1
Beginning Coding
Study Guide: Final Examination
Mrs. Dasalla
Please note that this may not be used during exam. You must submit it to me before you are given the exam.
What is a procedure or service descriptor? Words that follow a code number in CPT
What is a stand alone code? Code has all words that describe code that follows
What codes are used for procedures that are experimental? Does it require a report from third party payers? Unlisted/category II and are required by third
party payers who determine the content of the surgical package
List items that are included in a surgical package. General anesthesia, follow-up care, E/M visit to make decision for the surgery
What is local anesthesia? Local infiltration, metacarpal/digital block, topical anesthesia.
Other types: general, regional, local sedation
Conscious sedation-no pain to patient and they are not completely asleep
Anesthesia status modifiers-indicates patient’s condition at time anesthesia was given
Global surgery period for major procedures=90 days and includes all routine preoperative and postoperative care
Local anesthesia used for excision and simple closure benign lesions of skin.
Anesthesia codes divided by-anatomic site first, Anesthesia services-time begins when preparing the patient for anesthesia
CRNA-can administer anesthesia under direction of anesthesiologist
Divisions of surgery section based on-body systems
Surgical destruction-may be part of a surgical procedure
“Separate procedure” procedure usually minor that would be reported if it was the only service provided.
Appendix A-Modifiers-and inside cover of CPT
Appendix B-Additions, deletions
Appendix C-Clinical examples E/M codes
Appendix D-add-on codes
Revisions-reflect technological advances made in medicine
Guidelines-specific coding information about each section
CPT-published by AMA, which have codes with 5 digits and are considered Category I
Add-on codes-identify codes that are never used alone
Modifiers-provide additional info (bilateral procedure etc.)to third-party payers and can affect payment
Category III codes released twice a year
E/M levels based on documentation, key components, contributing factors
Subjective-chief complaint-patients words, Objective-examination
MDM-based on # of diagnoses, risks, data
Time-factor for critical care codes, Age-factor for preventative service code