The CPT Manual Questions And Answers With Real Tests

Abstract - 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. Anesthesia Codes (CPT-4 Codes) - The codes used in the anesthesia section of the tabular list are also known as CPT-4 codes. Anesthesiologists and Certified Registered Nurse Anesthetists (CRNAs) generally use these codes. These codes are used for conscious sedation and general anesthesia (which renders the patient unconscious during the procedure). Anesthesia coding is essentially different from any other form of coding in the way the anesthesia services are billed. Codes for conscious sedation are found in the medical section. CPT-4 codes start with a zero and are used to identify the anatomic location of surgery performed. Anesthesia Conversion Factor Formula - The dollar value of each basic unit is called the conversion factor. Each third-party payer issues a list of conversion factors. The conversion factor assigned to a specific location is multiplied with each basic unit value. Calculation of the payment of anesthesia service involves basic unit value (B), modifying unit (M), time unit (T), physical status modifier, if applicable (PS), and the conversion factor. The formula used for anesthesia billing is: (B + M + T + PS) × Conversion factor Anesthesia CPT Code Formula - To bill anesthesia services, the following standard formula is used: Basic unit values (B) + Time units (T) + Modifying units (M) Basic unit value (B) The numeric value assigned to each anesthesia service based on the level of complexity using the Relative Value Guide (RVG).Time Units (T) The time (in hours and minutes) of how long anesthesia services were administered to the patient. Generally, one time unit is equal to 15 minutes. The time starts when the anesthetist prepares the patient and ends when the patient is no longer under anesthetist care. The time is documented in the patient's health record. Modifying Units (M) A condition or circumstance that changes the environment in which the anesthesia service was provided. Modifying units are based on the qualifying circumstances and physical status modifiers, which are the modifying features of anesthesia services. The physical status modifiers include: P1 for a normal healthy patient P2 for a patient with mild systemic disease P3 for a patient with severe systemic disease P4 for a person with systemic disease that is threat to life P5 for a moribund patient who is not expected to survive without the procedure P6 for a declared brain-dead patient whose organs are being removed for donor purposes.Basic Steps for Coding - 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. Choosing E/M coding - Identify the POS: the MA should identify the place of service where the patient receives medical service from the provider to determine the most accurate CPT E/M code. Identify the patient status: the MA should identify the patient status as "new" or "established."Identify the subsection, category, or subcategory of service. Determine the level of service by determining the extent of the history obtained, the extent of examination performed, and the amount of complexity involved in making the medical decision. Ensure the selection of appropriate service by comparing the medical documentation with the examples in Appendix C of the CPT manual. History, examination, and medical decision-making are the key components while determining the level of service for E/M procedure coding. Contributing complexity factors (Coordination of Care) - A patient may be in need of care even after the visit or hospitalization. Coordination of care determines the level of service when it exceeds 50% of the patient encounter. Contributing complexity factors (Counseling) - This involves interacting with a patient and the family members regarding the diagnostic results, treatment options, and the follow-up.