for use by physicians, practitioners, providers and suppliers in completion of claims for payment. Now used on a limited basis.

Modifier

words that are added to main terms to supply more specific information about the patient's clinical picture. Modifiers provide the means by which the reporting healthcare provider can indicate that a service or procedure has been performed has been altered by some specific circumstance, but has not changed its definition or code.

Modifying term

descriptive words indented under the main term that provide further description of a procedure or service. A main term can have up to three modifying terms. The CPT coding, modifying terms often have an effect on the selection of the appropriate procedural code.

Neonates

Newborns 30 days old or younger.

New patient

A person who is new to the practice, regardless of location or service, or one who has not received any medical treatment by the healthcare provider or any other provider in that same office within the past 3 years.

Observation

In CPT coding, a classification for a patient who is not sick enough to qualify for the acute inpatient status, but requires hospitalization for a brief time.

Outpatient

A patient who has not been officially admitted to a hospital, but receives diagnostic tests or treatment in that facility or a clinic connected with it.

Past, family, and social history (PFSH)

Part of a physical examination that includes the patient's past illnesses, operations, injuries, and treatments, and any diseases or conditions other members of the patient's family might have which could be hereditary.

Physician's Current Procedural Terminology, Fourth Edition (CPT-4)

A manual containing a list of descriptive terms and identifying codes used in reporting medical services and procedures performed and supplies used by physicians and other professional healthcare providers in the care and treatment of patients.

Physician's Current Procedural Terminology, Fifth Edition (CPT-5)

An updated version of the CPT-4 manual, which the American Medical Association is in the process of developing, that will improve existing CPT features and correct deficiencies. The updated version is structured to respond to challenges presented by emerging user needs and HIPAA.

Review of systems

In a physical examination, information gathering that involves a series of questions the provider asks the patient to identify what body parts or body systems are involved.

Section

One of four classifications in the tabular section (Volume I) of the CPT manual. This section (e.g., Surgery or Radiology) is one of the six major areas into which all CPT codes and descriptions are categorized.

See

Used as a cross-reference term in the CPT alphabetic index and directs the coder to an alternate main term.

Special report

a report that accompanies the claim to help determine the appropriateness and medical necessity of the services or procedures. It is required by many third party payers when a rarely used, unusual, variable, or new service or procedure is preformed.

Stand-alone code

A CPT code that contains the full description of the procedure without additional explanation.

Subheading

One of four classifications in the tabular section (Volume I) of the CPT manual (see subsections).

Subjective information

Biased or personal information. A patient's history, for example, is based on what the patient tells the healthcare provider in his or her own words.

Subsection

One of four classifications in the tabular section (Volume I) of the CPT manual that further divides sections into smaller units usually by body system.

Unit/floor time

Time the physician spends on bedside care of the patient and reviewing the health record and writing orders.

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