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Medical Coding 2 Study Guide

Medical Coding 2 Study Guide

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Study Guide

Medical Coding 2

By

Jacqueline K. Wilson, RHIA

About the Author

Jacqueline K. Wilson is a Registered Health Information

Administrator (RHIA) who has more than 10 years of experience

consulting, writing, and teaching in the health care industry. She’s

a professional writer who has authored training manuals, study

guides/materials, online courses, and articles on a variety of topics.

In addition, Ms. Wilson develops curricula and teaches both tradi-

tional and online college courses in health information technology,

anatomy and medical terminology, and standards in health care. In

2005, she received the distinguished national award of being

included in Who’s Who Among America’s Teachers.

All terms mentioned in this text that are known to be trademarks or service
marks have been appropriately capitalized. Use of a term in this text should not be
regarded as affecting the validity of any trademark or service mark.

Copyright © 2011 by Penn Foster, Inc.
All rights reserved. No part of the material protected by this copyright may be
reproduced or utilized in any form or by any means, electronic or mechanical,
including photocopying, recording, or by any information storage and retrieval
system, without permission in writing from the copyright owner.
Requests for permission to make copies of any part of the work should be
mailed to Copyright Permissions, Penn Foster, 925 Oak Street, Scranton,
Pennsylvania 18515.
Printed in the United States of America

INSTRUCTIONS TO STUDENTS

1

LESSON ASSIGNMENTS

7

LESSON 1: ICD-9-CM HOSPITAL
INPATIENT CODING

9

EXAMINATION—LESSON 1

95

GRADED PROJECT

103

LESSON 2: INPATIENT/OUTPATIENT PROCEDURE
CODING/PHYSICIAN CODING/HCPCS LEVEL II

109

PROCTORED EXAMINATION PREPARATION

173

APPENDIX A: OVERVIEW OF CODING
AND REIMBURSEMENT

177

APPENDIX B: CODING REVIEW

191

APPENDIX C: HELPFUL ONLINE RESOURCES

207

PRACTICE EXERCISE ANSWERS

209

PROCTORED EXAMINATION
PREPARATION ANSWERS

231

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YOUR COURSE

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:

Medical Coding 2Study Guide (this guide)

2011 Professional ICD-9-CMcoding book

CPT 2011 Coding Book

Healthcare Common Procedure Coding System (HCPCS)
Level II Code List
(from the Centers for Medicare and

Medicaid Services Web site)

Clinical Coding Workout: Practice Exercises for Skill
Development
(2011 edition; published by the American

Health Information Management Association)

You should ensure that you have all of these materials before

starting the course. For your HCPCS Level IIexercises in this

study guide and your coding workbook, you should download

the HCPCS Level IIcodes (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,

Instructions to Students

2

NOTE:

Coding guidelines and
information for this
guide have been taken
from the appropriate
sources for coding:
CMS, American Medical
Association (AMA),
American Hospital
Association (AHA),
and American
Health Information
Management
Association (AHIMA).
All attempts have been
made to ensure that
coding guidelines are
current and accurate
for the time period of
this guide.

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-CMcoding 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
be your proctored final examination.

6.Complete the graded research project as assigned.

It’s impossible to present every coding guideline in this study

guide; therefore, the focus here is on basic (general), complex,

or frequently used guidelines. Because you received practice

coding basic principles in the Medical Coding 1 course, you’ll

encounter here more intermediate and advanced coding exer-

cises. When working through this course, you should pay

special attention to coding book reference introductions, code

references and notes, and review guidelines. In the different

sections of this study guide, you’ll find guidelines, tips, and

information relating to codes that are generally considered to

be the most difficult or confusing. However, not all subjects

and/or guidelines for coding have been covered under each

assignment. Working in the field, it’s necessary for a coder to

use a combination of resources for a complete and accurate

understanding of coding guidelines. Additional resource infor-

mation can be found in “Appendix C: Helpful Online Resources.”

Instructions to Students

3

OBJECTIVES

When you complete this course, you’ll be able to

Identify diagnoses and procedures contained on
medical reports

Apply principles to code services, conditions, and
procedures using ICD-9-CMand the Healthcare Common

Procedure Coding System (HCPCS)

Explain the official coding principles and guidelines of
ICD-9-CMand HCPCS

Determine the proper sequencing of codes for reporting
and billing

Discuss ICD-9-CMand HCPCS guidelines and coding
conventions

Discuss HCPCS procedural coding for different settings

YOUR STUDY GUIDE

This study guide is provided to you in place of a textbook.

When approaching each assignment, you should first read

the study guide and then follow the assignment directions for

that section in your study guide. The assignment directions

will specify which of the coding resources you’ll need to com-

plete the assignment. If at any point you don’t understand a

topic or section, take the time to reread the information. The

topic of coding is difficult and often confusing. It’s natural to

feel overwhelmed by the amount of information and resources

that need to be referenced. Remember, coding takes practice

before you feel completely comfortable. If at any point you

feel overwhelmed, take a break and then come back to the

information at a later time.

Instructions to Students

4

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.

Instructions to Students

5

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.

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.

Instructions to Students

6

Lesson 1: ICD-9-CM Hospital Inpatient Coding

For:

Read in the

Read in the

study guide:

coding references:

Assignment 1

Pages 9–19

See assignment directions

Quiz 40950900 Material in Assignment 1

Assignment 2

Pages 25–34

See assignment directions

Quiz 40951000 Material in Assignment 2

Assignment 3

Pages 41–56

See assignment directions

Quiz 40951100 Material in Assignment 3

Assignment 4

Pages 63–73

See assignment directions

Quiz 40951200 Material in Assignment 4

Assignment 5

Pages 79–88

See assignment directions

Quiz 40952000 Material in Assignment 5

Examination 40951300 Material in Lesson 1

Graded Project 40951400

Lesson 2: Inpatient/Outpatient Procedure
Coding/Physician Coding/HCPCS Level II

For:

Read in the

Read in the

study guide:

coding references:

Assignment 6

Pages 109–120

See assignment directions

Quiz 40952100 Material in Assignment 6

Assignment 7

Pages 127–149

See assignment directions

Quiz 40952200 Material in Assignment 7

Assignment 8

Pages 155–166

See assignment directions

Quiz 40952300 Material in Assignment 8

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NOTES

Lesson Assignments

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ICD-9-CM Hospital
Inpatient Coding

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-CMcoding
book).

Read the introduction to Chapter 17—“Injury and Poisoning”
(page 299 in your ICD-9-CMcoding book).

Read the introduction to Supplementary Classifications (V codes
on page 351 in your ICD-9-CMcoding 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.

Medical Coding 2

10

Symptoms, Signs, and Ill-Defined
Conditions (Categories 780–799)

A signis a physical presence or existence of a condition that

can be observed by the physician. A symptomis 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 theICD-9-CMcoding 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.

ICD-9-CMCoding Guidelines for Symptoms, Signs,
and Ill-Defined Conditions

The following guidelines don’t apply when coding hospital

outpatient records or physician services. In these cases, the

highest level of certainty (which may often be a symptom) is

reported as the reason for the outpatient encounter. You’ll

learn more about this scenario in Lesson 2.

1.Chapter 16 codes can’t be used as the principal diagnosis

(or reasons for outpatient visits) when related or definitive

diagnoses are established.

Example.A patient is admitted with convulsive seizures

due to cerebral brain cancer. The care is focused on the

seizures because the brain cancer has progressed to an

inoperable stage.

Codes

Principal diagnosis (PDX):Cerebral brain cancer

(191.0)

Secondary diagnosis:Other convulsions (780.39)

Reasoning. The convulsive seizures are the result of

the cerebral cancer and therefore are listed as the

secondary diagnosis.

2.Signs and symptoms can be listed as the principal

diagnosis only when no other cause can be found.

Lesson 1

11

When the sign/symptom is due to comparative or contrasting

conditions, the sign/symptom should be listed as the principal

diagnosis unless it’s integral to each of the conditions listed.

For comparative/contrasting diagnoses, the physician will

usually use terminology such as “either/or.” For example,

chest pain due to either pneumonia or angina is coded first as

chest pain followed by the codes for pneumonia and angina.

Example. A patient was admitted for prolonged fatigue. The

physician discharged the patient with a diagnosis of fatigue

due to either hypothyroidism or depression.

Codes

PDX:Other malaise and fatigue (780.79)

Secondary diagnosis:Unspecified hypothyroidism (244.9),

depressive disorder, not elsewhere classified (311)

Reasoning. The physician documented either/or—a clue that

this is probably a contrasting coding scenario. Because the

physician was unclear as to whether the hypothyroidism or

depression was causing the fatigue (and fatigue isn’t neces-

sarily inherent/integral with either diagnosis), the fatigue

(symptom) is listed as the principal diagnosis.

Additional scenarios in which Chapter 16 codes can be used

as principal diagnosesare as follows:

No specific diagnosis is made at the time of discharge.

Signs/symptoms last only a short time and no definitive
diagnosis can be made.

The patient is transferred/referred to another institute.

A residual of a late effect is the reason for admission.

Additional scenarios in which a Chapter 16 code can be used

as secondary diagnosesare

When the sign/symptom isn’t integral in the underlying
condition

When the sign/symptom affects the severity of a patient’s
condition or the treatment given

NOTES:

When there are two or
more equal causes,
the diagnosis with the
highest-weighted
diagnosis-related group
(DRG) should be listed
first. For example, if
the physician docu-
ments pneumonia or
angina, they would
both be coded with the
highest-weighted DRG
sequenced first.

Generally, if the physi-
cian documents that
the diagnoses are no
longer contrasting (for
example, chest pain
due to pneumonia and
angina), both condi-
tions should be coded
(with the symptom
code assigned only
if it meets coding
guidelines).

Medical Coding 2

12

3.Ill-defined conditionsare 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.

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 codesare 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.

Practice Exercise 1A

Books Needed:

Clinical Coding Workout: Practice Exercises for Skill Development

ICD-9-CM coding book

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.

Lesson 1

13

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:

Aftercare for a patient

Health care services unrelated to illness/disease

Birth status of a newborn (newborn’s record)

The following scenarios are situations in which V codes can

be listed as a secondary diagnosis:

History or problem that may influence the patient’s care

Outcome of delivery for an obstetric patient (mother’s
record)

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-CMcoding book).

E codesmake up categories E000–E999 and are used to

identify external causes of injuries and poisonings.

Medical Coding 2

14

E codes signify the following scenarios:

Cause of the injury or poisoning

Intent (for example, accidental, intentional, and so forth)

Place where the event occurred

E codes are reported for a variety of settings such as hospital

inpatients, outpatient clinics, emergency departments, and

physician offices (except when other guidelines apply).

Adverse effects (or reactions) are reactions to the properties

of certain drugs or medicinal substances (or a combination).

The reporting of adverse effects or reactions is just one

way that E codes are used. E codes are neverlisted as the

principal diagnosis.

E Code Guidelines

1.An E code may be used with any code (001–V82.9) that

indicates an injury, poisoning, or adverse effect due to

an external cause.

2.Code as many E codes as necessary to explain the cause.

3.The undetermined/unknown category of E codes

(E980–E989) is rarely used. The patient’s medical

record should provide sufficient detail to determine

the cause of the injury.

4.A late-effect E code should be used with any code

recorded as a late effect resulting from previous

injury or poisoning (those codes that fall into

categories 905–909).

Now let’s practice the principles for this section. Proceed to

the practical coding exercise for more information.

NOTE:

If space constraints
and limitations on the
billing claim form pro-
hibit assigning as many
E codes as necessary,
be sure to first assign
the ones that relate
most to the principal
diagnosis.

Lesson 1

15

Injury and Poisoning
(Categories 800–999)

Injuries and poisonings cover Chapter 17, categories

800–999, in your ICD-9-CMcoding book.

Injuries

Injuriesinclude conditions such as fractures, concussions,

wounds, lacerations, amputations, and burns. Let’s take a

look at the guidelines for coding injuries.

Coding Guidelines for Injuries

1.When coding multiple injuries, assign separate codes for

each injury unless a combination code is provided.

2.Sequence the most serious injury (as documented by the

physician) first.

3.Superficial injuries (for example, abrasions, contusions)

aren’t coded when associated with more severe injuries

of the same site.

Practice Exercise 1B

Books Needed:

Clinical Coding Workout: Practice Exercises for Skill Development

ICD-9-CM coding book

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.

Medical Coding 2

16

4.Excisional debridement (procedure) for wound, infection

or burn (86.22) can be performed only by a physician.

Nonexcisional debridements are also performed by physi-

cians or other health care professional (code 86.28).

5.Code burns with the highest degree sequenced first.

Burns can be difficult to code because they often involve

different sites and may have different degrees of severity.

Because of the difficulty, it’s worthwhile to spend some time

on specific burn guidelines.

Burns

Burns are covered by code categories 940–949. Some of the

causes of burns are as follows:

Electricity

Flame/fire

Heat

Lightning

Radiation

Chemicals

Burns are classified by depth (that is, the degree of burn),

extent, and causative agent. First-degree burnsresult in

erythema (redness). Second-degree burnsresult in blistering.

Third-degree burnsresult in full-thickness skin involvement.

Deep third-degree burnsresult 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:

Head and neck—9%

Each arm—9%

Each leg—18% (9% anterior, 9% posterior)

NOTES:

Some nonexcisional
debridements are
performed by health
care workers (such as
nurses) at the patient’s
bedside. In this case,
don’t assign a separate
code for the debride-
ment because it’s
covered in the nursing
service billing as part
of normal nursing
duties. However, some
physicians may per-
form a debridement at
the patient’s bedside.
These procedures
should be coded.

Remember, burns are
still classified under the
Injury and Poisoning
section. We’re spend-
ing time on burns here
(independent of the
other injuries) due to
the difficulty in coding.

Sunburns aren’t
included in this same
categoryand instead
are coded to category
692.

Lesson 1

17

Anterior trunk—18%

Posterior trunk—18%

Genitalia—1%

These percentages are used to help estimate body surface

involved in the burn and allows coders to assign the appro-

priate code. The term causative agentsrefer to the cause of

burns and are coded to the appropriate E code. Examples of

causative agents are fire, acid, and iron.

Let’s take a look at some specific guidelines for burns.

Coding Guidelines for Burns

1.Nonhealing burns should be assigned acute burn codes.

2.Necrosis of burned skin should be coded as a nonhealing

burn (acute).

3.When coding multiple burns, assign separate codes for

each burn site.

4.Codes from category 948—burns classified according to

extent of body surface involved—should be used only

when the site of the burn isn’t specified or as an addi-

tional code with categories 940–947.

5.Late effects of burns should be coded to the residual

condition followed by the appropriate late-effect code

and late-effect E code.

6.It’s possible that a current burn code, residual burn code,

and late-effect code may be present on the same record.

Poisoning

Poisoningis a drug overdose or ingestion of the wrong sub-

stance when drugs are given in error during procedures,

medications are given in error, medications/drugs are taken

in error by the patient, medications are taken in combina-

tions with alcoholic beverages, or a patient combines drugs/

medications.

Now let’s practice the principles for this section. Proceed to

the practical coding exercise for more information.

NOTES:

Category 946: Burns of
multiple specified sites
and Category 949:
Burns, unspecified
should be used only
if theburn locations
aren’t documented.

Adverse effects are clas-
sified differently than
poisonings in ICD-9-CM.
Adverse effects occur
when drugs are taken
as prescribed, but have
some adverse reaction
or effect (for example,
interaction from several
drugs taken together,
allergic reactions).
When a poisoning and
an adverse effect occur
together, code in the
following sequence:

1. Poisoning
2. Manifestation
3. E code

Medical Coding 2

18

Submitting Assignment Quizzes

After you take each assignment quiz and review your answers,

submit the completed quiz individually as an e-mail attach-

ment to edserv@pennfoster.com.On the subject line of the

e-mail, write “Quiz,” then the quiz number, and then Medical

Coding 2. For example, when you submit the Assignment 1

Quiz, on the subject line you’ll type: Quiz 40950900 Medical

Coding 2. In the body of the e-mail, be sure to include your

full name and student number. Then begin to record only

the answers to the quiz items. Be careful about the number-

ing. For the Part A items, write “Part A” and number the

items, each on a separate page. Then write only the letter

of the choice you think is correct for each item. After finishing

Part A, write “Part B” and record your answers, each on a

separate line. Use the exercise numbers from the assigned

exercises in Clinical Coding Workout: Practice Exercises for

Skill Development.If the answer requires one or more codes,

write the code(s). If the question is multiple-choice, write only

the letter of your choice.

If you’re unable to send in your quizzes as e-mail attachments,

you may use the answer sheet provided. In this case, for Part A,

“X” out your answer choice. For Part B, fill in the appropriate

answer—either the letter for multiple-choice questions or the

correct codes as required. Mail your completed answer sheet

to the following address:

Practice Exercise 1C

Books Needed:

Clinical Coding Workout: Practice Exercises for Skill Development

ICD-9-CM coding book

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.

Lesson 1

19

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-10coding classification system?

A.Difficulty in learning the new system
B.Cost of implementing
C.Lack of government support
D.Instability of the new system

(Continued)

Penn Foster

Student Service Center

925 Oak Street

Scranton, PA 18515

Be sure to include your full name, student number, quiz

number, and your complete mailing address.

The Penn Foster
Student Service Center
is under contract with
Penn Foster College.

Medical Coding 2

20

Assignment 1 Quiz

40950900

2.E codes are used to indicate which of the following?

A.Where an accident occurred
B.How an accident occurred
C.Whether a drug overdose was accidental or purposeful
D.All of the above

3.Which of the following bestdescribes late effects?

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.Code both diagnoses with either of the diagnoses sequenced first.
B.Code both of the diagnoses, sequencing the codes based on which diagnosis the physician
listed first on the discharge sheet.
C.Code only the diagnosis most closely related to the treatment.
D.Code only the diagnosis that’s the most resource-intensive.

5.In an acute care hospital, when is it appropriate to assign a code such as 794.31—abnormal
electrocardiographic findings?

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

6.Which of the following wouldn’t be a valid principal diagnosis?

A.873.42

C.496

B.E880.9

D.V25.1

(Continued)

Lesson 1

21

Assignment 1 Quiz

40950900

7.Which of the following codes fall under the categoryof providing codes for reporting factors
influencing health status and health service?

A.V67.4

C.47.09

B.E884.2

D.A4509

8.Unknown causes of morbidity or mortality should be coded onlywhen

A.the physician documents them on laboratory reports.
B.a more definitive diagnosis isn’t available.
C.reporting acute care hospital codes.
D.they meet UHDDS guidelines.

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.

Medical Coding 2

22

Note:In upcoming quizzes you’ll also be doing exercises on V and E codes
related to other body systems.

NAME ________________________________________________________________

ADDRESS ________________________________________________________________

CITY

________________________________________________________________

Check if this is a new address

PHONE

PLEASE PRINT

ANSWER SHEET

STUDENT NUMBER:

STATE/PROVINCE

ZIP/POSTAL CODE

CUT ALONG THIS LINE

INDICATE YOUR ANSWER TO EACH QUESTION BY MARKING AN XIN THE
APPROPRIATE SQUARE. EXAMPLE:

Part A

1.

6.

2.

7.

3.

8.

4.

9.

5.

10.

Part B

5.84 ___________________________________________________________________

5.85 ___________________________________________________________________

5.86 ___________________________________________________________________

5.87 ___________________________________________________________________

5.88 ___________________________________________________________________

5.89 ___________________________________________________________________

5.90 ___________________________________________________________________

HAVE YOU ENTERED YOUR STUDENT NUMBER IN THE SPACE PROVIDED?

A

B

C

D

A

B

C

D

X

A

B

C

D

A

B

C

D

A

B

C

D

A

B

C

D

A

B

C

D

A

B

C

D

A

B

C

D

A

B

C

D

A

B

C

D

ASSIGNMENT 1 QUIZ 40950900

Medical Coding 2

FOR YOUR INSTRUCTOR’S USE

GRADE

GRADEDBY

Lesson 1

25

ASSIGNMENT 2: INFECTIOUS
AND PARASITIC DISEASES/
NEOPLASMS/ENDOCRINE,
NUTRITIONAL, METABOLIC
DISEASES, AND IMMUNITY
DISORDERS/DISEASES OF
BLOOD AND BLOOD-FORMING
ORGANS

Read Sections C1—“Infectious and Parasitic Diseases” and
C2—“Neoplasms” (pp. 5–9) in the Coding Guidelines of your
ICD-9-CM coding book.

Read the introduction to Chapter 1 (p. 1)—“Infectious and
Parasitic Diseases”—in the Tabular Index of your ICD-9-CM
coding book.

Read the introduction to Chapter 2 (p. 31)—“Neoplasms”—in
the Tabular Index of your ICD-9-CMcoding book.

Read the introduction to Chapter 3 (p. 59)—“Endocrine,
Nutritional and Metabolic Diseases, and Immunity Disorders”—
in the Tabular Index of your ICD-9-CMcoding book.

Infectious and Parasitic Diseases
(Categories 001–139)

Infectious and parasitic diseases cover ICD-9-CMcode cate-

gories 001–139—Chapter 1 of the Tabular Index. Infectious

and parasitic diseases can be classified in several ways, so

exercise caution and refer to coding guidelines when coding

these conditions. A single code from Chapter 1 can indicate

the disease and the organism. For example, streptococcal

sore throat and scarlet fever—034.0 and 034.1. Combination

codes can identify both the condition and the organism or

cause (see definition for causative organism). Code 072.0 is

an example of this scenario—orchitis due to mumps.

Medical Coding 2

26

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.

Coding Guidelines for Infectious and
Parasitic Disease Diagnoses

1.Codes from Chapter 11 (“Complications of Pregnancy,

Childbirth, and the Puerperium”) take precedence over

codes from other chapters for the same condition.

2.Codes from categories 041 and 079 are assigned as

secondary diagnoses. In instances for which the site of

infection isn’t specified (and can’t be clarified by querying

the physician), codes from these categories can be

assigned as principal diagnoses.

3.When patients are admitted for treatment of human

immunodeficiency virus (HIV) infections or related condi-

tions, HIV is coded as the principal diagnosis followed by

additional codes for related conditions.

4.Asymptomatic patients who receive HIV testing should

be coded as V73.89—screening for other specified viral

disease.

5.Code only confirmed cases of HIV/acquired immuno-

deficiency syndrome (AIDS). Nevercode HIV if it’s listed

as suspected, possible, or likely.

NOTE:

Due to the serious
nature of HIV, guide-
lines direct that the
coder contact the
physician for clarifica-
tion or further
documentation related
to HIV status. (This is
an exception to the
general guideline. For
other non-HIV cases,
you would code this
condition as present.)

Lesson 1

27

NOTE:

Remember, late effects
are conditions that
linger, exist, or occur
after the acute phase
of an illness or injury.
A late effect is often
referred to as a residual
effect.
The current,
acute illness or injury
must resolve before
a late effect can be
coded.

Let’s review some additional guidelines for infectious and

parasitic diseases.

Late Effects

Forlate effects(for example, codes 137, 138, 139), code the

residual condition (that is, nature of the late effect) first,

followed by the cause of the late-effect code (except when

instructed otherwise by the index; see further rules explained

in bulleted list that follows). For example, scoliosis due to

poliomyelitis: 138, 737.43.

Coding of late effects requires two codes: residual condition

(or nature of the late effect) and cause of the late effect.

However, the following exceptions should be noted:

When the code for late effect is followed by a manifesta-
tion code identified in the Tabular List or

When the late-effect code has been changed or expanded
to include the manifestation (usually by fourth- or fifth-

digit classifications)

Septicemia versus Bacteremia

Septicemia (also known as blood poisoning) is a systemic

infection associated with the presence of microorganisms

and toxins in the blood. Bacteremiais the presence of fungi,

parasites, viruses, or bacteria in the blood after trauma or

infection. Septicemia is usually classified in category 038,

whereas bacteremia is coded as 790.7.

Urinary tract infection, which is the presence of pus or bac-

teria in the urine, is coded as 599.0. If you suspect that

the patient’s urinary tract infection should actually be docu-

mented as urosepsis (that is, if the urinary tract infection has

entered the bloodstream andbecome a generalized sepsis),

then you should query the physician to provide additional

or updated documentation so that the most accurate code

can be reported.

Medical Coding 2

28

Neoplasms (Categories 140–239)

Neoplasm codes are found in Chapter 2 of the ICD-9-CM

Tabular Index and make up code categories 140–239. The

best way to locate a neoplasm code is to look up the term

neoplasmin the index and then locate the anatomic site of

the tumor. Pages 193–208 of the index provide a neoplasm

chart that allows a coder to see six possible code categories

for each tumor or site.

Neoplasms, which are also calledtumors, are abnormal growths

that can be benign or malignant. Benigntumors aren’t life-

threatening. However, malignanttumors tend to infiltrate and

spread (metastasize)and thus may be life-threatening. These

tumors are also often referred to as cancerous.

When the physician simply documents the term tumor with

no further clarification, the coder should review the patient’s

pathology report in the medical record to determine if the

tumor is benign or malignant and then verify the findings

with the physician before assigning a code.

Primary versus Secondary

Tumors are classified in several ways. Primary neoplasmsare

tumors that are found in the primary organ where the tumor

growth started. Secondary neoplasmsare tumors that are

found in additional organs, spreading from the initial (or

primary) site. This spread is called metastasis.

Practice Exercise 2A

Books Needed:

Clinical Coding Workout: Practice Exercises for Skill Development

ICD-9-CM coding book

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.

NOTE:

Even though the neo-
plasm chart provides
great detail, a coder
should neverassign a
neoplasm code based
on information just
from the index. Be
sure to look up codes
located in the neo-
plasm chart within the
tabular list.

Lesson 1

29

NOTES:

Paying attention to the
way tumor information
is documented is very
helpful. For example,
if the physician docu-
ments “metastatic
from,” then the site
mentioned after “from”
is the primary site.
If the physician docu-
ments “metastatic to,”
then the site mentioned
after “to” is the second-
arysite. In situ
(pronounced in sigh-
too
) means that
cancerous cells are
present in the lining of
an organ but have not
spread to the organ
tissue.

Also assign the second-
ary diagnosis for the
acute malignancy.

Only use codes from
V10—personal history
of malignancy—when
the primary neoplasm
has been eradicated
and is no longer being
treated.

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:

Malignant (codes 140–209)

Benign (codes 210–229)

Carcinoma in situ (codes 230–234)

Uncertain behavior (codes 235–238)

Unspecified nature (code 239)

Coding Guidelines for Neoplasm Diagnoses

1.If the phrase “metastatic to” is documented, code the site
mentioned as secondary.

2.When coding a secondary site, the primary site should
also be coded if still present. If the primary site has been
eradicated(that is, removed, no longer exists, or is no
longer being treated), then a code from category V10
should be assigned. If the primary site isn’t identified,
code it as an unspecified site.

3.If “metastatic from” is documented, code the site
mentioned as primary. Code the additional (secondary)
site as an additional diagnosis.

4.When two or more sites are metastatic, code each as
secondary. However, also code the primary site.

5.When patients are admitted for complications due to
malignant neoplasms, code the complication as the prin-
cipal diagnosis. However, there are exceptions to this
guideline. Refer to coding guidelines and directions in
the coding book for such cases.

6.Assign a code from V58.0–V58.1X when a patient is
admitted for radiotherapy or chemotherapy.

Medical Coding 2

30

Endocrine, Nutritional and Metabolic
Diseases, and Immunity Disorders
(Categories 240–279)

Chapter 3 in the ICD-9-CMcoding book covers “Endocrine,

Nutritional and Metabolic Diseases, and Immunity Disorders.”

Category codes 240–279 cover these diseases and disorders.

This chapter covers a wide range of disorders that should be

coded according to the guidelines and directions in the cod-

ing book.

Diabetes Mellitus

Diabetesis a result of a deficiency, lack of, or resistance to

insulin secreted by the pancreas. Insulinis 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.

Practice Exercise 2B

Books Needed:

Clinical Coding Workout: Practice Exercises for Skill Development

ICD-9-CM coding book

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.

Lesson 1

31

NOTES:

Just because a patient
is receiving an insulin
injection doesn’t mean
that the patient has
type 1 diabetes. Refer
to the documentation
from the physician to
clarify the type of
diabetes.

Insulin-requiring isn’t
the same as insulin-
dependent.
Insulin-requiring usu-
ally refers to type 2
diabetics, whereas
insulin-dependent gen-
erally refers to type 1
diabetics. As always,
if there’s any question,
query the physician
for clarification.

A fifth digit of insulin-
dependence and/or
uncontrolled diabetes
can be assigned only
if the physician docu-
ments the condition
as such.

Type 1 versus Type 2

Diabetes mellitus is categorized by two types: type 1 and type 2.

Type 1 diabeteswas formerly known as insulin-dependent

diabetes mellitus (IDDM). Common practice now refers to

this condition as only type 1. Type 1 diabetes may also be

described many ways, including as juvenile typeor juvenile

onset.In type 1 diabetes, the body fails to produce insulin

and requires the patient to receive insulin injections.

Type 2 diabeteswas formerly referred to as non-insulin-

dependent diabetes mellitus (NIDDM). This designation has

gone out of style because of an increase in type 2 diabetes

that requires insulin. Type 2 may be described as adult onset

diabetes.In this type, insulin is produced but in a small

quantity or the body is unable to use it. Generally, type 2

diabetics don’t require insulin injections and may be treated

with oral medications and diet. For patients who may need

insulin, the physician may describe such a patient as “insulin-

requiring.”

Classifying Diabetes

Diabetes is coded under category 250; this category has two

classifications. The fourth digit indicates the presence of an

associated complication. The fifth digit indicates the type of

diabetes and whether it’s uncontrolled.

As illustrated on page 61 of the Tabular List (in the shaded

area of the first column) in your ICD-9-CMcoding book, sub-

classifications for the fifth digit include the following:

0—Type 2 or unspecified type, not stated as uncontrolled

1—Type 1, not stated as uncontrolled

2—Type 2 or unspecified type, uncontrolled

3—Type 1, uncontrolled

The presence of a fourth digit that defines associated compli-

cations tells you that there are many combination codes for

diabetes. This simply means that there’s one code that covers

both diseases/disorders when they’re related.

Example.250.11—Diabetes with ketoacidosis. The fourth

digit of 1 indicates the ketoacidosis. The fifth digit of 1 indi-

cates that the diabetes is type 1, not stated as uncontrolled.

Medical Coding 2

32

In other cases, dual codes are necessary to identify the dia-

betes and manifestations. Patients with diabetes often have

difficulties with other diseases and conditions that are cov-

ered by a dual code. In these cases, a code for the diabetes is

listed first with a secondary code to indicate the manifestation.

Example. On patient discharge, the physician documents the

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.

Guidelines for Coding Diabetes

1.With late/chronic complications of diabetes, first assign

the diabetic code followed by the manifestation code.

2.Don’t code type 1 diabetes just because a patient is

receiving an insulin injection. Query the physician for

further clarification.

3.Insulin-requiring is usually coded to type 2 diabetics.

Insulin-dependent is generally coded to type 1 diabetics.

4.Code insulin-dependence and/or uncontrolled diabetes

only if the physician documents it.

5.Diabetes complicating pregnancy is classified in Chapter 11.

Code the appropriate 648 code as the principal diagnosis

followed by the category 250 code for the diabetes. Please

note that this doesn’t apply for gestational diabetes.

6.When a patient is admitted to the hospital with a condi-

tion not related to diabetes but is still being monitored or

treated for diabetes (insulin, exercise, diet), code the dia-

betes as secondary.

7. Diabetic retinopathy is coded as 250.5x (the diabetes code

as principal) followed by a further code from 362.01–362.07

to classify the diabetic retinopathy.

NOTE:

Remember that a
manifestationis a
secondary condition
that’s associated
with another primary
condition.

NOTE:

Code 362.07, diabetic
macular edema, must
be used with a code for
diabetic retinopathy
(codes 362.01–362.06).

Lesson 1

33

Practice Exercise 2C

Books Needed:

Clinical Coding Workout: Practice Exercises for Skill Development

ICD-9-CM coding book

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.

NOTES:

The overweight and
obesity codes shouldn’t
be assigned unless
documented by the
physician.

If there’s indication/
documentation of
dietary surveillance
and counseling, code
V65.3 can be used.

Nutritional—New Codes for
Overweight and Obesity

In 2006, ICD-9-CMexpanded and included new codes for

overweight and obesity. The overweight and obesity code

(278.0X) includes fifth-digit classifications for

Obesity, unspecified (278.00)

Morbid obesity (125% or more over ideal body weight)
(278.01)

Overweight (278.02)

There’s also a new V category for body mass index. Add any

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.

Medical Coding 2

34

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

Anemiais 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:

Clinical Coding Workout: Practice Exercises for Skill Development

ICD-9-CM coding book

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.

Lesson 1

35

Assignment 2 Quiz

40951000

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.

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

2.Pyuria or bacteria in the urine should be coded to
A.790.7.

C.599.0.

B.038.8.

D.112.5.

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)

Medical Coding 2

36

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?

A.Whenever there’s a large amount of blood loss following a surgery
B.When the physician states that the large amount of blood loss is due to the surgery and
causing the anemia
C.When anemia follows surgery and hemoglobin levels are elevated beyond the normal

range

D.Never. Anemia is never considered a complication; instead, it’s considered a disease
or disorder.

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

10.When coding infectious and parasitic diseases,

A.a second code is assigned to indicate the causative organism.
B.fourth digits or additional codes may indicate the causative organism(s).
C.code categories 041–079 as principal, with a fourth digit indicating the causative
organism.
D.optional E codes are used to indicate the causative organism.

(Continued)

Lesson 1

37

(Continued)

Assignment 2 Quiz

40951000

Part B: Complete the following exercises in your Clinical Coding Workout: Practice
Exercises for Skill Developmentbook.

Exercises 4.1–4.5, “Disorders of the Blood and Blood-Forming Organs,” starting on page 94

Exercises 4.24–4.28, “Endocrine, Nutritional and Metabolic Diseases, and Immunity
Disorders,” starting on page 102

Exercises 4.37–4.41, “Infectious Diseases,” starting on page 107

Medical Coding 2

38

NOTES

NAME ________________________________________________________________

ADDRESS ________________________________________________________________

CITY

________________________________________________________________

Check if this is a new address

PHONE

PLEASE PRINT

ANSWER SHEET

STUDENT NUMBER:

STATE/PROVINCE

ZIP/POSTAL CODE

CUT ALONG THIS LINE

INDICATE YOUR ANSWER TO EACH QUESTION BY MARKING AN XIN THE
APPROPRIATE SQUARE. EXAMPLE:

Part A

1.

6.

2.

7.

3.

8.

4.

9.

5.

10.

Part B

4.1 ________________________________

4.37 ________________________________

4.2 ________________________________

4.38 ________________________________

4.3 ________________________________

4.39 ________________________________

4.4 ________________________________

4.40 ________________________________

4.5 ________________________________

4.41 ________________________________

4.24 ________________________________

4.25 ________________________________

4.26 ________________________________

4.27 ________________________________

4.28 ________________________________

HAVE YOU ENTERED YOUR STUDENT NUMBER IN THE SPACE PROVIDED?

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ASSIGNMENT 2 QUIZ 40951000

Medical Coding 2

FOR YOUR INSTRUCTOR’S USE

GRADE

GRADEDBY

Lesson 1

41

ASSIGNMENT 3: DISEASES OF
THE CIRCULATORY SYSTEM/
NERVOUS SYSTEM/MENTAL
DISORDERS/DISORDERS OF
THE RESPIRATORY SYSTEM

Read Section 7—“Diseases of the Circulatory System”—
(pp. 11–13) in the Coding Guidelines of your ICD-9-CMcoding
book. There’s no additional reading assignment for diseases of
the nervous and respiratory systems.

Mental Disorders (Categories 290–319)

Mental disorders are discussed in Chapter 5 of your ICD-9-CM

book, code categories 290–319. The term mental disorder

covers any emotional disturbance (by any cause) that impairs

functioning. Mental disorders comprise a large range that

may include the everyday life stress that affects a person’s

mood to severe emotional disturbances that incapacitate a

person and interfere with everyday functions—sometimes

to the extent that suicide is attempted. A few examples of

mental disorders are psychosis, senile dementia, depression,

attention deficit disorder, Alzheimer’s disease, schizophrenia,

neurosis, and psychosis.

Neurosis versus Psychosis

Neurosisis a mental disorder involving anxiety and avoidance

behavior that appears to have no organic cause. Neuroses

can include a variety of anxieties and depression. Psychosis

is a more severe distortion of a person’s perception of reality.

Psychosescan involve delusions, hallucinations, and bizarre

behavior.

Alcohol Abuse versus Alcohol Dependence

Alcohol and drug dependencies are also covered in this chapter.

Alcohol abuse (code 305.00) is a drinking problem without

physical dependence on alcohol. Code 305.00 is also assigned

for a diagnosis of drunkenness.

NOTES:

A code for psychosis
shouldn’t be assigned
unless this disorder is
clearly documented
by the physician.
Physicians may docu-
ment conditions such
as delirium, dementia,
psychosis, and halluci-
nation to indicate a
patient’s psychosis.
As always, query the
physician if the docu-
mentation is unclear.

Substance abuse and
substance dependency
may be used inter-
changeably in the
record documentation;
however, they’re coded
differently. Query the
physician for clarifica-
tion, if necessary.

Medical Coding 2

42

Alcohol dependencyis a chronic condition with a physical

dependence on alcohol. With this diagnosis, a physician may

document the terms alcoholismand alcoholic.

Coding Guidelines for Mental Disorder Diagnoses

1.When Alzheimer’s disease has associated dementia, code

first the Alzheimer’s disease followed by the dementia

code (294.1X).

2.Assign the fifth-digit subclassifications for schizophrenia

(category 295) based on the physician’s documentation.

3.Code acute reactions to stress to category 308 and

chronic reactions to stress to category 309.

4.For psychogenic conditions (category 316) with associated

physical conditions (NEC), code first the 316 code followed

by the code for the associated physical condition.

5.When coding anorexia nervosa (307.1), don’t code associ-

ated malnutrition (even if listed as a separate diagnosis

by the physician) because malnutrition is inherent in

anorexia nervosa.

6.When acute and chronic alcoholism is diagnosed, report

only code 303.0X to cover both conditions.

7.For recovering alcoholics, assign the appropriate 303.XX

code with a fifth digit of 3 (“in remission”).

8.Assign only one of the following category codes for alco-

holic withdrawal (based on physician documentation):

291.0, 291.3, 291.81.

9.When a patient is admitted for alcoholic withdrawal,

assign withdrawal as the principal diagnosis and

alcoholism as secondary.

10.For an admission of substance-related psychosis, code

first the psychosis followed by alcohol/drug abuse or

dependence.

11.When a patient is admitted for detoxification/rehabilita-

tion (that is, no withdrawal or psychosis), code first the

dependence.

NOTE:

Although there’s a code
for history of alcoholism
(V11.3), it’s rarely
assigned (that is, most
alcoholics stay in the
“recovering” phase for
their entire lives).
Query the physician
for clarification.

Lesson 1

43

12.Drugs don’t have to be given for a treatment code of

“detoxification” to be assigned. Detoxificationis 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.

Nervous System and Sense Organs
(Categories 320–389)

Diseases of the nervous system and sense organs appear in

Chapter 6, code categories 320–389. Examples of nervous

system disorders are Parkinson’s disease, encephalitis,

meningitis, seizures, and multiple sclerosis.

The nervous system is divided into two parts: the central

nervous system and the peripheral nervous system. The

central nervous system (CNS)is made up of the brain and

spinal cord. Central nervous system codes are assigned to

categories 320–349.

The peripheral nervous system (PNS) is made up of the cranial

and spinal nerves. Peripheral nervous system codes are

assigned to categories 350–359.

Practice Exercise 3A

Books Needed:

Clinical Coding Workout: Practice Exercises for Skill Development

ICD-9-CM coding book

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.

NOTE:

Understanding the
separation of classifica-
tions for CNS and PNS
codes will help you
more accurately code.
Many PNS codes are
manifestations of other
conditions and there-
fore appear as the
secondary diagnosis
(with underlying
condition listed first).

Medical Coding 2

44

Hemiplegia versus Hemiparesis

Conditions exist within this chapter that may cause hemiplegia

or hemiparesis.

Hemplegiais 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.

Coding Guidelines for Nervous System and
Sense Organ Diagnoses

1.Infectious disease of the nervous system may require dual

coding (follow code directions from your coding book). In

these cases, list the responsible organism or code first,

followed by the manifestation code.

2.Documentation of convulsions and seizures shouldn’t be

coded to epilepsy (category 345) unless specified by the

physician. Instead, assign code 780.39.

3.Don’t code hemiplegia that occurs with a cerebrovascular

accident (CVA) if the hemiplegia resolves before the patient

is discharged.

4.If hemiplegia is present at the time of discharge, assign a

hemiplegia code from category 342 as an additional code.

5.On subsequent admissions, hemiplegia should be coded

with the appropriate circulatory system (Chapter 7)

438.2X code to indicated that the condition is a late

effect of CVA.

6.If Parkinson’s disease is due to an adverse medication

effect, assign the appropriate Parkinson’s code with an E

code for the responsible drug as a secondary diagnosis.

7.Don’t code cataracts as senile or mature (regardless

of the patient’s age) unless documented as such by

the physician.

Lesson 1

45

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.

Circulatory System
(Code Categories 390–459)

Circulatory system disorders are coded to Chapter 7, code

categories 390–459.

Ischemic Heart Disease versus
Myocardial Infarctions

Ischemic heart diseaseis caused by a lack of oxygen to the

myocardial cells.

Ischemic heart disease is also known as coronary ischemia,

coronary artery disease, arteriosclerotic heart disease (ASHD),

or coronary arteriosclerosis/atherosclerosis.

Practice Exercise 3B

Books Needed:

Clinical Coding Workout: Practice Exercises for Skill Development

ICD-9-CM coding book

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.

NOTES:

Some circulatory
system disorders
have been reclassified
to Chapter 11,
“Complications of
Pregnancy, Childbirth,
and the Puerperium,”
and Chapter 14,
“Congenital Anomalies.”
Follow coding book
notes and guidelines
for the reclassifications
that aren’t coded in
Chapter 7.

Medical Coding 2

46

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

episode of care for the MI. These fifth digits are: 1—the initial

(first) episode of care; 2—the subsequent episode of care

(admission for further care of the cardiac condition any time

during the first eight weeks after the MI occurred). A fifth

digit of 0 is assigned if the episode of care is unspecified.

Cerebrovascular Disorders

Cerebrovascular disorders affect the cerebral arteries of the

brain. Cerebrovascular accidents (CVAs)are occlusions of

the brain caused by thrombosis, embolism, hemorrhage, or

ischemia. CVAs are also known as strokes.

CVA versus TIA

Cerebrovascular accidents are characterized by a sudden

irreversible loss of neurologic function secondary to the

ischemic death of brain tissue. Transient ischemic attacks

(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

NOTES:

The myocardiumis the
middle, muscular layer
of the heart.

A fifth digit of 1 is still
assigned if the patient
is transferred to another
facility during the initial
episode of care.

A negative finding
from a CT or MRI scan
doesn’t necessarily
rule out CVA. Don’t
code based on MRI/CT
results alone. When
there’s inadequate
documentation, query
the physician for
further coding
clarification.

Lesson 1

47

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 asprimary hypertensionorsecondary 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

other serious conditions and even death.

Benign hypertensionis a mild degree of hypertension over a

long (chronic) period of time. Secondary hypertensionis the

result of another disease. In many cases, once the underlying

disease is treated or controlled, the secondary hypertension

will disappear. Therefore, code the secondary hypertension

as secondary. In some cases, hypertension is described as

uncontrolled, controlled, or history of. There’s no code for

specifying that the hypertension is uncontrolled. Instead,

code it to the cause and nature. Controlled or history of may

refer to hypertension that’s still under treatment. In most

cases, it’s reported as a secondary diagnosis.

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

NOTES:

Code accelerated or
necrotizing hyperten-
sion to the malignant
hypertension category.

For controlled/history
of hypertension, look
to see if the patient is
still receiving medica-
tion or being treated.
If so, assign the appro-
priate hypertension
code.

Medical Coding 2

48

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).

Circulatory System Procedures

Cardiac catheterization(codes 37.21–37.23) is an invasive

procedure for diagnosing cardiovascular disease. Cardiac

catheterizations are done with a variety of other procedures. In

these cases, cardiac catheterization isn’t reported as a sepa-

rate code because it’s implicit in the other procedure codes.

Cardiac pacemakers provide electrical control of the heart

rate. Pacemaker placement can be temporary (code 37.78)

or permanent (two codes for initial insertion: 37.81–37.83

and 37.71–37.74). There are three types of pacemakers, all

with different codes:

Single-chamber device (uses a single lead)—code 37.81

Single-chamber device, rate responsive—code 37.82

Dual-chamber device (uses dual leads)—code 37.83

Percutaneous transluminal coronary angioplasy(PTCA)is

a treatment for atherosclerotic coronary heart disease and

angina wherein the plaque is flattened against the walls of

the artery by inflating and deflating a small balloon. This

allows a better flow of blood and decreases disease symptoms.

Codes for PTCA include the following:

Single vessel, without mention of thrombolytic agent:
00.66

Single vessel, with thrombolytic agent: 00.66 (PTCA),
99.10 (Injection/infusion of thrombolytic agent)

NOTES:

When hypertensive
heart and kidney
disease are present,
code 404.XX with addi-
tional codes to specify
the type of heart fail-
ure (428.0–428.43),
if known. Add an
additional code to
identify the stage
of chronic kidney
disease (585.1–585.6),
if known.

Lesson 1

49

Multiple vessel, performed during same operation, with
or without mention of thrombolytic agent: 00.66; code

also the number of vessels treated (00.40–00.43) and any

infusion of thrombolytic agent (99.10)

Coronary artery bypass grafting (CABG)is open heart surgery

in which a section of a blood vessel (or prosthesis) is grafted

onto a coronary artery for redirection, or bypass, of blood

flow around a blockage.

Coding Guidelines for
Circulatory System Diagnoses

1.Code acute myocardial infarctions (duration of 8 weeks

or less) to category 410.

2.Don’t assign code 410.9—myocardial infarction,

unspecified site, unless no other information is

provided and the physician can’t be queried.

3.For myocardial infarctions, assign a fifth digit of 1

(initial episode of care) if the patient was transferred

from another facility during the initial episode treatment.

4.When a patient experiences a second infarction during

an admission for an acute myocardial infarction, code

both infarctions with a fifth digit of 1 for both cases.

5.Don’t assign code 412—old myocardial infarction—when

current ischemic heart disease is present.

6.Assign code 412—old myocardial infarction—as a sec-

ondary diagnosis only when it has significance for the

current episode of care.

7.Code 411.1—intermediate coronary syndrome—is assigned

as principal diagnosis only when the underlying condition

isn’t identified and there’s no surgical intervention.

8.Assign code 411.81 if there’s an arterial occlusion/

thrombosis without infarction.

9.Don’t assign codes from categories 410 and 411 together

unless there’s a diagnosis of post-myocardial infarction

syndrome or post-infarction angina.

NOTES:

Assign additional codes
for insertion of coro-
nary artery stents
(36.06–36.07) and/or
number of vascular
stents inserted
(00.45–00.48).

Separate procedure
codes are used to
indicate the type of
bypass carried out
(code 36.1X). Assign
an additional (second-
ary) procedure code
for the extracorporeal
circulation (code 39.61)
that’s required for this
procedure.

When assigning a code
from category 410,
use a fourth digit to
classify the location of
the heart wall involved.
If the location isn’t
documented, review
the electrocardiograph
report and query the
physician.

Medical Coding 2

50

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

category code 402.

15.Code hypertensive heart disease with hypertensive renal

disease to category code 404.

16.Assign code 427.5—cardiac arrest—as principal diagnosis

only when a patient arrives in cardiac arrest and can’t be

resuscitated (or is only briefly resuscitated before being

pronounced as expired).

17.Assign code 427.5—cardiac arrest—as secondary

diagnosiswhen 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-

vasculardisease—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.

NOTES:

There are codes from
category 404 that
indicate whether the
disease is benign or
malignant. Query the
physician for clarifica-
tion before assigning
these codes.

Lesson 1

51

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

hypertension is coded to 796.2.

28.Postoperative hypertension is a complication of surgery

and should be coded to 997.91 along with a code to

identify the type of hypertension.

29.Assign V42.2—heart valve transplantation, V45.01—

cardiac pacemaker in situ, and V45.81—aorto-coronary

bypass status, only as additional diagnoses that indicate

a health status related to the circulatory system (only

when this additional diagnosis affects the patient’s

current episode).

30.When a patient is admitted for removal, replacement,

or reprogramming of a cardiac pacemaker, code

V53.31—fitting and adjustment of cardiac pacemaker

as the principal diagnosis.

NOTES:

A patient may have
elevated blood pres-
sure following surgery.
This isn’t considered
true post-operative
hypertension (unless
specified by the physi-
cian) and should be
coded to 796.2.

Code V53.31 includes
an admission for
replacement because
the pacemaker is
nearing the end of
expected life.

Medical Coding 2

52

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:

Clinical Coding Workout: Practice Exercises for Skill Development

ICD-9-CM coding book

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.

Lesson 1

53

Respiratory System
(Code Categories 460–519)

As stated at the beginning of this chapter, one of the most

important guidelines to remember when coding respiratory

system disorders is to code the organism (cause) of the respi-

ratory condition when documented. This is sometimes done

as one (combination) code to cover both the pneumonia and

the organism. For example, for pneumonia due to Klebsiella

code 482.0.

In other cases, pneumonia is a manifestation of an under-

lying disease and should be assigned two codes. For example:

Bronchial pneumonia in typhoid fever—code 002.0 and 484.8.

When no organism related to the pneumonia is documented

or no organism can be verified, code 486—pneumonia,

organism unspecified.

Types of Pneumonia

Lobar pneumoniadoesn’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 pneumoniais 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.

Chronic Obstructive Pulmonary Disease

Chronic obstructive pulmonary disease (COPD) refers to a

group of disorders that obstruct bronchial flow and usually

result from smoking. One or more of the following diseases

can be present in varying degrees:

Emphysema

Chronic bronchitis

NOTES:

Both Streptococcus
and Neisseriaare
found normally in the
respiratory system.
Their presence doesn’t
necessarily indicate
an infection.

Medical Coding 2

54

Bronchospasm

Bronchiolitis

When additional respiratory tract conditions such as acute

bronchitis and asthma exist, use combination codes for COPD.

Care should be taken to code the appropriate combination

code and not two separate codes for these conditions.

Respiratory Failure

Respiratory failureoccurs when there’s an inadequate

exchange of oxygen (O

2) and carbon dioxide (CO

2) in the lungs.

Patients in acute respiratory failure will have increased

breathing (rapid respiratory rate with use of accessory

muscles) and possible cyanosis.

The following codes are used for respiratory failure:

518.8X—Respiratory failure (acute, chronic, acute and
chronic, or NOS)

518.5—Pulmonary insufficiency following trauma and
surgery

770.84—Respiratory failure of newborn

According to the Coding Clinic published by the AHA (guide-

lines for coding ICD-9-CM), the following criteria apply to

respiratory failure: (1) inadequate exchange of O

2and CO

2;

(2) close monitoring and aggressive respiratory therapy

and/or ventilation are required due to the life-threatening

nature of respiratory failure.

Respiratory failure can be assigned as the principal diagnosis

if it’s the diagnosis that brings the patient into the hospital

due to a chronic or acute respiratory (pulmonary) disease,

with an additional code for the respiratory disease. When

respiratory failure develops after admission, code it as an

additional diagnosis.

NOTES:

It’s possible for the
two types of aspiration
pneumonia to be
present in the same
patient. In this case,
code both the 507 and
480–483 categories.

Don’t code respiratory
failure unless docu-
mented by the
physician.

Not all patients in
respiratory failure
are put on mechanical
ventilation.

Don’t code respiratory
failure as the principal
diagnosis when it’s due
to an acute, nonrespi-
ratory condition.

Lesson 1

55

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 exacerbationof 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

acutenonrespiratory 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.

Medical Coding 2

56

Practice Exercise 3D

Books Needed:

Clinical Coding Workout: Practice Exercises for Skill Development

ICD-9-CM coding book

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.

Lesson 1

57

Assignment 3 Quiz

40951100

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 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 Developmentbook.
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.

Part A: Complete the following multiple-choice questions.

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.

3.Don’t assign code 412 as a secondary code when

A.current ischemic heart disease is present.
B.the physician documents “healed MI.”
C.a previous heart attack is indicated by an electrocardiogram (EKG) and physician
documentation.
D.a past MI is causing no problems for the current admission.

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?

A.294.1

C.294.1, 331.0

B.331.0, 294.10

D.331.0

(Continued)

Medical Coding 2

58

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

7.Bacterial meningitis due to pneumococcus infection should be categorized to

A.one code.
B.two codes.
C.three codes.
D.no codes until the physician is queried for more information.

8.Code seizures and convulsions to category

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?

A.507.0 and 480.9

C.496 and 493.2

B.491.20 and 491.21

D.506.0 and 506.9

10.When a patient is admitted in respiratory failure due to an acute, nonrespiratory condition,
which of the following actions should the coder take?

A.Code respiratory failure as the principal diagnosis and sequenced first.
B.Code acute, nonrespiratory condition as the principal diagnosis and sequenced first.
C.Code respiratory condition causing the respiratory failure as the principal diagnosis and
sequenced first.
D.Query the physician for appropriate sequencing.

(Continued)

Lesson 1

59

Assignment 3 Quiz

40951100

Part B: Complete the following exercises in your Clinical Coding Workout: Practice
Exercises for Skill Development book:

Exercises 4.6–4.15, “Disorders of the Cardiovascular System,” starting on page 95

Exercises 4.47–4.51, “Behavioral Health Conditions,” starting on page 109

Exercises 4.67–4.71, “Disorders of the Nervous and Sense Organs,” starting on page 116

Exercises 4.87–4.91, “Disorders of the Respiratory System,” starting on page 121

NOTES

Medical Coding 2

60

NAME ________________________________________________________________

ADDRESS ________________________________________________________________

CITY

________________________________________________________________

Check if this is a new address

PHONE

PLEASE PRINT

FOR YOUR INSTRUCTOR’S USE

GRADE

GRADEDBY

STUDENT NUMBER:

STATE/PROVINCE

ZIP/POSTAL CODE

CUT ALONG THIS LINE

ASSIGNMENT 3 QUIZ 40951100

Medical Coding 2

INDICATE YOUR ANSWER TO EACH QUESTION BY MARKING AN XIN THE
APPROPRIATE SQUARE. EXAMPLE:

Part A

1.

6.

2.

7.

3.

8.

4.

9.

5.

10.

Part B

4.6 ________________________________4.50 ________________________________
4.7 ________________________________4.51 ________________________________
4.8 ________________________________4.67 ________________________________
4.9 ________________________________4.68 ________________________________
4.10 ________________________________4.69 ________________________________
4.11 ________________________________4.70 ________________________________
4.12 ________________________________4.71 ________________________________
4.13 ________________________________4.87 ________________________________
4.14 ________________________________4.88 ________________________________
4.15 ________________________________4.89 ________________________________
4.47 ________________________________4.90 ________________________________
4.48 ________________________________4.91 ________________________________

4.49 ________________________________

HAVE YOU ENTERED YOUR STUDENT NUMBER IN THE SPACE PROVIDED?

A

B

C

D

X

A

B

C

D

A

B

C

D

A

B

C

D

A

B

C

D

A

B

C

D

A

B

C

D

A

B

C

D

A

B

C

D

A

B

C

D

A

B

C

D

ANSWER SHEET

Lesson 1

63

ASSIGNMENT 4: DIGESTIVE
SYSTEM/DISEASES OF THE
GENITOURINARY SYSTEM/
DISEASES OF THE SKIN AND
SUBCUTANEOUS TISSUE

Review the kidney and nephron diagrams on the first page of
Chapter 10 (p. 193)—“Diseases of the Genitourinary System”—in
the Tabular List of yourICD-9-CMcoding book.

Review the skin and subcutaneous layer diagram on the
first page of Chapter 12 (p. 227)—“Diseases of the Skin and
Subcutaneous Tissue”—in the Tabular List of your ICD-9-CM
coding book.

Digestive System
(Categories 520–579)

Diseases of the digestive system are listed in Chapter 9 and

are classified to code categories 520–579.

Gastrointestinal Hemorrhage

Gastrointestinal (GI) hemorrhage can manifest itself in

several ways:

Hematemesis(vomiting of blood)—may indicate upper
GI hemorrhage

Melena(dark-colored blood in stool)—may indicate upper
or lower GI hemorrhage

Occult blood (microscopic blood in stool)—may indicate
upper or lower GI hemorrhage

Gastric ulcers, intestinal ulcers, and intestinal diverticular

disease are the most common causes of upper GI hemorrhage.

When hemorrhage is present for these conditions, there’s one

combination code that covers both the condition and the

hemorrhage. For example, acute gastritis with hemorrhage—

code 535.01 (covers both the condition and the bleeding).

NOTES:

There’s no additional
reading assignment for
the Digestive System.

Assign code category
578 when the physi-
cian notes that GI
bleeding is due to a
non-GI condition.

Medical Coding 2

64

Diverticulosis versus Diverticulitis

Diverticulosisindicates the presence of pouchlike herniations

(diverticula) throughout the intestine. Diverticulitisis 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

(without mention of hemorrhage).

Diverticula can be acquired or congenital. For certain sites

(such as colon), diverticula are assumed to be congenital. For

other sites (such as espophagus), diverticula are assumed to

be acquired unless otherwise documented. Pay close atten-

tion to medical record documentation and coding notes in

your coding book so that you’ll assign the appropriate code

for these distinctions.

Cholecystitis, Cholelithiasis,
and Choledocholithiasis

This section deals with diseases of the gallbladder. The

function of the gallbladder is to store excess bile until it’s

needed to break down fat. Cholecystitis is acute or chronic

inflammation of the gallbladder. Cholelithiasisis the presence

of gallstones in the gallbladder. If there are abnormally high

levels of bile salts or, more commonly, cholesterol, stones can

form. Choledocholithiasis is a condition of stones in the com-

mon bile duct. Choledocholithiasis may also be referred to as

biliary calculusorgallstones.

In ICD-9-CMclassification, there are codes that allow for

these three related conditions to be coded as one combina-

tion code. There are classification groups (code category 574)

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).

NOTES:

Diverticula can be
found on any hollow,
tubular organ (such as
intestine, esophagus,
bladder).

When diverticulosis
isn’t otherwise speci-
fied, it’s assumed to
be of the colon (code
562.10 [without
hemorrhage]).

The terms stoneand
calculusare synony-
mousand may be
used interchangeably
in documentation.

When removal of
stones is performed,
don’t code incision of
the cystic duct as a
separate procedure
because it’s implicit
in the basic procedure
code.

Lesson 1

65

Adhesions and Hernia

Adhesionsare bands of scar tissue that bind together internal

surfaces that are normally separate. Adhesions most commonly

form in the abdomen after abdominal surgery. Adhesions are

classified to codes 568.0 (peritoneal adhesions; postoperative,

post-infective) and 560.81 (intestinal or peritoneal adhesions

with obstruction; postoperative, post-infective). Adhesions are

treated by lysis(destruction/dissolution of the scar tissue)

and coded by the following approaches:

Laparoscopic lysis of peritoneal adhesions—code 54.51

Other lysis of peritoneal adhesions—code 54.59

Herniais a protrusion or projection of an organ through an

abnormal opening. In ICD-9-CM, hernias are classified by type

and site. For hernia repair, make sure that the diagnostic

code for hernia matches the procedure code. For example, if

a diagnosis of unilateral hernia is coded, it isn’t possible for a

bilateral hernia procedure to be coded. Errors in coding such

as this will result in denial of payment for the institution.

Coding Guidelines for Digestive System Diagnoses

1.Code category 578 (gastrointestinal hemorrhage) is

assigned only when the physician states GI bleeding

is caused by a condition other than GI.

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.

NOTES:

A patient may have
minor adhesions that
don’t cause issues.
When these adhesions
are lysed during another
procedure, don’t code
the adhesions or the
lysis. Code these
adhesions only when
they’re so extreme that
the surgeon must stop
the other procedure
in order to lyse the
adhesions. As always,
query the physician
for clarification when
needed.

It isn’t possible for a
bilateral repair to be
performed for a unilat-
eral hernia. However,
it’s possible for a
unilateral repair to be
done for a bilateral
hernia if repair for
one of the hernias
is necessary but not
for the other.

Medical Coding 2

66

8.Code functional diarrhea as 564.5 (564.4 if it follows

GI surgery).

Coding Guidelines for Digestive
System Procedures

1.When coding cholecystectomy, look for the following

additional performed procedures and assign additional

codes if present: removal of stones (51.41), other relief of

obstruction (51.42), intraoperative cholangiogram (87.53).

2. When removal of stones is performed during a cholecys-

tectomy, don’t code incision of the cystic duct as a

separate procedure because it’s implicit in the basic

procedure code.

3.When simple or minor adhesions are lysed during

another procedure, don’t code the adhesions or the lysis.

4.For appendectomy, assign code 47.1X, incidental appen-

dectomy, when an appendix is removed as a routine

measure during the course of other abdominal surgery.

5.For an appendix removed during exploratory laparo-

scopic surgery (with no other therapeutic procedure),

code 47.0X with no code for the approach.

Now let’s practice the principles for this section. Proceed to

the practical coding exercise for more information.

NOTES:

Infectious diarrhea
with organism is
assigned to Chapter 1,
“Infectious and
Parasitic Diseases”
(code categories
001–008). When no
condition/cause is
identified, code
diarrhea as a
sign/symptom
code (787.91).

For the code 47.0X
guideline, the appendix
doesn’t need to show
pathologic changes on
tissue examination for
this to be coded.

Practice Exercise 4A

Books Needed:

Clinical Coding Workout: Practice Exercises for Skill Development

ICD-9-CMcoding book

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.

Lesson 1

67

Genitourinary System
(Code Categories 580–629)

Chapter 10 in the ICD-9-CMbook categorizes diseases of the

genitourinary system (code categories 580–629).

Genitourinaryrefers to the organs and/or functions of both

the genitals and urinary system together. Genitourinary is

also called urogenital.

Urinary Tract Infections

Urinary tract infections (UTIs) may be one of the most com-

monly coded conditions from this chapter. A urinary tract

infection (UTI) is an infection of one or more structures in the

urinary system. UTIs are most commonly found in women

and commonly caused by gram-negative bacteria. Types of

urinary tract infections include

Cystitis—inflammation of the bladder and ureters

Pyelonephritis—inflammation of the renal pelvis of
the kidney

Urethritis—inflammation of the urethra

Codes for urinary tract infections include both combination

codes and single codes. Combination codes will use one code

to cover both the infection and the organism causing the

infection. Many of these codes are reclassified to a chapter

other than the genitourinary system chapter. For example,

gonococcal cystitis (bladder)—code 098.11—is reclassified to

Chapter 1, “Infections and Parasitic Disease,” to indicate the

organism Neisseria gonorrhoeaeas the infective agent causing

the cystitis.

When coding urinary tract infections to Chapter 10, use two

codes: infection code(coded first); organism code.For example,

in acute cystitis due to Escherichia coli code as follows: acute

cystitis—code 595.0 (assigned first); E. coli—041.4 (assigned

as secondary code). When the specific location of the UTI isn’t

documented, code 599.0—urinary tract infection, NOS. If the

organism is identified, use a secondary code following 599.0.

NOTES:

If cystitis and pyelo-
nephritis are
documented, look up
the actual disease
mentioned (that is, cys-
titis)in the Alphabetic
Index. Starting with
the term infection may
take you to the wrong
coding information.

The 599.0 code is used
commonly by coders.
Many times a specific
location/organism may
not be mentioned.

Medical Coding 2

68

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,

query the physician to determine if it should be coded as a

postoperative condition or secondary diagnosis.

Incontinence refers to the inability to control urination due to

anatomic, physiologic, or pathologic conditions.

Stress incontinenceis due to physical strain such as occurs

when a person coughs, sneezes, or laughs. Stress incontinence

in women is coded to 625.6 and in men to code 788.32.

Renal Disease

Renal disease is classified to code categories 580–593, with

the exception of that related to pregnancy/labor (reclassified

to Chapter 11). Renal failureis a result of other diseases and

can be acute or chronic. Acute kidney failureis the sudden

cessation of renal function (584.X). Chronic kidney disease,

orCKD(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-CMcoding 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

NOTES:

Incontinenceactually
refers to the inability
to control urination or
defecation. For the
purpose of this chapter,
we’re discussing incon-
tinence related
specifically to urination.

Unspecified renal
failure is coded to 586.

Lesson 1

69

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:

Acute renal failure exists with hypertension.

Hypertension is described as secondary.

Renal disease is specifically stated due to another cause
(other than hypertension).

Renal disease with diabetes (or diabetic nephropathy) is
also coded to another chapter—code 250.4X—diabetes with

renal manifestation. Assign an additional code to indicate a

manifestation (for example, renal failure, glomerulosclerosis).

Coding Guidelines for
Genitourinary System Diagnoses

1.When a UTI is due to the presence of an implant, graft, or

device (for example, indwelling catheter), code complication

code category 996.6X.

2.Code the symptom hematuria (599.7) only when it isn’t

implicit in other conditions or when the related condition

isn’t identified.

3.Regarding laboratory reports, code blood in urine as

791.2—hemoglobinuria—only if the physician documents

clinical significance.

4.When the underlying cause is known for incontinence,

code the underlying cause first followed by the inconti-

nence code.

5.Code both chronic renal failure and end-stage renal

disease to category 585.

6.Code renal insufficiency to 593.9—unspecified disorder of

the kidney and ureter.

7.When renal disease results from both hypertension and

diabetes mellitus, two combination codes from categories

403/404 and subcategory 250.4X are assigned (sequence

either code as principal diagnosis). However, don’t assign

a code from codes 585–587 with this scenario.

Medical Coding 2

70

8.When the patient is admitted for dialysis, code V56.0—

extracorporeal dialysis (hemodialysis) or V56.8—other

dialysis (peritoneal)—as the principal diagnosis.

Coding Guidelines for
Genitourinary System Procedures

1.When a patient is admitted for dialysis, also code the

insertion of venous catheter (38.95) or totally implantable

vascular access device (86.07). Code 39.95 for the asso-

ciated dialysis.

2.Don’t code cystoscopy used for diagnosing and treating

urinary conditions as a separate code. The procedures

include the cystoscopy in the code.

3.For prostate surgery, the approach (for example, per-

ineal, retropubic, transurethral) determines the code

assignment.

Note that code 60.5 is for radical prostatectomy regardless of

approach used.

Now let’s practice the principles for this section. Proceed to

the practical coding exercise for more information.

Practice Exercise 4B

Books Needed:

Clinical Coding Workout: Practice Exercises for Skill Development

ICD-9-CM coding book

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.

Lesson 1

71

Skin and Subcutaneous Tissue
(Code Categories 680–709)

Skin and subcutaneous tissue conditions are covered in

Chapter 12, code categories (680–709). They’re subdivided

into the following categories:

Infections (680–686)

Other inflammatory conditions (690–698)

Other disease of skin/subcutaneous tissue (700–709)

Cellulitis

Cellulitis is an acute infection of the skin and subcutaneous

tissue. Symptoms of cellulitis may range from localized heat,

redness, pain, and swelling to fever, chills, malaise, and head-

ache. Individuals who have diabetes, poor circulation, or

damaged skin are more prone to cellulitis.

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.

NOTES:

This chapter includes
conditions of the nails,
sweat glands, hair, and
hair follicles.

Cellulitis can occur in
other areas (aside from
skin/subcutaneoustis-
sue). In those cases,
code the cellulitis
to the appropriate
chapter.

Medical Coding 2

72

Debridement

Debridementis a procedure done to remove damaged tissue,

debris, and foreign objects from a wound or burn to prevent

infection and promote healing. There are two important

distinctions for debridement when coding this procedure;

86.22—excisional debridement of the skin—includes cutting

away of the tissue and is performed only by a physician.

Code 86.28 is a nonoperative (nonexcisional) procedure that

includes terms like brushing, irrigating, scrubbing, or other

methods to remove tissue or foreign material.

Coding Guidelines for Skin and
Subcutaneous Tissue Diagnoses

1.Code cellulitis due to a superficial injury, burn, or

frostbite to two codes—one for the injury and one for

cellulitis. Sequencing in this case depends on the cir-

cumstances of admission.

2.For abscess and/or lymphangitis with cellulitis, assign

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 cellulitisdue to injury/ulcer to

gangrene—785.4—as a secondary diagnosis with

the injury/ulcer sequenced as principal diagnosis.

NOTES:

Excisional debride-
ments may be carried
out at the patient’s
bedside or in an oper-
ating room. However,
just because a physi-
cian is performing the
debridement doesn’t
make it excisional.

Nonexcisional debride-
ments performed by
personnel other than
physicians shouldn’t
be coded.

Abscess and lymphan-
gitis are included in the
code for cellulitis.

Simple excision

involves only the skin.

Lesson 1

73

Coding Guidelines for Skin and
Subcutaneous Tissue Procedures

1.Code simple excision of lesions to category 86.3 (includes

local excision and method of destruction).

2.Code 86.4 for a radical or wide excision.

3.Nonexcisional debridements performed by personnel

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:

Clinical Coding Workout: Practice Exercises for Skill Development

ICD-9-CM coding book

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.

NOTE:

Radicalor wide
excision
involves
underlying/adjacent
tissue.

Medical Coding 2

74

Assignment 4 Quiz

40951200

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 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 Developmentbook.
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.

Part A: Complete the following multiple-choice questions.

1.Vomiting of blood may indicate which of the following types of hemorrhage?

A.Acute upper GI

C.Upper or lower GI

B.Chronic upper GI

D.Lower GI

2.Which of the following conditions is/are the mostcommon causes of upper GI bleed?

A.Gastric ulcers

C.Intestinal diverticular disease

B.Intestinal ulcers

D.All of the above

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)

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 exceptin the case of

A.acute renal failure.

C.renal disease with heart disease.

B.chronic renal failure.

D.acute renal disease.

7.Which of the following factors mostlikely determines the appropriate procedure code
assignment for prostatectomies?

A.The approach

C.The age of the patient

B.The case-mix index

D.The presence of secondary diseases

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.

Exercises 4.16–4.23, “Disorders of the Digestive System,” starting on page 98

Exercises 4.29–4.36, “Disorders of the Genitourinary System,” starting on page 105

Exercises 4.42–4.46, “Disorders of the Skin and Subcutaneous Tissue,” starting on
page 108

Medical Coding 2

76

NAME ________________________________________________________________

ADDRESS ________________________________________________________________

CITY

________________________________________________________________

Check if this is a new address

PHONE

PLEASE PRINT

FOR YOUR INSTRUCTOR’S USE

GRADE

GRADEDBY

STUDENT NUMBER:

STATE/PROVINCE

ZIP/POSTAL CODE

CUT ALONG THIS LINE

ASSIGNMENT 4 QUIZ 40951200

Medical Coding 2

INDICATE YOUR ANSWER TO EACH QUESTION BY MARKING AN XIN THE
APPROPRIATE SQUARE. EXAMPLE:

Part A

1.

6.

2.

7.

3.

8.

4.

9.

5.

10.

Part B

4.16 ________________________________ 4.32 ________________________________

4.17 ________________________________ 4.33 ________________________________

4.18 ________________________________ 4.34 ________________________________

4.19 ________________________________ 4.35 ________________________________

4.20 ________________________________ 4.36 ________________________________

4.21 ________________________________ 4.42 ________________________________

4.22 ________________________________ 4.43 ________________________________

4.23 ________________________________ 4.44 ________________________________

4.29 ________________________________ 4.45 ________________________________

4.30 ________________________________4.46 ________________________________

4.31 ________________________________

HAVE YOU ENTERED YOUR STUDENT NUMBER IN THE SPACE PROVIDED?

A

B

C

D

X

A

B

C

D

A

B

C

D

A

B

C

D

A

B

C

D

A

B

C

D

A

B

C

D

A

B

C

D

A

B

C

D

A

B

C

D

A

B

C

D

ANSWER SHEET

Lesson 1

79

ASSIGNMENT 5: DISEASES OF
THE MUSCULOSKELETAL SYSTEM
AND CONNECTIVE TISSUE/
COMPLICATIONS OF
PREGNANCY, CHILDBIRTH,
AND PUERPERIUM/NEWBORN
(PERINATAL)/CONGENITAL
ANOMALIES

Review the diagram for Chapter 13 (p. 237)—“Diseases of the
Musculoskeletal System and Connective Tissue”—in the
Tabular List of yourICD-9-CMcoding book.

Read Section 11—“Complications of Pregnancy, Childbirth,
and Puerperium”—(pp. 14–15) in the Coding Guidelines of your
ICD-9-CMcoding book.

Read Section 15—“Newborn (Perinatal) Guidelines”—(pp. 17–18)
in the Coding Guidelines of your ICD-9-CMcoding book.

Read Section 18, Letter d, Number 11—“Obstetrics and related
conditions” (p. 23), and Number 12—“Newborn, infant, and
child” (p. 23)—in the Coding Guidelines of your ICD-9-CM
coding book.

Musculoskeletal System and
Connective Tissue
(Code Categories 710–739)

Chapter 13 lists codes for the musculoskeletal system and

connective tissue (code categories 710–739). Many of the

categories for this chapter have fifth-digit subclassifications

that indicate the site involved. Follow notes in yourICD-9-CM

coding book for the appropriate fifth-digit assignment.

Arthritis

Arthritisis 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.

NOTE:

There’s no additional
reading assignment for
congenital anomalies.

Medical Coding 2

80

In these cases, assign the appropriate dual codes. Some

common examples of arthritis are osteoarthritis(code

category 715) and rheumatoid arthritis(code category 714).

Pathologic Fractures

Pathologic fractures are breaks in the bone caused by a

weakness in the bone tissue. If a fracture is described as

spontaneous,it’s a pathologic fracture and coded to

category 733.1X.

Coding Guidelines for Musculoskeletal System
and Connective Tissue Diagnoses

1.Code back pain in the following way: first code to site

of pain; lumbago,or low back pain—724.2; back pain,

NOS—724.5; cervicalgia,or neck pain—723.1.

2.Many back disorder codes make a distinction for those

persons with or without myelopathy (functional disturbance

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.

Coding Guidelines for Musculoskeletal System
and Connective Tissue Procedures

1.When a laminectomyis performed with excision of a

herniated disc, don’t code the laminectomy separately

(because it’s the approach). When a laminectomy is

performed for the sole purpose of exploration or decom-

pression of the spinal canal, use code 03.09.

NOTES:

The fifth digit indicates
the site.

Remember, fractures
due to injuries (trau-
matic) are coded to
Chapter 17—“Injury
and Poisoning.”

Back pain associated
with the herniation of
an intervertebral disc is
included in the hernia-
tion code 722.2 (no
separate code for back
pain is assigned).

Lesson 1

81

2.Assign replacement of joint—lower extremities—to

code 81.5X and upper extremities to code 81.8X.

3.When joint replacement also involves bone growth stimu-

lator, code the stimulator to 78.9X as an additional

procedure code.

4.When a bilateral replacement of a joint is performed, use

the joint replacement code twice to indicate both locations.

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.

Pregnancy, Childbirth, Puerperium
(Code Categories 630–679)

Chapter 11 codes—“Complications of Pregnancy, Childbirth,

and the Puerperium”—are classified to code categories

630–679. Any condition that arises during a pregnancy,

childbirth, or puerperium is considered a complication and

should be coded as such unless otherwise specified from the

physician. The following two guidelines are important to

remember when assigning codes from categories 630–679:

1.These codes are used only for reporting diagnoses in the

mother’s record and never coded in the newborn’s record.

Practice Exercise 5A

Books Needed:

Clinical Coding Workout: Practice Exercises for Skill Development

ICD-9-CM coding book

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.

NOTE:

The guideline for
Number 5 is used
after the joint has
been replaced the
initial time. Don’t
assign this code for
the first (initial)
joint replacement.

Medical Coding 2

82

2.These codes have sequencing priority over codes from

other chapters.

Chapter 11 is divided into the following sections:

Ectopic and molar pregnancies: code categories 630–633

Other pregnancies with abortive outcomes: code cate-
gories 634–639

Complications mainly related to pregnancy: code cate-
gories 640–649

Normal delivery (and other indications for care): code
categories 650–659

Complications occurring mainly during labor and delivery:
code categories 660–669

Complications of the puerperium: code categories
670–677

Fifth digit subclassifications used for code categories 640–649

and 650–659 provide more information. Pay close attention to

notes and guidelines for using these fifth digits. Fifth digits

can be assigned only at certain periods, and many can’t be

assigned to the same episode. The fifth digits are

0—Unspecified as to episode of care or not applicable

1—Delivered, with or without mention of antepartum
condition

2—Delivered, with mention of postpartum complication

3—Antepartum condition or complication when delivery
hasn’t occurred

4—Postpartum condition or complication when delivery
occurred during a previous episode of care

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).

NOTES:

Puerperiumis the time
after childbirth—
approximately six
weeks—in which a
woman’s anatomic and
physiologic changes
from the pregnancy
resolve.

Antepartummeans
occurring or existing
before birth. This stage
is often referred to as

prenatal. Postpartum

means occurring after
birth.

Lesson 1

83

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

record to indicate the outcome of delivery (for example,

single birth, multiple births, alive, stillborn) for the cur-

rent episode of care.

5.Code 650—normal delivery—only when the delivery is

normal with a single liveborn outcome. Criteria: head/

occipital delivery; antepartum complication resolved

before admission; no labor/delivery abnormalities; no

postpartum complications; outcome assigned V27;

no procedures other than episiotomy without forceps,

episiorrhaphy, amniotomy, manual delivery (no forceps),

administration of analgesia/anesthesia, fetal monitoring,

sterilization

6.When a patient is admitted for obstetric care other than

delivery, the principal diagnosis should be coded to the

pregnancy complication.

7.For routine prenatal visits (no complications), code

V22.0—surpervision of normal first pregnancy—or

V22.1—supervision of other normal pregnancy—as the

reason for the encounter.

8.When the patient delivers outside of the hospital and

no complications are present, code V24.0—postpartum

care and examination immediately after delivery—as the

principal diagnosis.

9.Code from categories 655 and 656 only when the fetal

condition is responsible for modifying the mother’s care.

NOTES:

Look up “Outcome of
delivery” (V27.X) in
the Alphabetic Index,
V code section, of your
ICD-9-CMcode book
to find these codes.

Code 650 is always
coded as principal
diagnosis and can’t be
coded with any other
codes from Chapter 11.

Don’t use codes V22.0
and V22.1 with any
codes from Chapter 11.

Medical Coding 2

84

10.Always code preexisting hypertension (category 642) as a

complication in pregnancy, delivery, or puerperium.

11.The physician must specify pre-eclampsia or eclampsia

before these conditions can be coded.

12.Postpartum complications that occur during the

admission for delivery are assigned a fifth digit of 2.

Postpartum complications that occur after discharge

are assigned a fifth digit of 4.

13.Code perineal lacerations to categories 664.0X–664.3X.

14.Assign a code from category V25 as the principal diagno-

sis when the admission/outpatient encounter is for

contraceptive management.

15. Assign code V25.2 (covers both male and female) when

the admission/encounter is solely for contraceptive

sterilization.

Coding Guidelines for Pregnancy, Childbirth, and
Puerperium Procedures

1.Assign additional codes for procedures that assist delivery:

artificial rupture of membranes (73.01), cervical dilation

(73.1), artificial rupture of membranes (after labor has

begun) (73.09), forceps rotation of fetal head (72.4),

manual rotation of fetal head (73.51).

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.

NOTES:

Diagnoses can’t be
assigned based solely
on elevated blood
pressure, abnormal
albumin level, or
edema.

Complications are con-
sidered postpartum if
they occur within six
weeks after delivery.

Don’t forget to also
assign a procedure
code for a contracep-
tive management visit
when appropriate.

If sterilization is per-
formed during the
same admission as
the delivery, assign
code V25.2 as the
secondary diagnosis.

Code 75.69 includes
repair of episiotomy, so
there’s no need for an
additional code.

Lesson 1

85

Congenital Anomalies (Categories 740–759)

Congenital means present at birth; therefore, a congenital

anomaly is a condition or disease that a baby is born with.

Congenital anomalies are represented in Chapter 14 of the

ICD-9-CM coding book, code categories 740–759.

Many anomalies occur as a set of symptoms or multiple

abnormalities. Because of the large amount of congenital

anomalies present in the medical field, it’s difficult to provide

a code for each and every anomaly. Sometimes the anomaly

will be specified even though there’s no specificICD-9-CM

code to match. In these cases, code other specified anomaly

of the specific type/site. When a specific anomaly code isn’t

available, code instead each of the manifestations present for

the anomaly.

Even though codes from this chapter are described as “peri-

natal,” they can be assigned to patients of any age. Many

congenital anomalies persist throughout a person’s lifetime

and have an impact on health and treatments.

Coding Guidelines for
Congenital Anomaly Diagnoses

1.When the anomaly is specified but there’s no specific

ICD-9-CMcode to match, code instead other specified

anomaly of the specific type/site with manifestation

codes of the anomaly.

Practice Exercise 5B

Books Needed:

Clinical Coding Workout: Practice Exercises for Skill Development

ICD-9-CM coding book

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.

NOTE:

Some congenital
perinatal conditions are
coded to Chapter 15
(instead of Chapter 14).
Follow coding notes in
your ICD-9-CMcoding
book for the correct
code assignment.

Medical Coding 2

86

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

category V30–V39 as principal diagnosis followed by

the additional anomaly code from Chapter 14.

4.When a renal cyst isn’t specified as congenital or

acquired, code the cyst as congenital.

Certain Conditions Originating in the Perinatal
Period (Code Categories 760–779)

Conditions originating in the perinatal period appear in

Chapter 15, code categories 760–779.

Perinatal refers to the time period around and including the

process of being born or giving birth. The newborn (perinatal)

period begins at birth and lasts through the 28th day follow-

ing birth.

Classification of Newborns

When coding births, assign a code from categories V30–V39

according to the type of birth and any other significant sec-

ondary diagnoses originating in the perinatal period.

Codes from categories V30–V39 are assigned to the medical

record as principal diagnosis and only one time to the new-

born record at the time of birth.

Prematurity and Fetal Growth Retardation

A premature infant is one who is born before 37 weeks’

gestation and hasn’t fully developed or matured. Fetal growth

retardationmeans that the infant is smaller than expected

at a specific gestational age. Codes for premature infants

and/or fetal growth retardation are assigned to code categories

764 and 765 with a fifth digit to indicate birth weight.

NOTES:

Newborn congenital
conditions are reported
even if they’re not
treated/evaluated
during the current
admission. This policy
is an exception to the
coding guideline for
reporting additional
diagnoses.

There’s no separate
coding exercise for the
congenital anomaly
section. Congenital
anomalies have been
grouped with the
next section.

Follow information in
the coding book for
correct assignment of
fourth- and fifth-digit
subdivisions of cate-
gories V30–V39.

Codes from categories
764 and 765 should be
assigned based on
physician documenta-
tion and not just on
gestational age and/or
birth weight. The
physician must docu-
ment prematurity-
relevant conditions to
be coded.

Lesson 1

87

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

hospitals (sufficient information should be provided to

code elsewhere).

4.Assign a V29 category code as secondary diagnosis when

a healthy newborn is evaluated for a suspected condition

that’s (after study) not present. Assign the V30 category

code as principal diagnosis.

5.Code a secondary diagnosis from category 766 for a long

gestation or unusually high birth weight.

6.Code fetal distress and asphyxia only when the condition

has been specifically identified and documented by the

physician. Don’t codes these conditions based on scores

or tests.

7.Code from categories 760 and 763—maternal causes of

perinatal morbidity—to the newborn record only when the

maternal condition is the cause for morbidity or mortality.

8.Assign routine vaccination of newborns as V05.3 (viral

hepatitis) and V05.4 (varicella).

9.Assign a code from category V20—health supervision of

infant/child—for routine encounters when no problem

has been identified.

Coding Guidelines for Perinatal Procedures

For routine newborn vaccinations, assign procedure

code 99.55.

Now let’s practice the principles for this section. Proceed to

the practical coding exercise for more information.

NOTES:

When the signs/
symptoms of a sus-
pected condition are
present, code instead
the sign or symptom
(and not the V29 cate-
gory code). A code
from V29 can be
assigned as principal
diagnosis for readmis-
sion or when V30 is no
longer appropriate.

760 and 763 codes are
assigned to newborn
records only when the
maternalcondition has
adversely affected the
newborn.

Code V20.2 is assigned
for routine examina-
tions (for example,
well baby clinic) at
clinics/offices but not
for hospital admissions.

Medical Coding 2

88

Practice Exercise 5C

Books Needed:

Clinical Coding Workout: Practice Exercises for Skill Development

ICD-9-CM coding book

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.

Lesson 1

89

Assignment 5 Quiz

40952000

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.

1.When coding back disorders, which of the following conditions should alwaysbe 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.a closure and inherent in the code.
B.an operative approach and inherent in the code.
C.an invasive surgical procedure.
D.never covered by third-party payers.

3.A code such as 733.13 can be assigned as principal diagnosis onlywhen

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)

Medical Coding 2

90

Assignment 5 Quiz

40952000

4.Which of the following is the correctcoding and sequencing—if applicable—for bilateral total
hip replacement?

A.81.51

C.81.51, 81.53

B.81.5

D.81.51, 81.51

5.Codes from Chapter 11 refer to codes for

A.the mother only.

C.the baby only.

B.the mother and baby.

D.pregnancy conditions only.

6.The onlycircumstance 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?

A.Live birth, full term, cephalic presentation with episiotomy repair
B.Live birth, full term, cephalic presentation, postpartum breast abscess
C.Live birth, full term, breech presentation, rotated by version before delivery
D.Live birth, full term, vertex presentation, low forceps

8.A scenario in which categories V30–V39 are assigned is once, as the __________ diagnosis
to the __________ record at the time of birth.

A.principal, newborn

C.secondary, newborn

B.principal, maternal

D.secondary, maternal

9.A valid documentation for codes 764 or 765 would be physician documentation stating

A.gestational age as 35 weeks.

C.low birth weight for 37 weeks.

B.fetal growth retardation.

D.prematurity.

10.Which of the following are all category codes that could be assigned for acute-care hospitals?

A.V20, V29, V37

C.V27, V29, V30

B.V27, V29, V33

D.V33, V37, V39

(Continued)

Assignment 5 Quiz

40952000

Part B: Complete the following exercises in your Clinical Coding Workout: Practice
Exercises for Skill Development workbook:

Exercises 4.52–4.59, “Disorders of the Musculoskeletal System and Connective Tissue,”
starting on page 110

Exercises 4.72–4.76, “Newborn/Congenital Disorders,” starting on page 117

Exercises 4.82–4.86, “Conditions of Pregnancy, Childbirth, and the Puerperium,” starting
on page 120

Lesson 1

91

Medical Coding 2

92

NOTES

NAME ________________________________________________________________

ADDRESS ________________________________________________________________

CITY

________________________________________________________________

Check if this is a new address

PHONE

PLEASE PRINT

FOR YOUR INSTRUCTOR’S USE

GRADE

GRADEDBY

ANSWER SHEET

STUDENT NUMBER:

STATE/PROVINCE

ZIP/POSTAL CODE

Assignment 5 Quiz 40952000

Medical Coding 2

CUT ALONG THIS LINE

INDICATE YOUR ANSWER TO EACH QUESTION BY MARKING AN XIN THE

APPROPRIATE SQUARE. EXAMPLE:

Part A

1.

6.

2.

7.

3.

8.

4.

9.

5.

10.

Part B

4.52 ________________________________ 4.73 ________________________________

4.53 ________________________________ 4.74 ________________________________

4.54 ________________________________ 4.75 ________________________________

4.55 ________________________________ 4.76 ________________________________

4.56 ________________________________ 4.82 ________________________________

4.57 ________________________________ 4.83 ________________________________

4.58 ________________________________ 4.84 ________________________________

4.59 ________________________________ 4.85 ________________________________

4.72 ________________________________ 4.86 ________________________________

HAVE YOU ENTERED YOUR STUDENT NUMBER IN THE SPACE PROVIDED?

A

B

C

D

X

A

B

C

D

A

B

C

D

A

B

C

D

A

B

C

D

A

B

C

D

A

B

C

D

A

B

C

D

A

B

C

D

A

B

C

D

A

B

C

D

95

Part A: Multiple-Choice Questions

1.A patient is admitted to undergo chemotherapy for cancer of
the sigmoid colon that was previously treated with resection.
Which code is sequenced first?
A.153.3

C.V58.1

B.153.9

D.V10

2.A patient was admitted to the hospital for chest pain due to
tachycardia. While in the hospital, the patient was also treated
for type 1 diabetes. Upon further review, the coder noted that
the documentation and EKG didn’t provide further evidence
of the type of tachycardia or underlying cardiac condition(s).
What should the coder report as the principal diagnosis?
A.Chest pain
B.Tachycardia, NOS
C.Insulin-dependent diabetes mellitus
D.Cardiac disease, NOS

E
x
a
m
in
a
t
io
n

E
x
a
m
in
a
t
io
n

Lesson 1
ICD-9-CM Hospital Inpatient Coding

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.

Send your completed exam to
Penn Foster
Student Service Center
925 Oak Street
Scranton, PA 18515

Questions 1–25: Select the one best answer to each question.
Record your answers on the answer sheet for this examination.

EXAMINATION NUMBER

40951300

Whichever method you use in submitting your exam
answers to the school, you must use the number above.

Examination, Lesson 1

96

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 correctcodes 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.

Examination, Lesson 1

97

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
correctcode 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 correctcoding 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 notbe listed as principal diagnosis?
A.784.7

C.E812.0

B.V30.00

D.307.81

14.Choose the correctcode 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

98

15.Read the following excerpt from medical record documentation and determine the
correctcode(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 correctcoding 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 correctcode 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.

20.A physician lists urosepsis as a secondary diagnosis on a patient’s discharge sheet.
How would you code this diagnosis?
A.Code it to 790.7.

C.Code it to 599.0.

B.Code it to 038.9.

D.Code 599.0, 038.9.

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

Examination, Lesson 1

99

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

24.Codes 331.9, 332.0, are conditions affecting the
A.central nervous system.

C.gastrointestinal system.

B.peripheral nervous system.

D.cardiovascular system.

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 correctcoding 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

Part B: Coding Record Scenarios

In your Clinical Coding Workout: Practice Exercises for Skill Developmentbook, 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.

Coding Inpatient Records

Complete the following exercises from Level III—Advanced Coding 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)

NOTES

Examination, Lesson 1

100

NAME ________________________________________________________________

ADDRESS ________________________________________________________________

CITY

________________________________________________________________

Check if this is a new address

PHONE

PLEASE PRINT

FOR YOUR INSTRUCTOR’S USE

GRADE

GRADEDBY

STUDENT NUMBER:

STATE/PROVINCE

ZIP/POSTAL CODE

CUT ALONG THIS LINE

EXAMINATION NUMBER 40951300

Lesson 1: Inpatient Coding

Medical Coding 2

INDICATE YOUR ANSWER TO EACH QUESTION BY MARKING AN XIN THE

APPROPRIATE SQUARE. EXAMPLE:

Part A

1.

10.

18.

2.

11.

19.

3.

12.

20.

4.

13.

21.

5.

14.

22.

6.

15.

23.

7.

16.

24.

8.

17.

25.

9.

Part B

7.1____________________________________7.22__________________________________

7.5____________________________________7.25__________________________________

7.6____________________________________7.27__________________________________

7.8____________________________________7.28__________________________________

7.9____________________________________7.31__________________________________

7.11____________________________________7.34__________________________________

7.13____________________________________7.36__________________________________

7.14____________________________________7.40__________________________________

7.15____________________________________7.41__________________________________

7.19____________________________________7.45__________________________________

HAVE YOU ENTERED YOUR STUDENT NUMBER IN THE SPACE PROVIDED?

A

B

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X

ANSWER SHEET

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?

GRADED PROJECT NUMBER

40951400

G
raded P

roject

G
raded P

roject

103

Lesson 1

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

Type your submission, double-spaced, in a standard,
size 12 print font. Use a standard document format with

one-inch margins. (Don’tuse any fancy or cursive fonts.)

Include the following information at the top of your paper:

Name and address

Student number

Course title and number (Medical Coding 2 HIT 204)

Research project number (40951400)

Read the assignment carefully and answer each question.

Be specific. Limit your submission to the questions
asked and issues mentioned.

Include a reference page that lists Web sites, journals, or
any other references used in preparing the submission.

Proofread your work carefully. Check for correct spelling,
grammar, punctuation, and capitalization.

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

Graded Project

104

Graded Project

105

The questions will be evaluated according to the following

criteria:

Content

The student

Provides clear answers to the assigned question(s)

Answers the question(s) in complete sentences, not just
simple yes or no statements

Supports his or her opinion by citing specific information
from the assigned Web sites and other references used

Stays focused on the assigned issues

Writes in his or her own words and uses quotation
marks to indicate direct quotations

Written Communication

The student

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

Uses correct grammar, spelling, punctuation, and sen-
tence structure

Provides clear organization by using words like first,
however, on the other hand, and so on, consequently,

since, next,and when

Makes sure the paper contains no typographical errors

Format

The paper is double-spaced and typed in font size 12. It

includes the student’s

Name and address

Student number

Course title and number (Medical Coding 2 HIT 204)

Research project number (40951400)

Graded Project

106

Submitting Your Project

After you complete your research project, submit it as an

e-mail attachment to edserv@pennfoster.com.On the sub-

ject line, write “Research Project,” then the project number,

40951400, then Medical Coding 2. In the body of the e-mail,

be sure to include your full name and student number.

If you’re unable to send in your research project as an e-mail

attachment, you may use the answer sheet provided. Attach

it to the project and mail the project to this address:

Penn Foster

Student Service Center

925 Oak Street

Scranton, PA 18515

Be sure to include your full name, your student number, the

project number and your complete mailing address.

Company 1

Part A—Company Information (5 points)

Score _____

Part B—Questions

Question 1 (5 points)

Score _____

Question 2 (10 points)

Score _____

Question 3 (10 points)

Score _____

Question 4 (10 points)

Score _____

Question 5 (10 points)

Score _____

Company 2

Part A—Company Information (5 points)

Score _____

Part B—Questions

Question 1 (5 points)

Score _____

Question 2 (10 points)

Score _____

Question 3 (10 points)

Score _____

Question 4 (10 points)

Score _____

Question 5 (10 points)

Score _____

Final Grade _____

Comments:

NAME ________________________________________________________________

ADDRESS ________________________________________________________________

CITY

________________________________________________________________

Check if this is a new address

PHONE

PLEASE PRINT

FOR YOUR INSTRUCTOR’S USE

GRADE

GRADEDBY

ANSWER SHEET

STUDENT NUMBER:

STATE/PROVINCE

ZIP/POSTAL CODE

CUT ALONG THIS LINE

EXAMINATION NUMBER 40951400

Graded Project

Medical Coding 2

109

Inpatient/Outpatient
Procedure Coding/
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-CMcoding 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-CMcoding 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.

L
e
s
s
o
n
2

L
e
s
s
o
n
2

Medical Coding 2

110

Coding Inpatient Procedures

For reimbursement and reporting, medical coders are

required by the UHDDS to code hospital inpatient proce-

dures. The UHDDS (to refresh your memory, the Uniform

Hospital Discharge Data Set) requires that all significant

procedures be reported. A significant procedure has the

following characteristics:

Surgical in nature

Has an anesthetic risk

Has a procedural risk

Requires specialized training to perform

Remember, hospital inpatient procedures are reported using

the codes from Volume 3 (Index to Procedures) of the ICD-9-CM

coding book. You learned about guidelines for some of these

procedures when working through the different body systems

in Lesson 1.

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 asambulatory care.

The CMS requires that outpatient procedures be reported

using HCPCS Level I (CPT) codes. ICD-9-CMprocedure 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-CMprocedure code for internal tracking or

statistical purposes.

NOTES:

There’s one exception
to the numeric order—
E/M codes (99201–
99499) are listed at
the beginning of the
CPT 2011coding book.

The UHDDS doesn’t
apply to the coding of
outpatient procedures.
The CPT system (from
the AMA) is the classi-
fication system that
determines reporting
guidelines for outpa-
tient procedures along
with the CMS.

You may also hear the
term encounterused
for an outpatient’s visit
or an inpatient stay at
the hospital.

Lesson 2

111

Coding Inpatient versus Outpatient Procedures

Two major differences exist between coding inpatient versus

outpatient records.

1.The UHDDS definition of principal diagnosis applies only

to inpatients (acute care hospitals).

2.Inconclusive diagnoses (probably, suspected, likely)

aren’t coded for outpatients. Instead, the highest level of

certainty is coded. This means that there may be times

when you’re coding a symptom as the reason for an out-

patient encounter.

Acute-Care Hospital Inpatient Procedural Coding

Hospital inpatient procedures are coded using ICD-9-CMpro-

cedure codes (categories 00–99.99) found in Volume 3 of the

ICD-9-CM coding book. Just as there’s a principal diagnosis in

inpatient coding, there’s also a principal procedure.A principal

procedure is performed for definitive treatment (rather than

diagnostic/exploratory) or treatment necessary to take care of

a complication. If there are two or more procedures performed,

then the one that most closely relates to the principal diagnosis

should be sequenced first as the principal procedure.

Basic Guidelines for Coding Inpatient Procedures

1.“Code Also”

For someICD-9-CMprocedures, you’ll see an instructional

note that says “Code Also.” Code alsomeans that an addi-

tional procedure should be coded if performed. If two code

assignments are needed, the index will often indicate this

by using slanted brackets [ ]around the additionalcode(s).

In this case, the additional codes must be assigned and

sequenced as indicated.

Example:Cardiotomy and pericardiotomy

Code also cardiopulmonary bypass [extracorporeal

circulation][heart-lung machine](39.61)

2.“Omit Code”

The omit codeinstruction means that no code for that

category is to be assigned.

NOTES:

This outpatient sce-
nario is different than
that for inpatient
guidelines wherein you
may code “probable,”
“suspected,” and
“likely” as if the
condition exists.

There may be times
when your principal
procedure and principal
diagnosis aren’t related.
Make sure that you
have adequate docu-
mentation for the
codes assigned so
that reimbursement
isn’t denied.

Medical Coding 2

112

3.Excision of Organ or Lesion

Excision of organs (or lesions) may also be listed under

the term resection.

4.Bilateral Procedures

Bilateral proceduresindicate that the procedure was

performed at two locations/sides. Assign the procedure

code twice for bilateral procedures (unless otherwise

indicated by the code).

5.Approaches and Closures

Operative approaches/closures (for example, incisions

and stitching up) and laparoscopic/thoracoscopic

approaches are usually considered an integral part of

the procedure and aren’t coded as separate codes.

6.Other Endoscopic Approaches

Endoscopic approaches are coded unless directed other-

wise by the Alphabetic Index, and/or a procedure was

performed with the endoscopy. When an endoscopy is

performed on more than one body cavity, the code

assignment should indicate the most distant site reached.

7.Biopsies

Closed biopsies are performed percutaneously(by needle),

by aspiration, or by endoscopy. The biopsy is coded

according to the procedure used. For example, when an

endoscopic approach is used, code the endoscopy and

biopsy with the endoscopy (the most intensive procedure)

coded first. For example, a colonoscopy of the large intestine

with biopsy is coded to 45.25 (ICD-9-CM) 45380 (CPT).

Open biopsies are performed by an incision. Because the

incision is implicit in the biopsy procedure, code only the

biopsy. When an open biopsy is performed with another

procedure, code both the biopsy and the procedure, with

the procedure sequenced first.

8.Canceled Procedures

When a procedure has been canceled after a patient

admission, code only ICD-9-CMdiagnosis code category

V64—persons encountering health services for specific

procedures, not carried out—as a secondary diagnosis

with no procedure code assigned.

NOTES:

The operative approach
is coded when the
opening is followed
only by a diagnostic
procedure (for exam-
ple, a biopsy). There
are a few exceptions
for coding laparo-
scopic/thoracoscopic
approaches separately.
Follow coding instruc-
tions in the coding
book closely.

Category V64 can’t be
assigned as a principal
diagnosis.

Lesson 2

113

9.Incomplete Procedures

When coding incomplete procedures (procedures that

weren’t completed for a reason), follow these guidelines:

Incision only performed: code to the site of incision

Endoscopic approach unable to reach site: code
endoscopy only

Cavity or space entered: code to exploration of site

10.Failed procedures

If a procedure didn’t achieve the needed results, it may

be considered as having failed. Code the full procedure

as normal. Review medical record documentation and/or

query the physician if questions arise.

11.Stents

Stentsare implants used to restore flow of fluid and are

usually performed with other procedures. Code both the

procedure and the insertion of the stent.

Now let’s practice the principles for this section. Proceed to

the practical coding exercise for more information.

Medical Coding 2

114

Level I HCPCS (CPT) Procedural Coding

Hospital Outpatient Procedural Coding

Outpatient procedures usually include ambulatory surgeries

performed in an operating room, on-site clinic, surgical suite,

or ambulatory surgery center. In addition, all claims for

emergency room visits and patient visits with the status of

“observation” must be submitted with HCPCS codes.

Often new coders—and sometimes even experienced coders—

have difficulty trying to determine which items to code. When

reviewing a medical record, the amount of information can be

overwhelming, and sometimes the tendency may be to code

everything as a safety net. When coding outpatients (and

surgical reports of inpatients), it may be easier to review

operative reports and look for terms such as the following:

incision, excision, endoscopy, exploration.These words can

help you to narrow down the procedures that should be coded.

Practice Exercise 6A

Books Needed:

Clinical Coding Workout: Practice Exercises for Skill Development

ICD-9-CM coding book

CPT coding book

In your Clinical Coding Workout: Practice Exercises for Skill Development, complete exercises
1.376–1.400, “ICD-9-CMProcedure 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.

NOTES:

Observation patients
aren’t technically con-
sidered inpatients until
they’ve been admitted
as such. Physicians
may assign this
observation status to
patients for determining
the need for treatment
or review of a condi-
tion or postsurgical
complication.

For outpatient records,
don’t code approaches
and closures (just as in
ICD-9-CM).

Lesson 2

115

Guidelines for Assigning HCPCS Level I (CPT) Codes

For hospital outpatients, the following information is required

by the CMS for reporting:

Diagnoses—ICD-9-CMdiagnosis codes

Procedures—HCPCS Level I (CPT) codes

Note:Some hospitals still use ICD-9-CMprocedure codes for

statistical reporting purposes.

Follow these steps in assigning a HCPCS Level I (CPT)

procedure code:

1.Determine the procedure, test, or service to be coded.

Remember, look for such action terms as excisionand

incision.

2.Locate the main term in the CPT index (check under the

following categories: procedure, anatomic site, condition,

synonym, eponym, service, or abbreviation).

If the procedure or service isn’t listed in the alphabetic

index, locate the organ/anatomic site, condition/diagno-

sis, or synonym/eponym instead. Also, follow coding

book notes/directions. For example, reconstruction may

be listed under revision.

3.Review/select the subterms (indented below main term).

4.Follow cross-references.

5.Find the code in the main list section.

6.Review all notes for the selected code.

7.If applicable for the particular setting, select the appro-

priate modifier.

Using the CPT Book

The CPT book is divided into six sections: (1) evaluation

and management, (2) anesthesia, (3) surgery, (4) radiology,

(5) pathology, and (6) laboratory medicine. Because we’re

discussing hospital ambulatory (outpatient) guidelines in this

lesson, you’ll be focusing on the surgery and laboratory medi-

cine sections of CPT here. You’ll learn about the other CPT

sections in the next section that deals with physician office

NOTE:

Nevercode directly
from the CPT index.

Medical Coding 2

116

coding. However, let’s take a moment and explain why the

other sections for hospital ambulatory guidelines aren’t dis-

cussed here.

Coding and the Chargemaster

In the hospital setting, the chargemaster automates the

billing of services such as pathology, laboratory, and radiology.

A chargemasteris a computerized list of service codes and

descriptions that automatically matches charges with these

specific service codes. When one of the service codes is

performed for a patient, the hospital computer system auto-

matically assigns the code and applies the charge for that

service to the patient’s bill.

So, you may be wondering how you know what to code and

what’s assigned automatically by the chargemaster? Well, this

task can be tricky for a new coder. A good rule when coding

hospital records—inpatient or outpatient—is to remember

that you don’t need to assign codes for procedures or items

such as laboratory tests, X-rays, needle sticks, and equipment.

These assignments are all done automatically via the charge-

master. In a hospital setting, you need to focus only on

diagnoses and procedures as defined in previous sections.

HCPCS Level I (CPT) Ambulatory Surgery Coding

As previously discussed, HCPCS Level I—most commonly

referred to as CPT—is a listing of codes that physicians and

other health care providers use to report medical services

and procedures performed. Hospitals are required to report

HCPCS Level I (CPT) codes for all outpatients.

Basic Coding Guidelines for
Hospital Outpatient Services

When coding for ambulatory surgery,ICD-9-CMcodes for

diagnoses are also required.

NOTES:

You may also hear the
chargemaster referred
to as the charge
description master.

It’s very important to
use the most current
coding book. Using
codes and/or coding
books from previous
years could result in
incorrect statistics
and possibly denial of
reimbursement for
payment.

Lesson 2

117

HCPCS Level I (CPT) Codes for Procedures

Some common rules and guidelines to remember when

coding for ambulatory surgery are as follows:

1.The appropriate diagnosis code(s) from 001.0–V82.9

must be used to identify diagnoses or reason(s) for the

encounter/visit.

2.Codes that describe symptoms and signs are acceptable

for reporting purposes when an established diagnosis

hasn’t been confirmed by the physician.

3.List first the ICD-9-CMcode for the diagnosis or reason

for the encounter/visit shown in the medical record to

be chiefly responsible for the services provided. List any

additional ICD-9-CMdiagnosis codes that describe any

coexisting conditions.

4.Don’t code diagnoses documented as probable, suspected,

questionable, or rule out. Code the condition(s) that have

been established to the highest degree of certainty for

that encounter/visit. Such information as symptoms,

signs, abnormal test results, or other reasons for the

visit should be included.

5.Chronic diseases treated on an ongoing basis may be

coded and reported as many times as the patient

receives treatment and care.

6.Code all documented conditions that coexist at the time

of the encounter/visit and require or affect patient care,

treatment, and management.

7.Don’t code conditions that were previously treated and

no longer exist.

8.For patients receiving diagnostic services only, sequence

first the diagnosis, condition, problem, or other reason

for the encounter/visit. Codes for other diagnoses (for

example, chronic conditions) can be sequenced as addi-

tional diagnoses.

The only exception to this rule is that for patients receiv-

ing chemotherapy, radiotherapy, or rehabilitation, the

appropriate V code for the service is listed first, and the

diagnosis or problem for which the service is being per-

formed is listed second.

NOTES:

This process for out-
patient surgery coding
runs contrary to the
coding practices used
by hospitals and health
information manage-
ment (medical records)
departments for coding
the diagnoses of
hospital inpatients.

History codes (V10–
V19) may be used as
secondary codes if the
historical condition or
family history has an
impact on current care
or influences treatment.

Medical Coding 2

118

9.For patients receiving preoperative evaluations only,

sequence a code from category V72.8X—other specified

examinations—to describe the preoperative consultations.

Assign a code for the condition to describe the reason for

the surgery as an additional diagnosis. Code also any

findings related to the preoperative evaluation.

10.For ambulatory surgery, code the diagnosis for which the

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.

NOTES:

If the patient is just
admitted for “observa-
tion” status and meets
observation guidelines,
then follow the
observation/outpatient
guidelines for coding.

Lesson 2

119

Category III/Unlisted Procedures in
HCPCS Level I (CPT)

Unlisted/Category III CPT Procedure Codes

A group of unlisted five-digit alphanumeric CPT (Category III)

procedure codes that bear “T” endings provide a way of

reporting codes for new technologies and procedures. These

codes are temporary codes that should be used only as a

last resort because they’re often automatically flagged for

review from the payer (and may frequently be denied for

reimbursement). The payer will require additional, supportive

documentation when a claim is submitted.

Practice Exercise 6B

Books Needed:

Clinical Coding Workout: Practice Exercises for Skill Development

CPT coding book

Note:Even though in a hospital outpatient setting a coder would sometimes code both the
ICD-9-CMdiagnosis 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 Developmentbook, 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.

NOTE:

The first four positions
of these Category III
codes will be numeric,
with the alpha charac-
ter in the fifth position.
These Category III
codes should notbe
confused with HCPCS
Level III codes, which
have alpha characters
in the first position,
followed by four
numeric digits.

Medical Coding 2

120

Unlisted HCPCS Procedures Codes

These Category III codes have the following characteristics:

Allow coders to assign a code to a procedure that’s not
listed in the CPT coding book

Should be assigned only as a last resort (that is, check
HCPCS Levels II and III codes first)

Must be accompanied by supporting documentation
(for example, operative reports)

According to AMA guidelines, any Category III code that

hasn’t been added as a permanent CPT code after five years

is archived. In 2011, for the first time, they’re using “recy-

cled” Category III codes. There are three T-codes that have

been used in the past for other code descriptions. The symbol

indicating a recycled code is ❍(an open circle).

Now let’s practice the principles for this section. Proceed to

the practical coding exercise for more information.

Practice Exercise 6C

Books Needed:

Clinical Coding Workout: Practice Exercises for Skill Development

CPT coding book

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.

NOTE:

A complete list of
these unlisted proce-
dure codes appears
in the index of the
CPT coding book
under “Unlisted
Services and
Procedures.”

Assignment 6 Quiz

40952100

Books Needed:

Clinical Coding Workout: Practice Exercises for Skill Development

ICD-9-CM coding book

CPT 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.
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.

Part A: Complete the following multiple-choice questions.

1.Which of the following is an example of a HCPCS Level I code?

A.81.52

C.96410

B.011.60

D.Q0084

2.Hospital inpatient procedures and interventions are reported using

A.Volume 3 of ICD-9-CM.
B.Volume 3 of ICD-9-CMand HCPCS Level I.
C.HCPCS Level I.
D.HCPCS Level II.

3.For outpatient procedures, the CMS requires reporting codes using

A.Volume 3 of ICD-9-CM.
B.Volume 3 of ICD-9-CMand HCPCS Level I.
C.HCPCS Level I.
D.HCPCS Level II.

(Continued)

Lesson 2

121

Assignment 6 Quiz

40952100

4.The UHDDS definition for principal diagnosis applies to

A.inpatients.

C.inpatients and outpatients.

B.outpatients.

D.all coded information.

5.Which rule is correctwhen an outpatient is seen for chemotherapy?

A.List first the diagnosis, followed by the chemotherapy V code.
B.List first the chemotherapy V code, followed by the diagnoses.
C.List only the V code for chemotherapy.
D.List only the code for the diagnosis.

6.Review the following ICD-9-CMcoding instruction excerpt: Cardiotomy and pericardiotomy—
Code also cardiopulmonary bypass [extracorporeal circulation][heart-lung machine] (39.61)

According to this excerpt, how many ICD-9-CMprocedure 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?

A.Code V64.X as the secondary diagnosis with no procedure code assigned
B.Code V64.X as the principal diagnosis with no procedure code assigned
C.Code V64.X as secondary diagnosis with the procedure coded as completed
D.Code V64.X as principal diagnosis with the procedure coded as completed

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)

Medical Coding 2

122

Lesson 2

123

Assignment 6 Quiz

40952100

10.HCPCS Level III codes

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)

Medical Coding 2

124

NOTES

NAME ________________________________________________________________

ADDRESS ________________________________________________________________

CITY

________________________________________________________________

Check if this is a new address

PHONE

PLEASE PRINT

FOR YOUR INSTRUCTOR’S USE

GRADE

GRADEDBY

ANSWER SHEET

STUDENT NUMBER:

STATE/PROVINCE

ZIP/POSTAL CODE

CUT ALONG THIS LINE

ASSIGNMENT 6 QUIZ 40952100

Medical Coding 2

INDICATE YOUR ANSWER TO EACH QUESTION BY MARKING AN XIN THE
APPROPRIATE SQUARE. EXAMPLE:

Part A

1.

6.

2.

7.

3.

8.

4.

9.

5.

10.

Part B

5.1 ___________________________________________________________________
5.11 ___________________________________________________________________
5.22 ___________________________________________________________________
5.45 ___________________________________________________________________
5.55 ___________________________________________________________________
5.61 ___________________________________________________________________
5.65 ___________________________________________________________________
5.70 ___________________________________________________________________
5.74 ___________________________________________________________________
5.77 ___________________________________________________________________

HAVE YOU ENTERED YOUR STUDENT NUMBER IN THE SPACE PROVIDED?

A

B

C

D

X

A

B

C

D

A

B

C

D

A

B

C

D

A

B

C

D

A

B

C

D

A

B

C

D

A

B

C

D

A

B

C

D

A

B

C

D

A

B

C

D

Lesson 2

127

ASSIGNMENT 7:
PHYSICIAN OFFICE CODING

Read “Evaluation and Management (E/M) Service Guidelines”
(pp. 4–10) in your Current Procedural Teminology: CPT coding
book.

Coding for Physician Offices

You probably remember from your reading in Appendix A that

physicians are required to report ICD-9-CMcodes for diagnoses

and HCPCS codes for procedures and services. When coding

for physician office services and care, it’s important to ask

what the physician (or practitioner) is doing when providing

care. As a coder, this awareness will help you assign the most

accurate and inclusive code possible for the services. In these

sections, you’ll learn about how to code from the physician

office perspective.

Let’s take a look at an example of how a hospital coder

reports codes versus how a physician coder reports codes.

Example.On June 23, 2005, a patient was admitted to

the hospital for a total abdominal hysterectomy due to

endometriosis of the uterus.

Codes

HospitalICD-9-CM diagnosis code—617.0

Hospital ICD-9-CMprocedure code—68.4

Physician office ICD-9-CMdiagnosis code—617.0

Physician office CPT procedure code—58150

Reasoning

The hospital coder will report and bill for the facility’s

services and charges for the hysterectomy procedure using

the ICD-9-CMprocedure code of 68.4. The physician office

coder will bill the surgeon’s charges on a CMS-1500 form

using the CPT code 58150 for the hysterectomy procedure.

Both the hospital and the physician’s office will report the

patient’s diagnosis using the same ICD-9-CMdiagnosis

code of 617.0—endometriosis of the uterus. Let’s review

some different areas of coding for physician offices.

NOTE:

Don’t let the “physician
office perspective” con-
fuse you. Remember,
physicians work in a
variety of settings (for
example, hospitals,
outpatient centers,
clinics, personal
offices). In this lesson,
we’re focusing on how
the physician codes
and bills for different
services no matter the
setting. Whether a
physician offers serv-
ices in an office or at a
hospital, the physician
services provided will
still need to be coded.

Medical Coding 2

128

HCPCS Level I (CPT) Evaluation and
Management Codes for Physician
Office Coding

Introduction

Evaluation and management—orE/M—codesare 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:

Consultations

Skilled nursing visits

Office visits

Hospital inpatient visits

E/M codes are represented by CPT codes 99201–99499 and

appear at the front of the CPT coding book. Coders working

in physician offices report these E/M codes for payment

of services rendered by the physicians. Coders working in

acute-care hospitals—hospitals that provide short-term care

for patient—aren’t required to report E/M codes. However,

don’t confuse this with the work that physicians do during an

inpatient, acute-care setting. Acute-care hospital coders will

code the appropriate ICD-9-CMdiagnosis and procedure codes

for a hospital admission. This is how the hospital gets paid

(that is, reimbursed from providers such as insurance compa-

nies).However, the physician’s office will separately code his

or her time and services for treating the patient while in the

hospital. This is how the physician gets reimbursed.

NOTE:

In this subsection,
you’re learning about
coding only as it
relates to reimburse-
ment. However, it’s
important to remember
that the reporting of
codes serves other
important functions
such as statistical
compilation of diseases
and treatments; thus,
coding has an impact
beyond reimbursement.

Lesson 2

129

Let’s look at an E/M coding example to help you better

understand the process.

Example. An emergency department physician provides

critical care services (including CPR) to a cardiac arrest

patient for more than two hours.

Codes

427.5—cardiac arrest

99291—critical care and evaluation and management of

the critically ill or critically injured patient; first 30 to 74

minutes

99292, 99292—critical care and evaluation and manage-

ment of the unstable critically ill or unstable critically

injured patient, requiring the constant attendance of the

physician; each additional 30 minutes list separately in

addition to code for primary service

Reasoning

The physician will report the ICD-9-CMdiagnosis code

and then the appropriate E/M codes that cover this level

of service.

Basics of E/M Codes

E/M codes have the following characteristics:

Begin with 99

Identify the place or type of service (for example, out-
patient service, physician office, initial/subsequent care)

Define the extent of service (for example, detailed history
or examination)

Describe the nature of the presenting problem (for
example, moderate severity)

Identify the time typically required to provide a service

NOTE:

The outpatient coder
for the hospital would
code 427.5 as the
diagnosis and 92950—
cardiopulmonary
resuscitation—as the
CPT procedure.

Medical Coding 2

130

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.

Seven E/M Components

1.History: Key Component

The patient’s history includes the following information:

Chief complaint (CC)

Reason for the encounter

History of the present illness (HPI)—a chronologic
description of the development of the patient’s

illness/problem

Review of systems (ROS)—an inventory of the body
systems obtained through a series of questions

Past, family, and/or social history (PFSH)—a review of
the patient’s past experiences with illnesses, injuries,

and treatments; a review of medical events in the

patient’s family; an age-appropriate review of past

and current activities

2.Examination: Key Component

The extent of the physical examination of the patient

depends on the clinician’s judgment as well as the nature

of the presenting problem(s)/illness. The levels of E/M

services are based on four types of examinations that are

documented by specific items.

Problem focused—a limited examination of the
affected body area or organ system

Expanded problem focused—a limited examination
of the affected body area or organ system and other

symptomatic or related organ system(s)

Lesson 2

131

Detailed—an extended examination of the affected
body area(s) and other symptomatic or related organ

system(s)

Comprehensive—a general multisystem or complete
examination of a single organ system and other

symptomatic or related body area(s) or organ system(s)

3.Medical Decision Making: Key Component

Medical decision making refers to establishing and/or

selecting management options as determined by the

number of possible diagnoses and/or the number of

management options that must be considered; amount

and/or complexity of medical records, diagnostic tests,

and/or other information that must be obtained, reviewed,

and analyzed; and the risk of significant complications,

morbidity, and/or mortality as well as comorbidities

associated with the patient’s presenting problem(s),

diagnostic procedure(s), and/or the possible management

options. The levels of E/M services recognize four typesof

medical decision making: straightforward, low complexity,

moderate complexity, and high complexity.

4.Counseling

Counseling involves discussing with a patient and/or

family members one or more of the following:

Diagnostic results, impressions, and/or recommended
diagnostic studies

Prognosis

Risks and benefits of treatment

Instructions for treatment and/or follow-up

5.Coordination of Care: Patient management with other

health care professionals

6.Nature of the Presenting Problem

The nature of the presenting problem or illness is the sign,

symptom, or condition (that is, reason for the encounter)

withor without a diagnosis being established. The nature

Medical Coding 2

132

of a presenting problem can be a disease, condition, ill-

ness, injury, symptom, sign, finding, complaint, or other

reasonfor 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 andcontent of an appropriate examination to be

done; it definesthe 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

Stable

Recovering

Responding poorly

Significant complication(s)

Unstable

Urgent evaluation needed

Life-threatening problem

Presenting problems can be defined as

Minimal severity—a problem that may not require
the presence of a physician, but a service is provided

under the physician’s supervision

Self-limited or minor severity—a problem that runs
a definite and prescribed course, is transient in

nature, and isn’t likely to permanently alter the

patient’s health status or has a good prognosis with

management (that is, treatment)

Low severity—a problem where the risk of morbidity
without treatment is low or there’s little to no risk of

mortality without treatment and a full recovery is

expected without functional impairment

Moderate severity—a problem for which the risk of
morbidity without treatment is moderate, there’s a

moderate risk of mortality without treatment, there’s

an uncertain prognosis, or there’s an increased

probability of prolonged functional impairment

Lesson 2

133

High severity—a problem for which the risk of
morbidity without treatment is high to extreme and

there’s a moderate-to-high risk of mortality without

treatment or there’s a high probability of severe,

prolonged functional impairment

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:

Initial hospital care

Emergency department

Office—new patient

Office and hospital consultations—E/M

Two of the three key or essential components are required for

the following:

Subsequent hospital

Office—established patient E/M services

Levels of E/M Codes

Various levels of E/M codes describe different items such as

skill, effort, time, responsibility, and so forth. Each E/M level

includes the following:

Examinations

Evaluations

Treatment

Conferences with or concerning patients

Preventive pediatric or adult health supervision

Other, similar medical services

Medical Coding 2

134

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.

Assigning E/M Codes

To help in assigning E/M codes, ask the following questions:

What type of service is the patient receiving?

What’s the place of service?

Is the patient a new or established patient?

A new patient is one who hasn’t been seen by any clinician

of the same specialty within the previous three years. For a

new-patient encounter, all three of the E/M key components

(history, examination, and medical decision making) must be

documented.

An established patientis one who has been seen by the clinician

or by another clinician of the same specialty within the past

three years. For an established-patient encounter, two of the

three E/M key components (history, examination, and medical

decision making) must be documented in the patient record.

The following CPT code ranges are the E/M codes that provide

distinctions between new and established patients.

99201–99215 Office/other outpatient services

99324–99337 Domiciliary, rest home, or custodial
services

99341–99350 Home services

99381–99397 Preventive medicine services

Lesson 2

135

These steps should be taken when selecting an E/M service.

1.Identify the category or subcategory of the service pro-

vided (for example, new patient, established patient,

consultation)

2.Review the reporting instructions for the selected cate-

gory or subcategory.

3.Review the level of E/M service descriptors and examples

in the selected category.

4.Determine the extent of history obtained.

5.Determine the extent of examination performed.

6.Determine the complexity of medical decision making.

7.Select the appropriate level of E/M service.

2010 CMS Final Rule in
Regard to Consultations

As of January 2010, CMS will no longer reimburse for con-

sultations. This doesn’t mean the codes for consultations will

be deleted from the CPT manual. As a coder, you’ll still have

to know how to code consultations. However, for billing

purposes, you must pay attention to the patient’s primary

insurer. If the primary insurer is Medicare in a consultation

situation, you must instead code an appropriate initial visit

E/M code as outlined in the following.

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

Medical Coding 2

136

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.

Lesson 2

137

NOTES:

Appendix A in the CPT
coding book provides a
list of currently used
modifiers for both
HCPCS Level I (CPT)
and HCPCS Level II.

HCPCS Level II modi-
fiers may be used with
any level of HCPCS
codes.

You’ll learn more
about HCPCS Level II
modifiers in the next
section.

Code Modifiers

Modifiersare two-digit alphanumeric, numeric, or alpha

codes that are appended to the end of HCPCS Level I (CPT)

and HCPCS Level II codes. A modifier indicates that a service or

procedure was altered by specific circumstances. Modifiers are

reported only by physicians and Medicare Part B providers—

and not by hospitals. The use of modifiers allows more specific

and accurate reporting. In many cases, modifiers allow physi-

cians to bill for the additional charges that are represented.

Modifiers for HCPCS Level I (CPT) are two-digit numeric

codes. Examples of CPT (HCPCS Level I) modifiers include

the following:

-25—Significant, separately identifiable evaluation and
management service by the same physician on the same

day of the procedure or other service

-50—Bilateral procedure

Let’s take a look at an example of coding HCPCS Level I (CPT)

with a modifier.

Example.The patient underwent a bilateral needle core

breast biopsy.

Procedure Codes. 19100-50: Biopsy of breast; percutaneous,

needle core, not using imaging guidance (separate procedure)—

bilateral

Practice Exercise 7A

Books Needed:

Clinical Coding Workout: Practice Exercises for Skill Development

CPT coding book

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.

Medical Coding 2

138

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

payment. If you understand when and how to use them,

you’ll likely reduce the problems caused by third-party payer

denials and also help expedite the processing of claims.

It’s important to note that modifiers can’t be used with all

HCPCS codes. For example, some modifiers may be used only

with E/M codes (for example, -24 or -25), and others are

used only with procedure codes (for example, -58 or -79). At

the beginning of each section of the CPT, guidelines appear

that list or describe the modifiers that may be used with the

codes in that section.

Place of Service Codes

For every physician service coded, you’ll need to indicate

where that service was provided. The majority of physician

services will probably be performed in the office (site of service

modifier). Sometimes the physician will see a patient at the

hospital or some other setting outside the office. This is indi-

cated by using a different place of service code.

Appropriate Use of Modifiers

Modifiers are reported only by physicians (and other Medicare

Part B providers) when they submit claims for services.

Modifiers aren’t used for outpatient hospital services.

You can ask some general questions when determining if you

should code modifiers. If the answer to any of the following

questions is yes, then it’s appropriate to use the applicable

modifier.

NOTE:

Appendix A of the CPT
manual contains a
comprehensive list of
the Level I modifiers
with definitions for
correct use. Use of the
CPT guidelines and
Appendix A is critical
to the appropriate use
of modifiers.

Lesson 2

139

NOTE:

Unbundling means
reporting multiple
codes for a procedure
when one procedure
would be sufficient to
cover all the services
mentioned. Unbundling
can be considered
a fraudulent practice
to gain a higher
reimbursement.

1.Will the modifier add more information regarding the

anatomic site of the procedure?

Example. Cataract Surgery on the Right or Left Eye

2.Will the modifier help eliminate the appearance of

duplicate billing?

Examples. Use modifier -77 to report the same proce-

dure performed more than once by different physicians.

Use modifier -25 to report significant, separately identifiable

evaluation and management service by the same physician

on the same day of the procedure or other service.

Use modifier -58 to report staged or related procedure or

service by the same physician during the postoperative

period.

Use modifier -78 to report a return to the operating room

for a related procedure during the postoperative period.

Use modifier -79 to report an unrelated procedure or

service by the same physician during the postoperative

period.

3.Would a modifier help eliminate the appearance of

unbundling?

Example.CPT codes 90760 (Infusion therapy, using

other than chemotherapeutic drugs, per visit) and 36000

(Introduction of needle or intracatheter, vein). If procedure

36000 was performed for a reason other than as part of the

IV infusion, modifier -59 would be appropriate (for a code

of 36000-59).

Let’s look at an example to help you understand the differ-

ences in coding physician services using modifiers and

outpatient services.

Example. Patient received bilateral reduction of inguinal

hernia as a hospital outpatient.

Procedure Codes

49505-50 (Physician claim)

49505, 49505 (Hospital claim)

Medical Coding 2

140

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.

HCPCS Level I (CPT) Medicine Coding
for Physician Offices

Medicineincludes a wide variety of specialties and services.

“Medicine” encompasses CPT codes 90281–99607. It’s impor-

tant to remember that some procedures or services listed in

this section may be performed in conjunction with other

services and procedures listed in other CPT sections. Pay

close attention to coding guidelines and notations in the CPT

coding book for correct coding assignment.

Modifiers Used with Medicine Codes

There’s an extensive list of medicine code modifiers. Pay

special attention to the notes in your CPT coding book

regarding the use of medicine code modifiers.

Practice Exercise 7B

Books Needed:

Clinical Coding Workout: Practice Exercises for Skill Development

CPT coding book

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.

NOTES:

When the immuniza-
tion is the only service
provided during an
encounter, the physi-
cian can also bill for
a minimal level of
service (for example,
99211) plus the
immunization code.

Lesson 2

141

NOTES:

For Medicare cases, the
appropriate Level II
HCPCS code list is also
required for identifica-
tion of a specific drug.
For other payers, code
99070 may be used.

Shunts, cannulas,
and fistulas for hemo-
dialysis are coded to
the surgery section.

The definitions for
new and established
patients apply for
ophthalmologic codes.

For Medicare cases, a
code from the HCPCS
Level II code list iden-
tifying the specific drug
must also be reported.
For other payers, code
96545 can be reported.

For Medicare cases, a
more specific code may
exist in the HCPCS
Level II codes for
reporting the supply.

Anesthesia codes
aren’t reported by
acute-care hospitals.

For physician reporting,
the anesthesiologist
determines the physi-
cal status modifier, and
supportive information
should be documented
in the medical record.

Basic CPT Coding Guidelines for
Medical Services and Procedures

1.Code series 90476–90749 for active and passive

immunization.

2.For procedures requiring prolonged intravenous infusion

with the presence of a physician, code 96365 (first hour

of infusion) and 96366 (each additional hour up to eight

hours). Codes 96367–96371 are other specific infusion

codes.

3.Therapeutic or diagnostic injections should be coded to

series 96372–96379.

4.Code psychiatric services to series 90801–90899.

5.Services related to end-stage renal disease, hemodialysis,

and peritoneal dialysis should be coded to series 90935–

90999.

6.Ophthalmologic medical services should be coded to

series 92002–92499.

7.Code cardiovascular diagnostic and therapeutic services

to series 92950–93799.

8.Code the administration of chemotherapy to series

96401–96549.

9.Code 99070 can be used for physician supplies and

materials.

HCPCS Level I (CPT) Anesthesiology
Coding for Physician Offices

Anesthesia services cover general, regional, or local anesthe-

sia. The anesthesia section covers codes 00100–01999; these

codes are arranged by body site and then by specific surgical

procedure performed. When looking up the codes in the CPT

index, reference under the terms anesthesiaand analgesia.

Medical Coding 2

142

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

when anesthesia services are provided during situations

or circumstances that make the administration of anes-

thesia more difficult.

Example. Anesthesia for total knee replacement for

72-year-old patient with mild systemic disease.

Codes

01402-P2—Anesthesia for open procedures on knee

joint; total knee arthroplasty (physical status modifier)

99100—E/M code for anesthesia for patient of extreme

age, that is, under 1 year and over age 70

4.Standard modifiers are applicable to this section.

Modifiers Commonly Used with
Anesthesia Services

-22—Unusual procedural services

-23—Usual anesthesia

-32—Mandated services

-51—Multiple procedures

-53—Discontinued procedure

-59—Distinct procedural service

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.

NOTES:

Conscious sedation
codes are found in
the “Medicine Section”
of the CPT manual
and aren’t reported in
conjunction with
anesthesia codes.
Procedures marked
with include con-
scious sedation, so
it can’t be coded
separately.

Modifier -47 (Anes-
thesia by surgeon) is
never used with anes-
thesia CPT codes
(series 00100–01999).

Lesson 2

143

NOTES:

The radiology codes
are coded/reported
by the office of the
radiologist performing
the services. If the
radiologic procedure
is performed in the
hospital, the hospital
coder won’t code it.
Instead, the radiologic
procedure is assigned
a HCPCS code auto-
matically through the
hospital’s computerized
chargemaster system.

Now let’s practice the principles for this section. Proceed to

the practical coding exercise for more information.

HCPCS Level I (CPT) Radiology Coding
for Physician Offices

Most physicians don’t have radiologic equipment in their

offices. In many cases, the physician refers patients for radio-

logic procedures to hospitals or other radiologic centers. In

this case, the physician office coder doesn’t assign radiology

codes unless the physician provides radiologic supervision

and interpretation.

HCPCS Level I (CPT) radiology codes have several subsections.

Diagnostic Radiology (diagnostic imaging)—70010–76499

Diagnostic Ultrasound—76506–76999

Radiologic Guidance—77001–77032

Breast, Mammography—77051–77059

Bone/Joint Studies—77071–77084

Radiation Oncology—77261–77799

Nuclear Medicine—78000–79999

Practice Exercise 7C

Books Needed:

Clinical Coding Workout: Practice Exercises for Skill Development

CPT coding book

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.

Medical Coding 2

144

Modifiers Commonly Used with Radiology

-22—Unusual procedural services

-26—Professional component

-51—Multiple procedures

-52—Reduced services

-53—Discontinued procedures

-59—Distinct procedural service

-RT & -LT—Bilateral radiology procedures for Medicare
claims (and other payers as directed)

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.

Radiologic Supervision and Interpretation

Many radiology codes include “radiological supervision and

interpretation.” These are codes that describe the procedure

performed by two physicians. If one physician performs both

the supervision and interpretation and the actual procedure,

then two codes are assigned. These codes include a radiology

code and procedure code (for example, surgery).

Let’s take a closer look with an example.

Example. A patient had a unilateral lymphangiography of

the extremity (complete procedure) all performed by the

same physician.

Codes

75801

38790

Reasoning

Code 75801 identifies the radiology procedure, including

interpretation.

Code 38790 identifies the lymphangiography injection.

NOTES:

Radiologic supervision
and interpretation
codes don’t apply to
codes 77261–77799
(radiation oncology).

Radiology procedures
can be referenced in
the CPTbook by look-
ing up the main term.
Terms such as X-ray,
MRI,
and MRAshould
be referenced by their
full term name. An
important point to
remember when
coding radiologic
procedures is that
there are different
codes if a contrast
material is used.

Lesson 2

145

NOTE:

The CPT medicine
section contains ultra-
sound procedure codes
for arterial, venous,
cerebrovascular
arterial, visceral/penile
vascular, and echocar-
diography (heart)
studies.

Diagnostic Radiology

Diagnostic radiology, or diagnostic imaging, is covered under

codes 70010–76499. The codes are subdivided by anatomic

site and then again by specific type of procedure performed.

Diagnostic radiology procedures include X-rays, computed

axial tomography (CAT) scans, magnetic resonance images

MRIs, and magnetic resonance angiograms MRAs.

Contrast materialsare radiopaque substances that help make

the structure(s) being viewed show up. Examples of contrast

agents include the following:

Barium (Gastrografin)

Iohexol

Iopamidol

Hypaque

Renografin

You may see contrast materials used with the following

examinations/procedures:

Barium enema

Angiography

Cystogram

Endoscopic retrograde cholangiopancreatography

Intravenous pyelogram

Urogram

Lymphangiography

Cholecystogram

Contrast materials may or may not be used with CT scans

and MRIs.

Medical Coding 2

146

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

ultrasoundor 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

Neoplastic tumors

Hodgkin’s disease

Small cell lung cancer

Head and neck cancers

Radiation can be used internally or externally. External

radiationis the delivery of ionizing radiation from an external

source through the patient’s skin to the tumor. Internal

radiation,also known as brachytherapy, applies a radioactive

material inside the patient’s body or in close proximity to the

patient.

Nuclear Medicine

Nuclear medicineis the administration of radioactive elements

(that is, radioisotopes) to help diagnose disease. Nuclear medi-

cinecodes are covered in 78000–79999.

Now let’s practice the principles for this section. Proceed to

the practical coding exercise for more information.

NOTE:

When these tests are
performed for cardio-
vascular stress testing,
use the appropriate
code from categories
93015–93018. Modifier
-51 is used with the
following nuclear
medicine diagnostic
procedures codes:
78306, 78320, 78803,
78806, and 78807.

Lesson 2

147

Practice Exercise 7D

Books Needed:

Clinical Coding Workout: Practice Exercises for Skill Development

CPT coding book

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.

NOTES:

Remember that in the
hospital setting the
chargemaster auto-
mates the codes for
the billing of laboratory
and pathology services.
Therefore, as a hospital
coder, you wouldn’t
code these services.

Some physicians now
send the sample/speci-
men to a freestanding
or hospital-based labo-
ratory for processing.
In this case, the coder
who works for the
physician can code only
the collection/ handling
of the specimen.

HCPCS Level I (CPT) Pathology
and Laboratory Coding for
Physician Offices

The “Pathology” and “Laboratory” sections cover CPT code

ranges 80047–89398.

Laboratory servicesencompass clinical laboratory settings

and services that are equipped for testing and analysis.

Pathology servicesare those that focus on microbiology,

immunopathology, blood/transfusion medicine, chemical

pathology, cytogenetics, hematology, coagulation, toxicology,

and medical microscopy.

Modifiers Commonly Used with
Pathology and Laboratory

-22—Unusual procedural services

-26—Professional component

-32—Mandated services

-52—Reduced services

-53—Discontinued procedures

-59—Distinct procedural service

-90—Reference (outside) laboratory

Medical Coding 2

148

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:

1.Each laboratory test billed must be medically necessary.

2.Determine if the physician performed the complete

procedure (or only part of it).

3.If all the tests in a panel aren’t being performed, code

the individual tests separately.

4.Individual chemistry tests not performed as part of

the automated multichannel tests should be coded to

series 82000–84999.

5.Hematology and coagulation (complete blood count, bone

marrow aspiration/biopsy, and so forth) should be coded

to series 85002–85999.

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.

NOTE:

Medicare and other
insurers want you to
use the panel codes
as much as possible
instead of billing
the tests separately.
However, each test
in the panel must be
necessary for the
diagnosis and/or treat-
ment of the patient.

Lesson 2

149

Practice Exercise 7E

Books Needed:

Clinical Coding Workout: Practice Exercises for Skill Development

CPT coding book

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.

Medical Coding 2

150

Assignment 7 Quiz

40952200

Books Needed:

Clinical Coding Workout: Practice Exercises for Skill Development

ICD-9-CM coding book

CPT coding book

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 Developmentbook.
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.

Part A: Complete the following multiple-choice questions.

1.Which of the following is the correctset of coding guidelines that physicians are
required to report?

A.ICD-9-CMcodes for diagnoses and HCPCS codes for procedures and services
B.ICD-9-CMcodes for diagnoses, HCPCS and ICD-9-CM codes for procedures
C.Only HCPCS and ICD-9-CMprocedure 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?

A.Only physician office services
B.Only services the physician perform in hospitals
C.Only services performed in outpatient centers
D.All physician services performed, no matter where the service occurred

3.A significant portion of the services that physicians provide are reported by _______ codes.

A.E

C.E/M

B.V

D.Q/T

4.Which of the following codes requires the use of modifiers?

A.ICD-9-CMprocedures

C.ICD-9-CM diagnosis codes

B.HCPCS

D.Varies according to the setting

(Continued)

Lesson 2

151

Assignment 7 Quiz

40952200

5.Using two or more codes when one code would be sufficient to represent all services is an

example of

A.unbundling.

C.“Code Also.”

B.bundling.

D.inclusion.

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?

A.73090-50

C.73090-LT, 73090-RT

B.73221

D.73090, 73090-59

9.How does a physician ensure that each laboratory test performed in his/her office is
reimbursed?

A.Assign a separate code for each test
B.Report the appropriate panel code for the tests.
C.Make sure that each test is documented
D.Only order and report medically necessary tests

10.What is the correctcode 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)

Medical Coding 2

152

Assignment 7 Quiz

40952200

Part B: Complete the following exercises in yourClinical Coding Workout: Practice
Exercises for Skill Development workbook.

Exercises

6.1 (p. 160)
6.6 (p. 162)
6.11 (p. 163)
6.16 (p. 166)
6.23 (p. 167)
6.28 (p. 168)
6.33 (p. 170)
6.38 (p. 171)
6.41 (p. 172)
6.53 (p. 175)

NAME ________________________________________________________________

ADDRESS ________________________________________________________________

CITY

________________________________________________________________

Check if this is a new address

PHONE

PLEASE PRINT

FOR YOUR INSTRUCTOR’S USE

GRADE

GRADEDBY

STUDENT NUMBER:

STATE/PROVINCE

ZIP/POSTAL CODE

ASSIGNMENT 7 QUIZ 40952200

Medical Coding 2

CUT ALONG THIS LINE

INDICATE YOUR ANSWER TO EACH QUESTION BY MARKING AN XIN THE
APPROPRIATE SQUARE. EXAMPLE:

Part A

1.

6.

2.

7.

3.

8.

4.

9.

5.

10.

Part B

6.1 ___________________________________________________________________
6.6 ___________________________________________________________________
6.11 ___________________________________________________________________
6.16 ___________________________________________________________________
6.23 ___________________________________________________________________
6.28 ___________________________________________________________________
6.33 ___________________________________________________________________
6.38 ___________________________________________________________________
6.41 ___________________________________________________________________
6.53 ___________________________________________________________________

HAVE YOU ENTERED YOUR STUDENT NUMBER IN THE SPACE PROVIDED?

A

B

C

D

X

A

B

C

D

A

B

C

D

A

B

C

D

A

B

C

D

A

B

C

D

A

B

C

D

A

B

C

D

A

B

C

D

A

B

C

D

A

B

C

D

ANSWER SHEET

Lesson 2

155

ASSIGNMENT 8:
HCPCS LEVEL II CODING

Introduction

Level II codesare 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

Ambulance services

Durable medical equipment

Prosthetics

Orthotics

Pharmaceuticals

Supplies

Procedures

Tests

In 2000, the Health Insurance Portability and Accountability

Act (HIPAA) requirement for standardized coding systems

named HCPCS Level II codes as the standardized coding system

for health care equipment and supplies that aren’t identified

by the HCPCS Level I (CPT) codes. Level II codes are developed

and maintained by the CMS with quarterly updates.

HCPCS Level II codes are made up of one alpha character

(a letter from A–V, excluding S), followed by four numeric

digits. Examples of Level II codes include

Q0084—Chemotherapy administration by IV infusion

J9190—Fluorouracil, 500 mg

A4367—Ostomy belt, each

P9021—Red blood cells, each unit

HCPCS Level II has modifiers that may either be alphanumeric

or two alpha characters. Also, the modifiers found in this level

may also be used in HCPCS Level I (CPT) when appropriate.

Be sure to follow coding guidelines when assigning modifiers.

Medical Coding 2

156

HCPCS Level II Sections

HCPCS Level II codes are broken into sections based on the

alpha character at the beginning of the code. These sections

include the following:

A codes: A0021–A9999—Transportation services,
including ambulance, chiropractic, medical and surgical

supplies, and miscellaneous

B codes: B4034–B9999—Enteral and parenteral therapy

C codes: C1178–C1900—Pass-through items used only
by hospital outpatient claims

D codes: D0120–D9999—Dental procedures

E codes: E0100–E8002—Durable medical equipment

G codes: G0008–G8628—Procedures/professional ser-
vices (not found in CPT); G9001–G9143—Coordination of

care/demonstration project items and services

H codes: H0001–H2037—Alcohol and drug abuse treat-
ment services

J codes: J0120–J9999—Drugs administered, including
oral and chemotherapy drugs (drugs require both Level I

and Level II codes)

K codes: K0001–K0899—Durable medical equipment,
prosthetics, orthotics, supplies

L codes: L0100–L9900—Orthotic and prosthetic proce-
dures, devices

M codes: M0064–M0301—Medical services

P codes: P2028–P9615—Pathology and laboratory services

Q codes: Q0035–Q9968—Miscellaneous services (tempo-
rary codes)

R codes: R0070–R0076—Radiology services

S codes: S0012–S9999—Temporary national codes
(nonmedical)

NOTE:

All codes beginning
with D are dental
codes copyrighted
by the American
Dental Association.

The HCPCS Level II
codes aren’t found in
the CPT book. If you
haven’t already done
so, you can download
these codes from the
CMS Web site. You’ll
find directions for the
download process in a
later section.

Lesson 2

157

T codes: T1000–T5999—National codes established for
state Medicaid agencies

V codes: V2020–V5364—Vision, hearing, and speech-
language pathology services

Types of HCPCS Level II Codes

Permanent National Codes

Permanent national codesare used by all private and public

health insurers to provide standardized coding for claims

submission and processing.

Dental Codes

Dental codes (D codes)are a separate category of national

codes. The Current Dental Terminology (CDT)is a publication

copyrighted by the American Dental Association (ADA) that

lists codes used for billing related to dental procedures and

supplies that are included in HCPCS Level II.

Miscellaneous Codes

HCPCS Level II includes categories for miscellaneous or not

otherwise classifiedcodes. These codes are used when there’s

no existing code for an item or service (that is, new services/

items or services/items that are rarely used).

Temporary National Codes

Temporary HCPCS Level II codesare assigned by the CMS

to cover immediate needs regarding items and services that

have no codes (that is, before the next annual update is pub-

lished). For example, G codes designate procedures and

services being reviewed before inclusion in CPT, and S codes

are assigned for private payers).

For annual updates, some temporary codes may be replaced

with permanent codes. This change is reflected in the annual

update by deleting the temporary code and redirecting the

coder to the cross-referenced permanent code.

NOTES:

Miscellaneous codes
should be used spar-
ingly by the coder.
Claims with miscella-
neous codes are
manually reviewed
by the payer. The
item or service being
billed must be clearly
described, and pricing
information must be
provided along with
documentation to
explain why the
beneficiary needs the
item or service.

Because S codes are
assigned for private
payers, they’re not
recognized by
Medicare.

Medical Coding 2

158

Types of Temporary HCPCS Codes

C codesare for items that could be billed under the hospital

outpatient prospective payment system (HOPPS).

G codesare used to identify professional health care procedures

and services that should be added to Level I (CPT).

Q codesidentify services that are needed for claims processing

but wouldn’t be classified as Level I (CPT) and aren’t identified

by Level II.

K codesare used by the durable medical equipment regional

carriers (DMERCs) when the currently existing permanent

Level II codes don’t include the codes needed to implement a

DMERC medical review policy.

S codesare used by private insurers to report drugs, serv-

ices, and supplies for which there are Level II codes, but for

which codes are needed by the private sector to implement

policies, programs, or claims processing for private insurance

processing.

H codesare used by those state Medicaid agencies that are

mandated by state law to establish separate codes for identifying

mental health services such as alcohol and drug treatment

services.

T codesare 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

NOTES:

C codes are used
exclusively for HOPPS
purposes and are valid
only for Medicare
claims submitted by
hospital outpatient
departments.

The Medicaid program
also uses these codes,
but they’re not payable
by Medicare.

T codes aren’t used
by Medicare but can
be used by private
insurers.

Level II modifiers apply
whether Medicare is
the primary or
secondary payer.

Lesson 2

159

As just mentioned, some situations require Level I (CPT)

codes and modifiers to be combined with Level II codes and

modifiers.This process may be referred to as multilevel coding.

Let’s look at an example to help you understand better.

Example. A Medicare patient has tendon surgery on the

right palm and left middle finger.

Codes

26180-F2

26170-59-RT

Reasoning

The 26180-F2 is a CPT code that reports excision of ten-

don, palm, flexor, single (separate procedure), each, and the

modifier F2 reports the third digit, left hand.

The 26170-59-RT is a CPT code that reports excision of

tendon, finger, flexor (separate procedure), and each ten-

don. The Level I (CPT) modifier -59 reports that this is a

separate procedure. The Level II modifier -RT reports that

this was performed on the right hand.

The 26180 code is reported first because this surgery has a

higher reimbursement value. However, you shouldn’t worry

about reimbursement value at this point. You’ll learn much

more about sequencing correctly for reimbursement in the

course on reimbursement.

Guidelines for Coding HCPCS Level II Codes

For the HCPCS Level II exercises in your study guide and

your coding workbook, you should use the following link to

download the current list of HCPCS Level II codes (provided

by the CMS for free). If you haven’t done so already, be sure

to download the HCPCS Level II code list before you go any

further.

Follow these steps to access the HCPCS Level II codes:

1.Go to the CMS Web site (http://www.cms.gov/
HCPCSReleaseCodeSets/ANHCPCS/list.asp).

2.Scroll down and click on 2011 Alpha-Numeric HCPCS

File.

3.Click on 2011 Alpha-Numeric HCPCS File (ZIP, 805KB).

NOTES:

Although a HCPCS
Level II coding book
isn’t required for this
course, you’ll have a
separate book if you’re
coding these types of
services in your job.
Unlike CPT, HCPCS
Level II codes aren’t
copyrighted by a
private organization
(with the exception of
D codes). Therefore,
there are several
different publishers
that produce HCPCS
Level II coding books.
The guidelines listed
next are the same
guidelines that are
followed when coding
with a HCPCS Level II
coding book.

Medical Coding 2

160

4.Click Openon 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.

Coding HCPCS Level II Drugs

HCPCS Level II drugs are listed under the J codes.J drug

codes cover the range from J0120–J9999. Drugs administered

include oral and chemotherapy drugs. Chemotherapy drugs

are listed within the range J8999–J9999.

For an oncology office—aside from the temporary G codes for

Medicare drug administration—the most important section of

HCPCS Level III is the J code section. The J codes describe

most of the drugs and injectable products that are adminis-

tered in the health care field.

It’s important to get a new HCPCS Level II coding book each

year, because new drugs are developed and approved each

year. Furthermore, the definition of a J code can change in

terms of dosage or billing units. If you aren’t aware of the

changes, you could bill incorrectly for drugs administered. For

instance, if the unit definition of a J code changes from 20 mg

to 5 mg, and you’re billing for a 100 mg dosage, that unit

definition change makes a big difference in billing increments.

NOTES:

Q codes are used for
chemotherapy adminis-
tration. Thus, J drug
codes are used for
coding chemotherapy
drugs, and Q codes
are used for coding
chemotherapy
administration.

Level II HCPCS codes
are updated on a quar-
terly basis. The annual
updates appear on the
CMS Web site in late
November or early
December. The Web
site address is listed in
the previous section
and in the Instructions
section of this study
guide.

Lesson 2

161

J codes describe not only a particular drug, but also a partic-

ular amount (for example, dosage, container quantity) of that

drug. The coder is also responsible for calculating the appro-

priate number of units to bill.

Now let’s practice the principles for this section. Proceed to

the practical coding exercise for more information.

Coding HCPCS Level II Supplies

Medical and surgical supplies are covered under HCPCS

Level II series codes A4206–A8999. An example of a medical/

surgical supply may be a sterile needle (A4215). Coding sup-

plies can be a tricky and confusing process because many

supplies are included within the code for the office visit or

the procedure performed.

Payment for many physician office medical supplies is consid-

ered included in the allowable amount for the service being

billed to Medicare and other insurers using the Medicare fee

schedule. Separate payment for supplies used incidental to

the physician’s service may be made by some payers if you

use CPT code 99070 (supplies and materials provided by the

physician over and above those usually included with the

office visit or other services rendered) or A4550 (surgical trays).

Practice Exercise 8A

Books Needed:

Clinical Coding Workout: Practice Exercises for Skill Development

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:

A good rule of thumb
to remember when
coding HCPCS Level II
supplies is: If the
physician’s office pro-
vides additional
supplies when perform-
ing a procedure (that
is, above and beyond
the supplies customar-
ily used for the type of
procedure), then a
HCPCS Level II code
should be assigned to
report the proper use
of resources and for
the physician to
receive proper
reimbursement.

Medical Coding 2

162

Billing for Surgical Trays (HCPCS A4550)

For certain procedures, billing for supplies in addition to

the procedure itself is allowed. When a separate payment is

allowed, use HCPCS code A4550 for a surgical supply tray

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.

Coding HCPCS Level II
Ambulance/Transportation

HCPCS Level II ambulance/transportation codes are listed

under series A0021–A0999. Ambulance transport services are

reported based on mileage (per mile). Ambulance waiting time

is measure in 30-minute (half-hour) increments.

Ambulance (transportation) services have special single-

character modifiers that indicate both the origin and

destination of the services. These modifiers include

-H: Hospital

-P: Physician’s office

-R: Residence

Practice Exercise 8B

Books Needed:

Clinical Coding Workout: Practice Exercises for Skill Development

HCPCS Level II list from the CMS Web site (see download directions on page 159)

In your Clinical Coding Workout: Practice Exercises for Skill Developmentworkbook, 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.

NOTE:

Medicare doesn’t allow
separate payment for
supplies or surgical
trays.

When coding transportation services, two modifiers are assigned.

The first indicates the origin of the transportation (pickup),

and the second indicates the destination (drop-off).

For example, if a patient was picked up at a physician’s office

and dropped off at a hospital, the modifier -PH is assigned to

the appropriate HCPCS Level II code.

Definitions: Level of Service

There are levels of service that are used with this category of

codes; each service must be deemed medically necessary to

be reimbursed.

Basic Life Support (BLS). Basic life support (BLS) services

include the establishment of a peripheral intravenous (IV) line.

Advanced Life Support, Level 1 (ALS1).This level includes

assessment by an advanced life support (ALS) provider and/or

one or more ALS interventions.

Advanced Life Support, Level 2 (ALS2). This level is defined

as the administration of at least three different medications

and/or one or more of the following ALS procedures:

Manual defibrillation/cardioversion

Endotracheal intubation

Establishment of a central venous line

Cardiac pacing

Chest decompression

Establishment of a surgical airway

Establishment of an intraosseous line

Specialty Care Transport (SCT).A level of interfacility

service provided for a critically injured/ill patient that’s

beyond the scope of paramedic service.

NOTES:

An ALS provider is
trained to the level of
the emergency medical
technician (EMT)—
intermediate or
paramedic. That is, an
ALS intervention is
beyond the scope of an
EMT—Basic.

Specialty Care
Transport
is necessary
when a patient’s condi-
tion requires ongoing
care that must be pro-
vided by one or more
health professionals
in an appropriate
specialty area (nursing,
medicine, respiratory
care, cardiovascular
care, or a paramedic
with additional
training).

Lesson 2

163

Medical Coding 2

164

Paramedic Intercept (PI). PI provides ALS services to a

patient who has been transported by ambulance staffed by

personnel not qualified to administer such services.

Fixed-Wing Air Ambulance (FW). This level of service is

provided when the patient’s medical condition is so severe

that transportation by either basic or advanced life support

ground ambulance isn’t appropriate.

Rotary Wing Air Ambulance

Rotary-Wing Air Ambulance (RW).Provided when the

patient’s medical condition is such that transportation by

either basic or advanced life support ground ambulance isn’t

appropriate.

Now let’s practice the principles for this section. Proceed to

the practical coding exercise for more information.

Practice Exercise 8C

Books Needed:

Clinical Coding Workout: Practice Exercises for Skill Development

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.

NOTES:

Sometimes fixed-wing
air ambulance may be
necessary because the
geographic point of
pickup is inaccessible
by land vehicle; in
other situations, great
distances or other
obstacles make fixed-
wing air ambulance
necessary.

Rotary-wing air
ambulance may be
necessary when the
point of pickup is
inaccessible by land
vehicle; in other situa-
tions, great distances
or other obstacles
make rotary-wing air
ambulance necessary.

Coding HCPCS Level II
Durable Medical Equipment

Durable medical equipment is covered under HCPCS Level II

E codes. The code ranges include

E0100–E0159: Ambulatory devices

E0160–E0175: Commodes and accessories

E1500–E1699: Artificial kidney machines and
accessories

Durable medical equipment (DME)is defined by Medicare as

equipment that meets the following specifications:

Serves a medical purpose

Can be used repeatedly

Is used in a patient’s home

Isn’t used if the patient didn’t have the illness/injury

Examples of durable medical equipment are canes, crutches,

walkers, commode chairs, wheelchairs, and blood glucose

monitors. The equipment is supplied to patients by durable

medical equipment, prosthetic, and orthotic supplies dealers.

Durable medical equipment regional carriers (DMERC) cover

this type of equipment.

Now let’s practice the principles for this section. Proceed to

the practical coding exercise for more information.

Practice Exercise 8D

Books Needed:

Clinical Coding Workout: Practice Exercises for Skill Development

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

NOTE:

Remember that modi-
fiers may be used with
HCPCS Level I or II
codes.

Medical Coding 2

166

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:

Clinical Coding Workout: Practice Exercises for Skill Development

HCPCS Level II list from the CMS Web site (see download directions on page 159)

Complete exercises 3.41–3.50, “Procedures/Services,” starting on page 89 of your Clinical
Coding Workout: Practice Exercises for Skill Development.
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

167

Assignment 8 Quiz

40952300

Books Needed:

Clinical Coding Workout: Practice Exercises for Skill Development

ICD-9-CM coding book

CPT coding book

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 Developmentbook. 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.

Part A: Complete the following multiple-choice questions.

1.Which of the following would be coded within the HCPCS Level II series code range of
A4206–A8004?

A.Ambulance ride to an emergency department
B.Artificial kidney machine
C.Commode chair
D.Sterile needle

2.HCPCS Level II drugs are listed mainlyin which of the following coding sections?

A.A codes

C.J codes

B.F codes

D.Q codes

3.HCPCS Level II modifiers may be used with

A.Level I or Level II HCPCS codes.

C.CPT codes only.

B.Level I, II, or III HCPCS codes.

D.CPT and ICD-9-CMprocedure codes.

4.Services like transportation and wheelchairs are reported under

A.ICD-9-CM.

C.HCPCS Level I codes.

B.CPT.

D.HCPCS Level II E codes.

(Continued)

Medical Coding 2

168

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

6.The code A4642 is classified under which of the following categories?

A.Drug

C.Ambulance service

B.Supply

D.Durable medical equipment

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 notidentified 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 truestatement 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)

Lesson 2

169

Part 2—Coding Record Scenarios

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.

1.Physician’s professional component of interpreting an abnormal Pap smear

2.Five surgical team members meet with the patient to determine a treatment course

3.Annual flu vaccine at a local grocery store

4.Infusion, albumin (human), 5%, 50 mL

5.Gastrostomy tubing

6.Heavy-duty folding walker with a seat and wheels

7.Psychiatrist screens a patient to determine eligibility for an alcohol and drug program

8.Transportation of a portable EKG to a physician’s office for a patient

9.Anterior chamber intraocular lens

10.TLSO corset front

Medical Coding 2

170

NOTES

NAME ________________________________________________________________

ADDRESS ________________________________________________________________

CITY

________________________________________________________________

Check if this is a new address

PHONE

PLEASE PRINT

FOR YOUR INSTRUCTOR’S USE

GRADE

GRADEDBY

ANSWER SHEET

STUDENT NUMBER:

STATE/PROVINCE

ZIP/POSTAL CODE

ASSIGNMENT 8 QUIZ 40952300

Medical Coding 2

CUT ALONG THIS LINE

INDICATE YOUR ANSWER TO EACH QUESTION BY MARKING AN XIN THE
APPROPRIATE SQUARE. EXAMPLE:

Part A

1.

6.

2.

7.

3.

8.

4.

9.

5.

10.

Part B

1. _________________________________________________________

2. _________________________________________________________

3. _________________________________________________________

4. _________________________________________________________

5. _________________________________________________________

6. _________________________________________________________

7. _________________________________________________________

8. _________________________________________________________

9. _________________________________________________________

10. _________________________________________________________

HAVE YOU ENTERED YOUR STUDENT NUMBER IN THE SPACE PROVIDED?

A

B

C

D

X

A

B

C

D

A

B

C

D

A

B

C

D

A

B

C

D

A

B

C

D

A

B

C

D

A

B

C

D

A

B

C

D

A

B

C

D

A

B

C

D

173

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