Study Guide

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FOP II
Chapter 18 & 19 – The Administrative Medical Assistant- Study Guide
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CPT is the abbreviation for Current Procedural Terminology
ICD-9 is the abbreviation for International Classification of Diseases, 9th Revision
CPT is used to report the medical, surgical and diagnostic procedures and services of physicians.
An outpatient is a patient who receives care at a hospital but is not admitted.
An inpatient is a patient who has been admitted to the hospital facility.
There are six sections to the CPT manual.
Evaluation and Management codes are used for physician office visits.
Conventions are special symbols used to provide additional information about certain codes. P.
329
Bundled codes are codes that are grouped together and billed as one. p. 326
An established patient is someone who has been seen within the last three years.
Unbundled codes are separated and reported separately. P. 326
Eponyms are procedures and treatment named after a person. P.326
The Six Sections of the CPT Manual are: p.329
E_____________& ______________________,
S_______________,
A____________A
P____________ & L________________,
M______________,
R____________Y
14. A plus sign is used to indicate an add-on code in the CPT Manual. P. 330
15. A new code is indicated with a black dot.p. 330
16. A Decision Tree is a series of questions that can help the coder navigate the index and main text
of the CPT. P. 334
17. To determine the proper code, the main term must be extracted from the information provided.
18. Anesthesia coding uses a grading system of P1-P6 to determine the health status of a patient
which aids in choosing the correct code, since anesthesia is coded differently than other
procedures. P 342.
19. Converting written descriptions into numeric designations is called coding.
20. The term “see also” or “see,” directs the coder to look elsewhere. P. 302
21. Etiology is the cause of a disorder.
QUIZ yourself:
_____H & P or HPE
a. chief complaint
_____and is also:
b. Symptoms, Objective, Assessment, Plan
_____SOAP
c. to create a summary of information from a text
_____CC
d. services that support the diagnosis
_____Ancillary Services
e. and/or
_____Operative Report
f. method of determining burn percentages in adults
_____V-codes
g. cause, nature or manifestation of a condition or problem
_____Discharge Summary
h. procedure code used when the patient is not currently ill,
_____Etiology
I. the physicians’ determination of the outcome of a diagnosis
_____Diagnosis
J. New growth
_____Neoplasm
K. procedure code for burns, poisoning or external causes
_____Rule of Nines
L. Statement for Patients leaving the hospital
_____E-codes
M. the origin or cause of a disorder.
_____Prognosis
N. Statement for Patients who have had surgery
_____abstract
O. history & physical examination
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