Question 1

Which of the following types of history focuses mainly on the chief complaint?

Accepted Answer

The problem-focused history is a type of history that focuses mainly on the chief complaint. It is a concise and targeted approach to gather information relevant to the presenting problem or concern. Other types of history such as detailed history, comprehensive history, and expanded problem-focused history are more extensive and cover a wider array of topics beyond the chief complaint.

Question 2

In the index of the CPT manual, which of the following may modifying terms NOT identify?

Accepted Answer

Modifying terms may identify a condition, procedure, or anatomic location, but they do not identify the time allotted for a procedure. Time is generally included in the code description itself, rather than in a modifying term.

Question 3

Describe how to use the most current procedural coding system

Accepted Answer

To use the most current procedural coding system, you will need to be familiar with the specific coding guidelines and conventions for that system. This may involve studying the official coding manuals and attending training sessions to stay up to date with any changes or updates.

Next, you would need to apply the correct codes to accurately describe the services or procedures performed during a patient encounter. This involves understanding the specific codes for each procedure or service, as well as any modifiers or additional information required to ensure accurate coding.

It is also important to use the most current version of the procedural coding system to ensure that you are capturing the most accurate and up-to-date information. This may involve regularly updating your coding resources and staying informed about any changes or revisions to the system.

Overall, using the most current procedural coding system involves staying informed, accurately applying the codes to describe services, and ensuring that you are using the most current version of the coding system. This is essential for accurately documenting and billing for healthcare services.

Question 4

How often should the medical office purchase new code books or computer code sets?

Accepted Answer

Code sets are constantly changing and updated with new codes, deleted codes, and revised codes. It is recommended that medical offices purchase new code books or update their computer code sets annually to ensure they are using the most accurate and up-to-date codes for billing purposes.

Question 5

Medical Office Business Procedures/Management

Accepted Answer

The answer of Medical Office Business Procedures/Management...

Question 6

Describe how to use the most current HCPCS coding

Accepted Answer

The answer of Describe how to use the most current...

Question 7

Which of the following is NOT a primary factors determining the level of service?

Accepted Answer

Coordination of care is not considered a primary factor in determining the level of service; instead, the primary factors include the extent of the history, the extent of the physical examination, and the complexity of medical decision-making.

Question 8

What is the format of most CPT codes?

Accepted Answer

Most CPT codes are five-digit codes that represent a specific medical service or procedure.

Question 9

Which organization compiled the first disease classification system in the United States?

Accepted Answer

The American Medical Association (AMA) compiled the first disease classification system in the United States, known as the International Classification of Diseases (ICD).

Question 10

What would be added to a code for a procedure that was extensive or unusual or that required an assistant?

Accepted Answer

Modifiers are used in medical coding to indicate that a service or procedure has been altered by some specific circumstance but not changed in its definition or code. A two-digit modifier provides this additional information without altering the basic code.

Question 11

If the patient has multiple problems and is seriously ill, what type of medical decision making is probably necessary?

Accepted Answer

When a patient has multiple problems and is seriously ill, high-complexity medical decision making is typically necessary. This often involves a detailed review of the patient's medical history, extensive diagnostic testing, and multiple treatment options. The decision-making process may also involve consultations with other healthcare providers and consideration of potential risks and benefits of various approaches.

Question 12

For which reason are procedure codes NOT used?

Accepted Answer

Procedure codes are used to identify and justify medical services a patient received, to set fees for those services, and to collect statistics about the frequency and effectiveness of procedures. They are not used to determine the frequency of diseases in the population; that is typically done through diagnosis codes and epidemiological studies.

Question 13

What do CPT Category II and Category III codes consist of?

Accepted Answer

CPT Category II and Category III codes consist of a combination of four digits and one letter. Category II codes are used to track performance measures, while Category III codes are used for emerging technologies, services, and procedures. These codes are optional and are not used for reimbursement by most insurance payers.

Question 14

What coding system is used by the Centers for Medicare and Medicaid Services for services and equipment that are not usually covered by ordinary health insurance?

Accepted Answer

HCPCS Level II codes are used by the Centers for Medicare and Medicaid Services for services and equipment that are not usually covered by ordinary health insurance. CPT codes are used for reporting medical procedures and services, DRG codes are used for billing inpatient hospital services, and ICD-9-CM codes are used for reporting diagnoses and conditions.

Question 15

Define upcoding and why it should be avoided

Accepted Answer

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Question 16

How does a classification system become a coding system?

Accepted Answer

A coding system replaces the names of items with numbers and/or letters to create a standardized system for easily identifying and organizing them. This is different from a classification system which simply groups items together based on common characteristics or traits.

Question 17

What is the first section of the CPT manual?

Accepted Answer

The first section of the CPT manual is Evaluation and Management, which includes codes for services related to patient evaluation, assessment, and management.

Question 18

Describe how to use the most current diagnostic coding classification system

Accepted Answer