Free CPC Exam Flashcards

AAPC/AMA coding system for medical procedures and services. Five-digit codes. Categories: I (procedures/services), II (performance measures), III (emerging technology). Updated annually. Most common in outpatient settings.

CPT codes 99202-99499 for patient encounters. Key elements: history, exam, medical decision making (MDM). 2021 updates base outpatient E/M on MDM or time only. Know levels for office visits and hospital services.

Determines E/M level based on: 1) Number/complexity of problems addressed, 2) Amount/complexity of data reviewed, 3) Risk of complications. Levels: Straightforward, Low, Moderate, High. Two of three elements determine level.

Services included in surgical CPT code: pre-op visit (day before), intra-operative services, immediate post-op care, typical follow-up (0, 10, or 90 days). Don't separately bill included services. Modifier -24 for unrelated E/M.

Significant, separately identifiable E/M service by same physician on same day as procedure. E/M must be above and beyond usual pre/post procedure care. Most audited modifier. Document medical necessity.

Distinct procedural service. Used when procedures not normally reported together are appropriate due to different session, site, organ system, incision, or lesion. Often overused—use more specific X{EPSU} modifiers when possible.

-26: Professional component only (physician interpretation). -TC: Technical component only (equipment, technician). Used when procedure has separate professional and technical portions. Without modifier = global (both).

Used when no specific CPT code exists. End in -99 (e.g., 49999 - unlisted digestive procedure). Requires operative report. Priced by comparison to similar procedures. Submit with documentation to payer.

International Classification of Diseases, 10th Revision, Clinical Modification. Diagnosis codes for US healthcare. 3-7 alphanumeric characters. First character always letter. Establishes medical necessity for procedures.

Characters 1-3: Category. Character 4: Etiology, site, manifestation. Character 5: Often laterality (right/left). Character 6: Additional specificity. Character 7: Extension (initial, subsequent, sequela). Code to highest specificity.

Condition established after study that is chiefly responsible for the admission. Inpatient only. Outpatient uses 'first-listed diagnosis.' May differ from admitting diagnosis. Affects DRG assignment and reimbursement.

Code first underlying disease, then manifestation. Etiology/manifestation: code both, etiology first. 'Use additional code' = sequence after main code. 'Code first' = sequence after indicated code. Follow conventions.

Required for certain codes (fractures, injuries). A = initial encounter (active treatment). D = subsequent encounter (routine healing). S = sequela (late effect/complication). Use placeholder X if needed to reach 7th position.

ICD-10-CM codes beginning with V, W, X, Y. Describe how injury occurred, intent, place, activity, status. Never principal/first-listed diagnosis. Used for injury prevention data. Many payers don't require.

Factors influencing health status and contact with health services. Used when patient isn't currently ill. Examples: Z23 (immunization), Z12 (screening), Z85 (history of cancer), Z79 (long-term medication use).

Healthcare Common Procedure Coding System. Alphanumeric codes (letter + 4 digits) for supplies, equipment, drugs, services not in CPT. Examples: J codes (drugs), E codes (DME), A codes (supplies). Medicare/Medicaid requirement.

HCPCS codes for drugs administered by healthcare provider (not self-administered). Billed with units based on dosage. Example: J1030 = injection, methylprednisolone, up to 40 mg. Updated quarterly.

Equipment that can withstand repeated use, primarily medical purpose, appropriate for home use. HCPCS E codes. Examples: wheelchairs, hospital beds, oxygen equipment. Requires physician order and medical necessity.

Root: core meaning (cardi = heart). Prefix: beginning, modifies meaning (tachy = fast). Suffix: ending, often procedure/condition (-itis = inflammation). Combining vowel (usually 'o') links parts. Break down unfamiliar terms.

A-/an- (without), brady- (slow), tachy- (fast), hyper- (excessive), hypo- (under), peri- (around), epi- (upon/above), endo- (within), sub- (under), trans- (across), bi- (two), uni- (one), hemi- (half).

-itis (inflammation), -ectomy (removal), -otomy (incision), -ostomy (opening), -plasty (repair), -scopy (visual exam), -graphy (recording), -osis (condition), -oma (tumor), -pathy (disease), -algia (pain).

Sagittal: divides left/right. Coronal (frontal): divides front/back. Transverse (horizontal): divides upper/lower. Midsagittal: equal left/right halves. Used to describe imaging and surgical approaches.

Anterior/ventral (front), Posterior/dorsal (back), Superior (above), Inferior (below), Medial (toward midline), Lateral (away from midline), Proximal (closer to origin), Distal (farther from origin), Superficial, Deep.

Services must be reasonable and necessary for diagnosis/treatment. Diagnosis codes must support procedures billed. Without medical necessity, payer can deny claim. Documentation must support codes selected.

Billing for more expensive service than actually provided. Example: billing 99215 when documentation supports 99213. Fraudulent. Results in overpayment, fines, exclusion. Ensure codes match documentation.

Separately billing services that should be billed as one comprehensive code. Example: billing component procedures individually instead of bundled surgical code. Check CCI edits. Can be fraud if intentional.

Medicare edits identifying code pairs that shouldn't be billed together. Column 1/Column 2 edits and Mutually Exclusive edits. Some bypassed with appropriate modifiers. Updated quarterly. Promotes correct coding.

Health Insurance Portability and Accountability Act. Protects patient health information (PHI). Requires safeguards, limits disclosures, gives patients rights. Violations: fines up to $1.5M+ and criminal penalties.

How surgeon accesses surgical site. Open: direct incision. Laparoscopic: small incisions, camera, instruments. Endoscopic: through natural opening. Percutaneous: through skin. Approach affects code selection.

Procedures marked 'separate procedure' in CPT. Integral to larger procedure—don't bill separately when done with comprehensive procedure. Only bill alone if performed independently for specific purpose.

Procedure performed on both sides of body during same session. Bill with -50 modifier or use specific bilateral CPT code if available. Reimbursement typically 150% of unilateral. Some payers want two line items with RT/LT.

Multiple procedures performed at same session by same provider. Primary procedure at 100%, additional procedures typically reduced (50%). List highest RVU procedure first. Some codes are -51 exempt.

70000 series CPT codes. Organized by body area and modality. Professional component (-26) = physician interpretation. Technical component (-TC) = equipment, staff, supplies. Many include 'with' or 'without' contrast.

General: physician available. Direct: physician in room/adjacent. Personal: physician performing procedure. Level required depends on procedure. Affects billing and compliance.

CPT codes for lab tests. Organ/disease panels (80047-80081): group of tests billed as one. Individual tests can be ordered separately. Some require specific specimen handling. Medicaid necessity rules apply.

88000 series includes: surgical pathology (specimen examination), cytopathology (cell examination), clinical pathology consultations. Levels based on complexity. Document specimen type and findings.

Non-surgical therapeutic services. Includes: immunizations, psychiatry, dialysis, ophthalmology, cardiovascular, pulmonary, allergy, neurology, physical medicine. Many require time documentation.

Two components: administration code (90460-90474) + vaccine/toxoid product code (90476-90756). Bill both. Administration includes counseling. Multiple vaccines = multiple admin codes. Report manufacturer lot numbers.

Starts when anesthesiologist begins preparing patient, ends when personal attendance ends. Reported in units (typically 15-minute increments). Total payment = (Base units + Time units + Modifiers) × Conversion factor.

P1-P6 describe patient condition. P1: normal healthy. P2: mild systemic disease. P3: severe systemic disease. P4: life-threatening. P5: not expected to survive. P6: brain-dead organ donor. Affects reimbursement.

Process of managing claims from patient encounter to payment. Steps: scheduling, registration, charge capture, coding, claim submission, payment posting, denial management, collections. Accurate coding is critical.

Rejection: claim not processed due to errors (incorrect format, missing info). Can resubmit. Denial: claim processed but payment refused. Must appeal or write off. Track denial reasons for improvement.

Explanation of Benefits (EOB): document to patient explaining claim processing. Electronic Remittance Advice (ERA): electronic version to provider. Shows charges, allowed amounts, adjustments, patient responsibility.

Process when patient has multiple insurance plans. Primary payer pays first, secondary pays remaining. Birthday rule for dependents: parent born earlier in year is primary. Non-duplication ensures no overpayment.

Two-digit codes indicating where service rendered. 11 = office, 21 = inpatient hospital, 22 = outpatient hospital, 23 = ER, 31 = skilled nursing. Affects reimbursement rates. Must match actual location.

Inpatient: formal admission, expected stay 24+ hours, uses ICD-10-PCS for procedures. Outpatient: same-day services, observation <24 hours, uses CPT/HCPCS. Different coding rules and reimbursement systems.

Skin procedures. Key factors: site, size (sq cm for lesion removal), complexity (simple, intermediate, complex for repairs), benign vs malignant. Measure lesion plus margins. Multiple repairs may be combined by type.

Fracture treatment: open vs closed, with/without manipulation. Joint procedures: arthroscopy vs open. Know anatomical sites and laterality. Includes bones, muscles, tendons, ligaments. Extensive modifier use.

Heart and vessel procedures. Catheterization: access site + procedure. Pacemaker/ICD: components billed separately. Vascular: identify vessels, approach, intervention. Many add-on codes for multiple vessels.

EGD (upper), colonoscopy (lower), ERCP (bile ducts). Code to farthest extent reached. Interventions (biopsy, removal, dilation) bundled or separate depending on scope. Know anatomy: esophagus through rectum.