The CPT Manual Exam Review Solution 2023

The CPT Manual Exam Review Solution 2023 The Current Procedural Terminology Manual (CPT) - ANS-The CPT manual is organized according to three categories of codes. Category I: Five-digit codes with descriptions arranged by sections within the tabular list of the CPT manual Category II: A set of supplemental or optional codes used to track performance measurement Category III: Temporary codes for emerging and new technology, procedures, and services that are not officially included in the tabular list of the CPT manual CPT Tabular List Sections - ANS-The six sections and their code ranges in the tabular list include: Evaluation and Management () Anesthesia (00100-01999, ) Surgery () Radiology, including nuclear medicine and diagnostic ultrasound () Pathology and Laboratory () Medicine, except Anesthesiology () Each level of a section provides more specificity about the procedure or service performed and the anatomic site or organ system involved. The tabular index is organized so that each level of a section provides more specificity about the procedure or service performed and the anatomic site or organ system involved. Purpose of CPT - ANS-The alphabetic index acts as a guide to finding data within the textbook. What is CPT Manual based on? - ANS-The alphabetic index is based on main terms such as an anatomic site or diagnosis. Basic Steps for Coding - ANS-Read, analyze, and abstract the procedure or service present in the health record. Compare it with the encounter form, operative report, or other documentation. Review the guidelines, notes, and conventions in the tabular list to ensure that the code selected is most accurate. Abstract - ANS-to collect pertinent medical information to make an informed decision on assigning a correct code. This process ensures that all medical procedures or services present in the medical record are identified without any omission. Further, abstracted data has sections such as main terms and subterms (also known as modifying terms). These terms help to find the code or code ranges in the alphabetical index. Main Terms - ANS-the primary procedure or procedure performed such as an excision Sub Terms - ANS-further defines or adds information to the main term such as the anatomic location or the organ excised, the type of instrument used, a special technique, or whether or not other procedures were performed at the same time as the excision, such as obtaining biopsy tissue for examination Using the Alphabetical Index - ANS-Abstract the procedures from the medical documentation and determine the main and modifying terms. Select the most appropriate main term. Select one or more modifying terms, if needed to narrow the search. Repeat steps 2 and 3 using a different main term, if no main or modifying term produces an appropriate code or code range. Find the code or code ranges that include the description of the procedure found in the medical record. Searching the Alphabetical Index - ANS-Use one of the four primary classifications (or types) of main and modifying term entries: Procedure or service (e.g., examination, excision, scope) Organ or anatomic site (e.g., clavicle, mandible, humerus, liver) Condition, illness, or injury (e.g., cholelithiasis, ulcer, fracture, pregnancy) Eponym, synonym, abbreviation, or acronym (e.g., MRI [magnetic resonance imaging], Mosenthal test, GERD [gastroesophageal reflux disease]) The see statement points to another location in the alphabetical index to find the code or code range. The see also statement points to additional codes or code ranges in the alphabetical index that may be useful to the code found in the original search. Adding a semicolon (;) at the end of a main description indicates that it is followed by modifying terms and descriptions. Every indented description below a stand-alone code relates to that stand-alone code. If a main term has no additional modifying terms, there will be no indentation. The next entry is a standalone description of a different procedure positioned flush left. Stand-Alone Codes and Code Ranges A procedure or service may list a single code or a range of possible codes that may match the medical documentation. Some medical procedures and diagnostic tests are complex and may have a single (stand-alone) code or a code range. Example: The code for "Craterization, phalanges, toe" is 28124, which is a stand-alone code. However, using the same main term, "Craterization," but adding any of the phalanges (toes or fingers) generates a range of codes: . Add a hyphen for code range to indicate that all codes within that range could be possible. Some services or procedures may have a stand-alone code and a range of codes. Example: "Craterization, femur" lists both the stand-alone code 27360 and the code range 27 Using Tabular List for Coding - ANS-Search the main text and find the first code or code range given in the alphabetical index search. Compare the code description with the medical documentation. Verify if there is any additional element or information in the code description that is not present in the documentation. Read the guidelines and notes for the section, subsection, and code. This ensures correctness and avoids contraindications on usage of the code. Evaluate the conventions, especially add-on codes, and exemption from modifiers. Determine whether or not any special circumstances require the use of a modifier or a Special Report. Document the appropriate CPT code in the health record next to the procedure and in the appropriate block of the insurance claim form. CPT Coding for Surgery - ANS-Abstract the procedures or services from the procedural statement in the surgical report. Select the most appropriate main term to search in the alphabetical index. (Determine whether or not the code must be modified.)...