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Step-by-Step Medical Coding, 2016 Edition - E-Book

Step-by-Step Medical Coding, 2016 Edition - E-Book

Carol J. Buck

(2015)

Additional Information

Book Details

Abstract

Take your first step toward a successful career in medical coding with guidance from the most trusted name in coding education! From bestselling author Carol J. Buck, Step-by-Step Medical Coding, 2016 Edition is a practical, easy-to-use resource that shows you exactly how to code using all current coding sets. Practice exercises follow each ‘step’ of information to reinforce your understanding of important concepts. In-depth coverage includes reimbursement, ICD-10-CM, CPT, HCPCS, and inpatient coding, with an Evolve website that includes 30-day access to TruCode® Encoder Essentials. No other text so thoroughly covers all coding sets in one source!

  • 30-day access to TruCode® Encoder Essentials and practice exercises on the Evolve companion website provide additional practice and help you understand how to utilize an encoder product.
  • A step-by-step approach makes it easier to build skills and remember the material.
  • Over 475 illustrations include medical procedures and conditions to help you understand the services being coded.
  • Real-world coding reports (cleared of any confidential information) simulate the reports you will encounter as a coder and help you apply coding principles to actual cases.
  • Dual coding includes answers for both ICD-10 and ICD-9 for every exercise, chapter review, and workbook question to help you ease into the full use of ICD-10.
  • Exercises, Quick Checks, and Toolbox features reinforce coding rules and concepts, and emphasize key information.
  • From the Trenches, Coding Shots, Stop!, Caution!, Check This Out!, and CMS Rules boxes offer valuable tips and helpful advice for working in today’s medical coding field.
  • Four coding-question variations develop your coding ability and critical thinking skills, including one-code or multiple-code answers.
  • Official Guidelines for Coding and Reporting boxes allow you to read the official wording for inpatient and outpatient coding alongside in-text explanations.
  • Coders’ Index makes it easy to quickly locate specific codes.
  • Appendix with sample Electronic Health Record screenshots provides examples similar to the EHRs you will encounter in the workplace.
  • Online practice activities on Evolve include questions such as multiple choice, matching, fill-in-the-blank, and coding reports.
  • A workbook corresponds to the textbook and offers review and practice with more than 1,200 theory, practical, and report exercises (odd-numbered answers provided in appendix) to reinforce your understanding of medical coding. Available separately.
  • NEW! Separate HCPCS chapter expands coverage of the HCPCS code set.
  • UPDATED content includes the latest coding information available, promoting accurate coding and success on the job.

Table of Contents

Section Title Page Action Price
Front cover Cover
Inside front cover 1
How to use i
2016 step-by-step v
Copyright vi
Dedication vii
Acknowledgments viii
Preface ix
Organization of this textbook ix
Distinctive features of our approach x
Extensive supplemental resources xii
Student online activities xii
Student workbook xiii
Teach instructor resources on evolve xiii
Evolve learning resources xiv
30-day access to trucode® encoder essentials xiv
Step-by-step medical coding online xiv
Development of this edition xv
Introduction xviii
References xxii
Table of contents xxiii
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 act 7
Electronic transactions⁹ 8
Code sets 8
Privacy requirements 9
Security requirements 9
National provider identification 9
Federal register 10
Outpatient resource-based relative value scale (RBRVS) 12
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
Nebulizer machines and related drugs—supplier compliance with payment requirements 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 review 24
Chapter 1, part I, theory 24
Chapter 1, part II, practical 24
References 25
2 ICD-10-CM 26
2 An overview of ICD-10-CM 26
Learning objectives 26
The ICD-10-CM 27
ICD-10-CM replaces the ICD-9-CM, volumes 1 and 2 29
Improvements in the ICD-10-CM 30
Structure of the system 31
Mapping 31
Flags 32
Approximate 32
Approximate, flag 0.  32
Approximate, flag 1.  32
No map.  35
Combination.  35
Scenario and choice list.  35
ICD-10-CM format 37
Index 37
Tabular 41
Chapters 41
Chapter format.  43
Section.  43
Category.  43
Subcategory.  43
Subclassification.  43
Bold type 43
Italicized type 43
Official instructional notations in the ICD-10-CM 44
Conventions 44
Nec.  45
Nos.  45
Brackets [ ]  45
Parentheses ( )  45
Nonessential modifiers.  45
Colon :  46
And and with.  46
And.  46
With.  46
Includes 46
Excludes 47
Excludes1.  47
Excludes2.  47
Code first/use additional code 47
Code also 47
Default codes 49
7th characters and placeholder X 49
Cross-references 50
Chapter review 51
Chapter 2, part I, theory 51
Chapter 2, part II, practical 52
3 ICD-10-CM outpatient coding and reporting guidelines 55
Learning objectives 55
First-listed diagnosis 56
Unconfirmed diagnosis 58
Outpatient surgery 59
Additional diagnoses 59
Z codes 60
Status code 62
External cause index 64
Index locations 65
Circumstances to assign Z codes 66
History of 68
Observation stay 69
First-listed diagnosis and coexisting conditions 70
Uncertain diagnoses 71
Chronic diseases 73
Documented conditions 73
Diagnostic services 74
Therapeutic services 75
Preoperative evaluation 76
Preoperative evaluations only 77
Prenatal visits 78
Chapter review 80
Chapter 3, part I, theory 80
Chapter 3, part II, practical 81
4 Using ICD-10-CM 82
Learning objectives 82
Organization of the guidelines 83
Accurate coding 83
Alphabetic index and tabular list 83
Level of specificity 85
Integral conditions 87
Multiple coding 89
Acute and chronic 91
Combination codes 93
Late effects 95
Reporting same diagnosis code more than once 97
Laterality 98
Chapter review 100
Chapter 4, part I, theory 100
Chapter 4, part II, practical 101
5 Chapter-specific guidelines (ICD-10-CM chapters 1-10) 102
Learning objectives 102
Certain infectious and parasitic diseases 103
Resistant infections 104
A codes (A00-A99) 104
Sepsis, severe sepsis, and septic shock 105
B codes (B00-B99) 108
Viral hepatitis 108
Human immunodeficiency 109
Neoplasms 111
Neoplasm classifications and staging 116
Sequencing and complications.  117
History of Z codes. 119
Unknown or unspecified site.  120
Diseases of the blood and blood-forming organs and certain disorders involving the immune mechanism 121
Anemia 122
Coagulation defects, purpura, and other hemorrhagic conditions 123
Other disorders of blood and blood-forming organs (D70-D77) 124
Endocrine, nutritional, and metabolic diseases 124
Mental, behavioral and neurodevelopmental disorders 128
Dementia 129
Substance use 129
Psychological disorders 129
Psychological pain 130
Diseases of the nervous system 131
Pain (non-psychological) 131
Dominant and nondominant sides 131
Diseases of the eye and adnexa 136
Hordeolum and chalazion 136
Entropion and ectropion 137
Lacrimal system 138
Diseases of the ear and mastoid process 138
Ear 139
External ear.  139
Middle ear and mastoid.  139
Inner ear.  140
Diseases of the circulatory system 140
Hypertension 140
Kidney disease and hypertension 144
Myocardial infarction 144
Diseases of the respiratory system 147
Chapter review 150
Chapter 5, part I, theory 150
Chapter 5, part II, practical 150
Case study 1 151
History of present illness 151
Course in hospital 151
Discharge diagnoses 151
Matching 151
6 Chapter-specific guidelines (ICD-10-CM chapters 11-14) 152
Learning objectives 152
Diseases of the digestive system 153
Hemorrhage 153
Diseases of the skin and subcutaneous tissue 154
Ulcers 156
Diseases of the musculoskeletal system and connective tissue 158
Infectious arthropathies 159
M00 reports direct infection from a known organism.  160
M01 reports direct infection of the joint due to infectious or parasitic disease that is classified elsewhere.  161
M02 reports indirect infections from an unknown organism.  161
Pathological fractures 162
Diseases of the genitourinary system 164
Chapter review 165
Chapter 6, part I, theory 165
Chapter 6, part II, practical 166
7 Chapter-specific guidelines (ICD-10-CM chapters 15-21) 167
Learning objectives 167
Pregnancy, childbirth, and the puerperium 168
General rules of obstetric diagnosis reporting 168
First-listed diagnosis in normal pregnancy 168
First-listed diagnosis in high-risk patients 168
First-listed diagnosis for delivery 168
Trimesters 168
Peripartum and postpartum periods 168
Normal delivery 168
Ectopic pregnancy 173
Hydatidiform mole 173
Hypertension in pregnancy 173
Fetal conditions 173
Diabetes mellitus in pregnancy 173
Certain conditions originating in the perinatal period 177
First-listed diagnosis 177
Congenital malformations, deformations and chromosomal abnormalities 178
Symptoms, signs, and abnormal clinical and laboratory findings, not elsewhere classified 181
Injury, poisoning, and certain other consequences of external causes 185
Code extensions 185
Coding injuries 185
Coding fractures 189
Coding burns and corrosions 189
Coding adverse effects, poisoning, underdosing, and toxic effects 189
Abuse, neglect, and other maltreatment 189
Open wounds, lacerations, and punctures 199
Complications 201
Medical device, graft, or implant.  202
Transplant.  202
Chapter review 204
Chapter 7, part I, theory 204
Chapter 7, part II, practical 205
3 CPT and HCPCS 206
8 Introduction to CPT 206
Learning objectives 206
The purpose of the CPT manual 207
Updating the CPT manual 207
CPT manual format 209
Important symbols and appendices 209
CPT sections 213
CPT guidelines 215
Code format 216
Modifiers 218
Unlisted procedures 219
Category II codes 220
Category III codes 222
Format of category III codes.  222
Publication of category III codes.  223
Special reports 223
Starting with the index 223
Locating the terms 223
Single code 223
Multiple codes 224
Range of codes 224
See 224
Chapter review 228
Chapter 8, part I, theory 228
Chapter 8, part II, practical 229
9 Introduction to the level II national codes (HCPCS) 230
Learning objectives 230
History of national level codes 231
Two levels of codes 231
Code groupings 232
Temporary procedure/professional services.  232
Updating the hcpcs manual 234
Hcpcs format 234
Index 234
Alphanumeric listing 235
General rules 235
Modifiers 236
Table of drugs 236
Routes of administration of drugs.  237
Durable medical equipment 238
National physician fee schedule 241
Chapter review 243
Chapter 9, part I, theory 243
Chapter 9, part II, practical 244
10 Modifiers 245
Learning objectives 245
CPT modifiers 246
-22, increased procedural services 247
-23, unusual anesthesia 248
-24, unrelated evaluation and management service by the same physician or other qualified health care professional during ... 249
-25, significant separately identifiable E/M service by the same physician or other qualified health care professional on ... 249
-26, professional component 250
-32, mandated services 252
-33, preventive service 252
-47, anesthesia by surgeon 252
-50, bilateral procedures 252
-51, multiple procedures 253
Same operation, different site.  254
Multiple operation(s), same operative session.  254
Procedure performed multiple times.  255
-52, reduced services 257
-53, discontinued procedure 259
Modifiers -54, -55, and -56 259
-54, surgical care only 260
-55, postoperative management only 260
-56, preoperative management only 261
-57, decision for surgery 261
-58, staged or related procedure or service by the same physician or other qualified health care professional during the p ... 262
-59, distinct procedural service 263
Modifiers -X{EPSU}  263
-62, two surgeons 264
-63, procedure performed on infants less than 4 kg 265
-66, surgical team 265
-76, repeat procedure or service by same physician or other qualified health care professional 266
-77, repeat procedure by another physician or other qualified health care professional 266
-78, unplanned return to the operating/procedure room by the same physician or other qualified health care professional fo ... 267
-79, unrelated procedure or service by the same physician or other qualified health care professional during the postopera ... 268
-80, assistant surgeon 268
-81, minimum assistant surgeon 269
-82, assistant surgeon (when qualified resident surgeon not available) 269
-90, reference (outside) laboratory 270
-91, repeat clinical diagnostic laboratory test 271
-92, alternative laboratory platform testing 271
-99, multiple modifiers 271
Chapter review 272
Chapter 10, part I, theory 272
Chapter 10, part II, practical 273
11 Evaluation and management (E/M) services 274
Learning objectives 274
Contents of the E/M section 275
Three factors of E/M codes 275
Place of service 275
Type of service 276
Patient status 276
Medical records documentation 277
Various levels of E/M service 278
Key components 278
Office, new patient 278
History.  279
Examination.  285
Examination levels.  285
Examination levels 285
Medical decision making.  289
Levels.  290
Medical decision-making complexity levels 290
Management options.  290
Data to be reviewed.  290
Risk.  291
Contributory factors 296
Counseling.  296
Coordination of care.  296
Nature of the presenting problem.  297
An E/M code example 298
Using the e/m codes 299
Office and other outpatient services 299
New patient.  299
Established patient.  301
Hospital observation services 303
Observation care discharge services.  303
Initial observation care.  303
Subsequent observation care.  304
Hospital inpatient services 305
Initial hospital care.  305
Subsequent hospital care.  306
Observation or inpatient care services (including admission and discharge services).  307
Hospital discharge services.  307
Consultation services 308
Office or other outpatient consultations.  309
Inpatient consultations.  310
Emergency department services 314
Other emergency department services.  314
Critical care services 315
Nursing facility services 317
Initial nursing facility care.  318
Subsequent nursing facility care.  318
Nursing facility discharge services.  318
Other nursing facility services.  318
Domiciliary, rest home (e.g., boarding home), or custodial care services 320
Domiciliary, rest home (e.g., assisted living facility), or home care plan oversight services 320
Home services 320
Prolonged services 321
Prolonged physician services with or without direct patient contact.  321
Standby services.  322
Case management services 323
Anticoagulant management.  323
Medical team conferences.  323
Care plan oversight services 324
Preventive medicine services 324
Counseling risk factor reduction and behavior change intervention.  325
Non-face-to-face services 325
Special evaluation and management services 325
Newborn care services 326
Inpatient neonatal intensive care and pediatric and neonatal critical care services (99466-99486) 326
Pediatric critical care patient transport.  326
Inpatient neonatal and pediatric critical care.  327
Initial and continuing intensive care services.  327
Care management services (99487-99490) 328
Chronic care management services (99490)  328
Complex chronic care management services (99487, 99489)  328
Transitional care management services (99495-99496) 328
Advance care planning (99497-99498) 328
Other evaluation and management services 328
Coding practice 328
Documentation guidelines 330
History of the development of guidelines 330
Chapter review 333
Chapter 11, part I, theory 333
Chapter 11, part II, practical 334
12 Anesthesia 336
Learning objectives 336
Types of anesthesia 337
Moderate (conscious) sedation 339
Anesthesia section format 340
Formula for anesthesia payment 341
B is for base unit 342
CMS’s base units.  343
T is for time 344
M is for modifying unit 345
Qualifying circumstances.  345
Physical status modifiers.  348
Summing it up! 349
Conversion factor.  350
Multiple procedures 350
Concurrent modifiers 351
Unlisted anesthesia code 352
Other reporting 354
Return to operating room 354
Pre-anesthetic examination 354
Chapter review 355
Chapter 12, part I, theory 355
Chapter 12, part II, practical 356
13 Surgery guidelines and general surgery 357
Learning objectives 357
Introduction to the surgery section 358
Notes and guidelines 358
Unlisted procedures 361
Special reports 362
Separate procedure 362
Surgical package 364
General subsection 367
Chapter review 369
Chapter 13, part I, theory 369
Chapter 13, part II, practical 370
14 Integumentary system 371
Learning objectives 371
Integumentary system 372
Format 372
Skin, subcutaneous, and accessory structures 373
Introduction and removal (10030-10036) 373
Incision and drainage 373
Debridement 373
Excision—debridement 374
Introduction to lesions 374
Lesion excision and destruction.  375
Closure of excision sites.  377
Paring or cutting 377
Biopsy 377
Skin tags 379
Shaving of epidermal or dermal lesions 380
Excision—benign lesions 380
Excision—malignant lesions 381
Nails 382
Pilonidal cyst 384
Introduction 384
Repair (closure) 385
Repair factors 385
Repair component 388
Tissue transfers, grafts, and flaps 388
Adjacent tissue transfer or rearrangement.  388
Skin replacement surgery (15002-15278).  389
Flaps.  391
Other procedures 393
Pressure ulcers 394
Burns 395
Destruction 398
Mohs micrographic surgery 398
Breast procedures 400
Chapter review 403
Chapter 14, part I, theory 403
Chapter 14, part II, practical 404
15 Musculoskeletal system 405
Learning objectives 405
Format 406
Fractures and dislocations 407
Fractures 407
Dislocations 411
General 412
Incision 412
Wound exploration 413
Excision 414
General introduction or removal 414
Grafts (or implants) 417
Other procedures 418
Spinal instrumentation and fixation 418
Foot and toe repairs 419
Application of casts and strapping 420
Endoscopy/arthroscopy 422
Chapter review 425
Chapter 15, part I, theory 425
Chapter 15, part II, practical 426
16 Respiratory system 427
Learning objectives 427
Format 428
Endoscopy 429
Nose 430
Incision 430
Excision 431
Introduction 432
Removal of a foreign body 433
Repair 433
Destruction 433
Other procedures 434
Accessory sinuses 435
Incision 435
Larynx 436
Excision 436
Introduction 436
Repair 437
Trachea/bronchi 438
Incision 438
Introduction 439
Excision/repair 439
Lungs and pleura 439
Incision 440
Excision 440
Removal 440
Surgical collapse therapy; thoracoplasty 442
Chapter review 443
Chapter 16, part I, theory 443
Chapter 16, part II, practical 443
17 Cardiovascular system 446
Learning objectives 446
Coding highlights 447
Coding from three sections 447
Invasive 447
Noninvasive 448
Electrophysiology 448
Nuclear cardiology 448
Cardiovascular coding in the surgery section 449
Heart and pericardium 450
Pericardium 451
Cardiac tumor 451
Transmyocardial revascularization 452
Pacemaker or implantable defibrillator 452
Approaches.  453
Electrophysiologic operative procedures 455
Patient-activated event recorder 455
Heart (including valves) and great vessels 455
Cardiac valves 455
Coronary artery anomalies 456
Coronary artery bypass 456
Extracorporeal membrane oxygenation and extracorporeal life support services 459
Arteries and veins 459
Vascular families—selective or nonselective placement 461
Embolectomy/thrombectomy 463
Vascular repairs 464
Bypass grafts 465
Vascular access 465
Vascular injection procedures 465
Cardiovascular coding in the medicine section 469
Therapeutic services and procedures 469
Cardiography and cardiovascular monitoring services 471
Implantable and wearable cardiac device evaluations 474
Echocardiography 474
Cardiac catheterization 476
Intracoronary brachytherapy 477
Intracardiac electrophysiologic procedures/studies 478
Peripheral arterial disease rehabilitation 479
Noninvasive physiologic studies and procedures 480
Other procedures 480
Cardiovascular coding in the radiology section 480
Heart 483
Aorta and arteries 483
Chapter review 485
Chapter 17, part I, theory 485
Chapter 17, part II, practical 486
18 Hemic, lymphatic, mediastinum, and diaphragm 487
Learning objectives 487
Hemic and lymphatic systems 488
Format 488
Coding highlights 489
Spleen.  489
Laparoscopy.  489
Introduction.  489
General.  489
Lymph nodes and lymphatic channels 490
Regions of neck lymph nodes.  491
Mediastinum and diaphragm 493
Mediastinum 493
Incision.  494
Excision.  494
Endoscopy.  494
Diaphragm 494
Chapter review 495
Chapter 18, part I, theory 495
Chapter 18, part II, practical 495
19 Digestive system 497
Learning objectives 497
Format 498
Lips 499
Vestibule of mouth 500
Tongue and floor of mouth 500
Dentoalveolar structures 502
Palate and uvula 502
Salivary gland and ducts 502
Pharynx, adenoids, and tonsils 504
Esophagus 506
Stomach 510
Intestines (except rectum) 511
Meckel’s diverticulum and the mesentery 513
Appendix 514
Colon and rectum 514
Endoscopy (proctosigmoidoscopy, sigmoidoscopy, and colonoscopy) 514
Proctosigmoidoscopy.  514
Sigmoidoscopy.  514
Diagnostic colonoscopy.  515
Colonoscopy.  515
Evaluation and management services reported with a diagnostic colonoscopy.  516
Colonoscopy injection.  518
Multiple procedures.  518
Virtual colonoscopy.  518
Anus 519
Liver 521
Biliary tract 522
Pancreas 522
Abdomen, peritoneum, and omentum 523
Chapter review 525
Chapter 19, part I, theory 525
Chapter 19, part II, practical 525
20 Urinary and male genital systems 527
Learning objectives 527
Urinary system 528
Kidney 528
Incision.  528
Excision.  531
Renal transplantation.  531
Introduction.  532
Repair.  532
Laparoscopy.  534
Endoscopy.  534
Kidney index locations.  534
Ureter 535
Incision/biopsy.  535
Excision.  535
Introduction.  536
Repair.  536
Laparoscopy.  536
Endoscopy.  536
Bladder 538
Incision.  538
Removal.  538
Excision.  539
Introduction.  539
Urodynamics.  540
Repair and laparoscopy.  540
Endoscopy.  540
Transurethral surgery.  541
Vesical neck and prostate.  542
Urethra 543
Incision.  543
Excision.  543
Repair.  544
Manipulation.  544
Male genital system 545
Format 545
Penis 545
Incisions.  545
Destruction.  546
Excision.  546
Introduction.  547
Repair.  547
Testis 548
Excision.  548
Exploration, repair, and laparoscopy.  548
Epididymis 548
Excision.  550
4 Inpatient Coding 694
27 Inpatient coding 694
Learning objectives 694
Differences between inpatient and outpatient coding 695
Selection of principal diagnosis 696
Symptoms, signs, and ill-defined conditions 697
Two or more interrelated conditions 698
Two or more diagnoses 699
Comparative or contrasting conditions 700
Original treatment plan not carried out 701
Complications 702
Uncertain diagnosis 703
Reporting additional diagnoses 705
Present on admission (POA) 708
Development of the ICD-10-PCS 708
The seven characters of the ICD-10-PCS 709
Character 1 identifies the section.  709
Changing characters.  710
Character 2 is the body system.  710
Character 3 is the root operation.  710
A closer look at root operations.  711
The index 712
The tabular list completes the code 712
Chapter review 720
Chapter 27, part I, theory 720
Chapter 27, part II, practical 721
ICD-9-CM 1 An overview of ICD-9-CM e
Learning objectives e
The ICD-9-CM e
ICD-9-CM format e
Format e
Tabular list, volume 1 e
Divisions e
Classification of diseases and injuries.  e
Chapter.  e
Section.  e
Category.  e
Subcategory.  e
Subclassification.  e
Bold type e
Italicized type e
Fourth and fifth-digit specificity.  e
Appendices in the tabular list, volume 1 e
Appendix A: morphology of neoplasms e
Appendix B: glossary of mental disorders e
Appendix C: drugs e
Appendix D: industrial accidents e
Appendix E: Three-digit categories e
Alphabetic index, volume 2 e
Conventions e
Nec and nos e
Nec.  e
Nos.  e
Brackets [ ]  e
Slanted brackets [ ]  e
Parentheses ( )  e
Colon :  e
Brace }  e
Includes.  e
Excludes.  e
Subcategories.  e
Codes in brackets e
And and with.  e
And e
With e
Cross references e
Use additional code.  e
Code first underlying disease.  e
Code, if applicable, any causal condition.  e
Notes e
Eponyms e
Procedures, volume 3 e
History e
Format e
Tabular list, volume 3 e
Alphabetic index, volume 3 e
Chapter review e
Chapter 1, part I, theory e
Chapter 1, part II, practical e
ICD-9-CM 2 ICD-9-CM outpatient coding and reporting guidelines e
Learning objectives e
First-listed diagnosis e
Unconfirmed diagnosis e
Outpatient surgery e
Observation stay e
Additional diagnoses e
V codes e
Index locations e
Four circumstances to assign e
Multiple gestation placenta status (V91) e
Observation e
Specificity e
Uncertain diagnosis e
Chronic diseases e
Diagnostic services e
Therapeutic services e
Surgery e
Prenatal visits e
Chapter review e
Chapter 2, part I, theory e
Chapter 2, part II, practical e
ICD-9-CM 3 Using ICD-9-CM e
Learning objectives e
Organization of the guidelines e
Level of specificity e
Integral conditions e
Multiple coding e
Acute and chronic e
Combination codes e
Late effects e
Impending or threatened condition e
Chapter Review e
Chapter 3, part I, theory e
Chapter 3, part II, practical e
ICD-9-CM 4 Chapter-specific guidelines (ICD-9-CM chapters 1-8) 1
Learning objectives 1
Infectious and parasitic diseases 2
Human immunodeficiency 3
Neoplasms 4
Neoplasm codes 5
Unknown site or unspecified 10
Endocrine, nutritional, and metabolic diseases and immunity disorders 12
Diseases of the blood and blood-forming organs 13
Mental, behavioral and neurodevelopmental disorders 15
Five-digit subclassification 15
Diseases of the nervous system and sense organs 16
Diseases of the circulatory system 18
Hypertension 18
Kidney disease and hypertension 21
Myocardial infarction 21
Diseases of the respiratory system 24
Chapter review 27
Chapter 4, part I, theory 27
Chapter 4, part II, practical 27
Case study 1 29
ICD-9-CM text exercise answers 1
Chapter 1 1
Exercise 1-1 1
Exercise 1-2 1
Exercise 1-3 1
Exercise 1-4 1
Exercise 1-5 1
Exercise 1-6 1
Exercise 1-7 1
Exercise 1-8 1
Exercise 1-9 1
Exercise 1-10 1
Exercise 1-11 1
Exercise 1-12 1
Exercise 1-13 2
Exercise 1-14 2
Exercise 1-15 2
Chapter 2 2
Exercise 2-1 2
Exercise 2-2 2
Exercise 2-3 2
Exercise 2-4 2
Exercise 2-5 2
Exercise 2-6 2
Exercise 2-7 2
Exercise 2-8 2
Exercise 2-9 2
Chapter 3 3
Exercise 3-1 3
Exercise 3-2 3
Exercise 3-3 3
Exercise 3-4 3
Exercise 3-5 3
Exercise 3-6 3
Exercise 3-7 3
Chapter 4 3
Exercise 4-1 3
Exercise 4-2 3
Exercise 4-3 3
Exercise 4-4 4
Exercise 4-5 4
Exercise 4-6 4
Exercise 4-7 4
Exercise 4-8 4
Exercise 4-9 4
Exercise 4-10 4
Chapter 5 4
Exercise 5-1 4
Exercise 5-2 4
Exercise 5-3 4
Exercise 5-4 4
Exercise 5-5 4
Exercise 5-6 5
Exercise 5-7 5
Exercise 5-8 5
Exercise 5-9 5
Exercise 5-10 5
Exercise 5-11 5
ICD-9-CM 5 Chapter-specific guidelines (ICD-9-CM chapters 9-17) 1
Learning objectives 1
Diseases of the digestive system 2
Diseases of the genitourinary system 2
Complications of pregnancy, childbirth, and the puerperium 5
Diseases of the skin and subcutaneous tissue 11
Diseases of the musculoskeletal system and connective tissue 12
Congenital anomalies and certain conditions originating in the perinatal period 14
Symptoms, signs, and ill-defined conditions 18
Injury and poisoning 19
Alphabetic index to external causes (E code) 23
Table of drugs and chemicals 25
Adverse effects 27
Burns 32
Fractures 36
Wounds 38
Complications 39
Chapter review 40
Chapter 5, part I, theory 40
Chapter 5, part II, practical 41
Case study 1 42
History of present illness 42
Physical examination 42
Laboratory data and course in hospital 42
Treatment 43
Final diagnosis 43
Procedure 43
ICD-9-CM quick check answers e
Chapter 1 e
Quick check 1-1 e
Quick check 1-2 e
Chapter 2 e
Quick check 2-1 e
Quick check 2-2 e
Chapter 3 e
Quick check 3-1 e
Chapter 4 e
Quick check 4-1 e
APPENDIX A Online resources 722
APPENDIX B Exercise answers 723
Chapter 1 723
Exercise 1-1 723
Exercise 1-2 723
Exercise 1-3 723
Exercise 1-4 723
Chapter 2 723
Exercise 2-1 723
Exercise 2-2 723
Exercise 2-3 723
Exercise 2-4 723
Exercise 2-5 723
Exercise 2-6 723
Chapter 3 723
Exercise 3-1 723
Exercise 3-2 723
Exercise 3-3 723
Exercise 3-4 724
Exercise 3-5 724
Exercise 3-6 724
Exercise 3-7 724
Exercise 3-8 724
Exercise 3-9 724
Exercise 3-10 724
Exercise 3-11 724
Exercise 3-12 724
Chapter 4 724
Exercise 4-1 724
Exercise 4-2 724
Exercise 4-3 724
Exercise 4-4 725
Exercise 4-5 725
Chapter 5 725
Exercise 5-1 725
Exercise 5-2 725
Exercise 5-3 725
Exercise 5-4 725
Exercise 5-5 725
Exercise 5-6 725
Exercise 5-7 725
Exercise 5-8 726
Exercise 5-9 726
Exercise 5-10 726
Exercise 5-11 726
Exercise 5-12 726
Chapter 6 726
Exercise 6-1 726
Exercise 6-2 726
Exercise 6-3 726
Chapter 7 726
Exercise 7-1 726
Exercise 7-2 726
Exercise 7-3 726
Exercise 7-4 726
Exercise 7-5 727
Exercise 7-6 727
Exercise 7-7 727
Chapter 8 727
Exercise 8-1 727
Exercise 8-2 727
Exercise 8-3 727
Exercise 8-4 727
Exercise 8-5 727
Exercise 8-6 727
Exercise 8-7 727
Exercise 8-8 727
Exercise 8-9 727
Exercise 8-10 727
Chapter 9 727
Exercise 9-1 727
Exercise 9-2 728
Chapter 10 728
Exercise 10-1 728
Exercise 10-2 728
Exercise 10-3 728
Exercise 10-4 728
Exercise 10-5 728
Chapter 11 728
Exercise 11-1 728
Exercise 11-2 729
Exercise 11-3 729
Exercise 11-4 729
Exercise 11-5 729
Exercise 11-6 729
Exercise 11-7 730
Exercise 11-8 730
Exercise 11-9 730
Exercise 11-10 730
Exercise 11-11 730
Exercise 11-12 730
Exercise 11-13 731
Exercise 11-14 731
Exercise 11-15 731
Exercise 11-16 731
Exercise 11-17 731
Exercise 11-18 731
Exercise 11-19 731
Exercise 11-20 732
Exercise 11-21 732
Exercise 11-22 732
Chapter 12 732
Exercise 12-1 732
Exercise 12-2 732
Exercise 12-3 732
Exercise 12-4 732
Chapter 13 732
Exercise 13-1 732
Exercise 13-2 732
Exercise 13-3 732
Chapter 14 733
Exercise 14-1 733
Exercise 14-2 733
Exercise 14-3 733
Exercise 14-4 733
Chapter 15 733
Exercise 15-1 733
Exercise 15-2 733
Exercise 15-3 734
Exercise 15-4 734
Chapter 16 734
Exercise 16-1 734
Exercise 16-2 734
Exercise 16-3 734
Exercise 16-4 734
Exercise 16-5 734
Exercise 16-6 734
Chapter 17 734
Exercise 17-1 734
Exercise 17-2 734
Exercise 17-3 735
Exercise 17-4 735
Exercise 17-5 735
Exercise 17-6 735
Exercise 17-7 735
Exercise 17-8 735
Exercise 17-9 735
Exercise 17-10 735
Chapter 18 735
Exercise 18-1 735
Exercise 18-2 736
Chapter 19 736
Exercise 19-1 736
Exercise 19-2 736
Exercise 19-3 736
Exercise 19-4 736
Exercise 19-5 736
Chapter 20 736
Exercise 20-1 736
Exercise 20-2 736
Exercise 20-3 736
Exercise 20-4 737
Exercise 20-5 737
Exercise 20-6 737
Exercise 20-7 737
Exercise 20-8 737
Chapter 21 737
Exercise 21-1 737
Exercise 21-2 737
Chapter 22 737
Exercise 22-1 737
Exercise 22-2 737
Chapter 23 737
Exercise 23-1 737
Exercise 23-2 737
Exercise 23-3 738
Chapter 24 738
Exercise 24-1 738
Exercise 24-2 738
Exercise 24-3 738
Exercise 24-4 738
Exercise 24-5 738
Exercise 24-6 738
Exercise 24-7 738
Exercise 24-8 738
Exercise 24-9 738
Exercise 24-10 738
Exercise 24-11 739
Exercise 24-12 739
Chapter 25 739
Exercise 25-1 739
Exercise 25-2 739
Exercise 25-3 739
Exercise 25-4 739
Exercise 25-5 739
Exercise 25-6 739
Exercise 25-7 739
Exercise 25-8 739
Chapter 26 740
Exercise 26-1 740
Exercise 26-2 740
Exercise 26-3 740
Exercise 26-4 740
Exercise 26-5 741
Exercise 26-6 741
Exercise 26-7 741
Exercise 26-8 741
Exercise 26-9 741
Exercise 26-10 741
Exercise 26-11 741
Exercise 26-12 741
Exercise 26-13 741
Exercise 26-14 742
Exercise 26-15 742
Exercise 26-16 742
Exercise 26-17 742
Chapter 27 742
Exercise 27-1 742
Exercise 27-2 742
Exercise 27-3 742
Exercise 27-4 742
Exercise 27-5 742
Exercise 27-6 743
Exercise 27-7 743
Exercise 27-8 743
Exercise 27-9 743
Exercise 27-10 743
Exercise 27-11 743
Exercise 27-12 743
Exercise 27-13 743
Exercise 27-14 743
APPENDIX C Quick check answers 744
Chapter 1 744
Quick check 1-1 744
Chapter 2 744
Quick check 2-1 744
Quick check 2-2 744
Quick check 2-3 744
Chapter 3 744
Quick check 3-1 744
Quick check 3-2 744
Chapter 4 744
Quick check 4-1 744
Quick check 4-2 744
Chapter 5 744
Quick check 5-1 744
Quick check 5-2 744
Chapter 7 744
Quick check 7-1 744
Quick check 7-2 744
Chapter 8 744
Quick check 8-1 744
Quick check 8-2 744
Quick check 8-3 744
Quick check 8-4 744
Chapter 9 744
Quick check 9-1 744
Quick check 9-2 744
Quick check 9-3 744
Quick check 9-4 744
Chapter 10 745
Quick check 10-1 745
Quick check 10-2 745
Quick check 10-3 745
Quick check 10-4 745
Chapter 11 745
Quick check 11-1 745
Quick check 11-2 745
Quick check 11-3 745
Quick check 11-4 745
Quick check 11-5 745
Quick check 11-6 745
Quick check 11-7 745
Quick check 11-8 745
Quick check 11-9 745
Quick check 11-10 745
Chapter 12 745
Quick check 12-1 745
Quick check 12-2 745
Quick check 12-3 745
Chapter 13 745
Quick check 13-1 745
Quick check 13-2 745
Quick check 13-3 745
Chapter 14 745
Quick check 14-1 745
Quick check 14-2 745
Quick check 14-3 745
Chapter 15 746
Quick check 15-1 746
Quick check 15-2 746
Quick check 15-3 746
Quick check 15-4 746
Chapter 16 746
Quick check 16-1 746
Chapter 17 746
Quick check 17-1 746
Quick check 17-2 746
Quick check 17-3 746
Quick check 17-4 746
Chapter 18 746
Quick check 18-1 746
Quick check 18-2 746
Chapter 19 746
Quick check 19-1 746
Quick check 19-2 746
Quick check 19-3 746
Chapter 20 746
Quick check 20-1 746
Quick check 20-2 746
Quick check 20-3 746
Quick check 20-4 746
Quick check 20-5 746
Quick check 20-6 746
Quick check 20-7 746
Quick check 20-8 746
Quick check 20-9 746
Quick check 20-10 746
Quick check 20-11 746
Quick check 20-12 746
Quick check 20-13 746
Quick check 20-14 746
Quick check 20-15 746
Chapter 21 747
Quick check 21-1 747
Quick check 21-2 747
Quick check 21-3 747
Chapter 22 747
Quick check 22-1 747
Quick check 22-2 747
Chapter 23 747
Quick check 23-1 747
Quick check 23-2 747
Quick check 23-3 747
Chapter 24 747
Quick check 24-1 747
Quick check 24-2 747
Chapter 25 747
Quick check 25-1 747
Quick check 25-2 747
Quick check 25-3 747
Chapter 26 747
Quick check 26-1 747
Quick check 26-2 747
Quick check 26-3 747
APPENDIX D Ehr screens 748
Glossary 755
Figure credits 770
Coders index 775
CPT codes 775
Icd-10-cm codes 775
Hcpcs codes 775
Index 787
A 787
B 787
C 788
D 790
E 791
F 792
G 792
H 792
I 792
J 795
K 795
L 795
M 795
N 797
O 797
P 798
Q 799
R 799
S 799
T 801
U 801
V 801
W 802
X 802
Z 802
Inside back cover 1