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Coding 101
E/M Documentation Guidelines
Coding Diabetes in ICD-10
Commonly Used Modifiers
Top Missed Coding Concepts
100
What does the acronym "CPT" stand for?
What is Current Procedural Terminology.
100
This is an individual who has not received any professional services from the physician/non-physician practitioner (NPP) or another physician of the same specialty who belongs to the same group practice within the previous three years
What is a new patient (CPT 99201 - 99205)
100
In this type of Diabetes Mellitus, the pancreas produces little to no insulin and daily insulin injections are required.
What is Type 1 Diabetes
100
This modifier is used for an unrelated E/M service by the same provider during a postoperative period.
What is modifier 24.
100
Under the 1995 Documentation Guidelines which organ system would "extremities: no edema" count towards?
What is cardiovascular.
200
This CPT code set is used voluntarily by physicians to report quality patient performance measurements.
What is CPT Category II Codes.
200
This is an inquiry about the system(s) directly related to the problem(s) identified in the HPI plus all additional (minimum of ten) organ systems
What is a Complete ROS
200
If the type of Diabetes is not documented in the medical record, this is the default
What is Type 2 Diabetes - E11.-
200
This global surgery package includes a total of 92 days.
What is major global surgery package.
200
This code is selected when there isn't an ICD-10-CM code that describes the specific information documented for the diagnosis.
What is NEC (Not Elsewhere Classified).
300
What symbol represents a CPT code that is used to report a supplemental or additional procedure appended to a primary procedure (stand-alone) code.
What is "+" (plus sign).
300
Time is considered the key or controlling factor to qualify for a particular E/M service if these two key components are met?
When counseling and/or coordination of care dominates more than 50% of the visit. When the documentation describes the counseling and/or activities to coordinate care
300
This diagnostic tool is used to check for glucose, proteins, and ketones in the urine
What is an urinalysis.
300
This modifier is used when a surgical case is terminated due to patient pain or discomfort.
What is modifier 53 (Discontinued Procedure)
300
This wound repair code would require extensive undermining, creation of defect, or debridement.
What is Complex.
400
This medical term suffix means "instrument for recording data"
What is -graph.
400
This is an extended examination of the affected body area(s) or organ system(s) and any other symptomatic or related body area(s) or organ system(s) (5 to 7 body areas or body systems)
What is a Detailed Examination
400
Diabetes mellitus codes are combination codes that include these three things?
Type - Body System Affected - and the Complication affecting that body system
400
This modifier would be appended if the procedure performed is more extensive than the original procedure performed
What is modifier 58 (Staged or Related procedure by the same provider during the postoperative period)
400
This type of fracture care is reported when the provider creates an opening to expose the bone to treat a fracture.
What is open fracture care.
500
This medical term prefix means "before;forward"
What is Ante-
500
This new patient office visit requires a detailed history, detailed examination, and a low complexity of medical decision making.
What is a 99203.
500
This complication of Diabetes is an acute life-threatening condition that requires immediate medical attention. It occurs when the body cannot use sugar (glucose) as a fuel source because there is no insulin or not enough insulin. Fat is used for fuel instead.
What is Diabetic ketoacidosis.
500
This modifier would be appended if the provider finishes the procedure and exclaims "Uh oh.....Where's my scalpel?" and determines it was accidently left in the patient.
What is modifier 78 (Unplanned Return to the Operating/Procedure Room by the Same Physician for Related Procedure During Post-Op Period)
500
A complicated I&D is reported when: performed on multiple abscesses, drains are inserted, packing with gauze, or there is a large amount of fluid expressed. What is this CPT code?
What is 10061.