1. List and explain two guidelines that should be followed when activating the physician query process ch.1 pg.15
    • Legibility- illegible handwritten patient records
    • Completeness- abnormal test results but clinical significance of results is not documented
  2. List and explain the two freestanding or hospital outpatient settings ch. 6 pg 310
    • -ambulatory surgical centers
    • -hospital-based outpatient department
  3. List three HCPC Level II codes sections ch. 7 pg. 351-356
    • -transportation services including ambulance
    • -medical and surgical supplies
    • -administrative, miscellaneous and investigational
  4. List four types of provider which CPT codes are used to report services and procedures performed ch. 8 pg. 372
    • -home health care & hospice agencies
    • -outpatient hospital departments
    • -physicians who are employees of a health care facility
    • -physicians who see patients in their offices or clinics and in patients homes
  5. List the CPT six sections and one CPT Appendix ch. 8 pg. 377
    • -evaluation & management
    • -Anesthesia
    • -Surgery
    • -Radiology
    • -Pathology & Laboratory
    • -Medicine
    • -Appendix A
  6. List the key components for E/M code ch. 9 pg. 414
    • -extent of history
    • -extent of examination
    • -complexity of medical decision making
  7. List the four extent of history type for E/M ch. 9 pg. 415
    • -problem focused history
    • -expanded problem focused history
    • -detailed history
    • -comprehensive history
  8. List two anesthesiologists services which are "bundled in the anesthesia code ch. 10 pg. 467-468
    • -airway management
    • -fluid management
  9. In order to locate a surgery code, list the four important components in an operative report ch. 11 pg 500
    • -body system
    • -anatomic site
    • -surgical approach
    • -type of procedures performed
  10. List three important factors or situations that is not included in the CMS global surgery package ch. 11 pg. 507
    • -initial consultation or evaluation services by the surgeon to determine need for major surgery
    • -visits unrealted to the diagnosis for which surgical procedure is performed
    • -diagnostic tests & procedures
  11. List and describe three types of skin lesions ch. 11 pg. 519
    • -Bulla (large blister): greater than 10mm
    • -Macule: less than 1 cm
    • -Nodule: greater than 10mm
  12. List three factors when assigning codes for skin grafts ch. 11 pg. 528
    • -permanent or temporary
    • -natural or manufactured graft material
    • -use of skin components
  13. List and explain two types of fractures and/or fracture treatment ch. 13 pg. 548
    • -closed fracture:broken bones do not protrude through skin, no open wounds
    • -open fracture:broken bones that can be seen, clinically requires an injury
  14. Replantation ch. 13 pg. 552
    -surgical attachment of a finger; a hand, a toe, a leg, or an arm that has been severed from body
  15. Arthrodesis ch. 12 pg. 561
    - surgical fixation
  16. Arthroscopy ch. 12 pg. 568
    - visual examination of inside joint
  17. Laryngoscopy ch. 12 pg. 575
    - visualization of the back of the throat
  18. Thoracentesis ch. 12 pg. 578
    -surgical puncture of chest wall with a needle to obtain fluid from the pleural cavity
  19. Pneumocentesis ch. 12 pg. 578
    puncture of the pleural space with a transthroacic needle to drain fluid or obtain material for diagnostic study.
  20. List and explain the two types of pacing cardioverter-defibrillator ch. 13 pg. 594
    • -single chamber: contains one single electrode positioned in hearts of the r. atrium, r. ventricle
    • -double chamber: contains two electrodes one placed in r.atrium and the other in the r.ventricle
  21. When coding procedures on the cardiac valves, the valves included are ch. 13 pg. 597
    • -aortic
    • -mitral
    • -pulmonary
    • -tricuspid
  22. Embolectomy ch. 13 pg. 606
    -surgical removal of blood clot
  23. Therapeutic apheresis ch. 13 pg. 615
    -removal of blood component, cells, or plasma solute
  24. Lymph nodes ch. 13 pg. 621
    -cluster of bean-shaped nodules that act as body filtration system
  25. Esophagoscopy ch. 14 pg. 641
    -endoscope inserted down through the esphagus direct visualization
  26. Enterolysis ch. 14 pg. 645
    -freeing of intestinal adhesions
  27. Illeostomy ch. 14 pg. 647
    -colon & rectum are removed, the small intestine is brought to the adominal wall.
  28. List four important guidelines to report codes correctly for a hernia repair procedure ch. 14 pg. 656
    • -determining the site
    • -patients age
    • -use of mesh
    • -what type it is
  29. The urinary system includes-explain two functions of the urinary system ch. 14 pg 657
    • -urtheter: dispose of wastes into a fluid form
    • -bladder: what holds the extra fluid wastes
  30. Vas deferens ch. 15 pg. 677
    -tube that carries spermatozoa from the testis
  31. Varicocele ch. 15 pg. 677
    -an abnormal dilation of veins of the spermatic cord in the scrotum
  32. Hysteroscopy ch. 15 pg. 683
    -direct visualization of the cerivcal canal and uterine cavity using a hysteroscope.
  33. List the three types of prostate biopsy ch. 15 pg. 679
    • -needle
    • -punch
    • -incisional
  34. List five services that are reported separately when performed during maternity care and delivery ch. 15 pg. 687
    • -Amniocentesis
    • -Chronci collid
    • -Cordocentesis
    • -Contractions
    • -Monitor testing of baby
  35. Incomplete abortion ch. 15 pg. 690
    -miscarriage in which part, but not all, of the uterine contents are expelled.
  36. List the four types of abortion ch. 15 pg. 690-691
    • -incomplete
    • -missed
    • -septic
    • -induced
  37. When skull base surgery is performed, list three facts when reviewing the operative report to ensure appropriate coding ch. 15 pg. 696
    • -size of tumor
    • -anatomy of patient
    • -if the procedure has been operated before
  38. Adhesiolysis ch. 15 pg. 698
    -purcutaneouslysis of epidural adhesions using solutions injection or mechanical means.
  39. Ocular Adnexa ch. 15 pg. 709
    -includes the orbit, eye muscles, eyelids, eyelashes, conjunctiva, and lacrimal apparatus.
  40. Tympanoplasty ch. 15 pg. 713
    -repair or reconstruction of the ear drum
  41. List and define five radiology procedures ch. 16 pg. 731-732
    • -MRI: device used to view the organ or structure
    • -PET: images of the body to track blood or metabolism
    • -X-Ray: image of the internal body to visualize bones and tendons.
    • -Ultrasound: a device used to see internal organs and fetal
    • -CT: x-ray of the body to view images
  42. Define the term specimen. List four types of laboratory sections ch. 17 pg. 772
    • -Biophysical
    • -Chemical
    • -Cytological
    • -Hematological
  43. What is the difference between pathology and laboratory? Describe the responsibilities of a pathologist. ch. 17 pg. 774-775
    • -pathology: tissue is submitted for examination
    • -laboratory: describes the performance of lab tests.
    • pathologists- assume responsibility for test resumes
  44. Define Clinical Laboratory Improvement Act (CLIA)ch. 17 pg 774
    National Coverage Determination (NCD) ch. 17 pg. 775
  45. CLIA- perform certain pathology and lab test
    NCD- define coverage for services and procedures
  46. List three categories for selecting psychiatric therapeutic procedure codes ch. 18 pg. 814
    • -cardiopulmonary resuscitation
    • -cardioversion
    • -thrombolysis
  47. When reporting codes for cardiac catheterization procedures, you must review the health record to determine three important factors ch. 18 pg. 818
    • -catheter placement
    • -injection procedure
    • -supervision and interpretation of fluroscopic guidance
  48. Explain "sleep medicine testing" ch. 18 pg. 821-822
    include sleep studies that are performed for continuous monitoring and recordings of sleep for 6 or more hours
  49. Explain how to report hydration codes ch. 18 pg. 826
    -hydration codes are reported for the IV of prepackaged fluids and electrolytes. Review patient record for documentation that the physician supervised: patient assessment, patient consent, staff members who provided infusion services
  50. List four types of third-party payers ch. 19 pg. 845
    • -Blue Cross and Blue Shield
    • -Commerical Insurance Companies
    • -Employer Self-Insurance Claims
    • -Workers Compensation
  51. What is the difference between CMS 1491, CMS 1500, UB 04 ch. 19 pg. 849
    • -CMS 1491: ambulance services
    • -CMS 1500: non-institutional providers and supplies
    • -UB 04: institutional providers (inpatient and ouptatient) non-institutional providers
  52. Prospective payment system (PPS) ch. 19 pg. 857
    -a reimbursement methodology that established predetermined rates based on patient category type of facility
  53. Inpatient Prospective Payment System ch. 19 pg. 858
    -diagnosis-related groups to reimburse short-term hospitals
  54. Skilled Nursing Facility PPS ch. 19 pg. 862
    -classifies residents into resource utilization groups.
  55. Explain the purpose of a charge-master ch. 19 pg. 870
    a document that contains a computer-generated list of procedures, services & supplies
  56. Advance Beneficiary Notice (ABN)
    A waiver signed by the patient acknowledge that because medical necessity for a procedure or service cannot be established.

    • Ambulatory
    • Includes any health care services provided to a patient who is admitted to facility
  57. Anesthesia services
    Includes radiological procedures and burn excision/debridement
  58. Anesthetic
    Drug or agent that causes a loss of feeling, awareness and/or consciousness
  59. Arthrocentesis
    A procedure done to puncture a joint for fluid removal or medication injection
  60. Arthrodesis
    surgical fixation
  61. Arthroscopy
    visual examination of inside joint
  62. Autograft
    Is the transplantation of tissue from the same individual
  63. Brushing
    involves combing the mucous lining of the trachea or bronchus, in order to collect cells.
  64. Caudal anesthesia
    local anesthesia is injected sacral portion of the spinal cord
  65. CMS 1500
    Standard claim submitted by physicians offices to third party payers.
  66. Coding
    The assignment of codes, to diagnosis, services and procedures based on patient record documentation.
  67. Coding compliance program
    ensures that the assignment of codes for diagnosis, procedures or services follow established coding guidelines by CMS.
  68. Concurrent coding
    The review of records and/or use of encounter forms or document during a visit or "real time".
  69. Continuity of Care
    Primary purpose of the health record
  70. Coordination of care
    When the physician makes arrangements with other providers or agencies for services to be provided to a patient
  71. CPT Index
    Is organized by alphabetical main terms printed in boldface
  72. CPT Modifiers
    Clarify services and procedures performed by providers
  73. Dermabrasion
    Is performed for conditions, such as acne and scarring and general keratosis.
  74. Embolectomy
    surgical removal of blood clot
  75. Esophagoscopy
    endoscope inserted down through the esphagus direct visualization
  76. Established patients
    Is one who has received professional services from the physician or same group practice
  77. Extensive cellulitis
    Acute inflammation of skin's connective tissue that is caused by infection with bacteria.
  78. First Listed diagnosis
    Reported for outpatient care instead of the principal diagnosis, it is the diagnosis, condition, problem or other reason for the encounter/visit.
  79. General anesthesia
    used for extensive surgeries and patient is unconscious
  80. HIPAA
    combat waste, fraud and abuse in health insurance and healthcare delivery
  81. Hospital discharge service
    Includes the final examination of the patient and discussion of the hospital delivery.
  82. Hospitalist
    often internists, who handles a patient's entire inpatient admission.
  83. Integrated record
    Arranged in strict chronological date order
  84. Laryngoscopy
    visualization of the back of the throat
  85. Lymph nodes
    cluster of bean-shaped nodules that act as body filtration system
  86. Medical necessity
    The information in the health record must justify diagnostic and/or services provided consistent with standards of good medical practice.
  87. Medical nomenclature
    a vocabulary of clinical medical terms
  88. Mycocutaneous flap
    Autologous graft consisting of both skin and muscle tissue form the donor site
  89. National Correct Coding Initiative
    Monitors inappropriate reimbursement of MEdicare Part B claims
  90. Nature of presenting problem
    Monitors inappropriate reimbursement of Medicare Part B claims.
  91. New patient
    Is one who has not received any professional services from the physician.
  92. Observation patients
    Receives services furnished on a hospitals premises that are ordered by a physician and including use of a bed and clinical services.
  93. Osteotomy
    Incision into bone
  94. Partial Hospitalization
    Is a short term, intensive treatment program where individuals who are experiencing an acute episode of an illness.
  95. Pilonidal cyst
    A tuft of hair that developed as the result of repeated friction, which caused hairs to penetrate the skin.
  96. Place of Service
    Refers to the physical location where health care is provided to patients
  97. Pneumocentesis
    puncture of the pleural space with a transthroacic needle to drain fluid or obtain material for diagnostic study.
  98. Pressure ulcer
    An ulceration of the skin and underlying tissue that occurs over a body prominence.
  99. Prolonged Service
    Physicians services involving patient contacts that are considered beyond the usual services
  100. Replantation
    surgical attachment of a finger; a hand, a toe, a leg, or an arm that has been severed from body
  101. Source oriented record
    Organized according to documentation source
  102. Subsequent hospital care
    Includes the review of the patient's record for changes in the patient condition.
  103. Therapeutic apheresis
    removal of blood component, cells, or plasma solute
  104. Thoracentesis
    surgical puncture of chest wall with a needle to obtain fluid from the pleural cavity
  105. Type of Service
    Refers to the kind of health care services provided to patients
  106. Uncertain diagnosis
    Includes probable, suspected and questionable diagnosis, which are not coded
  107. Unlisted procedure or service
    No CPT code and special report must accompany the claim
  108. Wedge resection
    Is the removal of a portion of lung, less than a "segment"
  109. Xenograft
    Is the transplantation of tissue from a different species.
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