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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

Another random document with
no related content on Scribd:
It was only the vicar's dog who had accidentally found his way in, but he was dressed in a paper cap,
and though he turned his head from side to side he could not get it off.

There was holly on the stair-rail and it pricked Noel; he leant over farther to get away from it, and
then to the horror of Nurse, who had followed him out, she saw him over balance himself, and with a
sudden awful thud, his little figure fell, his head striking the tiled floor of the hall with awful force.

Chris uttered a horrified cry which brought his mother out of her room.

She was the first to reach her darling, and raised him in her arms; but he lay still and unconscious. It
had been so swift, so sudden an accident, that he had not had time to utter a cry.

The little household gathered round him.

"He is killed!" cried Diana and Chris together.

"No—no—stunned!" said Mrs. Inglefield in her agony, still striving to allay the fears of her children.

Then she turned to Chris:

"Fetch the doctor. Go on your bicycle. Nurse, come with me."

Diana watched the limp, unconscious form of her small brother being carried upstairs. Mrs. Tubbs
followed Nurse; Cassy put her apron up to her eyes and began to cry.

"Oh, Miss Diana, 'tis his birthday; what an end to it!"

Diana seemed turned to stone.

How and why did these things happen? They were all so happy a few minutes ago, and now Noel
was perhaps dead and would never speak or laugh again.

She went slowly into the dining-room. The tea was all laid upon the table, the silver kettle boiling over
the methylated lamp. They would have all been sitting round the table now, mother would be pouring
out the tea, Noel's cake would have delighted him. It was a surprise—made by Mrs. Tubbs, who had
put her very best work into it. It was a big iced cake, and had seven candles upon it. In the centre
was a tiny little Christmas tree—a copy of Noel's. Its leaves and branches were frosted with sugar
and a robin perched on the topmost branch. In pink letters on the white surface was written:

"Noel Inglefield. Happy Returns of his Birthday,

and best Christmas Wishes."

As Diana gazed at the cake, tears crowded into her eyes.

Noel's cake! And he might never see it!

There were crackers round the table. What fun they would have had! There were jam sandwiches
and sugarcoated biscuits, and coco-nut cakes and shortbread.

Who would enjoy the tea now, when Noel lay dead or dying upstairs?

"Oh, it's awful! awful!" she cried, "worse than anything I have ever thought of or made up for my
stories! And I've spoken so crossly to him to-day, even though it was his birthday! Oh, what shall we
do! What shall we do!"
When Chris returned he found Diana pacing the hall like a demented person.

The doctor followed on his heels, and with two or three strides had mounted the stairs and gone into
the nursery.

"Oh, Chris," said Diana with tearful eyes, "what shall we do? I believe he is quite dead already."

"He can't be," said Chris. "Wasn't it awful seeing him fall! I've been thinking the whole way along to
the doctor's and back, of my cross words to him about the carol. We haven't been kind to him, Dinah
—over and over again we haven't! And we can't ask him to forgive us. And it's his birthday. Do you
think we could pray to God? Noel gets all his prayers answered, he says."

"He's so fond of God," moaned Diana; "perhaps God is very fond of him and wants him in heaven. I
wish mother would come to us."

But it was a long while before their mother came, and when she did, all the glow and brightness of
her face had vanished. She and the doctor went into her boudoir and talked a little, and then he went
away, saying:

"I'll be up the first thing in the morning, but there's nothing more can be done."

Then Chris and Diana crept up to their mother.

"Is he dead, Mums?" Chris whispered.

Mrs. Inglefield looked at them sorrowfully.

"He is very, very ill, dear. It is bad concussion of the brain, and he may be unconscious for a long
time. We must ask God to spare his precious little life."

A choke came in her voice, then she seemed to pull herself together.

"We must have some tea. Nurse is watching by him, and I will go and relieve her soon. Come along."

That was a most miserable meal for both mother and children.

Noel's chair opposite his cake was empty. His cheerful little voice, which was always making itself
heard, was hushed and silent now. Would they ever hear it again, his mother wondered?

And at last in desperation Chris spoke out his thoughts:

"Why has God let it happen on his birthday and on Christmas night, Mums? Any other time it
wouldn't have been so bad."

"Be quiet," said Diana in a whisper, giving him an angry nudge. "You'll only make Mums more
miserable."

Mrs. Inglefield caught the whisper.

"No, he won't, dear. God loves Noel better than any of us. He has sent this trouble to us for some
good reason. We must never question God's will."

The children were silent. They were glad when tea was over, but when their mother left them to
return to the sickroom, they wandered about the house, not knowing what to do with themselves.
Nurse came down at last, and told them that they must keep out of the nursery, as Noel must be kept
as quiet as possible.
"I should go to bed early if I were you," she told them. "Perhaps your little brother will be better to-
morrow morning."

"I know why God has let this accident happen," said Diana to Chris when Nurse had left them, and
they had gone into their mother's boudoir, and sitting down on two chairs near the fire had faced
each other in despairing silence; "it is to punish us. We haven't been good to him. We haven't loved
him, and now God is going to take him away from us."

"We'll miss him horribly if he dies," said Chris. "I wouldn't let him ride my bicycle the day before
yesterday."

"And I pushed him out of the nursery when I was writing," said Diana; "and told him he was a horrid
little bother."

These torturing memories went with them when they went to bed.

For the first time their mother failed to come and wish them good night. Nurse was having her
supper, and Mrs. Inglefield could not leave Noel.

But she did not forget them; only later on, when she did come, they had both forgotten their regrets,
and remorse, in sleep.

The following days were very sad. Noel lay unconscious for two days and two nights; and then when
he was able to eat, and take notice, his memory seemed to have left him. The house had to be kept
very quiet, and for days his life seemed to hang upon a thread.

It was astonishing how many friends the little fellow had. The back door was besieged by the
villagers during the first few days of his illness. Foster took the Christmas tree out of the drawing-
room and planted it in its old bed, but as he did so he was heard murmuring to himself:

"We'll never see his like again. He were too near heaven for a little chap like him!"

Mr. Wargrave, Miss Constance, Ted and Inez, all tried in turns to comfort and amuse poor Chris and
Diana.

As the days went on they began to hope, and when at last the doctor said that Noel was going to pull
through, they cheered up and began to smile once more.

But they were not allowed to see him. Mrs. Inglefield looked worn to a shadow; it was heart-breaking
to her to see her busy chattering little son lying in listless apathy on his bed, only moving his head to
and fro, and hardly recognizing his own mother.

Chris had to return to school before Noel was convalescent. Just before he went his mother let him
come in and see the little patient. Chris could hardly believe that the tiny pinched face with the big
restless eyes belonged to rosy, sturdy Noel.

He stooped over and kissed him very gently, and called him by name; but Noel took no notice, only
moved his head restlessly from side to side.

And Chris went out of the room fighting with his tears. The very next day Diana said to her mother:

"Will Noel never get better, Mums? God isn't answering our prayers. I pray ever so many times in the
day about him."

"Oh," cried her mother in anguish of tone, "don't pray too hard, darling, that we may keep him here.
God knows best. For his sake I dare not pray too earnestly for his recovery."
Diana could not understand this until she talked to Mrs. Tubbs in the kitchen about it.

"Bless your heart, missy, your poor mother is afraid he'll never get his senses again. Some is left
idiots after such a blow in the head. And Master Noel knows nobody yet, and p'r'aps never will."

This was a fresh horror to Diana. It was a good thing for her when Miss Morgan returned and lessons
began again.

But at last steady improvement set in, and Mrs. Inglefield went about with the light again in her eyes
and a smile upon her lips.

Inez came to wish Diana good-bye upon the day when the doctor was for the first time hopeful. She
was going to school, and had been dreadfully distressed about Noel.

"I liked him the best of you," she said; "he was always so funny and so naughty, and yet so very
good. And he talked like an angel. He's taught me more than anybody else, and I'm going to school
with quite a good character."

"I'll write to you, Inez, and tell you about him," said Diana, "and perhaps you'll like me to send you a
bit of my new story sometimes."

"I should love it."

They parted. Diana felt very lonely; she had never imagined that she would miss Noel so very much.

And then one Saturday when Chris was home, he and she went upstairs together to sit for a short
time with the little invalid.

He was decidedly better, his eyes were dear and bright, and he was able to talk a little, though his
voice was husky and weak. He smiled when he saw them.

"I've been very ill," he announced to them.

"Yes," said Diana, "we've missed you dreadfully, Noel. It will be nice when you're quite well again."

"I b'lieve," said Noel in his old slow way, "that I've been away to heaven, only I can't remember. I
know I haven't been here all the time."

Chris stooped over him:

"We'll never be cross to you again, Noel, never."

Noel looked at him, then asked gravely:

"Do you love me now?"

And Chris and Diana both cried out with all their hearts:

"Indeed we do. We'll always love you."

Noel smiled contentedly. Then after a pause he said: "Then will you be kind to my Chris'mas tree?
Will you give him some water and take care of him?"

"I'll water him every day," Diana rashly promised.

The interview was over; but Noel began to recover rapidly. It was a happy day when he was
downstairs again: and the first thing he did was to totter out into the garden, and make his way to his
beloved fir tree.

It stood there, looking rather bedraggled, and showing a great gap where the branch had been cut
off.

Noel was distressed at first, and then Chris, who was with him, said:

"He is like a soldier who has lost his arm in fighting for his King."

Noel's whole face brightened as he said:

"And he gave his branch to God for Jesus' birfday." He was comforted.

That same day, Bessie Sharpe came up to tell Mrs. Inglefield that her father had quietly passed
away.

"He were always talking of Master Noel. The last thing he said was, 'Tell Master Noel when he's well
enough to hear it, that my time of waiting is over and I'm going like his Christmas tree, to be taken in
for my Master's glory.'"

This message was given to Noel. He quite understood it.

"And Mr. Sharpe will be covered with glory," he said. "Everybody who goes to heaven will be like
Christmas trees lighted up. I almost wish I had wented there."

But Chris and Diana had cried out together:

"We want you here."

And their mother looked at them with a smile upon her face and deep thankfulness in her heart. She
knew now what had been the purpose in Noel's accident and illness. It was to bring the brothers and
sister closer together, and to bind them in a strong chain of love and understanding that would not
break under any provocation.

And Noel cried out:

"And I want to be here, for I love you all, specially—my dear Christmas tree."
 *** END OF THE PROJECT GUTENBERG EBOOK NOEL'S
CHRISTMAS TREE ***

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