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
List and explain the two freestanding or hospital outpatient settings ch. 6 pg 310
- -ambulatory surgical centers
- -hospital-based outpatient department
List three HCPC Level II codes sections ch. 7 pg. 351-356
- -transportation services including ambulance
- -medical and surgical supplies
- -administrative, miscellaneous and investigational
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
List the CPT six sections and one CPT Appendix ch. 8 pg. 377
- -evaluation & management
- -Pathology & Laboratory
- -Appendix A
List the key components for E/M code ch. 9 pg. 414
- -extent of history
- -extent of examination
- -complexity of medical decision making
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
List two anesthesiologists services which are "bundled in the anesthesia code ch. 10 pg. 467-468
- -airway management
- -fluid management
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
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
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
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
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
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
Arthrodesis ch. 12 pg. 561
- surgical fixation
Arthroscopy ch. 12 pg. 568
- visual examination of inside joint
Laryngoscopy ch. 12 pg. 575
- visualization of the back of the throat
Thoracentesis ch. 12 pg. 578
-surgical puncture of chest wall with a needle to obtain fluid from the pleural cavity
Pneumocentesis ch. 12 pg. 578
puncture of the pleural space with a transthroacic needle to drain fluid or obtain material for diagnostic study.
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
When coding procedures on the cardiac valves, the valves included are ch. 13 pg. 597
Embolectomy ch. 13 pg. 606
-surgical removal of blood clot
Therapeutic apheresis ch. 13 pg. 615
-removal of blood component, cells, or plasma solute
Lymph nodes ch. 13 pg. 621
-cluster of bean-shaped nodules that act as body filtration system
Esophagoscopy ch. 14 pg. 641
-endoscope inserted down through the esphagus direct visualization
Enterolysis ch. 14 pg. 645
-freeing of intestinal adhesions
Illeostomy ch. 14 pg. 647
-colon & rectum are removed, the small intestine is brought to the adominal wall.
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
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
Vas deferens ch. 15 pg. 677
-tube that carries spermatozoa from the testis
Varicocele ch. 15 pg. 677
-an abnormal dilation of veins of the spermatic cord in the scrotum
Hysteroscopy ch. 15 pg. 683
-direct visualization of the cerivcal canal and uterine cavity using a hysteroscope.
List the three types of prostate biopsy ch. 15 pg. 679
List five services that are reported separately when performed during maternity care and delivery ch. 15 pg. 687
- -Chronci collid
- -Monitor testing of baby
Incomplete abortion ch. 15 pg. 690
-miscarriage in which part, but not all, of the uterine contents are expelled.
List the four types of abortion ch. 15 pg. 690-691
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
Adhesiolysis ch. 15 pg. 698
-purcutaneouslysis of epidural adhesions using solutions injection or mechanical means.
Ocular Adnexa ch. 15 pg. 709
-includes the orbit, eye muscles, eyelids, eyelashes, conjunctiva, and lacrimal apparatus.
Tympanoplasty ch. 15 pg. 713
-repair or reconstruction of the ear drum
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
Define the term specimen. List four types of laboratory sections ch. 17 pg. 772
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
Define Clinical Laboratory Improvement Act (CLIA)ch. 17 pg 774
National Coverage Determination (NCD) ch. 17 pg. 775
CLIA- perform certain pathology and lab test
NCD- define coverage for services and procedures
List three categories for selecting psychiatric therapeutic procedure codes ch. 18 pg. 814
- -cardiopulmonary resuscitation
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
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
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
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
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
Prospective payment system (PPS) ch. 19 pg. 857
-a reimbursement methodology that established predetermined rates based on patient category type of facility
Inpatient Prospective Payment System ch. 19 pg. 858
-diagnosis-related groups to reimburse short-term hospitals
Skilled Nursing Facility PPS ch. 19 pg. 862
-classifies residents into resource utilization groups.
Explain the purpose of a charge-master ch. 19 pg. 870
a document that contains a computer-generated list of procedures, services & supplies
Advance Beneficiary Notice (ABN)
A waiver signed by the patient acknowledge that because medical necessity for a procedure or service cannot be established.
- Includes any health care services provided to a patient who is admitted to facility
Includes radiological procedures and burn excision/debridement
Drug or agent that causes a loss of feeling, awareness and/or consciousness
A procedure done to puncture a joint for fluid removal or medication injection
visual examination of inside joint
Is the transplantation of tissue from the same individual
involves combing the mucous lining of the trachea or bronchus, in order to collect cells.
local anesthesia is injected sacral portion of the spinal cord
Standard claim submitted by physicians offices to third party payers.
The assignment of codes, to diagnosis, services and procedures based on patient record documentation.
Coding compliance program
ensures that the assignment of codes for diagnosis, procedures or services follow established coding guidelines by CMS.
The review of records and/or use of encounter forms or document during a visit or "real time".
Continuity of Care
Primary purpose of the health record
Coordination of care
When the physician makes arrangements with other providers or agencies for services to be provided to a patient
Is organized by alphabetical main terms printed in boldface
Clarify services and procedures performed by providers
Is performed for conditions, such as acne and scarring and general keratosis.
surgical removal of blood clot
endoscope inserted down through the esphagus direct visualization
Is one who has received professional services from the physician or same group practice
Acute inflammation of skin's connective tissue that is caused by infection with bacteria.
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.
used for extensive surgeries and patient is unconscious
combat waste, fraud and abuse in health insurance and healthcare delivery
Hospital discharge service
Includes the final examination of the patient and discussion of the hospital delivery.
often internists, who handles a patient's entire inpatient admission.
Arranged in strict chronological date order
visualization of the back of the throat
cluster of bean-shaped nodules that act as body filtration system
The information in the health record must justify diagnostic and/or services provided consistent with standards of good medical practice.
a vocabulary of clinical medical terms
Autologous graft consisting of both skin and muscle tissue form the donor site
National Correct Coding Initiative
Monitors inappropriate reimbursement of MEdicare Part B claims
Nature of presenting problem
Monitors inappropriate reimbursement of Medicare Part B claims.
Is one who has not received any professional services from the physician.
Receives services furnished on a hospitals premises that are ordered by a physician and including use of a bed and clinical services.
Incision into bone
Is a short term, intensive treatment program where individuals who are experiencing an acute episode of an illness.
A tuft of hair that developed as the result of repeated friction, which caused hairs to penetrate the skin.
Place of Service
Refers to the physical location where health care is provided to patients
puncture of the pleural space with a transthroacic needle to drain fluid or obtain material for diagnostic study.
An ulceration of the skin and underlying tissue that occurs over a body prominence.
Physicians services involving patient contacts that are considered beyond the usual services
surgical attachment of a finger; a hand, a toe, a leg, or an arm that has been severed from body
Source oriented record
Organized according to documentation source
Subsequent hospital care
Includes the review of the patient's record for changes in the patient condition.
removal of blood component, cells, or plasma solute
surgical puncture of chest wall with a needle to obtain fluid from the pleural cavity
Type of Service
Refers to the kind of health care services provided to patients
Includes probable, suspected and questionable diagnosis, which are not coded
Unlisted procedure or service
No CPT code and special report must accompany the claim
Is the removal of a portion of lung, less than a "segment"
Is the transplantation of tissue from a different species.