CPT coding

CPT coding Category I codes Procedures or services identified by a five-digit CPT code and organized within the six sections. Main body of the CPT code book. Arranged in numeric order, with one exception the evaluation and Management section. parenthetical notes in the CPT code book indicate that a _______ code should not be reported with another code or codes. The triangle in CPT code book is used for? A revised code The + sign beside a CPT code indicates: Identifies add-on codes, for procedures that are performed at the same time and by the same surgeon The facing triangles in the CPT code book mean what? Contains new or revised text Telemedicine the remote diagnosis and treatment of patients by means of telecommunications technology. Preservice work is? paper work completed prior to the start of sadation. what paper work is completed prior to sadation? 1. Complete history with special focus on previous anesthesia or sedation. 2. Family history of family sadation 3. Summary of current medications and drug allergies 4. Physical exam of mouth, jaw, throat, neck, airway, chest, lungs, heart and circulation. 5. Vital signs 6. Review of pre-sadation testing 7. Immediate pre-sadation assessment prior to first sedation dose. 8. Intiation f IV access and fluids maintain to access. 9. reassessment form 10. Consent form P1 thru P6? classification of physical status in anesthesia patients. intraservice work(time) begins with the administration of the sadative and ends when the procedure is completed, the patient is stable for recovery status and the physician providing sadation ends personal continuous face-to-face time with the patient. in order to be required intraservice in sadation it must include these: 1. Ordering/ or adminisering the sadative. 2. Requires face-to-face time with the patient. 3. Requires monitoring patient response to the sadative including periodic assessment of the patient, administration of additional doses as needed, monitoring oxygen saturation, heart rate and blood pressure. postservice work in sadation: any additional work done after the intraservice time. like extra face-to-face time. during the wake-up time. talking with the family is also an example. this is not coded. SOAP Subjective, Objective, Assessment, and Plan layout in the medical record from the physician. CPT modifiers: there a two-digit suffix entered at the end of a CPT code. CPT Modifiers Identify how the service provided across from unusual description. Some affect payment, but others are informational only. CPT modifiers A two-character numeric descriptor used only with CPT codes. HCPCS modifiers A two character alphanumeric suffix. modifiers are used_______? Most frequently on surgery and or E/M codes and lab codes. Also common to have a hyphen in front of the modifier to separate it from the code number. CPT Modifiers are not used when_________? being entered for billing. Medicare Physician Fee Schedule Database ( MPFSDB): provides information about codes that can be used with modifiers and subsequent impact on reimbursement. ICD-10-CM and ICD-10-PCS do not have________? modifiers If nothing unusual is documented in the medical record, then you most likely will not use a modifier unless___________ It is to indicate a bilateral procedures or a HCPCS modifier to indicate the side if the body or anatomical things. HCPCS codes Healthcare Common Procedure Coding System -32 Mandatef services modifier used when required by a third-party payer, court, or other authory to perform the procedure. Second surgical opinion. -99 Multiple Modifiers Used when more than four modifiers required on a single CPT code. -GA Modifier used to allow the provider to bill the patient if medicare does not pay for the service. medical necessity not met usually. -GZ Modifier indicates an unsigned ABN and that services are expected to be denied.(Physician can not bill the patient). ABN stand for what in medical coding? Advance Beneficiary Notice Anatomic site modifiers are used on all sites except for the _____. Skin CPT modifier 50 must be used for bilateral procedures!!!! Evaluation and Management modifiers: used for encounters when procedures are not performed. An example is an H&P. Surgical/ procedural modifiers: Used when the surgical procedure is altered in a way that could affect its reimbursement. -24 modifier unrelated e/m (Evaluation and management code) service by the same physician during a postoperative period -25 modifier Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service. -32 modifier mandated services -57 modifier Decision for surgery -al modifier Principal physician of record or attending physician (Medicare) When all services included in the global package are not performed by the same physician, than a _________ is required. modifier anesthesia modifiers are? Billed and coded by the anesthesologist's office, separate from the codes of the surgeon. -53 modifier discontinued procedure -26 modifier professional component -76 modifier repeated procedure or service. -90 modifier reference (outside) lab -91 modifier medical necessity repeat test sample during the same encounter. When you have more than one procedure done on the same visit, then the_________ is sequenced first. most costly Codes that affect price or payment are generally sequenced before modifiers that are? used for informational purposes An established patient is? the patient has received professional services from the same physician or group within previous three years. All other are new patients. if a patient is not seen by the same physician or group within the past three year time frame then_____ They are considered new and can be charged the new patient fee. medical group A business organization sharing certain resources such as space and staff.