Medical Billing Software Medical Billing Software Coding & Documentation 2

Question 1

What are Evaluation and Management (E/M) codes used to report in medical billing?

Accepted Answer

Provider assessment and management of a patient's health, including office visits and consultations

Answer

E/M codes (CPT 99202–99499) report the clinical work involved in evaluating and managing a patient's condition during encounters such as office visits, hospital visits, and consultations.

Question 2

Under the 2021 AMA E/M guidelines, which two elements primarily determine the level of an office or outpatient E/M service?

Accepted Answer

Medical Decision Making or Total Time

Answer

The 2021 AMA E/M revisions base office and outpatient visit levels on either Medical Decision Making (MDM) complexity or total time spent on the date of the encounter.

Question 3

What is the role of a charge description master (CDM) in hospital billing?

Accepted Answer

A comprehensive database linking billable services to their corresponding charges and revenue codes

Answer

The CDM (also called a chargemaster) is a hospital's master list of all services, procedures, and supplies with associated charges and revenue codes used to generate itemized bills.

Question 4

What coding guideline applies when a condition is documented as 'probable' or 'suspected' in an outpatient setting?

Accepted Answer

Code the presenting signs and symptoms rather than the unconfirmed diagnosis

Answer

In outpatient coding, uncertain diagnoses documented as 'probable,' 'suspected,' or 'rule out' should not be coded; instead, the signs and symptoms prompting the encounter are reported.

Question 5

Which modifier is appended to indicate that a procedure was performed on the left side of the body?

Accepted Answer

-LT

Answer

Modifier -LT (Left Side) is appended to a procedure code to indicate that the service was performed on the left side of the body, as required by many payers for laterality.

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Medical Billing Software Medical Billing Software Coding & Documentation 2