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Primary Diagnosis

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a diagnosis that represents the patient's major illness or condition for an encounter

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Sub term

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A word or phrase that describes a main term in the alphabetic Index of ICD-9-CM. appearing in the Alphabetic Index under MAIN TERMS and always indented two spaces to the right

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Tabular List

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The section of the ICD-9-CM in which diagnosis codes are presented in numerical order. It consists of 17 chapters, codes range from 001-999, The chronological list of codes, VOLUME 1

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ICD-9-CM ; ICD-10-CM

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A manual that has the classification system for diseases and injuries

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eponyms

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Diseases or procedures named after a person

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etiology

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The study of the cause or origin of a disease

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manifestation

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A sign or symptom of a disease

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Late effects

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is a residual problem remaining after the acute phase of and illness or injury has terminated.

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Also known as the Tabular List, containing all the diagnostic codes grouped into 17 chapters of disease and injury

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Volume 1

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As part of the Medicare Catastrophic Coverage Act of 1988, providers were required to

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use ICD-9-CM Codes to document Conditions

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The Clinical Modification of the ICD-9 was developed by

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NCHS National Center for Health Statistics

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As of 1948, the ICD became known as

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International Classification of Diseases

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ICD information was used by WHO for the following reasons

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To keep track of Morbidity To keep track of mortality To make statistical assessments for international health

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The first form of Medical diagnostics coding date back to

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16th Century-England

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The London Bills of Mortality were first introduced mainly to

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warn us about the plague epidemics

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ICD - 9 codes are used by outside agencies to

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conduct studies of trends in diseases review costs forecast healthcare needs

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Diagnosis Codes submitted on insurance claim forms are generally used to

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determine benefit coverage

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The first step in the reimbursement process of healthcare claim is

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Reading and Understanding the Physician's documents or Medical reports.

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Diagnostic coding changes for Volumes 1&2 of the ICD-9-CM are made

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Annually on October 1

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Revisions to Volume 3 are made by:

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CMS; Centers for Medicare and Medicaid Services

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Updates to Volume 1&2 of the ICD-9-Cm may include:

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Adding New Codes Deleting Old Codes Revisions

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The ICD-10-CM uses codes that are:

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alpha-numeric

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Improvements in the ICD-10-CM include what

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Additional information that is relevant to Managed care. A reduction in the number of codes needed to fully describe a condition.

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Volume 1 of the ICD-9 is known as the

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Tabular list of Diseases or Numeric list of Diseases

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Volume 2 of the ICD-9 is known as the

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Alphabetic Index of diseases

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Volume 3 of the ICD-9 is known as the

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Tabular & Alphabetic Index of Procedures

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Volume 3 of the ICD-9-CM is used by

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Hospital to Code Procedures

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Tables found in Volume 2 of the ICD-9-CM include all of the following;

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hypertension Drugs and Chemicals Neoplasms

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External causes of poisoning include the following categories

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Assault suicide attempt therapeutic use ?

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When the physician determines the patients main reason for the encounter, it is called

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Primary diagnosis

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Sub terms in an ICD-9-CM may show

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the cause or the origin of the disease ?

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An example of a eponym

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Hodgkin's disease

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When coding a pregnancy test with a positive result using Volume 2 of ICD-9, the Main term to look up is:

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Positive ?

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When coding narrowing of the vertebral artery with cerebral infarction using Volume 2 of the I-9, the main term to look up is:

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Narrowing ?

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Volume 1 should be referred to by a coder after:

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the condition/disease has been located in Volume 2

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Square brackets are used i Volume 1 of the I-9 to enclose

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synonyms

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Instructional notes are used in Volume 1 of the I-9 to:

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Provide coding instructions

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The first step that should be followed in order to obtain the accurate, most -specific code is

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by reading the doctor's report locate the reason for the visit

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If the physician cannot determine the diagnosis at the time of the encounter, the specialist should:

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Code the symptoms, signs, or reason for the encounter

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If a patient is present with no complaints of illness or injury, the coding specialist should use:

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V codes ?

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Major categories of E codes include the following

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Accidental falls Assaults or purposely inflicted injury late effects of accidents or self injury

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When coding acute Serous otitis media, the main term a coder would look up is:

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Serous

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Coding burns are based on:

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The degree of severity of the burn The location of theburn The percentage of the total body burned

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Type 1 diabetes mellitus indicates that the

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patient is insulin-dependent

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The rule of nine

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used to estimate surface area of a burn. it divides the body into 11 pieces, each making up about 9% of the body. it is used to calculate fluid loss replacement necessary to prevent dehydration.

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The current procedural terminology (CPT) is published by

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AMA American Medical Association

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The current CPT system uses codes with how many digits

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5 digits

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CPT codes are implemented each year on:

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January 1

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The codes that describe a procedure or service with a five digit numeric code and descriptor are:

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Category 1 CPT codes

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The temporary codes used for emerging technology, services, or procedures are:

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Category 111 cpt codes Category one hundred eleven cpt codes

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The health Portability & Accountability Act HIPPA supports the

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elimination of category 111 cpt codes

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How are the 8 sections of the CPT code book divided?

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6 sections in Category 1 1 section in Category 2 1 section in Category 3

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What are the sections of the category 1 CPT codes?

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Evaluations and Management Surgery Medicine

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The first section of the CPT Code book is :

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Evaluation and Management 99201-99499

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The symbol "+" used with a CPT code indicates:

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add- on code

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The symbol a solid triangle used with a CPT code indicates:

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A revised code

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In order to report that a description of a service or procedure has been altered in someway, the coder should use:

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a Modifier

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The modifier 21 is used to indicate

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A prolonged evaluation and management service E/M

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The modifier 25 is used to indicate

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significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service.

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The modifier 52 is used to indicate:

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Reduced services

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The modifier 57 is used to indicate:

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a decision for surgery

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If a physician began an initial gynecological exam on a patient, but, due to the patient's extreme discomfort, discontinued it, the modifier would be

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modifier 52

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The most often reported evaluation and management services are:

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office & other out patient services.

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A new patient is considered one who has not received professional services from the doctor or another doctor of the same specialty in the same group within the past

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3 years,

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The transfer of the total care of a patient from one doctor to another is called

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Referral

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When a second physician examines a patient and renders an opinion, the service is referred to as a :

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consultation

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In order to code for an evaluation & Management service, the following are elements that must be documented:

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History, Exam, & medical decision making.

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counseling with a patient or family can be considered in coding an evaluation & management service if it pertains to :

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prognosis risks & benefits of treatment options diagnosis results

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The review of system (ROS) is considered part of :

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The history of the patient

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The classes of main entries found in the CPT index include the following

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organs, other anatomic site synonyms, eponyms abbreviations & conditions.

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If only one code for a procedure or service occurs in the index, the coder should

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Verify the code in the main text of the CPT book.

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Example of procedures or services include the following

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osteopathic manipulation evaluation & management arthroscopy

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In the CPT index, all topics referring to CPT code sections or chapters headings are listed in:

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bold uppercase letters

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If 2 codes apply to an entry in the CPT index, the codes are separated by a;

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Comma

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The modifier used to report a bilateral procedure is:

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modifier 50

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Modifier-47 is used to report

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anesthesia by a surgeon

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A special report submitted with a claim can be used to:

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detail the reason for the variable procedure

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The modifier used to identify a procedure that is discontinued is :

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modifier -53

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When one doctor provides surgical care only and does not provide the preoperative and or post operative management, the coder should use modifier

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modifier - 54

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When two or more modifiers are necessary to completely define a service, the medical coder should use:

answer

modifier - 99

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All services or procedures coded must be:

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preformed by the physician who is billing the patient, & documented in the patients chart.

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Codes to be reported for each day's services are ranked in the order of :

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highest to lowest reimbursment rate.

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The anesthesia section of the code book can be found directly before the:

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surgery section

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Anesthesia is reimbursed according to the :

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time under anesthesia

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A bundled code refers to a :

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group of related procedures covered by a single code.

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The usual services of an anesthesiologist include the following

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monitoring the patient post surgery recovery from anesthesia routine preoperative visits to evaluate the patient for planned anesthesia, & administration of fluids during the period of the anesthesia care.

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The subsections under anesthesia in the CPT Coding book are organized by:

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types of surgery or procedure.

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The physical status modifier P1 refers to a:

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normal, healthy person

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The add on code used to identify that a patient is younger than 1 year old and is receiving anesthesia is:

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+99100

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The largest section of the CPT coding book is :

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Surgery

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The subsection of the surgery section of the CPT Code book is broken down by:

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body system

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The body systems listed as subsections under surgery in the CPT code book include:

answer

integumentary system male genital system maternity care & delivery.

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Types of surgical procedures can be described as:

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excisions, removal, & incisions

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A closed manipulation or repair of a fraction is considered:

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surgery

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Add-on codes describe procedures/services that are performed:

answer

in addition to the primary procedure.

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Procedures that represent the total procedure that was performed are reported by using a

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stand alone code

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Examples of when add-on codes would be used:

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complicated closure of a second wound, anesthesia of a patient more than 70 years of age, & a biopsy of a second or third lesion.

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Codes identified by the symbol of a circle with a back slash through it are:

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exempt from modifier -51

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The globial surgical period is typically between

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0 - 90 days

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Globial surgical packages are determined by:

answer

each individual third party payer.

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