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MOT 130 Medical coding Flashcards

American Academy of Professional Coder
Certified Professional Coder Test for CPC-P
1. Codes and Ethics of Coders
2. Medical Terminology and Anatomy Review (all systems)
3. ICD-9-CM (complete)
4. CPT coding, surgery guidelines, HCPCS, and modifiers
5. Introduction to Integumentary system including ICD-9 and CPT codes
6. Introduction to Musculoskeletal System including ICD-9 and CPT codes
7. Introduction to Respiratory, Hemic, Lymphatic, Mediastinum and Diaphragm including ICD-9 and CPT codes
8. Introduction to Cardiovascular system including ICD-9 and CPT codes
9. Introduction to Digestive system including ICD-9 and Cpt Codes
10. Introduction to Urinary System and Male Genital System including ICD-9 and CPT codes
11. Female Reproductive system including ICD-9 and CPT codes
12. Edocrine and Nervous System including ICD-9 and CPT codes
13. Eye and Ocular Adnexa, Auditory System including ICD-9 and CPT codes
14. Anesthesia including ICD-9 and Cpt
15. Radiology including ICD -9 and Cpt
16. Pathology and Laboratory including ICD-9 and CPT
17. Evaluation and Management including ICD-9 and CPT
18. Medicine including ICD-9 and CPT

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2553895016Proper code assignment is determined bycontent of the medical record and by the unique rules that governs each code set0
2553895017What are 3 things that Coder must master1. anatomy 2. medical terminology 3. must be detail-oriented1
2553895018Medical coders assign a code to what1. Each diagnosis 2. Service/procedure 3. Supply, using the classification system when applicable2
2553895019The classification system determines ______the amount health care providers will be reimbursed if the patient is covered by Medicare, Medicaid, or other insurance programs using the system3
2553895020A coder must evaluate the medical record for1. completeness and accuracy 2. communicate regularly with physicians and the health care professional to clarify DX or obtain additional PT info.4
2553895021Techicians who speciallize in coding inpatient hospital services are referred as1. Health information coders 2. medical record coders 3. Coder/abstractors 4. Coding Specialist5
2553895022What is EHRElectronic health record6
2553895023Skilled coders may becomeconsulatants, educators or medical auditors7
2553895024What is the difference between Hospital and Physican Services1. Outpatient coding (physician services)- learning CPT, HCPCS, LEVEL II, ICD-9 CM codes Volume 1 and 2 2. Inpatient coding (Hospital services)- Learning CPT, ICD-9 CM codes Volumes 1,2,3 and MS-DRGS8
2553895025What is the coder's role in a physician's officeExtremely important for the proper reimbursement of services and the livelihood of the physician9
2553895026What is the most significant government insurerMedicare10
2553895027What is MedicareFederal health insurance program- Administered by the Center for Medicare & Medicaid Services (CMS)11
2553895028What is CMS and what does it provideCenter for Medicare & Medicaid Services (CMS) provides coverage for people over the age of 65, blind, or disabled individuals, people with end -stage renal disease12
2553895029What are the parts of MedicareMedicare A Medicare B Medicare C Medicare D13
2553895030What is Medicare Part A?Covers inpatient hospital care, as well as care provided in skilled nursing facilites, hospice care, and home health care14
2553895031What is Medicare Part B?Covers medically necessary doctors' services, outpatient care, other medical services (including some preventive service not covered under Medicare Part A)15
2553895032Medicare Part B is considered what?A optional benefit for which the patient must pay a premium and which generally requires a yearly copay16
2553895033Where is Medicare Part B usually usedPhysician offices (Outpatient Facility)17
2553895034What is Medicare Part CCombines the benefits of Medicare Part A, Part B, and sometimes Part D.18
2553895035What is PPOPreferred Provider Organizations19
2553895036What is HMOHealth Maintenace Organizations20
2553895037Which plan covers PPO and HMOMedicare Part C21
2553895038What is Medicare Part DPrescription drug coverage program available to all Medicare beneficiaries. Private companies approved by Medicare provide the coverage.22
2553895039What is MedicaidA health insurance assistance program for some low income people (especially children and pregnant women) sponsored by federal and state governments23
2553895040Medicaid is administered on___________a state-by-state basis and coverage varies- although each of the state programs adheres to certain federal guidelines24
2553895041When is a physican considered a "participating physician"When contracted with a insurance carrier whether that be a private insurance company or a governmental.25
2553895042Participating Providers (Par Providers) are required to accept__________________the allowed payment amount determined by the insurance carrier as the fee for payment and follow all other guidelines stipulated by the contract26
2553895043Non-participating Providers (non par) are?1. providers not contracted with the insurance carriers 2. not required to make the adjustment27
2553895044What is a medical recordDocumentation or the recording of pertinent facts and observation about an individual's health history, including past and present illness, tests, treatments and outcomes28
2553895045Medical record chronologicallydocuments patient care to assist in continuity of care between providers, facilitate claims review and payment29
2553895046Can a Medical record serve as legal documentYES30
2553895047All services provided to a patient are_______supported and documented in the medical record31
2553895048What are coders required to do with the medical records?Read and understand the documentation in the medical record in order to accurately code the services rendered.32
2553895049What are some different types of services documented in a medical record?Evaluation and management Operative reports X-Rays33
2553895050Evaluation and Management services are provided in what standard formatSOAP34
2553895051What is SOAP documentation?S- Subjective O-Objective A- Asssessment P-Plan35
2553895052What is the definition of O in SOAP?objective-The provider assesses and documents the patient's illness using observation, palpation, auscultation and percussion. Test and other services performed may be documented here as well36
2553895053What is the definition of A in SOAP?Assessment-Evaluation and conclusion made by the provider. This is usually where the diagnosis(es) for the services are found37
2553895054What is the definition of P in SOAP?Plan-Course of Action. Here, the provider will list eh next steps for the patient, whether it is ordering additional test, or taking over the counter medication38
2553895055What is a operative reporta document the detail of a procedure performed on a patient39
2553895056What is medical necessity related to?whether a procedure or service is considered appropriate in a given circumstance40
2553895057Generally what is a medically-necessary service?the least radical service/procedure that allows for effective treatment of the patient's complaint or condition41
2553895058What is the difference between Covered and Non-covered items1. Covered items-services and procedures are covered only when linked to designated, approved diagnosis 2. Non-covered items are deemed "not reasonable or necessary42
2553895059Medicare and many insurance plan may deny payment for a service that isnot reasonable or necessary according to the Medicare reimbursement rules.43
2553895060What is HIPAAHealth Insurance Portability and Accountability Act of 199644
2553895061What does the acronym HCPCS stand forHealthcare Common Procedure Coding System45
2553895062What does the acronym CPT stand for?Current Procedural Terminology46
2553895063When will ICD-10-CM be effective?October 1, 201347
2553895064What does the acronym NPI stand for and who uses it?1. National Provider Indentifier 2. indentifier for providers required on the transactions48
2553895065What is the acronym PHI stand for?Protected health information49
2553895066What is the HIPAA minimum necessary requirement?The minimum necessary protected health information should be provided to satisfy a particular purpose. if the information is not required to satisfy a particular purpose, it must be withheld.50
2553895067Identify the following prefix of location : Mes/omiddle51
2553895068Identify the following prefix of location : Dextr/oright52
2553895069Identify the following prefix of location: Sinister/oleft53
2553895070Identify the following prefix of location : Ab-away from54
2553895071Identify the following prefix of location: Ad-toward; near55
2553895072Identify the following prefix of location : Dia-Through; complete56
2553895073Identify the following prefix of location : Per-Through57
2553895074Identify the following prefix of location : Trans-through; across58
2553895075Identify the following prefix of time : Ante-before; forward59
2553895076Identify the following prefix of time : Pre-Before, in front of60
2553895077Identify the following prefix of time : Pro-Before, in front of61
2553895078Identify the following prefix of time :Post-after, behind62
2553895079Identify the following prefix of number : Mon/oone; single63
2553895080Identify the following prefix of number : Bi-two, twice64
2553895081Identify the following prefix of number :Tri-Three65
2553895082Identify the following prefix of number : Quadri-Four66
2553895083Identify the following prefix of number : Poly-Many, much67
2553895084What does the term "suffix" mean and where does come from?1. to fasten underneath 2. Latin word subfigure68
2553895085What are some of the common suffixes for diseases and meaning?1. -itis-inflammation 2. -oma-tumor 3. -pathy- disease of69
2553895086identify the following suffix :-grama record of data70
2553895087identify the following suffix: -graphinstrument for recording data71
2553895088identify the following suffix: -graphyact of recording data72
2553895089Identify the following suffix: -meterInstrument of measuring73
2553895090Identify the following suffix: -scopeinstrument for viewing or examining74
2553895091identify the following suffix: -scopyexamination of75
2553895092identify the following suffix: -centesispuncture, tap76
2553895093identify the following suffix: -desisbinding, fusion77
2553895094identify the following suffix: -ectomyexcision, surgical removal78
2553895095identify the following suffix: -pexysurgical fixation79
2553895096identify the following suffix: -plastyplastic repair, plastic surgery, reconstruction80
2553895097identify the following suffix: -rraphysurgical repair, suture81
2553895098identify the following suffix: -stomysurgical creation of an opening82
2553895099identify the following suffix: -tomeInstrument for incising (cutting)83
2553895100identify the following suffix: -tomyincision, cutting84
2553895101Identify the following suffix: - tripsycrushing85
2553895102What is the standard body position and what is it?1. anatomical position 2. an upright, face-forward position with the arms by the side and palms facing forward. The feet are parallel and slightly apart86
2553895103What does Anterior or Ventral mean?toward the front of the body87
2553895104What does Posterior or Dorsal mean?toward the back of the body88
2553895105What does Medial mean?Towards the mid line of the body89
2553895106What does Lateral mean?Toward the side of the body90
2553895107What does Proximal mean?nearer to the point of attachment or to the given reference point91
2553895108what does Distal mean?farther from the point of attachment or from a given reference point92
2553895109What does Superior (cranial) mean?above; toward the head93
2553895110What does Inferior (caudal) mean?below; toward the lower end of the spine94
2553895111what does Superficial (external)?Closer to the surface of the body95
2553895112What does Deep (internal)?Closer to the center of the body96
2553895113What does Sagittal plane mean?cuts through the mid line of the body from the front to back and divides the body into right and left sections97
2553895114What does Frontal (coronal) plane mean?cuts at a right angle to the mid line cut , from side to side and divides the body into front (anterior) and Back (posterior) sections98
2553895115What does Transverse (horizontal) plane mean?cuts horizontally through the body and separates the body into upper (superior) and lower (inferior) sections99
2553895116The structure of the human body falls into how many categories?4100
2553895117What are the categories of the human body?1. Cells 2. Tissues 3. Organs 4. Systems101
2553895118What is a cell?A basic unit of all living things102
2553895119What are 4 components of a cell and what do they do?1. cell membrane- forms the boundary of the cell 2. cytoplasm- make up the body of the cell 3. Nucleus- the small, round structure in the center of the cell 4. Chromosomes- located in the nucleus of the cell; they contain genes determining hereditary characteristics103
2553895120What are 4 types of tissue and what do they do?1. Muscle tissue- produces movement 2. Nerve tissue- conducts impulses to and from the brain 3. Connective tissue - connects and supports various body structures: Adipose (fat) and osseous (bone) 4. Epithelial tissue- found in the skin, lining of the blood vessels, respiratory, intestinal, urinary tracts, and other body systems104
2553895121What are organs?two or more kinds of tissue together performing special body functions105
2553895122What are systems?a group of organs working together to perform a complex body function106
2553895123What is cytology?Study of cells including the formation, structure and function of cells107
2553895124What does the acronym RNA mean and what does it do?1. Ribonucleic acid 2. Contained within the nucleus, is transcribed from DNA by enzymes and plays a crucial role in protein synthesis108
2553895125What is a gene?Specific segment of base pairs in chromosomes; functional unit of heredity109
2553895126What is mitosis?Cells divide and multiply to form two cells110
2553895127How many cavities does the body have?5111
2553895128What are the 5 types of body cavities and what is in the space?1. cranial cavity- inside the skull, or cranium, containing the brain 2. Spinal (Vertebral canal)- inside the spinal column containing the spinal cord 3. Thoracic or chest cavity- the space containing the heart, lungs, esophagus, trachea, bronchi, and thymus 4. Abdominal cavity- the space containing the lower portion of the esophagus, the stomach, intestines (excluding the sigmoid colon and rectum) kidneys, liver, gallbladder, pancreas, spleen and ureters 5. Pelvic cavity- the space containing the urinary bladder, certain reproductive organs, part of the large intestine, and the rectum112
2553895129How many types of membranes are there in the human body?5113
2553895130What are 5 types of membranes in the human body?1. Mucous Membrane 2. Serous Membrane 3. Synovial Membrane 4. Meninges114
2553895131What is the mucous membrane composed of?Epithelium overlaying a layer of connective tissue called Lamina Propria115
2553895132What is the job of epithelium in mucous membranes?It is involved in absorption and secretion116
2553895133Where do mucous membranes line?The interior walls of the organs and tubes opening to the outside of the body117
2553895134What is the serous membrane composed of?A layer of simple squamous epithelium overlaying a layer of loose connective tissue.118
2553895135What does the serous membrane support?internal organs119
2553895136What does the serous membrane compartmentalize?The large cavities to hinder spread of infection120
2553895137What does the serous membrane line?Cavities including the thoracic cavity and internal organs121
2553895138What is synovial membrane composed of?Connective tissue122
2553895139What do synovial membranes line?Joint cavities123
2553895140What do synovial membranes do?1. secrete synovial fluid into the joint cavity 2. lubricates the ends of of bones so they move freely124
2553895141What are meninges composed of?3 connective tissue membranes125
2553895142Where are meninges found?Located within the dorsal cavity126
2553895143What do the meninges do?They serve as a protective covering127
2553895144what does the cutaneous membrane consist ofa thin outer layer of stratified squamous epithelium attached to a thicker underlying layer of connective tissue.128
2553895145What does the cutaneous membrane form?the outer covering of the body129
2553895146What is another term for cutaneous membrane?skin130
2553895147What is connective tissue?A number of different tissues with common features.131
2553895148What is the purpose of connective tissue?Provides a framework to support the entire body by cartilage and bones132
2553895149What are the four general groups of connective tissue?1. Bone 2. Adipose tissue 3. Cartilage 4. Blood133
2553895150The largest organ system in the body is comprised of what 3 structures?1. skin 2. hair 3. Nail134
2553895151What is largest organ system called?integumentary system135
2553895152The integumentary system structures work together to provide what functions within the body?1. Protection from injury, fluid loss, and microorganism 2. Temperature regulation 3. Fluid balance-excretion 4. Sensation136
2553895153What 2 layers make up the human skin?1. Dermis 2. Epidermis137
2553895154Where is the dermis located?It is located under the epidermis.138
2553895155The dermis contains many important structures nourishing and innervating the skin, what are they?1. Vessels carrying blood and lymph 2. Nerves and nerve endings 3. Glands 4. Hair follicles139
2553895156What lies underneath the dermis?subcutaneous layer140
2553895157What is another name for subcutaneous layer?hypodermis141
2553895158The subcutaneous layer is not considered ______a layer of skin.142
2553895159Subcutaneous tissue is mostly composed of __________fatty or adipose tissue plus some areolar tissue143
2553895160Define cutaneousPertaining to the skin144
2553895161Define dermatologythe study of the skin145
2553895162Define dermatologistPhysician specializing in diseases of the skin and subcutaneous tissue146
2553895163Define decubitusPressure ulcer/bedsore147
2553895164Define ecchymosisCondition in which blood seeps into the skin causing discoloration148
2553895165Define hypodermicPertaining to under the skin149
2553895166Define intradermalPertaining to within the skin150
2553895167Define jaundiceYellowness of skin151
2553895168Define melaninPigment giving color to the skin152
2553895169Define melanomaPigmented tumor of the skin153
2553895170Define pediculosisInfestation with lice154
2553895171Define subcutaneousPertaining to below the skin155
2553895172Define tineaRingworm; a fungal infection of the skin156
2553895173Define alopeciaLoss of hair157
2553895174Define hair papillaKnoblike indentation at the bottom of the hair follicle containing the bloody supply to hair root158
2553895175The musculoskeletal system is made up of____________a systems of muscles, joints, tendons, ligament159
2553895176What does the muscloskeletal system provide?It provides movement, form, strength and protection160
2553895177Bones are composed of what?They are composed of rigid connective tissue161
2553895178Bones provide what functions?1. Form the skeleton 2. Provide the chief means of support for the body 3. Provide the mechanism for motion 4. Protect vital organs 5. Serve as a production factory for blood cells 6. Store calicum, phosphorus, and magnesium salts162
2553895179What are the seven classifications of bones?1. Long 2. Tubular 3. Short 4. seasmoid 5. Cuboidal 6. Flat 7. irregular163
2553895180What is cartilage?It is a type of flexible connective tisssue164
2553895181(T/F) Cartilage is nonvascular or has no blood vesselsTrue165
2553895182What is cartilage is made of?It is made of a matrix of chondrocytes, collagen, cells called proteoglycans depending on the type of cartilage166
2553895183Joints and articulating surfaces provide what?A connection between two or more parts of skeleton167
2553895184Joints are classified according to what?They are classified according to the type of connective tissue at the articulating surfaces168
2553895185What are the 3 types of joints?1. fibrous 2. cartilaginous 3. Synovial169
2553895186What are the characteristics of synovial joints?1. Articular cartilage that covers the bone ends 2. Joint cavity lined with synovial membrane 3. Joint capsule of fibrous connective tissue that surrounds and provides stability of the joint 4. Accessory ligament that give reinforcement170
2553895187The human skeleton is divided in which 2 parts1. Axial 2. Appendicular171
2553895188What does the axial skeleton consist of?It consists of the skull, hyoid/cervical spine, ribs, sternum, vertebrae, sacrum172
2553895189What does the appendicular skeleton consist ofIt consistes of the shoulder girdle, pelvic girdle, extremities173
2553895190What are 3 types of muscles found in the body1. Skeletal Muscle 2. Cardiac Muscle 3. Smooth Muscle174
2553895191What is skeletal muscle?Also called striated muscle, it is attached to the skeleton by tendons; contraction of skeletal muscle is under voluntary control175
2553895192What is cardiac muscle?Also called heart muscle, it contains interlocking involuntary striated muscles as well as smooth muscle, which allow the electrical impulses to pass quickly across the muscle fibers176
2553895193What is smooth muscle?Found in the walls of all the hollow organs of the body except the heart. Its condtraction reduces the size of these structures; movement generally is considered involunatry177
2553895194Define ankylosisCondition of stiffening of joint178
2553895195Define arthralgiapain in joint179
2553895196Define arthritisinflammation of joint180
2553895197Define arthrodesisIt is the surgical fixation of a joint181
2553895198Define arthropathyjoint disease182
2553895199Define bursitisInflammation of bursa183
2553895200Define carpalPetaining to the wrist bones184
2553895201Define chondralPertaining to cartilage185
2553895202Define chondralgiaPain around and in the cartilage186
2553895203Define coccygealPertaining to coccyx187
2553895204Define connective tissueTissue connecting or binding together188
2553895205Define dactylicPertaining to finger or toe189
2553895206Define femoralPertaining to femur or thigh bone190
2553895207Define iliacPertaining to the ilium191
2553895208Define kyphosisabnormal curvature of thoracic spine (humpback)192
2553895209Define lordosisAbnormal anterior curvature of spine usually lumbar193
2553895210Define metacarpalThey are the bones of the hand194
2553895211Define osteoblastIt is a bone-forming cell195
2553895212Define osteocarcinomaIt is a cancerous tumor of bone196
2553895213Define osteochondritisInflammation of bone and cartilage197
2553895214Define osteopeniaIt is a lower than average bone density, can be a precursor to osteporosis198
2553895215Define osteoporosisA disease of bones that leads to reduced bone mass and an increased risk of fracture.199
2553895216Define osteorrhaphyThe surgical suturing or joining of fragments of broken bone, usually by wiring them together.200
2553895217Define PatellarPertaining to patella201
2553895218Define PhalangealBones of fingers and toes202
2553895219Define ScoliosisLateral Curvature of spine203
2553895220Define Sternotomysurgical incision of sternum204
2553895221Define TendonitisInflammation of tendon205

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