Loose Leaf for Medical Coding Fundamentals

by Goldsmith, Susan; Leib, Marc

• ISBN13: 9780077755133
• ISBN10: 0077755138
• Edition: 1st
• Format: Nonspecific Binding
• Copyright: 2012-11-27
• Publisher: McGraw-Hill Education
• More Book Details
• Purchase Benefits

Summary

Medical Coding Fundamentals provides a fresh approach to medical coding that reflects the way real medical coders succeed in their jobs. An introductory chapter refreshes students on the basics of A&P and medical terminology. Authentic examples clearly illustrate key areas, from the basics of CPT, ICD and HCPCS through complex topics such as modifiers and E/M. In order to train students to become proficient, accurate coders who are well-prepared to take the steps towards coding certification, exercises throughout each chapter and the entire final chapter provide plenty of coding practice, as well as critical thinking to prepare the next generation of coders.

Don’t worry about ICD-10, either. Medical Coding Fundamentals tackles the transition head on, providing you with just the right blend of coverage.

Table of Contents

MEDICAL CODING FUNDAMENTALS

CHAPTER 1: MEDICAL TERMINOLOGY, ANATOMY, AND PHYSIOLOGY

Word Elements

Root Words

Combining Vowels and Combining Forms

Prefixes

Suffixes

Eponyms, Abbreviations, and Acronyms

Eponyms

Abbreviations and Acronyms

Anatomy and Physiology

Integumentary System

Musculoskeletal System

Cardiovascular System

Lymphatic System

Respiratory System

Digestive System

Urinary System

Reproductive System

Nervous System

Endocrine System

Hemic System

ICD-10-CM and Medical Terminology

PART I: ICD-9-CM AND ICD-10-CM

CHAPTER 2: INTRODUCTION TO ICD-9-CM

The Structure of the ICD-9-CM Manual

Using Volumes 1 and 2 to Determine Diagnosis Codes

Volume 2: Alphabetic Index of Diseases

Volume 1: Tabular List of Diseases

Volume 3: Tabular List and Alphabetic List for Procedure Codes

ICD-9-CM Conventions

Abbreviations

Punctuation

Use Additional Code Instruction

Code First Underlying Disease Instruction

Update Notations

Additional Digit Specificity Indicator

Diagnosis Code-Specific Color Highlights

Age Conflict Edits

Sex Conflict Edits

Hospital Acquired Condition (HAC) Indicator

Other and Unspecified Codes

"See" and "See Also" Instructions

Signs and Symptoms

Combination Codes

Outpatient Coding Principles

Specific Guidelines for Coding Outpatient Encounters

CHAPTER 3: ICD-9-CM CHAPTER-SPECIFIC GUIDELINES, PART I: CHAPTERS 1-10

Coding Diseases and Disorders, Chapters 1-3

Chapter 1: Infectious and Parasitic Diseases (001-139)

Chapter 2: Neoplasm (140-239)

Chapter 3: Endocrine, Nutritional, and Metabolic Diseases and Immunity Disorders (240-279)

Coding Diseases and Disorders, Chapters 4-6

Chapter 4: Diseases of Blood and Blood-forming Organs (280-289)

Chapter 5: Mental Disorders (290-319)

Chapter 6: Diseases of Nervous System and Sense Organs (320-389)

Coding Diseases, Chapters 7-8

Chapter 7: Diseases of the Circulatory System (390-459)

Chapter 8: Diseases of the Respiratory System (460-519)

Coding Diseases, Chapters 9-10

Chapter 9: Diseases of the Digestive System (520-579)

Chapter 10: Diseases of the Genitourinary System (580-629)

CHAPTER 4: ICD-9-CM CHAPTER-SPECIFIC GUIDELINES, PART II: CHAPTERS 11-19

Coding Conditions and Complications of Pregnancy, Chapter 11

Chapter 11: Pregnancy, Childbirth and the Puerperium (630-679)

Coding Diseases, Chapters 12-13

Chapter 12: Diseases of Skin and Subcutaneous Tissue (680-709)

Chapter 13: Diseases of the Musculoskeletal System and Connective Tissue (710-739)

Coding Abnormalities and Unusual Conditions, Chapters 14-17

Chapter 14: Congenital Anomalies (740-750)

Chapter 15: Certain Conditions Originating in the Perinatal Period (760-779)

Chapter 16: Symptoms, Signs, and Ill-Defined Conditions (780-799)

Chapter 17: Injury and Poisoning (800-999)

V-Codes and E-Codes, Chapters 18-19

Chapter 18: Supplemental Classification of Factors Influencing Health Status and Contact With Health Services (V01-V91)

Chapter 19: Supplemental Classification of External Causes of Injury and Poisoning (E000-E030, E800-E999)

CHAPTER 5: INTRODUCTION TO ICD-10-CM

Transitioning to the ICD-10-CM Coding System

General Equivalence Mapping

Diagnosis Code Structure

Laterality

Trimesters

Initial Treatment, Subsequent Encounter and Sequelae

Structure of the ICD-10-CM Manual

ICD-10-CM Conventions and General Guidelines

Conventions

General Guidelines

Introduction to ICD-10-PCS

Breakdown of Sections

PART II: CPT AND HCPCS

CHAPTER 6: INTRODUCTION TO CPT

Structure of the CPT Manual

Code Sections

Code Format and Additional Information

Indented Code Structure

Symbols

Parenthetical Notes

Modifiers

Separate Procedure

Other Information Included in the CPT Manual

Index

Appendices

Introductory Pages

Information Listed Inside Front and Back Covers

Reporting Category II Codes and Using Category II Modifiers

Format of Category II Codes

Types of Category II Performance Measurement Codes

Reporting Category III Codes

CHAPTER 7: MODIFIERS

The Function and Use of Modifiers

Services Provided During the Global Period

Modifier 24

Modifier 25

Modifier 57

Modifier 58

Modifier 76 and 77

Modifier 78

Modifier 79

Reporting Portions of a Procedure or Service

Professional and Technical Components

Surgical Procedure Components

Reporting Multiple Services on the Same Date

Modifier 50

Modifier 51

Modifier 59

Modifier 91

Identifying Additional Providers Involved in Procedures

Modifiers 80, 81, and 82

Modifier 62

Modifier 66

Reporting Procedures Involving Significantly More or Less Work Than Is Typical

Reporting Procedures Involving More Work Than Typical

Reporting Procedures Involving Less Work Than Typical

Reporting Mandatory Services, Physical Status and Genetic Tests

Mandatory Services

Physical Status Modifiers P1 through P6

Genetic Modifiers

HCPCS Modifiers

Anatomical Modifiers

Ambulance Modifiers

Equipment Modifiers

CHAPTER 8: EVALUATION AND MANAGEMENT SERVICES, PART I: STRUCTURE AND GUIDANCE

Categories and Subcategories of E/M Services

Subcategories of E/M Services

Defining Key Terms in E/M Coding

New vs. Established Patient

Chief Complaint

Concurrent Care and Transfer of Care

Counseling

Family History

History of Present Illness (HPI)

Nature of the Presenting Problem

Past History

Review of Systems

Physical Examination

Medical Decision Making

Social History

Time

Unlisted Services

Special Report

Selecting the Level of E/M Service

Working with Histories

Elements of History

The Physical Examination

The Complexity of Medical Decision Making

Selecting the Correct Level of E/M Services

Determining Coding Requirements

Special Situations

CHAPTER 9: EVALUATION AND MANAGEMENT SERVICES, PART II: CODE SELECTION

Outpatient Services Coding for New or Established Patients

New Patient (99201-99205)

Established Patient (99211-99215)

Categories and Suncategories of Hospital Services

Hospital Observation Services

Hospital Inpatient Services

Observation or Inpatient Care Services (IncludinSubcategoriesnd Discharge)

Hospital Discharge Services

Consultation Services

Office or Other Outpatient Consultations (99241-99245)

Inpatient Consultations (99251-99255)

Emergency Department Services

E/M Services for New or Established Patients (99281-99285)

Other Emergency Services (99288)

Reporting Critical Care Services

Services Included in Critical Care

Reporting E/M Codes in Other Settings

Nursing Facility Services

Domiciliary, Rest Home (e.g., Boarding Home), or Custodial Care Services

Home Services

New Patient (99341-99345)

Established Patient (99347-99350)

Prolonged Services and the Time Factor

Prolonged Physician Service with Direct Patient Contact (99354-99357)

Prolonged Physician Service Without Direct Patient Contact (99358-99359)

Physician Standby Services (99360)

Case Management and Care Plan Oversight Services

Case Management Services

Care Plan Oversight Services

Preventative Medicine Services

New Patient (99381-99387)

Established Patient (99391-99397)

Counseling Risk Factor Reduction and Behavior Change Intervention (99401-99412)

Special E/M Services

Telephone Services (99441-99443)

Online Medical Evaluation (99444)

Other Special E/M Services

Coding E/M Services for Pediatric Patients

Newborn Services

Inpatient Neonatal Intensive Care and Pediatric/Neonatal Critical Care

CHAPTER 10: ANESTHESIA SERVICES

Selecting Anesthesia CPT Codes Based on the Surgical Procedure

Anesthesia Time Units

Secondary Aspects of Anesthesia Coding

Physical Status Modifiers

Modifiers Identifying Professional Credentials of Anesthesia Providers

Modifiers Describing Reasons for Monitored Anesthesia Care (MAC)

Qualifying Circumstances Add-on Codes

Calculating Total Anesthesia Units

Selecting Anatomy-Based Anesthesia CPT Codes

Head (00100-00218)

Neck (00300-00352)

Thorax (Chest Wall and Shoulder Girdle) (00400-00474)

Intrathoracic Region (00500-00580)

Spine and Spinal Cords (00600-00670)

Upper Abdomen (00700-00797)

Lower Abdomen (00800-00882)

Perineum (00902-00952)

Pelvis (Except Hip) (01112-01190)

Upper Leg (Except Knee) (01200-01274)

Knee and Popliteal Area (01320-01444)

Lower Leg (Below Knee, Includes Ankle and Foot) (01462-01522)

Shoulder and Axilla (01610-01682)

Upper Arm and Elbow (01710-01782)

Forearm, Wrist and Hand (01810-01860)

Coding for Specific Procedures

Radiological Procedures (01916-01936)

Burn Excisions or Debridement (01951-01953)

Obstetric Anesthesia (01958-01969)

Other Procedures (01990-01999)

CHAPTER 11: RADIOLOGY SERVICES

Positions, Projections and Planes

Reporting Radiology Services

Unlisted Codes

Modifiers

Radiology CPT Coding

Diagnostic Radiology (Diagnostic Imaging) (70010-76499)

Diagnostic Ultrasound (76506-76999)

Radiologic Guidance (77001-77032)

Mammography Services (77051-77059)

Bone/Joint Studies (77071-77084)

Radiation Oncology (77261-77799)

Nuclear Medicine (78000-79999)

CHAPTER 12: SURGICAL PROCEDURES

Introduction

Follow-up Care

Multiple Procedures and "Separate Procedures"

Structure of the Surgical Section of the CPT

Module 12.1 General and Integumentary System

Reporting Procedures of the Skin and Subcutaneous Tissues

Wound Repair (Closure)

Skin Repair Procedures

Destruction of Lesions

Procedures on the Breast

Anesthesia Associated with Procedures on the Integumentary System

Module Review

Module 12.2 Musculoskeletal System

Musculoskeletal System Treatments

General Codes and Codes Describing Procedures on the Head, Neck, Thorax, Back and Flank

Codes Describing Procedures on the Back and Flank, Spinal Column and Abdomen

Codes Describing Procedures on the Extremeties and Joints

Casting, Strapping, Endoscopy and Arthroscopy

Anesthesia Associated with Procedures on the Musculoskeletal System

Module Review

Module 12.3 Respiratory System; Cardiovascular System; Hemic and Lymphatic Systems; Mediastinum and Diaphragm

Procedures on the Respiratory System (30000-32999)

Procedures on the Heart and Pericardium (33010-33999)

Procedures on the Arteries and Veins (34001-37799)

Procedures on the Hemic and Lymphatic System, Mediastinum, and Diaphragm

Anesthesia for Procedures in the 30000 Series

Module Review

Module 12.4 Digestive System

Procedures on the Mouth and Throat

Procedures on the Gastrointestinal Tract from the Esophagus to the Anus

Procedures on Organs Connected to the Digestive Tract

Anesthesia for Procedures in the 40000 Series

Module Review

Module 12.5 Urinary System, Male and Female Genital Systems, and Maternity Care and Delivery

Procedures on the Urinary System (50010-53899)

Procedures on the Male Genital System (54000-55899)

Procedures on the Female Genital System (56405-58999)

Maternal Care and Delivery (59000-59899)

Anesthesia for Procedures in the 50000 Series

Module Review

Module 12.6 Endocrine, Nervous, Ocular, and Auditory Systems

Endocrine System (60000-60699)

Procedures on the Skill, Meninges, and Brain (61000-62258)

Procedures on the Spine and Spinal Cord (62263-63746)

Procedures on Extracranial Nerves, Peripheral Nerves and the Autonomic Nervous System (64400-64999)

Procedures on Ocular Structures

Procedures on the Auditory System (69000-69979)

Anesthesia for Procedures in the 60000 Series

Module Review

CHAPTER 13: PATHOLOGY AND LABORATORY SERVICES

Organ or Disease-Oriented Panels (80047-80076)

Lab Tests Involving Drugs or Medicines

Drug Testing (80100-80104)

Therapeutic Drug Assay (80150-80299)

Evocative/Suppression Testing (80400-80440)

Reporting Other Lab Tests

Consultation (Clinical Pathology) (80500-80502)

Urinalysis (81000-81099)

Chemistry (82000-84999)

Hematology and Coagulation (85002-85999)

Immunology (86000-86849)

Transfusion Medicine (86850-86899)

Microbiology (87001-87999)

Pathology Services

Anatomic Pathology (88000-88099)

Cytopathology (88104-88199) and Cytogenetic Studies (88230-88299)

Surgical Pathology (88300-88399)

In Vivo Laboratory Procedures (88720-88741)

Reproductive Medicine Procedures (89250-89398)

CHAPTER 14: MEDICINE SERVICES

Medicine Chapter Structure and General Guidelines

Multiple Procedures

Add-on Codes

Separate Procedures

Unlisted Service or Procedure

Materials Supplied by Physician

Immune Globulins; Immunization Administration for Vaccines/Toxoids; Vaccines, Toxoids

Immune Globulins (90281-90399)

Immunization Administration for Vaccines/Toxoids (90460-90474)

Vaccines, Toxoids (90476-90479)

Psychiatry, Biofeedback, Dialysis, Gastroenterology, Ophthalomology, and Otorhinolaryngological Services

Psychiatry (90801-90899)

Biofeedback (90901 and 90911)

Dialysis (90935-90999)

Gastroenterology (91010-91299)

Ophthalmology (92002-92499)

Special Otorhinolaryngologic Services (92502-92700)

Cardiovascular, Immunological, and Neurological Services

Cardiovascular (92950-93799)

Noninvasive Vascular Diagnostic Studies (93875-93990)

Pulmonary (94002-94799)

Allergy and Clinical Immunology (95004-95199)

Endocrinology (95250-95251)

Neurology and Neuromuscular Procedures (95800-96020)

Medical Genetics and Genetic Counseling Services (96040)

Central Nervous System Assessments/Tests (96101-96125)

Health and Behavior Assessment/Intervention (96150-96155)

Injections and Infusions; Therapeutic Services; Rehabilitation; Moderate Sedation; Home Health and Medication Therapeutic Management Services

Hydration, Therapeutic Injections and Infusions, and Chemotherapy

Photodynamic Therapy (96567-96571)

Special Dermatological Procedures (96900-96999)

Physical Medicine and Rehabilitation (97001-97799)

Medical Nutrition Management (97802-97804)

Acupuncture (97810-97814)

Osteopathic Manipulative Treatment (98925-98929)

Chiropractic Manipulative Treatment (98940-98943)

Education and Training for Patient Self-Management (98960-98962)

Non-Face-to-Face Non-Physician Services (98966-98969)

Special Services, Procedures and Reports (99000-99091)

Qualifying Circumstances for Anesthesia (99100, 99116, 99135, and 99140)

Moderate Sedation (99143-99150)

Home Health Procedures/Services (99500-99602)

Medication Therapy Management Services (99605-99607)

CHAPTER 15: HCPCS

HCPCS Codes

Functions of HCPCS Codes

Uses of HCPCS Codes

Index and Tabular List of Services

Calculating Multiple Units of Service

Identifying Services Described by Each Category of HCPCS Codes

HCPCS A, B, C, D, and E Codes

A Codes: Transportation Services Including Ambulance; Medical & Surgical Supplies; Administrative, Miscellaneous & Investigational

B Codes: Enteral and Parenteral Therapy

C Codes: Outpatient HCPCS Codes

E Codes: Durable Medical Equipment

HCPCS G, H, J, K, L, and M Codes

G Codes: Procedures/Professional Services (Temporary); Physician's Voluntary Reporting Program Codes; Last Minute Additions

H Codes: Alcohol and Drug Abuse Treatment Services

J Codes: Drug Administered Other than Oral Method

K Codes: Temporary Codes

L Codes: Orthotic and Prosthetic Procedures (L0112-L9900)

Other Medical Services

HCPCS P, Q, R, S, T, and V Codes

P Codes: Pathology and Laboratory Services (P2028-P9615)

Q Codes: Miscellaneous Services (Temporary)

R Codes: Diagnostic Radiology Services

S Codes: Temporary National Codes (Non-Medicare)

T Codes: National T Codes Established for State Medicaid Agencies (T1000-T5999)

V Codes: Vision Services, Hearing Services & Speech-Language Pathology Services

HCPCS Modifiers and HCPCS Manual Appendices

Anatomic Modifiers

DME and Other Equipment Modifiers

Radiology Modifiers

Place of Service Modifier

Appendices

PART III: PRACTICUM

CHAPTER 16: PUTTING IT ALL TOGETHER

Coding Scenarios