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CBCS Exam Study Guide
- 2 ty pes of CPT Codes
*Stand Alone Codes; contain the full description of the procedure for the code *Indented Codes- these are codes listed under associated stand-alone codes. To com plete the the description for indented codes, one m ust refer to the portion of the stand alone code description before the sem i-colon
- 3 sections t o Alphabetic Index
Section 1) Index to diseases Section 2 ) Table of drugs and chemical Section 3 ) Index to External Cause of Injury (E Codes)
- - 24 Unrelated E/M Service by the same phy sician during a post operative period
this is attached to the code of the E/M service provided to a pt during the postop period to indicate that the service is not part of the postoperative care which is usually part of the package of services of the surgery performed. Major surgical procedures will usually have a postop period of 90 days, minor, 10 day s. Used only w/ E/M codes
- - 26 Professional
Component
Most procedures have both professional (physician) and technical components. This m odifier is attached to the procedure to indicate that the dr provided only the professional componenet
- - 32 Mandated Services used to indicate that the service provided was required by 3 rd party payer, gov, legislative or regulatory body. this does not include second opinion requested by a pt, family member, or another physician
- - 50 Bilateral Procedure used when the same procedure is performed on a m irror-image part of the body
- - 51 Mulitple Procedure used when
-m ore than 1 procedure is performed in the same surgical episode -one code does not describe all of the procedures performed -the secondary procedure is not m inor or incidental to the m ajor procedure Ex; same operat ion, different sit e, m ultiple operations, same operative session, *procedure performed m ultiple times
- - 58 St aged or Related Procedure or Service by the same Phy sician during the Postoperat ive Period
used to explain that the procedure or service done during a postop period was planned at the time of the original procedure. also used if a therapeutic procedure is performed b/c of the findings from a diagnostic procedure
- - 7 8 Ret urn t o Operating
Room for a Related Procedure During the Postoperat ive Period
to report a circumstance in which the dr returns to the operating room to address a complication stem ming from the initial procedure (third party payers usually pay the surgery portion of the com plications surgical package b/c the pt remains in the postop period of the initial procedure. docum entation must clearly indicate the reason for the return to the operating room)
- 7 9 Unrelated Procedure or Service by t he same phy sician during the postoperat ive period
used to indicate that the procedure or service provided during the postop period was not associated w/ the period. payment for the full fee of the subsequent procedure is requested and a new global period starts
- - 90 reference (out side) laboratory
used to indicate that the procedure was done by outside lab and not by reporting facililty
- - 99 Mult iple Modifiers used to report a procedure or service that has m ore than one m odifier but the payer does not allow the addition of m ultiple m odifiers to the code. is attached to the procedure code and the multiple m odifier are listed in block 19 of claim form
- a, an without
- Abduct ion m ov ement away from the midline
- Abuse incidences or practices, not usually considered fraudulent, that are inconsistent w/ the accepted medical business or fiscal practices in the industry.
- Accept Assignment m ean the provider agrees to accept what the ins co approves as payment in full for the claim
- Add-on codes som e procedures are carried out in addition to the primary procedure performed. Designated as "add- on" codes w/ a "+ " sign and they apply only to procedures performed by same dr to describe additional intraservice work provided. Are never used alone, rather they are always reported in addition to the prim ary procedure code. All add-on codes are m odifier - 51 (multiple procedures) exempt
- Adduction m ov ement towards the midline
- Albino deficient in pigment (melanin)
- - algia pain
- Alopecia absence of hair form areas where it normally grows
- Alphabetic Index (Volume 2)
Ev erything in the Index is listed by condition -that is, diagnosis, signs, symptoms, and conditions such as pregnancy or adm ission
- Anatomy & Phy siology
A professional medical coder must have knowledge of anatomy & physiology so that coding assignment is quick & accurate.
- Anest hesia 001 00-01999, 99100-99140 (knocked out=0)
- ante before
- Anterior, Ventral
front surface of the body
- anti against
- The Appendicular Skelet on
- Appendicular Skelet on
m ade up of the shoulder, collar, pelvic, arm & legs
- arth cartilage
- Assignment of Benefit s
reim bursement is sent directly from payer to provider
- Axial Skeleton consist of the skull, rib cage & spine
- The Axial Skelet on-Skull, Rib Cage, Spine
- Basic Billing & Reimbursement Steps:
-collect pt info -v erify insurances -prepare encounter form (should reflect the diagnosis and services provided to pt, this is used as the basis for billing) -code diagnosis and procedures -rev iew linkage and compliance, review should include the following appropriateness of t he codes link between the diagnosis and the procedure pay ers rules about t he diag and proc docum entation of the procedure *com pliance w/ regulations -calculate physician charges -prepare claims -transmit claims -pay er adjudication, claims received by the payers go through a series of steps to determine whether it should be paid -follow up reimbursement/record retention
- Chapt ers are the main division on the ICS- 9 - CM, they are divided into secctions
- Chief Complaint brief statement describing the symptom, problem, diagnosis, or condition that is the reason the pt seeks m edical care
- cholecy st gall bladder
- chondro cartilage
- Choose t he code that represents the current status of the neoplasm
a neoplasm code is assigned if the tumor has been removed and pt is still receiving chemotherapy tx or radiation. A V code is assigned if the tumor is no longer present or if the patient is not receiving treatment, but is returning for follow - up care
- Civil Monet ary Penalt ies Law (CMPL)
law passed by the fed gov to prosecute cases of m edicaid fraud
- Claim Status Various terms are used to describe the state of submitted forms.
- Clavicle or collarbone, is curved horizontal bones that attach to the upper sternum at one end, these bones help stabilize the shoulder
- Clean Claim has all required fields accurately filled out, contains no deficiencies and passes all edits, the carrier does not require inv estigation outside of the carrier's operation before paying the claim
- Coccy geal Coccy x (tailbone)
- Coding process of conv erting diagnosis, procedures, and services into numeric and alphanumeric characters
- Coinsurance percentage of the cost of cov ered services that a policyholder or a secondary ins pays. A common payment % for coinsurance is 80/20 which in dicates that 2 0% is the coinsurance for the beneficiary or secondary ins is responsible
- Collagen structural protein found in the skin & connective tissue
- Colles Fract ure the break of the distal end of the radius at the epiphysis often occurs when the pt has attempted to break his/her fall
- colp v agina
- Column 1/Column 2 edits (NCCI)
Identifies code pairs that should not be billed together b/c 1 code (Column 1) includes all the services described by another code (Column 2)
- Commercial Carriers
-are for profit organizations that operate in the private sector selling different health ins benefits plans to groups or individuals. Most have predefined pt yearly deductibles and coinsurance generally based on the 80/20 split. EX; Aetna, Cigna, Travelers, and Prudential -m ost have coordination of benefits (COB) clauses to identify the primary and secondary payer responsibility status for dependent children
- Common Prefixes:
- Common Root Words
- Common Suffixes used by Medicare:
A-Wage earner (upon retirement) B-Spouse of wage earner C-Disabled Child D-Widow HaD- Disabled Adult M- Part B benefits only T- Uninsured and entitled only to health ins benefits
- Communicated Fract ure
the bone is crushed and/or shattered
- Compliance regulations:
Most billing-related cases are based on HIPPA and False Claims Act
- Complicated
Fract ure
the bone is broken and the ends are driven into each other
- Compression
Fract ure
the fractured area of the bone collapses on itself
- Consult ation serv ice performed by a physician whose opinion or advice is requested by another physician in the evaluation or treatment of a pt's illness or suspected problem. The consultation does not assume any responsibility for the pt's care and m ust send a written report back to the requesting physician
- Contracted
Rates w/ MCO's
phy sicians agree to provide services at a discount of their usual fee in return for a pool of existing pt's
- Coordination of benefit s (COB)
when 2 ins co work together to coordinate payment of the benefits
- co-pay ment cost-sharing requirement for the insured to pay at the time of service. This amount is usually a specific dollar am ount
- CPT Current Procedural Terminology - codes from CPT code book used to report services and procedures by dr's. The CPT coding sy stem uses a 5 digit numeric system for coding services rendered by dr's. Some codes use a 2 digit m odifier to five a m ore accurate description of the services rendered
- CPT Modifiers these are 2 digit add-ons attached to regular codes to tell 3 rd party payers of circumstances in which the services or procedures were altered. All m odifiers are listed in CPT appendix A. Modifiers relevant to each of the CPT sections are also found in the section guidelines. One must use the m odifier that depicts the circumstances m ost accurately.
- Cranium includes following bones
*Frontal Bone- forms the anterior part of the skull & forehead *Parietal Bone- Form s the sides of the cranium *Occipital Bone- forms the back of the skull, there is a large hole at the ventral surface in this bone, called the foramen m agnum, which allows the brain communication w/ the spinal cord *Tem poral Bone- form s the 2 lower sides of the cranium *Ethmoid Bone- forms the roof of the nasal cavity *Sphenoid Bones- anterior to the temporal bones
- Deduct ible a cum ulative out-of-pocket amount that must be paid annually by the policyholder before benefits will be paid by the ins co
- derm skim
- Describe t he 6 columns of the neoplasm table
- Extension to increase the angle of the joint
- Facial Bones ...
- Fee-for-service fee that is charged for each procedure or service performed by the physician. This fee is obtained from a FEE SCHEDULE, which is a list of charges or allowances that have accepted for specific m edical services. The system in which fee schedules are determi ned is referred to a USUAL, CUSTOMARY, AND REASONABLE, (UCR)
- Femur thighbone
- Fibula sm aller, lateral leg bone
- Fiscal Int ermediary an ins co that bids for a contract w/ CMS to handle the m edicare program in a specific area
- Fissure- groov e or crack like sore
- Flat Bones are found covering the soft body parts, IE; SHOULDER BLADES, RIBS AND PELVIC BONES
- Flexion to decrease the angle of the joint
- Fract ures broken bone, m ost occur as a result of trama, however som e disease such as cancer or osteoporosis can also cause spontaneous fractures. Can be classified as simple or compound. Sim ple fractures don't rupture the skin as compound fractures split open the sk in allowing for an infection to occur.
- Fraud knowingly & intentionally deceiving or misrepresenting info that may result in unauthorized benefits. It is a felony and can result in fines and/or prison.
- Front al, Coronal Vertical plane dividing the body into anterior & posterior portions
- Full ROM diathroses are joints that have free movement, Ball-and-socket joints (hip) and hinge joints (knees) are common diathroses joints (synovial joints)
- Gangrene death of tissue associated w/ the loss of blood supply
- gastro stom ach
- Gender rule m ale of household is primary payer
- A geographic practice cost index is applied t o account for t he economic variation across t he different area of t he count ry
true
- gloss tongue
- The Good Samarit an Act
was dev eloped to protect healthcare professionals from liability of any civil damages as a result of rendering em ergency care
- - gram record
- - graphy process of recording
- Greenst ick Fract ure
the bone is partially bent & partially broken, this is a com mon fracture in children b/c their bones are still soft
- Group Pract ice group of 2 or m ore physicians and non-physician practitioners legally organized by a partnership, professional corporation, foundation, not -for-profit corporation, faculty practice plan, or similar association
- Hair com posed of tightly fused m eshwork of cells filled w/ hard protein called karatin. Has its roots in the dermis & together w/ their coverings, is called HAIR FOLLICES. Main function is to assist in regulating body temp. Holds heat when body is cold by standing on end & holding a layer of air as insulation.
- Hairline Fracture a m inor fracture appears as a thin line on x-ray; and m ay not extend completely through the bone
- Hair, Nail & Glands
- Healt h Care Financing Administration Common Procedure Coding Sy st em
HCPCS Reference Manual
- Healt h Insurance Port ability & Account ability Act (HIPPA)
Enacted in 1996, created by the Health Care Fraud & Abuse Control Program - enacted to check for fraud and abuse in the Medicare/Medicaid Programs and private payers
- Healt h Insurance Portabilit y And Account abilit y Act (HIPPA)
deals w/ the prevention of healthcare fraud and abuse of patients on Medicare/Medicaid
- Healt h Pract itioner
includes, but is not lim ited to, physician assistant, certified nurse - midwife, qualified psy chologist, nurse practitioner, clinical social worker, physical therapist, occupational therapist,, respiratory therapist, certified registered nurse anesthetist, or any other practitioner as m ay be specified
- hemi half, partial
- hepat o liv er
- HMO Health Maintenance Organization - managed care plan that provides wide range of services to individuals that are enrolled. Generally least costly but m ost restrictive. Uses a gatekeeper (primary care physician) whom the pt is required to visit initially for any case. If the pt goes to another physician w/o prior approval pcp pt will be responsible for all costs. Physician-Hospital Organization is when physicians, hospitals, and other health care providers contract w/ one or m ore HMO's or directly w/ employers to provide care.
- How are bones categorized?
as belonging to either the AXIAL SKELETON or the APPENDICULAR SKELETON.
- How are copay ments determined with TRICARE?
according to 2 programs a) active duty family members b) retirees, their families m embers and survivors of deceased personnel
- How are muscles by strong, fibrous bands of connective tissues called tendons. attached t o bones?
- How are payments determined under Medicare's RBRVS?
by m ultiplying a code's relative value by constant dollar amount called the conversion factor (multiplier). The conversion factors are determined annually by the CMS in cooperation with congress. The conversion factor varies according to the type of service provided such as m edical, surgical, non -surgical
- How many Volumes t o ICD manual?
*Volume 1- Disease: Tabular List *Volume 2- Disease: Alphabetic Index *Volume 3- Procedures: Tabular list and Alphabetic Index
- How much area does the skin cover?
an area of 2 2 sq ft (an average adult). It is the largest organ of the body
- How to ensure y ou have chosen the correct code?
First locate the code in the alphabetic index (Volume 2) then cross-reference this code in the Tabular List (Volume 1)
- Humerus upper arm bone
- Hy pertension table
found in the Index under the m ain term "Hy pertension" and it contains a list of conditions that are due to or associated with hy pertension. The Table classifies the conditions as:
- Malignant; an accelerated sever form of hypertension w/ v ascular damage and a diastolic pressure of 1 30mmHg>
- Benign; Mild or controlled hypertension & no damage to the v ascular system or organs
- Unspecified; This is not specified as benign or malignant in the diagnosis or m edical record
- hy po below, deficient
- hy st er uterus
- Impet igo bacterial inflammatory skin disease characterized by lesion, pustules, and vesicles
- Indemnity Insurance
also known as a fee-for-serv ice. under this plan, the serv ices that are paid for are listed in the policy and payments are based on the physicians charge for the serv ice. there are no restrictions as to the physicians or hospital the beneficiaries m ay use and pre-approval of m edical visits are not required. Each yr the beneficiary m ust meet a deductible, after which the benefit may cover for all or part of the charge. Usually a co-insurance for each service applies
- Inferior below another structure
- infra below
- Inpat ient term used when a patient is admitted to the hospital w/ the expectation that the pt will stay for a period of 2 4 hrs or m ore
- Integumentery Vocabulary
- inter between
- Invalid Claim contains complete necessary information but is incorrect or illogical in som e way
- Inversion turning inward
- Ischium lower portion of the pelvic bone
- Itemized stat ement
statement of the pt's account history, showing dates of serv ice, detailed charges, payment (deductibles, co-pays), the date the ins claim was subm itted, applicable adjustments and account balance
- - itis inflammation
- Joint s parts of the body where 2 or m ore bones of the skeleton join. Different joints have different ROM (range of m otion), ranging from no m ovement at all to full range of m ov ement
- Lacrimal Bones
paired bones at the corner of each eye that cradle the tear ducts
- lact m ilk
- lapar abdom en
- Lateral pertaining to the side
- Legal Aspect s ... of of Medical Billing & Coding:
- Level I Codes Consist of codes found in the CPT m anual. They have five position numeric codes used to report physicians services rendered to patients.
- Level II Codes (Nat ional Codes)
codes form ulated thru the joint efforts of the CMS, the health insurance association of am erica, and the bcbs association.they are five position alpha-numeric codes for phy sician and non -physician services not found in the cpt(level 1 ), start w/ a letter followed by 4 #'s and m ake up m ore than 2 ,400 5 digit alphanumeric codes divided into 2 2 sections, each covering a related group of items. Most of these item s are supplies, m aterials or injections that are cov ered by medicare. Some codes are for physicians & non-physician services not found in the CPT (Level I) Ex; E section is for the Durable Medical Equipment category which cov ers reusable m edical equipment ordered by the phy sician for use in the home, such as wheelchairs or portable oxygen tanks.
- Level III Codes
codes that were used locally or regionally have been eliminated by the CMS since the implementation of the HIPPA. Som e of the codes are now in the Level II
- Level of detail in coding
a category code is used only if it is not further su bdivided. Where subcategory and subclassifaction codes are prov ided, their assignment is m andatory. A code is invalid if it has not been coded to the level of specificity required for that code.
- Liability Insurance
a policy that covers losses to a 3 rd party caused by the insured, by an object owned by the insured, or on premises owned by insured. Liability ins claims are made to cover the cost of m edical care for traumatic injuries, lost wages, and in many cases, remuneration for the "pain and suffering" of the insured party. Most health ins contracts state that health ins benefits are secondary to liability ins.
- Life cy cle of Insurance Claims
I. Claims submission-transmission of claims data either electronically or m anually to payers or clearinghouses forprocessing II. Claims Processing-payers and clearinghouses verify the info found in the submitted claims about the pt and prov iderIII. Claims Adjudication-process by which the claim is com pared to payer edits and the pt's health plan benefits to v erify that: -required info is available to process claim -claim is not a duplicate -pay er rules and procedures have been followed -procedures performed or services provided are covered benefits
- Limited ROM am phiathroses are joints joined together by cartilage that is slightly moveable, such as the vertebrae of the spine or the pubic bone
- Medicare Part A aslo called the Hospital Insurance for the Aged and Disabled. It cov ers institutional providers for inpatient, hospice, and home health services, such as the following
- a bed pt in a hospital - pt's in a py sch hospital - bed pt's in a nursing facility - pt's receiving h ome health care services - term inally ill pt who has <6 to live and needs hospice care - term inally ill pt who needs respite care
- Medicare Part B referred to as Supplementary Medical Insurance (SMI). cov erage is a supplement of Part A, which cov ers m edical expenses, clinical lab services, home health care, outpatient hospital treatment, blood, and am bulatory surgical services.
- Medicare Part C Medicare Managed Care Plans (formally Medicare Plus (+) Choice Plan) was created to offer a # of healthcare services in addition to those available under Part A & Part B. The CMS contracts w/ managed care plans or PPO's to prov ide Medicare benefits. A premium similar to Part B m ay be required for cov erage to take affect
- Medicare Part D Prescription Drugs- enacted by the Medicare Prescription Drug, Im provement and Modernization Act in Dec 2 003 and began implementation in Jan 2006 where Medicare beneficiaries can enroll in the Medicare Prescription drug plan. the beneficiaries have the choice of among several plans that offer drug coverage for which they pay a m onthly premium
- Medicare's Resource Based Relat ive Vale Scale (RBRVS) Pay ment Schedule
under this schedule a procedure's relative value is the sum total of 3 elements
- Work; represents the amount of time, intensity of effort, and m edical skill required of the dr
- Ov erhead; practice costs related to the performing of the service
- Malpractice: cost of m edical malpractice insurance
- m edical m alpractice insurance that covers the insured only for those claims made while the policy is in force is called claims-made coverage
- Medicine (except anest hesiology )
902 81-99199, 99500-99602 (RPM-7 89, M=9)
- Med Term ...
- -megaly enlargement
- Melanin m ajor skin pigment
- Metacarpals the 5 radiating bones in the fingers. These are the bones in the palm of the hand.
- Metat arsal m idfoot bone
- - met er m easure
- Mult igravida a pregnant woman who has had at least one previous pregnancy
- Muscle Act ions ...
- Muscles Muscle is tissue com prised of cells. Have the ability to contract & relax.
- The Musculoskelet al Sy st em
includes bones, m uscles & joints. Acts as a framework for the organs, protects m any of those organs, and also prov ides the body w/ the ability to m ove
- Mutually Exclusive Edit s (NCCI)
ID's code pairs that, for clinical reasons, are unlikely to be performed on the same pt on t he same day
- my o m uscle
- Nails cov er & protect the dorsal surface of the distal bones of the fingers & toes. Part that is v isible is nail body, nail root is under skin @ the base of the nail and nail bed is the vascular tissue under the nail that appears pink when the blood is oxy genated or blue/purple when it is oxygen deficient.
- nat birth
- neo new
- Neoplasm Table this is located in the Index under the m ain term "Neoplasm" and is organized by anatomic site. Each site has 6 colum ns w/ 6 possible codes determined by whether the neoplasm is m alignant, benign, of uncertain behavior or of unspecified nature
- New Pat ient Indiv idual who has not received any professional services from the physician or another physician of the same specialty who belongs to the same group practice within the past 3 years.
- New Pat ient defined as one who has not received m edical services w/in the last 3 years
- Nodule solid, round or ov al elevated lesion m ore than 1 cm in diameter
- Non-covered benefit
any procedure or service reported on the ins claims that is not listed in the payer's m aster benefit list. This will result in the denial of the claim. Providers m ay be able to recover the charges from the pt
- Nonessent ial Modifers
the m ain term m ay be followed by these in paranthesis, their presence or absences does not have an effect on the the selection of the code listed for the m ain term
- No ROM m ost sy narthroses are immovable joints held together by fibrous tissue
- oligo scanty, little
- - oma tum or, m ass
- oophor ov ary
- - osis abnormal condition
- oste bone
- Other CPT Codes
*Add-on codes- used for procedures that is always performed during the same operative session as another surgery in addition to the primary service/procedure and is never performed separately *Modifiers-provide the means by which the reporting physician can indicate that a service or procedure that has been performed has been altered by som e specific circumstance but not changed by the definition of the code
- Outpatient pt who receives treatment in any of the following settings: -phy sicians office -hospital clinic, emergency department, hospital same day surgery unit, ambulatory surgical center (pt is released w/in 23 hrs) -hospital admission for observation
- Palatine bones Make up part of the roof of the m outh
- pan all
- Paper Claim traditional m ethod used by providers for submission of charges to ins co's. The m ost commonly used form is the CMS-1 500. Few plans will still accept the physicians encounter forms or superbill and Medicare will only accept claims onthe CMS-
- para beside
- Patella kneecap
- Pathologic Fracture any fracture occurring spontaneously as a result of disease
- pre before, in front of
- Pre-authorization requirement for som e health ins plans to obtain permission for a service or procedure before it is done. It indicates that a specific procedure or service is deem ed "m edical necessary"
- Pre-cert ification to determine coverage for a specific treatment such as surgery, hospitalization or tests, under the insured's policy
- Pre-det ermination to determine the pt's benefits and the m aximum dollar amount that the ins com pany will pay. Often the 1st step of the ins v erification process, it is com pleted prior to the first visit
- Preferred Provider Plan
the type of plan a patient may have where they can see providers outside their plan, the pt is responsible for higher portion of the fee
- Premium the cost of ins cov erage paid annually, semi-annually or m onthly to keep a policy in effect
- Primary Malignancy the original cancer site. Malignant tumors are considered primary unless documented as secondary or m astastic
- Procedural Suffixes:
- Pronat ion turning the palm or foot downward
- Protraction m ov ing a part of the body forward
- Proximal near the point of attachment to the trunk
- pseudo false
- Pubic Bone lower anterior part of the bone
- Qualified diagnosis working diagnosis which is not yet established
- Radiology (including nuclear medicine and diagnost ic ultrasound)
7 7010-79999 (RPM-789)
- Radius lateral lower arm bone (in line w/ the thumb)
- Reasons for Document ation
Im portant that every pt seen by dr has com prehensive legible documentation about pt's illness, treatment, & plans for following reasons: *Av oidance of denied or delayed payment by ins co inv estigating the m edical necessity of services *Enforcement of m edical record-keeping rules by ins co requiring accurate docum entation that supports procedure & diagnosis codes. *Subpoena of m edical records by state investigators or the court for review *Defense of professional liability claim
- Reject ed Claim requires investigation and needs further clarification
- Relative Value Pay ment Schedule Method
inv olves the use of relative value scales which assign a relative weight to individual services according to the basis for the scale. Services that are m ore difficult, tim e consuming, or resource intensive to perform ty pically have higher relative values t han other services
- Remittance Advice an electronic or paper-based report of payment sent by the payer to the provider
- Retention Of Medical Is gov erned by state & local laws & m ay vary from state-to-state. Most dr are required to retain records
Records indefinitely, deceased pt records should be kept for @ least 5 years
- Retract ion Mov ing a part of the backward
- rhin nose
- Rib Cage There are 12 pairs of ribs. The 1st 7 pairs join the sternum anteriorly through the cartilaginous attachments called COSTAL CARTILAGE. The TRUE RIBS #'s 1 - 7 attach directly to the sternum in the front of the body. The FALSE RIBS, #'s 8-1 0 are attached to the sternum by cartilage. Ribs 11 & 12 are FLOATING RIBS, b/c they are not attached at all
- Rotat ion rev olving a bone around its axis
- - rrhagia bursting forth of blood
- - rrhapy suture
- - rrhea discharge, flow
- Sacral Sacrum
- Sagittal v ertical plane dividing the body into right & left sides
- salping fallopian tubes
- Salter-Harris Fract ure
a fracture of the epiphyseal plate in children
- Scapula or shoulder blades are flat bones that help support the arms
- - sclerosis hardening
- - scopy to v iew
- - scopy v isual examination
314. SEBACEOUS
GLANDS
located in the dermal layer of the skin ov er the entire body, expect for palm of hands and soles of feet. Secrete oily substance called SEBUM. SEBUM CONTAINS LIPIDS THAT HELP LUBRICATE THE SKIN & MINIMIZE WATER LOSS. It is the ov erproduction of sebum during puberty that contributes to acne in some people
315. SEBACEOUS (OIL)
GLANDS &
SUDDORIFERIOUS
(SWEAT GLANDS)
produce secretions that allow the body to be m oisturized or cooled.
- Secondary Malignancy
cancer that has m etastasized (spread) to a secondary site either adjacent or remote region of the body
- Section 1: Index t o diseases
each term is followed by the code or codes that apply to that term
- Section 2: Table of Drugs and Chemicals
contains a list of drugs & chemicals w/ the corresponding poisoning code and E codes. The E codes are used to explain the circumstances surrounding the poisoning which m ay be:
- Accident: Poisoning was due to accidental overdose, wrong substance taken, acci dents in use of drugs and biologicals, external causes of poisoning classifiable to 980 - 989
- Therapeutic Use: instances when a correct substance properly taken is the cause of an adverse effect
- Suicide Attempt: the poisoning was self-inflicted
- Assault: poisoning was inflicted by another person w/ intent to kill or injury
- Understand: poisoning cannot be determined whether intentional or accidental
- Superior abov e another structure
- Supination turning the palm or foot upward
- Supplementary Classification Codes
- supra abov e, beyond
- Surgery 1 0021-69990 (Surgery always want to feel 100%)
- Surgical Package also called "global surgery" includes a variety of services rendered by a surgeon which includes the following: -surgical procedure performed -local infiltratration, m etacarpal/metatarsal/digital block or topical anesthesia -Preoperative E/M services; on day immediately prior to the day of the procedure -im m ediate postoperative care -Norm al, uncomplicated postop care
- Sy novial Joints free m oving joints, are surrounded by joint capsules. Many of the synovial joints have BURSAE-SACS OF FLUID THAT ARE LOCATED BETWEEN THE BONES OF THE JOINT AND THE TENDONS THAT HOLD THE MUSCLES IN PLACE.
- Tarsal hind foot bone
- tetra four
- - therapy treatment
- Thoracle Upper Back
- Tibia shin
- - tomy incision, to cut into
- Transverse, Cross-sect ional
Horizontal plane dividing the body into upper & lower portions
- TRICARE regionally managed health care program for active duty and retired m embers of the armed forces, their families and survivors. It is a service benefit and contains no premium. TRICARE is the new title for CHAMPUS program (Civ ilian Health and Medical Program of the Uniformed Services)
- Ulcer open sore on the skin or m ucous m embrane
- Ulna lower m edial arm bone
- Unauthorized Benefit
procedure or service provided w/o proper authorization or was not covered by a current authorization. The claim is denied and the provider cannot bill the pt for the charges
- Uncert ain Behavior
uncertain whether benign or malignant, borderline malignancy
- Unlisted Procedures
Procedures considered experimental, newly approved, or seldom used may not be listed in the CPT manual. Can be coded as unlisted procedures. they are located at the end of the subsections or subheadings. when unlisted procedure code is reported must be described in the accompanying documentation
- Unspecified Nature
a neoplasm is identified; however, no nature of the tumor is documented in the diagnosis of the m edical record
- Upper Appendicular Skelet on
includes the shoulder girdle which is m ade up of the SCAPULA, CLAVICLE, & UPPER EXTREMITIES
- Upper Extremities
consist of the following:
- Vesicle sm all collection of clear fluid; blister
- VI. Pay ment once the claim is approved for payment, a remittance advice (RA) is sent to the provider and an explanation of benefits (EOB) is m ailed to the policyholder
- Volume 1-Index to Diseases, Tabular List
contains the disease and condition codes and the descriptions, also contains the V codes and E codes
- Volume 2-Index to Diseases, Alphabetic Index
the is the alphabetic index of Volume 1; use this first then volume 1 to confirm codes
- Volume 3- Procedures
contains codes for surgical, therapeutic, and diagnosis procedures, used primarily in hospitals
- Vomer bone that forms posterior/inferior part of the nasal septal wall between the nostrils
- What 3 way s can an individual obt ain health insurance?
1 )Group Ins-when a group of em ployees & their dependents are insured under 1 group policy issued to the em ployer. Generally the em ployer pays the premium or portion of prem ium and the em ployee pay s the difference. 2 )Personal Insurance- an insurance plan issued to an individual. premium rates are usually higher than group rates and service availability is lessened w/ this type of cov erage 3 )Pre-paid health plan- pre-determined set of benefits covered under one set annual fee
- What are BC/BS plans reimbursement methodologies?
phy sician reimbursement had been based on the UCR m ethod but more plans have adapted the RBRVS m ethod while som e are using capitated rates.
- What are bones connect ed to one anot her by?
by fibrous bands of tissues called LIGAMENTS
- What are circumstances when V codes are used?
*When a person who is not currently sick encounters health services for som e specific reason such as to act as an organ donor or receive a vaccination. (IE; V5 9.3 is the code for donor of bone marrow) *When a person w/ a resolving disease or chronic condition presents for specific treatment of that disease or condition. (IE; V56.0 is used for extracorporeal dialysis) *When a circumstance may influence the pt's h ealth status but is not a current illness (IE; V16.3 is used for fam ily history of coronary artery disease) *To indicate the birth status of a newborn (IE; V30.0 is uused for a newborn male born in the hospital by c-section)
- What are common forms of fraud?
billing for services not furnished, unbundling, & m isrepresenting diagnosis to justify payment
- What are E codes? Supplementary Classification of External Causes of Injury and Poisoning -supplementary classification codes used to describe the reason of EXTERNAL CAUSE of injury, poisoning and other adverse effects. Can be found in both Volumes! & 2.
- What are examples of Abuse?
subm itting a claim for services/procedures performed that is not m edically necessary, and excessive charges for services, equipment or supplies.
- What are Medical Ethics? Standards of conduct based on m oral principle. They are generally accepted as a guide for behavior towards pt's, dr's, co-workers, the gov, and ins co's.
- What are Medicare Health Insurance Claim Numbers (HCIN'a)?
issued by CMS and are usually SS #'s with letter (alpha) or letter/number (alphanumeric) suffixes.
