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85 Cards in this Set
- Front
- Back
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What is an example of Coding by classifying data and assigning a representation for that data?
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A zip code is a representation for the area in which a person lives.
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Who has the copyright and publishes CPT? |
AMA |
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What year was CPT started? |
1966 |
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Why was CPT developed? |
for communication between M.D.'s and 3rd party payers |
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What is CPT's intended use? |
reimbursement |
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CPT is a nomenclature used to -
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report medical procedures and services performed by physicians.
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CPT is a registered trademark of the -
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American Medical Association.
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CPT is updated every _______ _. |
January 1 |
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T/F The new edition of CPT does not have to be used on January 1 of each new year. |
False |
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What is the official publication of CPT called? |
CPT Assistant |
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When was the CPT system adopted for application to the Medicare reimbursement system? |
1983 |
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What is CPT widely used as? |
the standard for outpatient and ambulatory care procedural coding and reimbursement |
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T/F The grace period for not using new CPT codes by January 1st of every year has been abolished. |
True |
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What are other purposes, other than reimbursement, that CPT codes are used for? |
*Permits retrieval of information for users for research,
*Quality studies, *Administrative decisions, *Serves as a method of communication between insurance carriers and medical professionals, *Enables comparisons of reimbursement amounts, *Speeds the processing of claims, *Provides data on trending and planning |
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What does a CPT code book contain? |
several additional appendices and an index of procedures |
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How many sections are there in CPT category 1? |
6 |
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What are the categories of CPT category 1? |
*Evaluation and Management *Anesthesia *Surgery *Radiology *Pathology and Laboratory *Medicine |
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What is category 2 CPT? |
Performance Measures |
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What is category 3 CPT? |
Emerging Technology |
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HCPCS Coding System |
*Level 1 = CPT, developed and maintained by American Medical Association - Identifies surgical procedures, office visits, laboratory services *Level 2 = HCPCS, developed and maintained by CMS, used for injectable drugs, devices, supplies, and equipment |
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What is HCPCS? |
Healthcare Common Procedure Coding System |
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HCPCS is |
a 2 part system developed by CMS to standardize the coding system used to process Medicare claims and is used for all services: surgical, medical, supplies, materials, and injections |
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What are the components of HCPCS? |
*evel 1: CPT Codes - 80% of HCPCS can be coded using CPT *Level 2: National Codes - developed by CMS to identify other services not in CPT |
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Level 2 National Codes are used for |
*Supplies: such as wheelchairs, hearing aid batteries and crutches *Injection codes: identify actual substances, such as penicillin *Other: dental, chiropractic, vision, orthotics |
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Example of HCPCS Level 2 code |
S8451 Splint, prefabricated, wrist or ankle |
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Overview of HCPCS System |
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Physician Offices use |
ICD-10-CM, CPT, & HCPCS |
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Hospital Outpatient Services use |
ICD-10-CM, CPT, and HCPCS |
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Hospital Inpatient Services use |
ICD-10-CM & ICD-10-PCS |
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ICD-10-CM: Ambulatory Care uses |
*Diagnosis only *Report at highest level of specificity *Explains reason for encounter *Linked to procedures for billing *Payers can deny payment based on reason - published lists of unapproved diagnoses |
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What codes does Medicare require for ambulatory facility and physician? |
*ICD-10-CM for diagnoses *HCPCS for procedures Note: Hospitals may choose to also useICD-10-PCS procedure codes for their own internal use. In addition, facilities may also collect CPTcodes for procedures on inpatients |
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What codes does Medicare require for inpatients? |
*Facility (hospital) - ICD-10-CM for diagnoses, ICD-10-PCS for procedures *Physician services - ICD-10-CM for diagnoses, HCPCS for procedures |
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Codes required in various settings |
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Why is health record documentation important? |
If you have complete documentation, correct medical coding, then you have appropriate reimbursement. |
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What is the Omnibus Budget Reconciliation Act of 1986 (OBRA)? |
*required CPT/HCPCS coding for outpatient services for federally funded patients *developed HCPCS to support the meed to bill for all services (not just those in CPT) |
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What did Health Insurance Portability and Accountability Act (HIPAA) provide? |
Providedadministrative simplification by:*streamlining and standardizing health insurance claims *establishing an approved list of code sets |
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What are the electronic formatted claim forms? |
*CMS - 1500 is used by physicians *CMS - 1540 (UB-04) is used primarily by hospitals (inpatient and outpatient |
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T/F The diagnosis and procedure must be linked on the claim forms. |
True |
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What does a diagnosis pointer do? |
links a diagnosis to a procedure |
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Linking diagnosis to procedure visual |
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How are CPT Category 1 codes composed? |
*five digits *primarily arranged in in numerical order within each section |
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What are the CPT supplementary codes? |
*CPT Category 2 codes *CPT Category 3 codes *Modifiers |
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What are CPT category 2 codes used for? |
used in performance assessment and quality improvement activities |
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How are CPT category 2 codes composed? |
five characters: four numbers and an alphabetic fifth character, capital letter F |
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What triggers the use of CPT category 2 codes? |
*clinical criteria such as the documentation of the diagnosis of coronary artery disease or hypertension for the use 2000F ( blood pressure measure) *use is optional *however, some payers may require CPT category 2 codes when submitting certain CPT 1 codes |
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What are CPT category 3 codes used for? |
*temporary codes representing emerging medical technologies, services, and procedures that have not yet been approved for general use by the FDA and so are not otherwise covered by CPT codes |
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What do CPT category 3 codes give physicians and other healthcare providers and researchers? |
*a system for documenting the use of unconventional methods so that their efficacy and outcomes can be tracked. |
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How are CPT category 3 codes composed? |
five characters: four numbers and an alphabetic fifth character, capital letter T |
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When are updated CPT category 3 codes released? |
semiannually on January 1 and July 1 via the AMA's CPT website |
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Where and when is the complete list of temporary codes published? |
annually in the CPT code book |
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What are CPT Modifiers? |
a 2 character code used with a CPT category 1- 5 digit code to provide additional information about any unusual circumstance under which a procedure was performed. |
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What is a CPT Modifier meant to do? |
support the medical necessity of procedures that might not otherwise quality for reimbursement |
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T/F Most of the 2-character modifiers for CPT category 1 codes are numerical. |
True |
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Who is Healthcare Financing Administration (HCFA)? |
the original name of Centers for Medicare and Medicaid Services (CMS). |
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When was HCFA's name changed to CMS? |
2001 |
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Who developed HCPCS (Healthcare Common Procedure Coding System)? |
HCFA, now known as CMS |
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1983 |
the year the original version of HCPCS was developed |
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What is the purpose of HCPCS in 1983? |
*designed to represent the physician and non-physician services provided to Social Security beneficiaries under the federal Medicare program |
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What is the purpose of HCPCS in 1985? |
*to fulfill the operational needs of the Medicare reimbursement system |
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What change was made to HCPCS purpose in 1986? |
*the federal government required that physicians use HCPCS to report services provided to Medicaid patients as well as Medicare patients |
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How did the Omnibus Reconciliation Act of 1986 effect HCPCS? |
hospitals are also required to report HCPCS codes on reimbursement claims for ambulatory surgery services, as well as radiology and other diagnostic services provided to Medicare and Medicaid patients |
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HCPCS codes include 2 separate levels of codes - |
*Level 1 is based on the current edition of CPT *Level 2 is made up of the National Codes that represent the medical supplies and services not included in CPT |
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HCPCS Level 1 CPT - |
*copyrighted and published by the American Medical Association (AMA) *consists of 5-digit Category 1 CPT codes *used by physicians to report services such as hospital visits, surgical procedures, radiological procedures, supervisory services, and other medical services *hospitals use Level 1 codes to report hospital-based outpatient services, such as laboratory and radio-logical procedures and ambulatory services to Medicare and other 3rd party payers *Level 1 codes represent approximately 80% of the HCPCS codes submitted for reimbursement each year |
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HCPCS Level 2 Codes (National Codes) - |
*developed by CMS for use in reporting medical services not covered in CPT *Medicare, Medicaid, and private health insures use HCPCS codes and modifiers for claims processing |
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HCPCS Level 2 codes are provided for - |
*injectable drugs *ambulance services *prosthetic devices *selected provider services |
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How are HCPCS Level 2 National Codes composed? |
5 characters: 1st character is a capital alphabetic letter & the following 4 characters are numbers |
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When are HCPCS Level 2 National codes updated? |
January 1 |
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Who developed ICD-10? |
World Health Organization (WHO) |
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Who developed the CM (clinical modification) aspect of ICD-10 for the United States? |
National Center for Health Statistics (NCHS) |
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What is medical necessity? |
the determination that a service or procedure rendered is reasonable and necessary for the diagnosis or treatment of an illness or injury |
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What to ICD-10-CM codes represent? |
the reasons why patients require and seek medical care |
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What is the Coding Clinic? |
a quarterly publication published by the American Hospital Association (AHA) with coding advice |
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What and where are the coding guidelines and who publishes them? |
The official coding guidelines for ICD-10-CM and are available from the National Center for Health Statistics and well as from the CMS website. The National Center for Health Statistics (NCHS) publishes them. |
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When was ICD-10-CM implemented in the US? |
October 1, 2015 |
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When is ICD-10-CM and PCS updated? |
annually on October 1 |
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Who developed the general principles of health record documentation? |
developed jointly by the AMA and CMS |
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What are the general principles of health record documentation? |
*the health record should be complete and legible *documentation of each patient encounter should include: -reason for the encounter and patient's relevant history, physical examination finding, and prior diagnostic test results -patient assessment, clinical impression, or diagnosis -plan for care -date of the encounter and the identity of the observer *rationale for ordering diagnostic and other ancillary services should be documented or easily inferred *past and present diagnoses should be accessible to the treating and consulting physicians *appropriate health risk factors should be identified *patient's progress and response to treatment and any revision in the treatment plan and diagnoses should be documented *CPT and ICD-10-CM codes reported on health insurance claim forms or billing statements should be supported by documentation in the health record |
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How is the Medicare program set up? |
*Part A covers hospital and facility care *Part B covers physician services and DME that are not paid for under Part A |
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What are the HIPAA Transaction and Code Set Standard's? |
*specify that all electronic data interchange formats be standardized *standards apply to any health plan, clearinghouse, and any healthcare providers that transmit health information in electronic form in connection with defined transactions *standardization of the reporting of medical procedures with industry-established and -maintained codes. |
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What code sets have been approved for use by HIPAA? |
*ICD-10-CM *ICD-10-PCS *CPT *HCPCS *CDT (Current Dental Terminology) *NDC (National Drug Codes) |
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How are claims submitted? |
electronically - there are limited exceptions |
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Who developed standards for electronic claims submission? |
developed by Accredited Standards Committee (ASC) and mandated by HIPAA |
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What must all covered entities have implemented by 2013? |
the 5010 version of the standards |
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What did the 5010 standard pave the way for? |
use of ICD-10 CM/PCS codes for data submission |
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What are the 2 types of coverage limits that Medicare policies include? |
*national coverage decisions (NCDs) *local coverage determinations (LCDs) policies include decisions on items and services that are reasonable and necessary for the diagnosis or treatment of an illness or injury |
