HIM 215 Test 1 part 3

rad2329's version from 2017-02-02 19:29

Section 1

Question Answer
When would you use a miscellaneous code?Reported when no adequate Level II HCPCS code is available. Temporary and serves as a placeholder until a more specific HCPCS code indentified.
For Ambulance Modifiers what does RH mean ?The first letter indicates the origin, who encountered (Residence). the second letter indicates the destination, where the service occurred (Hospital)
CPT Modifiers are used to ?describe alterations to CPT code (additional information about the procedure, more detail, has a financial impact)
Where can you find CPT modifiers ?Appendix A
What is CPT modifier -22 Increased Procedural Service, written report with supportive documentation
What is CPT modifier -23 Unusual Anesthesia (Use of anesthesia where no anesthesia or ____ would be the norm) Written report with submission of modifier may be required
What is CPT modifier -24 Unrelated E/M Services by Same Physician or Other Qualified Health Care Professional During a Postoperative Global Period
What is CPT modifier -25Significant, Separately Identifiable E/M Service, by the Same Physician or Other Qualified Health Care Professional and Same Day of Procedure or Other Service
What is CPT modifier -50Bilateral Procedure
What is CPT modifier -51Multiple Procedure - There are three types
What is CPT modifier -52Reduced Services, Physician directed reduction (based on clinical reasons)

Section 2

Question Answer
What is CPT modifier -53Discontinued Procedure, Surgical/diagnostic procedures (patient has already been anesthetized)
What is CPT modifier -58Subsequent procedure planned or related to the first surgery (surgery is done in stages) (exp. multiple skin grafts) Staged/Related Procedure/Service by Same Physician or Other Qualified Health Care Professional During Postoperative Period
What is CPT modifier -59Distinct Procedural Service Example: Physician removes several lesions from patient’s leg, also notes and biopsies a mole of torso - (Biopsy code for mole not part of lesion removal)
What is CPT modifier -62Two Surgions (Both function as co-surgeons/equals, usually different specialties)
What is CPT modifier -63Procedure Performed on Infants Less Than 4 kg (4 kg = 8.8 lb)
What is CPT modifier -66Surgical Team (3 or more sugeons with various specialties plus technicians and other support perssonnel) exp. transplant surgery
What is CPT modifier -76Repeat Procedure/Service by Same Physician or Other Qualified Health Care Professional (example: x-rays before and after fracture repair) Not typographical error
What is CPT modifier -77Repeat Procedure/Service by Another Physician or Other Qualified Health Care Professional (Performed by one individual, repeated by another individual) Submitted with a written report to establish medical necessity may be requested
What is CPT modifier -78Unplanned Return to Operating/Procedure Room Same Physician Following Initial Procedure for a Related Procedure During Postoperative Period (For complication of first procedure) Indicates not typographical error
What is CPT modifier -79Unrelated Procedure or Service by Same Physician or Other Qualified Health Care Professional During Postoperative Period (Diagnosis would be different, Remember the EM code would have -24

Section 3

Question Answer
What are the three types of Multiple Procedures associated with CPT modifier -51?Same procedure, different sites - Multiple operation(s), same operative session - Procedure performed multiple times
Code assignment in the E/M (Evaluation and Management) section varies according to what three factors:Place of service, Type of Service, Patient Status
The levels of E/M service are based on what three Key Components:History, Examination, Medical decistion making
E/M subsections codes are in red and are grouped by type and place of serviceConsultation - Office Visit - Hospital Admission
What are the types of Physician Status ?Attending (Primary or admitting physician) and Consultant (Opinion and/or advice requested by another physician)
What are the four types of patient statusNew, Established, Outpatient, Inpatient
If a patient has not been seen by any physician of the same group within _____ years, they would be considered a new patientthree
What are the two types of Hospital Inpatient ServicesInitial and Subsequent
When are subsequent hospital care codes usedTo report daily hospital visits while the patient is hospitalized
There are ____ elements in ROS (Review of Systems)fourteen
4 Elements of Medical Decision Making (MDM) may beMinimal, Low, Moderate, or high
What is unique to discharge codes ?Only attending physician can use this code, Code is based on time spent in service, Beginning and ending time must be documented

Section 4

Question Answer
What are the eight elements for the HPI (History of Present Illness)Location, Quality, Severity, Duration, timing, Context, Modifying factors, Associated signs and symptoms
E/M Levels are divided based on what ?Key Components (KC) and Contributory Factors (CF)
Key Components (KC) comprise of the MDM whatHistory, Examination, Medical decision making
Contributory Facotors (CF) are conditions that help the physician determine the extent of the history, examination, and decision making required to treat the patient. What are the contributory factors (CF)Counseling, Coordination of care, Nature of presenting problem, and time.
What are the four elements of a patient history (Key Component 1 of the E/M Service):Chief Complaint (CC), History of Present Illness (HPI), Review of Systems (ROS), Past Family and/or Social History (PFSH)
The Chife Complaint (CC) isReason for encounter, must be documented in medical record for each encounter
The Patient History (HPI) isSubjective, discription of development of current illness by patient, Eight elements in HPI
Part of The Patient History includes _________Physician and Patient Dialogue, Provider must document
The Review of Systems (ROS) are ______ and the extent of ROS depends onOrgan systems , The Chief Complaint (CC),
Past, Family, and/or Social History contains relevant information about pastMajor illnesses/injuries, Operations, Hospitalizations, Allergies, Immunizations, Dietary status, Sexual history, Other relevant social factors (exp. Employment/Military History), Past-present medications, Social tobacco/alcohol use
A "concurrent" type of care given is ?to a patient by more than one physician (Exp. Pulmonologist and cardiologist both treating patient for different conditions at the same time)
Regarding Hospital Discharge Services, the final status of a patient includes:Condition, Medications, Plan for return to physician, How hospital stay progressed, Discharged to home/nursing facility etc.

Section 5

Question Answer
Levels of E/M service are based onNature of the presenting problem, Skill required to provide service, Time spent, level of knowledge necessary to treat patient, Effort required/assumed, Responsiblity required
Regarding Key Component 1 & 2 of the E/M Service, Component 1 has four History Levels and Component 2 has four levels of Examination, what are theyProblem focused, Expanded problem focused, Detailed, Comprehensive
Key Component 2 of the E/M isObjective Examination of Patient
Key Component 1 of the E/M isHistory
Key Component 3 of the E/M isMedical Decision making (MDM)
What are the four levels of MDM complexityStraightforward, Low, Moderate, or high
What are the three elements of Medical Decision Making (MDM) Key Component 3Number of diagnoses or management options - Data to be reviewed by physician - Risk of complications or death
Constituional (OS) includes:Blood pressure, Pulse, Respirations, Temperature, Height, Weight, General apperance
Body Areas (BA) includes:Head, Neck, Chest, Abdomen, Genitalia, grouin, buttocks, Back, Each extremity
Organ system (OS) includes:Ophthalmologic (eyes), Otolaryngologic (ears, nose, mouth, throat), Cardiovascular, Respiratory, Gastrointestinal, Genitourinary, Musculoskeletal, Integumentary (skin), Neurologic, Psychiatric, Hematologic/Lymphatic/Immunologic
What are the three other contributory factors in establishing level of service:Counseling, Coordingation of Care, nature of Presenting Problem
Regarding number 3 of contributory factors in establishing level of service (Nature of Presenting Problem) there are 5 types of Presenting ProblemMinimal, Self-limiting, Low, Moderate, high

Section 6