BOOK
Buck's The Next Step: Advanced Medical Coding and Auditing, 2019/2020 Edition E-Book
(2018)
Additional Information
Book Details
Abstract
Master advanced coding skills! Buck’s The Next Step: Advanced Medical Coding and Auditing shows how to code for services such as medical visits, diagnostic testing and interpretation, treatments, surgeries, and anesthesia. Real-world cases (cleared of any patient identifiers) takes your coding proficiency a step further by providing hands-on practice with physician documentation. With this guide, you’ll learn to pull the right information from medical documents, select the right codes, determine the correct sequencing of those codes, and properly audit cases.
- Real-world patient cases (cleared of any patient identifiers) simulate the first year of coding on the job by using actual medical records, allowing you to practice coding with advanced material.
- UNIQUE! From the Trenches boxes highlight the real-life experiences of professional medical coders and include photographs, quotes, practical tips, and advice.
- UNIQUE! Evaluation and Management (E/M) audit forms include clear coding instructions to help reduce errors in determining the correct level of service.
- Over 170 full-color illustrations depict and clarify advanced coding concepts.
Table of Contents
| Section Title | Page | Action | Price |
|---|---|---|---|
| Front Cover | Cover | ||
| Advertisement | i | ||
| Front matter | v | ||
| Buck’s the next step: Advanced medical coding and auditing, 2019/2020 | vii | ||
| Copyright | viii | ||
| Dedication | ix | ||
| About the author | x | ||
| Acknowledgments | xi | ||
| Preface | xii | ||
| Organization of this textbook | xii | ||
| List of physicians | xii | ||
| Abbreviations and acronyms | xiii | ||
| Glossary | xiii | ||
| Evaluation | xiii | ||
| Distinctive features of our approach | xiii | ||
| Supplemental resources | xiv | ||
| Teach instructor resources on evolve | xv | ||
| Evolve learning resources | xv | ||
| A special note | xvi | ||
| Development of this edition | xvii | ||
| Senior Technical Collaborator and Query Manager | xvii | ||
| Senior Collaborator and ICD-10-CM Consultant | xvii | ||
| ICD-10-CM Consultant | xvii | ||
| Editorial Review Board | xvii | ||
| Introduction | xviii | ||
| Types of codes | xviii | ||
| Case numbering system | xix | ||
| Report format | xxi | ||
| Auditing review | xxii | ||
| Multiple modifiers | xxiii | ||
| Use of modifiers -26 and -TC | xxiii | ||
| Pathology and laboratory | xxiii | ||
| The top 10 list for coders | xxv | ||
| List of physicians | xxvi | ||
| Table of Contents | xxviii | ||
| 1 Evaluation and management services | 1 | ||
| E/M review—the basics | 2 | ||
| Three factors of E/M code | 2 | ||
| Place of service | 2 | ||
| Type of service | 2 | ||
| Patient status | 2 | ||
| Key components | 2 | ||
| History | 3 | ||
| Chief complaint. | 3 | ||
| History of present illness. | 3 | ||
| Review of systems (ROS). | 4 | ||
| 2 Medicine | 76 | ||
| Immune globulins/immunizations/vaccines/toxoids (90281-90756) | 77 | ||
| Diagnosis coding for vaccinations and immune globulins | 78 | ||
| Hydration, (96360, 96361); and therapeutic, prophylactic, and diagnostic injections and infusions (excludes chemotherapy a ... | 79 | ||
| Hydration | 79 | ||
| Therapeutic, prophylactic, and diagnostic injections and infusions (excludes chemotherapy and other highly complex drug or ... | 79 | ||
| Psychiatry | 80 | ||
| Dialysis | 82 | ||
| Peritoneal dialysis | 84 | ||
| Complications | 85 | ||
| Noninvasive vascular diagnostic studies | 87 | ||
| Late effects | 88 | ||
| Cardioversion | 89 | ||
| Ultrasound | 90 | ||
| Codes reviewed elsewhere | 90 | ||
| Central nervous system assessments/tests (e.g., neurocognitive, mental status, speech testing) | 91 | ||
| Dementia | 91 | ||
| Health and behavior assessment/intervention | 92 | ||
| Chemotherapy administration (96401-96549) | 92 | ||
| Diagnosis coding for chemotherapy | 92 | ||
| Photodynamic therapy | 93 | ||
| Physical medicine and rehabilitation (97010-97799) | 94 | ||
| Medical nutrition therapy | 96 | ||
| Osteopathic and chiropractic manipulative treatment | 96 | ||
| Special services, procedures, and reports | 96 | ||
| Hcpcs level II modifiers | 97 | ||
| 3 Radiology | 101 | ||
| Positions and placement | 103 | ||
| Component coding | 104 | ||
| Interventional radiology | 106 | ||
| Contrast | 107 | ||
| Facility specifics | 107 | ||
| Diagnostic radiology | 107 | ||
| Hemodialysis catheter placement | 108 | ||
| Types of catheters | 108 | ||
| Nasogastric tube | 109 | ||
| Cine-pharyngoesophagram | 111 | ||
| CAT/CT scans | 112 | ||
| Reconstruction | 113 | ||
| Congestive heart failure | 113 | ||
| Hypoxemia | 113 | ||
| CT guidance | 118 | ||
| Ultrasound | 119 | ||
| Modes and scans | 119 | ||
| Ultrasound guidance | 122 | ||
| Radiation oncology | 122 | ||
| Clinical treatment planning | 122 | ||
| Simulation | 123 | ||
| Radiation treatment management | 123 | ||
| Proton beam treatment delivery | 124 | ||
| Hyperthermia | 124 | ||
| Clinical brachytherapy | 124 | ||
| Treatment delivery | 127 | ||
| Nuclear medicine | 128 | ||
| Interventional radiology | 129 | ||
| Central venous access procedures | 129 | ||
| 4 Pathology and laboratory | 135 | ||
| Types of services | 136 | ||
| Superbill/requisition form | 136 | ||
| Organ- or disease-oriented panels | 138 | ||
| Therapeutic drug assays | 140 | ||
| Urinalysis, molecular pathology, and chemistry | 141 | ||
| Urine/stool | 141 | ||
| Timed urine | 142 | ||
| Molecular pathology | 142 | ||
| Chemistry | 142 | ||
| Calculations | 142 | ||
| Chromatography | 144 | ||
| Hematology and coagulation | 146 | ||
| Laboratory use only | 146 | ||
| Coagulation | 149 | ||
| Immunohematology | 150 | ||
| Immunology | 151 | ||
| Body fluid | 152 | ||
| Office testing | 153 | ||
| Other laboratory and pathology services | 154 | ||
| Presumptive drug class screening | 154 | ||
| Diagnoses coding in drug test and drug abuse | 154 | ||
| Evocative/suppression testing | 155 | ||
| Transfusion medicine | 156 | ||
| Microbiology | 156 | ||
| Anatomic pathology | 156 | ||
| Consultations (clinical pathology) | 156 | ||
| Cytopathology and cytogenetic studies | 157 | ||
| Surgical pathology | 157 | ||
| Specimens | 158 | ||
| Other procedures | 158 | ||
| 5 Integumentary system | 171 | ||
| Debridement | 172 | ||
| Skin tags | 175 | ||
| Lesion excision | 176 | ||
| Keratosis | 176 | ||
| Nails | 182 | ||
| Repair (closure) | 183 | ||
| Modifier -59 | 185 | ||
| Adjacent tissue transfers or rearrangements | 189 | ||
| Skin grafts | 191 | ||
| Other procedures | 194 | ||
| Pressure ulcers | 196 | ||
| Breast procedures | 196 | ||
| 6 Cardiovascular system | 210 | ||
| Evaluation and management services | 211 | ||
| Arteriosclerosis | 211 | ||
| Coronary artery bypass grafts | 212 | ||
| Pacemaker | 215 | ||
| Sick sinus syndrome | 215 | ||
| Echocardiography | 216 | ||
| Valve insufficiencies | 217 | ||
| Holter | 219 | ||
| Preimplantation, implantation, and postimplantation | 221 | ||
| Stress tests | 221 | ||
| Myocardial perfusion scan | 222 | ||
| Review of previous history | 224 | ||
| Cardiac catheterization | 229 | ||
| Miscellaneous reports | 239 | ||
| Cardioversion | 239 | ||
| 7 Digestive system, hemic/lymphatic system, and mediastinum/diaphragm | 248 | ||
| Digestive system | 249 | ||
| E/M services | 250 | ||
| Intestinal obstruction | 250 | ||
| External procedures | 250 | ||
| Hemorrhoids | 253 | ||
| Catheters | 254 | ||
| Endoscopy procedures | 255 | ||
| Gastritis and duodenitis | 255 | ||
| Ulcer | 255 | ||
| Hernia | 256 | ||
| Rectal procedures | 256 | ||
| Polyps | 257 | ||
| Abnormal findings | 258 | ||
| Abdominal pain | 259 | ||
| Cytomegalovirus | 266 | ||
| Laparoscopic procedures | 269 | ||
| Closed procedures converted to open procedures | 269 | ||
| Cholecystectomy | 270 | ||
| Incisional (open) surgical procedures | 277 | ||
| Crohn’s disease | 281 | ||
| Crohn’s disease diagnosis | 281 | ||
| Hernia | 287 | ||
| Hemic/lymphatic system | 289 | ||
| Diagnosis coding of hematopoietic and lymphatic neoplasms | 289 | ||
| 8 Musculoskeletal system | 297 | ||
| Arthrocentesis | 298 | ||
| Fractures | 299 | ||
| Fixation | 300 | ||
| Excision | 301 | ||
| Repair, revision, and reconstruction | 306 | ||
| Sprains and strains | 306 | ||
| Late effects | 310 | ||
| Fractures | 311 | ||
| Amputation | 312 | ||
| Arthroscopy | 317 | ||
| 9 Respiratory system | 326 | ||
| E/M services | 327 | ||
| Enzyme immunoassay | 328 | ||
| Residents | 329 | ||
| Medicine services | 338 | ||
| Spirometry | 339 | ||
| 94010 spirometry | 339 | ||
| 94060 spirometry with bronchodilator | 340 | ||
| 94070 spirometry with agents | 340 | ||
| 94727 FRC (functional residual capacity), also known as a nitrogen washout (lung volume determination) | 340 | ||
| 94726 TGV (thoracic gas volume), also known as plethysmography lung volume or lung volumes, includes (spirometry) | 340 | ||
| 94729 DLCO (diffusion capacity of carbon monoxide), also known as transfer factor (diffusing capacity) | 340 | ||
| 94726/94728 airway resistance (lung volume determination) | 340 | ||
| Sleep studies | 341 | ||
| Symptoms, signs, and ill-defined conditions | 341 | ||
| Symptoms as diagnoses | 341 | ||
| Nonspecific abnormal findings | 342 | ||
| Pulmonary stress test | 348 | ||
| Septoplasty and turbinates | 349 | ||
| Thoracentesis | 351 | ||
| Tracheostomy | 352 | ||
| Endoscopic procedures | 352 | ||
| 10 Urinary, male genital, and endocrine systems | 368 | ||
| Urinary system | 369 | ||
| Chronic renal failure | 369 | ||
| Diagnosis coding | 369 | ||
| Nephrostomy tube | 370 | ||
| Nephrectomy | 371 | ||
| Urinary system subcategories | 371 | ||
| Urinary system cysts | 371 | ||
| Renal calculus | 372 | ||
| Urodynamics | 372 | ||
| Stress incontinence | 374 | ||
| Bladder rupture | 375 | ||
| Hydronephrosis | 375 | ||
| Bladder stones | 376 | ||
| Urethral and ureteral strictures | 377 | ||
| Male genital system | 378 | ||
| Hemangioma | 378 | ||
| Diagnosis coding of hemangioma | 378 | ||
| Balanitis and circumcision | 379 | ||
| Vasectomy | 380 | ||
| Hydrocele | 381 | ||
| Prostate-specific antigen | 382 | ||
| Prostate cancer | 383 | ||
| Staging | 384 | ||
| Cryoablation | 385 | ||
| Endocrine system | 386 | ||
| 11 Female genital system and maternity care/delivery | 394 | ||
| Female genital system | 395 | ||
| Evaluation and management | 395 | ||
| Pains and other female genital organ symptoms | 395 | ||
| Surgical procedures | 396 | ||
| Menopausal and postmenopausal disorders | 396 | ||
| Colposcopy | 397 | ||
| Pelvic pain | 402 | ||
| Endometriosis | 403 | ||
| Dysfunctional uterine bleeding | 406 | ||
| Maternity care/delivery | 408 | ||
| Routine obstetric care | 408 | ||
| Admission for normal delivery | 408 | ||
| Echography | 409 | ||
| Cesarean section | 410 | ||
| 12 Nervous system | 424 | ||
| Twist drill or burr holes | 425 | ||
| Craniotomy | 426 | ||
| Subdural hematoma | 426 | ||
| Stealth surgery | 428 | ||
| Cranioplasty | 432 | ||
| Shunts | 433 | ||
| Lumbar puncture | 433 | ||
| Pump implantation | 434 | ||
| Laminotomy and foraminotomies | 437 | ||
| Spinal fusion | 442 | ||
| Neurology and neuromuscular procedures | 444 | ||
| 13 Eye and auditory systems | 450 | ||
| Eye | 451 | ||
| Eye examinations | 451 | ||
| Cataracts | 452 | ||
| Photocoagulation | 453 | ||
| Ectropion and entropion | 454 | ||
| Epiphora | 455 | ||
| Ear | 456 | ||
| Office services | 456 | ||
| Myringotomy and tympanostomy | 457 | ||
| 14 Anesthesia | 465 | ||
| Introduction | 466 | ||
| Anesthesia | 466 | ||
| Types of anesthesia | 466 | ||
| Central technique | 466 | ||
| Peripheral technique | 466 | ||
| Intravenous regional technique (bier block) | 466 | ||
| Anesthesia care and bundled services/procedures | 467 | ||
| Anesthesia care and separately reported services | 467 | ||
| Base units | 468 | ||
| Physical status modifiers | 468 | ||
| Concurrent care modifiers | 468 | ||
| Positioning | 469 | ||
| Qualifying circumstances | 469 | ||
| Anesthesia time | 469 | ||
| Calculation of charge/payment | 469 | ||
| Summary | 470 | ||
| Pain management | 470 | ||
| Obstetrics | 470 | ||
| Labor | 470 | ||
| Delivery | 470 | ||
| Hysterectomy | 470 | ||
| Critical care | 471 | ||
| Moderate (conscious) sedation | 471 | ||
| Patient-controlled analgesia | 471 | ||
| Anesthesia services in the hospital setting | 471 | ||
| Figure credits | 492 | ||
| Chapter 1 | 492 | ||
| Chapter 2 | 492 | ||
| Chapter 3 | 492 | ||
| Chapter 5 | 492 | ||
| Chapter 6 | 492 | ||
| Chapter 7 | 492 | ||
| Chapter 8 | 492 | ||
| Chapter 9 | 492 | ||
| Chapter 10 | 492 | ||
| Chapter 11 | 492 | ||
| Chapter 12 | 492 | ||
| Chapter 13 | 492 | ||
| APPENDIX A E/M audit form | 493 | ||
| APPENDIX B CMS AB-01-144 | 495 | ||
| Introduction | 495 | ||
| A. Determining the appropriate primary ICD-9-CM11Although this memorandum specifies ICD-9-CM, it is applicable to ICD-10-C ... | 495 | ||
| B. Instruction to determine the reason for the test | 496 | ||
| C. Incidental findings | 496 | ||
| D. Unrelated/co-existing conditions/diagnoses | 496 | ||
| E. Diagnostic tests ordered in the absence of signs and/or symptoms (e.g., screening tests) | 497 | ||
| F. Use of ICD-9-CM to the greatest degree of accuracy and completeness | 497 | ||
| APPENDIX C Resources | 498 | ||
| APPENDIX D Abbreviations | 499 | ||
| APPENDIX E Answers to every other case | 504 | ||
| glossary | 525 | ||
| Index | 529 | ||
| A | 529 | ||
| B | 530 | ||
| C | 530 | ||
| D | 531 | ||
| E | 532 | ||
| F | 533 | ||
| G | 534 | ||
| H | 534 | ||
| I | 535 | ||
| K | 535 | ||
| L | 535 | ||
| M | 536 | ||
| N | 537 | ||
| O | 537 | ||
| P | 537 | ||
| Q | 538 | ||
| R | 538 | ||
| S | 539 | ||
| T | 540 | ||
| U | 540 | ||
| V | 540 | ||
| W | 540 | ||
| X | 540 | ||
| Z | 540 | ||
| Inside back cover | IBC |