Study Guide

Medical Coding By

Sheila McCray

About the Author

Sheila D. McCray, MS, CCS, CCS-P, has worked in the healthcare industry since 1987 as a medical claims examiner, medical tran- scriptionist, medical transcription quality assurance editor, medical coder, healthcare instructional designer, and healthcare subject matter expert. She has also worked as an online adjunct professor for several online universities, teaching a variety of healthcare courses.

As a healthcare instructional designer, Sheila regularly writes, reviews, and revises courses about healthcare topics. She’s the owner of Avidity Medical Design, an instructional design consulting practice specializing in curriculum development for the healthcare sector.

Copyright © 2016 by Penn Foster, Inc.

All rights reserved. No part of the material protected by this copyright may be reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, or by any information storage and retrieval system, without permission in writing from the copyright owner.

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Printed in the United States of America

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INTRODUCTION As the healthcare industry continues to grow at an amazing rate, and with the Affordable Care Act (ACA) being signed into law in March 2010, many insurance companies, physicians’ offices, hospitals, and other healthcare organizations urgently need qualified medical coders. Medical coders play a key role in the healthcare industry for several reasons. First, medical coders optimize physician and hospital reimbursement through precise coding that adheres to coding guidelines and reflects the content of a patient’s medical record. Second, because medical coders must ask questions to clarify any areas of ambiguity in the medical record prior to selecting their codes, they help keep the medical record up to date. As questions are clarified, the record is updated with documents that explain the areas questioned by the medical coder. Third, medical coders assign codes that reflect new diseases, disorders, therapies, treatments, and medical devices. Medical coders select codes that are also used for statistical research on diseases and disorders. These codes are used to gauge the effectiveness of medical treatments throughout the United States.

In this course, you’ll learn how to assign diagnosis and pro- cedure codes using ICD-10-CM and ICD-10-PCS. You’ll also learn about the HCPCS Level I and Level II code set, which is used to assign codes for physician reimbursement in the out- patient setting. You’ll learn about assigning codes for office visits, surgeries, radiology procedures, medical devices, equipment, injections, supplies, and many other outpatient services.

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

� Describe the purpose of coding and the documentation used in coding

� Assign ICD-10 codes using the ICD-10 coding manual

� Correctly apply coding guidelines using ICD-10


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� Assign codes to different body systems using ICD-10

� Review coding for ICD-10

� Assign codes for services and procedures using CPT and HCPCS Level II

� Describe the relationship between HCPCS Level I and HCPCS Level II

� Outline the types of services and procedures described in the CPT

� Describe the types of patients seen in the outpatient setting

YOUR TEXTBOOK The textbook for your Medical Coding course is Step-by-Step Medical Coding. This textbook gives an overview of ICD-10- CM and ICD-10-PCS. It also covers CPT coding. Your textbook is divided into chapters. The table of contents, found on pages xxiii–xxx of Step-by-Step Medical Coding, out- lines the topics presented in each chapter. Take a few moments now to examine the table of contents to get a better feel for the topics and concepts you’ll be learning about. Next, read the preface on pages ix–xiv, which describes the depth, range, and purpose of the material presented. Now, look through the rest of your textbook. You’ll see that every chap- ter begins with a set of chapter topics and learning objectives, followed by a brief introduction to the topics you’ll explore. Read the learning objectives twice: once before you read each chapter, and again after you finish reading. This two-step learning approach reinforces your understanding of the major concepts covered in the chapter, and also confirms that you truly understand the material.

Instructions to Students2

CPT stands for Current Procedural Terminology. ICD stands for International Classification of Diseases. The number following the acronym ICD refers to the version. For example, ICD-10 is the tenth revision.

The back portion of Step-by-Step Medical Coding includes several helpful study resources. The textbook’s glossary on pages 755–769 defines important terms. You’ll find a detailed index on pages 787–802.

If you’re ever unsure about where to find specific codes that are referenced in the chapters, use the handy Coder’s Index on pages 775–786. This index lists the pages where you can find specific codes referenced in each of the chapters. The references to the ICD-10-CM codes begin on page 782.

Once you’ve explored the Step-by-Step Medical Coding text- book, you can use the textbook’s resources to refer to any topic that you want to review. Your textbook’s companion website provides Encoder practice exercises, extra coding cases, and an extra chapter on nursing homes, durable medical equipment (DME), and home health. Go to the intro- ductory pages of your textbook or click the link on your student portal for more information.

Please note that the textbook goes into much more detail about the ICD-10 coding system than we’ll be covering in the study guide. Remember to code to the highest level of speci- ficity when assigning your ICD-10 codes. The ICD-10 codes are listed in the answer section of the study guide.

In the later part of your course, you’ll turn your attention to HCPCS Level I and Level II. Take a few minutes now to review the chapters listed in Unit 3, the area of the text that covers CPT and HCPCS coding. Take some extra time to review the concepts and the guidelines for coding presented in this course. It will be well worth it in the long run! Re-read the chapters in your textbook until you feel certain that you understand every CPT guideline presented.

There are three types of exercises in the textbook: Quick Checks, Exercises, and Chapter Reviews. You should com- plete Quick Checks and Exercises as you come upon them during your reading. You can find Quick Check answers in Appendix C (pages 744–747) and Exercise answers in Appendix B (pages 723–743). You’ll be instructed on when to complete the Chapter Reviews in the instructions for each lesson assignment in this study guide. Answers to the Chapter Reviews are given at the end of this study guide.

Instructions to Students 3

Instructions to Students

Note: The questions found in the Chapter Reviews may include directions to find ICD-9-CM codes for diagnoses. Because ICD-10 has replaced ICD-9 as the standard coding system, you won’t have an ICD-9 book in which to find these codes; therefore, code for CPT and ICD-10 codes only.

YOUR STUDY GUIDE Use this study guide as a companion to your textbook. The study guide also includes a lesson study plan that helps you explore ICD-10 fundamentals quickly and easily.

This study guide is divided into lessons, each with a practical overview of the topic, and several study assignments. Each reading assignment in Step-by-Step Medical Coding includes a series of practical coding exercises, which you’ll need to com- plete as you work through the textbook assignments. At the end of each lesson, you must complete an online, multiple- choice examination. Submit each examination for grading as soon as you complete it.

COURSE MATERIALS This part of your program includes the following materials:

1. This study guide, which offers an introduction to your textbook, plus

� A lesson assignments page, which lists the study assignments in your textbook and lesson exams

� Explanatory material, which emphasizes the main points of the instruction to support the chapter material covered in Step-by-Step Medical Coding


Important: If you don’t fully understand ICD-10 coding concepts

now, you won’t be able to apply the concepts later on when you start

to assign medical codes to diagnoses and procedures using each of

these code sets. Therefore, it’s very important that you take the time

to learn each concept before moving on to the next.

Instructions to Students 5

2. Your program textbook, Step-by-Step Medical Coding, which contains your assigned readings, exercises and answers

3. ICD-10-CM Professional Edition for Physicians

4. ICD-10-PCS

5. CPT

Make sure you have all of these materials before starting the course.

A STUDY PLAN Take the time to review the material as many times as you need to. Your effort will be well worth it in the long run!

Each of your textbook assignments helps you develop a solid foundation in diagnosis and procedural coding. Using codes for both diagnosis of diseases and the procedures used to treat them facilitates payment for health services, research into quality and cost, and planning for future healthcare needs. You’ll learn a great deal of technical information, so take your time as you move through each chapter.

To get the most out of this course, you’ll need to schedule several study periods over the course of the week. Devote at least one to three hours each day to reading, learning, and mastering each set of coding concepts. Again, it’ll be well worth it! If you devote the time to your studies now, as you move through the course, you’ll feel less stressed and frus- trated when you start to code. You’ll also begin to gain confidence for the intermediate and advanced medical coding scenarios that will come later.

Work through this study guide one assignment at a time. Keep your ICD-10-CM and ICD-10-PCS references handy as you review each lesson. You’ll need them to complete the lesson exercises. Once you’ve finished all of the assignments included in each lesson, you’ll be ready to complete the exam.

Instructions to Students6

To get the most out of your studies, follow these steps to complete your assignments:

Step 1: Carefully note the pages where your assigned reading begins and ends. These pages are iden- tified in the Lesson Assignments section of this study guide.

Step 2: Skim through the assigned pages (in both the study guide and the textbook) for a general idea of their content. Try to develop an overall per- spective on the concepts and skills being taught and practiced in each assignment.

Step 3: Carefully read through the study guide’s assigned pages. These pages contain back- ground information about the material covered in the textbook.

Step 4: Read the assigned pages in your textbook, and take notes on any important concepts or terms.

Step 5: When you’ve mastered all of the material for each assignment, proceed to your next study guide assignment. Repeat steps 1–4 for the remaining assignments in each lesson.

Step 6: Once you’ve finished all the assignments, Quick Checks, Exercises, and Chapter Reviews in each lesson, proceed to the examination. Take your time with the exam. As you work, feel free to refer to your textbook, the study guide, and any notes you’ve taken.

Step 7: Repeat steps 1–6 for the remaining lessons in your study guide.

Remember: At any point in your studies, you can email your instructor for additional clarification. Now look over your les- son assignments and begin your study of medical coding with Lesson 1, Assignment 1.

Remember to regularly check your student portal. Your instructor may

post additional resources that you can access to enhance your learn-

ing experience.


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Lesson 1: Diagnosis Coding With ICD-10-CM For Read in the Read in the

study guide textbook

Assignment 1 12–16 Pages xviii-xxii

Assignment 2 17–22 Chapter 2, pages 26–40

Assignment 3 22–25 Chapter 2, pages 41–50

Assignment 4 25–27 Chapter 3

Assignment 5 27–29 Chapter 4

Examination 480822 Material in Lesson 1

Lesson 2: Procedure Coding With ICD-10-PCS For Read in the Read in the

study guide textbook

Assignment 6 31–47 Chapters 5–7

Assignment 7 47–50 Chapter 27

Examination 480823 Material in Lesson 2

Lesson 3: Evaluation and Management and Anesthesia Coding For Read in the Read in the

study guide textbook

Assignment 8 Pages 54–56 Chapter 8

Assignment 9 Pages 56–57 Chapter 10

Assignment 10 Pages 58–60 Chapter 11

Assignment 11 Page 61 Chapter 12

Examination 480824 Material in Lesson 3

Lesson 4: Surgical CPT Coding: Part 1 For: Read in the Read in the

study guide: textbook:

Assignment 12 Page 64 Chapter 13

Assignment 13 Page 65 Chapter 14

Assignment 14 Pages 66–67 Chapter 15

Lesson Assignments8

Assignment 15 Pages 67–68 Chapter 16

Assignment 16 Pages 68–72 Chapter 17

Examination 480825 Material in Lesson 4

Lesson 5: Surgical CPT Coding: Part 2 For: Read in the Read in the

study guide: textbook:

Assignment 17 Pages 74–75 Chapter 18

Assignment 18 Page 75 Chapter 19

Assignment 19 Pages 76–77 Chapter 20

Assignment 20 Pages 78–80 Chapter 21

Examination 480826 Material in Lesson 5

Lesson 6: Surgical CPT Coding: Part 3 For: Read in the Read in the

study guide: textbook:

Assignment 21 Pages 82–83 Chapter 22

Assignment 22 Pages 83–84 Chapter 23

Assignment 23 Page 85 Chapter 24

Assignment 24 Page 86 Chapter 25

Assignment 25 Pages 87–88 Chapter 26

Examination 480827 Material in Lesson 6

Lesson 7: Similarities and Differences between HCPCS Level II and CPT For: Read in the Read in the

study guide: textbook:

Assignment 26 Pages 90–93 No Readings

Graded Project 48082800 Materials in Lessons 1-7


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Diagnosis Coding with ICD-10-CM Medical coders review the documents in the patient’s medical record and abstract (collect clinical data) or retrieve informa- tion from specific documents. They then assign numeric or alphanumeric codes to each piece of data they retrieve.

Medical coders must use their skills in research, reasoning, and interpretation of medical coding guidelines to ensure that physicians and hospitals are reimbursed accurately and com- pletely for the services that they provide.

This part of your program will introduce you to this exciting field. You’ll learn all about ICD-10 medical coding and the steps involved in assigning diagnosis and procedure codes using this code set. The material that follows will lead you step-by-step through a wide range of ICD-10 coding exam- ples, offering invaluable tips and suggestions that you can use along the way. You’ll also find Quick Checks and Exercises in your textbook. Be sure to complete all of these additional practice tools to help you fine-tune your coding skills, master the fine points of ICD-10 coding, and learn about a wide range of medical terms. Doing so will further sharpen your skills, strengthen your ability to accurately interpret these terms, and, in turn, translate these terms into accurate code.

By choosing to learn medical coding, you’re embarking on a journey that essentially means learning a new language. Although this new language may seem a bit complicated and overwhelming at first, it becomes easier once you learn the basics of ICD-10 coding (and with lots and lots of practice). Your confidence will increase as you learn the basics and then apply what you learn to basic coding scenarios.

The important thing to remember is that you don’t ever have to feel lost. The coding steps, along with the coding guide- lines, tell you exactly what you need to do. If you do feel yourself getting off track though, connect with other students in the program on the Medical Billing and Coding Academic Space on the Penn Foster Community. You can see if other students are encountering the same difficulties and learn

Medical Coding10

how they’ve overcome these difficulties. You can also create study groups and find study buddies to help make your learning experience even better.

Your instructor is also a valuable resource. You can connect with your instructor on the Medical Billing and Coding Academic Space. It’s always much better to ask for help, rather than become frustrated and try to figure things out on your own. As you move forward, you’ll find yourself becoming more comfortable with the medical terms, processes, and pro- cedures that coders use every day. Just remember not to put too much pressure on yourself to master coding overnight. When you begin to code, don’t expect to get every single code right—you won’t. The key to learning medical coding is being willing to make mistakes. Experienced coders had to make many coding errors along the way to gain the experience they now have. When you make an error in your code selection, retrace your steps and find out where you went wrong, so the next time you’ll be less likely to make the same mistake. Remember that a mistake is never a mistake if you learn from it! Keep this in mind as you move forward through your coding courses.

By the time you finish Medical Coding, you’ll have gained many of the skills you need to accurately assign ICD-10 codes.

As a medical coder, you’ll use the ICD-10-CM (often called ICD-10 or I-10), to assign different codes depending on the circumstances surrounding the patient encounter. The patient encounter is the episode of care that takes place on one or more specific dates, when the physician evaluates the patient and provides treatment. During the encounter, the patient relates the symptoms or chief complaint that brought the patient to the office, clinic, or hospital. Based on the patient’s reported symptoms, as well as the results of any examinations, x-rays, laboratory reports, or specialist consul- tations, the physician will determine the most likely cause of the patient’s symptoms, or diagnosis. If the patient comes in complaining of coughing, sneezing, and congestion, the physician may ultimately determine that the patient has influenza. As a coder, you’d assign the diagnosis code for flu, along with codes that pertain to the service or treatment pro- vided in relation to the patient’s flu. Likewise, if the patient is

Lesson 1 11

seen because of difficulty walking due to a swollen ankle, an x-ray may reveal a fracture, in which case the physician’s diagnosis would be ankle fracture. The physician may also determine that the patient has more than one diagnosis, in addition to the one that brought him or her to the office. The physician may determine that in addition to the fractured ankle, the patient has several chronic conditions that require treatment. Examples of chronic conditions include hyperten- sion, diabetes mellitus, and any conditions that require ongoing treatment or monitoring and regularly prescribed medication. You’d assign diagnosis codes for the fractured ankle and the chronic conditions that require ongoing treatment.

As a medical coder, you’ll use the ICD-10-CM to look up the patient’s diagnosis (or diagnoses if there’s more than one). After you find the diagnosis, you’ll review the code descrip- tions, follow any additional instructions that are provided in the ICD-10-CM regarding code assignment, and then assign your code. You’ll then follow the same process to assign sub- sequent diagnosis codes. If you’re working as an inpatient coder, you’ll also use the ICD-10-CM to assign procedure codes for inpatient surgical procedures.

OBJECTIVES When you complete this lesson, you’ll be able to

� Define the process of medical coding

� Explain the tools used by medical coders

� Outline the skills necessary for a successful career in medical coding

� Summarize examples of medical coding certifications

� Describe other careers in medical coding

� Summarize the history of medical coding

� Explain the process of general equivalence mapping

� Summarize how to use ICD-10-CM

Medical Coding12

� Explain the guidelines for the first-listed diagnosis

� Explain the steps for accurate coding

� Locate and assign codes in ICD-10-CM

� Summarize key concepts of multiple coding, acute and chronic condition coding, and laterality coding

ASSIGNMENT 1 Read through the following material in your study guide. Then, read the Introduction in your textbook, Step-by-Step Medical Coding.

Introduction to Medical Coding Recent changes in healthcare have created a great demand for medical coders. An older population; advances in techno – logy; an increased demand for healthcare services; and an increase in the number of medical tests, treatments, and pro- cedures means that the number of people seeking healthcare services has increased. Additionally, the increased use of outpatient facilities means that the government is exerting greater control and becoming more involved with services provided to Medicare and Medicaid patients. These changes in healthcare have resulted in an increased demand for certi- fied medical coders.

Prominent healthcare organizations in the field of medical coding include the American Health Information Management Association (AHIMA) and the American Academy of Professional Coders (AAPC). Both of these organizations offer credentials in medical coding. Certifications offered by both organizations are nationally recognized and accepted by healthcare employ- ers worldwide. Most coders choose to sit for one of four certifications: the CPC-A, CPC, CCS, or CCS-P.

The CPC-A and the CPC are both offered by the AAPC. CPC (Certified Professional Coder) indicates that you’ve completed the necessary educational requirements and now have experi- ence in the field. In CPC-A, the A stands for apprentice. The CPC-A demonstrates that you’ve completed the necessary

Lesson 1 13

educational requirements for a career in coding, but haven’t yet obtained the required experience in reviewing, abstract- ing, interpreting, and correctly assigning codes. After you earn the required two years of full-time coding experience, the A is dropped from the credential and you become a CPC.

CCS and CCS-P are certifications offered by AHIMA. CCS (Certified Coding Specialist) demonstrates that you’ve gained proficiency in assigning codes to inpatient as well as outpatient medical records. CCS-P indicates that a coder is adept at coding medical records in the outpatient setting, such as in the physician’s office, emergency room, or clinic. Although many coders do, it isn’t necessary to earn more than one credential to demonstrate proficiency in a certain area of coding. At least one credential is needed to gain entry into the field of medical coding.

Success in medical coding means being able to convert medical terms into standardized numeric and alphanumeric codes for physician and hospital reimbursement. The rule of thumb for medical coding is: If it wasn’t documented, it wasn’t done.

While coders are primarily concerned with correct interpreta- tion of coding guidelines, accurate code assignment, and optimized reimbursement for physicians and hospitals, medical coding also involves ethical concerns. Medical coders must ensure that the codes they select accurately reflect what’s in the patient’s medical record. All diagnosis and procedure codes should be assigned based strictly on the content of the medical record.

Coders use standardized code sets to assign codes for diag- noses, procedures, drugs, medical devices, supplies, and equipment. (You’ll learn more about the code set used for drugs, medical devices, supplies, and equipment later in Medical Coding). Accurate and complete coding helps mini- mize turnaround in terms of medical claims processing, and as a result, it helps expedite reimbursement for physicians and hospitals. In addition to increasing the likelihood of faster claims turnaround, accurate and complete coding also minimizes the likelihood of fraud. Medical coders are required by law to assign codes based only on the documentation in the medical record. Assigning codes that aren’t supported by

Medical Coding14

the medical record to increase reimbursement constitutes fraud and can result in civil and criminal penalties for healthcare facilities.

Proficiency in medical coding means learning both how to determine the specific piece of data that requires a code assignment and the rules for assigning your codes.

Coders use two types of tools to assign codes: textbooks and encoders. Encoders are coding software programs that you can use to locate and assign diagnosis and procedure codes. However, when you test for a medical coding certification such as the CPC-A, you’ll be required to use your coding textbooks to assign codes. The textbooks that you’ll use in this course are

� The International Classification of Diseases, 10th Revision, Clinical Modification (commonly referred to as ICD-10-CM)

� The International Classification of Diseases, 10th Revision, Procedure Coding System (commonly referred to as ICD-10-PCS)

Being a Coder To be successful in medical coding, you must be

� Detail oriented. In medical coding, the old adage “little things mean a lot” is especially true. The descriptions for two codes may be identical except for one word. That one word may be the difference in choosing code A vs. code B. If you’re good at picking up on the little things, then you’ll enjoy coding.

� A detective. If you like being a sleuth and researching coding guidelines to understand how, when, and where you should assign a specific code, then you’ll like med- ical coding.

Note: As you proceed through your assigned reading, be sure to

complete the Quick Checks and Exercises, which will reinforce the

reading material.

Lesson 1 15

� A good storyteller. Much of coding involves reading the medical record and then painting a mental picture in your mind of what took place, as if you were right there in the doctor’s office or emergency room. If you can visualize what occurred based on what you read in the medical record, you’ll love medical coding.

� Analytical. If you’re good at analyzing pieces of infor- mation from different documents in the same record and finding contradictory information, then medical coding is a great career choice for you. Maybe you’re working on a medical chart for a patient who was admitted to the hospital. Dr. Brown’s report indicates that the patient has diabetes, which is well controlled on insulin, but Dr. Smith’s report indicates that the patient has diabetes, but it isn’t well controlled on insulin. These are two dif- ferent doctors saying two different things about the same patient’s diabetes, and hence, these two statements would translate into two different diabetes codes for the same admission. You would need to determine which statement is correct so that you can assign the right code.

In the previous example, you’d need to send a query to the hospital to determine whether the patient’s diabetes is con- trolled or out of control. You’d then assign your diabetes code based on the answer you receive from the hospital, and the answer would be placed in the patient’s medical record so that the record is kept up to date.

You develop each of these skills as you proceed through Medical Coding, as well as the courses that follow.

In addition to being able to accurately review and abstract clinical data from the medical record, good computer skills are essential to your success as a medical coder for several reasons.

1. If you work from home, you’ll need to set up a connec- tion to your employer’s office or the hospital client to which you’re assigned in order to access medical charts.

Your company’s IT department or the hospital’s technical support department will help you do this. You may need to access and navigate specific websites and download certain programs to sign in to the system and begin to

Medical Coding16

code your charts. The setup process should be relatively simple, but you’ll need to be able to follow the directions provided by the IT person to set up the website links on your computer and begin coding.

2. On a daily basis, you’ll log in to the website provided by your company, retrieve charts, open reports within each chart, and review the documents to locate your codes.

3. You’ll also need to go online to research medical or surgical terms that pertain to a specific diagnosis or pro- cedure. This is why it’s important to complete courses in medical terminology, anatomy, and physiology in addi- tion to your coursework in medical coding.

Once you start working as a coder, you’ll find that the oppor- tunities in coding are plentiful, from coding for doctors’ offices and hospitals to educating new coders. You’ll likely have more than one kind of coding position during your career. You might initially start working as a medical coder and later become a medical coding auditor, for example. A medical coding auditor reviews the charts coded by the med- ical coders, pinpoints errors, and provides feedback on making corrections. The auditor also provides references to supplemental coding documents to help coders improve their accuracy. You might become a medical coding supervisor, overseeing a team of medical coders and assigning accounts. Or, you may choose to specialize in one particular area of medical coding, such as cancer registry, where you review medical records and capture diagnoses for cancer patients, and obtain a medical coding certification in cancer registry.

Now that you’ve completed Assignment 1, it’s time to review the Introduction to Step-by-Step Coding. As you review the Introduction, you’ll learn more about the anticipated job growth in the medical coding field, as well as the salaries for credentialed medical coders, categorized by region, job responsibility, workplace, work setting, and job level.

Lesson 1 17

ASSIGNMENT 2 Read through the following material in your study guide. Then, read Chapter 2, pages 26–40, of your textbook, Step-by-Step Medical Coding.

History of ICD-10 Medical Coding In order to understand the history of ICD-10-CM in relation to medical coding, it’s necessary to understand how ICD-10 evolved and why it’s necessary for accurate coding.

The United States started using ICD-10 to report mortality in 1999, but didn’t fully adopt ICD-10 until October 1, 2015. However, the United Kingdom actually began using the ICD-10 in 1995, along with 200 other countries, that used all or part of ICD-10. The World Health Organization (WHO) still main- tains the ICD, although they stopped supporting the ICD-9 in 2012. The Centers for Medicare and Medicaid Services (CMS) along with the American Hospital Association (AHA) and the National Center for Health Statistics (NCHS) are responsible for maintaining the ICD-10-CM and ICD-10-PCS. ICD-10-PCS replaced ICD-9-CM Volume 3 as the component used to assign procedure codes for patients having surgery in the hospital. We’ll cover ICD-10-PCS later in this course.

ICD-10-CM was created for several reasons. First, ICD-9-CM had run out of room to expand. New diseases and new disor- ders are constantly being discovered, and the ICD-9-CM code set didn’t have room for any new codes. Since the ICD-9-CM code structure didn’t include sufficient detail about the patient’s condition, these codes needed to be revised for greater specificity and more comprehensive coverage of each element of the patient’s diagnosis.

ICD-10 is a new and improved version of the old ICD-9 code set. The ICD-10 is like a huge rubber band that can stretch to put more detail into each code, thereby eliminating the need for multiple codes while simultaneously improving specificity. The reason that more information can be packed into each ICD-10 code is because of its revised structure. ICD-10 incorporates common fourth- and fifth-character sub- classifications in one code. For example, a patient who is

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diagnosed with abusing alcohol and also having mood disor- ders because of the alcohol abuse can now be assigned to one code in ICD-10, rather than two codes in ICD-9. Each ICD-10 code can accommodate six characters, and even expand to seven characters, whereas ICD-9 codes only con- tained four digits and could only expand to a maximum of five characters. In a case involving a patient with complications resulting from diabetes mellitus, for example, the coder would have had to assign two codes: one for the diabetes mellitus and one for the complication resulting from it. However, ICD-10 can expand to combine everything in one code.

Symptoms can be combined with the diagnosis in the same code. Injury codes can be expanded to include more details, such as whether the patient is being seen the first time for the injury, whether it’s a subsequent visit, or whether the visit is due to a sequel, an aftereffect of a disease or injury.

The structure of ICD-10-CM is similar to the structure of the old ICD-9-CM, but the new ICD-10 code set includes two additional chapters: one pertaining to diseases of the eye, and one pertaining to diseases of the ear. ICD-10 also adds infor- mation pertaining to ambulatory and managed care visits.

In summary, improvements offered with ICD-10-CM include

� Adding information that pertains to ambulatory and managed care visits

� Expanded codes pertaining to injury

� Extensive injury code expansion to increase the speci- ficity of each code

� Combining diagnoses and symptoms in one code, thereby reducing the number of codes required to report a condition

� Adding a sixth character to the diagnosis code

� Incorporating subclassifications of fourth and fifth characters

� Updating codes for diabetes mellitus and making them more specific

� Making code assignment more specific

Lesson 1 19

Unlike ICD-9-CM, the category codes in the ICD-10-CM begin with a letter. The following sample illustrates the structure of the ICD-10-CM system:

Chapter 1: Certain Infectious and Parasitic Diseases (A00-B99)

Chapter 2: Neoplasms (C00-D49)

Chapter 3: Diseases of the Blood and Blood-Forming Organs (D50-D89)

Chapter 4: Endocrine, Nutritional and Metabolic Diseases (E00-E89)

Chapter 5: Mental, Behavioral and Neurodevelopmental Disorders (F01-F99)

General Equivalence Mapping (GEM) You may wonder how to confirm whether you have the cor- rect ICD-10-CM equivalent code that matches the code that you would have chosen in the earlier ICD-9-CM code set. The general equivalence mapping (GEM) files were developed to help you map ICD-10 codes back to the old ICD-9 code set and vice-versa. General equivalence mapping is bidirectional, meaning that you can map the new ICD-10 codes back to the original ICD-9 codes, and map the original ICD-9 codes to the new ICD-10 codes.

Mapping ICD-9 codes to ICD-10 codes is called forward mapping. When you map ICD-10 codes back to their original ICD-9 codes, the process is called backward mapping. One thing to keep in mind: when you review the GEM files to determine the equivalent mapping codes, you’ll notice that the GEM files don’t include decimals. Remember this when you map your codes. You’ll have to mentally insert the deci- mal point so that you understand the code that you’re seeing in the GEM file. For example, in ICD-9-CM, the diagnosis code for salmonella meningitis was 003.21. When you locate this ICD-9-CM code in your GEM file, you’ll see 00321, with- out the decimal. The new equivalent ICD-10-CM code is A02.21. So the old ICD-9-CM code 003.21 maps directly to the new ICD-10-CM code, which is A02.21. This is an

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example of forward mapping. If you found the ICD-10-CM code first, and then found the old ICD-9-CM code second, you would have done backward mapping.

There’s one GEM file for forward mapping and one GEM file for backward mapping. The GEM file for forward mapping has three columns in this order: ICD-9, ICD-10, and Flag. The GEM file for backward mapping also has three columns: ICD-10, ICD-9, and Flag. It all depends on the direction that you’re going in terms of mapping your codes.

Source code is the code that you’re mapping from and target code is the code that you’re mapping to. If you’re doing for- ward mapping from the old ICD-9 to the new ICD-10, your ICD-9 code is the source code and your ICD-10 code is the target code. If you’re doing backward mapping from the new ICD-10 to the old ICD-9, your source code becomes your ICD-10 code, and your target code now becomes your ICD-9 code. The Flag column tells you whether you have a direct match between the two codes. The flags are five-digit num- bers that appear in the third column of your GEM file. Each digit occupies a certain position in the overall flag number. The numbers are a combination of 0s, 1s, and 2s.

There are three types of flags:

� Approximate. You have an exact match.

� No Map. Sorry, you don’t have an exact match; no simi- lar codes available.

� Combination. You have a match, but your source code maps to more than one code in the target system.

Your goal is to match your ICD-10 code to the previous ICD-9 code and vice-versa, to make sure you select the cor- rect ICD-10 code that corresponds to the old ICD-9 code. The process is similar to translating a word in English to another language; you want to ensure that your translation is accu- rate. Sometimes your code match won’t be perfect, and you’ll have to add more codes to get a perfect combination for the coding scenario that you’ve indicated in the medical record. You may not always be able to make an exact match between a diagnosis in ICD-10 and a diagnosis in ICD-9.

Lesson 1 21

Here are some examples of the types of flags that you’ll see in the third column of the GEM file:

Flag# 00000. This means you have an exact diagnosis match between ICD-9 and ICD-10.

Flag# 10000. This means you have multiple diagnoses that might be a potential match between the old ICD-9 and the new ICD-10. For example, code 733.95 in ICD-9-CM (stress fracture of other bone) maps to 16 possible new codes in ICD-10-CM. This is what flag# 10000 is telling you: there are multiple possibilities. There isn’t a one-size- fits-all code available in this particular example. You have to review the medical record and choose the code that describes the specific encounter from one of the 16 possi- ble choices in ICD-10-CM.

Flag# 11000. A 1 in the second slot of the flag number tells you that you have a no map (or no match) because there’s no similar code that maps between the old ICD-9 and the new ICD-10. You’ll also see NoDx listed in one of the columns to indicate this.

Flag# 10112. A 1 in the third slot of the flag number tells you that you do have a diagnosis match between the old ICD-9 and the new ICD-10, but there’s more than one code in the target system that might be the perfect match. This is called the combination field.

Flag# 10112. The fourth slot of the flag number is the scenario field. This is a mapping situation that involves multiple codes, and a 1 in this slot indicates that there’s only one possible variation of diagnosis code combinations in the source code.

Flag# 10111. A 1 in the fifth slot of the flag number tells you that this is the choice field. The fifth slot tells you the possible number of target codes that make one complete coding scenario when you combine them. One example is ICD-9-CM codes 995.92 and 785.52. Code 995.92 was the ICD-9 code for severe sepsis, and 785.52 was the ICD-9 code for septic shock. The rules for septic shock indicated that 995.92 needed to be sequenced first, followed by 785.52. This is the only combination that could be assigned when the patient was diagnosed with septic

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shock. These two codes went together. The scenario field indicated that there was only one possible source code combination available in ICD-9-CM for severe sepsis and septic shock (995.92 + 785.52). The choice field pointed you to both of these ICD-9-CM codes. It essentially said that you must assign both of these codes together to paint the complete picture of the patient’s condition. Unlike the old ICD-9-CM codes, the new ICD-10 code for both severe sepsis and septic shock is R65.21.

Using ICD-10-CM You’ll use the Alphabetic Index and Tabular List to locate codes in the ICD-10-CM. The main terms in the Alphabetic Index appear in bold, with subterms indented directly beneath the main term. In ICD-10-CM, each code begins with a letter rather than a number, and the code descriptions become much more specific than those found in ICD-9-CM. As you begin to code using ICD-10-CM, you’ll see different sets of instructions to guide you along the way.

ASSIGNMENT 3 Read through the following material in your study guide. Then, read Chapter 2, pages 41–50, of your textbook, Step-by-Step Medical Coding. When you’ve finished reading Chapter 2, complete the Chapter Review on pages 51–54. You can check your answers using the Answers section at the end of this study guide.

ICD-10-CM codes are divided into sections, categories, sub- categories, and subclassifications. Sections are three-digit categories for conditions or related conditions. Categories are three-character codes that represent one condition or disease. Subcategories are four-character codes that are more specific than three-character codes. Subcategory codes provide more information on the site, cause, or manifestation of the condi- tion. Subclassifications provide even greater specificity than subcategory codes, using five to seven characters. Codes that can be expanded by adding more characters should be coded to the fullest extent possible.

Lesson 1 23

ICD-10-CM codes are listed in the Alphabetic Index and the Tabular List. You would locate the codes in the Alphabetic Index first, and then verify the codes in the Tabular List. Codes and titles in the Tabular List are in bold font. Codes not assigned as the first-listed diagnosis, as well as all exclu- sion notes, are listed in italicized font. Any codes listed in italicized type are always assigned as secondary codes (that is, after the primary diagnosis). For example, the phrase “code first,” which appears in italicized font, instructs the coder to assign another code first before assigning the code in italics.

As you code, pay attention to the instructional notes and conventions pertaining to diagnosis codes. These notes pro- vide guidance in accurately assigning your codes. Review the front matter of the ICD-10-CM manual to become familiar with the instructional notes and conventions pertaining to ICD-10-CM codes. Two commonly known conventions include NEC (not elsewhere classifiable) and NOS (not otherwise specified). The NEC convention indicates that a more specific code for the condition is not available. The NOS convention indicates that the information that you have, based on what’s indicated in the medical record, means that you can’t assign a more specific code (although a more specific code may be available). In this instance, you may need to query the physi- cian for more information and see if you can obtain a more specific diagnosis.

Additional conventions include brackets, parentheses, colons, as well as essential and nonessential modifiers. You’ll find brackets in the Tabular List enclosing synonyms, alternate words, or explanatory phrases. Parentheses enclose nonessential modifiers, also called supplementary words. Nonessential modifiers don’t affect the code assignment, but only clarify the diagnosis. For example, K56.7, the diag- nosis for inhibitory ileus, includes the term “inhibitory” in brackets. The term “inhibitory” is a nonessential modifier. It’s not essential for code assignment, but only further explains the diagnosis. Colons (:) appear after incomplete terms in the Tabular List. Incomplete terms require at least one modifier to assign the diagnosis code. Make special note of how the terms and and with are used in ICD-10-CM: The term and means and/or, while the term with means that the code

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includes two conditions, and both conditions must be present in order to assign the code. The note Includes provides addi- tional examples that pertain to the content of the category.

You’ll also see Excludes notes in ICD-10-CM. There are two types of Excludes notes: Excludes1 and Excludes2. The Excludes1 note means not coded here and indicates that you should not assign the excluded code along with the code being referenced prior to the note. The note for code D61.82, myelophthisis, in the Tabular List, includes Excludes1 notes for several conditions that shouldn’t be coded along with code D61.82. The Excludes2 note indicates not included here. This means that the condition being excluded is a distinct condi- tion that isn’t a part of the condition from which it’s being excluded, so the patient may have both conditions simultane- ously. If you see an Excludes2 note beneath a code, this indicates that you can assign the code and the Excludes2 code together. For example, in Chapter 1, the first Excludes2 note indicates that the infectious and parasitic disease doesn’t include the carrier of the suspected disease, so it’s possible for both conditions to exist at the same time.

You may code some conditions that have an underlying etiology, along with multiple manifestations. This coding sce- nario represents the etiology/manifestation paired code rule. You’ll recognize this rule when you see a notation that indi- cates code first and use additional code. This tells you to sequence the underlying condition first, and the code for the manifestation second. The term code first appears at the manifestation code. The term use additional code appears in relation to the etiology code. You’ll also see the code title in diseases classified elsewhere, which indicates that the code is a manifestation code. Code D77, “Other disorders of blood and blood-forming organs in diseases classified elsewhere,” is an example of this convention.

The term code also indicates that you may need to assign two codes in order to fully describe a condition. You would sequence the two codes according to the reason for the patient’s visit and the level of severity inherent in the condi- tion. In the example referenced earlier for code D61.82, in addition to the Excludes1 note, the Tabular List directs you

Lesson 1 25

to code the underlying disorder as well. Examples of under – lying disorders include malignant neoplasm of the breast (C50.-) and tuberculosis (A15.-).

A code adjacent to a main term in the Alphabetic Index of ICD-10-CM is a default code. The default code represents a common condition associated with the main term, or repre- sents the unspecified code for the condition. If a condition in the medical record doesn’t include additional information pertaining to the condition, assign the default code (that is, unspecified).

Any codes with fewer than six characters require a place- holder only if a seventh character is needed. You’ll assign a placeholder of X for any characters fewer than six. An example is code S43.50, unspecified sprain of the acromioclavicular joint, initial encounter, explained on page 49 of your text.

You’ll also encounter cross-references when assigning codes in ICD-10-CM. Cross-references are possible alternatives or synonyms for a term. Examples of cross-references include see, see also, and see category.

ASSIGNMENT 4 Read through the following material in your study guide. Then, read Chapter 3 of your textbook, Step-by-Step Medical Coding. When you’ve finished reading Chapter 3, complete the Chapter Review exercises on pages 80–81.

Guidelines for First-Listed Diagnosis One of the guidelines that you’ll encounter as a coder is for the first-listed diagnosis in the outpatient setting. This diag- nosis is the primary reason that the patient is being seen in the healthcare facility. If a patient with hypertension and diabetes mellitus is being seen due to cough and congestion, and the physician diagnosed bronchitis, then bronchitis would be the first-listed diagnosis. Hypertension and diabetes mellitus would be listed as additional diagnoses. In some instances, the physician may not be able to confirm the diagnosis, and the patient may require follow-up visits to determine the definitive diagnosis. Let’s say that a patient is

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scheduled for outpatient surgery or scheduled for observation of a medical condition. In these two cases, the reason for the surgery or the observation becomes the first-listed diagnosis. The first-listed diagnosis is called the principal diagnosis in the inpatient setting. The reason that the patient is seen for the medical encounter is called the chief complaint. You’ll review the chief complaint to determine the first-listed diag- nosis in the outpatient setting. In certain instances, the patient may need to return several times in order to deter- mine the patient’s definitive diagnosis.

When a diagnosis is unconfirmed, you code the signs and symptoms that brought the patient in for the medical encounter, since a definitive diagnosis hasn’t yet been established. If a patient is seen for outpatient surgery, and a situation develops in which the surgery isn’t performed, you would still assign the reason for the surgery as the first- listed diagnosis, even though the surgery wasn’t performed.

Existing conditions in addition to the first-listed diagnosis are assigned as secondary diagnoses. This is especially true for chronic conditions, such as hypertension, diabetes mellitus, asthma, and hyperlipidemia. If the patient is taking medica- tion or receiving medical treatment on a regular basis for chronic conditions, you would assign these codes as second- ary codes. Review the patient’s past medical history, along with the list of medications that the patient is taking on a regular basis, to determine whether secondary codes for chronic conditions should be assigned. For example, if the patient’s past medical history includes hypertension, and the patient’s list of medications includes lisinopril, a medication commonly prescribed for hypertension, the ICD-10-CM code for hypertension is assigned as a secondary code.

You’ll assign codes ranging from A00.0 to T88.9, as well as Z00-Z99 for diagnoses, problems, complaints, and other medical issues that pertain to the condition(s) for which the patient is being treated. Z codes are used to report factors that influence health status and contact with health services. Examples of Z codes are Z85.3, personal history of malignant neoplasm of the breast, and Z23, encounters for inoculations and vaccinations. Z codes are assigned in outpatient hospital departments, ambulatory surgery centers, and physicians’

Lesson 1 27

offices. If a patient receives a diagnostic service and no additional diagnostic statement is available, assign the reason for the service as the diagnosis. The same rule applies to therapeutic services.

ASSIGNMENT 5 Read through the following material in your study guide. Then read Chapter 4 of your textbook, Step-by-Step Medical Coding. When you’ve finished reading Chapter 4, complete the Chapter Review exercises on pages 100–101.

Steps for Accurate Coding There are certain steps that you must follow in exact order, every time, to accurately choose your code(s). If you don’t fol- low the steps in the correct order, or you omit a specific step, you’ll end up choosing the wrong code.

Your first step is to thoroughly review the medical record to determine the patient’s diagnosis. Once you determine the patient’s diagnosis, you must determine the main term in the diagnosis, and then any subterms in the diagnosis. The main term represents the most basic aspect of a disease or condition.

For example, the main term of a diagnosis involving a broken arm would be fracture. The anatomical location of a diag- nosed condition—in this case, arm—is never used as a main term. An easy way to think about the relationship between main terms and subterms is to think of the relationship between a noun and an adjective. If a patient comes to the doctor’s office wearing a blue dress, the word dress would be the main term, and the word blue would be the subterm because it describes the dress. Likewise, if a patient’s diagno- sis is abdominal pain, pain is the main term, and abdominal is the subterm because it describes the pain that the patient is having. After you locate the subterms under the main term in the Index, review any cross-reference instructions associ- ated with the code that you’re about to select.

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After you select the appropriate code(s) from the Alphabetic Index, verify them in the Tabular List. Then review any instructional notes in the Tabular List and assign your code. Your objective is to make sure that your code matches the descriptions of each diagnosis code that you select. Code to the highest level of specificity and completely identify all ele- ments of your code.

Remember, you must code to the fullest extent possible, so always assign the maximum number of characters available for a code. If a code has a maximum of seven characters available, and only three codes are assigned, the code is invalid.

When a patient is seen for a medical encounter, the patient’s signs and symptoms will be indicated. These signs and symp- toms are the reason for the patient’s visit. When signs and symptoms are listed, and a definitive diagnosis has been established, you won’t code the signs and symptoms. You’ll only code the definitive diagnosis. However, if the signs and symptoms aren’t related to the definitive diagnosis, then you can assign codes for the signs and symptoms. Let’s say that the patient is seen for itching of the skin and pain in the knee. The physician renders a final diagnosis of eczema. Since pain in the knee isn’t related to eczema, you’ll assign the code for knee pain.

You’ll also encounter scenarios that require multiple codes, in addition to the etiology/manifestation rule discussed ear- lier, as well as diagnoses for acute and chronic conditions. If a condition is described as being acute (or subacute), as well as chronic, and the Alphabetic Index includes a subentry for acute and another subentry for chronic, code both. Sequence the acute code for the condition first, and the chronic code second. Code K85.9 for acute pancreatitis and code K86.1 for chronic pancreatitis are two examples of this guideline.

You may also occasionally code late effects, a residual of a condition that occurs after the acute phase of the illness or injury has ended. Residual conditions may occur several months after the acute phase of the condition, or even longer. There’s no time limit on when a residual condition may occur, after the acute phase of the condition has ended. If a

Lesson 1 29

patient has a stroke, and then several weeks later experi- ences mild paralysis on the right side of the body that wasn’t initially apparent, the paralysis would be a late effect (that is, it occurred after the stroke ended).

If a diagnosis code includes a reference to laterality (right side, left side, or bilateral), assign the code reflected in the diagnosis. Conjunctivitis, for example, may occur in the left eye, the right eye, or both eyes (bilaterally). If there is no bilateral code available, assign two codes: one for the left side and one for the right side. If the laterality isn’t specified, assign the code for unspecified.

Review the medical record thoroughly, along with the coding guidelines, to ensure accurate coding for each of these scenarios.

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Procedure Coding with ICD-10-PCS

OBJECTIVES When you complete this lesson, you’ll be able to

� Describe the ICD-10-CM chapter-specific coding and reporting guidelines for ICD-10-CM Chapters 1–10

� Summarize the ICD-10-CM chapter-specific coding and reporting guidelines for ICD-10-CM Chapters 11–14

� Outline the ICD-10-CM chapter-specific coding and reporting guidelines for ICD-10-CM Chapters 15–21

� Explain the role of ICD-10-PCS

� Locate and assign codes in ICD-10-PCS

� Describe the format and structure of ICD-10-PCS

ASSIGNMENT 6 Read through the following material in your study guide. Then read Chapters 5, 6, and 7 of your textbook, Step-by-Step Medical Coding. At the end of each chapter, complete the Chapter Review on pages 150–151, 165–166, and 204–205. You can check your answers using the Answers section at the end of this study guide.

Chapter-Specific Coding Guidelines, Chapters 1–10 You previously learned about the general ICD-10-CM guidelines. Now, turn your attention to the chapter-specific guidelines, beginning with chapters 1–10. Chapter 5 of your text covers specific guidelines pertaining to assigning diagno- sis codes for

� Certain Infectious and Parasitic Diseases

� Neoplasms


L e

s s

o n

2 L

e s

s o

n 2

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� Diseases of the Blood and Blood-Forming Organs and Certain Disorders Involving the Immune Mechanism

� Endocrine, Nutritional, and Metabolic Diseases

� Mental, Behavioral, and Neurodevelopmental Disorders

� Diseases of the Nervous System

� Diseases of the Eye and Adnexa

� Diseases of the Ear and Mastoid Process

� Diseases of the Circulatory System

� Diseases of the Respiratory System

In your career as a medical coder, you’ll review charts that include diagnoses pertaining to infectious disease. These types of disease affect different parts of the body, and for this reason, it’s important to understand the different types of codes that pertain to infectious diseases. In some instances, you’ll assign a code that completely describes the condition and any manifestations of the condition. This is called a combination code. However, in other situations, you’ll need to assign more than one code to fully describe the condition. This is called multiple coding. A patient diagnosed with candidiasis of the mouth would be assigned to B37.0, a combination code. A patient diagnosed with a urinary tract infection due to an infection such as E. coli, would be assigned to N39.0, along with another code for the E. coli.

You’ll also assign diagnosis codes for patients diagnosed with systemic inflammatory response syndrome (SIRS), wherein microorganisms exist in the blood, skin, lungs, or urinary system, and the patient may experience fever, hypothermia, tachycardia, increased respiratory rate, and increased or decreased blood count. When a patient who has been diag- nosed with SIRS also has organ failure, SIRS becomes known as severe sepsis. If severe sepsis is documented in the

Lesson 2 33

patient’s medical record (and only if this is the case), you would assign a code from subcategory R65.2. Patients with severe sepsis require three codes:

1. A code for the underlying systemic infection

2. A code from the R65.2 subcategory

3. A code to report the specific type of organ dysfunction that the patient is experiencing

A patient may also experience septic shock, a type of organ dysfunction involving circulatory failure. In these instances, you would report the underlying infection, then assign code R65.21 for severe sepsis with septic shock, and then assign codes for the organ dysfunction.

Another infectious disease condition that you’ll code is viral hepatitis. Patients may be diagnosed with hepatitis A, B, C, D, or E. You’ll report these conditions with codes in the B15–B19 range. These codes are classified according to the type of hepatitis, as well as whether hepatic coma is a factor in the patient’s diagnosis.

A patient diagnosed with HIV will be reported with code B20, for human immunodeficiency virus diseases, including AIDS, which is caused by HIV. You’ll also report additional codes for any manifestation of the AIDS. Remember to read the chart carefully to determine whether the physician has con- firmed the AIDS diagnosis. A patient may be HIV positive, but without the manifestation of symptoms, in which case you would report Z21, asymptomatic HIV status. When assigning this code, the medical record documentation must state that the patient is HIV positive, has known HIV, is HIV test posi- tive, or include similar terms. If the chart includes AIDS or the patient is being treated for an illness related to HIV, or has a condition resulting from HIV, you would assign code B20.

If the patient has been exposed to HIV, but hasn’t tested positive, you would report Z20.6. Inconclusive HIV serology would be reported with R75. A pregnant patient who is HIV positive would be assigned to code O98.7, HIV-related illness complicating pregnancy, childbirth and the puerperium, with B20 assigned as the secondary code, along with additional

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codes for any illness related to HIV. Screening for HIV is assigned to code Z11.4. Additional codes include Z72.51 (high risk heterosexual behavior), Z72.52 (high risk homo – sexual behavior), Z72.53 (high risk bisexual behavior), or Z71.7 (HIV counseling).

Code range C00–D49 is used to report neoplasms. Neoplasms may be either benign or malignant. Benign neoplasms don’t spread and become cancerous. Malignant neoplasms are cancerous and may spread to other sites in the body. You’ll reference the neoplasm table in the Alphabetic Index first. However, if the histological term is documented in the med- ical record, you would locate the term in the Alphabetic Index first, and then find it in the Neoplasm table. This helps you select the correct column in the neoplasm table to locate your code. There are additional guidelines for coding treat- ments directed at a malignant neoplasm, treatment directed at a secondary neoplasm, anemia pertaining to malignancy, complications pertaining to malignancy, management of dehydration related to malignancy, pathologic fracture related to neoplasms, and other neoplasm guidelines.

Pay special attention to the chapter guidelines for coding anemia due to malignancy, as this is a change from the old ICD-9-CM chapter guidelines. In the ICD-9-CM, you would have been instructed to sequence the anemia code first and the malignancy code second if the patient’s anemia was due to malignancy. However, the new ICD-10-CM chapter guide- lines for anemia indicate that the order should now be reversed. Code the malignancy first and then the anemia.

You’ll use Z codes to indicate a history of malignant neoplasm. Review the documentation thoroughly to determine whether the cancer is still being treated or whether it occurred in the past and is no longer currently being treated before you select your code(s).

You’ll also review charts that include diagnoses pertaining to blood and blood-forming organs and immune disorders. You’ll assign codes for these disorders using code range D50–D89. One of the most common blood disorders is anemia. You’ll assign codes for common anemia disorders such as anemia of chronic disease and chronic simple anemia. The difference

Lesson 2 35

between these two conditions is that anemia of chronic disease is used when anemia is caused by another disease, whereas chronic simple anemia is a nutritional anemia. You’ll assign D63.8 for anemia of chronic disease, and code D53.9 for chronic simple anemia.

You’ll also assign codes for coagulation defects, such as von Willebrand’s disease, using code range D65–D69. A patient diagnosed with blood disorders such as neutropenia or an elevated white blood cell count would be reported with D70–D77. Codes ranging from D80–D89 are used to report immune disorders, such as Wiskott-Aldrich syndrome, an immunodeficiency disorder that impedes blood clot formation.

Part of your responsibility as a medical coder includes assigning codes for chronic endocrine, nutritional, and meta- bolic diseases, such as diabetes. You’ll find codes for these conditions in code range E00–E89. You’ll regularly assign codes for type 1 and type 2 diabetic patients, most notably type 2, using code range E08–E13. One of the key differences between the two is that type 1 diabetic patients develop dia- betes prior to reaching puberty. If the physician doesn’t document the type of diabetes, either type 1 or type 2, you would assign code E11-, for type 2 diabetes. If the patient is on long-term insulin, you would assign code Z79.4 as a sec- ondary code. In some instances, the patient may receive insulin via an insulin pump. If the insulin pump fails and the patient receives an underdose of insulin, you would assign code T85.6 to indicate the mechanical malfunction, and then an additional code to indicate the underdose of insulin (T38.3X6-), as well as any complications resulting from the underdose. If the insulin pump fails and the patient receives an overdose of insulin, you would assign code T85.6 followed by T38.3X1- for an overdose of insulin.

You’ll also assign codes for mental, behavioral, and neuro – developmental disorders using ICD-10. Mental conditions, in particular, may be harder to code because the physician may not be specific when indicating the diagnoses in the medical record. You’ll assign codes for different types of dementia, such as vascular dementia (F01), vascular dementia classified elsewhere (F02), and vascular dementia, unspecified (F03). Two of the most common mood disorders that you’ll code are

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depression (F32-) and anxiety (F41-). You’ll find these two codes in code range F30–F39. You’ll also frequently code sub- stance abuse disorders, such as alcohol-related disorders or dependence (F10), and assign codes for patients with psycho- logical disorders, such as schizophrenia (F20–F29).

Codes for nervous system disease are found in code range G00–G99. Codes for chronic pain and neoplasm-related pain, for example, are assigned with code G89. You would assign this code if the reason for the encounter is pain management. However, you would not assign this code if the underlying condition that’s causing the pain is known, and the under – lying condition is the reason for the treatment. If the patient is experiencing postoperative pain that’s expected after the surgery that was performed, you wouldn’t assign code G89 since the pain is expected. However, if the post operative pain is associated with a surgical complication, then you would assign G89. Be sure to review the guidelines for assigning code G89, as the rules for code assignment will vary depend- ing on the circumstances.

You’ll also regularly assign pain codes that are specific to cer- tain anatomical locations in the body. For example, a patient diagnosed with chest pain would be assigned to code range R07.1–R07.9, depending on the nature of the chest pain. Normally, you’ll assign code R07.9, for chest pain, unspeci- fied. A patient diagnosed with a headache would be assigned to code R51. Codes for paralysis are also assigned using codes from this chapter, depending on whether the paralysis occurs on the patient’s dominant or non-dominant side. You’ll find this information in the medical record.

You’ll report diseases of the eye and adnexa using code range H00–H59. Diseases related to the eye can be difficult to code, due to the complex structure of the eye and the surrounding structures (such as conjunctiva, sclera, cornea, iris, and so on). Be sure to consult a medical dictionary or search online if you’re unsure about a particular part of the eye. A patient diagnosed with conjunctivitis, inflammation of the conjunc- tiva, would be assigned to a code from code range H10–H11. A diagnosis of acute follicular conjunctivitis of the left eye, but not the right eye, would be assigned to code H10.012, for example.

Lesson 2 37

Definitions pertaining to certain eye conditions are equally important to understand for accurate code assignment. A patient with an entropion has an eyelid that turns inward. A patient with an ectropion has an eyelid that turns inside out. An entropion, if it’s not further specified as to type, is assigned to code H02.00-, while an ectropion, if unspecified, is assigned to code H02.10-.

Diseases of the ear and mastoid process are reported using code range H60–H95. Conditions of the ear pertain to the inner ear, middle ear, or external ear. Conditions of the inner ear are classified to code range H80–H83. Conditions of the middle ear are found in code range H65–H75. Conditions of the external ear appear in code range H60–H62. Two of the most common conditions that you’ll regularly code are otitis media, unspecified (H66.90 if the left or right ear is not indi- cated; H66.91 for otitis media of the right ear; H66.92 for otitis media of the left ear) and otitis externa (H60.90 for unspecified ear; H60.91 for the right ear; H60.92 for the left ear). Pediatric patients will often be coded for cerumen (ear wax) impaction. Code H61.20 is assigned for cerumen impaction if the ear is unspecified. Code H61.21 is assigned for cerumen impaction of the right ear. Code H61.22 is assigned for cerumen impaction of the left ear. Review the medical record closely to determine the correct anatomical location to assign the correct code.

The most common conditions that you’ll code in the circula- tory system (I00–I99) are hypertension and conditions related to hypertension. Hypertension may be benign (mild blood pressure elevation controlled on medication), malignant (accelerated hypertension with a poor prognosis and poten- tially resulting in organ failure), or unspecified (the physician doesn’t indicate whether the hypertension is benign or malig- nant). Hypertension may be controlled or uncontrolled, so review the medical record closely to see if this is indicated by the physician.

ICD-10 guidelines make a distinction between assigning diag- nosis codes for hypertension and chronic kidney disease vs. hypertension with heart disease. The key difference between these two sets of conditions is that a causal relationship is assumed between hypertension and chronic kidney disease, but not for hypertension with heart disease. The physician must state that the heart disease is due to the hypertension

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or must imply a causal relationship between the two condi- tions (as with hypertensive heart disease). Code category I11 is used to code these two conditions, plus an additional code from category I50, if the patient has heart failure. If the physician doesn’t establish a causal relationship between hypertension and heart disease, they must be coded separately and sequenced based on the circumstances of the encounter. Since chronic kidney disease is assumed to result from hypertension, a causal relationship is already established. You would assign a code from category I12, hypertensive chronic kidney disease, and an additional code from N18, chronic kidney disease, to indicate the stage of chronic kid- ney disease (Stage 1: N18.1, Stage 2: N18.2 [mild], Stage 3: N18.3 [moderate], Stage 4: N18.4 [severe], Stage 5: N18.5, Stage 6: N18.6 [end stage renal disease], and Stage 9: N18.9 [unspecified]).

Additional circulatory system diseases include myocardial infarction, categorized as either STEMI (ST elevation myo – cardial infarction) or NSTEMI (non-ST elevation myocardial infarction). The ST is an indicator on an electrocardiogram (a recording of heart activity). ST elevation indicates potential occlusion of the coronary artery or potential heart muscle damage. The diagnosis of STEMI is assigned to subcategory codes I21.0–I21.2 and I21.3. Code I21.4 is assigned for patients diagnosed with NSTEMI.

You’ll report diseases of the respiratory system using code range J00–J99. You’ll assign codes for common respiratory diseases and disorders including pneumonia (J18.9, if the organism isn’t specified), acute sinusitis, unspecified (J01.90), unspecified asthma with acute exacerbation (J45.901). You may regularly assign the code for unspecified conditions because the physician may not provide more specific infor- mation in the diagnosis. If the physician provides more specific information, then you would assign the code that includes the additional term(s). For example, if the physician indicates acute maxillary sinusitis rather than acute sinusitis (that is, the sinusitis is contained within the maxillary sinus only), then you would assign code J01.00 for acute maxillary sinusitis rather than acute sinusitis. You would also assign an additional code for the etiology (origin) of the condition, if known. Acute maxillary sinusitis due to Hemophilus influen- zae would be assigned to J01.00 and B96.3, respectively.

Lesson 2 39

Chapter-Specific Coding Guidelines, Chapters 11–14 This section discusses the guidelines in chapters 11–14. Chapter 6 of your text covers specific guidelines pertaining to diagnosis codes for

� Diseases of the Digestive System

� Diseases of the Skin and Subcutaneous Tissue

� Diseases of the Musculoskeletal System and Connective Tissue

� Diseases of the Genitourinary System

You’ll report diseases of the digestive system using code range K00–K95. A patient with gastrointestinal hemorrhage, unspecified, would be assigned to code K92.2. A patient diag- nosed with diverticulitis of the large intestine in the setting of perforation and abscess with bleeding would be assigned to code K57.21. Likewise, acute gastric ulcer with hemorrhage would be assigned to K25.0.

Diseases of the skin and subcutaneous tissue are assigned to code range L00–L99. A patient diagnosed with acne vulgaris would be coded to L70.0, which is found in code range L60–L75, disorders of skin and appendages. Cellulitis of the right finger would be coded as L03.011, whereas cellulitis of the left finger would be coded as L03.012. A patient who is bedridden for an extended period of time after being admitted to the hospital may develop pressure ulcers, which vary according to the stage of the ulcer and the anatomical loca- tion. Pressure ulcer of the left hip, stage 1, is coded as L89.221. On the other hand, a pressure ulcer of the sacrum, stage 4, is assigned to code L89.154. Skin, hair, and nail conditions that originate from birth (that is, congenital condi- tions) are assigned to codes Q80–Q89. Read the medical chart carefully when determining the correct code assignment.

Diseases of the musculoskeletal system and connective tissue are assigned to code range M00–M99. Common conditions coded using this code range include osteoarthritis (inflamma- tion of the bone and joint), arthritis (inflammation of the joints only), and fractures (breaks in the bone), for example. When you assign codes for these types of conditions, you

Medical Coding40

must review the medical record thoroughly to verify the anatomic site as well as the laterality that pertains to the diagnosis. The anatomic site indicates the part of the body where the condition occurred; laterality indicates the side of the body where the condition occurred. For example, a patient may be diagnosed with primary osteoarthritis occur- ring in the hip. The osteoarthritis may occur in the right hip, in the left hip, in both hips, or the physician may not indi- cate in which hip the condition occurred (unspecified). Additionally, for fractures, you must check the record to verify whether the patient sustained a pathologic fracture or a traumatic fracture. A pathologic fracture, or spontaneous fracture, occurs due to weakened bone resulting from the surrounding bone tissue or bone disease. A traumatic fracture occurs due to an accident, or trauma, sustained to the body that causes a break in the bone. Never assign a code for a traumatic fracture and a pathologic fracture to the same bone. It must be one or the other, based on the documenta- tion in the medical record.

You may also occasionally assign codes for infectious arthropathies using categories M00–M02. There are two types of infections: direct and indirect. Direct infections, an infection in which the invading organism has been identified, occur in the joint as well as in the synovial tissue. Indirect infections include reactive arthropathy (a condition in which the infection is found in the body, but the invading organism isn’t identified in the joint) and postinfective arthropathy (a condition in which a microbial immune response occurs, but the organism recovery is not regular, and multiplication of the microorganisms not apparent). Examples of infectious arthropathies include reactive arthritis (M02.3) and reactive arthropathy, unspecified (M02.9).

You’ll report diseases of the genitourinary system using code range N00–N99. Common conditions reported within this range include kidney stones (calculus, calculi, or calculous), different stages of chronic kidney disease (most notably in relation to hypertension, as discussed previously), and other diagnoses of the male genitalia, the female genitalia, and the urinary system.

Lesson 2 41

Chapter-Specific Coding Guidelines, Chapters 15–21 This section discusses the guidelines in chapters 15–21. Chapter 7 of your text covers specific guidelines pertaining to assigning diagnosis codes for

� Pregnancy, Childbirth, and Puerperium

� Certain Conditions Originating in the Perinatal Period

� Congenital Malformations, Deformations, and Chromosomal Abnormalities

� Symptoms, Signs, and Abnormal Clinical and Laboratory Findings, Not Elsewhere Classified

� Injury, Poisoning, and Certain Other Consequences of External Causes

� External Causes of Morbidity

� Factors Influencing Health Status and Contact with Health Services

As a coder, you’ll often assign codes that pertain to preg- nancy, childbirth, and the puerperium, but most notably during the patient’s pregnancy. Conditions that originate during pregnancy, childbirth, and the puerperium are assigned to categories O00–O9A, and found in Chapter 15. Obstetric coding is one of the most challenging forms of cod- ing that you’ll do, based on the wide variety of conditions and complications that may occur during the stages of pregnancy, as well as the guidelines for obstetric coding. One of the most important guidelines to remember when assigning codes related to pregnancy is that the pregnancy codes (O00-O9A) are always assigned first, before any other codes. These codes always take sequencing priority over codes from any other chapters. These codes are also always reported on the mother’s record, never on the newborn record. After you report these codes, you may assign additional codes pertaining to diag- noses from other chapters.

Medical Coding42

It’s also important to determine whether the patient’s condi- tion occurred before the pregnancy (a pre-existing condition) or whether it occurred sometime during or after the preg- nancy. If the physician indicates that the patient’s condition was incidental to the pregnancy, but not related to the pregnancy, you would assign code Z33.1, pregnant state, incidental. If the patient is seen only for routine supervision of pregnancy, you would assign a code from category Z34, encounter for supervision of normal pregnancy. However, if there are any complications pertaining to the pregnancy, you can’t assign code Z34. Instead, assign a code from O00–O9A as the principal diagnosis. You must always assign a code from category Z37, outcome of delivery, if the patient delivers during the medical encounter.

Pay special attention to the trimester indicated in the medical record. Trimesters are three-month periods counted from the first day of the patient’s last menstrual period. The patient may be having complications in the first, second, or third trimester of pregnancy. Accurate code assignment means selecting the diagnosis that includes the correct trimester. A first-trimester patient who is experiencing asthma during the pregnancy (or who has a past medical history of asthma, for which she’s using an inhaler), would be assigned O99.511, diseases of the respiratory system, complicating pregnancy, first trimester. If the patient was in her second trimester, you would use O99.512, and O99.513 in the third trimester. If the trimester is unspecified, the code to use is O99.519, diseases of the respiratory system, complicating pregnancy, unspecified.

Pregnancy Trimester Quick Reference

First trimester Less than 14 weeks since the patient’s last menstrual period

Second trimester 14 weeks to less than 28 weeks since the patient’s last menstrual period

Third trimester 28 or more weeks from the last menstrual period

Lesson 2 43

You’ll be able to determine the patient’s current trimester based on the statement in the medical record (usually found at the very beginning under History of Present Illness). The statement will indicate the number of weeks in relation to the reason for the patient’s medical encounter. For example, a statement that begins with “The patient is 22 weeks…,” indi- cates that the patient is in the second trimester of pregnancy. This tells you that the diagnosis for the patient’s condition should indicate the second trimester of pregnancy. You’ll also add another code for weeks of gestation (in this case 22) for greater specificity. You would also add a code for the specific respiratory condition indicated (in the example, asthma).

Complications may also occur in the peripartum period (the last month of pregnancy to five months postpartum) or in the postpartum period (shortly after the delivery until six weeks after the delivery). The important factor to remember is that the physician must document that the condition occurred in the postpartum period.

If the patient delivers a normal, full-term infant, you would assign code O80. If there are any pregnancy complications, you would instead assign the pregnancy complication code(s) previously indicated. If the complication previously existed but resolved prior to the delivery, you can still assign code O80. You would add code Z37, single live birth, for the out- come of delivery.

In addition to the example of asthma in pregnancy, you may also assign other chronic condition codes related to preg- nancy. Pre-existing hypertension in pregnancy would be assigned to category O10. A patient with diabetes mellitus in pregnancy would be assigned to code O24, followed by an additional code for the specific type of diabetes (E08–E14). If a patient was not diabetic prior to pregnancy but has devel- oped diabetes during the pregnancy, you would assign a code for gestational diabetes from subcategory O24.4. Abnormal glucose tolerance in pregnancy is assigned to subcategory code O99.81.

Note: This is the only code that you can assign as an outcome of

delivery code in connection with code O80.

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Using Chapter 16, you’ll assign codes for congenital condi- tions originating in the perinatal period (P00–P96). The perinatal period begins before birth and extends through 28 days after birth. Never assign codes for the newborn to the mother’s record or vice-versa. You would assign a code from category Z38, liveborn infants according to place of birth and type of delivery, as the principal diagnosis on the newborn record. Examples of the types of conditions reported using Chapter 16 codes include birth trauma, newborn infections in the perinatal period, and newborns affected by conditions inherent to the mother’s pregnancy.

Chapter 17 codes (Q00–Q99) pertain to congenital malforma- tions, deformations, and chromosomal abnormalities that begin in the perinatal period. An example of a common chromosomal abnormality is Down Syndrome (Q90). A chro- mosomal abnormality must be documented in the medical record by the physician. If the chromosomal abnormality isn’t documented, or if it’s unclear, ask the physician to clarify the diagnosis. The query is made in writing using a standard form that becomes a permanent part of the patient’s medical record after the physician’s written response is received.

Codes for Chapter 18 (R00–R99) are assigned for symptoms, signs, and abnormal clinical and laboratory findings. These codes are most often assigned when the physician can’t make a more definitive diagnosis because the cause of the patient’s symptoms can’t be determined. As indicated in Lesson 2, signs and symptoms shouldn’t be reported as the final diag- nosis when the physician makes a definitive diagnosis. For example, if a patient is seen for abdominal pain, and the physician renders a diagnosis of appendicitis, you would assign the final diagnosis code of appendicitis, not abdominal pain, since the abdominal pain is a common symptom of appendicitis. Some symptoms, however, may be unrelated to the final diagnosis.

Tip: If you’re ever unsure about the symptoms for the final diagnosis,

search the Internet using the final diagnosis, along with the word

symptoms. Select one or more results to review the common symp-

toms found in the diagnosis. For example, an Internet search of

appendicitis + symptoms would return a list of websites citing

abdominal pain as a common symptom of appendicitis.

Lesson 2 45

Chapter 19 codes (S00–T88) are external causes codes, used to report injury, poisoning, and other related conditions. When assigning injury codes, pay special attention to the seventh character. The seventh character indicates whether the patient’s visit is the initial encounter (A) or subsequent encounter (D). Or the patient’s visit may be a sequela (S), a condition that arises from a previously diagnosed condition, such as a scar that’s formed after a burn. S00–S99 codes are used to report injuries to specific locations of the body (such as the head, hip and thorax), while T07 and T14 are used to report injuries to unspecified body regions.

You’ll also use Chapter 19 to report conditions pertaining to injuries involving damage to the nerves and blood vessels, as well as open and closed traumatic fractures. When coding fractures, review the medical record thoroughly to determine whether the patient is still being actively treated for the frac- ture or whether the patient has completed active treatment and is in the recovery phase. If the patient has completed active treatment and is receiving aftercare, such as a cast change or cast removal, you’ll assign codes to indicate frac- ture aftercare. There may be other instances where the patient has delayed seeking treatment for the fracture and is currently being seen for the nonunion of the fracture. The seventh character of the code that you choose will change depending on the circumstances of the fracture, so be sure to review the guidelines for Chapter 19 coding in conjunction with the medical record when assigning codes for fractures.

Codes from Chapter 19 are also used when a patient is diag- nosed with

� Burns and corrosions

� Adverse effects, poisoning, underdosing, and toxic effects

� Abuse, neglect, and other maltreatment

� Open wounds, lacerations, and punctures

� Complications of care

When coding burns, you’ll assign diagnosis codes according to depth of the burn, extent of the burn, and the agent (using an X code). Burns may be first, second, or third degree. When the patient has more than one burn, sequence the highest

Medical Coding46

degree burn first. For example, a third-degree burn is more serious than a second- or first-degree burn; therefore, the third-degree burn would be sequenced first. Non-healing burns are coded as acute burns. Necrosis of burned skin is coded as a non-healing burn.

You’ll use the Table of Drugs and Chemicals to assign codes for adverse effects, poisoning, underdosing, and toxic effects. Never code directly from the Table of Drugs and Chemicals. Always verify your codes in the Tabular List, and use as many codes as possible. If the medical record indicates a drug overdose, review the record closely to determine whether the poisoning was accidental, intentional, assault, undeter- mined, an adverse effect (of a medication that was taken correctly) or due to underdosing.

For situations in which the patient is being abused, neglected, or mistreated, use a code from category T74- (confirmed child or adult abuse) or T76- (suspected child or adult abuse) fol- lowed by a mental health or injury code. The code Y07 (perpetrator of abuse) should also be added for confirmed cases of abuse. Additional guidelines apply for assigning physical injury codes pertaining to abuse, as well as observa- tion codes, and encounters in which abuse has been ruled out. Be sure to review the guidelines thoroughly when assign- ing codes for child or adult abuse situations.

When assigning codes for open wounds, you’ll locate the term wounds in the Alphabetic Index, followed by the subterm(s) pertaining to the wound. An example of a wound includes an open wound of the right knee (S81.001). Laceration is also a main term in the Alphabetic Index. Examples of lacerations include laceration of the right knee, without a foreign body in the knee (S81.011).

You may also assign codes for medical or surgical complica- tions. For example, a patient who undergoes a kidney transplant may experience complications as a result of the surgery; these would be assigned to code T86.1-.

Codes from Chapter 20, External Causes of Morbidity, are assigned as secondary codes to indicate the circumstances surrounding a patient’s injury (reported first with a code from Chapter 19). If the patient was painting a house and fell off a

Lesson 2 47

ladder, you would assign codes from Chapter 20 to indicate painting, house, and fall on and from ladder. These codes are always reported as secondary codes.

Chapter 21 codes are assigned for factors that influence a patient’s health status and contact with health services. These codes begin with the letter Z and can be used in any healthcare setting as a principal diagnosis only. If a patient comes to the doctor’s office for a flu vaccine, you would report Z23, encounter for immunization. If a patient is seen for an annual mammogram, you would report Z12.31, encounter for screening mammogram for malignant neoplasm of breast. Likewise, an encounter for a routine examination would be assigned to code Z01.41.

ASSIGNMENT 7 Read through the following material in your study guide. Then, read Chapter 27 of your textbook, Step-by-Step Medical Coding. When you’ve finished reading Chapter 27, complete the Chapter Review on pages 720–721. You can check your answers using the Answers section at the end of this study guide.

Procedure Coding With ICD-10-PCS The ICD-10-PCS (Procedure Coding System) replaced ICD-9-CM Volume 3. The ICD-10-PCS uses a completely different code structure for procedures. Rather than assigning a code with a generalized description, as in ICD-9-CM Volume 3, with the new ICD-10-PCS, you’ll assign codes that provide specific details of every element of the procedure. You’ll learn about the expandable multiaxial format of ICD-10-PCS, which allows room for more codes as new surgical procedures and treatments are created.

Introduction to ICD-10-PCS Previously, you would have used ICD-9-CM Volume 3 to assign procedure codes to surgeries performed on patients in the hospital. Now, you’ll use ICD-10-PCS in the same way. ICD-10-PCS isn’t in the back of the ICD-10-CM; instead, when you need to look up a surgical procedure, you’ll use a completely separate manual entitled ICD-10-PCS.

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In one ICD-10-PCS code, using seven characters in seven dif- ferent slots within the same code, you can tell the insurance carrier

� The section

� The body system on which the surgery was performed

� The type of operation performed (called the root operation)

� The specific body part within the body system that required surgery

� The surgical approach that the physician used to per- form the surgery

� The surgical device that was used (if any)

� Any additional circumstance surrounding the procedure (called the qualifier)

When you assign a medical and surgical code using the ICD-10-PCS code, you’re essentially “building” a code, just as you would if you were building a house. ICD-10-PCS gives you the first three “building blocks” (that is, the first three or four characters of the code) and then you add the remaining characters to the code for a total of seven characters alto- gether. You use the Tables section of ICD-10-PCS to add remaining characters to the code for a total of seven charac- ters. The specific characters added depend on what occurred during the surgery, as outlined in the medical record. Recall the example of the patient with appendicitis in Lesson 3. The patient diagnosed with appendicitis would undergo an appendectomy, or removal of the inflamed appendix. After assigning the diagnosis code for appendicitis, you’ll assign the surgery code for the appendectomy using ICD-10-PCS. Start by locating appendectomy in the ICD-10-PCS Index. The ICD-10-PCS Index is arranged according to body system, body part, operation (revisions), and device (changes). Instead of finding the complete code under appendectomy, you see two cross-references indented beneath the main term. The reference directs you to see Excision, Appendix 0DBJ. The second cross-reference directs you to see Resection, Appendix 0DTJ.

Lesson 2 49

Excision means cutting off or cutting out a portion of a body part without replacing it. Resection means cutting off or cut- ting out all of the body part. In this example, let’s assume that the patient had the entire appendix removed, so turn to Resection in the Index. Resection is listed as the main term and Appendix is a subterm in the indented list directly beneath the main term. Since the operation is a resection, the first four characters of your code are 0DTJ.

0 Medical and Surgical (The first character is for section)

D Gastrointestinal System (the second character is the body system where the surgery was performed)

T Resection (the third character is for the root operation that was performed)

J Appendix (the fourth character is for the body part on which the surgery was performed)

Turn to page 237 in your ICD-10-PCS manual to see how to finish coding this procedure. For purposes of the example, the surgeon used an open approach (a cut was made into the patient’s abdomen and the appendix was removed in its entirety). Since there are no special devices or qualifying circumstances for this procedure, the sixth and seventh characters are Z. Your final seven-character code is 0DTJ0ZZ. Review the table and compare the characters that you see in the table to the ones that were selected in the code to make sure you understand how it works. Remember that in order to “build” the remainder of your code, you’ll need to review the medical record to determine the body part, the approach, the device, and the qualifier. In most cases, there won’t be a qualifier, so your seventh character will automatically be Z. The Table includes other characters listed in the Qualifier Character column in ICD-10-PCS. Here are some additional pointers to keep in mind as you learn to assign procedure codes using ICD-10-PCS:

1. Don’t get stressed! The key to understanding ICD-10-PCS is to understand the logic of it. If you understand what you need to do in terms of reviewing the record so that you can build your codes, it’ll become easier.

Medical Coding50

2. Think of each character in your code as telling a part of the story (recall Lesson 1, how coders have to be good storytellers).

3. In addition to assigning codes for surgeries, you’ll use other sections of ICD-10-PCS to assign codes for services that don’t pertain to operations, such as radiation ther- apy, imaging, obstetrics, mental health, and substance abuse. Don’t let coding these procedures intimidate you. The process is still the same, although the characters may have different meanings than the ones that you find in the Medical and Surgical Section of ICD-10-PCS.


L e

s s

o n

3 L

e s

s o

n 3

Evaluation and Management and Anesthesia Coding HCPCS Level I and HCPCS Level II are the two code sets used to assign procedure codes in the outpatient setting. HCPCS Level I is the Current Procedural Terminology (CPT) manual. Updated and published annually by the American Medical Association, the CPT manual is used to describe and report medical procedures and services performed by physicians and other healthcare professionals. Note that CPT codes focus specifically on procedures rather than diagnoses or conditions, and only on procedures performed in the outpatient setting. The CPT manual is divided into three categories:

� Category I: Established procedures/services

� Category II: Data research/performance tracking

� Category III: Emerging technology

The codes in the CPT manual are grouped by specialty. The majority of the codes you’ll assign will be from the Evaluation and Management (E/M) section of CPT, the most frequently used section. You may occasionally assign codes from other sections of the CPT, but physicians normally use many of the same codes over and over again and usually stay within the code ranges pertaining to their specialties. For example, in addition to E/M codes, ophthalmologists use the Eye and Ocular Adnexa section (65091–68899), radiologists use the codes ranging from 70010–79999, and anesthesiologists use the codes starting with 0 (00100–01999). Review your CPT manual and see if you can identify the specialties that per- tain to each section.

The CPT manual uses many different symbols, and knowing what they mean is crucial to accurate coding. These symbols will alert you to extended definitions of a code, revised or new codes, and special circumstances related to a service or procedure.

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For example, the # sign indicates that a code is listed out of numerical sequence. For the current manuals, some codes were moved so they could be grouped with similar proce- dures. Instead of renumbering many items, the procedure codes were simply moved and notes were inserted to indicate where the code was moved to and from. Be on the lookout for these. An example is code 46220.

Guidelines and descriptions are found at the beginning of many sections of the CPT manual. It’s very important to read this information before coding within a section, since it explains the codes listed and sometimes may help refine a search or lead to a more appropriate code.

CPT Categories II and III are much less frequently used, but they’re still important. Neither replaces Category I codes.

Category II codes can be added to a claim with other codes to denote a specific type of care given. Category II codes can be found in the CPT manual following the Category I codes, before the Appendix section. Category III codes, listed after Category II, are for emerging treatment modalities. They may be used instead of an unlisted code when a treatment isn’t yet FDA approved or is used as an experimental treatment.

These codes are updated semiannually in February and July. If the physician is using new treatments or you find that you’re coding unlisted procedures frequently, you should consider using Category III codes instead.

Another important update to the CPT is the errata (errors) list. Despite careful scrutiny, it’s inevitable that errors find their way into the CPT manual each year. Check the AMA website after you receive your book every year. Note the cor- rections in your book next to each affected code and in your billing program to prevent errors in billing throughout the year. The index of the CPT manual provides an alphabetical listing of procedures. Before using a code, you must find the name of the procedure or service in the index and then follow up by finding the code number in the main section for a full description. You may discover when you look up a code as directed by the index, that there’s a more appropriate code than the one referenced there. Never assign a code using the index listing alone. This leads to inaccurate code assignment. You must always locate the code in the appropriate section of

Lesson 3 53

the CPT and read the code description. If the description doesn’t accurately reflect the nature of the service provided, you may need to choose another code.

You’ll start with a review of the first section in the CPT, which is the one you’ll use most often: Evaluation and Management (E/M). Encounters that don’t involve surgery are coded in this section. It’s important to note that this section isn’t bro- ken down by specialty; the codes listed in the E/M section are assigned across the board, regardless of the physician’s specialty.

You’ll also learn how to apply codes in the Anesthesia section when billing for the anesthesiologist’s services, as well as the special modifiers that apply to anesthesia coding only.

OBJECTIVES When you complete this lesson, you’ll be able to

� Outline the structure of the HCPCS Level I (CPT)

� Locate terms in the CPT Index

� Recognize and assign CPT modifiers to services and procedures

� Explain the role of E/M coding

� Outline the process and procedure for assigning codes from the E/M section of the CPT

� Describe the process of assigning codes using the Anesthesia section of the CPT

� Differentiate between anesthesia modifiers and qualifying circumstance codes assigned in anesthesia coding

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ASSIGNMENT 8: OVERVIEW OF CPT (HCPCS LEVEL I) Read through the following section in your study guide, then read Chapter 8 of your textbook.

Assigning the correct CPT coding means paying attention to every single word in every single part of a code description. As in diagnosis coding, the descriptions for two codes in the CPT may be identical except for a variation of a few words. Those few words may be the difference in choosing code A or choosing code B.

The CPT manual begins with an Introduction and Illustrated Anatomical and Procedural Review, and continues with major sections and subsections that pertain to services, procedures, and treatments commonly coded in the outpatient setting.

The CPT manual ends with Category II and Category III codes, a series of appendices that provide supplemental information pertaining to CPT codes in earlier sections, and the CPT Index, which is the starting point for assigning your CPT codes.

The major sections of the CPT that you’ll use to assign your codes are as follows:

� Evaluation and Management

� Anesthesia

� Surgery

� Radiology

� Pathology and Laboratory

� Medicine

The Evaluation and Management (E/M) section contains codes pertaining to office visits for new patients (those who haven’t been seen by the physician or another physician in the same practice within the past three years); office visits for existing patients (those who have been seen by a physician in the same practice within the last three years); hospital obser- vations for patients admitted and discharged on the same date of service (patients who are admitted to the hospital from observation status are assigned to the initial hospital

Lesson 3 55

care code); inpatient visits (initial, subsequent, and discharge day visits); consultations; critical care; emergency room visits; nursing home visits; preventive medicine visits; neonatal visits; and other types of services, including online, phone, and Internet consultations. The bulk of the codes that you assign will come from the E/M section of CPT. We’ll discuss E/M coding in the next lesson.

The other area of CPT that you’ll use often is the Surgery section. The surgery section is structured according to body system. You’ll assign codes from the Surgery section accord- ing to the services and procedures provided in relation to the physician’s specialty. The following subsections appear in the Surgery section:

� General

� Integumentary System

� Musculoskeletal System

� Respiratory System

� Cardiovascular System

� Hemic and Lymphatic System

� Mediastinum and Diaphragm

� Digestive System

� Urinary System

� Male Genital System

� Reproductive System Procedures

� Intersex Surgery

� Female Genital System

� Maternity Care and Delivery

� Endocrine System

� Nervous System

� Eye and Ocular Adnexa

� Auditory System

� Operating Microscope

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We’ll review each of these areas as we proceed through the study guide. Regardless of the surgical specialty areas to which you assign codes, abbreviated codes called modifiers can be appended to the code(s) that you assign to indicate special circumstances. Let’s take a closer look at modifiers and how they function in relation to CPT coding.

ASSIGNMENT 9: INTRODUCTION TO MODIFIERS Read through the following section in your study guide, then read Chapter 10 of your textbook.

Attaching a modifier to a CPT code indicates that a service or procedure was altered in some way, but not enough to change the code or the description of the code. For example, modifier -23 indicates that a procedure that would usually be performed under local or no anesthesia had to be performed under general anesthesia for some reason.

Modifiers and their descriptions can be found in Appendix A of the CPT manual. The codes, without descriptions, can also be found inside the front cover. Every year there are deletions, additions, revisions, and amendments to the CPT codes, including modifiers.

Modifier -59 is used to designate procedures that are sepa- rate and distinct from other procedures performed on the same day. Adding modifier -59 to a CPT code may indicate

1. Another procedure was performed.

2. A procedure was performed at a different session.

3. A procedure was performed through a separate site.

4. A procedure was performed on a different organ.

5. A procedure was performed through a separate incision or excision.

6. A separate lesion was removed in addition to an earlier lesion.

7. A separate injury or a separate area of an injury was treated, which is not ordinarily treated under different circumstances.

Lesson 3 57

Modifier -59 was formerly appended to the second code to address any one of these circumstances, but due to the mod- ifier’s generality, it was unclear which of these circumstances applied. As of January 1, 2015, there were four additional modifiers created by the Centers for Medicare and Medicaid Services (CMS) that are designed to make modifier -59 more specific in terms of how it’s applied. These modifiers are called modifiers -X{EPSU}. The four modifiers, which are sub- sets of modifier -59, are

� -XE, or Separate Encounter, indicates a service was per- formed during a separate and distinct encounter.

� -XS, or Separate Structure, indicates a procedure was performed on a separate organ or anatomical structure.

� -XP, or Separate Practitioner, indicates that a service is distinct because it was performed by a different doctor.

� -XU, or Unusual Non-Overlapping Service, indicates that a service doesn’t overlap other components of the primary procedure.

When you review the modifiers listed on the inside of your CPT manual, you’ll notice that some are listed as Level II (HCPCS/National) modifiers. These modifiers are also appended to CPT codes (HCPCS Level I). If you’re ever unclear about how modifiers should be applied in specific coding sit- uations, turn to Appendix A in the back of your CPT manual to review a more in-depth description of each modifier and how it should be applied to your CPT code(s). In Lesson 2, you’ll take a look at the specific sections that you’ll use to assign your CPT codes.

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ASSIGNMENT 10: EVALUATION AND MANAGEMENT CODING Read through the following section in your study guide, then read Chapter 11 of your textbook.

Almost every physician and healthcare provider who sees patients uses E/M codes. Fees are linked to each code in HCPCS Level I and Level II. Choosing accurate codes is crucial to the financial health of the physician’s practice and for compliance with coding regulations. CPT E/M codes are used primarily to describe procedures associated with a physician’s first encounter with a patient. The first encounter can occur in a wide variety of settings, including hospitals, medical offices, nursing homes, and clinics. Evaluation codes describe initial procedures used to provide a framework for under- standing a patient’s condition. Management codes describe the procedures used to diagnose and treat specific com- plaints or problems.

Several factors are involved in determining E/M codes. The first of these factors, history, is an account of medical, emo- tional, psychological, environmental, and other related details that may have contributed to the patient’s condition. The level of detail involved in obtaining a patient’s history will often have a significant impact on the level of service pro- vided by the physician.

Two additional factors that determine the E/M code assign- ment are examination and medical decision making. The term examination refers to the various tests performed in an effort to obtain objective information about a patient’s condition. These tests can range from obtaining simple measurements, such as body temperature and blood pressure, to more com- plex procedures, such as X-ray and ultrasound scans. The term medical decision making refers to the process of arriving at a diagnosis based on history and examination.

Several less critical factors also contribute to accurate E/M code assignment. For example, a certain amount of counseling is typically required to ensure patients understand the nature of their condition and their own role in the treatment

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program. Another factor, referred to as coordination of care, involves activities such as writing prescriptions, consulting other doctors, and scheduling referrals to specialists.

The severity of the presenting problem also contributes to the level of service provided by a physician. In general, the more severe the presenting problem is, the higher the level of service will be. Similarly, the time required to obtain a history, per- form examinations, counsel the patient, and coordinate care will also have a bearing on the level of service provided—and consequently, on the determination of appropriate E/M codes.

When E/M codes debuted in 1992, there was little direction on their use. The first audit of those codes showed such high error rates that in 1995 CMS (then Healthcare Financing Administration, HCFA) came out with the 1995 Documentation Guidelines for Evaluation and Management Services, com- monly referred to as 95 DGs, to quantify the information needed for each key component. The guidelines included areas of history, examination, and medical decision making, which needed to be documented in order to reach a certain E/M level. Coders counted the points in each section to determine the code, which reflected the amount of work involved on the part of the physician.

The greatest emphasis in the 95 DGs was on history and examination elements, leaving medical decision making vague. This led doctors to choose codes based mainly on those areas that could be quantified and to ignore the med- ical decision making section. The 95 DGs also required a broad physical exam to be able to code for higher levels. This meant that specialists who used expanded problem-focused exams, but at much higher levels than general practitioners, were prevented from using the higher codes even though their work should have allowed them to.

In 1997, CMS introduced new guidelines, 97 DGs, changing mainly the examination portion. These provided more options for counting, allowing intensive problem-specific examina- tions to be eligible for inclusion in higher-level services. However, this meant a lot more documentation of “normal” findings by name to achieve a certain level. The AMA protested the addition of more work to document an exam, and

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this led to the rule that physicians may use either the 95 DGs or the 97 DGs to document their encounters, based on whichever one benefits them more.

In truth, decision making speaks to medical necessity—and proper E/M code selection. The history and physical are there to support, or justify, the decision. Physicians generally do as much work as is needed to determine how to treat a condition, so the problem should dictate the history and physical level. For example, if a patient comes in with a sore throat and cough, the doctor is unlikely to perform an eight- system exam with a full past, family, and social history. The presenting problem calls for a problem-focused history of present illness (HPI) and problem-focused examination.

Coders must be careful to apply all of the rules for either the 95 DGs or the 97 DGs to a case. You must be familiar with both sets of rules. Caution: Don’t apply one DG to the history section of a patient’s chart and the other DG to the exam portion. Be consistent within each record. Even though the exam portion was the biggest change from 1995 to 1997, double-check documentation of both history and physical components against the rules to make sure they’re all in compliance for the chosen set of DGs. You can use one or the other set of DGs, and decide on a case-by-case basis, but you must be consistent within each patient’s record.

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ASSIGNMENT 11: ANESTHESIA CODING Read through the following material in your study guide, then read Chapter 12 of your textbook.

Used in a medical context, the term anesthesia refers to the administration of pharmacological drugs aimed at suppress- ing nerve functions. Anesthesia is often administered prior to surgery, according to three different categories:

� Local anesthesia numbs a specific part of the body.

� Regional anesthesia suppresses feeling in a wider anatomical area, such as the leg, arm, or face.

� General anesthesia is administered in cases that require suppression of the patient’s entire nervous system.

Codes located in the Anesthesia section of the CPT manual are used to report the administration of all categories of anesthesia by anesthesiologists and other qualified or super- vised healthcare practitioners. You should note, however, that some codes in the CPT manual include conscious sedation performed by the surgeon, not an anesthesiologist. These codes are preceded by the symbol . While under conscious sedation, the patient is pain-free but still able to respond to instructions from the medical team. An example is code 43453—dilation of esophagus, over guide wire.

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Surgical CPT Coding, Part 1 In this lesson, you’ll learn about the following sections in the CPT:

� Integumentary System

� Musculoskeletal System

� Respiratory System

� Cardiovascular System

Codes in the Integumentary System are for procedures performed on the skin, nails, breasts, and other areas of the integumentary system. You’ll assign codes from the Musculoskeletal System when a patient is seen for repair of bone fractures and dislocations, wound explorations, grafts, spinal fixation procedures, cast and splint applications, as well as other procedures performed on the musculoskeletal system. Patients presenting with respiratory disorders such as asthma and bronchitis will receive treatments classified to the Respiratory System. In the Respiratory System, you’ll code for endoscopies, removal of lesions and foreign bodies, as well as other procedures. Procedures coded to the Cardiovascular System include pacemaker insertions, removal of tumors in the heart, coronary artery bypass, excision of blood clots and blood masses, and other cardio- vascular procedures.

OBJECTIVES When you complete this lesson, you’ll be able to

� Explain general surgical guidelines

� Describe common procedures performed on the integu- mentary system and how they’re coded

� Specify common procedures that apply to the musculo – skeletal system and how they’re coded

� Outline common procedures coded within the respiratory system

� Detail common procedures that pertain to the cardio – vascular system

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ASSIGNMENT 12: SURGICAL GUIDELINES Read through the following material in your study guide, then read Chapter 13 of your textbook.

General surgery is a term used to describe operations on a wide range of anatomical systems. These include the respira- tory, cardiovascular, lymphatic, auditory, ocular, nervous, and digestive systems, as well as the male and female repro- ductive systems. Surgical procedures associated with each system are grouped together in separate sections of the CPT manual. Each of these sections is organized into subsections identifying the various organs that make up a particular sys- tem, as well as the surgical procedures performed on each organ. For example, the Respiratory System/Surgery section of the CPT manual, which we’ll discuss later on, is divided into four subsections: Nose, Larynx, Trachea and Bronchi, and Lungs and Pleura. The Nose subsection is subdivided into a variety of surgical categories, including incision, exci- sion, removal of a foreign body, and repair.

Within each surgical category, you’ll find a list of specific pro- cedures, along with the appropriate codes. HCPCS Level II modifiers are frequently used when reporting general surgical procedures to provide an additional level of detail. Accuracy and specificity are especially important when filing claims for general surgery. If you report unilateral procedures per- formed on the lungs, for example, you’ll need to append the left side (-LT) and right side (-RT) modifiers to each instance of the surgical code. Otherwise, an insurance company or other third-party payer may incorrectly deny a claim on the supposition that duplicate procedures have been reported.

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ASSIGNMENT 13: INTEGUMENTARY SYSTEM CODING Read through the following material in your study guide, then read Chapter 14 of your textbook.

Your first area of exploration will be the integumentary system, which is comprised of the skin, nails, hair, sebaceous glands, and sweat glands. Procedures involving the integumentary system are located at the beginning of the Surgery section of the CPT manual. A brief review of this part of the manual shows that the Integumentary System section is divided into the following five subheadings:

� Skin, Subcutaneous, and Accessory Structures

� Nails

� Repair

� Destruction

� Breast

Each subheading contains several categories. Under the Destruction subheading, for example, you’ll find the following categories:

� Destruction, Benign or Premalignant Lesions

� Destruction, Malignant Lesions, Any Method

� Mohs Micrographic Surgery

� Other Procedures

The codes listed in each category are used to report specific variations of the procedure described by the category heading. For example, code 17260 describes Destruction, malignant lesion (e.g., laser surgery, electrosurgery, cryosurgery, chemo- surgery, surgical curettement), trunk, arms or legs; lesion diameter 0.5 cm or less. Code 17261 is used for Destruction, malignant lesion (e.g., laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), trunk, arms or legs; lesion diameter 0.6 cm to 1.0 cm.

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ASSIGNMENT 14: MUSCULOSKELETAL SYSTEM CODING Read through the following material in your study guide, then read Chapter 15 of your textbook.

Unlike other types of procedures, CPT codes for reporting musculoskeletal system procedures are often determined on the basis of the treatment method. An open treatment of a radial shaft fracture, for example, involves surgical opening of the fracture site. The associated code is 25515—Open treat- ment of radial shaft fracture, includes internal fixation, when performed. A closed treatment of the same type of fracture, which is accomplished without surgically entering the frac- ture site, would be coded 25500—Closed treatment of radial shaft fracture; without manipulation if no manipulations were necessary, or 25505—Closed treatment of radial shaft frac- ture; with manipulation if the physician needed to manipulate the bone.

Several other aspects need to be considered when determin- ing the appropriate code for orthopedic procedures. For example, procedures performed on soft tissue—such as exci- sion of a ganglion cyst—are located in different areas of the Musculoskeletal section of the CPT manual than procedures performed on bone. Since treatments for traumatic injury are usually coded differently than treatments for medical condi- tions, the reason for treatment will also play a decisive role. The code for hip replacement to alleviate osteoarthritis, for instance, is located under the Repair, Revision and/or Reconstruction category of the Pelvis and Hip Joint sub – heading of the Musculoskeletal subsection of the CPT manual. By contrast, the code for hip replacement performed as a result of fracture is located under the Fracture and/or Dislocation category.

You’ll also want to be sure you’ve identified the most specific anatomical site on which a procedure was performed. Vertebral treatments, for example, are coded differently depending on whether the procedure was performed on the lumbar, thoracic, or cervical vertebrae. In addition, when

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coding procedures performed on multiple sites in the same area—such as repairing fractures to several fingers—you must either indicate the number of specific sites treated or enter the code multiple times. The method will depend on the code itself. Different codes require different procedures.

A final factor to consider is whether treatment required the insertion of pins, screws, or wires to immobilize an area, a procedure commonly referred to as fixation, or grafting. Some procedures, such as reconstruction of the midface, specifi- cally list bone grafts. When grafting or fixation is specifically identified, you’ll need to list the appropriate codes separately.

ASSIGNMENT 15: RESPIRATORY SYSTEM CODING Read through the following material, then read Chapter 16 of your textbook.

As a medical coder, you’ll assign codes for services and pro- cedures that pertain to the respiratory system. You’ll learn about coding procedures pertaining to the mouth, throat, nasal system, sinuses, larynx, trachea, bronchi, pleura, and other areas of the respiratory system.

One of the major procedures that you’ll code in the respira- tory system is endoscopy. During endoscopy, the physician inserts a scope into the patient’s nose and then passes it down into the larynx or bronchial tubes. Once the scope is inserted, the physician can see inside specific areas of the respiratory system. In some instances, the physician may perform more than one procedure using the scope insertion. For example, if the physician performs a bronchoscopy, passing the scope into the bronchi, the first procedure may involve taking a biopsy of the bronchus. The second proce- dure, still part of performing the bronchoscopy, may involve removing a foreign body. In this case, you would report both procedures, adding a -51 modifier to the second procedure involving removal of the foreign body.

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Different types of endoscopies include

� Laryngoscopy (the scope is inserted into the larynx)

� Tracheoscopy (the scope is inserted into the trachea)

� Bronchoscopy (the scope is inserted into the bronchus)

The code you assign for the endoscopy depends on the fur- thest extent that the scope is inserted. If the endoscopy begins as a laryngoscopy, but the scope is passed into the trachea and the trachea is examined, the furthest extent that the scope is passed is the trachea, so you would assign the code for tracheoscopy. If the scope is passed beyond the tra- chea and into the bronchus, then it becomes a bronchoscopy, and you would assign the code for bronchoscopy instead.

In addition to endoscopies, you’ll also code incisions and excisions that pertain to the respiratory system. It’s impor- tant to have a clear understanding of the different parts of the sinuses because you may code multiple procedures that are performed on different areas of the sinuses during the same operative session. The three areas of the sinuses are the frontal, maxillary, and ethmoid sinuses. You’ll need to read the code descriptions carefully and compare the descriptions to the information in the medical record. Keep a diagram of the sinuses nearby to help you interpret the code descrip- tions for the procedures that were performed.

ASSIGNMENT 16: CARDIOVASCULAR SYSTEM CODING Read through the following material in your study guide, then read Chapter 17 of your textbook.

As a medical coder, you’ll assign codes for services and pro- cedures that pertain to cardiology, which is the study of the heart. You’ll use one of three areas of the CPT to assign codes for cardiology services:

� Surgery section (33010–37799)

� Medicine section (92920–93799)

� Radiology section (75557–75791)

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The Surgery section pertains to operations performed on the heart. The Medicine section pertains to any procedures per- formed on the heart that aren’t surgical in nature. The Radiology section pertains to x-rays or other types of diag- nostic services performed in relation to the heart. We’ll review the Medicine and Radiology sections in future lessons.

Many types of cardiovascular procedures are covered in detail in your textbook. You’ll code some cardiovascular procedures more often than others, depending on the account that you’re assigned to work on and the volume of cardiology services performed. The cardiovascular procedures that you’ll code most often are

� Pacemaker insertions, repairs, and revisions

� Coronary artery bypass grafts (CABGs)

� Percutaneous transluminal coronary angioplasties (PTCAs) and stent placement

� Cardiac catheterizations

A pacemaker, as the name implies, ensures that the heart “keeps pace” as it should. The pacemaker regulates the patient’s heartbeat. The physician makes a pocket in the skin and inserts the pacemaker pulse generator along with the leads (the wires that connect to the pacemaker) into the patient’s chest. A wire is guided through a blood vessel to the heart. Patients may require replacement of a pacemaker, revision of an existing pacemaker, change of a battery in the pacemaker, or adjustment of a pacemaker lead. You’ll use codes 33202–33273 in the Surgery section to code surgeries related to pacemakers.

The key to coding pacemakers is to closely compare the sur- gery described in the medical record to the code descriptions in code range 33202–33273. Some descriptions pertain to insertion of a pacemaker pulse generator with leads. Other descriptions pertain to repair of one or more leads connected to an existing pacemaker. Some descriptions refer not to the pacemaker, but to relocation of the pocket into which the pacemaker is inserted. There are separate codes for tempo- rary pacemakers and permanent pacemakers, and different approaches used (such as epicardial and transvenous) to

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insert pacemakers. So for these reasons, it’s important to pay very close attention to the specific type of pacemaker surgery being performed and to read the code description carefully.

Coronary artery bypass grafts (CABGs) address blockages in the heart that restrict blood flow. Think of the coronary artery bypass graft as taking an alternate route on a highway with traffic congestion. The patient has a clogged artery in the heart that’s restricting blood flow. With a CABG, the physician takes a healthy blood vessel and attaches it above and below the clogged artery, using the healthy blood vessel to carry the blood that was previously being carried by the clogged artery. The clogged artery is “bypassed” and the blood is now being transported by the healthy blood vessel.

You need to ask yourself several questions when coding coro- nary artery bypass grafts:

� What’s being used to bypass the clogged artery? Is it another artery? Is it a vein? Is it both? The answer will determine the range from which you’ll choose to assign your codes. If an artery is being used as the new blood vessel, you’ll assign a code from the range 33533–33548. If a vein is being used, you’ll assign a code from the range 33510–33516. If both a vein and an artery are being used, you’ll assign a code from 33517–33523 plus an additional code from 33533–33548.

� How many bypasses did the doctor perform? The patient may have more than one clogged artery. In this case, the doctor may need to perform more than one graft.

Let’s look at an example of a coronary artery bypass graft in which the physician uses an artery and a vein to perform the bypass. The physician performs three venous (vein) grafts and five arterial (artery) grafts. You need two codes: one for the artery alone and one for the vein + artery combination. Turning to the index in the back of your CPT manual, locate “Coronary Artery Bypass Graft (CABG),” then “Arterial Bypass 33533–33536” along with “Bypass 33517–33519, 33521–33523, 33531.” The codes for the arterial bypass appear under “Arterial Grafting for Coronary Artery Bypass.” Your first code is the “artery alone” code. In this scenario,

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since the physician performed five arterial grafts, you choose code 33536—“Coronary artery bypass, using arterial graft(s); 4 or more coronary arterial grafts”.

Your second code is the “vein + artery combination” code. These codes appear under “Combined Arterial-Venous Grafting for Coronary Bypass.” You assign code +33519— “Coronary artery bypass, using venous graft(s) and arterial graft(s); 3 venous grafts”, without the + symbol, which indi- cates that 33519 is an add-on code. A note appears in parentheses below the code description for each code in the 33517–33523 range advising the coder that these codes are designed to be used in conjunction with the arterial grafting codes in range 33533–33536. Your final code selection for this example is 33536, 33519.

Instead of performing a coronary artery bypass graft, the physician might choose to perform a percutaneous transluminal coronary angioplasty (PTCA). In this instance, the physician inserts a catheter (a long tube) into the artery, runs a guide wire through the tube, and then inserts another catheter, called a balloon catheter, over the guide wire. Once the bal- loon is inserted into the blocked artery, it expands. As the balloon expands inside the artery, the blockage is pushed up against the artery walls, thereby restoring blood flow inside the artery. Then the balloon is deflated, both catheters are withdrawn from the artery, and a wire frame called a stent is left inside of the artery to keep it from closing again.

You’ll assign codes for PTCAs from code range 92920–92921 under “Coronary Therapeutic Services and Procedures.” When you turn to the Index, you’ll look for “Percutaneous Transluminal Coronary Angioplasty.” Directly beneath this heading, you’ll see a cross-reference note: “See Percutaneous Transluminal Angioplasty.” Under this heading, you’ll see “Coronary 92920–92921.” Codes 92928 and 92929 are assigned for the stent placement.

When coding for cardiac catheterizations, you’ll encounter right heart catheterizations, left heart catheterizations, and combined right and left heart catheterizations. Unlike the PTCA, where the physician inserts the catheter to clear a blocked artery and a stent to keep it open after the blockage is cleared, a cardiac catheterization is performed to diagnose

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heart problems. The catheter is inserted using a guide wire into either the right or left side of the heart. Once the catheter is inserted, the physician injects dye and then takes pictures of the heart to diagnose any problems with blood flow.

Assign code 93451 for a right heart catheterization, code 93452 for a left heart catheterization, and code 93453 for a combined right and left heart catheterization. Review the operative report and any additional medical documentation completely to pinpoint the type of catheterization that was done.


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Surgical CPT Coding, Part 2 In this lesson, you’ll learn about the following sections in the CPT:

� Hemic, Lymphatic, Mediastinum, and Diaphragm Systems

� Digestive System

� Urinary and Male Genital System

� Reproductive, Intersex Surgery, Female Genital System, and Maternity Care and Delivery Systems

The hemic system consists of the blood and the bone marrow, which produces blood. The lymphatic system plays an impor- tant role in maintaining the immune system and in the transportation of fluids, proteins, and fats. Bone marrow and stem cell procedures are examples of codes used in this section.

The digestive system includes structures that process food, disseminate nutrients, and eliminate wastes from the body. Using codes from the Digestive System, you’ll report proce- dures performed on the lips, mouth, pharynx, palate, uvula, intestines, appendix, colon, rectum, anus, and liver. The Urinary System section contains procedures that pertain to the kidney, urethra, ureter, and bladder. The Male Genital System section contains codes for procedures that pertain to the male anatomy, such as the penis, testis, scrotum, and vas deferens.

OBJECTIVES When you complete this lesson, you’ll be able to

� Explain the types of procedures coded in the Hemic, Lymphatic, Mediastinum, and Diaphragm Systems

� Outline the types of procedures and the codes assigned within the Digestive System

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� Specify the code ranges for the most common types of procedures coded in the Urinary and Male Genital Systems

� Describe the types of procedures and the codes assigned within the Reproductive, Intersex Surgery, Female Genital System, and Maternity Care and Delivery Systems

ASSIGNMENT 17: HEMIC, LYMPHATIC, MEDIASTINUM, AND DIAPHRAGM CODING Read through the following material in your study guide, then read Chapter 18 of your textbook.

A patient with a blood disease may require any of the follow- ing procedures, coded from the Hemic and Lymphatic Systems section:

� Bone marrow aspiration (38220), in which cells are obtained from the bone marrow cavity using a needle and a syringe

� Bone marrow biopsy (38221), where pieces of the marrow are obtained using a needle or a trocar

� Transplant using cells harvested from a bone marrow donor

Patients with diseases of the lymphatic system might require

� Splenectomy (removal of the spleen, the organ that filters and removes bacteria and destroys old blood cells)

� Limited lymphadenectomy (38562–38564)

� Radical lymphadenectomy (38700–38780)

The mediastinum is the structure that separates the lungs. The diaphragm is the structure that separates the thoracic and abdominal cavities.

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In the Mediastinum and Diaphragm subsection (39501–39599) you may code incisions, excisions, and endoscopies. A physi- cian may use different approaches to make an incision, and for different reasons. Incisions may be made through the patient’s neck, thorax, or sternum. The physician may make an incision to obtain a biopsy, excise a cyst or a tumor, for exploration, or to remove a foreign body. An endoscope may be inserted through a small incision above the sternum.

Regardless of the nature of the procedure or the area of CPT that you’re referencing, the important thing to remember is to carefully review the appropriate code descriptions to ensure accurate code assignment.

ASSIGNMENT 18: DIGESTIVE SYSTEM CODING Read through the following material in your study guide, then read Chapter 19 of your textbook.

Using codes in the Digestive System section, you’ll code pro- cedures performed on the mouth, lips, palate, uvula, pharynx, esophagus, stomach, appendix, liver, and other digestive organs. You may code repairs of congenital deformities, such as a cleft lip.

Two common procedures that you’ll code using the Digestive System are tonsillectomies and adenoidectomies (42820–42836). Other procedures performed on the digestive system include biopsies and injections.

As in the respiratory system and other areas of the anatomy that may require endoscopy, in the Digestive System you’ll code the endoscopy according to the farthest extent to which the scope is advanced. Sigmoidoscopy (45330–45342) indicates that the scope has been advanced into the sigmoid colon. Colonoscopy (45378–45398) indicates that the scope has been advanced into the colon. When the scope is advanced into the rectum and the sigmoid colon, it’s coded as a procto – sigmoidoscopy (45300–45327).

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ASSIGNMENT 19: URINARY AND MALE GENITAL SYSTEMS CODING Read through the following material in your study guide, then read Chapter 20 of your textbook.

The urinary and male genital systems are combined in one section of CPT. Let’s start by taking a look at the Urinary System section, which covers code span 50010–53899. Pay close attention to the areas of the urinary system when assigning your codes.

There are six areas of the urinary system:

� Renal pelvis

� Kidney

� Ureters

� Bladder

� Urethra

� Urethral meatus

The ureters pass urine from the kidneys into the bladder. The urethra passes urine from the bladder out of the body through the urethral meatus. These two areas of the urinary system are often confused when coding, so pay special atten- tion to these terms when one of them is indicated in the code description.

The types of procedures that you’ll code in relation to the Urinary System include incisions, excisions, repairs, endo- scope insertions, and the introduction and placement of stents, catheters, and tubes.

You’ll find a lot of closely related medical suffixes in this sec- tion, so it’s important to know what they mean. For example, a physician may perform a nephrotomy, which involves mak- ing an incision into the kidney for purposes of exploration and to pinpoint any tumors or stones. Nephrostomy means that the physician creates an opening into the kidney and inserts a catheter to drain the urine directly.

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A physician may also perform a percutaneous nephrolithotomy to remove kidney stones using ultrasonic waves. If you aren’t completely sure about the meaning of a term, break it down into its component parts. In this case percutaneous means “through the skin,” nephro means “kidney,” litho means “stone,” and otomy means “opening or incision.”

Another common procedure is urinary catheterization. You’ll most often assign a code for a temporary indwelling catheter, such as a Foley catheter (51702). The catheter is inserted into the bladder to drain residual urine during a surgical procedure.

In the Male Genital System section, you’ll assign codes for destruction, excision, introduction of injections, exploration, and repairs. One common procedure is the transurethral resection of the prostate (TURP), used to treat prostate condi- tions such as malignancy. Code 52601 is assigned for the complete transurethral resection of the prostate, including control of postoperative bleeding. Code 52630 is assigned for residual tissue or regrowth of tissue in the prostate in con- junction with the transurethral resection.

Some procedures on the male genital system may be per- formed bilaterally. For example, if the physician excises a lesion from the spermatic cord, and the excision is performed bilaterally, you’ll add modifier -50 to code 55520. Depending on the insurance carrier that you’re billing, you may need to assign the modifier -RT or -LT instead of modifier -50. The specific insurance carrier’s billing guidelines will determine the modifier assigned for a bilateral procedure.

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ASSIGNMENT 20: REPRODUCTIVE, INTERSEX SURGERY, FEMALE GENITAL SYSTEM, AND MATERNITY CARE AND DELIVERY CODING Read through the following material in your study guide, then read Chapter 21 of your textbook.

Reproductive System Procedures, immediately following the Male Genital System, consists of only one code, 55920. This code pertains to needle and catheter placement in the pelvic organs and/or genitalia.

Two codes, 55970 and 55980, appear in the Intersex Surgery subsection, immediately following Reproductive System Procedures. These codes are assigned for patients undergoing transgender surgery. Male patients transitioning to female are assigned to code 55970. Female patients transitioning to male are assigned to 55980.

The Female Genital System section is arranged according to the female anatomy. You’ll find codes for incisions, lesion destruction, excision for purposes of biopsy, cyst, and lesion removal, as well as codes for introduction of tubes and support devices in the vagina. You’ll assign code 58120 for dilatation and curettage (D&C), wherein the physician removes fragments of the patient’s endometrium for pathologic analysis. Since D&C is a diagnostic procedure, some insurance carriers may not reimburse for this procedure alone because it’s often included in another surgical procedure.

Note: When a physician performs a diagnostic procedure and then performs a surgical procedure, the diagnostic procedure is automatically included in the surgical procedure. The theory is that the physician had to perform the diagnostic part of the procedure anyway, prior to performing the surgery. Therefore, the physician shouldn’t be reimbursed separately for the diagnostic component of the procedure unless it was performed without surgical intervention. You’ll become more familiar with the billing requirements of specific insurance carriers after you begin working as a medical coder.

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The most common type of endoscopy that you’ll code in the Female Genital System is laparoscopy/hysteroscopy. In this procedure, the physician makes an incision in the abdomen and then inserts a scope into the abdomen to see the uterus. Laparoscopy/hysteroscopy codes appear in code range 58541–58579.

Maternity Care and Delivery codes pertain to any services and procedures provided to pregnant patients prior to deliv- ery (antepartum), during delivery (puerperal), and immediately following delivery (postpartum). In some instances, one physi- cian may treat the patient during the antepartum stage, a different physician may be present during labor and delivery, and another physician may provide the postpartum care.

One physician may provide the antepartum care, be present during labor and delivery, and monitor the patient’s status during the postpartum period. Caring for the patient through- out the entire pregnancy, from beginning to end, is called routine global obstetric care. The codes for global obstetric care are classified according to method of delivery. Assign code 59400 if the patient delivers vaginally and 59510 for a patient who delivers by cesarean. If the patient had a previ- ous cesarean delivery, and then delivers vaginally during the current pregnancy, assign code 59610. If the patient attempts a vaginal delivery after having previously delivered by cesarean, but the attempted vaginal delivery is unsuccessful and the patient again delivers by cesarean, assign code 59618.

The key is to read the code descriptions very carefully and to compare what’s in the code description with the content of the medical record. Determine the framework within which the physician provided care. If the physician provided ante – partum care only, how many visits occurred? Consider the following possibilities:

� Treatment during the antepartum stage only, 4–6 visits— assign code 59425.

� Treatment during the antepartum stage only, more than 7 visits, with no delivery performed—assign code 59426.

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� The physician saw the patient for only two visits during the antepartum stage—assign a code from the E/M cate- gory, not a code from Maternity Care and Delivery. This example illustrates the importance of reading, and rereading if necessary, the code descriptions that pertain to the encounter prior to assigning the obstetrics code.


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Surgical CPT Coding, Part 3 In this lesson, you’ll learn about the following sections in the CPT:

� Endocrine and Nervous Systems

� Eye, Ocular Adnexa, Auditory, and Operating Microscope

� Radiology

� Pathology/Laboratory

� Medicine

Codes in the Endocrine and Nervous Systems have to do with hormones secreted directly into the bloodstream and with response mechanisms and nerve impulses transmitted throughout the body. Codes in the Eye, Ocular Adnexa, and Auditory Systems cover surgical procedures related to the eyes and ears. Radiology lists codes for x-rays, ultrasounds, and nuclear medicine procedures. Pathology/Laboratory includes codes for chemistry panels, drug assays, organ and disease panels, anatomic pathology, and cytopathology, among others. Medicine codes are used for many procedures, including dialysis, ophthalmology, allergy testing, and right and left heart catheterization.

OBJECTIVES When you complete this lesson, you’ll be able to

� Describe the types of procedures coded in the Endocrine and Nervous System sections of CPT.

� Outline common procedures coded in Eye, Ocular Adnexa, Auditory, and Operating Microscope sections

� Explain the types of procedures coded in the Radiology section of the CPT

� Provide examples of common procedure codes assigned from the Pathology/Laboratory section of CPT

� Describe common procedures coded using the Medicine section of CPT

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ASSIGNMENT 21: ENDOCRINE AND NERVOUS SYSTEM CODING Read through the following material in your study guide, then read Chapter 22 of your textbook.

The endocrine system includes the thyroid, parathyroid, thymus, and adrenal glands. Endocrine glands don’t contain ducts, which means that hormones are secreted directly into the bloodstream. (An easy method of remembering the dis- tinction between endocrine and exocrine glands is using their prefixes. Endo means “within,” and exo means “outside of.”)

Some of the procedures that you’ll code in the Endocrine System include incisions and excisions. A patient may undergo a total thyroidectomy. Assign code 60240. If the thyroidectomy is being performed due to malignancy with a limited neck dissection use code 60252.

The key to assigning codes for endocrine procedures is to ensure that the code

� Accurately reflects the correct gland (thyroid, para – thyroid, thymus, or adrenal)

� Accurately reflects the procedure that was performed

The Nervous System includes codes for procedures performed on the brain, spinal cord, skull, and extracranial, peripheral, and autonomic areas of the nervous system. It also includes two glands not listed under the Endocrine System: the pitu- itary gland and the pineal gland.

One of the most common procedures that you’ll code in this section is a lumbar puncture (62270). A lumbar puncture, or spinal tap, involves inserting a needle into the lumbar region, withdrawing cerebrospinal fluid, and analyzing the fluid to diagnose certain conditions.

Certain spinal procedures require you to ascertain the patient’s condition based on the medical record, the approach used to perform the surgery, whether the procedure performed was unilateral or bilateral, and whether more than one proce- dure was performed. For this reason, it’s a good idea to keep an illustration of the parts of the spine nearby to help you

Lesson 6 83

form a mental picture of the type of procedure that’s being performed as outlined in the medical record. This is espe- cially helpful for procedures that involve injections.

For example, if the patient is given a steroid injection in the L5-S1 interspace, review your diagram to locate this space. An interspace is the area between two vertebrae—in this case, L5 and S1. So the injection was administered between the fifth vertebra of the lumbar spine (L5) and the first vertebra of the sacrum (S1). This corresponds to the code description for 64483: “Injection(s) anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT); lumbar or sacral, single level.” This example under- scores the importance of closely reviewing the code description as well as any additional supplemental references, such as anatomical diagrams and online videos, that help you under- stand how a procedure was performed and thereby accurately interpret one or more codes.

ASSIGNMENT 22: OCULAR AND AUDITORY SYSTEM CODING Read through the following material in your study guide, then read Chapter 23 of your textbook.

You’ll assign codes for procedures performed on the eyes (Ocular System) and ears (Auditory System) using the code range 65091–68899.

Standard ocular procedures include incisions, excisions, repairs, and destructions of the eye. You’ll also code removal of foreign bodies or of the eyes themselves. Removal of a for- eign body is one of the most common ocular procedures. A lighted microscope called a slit lamp is used to examine the eye and locate the foreign body. In the case of eye removals, the physician may remove the inside of the globe of the eye while leaving the sclera and extraocular muscles intact. This procedure is called evisceration. In other cases, the physician may choose enucleation, removing the eye while leaving the structures of the orbit intact. If the physician removes the adnexa, eye, and a portion of the orbit, the procedure is an exenteration.

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Some procedures that you’ll code pertain to specific areas of the eye, such as the cornea, anterior chamber, iris, ciliary body, lens, extraocular muscles, orbit, and eyelids. It may be helpful to keep a diagram of the eye nearby whenever you code ocular procedures. Another point to remember is that certain eye procedures, such as surgery performed on the eyelid, may require modifiers. When you report codes for eye- lid surgeries, you’ll append a modifier to the code to indicate the specific eyelid on which the surgery was performed. If the surgery was performed on the upper left eyelid, for instance, you’ll add modifier -E1. If the surgery was performed on the lower right eyelid, you’ll add modifier -E4, and so on.

Procedures performed on the ears are assigned to code range 69000–69979. Ear procedures are performed on anatomical structures within the inner ear, middle ear, or external ear. For example, you may assign codes for surgery on the tym- panic membrane in the middle ear, the vestibular nerve in the inner ear, or the external acoustic meatus of the external ear.

Myringotomies and tympanostomies are often performed on children to treat dysfunction of the eustachian tube. Myringotomy involves making an incision into the tympanic membrane and reinflating the eustachian tube, while tympanostomy involves inserting a tube to drain fluid from the ear. Myringotomies are assigned to codes 69420 and 69421. Tympanostomies are assigned to codes 69433 and 69436.

Some procedures include use of an operating microscope to enlarge the area being viewed during surgery. Whenever the operative report in the medical record indicates that an oper- ating microscope was used, assign code 69990 as an add-on code in addition to the primary CPT code.

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ASSIGNMENT 23: RADIOLOGY CODING Read through the following material in your study guide, then read Chapter 24 of your textbook.

There are a variety of radiology procedures that may be coded in the outpatient setting, including fluoroscopy, magnetic resonance imaging (MRI), tomography, diagnostic imaging, radiologic guidance procedures, mammography, bone and joint studies, nuclear medicine, and radiology oncology. Some radiology procedures, such as x-rays, may be per- formed by a technician under the guidance of a physician, who interprets the x-ray. In other instances, a technician may obtain the x-ray, which will be sent to another facility for the physician’s interpretation. You’ll add a modifier to the CPT code to indicate which of these situations applies.

� Modifier -26 indicates the radiology service provided was for the professional component (reviewed and interpreted by the physician).

� Modifier -TC indicates the technical component (obtained by the technician, but not reviewed or interpreted by the physician)

Global service—the hospital owns the radiology equipment, hires the technicians to obtain the x-ray, and hires the physi- cians who review and interpret the x-ray—doesn’t require a modifier.

One of the most common types of procedures that you’ll code is mammography. A mammography may be unilateral (per- formed on one breast) or bilateral (performed on two breasts). It may also be a screening mammography for a preventive breast exam. Assign code 77055 for a unilateral mammogra- phy, 77056 for a bilateral mammography, and 77057 for a screening mammography.

Radiation oncology codes are assigned for procedures performed to treat tumors. Examples of radiation oncology procedures include simple, intermediate, and complex clinical treatment planning; simple, intermediate, complex, and three-dimensional simulation; and clinical brachytherapy.

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ASSIGNMENT 24: PATHOLOGY AND LABORATORY CODING Read through the following material in your study guide, then read Chapter 25 of your textbook.

The Pathology and Laboratory section covers a wide range of tests and services. It begins with the Organ or Disease- Oriented Panel subsection. Each panel includes a series of individual tests. The key factor to keep in mind is that, in order to assign a code from the Organ or Disease-Oriented Panel subsection, all of the tests within a specific panel must be performed. For example, if the medical record indicates that an electrolyte panel was performed, all of the individual tests that comprise the panel (such as carbon dioxide, chlo- ride, potassium, and sodium) must have been performed. If the majority of the tests were performed, but not all of them, the panel code can’t be assigned. Instead, you’ll assign the codes for the individual tests.

The Surgical Pathology section spans code range 88300–88399 and describes evaluation of specimens to determine disease (pathology). It’s organized by level depending on the probabil- ity of disease or malignancy and whether the specimens require gross or microscopic evaluation. For example, for carpal tunnel tissue examined by a pathologist you would assign code 88304, which corresponds to Level III surgical pathology examination. For a biopsy of a patient’s cervix, you would assign code 88305, Level IV.

Unlike the organ and disease panels, not all of the specimens need to be present within a specific level in order to assign the code. Each ascending level indicates that more work is involved in terms of analyzing the specimens within the code group. Hence, Level IV (88305) requires more work in terms of specimen analysis than Level III (88304), which requires more work than Level II (88302).

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ASSIGNMENT 25: MEDICINE SECTION CODING Read through the following material in your study guide, then read Chapter 26 of your textbook.

Using the Medicine section, you’ll code both invasive and noninvasive services. Invasive procedures require entering the body, while noninvasive procedures don’t. Immunizations are a common procedure that you’ll code using the Medicine section. There are two types of immunizations: active and passive. Active immunizations, which include vaccines and toxoids, are given to stimulate the patient’s immune response in the anticipation that the patient may come in contact with a certain disease. Passive immunization provides antibodies called immune globulins. Vaccines and toxoids are reported with codes in the range of 90476–90749. Immune globulins are coded to 90281–90399. When you assign a code for a vaccine, you must also assign a code for the administration of the vaccine. These codes appear in the Immunization Administration subsection, 90460–90474.

Codes for psychiatry also appear in the Medicine section. You’ll assign codes from the range of 90785–90899 to identify psychiatric services such as psychotherapy visits with the patient and/or family members. If you’re assigning a code for psychotherapy services, pay special attention to the time noted in the code descriptions. The length of each visit may be 30, 45, or 60 minutes. Double-check the time noted in the medical record to ensure that you’re choosing the correct code.

Patients diagnosed with end-stage renal disease (ESRD) undergo monthly dialysis treatments. Patients may receive dialysis through home healthcare, as an inpatient, or on an outpatient basis. Specific codes describe the number of visits by the physician or other healthcare professional providing dialysis as well as the age of the patient undergoing dialysis. Pay special attention to these code descriptions when you’re assigning codes for dialysis patients.

Other procedures that you’ll often code using the Medicine section are hydration infusions, medication infusions or injections, and chemotherapy administration. Hydration

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infusions (packages of fluids, electrolytes, and normal saline) are coded with 96360 or 96361, depending on the length of administration time. These codes are used only for hydration infusions, not medication infusions. For medication infusions you’ll report 96365–96379, according to factors such as the length of infusion time, type of injection (intra-arterial, intra- venous push, subcutaneous, or intramuscular), route of access, and the substance or drug being administered.

Chemotherapy injection and infusion codes are found in the range 96401–96549. Additional chemotherapy services and procedures are also included in this range, such as chemo administration through an indwelling port (96446) and portable or implantable pump maintenance (96521 and 96522).


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Similarities and Differences Between HCPCS Level II and CPT You’ve already learned about HCPCS Level I, or CPT. Now we’ll review HCPCS Level II, which is the manual most people mean when they say “HCPCS.” This is a very important and often overlooked part of the billing system. HCPCS Level II is structured as follows:

1. Guide to Using the 2016 HCPCS Level II Codes

2. Symbols and Conventions

3. 2016 HCPCS Updates: Lists all of the HCPCS Level II codes and Level II modifiers that are new, revised, or deleted (as well as several from 2014), along with ASC (Ambulatory Surgical Center) payment indicators that provide details on how certain outpatient services are reimbursed according to Medicare guidelines

4. Netter’s Anatomy Plates: Anatomical illustrations that you can reference when reviewing and interpreting the HCPCS Level II code descriptions

5. 2016 HCPCS: Level II National Codes

6. 2016 HCPCS Index: The alphabetical listing that you’ll reference to find HCPCS Level II codes

� 2016 HCPCS Table of Drugs: Lists the names of drugs, their dosages, methods of administration, and their respective HCPCS codes

� Introduction: Summarizes the structure of HCPCS Level I, Level II, and Level III, the schedule for updates, and provides the list of Level II National Modifiers used in HCPCS Level II coding

� CMS Healthcare Common Procedure Coding System (HCPCS): Lists the codes for ambulance transporta- tion, medical surgical supplies, durable medical equipment, radiological supplies, enteral and par- enteral therapy services, dental procedures, orthotics, prosthetics, hearing devices, and other codes.

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� Appendix A—Chapter 1, General Correct Coding Policies for National Correct Coding Initiative Policy Manual for Medicare Services: Summarizes the general coding poli- cies for both HCPCS Level I and HCPCS Level II.

Now let’s take a look at HCPCS Level II in greater detail, including similarities and differences between HCPCS Level I (CPT) and HCPCS Level II.

OBJECTIVES When you complete this lesson, you’ll be able to

� Summarize similarities and distinctions between HCPCS Level II and CPT

� Provide examples of modifiers used in HCPCS Level II

� Describe the types of procedures and services coded in HCPCS Level II

ASSIGNMENT 26: CPT AND HCPCS CODING Read through the following material in your study guide. After you’ve read the study guide commentary, review any difficult concepts from previous chapters in your textbook, Step-by-Step Medical Coding.

What’s Covered HCPCS Level II was created to cover patient services not covered in HCPCS Level I, or CPT. For example, certain healthcare professionals—including ambulance personnel, orthodontists, and dentists—aren’t included in the CPT coding system. To increase the level of accuracy in reporting, many insurance companies require that healthcare providers use Level II codes to report services not covered in HCPCS Level I.

Certain kinds of medical supplies, such as drugs and durable medical equipment, aren’t covered under the CPT system either. Durable medical equipment (DME) includes a wide

Lesson 7 91

range of items, such as walkers and wheelchairs, used by patients suffering from disabling conditions. Claims for DME and related supplies can be paid only if the items meet the Medicare definition of covered DME and are medically neces- sary. Documentation provided by a physician is typically required to determine medical necessity. Such documentation may include medical records, plans of care, discharge plans, and prescriptions. Certificates of Medical Necessity (CMN) may also be submitted as documentation. You’ll have to check whether your Medicare carrier accepts HCPCS Level II codes. Sometimes these claims are paid separately by the Durable Medical Equipment Regional Carrier (DMERC).

Special Symbols Like CPT codes, HCPCS Level II codes are sometimes pre- ceded by symbols that indicate additions, changes, revisions, or other modifications to the code.

� New code:

� HCPCS Level II—green triangle pointing to the left ◄

� CPT—red dot •

� CPT revised code—blue triangle pointing upward ▲

� CPT—new or revised text (the description of the code, not the code itself) is indicated with two inward-pointing green arrowheads. ►◄

� HCPCS Level II—revisions to a line or code are indicated with a purple, semicircular arrow pointing to the left. 

� Reinstated code (the code was previously deleted and now is being used again):

� HCPCS Level II—green checkmark 

� CPT—clear circle 

� Circle with a line through it: 

� HCPCS Level II (red)—indicates that the code isn’t covered by Medicare 

� CPT (black)—indicates that the code is exempt from modifier -51 (multiple procedures) 

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Code Structure Unlike CPT codes, HCPCS Level II codes are alphanumeric. This is a key difference between the two types of codes. HCPCS Level II codes start with one of the following letters: A, B, D, E, G, H, J, K, L, M, P, Q, R, or V. A string of four num- bers follows the initial letter. Codes that begin with Q, G, or K are temporary codes, and indicate that a more exact decision regarding the service or supply will be provided later.

� Q codes are used to identify temporary assignments for procedures, services, and supplies.

� G codes identify temporary assignments for procedures or services only.

� K codes identify temporary assignments for durable med- ical equipment only.

HCPCS Level II uses J codes to identify medications and their administered dosages. J codes are rarely used to code orally administered medications, which are typically purchased by the patient after a visit to a healthcare provider. Most J codes refer to medications by their generic titles, rather than by brand or trade names. To help you locate the correct names and their associated codes, the HCPCS manual provides a Table of Drugs. The Table of Drugs includes a column labeled “Route of Administration.” This column lists the most com- mon methods of administering each medication, abbreviated as follows:

IM Intramuscular

INH Inhalant solution

IT Intrathecal

IV Intravenous

OTH Other routes

SC Subcutaneous

VAR Various routes

Intravenous administration includes all methods, such as gravity infusion, injections, and timed pushes.

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When several routes of administration are listed, the first list- ing is the most common method used. VAR denotes various routes of administration and is used for drugs commonly administered into joints, cavities, or tissues, as well as topi- cal applications. Listings with OTH alert the coder to other administration methods, such as suppositories or catheter injections. A dash (—) in a column signifies that no informa- tion is available for that particular listing.

Another key difference between the CPT and HCPCS Level II pertains to modifiers, which were briefly addressed in Lesson 2. The HCPCS Level II modifiers provide a high degree of speci- ficity. Alphanumeric modifiers appended to the five-digit national code are used to identify service providers, anatomic sites, or other pertinent details. For example, the modifier -T1 is used to specify the second toe of the left foot. The modifier -QN identifies ambulance services provided directly by a serv- ice provider. You can find a partial list of HCPCS Level II modifiers in Appendix A of the CPT manual.

In addition to HCPCS codes and the Table of Drugs, the HCPCS manual, like the CPT, includes general guidelines for coding, as well as an index. The alphabetical index includes main terms and subterms. The code for an item or service may be listed under more than one index entry. Dialysis kits, for example, can be found under both the “Dialysis” and “Kits” headings. Index entries cover a wide range of items, including tests, services, supplies, durable medical equipment, prostheses, drugs, therapies, and certain types of medical and surgical procedures. Once you locate a term in the index, you’ll need to verify the code number and description in the alphanumeric listing to be sure that you’ve selected the correct code. The alphanumeric listing also provides more detailed information to help you determine the proper code.

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GRADED PROJECT As a medical coder, you’ll assign CPT codes for physician pro- cedures and services. This graded project is designed to

1. Test your knowledge of CPT coding principles and procedures

2. Gauge your ability to accurately apply coding guidelines with regard to CPT codes and modifiers

3. Analyze your accuracy with respect to HCPCS code assignment

4. Determine your ability to differentiate CPT and HCPCS

5. Summarize what you’ve learned about CPT and HCPCS coding

INSTRUCTIONS Your graded project has three parts. Be sure to complete all three parts prior to submitting your project.

Part 1 Review the following scenario. Assign the CPT code(s). Add one or more modifiers, if necessary.

A 71-year-old male patient comes to the hospital after having been previously diagnosed with benign prostatic hypertrophy with urinary obstruction. Due to this condition, the patient is experiencing increased urination, straining during urination, and a continual feeling of fullness after the bladder has been emptied. The physician performs a cystourethroscopy to exam- ine the condition of the bladder and urethra, and then subsequently performs a UroLift transprostatic implant pro- cedure using three adjustable implants.

CPT code(s): ____________________________________________

(Part 1 is worth 40 points of your overall graded project.)

Graded Project96

Part 2a Review each of the following procedures. Assign the CPT code(s). Add one or more modifiers, if necessary.

1. An established patient comes to the office complaining of migraine headaches. The physician performs an expanded problem-focused history and exam. The physician’s med- ical decision making is of low complexity. During the office visit, the physician also removes a benign 0.5 cm lesion from the back of the patient’s left hand.

CPT code(s): ____________


2. A physician removes a foreign body from the anterior chamber of the patient’s eye. An allergy statement in the patient’s medical record indicates that the patient is allergic to local anesthesia. As a result, general anesthe- sia is administered.

CPT code(s): ____________


3. A surgeon performs a total abdominal hysterectomy with partial removal of the vagina, lymph node sampling, and removal of the ovary. The coder assigns code 58200-51. Is this code correct or incorrect? Why or why not?



Part 2b Review each of the following procedures. Assign the HCPCS code(s).

4. A patient weighing 252 pounds sustains a hip fracture. The physician prescribes a Group 2 standard single power wheelchair with a solid seat, solid back, and a sling.

HCPCS code(s): _______________


Graded Project 97

5. A patient comes to the emergency room complaining of a chronic migraine. The nurse administers a 1 unit injec- tion of onabotulinumtoxinA.

HCPCS code(s): _______________


6. A patient with chronic venous insufficiency comes to the doctor’s office complaining of leg pain. The physician pre- scribes two thigh-length gradient compression stockings, 45 mmHg each.

HCPCS code(s): _______________


(Part 2 is worth 40 points of your overall graded project: 20 points for Part 2a; 20 points for Part 2b.)

Part 3 Review the following coding scenario. Assign the CPT code(s) for the wound repair only. A patient comes to the emergency room after sustaining a 12.2-cm wound to the left side of her face. She was cut with a piece of glass during a physical altercation with her husband. The physician performs a detailed history and examination. Medical decision making was of moderate complexity. The physician repairs the facial wound without difficulty; however, the wound requires exten- sive cleaning to remove the glass particles beforehand. The physician also repaired a superficial 2.5-cm wound to the left ear. Both wounds were closed using 4-0 Vicryl.

CPT code(s):__________________


(Part 3 is worth 20 points of your overall graded project.)

Goal Your goal is to demonstrate your understanding of CPT and HCPCS and to assign codes accurately using both code sets.

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Writing Guidelines � Include the following information at the top of your

graded project:

� Name and address

� Student number

� Course title and number (HIT203, Medical Coding)

� Project number (48082800)

� Read the assignment carefully and answer each question.

GRADING CRITERIA Part 1 = 40 points

Part 2 = 40 points (2a = 20 points; 2b = 20 points)

Part 3 = 20 points

The graded project will be evaluated according to the following criteria:

Content The student

� Answers all questions presented.

� Includes all required codes and modifiers.

Format The project includes the student’s

� Name and address

� Student number

� Course title and number (HIT203, Medical Coding)

� Project number (48082800)

SUBMITTING YOUR PROJECT Submit your project online:

1. Go to

2. Log in to your student portal.

3. Click on Take Exam next to the lesson you’re working on.

4. Follow the instructions provided to complete your exam.

Be sure to keep a backup copy of any files you submit to the school!

Graded Project 99


Graded Project100


2. True

3. False

4. True

5. d

6. b

7. c

8. b

9. d


11. b

12. c, f

13. e

14. a

15. e

16. a

17. c

18. d

19. b

20. No, C91.01

21. No, Q62.2

22. G30.9, F02.81

23. E11.8, Z79.4

24. I12.0, N18.5

25. anemia

26. prostatitis


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27. malnutrition

28. Granuloma

29. Pain

30. No, N25.1

31. Yes

32. No, Q66.89

33. No, G90.3

34. No, K26

35. c

36. d

37. e

38. a

39. g

40. f

41. b

42. Human immunodeficiency virus (HIV) disease

43. Pruritus

44. Lymphadenitis

45. See condition

46. See Measles

47. Hyperpyrexia

48. See Hypertension

49. See Hypogonadism


2. True

3. True

4. True

5. False

6. False

Chapter Review Answers 103

7. True

8. False

9. False

10. False

CHAPTER 3, PART II, PRACTICAL 11. Diaper rash, L22

12. Congestive heart failure, I50.9. Dyspnea and lower extremity edema are not coded as they’re symptoms of the patient’s CHF exacerbation.

13. Either diagnosis, I10 hypertension or E53.8 vitamin B12 deficiency, can be first-listed.

14. Old anterior cruciate ligament tear, M23.8X2

15. Syncope, R55; Diabetes mellitus, E11.9

16. Postoperative pain, G89.18; Stage 4 CKD, N18.4

17. Preoperative exam, Z01.811, Carotid stenosis, single, I65.21, Emphysema, J43.9

18. Bladder cancer C67.9. The postoperative diagnosis of bladder cancer is the reason for the hematuria and more definitive diagnosis.

19. Z77.090 (Exposure, to, asbestos)

20. Z86.010 (History, personal, benign neoplasm, colonic polyps)

21. Z94.1 (Transplant, status, heart)

CHAPTER 4, PART I, THEORY 1. Any two of the following:

� American Hospital Association (AHA)

� American Health Information Management Association (AHIMA)

� Centers for Medicare and Medicaid Services (CMS)

� National Center for Health Statistics (NCHS)

Chapter Review Answers104

2. a. term or terms

b. Alphabetic

c. subterms

d. cross-reference

e. 2, 1

f. Tabular

g. specificity

h. elements

3. d

4. True

5. False

6. False

7. False

8. True

9. True

10. True

CHAPTER 4, PART II, PRACTICAL 11. Colicky pain, hematuria, pyuria, dysuria, oliguria,

abdominal distention, nausea and vomiting, fever and chills

12. Fever, cough, chills, chest pain, and sputum production (any two)

13. N41.0 (Prostatitis, acute); N41.1 (Prostatitis, chronic)

14. A87.9 (Meningitis, viral, NEC). Headache, stiff neck, and fever are symptoms of meningitis and aren’t coded.

15. N10 (Pyelonephritis, acute); N11.9 (Pyelonephritis, chronic)

16. K81.2 (Cholecystitis, acute and chronic). Abdominal pain is a symptom of cholecystitis and isn’t coded.

Chapter Review Answers 105

17. N39.0 (Infection, urinary [tract]); B96.4 (Infection, bacterial, as cause of disease classified elsewhere, Proteus [mirabilis])

18. G45.9 (Attack, transient ischemic [TIA])

19. M19.139 (Osteoarthritis, post-traumatic, wrist); S62.109S (Fracture, traumatic, wrist)

20. I69.391 (Dysphagia, following, cerebral infarction). Use additional code for type of dysphasia if known. Since we don’t know the type, it’s not necessary to code R13.10 (Dysphasia) as dysphasia is already mentioned in I69.391.

21. B97.4 (Infection, virus, respiratory syncytial)


2. False

3. False

4. True

5. False

6. False

7. False

8. False

9. a

10. b

CHAPTER 5, PART II, PRACTICAL 11. D51.0 (Anemia, pernicious); G32.0 (Degeneration,

combined, with anemia [pernicious])

12. D00.01 (Neoplasm, lip, vermilion border, upper, Carcinoma in situ)

13. I33.0 (Endocarditis, bacterial)

Chapter Review Answers

14. J44.0 (Bronchitis, acute, with chronic obstructive pulmonary disease)

15. J15.3 (Pneumonia, streptococcal, group B)

16. e

17. d

18. c

19. b

20. a


2. d

3. True

4. a

5. b

6. d

7. a

8. c

9. True

10. True

CHAPTER 6, PART II, PRACTICAL 11. K50.911 (Enteritis, regional, with, complication, rectal


12. K44.1 (Hernia, diaphragm, with, gangrene [and obstruction])

13. M24.411 (Dislocation, recurrent, shoulder)

14. L23.7 (Dermatitis, contact, allergic, due to, plants, non-food)

15. L03.039 (Cellulitis, toe)


16. K60.3 (Fistula, anus)

17. K55.21 (Angiodysplasia, with bleeding)

18. K38.2 (Diverticulum, appendix)

19. K80.12 (Calculus, gallbladder, with, cholecystitis, acute, with, chronic cholecystitis)

20. K56.60 (Obstruction, intestine)


2. False

3. True

4. False

5. True

6. False

7. True

8. True

9. False

10. True

CHAPTER 7, PART II, PRACTICAL 11. T85.79XA (Complications, breast implants, infection or


12. T60.3X1D (Herbicide NEC, Poisoning, Accidental)

13. O34.11 (Pregnancy, complicated by, fibroid [tumor] [uterus]); D25.9 (Fibroid, uterus)

14. O90.0 (Dehiscence, cesarean wound)

15. Z38.01 (Newborn, born in hospital, by, cesarean); P05.08 (Light-for-dates, with weight of, 2000–2499 grams)

16. T23.301D (Burn, hand, right, third degree); T31.0 (Burn, extent) (No X code is required for subsequent treatment.)

Chapter Review Answers 107

17. R03.0 (Blood, pressure, high, incidental reading, without diagnosis of hypertension)

18. Q99.2 (Syndrome, fragile X)

19. O47.1 (False, labor [pains], at or after 37 completed weeks of gestation)

20. O44.13 (Pregnancy, complicated by, placenta previa); O76 (Pregnancy, complicated by, fetal heart rate irregu- larity [bradycardia][deceleration][tachycardia]); O60.14X0 (Pregnancy, complicated by, preterm labor, third trimester, with third trimester preterm delivery); Z37.0 (Outcome of delivery, single, liveborn)

CHAPTER 27, PART I, THEORY 1. Inpatient

2. Outpatient

3. Outpatient

4. d

5. False

6. True

7. False

8. d

9. b

10. d

11. False

12. False

13. False

14. c

15. b

Chapter Review Answers108

Chapter Review Answers 109

CHAPTER 27, PART II, PRACTICAL 16. ICD-10-CM: C71.9 (Neoplasm, brain NEC, Malignant


17. ICD-10-CM: J18.9 (Pneumonia), I50.9 (Failure, heart, congestive)

18. ICD-10-CM: K81.0 (Cholecystitis, acute), K85.9 (Pancreatitis, acute)

19. ICD-10-CM: K81.0 (Cholecystitis, acute), K85.9 (Pancreatitis, acute)

20. ICD-10-CM: N95.0 (Hemorrhage, postmenopausal), Z53.09 (Procedure, [surgical] not done, because of contraindication)

21. ICD-10-CM: T81.31XA (Dehiscence, operation wound)

22. ICD-10-CM: I21.4 (Infarction, myocardium, non-ST evaluation)

23. ICD-10-CM: J12.9 (Pneumonia, viral)

24. ICD-10-CM: J44.1 (Disease, lung, obstructive [chronic], with, acute, exacerbation NEC)

25. ICD-10-CM: N99.89 (Complication, postprocedural, genitourinary), R33.9 (Retention, urine), K22.2 (Stricture, esophagus), Y83.8 (Complication, [delayed] of or following [medical or surgical procedure] surgical operation, specified NEC)

CHAPTER 8, PART I, THEORY 1. Current Procedural Terminology

2. Category III codes

3. revisions

4. unlisted

5. Guidelines

6. Category II codes

7. modifier

8. Appendix A

9. special report

10. B

11. D

12. hyphen

13. section

14. subsection

15. subheading

16. category

17. lightning bolt

18. K

19. I


21. -54

22. -47

23. -50

24. 67599

25. 45999

26. 40799

27. 20999

28. example has one code

29. example has a comma between two codes

30. example has a hyphen between two codes

31. See Thyroxine, Total

32. See Sex Hormone Binding Globulin

33. See Arm, Lower; Elbow; Ulna

34. See Physical Medicine/Therapy/Occupational Therapy

35. 49900

Chapter Review Answers110

Chapter Review Answers 111

36. 35907

37. 36147

38. 51040

39. 27238

40. 41874

41. 44010

CHAPTER 10, PART I, THEORY 1. team or surgical team

2. No, because a note in CPT Appendix A states modifier -22 cannot be appended to an E/M code.

3. -22

4. intraoperative or surgery

5. She is incorrect because modifier -32 is only assigned for mandated services, such as police, Workers’ Compensation, etc., not for requests made by the patient, family member, or another physician.

6. b

7. b

8. c and d

9. False

10. a


12. -62

13. -26

14. -99

15. -59

16. -32

17. -25

18. -81

19. -77

20. -79

21. -23

22. -78

23. -54

24. -52

25. -66

CHAPTER 11, PART I, THEORY 1. body area

2. new, established, inpatient, and outpatient (in any order)

3. initial, subsequent

4. status, type of service, place of service (any order)

5. four

6. expanded problem focused

7. a. problem focused

b. expanded problem focused

c. detailed

d. comprehensive

8. problem focused

9. Very Low Birth Weight

10. straightforward

11. inpatient

Chapter Review Answers112

Chapter Review Answers 113

CHAPTER 11, PART II, PRACTICAL 12. 99468 (Evaluation and Management, Neonatal Critical


13. 99201 (Evaluation and Management, Office and Other Outpatient) ICD-10-CM: L72.3 (Cyst, sebaceous)

14. 99214 (Evaluation and Management, Office and Other Outpatient)

15. 99385 (Preventive Medicine, New Patient) ICD-10-CM: Z00.00 (Examination, [general] [routine]), 30.09 (Contraceptive, counseling)

16. 99219 (Evaluation and Management, Hospital Services, Observation Initial Care) ICD-10-CM: R11.2 (Vomiting, with nausea), R42 (Dizziness), R41.0 (Confusion), E86.0 (Dehydration)

17. 99221 (Evaluation and Management, Hospital)

18. 99201 (Evaluation and Management, Office and Other Outpatient) ICD-10-CM: L22 (Rash, diaper)

19. 99215 (Evaluation and Management, Office and Other Outpatient) ICD-10-CM: M79.606 (Pain, limb, lower), R55 (Fainting), R11.2 (Vomiting, with nausea)

20. 99212 (Evaluation and Management, Office and Other Outpatient) ICD-10-CM: N63 (Mass, breast)

21. ICD-10-CM: S80.02XA (Contusion, knee), S50.01XA (Contusion, elbow)


2. begins preparing the patient to receive anesthesia, continues through the procedure, and ends when the patient is no longer under the personal care of the anes- thesiologist, or similar wording

3. -47

4. physical status

5. moribund

6. systemic

7. 6

8. qualifying

9. anatomic

10. complex, combined total (or total time)

11. no

12. Relative Value Guide

CHAPTER 12, PART II, PRACTICAL 13. 01610-P1 (Anesthesia, Shoulder)

14. 01967-P1 (Anesthesia, Neuraxial, Labor), 01969-P1 (Anesthesia, Hysterectomy, Cesarean). The patient had neuraxial labor analgesia (01967) that ended with a C-section (01969).

15. 01965-P5 (Anesthesia, Abortion, Incomplete)

16. 00215-P2 (Anesthesia, Cranioplasty)

17. 01214-P2 (Anesthesia, Hip), 99100 (Anesthesia, Special Circumstances)

18. 01952-P1 (Anesthesia, Burn, Debridement and/or Excision)

19. 01996 × 5 (Anesthesia, Drug Administration Epidural or Subarachnoid)

20. 01832-P1 (Anesthesia, Replacement, Wrist)

CHAPTER 16, PART I, THEORY 1. anatomic

2. endoscopic procedure or endoscopy

3. extent

4. -51

5. diagnostic

Chapter Review Answers114

6. indirect

7. direct

8. ear, nose, throat

9. Integumentary

10. Respiratory

11. inferior, middle, and superior

12. displacement

CHAPTER 16, PART II, PRACTICAL 13. 32997 (Lung, Lavage, Total) ICD-10-CM: J70.5

(Inhalation, smoke)

14. 32310 (Pleurectomy, Parietal) ICD-10-CM: J90 (Pleurisy, with effusion)

15. 32504 (Lung, Excision, Tumor) ICD-10-CM: C78.00 (Neoplasm, lung, upper lobe [unspecified side], Malignant Secondary), C80.1 (Neoplasm, unknown site or unspeci- fied Malignant Primary)

16. 30300 (Removal, Foreign Bodies, Nose) ICD-10-CM: T17.1XXA (Foreign body, nostril)

17. 31237-RT (Nose, Endoscopy, Surgical) ICD-10-CM: J33.0 (Polyp, nasal, cavity)

18. 31530 (Larynx, Endoscopy, Operative) ICD-10-CM: T17.308A (Foreign body, larynx)

19. 31510 (Larynx, Endoscopy, Indirect) ICD-10-CM: J38.7 (Nodule[s], larynx)

20. 30000 (Nose, Hematoma, Incision and Drainage) ICD-10-CM: S00.33XA (Contusion, nose)

21. 31070-LT (Sinusotomy, Frontal Sinus, Exploratory) ICD-10-CM: J32.1 (Sinusitis, frontal)

22. 31287 (Sphenoidotomy, Excision, with Nasal/Sinus Endoscopy) ICD-10-CM: J01.30 (Sinusitis, sphenoidal, acute)

23. 30520 (Nose, Reconstruction, Septum) ICD-10-CM: M95.0 (Deformity, nose [acquired])

Chapter Review Answers 115

24. 31625 (Bronchoscopy, Biopsy), 32480 (Lung, Excision, Lobe) ICD-10-CM: C34.10 (Neoplasm, lung, upper lobe, Malignant Primary)

25. 31255-RT (Ethmoidectomy, Endoscopic) ICD-10-CM: J32.2 (Sinusitis, ethmoidal), J33.9 (Polyp, nasal) Note: You might have incorrectly coded an endoscopy with 31237 in addition to the ethmoidectomy 31255; however, the endoscopy 31237 has “separate procedure” following it, which means the endoscopy (31237) is bun- dled into the ethmoidectomy—the major procedure, 31255.

26. 30901 (Hemorrhage, Control, Nasal, Simple) ICD-10-CM: R04.0 (Hemorrhage, nose), I10 (Hypertension, Benign)

CHAPTER 17, PART I, THEORY 1. Heart and Pericardium, Arteries and Veins

2. cardiology

3. Surgery, Medicine, and Radiology (in any order)

4. invasive or interventional

5. noninvasive

6. electrophysiology

7. nuclear medicine

8. selective

9. nonselective

10. percutaneously

CHAPTER 17, PART II, PRACTICAL 11. 99215-57 (Office and Other Outpatient Services,

Established Patient), 33430 (Mitral Valve, Replacement) ICD-10-CM: I05.2 (Stenosis, mitral, with regurgitation)

12. 35875 (Thrombectomy, Bypass Graft Other Than Hemodialysis Graft or Fistula)

Chapter Review Answers116

13. 35141 (Artery, Femoral, Aneurysm)

14. 33514-80 (Artery, Coronary, Bypass) ICD-10-CM: I25.10 (Arteriosclerosis, coronary [artery])

15. 33425 (Mitral Valve, Repair)

16. 33241 (Pulse Generator, Implantable Defibrillator, Removal)

17. 33020 (Pericardiotomy, Removal, Clot)

18. 33697 (Tetralogy of Fallot)

19. 33750 (Shunt[s], Great Vessel, Subclavian Pulmonary Artery) ICD-10-CM: Q21.3 (Tetralogy of Fallot)

20. 33916 (Endarterectomy, Pulmonary)

21. 35005 (Artery, Vertebral, Aneurysm) ICD-10-CM: I72.8 (Aneurysm, specified), I65.09 (Occlusion, unspecified ver- tebral artery)

22. 35351 (Thromboendarterectomy, Iliac Artery) ICD-10-CM: I74.5 (Thrombosis, artery, iliac)

CHAPTER 18, PART I, THEORY 1. approach

2. bacteria

3. separate

4. blood cell

5. aspiration

6. allogenic

7. autologous

8. limited

9. surgical approach

10. phrenic

Chapter Review Answers 117

Chapter Review Answers118

CHAPTER 18, PART II, PRACTICAL 11. 38380 (Ligation, Thoracic Duct)

12. 38571 (Lymphadenectomy, Bilateral Pelvic, Total)

13. 38765 (Lymphadenectomy, Inguinofemoral)

14. 39561 (Resection, Diaphragm) ICD-10-CM: C79.89 (Neoplasm, diaphragm, Malignant Secondary), Z85.42 (History, personal [of] malignant neoplasm [of], uterus)

15. 38500 (Biopsy, Lymph Nodes, Open) ICD-10-CM: C85.91 (Lymphoma, non-Hodgkin)

16. 38542 (Dissection, Lymph Nodes) ICD-10-CM: C73 (Neoplasm, thyroid, Malignant Primary)

17. 38555 (Lymph Nodes, Hygroma, Axillary/Cervical, Excision) ICD-10-CM: D18.1 (Hygroma)

18. 38562 (Lymphadenectomy, Limited, for Staging, Para- Aortic) ICD-10-CM: C61 (Neoplasm, prostate gland, Malignant Primary)

19. 38790 (Lymphangiography, Injection) ICD-10-CM: R59.0 (Hypertrophy, lymph, lymphatic, gland, Localized)

20. 39401 (Mediastinoscopy) ICD-10-CM: R22.2 (Mass, chest)

CHAPTER 19, PART I, THEORY 1. mouth, anus

2. gastroscope or endoscope

3. diagnostic

4. laparotomy

5. reducible

CHAPTER 19, PART II, PRACTICAL 6. 49565 (Repair, Hernia, Incisional, Recurrent, Reducible)

7. 49582 (Repair, Hernia, Umbilical, Incarcerated)

8. 40527 (Reconstruction, Lip)

9. 43135 (Diverticulectomy, Esophagus)

10. 44150 (Colectomy, Total, Open, with Ileostomy)

11. 44361 (Endoscopy, Intestines, Small, Biopsy)

12. 45300 (Proctosigmoidoscopy, Exploration)

13. 45331 (Sigmoidoscopy, Biopsy) ICD-10-CM: K63.3 (Ulcer, rectosigmoid) ICD-9-CM: 569.82 (Ulcer, rectosigmoid)

14. 43245 (Endoscopy, Gastrointestinal, Upper, Dilation), 43239 (Endoscopy, Gastrointestinal, Upper, Biopsy) ICD-10-CM: K31.1 (Obstruction, gastric outlet) ICD-9-CM: 537.0 (Obstruction, gastric outlet)

15. 45385 (Colonoscopy, Flexible, Removal, Polyp), 45384 (Colonoscopy, Removal, Polyp)

16. 43249 (Endoscopy, Gastrointestinal, Upper Dilation), 43239 (Endoscopy, Gastrointestinal, Upper Biopsy)


2. Integumentary System (Note: Only deep abscess codes are located in the Male Genital subsection.)

3. urodynamics

4. -26

5. anatomically

6. retroperitoneal

7. nephrostomy

8. staghorn

9. E/M

10. hydronephrosis

12. calculus

13. gender

Chapter Review Answers 119

Chapter Review Answers120

CHAPTER 20, PART II, PRACTICAL 14. 54015 (Incision and Drainage, Penis) ICD-10-CM: N48.21

(Abscess, penis)

15. 54065 (Penis, Lesion, Destruction, Extensive) ICD-10-CM: A60.01 (Herpes, penis)

16. 50200 (Biopsy, Kidney) ICD-10-CM: R80.9 (Microalbuminuria)

17. 51600 (Cystography, Injection); 74430 (Cystography, Bladder) ICD-10-CM: R31.9 (Hematuria)

18. 54322 (Hypospadias, Repair, One Stage, Meatal Advancement) ICD-10-CM: Q54.1 (Hypospadias, penile) ICD-9-CM: 752.61(Hypospadias) 55700 (Biopsy, Prostate); 76942 (Ultrasound, Guidance, Needle Biopsy) ICD-10-CM: R97.2 (Elevated, prostate specific antigen [PSA])

19. 53600 (Dilation, Urethra, Stricture) ICD-10-CM: A52.76 (Stricture, urethra, syphilitic)

20. 54200 (Injection, Penis, Peyronie’s Disease) ICD-10-CM: N48.6 (Peyronie’s disease)

CHAPTER 21, PART I, THEORY 1. anatomic

2. Urinary System

3. pubis, majora, minora, vestibule, lesser Bartholin’s

4. the physician

5. False, destruction is obliteration or eradication; excision is removal.

6. No, destruction is obliteration or eradication.

7. vulvectomy

8. extent and size

9. simple

10. radical

11. partial, complete

CHAPTER 21, PART II, PRACTICAL 12. 58550 (Hysterectomy, Vaginal, Laparoscopic)

ICD-10-CM: C55 (Neoplasm, uterus, Malignant, Primary)

13. 58670 (Laparoscopy, Ovary/Oviduct, Oviduct Surgery) ICD-10-CM: N97.1 (Occlusion, oviduct)

14. 58970 (Oocyte, Retrieval, for In Vitro Fertilization) ICD-10-CM: Z52.819 (Donor, egg) Note: Code 76948-26 (Ultrasound, Guidance, Ova Retrieval) would also be reported when used, as stated in the parenthetical note following CPT 58970.

15. 59510 (Cesarean Delivery, Routine Care), 58611 (Cesarean Delivery, Tubal Ligation at Time of) ICD-10-CM: O32.1XX0 (Delivery cesarean [for], breech presentation), Z37.0 (Outcome of delivery, single liveborn), Z30.2 (Encounter for, sterilization)

16. 57280 (Colpopexy, Abdominal) ICD-10-CM: N85.4 (Malposition, uterus)

17. 56605 (Vulva, Perineum, Biopsy), 56606 × 2 (Vulva, Perineum, Biopsy) ICD-10-CM: C51.9 (Neoplasm, vulva, Malignant Primary)

18. 57170 (Fitting, Diaphragm); 99070 supply of diaphragm (Supply, Materials) or A4266 (Contraceptive, diaphragm)

19. 57105 (Vagina Biopsy, Extensive)

20. 57800 (Dilation, Cervix, Canal)

21. 56405 (Abscess, Vulva, Incision and Drainage)

22. 57020 (Colpocentesis)


2. Nervous System

3. Digestive System

4. total

5. burr

Chapter Review Answers 121

Chapter Review Answers122

6. approach, definitive

7. cerebrospinal fluid

8. carpal tunnel

9. carotid body

10. yes

CHAPTER 22, PART II, PRACTICAL 1. 60240 (Thyroidectomy, Total)

2. 60650 (Laparoscopy, Adrenal Gland, Excision)

3. 60505 (Parathyroidectomy)

4. 61720 (Stereotaxis, Creation Lesion, Brain, Deep)

5. 62180 (Torkildsen Procedure)

6. 62350 (Catheterization, Spinal Cord). Note that to locate this code in the index of the CPT manual, the coder must know that epidural is referring to the spinal cord.

7. 63081 (Vertebral, Body, Excision, Decompression)

8. 64405 (Injection, Nerve, Anesthetic)

9. 64742 (Transection, Nerve)

10. 64891 (Nerves, Graft)


2. a

3. b

4. a

5. c

6. d

7. b

8. c

9. c

10. a

CHAPTER 23, PART II, PRACTICAL 11. 65400-RT (Excision, Lesion, Cornea)

12. 66600-LT (Iridectomy, Excision with Corneoscleral or Corneal Section)

13. 65710-LT (Keratoplasty, Lamellar, Anterior)

14. 65410-RT (Biopsy, Cornea)

15. 65800-LT (Paracentesis, Eye, with Aqueous Aspiration)

16. 66984-RT (Cataract, Removal/Extraction, Extracapsular)

17. 66983-LT (Cataract, Removal/Extraction, Intracapsular)

18. 66600-RT (Iris, Excision, with Corneoscleral or Corneal Section)

19. 67228-RT (Photocoagulation, Lesion, Retina) ICD-10-CM: E11.319 (Diabetes, with retinopathy), H35.61 (Hemorrhage, retina, retinal)

20. 67107-RT (Retina, Repair, Detachment, Scleral Buckling) ICD-10-CM: H33.21 (Detachment, retina)

CHAPTER 24, PART I, THEORY 1. Radiology

2. Diagnostic Ultrasound, Radiation Oncology

3. separate procedure

4. 100

5. -26

6. supervision, interpretation

7. diagnostic ultrasound or echography

8. type

9. physics

10. dosimetry

12. energy

13. megaelectron volt

Chapter Review Answers 123

14. 5

15. tracer

16. median

17. horizontal or transverse

18. frontal

CHAPTER 24, PART II, PRACTICAL 18. 99212 (E/M, Office and Other Outpatient, Established

Patient); 71020 (X-ray, Chest); 99244 (E/M, Consultation); 71250-26 (CT Scan, without Contrast, Thorax); 31628 (Bronchoscopy, Biopsy)

19. 99202 (E/M, Office and Other Outpatient); 70134 (X-ray, Auditory Meatus); 69433 (Ventilating Tube, Insertion) ICD-10-CM: H92.09 (Otalgia)

20. 99205 (E/M, Office and Other Outpatient) ICD-10-CM: R60.0 (Edema, legs)

21A. 75801 (Lymphangiography, Leg) ICD-10-CM: M79.89 (Swelling, arm), Z85.3 (History, personal, [of] malig- nant neoplasm, breast)

21B. 38790 (Lymphangiography, Injection) ICD-10-CM: M79.89 (Swelling, arm), Z85.3 (History, personal, [of] malignant neoplasm, breast)

CHAPTER 25, PART I, THEORY 1. test(s)

2. indicators

3. Organ or Disease Oriented or panel

4. No

5. Yes

Chapter Review Answers124

CHAPTER 25, PART II, PRACTICAL 6. 85004 (Blood Cell Count, Differential WBC Count);

85032 (Hemogram, Manual)

7. 88304 (Pathology, Surgical, Gross and Micro Exam, Level III)

8. 88302 (Pathology, Surgical, Gross and Micro Exam, Level II)

9. 88300 (Pathology, Surgical, Gross Exam, Level I)

10. 84181 (Western Blot, Protein)

11. 84597 (Vitamin K)

12. 80323 (Drug Assay, Definitive Drug Class, Alkaloids)

13. 82930 × 3 (Gastric Acid)

14. 83003 (Growth Hormone)

15. 83525 (Insulin, Blood)

16. 83721 (Lipoprotein, LDL)

17. 85032 (White Blood Cell, Count)

18. 85060 (Blood Smear, Peripheral)

19. 85730 (Thromboplastin, Partial Time). Note: PTT in the CPT index directs you to correct location.

20. 85652 (Sedimentation Rate, Blood Cell, Automated) ICD-10-CM: R50.9 (Fever), M79.89 (Swelling, hand) ICD-9-CM: 780.60 (Fever); 729.81 (Swelling, hand)

21. 85345 (Coagulation Time)

22. 85280 (Hageman Factor) ICD-10-CM: N92.4 (Bleeding, excessive, associated with menopausal onset)

23. 86910 (Paternity Testing) per individual

24. 87086 (Culture, Bacteria, Urine) ICD-10-CM: R30.0 (Dysuria)

25. 87197 (Schlichter Test) ICD-10-CM: M79.606 (Pain, limb, lower), R50.9 (Fever)

26. 88007 (Autopsy, Gross Exam)

Chapter Review Answers 125

27. 80162 (Therapeutic Drug Assay, Digoxin) and 80202 (Therapeutic Drug Assay, Vancomycin) ICD-10-CM: R00.1 (Bradycardia)

28. 88329 (Pathology, Surgical, Consultation, Inoperative)

CHAPTER 26, PART I, THEORY 1. therapeutic

2. a. intravenous

b. intramuscular

c. subcutaneous

3. hemodialysis

4. peritoneal

5. tonometry

6. anomaloscope

7. otorhinolaryngology

8. Cardiovascular

9. duplex scan

10. Doppler

11. Pulmonary

12. methods (of tests)

13. types (of tests)

14. Special Services, Procedures, and Reports

CHAPTER 26, PART II, PRACTICAL 15. 90702 (Vaccines, Diphtheria Tetanus [DT]); 90460

(Immunization Administration, One Vaccine/Toxoid, with Counseling), 90461 (Immunization Administration, Each Additional Vaccine/Toxoid, with Counseling) for the tetanus ICD-10-CM: Z23 (Vaccination, encounter for), Z71.89 (Counseling, medical [for], specified reason NEC)

Chapter Review Answers126

16. 90714 (Vaccine, Tetanus and Diphtheria, Toxoid); 90471 (Immunization Administration, One Vaccine/Toxoid) ICD-10-CM: Z23 (Vaccination, encounter for)

17. 99201-25 (Evaluation and Management, Office and Other Outpatient), 90700 (Vaccine, Diphtheria, Tetanus, Acellular Pertussis [DTaP]), 90479 (Vaccine, Poliovirus, Live, Oral), 90471 (Immunization Administration, One Vaccine/Toxoid), 90472 (Immunization Administration, Each Additional Vaccine/Toxoid) ICD-10-CM: J06.9 (Infection, respiratory, upper [acute]), Z23 (Vaccination, encounter for)

18. 90658 (Vaccines, Influenza, for Intramuscular Use), 90732 (Vaccines, Pneumococcal, Polysaccharide 23-valet); G0008 (Vaccination, administration, influenza virus), G0009 (Vaccination, administration, pneumococcal) ICD-10-CM: Z23 (Vaccination, encounter for) Note: patient is established and the report only indicates the vaccinations; therefore, no E/M code is reported.

19. 95115 (Allergen Immunotherapy, Allergenic Extracts, Injection) ICD-10-CM: J30.1 (Allergy, primrose)

20. 97761 × 2 (Training, Prosthetics) ICD-10-CM: Q71.20 (Agenesis, forearm, and hand)

21. 94070 (Pulmonology, Diagnostic, Spirometry); 99070 (Supply, Materials) ICD-10-CM: R06.02 (Shortness, breath)

22. 92511 (Nasopharyngoscopy) ICD-10-CM: R04.0 (Nosebleed or epistaxis)

23. 90960 (Dialysis, End Stage Renal Disease) lCD-10-CM: N18.6 (Disease, renal, end-stage)

24. 92002 (Opthalmology, Diagnostic, Eye Exam, New Patient) ICD-I0-CM: E05.00 (Hyperthyroidism, with goiter), H02.403 (Blepharoptosis), H11.423 (Edema, conjunctiva), H25.13 (Cataract, senile, nuclear), Z79.52 (Long-term [current] drug therapy [use of], steroids, systemic)

Chapter Review Answers 127

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