CPT Coding - Midterm Study Guide

What is the generally accepted period considered to be for minor procedures? 3 days 90 days 10 days 120 days

10 days

One time unit in anesthesia is usually measured in _______ increments. 30-minute 60-minute 15-minute 45-minute

15-minute

What is the generally accepted global period considered to be for major procedures? 3 days 90 days 10 days 120 days

90 days

Which of the following would be considered usual monitoring services during a surgical procedure? ECG BP Temperature All of these

All of these

How is topical anesthesia administered? Injection into the muscle Injection into the tendon Applied to the skin Injection into the nerve

Applied to the skin

A biopsy is what type of procedure? Prophylactic treatment Diagnostic procedure Therapeutic procedure Separate procedure

Diagnostic procedure

When using time reporting, when does anesthesia time begin? When the case is assigned to the anesthesiologist During the preoperative visit During the preparation for the administration of the anesthesia When the surgeon begins the procedure

During the preparation for the administration of the anesthesia

When a patient has a detailed history, the review of systems must fall into which category? No review of systems Problem-pertinent review of systems Extended problem-pertinent review of systems Complete review of systems

Extended problem-pertinent review of systems

Category II codes end in the letter____. T X F W

F

_______ also utilizes x-rays to visualize internal organ structure and function. Ultrasound Nuclear Medicine PET Fluoroscopy

Fluoroscopy

What does HCT stand for? Hematologic coagulation test Hemoglobin concentration Hematocrit Hepatic function panel

Hematocrit

When a patient has several possible diagnoses and has a high risk of significant complications from the standard treatment, the MDM would fall into which category? Straightforward Low complexity Moderate complexity High complexity

High complexity

Today, Dr. Nepal discharged Emil Stanton from the hospital and admitted him to a nursing facility for continued care. How will Dr. Nepal's services for today be coded? Hospital discharge service + initial nursing facility care Initial nursing facility care only Hospital discharge service only Subsequent hospital care

Hospital discharge service + initial nursing facility care

What does the level of medical decision-making describe? How much time and expertise the provider used to determine the diagnosis and treatment plan How much knowledge and expertise the provider used to determine the diagnosis and treatment plan How much knowledge and time the provider used to determine the diagnosis and treatment plan How much time the provider used to determine the diagnosis and treatment plan

How much knowledge and expertise the provider used to determine the diagnosis and treatment plan

What does the acronym PFSH stand for? Present, Family, and Social History Past, Friend, and System History Past, Family, and Social History Present, Friend, and System History

Past, Family, and Social History

What services do Evaluation and Management codes report? Laboratory test Chest x-ray Physician encounter Biopsy

Physician encounter

What are modifiers used for? Presenting additional information pertinent to a procedure or service Coding surgical procedures Coding diagnosis Presenting additional information pertinent to a diagnosis

Presenting additional information pertinent to a procedure or service

Giving a patient a prescription for a smoking cessation patch falls into which of the following categories? Counseling Anticipatory guidance Consultation Risk-factor reduction intervention

Risk-factor reduction intervention

How are multiple modifiers sequenced? Service-related modifier closest to the code Personnel modifier closest to the code In numerical order It does not matter

Service-related modifier closest to the code

What does the physical status modifier describe? The condition of the patient at the time anesthesia is administered. The patient had a complication and had to return to the operating room. The patient had a procedure performed on both sides of the body. The patient had more than one surgeon operating on him or her.

The condition of the patient at the time anesthesia is administered.

What does MAC require? The elimination of pain sensation That the patient be conscious The presence of a trained anesthesiologist That the patient be rendered unconscious

The presence of a trained anesthesiologist

What do personnel modifiers explain? They indicate a service or procedure was performed by more than one physician. They are an indicator of the level of complexity of services required to treat that patient. They explain special circumstances relating to the health care professionals involved in the treatment of the patient. They indicate that a service or procedure was not performed in total.

They explain special circumstances relating to the health care professionals involved in the treatment of the patient.

Critical care service codes are determined by which criteria? Time spent Location The age of the patient Severity of injuries

Time spent

How many characters are in a HCPCS Level II Modifier? Two characters: letters or numbers Three letters Three characters: letters or numbers Two numbers

Two characters: letters or numbers

When should a coder query the physician? When there is unclear or missing information necessary to code an encounter When the supporting documentation is in the progress note When the chart has been updated When the chart is missing

When there is unclear or missing information necessary to code an encounter

An established patient is defined as: a patient who has never been seen before by the provider. a patient who was seen four years ago. a patient who was seen five years ago. a patient who has been seen within the last three years.

a patient who has been seen within the last three years.

All anesthesia codes must include: the modifier AA. a physical status modifier. a qualifying circumstance code. the modifier 25.

a physical status modifier.

The triangle symbol next to a CPT code indicates: a revised code. a new code. an add-on code. the code is exempt from modifier 51.

a revised code.

The pathology code includes: collection and testing of the specimen. testing with written report. accession, testing, and written report of specimen. diagnosis of the specimen.

accession, testing, and written report of specimen.

A panel code can be used when: more than half the panel tests were performed. all but one panel test is done. all but two of the panel tests are done. all of the panel tests were performed.

all of the panel tests were performed.

Anesthesia codes are determined by the: location of service. type of general anesthesia. anatomical site of the procedure. age of the patient.

anatomical site of the procedure.

Multiple wounds are reported first by the: anatomical site. individual length of each wound. total length of all wounds. type of sutures.

anatomical site.

If fewer tests are done in the panel, ______________ assign the panel code with modifier 52. assign codes for each test. assign panel code with modifier 99. assign codes for each test with panel code and modifier 52.

assign codes for each test.

Microbiological tests study: bacteria, fungi, and viruses. infections and diseases. antibodies. fluids, washings, and brushing.

bacteria, fungi, and viruses.

Examples of clinical chemistries include: CBC and lipids. WBC and blood glucose. blood glucose and RBC. blood glucose.

blood glucose.

A specimen sent to the lab for testing may include: urine and blood. tissue and blood. blood, tissue, and urine. tissue and cytology.

blood, tissue, and urine.

A general multisystem examination is described as: problem-focused. expanded problem-focused. detailed. comprehensive.

comprehensive.

Levels of history obtained include: straightforward. low complexity. moderate complexity. comprehensive.

comprehensive.

Use a separate biopsy code only when the procedure is: conducted individually. done with several other procedures. always included. done at the same time.

conducted individually.

Moderate sedation is also known as: minimal sedation. conscious sedation. deep sedation. monitored anesthesia care.

conscious sedation.

Therapeutic transcatheter radiological supervision codes include: contrast injections. blood chemistry. percutaneous transhepatic portography. ultrasound.

contrast injections.

A Pap smear is a: cytopathologic test. microbiologic test. surgical pathologic test. clinical chemistry test.

cytopathologic test.

Pediatric critical care codes are measured by: minutes. hours. days. total length of stay.

days.

The process of cleaning out a wound to encourage the healing process is known as: incision and drainage. biopsy. excision. debridement.

debridement.

A procedure or test that a physician uses to gather more details about the condition or concern at issue is known as a: prophylactic treatment. diagnostic procedure. therapeutic procedure. separate procedure.

diagnostic procedure.

Dr. Schillinger first saw Mary Lou Renney at the hospital last week, the day she was born. Her mom brings her in today for a checkup. History, exam, and medical decision making are documented. This is coded as a(n): new patient. established patient. initial care. subsequent care.

established patient

An open circle with slash symbol next to a code indicates: a new code. new or revised text. out-of-numerical sequence code. exemptions to modifier 51.

exemptions to modifier 51.

Category II codes are: for supplemental tracking of performance measurement. temporary codes. modifiers and other relevant additional information. eponyms, synonyms, or abbreviations.

for supplemental tracking of performance measurement.

Category III codes are: four numbers followed by the letter T. four numbers followed by the letter F. five numbers with no punctuation. one number and one letter.

four numbers followed by the letter T.

AP means the x-ray was taken: from front to back. from back to front. at an angle from the right front. at an angle from the left front.

from front to back.

The bullet symbol next to a CPT code: indicates a revised code. distinguishes a code whose description has been changed since the last edition of CPT. identifies codes that are not permitted to be appended with modifier 52 Multiple Procedures. identifies a new code, one that is in the CPT book for the first time.

identifies a new code, one that is in the CPT book for the first time.

For a CT arthrography without radiographic arthrography, you will need to code the: imaging guidance of the placement of the needle to inject the contrast material. injection of the contrast material into the specific joint. imaging guidance of the placement of the needle to inject the contrast material, the injection of the contrast material into the specific joint, and the appropriate CT or MR. the appropriate CT or MR only.

imaging guidance of the placement of the needle to inject the contrast material, the injection of the contrast material into the specific joint, and the appropriate CT or MR.

Simple closures are: coded separately. included in the excision code. reported with a modifier. coded by their length.

included in the excision code.

A plus sign next to a CPT code: indicates the code can be listed as a primary procedure. indicates the code cannot be reported alone. distinguishes a code whose description has been changed since the last edition of CPT. indicates the code has been revised or is being shown for the first time in this year's CPT book.

indicates the code cannot be reported alone.

The amount of detail involved in the documentation of the patient history that has been taken during this encounter will identify the: level of patient history. place of service. consultation given. medical decision-making.

level of patient history.

The injection of a drug to prevent sensation in a specific portion of the body is known as a: topical anesthetic. local anesthetic. regional anesthetic. general anesthetic.

local anesthetic.

The patient comes in with a broken bone sticking out from his arm. The level of MDM for the physician to determine what to do next is: straightforward. low complexity. moderate complexity. high complexity.

low complexity.

Types of regional anesthesia include: infiltration anesthesia. pudendal blocks. nerve blocks. digital blocks.

nerve blocks. (will only allow 1 answer)

An example of an organ system is: genitalia. neurologic. neck. head.

neurologic.

The double sideways triangles next to a CPT code indicate: a new code. new or revised text. product pending FDA approval. telemedicine.

new or revised text.

A consultation requested by the patient is coded as a(n): new patient visit. established patient visit. initial consultation. home services.

new patient visit.

Consultation services are coded based upon who requested the service and the: length of time of the exam. age of the patient. office or hospital location. initial or subsequent visit.

office or hospital location.

The term cytology means the study of: tissues in organs. biopsies. one cell at a time to discover abnormalities. surgical pathology.

one cell at a time to discover abnormalities.

A hospital emergency department is considered: an ambulatory care center. outpatient services. inpatient services. an acute care facility.

outpatient services.

P3 is an example of a/an: surgical team modifier. physical status modifier. ambulatory surgery center modifier. multiple procedure modifier.

physical status modifier.

PA stands for: post-anatomical. posteroanterior. posterior angular. posteroaspect.

posteroanterior.

Using correct modifiers can: promote efficient reimbursement for the facility. cause the claim to be rejected. identify causes of the patient's condition. decrease reimbursement for the facility.

promote efficient reimbursement for the facility.

A ______ is a treatment that is performed to prevent a condition from developing. prophylactic treatment diagnostic procedure therapeutic procedure separate procedure

prophylactic treatment

A consultation is defined as when a physician _____ at the request of another physician. assumes full care of the patient admits a patient provides advice or an opinion on a patient's treatment performs surgery

provides advice or an opinion on a patient's treatment

One of the organ systems recognized by CPT is the: abdomen. psychiatric. neck. genitalia.

psychiatric.

A white blood cell count test is: qualitative. microscopic. gross. quantitative.

quantitative.

The professional component of a radiology code reimburses for the: use of the equipment. radiologist to interpret the films. technician who runs the machine. supplies.

radiologist to interpret the films.

An arrow in a circle symbol indicates: new or revised text. out-of-numerical sequence code. exemptions to modifier 51. reference to CPT Assistant, Clinical Examples in Radiology, and CPT changes.

reference to CPT Assistant, Clinical Examples in Radiology, and CPT changes.

A procedure that is carried out independently or considered to be unrelated to another procedure is known as a: prophylactic treatment. diagnostic procedure. therapeutic procedure. separate procedure.

separate procedure.

The CPT book categorizes: 11 body areas and six organ systems. five body areas and seven organ systems. seven body areas and 11 organ systems. nine body areas and 12 organ systems.

seven body areas and 11 organ systems.

A patient comes in with one or two possible minimal diagnoses, is on no medication, and has no other co-morbidities. The level of decision making would be: straightforward. low complexity. moderate complexity. high complexity.

straightforward.

In many situations when a modifier is used, a _________ is needed for additional clarification. formal report medical report supplemental report circumstance report

supplemental report

General anesthesia is also known as: local anesthesia. surgical anesthesia. topical anesthesia. regional blocks.

surgical anesthesia.

A star symbol next to a CPT code indicates: a revised code. a new code. telemedicine. an add-on code.

telemedicine.

Etiology is the study of: diseases. the cause of diseases. the treatment of diseases. the prognosis of diseases.

the cause of diseases.

Quantitative indicates: the counting or measurement of something. the determination of character or essential element(s). counting or measurement and the determination of character. the size of the specimen.

the counting or measurement of something.

Surgical pathology is: the study of tissues removed from a living patient during a surgical procedure. the study of diseases. the study of infections. the study of body systems that are diseased.

the study of tissues removed from a living patient during a surgical procedure.

A _____ is a procedure that is provided, most often, to correct or fix a problem. prophylactic treatment diagnostic procedure therapeutic procedure separate procedure

therapeutic procedure

Therapeutic radiology simulation is described as: A-mode. M-mode. three-dimensional. All of these

three-dimensional.

All modifiers consist of: three numbers. three letters. two characters. two letters.

two characters.

Genetic testing is a(n): immunology test. type of molecular diagnostic test. multianalyte assay with algorithmic analyses. tissue typing.

type of molecular diagnostic test.

The technical component of a radiology code reimburses for the: supervision of the technician. radiologist to read the films. use of the equipment. written report.

use of the equipment.

The CPT codes are used to report: who came to see the physician for treatment. why the patient came to see the physician. what treatments were provided to the patient. All of these

what treatments were provided to the patient.

Inpatient neonatal critical care services are coded by the patient's age and: whether the patient is new or established. the length of time spent. whether it is initial or subsequent care. the age of the patient.

whether it is initial or subsequent care.

A lab test referred to as measuring WBC means: well-baby clinic. weight bearing with crutches. white blood count. whole blood clotting.

white blood count.

A patient came in to see the specialist in your office for the first time. What is this patient's relationship? Initial visit Subsequent visit New patient Established patient

New patient

One of the most common hematology tests run is a(n): chemistry panel. drug assay. lipids. CBC.

CBC.

A physician performed a colposcopy in the medical office. Which code set would be used? ICD-10-PCS ICD-10-CM CPT HCPCS

CPT

Procedures provided by the physician are reported with what classification system? CPT ICD-10-CM HCPCS DME

CPT

Procedures on the heart as well as the entire network of veins, arteries, and capillaries are coded from which section of the CPT book? Respiratory System Musculoskeletal System Cardiovascular System Digestive System

Cardiovascular System

What is the fifth step in the coding process? Read the case carefully. Check for any relevant guidance, including reading all of the symbols and notations. Determine the correct CPT procedure code or codes. Double-check your work.

Check for any relevant guidance, including reading all of the symbols and notations.

CPT stands for: Current Procedural Terminology. Capitation Procedures and Treatments. Certified Procedures and Treatments. Current Procedures and Treatments.

Current Procedural Terminology.

New CPT codes go into effect each year on: April 1st. October 1st. July 1st. January 1st.

January 1st.

______________ provides three-dimensional views of internal body organs, in real time, with greater visibility of variations within soft tissues, making visualization of brain, spine, muscles, joints, and other structures more informative. Magnetic Resonance Imaging (MRI) Computed Tomography (CT) Scans Radiography Positron Emission Tomography (PET)

Magnetic Resonance Imaging (MRI)

MIPS stands for: Million Instructions Per Second. Merit-based Incentive Payment System. Meaningless Indicator of Processor Speed. Medical & Industrial Pipeline Systems.

Merit-based Incentive Payment System.