CPT

Professional component

26

Assistant surgeon

80

To report the services of the assistant surgeon, add modifier

80

Appendix A

Detailed description of each of the modifiers used with CPT codes

Tendons are thin sheets of fibrous connective tissue

False, fascia is

An osteotomy is the completion of plastic surgery on a bone

False, it is osteoplasty vs sawing or cutting of a bone

bundle of His

a conduction of fibers that cause contraction of the heart

dermatome

a cutting instrument that cuts slices of skin; the thickness is determined by the surgeon

tendon

a dense fibrous band of connective tissue that attaches muscles to bones

venous access device

a device or catheter that allows for access to the venous system

pedicle flap

a flap of skin that hangs on a stem of skin that contains a blood vessel

free graft

a graft in which the tissue is totally freed from its original site

homograft or homologous graft

a graft involving tissue from an individual of the same species; also called a homograft

epidermal autograft

a graft of the epidermal layer only

rhinotomy

a surgical incision that is made along one side of the nose

thoracoscopy

examination of the pleura, lungs, and/or mediastinum using an endoscope to visualize the area

Excision

full-thickness removal of a lesion and the margins of tissue that surround the lesion that were also removed

veins

move deoxygenated blood back to the heart (with the exception of the pulmonary vein)

arteries

move oxygen-rich blood from the heart to the rest of the body (with the exception of the pulmonary artery)

Modifier 58

staged or related procedure or service by the same physician during the postoperative period

Modifier 79

unrelated procedure or service by the same physician during the postoperative period

Modifier 23

unusual use of general anesthesia

atria

upper chambers of the heart 2 receive blood from the veins

strapping

use of tape or bandage to bind, protect, or immobilize an anatomical structure

therapeutic procedures

used as part of the care plan and treatment of a diagnosis

A mandated service is reported using modifier

32

Important components of the definition for new patient, to be considered when you select a code include the terms

*Same specialty or subspeciality. •Same group practice. •Three years.

Place of Service Code(s) and Place of Service Name

01 Pharmacy 02 Unassigned 03 School 04 Homeless Shelter 05 Indian Health Service Freestanding Facility 06 Indian Health Service Provider-Based Facility 07 Tribal 638 Freestanding Facility 08 Tribal 638 Provider-Based Facility 09 Prison-Correctional Facility 10 Unassigned 11 Office 12 Home 13 Assisted Living Facility 14 Group Home 15 Mobile Unit 16 Temporary Lodging 17 Walk-in Retail Health Clinic 18 Place of Employment-Worksite 19 Unassigned 20 Urgent Care Facility 21 Inpatient Hospital 22 Outpatient Hospital 23 Emergency Room—Hospital 24 Ambulatory Surgical Center 25 Birthing Center 26 Military Treatment Facility 27-30 Unassigned 31 Skilled Nursing Facility 32 Nursing Facility 33 Custodial Care Facility 34 Hospice 35-40 Unassigned 41 Ambulance—Land 42 Ambulance—Air or Water 43-48 Unassigned 49 Independent Clinic 50 Federally Qualified Health Center 51 Inpatient Psychiatric Facility 52 Psychiatric Facility—Partial Hospitalization 53 Community Mental Health Center 54 Intermediate Care Facility/Mentally Retarded 55 Residential Substance Abuse Treatment Facility 56 Psychiatric Residential Treatment Center 57 Non-residential Substance-Abuse Treatment Facility 58-59 Unassigned 60 Mass Immunization Center 61 Comprehensive Inpatient Rehabilitation Facility 62 Comprehensive Outpatient Rehabilitation Facility 63-64 Unassigned 65 End-Stage Renal Disease Treatment Facility 66-70 Unassigned 71 Public Health Clinic 72 Rural Health Clinic 73-80 Unassigned 81 Independent Laboratory 82-98 Unassigned 99 Other Place of Service

For services to a neonate in the intensive care unit to be coded with a 99479, the birth weight of the infant must fall between ______ and _____

1,500 grams and 2,500 grams

Three major questions must be asked when you are identifying an Evaluation and Management code:

1. Is the patient a new or an established patient? 2.Where is the service provided? 3.What is the degree of the service rendered?

CPT codes are used to report services & procedures performed on patients:

1. by providers in offices, clinics and private homes 2. by providers in hospitals, nursing facilities and hospices 3. when d provider is employed by the healthcare facility 4. by a hospital outpatient department.

CPT sections (6 total)

1. evaluation and management (E/M) 2. anesthesia 3. surgery 4. radiology 5. pathology 6. Medicine

A place of service code is required in box

24B of the CMS-1500 form.

In which year were CPT codes incorporated as Level I codes into the Heathcare Procedural Coding System (HCPCS)

1983

Increased procedural services

22

outpatient surgery NOT aproved modifiers

22, 53, 62, 66, TC

Unusual anesthesia

23

The heart is divided into ____ chambers. (8.1)

4

When modifiers are reported for Hospital outpatient services they should be place in field

44 of that form.

When a bilateral procedure is performed in the same operative session and the CPT code describes a unilateral procedure, which modifier should be appended to the CPT code

50

outpatient surgery APPROVED modifiers

50, 59, 73, 76, E4, RT,F3, RC, GG, T1

Reduced services

52

Discontinued procedure

53

When a surgeon completes only the surgical care, modifier _________should be appended to the CPT procedure code.

54

Postoperative management only

55

Which modifier is used to indicate that a different provider performed the preoperative procedure management of a patient

56

Decision for surgery

57

The CPT book contains _______ main sections.

6

Two surgeons

62

Surgical team

66

Anesthesia complicated by utilization of total body hypothermia would be assigned the add-on code_____.

99116

codes ______ are used when a patient is admitted and discharged on the same date of service.

99234-99236

Add-on code 99467 would be reported for each additional 30 minutes of face-to-face services during and interfacility transport of a critically ill or injured pediatric patient, 24 months of age or younger with code

99466

Seventy minutes of complex chronic care management services with one face-to-face visit would be reported with code

99487

Joan Seap lives at home, has COPD and ASHD, and is functionally declining. Dr. Smith has revised her comprehensive care plan. Thirty minutes was spent this month completing these services.

99490 Chronic care management services of less than 20 minutes, in a calendar month are not reported separately.

Transitional care management service code ____ reports communication with a patient within 2 business days, high complexity medical decision making, and face-to-face visit within 7 calendar days of discharge.

99496

What is in Appendix A

A complete listing of level I modifiers

open treatment

A site is surgically exposed and visualized to determine treatment course.

When the impulse reaches the junction of the atria and the ventricles, the ____ directs the impulse to the ventricles, causing them to contract. (8.1)

AV Node

Appendix B

Additions, deletions, and revised CPT codes for the new year

Preoperative visits

All preoperative visits are included in the package after the decision is made to operate, beginning with the day before the day of surgery for major procedures and the day of surgery for minor procedures.

Modifier 52 is an acceptable modifier for

Ambulatory Surgery Center Hospital Outpatient use.

CPT is developed by the __________

American Medical Association

The subsections in the surgery section are organized _________.

Anatomically, body area or organ system

An _____ is a physician who is board certified to administer anesthesia.

Anesthesiologist

A complete and detailed description of all modifiers used in CPT is found in __________.

Appendix A

A complete list of Level I modifiers commonly found in the CPT coding book can be found in

Appendix A

The AV in the term "AV node" means? (8.1)

Atrioventricular Node

Anesthesia formula

Basic Value+Time Units +Modifying Units=Total Units Total Units x Conversion Factor = Total Reimbursement Amount

Why does the surgery section contain multiple codes that describe similar procedures?

Because procedures can be performed in a variety of methods and different combinations

Preoperative and postoperative services are considered _____into the procedure.

Bundled

Medicare requires the use of

CPT anesthesia codes

the American Medical Association (AMA) developed the

CPT codes, including those for anesthesia

Appendix C

Clinical examples for codes found in the Evaluation and Management section of CPT

________ a patient and/or family member usually involves treatment options and instruction on medicine.

Counseling

CPT is an abbreviation for __________

Current Procedural Terminology

Appendix J

Electrodiagnostic Medicine Listing of Nerves

________ anesthesia is accomplished when an agent is administered into the peridural space of the spinal cord.

Epidural block or Spinal

a patient who has received face to face services from a provider of the same specialty within the same group practice would be considered a(n) _______ patient.

Established

E/M

Evaluation and Management

Section Numbers and their sequences

Evaluation and Management- 99201-99499 Anesthesiology 00100-01999,99100-99140 Surgery 10021-69990 Radiology 70010-79999 Pathology and Laboratory 80047-89398 Medicine (except anesthesiology) 90281-99199, 99500-99607

ANESTHESIA-SPECIFIC MODIFiERS ARE REQUIRED ONLY IF THE ANESTHESIOLOGIST DEEMS IT NECESSARY

FALSE

THE P4 MODIFIER IS REQUIRED FOR SERVICES RENDERED TO A PATIENT WHO HAS A MILD SYSTEMIC DISEASE

FALSE, A SEVERE SYSTEMIC DISEASE

RVG STANDS FOR "RELATIVE VALUE GUIDE" AND IS PUBLISHED BY THE AMA

FALSE, PUBLISHED BY THE ASA

Diagnostic and therapeutic arthroscopes are coded using the same code

False

Procedures related to the musculoskeletal system start with the lower extremities and end with those performed on the head.

False

Appendix I

Genetic testing code modifiers

preoperative visits

H&P

Centers for medicare and medicaid services (CMS) formerly the Health Care Financing Administration (HCFA) incorporated CPT codes into ______________ to provide a uniform system of reporting services, procedures, and supplies.

Healthcare Common Procedural Coding System (HCPCS)

Cardiovascular subsections

Heart and pericardium and Arteries and Vessels

Materials Supplied by Physician

If the provider supplies additional materials over what is typically used for the procedure, the provider can bill drugs, trays, supplies, and other materials. However, caution should be used when billing these codes because the documentation has to provide evidence of the necessity for these additional materials.

When did the AMA and the CMS develop documentation guidelines for Evaluation and Management services.

In 1995 and 1997,

Blood enters the right atrium through the superior vena cava from the upper part of the body and through the ____ from the lower part of the body. (8.1)

Inferior vena cava

statistical modifiers or informational modifiers are used for..

Informational purposes and have an impact on the processing or payment of the code billed but do NOT affect the fee.

Intraoperative services

Intraoperative services that are normally a usual and necessary part of a surgical procedure, including the prep for surgery, wound irrigation and closure, placement and removal of surgical drains, and dressing applications, are included here.

Codes and descriptions are updated annually by CMS on

January 1st

Appendix H

Lists the Alphabetical Clinical Topics Listing, has been removed from the CPT codebook. The AMA Web site can be used to obtain this information

Who doesn't accept physical status modifiers

Medicare does not accept physical status modifiers.

Differentiate between modifiers 76 and 77

Modifier 76 is used to indicate that it was necessary to indicate that a procedure or service was repeated by the same physician or other qualified health care professional subsequent to the original procedure or service. Modifier 77 is used when a physician or other qualified health care professional needs to indicate that a basic procedure or service performed by another physician or other qualified health care professional had to be repeated.

The middle layer of the heart is the ____. (8.1)

Myocardium

Postsurgical pain management

Pain management that is managed by the surgeon is included in the package.

The heart is enclosed in the ____, a double-walled sac. (8.1)

Pericardial sac pericardium

hematoma

a collection of blood in a particular space or organ

open reduction internal fixation (ORIF)

Pins or a plate are placed internally into the bone to hold in place for better healing; also known as internal fixation.

When billing physician services

Place modifiers in item 24d of the CM-1500 form, following the CPT code.

Evaluation and Management section of CPT is divided into categories according to the location of the service.

Place of Service

Services that are included in Medicare's global surgical package include:

Preoperative visits Intraoperative services Complications following surgery Postoperative visits Postsurgical pain management Supplies Miscellaneous services

____________ services are services provided to a patient who is presenting for a well visit.

Preventive medicine

Diagnostic Procedures

Procedures completed to determine a diagnosis and establish a care plan are referred to as ____procedures.

When reporting more than one statistical or informational modifier with no other pricing modifiers, you can report the statistical or informational modifier in any order with the exception of the

QT QW and SF modifiers (These modifiers are valid for use only in the first modifier field.

Each anesthesia code has a ______attached to it.

RVG- (relative value guide or basic value)

place of service (POS)

a code number used to convey the place where the patient received care or service

Organization of sections

Section (Surgery) - Subsection (Musculoskeletal) - Subcategory (Head) - Heading (Incision) - Procedure

The ____ is found where the superior vena cava and the right atrium meet. (8.1)

Sinoatrial Node (SA node)

open reduction

Site is surgically opened to realign the bone or joint.

Appendix D

Summary of CPT add-on codes

Appendix G

Summary of CPT codes that include moderate sedation

ANESTHESIA COMPLICATED BY EMERGENCY CONDITIONS IS REPORTED WITH THE ADD-ON CODE 99140

TRUE

DOCUMENTATION OF TIME IS NECESSARY IN BILLING ANESTHESIA SERVICES

TRUE

WITHIN THE SUBSECTIONS OF THE SURGERY SECTION, THE CPT CODES ARE FIRST ARRANGED BY BODY SYSTEM AND THEN BY ANATOMICAL SITE

TRUE

Within thew subsections of the Surgery section, the CPT codes are first arranged by body systems and then by anatomical site

TRue

The CPT coding system was first published in 1966 by ____________.

The American Medical Association

Appendix E

The codes listed here are exempt from use of a -51 modifier

Appendix F

The codes listed here are exempt from use of a -63 modifier

What guides the selection of the appropriate code for reimbursement?

The documented op report and other patient documentation

Miscellaneous services

The following services, such as dressing changes; local incisional care; removal of an operative pack; removal of cutaneous sutures and staples, lines, wires, tubes, drains, casts, and splints; insertion, irrigation, and removal of urinary catheters; routine peripheral intravenous lines, nasogastric and rectal tubes; and changes and removal of tracheostomy tubes.

What is the surgery section?

The largest section of CPT which contains codes and code descriptions for surgical procedures performed by physicians

Reporting More than One Procedure/Service

The next section in the Surgery Guidelines states that if more than one procedure/service is completed on the same date, session, or during the postoperative period, codes should be appended with CPT modifiers

Three factors of medical decision making

The number of diagnoses or management options The amount and complexity of data to be reviewed The risk of complications or morbidity or mortality

What guides the physician to do one or multiple procedures?

The patient's physical status

Complications following surgery

These are all additional medical or surgical services required of the surgeon during the postoperative period of the surgery due to complications that do not require additional trips to the operating room.

Postoperative visits

These are follow-up visits during the postoperative period of the surgery that are related to recovery from the surgery. Keep in mind that the postoperative period will be 0, 10, or 90 days based on the complexity of the surgery.

Supplies

These are supplies other than those identified as exclusions in the CMS manual.

Separate Procedure

These codes report procedures that are typically part of a larger service or procedure and therefore are not reported if the larger procedure is performed. If the code with "separate procedure" is completed alone, then the code is reported.

Why was the documentation guidelines for Evaluation and Management services developed

This was done to provide the health-care industry with a reference tool that could be used to give providers guidance in documenting and selecting Evaluation and Management codes, as well as a way to measure code selection.

Explain when modifier 26 is used

To report the professional component of a code

A dynamic splint is used only when limited mobility is allowed.

True

Debridement of the wound is included in traumatic wound exploration codes 20100-20103

True

External fixation involves the application of pins through the tissue and bone to hold an external appliance in place.

True

Local anesthetics are injected into the carpal tunnel area to relieve pain

True

Wound exploration is completed to determine the extent of a wound.

True

Fluid is drained from the pericardial space by a long needle. The needle is exchanged for an indwelling catheter. This procedure is called _____. (8.1)

Tube Pericardiostomy

Level II (HCPCS/National) modifiers

Two digit alphanumeric modifiers.

Level I CPT modifier

Two digit numeric codes

Hospital outpatient services are reported on the:

UB-04 form.

What type of code ends with 99

Unlisted procedurer

When reporting modifiers for medicare claims

When you enter only one modefier,enter it in the first modifier field.

Follow-Up Care for Diagnostic and Therapeutic Surgical Procedures

Within the Surgery Guidelines of CPT, the guidelines state that follow-up care includes only the care related to the recovery from the procedure. Care for conditions, complications, exacerabertions, recurrence, or the presence of other disease or injuries is to be reported separately.

intranasal biopsy

a biopsy that is completed within the nasal cavity

problem-focused history

a brief history of present illness that is related to the problem that brought the patient to the office

history of present illness (HPI)

a chronological description of the patient's present illness location of problem, how long, severity, quality, timing, context, signs and symptoms

pilondial cyst

a closed sac, located in the sacrococcygeal are, that contains epithelial tissue with hair nested within the sac.

Treatment of fractures and dislocations contains EACH

a code is reported for each fracture or dislocation for facility NO modifier for physician with modifier

full thickness graft

a graft that contains a portion of both the epidermis and dermis of the donor site with a section that is equal, continuous, and totally free for transfer

xenograft

a graft that is made up of material that is not human, such as pig skin

tissue cultured epidermal autograft

a graft where tissue is harvested in a split tissue autograft and then cultured tissue is grafted back to the donor

Emergency Department (ED)

a hospital-based facility that provides episodic services to patients who present for immediate medical attention

heart

a large muscle that acts like a pump moving blood through the veins and arteries

structural allograft

a large segment of bone is harvested from a donor source other than the patient and is placed into the interspace of the spine

malignant lesion

a lesion in which the abnormal cell growth is found to be cancerous basal cell carcinoma, papillocystic carcinoma, squamous cell carcinoma, melanoma of the skin

benign lesion

a lesion in which the cell growth is abnormal but not life-threatening cyst, neoplasm, tumor, growth cicatricial, fibrous, inflammatory, congenital, cystic

new patient

a patient who has not received professional services within the past three years from a physician or another physician of the same specialty who belongs to the same group practice

established patient

a patient who has received professional services from a physician or another physician of the same specialty within the past three years in the same group setting

critical care

a patient who requires constant attention by the provider due to situations related to the patient's medical condition and whose illness or injuries would put the patient at high risk should he or she not get this constant attention

anesthesiologist

a physician qualified to administer anesthesia who is board-certified

angioplasty

a procedure in which a balloon is inflated in the vessel to push and flatten plaque against the vessel wall

angioscopy

a procedure in which a fiberoptic scope is used to visualize within a noncoronary vessel

thoracentesis

a procedure in which a needle is inserted through the patient's skin and chest wall into the pleural space to collect or remove fluid

biopsy

a procedure in which a sampling of tissue is removed for pathological examination to differentiate between malignant and benign tissue

aspiration

a procedure in which fluid is surgically removed from the body

wedge excision

a procedure in which the excised sample is shaped like a wedge physician excises skin in the area of the ingrown toenail

pericardiocentesis

a procedure in which the physician removes fluid from the pericardial space by insertion of a fine needle to aspirate the fluid

endarterectomy

a procedure used to remove the plaque deposits from the blood vessels

diagnostic nasal endoscopy

a procedure where a scope is used to inspect the nasal cavity, the meatus, the turbinates, and the sphenoethmoid recess to determine a diagnosis in event of injury or disease

endotracheal intubation

a procedure where an endotracheal tube is placed into the trachea to keep the airway open

imaging guidance

a radiologic procedure that assists the physician in locating the area to be addressed, usually by ultrasound or computed tomography (CT) imaging

complex repair

a repair that involves reconstruction, skin grafting, stents, retention sutures, or time-consuming techniques in addition to a layered closure layered closure (scar revision! debridement, extensive undermining, stents, or retention sutures)

pertinent PFSH

a review of the history area related to the problem identified in the HPI - one item from three areas

flexible bronchoscope

a scope used to view the bronchus; can be inserted through the mouth or nose

graft

a section of tissue that is moved from one site to another in an effort to heal or repair a defect

care plan oversight

a service billed once a month, which includes all care rendered to a patient over a 30-day period of time

unlisted procedure or service

a service may be provided that is not specifically listed in the CPT manual.

case management

a service provided by an attending physician in which the physician not only supervises but coordinates direct care received by a patient

fascia

a sheet of fibrous tissue

simple repair

a simple, single layer closure where the laceration does not go deeper than the subcutaneous tissue is not reported separately when other procedure is performed on the same wound.

acellular dermal replacement

a skin substitute for areas that require a temporary closure

skin tag

a small lesion that can be brownish or flesh color and is raised away from the body

pinch graft

a smaller form of autograft

Notes located throughout the surgery section apply to _________

a specific subsection, heading, or subheading based on type and site of procedure

mastotomy

a surgical incision of the breast

fine needle aspiration

a type of aspiration in which a very fine needle is inserted into the site and fluid is drawn

Mohs Micrographic Surgery

a type of chemotherapy where a chemical agent that acts as a chemical fixative is placed onto the lesion before it is excised; the surgeon acts as a pathologist

debridement

a type of cleansing, removal of dirt or foreign objects along with tissue that is necrotic or damaged

autograft

a type of graft that involves only one individual in which the donor and recipient sites are of the same individual

heterodermic graft

a type of graft where tissue from a different species is used for repair

autogenous graft

a type of graft where tissue is taken from one part of a person's body and put on another part of the same person's body

aneurysm

a weakened area in an artery that balloons or expands, which causes more weakness of the vessel

contaminated wound

a wound that has a major break in surgical technique and acute nonpurulent inflammation is present

clean-contaminated wound

a wound that has low infection rate and involves a minor break in surgical technique, but no inflammation is present

clean wound

a wound that has very low infection rate and involves no inflammation or break in sterile technique

dirty and infected wound

a wound that involves nonsterile conditions in which inflammation and infection are present

anesthesia

administered to relieve pain brought on by any number of causes, including surgery

Intraoperative care

administration of fluids and blood products, monitoring of noninvasive vitals, such as ECG, T, blood pressure, pulse oximetry, capnography, and mass spectrometry, and the administration of anesthesia

The guidelines located at the beginning of the surgery section apply to ________

all codes in the section

Acellular dermal ________ is a chemically treated slice of cadaver tissue that has been processed to make it immunologically inert

allograft

local codes

also called Level III codes, used by specific Medicare carriers and fiscal intermediaries to replace unlisted procedure codes

global package

also referred to as the surgical package or global days; E/M services performed on one calendar date prior to or on the day of surgery unless the decision for surgery occurs during the visit and extends through the postop period preoperative services, postoperative services, and the procedure

general anesthesia

alters a patient's perception and affects the whole body, causing a loss of consciousness

anomaly

an abnormality or a deviation from the norm in a structure

pneumothorax

an accumulation of air or gas in the pleural cavity

local anesthesia

an anesthetic agent applied topically to the skin or injected subcutaneously finger or toe, dental procedures and brief surgical procedures

injection

an anesthetic being administered directly into the bloodstream

reduction

an attempt to realign the bone or joint

excisional biopsy

an entire lesion including margins is removed and then sent for pathology (biopsy is included in removal - do not fragment)

bronchoscopy

an examination of the bronchi using a scope

thoracostomy

an incision into the chest wall

lateral nasal wall reconstruction

an incision is made in the upper lateral cartilage of the nose and continued into the medial aspect of the nasal bones where a graft is inserted to widen the nasal vestibule area; also called spreader grafting

low birth weight (LBW)

an infant with present body weight of 1,500 to 2,500 grams

burn

an injury to body tissue that is a result of heat, flame, sun, chemicals, radiation, or electricity

review of systems (ROS)

an inventory of body systems that is obtained from the patient to identify signs and symptoms that the patient may be experiencing or has experienced eyes, ears, nose, mouth, throat, cardiovascular, respiratory, gastrointestinal, genitourinary, musculoskeletal, neurological, psychiatric, endocrine, lymphatic

hyperkeratotic

an overgrowth of skin

Modifier 47

anesthesia by surgeon when regional or general anesthesia is provided by the same physician or surgeon who is performing the procedure or service

regional anesthesia

anesthetizes a particular area or region of the body through nerve or field blocking along a major nerve tract block anesthesia, conduction anesthesia

past history

any past medical information that may impact the medical decision-making process major illnesses, surgeries, injuries, medications

Decision for surgery--Modifier 57

append to an evaluation and management service code when, during the service, the initial decision was made to perform surgery

skeletal traction

application of force to a limb by a clamp, pin, screw, or wire that is attached to bone

skin traction

application of force to a limb by using felt that is applied to the skin

third-degree burn

are also called full-thickness burns; the burn goes at least to the subcutaneous layer or further

add-on codes

are codes that are listed as secondary to a main procedure and are used in conjunction with the main code. Add-on codes are NOT to be reported alone

Modifiers

are two-digit codes that are appended to CPT code to enhance or further describe a services provided

percutaneous ventricular assist device

assist a weakened heart in ejecting blood to the body via mechanical pump

Modifier 80

assistant surgeon

Modifier 82

assistant surgeon when qualified resident surgeon is not available in a teaching facility; used in a teaching hospital setting residency program

electrodes

attached to the pulse generator of a cardiac pacemaker to send the signal to the heart one - right ventricular apex second - right atrial appendage

ligament

band of connective tissue that binds the joints together and connects the articular bones and cartilage to cause movement

exostosis

benign bony growth that projects from the surface of a bone

structural autograft

bicortical or tricortical graft that is harvested through a separate incision

Le Fort fracture

bilateral fracture of the maxilla

Modifier 50

bilateral procedure

Bilateral procedure--Modifier 50

bilateral procedures performed in the same operative session

sinus

cavity that is located in the skull close to the paranasal area

Mohs micrographic surgery is a type of ______

chemosurgery

Flash symbol

codes for products that are pending FDA approval

Level I

codes that are divided into Category I, Category II, and Category III codes

Category II

codes that are not mandatory and are considered tracking codes

Category III

codes that are used for collection of statistical data

Level II

codes that are used to bill for services and procedures that are not found in the main body of CPT codes. National Codes

Category I

codes that form the 6 main sections of CPT

subungual hematoma

collection of blood under the fingernail or toenail

National Codes

commonly referred to as Level II codes, published annually by Medicare and used to bill for services and procedures that are not included in the Level I codes

surgical package

composed of E/M services performed on one calendar date prior to or on the day of surgery unless the decision for surgery occurs during the visit and extends through the postop period preoperative services, postoperative services, and the procedure

extended HPI history of present illness

consists of at least four elements of the HPI location of problem, how long, severity, quality, timing, context, signs and symptoms

arthroscopy

examination of the interior of a joint by use of an arthroscope

brief HPI

consists of one to three elements of the history of the presenting illness (HPI) location of problem, how long, severity, quality, timing, context, signs and symptoms

basic value

consists of the value of the usual services attached to anesthesia services and also the value of the work associated with anesthesia; also referred to as basic unit or relative value, base unit, base unit value

a(n) _______ is a service rendered by a provider when his or her opinion or expertise is requested by another provider or appropriate source.

consultation

Relative Value Guide (RVG)

contains the basic value of each of the anesthesia services and additional codes that act as supplements to the regular CPT codes, along with narratives, which are similar but in some cases differ slightly from what is written in the CPT book

pulse generator

controls the heart rate, energy output, and pacing modes in a pacemaker

Time is considered a key factor when determining level of service when 50% of the physician time is spent doing what?

counseling

Modifier 57

decision for surgery

guidelines

define items that are necessary to appropriately interpret and report the procedures and services contained in that section

Modifying units

determined by physical conditions and qualifying circumstances that affect the administration of anesthesia

revision rhinoplasty

determined by the extent of the repair

secondary rhinoplasty

determined by the extent of the repair

sinogram

diagnostic procedure performed on the sinuses

direct laryngoscopy

direct viewing of the larynx and adjacent structures by use of a laryngoscope

Modifier 74

discontinued outpatient hospital/ASC procedure after administration of anesthesia

Modifier 73

discontinued outpatient hospital/ASC procedure prior to the administration of anesthesia

Modifier 53

discontinued procedure; termination of a surgical or diagnostic procedure because of extenuating circumstances that threaten the well-being of the patient

Counseling

discussion with patient or family results, diagnosis, risk and benefits, instructions, education

dislocation

displacement of a bone

Modifier 59

distinct procedural service

comprehensive history

documentation of four or more elements of the HPI, a complete review of systems (ROS), and a complete PFSH

Incision and drainage refer to surgically cutting over an area and then ______ the area

draining

an organized hospital based facility that renders unscheduled episodic services to patients who require immediate attention is know as a(n)

emergency department (ED)

arthroscope

endoscopic instrument used to visualize the interior of a joint

ulcers

erosions of the tissue in which it becomes inflamed and then is lost

detailed examination

examination of affected area, but also other systems or related organs

mastectomy

excision of the breast or breast tissue

contributory components

factors that contribute to the selection of E/M codes: counseling, coordination of care, and nature of the presenting problem

CPT codes tell the insurance carrier what brought the patient to the physician's office.

false

The CPt code book is updated annually every July 1

false

The Surgery section of codes begins with code 1001 and goes through code 69999

false

The lowest level of code for an office visit when you are charging for a problem focused new patient visit is code 99211.

false

The CMS-1500 for physician services form contains .

modifier fields

a 99233 is coded for a high level initial hospital care visit.

false

to code a preventative physical exam, the coder first must determine the level of history the provider has recorded.

false

The POS for an office visit is 23

false, 11

a new patient is one who has not received face to face care from their provider within 2 years.

false- 3 yrs

there are seven key components to choosing a level of E/M service.

false-There are only three/3 KEY components: history, exam, and medical decision making.

Anesthesia section is organized

first by anatomic site and then by procedure

Current Procedural Terminology (CPT)

five-digit codes that are part of the language used by physicians and insurance companies to convey what service was provided to the patient during an encounter

conscious sedation

form of anesthetizing the patient with or without analgesia that causes a controlled state of depressed consciousness; also called moderate sedation

sinoatrial node (SA)

found where the superior vena cava and the right atrium meet cause contractions pushing the blood into the vebtricles

detailed history

four or more elements of the HPI, a ROS of 2-9 systems, and an element from the PFSH related to the patient's problem

Cpt manual is also arranged

from head to toe and from the trunk outward

balanced anesthesia

general anesthesia delivered by a combination of inhalation, injection, and instillation

dermal autograft

graft involving only the dermal tissue in the harvest process

nasal polyps

growths in the nasal cavity that are commonly associated with rhinitis

morselized autograft

harvesting small pieces of the patient's own bone through a separate incision

What is a stand alone code

have full description

tricuspid valve

heart valve that lies between the right atrium and right ventricle

aortic valve

heart valve that sits between the aorta and the left ventricle

pulmonary valve

heart valve that sits between the pulmonary artery and the right ventricle

moderate-complexity medical decision making

higher level of elements and more complex combination of risk factors that need to be decided on

comprehensive examination

highest level of examination and consists of a multisystem examination or complete examination of a single organ system

history

history of present illness, review of systems, and past, family, and social history make up the complete patient history

a + (plus) sign

identifies add-on codes to list procedures that are completed in addition to the primary procedure or service

forbidden symbol 0 crossed

identifies codes that are not to be used with modifier -51

Multiple wounds repair

if wounds from the same classification and anatomical site then the lengths of the repair for the specific classification are added together and reported with one code from the classification

casts

immobilize to prevent movement in a body area

National Correct Coding Initiative (NCCI)

implemented to standardize proper coding and payment for Medicare Part B claims

established patient

in cases where another physician was covering or was on call for a physician, the patient's encounter is billed as though the patient had been seen by the physician who was not available.

maxillary sinusotomy

incision made into the maxillary sinus

sphenoid sinusotomy

incision made into the sphenoid sinus

tracheostomy

incision made into the trachea

frontal sinusotomy

incisions made into the frontal sinuses

what is indented codes

include portion of the stand alone code description that precedes the semicolon

Pricing modifiers will either

increase or decrease the fee for the service

Modifier 22

increased procedural service; service provided greater than that usually required for listed procedure

The _________ is organized by main terms.

index

bull's eye symbol

indicates a procedure that includes moderate (conscious) sedation.

Modifier 99

indicates multiple modifiers are needed for an individual CPT code

family history

information regarding immediate family members who suffer from a chronic or acute illness that would impact the care of the patient

Statistical modifiers, also known as______________modifiers, are used for informational purposes and affect the processing or payment of the code billed but do not affect the fee.

informational

Bier block

injection of an anesthetic agent into the arm below the elbow or in the leg below the knee

epidural anesthesia

injection of an anesthetic agent into the epidural space above the dura mater, which contains the spinal nerves and cerebrospinal fluid, most commonly lumbar region intraspinal a., peridural a., spinal a., subarachnoid a.

endocardium

innermost layer of the heart, lining of the heart

physical status modifier

modifier used to describe the patient's health status

Unusual sevices

intra-arterial, central venous, and Swan-Ganz monitoring, as well as pain management services for relief of severe postoperative pain

Unusual services that can be billed include

intra-arterial, central venous, and Swan-Ganz monitoring, as well as pain management services for relief of severe postoperative pain.

low-complexity medical decision making

involves medical decision-making that is of low risk to the patient

Alphabetical Reference index

is an expanded alphabetical index that includes listings by the name of the procedure and anatomic site.

wound exploration

is completed to determine the extent of the injury and includes surgical exploration of the wound area with enlargement of the wound if necessary

Surgical Destruction

is considered a part of a surgical procedure. Exceptions to this are listed as separate code numbers

Modifier 90

is used on outside laboratory procedure codes to indicate that the procedure was performed by a party other that the treating or reporting physician

Modifier 56

is used only when preoperative management is provided

bronchus

large air passage in the lung through which air is inhaled and exhaled

subcutaneous

layer of skin that makes the connection to the muscle surface

intermediate repair

layered closure of laceration or wound of epidermis, dermis and subcutenous tissue of one or more deeper layers of subcutaneous tissue and superficial (nonmuscle) fascia

a triangle

located to the left of a code number identifies a code description that has been revised.

a bullet

located to the left of a code number identifies new procedure and services added to CPT, new code

anesthesia

loss of sensation

ventricles

lower chambers of the heart send blood to the arteries

global days

major surgeries - 90 days, minor -0-10 days postop also referred to as the surgical package or global package; E/M services performed on one calendar date prior to or on the day of surgery unless the decision for surgery occurs during the visit and extends through the postop period

Modifier 32

mandated services; required or mandated by a peer review organization, insurance company, governmental, legislative, or regulatory agency

closed reduction

manually applying force to an injured area to realign the bone or joint

Special Report

may be required by some third party payers when an unusual, variable, or new service is provided.includes description of nature, extent and need for the procedure

high-complexity medical decision-making

medical decision-making of a higher or more complex level

straightforward medical decision-making

medical decision-making that is of low or straightforward risk

myocardium

middle layer of the heart

Modifier 81

minimum assistant surgeon

genioplasty

plastic surgery of the chin

Modifier 51

multiple procedures; additional procedure(s) or service(s) would be reported with this modifier; not used by facilities

a patient who has NOT received face to face services from a provider of the same specialty within the same group practice would be considered a(n) _______ patient.

new

each first encounter in a different specialty can be considered:

new when the patient has not been seen by that specialty within the same group practice.

internal fixation

occurs when pins or a plate are placed into the bone to hold it in place for better healing; also known as open reduction internal fixation (ORIF)

unbundling

occurs when procedures are performed and services are separately coded and submitted to the insurance company for payment

closed treatment

occurs when the fracture site is not surgically exposed or opened

simple nasal polyp excision

occurs when the polyp's shape allows it to be removed easily

extensive nasal polyp excision

occurs when the polyp's shape, thickness, or the number of polyps present may require more skill and effort for removal

split-skin graft or split-thickness graft

one in which the tissue is about half or more of the thickness of the skin; also referred to as a split-skin graft

expanded problem-focused history

one to three elements of the history of the present illness as well as a review of systems directly related to the chief complaint

repair is not used for

only adhesive strips used for closure

Explain when modifier 47 is used

only by physicians or surgeons when regional or general anesthesia is provided by the same physician or surgeon who is completing a procedure or service.

problem-focused examination

only the problem that brought the patient into the office

endoscope

optic illuminated instrument used for the visualization of an internal body organ or cavity

Number symbol #

out of numerical sequence

visceral pericardium also serous pericardium

outermost layer of the heart; also called the epicardium also inner layer of the double-walled sac

epicardium

outermost layer of the heart; also called the visceral pericardium

parietal pericardium also fibrous repicardium

outermost layer of the pericardium

lungs

pair of organs that are located in the thorax and which constitute the main organ of the respiratory system

social history

part of the HPI that discusses the patient's marital status; use of tobacco, alcohol, drugs; and other social factors that would impact patient care

partial laryngectomy

partial removal of the larynx; also known as a hemilaryngectomy

hemilaryngectomy

partial removal of the larynx; also known as a partial laryngectomy

second-degree burn

partial-thickness burns that form blisters

Discontinued procedure--Modifier 53

physician may terminate a surgical or diagnostic procedure because of extenuating circumstances that threaten the well-being of the patient

physician standby services

physician requests another physician to stand by in the event the first physician's services are needed

the _______ is the location whre care was rendered.

place of service

external fixation

placement of pins through soft tissue and into bone to hold an external appliance in place

nonselective placement

placement where the catheter is functioning in the punctured vessel and does not go into any other vessel

selective placement

placement where the catheter moves into one of the great vessels off the aorta, not including the vessel punctured for access

osteoplasty

plastic surgery completed on bone tissue

arthroplasty

plastic surgery of a joint

Postoperative visits

postanesthesia recovery period, all care until the patient is released to the surgeon or to another physician

Modifier 55

postoperative management only

Modifier 56

preoperative management only

Modifiers that affect prices are referred to as

pricing modifiers

drainage procedure

procedure completed to remove fluid from an area

spreader grafting

procedure involving an incision made in the upper lateral cartilage of the nose and continued into the medial aspect of the nasal bones, where a graft is inserted to widen the nasal vestibule area; also called lateral nasal wall reconstruction

Modifier 63

procedure performed on infants less than 4 kg

tube pericardiostomy

procedure where fluid is drained from the pericardial space by placing a long needle into the pericardial space and then exchanging the needle for an indwelling catheter

backbench work

procedure where the physician prepares the donor organ prior to transplantation, including dissection of tissue

microlaryngoscopy

procedures on the larynx using an operating microscope

osteoclasis

process of creating a surgical fracture of a bone to correct a deformity

curettage

process of removing tissue by scraping

Modifier 26

professional component; physician reports only the professional component of a service rendered

SOAP note

provider note that contains the subjective HPI, objective EXAM, assessment DIAGNOSIS, and plan of a patient encounter MEDICAL DECISION MAKING

Modifier 52

reduced services; procedure is partially reduced or eliminated at the physician's discretion

Modifier 90

reference outside laboratory; laboratory procedures are performed by a party other than the treating or reporting physician

single chamber system

refers to a pacemaker system that has one electrode in either the right atrium or right ventricle

dual chamber system

refers to a pacemaker system that has two electrodes, one in the atrium and one in the ventricle

class findings

reflect clinical findings of patients with severe peripheral involvement (routine foot care)

certified registered nurse anesthetist (CRNA)

registered nurse with 36 months' additional training in anesthesiology and who is certified to administer anesthesia

hollow circle 0

reinstated or recycled code in CPT

pneumonectomy

removal of a lung

ostectomy

removal of bone; also known as osteoectomy

fasciectomy

removal of fascia

debridement

removal of foreign material or devitalized or contaminated tissue from an area

escharotomy

removal of necrosed tissue of severely burned skin

synovectomy

removal of synovial membrane of a joint

maxillectomy

removal of the maxillary sinus

between two pericardial layers

space filled with pericardial fluid which prevents rubbing

septoplasty

repair of the septum

Modifier 91

repeat clinical diagnostic laboratory test

Modifier 77

repeat procedure by another physician; basic procedure or service performed by another physician had to be repeated

Modifier 76

repeat procedure by same physician

partial replacement

replacement of only a catheter component but not the whole device

complete replacement

replacement of the whole device by the same access site

Modifiers

report or indicate that a service or procedure that has been performed has been altered by some specific circumstance but not changed in its main definition or code. further describes the service performed

time unit

represents a defined time increment actual time spent providing the anesthesia service one time unit for each 15 minutes

Name ONE of the "three R's" for consultation coding and billing.

request, render an opinion, and report back to the requesting provider

complete PFSH

review of two or all three of the past, family, and/or social history areas

What should you do before looking in the index for the appropriate code?

review the op report to determine the body system, site, surgical approach, and type of procedure performed, and if multiple procedures were performed

primary rhinoplasty

rhinoplasty that involves the lateral and alar cartilages and/or elevation of the nasal tip

initial rhinoplasty

rhinoplasty that involves the lateral and alar cartilages or elevation of the nasal tip

rhinophyma

rosasea condition of the skin of the nose

osteotomy

sawing or cutting of a bone

diagnostic arthroscopy

scope procedure of the joint to determine the extent of an injury or disease process and to establish a diagnosis

surgical nasal endoscopy

scope procedure that is performed to complete a surgical procedure of the nose

diagnostic endoscopy

scope procedure to determine the extent of injury or disease process of an internal body organ or structure to establish a diagnosis

surgical endoscopy

scope procedure to treat an injury or disease process of an internal body organ or structure

surgical arthroscope

scope used to view a joint and to treat an injury or disease process

evaluation and management (E/M)

section in CPT that is used to report the evaluation of a patient's condition and then the management or care plan for the condition

The ___________ separates the common portion of the code description from additional portions of the code.

semicolon

preventive medicine services

services provided to a patient who is presenting to a medical office for a "well visit" or a physical examination that includes a routine checkup, annual gynecological examination, or other examinations whose focus is promoting health

consultation

services rendered by a provider when his or her opinion or expertise is requested by another provider or appropriate source

Modifier 25

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

maxillary sinuses

sinuses located below the eye and lateral to the nasal cavity

ethmoid sinuses

sinuses located between the eyes

sphenoid sinuses

sinuses located directly behind the nose at the center of the skull

frontal sinuses

sinuses located with the frontal bone behind the eyebrows

Time

starts when the provider is in personal attendance to prepare the patient and ENDS when the provider is no longer in attendance and the patient may be safely sent to the post recovery area

the remaining modifiers are referred to as

statistical modifiers or informational modifiers

pacing cardioverter-defibrillator

stimulates the heart differently than does a pacemaker in that it emits defibrillating shocks that stimulate the heart and treat ventricular fibrillation or ventricular tachycardia

vessels

structures that move fluid throughout the body

The American Society of Anesthesiologists (ASA) publishes

supplemental codes and guidelines similar to those in CPT, as well as the Relative Value Guide (RVG).

some third-party payers require the use of

surgery codes to bill for anesthesia services

Modifier 54

surgical care only

repair

surgical closure of an area that may have been injured as a result of trauma or surgery involving sutures, staples, or tissue adhesives such as Dermabond

arytenoidectomy

surgical excision of the arytenoid cartilage (the cartilage that the vocal cords are attached to)

epiglottidectomy

surgical excision of the epiglottis

pharyngolaryngectomy

surgical excision of the hypopharynx and the larynx

arthrotomy

surgical incision of a joint

thromboendarterectomy

surgical incision that is made into an artery to remove a thrombus or plaque in the arterial lining

thoracotomy

surgical opening into the thoracic cavity

hip arthroplasty

surgical plastic repair of the hip

pneumocentesis

surgical puncturing of a lung for aspiration

reconstruction

surgical rebuilding of an anatomical structure

excision

surgical removal of a structure

laryngectomy

surgical removal of the larynx

pleurectomy

surgical removal of the pleura

knee arthroplasty

surgical repair of the knee

rhinoplasty

surgical repair of the nose

arthrodesis

surgical repair or reconstruction fixation of a joint

Modifier 66

surgical team; several physicians of different specialties, other highly skilled and specially trained personnel, and various types of complex equipment used during the operative procedure

incision and drainage (I & D)

surgically cutting over the area to be drained and then withdrawing the fluid or draining it

augmentation

surgically increase the size of an anatomical structure

Horizontal triangles

surround revised guidelines and notes. this symbol IS NOT USED for revised code description.

elements of examination

system or body area that was examined by the provider

Seven vital signs make up constitutional for an exam. Name three.

temperature, pulse, respiration, blood pressure supine, blood pressure sitting or standing, height, and weight

Place of service codes are maintained by and

the Centers for Medicare and Medicaid Services (CMS) to specify where a service was rendered.

revenue

the amount of money a practice will make

donor site

the area that provides the tissue used to make a repair

recipient site

the area that will receive a graft; also referred to as the defect site

cardiovascular system

the body system that pumps blood through the body via the heart and blood vessels

Musculoskeletal organization

the codes for musculoskeletal system are organized from HEAD to TOE, within each subsection the codes are then organized by types of procedures incision, excision, introduction or removal, repair, revision, reconstruction, fracture, dislocation

pericardium or pericardial sac

the double-walled sac that encloses the heart

scalpel

the handle part of a surgical knife

mitral valve

the heart valve between the left atrium and left ventricle

inhalation

the inhaling of an agent, requiring the use of the circulatory and respiratory systems to efficiently move the agent through the body using vaporizer usually

initial observation care

the initial care for patients who are seen for evaluation and management services during observation, in the hospital for a shoty time, less than 24 hours

instillation

the introduction of an anesthetic agent into a cavity of the body where there is a mucous membrane (rectum)

atrioventricular node (AV)

the junction of the atria and the ventricles that directs the impulses to the ventricles, causing them to contract

integumentary system

the largest body system made up of hair, skin, and nails, which acts as a natural shield for the body

past, family, and/or social history (PFSH)

the last portion of the history of the present illness; consists of past, family and social history of the patient

first-degree burn

the least severe burn, which presents no danger to the patient

When more than one modifier is submitted,

the modifiers must be ranked according to whether the modifier will affect the fee for the service.

nasal vestibular stenosis

the narrowing of the nasal vestibule

epidermis

the outermost layer of the skin - no blood vessel, no connective tissue

ethmoidectomy

the partial or total removal of the ethmoid bone or ethmoid cells with the ethmoid sinus

fixation

the process of suturing or fastening a structure in place

Anesthesia codes are used to report:

the professional services of the providers who anesthetized the patient. If the hospital is billing for the professional services of the anesthesiology staff, the anesthesia codes are used.

chief complaint (CC)

the reason for the patient encounter

manipulation

the reduction of a dislocation or fracture

rhinectomy

the removal of the nose

decubitus ulcer or pressure ulcer

the result of continuous pressure in an area that eventually limits or stops the oxygen flow to this area, causing a sore

nature of the presenting problem

the severity of the presenting problem; five types of presenting problems are present in CPT minimal, minor, low severity, moderate severity, high severity

mammary ductogram

the study done on the mammary duct to the mammary gland, which secretes milk from the breast

destruction

the term used to describe a procedure that totally destroys or removes something

imaging guidance

the use of radiological techniques or procedures to visualize the placement of a needle, catheter, or other device

larynx

the voice organ that connects the pharynx with the trachea

dermis

thick layer of tissue located below the epidermis; the layer of skin that enables a person to recognize touch, pain, pressure, and temperature changes contains blood and lymph vessels

cartilage

thin sheets of fibrous connective tissue

critical care codes are _____ based.

time

muscle

tissue consisting of fibers and cells that cause movement and is able to contract

Anesthesia codes are used

to report the professional services of the providers who anesthetized the patient

psychiatric residential treatment center

treatment center that provides 24-hour care that includes a therapeutically planned and professionally staffed group living and learning environment with physician assessment and care plans

After a patient is evaluated, a management plan is implemented and recorded in the medical facility.

true

For proper code selection, the coder should reference the index and then the main section of the CPT Coding book.​

true

Text, symbols, and the history of CPT are found in the introduction of the book.

true

The ROS is the part of the note in which the provider documents any body system(s) that might be affected by the chief complaint.

true

an incorrect place of service can result in a rejection by insurance carriers.

true

when time is used as a key component in billing an E/M service, the provider must document face to face time with the patient and how much time was spent counseling the patient with the family.

true

▲ Is the symbol for a revised code

true

trachea

tube-shaped structure in the neck that extends from the larynx to the bronchi

pharynx

tubular structure that extends from the base of the skull to the esophagus

A CPT modifier is a(n) ___ digit modifier appended to a CPT code to indicate that a service or procedure has been altered

two

Modifier 62

two surgeons; two primary surgeons work together to perform distinct parts of a single reportable procedure

CPT modifier

two-digit code that is appended to the CPT code to indicate that a service or procedure has been altered for some reason, but main definition of the code has not changed

block

type of anesthetic that is injected along a major nerve tract interrupting the nerve conductivity in a region of the body; also known as block anesthesia

block anesthesia

type of of anesthetic that is injected along a major nerve tract interrupting the nerve conductivity in a region of the body; also known as block

Categories and subcategories are organized within subsections according to _____________.

type of procedure

open-tube bronchoscope

type of scope used to view the bronchus and which is passed through the mouth; also referred to as a rigid bronchoscope

rigid bronchoscope

type of scope used to view the bronchus and which is passed through the mouth; also referred to as an open-tube bronchoscope

coronary artery bypass grafts (CABG)

types of grafts performed on the heart that are completed using a vein, artery, or combination of a vein and artery

Modifier 78

unplanned return to the operating room for a related procedure during the postoperative period

Modifier 24

unrelated E/M service, same physician, during postoperative period

unit/floor time

used for hospital observation services, inpatient hospital care, initial and follow-up hospital consultations and nursing facilities; time includes when the provider is present on the patient's unit and at the bedside rendering services

face-to-face time

used for office and other outpatient visits and consultations; the time a physician spends face-to-face with the patient and or family

Discontinued outpatient procedure prior to anesthesia administration--Modifier 73

used for outpatient ambulatory surgery centers and used when, due to extenuating circumstances or situation that threatens the well-being of the patient, the physician decides to cancel the surgery or diagnostic procedure subsequent to the patient's surgical preparation

Mandated services--Modifier 32

used if services are performed because the service is required or mandated by a peer review organization, insurance company, governmental, legislative, or regulatory agency

Minimum assistant surgeon--Modifier 81

used if the circumstances required a second surgeon for a short period of time, but not throughout the whole procedure

Anesthesia by surgeon--Modifier 47

used only by physicians or surgeons when regional or general anesthesia is provided by the same physician or surgeon who is completing the procedure or service

dynamic splint

used to allow limited mobility

cardiac pacemaker

used to correct and manage heart dysrhythmias is made of pulse generator and electrodes

Assistant surgeon--Modifier 80

used to indicate that one surgeon was in the operating room to assist the primary surgeon

static splint

used to prohibit mobility

Multiple modifiers--Modifier 99

used to report more than four modifiers were necessary to completely delineate a service

Assistant surgeon (when a qualified resident surgeon is not available in a teaching facility)--Modifier 82

used when there is the unavailability of a qualified resident surgeon

Discontinued outpatient hospital/ASC procedure after administration of anesthesia--Modifier 74

used when, due to extenuating circumstances or those that threaten the well-being of the patient, the physician terminates a surgical or diagnostic procedure after the administration of anesthesia or after the procedure was started

indirect laryngoscopy

viewing of the larynx by use of a laryngeal mirror that is placed in the back of the throat and a second mirror that is held outside of the mouth to view the larynx

very low birth weight (VLBW)

weight of an infant less than 1,500 grams

metastasis

when a malignant growth or tumor spreads from one part of the body to another part of the body

Coding initial application of casts, strap or splint

when casts straps are used during treatment, the application and removal of the first cast or traction device is included on the code for the treatment cast application are coded with 29000-29799 when no treatment of fracture

chemical pleurodesis

where a chemical is placed into the pleural space to cause inflammation and thus reduce the effusion in the area

morselized allograft

where a small piece of bone is harvested to form the graft from a source other than the patient

downcoding

where although the service performed can be reported by one code that explains the service rendered, the service is actually coded at a lower level to use additional codes

adjacent tissue transfer

where healthy tissue is manipulated or rearranged from a site close to or next to an area that is open due to disease or injury rotation, Z-plasty, W-plasty, VY-plasty, advancement, Rhombic flaps, double pedicle flaps

local autograft

where only one incision is used to harvest the graft and complete the procedure

fragmenting

where several procedures are performed at one surgical encounter, but instead of using one code to capture all services rendered, each service is broken out and assigned its own code

expanded problem-focused examination

where the affected area is examined along with other body systems or areas that might also be affected by the problem that brought the patient to the office

percutaneous skeletal fixation

where the fracture site is neither open or closed with fixation being placed across the fracture site

observation/observation status

where the patient is in the hospital for a short time to determine the course of action

bundled

where the preoperative services, postoperative services, and procedure itself are included in the price the physician receives for the procedure and should not be broken out and billed separately all services by one physician including anesthesia - anesthesia is not billed separately

shaving

where the scalpel blade is moved in a horizontal movement to remove a lesion without incision or slicing into the subcutaneous level of the skin