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Conquer Medical Coding 2016: A Critical Thinking Approach with Coding Simulations [Mīkstie vāki]

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Stacey Mosay, Daphne Neris, Jean H. Jurek

Formāts: Paperback / softback, 608 pages, height x width x depth: 279x216x44 mm
Izdošanas datums: 08-Feb-2016
Izdevniecība: F.A. Davis Company
ISBN-10: 0803638183
ISBN-13: 9780803638181

Citas grāmatas par šo tēmu:

Clinical & internal medicine - (Noliktavā: 84 punkts)
Diseases & disorders - (Noliktavā: 23 punkts)
Nursing & ancillary services - (Noliktavā: 22 punkts)

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Formāts: Paperback / softback, 608 pages, height x width x depth: 279x216x44 mm
Izdošanas datums: 08-Feb-2016
Izdevniecība: F.A. Davis Company
ISBN-10: 0803638183
ISBN-13: 9780803638181

Citas grāmatas par šo tēmu:

Clinical & internal medicine - (Noliktavā: 84 punkts)
Diseases & disorders - (Noliktavā: 23 punkts)
Nursing & ancillary services - (Noliktavā: 22 punkts)

Permanent link: https://www.kriso.lv/db/9780803638181.html

Keywords:

Nosology

In this book, authors Jurek, Mosay, and Neris present readers with a comprehensive examination of the contemporary practice of medical coding. The authors cover medical coding and its position in the world of health care, the regulatory environment of coding, and careers in medical coding in part one of the text. Parts two and three of the book are focused on ICD-10-CM coding and CPT and HCPCS coding. Jean Jurek is with Jean Jurek Associates Inc. of New York. Stacey Mosay is with Cotiviti Healthcare of Georgia. Daphne Neris is a medical coding consultant. Annotation ©2016 Ringgold, Inc., Portland, OR (protoview.com)

Learn. Practice. Apply.

Conquer Medical Coding and Medical Coding Lab work together to create a complete learning experience that develops the critical-thinking and investigative skills you need to launch a successful career. Interactive exercises and realistic coding simulations guide you every step of the way, making the coding process easier to learn, practice, and apply.

Text

Conquer Medical Coding
A Critical-Thinking Approach with Coding Simulations

Take a real-world approach to coding that prepares you for the AAPC or AHIMA certification exams and for professional practice in any health care setting. The book is also a handy resource you can turn to throughout your career.

Unique decision trees show you how to logically assign a code. It's the only text that breaks down the decision-making process into a visual and repeatable process!

Click here for a sneak peek.

You’ll learn exactly how to select the correct ICD-10, CPT, and HCPCS codes. Each section parallels the Official Coding Guidelines, with a special emphasis on commonly used codes. A wealth of learning tools and tips, along with critical-thinking exercises and real-life case studies, provide the practice you need to master coding. Brief reviews of A&P and pathophysiology put the codes into perfect context.

MedicalCodingLab.com

This interactive online program guides you step by step through an immersive multimedia experience that tracks your progress until you’ve mastered the concepts and are ready to apply them in practice. It’s your path to medical coding success. An access code inside new, printed texts unlocks Medical Coding Lab.

Learn more. Visit www.MedicalCodingLab.com.

Part I Medical Coding and the World of Health Care

(50)

Chapter 1 Your Career as a Medical Coder

(22)

The Importance of Medical Coding

(4)

Medical Code Sets

(1)

Medical Coders

(1)

Medical Necessity for Payment

(3)

A Medical Coder's Working Environment

(2)

Facility-Based Employment

(1)

Physician Practice Employment

(1)

Nontraditional Employers

(1)

Medical Coding: Accurate and Compliant

(6)

Documentation

(6)

Coding Skills, Personal Attributes, and Ethics

(2)

Coding Skills

(1)

Personal Attributes

(1)

Medical Ethics

(1)

Moving Ahead in Your Career

(7)

Formal Education

(1)

Job Experience

(1)

Membership in Professional Organizations

(1)

Certification as a Medical Coder

(2)

Continuing Your Education Throughout Your Career

(1)

A Look to the Future

(5)

Chapter 2 The Regulatory Environment of Coding

(26)

Documenting Encounters

(7)

Evaluation and Management Services Documentation

(1)

Physician Orders

(1)

Procedural Services Documentation

(1)

Other Chart Notes

(2)

Electronic, Paper, and Hybrid Medical Records

(2)

HIPAA/HITECH: The HIPAA Privacy Rule and Meaningful Use

(5)

Three Key HIPAA Administrative Simplification Provisions

(1)

HIPAA Privacy Rule

(4)

HITECH and Meaningful Use

(1)

Enforcement of HIPAA Privacy Rules

(1)

HIPAA Security Rule and Breach Notification Rule

(2)

Administrative, Physical, and Technical Safeguards

(1)

Breach Notification Rule

(1)

HIPAA Electronic Health Care Transactions and Code Sets

(1)

Standard Transactions

(1)

Standard Code Sets

(1)

Governmental Regulations/Fraud and Abuse

(4)

Regulations

(1)

Fraud and Abuse

(3)

Compliance Plans

(6)

Physician Training

(1)

Staff Training

(5)

Part II ICD-10-CM Coding

(316)

Chapter 3 ICD-10-CM Basics

(38)

History and Purpose of ICD-10-CM

(5)

ICD-9-CM Background

(1)

ICD-10-CM Background

(1)

ICD-10-CM Today

(1)

ICD-10-CM Official Guidelines

(1)

Purposes of ICD-10-CM

(3)

Organizational and Structural Changes in ICD-10-CM

(1)

Transitioning from ICD-9-CM to ICD-10-CM

(2)

ICD-10-CM Basic Coding Process

(1)

ICD-10-CM Index to Diseases and Injuries

(5)

Main Terms and Subterms

(1)

Indention and Carryover Lines

(3)

ICD-10-CM Tabular List of Diseases and Injuries

(7)

Chapters

(1)

ICD-10-CM Tabular List of Diseases and Injuries Format

(5)

ICD-10-CM Coding Conventions

(8)

Abbreviations

(1)

Terms

(1)

Cross-References

(1)

Punctuation

(2)

Instructional Notations

(1)

Tables

(1)

ICD-10-CM Coding Resources

(10)

AHA Coding Clinic® for ICD-10-CM

(1)

NCHS Website

(3)

Medical References

(1)

Computer-Aided Coding

(1)

Computer-Assisted Coding Systems (CACSs)

(6)

Chapter 4 ICD-10-CM Coding Guidelines

(44)

"General Coding Guidelines": Inpatient and Outpatient

(12)

Use of Both the Index and the Tabular List

(3)

Level of Detail in Coding

(2)

Coding Decisions for Signs, Symptoms, and Integral Conditions

(2)

Multiple Coding for a Single Condition

(1)

Acute and Chronic Conditions

100

(1)

Combination Codes

101

(1)

Sequelae (Late Effects)

102

(1)

Impending or Threatened Conditions

103

(1)

Reporting the Same Diagnosis Code More Than Once

103

(1)

Laterality

103

(1)

Documentation for BMI and Pressure Ulcer Stages

103

(1)

Syndromes

104

(1)

Complications of Care

104

(1)

Selection of Principal Diagnosis/Additional Diagnoses for the Inpatient Setting

104

(18)

The Uniform Hospital Discharge Data Set (UHDDS)

107

(1)

Documentation in the Inpatient Setting

107

(3)

Section II Selection of the Principal Diagnosis in the Inpatient Setting

110

(7)

Section III Reporting Additional Diagnoses

117

(5)

Present on Admission (POA) Guidelines

122

(13)

Conditions Present on Admission---Indicator of Y

126

(1)

Conditions Not Present on Admission---Indicator of N

126

(1)

Unknown (U) or Undetermined (W) Conditions

126

(1)

Special Circumstances for Assigning POA Indicators

127

(8)

Chapter 5 ICD-10-CM
Chapters 1 Through 5: A00--F99

135

(52)

Resources for Correct Coding

136

(1)

Official Guidelines

136

(1)

Coding Clinic

136

(1)

Resources for Understanding the Disease Process

137

(1)

Certain Infectious and Parasitic Diseases (Chapter 1: A00--B99)

137

(16)

General Guidance

137

(4)

Human Immunodeficiency Virus (HIV)

141

(4)

Systemic Inflammatory Response Syndrome, Sepsis, and Severe Sepsis

145

(7)

Methicillin-Resistant Staphylococcus aureus (MRSA) and Methicillin-Susceptible Staphylococcus aureus (MSSA) Conditions

152

(1)

Neoplasms (Chapter 2: C00--D49)

153

(15)

Neoplasm Table in the Alphabetic Index

153

(4)

Basic Coding of Neoplasms

157

(3)

Coding Malignant Neoplasms with Metastasis

160

(1)

Sequencing of Malignant Neoplasms

161

(7)

Diseases of the Blood and Blood-Forming Organs and Certain Disorders Involving the Immune Mechanism (Chapter 3: D50--D89)

168

(3)

Anemia

169

(1)

Postoperative Anemia

169

(1)

Sickle-Cell Disease and Sickle-Cell Thalassemia

169

(1)

Pancytopenia and Aplastic Anemia

170

(1)

Blood Loss Anemia

170

(1)

Endocrine, Nutritional, and Metabolic Diseases (Chapter 4: E00--E89)

171

(7)

Diabetes Mellitus

171

(5)

Nutritional Disorders

176

(2)

Mental, Behavioral, and Neurodevelopmental Disorders (Chapter 5: F01--F99)

178

(9)

Pain Disorders Related to Psychological Factors

178

(1)

Mental and Behavioral Disorders Due to Psychoactive Substance Use

178

(9)

Chapter 6 ICD-10-CM
Chapters 6 Through 10: G00--J99

187

(36)

Diseases of the Nervous System (Chapter 6: G00--G99)

188

(7)

Pain Management---Category G89

188

(6)

Paralysis

194

(1)

Epilepsy and Seizure Disorders

195

(1)

Diseases of the Eye and Adnexa (Chapter 7: H00--H59)

195

(4)

Visual Impairment

195

(4)

Diseases of the Ear and Mastoid Process (Chapter 8: H60--H95)

199

(1)

Diseases of the Circulatory System (Chapter 9: I00--I99)

200

(12)

Hypertensive Disease

200

(5)

Cerebrovascular Infarction, Stroke, Cerebrovascular Accident (CVA)

205

(3)

Acute Myocardial Infarction

208

(1)

Coronary Artery Disease and Angina

209

(1)

Heart Failure

209

(3)

Diseases of the Respiratory System (Chapter 10: J00--J99)

212

(11)

Chronic Obstructive Pulmonary Disease

212

(1)

Acute Exacerbation of Asthma and Status Asthmaticus

212

(4)

Acute Respiratory Failure

216

(1)

Pneumonia

216

(7)

Chapter 7 ICD-10-CM
Chapters 11 Through 14: K00--N99

223

(28)

Diseases of the Digestive System (Chapter 11: K00--K95)

224

(4)

Gastrointestinal Hemorrhage Associated with Digestive Disorders

224

(2)

Diseases of the Biliary System

226

(1)

Liver Cirrhosis and Hepatitis

227

(1)

Hernias of the Abdominal Cavity

227

(1)

Diseases of the Skin and Subcutaneous Tissue (Chapter 12: L00--L99)

228

(6)

Cellulitis

228

(2)

Skin Ulcers

230

(4)

Diseases of the Musculoskeletal System and Connective Tissue (Chapter 13: M00--M99)

234

(6)

Arthritis

234

(3)

Pathological Fractures

237

(1)

Stress Fractures

237

(1)

Osteomyelitis

238

(2)

Diseases of the Genitourinary System (Chapter 14: N00--N99)

240

(11)

Chronic Kidney Disease and Renal Failure

240

(2)

Chronic Kidney Disease and Renal Transplant Status

242

(1)

Chronic Kidney Disease with Hypertension

242

(1)

Acute Renal Failure

243

(2)

Urinary Calculi

245

(1)

Benign Prostatic Hypertrophy

246

(1)

Genital Prolapse

246

(1)

Urinary Tract Infections

246

(5)

Chapter 8 ICD-10-CM
Chapters 15 Through 17: O00--Q99

251

(24)

Pregnancy, Childbirth, and the Puerperium (Chapter 15: O00--O9a)

252

(13)

General Guidelines

252

(5)

Childbirth and Conditions Related to Pregnancy

257

(1)

Selection of the Principal Diagnosis

258

(2)

Preexisting Conditions versus Conditions Due to Pregnancy

260

(1)

Fetal Conditions Affecting Management of the Mother

260

(1)

HIV Infection

261

(1)

Diabetes Mellitus in Pregnancy

261

(1)

Sepsis Complicating Abortion, Pregnancy, Childbirth, and the Puerperium

261

(1)

Alcohol and Tobacco Use during the Obstetrical Period

261

(1)

Normal Delivery

262

(1)

Postpartum Complications

262

(1)

Present on Admission Reporting for Obstetrical Conditions When Reporting Hospital Inpatient Services

262

(1)

Contraceptive Management and Sterilization

263

(1)

Termination of Pregnancy and Spontaneous Abortions

263

(2)

Certain Conditions Originating in the Perinatal Period (Chapter 16: P00--P96)

265

(5)

General Reporting Guidelines

267

(1)

Prematurity and Fetal Growth Retardation

268

(1)

Bacterial Sepsis of Newborn

269

(1)

Stillbirth

269

(1)

Congenital Malformations, Deformations, and Chromosomal Abnormalities (Chapter 17: Q00--Q99)

270

(5)

Chapter 9 ICD-10-CM
Chapters 18 Through 21: R00--Z99

275

(44)

Symptoms, Signs, and Abnormal Clinical and Laboratory Findings, Not Elsewhere Classified (Chapter 18: R00--R99)

276

(5)

Signs and Symptoms That Are Integral to the Disease Process

276

(1)

Signs and Symptoms That Are Not Integral to the Disease Process

276

(2)

Outpatient and Inpatient Coding

278

(1)

Combination Codes That Include Symptoms

279

(1)

Sequencing of Signs and Symptoms as the Principal Diagnosis in the Inpatient Setting

279

(1)

Coma Scale

280

(1)

Injury, Poisoning, and Certain Other Consequences of External Causes (Chapter 19: S00--T88)

281

(17)

Injuries, Fractures, Dislocations, Sprains and Strains, and Wounds

281

(4)

Burns

285

(4)

Adverse Effects, Poisoning, and Toxic Effects

289

(5)

Complications of Care

294

(3)

Pain Due to Medical Devices

297

(1)

Transplant Complications

297

(1)

External Causes of Morbidity (Chapter 20: V00--Y99)

298

(7)

General External Cause Coding Guidelines

302

(1)

Place of Occurrence Guideline

302

(1)

Activity Codes

302

(1)

External Cause Status

303

(1)

Multiple-Cause Coding Guidelines

303

(1)

Adult and Child Abuse, Neglect, and Other Maltreatment

303

(1)

Unknown or Undetermined Intent Guideline

303

(1)

Terrorism Guidelines

304

(1)

Factors Influencing Health Status and Contact with Health Services (Chapter 21: Z00--Z99)

305

(14)

Sequencing Z Codes

306

(1)

Categories of Z Codes

306

(13)

Chapter 10 ICD-10-CM Outpatient Coding Guidelines

319

(22)

Basic Coding Guidelines for Outpatient Settings

320

(6)

Definition of Outpatient Visit

320

(4)

Level of Detail in Coding

324

(1)

Guidelines for Code Selection

324

(2)

Selection of First-Listed Diagnosis

326

(9)

Outpatient Procedures and Ambulatory Surgery

328

(1)

Observation Stay

329

(1)

Diagnostic Services

329

(1)

Therapeutic Services

330

(2)

Preoperative Evaluations

332

(1)

Routine Outpatient Prenatal Visits

332

(1)

Uncertain Diagnoses

333

(1)

Emergency Department Visits

334

(1)

Reporting Secondary Diagnoses and External Cause Codes in Outpatient Settings

335

(6)

Chronic Diseases

336

(1)

Coexisting Conditions

336

(1)

E Codes

336

(5)

Chapter 11 ICD-10-PCS Overview and Format

341

(26)

History and Purpose of ICD-10-PCS

342

(2)

ICD-10-PCS Comparison to ICD-9-CM, Volume 3

342

(1)

General Equivalence Mappings (GEMS)

343

(1)

ICD-10-PCS Basics

344

(3)

ICD-10-PCS References

344

(3)

ICD-10-PCS Basic Coding Process

347

(1)

ICD-10-PCS Format and Structure

347

(4)

ICD-10-PCS Index

348

(1)

Cross-References Used in the Index

349

(2)

ICD-10-PCS Code Tables

351

(6)

ICD-10-PCS Coding Simulation

357

(10)

Code Tables and Index

357

(10)

Part III CPT and HCPCS Coding

367

(670)

Chapter 12 CPT Basics

369

(42)

History and Purpose of CPT

371

(1)

CPT Background

371

(1)

CPT Today

372

(1)

CPT Organization and Content

372

(8)

Introduction to CPT

374

(1)

Category I Codes: Six Sections

374

(3)

Category II Codes

377

(1)

Category III Codes

378

(1)

Appendixes

378

(2)

CPT Punctuation and Symbols

380

(4)

Semicolon (;)

380

(1)

Bullet (•et;)

380

(1)

Triangle

380

(1)

Plus Symbol (+)

380

(1)

Modifier --51 Exempt

381

(1)

Facing Triangles

381

(1)

Circled Bullet

381

(1)

Lightning Bolt

381

(1)

Pound Sign (#)

381

(1)

CPT Assistant or CPT Changes: An Insider's View

382

(2)

CPT Modifiers

384

(16)

Types of Modifiers

384

(5)

Proper Use of Modifiers

389

(8)

Supporting Documentation

397

(1)

Payer Requirements

397

(3)

CPT Updates

400

(1)

A Review: ICD-10-CM and CPT Comparison

400

(2)

How to Assign CPT Codes and Modifiers

402

(3)

Step 1 Review the Complete Medical Documentation

402

(1)

Step 2 Abstract the Medical Procedures That Need Coding

402

(1)

Step 3 Identify the Main Term and Related Terms

402

(1)

Step 4 Locate the Terms in the CPT Index

403

(1)

Step 5 Review the Codes, Descriptors, and Notes

403

(1)

Step 6 Verify the Code Against the Documentation

403

(1)

Step 7 Assign Codes for All Significant Services

403

(1)

Step 8 Assign Modifiers If Appropriate

403

(1)

Step 9 Check All Possibilities before Final Assignment

404

(1)

Coding Example

404

(1)

CPT Coding Resources

405

(6)

Chapter 13 CPT: Evaluation and Management Codes

411

(54)

Introduction to Evaluation and Management Codes

412

(4)

Evaluation and Management Codes Organization

412

(1)

Basic Selection Process

412

(4)

Example of Code Selection

416

(1)

Determining the Level of Service

416

(9)

Step 1 Determine the History Level

417

(1)

Step 2 Determine the Examination Level

418

(1)

Step 3 Determine the Medical Decision-Making Level

418

(3)

Working with the Level of Service Requirements

421

(2)

The Contributory E/M Components

423

(1)

Time

423

(1)

Evaluation and Management Flowchart and Matrix

424

(1)

Office or Other Outpatient Services

425

(3)

Professional Services and New or Established Patients

426

(1)

Criteria

426

(1)

Documentation Guidelines

426

(1)

Code 99211: The Exception

427

(1)

Hospital Observation Services

428

(2)

Observation Care Discharge

428

(1)

Initial Observation Care

428

(1)

Subsequent Observation Care

429

(1)

Roll-Up Rule

429

(1)

Hospital Inpatient Services

430

(2)

Initial Hospital Care

430

(1)

Subsequent Hospital Care

431

(1)

Same-Day Admission and Discharge

431

(1)

Hospital Discharge Services

431

(1)

Consultations

432

(4)

Criteria for Coding a Consultation

432

(2)

Preoperative Consultations

434

(1)

Medicare's Revisions to Consultation Services

435

(1)

Emergency Department Services

436

(1)

Criteria

437

(1)

Physician Direction of Emergency Medical Systems

437

(1)

Critical Care Services

437

(3)

Nursing Facility Services

440

(1)

Domiciliary, Rest Home, or Custodial Care Services

441

(1)

Domiciliary, Rest Home, or Home Care Plan Oversight Services

442

(1)

Home Services

443

(1)

Prolonged Services

443

(4)

Criteria

444

(1)

Calculating Time

445

(1)

Physician Standby Services

446

(1)

Case Management Services

447

(1)

Anticoagulant Management

447

(1)

Medical Team Conferences

448

(1)

Care Plan Oversight Services

448

(1)

Preventive Medicine Services

449

(2)

Counseling Risk-Factor Reduction

450

(1)

Behavior Change Intervention

450

(1)

Non--Face-To-Face Physician Services

450

(1)

Special Evaluation and Management Services

451

(1)

Newborn Care

451

(2)

Pediatric Critical Care Patient Transport

452

(1)

Inpatient Neonatal Intensive Care Services and Pediatric and Neonatal Critical Care Services

453

(3)

Inpatient Neonatal Critical Care

454

(1)

Initial and Continuing Intensive Care Services

455

(1)

Care Management Services

456

(1)

Chronic Care Management Services

456

(1)

Complex Chronic Care Management Services (CCCM)

456

(1)

Transitional Care Management Services (TCM)

457

(1)

Advance Care Planning

458

(1)

Information on CCCC and TCM

458

(1)

Modifier--25

458

(7)

Chapter 14 CPT: Evaluation and Management Auditing

465

(46)

The Evaluation and Management Services Documentation Guidelines

466

(3)

CPT Guidance on Determining Service Levels

467

(1)

Development of the Documentation Guidelines for E/M Services

467

(1)

Importance of Documentation Guidelines

468

(1)

General Principles

469

(1)

Comparison of 1995 and 1997 Documentation Guidelines

469

(2)

Elements of Key Components

471

(2)

Working with the 1995/1997 History Guidelines

473

(7)

The History of Present Illness Element

474

(2)

The Review of Systems Element

476

(1)

The Past, Family, and/or Social History Element

477

(1)

Additional Guidelines for ROS and PFSH

478

(1)

Putting the History Component Together

479

(1)

Working with the 1995 Examination Guidelines

480

(1)

Working with the 1995/1997 Medical Decision-Making Guidelines

481

(4)

Number of Diagnoses or Management Options

483

(1)

Amount and/or Complexity of Data

483

(1)

Risk of Significant Complications, Morbidity, and/or Mortality

483

(1)

Putting the Medical Decision-Making Component Together

483

(2)

Determining the E/M Level Based on the 1995 Documentation Guidelines

485

(3)

Applying the 1997 Documentation Guidelines to the Examination Key Component

488

(6)

The General Multisystem Guidelines

488

(1)

The Specialty-Specific Guidelines

488

(6)

Coding, Reimbursement, and Fraud

494

(1)

Auditing E/M Services

494

(1)

Auditing Tools

495

(6)

Using the Audit Form

498

(1)

Providing Feedback on Documentation Errors

498

(2)

Office of the Inspector General and Compliance

500

(1)

Auditing the Electronic Health Record System

501

(10)

Prepopulated Fields

501

(1)

Prompts

501

(1)

Use of Templates

501

(1)

Signatures

502

(1)

1995 or 1997 Documentation Guidelines?

503

(8)

Chapter 15 CPT: Anesthesia Codes

511

(20)

Anesthesia Background

512

(1)

Types of Anesthesia

512

(2)

General Anesthesia

512

(1)

Regional Anesthesia

513

(1)

Peripheral Nerve Blocks

513

(1)

Monitored Anesthesia Care

514

(1)

Anesthesia Coding

514

(1)

Anesthesia Services Package

515

(3)

Services Not Included in Routine Anesthesia Services

515

(1)

Swan-Ganz Catheter Insertion

516

(1)

Transesophageal Echocardiography

516

(1)

Obstetrical Anesthesia

517

(1)

Anesthesia Modifiers

518

(3)

Physical Status Modifiers

518

(1)

CPT Modifiers

519

(1)

HCPCS Level II Modifiers

519

(2)

Qualifying Circumstances

521

(1)

Anesthesia Documentation

522

(2)

Anesthesia Time

524

(1)

Assigning Anesthesia Codes

524

(2)

Anesthesia Coding and Billing Resources

526

(5)

Chapter 16 CPT: Surgery Codes

531

(54)

Surgery Coding

532

(12)

Surgery Section Format and Organization

532

(1)

Surgery Guidelines

533

(11)

Surgical Terminology

544

(1)

Surgical Procedure Types

544

(1)

Diagnostic Procedures

544

(1)

Therapeutic Procedures

545

(1)

Operative Report

545

(2)

Surgery Modifiers

547

(9)

Proper Use

547

(1)

Modifier Descriptions

548

(6)

Modifier Methodology

554

(1)

Procedure Sequencing

554

(2)

Integumentary System

556

(3)

Organization of the Integumentary Section

556

(1)

Incision and Drainage

557

(1)

Excision and Destruction

557

(1)

Repair (Closure)

558

(1)

Musculoskeletal System

559

(4)

Accurately Coding Orthopedic Procedures

559

(1)

Wound Exploration

560

(1)

Injection of Sinus Tracts, Joints, Tendons, and Trigger Points

560

(1)

Fixation Devices

561

(1)

Foreign Body Removal

561

(1)

Fractures

561

(1)

Arthroscopy

562

(1)

Respiratory System

563

(2)

Nasal Procedures

563

(1)

Procedures on the Larynx

564

(1)

Procedures on the Lungs, Trachea, and Bronchi

564

(1)

Cardiovascular System

565

(3)

Pacemaker and Pacing Cardioverter Defibrillator

565

(1)

Heart and Great Vessels

566

(1)

Procedures on Veins and Arteries

567

(1)

Varicose Veins

567

(1)

Hemangiomas and Arteriovenous Malformations

567

(1)

Hemic and Lymphatic Systems; Mediastinum and Diaphragm

568

(1)

Lymph Node Biopsy

568

(1)

Digestive System

569

(3)

Tonsils and Adenoids

569

(1)

Lips

570

(1)

Esophagogastroduodenoscopy

570

(1)

Appendectomy

570

(1)

Colonoscopy

570

(1)

Hemorrhoidectomy

570

(1)

Cholecystectomy

571

(1)

Hernia Repairs

571

(1)

Urinary System

572

(1)

Endoscopy

572

(1)

Prostate Procedures

572

(1)

Male Genital System; Intersex Surgery

572

(2)

Orchiopexy

573

(1)

Destruction of Lesions

573

(1)

Orchiectomy

573

(1)

Circumcision

573

(1)

Sterilization (Vasectomy)

573

(1)

Female Genital System; Maternity Care and Delivery

574

(2)

Laser Ablation of the Cervix

575

(1)

Sterilization

575

(1)

Maternity Care and Delivery

575

(1)

Abortion

576

(1)

Nervous System

576

(3)

Spinal Injections and Pain Management

577

(1)

Neurosurgery

578

(1)

Eye and Ocular Adnexa; Auditory System; Operating Microscope

579

(6)

Eye

580

(1)

Ear

580

(1)

Operating Microscope

581

(4)

Chapter 17 CPT: Integumentary System

585

(44)

Introduction

586

(1)

Surgical Terminology

586

(2)

Directional Terms

586

(1)

Distinguishing Simple, Intermediate, and Complicated Procedures

587

(1)

Integumentary System

588

(1)

Organization of Integumentary Subsection

588

(1)

Modifiers

589

(2)

Integumentary Anatomy

591

(2)

Surgical Techniques

591

(2)

Common Diseases and Disorders of the Integument

593

(2)

Skin Neoplasms

593

(1)

Other Nonneoplastic Lesions and Growths

593

(1)

Abscesses

594

(1)

Skin Wounds

595

(1)

Nails

595

(1)

Common Procedures Performed on the Integument

595

(9)

Incision and Drainage and Foreign Body Removal

595

(1)

Biopsy

596

(2)

Destruction

598

(1)

Excision

599

(1)

Measurement of Lesions

600

(2)

Wound Repair (Closure)

602

(1)

Simple Repair

602

(1)

Intermediate Repair

603

(1)

Complex Repair

603

(1)

Assigning Codes for Wound Repair

604

(1)

Pulling It Together: Excision and Repair Code Assignment

604

(3)

Burns

607

(2)

Wound Care Debridement

609

(5)

Wound Dressing

613

(1)

Hyperbaric Oxygen Therapy (HBO2)

614

(1)

Mohs Micrographic Surgery

614

(1)

Procedure

614

(1)

Code Assignment

614

(1)

Breast Procedures

615

(5)

Fine Needle Aspiration

616

(1)

Needle Core Biopsy

616

(1)

Open Biopsy

616

(1)

Breast Reduction

617

(1)

Nipple Reconstruction

618

(1)

Mastopexy

619

(1)

Augmentation

619

(1)

Skin Resurfacing

620

(1)

Dermabrasion

620

(1)

Dermaplaning

620

(1)

Actinotherapy

621

(1)

Photochemotherapy

621

(1)

Cosmetic Procedures

621

(2)

Abdominoplasty

621

(1)

Liposuction

622

(1)

Rhytidectomy

622

(1)

Coding Resources

623

(6)

Chapter 18 CPT: Musculoskeletal System

629

(46)

Organization

630

(1)

Modifiers

630

(3)

Intraoperative Services and Image Guidance

633

(1)

Included Services

633

(1)

Image Guidance

633

(1)

Surgical Techniques

634

(3)

Amputation

635

(1)

Arthrodesis

635

(1)

Arthrotomy

635

(1)

Arthroscopy

635

(1)

Arthroplasty

635

(1)

Endoscopy

636

(1)

Exostectomy

636

(1)

Lysis

636

(1)

Manipulation

636

(1)

Reduction

636

(1)

Release

636

(1)

Replantation

637

(1)

Revision

637

(1)

Sequestrectomy

637

(1)

Traction

637

(1)

General Musculoskeletal Procedures

637

(4)

Diagnostic and Therapeutic Procedures

637

(1)

Injection of Joints, Tendons, Trigger Points, and Sinuses

638

(1)

Excisions

639

(1)

Foreign Body Removal

640

(1)

Fracture and Dislocation Treatment

641

(6)

Closed Treatment of Fractures

641

(1)

Open Treatment of Fractures

642

(1)

Percutaneous Skeletal Fixation

643

(1)

External Fixation Devices

643

(2)

Steps in Coding Fractures and Dislocations

645

(2)

Arthroscopy/Endoscopy

647

(1)

Shoulder, Elbow, and Wrist

648

(5)

Shoulder Procedures

648

(3)

Elbow Procedures

651

(1)

Wrist Procedures

652

(1)

Hand

653

(4)

Common Disorders and Procedures on the Hand

653

(3)

Hand Joint Arthroplasty

656

(1)

Hip

657

(2)

Common Disorders and Procedures on the Hip

657

(2)

Knee

659

(5)

Common Knee Injuries and Procedures

659

(3)

Arthroplasty

662

(2)

Foot

664

(11)

Common Podiatric Surgeries and Conditions

665

(10)

Chapter 19 CPT: Respiratory System

675

(40)

Organization

676

(1)

Respiratory Anatomy

677

(4)

Upper Respiratory Tract

677

(2)

Lower Respiratory Tract

679

(2)

Common Procedures of the Nose

681

(6)

Removal of Nasal Polyps

681

(1)

Removal of Foreign Body

681

(1)

Resection of Turbinates

681

(2)

Septoplasty

683

(1)

Rhinoplasty

683

(1)

Repair of Nasal Vestibular Stenosis

684

(1)

Control of Nasal Hemorrhage

684

(1)

Treatment of Blockage of Nasolacrimal Duct

685

(1)

Nasal Fracture Procedures

685

(2)

Common Procedures of the Sinuses

687

(8)

Sinus Endoscopy

687

(8)

Common Procedures of the Larynx

695

(5)

Flexible Fiber-Optic Laryngoscopy

696

(1)

Laryngectomy

696

(4)

Steps in Assigning Laryngectomy Codes

700

(1)

Common Procedures of the Pharynx

700

(2)

Pharyngectomy Procedure

701

(1)

Tracheostomy

702

(1)

Common Procedures of the Lung and Bronchi

702

(13)

Bronchoscopy and Tracheobronchoscopy

702

(1)

Transbronchial Lung Biopsy

703

(1)

Thoracoscopy

704

(1)

Thoracentesis

704

(1)

Thoracotomy

704

(1)

Pneumonectomy

705

(2)

Lung Transplants

707

(8)

Chapter 20 CPT: Cardiovascular, Hemic, and Lymphatic Systems

715

(34)

Cardiovascular Anatomy

716

(3)

Heart

716

(1)

Heart Function

717

(1)

Valves

717

(1)

Aorta

718

(1)

Cardiovascular System Coding Issues

719

(21)

Pacemakers and Implantable Defibrillator Systems

719

(2)

Electrophysiological Operative Procedures

721

(1)

Heart (Including Valves) and Great Vessels

721

(1)

Coronary Artery Bypass Grafts

722

(1)

Heart and Lung Transplants

723

(1)

Cardiac Assist

724

(1)

Procedures on Arteries and Veins

724

(16)

Hemic and Lymphatic Systems

740

(1)

Hemic and Lymphatic Anatomy

740

(1)

Common Conditions of the Hemic and Lymphatic Systems Requiring Treatment

741

(2)

Lymphadenopathy

741

(1)

Lymphoma

741

(1)

Lymphedema

741

(1)

Splenomegaly

741

(1)

Bone Marrow Diseases

742

(1)

Mediastinum and Diaphragm Anatomy

743

(1)

Common Conditions of the Mediastinum and Diaphragm Requiring Treatment

743

(6)

Hiatal Hernia

743

(1)

Diaphragmatic Hernia

744

(1)

Trauma

744

(5)

Chapter 21 CPT: Digestive System

749

(34)

Organization

750

(1)

Digestive System Anatomy

750

(2)

Endoscopy Rules

752

(1)

Endoscopy Coding Points

752

(1)

Definitions of Surgical GI Endoscopy Terms

753

(1)

Common Procedures

754

(9)

Excision of the Tonsils and Adenoids

754

(1)

Excision to Treat Tongue Tie

754

(1)

Treatment of Lip Lesions and Injuries

754

(1)

Repairs of Mouth Disease and Injuries

755

(1)

Cleft Lip and Palate

755

(1)

Hemorrhoids

756

(1)

Anal Fistula

757

(1)

Varices

757

(1)

Achalasia

757

(1)

Repair of Hernias

758

(2)

Appendectomy

760

(1)

Cholecystectomy

761

(2)

Common Endoscopic-Only Procedures

763

(9)

Endoscopic Retrograde Cholangiopancreatography

763

(1)

Esophagoscopy

763

(1)

Esophagogastroduodenoscopy

763

(2)

Anoscopy, Proctoscopy, and Proctosigmoidoscopy

765

(1)

Flexible Sigmoidoscopy

766

(1)

Colonoscopy

766

(6)

Common Diseases of the Colon

772

(1)

Colectomy

772

(1)

Ileostomy and Colostomy

773

(1)

Bariatric Procedures

773

(10)

Gastric Restrictive Procedures

774

(1)

Gastric Bypass

775

(8)

Chapter 22 CPT: Urinary System

783

(22)

Organization

784

(1)

Subsection Structure

784

(1)

Abbreviations

784

(1)

Urinary System Anatomy

785

(2)

Endoscopy

787

(2)

Catheter Insertions

788

(1)

Urodynamics

789

(2)

Cystometrogram

789

(1)

Uroflowmetry

790

(1)

Urethral Pressure Profile

790

(1)

Neuromuscular Studies

790

(1)

Voiding Pressure Studies

790

(1)

Diseases and Disorders of the Urinary System and Surgical Therapies

791

(14)

Hematuria

791

(1)

Urethral Strictures

791

(2)

Ureter Stricture

793

(1)

Incontinence

793

(2)

Bladder Neoplasms

795

(1)

Interstitial Cystitis

796

(1)

Kidney Tumors

796

(1)

Kidney Stones

796

(1)

Treatment Methods

796

(3)

Foreign Body

799

(1)

Renal Transplants

800

(5)

Chapter 23 CPT: Male Genital System

805

(16)

Organization

806

(1)

Male Anatomy

806

(2)

Male Preventive Services

808

(1)

Common Problems of the Male Genital System and Surgical Therapies

809

(12)

Penis

809

(3)

Testes

812

(2)

Sterilization

814

(1)

Prostate

815

(6)

Chapter 24 CPT: Female Genital System and Maternity Care and Delivery

821

(24)

Organization

822

(1)

Female Anatomy

823

(2)

Preventive Exam

825

(1)

Pap Smear

825

(1)

Common Problems of the Female Genital System and Associated Therapies

826

(8)

Ovarian Cysts

826

(1)

Hydrosalpinx

827

(1)

Pelvic Adhesions

827

(1)

Endometriosis

827

(1)

Abnormal Bleeding

827

(1)

Cervical Dysplasia

828

(1)

Sterilization

829

(1)

Birth Control Maintenance

829

(1)

Bartholin's Gland Abscess

830

(1)

Lesions of the Vulva

830

(1)

Uterine Fibroids

831

(1)

Hysterectomy

831

(1)

Paravaginal Defects

832

(2)

Maternity Care and Delivery

834

(2)

Organization of Section

834

(1)

Routine Obstetrical Care

834

(2)

Common Obstetrical Conditions and Procedures

836

(3)

Amniotic Fluid

836

(1)

Incompetent Cervix

837

(1)

Cesarean Section Delivery

837

(1)

Delivery of Twins

837

(1)

Ectopic Pregnancy

838

(1)

Abortion

838

(1)

Infertility

839

(6)

Blocked Fallopian Tubes

840

(1)

In Vitro Fertilization

840

(1)

Intrauterine Insemination

840

(5)

Chapter 25 CPT: Endocrine and Nervous Systems

845

(32)

Endocrine System: Anatomy and Coding Issues

846

(1)

Anatomy

846

(1)

Coding Issues

847

(1)

Nervous System Anatomy

847

(5)

Nervous System Organization

852

(1)

Procedures of the Skull and Brain

852

(1)

Skull Base Surgery

853

(3)

Endovascular Therapy

854

(1)

Surgery for Aneurysm, Arteriovenous Malformation, or Vascular Disease

854

(1)

Stereotactic Radiosurgery

854

(2)

Common Nerve Conditions Requiring Treatment

856

(9)

Nerve Pain

857

(1)

Spastic Conditions

858

(1)

Nerve Injury

858

(7)

Spinal Injections and Pain Management

865

(3)

Fluoroscopic Guidance

866

(1)

Spinal Blocks (Pain Blocks)

866

(2)

Assigning Spinal Injection Procedure Codes

868

(1)

Spinal/Decompression Procedures

868

(9)

Spinal Decompression Procedure Components

869

(2)

Let's Code It

871

(6)

Chapter 26 CPT: Eye and Ear

877

(28)

Eye and Ocular Adnexa

878

(1)

Organization

878

(1)

Modifiers

878

(1)

Eye Anatomy

879

(1)

Diseases and Injuries of the Eye and Associated Procedures

880

(10)

Cataract

880

(2)

Secondary Cataract

882

(1)

IOL Procedures

882

(1)

Ophthalmic Endoscope

883

(1)

Surgically Induced Astigmatism

883

(1)

Pterygium

883

(1)

Trichiasis

884

(1)

Glaucoma

884

(1)

Vision Correction Surgery

884

(1)

Eyelid Lesions

885

(1)

Foreign Body

885

(1)

Retinal Detachment

886

(1)

Corneal Disease

887

(1)

Ocular Trauma

888

(1)

Cancer

888

(1)

Strabismus

889

(1)

Oculoplastic Surgery

890

(3)

Eyelid and Muscle Anatomy

890

(1)

Eyelid Ptosis

891

(1)

Entropion Repair

892

(1)

Ectropion Repair

892

(1)

Auditory System

893

(1)

Organization

893

(1)

Modifiers

894

(1)

Ear Anatomy

894

(1)

Common Problems of the Ear and Associated Procedures

894

(11)

Foreign Body in the Ear

894

(1)

Otitis Media

895

(4)

Oval or Round Window Fistula

899

(1)

Hearing Loss

900

(5)

Chapter 27 CPT: Radiology Codes

905

(36)

Ancillary Services

906

(1)

Radiology

906

(1)

Radiology Section Guidelines

907

(4)

Required Order and Radiology Report

908

(1)

Administration of Contrast Materials

909

(1)

Radiographic Positions

910

(1)

Diagnostic Radiology

911

(1)

Common Procedures

911

(7)

Computerized Axial Tomography

912

(1)

Magnetic Resonance Imaging

912

(1)

Bone/Joint Studies

913

(1)

Magnetic Resonance Angiography

913

(1)

Administration of Contrast Materials

913

(1)

Spine Studies

914

(1)

Diagnostic Ultrasound

915

(1)

Obstetrical Ultrasound

915

(1)

Radiology Modifiers

916

(1)

Fluoroscopy

917

(1)

Radiological Guidance

917

(1)

Breast, Mammography

917

(1)

Bone/Joint Studies

918

(1)

Assigning Radiology Codes

918

(2)

Modifier Guidelines

918

(2)

Steps in Assigning Radiology Codes

920

(1)

Radiological Supervision and Interpretation

920

(4)

Interventional Radiology

924

(6)

IR Procedures

925

(1)

Vascular Interventional Radiology

925

(2)

Nonvascular Interventional Radiology

927

(1)

IR Coding Guidelines

928

(1)

Component Coding and Billing

928

(2)

Radiation Oncology

930

(5)

Initial Consultation

930

(1)

Clinical Treatment Planning

931

(1)

Simulation

931

(1)

Radiation Treatment Delivery

931

(1)

Radiation Treatment Management

932

(1)

Proton Beam Treatment Delivery

932

(1)

Clinical Brachytherapy

933

(2)

Nuclear Medicine

935

(6)

Positron Emission Tomography

935

(1)

Single-Proton Emission Computerized Tomography

936

(5)

Chapter 28 CPT: Pathology and Laboratory Codes

941

(26)

Pathology and Laboratory Overview

942

(4)

Pathology and Laboratory General Guidelines

943

(1)

Location of Testing

943

(1)

Organization of the Path/Lab Section

944

(1)

Physician Orders and Test Requisitions

945

(1)

Complete Lab Codes

946

(1)

Modifiers

946

(2)

Major Pathology/Laboratory Procedures

948

(19)

Organ or Disease-Oriented Panels

948

(3)

Drug Testing

951

(1)

Evocative/Suppression Testing

952

(1)

Urinalysis

953

(1)

Molecular Pathology

953

(1)

Multianalyte Assays with Algorithmic Analyses

954

(1)

Chemistry

954

(1)

Hematology and Coagulation

955

(1)

Immunology

955

(1)

Transfusion Medicine

956

(1)

Microbiology

956

(1)

Cytopathology

957

(1)

Consultations (Clinical Pathology)

958

(1)

Surgical Pathology

958

(1)

Rules for Billing Surgical Pathology Codes

958

(3)

Assigning Pathology and Laboratory Codes

961

(6)

Chapter 29 CPT: Medicine Codes

967

(44)

Immune Globulin Administration and Products

968

(1)

Immunization Administration for Vaccines/Toxoids

969

(3)

Symbols

971

(1)

Multiple Procedures

971

(1)

Psychiatry

972

(2)

Psychiatric Diagnostic Procedures

972

(1)

Interactive Complexity

973

(1)

Psychotherapy

973

(1)

Psychotherapy for Crisis

974

(1)

Dialysis

974

(3)

Hemodialysis

974

(1)

Miscellaneous Dialysis Procedures

975

(1)

End-Stage Renal Disease Services

975

(2)

Gastroenterology

977

(1)

Ophthalmology

977

(1)

General Ophthalmology Services

977

(1)

Special Otorhinolaryngologic Services

977

(1)

Cardiovascular

978

(12)

Therapeutic Services

978

(3)

Cardiography

981

(1)

Cardiovascular Monitoring Services

982

(1)

Implantable and Wearable Cardiac Device Evaluations

982

(1)

Echocardiography

982

(2)

Cardiac Catheterization

984

(3)

Intracardiac Electrophysiological Procedures/Studies

987

(1)

Noninvasive Vascular Diagnostic Studies

988

(2)

Pulmonary

990

(1)

Allergy and Clinical Immunology

990

(4)

Allergy Testing

990

(1)

Immunotherapy

991

(3)

Neurology and Neuromuscular Procedures

994

(3)

Sleep Studies

994

(1)

Routine Electroencephalography

995

(1)

Nerve Conduction Studies

995

(1)

Neurostimulators, Analysis--Programming

996

(1)

Medical Genetics and Genetic Counseling Services

997

(1)

Health and Behavior Assessment/Intervention

997

(1)

Hydration, Therapeutic, Prophylactic, Diagnostic Injections and Infusions, and Chemotherapy and Other Highly Complex Drug or Highly Complex Biologic Agent Administration

998

(3)

Coding IV Infusion

999

(1)

Situations in Which Infusion Is Not Coded

999

(1)

Concurrent and Other Infusion Situations

1000

(1)

Therapeutic, Prophylactic, and Diagnostic Injections

1001

(1)

Chemotherapy Administration

1001

(2)

Non-Face-to-Face Services

1003

(1)

Special Services, Procedures, and Reports

1004

(1)

Moderate (Conscious) Sedation

1004

(7)

Chapter 30 HCPCS

1011

(26)

History and Purpose of HCPCS

1012

(4)

HCPCS Background

1012

(1)

Purpose of HCPCS

1012

(2)

HCPCS Today

1014

(1)

HCPCS Code Format

1015

(1)

How HCPCS Codes Are Created

1016

(1)

Permanent Codes

1016

(1)

Temporary Codes

1016

(1)

Features of HCPCS Codebooks and Other Coding Resources

1016

(4)

Introduction

1017

(1)

HCPCS Index and Code Sections

1017

(3)

Symbols

1020

(1)

HCPCS Coding Resources

1020

(1)

HCPCS Updates

1020

(1)

HCPCS Clearinghouse

1021

(1)

AHA Coding Clinic for HCPCS

1021

(1)

HCPCS Code Sections

1021

(6)

Section A Transportation Services Including Ambulance, Medical/Surgical Supplies, and Administrative, Miscellaneous, and Investigational (A0000--A9999)

1022

(1)

Section B Enteral and Parenteral Therapy (B4000--B9999)

1022

(1)

Section C Outpatient Prospective Payment System (C1300--C9999)

1022

(1)

Section E Durable Medical Equipment (E0100--E9999)

1023

(1)

Section G Procedures/Professional Services (G0000--G9999)

1023

(1)

Section H Alcohol and Drug Abuse Treatment Services (H0001--H2037)

1024

(1)

Section J Drugs Administered Other Than Oral Method, Chemotherapy Drugs (J0000--J9999)

1024

(1)

Section K Durable Medical Equipment for Medicare Administrative Contractors (Temporary Codes) (K0000--K9999)

1025

(1)

Section L Orthotic and Prosthetic Procedures, Devices (L0000--L9999)

1025

(1)

Section M Medical Services (M0000--M0301)

1025

(1)

Section P Pathology and Laboratory Services (P0000--P9999)

1025

(1)

Section Q Miscellaneous Services (Temporary Codes) (Q0000--Q9974)

1025

(1)

Section R Diagnostic Radiology Services (R0000--R5999)

1025

(1)

Section S Temporary National Codes (Non-Medicare) (S0000--S9999)

1026

(1)

Section T National T Codes (T1000--T9999)

1026

(1)

Section V Vision, Hearing, and Speech--Language Pathology Services (V0000--V5999)

1026

(1)

Miscellaneous/Unclassified Codes

1026

(1)

Modifiers

1027

(3)

Anesthesia Modifiers

1027

(3)

Assigning HCPCS Codes

1030

(7)

Coding Steps

1031

(1)

Hierarchy of Assigning a HCPCS Level II Code versus a HCPCS Level I CPT Code

1031

(1)

Using the Table of Drugs

1032

(5)

Abbreviations and Acronyms

1037

(10)

Professional Resources

1047

(8)

Index

1055

Conquer Medical Coding 2016: A Critical Thinking Approach with Coding Simulations [Mīkstie vāki]

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