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Study Guide

Medical Coding, Part 1


Contents
INSTRUCTIONS TO STUDENTS 1

LESSON ASSIGNMENTS 7

LESSON 1: CODING FUNDAMENTALS 9

LESSON 2: CPT BASICS AND EVALUATION


AND MANAGEMENT 21

LESSON 3: ANESTHESIA AND


GENERAL SURGERY 27

EXAMINATION—LESSONS 1, 2, AND 3 29

LESSON 4: THE INTEGUMENTARY


SYSTEM AND ORTHOPEDICS 37

TEXTBOOK EXERCISE ANSWERS 41

iii
INTRODUCTION

I ns tructions
The health care industry is growing at an amazing rate, and
many insurance companies, physicians’ offices, hospitals,
and other health care organizations urgently need qualified
staff to manage the workload. Among other duties, medical
office personnel are often responsible for generating and pro-
cessing medical claims. This crucial task involves translating
diagnoses, symptoms, procedures, and other health-related
information into numerical or alphanumeric codes. This
conversion process is commonly referred to as coding.

truction s
This part of your program provides you with detailed instruc-
tions to walk you through the coding process. The material
will lead you step-by-step through a wide range of coding
procedures, offering invaluable tips and suggestions along
the way. Your textbook also offers quite a number of practi-
cal exercises to assist you in mastering the fine points of the
coding process. At the same time, you’ll have a chance to
become familiar with a broad variety of medical terms, fur-
ther increasing your skill.
The material related to medical coding might seem complicated
at first—after all, you’re being asked to learn a new “language.”
As you proceed, however, you’ll find yourself growing more
and more comfortable with the terms and procedures used
by health care professionals every day. By the time you
finish the course, you’ll have gained many of the skills you
need to land a great job in the health care industry!

OBJECTIVES
When you complete this part of your program, you’ll be able to
n Discuss the differences between ICD-9-CM, CPT, and
HCPCS Level II codes

n Explain the format and functions of the ICD-9-CM and


CPT manuals

n Accurately review medical records to identify diagnoses


and procedures

1
n Properly code services, conditions, and procedures using
ICD-9-CM and CPT specifications

n Describe the basic procedures involved in evaluation and


management and primary care

n Discuss common services associated with general surgery

n Identify common medical terms and treatments

KNOW YOUR TEXTBOOK


The textbook for this part of your program is Understanding
Medical Coding. Your textbook provides a complete overview of
ICD-9-CM and CPT coding procedures. The book is divided into
16 chapters. This study guide, Medical Coding, Part 1, focuses
on the first eight chapters of the textbook. Your next study
guide, Medical Coding, Part 2, will continue through the second
eight chapters of the textbook.
The contents, found on pages v–xi of Understanding Medical
Coding, outlines the topics presented in each chapter. Take a
few moments now to examine the table of contents to get a
feel for the topics and concepts you’ll be learning.
Next, read the preface of Understanding Medical Coding
(pages xiii–xvi), which will give you a basic idea of the range
and purpose of the material presented. The preface also
introduces the workbook, StudyWARE software, and Web
Tutor program. These supplemental tools are designed to
increase your knowledge and skill as you progress through
the material.
Now, look through the rest of your textbook. You’ll see that
every chapter begins with a set of learning objectives, followed
by a brief introduction to the topic to be explored. A bar above
the learning objectives lists key terms that you’ll focus on
throughout the chapter. In addition to reading the objectives
and key terms before you work through the textbook material,
you should review the list of key terms and learning objectives
after you complete each chapter, to make sure you’ve fully
grasped the material. Each chapter concludes with a short
summary of essential points, followed by a list of books and
articles for further study.

2 Instructions to Students
As you proceed through the text, you’ll see that each chapter
includes a series of coding exercises. These exercises typically
follow the presentation of new information, and are designed
to provide you with an immediate and practical means of
applying what you’ve learned. Complete each exercise in
the order in which it appears.
The back portion of Understanding Medical Coding includes
several helpful study resources. The textbook’s glossary
(pages 593–605) provides an alphabetical listing of important
terms, accompanied by their definitions. A detailed index of
the subjects discussed in your textbook can be found on
pages 607–619. Once you’re done studying Understanding
Medical Coding, you can use these resources to refer back
to any topic you wish to review.
Each of your textbook assignments is geared to assist you in
developing a solid working knowledge of coding procedures and
medical terms. A great deal of technical information will be
presented to you, so take your time absorbing all the details.
You’ll need to dedicate both time and concentration to work
through the textbook exercises. To get the most out of this
essential part of your program, it’s a good idea to schedule sev-
eral study periods throughout each week. As you proceed
through the program, you’ll soon discover the rewards of the
effort you put into your study.

YOUR STUDY GUIDE


This study guide is a companion to your textbook and pro-
vides a study plan of lessons that will help you explore the
fundamentals of medical coding quickly and easily. This
study guide is divided into four lessons, each of which pro-
vides a practical overview of the subjects covered, as well as
several study assignments. As noted earlier, each reading
assignment in Understanding Medical Coding includes a series
of practical coding exercises, which you’ll need to complete
as you work through the textbook assignments. At the end of
Lessons 3 and 6, you’ll be asked to complete a multiple-choice
examination. Submit each examination for grading as soon
as you complete it. There will also be a final examination at
the end of Part 2.

Instructions to Students 3
PROGRAM MATERIALS
This part of your program provides you with the following
materials:
1. This study guide, which includes an introduction to your
textbook, plus
n A lesson assignment page, which lists the schedule
of the study assignments in your textbook and
lesson exams

n Explanatory material, which emphasizes the main


points in the instructional part of each lesson

n Answers to the exercises found in Understanding


Medical Coding

2. Your program textbook Understanding Medical Coding,


which contains your assigned readings and exercises
3. ICD-9-CM 2010 manual, Volumes 1, 2, and 3
4. CPT 2010 manual
5. Healthcare Common Procedure Coding System (HCPCS)
Level II Code List (from the Centers for Medicare and
Medicaid Services Web site)
You should ensure that you have all of these materials before
starting the course. For your HCPCS Level II exercises in this
study guide, you should use the following link to print out the
current list of HCPCS Level II codes (provided by the CMS for
free). Print the HCPCS Level II codes from the following Web site:
http://www.cms.hhs.gov/HCPCSReleaseCodeSets/ANHCPCS
Scroll down to the list of files, click on the 2010 link to the
left of 2010 Alpha-Numeric HCPCS File, then click on 2010
Alpha-Numeric HCPCS File (ZIP, 863KB). Read the License
Agreement and click Accept. Then, click Save and choose a
location to save the zip file to your hard drive. Once you’ve
saved the zip file, you can open either the Excel spreadsheet
(10anweb.xls) or the text file (10anweb2.txt) to access the
HCPCS Level II codes.

4 Instructions to Students
A STUDY PLAN
Work through this study guide one assignment at a time. Keep
your ICD-9-CM and CPT manuals on hand as you make your
way through your lessons, as you’ll need them to complete the
exercises in each assignment.
Once you’ve finished all of the assignments included in each
lesson, you’ll be ready to complete the examination. Before
you attempt to complete this exam, make sure you’ve read all
of the assigned material and have completed all the assigned
exercises. To get the most out of your studies, follow these
steps to completing your assigned work:
Step 1: Carefully note the pages where your assigned reading
begins and ends. These pages are identified in the
Lesson Assignments section of this study guide.
Step 2: Skim through the assigned pages (in both the study
guide and the textbook) to get a general idea of their
content. Try to develop an overall perspective on the
concepts and skills being taught and practiced in
each assignment.
Step 3: Carefully read through the study guide’s assigned
pages. These pages contain background information
about the material covered in each textbook module.
Step 4: Read the assigned pages in your textbook, and take
notes on any important points or terms that you feel
are especially significant.
Step 5: When you feel you’ve mastered all of the material
presented in each assignment, proceed to your next
study guide assignment. Repeat steps 1–4 for the
remaining assignments in each lesson.
Step 6: Once you’ve finished all the assignments and self-
checks, proceed to the next section. If the next
item in your study guide is an examination, care-
fully complete it. Take your time with the exam. As
you work, feel free to refer to your textbook, the
study guide, and any notes you may have taken.
Repeat steps 1–6 for the remaining lessons in your
study guide.

Instructions to Students 5
Remember, at any point in your studies, you can e-mail
your instructor for further information or clarification.
Your instructor can answer questions, provide additional
information, and further explain any of your study materials.
You should find your instructor’s guidance and suggestions
very helpful.
Now look over your lesson assignments and begin your study
of medical coding with Lesson 1, Assignment 1.

Remember to regularly check “My Courses” on your student home-


page. Your instructor may post additional resources that you can
access to enhance your learning experience.

6 Instructions to Students
Lesson 1: Coding Fundamentals
For: Read in the Read in

A s s ignments
study guide: the textbook:

Assignment 1 Pages 9–10 Pages 1–10

Assignment 2 Pages 11–13 Pages 11–83

Assignment 3 Pages 14–17 Pages 85–101

Lesson 2: CPT Basics and Evaluation and Management


For: Read in the Read in
study guide: the textbook:

Assignment 4 Pages 21–23 Pages 103–124

ignment s
Assignment 5 Pages 24–25 Pages 125–180

Lesson 3: Anesthesia and General Surgery


For: Read in the Read in
study guide: the textbook:

Assignment 6 Pages 27–28 Pages 181–208

Examination 38189701 Material in Lessons 1, 2, and 3

Lesson 4: The Integumentary System and Orthopedics


For: Read in the Read in
study guide: the textbook:

Assignment 7 Pages 37–38 Pages 209–243

Assignment 8 Pages 39–40 Pages 245–272

7
NOTES

8 Lesson Assignments
Coding Fundamentals
Your first lesson begins with an overview of coding concepts,

Lesson 1
terms, and procedures. You’ll learn about the different levels
of standardized codes, as well as why accurate coding is
an essential element of reporting medical conditions and
treatments. You’ll begin to work directly with the ICD-9-CM
manual, looking up codes and using them to create medical
reports. You’ll also be introduced to the HCPCS Level II man-
ual, an essential part of the coding arsenal.

ASSIGNMENT 1
Read through the following material in your study guide. After
you’ve read the study guide commentary, read pages 1–10 of
your textbook Understanding Medical Coding.

Introduction to Coding
Medical coding is a process of converting medical terms into
standardized numeric and alphanumeric equivalents that
are defined by national and international health agencies.
Reliance on standardized coding systems greatly expedites
the processing of health insurance claims, so patients and
health care practitioners can be reimbursed more quickly.
Proper coding also helps prevent the submission of erroneous
or fraudulent insurance claims, while providing a wide
range of health care organizations with accurate statistics
on disease, mortality, and treatments.
Health care employees responsible for coding are expected
to be familiar with two different coding systems:
n The Health Care Financing Administration Common
Procedural Coding System (commonly referred to
as HCPCS ), made up of two manuals: the Current
Procedural Terminology (CPT) and National Coding
Manual

n The International Classification of Diseases, 9th Revision,


Clinical Modification (commonly referred to as ICD-9-CM )

9
A career in medical coding can involve many jobs, from
coding for doctors’ offices and hospitals to educating new
coders. It’s therefore likely that you’ll hold more than one
kind of coding position during your career. Opportunities
in this field will increase in the coming years.
Most coders have a combination of formal education and
on-the-job experience. Although not all coders are required
to be certified, certification is recommended and leads to
more opportunities and higher pay. Three institutions offer
certification for coders. The organization you choose will
depend on what you want from your career. However,
choosing one organization doesn’t prevent you from
choosing another in the future.
Computer skills are necessary for today’s coding environment.
Though you’ll receive training on the job for the particular
billing program used by each office, a familiarity with basic
applications and the Internet will make your learning process
much easier. Knowledge of medical terminology, anatomy,
and physiology is also helpful in this field.
Insurance fraud and abuse are partly responsible for increased
premiums and rising health care costs. The Health Insurance
Portability and Accountability Act (HIPAA) and the Omnibus
Budget Reconciliation Act (OBRA) both have detection and
penalty measures in place to help prevent fraud and abuse.
The only way to avoid even the appearance of wrongdoing is
to follow meticulous record-keeping practices and to continu-
ously update your knowledge of current coding regulations.
Purchasing updated coding materials every year, participating
in continuing-education seminars, reading coding newsletters
and Internet sites regularly, and scrupulously documenting
patient charts are crucial to this job.

10 Medical Coding, Part 1


ASSIGNMENT 2
Read through the following material in your study guide. After
you’ve read the study guide commentary, read pages 11–83 of
your textbook Understanding Medical Coding.

ICD-9-CM
Assignment 2 focuses primarily on the ICD coding system,
which was originally created by the World Health Organization
for collecting and analyzing statistics relating to diseases and
treatments. The system is currently in its ninth revision, with
a tenth revision due for publication in the near future. Now
regularly used to track diagnoses and procedures performed
in a hospital setting, ICD-9-CM codes provide the highest
degree of specificity in describing medical conditions and
procedures.
The ICD-9-CM system is contained in three separate volumes.
Volume 1 consists of a tabular numerical listing of diagnostic
codes, while Volume 2 provides an alphabetical listing of
diagnostic codes. Volume 3 consists of both a tabular and
alphabetical lists of medical procedures, most of which
are performed in a hospital setting. All three volumes are
contained in one book.
Hospital patients may present a variety of symptoms and
conditions upon admission. The first—and most important—
step in ICD-9-CM coding therefore involves determining the
primary condition that led a patient to seek hospital care.
This primary condition is commonly referred to as the principal
diagnosis, while the process of distinguishing the principal
diagnosis is known as sequencing.
Once you’ve determined the principal diagnosis, you can find
the appropriate ICD-9-CM code by looking up the main term
of the diagnosis in Volume 2 of the ICD-9-CM manual. The
main term represents the most basic aspect of a disease or
condition. For example, the main term of a diagnosis involving
a broken arm would be “fracture.” The anatomical location
of a diagnosed condition—in this case, “arm”—is never used
as a main term.

Lesson 1 11
You can really grasp the specificity of ICD-9-CM when you
examine the number and variety of subterms and modifiers
associated with most main terms. Subterms provide more
precise details about main term conditions. For example, the
list of subterms associated with main term “fracture” covers
several pages, and includes a wide assortment of locations,
causes, and related conditions. In most cases, you’ll find the
appropriate ICD-9-CM code listed alongside a subterm of the
main term.
After you locate the correct ICD-9-CM code in the alphabetical
index, verify the code in the tabular list in Volume 1 of the
ICD-9-CM manual. The tabular list is divided into 17 sections,
while the codes themselves are broken down into categories,
subcategories, and subclassifications.
n Category codes consist of three digits, and may represent
either the main term of a single disease or condition or a
group of several similar diseases.

n Subcategory codes, which consist of four digits, provide


greater detail, such as the cause or location of an illness
or condition.

n Subclassification codes consist of five digits, representing


the most specific level of detail regarding a particular dis-
ease or condition.

Assignment 2 will guide you step-by-step through the specific


conventions and formats used in the ICD-9-CM manual. Be
sure to complete each of the practice exercises that accompany
each section of your reading assignment.
Particular attention is given to diagnosing tumors or growths,
which medical professionals commonly refer to as neoplasms.
Accuracy is crucial when coding neoplasms, because incor-
rectly listing a tumor as malignant or cancerous on a patient’s
medical record can negatively affect that patient’s insurance
coverage. You’ll also be working with injuries, fractures,
burns, and poisonings.
Several special areas of concern are covered in Assignment 2,
including E codes, which are special secondary codes used to
describe external causes of injury. Two ranges of codes are

12 Medical Coding, Part 1


new in 2010: E000 codes for external cause status and
E001–E030 for activity codes. Both sets of codes add speci-
ficity to external causes of injury. For example, in 2009 the
E-code for a soldier injured by falling from a cliff during a
mountain-climbing training session would have been E884.1.
Beginning in 2010, you would use three E-codes for this sce-
nario: E000.1 to indicate that the injury happened during a
military activity, E004.0 to indicate the mountain climbing,
and E884.1 to indicate the fall. Not all E-coding will require
these extra codes, but it’s a good idea to review these new
categories (E000–E030) so you’ll know when to add them.
In addition, many complications resulting from surgical pro-
cedures or implanted medical devices, such as pacemakers,
require special codes located in the 996–999 series of ICD-9-
CM codes. You’ll also learn about coding late effects, a term
used to describe side effects or conditions that appear after
the acute phase of an illness or injury has passed. Late effects
can sometimes present months or years after the termination
of a primary disease or injury. Assignment 2 concludes with
an exciting preview of ICD-10 codes, which are due to be
released in the very near future.
The ICD-10-CM project has been delayed for several years.
The manual is such a significant departure from the ICD-9-
CM that the transition is expected to be difficult. Personnel
training, computer program updating, and the printing of edu-
cational materials represent only part of the tasks necessary
for transition to this new system.
The codes in the ICD-10-CM will be alphanumeric (like the
current “V” and “E” codes). The 21 chapters will provide more
detailed descriptions of every known disease and variation
thereof. There will be far fewer NOS (Not Otherwise Specified)
and NEC (Not Elsewhere Classified) codes. Coding in the
future will be even more specific than it is now.
The procedure index currently included in the ICD-9-CM (for
inpatient coding procedures) will be a separate manual known
as the ICD-10-PCS. The codes in this manual will be extended
to seven alphanumeric characters.

Lesson 1 13
ASSIGNMENT 3
Read through the following material in your study guide. After
you’ve read the study guide commentary, read pages 85–101 in
Understanding Medical Coding.

HCPCS Level II Overview


The second level of HCPCS coding, the manual most people
refer to as “HCPCS,” is a very important and often over-
looked part of the billing system. There was a third level to
this billing system, but it was phased out in 2003.
HCPCS Level II codes, contained in the National Coding
Manual, were designed initially for use with Medicare and
Medicaid claims. The use of Level II codes is mandatory for
most supplies and services provided to Medicare and Medicaid
patients. National codes are not used to report inpatient ser-
vices. Inpatient health care facilities use ICD-9-CM Volume 3
codes to report inpatient services and procedures provided to
Medicare patients.
The material in Assignment 2 mentioned that the CPT coding
system doesn’t cover all patient services. For example, certain
health care professionals—including ambulance personnel,
orthodontists, and dentists—aren’t included in the CPT coding
system. To better ensure accuracy in reporting, many insur-
ance companies have begun requiring health care providers
to use Level II codes even on bills submitted for non-Medicare
patients.
Certain kinds of medical supplies, such as drugs and durable
medical equipment, aren’t covered under the CPT system,
either. Durable medical equipment (DME) includes a wide range
of items, such as walkers and wheelchairs, used by patients
suffering from chronic disabling conditions. Claims for DME
and related supplies can be paid only if the items meet the
Medicare definition of covered DME and are medically neces-
sary. Documentation provided by a physician is typically
required to determine medical necessity. Such documentation
may include medical records, plans of care, discharge plans,
and prescriptions. Forms specifically designed to certify med-
ical necessity—commonly referred to as Certificates of Medical
Necessity (CMN)—may also be submitted as documentation.

14 Medical Coding, Part 1


You’ll also have to check whether your Medicare carrier
accepts HCPCS Level II codes. Sometimes these claims are
paid separately by the Durable Medical Equipment Regional
Carrier (DMERC).

HCPCS Code Structure


Unlike CPT codes, HCPCS Level II codes are alphanumeric.
The first item in the code consists of one of the following
letters: A, B, D, E, G, H, J, K, L, M, P, Q, R, or V. A string of
four numbers follows the initial letter.
Codes that begin with the Q, G, or K are temporary codes, and
indicate that a more exact decision regarding the service or
supply will be provided later on. Q codes are used to identify
temporary assignments for procedures, services, and supplies.
G codes identify temporary assignments only for procedures
or services. K codes identify temporary assignments only for
durable medical equipment.
HCPCS Level II uses J codes to identify medications, as well
as the administered dosages. J codes are rarely used to
code orally administered medications, which are typically
purchased by the patient after a visit to a health care provider.
In addition, most J codes refer to the medications by their
generic titles, rather than by brand or trade names.
To assist you in locating the correct names and their
associated codes, the HCPCS manual provides a Table
of Drugs. The Table of Drugs includes a column labeled
“Route of Administration.” This column lists the most
common methods of administering specific medications,
which are abbreviated as follows:
IT Intrathecal
IV Intravenous
IM Intramuscular
SC Subcutaneous
INH Inhalant solution
VAR Various routes
OTH Other routes

Lesson 1 15
Intravenous administration includes all methods, such as
gravity infusion, injections, and timed pushes. When several
routes of administration are listed, the first listing is the most
common method. A VAR posting denotes various routes of
administration and is used for drugs commonly administered
into joints, cavities, or tissues, as well as topical applications.
Listings posted with OTH alert the coder to other administra-
tion methods, such as suppositories or catheter injections.
A dash (—) in a column signifies that no information is
available for that particular listing.
HCPCS Level II provides an even higher degree of specificity
through the use of alphanumeric modifiers that may be
appended to the five-digit national code. These modifiers
may be used to identify service providers, anatomic sites, or
other pertinent details. For example, the modifier -T1 is used
to specify the second toe of the left foot. The modifier -QN
identifies ambulance services provided directly by a service
provider. You can find a partial list of HCPCS Level II
modifiers in Appendix A of the CPT manual.

Using the HCPCS Manual


In addition to HCPCS codes and the Table of Drugs, the
HCPCS manual includes a set of general guidelines for coding,
as well as an index. The index is organized in alphabetical
order and includes main terms and subterms. When you
look up a code, be aware that the item or service you need
may be listed under more than one index entry. If you’re
looking for the appropriate code for dialysis kits, for example,
you can look for either the heading “Dialysis” or “Kits.”
Index entries cover a wide range of items, including tests,
services, supplies, durable medical equipment, prostheses,
drugs, therapies, and certain types of medical and surgical
procedures. Note that many of the headings in the HCPCS
index are followed by a range of codes available for the
associated service or supply. As shown in Figure 1, two
separate code ranges follow the heading “Wheelchair.” One
range begins with E0950 and ends with E1298. The other,
which represents a temporary assignment, begins with
K0001 and ends with K0109.

16 Medical Coding, Part 1


FIGURE 1—An Example
Wheelchair, E0950–E1298, K0001–K0108 of the HCPCS Level II
accessories, E0192, E0950–E1001, Index Format
E1065–E1069, E2211–E2230,
E2300–E2399
cushions, E2601–E2619
High Profile, 4-inch, E0965
Low Profile, 2-inch, E0963
tray, K0107

As you examine Figure 1, you’ll also see that a number of


descriptive subheadings are listed immediately below the main
heading. These subheadings provide more detailed information
about the type of supplies or services provided, and are
followed by a specific code to be used when submitting a
claim. To avoid errors in coding, be sure to review all the
subheadings found under the main index entry.
Once you locate a term in the index, you’ll need to verify the
code number and description in the alphanumeric listing,
to be sure that you’ve selected the correct code that
describes the item you’re coding. The alphanumeric listing
also provides more detailed information about the code, to
help you in determining that you’ve selected the proper code.
Though you don’t receive a HCPCS manual with your program,
the material you’ve just covered in Assignment 3 (in your
study guide and textbook) will give you sufficient informa-
tion to complete the following self-check.
Once you’ve studied the material in Assignment 3, com-
plete the HCPCS self-check that follows. If you’re unsure
of an answer, take a few minutes to go back and reread
the material in this study guide.

Lesson 1 17
HCPCS Self-Check
Check your understanding of what you’ve learned about HCPCS codes by completing the
self-check below.

1. Which of the following groups of letters is used to indicate temporary HCPCS Level II codes?

a. A, C, K c. J, V, E
b. G, K, Q d. H, M, P

2. Which of the following statements best represents the main difference between CPT and
HCPCS codes?

a. HCPCS codes may consist of three or more numbers.


b. HCPCS codes begin with a letter.
c. Modifiers may not be used with HCPCS codes.
d. HCPCS codes end with a letter.

3. In the Table of Drugs, the abbreviation _______ is used to indicate medications that are
typically administered into joints, cavities, or tissues.

a. OTH c. CAV
b. JOI d. VAR

4. Service providers, anatomic sites, and other important details are indicated by attaching
_______ modifiers to the end of a five-digit HCPCS code.

a. five-digit c. alphanumeric
b. alphabetical d. three-digit

5. HCPCS drug codes begin with a

a. D. c. M.
b. 5. d. J.

6. When providing supplies and/or services to Medicare and Medicaid patients, the use of HCPCS
national codes is

a. optional. c. unnecessary.
b. mandatory. d. voluntary.

Check your answers with those on the next page.

18 Medical Coding, Part 1


HCPCS Self-Check Answers
1. b
2. b
3. d
4. c
5. d
6. b

After you’ve finished Lesson 1, take the time to review all the
study assignments. Then, proceed to Lesson 2.

Lesson 1 19
NOTES

20 Medical Coding, Part 1


CPT Basics and Evaluation
and Management

Lesson 2
Chapters 4 and 5 make up Lesson 2. In these chapters, you’ll
learn how to use the CPT manual in general and then delve
into the knowledge needed for Evaluation and Management
coding. E/M coding, as it’s often referred to, has become very
important in the industry. Almost every physician and health
care provider who sees patients uses these codes in practice.
Like the HCPCSII, the CPT manual holds codes to which fees
are linked. It’s essential to the financial health of the practice
and to compliance with coding regulations to be able to choose
accurate and appropriate codes.

ASSIGNMENT 4
Read through the following material in your study guide.
After you’ve read the study guide commentary, read
pages 103–124 of your textbook Understanding Medical
Coding.

Current Procedural Terminology


(CPT) Basics
In Chapter 4, you’ll work with CPT codes, which are found
in the manual of Current Procedural Terminology (CPT).
Updated and published annually by the American Medical
Association, the CPT manual is used to describe and report
medical procedures and services performed by physicians
and other health care professionals. Note that CPT codes
focus specifically on procedures rather than diagnoses or
conditions. Unlike ICD-9-CM, the purpose of CPT coding
is to describe the activities of the provider, rather than the
status of the patient.

21
The CPT manual is the Level I coding manual for the HCPCS
system of coding. This manual is divided into three categories:
Category I Established procedures/services
Category II Data research/performance tracking
Category III Emerging technology
The codes in the CPT manual are grouped by specialty. You’ll
find that, when coding for a specialty, the majority of the
codes you use will be in one or two sections of the manual.
Although you may occasionally stray from these sections,
most physicians use many of the same codes over and over
again and usually stay within the codes in their specialties.
Just about everyone uses E/M codes, but besides these,
ophthalmologists mainly stick to the Eye and Ocular Adnexa
section (65091–68899), radiologists use the codes ranging
from 70010–79999, and anesthesiologists stick to codes
starting with “0” (00100–01999). Go through your CPT man-
ual and see if you can identify the specialties that go with
each section.
The CPT manual uses many symbols, and knowing what they
mean is crucial to accurate coding. These symbols will alert
you to extended definitions of a code, revised or new codes,
and special circumstances related to a service or procedure.
One new symbol you’ll see in 2010 is #. This symbol indicates
that a code is listed out of numerical sequence. For the 2010
manual, some codes were moved so they could be grouped
with similar procedures. Instead of renumbering many items,
they simply moved the procedure codes and inserted clear
notes where the code was moved to and from. Be on the look-
out for these. An example is code 46220.
Guidelines and descriptions are found at the beginning of
many sections of the CPT manual. It’s very important to read
this information before coding within a section, since it
explains the codes listed and sometimes may help refine a
search or lead to a more appropriate code.

22 Medical Coding, Part 1


CPT categories II and III are much less frequently used, but
they’re still important. Neither replaces Category I codes.
Category II codes can be added to a claim with other codes
to denote a specific type of care given. For example, a regular
E/M code could be given to a visit with a patient being evalu-
ated for asthma. The insurer would pay according to the level
of visit billed, but adding the code 1005F to the claim allows
the insurer to determine the total number of clients at the
facility with asthma and to track how often they’re treated.
Category II codes can be found in the CPT manual following
the Category I codes, before the Appendix section. Detailed
information about these codes is located in Appendix H.
Category III codes, listed after Category II, are for emerging
treatment modalities. They may be used instead of an
“unlisted” code when a treatment isn’t yet FDA approved
or is used as an experimental treatment. These codes are
updated semiannually in February and July. If the physician
is using new treatments or you find that you’re coding
unlisted procedures frequently, you should look into using
Category III codes instead.
Another important update to the CPT is the errata (errors)
list. Despite careful scrutiny, it’s inevitable that errors find
their way into the CPT manual each year. Check the AMA
Web site after you receive your book every year. Note the
corrections in your book next to each affected code and in
your billing program to prevent errors in billing throughout
the year.
The index of the CPT manual provides an alphabetical listing
of procedures you may be looking for. Before using a code,
it’s very important that you find the name of the procedure
or service in the index and then follow up by finding the code
number in the main section for a full description. You may
find when you look up a code as directed by the index that
there’s a better one referenced within that code description.
Never code by the index listing alone.
Once you’ve mastered the material in Assignment 4
and have completed all of the textbook exercises in
Chapter 4 of your textbook, you can proceed to
Assignment 5.

Lesson 2 23
ASSIGNMENT 5
Read through the following material in your study guide. After
you’ve read the study guide commentary, read pages 125–180
of your textbook Understanding Medical Coding.

Evaluation and Management


CPT Evaluation and Management (E/M) codes are used pri-
marily to describe procedures associated with a physician’s
first encounter with a patient. The first encounter can occur
in a wide variety of settings, including hospitals, medical
offices, nursing homes, and clinics. Evaluation codes describe
initial procedures used to provide a framework for under-
standing a patient’s condition. Management codes, meanwhile,
describe the procedures used to diagnose and treat specific
complaints or problems.
Several factors are involved in determining E/M codes. The
first of these factors, commonly referred to as history, is an
account of medical, emotional, psychological, environmental,
and other related details that may have contributed to the
patient’s condition. The level of detail achieved in obtaining
a patient’s history will often have a significant impact on the
level of service provided by the physician.
Other important factors influencing the assignment of E/M
codes include examination and medical decision making. The
term examination refers to the various tests performed in
an effort to obtain objective data about a patient’s condition.
These tests can range from obtaining simple measurements,
such as body temperature and blood pressure, to more com-
plex procedures, such as X-ray and ultrasound scans. The
term medical decision making refers to the process of arriving
at a diagnosis based on history and examination.
Several less critical factors will also contribute to the accurate
determination of E/M codes. For example, a certain amount
of counseling is typically required to ensure patients under-
stand both the nature of their conditions and their own role
in the treatment program. Another factor, referred to as
coordination of care, involves various activities such as writing

24 Medical Coding, Part 1


prescriptions, consulting other doctors, and instructing office
personnel to arrange referrals to specialists.
The severity of the presenting problem also contributes to
the level of service provided by a physician. In general, the
more severe the presenting problem is, the higher the level of
service will be. Similarly, the time required to obtain a history,
perform examinations, counsel patients, and coordinate care
will also have a bearing on the level of service provided—and
consequently, on the determination of appropriate E/M codes.
After you’ve finished Lesson 2, take the time to review all of
the study assignments. Then, you can proceed to Lesson 3.

Lesson 2 25
NOTES

26 Medical Coding, Part 1


Anesthesia and
General Surgery

Lesson 3
Lesson 3 examines the CPT codes used to describe procedures
involving anesthesia and general surgical treatments. This
fascinating section of your course provides you with the tools
you need to code anesthesia and general surgery procedures,
as well as a valuable overview of various anatomical systems
of the human body. Although later lessons will take a deeper
look at procedures associated with specific anatomical sites
and systems, Lesson 3 gives you a head start on learning
specialized medical terminology.

ASSIGNMENT 6
Read through the following material in your study guide. After
you’ve read the study guide commentary, read pages 181–208 of
your textbook Understanding Medical Coding.

Coding Anesthesia and


General Surgery Procedures
Used in a medical context, the term anesthesia refers to the
administration of pharmacological drugs aimed at suppressing
nerve functions. Anesthesia is often administered prior to sur-
gery, according to three different categories. Local anesthesia
numbs a specific part of the body. Regional anesthesia sup-
presses feeling in a wider anatomical area, such as the leg,
arm, or face. General anesthesia is administered in cases that
require suppression of the patient’s entire nervous system.
Conscious sedation is a form of anesthesia that’s being used
more often. While under conscious sedation, the patient is
pain-free but still able to respond to instructions from the
medical team. Codes located in the Anesthesia section of the
CPT manual are used to report the administration of all cate-
gories of anesthesia by anesthesiologists and other qualified
or supervised physicians.

27
General surgery is a term used to describe operations on a
wide range of anatomical systems. These include the respira-
tory, cardiovascular, lymphatic, auditory, ocular, nervous, and
digestive systems, as well as the male and female reproductive
systems. Surgical procedures associated with each system are
grouped together in separate sections of the CPT manual.
Each of these sections is organized into subsections identifying
the various organs that make up a particular system, as
well as the surgical procedures performed on each organ.
For example, the Respiratory System/Surgery section of the
CPT manual is divided into four subsections: Nose, Larynx,
Trachea and Bronchi, and Lungs and Pleura. The Nose sub-
section is subdivided into a variety of surgical categories,
including incision, excision, removal of a foreign body, and
repair. Within each surgical category, you’ll find a list of
specific procedures, along with the appropriate codes.
HCPCS Level II modifiers are frequently used when reporting
general surgical procedures, to provide an additional level of
detail. Accuracy and specificity are especially important when
filing claims for general surgery. To report unilateral proce-
dures performed on the lungs, for example, you’ll need to
append the left side (-LT) and right side (-RT) modifiers to
each instance of the surgical code. Otherwise, an insurance
company or other third-party payer may incorrectly deny a
claim on the supposition that duplicate procedures have
been reported.
After you’ve finished Lesson 3, take the time to review all
of the study assignments. Then, take the examination for
Lessons 1, 2, and 3.

28 Medical Coding, Part 1


Lessons 1, 2, and 3
Medical Coding 1
Exam 1

Examination
Examinat io n
EXAMINATION NUMBER:

38189701
Whichever method you use in submitting your exam
answers to the school, you must use the number above.

For the quickest test results, go to


http://www.takeexamsonline.com

When you feel confident that you have mastered the material
in Lessons 1, 2, and 3, go to http://www.takeexamsonline.com
and submit your answers online. If you don’t have access to
the Internet, you can phone in or mail in your exam. If you’re
unable to take the exam by telephone or online, please call
Student Services and request the special answer sheet and mail
in your exam. Submit your answers for this examination as soon
as you complete it. Do not wait until another examination is ready.

Note: When you receive your examination evaluation after sub-


mitting your answers for grading, “Book 1” will refer to your
Understanding Medical Coding textbook. “Book 2” will refer to
your ICD-9-CM manual. “Book 3” will refer to your CPT manual.

Questions 1–50: Select the one best answer to each question.

1. Which of the following types of examination is limited to


an affected body area or organ system and other related
organ systems?
A. Problem focused C. Detailed
B. Expanded problem focused D. Comprehensive

2. What code should you use for an office visit for an estab-
lished patient if the level of history and examination is
detailed and the decision making is of moderate complexity?
A. 99203 C. 99213
B. 99204 D. 99214

29
3. What convention in the Alphabetic Index tells you to look elsewhere before assigning
a code?
A. Note C. Summary
B. Cross-reference term D. Abbreviation

4. The letter _______ designates a temporary HCPCS Level II code for durable medical
equipment only.
A. G C. K
B. Q D. J

5. The reason given by a patient for seeking health care is referred to as the
A. chief complaint. C. brief history.
B. primary diagnosis. D. morbidity factor.

6. Which one of the following items must be included in a general multisystem


examination of a constitutional system?
A. Vital signs C. Auscultation of the lungs
B. Inspection of teeth and gums D. Palpation of lymph nodes

7. The abbreviation NOS is used


A. when a separate code for a specific condition isn’t provided in the classification
system.
B. when the medical record doesn’t provide enough information to permit assignment
of a more specific code.
C. to indicate that another code may describe the condition more completely or
specifically.
D. to provide assurance that the code is correct by listing various terms that are
covered by the code.

8. In the Alphabetic Index to Procedures of the ICD-9-CM manual, locate the correct code
for “ligation and stripping of varicose veins in the lower limb.” Verify the code in the
Tabular List. The code is
A. 38.50. C. 38.58.
B. 38.53. D. 38.59.

9. One of the factors used to determine CABG procedure codes is the number
of _______ involved.
A. catheters C. vessels
B. organs D. physicians

30 Examination, Lessons 1, 2, and 3


10. Which of the following codes is used for the diagnosis “closed dislocation of
the sternum”?
A. 839.61 C. 839.71
B. 839.8 D. 839.9

11. A 50-year-old new female patient has had a sore throat and head congestion for five
days. The physician performs an expanded problem-focused history and examination
and straightfoward medical decision making. What is the correct code for this service?
A. 99201 C. 99212
B. 99202 D. 99213

12. A discharge summary contains the diagnosis “acute ethmoidal sinusitis.” Which of the
following codes represents the correct entry for this diagnosis?
A. 461.2 C. 473.2
B. 461.9 D. 473.9

13. Which one of the following subcategories of the E/M section has separate codes for
new and established patients?
A. Office or Other Outpatient Services
B. Hospital Observation Services
C. Initial Inpatient Consultation
D. Emergency Department Services

14. Which of the following initial inpatient consultation codes is used in situations involving
an expanded problem focused history and examination and straightforward medical
decision making?
A. 99251 C. 99253
B. 99252 D. 99254

15. Which of the following E codes take priority over all other E codes?
A. Cataclysmic events C. Suicide and self-inflicted injury
B. Transport accidents D. Child or adult abuse

16. Single braces are used in the Tabular List to


A. indicate fifth digits required with a code.
B. connect terms on both sides of the braces.
C. include nonessential modifiers and alternative codes.
D. connect a series of terms on the left with one term on the right.

Examination, Lessons 1, 2, and 3 31


17. An operative report shows “open reduction of humerus for separation of epiphysis, with
internal fixation.” Identify the correct code in the Alphabetic Index to Procedures and
verify it in the Tabular List.
A. 79.3 C. 79.5
B. 79.31 D. 79.51

18. The chief complaint, a brief history of present illness, and a problem-specific review of
systems are documented in what type of history level for E/M coding?
A. Detailed C. Expanded problem focused
B. Brief D. Comprehensive

19. An attending physician asks a specialist to see a patient about a specific problem and
to advise him regarding treatment. This situation is called a
A. confirmatory consultation. C. transfer of care.
B. referral. D. consultation.

20. When coding late effects, the code for the _______ is usually sequenced first.
A. original cause C. modifier
B. residual condition D. complication

21. Provide a code for the following situation: initial admission to hospital for observation
care with a detailed history and examination and moderate decision making.
A. 99217 C. 99219
B. 99218 D. 99220

22. What is the main term in the diagnosis “pituitary gland hypofunction”?
A. Ablation C. Gland
B. Pituitary D. Hypofunction

23. A physician provides an office consultation for a new patient. The history and
examination levels are comprehensive and the medical decision making is of
high complexity. What is the correct code for this situation?
A. 99254 C. 99244
B. 99255 D. 99245

24. Provide the ICD-9-CM and CPT codes for a history and physical examination of a single
liveborn delivered in hospital by caesarian section.
A. V30.00, 99430 C. V30.02, 99432
B. V30.01, 99460 D. V30.03, 99433

32 Examination, Lessons 1, 2, and 3


25. _______ are used to indicate factors influencing health status and contact with
health services.
A. Manifestation codes C. E codes
B. Cross-reference codes D. V codes

26. In the Tabular List, where would you find alternative terms and explanatory phrases?
A. In square brackets C. In double braces
B. After a colon D. In parentheses

27. The minimum examination level required to code 99203 is


A. problem focused. C. comprehensive.
B. expanded problem focused. D. detailed.

28. According to the Tabular List for code 463, which one of the following conditions is
excluded from the code?
A. Follicular tonsillitis C. Septic sore throat
B. Acute viral tonsillitis D. Septic tonsillitis

29. Which of the following range of codes is located in the Evaluation and Management
section of the CPT manual?
A. 90001–90699 C. 89000–89999
B. 99201–99450 D. 80600–88999

30. J codes in the HCPCS Level II system are used to indicate


A. bandages. C. durable medical equipment.
B. medications and dosages. D. ambulance services.

31. The _______ medical decision-making category includes minimal diagnoses, minimal
complexity of data, and minimal risk of complications.
A. straightforward C. low complexity
B. simple D. uncomplex

32. When is it correct to assign a four-digit category code?


A. When a manifestation code is given
B. When no fifth-digit subcategory codes are in that category
C. When the cross reference tells you to do so
D. When there are no nonessential modifiers

Examination, Lessons 1, 2, and 3 33


33. Which of the following ICD-9-CM and CPT codes would you use to describe
physician supervision only of a cardiovascular stress test on a patient with an
abnormal electrocardiogram?
A. 794.31, 93016 C. 787.1, 93012
B. 793.40, 93000 D. V70.01, 93014

34. Which of the following codes is used for initial neonatal critical care?
A. 99477 C. 99468
B. 99469 D. 99472

35. When coding, you should always use the Tabular List to
A. verify the codes you’ve located in the Alphabetic Index.
B. locate codes not found in the Alphabetic Index.
C. find the range of codes for a particular disease.
D. determine if there are any cross references for the code.

36. How many bulleted topics must be included in documentation relating to a detailed
psychiatric analysis?
A. 1–5 C. 7
B. 6 D. Any 12

37. Which of the following categories is used to code heart conditions caused by hypertension?
A. 429 C. 402
B. 425 D. 405

38. Which of the following codes would be used for a one-hour initial therapeutic
intravenous infusion under the supervision of a physician?
A. 96365 C. 96367
B. 96366 D. 96369

39. In the Alphabetic Index to Procedures in the ICD-9-CM manual, locate the correct code
for “open drainage of the chest by incision.” Verify the code in the Tabular List.
A. 34.09 C. 34.04
B. 34.05 D. 34.01

40. Which of the following range of codes is used to report Emergency Department Services?
A. 99271–99280 C. 99289–99297
B. 99281–99288 D. 99298–99305

41. Which of the following physical status modifiers would be used to code a patient with a
mild systemic disease?
A. P1 C. P3
B. P2 D. P4

34 Examination, Lessons 1, 2, and 3


42. What is the code for the unlisted surgery procedure for the inner ear?
A. 25999 C. 58999
B. 43499 D. 69949

43. Anesthesia procedure codes are grouped according to


A. patient status. C. anatomic site.
B. time required. D. procedure used.

44. Which of the following code ranges is used to report a coronary bypass graft using
veins only?
A. 33510–33516 C. 33517–33523
B. 33533–33545 D. 33533–33536

45. Which of the following HCPCS Level II modifiers is used to indicate a procedure
performed on the thumb of the left hand?
A. -FA C. -FT
B. -F1 D. -L1

46. A diagnosis of spinal stenosis of the lumbar spine is coded to


A. 723.00. C. 724.01.
B. 724.00. D. 724.02.

47. Which of the following range of codes is used to describe laparoscopic removal of
the gallbladder?
A. 47562–47564 C. 56340–56342
B. 47611–47620 D. 56345–56347

48. Which of the following procedures is used to correct sleep apnea?


A. ICCE C. ERCP
B. PEG D. UPPP

49. In addition to the CPT codes, _______ are frequently used when reporting general
surgical procedures to provide better detail.
A. modifiers C. physician signatures
B. ICD-9-CM codes D. anesthesiologist reports

50. Which of the following procedures involves inserting an endoscope past the third part
of the duodenum?
A. ERCP C. EGD
B. Esophagoscopy D. Ileoscopy

Examination, Lessons 1, 2, and 3 35


NOTES

36 Examination, Lessons 1, 2, and 3


The Integumentary System
and Orthopedics

Lesson 4
In Lesson 4, you’ll begin using both the ICD-9-CM and
the CPT manuals to describe diagnoses and procedures.
By focusing on specific anatomical systems, your textbook
assignments are designed to ease you gradually into the
process of using both manuals to code reports. Your first
area of exploration will be the integumentary system, which
is comprised of the skin, nails, hair, sebaceous glands, and
sweat glands. After you’ve thoroughly familiarized yourself
with the terms, procedures, and codes associated with this
system, you’ll have a chance to learn about conditions and
procedures associated with the musculoskeletal system.

ASSIGNMENT 7
Read through the following material in your study guide.
After you’ve read the study guide commentary, read pages
209–243 of your textbook Understanding Medical Coding.

The Integumentary System


Procedures involving the integumentary system are located
at the beginning of the Surgery section of the CPT manual.
A brief glance through this part of the manual shows that
the Integumentary subsection is divided into the following
five subheadings:
n Skin, Subcutaneous and Accessory Structures

n Nails

n Repair

n Destruction

n Breast

37
Each subheading contains several categories that describe
procedures appropriate to each subheading of the integu-
mentary system. Under the Destruction subheading, for
example, you’ll find the following categories:
n Destruction, Benign or Premalignant Lesions

n Destruction, Malignant Lesions, Any Method

n Mohs Microscopic Surgery

n Other Procedures

The codes listed in each category are used to report specific


variations of the procedure described by the category head-
ing. For example, CPT code 17260 is used to describe the
destruction of malignant lesions measuring 0.5 cm or less in
diameter, while 17261 is used to report the destruction of
lesions measuring between 0.6 and 1.0 cm in diameter.
Most of the diagnostic codes associated with the skin,
subcutaneous tissue, hair, and nails are grouped together
in Chapter 12 of the ICD-9-CM manual. Bear in mind, though,
that certain integumentary system conditions may be listed
in other chapters of the manual dealing with larger categories
of illness or injury. ICD-9-CM codes for burns and cuts, for
example, are located in the Injury and Poison chapter (17),
while skin and subcutaneous tissue conditions caused by
neoplasms are located in the Neoplasm chapter (2).

38 Medical Coding, Part 1


ASSIGNMENT 8
Read through the following material in your study guide. After
you’ve read the study guide commentary, read pages 245–272 of
your textbook Understanding Medical Coding.

Orthopedics
Unlike other types of procedures, CPT codes for reporting
musculoskeletal system procedures are often determined on
the basis of treatment method. An open treatment of a radial
shaft fracture, for example, involves surgical opening of the
fracture site. The associated CPT code is 25515. A closed
treatment of the same type of fracture, which is accomplished
without surgically entering the fracture site, would be coded
25500 if no manipulation were necessary, and 25505 if the
physician needed to manipulate the bone.
Several other aspects need to be considered when determining
the appropriate code for orthopedic procedures. For example,
procedures performed on soft tissue—such as excision of a
ganglion cyst—are located in different areas of the Musculo-
skeletal section of the CPT manual than procedures performed
on bone.
Since treatments for traumatic injury are usually coded
differently than treatments for medical conditions, the reason
for treatment will also play a decisive role. The code for hip
replacement to alleviate osteoarthritis, for instance, is located
under the Repair, Revision and/or Reconstruction category of
the Pelvis and Hip Joint subheading of the Musculoskeletal
subsection of the CPT manual. By contrast, the code for hip
replacement performed as a result of fracture is located under
the Fracture and/or Dislocation category.
You’ll also want to be sure you’ve identified the most specific
anatomical site on which a procedure was performed.
Vertebral treatments, for example, are coded differently
depending on whether the procedure was performed on the
lumbar, thoracic, or cervical vertebrae. In addition, when
coding procedures performed on multiple sites in the same
area—such as repairing fractures to several fingers—you
must either indicate the number of specific sites treated or

Lesson 4 39
enter the code multiple times. The method will depend on
the code itself. Different codes require different procedures.
A final factor to consider is whether treatment required the
insertion of pins, screws, or wires to immobilize an area—
a procedure commonly referred to as fixation—or grafting.
Some procedures, such as reconstruction of the midface,
specifically list bone grafts. When grafting or fixation isn’t
specifically identified, you may need to list the appropriate
code separately.
Note: Exercise 8-3 in your textbook lists spaces for the
numbers of codes in each category. The code expansions
have affected question 2 in that exercise. This question
now requires two ICD-9-CM codes, one ICD-9-CM Volume 3
code, and two CPT codes.
After you’ve finished Lesson 4, take the time to review all the
study assignments. Then, move on to Lesson 5 in Medical
Coding, Part 2. The examination for Lesson 4 is included in
that study guide.

40 Medical Coding, Part 1


TEXTBOOK EXERCISE ANSWERS

Chapter 1

A n s we r s
Exercise 1-1
Research only

Exercise 1-2
Research only

Exercise 1-3
Research only

Chapter 2

Exercise 2-1
1. Senile cataract
2. Carcinoma of the breast
3. Mitral valve prolapse
4. Urinary cystitis
5. Hypertensive cardiovascular disease (can be located
under either main term)
6. Sudden infant death syndrome
7. Nontoxic thyroid goiter
8. Sickle cell anemia (can be located under either
main term)
9. Acute situational depression
10. Upper respiratory tract infection
11. Sore throat
12. Migraine headache

41
13. Chronic lower back pain
14. Rectal mass
15. Left ureteral calculus

Exercise 2-2
1. 346.90
2. 428.0
3. 250.03
4. 410.11
5. 820.8
6. 558.9
7. 530.20
8. 411.89
9. 351.0
10. 244.9
11. 788.20
12. 331.0
13. 042
14. 780.2
15. 339.10
16. 463
17. 729.5
18. 784.7
19. 300.02
20. 710.3

Exercise 2-3
1. 51.22 (open) or 51.23 (laparoscopic). The coder should
review the medical record to determine whether this was
an open or laparoscopic procedure.
2. 45.13

42 Answers
3. 86.59
4. 53.14 (The laparotomy isn’t coded because it’s an
operative approach.)
5. 85.21 (The coder should review the pathology report
to see whether this is a benign or malignant lesion.)
6. 50.11
7. 60.29
8. 89.52
9. 06.2
10. 51.23

Exercise 2-4
1. Diagnoses: 218.9, 617.1
Procedures: 68.49, 65.29
2. Diagnosis: 722.10
Procedure: 80.51
Question for physician: Findings indicated an osteo-
arthritic spur. Is this significant enough to code?
3. Diagnoses: 574.00, V64.41
Procedure: 51.22

Exercise 2-5
1. Sign
2. Symptom
3. Sign
4. Sign
5. Sign
6. Sign
7. Symptom
8. Sign
9. Symptom
10. Sign

Answers 43
Exercise 2-6
1. 794.31
2. 786.50
3. 780.60
4. 795.5
5. 783.21
6. 794.2
7. V08
8. 795.19
9. 790.22
10. 795.39

Exercise 2-7
1. Diagnoses: 430 (the cause of the CVA is coded, so code
436 isn’t coded), 342.90 (since the aphasia had cleared, it
wouldn’t normally be coded). The hemiplegia is present
on discharge and will require home care, so it should
be coded.
2. Diagnoses: 574.00, 401.9, 714.0, 250.00, V45.81, 51.23
(This previous bypass “Status Post CABG” is significant,
especially since the patient is having surgery.)
3. Diagnoses: 042, 276.51, 558.9
4. Diagnoses: 042, 481, 176.0
5. Diagnoses: 038.42, 599.0, 041.4
Question for physician: Renal insufficiency (593.9) is
noted as positive in the ER findings but isn’t mentioned
in the remainder of the discharge summary. Should it
be coded?
6. Diagnoses: 410.21, 412 (The patient had a previous
infarction three years ago that’s separate from the cur-
rent illness, but does have an impact on treatment at
this time, so it’s normally coded.)

44 Answers
Exercise 2-8
1. 250.70 785.4
2. 250.80 707.9
3. 250.40 581.81
4. 250.53 366.41
5. 250.41 581.81
6. 250.50 362.01
7. 250.11
8. 648.80
9. 648.00 250.00
10. 251.0

Exercise 2-9
1. V70.3
2. V16.0
3. V01.82
4. V25.02
5. V17.3
6. V14.0
7. V22.2
8. V72.31, V76.47
9. V04.81
10. V20.2
11. V82.81
12. V01.81
13. V61.10
14. V15.85
15. V70.4

Answers 45
Exercise 2-10
1. Diagnosis: V23.2, supervision of high-risk pregnancy
with history of miscarriage
Question for physician: Are there any current problems
such as bleeding, contractions, and so forth that should
be coded?
2. Diagnoses: 751.61, 774.5 (The coder should review the
radiology report to determine the type of procedure
performed and the proper code.)
3. Diagnoses: V30.1, 765.18, 765.28
4. Diagnoses: 666.22, V27.0

Exercise 2-11
1. Diagnosis: 153.5
Procedures: 47.09, 45.72
2. Diagnoses: 185, 198.5. Sequencing of these two
malignancies would depend on the circumstances
of admission.
3. Diagnosis: 201.90 (This code is for an unspecified site of
Hodgkin’s disease. The coder should review the medical
record and biopsy results to determine whether a more
specific code can be used.)
Procedure: 40.11
4. Diagnosis: 188.9
5. Diagnoses: 162.9, 198.3 (Sequencing of these two
malignancies would depend on the circumstances
of admission.)
6. Diagnosis: 233.1
7. Diagnoses: 174.5, 197.0 (Sequencing depends on
circumstances.)
8. Diagnosis: 210.1
9. Diagnosis: 141.9
10. Diagnoses: 188.3, 197.5 (Sequencing depends on
circumstances.)
11. Diagnoses: 174.9, 196.3 (Sequencing depends on
circumstances.)

46 Answers
12. Diagnoses: 174.9, 196.3, 197.0 (Sequencing depends on
circumstances.)
13. Diagnosis: 176.9
14. Diagnosis: 213.0
15. Diagnosis: 173.3
16. Diagnosis: 174.9 (The coder should review the pathology
report and other documentation in the medical record to
determine a more exact location of the carcinoma within
the breast.)
Procedure: 85.43

Exercise 2-12
1. 850.9, E819.0
2. 873.42, E916, E908.9
3. 883.0, E920.5

Exercise 2-13
1. 826.0
2. 733.13, 733.01
3. 808.41, 250.00
4. 821.29
5. 802.5
6. 813.23, 873.42, E819.1, E849.5

Exercise 2-14
1. 944.20, 944.10, E924.0
2. 947.0, 947.2, 948.00
3. 692.71
4. 945.06, E898.1
5. 941.12

Answers 47
Exercise 2-15
1. 983.9, E864.3
2. 964.2, E858.2, 459.0
3. 969.0, E854.0, 780.4

Exercise 2-16
1. 276.8, E944.3
2. 708.0, E930.4
3. 780.09, E933.0
4. 785.0, E933.0
5. 995.0, E930.0

Exercise 2-17
1. Diagnosis: 996.61
2. Diagnoses: 558.1, 153.9, E879.2

Exercise 2-18
1. 138
2. 438.21
3. 716.17, 824.8
4. 389.12, 139.8 (late effect of disease classifiable to code
055.9)
5. 348.9, 326, 324.0

Chapter 3

Exercise 3-1
1. E1231–E1238
2. A5105, A5112

48 Answers
3. Notice the index lists many medications for the term
Depo. The index doesn’t always list the brand name
(Depo-Provera), and you may need to use the Table of
Drugs, the Physicians’ Desk Reference, or the package
insert of the medication.
a. To select the code, you need documentation to sup-
port contraceptive versus other medical indication.

b. For Provera, review J1051 and J1055.

c. The code has quantity alerts and policy alert sym-


bols, guiding to obtain the policy and/or the ABN
prior to rendering the medication. This code is used
as a quantity 1 per 150 mg, so for the additional
dose given to this patient, the unit quantity is 2
(150 + 50 mg). Read the descriptions carefully for
the dose.

d. Answer, J1055 × 2. Injection medroxyprogesterone


acetate for contraceptive use, 150 mg.

Exercise 3-2
1. G0107 Colorectal cancer screening, fecal occult blood
test 1–3 simultaneous determinations

Exercise 3-3
The amount of medication that’s rendered must be
documented, and the medical necessity is required for
reimbursement purposes. Certainly, who/licensure,
where, and how rendered would be better charting
for medical standards. To select the code, we must
have the amount that’s given each date of service.
Rocephin 1 Gm injection IM, RUQ, csm is much
better documentation.

Exercise 3-4
1. J0150 × 2 (The code quantity is per 6 mg. Since dosage
is more than 6 mg, use × 2 for quantity.)
2. J0152

Answers 49
3. J2353 × 180 (The quantity is reported per amount given,
even if the payer has limitations for the amount.)
4. J1890

Exercise 3-5
IA Intra-arterially
IV Intravenous
IM Intramuscular
IT Intrathecal
SC Subcutaneously
INH Inhaled solution via IPPB
INJ Injection not otherwise specified
VAR Variously, into joint, cavity tissue or topical
OTH Into catheter or suppositories
Oral Oral per drops

Chapter 4

Exercise 4-1
False

Exercise 4-2
1. Semicolon (;)—Used to save space in the description to
avoid repetition in the descriptor portion of the code.
Example: 99238
2. Plus sign (+)—Used for add-on codes. Example: 01953
3. Revised code ()—Description of the code has changed
from the previous year. Example: 67901
4. New code (•)—New code for the current year. Example:
50592
5. New or revised wording ()—Alerts to wording or
content change. Frequently seen in Guidelines.
Example: 76394

50 Answers
6. Reference to CPT publications (Â)—Alerts to any changes
recently published in other books or newsletters. Example:
11021
7. Modifier 51 exempt ([[ )—Normally added to second and
subsequent surgeries. The symbol means the code may be
listed as a secondary code without the use of a modifier.
Example: 35600
8. Moderate sedation (~)—Included in the performance of
a procedure. An additional conscious sedation code isn’t
selected. Example: 44360

Exercise 4-3
The surgical guidelines are listed on page 52 of the
2010 AMA CPT. They’re usually located just after CPT
code 01999 for non-AMA publications.

Exercise 4-4
The term separate procedure means a procedure is com-
monly part of another code. Don’t report in addition to
the code that it may be considered an integral part of
the code. If the procedure is independently performed,
unrelated, or distinct, modifier -59 is attached to the
code. Select modifier -59 for a different session, different
encounter, different procedure, different site or organ
system, separate incision/excision, separate lesion, or
separate injury.

Exercise 4-5
1. A modifier is selected to indicate special circumstances
or variances from the description of the base code.
2. Modifiers are placed following the CPT code. An example
is 99215-25. The hyphen isn’t typically entered on the
claim and is used just for visual clarification.

Exercise 4-6
57105 Biopsy of the vaginal mucosa; extensive requiring
suture (including cysts) is selected. If the procedure is
performed using a colposcopy, a different code would be
selected. If the cyst is excised in its entirety, a different
code would be selected.

Answers 51
Exercise 4-7
1. Laparoscopy, surgical; with bilateral total pelvic lym-
phadenopathy and periaortic lymph node sampling
(biopsy), single or multiple.
2. The codes are 99201–99499, located in the front of
the AMA/CPT, in the Evaluation/Management section
of the CPT.

Chapter 5

Exercise 5-1
No answers; research practice only.

Exercise 5-2
1. A new patient is one who hasn’t received any professional
services from the physician or another physician of the
same specialty who belongs to the same group practice
within the past three years.
2. An established patient is one who has received profes-
sional service from the physician or another physician of
the same specialty who belongs to the same group practice
within the past three years. (The on-call paragraph states
that you use the same code “as the absent physician”
would use. In other words, if the patient is established,
while on call, select established, not new patient.)
3. History, exam, and decision making
4. Counseling, coordination of care, nature of presenting
problem, and time
5. The chief complaint typically contains a concise statement
describing the symptom, problem, condition, diagnosis, or
other factor that’s the reason for the encounter, usually in
the patient’s own words.
6. History of present illness
7. Location, quality, severity, timing, context, modifying
factors, and associated signs and symptoms related to
today’s problem

52 Answers
8. No, only information significantly related is considered
for code selection.
9. Review of systems
10. ROS data define the problem, clarify the differential
diagnoses, and identify testing of baseline data that
might affect management options.
11. Chief complaint, brief history, and present illness
12. CC, HPI, and problem-pertinent system review
13. Expanded problem-focused history. The ROS is two
systems: constitutional and genitourinary. There are
no further questions regarding musculoskeletal, neuro-
logical, skin, for example, that may influence testing and
diagnosing. Past history and family and social history
aren’t stated. (AMA/CPT, 1995, and 1997)
14. Detailed history
15. Complete history

Exercise 5-3
1. Exam of the ENMT limited, Lymph limited affected, and
Respiratory limited asymptomatic is performed. AMA/CPT
and 1995=EPF; OR 1997 CMS Exam of oropharynx. Exam
of lymph neck doesn’t meet criteria as only the neck is
examined, and the criteria require two areas. Exam
Auscultation of the lungs, two elements are completed. PF
exam for 1997. OR 1997 ENT specialty exam oropharynx,
lymph, respiratory for three elements completed, PF exam.
2. AMA/CPT and the 1995 are single-specialty complete
examinations of the ENMT examinations. 1997 CMS exam
oropharynx, otoscopic, lymph doesn’t meet criteria, respi-
ratory auscultation, cardiac auscultation, skin. Exam of
ENMT, Lymph, Respiratory, Cardiac, Skin, no credit for
Temp; Extended exam affected area, plus additional symp-
tomatic, Detailed. 1995 is also Detailed, however, credit
is given for the Temp as Constitutional exam. 1997 CMS
Oropharynx, otoscopic, lymph doesn’t meet criteria, respi-
ratory auscultation, cardiac auscultation, skin is history
not defined in the exam as noted today, Temp is only one
of three vitals, so criteria aren’t met. Four elements are

Answers 53
met, PF exam. 1997 ENT oropharynx, otoscopic, lymph,
respiratory, cardiac, skin is history, Temp is only one,
requires three vitals. Five elements met, PF exam. In
reality, the physician probably did assess the skin when
the mother described the rash the day prior; however,
this information isn’t documented. If the skin assess-
ment was documented, the examination would have
increased a level to an EPF exam, meeting six elements
for the ENT exam.
3. AMA/CPT and the 1995 are single-specialty complete
examinations of the ENMT examinations. 1997 CMS exam
oropharynx, otoscopic, lymph doesn’t meet the criteria,
respiratory auscultation, cardiac auscultation, skin,
Temp is only one of three vitals, so criteria aren’t met.
Five elements are met, PF exam. 1997 ENT oropharynx,
otoscopic, lymph respiratory, cardiac, skin, Temp is only
one, requires three vitals. Six elements met, EPF exam.
The statement of noncontributory doesn’t satisfy the 1997
examination elements, so it doesn’t affect the selection.

Exercise 5-4
1. Number of diagnoses or management options, amount
and/or complexity of data to be reviewed, risk of compli-
cations and/or morbidity or mortality. Two of three
components of decision making must match in selecting
the correct level.
2. No
3. a. The 50 percent coordination of care rule applies.
No history, exam, or decision making needs to
be charted.
b. 99214

Exercise 5-5
New patient:
1. 99201
2. 99203
3. 99202
Established patient:
1. 99214

54 Answers
Exercise 5-6
1. The code is 99233 because you need only two of three
components to meet or exceed the requirements, and the
history and exam meet the level 3 requirements.
2. 99214. For second-day observation services, use “office
or other outpatient services” codes for an established
patient.
3. 99234

Exercise 5-7
1. 99221
2. N/A (Level of history not high enough even to code
level 1 initial inpatient visit.)
3. 99221
4. 99231

Exercise 5-8
1. Opinion requested by another physician, regarding
a specific problem, initiate care only, written report
advising care recommendations
2. 99243
3. 99253

Exercise 5-9
1. 99282. If the ER doctor already saw the patient, he
would code for the ER visit. Another doctor coming in
to see him can code only for an established patient out-
patient visit.
2. 99213

Exercise 5-10
99291 × 1
99292 × 2

Answers 55
Exercise 5-11
99441–99443, depending on the time it took. Note: You
can’t code for this at all if the patient has seen the doc-
tor in the past seven days or will see the doctor in the
next 24 hours.

Exercise 5-12
1. 99396
2. 99396, 99213-25

Chapter 6

Exercise 6-1
1. B
2. E
3. C
4. F
5. A
6. D

Exercise 6-2
Items 1–6: All of these forms of sedation are covered by
codes 99143–99150. The code is determined by the age
of the patient and the length of time sedated.

Exercise 6-3
1. 00832-P2
2. 01220-P1
3. 00172, 99100
4. 00944-P2
5. 01622-P2

56 Answers
Exercise 6-4
1. 30901
2. 30903
3. 30110-50
4. 31238
5. 31535
6. 31622
7. 32422
8. 31090
9. 31530
10. 32420

Exercise 6-5
1. 45380
2. 42821
3. 46221
4. 43456
5. 49505-RT (You can’t code separately for mesh implanta-
tion for an inguinal hernia repair—only for ventral or
incisional hernia repair.)
6. 47562
7. 47605
8. 44960
9. 45385
10. 43263

Exercise 6-6
1. 55706
2. 55250
3. 66984-LT
4. 69210

Answers 57
5. 69090
6. 69420
7. 54520
8. 50590
9. 61760
10. 63030

Chapter 7

Exercise 7-1
ICD-9-CM 702.0
CPT 11442

Select excision benign rather than biopsy because the


entire lesion is removed by the surgeon obtaining the
biopsy. The entire margin is added together for a total
of 1.5 cm. Always use the margin dictated by the sur-
geon, as the pathology specimen may be smaller due
to tissue shrinkage.

Exercise 7-2
ICD-9-CM 705.83
CPT 11450

Exercise 7-3
CPT 12005-LT (total of 16.5 cm)
ICD-9-CM: 891.0 open wound leg; 881.00, open
wound forearm; 882.0, open wound hand; E007.3
playing baseball

Exercise 7-4
CPT 12032
ICD-9-CM: 890.0 open wound thigh; E928.8 “other”
accident

58 Answers
Exercise 7-5
Preoperative: 707.9 (Lesions can be coded as neoplasms
only after a pathology determination. As a preoperative
diagnosis, you must code it as an ulcerative lesion of
the skin.)
Postoperative: 173.2
Lesion site measurement 1.3 cm × 1 cm × 1.5 cm =
1.95 cm
Adjacent tissue measurement 1.5 cm × 2 cm = 3.0 cm
Total square cm code selection 4.95 cm
CPT code 14060—no cartilage or derma fascia grafting
is provided. The tissue transfer code includes the exci-
sion of the lesion.
ICD-9-CM 173.2

Exercise 7-6
ICD-9-CM 873.30 (The description of “complicated”
includes delayed healing. There’s no entry for “skin
of nose,” so you have to indicate “unspecified site.”)
CPT 15120

Exercise 7-7
ICD-9-CM 174.4
CPT 19290, 19125

Chapter 8

Exercise 8-1
1. 812.01, 79.11, 23675
2. 825.22, 825.23, 79.27, 28465 q=2 (This CPT code can be
used for cuboid, navicular, or any of the three cuneiform
bones. Code once for each bone treated.)
3. 813.41, 79.02, 78.13, 25606
4. 836.3, 79.76, 27552
5. 733.19, 733.00, 79.09, 27194
6. 820.21, 81.52, 27236

Answers 59
Exercise 8-2
1. 711.01, 041.7, 80.13, 80.11, 23031, 25031
2. 717.41, 80.6, 80.7, 80.86, 29881
3. 203.00, 713.2, 77.62, 23184
4. 715.26, 715.25, 278.01, 81.54, 27447-50
5. 717.9, 719.16, 80.16, 27301

Exercise 8-3
1. 721.1, 80.51, 63075
2. 722.10, 724.02, 03.09, 63047, 63048 (This CPT code
is for each segment, not interspace, so you need two
codes: 63047 for C1 and 63048 for C2.)
3. 738.4, 81.04, 22810, 22846
4. 721.2, 721.3, 722.11, 80.51, 03.09, 81.05, 77.79,
63046, 22610, 22614, 20930

Exercise 8-4
1. 996.40, 81.08, 77.79, 22630, 20931
2. 730.03, 041.4, 77.03, 83.49, 20005, 24136

60 Answers

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