BOOK
Workbook for ICD-10-CM/PCS Coding: Theory and Practice, 2014 Edition - E-Book
Karla R. Lovaasen | Jennifer Schwerdtfeger
(2014)
Additional Information
Book Details
Abstract
Reinforce your understanding of ICD-10-CM and ICD-10-PCS medical coding concepts with practical applications! Corresponding to the chapters in ICD-10-CM/PCS Coding: Theory and Practice, 2014 Edition, this workbook includes engaging, interactive exercises to help you review concepts and prepare for successful employment in medical coding.
- Hands-on application activities and case studies help you master coding concepts and apply them in real-world scenarios.
- Matching exercises, multiple-choice questions, coding questions, and case scenarios with MS-DRG assignments reinforce key content from the text.
- ICD-10-CM/PCS codes are included for all coding exercises and examples, in preparation for the October 2014 implementation of ICD-10.
- Evolve companion website for the ICD-10-CM/PCS Coding text offers convenient online access to updates, partial answer keys, and coding guidelines.
- Updated content includes the icd-10 code revisions released in Spring 2013, ensuring you have the latest coding information available.
Table of Contents
| Section Title | Page | Action | Price |
|---|---|---|---|
| Front Cover | Cover | ||
| Inside Front Cover | ES2 | ||
| Workbook for ICD-10-CM/PCS Coding: Theory and Practice, 2014 Edition | i | ||
| Copyright | ii | ||
| Reviewers | iii | ||
| Contents | v | ||
| Chapter 1: The Rationale for and History of Coding | 1 | ||
| ABBREVIATIONS/ACRONYMS | 1 | ||
| GLOSSARY DEFINITIONS | 1 | ||
| MULTIPLE CHOICE | 1 | ||
| Chapter 2: The Health Record as the Foundation of Coding | 3 | ||
| ABBREVIATIONS/ACRONYMS | 3 | ||
| GLOSSARY DEFINITIONS | 3 | ||
| MULTIPLE CHOICE | 4 | ||
| Chapter 3: ICD-10-CM Format and Conventions | 7 | ||
| ABBREVIATIONS/ACRONYMS | 7 | ||
| GLOSSARY DEFINITIONS | 7 | ||
| MULTIPLE CHOICE | 7 | ||
| SHORT ANSWER | 8 | ||
| Chapter 4: Basic Steps of Coding | 11 | ||
| ABBREVIATIONS/ACRONYMS | 11 | ||
| GLOSSARY DEFINITIONS | 11 | ||
| CODING | 11 | ||
| MULTIPLE CHOICE | 12 | ||
| Chapter 5: General Coding Guidelines for Diagnosis | 13 | ||
| ABBREVIATIONS/ACRONYMS | 13 | ||
| GLOSSARY DEFINITIONS | 13 | ||
| CODING | 14 | ||
| Chapter 6: General Coding Guidelines for Medical and Surgical Procedures | 15 | ||
| ABBREVIATIONS/ACRONYMS | 15 | ||
| GLOSSARY DEFINITIONS | 15 | ||
| MULTIPLE CHOICE/SHORT ANSWER | 16 | ||
| Chapter 7: General Coding Guidelines for Other Medical- and Surgical-Related Procedures and Ancillary Procedures | 19 | ||
| ABBREVIATIONS/ACRONYMS | 19 | ||
| GLOSSARY DEFINITIONS | 19 | ||
| MULTIPLE CHOICE/SHORT ANSWER | 19 | ||
| CODING | 21 | ||
| Chapter 8: Symptoms, Signs, and Abnormal Clinical and Laboratory Findings Not Elsewhere Classified, and Z Codes (ICD-10-CM ... | 23 | ||
| ABBREVIATIONS/ACRONYMS | 23 | ||
| GLOSSARY DEFINITIONS | 23 | ||
| CODING | 23 | ||
| MULTIPLE CHOICE | 24 | ||
| CASE SCENARIOS | 25 | ||
| CASE STUDIES | 27 | ||
| 8-1. CASE STUDY | 27 | ||
| History and Physical | 27 | ||
| Physical Examination: | 27 | ||
| Sigmoidoscopy Report | 28 | ||
| Discharge Summary | 28 | ||
| Diagnoses/Problems | 28 | ||
| Procedures | 28 | ||
| History, Major Findings, and Hospital Course | 28 | ||
| Discharge Medications | 28 | ||
| Discharge Instructions | 28 | ||
| Follow-up Care | 29 | ||
| Operative Report | 29 | ||
| Surgeon’s Narrative | 29 | ||
| Progress Note: OP Note | 29 | ||
| CASE STUDY QUESTIONS | 33 | ||
| 8-2. CASE STUDY | 34 | ||
| History and Physical | 34 | ||
| Physical Examination: | 34 | ||
| Discharge Summary | 35 | ||
| Diagnoses/Problems | 35 | ||
| Procedures | 35 | ||
| History, Major Findings, and Hospital Course | 35 | ||
| Hospital Course by Systems | 36 | ||
| Discharge Medications | 37 | ||
| Follow-up Care | 37 | ||
| Progress Notes | 37 | ||
| Day 1 | 37 | ||
| Day 2 | 37 | ||
| CASE STUDY QUESTIONS | 37 | ||
| 8-3. CASE STUDY | 38 | ||
| History and Physical | 38 | ||
| Physical Examination | 38 | ||
| Discharge Summary | 39 | ||
| Diagnoses/Problems | 39 | ||
| Procedures | 39 | ||
| History, Major Findings, and Hospital Course | 39 | ||
| Discharge Medications | 40 | ||
| Follow-up Care | 40 | ||
| Brain Without IV Contrast, CT | 40 | ||
| Progress Notes | 40 | ||
| Day 1 | 40 | ||
| Day 2 | 40 | ||
| CASE STUDY QUESTIONS | 41 | ||
| Chapter 9: Certain Infectious and Parasitic Diseases (ICD-10-CM Chapter 1, Codes A00-B99) | 43 | ||
| ABBREVIATIONS/ACRONYMS | 43 | ||
| GLOSSARY DEFINITIONS | 43 | ||
| CODING | 43 | ||
| CASE SCENARIOS | 44 | ||
| CASE STUDIES | 46 | ||
| 9-1. CASE STUDY | 46 | ||
| History and Physical | 46 | ||
| Physical Examination | 46 | ||
| Assessment/Plan | 46 | ||
| Discharge Summary | 46 | ||
| Diagnoses/Problems | 46 | ||
| History, Major Findings, and Hospital Course | 47 | ||
| Discharge Medications | 47 | ||
| Follow-up Care | 47 | ||
| Social Work Screening | 47 | ||
| Progress Notes | 47 | ||
| Day 1 | 47 | ||
| Day 2 | 47 | ||
| Day 3 | 47 | ||
| CASE STUDY QUESTIONS | 47 | ||
| 9-2. CASE STUDY | 48 | ||
| History and Physical | 48 | ||
| Physical Examination | 49 | ||
| Assessment/Plan | 49 | ||
| Discharge Summary | 49 | ||
| Diagnoses/Problems | 49 | ||
| Procedures | 50 | ||
| History, Major Findings, and Hospital Course | 50 | ||
| Assessment | 51 | ||
| Hospital Course/Plan | 51 | ||
| Discharge Medications | 51 | ||
| Discharge Instructions | 51 | ||
| Follow-up Care | 51 | ||
| Diagnostic Bronchoscopy | 53 | ||
| Progress Notes | 54 | ||
| Day 1 | 54 | ||
| Day 2 | 54 | ||
| Day 3 | 54 | ||
| Day 4 | 54 | ||
| Day 5 | 54 | ||
| CASE STUDY QUESTIONS | 54 | ||
| 9-3. CASE STUDY | 55 | ||
| History and Physical | 55 | ||
| Physical Examination | 56 | ||
| Assessment/Plan | 56 | ||
| Discharge Summary | 57 | ||
| Diagnoses/Problems | 57 | ||
| Procedures | 57 | ||
| History, Major Findings, and Hospital Course | 57 | ||
| Physical Examination on Admission | 58 | ||
| Discharge Medications | 58 | ||
| Discharge Instructions | 59 | ||
| Follow-up Care | 59 | ||
| Progress Notes | 59 | ||
| Day 1 | 59 | ||
| Day 2 | 59 | ||
| CASE STUDY QUESTIONS | 59 | ||
| Chapter 10: Neoplasms (ICD-10-CM Chapter 2, Codes C00-D49) | 61 | ||
| ABBREVIATIONS/ACRONYMS | 61 | ||
| GLOSSARY DEFINITIONS | 61 | ||
| CODING | 62 | ||
| CASE SCENARIOS | 63 | ||
| CASE STUDIES | 65 | ||
| 10-1. CASE STUDY | 65 | ||
| History and Physical | 65 | ||
| Review of Systems | 65 | ||
| Problems | 66 | ||
| Discharge Summary | 66 | ||
| Diagnoses/Problems | 66 | ||
| Procedures | 66 | ||
| History, Major Findings, and Hospital Course | 66 | ||
| Discharge Medications | 67 | ||
| Follow-up Care | 67 | ||
| Progress Notes | 67 | ||
| Day 1 | 67 | ||
| Day 2 | 67 | ||
| CASE STUDY QUESTIONS | 67 | ||
| 10-2. CASE STUDY | 68 | ||
| Clinic Note/Preoperative Evaluation | 68 | ||
| Chapter 11: Diseases of the Blood and Blood-Forming Organs and Certain Disorders Involving the Immune Mechanism (ICD-10-CM ... | 79 | ||
| ABBREVIATIONS/ACRONYMS | 79 | ||
| GLOSSARY DEFINITIONS | 79 | ||
| CODING | 80 | ||
| CASE SCENARIOS | 81 | ||
| CASE STUDIES | 82 | ||
| 11-1. CASE STUDY | 82 | ||
| History and Physical | 82 | ||
| Physical Examination | 83 | ||
| Discharge Summary | 83 | ||
| Diagnoses/Problems | 83 | ||
| Procedures | 83 | ||
| History, Major Findings, and Hospital Course | 83 | ||
| Hospital Course | 83 | ||
| Discharge Medications | 84 | ||
| Progress Notes | 84 | ||
| Day 1 | 84 | ||
| Day 2 | 84 | ||
| Day 3 | 84 | ||
| CASE STUDY QUESTIONS | 84 | ||
| 11-2. CASE STUDY | 85 | ||
| Clinic Note | 85 | ||
| Major Findings | 85 | ||
| Physical Examination | 85 | ||
| Assessments | 86 | ||
| History and Physical | 86 | ||
| Physical Examination | 87 | ||
| Operative Report | 87 | ||
| Surgeon’s Narrative | 88 | ||
| Discharge Summary | 88 | ||
| Diagnoses/Problems | 88 | ||
| Procedure | 88 | ||
| History, Major Findings, and Hospital Course | 88 | ||
| Discharge Medications | 89 | ||
| Discharge Instructions | 89 | ||
| Progress Notes | 89 | ||
| Day 1 | 89 | ||
| Day 2 | 89 | ||
| CASE STUDY QUESTIONS | 90 | ||
| Chapter 12: Endocrine, Nutritional, and Metabolic Diseases (ICD-10-CM Chapter 4,Codes E00-E89) | 91 | ||
| ABBREVIATIONS/ACRONYMS | 91 | ||
| GLOSSARY DEFINITIONS | 91 | ||
| CODING | 92 | ||
| CASE SCENARIOS | 93 | ||
| 12-1. CASE STUDY | 95 | ||
| History and Physical | 95 | ||
| Physical Examination | 95 | ||
| Assessment and Plan | 95 | ||
| Discharge Summary | 95 | ||
| Diagnoses/Problems | 95 | ||
| Procedures | 96 | ||
| History, Major Findings, and Hospital Course | 96 | ||
| Physical Examination | 96 | ||
| Hospital Course by System | 97 | ||
| Discharge Medications | 97 | ||
| Follow-up Care | 97 | ||
| Contrast CT | 97 | ||
| Chest, Abdomen, and Pelvis | 97 | ||
| Progress Notes | 98 | ||
| Day 1 | 98 | ||
| CASE STUDY QUESTIONS | 98 | ||
| 12-2. CASE STUDY | 99 | ||
| History and Physical | 99 | ||
| Physical Examination | 100 | ||
| Discharge Summary | 100 | ||
| Diagnoses/Problems | 100 | ||
| Procedure | 100 | ||
| History, Major Findings, and Hospital Course | 100 | ||
| Discharge Medications | 101 | ||
| Discharge Instructions | 101 | ||
| Follow-up Care | 101 | ||
| Operative Report | 101 | ||
| Surgeon’s Narrative | 101 | ||
| Path Report | 102 | ||
| Progress Notes | 102 | ||
| Brief Operative Note | 102 | ||
| Day 1 | 103 | ||
| Day 2 | 103 | ||
| Day 3 | 103 | ||
| CASE STUDY QUESTIONS | 103 | ||
| 12-3. CASE STUDY | 104 | ||
| History and Physical | 104 | ||
| Chapter 13: Mental, Behavioral, and Neurodevelopmental Disorders (ICD-10-CM Chapter 5, Codes F01-F99) | 119 | ||
| ABBREVIATIONS/ACRONYMS | 119 | ||
| GLOSSARY DEFINITIONS | 119 | ||
| CODING | 120 | ||
| CASE SCENARIOS | 121 | ||
| CASE STUDIES | 123 | ||
| 13-1. CASE STUDY | 123 | ||
| History and Physical | 123 | ||
| Discharge Summary | 123 | ||
| Diagnoses/Problems | 123 | ||
| Procedures | 123 | ||
| History, Major Findings, and Hospital Course | 124 | ||
| Follow-up Care | 124 | ||
| Chest | 124 | ||
| Brain Without IV Contrast, CT | 124 | ||
| Results | 124 | ||
| CT C-spine Without Contrast Complex | 125 | ||
| Progress Notes | 125 | ||
| Day 1 | 125 | ||
| Day 2 | 125 | ||
| CASE STUDY QUESTIONS | 125 | ||
| 13-2. CASE STUDY | 127 | ||
| History and Physical | 127 | ||
| Discharge Summary | 127 | ||
| Progress Notes | 128 | ||
| Day 1 | 128 | ||
| Day 2 | 128 | ||
| Day 3 | 128 | ||
| CASE STUDY QUESTIONS | 128 | ||
| Chapter 14: Diseases of the Nervous System, Diseases of the Eye and Adnexa, and Diseases of the Ear and Mastoid Process (I ... | 131 | ||
| ABBREVIATIONS/ACRONYMS | 131 | ||
| GLOSSARY DEFINITIONS | 131 | ||
| CODING | 132 | ||
| CASE SCENARIOS | 132 | ||
| CASE STUDIES | 134 | ||
| 14-1. CASE STUDY | 134 | ||
| History and Physical | 134 | ||
| Review of Systems | 134 | ||
| Discharge Summary | 135 | ||
| Diagnoses/Problems | 135 | ||
| Procedures | 135 | ||
| History, Major Findings, and Hospital Course | 135 | ||
| Report of Electroencephalogram | 136 | ||
| Progress Notes | 137 | ||
| Day 1 | 137 | ||
| Day 2 | 137 | ||
| Day 3 | 137 | ||
| CASE STUDY QUESTIONS | 137 | ||
| 14-2. CASE STUDY | 138 | ||
| History and Physical | 138 | ||
| Review of Systems | 139 | ||
| Physical Examination | 139 | ||
| Discharge Summary | 140 | ||
| Diagnoses/Problems | 140 | ||
| Procedures | 140 | ||
| History, Major Findings, and Hospital Course | 140 | ||
| Discharge Instructions | 141 | ||
| Follow-up Care | 141 | ||
| MRI, Brain With and Without Contrast With Diff | 141 | ||
| Brain Without IV Contrast CT | 142 | ||
| Progress Notes | 142 | ||
| Day 1 | 142 | ||
| Day 2 | 142 | ||
| CASE STUDY QUESTIONS | 143 | ||
| 14-3. CASE STUDY | 144 | ||
| Admission History and Physical Examination | 144 | ||
| Physical Examination | 144 | ||
| Discharge Summary | 145 | ||
| Diagnoses/Problems | 145 | ||
| Procedures | 145 | ||
| History, Major Findings, and Hospital Course | 145 | ||
| Discharge Instructions | 146 | ||
| Follow-up Care | 146 | ||
| Procedure Note | 146 | ||
| Day 1 | 146 | ||
| Day 2 | 146 | ||
| Day 3 | 147 | ||
| Day 4 | 147 | ||
| CASE STUDY QUESTION | 147 | ||
| Chapter 15: Diseases of the Circulatory System (ICD-10-CM Chapter 9, Codes I00-I99) | 149 | ||
| ABBREVIATIONS/ACRONYMS | 149 | ||
| GLOSSARY DEFINITIONS | 149 | ||
| CODING | 150 | ||
| CASE SCENARIOS | 150 | ||
| CASE STUDIES | 152 | ||
| 15-1. CASE STUDY | 152 | ||
| History and Physical | 152 | ||
| Physical Examination | 152 | ||
| Assessment/Plan | 153 | ||
| Discharge Summary | 153 | ||
| Diagnoses/Problems | 153 | ||
| Procedures | 153 | ||
| History, Major Findings, and Hospital Course | 153 | ||
| Discharge Medications | 154 | ||
| Discharge Instructions | 154 | ||
| Follow-up Care | 154 | ||
| Electrocardiogram Report | 154 | ||
| Transthoracic Echocardiogram | 154 | ||
| Chest AP Portable | 155 | ||
| Thoracic CT | 155 | ||
| Progress Notes | 156 | ||
| Day 1 | 156 | ||
| Day 2 | 156 | ||
| Day 3 | 156 | ||
| Day 4 | 156 | ||
| CASE STUDY QUESTIONS | 156 | ||
| 15-2. CASE STUDY | 157 | ||
| History and Physical | 157 | ||
| Review of Systems | 157 | ||
| Physical Examination | 158 | ||
| Assessment/Plan | 158 | ||
| Procedures Performed | 158 | ||
| Past Medical History | 158 | ||
| Procedure Description | 159 | ||
| Impression | 159 | ||
| Recommendations | 160 | ||
| Procedure Data | 160 | ||
| Case Medications | 160 | ||
| Vital Signs | 160 | ||
| EPS/Ablation Methods | 160 | ||
| Anesthesia | 160 | ||
| Vascular Access | 161 | ||
| Chapter 16: Diseases of the Respiratory System (ICD-10-CM Chapter 10, Codes J00-J99) | 173 | ||
| ABBREVIATIONS/ACRONYMS | 173 | ||
| GLOSSARY DEFINITIONS | 173 | ||
| CODING | 174 | ||
| CASE SCENARIOS | 175 | ||
| CASE STUDIES | 177 | ||
| 16-1. CASE STUDY | 177 | ||
| Admission History and Physical | 177 | ||
| Thoracic With Contrast CT | 178 | ||
| Result | 178 | ||
| Discharge Summary | 178 | ||
| Diagnoses/Problems | 178 | ||
| History, Major Findings, and Hospital Course | 179 | ||
| Discharge Medications | 179 | ||
| Discharge Instructions | 179 | ||
| Follow-up Care | 180 | ||
| Progress Notes | 180 | ||
| Day 1 | 180 | ||
| Day 2 | 180 | ||
| Day 3 | 180 | ||
| Oncology Consultation | 180 | ||
| CASE STUDY QUESTIONS | 181 | ||
| 16‑2. CASE STUDY | 182 | ||
| History and Physical | 182 | ||
| Physical Examination | 182 | ||
| Discharge Summary | 183 | ||
| Diagnoses/Problems | 183 | ||
| Procedures | 183 | ||
| History, Major Findings, and Hospital Course | 183 | ||
| Discharge Medications | 184 | ||
| Follow-up Care | 184 | ||
| Progress Notes | 184 | ||
| Day 1 | 184 | ||
| Day 2 | 185 | ||
| Day 3 | 185 | ||
| CASE STUDY QUESTIONS | 185 | ||
| 16‑3. CASE STUDY | 186 | ||
| History and Physical | 186 | ||
| Discharge Summary | 187 | ||
| Diagnoses/Problems | 187 | ||
| Procedures | 187 | ||
| History, Major Findings, and Hospital Course | 187 | ||
| Discharge Medications | 188 | ||
| Discharge Instructions | 188 | ||
| Follow-up Care | 188 | ||
| Progress Notes | 188 | ||
| Day 1 | 188 | ||
| Day 2 | 189 | ||
| Day 3 | 189 | ||
| Day 4 | 189 | ||
| CASE STUDY QUESTIONS | 189 | ||
| Chapter 17: Diseases of the Digestive System (ICD-10-CM Chapter 11, Codes K00-K95) | 191 | ||
| ABBREVIATIONS/ACRONYMS | 191 | ||
| GLOSSARY DEFINITIONS | 191 | ||
| CODING | 192 | ||
| CASE SCENARIOS | 192 | ||
| CASE STUDIES | 194 | ||
| 17-1. CASE STUDY | 194 | ||
| History and Physical | 194 | ||
| Discharge Summary | 195 | ||
| Diagnoses/Problems | 195 | ||
| Procedures | 195 | ||
| History, Major Findings, and Hospital Course | 195 | ||
| Progress Notes | 195 | ||
| Day 1 | 195 | ||
| Day 2 | 196 | ||
| CASE STUDY QUESTION | 196 | ||
| 17-2. CASE STUDY | 197 | ||
| History and Physical | 197 | ||
| Discharge Summary | 198 | ||
| Diagnoses/Problems | 198 | ||
| Procedures | 198 | ||
| History, Major Findings, and Hospital Course | 198 | ||
| Stomach/Pylorus | 198 | ||
| Upper GI Series | 198 | ||
| Progress Notes | 199 | ||
| Day 1 | 199 | ||
| Day 2 | 199 | ||
| Day 3 | 199 | ||
| CASE STUDY QUESTION | 199 | ||
| 17-3. CASE STUDY | 200 | ||
| History and Physical | 200 | ||
| Review of Systems | 201 | ||
| Discharge Summary | 201 | ||
| Diagnoses/Problems | 201 | ||
| Procedures | 202 | ||
| History, Major Findings, and Hospital Course | 202 | ||
| Discharge Instructions | 203 | ||
| Follow-up Care | 204 | ||
| CT Abd With and Without Contrast With Pelvis | 204 | ||
| Progress Notes | 204 | ||
| Day 1 | 204 | ||
| Day 2 | 204 | ||
| Day 3 | 204 | ||
| Day 4 | 204 | ||
| Day 5 | 204 | ||
| Day 6 | 204 | ||
| CASE STUDY QUESTIONS | 205 | ||
| Chapter 18: Diseases of the Skin and Subcutaneous Tissue (ICD-10-CM Chapter 12, Codes L00-L99) | 207 | ||
| ABBREVIATIONS/ACRONYMS | 207 | ||
| GLOSSARY DEFINITIONS | 207 | ||
| CODING | 207 | ||
| CASE SCENARIOS | 208 | ||
| CASE STUDIES | 209 | ||
| 18-1. CASE STUDY | 209 | ||
| History and Physical | 209 | ||
| Review of Systems | 210 | ||
| Physical Examination | 210 | ||
| Inpatient Dermatology Consultation Note | 211 | ||
| Discharge Summary | 211 | ||
| Diagnoses/Problems | 211 | ||
| Procedures | 212 | ||
| History, Major Findings, and Hospital Course | 212 | ||
| Discharge Instructions | 213 | ||
| Follow-up Care | 213 | ||
| Wound Care Specialist | 213 | ||
| Progress Notes | 213 | ||
| Day 1 | 213 | ||
| Day 2 | 213 | ||
| Day 3 | 213 | ||
| Day 4 | 214 | ||
| CASE STUDY QUESTIONS | 214 | ||
| 18-2. CASE STUDY | 215 | ||
| History and Physical | 215 | ||
| Discharge Summary | 216 | ||
| Procedures | 216 | ||
| History, Major Findings, and Hospital Course | 216 | ||
| Hospital Course by Symptoms | 216 | ||
| Follow-up Care | 217 | ||
| Wound Care Specialist | 217 | ||
| Final Report | 217 | ||
| Progress Notes | 217 | ||
| Day 1 | 217 | ||
| Day 2 | 217 | ||
| Day 3 | 218 | ||
| CASE STUDY QUESTIONS | 218 | ||
| Chapter 19: Diseases of the Musculoskeletal System and Connective Tissue (ICD-10-CM Chapter 13, Codes M00-M99) | 219 | ||
| ABBREVIATIONS/ACRONYMS | 219 | ||
| GLOSSARY DEFINITIONS | 219 | ||
| CODING | 220 | ||
| CASE SCENARIOS | 221 | ||
| CASE STUDIES | 223 | ||
| 19-1. CASE STUDY | 223 | ||
| History and Physical | 223 | ||
| Physical Examination | 223 | ||
| Podiatry Consult | 224 | ||
| Diagnosis | 224 | ||
| X-ray: Foot, Left | 225 | ||
| MRI Left Lower Extremity | 225 | ||
| Discharge Summary | 226 | ||
| Diagnoses/Problems | 226 | ||
| Procedures | 226 | ||
| History, Major Findings, and Hospital Course | 226 | ||
| Discharge Instructions | 226 | ||
| Follow-up Care | 226 | ||
| Progress Notes | 226 | ||
| Day 1 | 226 | ||
| Day 2 | 227 | ||
| Day 3 | 227 | ||
| CASE STUDY QUESTIONS | 227 | ||
| 19-2. CASE STUDY | 228 | ||
| Clinic Note/Preop Evaluation | 228 | ||
| Discharge Summary | 229 | ||
| Diagnoses/Problems | 229 | ||
| Procedures | 229 | ||
| History, Major Findings, and Hospital Course | 229 | ||
| Discharge Instructions | 229 | ||
| Operative Report | 229 | ||
| Surgeon’s Narrative | 230 | ||
| Shoulder X-ray | 231 | ||
| CASE STUDY QUESTIONS | 235 | ||
| 19-3. CASE STUDY | 236 | ||
| Clinic Note/Preop Evaluation | 236 | ||
| Discharge Summary | 236 | ||
| Diagnoses/Problems | 236 | ||
| Procedures | 237 | ||
| History, Major Findings, and Hospital Course | 237 | ||
| Discharge Instructions | 237 | ||
| Follow-up Care | 237 | ||
| Operative Report | 237 | ||
| Surgeon’s Narrative | 238 | ||
| Lumbar Spine Port in OR | 239 | ||
| CT Left Spine Without Contrast Complex | 239 | ||
| Progress Notes | 240 | ||
| Postop Note | 240 | ||
| Day 1 | 240 | ||
| Day 2 | 241 | ||
| Day 3 | 241 | ||
| CASE STUDY QUESTIONS | 241 | ||
| Chapter 20: Diseases of the Genitourinary System (ICD-10-CM Chapter 14, Codes N00-N99) | 243 | ||
| ABBREVIATIONS/ACRONYMS | 243 | ||
| GLOSSARY DEFINITIONS | 243 | ||
| CODING | 244 | ||
| CASE SCENARIOS | 245 | ||
| CASE STUDIES | 247 | ||
| 20-1. CASE STUDY | 247 | ||
| Clinic Note/Preop Evaluation | 247 | ||
| Problems/Diagnoses | 248 | ||
| Plans | 248 | ||
| Discharge Summary | 248 | ||
| Diagnoses/Problems | 248 | ||
| Procedures | 248 | ||
| History, Major Findings, and Hospital Course | 248 | ||
| Discharge Medications | 248 | ||
| Discharge Instructions | 249 | ||
| Follow-up Care | 249 | ||
| Operative Report | 249 | ||
| Surgeon’s Narrative | 249 | ||
| Progress Notes | 250 | ||
| Transplant Surgery Note | 250 | ||
| Day 1 | 250 | ||
| Day 2 | 250 | ||
| CASE STUDY QUESTIONS | 250 | ||
| 20-2. CASE STUDY | 251 | ||
| History and Physical | 251 | ||
| Review of Systems | 252 | ||
| Physical Examination | 252 | ||
| Discharge Summary | 252 | ||
| Diagnoses/Problems | 252 | ||
| Procedures | 252 | ||
| History, Major Findings, and Hospital Course | 253 | ||
| Hospital Course by Systems | 253 | ||
| Discharge Medications | 254 | ||
| Follow-up Care | 254 | ||
| Progress Note | 254 | ||
| Day 1 | 254 | ||
| Day 2 | 254 | ||
| Day 3 | 254 | ||
| Day 4 | 254 | ||
| DNR/DNI Discussion | 254 | ||
| Day 5 | 255 | ||
| CASE STUDY QUESTIONS | 255 | ||
| 20-3. CASE STUDY | 256 | ||
| History and Physical | 256 | ||
| Review of Systems | 256 | ||
| Physical Examination | 256 | ||
| Discharge Summary | 257 | ||
| Procedures | 257 | ||
| History, Major Findings, and Hospital Course | 257 | ||
| Discharge Medications | 258 | ||
| Discharge Instructions | 258 | ||
| Follow-up Care | 258 | ||
| Progress Notes | 258 | ||
| Day 1 | 258 | ||
| Day 2 | 258 | ||
| CASE STUDY QUESTIONS | 259 | ||
| Chapter 21: Pregnancy, Childbirth, and the Puerperium (ICD-10-CM Chapter 15, Codes O00-O9A) | 261 | ||
| ABBREVIATIONS/ACRONYMS | 261 | ||
| GLOSSARY DEFINITIONS | 261 | ||
| CODING | 261 | ||
| CASE SCENARIOS | 262 | ||
| CASE STUDIES | 263 | ||
| 21-1. CASE STUDY | 263 | ||
| History and Physical | 263 | ||
| OB Delivery Summary | 264 | ||
| Membranes Monitoring | 265 | ||
| Delivery Information | 265 | ||
| Episiotomy/Laceration Information | 265 | ||
| Delivery Diagnosis | 266 | ||
| Delivery Procedures | 266 | ||
| Discharge Summary | 266 | ||
| Procedures | 266 | ||
| History, Major Findings, and Hospital Course | 267 | ||
| Discharge Instructions | 268 | ||
| Follow-up Care | 268 | ||
| Progress Notes | 268 | ||
| Day 1 | 268 | ||
| Day 2 | 268 | ||
| CASE STUDY QUESTIONS | 268 | ||
| 21-2. CASE STUDY | 269 | ||
| History and Physical | 269 | ||
| Physical Examination | 269 | ||
| OB/Delivery Summary | 270 | ||
| Membranes/Monitoring | 270 | ||
| Delivery Information | 270 | ||
| Delivery/Diagnosis | 271 | ||
| Delivery Procedures | 271 | ||
| Discharge Summary | 271 | ||
| Diagnoses/Problems | 271 | ||
| Procedures | 271 | ||
| History, Major Findings, and Hospital Course | 272 | ||
| Discharge Instructions | 273 | ||
| Follow-up Care | 273 | ||
| Operative Report | 273 | ||
| Surgeon’s Narrative | 273 | ||
| Operative Report | 274 | ||
| Surgeon’s Narrative | 274 | ||
| Progress Notes | 275 | ||
| Day 1 | 275 | ||
| Day 2 | 275 | ||
| Day 3 | 275 | ||
| Day 4 | 276 | ||
| Day 5 | 276 | ||
| Day 6 | 276 | ||
| CASE STUDY QUESTIONS | 276 | ||
| 21-3. CASE STUDY | 277 | ||
| History and Physical | 277 | ||
| Discharge Summary | 278 | ||
| Diagnoses/Problems | 278 | ||
| Procedures | 278 | ||
| History, Major Findings, and Hospital Course | 278 | ||
| Discharge Instructions | 279 | ||
| Follow-up Care | 279 | ||
| Ultrasound Examination | 279 | ||
| Examination Indications | 279 | ||
| General Results | 279 | ||
| Fetal Doppler Studies | 280 | ||
| Social Work Progress Note | 280 | ||
| Progress Notes | 280 | ||
| Day 1 | 280 | ||
| Day 2 | 281 | ||
| Day 3 | 281 | ||
| Day 4 | 281 | ||
| Day 5 | 281 | ||
| Day 6 | 281 | ||
| Day 7 | 281 | ||
| Day 8 | 281 | ||
| CASE STUDY QUESTIONS | 281 | ||
| Chapter 22: Certain Conditions Originating in the Perinatal Period and Congenital Malformations, Deformations, and Chromos ... | 283 | ||
| ABBREVIATIONS/ACRONYMS | 283 | ||
| GLOSSARY DEFINITIONS | 283 | ||
| CODING | 283 | ||
| CASE SCENARIOS | 284 | ||
| CASE STUDIES | 285 | ||
| 22-1. CASE STUDY | 285 | ||
| History and Physical Examination | 285 | ||
| Discharge Summary | 286 | ||
| Procedures | 286 | ||
| History, Major Findings, and Hospital Course | 286 | ||
| Angio Carotid Cerebral Bilat | 286 | ||
| Progress Note | 287 | ||
| CASE STUDY QUESTIONS | 287 | ||
| 22-2. CASE STUDY | 288 | ||
| Admission Examination | 288 | ||
| Discharge Examination | 289 | ||
| Circumcision Note | 289 | ||
| Discharge Summary | 289 | ||
| Diagnoses/Problems | 289 | ||
| Procedures | 289 | ||
| History, Major Findings, and Hospital Course | 289 | ||
| Discharge Instructions | 290 | ||
| Follow-up Care | 290 | ||
| CASE STUDY QUESTIONS | 290 | ||
| 22-3. CASE STUDY | 291 | ||
| Admission Examination | 291 | ||
| Discharge Examination | 291 | ||
| Discharge Summary | 291 | ||
| Diagnoses/Problems | 291 | ||
| Procedures | 292 | ||
| History, Major Findings, and Hospital Course | 292 | ||
| Discharge Instructions | 292 | ||
| Follow-up Care | 292 | ||
| CASE STUDY QUESTIONS | 292 | ||
| Chapter 23: Injury and Certain Other Consequences of External Causes and External Causes of Morbidity (ICD-10-CM Chapter 1 ... | 295 | ||
| ABBREVIATIONS/ACRONYMS | 295 | ||
| GLOSSARY DEFINITIONS | 295 | ||
| CODING | 296 | ||
| CASE SCENARIOS | 297 | ||
| CASE STUDIES | 299 | ||
| 23-1. CASE STUDY | 299 | ||
| History and Physical | 299 | ||
| Discharge Summary | 299 | ||
| Diagnoses/Problems | 299 | ||
| Procedures | 299 | ||
| History, Major Findings, and Hospital Course | 299 | ||
| Discharge Instructions | 300 | ||
| Follow-up Care | 300 | ||
| Brain Without IV Contrast CT | 300 | ||
| CT of the Maxillofacial Bones With Contrast | 300 | ||
| CT Cervical Spine Without Contrast | 300 | ||
| Progress Note | 301 | ||
| CASE STUDY QUESTIONS | 301 | ||
| 23.2. CASE STUDY | 302 | ||
| History and Physical | 302 | ||
| Operative Report | 302 | ||
| Surgeon’s Narrative | 303 | ||
| Discharge Summary | 304 | ||
| Diagnoses/Problems | 304 | ||
| Procedures | 304 | ||
| History, Major Findings, and Hospital Course | 304 | ||
| Discharge Instructions | 305 | ||
| Follow-up Care | 305 | ||
| Pelvis and Hip, Right | 305 | ||
| Tibia and Fibula, Right | 305 | ||
| Progress Notes | 305 | ||
| Day 1 | 305 | ||
| Day 2 | 305 | ||
| Day 3 | 306 | ||
| Day 4 | 306 | ||
| CASE STUDY QUESTIONS | 306 | ||
| 23-3. CASE STUDY | 307 | ||
| History and Physical | 307 | ||
| Discharge Summary | 307 | ||
| Diagnoses/Problems | 307 | ||
| Procedures | 308 | ||
| History, Major Findings, and Hospital Course | 308 | ||
| Progress Note | 308 | ||
| CASE STUDY QUESTIONS | 308 | ||
| Chapter 24: Burns, Adverse Effects, and Poisonings (ICD-10-CM Chapters 19 and 20, Codes S00-Y99) | 311 | ||
| ABBREVIATIONS/ACRONYMS | 311 | ||
| GLOSSARY DEFINITIONS | 311 | ||
| CODING | 312 | ||
| CASE SCENARIOS | 313 | ||
| CASE STUDIES | 315 | ||
| 24-1. CASE STUDY | 315 | ||
| History and Physical | 315 | ||
| Discharge Summary | 316 | ||
| Diagnoses/Problems | 316 | ||
| Procedures | 316 | ||
| History, Major Findings, and Hospital Course | 316 | ||
| Progress Note | 316 | ||
| CASE STUDY QUESTIONS | 316 | ||
| 24-2. CASE STUDY | 317 | ||
| Clinic Note/History and Physical | 317 | ||
| Discharge Summary | 318 | ||
| Diagnoses/Problems | 318 | ||
| Procedures | 318 | ||
| History, Major Findings, and Hospital Course | 318 | ||
| Hospital Course by System | 319 | ||
| Chest PA and Lateral | 320 | ||
| Progress Note | 320 | ||
| CASE STUDY QUESTIONS | 320 | ||
| 24-3. CASE STUDY | 321 | ||
| History and Physical | 321 | ||
| Discharge Summary | 322 | ||
| Diagnoses/Problems | 322 | ||
| Procedures | 322 | ||
| History, Major Findings, and Hospital Course | 322 | ||
| Hospital Course by System | 323 | ||
| Discharge Instructions | 323 | ||
| Follow-up Care | 323 | ||
| Progress Notes | 323 | ||
| Day 1 | 323 | ||
| Day 2 | 324 | ||
| CASE STUDY QUESTIONS | 324 | ||
| Chapter 25: Complications of Surgical and Medical Care | 325 | ||
| ABBREVIATIONS/ACRONYMS | 325 | ||
| GLOSSARY DEFINITIONS | 325 | ||
| CODING | 325 | ||
| CASE SCENARIOS | 326 | ||
| CASE STUDIES | 327 | ||
| 25-1. CASE STUDY | 327 | ||
| History and Physical | 327 | ||
| Review of Systems | 328 | ||
| Physical Examination | 328 | ||
| Discharge Summary | 328 | ||
| Diagnoses/Problems | 328 | ||
| Procedures | 328 | ||
| History, Major Findings, and Hospital Course | 328 | ||
| Progress Notes | 329 | ||
| Day 1 | 329 | ||
| Day 2 | 329 | ||
| CASE STUDY QUESTIONS | 329 | ||
| 25-2. CASE STUDY | 330 | ||
| History and Physical | 330 | ||
| Discharge Summary | 331 | ||
| Diagnoses/Problems | 331 | ||
| Procedures | 331 | ||
| History, Major Findings, and Hospital Course | 331 | ||
| Discharge Instructions | 332 | ||
| Follow-up Care | 332 | ||
| Abscess Drain Cath. Placement | 332 | ||
| CT Abd and Pelvis With Contrast | 333 | ||
| Progress Notes | 333 | ||
| Day 1 | 333 | ||
| Day 2 | 333 | ||
| Day 3 | 333 | ||
| Day 4 | 333 | ||
| CASE STUDY QUESTIONS | 334 | ||
| 25-3. CASE STUDY | 335 | ||
| History and Physical | 335 | ||
| Discharge Summary | 336 | ||
| Diagnoses/Problems | 336 | ||
| Procedures | 336 | ||
| History, Major Findings, and Hospital Course | 336 | ||
| Discharge Instructions | 337 | ||
| Follow-up Care | 337 | ||
| Pediatric Inpatient Hematology Consultation | 337 | ||
| Duplex Scan, Ven lt Low Ext | 339 | ||
| Ultrasound, Single Quad | 339 | ||
| Mechanical Thrombolysis | 339 | ||
| Angio: Infusion/embolized | 340 | ||
| Progress Notes | 341 | ||
| Day 1 | 341 | ||
| Day 2 | 341 | ||
| Day 3 | 341 | ||
| Day 4 | 341 | ||
| CASE STUDY QUESTIONS | 342 | ||
| Chapter 26: Reimbursement Methodologies | 343 | ||
| ABBREVIATIONS/ACRONYMS | 343 | ||
| GLOSSARY DEFINITIONS | 343 | ||
| MULTIPLE CHOICE/SHORT ANSWER | 344 | ||
| Chapter 27: Outpatient Coding | 347 | ||
| ABBREVIATIONS/ACRONYMS | 347 | ||
| GLOSSARY DEFINITIONS | 347 | ||
| CODING | 347 | ||
| CASE SCENARIOS | 348 | ||
| Additional Practice Exercises | 351 | ||
| CASE SCENARIOS | 351 | ||
| Home Health | 351 | ||
| CASE SCENARIOS | 352 | ||
| Mental Health | 352 | ||
| CASE SCENARIOS | 353 | ||
| Rehabilitation/Nursing Home | 353 | ||
| CASE SCENARIOS | 354 | ||
| CASE STUDIES | 357 | ||
| 18. CASE STUDY | 357 | ||
| Title of Operation | 357 | ||
| Indications for Surgery | 357 | ||
| Preoperative Diagnosis | 357 | ||
| Postoperative Diagnosis | 357 | ||
| Anesthesia | 357 | ||
| Prosthetic Device/Implant | 357 | ||
| Surgeons Narrative | 357 | ||
| 19. CASE STUDY | 358 | ||
| Title of Operation | 358 | ||
| Indications for Surgery | 358 | ||
| Preoperative Diagnosis | 358 | ||
| Postoperative Diagnosis | 358 | ||
| Anesthesia | 358 | ||
| Prosthetic Device/Implant | 358 | ||
| Surgeon's Narrative | 358 | ||
| 20. CASE STUDY | 359 | ||
| Title of Operation | 359 | ||
| Indications for Surgery | 359 | ||
| Preoperative Diagnosis | 359 | ||
| Postoperative Diagnosis | 359 | ||
| Surgeon's Narrative | 359 | ||
| 21. CASE STUDY | 360 | ||
| Title of Operation | 360 | ||
| Indications for Surgery | 360 | ||
| Preoperative Diagnosis | 360 | ||
| Postoperative Diagnosis | 360 | ||
| Anesthesia | 360 | ||
| Specimen (Bacteriologic, Pathologic, or Other) | 360 | ||
| Surgeon's Narrative | 361 | ||
| 22. CASE STUDY | 361 | ||
| Title of Operation | 361 | ||
| Indications for Surgery | 361 | ||
| Preoperative Diagnosis | 361 | ||
| Postoperative Diagnosis | 361 | ||
| Anesthesia | 362 | ||
| Specimen (Bacteriologic, Pathologic, or Other) | 362 | ||
| Surgeon's Narrative | 362 | ||
| 23. CASE STUDY | 363 | ||
| Title of Operation | 363 | ||
| Indications for Surgery | 363 | ||
| Preoperative Diagnosis | 363 | ||
| Postoperative Diagnosis | 363 | ||
| Anesthesia | 363 | ||
| Specimen (Bacteriologic, Pathologic, or Other) | 363 | ||
| Prosthetic Device/Implant | 363 | ||
| Pathology | 364 | ||
| Cultures | 364 | ||
| Drain | 364 | ||
| Surgeon's Narrative | 364 | ||
| 24. CASE STUDY | 365 | ||
| Title of Operation | 365 | ||
| Indications for Surgery | 365 | ||
| Preoperative Diagnosis | 365 | ||
| Postoperative Diagnosis | 365 | ||
| Anesthesia | 365 | ||
| Specimen (Bacteriologic, Pathologic, or Other) | 365 | ||
| Prosthetic Device/Implant | 365 | ||
| Surgeon's Narrative | 365 | ||
| 25. CASE STUDY | 366 | ||
| Title of Operation | 366 | ||
| Indications for Surgery | 366 | ||
| Preoperative Diagnosis | 366 | ||
| Postoperative Diagnosis | 366 | ||
| Surgeon's Narrative | 366 | ||
| 26. CASE STUDY | 367 | ||
| Title of Operation | 367 | ||
| Indications for Surgery | 367 | ||
| Preoperative Diagnosis | 367 | ||
| Postoperative Diagnosis | 367 | ||
| Surgeon's Narrative | 367 | ||
| 27. CASE STUDY | 368 | ||
| Title of Operation | 368 | ||
| Indications for Surgery | 368 | ||
| Preoperative Diagnosis | 368 | ||
| Postoperative Diagnosis | 368 | ||
| Anesthesia | 368 | ||
| Specimen (Bacteriologic, Pathologic, or Other) | 368 | ||
| Prosthetic Device/Implant | 368 | ||
| Surgeon's Narrative | 368 | ||
| 28. CASE STUDY | 369 | ||
| Title of Operation | 369 | ||
| Preoperative Diagnosis | 369 | ||
| Postoperative Diagnosis | 369 | ||
| Anesthesia | 369 | ||
| Surgeon's Narrative | 369 | ||
| 29. CASE STUDY | 370 | ||
| Title of Operation | 370 | ||
| Indications for Surgery | 370 | ||
| Preoperative Diagnosis | 370 | ||
| Postoperative Diagnosis | 370 | ||
| Anesthesia | 370 | ||
| Prosthetic Device/Implant | 370 | ||
| Surgeon's Narrative | 370 | ||
| 30. CASE STUDY | 372 | ||
| Title of Operation | 372 | ||
| Indications for Surgery | 372 | ||
| Preoperative Diagnosis | 372 | ||
| Postoperative Diagnosis | 372 | ||
| Anesthesia | 372 | ||
| Specimen (Bacteriologic, Pathologic, and Other) | 372 | ||
| Prosthetic Device/Implant | 372 | ||
| Surgeon's Narrative | 372 | ||
| 31. CASE STUDY | 373 | ||
| Title of Operation | 373 | ||
| Indications for Surgery | 373 | ||
| Preoperative Diagnosis | 373 | ||
| Postoperative Diagnosis | 373 | ||
| Anesthesia | 373 | ||
| Specimen (Bacteriologic, Pathologic, or Other) | 373 | ||
| Surgeon's Narrative | 373 | ||
| 32. CASE STUDY | 374 | ||
| Title of Operation | 374 | ||
| Preoperative Diagnosis | 374 | ||
| Postoperative Diagnosis | 374 | ||
| Surgeon's Narrative | 374 | ||
| 33. CASE STUDY | 375 | ||
| Title of Operation | 375 | ||
| Indications for Surgery | 375 | ||
| Preoperative Diagnosis | 375 | ||
| Postoperative Diagnosis | 375 | ||
| Anesthesia | 375 | ||
| Specimen (Bacteriologic, Pathologic, or Other) | 375 | ||
| Surgeon's Narrative | 375 | ||
| 34. CASE STUDY | 377 | ||
| Title of Operation | 377 | ||
| Indications for Surgery | 377 | ||
| Preoperative Diagnosis | 377 | ||
| Postoperative Diagnosis | 377 | ||
| Anesthesia | 377 | ||
| Specimen (Bacteriologic, Pathologic, or Other) | 377 | ||
| Surgeon's Narrative | 377 | ||
| 35. CASE STUDY | 378 | ||
| Title of Operation | 378 | ||
| Indications for Surgery | 378 | ||
| Preoperative Diagnosis | 378 | ||
| Postoperative Diagnosis | 378 | ||
| Anesthesia | 378 | ||
| Specimen (Bacteriologic, Pathologic, or Other) | 379 | ||
| Surgeon's Narrative | 379 | ||
| 36. CASE STUDY | 380 | ||
| Title of Operation | 380 | ||
| Indications for Surgery | 380 | ||
| Preoperative Diagnosis | 380 | ||
| Postoperative Diagnosis | 380 | ||
| Anesthesia | 380 | ||
| Specimen (Bacteriologic, Pathologic, or Other) | 380 | ||
| Prosthetic Device/Implant | 380 | ||
| Surgeon's Narrative | 380 | ||
| 37. CASE STUDY | 381 | ||
| Electrophysiology Procedure Report | 381 | ||
| Procedure Performed | 381 | ||
| History | 381 | ||
| Procedure Description | 382 | ||
| Complications | 382 | ||
| Procedure Data | 383 | ||
| Case Medications | 383 | ||
| Contrast | 383 | ||
| Vital Signs | 383 | ||
| Devices | 383 | ||
| Generator | 383 | ||
| Upper Extremity Venogram | 383 | ||
| Vascular Access | 383 | ||
| Guidance Methods, Needles, and Wires | 384 | ||
| PPM/ICD System Revision | 384 | ||
| Indication(s) | 384 | ||
| Summary Findings | 384 | ||
| Revision Procedures (in order) | 384 | ||
| Generator Pacing Parameters | 384 | ||
| Leads | 385 | ||
| Final Defibrillation Threshold | 385 | ||
| Final Zone Settings | 386 | ||
| Inside Back Cover | ES3 |