CPT Codebook and Evaluation and Management Coding Homework

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Feb 20, 2024

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CPT Codebook and Evaluation and Management Coding Homework Part 1: Navigating the CPT Codebook Question Your Response 1.CMS adopted CPT codes in which year? 1983 2.There are how many sections in the CPT codebook? 6 3.In your CPT codebook, what page is your CPT Index located on? In the back of the book starting on page 1043 4. What is a CPT code symbol? A solid dot ( ) preceding a code number identifies a new CPT code. 5. Define what a Main Term is. The condition, name of procedure or medical service, name of anatomic site or organ, or synonyms, eponyms or abbreviations. 6) CPT Section Matching Answer Select from drop down (a- f) CPT Code from this Section 1. Contains codes for x-rays, MRIs, diagnostic ultrasounds, nuclear medicine, and radiation oncology. Radiology (70010– 79999) 2. Contains codes for the evaluation, therapeutic, and diagnostic procedures. Types of services include immunizations, injections, dialysis, infusions, vascular studies, EKGs, Holter monitors, pacemaker procedures, Medicine (90281– 99607)

cardiac catheterizations, occupational, physical and speech therapies, allergy services, psychiatry, optometry, and chiropractic services, etc. 3. Contains codes that report anesthesia services performed by or supervised by a physician. The services include general and regional anesthesia, and the code covers preop evaluation and planning, care during the procedure and routine post op care. Anesthesiolog y (00100– 01999) 4. Contains codes that cover services that represent services associated with performing tests and analyzing and reporting the test results; organized by type of test; ex: organ or disease- oriented panels, drug testing drug assays, consults, surgical pathology. Pathology and Labortory (80047– 89398) 5. Contains codes for services that are performed that include incision & drainage, debridement, biopsies, excisions, amputation, colonoscopy, OB care, digestive procedures, chemo denervation, etc. and is the largest section of the CPT codebook for procedures. Surgery (10021– 69990) 6. Contains codes that cover services that are performed by a physician or other qualified healthcare professional and the provider is involved in evaluating or managing the patient’s health. Evalutation and Managment (99202– 99499) 7) Code Symbol Description and Matching Answer Provide CPT code with Code Symbol

Appendix Select from drop down (a-d) Indicator ⦸ Appendix E A. Exempt Modifier 51 ⦸ 64462 * Appendix P D. Telemedicine * 99452 ▲ Appendix B C. Revised Code ▲ 12345 ~ Appendix K B. Pending FDA Approval ~ 90678 Part 2: CPT and HCPCS Modifiers Question Your Response 1. What is the purpose of a coding modifier? The modifier provides additional information about the medical procedure, service, or supply involved without changing the meaning of the code. 2. In your CPT codebook, where will you locate all the CPT modifiers applicable to CPT 2023 codes? CPT modifiers are added to the end of a CPT code with a hyphen. In the case of more than one modifier, you code the “functional” modifier first, and the “informational” modifier second. 3. What is the modifier that you would use if under certain circumstances a service being performed in an Ambulatory Surgery Center (ASC) was cancelled by the doctor because the wellbeing of the patient was being threatened prior to the administration of anesthesia? Modifier 73

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4. What is the modifier you would use for Anesthesia provided by the ENT physician during a tympanoplasty for repair of a tympanic membrane perforation. Modifiers -47 5. True or False - CPT and HCPCS modifiers may be used with CPT codes and HCPCS Level II codes but CPT modifiers cannot be used with HCPCS Level II codes. False 6. What Level II modifier indicates the upper left eyelid? Modifier -E1 Part 3: CPT Evaluation and Management (E/M) Coding Question Provide CPT E/M Code 1. True or False - Time alone can be used for all CPT E/M codes. True True 2. Where can you locate Table 1: Levels of Medical Decision Making (MDM) for Evaluation and Management Services in your CPT codebook? Page 8 of the codebook 3. True or False - If the doctor documented 25 minutes and low-level medical decision making for an established office encounter, the correct e/m service would be 99203. True 4. For a patient seen in the Emergency Room, the physician documents a moderate level of medical decision making, and a medical appropriate history and exam. Which E/M code is assigned? 99284 5. The patient is a 52-year-old male from out of 99202

state visiting his son. He realized he left his medications for his benign hypertension at home and is now being seen in our clinic in need of a prescription refill. This is the first time we have seen the patient in our office even though his son is an established patient. A history and examination are performed, and straightforward MDM. A prescription is given to the patient. Which E/M code is assigned? 6. A 2-year-old boy with bacterial pneumonia was hospitalized and had 5 days of antibiotic therapy and the patient was discharged last week. Today, his mother brings him to the office because he has developed a fever of 101° F with a mild rash on his torso. The patient was last seen in our office 6 months ago for his well-child exam. His pediatrician performed a problem-focused history and examination. The MDM complexity was low. Which E/M code is assigned? 99471 7. A female presents to the emergency department with a wrist sprain sustained in a softball game when she slid into home plate, striking her hand on home plate. She is in apparent pain with a swollen wrist and states it is a 8 out of 10 and she cannot flex. A history and physical examination are done. The x-ray shows a Colles’ fracture of the distal radius. The MDM complexity was low. Which E/M code is assigned? 99291 8. True or False? When calculating the level of Medical Decision Making, 2 out of the 3 elements have to meet or exceed? True 9. The physician performs an initial hospital inpatient visit that consists of a medically appropriate history and examination and medical decision-making of low complexity. What is the appropriate level of E/M service? 20-29 mintues