73 terms

Marcy's CPT fundementals Final review

final exam reveiw
CPT stands for
Current Procedural Terminology
How many sections is the CPT manual divided into?
Where is specific coding information about each section located?
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?
A code that has all of the words that describe the code following it, is called what type of code?
Procedures that are experimental, newly approved, or seldom used are reported with what type of code?
According to the Surgery Guidelines is surgical destruction part of a surgical procedure
The updated manual of the CPT is published in what month?
What type of code has only a portion of the code description
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.
CPT codes into the Healthcare common Procedural Coding System HCPCS to provide a uniform system of reporting services, procedures, and supplies
Per CPT guidelines, a seperate procedure
Is considered to be an integral part of another, larger service
CPT was developed and is maintained by
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
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
Mohs micrographic surgery requires a single physician to act in two integrated but separate and distinct capabilities of a surgeon and a(n):
When reporting a staged procedure what modifier is added to the CPT code
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
Physicians are required to use the documentation guidelines developed by the AMA and CMS, formerly the HCFA
A referral is the same as a consultation
An eponym should not be used when a comparable anatomic term can be used in its place
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
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
The modifier reported when a physician component is reported separately is
A ____ procedure is one that is performed independently of, and not immediately related to, another service
What is the modifier used to identify the technical component of a radiologic procedure
A service that is rarely provided, unusual, variable, or new would always require a special report in determining medical appropriateness of the service
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
What type of drug test measures the presence of a drug in the specimen?
Quantitative analysis is defined as
. determining the amounts and proportions of chemical constituents
Psychiatric diagnostic interview examination includes
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
The Cardiovascular subsection contains many diagnostic/therapeutic procedures and services that are primarily divided as to whether the procedures or services are invasive or
What does the abbreviation EMG stand for
Level II national codes are not used in which setting?
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
Introduction of catheter into the aorta
A thyroid-stimulating hormone (TSH) test.
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)
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?
Percutaneous gastrostomy tube placement
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
A qualitative screening for methamphetamine
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?
SMR of nasal turbinates
Radiologic examination, nasal bones, complete, minimum of three views
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: ____________________
A wet mount to determine a vaginal yeast infection using a KOH prep.
CPT Code: ____________________
A routine ECG with 12 leads, tracing only was performed
Postoperative follow-up visit 4 weeks after a surgery that has a 90-day global period.
CPT Code: ____________________
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
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
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
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
Now provide the ICD-9 and CPT codes for the above scenario for Roy A Takashima
99215, or 99214;