A tumor or tissue that had been found to be noncancerous is termed
Benign
What is the term that is used for two simultaneous conditions?
Comorbidity
A disease or condition that has a rapid onset and a short, severe course is said to be
Acute
A disease or condition that progresses slowly and has a long duration is said to be
Chronic
A disease process or condition that develops more slowly than an acute process but more rapidly than a chronic condition is said to be
Subacute
An area of new and abnormal tissue growth is a
Neoplasm
The prevalence of a disease in a certain population is its rate of
Morbidity
Coded medical data is used to track the number of deaths due to a particular cause in a certain population; this is known as
Mortality
Which coding system for medical services uses 5-digit numbers with 2-digit modifiers
Current Procedural Terminology (CPT)
How often are diagnostic and procedural codebooks updated?
Every year, before October 1st
Computer assisted coding software converts words and phrases entered about a patient's condition into which type of data that must be checked and edited by a professional coder?
Codes
The typical services provided by one surgeon for all services involved in a surgical procedure code make up the
Surgical Package
ICD-10-CM includes how many more codes than ICD-9-CM to cover more diseases and conditions and allow for greater specificity in coding
Over 55,000 additional codes
The coding system used to document the diagnoses made by physicians is
International Classification of Diseases (ICD)
The coding system used to document services and supplies provided to patients and procedures performed is the
HCPCS Level I & II
In the CPT codebook, a code with a bullet beside it is a
New Code
In the new CPT codebook, a code with a triangle beside it is a
/\ Revised code
ICD-10-cm codes used for diagnoses in an outpatient setting may be found in
Volumes I & II
Which CPT modifier indicates that the services required were substantially greater than usual for a particular procedure
-22
Which CPT modifier indicates that the service was mandated by a third party, such as an insurance company or government payer
-32
Which CPT modifier indicates the professional component in a technical diagnostic procedure, such as when he or she interprets the result of a laboratory test or xray
-26
Diagnostic codes are input into a nationwide central computer database which is accessed by ____ and used for _____.
All insurance companies, International statistical reporting
Who addresses coding regulations
HIPAA, OSHA, Stark I & II regulations
Electronic coding programs are considered a vital tool: however, to reduce possible return errors it is prudent to use
Correct coding initiative edits
What does a CAC do
Computer-assisted coding, automatically assigns codes to clinical procedures and services
HCPCS Level II codes are both temporary and
Permanent codes
National correct coding initiative (NCCI) edits relate to
Both CPT and HCPCS codes
When a similar service is provided to a hospital patient by more than one physician on the same day, it is referred to as
Concurrent Care
The use of consultation codes has been eliminated by
Medicare
Over-utilized CPT codes are codes that are
Upcoded frequently
In CPT, the E/M section is used to code
Office and hospital visits
The largest section of the CPT is the
Surgery section
The musculoskeletal subsection is part of what section
Surgery section
If a Medicare patient, who has been scheduled for surgery, is seen for a pre-operative visit one day prior to being admitted to the hospital, why would you not bill for the E/M service
Because it's included in global package
Days that follow major surgery and are included in the price of surgery (surgical or global package) are called
Follow-up days
A "CABG" (coronary artery bypass graft) is a procedure performed on what system
Cardiovascualr
When cutting open the abdomen to perform surgery, it is referred to as a ____ procedure
Laparotomy
Codes are arranged in the urinary subsection according to
Anatomic site starting with the kidney
In CPT, intersex surgery is listed as a separate _____ in the surgery subsection
Subsection
A total abdominal hysterectomy is the removal of the
Uterus (Corpus & Cervix)
What section would the procedure amniocentesis be found in
Maternity Care & Deilvery Section
When frequent tests are grouped together in the pathology and laboratory section, they are called
Panels
What section are vaccines found in
Medicine section
What is the compliance date that all health care providers have to implement the use of ICD-10-CM
October 1, 2013
ICD-10-CM coding guidelines have been developed by the
Centers for Medicare & Medicaid services (CMS), National Center for Health Statistics
When a diagnostic code has "NEC" by it, it means
The description necessary to code in a more specific category is not listed
When you read the term "and" in a narrative statement, it represents
And/Or
Some conditions have an underlying cause along with a disease that occurs due to the underlying condition. In such cases code the _____ first and the _____ second
Underlying condition (Etiolgy), manifestation
All ICD-10-CM codes have how many digits
3-7 alphanumeric digits
In the diagnostic statement, "malignant mass of the left arm," the main term is
Mass
In the diagnostic statement, "umbilical hernia in a 3-year old child," the main term is
Hernia
Most categories for sprains, strains, and fractures coded from chapter 19 to have 7th character extensions that are required to indicate the
Type of encounter
What is an adverse effect
When a drug has been properly administered but a patient has a reaction to it
When a patient has a personal or family history of a disease that affects their current condition; the risk factor should be coded with a _____ code.
Z
Bundling
One or more services covered under a main procedure code
Unbundling
Fraudulent practice, also known as exploding, in which a procedure is broken down into separate billable codes to obtain a higher payment
Coding
Assigning a numerical code to a medical diagnosis procedure
Upcoding
Fraudulent practice of billing for higher procedure codes than services actually performed to obtain a higher payment
Down Coding
Converting a submitted code to a lower-level code, which typically results in a lower payment
Modifier
Two- digit code used in addition to the five-digit code to add specific information about the circumstances
Placeholder
Character used in the ICD-10-CM codebook that allows for future expansion and is required for the code to be considered valid
Add-on Code
CPT code indicated by a +, used in combination with a primary procedure code
Code Linkage
On an insurance claim, when the submitted procedure codes match up with appropriate diagnostic codes
Symbol
Character shown alongside certain CPT codes to provide additional information about the code
Biopsy
Removal and examination of a tissue sample for diagnostic purposes
Endoscopy
Examination that visualizes body cavities and hallow organs using a special instrument
Consultation
Physician provides a second opinion regarding a patients condition or need for surgery
Counseling
Physician meets with patient to discuss test results, diagnosis, prognosis, or the risks and benefits of various treatments
Encounter
The physician meets with the patient and provides some type of care
Postoperative Care
Period immediately following surgery
Concurrent Care
Services provided by more than one physician to the same patient on the same day
Critical Care
Services provided to a patient who is unstable or acutely ill or injures
Quantitative Analysis
Laboratory test that measures the amount of a substance present in a fluid or tissue
Qualitative Analysis
Laboratory test that determines the presence of an agent within the body
The cause of a disease is know as its
Etiology
A physician provides a _____ diagnosis when he or she tells the patient that a disease or condition is suspected or likely but has not yet been confirmed
Qualified
A coding _____ program is put in place to ensure that medical coding is done in alignment with HIPAA regulations and other legislative requirements
Compliance
A secondary term used in the diagnostic codebook that reports specific circumstances or additional information related to a diagnosis is a _____
Subterm
Both a _____ code and an administration code must be included for injections
Product
If a patient presents with an _____ fracture, this means a bone has broken through the skin
Open
When a medical practice hires a company to provide billing and coding services instead of having employees perform those functions, this is known as _____
Outsoucing
When a physician moves or adjusts tissue or bone as part of treatment, this is _____ of the affected body part
Manipulation