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 Let’s Code It!
2022–2023 CODE EDITION

ISTUDY
ISTUDY
 Let’s Code It!
2022–2023 CODE EDITION

Shelley C. Safian, PhD, RHIA

MAOM/HSM/HI, CCS-P, COC, CPC-I, HCISPP,
AHIMA-Approved ICD-10-CM/PCS Trainer

Mary A. Johnson, MBA-HM-HI, CPC

Central Carolina Technical College

ISTUDY
 Rev. Confirming
Revised
First Pages

LET’S CODE IT!

Published by McGraw Hill LLC, 1325 Avenue of the Americas, New York, NY 10019. Copyright
©2023 by McGraw Hill LLC. All rights reserved. Printed in the United States of America. No part
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ISTUDY saf5080X_fm_ise.indd i 02/15/22 11:21 AM

 ABOUT THE AUTHORS

Shelley C. Safian
Shelley Safian has been teaching medical coding and health information management
for more than 20 years, at both on-ground and online campuses. In addition to her regu-
lar teaching responsibilities at University of Maryland Global Campus and Colorado
State University-Global, she regularly presents webinars/seminars and writes about cod-
ing for the Just Coding newsletter. Safian is the course author for multiple distance edu-
cation courses on various coding topics, including ICD-10-CM, ICD-10-PCS, CPT, and
HCPCS Level II coding.
Safian is a Registered Health Information Administrator (RHIA) and a Certified
Coding Specialist–Physician-based (CCS-P) from the American Health Information
Management Association and a Certified Outpatient Coder (COC) and a Certified
Professional Coding Instructor (CPC-I) from the American Academy of Professional Courtesy of Shelley C. Safian
Coders. She is also a Health Care Information Security and Privacy Practitioner
(HCISPP) and a Certified HIPAA Administrator (CHA) and has earned the designa-
tion of AHIMA-Approved ICD-10-CM/PCS Trainer.
Safian completed her Graduate Certificate in Health Care Management at Keller
Graduate School of Management. The University of Phoenix awarded her the Master
of Arts/Organizational Management degree and a Graduate Certificate in Health Infor-
matics. She earned her Ph.D. in Health Care Administration with a focus in Health
Information Management.

Mary A. Johnson
Mary Johnson is the Medical Record Coding Program Director at Central Carolina
Technical College in Sumter, South Carolina. She is also an adjunct faculty member for
Southern New Hampshire University and Bryan University. Her background includes
corporate training using both on-campus and online platforms. Johnson has over a dec-
ade of teaching experience in medical coding and Health Information Management and
specializes in the design and implementation of customized coding curricula. Johnson
received her Bachelor of Arts dual degree in Business Administration and Marketing
from Columbia College, and earned a Masters of Business Administration with a dual
focus in Healthcare Management and Health Informatics from New England College.
Johnson is a Certified Professional Coder (CPC) credentialed through the American
Academy of Professional Coders (AAPC).

Dedications
—This book is dedicated to all of those who have come into my life sharing encourage-
Courtesy of Jimmy Wood and Mary A.
ment and opportunity to pursue work that I love; for the benefit of all of my students: Johnson
past, present, and future. —Shelley

—This book is dedicated in loving memory of my parents, Dr. and Mrs. Clarence J. Johnson Sr.,
for their love and support. Also, to those students with whom I have had the privilege
to work and to those students who are beginning their journey into the world of medical
­coding. —Mary

ISTUDY
ISTUDY
 BRIEF CONTENTS

Guided Tour xvi

Preface xxi

PART I: Medical Coding Fundamentals 1

1 Introduction to the Languages of Coding 2
2 Abstracting Clinical Documentation 22
3 The Coding Process 39

PART II: Reporting Diagnoses 53

4 Introduction to ICD-10-CM 54
5 Coding Infectious Diseases 101
6 Coding Neoplasms 147
7 Coding Conditions of the Blood and Immunological Systems 175
8 Coding Endocrine Conditions 200
9 Coding Mental, Behavioral, and Neurologic Disorders 230
10 Coding Dysfunction of the Optical and Auditory Systems 265
11 Coding Cardiovascular Conditions 296
12 Coding Respiratory Conditions 332
13 Coding Digestive System Conditions 359
14 Coding Integumentary Conditions 386
15 Coding Muscular and Skeletal Conditions 410
16 Coding Injury, Poisoning, and External Causes 433
17 Coding Genitourinary, Gynecology, Obstetrics, Congenital, and Pediatrics Conditions 474
18 Factors Influencing Health Status (Z Codes) 523
19 Inpatient (Hospital) Diagnosis Coding 545
20 Diagnostic Coding Capstone 572

PART III: Reporting Physician Services and Outpatient

Procedures 581
21 Introduction to CPT 582
22 CPT and HCPCS Level II Modifiers 606
23 CPT Evaluation and Management Coding 645
24 CPT Anesthesia Section 695

ISTUDY
 25 CPT Surgery Section 721
26 CPT Radiology Section 801
27 CPT Pathology & Lab Section 832
28 CPT Medicine Section 862
29 Physicians’ Services Capstone 900

PART IV: DMEPOS & Transportation 909

30 HCPCS Level II 910
31 DMEPOS and Transportation Capstone 946

PART V: Inpatient (Hospital) Reporting 953

32 Introduction to ICD-10-PCS 954
33 ICD-10-PCS Medical and Surgical Section 979
34 Obstetrics Section 1019
35 Placement through Chiropractic Sections 1044
36 Imaging, Nuclear Medicine, and Radiation Therapy Sections 1091
37 Physical Rehabilitation and Diagnostic Audiology through New Technology
Sections 1115
38 Inpatient Coding Capstone 1146

PART VI: Reimbursement, Legal, and Ethical Issues 1161

39 Reimbursement 1162
40 Introduction to Health Care Law and Ethics 1191

Appendix A-1
Glossary G-1
Index I-1

viii BRIEF CONTENTS

ISTUDY
 CONTENTS

Guided Tour xvi PART II: Reporting Diagnoses 53

Preface xxi
4 INTRODUCTION TO ICD-10-CM 54
PART I: Medical Coding 4.1 Introduction and Official Conventions 54
Fundamentals 1 4.2 ICD-10-CM Official Guidelines for
1 INTRODUCTION TO THE LANGUAGES OF Coding and Reporting 63
CODING 2 4.3 The Alphabetic Index and Ancillaries 72
1.1 The Purpose of Coding 2 4.4 The Tabular List 78
1.2 Diagnosis Coding 3 4.5 Which Conditions to Code 84
1.3 Procedure Coding 9 4.6 Putting It All Together: ICD-10-CM
1.4 Equipment and Supplies 16 Basics 88
Chapter Summary and Review 19 Chapter Summary and Review 91

2 ABSTRACTING CLINICAL DOCUMENTATION 22 5 CODING INFECTIOUS DISEASES 101

2.1 For Whom You Are Reporting 22 5.1 Infectious and Communicable
2.2 The Process of Abstracting 23 Diseases 101
2.3 Deconstructing Diagnostic 5.2 Bacterial Infections 104
Statements 25 5.3 Viral Infections 109
2.4 Identifying Manifestations, 5.4 Parasitic and Fungal Infections 117
Co-morbidities, and Sequelae 28 5.5 Infections Caused by Several
2.5 Reporting External Causes 30 Pathogens 120
2.6 Deconstructing Procedural 5.6 Immunodeficiency Conditions 123
Statements 31 5.7 Septicemia and Other Blood Infections 129
2.7 How to Query 34 5.8 Antimicrobial Resistance 135
Chapter Summary and Review 35 Chapter Summary and Review 139

3 THE CODING PROCESS 39 6 CODING NEOPLASMS 147

3.1 The Coding Process Overview 39 6.1 Screening and Diagnosis 147
3.2 The Alphabetic Indexes 40 6.2 Abstracting the Details about
3.3 The Tabular List, Main Section, Neoplasms 151
Tables, and Alphanumeric 6.3 Reporting the Neoplastic Diagnosis 153
Section 43 6.4 Neoplasm Chapter Notes 158
3.4 The Official Guidelines 45 6.5 Admissions Related to Neoplastic
3.5 Confirming Medical Necessity 47 Treatments 162
Chapter Summary and Review 49 Chapter Summary and Review 166

ISTUDY
 7 CODING CONDITIONS OF THE BLOOD AND
IMMUNOLOGICAL SYSTEMS 175
7.1 Reporting Blood Conditions 175
7.2 Coagulation Defects and Other
­Hemorrhagic Conditions 180
7.3 Conditions Related to Blood Types
and the Rh Factor 184
7.4 Disorders of White Blood Cells
and Blood-Forming Organs 187
7.5 Disorders Involving the Immune
System 190
Chapter Summary and Review 192
8 CODING ENDOCRINE CONDITIONS 200
8.1 Disorders of the Thyroid Gland 200
8.2 Diabetes Mellitus 205
8.3 Diabetes-Related Conditions 210
8.4 Other Endocrine Gland Disorders 212
8.5 Nutritional Deficiencies
and Weight Factors 214
8.6 Metabolic Disorders 218
Chapter Summary and Review 220
9 CODING MENTAL, BEHAVIORAL, AND
NEUROLOGIC DISORDERS 230
9.1 Conditions That Affect Mental
Health 230
9.2 Mood (Affective) and Nonmood
­(Psychotic) Disorders 238
9.3 Anxiety, Dissociative, Stress-Related,
Somatoform, and Other Nonpsychotic
Mental Disorders 243
9.4 Physiological Conditions Affecting the
Central Nervous System 246
x CONTENTS
ISTUDY
9.5 Physiological Conditions Affecting
the Peripheral Nervous System 251
9.6 Pain Management 253
Chapter Summary and Review 257
10 CODING DYSFUNCTION OF THE OPTICAL AND
AUDITORY SYSTEMS 265
10.1 Diseases of the External Optical
System 265
10.2 Diseases of the Internal Optical System 269
10.3 Other Conditions Affecting the Eyes 275
10.4 Dysfunctions of the Auditory System 280
10.5 Causes, Signs, and Symptoms of Hearing
Loss 282
Chapter Summary and Review 286
11 CODING CARDIOVASCULAR CONDITIONS 296
11.1 Heart Conditions 296
11.2 Cardiovascular Conditions 303
11.3 Hypertension 307
11.4 Manifestations of Hypertension 313
11.5 CVA and Cerebral Infarction 318
11.6 Sequelae of Cerebrovascular Disease 322
Chapter Summary and Review 323
12 CODING RESPIRATORY CONDITIONS 332
12.1 Underlying Causes of Respiratory
Disease 332
12.2 Disorders of the Respiratory System 336
12.3 Pneumonia and Influenza 339
12.4 Chronic Respiratory Disorders 343
12.5 Reporting Tobacco Involvement 346
12.6 Respiratory Conditions Requiring ­External
Cause Codes 348
Chapter Summary and Review 350
 13 CODING DIGESTIVE SYSTEM
CONDITIONS 359
13.1 Diseases of Oral Cavity and Salivary
Glands 359
13.2 Conditions of the Esophagus and
Stomach 363
13.3 Conditions Affecting the
Intestines 367
13.4 Dysfunction of the Digestive Accessory
Organs and Malabsorption 373
13.5 Reporting the Involvement of Alcohol in
Digestive Disorders 377
Chapter Summary and Review 378
14 CODING INTEGUMENTARY
CONDITIONS 386
14.1 Disorders of the Skin 386
14.2 Disorders of the Nails, Hair, Glands, and
Sensory Nerves 391
14.3 Lesions 397
14.4 Prevention and Screenings 400
Chapter Summary and Review 401
15 CODING MUSCULAR AND SKELETAL
CONDITIONS 410
15.1 Arthropathies 410
15.2 Dorsopathies and Spondylopathies
(Conditions Affecting the Joints of the
Spine) 415
15.3 Soft Tissue Disorders 419
15.4 Musculoskeletal Disorders from Other
Body Systems 422
15.5 Pathological Fractures 423
Chapter Summary and Review 425
ISTUDY
16 CODING INJURY, POISONING, AND EXTERNAL
CAUSES 433
16.1 Reporting External Causes of
Injuries 433
16.2 Traumatic Injuries 436
16.3 Using Seventh Characters to Report
Status of Care 443
16.4 Using the Table of Drugs and
Chemicals 444
16.5 Adverse Effects, Poisoning, Underdosing,
and Toxic Effects 448
16.6 Reporting Burns 454
16.7 Abuse, Neglect, and Maltreatment 461
16.8 Complications of Care 462
Chapter Summary and Review 464
17 CODING GENITOURINARY, GYNECOLOGY,
OBSTETRICS, CONGENITAL, AND PEDIATRICS
CONDITIONS 474
17.1 Renal and Urologic Malfunctions 474
17.2 Diseases of the Male
Genital Organs 483
17.3 Sexually Transmitted Diseases 486
17.4 Gynecologic Care 489
17.5 Routine Obstetrics Care 492
17.6 Pregnancies with Complications 499
17.7 Neonates and Congenital Anomalies 503
Chapter Summary and Review 512
18 FACTORS INFLUENCING HEALTH STATUS
(Z CODES) 523
18.1 Preventive Care 523
18.2 Early Detection 525
18.3 Genetic Susceptibility 527
18.4 Observation 528
 18.5 Continuing Care and Aftercare 529
18.6 Organ Donation 531
18.7 Resistance to Antimicrobial Drugs 532
18.8 Z Codes as First-Listed/Principal
Diagnosis 535
18.9 Social Determinants of Health 536
Chapter Summary and Review 537
19 INPATIENT (HOSPITAL) DIAGNOSIS CODING 545 23 CPT EVALUATION AND MANAGEMENT
19.1 Concurrent and Discharge Coding 545
19.2 Official Coding Guidelines 548
19.3 Present-On-Admission Indicators 549
19.4 Diagnosis-Related Groups 554
19.5 Uniform Hospital Discharge Data Set 556
Chapter Summary and Review 557
20 DIAGNOSTIC CODING CAPSTONE 572
PART III: Reporting Physician
Services and Outpatient
Procedures 581
21 INTRODUCTION TO CPT 582
21.1 Abstracting for Procedure Coding 582
21.2 CPT Code Book 583
21.3 Understanding Code Descriptions 585
21.4 Notations and Symbols 587
21.5 Official Guidelines 591
21.6 Category II and Category III Coding 594
Chapter Summary and Review 597
22 CPT AND HCPCS LEVEL II MODIFIERS 606
22.1 Modifiers Overview 606
22.2 Personnel Modifiers 610
22.3 Anesthesia Physical Status Modifiers 613
xii CONTENTS
ISTUDY
22.4 Ambulatory Surgery Center Hospital
Outpatient Use Modifiers 615
22.5 Anatomical Site Modifiers 617
22.6 Service-Related Modifiers 619
22.7 Sequencing Multiple Modifiers 632
22.8 Supplemental Reports 635
Chapter Summary and Review 636
CODING 645
23.1 What Are E/M Codes? 645
23.2 Location Where the E/M Services Were
Provided 646
23.3 Relationship Between Provider
and Patient 648
23.4 Types of E/M Services 651
23.5 Preventive Medicine Services 671
23.6 Abstracting the Physician’s Notes 673
23.7 E/M in the Global Surgical
Package 675
23.8 E/M Modifiers and Add-On Codes 676
23.9 Special Evaluation Services 680
23.10 Coordination and Management
Services 681
Chapter Summary and Review 684
24 CPT ANESTHESIA SECTION 695
24.1 Types of Anesthesia 695
24.2 Coding Anesthesia Services 698
24.3 Anesthesia Guidelines 702
24.4 Time Reporting 705
24.5 Qualifying Circumstances 706
24.6 Special Circumstances 707
24.7 HCPCS Level II Modifiers 709
Chapter Summary and Review 711
 25 CPT SURGERY SECTION 721
25.1 Types of Surgical Procedures 722
25.2 The Surgical Package 724
25.3 Global Period Time Frames 728
25.4 Unusual Services and
Treatments 729
25.5 Integumentary System 732
25.6 Musculoskeletal System 743
25.7 Respiratory System 751
25.8 Cardiovascular System 753
25.9 Digestive System 763
25.10 Urinary System 766
25.11 The Genital Systems: Male and
Female 768
25.12 Nervous System 772
25.13 The Optical and Auditory
Systems 777
25.14 Organ Transplantation 783
25.15 Operating Microscope 788
Chapter Summary and Review 790
26 CPT RADIOLOGY SECTION 801
26.1 Types of Imaging 801
26.2 Purposes for Imaging 805
26.3 Technical vs. Professional 807
26.4 Number of Views 809
26.5 Procedures With or Without
Contrast 811
26.6 Diagnostic Radiology 813
26.7 Mammography 817
26.8 Bone and Joint Studies 818
26.9 Radiation Oncology 819
26.10 Nuclear Medicine 822
Chapter Summary and Review 823
ISTUDY
27 CPT PATHOLOGY & LAB SECTION 832
27.1 Specimen Collection and Testing 832
27.2 Testing Methodology and Desired
Results 834
27.3 Panels 837
27.4 Blood Test Documentation 839
27.5 Clinical Chemistry 842
27.6 Molecular Diagnostics 843
27.7 Immunology, Microbiology, and
Cytopathology 844
27.8 Surgical Pathology 847
27.9 Modifiers for Laboratory Coding 851
27.10 Pathology and Lab Abbreviations 852
Chapter Summary and Review 854
28 CPT MEDICINE SECTION 862
28.1 Immunizations 862
28.2 Injections and Infusions 866
28.3 Psychiatry, Psychotherapy, and
Biofeedback 869
28.4 Dialysis and Gastroenterology Services 871
28.5 Ophthalmology and ­Otorhinolaryngologic
Services 874
28.6 Cardiovascular Services 876
28.7 Pulmonary 881
28.8 Allergy and Clinical Immunology 882
28.9 Neurology and Neuromuscular
Procedures 884
28.10 Physical Medicine and Rehabilitation 885
28.11 Acupuncture, Osteopathic, and
­Chiropractic Treatments 887
28.12 Other Services Provided 889
Chapter Summary and Review 891
29 PHYSICIANS’ SERVICES CAPSTONE 900
 PART IV: DMEPOS &
Transportation 909
30 HCPCS LEVEL II 910
30.1 HCPCS Level II Categories 910
30.2 The Alphabetic Index 912
30.3 The Alphanumeric Listing Overview 914
30.4 Symbols and Notations 928
30.5 Appendices 936
Chapter Summary and Review 937
31 DMEPOS AND TRANSPORTATION
CAPSTONE 946
PART V: Inpatient (Hospital)
Reporting 953
32 INTRODUCTION TO ICD-10-PCS 954
32.1 The Purpose of ICD-10-PCS 954
32.2 The Structure of ICD-10-PCS
Codes 954
32.3 The ICD-10-PCS Book 962
32.4 ICD-10-PCS General Conventions 968
32.5 Selection of Principal Procedure 971
Chapter Summary and Review 972
33 ICD-10-PCS MEDICAL AND SURGICAL
SECTION 979
33.1 Medical/Surgical Section/Body Systems:
Characters 1 and 2 979
33.2 Medical/Surgical Root Operations:
­Character 3 982
33.3 Medical/Surgical Body Parts:
Character 4 991
33.4 Medical/Surgical Approaches:
Character 5 993
33.5 Medical/Surgical Devices: Character 6 997
33.6 Medical/Surgical Qualifiers:
Character 7 999
33.7 Multiple and Discontinued Procedures in
Medical and Surgical Cases 1000
33.8 Medical/Surgical Coding:
Putting It All Together 1003
Chapter Summary and Review 1007
34 OBSTETRICS SECTION 1019
34.1 Obstetrics Section/Body System:
­Characters 1 and 2 1019
34.2 Obstetrics Root Operations:
Character 3 1020
34.3 Obstetrics Body Parts: Character 4 1025
34.4 Obstetrics Approaches:
Character 5 1026
34.5 Obstetrics Devices: Character 6 1028
34.6 Obstetrics Qualifiers: Character 7 1028
34.7 Obstetrics Coding: Putting It All
Together 1032
Chapter Summary and Review 1034
35 PLACEMENT THROUGH CHIROPRACTIC
SECTIONS 1044
35.1 Reporting Services from the Placement
Section 1044
35.2 Reporting Services from the
­Administration Section 1050
35.3 Reporting Services from the ­Measurement
and Monitoring Section 1054
35.4 Reporting Services from the
Extracorporeal or Systemic Assistance
and Performance Section 1058
35.5 Reporting Services from the Extracorporeal
or Systemic Therapies Section 1062
35.6 Reporting Osteopathic Services 1067

xiv CONTENTS

ISTUDY
 35.7 Reporting from the Other Procedures
Section 1070
35.8 Reporting Inpatient Chiropractic
Services 1074
35.9 Sections 2–9: Putting It All Together 1078
Chapter Summary and Review 1080
36 IMAGING, NUCLEAR MEDICINE, AND
RADIATION THERAPY SECTIONS 1091
36.1 Reporting from the Imaging Section 1091
36.2 Reporting from the Nuclear Medicine
Section 1096
36.3 Reporting from the Radiation Therapy
Section 1100
36.4 Sections B, C, and D: Putting It All
Together 1105
Chapter Summary and Review 1108
37 PHYSICAL REHABILITATION AND DIAGNOSTIC
AUDIOLOGY THROUGH NEW TECHNOLOGY
SECTIONS 1115
37.1 Reporting Services from the ­Physical
Rehabilitation and Diagnostic ­Audiology
Section 1115
37.2 Reporting Services from the Mental
Health Section 1119
37.3 Reporting from the Substance Abuse
Treatment Section 1123
37.4 Reporting from the New Technology
Section 1126
37.5 Sections F–X: Putting It All
Together 1134
Chapter Summary and Review 1138
38 INPATIENT CODING CAPSTONE 1146
ISTUDY
PART VI: Reimbursement, Legal,
and Ethical Issues 1161
39 REIMBURSEMENT 1162
39.1 The Role of Insurance in Health
Care 1162
39.2 Types of Insurance Plans 1164
39.3 Methods of Compensation 1169
39.4 NCCI Edits and NCD/LCD 1171
39.5 Place-of-Service and
Type-of-Service Codes 1173
39.6 Organizing Claims: Resubmission,
­Denials, and Appeals 1178
Chapter Summary and Review 1186
40 INTRODUCTION TO HEALTH CARE LAW AND
ETHICS 1191
40.1 Sources for Legal Guidance 1191
40.2 Rules for Ethical and Legal
Coding 1196
40.3 False Claims Act 1199
40.4 Health Insurance Portability and
Accountability Act (HIPAA) 1201
40.5 Health Care Fraud and
Abuse Control Program 1211
40.6 Codes of Ethics 1212
40.7 Compliance Programs 1213
Chapter Summary and Review 1214
Appendix A-1
Glossary G-1
Index I-1
 GUIDED TOUR
Let’s Code It! was developed with student success in mind: success in college, success taking the certifica-
tion exam, and success in their future health care career.
Chapter Openers
Each chapter begins by clearly identifying the 1 Introduction to the seen and treated.
Learning Outcomes students need to master Key Terms
Classification Systems
along with the Key Terms that they need to learn. Condition
Diagnosis
Eponym
External Cause
Inpatient
Medical Necessity
Nonessential Modifiers
Outpatient
Procedure
Reimbursement
Services
Treatments
CODING BITES
We use the concept of
“languages” to help
you relate medical
coding—and its code
sets—to an idea you
already understand. In
the health care industry,
however, the various
code sets, such as ICD-
10-CM or HCPCS Level
II, are referred to as
Classification Systems.
Classification Systems
The term used in health care
to identify ICD-10-CM, CPT,
ICD-10-PCS, and HCPCS Level
II code sets.
Coding Bites
CODING BITES
A diagnosis explains
WHY the patient requires
the attention of a health
care provider and a
procedure explains
These appear throughout the text to highlight key
WHAT the physician or
health care provider did
for the patient.
concepts and tips to further support understanding and 2 the code book. You will
learning.
saf6657X_ch01_001-021.indd 2
Condition
The state of abnormality or
dysfunction.
Eponym
A disease or condition named
for a person.
xvi
ISTUDY
Confirming Pages
or diagnostic statement, in the
Languages of Coding The physician’s notes explai
The notes may document a spec
Learning Outcomes
unnamed problem, or another
After completing this chapter, the student should be able to:
LO 1.1 Explain the four purposes of medical coding. As a coding specialist, it is your
LO 1.2 Identify the structure of the ICD-10-CM diagnosis coding
manual.
(or codes) so that everyone inv
LO 1.3 Differentiate between the types of procedures and the
various procedure coding manuals.
patient at a particular time.
LO 1.4 Examine the HCPCS Level II coding manual used to report
the provision of equipment and supplies.
The International Classifica
1.1 The Purpose of Coding tion (ICD-10-CM) code book c
report the reason why the healt
Around the world, languages exist to enable clear and accurate communication
between individuals in similar groups or working together in similar functions. The
purpose of using health care coding languages is to enable the sharing of information,
cific encounter.
in a specific and efficient way, between all those involved in health care.
Coding languages are constructed of individual codes that are more precise than
words. (You will discover this as you venture through this textbook.) By communi-
cating using codes rather than words, you can successfully convey to others involved
(1) exactly what happened during a provider-patient encounter and (2) why it occurred.
Overview of the Interna
You, as the professional coding specialist, have the responsibility to accurately interpret
health care terms and definitions (medical terminology) into numbers or number-letter
combinations (alphanumeric codes) that specifically convey diagnoses and procedures.
Revision – Clinical Mod
Why is it so critical to code diagnoses and procedures accurately? The coding lan-
guages, known as classification systems, communicate information that is key to various
aspects of the health care system, including
•
•
Medical necessity
Statistical analyses
Book Sections
• Reimbursement
• Resource allocation
The ICD-10-CM code book (w
Medical Necessity
tions. Here is an overview of its
The diagnosis codes that you report explain the justification for the procedure, service,
CODING BITES sections to determine the most
or treatment provided to a patient during his or her encounter. Every time a health
care professional provides care to a patient, there must be a valid medical reason.
Patients certainly want to know that health care professionals performed procedures
encounter occurred.
or provided care for a specific, justified purpose, and so do third-party payers! This is
This is just an overview
referred to as medical necessity. Requiring medical necessity ensures that health care
providers are not performing tests or giving injections without a good medical reason.
to help you orient your-
Diagnosis codes explain why the individual came to see the physician and support the
physician’s decision about what procedures to provide.
Index to Diseases and In
Medical necessity is one of the reasons why it is so very important to code the diag-
self to the structure of
nosis accurately and with all the detail possible. If you are one number off in your code
The Alphabetic Index [Index t
learn, in depth, how terms used by the physician to
to use the ICD-10-CM from a health care professional.
code set to report any The Alphabetic Index lists al
04/19/19 04:37 PM
and all of the reasons their basic description alphabet
why a patient needs the tions are listed by
care of a health care • Condition (e.g., infection, fra
professional in Part II:
• Eponym (e.g., Epstein-Barr s
Reporting Diagnoses.
• Other descriptors (e.g., perso
So, whichever type of words you
them in the Alphabetic Index in
The Alphabetic Index can on
sis, and you will use this suggest
Abnormal, abnormality, abno
- acid-base balance (mixed) E
- albumin R77.0
- alphafetoprotein R77.2
- alveolar ridge K08.9
 the suffix -oma means
Pathology reports also may provide information
to be malignant on the grading and/or staging of the
or benign.
tumor.
tumor. Grading a tumor is the microscopic analysis
Often, when youoflook
the tumor
up onecells and tissue
of these to describe
specific neoplasm terms in the Alph
how abnormal they appear. Staging,
Index, it will provide youthe
however, evaluates sizesome
with and location of the tumor,about the tumor. Let’s
specific information
as well as determination of anylook
signsinor
theevidence of metastasis.
ICD-10-CM AlphabeticInIndex
someunder
cases,
theyou willwritten by the physicia
term
need to know the grade of a patient’s tumor so you can determine the correct code.
Fibroxanthoma (see also Neoplasm, connective tissue, benign)
atypical — see Neoplasm, connective tissue, uncertain behavior
EXAMPLES malignant — see Neoplasm, connective tissue, malignant

Examples, Let’s Code It! Scenarios,

Fibroxanthosarcoma — see Neoplasm, connective tissue, malignant
C82.07 Follicular lymphoma grade I, spleen
C82.16 Follicular lymphoma
You cangrade II, intrapelvic
see that lymphnot
while you might nodes
know if a fibroxanthoma is malignant or b
the Alphabetic Index will tell you.

and You Code It! Case Studies

These two codes are examples of those with code descriptions that require you to
check the physician’s documentation and pathology reports to identify the grade
of the tumor.

ICD-10-CM
LET’S CODE IT! SCENARIO
CHAPTER 6 | CODING NEOPLA
Abby Shantner, a 41-year-old female, comes to see Dr. Branson to get the results of her biopsy. Dr. Branson expl
Examples are included throughout each chapter to help that Abby has an alpha cell adenoma of the pancreas. Dr. Branson spends 30 minutes discussing treatment opti

Let’s Code It!

students make the connection between theoretical and Dr. Branson has diagnosed Abby with an alpha cell adenoma of the pancreas. You have been working Confirm wi
Dr. Branson as his coder for a while, so you know that an adenoma is a neoplasm, but what kind of neoplasm
practical coding. Let’s Code It! Scenarios walk students it—benign or malignant?
saf6657X_ch06_145-172.indd To help you determine this, instead of going to neoplasm, let’s see if there is a listing
147

the Alphabetic Index under adenoma. When you find adenoma, the book refers you to

through abstracting and the coding process, step-by-step, Adenoma (see also Neoplasm, benign, by site)
This tells you an adenoma is a benign tumor. Or you can continue down this list to the indented term, and find
to determine the correct code. And You Code It! Case Adenoma EXAMPLE
alpha-cell
Studies provide students with hands-on practice coding pancreas D13.7
N30 Cystitis

Also, read the next notation carefully:

Use additional code to identify infectious agent (B95–B97)
Turn to the Tabular List and read the complete description of code category D13:
scenarios and case studies throughout each chapter. In D13 Benign neoplasm Very often,
of other andthe ICD-10-CM
ill-defined
Use
will
parts oftell you that
digestive
additional
you will need this second code
system
code to identify any fam
The noteidentify therelate
does not specific pathogen.
to this patient’s diagnosis for this encounter, so continue
addition, You Interpret It! questions present opportuni- D13.7
reading down the column to review all of the choices for the required fourth character.
ICD-10-CM reminds you that an additional
Benign neoplasm of endocrine pancreas
factor for the screening is not age but family
ties for students to use critical-thinking skills to identify YOu
That INTERPRET IT! diagnosis.
matches Dr. Branson’s
in the
Check the top of this subsection and the head of thispatient’s past bloodline
chapter in ICD-10-CM. There are had
severalbeen diag
NOTES. Rea

details needed for accurate coding.

carefully. Do any relate to Dr. Branson’s diagnosis of Abby? No. Turn to the Official Guidelines and read Sectio
What is the mode of transmission for eachand it is known that this places the patient a
condition?
I.C.2. There is nothing specifically applicable here, either.
1. Hepatitis
Good job!B ___________ 4. Insect bites ___________
2. Measles ___________ 5. Influenza ___________
3. Cholera ___________
EXAMPLE
5.2 Bacterial You would report code:
Infections
Malignant Primary
Types
The term of Bacteria
primary Z80.42
indicates the anatomicalFamily history
site (the place in theof malignan
body) where the
nant neoplasm was first seen and identified. If the physician’s notes do not s
Bacteria aresecondary,
Bacteriaor single-celled organisms named byis their shape (see Figure 5-1). R
Single-celled microorganisms
primary in addition
then to code
the site mentioned Z12.5
primary. for an encoun
bacteria, called bacilli, are responsible for the development of diphtheria, te
that cause disease. tuberculosis, among a others.
screeningSpirilla,prostate exam because
bacterial organisms shaped likehis f
a sp
150 PART II | REPORTING DIAGNOSES with prostate cancer, dramatically increa

Guidance Connections
GUIDANCE
CONNECTION
A personal history code (Z85.-) shoul
Read the ICD-10-CM receive screening tests more frequently tha
Official Guidelines
saf6657X_ch06_145-172.indd 150 for tory of breast cancer may get mammogram 04/26/19

Each of these boxes connects the concepts Coding and Reporting, personal history of breast cancer code will
section I. Conventions, in the frequency of testing.
students are learning in the chapter to General Coding Guide-
lines and Chapter-
the related, specific Official Guidelines in (a) Specific Guidelines, EXAMPLE
(c)

order to further students’ knowledge and subsection C. Chapter-

Specific Coding
You would report code:

understanding of coding resources. Guidelines, chapter 21.

Z85.3 Personal history of malign
Factors influencing in addition to code Z12.31 Encounter f
health status and con- nant neoplasm of breast for an encount
tact with health services for a screening mammogram every 6 mo
(Z00–Z99), subsection because the fact that she had a malignan
c.4) History (of). dramatically increases her risk for a recu

(b) The(d)Z12 code category also carries an

ference
FIGuRE 5-1 Types of bacteria: (a) coccus, (b) bacillus, (c) between a (d)
spirillum, and diagnostic test,
vibrio (a) Source: which
Janice Carr/CDC; is
(b) Source: Janice Carr/CDC; (c) ©Melba Photo Agency/Alamy; (d) Source: Janice Carr/CDC
or symptoms, and a screening test, which is
tion of disease without signs or symptoms.
104 PART II | REPORTING DIAGNOSES
encounter for diagnostic

EXAMPLE
saf6657X_ch05_101-144.indd 104
You would report code: 04

N63.- Unspecified lump in breas

for an encounter when a 62-year-old fem
she felt a lump in her breast during her m
confirmed it was suspicious.

Confirming a Diagnosis
Once the patient exhibits signs, such as a
or an abnormality identified during a scree
essence of the neoplasm. This is the only w
cells and malignant cells.

146 PART II | REPORTING DIAGNOSES

saf6657X_ch06_145-172.indd 146

ISTUDY
 First Pages

End-of-Chapter Reviews CHAPTER 39 REVIEW

CHAPTER 39 REVIEW
®

Reimbursement Enhance your learning by

completing these exercises and
more at mcgrawhillconnect.com!

Let’s Check It! Terminology

Most chapters end with the following assess- Match each term to the appropriate definition.

Part I
ment types to reinforce the chapter learning 1. LO 39.2 A physician, typically a family practitioner or an internist, who serves as
the primary care physician for an individual. This physician is responsible
A. Automobile Insurance
B. Capitation Plans
outcomes: Let’s Check It! Terminology; Let’s for evaluating and determining the course of treatment or services, as well
as for deciding whether or not a specialist should be involved in care.
C. Centers for Medicare
& Medicaid Services

Check It! Concepts; Let’s Check It! Guide-

2. LO 39.1 A type of health insurance coverage that controls the care of each sub- (CMS)
scriber (or insured person) by using a primary care provider as a central
D. Dependents
health care supervisor.

lines; Let’s Check It! Rules and Regulations;

E. Disability
3. LO 39.2 A type of health insurance that uses a primary care physician, also
Compensation
known as a gatekeeper, to manage all health care services for an
individual. F. Discounted FFS

and You Code It! Basics. 4. LO 39.2 A policy that covers loss or injury to a third party caused by the insured
or something belonging to the insured.
G. Episodic Care
H. Fee-for-Service (FFS)
5. LO 39.1 The total management of an individual’s well-being by a health care Plans
professional. I. Gatekeeper
6. LO 39.3 An insurance company pays a provider one flat fee to cover the entire J. Health Care
course of treatment for an individual’s condition. K. Health Maintenance
7. LO 39.2 The agency under the Department of Health and Human Services Organization (HMO)
(DHHS) in charge of regulation and control over services for those cov- L. Insurance Premium
ered by Medicare and Medicaid. M. Liability Insurance
8. LO 39.3 Payment agreements that outline, in a written fee schedule, exactly how N. Managed Care
much money the insurance carrier will pay the physician for each treat-
ment and/or service provided.
9. LO 39.3 An extra reduction in the rate charged to an insurer for services pro-
vided by the physician to the plan’s members.
10. LO 39.1 The amount of money, often paid monthly, by a policyholder or insured,
to an insurance company to obtain coverage.
11. LO 39.2 Auto accident liability coverage will pay for medical bills, lost wages,
and compensation for pain and suffering for any person injured by the
insured in an auto accident.
12. LO 39.3 Agreements between a physician and a managed care organization that
pay the physician a predetermined amount of money each month for
each member of the plan who identifies that provider as his or her pri-
mary care physician.
13. LO 39.2 A plan that reimburses a covered individual a portion of his or her
income that is lost as a result of being unable to work due to illness or
injury.
14. LO 39.2 Individuals who are supported, either financially or with regard to insur-
ance coverage, by others.

Confirming Pages

CHAPTER 39 | REIMBURSEMEnT 1183

CHAPTER 6 REVIEW

saf6657X_ch39_1157-1186.indd 1183 06/27/19 06:18 PM

7. Follicular grade III lymphoma, lymph nodes of 11. Malignant odontogenic tumor, upper jaw bone:

Real Abstracting Practice with You Code It! Practice, You

inguinal region and lower limbs: a. main term: _____ b. diagnosis: _____
a. main term: _____ b. diagnosis: _____ 12. Secondary malignant neoplasm of vallecula:

Code It! Application, and Capstone Case Studies Chapters

8. Acral lentiginous, right heel melanoma: a. main term: _____ b. diagnosis: _____
a. main term: _____ b. diagnosis: _____ 13. Carcinoma in situ neoplasm of left eyeball:
9. Lipoma of the kidney: a. main term: _____ b. diagnosis: _____
a. main term: _____ b. diagnosis: _____ 14. Benign neoplasm of cerebrum peduncle:
10. Primary malignant neoplasm of right male breast, a. main term: _____ b. diagnosis: _____
upper-outer quadrant: 15. Myelofibrosis with myeloid metaplasia:

Gain real-world experience by using actual a. main term: _____ b. diagnosis: _____ a. main term: _____ b. diagnosis: _____

patient records (with names and other

identifying information changed) to practice
ICD-10-CM, ICD-10-PCS, CPT, and HCPCS
Level II coding for both inpatients and
outpatients. You Code It! Practice exercises
give students the chance to practice coding
with short coding scenarios. You Code It!
Application exercises give students the chance
ICD-10-CM
YOU CODE IT! Practice
Using the techniques described in this chapter, carefully read through the case studies and determine the most accurate
ICD-10-CM code(s) and external cause code(s), if appropriate, for each case study.
1. George Donmoyer, a 58-year-old male, presents today with a sore throat, persistent cough, and earache.
Dr. Selph completes an examination and appropriate tests. The blood-clotting parameters, the thyroid function
studies, as well as the tissue biopsy confirm a diagnosis of malignant neoplasm of the extrinsic larynx.
2. Monica Pressley, a 37-year-old female, comes to see Dr. Wheaten today because she has been having diarrhea
and abdominal cramping and states her heart feels like it’s quivering. The MRI scan confirms a diagnosis of
benign pancreatic islet cell adenoma.
3. Suber Wilson, a 57-year-old male, was diagnosed with a malignant neoplasm of the liver metastasized from the
prostate; both sites are being addressed in today’s encounter.
4. William Amerson, a 41-year-old male, comes in for his annual eye examination. Dr. Leviner notes a benign

to review and abstract physicians’ notes right conjunctiva nevus.

5. Edward Bakersfield, a 43-year-old male, presents with shortness of breath, chest pain, and coughing up blood.
documenting real patient encounters in order After a thorough examination, Dr. Benson notes stridor and orders an MRI scan. The results of the MRI con-
firm the diagnosis of bronchial adenoma.

to code those scenarios. Both of these types
of exercises can be found at the end of most
chapters. Capstone Chapters come at the
end of Parts II–V and include 15 additional
real-life outpatient and inpatient case studies
to help students synthesize and apply what
they have learned through hands-on coding
practice with each code set.
6. Elizabeth Conyers, a 56-year-old female, presents with unexplained weakness, weight loss, and dizziness.
Dr. Amos completes a thorough examination and does a workup. The protein electrophoresis (SPEP) and
quantitative immunoglobulin results confirm the diagnosis of Waldenström’s macroglobulinemia.
7. James Buckholtz, a 3-year-old male, is brought in by his parents. Jimmy has lost his appetite and is losing
weight. Mrs. Buckholtz tells Dr. Ferguson that Jimmy’s gums bleed and he seems short of breath. Dr. Ferguson
notes splenomegaly and admits Jimmy to Weston Hospital. After reviewing the blood tests, MRI scan, and
bone marrow aspiration results, Jimmy is diagnosed with acute lymphoblastic leukemia.
8. Kelley Young, a 39-year-old female, presents to Dr. Clerk with the complaints of sudden blurred vision, dizzi-
ness, and numbness in her face. Kelley states she feels very weak and has headaches. Dr. Clerk admits Kelley
to the hospital. After reviewing the MRI scan, her hormone levels from the blood workup, and urine tests, Kel-
ley is diagnosed with a primary malignant neoplasm of the pituitary gland.
9. Ralph Bradley, a 36-year-old male, comes to see Dr. Harper because he is weak, losing weight, and vomiting
and has diarrhea with some blood showing. Ralph was diagnosed with HIV 3 years ago. Dr. Harper completes
an examination noting paleness, tachycardia, and tachypnea. Ralph is admitted to the hospital. The biopsied
tissue from an endoscopy confirms a diagnosis of Kaposi’s sarcoma of gastrointestinal organ.

168 PART II | REPORTING DIAGNOSES

xviii

ISTUDY saf6657X_ch06_145-172.indd 168


In addition, all of the exercises in the
Chapter Review can be assigned through
Connect. Of particular note are the You
Code It! Practice exercises, which offer
our unique CodePath option. In Connect,
students are presented with a series of
questions to guide them through the
critical thinking process to determine the
correct code.
saf34625_ch04_053-100.indd
ISTUDY
Confirming Pages
CHAPTER 4 REVIEW
YOU CODE IT! Application
ICD-10-CM
The following exercises provide practice in abstracting physician documentation from our health care facility, Prader,
Bracker, & Associates. These case studies are modeled on real patient encounters. Using the techniques described in this
chapter, carefully read through the case studies and determine the most accurate ICD-10-CM code(s) for each case study.
Remember to include external cause codes, if appropriate.
PRADER, BRACKER, & ASSOCIATES
A Complete Health Care Facility
159 Healthcare Way • SOMEWHERE, FL 32811 • 407-555-6789
PATIENT: Kassandra, Kelly
ACCOUNT/EHR #: KASSKE001
DATE: 09/16/22
Attending Physician: Oscar R. Prader, MD
S: Pt is a 19-year-old female who has had a sore throat and cough for the past week. She states that
she had a temperature of 101.5 F last night. She also admits that it is painful to swallow. No OTC medi-
cation has provided any significant relief.
O: Ht 5′5″ Wt. 148 lb. R 20. T 101 F. BP 125/82. Pharynx is inspected, tonsils enlarged. There is pus
noted in the posterior pharynx. Neck: supple, no nodes. Chest: clear. Heart: regular rate and rhythm
without murmur.
A: Acute pharyngitis
P: 1. Send pt for Strep test
2. Recommend patient gargle with warm salt water and use OTC lozenges to keep throat moist
3. Rx if needed once results of Strep test come back
4. Return in 2 weeks for follow-up
Determine the most accurate ICD-10-CM code(s).
WESTON HOSPITAL
629 Healthcare Way • SOMEWHERE, FL 32811 • 407-555-6541
PATIENT: DAVIS, HELEN
ACCOUNT/EHR #: DAVIHE001
DATE: 10/21/22
Attending Physician: Renee O. Bracker, MD
Patient, an 82-year-old that presents today to see Dr. Newson. Dr. Newson saw this patient 10 days ago
in office, where she was diagnosed with a UTI and prescribed nitrofurantoin PO. Today she presents
with the complaints of dysuria, low back pain, abdominal pain, nausea, and diarrhea. After a positive UA
she was admitted to Weston Hospital.
(continued)
CHAPTER 4 | INTRODUCTION TO ICD-10-CM 97
97 11/17/21 05:45 PM
ISTUDY
 PREFACE

Welcome to Let’s Code It! This product has been created to instruct students on how
to become proficient in medical coding—a health care field that continues to be in
high demand. The Bureau of Labor Statistics notes the demand for health information
management professionals (which includes coders) will continue to increase incredibly
through 2029 and beyond.
Let’s Code It! offers a 360-degree learning experience for anyone interested in
the field of medical coding, with strong guidance down the path to coding certifica-
tion. Theory is presented in easy-to-understand language and accompanied by lots
of examples. Hands-on practice is included with real-life physician documentation,
from both outpatient and inpatient facilities, to promote critical thinking analysis
and evaluation. This is in addition to determination of accurate codes to report
diagnoses, procedures, and ancillary services. All of this is assembled to support the
reader’s development of a solid foundation upon which to build a successful career
after graduation.
Let’s Code It! is designed to give your students the medical coding experience
they need in order to pass their first medical coding certification exams, such as the
CCS/CCS-P or CPC/COC. This product offers students a variety of practice oppor-
tunities by reinforcing the learning outcomes set forth in every chapter. The chapter
materials are organized in short bursts of text followed by practice—keeping students
active and coding!
What’s new for the 2022–2023 Code Edition: Our content has been updated to include
key advancements in our industry through the last year. For example, coding for cases of
COVID-19 (testing through confirmed diagnosis) and Social Determinants of Health,
have been added to this edition. All codes within the text, as well as the Instructor
Manual answer keys, have been updated to be compliant with the 2022 code sets: ICD-
10-CM, CPT, HCPCS Level II, and ICD-10-PCS. Updates will continue to be made to
the answer keys and Connect exercises as necessary for currency.

Here’s What You Can Expect from

Let’s Code It!
• Each of the six parts of this product includes an Introduction to provide students
with an overview of the information within that part and how they can use this
knowledge.
• Part I: Medical Coding Fundamentals
• Part II: Reporting Diagnoses
• Part III: Reporting Physicians Services and Outpatient Procedures
• Part IV: DMEPOS & Transportation
• Part V: Inpatient (Hospital) Reporting
• Part VI: Legal, Ethical, and Reimbursement Issues
• Part I: Medical Coding Fundamentals helps students build a strong theoretical founda-
tion regarding the various code sets. The chapters teach students how and when each
code set is used and how to abstract documentation. These chapters also teach them
how to use a solid coding process, including the importance of queries, how to write a
legal query, exposure to the Official Guidelines, and confirmation of medical necessity.

ISTUDY
 • Part II: Reporting Diagnoses provides students with an incremental walkthrough of
the ICD-10-CM code set.
• Part III: Reporting Physicians Services and Outpatient Procedures provides students
with a progressive learning experience for using CPT® procedure codes.
• Part IV: DMEPOS & Transportation gives students insight into, and hands-on practice
using, the HCPCS Level II code set to report the provision of durable medical equip-
ment, prosthetics, orthotics, and other medical supplies.
• Part V: Inpatient (Hospital) Reporting shows students how to build an accurate ICD-
10-PCS code to report inpatient procedures, services, and treatments.
• The coding chapters in Parts II–V all include real-life scenarios, as well as physician
documentation mainly in the form of procedure notes and operative reports (both
inpatient and outpatient) for students to practice abstracting and coding.
• Let’s Code It! Scenarios provide step-by-step instruction so students can learn to
use their critical-thinking skills throughout the coding process to determine the
correct code.
• You Code It! Case Studies provide students with hands-on practice coding sce-
narios and case studies throughout each chapter.
• You Interpret It! questions present additional opportunities for students to use
critical-thinking skills to identify details required for accurate coding.
• Chapter Reviews include assessments of chapter concepts:
• Let’s Check It! Terminology
• Let’s Check It! Concepts
• Let’s Check It! Guidelines
• Let’s Check It! Rules and Regulations
• You Code It! Basics
• You Code It! Practice Case Studies
• You Code It! Application Case Studies
• Examples are included throughout each chapter to help students make the connec-
tion between theoretical and practical coding.
• Coding Bites highlight key concepts and tips to further support understanding and
learning.
• Guidance Connection features point to the specific Official Guideline applicable for
the concept being discussed.
• Capstone Chapters come at the end of Parts II–V with 15 additional real-life outpa-
tient and inpatient case studies to help students synthesize and apply what they have
learned through hands-on coding practice with each code set.
• Part VI: Legal, Ethical, and Reimbursement Issues provides a concise overview con-
necting these broad topics to a professional coding specialist’s job requirements.
• Examples again take students through real-life scenarios to help them understand
how they will use this information.
• Coding Bites provide tips and highlight key concepts.
• This part also includes material to teach students how to access credible resources
on the Internet.
• Codes of Ethics from both AHIMA and AAPC are discussed as well as information
on compliance plans.
• You Interpret It! questions present students with opportunities to use critical-thinking
skills to identify details required for accurate job performance.

xxii PREFACE

ISTUDY
 • Chapter Reviews include assessments of chapter concepts:
• Let’s Check It! Terminology
• Let’s Check It! Concepts
• Let’s Check It! Which Type of Insurance?
• Let’s Check It! Rules and Regulations
• You Code It! Application Case Studies

ISTUDY
 Instructors: Student Success Starts with You
Tools to enhance your unique voice
Want to build your own course? No problem. Prefer to use an
OLC-aligned, prebuilt course? Easy. Want to make changes throughout
65%
Less Time
the semester? Sure. And you’ll save time with Connect’s auto-grading too.
Grading

Study made personal

Incorporate adaptive study resources like
SmartBook® 2.0 into your course and help your
students be better prepared in less time. Learn
more about the powerful personalized learning
experience available in SmartBook 2.0 at
www.mheducation.com/highered/connect/smartbook

Laptop: McGraw Hill; Woman/dog: George Doyle/Getty Images

Affordable solutions, Solutions for

added value your challenges
Make technology work for you with A product isn’t a solution. Real
LMS integration for single sign-on access, solutions are affordable, reliable,
mobile access to the digital textbook, and come with training and
and reports to quickly show you how ongoing support when you need
each of your students is doing. And with it and how you want it. Visit www.
our Inclusive Access program you can supportateverystep.com for videos
provide all these tools at a discount to and resources both you and your
your students. Ask your McGraw Hill students can use throughout the
representative for more information. semester.

Padlock: Jobalou/Getty Images Checkmark: Jobalou/Getty Images

ISTUDY
 Students: Get Learning That Fits You
Effective tools for efficient studying
Connect is designed to help you be more productive with simple, flexible, intuitive tools that maximize
your study time and meet your individual learning needs. Get learning that works for you with Connect.

Study anytime, anywhere “I really liked this

Download the free ReadAnywhere app and access app—it made it easy
your online eBook, SmartBook 2.0, or Adaptive to study when you
Learning Assignments when it’s convenient, even don't have your text-
if you’re offline. And since the app automatically
syncs with your Connect account, all of your work is book in front of you.”
available every time you open it. Find out more at
www.mheducation.com/readanywhere - Jordan Cunningham,
Eastern Washington University

Everything you need in one place

Your Connect course has everything you need—whether reading on
your digital eBook or completing assignments for class, Connect makes
it easy to get your work done.

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Learning for everyone

McGraw Hill works directly with Accessibility Services
Departments and faculty to meet the learning needs
of all students. Please contact your Accessibility
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ISTUDY
 CONNECT FOR LET’S CODE IT!
McGraw-Hill Connect for Let’s Code It! includes:
• All end-of-chapter questions.
• CodePath versions of You Code It! practice questions, in which students are pre-
sented with a series of questions to guide them through the critical thinking process
to determine the correct code.
• Interactive Exercises, such as Matching, Sequencing, and Labeling activities.
• Testbank questions.
• Lecture-style videos, which provide additional guidance on challenging coding ques-
tions. With the 2022–2023 Code Edition, the videos are now assignable through the
Question Bank with new assessment questions for students to complete after each
video. The videos are also available in the Connect Media Bank.

INSTRUCTORS’ RESOURCES
You can rely on the following materials to help you and your students work through
the material in the book; Instructor’s manual, PowerPoint presentations, testbank,
and additional tools to plan your course. These materials are available in the Instruc-
tor Resources under the Library tab in Connect (available only to instructors who are
logged in to Connect).
Want to learn more about this product? Attend one of our online webinars. To learn
more about them, please contact your McGraw-Hill learning technology representa-
tive. To find your McGraw-Hill representative, go to www.mheducation.com and click
“Get Support,” select “Higher Ed” and then click the “Get Started” button under the
“Find Your Sales Rep” section.
Need help? Contact the McGraw-Hill Education Customer Experience Group
(CXG). Visit the CXG website at www.mhhe.com/support. Browse our frequently asked
questions (FAQs) and product documentation and/or contact a CXG representative.

xxvi PREFACE

ISTUDY
 ACKNOWLEDGMENTS

Digital Tool Development

Special thanks to the instructors who helped with the development of Connect and
SmartBook.

Tammy L. Burnette, PhD, CPC, CPB, Shauna Phillips, RMA, AHI, CCMA,
Tyler Junior College CMAA, CPT, PIMA Medical Institute
Judith Hurtt, MEd, East Central Patricia A. Saccone, MA, RHIA, CCS-P,
Community College Waubonsee Community College

Board of Advisors
A select group of instructors participated in our Coding Board of Advisors to help
develop the first editions of the series. They provided timely and focused guidance to
the author team on all aspects of content development. We are extremely grateful for
their input on this project.

Christine Cusano, CMA (AAMA), CPhT, Tatyana Pashnyak, CHTS-TR, Bainbridge

Lincoln Technical Institute
Gerry Gordon, BA, CPC, CPB, Daytona
College
Shalena Jarvis, RHIT, CCS
Janis A. Klawitter, AS, CPC, CPB,
CPC-I, San Joaquin Valley College
State College
Patricia Saccone, MA, RHIA, CCS-P,
Waubonsee Community College
Stephanie Scott, MSHI, RHIA, CDIP,
CCS, CCS-P, Moraine Park Technical
College

First Edition Reviewers

Many instructors reviewed the manuscript while it was in development and provided
valuable feedback that directly affected the product’s development. Their contributions
are greatly appreciated.

Julie Alles-Grice, MSCTE, RHIA
Alicia Alva, AS, San Joaquin Valley
College
Kelly Berge, MSHA, CPC, CCS-P,
Berkeley College
Valerie Brock, EdS, MBA, RHIA, CDIP,
CPC, Tennessee State University
William Butler, MHA, UNC Healthcare
Heather Copen, RHIA, CCS-P, Ivy Tech
Community College
Gerard Cronin, MS, DC, Salem
Community College
Christine Cusano, CMA (AAMA), CPhT,
Lincoln Technical Institute
Patti Fayash, CCS, ICD-10-CM/PCS
AHIMA Approved Trainer, Luzerne
County Community College

ISTUDY
 Rashmi Gaonkar, BS, MS, MHA/
Informatics, ASA College
Savanna Garrity, MPA, CPC,
Madisonville Community College
Deborah Gilbert, RHIA, MBA, CMA,
Dalton State College
Terri Gilbert, MS, ECPI University
Gerry Gordon, BA, CPC, CPB, Daytona
College
Michelle A. Harris, CPC, CPB, CPC-I,
Bossier Parish Community College
Susan Hernandez, B.S.B.A., San Joaquin
Valley College
Judith Hurtt, MEd, East Central
Community College
Beverlee Jackson, BA, RHIT, CCS,
AHIMA Ambassador, Central Oregon
Community College
Shalena Jarvis, RHIT, CCS
Mary Z. Johnston, RN, BSN, RHIA,
CPC, CPC-H, CPC-I, Ultimate Medical
Academy
Janis A. Klawitter, AS, CPC, CPB, CPC-I,
San Joaquin Valley College
Jennifer Lamé, MPH, RHIT, Southwest
Wisconsin Technical College
Jorell Lawrence, MSA, CPC, Stratford
University
Tracey Lee, MSA, CPC, Vista College
Angela Leuvoy, AAS, CMA, CPT, CBCS,
Fortis College
Glenda Lloyd, MBA, BS, RHIA,
Rasmussen College, Vista College
Lynnae Lockett, RN, RMA, CMRS,
MSN, Bryant & Stratton College
Marta Lopez, MD, BXMO, RMA, Miami
Dade College
JanMarie Malik, MBA, RHIA, CCS-P,
National University
Barbara Marchelletta, BS, CMA
(AAMA), CPT, CPC, AHI, Beal College
xxviii ACKNOWLEDGMENTS
ISTUDY
David Martinez, MHSA, RHIT, RMA,
University of Phoenix
Jillian McDonald, BS, RMA (AMT),
EMT, CPT(NPA)
Cheryl Miller, MBA/HCM, Westmoreland
County Community College
Robin Moore, CPC, CCMA, Davis
College
Lisa Nimmo, CPC, CFPC, Central
Carolina Technical College
Melissa Oelfke, RHIA, HIT Program
Coordinator, Rasmussen College
Barbara Parker, CPC, CCS-P, CMA
(AAMA), Olympic College
Brenda Parks-Brown, MHS, HCA, CCS,
CMA, Miller-Motte Technical College
Tatyana Pashnyak, CHTS-TR, Bainbridge
State College
Staci Porter, AA, San Joaquin Valley
College
Terri Randolph, MBA/HCM, CAHI,
CBCS, CEHRS, Eagle Gate College
Lisa Riggs, CPC, CPC-I, Ultimate
Medical Academy
Rolando Russell, MBA, RHIA, CPC,
CPAR, Ultimate Medical Academy
Patricia A. Saccone, MA, RHIA, CCS-P,
Waubonsee Community College
Georgina Sampson, RHIA, Anoka
Technical College
Stephanie Scott, MSHI, RHIA, CDIP,
CCS, CCS-P, Moraine Park Technical
College
Mary Jo Slater, MS, MIE, Community
College of Beaver County
Karen K. Smith, MEd, RHIA, CDIP,
CPC, University of Arkansas for Medical
Sciences
Kameron Stutzman, MEd, CMBS, IBMC
College
Stephanie Vergne, MAEd, RHIA, CPC,
Hazard Community & Technical College
 PART I
MEDICAL CODING FUNDAMENTALS
INTRODUCTION
Coding is not like anything you have ever studied before. No courses that you ­experienced
in elementary, middle, or high school have prepared you for learning this skill. Biology
and your science classes began your education that your anatomy and physiology class
­continued. Other courses you are taking as part of this program also typically connect to
something, in some way, you have previously learned.
As you begin this educational journey, you will use your critical thinking skills as well as
some experiences you may have had as a patient yourself (or as the loved one of a patient).
For the most part, though, this will be different, so prepare yourself for a new learning
experience.
In Part I, the chapters Introduction to the Languages of Coding, Abstracting Clinical
Documentation, and The Coding Process share an overview of the concepts and skills you
will apply in the chapters that follow. You will be introduced to the tools you have and
will need to use as a professional coding specialist. Together, these three chapters create
the ­foundation, the first layer, of a multilayered approach to learning coding. Then, the
­remaining parts will share with you, one by one, the best practices for how to use each of
these tools correctly. You will then be given many opportunities for hands-on practice so that
you can build your skills and reinforce the knowledge you have obtained.

ISTUDY
 1
Key Terms
Introduction to the
Languages of Coding
Learning Outcomes
Classification Systems After completing this chapter, the student should be able to:
Condition
Diagnosis LO 1.1 Explain the four purposes of medical coding.
Eponym LO 1.2 Identify the structure of the ICD-10-CM diagnosis coding
External Cause manual.
Inpatient LO 1.3 Differentiate between the types of procedures and the
Medical Necessity ­various procedure coding manuals.
Nonessential Modifiers LO 1.4 Examine the HCPCS Level II coding manual used to report
Outpatient
Procedure the provision of equipment and supplies.
Reimbursement
Services
Treatments 1.1 The Purpose of Coding
Around the world, languages exist to enable clear and accurate communication
between individuals in similar groups or working together in similar functions. The
CODING BITES purpose of using health care coding languages is to enable the sharing of information,
We use the concept of in a specific and efficient way, between all those involved in health care.
“languages” to help Coding languages are constructed of individual codes that are more precise than
you relate medical words. (You will discover this as you venture through this textbook.) By communi-
coding—and its code cating using codes rather than words, you can successfully convey to others involved
sets—to an idea you (1) exactly what happened during a provider-patient encounter and (2) why it occurred.
already understand. In You, as the professional coding specialist, have the responsibility to accurately interpret
the health care industry, health care terms and definitions (medical terminology) into numbers or number-letter
however, the various combinations (alphanumeric codes) that specifically convey diagnoses and procedures.
code sets, such as ICD- Why is it so critical to code diagnoses and procedures accurately? The coding lan-
10-CM or HCPCS Level guages, known as classification systems, communicate information that is key to various
II, are referred to as aspects of the health care system, including
­Classification Systems.
• Medical necessity
• Statistical analyses
Classification Systems
• Reimbursement
The term used in health care
to identify ICD-10-CM, CPT, • Resource allocation
ICD-10-PCS, and HCPCS Level
II code sets. Medical Necessity
The diagnosis codes that you report explain the justification for the procedure, service,
CODING BITES or treatment provided to a patient during his or her encounter. Every time a health
A diagnosis explains care professional provides care to a patient, there must be a valid medical reason.
WHY the patient requires Patients certainly want to know that health care professionals performed procedures
the attention of a health or provided care for a specific, justified purpose, and so do third-party payers! This is
care provider and a referred to as medical necessity. Requiring medical necessity ensures that health care
­procedure explains providers are not performing tests or giving injections without a good medical reason.
WHAT the physician or Diagnosis codes explain why the individual came to see the physician and support the
health care provider did physician’s decision about what procedures to provide.
for the patient. Medical necessity is one of the reasons why it is so very important to code the diag-
nosis accurately and with all the detail possible. If you are one number off in your code

ISTUDY
 selection, you could accidentally cause a claim to be denied because the diagnosis, Diagnosis
identified by your incorrect code, does not justify the procedure. A physician’s determination of
Let’s analyze an example: a patient’s condition, illness,
or injury.

EXAMPLE Procedure
Action taken, in accordance
Dr. Justini performs a colonoscopy on Shoshanna because a lab test identified with the standards of care, by
that she had blood in her feces (melena). the physician to accomplish
a predetermined objective
(result); a surgical operation.
A colonoscopy involves the insertion of a camera, with surgical tools, into the patient’s
anus, rectum, and up through the large intestine. If you are Shoshanna, or if you are Medical Necessity
the one paying for this procedure, you want to make certain that this colonoscopy was The assessment that the
done to support Shoshanna’s good health and not any other reason. This is clearly ­provider was acting according
communicated when you report the code K92.1 Melena (the presence of blood in to standard practices in
feces). Now, whether for resource allocation or reimbursement, it is understood that providing a procedure or
Dr. Justini was caring properly for Shoshanna and her good health. service for an individual with a
specific diagnosis.

Statistical Analyses
CODING BITES
Research organizations and government agencies statistically analyze the data pro-
vided by codes to develop programs, identify research areas, allocate funds, and write The WHY justifies the
public health policies that will best address areas of concern for the health of our WHAT.
nation. For example, we can only know that a disease such as Alzheimer’s needs diag-
nostic tests, treatments, and possibly a vaccine or a cure by studying statistics to see
what individual signs and symptoms are being identified and treated around the coun-
try and around the world.

Reimbursement
In most cases, there are three parties involved in virtually every encounter: the health
care provider, the patient, and the person or organization paying for the care provided
(frequently, a health care insurance company). However, the insurance company is not
always an actual insurance company, so the broader term “third-party payer” is used.
Third-party payers use our coding data to determine how much they should pay health
care professionals for the attention and services they provide patients. This is the role
that coding plays in the reimbursement process. The codes make it easier for the orga- Reimbursement
nizations involved to evaluate and manage all their data. The process of paying for
health care services after they
have been provided.
Resource Allocations
Whether a health care facility is a one-physician office or a large hospital, there are
not unlimited resources available. Administrators and managers must ensure that all
resources are employed in the most efficient and effective manner. Computer pro- CODING BITES
grams can easily and quickly organize data (the codes) to identify the largest patient In most cases, there are
population’s diagnoses and the most frequently provided treatments and services. With three parties involved in
these details, staff members, equipment, and money can be directed to those patients reimbursement:
and locations that need them the most. • The health care
­provider = First party

1.2 Diagnosis Coding • The patient =

­Second party
When a person goes to see a health care provider, he or she must have a reason— • The insurance
a health-related reason. After all, as much as you might like your physician, you ­company or other
probably wouldn’t make an appointment, sit in the waiting room, and go through organization financially
all the paperwork just to say, “hello.” Whether the reason is a checkup, a flu shot, responsible =
or something more serious, there is always a reason why. The physician will create Third-party payer
notes, either written or dictated, recounting the events of the visit. The diagnosis,

CHAPTER 1 | Introdu

ISTUDY
 or diagnostic statement, in these notes will explain the reason why the patient was
seen and treated.
The physician’s notes explain, in writing, the reasons why the encounter occurred.
The notes may document a specific condition or illness, the signs or symptoms of a yet-
unnamed problem, or another reason for the encounter, such as a preventive service.
As a coding specialist, it is your job to translate this explanation into a diagnosis code
(or codes) so that everyone involved will clearly understand the issues of a particular
patient at a particular time.
The International Classification of Diseases – 10th Revision – Clinical Modifica-
tion (ICD-10-CM) code book contains all of the codes from which you will choose to
report the reason why the health care professional cared for the patient during a spe-
cific encounter.

Overview of the International Classification of Diseases – 10th

Revision – Clinical Modification (ICD-10-CM) Code
Book Sections
The ICD-10-CM code book (whether paper or electronic) is made up of several sec-
tions. Here is an overview of its parts and how you will utilize the information in these
CODING BITES sections to determine the most accurate code or codes to report the reasons why an
encounter occurred.
This is just an overview
to help you orient your-
Index to Diseases and Injuries [aka Alphabetic Index]
self to the structure of
the code book. You will The Alphabetic Index [Index to Diseases and Injuries] lists, in alphabetic order, the
learn, in depth, how terms used by the physician to describe the reasons why the patient required attention
to use the ICD-10-CM from a health care professional.
code set to report any The Alphabetic Index lists all diagnoses and other reasons to provide health care by
and all of the reasons their basic description alphabetically from A to Z (see Figure 1-1). Diagnostic descrip-
why a patient needs the tions are listed by
care of a health care • Condition (e.g., infection, fracture, and wound)
professional in Part II:
• Eponym (e.g., Epstein–Barr syndrome and Cushing’s disease)
Reporting Diagnoses.
• Other descriptors (e.g., personal history, family history)
Condition Therefore, whichever type of words you read in the documentation, you should be able
The state of abnormality or to find them in the Alphabetic Index in one form or another.
dysfunction. The Alphabetic Index can only suggest a possible code to report the patient’s diagno-
Eponym sis, and you will use this suggestion to guide you to the correct page or subsection in the
A disease or condition named
for a person. Abnormal, abnormality, abnormalities (see also Anomaly)
acid–base balance (mixed) E87.4
albumin R77.0
alphafetoprotein R77.2
alveolar ridge K08.9
anatomical relationship Q89.9
apertures, congenital, diaphragm Q79.1
auditory perception H93.29-
diplacusis—see Diplacusis
hyperacusis—see Hyperacusis
recruitment—see Recruitment, auditory
threshold shift—see Shift, auditory threshold
autosomes Q99.9

FIGURE 1-1 ICD-10-CM Alphabetic Index, partial listing under main term Abnormal

4 PART I | MEDICAL CODING FUNDAMENTALS

ISTUDY
 B67 Echinococcosis CODING BITES
hydatidosis Notations in the Tabular
List help make your
B67.0 Echinococcus granulosus infection of liver
coding process more
B67.1 Echinococcus granulosus infection of lung accurate and a bit easier.
For example, as you can
B67.2 Echinococcus granulosus infection of bone
see in Figure 1-2, the
B67.3 Echinococcus granulosus infection, other and multiple sites condition represented
by code category B67
B67.31 Echinococcus granulosus infection, thyroid gland
is Echinococcosis. Now,
B67.32 Echinococcus granulosus infection, multiple sites read the note
directly below B67;
B67.39 Echinococcus granulosus infection, other sites
it reads . . .
B67.4 Echinococcus granulosus infection, unspecified hydatidosis. This notation
lets you know that, if
Dog tapeworm (infection)
the physician wrote
“echinococcosis” or
FIGURE 1-2 ICD-10-CM Tabular List, partial list of codes included in code “hydatidosis” in the
­category B67 Echinococcosis documentation, this is the
correct code category.
Tabular List (see the next subsection of this text, Tabular List of Diseases and Injuries). In ICD-10-CM, the
The Official Guidelines require you to always find a suggested code in the Tabular List note provides
to confirm it is accurate, or to find another code that might be better. you with alternative
words or phrases that
Tabular List of Diseases and Injuries the physician might use
The Tabular List provides you with each and every available code in the ICD-10-CM that mean the same
code book, in order of the code characters—alphanumeric order. You need to carefully condition. In English, they
read the descriptions, beginning at the top of the three-character code category. When are known as synonyms.
you begin reading at this point, you can make certain that you find the best code, to In ICD-10-CM, they are
the highest level of specificity, according to the physician’s documentation. known as n ­ onessential
You will find that the Tabular List section shows all ICD-10-CM codes, first in alpha- modifiers.
betic order and then in numeric order: A00 through Z99.89 (see Figure 1-2), along with You will learn more
additional details (notations and symbols) that guide you to the accurate code. about notations in the
Introduction to
Ancillary Sections of ICD-10-CM ICD-10-CM chapter.
Neoplasm Table
Nonessential Modifiers
The Neoplasm Table (Figure 1-3) itemizes all of the anatomical sites in the human
Descriptors whose inclusion in
body that may develop a tumor (neoplasm). Columns in this table further describe the physician’s notes are not
the type of neoplasm and suggest a code that may be accurate. As with other codes absolutely necessary and that
suggested by the Alphabetic Index, you will need to go to the Tabular List to look up are provided simply to further
any code found on the Neoplasm Table to confirm accuracy, additional characters clarify a code description;
required, and other details before you can determine the accurate code to report. optional terms.
You will learn how to use the Neoplasm Table to report diagnoses of benign, malig-
nant, and other types of neoplasms in the Coding Neoplasms chapter.

Table of Drugs and Chemicals

The Table of Drugs and Chemicals (Figure 1-4) lists pharmaceuticals and chemicals that
may cause poisoning or adverse effects in the human body. The multiple columns in this
table categorize the intent of how or why the patient became ill from the drug or chemi-
cal to suggest a possible code. As with all of these, this suggested code must be reviewed
in the Tabular List to ensure completeness and accuracy before you can report it.
You will learn how to use the Table of Drugs and Chemicals in the chapter Coding
Injury, Poisoning, and External Causes.

CHAPTER 1 | Introdu

ISTUDY
 Malignant Malignant Ca in Uncertain Unspecified
Primary Secondary situ Benign Behavior Behavior
Neoplasm, neoplastic C80.1 C79.9 D09.9 D36.9 D48.9 D49.9
abdomen, abdominal C76.2 C79.8- D09.8 D36.7 D48.7 D49.89
cavity C76.2 C79.8- D09.8 D36.7 D48.7 D49.89
organ C76.2 C79.8- D09.8 D36.7 D48.7 D49.89
viscera C76.2 C79.8- D09.8 D36.7 D48.7 D49.89
 all (see also Neoplasm,
w C44.509 C79.2- D04.5 D23.5 D48.5 D49.2
­abdomen, wall, skin)
connective tissue C49.4 C79.8- — D21.4 D48.1 D49.2
skin C44.509 — — — — —
basal cell carcinoma C44.519 — — — — —
specified type NEC C44.599 — — — — —
squamous cell carcinoma C44.529 — — — — —

FIGURE 1-3 The Neoplasm Table from ICD-10-CM, listings for abdominal neoplasms

Poisoning, Poisoning,
Accidental Intentional Poisoning, Poisoning, Adverse
Substance (Unintentional) Self-harm Assault Undetermined Effect Underdosing
Acefylline piperazine T48.6X1 T48.6X2 T48.6X3 T48.6X4 T48.6X5 T48.6X6
Acemorphan T40.2X1 T40.2X2 T40.2X3 T40.2X4 T40.2X5 T40.2X6
Acenocoumarin T45.511 T45.512 T45.513 T45.514 T45.515 T45.516
Acenocoumarol T45.511 T45.512 T45.513 T45.514 T45.515 T45.516
Acepifylline T48.6X1 T48.6X2 T48.6X3 T48.6X4 T48.6X5 T48.6X6
Acepromazine T43.3X1 T43.3X2 T43.3X3 T43.3X4 T43.3X5 T43.3X6
Acesulfamethoxypyridazine T37.0X1 T37.0X2 T37.0X3 T37.0X4 T37.0X5 T37.0X6
Acetal T52.8X1 T52.8X2 T52.8X3 T52.8X4 — —
Acetaldehyde (vapor) T52.8X1 T52.8X2 T52.8X3 T52.8X4 — —
liquid T65.891 T65.892 T65.893 T65.894 — —
P-Acetamidophenol T39.1X1 T39.1X2 T39.1X3 T39.1X4 T39.1X5 T39.1X6
Acetaminophen T39.1X1 T39.1X2 T39.1X3 T39.1X4 T39.1X5 T39.1X6

FIGURE 1-4 The Table of Drugs and Chemicals from ICD-10-CM, listings from Acefylline piperazine to Acetaminophen
Source: ICD-10-CM Official Guidelines for Coding and Reporting, The Centers for Medicare and Medicaid Services (CMS) and the National Center for Health
­Statistics (NCHS)

Index to External Causes

External Cause
An event, outside the body,
that causes injury, poisoning,
or an adverse reaction.
The Index to External Causes (Figure 1-5) lists the causes of injury and poisoning.
These codes are used to explain how a patient got injured and where (place of occur-
rence) he or she was when the injury happened.
As with the other content in the Alphabetic Index, the code or codes shown here are
only suggestions and must be confirmed in the Tabular List before you are permitted
to report them. You will learn about the importance of reporting these codes as you
progress through your learning experience, particularly in the chapter Coding Injury,
Poisoning, and External Causes.

6 PART I | MEDICAL CODING FUNDAMENTALS

ISTUDY
 Abandonment (causing exposure to weather conditions) (with intent to injure or
kill) NEC X58
Abuse (adult) (child) (mental) (physical) (sexual) X58
Accident (to) X58
aircraft (in transit) (powered) (see also Accident, transport, aircraft)
due to, caused by cataclysm—see Forces of nature, by type
animal-rider—see Accident, transport, animal-rider
animal-drawn vehicle—see Accident, transport, animal-drawn vehicle occupant
automobile—see Accident, transport, car occupant
bare foot water skier V94.4
boat, boating (see also Accident, watercraft)
striking swimmer
powered V94.11
unpowered V94.12
bus—see Accident, transport, bus occupant
cable car, not on rails V98.0

FIGURE 1-5 The Index to External Causes, first listings including main terms
Abandonment, Abuse, and Accident

The Format of ICD-10-CM Codes CODING BITES

A complete, valid ICD-10-CM code will always begin with a three (3)-character code When additional
category: a letter of the alphabet followed by a minimum of two (2) characters (either characters are required,
letters or numbers). those codes with fewer
characters are invalid.
E54 Ascorbic acid deficiency (scurvy) The need for additional
L26 Exfoliative dermatitis characters is mandatory,
not a suggestion.
A majority of the codes will require additional characters to communicate more
specific information about the patient’s condition. When an additional character is
needed to complete the code, a symbol to the left of the code in the Tabular List will
identify that additional characters are necessary. The symbol may be a bullet or
it may be a box with a check mark , depending upon the publisher of your code
book. You will find a legend to explain the meaning of each symbol at the bottom
of the page in your code book. As you evaluate the options available for the addi-
tional character, make certain to place a dot (period) between the third and fourth
characters.
Let’s take a look at an example together:

M17 Osteoarthritis of knee

M17.0 Bilateral primary osteoarthritis of knee

The symbol to the left of code M17 alerts you that this code requires a fourth (4th)
character. In looking at the second line of this example (M17.0), you can see that
this fourth character shares additional, important information about the patient’s
condition. It is not enough to communicate that the patient has been diagnosed with
osteoarthritis of the knee. You must explain the specific location (from our example,
bilateral = both knees) and specific type of condition (from our example, primary
osteoarthritis).
ICD-10-CM codes can be as short as three (3) characters and can add additional
characters containing more specificity about the patient’s condition . . . up to a total of
seven (7) characters. These additional characters ensure that as much detail as possible
about the patient’s condition is communicated accurately and completely.

CHAPTER 1 | Introdu

ISTUDY
 EXAMPLE
The Tabular List shows you which details to abstract from the documentation. All you
have to do is keep reading. The portion of the ICD-10-CM Tabular List below shows
options for additional characters and the information these characters convey.
S43.3 Subluxation and dislocation of other and unspecified parts of shoulder
girdle
CODING BITES S43.30 Subluxation and dislocation of unspecified parts of shoulder girdle
Dislocation of shoulder girdle NOS
You will learn many
Subluxation of shoulder girdle NOS
more details about
reporting diagnoses S43.301 Subluxation of unspecified parts of right shoulder girdle
in Part II: Reporting S43.302 Subluxation of unspecified parts of left shoulder girdle
Diagnoses, with more S43.303 Subluxation of unspecified parts of unspecified shoulder girdle
in-depth introduction to S43.304 Dislocation of unspecified parts of right shoulder girdle
ICD-10-CM as well as S43.305 Dislocation of unspecified parts of left shoulder girdle
details by body system. S43.306 Dislocation of unspecified parts of unspecified shoulder girdle

ICD-10-CM
LET’S CODE IT! SCENARIO
MCGRAW GENERAL HOSPITAL
DATE OF ADMISSION: 05/27/22
DATE OF DISCHARGE: 05/28/22
PATIENT: YOUNG, MATTHEW JAMES
HISTORY: Neonate is male, delivered 05/27/2022 at 1915 hours by C-section due to previous C-section. Mother is:
• gravida 2, para 2, AB 1
• blood type B positive
• GBS negative
• hepatitis B surface antigen negative
• rubella immune
• VDRL nonreactive

VITAL SIGNS:
Weight: 6 pounds 9 ounces
Height: 19-1/2 inches
Head circumference: 14 inches

GENERAL:
APGAR = 10 @1 min., 10 @ 5 min
SKIN: Portwine nevus on right ankle
NEUROLOGIC: Alert, vigorous cry, good tone, nonfocal

DISPOSITION:
The neonate was discharged to his mother. I instructed the mother to phone me PRN. I told her that I want to see
both in my office in 10 days for a follow-up.

Let’s Code It!

Dr. Michaels delivered Matthew James Young and examined him. Being born is the confirmed reason why
the baby needed Dr. Michael’s time and expertise. You need to translate the reason why into an ICD-10-CM

8 PART I | MEDICAL CODING FUNDAMENTALS

ISTUDY
 diagnosis code. Therefore, begin in the Alphabetic Index of your ICD-10-CM manual. What should you look up?
Matthew needed to be examined right after being born, so let’s look up:
Birth . . . nothing here that matches.
Next, try: Newborn. We have a match!
Newborn (infant) (liveborn) (singleton) Z38.2
Turn in the Tabular List to this code and begin by reading at the three-character code category:
Z38 Liveborn infants according to place of birth and type of delivery
 OTE: This category is for use as the principal code on the initial record of a newborn baby. It is to be used
N
for the initial birth record only. It is not to be used on the mother’s record.
You know that Matthew was just born, so this note confirms you are in the right place in the code book. Notes,
notations, symbols, and other marks in the code book are there to help point you in the right direction and to
support your determination of the correct code.
Our next step is to look at the mark to the left of the code . . . it may be a box with a check mark , it may be a
dot , or the following lines may just be indented. However your copy of the code book alerts you, it is clear . . .
this code needs an additional character. And this is not a suggestion; it is mandatory.
There are three options for a fourth character:
Z38.0 Single liveborn infant, born in hospital
Z38.1 Single liveborn infant, born outside hospital
Z38.2 Single liveborn infant, unspecified as to place of birth
You can see in the record above that Matthew was born in McGraw General Hospital and, therefore, Z38.0 is the
most accurate.
But we aren’t done yet. There is a symbol to the left of code Z38.0. It is telling you that an additional character is
required. Let’s look at the two options:
Z38.00 Single liveborn infant, delivered vaginally
Z38.01 Single liveborn infant, delivered by cesarean
Go back to the documentation and read the information provided by the doctor. He noted that Matthew was
born via a C-section (the C stands for cesarean).
There are no more symbols or notations here in the Tabular List. Next, double-check the Official Guidelines,
Section 1C. Chapter 21, subsection 12) Newborns and Infants as well as Chapter 16, subsection 6) Code
all clinically significant conditions. It appears that there are no further details or codes needed . . . so this is
the code.
Good job! You were able to determine that code Z38.01 most accurately reports Matthew’s birth. You did it!

1.3 Procedure Coding

Once the physician has determined the patient’s condition or problem, he or she can
then establish a treatment plan. Generally, there are three terms used to describe
actions that the physician can take to support a patient’s good health or to improve a
current condition:
Services
Procedures are actions, or a series of actions, taken to accomplish an objective Spending time with a patient
(result). For example, surgically removing a mole or resectioning the small intestine. and/or family about health
Services are actions that will most often involve counseling, educating, and advising the care situations.
patient, such as discussing test results or sharing recommendations for risk reduction. Treatment
Treatments are typically an application of a health care service, such as radiation The provision of medical care
treatments for tumor reduction or acupuncture. for a disorder or disease.

CHAPTER 1 | Introdu

ISTUDY
 These actions provided by the physician, or other health care professional, are done for
one of three reasons:
Diagnostic tests or procedures are performed to provide the physician with addi-
tional information required to determine a confirmed diagnosis.
Preventive procedures and services are provided to keep a healthy patient healthy. In
other words . . . to avoid illness or injury. These also include early detection testing,
known as screenings.
Therapeutic procedures, treatments, and services are performed with the intention
of removing, correcting, or repairing an abnormality or condition.
There are three different code sets available for you to use to translate health care
procedures, services, and treatments into codes. These three code sets are
Current Procedural Terminology (CPT)
International Classification of Diseases – 10th Revision – Procedure Coding System
(ICD-10-PCS)
Healthcare Common Procedure Coding System (HCPCS) Level II

Current Procedural Terminology (CPT)

Outpatient
An outpatient is a patient who
receives services for a short
amount of time (less than
24 hours) in a physician’s
office or clinic, without being
kept overnight. An outpatient
facility includes a hospital
emergency room, ambulatory
care center, same-day surgery
center, or walk-in clinic.
CPT codes are used to describe procedures performed by a physician in any location.
These services range from speaking with a patient about test results to performing
surgery or determining a treatment plan. In addition, CPT codes are used to report the
contribution made by outpatient facilities (a physician’s office, a clinic, an ambulatory
surgical center, or the emergency department of a hospital) such as a sterile procedure
room, trained nursing and support staff, etc.
The Organization of the CPT Code Book
The CPT book has two parts, which in turn have many sections.
The CPT book (see Figure 1-6) has six sections, which are generally presented in
numeric order by code number:
• Evaluation and Management: 99202–99499
• Anesthesia: 00100–01999 and 99100–99140

pancreas, 49180 for abdominal or retroperitoneal mass,

50200 for kidney, 54500 for testis, 54800 for epididymis,
60100 for thyroid, 62267 for nucleus pulposus,
intervertebral disc, or paravertebral tissue, 62269 for
spinal cord)
(For evaluation of fine needle aspirate, see 88172, 88173)
Integumentary System
Skin, Subcutaneous, and Accessory
Structures
Introduction and Removal
Incision and Drainage
(For excision, see 11400, et seq)
10040 Acne surgery (e.g., marsupialization, opening or removal
of multiple milia, comedones, cysts, pustules)
CPT Assistant Fall 92:10, Feb 08:8
10060 Incision and drainage of abscess (e.g., carbuncle,
suppurative hidradenitis, cutaneous or subcutaneous
abscess, cyst, furuncle, or paronychia); simple or single
CPT Assistant Sep 12:10
10061 complicated or multiple
CPT Assistant Sep 12:10
10080 Incision and drainage of pilonidal cyst; simple
CPT Assistant Fall 92:13, Dec 06:15, May 07:5

10030 Image-guided fluid collection drainage by catheter (e.g., 10081 complicated

abscess, hematoma, seroma, lymphocele, cyst), soft
tissue (e.g., extremity, abdominal wall, neck),
percutaneous
CPT Changes: An Insider’s View 2014
CPT Assistant Fall 13:6, May 14:3, 9
Clinical Examples in Radiology Summer 14:9
CPT Assistant Fall 92:13, Dec 06:15, May 07:5
(For excision of pilonidal cyst, see 11770-11772)
10120 Incision and removal of foreign body, subcutaneous
tissues: simple
CPT Assistant Sep 12:10, Apr 13:10, Dec 13:16

(Report 10030 for each individual collection drained with 10121 complicated
a separate catheter) CPT Assistant Spring 91:7, Dec 06:15, Sep 12:10, Dec 13:16

(Do not report 10030 in conjunction with 75989, 76942, (To report wound exploration due to penetrating trauma
77002, 77003, 77012, 77021) without laparotomy or thoracotomy, one 20100-20103,
as appropriate)

FIGURE 1-6 CPT main section, showing codes 10030–10121 Source: American Medical
Association, CPT Professional Manual

10 PART I | MEDICAL CODING FUNDAMENTALS

ISTUDY
 • Surgery: 10004–69990
• Radiology: 70010–79999 CODING BITES
• Pathology and Laboratory: 80047–89398, 0001U-0222U CPT codes and sections
run, generally, in
• Medicine: 90281–99199, 99500–99607 numeric order; however,
The second part of the CPT book also contains several sections, including there are exceptions
throughout. Bottom line
• Category II codes: used for supplemental tracking of performance measurements. . . . read carefully and
These codes are not reimbursable but support research on specific physician actions completely.
taken on behalf of a patient’s health.
• Category III codes: temporary codes used to report emerging technological proce-
dures. Technology and health care are innovating and improving every day. These
codes enable tracking physician adoption and the frequency of use to identify what CODING BITES
should stay and what will be deleted. More information about
Category II and ­Category
• Appendixes A–P: modifiers and other relevant additional information.
III codes will be covered
• Alphabetic Index: all the CPT codes in alphabetical order by code description, pre- in the ­chapter Introduc-
sented in four types of entries (see Figure 1-7): tion to CPT.
a. Procedures or services, such as bypass, decompression, insertion.
b. Anatomical site or organ, such as brain stem, spinal cord, lymph nodes.
c. Condition, such as pregnancy, fracture, abscess.
d. Eponyms, synonyms, or abbreviations, such as Potts-Smith Procedure or EEG.

The Formats of CPT Codes

Each code listed in the various CPT sections has a different structure:
CPT codes (Category I codes) are five-digit codes. They have all numbers (no letters,
no punctuation). Example: 51100 Aspiration of bladder; by needle.
Category II codes are five-character codes, with four numbers followed by the letter
“F.” Example: 2001F Weight recorded (PAG).

Activity, Glomerular Procoagulant Alanine Transaminase

Activity, Glomerular Procoagulant Labial Adult T Cell Leukemia Lymphoma

See Thromboplastin Lysis. . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . .56441 Virus I
Liver See HTLV-I
Acupuncture Lysis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58660
with Electrical Stimulation . . . . . . . . . .97813, 97814 Lungs Advanced Life Support
without Electrical Stimulation. . . . . . . .97810, 97811 Pneumonolysis. . . . . . . . . . . . . . . .32174, 32940 Physician/Health Care Professional Direction 99288
Nose
Acute Poliomyelitis Lysis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30560 Advancement
See Polio Genioglossus. . . . . . . . . . . . . . . . . . . . . . . . . . . 21199
Pelvic
Acylcarnitines . . . . . . . . 82016, 82017 Lysis. . . . . . . . . . . . . . . . . . . . . . . .58660, 58740 Tendon
Penile Tibia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .28238
Adamantinoma, Pituitary Lysis
See Craniopharyngioma Post-circumcision. . . . . . . . . . . . . . . . . . .54162
Advancement Flap
See Skin, Adjacent Tissue Transfer
Preputial
Adaptive Behavior Treatment
Assessment
Lysis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54450 Aerosol Inhalation
Urethral See Pulmonology, Therapeutic
Adductor Tenotomy of Hip Lysis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53500 Pentamidine. . . . . . . . . . . . . . . . . . . . . . . . . . . 94642
See Tenotomy, Hip, Adductor
Adipectomy AFB
Adenoidectomy See Lipectomy See Acid-Fast Bacilli (AFB)
Index

See Adenoids, Excision

ADL Afferent Nerve
Adenoids See Activities of Daily Living See Sensory Nerve
Excision. . . . . . . . . . . . . . . . . . . . . . . . .42830, 42836
with Tonsils. . . . . . . . . . . . . . . . . . .42820, 42821
Administration AFP
Immunization See Alpha-Fetoprotein (AFP)
Unlisted Services and Procedures. . . . . . . . . .42999
Each Additional Vaccine/Toxoid 90472, 90474
Adenoma with Counseling. . . . . . . . . . . . . . . . . . . .90461 After Hours Medical Services. . 99050
Pancreas One vaccine/Toxoid. . . . . . . . . . . . .90471, 90473
with Counseling. . . . . . . . . . . . . . . . . . . 90460
Agents, Anticoagulant
Excision . . . . . . . . . . . . . . . . . . . . . . . . . . . .48120
Occlusive Substance. . . . . . . . . . . . . . . . . . . . . 31634 See Clotting Inhibitors
Parathyroid
Localization Pharrnacologic Agent. . . . . . . . . . . . . . . . . . . .93463 Agglutinin
Injection Procedure. . . . . . . . . . . . . . . . .78808
Thyroid Gland Excision. . . . . . . . . . . . . . . . . . 60200
ADP Cold. . . . . . . . . . . . . . . . . . . . . . . . . . . . 86156, 86157
See Adenosine Diphosphate Febrile. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86000

FIGURE 1-7 CPT Alphabetic Index, partial listings from Activity, Glomerular
­Procoagulant to Agglutinin Source: American Medical Association, CPT Professional Manual

CHAPTER 1 | Introdu

ISTUDY
 ICD-10-CM
LET’S CODE IT! SCENARIO
Corey Carter, a 55-year-old male, came to the McGraw Ambulatory Surgery Center, an outpatient facility, so
Dr. Lucano could perform a percutaneous core needle biopsy on his thyroid. Corey’s primary care physician referred
him to Dr. Lucano after noting a lump on his thyroid during an annual physical.

Let’s Code It!

Open your CPT book to the Alphabetic Index. Which term should you look up? Let’s dissect the scenario:
Biopsy = the procedure
Percutaneous core needle = the type of biopsy
Thyroid = the anatomical site
Let’s begin by finding Biopsy in the Alphabetic Index:
Biopsy
See Brush Biopsy; Needle Biopsy
Abdomen . . . . . . . . . . . 49000, 49321
Notice that Abdomen is the beginning of a long list of anatomical sites on which a biopsy can be done. Read
down the list to find:
Thyroid . . . . . . . . . . . . . . . . . . . . 60100
Now, turn into the Main Section of CPT to find code 60100. You can see:
60100 Biopsy thyroid, percutaneous core needle
This matches Dr. Lucano’s documentation perfectly—you can report this procedure code with confidence!

Category III codes are five-character codes. These codes also have four numbers;
CODING BITES however, Category III codes are followed by the letter “T.” Example: 0208T Pure tone
You will learn many audiometry (threshold), automated; air only.
more details about Modifiers (listed in Appendix A of your CPT code book) are two characters: two
reporting procedures numbers, two letters, or one letter and one number. Modifiers are appended to CPT
in Part III: Reporting codes under special circumstances, such as the use of unusual anesthesia, two surgeons
­Physician Services and working on the same patient at the same time, or a multipart procedure performed
Outpatient Procedures. over time. When required, a modifier is added after the main CPT code with a hyphen.
Example: 47600-54 Cholecystectomy, surgical care only.

International Classification of Diseases – 10th Revision –

­Procedure Coding System (ICD-10-PCS)
The International Classification of Diseases – 10th Revision – Procedure Coding Sys-
tem (ICD-10-PCS) codes are used to describe the contribution made by the hospital
Inpatient to a procedure provided to an inpatient (a patient admitted into an acute care facility).
An individual admitted for an These are known as “facility charges” because they report what the hospital provided
overnight or longer stay in a during a specific procedure, service, or treatment, such as the skilled nursing staff, the
hospital. operating room, the equipment, and whatever else is required.
ICD-10-PCS contains an Alphabetic Index and a Tables section (Figure 1-8). The
Alphabetic Index is used in the same way you use this part of the other code books—to
get an idea of where in the Tables section to find codes. However, the Tables section of
this code set is very different. Rather than a listing of the codes in numeric or alphanu-
meric order, you will find Tables listing various characters and their meanings. Then,
you will actually build the code, according to the physician’s documentation.
The Format of ICD-10-PCS Codes
ICD-10-PCS codes have seven (7) characters and are alphanumeric (both letters
and numbers). Each of the seven positions in the code represents a specific piece

12 PART I | MEDICAL CODING FUNDAMENTALS

ISTUDY
 Section 0 Medical and Surgical
Body System 2 Heart and Greater Vessels
Operation 5  estruction: Physical eradication of all or a portion of a body part by the direct use of energy,
D
force, or a destructive agent
Body Part Approach Device Qualifier
Character 4 Character 5 Character 6 Character 7
4 Coronary Vein 0 Open Z No Device Z No Qualifier
5 Atrial Septum 3 Percutaneous
6 Atrium, Right 4 Percutaneous Endoscopic
8 Conduction Mechanism
9 Chordae Tendineae
D Papillary Muscle
F Aortic Valve
G Mitral Valve
H Pulmonary Valve
J Tricuspid Valve
K Ventricle, Right
L Ventricle, Left
M Ventricular Septum
N Pericardium
P Pulmonary Trunk
Q Pulmonary Artery, Right
R Pulmonary Artery, Left
S Pulmonary Vein, Right
T Pulmonary Vein, Left
V Superior Vena Cava
W Thoracic Aorta, Descending
X Thoracic Aorta, Ascending/Arch
7 Atrium, Left 0 Open Z No Device K Left Atrial Appendage
3 Percutaneous Z No Qualifier
4 Percutaneous Endoscopic

FIGURE 1-8 Table 025, one of the tables from the ICD-10-PCS Tables section

of information relating to a procedure, service, or treatment provided. These mean-

ings change for each section of the codebook. But don’t worry. No memorization is
required . . . the code book provides you with what you need to know. All you have to
do is read carefully.
For example, in the Medical and Surgical Section, each character reports the:
1. Section of the ICD-10-PCS code set.
2. Body system upon which the procedure or service was performed.
3. Root operation, which explains the category or type of procedure.
4. Body part, which identifies the specific anatomical site involved in the procedure.
5. Approach, which reports which method was used to perform the service or treatment.
6. Device, which reports, when applicable, what type of device was involved in the ser-
vice or procedure.
7. Qualifier, which adds any additional detail.

CHAPTER 1 | Introdu

ISTUDY
 EXAMPLES
0DQ48ZZ Repair of the esophagogastric junction, via natural opening
endoscopic
0RRJ0J6 Replacement of shoulder joint humeral surface with synthetic
­substitute, right side, open approach

Whereas in the Imaging Section, each character reports the:

1. Section of the ICD-10-PCS code set.
2. Body system upon which the procedure or service was performed.
3. Root type, which explains the type of imaging, such as MRI or CT scan.
4. Body part, which identifies the specific anatomical site imaged and recorded.
5. Contrast, which reports if contrast materials were used in the imaging process.
6. Qualifier, which adds any additional detail.
7. Qualifier, which adds any additional detail.

EXAMPLES
B31M110 Intraoperative fluoroscopy of the spinal arteries, low osmolar
­contrast, laser
BB24ZZZ Bilateral CT scan of lungs, no contrast

ICD-10-CM
LET’S CODE IT! SCENARIO
Marlena Takamoto, a 37-year-old female, contracted hepatitis seven years ago. The disease severely damaged her
liver. She was admitted to Carolina Brookdale Hospital today so Dr. Lewis and his team can perform a liver trans-
plantation, open approach. The liver donor was killed in a car accident early this morning.

Let’s Code It!

The physicians will transplant a liver, using an open approach, from the donor to Marlena. The coder who works
for Dr. Lewis will use CPT codes to report his services provided to Marlena. You work as the coder for Carolina
Brookdale Hospital, so you need to use ICD-10-PCS to report the hospital’s contribution in this surgery (the oper-
ating room, the support staff [surgical nurses, technicians], and other equipment).
The procedure is a transplant, so let’s start by looking in the Alphabetic Index in ICD-10-PCS for transplant. In
the index, we find
Transplantation
Liver 0FY00Z-

In this particular case, the Alphabetic Index provides you with the first six of the required seven characters. In
other cases, you may find the Alphabetic Index will only provide you with three or four characters. Regardless,
you must find this Table in the Tables section to complete the seven (7) characters. Using the first three charac-
ters provided by the Alphabetic Index, turn in the Tables section to the Table that begins with 0FY (see below):

Section 0 Medical and Surgical

Body System F Hepatobiliary System and Pancreas
Operation Y  ransplantation: Putting in or on all or a portion of a living body part taken from
T
another individual or animal to physically take the place and/or function of all or a
portion of a similar body part

14 PART I | MEDICAL CODING FUNDAMENTALS

ISTUDY
 Body Part Approach Device Qualifier
0 Liver 0 Open Z No Device 0 Allogeneic
G Pancreas 1 Syngeneic
2 Zooplastic

Now, with all of this information, let’s build the correct code:
1. Section of the ICD-10-PCS code set = Medical and Surgical 0
2. Body system upon which the procedure was performed = Hepatobiliary F

Remember, the liver is an organ that is part of the Hepatobiliary System.

3. Root operation: the type of procedure = Transplantation Y
4. Body part: the specific anatomical site involved in the procedure = Liver 0
5. Approach: method used to perform the transplant = Open 0
6. Device, when applicable = No Device Z
7. Qualifier: any additional detail = Allogeneic 0
Before reporting this code . . . check the Official Guidelines, specifically B3.16 Transplantation vs. Administration.
This confirms that you used the correct root operation term of Transplantation.
Good job! Now you have built the ICD-10-PCS code for this procedure: 0FY00Z0.

It would not be unusual for one patient encounter, for a patient admitted into the
hospital, to ultimately require interpretation into all three coding languages: ICD-
10-CM, CPT, and ICD-10-PCS.
CODING BITES
EXAMPLE Use a medical
Injured in an accident, Terence McCarthy was admitted into McGraw General ­dictionary whenever
Hospital with a major contusion of the spleen. Terence was brought into the oper- you do not know the
ating room, he was placed in the supine position, and general anesthesia was meaning of a term:
administered by Dr. London. Dr. Berring performed a total splenectomy. Allogeneic means
Together, let’s review all of the codes that will be reported for this surgical coming from a different
procedure: individual of the same
• The professional coding specialist for Dr. Berring, the surgeon, will report: species.
Syngeneic means
S36.021A Major contusion of spleen, initial encounter
coming from a genetic
38100 Splenectomy; total
identical, such as from
• The professional coding specialist for Dr. London, the anesthesiologist, will report: an identical twin.
S36.021A Major contusion of spleen, initial encounter Zooplastic means
00790-P1 Anesthesia for intraperitoneal procedures in upper abdomen the tissue or organ is
including laparoscopy; not otherwise specified, a normal coming from a donor of
healthy patient another species into a
human.
•  he professional coding specialist for McGraw General Hospital, the facility,
T
will report:
S36.021A Major contusion of spleen, initial encounter CODING BITES
07TP0ZZ Splenectomy, open approach You will learn many
more details about
HCPCS Level II Procedure Codes reporting inpatient
procedures in Part V:
In some cases, you might determine that the CPT code set does not contain a code Inpatient (Hospital)
that accurately and completely reports a procedure or service. It is possible that a Reporting.
HCPCS Level II code may do the job.

CHAPTER 1 | Introdu

ISTUDY
 HCPCS (pronounced “hick-picks”) is the abbreviation for Healthcare Common Pro-
cedure Coding System.
• HCPCS Level I codes are actually called CPT codes. While CPT codes are main-
tained by the American Medical Association (AMA), this code set was adopted by
our industry as the first level of HCPCS.
• HCPCS Level II codes are referred to as HCPCS Level II codes.
For the most part, health care services are listed in the HCPCS Level II section titled
Procedures/Professional Services (Temporary) G0008–G9999 [but not exclusively,
so be certain to check the Alphabetic Index first]. As always, reading carefully and
completely is required. However, as you scan the codes and their descriptions in this
­section of HCPCS Level II, you may find some are very close to CPT code descriptions.
But . . . not exactly. Let’s look at the simple repair of a 2.1 cm superficial laceration on
the patient’s left hand being repaired with tissue adhesive.
In CPT, under REPAIR (CLOSURE), the in-section guidelines state: “Use the codes
in this section to designate wound closure utilizing sutures, staples, or tissue adhesives,
either singly or in combination with each other or in combination with adhesive strips.”
The definition in CPT of a simple repair includes “. . . requires simple one layer clo-
sure.” With this scenario, this would lead to code
12001 Simple repair of superficial wounds of scalp, neck, axillae, exter-
nal genitalia, trunk and/or extremities (including hands and feet);
2.5 cm or less
Compare this with the most appropriate HCPCS Level II code:
G0168 Wound closure utilizing tissue adhesive(s) only
Which code reports the repair more accurately? You must go back to the documenta-
tion and read carefully, looking for the additional details included in the definition of
Simple Repair in CPT. Was a one-layer closure performed? Was local anesthesia used?
Was anything else done by the physician in addition to the application of the tissue
adhesive?
If the answer to any of these questions is Yes, then you need to report the CPT code
12001. If the answers to all of these questions are No, then report G0168.
Let’s look at an example that is perhaps a bit less complex. Compare and contrast
these two codes, both of which are used for reporting speech therapy services:
92507 Treatment of speech, language, voice, communication, and/or
auditory processing disorder; individual
S9128 Speech therapy, in the home, per diem
CODING BITES
Learn about the other These two codes report similar services: speech therapy provided to an individual.
types of HCPCS Level However, they differ with regard to location, length of the session, and possibly the
II codes in the section ­professional providing the therapy. Be certain to read the CPT in-section guidelines
Equipment and Supplies related to the reporting of 92507 (and other codes in this subsection) before you decide.
in this chapter. And, of course, you need to carefully abstract the details within the documentation
And learn more from which you are coding and compare the specifics to each of the code descriptions,
about the HCPCS and perhaps to any others available. Then, and only then, can you determine which
Level II code set in the code to report.
chapter HCPCS Level II. Don’t worry . . . one item, one detail, one concept at a time. It will take time, but we are
confident you will be able to understand, learn, and master coding for health care services.

1.4 Equipment and Supplies

A large number of components of health care extend beyond what are usually referred
to as procedures, services, and treatments you learned about earlier in Section 1.3

16 PART I | MEDICAL CODING FUNDAMENTALS

ISTUDY
Another random document with
no related content on Scribd:
rebel resistance by proclaiming that it was the intention of the Duke
of Cumberland to transport the Highlanders to America. On April 3rd,
the rebels captured Blair Castle, and on the 16th the duke’s victory
at Culloden proved decisive of the fate of the Stuarts.
Exactly a week after the Duke of Cumberland gained the victory, a
report to that effect reached London, but there was no news from the
duke himself till the 25th. His business-like account of the battle
appeared in the ‘London Gazette’ next day. In the interim the London
Jacobites in their places of resort asserted loudly that the duke was
in full retreat; and it was whispered that if he was hopelessly beaten,
the ‘Papists would rise all over the kingdom.’ But now ‘hope’ herself
was beaten out of the souls of Papists and Jacobites. The military in
London were in a vein of swaggering delight. They talked of the
young duke’s briefly heroic address to a cavalry regiment on the
point of charging. He patted the nearest man to him on the back, and
cried aloud, ‘One brush, my lads, for the honour of old Cobham!’
Then was curiosity stirred in London barracks as to
NEWS OF
which regiments were to get the prize for bravery, CULLODEN.
subscribed by the Corporation of London—namely
5,000l. The duke so wisely distributed it as to rebuke nobody.
Veterans at Chelsea were looking at the vacant spaces where they
should hang the captured flags, and were disappointed when they
heard at the Horse Guards that the duke, considering that it was said
how little honour was connected with such trophies, had sent the
flags to Edinburgh to be burnt by the common hangman. The
Chelsea veterans, however, envied the capturers of the (four) flags;
for to each man the duke gave sixteen guineas. Medals and crosses
were not yet thought of. His generosity was lauded as
enthusiastically as his valour.
While the Jacobites were overwhelming him with charges of
cruelty and meanness, the friends of ‘the present happy
establishment’ were circulating stories in and about London of his
humanity and liberality. Soldiers of the young Chevalier’s army had
wreaked their vengeance upon Mr. Rose, the minister at Nairn—on
himself and his house. He was a Whig and anti-Romanist, who had
favoured the escape of some prisoners taken by the Jacobite army.
The Highlanders burnt his house, and, tying the minister up, they
gave him 500 lashes. The duke, on hearing of this outrage, fell into
uncontrollable fury, and swore he would avenge it. If there was some
savagery at and after Culloden, no wonder! Such, at least, was the
London feeling among the duke’s friends. But the feeling generally
was one of ecstacy at the decisive victory. Lord Bury, who had
arrived on the 25th with the news direct from the duke to the king,
could hardly walk along the then terraced St. James’s Street for the
congratulations of the crowd. Nobody thought such a halcyon
messenger was too highly rewarded with a purse of a thousand
guineas, and with being nominated own aide-de-camp to King
George.
That 25th of April was indeed a gala day for the
A POPULAR
London mob. They had ample time for breakfast HOLIDAY.
before they gathered at the ‘end of New Bond Street,
in Tyburn Road’ (as Oxford Street was then called), to see the young
footman, Henderson, hanged for the murder of his mistress, Lady
Dalrymple. The culprit did not die ‘game,’ and the brutes were
disappointed, but they found consolation in the fall of a scaffolding
with all its occupants. Then they had time to pour into the Park and
see four or five sergeants shot for trying to desert from King
George’s service to King James’s. Moreover there was a man to be
whipt somewhere in the City, and a pretty group of sight-seers
assembled at Charing Cross in expectation of ‘a fellow in the pillory.’
What with these delights, and the pursuing Lord Bury with
vociferations of sanguinary congratulation, the day was a thorough
popular holiday.
The anxiety that had been felt in London before Culloden may be
measured by the wild joy which prevailed when the news of the
victory arrived. Walpole, in Arlington Street, on the evening of the
25th April, writes: ‘The town is all blazing around me as I write with
fireworks and illuminations. I have some inclination to wrap up half a
dozen sky-rockets to make you drink the duke’s health. Mr.
Dodington, on the first report, came out with a very pretty
illumination, so pretty that I believe he had it by him, ready for any
occasion.’
 On the same evening the Rev. Mr. Harris wrote from London to
the mother of the future first Earl of Malmesbury, just born: ‘You
cannot imagine the prodigious rejoicings that have been made this
evening in every part of the town; and indeed it is a proper time for
people to express their joy when the enemies of their country are
thus cut off.’
On that evening Alexander Carlyle was with CARLYLE AND
Smollett in the Golden Ball coffee-house, Cockspur SMOLLETT.
Street. ‘London,’ he says, ‘was in a perfect uproar of
joy. About nine o’clock I asked Smollett if he was ready to go, as he
lived at May Fair’ (Carlyle was bound for New Bond Street on a
supper engagement). ‘He said he was, and would conduct me. The
mob were so riotous and the squibs so numerous and incessant that
we were glad to go into a narrow entry to put our wigs into our
pockets, and to take our swords from our belts and walk with them in
our hands, as everybody then wore swords; and after cautioning me
against speaking a word lest the mob should discover my country
and become insolent, “John Bull,” says he, “is as haughty and valiant
to-night, as he was abject and cowardly on the Black Wednesday
(Friday?) when the Highlanders were at Derby.” After we got to the
head of the Haymarket through incessant fire, the doctor led me by
narrow lanes where we met nobody but a few boys at a pitiful
bonfire, who very civilly asked us for sixpence, which I gave them. I
saw not Smollett again for some time after, when he showed Smith
and me the manuscript of his “Tears of Scotland,” which was
published not long after, and had such a run of approbation.’
Smollett was one of those Tories who, like many of
‘TEARS OF
the Nonjurors, were not necessarily or consequently SCOTLAND.’
Jacobites. They were more willing to make the best of
a foreign king than to risk their liberties under an incapable bigot like
James Stuart, who, save for the accident of birth, was less of an
Englishman and knew less of England (in which, throughout his life,
he had only spent a few months) than either of the Georges. But
Smollett felt keenly the sufferings of his country, and out of the
feeling sprung his verses so full of a tenderly expressed grief,—‘The
Tears of Scotland!’ How that mournful ode was written in London in
this year of mournful memories for the Jacobites, no one can tell
better than Walter Scott. ‘Some gentlemen having met at a tavern,
were amusing themselves before supper with a game of cards, while
Smollett, not choosing to play, sat down to write. One of the
company (Graham of Gartmoor), observing his earnestness and
supposing he was writing verses, asked him if it was not so. He
accordingly read them the first sketch of the “Tears of Scotland,”
consisting only of six stanzas, and on their remarking that the
termination of the poem being too strongly expressed might give
offence to persons whose political opinions were different, he sat
down without reply and, with an air of great indignation, subjoined
the concluding stanza:—
While the warm blood bedews my veins INDIGNATION
And unimpair’d remembrance reigns, VERSES.
Resentment of my country’s fate
Within my filial breast shall beat.
Yes! spite of thine insulting foe,
My sympathising verse shall flow;
Mourn, hapless Caledonia, mourn
Thy banish’d peace, thy laurels torn!’
The following were the lines which were supposed to be likely to
offend the friends of the hero of Culloden; but the sentiment was
shared by many who were not friends of the Stuart cause:—
Yet, when the rage of battle ceased,
The victor’s rage was not appeased;
The naked and forlorn must feel
Devouring flames and murd’ring steel.
The pious mother, doom’d to death,
Forsaken, wanders o’er the heath, &c., &c.
The picture was somewhat over-drawn, but there were thousands
who believed it to be true to the very letter.
 CHAPTER VII.

(1746.)
he players and the playwrights were zealous Whigs
throughout the rebellion. The Drury Lane company to a
man became volunteers, under their manager, Mr.
Lacy, who had asked the royal permission to raise a
couple of hundred men, in defence of his Majesty’s
person and Government. To attract loyal audiences at a time when
the public could not be readily tempted to the theatre, ‘The Nonjuror’
was revived, at both houses. Two players, Macklin and Elderton, set
to work to produce plays for their respective theatres, on the subject
of Perkin Warbeck. While Macklin was delivering what he wrote,
piecemeal, to the actors, for study, and Elderton was perspiring over
his laborious gestation of blank-verse, the proprietors of the
playhouse in Goodman’s Fields forestalled both by bringing out
Ford’s old play, which is named after the Pretender to the throne of
Henry VII. Macklin called his piece ‘Henry VII., or the Popish
Impostor.’ This absurd allusion to Perkin was a shaft aimed at the
actual Pretender. The Whigs approved of both title and play, and
they roared at every line which they could apply against Tories and
Jacobites. At both houses, occasional prologues
THE PLAYERS.
stirred the loyal impulses or provoked the indignation
of the audience. At Covent Garden, ‘Tamerlane,’ which was always
solemnly brought out when the popular wrath was to be excited
against France, was preceded by a patriotic prologue which Mrs.
Pritchard delivered in her best manner, and Dodsley sold the next
day, as fast as he could deliver copies over the counter of his shop in
Pall Mall. Rich and his Covent Garden players did not turn soldiers,
but he gave the house, gratis, for three days for the benefit of a
scheme that was to be to the advantage of the veterans of the army;
and this brought 600l. to the funds. The actors sacrificed their
salaries, and charming Mrs. Cibber sang as Polly, in the ‘Beggars’
Opera’ more exquisitely than ever, to prove (as she said) that,
‘though she was a Catholic, she was sincerely attached to the family
who was in possession of the Throne, and she acknowledged the
favour and honour she had received from them.’ On the night when
the first report of the victory at Culloden was circulated, Drury Lane
got up a play that had not been acted for thirty years, ‘The Honours
of the Army,’ and Mrs. Woffington, as ‘The Female Officer,’ ‘new
dressed,’ spoke a dashing prologue. A night or two later, Theophilus
Cibber wrote and delivered a prologue on the Duke of Cumberland’s
victories. At Covent Garden were revived two pieces, by Dennis:
‘Liberty Asserted’ and ‘Plot and no Plot.’ Genest says of the first
piece that it was revived ‘for the sake of the invectives against the
French; and “Plot and no Plot,” for the sake of the cuts on the
Jacobites,—at this time almost every play was revived, which might
be expected to attract, from its political tendency.’
The minor, or unlicensed, theatres tempted loyal people with
coarser fare,—to the same end, keeping up a hostile feeling against
the French and the Jacobites. Observe with what quaint delicacy the
matter is put in the following advertisements.
‘As the Proprietors of Sadler’s Wells have diligently
SADLER’S
embraced every opportunity of giving their audiences WELLS AND
satisfaction, they would have thought themselves THE NEW
guilty of the highest Error to have been silent upon WELLS.
the present happy occasion. Every Class of Britons must be pleased
at the least Hint of Gratitude to the excellent Prince who has
exposed himself to so many Difficulties for the sake of his country,
and therefore they have endeavour’d to show a Natural Scene of
what perhaps may happen to many a honest Countryman in
consequence of the late happy Victory, in a new Interlude of Music,
called Strephon’s Return, or the British Hero, which will be perform’d
this Night, with many advantages of Dress and Decoration.’
But ‘how the wit brightens and the style refines’ in the following
announcement from Mr. Yeates!
‘The Applause that was so universally express’d
CULLODEN
last Night, by the numbers of Gentlemen et cætera ON THE
who honoured the New Wells near the London Spaw, STAGE.
Clerkenwell, with their Company, is thankfully acknowledg’d; but Mr.
Yeates humbly hopes that the Ideas of Liberty and Courage (tho’ he
confesses them upon the present Occasion extremely influencing)
will not for the future so far transport his Audiences as to prove of
such Detriment to his Benches; several hearty Britons, when
Courage appeared (under which Character, the illustrious Duke,
whom we have so much reason to admire, is happily represented)
having exerted their Canes in such a Torrent of Satisfaction as to
have render’d his Damage far from inconsiderable.’
The other ‘New Wells’ declined to be outdone. There too, love and
liquor were shown to be the reward due to valiant Strephons
returning from Culloden to London. There, they were taught to ‘hate
a Frenchman like the Devil;’ and there, they and the public might see
all the phases of the half-hour’s battle, and of some striking incidents
before and after it, all painted on one canvas.
‘At the New Wells, the Bottom of Lemon Street, Goodman’s
Fields, this present Evening will be several new Exercises of Rope-
dancing, Tumbling, Singing, and Dancing, with several new Scenes
in grotesque Characters call’d Harlequin a Captive in France, or the
Frenchman trapt at last. The whole to conclude with an exact view of
our Gallant Army under the Command of their Glorious Hero passing
the River Spey, giving the Rebels Battle and gaining a Complete
Victory near Culloden House, with the Horse in pursuit of the
Pretender.’
To these unlicensed houses, admission was gained not by
entrance money, but by paying for a certain quantity of wine or
punch.
It would, however, appear as if some of the bards, MRS.
like Bubb Dodington with his transparency, had so WOFFINGTON.
contemplated the result of the war, as to be ready to
hail any issue, and any victor. One of these, the Jacobites being
defeated, wrote an epilogue, ‘designed to be spoken by Mrs.
Woffington, in the character of a Volunteer;’—but the poem was not
finished till interest in the matter had greatly evaporated, and the
poet was told he was ‘too late.’ Of course, he shamed the rogues by
printing his work,—which is one illustrating both the morals and the
manners of the time. It illustrates the former by infamously indecent
inuendo, and the latter by the following outburst, for some of the
ideas of which the writer had rifled Addison’s ‘Freeholder.’
Joking apart, we women have strong reason
To sap the progress of this popish treason;
For now, when female liberty’s at stake,
All women ought to bustle for its sake.
Should these malicious sons of Rome prevail,
Vows, convents, and that heathen thing, a veil,
Must come in fashion; and such institutions
Would suit but oddly with our constitutions.
What gay coquette would brook a nun’s profession?
And I’ve some private reasons ’gainst confession.
Besides, our good men of the Church, they say
(Who now, thank Heaven, may love as well as pray)
Must then be only wed to cloister’d houses;—
Stop! There we’re fobb’d of twenty thousand spouses!
And, faith! no bad ones, as I’m told; then judge ye,
Is’t fit we lose our benefit of clergy?
In Freedom’s cause, ye patriot fair, arise!
Exert the sacred influence of your eyes.
On valiant merit deign alone to smile,
And vindicate the glory of our isle.
To no base coward prostitute our charms;
Disband the lover who deserts his arms.
So shall ye fire each hero to his duty,
And British rights be saved by British beauty.
The Whig press was, of course, jubilant. The THE PRESS,
papers in the opposite interest put as good a face as ON
CULLODEN.
they could on the matter, and expressed a conviction
that they ‘ventured no treason in hoping that the weather might
change.’
 The ‘Craftsman’ was, or affected to be, beside itself for joy at the
thought that no foreign mercenaries had helped to reap the laurels at
Culloden. The victory was won by British troops only; and the duke
might say, like Coriolanus, ‘Alone, I did it!’ The ‘True Patriot’ insisted
on some share of the laurels being awarded to the king, since he
stood singly in refusing to despair of the monarchy, when all other
men were, or seemed, hopeless and helpless. To which the ‘Western
Journal’ added that not merely was the king far-seeing, and the duke
victorious at the head of English troops without foreign auxiliaries,
but that never before had an English army made its way so far into
the country, to crush a Scottish foe. The ‘Journal,’ much read in all
London coffee-houses resorted to by Western gentlemen, was
opposed to the killing of rebels in cold blood, and could not see what
profit was to be got by hanging them. This paper suggested that
some benefit might be obtained by making slaves of them; not by
transporting them to the Plantations, but by compelling them to serve
in the herring and salmon fisheries, for the advantage of the
compellers, that is, the Government!
In the ‘General Advertiser,’ a man who probably
SAVAGERY
had reached the age when a sense of humanity fails AND SATIRE.
before any of the other senses, asked what objection
was to be found with such terms as ‘Extermination,’ ‘Extirpation,’ and
similar significances applied to those savages, the Highlanders? This
ogre, in his easy chair, cared not to see that, in driving out a whole
race, more cruelty would be deliberately inflicted on innocent human
beings, than the savage Highlanders had inflicted in their fury. And
indeed, the latter did not spare their own people, if the milkmaids’
song be true, in which the illustrative line occurs, ‘We dare na gae a
milkin’ for fear o’ Charlie’s men.’ However, the least punishment
which the correspondent of the ‘Advertiser’ would accept was a
general transportation of the race to Africa and America, and a
settlement on their lands of English tenants at easy rents! This sort
of Highlander-phobia and the threatened application of severe laws
which included the suppression of what has been called ‘the Garb of
old Gael,’ or Highland dress, gave rise to some good-natured satire.
‘We hear,’ said one of the newspapers, ‘that the dapper wooden
Highlanders, who guard so heroically the doors of snuff shops,
intend to petition the Legislature in order that they may be excused
from complying with the Act of Parliament with regard to their change
of dress, alleging that they had ever been faithful subjects to his
Majesty, having constantly supplied his Guards with a pinch out of
their Mulls, when they marched by them; and so far from engaging in
any Rebellion, that they have never entertained a rebellious thought,
whence they humbly hope that they shall not be put to the expense
of buying new Cloaths.’
So spoke the fun-loving spirits; but there were
THE
baser spirits on the conquering side, and these CARICATURIS
speedily exhibited an indecent exultation. The TS.
ignominious caricaturists attracted crowds to the print
shops to gaze at the facility with which vulgar minds can degrade
solemn and lofty themes. On the one hand, the defeat of the
Highlanders and the consternation of Sullivan, the standard-bearer in
Charles Edward’s army, attracted laughter. On the other hand, the
too early, and altogether vain, boast conveyed on the young
Chevalier’s banner, ‘Tandem triumphans,’ was more legitimately
satirised in an engraving in which the standard-bearer is an ass, and
on his standard are three crowns surmounted by a coffin, with the
motto ‘Tandem triumphans,’ done into English by the Duke of
Cumberland, as equivalent to ‘Every dog has his day;’—which, after
all, was no great compliment to the duke. The triple crown and coffin
represented the issue of crown or grave; in one print the Devil is
seen flying with it over Temple Bar, as if it merited to be planted
there, as were afterwards the spiked heads of Towneley and of
Fletcher.
Jacobite sympathies were attracted and puzzled PSEUDO-
by a portrait of ‘The young Chevalier,’ which was to PORTRAIT OF
be seen, for sale, in every printshop. Alexander CHARLES
Carlyle gives an amusing account of it in his EDWARD.
‘Autobiography.’ ‘As I had seen,’ he says, ‘the Chevalier Prince
Charles frequently in Scotland, I was appealed to, if a print that was
selling in all the shops was not like him? My answer was, that it had
not the least resemblance. Having been taken one night, however, to
a meeting of the Royal Society, by Microscope Baker, there was
introduced a Hanoverian Baron, whose likeness was so strong to the
print which passed for the young Pretender, that I had no doubt that,
he being a stranger, the printsellers had got him sketched out, that
they might make something of it before the vera effigies could be
had. The latter, when it could at last be procured, was advertised in
cautious terms, as ‘A curious Head, painted from the Life, by the
celebrated M. Torcque, and engraved in France, by J. G. Will, with
proper decorations in a new taste.’ Beneath the portrait, the following
verses were inscribed:—
‘Few know my face, though all men do my fame,
Look strictly and you’ll quickly guess my name.
Through deserts, snows, and rain I made my way,
My life was daily risk’d to gain the day.
Glorious in thought, but now my hopes are gone,
Each friend grows shy, and I’m at last undone.’
Fear of him, and of his followers, was far from having died out. A
letter in the ‘Malmesbury Correspondence,’ dated May, might almost
have been written by the advocate of Extermination, in the
‘Advertiser;’—the rev. writer says: ‘A Bill is now preparing and will
soon be brought into the House of Lords, for putting the Highlands of
Scotland under quite a new regulation, and you may be assured,
until some bill is passed effectually to subdue that herd of savages,
we shall never be free from alarms of invasion in the North of
England.’
Lord Stair, then in London, was more hopeful, and expressed a
belief that the king would now have weight in the affairs of Europe.
‘Fifty battalions and fifty squadrons well employed, can cast the
balance which way his Majesty pleases.’ Derby captains now looked
to shake themselves out of mere tavern-life; while spirited young
fellows thought of commissions, and the figure they would cut in new
uniforms.
Meanwhile, the Government was not meanly
THE DUKE OF
hostile to their dead enemies. The Duke of Ormond, ORMOND.
the boldest and frankest of conspirators against the
Hanoverian succession; the man who more than once would have
invaded his country at the head of foreign troops; he who had
fostered rebellion, and maintained foiled rebels, during his thirty
years’ exile, had, at last, died in his eighty-third year. King and
ministers made no opposition to the interment of this splendid arch-
traitor in Westminster Abbey. His anonymous biographer (1747),
after stating that the duke died, on November 14th, 1745, at
Avignon, says: ‘On the 18th, his body was embalmed by four
surgeons and three physicians, and in the following month, May, as
a bale of goods, brought through France to England, and lodg’d in
the Jerusalem Chamber, and soon after, decently enterr’d.’
There was something more than mere ‘decency.’ In BURIAL OF
the ‘General Advertiser,’ May 23rd, it is announced, ORMOND.
but without a word of comment on the great Jacobite:
—‘Last night, about Eleven o’Clock, the Corps of the late Duke of
Ormond was, after lying in State, in the Jerusalem Chamber,
Westminster Abbey, interr’d in great Funeral Pomp and Solemnity, in
the Ormond Vault in King Henry the Seventh’s Chapel, the whole
Choir attending, and the Ceremony was perform’d, by the Right Rev.
the Lord Bishop of Rochester and Dean of Westminster.’
But the popular attention was directed to the other ‘Duke.’
Whatever Tories may have said at the time, or people generally,
since that period as to the character of the Duke of Cumberland, he
was the popular hero from the moment he arrived in London, after
the victory at Culloden. The papers were full of his praises. They
lauded not only his valour but his piety. After the battle, so they said,
he had gone unattended over the battle-field, and he was not only
seen in profound meditation, but was heard to exclaim,—his hands
on his breast, and his eyes raised to heaven—‘Lord! what am I that I
should be spared, when so many brave men lie dead upon the
spot?’ Even Scotsmen have owned that the duke attributed his
victory to God, alone, and that he was unmoved by the adulation of
that large body of Englishmen who were grateful at having been
relieved by him from a great danger. They compared him with the
Black Prince, who won the day at Poictiers, when he was about the
same age as the duke, when he triumphed at Culloden. The latter
was then in his twenty-sixth year.
 The orderly-books of the Duke of Cumberland,
THE
recently published, fail to confirm the reports of his QUESTION OF
cruelty after Culloden. The Jacobites exaggerated his INHUMANITY.
severity, and they gave the provocation. That an order
was given to the Highlanders to refuse quarter to the troops under
the Duke of Cumberland is proved by Wolfe’s well-known letter. The
only trace of retaliatory rigour is to be found in the following entry in
the above book (Maclachlan’s ‘William Augustus, Duke of
Cumberland,’ p. 293): ‘Inverness, April 17th.—The ‘Officers next
from Duty to come from Camp, in order to divide and search the
Town for Rebels, their effects, stores, and baggage. A Captain and
50 Men to march immediately to the field of Battle, and search all
cottages in the neighbourhood for Rebels. The Officers and Men will
take notice that the public orders of the Rebels yesterday were to
give us no quarter.’ In Wolfe’s letter (he was then on the staff, and
one of Hawley’s aides-de-camp), written on the day the above order
was issued, that young officer says: ‘Orders were publicly given in
the rebel army, the day before the action, that no quarter should be
given to our troops.’ The latter, it is equally true, had said on leaving
London for the North that they would neither give nor take quarter;
but they had no orders to such cruel effect. It was soldierly swagger.
At the very outset, what savagery there was, was fostered by the
London gentlemen who lived at home at ease. Walpole suggested if
Cumberland were sent against the Jacobite army, ‘it should not be
with that sword of Mercy with which the present Family have
governed their people. Can rigour be displaced against bandits?’
But, if the young duke should be full of compassion after victory,
Walpole rejoiced to think that in General Hawley there was a military
magistrate of some fierceness, who would not sow the seeds of
disloyalty by too easily pardoning the rebels.
It was said in the London newspapers that the INSTIGATORS
French did not act at the Battle of Culloden, by reason OF CRUELTY.
of their being made acquainted with the order of
giving no quarter to our troops; and that the French Commanding
Officer declared that rather ‘than comply with such a Resolution he
would resign himself and Troops into the Hands of the Duke of
Cumberland; for his directions were to fight and not to commit
Murder.’
While London was awaiting the return of the hero, THE
whose triumphs had already been celebrated, the PRISONERS IN
anti-Jacobites were disappointed by being deprived of LONDON.
greeting in their rough way the arrival of the captured
rebel lords. As early, indeed, as November 1745, Charles Radcliffe
(calling himself Lord Derwentwater) had been taken with his son on
board the ‘Soleil,’ bound for Scotland and high treason, and these
had been got into the Tower, at peril to their lives. But others were
expected. The Earl of Cromartie and his son, Lord Macleod, had
been taken at Dunrobin the day before Culloden. The Earl of
Kilmarnock had been captured in the course of the fight; Lord
Balmerino a day or two after. The old Marquis of Tullibardine, who
had been in the fray of ’15, the attempt in ’19, and had escaped after
both, missed now his old luck; that passed to his brother, Lord
George Murray, who got clear off to the Continent. Lord Tullibardine
being sorely pressed and in great distress, sought the house of
Buchanan of Drummakill. It is a question whether Tullibardine asked
asylum or legally surrendered himself. In either case, he was given
up. The above lords were despatched to London by sea in two
separate voyages. Thus they were spared the insults undergone
thirty years before by Lord Derwentwater and his unfortunate
companions. On June 29th, Walpole writes: ‘Lady Cromartie went
down incog. to Woolwich to see her son pass by, without the power
of speaking to him. I never heard a more melancholy instance of
affection.’ Lord Elcho, who had escaped, solicited a pardon; but,
says Walpole, ‘as he has distinguished himself beyond all the rebel
commanders by brutality and insults and cruelty to our prisoners, I
think he is likely to remain where he is.’ Walpole was of opinion that
the young Chevalier was allowed to escape. He also says: ‘The duke
gave Brigadier Mordaunt the Pretender’s coach, on condition he
rode up to London in it. “That I will, sir,” said he, “and drive till it stops
of its own accord at the Cocoa Tree”—the Jacobite Coffee House in
St. James’s Street.’
 With leafy June came the duke; but before him
THE DUKE IN
arrived his baggage. When that baggage which the ABERDEEN.
duke and General Hawley brought with them from
Scotland was unpacked in London, the articles of which it consisted
must have excited some surprise. To show what it was, it is
necessary to go northward to the house of Mr. Thompson, advocate,
in the Great Row, Aberdeen. The duke had his quarters in that
house, after his state entry into the granite city, in February 1746. Six
weeks were the Thompsons constrained to bear with their illustrious
but unprofitable lodger. They had to supply him with coals, candles,
the rich liquids in the advocate’s cellars, and all the milk of his sole
cow. The bed and table linen was both used and abused. The duke
is even charged with breaking up a press which was full of sugar, of
which he requisitioned every grain. At the end of the six weeks,
when about to march from the city, the duke left among the three
servants of the house as many guineas. This was not illiberal; but
Mr. and Mrs. Thompson were chiefly aggrieved by his Highness’s
lack of courtesy. He went away without asking to see them, or
leaving any acknowledgment of their hospitality by sending even a
curt thank ye! General Hawley behaved even more rudely in the
house of Mrs. Gordon of Hallhead. Before he took possession it was
understood that everything was to be locked up, and that the general
was only to have the use of the furniture. This gallant warrior, as
soon as he had flung his plumed hat on the table, demanded the
keys. Much disputation followed, with angry
LOOTING.
squabbling, and the keys were only given up on the
general’s threat that he would smash every lock in the house. The
yielding came too late. General and duke together declared all the
property of Mrs. Gordon to be confiscated, except the clothes she
wore. ‘Your loyalty, Madam,’ said Major Wolfe to her, ‘is not
suspected;’ which made the poor lady only the more perplexed as to
why she was looted. The major politely offered to endeavour to get
restored to her any article she particularly desired to recover. ‘I
should like to have all my tea back,’ said Mrs. Gordon. ‘It is good
tea,’ said the major. ‘Tea is scarce in the army. I do not think it
recoverable.’ It was the same with the chocolate and many other
things agreeable to the stomach. ‘At all events,’ said the lady, ‘let me
have my china again!’ ‘It is very pretty china,’ replied the provoking
major, ‘there is a good deal of it; and we are fond of china ourselves;
but, we have no ladies travelling with us. I think you should have
some of the articles.’ Mrs. Gordon, however, obtained nothing. She
petitioned the duke, and he promised restitution; but, says the lady
herself, ‘when I sent for a pair of breeches for my son, for a little tea
for myself, for a bottle of ale, for some flour to make bread, because
there was none to be bought in the town, all was refused me!’ ‘In
fact, Hawley, on the eve of his departure,’ Mrs. Gordon tells us,
‘packed up every bit of china I had, all my bedding and table linen,
every book, my repeating clock, my worked screen, every rag of my
husband’s clothes, the very hat, breeches, night-gown, shoes, and
what shirts there were of the child’s; twelve tea-spoons, strainer and
tongs, the japanned board on which the chocolate and coffee cups
stood; and he put them on board a ship in the night time.’
Out of this miscellaneous plunder, a tea equipage
THE DUKE
and a set of coloured table china, addressed to the AND HIS
Duke of Cumberland at St. James’s, reached their PLUNDER.
destination. With what face his Highness could show
to his London friends the valuable china he had stolen from a lady
whose loyalty, he allowed, was above suspicion, defies conjecture.
The spoons, boy’s shirts, breeches, and meaner trifles, were packed
up under an address to General Hawley, London. ‘A house so
plundered,’ wrote the lady, ‘I believe was never heard of. It is not
600l. would make up my loss; nor have I at this time a single table-
cloth, napkin, or towel, teacup, glass, or any one convenience.’ One
can hardly believe that any but the more costly articles reached
London. Moreover, whatever censure the Londoners may have cast
upon the plunderers, the duke was not very ill thought of by the
Aberdeen authorities. When the duke was perhaps sipping his tea
from the cups, or banquetting his friends at St. James’s off Mrs.
Gordon’s dinner-service, a deputation from Aberdeen brought to his
Highness the ‘freedom’ of the city, with many high compliments on
the bravery and good conduct of the victor at Culloden!
The duke got tired of his tea-set. He is said to have presented it to
one of the daughters of husseydom, and the damsel sold it to a
dealer in such things. A friend of Mrs. Gordon’s saw the set exposed
for sale in the dealer’s window, and on inquiry he learnt, from the
dealer himself, through what clean hands it had come into his
possession.
If report might be credited the Duke of Cumberland A HUMAN
brought with him to London, and in his own carriage, HEAD.
a human head, which he believed to be that of
Charles Edward! Young Roderick Mackenzie called to the soldiers
who shot him down in the Braes of Glenmorristen, ‘Soldiers, you
have killed your lawful prince!’ These words, uttered to divert pursuit
from the young Chevalier, were believed, and when Roderick died,
the soldiers cut off his head and brought it to the Duke of
Cumberland’s quarters. Robert Chambers, in his ‘History of the
Rebellion,’ qualifies with an ‘it is said’ the story that the duke stowed
away the head in his chaise, and carried it to London. Dr. Chambers
adds, as a fact, that Richard Morrison, Charles Edward’s body-
servant, and a prisoner at Carlisle, was sent for to London, as the
best witness to decide the question of identity. Morrison fainted at
this trial of his feelings; but regaining composure, he looked steadily
at the relic, and declared that it was not the head of his beloved
master.
But all minor matters were forgotten in the general ‘SWEET
joy. Now the duke was back in person, loyal London WILLIAM.’
went mad about ‘the son of George, the image of
Nassau!’ Flattery, at once flowery and poetical, was heaped upon
him. A flower once dedicated to William III. was now dedicated to
him. The white rose in a man’s button-hole or on a lady’s bosom, in
the month of June, was not greater warranty of a Jacobite than the
‘Sweet-William,’ with its old appropriate name, was of a Whig to the
back-bone. Of the poetical homage, here is a sample:—
The pride of France is lily-white,
The rose in June is Jacobite;
The prickly thistle of the Scot
Is Northern knighthood’s badge and lot.
But since the Duke’s victorious blows,
The Lily, Thistle, and the Rose
 All droop and fade and die away:
Sweet William’s flower rules the day.
’Tis English growth of beauteous hue,
Clothed, like our troops, in red and blue.
No plant with brighter lustre grows,
Except the laurel on his brows.
Poetasters converted Horace’s laudation of Augustus FLATTERY.
into flattery of Cumberland. Fables were written in
which sweet William served at once for subject and for moral.
Epigrams from Martial, or from a worse source—the writers’ own
brains—were fresh but bluntly pointed in his favour. Some of them
compared him to the sun, at whose warmth ‘vermin cast off their
coats and took wing.’ Others raised him far above great Julius; for
Cumberland ‘conquers, coming; and before he sees.’ Sappho, under
the name of Clarinda, told the world, on hearing a report of the
duke’s illness, that if Heaven took him, it would be the death of her,
and that the world would lose a Hero and a Maid together. Heroic
writers, trying Homer’s strain, and not finding themselves equal to it,
blamed poor Homer, and declared that the strings of his lyre were
too weak to bear the strain of the modern warrior’s praise.
Occasional prologues hailed him as ‘the martial boy,’ on the day he
entered his twenty-sixth year. Pinchbeck struck a medal in his
honour; punsters in coffee-houses rang the changes on metal and
mettle, and Pinchbeck became almost as famous for the medal as
he subsequently became for his invention of new candle-snuffers,
when the poets besought him to ‘snuff the candle of the state, which
burned a little blue.’ In fine, ballads, essays, apologues, prose and
poetry, were exhausted in furnishing homage to the hero. The
homage culminated when the duke’s portrait appeared in all the
shops, bearing the inscription, ‘Ecce Homo!’