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 PEARSON’S

COMPREHENSIVE
MEDICAL CODING
A Path to Success
LORRAINE M. PAPAZIAN-BOYCE

TED W
DA

UP

ITH
UPDATED

2018
WITH
2015
CODES

CO
DES

Includes:
ICD-10-CM/PCS
ICD-9-CM
CPT
HCPCS

knows what today’s students need to succeed in the medical
workplace. Her driving passion is taking complex technical sub-
jects and breaking them down into practical, understandable
pieces that others can implement.
She is a contributor and/or subject matter expert to sev-
eral Pearson texts, including Pearson’s Comprehensive Medi-
cal Assisting, 4th ed., by Nina M. Beaman, et al.; Medical
Coding: A Journey, by Beth A. Rich; Administrative Medical
Assisting: Foundations and Practices, 2nd ed., by Christine
Malone; Guide to Medical Billing and Coding, 3rd edition, by
Sarah Brown and Lori Tyler; Comprehensive Health Insur-
ance: Billing, Coding, and Reimbursement, by Deborah Vines,
Ann Braceland, Elizabeth Rollins, and Susan H. Miller; A
Guided Approach to Intermediate and Advanced Coding, by
Jennifer Lame and Glenna Young; Mastering Medisoft, by
Bonnie J. Flom; Medical Assisting: Foundations and Practices,
by Margaret Frazier, et al; and Medical Insurance Billing
Course Connect.
Acknowledgements
Developing this text has been a long, challenging, exciting, and
rewarding experience. I am deeply appreciative to those who
walked with me on this journey. Marlene Pratt, Acquisitions
Editor, recognized my unique approach to coding and sup-
ported my vision to create a comprehensive coding solution
using the framework of my successful first text, ICD-10-CM/
PCS Coding: A Map for Success. She assembled a development
and production team who worked tirelessly through the ups
and downs of the project: Alexis Breen Ferraro, Developmental
Editor, and Susan Simpfenderfer, Principal, of iD8-TripleSSS
Media Development; Faye Gemmellaro, Yagnesh Jani, and
Lauren Bonilla of Pearson; Dennis Free and his team from
Aptara; and many others unknown to me who finessed the
details of this book.
Preface vii
Subject Matter Experts
A special thank you goes to my team of subject matter experts
who wrote exercises, reviewed content for accuracy, and other-
wise performed tasks that would have been impossible for me
to do while maintaining a rigorous writing schedule. The pro-
fessionalism and enthusiasm demonstrated by each individual
made working with them my pleasure.
• Angela R. Campbell, RHIA, AHIMA Approved ICD-
10-CM/PCS Trainer; Medical Insurance Manager, Eastern
Illinois University; Curriculum Designer/Adjunct Instructor,
Northwestern College; Lead Faculty Member/Adjunct
Instructor, Ultimate Medical Academy; Adjunct Instructor,
The College of Health Care Professions, who, in addition to
writing exercises and performing accuracy checks, reviewed
hundreds of chapter files as they made their way through the
production process. Without her unceasing effort, this book
could not have been finished within the desired time frame.
• Kate Gabriel-Jones, CPC, author, Medical Coding:
Evaluation and Management, who lent her expertise on CPT
Evaluation and Management coding to enhance students’
understanding of this complex topic.
• Mary Lou Hilbert, MBA, RHIT, CCS, Program Manager,
Health Information Technology and Medical Coding and
Billing, Seminole State College of Florida; whose keen eye
and commitment to this project from beginning to end
helped ensure attention to detail.
• Krystal S. Phillips, RHIA, CHTS-IS, AHIMA ICD-10-CM/
PCS Ambassador; Adjunct Instructor, Columbus State
Community College, whose hard work on the CPT chapters
and endless enthusiasm are much appreciated.
• Christine Tufts-Maher, MSHI, MS, RHIA, Professor,
Seminole State College of Florida, whose expertise on ICD-
10-PCS helped us put the finishing touches on the project.
viii Preface

Reviewers Bobbie J. Lautenschlager, CCA, CMRS, CPC

The following educators and healthcare professionals provided Program Director, Medical Billing & Coding
invaluable feedback during development: American School of Technology
Columbus, Ohio
Geanetta Johnson Agbona CPC, CPC-I, CBCS
Instructor, Medical Coding Robin Maddalena, CMT, CEHRS
South Piedmont Community College Adjunct Professor, Medical Insurance/Billing & Coding,
Charlotte, North Carolina ­Electronic Health Records
Tunxis Community College
Felecia Calloway, MBA, CCA, CBCS Farmington, Connecticut
Instructional Systems Designer
Virginia College Kim S. Norris, MBA, CPC
Montgomery, Alabama Program Director, Medical Billing & Coding
Carrington College
Ora Clark, RHIT, AHIMA, CPC, AAPC Tucson, Arizona
Medical Insurance/Billing & Coding Adjunct Faculty
Oconee Fall Line Technical College Lakisha Parker, AAS, CPC, CPC-I, ACPAR
Dublin, Georgia Program Director, Medical Billing & Coding/Healthcare
Reimbursement
Michelle Cranney, DHSc, RHIA, CCS-P, CPC Virginia College
Assistant Professor, Health Information Management Birmingham, Alabama
Ashford University
Seattle, Washington Elizabeth Roberts, CPC, CBCS, ICD-10 CM/PCS Trainer
Former Instructor, Medical Billing & Coding at Virginia
Janet A. Evans, RN, MBA, MS, CCS, CPC-I College
Instructor, Introduction to HCPCS (CPT) Coding Current Independent ICD-10 Consultant
Burlington County College Las Cruces, New Mexico
Pemberton, New Jersey
Gerald Robinson, CPC, ICD-10-CM/PCS Trainer
Chemo Faustino, CPC HIM Director & Adjunct Instructor
Program Director, Medical Billing & Coding Ultimate Medical Academy
Sanford-Brown College Tampa, Florida
Ft. Lauderdale, Florida
Rolando Russell, MBA/HCM, CPC, CPAR
Michelle Griggs, CPC, CPC-I, CPMA Program Director
Program Director, Medical Insurance/Billing & Coding Ultimate Medical Academy
Virginia College Tampa, Florida
Richmond, Virginia
Jennifer J. Talbot, RHIA, CCS-P, ICD-10-CM/PCS Trainer
Wahiyda Harding, RHIA, CCS, CTR, Program Director, HIT
Program Chair, Medical Insurance/Billing & Coding Kirtland Community College
Westwood College Roscommon, Michigan
Atlanta, Georgia
Jeanette Thomas, RHIA, RHIT, CPC-H, CPC
Kerry Heinecke, MS, RHIA Instructor, Health Information Systems
Program Director, HIM Clayton State University
Mid-State Technical College Morrow, Georgia
Marshfield, Wisconsin
Lydia Wikoff
Susan Herzberg, RHIA, CCS, CCS-P Instructor, Billing & Coding
Adjunct Professor, Medical Coding Southeastern College
Westchester Community College Jacksonville, Florida
Valhalla, New York

Mary Anita Kahler, RHIT, ICD 10-CM Trainer

Instructor, Medical Insurance/Billing & Coding
Coastal Carolina Community College
Jacksonville, North Carolina
Contents in Brief

Chapter 21: Certain Infectious and Parasitic Diseases

section one
Foundations of Coding
Chapter 1: Your Career and Coding 2
Chapter 2: Coding and Reimbursement 13
Chapter 3: The Transition to ICD-10-CM/PCS 24
section TWO
ICD-10-CM Diagnosis Coding
(A00-B99) 336
1 Chapter 22: Diseases of the Genitourinary System
(N00-N99) 357
Chapter 23: Pregnancy, Childbirth, and the Puerperium
(O00-O9A) 378
Chapter 24: Certain Conditions Originating in the Perinatal
Period (P00-P96) 404
Chapter 25: Congenital Malformations, Deformations, and
Chromosomal Abnormalities (Q00-Q99) 425
35

Chapter 4: Introduction to ICD-10-CM Diagnosis Coding 36

Chapter 5: Neoplasms (C00-D49) 60 section three
Chapter 6: Symptoms, Signs, and Abnormal Clinical and
Laboratory Findings, Not Elsewhere Classified (R00-R99) 79
ICD-9-CM Coding 441

Chapter 7: Factors Influencing Health Status and Contact with Chapter 26: Introduction to ICD-9-CM 442
Health Services (Z00-Z99) 94 Chapter 27: ICD-9-CM Body System Coding (000-999,
Chapter 8: External Causes of Morbidity (V00-Y99) 108 V01-V99, E000-E999) 455

Chapter 9: Diseases of the Digestive System (K00-K95) 123

Chapter 10: Endocrine, Nutritional, and Metabolic Diseases
(E00-E89) 141
section four
Chapter 11: Diseases of the Skin and Subcutaneous Tissue
(L00-L99) 159 CPT/HCPCS Procedure Coding 469
Chapter 12: Diseases of the Musculoskeletal System and Chapter 28: Introduction to CPT Coding 470
Connective Tissue (M00-M99) 174
Chapter 29: Introduction to HCPCS Coding
Chapter 13: Injury, Poisoning, and Certain Other (A0000-V5999) 492
Consequences of External Causes (S00-T88) 190
Chapter 30: CPT Modifiers 508
Chapter 14: Diseases of the Circulatory System (I00-I99) 211
Chapter 31: Evaluation and Management Services
Chapter 15: Diseases of the Blood and Blood-Forming Organs (99201-99499) 521
and Certain Disorders Involving the Immune Mechanism
(D50-D89) 233 Chapter 32: Medicine Procedures (90281-99199,
99500-99607) 555
Chapter 16: Diseases of the Respiratory System (J00-J99) 251
Chapter 33: Overview of Surgery Coding (10021-10022) 594
Chapter 17: Diseases of the Nervous System and Sense Organs
(G00-G99) 270 Chapter 34: Anesthesia Procedures (00100-01999) 615
Chapter 18: Mental, Behavioral, and Neurodevelopmental Chapter 35: Digestive System Procedures (40490-49999) 638
Disorders (F01-F99) 287 Chapter 36: Endocrine System Procedures
Chapter 19: Diseases of the Eye and Adnexa (H00-H59) 307 (60000-60699) 669
Chapter 20: Diseases of the Ear and Mastoid Process Chapter 37: Integumentary System Procedures
(H60-H95) 322 (10030-19499) 686
(continued )
x Contents in Brief

Chapter 38: Musculoskeletal System Procedures

(20005-29999) 717 section Five

Chapter 39: Cardiovascular System Procedures ICD-10-PCS Procedure Coding 975

(33010-37799) 742
Chapter 40: Hemic and Lymphatic Systems (38199-38999) and
Mediastinum and Diaphragm Procedures (39000-39599) 769
Chapter 41: Respiratory System Procedures
(30000-32999) 790
Chapter 42: Nervous System Procedures (61000-64999) 811
Chapter 43: Eye and Ocular Adnexa Procedures
(65091-68899) 836
Chapter 44: Auditory System (69000-69979) and Operating
Microscope Procedures (69990) 856
Chapter 45: Urinary (50010-53899), Male Genital System
Procedures (54000-55899), Reproductive System (55920), and
Intersex Surgery (55970-55980) Procedures 876
Chapter 46: Female Genital System (56405-58999) and
Maternity Care and Delivery Procedures (59000-59899) 902
Chapter 47: Radiology Services (70010-79999) 929
Chapter 48: Pathology and Laboratory Services
(80047-89398) 951
Chapter 49: Introduction to ICD-10-PCS Procedure
Coding 976
Chapter 50: Overview of Medical and Surgical Procedures
(Section 0) 996
Chapter 51: Coding for Medical and Surgical Procedures
(Section 0) 1008
Chapter 52: Section 0: Root Operations B, T, 6, 5, D 1030
Chapter 53: Section 0: Root Operations Y, M, X, S 1053
Chapter 54: Section 0: Root Operations V, L, 7, 1 1073
Chapter 55: Section 0: Root Operations 9, C, F, 8, N, J,
and K 1090
Chapter 56: Section 0: Root Operations H, R, U, 2, P, W, 3, Q,
G, 0, 4 1111
Chapter 57: Sections 1–9: Medical and Surgical-Related
Procedures 1134
Chapter 58: Sections B-D, F-H, X: Ancillary Procedures and
New Technology 1157
Glossary 1179
Index 1212

Online Chapters

Section Six

Putting It All Together

Chapter 59: Advanced Coding and Health Information
Technology
Chapter 60: Professionalism and Patient Relations
Contents
SECTION One
Foundations of Coding
Chapter 1: Your Career and Coding
What is Coding? 3
Code Sets 3
Three Skills of an Ace Coder 4
Understanding Patient Encounters
Types of Encounters 4
Steps in the Encounter 5
Certification 7
AAPC 7
AHIMA 7
Coding Careers 8 Diagnosis Coding 36
Career Path 8
Performance Expectations 10
Chapter 2: Coding and Reimbursement
Healthcare Payers 14
Government Programs 14
Private Health Insurance 15
Workers’ Compensation 15
Automobile Insurance 15
Managed Care Plans 15
Documentation 16
Medical Necessity 16
The Medical Record 17
Life Cycle of an Insurance Claim
Before the Encounter 19
During the Encounter 19
After the Encounter 19
At the Insurance Company 19
After Insurance Processing 20
Federal Compliance 21
Office of the Inspector General 21
Recovery Audit Contractor 22
Chapter 3: The Transition to ICD-10-CM/PCS
History of ICD-10-CM/PCS 25
Background of ICD-10-CM 25
Background of ICD-10-PCS 25
Benefits of ICD-10-CM/PCS 26
Overview of the Transition Process 26
Reasons for Change 26
Preparing for the Change 27
Impact on Healthcare Information Systems
Impact on Medical Providers 28
Impact on Documentation 28
Impact on Scheduling 29
Impact on Treatment 29
Impact on Medical Coders 29
New Terminology 30
New Abstracting Challenges 30
1 New Coding Challenges 30
Coder Training and Certification 32
2 Appropriate Use of GEMs 32
4
SECTION Two
ICD-10-CM Diagnosis Coding 35
Chapter 4: Introduction to ICD-10-CM
Organization of ICD-10-CM 37
Updates in ICD-10-CM 37
13 Overall Organization 37
Chapter Structure 38
ICD-10-CM Guidelines and Conventions 39
Official Guidelines for Coding and Reporting 39
Conventions 40
How to Code Diagnoses 44
Abstracting Diagnoses 44
Assigning Diagnosis Codes 46
Arranging Diagnosis Codes 51
Chapter 5: Neoplasms (C00-D49) 60
19
Neoplasm Refresher 61
Neoplasm-Related Terminology 61
Benign Neoplasm Behavior 61
Malignant Neoplasm Behavior 61
Coding Overview of Neoplasms 65
Abstracting for Neoplasms 65
Abstracting Metastases 66
Guided Example of Abstracting Neoplasms 66
Assigning Codes for Neoplasms 68
24 Search for the Histological Term in the Index 68
Locate Site and Behavior in the Table of Neoplasms 69
Verify Codes in the Tabular List 70
Guided Example of Assigning Neoplasm Codes 70
Arranging Codes for Neoplasms 72
Evaluation or Treatment Directed at the Primary
Malignancy 72
Evaluation or Treatment of the Metastasis 72
27 Encounter Solely for Chemo-, Radio-, or
Immunotherapy 73
Evaluation or Treatment for a Complication 73
Personal or Family History of Malignant Neoplasm 74
Guided Example of Arranging Neoplasm Codes 74
xii Contents
Chapter 6: Symptoms, Signs, and Abnormal Clinical
and Laboratory Findings, Not Elsewhere Classified
(R00-R99) 79
Symptoms and Signs Refresher 80
Coding Overview of Symptoms and Signs 81
Abstracting Symptoms and Signs 81
Integral, Related, and Unrelated Findings 82
Uncertain Diagnoses 83
Abnormal Clinical and Laboratory Findings 84
Guided Example of Abstracting Symptoms and
Signs 84
Assigning Codes for Symptoms and Signs 86
Codes for Symptoms and Signs 86
Combination Codes 86
Codes for Abnormal Findings 86
Guided Example of Assigning Symptoms and Signs
Codes 86
Arranging Codes for Symptoms and Signs 88
Confirmed Diagnosis and Related Symptoms 88
Confirmed Diagnosis and Unrelated Symptoms 88
Symptom Followed by Diagnoses 88
Symptoms with No Confirmed Diagnosis 89
Guided Example of Arranging Symptoms and Signs
Codes 89
Chapter 7: Factors Influencing Health Status and Contact
with Health Services (Z00-Z99) 94
Introduction to Z Codes 95
Coding Overview of Z Codes 97
Abstracting for Z Codes 97
Reason for the Encounter 97
Instructional Notes 98
Official Guidelines 98
Guided Example of Abstracting Z Codes 98
Assigning Z Codes 100
Locating Main Terms 100
Diagnosis vs. Procedure Codes 100
When Not to Use Z Codes 100
Guided Example of Assigning Z Codes 101
Arranging Z Codes 103
Principal or First-Listed Diagnosis 103
Sole Diagnosis Code 103
Additional Diagnosis Codes 103
Chapter 8: External Causes of Morbidity (V00-Y99) 108
Introduction to External Causes 109
Coding Overview of External Causes 109
Abstracting for External Causes 109
Intent and Cause 109
Place of Occurrence (Y92.-) 110
Activity (Y93.-) 110
Status (Y99.-) 110
Guided Example of Abstracting External Causes 110
Assigning Codes for External Causes 113
Index to External Causes 113
Verify in Tabular List 114
Guided Example of Assigning External Cause
Codes 115
Arranging Codes for External Causes 117
Guided Example of Arranging External Cause Codes 118
Chapter 9: Diseases of the Digestive
System (K00-K95) 123
Digestive System Refresher 124
Conditions of the Digestive System 125
Coding Overview of the Digestive System 127
Abstracting for Digestive System Conditions 127
Guided Example of Abstracting for Digestive System
Conditions 128
Assigning Codes for Digestive System Diagnoses 130
Guided Example of Assigning Digestive System
Diagnosis Codes 130
Arranging Codes for Digestive System Conditions 132
Guided Example of Arranging Digestive System
Diagnosis Codes 133
Coding Neoplasms of the Digestive System 135
Chapter 10: Endocrine, Nutritional, and
Metabolic Diseases (E00-E89) 141
Endocrine System Refresher 142
Conditions of the Endocrine System 142
Coding Overview of the Endocrine System 145
Abstracting for Endocrine System Conditions 145
Abstracting for Diabetes Mellitus 145
Abstracting for Thyroid Disorders 146
Guided Example of Abstracting Diagnoses for the
Endocrine System 146
Assigning Codes for Endocrine System Conditions 148
Guided Example of Assigning Endocrine System
Diagnosis Codes 150
Arranging Codes for Endocrine System Conditions 151
Multiple Coding for Diabetes 151
Multiple Coding for Other Endocrine System
Conditions 152
Guided Example of Arranging Endocrine System
Diagnosis Codes 153
Coding Neoplasms of the Endocrine System 154
Chapter 11: Diseases of the Skin and
Subcutaneous Tissue (L00-L99) 159
Integumentary System Refresher 160
Conditions of the Integumentary System 161
Coding Overview of the Skin and Subcutaneous
Tissue 162
Abstracting for Conditions of the Integumentary
System 162
Guided Example of Abstracting Diagnoses for the
Integumentary System 163
Assigning Codes for Conditions of the Integumentary
System 165
Guided Example of Assigning Integumentary System
Diagnosis Codes 165
Arranging Codes for Conditions of the Integumentary
System 167
Guided Example of Arranging Integumentary System
Diagnosis Codes 167
Coding Neoplasms of the Integumentary System 169

Chapter 12: Diseases of the Musculoskeletal System and
Connective Tissue (M00-M99) 174
Musculoskeletal System Refresher 175
Skeletal System 175
Muscular System 176
Conditions of the Musculoskeletal System 176
Coding Overview of the Musculoskeletal System 177
Abstracting for Conditions of the Musculoskeletal
System 178
Guided Example of Abstracting Diagnoses for the
Musculoskeletal System 178
Assigning Codes for Conditions of the Musculoskeletal
System 180
Guided Example of Assigning Musculoskeletal System
Diagnosis Codes 181
Arranging Codes for Conditions of the Musculoskeletal
System 182
Pathologic Fractures 182
Infectious Conditions 182
Osseous Defects 182
External Cause 183
Multiple Sites 184
Coding Neoplasms of the Musculoskeletal System
Chapter 13: Injury, Poisoning, and Certain Other
Consequences of External Causes (S00-T88) 190
Injury and Poisoning Refresher 191
Burns 191
Traumatic Fractures 191
Poisoning, Adverse Effects, and Underdosing 193
Coding Overview of Injury and Poisoning 194
Abstracting Diagnoses for Injury and Poisoning 194
Abstracting Burns 195
Abstracting Traumatic Fractures 195
Abstracting Poisoning 195
Guided Example of Abstracting Diagnoses for Injury and
Poisoning 195
Assigning Diagnosis Codes for Injury and Poisoning 198
Assigning Codes for Burns 198
Assigning Codes for Traumatic Fractures 199
Assigning Codes for Poisoning 201
Guided Example of Assigning Injury and Poisoning
Diagnosis Codes 202
Special Topics 202
Arranging Diagnosis Codes for Injury and
Poisoning 205
Arranging Codes for Burns 205
Arranging Codes for Traumatic Fractures 205
Arranging Codes for Poisoning 205
Guided Example of Arranging Injury and Poisoning
Diagnosis Codes 206
Chapter 14: Diseases of the Circulatory System (I00-I99) 211
Circulatory System Refresher 212
The Heart Muscle 212
The Conduction System 214
The Blood Vessels 214
Conditions of the Circulatory System 215
Contents xiii
Coding Overview of the Circulatory System 218
Abstracting for Circulatory System Conditions 218
Guided Example of Abstracting for Circulatory System
Conditions 218
Assigning Codes for Circulatory System
Conditions 221
Hypertension 221
Hypertension with Heart Disease 221
Hypertensive Chronic Kidney Disease 222
Hypertensive Kidney Disease and Hypertensive Heart
Disease 222
Hypertension and Other Conditions 222
Guided Example of Assigning Codes for Circulatory
System Conditions 223
Arranging Codes for Circulatory System
Conditions 225
Myocardial Infarction and Coronary Artery Disease 225
Acute and Subsequent Myocardial Infarction 226
Guided Example of Arranging Codes for Circulatory
System Conditions 226
Chapter 15: Diseases of the Blood and Blood-Forming
185 Organs and Certain Disorders Involving the Immune
Mechanism (D50-D89) 233
Blood Refresher 234
Conditions of the Blood 234
Coding Overview of the Blood 236
Abstracting for the Blood 236
Guided Example of Abstracting for Conditions of the
Blood 237
Assigning Codes for Conditions of the Blood 240
Guided Example of Assigning Codes for Conditions of
the Blood 241
Arranging Codes for Conditions of the Blood 243
Admission for Anemia Due to Neoplastic Disease 243
Admission for Anemia Due to Chemotherapy or
Immunotherapy 243
Admission for Anemia Due to Radiotherapy 243
Admission for Adjunct Therapy 243
Guided Example of Arranging Codes for Conditions of
the Blood 244
Coding Malignancies of the Blood 245
Chapter 16: Diseases of the Respiratory System
(J00-J99) 251
Respiratory System Refresher 252
Conditions of the Respiratory System 253
Coding Overview of the Respiratory System 256
Abstracting for Respiratory System Conditions 256
Guided Example of Abstracting for Respiratory System
Conditions 256
Assigning Codes for Respiratory System Conditions 259
Chapter-Wide Coding 259
Assigning Codes for Asthma 259
Assigning Codes for COPD and Asthma 260
Assigning Codes for Influenza 260
Guided Example of Assigning Codes for Respiratory
System Conditions 261
xiv Contents
Arranging Codes for Respiratory System Conditions 263
Arranging Codes for Ventilator-Associated Pneumonia 263
Arranging Codes for Acute Respiratory Failure 264
Guided Example of Arranging Codes for Respiratory
System Conditions 264
Coding Neoplasms of the Respiratory System 265
Chapter 17: Diseases of the Nervous System and Sense
Organs (G00-G99) 270
Nervous System Refresher 271
Conditions of the Nervous System 272
Coding Overview of the Nervous System 274
Abstracting for Conditions of the Nervous System 274
Guided Example of Abstracting for Nervous System
Conditions 275
Assigning Codes for Conditions of the Nervous
System 278
Assigning Codes for Hemiplegia and Monoplegia 278
Assigning Codes for Pain 278
Guided Example of Assigning Codes for Nervous System
Conditions 279
Arranging Codes for Conditions of the Nervous
System 281
Guided Example of Arranging Codes for Nervous
System Conditions 281
Coding Neoplasms of the Nervous System 282
Chapter 18: Mental, Behavioral, and Neurodevelopmental
Disorders (F01-F99) 287
Psychiatry Refresher 288
Psychiatric Conditions 289
Coding Overview of Psychiatry 291
Abstracting Diagnoses for Psychiatry 292
Guided Example of Abstracting Diagnoses for
Psychiatry 292
Assigning Diagnosis Codes for Psychiatry 294
Assigning Codes for Bipolar Disorder 294
Assigning Codes for Schizophrenic Spectrum
Disorders 295
Assigning Codes for Psychoactive Substance Disorders 296
Guided Example of Assigning Diagnosis Codes for
Psychiatry 297
Arranging Diagnosis Codes for Psychiatry 300
Arranging Codes for Pain 300
Arranging Codes for Intellectual Disabilities 301
Guided Example of Arranging Diagnosis Codes for
Psychiatry 301
Chapter 19: Diseases of the Eye and Adnexa (H00-H59) 307
Eye Refresher 308
Conditions of the Eye 308
Coding Overview of the Eye 310
Abstracting for Eye Conditions 310
Abstracting Diabetic Eye Conditions 310
Guided Example of Abstracting for Eye Conditions 311
Assigning Codes for Eye Conditions 313
Assigning Codes for Diabetic Eye Conditions 313
Guided Example of Assigning Codes for Eye
Conditions 313
Arranging Codes for Eye Conditions 316
Guided Example of Arranging Codes for Eye
Conditions 316
Coding Neoplasms of the Eye 317
Chapter 20: Diseases of the Ear and Mastoid Process
(H60-H95) 322
Ear Refresher 323
Conditions of the Ear 324
Coding Overview of the Ear 325
Abstracting for Ear Conditions 325
Abstracting Laterality 325
Abstracting for Otitis Media 326
Guided Example of Abstracting for the Ear 326
Assigning Codes for Ear Conditions 328
Assigning Codes for Hearing Loss 328
Assigning Codes for Otitis Media 329
Guided Example of Assigning Codes for Ear
Conditions 329
Arranging Codes for Ear Conditions 331
Guided Example of Arranging Codes for Ear
Conditions 331
Chapter 21: Certain Infectious and Parasitic Diseases
(A00-B99) 336
Infectious Disease Refresher 337
Common Infectious Diseases 338
Coding Overview of Infectious Diseases 340
Abstracting for Infectious Diseases 340
Abstracting HIV and AIDS 341
Abstracting Sepsis, Severe Sepsis, and Septic Shock 341
Guided Example of Abstracting for Infectious
Diseases 342
Assigning Codes for Infectious Diseases 345
Assigning Codes for Infectious Organisms 345
Assigning Codes for HIV and AIDS 345
Assigning Codes for Sepsis and Severe Sepsis 347
Guided Example of Assigning Infectious Disease
Codes 348
Arranging Codes for Infectious Diseases 350
Arranging Codes for HIV and AIDS 351
Arranging Codes for Severe Sepsis and Septic Shock 351
Guided Example of Arranging Infectious Disease
Codes 352
Chapter 22: Diseases of the Genitourinary System
(N00-N99) 357
Genitourinary System Refresher 358
Urinary System Refresher 358
Male Reproductive System Refresher 359
Female Reproductive System Refresher 359
Conditions of the Urinary System 360
Conditions of the Male Reproductive System 362
Conditions of the Female Reproductive System 363
Coding Overview of the Genitourinary System 364
Abstracting for Genitourinary System Conditions 364
Guided Example of Abstracting for Urinary System
Conditions 365
 Contents xv

Assigning Codes for Genitourinary System Assigning Codes for Neonatal Examinations 414
Conditions 367 Guided Example of Assigning Perinatal Codes 414
Assigning Codes for Nephritic Syndrome and Nephrotic Arranging Codes for Perinatal Conditions 418
Syndrome 367 Selecting the Principal Diagnosis for Birth
Guided Example of Assigning Codes for Urinary System Encounters 418
Conditions 368 Arranging Codes for Birth Weight and Estimated
Arranging Codes for Genitourinary System Gestational Age 418
Conditions 370 Arranging Codes for Bacterial Newborn Sepsis 418
Arranging Codes for Genitourinary Conditions Due to Guided Example of Arranging Perinatal Codes 418
Infections 370
Arranging Codes for Enlarged Prostate 370 Chapter 25: Congenital Malformations, Deformations, and
Guided Example of Arranging Codes for Urinary System Chromosomal Abnormalities (Q00-Q99) 425
Conditions 370 Congenital Abnormalities Refresher 426
Coding Neoplasms of the Genitourinary System 372 Conditions Related to Congenital Abnormalities 426
Coding Overview of Congenital Abnormalities 428
Chapter 23: Pregnancy, Childbirth, and the Puerperium Abstracting for Congenital Abnormalities 428
(O00-O9A) 378 Guided Example of Abstracting Congenital
Obstetrics Refresher 379 Abnormalities 429
Conditions of Pregnancy 380 Assigning Codes for Congenital Abnormalities 432
Conditions of Childbirth 382 Guided Example of Assigning Congenital Abnormalities
Conditions of the Puerperium 383 Codes 432
Coding Overview of Obstetrics 384 Arranging Codes for Congenital Abnormalities 434
Abstracting Diagnoses for Obstetrics 385 Guided Example of Arranging Congenital Abnormalities
Abstracting Conditions of Pregnancy 385 Codes 434
Abstracting Conditions of Childbirth 386
Abstracting Conditions of the Puerperium 386
Abstracting from Obstetric Records 386
Guided Example of Abstracting Diagnoses for SECTION Three
Obstetrics 386
Assigning Diagnosis Codes for Obstetrics 391 ICD-9-CM Coding 441
Locating Obstetrical Main Terms in the Index 391
Assigning Codes for the Mother’s Condition 391 Chapter 26: Introduction to ICD-9-CM 442
Assigning Codes to Identify the Term of Pregnancy 391 Purpose of ICD-9-CM 443
Assigning Codes to Identify the Trimester and Claims Before the Transition Date 443
Weeks 391 Data Tracking 443
Assigning Codes to Identify the Fetus 392 Non-HIPAA Transactions 443
Assigning Codes for Prenatal Visits 392 Organization of ICD-9-CM 443
Guided Example of Assigning Obstetrics Diagnosis Introductory Material 443
Codes 393 Volume 2: Index 445
Arranging Diagnosis Codes for Obstetrics 397 Volume 1: Tabular List of Diseases 446
Arranging Codes for When a Delivery Occurs 397 Assigning Fourth and Fifth Digits 447
Arranging Chapter 15 Codes with Codes from Other Volume 3: Inpatient Hospital Procedures 447
Chapters 398 How to Code Diagnoses in ICD-9-CM 450
Guided Example of Arranging Obstetrics Diagnosis Guided Example of Abstracting for ICD-9-CM 450
Codes 398 Guided Example of Assigning Codes in ICD-9-CM 450
Guided Example of Arranging Codes in ICD-9-CM 451
Chapter 24: Certain Conditions Originating in the Perinatal
Period (P00-P96) 404 Chapter 27: ICD-9-CM Body System Coding (000-999,
Perinatal Refresher 405 V01-V99, E000-E999) 455
Conditions Originating in the Perinatal Period 405 ICD-9-CM Coding Guidelines 456
Coding Overview of Perinatal Conditions 408 HIV 456
Abstracting for Perinatal Conditions 408 Anemia Associated with Malignancy 456
Abstracting from Newborn Records 409 Diabetes Mellitus 456
Guided Example of Abstracting for Perinatal Hypertension 457
Conditions 409 Myocardial Infarction 457
Assigning Codes for Perinatal Conditions 413 Asthma 458
Assigning Codes for Newborn Birth Status 413 Obstetrics 458
Assigning Codes for Conditions 413 Pressure Ulcer 460
xvi Contents

Fractures 460 Coding for Medical Supplies (A4206-A9300,

Table of Drugs and Chemicals 460
V Codes 461
Using General Equivalency Mappings 462
Exact Mapping 463
Approximate Mapping 463
One-to-Many Mapping 463
Many-to-One Forward Mapping 463
Misuse of GEMs 464
SECTION FOUR
CPT/HCPCS Procedure Coding 469
Chapter 28: Introduction to CPT Coding 470
Overview of CPT Coding 471
The History of CPT Coding 471
The Purpose of CPT Coding 471
Medical Terminology Used in CPT Coding 473
Organization of the CPT Manual 473
Introduction 474
Tabular List 474
Appendices 476
Index 476
Abstracting Procedures for CPT Coding 477
Identify the Primary Service or Procedure 477
Identify Secondary Services or Procedures 477
Identify the Quantity of Each Procedure 478
Guided Example of Abstracting Procedures 478
Assigning CPT Codes 479
Research the Procedure in the Index 479
Verify the Code in the Tabular List 480
Guided Example of Assigning CPT Codes 483
Arranging CPT Procedure Codes 485
CPT Coding and Reimbursement 485
Diagnosis–Procedure Linking 485
Reimbursement Edits 485
Physician Fees 486
Outpatient Hospital Reimbursement 487
Chapter 29: Introduction to HCPCS Coding
(A0000-V5999) 492
Overview of HCPCS Codes 493
Categories of HCPCS Codes 493
Organization of the HCPCS Manual 493
Introduction 494
HCPCS Index 494
HCPCS Tabular List 494
Table of Drugs 495
Modifiers 495
Appendices 495
Guidelines 495
Abstracting for HCPCS Codes and Modifiers 496
Assigning HCPCS Codes 497
Coding for Transportation Services Including
Ambulance (A0021-A0999) 497
A9900-A9999) 498
Coding for Radiopharmaceutical Drugs
(A9500-A9700) 499
Coding for Enteral and Parenteral Therapy
(B4034–B9999) 499
Coding for Durable Medical Equipment
(E0100–E8002) 499
Coding for Procedural/Professional Services
(G0008-G9862) 502
Coding for Drugs (J0120-J9999) 502
Orthotics (L0112-L9900) 503
Chapter 30: CPT Modifiers 508
Overview of CPT Modifiers 509
Abstracting for CPT Modifiers 510
Assigning Codes Using CPT Modifiers 511
General CPT Modifiers 511
Anatomic Site Modifiers 513
Evaluation and Management Modifiers 513
Surgical/Procedural Modifiers 514
Anesthesia Modifiers 515
Radiology Modifiers 515
Laboratory Modifiers 515
Hospital Outpatient/Ambulatory Surgery Center
Modifiers 517
Arranging Codes with CPT Modifiers 518
Chapter 31: Evaluation and Management
Services (99201-99499) 521
Overview of Evaluation and Management
Services 522
Guidelines for Evaluation and Management
Services 523
E/M Section Guidelines 523
Category Special Instructions 524
1995 Documentation Guidelines for Evaluation and
Management Services 524
1997 Documentation Guidelines for Evaluation and
Management Services 524
Abstracting Evaluation and Management Services 525
Abstracting the Setting 525
Abstracting the Patient Type 532
Abstracting the Level of Service 533
Guided Example of Abstracting E/M Services 536
Assigning Codes for Evaluation and Management
Services 539
Evaluate the Key Components 539
Determine Whether Modifiers are Needed 540
Determine Whether Special Circumstances Apply 542
Guided Example of Assigning E/M Codes 543
Advanced Coding for Evaluation and Management
Services 545
Determining the Level of History 545
Determining the Level of Examination 546
Determining the Level of Medical Decision
Making 548
Hospital Outpatient E/M Coding 548
 Contents xvii

Chapter 32: Medicine Procedures Arranging Surgery Codes 612

(90281-99199, 99500-99607) 555 Surgery: General Subsection (10021-10022) 612
Medicine Procedure Basics 556
Medical Terminology 556 Chapter 34: Anesthesia Procedures (00100-01999) 615
Coding Overview of the Medicine Section 557 Anesthesia Basics 616
Abstracting Medicine Procedures 558 Anesthesia Providers 616
Abstracting Immune Globulins and Immunizations 558 Anesthesia Care Cycle 616
Abstracting Psychiatry 559 Types of Anesthesia 617
Abstracting Dialysis and ESRD Procedures 560 Coding Overview of the Anesthesia Section 619
Abstracting Gastroenterology Procedures 560 Abstracting Anesthesia Procedures 619
Abstracting Ophthalmology Services 561 Guided Example of Abstracting Anesthesia Codes 622
Abstracting Hearing Services 562 Assigning Anesthesia Codes 624
Abstracting Cardiovascular Procedures 562 Identify the Surgical Procedure 624
Abstracting Noninvasive Vascular Studies 565 Assign the Anesthesia Code 625
Allergy Procedures 565 Assign the Physical Status Modifier (P1-P6) 625
Abstracting Neurology Procedures 565 Assign Any Moderate Sedation Codes
Abstracting Infusion and Injection Procedures 566 (99151-99157) 625
Abstracting Physical Medicine, Osteopathic, and Assign Any Qualifying Circumstances Codes
Chiropractic 567 (99100-99140) 626
Guided Example of Abstracting Medicine Services 567 Assign CPT and HCPCS Modifiers 626
Assigning Codes for Medicine Procedures 569 Assign Code(s) for Any Unusual Monitoring
Immune Globulins and Immunizations (90281-90399, Services 627
90460-90749) 569 Calculate the Anesthesia Payment Formula 628
Psychiatry (90785-90899) 571 Guided Example of Assigning Anesthesia Codes 629
Dialysis Procedures (90935-90999) 571 Arranging Anesthesia Codes 631
Gastroenterology Procedures (91010-91299) 572 Guided Example of Arranging Anesthesia Codes 631
Ophthalmology and Hearing Services (92002-92499,
92502-92700) 573 Chapter 35: Digestive System Procedures
Cardiovascular Procedures (92920-93799) 574 (40490-49999) 638
Noninvasive Vascular Studies (93880-93998) 576 Digestive System Procedure Basics 639
Allergy Procedures (95004-95199) 576 Procedures of the Upper GI Tract 639
Neurology Procedures (95782-96020) 577 Procedures of the Lower GI Tract 642
Infusion and Injection Procedures (96360-96549) 577 Procedures of the Accessory Digestive Organs 643
Physical Medicine, Osteopathic, and Chiropractic Procedures of the Abdominal Structures 644
(97010-97799, 98925-98929, 98940-98943) 578 Coding Overview of Digestive System
Other Medicine Procedures 579 Procedures 645
Guided Example of Assigning Medicine Codes 580 Abstracting Digestive System Procedures 646
Arranging Codes for Medicine Procedures 582 Guided Example of Abstracting Digestive System
Using Modifiers with Medicine Codes 582 Procedures 646
Guided Example of Arranging Medicine Codes 584 Assigning Codes for Digestive System
E/M Coding for Medicine 586 Procedures 649
Guided Example of E/M Coding for Psychiatry 587 Tonsillectomy 649
Appendectomy 650
Chapter 33: Overview of Surgery Coding Anastomosis 650
(10021-10022) 594 Endoscopy 650
Surgery Basics 595 Transplants 653
Classifications of Surgery 595 Repairs 653
The Surgical Facility 597 Adhesions 653
Coding Overview of the Surgery Section 599 Guided Example of Assigning Digestive System
Abstracting Surgery Section Procedures 600 Procedure Codes 654
Patient Position 600 Arranging Codes for Digestive System
Surgical Approach 600 Procedures 656
Incision Site 601 Modifiers 656
Operative Report 601 Guided Example of Arranging Digestive System
Assigning Surgery Codes 603 Procedure Codes 658
Surgical Care Process 604 E/M Coding for Gastroenterology 660
Surgical Package 606 Guided Example of E/M Coding for
Surgery Modifiers 607 Gastroenterology 660
xviii Contents

Chapter 36: Endocrine System Procedures Coding Overview of Musculoskeletal System

(60000-60699) 669 Procedures 722
Endocrine System Procedure Basics 670 Abstracting Procedures for the Musculoskeletal
Procedures on the Endocrine System 670 System 723
Coding Overview of Endocrine System Procedures 672 Guided Example of Abstracting Musculoskeletal System
Abstracting Endocrine System Procedures 672 Procedures 724
Guided Example of Abstracting Endocrine System Assigning Codes for Musculoskeletal System
Procedures 672 Procedures 726
Assigning Codes for Endocrine System Indexing of Joints and Bones 726
Procedures 675 Assigning Codes for Fracture Care 726
Guided Example of Assigning Endocrine System Guided Example of Assigning Musculoskeletal System
Procedure Codes 675 Procedure Codes 727
Arranging Codes for Endocrine System Procedures 677 Arranging Codes for Musculoskeletal System
Bilateral Procedures 677 Procedures 730
-59 Distinct Procedural Service 677 Modifiers 731
Modified Radical Neck Dissection 677 Guided Example of Arranging Musculoskeletal System
Imaging Guidance 677 Procedure Codes 731
Guided Example of Arranging Endocrine System E/M Coding for Orthopedics 734
Procedure Codes 678 Guided Example of E/M Coding for the Musculoskeletal
E/M Coding for Endocrinology 678 System 734
Guided Example of E/M Coding for
Chapter 39: Cardiovascular System Procedures
Endocrinology 679
(33010-37799) 742
Cardiovascular System Procedure Basics 743
Chapter 37: Integumentary System Procedures
Procedures of the Cardiovascular System 743
(10030-19499) 686
Coding Overview of Cardiovascular System
Integumentary System Procedure Basics 687
Procedures 748
Procedures of the Integumentary System 687
Abstracting Cardiovascular System Procedures 748
Coding Overview of Integumentary System
Guided Example of Abstracting Cardiovascular System
Procedures 692
Procedures 749
Abstracting Integumentary System Procedures 692
Assigning Codes for Cardiovascular System
Guided Example of Abstracting Integumentary System
Procedures 752
Procedures 693
Researching CPT Guidelines 752
Assigning Codes for Integumentary System
Blood Collection 753
Procedures 695
Pacemaker Procedures 753
Using the Index 695
Nonselective and Selective Catheterization 754
Code Families 695
Congenital Heart Defect Procedures 755
Determining Quantity 696
Coronary Artery Bypass Graft 756
Lesion Removal 697
Guided Example of Assigning Cardiovascular System
Wound Repair 699
Procedure Codes 756
Breast Procedures 700
Arranging Codes for Cardiovascular System
Skin Replacements 700
Procedures 759
Guided Example of Assigning Integumentary System
Radiology Services 759
Procedure Codes 701
Multiple Surgeons 759
Arranging Codes for Integumentary System
Laterality 759
Procedures 704
Coronary Arteries 759
Sequencing Excision of Lesion Codes 704
Guided Example of Arranging Cardiovascular System
Sequencing Wound Repair Codes 705
Procedure Codes 759
Using Modifiers with Integumentary System Codes 705
E/M Coding for Cardiology 761
Guided Example of Arranging Integumentary System
Guided Example of E/M Coding for Cardiology 761
Procedure Codes 706
E/M Coding for Dermatology 709 Chapter 40: Hemic and Lymphatic Systems (38199-38999) and
Guided Example of E/M Coding for Integumentary Mediastinum and Diaphragm Procedures (39000-39599) 769
System 709 Hemic and Lymphatic Systems Procedure Basics 770
Procedures of the Hemic and Lymphatic Systems 772
Chapter 38: Musculoskeletal System Procedures Coding Overview of Hemic and Lymphatic Systems
(20005-29999) 717 Procedures 773
Musculoskeletal System Procedure Basics 718 Abstracting Hemic and Lymphatic Systems
Procedures of the Musculoskeletal System 719 Procedures 773

Guided Example of Abstracting Hemic and Lymphatic
Systems Procedures 774
Assigning Codes for Hemic and Lymphatic System
Procedures 776
Bone Marrow/Stem Cell/ Transplantation
Procedures 776
Lymphadenectomy 776
Guided Example of Assigning Hemic and Lymphatic
Systems Procedure Codes 777
Arranging Codes for Hemic and Lymphatic Systems
Procedures 779
Modifiers 779
Guided Example of Arranging Hemic and Lymphatic
Systems Procedure Codes 780
E/M Coding for the Hemic and Lymphatic Systems 781
Guided Example of E/M Coding for the Hemic and
Lymphatic Systems 782
Chapter 41: Respiratory System Procedures
(30000-32999) 790
Respiratory System Procedure Basics 791
Procedures of the Respiratory System 792
Coding Overview of Respiratory System
Procedures 794
Abstracting Respiratory System Procedures 794
Anatomic Approach 794
Procedure Type or Variation 794
Guided Example of Abstracting Respiratory System
Procedures 795
Assigning Codes for Respiratory System
Procedures 797
Adjacent Sites or Systems 797
Biopsy 798
Endoscopy 798
Guided Example of Assigning Respiratory System
Procedure Codes 798
Arranging Codes for Respiratory System Procedures 801
Modifiers 801
Guided Example of Arranging Respiratory System
Procedure Codes 802
E/M Coding for Pulmonology 803
Guided Example of E/M Coding for Pulmonology 803
Chapter 42: Nervous System Procedures
(61000-64999) 811
Nervous System Procedure Basics 812
Procedures of the Nervous System 814
Coding Overview of Nervous System Procedures
Abstracting Nervous System Procedures 817
Guided Example of Abstracting Nervous System
Procedures 818
Assigning Codes for Nervous System Procedures 821
Assigning Codes for Basilar Skull Procedures 821
Assigning Codes for Laminectomy Procedures 822
Guided Example of Assigning Nervous System
Procedure Codes 823
Arranging Codes for Nervous System Procedures
Modifiers 826
Contents xix
Guided Example of Arranging Nervous System
Procedure Codes 826
E/M Coding for Neurology 828
Guided Example of E/M Coding for Neurology 828
Chapter 43: Eye and Ocular Adnexa Procedures
(65091-68899) 836
Eye Procedure Basics 837
Procedures of the Eye and Ocular Adnexa 837
Coding Overview of Eye Procedures 840
Abstracting Eye Procedures 841
Guided Example of Abstracting Eye Procedures 842
Assigning Codes for Eye Procedures 843
Guided Example of Assigning Eye Procedure Codes 844
Arranging Codes for Eye Procedures 846
Guided Example of Arranging Eye Procedure Codes 847
E/M Coding for Ophthalmology 849
Guided Example of E/M Coding for
Ophthalmology 849
Chapter 44: Auditory System (69000-69979) and Operating
Microscope Procedures (69990) 856
Auditory System Procedure Basics 857
Procedures of the Auditory System 857
Coding Overview of Auditory System Procedures 859
Coding for the Operating Microscope 860
Abstracting Auditory System Procedures 861
Guided Example of Abstracting Auditory System
Procedures 862
Assigning Codes for Auditory System Procedures 863
Assigning Codes for Myringotomy and
Tympanostomy 863
Assigning Codes for Removal of Foreign Bodies and
Impacted Cerumen 864
Assigning Codes for the Middle and Inner Ear 864
Guided Example of Assigning Auditory System
Procedure Codes 865
Arranging Codes for Auditory System Procedures 866
Unbundling 866
-47 Anesthesia by Surgeon 866
Guided Example of Arranging Auditory System
Procedure Codes 866
E/M Coding for Otolaryngology 868
Guided Example of E/M Coding for
Otolaryngology 868
Chapter 45: Urinary (50010-53899), Male Genital System
817 Procedures (54000-55899), Reproductive System (55920),
and Intersex Surgery (55970-55980) Procedures 876
Urinary and Male Genital System Procedure
Basics 877
Obstructive Uropathy 877
Calculi 879
Congenital Anomalies 879
Bladder Reconstruction 879
Coding Overview of Urinary System Procedures 880
826 Coding Overview of Male Genital System and Other
Reproductive Procedures 881
xx Contents

Abstracting Procedures for the Urinary and Male Genital
Systems 881
Abstracting the Anatomic Approach 881
Abstracting Gender 882
Guided Example of Abstracting Urinary System
Procedures 882
Assigning Codes for Urinary and Male Genital System
Procedures 885
Assigning Gender-Specific Codes 885
Assigning Codes for Urinary Catheterization 885
Assigning Codes Requiring Radiologic Guidance 886
Guided Example of Assigning Urinary System Procedure
Codes 887
Arranging Codes for Urinary and Male Genital System
Procedures 889
Endoscopy Coding 889
Laterality Modifiers 889
Modifiers for ESWL 890
Guided Example of Arranging Urinary System
Procedure Codes 891
E/M Coding for Urology 893
Guided Example of E/M Coding for Urology 893
Chapter 46: Female Genital System (56405-58999)
and Maternity Care and Delivery Procedures
(59000-59899) 902
OB/GYN Procedure Basics 903
Procedures of the Female Genital System 903
Maternity Care and Delivery Procedures 905
Coding Overview of OB/GYN Procedures 907
Abstracting OB/GYN Procedures 908
Anatomic Approach 908
Extent of Procedure 908
Guided Example of Abstracting OB/GYN
Procedures 908
Assigning Codes for OB/GYN Procedures 911
Assigning Codes for Hysterectomy 911
Assigning Codes for the Global Obstetric Package 912
Guided Example of Assigning Obstetrical Procedure
Codes 916
Arranging Codes for OB/GYN Procedures 918
Modifiers Commonly Used with OB/GYN Codes 918
Guided Example of Arranging OB/GYN Procedure
Codes 919
E/M Coding for OB/GYN 921
Guided Example of E/M Coding for Gynecology 921
Chapter 47: Radiology Services (70010-79999) 929
Radiology Procedure Basics 930
Radiology Procedures 930
Coding Overview of Radiology Procedures 935
Radiology Guidelines 935
Abstracting Radiology Procedures 936
Guided Example of Abstracting Radiology
Procedures 938
Assigning Codes for Radiology Procedures 940
Assigning Codes for Ultrasound 940
Assigning Codes for Mammography 940
Assigning Codes for with and without Contrast 941
Assigning Codes for Radiation Oncology 941
Guided Example of Assigning Radiology Procedure
Codes 942
Arranging Codes for Radiology Procedures 944
Multiple Coding for Radiologic Guidance 944
Modifiers Used with Radiology 945
Guided Example of Arranging Radiology Procedure
Codes 945
Chapter 48: Pathology and Laboratory Services
(80047-89398) 951
Pathology and Laboratory Procedure Basics 952
Overview of the Laboratory Testing Process 952
Clinical Laboratory Improvement Amendments 954
Coding Overview of Pathology and Laboratory
Procedures 955
Diagnosis Coding Based on Laboratory Results 955
Abstracting Procedures for Pathology and
Laboratory 957
Guided Example of Abstracting Pathology and
Laboratory Procedures 957
Assigning Codes for Pathology and Laboratory
Procedures 960
Assigning Codes for Specimen Collection 960
Assigning Codes for Urinalysis 960
Assigning Codes for Drug Assays 960
Assigning Codes for Rapid Strep Tests 961
Assigning Codes for Surgical Pathology 961
Assigning Codes for Pap Smears 963
Billing for Laboratory Tests 963
Guided Example of Assigning Pathology and Laboratory
Procedure Codes 965
Arranging Codes for Pathology and Laboratory
Procedures 967
Modifiers 967
Guided Example of Arranging Pathology and Laboratory
Procedure Codes 968
SECTION FIVE
ICD-10-PCS Procedure Coding 975
Chapter 49: Introduction to ICD-10-PCS Procedure
Coding 976
The Purpose of ICD-10-PCS 977
History of the ICD-10-PCS Code Set 977
Characteristics of ICD-10-PCS 977
ICD-10-PCS Compared with ICD-10-CM and CPT 978
Physician Documentation for PCS 978
Inpatient Hospital Billing 979
Guided Example of the Use of ICD-10-PCS 982
ICD-10-PCS Coding Manual Organization 983
ICD-10-PCS Code Structure 985
Character 1: Section 986
Character 2: Body System 986

Character 3: Root Operation 986
Character 4: Body Part 987
Character 5: Approach 987
Character 6: Device 987
Character 7: Qualifier 988
Guided Example of Building a PCS Code 988
ICD-10-PCS Coding Guidelines 989
A—Conventions 989
B—Medical and Surgical Section Guidelines
(Section 0) 989
C—Obstetrics and D-New Technology 989
Introduction to the Steps of ICD-10-PCS Procedure
Coding 990
Abstract Procedures from the Medical Record 990
Assign ICD-10-PCS Codes 990
Arrange ICD-10-PCS Codes 991
Chapter 50: Overview of Medical and Surgical Procedures
(Section 0) 996
Medical and Surgical Basics 997
Treatment and Diagnostic Procedures 997
Surgical Approaches 997
The Characters of Medical and Surgical Codes 998
Character 2: Medical and Surgical Body System 998
Character 3: Medical and Surgical Root Operation 1000
Character 4: Medical and Surgical Body Part 1002
Character 5: Medical and Surgical Approach 1003
Character 6: Medical and Surgical Device 1004
Character 7: Medical and Surgical Qualifier 1004
Chapter 51: Coding for Medical and Surgical Procedures
(Section 0) 1008
Abstracting Medical and Surgical Procedures 1009
Key Criteria for Abstracting Medical and Surgical
Procedures 1009
Abstracting Procedure Reports 1009
Guided Example of Abstracting PCS Procedures 1013
Assigning Medical and Surgical Procedure Codes 1018
ICD-10-PCS Index 1018
Guided Example of Using the PCS Index 1018
ICD-10-PCS Tables 1019
Bypass Procedures 1021
Guided Example of Using PCS Tables 1021
Arranging Medical and Surgical Procedure Codes 1023
Components of a Procedure 1023
Multiple Body Parts 1023
Multiple Body Sites with the Same Body Part
Value 1024
Multiple Root Operations on the Same Body Part 1025
Chapter 52: Section 0: Root Operations B, T, 6, 5, D 1030
Basics of Procedures That Take Out Some or All of a
Body Part 1031
Coding Overview of Root Operations B, T, 6, 5,
and D 1032
Guidelines for Coding Multiple Procedures 1032
Guidelines for Root Operations B, T, 6, 5, and D 1033
Abstracting for Root Operations B, T, 6, 5, and D 1033
Contents xxi
Abstracting for Excision (B) 1033
Abstracting for Resection (T) 1033
Abstracting for Detachment (6) 1034
Abstracting for Destruction (5) 1034
Abstracting for Extraction (D) 1034
Key Criteria for Abstracting 1035
Guided Example of Abstracting for Excision and
Resection 1036
Assigning Characters 4–7 for Root Operations B, T, 6, 5,
and D 1039
Character 4: Body Part 1039
Character 5: Approach 1040
Character 6: Device 1040
Character 7: Qualifier 1040
Guided Example of Assigning Characters 4–7 for
Excision and Resection 1041
Arranging Codes for Root Operations B, T, 6, 5,
and D 1045
Guided Example of Arranging Codes for Excision and
Resection 1046
Chapter 53: Section 0: Root Operations Y, M, X, S 1053
Basics of Procedures That Put in/Put Back or Move
Some/All of a Body Part 1054
Coding Overview of Root Operations Y, M, X,
and S 1055
Abstracting for Root Operations Y, M, X, and S 1056
Abstracting for Transplantation (Y) 1056
Abstracting for Reattachment (M) 1056
Abstracting for Transfer (X) 1056
Abstracting for Reposition (S) 1056
Key Criteria for Abstracting 1057
Guided Example of Abstracting for Reposition 1057
Assigning Characters 4–7 for Root Operations Y, M, X,
and S 1061
Character 4: Body Part 1061
Character 5: Approach 1061
Character 6: Device 1061
Character 7: Qualifier 1063
Guided Example of Assigning Characters 4–7 for
Reposition 1063
Arranging Codes for Root Operations Y, M, X,
and S 1066
Guided Example of Arranging Codes for
Reposition 1066
Chapter 54: Section 0: Root Operations V, L, 7, 1 1073
Basics of Procedures That Alter the Diameter/Route of a
Tubular Body Part 1074
Coding Overview of Root Operations V, L, 7,
and 1 1075
Occlusion and Restriction 1075
Bypass 1075
Abstracting for Root Operations V, L, 7, and 1 1076
Abstracting for Restriction (V) 1076
Abstracting for Occlusion (L) 1076
Abstracting for Dilation (7) 1076
Abstracting for Bypass (1) 1077
xxii Contents

Key Criteria for Abstracting 1077
Guided Example of Abstracting for Bypass 1077
Assigning Characters 4–7 for Root Operations V, L, 7,
and 1 1080
Character 4: Body Part 1080
Character 5: Approach 1080
Character 6: Device 1081
Character 7: Qualifier 1081
Guided Example of Assigning Characters 4–7 for
Bypass 1081
Arranging Codes for Root Operations V, L, 7,
and 1 1083
Guided Example of Arranging Codes for Bypass 1084
Chapter 55: Section 0: Root Operations 9, C, F, 8, N, J,
and K 1090
Basics of Procedures 9, C, F, 8, N, J, and K 1091
Basics of Procedures That Take Out Solids/Fluids/Gases
from a Body Part (9, C, F) 1091
Basics of Procedures Involving Cutting or Separation
Only (8, N) 1091
Basics of Procedures Involving Examination Only
(J, K) 1091
Coding Overview of Root Operations 9, C, F, 8, N, J,
and K 1093
Guidelines for Inspection 1093
Guidelines for Drainage 1093
Guidelines for Release and Division 1093
Abstracting for Root Operations 9, C, F, 8, N, J,
and K 1093
Abstracting for Procedures That Take Out Solids, Fluids,
or Gases from a Body Part 1093
Abstracting for Procedures Involving Cutting or
Separation Only 1095
Abstracting for Procedures Involving Examination
Only 1096
Guided Example of Abstracting for Inspection, Release,
and Resection 1096
Assigning Characters 4–7 for Root Operations 9, C, F, 8,
N, J, and K 1099
Character 4: Body Part 1099
Character 5: Approach 1100
Character 6: Device 1100
Character 7: Qualifier 1100
Guided Example of Assigning Characters 4–7 for
Inspection, Release, and Resection 1100
Arranging Codes for Root Operations 9, C, F, 8, N, J,
and K 1104
Guided Example of Arranging Codes for Inspection,
Release, and Resection 1104
Chapter 56: Section 0: Root Operations H, R, U, 2, P, W, 3,
Q, G, 0, 4 1111
Basics of Procedures H, R, U, 2, P, W, 3, Q, G, 0,
and 4 1112
Basics of Procedures That Always Involve a
Device 1112
Basics of Procedures That Define Other Repairs 1112
Basics of Procedures That Define Other
Objectives 1113
Coding Overview of Root Operations H, R, U, 2, P, W, 3,
Q, G, 0, and 4 1114
Abstracting for Root Operations H, R, U, 2, P, W, 3, Q,
G, 0, and 4 1114
Abstracting for Procedures That Always Involve a
Device 1114
Abstracting for Procedures That Define Other
Repairs 1116
Abstracting for Procedures That Define Other
Objectives 1117
Guided Example of Abstracting for Fusion, Insertion,
and Resection 1118
Assigning Characters 4–7 for Root Operations H, R, U,
2, P, W, 3, Q, G, 0, and 4 1121
Character 4: Body Part 1121
Character 5: Approach 1122
Character 6: Device 1122
Character 7: Qualifier 1123
Guided Example of Assigning Characters 4–7 for Fusion,
Insertion, and Resection 1124
Arranging Codes for Root Operations H, R, U, 2, P, W, 3,
Q, G, 0, and 4 1127
Guided Example of Arranging Codes for Fusion,
Insertion, and Resection 1127
Chapter 57: Sections 1–9: Medical and Surgical-Related
Procedures 1134
Basics of Medical and Surgical-Related
Procedures 1135
Coding Overview of Medical and Surgical-Related
Procedures 1137
Abstracting for Medical and Surgical-Related
Procedures 1137
Abstracting for Obstetrics (Section 1) 1138
Abstracting for the Placement (2), Administration (3),
and Measurement and Monitoring (4) Sections 1139
Abstracting for the Extracorporeal (5) (6) Procedures
Sections 1142
Abstracting for the Osteopathic (7), Chiropractic (9),
and Other Procedures (8) Sections 1143
Guided Example of Abstracting for Medical and
Surgical-Related Procedures 1145
Assigning Characters 4–7 for Medical and Surgical-
Related Procedures 1148
Assigning Codes for Obstetrics (1) 1148
Guided Example of Assigning Characters 4–7 for
Medical and Surgical-Related Procedures 1148
Arranging Codes for Medical and Surgical-Related
Procedures 1151
Guided Example of Arranging Codes for Medical and
Surgical-Related Procedures 1151
Chapter 58: Sections B–D, F–H, X: Ancillary Procedures
and New Technology 1157
Basics of Ancillary Procedures 1158
Coding Overview of Ancillary Procedures 1160
 Contents xxiii

Abstracting for Ancillary Procedures 1160 Glossary 1179

Key Criteria for Abstracting Ancillary Procedures 1160
Index 1212
Abstracting for Radiology Procedures (Sections B, C,
and D) 1161
Abstracting for Sections F, G, and H 1163 Online Chapters
Guided Example of Abstracting for Ancillary
Procedures 1164
Assigning Characters 4–7 for Ancillary
Procedures 1168 Section Six
Guided Example of Assigning Characters 4–7 for
Ancillary Procedures 1168 Putting It All Together
Arranging Codes for Ancillary Procedures 1171
Chapter 59: Advanced Coding and Health Information
Guided Example of Arranging Codes for Ancillary
Technology
Procedures 1171
New Technology (Section X) 1173 Chapter 60: Professionalism and Patient Relations
 Respiratory System
Diseases(J00-J99)
of the Cha
Guide to
Respiratory System
Key(J00-J99)
Features
Learning Objectives
16
After
This Guide to Key Features acquaints users with the text and shows them how completing
to use this chapter,
the pedagogical you should
features havegreatest
to their the skillsadvantage.
to:
16.1 Spell and define the key words, medical terms, and abbreviations related to
respiratory system.
Chapter Opener Features
Learning Objectives 16.2 Discuss the structure, function, and common conditions of the Chapter
respiratoryO
Learning Objectives—Each chapter system.
After completing this chapter, you should have the skills to: • Respirato
begins with a list of the primary skills 16.3 Identify the main characteristics of coding for respiratory system condition
16.1 Spell and define the key words, medical terms, and abbreviations related to the Refreshe
students should have after completing 16.4 Abstract diagnostic information from the medical record for coding diseas
respiratory system. • Coding O
the chapter. of the respiratory system.
16.2 Discuss the structure, function, and common conditions of the respiratory Respirato
16.5 Assign codes for diseases of the respiratory system.
system. • Abstracti
16.6 Arrange multiple diagnosis codes for diseases of the respiratory system.
16.3 Identify the main characteristics of coding for respiratory system conditions. System C
16.7 Code neoplasms of the respiratory system.
16.4 Abstract diagnostic information from the medical record for coding diseases • Assigning
16.8 Discuss the Official Guidelines for Coding and Reporting related to the
of the respiratory system. Respirato
respiratory system.
16.5 Assign codes for diseases of the respiratory system. Condition
Key Terms and Abbreviations—A list of the important terms multiple diagnosis codes for diseases of the respiratory system.
16.6 Arrange • Arranging
students need to know but may not have learned in16.7 previous
Code neoplasms of the respiratory system. Respirato
classes is provided at the beginning of each chapter. These
16.8 Key Terms and Abbreviations
Discuss the Official Guidelines for Coding and Reporting related to the Condition
terms are set in blue boldface type and are defined upon first respiratory system. • Coding N
acute exacerbation chronic bronchitis laryngitis
C16.indd Page 251 02/07/15 9:04 AM f-447 /203/PH01715/9780133797787_PAPAZIAN/PAPAZIAN_COMPREHENSIVE_MEDICAL_CODING1_SE_978
appearance in the chapter. They also are included in the ... Respirato
acute rhinitis chronic obstructive pulmonary larynx
Glossary at the end of the book. Supplemental terms are set in aerosol therapy disease (COPD) lobe
black boldface type and are defined in the Glossary. Key Terms and Abbreviations airway obstruction culture and sensitivity lower respirator
allergic rhinitis emphysema lung
acute exacerbation alveolus chronic bronchitis laryngitis
endotracheal intubation intrinsic sinusi
acute rhinitis atopic chronic obstructive pulmonary
exchange larynx nonatopicstatus
aerosol therapy bronchodilatordisease (COPD) extrinsic lobe pharyngitisthorac
airway obstruction culture and sensitivity
bronchogenic lower respiratory
hospital-acquired condition tract pharynx trache
bronchus emphysema

Chapter
allergic rhinitis (HAC) lung productivetrache
coug

eases of the
M16_PAPA7787_01_SE_C16.indd Page 252 02/07/15 9:04 AM f-447 alveolus /203/PH01715/9780133797787_PAPAZIAN/PAPAZIAN_COMPREHENSIVE_MEDICAL_CODING1_SE_978 ...
bronchial endotracheal
tree intubation hypercapniaintrinsic pulmonarytrache
func

16
atopic bronchiole exchange hypoxemianonatopic respiratoryupper
syst
Introduction—The text uses analogies at the beginning of extrinsic
bronchodilator pharyngitis ventila

spiratory System
chapters to create a “hook” with a common frame bronchogenic
of reference hospital-acquired condition pharynx ventila
and provides a familiar perspective for relating to bronchus
new (HAC) pne
In addition to the key terms listed here, students productive
should know cough
the terms defined within tables
information. bronchial tree hypercapnia pulmonary function test ventila

0-J99) 252 SECTION TWO ICD-10-CM Diagnosis Coding bronchiole hypoxemia respiratory system

IntroduCtIon which consists of the trachea (windpipe), bronchi, and lungs

As you travel to a higher elevation than what you’re accustomed (■ Figure 16-1). As air enters the nasal cavity or oral cavity, it
In addition to the key terms listed here,
Chapter students shouldof
Outline—A knowthethe terms topics
defined covered
within tables in this chapter.
to, breathing becomes more difficult. This is not because there is is warmed and moistened, list then passes major
through the pharynx,in the
less oxygen in the air but because a decrease in air pressure chapter
larynx, and appears
trachea. atThethetrachea
beginning.
dividesA consistent framework
into two bronchi For upd
causes us to inhale less air with each breath. across
(bronchial all coding
tubes) that chapters
lead to themakes
two it
lungs. easy to
Rings transition
of tracheal among
A pulmonologist specializes in diagnosing and treating con- body systems.
cartilage keep the trachea and bronchi open. In the bron- www.p
ditions of the lungs and lower respiratory system. An otolaryn- chial tree, the bronchi subdivide into smaller and smaller
gologist specializes in diagnosing and treating conditions of the branches, with the smallest being the bronchioles, which do
ng Objectives upper respiratory system. Primary care physicians treat uncom- Chapter
not contain Outline
rings of cartilage. Bronchioles end in small Forair
updates and corrections, visit o
plicated conditions of the respiratory system and refer more sacs in the lungs, alveoli.
pleting this chapter, you should www.pearsonhighered.com/hea
complicated cases tohave the skills to:
specialists. • Respiratory
The lungs consist of spongy System
tissue with interlacing networks
l and define the key words, medical terms, and abbreviations related to theof bronchioles, Refresher
alveoli, alveolar sacs, blood vessels, and capillar-
respIratory system refresher
iratory system. ies. The •
lungs are divided
Coding into lobesof
Overview (segments).
the The right lung
The function of the respiratory system is to obtain
cuss the structure, function, and common conditions of the respiratory oxygen (O 2) has three lobes: the
Respiratorysuperior, middle,
System and inferior. The left lung
from the air and deliver it to the lungs and blood for distribu- has two lobes: the superior and inferior. The lungs receive de-
em. • Abstracting
tion to tissue cells and to remove the gaseous waste product car- oxygenated blood from the for heartRespiratory
through the pulmonary ar-
ntify the mainboncharacteristics of coding for respiratory system conditions.
dioxide (CO2) from the blood and lungs and expel it. This System Conditions
tery, reoxygenate it, and send it back to the heart through the
tract diagnostic information
process from theThe
is called exchange. medical record
respiratory for coding
system diseases
also makes it pulmonary• Assigning
vein so the heart Codes
can pumpforthe blood out to the rest
he respiratorypossible
system.to cough, sneeze, and talk. of the body.Respiratory System
The respiratory
gn codes for diseases divided into the upper respi-
system issystem.
of the respiratory In FigureConditions
16-1, each structure in the respiratory system is
ratory tract, which consists of the nose, pharynx (throat), labeled with its name as well as its medical terminology root/
ange multiple diagnosis codes for diseases of the respiratory system. • Arranging Codes for
and larynx (voice box); and the lower respiratory tract, combining form, where applicable. Refer to ■ Table 16-1 for a
de neoplasms of the respiratory system. Respiratory System
cuss the Official Guidelines for Coding and Reporting related to the Conditions
iratory system. • Coding Neoplasms of the
 w
ICD-10-CM Chapter 10 provides an instructional note at the Certain
•multiple treatments
endoscopyfirst-level for respiratory
subterms,
(laryngoscopy, and it conditions requireconfused.
is easy to become
bronchoscopy) status Z
beginning of the chapter that instructs coders to use an addi- codes. The
By searching most common
the Indexare forthe
theexistence
Main Term
• pulmonary function tests—diagnostic tests that measure of a tracheostomy,
Asthma , then (1
anlocating
encountera subterm
for for either intermittent
tracheostomy care, or
long-term use of
persistent , cod-
oxygen,
tional code, when applicable, to identify various situations air flow in and out of the lungs, Guidelung to Key and gasxxv
Features
volumes, (2
A. Lobular or bronchopneumonia
related to tobacco use, dependence, and exposure to tobacco ers can ventilator
and/or locate most of the codes
assistance in they need.
breathing. If The subterm
there are complica-
inter-
exchange between the lungs and blood
smoke ( Figure 16-3). Exposure may include environmental tions
mittent from contains
any of only
theseone level of
devices, severity,
code mild, then provides
the complication and do
In-Chapter Features
■
•not ultrasound
choices for scanning or asthmaticus.
Figu
tobacco smoke, occupational exposure to tobacco smoke, and assign a Z code.
with exacerbation with status
Success Step—Short
exposure tips throughout
to tobacco smoke during thethe chapterperiod
perinatal help students
(before •The subterm
ventilation-perfusion
Locate
Coding codes
persistent
Caution—Short provides
warningsadditional
scan—a
for tracheostomy nuclear
status
throughout subterms
medicine
and testforuseful
tracheostomy
the chapter care,
mild
in
moderate
under , or
identifying
the Main , then
pulmonary
severe provides
emboli choices
by under
showing each
whether forblood
with W
abstract,
birth assign,
through theand
firstarrange
28 days(sequence) codes.
after birth). alert students to Term
codingTracheostomy
situations that can in the Index.orLocate the
be tricky
is flowing
exacerbation toorallwith
parts ofventilator
theasthmaticus
status lung use under (■ Figure 16-6). entry
Z codes
confusing. for oxygen and the Main Term
ease
Dependence in the Index (■ Figure 16-5).
Respiratory diseases are treated by medications, surgery, and the T
SucceSS Step
B. Lobar pneumonia coding
respiratory caution
therapy, including the following: the t
assigning Codes for asthma
bron
ICD-9-CM provided a chapter-wide note to assign an addi- • In ICD-9-CM
Assigning
aerosol codesasthma codes has
for asthma
therapy—medication were divided
new based on whether
requirements
suspended in a mist in ICD-
that is
tional code to identify the infectious organism. Because asthma
10-CM. was extrinsic or intrinsic. In ICD-10-CM,
To assign codes for asthma, coders need to identify these stanc
inhaled
ICD-10-CM has many combination codes that describe the howterms lead you has
the physician to default codes the
documented for severity
unspecified
of theasthma.
patient’s
condition and the organism, this chapter-wide note was
bronchodilator—a
• Instead, you need medication
to locate that relaxes
asthma based muscle
on spasms
the severity ass
condition. Be
in bronchial attentive
tubes when navigating the Main Term for Whe
eliminated. However, you still see a similar note in certain level as mild intermittent, moderate intermittent, moderate
endotracheal
• persistent, and intubation—placement
severe persistent. of a tube through type
categories that do not provide a combination code.
the Dependence
mouth and glottis into the F19.20
trachea to create a viable divid
(on) (syndrome)
airway influ
C. Interstitial pneumonia
assigning Codes for Copd and asthma Nove
•Thepulmonectomy or lobectomy
codes in categories J44 Other chronic obstructive pul-
Multiple Sites Affected has a
Figure 16-2 ■ (A) Lobular or Bronchopneumonia with Localized • thoracentesis—surgical
monary disease and J45 puncture
Asthma of the chest wall tobetween
distinguish Code
Respiratory conditions mayexercises
Coding Practice—Coding affect more than onepoints
at multiple site within the
throughout the chapter consist of three to sixinpatient scenarios related to a
Pattern (B) Lobar Pneumonia with a Diffuse Pattern within a Lung Lobe remove fluids
uncomplicated
on terms related to the body system or type of An acute
cases and those acute exacerbation. only
respiratory
specific system,
chapter such
topic. The as the
first tonsils
exercise and
in theadenoids,
coding trachea
chapters reviews medical
•exacerbation is a worsening of a chronic condition. An acute
(C) Interstitial Pneumonia Is Typically Diffuse and Bilateral inclu
and bronchi,
procedure andorintroduces
bronchi and lung. When
students the coding
to simple site is not
for specifi-
the body system. tracheostomy
exacerbation is not the same as an infection superimposed on a state
cally indexed, assign a code for the lowest anatomical site. This
chronic condition, although an exacerbation may be triggered labor
requires coders to follow conventions in the Index carefully and by an infection. or po
to have knowledge of respiratory system anatomy.
from
coding practice
For example, consider a patient seen for tracheobron- machine Z99.89
enabling NEC Z99.89 viru
chitis, an inflammation (-itis) of the trachea (trache/o) and Asthma, asthmatic (bronchial) (catarrh)
specified type NEC Z99.89 due
(spasmodic) J45.909
Exercise 16.1 Respiratory System Refresher • Define the meaning of (hemodialysis)
renal dialysis
the word, based (peritoneal) Z99.2
on the meaning of each
Use additional code, where applicable, to identify: respirator Z99.11
word part.ventilator Z99.11
exposure to environmental tobacco smoke (Z77.22) c
Instructions: Use your
exposure medicalsmoke
to tobacco terminology skills and
in the perinatal resources
period (P96.81)to • Assign thewheelchair
default ICD-10-CM
Z99.3M16_PAPAdiagnosis
778
code for the condition
define thehistory
following conditions
of tobacco related to the respiratory system,
use (Z87.891) opiate — see
using intermittent
the Index and Dependence,
Tabular
7_0
List. drug, 1_S
E_Copioid OG
(mild) J45.20 16.in

then assign the diagnosis

occupational code. to
exposure Follow these steps:
environmental tobacco smoke opioids — see Dependence, drug, opioid dd P
age
266
02/0
ca
with
opium (alkaloids) (derivatives) (tincture) — see7/15 9:04 A
(Z57.31) M f- ho
• Use slash marksdependence
tobacco “/” to break(F17.-)
down each term into its root(s) and exacerbationdrug,
Dependence, (acute)
26 J45.21
opioid subterms 447

status asthmaticus 6 S
J45.22 for
co
suffix. tobacco use (Z72.0) oxygen (long-term) (supplemental) E CTIO
NT
Z99.81 /203
/PH
be
017
WO frequency 15/9
co ICD-
10-C
Example: tonsillitis tonsil/itis Meaning: inflammation of the tonsils
din
ICD-10-CM
g Code:
MD
J03.90
ia ing
Figure 16-3 ■ Tabular List Instructional Notes That Apply to All Figure 16-5 ■ Index Entries for Dependence pr on Ventilatorg n o sis C or
Codes in Chapter 10 Oxygen Exe ac
tc
odin
g fol
1. pneumatocele Meaning Sys
rcis
tem
e 16 ICD-10-CM iCode
.5 e
persistent Cod
in
2. bronchiolitis Meaning In s t r
u
ICD-10-CM Code g Ne
opla
mild J45.30 enco c t io n s :
Read
sms
of th subterms Fo
unte
3. pneumohemothorax Meaning nosis ICD-10-CM Code
r, the t h e m
e Re
spir
with the li
ne p
c o des
u s
n a b strac
t,
in i- m e
d
for severity
ator
y scrib
rovid ing the In assign, ic a l- r e c
4. rhinorrhea Meaning exacerbation (acute) ICD-10-CM Code
e d . J45.31
d e x an a n d o r d
d Tab sequen o f e a c h 3. IN
status 1asthmaticus
. INP J45.32 ular List. Wce ICD-10- pa tient’s Reas
PAT • pn
IEN
5. nasopharyngitis Meaning Reas
ATIE ICD-10-CM Code
NT H r it e the C M diag
on fo
r enc
TH
moderate tJ45.40 on fo
r
OSP
ITAL
code
(s
- A ssessm
ent:• ot ount
6. bronchoalveolitis Meaning o cig
ICD-10-CM Code
arett encounte Ge
) on lymp
h
past nodes, aryn
ph
with Assessmen e smokingr: radiothe nder: F histo patie• ga nt
7. laryngoplegia Meaning Plan
exacerbation
: ret ICD-10-CM Code
t: N
(acute)
SCLC
rapy
, upp J45.41 r lung ca
fo
Age:
51
Plan
: rad
r y of
nico
t
3 IC urn f
or da e r left nce r Tip :L
iatio
•n theren
8. pyothorax Meaning statusD-asthmaticus
10-C ily tr J45.42
ICD-10-CM Code lobe due lymp ymphad ap
MC e atm h node e nect
severe J45.50 odes ents 4 IC
D-10
. • m
omy
i
9. tracheostenosis Meaning ICD-10-CM Code -CM
C od
Subsequent exercises walk students through the skills of with • es ot
10. hydropneumothorax Meaning 2.exacerbation (acute)ICD-10-CM Code
abstracting, assigning, and sequencing codes. Exercises Reas
INP ATIE
NT H
J45.51
4. IN
• ot
status
o asthmaticus J45.52
increase in difficulty as the chapter progresses, while remaining X-ra n for en
c
OSP
ITAL Reas
PAT
IEN
T HO
y
scan when pa ounter: Gen on fo SPIT Instr
appropriate for an introductory course. was
incon
tient
w
lung
biop
der:
F A Asse
ssme
r enc
ount AL
G
Figure 16-6 Asse
s ■ Example
infer sment: b
clus asof
ive trethe
sy o
ated Index f m Entry ge: 5for
6 Asthma cupa t: bila er: right p e
o c n assig
ior lo enign for p ass fou Plan
tiona
l exp
tera
l pleu
ulm
b neum nd : rad r
Plan e n eopla onia on o sure a l
need
: Pat
ie sm in , CT Tip: iothe
rapy to a malig
R sbes
to d n t h a s b right accid ememb to
oar
1 IC
D-10 esec een asym enta
l asb
er to
u
-CM tion
at th ptomatic
2 IC
D-10 estos se an ex
pois te
C od
e is tim so t -CM
C od onin rnal cau
e. here es g. s
is no
5. O
FFIC
Reas E G
on fo ende
r enc r: M
Asse ount Age:
ssme er: s 46
sinus nt: s inus
quam pain
Plan ous c , fac
ch : sur ell ca ial nu
ap radio gic rcino mb
t er ther al remo ma (
In th Su 1 IC apy val o SCC
is ch mm D-10 a nd c f tum A),
• Th apte h emo o
e fun r you ar -CM ther r, to be
the a c ti on of
learn
ed th y C od
e apy follo
ir at: wed
tissu and deli the respir w
e v a
 wer re- associated pneumonia (VAP) due to Pseudomonas.
knowledge
❑ Does a lungofabscess
the disease
exist? processes because multiple
s, lung perforated tympanic
Hospital membrane,
stay was sinusitis,
prolonged due tothe
thetype
VAP.of pneumo-
comorbidities
❑ What is the infectious organism?Coders
are common. need
Is it a virus to distinguish
or bacteria? Diseas
It does nia, and any additional manifestations.
betweenGuide
xxvi diseasesKey to Features
ensure they abstract all of the required Plan: discharged home after 10 days, continue
symp- ❑ What are all to of the respiratory-related comorbidities?
details. In addition to identifying the conditions, coders guided antibiotics,
example startofsupplemental
assigning O2Codes for
d con- ❑ Does influenza or asthma
must also identify the coexist with another
infectious respiratory
organism and condition?
lifestyle
Guided Examples—Step-by-step demonstrations respiratory systemto Conditions
allow students experience the thinking
10-CM
habits
❑ Is therelated
conditiontoin tobacco. ■ Table 16-3 lists important To practice skills for sequencing codes for the respiratory sys-
acute exacerbation?
process of a seasoned coder as they observe aFollow coder along
abstract,
questions system tem, continue withasthe Leanne and
assign, sequence
Riehl, codes from
CCS, abstracts the adiagnosis. lumbo
oding ❑ If asthma to ask whenmini-medical-record.
is documented, abstracting
what respiratory
is the level of severity? example from earlier in the chapter lung J
conditions. Check off each step after you complete it.
em in ❑ Is asthma in acute exacerbation or status asthmaticus? about patient Jared Hershman, who was admitted to Branton
discus- P Leanne
Medical Centerreads
due tothrough the entire record, paying special
dehydration.
❑ Is the condition the result of an external cause or procedural
sthma, guided example of abstracting attention
Follow along to
in the
your reason for the
ICD-10-CM encounter
manual and Riehl,
as Leanne the final
complication?
associ- assessment.
CCS, assigns codes. Check off each step after you complete it.
for
❑ Ifrespiratory system
influenza is documented, Conditions
what manifestations exist?
ob
Refer to the following example throughout this chapter to P First, ❑ Leanne She sees reviews
that there all theare information
quite a few shethings
abstractedgoingabout on with w
10-CM ❑ Is the condition recurrent?
APA7787_01_SE_C16.indd practicePage 263 02/07/15 skills 9:04 AM for f-447abstracting, assigning, and sequencing respi-
/203/PH01715/9780133797787_PAPAZIAN/PAPAZIAN_COMPREHENSIVE_MEDICAL_CODING1_SE_978 the patient. this
... She willso
patient, tackle
she eachneedscondition,
to breakone it downat a time.
step by step.
should ❑ Doessystem
ratory the patient codes. use Leanne supplemental Riehl, oxygen CCS,or isa ventilator a fictional coder She
❑ The patient was admitted for dehydration. refers to the Key Criteria for Abstracting Condi-
festyle who(aguides machine you thatthrough assists inthe breathing)?coding process. tions of the Respiratory System (Table 16-3). Because
posure. CHAPTER 16 Diseases of the Respiratory System (J00-J99) 263
❑ He has COPD.
assign Figure 16-9
❑ He experienced an acute exacerbation of COPD. Disease with
tem is 1. (continued) Date: 6/16/yy Location: 3.Branton MedicalGender: Center
INPATIENT HOSPITAL M Age: 72
Tabular Plan: oral steroids and quick relief bronchodilator inhaler Reason for encounter: management of chronic
M16_PAPA7787_01_SE_C16.indd Page 252 02/07/15 9:04 AM f-447
❑ He has a history of cigarette smoking. /203/PH01715/9780133797787_PAPAZIAN/PAPAZIAN_COMPREHENSIVE_MEDICAL_CODING

red for Provider: Gilbert Stagg, MDobstructive pulmonary disease, recent self-
Tip: Assign a code for the severity, not extrinsic vs. intrinsic.
❑ She
administered spirometry results have been declining, ❑ He acquired VAP due to Pseudomonas.
1 ICD-10-CM Code
Patient: Jared Hershman Gender: increased SOB M Age: 73 ❑ She
Assessment: COPD with chronic bronchitis and
emphysema started IV fluids 252 SECTION TWO ICD-10-CM Diagnosis Coding
P Leanne searches the Index for the Main Term Dehydration. exa
2. OFFICE Gender: F Age: 69
Reason for admission: dehydration,
Plan: nebulizer treatment to administer
smoked cigarettes forAs you travel to a❑
IntroduCtIon She identifies the default code E86.0of. the trachea (windpipe), bronchi, and lungs
which consists
Assessment: Patient who previously (■ Figure 16-1). As air enters the nasal cavity or oral cavity, it ❑ Now
Reason for encounter: productive cough and fever, bronchodilators
patient is concerned that she may need medication for higher elevation than what you’re accustomed
COPD which she50 has not years needed(nicotine for several years dependence)
Tip: Compare the codes for COPD, COPD with to, breathing becomes more difficult. This is not because there is
bronchitis,wasandplaced COPD with onemphysema.ventilator less oxygen in the❑air but Shebecause reviews thein three subterms
is warmed and moistened, then passes through the pharynx,
andtrachea.
larynx, and verifies that divides
The trachea noneinto of two bronchi COP
a decrease air pressure
Assessment: viral pneumonia unrelated to patient’s
due to COPD exacerbation. Patient
1 ICD-10-CMacquired Code ventilator causes us to inhale less air them with each are documented.
breath. (bronchial tubes) that lead to the two lungs. Rings of tracheal code
quires past history of COPD A pulmonologist specializes in diagnosing and treating con- cartilage keep the trachea and bronchi open. In the bron-
Plan: Rx cough associated pneumonia take aspirin (VAP) due to Pseudomonas. chial tree, the bronchi subdivide into smaller and smaller
ultiple
medicine with expectorant,
for fever, drink plenty of fluids to prevent dehydration
ditions of the lungs and lower respiratory system. An otolaryn-
gologist specializes P Leanne in diagnosing verifies
and treating code E86.0
conditions of the in branches,
the Tabular List. being the bronchioles, which
with the smallest
Pdo Leanne
Hospital stay was prolonged due to the VAP. not contain rings of cartilage. Bronchioles end in small air
nguish 1 ICD-10-CM Code upper respiratory system. Primary care physicians treat uncom-
❑ She
Plan: discharged home after 10 days, continue
plicated conditions ❑ of She the respiratory reads system the code title
and refer morefor E86.0, Dehydration and con-
sacs in the lungs, alveoli.
quired complicated cases to specialists. The lungs consist of spongy tissue with interlacing networks
pulm
firms that this accurately describes
ING1_SE_
978 ... the
of bronchioles, documentation.
alveoli, alveolar sacs, blood vessels, and capillar-
coders antibiotics, start supplemental AL _C ODING1_S
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2 respIratory system refresher REHENS
IVE_MED
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firm
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PAZIA has three lobes: the superior, middle, and inferior. The left lung
REHENS
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1. Confirm that the provider has documented the relationship 17 15/978013
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from the air
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PAZIAN/PA
deliver it to the checks lungs andfor bloodinstructional
for distribu- has notes
two lobes:in
thethe Tabular
superior List.
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oxygenated blood from the heart through the pulmonary ar- ❑ She
13 /203/PH0
respIratory system 1715/9780 CondItIons between the ventilator use and the pneumonia. tion to tissue cells and to remove the gaseous waste product car-
ortant 4 AM f-447
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Page 260
02/07/15
9:04 AM
f-447
bon dioxide (CO❑ 2) from She the blood cross-references
and lungs and expel it. This the tery, beginning
reoxygenate it, of
and category
send it back to theE86 , through the
heart
/07/15 9:0 Follow along as Leanne Riehl, CCS, abstracts the diagnosis.
OGCR provides specific instructions regarding sequencing 2. Assign code J95.851 Ventilator associated pneumonia .
ystem codes C16.i ndfor
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_PAPA7787_01_S E_
tory failure (ARF). Check off each step after youm (J0 0- J9 9)
9
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complete it. possible to cough, sneeze, reads and talk. the Excludes1 notes, and
of the verifies
body. that they do not
Figures—Anatomic the Respira
seases of illustrations
tory Syste
show EnglishM Diagnames
4. Do not assign a code from categories J12 to J18 to identify
and ratory ttetract,
The respiratory system is divided into the upper respi-
asthma apply to this case.
In Figure 16-1, each structure in the respiratory system Pis Leanne
R 16 Di nosis Codin
g persistent consists of the nose, pharynx (throat),
severe which labeled with its name as well as its medical terminology root/
arranging Codes for CHAPTE
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medical terms reads forBronmajor through e or chrothe entire record,
nic
the type of pneumonia.
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h COPD islarynx (voice box); and the lower respiratory tract,
and combining form, where applicable. Refer to ■ Table 16-1 for a
t specifie body parts 26and
IONorgans.
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entive to th e OGCby R toICD-10-CM. for Bronch
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searchpatient
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her inteat . Theandsubterm inSequence 16this
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assign sees
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VAP, -4 follows: are quite
bular List
■
the principal a lofew g a su
catindiagnosis.
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en on with
prov ides Fi gu re -7 Ex ■
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sion Term n Term locate mos with COPD ❑, the Leanne lmonary
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finalizes the code E86.0, Dehydration.
g respi- cofademsilifoarr rewiclarify sp
ide codingnew PD, and ininformation.
as an Inclu r the Mai ain ers can ntains only one level with status asth r mild, ma occurs nic obstructive pu . However,
m
fluenza.
th chapter-w r asthma, CO this patient, so she
o) . Th e Indeneeds
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de rs e M break m ittent co it down er ba tion or step
na l su bt erms fo by step. When asth with chNose ro (nas/o,
m bi na tio code
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ifically fo ronch/ nces co than r with ex ac
additio for with entry Asthm appears to be a co an additional code
a,
bronchi (b hitis cross-refere i are located lower s choices fo persistent provides choices under each ).
coder information spec oding Shespirarefers System Trac to heobrothe nc Key e bronch Criteria Bronchiti for subterm Abstracting provides re 16Condi-
-6 ease J44.
9, which P
ts codersLeanne
Nasal assign
tocavity ronic obstrproceeds
uctive to assign a code for COPD.
ide C
Chapter-wChapter 10, Diseasestions
of the Re
to ry be ca us e th Te rm
to all Term Bronchitis x entry for the Main the Tabular List, moderate, or se ith status asthmat
Th e ve re , then icu s ( Fi gu ■ Li st instr
the Tabular thma. ThThroat
uc
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fo r ch
nds on th ).
e circu m -
Sh ■

tional notes of ning

that apply the Respiratory Inde re 16-4). System der the exac(Table 16-3). Because cing depe
In or w as
chea. The erbation the type of th asthma. Sequen .a.1)) ( Figure 16-7
ICD-10-CM ns with two instruc n pertains to assig n the tra ders to J40 ( Figu inclusion term un .
gi tio
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an on ch iti s wi GC ❑
R I.C .10 She searches the Index for the Main Term Disease and
■
ap
be tio co br n. (O box (laryng/o)
(J00-J99), chapter. One instruc the other instruc - directs s as roni c
tis appear missioVoice
ute or ch Supporting
aution vided based on wheth e stances of ad
er
e bits; spira
codes in th des for lifestyle ha sites within the re Z Trache onchitis, not spec
obronchi ified as ac
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za
mus t id entify the lung. cartilage
do
nal co multiple status J40 Br thma co ICD-1 0- Cod , code rs s are
additio de when
how to co d. Coders should als
o assign code
tus Z CM as ic. In
In ICD-9- extrinsic or intrins r unspecified asth
ma. assigningningWindpipe influenza . Influenza code
codes for (trache/o) novel
Air space
describes require sta y, s s fo rity stations
When assig za and the manife ase is identified as ed.
m are affec
te conditions m asthma wa u to default code based on the seve
to ry sy ste Z Codes ents for respiratory istence of a tracheosto , s lea d yo te asth m a moder ate type of in flu en e dise
her thtubes is uniden 1,
tifi Respiratory
needed. tre atm th e ex ox yg en te rm to lo ca m itten t, wh
Bronchial
on et th e vi ru s epithelium
codes when Certain mon are rm use of u need
Instead, yo intermittent, moder
ate inter sed
divided ba (bronch/o) rus, or
s, other vi des avian influenza re 16-8).
and H1N
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eo er ild influen ich inclu (■ Figu
instructiona ter for trach thing. If th level as m d severe persistent.
Connective tissue
Lifestyle
Habits provides an coders to use an ad
di-
an encoun tor assistance in brea the complication an
d do enza A, wh in the Tabular List J09.X and J10
an Novel influ subcate
(lamina propria)
Chapter 10 ucts ventila , code persistent, gory ategory
ICD-10-CM the chapter that instr entify various situa o and/or any of these devices
tions
re d an d a sthma pul- has a specLung ific (pneum/o)
n co de s from subc of those listed in th
e
of id bacc m eostomy ca Cop ould as sig as on e nostic
Section of trachea
odes for Other chronic obstru between Coders sh the virus is confirmed quires a definitive diagpositive
ctive
beginning when applicable, to and exposure to to tal tions fro a Z code. tu s and trach Locate the ng C
de , en ce ,
tional co cco use, depend ay include environ d not as m en sig n eosto m y sta dex. ass ig ni ies J44 stingui sh when ation re ire a
s for trach y in the In rm in categor thma di acute only Diaphragm . Confirm es not requ
toba m
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e, an Locate code Term Tracheostom under the Main Te The codes ase and J45 As ute exacerbation. An ute inclusion notes e physician but do documents suspec
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ain e
ilator uscreate ose in ac cPaul ac th Bronchiole
Figure 16-10 Figu
smoke (■ ■e, occuVentilatorspa
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patients d (befowith un der the M but
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onarpneumonia.
ca se s an d thSources: ni co nd ition. An a statement from ever, if the provider not assign a code
ok g th perin
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cc o sm du rin co de x ( Fi un co en in g pe rim ato ry ian infl in flu
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st hma ments in ICD- exexacerbation is not the sa ugh an exacerbation m
m ay or poss due to
Influenza code from categor .10.c).
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9.
birth th w require tify ition, altho from J0
sign a R I.C
assigning des for asthma has ne a, coders need to iden nt’s chronic condtion. viruses.
Instead, as fluenza virus (OGC
in
Air space
co m tie specified
p ad di - Assigning sign codes for asth e severity of the pa r by an infec due to un
SS St e sign an . To as ented th Term fo
Succe e note to as e 10-CM ysician has docum vigating the Main ) (catarrh)
Squamous
chapter-wid us organism. Becaus e ph na (bronchial
tion nfirmed
provided a e how th . Be attentive when
epithelium
asthmatic 09
ICD-9-CM identify the infect des that describe th
io Asthma, g cau ding unco to the
to n co s co nd iti on as mo dic ) J45.9 codin ohibits co
which pr za, is an exception to
tional code s many combinatio apter-wide note wa
(sp
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ICD-10-C the organism, this ilar note in certa ndrome)
F19.20 ian -
and a sim ce (on) (sy cases of av tient guideline OGC they exist. Remem
condition owever, you still see nation code. Dependen pa
hospital in in conditions as th tween a general co
ough d- Alveolar structure
H m bi
eliminated. do not provide a co (m ild ) J4 5.20 un ce rta
code16-1 ■there The a di ffe re nc e be
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follow the
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-
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Mul tiple
co nd iti on s may ils an d aden oi
ifi - in flu en za , assign a co include the following
ns ec ces
Respiratory stem, such as the to hen the site is not sp is s of
For all type station(s). The choi
tory sy lu ng . W l sit e. Th m an ife
respira i and atomica subterm s
scribes the
i, or bronch e lowest an and persistent
and bronch assign a code for th in the Index carefully Z99.89 0 for severity
onia
d,
cally indexe to follow conventio m anatomy.
ns machine
ling NEC
Z99.89 mild J45.3 • pneum
ders ste bron- en ab Z9 9.8 9 9.2 spiratory
type NEC is) (peritoneal) Z9 • other re
5.31
requires co ge of respiratory sy seen for tracheo d specified dialys
with (acute) J4
erbation s J45.32
led nt ointestinal
ow ) an mo ac
to have kn e, consider a patie e trachea (trache/o lys is (he ex
renal dia 1 sta tus asthmaticu • ga str
pl
For exam mation (-itis) of th
Z99.1
respirator J45.40 alopathy
inflam Z99.11
ventilator 9.3
moderate • enceph
chitis, an Z9 opioid yocarditis
, to ide ntify: wheelchair pendence, drug, d with on (ac ute ) J45.41 • m
plicable 77.22) see De g, opioi exacerbati aticus J45.42 edia
, where ap tobacco smoke (Z d (P96.81) opiate — e Dependence, dru re) — see
ional code l rio se ctu status as
thm • otitis m rs to
Use addit re to environmenta in the perinatal pe opioids — ds) (derivatives) (tin struct code n,
exposu co smoke (alkaloi d vere J45.5
0
• other List also in fusio
the Tabular scess, pleural ef
to tob ac 1) e op ium dru g, op ioi 1 se
exposure e (Z87.89 ac co smok pe ndence, en tal) Z99.8 no tes in
co us l tob De lem na l ab
Instructio nal codes for lung
tobac nta pp
history of exposure to environ
me ng-term)
(su with ) J45.51
oxygen (lo lator or on (acute
nal ce on Venti exacerbati cus J45.52 ditio
occupatio
s for Dependen status asthmati assign ad
(Z57.31) nce (F17.-) Index Entrie hma
 Plan: radiation therapy
Tip: Lymphadenectomy is the surgical removal of a
M16_PAPA7787_01_SE_C16.indd
1. INPATIENT HOSPITAL Gender: FPage
Age: 254
51 02/07/15 lymph
9:04 node.
AM f-447 /203/PH01715/9780133797787_PAPAZIAN/PAPAZIAN_COMPREHENSIVE_MEDICAL_CODING1_SE
Reason for encounter: radiotherapy for lung cancer due 4 ICD-10-CM Codes
to cigarette smoking
Assessment: NSCLC, upper left lobe
Guide to Key Features xxvii
Plan: return for daily treatments
Tables—Tables
3 ICD-10-CM Codes throughout the text provide definitions
4. INPATIENT HOSPITAL of terms,
Gender: M conditions,
Age: 68 and treatments, as well as comparative information
Reason for encounter: right pulmonectomy
that highlights key concepts.
254 SECTION TWO ICD-10-CM Diagnosis Coding
Assessment: bilateral pleural malignant mesothelioma,
occupational exposure to asbestos
Plan: radiotherapy
Conditions
Table 16-2 ■ Gender:
2. INPATIENT HOSPITAL F Age: 56 of thETip:
rEspiratory systEm
Remember to use an external cause code for
Reason for encounter: lung biopsy of mass found on accidental asbestos poisoning.
X-ray when patient was treated for pneumonia, CT
Condition definition
2 ICD-10-CM Codes
scan was inconclusive
acutebenign
Assessment: respiratory
neoplasm indistress
right Acute respiratory failure that results in widespread injury to the endothelium in the lung, caused by sepsis,
inferiorsyndrome
lobe (ards) massive blood transfusion, aspiration of gastric contents, or pneumonia
5. OFFICE Gender: M Age: 46
Plan: Patient has been asymptomatic so there is no
need to do a resection at this time. Reason for encounter: sinus pain, facial numbness
acute respiratory failure (arf) Insufficient oxygen passing from the lungs to the blood, due to hypercapnia (high carbon dioxide level ),
Assessment: squamous cell carcinoma (SCCA), maxillary
1 ICD-10-CM Code
hypoxemia
sinus (low oxygen level ), or both
Plan: surgical removal of tumor, to be followed with
asthma A chronic lung
radiotherapy anddisease that affects the bronchi and is characterized by inflammation of the airway, a
chemotherapy
reversible
1 ICD-10-CMobstruction,
Code and reshaping of the airway
atelectasis Collapse of a lung, preventing the exchange of oxygen and carbon dioxide
Chronic bronchitis
chapter Summary Inflammation of the bronchi
M16_PAPA7787_01_SE_C16.indd with
Page a productive
267 02/07/15 coughSummary—Each
9:04 AM f-447 for three months in two consecutive
endsyears
/203/PH01715/9780133797787_PAPAZIAN/PAPAZIAN_COMPREHENSIVE_MEDICAL_CODING1_SE_978
chapter with a brief
...

Chronic
In this chapter obstructive
you learned that: pulmonary restatement
The combination of chronic bronchitis and emphysema of key points in the chapter.
as comorbidities
disease
• The function (Copd)system is to obtain oxygen from
of the respiratory • OGCR provide specific instructions regarding sequencing codes
the air and deliver it to the lungs and blood for distribution to for ventilator associated pneumonia and acute respiratory failure.
tissue cells, and to remove the gaseous waste product carbon CHAPTER 16 Diseases of the Respiratory System (J00-J99) 267
Emphysema
dioxide from the blood and lungs and expel it.
• Codes for neoplasms of the respiratory system appear in the
An enlargement and rupture of alveolar sacs at the end of the bronchioles, causing an abnormal
block C30 to C39 in the neoplasm chapter; the most common
• ICD-10-CM Chapter 10, Diseases of the Respiratory System accumulation oftheairlung.
site of neoplasms is in the tissue
(J00-J99), contains 11 blocks or subchapters that are divided by • ICD-10-CM Officialconcept
Guidelines for CodingQuiz
and Reporting (OGCR)
influenza
type of disorder and anatomic site. Anforacute respiratory
the respiratory system, ininfection
OGCR sectionwith
I.C.10,sudden
provide onset caused by a virus and characterized by fever, chills,
Takeof achronic
moment to look pulmonary
back at thedisease
respiratory system and solidify C. Moderate intermittent
• Coders should become familiar with chapter-wide coding
considerations as well as information specifically for asthma,
headache, muscle
detailed discussion aches, cough,
obstructive and sore throat
and
your skills. Try to answer the questions from memory first, then refer D. Moderate persistent
asthma, acute respiratory failure, influenza, and ventilator
COPD, and influenza. back to the discussion in the chapter if you need a little extra help.
associated pneumonia. 3. A reduction in the amount of air inhaled during each breath,
laryngitis Inflammation of the larynx, resulting in hoarseness most commonly caused by a reduction in the diameter of the
Completion
bronchioles due to inflammation, is called
lobar pneumonia Bacterial pneumonia that primarily affects one lobe of the lung
Instructions: Write the term that answers each question based on the A. airway obstruction.
information you learned in this chapter. Choose from the list below. B. asthma.
Some choices may be used more than once and some choices may C. COPD.
lobular pneumonia Pneumonia thatnot beprimarily
used at all. affects the bronchi and lobules (clusters ofD.alveoli
M16_PAPA7787_01_SE_C16.indd Page 268 02/07/15 9:04 AM f-447 that surround each bronchial
/203/PH01715/9780133797787_PAPAZIAN/PAPAZIAN_COMPREHENSIVE_MEDICAL_CODING1_SE_97
status asthmaticus.
branch); alsoacute
called bronchopneumonia
exacerbation laryngitis 4. Ventilator-associated pneumonia should be coded
End of Chapter Features acute respiratory failure lobar A. whenever a patient on mechanical ventilation has pneumonia.
pharyngitis Inflammationalveoli
of the throat B. when a hospitalized patient acquires pneumonia after admission.
The review at the end of each chapter lobular C. when the physician documents that ventilation was
asthma 268 SECTION TWO ICD-10-CM lower Diagnosis Coding required due to pneumonia.
reinforces key concepts and provides
pleurisy Inflammationatelectasis
of the lining of the lungs and thoracic cavity with oozing
pharyngitis of fluid or fibrinous material into the
D. when the physician documents the relationship between
opportunity for additional skills practice. pleural cavityavian coding challenge pleura mechanical ventilation and pneumonia.
bronchi status asthmaticus 5. Which of the following is NOT classified in ICD-10-CM Chapter
pneumoconiosis Abnormal condition of the lung
Instructions:
chronic bronchitis Read caused by inhalation
the mini-medical-record
tonsillitis of each of dustencoun-
patient’s particles, 10,4.such
Diseases asof coal
(continued) dust (anthracosis),
the Respiratory System (J00-J99)?
asbestos (asbestosis), ironabstract,
ter, then
M16_PAPA7787_01_SE_C16.indd
emphysema dustassign,(siderosis),
Page 269and tracheostomy
sequence
02/07/15 or9:04quartz
AM f-447(silicosis)
ICD-10-CM diagnosis codes A. Chronic obstructive diseases
/203/PH01715/9780133797787_PAPAZIAN/PAPAZIAN_COMPREHENSIVE_MEDICAL_CODING1_SE_978
Tip: A cracked tracheostomy tube is a mechanical
...

Concept Quiz—Definitions and key H1N1

using the Index and Tabular List. Write the code(s) on the line provided.
upper
B. Toxic effects of smoke
complication of a tracheostomy.
C. Lung diseases due to external agents
pneumonia
concepts are reviewed using ten Inflammatory 1.condition
The of the lung in which the alveoli
respiratory andofair spaces
tract consists fill withoffluid;
D. 2Infections
ICD-10-CM theCodes
uppercaused bytract
respiratory bacterial,
virus, fungi, or chemical irritants
the nose,1.pharynx,
OFFICE (■ Figure
andGender:
larynx. F Age: 16-2) 1 6. When a condition affects more than one site in the respiratory
completion and ten multiple-choice 2. BronchiolesReason endfor in small air sacs
encounter: in the lungs
productive calledSOB, fever
cough, system
CHAPTER 16 and the Index
Diseases does
of the not provide
Respiratory a separate
System entry,269
(J00-J99) how
questions. pneumothorax A collection of3.air between Assessment: the chest Chest X-ray wall andand sputumlungs,
is the collapse of a lung.
culturewhich may cause
positive
A.
5.the
should
Assign
lung
INPATIENT
codes toHOSPITAL
collapse Gender: M Age: 33
be assigned?
separate codes for each site
Reason for encounter: ethmoidectomy and nasal involved.
for acute bronchitis due to Streptococcus pneumonia.
4. COPD isChildthe9. INPATIENT
combination
exposed toof HOSPITAL
cigarette smoke Gender: M Age:
prenatally andand36 10. INPATIENT
a code for HOSPITAL
B. reconstruction
Assign Gender: Fsite.Age: 6
the highest anatomical
pulmonary edema An abnormal accumulation ofbecause
fluid in the
herasmother
lungs,
comorbidities. especially the alveoli, resulting
C. Assign
Reasonafor code infordyspnea
the lowest anatomical site.
Reason for
currently admission: difficulty breathing
smoked during Assessment: ethmoidalT&A
encounter: polyps and hypertrophy of nasal
Coding Challenge—Ten coding scenarios 5. pregnancy
Assessment: andspontaneous is a chronic
still does. lung disease
pneumothorax that
secondary to
D. Assign a code
Assessment:due
turbinates
for unspecified
to deviated
chronic
site.
nasal
tonsillitis withseptum
adenoiditis
tonsillitis Inflammation of affects
the tonsils
the abronchi and is characterized by reversible 7. Which of the following is NOT a key criterion for abstracting
drawn from all sections of the chapter obstruction
Plan:
fever,
ruptured
and
Plan:FU
reshaping
X-ray
bulla
OTC expectorant,
one confirmedof the
week or sooner
acetaminophen
airway. if necessary.
reexpansion
to reduce
of lung, pulmonary
Plan:
Plan:excised
conditions of the
polyps
FU in office and repaired deviated nasal
1 week
respiratory system?
septum
A. Is1 the
ICD-10-CM Code or extrinsic?
review coding skills learned in the chapter. 6.
and is also
Tip:clinic FU 1 one
Assign
called
weekcode for
bronchopneumonia.
pneumonia affects the alveoli
the bronchitis and two codes for
cause intrinsic
B. 3IsICD-10-CM
the conditionCodesacute or chronic?
smoke exposure.Codes
The Coding Challenge in procedure coding 7.
2 ICD-10-CM
3 ICD-10-CM Codes
is an asthma exacerbation that C. Is the condition in acute exacerbation?
does not respond to standard treatments. D. Does a lung abscess exist?
chapters requires both diagnosis and
The damage it causes is irreversible, unlike asthma, 8. Ain which the is a surgical opening in the 8. What is the correct coding for ventilator-assisted pneumonia
procedure codes.
obstruction is reversible. neck leading to the trachea. SucceSS Step due6.toINPATIENT
Pseudomonas ?
HOSPITAL Gender: F Age: 23
9. Codes for Keep on coding and A. Reason
J15.1 Pneumonia
for encounter:due to Pseudomonas
acute sinus pain, toothache,
2. OFFICE Gender: influenza VAP
F Age: can is
9 be anassigned
exampleonly hospital-acquired condition
of a headache
B. J95.851 Ventilator associated pneumonia
C. J95.851 Ventilator associated pneumonia and
Ventilator-Associated Pneumonia
Keep on Coding—Twenty-five coding
when the physician encounter:
Instructions:
Reason forRead
documents (HAC),
a confirmed
the diagnostic
coughing, statement, a serious
diagnosis.
wheezing,then SOB,
use theand condition
Index that
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List
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Pneumonia
and sequence
acute toafter
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sinusitis,
Pseudomonas right maxillary
10. Inflammation
chestoftightness
ICD-10-CM the throatduring
diagnosis iscodes.
called Write10 thetocode(s) on the line .
provided.
Medicare
and
does
15 minutes
not
after
pay D. sinus
hospitals for the costs incurred and to
Ventilator-associated pneumonia (VAP) is pneumonia
exercises in a one-line statement format exercisingthat during gym
1. Acute pharyngitis: at school
ICD-10-CM Code(s)
J95.851 Ventilator
Plan:
B96.5Schedule
Pseudomonas
associated pneumonia
CT scan of sinuses, analgesic, antihistamine,
Multiple Choice care for HACs and hospitals cannot bill patients for them.
develops 48 hours or more after mechanical ventilation
provide additional student practice. is initi-
Assessment: acute
2. Atelectasis: ICD-10-CM Code(s)exacerbation of mild persistent and antibiotic therapy. FU office visit 10 days.
9. Which of the following is NOT generally a manifestation of
ated. Mechanical ventilation is the administration Instructions:
of oxygen
based on thePlan:
Circle theintrinsic
asthma,
usingeffusion
information
3. Chylous
letter of the best answer to each question
you learned inuse
of the pleura: thisprior
chapter.
ICD-10-CM Code(s)FU office
1 ICD-10-CM Code
pneumonia?
Rx bronchodilator, to exercise. A. Nicotine dependence
an endotracheal tube or tracheostomy tube (a surgical opening
1. A collection
visit ofinair
4. Allergicone inbetween
month.
rhinitis thetochest
due pollen:wall and lungs,
ICD-10-CM which
Code(s) B. Encephalopathy
the neck leading to the trachea). Intubation allows microorganisms
may cause Tip: theRemember
lung to collapse
5. Malignant
A. atelectasis. neoplasm code isthe severity of the asthma.
to Diagnosis
of the ethmoid sinus, and right:Treatment
C. 7.
ICD-10-CM Code(s)D. of
Myocarditis
Respiratory
INPATIENT
Otitis media
HOSPITAL Conditions
Gender: M Age: 89
Reason for admission: admitted from emergency
from oral and gastric secretions to invade the tissuesB.ofpneumonia.
the6. lower
1 ICD-10-CM Code
Stenosis of the larynx: DiseasesICD-10-CM of the respiratory
Code(s) system
10. The are
instructional diagnosed
note Use additional
department due to acute respiratory withwhere
code, a wide
failure applicable, to
C. pneumothorax.
respiratory tract and lung. VAP is more serious than other types
D. pulmonary7. Chlamydial of
edema. pneumonia: variety ICD-10-CM of techniques,
Code(s) including identify the following:
exposure
Assessment:
to environmental tobacco smoke (Z77.22)
ARF is due to aspiration pneumonia due to
applies to secretions, lung abscess, diabetes type 2 with
pneumonia because patients who acquire it are in2.poorer Which of3. health
INPATIENT
8.the following
Acute isHOSPITAL
NOT tonsillitis:
streptococcal one of the Gender: Age:
M Code(s)
four severity
ICD-10-CM levels82
gastric
A. gastroparesis
only codes for asthma.
• arterial blood gasses to determine 2 and
Ofor CO concentrations
and2COPD.
than the average person. In addition, the types of germs used present
to classify
Reason
9. Avianfor
A. Mild intermittent
in
asthma?
flu:admission:
ICD-10-CM Code(s)pneumonococcal pneumonia B. only
C. Plan:
codes
Discharged
only codes
asthma
to a skilled
for asthma, COPD, nursing facility.
and pneumonia.
Assessment: COPD•withbiopsy
a hospital are often more dangerous and more resistant B. Mildto treat-
persistent
10. Acute
ventilation
acute exacerbation required
bronchiolitis due to respiratory syncytial virus: ICD-10-CM Code(s) D. 4allICD-10-CM Codes Chapter 10.
codes in ICD-10-CM
ment than those found in the community at large. 11.
Plan: Chronic •ICD-10-CM
tonsillitis:to
discharged chest
skilled X-ray
Code(s)
nursing facility with oxygen
2 ICD-10-CM
12. Codesbronchospasm: ICD-10-CM Code(s)
Exercised induced
13. Postprocedural respiratory failure: ICD-10-CM Code(s) 8. INPATIENT HOSPITAL Gender: M Age: 72
Reason for admission: gram-negative pneumonia
14. Hernia of the mediastinum: ICD-10-CM Code(s)
Assessment: Patient’s left-sided congestive heart
15. Mixed simple
4. OFFICE and mucopurulent
Gender: F Age: 84 chronic bronchitis: ICD-10-CM Code(s)failure and pulmonary edema were managed in addition
16. COPD (chronic obstructive pulmonary disease)
Reason for encounter: cracked tracheostomy tube with acute toICD-10-CM
exacerbation: the pneumonia.
Code(s) Patient also has chronic back pain
with an unknown etiology but it was not a factor during
Assessment:
17. Carcinoma Patient also has
of the trachea: sarcoidosis
ICD-10-CM Code(s)with lung this admission.
involvement.
18. Acute respiratory failure with hypoxia: ICD-10-CM Code(s) Plan: FU with pulmonary clinic and cardiologist in one week
Plan: replaced tracheostomy tube
This page intentionally left blank
 SECTION ONE

Foundations of Coding

Welcome to your new career in coding! You are in for the trip of a lifetime, one that is sure to take
you to new and unknown places, a few familiar ones, and perhaps some that seem a little scary.
This text is your road map, complete with success steps and caution signs.
Section One: Foundations of Coding acquaints you with the medical coding field, potential
career opportunities, how coding relates to reimbursement and payment, and provides an over-
view of the transition to ICD-10-CM/PCS.

Professional Profile and Summit—sometimes coding for several companies at

Meet…
Kristy Rodecker, CPC, CPC-H, CMA
Home-Based Medical Coder
I have been in the medical billing and coding field for ten
years. I was certified as a CPC five years ago and have been
coding from home since then. I started out as a front desk
receptionist in a busy, multi-physician neurology office and
worked my way through school to be an administrative medical
assistant.
When the opportunity arose, I took a data entry position at
a small billing company that was a one-and-a-half hour drive
(one way) and paid peanuts! The experience I gained was
priceless and it was the stepping stone for the rest of my career.
The company allowed coders to work from home once they
worked at the facility for six to twelve months. They wanted
coders to understand the way the company worked to make
sure the coders knew what they were doing before they worked
independently. Once I could pass all of their milestones I began
to code remotely. Eventually, I took on assignments for other
coding companies as well, including Nicka, MRSI, Med Data,
once. For some companies I am a regular employee and for
others I work as an independent contractor.
As a home-based medical coder, I log in remotely to the cus-
tomer’s database to access the medical records, code them, and
submit the claims to insurance companies. I enjoy reading the
interesting medical records, learning about new procedures,
and the challenge of finding an accurate code. I also enjoy the
flexibility of setting my own hours.
The most challenging aspect of my job is isolation. Working
from home can give you a good dose of cabin fever. I find it
important to attend my local AAPC chapter meetings and I also
volunteer at the hospital so that I can stay involved in our local
medical community.
I am frequently asked by aspiring coders how to work
from home, so I created a free, informational website (www.
medicalbillingandmedicalcoding.com) to help them avoid
unscrupulous get-rich-quick schemes and find ways to be
­successful.
My advice to coding students is to set an achievable goal and
go for it! Be willing to take an entry-level position, ask lots of
questions, and go the extra mile to prove you are an asset.
 Chapter

1 Your Career and Coding

Chapter Outline Learning Objectives

• What Is Coding? After completing this chapter, you should have the skills to:
• Understanding Patient 1.1 Spell and define the key words, medical terms, and abbreviations related to your
Encounters career and coding.
• Certification 1.2 Define coding, HIPAA-mandated code sets, and coding skills.
• Coding Careers 1.3 Describe how patient encounters relate to coding.
1.4 Identify the types of coding certification.
1.5 Understand the career path and performance expectations for a coding career.

Key Terms and Abbreviations

AAPC ancillary code set inpatient encounter
abstract attending physician coding midlevel job
admitting privileges assign diagnosis outpatient encounter
advanced-level job arrange document payers
amend career path encounter procedure
American Health Information case production entry-level job query
Management Association certification Health Insurance Portability and sequence
(AHIMA) code Accountability Act (HIPAA)

In addition to the key terms listed here, students should know the terms defined within tables in this chapter.

For updates and corrections, visit our student resource site at

www.pearsonhighered.com/healthprofessionsresources
 CHAPTER 1 Your Career and Coding 3

Introduction What is Coding?

When starting on a trip, you are more likely to get where you
want to go when you have a destination in mind. In this chapter
you will learn about your ultimate destination: the coding pro-
fession. By understanding what coding is, the relationship
between physicians and coders, and potential career opportuni-
ties, you will formulate ideas on your career goals and the steps
needed to reach them.
Many jobs in the healthcare field work with codes even though
they may not have a job title of Coder. For example, medical
assistants, billers, schedulers, and medical secretaries may use
codes as part of their jobs. This text uses the term coder to refer to
anyone who assigns, reads, or uses codes as part of their job.
A wide variety of healthcare professionals provides patient
services and uses codes to bill for their services in addition to
medical doctors (MDs). For example, dentists (DDSs or
DMDs), osteopaths (DOs), chiropractors (DCs), and nurse
practitioners (NPs) also bill their services with the same codes
as physicians. This text uses the terms physician and provider
interchangeably to refer to any healthcare professional who pro-
vides services that are billed with codes.
Coding is the process of accurately assigning codes to verbal
descriptions of patients’ conditions and the healthcare services
provided to treat those conditions. Medical codes are a combi-
nation of letters and numbers, three to seven characters in
length. Diagnosis codes describe patient illnesses, diseases,
conditions, injuries, or other reasons for seeking healthcare ser-
vices. Procedure codes describe the services healthcare profes-
sionals provide to patients, such as evaluation, consultation,
testing, treatments, and surgery.
Code Sets
The healthcare system in the United States uses several distinct
systems of medical codes, called code sets, for different purposes.
The various systems were developed by different organizations
and follow different guidelines for their use. The Health Insurance
Portability and Accountability Act (HIPAA), a federal law passed
in 1996, has numerous provisions relating to consumer health
insurance and electronic health transactions. HIPAA defines the
code sets that covered entities must use for electronic health
transactions and the purpose of each (■ Table 1-1).

Table 1-1 ■ Hipaa-Mandated Code Sets

Code Set Name
CDT
Codes on Dental Procedures
and Nomenclature
CPT
Current Procedural
Terminology
HCPCS
Healthcare Common
Procedure Coding System
ICD-10-CM
International Classification of
Diseases, 10th Revision,
Clinical Modification
ICD-10-PCS
International Classification of
Diseases, 10th Revision,
Procedure Coding System
ICD-9-CM
International Classification of
Diseases, 9th Revision,
Clinical Modification
ICD-9-CM procedure codes
NDC
National Drug Codes
Purpose Developed By Code Format/Examples
Dental services (occupies American Dental Association Letter D + 4 numbers
section D of HCPCS codes) (ADA) • D7230
Hospital outpatient and physician American Medical 5 numbers
procedure coding Association (AMA) • 99213
• 36415
Supplies, items, and services not Centers for Medicare and 1 letter + 4 numbers
covered by CPT, physician and Medicaid Services (CMS) • A1234
nonphysician services, Medicare • G9874
services, supplies
Diagnosis coding (replacement National Center for Health 3 to 7 alphanumeric characters
system for ICD-9-CM) Statistics (NCHS) based on • I10
ICD-10 from the World Health • A52.15
Organization (WHO)
• T50.A11D
Hospital inpatient procedure coding CMS 7 alphanumeric characters
(replacement system for ICD-9-CM, • 0B7B8DZ
Volume 3) • 4A04XB1
• 01500ZZ
Diagnosis coding, implemented 1979 NCHS 3 to 5 numbers; supplemental codes
(replaced by ICD-10-CM) that begin with V or E
• 123
• 123.45
• V10.23
• E987.4
Hospital inpatient procedure coding, NCHS 3 or 4 numbers
implemented 1979 (replaced by • 12.3
ICD-10-PCS) • 12.34
Identifies the manufacturer, product, Department of Health and 10 numbers divided into 3 segments
and package size of all drugs and Human Services (HHS) • 1234-5678-90
biologics recognized by the Food and • 12345-678-90
Drug Administration (FDA)
• 12345-6789-0
4 SECTION one  Foundations of Coding
Three Skills of an Ace Coder
Coding is more than looking up numbers in a manual or soft-
ware program. Accurate coding requires three major skills,
which are described next: abstracting, assigning, and arranging
(sequencing).
Abstracting
Before coders can assign codes, they abstract information from
the medical record. To abstract, coders read the medical record
and determine which elements of the encounter require codes.
They identify the reason for the encounter, diagnostic state-
ments from the physician, complications and coexisting condi-
tions, and the services provided. If the medical record is not
properly abstracted, it is impossible to assign the correct codes.
Each code set has various rules for abstracting, and some rules
are specific to a particular condition or procedure.
Success Step
The term abstract also describes a task in health informa-
tion management in which inpatient coders review the
medical record and cull data required for reporting, such as
patient demographics and length of stay.
Coding Practice
Exercise 1.1 What Is Coding?
Instructions: Write the answers to the following questions in the
space provided.
1. Define coding.
Understanding Patient
Encounters
Coders assign diagnosis and procedure codes to a patient
encounter (a specific interaction between a patient and health-
care provider) after an encounter has been completed. The
provider documents the reason(s) for the encounter and the
services provided in the patient’s medical record. Coders
read the medical record and other information the physician
provides to identify the main reason for the encounter, any
additional reasons for the service, the main service provided,
and any additional services provided. The following sections
provide an overview of patient encounters with the health-
care system, including the types of encounters and the pro-
cess of an encounter. This helps coders better understand
their role.
Assigning
The codes a coder selects or assigns must accurately describe
both the information documented in the medical record and
the patient’s condition and services. Each character of the code
must be correct. Diagnosis and procedure codes must reflect
the highest level of specificity possible and contain the correct
number of characters for that code. The official guidelines on
how to assign codes vary among code sets because each has
slightly different requirements.
Arranging
When more than one diagnosis or procedure code is required
for an encounter, coders must arrange, or sequence, the codes
in a specific order. Official coding guidelines dictate the proper
sequencing, which varies depending on the codes assigned and
the circumstances of the patient encounter. Codes that are not
sequenced properly are not considered to be correct.
Success Step
Memorize the definitions of the three coding skills: abstract-
ing, assigning, and arranging. Remind yourself of these
each time you sit down to code.
2. What is the difference between diagnosis coding and procedure
coding?
3. List and briefly define the three skills of an “ace” coder.
Types of Encounters
Patient encounters are generally classified by the location of the
encounter because different coding and billing rules apply to
each. The two basic types of locations are outpatient and inpa-
tient, which are described next.
Outpatient Encounters
Outpatient encounters are physician interactions with patients
who receive services and have not been formally admitted to a
healthcare institution, such as an acute-care hospital, long-term
care facility, or rehabilitation facility. Patients request outpatient
encounters when they have particular health problems, need
preventive services, or for follow-up or ongoing treatment for
known problems. ■ Table 1-2 lists examples of outpatient
encounters.
 CHAPTER 1 Your Career and Coding 5

Table 1-2 ■ Examples of Outpatient Encounters

Setting Purpose Examples
Ambulatory surgery Surgical procedure that does not require an overnight stay Tonsillectomy, cataract removal
in the hospital
Cardiology lab Testing to evaluate a heart problem EKG, echocardiogram, cardiac catheterization
Diagnostic radiology Imaging study to evaluate or diagnose a health problem X-ray, MRI, CT, PET
Emergency department Treatment of an injury or health problem that cannot be delayed Broken leg, chest pain
without harm to the patient
Laboratory Specimen collection Blood draw
Observation Extended monitoring which may require an overnight stay but does Chest pain
not meet the requirements for a formal inpatient admission
Physical therapy Treatment of a musculoskeletal problem Therapeutic exercises, electrical muscle
stimulation
Physician office Evaluation and management of a new or existing health problem; Back pain, diabetes check-up, immunization
preventive care services
Therapeutic radiology Receive a treatment using radiation Anticancer radiation therapy

Inpatient Encounters Diagnosis

Inpatient encounters are physician interactions with patients
who have been formally admitted to a healthcare facility, such
as an acute-care hospital, long-term care facility, or rehabilita-
tion facility. Patients cannot admit themselves to a facility; a
physician must admit a patient for a specific medical reason,
which is to either diagnose or treat a health problem. Physicians
contract with hospitals for admitting privileges, meaning they
have authority to admit patients and care for them in a specific
hospital. They write admitting orders, conduct an admitting
history and physical, and complete paperwork required by the
institution. One physician, usually the one who admits the
patient, is the attending physician who oversees and coordi-
nates all aspects of the patient’s care while an inpatient. Other
physicians also may be involved in the diagnosis or treatment of
the patient. A patient may also receive ancillary services, such
as laboratory, radiology, or physical therapy, as an inpatient.
The facility codes and bills for the room, board, nursing
care, use of the operating room, and most ancillary services.
Physicians code and bill for services they personally provide,
such as hospital visits, surgical procedures, and interpretation
of laboratory or radiology tests. A third-party company may
contract with the facility to provide services such as radiology
or physical therapy, in which case that company codes and bills
its own services to the patient.
Therefore, coders do not code for everything pertaining to
a specific patient. They code for the services provided by their
employer, such as the hospital, the surgeon, or the physical
therapist. They also code for the diagnoses that describe why
the patient received these particular services, but they do not
code for unrelated diagnoses.
Steps in the Encounter
While each encounter is unique to the patient’s situation,
it generally involves three steps: diagnosis, treatment, and
documentation.
When a patient presents to a physician with a health problem,
the physician needs to establish a diagnosis. If a diagnosis was
established in a previous encounter, the physician reviews the
patient’s progress and updates the diagnosis. Establishing or
updating a diagnosis involves a history, a physical examination,
and testing.
History. A physician takes a patient’s medical history, which
includes questions about current symptoms and past medical
problems. Because most symptoms can be caused by several
different conditions, the physician asks a series of questions to
narrow the possibilities. If a diagnosis was established in a pre-
vious encounter, the physician updates the history based on
what has happened since the last encounter.
Physical Examination. The physician conducts a physical
examination to further identify and evaluate abnormalities. The
examination may focus on a specific body system or it may
cover the entire body. Examinations include visual inspection,
palpation (physical touching), and auscultation (listening to vari-
ous parts of the body).
Testing. A physician performs or orders diagnostic tests, such
as blood tests, imaging, biopsies, and physical function tests,
such as EKGs, based on the patient’s situation. In some cases,
the patient’s condition does not require any tests.
Based on the findings from these sources, the physician
identifies the most likely diagnosis and the rationale for it.
Depending on the complexity of the problem, the physician
may determine the diagnosis in a single encounter or it may
take multiple patient encounters and multiple rounds of testing
to arrive at a conclusion.
Guided Example of Physician Diagnosis. Refer to the follow-
ing example throughout this chapter to learn more about
6 SECTION one  Foundations of Coding
patient encounters. The first portion of the example demon-
strates how physicians diagnose conditions.
P Patient Norman Markowitz, age 41, schedules an office
appointment to see Dr. Kristen Conover, a family practice
physician, on January 5, due to back pain.
❑ Dr. Conover takes a history by asking Mr. Markowitz
when the pain started, how severe it is, what makes it
better or worse, and if it has occurred before.
❑ She performs a physical examination to see if she can
detect abnormalities such as tightness, lumps, knots, or
protrusions.
❑ She asks Mr. Markowitz to perform specific maneuvers,
such as standing, sitting, and leaning forward or back-
ward, to determine his physical abilities.
❑ She uses a reflex hammer to test his reflexes.
❑ She takes an X-ray in the office, which is negative for a
fracture.
❑ She orders blood tests, which come back negative for
arthritis on January 12.
❑ She then schedules Mr. Markowitz for an MRI examina-
tion on January 17, which reveals a displaced interverte-
bral disc.
P Next, Dr. Conover will provide a treatment plan.
Treatment Plan
After establishing the diagnosis, the physician formulates a treat-
ment plan. The treatment plan may include medication, surgery,
lifestyle changes, or therapy. For complicated problems that take
time to diagnose, the physician may treat symptoms to provide
relief to the patient until the underlying cause is determined.
Guided Example of a Treatment Plan. Continue with the
example of patient Norman Markowitz, who saw Dr. Conover
due to back pain, to learn more about the treatment plan.
P Dr. Conover prescribes medication to relieve Mr. Markow-
itz’s back pain while waiting for results of the blood tests
and MRI.
❑ After she receives the MRI results of a displaced disc,
she asks Mr. Markowitz to schedule another appoint-
ment for follow-up.
❑ On January 24, they discuss treatment options and
decide to continue medication and refer Mr. Markowitz
for physical therapy.
❑ They also discuss the possibility of surgery if physical
therapy does not provide adequate relief.
P Next, Dr. Conover will document the encounter.
Documentation
After each patient encounter, the physician documents the
encounter, recording the reason for the encounter, the diagnos-
tic techniques used, tests or treatments planned, and the overall
assessment of the patient. This documentation is the basis from
which coders assign diagnostic and procedure codes for each
encounter. Coders do not do the following:
• determine what is wrong with the patient
• determine what condition(s) the patient has based on the
symptoms
• code for services provided prior to the current encounter
• code for services planned but not provided during the
current encounter
• code for services delivered by other providers
• code for past conditions that are resolved
• code for current conditions that the physician does not
document as relevant to the current encounter
When the documentation is unclear, coders do not make
assumptions about missing information. They query (ask) the
physician for clarification and the physician amends (adds in-
formation to) the medical record, if necessary.
Guided Example of Documentation. Continue with the exam-
ple of Norman Markowitz, who saw Dr. Conover due to back
pain, to learn more about documentation. Sherry Whittle, CPC,
is a fictitious certified coder who guides you through documen-
tation and coding.
P Sherry Whittle, CPC, codes for two outpatient encounters
for Mr. Markowitz, January 5 and January 24, because those
were the two dates that Dr. Conover saw him in the office.
❑ For the January 5 encounter, Sherry assigns the ICD-
10-CM diagnosis code M54.5, Low back pain (or
ICD-9-CM code 724.2 Lumbago), because Dr. Conover
had not yet determined the cause of the back pain.
❑ She assigns CPT procedure codes for the office visit and
the X-ray that was performed in the office.
❑ She does not assign procedure codes for the blood test
or the MRI because Dr. Conover did not provide those
services. These services will be billed by the organiza-
tion that provides the service.
P For the January 24 encounter, Sherry assigns the ICD-
10-CM diagnosis code M51.26, Other intervertebral disc
displacement, lumbar region (or ICD-9-CM code 722.10
Displacement of lumbar intervertebral disc without
myelopathy), because Dr. Conover established the diagno-
sis based on the MRI results.
❑ She also assigns a CPT code for the office visit.
❑ She does not assign procedure codes for physical ther-
apy because Mr. Markowitz will go to a physical therapy
clinic for the service. The physical therapy clinic will bill
for the services it provides.
❑ She does not assign procedure codes for surgery because
surgery was not performed.
P Finally, the codes and billing information will be entered
into the computer and submitted to the patient’s insurance
company for payment.
Another random document with
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 DANCE ON STILTS AT THE GIRLS’ UNYAGO, NIUCHI

Newala, too, suffers from the distance of its water-supply—at least

the Newala of to-day does; there was once another Newala in a lovely
valley at the foot of the plateau. I visited it and found scarcely a trace
of houses, only a Christian cemetery, with the graves of several
missionaries and their converts, remaining as a monument of its
former glories. But the surroundings are wonderfully beautiful. A
thick grove of splendid mango-trees closes in the weather-worn
crosses and headstones; behind them, combining the useful and the
agreeable, is a whole plantation of lemon-trees covered with ripe
fruit; not the small African kind, but a much larger and also juicier
imported variety, which drops into the hands of the passing traveller,
without calling for any exertion on his part. Old Newala is now under
the jurisdiction of the native pastor, Daudi, at Chingulungulu, who,
as I am on very friendly terms with him, allows me, as a matter of
course, the use of this lemon-grove during my stay at Newala.
 FEET MUTILATED BY THE RAVAGES OF THE “JIGGER”
(Sarcopsylla penetrans)

The water-supply of New Newala is in the bottom of the valley,

some 1,600 feet lower down. The way is not only long and fatiguing,
but the water, when we get it, is thoroughly bad. We are suffering not
only from this, but from the fact that the arrangements at Newala are
nothing short of luxurious. We have a separate kitchen—a hut built
against the boma palisade on the right of the baraza, the interior of
which is not visible from our usual position. Our two cooks were not
long in finding this out, and they consequently do—or rather neglect
to do—what they please. In any case they do not seem to be very
particular about the boiling of our drinking-water—at least I can
attribute to no other cause certain attacks of a dysenteric nature,
from which both Knudsen and I have suffered for some time. If a
man like Omari has to be left unwatched for a moment, he is capable
of anything. Besides this complaint, we are inconvenienced by the
state of our nails, which have become as hard as glass, and crack on
the slightest provocation, and I have the additional infliction of
pimples all over me. As if all this were not enough, we have also, for
the last week been waging war against the jigger, who has found his
Eldorado in the hot sand of the Makonde plateau. Our men are seen
all day long—whenever their chronic colds and the dysentery likewise
raging among them permit—occupied in removing this scourge of
Africa from their feet and trying to prevent the disastrous
consequences of its presence. It is quite common to see natives of
this place with one or two toes missing; many have lost all their toes,
or even the whole front part of the foot, so that a well-formed leg
ends in a shapeless stump. These ravages are caused by the female of
Sarcopsylla penetrans, which bores its way under the skin and there
develops an egg-sac the size of a pea. In all books on the subject, it is
stated that one’s attention is called to the presence of this parasite by
an intolerable itching. This agrees very well with my experience, so
far as the softer parts of the sole, the spaces between and under the
toes, and the side of the foot are concerned, but if the creature
penetrates through the harder parts of the heel or ball of the foot, it
may escape even the most careful search till it has reached maturity.
Then there is no time to be lost, if the horrible ulceration, of which
we see cases by the dozen every day, is to be prevented. It is much
easier, by the way, to discover the insect on the white skin of a
European than on that of a native, on which the dark speck scarcely
shows. The four or five jiggers which, in spite of the fact that I
constantly wore high laced boots, chose my feet to settle in, were
taken out for me by the all-accomplished Knudsen, after which I
thought it advisable to wash out the cavities with corrosive
sublimate. The natives have a different sort of disinfectant—they fill
the hole with scraped roots. In a tiny Makua village on the slope of
the plateau south of Newala, we saw an old woman who had filled all
the spaces under her toe-nails with powdered roots by way of
prophylactic treatment. What will be the result, if any, who can say?
The rest of the many trifling ills which trouble our existence are
really more comic than serious. In the absence of anything else to
smoke, Knudsen and I at last opened a box of cigars procured from
the Indian store-keeper at Lindi, and tried them, with the most
distressing results. Whether they contain opium or some other
narcotic, neither of us can say, but after the tenth puff we were both
“off,” three-quarters stupefied and unspeakably wretched. Slowly we
recovered—and what happened next? Half-an-hour later we were
once more smoking these poisonous concoctions—so insatiable is the
craving for tobacco in the tropics.
Even my present attacks of fever scarcely deserve to be taken
seriously. I have had no less than three here at Newala, all of which
have run their course in an incredibly short time. In the early
afternoon, I am busy with my old natives, asking questions and
making notes. The strong midday coffee has stimulated my spirits to
an extraordinary degree, the brain is active and vigorous, and work
progresses rapidly, while a pleasant warmth pervades the whole
body. Suddenly this gives place to a violent chill, forcing me to put on
my overcoat, though it is only half-past three and the afternoon sun
is at its hottest. Now the brain no longer works with such acuteness
and logical precision; more especially does it fail me in trying to
establish the syntax of the difficult Makua language on which I have
ventured, as if I had not enough to do without it. Under the
circumstances it seems advisable to take my temperature, and I do
so, to save trouble, without leaving my seat, and while going on with
my work. On examination, I find it to be 101·48°. My tutors are
abruptly dismissed and my bed set up in the baraza; a few minutes
later I am in it and treating myself internally with hot water and
lemon-juice.
Three hours later, the thermometer marks nearly 104°, and I make
them carry me back into the tent, bed and all, as I am now perspiring
heavily, and exposure to the cold wind just beginning to blow might
mean a fatal chill. I lie still for a little while, and then find, to my
great relief, that the temperature is not rising, but rather falling. This
is about 7.30 p.m. At 8 p.m. I find, to my unbounded astonishment,
that it has fallen below 98·6°, and I feel perfectly well. I read for an
hour or two, and could very well enjoy a smoke, if I had the
wherewithal—Indian cigars being out of the question.
Having no medical training, I am at a loss to account for this state
of things. It is impossible that these transitory attacks of high fever
should be malarial; it seems more probable that they are due to a
kind of sunstroke. On consulting my note-book, I become more and
more inclined to think this is the case, for these attacks regularly
follow extreme fatigue and long exposure to strong sunshine. They at
least have the advantage of being only short interruptions to my
work, as on the following morning I am always quite fresh and fit.
My treasure of a cook is suffering from an enormous hydrocele which
makes it difficult for him to get up, and Moritz is obliged to keep in
the dark on account of his inflamed eyes. Knudsen’s cook, a raw boy
from somewhere in the bush, knows still less of cooking than Omari;
consequently Nils Knudsen himself has been promoted to the vacant
post. Finding that we had come to the end of our supplies, he began
by sending to Chingulungulu for the four sucking-pigs which we had
bought from Matola and temporarily left in his charge; and when
they came up, neatly packed in a large crate, he callously slaughtered
the biggest of them. The first joint we were thoughtless enough to
entrust for roasting to Knudsen’s mshenzi cook, and it was
consequently uneatable; but we made the rest of the animal into a
jelly which we ate with great relish after weeks of underfeeding,
consuming incredible helpings of it at both midday and evening
meals. The only drawback is a certain want of variety in the tinned
vegetables. Dr. Jäger, to whom the Geographical Commission
entrusted the provisioning of the expeditions—mine as well as his
own—because he had more time on his hands than the rest of us,
seems to have laid in a huge stock of Teltow turnips,[46] an article of
food which is all very well for occasional use, but which quickly palls
when set before one every day; and we seem to have no other tins
left. There is no help for it—we must put up with the turnips; but I
am certain that, once I am home again, I shall not touch them for ten
years to come.
Amid all these minor evils, which, after all, go to make up the
genuine flavour of Africa, there is at least one cheering touch:
Knudsen has, with the dexterity of a skilled mechanic, repaired my 9
× 12 cm. camera, at least so far that I can use it with a little care.
How, in the absence of finger-nails, he was able to accomplish such a
ticklish piece of work, having no tool but a clumsy screw-driver for
taking to pieces and putting together again the complicated
mechanism of the instantaneous shutter, is still a mystery to me; but
he did it successfully. The loss of his finger-nails shows him in a light
contrasting curiously enough with the intelligence evinced by the
above operation; though, after all, it is scarcely surprising after his
ten years’ residence in the bush. One day, at Lindi, he had occasion
to wash a dog, which must have been in need of very thorough
cleansing, for the bottle handed to our friend for the purpose had an
extremely strong smell. Having performed his task in the most
conscientious manner, he perceived with some surprise that the dog
did not appear much the better for it, and was further surprised by
finding his own nails ulcerating away in the course of the next few
days. “How was I to know that carbolic acid has to be diluted?” he
mutters indignantly, from time to time, with a troubled gaze at his
mutilated finger-tips.
 Since we came to Newala we have been making excursions in all
directions through the surrounding country, in accordance with old
habit, and also because the akida Sefu did not get together the tribal
elders from whom I wanted information so speedily as he had
promised. There is, however, no harm done, as, even if seen only
from the outside, the country and people are interesting enough.
The Makonde plateau is like a large rectangular table rounded off
at the corners. Measured from the Indian Ocean to Newala, it is
about seventy-five miles long, and between the Rovuma and the
Lukuledi it averages fifty miles in breadth, so that its superficial area
is about two-thirds of that of the kingdom of Saxony. The surface,
however, is not level, but uniformly inclined from its south-western
edge to the ocean. From the upper edge, on which Newala lies, the
eye ranges for many miles east and north-east, without encountering
any obstacle, over the Makonde bush. It is a green sea, from which
here and there thick clouds of smoke rise, to show that it, too, is
inhabited by men who carry on their tillage like so many other
primitive peoples, by cutting down and burning the bush, and
manuring with the ashes. Even in the radiant light of a tropical day
such a fire is a grand sight.
Much less effective is the impression produced just now by the
great western plain as seen from the edge of the plateau. As often as
time permits, I stroll along this edge, sometimes in one direction,
sometimes in another, in the hope of finding the air clear enough to
let me enjoy the view; but I have always been disappointed.
Wherever one looks, clouds of smoke rise from the burning bush,
and the air is full of smoke and vapour. It is a pity, for under more
favourable circumstances the panorama of the whole country up to
the distant Majeje hills must be truly magnificent. It is of little use
taking photographs now, and an outline sketch gives a very poor idea
of the scenery. In one of these excursions I went out of my way to
make a personal attempt on the Makonde bush. The present edge of
the plateau is the result of a far-reaching process of destruction
through erosion and denudation. The Makonde strata are
everywhere cut into by ravines, which, though short, are hundreds of
yards in depth. In consequence of the loose stratification of these
beds, not only are the walls of these ravines nearly vertical, but their
upper end is closed by an equally steep escarpment, so that the
western edge of the Makonde plateau is hemmed in by a series of
deep, basin-like valleys. In order to get from one side of such a ravine
to the other, I cut my way through the bush with a dozen of my men.
It was a very open part, with more grass than scrub, but even so the
short stretch of less than two hundred yards was very hard work; at
the end of it the men’s calicoes were in rags and they themselves
bleeding from hundreds of scratches, while even our strong khaki
suits had not escaped scatheless.

NATIVE PATH THROUGH THE MAKONDE BUSH, NEAR

MAHUTA

I see increasing reason to believe that the view formed some time
back as to the origin of the Makonde bush is the correct one. I have
no doubt that it is not a natural product, but the result of human
occupation. Those parts of the high country where man—as a very
slight amount of practice enables the eye to perceive at once—has not
yet penetrated with axe and hoe, are still occupied by a splendid
timber forest quite able to sustain a comparison with our mixed
forests in Germany. But wherever man has once built his hut or tilled
his field, this horrible bush springs up. Every phase of this process
may be seen in the course of a couple of hours’ walk along the main
road. From the bush to right or left, one hears the sound of the axe—
not from one spot only, but from several directions at once. A few
steps further on, we can see what is taking place. The brush has been
cut down and piled up in heaps to the height of a yard or more,
between which the trunks of the large trees stand up like the last
pillars of a magnificent ruined building. These, too, present a
melancholy spectacle: the destructive Makonde have ringed them—
cut a broad strip of bark all round to ensure their dying off—and also
piled up pyramids of brush round them. Father and son, mother and
son-in-law, are chopping away perseveringly in the background—too
busy, almost, to look round at the white stranger, who usually excites
so much interest. If you pass by the same place a week later, the piles
of brushwood have disappeared and a thick layer of ashes has taken
the place of the green forest. The large trees stretch their
smouldering trunks and branches in dumb accusation to heaven—if
they have not already fallen and been more or less reduced to ashes,
perhaps only showing as a white stripe on the dark ground.
This work of destruction is carried out by the Makonde alike on the
virgin forest and on the bush which has sprung up on sites already
cultivated and deserted. In the second case they are saved the trouble
of burning the large trees, these being entirely absent in the
secondary bush.
After burning this piece of forest ground and loosening it with the
hoe, the native sows his corn and plants his vegetables. All over the
country, he goes in for bed-culture, which requires, and, in fact,
receives, the most careful attention. Weeds are nowhere tolerated in
the south of German East Africa. The crops may fail on the plains,
where droughts are frequent, but never on the plateau with its
abundant rains and heavy dews. Its fortunate inhabitants even have
the satisfaction of seeing the proud Wayao and Wamakua working
for them as labourers, driven by hunger to serve where they were
accustomed to rule.
But the light, sandy soil is soon exhausted, and would yield no
harvest the second year if cultivated twice running. This fact has
been familiar to the native for ages; consequently he provides in
time, and, while his crop is growing, prepares the next plot with axe
and firebrand. Next year he plants this with his various crops and
lets the first piece lie fallow. For a short time it remains waste and
desolate; then nature steps in to repair the destruction wrought by
man; a thousand new growths spring out of the exhausted soil, and
even the old stumps put forth fresh shoots. Next year the new growth
is up to one’s knees, and in a few years more it is that terrible,
impenetrable bush, which maintains its position till the black
occupier of the land has made the round of all the available sites and
come back to his starting point.
The Makonde are, body and soul, so to speak, one with this bush.
According to my Yao informants, indeed, their name means nothing
else but “bush people.” Their own tradition says that they have been
settled up here for a very long time, but to my surprise they laid great
stress on an original immigration. Their old homes were in the
south-east, near Mikindani and the mouth of the Rovuma, whence
their peaceful forefathers were driven by the continual raids of the
Sakalavas from Madagascar and the warlike Shirazis[47] of the coast,
to take refuge on the almost inaccessible plateau. I have studied
African ethnology for twenty years, but the fact that changes of
population in this apparently quiet and peaceable corner of the earth
could have been occasioned by outside enterprises taking place on
the high seas, was completely new to me. It is, no doubt, however,
correct.
The charming tribal legend of the Makonde—besides informing us
of other interesting matters—explains why they have to live in the
thickest of the bush and a long way from the edge of the plateau,
instead of making their permanent homes beside the purling brooks
and springs of the low country.
“The place where the tribe originated is Mahuta, on the southern
side of the plateau towards the Rovuma, where of old time there was
nothing but thick bush. Out of this bush came a man who never
washed himself or shaved his head, and who ate and drank but little.
He went out and made a human figure from the wood of a tree
growing in the open country, which he took home to his abode in the
bush and there set it upright. In the night this image came to life and
was a woman. The man and woman went down together to the
Rovuma to wash themselves. Here the woman gave birth to a still-
born child. They left that place and passed over the high land into the
valley of the Mbemkuru, where the woman had another child, which
was also born dead. Then they returned to the high bush country of
Mahuta, where the third child was born, which lived and grew up. In
course of time, the couple had many more children, and called
themselves Wamatanda. These were the ancestral stock of the
Makonde, also called Wamakonde,[48] i.e., aborigines. Their
forefather, the man from the bush, gave his children the command to
bury their dead upright, in memory of the mother of their race who
was cut out of wood and awoke to life when standing upright. He also
warned them against settling in the valleys and near large streams,
for sickness and death dwelt there. They were to make it a rule to
have their huts at least an hour’s walk from the nearest watering-
place; then their children would thrive and escape illness.”
The explanation of the name Makonde given by my informants is
somewhat different from that contained in the above legend, which I
extract from a little book (small, but packed with information), by
Pater Adams, entitled Lindi und sein Hinterland. Otherwise, my
results agree exactly with the statements of the legend. Washing?
Hapana—there is no such thing. Why should they do so? As it is, the
supply of water scarcely suffices for cooking and drinking; other
people do not wash, so why should the Makonde distinguish himself
by such needless eccentricity? As for shaving the head, the short,
woolly crop scarcely needs it,[49] so the second ancestral precept is
likewise easy enough to follow. Beyond this, however, there is
nothing ridiculous in the ancestor’s advice. I have obtained from
various local artists a fairly large number of figures carved in wood,
ranging from fifteen to twenty-three inches in height, and
representing women belonging to the great group of the Mavia,
Makonde, and Matambwe tribes. The carving is remarkably well
done and renders the female type with great accuracy, especially the
keloid ornamentation, to be described later on. As to the object and
meaning of their works the sculptors either could or (more probably)
would tell me nothing, and I was forced to content myself with the
scanty information vouchsafed by one man, who said that the figures
were merely intended to represent the nembo—the artificial
deformations of pelele, ear-discs, and keloids. The legend recorded
by Pater Adams places these figures in a new light. They must surely
be more than mere dolls; and we may even venture to assume that
they are—though the majority of present-day Makonde are probably
unaware of the fact—representations of the tribal ancestress.
 The references in the legend to the descent from Mahuta to the
Rovuma, and to a journey across the highlands into the Mbekuru
valley, undoubtedly indicate the previous history of the tribe, the
travels of the ancestral pair typifying the migrations of their
descendants. The descent to the neighbouring Rovuma valley, with
its extraordinary fertility and great abundance of game, is intelligible
at a glance—but the crossing of the Lukuledi depression, the ascent
to the Rondo Plateau and the descent to the Mbemkuru, also lie
within the bounds of probability, for all these districts have exactly
the same character as the extreme south. Now, however, comes a
point of especial interest for our bacteriological age. The primitive
Makonde did not enjoy their lives in the marshy river-valleys.
Disease raged among them, and many died. It was only after they
had returned to their original home near Mahuta, that the health
conditions of these people improved. We are very apt to think of the
African as a stupid person whose ignorance of nature is only equalled
by his fear of it, and who looks on all mishaps as caused by evil
spirits and malignant natural powers. It is much more correct to
assume in this case that the people very early learnt to distinguish
districts infested with malaria from those where it is absent.
This knowledge is crystallized in the
ancestral warning against settling in the
valleys and near the great waters, the
dwelling-places of disease and death. At the
same time, for security against the hostile
Mavia south of the Rovuma, it was enacted
that every settlement must be not less than a
certain distance from the southern edge of the
plateau. Such in fact is their mode of life at the
present day. It is not such a bad one, and
certainly they are both safer and more
comfortable than the Makua, the recent
intruders from the south, who have made USUAL METHOD OF
good their footing on the western edge of the CLOSING HUT-DOOR
plateau, extending over a fairly wide belt of
country. Neither Makua nor Makonde show in their dwellings
anything of the size and comeliness of the Yao houses in the plain,
especially at Masasi, Chingulungulu and Zuza’s. Jumbe Chauro, a
Makonde hamlet not far from Newala, on the road to Mahuta, is the
most important settlement of the tribe I have yet seen, and has fairly
spacious huts. But how slovenly is their construction compared with
the palatial residences of the elephant-hunters living in the plain.
The roofs are still more untidy than in the general run of huts during
the dry season, the walls show here and there the scanty beginnings
or the lamentable remains of the mud plastering, and the interior is a
veritable dog-kennel; dirt, dust and disorder everywhere. A few huts
only show any attempt at division into rooms, and this consists
merely of very roughly-made bamboo partitions. In one point alone
have I noticed any indication of progress—in the method of fastening
the door. Houses all over the south are secured in a simple but
ingenious manner. The door consists of a set of stout pieces of wood
or bamboo, tied with bark-string to two cross-pieces, and moving in
two grooves round one of the door-posts, so as to open inwards. If
the owner wishes to leave home, he takes two logs as thick as a man’s
upper arm and about a yard long. One of these is placed obliquely
against the middle of the door from the inside, so as to form an angle
of from 60° to 75° with the ground. He then places the second piece
horizontally across the first, pressing it downward with all his might.
It is kept in place by two strong posts planted in the ground a few
inches inside the door. This fastening is absolutely safe, but of course
cannot be applied to both doors at once, otherwise how could the
owner leave or enter his house? I have not yet succeeded in finding
out how the back door is fastened.

MAKONDE LOCK AND KEY AT JUMBE CHAURO

 This is the general way of closing a house. The Makonde at Jumbe
Chauro, however, have a much more complicated, solid and original
one. Here, too, the door is as already described, except that there is
only one post on the inside, standing by itself about six inches from
one side of the doorway. Opposite this post is a hole in the wall just
large enough to admit a man’s arm. The door is closed inside by a
large wooden bolt passing through a hole in this post and pressing
with its free end against the door. The other end has three holes into
which fit three pegs running in vertical grooves inside the post. The
door is opened with a wooden key about a foot long, somewhat
curved and sloped off at the butt; the other end has three pegs
corresponding to the holes, in the bolt, so that, when it is thrust
through the hole in the wall and inserted into the rectangular
opening in the post, the pegs can be lifted and the bolt drawn out.[50]

MODE OF INSERTING THE KEY

With no small pride first one householder and then a second

showed me on the spot the action of this greatest invention of the
Makonde Highlands. To both with an admiring exclamation of
“Vizuri sana!” (“Very fine!”). I expressed the wish to take back these
marvels with me to Ulaya, to show the Wazungu what clever fellows
the Makonde are. Scarcely five minutes after my return to camp at
Newala, the two men came up sweating under the weight of two
heavy logs which they laid down at my feet, handing over at the same
time the keys of the fallen fortress. Arguing, logically enough, that if
the key was wanted, the lock would be wanted with it, they had taken
their axes and chopped down the posts—as it never occurred to them
to dig them out of the ground and so bring them intact. Thus I have
two badly damaged specimens, and the owners, instead of praise,
come in for a blowing-up.
The Makua huts in the environs of Newala are especially
miserable; their more than slovenly construction reminds one of the
temporary erections of the Makua at Hatia’s, though the people here
have not been concerned in a war. It must therefore be due to
congenital idleness, or else to the absence of a powerful chief. Even
the baraza at Mlipa’s, a short hour’s walk south-east of Newala,
shares in this general neglect. While public buildings in this country
are usually looked after more or less carefully, this is in evident
danger of being blown over by the first strong easterly gale. The only
attractive object in this whole district is the grave of the late chief
Mlipa. I visited it in the morning, while the sun was still trying with
partial success to break through the rolling mists, and the circular
grove of tall euphorbias, which, with a broken pot, is all that marks
the old king’s resting-place, impressed one with a touch of pathos.
Even my very materially-minded carriers seemed to feel something
of the sort, for instead of their usual ribald songs, they chanted
solemnly, as we marched on through the dense green of the Makonde
bush:—
 “We shall arrive with the great master; we stand in a row and have
no fear about getting our food and our money from the Serkali (the
Government). We are not afraid; we are going along with the great
master, the lion; we are going down to the coast and back.”
With regard to the characteristic features of the various tribes here
on the western edge of the plateau, I can arrive at no other
conclusion than the one already come to in the plain, viz., that it is
impossible for anyone but a trained anthropologist to assign any
given individual at once to his proper tribe. In fact, I think that even
an anthropological specialist, after the most careful examination,
might find it a difficult task to decide. The whole congeries of peoples
collected in the region bounded on the west by the great Central
African rift, Tanganyika and Nyasa, and on the east by the Indian
Ocean, are closely related to each other—some of their languages are
only distinguished from one another as dialects of the same speech,
and no doubt all the tribes present the same shape of skull and
structure of skeleton. Thus, surely, there can be no very striking
differences in outward appearance.
 Even did such exist, I should have no time
to concern myself with them, for day after day,
I have to see or hear, as the case may be—in
any case to grasp and record—an
extraordinary number of ethnographic
phenomena. I am almost disposed to think it
fortunate that some departments of inquiry, at
least, are barred by external circumstances.
Chief among these is the subject of iron-
working. We are apt to think of Africa as a
country where iron ore is everywhere, so to
speak, to be picked up by the roadside, and
where it would be quite surprising if the
inhabitants had not learnt to smelt the
material ready to their hand. In fact, the
knowledge of this art ranges all over the
continent, from the Kabyles in the north to the
Kafirs in the south. Here between the Rovuma
and the Lukuledi the conditions are not so
favourable. According to the statements of the
Makonde, neither ironstone nor any other
form of iron ore is known to them. They have
not therefore advanced to the art of smelting
the metal, but have hitherto bought all their
THE ANCESTRESS OF
THE MAKONDE
iron implements from neighbouring tribes.
Even in the plain the inhabitants are not much
better off. Only one man now living is said to
understand the art of smelting iron. This old fundi lives close to
Huwe, that isolated, steep-sided block of granite which rises out of
the green solitude between Masasi and Chingulungulu, and whose
jagged and splintered top meets the traveller’s eye everywhere. While
still at Masasi I wished to see this man at work, but was told that,
frightened by the rising, he had retired across the Rovuma, though
he would soon return. All subsequent inquiries as to whether the
fundi had come back met with the genuine African answer, “Bado”
(“Not yet”).
 BRAZIER

Some consolation was afforded me by a brassfounder, whom I

came across in the bush near Akundonde’s. This man is the favourite
of women, and therefore no doubt of the gods; he welds the glittering
brass rods purchased at the coast into those massive, heavy rings
which, on the wrists and ankles of the local fair ones, continually give
me fresh food for admiration. Like every decent master-craftsman he
had all his tools with him, consisting of a pair of bellows, three
crucibles and a hammer—nothing more, apparently. He was quite
willing to show his skill, and in a twinkling had fixed his bellows on
the ground. They are simply two goat-skins, taken off whole, the four
legs being closed by knots, while the upper opening, intended to
admit the air, is kept stretched by two pieces of wood. At the lower
end of the skin a smaller opening is left into which a wooden tube is
stuck. The fundi has quickly borrowed a heap of wood-embers from
the nearest hut; he then fixes the free ends of the two tubes into an
earthen pipe, and clamps them to the ground by means of a bent
piece of wood. Now he fills one of his small clay crucibles, the dross
on which shows that they have been long in use, with the yellow
material, places it in the midst of the embers, which, at present are
only faintly glimmering, and begins his work. In quick alternation
the smith’s two hands move up and down with the open ends of the
bellows; as he raises his hand he holds the slit wide open, so as to let
the air enter the skin bag unhindered. In pressing it down he closes
the bag, and the air puffs through the bamboo tube and clay pipe into
the fire, which quickly burns up. The smith, however, does not keep
on with this work, but beckons to another man, who relieves him at
the bellows, while he takes some more tools out of a large skin pouch
carried on his back. I look on in wonder as, with a smooth round
stick about the thickness of a finger, he bores a few vertical holes into
the clean sand of the soil. This should not be difficult, yet the man
seems to be taking great pains over it. Then he fastens down to the
ground, with a couple of wooden clamps, a neat little trough made by
splitting a joint of bamboo in half, so that the ends are closed by the
two knots. At last the yellow metal has attained the right consistency,
and the fundi lifts the crucible from the fire by means of two sticks
split at the end to serve as tongs. A short swift turn to the left—a
tilting of the crucible—and the molten brass, hissing and giving forth
clouds of smoke, flows first into the bamboo mould and then into the
holes in the ground.
The technique of this backwoods craftsman may not be very far
advanced, but it cannot be denied that he knows how to obtain an
adequate result by the simplest means. The ladies of highest rank in
this country—that is to say, those who can afford it, wear two kinds
of these massive brass rings, one cylindrical, the other semicircular
in section. The latter are cast in the most ingenious way in the
bamboo mould, the former in the circular hole in the sand. It is quite
a simple matter for the fundi to fit these bars to the limbs of his fair
customers; with a few light strokes of his hammer he bends the
pliable brass round arm or ankle without further inconvenience to
the wearer.
SHAPING THE POT

SMOOTHING WITH MAIZE-COB

CUTTING THE EDGE

 FINISHING THE BOTTOM

LAST SMOOTHING BEFORE

BURNING

FIRING THE BRUSH-PILE

 LIGHTING THE FARTHER SIDE OF
THE PILE

TURNING THE RED-HOT VESSEL

NYASA WOMAN MAKING POTS AT MASASI

Pottery is an art which must always and everywhere excite the
interest of the student, just because it is so intimately connected with
the development of human culture, and because its relics are one of
the principal factors in the reconstruction of our own condition in
prehistoric times. I shall always remember with pleasure the two or
three afternoons at Masasi when Salim Matola’s mother, a slightly-
built, graceful, pleasant-looking woman, explained to me with
touching patience, by means of concrete illustrations, the ceramic art
of her people. The only implements for this primitive process were a
lump of clay in her left hand, and in the right a calabash containing
the following valuables: the fragment of a maize-cob stripped of all
its grains, a smooth, oval pebble, about the size of a pigeon’s egg, a
few chips of gourd-shell, a bamboo splinter about the length of one’s
hand, a small shell, and a bunch of some herb resembling spinach.
 Nothing more. The woman scraped with the
shell a round, shallow hole in the soft, fine
sand of the soil, and, when an active young
girl had filled the calabash with water for her,
she began to knead the clay. As if by magic it
gradually assumed the shape of a rough but
already well-shaped vessel, which only wanted
a little touching up with the instruments
before mentioned. I looked out with the
MAKUA WOMAN closest attention for any indication of the use
MAKING A POT. of the potter’s wheel, in however rudimentary
SHOWS THE a form, but no—hapana (there is none). The
BEGINNINGS OF THE embryo pot stood firmly in its little
POTTER’S WHEEL
depression, and the woman walked round it in
a stooping posture, whether she was removing
small stones or similar foreign bodies with the maize-cob, smoothing
the inner or outer surface with the splinter of bamboo, or later, after
letting it dry for a day, pricking in the ornamentation with a pointed
bit of gourd-shell, or working out the bottom, or cutting the edge
with a sharp bamboo knife, or giving the last touches to the finished
vessel. This occupation of the women is infinitely toilsome, but it is
without doubt an accurate reproduction of the process in use among
our ancestors of the Neolithic and Bronze ages.
There is no doubt that the invention of pottery, an item in human
progress whose importance cannot be over-estimated, is due to
women. Rough, coarse and unfeeling, the men of the horde range
over the countryside. When the united cunning of the hunters has
succeeded in killing the game; not one of them thinks of carrying
home the spoil. A bright fire, kindled by a vigorous wielding of the
drill, is crackling beside them; the animal has been cleaned and cut
up secundum artem, and, after a slight singeing, will soon disappear
under their sharp teeth; no one all this time giving a single thought
to wife or child.
To what shifts, on the other hand, the primitive wife, and still more
the primitive mother, was put! Not even prehistoric stomachs could
endure an unvarying diet of raw food. Something or other suggested
the beneficial effect of hot water on the majority of approved but
indigestible dishes. Perhaps a neighbour had tried holding the hard
roots or tubers over the fire in a calabash filled with water—or maybe
an ostrich-egg-shell, or a hastily improvised vessel of bark. They
became much softer and more palatable than they had previously
been; but, unfortunately, the vessel could not stand the fire and got
charred on the outside. That can be remedied, thought our
ancestress, and plastered a layer of wet clay round a similar vessel.
This is an improvement; the cooking utensil remains uninjured, but
the heat of the fire has shrunk it, so that it is loose in its shell. The
next step is to detach it, so, with a firm grip and a jerk, shell and
kernel are separated, and pottery is invented. Perhaps, however, the
discovery which led to an intelligent use of the burnt-clay shell, was
made in a slightly different way. Ostrich-eggs and calabashes are not
to be found in every part of the world, but everywhere mankind has
arrived at the art of making baskets out of pliant materials, such as
bark, bast, strips of palm-leaf, supple twigs, etc. Our inventor has no
water-tight vessel provided by nature. “Never mind, let us line the
basket with clay.” This answers the purpose, but alas! the basket gets
burnt over the blazing fire, the woman watches the process of
cooking with increasing uneasiness, fearing a leak, but no leak
appears. The food, done to a turn, is eaten with peculiar relish; and
the cooking-vessel is examined, half in curiosity, half in satisfaction
at the result. The plastic clay is now hard as stone, and at the same
time looks exceedingly well, for the neat plaiting of the burnt basket
is traced all over it in a pretty pattern. Thus, simultaneously with
pottery, its ornamentation was invented.
Primitive woman has another claim to respect. It was the man,
roving abroad, who invented the art of producing fire at will, but the
woman, unable to imitate him in this, has been a Vestal from the
earliest times. Nothing gives so much trouble as the keeping alight of
the smouldering brand, and, above all, when all the men are absent
from the camp. Heavy rain-clouds gather, already the first large
drops are falling, the first gusts of the storm rage over the plain. The
little flame, a greater anxiety to the woman than her own children,
flickers unsteadily in the blast. What is to be done? A sudden thought
occurs to her, and in an instant she has constructed a primitive hut
out of strips of bark, to protect the flame against rain and wind.
This, or something very like it, was the way in which the principle
of the house was discovered; and even the most hardened misogynist
cannot fairly refuse a woman the credit of it. The protection of the
hearth-fire from the weather is the germ from which the human
dwelling was evolved. Men had little, if any share, in this forward
step, and that only at a late stage. Even at the present day, the
plastering of the housewall with clay and the manufacture of pottery
are exclusively the women’s business. These are two very significant
survivals. Our European kitchen-garden, too, is originally a woman’s
invention, and the hoe, the primitive instrument of agriculture, is,
characteristically enough, still used in this department. But the
noblest achievement which we owe to the other sex is unquestionably
the art of cookery. Roasting alone—the oldest process—is one for
which men took the hint (a very obvious one) from nature. It must
have been suggested by the scorched carcase of some animal
overtaken by the destructive forest-fires. But boiling—the process of
improving organic substances by the help of water heated to boiling-
point—is a much later discovery. It is so recent that it has not even
yet penetrated to all parts of the world. The Polynesians understand
how to steam food, that is, to cook it, neatly wrapped in leaves, in a
hole in the earth between hot stones, the air being excluded, and
(sometimes) a few drops of water sprinkled on the stones; but they
do not understand boiling.
To come back from this digression, we find that the slender Nyasa
woman has, after once more carefully examining the finished pot,
put it aside in the shade to dry. On the following day she sends me
word by her son, Salim Matola, who is always on hand, that she is
going to do the burning, and, on coming out of my house, I find her
already hard at work. She has spread on the ground a layer of very
dry sticks, about as thick as one’s thumb, has laid the pot (now of a
yellowish-grey colour) on them, and is piling brushwood round it.
My faithful Pesa mbili, the mnyampara, who has been standing by,
most obligingly, with a lighted stick, now hands it to her. Both of
them, blowing steadily, light the pile on the lee side, and, when the
flame begins to catch, on the weather side also. Soon the whole is in a
blaze, but the dry fuel is quickly consumed and the fire dies down, so
that we see the red-hot vessel rising from the ashes. The woman
turns it continually with a long stick, sometimes one way and
sometimes another, so that it may be evenly heated all over. In
twenty minutes she rolls it out of the ash-heap, takes up the bundle
of spinach, which has been lying for two days in a jar of water, and
sprinkles the red-hot clay with it. The places where the drops fall are
marked by black spots on the uniform reddish-brown surface. With a
sigh of relief, and with visible satisfaction, the woman rises to an
erect position; she is standing just in a line between me and the fire,
from which a cloud of smoke is just rising: I press the ball of my
camera, the shutter clicks—the apotheosis is achieved! Like a
priestess, representative of her inventive sex, the graceful woman
stands: at her feet the hearth-fire she has given us beside her the
invention she has devised for us, in the background the home she has
built for us.
At Newala, also, I have had the manufacture of pottery carried on
in my presence. Technically the process is better than that already
described, for here we find the beginnings of the potter’s wheel,
which does not seem to exist in the plains; at least I have seen
nothing of the sort. The artist, a frightfully stupid Makua woman, did
not make a depression in the ground to receive the pot she was about
to shape, but used instead a large potsherd. Otherwise, she went to
work in much the same way as Salim’s mother, except that she saved
herself the trouble of walking round and round her work by squatting
at her ease and letting the pot and potsherd rotate round her; this is
surely the first step towards a machine. But it does not follow that
the pot was improved by the process. It is true that it was beautifully
rounded and presented a very creditable appearance when finished,
but the numerous large and small vessels which I have seen, and, in
part, collected, in the “less advanced” districts, are no less so. We
moderns imagine that instruments of precision are necessary to
produce excellent results. Go to the prehistoric collections of our
museums and look at the pots, urns and bowls of our ancestors in the
dim ages of the past, and you will at once perceive your error.
MAKING LONGITUDINAL CUT IN
BARK

DRAWING THE BARK OFF THE LOG

REMOVING THE OUTER BARK

 BEATING THE BARK

WORKING THE BARK-CLOTH AFTER BEATING, TO MAKE IT

SOFT

MANUFACTURE OF BARK-CLOTH AT NEWALA

To-day, nearly the whole population of German East Africa is
clothed in imported calico. This was not always the case; even now in
some parts of the north dressed skins are still the prevailing wear,
and in the north-western districts—east and north of Lake
Tanganyika—lies a zone where bark-cloth has not yet been
superseded. Probably not many generations have passed since such
bark fabrics and kilts of skins were the only clothing even in the
south. Even to-day, large quantities of this bright-red or drab
material are still to be found; but if we wish to see it, we must look in
the granaries and on the drying stages inside the native huts, where
it serves less ambitious uses as wrappings for those seeds and fruits
which require to be packed with special care. The salt produced at
Masasi, too, is packed for transport to a distance in large sheets of
bark-cloth. Wherever I found it in any degree possible, I studied the
process of making this cloth. The native requisitioned for the
purpose arrived, carrying a log between two and three yards long and
as thick as his thigh, and nothing else except a curiously-shaped
mallet and the usual long, sharp and pointed knife which all men and
boys wear in a belt at their backs without a sheath—horribile dictu!
[51]
Silently he squats down before me, and with two rapid cuts has
drawn a couple of circles round the log some two yards apart, and
slits the bark lengthwise between them with the point of his knife.
With evident care, he then scrapes off the outer rind all round the
log, so that in a quarter of an hour the inner red layer of the bark
shows up brightly-coloured between the two untouched ends. With
some trouble and much caution, he now loosens the bark at one end,
and opens the cylinder. He then stands up, takes hold of the free
edge with both hands, and turning it inside out, slowly but steadily
pulls it off in one piece. Now comes the troublesome work of
scraping all superfluous particles of outer bark from the outside of
the long, narrow piece of material, while the inner side is carefully
scrutinised for defective spots. At last it is ready for beating. Having
signalled to a friend, who immediately places a bowl of water beside
him, the artificer damps his sheet of bark all over, seizes his mallet,
lays one end of the stuff on the smoothest spot of the log, and
hammers away slowly but continuously. “Very simple!” I think to
myself. “Why, I could do that, too!”—but I am forced to change my
opinions a little later on; for the beating is quite an art, if the fabric is
not to be beaten to pieces. To prevent the breaking of the fibres, the
stuff is several times folded across, so as to interpose several
thicknesses between the mallet and the block. At last the required
state is reached, and the fundi seizes the sheet, still folded, by both
ends, and wrings it out, or calls an assistant to take one end while he
holds the other. The cloth produced in this way is not nearly so fine
and uniform in texture as the famous Uganda bark-cloth, but it is
quite soft, and, above all, cheap.
Now, too, I examine the mallet. My craftsman has been using the
simpler but better form of this implement, a conical block of some
hard wood, its base—the striking surface—being scored across and
across with more or less deeply-cut grooves, and the handle stuck
into a hole in the middle. The other and earlier form of mallet is
shaped in the same way, but the head is fastened by an ingenious
network of bark strips into the split bamboo serving as a handle. The
observation so often made, that ancient customs persist longest in
connection with religious ceremonies and in the life of children, here
finds confirmation. As we shall soon see, bark-cloth is still worn
during the unyago,[52] having been prepared with special solemn
ceremonies; and many a mother, if she has no other garment handy,
will still put her little one into a kilt of bark-cloth, which, after all,
looks better, besides being more in keeping with its African
surroundings, than the ridiculous bit of print from Ulaya.
MAKUA WOMEN