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 Carol J. Buck, the bestselling Step-by-Step Medical Coding is a practical, easy-to-use resource that shows you exactly how to code using all current coding sets. Explanations of coding concepts are followed by practice exercises to reinforce understanding of the material. In addition to coverage of reimbursement, ICD-10-CM, CPT, HCPCS, and inpatient coding, an Evolve website includes 30-day access to TruCode® Encoder Essentials. No other text so thoroughly covers all coding sets in one source!
- A step-by-step approach makes it easier to build your skills and remember the material.
- 30-day trial access to TruCode® Encoder Essentials gives you experience with using an encoder (in addition to separate encoder practice exercises on the Evolve website).
- Learning Objective Review questions are included at the end of each chapter.
- UNIQUE! Concrete "real-life" 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.
- Instructor-led assessments on the companion Evolve website provide additional assessment options in classroom settings (answers and rationales provided at the discretion of your instructor).
- UNIQUE! Four coding-question variations — covering both single-code questions and multiple-code questions and scenarios — develop your coding ability and critical thinking skills.
- Over 450 total illustrations help you understand the types of medical conditions and procedures being coded, along with examples taken directly from Elsevier's professional ICD-10 and HCPCS manuals.
- Official Guidelines for Coding and Reporting boxes show the official guidelines wording for inpatient and outpatient coding alongside in-text explanations.
- UNIQUE! Coders’ Index in the back of the book makes it easy to quickly locate specific codes.
- Exercises, Quick Checks, and Toolbox features reinforce coding rules and concepts and emphasize key information.
- Valuable tips and advice are offered in features such as From the Trenches, Coding Shots, Stop!, Caution!, Check This Out, and CMS Rules.
- Sample electronic health record screenshots (located in Appendix D) show examples similar to the EHRs you will encounter in the workplace.
- NEW! Updated content includes the latest coding information available, promoting accurate coding and success on the job.
- NEW! Glossary review questions are included at the end of each chapter.
Table of Contents
| Section Title | Page | Action | Price |
|---|---|---|---|
| Front Cover | Cover | ||
| How to use | i | ||
| Front matter | iii | ||
| Step-by-step medical coding 2018 edition | iii | ||
| Copyright | iv | ||
| Dedication | v | ||
| About the author | vi | ||
| Acknowledgments | vii | ||
| Preface | viii | ||
| Development of this edition | xiv | ||
| Introduction | xvii | ||
| References | xix | ||
| Table of Contents | xx | ||
| 1 REIMBURSEMENT | 1 | ||
| 1 Reimbursement, hipaa, and compliance | 1 | ||
| Introduction | 2 | ||
| Basic structure of the medicare program | 2 | ||
| Quality improvement organizations (QIOs) | 4 | ||
| Part A: Hospital insurance | 4 | ||
| Part B: Supplementary insurance | 5 | ||
| Part C: Medicare advantage organizations | 5 | ||
| Part D: Prescription drugs | 6 | ||
| Health insurance portability and accountability act | 6 | ||
| Electronic transactions | 7 | ||
| Code sets | 7 | ||
| Privacy requirements | 8 | ||
| Security requirements | 8 | ||
| National provider identification | 8 | ||
| Federal register | 9 | ||
| Outpatient resource-based relative value scale (rbrvs) | 11 | ||
| Relative value unit | 12 | ||
| Geographic practice cost index | 12 | ||
| Conversion factor | 12 | ||
| Medicare volume performance standards | 13 | ||
| Beneficiary protection | 13 | ||
| Limiting charge | 13 | ||
| Uniformity provision | 14 | ||
| Adjustments | 14 | ||
| Site-of-service limitations | 14 | ||
| Surgical modifier circumstances | 15 | ||
| Multiple surgeries | 15 | ||
| General. | 15 | ||
| Endoscopic procedures. | 15 | ||
| Dermatologic surgery. | 15 | ||
| Providers furnishing part of the global fee package. | 15 | ||
| Physicians who assist at surgery. | 15 | ||
| Two surgeons and surgical team. | 15 | ||
| Purchased diagnostic services. | 16 | ||
| Reoperations. | 16 | ||
| Medicare fraud | 16 | ||
| Fraud defined | 16 | ||
| Who are the violators? | 17 | ||
| What forms does fraud take? | 17 | ||
| Who says what is fraudulent? | 17 | ||
| Specific regulations are in the ioms | 18 | ||
| How to protect yourself. | 19 | ||
| Managed health care | 19 | ||
| Types of HMOs | 20 | ||
| Drawbacks of the HMO. | 21 | ||
| Learning objective review | 23 | ||
| Glossary review | 23 | ||
| 2 ICD-10-CM | 24 | ||
| 2 An overview of icd-10-CM | 24 | ||
| The ICD-10-CM | 25 | ||
| ICD-10-CM replaces the ICD-9-CM, volumes 1 and 2 | 26 | ||
| Improvements in the ICD-10-CM | 26 | ||
| Structure of the system | 28 | ||
| Mapping | 29 | ||
| Flags | 29 | ||
| Approximate | 29 | ||
| Approximate, flag 0. | 29 | ||
| Approximate, flag 1. | 30 | ||
| No map. | 32 | ||
| Combination. | 32 | ||
| Scenario and choice list. | 32 | ||
| Icd-10-cm format | 34 | ||
| Index | 34 | ||
| Tabular | 38 | ||
| Chapters | 38 | ||
| Chapter format. | 39 | ||
| Section. | 39 | ||
| Category. | 40 | ||
| Subcategory. | 40 | ||
| Subclassification. | 40 | ||
| Bold type | 40 | ||
| Italicized type | 40 | ||
| Official instructional notations in the icd-10-cm | 41 | ||
| Conventions | 41 | ||
| Nec. | 42 | ||
| Nos. | 42 | ||
| Brackets [ ] | 42 | ||
| Parentheses ( ) | 42 | ||
| Nonessential modifiers. | 42 | ||
| Colon : | 43 | ||
| And and with. | 43 | ||
| And. | 43 | ||
| With. | 43 | ||
| Includes | 43 | ||
| Excludes | 44 | ||
| Excludes1. | 44 | ||
| Excludes2. | 44 | ||
| Code first/use additional code | 45 | ||
| Code also | 45 | ||
| Default codes | 46 | ||
| Code assignment and clinical criteria | 46 | ||
| 7th characters and placeholder X | 46 | ||
| Cross-references | 47 | ||
| Learning objective review | 48 | ||
| Glossary review | 48 | ||
| 3 ICD-10-CM outpatient coding and reporting guidelines | 49 | ||
| First-listed diagnosis | 50 | ||
| Unconfirmed diagnosis | 52 | ||
| Outpatient surgery | 53 | ||
| Additional diagnoses | 53 | ||
| Z codes | 54 | ||
| Status code | 56 | ||
| External cause index | 59 | ||
| Index locations | 59 | ||
| Circumstances to assign Z codes | 60 | ||
| History of | 62 | ||
| Observation stay | 63 | ||
| First-listed diagnosis and coexisting conditions | 64 | ||
| Uncertain diagnoses | 65 | ||
| Chronic diseases | 67 | ||
| Documented conditions | 67 | ||
| Diagnostic services | 68 | ||
| Therapeutic services | 69 | ||
| Preoperative evaluation | 70 | ||
| Preoperative evaluations only | 71 | ||
| Prenatal visits | 72 | ||
| Learning objective review | 74 | ||
| Glossary review | 74 | ||
| 4 Using ICD-10-CM | 75 | ||
| Organization of the guidelines | 76 | ||
| Accurate coding | 76 | ||
| Alphabetic index and tabular list | 76 | ||
| Level of specificity | 78 | ||
| Integral conditions | 80 | ||
| Multiple coding | 82 | ||
| Acute and chronic | 84 | ||
| Combination codes | 86 | ||
| Late effects | 88 | ||
| Reporting same diagnosis code more than once | 90 | ||
| Laterality | 91 | ||
| Learning objective review | 93 | ||
| Glossary review | 93 | ||
| 5 Chapter-specific guidelines (ICD-10-CM chapters 1-10) | 94 | ||
| Certain infectious and parasitic diseases | 95 | ||
| Resistant infections | 96 | ||
| A codes (a00-a99) | 96 | ||
| Sepsis, severe sepsis, and septic shock | 97 | ||
| Zika virus infections | 100 | ||
| B codes (b00-b99) | 100 | ||
| Viral hepatitis | 101 | ||
| Human immunodeficiency | 101 | ||
| Neoplasms | 103 | ||
| Neoplasm classifications and staging | 108 | ||
| Sequencing and complications. | 109 | ||
| History of z codes. | 111 | ||
| Unknown or unspecified site. | 112 | ||
| Diseases of the blood and blood-forming organs and certain disorders involving the immune mechanism | 113 | ||
| Anemia | 114 | ||
| Coagulation defects, purpura, and other hemorrhagic conditions | 115 | ||
| Other disorders of blood and blood-forming organs (D70-D77) | 116 | ||
| Endocrine, nutritional, and metabolic diseases | 116 | ||
| Mental, behavioral, and neurodevelopmental disorders | 120 | ||
| Dementia | 121 | ||
| Substance use | 121 | ||
| Psychological disorders | 121 | ||
| Psychological pain | 122 | ||
| Diseases of the nervous system | 123 | ||
| Pain (non-psychological) | 124 | ||
| Dominant and nondominant sides | 127 | ||
| Diseases of the eye and adnexa | 128 | ||
| Hordeolum and chalazion | 128 | ||
| Entropion and ectropion | 129 | ||
| Lacrimal system | 129 | ||
| Diseases of the ear and mastoid process | 130 | ||
| Ear | 130 | ||
| External ear. | 130 | ||
| Middle ear and mastoid. | 131 | ||
| Inner ear. | 131 | ||
| Diseases of the circulatory system | 131 | ||
| Hypertension | 132 | ||
| Kidney disease and hypertension | 135 | ||
| Myocardial infarction | 135 | ||
| Diseases of the respiratory system | 138 | ||
| Learning objective review | 141 | ||
| Glossary review | 141 | ||
| 6 Chapter-specific guidelines (ICD-10-CM chapters 11-14) | 143 | ||
| Diseases of the digestive system | 144 | ||
| Hemorrhage | 144 | ||
| Diseases of the skin and subcutaneous tissue | 145 | ||
| Ulcers | 147 | ||
| Diseases of the musculoskeletal system and connective tissue | 149 | ||
| Infectious arthropathies | 150 | ||
| M00 reports direct infection from a known organism. | 151 | ||
| M01 reports direct infection of the joint due to infectious or parasitic disease that is classified elsewhere. | 152 | ||
| M02 reports indirect infections from an unknown organism. | 152 | ||
| Pathological fractures | 153 | ||
| Diseases of the genitourinary system | 155 | ||
| Learning objective review | 156 | ||
| Glossary review | 156 | ||
| 7 Chapter-specific guidelines (ICD-10-CM chapters 15-21) | 157 | ||
| Pregnancy, childbirth, and the puerperium | 158 | ||
| General rules of obstetric diagnosis reporting | 158 | ||
| First-listed diagnosis in normal pregnancy | 159 | ||
| First-listed diagnosis in high-risk patients | 159 | ||
| First-listed diagnosis for delivery | 159 | ||
| Trimesters | 160 | ||
| Peripartum and postpartum periods | 162 | ||
| Normal delivery | 162 | ||
| Ectopic pregnancy | 163 | ||
| Hydatidiform mole | 163 | ||
| Hypertension in pregnancy | 164 | ||
| Fetal conditions | 165 | ||
| Diabetes mellitus in pregnancy | 166 | ||
| Certain conditions originating in the perinatal period | 167 | ||
| First-listed diagnosis | 168 | ||
| Congenital malformations, deformations and chromosomal abnormalities | 168 | ||
| Symptoms, signs, and abnormal clinical and laboratory findings, not elsewhere classified | 171 | ||
| Injury, poisoning, and certain other consequences of external causes | 175 | ||
| Code extensions | 176 | ||
| Coding injuries | 177 | ||
| Coding fractures | 178 | ||
| Coding burns and corrosions | 180 | ||
| Coding adverse effects, poisoning, underdosing, and toxic effects | 184 | ||
| Abuse, neglect, and other maltreatment | 188 | ||
| Open wounds, lacerations, and punctures | 189 | ||
| Complications | 191 | ||
| Medical device, graft, or implant. | 192 | ||
| Transplant. | 192 | ||
| Learning objective review | 194 | ||
| Glossary review | 194 | ||
| 3 CPT AND HCPCS | 195 | ||
| 8 Introduction to CPT | 195 | ||
| The purpose of the CPT manual | 196 | ||
| Updating the CPT manual | 196 | ||
| CPT manual format | 198 | ||
| Important symbols and appendices | 199 | ||
| CPT sections | 202 | ||
| The sections of the CPT manual | 202 | ||
| CPT guidelines | 204 | ||
| Code format | 205 | ||
| Modifiers | 207 | ||
| Unlisted procedures | 208 | ||
| Category II codes | 209 | ||
| Category III codes | 211 | ||
| Format of category III codes. | 211 | ||
| Publication of category III codes. | 212 | ||
| Special reports | 212 | ||
| Starting with the index | 212 | ||
| Locating the terms | 212 | ||
| Single code | 212 | ||
| Multiple codes | 213 | ||
| Range of codes | 213 | ||
| See | 216 | ||
| Learning objective review | 217 | ||
| Glossary review | 217 | ||
| 9 Introduction to the level II national codes (HCPCS) | 218 | ||
| History of national level codes | 219 | ||
| Two levels of codes | 219 | ||
| Code groupings | 220 | ||
| Temporary procedure/professional services. | 222 | ||
| G codes | 222 | ||
| K codes | 222 | ||
| Q codes | 223 | ||
| S codes | 223 | ||
| T codes | 223 | ||
| Miscellaneous codes | 224 | ||
| Updating the hcpcs manual | 225 | ||
| Hcpcs format | 225 | ||
| Index | 225 | ||
| Alphanumeric listing | 226 | ||
| General rules | 227 | ||
| Modifiers | 227 | ||
| Medicare advanced beneficiary notice of noncoverage (abn) the | 228 | ||
| -GA | 228 | ||
| -GX | 228 | ||
| -GY | 228 | ||
| -GZ | 228 | ||
| Table of drugs | 229 | ||
| Routes of administration of drugs. the route of administratio | 230 | ||
| Durable medical equipment | 231 | ||
| National physician fee schedule | 234 | ||
| Learning objective review | 236 | ||
| Glossary review | 236 | ||
| 10 Modifiers | 237 | ||
| CPT modifiers | 238 | ||
| -22, increased procedural services | 238 | ||
| -23, unusual anesthesia | 239 | ||
| -24, unrelated evaluation and management service by the same physician or other qualified health ... | 240 | ||
| -25, significant separately identifiable e/m service by the same physician or other qualified health ... | 240 | ||
| -26, professional component | 241 | ||
| -32, mandated services | 243 | ||
| -33, preventive service | 243 | ||
| -47, anesthesia by surgeon | 243 | ||
| -50, bilateral procedures | 243 | ||
| -51, multiple procedures | 244 | ||
| Same operation, different site. | 245 | ||
| Multiple operation(s), same operative session. | 245 | ||
| Procedure performed multiple times. | 246 | ||
| -52, reduced services | 248 | ||
| -53, discontinued procedure | 250 | ||
| Modifiers -54, -55, and -56 | 250 | ||
| -54, surgical care only | 251 | ||
| -55, postoperative management only | 251 | ||
| -56, preoperative management only | 252 | ||
| -57, decision for surgery | 252 | ||
| -58, staged or related procedure or service by the same physician or other qualified health care ... | 253 | ||
| -59, distinct procedural service | 254 | ||
| Modifiers -x{epsu} | 254 | ||
| -62, two surgeons | 255 | ||
| -63, procedure performed on infants less than 4 kg | 256 | ||
| -66, surgical team | 256 | ||
| -76, repeat procedure or service by same physician or other qualified health care professional | 257 | ||
| -77, repeat procedure by another physician or other qualified health care professional | 257 | ||
| -78, unplanned return to the operating/procedure room by the same physician or other... | 258 | ||
| -79, unrelated procedure or service by the same physician or other qualified health care ... | 259 | ||
| -80, assistant surgeon | 259 | ||
| -81, minimum assistant surgeon | 260 | ||
| -82, assistant surgeon (when qualified resident surgeon not available) | 260 | ||
| -90, reference (outside) laboratory | 261 | ||
| -91, repeat clinical diagnostic laboratory test | 261 | ||
| -92, alternative laboratory platform testing | 262 | ||
| -95, synchronous telemedicine services | 262 | ||
| -99, multiple modifiers | 262 | ||
| Learning objective review | 263 | ||
| Glossary review | 264 | ||
| 11 Evaluation and management (E/M) services | 265 | ||
| Contents of the e/m section | 266 | ||
| Three factors of E/M codes | 266 | ||
| Place of service | 266 | ||
| Type of service | 267 | ||
| Patient status | 267 | ||
| Medical records documentation | 268 | ||
| Various levels of E/M service | 269 | ||
| Key components | 269 | ||
| Office, new patient | 269 | ||
| History. | 271 | ||
| Examination. | 277 | ||
| Examination levels. | 277 | ||
| Examination levels | 277 | ||
| Medical decision making. | 281 | ||
| Levels. | 282 | ||
| Medical decision making complexity levels | 282 | ||
| Management options. | 282 | ||
| Data to be reviewed. | 282 | ||
| Risk. | 283 | ||
| Contributory factors | 288 | ||
| Counseling. | 288 | ||
| Coordination of care. | 288 | ||
| Nature of the presenting problem. | 289 | ||
| An E/M code example | 290 | ||
| Using the E/M codes | 291 | ||
| Office and other outpatient services | 291 | ||
| New patient. | 291 | ||
| Established patient. | 293 | ||
| Hospital observation services | 295 | ||
| Observation care discharge services. | 295 | ||
| Initial observation care. | 295 | ||
| Subsequent observation care. | 296 | ||
| Hospital inpatient services | 297 | ||
| Initial hospital care. | 297 | ||
| Subsequent hospital care. | 298 | ||
| Observation or inpatient care services (including admission and discharge services). | 299 | ||
| Hospital discharge services. | 299 | ||
| Consultation services | 300 | ||
| Office or other outpatient consultations. | 301 | ||
| Inpatient consultations. | 302 | ||
| Emergency department services | 306 | ||
| Other emergency department services. | 306 | ||
| Critical care services | 307 | ||
| Nursing facility services | 309 | ||
| Initial nursing facility care. | 310 | ||
| Subsequent nursing facility care. | 310 | ||
| Nursing facility discharge services. | 310 | ||
| Other nursing facility services. | 310 | ||
| Domiciliary, rest home (e.g., boarding home), or custodial care services | 312 | ||
| Domiciliary, rest home (e.g., assisted living facility), or home care plan oversight services | 312 | ||
| Home services | 312 | ||
| Prolonged services | 313 | ||
| Prolonged physician services with or without direct patient contact. | 313 | ||
| Standby services. | 314 | ||
| Case management services | 315 | ||
| Medical team conferences. | 315 | ||
| Care plan oversight services | 316 | ||
| Preventive medicine services | 316 | ||
| Counseling risk factor reduction and behavior change intervention. | 317 | ||
| Non-face-to-face services | 317 | ||
| Special evaluation and management services | 317 | ||
| Newborn care services | 318 | ||
| Inpatient neonatal intensive care and pediatric and neonatal critical care services (99466-99486) | 318 | ||
| Pediatric critical care patient transport. | 318 | ||
| Inpatient neonatal and pediatric critical care. | 319 | ||
| Initial and continuing intensive care services. | 319 | ||
| Care management services (99487-99490) | 320 | ||
| Chronic care management services (99490) | 320 | ||
| Complex chronic care management services (99487, 99489) | 320 | ||
| Transitional care management services (99495-99496) | 320 | ||
| Advance care planning (99497-99498) | 320 | ||
| Other evaluation and management services | 320 | ||
| Coding practice | 320 | ||
| Documentation guidelines | 322 | ||
| History of the development of guidelines | 322 | ||
| Learning objective review | 325 | ||
| Glossary review | 325 | ||
| 12 Anesthesia | 326 | ||
| Types of anesthesia | 327 | ||
| Moderate (conscious) sedation | 329 | ||
| Anesthesia section format | 330 | ||
| Formula for anesthesia payment | 331 | ||
| B is for base unit | 332 | ||
| Cms’s base units. | 333 | ||
| T is for time | 334 | ||
| M is for modifying unit | 335 | ||
| Qualifying circumstances. | 335 | ||
| Physical status modifiers. | 338 | ||
| Summing it up! | 339 | ||
| Conversion factor. | 340 | ||
| Multiple procedures | 340 | ||
| Concurrent modifiers | 341 | ||
| Unlisted anesthesia code | 342 | ||
| Other reporting | 344 | ||
| Return to operating room | 344 | ||
| Pre-anesthetic examination | 344 | ||
| Learning objective review | 345 | ||
| Glossary review | 345 | ||
| 13 Surgery guidelines and general surgery | 346 | ||
| Introduction to the surgery section | 347 | ||
| Notes and guidelines | 347 | ||
| Unlisted procedures | 350 | ||
| Special reports | 351 | ||
| Separate procedure | 351 | ||
| Surgical package | 353 | ||
| General subsection | 356 | ||
| Learning objective review | 358 | ||
| Glossary review | 358 | ||
| 14 Integumentary system | 359 | ||
| Integumentary system | 360 | ||
| Format | 360 | ||
| Skin, subcutaneous, and accessory structures | 361 | ||
| Introduction and removal (10030-10036) | 361 | ||
| Incision and drainage | 361 | ||
| Debridement | 361 | ||
| Excision—debridement | 362 | ||
| Introduction to lesions | 362 | ||
| Lesion excision and destruction. | 363 | ||
| Closure of excision sites. | 365 | ||
| Paring or cutting | 365 | ||
| Biopsy | 366 | ||
| Skin tags | 367 | ||
| Shaving of epidermal or dermal lesions | 368 | ||
| Excision—benign lesions | 368 | ||
| Excision—malignant lesions | 369 | ||
| Nails | 370 | ||
| Pilonidal cyst | 372 | ||
| Introduction | 372 | ||
| Repair (closure) | 373 | ||
| Repair factors | 373 | ||
| Repair component | 376 | ||
| Tissue transfers, grafts, and flaps | 376 | ||
| Adjacent tissue transfer or rearrangement. | 376 | ||
| Skin replacement surgery (15002-15278). | 377 | ||
| Flaps. | 379 | ||
| Other procedures | 381 | ||
| Pressure ulcers | 382 | ||
| Burns | 383 | ||
| Destruction | 386 | ||
| Mohs micrographic surgery | 386 | ||
| Breast procedures | 388 | ||
| Learning objective review | 391 | ||
| Glossary review | 391 | ||
| 15 Musculoskeletal system | 392 | ||
| Format | 393 | ||
| Fractures and dislocations | 394 | ||
| Fractures | 394 | ||
| Dislocations | 398 | ||
| General | 399 | ||
| Incision | 399 | ||
| Wound exploration | 400 | ||
| Excision | 401 | ||
| General introduction or removal | 401 | ||
| Grafts (or implants) | 404 | ||
| Other procedures | 405 | ||
| Spinal instrumentation and fixation | 405 | ||
| Foot and toe repairs | 406 | ||
| Application of casts and strapping | 407 | ||
| Endoscopy/arthroscopy | 409 | ||
| Learning objective review | 412 | ||
| Glossary review | 412 | ||
| 16 Respiratory system | 413 | ||
| Format | 414 | ||
| Endoscopy | 415 | ||
| Nose | 416 | ||
| Incision | 416 | ||
| Excision | 417 | ||
| Introduction | 418 | ||
| Removal of a foreign body | 419 | ||
| Repair | 419 | ||
| Destruction | 419 | ||
| Other procedures | 420 | ||
| Accessory sinuses | 421 | ||
| Incision | 421 | ||
| Larynx | 422 | ||
| Excision | 422 | ||
| Introduction | 422 | ||
| Repair | 423 | ||
| Trachea/bronchi | 424 | ||
| Incision | 424 | ||
| Introduction | 425 | ||
| Excision/repair | 425 | ||
| Lungs and pleura | 425 | ||
| Incision | 426 | ||
| Excision | 426 | ||
| Removal | 426 | ||
| Surgical collapse therapy; thoracoplasty | 428 | ||
| Learning objective review | 429 | ||
| Glossary review | 429 | ||
| 17 Cardiovascular system | 430 | ||
| Coding highlights | 431 | ||
| Coding from three sections | 431 | ||
| Invasive | 431 | ||
| Noninvasive | 432 | ||
| Electrophysiology | 432 | ||
| Nuclear cardiology | 432 | ||
| Cardiovascular coding in the surgery section | 433 | ||
| Heart and pericardium | 434 | ||
| Pericardium. | 435 | ||
| Cardiac tumor. | 435 | ||
| Transmyocardial revascularization. | 436 | ||
| Pacemaker or implantable defibrillator. | 436 | ||
| Approaches. | 437 | ||
| Electrophysiologic operative procedures. | 439 | ||
| Patient-activated event recorder. | 439 | ||
| Heart (including valves) and great vessels. | 439 | ||
| Cardiac valves. | 439 | ||
| Coronary artery anomalies. | 440 | ||
| Coronary artery bypass. | 440 | ||
| Extracorporeal membrane oxygenation and extracorporeal life support services. | 443 | ||
| Arteries and veins | 443 | ||
| Vascular families—selective or nonselective placement. | 445 | ||
| Embolectomy/thrombectomy. | 447 | ||
| Vascular repairs. | 448 | ||
| Bypass grafts. | 449 | ||
| Vascular access. | 449 | ||
| Vascular injection procedure. | 449 | ||
| Cardiovascular coding in the medicine section | 453 | ||
| Other therapeutic services and procedures | 453 | ||
| Cardiography and cardiovascular monitoring services | 455 | ||
| Implantable and wearable cardiac device evaluations | 458 | ||
| Echocardiography | 458 | ||
| Cardiac catheterization | 460 | ||
| Intracoronary brachytherapy | 461 | ||
| Intracardiac electrophysiologic procedures/studies | 462 | ||
| Peripheral arterial disease rehabilitation | 463 | ||
| Noninvasive physiologic studies and procedures | 464 | ||
| Other procedures | 464 | ||
| Cardiovascular coding in the radiology section | 464 | ||
| Heart | 467 | ||
| Aorta and arteries | 467 | ||
| Learning objective review | 469 | ||
| Glossary review | 469 | ||
| 18 Hemic, lymphatic, mediastinum, and diaphragm | 470 | ||
| Hemic and lymphatic systems | 471 | ||
| Format | 471 | ||
| Coding highlights | 472 | ||
| Spleen. | 472 | ||
| Laparoscopy. | 472 | ||
| Introduction. | 472 | ||
| General. | 472 | ||
| Lymph nodes and lymphatic channels | 473 | ||
| Regions of neck lymph nodes. | 474 | ||
| Mediastinum and diaphragm | 475 | ||
| Mediastinum | 475 | ||
| Incision. | 475 | ||
| Excision. | 476 | ||
| Endoscopy. | 476 | ||
| Diaphragm | 476 | ||
| Learning objective review | 478 | ||
| Glossary review | 478 | ||
| 19 Digestive system | 479 | ||
| Format | 480 | ||
| Lips | 481 | ||
| Vestibule of mouth | 482 | ||
| Tongue and floor of mouth | 482 | ||
| Dentoalveolar structures | 484 | ||
| Palate and uvula | 484 | ||
| Salivary gland and ducts | 484 | ||
| Pharynx, adenoids, and tonsils | 486 | ||
| Esophagus | 488 | ||
| Stomach | 492 | ||
| Intestines (except rectum) | 493 | ||
| Meckel’s diverticulum and the mesentery | 495 | ||
| Appendix | 496 | ||
| Colon and rectum | 496 | ||
| Endoscopy (proctosigmoidoscopy, sigmoidoscopy, and colonoscopy) | 496 | ||
| Proctosigmoidoscopy. | 496 | ||
| Sigmoidoscopy. | 496 | ||
| Diagnostic colonoscopy. | 497 | ||
| Colonoscopy. | 497 | ||
| Evaluation and management services reported with a diagnostic colonoscopy. | 498 | ||
| Colonoscopy injection. | 500 | ||
| Multiple procedures. | 500 | ||
| Virtual colonoscopy. | 500 | ||
| Anus | 501 | ||
| Liver | 503 | ||
| Biliary tract | 504 | ||
| Pancreas | 504 | ||
| Abdomen, peritoneum, and omentum | 505 | ||
| Learning objective review | 507 | ||
| Glossary review | 507 | ||
| 20 Urinary and male genital systems | 508 | ||
| Urinary system | 509 | ||
| Kidney | 509 | ||
| Incision. | 509 | ||
| Excision. | 512 | ||
| Renal transplantation. | 512 | ||
| Introduction. | 513 | ||
| Repair. | 513 | ||
| Laparoscopy. | 515 | ||
| Endoscopy. | 515 | ||
| Kidney index locations. | 515 | ||
| Ureter | 516 | ||
| Incision/biopsy. | 516 | ||
| Excision. | 516 | ||
| Introduction. | 517 | ||
| Repair. | 517 | ||
| Laparoscopy. | 517 | ||
| Endoscopy. | 517 | ||
| Bladder | 519 | ||
| Incision. | 519 | ||
| Removal. | 519 | ||
| Excision. | 520 | ||
| Introduction. | 520 | ||
| Urodynamics. | 521 | ||
| Repair and laparoscopy. | 521 | ||
| Endoscopy. | 521 | ||
| Transurethral surgery. | 522 | ||
| Vesical neck and prostate. | 523 | ||
| Urethra | 524 | ||
| Incision. | 524 | ||
| Excision. | 524 | ||
| Repair. | 525 | ||
| Manipulation. | 525 | ||
| Male genital system | 526 | ||
| Format | 526 | ||
| Penis | 526 | ||
| Incisions. | 526 | ||
| Destruction. | 527 | ||
| Excision. | 527 | ||
| Introduction. | 528 | ||
| Repair. | 528 | ||
| Testis | 529 | ||
| Excision. | 529 | ||
| Exploration, repair, and laparoscopy. | 529 | ||
| Epididymis | 530 | ||
| Excision. | 531 | ||
| 4 INPATIENT CODING | 665 | ||
| 27 Inpatient coding | 665 | ||
| Differences between inpatient and outpatient coding | 666 | ||
| Selection of principal diagnosis | 667 | ||
| Symptoms, signs, and ill-defined conditions | 668 | ||
| Two or more interrelated conditions | 669 | ||
| Two or more diagnoses | 670 | ||
| Comparative or contrasting conditions | 671 | ||
| Original treatment plan not carried out | 672 | ||
| Complications | 673 | ||
| Uncertain diagnosis | 674 | ||
| Reporting additional diagnoses | 676 | ||
| Present on admission (POA) | 679 | ||
| Development of the icd-10-PCS | 679 | ||
| The seven characters of the icd-10-PCS | 680 | ||
| Character 1 identifies the section. | 680 | ||
| Changing characters. | 681 | ||
| Character 2 is the body system. | 681 | ||
| Character 3 is the root operation. | 681 | ||
| A closer look at root operations. | 682 | ||
| The index | 683 | ||
| The tabular list completes the code | 683 | ||
| Learning objective review | 691 | ||
| Glossary review | 691 | ||
| APPENDIX A Online resources | 692 | ||
| APPENDIX B Exercise, quick check, and toolbox answers | 693 | ||
| Chapter 1 | 693 | ||
| APPENDIX C Learning objective and glossary review answers | 717 | ||
| Chapter 1 | 717 | ||
| APPENDIX D Ehr screens | 723 | ||
| Glossary | 730 | ||
| Figure credits | 745 | ||
| Introduction | 745 | ||
| Chapter 1 | 745 | ||
| Chapter 2 | 745 | ||
| Chapter 3 | 745 | ||
| Chapter 4 | 745 | ||
| Chapter 5 | 745 | ||
| Chapter 6 | 745 | ||
| Chapter 7 | 745 | ||
| Chapter 8 | 745 | ||
| Chapter 9 | 745 | ||
| Chapter 10 | 745 | ||
| Chapter 11 | 746 | ||
| Chapter 12 | 746 | ||
| Chapter 13 | 746 | ||
| Chapter 14 | 746 | ||
| Chapter 15 | 746 | ||
| Chapter 16 | 746 | ||
| Chapter 17 | 747 | ||
| Chapter 18 | 747 | ||
| Chapter 19 | 747 | ||
| Chapter 20 | 747 | ||
| Chapter 21 | 747 | ||
| Chapter 22 | 747 | ||
| Chapter 23 | 747 | ||
| Chapter 24 | 747 | ||
| Chapter 25 | 748 | ||
| Chapter 26 | 748 | ||
| Chapter 27 | 748 | ||
| Coders index | 749 | ||
| CPT codes | 749 | ||
| ICD-10-CM codes | 749 | ||
| HCPCS codes | 749 | ||
| Index | 759 | ||
| A | 759 | ||
| B | 759 | ||
| C | 760 | ||
| D | 762 | ||
| E | 762 | ||
| F | 763 | ||
| G | 764 | ||
| H | 764 | ||
| I | 765 | ||
| J | 766 | ||
| K | 766 | ||
| L | 766 | ||
| M | 766 | ||
| N | 768 | ||
| O | 768 | ||
| P | 769 | ||
| Q | 769 | ||
| R | 770 | ||
| S | 771 | ||
| T | 772 | ||
| U | 772 | ||
| V | 772 | ||
| W | 772 | ||
| X | 773 | ||
| Z | 773 |