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50 terms

CPT Final

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False
The principal diagnosis is defined as the most serious condition during a patient's hospital stay.
False
The American Hospital Association is responsible for the development of ICD-10-PCS.
True
A principal procedure is one that is performed for definitive treatment rather than for diagnostic or exploratory purposes, or one necessary to take care of a complication.
Carries an anesthetic shock.
Is surgical in nature.
Requires specialized training.
A significant procedure is one that:
True
The removal of a tooth is an example of an extraction.
Resection
The root operation that is defined as cutting out or off, without replacement, all of a body part is:
True
The Centers for Medicare and Medicaid Services (CMS) is responsible for the development of ICD-10-PCS.
True
The ICD-10-PCS has a seven character alphanumeric code structure.
True
The Official Guidelines for Coding and Reporting are updated every year.
True
In the inpatient setting, the physician documents possible aspiration pneumonia in the discharge summary. The aspiration pneumonia is coded as if it exists.
Abdominal pain, peptic ulcer disease, cholecystitis
The discharge summary states the patient's diagnosis is acute abdominal pain due to peptic ulcer disease or cholecystitis. Which diagnosis should be reported?
Release
The root operation that is defined as freeing of a body part is:
False
It is unacceptable to assign codes in the inpatient setting to diagnoses that are documented as being "probable," "suspected," or "likely."
False
In the inpatient setting, a CPT code would be assigned for a procedure code.
Drainage
The root operation that is defined as taking into or letting out of fluids and/or gases in a part of a body is:
False
In the inpatient setting, the principal diagnosis is also called the "first-listed" diagnosis.
True
The tabular list contains grids that represent the last four characters of a procedure code.
Exacerbation of asthma
Patient is admitted following an outpatient procedure because of an exacerbation of the patient's asthma. What is the principal diagnosis?
Revision of device in
The root operation is defined as correcting a portion of a previously performed procedure is:
True
In the inpatient setting, a procedure code from ICD-9-CM Volume 3 would be assigned to identify a procedure.
Urinary tract infection
Patient is admitted with dysuria due to a severe urinary tract infection. Which diagnosis should be reported?
Uniform Hospital Discharge Data Set
The acronym UHDDS stands for:
True
The use of a POA indicator is required for all acute-care facilities that are reimbursed under MS-DRGs.
Both peptic ulcer disease and chronic cholecystitis (either can be principal)
The discharge summary states the patient's diagnoses are peptic ulcer disease versus chronic cholecystitis. Which diagnoses should be reported?
True
When two or more diagnoses equally meet the definition for principal diagnosis, either one can be selected as the principal diagnosis.
procedures
CPT is used to code:
annually
The CPT code book is updated:
AMA
Who publishes the CPT code book?
A diagnosis
What must each procedure submitted on a claim be linked to?
Evaluation and Management
What does E/M stand for in CPT?
5
A CPT code is a ____ digit number with the possiblity of a two digit modifier.
Modifier
A two digit ___ may be added after the main CPT number when necessary to indicate that additional factors should be considered or to further explain the situation.
Bullet
A ___ in the CPT code book indicates a new code.
Semicolon
A ___ separates main and subordinate clauses in code description -- used to save space.
Established
An ____ patient has been seen by the doctor or a doctor from that practice within the past three years.
Medical Decision Making
MDM stands for:
Durable Medical Equipment
DME stands for:
Base + Time + Modifying * Conversion Factor
What is the anesthesia formula?
Guidelines
Where is specific coding information about each section located in the CPT code book?
Current Procedural Terminology
CPT stands for:
CMS 1500
The universal health insurance form for submission for outpatient services is the:
Very low birth weight
VLBW stands for:
Range
If the index shows the following suggested numbers 99211-99214, this is called a ____ of numbers.
Physical status modifiers, qualifying circumstances
When coding anesthesia, there are two types of modifiers you add when given the information. List one of these modifiers.
Outpatient
A patient who has not been formally admitted to a health care facility like a hospital is called an:
Comprehensive
The highest level of examination is the:
Initial
The first visit made by the doctor with the patient is called an ___ visit.
Subsequent
The second visit made by the doctor with the patient is called the ___ visit.
Space
Semicolons and indentations are used in CPT code book to save:
1. Never code directly from the index.
2. Analyze the statement or description provided that designates the item that requires a code.
3. Identify the main term in the index.
4. Check for relevant subterms under the main term.
5. Note the code(s) found after the selected main term or subterm.
6. Verify the code in the tabular.
CPT Coding Process: