Test Bank For Kinn's The Administrative Medical
Assistant, 15th Edition
List and describe the three code categories in the Current Procedural Terminology (CPT) manual.
- ANSWERSThe CPT manual comprises three category codes: Category I, Category II, and
Category III codes. Category I codes are 5-digit codes that are listed in the Tabular List. Category
II codes are used for performance measurement, and their use is optional. Category III codes
are temporary codes for emerging medical technologies.
Distinguish between the Alphabetic Index and the Tabular List in the CPT code set. Also, list the
six different sections of the Tabular List. - ANSWERSThe CPT has two primary divisions, the
Alphabetic Index and the Tabular List. The Alphabetic Index is like any other index in a textbook;
it is simply a guide to finding data in the body of the textbook. The Tabular List is divided into six
sections, and codes are listed in numeric order in each section.
The six sections of the Tabular List are Evaluation and Management, Anesthesia, Surgery,
Radiology, Pathology and Laboratory, and Medicine. Sections are divided into subsections;
subsections are further divided into categories; and categories can be subdivided into
subcategories.
Discuss special reports and explain the importance of modifiers in assigning CPT codes. -
ANSWERSWhen a bill is submitted for a service that is unlisted, unusual, or newly adopted, the
third-party carrier requires a special consultation report. Modifiers are used in CPT codes to
indicate that a service or procedure performed was altered by specific circumstances. Two-digit
alphanumeric modifiers, included with the 5-digit CPT code, can be used to supply additional
information or to describe extenuating circumstances that affected the rendered procedure or
service.
Review various conventions in the CPT code set. - ANSWERSConventions are used to provide
additional information about certain codes. Examples of conventions include triangular and
round symbols, which indicate that a code or description was revised, removed, or added.
Identify the required medical documentation for accurate procedural coding - ANSWERSMedical
records used for procedural coding can include any or all of the following: encounter form,
, history and physical report (H&P), progress notes, discharge summary, operative report,
pathology report, anesthesia record, and/or radiology report. When the medical documentation
is compared against any code description, all the elements of that code must substantially
match, with nothing added or missing.
Describe the steps that should be taken in order to be efficient with CPT procedural coding. Also
discuss how to use the alphabetic index and the tabular list. - ANSWERSThe basic steps in
procedural coding are: (1) read, analyze, and abstract the procedure or service documented in
the health record and (2) compare it with the encounter form, operative report, or other
documentation to ensure that all services and procedures have been recorded. After searching
the Alphabetic Index, the medical assistant should turn to the appropriate codes in the Tabular
List to perform the final coding steps. Read the section thoroughly to determine the most
accurate code to assign to the procedure or service, and then code the procedure or service.
The process for procedural coding for surgery with the CPT code set is detailed in Procedure
17.1 on p. 371.
370The Alphabetic Index is a comprehensive, alphabetic listing of all main terms used in
procedural coding. However, it is not a substitute for the Tabular List. It is organized by main
terms, and modifying terms are indented two spaces below that term. Begin the search of the
Alphabetic Index by using one of the four primary classifications of main and modifying term
entries. In the Tabular List, look up each code or code range found in the Alphabetic Index.
Identify CPT coding guidelines for evaluation and management (E/M) procedures. In addition,
perform procedural coding of an office visit and an immunization. - ANSWERSTo properly code
E/M services, the medical assistant must understand important differences, or variations, from
the basic steps. Assigning the correct E/M code includes identifying the section, subsection,
category, and subcategory of the procedure or service; reviewing the reporting instructions and
guidelines for the code chosen; reviewing the level of E/M service; determining the extent of
the history obtained and examination performed; and determining the complexity of medical
decision making.
To code an office visit, the coder first must determine the level of all key components, which
include the history, examination, and medical decision making. (See Procedure 17.2, Part A on
p. 373.)
An immunization procedure is coded using the HCPCS code set. Coding for HCPCS is almost
identical to coding for CPT because both manuals have an Alphabetic Index and a Tabular List.
After searching the Alphabetic Index, the coder turns to the appropriate codes in the Tabular
Assistant, 15th Edition
List and describe the three code categories in the Current Procedural Terminology (CPT) manual.
- ANSWERSThe CPT manual comprises three category codes: Category I, Category II, and
Category III codes. Category I codes are 5-digit codes that are listed in the Tabular List. Category
II codes are used for performance measurement, and their use is optional. Category III codes
are temporary codes for emerging medical technologies.
Distinguish between the Alphabetic Index and the Tabular List in the CPT code set. Also, list the
six different sections of the Tabular List. - ANSWERSThe CPT has two primary divisions, the
Alphabetic Index and the Tabular List. The Alphabetic Index is like any other index in a textbook;
it is simply a guide to finding data in the body of the textbook. The Tabular List is divided into six
sections, and codes are listed in numeric order in each section.
The six sections of the Tabular List are Evaluation and Management, Anesthesia, Surgery,
Radiology, Pathology and Laboratory, and Medicine. Sections are divided into subsections;
subsections are further divided into categories; and categories can be subdivided into
subcategories.
Discuss special reports and explain the importance of modifiers in assigning CPT codes. -
ANSWERSWhen a bill is submitted for a service that is unlisted, unusual, or newly adopted, the
third-party carrier requires a special consultation report. Modifiers are used in CPT codes to
indicate that a service or procedure performed was altered by specific circumstances. Two-digit
alphanumeric modifiers, included with the 5-digit CPT code, can be used to supply additional
information or to describe extenuating circumstances that affected the rendered procedure or
service.
Review various conventions in the CPT code set. - ANSWERSConventions are used to provide
additional information about certain codes. Examples of conventions include triangular and
round symbols, which indicate that a code or description was revised, removed, or added.
Identify the required medical documentation for accurate procedural coding - ANSWERSMedical
records used for procedural coding can include any or all of the following: encounter form,
, history and physical report (H&P), progress notes, discharge summary, operative report,
pathology report, anesthesia record, and/or radiology report. When the medical documentation
is compared against any code description, all the elements of that code must substantially
match, with nothing added or missing.
Describe the steps that should be taken in order to be efficient with CPT procedural coding. Also
discuss how to use the alphabetic index and the tabular list. - ANSWERSThe basic steps in
procedural coding are: (1) read, analyze, and abstract the procedure or service documented in
the health record and (2) compare it with the encounter form, operative report, or other
documentation to ensure that all services and procedures have been recorded. After searching
the Alphabetic Index, the medical assistant should turn to the appropriate codes in the Tabular
List to perform the final coding steps. Read the section thoroughly to determine the most
accurate code to assign to the procedure or service, and then code the procedure or service.
The process for procedural coding for surgery with the CPT code set is detailed in Procedure
17.1 on p. 371.
370The Alphabetic Index is a comprehensive, alphabetic listing of all main terms used in
procedural coding. However, it is not a substitute for the Tabular List. It is organized by main
terms, and modifying terms are indented two spaces below that term. Begin the search of the
Alphabetic Index by using one of the four primary classifications of main and modifying term
entries. In the Tabular List, look up each code or code range found in the Alphabetic Index.
Identify CPT coding guidelines for evaluation and management (E/M) procedures. In addition,
perform procedural coding of an office visit and an immunization. - ANSWERSTo properly code
E/M services, the medical assistant must understand important differences, or variations, from
the basic steps. Assigning the correct E/M code includes identifying the section, subsection,
category, and subcategory of the procedure or service; reviewing the reporting instructions and
guidelines for the code chosen; reviewing the level of E/M service; determining the extent of
the history obtained and examination performed; and determining the complexity of medical
decision making.
To code an office visit, the coder first must determine the level of all key components, which
include the history, examination, and medical decision making. (See Procedure 17.2, Part A on
p. 373.)
An immunization procedure is coded using the HCPCS code set. Coding for HCPCS is almost
identical to coding for CPT because both manuals have an Alphabetic Index and a Tabular List.
After searching the Alphabetic Index, the coder turns to the appropriate codes in the Tabular
