Additional Information
Book Details
Abstract
Take your first step toward a successful career in medical coding with in-depth coverage from the most trusted name in coding education! Carol J. Buck’s Step-by-Step Medical Coding, 2014 Edition is a practical, easy-to-use resource that shows you exactly how to code using all current coding systems. Explanations of coding concepts are followed by practice exercises to reinforce your understanding. In addition to coverage of reimbursement, ICD-9-CM, CPT, HCPCS, and inpatient coding, this edition provides complete coverage of the ICD-10-CM diagnosis coding system in preparation for the upcoming ICD-10 transition. No other text on the market so thoroughly covers all coding sets in one source!
- Over 500 illustrations of medical procedures and conditions help you understand the services being coded.
- Real-life coding reports simulate the reports you will encounter as a coder and help you apply coding principles to actual cases.
- Complete coverage of ICD-10-CM prepares you for the upcoming transition to ICD-10.
- Dual coding addresses the transition to ICD-10 by providing coding answers in both ICD-9 and ICD-10.
- Official Guidelines for Coding and Reporting boxes allow you to read the official wording for inpatient and outpatient coding alongside in-text explanations.
- From the Trenches, Coding Shots, Stop!, Caution!, Check This Out!, and CMS Rules boxes offer valuable, up-to-date tips and advice for working in today’s medical coding field.
- Exercises, Quick Checks, and Toolbox features reinforce coding rules and concepts, and emphasize key information.
- Four coding question variations develop your coding ability and critical thinking skills.
- Coder’s Index makes it easy to quickly locate specific codes.
- Updated content includes the latest coding information available, promoting accurate coding and success on the job.
- New appendix with sample Electronic Health Record (EHR) screenshots provides examples similar to the EHRs you will encounter in the workplace.
Table of Contents
| Section Title | Page | Action | Price |
|---|---|---|---|
| Front cover | Cover | ||
| Copyright page | viii | ||
| Dedication | ix | ||
| Acknowledgments | x | ||
| Preface | xi | ||
| Organization of this textbook | xi | ||
| Distinctive features of our approach | xii | ||
| Extensive supplemental resources | xiv | ||
| Student online activities | xiv | ||
| Student workbook | xv | ||
| Teach instructor resources on evolve | xv | ||
| Evolve learning resources | xvi | ||
| Step-by-step medical coding online | xvi | ||
| Development of this edition | xvii | ||
| Introduction | xx | ||
| References | xxiv | ||
| Table of contents | xxv | ||
| 1 Reimbursement | 1 | ||
| 1 Reimbursement, HIPAA, and compliance | 1 | ||
| Learning objectives | 1 | ||
| Introduction | 2 | ||
| Basic structure of the medicare program | 2 | ||
| Quality improvement organizations (qios) | 5 | ||
| Part a: Hospital insurance | 5 | ||
| Part b: Supplementary insurance | 6 | ||
| Part c: Medicare advantage organizations | 6 | ||
| Part d: Prescription drugs | 6 | ||
| Health insurance portability and accountability act⁹ | 7 | ||
| Electronic transactions | 8 | ||
| Code sets | 8 | ||
| Privacy requirements | 9 | ||
| Security requirements | 9 | ||
| National provider identification | 9 | ||
| Federal register | 9 | ||
| Outpatient resource-based relative value scale (RBRVS) | 11 | ||
| Relative value unit | 13 | ||
| Geographic practice cost index | 13 | ||
| Conversion factor | 13 | ||
| Medicare volume performance standards | 14 | ||
| Beneficiary protection | 14 | ||
| Limiting charge | 14 | ||
| Uniformity provision | 15 | ||
| Adjustments | 15 | ||
| Site-of-service limitations | 15 | ||
| Surgical modifier circumstances | 16 | ||
| Multiple surgeries | 16 | ||
| General. | 16 | ||
| Endoscopic procedures. | 16 | ||
| Dermatologic surgery. | 16 | ||
| Providers furnishing part of the global fee package. | 16 | ||
| Physicians who assist at surgery. | 16 | ||
| Two surgeons and surgical team. | 16 | ||
| Purchased diagnostic services. | 17 | ||
| Reoperations. | 17 | ||
| Medicare fraud | 17 | ||
| Fraud defined | 17 | ||
| Who are the violators? | 18 | ||
| What forms does fraud take? | 18 | ||
| Who says what is fraudulent? | 18 | ||
| Lower limb prostheses—supplier compliance with payment requirements (new) | 19 | ||
| Specific regulations are in the ioms | 19 | ||
| How to protect yourself. | 20 | ||
| Managed health care | 20 | ||
| Types of HMOs | 21 | ||
| Drawbacks of the HMO. | 22 | ||
| Chapter 1, part I, theory | 24 | ||
| Chapter 1, part II, practical | 24 | ||
| References | 25 | ||
| 3 ICD-9-CM | 198 | ||
| 8 An overview of ICD-9-CM | 198 | ||
| Learning objectives | 198 | ||
| The ICD-9-CM | 199 | ||
| ICD-9-CM format | 200 | ||
| Format | 201 | ||
| Tabular list, volume 1 | 201 | ||
| Divisions | 201 | ||
| Classification of diseases and injuries. | 203 | ||
| Chapter. | 203 | ||
| Section. | 203 | ||
| Category. | 204 | ||
| Subcategory. | 204 | ||
| Subclassification. | 204 | ||
| Bold type | 205 | ||
| Italicized type | 205 | ||
| Fourth and fifth-digit specificity. | 206 | ||
| Appendices in the tabular list, volume 1 | 209 | ||
| Appendix a: Morphology of neoplasms | 209 | ||
| Appendix b: Glossary of mental disorders | 210 | ||
| Appendix c: Drugs | 210 | ||
| Appendix d: Industrial accidents | 210 | ||
| Appendix e: Three-digit categories | 211 | ||
| Alphabetic index, volume 2 | 211 | ||
| Conventions | 214 | ||
| NEC and NOS | 214 | ||
| NEC. | 215 | ||
| NOS. | 215 | ||
| Brackets [ ] | 217 | ||
| Slanted brackets [ ] | 217 | ||
| Parentheses ( ) | 218 | ||
| Colon : | 219 | ||
| Brace } | 219 | ||
| Includes. | 219 | ||
| Excludes. | 220 | ||
| Subcategories. | 222 | ||
| Codes in brackets | 223 | ||
| And and with. | 225 | ||
| And | 225 | ||
| With | 225 | ||
| Cross references | 226 | ||
| Use additional code. | 227 | ||
| Code first underlying disease. | 227 | ||
| Code, if applicable, any causal condition. | 228 | ||
| Notes | 228 | ||
| Eponyms | 230 | ||
| Procedures, volume 3 | 231 | ||
| History | 231 | ||
| Format | 232 | ||
| Tabular list, volume 3 | 234 | ||
| Alphabetic index, volume 3 | 236 | ||
| Chapter 8, part I, theory | 243 | ||
| Chapter 8, part II, practical | 244 | ||
| 9 ICD-9-CM outpatient coding and reporting guidelines | 246 | ||
| Learning objectives | 246 | ||
| First-listed diagnosis | 247 | ||
| Unconfirmed diagnosis | 248 | ||
| Outpatient surgery | 249 | ||
| Observation stay | 250 | ||
| Additional diagnoses | 251 | ||
| V codes | 252 | ||
| Index locations | 253 | ||
| Four circumstances to assign | 254 | ||
| Multiple gestation placenta status (V91) | 256 | ||
| Observation | 257 | ||
| Specificity | 258 | ||
| Uncertain diagnosis | 259 | ||
| Chronic diseases | 260 | ||
| Diagnostic services | 261 | ||
| Therapeutic services | 262 | ||
| Surgery | 263 | ||
| Prenatal visits | 264 | ||
| Chapter 9, part I, theory | 266 | ||
| Chapter 9, part II, practical | 267 | ||
| 10 Using ICD-9-CM | 268 | ||
| Learning objectives | 268 | ||
| Organization of the guidelines | 269 | ||
| Level of specificity | 271 | ||
| Integral conditions | 272 | ||
| Multiple coding | 275 | ||
| Acute and chronic | 277 | ||
| Combination codes | 279 | ||
| Late effects | 280 | ||
| Impending or threatened condition | 283 | ||
| Chapter 10, part I, theory | 285 | ||
| Chapter 10, part II, practical | 286 | ||
| 11 Chapter-specific guidelines (ICD-9-CM chapters 1-8) | 287 | ||
| Learning objectives | 287 | ||
| Infectious and parasitic diseases | 288 | ||
| Human immunodeficiency | 289 | ||
| Neoplasms | 290 | ||
| Neoplasm codes | 291 | ||
| Unknown site or unspecified | 296 | ||
| Endocrine, nutritional, and metabolic diseases and immunity disorders | 298 | ||
| Diseases of the blood and blood-forming organs | 299 | ||
| Mental, behavioral and neurodevelopmental disorders | 301 | ||
| Five-digit subclassification | 301 | ||
| Diseases of the nervous system and sense organs | 302 | ||
| Diseases of the circulatory system | 304 | ||
| Hypertension | 304 | ||
| Kidney disease and hypertension | 307 | ||
| Myocardial infarction | 307 | ||
| Diseases of the respiratory system | 310 | ||
| Chapter 11, part I, theory | 313 | ||
| Chapter 11, part II, practical | 313 | ||
| Case study 1 | 315 | ||
| 4 CPT and HCPCS | 360 | ||
| 13 Introduction to the CPT and level II national codes (HCPCS) | 360 | ||
| Learning objectives | 360 | ||
| The purpose of the CPT manual | 361 | ||
| Updating the CPT manual | 361 | ||
| CPT manual format | 363 | ||
| Important symbols and appendices | 364 | ||
| CPT sections | 367 | ||
| The sections of the CPT manual | 367 | ||
| CPT guidelines | 369 | ||
| Code format | 370 | ||
| Modifiers | 372 | ||
| Unlisted procedures | 373 | ||
| Category II codes | 374 | ||
| Category III codes | 376 | ||
| Format of category III codes. | 376 | ||
| Publication of category III codes. | 377 | ||
| Special reports | 377 | ||
| Starting with the index | 377 | ||
| Locating the terms | 377 | ||
| Single code | 377 | ||
| Multiple codes | 378 | ||
| Range of codes | 378 | ||
| Location methods | 379 | ||
| See | 381 | ||
| History of national level codes | 382 | ||
| Two levels of codes | 382 | ||
| General guidelines. | 384 | ||
| Code groupings | 385 | ||
| Index. | 385 | ||
| Table of drugs. | 387 | ||
| Routes of administration of drugs. | 388 | ||
| Durable medical equipment. | 389 | ||
| National physician fee schedule. | 389 | ||
| Chapter 13, part I, theory | 394 | ||
| Chapter 13, part II, practical | 395 | ||
| 14 Modifiers | 397 | ||
| Learning objectives | 397 | ||
| CPT modifiers | 398 | ||
| -22, increased procedural services | 399 | ||
| -23, unusual anesthesia | 400 | ||
| -24, unrelated evaluation and management service by the same physician or other qualified health care professional during ... | 401 | ||
| -25, significant separately identifiable E/M service | 401 | ||
| -26, professional component | 402 | ||
| -32, mandated services | 404 | ||
| -33, preventive service | 404 | ||
| -47, anesthesia by surgeon | 404 | ||
| -50, bilateral procedures | 404 | ||
| -51, multiple procedures | 405 | ||
| Same operation, different site. | 406 | ||
| Multiple operation(s), same operative session. | 406 | ||
| Procedure performed multiple times. | 407 | ||
| -52, reduced services | 409 | ||
| -53, discontinued procedure | 411 | ||
| Modifiers -54, -55, and -56 | 411 | ||
| -54, surgical care only | 412 | ||
| -55, postoperative management only | 412 | ||
| -56, preoperative management only | 413 | ||
| -57, decision for surgery | 413 | ||
| -58, staged or related procedure or service by the same physician or other qualified health care professional during the p ... | 414 | ||
| -59, distinct procedural service | 415 | ||
| -62, two surgeons | 416 | ||
| -63, procedure performed on infants less than 4 kg | 417 | ||
| -66, surgical team | 417 | ||
| -76, repeat procedure or service by same physician or other qualified health care professional | 418 | ||
| -77, repeat procedure by another physician or other qualified health care professional | 418 | ||
| -78, unplanned return to the operating/procedure room by the same physician or other qualified health care professional fo ... | 419 | ||
| -79, unrelated procedure or service by the same physician or other qualified health care professional during the postopera ... | 420 | ||
| -80, assistant surgeon | 420 | ||
| -81, minimum assistant surgeon | 421 | ||
| -82, assistant surgeon (when qualified resident surgeon not available) | 421 | ||
| -90, reference (outside) laboratory | 422 | ||
| -91, repeat clinical diagnostic laboratory test | 423 | ||
| -92, alternative laboratory platform testing | 423 | ||
| -99, multiple modifiers | 423 | ||
| Chapter 14, part I, theory | 424 | ||
| Chapter 14, part II, practical | 425 | ||
| 5 Inpatient Coding | 851 | ||
| 31 Inpatient coding | 851 | ||
| Learning objectives | 851 | ||
| Differences between inpatient and outpatient coding | 852 | ||
| Selection of principal diagnosis | 853 | ||
| Symptoms, signs, and ill-defined conditions | 853 | ||
| Stop | 854 | ||
| Two or more interrelated conditions | 855 | ||
| Two or more diagnoses | 856 | ||
| Comparative or contrasting conditions | 857 | ||
| Stop | 858 | ||
| Symptom(s) followed by contrasting/comparative diagnoses | 858 | ||
| Original treatment plan not carried out | 859 | ||
| Complications | 860 | ||
| Uncertain diagnosis | 861 | ||
| Reporting additional diagnoses | 863 | ||
| Present on admission (POA) | 866 | ||
| Development of the ICD-10-PCS | 866 | ||
| The seven characters of the ICD-10-PCS | 867 | ||
| Character 1 identifies the section. | 867 | ||
| Changing characters. | 868 | ||
| Character 2 is the body system. | 868 | ||
| Character 3 is the root operation. | 868 | ||
| A Closer Look at Root Operations. | 869 | ||
| The index | 870 | ||
| The tabular list completes the code | 870 | ||
| Chapter 31, part I, theory | 878 | ||
| Chapter 31, part II, practical | 879 | ||
| APPENDIX A Online resources | 881 | ||
| APPENDIX C EHR screens | 908 | ||
| Glossary | 915 | ||
| Figure credits | 930 | ||
| Coders index | 935 | ||
| Current procedural terminology (CPT) codes | 935 | ||
| ICD-9-CM | 943 | ||
| ICD-10-CM/PCS | 946 | ||
| HCPCS codes | 950 | ||
| Index | 951 | ||
| A | 951 | ||
| B | 951 | ||
| C | 952 | ||
| D | 954 | ||
| E | 955 | ||
| F | 955 | ||
| G | 956 | ||
| H | 956 | ||
| I | 957 | ||
| J | 960 | ||
| K | 960 | ||
| L | 960 | ||
| M | 961 | ||
| N | 962 | ||
| O | 963 | ||
| P | 963 | ||
| Q | 964 | ||
| R | 964 | ||
| S | 965 | ||
| T | 966 | ||
| U | 966 | ||
| V | 967 | ||
| W | 967 | ||
| X | 967 | ||
| Z | 967 | ||
| Copyright | viii | ||
| 2 An overview of ICD-10-CM | 26 | ||
| Learning objectives | 26 | ||
| Development of the ICD-10-CM | 27 | ||
| ICD-10-CM replaces the ICD-9-CM, volumes 1 and 2 | 27 | ||
| Improvements in the ICD-10-CM | 28 | ||
| Structure of the system | 30 | ||
| Mapping | 31 | ||
| Flags | 31 | ||
| Approximate | 31 | ||
| Approximate, flag 0. | 31 | ||
| Approximate, flag 1. | 32 | ||
| No map. | 34 | ||
| Combination. | 35 | ||
| Scenario and choice list. | 35 | ||
| Index | 37 | ||
| Tabular | 38 | ||
| Official instructional notations in the ICD-10-CM | 40 | ||
| Includes | 40 | ||
| Excludes | 41 | ||
| Excludes1. | 41 | ||
| Excludes2. | 41 | ||
| Code first/use additional code | 41 | ||
| Code also | 42 | ||
| Code also | 41 | ||
| 7th characters and placeholder X | 43 | ||
| Chapter 2, part I, theory | 45 | ||
| Chapter 2, part I, theory | 43 | ||
| Chapter 2, part II, practical | 46 | ||
| 3 ICD-10-CM outpatient coding and reporting guidelines | 47 | ||
| Learning objectives | 47 | ||
| First-listed diagnosis | 48 | ||
| Unconfirmed diagnosis | 50 | ||
| Outpatient surgery | 51 | ||
| Additional diagnoses | 51 | ||
| Z codes | 52 | ||
| Status code | 54 | ||
| External cause index | 56 | ||
| Index locations | 57 | ||
| Circumstances to assign Z codes | 58 | ||
| History of | 60 | ||
| Observation stay | 61 | ||
| First-listed diagnosis and coexisting conditions | 62 | ||
| Uncertain diagnoses | 63 | ||
| Chronic diseases | 65 | ||
| Documented conditions | 65 | ||
| Diagnostic services | 66 | ||
| Therapeutic services | 67 | ||
| Preoperative evaluation | 68 | ||
| Preoperative evaluations only | 69 | ||
| Prenatal visits | 70 | ||
| Chapter 3, part I, theory | 71 | ||
| Chapter 3, part II, practical | 72 | ||
| 4 Using ICD-10-CM | 74 | ||
| Learning objectives | 74 | ||
| Organization of the guidelines | 75 | ||
| Accurate coding | 75 | ||
| Steps to accurate coding | 75 | ||
| Alphabetic index and tabular list | 75 | ||
| Level of specificity | 77 | ||
| Integral conditions | 79 | ||
| Multiple coding | 81 | ||
| Acute and chronic | 83 | ||
| Combination codes | 85 | ||
| Late effects | 87 | ||
| Reporting same diagnosis code more than once | 89 | ||
| Laterality | 90 | ||
| Chapter 4, part I, theory | 92 | ||
| Chapter 4, part II, practical | 93 | ||
| 5 Chapter-specific guidelines (ICD-10-CM chapters 1-10) | 94 | ||
| Learning objectives | 94 | ||
| Certain infectious and parasitic diseases | 95 | ||
| Resistant infections | 96 | ||
| A codes (A00-A99) | 96 | ||
| Sepsis, severe sepsis, and septic shock | 97 | ||
| B codes (B00-B99) | 100 | ||
| Viral hepatitis | 100 | ||
| Human immunodeficiency | 101 | ||
| Neoplasms | 103 | ||
| Neoplasm classifications and staging | 108 | ||
| Sequencing and complications. | 109 | ||
| History of z codes. | 111 | ||
| Unknown or unspecified site. | 112 | ||
| Diseases of the blood and blood-forming organs and certain disorders involving the immune mechanism | 113 | ||
| Anemia | 114 | ||
| Coagulation defects, purpura, and other hemorrhagic conditions | 115 | ||
| Other disorders of blood and blood-forming organs (D70-D77) | 116 | ||
| Endocrine, nutritional, and metabolic diseases | 116 | ||
| Mental, behavioral and neurodevelopmental disorders | 120 | ||
| Dementia | 121 | ||
| Substance use | 121 | ||
| Psychological disorders | 121 | ||
| Psychological pain | 122 | ||
| Diseases of the nervous system | 123 | ||
| Pain (non-psychological) | 124 | ||
| Example site-specific pain codes | 126 | ||
| Dominant and nondominant sides | 127 | ||
| Diseases of the eye and adnexa | 128 | ||
| Hordeolum and chalazion | 128 | ||
| Entropion and ectropion | 129 | ||
| Lacrimal system | 130 | ||
| Diseases of the ear and mastoid process | 130 | ||
| Ear | 131 | ||
| External ear. | 131 | ||
| Middle ear and mastoid. | 131 | ||
| Inner ear. | 132 | ||
| Diseases of the circulatory system | 132 | ||
| Hypertension | 133 | ||
| Kidney disease and hypertension | 136 | ||
| Myocardial infarction | 136 | ||
| Diseases of the respiratory system | 139 | ||
| Chapter 5, part I, theory | 142 | ||
| Chapter 5, part ii, practical | 142 | ||
| Case study 1 | 143 | ||
| History of present illness | 143 | ||
| Course in hospital | 143 | ||
| Discharge diagnoses | 143 | ||
| Matching | 143 | ||
| 6 Chapter-specific guidelines (ICD-10-CM chapters 11-14) | 144 | ||
| Learning objectives | 144 | ||
| Diseases of the digestive system | 145 | ||
| Hemorrhage | 145 | ||
| Diseases of the skin and subcutaneous tissue | 146 | ||
| Ulcers | 148 | ||
| Diseases of the musculoskeletal system and connective tissue | 150 | ||
| Infectious arthropathies | 151 | ||
| M00 reports direct infection from a known organism. | 152 | ||
| M01 reports direct infection of the joint due to infectious or parasitic disease that is classified elsewhere. | 153 | ||
| M02 reports indirect infections from an unknown organism. | 153 | ||
| Pathological fractures | 154 | ||
| Diseases of the genitourinary system | 156 | ||
| Chapter 6, part I, theory | 157 | ||
| Chapter 6, part II, practical | 158 | ||
| 7 Chapter-specific guidelines (ICD-10-CM chapters 15-21) | 159 | ||
| Learning objectives | 159 | ||
| Pregnancy, childbirth, and the puerperium | 160 | ||
| General rules of obstetric diagnosis reporting | 160 | ||
| First-listed diagnosis in normal pregnancy | 161 | ||
| First-listed diagnosis in high-risk patients | 161 | ||
| First-listed diagnosis for delivery | 161 | ||
| Trimesters | 162 | ||
| Peripartum and postpartum periods | 164 | ||
| Normal delivery | 164 | ||
| Ectopic pregnancy | 165 | ||
| Hydatidiform mole | 165 | ||
| Hypertension in pregnancy | 166 | ||
| Fetal conditions | 167 | ||
| Diabetes mellitus in pregnancy | 168 | ||
| Certain conditions originating in the perinatal period | 169 | ||
| First-listed diagnosis | 170 | ||
| Congenital malformations, deformations and chromosomal abnormalities | 170 | ||
| Symptoms, signs, and abnormal clinical and laboratory findings, not elsewhere classified | 173 | ||
| Injury, poisoning, and certain other consequences of external causes | 177 | ||
| Code extensions | 178 | ||
| Coding injuries | 179 | ||
| Coding fractures | 180 | ||
| Coding burns and corrosions | 182 | ||
| Coding adverse effects, poisoning, underdosing, and toxic effects | 186 | ||
| Abuse, neglect, and other maltreatment | 190 | ||
| Open wounds, lacerations, and punctures | 191 | ||
| Complications | 193 | ||
| Medical device, graft, or implant. | 194 | ||
| Transplant. | 194 | ||
| Chapter 7, part I, theory | 196 | ||
| Chapter 7, part II, practical | 197 | ||
| 15 Evaluation and management (E/M) services | 426 | ||
| Learning objectives | 426 | ||
| Contents of the E/M section | 427 | ||
| Three factors of E/M codes | 427 | ||
| Place of service | 427 | ||
| Type of service | 428 | ||
| Patient status | 428 | ||
| Medical records documentation | 429 | ||
| Various levels of E/M service | 430 | ||
| Key components | 430 | ||
| Office, new patient | 430 | ||
| History. | 431 | ||
| The four elements of a history | 431 | ||
| History elements. | 431 | ||
| History elements. | 432 | ||
| History levels. | 435 | ||
| History levels | 435 | ||
| Examination. | 437 | ||
| Examination levels. | 437 | ||
| Examination levels | 437 | ||
| Medical decision making. | 441 | ||
| Levels. | 442 | ||
| Medical decision-making complexity levels | 442 | ||
| Management options. | 442 | ||
| Data to be reviewed. | 442 | ||
| Risk. | 443 |