CPC Medical Coding flashcards

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

Principal diagnosis

In inpatient coding, the condition established after study to be chiefly responsible for occasioning the admission; it is sequenced first unless a guideline requires otherwise.

First-listed diagnosis

The diagnosis reported first on an outpatient claim, representing the condition chiefly responsible for the services provided; it is conceptually equivalent to the inpatient principal diagnosis.

Excludes1 note

An ICD-10-CM instruction meaning the two conditions cannot be coded together because they are mutually exclusive; only the condition documented by the provider is coded.

Excludes2 note

An ICD-10-CM note indicating the excluded condition is not part of the coded condition and may be reported separately when both conditions are documented.

Seventh character A

An ICD-10-CM placeholder indicating the initial encounter for an injury or condition; subsequent encounters use D, and sequelae use S.

CPT add-on code

A CPT code designated by a plus sign that is always reported with a primary procedure and never alone; it is exempt from modifier 51.

HCPCS Level II

A five-character alphanumeric code set beginning with a letter, used for supplies, drugs, durable medical equipment, and services not represented in CPT.

ICD-10-PCS

The inpatient procedure coding system with seven alphanumeric characters and no decimals, organized by root operation rather than by body system.

Code also instruction

An ICD-10-CM instruction requiring an additional code to fully describe the condition; both codes are reported, with sequencing determined by the applicable guideline.

Unspecified code use

Reported only when documentation does not support a more specific diagnosis; coders should not assign unspecified codes merely because a specific code is unavailable.

Laterality in ICD-10-CM

Many ICD-10-CM codes require a right or left designation; if laterality is not documented, the coder should query the provider rather than defaulting to one side.

Established patient

A patient who has received a face-to-face professional service from the same specialty and same practice within the previous three years.

New patient

A patient who has not received any face-to-face professional service from the same specialty and same practice within the past three years.

Modifier 25

Appended to an evaluation and management service when a significant, separately identifiable E/M service is performed on the same day as a procedure or other service.

Modifier 57

Used on an E/M service when the encounter results in the decision for surgery, distinguishing the E/M from the surgical procedure's global package.

Global surgical package

The bundle of preoperative, intraoperative, and postoperative services included with a surgical CPT code; Medicare uses 0-, 10-, or 90-day postoperative periods.

Modifier 50

Reported for bilateral procedures performed on both sides of the body during the same operative session when the CPT code permits a bilateral designation.

Modifier 51

Indicates multiple procedures were performed during the same session; the secondary procedure is typically reimbursed at a reduced rate by the payer.

Incident-to services

Services furnished by auxiliary personnel under a physician's direct supervision as an integral part of the physician's plan of care, reported under the physician's NPI.

Place of service 11

The POS code for a physician's office; other common codes include 22 for outpatient hospital, 24 for ambulatory surgical center, and 21 for inpatient hospital.

Split/shared E/M

An E/M service furnished jointly by a physician and nonphysician practitioner in a facility; the billing practitioner must perform the substantive portion of the encounter.

Modifier 33

Indicates a preventive service was provided; used when a preventive service is rendered during a problem-oriented encounter or when payer rules require identification.

E/M medical decision making

One of the components used to select an office or outpatient E/M level under the 2021 guidelines; it considers number and complexity of problems, data, and risk.

False Claims Act

A federal statute imposing liability on persons who knowingly submit or cause false claims to government payers; penalties include treble damages and per-claim fines.

Anti-Kickback Statute

A federal law prohibiting knowingly offering or receiving remuneration to induce referrals for items or services covered by federal healthcare programs.

Stark Law

A strict-liability physician self-referral statute prohibiting referrals of designated health services to entities with which the physician has a financial relationship, absent an exception.

NCCI edits

Medicare's National Correct Coding Initiative edits that identify code pairs not separately payable; the column one code is payable and the column two code is bundled.

Modifier 59

Used to indicate a procedure or service was distinct and independent from another service on the same day; payer rules restrict when it may be used.

Advance Beneficiary Notice

A written notice given to a Medicare beneficiary before a service likely to be denied as not medically necessary, shifting financial liability if the denial occurs.

Minimum necessary standard

A HIPAA requirement to limit uses and disclosures of protected health information to the least amount needed to accomplish the intended purpose.

Upcoding

Assigning a higher-level or more complex code than the documentation supports, which can constitute false claims and healthcare fraud.

Unbundling

Reporting components of a bundled service separately to increase payment, a compliance risk when NCCI edits or CPT rules prohibit separate reporting.