Clinical Sciences Test 1 Coding 101

Front 1

ICD-9-CM
(What does this stand for?)

Back 1

International Classification of Diseases -9- Clinical Modification

Front 2

CPT-4 E/M
(What does this stand for)

Back 2

Current Procedural Terminology for Evaluation and Management Services

Front 3

HCPCS
(What does this stand for?)
(When do you you use these?)

Back 3

Healthcare Common Procedure Coding System
Used with materials that are deemed medically necessary (eg glasses)

Front 4

NCCI
(What does this stand for?)
(How is NCCI used?)

Back 4

National Correct Coding Initiative
Codes conflict so are used as a cross check before claims are filed

Front 5

"E/M" Codes
(What is this?)

Back 5

Evaluation Management Services
Is a set of RULES for using the codes for reimbursement

Front 6

Codes 001 to 999
(These codes are used for...)

Back 6

Diseases

Front 7

Symptom Codes
(These are used when...)

Back 7

Used when a definitive diagnosis can not be made.

Front 8

Diagnosis/findings codes
(These are used for...)

Back 8

Used for a complete disease diagnosis and a finding of a disease or other defect are given along with inclusions and exclusions for that code

Front 9

E-Codes (E800-E999)
(Used for...)
(What are these codes used along with?)

Back 9

External classification of external causes of injury and poisoning.
Used along with the disease code to explain the causes.

Front 10

V-Codes
(Used for...)
(Use these codes along w/...)

Back 10

Used for occasions other than disease or injury when using a code not accepted by Medicare that require additional clarification.
Use along with the disease code to explain the need for the procedure

Front 11

CPT-4 codes are used to:
it does not code for:

Back 11

-provide uniform language to describe medical, surgical & Dx services
-non-MD's or supplies

Front 12

CPT-4 has 2 parts:

Back 12

1. Procedure codes
2. Documentation guidelines for E/M

Front 13

CPT-4 Level I National Codes have 2 levels of care:

Back 13

1. Prevention/Routine care ("92" codes; 92001-92015)
2. Medical care ("99" codes; 00201-99214)

Front 14

CPT procedures wil have a different code for new vs established pts w/ differing reimbursement rates T/F?

An established pt who hasn't been seen for ___ years would be coded as new

Back 14

True
3 years

Front 15

HCPCS Level II National Codes: what is this? Codes consist of:

Back 15

-codes that supplement CPT's, are more specific
-a letter then 4 digits. May have additional 2-letter modifiers

Front 16

Level II Modifiers - why is this important?

Back 16

important for audits and payments

Front 17

What is AQ? (Level II Modifiers)

Back 17

Any service in a HPSA
(services broken down to technical (TC) and professional (26) components)

Front 18

What is HPSA? (Level II Modifiers)
What is this determined by?

Back 18

-Health Provider Shortage Area
-determined by zip codes & by the population to providers ratio at a county level or urban zone. (Services reimbursed at higher rate)

Front 19

Level III Local Codes - what does the code consist of? When is it used?

Back 19

-5-digit alpha/numeric code (s, w-z)
-used for specific supplies if no level II code
(code is now deleted)

Front 20

CPT codes are linked to a:

Back 20

Dx

Front 21

Coded diagnosis must follow the:

Back 21

ICD-9's terminology

Front 22

The 3 key components in an exam are: (imp for level of codes)

Back 22

Hx, Examination, Medical decision making
-the lowest level of each determines the case level-
-the RFV (hx) carries the most weight

Front 23

RFV can be for a: (3 things)

Back 23

1. Vision Complaint (CC)
- refractive, heath
2. Routine Exam
- New pt, well checks
3. Dr. recommended return

Front 24

4 key elements of the Hx:

Back 24

1. CC
2. HPI
3. ROS
4. PFSH (past fam & social hx)

Front 25

what is the difference between "92" vs "99" codes?

Back 25

92000 are the old routine care eye exam codes. Replaced with problem focus codes "99's" in all the other health areas.

Front 26

"92" codes are still used in:
How many times/yr can they be used?
2 levels:

Back 26

-eye care as prevention level care codes
-once a year
-Intermediate and Comprehensive

Front 27

Intermediate Ophth Exams (92002 & 92012) used for:
-may be billed:
-must consist of:

Back 27

-evaluation of a new or existing condition complicated w/ a new Dx or Tx problem: must give an Rx!
-once each year
-7 exam elements

Front 28

Comprehensive Ophth Exam (92004 & 92014) used for:
-must consist of:
-always include:

Back 28

- new pts and pts that haven't been seen in 3 yrs
-8 exam elements
- initiation of Dx & Tx programs (giving some sort of tx, glasses, CL, drops etc)

Front 29

Exam Elements may consist of:

Back 29

1. Visual Acuity
2. Orientation
3. Mood and Affect
4. Screening VF
5. Motility (EOMs) & CT
6. Pupils/Iris
7. External
8. Bulbar & Palp Conj
9. Cornea
10. IOP
11. Ant. Chamber
12. Lens
13. Optic Disk eval.
14. Post Pole (dilated or not)

Front 30

Refraction-Basic (92015) Code
-must include
-not covered by ___ if coded on the same visit
-can be billed if part of:

Back 30

-a 99 or 92 visit code
-medicare (will be denied)
-a diabetic exam or post op F/U

Front 31

99000 codes are:

Back 31

problem based eye exam codes, "medical problem focus codes"
(MUST be linked to medical Dx)

Front 32

the 4 levels of 99000 codes:

Back 32

1. Problem focus
2. Expanded Problem
3. Detail Examination
4. Comprehensive

Front 33

99000 - different coding and requirements for new pts vs established. Levels are differentiated based on:

Back 33

1. The amount of Hx required
2. How many elements of the exam are done
3. How complex the case is based on: Dr.'s time, # of Dx possible, & # of Tx options
4. Risk

Front 34

Examination "99" Codes
Level #1 - New Pt (problem focused) 99201
-Hx
-Exam elements?
-Complexity?
-Risk?

Back 34

-1 question of HPI + CC
-1 exam element
-not complex - 1 Tx option/examiner time: 10 min
-Minimal Risk

Front 35

Examination "99" Codes
Level #2 - New (ext prob focused) 99202
-Hx
-Exam Elements?
-Complexity?
-Risk?

Back 35

-Minimal Hx, 1 questtion of HPI+CC
-6/14 exam elements
-Not complex - 1 Tx option/examiner time: 20 min
-Minimal risk

Front 36

Codes: 99000
Examples of Level #2 Visits:

Back 36

-Dry eye examination with SPK
-Cataract Eval
-Glaucoma Eval
-Blepharo/Conjunctivitis w/ lid scrubs

Front 37

Codes 99000 (''99" codes)
Level #3 (comprehensive)
-Hx
-Exam Elements
-Complexity
-Risk

Back 37

-1 Question of HOP + Ocular Hx
-9/14 Exam elements
-2 Dx & Tx options / 30 min
-1 of the following risk:
-Two level 1 or 2 problems
-one chronic problem
-one acute problem
-one uncomplicated injury

Front 38

Codes: 99000
Examples of Level #3 Visits:

Back 38

-Initial CL red eye visit w/ Dx & start of Tx
-Eval of Flashes/Floaters to R/O RD
-Eval of blunt force trauma w/ DFE & requiring F/U for AC Rxn
-Acute Ant Uveitis w/ multiple Tx
-ARMD eval of possible neovascular net

Front 39

99000 Codes ("99)
Level #4 (Comprehensive - usually in Ophthalmology visits, not Optometry)
-Hx
-Exam elements
-Complexity
-Risk

Back 39

-CC & 4 HOP, 2-9 ROS
-All exam elements
-45 min/3 new or est problems/est problem worsening plus 1 new problem
-one of the following risks: est problem worsening, 2 chronic problems, 1 acute problem w/ multiple Sx, 1 acute complicated injury

Front 40

"99" Codes - general usage
-Level 1
-Level 2
-Level 3

Back 40

-office visits, F/U or simple procedures not requiring a Dr (Va check)
-F/U & less complex problems
-initial red eye eval, full exams for med reasons &/or less that 1 yr from last visit

Front 41

"99" Codes should be billed w/ the EM codes. However, you may not bill the following tests separately:

Back 41

-SLEx
-Tear film testing
-Corneal sensation
-Pachometry
-Keratometry
-Exophthalmometry
-Potential Acuity

Front 42

What is the standard filing format for Medicare, Medicaid, and most insurance programs?

Back 42

CMS Form1500