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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
Contents
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

iii
YOUR COURSE

Instructions
Welcome to the Medical Coding 2 course! This course pro-
vides important information that’s essential for your career
as a coder. You’ll be using the following main sources of
information and references for this course:
Q Medical Coding 2 Study Guide (this guide)

Q 2011 Professional ICD-9-CM coding book

Q CPT 2011 Coding Book

Q Healthcare Common Procedure Coding System (HCPCS)
Level II Code List (from the Centers for Medicare and
Medicaid Services Web site)

Q 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 II exercises in this
study guide and your coding workbook, you should download
the HCPCS Level II codes (provided by the CMS for free).
Follow these steps to access the HCPCS Level II codes:
1. Go to the CMS Web site (http://www.cms.hhs.gov/
HCPCSReleaseCodeSets/).
2. Click on HCPCS General Information.
3. Scroll down to the “Related Links Inside CMS” section,
and click on HCPCS Annual Update.
4. Click on 2011 Alpha-Numeric Index.
5. Click on 2011 Alpha-Numeric Index (PDF, 166KB).
6. Save the document to your hard drive for use in your
exercises and exams.
7. Repeat these steps to download the 2011 Alpha-
Numeric HCPCS File (11anweb_V3.xls) and the 2011
Table of Drugs.
An optional resource that you may find quite useful when
working your way through this course is a medical dictionary.
You aren’t required to purchase a medical dictionary; however,

1
many terms, conditions, diseases, and illnesses mentioned in
this course—as well as in the field—may not be familiar to you.
Having a medical dictionary handy will make coding these
conditions much easier. Several good medical dictionaries are
on the market and can be obtained through any major book
chain.
You should do the following for this course:
1. Read the assigned pages in your study guide. Begin with
Appendix A and Appendix B.
2. Read the information from the corresponding coding
source (2011 Professional ICD-9-CM coding book, CPT
2011 coding book, or HCPCS Level II code list from
the CMS).
3. Complete the exercises in your Clinical Coding Workout
textbook at the end of each assignment. These exercises
aren’t graded, but they’ll help ensure that you understand
the information covered as well as help you practice your
coding skills before each assignment’s quiz.
4. Complete each assignment quiz.
5. Complete the Lesson 1 examination. Note that there’s no
examination for Lesson 2. Instead, that examination will
NOTE: be your proctored final examination.

Coding guidelines and 6. Complete the graded research project as assigned.
information for this
It’s impossible to present every coding guideline in this study
guide have been taken
from the appropriate
guide; therefore, the focus here is on basic (general), complex,
sources for coding: or frequently used guidelines. Because you received practice
CMS, American Medical coding basic principles in the Medical Coding 1 course, you’ll
Association (AMA), encounter here more intermediate and advanced coding exer-
American Hospital
cises. When working through this course, you should pay
Association (AHA),
and American
special attention to coding book reference introductions, code
Health Information references and notes, and review guidelines. In the different
Management sections of this study guide, you’ll find guidelines, tips, and
Association (AHIMA). information relating to codes that are generally considered to
All attempts have been
be the most difficult or confusing. However, not all subjects
made to ensure that
and/or guidelines for coding have been covered under each
coding guidelines are
current and accurate assignment. Working in the field, it’s necessary for a coder to
for the time period of use a combination of resources for a complete and accurate
this guide. understanding of coding guidelines. Additional resource infor-
mation can be found in “Appendix C: Helpful Online Resources.”

2 Instructions to Students
OBJECTIVES
When you complete this course, you’ll be able to
Q Identify diagnoses and procedures contained on
medical reports

Q Apply principles to code services, conditions, and
procedures using ICD-9-CM and the Healthcare Common
Procedure Coding System (HCPCS)

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

Q Determine the proper sequencing of codes for reporting
and billing

Q Discuss ICD-9-CM and HCPCS guidelines and coding
conventions

Q 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 3
A STUDY PLAN
Follow these steps to ensure your success in the course:
1. Read the assigned pages in your study guide. Take your
time so you can fully understand each topic presented.
2. Follow along with the code section in the appropriate
coding resource.
3. Complete the workbook exercises and assignment
quizzes at the end of each assignment in your study
guide. Before completing an assignment—or, more
important, the lesson examination or graded project—
be sure that you fully understand the concepts presented
in the assignment or lesson. If you’re uncomfortable with
the information, go back and reread that particular
information or the entire assignment again. Fully
understanding the concepts is integral to your success
in this course.

Assignments
Read the individualized directions for each assignment before
starting the assignment.

Practice Exercises
For each assignment, you’ll complete practice coding exercises
that appear at the end of an assignment. These exercises will
help you practice the guidelines and principles discussed in
that assignment. The exercises won’t be graded, and the
answers are provided in the back of this study guide.

Assignment Quizzes
At the end of each assignment, an assignment quiz will test
your understanding of the coding principles presented in that
assignment. Upon completion, these quizzes will be submit-
ted to your instructor for grading. This procedure will ensure
that you understand the principles and concepts before com-
pleting the lesson examination.

4 Instructions to Students
There are two sets of questions for each quiz: a set of multiple-
choice questions followed by intermediate-level scenarios
taken from your Clinical Coding Workout: Practice Exercises
for Skill Development workbook. These intermediate-level
scenarios contain short paragraphs describing medical situa-
tions. You’ll have to extract the appropriate information for
coding. The quiz questions will be slightly more difficult than
the coding exercises previously described. Because the quizzes
will be submitted for grading, it’s not recommend that you
attempt them until you’ve completed the assignment and the
practice exercises, fully understand the concepts reviewed in
the particular assignment, and feel comfortable with the sub-
ject matter.

Lesson Examination
There are two examinations for this course. Examination 1
appears at the end of Lesson 1. The second examination
will be your proctored final examination for this course. The
examination questions are formatted as multiple-choice and
coding scenarios. You’ll also be asked to code advanced-level
coding scenarios. These coding scenarios are set up as if you
were looking at documentation from an actual medical record.
You’ll be required to read the information and extract the
appropriate clinical information that needs to be coded for
the setting involved. It’s important to fully understand the
coding guidelines and to have practice coding with the section
exercises before completing the lesson examination.

Graded Project
You’ll be responsible for completing a graded project for this
course, which is assigned at the end of Lesson 1. You’ll be
asked to do research on the Internet, then answer specific
questions based on your research. Remember that you must
put all information you gather into your own words, use
quotation marks and in-text citations for any material copied
from sources, and include a reference page that lists your
sources, the dates you accessed them, and the author, article,
and section you used.

Instructions to Students 5
One Last Word
Finally, remember that you’re responsible for the content from
Medical Coding 1. Medical Coding 1 and Medical Coding 2
can’t be strictly divided. The second course builds upon the
first. Much of what you learned in the first course may
reappear here. You can’t be excused from knowing that
information or retaining those skills.

6 Instructions to Students
Lesson 1: ICD-9-CM Hospital Inpatient Coding

Assignments
For: Read in the Read in the
study guide: coding references:

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

7
NOTES

8 Lesson Assignments
ICD-9-CM Hospital
Inpatient Coding

Lesson 1
ASSIGNMENT 1:
SUPPLEMENTARY
CLASSIFICATIONS—SIGNS,
SYMPTOMS, ILL-DEFINED
CONDITIONS/INJURIES,
POISONINGS/V AND E CODES
Read Sections 17 (pp. 18–20), 18 (pp. 20–25), and 19 (pp. 25–27)
of the Coding Guidelines in your ICD-9-CM coding book.
Read the introduction to Chapter 16—“Symptoms, Signs, and
Ill-Defined Conditions” (page 283 in your ICD-9-CM coding
book).
Read the introduction to Chapter 17—“Injury and Poisoning”
(page 299 in your ICD-9-CM coding book).
Read the introduction to Supplementary Classifications (V codes
on page 351 in your ICD-9-CM coding book and page 1 in the
E-Code section directly following the V code section).

Introduction
Sometimes there are diagnoses or procedures that don’t seem
to fit into any specific coding category. They may be signs,
symptoms, or ill-defined conditions; or they may simply pro-
vide more information about a specific diagnosis or illness.
In this first section, you’ll concentrate on these unique situa-
tions that can be difficult to classify and code.

9
Symptoms, Signs, and Ill-Defined
Conditions (Categories 780–799)
A sign is a physical presence or existence of a condition that
can be observed by the physician. A symptom is evidence of a
disorder or disease that indicates a change in normal func-
tion. The symptom is experienced by the patient but not
confirmed by the physician. Symptoms, signs, and ill-defined
conditions appear in Chapter 16 of the ICD-9-CM coding book
and cover code categories 780–799. This chapter is used for
signs, symptoms, and ill-defined conditions that are of unex-
plained etiology (origin) and may be due to more than one
disease.

ICD-9-CM Coding 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.

10 Medical Coding 2
When the sign/symptom is due to comparative or contrasting NOTES:
conditions, the sign/symptom should be listed as the principal
diagnosis unless it’s integral to each of the conditions listed. When there are two or
more equal causes,
For comparative/contrasting diagnoses, the physician will
the diagnosis with the
usually use terminology such as “either/or.” For example, highest-weighted
chest pain due to either pneumonia or angina is coded first as diagnosis-related group
chest pain followed by the codes for pneumonia and angina. (DRG) should be listed
first. For example, if
Example. A patient was admitted for prolonged fatigue. The the physician docu-
physician discharged the patient with a diagnosis of fatigue ments pneumonia or
due to either hypothyroidism or depression. angina, they would
both be coded with the
Codes highest-weighted DRG
PDX: Other malaise and fatigue (780.79) sequenced first.

Secondary diagnosis: Unspecified hypothyroidism (244.9), Generally, if the physi-
depressive disorder, not elsewhere classified (311) cian documents that
the diagnoses are no
Reasoning. The physician documented either/or—a clue that longer contrasting (for
this is probably a contrasting coding scenario. Because the example, chest pain
physician was unclear as to whether the hypothyroidism or due to pneumonia and
depression was causing the fatigue (and fatigue isn’t neces- angina), both condi-
tions should be coded
sarily inherent/integral with either diagnosis), the fatigue
(with the symptom
(symptom) is listed as the principal diagnosis.
code assigned only
Additional scenarios in which Chapter 16 codes can be used if it meets coding
guidelines).
as principal diagnoses are as follows:
Q No specific diagnosis is made at the time of discharge.

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

Q The patient is transferred/referred to another institute.

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

Additional scenarios in which a Chapter 16 code can be used
as secondary diagnoses are
Q When the sign/symptom isn’t integral in the underlying
condition

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

Lesson 1 11
3. Ill-defined conditions are those conditions with unknown
causes. As with the other symptom codes, the ill-defined
condition codes shouldn’t be used when a more definitive
diagnosis exists. Examples of ill-defined conditions
include nervousness and debility without known causes.
Now let’s practice the principles for this section. Proceed to
the practical coding exercise for more information.

Practice Exercise 1A
Books Needed:

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.

Supplementary Classifications
(Categories V01–V89 and E800–E999)
Some people find the coding of V and E codes very easy,
whereas others find it somewhat confusing. Because of this and
their relationships to other chapter codes, it’s important for you
to understand their use before going on to other assignments.

V Codes
V codes are supplementary codes. They’re listed as
Supplementary Classification of Factors Influencing Health
Status and Contact with Health Services. There are 15
different categories of V codes represented in sections
V01–V89 of your coding book that deal with circumstances
other than disease or injury.

12 Medical Coding 2
V codes are used in both inpatient and outpatient settings.
As you learned from your assignment reading, there are four
reasons you may use V codes:
1. To indicate that a person who isn’t currently sick receives
health services for a specific reason (e.g., inoculations/
health screenings, counseling, organ donation)
2. To indicate aftercare for a previous disease or injury
(e.g., dialysis for renal disease, changing of a cast for
a fracture)
3. When a circumstance or problem influences a person’s
health status
4. To indicate the birth status of a newborn
V codes may be listed first, as the principal diagnosis, or as a
secondary code (depending on the encounter or circumstance).
However, be careful. Be sure to follow the notes in your coding
book because there are some V codes that can’t be used as
principal diagnosis, whereas others must be listed first. The
following scenarios are situations in which V codes can be
listed as the principal diagnosis:
Q Aftercare for a patient

Q Health care services unrelated to illness/disease

Q Birth status of a newborn (newborn’s record)

The following scenarios are situations in which V codes can
be listed as a secondary diagnosis:
Q History or problem that may influence the patient’s care

Q 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-CM coding book).
E codes make up categories E000–E999 and are used to
identify external causes of injuries and poisonings.

Lesson 1 13
E codes signify the following scenarios:
Q Cause of the injury or poisoning

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

Q 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 never listed as the
principal diagnosis.

NOTE: E Code Guidelines
If space constraints 1. An E code may be used with any code (001–V82.9) that
and limitations on the indicates an injury, poisoning, or adverse effect due to
billing claim form pro- an external cause.
hibit assigning as many
E codes as necessary, 2. Code as many E codes as necessary to explain the cause.
be sure to first assign
3. The undetermined/unknown category of E codes
the ones that relate
most to the principal
(E980–E989) is rarely used. The patient’s medical
diagnosis. 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.

14 Medical Coding 2
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.

Injury and Poisoning
(Categories 800–999)
Injuries and poisonings cover Chapter 17, categories
800–999, in your ICD-9-CM coding book.

Injuries
Injuries include 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.

Lesson 1 15
NOTES:
4. Excisional debridement (procedure) for wound, infection
or burn (86.22) can be performed only by a physician.
Some nonexcisional Nonexcisional debridements are also performed by physi-
debridements are
cians or other health care professional (code 86.28).
performed by health
care workers (such as 5. Code burns with the highest degree sequenced first.
nurses) at the patient’s
bedside. In this case, Burns can be difficult to code because they often involve
don’t assign a separate different sites and may have different degrees of severity.
code for the debride- Because of the difficulty, it’s worthwhile to spend some time
ment because it’s on specific burn guidelines.
covered in the nursing
service billing as part
of normal nursing Burns
duties. However, some
physicians may per- Burns are covered by code categories 940–949. Some of the
form a debridement at causes of burns are as follows:
the patient’s bedside.
These procedures Q Electricity
should be coded.
Q Flame/fire
Remember, burns are Q Heat
still classified under the
Injury and Poisoning Q Lightning
section. We’re spend-
ing time on burns here Q Radiation
(independent of the
other injuries) due to Q Chemicals
the difficulty in coding.
Burns are classified by depth (that is, the degree of burn),
Sunburns aren’t extent, and causative agent. First-degree burns result in
included in this same erythema (redness). Second-degree burns result in blistering.
category and instead Third-degree burns result in full-thickness skin involvement.
are coded to category
692. Deep third-degree burns result in full-thickness involvement,
necrosis, and scabbing/crusting.
Extent of the burn refers to the extent of body surface involved.
This extent is reported in percentages (e.g., burns on 25%
of the body). Extent should be coded to code category 948—
burns classified according to extent of body surface involved.
This code category is based on something called “the rule of
nines” that estimates the body surface as follows:
Q Head and neck—9%

Q Each arm—9%

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

16 Medical Coding 2
Q Anterior trunk—18%

Q Posterior trunk—18%

Q 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 agents refer 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). NOTES:
3. When coding multiple burns, assign separate codes for
Category 946: Burns of
each burn site. multiple specified sites
and Category 949:
4. Codes from category 948—burns classified according to
Burns, unspecified
extent of body surface involved—should be used only should be used only
when the site of the burn isn’t specified or as an addi- if the burn locations
tional code with categories 940–947. aren’t documented.

5. Late effects of burns should be coded to the residual
Adverse effects are clas-
condition followed by the appropriate late-effect code sified differently than
and late-effect E code. poisonings in ICD-9-CM.
Adverse effects occur
6. It’s possible that a current burn code, residual burn code,
when drugs are taken
and late-effect code may be present on the same record. as prescribed, but have
some adverse reaction
or effect (for example,
Poisoning interaction from several
drugs taken together,
Poisoning is a drug overdose or ingestion of the wrong sub- allergic reactions).
stance when drugs are given in error during procedures, When a poisoning and
an adverse effect occur
medications are given in error, medications/drugs are taken
together, code in the
in error by the patient, medications are taken in combina-
following sequence:
tions with alcoholic beverages, or a patient combines drugs/
medications. 1. Poisoning
2. Manifestation
Now let’s practice the principles for this section. Proceed to 3. E code
the practical coding exercise for more information.

Lesson 1 17
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.

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:

18 Medical Coding 2
Penn Foster
Student Service Center
The Penn Foster
925 Oak Street Student Service Center
Scranton, PA 18515 is under contract with
Penn Foster College.
Be sure to include your full name, student number, quiz
number, and your complete mailing address.

Assignment 1 Quiz
40950900

Books Needed:
Clinical Coding Workout: Practice Exercises for Skill Development
ICD-9-CM coding book

Directions: Each assignment quiz is divided into two parts. Part A is composed of multiple-
choice coding questions, and Part B requires you to code the information from a coding
scenario found in your Clinical Coding Workout: Practice Exercises for Skill Development
book. Complete all required and relevant codes for each given scenario. When you’re com-
fortable with your answers for both parts, submit this quiz to your instructor for grading.

Part A: Complete the following multiple-choice questions. Choose the best answer for each
question. Record your answer on the corresponding answer sheets that can be found in the
back of this study guide. Upon completion, submit your quiz answers to your instructor.

1. What is the main reason that insurance companies are hesitant to push for a quick release of
the new ICD-10 coding classification system?

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

(Continued)

Lesson 1 19
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 best describes 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)

20 Medical Coding 2
Assignment 1 Quiz
40950900

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

A. V67.4 C. 47.09
B. E884.2 D. A4509

8. Unknown causes of morbidity or mortality should be coded only when

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.

Lesson 1 21
Note: In upcoming quizzes you’ll also be doing exercises on V and E codes
related to other body systems.

22 Medical Coding 2
ANSWER SHEET
FOR YOUR INSTRUCTOR’S USE
GRADE GRADED BY

ASSIGNMENT 1 QUIZ 40950900
STUDENT NUMBER:
PLEASE PRINT Medical Coding 2

NAME ________________________________________________________________

ADDRESS ________________________________________________________________

CITY ________________________________________________________________
STATE/PROVINCE ZIP/POSTAL CODE

S Check if this is a new address
PHONE

INDICATE YOUR ANSWER TO EACH QUESTION BY MARKING AN X IN THE
APPROPRIATE SQUARE. EXAMPLE: XA B C D

Part A
CUT ALONG THIS LINE

1. A B C D 6. A B C D

2. A B C D 7. A B C D

3. A B C D 8. A B C D

4. A B C D 9. A B C D

5. A B C D 10. A B C D

Part B

5.84 ___________________________________________________________________

5.85 ___________________________________________________________________

5.86 ___________________________________________________________________

5.87 ___________________________________________________________________

5.88 ___________________________________________________________________

5.89 ___________________________________________________________________

5.90 ___________________________________________________________________

HAVE YOU ENTERED YOUR STUDENT NUMBER IN THE SPACE PROVIDED?
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-CM coding 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-CM coding book.

Infectious and Parasitic Diseases
(Categories 001–139)
Infectious and parasitic diseases cover ICD-9-CM code 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.

Lesson 1 25
Dual classifications are also used in Chapter 1. For example,
you may have an illness/condition from Chapter 1 and an
additional code from another chapter (in this case, “Respiratory
System”) to describe the associated other illness/condition:
Pneumonia due to whooping cough, 033.X, 484.3. In some
cases, a fourth and fifth digit of the diagnosis code will indicate
the organism: Pneumonia due to Staphylococcus: 482.4X.
You may be wondering whether to use one or two codes with
a condition/underlying disease/organism scenario. This situ-
ation points out the importance of knowing coding guidelines
as well as reading the information and narratives carefully
when coding from a coding book. For example, code 484.3—
pneumonia due to whooping cough—lists the note “Code first
underlying disease” (033.0–033.9). If the coder didn’t read the
complete code description and reported only code 484.3, the
bill could be denied and reimbursement would be lost.

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
NOTE:
the physician), codes from these categories can be
Due to the serious assigned as principal diagnoses.
nature of HIV, guide-
3. When patients are admitted for treatment of human
lines direct that the
coder contact the immunodeficiency virus (HIV) infections or related condi-
physician for clarifica- tions, HIV is coded as the principal diagnosis followed by
tion or further additional codes for related conditions.
documentation related
to HIV status. (This is 4. Asymptomatic patients who receive HIV testing should
an exception to the be coded as V73.89—screening for other specified viral
general guideline. For disease.
other non-HIV cases,
you would code this 5. Code only confirmed cases of HIV/acquired immuno-
condition as present.) deficiency syndrome (AIDS). Never code HIV if it’s listed
as suspected, possible, or likely.

26 Medical Coding 2
Let’s review some additional guidelines for infectious and
parasitic diseases.

Late Effects
For late effects (for example, codes 137, 138, 139), code the
NOTE:
residual condition (that is, nature of the late effect) first,
followed by the cause of the late-effect code (except when Remember, late effects
instructed otherwise by the index; see further rules explained are conditions that
linger, exist, or occur
in bulleted list that follows). For example, scoliosis due to
after the acute phase
poliomyelitis: 138, 737.43. of an illness or injury.
A late effect is often
Coding of late effects requires two codes: residual condition
referred to as a residual
(or nature of the late effect) and cause of the late effect.
effect. The current,
However, the following exceptions should be noted: acute illness or injury
must resolve before
Q When the code for late effect is followed by a manifesta-
a late effect can be
tion code identified in the Tabular List or coded.

Q 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. Bacteremia is 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 and become a generalized sepsis),
then you should query the physician to provide additional
or updated documentation so that the most accurate code
can be reported.

Lesson 1 27
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.

Neoplasms (Categories 140–239)
NOTE: Neoplasm codes are found in Chapter 2 of the ICD-9-CM
Even though the neo- Tabular Index and make up code categories 140–239. The
plasm chart provides best way to locate a neoplasm code is to look up the term
great detail, a coder neoplasm in the index and then locate the anatomic site of
should never assign a the tumor. Pages 193–208 of the index provide a neoplasm
neoplasm code based
chart that allows a coder to see six possible code categories
on information just
from the index. Be for each tumor or site.
sure to look up codes Neoplasms, which are also called tumors, are abnormal growths
located in the neo-
that can be benign or malignant. Benign tumors aren’t life-
plasm chart within the
tabular list. threatening. However, malignant tumors 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 neoplasms are
tumors that are found in the primary organ where the tumor
growth started. Secondary neoplasms are tumors that are
found in additional organs, spreading from the initial (or
primary) site. This spread is called metastasis.

28 Medical Coding 2
Morphology
Morphology identifies the form and structure of tumor cells for
classification of origin. There’s a listing of morphology codes
(starting with “M”) that are used mainly by cancer registries
and rarely by hospital coders. We won’t cover morphology
codes in this course.

Classifications
As mentioned previously, neoplasms are classified according
to behavior (for example, malignant, benign) or anatomic site.
Neoplasm groups include the following categories: NOTES:
Q Malignant (codes 140–209) Paying attention to the
way tumor information
Q Benign (codes 210–229)
is documented is very
Q Carcinoma in situ (codes 230–234) helpful. For example,
if the physician docu-
Q Uncertain behavior (codes 235–238) ments “metastatic
from,” then the site
Q Unspecified nature (code 239) mentioned after “from”
is the primary site.
If the physician docu-
Coding Guidelines for Neoplasm Diagnoses ments “metastatic to,”
1. If the phrase “metastatic to” is documented, code the site then the site mentioned
after “to” is the second-
mentioned as secondary.
ary site. In situ
2. When coding a secondary site, the primary site should (pronounced in sigh-
also be coded if still present. If the primary site has been too) means that
eradicated (that is, removed, no longer exists, or is no cancerous cells are
longer being treated), then a code from category V10 present in the lining of
should be assigned. If the primary site isn’t identified, an organ but have not
code it as an unspecified site. spread to the organ
tissue.
3. If “metastatic from” is documented, code the site
mentioned as primary. Code the additional (secondary) Also assign the second-
site as an additional diagnosis. ary diagnosis for the
4. When two or more sites are metastatic, code each as acute malignancy.
secondary. However, also code the primary site.
Only use codes from
5. When patients are admitted for complications due to V10—personal history
malignant neoplasms, code the complication as the prin- of malignancy—when
cipal diagnosis. However, there are exceptions to this the primary neoplasm
guideline. Refer to coding guidelines and directions in has been eradicated
the coding book for such cases. and is no longer being
treated.
6. Assign a code from V58.0–V58.1X when a patient is
admitted for radiotherapy or chemotherapy.

Lesson 1 29
Practice Exercise 2B
Books Needed:

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.

Endocrine, Nutritional and Metabolic
Diseases, and Immunity Disorders
(Categories 240–279)
Chapter 3 in the ICD-9-CM coding 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
Diabetes is a result of a deficiency, lack of, or resistance to
insulin secreted by the pancreas. Insulin is a hormone that
works to regulate glucose (sugar) metabolism and metabolize
fats, carbohydrates, and proteins. Unfortunately, many
people suffer from diabetes. Because this condition is probably
the most common ailment in this chapter, this section deals
solely with the coding guidelines for diabetes.

30 Medical Coding 2
Type 1 versus Type 2 NOTES:
Diabetes mellitus is categorized by two types: type 1 and type 2. Just because a patient
Type 1 diabetes was formerly known as insulin-dependent is receiving an insulin
diabetes mellitus (IDDM). Common practice now refers to injection doesn’t mean
this condition as only type 1. Type 1 diabetes may also be that the patient has
type 1 diabetes. Refer
described many ways, including as juvenile type or juvenile
to the documentation
onset. In type 1 diabetes, the body fails to produce insulin from the physician to
and requires the patient to receive insulin injections. clarify the type of
Type 2 diabetes was formerly referred to as non-insulin- diabetes.

dependent diabetes mellitus (NIDDM). This designation has
Insulin-requiring isn’t
gone out of style because of an increase in type 2 diabetes
the same as insulin-
that requires insulin. Type 2 may be described as adult onset dependent.
diabetes. In this type, insulin is produced but in a small Insulin-requiring usu-
quantity or the body is unable to use it. Generally, type 2 ally refers to type 2
diabetics don’t require insulin injections and may be treated diabetics, whereas
insulin-dependent gen-
with oral medications and diet. For patients who may need
erally refers to type 1
insulin, the physician may describe such a patient as “insulin- diabetics. As always,
requiring.” if there’s any question,
query the physician
for clarification.
Classifying Diabetes
Diabetes is coded under category 250; this category has two A fifth digit of insulin-
classifications. The fourth digit indicates the presence of an dependence and/or
associated complication. The fifth digit indicates the type of uncontrolled diabetes
can be assigned only
diabetes and whether it’s uncontrolled.
if the physician docu-
As illustrated on page 61 of the Tabular List (in the shaded ments the condition
as such.
area of the first column) in your ICD-9-CM coding book, sub-
classifications for the fifth digit include the following:
Q 0—Type 2 or unspecified type, not stated as uncontrolled

Q 1—Type 1, not stated as uncontrolled

Q 2—Type 2 or unspecified type, uncontrolled

Q 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.

Lesson 1 31
NOTE:
In other cases, dual codes are necessary to identify the dia-
betes and manifestations. Patients with diabetes often have
Remember that a difficulties with other diseases and conditions that are cov-
manifestation is a
ered by a dual code. In these cases, a code for the diabetes is
secondary condition
that’s associated
listed first with a secondary code to indicate the manifestation.
with another primary Example. On patient discharge, the physician documents the
condition.
following information on the discharge sheet in the patient’s
medical record: nephritis with nephropathy; insulin-dependent
diabetes.
Codes
PDX: Type I diabetes with renal manifestations (250.41)
Secondary diagnosis: Nephritis and nephropathy (583.81)
Reasoning. Per coding guidelines, the diabetic/manifestation
code is sequenced first (as principal diagnosis), followed by
the manifestation (583.81). The nephritis and nephropathy
wasn’t specified as acute or chronic.

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.

NOTE: 6. When a patient is admitted to the hospital with a condi-
tion not related to diabetes but is still being monitored or
Code 362.07, diabetic
treated for diabetes (insulin, exercise, diet), code the dia-
macular edema, must
be used with a code for
betes as secondary.
diabetic retinopathy 7. Diabetic retinopathy is coded as 250.5x (the diabetes code
(codes 362.01–362.06).
as principal) followed by a further code from 362.01–362.07
to classify the diabetic retinopathy.

32 Medical Coding 2
Nutritional—New Codes for
Overweight and Obesity
NOTES:
In 2006, ICD-9-CM expanded and included new codes for
overweight and obesity. The overweight and obesity code The overweight and
(278.0X) includes fifth-digit classifications for obesity codes shouldn’t
be assigned unless
Q Obesity, unspecified (278.00) documented by the
physician.
Q Morbid obesity (125% or more over ideal body weight)
(278.01)
If there’s indication/
documentation of
Q Overweight (278.02)
dietary surveillance
There’s also a new V category for body mass index. Add any and counseling, code
V65.3 can be used.
additional code from category V85.XX as indicated by the
physician’s documentation.
Now let’s practice the principles for this section. Proceed to
the practical coding exercise for more information.

Practice Exercise 2C
Books Needed:

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.

Lesson 1 33
Diseases of the Blood and Blood-
Forming Organs (Categories 280–289)
“Diseases of the Blood and Blood-Forming Organs” make up
Chapter 4 (code categories 280–289) in your coding book.
This chapter includes diseases such as anemias, sickle cell
disease, diseases of the white blood cells, and so forth.

Anemia
Anemia is probably the most coded condition from Chapter 4.
This condition involves a decrease in hemoglobin levels in the
blood. Anemia can be caused by several factors, such as blood
loss, a decrease in red blood cell production, or destruction of
red blood cells. Because of the variety of causes, coders should
pay close attention to documentation and take care to clarify
any questionable cases with the physician. For example, just
because a patient loses blood after an operation or procedure
doesn’t necessarily indicate a surgical complication. Reviewing
coding book notes and working with the physician will help
clarify coding for these types of situations.
Now let’s practice the principles for this section. Proceed to
the practical coding exercise for more information.

Practice Exercise 2D
Books Needed:

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.

34 Medical Coding 2
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)

Lesson 1 35
Assignment 2 Quiz
40951000

6. Hypopotassemia is coded as

A. 266.5. C. 276.8.
B. 244.0. D. 251.2.

7. Conditions that have a decrease in hemoglobin levels in the blood can be coded to Chapter
A. 2.
B. 3.
C. 4.
D. Need more information

8. When should acute blood loss anemia following surgery be coded as a complication of the
surgery?

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)

36 Medical Coding 2
(Continued)

Assignment 2 Quiz
40951000

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

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

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

Lesson 1 37
NOTES

38 Medical Coding 2
ANSWER SHEET
FOR YOUR INSTRUCTOR’S USE
GRADE GRADED BY

ASSIGNMENT 2 QUIZ 40951000
STUDENT NUMBER:
PLEASE PRINT
Medical Coding 2

NAME ________________________________________________________________

ADDRESS ________________________________________________________________

CITY ________________________________________________________________
STATE/PROVINCE ZIP/POSTAL CODE

S Check if this is a new address
PHONE

INDICATE YOUR ANSWER TO EACH QUESTION BY MARKING AN X IN THE
APPROPRIATE SQUARE. EXAMPLE: XA B C D

Part A
CUT ALONG THIS LINE

1. A B C D 6. A B C D

2. A B C D 7. A B C D

3. A B C D 8. A B C D

4. A B C D 9. A B C D

5. A B C D 10. A B C D

Part B

4.1 ________________________________ 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?
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-CM coding
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 NOTES:
mood to severe emotional disturbances that incapacitate a
person and interfere with everyday functions—sometimes A code for psychosis
shouldn’t be assigned
to the extent that suicide is attempted. A few examples of
unless this disorder is
mental disorders are psychosis, senile dementia, depression, clearly documented
attention deficit disorder, Alzheimer’s disease, schizophrenia, by the physician.
neurosis, and psychosis. Physicians may docu-
ment conditions such
as delirium, dementia,
Neurosis versus Psychosis psychosis, and halluci-
nation to indicate a
Neurosis is a mental disorder involving anxiety and avoidance
patient’s psychosis.
behavior that appears to have no organic cause. Neuroses As always, query the
can include a variety of anxieties and depression. Psychosis physician if the docu-
is a more severe distortion of a person’s perception of reality. mentation is unclear.
Psychoses can involve delusions, hallucinations, and bizarre
behavior. Substance abuse and
substance dependency
may be used inter-
Alcohol Abuse versus Alcohol Dependence changeably in the
record documentation;
Alcohol and drug dependencies are also covered in this chapter. however, they’re coded
Alcohol abuse (code 305.00) is a drinking problem without differently. Query the
physical dependence on alcohol. Code 305.00 is also assigned physician for clarifica-
for a diagnosis of drunkenness. tion, if necessary.

Lesson 1 41
Alcohol dependency is a chronic condition with a physical
dependence on alcohol. With this diagnosis, a physician may
document the terms alcoholism and alcoholic.

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
NOTE:
anorexia nervosa.
Although there’s a code
6. When acute and chronic alcoholism is diagnosed, report
for history of alcoholism
(V11.3), it’s rarely only code 303.0X to cover both conditions.
assigned (that is, most
7. For recovering alcoholics, assign the appropriate 303.XX
alcoholics stay in the
code with a fifth digit of 3 (“in remission”).
“recovering” phase for
their entire lives). 8. Assign only one of the following category codes for alco-
Query the physician
holic withdrawal (based on physician documentation):
for clarification.
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.

42 Medical Coding 2
12. Drugs don’t have to be given for a treatment code of
“detoxification” to be assigned. Detoxification is the
observation/management of the patient’s withdrawal
from a substance and doesn’t necessarily include drug
treatment. Query the physician for appropriate coding.
Now let’s practice the principles for this section. Proceed to
the practical coding exercise for more information.

Practice Exercise 3A
Books Needed:

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.

Nervous System and Sense Organs
(Categories 320–389)
Diseases of the nervous system and sense organs appear in NOTE:
Chapter 6, code categories 320–389. Examples of nervous Understanding the
system disorders are Parkinson’s disease, encephalitis, separation of classifica-
meningitis, seizures, and multiple sclerosis. tions for CNS and PNS
codes will help you
The nervous system is divided into two parts: the central more accurately code.
nervous system and the peripheral nervous system. The Many PNS codes are
central nervous system (CNS) is made up of the brain and manifestations of other
spinal cord. Central nervous system codes are assigned to conditions and there-
fore appear as the
categories 320–349.
secondary diagnosis
The peripheral nervous system (PNS) is made up of the cranial (with underlying
and spinal nerves. Peripheral nervous system codes are condition listed first).
assigned to categories 350–359.

Lesson 1 43
Hemiplegia versus Hemiparesis
Conditions exist within this chapter that may cause hemiplegia
or hemiparesis.
Hemplegia is paralysis of one side of the body. Hemiparesis is
weakness of one half of the body. Hemiplegia and hemiparesis
isn’t always coded as an additional code. Sometimes, these
conditions are included within the condition being coded and
thus don’t require a separate code. Other times they’re assigned
as separate secondary diagnoses. Coders should follow the
coding guidelines and coding book notations for assigning
hemiplegia and hemiparesis codes.

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.

44 Medical Coding 2
8. For patients with true diabetic cataracts (as documented
by the physician), code first the appropriate diabetes
code followed by the cataract code as secondary.
9. If cataracts are extracted and an artificial lens is
implanted simultaneously, code first the extraction
procedure code followed by the lens implantation.
10. Code fitting of a hearing aid to V-code V53.2 and proce-
dure code 95.48.
Now let’s practice the principles for this section. Proceed to
the practical coding exercise for more information.

Practice Exercise 3B
Books Needed:

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.

Circulatory System
(Code Categories 390–459) NOTES:

Some circulatory
Circulatory system disorders are coded to Chapter 7, code system disorders
categories 390–459. have been reclassified
to Chapter 11,
“Complications of
Ischemic Heart Disease versus Pregnancy, Childbirth,
Myocardial Infarctions and the Puerperium,”
and Chapter 14,
Ischemic heart disease is caused by a lack of oxygen to the “Congenital Anomalies.”
myocardial cells. Follow coding book
notes and guidelines
Ischemic heart disease is also known as coronary ischemia, for the reclassifications
coronary artery disease, arteriosclerotic heart disease (ASHD), that aren’t coded in
or coronary arteriosclerosis/atherosclerosis. Chapter 7.

Lesson 1 45
Myocardial infarctions (MIs) are acute ischemic conditions of
obstruction in the coronary artery caused by thrombosis,
atherosclerosis, or spasm. Myocardial infarctions are also
known as heart attacks.
Fifth-digit subclassifications are provided to indicate the
NOTES:
episode of care for the MI. These fifth digits are: 1—the initial
The myocardium is the (first) episode of care; 2—the subsequent episode of care
middle, muscular layer
(admission for further care of the cardiac condition any time
of the heart.
during the first eight weeks after the MI occurred). A fifth
digit of 0 is assigned if the episode of care is unspecified.
A fifth digit of 1 is still
assigned if the patient
is transferred to another Cerebrovascular Disorders
facility during the initial
episode of care. Cerebrovascular disorders affect the cerebral arteries of the
brain. Cerebrovascular accidents (CVAs) are occlusions of
A negative finding the brain caused by thrombosis, embolism, hemorrhage, or
from a CT or MRI scan
ischemia. CVAs are also known as strokes.
doesn’t necessarily
rule out CVA. Don’t
code based on MRI/CT CVA versus TIA
results alone. When
there’s inadequate Cerebrovascular accidents are characterized by a sudden
documentation, query
irreversible loss of neurologic function secondary to the
the physician for
ischemic death of brain tissue. Transient ischemic attacks
further coding
clarification. (TIAs) are episodes of cerebrovascular insufficiency with
accompanying symptoms that last only a few minutes (or,
in rare cases, clear within 24 hours).
In this section, we’ll discuss CVA (code category 434) and
transient ischemic attack (TIA) (code category 435) because
symptoms often look the same for these two conditions.
Thus, CVA and TIA can be difficult to distinguish between
for coding purposes.
As just mentioned, CVA and TIA symptoms may appear the
same: disturbance of normal vision, numbness, weakness,
dizziness, dysphasia, hemiplegia, and so forth. Also, a com-
puted tomographic (CT) scan may not detect a CVA for up
to 48 hours. Because of these circumstances, it’s easy to code
a TIA when it’s really a CVA (or vice versa). A good rule to
remember is that neurologic deficits (for example, hemiplegia,
facial droop) usually clear within 24 hours with a TIA. Persistent
defects that last longer than 24 hours usually indicate a CVA.
A magnetic resonance image (MRI) will show positive findings

46 Medical Coding 2
for an acute ischemic stroke within two hours and a hemor-
rhagic stroke after six hours. Conversely, a CT scan may show
positive findings for a hemorrhagic stroke immediately, but
negative findings for an ischemic stroke. Review the documen-
tation and query the physician for appropriate coding.

Hypertension
Hypertension (HTN), also known as high blood pressure (HBP),
is classified to code categories 401–405. Hypertension can be
classified as primary hypertension or secondary hypertension,
and benign, malignant, or unspecified. Malignant hypertension
is severe, elevated blood pressure that commonly damages
blood vessels and organs. Malignant hypertension can lead to NOTES:
other serious conditions and even death.
Code accelerated or
Benign hypertension is a mild degree of hypertension over a necrotizing hyperten-
long (chronic) period of time. Secondary hypertension is the sion to the malignant
result of another disease. In many cases, once the underlying hypertension category.

disease is treated or controlled, the secondary hypertension
For controlled/history
will disappear. Therefore, code the secondary hypertension
of hypertension, look
as secondary. In some cases, hypertension is described as to see if the patient is
uncontrolled, controlled, or history of. There’s no code for still receiving medica-
specifying that the hypertension is uncontrolled. Instead, tion or being treated.
code it to the cause and nature. Controlled or history of may If so, assign the appro-
priate hypertension
refer to hypertension that’s still under treatment. In most
code.
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

Lesson 1 47
physician for appropriate coding. When the documentation
doesn’t specify a causal relationship, two codes for each
unrelated condition must be assigned.
One exception in causal relationships is for hypertensive kid-
ney disease. Guidelines dictate that a causal relationship is
assumed between hypertension and renal disease. Therefore,
code renal failure with hypertension as hypertensive kidney
disease to code 403.XX (with the fifth digit indicating with (.00)
or without (.01) chronic kidney disease) unless the physician
specifically states the kidney disease isn’t due to hypertension.
With code category 403, use an additional code to identify the
stage of chronic kidney disease if known (585.1–585.6).

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

Q Single-chamber device, rate responsive—code 37.82
NOTES:
Q Dual-chamber device (uses dual leads)—code 37.83
When hypertensive
heart and kidney Percutaneous transluminal coronary angioplasy (PTCA) is
disease are present, a treatment for atherosclerotic coronary heart disease and
code 404.XX with addi- angina wherein the plaque is flattened against the walls of
tional codes to specify the artery by inflating and deflating a small balloon. This
the type of heart fail-
allows a better flow of blood and decreases disease symptoms.
ure (428.0–428.43),
if known. Add an Codes for PTCA include the following:
additional code to Q Single vessel, without mention of thrombolytic agent:
identify the stage
00.66
of chronic kidney
disease (585.1–585.6),
Q Single vessel, with thrombolytic agent: 00.66 (PTCA),
if known.
99.10 (Injection/infusion of thrombolytic agent)

48 Medical Coding 2
Q Multiple vessel, performed during same operation, with NOTES:
or without mention of thrombolytic agent: 00.66; code
also the number of vessels treated (00.40–00.43) and any Assign additional codes
for insertion of coro-
infusion of thrombolytic agent (99.10)
nary artery stents
Coronary artery bypass grafting (CABG) is open heart surgery (36.06–36.07) and/or
number of vascular
in which a section of a blood vessel (or prosthesis) is grafted
stents inserted
onto a coronary artery for redirection, or bypass, of blood (00.45–00.48).
flow around a blockage.
Separate procedure
codes are used to
Coding Guidelines for
indicate the type of
Circulatory System Diagnoses bypass carried out
(code 36.1X). Assign
1. Code acute myocardial infarctions (duration of 8 weeks an additional (second-
or less) to category 410. ary) procedure code
for the extracorporeal
2. Don’t assign code 410.9—myocardial infarction,
circulation (code 39.61)
unspecified site, unless no other information is that’s required for this
provided and the physician can’t be queried. procedure.

3. For myocardial infarctions, assign a fifth digit of 1
When assigning a code
(initial episode of care) if the patient was transferred
from category 410,
from another facility during the initial episode treatment. use a fourth digit to
classify the location of
4. When a patient experiences a second infarction during
the heart wall involved.
an admission for an acute myocardial infarction, code
If the location isn’t
both infarctions with a fifth digit of 1 for both cases. documented, review
the electrocardiograph
5. Don’t assign code 412—old myocardial infarction—when
report and query the
current ischemic heart disease is present. physician.
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.

Lesson 1 49
10. It’s rare to use code 414.9—chronic ischemic heart
disease, unspecified—in an acute care setting. Query
the physician for more information.
11. Arteriosclerosis of a bypassed blood vessel isn’t consid-
ered a postoperative complication and instead should be
coded to the appropriate arteriosclerosis code.
12. When a patient is admitted to the hospital with stable
angina, code first the underlying cause as the principal
diagnosis followed by the angina code.
13. When coding heart failure, codes 428.0 and 428.1
shouldn’t be assigned together. Code 428.0 should
take precedence.
14. Code hypertensive heart disease with heart failure to
NOTES:
category code 402.
There are codes from
category 404 that
15. Code hypertensive heart disease with hypertensive renal
indicate whether the disease to category code 404.
disease is benign or
16. Assign code 427.5—cardiac arrest—as principal diagnosis
malignant. Query the
physician for clarifica-
only when a patient arrives in cardiac arrest and can’t be
tion before assigning resuscitated (or is only briefly resuscitated before being
these codes. pronounced as expired).
17. Assign code 427.5—cardiac arrest—as secondary
diagnosis when cardiac arrest occurs during hospitaliza-
tion and the patient is resuscitated. Code the underlying
cause as the principal diagnosis.
18. Don’t assign code 436—acute, but ill-defined, cerebro-
vascular disease—when the documentation states stroke
or CVA of specified type.
19. Late effects of cerebrovascular accidents (for example,
aphasia, hemiparesis) aren’t coded if they’ve resolved
at discharge. If still present at discharge, code the late
effects as secondary diagnoses (with CVA as the principal
diagnosis).
20. Assign a code from category 438—late effects of cerebro-
vascular disease—when a patient is admitted at a later
date with residual effects of a CVA that have bearing on
the current episode of care. Codes from category 438 may
be assigned as the principal diagnosis when appropriate.

50 Medical Coding 2
21. Assign a code from category V57 as principal diagnosis
when the patient is admitted for rehabilitation after a CVA.
Assign additional codes from category 438 to indicate the
residuals.
22. If hypertension isn’t specified as benign or malignant,
assign code 401.9 (rarely assigned as principal diagnosis).
23. Code secondary hypertension (category 405) as the second-
ary diagnosis with the underlying cause sequenced first.
24. Always assume a causal relationship between renal
failure and hypertension and code it as hypertensive
renal disease.
25. When documentation indicates that both hypertension
and diabetes are responsible for chronic renal failure,
code both conditions (category code 403 or 404 and
250.4X) with sequencing optional.
26. Code hypertension associated with pregnancy, childbirth,
or puerperium to category code 642.
27. Elevated blood pressure without the documentation of NOTES:
hypertension is coded to 796.2.
A patient may have
28. Postoperative hypertension is a complication of surgery elevated blood pres-
and should be coded to 997.91 along with a code to sure following surgery.
identify the type of hypertension. This isn’t considered
true post-operative
29. Assign V42.2—heart valve transplantation, V45.01— hypertension (unless
cardiac pacemaker in situ, and V45.81—aorto-coronary specified by the physi-
bypass status, only as additional diagnoses that indicate cian) and should be
coded to 796.2.
a health status related to the circulatory system (only
when this additional diagnosis affects the patient’s
Code V53.31 includes
current episode). an admission for
30. When a patient is admitted for removal, replacement, replacement because
the pacemaker is
or reprogramming of a cardiac pacemaker, code
nearing the end of
V53.31—fitting and adjustment of cardiac pacemaker— expected life.
as the principal diagnosis.

Lesson 1 51
Coding Guidelines for
Circulatory System Procedures
1. Total replacement of a pacemaker requires two proce-
dure codes—replacement of leads (37.74 or 37.76) and
replacement of pacemaker (37.85–37.87).
2. For a PTCA, code (00.66). For single vessels with throm-
bolytic agents, code 00.66 and 99.10. For multiple
vessels, code 00.66, and then additional codes for num-
ber of vessels treated (00.40–00.43) and infusion of
thrombolytic agent (99.10).
3. Code an incomplete PTCA as a coronary arteriogram—
code 88.5X.
4. For a CABG, assign an additional (secondary) procedure
code for the extracorporeal circulation (code 39.61) that’s
required for this procedure. (Don’t assign hypothermia,
cardioplegia, intraoperative pacing, and chest tube
insertion as separate codes because they’re integral to a
CABG).
Now let’s practice the principles for this section. Proceed to
the practical coding exercise for more information.

Practice Exercise 3C
Books Needed:

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.

52 Medical Coding 2
Respiratory System
(Code Categories 460–519)
NOTES:
As stated at the beginning of this chapter, one of the most
important guidelines to remember when coding respiratory Both Streptococcus
system disorders is to code the organism (cause) of the respi- and Neisseria are
found normally in the
ratory condition when documented. This is sometimes done
respiratory system.
as one (combination) code to cover both the pneumonia and Their presence doesn’t
the organism. For example, for pneumonia due to Klebsiella— necessarily indicate
code 482.0. an infection.

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 pneumonia doesn’t actually refer to a lobe of the lung,
but instead to a specific type of pneumonia. Only use code 481,
lobar pneumonia, when specified by the physician.
Gram-negative pneumonia is caused by gram-negative bacte-
ria and is coded to category 482.83—pneumonia due to other
gram-negative bacteria.
Aspiration pneumonia is a severe pneumonia that results from
inhaling a foreign body or material (for example, vomitus,
food, liquids) into the respiratory tract. Pneumonia due to a
specific foreign body should be coded to category 507. Pneu-
monia due to the aspiration of microorganisms (for example,
gram-negative bacteria) is coded to categories 480–483.

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:
Q Emphysema

Q Chronic bronchitis

Lesson 1 53
NOTES:
Q Bronchospasm

It’s possible for the Q Bronchiolitis
two types of aspiration
pneumonia to be
When additional respiratory tract conditions such as acute
present in the same bronchitis and asthma exist, use combination codes for COPD.
patient. In this case, Care should be taken to code the appropriate combination
code both the 507 and code and not two separate codes for these conditions.
480–483 categories.

Don’t code respiratory Respiratory Failure
failure unless docu-
Respiratory failure occurs when there’s an inadequate
mented by the
physician.
exchange of oxygen (O2) and carbon dioxide (CO2) in the lungs.
Patients in acute respiratory failure will have increased
Not all patients in breathing (rapid respiratory rate with use of accessory
respiratory failure muscles) and possible cyanosis.
are put on mechanical
ventilation.
The following codes are used for respiratory failure:
Q 518.8X—Respiratory failure (acute, chronic, acute and
Don’t code respiratory chronic, or NOS)
failure as the principal
diagnosis when it’s due Q 518.5—Pulmonary insufficiency following trauma and
to an acute, nonrespi- surgery
ratory condition.
Q 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 O2 and CO2;
(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.

54 Medical Coding 2
Coding Guidelines for
Respiratory Disease Diagnoses
1. Code 481—lobar pneumonia—only when specified by
the physician.
2. When the two types of aspiration pneumonia are present
in the same patient, code both the 507 category code
and the code from categories 480–483.
3. Code COPD as 496—chronic airway obstruction, NEC—
only when assignment of a more specific code isn’t
possible.
4. An admission for acute exacerbation of COPD should be
assigned code 491.21—chronic obstructive bronchitis
with acute exacerbation.
5. When a patient is admitted with acute bronchitis and
COPD with acute exacerbation, assign code 491.22—
obstructive chronic bronchitis with acute bronchitis. Don’t
assign code 466.0—acute bronchitis—as an additional
code because it’s implicit in category 491.22.
6. Assign respiratory failure as the principal diagnosis if it
brings the patient to the hospital and is caused by a
respiratory condition.
7. Don’t code respiratory failure as the principal diagnosis if
the patient is admitted with respiratory failure due to an
acute nonrespiratory condition. Code the nonrespiratory
condition as principal diagnosis, followed by a secondary
code for the respiratory failure.
8. When a patient is admitted in respiratory failure due
to/associated with a chronic nonrespiratory condition,
code the respiratory failure as principal followed by the
chronic nonrespiratory condition as secondary.
Now let’s practice the principles for this section. Proceed to
the practical coding exercise for more information.

Lesson 1 55
Practice Exercise 3D
Books Needed:

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.

56 Medical Coding 2
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 Development book.
Complete all required and relevant codes for each given scenario. When you’re comfortable
with your answers for both parts, submit this quiz to your instructor for grading.

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)

Lesson 1 57
Assignment 3 Quiz
40951100

5. One of the patient’s diagnoses is listed as alcoholism in remission. Which of the following
codes should be reported for this condition?

A. 303.03 C. 303.93
B. 305.0 D. V11.3

6. A right-handed patient has right-sided hemiplegia from a current, unspecified CVA that clears
before patient discharge. Which of the following could be the correct code assignment(s) and
sequencing (if applicable)?

A. 436 C. 438.21
B. 436, 342.91 D. 438.21, 342.91

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)

58 Medical Coding 2
Assignment 3 Quiz
40951100

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

Exercises 4.6–4.15, “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

Lesson 1 59
NOTES

60 Medical Coding 2
ANSWER SHEET
FOR YOUR INSTRUCTOR’S USE
GRADE GRADED BY

STUDENT NUMBER:
ASSIGNMENT 3 QUIZ 40951100
PLEASE PRINT
Medical Coding 2

NAME ________________________________________________________________

ADDRESS ________________________________________________________________

CITY ________________________________________________________________
STATE/PROVINCE ZIP/POSTAL CODE

S Check if this is a new address
PHONE

INDICATE YOUR ANSWER TO EACH QUESTION BY MARKING AN X IN THE
APPROPRIATE SQUARE. EXAMPLE: X
A B C D

Part A
CUT ALONG THIS LINE

1. A B C D 6. A B C D

2. A B C D 7. A B C D

3. A B C D 8. A B C D

4. A B C D 9. A B C D

5. A B C D 10. A B C D

Part B

4.6 ________________________________ 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?
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 your ICD-9-CM coding 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 NOTES:

(Categories 520–579) There’s no additional
reading assignment for
Diseases of the digestive system are listed in Chapter 9 and the Digestive System.
are classified to code categories 520–579.
Assign code category
578 when the physi-
Gastrointestinal Hemorrhage cian notes that GI
bleeding is due to a
Gastrointestinal (GI) hemorrhage can manifest itself in non-GI condition.
several ways:
Q Hematemesis (vomiting of blood)—may indicate upper
GI hemorrhage

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

Q 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).

Lesson 1 63
Diverticulosis versus Diverticulitis
Diverticulosis indicates the presence of pouchlike herniations
(diverticula) throughout the intestine. Diverticulitis is inflam-
mation of the diverticula.
When both diverticulosis and diverticulitis are documented,
code only the diverticulitis because the condition assumes
the presence of the pouchlike herniations (from diverticulo-
sis). For example, for diverticulosis with diverticulitis of the
duodenum—code 562.01—diverticulitis of the small intestine
NOTES:
(without mention of hemorrhage).
Diverticula can be acquired or congenital. For certain sites
Diverticula can be
found on any hollow, (such as colon), diverticula are assumed to be congenital. For
tubular organ (such as other sites (such as espophagus), diverticula are assumed to
intestine, esophagus, be acquired unless otherwise documented. Pay close atten-
bladder). tion to medical record documentation and coding notes in
your coding book so that you’ll assign the appropriate code
When diverticulosis
for these distinctions.
isn’t otherwise speci-
fied, it’s assumed to
be of the colon (code Cholecystitis, Cholelithiasis,
562.10 [without
hemorrhage]).
and Choledocholithiasis
This section deals with diseases of the gallbladder. The
The terms stone and
function of the gallbladder is to store excess bile until it’s
calculus are synony-
mous and may be
needed to break down fat. Cholecystitis is acute or chronic
used interchangeably inflammation of the gallbladder. Cholelithiasis is the presence
in documentation. of gallstones in the gallbladder. If there are abnormally high
levels of bile salts or, more commonly, cholesterol, stones can
When removal of form. Choledocholithiasis is a condition of stones in the com-
stones is performed, mon bile duct. Choledocholithiasis may also be referred to as
don’t code incision of
biliary calculus or gallstones.
the cystic duct as a
separate procedure In ICD-9-CM classification, there are codes that allow for
because it’s implicit
these three related conditions to be coded as one combina-
in the basic procedure
tion code. There are classification groups (code category 574)
code.
based on location of the calculus. The fourth digit within the
category indicates if there’s associated cholecystitis and if it’s
acute. Fifth digits indicate any presence of obstruction.
Cholecystectomy, or removal of the gallbladder, is a procedure
that can be performed as total or partial via either an open
approach (51.21–51.22) or a laparoscopic approach
(51.23–51.24).

64 Medical Coding 2
Adhesions and Hernia NOTES:

Adhesions are bands of scar tissue that bind together internal A patient may have
surfaces that are normally separate. Adhesions most commonly minor adhesions that
form in the abdomen after abdominal surgery. Adhesions are don’t cause issues.
When these adhesions
classified to codes 568.0 (peritoneal adhesions; postoperative,
are lysed during another
post-infective) and 560.81 (intestinal or peritoneal adhesions procedure, don’t code
with obstruction; postoperative, post-infective). Adhesions are the adhesions or the
treated by lysis (destruction/dissolution of the scar tissue) lysis. Code these
and coded by the following approaches: adhesions only when
they’re so extreme that
Q Laparoscopic lysis of peritoneal adhesions—code 54.51 the surgeon must stop
the other procedure
Q Other lysis of peritoneal adhesions—code 54.59 in order to lyse the
adhesions. As always,
Hernia is a protrusion or projection of an organ through an query the physician
abnormal opening. In ICD-9-CM, hernias are classified by type for clarification when
and site. For hernia repair, make sure that the diagnostic needed.
code for hernia matches the procedure code. For example, if
a diagnosis of unilateral hernia is coded, it isn’t possible for a It isn’t possible for a
bilateral hernia procedure to be coded. Errors in coding such bilateral repair to be
performed for a unilat-
as this will result in denial of payment for the institution.
eral hernia. However,
it’s possible for a
Coding Guidelines for Digestive System Diagnoses unilateral repair to be
done for a bilateral
1. Code category 578 (gastrointestinal hemorrhage) is hernia if repair for
one of the hernias
assigned only when the physician states GI bleeding
is necessary but not
is caused by a condition other than GI.
for the other.
2. Assign GI conditions with hemorrhage to the appropriate
combination code.
3. Obstruction of gallbladder—code 575.2—and obstruction
of bile duct—code 576.2—should be assigned only when
there’s obstruction but no calculi.
4. Calculus of the gallbladder and bile duct with both acute
and chronic cholecystitis should be coded to 574.8X.
5. When coding postcholecystectomy syndrome—code
576.0—don’t code a postoperative complication code
(categories 996–999).
6. With femoral and inguinal hernias, use the fifth-digit
subclassification to indicate if the hernia is unilateral or
bilateral and whether it’s recurrent.
7. Code incarcerated or strangulated hernias as obstructed.

Lesson 1 65
8. Code functional diarrhea as 564.5 (564.4 if it follows
GI surgery).

Coding Guidelines for Digestive
System Procedures
1. When coding cholecystectomy, look for the following
NOTES:
additional performed procedures and assign additional
Infectious diarrhea codes if present: removal of stones (51.41), other relief of
with organism is obstruction (51.42), intraoperative cholangiogram (87.53).
assigned to Chapter 1,
“Infectious and 2. When removal of stones is performed during a cholecys-
Parasitic Diseases” tectomy, don’t code incision of the cystic duct as a
(code categories separate procedure because it’s implicit in the basic
001–008). When no
procedure code.
condition/cause is
identified, code 3. When simple or minor adhesions are lysed during
diarrhea as a another procedure, don’t code the adhesions or the lysis.
sign/symptom
code (787.91). 4. For appendectomy, assign code 47.1X, incidental appen-
dectomy, when an appendix is removed as a routine
For the code 47.0X measure during the course of other abdominal surgery.
guideline, the appendix
doesn’t need to show 5. For an appendix removed during exploratory laparo-
pathologic changes on scopic surgery (with no other therapeutic procedure),
tissue examination for code 47.0X with no code for the approach.
this to be coded.
Now let’s practice the principles for this section. Proceed to
the practical coding exercise for more information.

Practice Exercise 4A
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
1.176–1.195, “Digestive System,” starting on page 19. When you’re finished, check your
answers at the back of this study guide. Once you’re confident you understand the coding prin-
ciples for this section, move on to the next section.

66 Medical Coding 2
Genitourinary System
(Code Categories 580–629)
Chapter 10 in the ICD-9-CM book categorizes diseases of the
genitourinary system (code categories 580–629).
Genitourinary refers to the organs and/or functions of both
the genitals and urinary system together. Genitourinary is
also called urogenital.

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
Q Cystitis—inflammation of the bladder and ureters

Q Pyelonephritis—inflammation of the renal pelvis of
the kidney

Q 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
NOTES:
infection. Many of these codes are reclassified to a chapter
other than the genitourinary system chapter. For example, If cystitis and pyelo-
gonococcal cystitis (bladder)—code 098.11—is reclassified to nephritis are
Chapter 1, “Infections and Parasitic Disease,” to indicate the documented, look up
the actual disease
organism Neisseria gonorrhoeae as the infective agent causing
mentioned (that is, cys-
the cystitis. titis) in the Alphabetic
When coding urinary tract infections to Chapter 10, use two Index. Starting with
the term infection may
codes: infection code (coded first); organism code. For example,
take you to the wrong
in acute cystitis due to Escherichia coli code as follows: acute coding information.
cystitis—code 595.0 (assigned first); E. coli—041.4 (assigned
as secondary code). When the specific location of the UTI isn’t The 599.0 code is used
documented, code 599.0—urinary tract infection, NOS. If the commonly by coders.
organism is identified, use a secondary code following 599.0. Many times a specific
location/organism may
not be mentioned.

Lesson 1 67
Hematuria and Incontinence
Hematuria, or blood in the urine, is a symptom of certain
conditions. The hematuria code (599.7) should be assigned
only when the condition causing it isn’t identified. In some
cases (for example, after urinary procedures), some amount
of hematuria is expected and shouldn’t be coded. If documen-
tation indicates that hematuria after a procedure is excessive,
NOTES: query the physician to determine if it should be coded as a
postoperative condition or secondary diagnosis.
Incontinence actually
refers to the inability Incontinence refers to the inability to control urination due to
to control urination or anatomic, physiologic, or pathologic conditions.
defecation. For the
purpose of this chapter, Stress incontinence is due to physical strain such as occurs
we’re discussing incon- when a person coughs, sneezes, or laughs. Stress incontinence
tinence related in women is coded to 625.6 and in men to code 788.32.
specifically to urination.

Unspecified renal
Renal Disease
failure is coded to 586.
Renal disease is classified to code categories 580–593, with
the exception of that related to pregnancy/labor (reclassified
to Chapter 11). Renal failure is a result of other diseases and
can be acute or chronic. Acute kidney failure is the sudden
cessation of renal function (584.X). Chronic kidney disease,
or CKD (585.X), is the inability of the kidneys to function
adequately on a long-term basis. According to the “Clinical
Practice Guidelines for CKD” by the National Kidney
Foundation (http://www.kidney.org), CKD is defined as
kidney damage or greater than or equal to three months.
Kidney damage is pathologic abnormalities or markers of
damage (including abnormalities in blood or urine tests or
imaging studies).
The ICD-9-CM coding book provides fourth digits to cover
all stages of kidney disease (Stage I–V and then “End Stage”).
Chronic kidney disease includes chronic renal disease, chronic
renal failure NOS, and chronic renal insufficiency, which are
all included in code 585.9. If applicable, an additional code
(V42.0) should be used to identify the kidney transplant status.
As discussed in the circulatory system chapter, ICD-9-CM
assumes a relationship between hypertension and kidney dis-
ease (reclassified to categories 403 or 404). However, acute

68 Medical Coding 2
renal failure isn’t assumed to be caused by hypertension. In
this case, assign first the code for acute renal failure (584.9)
followed by the code for hypertension (401.9). Don’t use codes
from categories 403 or 404 if the following scenarios exist:
Q Acute renal failure exists with hypertension.

Q Hypertension is described as secondary.

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

Q 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.

Lesson 1 69
8. When the patient is admitted for dialysis, code V56.0—
extracorporeal dialysis (hemodialysis) or V56.8—other
dialysis (peritoneal)—as the principal diagnosis.

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.

70 Medical Coding 2
Skin and Subcutaneous Tissue
(Code Categories 680–709)
NOTES:
Skin and subcutaneous tissue conditions are covered in
Chapter 12, code categories (680–709). They’re subdivided This chapter includes
into the following categories: conditions of the nails,
sweat glands, hair, and
Q Infections (680–686) hair follicles.

Q Other inflammatory conditions (690–698)
Cellulitis can occur in
Q Other disease of skin/subcutaneous tissue (700–709) other areas (aside from
skin/subcutaneous tis-
sue). In those cases,
Cellulitis code the cellulitis
to the appropriate
Cellulitis is an acute infection of the skin and subcutaneous chapter.
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.

Lesson 1 71
NOTES: Debridement
Excisional debride- Debridement is a procedure done to remove damaged tissue,
ments may be carried debris, and foreign objects from a wound or burn to prevent
out at the patient’s infection and promote healing. There are two important
bedside or in an oper-
distinctions for debridement when coding this procedure;
ating room. However,
just because a physi-
86.22—excisional debridement of the skin—includes cutting
cian is performing the away of the tissue and is performed only by a physician.
debridement doesn’t
Code 86.28 is a nonoperative (nonexcisional) procedure that
make it excisional.
includes terms like brushing, irrigating, scrubbing, or other
Nonexcisional debride-
methods to remove tissue or foreign material.
ments performed by
personnel other than
Coding Guidelines for Skin and
physicians shouldn’t
be coded. Subcutaneous Tissue Diagnoses
1. Code cellulitis due to a superficial injury, burn, or
Abscess and lymphan-
gitis are included in the
frostbite to two codes—one for the injury and one for
code for cellulitis. cellulitis. Sequencing in this case depends on the cir-
cumstances of admission.
Simple excision
2. For abscess and/or lymphangitis with cellulitis, assign
involves only the skin.
only the appropriate code for cellulitis. Assign an addi-
tional code for the causative organism.
3. Assign cellulitis as a complication of a chronic skin ulcer
to code category 707 with a secondary code to identify
the cellulitis. Sequencing depends on the circumstances
for admission.
4. Code gangrenous cellulitis due to injury/ulcer to
gangrene—785.4—as a secondary diagnosis with
the injury/ulcer sequenced as principal diagnosis.

72 Medical Coding 2
Coding Guidelines for Skin and
Subcutaneous Tissue Procedures
1. Code simple excision of lesions to category 86.3 (includes
NOTE:
local excision and method of destruction).
Radical or wide
2. Code 86.4 for a radical or wide excision.
excision involves
3. Nonexcisional debridements performed by personnel underlying/adjacent
tissue.
other than physicians shouldn’t be coded.
Now let’s practice the principles for this section. Proceed to
the practical coding exercise for more information.

Practice Exercise 4C
Books Needed:

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.

Lesson 1 73
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 Development book.
Complete all required and relevant codes for each given scenario. When you’re comfortable
with your answers for both parts, submit this quiz to your instructor for grading.

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 most common 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)

74 Medical Coding 2
Assignment 4 Quiz
40951200

5. How should the presence of hematuria after a urinary tract procedure or prostatectomy
be coded?

A. 599.0
B. 599.7
C. 998.89
D. It shouldn’t be coded unless directed by the physician.

6. When a patient has both hypertension and renal disease, a relationship is presumed and
coded as one code together except in the case of

A. acute renal failure. C. renal disease with heart disease.
B. chronic renal failure. D. acute renal disease.

7. Which of the following factors most likely 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

76 Medical Coding 2
ANSWER SHEET
FOR YOUR INSTRUCTOR’S USE
GRADE GRADED BY

ASSIGNMENT 4 QUIZ 40951200
STUDENT NUMBER:
PLEASE PRINT
Medical Coding 2

NAME ________________________________________________________________

ADDRESS ________________________________________________________________

CITY ________________________________________________________________
STATE/PROVINCE ZIP/POSTAL CODE

S Check if this is a new address
PHONE

INDICATE YOUR ANSWER TO EACH QUESTION BY MARKING AN X IN THE
APPROPRIATE SQUARE. EXAMPLE: X
A B C D

Part A

1. A B C D 6. A B C D
CUT ALONG THIS LINE

2. A B C D 7. A B C D

3. A B C D 8. A B C D

4. A B C D 9. A B C D

5. A B C D 10. A B C D

Part B

4.16 ________________________________ 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?
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
NOTE:
Musculoskeletal System and Connective Tissue”—in the
Tabular List of your ICD-9-CM coding book. There’s no additional
Read Section 11—“Complications of Pregnancy, Childbirth, reading assignment for
and Puerperium”—(pp. 14–15) in the Coding Guidelines of your congenital anomalies.
ICD-9-CM coding book.
Read Section 15—“Newborn (Perinatal) Guidelines”—(pp. 17–18)
in the Coding Guidelines of your ICD-9-CM coding 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 your ICD-9-CM
coding book for the appropriate fifth-digit assignment.

Arthritis
Arthritis is an inflammatory condition of the joints that causes
pain, redness, swelling, and also limits movement. Arthritis
may occur alone or as a manifestation of another disease.

Lesson 1 79
In these cases, assign the appropriate dual codes. Some
common examples of arthritis are osteoarthritis (code
category 715) and rheumatoid arthritis (code category 714).

NOTES:
Pathologic Fractures

The fifth digit indicates Pathologic fractures are breaks in the bone caused by a
the site. weakness in the bone tissue. If a fracture is described as
spontaneous, it’s a pathologic fracture and coded to
Remember, fractures category 733.1X.
due to injuries (trau-
matic) are coded to
Chapter 17—“Injury Coding Guidelines for Musculoskeletal System
and Poisoning.” and Connective Tissue Diagnoses
Back pain associated 1. Code back pain in the following way: first code to site
with the herniation of of pain; lumbago, or low back pain—724.2; back pain,
an intervertebral disc is NOS—724.5; cervicalgia, or neck pain—723.1.
included in the hernia-
tion code 722.2 (no 2. Many back disorder codes make a distinction for those
separate code for back persons with or without myelopathy (functional disturbance
pain is assigned). and/or pathologic change in the spinal cord). Follow the
medical record documentation for appropriate assignment.
3. A pathologic fracture (733.1X) is sequenced as principal
diagnosis only when admission is for treatment of the
fracture and no other underlying condition exists.
4. Never assign traumatic fracture and pathologic fracture
of the same bone together.
5. Assign code V43.6—joint replacement status—as an
additional code if the presence of the replacement is
significant for the patient’s current episode of care.

Coding Guidelines for Musculoskeletal System
and Connective Tissue Procedures
1. When a laminectomy is 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.

80 Medical Coding 2
2. Assign replacement of joint—lower extremities—to NOTE:
code 81.5X and upper extremities to code 81.8X.
The guideline for
3. When joint replacement also involves bone growth stimu- Number 5 is used
lator, code the stimulator to 78.9X as an additional after the joint has
procedure code. been replaced the
initial time. Don’t
4. When a bilateral replacement of a joint is performed, use assign this code for
the joint replacement code twice to indicate both locations. the first (initial)
joint replacement.
5. Code revision or replacement of a joint replacement of
lower extremity to 81.5X.
Now let’s practice the principles for this section. Proceed to
the practical coding exercise for more information.

Practice Exercise 5A
Books Needed:

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.

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.

Lesson 1 81
2. These codes have sequencing priority over codes from
other chapters.
Chapter 11 is divided into the following sections:
Q Ectopic and molar pregnancies: code categories 630–633

Q Other pregnancies with abortive outcomes: code cate-
gories 634–639
NOTES:
Q Complications mainly related to pregnancy: code cate-
Puerperium is the time
gories 640–649
after childbirth—
approximately six Q Normal delivery (and other indications for care): code
weeks—in which a
categories 650–659
woman’s anatomic and
physiologic changes Q Complications occurring mainly during labor and delivery:
from the pregnancy
code categories 660–669
resolve.

Q Complications of the puerperium: code categories
Antepartum means
670–677
occurring or existing
before birth. This stage Fifth digit subclassifications used for code categories 640–649
is often referred to as
and 650–659 provide more information. Pay close attention to
prenatal. Postpartum
means occurring after
notes and guidelines for using these fifth digits. Fifth digits
birth. can be assigned only at certain periods, and many can’t be
assigned to the same episode. The fifth digits are
Q 0—Unspecified as to episode of care or not applicable

Q 1—Delivered, with or without mention of antepartum
condition

Q 2—Delivered, with mention of postpartum complication

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

Q 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).

82 Medical Coding 2
Coding Guidelines for Pregnancy, Childbirth, and
Puerperium Diagnoses
1. When an encounter is for a condition unrelated to the
pregnancy, code the condition for admission first followed
by V22.2—pregnant state, incidental.
2. Fifth digits 1 and 2 can be used together for the same
episode, but not with any other fifth digits (from other
codes in this chapter).
3. For complications, fifth digits 3 (antepartum) and 4
(postpartum) can’t be used together or with any other
fifth digit.
4. Assign a secondary category code V27.X to the mother’s
NOTES:
record to indicate the outcome of delivery (for example,
single birth, multiple births, alive, stillborn) for the cur- Look up “Outcome of
rent episode of care. delivery” (V27.X) in
the Alphabetic Index,
5. Code 650—normal delivery—only when the delivery is V code section, of your
normal with a single liveborn outcome. Criteria: head/ ICD-9-CM code book
occipital delivery; antepartum complication resolved to find these codes.

before admission; no labor/delivery abnormalities; no
Code 650 is always
postpartum complications; outcome assigned V27;
coded as principal
no procedures other than episiotomy without forceps, diagnosis and can’t be
episiorrhaphy, amniotomy, manual delivery (no forceps), coded with any other
administration of analgesia/anesthesia, fetal monitoring, codes from Chapter 11.
sterilization
Don’t use codes V22.0
6. When a patient is admitted for obstetric care other than and V22.1 with any
delivery, the principal diagnosis should be coded to the codes from Chapter 11.
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.

Lesson 1 83
NOTES:
10. Always code preexisting hypertension (category 642) as a
complication in pregnancy, delivery, or puerperium.
Diagnoses can’t be
assigned based solely 11. The physician must specify pre-eclampsia or eclampsia
on elevated blood before these conditions can be coded.
pressure, abnormal
12. Postpartum complications that occur during the
albumin level, or
edema. admission for delivery are assigned a fifth digit of 2.
Postpartum complications that occur after discharge
Complications are con- are assigned a fifth digit of 4.
sidered postpartum if
13. Code perineal lacerations to categories 664.0X–664.3X.
they occur within six
weeks after delivery. 14. Assign a code from category V25 as the principal diagno-
sis when the admission/outpatient encounter is for
Don’t forget to also contraceptive management.
assign a procedure
code for a contracep- 15. Assign code V25.2 (covers both male and female) when
tive management visit the admission/encounter is solely for contraceptive
when appropriate.
sterilization.

If sterilization is per-
formed during the Coding Guidelines for Pregnancy, Childbirth, and
same admission as Puerperium Procedures
the delivery, assign
code V25.2 as the 1. Assign additional codes for procedures that assist delivery:
secondary diagnosis.
artificial rupture of membranes (73.01), cervical dilation
(73.1), artificial rupture of membranes (after labor has
Code 75.69 includes
begun) (73.09), forceps rotation of fetal head (72.4),
repair of episiotomy, so
there’s no need for an manual rotation of fetal head (73.51).
additional code.
2. Episiotomies are coded to category 73.6 (without forceps
delivery) or category 72.1 (low forceps delivery).
3. Repair of perineal lacerations are coded to category 75.69.
4. Cesarean sections are coded as 74.0 (classical), 74.1 (low
cervical), or 74.2 (extraperitoneal).
5. Code female contraceptive/sterilization procedures to
categories 66.2 and 66.3; code male contraceptive/
sterilization procedures to 63.7.
Now let’s practice the principles for this section. Proceed to
the practical coding exercise for more information.

84 Medical Coding 2
Practice Exercise 5B
Books Needed:

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.

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 NOTE:
abnormalities. Because of the large amount of congenital
anomalies present in the medical field, it’s difficult to provide Some congenital
perinatal conditions are
a code for each and every anomaly. Sometimes the anomaly
coded to Chapter 15
will be specified even though there’s no specific ICD-9-CM (instead of Chapter 14).
code to match. In these cases, code other specified anomaly Follow coding notes in
of the specific type/site. When a specific anomaly code isn’t your ICD-9-CM coding
available, code instead each of the manifestations present for book for the correct
code assignment.
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-CM code to match, code instead other specified
anomaly of the specific type/site with manifestation
codes of the anomaly.

Lesson 1 85
2. Conditions due to birth injuries are reclassified to
perinatal conditions, birth trauma, code category 767
(Chapter 15).
3. Code a newborn with a congenital anomaly to code
NOTES:
category V30–V39 as principal diagnosis followed by
Newborn congenital the additional anomaly code from Chapter 14.
conditions are reported
even if they’re not 4. When a renal cyst isn’t specified as congenital or
treated/evaluated acquired, code the cyst as congenital.
during the current
admission. This policy
is an exception to the Certain Conditions Originating in the Perinatal
coding guideline for Period (Code Categories 760–779)
reporting additional
diagnoses. Conditions originating in the perinatal period appear in
Chapter 15, code categories 760–779.
There’s no separate
coding exercise for the
Perinatal refers to the time period around and including the
congenital anomaly process of being born or giving birth. The newborn (perinatal)
section. Congenital period begins at birth and lasts through the 28th day follow-
anomalies have been ing birth.
grouped with the
next section.
Classification of Newborns
Follow information in
the coding book for
When coding births, assign a code from categories V30–V39
correct assignment of according to the type of birth and any other significant sec-
fourth- and fifth-digit ondary diagnoses originating in the perinatal period.
subdivisions of cate-
gories V30–V39.
Codes from categories V30–V39 are assigned to the medical
record as principal diagnosis and only one time to the new-
Codes from categories born record at the time of birth.
764 and 765 should be
assigned based on
physician documenta-
Prematurity and Fetal Growth Retardation
tion and not just on
A premature infant is one who is born before 37 weeks’
gestational age and/or
birth weight. The
gestation and hasn’t fully developed or matured. Fetal growth
physician must docu- retardation means that the infant is smaller than expected
ment prematurity- at a specific gestational age. Codes for premature infants
relevant conditions to and/or fetal growth retardation are assigned to code categories
be coded.
764 and 765 with a fifth digit to indicate birth weight.

86 Medical Coding 2
Coding Guidelines for Perinatal Diagnoses
1. When coding the birth of an infant, assign to the new-
born record a code from category V30–V39 according to
type of birth.
2. Don’t code from category V30–39 when a newborn has
been transferred from another institution. Code instead
the condition responsible for the transfer as principal
diagnosis (with no V30–V39 series coded).
3. Don’t code categories V33, V37, and V39 for acute care
NOTES:
hospitals (sufficient information should be provided to
code elsewhere). When the signs/
symptoms of a sus-
4. Assign a V29 category code as secondary diagnosis when pected condition are
a healthy newborn is evaluated for a suspected condition present, code instead
that’s (after study) not present. Assign the V30 category the sign or symptom
code as principal diagnosis. (and not the V29 cate-
gory code). A code
5. Code a secondary diagnosis from category 766 for a long from V29 can be
gestation or unusually high birth weight. assigned as principal
diagnosis for readmis-
6. Code fetal distress and asphyxia only when the condition sion or when V30 is no
has been specifically identified and documented by the longer appropriate.
physician. Don’t codes these conditions based on scores
or tests. 760 and 763 codes are
assigned to newborn
7. Code from categories 760 and 763—maternal causes of records only when the
perinatal morbidity—to the newborn record only when the maternal condition has
maternal condition is the cause for morbidity or mortality. adversely affected the
newborn.
8. Assign routine vaccination of newborns as V05.3 (viral
hepatitis) and V05.4 (varicella). Code V20.2 is assigned
9. Assign a code from category V20—health supervision of for routine examina-
tions (for example,
infant/child—for routine encounters when no problem
well baby clinic) at
has been identified. clinics/offices but not
for hospital admissions.

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.

Lesson 1 87
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.

88 Medical Coding 2
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 always be considered for
inclusion in the code?

A. Degeneration C. Herniation
B. Myelopathy D. Arthritis

2. Laminectomy when performed with excision of herniated disc shouldn’t be coded separately
because this procedure is

A. 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 only when

A. the physician lists it first on the admission sheet with no other conditions.
B. there’s no underlying condition that’s being treated.
C. there’s an underlying condition that’s coded as secondary.
D. it has been ruled out as the secondary diagnosis.

(Continued)

Lesson 1 89
Assignment 5 Quiz
40952000

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

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 only circumstance for which code V27 can be assigned is on the
A. newborn’s record for birth in the hospital during the current episode of care.
B. newborn’s record to indicate birth on subsequent episodes of care.
C. mother’s record for delivery in hospital during current episode of care.
D. mother’s record to indicate delivery on subsequent episodes of care.

7. Which of the following scenarios would be assigned the code for normal delivery on the
mother’s record?

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)

90 Medical Coding 2
Assignment 5 Quiz
40952000

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

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
NOTES

92 Medical Coding 2
ANSWER SHEET
FOR YOUR INSTRUCTOR’S USE
GRADE GRADED BY

Assignment 5 Quiz 40952000
STUDENT NUMBER:
PLEASE PRINT
Medical Coding 2

NAME ________________________________________________________________

ADDRESS ________________________________________________________________

CITY ________________________________________________________________
STATE/PROVINCE ZIP/POSTAL CODE

S Check if this is a new address
PHONE

INDICATE YOUR ANSWER TO EACH QUESTION BY MARKING AN X IN THE
APPROPRIATE SQUARE. EXAMPLE: X
A B C D

Part A
CUT ALONG THIS LINE

1. A B C D 6. A B C D

2. A B C D 7. A B C D

3. A B C D 8. A B C D

4. A B C D 9. A B C D

5. A B C D 10. A B C D

Part B

4.52 ________________________________ 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?
Lesson 1
ICD-9-CM Hospital Inpatient Coding

Examination
EXAMINATION NUMBER

40951300
Whichever method you use in submitting your exam
answers to the school, you must use the number above.

When you feel confident that you have mastered the material
in Lesson 1, submit your answers by e-mail attachment to
edserv@pennfoster.com. On the subject line of the e-mail, write
Exam 409513, then Medical Coding 2. Follow the directions given
for submitting assignment quizzes. If you don’t have access to
e-mail, you can mail in your exam. Submit your answers for this
examination as soon as you complete it. Do not wait until another
examination is ready.

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.

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

95
3. Dr. Smith recorded the following diagnoses on the patient’s discharge sheet:
gastrointestinal bleeding due to acute gastritis and angiodysplasia. The principal
diagnosis is coded as
A. GI bleeding.
B. acute gastritis.
C. angiodysplasia.
D. either acute gastritis or angiodysplasia.

4. A patient was admitted with extreme fatigue and lethargy. Upon discharge, the
physician documents: fatigue due to either depression or hypothyroidism. Which
of the following are correct codes and sequencing for the scenario?
A. 780.79, 311, 244.9 C. 249.9, 311
B. 311, 249.9, 789.79 D. 789.79

5. Of the following, which code would take precedence over the other?
A. 072.0 over 033.0 C. 486 over 480
B. 595.0 over 131.09 D. 112.2 over 599.0

6. Upon discharge, the physician documents the following on the patient’s discharge
sheet: ?HIV infection. As the inpatient coder, your next step should be to
A. code the HIV infection as if it exists (according to UHDDS guidelines) and report it
as the principal diagnosis.
B. review the UHDDS guidelines for assigning possible HIV infection codes versus
AIDS codes.
C. query the physician and request that the statement be amended with a positive
(or negative) confirmation of the HIV infection.
D. wait to code the patient’s record until a positive finding on the serology report
confirms the HIV diagnosis.

7. For which of the following scenarios would it be appropriate to query the physician for
more information before coding and/or sequencing?
A. A patient was admitted with severe abdominal pain. At discharge, the physician
documents: abdominal pain due to either hiatal hernia or diverticula.
B. A patient was admitted with congestive heart failure (treated with IV furosemide)
and unstable angina (treated with nitrates).
C. A patient has low potassium levels noted on the laboratory report (treated with
orally administered potassium).
D. A patient is admitted with dysuria with no cause found.

96 Examination, Lesson 1
8. Which of the following statements is true?
A. A patient has diabetes and an ulcer. Code the ulcer as diabetic.
B. A pregnant patient has diabetes. Code diabetes as complicating the pregnancy.
C. A patient has diabetes and cardiomyopathy. Code the cardiomyopathy as a diabetic
complication.
D. A patient has diabetes and cataracts. Code diabetic cataracts.

9. A patient was admitted for metastatic carcinoma from the breast to several lymph
node sites. Two years ago she had a double mastectomy. Which of the following is the
correct code assignment for this case?
A. 196.8, V10.3 C. 196.8, 174.9, 85.42
B. 174.9, 196.8 D. 196.8, 174.9, V10.3

10. One of the secondary diagnoses listed on the patient’s discharge sheet is seizures. As
a coder, your next step is probably
A. coding seizures to 780.39.
B. coding seizures to 345.
C. not reporting the code because it’s a symptom.
D. querying the physician for more information/clarification.

11. A patient was discharged with the diagnosis of acute bronchitis with chronic obstructive
asthma. Which of the following is the correct coding and sequencing (if applicable) for
this patient?
A. 493.21 C. 466.0, 493.21
B. 493.21, 496 D. 493.91

12. Code 780.2 can be listed as principal diagnosis in which of the following cases?
A. For an outpatient encounter when the cause has been determined
B. For an inpatient encounter when the cause hasn’t been determined
C. When it’s listed with a contrasting diagnosis
D. It can never be listed as principal diagnosis.

13. Which of the following codes should not be listed as principal diagnosis?
A. 784.7 C. E812.0
B. V30.00 D. 307.81

14. Choose the correct code and sequencing for the following scenario: Reduction of right
humerus fracture with cast.
A. 79.00 C. 79.00, 93.53
B. 79.01 D. 79.01, 93.53

Examination, Lesson 1 97
15. Read the following excerpt from medical record documentation and determine the
correct code(s) for coding. The physician writes: “…noted burn on the arm skin with
redness. Patient complained of tenderness to the touch.”
A. 943.01 C. 943.21
B. 943.10 D. 943.30

16. A patient was admitted in a coma from intentionally ingesting an entire bottle of
sedatives. Which of the following is the correct coding and sequencing assignment?
A. 780.01, 967.8 C. 967.8, E950.2
B. 780.01, 967.8, E950.2 D. 967.8, 780.01, E950.2

17. Which of the following situations would allow the assigning of a V code for a principal
diagnosis?
A. Mother admitted for birth of infant, no complications
B. Patient admitted for dialysis
C. Patient admitted for metastatic breast cancer with a history of ovarian cancer
D. Patient admitted for poisoning has a history of alcoholism

18. A patient was admitted for nausea and vomiting due to gastroenteritis. Which of the
following is the correct code reporting and sequencing?
A. 787.01, 787.02, 558.9 C. 558.9, 787.01
B. 787.02, 787.03, 558.9 D. 558.9

19. A physician lists positive findings on a purified protein derivative (PPD) test as a
secondary diagnosis on the patient’s discharge sheet. How should this listing be coded?
A. 795.5
B. 010.95
C. 011.05
D. This listing shouldn’t be coded.

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

98 Examination, Lesson 1
22. A patient was discharged with a diagnosis of diabetes with nephropathy and chronic
renal failure. How many codes would be reported for this patient?
A. One
B. Two
C. Three
D. Need more information on the type of diabetes

23. If the physician describes the patient as presently in a manic phase, but has
experienced depression in the past, this condition may be coded as
A. 296.4X C. 296.6X
B. 296.5X D. Need more information

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 correct coding and
sequencing for this case?
A. 518.81, 491.21 C. 518.81, 496
B. 491.21, 518.81 D. 493.91, 496, 518.81

Part B: Coding Record Scenarios

In your Clinical Coding Workout: Practice Exercises for Skill Development book, code the
following health record scenarios. Record your answers on the answer sheet for this
examination. In some cases, you’ll select codes from a multiple-choice list. In other cases,
you’ll be assigning the actual diagnosis and procedure codes. When assigning codes, be
sure to report them on the answer sheet in the order that you would sequence them (if
appropriate).

Be sure to read the directions on pages 189–190 (Case Studies from Inpatient Health
Records) before beginning these exercises.

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)

Examination, Lesson 1 99
NOTES

100 Examination, Lesson 1
ANSWER SHEET
FOR YOUR INSTRUCTOR’S USE
GRADE GRADED BY

EXAMINATION NUMBER 40951300
STUDENT NUMBER:
PLEASE PRINT
Lesson 1: Inpatient Coding

Medical Coding 2
NAME ________________________________________________________________

ADDRESS ________________________________________________________________

CITY ________________________________________________________________
STATE/PROVINCE ZIP/POSTAL CODE

S Check if this is a new address
PHONE

INDICATE YOUR ANSWER TO EACH QUESTION BY MARKING AN X IN THE
APPROPRIATE SQUARE. EXAMPLE: X
A B C D

Part A

1. A B C D 10. A B C D 18. A B C D
CUT ALONG THIS LINE

2. A B C D 11. A B C D 19. A B C D

3. A B C D 12. A B C D 20. A B C D

4. A B C D 13. A B C D 21. A B C D

5. A B C D 14. A B C D 22. A B C D

6. A B C D 15. A B C D 23. A B C D

7. A B C D 16. A B C D 24. A B C D

8. A B C D 17. A B C D 25. A B C D

9. A B C D

Part B

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?
Graded Project
Lesson 1

GRADED PROJECT NUMBER

40951400

RESEARCH PROJECT

Background
Some hospitals, organizations, and physicians now outsource,
or hire contract coders, to perform their coding. There are
commercial coding companies that engage pools of coders to
meet these outsourcing needs.

Procedure
Use the internet to research coding companies. Select two
and provide the following information for each company:
Part A—Company Information
1. Company Name
2. URL (Web address)
Part B—Questions
1. How long has the company been in business?
2. List the range of services the company provides.
3. What kind of health care providers does the company
work with?
4. What are the requirements (educational, certification,
experience, and so on) to work for this company?
5. Would you like to work for this company? Why or why
not? What additional skills would you need to acquire
before working for this company?

103
Goal
Your goal is to become aware of these coding companies,
the health care providers they work with, and the skills and
experience coders must have to work for individual companies.

Writing Guidelines
Q Type your submission, double-spaced, in a standard,
size 12 print font. Use a standard document format with
one-inch margins. (Don’t use any fancy or cursive fonts.)

Q 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)

Q Read the assignment carefully and answer each question.

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

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

Q 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

104 Graded Project
The questions will be evaluated according to the following
criteria:

Content
The student
Q Provides clear answers to the assigned question(s)

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

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

Q Stays focused on the assigned issues

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

Written Communication
The student
Q As necessary, answers each question in a complete para-
graph that includes an introductory sentence, at least
four sentences of explanation, and a concluding sentence

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

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

Q 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
Q Name and address

Q Student number

Q Course title and number (Medical Coding 2 HIT 204)

Q Research project number (40951400)

Graded Project 105
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.

106 Graded Project
ANSWER SHEET
FOR YOUR INSTRUCTOR’S USE
GRADE GRADED BY

EXAMINATION NUMBER 40951400
STUDENT NUMBER:
PLEASE PRINT
Graded Project

Medical Coding 2
NAME ________________________________________________________________

ADDRESS ________________________________________________________________

CITY ________________________________________________________________
STATE/PROVINCE ZIP/POSTAL CODE

S Check if this is a new address
PHONE

Company 1

Part A—Company Information (5 points) Score _____

Part B—Questions

Question 1 (5 points) Score _____
CUT ALONG THIS LINE

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:
Inpatient/Outpatient
Procedure Coding/

Lesson 2
Physician Coding/
HCPCS Level II
ASSIGNMENT 6: HOSPITAL
(ACUTE CARE) INPATIENT AND
AMBULATORY (OUTPATIENT)
PROCEDURE CODING
Read Section IV—“Diagnostic Coding and Reporting Guidelines
for Outpatient Services”—(p. 28–29) in the Coding Guidelines
of your ICD-9-CM coding book.
Read the Introduction (pp. xiv–xvii) in your Current Procedural
Terminology: CPT coding book.

INTRODUCTION
In this lesson you’ll learn about general coding guidelines for
inpatient and outpatient procedures and physician office
coding using ICD-9-CM, HCPCS Level I, and HCPCS Level II
procedure coding.
ICD-9-CM procedure codes are found in volume 3 of the
ICD-9-CM coding book and are used to code acute-care hospital
inpatient and outpatient procedures. Volume 3 (Index to
Procedures) is arranged mainly by specific body system.
HCPCS Level I (CPT) is found in your CPT 2011 coding book
arranged in six sections by numeric order.
The HCPCS Level II list from CMS is arranged alphanumeri-
cally. Most HCPCS Level II coding books are arranged by code
letter section (for example, all A codes are in one section, and
B codes are in a separate section). Note: You don’t have a
HCPCS Level II textbook. Instead, you’ll use the lists you
downloaded earlier from the CMS Web site.
For this section, you’ll focus on hospital inpatient and out-
patient procedure coding guidelines.

109
NOTES: Coding Inpatient Procedures
There’s one exception For reimbursement and reporting, medical coders are
to the numeric order—
required by the UHDDS to code hospital inpatient proce-
E/M codes (99201–
99499) are listed at
dures. The UHDDS (to refresh your memory, the Uniform
the beginning of the Hospital Discharge Data Set) requires that all significant
CPT 2011 coding book. procedures be reported. A significant procedure has the
following characteristics:
The UHDDS doesn’t
apply to the coding of
Q Surgical in nature
outpatient procedures.
Q Has an anesthetic risk
The CPT system (from
the AMA) is the classi-
Q Has a procedural risk
fication system that
determines reporting Q Requires specialized training to perform
guidelines for outpa-
tient procedures along Remember, hospital inpatient procedures are reported using
with the CMS.
the codes from Volume 3 (Index to Procedures) of the ICD-9-CM
coding book. You learned about guidelines for some of these
You may also hear the
procedures when working through the different body systems
term encounter used
for an outpatient’s visit in Lesson 1.
or an inpatient stay at
the hospital.
Coding Outpatient Procedures
An outpatient is defined as an individual who receives hospital
services and isn’t expected to be admitted to the hospital or
remain in the hospital over a period of 24 hours. Outpatient
care may also be referred to as ambulatory care.
The CMS requires that outpatient procedures be reported
using HCPCS Level I (CPT) codes. ICD-9-CM procedure codes
aren’t required for reporting; however, the administrators of
some hospitals and other health care institutions may choose
to have the coder report both the HCPCS Level I (CPT) code
and the ICD-9-CM procedure code for internal tracking or
statistical purposes.

110 Medical Coding 2
Coding Inpatient versus Outpatient Procedures NOTES:

Two major differences exist between coding inpatient versus This outpatient sce-
outpatient records. nario is different than
that for inpatient
1. The UHDDS definition of principal diagnosis applies only guidelines wherein you
to inpatients (acute care hospitals). may code “probable,”
“suspected,” and
2. Inconclusive diagnoses (probably, suspected, likely)
“likely” as if the
aren’t coded for outpatients. Instead, the highest level of condition exists.
certainty is coded. This means that there may be times
when you’re coding a symptom as the reason for an out- There may be times
patient encounter. when your principal
procedure and principal
diagnosis aren’t related.
Acute-Care Hospital Inpatient Procedural Coding Make sure that you
have adequate docu-
Hospital inpatient procedures are coded using ICD-9-CM pro- mentation for the
cedure codes (categories 00–99.99) found in Volume 3 of the codes assigned so
ICD-9-CM coding book. Just as there’s a principal diagnosis in that reimbursement
inpatient coding, there’s also a principal procedure. A principal isn’t denied.

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 some ICD-9-CM procedures, you’ll see an instructional
note that says “Code Also.” Code also means 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 additional code(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 code instruction means that no code for that
category is to be assigned.

Lesson 2 111
3. Excision of Organ or Lesion
Excision of organs (or lesions) may also be listed under
the term resection.
4. Bilateral Procedures
Bilateral procedures indicate that the procedure was
performed at two locations/sides. Assign the procedure
code twice for bilateral procedures (unless otherwise
indicated by the code).

NOTES: 5. Approaches and Closures
Operative approaches/closures (for example, incisions
The operative approach
is coded when the and stitching up) and laparoscopic/thoracoscopic
opening is followed approaches are usually considered an integral part of
only by a diagnostic the procedure and aren’t coded as separate codes.
procedure (for exam-
ple, a biopsy). There 6. Other Endoscopic Approaches
are a few exceptions
Endoscopic approaches are coded unless directed other-
for coding laparo-
scopic/thoracoscopic
wise by the Alphabetic Index, and/or a procedure was
approaches separately. performed with the endoscopy. When an endoscopy is
Follow coding instruc- performed on more than one body cavity, the code
tions in the coding assignment should indicate the most distant site reached.
book closely.
7. Biopsies
Category V64 can’t be Closed biopsies are performed percutaneously (by needle),
assigned as a principal
by aspiration, or by endoscopy. The biopsy is coded
diagnosis.
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-CM diagnosis code category
V64—persons encountering health services for specific
procedures, not carried out—as a secondary diagnosis
with no procedure code assigned.

112 Medical Coding 2
9. Incomplete Procedures
When coding incomplete procedures (procedures that
weren’t completed for a reason), follow these guidelines:
Q Incision only performed: code to the site of incision

Q Endoscopic approach unable to reach site: code
endoscopy only

Q 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
Stents are 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.

Lesson 2 113
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-CM Procedure Coding,” starting on page 36. When you’re finished, check
your answers at the back of this study guide. Once you’re confident you understand the coding
principles for this section, move on to the next section.

NOTES: Level I HCPCS (CPT) Procedural Coding
Observation patients
aren’t technically con- Hospital Outpatient Procedural Coding
sidered inpatients until
they’ve been admitted Outpatient procedures usually include ambulatory surgeries
as such. Physicians
performed in an operating room, on-site clinic, surgical suite,
may assign this
observation status to
or ambulatory surgery center. In addition, all claims for
patients for determining emergency room visits and patient visits with the status of
the need for treatment “observation” must be submitted with HCPCS codes.
or review of a condi-
tion or postsurgical
Often new coders—and sometimes even experienced coders—
complication. have difficulty trying to determine which items to code. When
reviewing a medical record, the amount of information can be
For outpatient records, overwhelming, and sometimes the tendency may be to code
don’t code approaches everything as a safety net. When coding outpatients (and
and closures (just as in
surgical reports of inpatients), it may be easier to review
ICD-9-CM).
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.

114 Medical Coding 2
Guidelines for Assigning HCPCS Level I (CPT) Codes
For hospital outpatients, the following information is required
by the CMS for reporting:
Q Diagnoses—ICD-9-CM diagnosis codes

Q Procedures—HCPCS Level I (CPT) codes

Note: Some hospitals still use ICD-9-CM procedure 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 excision and NOTE:
incision.
Never code directly
2. Locate the main term in the CPT index (check under the from the CPT index.
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

Lesson 2 115
coding. However, let’s take a moment and explain why the
other sections for hospital ambulatory guidelines aren’t dis-
cussed here.

Coding and the Chargemaster
NOTES:
In the hospital setting, the chargemaster automates the
You may also hear the billing of services such as pathology, laboratory, and radiology.
chargemaster referred A chargemaster is a computerized list of service codes and
to as the charge descriptions that automatically matches charges with these
description master.
specific service codes. When one of the service codes is
performed for a patient, the hospital computer system auto-
It’s very important to
use the most current
matically assigns the code and applies the charge for that
coding book. Using service to the patient’s bill.
codes and/or coding
So, you may be wondering how you know what to code and
books from previous
years could result in
what’s assigned automatically by the chargemaster? Well, this
incorrect statistics task can be tricky for a new coder. A good rule when coding
and possibly denial of hospital records—inpatient or outpatient—is to remember
reimbursement for that you don’t need to assign codes for procedures or items
payment.
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-CM codes for
diagnoses are also required.

116 Medical Coding 2
HCPCS Level I (CPT) Codes for Procedures NOTES:

Some common rules and guidelines to remember when This process for out-
coding for ambulatory surgery are as follows: patient surgery coding
runs contrary to the
1. The appropriate diagnosis code(s) from 001.0–V82.9 coding practices used
must be used to identify diagnoses or reason(s) for the by hospitals and health
encounter/visit. information manage-
ment (medical records)
2. Codes that describe symptoms and signs are acceptable departments for coding
for reporting purposes when an established diagnosis the diagnoses of
hasn’t been confirmed by the physician. hospital inpatients.

3. List first the ICD-9-CM code for the diagnosis or reason
History codes (V10–
for the encounter/visit shown in the medical record to V19) may be used as
be chiefly responsible for the services provided. List any secondary codes if the
additional ICD-9-CM diagnosis codes that describe any historical condition or
coexisting conditions. family history has an
impact on current care
4. Don’t code diagnoses documented as probable, suspected, or influences treatment.
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.

Lesson 2 117
NOTES:
9. For patients receiving preoperative evaluations only,
sequence a code from category V72.8X—other specified
If the patient is just examinations—to describe the preoperative consultations.
admitted for “observa-
Assign a code for the condition to describe the reason for
tion” status and meets
observation guidelines,
the surgery as an additional diagnosis. Code also any
then follow the findings related to the preoperative evaluation.
observation/outpatient
10. For ambulatory surgery, code the diagnosis for which the
guidelines for coding.
surgery was performed. If the postoperative diagnosis is
known to be different from the preoperative diagnosis at
the time the diagnosis is confirmed, select the postopera-
tive diagnosis for coding.
11. When a patient is admitted as an inpatient for a compli-
cation due to an outpatient procedure, code the principal
diagnosis as the condition that required the inpatient
admission, followed by the condition for the procedure/
surgery, and the procedure code.
Example. An outpatient tonsillectomy is performed for
chronic tonsillitis with postoperative bleeding noted. The
patient was admitted to the hospital for control of the
bleeding. Code as follows:
Principal diagnosis: Postoperative bleeding
Secondary: Chronic tonsillitis
Procedure: Tonsillectomy
Now let’s practice the principles for this section. Proceed to
the practical coding exercise for more information.

118 Medical Coding 2
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-CM diagnosis codes (for internal reporting) and the HCPCS Level I (CPT) procedure
codes, for the purpose of this exercise you only need to be concerned with coding the HCPCS
Level I (CPT) procedure codes.

In your Clinical Coding Workout: Practice Exercises for Skill Development book, complete the
following exercises: 2.56 (p. 51); 2.62 (p. 51); 2.69 (p. 52); 2.79 (p. 53); 2.83 (p. 54);
2.93 (p. 55); 2.105 (p. 56); 2.134 (p. 59); 2.139 (p. 59); 2.153 (p. 60); 2.156 (p. 60);
2.180 (p. 62); 2.183 (p. 63); 2.196 (p. 64); 2.222 (p. 66); 2.232 (p. 66); 2.240 (p. 67);
2.258 (p. 69)

When you’re finished, check your answers at the back of this study guide. Once you’re confi-
dent you understand the coding principles for this section, move on to the next section.

Category III/Unlisted Procedures in NOTE:

HCPCS Level I (CPT) The first four positions
of these Category III
codes will be numeric,
with the alpha charac-
Unlisted/Category III CPT Procedure Codes ter in the fifth position.
These Category III
A group of unlisted five-digit alphanumeric CPT (Category III) codes should not be
procedure codes that bear “T” endings provide a way of confused with HCPCS
reporting codes for new technologies and procedures. These Level III codes, which
have alpha characters
codes are temporary codes that should be used only as a in the first position,
last resort because they’re often automatically flagged for followed by four
review from the payer (and may frequently be denied for numeric digits.
reimbursement). The payer will require additional, supportive
documentation when a claim is submitted.

Lesson 2 119
Unlisted HCPCS Procedures Codes
These Category III codes have the following characteristics:
Q Allow coders to assign a code to a procedure that’s not
listed in the CPT coding book

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

NOTE: Q Must be accompanied by supporting documentation
A complete list of (for example, operative reports)
these unlisted proce-
dure codes appears According to AMA guidelines, any Category III code that
in the index of the hasn’t been added as a permanent CPT code after five years
CPT coding book
is archived. In 2011, for the first time, they’re using “recy-
under “Unlisted
Services and cled” Category III codes. There are three T-codes that have
Procedures.” 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.

120 Medical Coding 2
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-CM and 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-CM and 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 correct when 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-CM coding instruction excerpt: Cardiotomy and pericardiotomy—
Code also cardiopulmonary bypass [extracorporeal circulation][heart-lung machine] (39.61)

According to this excerpt, how many ICD-9-CM procedure codes should be assigned?

A. 0 C. 2
B. 1 D. Need more information

7. For an outpatient with gallstones who had a laparoscopic cholecystectomy performed, how
many codes are required for reporting?

A. 1 C. 3
B. 2 D. 4

8. What happens when an inpatient procedure is canceled after a patient has been admitted?

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)

122 Medical Coding 2
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)

Lesson 2 123
NOTES

124 Medical Coding 2
ANSWER SHEET
FOR YOUR INSTRUCTOR’S USE
GRADE GRADED BY

ASSIGNMENT 6 QUIZ 40952100
STUDENT NUMBER:
PLEASE PRINT
Medical Coding 2

NAME ________________________________________________________________

ADDRESS ________________________________________________________________

CITY ________________________________________________________________
STATE/PROVINCE ZIP/POSTAL CODE

S Check if this is a new address
PHONE

INDICATE YOUR ANSWER TO EACH QUESTION BY MARKING AN X IN THE
APPROPRIATE SQUARE. EXAMPLE: XA B C D

Part A
CUT ALONG THIS LINE

1. A B C D 6. A B C D

2. A B C D 7. A B C D

3. A B C D 8. A B C D

4. A B C D 9. A B C D

5. A B C D 10. A B C D

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

HAVE YOU ENTERED YOUR STUDENT NUMBER IN THE SPACE PROVIDED?
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 NOTE:
physicians are required to report ICD-9-CM codes for diagnoses Don’t let the “physician
and HCPCS codes for procedures and services. When coding office perspective” con-
for physician office services and care, it’s important to ask fuse you. Remember,
what the physician (or practitioner) is doing when providing physicians work in a
variety of settings (for
care. As a coder, this awareness will help you assign the most
example, hospitals,
accurate and inclusive code possible for the services. In these outpatient centers,
sections, you’ll learn about how to code from the physician clinics, personal
office perspective. offices). In this lesson,
we’re focusing on how
Let’s take a look at an example of how a hospital coder
the physician codes
reports codes versus how a physician coder reports codes. and bills for different
Example. On June 23, 2005, a patient was admitted to services no matter the
setting. Whether a
the hospital for a total abdominal hysterectomy due to
physician offers serv-
endometriosis of the uterus.
ices in an office or at a
Codes hospital, the physician
services provided will
Hospital ICD-9-CM diagnosis code—617.0 still need to be coded.
Hospital ICD-9-CM procedure code—68.4
Physician office ICD-9-CM diagnosis 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-CM procedure 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-CM diagnosis
code of 617.0—endometriosis of the uterus. Let’s review
some different areas of coding for physician offices.

Lesson 2 127
HCPCS Level I (CPT) Evaluation and
Management Codes for Physician
Office Coding

Introduction
Evaluation and management—or E/M—codes are used by
physicians to report a significant portion of the services they
provide. E/M codes encompass the wide variation in skill,
effort, time, responsibility, and medical knowledge that’s
required for the promotion of optimal health and the prevention
or diagnosis and treatment of an illness or injury. Examples
of some physician services covered by E/M codes include
the following:
Q Consultations

Q Skilled nursing visits

Q Office visits

Q Hospital inpatient visits

NOTE: E/M codes are represented by CPT codes 99201–99499 and
In this subsection,
appear at the front of the CPT coding book. Coders working
you’re learning about in physician offices report these E/M codes for payment
coding only as it of services rendered by the physicians. Coders working in
relates to reimburse- acute-care hospitals—hospitals that provide short-term care
ment. However, it’s
for patient—aren’t required to report E/M codes. However,
important to remember
don’t confuse this with the work that physicians do during an
that the reporting of
codes serves other inpatient, acute-care setting. Acute-care hospital coders will
important functions code the appropriate ICD-9-CM diagnosis and procedure codes
such as statistical for a hospital admission. This is how the hospital gets paid
compilation of diseases (that is, reimbursed from providers such as insurance compa-
and treatments; thus,
nies). However, the physician’s office will separately code his
coding has an impact
beyond reimbursement. or her time and services for treating the patient while in the
hospital. This is how the physician gets reimbursed.

128 Medical Coding 2
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 NOTE:
99291—critical care and evaluation and management of
The outpatient coder
the critically ill or critically injured patient; first 30 to 74 for the hospital would
minutes code 427.5 as the
diagnosis and 92950—
99292, 99292—critical care and evaluation and manage-
cardiopulmonary
ment of the unstable critically ill or unstable critically resuscitation—as the
injured patient, requiring the constant attendance of the CPT procedure.
physician; each additional 30 minutes list separately in
addition to code for primary service
Reasoning
The physician will report the ICD-9-CM diagnosis 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:
Q Begin with 99

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

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

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

Q Identify the time typically required to provide a service

Lesson 2 129
Documentation for E/M Codes
An evaluation and management (E/M) service has seven
specific components. The first three of these components
are considered to be key or essential for providing any E/M
service in any location.

Seven E/M Components
1. History: Key Component
The patient’s history includes the following information:
Q Chief complaint (CC)

Q Reason for the encounter

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

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

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

Q Expanded problem focused—a limited examination
of the affected body area or organ system and other
symptomatic or related organ system(s)

130 Medical Coding 2
Q Detailed—an extended examination of the affected
body area(s) and other symptomatic or related organ
system(s)

Q 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 types of
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:
Q Diagnostic results, impressions, and/or recommended
diagnostic studies

Q Prognosis

Q Risks and benefits of treatment

Q 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)
with or without a diagnosis being established. The nature

Lesson 2 131
of a presenting problem can be a disease, condition, ill-
ness, injury, symptom, sign, finding, complaint, or other
reason for the encounter. The nature of the presenting
problem drives the E/M encounter. It establishes the
necessity for the type of history to be taken; it determines
the detail and content of an appropriate examination to be
done; it defines the rationale for the medical decision-
making process; and it establishes the necessity for any
counseling or coordination of care. Documentation in the
medical record should include terms or phrases such as
Q Stable

Q Recovering

Q Responding poorly

Q Significant complication(s)

Q Unstable

Q Urgent evaluation needed

Q Life-threatening problem

Presenting problems can be defined as
Q Minimal severity—a problem that may not require
the presence of a physician, but a service is provided
under the physician’s supervision

Q 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)

Q 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

Q 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

132 Medical Coding 2
Q 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:
Q Initial hospital care

Q Emergency department

Q Office—new patient

Q Office and hospital consultations—E/M

Two of the three key or essential components are required for
the following:
Q Subsequent hospital

Q 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:
Q Examinations

Q Evaluations

Q Treatment

Q Conferences with or concerning patients

Q Preventive pediatric or adult health supervision

Q Other, similar medical services

Lesson 2 133
It’s also important to understand that within each category the
levels aren’t the same. For example, code 99202—New Patient—
requires the documentation of all three key components:
(1) an expanded problem-focused history; (2) an expanded
problem-focused examination; and (3) straightforward
medical decision-making level.
Code 99212—Established Patient—requires two of the three
key components: (1) a problem-focused history; (2) a problem-
focused examination; and (3) straightforward medical
decision making.

Assigning E/M Codes
To help in assigning E/M codes, ask the following questions:
Q What type of service is the patient receiving?

Q What’s the place of service?

Q 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 patient is 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.
Q 99201–99215 Office/other outpatient services

Q 99324–99337 Domiciliary, rest home, or custodial
services

Q 99341–99350 Home services

Q 99381–99397 Preventive medicine services

134 Medical Coding 2
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

Lesson 2 135
consultants identify their specialties on their claims, because
multiple claims carrying the code set 99221–99223 won’t be
denied, but inquiry is possible if it’s not clear that these con-
sultations were done by separate specialties. If the admitting
physician doesn’t append the modifier, any subsequent claims
submitted for that admission with these initial codes on them
will be subject to review.

Outpatient Consultations
Outpatient consultations for Medicare should now be coded
to the appropriate new patient (99201–99205) or established
patient (99212–99215) E/M encounters. No modifiers are
needed for any of these codes to indicate that they’re
consultations.

Ramifications
Some physicians are concerned about the lower reimburse-
ment rates associated with the codes to be substituted for
consultation codes. CMS has raised the reimbursement for
all of these codes, but minimally, so they still don’t compete
with the past rates reimbursed for consultations. Practices
with high rates of consultations are facing significant reduc-
tions in revenue. Of course, we have yet to see if other
insurance companies will follow the lead of CMS, as they
usually do. Before that happens, however, another problem
has yet to be worked out. What happens for inpatients with a
commercial secondary payer? If a consultant codes an initial
visit for a consultation, as required by Medicare, and the sec-
ondary carrier doesn’t recognize this process, the secondary
payment (20 percent of the total) will likely be denied for all
consultations. This will have to be written off by the physi-
cian or billed to the patients, depending on the requirements
of the secondary insurance. Neither option is likely to be pop-
ular. This issue will be interesting to follow in the coming
years, and it will impact the work you’ll be doing as you
become a coder.
Now let’s practice the principles for this section. Proceed to
the practical coding exercise for more information.

136 Medical Coding 2
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.

Code Modifiers
Modifiers are two-digit alphanumeric, numeric, or alpha NOTES:

codes that are appended to the end of HCPCS Level I (CPT) Appendix A in the CPT
and HCPCS Level II codes. A modifier indicates that a service or coding book provides a
procedure was altered by specific circumstances. Modifiers are list of currently used
modifiers for both
reported only by physicians and Medicare Part B providers—
HCPCS Level I (CPT)
and not by hospitals. The use of modifiers allows more specific
and HCPCS Level II.
and accurate reporting. In many cases, modifiers allow physi-
cians to bill for the additional charges that are represented. HCPCS Level II modi-
fiers may be used with
Modifiers for HCPCS Level I (CPT) are two-digit numeric
any level of HCPCS
codes. Examples of CPT (HCPCS Level I) modifiers include
codes.
the following:
Q -25—Significant, separately identifiable evaluation and You’ll learn more
about HCPCS Level II
management service by the same physician on the same
modifiers in the next
day of the procedure or other service
section.

Q -50—Bilateral procedure

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

Lesson 2 137
Reasoning. 19100 is the CPT (HCPCS Level I) code for the
breast biopsy. The modifier -50 indicates that the procedure
is bilateral.
HCPCS Level II modifiers are either alphanumeric or two letters.
Examples of HCPCS Level II modifiers include the following:
-RC—Right coronary artery
-RT—Right side (used to identify a procedure performed
on the right side of the body)
-T1—Left foot, second digit
Modifiers are important to ensure appropriate and timely
NOTE:
payment. If you understand when and how to use them,
Appendix A of the CPT you’ll likely reduce the problems caused by third-party payer
manual contains a denials and also help expedite the processing of claims.
comprehensive list of
the Level I modifiers It’s important to note that modifiers can’t be used with all
with definitions for HCPCS codes. For example, some modifiers may be used only
correct use. Use of the with E/M codes (for example, -24 or -25), and others are
CPT guidelines and
used only with procedure codes (for example, -58 or -79). At
Appendix A is critical
to the appropriate use the beginning of each section of the CPT, guidelines appear
of modifiers. that list or describe the modifiers that may be used with the
codes in that section.

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.

138 Medical Coding 2
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.
NOTE:
3. Would a modifier help eliminate the appearance of
unbundling? Unbundling means
reporting multiple
Example. CPT codes 90760 (Infusion therapy, using
codes for a procedure
other than chemotherapeutic drugs, per visit) and 36000 when one procedure
(Introduction of needle or intracatheter, vein). If procedure would be sufficient to
36000 was performed for a reason other than as part of the cover all the services
IV infusion, modifier -59 would be appropriate (for a code mentioned. Unbundling
can be considered
of 36000-59).
a fraudulent practice
Let’s look at an example to help you understand the differ- to gain a higher
ences in coding physician services using modifiers and reimbursement.

outpatient services.
Example. Patient received bilateral reduction of inguinal
hernia as a hospital outpatient.
Procedure Codes
49505-50 (Physician claim)
49505, 49505 (Hospital claim)

Lesson 2 139
Reasoning
49505-50 is reported on the physician claim with the –50
to indicate the bilateral procedure.
49505 is coded twice on the hospital claim to indicate
that the procedure was performed bilaterally.
Now let’s practice the principles for this section. Proceed to
the practical coding exercise for more information.

Practice Exercise 7B
Books Needed:

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.

HCPCS Level I (CPT) Medicine Coding
for Physician Offices
NOTES: Medicine includes a wide variety of specialties and services.
When the immuniza-
“Medicine” encompasses CPT codes 90281–99607. It’s impor-
tion is the only service tant to remember that some procedures or services listed in
provided during an this section may be performed in conjunction with other
encounter, the physi- services and procedures listed in other CPT sections. Pay
cian can also bill for
close attention to coding guidelines and notations in the CPT
a minimal level of
service (for example,
coding book for correct coding assignment.
99211) plus the
immunization code.
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.

140 Medical Coding 2
Basic CPT Coding Guidelines for
Medical Services and Procedures NOTES:

1. Code series 90476–90749 for active and passive For Medicare cases, the
appropriate Level II
immunization.
HCPCS code list is also
2. For procedures requiring prolonged intravenous infusion required for identifica-
tion of a specific drug.
with the presence of a physician, code 96365 (first hour
For other payers, code
of infusion) and 96366 (each additional hour up to eight
99070 may be used.
hours). Codes 96367–96371 are other specific infusion
codes. Shunts, cannulas,
and fistulas for hemo-
3. Therapeutic or diagnostic injections should be coded to
dialysis are coded to
series 96372–96379.
the surgery section.
4. Code psychiatric services to series 90801–90899.
The definitions for
5. Services related to end-stage renal disease, hemodialysis, new and established
and peritoneal dialysis should be coded to series 90935– patients apply for
90999. ophthalmologic codes.

6. Ophthalmologic medical services should be coded to
For Medicare cases, a
series 92002–92499. code from the HCPCS
7. Code cardiovascular diagnostic and therapeutic services Level II code list iden-
tifying the specific drug
to series 92950–93799.
must also be reported.
8. Code the administration of chemotherapy to series For other payers, code
96401–96549. 96545 can be reported.

9. Code 99070 can be used for physician supplies and For Medicare cases, a
materials. more specific code may
exist in the HCPCS
Level II codes for
HCPCS Level I (CPT) Anesthesiology reporting the supply.

Coding for Physician Offices Anesthesia codes
aren’t reported by
Anesthesia services cover general, regional, or local anesthe- acute-care hospitals.
sia. The anesthesia section covers codes 00100–01999; these
codes are arranged by body site and then by specific surgical For physician reporting,
procedure performed. When looking up the codes in the CPT the anesthesiologist
determines the physi-
index, reference under the terms anesthesia and analgesia.
cal status modifier, and
supportive information
should be documented
in the medical record.

Lesson 2 141
General Guidelines
1. Anesthesia services are reported based on time. Time
begins when the anesthesiologist begins preparing the
patient to receive anesthesia and ends when the anes-
thesiologist is no longer in personal attendance.
2. All anesthesia services require a physical status modifier.
This modifier indicates the patient’s condition at the time
of anesthesia and identifies the complexity of services
provided.
3. Report a qualifying circumstance as an additional code
NOTES:
when anesthesia services are provided during situations
Conscious sedation or circumstances that make the administration of anes-
codes are found in thesia more difficult.
the “Medicine Section”
of the CPT manual Example. Anesthesia for total knee replacement for
and aren’t reported in 72-year-old patient with mild systemic disease.
conjunction with
anesthesia codes. Codes
Procedures marked
01402-P2—Anesthesia for open procedures on knee
with  include con-
joint; total knee arthroplasty (physical status modifier)
scious sedation, so
it can’t be coded 99100—E/M code for anesthesia for patient of extreme
separately.
age, that is, under 1 year and over age 70

Modifier -47 (Anes- 4. Standard modifiers are applicable to this section.
thesia by surgeon) is
never used with anes-
thesia CPT codes
Modifiers Commonly Used with
(series 00100–01999). Anesthesia Services
Q -22—Unusual procedural services

Q -23—Usual anesthesia

Q -32—Mandated services

Q -51—Multiple procedures

Q -53—Discontinued procedure

Q -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.

142 Medical Coding 2
Now let’s practice the principles for this section. Proceed to
the practical coding exercise for more information.

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.

HCPCS Level I (CPT) Radiology Coding
for Physician Offices
Most physicians don’t have radiologic equipment in their NOTES:
offices. In many cases, the physician refers patients for radio- The radiology codes
logic procedures to hospitals or other radiologic centers. In are coded/reported
this case, the physician office coder doesn’t assign radiology by the office of the
codes unless the physician provides radiologic supervision radiologist performing
the services. If the
and interpretation.
radiologic procedure
HCPCS Level I (CPT) radiology codes have several subsections. is performed in the
hospital, the hospital
Q Diagnostic Radiology (diagnostic imaging)—70010–76499 coder won’t code it.
Instead, the radiologic
Q Diagnostic Ultrasound—76506–76999 procedure is assigned
a HCPCS code auto-
Q Radiologic Guidance—77001–77032
matically through the
hospital’s computerized
Q Breast, Mammography—77051–77059
chargemaster system.
Q Bone/Joint Studies—77071–77084

Q Radiation Oncology—77261–77799

Q Nuclear Medicine—78000–79999

Lesson 2 143
Modifiers Commonly Used with Radiology
Q -22—Unusual procedural services

Q -26—Professional component

Q -51—Multiple procedures

Q -52—Reduced services

Q -53—Discontinued procedures

Q -59—Distinct procedural service

Q -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.

NOTES:
Radiologic Supervision and Interpretation

Radiologic supervision Many radiology codes include “radiological supervision and
and interpretation interpretation.” These are codes that describe the procedure
codes don’t apply to performed by two physicians. If one physician performs both
codes 77261–77799 the supervision and interpretation and the actual procedure,
(radiation oncology).
then two codes are assigned. These codes include a radiology
code and procedure code (for example, surgery).
Radiology procedures
can be referenced in Let’s take a closer look with an example.
the CPT book by look-
ing up the main term. Example. A patient had a unilateral lymphangiography of
Terms such as X-ray, the extremity (complete procedure) all performed by the
MRI, and MRA should same physician.
be referenced by their
full term name. An Codes
important point to
75801
remember when
coding radiologic 38790
procedures is that
there are different Reasoning
codes if a contrast
Code 75801 identifies the radiology procedure, including
material is used.
interpretation.
Code 38790 identifies the lymphangiography injection.

144 Medical Coding 2
Diagnostic Radiology NOTE:

Diagnostic radiology, or diagnostic imaging, is covered under The CPT medicine
codes 70010–76499. The codes are subdivided by anatomic section contains ultra-
site and then again by specific type of procedure performed. sound procedure codes
for arterial, venous,
Diagnostic radiology procedures include X-rays, computed
cerebrovascular
axial tomography (CAT) scans, magnetic resonance images arterial, visceral/penile
MRIs, and magnetic resonance angiograms MRAs. vascular, and echocar-
diography (heart)
Contrast materials are radiopaque substances that help make
studies.
the structure(s) being viewed show up. Examples of contrast
agents include the following:
Q Barium (Gastrografin)

Q Iohexol

Q Iopamidol

Q Hypaque

Q Renografin

You may see contrast materials used with the following
examinations/procedures:
Q Barium enema

Q Angiography

Q Cystogram

Q Endoscopic retrograde cholangiopancreatography

Q Intravenous pyelogram

Q Urogram

Q Lymphangiography

Q Cholecystogram

Contrast materials may or may not be used with CT scans
and MRIs.

Lesson 2 145
Diagnostic Ultrasound
Diagnostic ultrasound procedures use high-frequency sound
waves to visualize internal structures of the body. They’re
commonly performed for evaluation of the abdomen, pelvis,
and heart. These procedures cover codes 76506–76999 by
anatomic site. When looking up diagnostic ultrasound proce-
dures in the CPT coding book index, reference terms like
ultrasound or echocardiography.

Radiation Oncology
Radiation oncology, codes 77261–77799, is the medical field
in which radiation is used to treat diseases like tumors and
malignancies. Some of these conditions are
Q Neoplastic tumors

Q Hodgkin’s disease

Q Small cell lung cancer

Q Head and neck cancers

Radiation can be used internally or externally. External
radiation is the delivery of ionizing radiation from an external
NOTE: source through the patient’s skin to the tumor. Internal
radiation, also known as brachytherapy, applies a radioactive
When these tests are
performed for cardio-
material inside the patient’s body or in close proximity to the
vascular stress testing, patient.
use the appropriate
code from categories
93015–93018. Modifier
Nuclear Medicine
-51 is used with the
Nuclear medicine is the administration of radioactive elements
following nuclear
medicine diagnostic
(that is, radioisotopes) to help diagnose disease. Nuclear medi-
procedures codes: cine codes are covered in 78000–79999.
78306, 78320, 78803,
Now let’s practice the principles for this section. Proceed to
78806, and 78807.
the practical coding exercise for more information.

146 Medical Coding 2
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.

HCPCS Level I (CPT) Pathology
NOTES:
and Laboratory Coding for
Remember that in the
Physician Offices hospital setting the
chargemaster auto-
The “Pathology” and “Laboratory” sections cover CPT code mates the codes for
ranges 80047–89398. the billing of laboratory
and pathology services.
Laboratory services encompass clinical laboratory settings Therefore, as a hospital
and services that are equipped for testing and analysis. coder, you wouldn’t
Pathology services are those that focus on microbiology, code these services.
immunopathology, blood/transfusion medicine, chemical
pathology, cytogenetics, hematology, coagulation, toxicology, Some physicians now
send the sample/speci-
and medical microscopy.
men to a freestanding
or hospital-based labo-
Modifiers Commonly Used with ratory for processing.
In this case, the coder
Pathology and Laboratory who works for the
physician can code only
Q -22—Unusual procedural services
the collection/ handling
of the specimen.
Q -26—Professional component

Q -32—Mandated services

Q -52—Reduced services

Q -53—Discontinued procedures

Q -59—Distinct procedural service

Q -90—Reference (outside) laboratory

Lesson 2 147
The modifiers listed here are those most commonly used with
pathology and laboratory. This doesn’t mean that coders can’t
assign other modifiers with codes from this section.

Laboratory Services
Medicare and CMS have often changed the rules surrounding
the coding and billing of laboratory services. As a result, even
if you aren’t a new coder, you may have some questions
about choosing the appropriate codes. Here are some general
guidelines for coding laboratory physician services:

NOTE: 1. Each laboratory test billed must be medically necessary.

Medicare and other 2. Determine if the physician performed the complete
insurers want you to procedure (or only part of it).
use the panel codes
3. If all the tests in a panel aren’t being performed, code
as much as possible
instead of billing the individual tests separately.
the tests separately.
4. Individual chemistry tests not performed as part of
However, each test
the automated multichannel tests should be coded to
in the panel must be
necessary for the series 82000–84999.
diagnosis and/or treat-
5. Hematology and coagulation (complete blood count, bone
ment of the patient.
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.

148 Medical Coding 2
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.

Lesson 2 149
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 Development book.
Complete all required and relevant codes for each given scenario. When you’re comfortable
with your answers for both parts, submit this quiz to your instructor for grading.

Part A: Complete the following multiple-choice questions.

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

A. ICD-9-CM codes for diagnoses and HCPCS codes for procedures and services
B. ICD-9-CM codes for diagnoses, HCPCS and ICD-9-CM codes for procedures
C. Only HCPCS and ICD-9-CM procedure codes
D. Only HCPCS procedure and service codes

2. In a physician’s office, coding and billing is done for which of the following categories?

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-CM procedures C. ICD-9-CM diagnosis codes
B. HCPCS D. Varies according to the setting

(Continued)

150 Medical Coding 2
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 correct code for IV infusion for therapy/diagnosis, administered by physician or
under direct supervision of physician—up to one hour?

A. 96365 C. 90782
B. 90779 D. 90783

(Continued)

Lesson 2 151
Assignment 7 Quiz
40952200

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

Exercises

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)

152 Medical Coding 2
ANSWER SHEET
FOR YOUR INSTRUCTOR’S USE
GRADE GRADED BY

ASSIGNMENT 7 QUIZ 40952200
STUDENT NUMBER:
PLEASE PRINT
Medical Coding 2

NAME ________________________________________________________________

ADDRESS ________________________________________________________________

CITY ________________________________________________________________
STATE/PROVINCE ZIP/POSTAL CODE

S Check if this is a new address
PHONE

INDICATE YOUR ANSWER TO EACH QUESTION BY MARKING AN X IN THE
APPROPRIATE SQUARE. EXAMPLE: XA B C D

Part A
CUT ALONG THIS LINE

1. A B C D 6. A B C D

2. A B C D 7. A B C D

3. A B C D 8. A B C D

4. A B C D 9. A B C D

5. A B C D 10. A B C D

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

HAVE YOU ENTERED YOUR STUDENT NUMBER IN THE SPACE PROVIDED?
ASSIGNMENT 8:
HCPCS LEVEL II CODING

Introduction
Level II codes are five-digit alphanumeric codes that describe
products, supplies, and services not included in the HCPCS
Level I (CPT) codes. Level II codes include items and services
such as
Q Ambulance services

Q Durable medical equipment

Q Prosthetics

Q Orthotics

Q Pharmaceuticals

Q Supplies

Q Procedures

Q 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
Q Q0084—Chemotherapy administration by IV infusion

Q J9190—Fluorouracil, 500 mg

Q A4367—Ostomy belt, each

Q 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.

Lesson 2 155
NOTE: HCPCS Level II Sections
All codes beginning HCPCS Level II codes are broken into sections based on the
with D are dental alpha character at the beginning of the code. These sections
codes copyrighted include the following:
by the American
Q A codes: A0021–A9999—Transportation services,
Dental Association.
including ambulance, chiropractic, medical and surgical
The HCPCS Level II supplies, and miscellaneous
codes aren’t found in
Q B codes: B4034–B9999—Enteral and parenteral therapy
the CPT book. If you
haven’t already done Q C codes: C1178–C1900—Pass-through items used only
so, you can download
by hospital outpatient claims
these codes from the
CMS Web site. You’ll Q D codes: D0120–D9999—Dental procedures
find directions for the
download process in a Q E codes: E0100–E8002—Durable medical equipment
later section.
Q G codes: G0008–G8628—Procedures/professional ser-
vices (not found in CPT); G9001–G9143—Coordination of
care/demonstration project items and services

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

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

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

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

Q M codes: M0064–M0301—Medical services

Q P codes: P2028–P9615—Pathology and laboratory services

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

Q R codes: R0070–R0076—Radiology services

Q S codes: S0012–S9999—Temporary national codes
(nonmedical)

156 Medical Coding 2
Q T codes: T1000–T5999—National codes established for
state Medicaid agencies

Q V codes: V2020–V5364—Vision, hearing, and speech-
language pathology services

Types of HCPCS Level II Codes

Permanent National Codes
Permanent national codes are used by all private and public
health insurers to provide standardized coding for claims
submission and processing.

Dental Codes NOTES:

Dental codes (D codes) are a separate category of national Miscellaneous codes
codes. The Current Dental Terminology (CDT) is a publication should be used spar-
ingly by the coder.
copyrighted by the American Dental Association (ADA) that
Claims with miscella-
lists codes used for billing related to dental procedures and neous codes are
supplies that are included in HCPCS Level II. manually reviewed
by the payer. The
item or service being
Miscellaneous Codes billed must be clearly
described, and pricing
HCPCS Level II includes categories for miscellaneous or not
information must be
otherwise classified codes. These codes are used when there’s provided along with
no existing code for an item or service (that is, new services/ documentation to
items or services/items that are rarely used). explain why the
beneficiary needs the
item or service.
Temporary National Codes
Because S codes are
Temporary HCPCS Level II codes are assigned by the CMS
assigned for private
to cover immediate needs regarding items and services that payers, they’re not
have no codes (that is, before the next annual update is pub- recognized by
lished). For example, G codes designate procedures and Medicare.
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.

Lesson 2 157
NOTES: Types of Temporary HCPCS Codes
C codes are used C codes are for items that could be billed under the hospital
exclusively for HOPPS outpatient prospective payment system (HOPPS).
purposes and are valid
only for Medicare G codes are used to identify professional health care procedures
claims submitted by and services that should be added to Level I (CPT).
hospital outpatient
Q codes identify services that are needed for claims processing
departments.
but wouldn’t be classified as Level I (CPT) and aren’t identified
The Medicaid program by Level II.
also uses these codes, K codes are used by the durable medical equipment regional
but they’re not payable
carriers (DMERCs) when the currently existing permanent
by Medicare.
Level II codes don’t include the codes needed to implement a
T codes aren’t used DMERC medical review policy.
by Medicare but can S codes are used by private insurers to report drugs, serv-
be used by private
ices, and supplies for which there are Level II codes, but for
insurers.
which codes are needed by the private sector to implement
Level II modifiers apply policies, programs, or claims processing for private insurance
whether Medicare is processing.
the primary or
H codes are used by those state Medicaid agencies that are
secondary payer.
mandated by state law to establish separate codes for identifying
mental health services such as alcohol and drug treatment
services.
T codes are used by state Medicaid agencies to establish
codes related to items for which there are no permanent Level II
codes and for which codes are necessary to meet a national
Medicaid program operating need.

Code Modifiers
Level II HCPCS modifiers are either composed of alphanumeric
characters or two alpha characters. When coding Medicare
cases, HCPCS Level II modifiers may be used with Level I
(CPT) or Level II HCPCS codes. If more than one Level II
modifier applies, the HCPCS code is repeated on another line
with the additional and appropriate Level II modifier.
Example. Code 26010—drainage of finger abscess; simple; on
the left thumb and second finger—would be coded as follows:
26010-FA
26010-F1

158 Medical Coding 2
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.
NOTES:
The 26180 code is reported first because this surgery has a
higher reimbursement value. However, you shouldn’t worry Although a HCPCS
Level II coding book
about reimbursement value at this point. You’ll learn much
isn’t required for this
more about sequencing correctly for reimbursement in the course, you’ll have a
course on reimbursement. separate book if you’re
coding these types of
services in your job.
Guidelines for Coding HCPCS Level II Codes Unlike CPT, HCPCS
Level II codes aren’t
For the HCPCS Level II exercises in your study guide and
copyrighted by a
your coding workbook, you should use the following link to private organization
download the current list of HCPCS Level II codes (provided (with the exception of
by the CMS for free). If you haven’t done so already, be sure D codes). Therefore,
to download the HCPCS Level II code list before you go any there are several
different publishers
further.
that produce HCPCS
Follow these steps to access the HCPCS Level II codes: Level II coding books.
The guidelines listed
1. Go to the CMS Web site (http://www.cms.gov/ next are the same
HCPCSReleaseCodeSets/ANHCPCS/list.asp). guidelines that are
2. Scroll down and click on 2011 Alpha-Numeric HCPCS followed when coding
with a HCPCS Level II
File.
coding book.
3. Click on 2011 Alpha-Numeric HCPCS File (ZIP, 805KB).

Lesson 2 159
4. Click Open on the pop-up box.
5. Double-click on 11anweb_V3.xls (an Excel file) or
11anweb_V3.txt (a text file) to read the codes.
6. Repeat these steps to download the 2011 Alpha-
Numeric Index (PDF, 166KB) and the 2011 Table of
Drugs.
The guidelines for assigning HCPCS Level II codes from a
HCPCS Level II coding book are basically the same as the
guidelines for using your CPT coding book. When assigning
HCPCS Level II codes from a HCPCS Level II book, you
should follow the following basic steps:
1. Identify the services and/or procedures the patient
received.
2. Look up the appropriate term in the Index.
3. Note the code from the Index.
4. Locate the code in the appropriate section.
5. Determine if modifiers should be assigned with the code.

NOTES: Coding HCPCS Level II Drugs
Q codes are used for HCPCS Level II drugs are listed under the J codes. J drug
chemotherapy adminis- codes cover the range from J0120–J9999. Drugs administered
tration. Thus, J drug
include oral and chemotherapy drugs. Chemotherapy drugs
codes are used for
are listed within the range J8999–J9999.
coding chemotherapy
drugs, and Q codes For an oncology office—aside from the temporary G codes for
are used for coding
Medicare drug administration—the most important section of
chemotherapy
administration.
HCPCS Level III is the J code section. The J codes describe
most of the drugs and injectable products that are adminis-
Level II HCPCS codes tered in the health care field.
are updated on a quar-
It’s important to get a new HCPCS Level II coding book each
terly basis. The annual
updates appear on the
year, because new drugs are developed and approved each
CMS Web site in late year. Furthermore, the definition of a J code can change in
November or early terms of dosage or billing units. If you aren’t aware of the
December. The Web changes, you could bill incorrectly for drugs administered. For
site address is listed in
instance, if the unit definition of a J code changes from 20 mg
the previous section
to 5 mg, and you’re billing for a 100 mg dosage, that unit
and in the Instructions
section of this study definition change makes a big difference in billing increments.
guide.

160 Medical Coding 2
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.

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:
Coding HCPCS Level II Supplies A good rule of thumb
to remember when
Medical and surgical supplies are covered under HCPCS coding HCPCS Level II
Level II series codes A4206–A8999. An example of a medical/ supplies is: If the
surgical supply may be a sterile needle (A4215). Coding sup- physician’s office pro-
vides additional
plies can be a tricky and confusing process because many
supplies when perform-
supplies are included within the code for the office visit or ing a procedure (that
the procedure performed. is, above and beyond
the supplies customar-
Payment for many physician office medical supplies is consid-
ily used for the type of
ered included in the allowable amount for the service being procedure), then a
billed to Medicare and other insurers using the Medicare fee HCPCS Level II code
schedule. Separate payment for supplies used incidental to should be assigned to
the physician’s service may be made by some payers if you report the proper use
of resources and for
use CPT code 99070 (supplies and materials provided by the
the physician to
physician over and above those usually included with the receive proper
office visit or other services rendered) or A4550 (surgical trays). reimbursement.

Lesson 2 161
NOTE: Billing for Surgical Trays (HCPCS A4550)
Medicare doesn’t allow For certain procedures, billing for supplies in addition to
separate payment for the procedure itself is allowed. When a separate payment is
supplies or surgical allowed, use HCPCS code A4550 for a surgical supply tray
trays.
used during the course of a procedure. Only one tray can be
billed for regardless of the number used.
Now let’s practice the principles for this section. Proceed to
the practical coding exercise for more information.

Practice Exercise 8B
Books Needed:

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 3.11–3.20, “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.

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
Q -H: Hospital

Q -P: Physician’s office

Q -R: Residence

162 Medical Coding 2
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.
NOTES:
Advanced Life Support, Level 2 (ALS2). This level is defined
as the administration of at least three different medications An ALS provider is
and/or one or more of the following ALS procedures: trained to the level of
the emergency medical
Q Manual defibrillation/cardioversion technician (EMT)—
intermediate or
Q Endotracheal intubation paramedic. That is, an
ALS intervention is
Q Establishment of a central venous line
beyond the scope of an
EMT—Basic.
Q Cardiac pacing

Q Chest decompression Specialty Care
Transport is necessary
Q Establishment of a surgical airway when a patient’s condi-
tion requires ongoing
Q Establishment of an intraosseous line care that must be pro-
vided by one or more
Specialty Care Transport (SCT). A level of interfacility health professionals
service provided for a critically injured/ill patient that’s in an appropriate
beyond the scope of paramedic service. specialty area (nursing,
medicine, respiratory
care, cardiovascular
care, or a paramedic
with additional
training).

Lesson 2 163
NOTES:
Paramedic Intercept (PI). PI provides ALS services to a
patient who has been transported by ambulance staffed by
Sometimes fixed-wing personnel not qualified to administer such services.
air ambulance may be
necessary because the Fixed-Wing Air Ambulance (FW). This level of service is
geographic point of provided when the patient’s medical condition is so severe
pickup is inaccessible that transportation by either basic or advanced life support
by land vehicle; in
ground ambulance isn’t appropriate.
other situations, great
distances or other
obstacles make fixed- Rotary Wing Air Ambulance
wing air ambulance
necessary. Rotary-Wing Air Ambulance (RW). Provided when the
patient’s medical condition is such that transportation by
Rotary-wing air either basic or advanced life support ground ambulance isn’t
ambulance may be
appropriate.
necessary when the
point of pickup is Now let’s practice the principles for this section. Proceed to
inaccessible by land the practical coding exercise for more information.
vehicle; in other situa-
tions, great distances
or other obstacles
make rotary-wing air
ambulance necessary.

Practice Exercise 8C
Books Needed:

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.

164 Medical Coding 2
Coding HCPCS Level II
Durable Medical Equipment
Durable medical equipment is covered under HCPCS Level II
E codes. The code ranges include
Q E0100–E0159: Ambulatory devices

Q E0160–E0175: Commodes and accessories

Q E1500–E1699: Artificial kidney machines and
accessories

Durable medical equipment (DME) is defined by Medicare as
equipment that meets the following specifications:
Q Serves a medical purpose

Q Can be used repeatedly

Q Is used in a patient’s home

Q 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
NOTE:
medical equipment, prosthetic, and orthotic supplies dealers.
Durable medical equipment regional carriers (DMERC) cover Remember that modi-
this type of equipment. fiers may be used with
HCPCS Level I or II
Now let’s practice the principles for this section. Proceed to codes.
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
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.

166 Medical Coding 2
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 Development book. Complete all
required and relevant codes for each given scenario. When you’re comfortable with your
answers for both parts, submit this quiz to your instructor for grading.

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 mainly in 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-CM procedure 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)

Lesson 2 167
Assignment 8 Quiz
40952300

5. An ambulance picks up a patient at her sister’s house. Which of the following is the correct
modifier for this type of service?

A. -H C. -R
B. -P D. -RH

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 not identified by Levels I or II?

A. A codes C. J codes
B. G codes D. Q codes

9. Which of the following is the HCPCS Level II code for a single-use chemotherapy pump?

A. E0781 C. A9270
B. G0361 D. 99070

10. Which of the following is a true statement about HCPCS Level II supplies?
A. They’re often included within the procedure code.
B. They’re always coded separately.
C. They’re covered under “unlisted” procedure codes.
D. They’re covered under HCPCS Level I.
(Continued)

168 Medical Coding 2
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

Lesson 2 169
NOTES

170 Medical Coding 2
ANSWER SHEET
FOR YOUR INSTRUCTOR’S USE
GRADE GRADED BY

ASSIGNMENT 8 QUIZ 40952300
STUDENT NUMBER:
PLEASE PRINT
Medical Coding 2

NAME ________________________________________________________________

ADDRESS ________________________________________________________________

CITY ________________________________________________________________
STATE/PROVINCE ZIP/POSTAL CODE

S Check if this is a new address
PHONE

INDICATE YOUR ANSWER TO EACH QUESTION BY MARKING AN X IN THE
APPROPRIATE SQUARE. EXAMPLE: XA B C D

Part A
CUT ALONG THIS LINE

1. A B C D 6. A B C D

2. A B C D 7. A B C D

3. A B C D 8. A B C D

4. A B C D 9. A B C D

5. A B C D 10. A B C D

Part B

1. _________________________________________________________

2. _________________________________________________________

3. _________________________________________________________

4. _________________________________________________________

5. _________________________________________________________

6. _________________________________________________________

7. _________________________________________________________

8. _________________________________________________________

9. _________________________________________________________

10. _________________________________________________________

HAVE YOU ENTERED YOUR STUDENT NUMBER IN THE SPACE PROVIDED?
PROCTORED EXAMINATION PREPARATION
Note: If you’re taking the certificate version of this course, you won’t take a proctored
final examination.
The material in Lesson 2 will be tested in your proctored final examination. To
help you prepare for the final, we’ve provided the following exercises. The proctored
examination will be presented in like format and you’ll use your coding resources:
ICD-9-CM Coding Book, CPT Coding Book, and Clinical Coding Workout: Practice
Exercises for Skill Development to find the answers during the proctored examination.

Part 1—Multiple Choice

1. The HCPCS Level I codes used by all specialties no matter the location are included in
code category ranges
A. 00100–01999.
B. 10040–69990.
C. 99201–99499.
D. 90281–99199.

2. A patient was seen due to continuing congestion and sniffling. She complained of
pressure when breathing through her nose. The physician documented a diagnosis of
edema of nasal mucosa likely due to allergic rhinitis and performed rhinoscopy. The
coder codes 478.25, 31231, 21.21. This patient was most likely seen in what setting?
A. Inpatient
B. Outpatient surgical unit
C. Physician office
D. Need more information

3. In which of the following scenarios is it appropriate to assign a HCPCS Level II code in
addition to the CPT code?
A. Four extra surgical trays are used.
B. A surgery is repeated due to special circumstances.
C. A patient is transferred to a nursing home after surgery.
D. A physician performs an examination and realizes the patient needs IV antibiotics.

4. Code 27709 can be interpreted as
A. tibia and fibula.
B. osteotomy, tibia.
C. osteotomy, tibia and fibula.
D. osteotomy, fibula.

173
5. A physician excised a 3.5 cm benign lesion from an outpatient’s scalp. Code:
A. 11421
B. 11422
C. 11423
D. 11424

6. Which of the following scenarios would require the assignment of both a HCPCS Level I
and Level II code?
A. Injection of Botulinum toxin type A, per unit
B. Appendectomy with anesthesia
C. Review of HIV test
D. Hernia repair with mesh

7. Which indicates Diagnostic Radiopharmaceutical Imaging Agent NOC?
A. Q3000
B. Q3002
C. A4642
D. A4641

8. Adenosine 3mg IV is drawn from a 6 mg ampule and administered to convert a
supraventricular arrhythmia. How should this be reported?
A. J0150
B. S1001
C. Q0159
D. 82030

9. Which of the following is the correct modifier to use when 97112 and 97116 are
both billed?
A. -20
B. -59
C. -76
D. -80

10. HCPCS Level II codes are developed and maintained by
A. AMA.
B. AHIMA.
C. CMS.
D. UHDDS.

174 Medical Coding 2
Note: Exercises for Part 2 are found in the Clinical Coding Workout textbook.

Coding Ambulatory Health Records

Complete the following exercises:

1. 8.1 (p. 296) A B C D

2. 8.11 (p. 304) A B C D

3. 8.19 (p. 312) A B C D

4. 8.20 (p. 312) A B C D

5. 8.25 (p. 316) A B C D

6. 8.35 (p. 326) A B C D

7. 8.42 (p. 332) A B C D

8. 8.48 (p. 339) A B C D

9. 8.55 (p. 344) A B C D

Coding Physician-Based Health Records

Complete the following exercises:

10. 9.3 (p. 349) A B C D

11. 9.5 (p. 349) A B C D

12. 9.14 (p. 355) A B C D

13. 9.18 (p. 358) A B C D

14. 9.19 (p. 358) A B C D

15. 9.31 (p. 365) A B C D

16. 9.39 (p. 370) A B C D

17. 9.41 (p. 371) A B C D

18. 9.54 (p. 387) A B C D

19. 9.55 (p. 387) A B C D

20. 9.62 (p. 391) A B C D

Check your answers with those on page 231 of this study guide.

Proctored Examination Preparation 175
NOTES

176 Medical Coding 2
OVERVIEW OF CODING
AND REIMBURSEMENT

Appendix A
Read pages ii–x in your ICD-9-CM coding book.

Introduction
As you learned in Medical Coding 1, accuracy and consistency
is the cornerstone to successful coding. To be accurate and
consistent, a coder must follow specific guidelines and rules.
In 2009, CMS reported that more than $24.1 billion was paid
in error by just federal government health care plans, which
was almost double the error rate from 2008. Some of these
errors are due to errors in coding and DRG assignments.
In the next few sections you’ll be reviewing basic coding
guidelines and building on what you’ve learned in Medical
Coding 1. You’ll also be exposed to additional guidelines that
may be new to you. In this course you’ll focus on more
advanced inpatient coding and also on some additional
aspects of outpatient and physician office coding.
Let’s get started!

Coding Classifications
As you know, coding is an assignment of numerals (and some-
times alpha letters) that correspond with a patient’s diagnoses
and procedures. You may be wondering who came up with
these numeric codes for the diagnoses and procedures. It isn’t
just a random assignment of numbers. It’s an organized
method and classification system.

177
There are several coding classification systems that include
the following:
International Classification of Diseases, 9th Revision,
Clinical Modification.
This coding classification system is commonly known as
ICD-9-CM (often called ICD-9 or I-9 by those in the coding
business). ICD-9-CM is used to code diagnoses and procedures
for hospital patients report diagnoses and reasons for visits
in physician offices.
The ICD-9-CM codes contain two or three digits that may be
followed with a decimal point and then either one or two more
digits. Here are examples of what ICD-9-CM codes look like:
NOTE: ICD-9-CM diagnosis codes—250.00, 486, 315.4
It’s not important for ICD-9-CM procedure code—80.51
you to understand
what each of these HCFA Common Procedure Coding System—This coding
codes means at this classification system is commonly known as HCPCS (often
point. Right now you
should just know pronounced “hic-pics”). Several different levels exist within
what the ICD-9-CM the HCPCS classification system. The most commonly used
codes look like. level is the Level I Current Procedural Terminology, or CPT,
level. The CPT level codes are published by the AMA. These
codes are five-digit numeric codes used to describe the
procedures and services from providers, especially from
physician offices and in outpatient settings.
Here are some examples of what CPT codes look like: 49605,
61711, 89320, 93922. Notice that CPT codes are written dif-
ferently than ICD-9-CM codes. Remember, CPT codes are five
digits with no decimal points. You may be wondering what
the difference is between ICD-9-CM codes and CPT codes.
Don’t they both assign numeric codes to diagnoses and pro-
cedures? The answer is yes and no.

178 Appendix A
Some important points to remember are
Q ICD-9-CM codes are both diagnosis and procedure codes,
but the procedure codes are used only for inpatient hos-
pital settings.

Q CPT codes are procedure (or service) codes used mainly
in outpatient and physician settings.

Let’s take a closer look at some examples of code assignment
that will help you put the coding process into perspective.

Coding Example Using the
ICD-9-CM Coding Classification
System for an Inpatient
Patient Smith was discharged from the hospital with the
principal diagnosis of a bleeding duodenal ulcer and an addi-
tional diagnosis of anemia. The patient had a small-intestine
endoscopy procedure. The ICD-9-CM code assignments are as
follows:
Duodenal ulcer with hemorrhage—principal diagnosis
ICD-9-CM code 532.40
Acute posthemorrhagic anemia—secondary diagnosis
ICD-9-CM code 285.1
Endoscopy of small intestine—principal ICD-9-CM procedure
code 45.13
DRG Assignment (grouped based on all codes)—174:
Gastrointestinal Hemorrhage with CC
In this example, the hospital will be reimbursed based on the
predetermined payment formula amount for DRG 174.
You’ll learn a little more about DRGs and reimbursement
later in this course.

Appendix A 179
NOTES: Coding Example Using the CPT
Notice that in the in- Coding Classification System
patient example there
were only ICD-9-CM for an Outpatient Surgery
codes assigned (and
no CPT codes). A patient received an outpatient laparoscopic cholecystec-
Remember, CPT (or tomy for cholecystitis.
HCPCS Level I) codes
are procedure codes Cholecystitis—principal diagnosis ICD-9-CM code 575.0
that are assigned to
Laparoscopic cholecystectomy—ICD-9-CM code 51.23, CPT
outpatient cases.
ICD-9-CM codes are
procedure code 47562
both diagnosis and
procedure codes. For
the inpatient case Assigning Codes to
there was no need for
CPT code assignment. Clinical Documentation
However, for the out-
patient surgery Assigning codes to clinical documentation can be a tricky
performed at the process. The following two elements are needed to code
hospital, the coder correctly:
reported the ICD-9-CM
diagnosis code, the Q Sharp coding skills
ICD-9-CM procedure
code, and the CPT Q Clear and concise clinical documentation
procedure code.
Coders can only apply a code to a diagnosis or procedure that’s
well documented in the patient’s medical record. CPT and
ICD-9-CM codes reported on the health insurance claim form
or billing statement must be supported by the documentation
in the medical record. Clear and concise medical record
documentation is crucial to arrive at the correct code. Medical
record documentation includes notations from physicians,
nurses, and other health care practitioners as well as results
of ancillary diagnostic and therapeutic procedures.
As discussed previously, ICD-9-CM codes are applied only to
those diagnoses and procedures that are shown to have
clinical significance as documented by the physician. It’s
imperative that physician documentation in the progress
notes address all pertinent diagnoses and procedures, includ-
ing any laboratory data and other diagnostic tests.
One of the biggest mistakes that new coders make is to code
everything that they see in the health record documentation.
There are precise coding guidelines that dictate what should

180 Appendix A
and shouldn’t be coded and reported based on setting (hospital,
outpatient, or physician office). For example, diagnosis coding
is often difficult because of the complexity of assigning precise
codes to the many diagnoses that may be listed and the correct
sequencing of diagnoses. The principles governing the correct
code assignment and sequencing are based on the American
Hospital Association’s (AHA) Coding Clinic guidelines. In
addition, the CMS, AHA, and AHIMA serve to provide guide-
lines and assistance with coding principles.
What does all of this mean? In short it means that coders must
follow specific guidelines for coding of diagnoses and proce-
dures that must be sequenced, or ordered, a certain way in
order for the hospital or organization to be reimbursed fully.
You’ll learn more about the importance of sequencing later.

Requirements for Inpatient,
Outpatient, and Physician
Office Coding
Here are some simple guidelines that will help you remember
what coding classification system to use for which patient.
Memorizing these guidelines early will help you code clearly.
For hospital inpatients:
ICD-9-CM for both diagnoses and procedures
Linked to codes and DRGs for reimbursement
NOTE:
For hospital outpatients:
Some hospitals may
ICD-9-CM for diagnosis, HCPCS Level I (CPT) for proce-
choose to report
dures (Some hospitals may report ICD-9-CM for outpatient ICD-9-CM codes for
procedures, too.) outpatient procedures
for internal tracking or
Report at highest level of specificity in billing forms to
if required by a health
explain reason for encounter plan to report them
Linked to procedures for billing this way. Coders will
need to inquire with
For physician offices/services: the hospital for internal
coding guidelines that
ICD-9-CM for diagnoses may be supplemental
HCPCS for procedures to governmental
reporting requirements.

Appendix A 181
HIPAA and Coding
The Administrative Simplification Section of the Health
Insurance Portability and Accountability Act (HIPAA) of 1996
required the Department of Health and Human Services to
name national standards for electronic transmission of health
care information including transactions and code sets. The
rule named HCPCS Levels I and II (including modifiers) as
the procedure code set for
Q Physician services

Q Physical and occupational therapy services

Q Radiologic procedures

Q Clinical laboratory tests

Q Other medical diagnostic procedures

Q Hearing and vision services

Q Transportation services (including ambulance services)

The Final Rule also named ICD-9-CM volume 1 and 2 as the
NOTE:
code set for diagnosis codes, ICD-9-CM volume 3 for inpatient
Remember, the Centers hospital services (for example, procedures and treatments);
for Medicare and CDT for dental services; and NDC codes for drugs.
Medicaid Services
(CMS) requires the use According to CMS (2005), “ICD-9-CM procedure codes were
of HCPCS Level I (CPT) named as the HIPAA standard code set for inpatient hospital
for billing Medicare and procedures. The ICD-9-CM procedure codes were not named
Medicaid outpatients.
a HIPAA standard for procedures in other settings such as
hospital outpatient services or other types of ambulatory
services. Hospitals may capture the ICD-9-CM procedure codes
for internally tracking or monitoring hospital outpatient services;
but when conducting standard transactions, hospitals must
use HCPCS codes to report outpatient services at the service line
level and the claim level . . .” (http://questions.cms.hhs.gov).

UHDDS
The Uniform Hospital Discharge Data Set (UHDDS) definitions
are used by acute care short-term hospitals to report inpa-
tient data elements in a standardized manner. The UHDDS

182 Appendix
Appendix
A
requires that common data on individual acute care, short-
term hospital discharges in Medicare and Medicaid programs
be reported. Part of the current UHDDS includes the following
specific items pertaining to patients and their episodes of care:
Personal identification: The unique number assigned to
each patient that distinguishes the patient, and his or her
health record, from all others.
Date of birth
Sex
Race
Ethnicity
Residence: The zip code or code for foreign residence
Hospital identification: The unique number assigned to
each institution
Physician identification: The unique number assigned to
each physician within the hospital (the attending physician
and the operating physician [if applicable] are to be identified)
Disposition of patient: The way in which the patient left the
hospital—discharged to home, left against medical advice, NOTE:
discharged to another short-term hospital, discharged to a
Payers can deny
long-term care institution, died, or other
payment (or reim-
Expected payer for most of the bill: The single major bursement) based on
published lists of unap-
source the patient expects will pay for this bill (for example,
proved diagnoses
Blue Cross/Blue Shield, Medicare, Medicaid, workers’
(ICD-9-CM). This may
compensation) be due to the wrong or
outdated code being
used or may simply
Updating the Coding System be codes (diagnoses
or procedures) for
You may be wondering if, when, and how the ICD-9-CM coding which the payer
system gets updated. Because treatments change and new won’t reimburse.

diseases and procedures are discovered, codes must be changed
regularly to reflect the new updates in the medical field.
Coding changes occur, usually quarterly. An addendum may
be sent out to you if you’ve purchased a coding book. The
addendum will keep you updated on the new codes that you
should be using.

Appendix A 183
An Entirely New Classification System?
AHIMA is currently working on transitioning to the ICD-10
classification system. Yes, that’s right, an update of the entire
system and not just specific codes! Let’s learn a little more about
ICD-10.
The Centers for Medicare and Medicaid (CMS, formerly known
as HCFA) is responsible for maintenance of the coding system
for reporting inpatient procedures for Medicare and Medicaid.
The current ICD-9-CM system was perceived as having limita-
tions. Because of those limitations, the CMS contracted with
the for-profit company 3M Health Information Systems and
AHIMA to develop a new procedure coding system to be used
with the forthcoming disease coding system, the International
Classification of Diseases, 10th Revision, Clinical Modification
(ICD-10-CM), being developed by the United States National
Center for Health Statistics.
Things are moving forward for the ICD-10-CM at a very fast
pace. The ICD-10-CM will be implemented in October 2013,
which means its use will be mandatory as of January 1, 2014.
Right now, 99 countries use the ICD-10-CM, and Europe and
Canada are preparing to move to the ICD-11-CM. Just a few
third-world countries and the United States aren’t yet using
it. We actually do use it to report morbidity and mortality,
but that’s all. The move to the system has been slow because
the other countries using it are under a single-payer system.
Moving one payer to using a new classification system is
easier than moving hundreds or thousands to using it at the
same time!
The format of the ICD-10-CM (or I-10) is similar to the ICD-9-
CM, but it’s hugely expanded. The ICD-9-CM is running out
of room, especially in Volume 3. The ICD-9-CM has a limit
of 10,000 codes in Volumes 1 and 2, and it’s almost at capac-
ity. Volume 3 of the ICD-9-CM has 13,500 codes. It contains
many duplicate codes and some outdated terminology. The
I-10 expands injury codes, E-codes, pregnancy codes, alcohol-
and substance-abuse codes, and postoperative complications.
The I-10 will contain greater specificity in these areas and
increase clinical language use. In addition, the I-10 will be
able to hold up to 120,000 codes, and it currently holds only

184 Appendix
Appendix
A
68,000. In the I-10, the rubrics (the three digit numbers) are
called “blocks.” There are more combination codes, but they
require better documentation. The codes consist of up to
seven characters, and the first characters are alpha charac-
ters, not numbers.
The United Kingdom and other countries have written a lot
about their experiences in transferring to this system, and
the United States is using those experiences to figure out
what to do. The United Kingdom obtained a minimum of 70
hours of training (per coder), and they felt this was inade-
quate. The national cost for training alone is estimated at
$100 million. In addition, productivity will be affected during
training, which will put a revenue crunch on offices and hos-
pitals temporarily during the transition. The U.S. Department
of Health and Human Services estimates that the implemen-
tation will cost an estimated $2.2 billion.
The ICD-10-PCS (Procedure Coding System) is being developed
by CMS as a replacement for the ICD-9-CM procedure codes
in Volume III. The ICD-10-PCS is an expandable code system
allowing for incorporation of new technology and procedures.

Coding Reimbursement: How
Do Hospitals and Physician
Offices Get Paid?

Introduction
As you can imagine, hospitals and physician offices are NOTE:
reimbursed for the services that they provide to patients. Because there’s an
But how? Let’s take a closer look, first starting with the way entire course dedicated
that hospitals are reimbursed for inpatients. Because many specifically to reim-
payers based their reimbursement systems on the Medicare bursement, you’ll
receive only a brief
systems, Medicare is the base point from which you’ll learn
overview of reimburse-
about these systems. ment in this course.
Medicare pays for hospital inpatient operating costs using a
per-discharge rate based upon the diagnoses and procedures
that best represent the patient’s clinical status. The payment
rate is represented by diagnosis-related groups (DRGs) that
vary in payment depending upon the complexity of the case.

Appendix A 185
For example, malignant breast disorders without complica-
tions are addressed by DRG 275, whereas malignant breast
disorders with complications and co-morbidities are addressed
by DRG 274.
Payments for hospital outpatient services are based on
Outpatient Prospective Payment System (OPPS) using
Ambulatory Payment Classifications (APCs). APCs are
clinically consistent groups that receive a defined payment.
Unlike DRGs, one visit can create multiple APCs.
Physician payments are based on the Resource Based
Relative Value Scale (RBRVS) fee schedule. In the RBRVS
system, payments for services are determined by the resource
NOTE:
costs needed to provide them. The cost of providing each
It’s important to service is divided into three components: physician work,
note that claims often practice expense and professional liability insurance. Payments
require the use of are then calculated by multiplying the combined costs of a
codes from multiple
service by a conversion factor (a monetary amount that’s
coding systems, and
coding requirements determined by CMS). Payments are also adjusted for geo-
will vary by payer. graphical differences in resource costs.
For example, hospital
outpatient claims to
Medicare Part A for
Inpatient Prospective Payment System
chemotherapy infusion
In response to the rising costs of health care services, the
require ICD-9-CM diag-
nosis codes, revenue federal government instituted a new reimbursement system
codes for pharmacy, in 1984. The federal government introduced a Medicare
and CPT or HCPCS prospective payment system (PPS) based on a classification
codes for the provider system called diagnoses related groups (or DRGs).
services, whereas a
pharmacy claim to The main goal of the program is to encourage hospitals under
Medicaid would only the Medicare program to reduce hospital costs. The prospective
require NDC codes payment system is set up to reimburse the provider (for
and, in some cases,
example, hospital) based on a fixed reimbursement amount
a diagnosis code.
determined before the services are rendered.
You may be wondering how a reimbursement amount can be
determined before a patient receives services. Reimbursement
amounts under this prospective payment system are based
on a set formula for the number of days a patient is in the
hospital and the amount of resources that should be used to
treat a patient with a particular illness or injury. The amount
from this formula is then paid to the hospital regardless of the
actual costs of the services. This means that if the hospital
uses more resources than is anticipated then they’ll lose

186 Appendix
Appendix
A
money. It also means that if the hospital uses fewer resources,
then the hospital will make money. The reimbursement
amount is fixed and the provider will receive that amount
and nothing more or less.
The prospective payment system was a key factor in changing
the way hospitals and physicians provide services. This new
reimbursement system brought about changes in not only
hospitals, but also the medical and health care industry as
a whole. Health care facilities began to operate much more
efficiently. Many other insurance providers (other than
Medicare) have instituted a reimbursement model based on
the Medicare prospective payment system.

Outpatient Prospective Payment System
The Hospital Outpatient Prospective Payment System (PPS)
was created by HCFA (CMS) in 1998 to identify services
provided to Medicare patients in an outpatient setting.
The primary reason for this system is to bundle hospital
outpatient services into payment groups, called Ambulatory
Payment Classification (APC) Groups. These groups vary from
those used for payment of inpatient services (DRG) as they’re
identified by CPT codes rather than ICD-9-CM procedure codes.
Examples of APCs
APC 0028—Level I Breast Surgery
APC 0099—Electrocardiograms
APC 0611—Mid Level Emergency Visits

Outpatient Code Editor (OCE)
The outpatient code editor (OCE) is a software package
that edits hospital outpatient claims. This software reviews
CPT/HCPCS codes and ICD-9-CM codes for validity. With the
implementation of the outpatient prospective payment system
(OPPS), OCE has a key role in the processing of outpatient
claims. The two main functions of the OCE under OPPS are
(1) to identify errors, and (2) assign ambulatory payment
classifications (APCs).

Appendix A 187
Physician Office Reimbursement
Physicians receive reimbursement based on something called
usual, customary, and reasonable (UCR) charges. These are
charges for health care services that are based on the physi-
cian’s usual charge for the service (“usual”), the amount that
other physician in the area charge (“customary”), and whether
the amount charged is reasonable for the service (“reasonable”).
Physicians may also be reimbursed based on fee-for-service.
This is a method by which a physician or provider bills for
each service or visit instead of on a prepaid or all-inclusive
basis. The services are usually reimbursed according to a fee
schedule (at a set amount) or at a discount from the physi-
cian’s charges.
RBRVS stands for Resource-Based Relative Value Scale. This
system assigns three values to each procedure code based on
Q The amount of work

Q Practice expense

Q Malpractice insurance associated with that particular
service

The system is designed as a resource-based system which is
supposed to pay more for services that are more time intensive,
costly and risky, and pay less for services that are routine, safe
and don’t require the use of as many staff and supplies.
Private insurers still pay many on a fee-for-service basis.
Private payers often have a set fee schedule that lists the
services that will be reimbursed, similar to Medicare. Many
private insurers now use the Medicare RBRVS (fee schedule)
methodology as the basis for their fee schedules.

Claim Forms
You may be wondering how hospitals or physicians actually
report the codes in order to receive reimbursement. Many
institutes now have an electronic means of reporting codes
to payers. Coders code directly into a computerized system,
referred to as an encoder. The encoder software system helps
to assign diagnosis and procedure codes and the appropriate

188 Appendix
Appendix
A
reimbursement value. For example, if the patient is an inpa-
tient, it may assign a Diagnosis Related Group (DRG) for
payment. The information is later transmitted to the insurance
company or payer. Even if the information is transmitted elec-
tronically, it still must be in a particular format. To ensure
this format, institutes are required to report information
using special forms known as claim forms.
According to the CMS, in 1975, the National Uniform Billing
Committee (NUBC) was established with the goal of develop-
ing an acceptable, uniform bill that would consolidate the
numerous billing forms hospitals were required to use.
In 1982, the Uniform Bill-82 (UB-82), also known as the
HCFA-1450 form, was implemented for use in billing services
to Medicare fiscal intermediaries and other third-party payers.
In 1998, the NUBC began preparations for a revised uniform
bill. The resulting Uniform Bill-92 (UB-92) was implemented
in October 1993 and provided for the collection of additional
statistical data, including clinical information.
The newest revision, UB-04, is currently in use and allows
hospitals to report ten diagnosis codes (nine diagnosis fields
and one E code field) and six procedure codes. Although the
billing office collects data for the billing form, the health
information department supplies the clinical data placed on
the form and thus must ensure the data’s accuracy. An alter-
nate name for the UB-04 is CMS-1450.

CMS-1500
The claim form used by physicians in their offices.

Appendix A 189
NOTES

190 Appendix
Appendix
A
CODING REVIEW

Appendix B
Read the Coding Guidelines, pages 1–5 (stop at C: Chapter-
specific Coding Guidelines on page 5) at the front of your
ICD-9-CM coding book.

Read xiv–xv in your CPT coding book.

You’ve learned most of this information in the Medical Coding 1
course. Because these are important concepts for coding, you
should spend time in this Appendix reviewing both ICD-9-CM
and HCPCS coding and conventions.

ICD-9-CM Coding Review
Remember, ICD-9-CM is the current standard used for coding
inpatient and outpatient diagnoses and inpatient procedures.
Diagnoses (abbreviated DX) are the patient’s illnesses or
diseases. ICD-9-CM diagnosis codes are three-digit codes, some-
times followed by a decimal point, and then either one or two
digits. The more digits after the decimal point, generally the
higher the specificity of an illness or a disease. Volumes 1
and 2 in the ICD-9-CM coding book cover diagnoses.
Procedures (abbreviated PX) refer to the treatment or surgery
that’s given to a patient. ICD-9-CM procedure codes are two-
digit codes followed by a decimal point and then either one
or two digits after the decimal point. Just as for diagnosis
codes, the more digits after a decimal point, the higher the
specificity of the procedure. Volume 3 in the ICD-9-CM coding
book covers procedures.
Even if you don’t know the exact meaning of a code, it’s very
easy to determine if an ICD-9-CM code is a diagnosis or pro-
cedure code just by looking at it. Look at the following codes
and see if you can determine if they’re diagnosis or procedure
codes:
486
32.11
404.10

191
Do you know which are diagnosis and which are procedure
codes? Remember, ICD-9-CM diagnosis codes always have three
digits (and then possibly a decimal point followed by one or
two more digits), whereas ICD-9-CM procedure codes have
two digits before the decimal point (followed by either one or
two digits after the decimal point). Check your answers:
486 is a diagnosis code. It has three digits (and no
decimal point).
32.11 is a procedure code. It has two digits before the
decimal point.
404.10 is a diagnosis code. It has three digits before the
decimal point.
Each chapter in the ICD-9-CM coding book is structured
into subdivisions the same way. They’re categorized in the
following way:
Sections—groups of three-digit categories
Categories—three-digit code numbers
Subcategories—four-digit code numbers
Fifth-digit subclassifications—five-digit
code numbers
Let’s take a look at an example of the different categorizations.

Diseases of the Circulatory
System (390–459) (Section)
402 Hypertensive heart disease (Category)
402.0 Hypertensive heart disease, malignant (Subcategory)
402.00 Hypertensive heart disease, malignant, without
heart failure (Fifth-digit subclassification)

Inpatient Code Sequencing: Which Comes First?
Read Sections II and III, p. 27–28, in the “Coding Guidelines”
section of your ICD-9-CM coding book.

192 Appendix
Appendix
B
Diagnosis and procedure codes were discussed in the previous
sections. One important area is the sequencing of diagnosis
codes. The way you list your codes when you’re reporting them
is very important and could mean the difference in thousands
of dollars in payment for the hospital or other health care
organization. A patient’s diagnoses may be assigned a special
category such as principal, secondary, or admitting diagnosis.
How a diagnosis is categorized will depend on how you
sequence, or the order in which you record them, for report-
ing purposes.
Let’s take a closer look at each of the diagnostic categories.

Principal Diagnosis
Principal diagnosis (abbreviated as PDX) refers to the condi-
tion established after study to be chiefly responsible for the
patient’s admission to the hospital. You may be wondering
what “after study” means in this description. This phrase
means that you must review the record documentation
thoroughly (“study”) to determine the principal diagnosis.
Here’s an example that may help you understand better.
Example of determining principal diagnosis. A patient
was admitted to the hospital with cough, chest pains, fever,
and chills. After further work-up, it was determined that the
patient had left lower lobar pneumonia. The pneumonia is
coded as the principal diagnosis because it’s the reason after
study that the patient was admitted. Even though the cough,
chest pain, and other symptoms prompted the patient to
come to the hospital, it was determined after work-up that
the cause of the symptoms was pneumonia. The selection of
principal diagnosis is determined by the circumstances of
admission, diagnostic workup, and/or the therapy provided.
The condition that best satisfies these three criteria is listed
as the principal diagnosis.

Documentation and the Principal Diagnosis
Documentation in the patient’s medical record should clearly
support and reflect the coded principal diagnosis. The reason
for the patient’s admission has to be clearly identified. The
principal diagnosis is the definitive diagnosis that was

Appendix B 193
NOTE:
established and should relate to the chief complaint on
admission. If it’s unclear, the physician should be queried
As a coder, you must and the outcome should be corroborated with supporting
be careful and precise
documentation in the medical record.
in sequencing of codes.
A hospital can’t Sometimes when there are several (or many) codes, it may
sequence a code first be difficult to determine which code should be listed as the
(or as principal) just
principal diagnosis. When two or more diagnoses equally
because it reimburses
more money. This is
meet the criteria for principal diagnosis as determined by the
considered fraudulent circumstances of admission, diagnostic work-up, and/or
and may be punishable therapy provided, any one of the diagnoses may be sequenced
under penalties of law. first. For example, a patient presents with multiple problems:
A hospital or institute
shortness of breath, fever, and chest pain. Chest x-ray
will look to the coding
expert to ensure that
demonstrates an exacerbated CHF, examination reveals acute
diagnoses and proce- bronchitis, and prior history and current EKG findings are
dures are accurately consistent with unstable angina. The three conditions were
coded and sequenced treated with medications. All three diagnoses—CHF, acute
based on coding
bronchitis, unstable angina—equally meet the criteria for the
guidelines.
definition of principal diagnosis and the hospital can sequence
any one as the principal diagnosis. In this case, the hospital
will generally choose to list the code that reimburses the
most as the principal diagnosis.

Secondary Diagnoses
Other Diagnoses (ODX), also known as secondary diagnoses
or additional diagnoses, are conditions that either coexist at
the time of admission or develop subsequently and affect
patient care for the current hospital episode. Affecting patient
care signifies conditions requiring any of the following:
Q Clinical evaluation

Q Therapeutic treatment

Q Diagnostic procedures

Q Extended the length of hospital stay

Q Increased nursing care and/or monitoring

Any diagnosed condition requiring significant additional hos-
pital resources (for example, additional testing, procedures,
increased length of stay, increased level of care) is considered
a valid secondary diagnosis.

194 Appendix
Appendix
B
Diagnoses that relate to a previous hospital stay and have NOTE:
no bearing on the current treatment shouldn’t be coded.
Some physicians may
Let’s take a look at a case example that includes secondary include these previous
diagnoses to help you understand better. diagnoses on the
patient’s discharge
Example of secondary diagnoses. A patient is admitted
summary. Even then,
with a cough, fever, and chills for the past four days. After those previous diag-
work-up, the patient is found to have pneumonia with under- noses not affecting the
lying chronic obstructive pulmonary disease (COPD). The current admission
patient is also on medication for chronic diabetes and suffered shouldn’t be coded
unless hospital policy
a fractured femur five years ago. The patient is treated with
states otherwise.
intravenous (IV) antibiotics, respiratory therapy, and continues
his medication for diabetes. On the third day, the patient
complains of chest pain. Tests confirm that the patient has
suffered a left anterior myocardial infarction. The secondary
diagnoses in this case are COPD, diabetes, and myocardial
infarction. Pneumonia is the principal diagnosis and is
sequenced (or listed) first when reporting the codes. The
fracture isn’t coded because it was an injury that occurred
previously and has no bearing on the current treatment.

Admitting Diagnosis
The admitting diagnosis is simply the diagnosis that brought
the patient into the hospital. Using the same example as
above, the patient’s admitting diagnosis may have been cough.
When tests were completed that confirmed the cough was due
to pneumonia, pneumonia then became the principal diagnosis;
however, cough still remains as the admitting diagnosis.

Primary Diagnosis
The primary diagnosis is used by the physician to describe
the diagnosis most often determined to be the most clinically
intense and isn’t often a term used by coding professionals.
Many times the primary diagnosis isn’t the same as the prin-
cipal diagnosis; however, many physicians and clinicians will
often (incorrectly) interchange the terms primary diagnosis
and principal diagnosis. For the purpose of coding, you need
to be concerned only with the principal diagnosis (and not
the primary diagnosis).

Appendix B 195
Principal Procedure
A principal procedure is a procedure that’s performed for
treatment of a disease/condition rather than performed for
diagnostic or exploratory purposes. If there are two or more
procedures performed on a patient then the one most closely
related to the principal diagnosis should be sequenced first.

Sequencing
Now that the categories have been described, look at an
example of how codes are sequenced—or listed—when reporting.
Example. A patient is admitted to the hospital due to severe
chest pain that ends up being an acute myocardial infarction.
The patient is also treated for uncontrolled Type 1 diabetes.
Codes
410.90—Acute myocardial infarction
250.03—Type 1 diabetes, uncontrolled
Reasoning
Even though the patient was admitted with chest pain,
NOTES:
after workup it was found to be a myocardial infarction
In an outpatient which is sequenced first as the principal diagnosis with
setting, the primary the uncontrolled diabetes listed second as a complication/
diagnosis, or what
co-morbidity that increases the DRG payment. If a coder
brought the patient
had incorrectly sequenced the chest pain as first, it may
to the encounter,
is sequenced first. have cost the hospital hundreds (or sometimes thousands)
of dollars in reimbursement payment.
There’s often more
information in the
tabular list that
Basic ICD-9-CM Coding Guidelines
doesn’t appear in the The guidelines discussed in this section will be used whenever
Alphabetic Index. This
you’re coding ICD-9-CM codes (inpatients, hospital outpatients,
information will help
you assign the most
and so forth). By following these guidelines, you’ll ensure that
accurate code. you’re assigning valid codes and sequencing properly.
1. Use both the alphabetic index and tabular list.
As discussed previously, you should never code from just
the Alphabetic Index in which you first look up the code.
To ensure correct coding assigning, look up the code in the
alphabetic index and verify the code in the tabular list.

196 Appendix
Appendix
B
2. Code to highest level of specificity. NOTE:
A coder must record the most accurate diagnosis and
Coding books will use
procedure codes. To do this, you’ll need to code to the the section symbol for
highest level of specificity. This simply means that when codes that require a
assigning diagnosis codes, assign a three-digit code only fifth digit. The section
when there’s no four-digit codes for that category, assign symbol looks like
this: §
a four-digit code only when there’s no five-digit code for
that category, and assign a fifth digit any time it’s available
as a subclassification.
The same principles apply for procedure codes (using
two-, three-, and four-digit codes).
3. Ensure that the use of residual codes is appropriate
and accurate.
Residual efffects are conditions that are produced after
the acute phase of an injury or illness. Residual codes
are codes that are classified as
NOS—Not Otherwise Specified
NEC—Not Elsewhere Classified
If documentation in the patient’s medical record doesn’t
document specifics, the coder should still review the
code category in the tabular list to determine if there’s a
better code (other than NOS or NEC categories). The NOS
code shouldn’t be assigned when a more specific code
exists. In some cases the coder will need to query the
physician for an addendum to documentation for the
more specific code.
4. Code unconfirmed or uncertain diagnoses as if confirmed.

Appendix B 197
There are some cases in which physicians are unsure of
the patient’s diagnoses, even at the time of discharge.
The physician may document these cases as
Q Possible

Q Probable

Q Suspected

Q Likely

Q Questionable

Q ? (that is, using a question mark before a condition,
like “? pneumonia”)

Q Rule out

When the physician documents the case in this manner,
NOTE:
the coder should code the diagnosis as if it exists. You
This guideline applies may be wondering how this is accomplished. Is it consid-
only to inpatients. If ered legal coding? The answer is yes. This guideline is
an outpatient record
based on the fact that the physician (and hospital) used
contains any of the
above qualifiers then the same amount of resources (diagnostic work-up, tests,
the sign, symptom, or and so forth) that would have been used if the patient
abnormal finding that had the condition. Therefore, the hospital is eligible for
brought the patient to the same amount of reimbursement.
the hospital is coded.
5. Understand the difference between rule out and ruled out.
Believe it or not, there’s a significant difference between
rule out and ruled out that could result in completely
different codes with different reimbursement levels.
“Rule out” means that a diagnosis is still considered a
possibility. In this case the condition should be coded as
if it exists.
“Ruled out” means that the condition doesn’t exist and
no code should be assigned. If another condition wasn’t
identified, then the symptom that brought the patient to
the hospital should be coded.

198 Appendix
Appendix
B
6. Code acute and chronic conditions as determined in the NOTES:
alphabetic index/tabular list.
If a condition lists both
In some cases, the same condition may be described as acute and chronic at
both acute and chronic. Refer to the alphabetic index/ the same indentation
tabular list in your coding book for guidelines on the in the coding book
specific code. then both are coded
with the acute condi-
7. Code late effects only if an injury or illness has been resolved. tion sequenced first.

Late effects are residual conditions that remain after an
The code for the acute
acute injury or illness has been resolved. Late effects
phase of an illness or
may be described as late, old, due to (previous injury/ injury that led to the
illness), or traumatic (with no evidence of current injury). late effect is never
Accurate reporting of late effects requires two codes: used with a code for
(1) the residual condition (regular code, sequenced first) the cause of the late
effect.
and (2) the cause of the late effect (E code).
Let’s take a look at an example that will help you
better understand.
Example. A patient was badly burned during a house
fire one year ago. She’s admitted for surgery to her face
and neck for the scarring.
Conditions to Code
Diagnoses:
Facial scarring (PDX)
Previous burn (secondary)
Procedure:
Surgery (procedure)
Reasoning:
The scarring of the face and neck is the current condi-
tion for which the patient is admitted and therefore is
listed as the principal diagnosis. Late effect of burn is
coded as the secondary diagnosis.
8. When coding procedures, “Code Also” should be used
only if the additional procedure was performed.
“Code Also” is used in the ICD-9-CM procedure coding
section of the coding book to ensure that individual com-
ponents of procedures are coded. An additional code is
assigned when certain procedures or equipment are used.

Appendix B 199
NOTES:
33.6 Combined heart-lung transplantation
Code also cardiopulmonary bypass [extracorporeal
In your coding book,
the additional proce- circulation][heart-lung machine] (39.61)
dure to be coded is Refer to page 105 in Volume 3 of your ICD-9-CM coding
enclosed in brackets
book to see this example.
like in this example.
9. Code canceled procedures with the appropriate V64 code.
Code V64 can’t be
assigned as principal
If a procedure has been canceled (after patient was
diagnosis. Instead, list admitted), then assign the appropriate V64 code to
the illness/injury for indicate the reason for cancellation. No procedure code
which the surgery was should be assigned.
planned as principal
and then V64.X as the 10. Code incomplete procedures to the extent the procedure
secondary diagnosis. was completed.
When a procedure has begun, but wasn’t completed (for
If the procedure doesn’t
involve incisions (for
whatever reason), use the following guidelines:
example, the proce- Q Incision only, code to incision site
dure was a reduction
of a fracture), then Q Endoscopy was unable to reach site, code endoscopy
no procedure code is
only
assigned. Instead, use
the appropriate V64 Q Cavity/space was entered, code to exploration of that site
code as the secondary
diagnosis.

HCPCS Coding Review
For this course, both HCPCS Levels I and II are covered. In
the Medical Coding 1 course you received a thorough study
of Level I (CPT). In this course, you’ll build on what you’ve
learned in Medical Coding 1 and also learn further about
HCPCS Level II.
Reporting of HCPCS codes is required of acute-care hospitals
including those paid under alternate payment system. HCPCS
codes are also required in rehabilitation and psychiatric
hospitals. HCPCS codes are required for all outpatient hospital
services (unless specifically excepted). This means that codes
are required on surgery, radiology, other diagnostic procedures,
clinical diagnostic laboratory, durable medical equipment,
orthotic-prosthetic devices, take-home surgical dressings,
therapies, preventative services, immunosuppressive drugs,
other covered drugs, and most other services.

200 Appendix
Appendix
B
As you probably remember from Medical Coding 1, the rules NOTES:
for coding HCPCS are a little different than coding ICD-9-CM.
The HCPCS index is a little more free form than the ICD-9-CM Coding directly from
the CPT index or the
index. The HCPCS index codes are tentative and need to be
ICD-9-CM index could
explored beyond the index. The tabular codes rule the coding result in the assignment
process in HCPCS, therefore a coder should never code straight of incorrect codes
from the index in the HCPCS book. Instead, after looking up and denial in
the code choice(s) in the index, the coder should then locate reimbursement.
the code in the tabular and use process of elimination (based
on coding guidelines) to assign the correct code. HCPCS versus CPT:
What’s the Difference?
According to the CMS, in 1996 under OBRA, or the Omnibus Level I codes are
Budget Reconciliation Act of 1986, the federal government usually referred to
simply as CPT codes
required reporting of outpatient visits using the system called
and Level II codes
HCPCS when billing for outpatient services for federally
are usually referred
funded patients. HCPCS was developed to support the need to simply as HCPCS
to bill for all services (not just those that fall within CPT codes or national codes.
classification).
HCFA (now CMS) developed a three-part system to standard-
ize coding used to process Medicare claims. It’s used for all
services: surgical, medical, supplies, materials, injections,
and so forth. The most commonly used level is the CPT, or
Current Procedural Terminology, level. According to the CMS,
approximately 80% of HCPCS can be coded using the CPT
level. CPT is the most known and used level of HCPCS codes.

Level I versus Level II—
Which Takes Precedence?
While coding, you may find that the same procedure can be
coded to different levels (HCPCS Level I and Level II). When a
HCPCS Level I (CPT) and HCPCS Level II code have the same
explanation (code narrative) for a procedure or service, use
the CPT (Level I) code. If the narratives aren’t identical, use
the level code with the more specific narrative. For example,
the CPT (Level I) code narrative may be generic and the
HCPCS Level II code narrative may be more specific. In this
case, use the Level II code.
Now let’s take a closer look at each of the HCPCS levels.

Appendix B 201
NOTE: HCPCS Level I: CPT Codes
CPT doesn’t provide
codes for nonphysician
Introduction
procedures, services,
and specific supplies. The Physicians’ Current Procedural Terminology (CPT), pub-
lished (and updated) annually by the AMA, is a systematic
listing and coding of procedures and services performed by
physicians. The purpose is to provide a uniform language
that will accurately describe medical, surgical, and diagnostic
services. It also provides a reliable nationwide reporting and
communication method among physicians, patients, and
third parties.
Each CPT procedure or service is identified with a five-digit
code. The use of CPT codes simplifies the reporting of medical
service. Using this coding provides the physician or health
care professional a means of accurately recording the service.
Each section of the CPT book has introductory material that
contains important coding guidelines and information. Be
sure to read the introduction before coding from that section.
Specific guidelines are presented at the beginning of each of
the six sections. These guidelines define items that are neces-
sary to appropriately interpret and report the procedures and
service contained in that section. They also provide explana-
tions regarding terms that apply only to that particular section.
Within each section are headings and subheadings followed
by additional distinctive instructions and in some cases, a
unique narrative description of the technical process of
providing these procedures.
Although you’ll learn about some commonly coded—or
miscoded—guidelines in this lesson, it isn’t possible to cover
each and every guideline. Be sure to read the introductory
material at the beginning of each CPT code section.
HCPCS Level I (CPT) codes are numeric codes that represent
services provided by physicians and health care providers.
Level I codes are used to report hospital outpatient procedures
and physician office codes.
The layout and design of CPT is intended to provide quick
and easy location of services and procedure codes. The main
body of the manual is listed in six sections. Within each

202 Appendix
Appendix
B
section are subsections with anatomic, procedural, condition NOTES:
or description subheadings. The manual itself lists services
and procedures in numeric order with one exception—the You’ll learn more about
E/M codes in the CPT
entire evaluation and management (E/M) section has been
lesson.
placed at the beginning of the book for easy access.
Refer back to pages
Conventions and Formatting in CPT x–xiii in your CPT cod-
ing book if you need
(HCPCS Level I) more information on
how to use your CPT
There are certain formatting, conventions, characteristics,
coding book.
and symbols that you should understand in order to code
CPT correctly.

Semicolon
The semicolon is a normal semicolon that looks like this:
;
This is one of the most confusing format concepts. If a code
description contains a semicolon and there are one or more
code descriptions indented underneath then the description
before the semicolon is a home description and the indented
code needs the home description to fully complete the code
description.
Let’s take a look at a coding excerpt using a semicolon.
30150 Rhinectomy; partial
30160 total
If the physician documented that the patient had a total
rhinectomy, the correct code would be 30160. You would
never code 30150 and 30160 together because the rhinec-
tomy must be either partial or total, but couldn’t be both.

Bullet
The bullet symbol looks like this:

When it’s next to a code it means that the code is a new code.

Appendix B 203
Triangle
The triangle looks like this:
V
It means that the code is a revised code.

Facing Triangles
Facing triangles look like this:
cb
Facing triangles indicate that the text is either new
or revised.

Plus Sign
The plus sign looks like this:
+
The plus sign indicates that this is an add-on code and
should be used in conjunction with another code. For
example, 75968—transluminal balloon angioplasty, each
additional artery—must be used in conjunction with 75966—
transluminal balloon angioplasty.

Modifiers
Modifiers emphasize the difference between modifiers used
for hospital outpatients versus modifiers for physicians. CPT
coding books have a quick reference on the reverse of the
front page, and the full descriptions of modifiers are in
Appendix A.

Circle Symbol
The circle symbol looks like this:
;
It means that these codes are exempt from modifier -51.

204 Appendix
Appendix
B
HCPCS Level II: National Codes
HCPCS Level II codes, or national codes, are alphanumeric
codes developed by HCFA (CMS) to identify other services
(those not provided by a physician) that aren’t covered under
the CPT level. These were developed by HCFA as a second
level of codes, as CPT doesn’t contain all the codes needed to
report medical services and supplies. These codes are consid-
ered a permanent level, are maintained by the HCPCS
National Panel, and are updated by the CMS quarterly. This
panel is made up of representatives from the Blue Cross Blue
Shield Association (BCBSA), the Health Insurance Association
of America (HIAA) and CMS. This Panel is responsible for
making decisions about additions, revisions and deletions to
the national alphanumeric code system.
In contrast to the five-digit codes found in Level I (CPT) these
codes consist of one alphabetic character (a letter from A–V)
followed by four digits. (All D codes are copyrighted by the
American Dental Association.) HCPCS is grouped by the type
of service or supply they represent and are updated annually.
This coding system is also required for reporting most medical
services and supplies provided to Medicare and Medicaid
patients and by most third-party payers.
One of the most important elements of this coding system for
clinicians is the Level II modifiers.
These modifiers, which are either alphanumeric or two-letter
in the range from A1–VP, should be applied to the appropriate
CPT code to identify additional situations or circumstance.
The listing of one of these codes doesn’t assure coverage of
the specific item or service in a given case. To be eligible for
payment from Medicare, the item must be considered reasonable
and necessary. Examples include Supplies (durable medical
equipment such as wheelchairs, hearing aid batteries, crutches);
Injection codes (identifies actual substances); Dispensing of
medication; and Other (dental, chiropractic, vision, orthotics).

Appendix B 205
Frequent Coding and Billing Errors
Here are some of the frequent errors that you can look out
for when coding health records:
Q No documentation for services billed

Q No signature or authentication of documentation

Q Always assigning the same level of service

Q Billing of consult versus outpatient office visit

Q Invalid codes billed due to old resources

Q Unbundling of procedure codes

Q Misinterpreted abbreviations

Q No chief complaint listed for each visit

Q Billing of service(s) included in global fee as a separate
professional fee

Q Inappropriate or no modifier used for accurate payment
of claim

Now that we’ve reviewed both ICD-9-CM and HCPCS informa-
tion and conventions, let’s get started! You’ll first learn about
ICD-9-CM coding and then will move on to HCPCS later. Go
back to the beginning of this study guide and start with
Lesson 1. Good luck!

206 Appendix
Appendix
B
HELPFUL ONLINE RESOURCES

Appendix C
AMA CPT Code Lookup
https://catalog.ama-assn.org/Catalog/cpt/cpt_search.jsp

National Center for Health Statistics—ICD-9-CM
Diagnosis and Procedure Coding Information
http://www.cdc.gov/nchs/icd.htm

Human Anatomy Online
http://www.innerbody.com/

National Correct Coding Initiative Edits
http://www.cms.gov/nationalcorrectcodinited/

Online Medical Terminology
http://www.online-medical-dictionary.org/

CMS HCPCS Level II Information
http://www.cms.gov/medhcpcsgeninfo/

CMS Question Search
http://questions.cms.hhs.gov/app/answers/list

CMS Hospital Outpatient Prospective
Payment System (HOPPS)
http://www.cms.hhs.gov/hospitaloutpatientPPS/

ICD-9 Coding Guidelines
http://www.cdc.gov/nchs/data/icd9/icdguide10.pdf

Appendix 207
Online Coding Software
http://www.eicd.com/SiteMap.htm

Free Online Coding Newsletter
http://www.hcmarketplace.com/prod.cfm?id=3288

Free and Paid Resources Including
Weekly Quizzes
http://www.justcoding.com

Coder’s Club (Free Coding Updates)
http://pmiconline.stores.yahoo.net/codersclub.html

AHIMA
http://www.ahima.org

AAPC
http://www.aapc.com

208 Appendix
AppendixC
PRACTICE EXERCISE ANSWERS

Exercise 1A

Answers
1.296. 783.0
1.297. 783.7
1.298. 780.91
1.299. 780.66
1.300. 780.2
1.301. 780.71
1.302. 786.50
1.303. 780.33
1.304. 799.51
1.305. 790.29
1.306. 787.01
1.307. 789.7
1.308. 788.41
1.309. 789.01
1.310. 794.02
1.311. 793.3
1.312. 793.80
1.313. 798.0
1.314. 799.4
1.315. 786.01

Exercise 1B
1.336. E886.0, E849.4, E007.0, E000.8
1.337. E881.0, E849.3, E016.2, E000.0
1.338. E893.1

209
1.339. E905.0
1.340. E909.2
1.341. E917.3, E849.0, E013.9, E000.8
1.342. E910.4
1.343. E923.0
1.344. E004.1
1.345. 882.0, E966
1.346. 847.0, E816.0
1.347. 813.82, E818.3
1.348. E017.0
1.349. E906.0
1.350. E849.5
1.351. E871.0
1.352. E909.0
1.353. E919.3
1.354. E955.1, E849.3, E000.0
1.355. 872.11, E928.3
1.356. V26.1
1.357. V02.61
1.358. V10.3
1.359. V12.72
1.360. V16.41
1.361. V20.2
1.362. V22.2
1.363. V33.01
1.364. V28.0
1.365. V85.42
1.366. V45.11
1.367. V45.01
1.368. V53.32

210 Answers
1.369. V54.27
1.370. V55.0
1.371. V55.3
1.372. V58.11
1.373. V49.86
1.374. V71.4
1.375. V76.12

Exercise 1C
1.316. 803.75
1.317. 806.01
1.318. 807.07
1.319. 808.43
1.320. 812.01
1.321. 813.47
1.322. 832.2
1.323. 822.1
1.324. 830.0
1.325. 842.00
1.326. 860.1
1.327. 911.5
1.328. 944.35
1.329. 965.1
1.330. 995.64
1.331. 991.0
1.332. 996.02
1.333. 996.82
1.334. 998.2
1.335. 995.81

Answers 211
Exercise 2A
1.16. 047.1
1.17. 052.9
1.18. 022.1
1.19. Negative
1.20. 054.10
1.21. 042
1.22. 098.17
1.23. a. 042
1.24. c. 070.54
1.25. 002.1
1.26. 005.0
1.27. 009.2
1.28. 011.93
1.29. 034.1
1.30. 038.0
1.31. 110.0
1.32. 055.1
1.33. 072.9
1.34. 078.12
1.35. 075

Exercise 2B
1.36. 201.22
1.37. 162.9
1.38. V58.0
1.39. d. Either a or b
1.40. 183.3
1.41. 211.7

212 Answers
1.42. Benign
1.43. 172.5
1.44. 151.5
1.45. 198.89
1.46. 211.3
1.47. 233.0
1.48. b. Malignant
1.49. Connective tissue
1.50. Primary
1.51. 162.9
1.52. 233.1
1.53. a. Lymph nodes of inguinal region and lower limb
1.54. 209.32
1.55. 205.02

Exercise 2C
1.56. 275.01
1.57. 276.1
1.58. 272.0
1.59. b. Hyperaldosteronism
1.60. 250.43, 581.81
1.61. 249.00
1.62. 250.51, 362.02
1.63. 250.13
1.64. 250.51
1.65. 251.3
1.66. d. All of the above
1.67. 253.3
1.68. 276.8
1.69. 277.02

Answers 213
1.70. Mucopolysaccharidosis
1.71. 278.01, V85.4
1.72. 256.4
1.73. 271.4
1.74. 242.30
1.75. 243

Exercise 2D
1.76. 280.0
1.77. b. Hereditary hemolytic anemias
1.78. 282.5
1.79. 285.1
1.80. 285.3
1.81. a. Fanconi’s anemia
1.82. 286.4
1.83. White
1.84. 284.9
1.85. 281.2
1.86. 281.3
1.87. 289.89
1.88. 287.41
1.89. 287.30
1.90. 287.49
1.91. 285.9
1.92. 284.01
1.93. 288.3
1.94. 281.1
1.95. 286.0

214 Answers
Exercise 3A
1.96. b. Two codes
1.97. 291.2
1.98. 295.34
1.99. 301.11
1.100. 300.01
1.101. a. Dissociative identity disorder
1.102. 299.0
1.103. d. All of the above
1.104. 303.00
1.105. 304.03
1.106. 304.70
1.107. 306.0
1.108. 307.23
1.109. 296.30
1.110. 309.21
1.111. 318.0
1.112. 314.01
1.113. 291.5
1.114. 291.0
1.115. 290.43, 437.0

Practice Exercise 3B
1.116. 360.01
1.117. 359.1
1.118. c. 250.51, 362.02
1.119. 362.31
1.120. 370.8, 136.21
1.121. 361.81

Answers 215
1.122. 366.14
1.123. 365.22
1.124. 368.53
1.125. 371.23
1.126. 348.81
1.127. c. Presbyopia
1.128. 381.10
1.129. 382.01
1.130. 385.33
1.131. 386.51
1.132. 379.41
1.133. 380.14
1.134. 345.91
1.135. 337.21

Practice Exercise 3C
1.136. 417.1
1.137. d. 402.01, 428.0
1.138. 396.1
1.139. 410.21
1.140. 8
1.141. 401.9
1.142. Stenosis
1.143. 427.32
1.144. 427.41
1.145. 428.31
1.146. 411.1
1.147. 415.19
1.148. 414.06 (if native artery), or 414.07 (if of
bypass graft)

216 Answers
1.149. 414.04
1.150. 438.13
1.151. 433.21
1.152. 416.2
1.153. 458.0
1.154. 454.0
1.155. 441.3

Practice Exercise 3D
1.156. 466.0
1.157. 464.01
1.158. 474.10
1.159. 471.8
1.160. b. 480.1
1.161. 482.42
1.162. 491.21
1.163. 492.8
1.164. 486
1.165. 488.11
1.166. 493.21
1.167. 512.1
1.168. 518.83
1.169. 519.02
1.170. 494.0
1.171. c. 493.01
1.172. 512.8
1.173. 493.00
1.174. 508.0
1.175. 460

Answers 217
Practice Exercise 4A
1.176. 521.00
1.177. 532.00
1.178. 531.90
1.179. 528.6
1.180. b. 530.11
1.181. d. 531.10
1.182. 537.82
1.183. 535.31
1.184. 540.9
1.185. 553.21
1.186. 550.93
1.187. 552.00
1.188. 555.0
1.189. 556.9
1.190. 560.31
1.191. c. 562.10
1.192. 568.0
1.193. 574.00, 574.10
1.194. 577.1
1.195. 569.71

Exercise 4B
1.196. 584.5
1.197. 592.1
1.198. 590.10
1.199. 594.2
1.200. 591
1.201. 599.0

218 Answers
1.202. 596.51
1.203. 599.71
1.204. b. 598.9
1.205. b. The urinary tract infection
1.206. c. 600.00
1.207. 602.3
1.208. a. The tuberculosis
1.209. 611.82
1.210. 614.3
1.211. 617.3
1.212. 620.1
1.213. 625.3
1.214. 627.3
1.215. 622.12

Practice Exercise 4C
1.236. 680.4
1.237. 681.02
1.238. 692.71
1.239. 682.0
1.240. 685.0
1.241. 692.6
1.242. 692.84
1.243. 695.4
1.244. 701.4
1.245. 702.0
1.246. 704.01
1.247. 705.83
1.248. c. 707.07, 707.22
1.249. b. The diabetes mellitus

Answers 219
1.250. 697.0
1.251. 692.0
1.252. 682.3
1.253. 691.0
1.254. 695.10
1.255. 692.76

Practice Exercise 5A
1.256. 711.05
1.257. 714.0
1.258. 733.42
1.259. 715.36
1.260. 715.09
1.261. 717.41
1.262. 717.7
1.263. 719.11
1.264. 720.0
1.265. 721.1
1.266. 722.10
1.267. 722.52
1.268. 724.2
1.269. 727.40
1.270. 710.0
1.271. 730.07
1.272. 733.01
1.273. 733.14
1.274. 735.0
1.275. 737.10

220 Answers
Practice Exercise 5B
1.216. 653.11
1.217. 648.83
1.218. 669.22
1.219. Six
1.220. 35
1.221. 656.61
1.222. 661.01
1.223. 664.21
1.224. 670.24
1.225. 643.13
1.226. 644.13
1.227. 654.03
1.228. 674.14
1.229. 673.12
1.230. 2
1.231. 4
1.232. c. Deficient amount of amniotic fluid
1.233. 632
1.234. 5
1.235. d. a and b

Practice Exercise 5C
1.276. 741.03
1.277. 744.42
1.278. 745.4
1.279. 747.10
1.280. 749.03
1.281. 752.61

Answers 221
1.282. 753.12
1.283. 754.35
1.284. 755.11
1.285. 756.12
1.286. 752.39
1.287. 758.7
1.288. 756.51
1.289. 771.1
1.290. 770.12
1.291. 773.0
1.292. 756.72
1.293. 779.5
1.294. b. V30.00
1.295 777.50

Practice Exercise 6A
1.376. 63.73
1.377. 37.36
1.378. 06.2
1.379. 11.62
1.380. 20.01
1.381. 27.62
1.382. 32.22
1.383. 35.51
1.384. 00.66
1.385. 36.16
1.386. 40.42
1.387. 45.81
1.388. 52.7
1.389. 53.03
1.390. 55.53

222 Answers
1.391. 59.6
1.392. 68.8
1.393. 75.62
1.394. 81.51
1.395. 84.24
1.396. 72.21
1.397. 60.4
1.398. 45.62
1.399. 36.32
1.400. 36.07, 00.45

Practice Exercise 6B
2.56. 00921
2.62. 00567
2.69. a. 19120
2.79. 12004
2.83. 19125
2.93. 28292
2.105. 20240
2.134. 33207
2.139. 33968
2.153. 43282
2.156. 43239
2.180. 52282
2.183. 52601
2.196. 55250
2.222. 60500
2.232. 61154
2.240. 64475
2.258. 67312

Answers 223
Practice Exercise 6C
2.382. d. All of the above.
2.383. b. Report the Category III code.
2.384. a. Will be archived unless there’s evidence that a
temporary code is still needed
2.385. 0171T, 0172T
2.386. 0103T
2.387. 0184T
2.388. 0195T
2.389. b. Semiannually
2.390. 0030T
2.391. 0188T
2.392. 0170T
2.393. 0186T
2.394. 22856, 0092T
2.395. c. Hospitals, physicians, insurers, health services
researchers
2.396. 0179T
2.397. 0017T
2.398. 0156T
2.399. 0067T
2.400. 0140T
2.401. 0042T

Practice Exercise 7A
2.23. c. 99309
2.24. a. Documentation of history, examination, and
medical decision making
2.25. 99205
2.26. 99202

224 Answers
2.27. 99213
2.28. Time
2.29. d. A patient is placed in designated observation
status.
2.30. d. One code for the inpatient admission only
2.31. Key
2.32. d. a and b above
2.33. b. Social history
2.34. d. Has a moderate risk of morbidity without treat-
ment, a moderate risk of mortality without
treatment, uncertain prognosis or increased
probability of functional impairment
2.35. 99471
2.36. c. Subsequent hospital care codes
2.37. 99243
2.38. b. Chief complaint
2.39. d. All of the above.
2.40. c. Domiciliary, rest home, or custodial care services
2.41. b. Age of the patient
2.42. b. Office or other outpatient services codes
2.43. 30 (thirty)

Practice Exercise 7B
2.362. 51 or -51
2.363. RC or -RC
2.364. d. All of the above.
2.365. 26 or -26
2.366. 67916E1 or 67916-E1
2.367. 54 or -54
2.368. 26045RT or 26045-RT
2.369. a. Assign the code for a colonoscopy with modifier -74.

Answers 225
2.370. 91, -91
2.371. c. Assign a code for the procedure and one for the
evaluation and management service, with modifier
-25 appended to the evaluation and management
code.
2.372. 50 or -50
2.373. 45307-53
2.374. 25 or -25
2.375. 32 or -32
2.376. 27 or -27
2.377. QM, -QM
2.378. 59 or -59
2.379. 80 or -80
2.380. 62 or -62
2.381. 58 or -58

Practice Exercise 7C
2.44. b. When the anesthesiologist is no longer in personal
attendance on the patient
2.45. b. Has severe systemic disease
2.46. d. All of the above
2.47. 99140
2.48. 00172
2.49. 00326
2.50. 00530
2.51. 00670
2.52. 00832, 99100
2.53. 00862
2.54. 01400
2.55. 01214
2.56. 00921

226 Answers
2.57. 01967, 01968
2.58. 01232, 99140
2.59. 01480
2.60. 00563
2.61. 00794
2.62. 00567
2.63. 00944

Practice Exercise 7D
2.292. a. True
2.293. 70100
2.294. 70370
2.295. 70470
2.296. 71020
2.297. 78813
2.298. 72052
2.299. 72240
2.300. 73040
2.301. 73530
2.302. 74270
2.303. 74320
2.304. 74400
2.305. 75660
2.306. 76805
2.307. 75746
2.308. 78320
2.309. 75960
2.310. 77032
2.311. 76770
2.312. 78278

Answers 227
Practice Exercise 7E
2.313. d. FDA approval of the vaccine is pending.
2.314. a. 82270
2.315. b. False
2.316. b. HIV patients on antiretroviral therapy
2.317. 82552
2.318. 83090
2.319. 84154
2.320. 83986
2.321. 80076
2.322. 84300
2.323. 85025
2.324. 81025
2.325. 85610
2.326. 86039
2.327. 86592
2.328. 86706
2.329. 86632
2.330. 85652
2.331. 88305
2.332. 88309
2.333. 86618
2.334. 81001
2.335. 88164
2.336. 87040

Practice Exercise 8A
3.1 d. All of the above
3.2 J0295
3.3 J0476

228 Answers
3.4. J0585, J0585, J0585, or J0585×3
3.5. J1170
3.6. J2790
3.7. J9100
3.8. J9291
3.9. J1160
3.10. J7325

Practice Exercise 8B
3.11. E0601
3.12. A4750
3.13. A5071
3.14. A6197
3.15. A9503
3.16. A4346
3.17. A4605
3.18. A4253
3.19. A7018
3.20. A4550

Practice Exercise 8C
3.21. A0384
3.22. -HN
3.23. A0380
3.24. b. Per mile
3.25. A0436
3.26. A0424
3.27. c. Half hours
3.28. A0382
3.29. A0225
3.30. A0422

Answers 229
Practice Exercise 8D
3.31. E0434
3.32. E0297, E0277
3.33. E1594
3.34. E1300
3.35. E1180
3.36. E1038
3.37. E0445
3.38. E0199
3.39. E0730
3.40. E0619

Practice Exercise 8E
3.41. a. True
3.42. G0122
3.43. G0206
3.44. G0219
3.45. G0379
3.46. G0290
3.47. G0259
3.48. G0109
3.49. G0127
3.50 G0008

230 Answers
PROCTORED EXAMINATION
PREPARATION ANSWERS

Part 1—Multiple Choice
1. c (REF: pp. 103–104, CPT Coding and E/M guidelines)
2. b (REF: pp. 87-88, Inpatient/outpatient guidelines for
reporting principal diagnoses and procedures)
3. a (p. 136, HCPCS Level II Supplies guideline)
4. c (REF: Coding Guidelines and CPT Book p. 96)
5. d (REF: CPT coding book p. 47—3.5 cm. Look up
excision>lesion>scalp, L2S7)
6. a (REF: p. 128, HCPCS coding guidelines for drugs)
7. d (REF: pp. 119–120, HCPCS Level II, Nuclear Medicine)
8. a (REF: pp. 134–135, HCPCS Level II Drug Guidelines—
Report HCPCS code J0150 once, even though the
entire 6 mg ampule dose was not administered, L2S8)
9. b (REF: p. 114, HCPCS Modifiers)
10. c (REF: p. 153)

Part 2—Coding Record Scenarios
Coding Ambulatory Health Records
1. d
2. d
3. d
4. a
5. b
6. d
7. c
8. b
9. b

Answers 231
Coding Physician-Based Health Records
10. c
11. a
12. a
13. b
14. c
15. c
16. a
17. a
18. d
19. c
20. c

232 Answers