COC (Formerly CPC-H) flashcards

32 cards. Read the term and the definition here. The deck at the top of this page is optional.

7th character A

In ICD-10-CM injury coding, the 7th character A means initial encounter, indicating active treatment for the condition; subsequent encounters use D and sequelae use S.

CPT Category III code

A CPT Category III code is a temporary five-character code with four digits followed by T, used for emerging technology, services, or procedures; it is not a Category I code.

HCPCS Level II code

A HCPCS Level II code begins with one letter followed by four digits and reports supplies, drugs, durable medical equipment, and services not represented in CPT.

Outpatient principal diagnosis

The outpatient principal diagnosis is the condition chiefly responsible for the encounter after study; it is reported first on the facility claim and must be supported by documentation.

Modifier 25

Modifier 25 indicates a significant, separately identifiable evaluation and management service by the same physician on the same day as a procedure or other service.

NCCI column 1 code

In an NCCI procedure-to-procedure edit, the column 1 code is the primary procedure that may be payable; the column 2 code is generally bundled unless an appropriate modifier applies.

Add-on code billing

An add-on CPT code is reported in addition to a primary procedure, cannot stand alone, and typically is exempt from multiple-procedure reduction under modifier 51 rules.

J-code billing units

For a HCPCS Level II J-code, billed units are calculated by dividing the total drug dose administered by the dose unit stated in the code descriptor.

Non-leading query

A non-leading documentation query asks the provider to clarify ambiguous or missing information without suggesting a specific answer, preserving the integrity of the medical record.

Medical necessity

Medical necessity means services are reasonable and necessary for diagnosing or treating a condition, meet accepted standards, and are supported by documentation in the record.

Incident-to supervision

Incident-to billing requires direct supervision, meaning the physician is immediately available to assist and direct auxiliary personnel during the service, not merely on call.

ABN purpose

An Advance Beneficiary Notice informs a Medicare beneficiary that a service may be denied as not medically necessary, allowing the patient to accept financial responsibility.

Teaching physician presence

For teaching physician billing, the attending must personally perform the service or be physically present for key portions; documentation must establish that presence.

HIPAA minimum necessary

The HIPAA minimum necessary standard requires limiting protected health information used or disclosed to the least amount reasonably needed to accomplish the intended purpose.

Cloning documentation

Cloning is copying identical or nearly identical documentation across encounters or patients; it creates compliance risk because it may not reflect the actual service provided.

Time-based E/M coding

Time may determine an E/M level only when the CPT code descriptor includes time; otherwise the level is based on required key components or facility criteria.

ED facility level

Emergency department facility E/M levels 99281–99285 reflect hospital resources and interventions used, such as staff, equipment, and supplies, rather than physician decision making alone.

Observation status

Observation is an outpatient status used for evaluation and management while deciding whether inpatient admission is needed; a formal inpatient order changes the status.

G0378 observation hours

HCPCS G0378 reports hospital observation services per hour; documented observation time and the observation order support the units billed.

Critical care 99291

CPT 99291 reports the first 30 to 74 minutes of critical care for a critically ill or injured patient; 99292 reports each additional 30 minutes.

Hospital-based clinic claim

A hospital-based clinic service is billed by the hospital on a facility claim with an E/M code and clinic revenue code, while the physician bills separately.

APC status indicator

An OPPS status indicator describes how a HCPCS/CPT code is paid, such as separately payable, packaged, or not payable, and drives APC assignment.

Same-day surgery facility claim

For same-day surgery, the hospital facility claim reports the CPT procedure and ICD-10-CM diagnosis; the surgeon’s professional service is billed separately.

Endoscopy bundling

When multiple endoscopic procedures are performed, CPT hierarchy and NCCI edits determine which procedure is primary and which services are bundled or separately reportable.

Revenue code 0360

Revenue code 0360 identifies operating room services on a hospital facility claim and is used with the appropriate CPT procedure code for surgical cases.

OPPS APC assignment

Under the Outpatient Prospective Payment System, a payable HCPCS/CPT code is assigned to an ambulatory payment classification, or APC, which determines the facility payment rate.

Status indicator T

In OPPS, status indicator T generally identifies a significant surgical procedure subject to multiple-procedure reduction when performed with other procedures on the same date.

Multiple-procedure reduction

OPPS generally reduces payment for second and subsequent status T procedures to 50 percent of the APC rate, with exceptions defined by Medicare payment rules.

MUE edit

A medically unlikely edit sets the maximum units of a HCPCS/CPT code allowed per date of service; units above the MUE require review and may be denied.

Timely filing denial

A timely filing denial occurs when a claim is received after the payer’s deadline; appeals require proof of timely submission or a qualifying exception.

Contractual allowance

A contractual allowance is the difference between the provider’s billed charge and the payer’s allowed amount; it is not billed to the patient.

Clean claim

A clean claim contains complete, accurate, and consistent information required by the payer, allowing adjudication without additional documentation or correction.