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Medical Coding 2
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LESSON ASSIGNMENTS 7
EXAMINATION—LESSON 1 95
PROCTORED EXAMINATION
PREPARATION ANSWERS 231
iii
YOUR COURSE
Instructions
Welcome to the Medical Coding 2 course! This course pro-
vides important information that’s essential for your career
as a coder. You’ll be using the following main sources of
information and references for this course:
Q Medical Coding 2 Study Guide (this guide)
You should ensure that you have all of these materials before
starting the course. For your HCPCS Level II exercises in this
study guide and your coding workbook, you should download
the HCPCS Level II codes (provided by the CMS for free).
Follow these steps to access the HCPCS Level II codes:
1. Go to the CMS Web site (http://www.cms.hhs.gov/
HCPCSReleaseCodeSets/).
2. Click on HCPCS General Information.
3. Scroll down to the “Related Links Inside CMS” section,
and click on HCPCS Annual Update.
4. Click on 2011 Alpha-Numeric Index.
5. Click on 2011 Alpha-Numeric Index (PDF, 166KB).
6. Save the document to your hard drive for use in your
exercises and exams.
7. Repeat these steps to download the 2011 Alpha-
Numeric HCPCS File (11anweb_V3.xls) and the 2011
Table of Drugs.
An optional resource that you may find quite useful when
working your way through this course is a medical dictionary.
You aren’t required to purchase a medical dictionary; however,
1
many terms, conditions, diseases, and illnesses mentioned in
this course—as well as in the field—may not be familiar to you.
Having a medical dictionary handy will make coding these
conditions much easier. Several good medical dictionaries are
on the market and can be obtained through any major book
chain.
You should do the following for this course:
1. Read the assigned pages in your study guide. Begin with
Appendix A and Appendix B.
2. Read the information from the corresponding coding
source (2011 Professional ICD-9-CM coding book, CPT
2011 coding book, or HCPCS Level II code list from
the CMS).
3. Complete the exercises in your Clinical Coding Workout
textbook at the end of each assignment. These exercises
aren’t graded, but they’ll help ensure that you understand
the information covered as well as help you practice your
coding skills before each assignment’s quiz.
4. Complete each assignment quiz.
5. Complete the Lesson 1 examination. Note that there’s no
examination for Lesson 2. Instead, that examination will
NOTE: be your proctored final examination.
2 Instructions to Students
OBJECTIVES
When you complete this course, you’ll be able to
Q Identify diagnoses and procedures contained on
medical reports
Instructions to Students 3
A STUDY PLAN
Follow these steps to ensure your success in the course:
1. Read the assigned pages in your study guide. Take your
time so you can fully understand each topic presented.
2. Follow along with the code section in the appropriate
coding resource.
3. Complete the workbook exercises and assignment
quizzes at the end of each assignment in your study
guide. Before completing an assignment—or, more
important, the lesson examination or graded project—
be sure that you fully understand the concepts presented
in the assignment or lesson. If you’re uncomfortable with
the information, go back and reread that particular
information or the entire assignment again. Fully
understanding the concepts is integral to your success
in this course.
Assignments
Read the individualized directions for each assignment before
starting the assignment.
Practice Exercises
For each assignment, you’ll complete practice coding exercises
that appear at the end of an assignment. These exercises will
help you practice the guidelines and principles discussed in
that assignment. The exercises won’t be graded, and the
answers are provided in the back of this study guide.
Assignment Quizzes
At the end of each assignment, an assignment quiz will test
your understanding of the coding principles presented in that
assignment. Upon completion, these quizzes will be submit-
ted to your instructor for grading. This procedure will ensure
that you understand the principles and concepts before com-
pleting the lesson examination.
4 Instructions to Students
There are two sets of questions for each quiz: a set of multiple-
choice questions followed by intermediate-level scenarios
taken from your Clinical Coding Workout: Practice Exercises
for Skill Development workbook. These intermediate-level
scenarios contain short paragraphs describing medical situa-
tions. You’ll have to extract the appropriate information for
coding. The quiz questions will be slightly more difficult than
the coding exercises previously described. Because the quizzes
will be submitted for grading, it’s not recommend that you
attempt them until you’ve completed the assignment and the
practice exercises, fully understand the concepts reviewed in
the particular assignment, and feel comfortable with the sub-
ject matter.
Lesson Examination
There are two examinations for this course. Examination 1
appears at the end of Lesson 1. The second examination
will be your proctored final examination for this course. The
examination questions are formatted as multiple-choice and
coding scenarios. You’ll also be asked to code advanced-level
coding scenarios. These coding scenarios are set up as if you
were looking at documentation from an actual medical record.
You’ll be required to read the information and extract the
appropriate clinical information that needs to be coded for
the setting involved. It’s important to fully understand the
coding guidelines and to have practice coding with the section
exercises before completing the lesson examination.
Graded Project
You’ll be responsible for completing a graded project for this
course, which is assigned at the end of Lesson 1. You’ll be
asked to do research on the Internet, then answer specific
questions based on your research. Remember that you must
put all information you gather into your own words, use
quotation marks and in-text citations for any material copied
from sources, and include a reference page that lists your
sources, the dates you accessed them, and the author, article,
and section you used.
Instructions to Students 5
One Last Word
Finally, remember that you’re responsible for the content from
Medical Coding 1. Medical Coding 1 and Medical Coding 2
can’t be strictly divided. The second course builds upon the
first. Much of what you learned in the first course may
reappear here. You can’t be excused from knowing that
information or retaining those skills.
6 Instructions to Students
Lesson 1: ICD-9-CM Hospital Inpatient Coding
Assignments
For: Read in the Read in the
study guide: coding references:
7
NOTES
8 Lesson Assignments
ICD-9-CM Hospital
Inpatient Coding
Lesson 1
ASSIGNMENT 1:
SUPPLEMENTARY
CLASSIFICATIONS—SIGNS,
SYMPTOMS, ILL-DEFINED
CONDITIONS/INJURIES,
POISONINGS/V AND E CODES
Read Sections 17 (pp. 18–20), 18 (pp. 20–25), and 19 (pp. 25–27)
of the Coding Guidelines in your ICD-9-CM coding book.
Read the introduction to Chapter 16—“Symptoms, Signs, and
Ill-Defined Conditions” (page 283 in your ICD-9-CM coding
book).
Read the introduction to Chapter 17—“Injury and Poisoning”
(page 299 in your ICD-9-CM coding book).
Read the introduction to Supplementary Classifications (V codes
on page 351 in your ICD-9-CM coding book and page 1 in the
E-Code section directly following the V code section).
Introduction
Sometimes there are diagnoses or procedures that don’t seem
to fit into any specific coding category. They may be signs,
symptoms, or ill-defined conditions; or they may simply pro-
vide more information about a specific diagnosis or illness.
In this first section, you’ll concentrate on these unique situa-
tions that can be difficult to classify and code.
9
Symptoms, Signs, and Ill-Defined
Conditions (Categories 780–799)
A sign is a physical presence or existence of a condition that
can be observed by the physician. A symptom is evidence of a
disorder or disease that indicates a change in normal func-
tion. The symptom is experienced by the patient but not
confirmed by the physician. Symptoms, signs, and ill-defined
conditions appear in Chapter 16 of the ICD-9-CM coding book
and cover code categories 780–799. This chapter is used for
signs, symptoms, and ill-defined conditions that are of unex-
plained etiology (origin) and may be due to more than one
disease.
10 Medical Coding 2
When the sign/symptom is due to comparative or contrasting NOTES:
conditions, the sign/symptom should be listed as the principal
diagnosis unless it’s integral to each of the conditions listed. When there are two or
more equal causes,
For comparative/contrasting diagnoses, the physician will
the diagnosis with the
usually use terminology such as “either/or.” For example, highest-weighted
chest pain due to either pneumonia or angina is coded first as diagnosis-related group
chest pain followed by the codes for pneumonia and angina. (DRG) should be listed
first. For example, if
Example. A patient was admitted for prolonged fatigue. The the physician docu-
physician discharged the patient with a diagnosis of fatigue ments pneumonia or
due to either hypothyroidism or depression. angina, they would
both be coded with the
Codes highest-weighted DRG
PDX: Other malaise and fatigue (780.79) sequenced first.
Lesson 1 11
3. Ill-defined conditions are those conditions with unknown
causes. As with the other symptom codes, the ill-defined
condition codes shouldn’t be used when a more definitive
diagnosis exists. Examples of ill-defined conditions
include nervousness and debility without known causes.
Now let’s practice the principles for this section. Proceed to
the practical coding exercise for more information.
Practice Exercise 1A
Books Needed:
In your Clinical Coding Workout: Practice Exercises for Skill Development workbook, complete
exercises 1.296–1.315, “Symptoms, Signs, and Ill-Defined Conditions,” starting on page 29.
When you’re finished, check your answers at the back of this study guide. Once you’re
confident you understand the coding principles for this section, move on to the next section.
Supplementary Classifications
(Categories V01–V89 and E800–E999)
Some people find the coding of V and E codes very easy,
whereas others find it somewhat confusing. Because of this and
their relationships to other chapter codes, it’s important for you
to understand their use before going on to other assignments.
V Codes
V codes are supplementary codes. They’re listed as
Supplementary Classification of Factors Influencing Health
Status and Contact with Health Services. There are 15
different categories of V codes represented in sections
V01–V89 of your coding book that deal with circumstances
other than disease or injury.
12 Medical Coding 2
V codes are used in both inpatient and outpatient settings.
As you learned from your assignment reading, there are four
reasons you may use V codes:
1. To indicate that a person who isn’t currently sick receives
health services for a specific reason (e.g., inoculations/
health screenings, counseling, organ donation)
2. To indicate aftercare for a previous disease or injury
(e.g., dialysis for renal disease, changing of a cast for
a fracture)
3. When a circumstance or problem influences a person’s
health status
4. To indicate the birth status of a newborn
V codes may be listed first, as the principal diagnosis, or as a
secondary code (depending on the encounter or circumstance).
However, be careful. Be sure to follow the notes in your coding
book because there are some V codes that can’t be used as
principal diagnosis, whereas others must be listed first. The
following scenarios are situations in which V codes can be
listed as the principal diagnosis:
Q Aftercare for a patient
E Codes (E000–E999)
The E code chapter immediately follows the V code chapter
(at the end of the main section of your ICD-9-CM coding book).
E codes make up categories E000–E999 and are used to
identify external causes of injuries and poisonings.
Lesson 1 13
E codes signify the following scenarios:
Q Cause of the injury or poisoning
14 Medical Coding 2
Practice Exercise 1B
Books Needed:
In your Clinical Coding Workout: Practice Exercises for Skill Development, complete exercises
1.336–1.355, “E Codes,” starting on page 32 and exercises 1.356–1.375, “V Codes,” starting on
page 34. When you’re finished, check your answers at the back of this study guide. Once you’re
confident you understand the coding principles for this section, move on to the next section.
Injuries
Injuries include conditions such as fractures, concussions,
wounds, lacerations, amputations, and burns. Let’s take a
look at the guidelines for coding injuries.
Lesson 1 15
NOTES:
4. Excisional debridement (procedure) for wound, infection
or burn (86.22) can be performed only by a physician.
Some nonexcisional Nonexcisional debridements are also performed by physi-
debridements are
cians or other health care professional (code 86.28).
performed by health
care workers (such as 5. Code burns with the highest degree sequenced first.
nurses) at the patient’s
bedside. In this case, Burns can be difficult to code because they often involve
don’t assign a separate different sites and may have different degrees of severity.
code for the debride- Because of the difficulty, it’s worthwhile to spend some time
ment because it’s on specific burn guidelines.
covered in the nursing
service billing as part
of normal nursing Burns
duties. However, some
physicians may per- Burns are covered by code categories 940–949. Some of the
form a debridement at causes of burns are as follows:
the patient’s bedside.
These procedures Q Electricity
should be coded.
Q Flame/fire
Remember, burns are Q Heat
still classified under the
Injury and Poisoning Q Lightning
section. We’re spend-
ing time on burns here Q Radiation
(independent of the
other injuries) due to Q Chemicals
the difficulty in coding.
Burns are classified by depth (that is, the degree of burn),
Sunburns aren’t extent, and causative agent. First-degree burns result in
included in this same erythema (redness). Second-degree burns result in blistering.
category and instead Third-degree burns result in full-thickness skin involvement.
are coded to category
692. Deep third-degree burns result in full-thickness involvement,
necrosis, and scabbing/crusting.
Extent of the burn refers to the extent of body surface involved.
This extent is reported in percentages (e.g., burns on 25%
of the body). Extent should be coded to code category 948—
burns classified according to extent of body surface involved.
This code category is based on something called “the rule of
nines” that estimates the body surface as follows:
Q Head and neck—9%
Q Each arm—9%
16 Medical Coding 2
Q Anterior trunk—18%
Q Posterior trunk—18%
Q Genitalia—1%
Lesson 1 17
Practice Exercise 1C
Books Needed:
In your Clinical Coding Workout: Practice Exercises for Skill Development, complete exercises
1.316–1.335, “Trauma/Poisoning,” starting on page 30. When you’re finished, check your
answers at the back of this study guide. Once you’re confident you understand the coding
principles for this section, move on to the next section.
18 Medical Coding 2
Penn Foster
Student Service Center
The Penn Foster
925 Oak Street Student Service Center
Scranton, PA 18515 is under contract with
Penn Foster College.
Be sure to include your full name, student number, quiz
number, and your complete mailing address.
Assignment 1 Quiz
40950900
Books Needed:
Clinical Coding Workout: Practice Exercises for Skill Development
ICD-9-CM coding book
Directions: Each assignment quiz is divided into two parts. Part A is composed of multiple-
choice coding questions, and Part B requires you to code the information from a coding
scenario found in your Clinical Coding Workout: Practice Exercises for Skill Development
book. Complete all required and relevant codes for each given scenario. When you’re com-
fortable with your answers for both parts, submit this quiz to your instructor for grading.
Part A: Complete the following multiple-choice questions. Choose the best answer for each
question. Record your answer on the corresponding answer sheets that can be found in the
back of this study guide. Upon completion, submit your quiz answers to your instructor.
1. What is the main reason that insurance companies are hesitant to push for a quick release of
the new ICD-10 coding classification system?
(Continued)
Lesson 1 19
Assignment 1 Quiz
40950900
A. Residual effects that remain after the acute phase of an injury or illness
B. Effects that are always coded alone
C. Effects categorized according to the nature and time of the disease, condition, or injury
D. E codes that describe where the injury, illness, or condition occurred
4. When two or more diagnoses equally meet the criteria for principal diagnosis, what action
should the coder take?
A. When the laboratory or testing report shows that the abnormal finding meets Uniform
Hospital Discharge Data Set (UHDDS) criteria
B. When the physician has documented the abnormal finding in the Progress Notes
C. When the physician hasn’t been able to arrive at a diagnosis, and the diagnosis meets the
guidelines for that particular code
D. It’s never appropriate to assign codes of this type for an acute care setting
A. 873.42 C. 496
B. E880.9 D. V25.1
(Continued)
20 Medical Coding 2
Assignment 1 Quiz
40950900
7. Which of the following codes fall under the category of providing codes for reporting factors
influencing health status and health service?
A. V67.4 C. 47.09
B. E884.2 D. A4509
9. Which of the following scenarios could be classified within code ranges 960–979?
A. Patient has lethargy for unintentionally taking too much of her prescribed sleeping pill.
B. Patient had an allergic reaction to her normal dose of antihistamine.
C. Patient experienced lightheadedness due to the interaction of two drugs prescribed by her
family doctor.
D. Patient is experiencing increased heart rate due to daily dose of Valium that has been
taken as prescribed.
10. A patient was admitted to the hospital with a deep burn to the dermis of the arm. For coding
purposes, you would classify this condition as
A. a first-degree burn.
B. a second-degree burn.
C. a third-degree burn.
D. undeterminable until the physician clarified with more information.
Part B: Complete the following exercises in your Clinical Coding Workout: Practice
Exercises for Skill Development workbook.
Exercises 5.84–5.90, “Trauma and Poisoning,” pages 154–157. Note that for non-multiple-
choice questions, you should indicate the correct codes for the given scenarios in the same
manner as the other non-multiple-choice questions in this section.
Lesson 1 21
Note: In upcoming quizzes you’ll also be doing exercises on V and E codes
related to other body systems.
22 Medical Coding 2
ANSWER SHEET
FOR YOUR INSTRUCTOR’S USE
GRADE GRADED BY
NAME ________________________________________________________________
ADDRESS ________________________________________________________________
CITY ________________________________________________________________
STATE/PROVINCE ZIP/POSTAL CODE
Part A
CUT ALONG THIS LINE
1. A B C D 6. A B C D
2. A B C D 7. A B C D
3. A B C D 8. A B C D
4. A B C D 9. A B C D
5. A B C D 10. A B C D
Part B
5.84 ___________________________________________________________________
5.85 ___________________________________________________________________
5.86 ___________________________________________________________________
5.87 ___________________________________________________________________
5.88 ___________________________________________________________________
5.89 ___________________________________________________________________
5.90 ___________________________________________________________________
Lesson 1 25
Dual classifications are also used in Chapter 1. For example,
you may have an illness/condition from Chapter 1 and an
additional code from another chapter (in this case, “Respiratory
System”) to describe the associated other illness/condition:
Pneumonia due to whooping cough, 033.X, 484.3. In some
cases, a fourth and fifth digit of the diagnosis code will indicate
the organism: Pneumonia due to Staphylococcus: 482.4X.
You may be wondering whether to use one or two codes with
a condition/underlying disease/organism scenario. This situ-
ation points out the importance of knowing coding guidelines
as well as reading the information and narratives carefully
when coding from a coding book. For example, code 484.3—
pneumonia due to whooping cough—lists the note “Code first
underlying disease” (033.0–033.9). If the coder didn’t read the
complete code description and reported only code 484.3, the
bill could be denied and reimbursement would be lost.
26 Medical Coding 2
Let’s review some additional guidelines for infectious and
parasitic diseases.
Late Effects
For late effects (for example, codes 137, 138, 139), code the
NOTE:
residual condition (that is, nature of the late effect) first,
followed by the cause of the late-effect code (except when Remember, late effects
instructed otherwise by the index; see further rules explained are conditions that
linger, exist, or occur
in bulleted list that follows). For example, scoliosis due to
after the acute phase
poliomyelitis: 138, 737.43. of an illness or injury.
A late effect is often
Coding of late effects requires two codes: residual condition
referred to as a residual
(or nature of the late effect) and cause of the late effect.
effect. The current,
However, the following exceptions should be noted: acute illness or injury
must resolve before
Q When the code for late effect is followed by a manifesta-
a late effect can be
tion code identified in the Tabular List or coded.
Lesson 1 27
Practice Exercise 2A
Books Needed:
In your Clinical Coding Workout: Practice Exercises for Skill Development, complete exercises
1.16–1.35, “Infectious and Parasitic Diseases,” starting on page 5. When you’re finished, check
your answers at the back of this study guide. Once you’re confident you understand the coding
principles for this section, move on to the next section.
28 Medical Coding 2
Morphology
Morphology identifies the form and structure of tumor cells for
classification of origin. There’s a listing of morphology codes
(starting with “M”) that are used mainly by cancer registries
and rarely by hospital coders. We won’t cover morphology
codes in this course.
Classifications
As mentioned previously, neoplasms are classified according
to behavior (for example, malignant, benign) or anatomic site.
Neoplasm groups include the following categories: NOTES:
Q Malignant (codes 140–209) Paying attention to the
way tumor information
Q Benign (codes 210–229)
is documented is very
Q Carcinoma in situ (codes 230–234) helpful. For example,
if the physician docu-
Q Uncertain behavior (codes 235–238) ments “metastatic
from,” then the site
Q Unspecified nature (code 239) mentioned after “from”
is the primary site.
If the physician docu-
Coding Guidelines for Neoplasm Diagnoses ments “metastatic to,”
1. If the phrase “metastatic to” is documented, code the site then the site mentioned
after “to” is the second-
mentioned as secondary.
ary site. In situ
2. When coding a secondary site, the primary site should (pronounced in sigh-
also be coded if still present. If the primary site has been too) means that
eradicated (that is, removed, no longer exists, or is no cancerous cells are
longer being treated), then a code from category V10 present in the lining of
should be assigned. If the primary site isn’t identified, an organ but have not
code it as an unspecified site. spread to the organ
tissue.
3. If “metastatic from” is documented, code the site
mentioned as primary. Code the additional (secondary) Also assign the second-
site as an additional diagnosis. ary diagnosis for the
4. When two or more sites are metastatic, code each as acute malignancy.
secondary. However, also code the primary site.
Only use codes from
5. When patients are admitted for complications due to V10—personal history
malignant neoplasms, code the complication as the prin- of malignancy—when
cipal diagnosis. However, there are exceptions to this the primary neoplasm
guideline. Refer to coding guidelines and directions in has been eradicated
the coding book for such cases. and is no longer being
treated.
6. Assign a code from V58.0–V58.1X when a patient is
admitted for radiotherapy or chemotherapy.
Lesson 1 29
Practice Exercise 2B
Books Needed:
In your Clinical Coding Workout: Practice Exercises for Skill Development, complete exercises
1.36–1.55, “Neoplasms,” starting on page 7. When you’re finished, check your answers at the
back of this study guide. Once you’re confident that you understand the coding principles for
this section, move on to the next section.
Diabetes Mellitus
Diabetes is a result of a deficiency, lack of, or resistance to
insulin secreted by the pancreas. Insulin is a hormone that
works to regulate glucose (sugar) metabolism and metabolize
fats, carbohydrates, and proteins. Unfortunately, many
people suffer from diabetes. Because this condition is probably
the most common ailment in this chapter, this section deals
solely with the coding guidelines for diabetes.
30 Medical Coding 2
Type 1 versus Type 2 NOTES:
Diabetes mellitus is categorized by two types: type 1 and type 2. Just because a patient
Type 1 diabetes was formerly known as insulin-dependent is receiving an insulin
diabetes mellitus (IDDM). Common practice now refers to injection doesn’t mean
this condition as only type 1. Type 1 diabetes may also be that the patient has
type 1 diabetes. Refer
described many ways, including as juvenile type or juvenile
to the documentation
onset. In type 1 diabetes, the body fails to produce insulin from the physician to
and requires the patient to receive insulin injections. clarify the type of
Type 2 diabetes was formerly referred to as non-insulin- diabetes.
Q 3—Type 1, uncontrolled
Lesson 1 31
NOTE:
In other cases, dual codes are necessary to identify the dia-
betes and manifestations. Patients with diabetes often have
Remember that a difficulties with other diseases and conditions that are cov-
manifestation is a
ered by a dual code. In these cases, a code for the diabetes is
secondary condition
that’s associated
listed first with a secondary code to indicate the manifestation.
with another primary Example. On patient discharge, the physician documents the
condition.
following information on the discharge sheet in the patient’s
medical record: nephritis with nephropathy; insulin-dependent
diabetes.
Codes
PDX: Type I diabetes with renal manifestations (250.41)
Secondary diagnosis: Nephritis and nephropathy (583.81)
Reasoning. Per coding guidelines, the diabetic/manifestation
code is sequenced first (as principal diagnosis), followed by
the manifestation (583.81). The nephritis and nephropathy
wasn’t specified as acute or chronic.
32 Medical Coding 2
Nutritional—New Codes for
Overweight and Obesity
NOTES:
In 2006, ICD-9-CM expanded and included new codes for
overweight and obesity. The overweight and obesity code The overweight and
(278.0X) includes fifth-digit classifications for obesity codes shouldn’t
be assigned unless
Q Obesity, unspecified (278.00) documented by the
physician.
Q Morbid obesity (125% or more over ideal body weight)
(278.01)
If there’s indication/
documentation of
Q Overweight (278.02)
dietary surveillance
There’s also a new V category for body mass index. Add any and counseling, code
V65.3 can be used.
additional code from category V85.XX as indicated by the
physician’s documentation.
Now let’s practice the principles for this section. Proceed to
the practical coding exercise for more information.
Practice Exercise 2C
Books Needed:
In your Clinical Coding Workout: Practice Exercises for Skill Development book, complete
exercises 1.56–1.75, “Endocrine, Nutritional and Metabolic Diseases, and Immunity Disorders,”
starting on page 9. When you’re finished, check your answers at the back of this study guide.
Once you’re confident you understand the coding principles for this section, move on to the
next section.
Lesson 1 33
Diseases of the Blood and Blood-
Forming Organs (Categories 280–289)
“Diseases of the Blood and Blood-Forming Organs” make up
Chapter 4 (code categories 280–289) in your coding book.
This chapter includes diseases such as anemias, sickle cell
disease, diseases of the white blood cells, and so forth.
Anemia
Anemia is probably the most coded condition from Chapter 4.
This condition involves a decrease in hemoglobin levels in the
blood. Anemia can be caused by several factors, such as blood
loss, a decrease in red blood cell production, or destruction of
red blood cells. Because of the variety of causes, coders should
pay close attention to documentation and take care to clarify
any questionable cases with the physician. For example, just
because a patient loses blood after an operation or procedure
doesn’t necessarily indicate a surgical complication. Reviewing
coding book notes and working with the physician will help
clarify coding for these types of situations.
Now let’s practice the principles for this section. Proceed to
the practical coding exercise for more information.
Practice Exercise 2D
Books Needed:
In your Clinical Coding Workout: Practice Exercises for Skill Development, complete exercises
1.76–1.95, “Disorders of the Blood and Blood-Forming Organs,” starting on page 10. When
you’re finished, check your answers at the back of this study guide. Once you’re confident you
understand the coding principles for this section, move on to the next section.
34 Medical Coding 2
Assignment 2 Quiz
40951000
Books Needed:
Directions: Each assignment quiz is divided into two parts. Part A is composed of multiple-
choice coding questions, and Part B requires you to code the information from a coding
scenario found in your Clinical Coding Workout: Practice Exercises for Skill Development
book. Complete all required and relevant codes for each given scenario. When you’re com-
fortable with your answers for both parts, submit this quiz to your instructor for grading.
1. Which of the following code categories should be chosen over codes from other chapters for
the same condition?
A. Complications of pregnancy
B. Neoplasms
C. Blood disorders
D. Metabolic and nutritional diseases
3. A patient returns to learn the results of an HIV test, which are negative. Which code is listed
as the reason for the encounter?
A. V65.44 C. 042
B. 795.71 D. V08
4. A patient has a condition wherein the body fails to produce insulin. She requires daily insulin
shots for control that seem to stabilize the condition. She isn’t experiencing any significant
health issues. This condition is coded as
A. 250.01. C. 250.02.
B. 250.00. D. 250.03.
5. A patient is experiencing diabetic nephropathy with hypertensive renal disease and renal
failure. How many codes would be assigned for this patient?
A. 1 C. 3
B. 2 D. 4
(Continued)
Lesson 1 35
Assignment 2 Quiz
40951000
6. Hypopotassemia is coded as
A. 266.5. C. 276.8.
B. 244.0. D. 251.2.
7. Conditions that have a decrease in hemoglobin levels in the blood can be coded to Chapter
A. 2.
B. 3.
C. 4.
D. Need more information
8. When should acute blood loss anemia following surgery be coded as a complication of the
surgery?
9. Which of the following should be used as a guideline when coding diabetes as uncontrolled
versus controlled?
A. Blood glucose levels outside of the normal range as documented in the patient’s medical
record
B. Physician documentation stating uncontrolled or controlled
C. The need for daily insulin injections
D. Any of the above
(Continued)
36 Medical Coding 2
(Continued)
Assignment 2 Quiz
40951000
Part B: Complete the following exercises in your Clinical Coding Workout: Practice
Exercises for Skill Development book.
Exercises 4.1–4.5, “Disorders of the Blood and Blood-Forming Organs,” starting on page 94
Lesson 1 37
NOTES
38 Medical Coding 2
ANSWER SHEET
FOR YOUR INSTRUCTOR’S USE
GRADE GRADED BY
NAME ________________________________________________________________
ADDRESS ________________________________________________________________
CITY ________________________________________________________________
STATE/PROVINCE ZIP/POSTAL CODE
Part A
CUT ALONG THIS LINE
1. A B C D 6. A B C D
2. A B C D 7. A B C D
3. A B C D 8. A B C D
4. A B C D 9. A B C D
5. A B C D 10. A B C D
Part B
4.24 ________________________________
4.25 ________________________________
4.26 ________________________________
4.27 ________________________________
4.28 ________________________________
Lesson 1 41
Alcohol dependency is a chronic condition with a physical
dependence on alcohol. With this diagnosis, a physician may
document the terms alcoholism and alcoholic.
42 Medical Coding 2
12. Drugs don’t have to be given for a treatment code of
“detoxification” to be assigned. Detoxification is the
observation/management of the patient’s withdrawal
from a substance and doesn’t necessarily include drug
treatment. Query the physician for appropriate coding.
Now let’s practice the principles for this section. Proceed to
the practical coding exercise for more information.
Practice Exercise 3A
Books Needed:
In your Clinical Coding Workout: Practice Exercises for Skill Development, complete exercises
1.96–1.115, “Mental Disorders,” starting on page 12. When you’re finished, check your answers
at the back of this study guide. Once you’re confident you understand the coding principles for
this section, move on to the next section.
Lesson 1 43
Hemiplegia versus Hemiparesis
Conditions exist within this chapter that may cause hemiplegia
or hemiparesis.
Hemplegia is paralysis of one side of the body. Hemiparesis is
weakness of one half of the body. Hemiplegia and hemiparesis
isn’t always coded as an additional code. Sometimes, these
conditions are included within the condition being coded and
thus don’t require a separate code. Other times they’re assigned
as separate secondary diagnoses. Coders should follow the
coding guidelines and coding book notations for assigning
hemiplegia and hemiparesis codes.
44 Medical Coding 2
8. For patients with true diabetic cataracts (as documented
by the physician), code first the appropriate diabetes
code followed by the cataract code as secondary.
9. If cataracts are extracted and an artificial lens is
implanted simultaneously, code first the extraction
procedure code followed by the lens implantation.
10. Code fitting of a hearing aid to V-code V53.2 and proce-
dure code 95.48.
Now let’s practice the principles for this section. Proceed to
the practical coding exercise for more information.
Practice Exercise 3B
Books Needed:
In your Clinical Coding Workout: Practice Exercises for Skill Development, complete exercises
1.116–1.135, “Nervous System and Sense Organs,” starting on page 14. When you’re finished,
check your answers at the back of this study guide. Once you’re confident you understand the
coding principles for this section, move on to the next section.
Circulatory System
(Code Categories 390–459) NOTES:
Some circulatory
Circulatory system disorders are coded to Chapter 7, code system disorders
categories 390–459. have been reclassified
to Chapter 11,
“Complications of
Ischemic Heart Disease versus Pregnancy, Childbirth,
Myocardial Infarctions and the Puerperium,”
and Chapter 14,
Ischemic heart disease is caused by a lack of oxygen to the “Congenital Anomalies.”
myocardial cells. Follow coding book
notes and guidelines
Ischemic heart disease is also known as coronary ischemia, for the reclassifications
coronary artery disease, arteriosclerotic heart disease (ASHD), that aren’t coded in
or coronary arteriosclerosis/atherosclerosis. Chapter 7.
Lesson 1 45
Myocardial infarctions (MIs) are acute ischemic conditions of
obstruction in the coronary artery caused by thrombosis,
atherosclerosis, or spasm. Myocardial infarctions are also
known as heart attacks.
Fifth-digit subclassifications are provided to indicate the
NOTES:
episode of care for the MI. These fifth digits are: 1—the initial
The myocardium is the (first) episode of care; 2—the subsequent episode of care
middle, muscular layer
(admission for further care of the cardiac condition any time
of the heart.
during the first eight weeks after the MI occurred). A fifth
digit of 0 is assigned if the episode of care is unspecified.
A fifth digit of 1 is still
assigned if the patient
is transferred to another Cerebrovascular Disorders
facility during the initial
episode of care. Cerebrovascular disorders affect the cerebral arteries of the
brain. Cerebrovascular accidents (CVAs) are occlusions of
A negative finding the brain caused by thrombosis, embolism, hemorrhage, or
from a CT or MRI scan
ischemia. CVAs are also known as strokes.
doesn’t necessarily
rule out CVA. Don’t
code based on MRI/CT CVA versus TIA
results alone. When
there’s inadequate Cerebrovascular accidents are characterized by a sudden
documentation, query
irreversible loss of neurologic function secondary to the
the physician for
ischemic death of brain tissue. Transient ischemic attacks
further coding
clarification. (TIAs) are episodes of cerebrovascular insufficiency with
accompanying symptoms that last only a few minutes (or,
in rare cases, clear within 24 hours).
In this section, we’ll discuss CVA (code category 434) and
transient ischemic attack (TIA) (code category 435) because
symptoms often look the same for these two conditions.
Thus, CVA and TIA can be difficult to distinguish between
for coding purposes.
As just mentioned, CVA and TIA symptoms may appear the
same: disturbance of normal vision, numbness, weakness,
dizziness, dysphasia, hemiplegia, and so forth. Also, a com-
puted tomographic (CT) scan may not detect a CVA for up
to 48 hours. Because of these circumstances, it’s easy to code
a TIA when it’s really a CVA (or vice versa). A good rule to
remember is that neurologic deficits (for example, hemiplegia,
facial droop) usually clear within 24 hours with a TIA. Persistent
defects that last longer than 24 hours usually indicate a CVA.
A magnetic resonance image (MRI) will show positive findings
46 Medical Coding 2
for an acute ischemic stroke within two hours and a hemor-
rhagic stroke after six hours. Conversely, a CT scan may show
positive findings for a hemorrhagic stroke immediately, but
negative findings for an ischemic stroke. Review the documen-
tation and query the physician for appropriate coding.
Hypertension
Hypertension (HTN), also known as high blood pressure (HBP),
is classified to code categories 401–405. Hypertension can be
classified as primary hypertension or secondary hypertension,
and benign, malignant, or unspecified. Malignant hypertension
is severe, elevated blood pressure that commonly damages
blood vessels and organs. Malignant hypertension can lead to NOTES:
other serious conditions and even death.
Code accelerated or
Benign hypertension is a mild degree of hypertension over a necrotizing hyperten-
long (chronic) period of time. Secondary hypertension is the sion to the malignant
result of another disease. In many cases, once the underlying hypertension category.
Hypertensive Diseases
Many diseases are caused by underlying conditions of hyper-
tension. Examples of hypertensive diseases are hypertensive
heart disease (code category 402) and hypertensive kidney
disease (code category 403). To assign these dual codes,
look for terminology such as “due to hypertension” or
“hypertensive.”
Use caution when assigning combination codes. Just because
a patient has hypertension and—for example—heart disease, it
doesn’t necessarily mean the patient suffers from hypertensive
heart disease. Review the documentation and query the
Lesson 1 47
physician for appropriate coding. When the documentation
doesn’t specify a causal relationship, two codes for each
unrelated condition must be assigned.
One exception in causal relationships is for hypertensive kid-
ney disease. Guidelines dictate that a causal relationship is
assumed between hypertension and renal disease. Therefore,
code renal failure with hypertension as hypertensive kidney
disease to code 403.XX (with the fifth digit indicating with (.00)
or without (.01) chronic kidney disease) unless the physician
specifically states the kidney disease isn’t due to hypertension.
With code category 403, use an additional code to identify the
stage of chronic kidney disease if known (585.1–585.6).
48 Medical Coding 2
Q Multiple vessel, performed during same operation, with NOTES:
or without mention of thrombolytic agent: 00.66; code
also the number of vessels treated (00.40–00.43) and any Assign additional codes
for insertion of coro-
infusion of thrombolytic agent (99.10)
nary artery stents
Coronary artery bypass grafting (CABG) is open heart surgery (36.06–36.07) and/or
number of vascular
in which a section of a blood vessel (or prosthesis) is grafted
stents inserted
onto a coronary artery for redirection, or bypass, of blood (00.45–00.48).
flow around a blockage.
Separate procedure
codes are used to
Coding Guidelines for
indicate the type of
Circulatory System Diagnoses bypass carried out
(code 36.1X). Assign
1. Code acute myocardial infarctions (duration of 8 weeks an additional (second-
or less) to category 410. ary) procedure code
for the extracorporeal
2. Don’t assign code 410.9—myocardial infarction,
circulation (code 39.61)
unspecified site, unless no other information is that’s required for this
provided and the physician can’t be queried. procedure.
Lesson 1 49
10. It’s rare to use code 414.9—chronic ischemic heart
disease, unspecified—in an acute care setting. Query
the physician for more information.
11. Arteriosclerosis of a bypassed blood vessel isn’t consid-
ered a postoperative complication and instead should be
coded to the appropriate arteriosclerosis code.
12. When a patient is admitted to the hospital with stable
angina, code first the underlying cause as the principal
diagnosis followed by the angina code.
13. When coding heart failure, codes 428.0 and 428.1
shouldn’t be assigned together. Code 428.0 should
take precedence.
14. Code hypertensive heart disease with heart failure to
NOTES:
category code 402.
There are codes from
category 404 that
15. Code hypertensive heart disease with hypertensive renal
indicate whether the disease to category code 404.
disease is benign or
16. Assign code 427.5—cardiac arrest—as principal diagnosis
malignant. Query the
physician for clarifica-
only when a patient arrives in cardiac arrest and can’t be
tion before assigning resuscitated (or is only briefly resuscitated before being
these codes. pronounced as expired).
17. Assign code 427.5—cardiac arrest—as secondary
diagnosis when cardiac arrest occurs during hospitaliza-
tion and the patient is resuscitated. Code the underlying
cause as the principal diagnosis.
18. Don’t assign code 436—acute, but ill-defined, cerebro-
vascular disease—when the documentation states stroke
or CVA of specified type.
19. Late effects of cerebrovascular accidents (for example,
aphasia, hemiparesis) aren’t coded if they’ve resolved
at discharge. If still present at discharge, code the late
effects as secondary diagnoses (with CVA as the principal
diagnosis).
20. Assign a code from category 438—late effects of cerebro-
vascular disease—when a patient is admitted at a later
date with residual effects of a CVA that have bearing on
the current episode of care. Codes from category 438 may
be assigned as the principal diagnosis when appropriate.
50 Medical Coding 2
21. Assign a code from category V57 as principal diagnosis
when the patient is admitted for rehabilitation after a CVA.
Assign additional codes from category 438 to indicate the
residuals.
22. If hypertension isn’t specified as benign or malignant,
assign code 401.9 (rarely assigned as principal diagnosis).
23. Code secondary hypertension (category 405) as the second-
ary diagnosis with the underlying cause sequenced first.
24. Always assume a causal relationship between renal
failure and hypertension and code it as hypertensive
renal disease.
25. When documentation indicates that both hypertension
and diabetes are responsible for chronic renal failure,
code both conditions (category code 403 or 404 and
250.4X) with sequencing optional.
26. Code hypertension associated with pregnancy, childbirth,
or puerperium to category code 642.
27. Elevated blood pressure without the documentation of NOTES:
hypertension is coded to 796.2.
A patient may have
28. Postoperative hypertension is a complication of surgery elevated blood pres-
and should be coded to 997.91 along with a code to sure following surgery.
identify the type of hypertension. This isn’t considered
true post-operative
29. Assign V42.2—heart valve transplantation, V45.01— hypertension (unless
cardiac pacemaker in situ, and V45.81—aorto-coronary specified by the physi-
bypass status, only as additional diagnoses that indicate cian) and should be
coded to 796.2.
a health status related to the circulatory system (only
when this additional diagnosis affects the patient’s
Code V53.31 includes
current episode). an admission for
30. When a patient is admitted for removal, replacement, replacement because
the pacemaker is
or reprogramming of a cardiac pacemaker, code
nearing the end of
V53.31—fitting and adjustment of cardiac pacemaker— expected life.
as the principal diagnosis.
Lesson 1 51
Coding Guidelines for
Circulatory System Procedures
1. Total replacement of a pacemaker requires two proce-
dure codes—replacement of leads (37.74 or 37.76) and
replacement of pacemaker (37.85–37.87).
2. For a PTCA, code (00.66). For single vessels with throm-
bolytic agents, code 00.66 and 99.10. For multiple
vessels, code 00.66, and then additional codes for num-
ber of vessels treated (00.40–00.43) and infusion of
thrombolytic agent (99.10).
3. Code an incomplete PTCA as a coronary arteriogram—
code 88.5X.
4. For a CABG, assign an additional (secondary) procedure
code for the extracorporeal circulation (code 39.61) that’s
required for this procedure. (Don’t assign hypothermia,
cardioplegia, intraoperative pacing, and chest tube
insertion as separate codes because they’re integral to a
CABG).
Now let’s practice the principles for this section. Proceed to
the practical coding exercise for more information.
Practice Exercise 3C
Books Needed:
In your Clinical Coding Workout: Practice Exercises for Skill Development, complete exercises
1.136–1.155, “Circulatory System,” starting on page 16. When you’re finished, check your
answers at the back of this study guide. Once you’re confident you understand the coding prin-
ciples for this section, move on to the next section.
52 Medical Coding 2
Respiratory System
(Code Categories 460–519)
NOTES:
As stated at the beginning of this chapter, one of the most
important guidelines to remember when coding respiratory Both Streptococcus
system disorders is to code the organism (cause) of the respi- and Neisseria are
found normally in the
ratory condition when documented. This is sometimes done
respiratory system.
as one (combination) code to cover both the pneumonia and Their presence doesn’t
the organism. For example, for pneumonia due to Klebsiella— necessarily indicate
code 482.0. an infection.
Types of Pneumonia
Lobar pneumonia doesn’t actually refer to a lobe of the lung,
but instead to a specific type of pneumonia. Only use code 481,
lobar pneumonia, when specified by the physician.
Gram-negative pneumonia is caused by gram-negative bacte-
ria and is coded to category 482.83—pneumonia due to other
gram-negative bacteria.
Aspiration pneumonia is a severe pneumonia that results from
inhaling a foreign body or material (for example, vomitus,
food, liquids) into the respiratory tract. Pneumonia due to a
specific foreign body should be coded to category 507. Pneu-
monia due to the aspiration of microorganisms (for example,
gram-negative bacteria) is coded to categories 480–483.
Q Chronic bronchitis
Lesson 1 53
NOTES:
Q Bronchospasm
54 Medical Coding 2
Coding Guidelines for
Respiratory Disease Diagnoses
1. Code 481—lobar pneumonia—only when specified by
the physician.
2. When the two types of aspiration pneumonia are present
in the same patient, code both the 507 category code
and the code from categories 480–483.
3. Code COPD as 496—chronic airway obstruction, NEC—
only when assignment of a more specific code isn’t
possible.
4. An admission for acute exacerbation of COPD should be
assigned code 491.21—chronic obstructive bronchitis
with acute exacerbation.
5. When a patient is admitted with acute bronchitis and
COPD with acute exacerbation, assign code 491.22—
obstructive chronic bronchitis with acute bronchitis. Don’t
assign code 466.0—acute bronchitis—as an additional
code because it’s implicit in category 491.22.
6. Assign respiratory failure as the principal diagnosis if it
brings the patient to the hospital and is caused by a
respiratory condition.
7. Don’t code respiratory failure as the principal diagnosis if
the patient is admitted with respiratory failure due to an
acute nonrespiratory condition. Code the nonrespiratory
condition as principal diagnosis, followed by a secondary
code for the respiratory failure.
8. When a patient is admitted in respiratory failure due
to/associated with a chronic nonrespiratory condition,
code the respiratory failure as principal followed by the
chronic nonrespiratory condition as secondary.
Now let’s practice the principles for this section. Proceed to
the practical coding exercise for more information.
Lesson 1 55
Practice Exercise 3D
Books Needed:
In your Clinical Coding Workout: Practice Exercises for Skill Development, complete exercises
1.156–1.175, “Respiratory System,” starting on page 17. When you’re finished, check your
answers at the back of this study guide. Once you’re confident you understand the coding
principles for this section, move on to the next section.
56 Medical Coding 2
Assignment 3 Quiz
40951100
Books Needed:
Directions: Each assignment quiz is divided into two parts. Part A contains multiple-choice
coding questions, whereas Part B requires you to code the information from a coding sce-
nario found in your Clinical Coding Workout: Practice Exercises for Skill Development book.
Complete all required and relevant codes for each given scenario. When you’re comfortable
with your answers for both parts, submit this quiz to your instructor for grading.
1. Conditions such as myocardial infarction and angina pectoris are included in which code
category range?
A. 410–414 C. 400–410
B. 434–497 D. 417–427
2. A myocardial infarction that occurred three weeks ago should be coded to category
A. 413. C. 411.
B. 412. D. 410.
4. Which of the following is the appropriate coding and sequencing (if applicable) for a diagnosis
of dementia without behavioral disturbance due to Alzheimer’s disease?
(Continued)
Lesson 1 57
Assignment 3 Quiz
40951100
5. One of the patient’s diagnoses is listed as alcoholism in remission. Which of the following
codes should be reported for this condition?
A. 303.03 C. 303.93
B. 305.0 D. V11.3
6. A right-handed patient has right-sided hemiplegia from a current, unspecified CVA that clears
before patient discharge. Which of the following could be the correct code assignment(s) and
sequencing (if applicable)?
A. 436 C. 438.21
B. 436, 342.91 D. 438.21, 342.91
A. one code.
B. two codes.
C. three codes.
D. no codes until the physician is queried for more information.
A. 345. C. 436.
B. 780. D. Need more information
9. Which of the following are examples of codes that can be assigned to the same patient for the
same encounter?
10. When a patient is admitted in respiratory failure due to an acute, nonrespiratory condition,
which of the following actions should the coder take?
(Continued)
58 Medical Coding 2
Assignment 3 Quiz
40951100
Part B: Complete the following exercises in your Clinical Coding Workout: Practice
Exercises for Skill Development book:
Exercises 4.67–4.71, “Disorders of the Nervous and Sense Organs,” starting on page 116
Lesson 1 59
NOTES
60 Medical Coding 2
ANSWER SHEET
FOR YOUR INSTRUCTOR’S USE
GRADE GRADED BY
STUDENT NUMBER:
ASSIGNMENT 3 QUIZ 40951100
PLEASE PRINT
Medical Coding 2
NAME ________________________________________________________________
ADDRESS ________________________________________________________________
CITY ________________________________________________________________
STATE/PROVINCE ZIP/POSTAL CODE
Part A
CUT ALONG THIS LINE
1. A B C D 6. A B C D
2. A B C D 7. A B C D
3. A B C D 8. A B C D
4. A B C D 9. A B C D
5. A B C D 10. A B C D
Part B
4.49 ________________________________
Lesson 1 63
Diverticulosis versus Diverticulitis
Diverticulosis indicates the presence of pouchlike herniations
(diverticula) throughout the intestine. Diverticulitis is inflam-
mation of the diverticula.
When both diverticulosis and diverticulitis are documented,
code only the diverticulitis because the condition assumes
the presence of the pouchlike herniations (from diverticulo-
sis). For example, for diverticulosis with diverticulitis of the
duodenum—code 562.01—diverticulitis of the small intestine
NOTES:
(without mention of hemorrhage).
Diverticula can be acquired or congenital. For certain sites
Diverticula can be
found on any hollow, (such as colon), diverticula are assumed to be congenital. For
tubular organ (such as other sites (such as espophagus), diverticula are assumed to
intestine, esophagus, be acquired unless otherwise documented. Pay close atten-
bladder). tion to medical record documentation and coding notes in
your coding book so that you’ll assign the appropriate code
When diverticulosis
for these distinctions.
isn’t otherwise speci-
fied, it’s assumed to
be of the colon (code Cholecystitis, Cholelithiasis,
562.10 [without
hemorrhage]).
and Choledocholithiasis
This section deals with diseases of the gallbladder. The
The terms stone and
function of the gallbladder is to store excess bile until it’s
calculus are synony-
mous and may be
needed to break down fat. Cholecystitis is acute or chronic
used interchangeably inflammation of the gallbladder. Cholelithiasis is the presence
in documentation. of gallstones in the gallbladder. If there are abnormally high
levels of bile salts or, more commonly, cholesterol, stones can
When removal of form. Choledocholithiasis is a condition of stones in the com-
stones is performed, mon bile duct. Choledocholithiasis may also be referred to as
don’t code incision of
biliary calculus or gallstones.
the cystic duct as a
separate procedure In ICD-9-CM classification, there are codes that allow for
because it’s implicit
these three related conditions to be coded as one combina-
in the basic procedure
tion code. There are classification groups (code category 574)
code.
based on location of the calculus. The fourth digit within the
category indicates if there’s associated cholecystitis and if it’s
acute. Fifth digits indicate any presence of obstruction.
Cholecystectomy, or removal of the gallbladder, is a procedure
that can be performed as total or partial via either an open
approach (51.21–51.22) or a laparoscopic approach
(51.23–51.24).
64 Medical Coding 2
Adhesions and Hernia NOTES:
Adhesions are bands of scar tissue that bind together internal A patient may have
surfaces that are normally separate. Adhesions most commonly minor adhesions that
form in the abdomen after abdominal surgery. Adhesions are don’t cause issues.
When these adhesions
classified to codes 568.0 (peritoneal adhesions; postoperative,
are lysed during another
post-infective) and 560.81 (intestinal or peritoneal adhesions procedure, don’t code
with obstruction; postoperative, post-infective). Adhesions are the adhesions or the
treated by lysis (destruction/dissolution of the scar tissue) lysis. Code these
and coded by the following approaches: adhesions only when
they’re so extreme that
Q Laparoscopic lysis of peritoneal adhesions—code 54.51 the surgeon must stop
the other procedure
Q Other lysis of peritoneal adhesions—code 54.59 in order to lyse the
adhesions. As always,
Hernia is a protrusion or projection of an organ through an query the physician
abnormal opening. In ICD-9-CM, hernias are classified by type for clarification when
and site. For hernia repair, make sure that the diagnostic needed.
code for hernia matches the procedure code. For example, if
a diagnosis of unilateral hernia is coded, it isn’t possible for a It isn’t possible for a
bilateral hernia procedure to be coded. Errors in coding such bilateral repair to be
performed for a unilat-
as this will result in denial of payment for the institution.
eral hernia. However,
it’s possible for a
Coding Guidelines for Digestive System Diagnoses unilateral repair to be
done for a bilateral
1. Code category 578 (gastrointestinal hemorrhage) is hernia if repair for
one of the hernias
assigned only when the physician states GI bleeding
is necessary but not
is caused by a condition other than GI.
for the other.
2. Assign GI conditions with hemorrhage to the appropriate
combination code.
3. Obstruction of gallbladder—code 575.2—and obstruction
of bile duct—code 576.2—should be assigned only when
there’s obstruction but no calculi.
4. Calculus of the gallbladder and bile duct with both acute
and chronic cholecystitis should be coded to 574.8X.
5. When coding postcholecystectomy syndrome—code
576.0—don’t code a postoperative complication code
(categories 996–999).
6. With femoral and inguinal hernias, use the fifth-digit
subclassification to indicate if the hernia is unilateral or
bilateral and whether it’s recurrent.
7. Code incarcerated or strangulated hernias as obstructed.
Lesson 1 65
8. Code functional diarrhea as 564.5 (564.4 if it follows
GI surgery).
Practice Exercise 4A
Books Needed:
In your Clinical Coding Workout: Practice Exercises for Skill Development, complete exercises
1.176–1.195, “Digestive System,” starting on page 19. When you’re finished, check your
answers at the back of this study guide. Once you’re confident you understand the coding prin-
ciples for this section, move on to the next section.
66 Medical Coding 2
Genitourinary System
(Code Categories 580–629)
Chapter 10 in the ICD-9-CM book categorizes diseases of the
genitourinary system (code categories 580–629).
Genitourinary refers to the organs and/or functions of both
the genitals and urinary system together. Genitourinary is
also called urogenital.
Lesson 1 67
Hematuria and Incontinence
Hematuria, or blood in the urine, is a symptom of certain
conditions. The hematuria code (599.7) should be assigned
only when the condition causing it isn’t identified. In some
cases (for example, after urinary procedures), some amount
of hematuria is expected and shouldn’t be coded. If documen-
tation indicates that hematuria after a procedure is excessive,
NOTES: query the physician to determine if it should be coded as a
postoperative condition or secondary diagnosis.
Incontinence actually
refers to the inability Incontinence refers to the inability to control urination due to
to control urination or anatomic, physiologic, or pathologic conditions.
defecation. For the
purpose of this chapter, Stress incontinence is due to physical strain such as occurs
we’re discussing incon- when a person coughs, sneezes, or laughs. Stress incontinence
tinence related in women is coded to 625.6 and in men to code 788.32.
specifically to urination.
Unspecified renal
Renal Disease
failure is coded to 586.
Renal disease is classified to code categories 580–593, with
the exception of that related to pregnancy/labor (reclassified
to Chapter 11). Renal failure is a result of other diseases and
can be acute or chronic. Acute kidney failure is the sudden
cessation of renal function (584.X). Chronic kidney disease,
or CKD (585.X), is the inability of the kidneys to function
adequately on a long-term basis. According to the “Clinical
Practice Guidelines for CKD” by the National Kidney
Foundation (http://www.kidney.org), CKD is defined as
kidney damage or greater than or equal to three months.
Kidney damage is pathologic abnormalities or markers of
damage (including abnormalities in blood or urine tests or
imaging studies).
The ICD-9-CM coding book provides fourth digits to cover
all stages of kidney disease (Stage I–V and then “End Stage”).
Chronic kidney disease includes chronic renal disease, chronic
renal failure NOS, and chronic renal insufficiency, which are
all included in code 585.9. If applicable, an additional code
(V42.0) should be used to identify the kidney transplant status.
As discussed in the circulatory system chapter, ICD-9-CM
assumes a relationship between hypertension and kidney dis-
ease (reclassified to categories 403 or 404). However, acute
68 Medical Coding 2
renal failure isn’t assumed to be caused by hypertension. In
this case, assign first the code for acute renal failure (584.9)
followed by the code for hypertension (401.9). Don’t use codes
from categories 403 or 404 if the following scenarios exist:
Q Acute renal failure exists with hypertension.
Lesson 1 69
8. When the patient is admitted for dialysis, code V56.0—
extracorporeal dialysis (hemodialysis) or V56.8—other
dialysis (peritoneal)—as the principal diagnosis.
Practice Exercise 4B
Books Needed:
In your Clinical Coding Workout: Practice Exercises for Skill Development, complete exercises
1.196–1.215, “Genitourinary System,” starting on page 21. When you’re finished, check your
answers at the back of this study guide. Once you’re confident you understand the coding prin-
ciples for this section, move on to the next section.
70 Medical Coding 2
Skin and Subcutaneous Tissue
(Code Categories 680–709)
NOTES:
Skin and subcutaneous tissue conditions are covered in
Chapter 12, code categories (680–709). They’re subdivided This chapter includes
into the following categories: conditions of the nails,
sweat glands, hair, and
Q Infections (680–686) hair follicles.
Skin Ulcers
Decubitus ulcer, or pressure sore/ulcer, is a sore or ulcer
that occurs most frequently at “pressure points,” especially
those when the patient is lying down for long periods of time.
Elderly and debilitated patients are at a higher risk for decu-
bitus ulcers. For example, elderly or paralyzed individuals
who lie or sit in one position for long periods may develop
decubitus ulcers on their sacral/buttock area. Code these
ulcers to 707.0X.
Lesson 1 71
NOTES: Debridement
Excisional debride- Debridement is a procedure done to remove damaged tissue,
ments may be carried debris, and foreign objects from a wound or burn to prevent
out at the patient’s infection and promote healing. There are two important
bedside or in an oper-
distinctions for debridement when coding this procedure;
ating room. However,
just because a physi-
86.22—excisional debridement of the skin—includes cutting
cian is performing the away of the tissue and is performed only by a physician.
debridement doesn’t
Code 86.28 is a nonoperative (nonexcisional) procedure that
make it excisional.
includes terms like brushing, irrigating, scrubbing, or other
Nonexcisional debride-
methods to remove tissue or foreign material.
ments performed by
personnel other than
Coding Guidelines for Skin and
physicians shouldn’t
be coded. Subcutaneous Tissue Diagnoses
1. Code cellulitis due to a superficial injury, burn, or
Abscess and lymphan-
gitis are included in the
frostbite to two codes—one for the injury and one for
code for cellulitis. cellulitis. Sequencing in this case depends on the cir-
cumstances of admission.
Simple excision
2. For abscess and/or lymphangitis with cellulitis, assign
involves only the skin.
only the appropriate code for cellulitis. Assign an addi-
tional code for the causative organism.
3. Assign cellulitis as a complication of a chronic skin ulcer
to code category 707 with a secondary code to identify
the cellulitis. Sequencing depends on the circumstances
for admission.
4. Code gangrenous cellulitis due to injury/ulcer to
gangrene—785.4—as a secondary diagnosis with
the injury/ulcer sequenced as principal diagnosis.
72 Medical Coding 2
Coding Guidelines for Skin and
Subcutaneous Tissue Procedures
1. Code simple excision of lesions to category 86.3 (includes
NOTE:
local excision and method of destruction).
Radical or wide
2. Code 86.4 for a radical or wide excision.
excision involves
3. Nonexcisional debridements performed by personnel underlying/adjacent
tissue.
other than physicians shouldn’t be coded.
Now let’s practice the principles for this section. Proceed to
the practical coding exercise for more information.
Practice Exercise 4C
Books Needed:
In your Clinical Coding Workout: Practice Exercises for Skill Development, complete exercises
1.236–1.255, “Skin and Subcutaneous Tissue,” starting on page 24. When you’re finished,
check your answers at the back of this study guide. Once you’re confident you understand
the coding principles for this section, move on to the next section.
Lesson 1 73
Assignment 4 Quiz
40951200
Books Needed:
Directions: Each assignment quiz is divided into two parts. Part A contains multiple-choice
coding questions, and Part B requires you to code the information from a coding scenario
found in your Clinical Coding Workout: Practice Exercises for Skill Development book.
Complete all required and relevant codes for each given scenario. When you’re comfortable
with your answers for both parts, submit this quiz to your instructor for grading.
2. Which of the following conditions is/are the most common causes of upper GI bleed?
3. A patient is admitted with a small pouch extending from the duodenum. The coder will
probably report category
A. 562.01—diverticulitis. C. 532.30—duodenal ulcer.
B. 562.00—diverticulosis. D. 531.30—acute gastric ulcer.
4. When minor adhesions are lysed as part of another procedure, how should you code the lysis
of adhesions?
A. As an additional procedure
B. As an incision
C. Don’t code the lysis of adhesions.
D. Depends on the approach used
(Continued)
74 Medical Coding 2
Assignment 4 Quiz
40951200
5. How should the presence of hematuria after a urinary tract procedure or prostatectomy
be coded?
A. 599.0
B. 599.7
C. 998.89
D. It shouldn’t be coded unless directed by the physician.
6. When a patient has both hypertension and renal disease, a relationship is presumed and
coded as one code together except in the case of
7. Which of the following factors most likely determines the appropriate procedure code
assignment for prostatectomies?
8. A sacral decubitus ulcer with gangrene is coded and sequenced (if applicable) as codes
A. 707.03. C. 785.4.
B. 707.03, 785.4. D. 785.4, 707.03.
9. How many codes should be assigned for cellulitis as a complication of chronic skin ulcers?
A. One
B. Two
C. Three
D. Unsure, need to query physician
10. Any skin debridement performed by a physician should be coded to which of the following
procedure codes?
A. 86.22
B. 86.27
C. 86.28
D. Need more information; must query physician for type of debridement used
(Continued)
Lesson 1 75
Assignment 4 Quiz
40951200
Part B: Complete the following exercises in your Clinical Coding Workout: Practice
Exercises for Skill Development workbook.
76 Medical Coding 2
ANSWER SHEET
FOR YOUR INSTRUCTOR’S USE
GRADE GRADED BY
NAME ________________________________________________________________
ADDRESS ________________________________________________________________
CITY ________________________________________________________________
STATE/PROVINCE ZIP/POSTAL CODE
Part A
1. A B C D 6. A B C D
CUT ALONG THIS LINE
2. A B C D 7. A B C D
3. A B C D 8. A B C D
4. A B C D 9. A B C D
5. A B C D 10. A B C D
Part B
4.31 ________________________________
Arthritis
Arthritis is an inflammatory condition of the joints that causes
pain, redness, swelling, and also limits movement. Arthritis
may occur alone or as a manifestation of another disease.
Lesson 1 79
In these cases, assign the appropriate dual codes. Some
common examples of arthritis are osteoarthritis (code
category 715) and rheumatoid arthritis (code category 714).
NOTES:
Pathologic Fractures
The fifth digit indicates Pathologic fractures are breaks in the bone caused by a
the site. weakness in the bone tissue. If a fracture is described as
spontaneous, it’s a pathologic fracture and coded to
Remember, fractures category 733.1X.
due to injuries (trau-
matic) are coded to
Chapter 17—“Injury Coding Guidelines for Musculoskeletal System
and Poisoning.” and Connective Tissue Diagnoses
Back pain associated 1. Code back pain in the following way: first code to site
with the herniation of of pain; lumbago, or low back pain—724.2; back pain,
an intervertebral disc is NOS—724.5; cervicalgia, or neck pain—723.1.
included in the hernia-
tion code 722.2 (no 2. Many back disorder codes make a distinction for those
separate code for back persons with or without myelopathy (functional disturbance
pain is assigned). and/or pathologic change in the spinal cord). Follow the
medical record documentation for appropriate assignment.
3. A pathologic fracture (733.1X) is sequenced as principal
diagnosis only when admission is for treatment of the
fracture and no other underlying condition exists.
4. Never assign traumatic fracture and pathologic fracture
of the same bone together.
5. Assign code V43.6—joint replacement status—as an
additional code if the presence of the replacement is
significant for the patient’s current episode of care.
80 Medical Coding 2
2. Assign replacement of joint—lower extremities—to NOTE:
code 81.5X and upper extremities to code 81.8X.
The guideline for
3. When joint replacement also involves bone growth stimu- Number 5 is used
lator, code the stimulator to 78.9X as an additional after the joint has
procedure code. been replaced the
initial time. Don’t
4. When a bilateral replacement of a joint is performed, use assign this code for
the joint replacement code twice to indicate both locations. the first (initial)
joint replacement.
5. Code revision or replacement of a joint replacement of
lower extremity to 81.5X.
Now let’s practice the principles for this section. Proceed to
the practical coding exercise for more information.
Practice Exercise 5A
Books Needed:
In your Clinical Coding Workout: Practice Exercises for Skill Development, complete exercises
1.256–1.275, “Musculoskeletal System and Connective Tissue,” starting on page 26. When
you’re finished, check your answers at the back of this study guide. Once you’re confident you
understand the coding principles for this section, move on to the next section.
Lesson 1 81
2. These codes have sequencing priority over codes from
other chapters.
Chapter 11 is divided into the following sections:
Q Ectopic and molar pregnancies: code categories 630–633
Other Conditions
Some conditions classified to other chapters (for example,
hypertension, diabetes, anemia) are reclassified to Chapter 11
when they affect or complicate a pregnancy, delivery, or
puerperium. For example, during these periods benign hyper-
tension is coded to categories 642.00–642.9 (Chapter 11)
instead of to the normal code 401.1 (Chapter 7).
82 Medical Coding 2
Coding Guidelines for Pregnancy, Childbirth, and
Puerperium Diagnoses
1. When an encounter is for a condition unrelated to the
pregnancy, code the condition for admission first followed
by V22.2—pregnant state, incidental.
2. Fifth digits 1 and 2 can be used together for the same
episode, but not with any other fifth digits (from other
codes in this chapter).
3. For complications, fifth digits 3 (antepartum) and 4
(postpartum) can’t be used together or with any other
fifth digit.
4. Assign a secondary category code V27.X to the mother’s
NOTES:
record to indicate the outcome of delivery (for example,
single birth, multiple births, alive, stillborn) for the cur- Look up “Outcome of
rent episode of care. delivery” (V27.X) in
the Alphabetic Index,
5. Code 650—normal delivery—only when the delivery is V code section, of your
normal with a single liveborn outcome. Criteria: head/ ICD-9-CM code book
occipital delivery; antepartum complication resolved to find these codes.
Lesson 1 83
NOTES:
10. Always code preexisting hypertension (category 642) as a
complication in pregnancy, delivery, or puerperium.
Diagnoses can’t be
assigned based solely 11. The physician must specify pre-eclampsia or eclampsia
on elevated blood before these conditions can be coded.
pressure, abnormal
12. Postpartum complications that occur during the
albumin level, or
edema. admission for delivery are assigned a fifth digit of 2.
Postpartum complications that occur after discharge
Complications are con- are assigned a fifth digit of 4.
sidered postpartum if
13. Code perineal lacerations to categories 664.0X–664.3X.
they occur within six
weeks after delivery. 14. Assign a code from category V25 as the principal diagno-
sis when the admission/outpatient encounter is for
Don’t forget to also contraceptive management.
assign a procedure
code for a contracep- 15. Assign code V25.2 (covers both male and female) when
tive management visit the admission/encounter is solely for contraceptive
when appropriate.
sterilization.
If sterilization is per-
formed during the Coding Guidelines for Pregnancy, Childbirth, and
same admission as Puerperium Procedures
the delivery, assign
code V25.2 as the 1. Assign additional codes for procedures that assist delivery:
secondary diagnosis.
artificial rupture of membranes (73.01), cervical dilation
(73.1), artificial rupture of membranes (after labor has
Code 75.69 includes
begun) (73.09), forceps rotation of fetal head (72.4),
repair of episiotomy, so
there’s no need for an manual rotation of fetal head (73.51).
additional code.
2. Episiotomies are coded to category 73.6 (without forceps
delivery) or category 72.1 (low forceps delivery).
3. Repair of perineal lacerations are coded to category 75.69.
4. Cesarean sections are coded as 74.0 (classical), 74.1 (low
cervical), or 74.2 (extraperitoneal).
5. Code female contraceptive/sterilization procedures to
categories 66.2 and 66.3; code male contraceptive/
sterilization procedures to 63.7.
Now let’s practice the principles for this section. Proceed to
the practical coding exercise for more information.
84 Medical Coding 2
Practice Exercise 5B
Books Needed:
In your Clinical Coding Workout: Practice Exercises for Skill Development, complete exercises
1.216–1.235, “Pregnancy, Childbirth, and the Puerperium,” starting on page 22. When you’re
finished, check your answers at the back of this study guide. Once you’re confident you under-
stand the coding principles for this section, move on to the next section.
Lesson 1 85
2. Conditions due to birth injuries are reclassified to
perinatal conditions, birth trauma, code category 767
(Chapter 15).
3. Code a newborn with a congenital anomaly to code
NOTES:
category V30–V39 as principal diagnosis followed by
Newborn congenital the additional anomaly code from Chapter 14.
conditions are reported
even if they’re not 4. When a renal cyst isn’t specified as congenital or
treated/evaluated acquired, code the cyst as congenital.
during the current
admission. This policy
is an exception to the Certain Conditions Originating in the Perinatal
coding guideline for Period (Code Categories 760–779)
reporting additional
diagnoses. Conditions originating in the perinatal period appear in
Chapter 15, code categories 760–779.
There’s no separate
coding exercise for the
Perinatal refers to the time period around and including the
congenital anomaly process of being born or giving birth. The newborn (perinatal)
section. Congenital period begins at birth and lasts through the 28th day follow-
anomalies have been ing birth.
grouped with the
next section.
Classification of Newborns
Follow information in
the coding book for
When coding births, assign a code from categories V30–V39
correct assignment of according to the type of birth and any other significant sec-
fourth- and fifth-digit ondary diagnoses originating in the perinatal period.
subdivisions of cate-
gories V30–V39.
Codes from categories V30–V39 are assigned to the medical
record as principal diagnosis and only one time to the new-
Codes from categories born record at the time of birth.
764 and 765 should be
assigned based on
physician documenta-
Prematurity and Fetal Growth Retardation
tion and not just on
A premature infant is one who is born before 37 weeks’
gestational age and/or
birth weight. The
gestation and hasn’t fully developed or matured. Fetal growth
physician must docu- retardation means that the infant is smaller than expected
ment prematurity- at a specific gestational age. Codes for premature infants
relevant conditions to and/or fetal growth retardation are assigned to code categories
be coded.
764 and 765 with a fifth digit to indicate birth weight.
86 Medical Coding 2
Coding Guidelines for Perinatal Diagnoses
1. When coding the birth of an infant, assign to the new-
born record a code from category V30–V39 according to
type of birth.
2. Don’t code from category V30–39 when a newborn has
been transferred from another institution. Code instead
the condition responsible for the transfer as principal
diagnosis (with no V30–V39 series coded).
3. Don’t code categories V33, V37, and V39 for acute care
NOTES:
hospitals (sufficient information should be provided to
code elsewhere). When the signs/
symptoms of a sus-
4. Assign a V29 category code as secondary diagnosis when pected condition are
a healthy newborn is evaluated for a suspected condition present, code instead
that’s (after study) not present. Assign the V30 category the sign or symptom
code as principal diagnosis. (and not the V29 cate-
gory code). A code
5. Code a secondary diagnosis from category 766 for a long from V29 can be
gestation or unusually high birth weight. assigned as principal
diagnosis for readmis-
6. Code fetal distress and asphyxia only when the condition sion or when V30 is no
has been specifically identified and documented by the longer appropriate.
physician. Don’t codes these conditions based on scores
or tests. 760 and 763 codes are
assigned to newborn
7. Code from categories 760 and 763—maternal causes of records only when the
perinatal morbidity—to the newborn record only when the maternal condition has
maternal condition is the cause for morbidity or mortality. adversely affected the
newborn.
8. Assign routine vaccination of newborns as V05.3 (viral
hepatitis) and V05.4 (varicella). Code V20.2 is assigned
9. Assign a code from category V20—health supervision of for routine examina-
tions (for example,
infant/child—for routine encounters when no problem
well baby clinic) at
has been identified. clinics/offices but not
for hospital admissions.
Lesson 1 87
Practice Exercise 5C
Books Needed:
In your Clinical Coding Workout: Practice Exercises for Skill Development, complete exercises
1.276–1.295, “Newborn/Congenital Disorders,” starting on page 27. When you’re finished,
check your answers at the back of this study guide. Once you’re confident you understand the
coding principles for this section, move on to the next section.
88 Medical Coding 2
Assignment 5 Quiz
40952000
Books Needed:
Directions: Each assignment quiz is divided into two parts. Part A is composed of multiple-
choice coding questions, and Part B requires you to code the information from a coding
scenario found in your Clinical Coding Workout: Practice Exercises for Skill Development
book. Complete all required and relevant codes for each given scenario. When you’re com-
fortable with your answers for both parts, submit this quiz to your instructor for grading.
1. When coding back disorders, which of the following conditions should always be considered for
inclusion in the code?
A. Degeneration C. Herniation
B. Myelopathy D. Arthritis
2. Laminectomy when performed with excision of herniated disc shouldn’t be coded separately
because this procedure is
A. the physician lists it first on the admission sheet with no other conditions.
B. there’s no underlying condition that’s being treated.
C. there’s an underlying condition that’s coded as secondary.
D. it has been ruled out as the secondary diagnosis.
(Continued)
Lesson 1 89
Assignment 5 Quiz
40952000
4. Which of the following is the correct coding and sequencing—if applicable—for bilateral total
hip replacement?
6. The only circumstance for which code V27 can be assigned is on the
A. newborn’s record for birth in the hospital during the current episode of care.
B. newborn’s record to indicate birth on subsequent episodes of care.
C. mother’s record for delivery in hospital during current episode of care.
D. mother’s record to indicate delivery on subsequent episodes of care.
7. Which of the following scenarios would be assigned the code for normal delivery on the
mother’s record?
8. A scenario in which categories V30–V39 are assigned is once, as the __________ diagnosis
to the __________ record at the time of birth.
9. A valid documentation for codes 764 or 765 would be physician documentation stating
10. Which of the following are all category codes that could be assigned for acute-care hospitals?
(Continued)
90 Medical Coding 2
Assignment 5 Quiz
40952000
Part B: Complete the following exercises in your Clinical Coding Workout: Practice
Exercises for Skill Development workbook:
Lesson 1 91
NOTES
92 Medical Coding 2
ANSWER SHEET
FOR YOUR INSTRUCTOR’S USE
GRADE GRADED BY
NAME ________________________________________________________________
ADDRESS ________________________________________________________________
CITY ________________________________________________________________
STATE/PROVINCE ZIP/POSTAL CODE
Part A
CUT ALONG THIS LINE
1. A B C D 6. A B C D
2. A B C D 7. A B C D
3. A B C D 8. A B C D
4. A B C D 9. A B C D
5. A B C D 10. A B C D
Part B
Examination
EXAMINATION NUMBER
40951300
Whichever method you use in submitting your exam
answers to the school, you must use the number above.
When you feel confident that you have mastered the material
in Lesson 1, submit your answers by e-mail attachment to
edserv@pennfoster.com. On the subject line of the e-mail, write
Exam 409513, then Medical Coding 2. Follow the directions given
for submitting assignment quizzes. If you don’t have access to
e-mail, you can mail in your exam. Submit your answers for this
examination as soon as you complete it. Do not wait until another
examination is ready.
95
3. Dr. Smith recorded the following diagnoses on the patient’s discharge sheet:
gastrointestinal bleeding due to acute gastritis and angiodysplasia. The principal
diagnosis is coded as
A. GI bleeding.
B. acute gastritis.
C. angiodysplasia.
D. either acute gastritis or angiodysplasia.
4. A patient was admitted with extreme fatigue and lethargy. Upon discharge, the
physician documents: fatigue due to either depression or hypothyroidism. Which
of the following are correct codes and sequencing for the scenario?
A. 780.79, 311, 244.9 C. 249.9, 311
B. 311, 249.9, 789.79 D. 789.79
5. Of the following, which code would take precedence over the other?
A. 072.0 over 033.0 C. 486 over 480
B. 595.0 over 131.09 D. 112.2 over 599.0
6. Upon discharge, the physician documents the following on the patient’s discharge
sheet: ?HIV infection. As the inpatient coder, your next step should be to
A. code the HIV infection as if it exists (according to UHDDS guidelines) and report it
as the principal diagnosis.
B. review the UHDDS guidelines for assigning possible HIV infection codes versus
AIDS codes.
C. query the physician and request that the statement be amended with a positive
(or negative) confirmation of the HIV infection.
D. wait to code the patient’s record until a positive finding on the serology report
confirms the HIV diagnosis.
7. For which of the following scenarios would it be appropriate to query the physician for
more information before coding and/or sequencing?
A. A patient was admitted with severe abdominal pain. At discharge, the physician
documents: abdominal pain due to either hiatal hernia or diverticula.
B. A patient was admitted with congestive heart failure (treated with IV furosemide)
and unstable angina (treated with nitrates).
C. A patient has low potassium levels noted on the laboratory report (treated with
orally administered potassium).
D. A patient is admitted with dysuria with no cause found.
96 Examination, Lesson 1
8. Which of the following statements is true?
A. A patient has diabetes and an ulcer. Code the ulcer as diabetic.
B. A pregnant patient has diabetes. Code diabetes as complicating the pregnancy.
C. A patient has diabetes and cardiomyopathy. Code the cardiomyopathy as a diabetic
complication.
D. A patient has diabetes and cataracts. Code diabetic cataracts.
9. A patient was admitted for metastatic carcinoma from the breast to several lymph
node sites. Two years ago she had a double mastectomy. Which of the following is the
correct code assignment for this case?
A. 196.8, V10.3 C. 196.8, 174.9, 85.42
B. 174.9, 196.8 D. 196.8, 174.9, V10.3
10. One of the secondary diagnoses listed on the patient’s discharge sheet is seizures. As
a coder, your next step is probably
A. coding seizures to 780.39.
B. coding seizures to 345.
C. not reporting the code because it’s a symptom.
D. querying the physician for more information/clarification.
11. A patient was discharged with the diagnosis of acute bronchitis with chronic obstructive
asthma. Which of the following is the correct coding and sequencing (if applicable) for
this patient?
A. 493.21 C. 466.0, 493.21
B. 493.21, 496 D. 493.91
12. Code 780.2 can be listed as principal diagnosis in which of the following cases?
A. For an outpatient encounter when the cause has been determined
B. For an inpatient encounter when the cause hasn’t been determined
C. When it’s listed with a contrasting diagnosis
D. It can never be listed as principal diagnosis.
13. Which of the following codes should not be listed as principal diagnosis?
A. 784.7 C. E812.0
B. V30.00 D. 307.81
14. Choose the correct code and sequencing for the following scenario: Reduction of right
humerus fracture with cast.
A. 79.00 C. 79.00, 93.53
B. 79.01 D. 79.01, 93.53
Examination, Lesson 1 97
15. Read the following excerpt from medical record documentation and determine the
correct code(s) for coding. The physician writes: “…noted burn on the arm skin with
redness. Patient complained of tenderness to the touch.”
A. 943.01 C. 943.21
B. 943.10 D. 943.30
16. A patient was admitted in a coma from intentionally ingesting an entire bottle of
sedatives. Which of the following is the correct coding and sequencing assignment?
A. 780.01, 967.8 C. 967.8, E950.2
B. 780.01, 967.8, E950.2 D. 967.8, 780.01, E950.2
17. Which of the following situations would allow the assigning of a V code for a principal
diagnosis?
A. Mother admitted for birth of infant, no complications
B. Patient admitted for dialysis
C. Patient admitted for metastatic breast cancer with a history of ovarian cancer
D. Patient admitted for poisoning has a history of alcoholism
18. A patient was admitted for nausea and vomiting due to gastroenteritis. Which of the
following is the correct code reporting and sequencing?
A. 787.01, 787.02, 558.9 C. 558.9, 787.01
B. 787.02, 787.03, 558.9 D. 558.9
19. A physician lists positive findings on a purified protein derivative (PPD) test as a
secondary diagnosis on the patient’s discharge sheet. How should this listing be coded?
A. 795.5
B. 010.95
C. 011.05
D. This listing shouldn’t be coded.
21. A patient is admitted for metastatic adenocarcinoma of the sacrum from the prostate.
A prostatectomy was performed 11 months ago. Which of the following should be
reported as the principal diagnosis for this patient?
A. V10 C. 198.5
B. 185 D. 170.6
98 Examination, Lesson 1
22. A patient was discharged with a diagnosis of diabetes with nephropathy and chronic
renal failure. How many codes would be reported for this patient?
A. One
B. Two
C. Three
D. Need more information on the type of diabetes
23. If the physician describes the patient as presently in a manic phase, but has
experienced depression in the past, this condition may be coded as
A. 296.4X C. 296.6X
B. 296.5X D. Need more information
25. A patient was admitted with an acute exacerbation of chronic obstructive bronchitis
and found to be in respiratory failure. Which of the following is the correct coding and
sequencing for this case?
A. 518.81, 491.21 C. 518.81, 496
B. 491.21, 518.81 D. 493.91, 496, 518.81
In your Clinical Coding Workout: Practice Exercises for Skill Development book, code the
following health record scenarios. Record your answers on the answer sheet for this
examination. In some cases, you’ll select codes from a multiple-choice list. In other cases,
you’ll be assigning the actual diagnosis and procedure codes. When assigning codes, be
sure to report them on the answer sheet in the order that you would sequence them (if
appropriate).
Be sure to read the directions on pages 189–190 (Case Studies from Inpatient Health
Records) before beginning these exercises.
7.1 (p. 190), 7.5 (p. 196), 7.6 (p. 196), 7.8 (p. 196), 7.9 (p. 197), 7.11 (p. 199), 7.13
(p. 203), 7.14 (p. 206), 7.15 (p. 207), 7.19 (p. 217), 7.22 (p. 221), 7.25 (p. 224),
7.27 (p. 226), 7.28 (p. 227), 7.31 (p. 231), 7.34 (p. 234), 7.36 (p. 237), 7.40
(p. 246), 7.41 (p. 246), 7.45 (p. 250)
Examination, Lesson 1 99
NOTES
Medical Coding 2
NAME ________________________________________________________________
ADDRESS ________________________________________________________________
CITY ________________________________________________________________
STATE/PROVINCE ZIP/POSTAL CODE
Part A
1. A B C D 10. A B C D 18. A B C D
CUT ALONG THIS LINE
2. A B C D 11. A B C D 19. A B C D
3. A B C D 12. A B C D 20. A B C D
4. A B C D 13. A B C D 21. A B C D
5. A B C D 14. A B C D 22. A B C D
6. A B C D 15. A B C D 23. A B C D
7. A B C D 16. A B C D 24. A B C D
8. A B C D 17. A B C D 25. A B C D
9. A B C D
Part B
40951400
RESEARCH PROJECT
Background
Some hospitals, organizations, and physicians now outsource,
or hire contract coders, to perform their coding. There are
commercial coding companies that engage pools of coders to
meet these outsourcing needs.
Procedure
Use the internet to research coding companies. Select two
and provide the following information for each company:
Part A—Company Information
1. Company Name
2. URL (Web address)
Part B—Questions
1. How long has the company been in business?
2. List the range of services the company provides.
3. What kind of health care providers does the company
work with?
4. What are the requirements (educational, certification,
experience, and so on) to work for this company?
5. Would you like to work for this company? Why or why
not? What additional skills would you need to acquire
before working for this company?
103
Goal
Your goal is to become aware of these coding companies,
the health care providers they work with, and the skills and
experience coders must have to work for individual companies.
Writing Guidelines
Q Type your submission, double-spaced, in a standard,
size 12 print font. Use a standard document format with
one-inch margins. (Don’t use any fancy or cursive fonts.)
± Student number
Grading Criteria
You’re researching two companies. The information for each
company is worth 50 percent. Your responses for each com-
pany count as follows:
Part A 5%
Part B
Question 1 5%
Questions 2–5 10% each
Content
The student
Q Provides clear answers to the assigned question(s)
Written Communication
The student
Q As necessary, answers each question in a complete para-
graph that includes an introductory sentence, at least
four sentences of explanation, and a concluding sentence
Format
The paper is double-spaced and typed in font size 12. It
includes the student’s
Q Name and address
Q Student number
Medical Coding 2
NAME ________________________________________________________________
ADDRESS ________________________________________________________________
CITY ________________________________________________________________
STATE/PROVINCE ZIP/POSTAL CODE
Company 1
Part B—Questions
Company 2
Part B—Questions
Comments:
Inpatient/Outpatient
Procedure Coding/
Lesson 2
Physician Coding/
HCPCS Level II
ASSIGNMENT 6: HOSPITAL
(ACUTE CARE) INPATIENT AND
AMBULATORY (OUTPATIENT)
PROCEDURE CODING
Read Section IV—“Diagnostic Coding and Reporting Guidelines
for Outpatient Services”—(p. 28–29) in the Coding Guidelines
of your ICD-9-CM coding book.
Read the Introduction (pp. xiv–xvii) in your Current Procedural
Terminology: CPT coding book.
INTRODUCTION
In this lesson you’ll learn about general coding guidelines for
inpatient and outpatient procedures and physician office
coding using ICD-9-CM, HCPCS Level I, and HCPCS Level II
procedure coding.
ICD-9-CM procedure codes are found in volume 3 of the
ICD-9-CM coding book and are used to code acute-care hospital
inpatient and outpatient procedures. Volume 3 (Index to
Procedures) is arranged mainly by specific body system.
HCPCS Level I (CPT) is found in your CPT 2011 coding book
arranged in six sections by numeric order.
The HCPCS Level II list from CMS is arranged alphanumeri-
cally. Most HCPCS Level II coding books are arranged by code
letter section (for example, all A codes are in one section, and
B codes are in a separate section). Note: You don’t have a
HCPCS Level II textbook. Instead, you’ll use the lists you
downloaded earlier from the CMS Web site.
For this section, you’ll focus on hospital inpatient and out-
patient procedure coding guidelines.
109
NOTES: Coding Inpatient Procedures
There’s one exception For reimbursement and reporting, medical coders are
to the numeric order—
required by the UHDDS to code hospital inpatient proce-
E/M codes (99201–
99499) are listed at
dures. The UHDDS (to refresh your memory, the Uniform
the beginning of the Hospital Discharge Data Set) requires that all significant
CPT 2011 coding book. procedures be reported. A significant procedure has the
following characteristics:
The UHDDS doesn’t
apply to the coding of
Q Surgical in nature
outpatient procedures.
Q Has an anesthetic risk
The CPT system (from
the AMA) is the classi-
Q Has a procedural risk
fication system that
determines reporting Q Requires specialized training to perform
guidelines for outpa-
tient procedures along Remember, hospital inpatient procedures are reported using
with the CMS.
the codes from Volume 3 (Index to Procedures) of the ICD-9-CM
coding book. You learned about guidelines for some of these
You may also hear the
procedures when working through the different body systems
term encounter used
for an outpatient’s visit in Lesson 1.
or an inpatient stay at
the hospital.
Coding Outpatient Procedures
An outpatient is defined as an individual who receives hospital
services and isn’t expected to be admitted to the hospital or
remain in the hospital over a period of 24 hours. Outpatient
care may also be referred to as ambulatory care.
The CMS requires that outpatient procedures be reported
using HCPCS Level I (CPT) codes. ICD-9-CM procedure codes
aren’t required for reporting; however, the administrators of
some hospitals and other health care institutions may choose
to have the coder report both the HCPCS Level I (CPT) code
and the ICD-9-CM procedure code for internal tracking or
statistical purposes.
Two major differences exist between coding inpatient versus This outpatient sce-
outpatient records. nario is different than
that for inpatient
1. The UHDDS definition of principal diagnosis applies only guidelines wherein you
to inpatients (acute care hospitals). may code “probable,”
“suspected,” and
2. Inconclusive diagnoses (probably, suspected, likely)
“likely” as if the
aren’t coded for outpatients. Instead, the highest level of condition exists.
certainty is coded. This means that there may be times
when you’re coding a symptom as the reason for an out- There may be times
patient encounter. when your principal
procedure and principal
diagnosis aren’t related.
Acute-Care Hospital Inpatient Procedural Coding Make sure that you
have adequate docu-
Hospital inpatient procedures are coded using ICD-9-CM pro- mentation for the
cedure codes (categories 00–99.99) found in Volume 3 of the codes assigned so
ICD-9-CM coding book. Just as there’s a principal diagnosis in that reimbursement
inpatient coding, there’s also a principal procedure. A principal isn’t denied.
Lesson 2 111
3. Excision of Organ or Lesion
Excision of organs (or lesions) may also be listed under
the term resection.
4. Bilateral Procedures
Bilateral procedures indicate that the procedure was
performed at two locations/sides. Assign the procedure
code twice for bilateral procedures (unless otherwise
indicated by the code).
Lesson 2 113
Practice Exercise 6A
Books Needed:
In your Clinical Coding Workout: Practice Exercises for Skill Development, complete exercises
1.376–1.400, “ICD-9-CM Procedure Coding,” starting on page 36. When you’re finished, check
your answers at the back of this study guide. Once you’re confident you understand the coding
principles for this section, move on to the next section.
Lesson 2 115
coding. However, let’s take a moment and explain why the
other sections for hospital ambulatory guidelines aren’t dis-
cussed here.
Some common rules and guidelines to remember when This process for out-
coding for ambulatory surgery are as follows: patient surgery coding
runs contrary to the
1. The appropriate diagnosis code(s) from 001.0–V82.9 coding practices used
must be used to identify diagnoses or reason(s) for the by hospitals and health
encounter/visit. information manage-
ment (medical records)
2. Codes that describe symptoms and signs are acceptable departments for coding
for reporting purposes when an established diagnosis the diagnoses of
hasn’t been confirmed by the physician. hospital inpatients.
Lesson 2 117
NOTES:
9. For patients receiving preoperative evaluations only,
sequence a code from category V72.8X—other specified
If the patient is just examinations—to describe the preoperative consultations.
admitted for “observa-
Assign a code for the condition to describe the reason for
tion” status and meets
observation guidelines,
the surgery as an additional diagnosis. Code also any
then follow the findings related to the preoperative evaluation.
observation/outpatient
10. For ambulatory surgery, code the diagnosis for which the
guidelines for coding.
surgery was performed. If the postoperative diagnosis is
known to be different from the preoperative diagnosis at
the time the diagnosis is confirmed, select the postopera-
tive diagnosis for coding.
11. When a patient is admitted as an inpatient for a compli-
cation due to an outpatient procedure, code the principal
diagnosis as the condition that required the inpatient
admission, followed by the condition for the procedure/
surgery, and the procedure code.
Example. An outpatient tonsillectomy is performed for
chronic tonsillitis with postoperative bleeding noted. The
patient was admitted to the hospital for control of the
bleeding. Code as follows:
Principal diagnosis: Postoperative bleeding
Secondary: Chronic tonsillitis
Procedure: Tonsillectomy
Now let’s practice the principles for this section. Proceed to
the practical coding exercise for more information.
Note: Even though in a hospital outpatient setting a coder would sometimes code both the
ICD-9-CM diagnosis codes (for internal reporting) and the HCPCS Level I (CPT) procedure
codes, for the purpose of this exercise you only need to be concerned with coding the HCPCS
Level I (CPT) procedure codes.
In your Clinical Coding Workout: Practice Exercises for Skill Development book, complete the
following exercises: 2.56 (p. 51); 2.62 (p. 51); 2.69 (p. 52); 2.79 (p. 53); 2.83 (p. 54);
2.93 (p. 55); 2.105 (p. 56); 2.134 (p. 59); 2.139 (p. 59); 2.153 (p. 60); 2.156 (p. 60);
2.180 (p. 62); 2.183 (p. 63); 2.196 (p. 64); 2.222 (p. 66); 2.232 (p. 66); 2.240 (p. 67);
2.258 (p. 69)
When you’re finished, check your answers at the back of this study guide. Once you’re confi-
dent you understand the coding principles for this section, move on to the next section.
Lesson 2 119
Unlisted HCPCS Procedures Codes
These Category III codes have the following characteristics:
Q Allow coders to assign a code to a procedure that’s not
listed in the CPT coding book
Practice Exercise 6C
Books Needed:
In your Clinical Coding Workout: Practice Exercises for Skill Development, complete exercises
2.382–2.401, “Category III Codes,” starting on page 80. When you’re finished, check your
answers at the back of this study guide. Once you’re confident you understand the coding
principles for this section, move on to the next section.
Books Needed:
Directions: Each assignment quiz is divided into two parts. Part A is composed of multiple-
choice coding questions, and Part B requires you to code the information from a coding
scenario found in your Clinical Coding Workout: Practice Exercises for Skill Development.
Complete all required and relevant codes for each given scenario. When you’re comfortable
with your answers for both parts, submit this quiz to your instructor for grading.
A. 81.52 C. 96410
B. 011.60 D. Q0084
A. Volume 3 of ICD-9-CM.
B. Volume 3 of ICD-9-CM and HCPCS Level I.
C. HCPCS Level I.
D. HCPCS Level II.
A. Volume 3 of ICD-9-CM.
B. Volume 3 of ICD-9-CM and HCPCS Level I.
C. HCPCS Level I.
D. HCPCS Level II.
(Continued)
Lesson 2 121
Assignment 6 Quiz
40952100
6. Review the following ICD-9-CM coding instruction excerpt: Cardiotomy and pericardiotomy—
Code also cardiopulmonary bypass [extracorporeal circulation][heart-lung machine] (39.61)
According to this excerpt, how many ICD-9-CM procedure codes should be assigned?
A. 0 C. 2
B. 1 D. Need more information
7. For an outpatient with gallstones who had a laparoscopic cholecystectomy performed, how
many codes are required for reporting?
A. 1 C. 3
B. 2 D. 4
8. What happens when an inpatient procedure is canceled after a patient has been admitted?
9. If you were looking for corneal reconstruction in the CPT Index, what term gets you to the
right code?
A. Cornea C. Revision
B. Eye D. Reconstruction
(Continued)
A. identify emerging technology, services, and procedures for which there are no codes yet.
B. are those local codes that have been phased out.
C. list frequently unused procedures.
D. require AMA approval for use and assignment.
Part B: Complete the following exercises in your Clinical Coding Workout: Practice
Exercises for Skill Development book:
Note: Read the directions for coding the ambulatory health record case studies found on page 125 of
the Clinical Coding Workout book.
Exercises 5.1 (p. 126); 5.11 (p. 129); 5.22 (p. 136); 5.45 (p. 142); 5.55 (p. 144);
5.61 (p. 147); 5.65 (p. 148); 5.70 (p. 150); 5.74 (p. 151); 5.77 (p. 153)
Lesson 2 123
NOTES
NAME ________________________________________________________________
ADDRESS ________________________________________________________________
CITY ________________________________________________________________
STATE/PROVINCE ZIP/POSTAL CODE
Part A
CUT ALONG THIS LINE
1. A B C D 6. A B C D
2. A B C D 7. A B C D
3. A B C D 8. A B C D
4. A B C D 9. A B C D
5. A B C D 10. A B C D
Part B
5.1 ___________________________________________________________________
5.11 ___________________________________________________________________
5.22 ___________________________________________________________________
5.45 ___________________________________________________________________
5.55 ___________________________________________________________________
5.61 ___________________________________________________________________
5.65 ___________________________________________________________________
5.70 ___________________________________________________________________
5.74 ___________________________________________________________________
5.77 ___________________________________________________________________
Lesson 2 127
HCPCS Level I (CPT) Evaluation and
Management Codes for Physician
Office Coding
Introduction
Evaluation and management—or E/M—codes are used by
physicians to report a significant portion of the services they
provide. E/M codes encompass the wide variation in skill,
effort, time, responsibility, and medical knowledge that’s
required for the promotion of optimal health and the prevention
or diagnosis and treatment of an illness or injury. Examples
of some physician services covered by E/M codes include
the following:
Q Consultations
Q Office visits
Lesson 2 129
Documentation for E/M Codes
An evaluation and management (E/M) service has seven
specific components. The first three of these components
are considered to be key or essential for providing any E/M
service in any location.
Q Prognosis
Lesson 2 131
of a presenting problem can be a disease, condition, ill-
ness, injury, symptom, sign, finding, complaint, or other
reason for the encounter. The nature of the presenting
problem drives the E/M encounter. It establishes the
necessity for the type of history to be taken; it determines
the detail and content of an appropriate examination to be
done; it defines the rationale for the medical decision-
making process; and it establishes the necessity for any
counseling or coordination of care. Documentation in the
medical record should include terms or phrases such as
Q Stable
Q Recovering
Q Responding poorly
Q Significant complication(s)
Q Unstable
Q Life-threatening problem
7. Time
The inclusion of time in the definition of the levels of
E/M services should be recognized as representing aver-
ages, and therefore this component represents a range of
times that may be higher or lower, depending on actual
clinical circumstances.
All three key or essential components are required for the
following:
Q Initial hospital care
Q Emergency department
Q Office—new patient
Q Evaluations
Q Treatment
Lesson 2 133
It’s also important to understand that within each category the
levels aren’t the same. For example, code 99202—New Patient—
requires the documentation of all three key components:
(1) an expanded problem-focused history; (2) an expanded
problem-focused examination; and (3) straightforward
medical decision-making level.
Code 99212—Established Patient—requires two of the three
key components: (1) a problem-focused history; (2) a problem-
focused examination; and (3) straightforward medical
decision making.
Inpatient Consultations
Inpatient consultations are normally coded to the code set
99251–99255. Now, the consultant should use the code set
99221–99223—initial hospital care. An admitting physician
would use these codes for the initial admission encounter
for a patient. Normally, these codes are used only once per
admission and only to admit the patient. Now, to differentiate
between the admission encounter and any subsequent con-
sultations, the admitting physician is required to append a
new modifier—AI—to these codes. Consultants don’t append
any modifiers to these codes when they’re used to represent
consultations on an inpatient. However, it’s important that
Lesson 2 135
consultants identify their specialties on their claims, because
multiple claims carrying the code set 99221–99223 won’t be
denied, but inquiry is possible if it’s not clear that these con-
sultations were done by separate specialties. If the admitting
physician doesn’t append the modifier, any subsequent claims
submitted for that admission with these initial codes on them
will be subject to review.
Outpatient Consultations
Outpatient consultations for Medicare should now be coded
to the appropriate new patient (99201–99205) or established
patient (99212–99215) E/M encounters. No modifiers are
needed for any of these codes to indicate that they’re
consultations.
Ramifications
Some physicians are concerned about the lower reimburse-
ment rates associated with the codes to be substituted for
consultation codes. CMS has raised the reimbursement for
all of these codes, but minimally, so they still don’t compete
with the past rates reimbursed for consultations. Practices
with high rates of consultations are facing significant reduc-
tions in revenue. Of course, we have yet to see if other
insurance companies will follow the lead of CMS, as they
usually do. Before that happens, however, another problem
has yet to be worked out. What happens for inpatients with a
commercial secondary payer? If a consultant codes an initial
visit for a consultation, as required by Medicare, and the sec-
ondary carrier doesn’t recognize this process, the secondary
payment (20 percent of the total) will likely be denied for all
consultations. This will have to be written off by the physi-
cian or billed to the patients, depending on the requirements
of the secondary insurance. Neither option is likely to be pop-
ular. This issue will be interesting to follow in the coming
years, and it will impact the work you’ll be doing as you
become a coder.
Now let’s practice the principles for this section. Proceed to
the practical coding exercise for more information.
In your Clinical Coding Workout: Practice Exercises for Skill Development, complete exercises
2.23–2.43, “Evaluation and Management (E/M) Services,” starting on page 47. When you’re
finished, check your answers at the back of this study guide. Once you’re confident you under-
stand the coding principles for this section, move on to the next section.
Code Modifiers
Modifiers are two-digit alphanumeric, numeric, or alpha NOTES:
codes that are appended to the end of HCPCS Level I (CPT) Appendix A in the CPT
and HCPCS Level II codes. A modifier indicates that a service or coding book provides a
procedure was altered by specific circumstances. Modifiers are list of currently used
modifiers for both
reported only by physicians and Medicare Part B providers—
HCPCS Level I (CPT)
and not by hospitals. The use of modifiers allows more specific
and HCPCS Level II.
and accurate reporting. In many cases, modifiers allow physi-
cians to bill for the additional charges that are represented. HCPCS Level II modi-
fiers may be used with
Modifiers for HCPCS Level I (CPT) are two-digit numeric
any level of HCPCS
codes. Examples of CPT (HCPCS Level I) modifiers include
codes.
the following:
Q -25—Significant, separately identifiable evaluation and You’ll learn more
about HCPCS Level II
management service by the same physician on the same
modifiers in the next
day of the procedure or other service
section.
Q -50—Bilateral procedure
Lesson 2 137
Reasoning. 19100 is the CPT (HCPCS Level I) code for the
breast biopsy. The modifier -50 indicates that the procedure
is bilateral.
HCPCS Level II modifiers are either alphanumeric or two letters.
Examples of HCPCS Level II modifiers include the following:
-RC—Right coronary artery
-RT—Right side (used to identify a procedure performed
on the right side of the body)
-T1—Left foot, second digit
Modifiers are important to ensure appropriate and timely
NOTE:
payment. If you understand when and how to use them,
Appendix A of the CPT you’ll likely reduce the problems caused by third-party payer
manual contains a denials and also help expedite the processing of claims.
comprehensive list of
the Level I modifiers It’s important to note that modifiers can’t be used with all
with definitions for HCPCS codes. For example, some modifiers may be used only
correct use. Use of the with E/M codes (for example, -24 or -25), and others are
CPT guidelines and
used only with procedure codes (for example, -58 or -79). At
Appendix A is critical
to the appropriate use the beginning of each section of the CPT, guidelines appear
of modifiers. that list or describe the modifiers that may be used with the
codes in that section.
outpatient services.
Example. Patient received bilateral reduction of inguinal
hernia as a hospital outpatient.
Procedure Codes
49505-50 (Physician claim)
49505, 49505 (Hospital claim)
Lesson 2 139
Reasoning
49505-50 is reported on the physician claim with the –50
to indicate the bilateral procedure.
49505 is coded twice on the hospital claim to indicate
that the procedure was performed bilaterally.
Now let’s practice the principles for this section. Proceed to
the practical coding exercise for more information.
Practice Exercise 7B
Books Needed:
In your Clinical Coding Workout: Practice Exercises for Skill Development, complete exercises
2.362–2.381, “Modifiers,” starting on page 78. When you’re finished, check your answers at the
back of this study guide. Once you’re confident you understand the coding principles for this
section, move on to the next section.
1. Code series 90476–90749 for active and passive For Medicare cases, the
appropriate Level II
immunization.
HCPCS code list is also
2. For procedures requiring prolonged intravenous infusion required for identifica-
tion of a specific drug.
with the presence of a physician, code 96365 (first hour
For other payers, code
of infusion) and 96366 (each additional hour up to eight
99070 may be used.
hours). Codes 96367–96371 are other specific infusion
codes. Shunts, cannulas,
and fistulas for hemo-
3. Therapeutic or diagnostic injections should be coded to
dialysis are coded to
series 96372–96379.
the surgery section.
4. Code psychiatric services to series 90801–90899.
The definitions for
5. Services related to end-stage renal disease, hemodialysis, new and established
and peritoneal dialysis should be coded to series 90935– patients apply for
90999. ophthalmologic codes.
9. Code 99070 can be used for physician supplies and For Medicare cases, a
materials. more specific code may
exist in the HCPCS
Level II codes for
HCPCS Level I (CPT) Anesthesiology reporting the supply.
Lesson 2 141
General Guidelines
1. Anesthesia services are reported based on time. Time
begins when the anesthesiologist begins preparing the
patient to receive anesthesia and ends when the anes-
thesiologist is no longer in personal attendance.
2. All anesthesia services require a physical status modifier.
This modifier indicates the patient’s condition at the time
of anesthesia and identifies the complexity of services
provided.
3. Report a qualifying circumstance as an additional code
NOTES:
when anesthesia services are provided during situations
Conscious sedation or circumstances that make the administration of anes-
codes are found in thesia more difficult.
the “Medicine Section”
of the CPT manual Example. Anesthesia for total knee replacement for
and aren’t reported in 72-year-old patient with mild systemic disease.
conjunction with
anesthesia codes. Codes
Procedures marked
01402-P2—Anesthesia for open procedures on knee
with include con-
joint; total knee arthroplasty (physical status modifier)
scious sedation, so
it can’t be coded 99100—E/M code for anesthesia for patient of extreme
separately.
age, that is, under 1 year and over age 70
Q -23—Usual anesthesia
Q -32—Mandated services
Q -51—Multiple procedures
Q -53—Discontinued procedure
The modifiers listed here are those most commonly used with
anesthesia. This doesn’t mean that coders can’t assign other
appropriate modifiers with anesthesia codes.
Practice Exercise 7C
Books Needed:
In your Clinical Coding Workout: Practice Exercises for Skill Development, complete exercises
2.44–2.63, “Anesthesia Services,” starting on page 50. When you’re finished, check your
answers at the back of this study guide. Once you’re confident you understand the coding
principles for this section, move on to the next section.
Q Radiation Oncology—77261–77799
Q Nuclear Medicine—78000–79999
Lesson 2 143
Modifiers Commonly Used with Radiology
Q -22—Unusual procedural services
Q -26—Professional component
Q -51—Multiple procedures
Q -52—Reduced services
Q -53—Discontinued procedures
The modifiers listed here are those most commonly used with
radiology. This doesn’t mean that coders can’t assign other
modifiers with radiology codes.
NOTES:
Radiologic Supervision and Interpretation
Q Iohexol
Q Iopamidol
Q Hypaque
Q Renografin
Q Angiography
Q Cystogram
Q Intravenous pyelogram
Q Urogram
Q Lymphangiography
Q Cholecystogram
Lesson 2 145
Diagnostic Ultrasound
Diagnostic ultrasound procedures use high-frequency sound
waves to visualize internal structures of the body. They’re
commonly performed for evaluation of the abdomen, pelvis,
and heart. These procedures cover codes 76506–76999 by
anatomic site. When looking up diagnostic ultrasound proce-
dures in the CPT coding book index, reference terms like
ultrasound or echocardiography.
Radiation Oncology
Radiation oncology, codes 77261–77799, is the medical field
in which radiation is used to treat diseases like tumors and
malignancies. Some of these conditions are
Q Neoplastic tumors
Q Hodgkin’s disease
In your Clinical Coding Workout: Practice Exercises for Skill Development, complete exercises
2.292–2.312, “Radiology Services,” starting on page 71. When you’re finished, check your
answers at the back of this study guide. Once you’re confident you understand the coding
principles for this section, move on to the next section.
Q -32—Mandated services
Q -52—Reduced services
Q -53—Discontinued procedures
Lesson 2 147
The modifiers listed here are those most commonly used with
pathology and laboratory. This doesn’t mean that coders can’t
assign other modifiers with codes from this section.
Laboratory Services
Medicare and CMS have often changed the rules surrounding
the coding and billing of laboratory services. As a result, even
if you aren’t a new coder, you may have some questions
about choosing the appropriate codes. Here are some general
guidelines for coding laboratory physician services:
Pathology Services
Surgical pathology, codes 88300–88399, involves specimens
(tissues or samples) that are taken from a patient during
surgery and examined for diagnosis. When two or more speci-
mens are obtained from the same patient, use separate codes
to report the specimens.
Now let’s practice the principles for this section. Proceed to
the practical coding exercise for more information.
In your Clinical Coding Workout: Practice Exercises for Skill Development, complete exercises
2.313–2.336, “Pathology/Laboratory Services,” starting on page 73. When you’re finished,
check your answers at the back of this study guide. Once you’re confident you understand the
coding principles for this section, move on to the next section.
Lesson 2 149
Assignment 7 Quiz
40952200
Books Needed:
Directions: Each lesson quiz is divided into two parts. Part A is multiple-choice coding
questions, whereas Part B requires you to code the information from a coding scenario
found in your Clinical Coding Workout: Practice Exercises for Skill Development book.
Complete all required and relevant codes for each given scenario. When you’re comfortable
with your answers for both parts, submit this quiz to your instructor for grading.
1. Which of the following is the correct set of coding guidelines that physicians are
required to report?
A. ICD-9-CM codes for diagnoses and HCPCS codes for procedures and services
B. ICD-9-CM codes for diagnoses, HCPCS and ICD-9-CM codes for procedures
C. Only HCPCS and ICD-9-CM procedure codes
D. Only HCPCS procedure and service codes
2. In a physician’s office, coding and billing is done for which of the following categories?
3. A significant portion of the services that physicians provide are reported by _______ codes.
A. E C. E/M
B. V D. Q/T
(Continued)
5. Using two or more codes when one code would be sufficient to represent all services is an
example of
6. A Medicare patient had a benign lesion measuring 0.5 cm removed from his back at his
physician’s office. Which of the following codes is correct?
A. 17000 C. 11600-57
B. 11400-57 D. 11400
7. What is the proper modifier to use for referring to services performed by a physician who
repaired a broken leg and a broken arm at the same operative session?
A. -51 C. -62
B. -59 D. -77
8. Which code is appropriate for a radiologist’s report on a 23-year-old patient who had an X-ray
of the left and right forearms?
9. How does a physician ensure that each laboratory test performed in his/her office is
reimbursed?
10. What is the correct code for IV infusion for therapy/diagnosis, administered by physician or
under direct supervision of physician—up to one hour?
A. 96365 C. 90782
B. 90779 D. 90783
(Continued)
Lesson 2 151
Assignment 7 Quiz
40952200
Part B: Complete the following exercises in your Clinical Coding Workout: Practice
Exercises for Skill Development workbook.
Exercises
NAME ________________________________________________________________
ADDRESS ________________________________________________________________
CITY ________________________________________________________________
STATE/PROVINCE ZIP/POSTAL CODE
Part A
CUT ALONG THIS LINE
1. A B C D 6. A B C D
2. A B C D 7. A B C D
3. A B C D 8. A B C D
4. A B C D 9. A B C D
5. A B C D 10. A B C D
Part B
6.1 ___________________________________________________________________
6.6 ___________________________________________________________________
6.11 ___________________________________________________________________
6.16 ___________________________________________________________________
6.23 ___________________________________________________________________
6.28 ___________________________________________________________________
6.33 ___________________________________________________________________
6.38 ___________________________________________________________________
6.41 ___________________________________________________________________
6.53 ___________________________________________________________________
Introduction
Level II codes are five-digit alphanumeric codes that describe
products, supplies, and services not included in the HCPCS
Level I (CPT) codes. Level II codes include items and services
such as
Q Ambulance services
Q Prosthetics
Q Orthotics
Q Pharmaceuticals
Q Supplies
Q Procedures
Q Tests
Q J9190—Fluorouracil, 500 mg
Lesson 2 155
NOTE: HCPCS Level II Sections
All codes beginning HCPCS Level II codes are broken into sections based on the
with D are dental alpha character at the beginning of the code. These sections
codes copyrighted include the following:
by the American
Q A codes: A0021–A9999—Transportation services,
Dental Association.
including ambulance, chiropractic, medical and surgical
The HCPCS Level II supplies, and miscellaneous
codes aren’t found in
Q B codes: B4034–B9999—Enteral and parenteral therapy
the CPT book. If you
haven’t already done Q C codes: C1178–C1900—Pass-through items used only
so, you can download
by hospital outpatient claims
these codes from the
CMS Web site. You’ll Q D codes: D0120–D9999—Dental procedures
find directions for the
download process in a Q E codes: E0100–E8002—Durable medical equipment
later section.
Q G codes: G0008–G8628—Procedures/professional ser-
vices (not found in CPT); G9001–G9143—Coordination of
care/demonstration project items and services
Lesson 2 157
NOTES: Types of Temporary HCPCS Codes
C codes are used C codes are for items that could be billed under the hospital
exclusively for HOPPS outpatient prospective payment system (HOPPS).
purposes and are valid
only for Medicare G codes are used to identify professional health care procedures
claims submitted by and services that should be added to Level I (CPT).
hospital outpatient
Q codes identify services that are needed for claims processing
departments.
but wouldn’t be classified as Level I (CPT) and aren’t identified
The Medicaid program by Level II.
also uses these codes, K codes are used by the durable medical equipment regional
but they’re not payable
carriers (DMERCs) when the currently existing permanent
by Medicare.
Level II codes don’t include the codes needed to implement a
T codes aren’t used DMERC medical review policy.
by Medicare but can S codes are used by private insurers to report drugs, serv-
be used by private
ices, and supplies for which there are Level II codes, but for
insurers.
which codes are needed by the private sector to implement
Level II modifiers apply policies, programs, or claims processing for private insurance
whether Medicare is processing.
the primary or
H codes are used by those state Medicaid agencies that are
secondary payer.
mandated by state law to establish separate codes for identifying
mental health services such as alcohol and drug treatment
services.
T codes are used by state Medicaid agencies to establish
codes related to items for which there are no permanent Level II
codes and for which codes are necessary to meet a national
Medicaid program operating need.
Code Modifiers
Level II HCPCS modifiers are either composed of alphanumeric
characters or two alpha characters. When coding Medicare
cases, HCPCS Level II modifiers may be used with Level I
(CPT) or Level II HCPCS codes. If more than one Level II
modifier applies, the HCPCS code is repeated on another line
with the additional and appropriate Level II modifier.
Example. Code 26010—drainage of finger abscess; simple; on
the left thumb and second finger—would be coded as follows:
26010-FA
26010-F1
Lesson 2 159
4. Click Open on the pop-up box.
5. Double-click on 11anweb_V3.xls (an Excel file) or
11anweb_V3.txt (a text file) to read the codes.
6. Repeat these steps to download the 2011 Alpha-
Numeric Index (PDF, 166KB) and the 2011 Table of
Drugs.
The guidelines for assigning HCPCS Level II codes from a
HCPCS Level II coding book are basically the same as the
guidelines for using your CPT coding book. When assigning
HCPCS Level II codes from a HCPCS Level II book, you
should follow the following basic steps:
1. Identify the services and/or procedures the patient
received.
2. Look up the appropriate term in the Index.
3. Note the code from the Index.
4. Locate the code in the appropriate section.
5. Determine if modifiers should be assigned with the code.
Practice Exercise 8A
Books Needed:
HCPCS Level II list from the CMS Web site (see download directions on page 159)
Complete exercises 3.1–3.10, “Drugs,” starting on page 85 of your Clinical Coding Workout:
Practice Exercises for Skill Development. Please note that for J codes, the workbook uses
generic names for drugs, whereas the HCPCS code list uses generic drug names. Thus, when
you work on these exercises, you’ll need a reference source for cross-checking (for example,
the Internet, Physicians’ Desk Reference). When you’re finished, check your answers at the
back of this study guide. Once you’re confident you understand the coding principles for this
section, move on to the next section.
NOTE:
Coding HCPCS Level II Supplies A good rule of thumb
to remember when
Medical and surgical supplies are covered under HCPCS coding HCPCS Level II
Level II series codes A4206–A8999. An example of a medical/ supplies is: If the
surgical supply may be a sterile needle (A4215). Coding sup- physician’s office pro-
vides additional
plies can be a tricky and confusing process because many
supplies when perform-
supplies are included within the code for the office visit or ing a procedure (that
the procedure performed. is, above and beyond
the supplies customar-
Payment for many physician office medical supplies is consid-
ily used for the type of
ered included in the allowable amount for the service being procedure), then a
billed to Medicare and other insurers using the Medicare fee HCPCS Level II code
schedule. Separate payment for supplies used incidental to should be assigned to
the physician’s service may be made by some payers if you report the proper use
of resources and for
use CPT code 99070 (supplies and materials provided by the
the physician to
physician over and above those usually included with the receive proper
office visit or other services rendered) or A4550 (surgical trays). reimbursement.
Lesson 2 161
NOTE: Billing for Surgical Trays (HCPCS A4550)
Medicare doesn’t allow For certain procedures, billing for supplies in addition to
separate payment for the procedure itself is allowed. When a separate payment is
supplies or surgical allowed, use HCPCS code A4550 for a surgical supply tray
trays.
used during the course of a procedure. Only one tray can be
billed for regardless of the number used.
Now let’s practice the principles for this section. Proceed to
the practical coding exercise for more information.
Practice Exercise 8B
Books Needed:
HCPCS Level II list from the CMS Web site (see download directions on page 159)
In your Clinical Coding Workout: Practice Exercises for Skill Development workbook, complete
exercises 3.11–3.20, “Supplies,” starting on page 86. When you’re finished, check your answers
at the back of this study guide. Once you’re confident you understand the coding principles for
this section, move on to the next section.
Q -R: Residence
Lesson 2 163
NOTES:
Paramedic Intercept (PI). PI provides ALS services to a
patient who has been transported by ambulance staffed by
Sometimes fixed-wing personnel not qualified to administer such services.
air ambulance may be
necessary because the Fixed-Wing Air Ambulance (FW). This level of service is
geographic point of provided when the patient’s medical condition is so severe
pickup is inaccessible that transportation by either basic or advanced life support
by land vehicle; in
ground ambulance isn’t appropriate.
other situations, great
distances or other
obstacles make fixed- Rotary Wing Air Ambulance
wing air ambulance
necessary. Rotary-Wing Air Ambulance (RW). Provided when the
patient’s medical condition is such that transportation by
Rotary-wing air either basic or advanced life support ground ambulance isn’t
ambulance may be
appropriate.
necessary when the
point of pickup is Now let’s practice the principles for this section. Proceed to
inaccessible by land the practical coding exercise for more information.
vehicle; in other situa-
tions, great distances
or other obstacles
make rotary-wing air
ambulance necessary.
Practice Exercise 8C
Books Needed:
HCPCS Level II list from the CMS Web site (see download directions on page 159)
In your Clinical Coding Workout: Practice Exercises for Skill Development workbook, complete
exercises 3.21–3.30, “Ambulance,” starting on page 87. When you’re finished, check your
answers at the back of this study guide. Once you’re confident you understand the coding
principles for this section, move on to the next section.
Practice Exercise 8D
Books Needed:
HCPCS Level II list from the CMS Web site (see download directions on page 159)
In your Clinical Coding Workout: Practice Exercises for Skill Development workbook, complete
exercises 3.31–3.40, “Durable Medical Equipment,” starting on page 88. When you’re finished,
check your answers at the back of this study guide. Once you’re confident you understand the
coding principles for this section, move on to the next section.
Lesson 2 165
Coding HCPCS Level II
Procedures/Services
G0008–G9142 are temporary codes that cover procedures and
professional services. Other outside factors that influence
coding assignments are the transmittals and program memos
that the CMS issues on a regular basis. These codes are often
changed to CPT codes within a given time period and should
be reviewed and updated annually. The codes often include
coding guidance, instructions on the use of temporary
HCPCS Level II G codes versus CPT procedure codes, and
documentation criteria that must accompany claims.
Now let’s practice the principles for this section. Proceed to
the practical coding exercise for more information.
Practice Exercise 8E
Books Needed:
HCPCS Level II list from the CMS Web site (see download directions on page 159)
Books Needed:
Directions: Each lesson quiz is divided into two parts. Part A is multiple-choice coding
questions, and Part B requires you to code the information from a coding scenario found in
your Clinical Coding Workout: Practice Exercises for Skill Development book. Complete all
required and relevant codes for each given scenario. When you’re comfortable with your
answers for both parts, submit this quiz to your instructor for grading.
1. Which of the following would be coded within the HCPCS Level II series code range of
A4206–A8004?
2. HCPCS Level II drugs are listed mainly in which of the following coding sections?
A. A codes C. J codes
B. F codes D. Q codes
Lesson 2 167
Assignment 8 Quiz
40952300
5. An ambulance picks up a patient at her sister’s house. Which of the following is the correct
modifier for this type of service?
A. -H C. -R
B. -P D. -RH
7. What is the corresponding HCPCS Level II code for HCPCS Level I code 96360?
A. S9373 C. S9376
B. S9374 D. S9375
8. In what category do you code administration of Procrit if not identified by Levels I or II?
A. A codes C. J codes
B. G codes D. Q codes
9. Which of the following is the HCPCS Level II code for a single-use chemotherapy pump?
A. E0781 C. A9270
B. G0361 D. 99070
10. Which of the following is a true statement about HCPCS Level II supplies?
A. They’re often included within the procedure code.
B. They’re always coded separately.
C. They’re covered under “unlisted” procedure codes.
D. They’re covered under HCPCS Level I.
(Continued)
Assignment 8 Quiz
40952300
Part B: Complete the following exercises by using the appropriate codes. Report the codes
on your answer sheet.
Directions: Code only the HCPCS Level II code or codes (plus modifiers, if applicable) for
each example. Use the lists that you downloaded from the CMS.
2. Five surgical team members meet with the patient to determine a treatment course
5. Gastrostomy tubing
7. Psychiatrist screens a patient to determine eligibility for an alcohol and drug program
Lesson 2 169
NOTES
NAME ________________________________________________________________
ADDRESS ________________________________________________________________
CITY ________________________________________________________________
STATE/PROVINCE ZIP/POSTAL CODE
Part A
CUT ALONG THIS LINE
1. A B C D 6. A B C D
2. A B C D 7. A B C D
3. A B C D 8. A B C D
4. A B C D 9. A B C D
5. A B C D 10. A B C D
Part B
1. _________________________________________________________
2. _________________________________________________________
3. _________________________________________________________
4. _________________________________________________________
5. _________________________________________________________
6. _________________________________________________________
7. _________________________________________________________
8. _________________________________________________________
9. _________________________________________________________
10. _________________________________________________________
1. The HCPCS Level I codes used by all specialties no matter the location are included in
code category ranges
A. 00100–01999.
B. 10040–69990.
C. 99201–99499.
D. 90281–99199.
2. A patient was seen due to continuing congestion and sniffling. She complained of
pressure when breathing through her nose. The physician documented a diagnosis of
edema of nasal mucosa likely due to allergic rhinitis and performed rhinoscopy. The
coder codes 478.25, 31231, 21.21. This patient was most likely seen in what setting?
A. Inpatient
B. Outpatient surgical unit
C. Physician office
D. Need more information
173
5. A physician excised a 3.5 cm benign lesion from an outpatient’s scalp. Code:
A. 11421
B. 11422
C. 11423
D. 11424
6. Which of the following scenarios would require the assignment of both a HCPCS Level I
and Level II code?
A. Injection of Botulinum toxin type A, per unit
B. Appendectomy with anesthesia
C. Review of HIV test
D. Hernia repair with mesh
9. Which of the following is the correct modifier to use when 97112 and 97116 are
both billed?
A. -20
B. -59
C. -76
D. -80
Check your answers with those on page 231 of this study guide.
Appendix A
Read pages ii–x in your ICD-9-CM coding book.
Introduction
As you learned in Medical Coding 1, accuracy and consistency
is the cornerstone to successful coding. To be accurate and
consistent, a coder must follow specific guidelines and rules.
In 2009, CMS reported that more than $24.1 billion was paid
in error by just federal government health care plans, which
was almost double the error rate from 2008. Some of these
errors are due to errors in coding and DRG assignments.
In the next few sections you’ll be reviewing basic coding
guidelines and building on what you’ve learned in Medical
Coding 1. You’ll also be exposed to additional guidelines that
may be new to you. In this course you’ll focus on more
advanced inpatient coding and also on some additional
aspects of outpatient and physician office coding.
Let’s get started!
Coding Classifications
As you know, coding is an assignment of numerals (and some-
times alpha letters) that correspond with a patient’s diagnoses
and procedures. You may be wondering who came up with
these numeric codes for the diagnoses and procedures. It isn’t
just a random assignment of numbers. It’s an organized
method and classification system.
177
There are several coding classification systems that include
the following:
International Classification of Diseases, 9th Revision,
Clinical Modification.
This coding classification system is commonly known as
ICD-9-CM (often called ICD-9 or I-9 by those in the coding
business). ICD-9-CM is used to code diagnoses and procedures
for hospital patients report diagnoses and reasons for visits
in physician offices.
The ICD-9-CM codes contain two or three digits that may be
followed with a decimal point and then either one or two more
digits. Here are examples of what ICD-9-CM codes look like:
NOTE: ICD-9-CM diagnosis codes—250.00, 486, 315.4
It’s not important for ICD-9-CM procedure code—80.51
you to understand
what each of these HCFA Common Procedure Coding System—This coding
codes means at this classification system is commonly known as HCPCS (often
point. Right now you
should just know pronounced “hic-pics”). Several different levels exist within
what the ICD-9-CM the HCPCS classification system. The most commonly used
codes look like. level is the Level I Current Procedural Terminology, or CPT,
level. The CPT level codes are published by the AMA. These
codes are five-digit numeric codes used to describe the
procedures and services from providers, especially from
physician offices and in outpatient settings.
Here are some examples of what CPT codes look like: 49605,
61711, 89320, 93922. Notice that CPT codes are written dif-
ferently than ICD-9-CM codes. Remember, CPT codes are five
digits with no decimal points. You may be wondering what
the difference is between ICD-9-CM codes and CPT codes.
Don’t they both assign numeric codes to diagnoses and pro-
cedures? The answer is yes and no.
178 Appendix A
Some important points to remember are
Q ICD-9-CM codes are both diagnosis and procedure codes,
but the procedure codes are used only for inpatient hos-
pital settings.
Appendix A 179
NOTES: Coding Example Using the CPT
Notice that in the in- Coding Classification System
patient example there
were only ICD-9-CM for an Outpatient Surgery
codes assigned (and
no CPT codes). A patient received an outpatient laparoscopic cholecystec-
Remember, CPT (or tomy for cholecystitis.
HCPCS Level I) codes
are procedure codes Cholecystitis—principal diagnosis ICD-9-CM code 575.0
that are assigned to
Laparoscopic cholecystectomy—ICD-9-CM code 51.23, CPT
outpatient cases.
ICD-9-CM codes are
procedure code 47562
both diagnosis and
procedure codes. For
the inpatient case Assigning Codes to
there was no need for
CPT code assignment. Clinical Documentation
However, for the out-
patient surgery Assigning codes to clinical documentation can be a tricky
performed at the process. The following two elements are needed to code
hospital, the coder correctly:
reported the ICD-9-CM
diagnosis code, the Q Sharp coding skills
ICD-9-CM procedure
code, and the CPT Q Clear and concise clinical documentation
procedure code.
Coders can only apply a code to a diagnosis or procedure that’s
well documented in the patient’s medical record. CPT and
ICD-9-CM codes reported on the health insurance claim form
or billing statement must be supported by the documentation
in the medical record. Clear and concise medical record
documentation is crucial to arrive at the correct code. Medical
record documentation includes notations from physicians,
nurses, and other health care practitioners as well as results
of ancillary diagnostic and therapeutic procedures.
As discussed previously, ICD-9-CM codes are applied only to
those diagnoses and procedures that are shown to have
clinical significance as documented by the physician. It’s
imperative that physician documentation in the progress
notes address all pertinent diagnoses and procedures, includ-
ing any laboratory data and other diagnostic tests.
One of the biggest mistakes that new coders make is to code
everything that they see in the health record documentation.
There are precise coding guidelines that dictate what should
180 Appendix A
and shouldn’t be coded and reported based on setting (hospital,
outpatient, or physician office). For example, diagnosis coding
is often difficult because of the complexity of assigning precise
codes to the many diagnoses that may be listed and the correct
sequencing of diagnoses. The principles governing the correct
code assignment and sequencing are based on the American
Hospital Association’s (AHA) Coding Clinic guidelines. In
addition, the CMS, AHA, and AHIMA serve to provide guide-
lines and assistance with coding principles.
What does all of this mean? In short it means that coders must
follow specific guidelines for coding of diagnoses and proce-
dures that must be sequenced, or ordered, a certain way in
order for the hospital or organization to be reimbursed fully.
You’ll learn more about the importance of sequencing later.
Appendix A 181
HIPAA and Coding
The Administrative Simplification Section of the Health
Insurance Portability and Accountability Act (HIPAA) of 1996
required the Department of Health and Human Services to
name national standards for electronic transmission of health
care information including transactions and code sets. The
rule named HCPCS Levels I and II (including modifiers) as
the procedure code set for
Q Physician services
Q Radiologic procedures
UHDDS
The Uniform Hospital Discharge Data Set (UHDDS) definitions
are used by acute care short-term hospitals to report inpa-
tient data elements in a standardized manner. The UHDDS
182 Appendix
Appendix
A
requires that common data on individual acute care, short-
term hospital discharges in Medicare and Medicaid programs
be reported. Part of the current UHDDS includes the following
specific items pertaining to patients and their episodes of care:
Personal identification: The unique number assigned to
each patient that distinguishes the patient, and his or her
health record, from all others.
Date of birth
Sex
Race
Ethnicity
Residence: The zip code or code for foreign residence
Hospital identification: The unique number assigned to
each institution
Physician identification: The unique number assigned to
each physician within the hospital (the attending physician
and the operating physician [if applicable] are to be identified)
Disposition of patient: The way in which the patient left the
hospital—discharged to home, left against medical advice, NOTE:
discharged to another short-term hospital, discharged to a
Payers can deny
long-term care institution, died, or other
payment (or reim-
Expected payer for most of the bill: The single major bursement) based on
published lists of unap-
source the patient expects will pay for this bill (for example,
proved diagnoses
Blue Cross/Blue Shield, Medicare, Medicaid, workers’
(ICD-9-CM). This may
compensation) be due to the wrong or
outdated code being
used or may simply
Updating the Coding System be codes (diagnoses
or procedures) for
You may be wondering if, when, and how the ICD-9-CM coding which the payer
system gets updated. Because treatments change and new won’t reimburse.
Appendix A 183
An Entirely New Classification System?
AHIMA is currently working on transitioning to the ICD-10
classification system. Yes, that’s right, an update of the entire
system and not just specific codes! Let’s learn a little more about
ICD-10.
The Centers for Medicare and Medicaid (CMS, formerly known
as HCFA) is responsible for maintenance of the coding system
for reporting inpatient procedures for Medicare and Medicaid.
The current ICD-9-CM system was perceived as having limita-
tions. Because of those limitations, the CMS contracted with
the for-profit company 3M Health Information Systems and
AHIMA to develop a new procedure coding system to be used
with the forthcoming disease coding system, the International
Classification of Diseases, 10th Revision, Clinical Modification
(ICD-10-CM), being developed by the United States National
Center for Health Statistics.
Things are moving forward for the ICD-10-CM at a very fast
pace. The ICD-10-CM will be implemented in October 2013,
which means its use will be mandatory as of January 1, 2014.
Right now, 99 countries use the ICD-10-CM, and Europe and
Canada are preparing to move to the ICD-11-CM. Just a few
third-world countries and the United States aren’t yet using
it. We actually do use it to report morbidity and mortality,
but that’s all. The move to the system has been slow because
the other countries using it are under a single-payer system.
Moving one payer to using a new classification system is
easier than moving hundreds or thousands to using it at the
same time!
The format of the ICD-10-CM (or I-10) is similar to the ICD-9-
CM, but it’s hugely expanded. The ICD-9-CM is running out
of room, especially in Volume 3. The ICD-9-CM has a limit
of 10,000 codes in Volumes 1 and 2, and it’s almost at capac-
ity. Volume 3 of the ICD-9-CM has 13,500 codes. It contains
many duplicate codes and some outdated terminology. The
I-10 expands injury codes, E-codes, pregnancy codes, alcohol-
and substance-abuse codes, and postoperative complications.
The I-10 will contain greater specificity in these areas and
increase clinical language use. In addition, the I-10 will be
able to hold up to 120,000 codes, and it currently holds only
184 Appendix
Appendix
A
68,000. In the I-10, the rubrics (the three digit numbers) are
called “blocks.” There are more combination codes, but they
require better documentation. The codes consist of up to
seven characters, and the first characters are alpha charac-
ters, not numbers.
The United Kingdom and other countries have written a lot
about their experiences in transferring to this system, and
the United States is using those experiences to figure out
what to do. The United Kingdom obtained a minimum of 70
hours of training (per coder), and they felt this was inade-
quate. The national cost for training alone is estimated at
$100 million. In addition, productivity will be affected during
training, which will put a revenue crunch on offices and hos-
pitals temporarily during the transition. The U.S. Department
of Health and Human Services estimates that the implemen-
tation will cost an estimated $2.2 billion.
The ICD-10-PCS (Procedure Coding System) is being developed
by CMS as a replacement for the ICD-9-CM procedure codes
in Volume III. The ICD-10-PCS is an expandable code system
allowing for incorporation of new technology and procedures.
Introduction
As you can imagine, hospitals and physician offices are NOTE:
reimbursed for the services that they provide to patients. Because there’s an
But how? Let’s take a closer look, first starting with the way entire course dedicated
that hospitals are reimbursed for inpatients. Because many specifically to reim-
payers based their reimbursement systems on the Medicare bursement, you’ll
receive only a brief
systems, Medicare is the base point from which you’ll learn
overview of reimburse-
about these systems. ment in this course.
Medicare pays for hospital inpatient operating costs using a
per-discharge rate based upon the diagnoses and procedures
that best represent the patient’s clinical status. The payment
rate is represented by diagnosis-related groups (DRGs) that
vary in payment depending upon the complexity of the case.
Appendix A 185
For example, malignant breast disorders without complica-
tions are addressed by DRG 275, whereas malignant breast
disorders with complications and co-morbidities are addressed
by DRG 274.
Payments for hospital outpatient services are based on
Outpatient Prospective Payment System (OPPS) using
Ambulatory Payment Classifications (APCs). APCs are
clinically consistent groups that receive a defined payment.
Unlike DRGs, one visit can create multiple APCs.
Physician payments are based on the Resource Based
Relative Value Scale (RBRVS) fee schedule. In the RBRVS
system, payments for services are determined by the resource
NOTE:
costs needed to provide them. The cost of providing each
It’s important to service is divided into three components: physician work,
note that claims often practice expense and professional liability insurance. Payments
require the use of are then calculated by multiplying the combined costs of a
codes from multiple
service by a conversion factor (a monetary amount that’s
coding systems, and
coding requirements determined by CMS). Payments are also adjusted for geo-
will vary by payer. graphical differences in resource costs.
For example, hospital
outpatient claims to
Medicare Part A for
Inpatient Prospective Payment System
chemotherapy infusion
In response to the rising costs of health care services, the
require ICD-9-CM diag-
nosis codes, revenue federal government instituted a new reimbursement system
codes for pharmacy, in 1984. The federal government introduced a Medicare
and CPT or HCPCS prospective payment system (PPS) based on a classification
codes for the provider system called diagnoses related groups (or DRGs).
services, whereas a
pharmacy claim to The main goal of the program is to encourage hospitals under
Medicaid would only the Medicare program to reduce hospital costs. The prospective
require NDC codes payment system is set up to reimburse the provider (for
and, in some cases,
example, hospital) based on a fixed reimbursement amount
a diagnosis code.
determined before the services are rendered.
You may be wondering how a reimbursement amount can be
determined before a patient receives services. Reimbursement
amounts under this prospective payment system are based
on a set formula for the number of days a patient is in the
hospital and the amount of resources that should be used to
treat a patient with a particular illness or injury. The amount
from this formula is then paid to the hospital regardless of the
actual costs of the services. This means that if the hospital
uses more resources than is anticipated then they’ll lose
186 Appendix
Appendix
A
money. It also means that if the hospital uses fewer resources,
then the hospital will make money. The reimbursement
amount is fixed and the provider will receive that amount
and nothing more or less.
The prospective payment system was a key factor in changing
the way hospitals and physicians provide services. This new
reimbursement system brought about changes in not only
hospitals, but also the medical and health care industry as
a whole. Health care facilities began to operate much more
efficiently. Many other insurance providers (other than
Medicare) have instituted a reimbursement model based on
the Medicare prospective payment system.
Appendix A 187
Physician Office Reimbursement
Physicians receive reimbursement based on something called
usual, customary, and reasonable (UCR) charges. These are
charges for health care services that are based on the physi-
cian’s usual charge for the service (“usual”), the amount that
other physician in the area charge (“customary”), and whether
the amount charged is reasonable for the service (“reasonable”).
Physicians may also be reimbursed based on fee-for-service.
This is a method by which a physician or provider bills for
each service or visit instead of on a prepaid or all-inclusive
basis. The services are usually reimbursed according to a fee
schedule (at a set amount) or at a discount from the physi-
cian’s charges.
RBRVS stands for Resource-Based Relative Value Scale. This
system assigns three values to each procedure code based on
Q The amount of work
Q Practice expense
Claim Forms
You may be wondering how hospitals or physicians actually
report the codes in order to receive reimbursement. Many
institutes now have an electronic means of reporting codes
to payers. Coders code directly into a computerized system,
referred to as an encoder. The encoder software system helps
to assign diagnosis and procedure codes and the appropriate
188 Appendix
Appendix
A
reimbursement value. For example, if the patient is an inpa-
tient, it may assign a Diagnosis Related Group (DRG) for
payment. The information is later transmitted to the insurance
company or payer. Even if the information is transmitted elec-
tronically, it still must be in a particular format. To ensure
this format, institutes are required to report information
using special forms known as claim forms.
According to the CMS, in 1975, the National Uniform Billing
Committee (NUBC) was established with the goal of develop-
ing an acceptable, uniform bill that would consolidate the
numerous billing forms hospitals were required to use.
In 1982, the Uniform Bill-82 (UB-82), also known as the
HCFA-1450 form, was implemented for use in billing services
to Medicare fiscal intermediaries and other third-party payers.
In 1998, the NUBC began preparations for a revised uniform
bill. The resulting Uniform Bill-92 (UB-92) was implemented
in October 1993 and provided for the collection of additional
statistical data, including clinical information.
The newest revision, UB-04, is currently in use and allows
hospitals to report ten diagnosis codes (nine diagnosis fields
and one E code field) and six procedure codes. Although the
billing office collects data for the billing form, the health
information department supplies the clinical data placed on
the form and thus must ensure the data’s accuracy. An alter-
nate name for the UB-04 is CMS-1450.
CMS-1500
The claim form used by physicians in their offices.
Appendix A 189
NOTES
190 Appendix
Appendix
A
CODING REVIEW
Appendix B
Read the Coding Guidelines, pages 1–5 (stop at C: Chapter-
specific Coding Guidelines on page 5) at the front of your
ICD-9-CM coding book.
191
Do you know which are diagnosis and which are procedure
codes? Remember, ICD-9-CM diagnosis codes always have three
digits (and then possibly a decimal point followed by one or
two more digits), whereas ICD-9-CM procedure codes have
two digits before the decimal point (followed by either one or
two digits after the decimal point). Check your answers:
486 is a diagnosis code. It has three digits (and no
decimal point).
32.11 is a procedure code. It has two digits before the
decimal point.
404.10 is a diagnosis code. It has three digits before the
decimal point.
Each chapter in the ICD-9-CM coding book is structured
into subdivisions the same way. They’re categorized in the
following way:
Sections—groups of three-digit categories
Categories—three-digit code numbers
Subcategories—four-digit code numbers
Fifth-digit subclassifications—five-digit
code numbers
Let’s take a look at an example of the different categorizations.
192 Appendix
Appendix
B
Diagnosis and procedure codes were discussed in the previous
sections. One important area is the sequencing of diagnosis
codes. The way you list your codes when you’re reporting them
is very important and could mean the difference in thousands
of dollars in payment for the hospital or other health care
organization. A patient’s diagnoses may be assigned a special
category such as principal, secondary, or admitting diagnosis.
How a diagnosis is categorized will depend on how you
sequence, or the order in which you record them, for report-
ing purposes.
Let’s take a closer look at each of the diagnostic categories.
Principal Diagnosis
Principal diagnosis (abbreviated as PDX) refers to the condi-
tion established after study to be chiefly responsible for the
patient’s admission to the hospital. You may be wondering
what “after study” means in this description. This phrase
means that you must review the record documentation
thoroughly (“study”) to determine the principal diagnosis.
Here’s an example that may help you understand better.
Example of determining principal diagnosis. A patient
was admitted to the hospital with cough, chest pains, fever,
and chills. After further work-up, it was determined that the
patient had left lower lobar pneumonia. The pneumonia is
coded as the principal diagnosis because it’s the reason after
study that the patient was admitted. Even though the cough,
chest pain, and other symptoms prompted the patient to
come to the hospital, it was determined after work-up that
the cause of the symptoms was pneumonia. The selection of
principal diagnosis is determined by the circumstances of
admission, diagnostic workup, and/or the therapy provided.
The condition that best satisfies these three criteria is listed
as the principal diagnosis.
Appendix B 193
NOTE:
established and should relate to the chief complaint on
admission. If it’s unclear, the physician should be queried
As a coder, you must and the outcome should be corroborated with supporting
be careful and precise
documentation in the medical record.
in sequencing of codes.
A hospital can’t Sometimes when there are several (or many) codes, it may
sequence a code first be difficult to determine which code should be listed as the
(or as principal) just
principal diagnosis. When two or more diagnoses equally
because it reimburses
more money. This is
meet the criteria for principal diagnosis as determined by the
considered fraudulent circumstances of admission, diagnostic work-up, and/or
and may be punishable therapy provided, any one of the diagnoses may be sequenced
under penalties of law. first. For example, a patient presents with multiple problems:
A hospital or institute
shortness of breath, fever, and chest pain. Chest x-ray
will look to the coding
expert to ensure that
demonstrates an exacerbated CHF, examination reveals acute
diagnoses and proce- bronchitis, and prior history and current EKG findings are
dures are accurately consistent with unstable angina. The three conditions were
coded and sequenced treated with medications. All three diagnoses—CHF, acute
based on coding
bronchitis, unstable angina—equally meet the criteria for the
guidelines.
definition of principal diagnosis and the hospital can sequence
any one as the principal diagnosis. In this case, the hospital
will generally choose to list the code that reimburses the
most as the principal diagnosis.
Secondary Diagnoses
Other Diagnoses (ODX), also known as secondary diagnoses
or additional diagnoses, are conditions that either coexist at
the time of admission or develop subsequently and affect
patient care for the current hospital episode. Affecting patient
care signifies conditions requiring any of the following:
Q Clinical evaluation
Q Therapeutic treatment
Q Diagnostic procedures
194 Appendix
Appendix
B
Diagnoses that relate to a previous hospital stay and have NOTE:
no bearing on the current treatment shouldn’t be coded.
Some physicians may
Let’s take a look at a case example that includes secondary include these previous
diagnoses to help you understand better. diagnoses on the
patient’s discharge
Example of secondary diagnoses. A patient is admitted
summary. Even then,
with a cough, fever, and chills for the past four days. After those previous diag-
work-up, the patient is found to have pneumonia with under- noses not affecting the
lying chronic obstructive pulmonary disease (COPD). The current admission
patient is also on medication for chronic diabetes and suffered shouldn’t be coded
unless hospital policy
a fractured femur five years ago. The patient is treated with
states otherwise.
intravenous (IV) antibiotics, respiratory therapy, and continues
his medication for diabetes. On the third day, the patient
complains of chest pain. Tests confirm that the patient has
suffered a left anterior myocardial infarction. The secondary
diagnoses in this case are COPD, diabetes, and myocardial
infarction. Pneumonia is the principal diagnosis and is
sequenced (or listed) first when reporting the codes. The
fracture isn’t coded because it was an injury that occurred
previously and has no bearing on the current treatment.
Admitting Diagnosis
The admitting diagnosis is simply the diagnosis that brought
the patient into the hospital. Using the same example as
above, the patient’s admitting diagnosis may have been cough.
When tests were completed that confirmed the cough was due
to pneumonia, pneumonia then became the principal diagnosis;
however, cough still remains as the admitting diagnosis.
Primary Diagnosis
The primary diagnosis is used by the physician to describe
the diagnosis most often determined to be the most clinically
intense and isn’t often a term used by coding professionals.
Many times the primary diagnosis isn’t the same as the prin-
cipal diagnosis; however, many physicians and clinicians will
often (incorrectly) interchange the terms primary diagnosis
and principal diagnosis. For the purpose of coding, you need
to be concerned only with the principal diagnosis (and not
the primary diagnosis).
Appendix B 195
Principal Procedure
A principal procedure is a procedure that’s performed for
treatment of a disease/condition rather than performed for
diagnostic or exploratory purposes. If there are two or more
procedures performed on a patient then the one most closely
related to the principal diagnosis should be sequenced first.
Sequencing
Now that the categories have been described, look at an
example of how codes are sequenced—or listed—when reporting.
Example. A patient is admitted to the hospital due to severe
chest pain that ends up being an acute myocardial infarction.
The patient is also treated for uncontrolled Type 1 diabetes.
Codes
410.90—Acute myocardial infarction
250.03—Type 1 diabetes, uncontrolled
Reasoning
Even though the patient was admitted with chest pain,
NOTES:
after workup it was found to be a myocardial infarction
In an outpatient which is sequenced first as the principal diagnosis with
setting, the primary the uncontrolled diabetes listed second as a complication/
diagnosis, or what
co-morbidity that increases the DRG payment. If a coder
brought the patient
had incorrectly sequenced the chest pain as first, it may
to the encounter,
is sequenced first. have cost the hospital hundreds (or sometimes thousands)
of dollars in reimbursement payment.
There’s often more
information in the
tabular list that
Basic ICD-9-CM Coding Guidelines
doesn’t appear in the The guidelines discussed in this section will be used whenever
Alphabetic Index. This
you’re coding ICD-9-CM codes (inpatients, hospital outpatients,
information will help
you assign the most
and so forth). By following these guidelines, you’ll ensure that
accurate code. you’re assigning valid codes and sequencing properly.
1. Use both the alphabetic index and tabular list.
As discussed previously, you should never code from just
the Alphabetic Index in which you first look up the code.
To ensure correct coding assigning, look up the code in the
alphabetic index and verify the code in the tabular list.
196 Appendix
Appendix
B
2. Code to highest level of specificity. NOTE:
A coder must record the most accurate diagnosis and
Coding books will use
procedure codes. To do this, you’ll need to code to the the section symbol for
highest level of specificity. This simply means that when codes that require a
assigning diagnosis codes, assign a three-digit code only fifth digit. The section
when there’s no four-digit codes for that category, assign symbol looks like
this: §
a four-digit code only when there’s no five-digit code for
that category, and assign a fifth digit any time it’s available
as a subclassification.
The same principles apply for procedure codes (using
two-, three-, and four-digit codes).
3. Ensure that the use of residual codes is appropriate
and accurate.
Residual efffects are conditions that are produced after
the acute phase of an injury or illness. Residual codes
are codes that are classified as
NOS—Not Otherwise Specified
NEC—Not Elsewhere Classified
If documentation in the patient’s medical record doesn’t
document specifics, the coder should still review the
code category in the tabular list to determine if there’s a
better code (other than NOS or NEC categories). The NOS
code shouldn’t be assigned when a more specific code
exists. In some cases the coder will need to query the
physician for an addendum to documentation for the
more specific code.
4. Code unconfirmed or uncertain diagnoses as if confirmed.
Appendix B 197
There are some cases in which physicians are unsure of
the patient’s diagnoses, even at the time of discharge.
The physician may document these cases as
Q Possible
Q Probable
Q Suspected
Q Likely
Q Questionable
Q Rule out
198 Appendix
Appendix
B
6. Code acute and chronic conditions as determined in the NOTES:
alphabetic index/tabular list.
If a condition lists both
In some cases, the same condition may be described as acute and chronic at
both acute and chronic. Refer to the alphabetic index/ the same indentation
tabular list in your coding book for guidelines on the in the coding book
specific code. then both are coded
with the acute condi-
7. Code late effects only if an injury or illness has been resolved. tion sequenced first.
Appendix B 199
NOTES:
33.6 Combined heart-lung transplantation
Code also cardiopulmonary bypass [extracorporeal
In your coding book,
the additional proce- circulation][heart-lung machine] (39.61)
dure to be coded is Refer to page 105 in Volume 3 of your ICD-9-CM coding
enclosed in brackets
book to see this example.
like in this example.
9. Code canceled procedures with the appropriate V64 code.
Code V64 can’t be
assigned as principal
If a procedure has been canceled (after patient was
diagnosis. Instead, list admitted), then assign the appropriate V64 code to
the illness/injury for indicate the reason for cancellation. No procedure code
which the surgery was should be assigned.
planned as principal
and then V64.X as the 10. Code incomplete procedures to the extent the procedure
secondary diagnosis. was completed.
When a procedure has begun, but wasn’t completed (for
If the procedure doesn’t
involve incisions (for
whatever reason), use the following guidelines:
example, the proce- Q Incision only, code to incision site
dure was a reduction
of a fracture), then Q Endoscopy was unable to reach site, code endoscopy
no procedure code is
only
assigned. Instead, use
the appropriate V64 Q Cavity/space was entered, code to exploration of that site
code as the secondary
diagnosis.
200 Appendix
Appendix
B
As you probably remember from Medical Coding 1, the rules NOTES:
for coding HCPCS are a little different than coding ICD-9-CM.
The HCPCS index is a little more free form than the ICD-9-CM Coding directly from
the CPT index or the
index. The HCPCS index codes are tentative and need to be
ICD-9-CM index could
explored beyond the index. The tabular codes rule the coding result in the assignment
process in HCPCS, therefore a coder should never code straight of incorrect codes
from the index in the HCPCS book. Instead, after looking up and denial in
the code choice(s) in the index, the coder should then locate reimbursement.
the code in the tabular and use process of elimination (based
on coding guidelines) to assign the correct code. HCPCS versus CPT:
What’s the Difference?
According to the CMS, in 1996 under OBRA, or the Omnibus Level I codes are
Budget Reconciliation Act of 1986, the federal government usually referred to
simply as CPT codes
required reporting of outpatient visits using the system called
and Level II codes
HCPCS when billing for outpatient services for federally
are usually referred
funded patients. HCPCS was developed to support the need to simply as HCPCS
to bill for all services (not just those that fall within CPT codes or national codes.
classification).
HCFA (now CMS) developed a three-part system to standard-
ize coding used to process Medicare claims. It’s used for all
services: surgical, medical, supplies, materials, injections,
and so forth. The most commonly used level is the CPT, or
Current Procedural Terminology, level. According to the CMS,
approximately 80% of HCPCS can be coded using the CPT
level. CPT is the most known and used level of HCPCS codes.
Appendix B 201
NOTE: HCPCS Level I: CPT Codes
CPT doesn’t provide
codes for nonphysician
Introduction
procedures, services,
and specific supplies. The Physicians’ Current Procedural Terminology (CPT), pub-
lished (and updated) annually by the AMA, is a systematic
listing and coding of procedures and services performed by
physicians. The purpose is to provide a uniform language
that will accurately describe medical, surgical, and diagnostic
services. It also provides a reliable nationwide reporting and
communication method among physicians, patients, and
third parties.
Each CPT procedure or service is identified with a five-digit
code. The use of CPT codes simplifies the reporting of medical
service. Using this coding provides the physician or health
care professional a means of accurately recording the service.
Each section of the CPT book has introductory material that
contains important coding guidelines and information. Be
sure to read the introduction before coding from that section.
Specific guidelines are presented at the beginning of each of
the six sections. These guidelines define items that are neces-
sary to appropriately interpret and report the procedures and
service contained in that section. They also provide explana-
tions regarding terms that apply only to that particular section.
Within each section are headings and subheadings followed
by additional distinctive instructions and in some cases, a
unique narrative description of the technical process of
providing these procedures.
Although you’ll learn about some commonly coded—or
miscoded—guidelines in this lesson, it isn’t possible to cover
each and every guideline. Be sure to read the introductory
material at the beginning of each CPT code section.
HCPCS Level I (CPT) codes are numeric codes that represent
services provided by physicians and health care providers.
Level I codes are used to report hospital outpatient procedures
and physician office codes.
The layout and design of CPT is intended to provide quick
and easy location of services and procedure codes. The main
body of the manual is listed in six sections. Within each
202 Appendix
Appendix
B
section are subsections with anatomic, procedural, condition NOTES:
or description subheadings. The manual itself lists services
and procedures in numeric order with one exception—the You’ll learn more about
E/M codes in the CPT
entire evaluation and management (E/M) section has been
lesson.
placed at the beginning of the book for easy access.
Refer back to pages
Conventions and Formatting in CPT x–xiii in your CPT cod-
ing book if you need
(HCPCS Level I) more information on
how to use your CPT
There are certain formatting, conventions, characteristics,
coding book.
and symbols that you should understand in order to code
CPT correctly.
Semicolon
The semicolon is a normal semicolon that looks like this:
;
This is one of the most confusing format concepts. If a code
description contains a semicolon and there are one or more
code descriptions indented underneath then the description
before the semicolon is a home description and the indented
code needs the home description to fully complete the code
description.
Let’s take a look at a coding excerpt using a semicolon.
30150 Rhinectomy; partial
30160 total
If the physician documented that the patient had a total
rhinectomy, the correct code would be 30160. You would
never code 30150 and 30160 together because the rhinec-
tomy must be either partial or total, but couldn’t be both.
Bullet
The bullet symbol looks like this:
•
When it’s next to a code it means that the code is a new code.
Appendix B 203
Triangle
The triangle looks like this:
V
It means that the code is a revised code.
Facing Triangles
Facing triangles look like this:
cb
Facing triangles indicate that the text is either new
or revised.
Plus Sign
The plus sign looks like this:
+
The plus sign indicates that this is an add-on code and
should be used in conjunction with another code. For
example, 75968—transluminal balloon angioplasty, each
additional artery—must be used in conjunction with 75966—
transluminal balloon angioplasty.
Modifiers
Modifiers emphasize the difference between modifiers used
for hospital outpatients versus modifiers for physicians. CPT
coding books have a quick reference on the reverse of the
front page, and the full descriptions of modifiers are in
Appendix A.
Circle Symbol
The circle symbol looks like this:
;
It means that these codes are exempt from modifier -51.
204 Appendix
Appendix
B
HCPCS Level II: National Codes
HCPCS Level II codes, or national codes, are alphanumeric
codes developed by HCFA (CMS) to identify other services
(those not provided by a physician) that aren’t covered under
the CPT level. These were developed by HCFA as a second
level of codes, as CPT doesn’t contain all the codes needed to
report medical services and supplies. These codes are consid-
ered a permanent level, are maintained by the HCPCS
National Panel, and are updated by the CMS quarterly. This
panel is made up of representatives from the Blue Cross Blue
Shield Association (BCBSA), the Health Insurance Association
of America (HIAA) and CMS. This Panel is responsible for
making decisions about additions, revisions and deletions to
the national alphanumeric code system.
In contrast to the five-digit codes found in Level I (CPT) these
codes consist of one alphabetic character (a letter from A–V)
followed by four digits. (All D codes are copyrighted by the
American Dental Association.) HCPCS is grouped by the type
of service or supply they represent and are updated annually.
This coding system is also required for reporting most medical
services and supplies provided to Medicare and Medicaid
patients and by most third-party payers.
One of the most important elements of this coding system for
clinicians is the Level II modifiers.
These modifiers, which are either alphanumeric or two-letter
in the range from A1–VP, should be applied to the appropriate
CPT code to identify additional situations or circumstance.
The listing of one of these codes doesn’t assure coverage of
the specific item or service in a given case. To be eligible for
payment from Medicare, the item must be considered reasonable
and necessary. Examples include Supplies (durable medical
equipment such as wheelchairs, hearing aid batteries, crutches);
Injection codes (identifies actual substances); Dispensing of
medication; and Other (dental, chiropractic, vision, orthotics).
Appendix B 205
Frequent Coding and Billing Errors
Here are some of the frequent errors that you can look out
for when coding health records:
Q No documentation for services billed
Q Misinterpreted abbreviations
206 Appendix
Appendix
B
HELPFUL ONLINE RESOURCES
Appendix C
AMA CPT Code Lookup
https://catalog.ama-assn.org/Catalog/cpt/cpt_search.jsp
Appendix 207
Online Coding Software
http://www.eicd.com/SiteMap.htm
AHIMA
http://www.ahima.org
AAPC
http://www.aapc.com
208 Appendix
AppendixC
PRACTICE EXERCISE ANSWERS
Exercise 1A
Answers
1.296. 783.0
1.297. 783.7
1.298. 780.91
1.299. 780.66
1.300. 780.2
1.301. 780.71
1.302. 786.50
1.303. 780.33
1.304. 799.51
1.305. 790.29
1.306. 787.01
1.307. 789.7
1.308. 788.41
1.309. 789.01
1.310. 794.02
1.311. 793.3
1.312. 793.80
1.313. 798.0
1.314. 799.4
1.315. 786.01
Exercise 1B
1.336. E886.0, E849.4, E007.0, E000.8
1.337. E881.0, E849.3, E016.2, E000.0
1.338. E893.1
209
1.339. E905.0
1.340. E909.2
1.341. E917.3, E849.0, E013.9, E000.8
1.342. E910.4
1.343. E923.0
1.344. E004.1
1.345. 882.0, E966
1.346. 847.0, E816.0
1.347. 813.82, E818.3
1.348. E017.0
1.349. E906.0
1.350. E849.5
1.351. E871.0
1.352. E909.0
1.353. E919.3
1.354. E955.1, E849.3, E000.0
1.355. 872.11, E928.3
1.356. V26.1
1.357. V02.61
1.358. V10.3
1.359. V12.72
1.360. V16.41
1.361. V20.2
1.362. V22.2
1.363. V33.01
1.364. V28.0
1.365. V85.42
1.366. V45.11
1.367. V45.01
1.368. V53.32
210 Answers
1.369. V54.27
1.370. V55.0
1.371. V55.3
1.372. V58.11
1.373. V49.86
1.374. V71.4
1.375. V76.12
Exercise 1C
1.316. 803.75
1.317. 806.01
1.318. 807.07
1.319. 808.43
1.320. 812.01
1.321. 813.47
1.322. 832.2
1.323. 822.1
1.324. 830.0
1.325. 842.00
1.326. 860.1
1.327. 911.5
1.328. 944.35
1.329. 965.1
1.330. 995.64
1.331. 991.0
1.332. 996.02
1.333. 996.82
1.334. 998.2
1.335. 995.81
Answers 211
Exercise 2A
1.16. 047.1
1.17. 052.9
1.18. 022.1
1.19. Negative
1.20. 054.10
1.21. 042
1.22. 098.17
1.23. a. 042
1.24. c. 070.54
1.25. 002.1
1.26. 005.0
1.27. 009.2
1.28. 011.93
1.29. 034.1
1.30. 038.0
1.31. 110.0
1.32. 055.1
1.33. 072.9
1.34. 078.12
1.35. 075
Exercise 2B
1.36. 201.22
1.37. 162.9
1.38. V58.0
1.39. d. Either a or b
1.40. 183.3
1.41. 211.7
212 Answers
1.42. Benign
1.43. 172.5
1.44. 151.5
1.45. 198.89
1.46. 211.3
1.47. 233.0
1.48. b. Malignant
1.49. Connective tissue
1.50. Primary
1.51. 162.9
1.52. 233.1
1.53. a. Lymph nodes of inguinal region and lower limb
1.54. 209.32
1.55. 205.02
Exercise 2C
1.56. 275.01
1.57. 276.1
1.58. 272.0
1.59. b. Hyperaldosteronism
1.60. 250.43, 581.81
1.61. 249.00
1.62. 250.51, 362.02
1.63. 250.13
1.64. 250.51
1.65. 251.3
1.66. d. All of the above
1.67. 253.3
1.68. 276.8
1.69. 277.02
Answers 213
1.70. Mucopolysaccharidosis
1.71. 278.01, V85.4
1.72. 256.4
1.73. 271.4
1.74. 242.30
1.75. 243
Exercise 2D
1.76. 280.0
1.77. b. Hereditary hemolytic anemias
1.78. 282.5
1.79. 285.1
1.80. 285.3
1.81. a. Fanconi’s anemia
1.82. 286.4
1.83. White
1.84. 284.9
1.85. 281.2
1.86. 281.3
1.87. 289.89
1.88. 287.41
1.89. 287.30
1.90. 287.49
1.91. 285.9
1.92. 284.01
1.93. 288.3
1.94. 281.1
1.95. 286.0
214 Answers
Exercise 3A
1.96. b. Two codes
1.97. 291.2
1.98. 295.34
1.99. 301.11
1.100. 300.01
1.101. a. Dissociative identity disorder
1.102. 299.0
1.103. d. All of the above
1.104. 303.00
1.105. 304.03
1.106. 304.70
1.107. 306.0
1.108. 307.23
1.109. 296.30
1.110. 309.21
1.111. 318.0
1.112. 314.01
1.113. 291.5
1.114. 291.0
1.115. 290.43, 437.0
Practice Exercise 3B
1.116. 360.01
1.117. 359.1
1.118. c. 250.51, 362.02
1.119. 362.31
1.120. 370.8, 136.21
1.121. 361.81
Answers 215
1.122. 366.14
1.123. 365.22
1.124. 368.53
1.125. 371.23
1.126. 348.81
1.127. c. Presbyopia
1.128. 381.10
1.129. 382.01
1.130. 385.33
1.131. 386.51
1.132. 379.41
1.133. 380.14
1.134. 345.91
1.135. 337.21
Practice Exercise 3C
1.136. 417.1
1.137. d. 402.01, 428.0
1.138. 396.1
1.139. 410.21
1.140. 8
1.141. 401.9
1.142. Stenosis
1.143. 427.32
1.144. 427.41
1.145. 428.31
1.146. 411.1
1.147. 415.19
1.148. 414.06 (if native artery), or 414.07 (if of
bypass graft)
216 Answers
1.149. 414.04
1.150. 438.13
1.151. 433.21
1.152. 416.2
1.153. 458.0
1.154. 454.0
1.155. 441.3
Practice Exercise 3D
1.156. 466.0
1.157. 464.01
1.158. 474.10
1.159. 471.8
1.160. b. 480.1
1.161. 482.42
1.162. 491.21
1.163. 492.8
1.164. 486
1.165. 488.11
1.166. 493.21
1.167. 512.1
1.168. 518.83
1.169. 519.02
1.170. 494.0
1.171. c. 493.01
1.172. 512.8
1.173. 493.00
1.174. 508.0
1.175. 460
Answers 217
Practice Exercise 4A
1.176. 521.00
1.177. 532.00
1.178. 531.90
1.179. 528.6
1.180. b. 530.11
1.181. d. 531.10
1.182. 537.82
1.183. 535.31
1.184. 540.9
1.185. 553.21
1.186. 550.93
1.187. 552.00
1.188. 555.0
1.189. 556.9
1.190. 560.31
1.191. c. 562.10
1.192. 568.0
1.193. 574.00, 574.10
1.194. 577.1
1.195. 569.71
Exercise 4B
1.196. 584.5
1.197. 592.1
1.198. 590.10
1.199. 594.2
1.200. 591
1.201. 599.0
218 Answers
1.202. 596.51
1.203. 599.71
1.204. b. 598.9
1.205. b. The urinary tract infection
1.206. c. 600.00
1.207. 602.3
1.208. a. The tuberculosis
1.209. 611.82
1.210. 614.3
1.211. 617.3
1.212. 620.1
1.213. 625.3
1.214. 627.3
1.215. 622.12
Practice Exercise 4C
1.236. 680.4
1.237. 681.02
1.238. 692.71
1.239. 682.0
1.240. 685.0
1.241. 692.6
1.242. 692.84
1.243. 695.4
1.244. 701.4
1.245. 702.0
1.246. 704.01
1.247. 705.83
1.248. c. 707.07, 707.22
1.249. b. The diabetes mellitus
Answers 219
1.250. 697.0
1.251. 692.0
1.252. 682.3
1.253. 691.0
1.254. 695.10
1.255. 692.76
Practice Exercise 5A
1.256. 711.05
1.257. 714.0
1.258. 733.42
1.259. 715.36
1.260. 715.09
1.261. 717.41
1.262. 717.7
1.263. 719.11
1.264. 720.0
1.265. 721.1
1.266. 722.10
1.267. 722.52
1.268. 724.2
1.269. 727.40
1.270. 710.0
1.271. 730.07
1.272. 733.01
1.273. 733.14
1.274. 735.0
1.275. 737.10
220 Answers
Practice Exercise 5B
1.216. 653.11
1.217. 648.83
1.218. 669.22
1.219. Six
1.220. 35
1.221. 656.61
1.222. 661.01
1.223. 664.21
1.224. 670.24
1.225. 643.13
1.226. 644.13
1.227. 654.03
1.228. 674.14
1.229. 673.12
1.230. 2
1.231. 4
1.232. c. Deficient amount of amniotic fluid
1.233. 632
1.234. 5
1.235. d. a and b
Practice Exercise 5C
1.276. 741.03
1.277. 744.42
1.278. 745.4
1.279. 747.10
1.280. 749.03
1.281. 752.61
Answers 221
1.282. 753.12
1.283. 754.35
1.284. 755.11
1.285. 756.12
1.286. 752.39
1.287. 758.7
1.288. 756.51
1.289. 771.1
1.290. 770.12
1.291. 773.0
1.292. 756.72
1.293. 779.5
1.294. b. V30.00
1.295 777.50
Practice Exercise 6A
1.376. 63.73
1.377. 37.36
1.378. 06.2
1.379. 11.62
1.380. 20.01
1.381. 27.62
1.382. 32.22
1.383. 35.51
1.384. 00.66
1.385. 36.16
1.386. 40.42
1.387. 45.81
1.388. 52.7
1.389. 53.03
1.390. 55.53
222 Answers
1.391. 59.6
1.392. 68.8
1.393. 75.62
1.394. 81.51
1.395. 84.24
1.396. 72.21
1.397. 60.4
1.398. 45.62
1.399. 36.32
1.400. 36.07, 00.45
Practice Exercise 6B
2.56. 00921
2.62. 00567
2.69. a. 19120
2.79. 12004
2.83. 19125
2.93. 28292
2.105. 20240
2.134. 33207
2.139. 33968
2.153. 43282
2.156. 43239
2.180. 52282
2.183. 52601
2.196. 55250
2.222. 60500
2.232. 61154
2.240. 64475
2.258. 67312
Answers 223
Practice Exercise 6C
2.382. d. All of the above.
2.383. b. Report the Category III code.
2.384. a. Will be archived unless there’s evidence that a
temporary code is still needed
2.385. 0171T, 0172T
2.386. 0103T
2.387. 0184T
2.388. 0195T
2.389. b. Semiannually
2.390. 0030T
2.391. 0188T
2.392. 0170T
2.393. 0186T
2.394. 22856, 0092T
2.395. c. Hospitals, physicians, insurers, health services
researchers
2.396. 0179T
2.397. 0017T
2.398. 0156T
2.399. 0067T
2.400. 0140T
2.401. 0042T
Practice Exercise 7A
2.23. c. 99309
2.24. a. Documentation of history, examination, and
medical decision making
2.25. 99205
2.26. 99202
224 Answers
2.27. 99213
2.28. Time
2.29. d. A patient is placed in designated observation
status.
2.30. d. One code for the inpatient admission only
2.31. Key
2.32. d. a and b above
2.33. b. Social history
2.34. d. Has a moderate risk of morbidity without treat-
ment, a moderate risk of mortality without
treatment, uncertain prognosis or increased
probability of functional impairment
2.35. 99471
2.36. c. Subsequent hospital care codes
2.37. 99243
2.38. b. Chief complaint
2.39. d. All of the above.
2.40. c. Domiciliary, rest home, or custodial care services
2.41. b. Age of the patient
2.42. b. Office or other outpatient services codes
2.43. 30 (thirty)
Practice Exercise 7B
2.362. 51 or -51
2.363. RC or -RC
2.364. d. All of the above.
2.365. 26 or -26
2.366. 67916E1 or 67916-E1
2.367. 54 or -54
2.368. 26045RT or 26045-RT
2.369. a. Assign the code for a colonoscopy with modifier -74.
Answers 225
2.370. 91, -91
2.371. c. Assign a code for the procedure and one for the
evaluation and management service, with modifier
-25 appended to the evaluation and management
code.
2.372. 50 or -50
2.373. 45307-53
2.374. 25 or -25
2.375. 32 or -32
2.376. 27 or -27
2.377. QM, -QM
2.378. 59 or -59
2.379. 80 or -80
2.380. 62 or -62
2.381. 58 or -58
Practice Exercise 7C
2.44. b. When the anesthesiologist is no longer in personal
attendance on the patient
2.45. b. Has severe systemic disease
2.46. d. All of the above
2.47. 99140
2.48. 00172
2.49. 00326
2.50. 00530
2.51. 00670
2.52. 00832, 99100
2.53. 00862
2.54. 01400
2.55. 01214
2.56. 00921
226 Answers
2.57. 01967, 01968
2.58. 01232, 99140
2.59. 01480
2.60. 00563
2.61. 00794
2.62. 00567
2.63. 00944
Practice Exercise 7D
2.292. a. True
2.293. 70100
2.294. 70370
2.295. 70470
2.296. 71020
2.297. 78813
2.298. 72052
2.299. 72240
2.300. 73040
2.301. 73530
2.302. 74270
2.303. 74320
2.304. 74400
2.305. 75660
2.306. 76805
2.307. 75746
2.308. 78320
2.309. 75960
2.310. 77032
2.311. 76770
2.312. 78278
Answers 227
Practice Exercise 7E
2.313. d. FDA approval of the vaccine is pending.
2.314. a. 82270
2.315. b. False
2.316. b. HIV patients on antiretroviral therapy
2.317. 82552
2.318. 83090
2.319. 84154
2.320. 83986
2.321. 80076
2.322. 84300
2.323. 85025
2.324. 81025
2.325. 85610
2.326. 86039
2.327. 86592
2.328. 86706
2.329. 86632
2.330. 85652
2.331. 88305
2.332. 88309
2.333. 86618
2.334. 81001
2.335. 88164
2.336. 87040
Practice Exercise 8A
3.1 d. All of the above
3.2 J0295
3.3 J0476
228 Answers
3.4. J0585, J0585, J0585, or J0585×3
3.5. J1170
3.6. J2790
3.7. J9100
3.8. J9291
3.9. J1160
3.10. J7325
Practice Exercise 8B
3.11. E0601
3.12. A4750
3.13. A5071
3.14. A6197
3.15. A9503
3.16. A4346
3.17. A4605
3.18. A4253
3.19. A7018
3.20. A4550
Practice Exercise 8C
3.21. A0384
3.22. -HN
3.23. A0380
3.24. b. Per mile
3.25. A0436
3.26. A0424
3.27. c. Half hours
3.28. A0382
3.29. A0225
3.30. A0422
Answers 229
Practice Exercise 8D
3.31. E0434
3.32. E0297, E0277
3.33. E1594
3.34. E1300
3.35. E1180
3.36. E1038
3.37. E0445
3.38. E0199
3.39. E0730
3.40. E0619
Practice Exercise 8E
3.41. a. True
3.42. G0122
3.43. G0206
3.44. G0219
3.45. G0379
3.46. G0290
3.47. G0259
3.48. G0109
3.49. G0127
3.50 G0008
230 Answers
PROCTORED EXAMINATION
PREPARATION ANSWERS
Answers 231
Coding Physician-Based Health Records
10. c
11. a
12. a
13. b
14. c
15. c
16. a
17. a
18. d
19. c
20. c
232 Answers