Additional Information
Book Details
Abstract
Take your first step toward a successful career in medical coding with comprehensive coverage from the most trusted source in the field! Step-by-Step Medical Coding is the practical, easy-to-use resource that shows you exactly how to code using all of today's coding systems, providing an in-depth introduction to essential coding concepts followed by practice exercises that reinforce your understanding. In addition to coverage of reimbursement, ICD-9-CM, CPT, HCPCS, and inpatient coding, the 2011 edition now provides full coverage of the ICD-10-CM diagnosis coding system in preparation for the transition in 2013. No other text on the market so thoroughly prepares you for all coding systems in one source!
- Carol J. Buck's proven step-by-step approach guides you through difficult concepts in the most direct, straightforward manner to ensure complete understanding.
- Dual coding prepares you for the switch to ICD-10. In Units 3-5, for every exercise and chapter review question with an ICD-9 answer, you are provided with the matching ICD-10 code.
- In-text exercises throughout each chapter reinforce coding rules and concepts and follow the book's step-by-step approach.
- Quick Check features immediately reinforce key concepts and test your retention and understanding.
- Toolbox features provide additional real world cases for analysis and applying knowledge to specific case elements.
- Concrete "real-life" coding examples allow you to apply important coding principles and practices to actual scenarios from the field.
- Full-color design with over 450 illustrations ensures easy navigation and presents material in a unique, compelling way.
- Coding Shots provide tips for complicated coding scenarios and advice for entering the job market.
- From the Trenches quotes provide valuable, up-to-date insights from instructors and professionals in the medical coding field.
- Stop! notes offer a brief summary of material just covered to help ensure retention and understanding and provide a transition into the next topic.
- Caution! notes warn of common coding mistakes and reinforce the concept of coding as an exact science.
- Check This Out! boxes offer notes on accessing reference information, primarily via the Internet.
- Official Guidelines for Coding and Reporting boxes in Units 2 and 5 present the official outpatient and inpatient guidelines alongside text discussions.
- Coder's Index makes it easy to instantly locate specific codes.
- Practice activities and Coding Guidelines are available on the companion Evolve Resources website to help reinforce key concepts from the text and provide fast, easy access to the most up-to-date content.
- A free 30-day demo of SpeedECoder lets you complete cases using an actual online encoder.
Table of Contents
| Section Title | Page | Action | Price |
|---|---|---|---|
| Front Cover | Cover | ||
| STEP-BY-STEP MEDICAL CODING, 2011 EDITION | vii | ||
| Copyright Page | viii | ||
| DEDICATION | ix | ||
| ACKNOWLEDGMENTS | xi | ||
| PREFACE | xiii | ||
| DEVELOPMENT OF THIS EDITION | xix | ||
| INTRODUCTION | xxiii | ||
| Table of Contents | xxix | ||
| UNIT 1 Reimbursement | 1 | ||
| CHAPTER 1 Reimbursement, HIPAA, and Compliance | 1 | ||
| Introduction | 2 | ||
| Basic Structure of the Medicare Program | 2 | ||
| Health Insurance Portability and Accountability Act⁷ | 7 | ||
| Federal Register | 9 | ||
| Outpatient Resource-Based Relative Value Scale (RBRVS) | 11 | ||
| Medicare Fraud and Abuse | 18 | ||
| Managed Health Care | 21 | ||
| Chapter Review | 24 | ||
| Quick Check Answers | 25 | ||
| References | 25 | ||
| UNIT 2 ICD-9-CM | 26 | ||
| CHAPTER 2 An Overview of ICD-9-CM | 26 | ||
| The ICD-9-CM | 27 | ||
| ICD-9-CM Format | 28 | ||
| Tabular List, Volume 1 | 29 | ||
| Appendices in the Tabular List, Volume 1 | 38 | ||
| Alphabetic Index, Volume 2 | 40 | ||
| Procedures, Volume 3 | 60 | ||
| Chapter Review | 72 | ||
| Quick Check Answers | 74 | ||
| CHAPTER 3 ICD-9-CM Outpatient Coding and Reporting Guidelines | 75 | ||
| First-Listed Diagnosis | 76 | ||
| Additional Diagnoses | 80 | ||
| V Codes | 81 | ||
| Specificity | 87 | ||
| Uncertain Diagnosis | 88 | ||
| Chronic Diseases | 89 | ||
| Diagnostic Services | 90 | ||
| Therapeutic Services | 91 | ||
| Surgery | 92 | ||
| Prenatal Visits | 93 | ||
| Chapter Review | 95 | ||
| CHAPTER 4 Using ICD-9-CM | 97 | ||
| Organization of the Guidelines | 98 | ||
| Level of Specificity | 100 | ||
| Integral Conditions | 102 | ||
| Multiple Coding | 104 | ||
| Acute and Chronic | 107 | ||
| Combination Codes | 109 | ||
| Late Effects | 110 | ||
| Impending or Threatened Condition | 113 | ||
| Chapter Review | 115 | ||
| Quick Check Answers | 116 | ||
| CHAPTER 5 Chapter-Specific Guidelines (ICD-9-CM Chapters 1-8) | 117 | ||
| Infectious and Parasitic Diseases | 118 | ||
| Neoplasms | 120 | ||
| Endocrine, Nutritional, and Metabolic Diseases and Immunity Disorders | 128 | ||
| Diseases of the Blood and Blood-Forming Organs | 130 | ||
| Mental Disorders | 131 | ||
| Diseases of the Nervous System and Sense Organs | 133 | ||
| Diseases of the Circulatory System | 134 | ||
| Diseases of the Respiratory System | 140 | ||
| Chapter Review | 143 | ||
| Quick Check Answers | 146 | ||
| CHAPTER 6 Chapter-Specific Guidelines (ICD-9-CM Chapters 9-17) | 147 | ||
| Diseases of the Digestive System | 148 | ||
| Diseases of the Genitourinary System | 150 | ||
| Complications of Pregnancy, Childbirth, and the Puerperium | 151 | ||
| Diseases of the Skin and Subcutaneous Tissue | 157 | ||
| Diseases of the Musculoskeletal System and Connective Tissue | 159 | ||
| Congenital Anomalies and Certain Conditions Originating in the Perinatal Period | 161 | ||
| Symptoms, Signs, and Ill-Defi ned Conditions | 165 | ||
| Injury and Poisoning | 166 | ||
| Chapter Review | 189 | ||
| Quick Check Answers | 191 | ||
| UNIT 3 ICD-10-CM | 192 | ||
| CHAPTER 7 An Overview of ICD-10-CM | 192 | ||
| Development of the ICD-10-CM | 193 | ||
| ICD-10-CM Replaces the ICD-9-CM, Volumes 1 and 2 | 193 | ||
| Improvements in the ICD-10-CM | 194 | ||
| Structure of the System | 196 | ||
| Mapping | 197 | ||
| Index | 202 | ||
| Tabular | 204 | ||
| Official Instructional Notations in the ICD-10-CM | 206 | ||
| Chapter Review | 210 | ||
| Quick Check Answers | 211 | ||
| CHAPTER 8 ICD-10-CM Outpatient Coding and Reporting Guidelines | 212 | ||
| First-Listed Diagnosis | 213 | ||
| Unconfirmed Diagnosis | 214 | ||
| Outpatient Surgery | 215 | ||
| Additional Diagnoses | 216 | ||
| Z Codes | 217 | ||
| Observation Stay | 224 | ||
| First-Listed Diagnosis and Coexisting Conditions | 226 | ||
| Uncertain Diagnoses | 227 | ||
| Chronic Diseases | 229 | ||
| Documented Conditions | 229 | ||
| Diagnostic Services | 230 | ||
| Therapeutic Services | 231 | ||
| Preoperative Evaluation | 232 | ||
| Prenatal Visits | 234 | ||
| Chapter Review | 235 | ||
| Quick Check Answers | 236 | ||
| CHAPTER 9 Using ICD-10-CM | 237 | ||
| Organization of the Guidelines | 238 | ||
| Accurate Coding | 238 | ||
| Alphabetic Index and Tabular List | 238 | ||
| Level of Specificity | 240 | ||
| Integral Conditions | 242 | ||
| Multiple Coding | 244 | ||
| Acute and Chronic | 246 | ||
| Combination Codes | 248 | ||
| Late Effects | 250 | ||
| Reporting Same Diagnosis Code More Than Once | 253 | ||
| Laterality | 253 | ||
| Chapter Review | 255 | ||
| Quick Check Answers | 256 | ||
| CHAPTER 10 Chapter-Specific Guidelines (ICD-10-CM Chapters 1-10) | 257 | ||
| Certain Infectious and Parasitic Diseases | 258 | ||
| Neoplasms | 267 | ||
| Diseases of the Blood and Blood-Forming Organs and Certain Disorders Involving the Immune Mechanism | 276 | ||
| Endocrine, Nutritional, and Metabolic Diseases | 280 | ||
| Mental and Behavioral Disorders | 283 | ||
| Diseases of the Nervous System | 286 | ||
| Diseases of the Eye and Adnexa | 291 | ||
| Diseases of the Ear and Mastoid Process | 294 | ||
| Diseases of the Circulatory System | 295 | ||
| Diseases of the Respiratory System | 302 | ||
| Chapter Review | 305 | ||
| Quick Check Answers | 307 | ||
| CHAPTER 11 Chapter-Specific Guidelines (ICD-10-CM Chapters 11-14) | 308 | ||
| Diseases of the Digestive System | 309 | ||
| Diseases of the Skin and Subcutaneous Tissue | 311 | ||
| Diseases of the Musculoskeletal System and Connective Tissue | 314 | ||
| Chapter Review | 322 | ||
| CHAPTER 12 Chapter-Specific Guidelines (ICD-10-CM Chapters 15-21) | 324 | ||
| Pregnancy, Childbirth, and the Puerperium | 325 | ||
| Certain Conditions Originating in the Perinatal Period | 334 | ||
| Congenital Malformations, Deformations and Chromosomal Abnormalities | 335 | ||
| Symptoms, Signs, and Abnormal Clinical and Laboratory Findings, Not Elsewhere Classified | 338 | ||
| Injury, Poisoning, and Certain Other Consequences of External Causes | 342 | ||
| Chapter Review | 361 | ||
| Quick Check Answers | 362 | ||
| UNIT 4 CPT and HCPCS | 363 | ||
| CHAPTER 13 Introduction to the CPT and Level II National Codes (HCPCS) | 363 | ||
| The Purpose of the CPT Manual | 364 | ||
| Updating the CPT Manual | 364 | ||
| CPT Manual Format | 366 | ||
| Starting with the Index | 381 | ||
| History of National Level Codes | 385 | ||
| Chapter Review | 398 | ||
| Quick Check Answers | 400 | ||
| CHAPTER 14 Modifiers | 401 | ||
| CPT Modifiers | 402 | ||
| Modifier-22, Increased Procedural Services | 403 | ||
| Modifier-23, Unusual Anesthesia | 404 | ||
| Modifier-24, Unrelated Evaluation and Management Service by the Same Physician During a Postoperative Period | 405 | ||
| Modifier-25, Significant Separately Identifiable E/M Service by the Same Physician on the Same Day of the Procedure or Other Service | 406 | ||
| Modifier-26, Professional Component | 406 | ||
| Modifier-32, Mandated Services | 408 | ||
| Modifier-47, Anesthesia by Surgeon | 408 | ||
| Modifier-50, Bilateral Procedures | 408 | ||
| Modifier-51, Multiple Procedures | 409 | ||
| Modifier-52, Reduced Services | 413 | ||
| Modifier-53, Discontinued Procedure | 416 | ||
| Modifiers -54, -55,and -56 | 416 | ||
| Modifier-54, Surgical Care Only | 416 | ||
| Modifier-55, Postoperative Management Only | 417 | ||
| Modifier-56, Preoperative Management Only | 417 | ||
| Modifier-57, Decision for Surgery | 418 | ||
| Modifier-58, Staged or Related Procedure or Service by the Same Physician During the Postoperative Period | 419 | ||
| Modifier-59, Distinct Procedural Service | 420 | ||
| Modifier-62, Two Surgeons | 421 | ||
| Modifier-63, Procedure Performed on Infants Less than 4 kg | 422 | ||
| Modifier-66, Surgical Team | 422 | ||
| Modifier-76 Repeat Procedure or Service by Same Physician | 423 | ||
| Modifier-77, Repeat Procedure by Another Physician | 423 | ||
| Modifier-78, Unplanned Return to the Operating/Procedure Room by the Same Physician Following Initial Procedure for a Related Procedure During the Postoperative Period | 424 | ||
| Modifier-79, Unrelated Procedure or Service by the Same Physician During the Postoperative Period | 425 | ||
| Modifier-80, Assistant Surgeon | 425 | ||
| Modifier-81, Minimum Assistant Surgeon | 425 | ||
| Modifier-82, Assistant Surgeon (When Qualified Resident Surgeon Not Available) | 426 | ||
| Modifier-90, Reference (Outside) Laboratory | 427 | ||
| Modifier-91, Repeat Clinical Diagnostic Laboratory Test | 428 | ||
| Modifier-92, Alternative Laboratory Platform Testing | 428 | ||
| Modifier-99, Multiple Modifiers | 428 | ||
| Chapter Review | 429 | ||
| Quick Check Answers | 430 | ||
| CHAPTER 15 Evaluation and Management (E/M) Services | 431 | ||
| Contents of the E/M Section | 432 | ||
| Three Factors of E/M Codes | 432 | ||
| Various Levels of E/M Service | 435 | ||
| An E/M Code Example | 456 | ||
| Using the E/M Codes | 457 | ||
| Documentation Guidelines | 490 | ||
| Chapter Review | 493 | ||
| Quick Check Answers | 496 | ||
| CHAPTER 16 Anesthesia | 497 | ||
| Types of Anesthesia | 498 | ||
| Anesthesia Section Format | 501 | ||
| Formula for Anesthesia Payment | 503 | ||
| Concurrent Modifiers | 512 | ||
| Unlisted Anesthesia Code | 515 | ||
| Other Reporting | 516 | ||
| Chapter Review | 517 | ||
| Quick Check Answers | 518 | ||
| CHAPTER 17 Surgery Guidelines and General Surgery | 519 | ||
| Introduction to the Surgery Section | 520 | ||
| Notes and Guidelines | 520 | ||
| Unlisted Procedures | 523 | ||
| Special Reports | 524 | ||
| Separate Procedure | 524 | ||
| Surgical Package | 529 | ||
| General Subsection | 530 | ||
| Chapter Review | 531 | ||
| Quick Check Answers | 532 | ||
| CHAPTER 18 Integumentary System | 533 | ||
| Integumentary System | 534 | ||
| Format | 534 | ||
| Skin, Subcutaneous, and Accessory Structures | 535 | ||
| Nails | 546 | ||
| Repair (Closure) | 549 | ||
| Burns | 561 | ||
| Destruction | 565 | ||
| Breast Procedures | 567 | ||
| Chapter Review | 571 | ||
| Quick Check Answers | 572 | ||
| CHAPTER 19 Musculoskeletal System | 573 | ||
| Format | 574 | ||
| Fractures and Dislocations | 575 | ||
| General | 581 | ||
| Application of Casts and Strapping | 590 | ||
| Endoscopy/Arthroscopy | 593 | ||
| Chapter Review | 595 | ||
| Quick Check Answers | 596 | ||
| CHAPTER 20 Respiratory System | 597 | ||
| Format | 598 | ||
| Endoscopy | 599 | ||
| Nose | 601 | ||
| Accessory Sinuses | 607 | ||
| Larynx | 608 | ||
| Trachea/Bronchi | 610 | ||
| Lungs and Pleura | 613 | ||
| Chapter Review | 617 | ||
| Quick Check Answers | 619 | ||
| CHAPTER 21 Cardiovascular System | 620 | ||
| Coding Highlights | 621 | ||
| Cardiovascular Coding in the Surgery Section | 623 | ||
| Cardiovascular Coding in the Medicine Section | 645 | ||
| Cardiovascular Coding in the Radiology Section | 659 | ||
| Chapter Review | 663 | ||
| Quick Check Answers | 665 | ||
| CHAPTER 22 Hemic, Lymphatic, Mediastinum, and Diaphragm | 666 | ||
| Hemic and Lymphatic Systems | 667 | ||
| Mediastinum and Diaphragm | 672 | ||
| Chapter Review | 674 | ||
| Quick Check Answers | 675 | ||
| CHAPTER 23 Digestive System | 676 | ||
| Format | 677 | ||
| Lips | 677 | ||
| Vestibule of Mouth | 679 | ||
| Tongue and Floor of Mouth | 679 | ||
| Dentoalveolar Structures | 681 | ||
| Palate and Uvula | 683 | ||
| Salivary Gland and Ducts | 683 | ||
| Pharynx, Adenoids, and Tonsils | 685 | ||
| Esophagus | 686 | ||
| Stomach | 691 | ||
| Intestines (Except Rectum) | 692 | ||
| Meckel’s Diverticulum and the Mesentery | 695 | ||
| Appendix | 696 | ||
| Rectum | 696 | ||
| Anus | 702 | ||
| Liver | 705 | ||
| Biliary Tract | 706 | ||
| Pancreas | 706 | ||
| Abdomen, Peritoneum, and Omentum | 707 | ||
| Chpater Review | 709 | ||
| Quick Check Answers | 710 | ||
| CHAPTER 24 Urinary and Male Genital Systems | 711 | ||
| Urinary System | 712 | ||
| Male Genital System | 730 | ||
| Chapter Review | 744 | ||
| Quick Check Answers | 746 | ||
| CHAPTER 25 Reproductive, Intersex Surgery, Female Genital System, and Maternity Care and Delivery | 747 | ||
| Reproductive System Procedures | 748 | ||
| Intersex Surgery | 748 | ||
| Female Genital System | 748 | ||
| Maternity Care and Delivery | 763 | ||
| Chapter Review | 770 | ||
| Quick Check Answers | 772 | ||
| CHAPTER 26 Endocrine and Nervous Systems | 773 | ||
| Endocrine System | 774 | ||
| Nervous System | 778 | ||
| Chapter Review | 789 | ||
| Quick Check Answers | 790 | ||
| CHAPTER 27 Eye, Ocular Adnexa, Auditory, and Operating Microscope | 791 | ||
| Eye and Ocular Adnexa | 792 | ||
| Auditory System | 799 | ||
| Operating Microscope | 799 | ||
| Chapter Review | 806 | ||
| Quick Check Answers | 807 | ||
| CHAPTER 28 Radiology | 808 | ||
| Format | 809 | ||
| Radiology Terminology | 809 | ||
| Terms | 810 | ||
| Planes | 810 | ||
| Guidelines | 816 | ||
| Diagnostic Radiology | 820 | ||
| Breast, Mammography | 822 | ||
| Diagnostic Ultrasound | 823 | ||
| Radiation Oncology | 827 | ||
| Nuclear Medicine | 832 | ||
| Chapter Review | 834 | ||
| Quick Check Answers | 836 | ||
| CHAPTER 29 Pathology/Laboratory | 837 | ||
| Format | 838 | ||
| Organ or Disease Oriented Panels | 838 | ||
| Drug Testing | 839 | ||
| Therapeutic Drug Assays | 840 | ||
| Evocative/Suppression Testing | 841 | ||
| Consultations (Clinical Pathology) | 842 | ||
| Urinalysis and Chemistry | 843 | ||
| Hematology and Coagulation | 844 | ||
| Immunology | 846 | ||
| Transfusion Medicine | 846 | ||
| Microbiology | 847 | ||
| Anatomic Pathology | 848 | ||
| Cytopathology and Cytogenic Studies | 849 | ||
| Surgical Pathology | 849 | ||
| Other Procedures | 851 | ||
| Chapter Review | 852 | ||
| Quick Check Answers | 854 | ||
| CHAPTER 30 Medicine | 855 | ||
| Format | 856 | ||
| Introduction to Immunizations | 857 | ||
| Psychiatry | 862 | ||
| Biofeedback | 864 | ||
| Dialysis | 865 | ||
| Gastroenterology | 868 | ||
| Ophthalmology | 869 | ||
| Special Otorhinolaryngologic Services | 872 | ||
| Cardiovascular | 872 | ||
| Pulmonary | 874 | ||
| Allergy and Clinical Immunology | 875 | ||
| Endocrinology | 876 | ||
| Neurology and Neuromuscular Procedures | 877 | ||
| Central Nervous System Assessments/Tests | 879 | ||
| Health and Behavior Assessment/Intervention | 880 | ||
| Chemotherapy Administration | 881 | ||
| Photodynamic Therapy | 885 | ||
| Special Dermatological Procedures | 885 | ||
| Physical Medicine and Rehabilitation | 886 | ||
| Medical Nutrition Therapy | 889 | ||
| Osteopathic Manipulative Treatment (OMT) | 889 | ||
| Chiropractic Manipulative Treatment (CMT) | 889 | ||
| Non-Face-to-Face Nonphysician Services | 890 | ||
| Special Services, Procedures, and Reports | 890 | ||
| Other Services and Procedures | 891 | ||
| Home Health Procedures/Services | 891 | ||
| Medication Therapy Management Services | 891 | ||
| Chapter Review | 892 | ||
| Quick Check Answers | 894 | ||
| UNIT 5 Inpatiet Coding | 895 | ||
| CHAPTER 31 Inpatient Coding | 895 | ||
| Differences between Inpatient and Outpatient Coding | 896 | ||
| Selection of Principal Diagnosis | 897 | ||
| Reporting Additional Diagnoses | 908 | ||
| Present on Admission (POA) | 911 | ||
| Development of the ICD-10-PCS | 911 | ||
| Chapter Review | 923 | ||
| APPENDIX A Online Resources | 925 | ||
| ICD-9-CM Official Guidelines for Coding and Reporting | 925 | ||
| ICD-10-CM Official Guidelines for Coding and Reporting | 925 | ||
| 1995 Guidelines for E/M Services | 925 | ||
| 1997 Documentation Guidelines for Evaluation and Management Services | 925 | ||
| CPT Updates | 925 | ||
| ICD-9-CM Updates | 925 | ||
| HCPCS Updates | 925 | ||
| Study Tips | 925 | ||
| WebLinks | 925 | ||
| APPENDIX B Exercise Answers | 926 | ||
| APPENDIX C SpeedECoder Exercises | 972 | ||
| Glossary | 1002 | ||
| Coder's Index | 1019 | ||
| Index | 1039 |