chapter 6 billing/coding

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Know what E/M services are

Services that the physician provides to evaluate patients that were previously referred to as office, hospital or home visits.

How many key components need to be present to assign a code

New patient encounter three of three need to be present
Established patient only requires two of three

What are the key components used to I.D. the correct level of service

History
physical examination
medical decision making

What are the contributory factors

counseling
coordination of care
nature of presenting problem
face-to-face time

New patient

patient has not received any professional services from the physician within the past three years

Established patient

patient has been seen in the office in the past three years

Inpatient

patient is formally admitted to the hospital

what is a consult?

services rendered by a physician whose opinion or advice is requested by another physician or agency in the evaluation or treatment of a patient's illness or suspected problem.

what is a follow-up?

patient comes back after the initial visit

How do you code a consult & a follow-up?

After the consult is complete and the phsyician assumes management of all patients conditions, then use an established patient code for the follow-up visit. Consults are coded in the preventative medicine sectiion

initial new patient consult

first visit by consulting doctor

follow-up consult

doctor has not assumed responsibility for the patients condition (2nd visit)

Confirmatory consult

consulting doctor offers an opinion about the treatment plan after a diagnosis has been made

Office/outpatient consult

when a patient is seen in the office by a specialist

what is a referral?

the transfer of the total or specifica care of a patient from one physician to another for known problems

How can a referral be used?

a referral is also an authorization for a patient to receive services

What criteria needs to be met in order to bill 99211?

face to face contact with the patient
doctor must be in the office
separate service must be provided (injection)
proper documentation

What bundled services means?

codes that are grouped together that are related to a procedure

What is preventative medicine?

services provided to prevent the occurance of illness, injury and disease. Such as vaccine immunizations, routine physical exams and counseling

How is preventative medicine categorized?

according to the patients age

Inpatient

patient is formally admitted to the hospital

outpatient

patient receives services in a health care facility and goes home the same day

observation status

patient is admitted under observation, but has not formally been admitted to the hospital. There are 24 hours to make a decision to admit fully or discharge

How many codes are there in the CPT code

5 digits

what does CPT stand for?

Current Procedural Terminology

How many levels of HCPCS are there?

there are 3 levels

How often are CPT codes revised?

annualy

Who developed HCPCS codes?

Centers for Medicare and Medicaid services (CMS)

emergency care

health care services provided to prevent serious impairment of bodily functions or serious dysfunction to any body organ or part

Critical care

intensive care provided in a variety of acute life-threatening conditions requiring constant bedside attention by a physician

Counseling

aspect of preventative medicine. Discussion between the physician and a patient, family or both concerning the diagnosis, recommeded studies or tests, treatmen options, risks and benefits of treatment, treatment options, patient and family education

Modifier

In CPT coding, a two-digit add-on number placed after the usual procedural code number to indicate a procedure or service has been altered by specific circumstances

consultation

services rendered by a physician whose opinion or advice is requested by another physician or agency in the evaluation or treatment of a patient's illness or suspected problem

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