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Chief Complaint

The reason that the patient is seeing the physician, usually stated in his or her own words, is known as the:

Established patient

In CPT coding, a patient who was seen on October 1, 2008and then not seen again in the same medical practice until August 30, 2010, classified as a(n)


The time the health care provider spends in direct contact with a patient is called:

Level 1 codes

The AMA 5-digit codes used for reporting services performed by healthcare professionals are:


A patient's medical record must contain sufficient documentation to support the use of:

Modifying terms

A main term can stand alone, or it can be followed by up to three

Special reports

accompany the claim when a rarely used, unusual, variable or new service is performed?

Stand-alone codes.

The type of code that contains the full description of the procedure without additional explanation is the

There are ________ levels of procedural codes


The six sections listed in the main body of the CPT manual called

Category III codes

Evaluation & Management (E&M) list the three key components.

History; examination; complexity of medical decision making

Purpose of CPT coding

Accurately describes professional service(s) performed

Name the three different ways the CPT codes can be displayed.

As a single code; as multiple codes; as a range of codes

Name the four contributing factors that impact the Evaluation & Management (E&M) coding

Contributing factors

Like history-taking there are _____ degrees of patient examination


Time is never a factor when a patient is seen in an

Emergency department

How do you determine complexity of decision making?

diagnostic and treatment options were considered: the amount and complexity of data reviewed; and the amount of risk for complication, morbidity or mortality determine the

Name these symbols:



symbol is used to show that the code has been changed or modified


Symbol representing a code that is a new to the CPT book:

Horizorial triangles

Symbol identifying a change in wording of a new/revised code:

lighting Bolt

Symbol used to indicate codes for vaccines pending FDA approval:

Plus sign

Symbol indicating an add-on code

Circle with line cancel/no symbol

Symbol denoting modifier exempt codes:

Circle with dot

Symbol identifying codes that include conscious sedation:

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