Study Guide. Medical Coding 2. Jacqueline K. Wilson, RHIA

Transcription

1 Study Guide Medical Coding 2 By Jacqueline K. Wilson, RHIA

2 About the Author Jacqueline K. Wilson is a Registered Health Information Administrator (RHIA) who has more than 10 years of experience consulting, writing, and teaching in the health care industry. She s a professional writer who has authored training manuals, study guides/materials, online courses, and articles on a variety of topics. In addition, Ms. Wilson develops curricula and teaches both traditional and online college courses in health information technology, anatomy and medical terminology, and standards in health care. In 2005, she received the distinguished national award of being included in Who s Who Among America s Teachers.

3 INSTRUCTIONS TO STUDENTS 1 LESSON ASSIGNMENTS 7 LESSON 1: ICD-9-CM HOSPITAL INPATIENT CODING 9 EXAMINATION LESSON 1 95 GRADED PROJECT 103 LESSON 2: INPATIENT/OUTPATIENT PROCEDURE CODING/PHYSICIAN CODING/HCPCS LEVEL II 109 PROCTORED EXAMINATION PREPARATION 173 APPENDIX A: OVERVIEW OF CODING AND REIMBURSEMENT 177 APPENDIX B: CODING REVIEW 191 APPENDIX C: HELPFUL ONLINE RESOURCES 207 PRACTICE EXERCISE ANSWERS 209 PROCTORED EXAMINATION PREPARATION ANSWERS 231 Contents iii

4 YOUR COURSE Welcome to the Medical Coding 2 course! This course provides important information that s essential for your career as a coder. You ll be using the following main sources of information and references for this course: Medical Coding 2 Study Guide (this guide) 2011 Professional ICD-9-CM coding book CPT 2011 Coding Book Healthcare Common Procedure Coding System (HCPCS) Level II Code List (from the Centers for Medicare and Medicaid Services Web site) Clinical Coding Workout: Practice Exercises for Skill Development (2011 edition; published by the American Health Information Management Association) You should ensure that you have all of these materials before starting the course. For your HCPCS Level II exercises in this study guide and your coding workbook, you should download the HCPCS Level II codes (provided by the CMS for free). Follow these steps to access the HCPCS Level II codes: 1. Go to the CMS Web site ( HCPCSReleaseCodeSets/). 2. Click on HCPCS General Information. 3. Scroll down to the Related Links Inside CMS section, and click on HCPCS Annual Update. 4. Click on 2011 Alpha-Numeric Index. 5. Click on 2011 Alpha-Numeric Index (PDF, 166KB). 6. Save the document to your hard drive for use in your exercises and exams. 7. Repeat these steps to download the 2011 Alpha- Numeric HCPCS File (11anweb_V3.xls) and the 2011 Table of Drugs. An optional resource that you may find quite useful when working your way through this course is a medical dictionary. You aren t required to purchase a medical dictionary; however, Instructions 1

5 many terms, conditions, diseases, and illnesses mentioned in this course as well as in the field may not be familiar to you. Having a medical dictionary handy will make coding these conditions much easier. Several good medical dictionaries are on the market and can be obtained through any major book chain. NOTE: Coding guidelines and information for this guide have been taken from the appropriate sources for coding: CMS, American Medical Association (AMA), American Hospital Association (AHA), and American Health Information Management Association (AHIMA). All attempts have been made to ensure that coding guidelines are current and accurate for the time period of this guide. You should do the following for this course: 1. Read the assigned pages in your study guide. Begin with Appendix A and Appendix B. 2. Read the information from the corresponding coding source (2011 Professional ICD-9-CM coding book, CPT 2011 coding book, or HCPCS Level II code list from the CMS). 3. Complete the exercises in your Clinical Coding Workout textbook at the end of each assignment. These exercises aren t graded, but they ll help ensure that you understand the information covered as well as help you practice your coding skills before each assignment s quiz. 4. Complete each assignment quiz. 5. Complete the Lesson 1 examination. Note that there s no examination for Lesson 2. Instead, that examination will be your proctored final examination. 6. Complete the graded research project as assigned. It s impossible to present every coding guideline in this study guide; therefore, the focus here is on basic (general), complex, or frequently used guidelines. Because you received practice coding basic principles in the Medical Coding 1 course, you ll encounter here more intermediate and advanced coding exercises. When working through this course, you should pay special attention to coding book reference introductions, code references and notes, and review guidelines. In the different sections of this study guide, you ll find guidelines, tips, and information relating to codes that are generally considered to be the most difficult or confusing. However, not all subjects and/or guidelines for coding have been covered under each assignment. Working in the field, it s necessary for a coder to use a combination of resources for a complete and accurate understanding of coding guidelines. Additional resource information can be found in Appendix C: Helpful Online Resources. 2 Instructions to Students

6 OBJECTIVES When you complete this course, you ll be able to Identify diagnoses and procedures contained on medical reports Apply principles to code services, conditions, and procedures using ICD-9-CM and the Healthcare Common Procedure Coding System (HCPCS) Explain the official coding principles and guidelines of ICD-9-CM and HCPCS Determine the proper sequencing of codes for reporting and billing Discuss ICD-9-CM and HCPCS guidelines and coding conventions Discuss HCPCS procedural coding for different settings YOUR STUDY GUIDE This study guide is provided to you in place of a textbook. When approaching each assignment, you should first read the study guide and then follow the assignment directions for that section in your study guide. The assignment directions will specify which of the coding resources you ll need to complete the assignment. If at any point you don t understand a topic or section, take the time to reread the information. The topic of coding is difficult and often confusing. It s natural to feel overwhelmed by the amount of information and resources that need to be referenced. Remember, coding takes practice before you feel completely comfortable. If at any point you feel overwhelmed, take a break and then come back to the information at a later time. Instructions to Students 3

7 A STUDY PLAN Follow these steps to ensure your success in the course: 1. Read the assigned pages in your study guide. Take your time so you can fully understand each topic presented. 2. Follow along with the code section in the appropriate coding resource. 3. Complete the workbook exercises and assignment quizzes at the end of each assignment in your study guide. Before completing an assignment or, more important, the lesson examination or graded project be sure that you fully understand the concepts presented in the assignment or lesson. If you re uncomfortable with the information, go back and reread that particular information or the entire assignment again. Fully understanding the concepts is integral to your success in this course. Assignments Read the individualized directions for each assignment before starting the assignment. Practice Exercises For each assignment, you ll complete practice coding exercises that appear at the end of an assignment. These exercises will help you practice the guidelines and principles discussed in that assignment. The exercises won t be graded, and the answers are provided in the back of this study guide. Assignment Quizzes At the end of each assignment, an assignment quiz will test your understanding of the coding principles presented in that assignment. Upon completion, these quizzes will be submitted to your instructor for grading. This procedure will ensure that you understand the principles and concepts before completing the lesson examination. 4 Instructions to Students

8 There are two sets of questions for each quiz: a set of multiplechoice questions followed by intermediate-level scenarios taken from your Clinical Coding Workout: Practice Exercises for Skill Development workbook. These intermediate-level scenarios contain short paragraphs describing medical situations. You ll have to extract the appropriate information for coding. The quiz questions will be slightly more difficult than the coding exercises previously described. Because the quizzes will be submitted for grading, it s not recommend that you attempt them until you ve completed the assignment and the practice exercises, fully understand the concepts reviewed in the particular assignment, and feel comfortable with the subject matter. Lesson Examination There are two examinations for this course. Examination 1 appears at the end of Lesson 1. The second examination will be your proctored final examination for this course. The examination questions are formatted as multiple-choice and coding scenarios. You ll also be asked to code advanced-level coding scenarios. These coding scenarios are set up as if you were looking at documentation from an actual medical record. You ll be required to read the information and extract the appropriate clinical information that needs to be coded for the setting involved. It s important to fully understand the coding guidelines and to have practice coding with the section exercises before completing the lesson examination. Graded Project You ll be responsible for completing a graded project for this course, which is assigned at the end of Lesson 1. You ll be asked to do research on the Internet, then answer specific questions based on your research. Remember that you must put all information you gather into your own words, use quotation marks and in-text citations for any material copied from sources, and include a reference page that lists your sources, the dates you accessed them, and the author, article, and section you used. Instructions to Students 5

9 One Last Word Finally, remember that you re responsible for the content from Medical Coding 1. Medical Coding 1 and Medical Coding 2 can t be strictly divided. The second course builds upon the first. Much of what you learned in the first course may reappear here. You can t be excused from knowing that information or retaining those skills. 6 Instructions to Students

10 Lesson 1: ICD-9-CM Hospital Inpatient Coding For: Read in the Read in the study guide: coding references: Assignment 1 Pages 9 19 See assignment directions Quiz Material in Assignment 1 Assignment 2 Pages See assignment directions Quiz Material in Assignment 2 Assignment 3 Pages See assignment directions Quiz Material in Assignment 3 Assignment 4 Pages See assignment directions Quiz Material in Assignment 4 Assignment 5 Pages See assignment directions Quiz Material in Assignment 5 Examination Material in Lesson 1 Graded Project Lesson 2: Inpatient/Outpatient Procedure Coding/Physician Coding/HCPCS Level II For: Read in the Read in the study guide: coding references: Assignment 6 Pages See assignment directions Quiz Material in Assignment 6 Assignment 7 Pages See assignment directions Quiz Material in Assignment 7 Assignment 8 Pages See assignment directions Quiz Material in Assignment 8 Assignments 7

11 NOTES 8 Lesson Assignments

12 ICD-9-CM Hospital Inpatient Coding ASSIGNMENT 1: SUPPLEMENTARY CLASSIFICATIONS SIGNS, SYMPTOMS, ILL-DEFINED CONDITIONS/INJURIES, POISONINGS/V AND E CODES Read Sections 17 (pp ), 18 (pp ), and 19 (pp ) of the Coding Guidelines in your ICD-9-CM coding book. Read the introduction to Chapter 16 Symptoms, Signs, and Ill-Defined Conditions (page 283 in your ICD-9-CM coding book). Read the introduction to Chapter 17 Injury and Poisoning (page 299 in your ICD-9-CM coding book). Read the introduction to Supplementary Classifications (V codes on page 351 in your ICD-9-CM coding book and page 1 in the E-Code section directly following the V code section). Introduction Sometimes there are diagnoses or procedures that don t seem to fit into any specific coding category. They may be signs, symptoms, or ill-defined conditions; or they may simply provide more information about a specific diagnosis or illness. In this first section, you ll concentrate on these unique situations that can be difficult to classify and code. Lesson 1 9

13 Symptoms, Signs, and Ill-Defined Conditions (Categories ) A sign is a physical presence or existence of a condition that can be observed by the physician. A symptom is evidence of a disorder or disease that indicates a change in normal function. The symptom is experienced by the patient but not confirmed by the physician. Symptoms, signs, and ill-defined conditions appear in Chapter 16 of the ICD-9-CM coding book and cover code categories This chapter is used for signs, symptoms, and ill-defined conditions that are of unexplained etiology (origin) and may be due to more than one disease. ICD-9-CM Coding Guidelines for Symptoms, Signs, and Ill-Defined Conditions The following guidelines don t apply when coding hospital outpatient records or physician services. In these cases, the highest level of certainty (which may often be a symptom) is reported as the reason for the outpatient encounter. You ll learn more about this scenario in Lesson Chapter 16 codes can t be used as the principal diagnosis (or reasons for outpatient visits) when related or definitive diagnoses are established. Example. A patient is admitted with convulsive seizures due to cerebral brain cancer. The care is focused on the seizures because the brain cancer has progressed to an inoperable stage. Codes Principal diagnosis (PDX): Cerebral brain cancer (191.0) Secondary diagnosis: Other convulsions (780.39) Reasoning. The convulsive seizures are the result of the cerebral cancer and therefore are listed as the secondary diagnosis. 2. Signs and symptoms can be listed as the principal diagnosis only when no other cause can be found. 10 Medical Coding 2

14 When the sign/symptom is due to comparative or contrasting conditions, the sign/symptom should be listed as the principal diagnosis unless it s integral to each of the conditions listed. For comparative/contrasting diagnoses, the physician will usually use terminology such as either/or. For example, chest pain due to either pneumonia or angina is coded first as chest pain followed by the codes for pneumonia and angina. Example. A patient was admitted for prolonged fatigue. The physician discharged the patient with a diagnosis of fatigue due to either hypothyroidism or depression. Codes PDX: Other malaise and fatigue (780.79) Secondary diagnosis: Unspecified hypothyroidism (244.9), depressive disorder, not elsewhere classified (311) Reasoning. The physician documented either/or a clue that this is probably a contrasting coding scenario. Because the physician was unclear as to whether the hypothyroidism or depression was causing the fatigue (and fatigue isn t necessarily inherent/integral with either diagnosis), the fatigue (symptom) is listed as the principal diagnosis. Additional scenarios in which Chapter 16 codes can be used as principal diagnoses are as follows: NOTES: When there are two or more equal causes, the diagnosis with the highest-weighted diagnosis-related group (DRG) should be listed first. For example, if the physician documents pneumonia or angina, they would both be coded with the highest-weighted DRG sequenced first. Generally, if the physician documents that the diagnoses are no longer contrasting (for example, chest pain due to pneumonia and angina), both conditions should be coded (with the symptom code assigned only if it meets coding guidelines). No specific diagnosis is made at the time of discharge. Signs/symptoms last only a short time and no definitive diagnosis can be made. The patient is transferred/referred to another institute. A residual of a late effect is the reason for admission. Additional scenarios in which a Chapter 16 code can be used as secondary diagnoses are When the sign/symptom isn t integral in the underlying condition When the sign/symptom affects the severity of a patient s condition or the treatment given Lesson 1 11

15 3. Ill-defined conditions are those conditions with unknown causes. As with the other symptom codes, the ill-defined condition codes shouldn t be used when a more definitive diagnosis exists. Examples of ill-defined conditions include nervousness and debility without known causes. Now let s practice the principles for this section. Proceed to the practical coding exercise for more information. Practice Exercise 1A Books Needed: Clinical Coding Workout: Practice Exercises for Skill Development ICD-9-CM coding book In your Clinical Coding Workout: Practice Exercises for Skill Development workbook, complete exercises , Symptoms, Signs, and Ill-Defined Conditions, starting on page 29. When you re finished, check your answers at the back of this study guide. Once you re confident you understand the coding principles for this section, move on to the next section. Supplementary Classifications (Categories V01 V89 and E800 E999) Some people find the coding of V and E codes very easy, whereas others find it somewhat confusing. Because of this and their relationships to other chapter codes, it s important for you to understand their use before going on to other assignments. V Codes V codes are supplementary codes. They re listed as Supplementary Classification of Factors Influencing Health Status and Contact with Health Services. There are 15 different categories of V codes represented in sections V01 V89 of your coding book that deal with circumstances other than disease or injury. 12 Medical Coding 2

16 V codes are used in both inpatient and outpatient settings. As you learned from your assignment reading, there are four reasons you may use V codes: 1. To indicate that a person who isn t currently sick receives health services for a specific reason (e.g., inoculations/ health screenings, counseling, organ donation) 2. To indicate aftercare for a previous disease or injury (e.g., dialysis for renal disease, changing of a cast for a fracture) 3. When a circumstance or problem influences a person s health status 4. To indicate the birth status of a newborn V codes may be listed first, as the principal diagnosis, or as a secondary code (depending on the encounter or circumstance). However, be careful. Be sure to follow the notes in your coding book because there are some V codes that can t be used as principal diagnosis, whereas others must be listed first. The following scenarios are situations in which V codes can be listed as the principal diagnosis: Aftercare for a patient Health care services unrelated to illness/disease Birth status of a newborn (newborn s record) The following scenarios are situations in which V codes can be listed as a secondary diagnosis: History or problem that may influence the patient s care Outcome of delivery for an obstetric patient (mother s record) E Codes (E000 E999) The E code chapter immediately follows the V code chapter (at the end of the main section of your ICD-9-CM coding book). E codes make up categories E000 E999 and are used to identify external causes of injuries and poisonings. Lesson 1 13

17 E codes signify the following scenarios: Cause of the injury or poisoning Intent (for example, accidental, intentional, and so forth) Place where the event occurred E codes are reported for a variety of settings such as hospital inpatients, outpatient clinics, emergency departments, and physician offices (except when other guidelines apply). Adverse effects (or reactions) are reactions to the properties of certain drugs or medicinal substances (or a combination). The reporting of adverse effects or reactions is just one way that E codes are used. E codes are never listed as the principal diagnosis. NOTE: If space constraints and limitations on the billing claim form prohibit assigning as many E codes as necessary, be sure to first assign the ones that relate most to the principal diagnosis. E Code Guidelines 1. An E code may be used with any code (001 V82.9) that indicates an injury, poisoning, or adverse effect due to an external cause. 2. Code as many E codes as necessary to explain the cause. 3. The undetermined/unknown category of E codes (E980 E989) is rarely used. The patient s medical record should provide sufficient detail to determine the cause of the injury. 4. A late-effect E code should be used with any code recorded as a late effect resulting from previous injury or poisoning (those codes that fall into categories ). Now let s practice the principles for this section. Proceed to the practical coding exercise for more information. 14 Medical Coding 2

18 Practice Exercise 1B Books Needed: Clinical Coding Workout: Practice Exercises for Skill Development ICD-9-CM coding book In your Clinical Coding Workout: Practice Exercises for Skill Development, complete exercises , E Codes, starting on page 32 and exercises , V Codes, starting on page 34. When you re finished, check your answers at the back of this study guide. Once you re confident you understand the coding principles for this section, move on to the next section. Injury and Poisoning (Categories ) Injuries and poisonings cover Chapter 17, categories , in your ICD-9-CM coding book. Injuries Injuries include conditions such as fractures, concussions, wounds, lacerations, amputations, and burns. Let s take a look at the guidelines for coding injuries. Coding Guidelines for Injuries 1. When coding multiple injuries, assign separate codes for each injury unless a combination code is provided. 2. Sequence the most serious injury (as documented by the physician) first. 3. Superficial injuries (for example, abrasions, contusions) aren t coded when associated with more severe injuries of the same site. Lesson 1 15

19 NOTES: Some nonexcisional debridements are performed by health care workers (such as nurses) at the patient s bedside. In this case, don t assign a separate code for the debridement because it s covered in the nursing service billing as part of normal nursing duties. However, some physicians may perform a debridement at the patient s bedside. These procedures should be coded. Remember, burns are still classified under the Injury and Poisoning section. We re spending time on burns here (independent of the other injuries) due to the difficulty in coding. Sunburns aren t included in this same category and instead are coded to category Excisional debridement (procedure) for wound, infection or burn (86.22) can be performed only by a physician. Nonexcisional debridements are also performed by physicians or other health care professional (code 86.28). 5. Code burns with the highest degree sequenced first. Burns can be difficult to code because they often involve different sites and may have different degrees of severity. Because of the difficulty, it s worthwhile to spend some time on specific burn guidelines. Burns Burns are covered by code categories Some of the causes of burns are as follows: Electricity Flame/fire Heat Lightning Radiation Chemicals Burns are classified by depth (that is, the degree of burn), extent, and causative agent. First-degree burns result in erythema (redness). Second-degree burns result in blistering. Third-degree burns result in full-thickness skin involvement. Deep third-degree burns result in full-thickness involvement, necrosis, and scabbing/crusting. Extent of the burn refers to the extent of body surface involved. This extent is reported in percentages (e.g., burns on 25% of the body). Extent should be coded to code category 948 burns classified according to extent of body surface involved. This code category is based on something called the rule of nines that estimates the body surface as follows: Head and neck 9% Each arm 9% Each leg 18% (9% anterior, 9% posterior) 16 Medical Coding 2

20 Anterior trunk 18% Posterior trunk 18% Genitalia 1% These percentages are used to help estimate body surface involved in the burn and allows coders to assign the appropriate code. The term causative agents refer to the cause of burns and are coded to the appropriate E code. Examples of causative agents are fire, acid, and iron. Let s take a look at some specific guidelines for burns. Coding Guidelines for Burns 1. Nonhealing burns should be assigned acute burn codes. 2. Necrosis of burned skin should be coded as a nonhealing burn (acute). 3. When coding multiple burns, assign separate codes for each burn site. 4. Codes from category 948 burns classified according to extent of body surface involved should be used only when the site of the burn isn t specified or as an additional code with categories Late effects of burns should be coded to the residual condition followed by the appropriate late-effect code and late-effect E code. 6. It s possible that a current burn code, residual burn code, and late-effect code may be present on the same record. Poisoning Poisoning is a drug overdose or ingestion of the wrong substance when drugs are given in error during procedures, medications are given in error, medications/drugs are taken in error by the patient, medications are taken in combinations with alcoholic beverages, or a patient combines drugs/ medications. Now let s practice the principles for this section. Proceed to the practical coding exercise for more information. NOTES: Category 946: Burns of multiple specified sites and Category 949: Burns, unspecified should be used only if the burn locations aren t documented. Adverse effects are classified differently than poisonings in ICD-9-CM. Adverse effects occur when drugs are taken as prescribed, but have some adverse reaction or effect (for example, interaction from several drugs taken together, allergic reactions). When a poisoning and an adverse effect occur together, code in the following sequence: 1. Poisoning 2. Manifestation 3. E code Lesson 1 17

21 Practice Exercise 1C Books Needed: Clinical Coding Workout: Practice Exercises for Skill Development ICD-9-CM coding book In your Clinical Coding Workout: Practice Exercises for Skill Development, complete exercises , Trauma/Poisoning, starting on page 30. When you re finished, check your answers at the back of this study guide. Once you re confident you understand the coding principles for this section, move on to the next section. Submitting Assignment Quizzes After you take each assignment quiz and review your answers, submit the completed quiz individually as an attachment to On the subject line of the , write Quiz, then the quiz number, and then Medical Coding 2. For example, when you submit the Assignment 1 Quiz, on the subject line you ll type: Quiz Medical Coding 2. In the body of the , be sure to include your full name and student number. Then begin to record only the answers to the quiz items. Be careful about the numbering. For the Part A items, write Part A and number the items, each on a separate page. Then write only the letter of the choice you think is correct for each item. After finishing Part A, write Part B and record your answers, each on a separate line. Use the exercise numbers from the assigned exercises in Clinical Coding Workout: Practice Exercises for Skill Development. If the answer requires one or more codes, write the code(s). If the question is multiple-choice, write only the letter of your choice. If you re unable to send in your quizzes as attachments, you may use the answer sheet provided. In this case, for Part A, X out your answer choice. For Part B, fill in the appropriate answer either the letter for multiple-choice questions or the correct codes as required. Mail your completed answer sheet to the following address: 18 Medical Coding 2

22 Penn Foster Student Service Center 925 Oak Street Scranton, PA Be sure to include your full name, student number, quiz number, and your complete mailing address. The Penn Foster Student Service Center is under contract with Penn Foster College. Assignment 1 Quiz Books Needed: Clinical Coding Workout: Practice Exercises for Skill Development ICD-9-CM coding book Directions: Each assignment quiz is divided into two parts. Part A is composed of multiplechoice coding questions, and Part B requires you to code the information from a coding scenario found in your Clinical Coding Workout: Practice Exercises for Skill Development book. Complete all required and relevant codes for each given scenario. When you re comfortable with your answers for both parts, submit this quiz to your instructor for grading. Part A: Complete the following multiple-choice questions. Choose the best answer for each question. Record your answer on the corresponding answer sheets that can be found in the back of this study guide. Upon completion, submit your quiz answers to your instructor. 1. What is the main reason that insurance companies are hesitant to push for a quick release of the new ICD-10 coding classification system? A. Difficulty in learning the new system B. Cost of implementing C. Lack of government support D. Instability of the new system (Continued) Lesson 1 19

23 Assignment 1 Quiz E codes are used to indicate which of the following? A. Where an accident occurred B. How an accident occurred C. Whether a drug overdose was accidental or purposeful D. All of the above 3. Which of the following best describes late effects? A. Residual effects that remain after the acute phase of an injury or illness B. Effects that are always coded alone C. Effects categorized according to the nature and time of the disease, condition, or injury D. E codes that describe where the injury, illness, or condition occurred 4. When two or more diagnoses equally meet the criteria for principal diagnosis, what action should the coder take? A. Code both diagnoses with either of the diagnoses sequenced first. B. Code both of the diagnoses, sequencing the codes based on which diagnosis the physician listed first on the discharge sheet. C. Code only the diagnosis most closely related to the treatment. D. Code only the diagnosis that s the most resource-intensive. 5. In an acute care hospital, when is it appropriate to assign a code such as abnormal electrocardiographic findings? A. When the laboratory or testing report shows that the abnormal finding meets Uniform Hospital Discharge Data Set (UHDDS) criteria B. When the physician has documented the abnormal finding in the Progress Notes C. When the physician hasn t been able to arrive at a diagnosis, and the diagnosis meets the guidelines for that particular code D. It s never appropriate to assign codes of this type for an acute care setting 6. Which of the following wouldn t be a valid principal diagnosis? A C. 496 B. E880.9 D. V25.1 (Continued) 20 Medical Coding 2

24 Assignment 1 Quiz Which of the following codes fall under the category of providing codes for reporting factors influencing health status and health service? A. V67.4 C B. E884.2 D. A Unknown causes of morbidity or mortality should be coded only when A. the physician documents them on laboratory reports. B. a more definitive diagnosis isn t available. C. reporting acute care hospital codes. D. they meet UHDDS guidelines. 9. Which of the following scenarios could be classified within code ranges ? A. Patient has lethargy for unintentionally taking too much of her prescribed sleeping pill. B. Patient had an allergic reaction to her normal dose of antihistamine. C. Patient experienced lightheadedness due to the interaction of two drugs prescribed by her family doctor. D. Patient is experiencing increased heart rate due to daily dose of Valium that has been taken as prescribed. 10. A patient was admitted to the hospital with a deep burn to the dermis of the arm. For coding purposes, you would classify this condition as A. a first-degree burn. B. a second-degree burn. C. a third-degree burn. D. undeterminable until the physician clarified with more information. Part B: Complete the following exercises in your Clinical Coding Workout: Practice Exercises for Skill Development workbook. Exercises , Trauma and Poisoning, pages Note that for non-multiplechoice questions, you should indicate the correct codes for the given scenarios in the same manner as the other non-multiple-choice questions in this section. Lesson 1 21

25 Note: In upcoming quizzes you ll also be doing exercises on V and E codes related to other body systems. 22 Medical Coding 2

26 ANSWER SHEET FOR YOUR INSTRUCTOR S USE GRADE GRADED BY STUDENT NUMBER: PLEASE PRINT ASSIGNMENT 1 QUIZ Medical Coding 2 NAME ADDRESS CITY STATE/PROVINCE ZIP/POSTAL CODE Check if this is a new address PHONE INDICATE YOUR ANSWER TO EACH QUESTION BY MARKING AN X IN THE APPROPRIATE SQUARE. EXAMPLE: A B C D Part A X CUT ALONG THIS LINE 1. A B C D A B C D A B C D A B C D A B C D 10. A B C D A B C D A B C D A B C D A B C D Part B HAVE YOU ENTERED YOUR STUDENT NUMBER IN THE SPACE PROVIDED?

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28 ASSIGNMENT 2: INFECTIOUS AND PARASITIC DISEASES/ NEOPLASMS/ENDOCRINE, NUTRITIONAL, METABOLIC DISEASES, AND IMMUNITY DISORDERS/DISEASES OF BLOOD AND BLOOD-FORMING ORGANS Read Sections C1 Infectious and Parasitic Diseases and C2 Neoplasms (pp. 5 9) in the Coding Guidelines of your ICD-9-CM coding book. Read the introduction to Chapter 1 (p. 1) Infectious and Parasitic Diseases in the Tabular Index of your ICD-9-CM coding book. Read the introduction to Chapter 2 (p. 31) Neoplasms in the Tabular Index of your ICD-9-CM coding book. Read the introduction to Chapter 3 (p. 59) Endocrine, Nutritional and Metabolic Diseases, and Immunity Disorders in the Tabular Index of your ICD-9-CM coding book. Infectious and Parasitic Diseases (Categories ) Infectious and parasitic diseases cover ICD-9-CM code categories Chapter 1 of the Tabular Index. Infectious and parasitic diseases can be classified in several ways, so exercise caution and refer to coding guidelines when coding these conditions. A single code from Chapter 1 can indicate the disease and the organism. For example, streptococcal sore throat and scarlet fever and Combination codes can identify both the condition and the organism or cause (see definition for causative organism). Code is an example of this scenario orchitis due to mumps. Lesson 1 25

29 Dual classifications are also used in Chapter 1. For example, you may have an illness/condition from Chapter 1 and an additional code from another chapter (in this case, Respiratory System ) to describe the associated other illness/condition: Pneumonia due to whooping cough, 033.X, In some cases, a fourth and fifth digit of the diagnosis code will indicate the organism: Pneumonia due to Staphylococcus: 482.4X. You may be wondering whether to use one or two codes with a condition/underlying disease/organism scenario. This situation points out the importance of knowing coding guidelines as well as reading the information and narratives carefully when coding from a coding book. For example, code pneumonia due to whooping cough lists the note Code first underlying disease ( ). If the coder didn t read the complete code description and reported only code 484.3, the bill could be denied and reimbursement would be lost. Coding Guidelines for Infectious and Parasitic Disease Diagnoses 1. Codes from Chapter 11 ( Complications of Pregnancy, Childbirth, and the Puerperium ) take precedence over codes from other chapters for the same condition. NOTE: Due to the serious nature of HIV, guidelines direct that the coder contact the physician for clarification or further documentation related to HIV status. (This is an exception to the general guideline. For other non-hiv cases, you would code this condition as present.) 2. Codes from categories 041 and 079 are assigned as secondary diagnoses. In instances for which the site of infection isn t specified (and can t be clarified by querying the physician), codes from these categories can be assigned as principal diagnoses. 3. When patients are admitted for treatment of human immunodeficiency virus (HIV) infections or related conditions, HIV is coded as the principal diagnosis followed by additional codes for related conditions. 4. Asymptomatic patients who receive HIV testing should be coded as V73.89 screening for other specified viral disease. 5. Code only confirmed cases of HIV/acquired immunodeficiency syndrome (AIDS). Never code HIV if it s listed as suspected, possible, or likely. 26 Medical Coding 2

30 Let s review some additional guidelines for infectious and parasitic diseases. Late Effects For late effects (for example, codes 137, 138, 139), code the residual condition (that is, nature of the late effect) first, followed by the cause of the late-effect code (except when instructed otherwise by the index; see further rules explained in bulleted list that follows). For example, scoliosis due to poliomyelitis: 138, Coding of late effects requires two codes: residual condition (or nature of the late effect) and cause of the late effect. However, the following exceptions should be noted: When the code for late effect is followed by a manifestation code identified in the Tabular List or When the late-effect code has been changed or expanded to include the manifestation (usually by fourth- or fifthdigit classifications) NOTE: Remember, late effects are conditions that linger, exist, or occur after the acute phase of an illness or injury. A late effect is often referred to as a residual effect. The current, acute illness or injury must resolve before a late effect can be coded. Septicemia versus Bacteremia Septicemia (also known as blood poisoning) is a systemic infection associated with the presence of microorganisms and toxins in the blood. Bacteremia is the presence of fungi, parasites, viruses, or bacteria in the blood after trauma or infection. Septicemia is usually classified in category 038, whereas bacteremia is coded as Urinary tract infection, which is the presence of pus or bacteria in the urine, is coded as If you suspect that the patient s urinary tract infection should actually be documented as urosepsis (that is, if the urinary tract infection has entered the bloodstream and become a generalized sepsis), then you should query the physician to provide additional or updated documentation so that the most accurate code can be reported. Lesson 1 27

31 Practice Exercise 2A Books Needed: Clinical Coding Workout: Practice Exercises for Skill Development ICD-9-CM coding book In your Clinical Coding Workout: Practice Exercises for Skill Development, complete exercises , Infectious and Parasitic Diseases, starting on page 5. When you re finished, check your answers at the back of this study guide. Once you re confident you understand the coding principles for this section, move on to the next section. NOTE: Even though the neoplasm chart provides great detail, a coder should never assign a neoplasm code based on information just from the index. Be sure to look up codes located in the neoplasm chart within the tabular list. Neoplasms (Categories ) Neoplasm codes are found in Chapter 2 of the ICD-9-CM Tabular Index and make up code categories The best way to locate a neoplasm code is to look up the term neoplasm in the index and then locate the anatomic site of the tumor. Pages of the index provide a neoplasm chart that allows a coder to see six possible code categories for each tumor or site. Neoplasms, which are also called tumors, are abnormal growths that can be benign or malignant. Benign tumors aren t lifethreatening. However, malignant tumors tend to infiltrate and spread (metastasize) and thus may be life-threatening. These tumors are also often referred to as cancerous. When the physician simply documents the term tumor with no further clarification, the coder should review the patient s pathology report in the medical record to determine if the tumor is benign or malignant and then verify the findings with the physician before assigning a code. Primary versus Secondary Tumors are classified in several ways. Primary neoplasms are tumors that are found in the primary organ where the tumor growth started. Secondary neoplasms are tumors that are found in additional organs, spreading from the initial (or primary) site. This spread is called metastasis. 28 Medical Coding 2

32 Morphology Morphology identifies the form and structure of tumor cells for classification of origin. There s a listing of morphology codes (starting with M ) that are used mainly by cancer registries and rarely by hospital coders. We won t cover morphology codes in this course. Classifications As mentioned previously, neoplasms are classified according to behavior (for example, malignant, benign) or anatomic site. Neoplasm groups include the following categories: Malignant (codes ) Benign (codes ) Carcinoma in situ (codes ) Uncertain behavior (codes ) Unspecified nature (code 239) Coding Guidelines for Neoplasm Diagnoses 1. If the phrase metastatic to is documented, code the site mentioned as secondary. 2. When coding a secondary site, the primary site should also be coded if still present. If the primary site has been eradicated (that is, removed, no longer exists, or is no longer being treated), then a code from category V10 should be assigned. If the primary site isn t identified, code it as an unspecified site. 3. If metastatic from is documented, code the site mentioned as primary. Code the additional (secondary) site as an additional diagnosis. 4. When two or more sites are metastatic, code each as secondary. However, also code the primary site. 5. When patients are admitted for complications due to malignant neoplasms, code the complication as the principal diagnosis. However, there are exceptions to this guideline. Refer to coding guidelines and directions in the coding book for such cases. 6. Assign a code from V58.0 V58.1X when a patient is admitted for radiotherapy or chemotherapy. NOTES: Paying attention to the way tumor information is documented is very helpful. For example, if the physician documents metastatic from, then the site mentioned after from is the primary site. If the physician documents metastatic to, then the site mentioned after to is the secondary site. In situ (pronounced in sightoo) means that cancerous cells are present in the lining of an organ but have not spread to the organ tissue. Also assign the secondary diagnosis for the acute malignancy. Only use codes from V10 personal history of malignancy when the primary neoplasm has been eradicated and is no longer being treated. Lesson 1 29

33 Practice Exercise 2B Books Needed: Clinical Coding Workout: Practice Exercises for Skill Development ICD-9-CM coding book In your Clinical Coding Workout: Practice Exercises for Skill Development, complete exercises , Neoplasms, starting on page 7. When you re finished, check your answers at the back of this study guide. Once you re confident that you understand the coding principles for this section, move on to the next section. Endocrine, Nutritional and Metabolic Diseases, and Immunity Disorders (Categories ) Chapter 3 in the ICD-9-CM coding book covers Endocrine, Nutritional and Metabolic Diseases, and Immunity Disorders. Category codes cover these diseases and disorders. This chapter covers a wide range of disorders that should be coded according to the guidelines and directions in the coding book. Diabetes Mellitus Diabetes is a result of a deficiency, lack of, or resistance to insulin secreted by the pancreas. Insulin is a hormone that works to regulate glucose (sugar) metabolism and metabolize fats, carbohydrates, and proteins. Unfortunately, many people suffer from diabetes. Because this condition is probably the most common ailment in this chapter, this section deals solely with the coding guidelines for diabetes. 30 Medical Coding 2

34 Type 1 versus Type 2 Diabetes mellitus is categorized by two types: type 1 and type 2. Type 1 diabetes was formerly known as insulin-dependent diabetes mellitus (IDDM). Common practice now refers to this condition as only type 1. Type 1 diabetes may also be described many ways, including as juvenile type or juvenile onset. In type 1 diabetes, the body fails to produce insulin and requires the patient to receive insulin injections. Type 2 diabetes was formerly referred to as non-insulindependent diabetes mellitus (NIDDM). This designation has gone out of style because of an increase in type 2 diabetes that requires insulin. Type 2 may be described as adult onset diabetes. In this type, insulin is produced but in a small quantity or the body is unable to use it. Generally, type 2 diabetics don t require insulin injections and may be treated with oral medications and diet. For patients who may need insulin, the physician may describe such a patient as insulinrequiring. Classifying Diabetes Diabetes is coded under category 250; this category has two classifications. The fourth digit indicates the presence of an associated complication. The fifth digit indicates the type of diabetes and whether it s uncontrolled. As illustrated on page 61 of the Tabular List (in the shaded area of the first column) in your ICD-9-CM coding book, subclassifications for the fifth digit include the following: NOTES: Just because a patient is receiving an insulin injection doesn t mean that the patient has type 1 diabetes. Refer to the documentation from the physician to clarify the type of diabetes. Insulin-requiring isn t the same as insulindependent. Insulin-requiring usually refers to type 2 diabetics, whereas insulin-dependent generally refers to type 1 diabetics. As always, if there s any question, query the physician for clarification. A fifth digit of insulindependence and/or uncontrolled diabetes can be assigned only if the physician documents the condition as such. 0 Type 2 or unspecified type, not stated as uncontrolled 1 Type 1, not stated as uncontrolled 2 Type 2 or unspecified type, uncontrolled 3 Type 1, uncontrolled The presence of a fourth digit that defines associated complications tells you that there are many combination codes for diabetes. This simply means that there s one code that covers both diseases/disorders when they re related. Example Diabetes with ketoacidosis. The fourth digit of 1 indicates the ketoacidosis. The fifth digit of 1 indicates that the diabetes is type 1, not stated as uncontrolled. Lesson 1 31

35 NOTE: Remember that a manifestation is a secondary condition that s associated with another primary condition. In other cases, dual codes are necessary to identify the diabetes and manifestations. Patients with diabetes often have difficulties with other diseases and conditions that are covered by a dual code. In these cases, a code for the diabetes is listed first with a secondary code to indicate the manifestation. Example. On patient discharge, the physician documents the following information on the discharge sheet in the patient s medical record: nephritis with nephropathy; insulin-dependent diabetes. Codes PDX: Type I diabetes with renal manifestations (250.41) Secondary diagnosis: Nephritis and nephropathy (583.81) Reasoning. Per coding guidelines, the diabetic/manifestation code is sequenced first (as principal diagnosis), followed by the manifestation (583.81). The nephritis and nephropathy wasn t specified as acute or chronic. Guidelines for Coding Diabetes 1. With late/chronic complications of diabetes, first assign the diabetic code followed by the manifestation code. 2. Don t code type 1 diabetes just because a patient is receiving an insulin injection. Query the physician for further clarification. 3. Insulin-requiring is usually coded to type 2 diabetics. Insulin-dependent is generally coded to type 1 diabetics. 4. Code insulin-dependence and/or uncontrolled diabetes only if the physician documents it. 5. Diabetes complicating pregnancy is classified in Chapter 11. Code the appropriate 648 code as the principal diagnosis followed by the category 250 code for the diabetes. Please note that this doesn t apply for gestational diabetes. NOTE: Code , diabetic macular edema, must be used with a code for diabetic retinopathy (codes ). 6. When a patient is admitted to the hospital with a condition not related to diabetes but is still being monitored or treated for diabetes (insulin, exercise, diet), code the diabetes as secondary. 7. Diabetic retinopathy is coded as 250.5x (the diabetes code as principal) followed by a further code from to classify the diabetic retinopathy. 32 Medical Coding 2

36 Nutritional New Codes for Overweight and Obesity In 2006, ICD-9-CM expanded and included new codes for overweight and obesity. The overweight and obesity code (278.0X) includes fifth-digit classifications for Obesity, unspecified (278.00) Morbid obesity (125% or more over ideal body weight) (278.01) Overweight (278.02) There s also a new V category for body mass index. Add any additional code from category V85.XX as indicated by the physician s documentation. NOTES: The overweight and obesity codes shouldn t be assigned unless documented by the physician. If there s indication/ documentation of dietary surveillance and counseling, code V65.3 can be used. Now let s practice the principles for this section. Proceed to the practical coding exercise for more information. Practice Exercise 2C Books Needed: Clinical Coding Workout: Practice Exercises for Skill Development ICD-9-CM coding book In your Clinical Coding Workout: Practice Exercises for Skill Development book, complete exercises , Endocrine, Nutritional and Metabolic Diseases, and Immunity Disorders, starting on page 9. When you re finished, check your answers at the back of this study guide. Once you re confident you understand the coding principles for this section, move on to the next section. Lesson 1 33

37 Diseases of the Blood and Blood- Forming Organs (Categories ) Diseases of the Blood and Blood-Forming Organs make up Chapter 4 (code categories ) in your coding book. This chapter includes diseases such as anemias, sickle cell disease, diseases of the white blood cells, and so forth. Anemia Anemia is probably the most coded condition from Chapter 4. This condition involves a decrease in hemoglobin levels in the blood. Anemia can be caused by several factors, such as blood loss, a decrease in red blood cell production, or destruction of red blood cells. Because of the variety of causes, coders should pay close attention to documentation and take care to clarify any questionable cases with the physician. For example, just because a patient loses blood after an operation or procedure doesn t necessarily indicate a surgical complication. Reviewing coding book notes and working with the physician will help clarify coding for these types of situations. Now let s practice the principles for this section. Proceed to the practical coding exercise for more information. Practice Exercise 2D Books Needed: Clinical Coding Workout: Practice Exercises for Skill Development ICD-9-CM coding book In your Clinical Coding Workout: Practice Exercises for Skill Development, complete exercises , Disorders of the Blood and Blood-Forming Organs, starting on page 10. When you re finished, check your answers at the back of this study guide. Once you re confident you understand the coding principles for this section, move on to the next section. 34 Medical Coding 2

38 Assignment 2 Quiz Books Needed: Clinical Coding Workout: Practice Exercises for Skill Development ICD-9-CM coding book Directions: Each assignment quiz is divided into two parts. Part A is composed of multiplechoice coding questions, and Part B requires you to code the information from a coding scenario found in your Clinical Coding Workout: Practice Exercises for Skill Development book. Complete all required and relevant codes for each given scenario. When you re comfortable with your answers for both parts, submit this quiz to your instructor for grading. Part A: Complete the following multiple-choice questions. 1. Which of the following code categories should be chosen over codes from other chapters for the same condition? A. Complications of pregnancy B. Neoplasms C. Blood disorders D. Metabolic and nutritional diseases 2. Pyuria or bacteria in the urine should be coded to A C B D A patient returns to learn the results of an HIV test, which are negative. Which code is listed as the reason for the encounter? A. V65.44 C. 042 B D. V08 4. A patient has a condition wherein the body fails to produce insulin. She requires daily insulin shots for control that seem to stabilize the condition. She isn t experiencing any significant health issues. This condition is coded as A C B D A patient is experiencing diabetic nephropathy with hypertensive renal disease and renal failure. How many codes would be assigned for this patient? A. 1 C. 3 B. 2 D. 4 (Continued) Lesson 1 35

39 Assignment 2 Quiz Hypopotassemia is coded as A C B D Conditions that have a decrease in hemoglobin levels in the blood can be coded to Chapter A. 2. B. 3. C. 4. D. Need more information 8. When should acute blood loss anemia following surgery be coded as a complication of the surgery? A. Whenever there s a large amount of blood loss following a surgery B. When the physician states that the large amount of blood loss is due to the surgery and causing the anemia C. When anemia follows surgery and hemoglobin levels are elevated beyond the normal range D. Never. Anemia is never considered a complication; instead, it s considered a disease or disorder. 9. Which of the following should be used as a guideline when coding diabetes as uncontrolled versus controlled? A. Blood glucose levels outside of the normal range as documented in the patient s medical record B. Physician documentation stating uncontrolled or controlled C. The need for daily insulin injections D. Any of the above 10. When coding infectious and parasitic diseases, A. a second code is assigned to indicate the causative organism. B. fourth digits or additional codes may indicate the causative organism(s). C. code categories as principal, with a fourth digit indicating the causative organism. D. optional E codes are used to indicate the causative organism. (Continued) 36 Medical Coding 2

40 (Continued) Assignment 2 Quiz Part B: Complete the following exercises in your Clinical Coding Workout: Practice Exercises for Skill Development book. Exercises , Disorders of the Blood and Blood-Forming Organs, starting on page 94 Exercises , Endocrine, Nutritional and Metabolic Diseases, and Immunity Disorders, starting on page 102 Exercises , Infectious Diseases, starting on page 107 Lesson 1 37

41 NOTES 38 Medical Coding 2

42 ANSWER SHEET FOR YOUR INSTRUCTOR S USE GRADE GRADED BY STUDENT NUMBER: PLEASE PRINT ASSIGNMENT 2 QUIZ Medical Coding 2 NAME ADDRESS CITY STATE/PROVINCE ZIP/POSTAL CODE Check if this is a new address PHONE INDICATE YOUR ANSWER TO EACH QUESTION BY MARKING AN X IN THE APPROPRIATE SQUARE. EXAMPLE: A B C D Part A X CUT ALONG THIS LINE 1. A B C D A B C D A B C D A B C D A B C D 10. A B C D A B C D A B C D A B C D A B C D Part B HAVE YOU ENTERED YOUR STUDENT NUMBER IN THE SPACE PROVIDED?

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44 ASSIGNMENT 3: DISEASES OF THE CIRCULATORY SYSTEM/ NERVOUS SYSTEM/MENTAL DISORDERS/DISORDERS OF THE RESPIRATORY SYSTEM Read Section 7 Diseases of the Circulatory System (pp ) in the Coding Guidelines of your ICD-9-CM coding book. There s no additional reading assignment for diseases of the nervous and respiratory systems. Mental Disorders (Categories ) Mental disorders are discussed in Chapter 5 of your ICD-9-CM book, code categories The term mental disorder covers any emotional disturbance (by any cause) that impairs functioning. Mental disorders comprise a large range that may include the everyday life stress that affects a person s mood to severe emotional disturbances that incapacitate a person and interfere with everyday functions sometimes to the extent that suicide is attempted. A few examples of mental disorders are psychosis, senile dementia, depression, attention deficit disorder, Alzheimer s disease, schizophrenia, neurosis, and psychosis. Neurosis versus Psychosis Neurosis is a mental disorder involving anxiety and avoidance behavior that appears to have no organic cause. Neuroses can include a variety of anxieties and depression. Psychosis is a more severe distortion of a person s perception of reality. Psychoses can involve delusions, hallucinations, and bizarre behavior. Alcohol Abuse versus Alcohol Dependence Alcohol and drug dependencies are also covered in this chapter. Alcohol abuse (code ) is a drinking problem without physical dependence on alcohol. Code is also assigned for a diagnosis of drunkenness. NOTES: A code for psychosis shouldn t be assigned unless this disorder is clearly documented by the physician. Physicians may document conditions such as delirium, dementia, psychosis, and hallucination to indicate a patient s psychosis. As always, query the physician if the documentation is unclear. Substance abuse and substance dependency may be used interchangeably in the record documentation; however, they re coded differently. Query the physician for clarification, if necessary. Lesson 1 41

45 Alcohol dependency is a chronic condition with a physical dependence on alcohol. With this diagnosis, a physician may document the terms alcoholism and alcoholic. Coding Guidelines for Mental Disorder Diagnoses 1. When Alzheimer s disease has associated dementia, code first the Alzheimer s disease followed by the dementia code (294.1X). 2. Assign the fifth-digit subclassifications for schizophrenia (category 295) based on the physician s documentation. 3. Code acute reactions to stress to category 308 and chronic reactions to stress to category For psychogenic conditions (category 316) with associated physical conditions (NEC), code first the 316 code followed by the code for the associated physical condition. NOTE: Although there s a code for history of alcoholism (V11.3), it s rarely assigned (that is, most alcoholics stay in the recovering phase for their entire lives). Query the physician for clarification. 5. When coding anorexia nervosa (307.1), don t code associated malnutrition (even if listed as a separate diagnosis by the physician) because malnutrition is inherent in anorexia nervosa. 6. When acute and chronic alcoholism is diagnosed, report only code 303.0X to cover both conditions. 7. For recovering alcoholics, assign the appropriate 303.XX code with a fifth digit of 3 ( in remission ). 8. Assign only one of the following category codes for alcoholic withdrawal (based on physician documentation): 291.0, 291.3, When a patient is admitted for alcoholic withdrawal, assign withdrawal as the principal diagnosis and alcoholism as secondary. 10. For an admission of substance-related psychosis, code first the psychosis followed by alcohol/drug abuse or dependence. 11. When a patient is admitted for detoxification/rehabilitation (that is, no withdrawal or psychosis), code first the dependence. 42 Medical Coding 2

46 12. Drugs don t have to be given for a treatment code of detoxification to be assigned. Detoxification is the observation/management of the patient s withdrawal from a substance and doesn t necessarily include drug treatment. Query the physician for appropriate coding. Now let s practice the principles for this section. Proceed to the practical coding exercise for more information. Practice Exercise 3A Books Needed: Clinical Coding Workout: Practice Exercises for Skill Development ICD-9-CM coding book In your Clinical Coding Workout: Practice Exercises for Skill Development, complete exercises , Mental Disorders, starting on page 12. When you re finished, check your answers at the back of this study guide. Once you re confident you understand the coding principles for this section, move on to the next section. Nervous System and Sense Organs (Categories ) Diseases of the nervous system and sense organs appear in Chapter 6, code categories Examples of nervous system disorders are Parkinson s disease, encephalitis, meningitis, seizures, and multiple sclerosis. The nervous system is divided into two parts: the central nervous system and the peripheral nervous system. The central nervous system (CNS) is made up of the brain and spinal cord. Central nervous system codes are assigned to categories The peripheral nervous system (PNS) is made up of the cranial and spinal nerves. Peripheral nervous system codes are assigned to categories NOTE: Understanding the separation of classifications for CNS and PNS codes will help you more accurately code. Many PNS codes are manifestations of other conditions and therefore appear as the secondary diagnosis (with underlying condition listed first). Lesson 1 43

47 Hemiplegia versus Hemiparesis Conditions exist within this chapter that may cause hemiplegia or hemiparesis. Hemplegia is paralysis of one side of the body. Hemiparesis is weakness of one half of the body. Hemiplegia and hemiparesis isn t always coded as an additional code. Sometimes, these conditions are included within the condition being coded and thus don t require a separate code. Other times they re assigned as separate secondary diagnoses. Coders should follow the coding guidelines and coding book notations for assigning hemiplegia and hemiparesis codes. Coding Guidelines for Nervous System and Sense Organ Diagnoses 1. Infectious disease of the nervous system may require dual coding (follow code directions from your coding book). In these cases, list the responsible organism or code first, followed by the manifestation code. 2. Documentation of convulsions and seizures shouldn t be coded to epilepsy (category 345) unless specified by the physician. Instead, assign code Don t code hemiplegia that occurs with a cerebrovascular accident (CVA) if the hemiplegia resolves before the patient is discharged. 4. If hemiplegia is present at the time of discharge, assign a hemiplegia code from category 342 as an additional code. 5. On subsequent admissions, hemiplegia should be coded with the appropriate circulatory system (Chapter 7) 438.2X code to indicated that the condition is a late effect of CVA. 6. If Parkinson s disease is due to an adverse medication effect, assign the appropriate Parkinson s code with an E code for the responsible drug as a secondary diagnosis. 7. Don t code cataracts as senile or mature (regardless of the patient s age) unless documented as such by the physician. 44 Medical Coding 2

48 8. For patients with true diabetic cataracts (as documented by the physician), code first the appropriate diabetes code followed by the cataract code as secondary. 9. If cataracts are extracted and an artificial lens is implanted simultaneously, code first the extraction procedure code followed by the lens implantation. 10. Code fitting of a hearing aid to V-code V53.2 and procedure code Now let s practice the principles for this section. Proceed to the practical coding exercise for more information. Practice Exercise 3B Books Needed: Clinical Coding Workout: Practice Exercises for Skill Development ICD-9-CM coding book In your Clinical Coding Workout: Practice Exercises for Skill Development, complete exercises , Nervous System and Sense Organs, starting on page 14. When you re finished, check your answers at the back of this study guide. Once you re confident you understand the coding principles for this section, move on to the next section. Circulatory System (Code Categories ) Circulatory system disorders are coded to Chapter 7, code categories Ischemic Heart Disease versus Myocardial Infarctions Ischemic heart disease is caused by a lack of oxygen to the myocardial cells. Ischemic heart disease is also known as coronary ischemia, coronary artery disease, arteriosclerotic heart disease (ASHD), or coronary arteriosclerosis/atherosclerosis. NOTES: Some circulatory system disorders have been reclassified to Chapter 11, Complications of Pregnancy, Childbirth, and the Puerperium, and Chapter 14, Congenital Anomalies. Follow coding book notes and guidelines for the reclassifications that aren t coded in Chapter 7. Lesson 1 45

49 Myocardial infarctions (MIs) are acute ischemic conditions of obstruction in the coronary artery caused by thrombosis, atherosclerosis, or spasm. Myocardial infarctions are also known as heart attacks. NOTES: The myocardium is the middle, muscular layer of the heart. A fifth digit of 1 is still assigned if the patient is transferred to another facility during the initial episode of care. A negative finding from a CT or MRI scan doesn t necessarily rule out CVA. Don t code based on MRI/CT results alone. When there s inadequate documentation, query the physician for further coding clarification. Fifth-digit subclassifications are provided to indicate the episode of care for the MI. These fifth digits are: 1 the initial (first) episode of care; 2 the subsequent episode of care (admission for further care of the cardiac condition any time during the first eight weeks after the MI occurred). A fifth digit of 0 is assigned if the episode of care is unspecified. Cerebrovascular Disorders Cerebrovascular disorders affect the cerebral arteries of the brain. Cerebrovascular accidents (CVAs) are occlusions of the brain caused by thrombosis, embolism, hemorrhage, or ischemia. CVAs are also known as strokes. CVA versus TIA Cerebrovascular accidents are characterized by a sudden irreversible loss of neurologic function secondary to the ischemic death of brain tissue. Transient ischemic attacks (TIAs) are episodes of cerebrovascular insufficiency with accompanying symptoms that last only a few minutes (or, in rare cases, clear within 24 hours). In this section, we ll discuss CVA (code category 434) and transient ischemic attack (TIA) (code category 435) because symptoms often look the same for these two conditions. Thus, CVA and TIA can be difficult to distinguish between for coding purposes. As just mentioned, CVA and TIA symptoms may appear the same: disturbance of normal vision, numbness, weakness, dizziness, dysphasia, hemiplegia, and so forth. Also, a computed tomographic (CT) scan may not detect a CVA for up to 48 hours. Because of these circumstances, it s easy to code a TIA when it s really a CVA (or vice versa). A good rule to remember is that neurologic deficits (for example, hemiplegia, facial droop) usually clear within 24 hours with a TIA. Persistent defects that last longer than 24 hours usually indicate a CVA. A magnetic resonance image (MRI) will show positive findings 46 Medical Coding 2

50 for an acute ischemic stroke within two hours and a hemorrhagic stroke after six hours. Conversely, a CT scan may show positive findings for a hemorrhagic stroke immediately, but negative findings for an ischemic stroke. Review the documentation and query the physician for appropriate coding. Hypertension Hypertension (HTN), also known as high blood pressure (HBP), is classified to code categories Hypertension can be classified as primary hypertension or secondary hypertension, and benign, malignant, or unspecified. Malignant hypertension is severe, elevated blood pressure that commonly damages blood vessels and organs. Malignant hypertension can lead to other serious conditions and even death. Benign hypertension is a mild degree of hypertension over a long (chronic) period of time. Secondary hypertension is the result of another disease. In many cases, once the underlying disease is treated or controlled, the secondary hypertension will disappear. Therefore, code the secondary hypertension as secondary. In some cases, hypertension is described as uncontrolled, controlled, or history of. There s no code for specifying that the hypertension is uncontrolled. Instead, code it to the cause and nature. Controlled or history of may refer to hypertension that s still under treatment. In most cases, it s reported as a secondary diagnosis. NOTES: Code accelerated or necrotizing hypertension to the malignant hypertension category. For controlled/history of hypertension, look to see if the patient is still receiving medication or being treated. If so, assign the appropriate hypertension code. Hypertensive Diseases Many diseases are caused by underlying conditions of hypertension. Examples of hypertensive diseases are hypertensive heart disease (code category 402) and hypertensive kidney disease (code category 403). To assign these dual codes, look for terminology such as due to hypertension or hypertensive. Use caution when assigning combination codes. Just because a patient has hypertension and for example heart disease, it doesn t necessarily mean the patient suffers from hypertensive heart disease. Review the documentation and query the Lesson 1 47

51 physician for appropriate coding. When the documentation doesn t specify a causal relationship, two codes for each unrelated condition must be assigned. One exception in causal relationships is for hypertensive kidney disease. Guidelines dictate that a causal relationship is assumed between hypertension and renal disease. Therefore, code renal failure with hypertension as hypertensive kidney disease to code 403.XX (with the fifth digit indicating with (.00) or without (.01) chronic kidney disease) unless the physician specifically states the kidney disease isn t due to hypertension. With code category 403, use an additional code to identify the stage of chronic kidney disease if known ( ). Circulatory System Procedures Cardiac catheterization (codes ) is an invasive procedure for diagnosing cardiovascular disease. Cardiac catheterizations are done with a variety of other procedures. In these cases, cardiac catheterization isn t reported as a separate code because it s implicit in the other procedure codes. Cardiac pacemakers provide electrical control of the heart rate. Pacemaker placement can be temporary (code 37.78) or permanent (two codes for initial insertion: and ). There are three types of pacemakers, all with different codes: Single-chamber device (uses a single lead) code NOTES: When hypertensive heart and kidney disease are present, code 404.XX with additional codes to specify the type of heart failure ( ), if known. Add an additional code to identify the stage of chronic kidney disease ( ), if known. Single-chamber device, rate responsive code Dual-chamber device (uses dual leads) code Percutaneous transluminal coronary angioplasy (PTCA) is a treatment for atherosclerotic coronary heart disease and angina wherein the plaque is flattened against the walls of the artery by inflating and deflating a small balloon. This allows a better flow of blood and decreases disease symptoms. Codes for PTCA include the following: Single vessel, without mention of thrombolytic agent: Single vessel, with thrombolytic agent: (PTCA), (Injection/infusion of thrombolytic agent) 48 Medical Coding 2

52 Multiple vessel, performed during same operation, with or without mention of thrombolytic agent: 00.66; code also the number of vessels treated ( ) and any infusion of thrombolytic agent (99.10) Coronary artery bypass grafting (CABG) is open heart surgery in which a section of a blood vessel (or prosthesis) is grafted onto a coronary artery for redirection, or bypass, of blood flow around a blockage. Coding Guidelines for Circulatory System Diagnoses 1. Code acute myocardial infarctions (duration of 8 weeks or less) to category Don t assign code myocardial infarction, unspecified site, unless no other information is provided and the physician can t be queried. 3. For myocardial infarctions, assign a fifth digit of 1 (initial episode of care) if the patient was transferred from another facility during the initial episode treatment. 4. When a patient experiences a second infarction during an admission for an acute myocardial infarction, code both infarctions with a fifth digit of 1 for both cases. 5. Don t assign code 412 old myocardial infarction when current ischemic heart disease is present. 6. Assign code 412 old myocardial infarction as a secondary diagnosis only when it has significance for the current episode of care. NOTES: Assign additional codes for insertion of coronary artery stents ( ) and/or number of vascular stents inserted ( ). Separate procedure codes are used to indicate the type of bypass carried out (code 36.1X). Assign an additional (secondary) procedure code for the extracorporeal circulation (code 39.61) that s required for this procedure. When assigning a code from category 410, use a fourth digit to classify the location of the heart wall involved. If the location isn t documented, review the electrocardiograph report and query the physician. 7. Code intermediate coronary syndrome is assigned as principal diagnosis only when the underlying condition isn t identified and there s no surgical intervention. 8. Assign code if there s an arterial occlusion/ thrombosis without infarction. 9. Don t assign codes from categories 410 and 411 together unless there s a diagnosis of post-myocardial infarction syndrome or post-infarction angina. Lesson 1 49

53 10. It s rare to use code chronic ischemic heart disease, unspecified in an acute care setting. Query the physician for more information. 11. Arteriosclerosis of a bypassed blood vessel isn t considered a postoperative complication and instead should be coded to the appropriate arteriosclerosis code. 12. When a patient is admitted to the hospital with stable angina, code first the underlying cause as the principal diagnosis followed by the angina code. 13. When coding heart failure, codes and shouldn t be assigned together. Code should take precedence. NOTES: There are codes from category 404 that indicate whether the disease is benign or malignant. Query the physician for clarification before assigning these codes. 14. Code hypertensive heart disease with heart failure to category code Code hypertensive heart disease with hypertensive renal disease to category code Assign code cardiac arrest as principal diagnosis only when a patient arrives in cardiac arrest and can t be resuscitated (or is only briefly resuscitated before being pronounced as expired). 17. Assign code cardiac arrest as secondary diagnosis when cardiac arrest occurs during hospitalization and the patient is resuscitated. Code the underlying cause as the principal diagnosis. 18. Don t assign code 436 acute, but ill-defined, cerebrovascular disease when the documentation states stroke or CVA of specified type. 19. Late effects of cerebrovascular accidents (for example, aphasia, hemiparesis) aren t coded if they ve resolved at discharge. If still present at discharge, code the late effects as secondary diagnoses (with CVA as the principal diagnosis). 20. Assign a code from category 438 late effects of cerebrovascular disease when a patient is admitted at a later date with residual effects of a CVA that have bearing on the current episode of care. Codes from category 438 may be assigned as the principal diagnosis when appropriate. 50 Medical Coding 2

54 21. Assign a code from category V57 as principal diagnosis when the patient is admitted for rehabilitation after a CVA. Assign additional codes from category 438 to indicate the residuals. 22. If hypertension isn t specified as benign or malignant, assign code (rarely assigned as principal diagnosis). 23. Code secondary hypertension (category 405) as the secondary diagnosis with the underlying cause sequenced first. 24. Always assume a causal relationship between renal failure and hypertension and code it as hypertensive renal disease. 25. When documentation indicates that both hypertension and diabetes are responsible for chronic renal failure, code both conditions (category code 403 or 404 and 250.4X) with sequencing optional. 26. Code hypertension associated with pregnancy, childbirth, or puerperium to category code Elevated blood pressure without the documentation of hypertension is coded to Postoperative hypertension is a complication of surgery and should be coded to along with a code to identify the type of hypertension. 29. Assign V42.2 heart valve transplantation, V45.01 cardiac pacemaker in situ, and V45.81 aorto-coronary bypass status, only as additional diagnoses that indicate a health status related to the circulatory system (only when this additional diagnosis affects the patient s current episode). 30. When a patient is admitted for removal, replacement, or reprogramming of a cardiac pacemaker, code V53.31 fitting and adjustment of cardiac pacemaker as the principal diagnosis. NOTES: A patient may have elevated blood pressure following surgery. This isn t considered true post-operative hypertension (unless specified by the physician) and should be coded to Code V53.31 includes an admission for replacement because the pacemaker is nearing the end of expected life. Lesson 1 51

55 Coding Guidelines for Circulatory System Procedures 1. Total replacement of a pacemaker requires two procedure codes replacement of leads (37.74 or 37.76) and replacement of pacemaker ( ). 2. For a PTCA, code (00.66). For single vessels with thrombolytic agents, code and For multiple vessels, code 00.66, and then additional codes for number of vessels treated ( ) and infusion of thrombolytic agent (99.10). 3. Code an incomplete PTCA as a coronary arteriogram code 88.5X. 4. For a CABG, assign an additional (secondary) procedure code for the extracorporeal circulation (code 39.61) that s required for this procedure. (Don t assign hypothermia, cardioplegia, intraoperative pacing, and chest tube insertion as separate codes because they re integral to a CABG). Now let s practice the principles for this section. Proceed to the practical coding exercise for more information. Practice Exercise 3C Books Needed: Clinical Coding Workout: Practice Exercises for Skill Development ICD-9-CM coding book In your Clinical Coding Workout: Practice Exercises for Skill Development, complete exercises , Circulatory System, starting on page 16. When you re finished, check your answers at the back of this study guide. Once you re confident you understand the coding principles for this section, move on to the next section. 52 Medical Coding 2

56 Respiratory System (Code Categories ) As stated at the beginning of this chapter, one of the most important guidelines to remember when coding respiratory system disorders is to code the organism (cause) of the respiratory condition when documented. This is sometimes done as one (combination) code to cover both the pneumonia and the organism. For example, for pneumonia due to Klebsiella code NOTES: Both Streptococcus and Neisseria are found normally in the respiratory system. Their presence doesn t necessarily indicate an infection. In other cases, pneumonia is a manifestation of an underlying disease and should be assigned two codes. For example: Bronchial pneumonia in typhoid fever code and When no organism related to the pneumonia is documented or no organism can be verified, code 486 pneumonia, organism unspecified. Types of Pneumonia Lobar pneumonia doesn t actually refer to a lobe of the lung, but instead to a specific type of pneumonia. Only use code 481, lobar pneumonia, when specified by the physician. Gram-negative pneumonia is caused by gram-negative bacteria and is coded to category pneumonia due to other gram-negative bacteria. Aspiration pneumonia is a severe pneumonia that results from inhaling a foreign body or material (for example, vomitus, food, liquids) into the respiratory tract. Pneumonia due to a specific foreign body should be coded to category 507. Pneumonia due to the aspiration of microorganisms (for example, gram-negative bacteria) is coded to categories Chronic Obstructive Pulmonary Disease Chronic obstructive pulmonary disease (COPD) refers to a group of disorders that obstruct bronchial flow and usually result from smoking. One or more of the following diseases can be present in varying degrees: Emphysema Chronic bronchitis Lesson 1 53

57 NOTES: It s possible for the two types of aspiration pneumonia to be present in the same patient. In this case, code both the 507 and categories. Don t code respiratory failure unless documented by the physician. Not all patients in respiratory failure are put on mechanical ventilation. Don t code respiratory failure as the principal diagnosis when it s due to an acute, nonrespiratory condition. Bronchospasm Bronchiolitis When additional respiratory tract conditions such as acute bronchitis and asthma exist, use combination codes for COPD. Care should be taken to code the appropriate combination code and not two separate codes for these conditions. Respiratory Failure Respiratory failure occurs when there s an inadequate exchange of oxygen (O 2 ) and carbon dioxide (CO 2 ) in the lungs. Patients in acute respiratory failure will have increased breathing (rapid respiratory rate with use of accessory muscles) and possible cyanosis. The following codes are used for respiratory failure: 518.8X Respiratory failure (acute, chronic, acute and chronic, or NOS) Pulmonary insufficiency following trauma and surgery Respiratory failure of newborn According to the Coding Clinic published by the AHA (guidelines for coding ICD-9-CM), the following criteria apply to respiratory failure: (1) inadequate exchange of O 2 and CO 2 ; (2) close monitoring and aggressive respiratory therapy and/or ventilation are required due to the life-threatening nature of respiratory failure. Respiratory failure can be assigned as the principal diagnosis if it s the diagnosis that brings the patient into the hospital due to a chronic or acute respiratory (pulmonary) disease, with an additional code for the respiratory disease. When respiratory failure develops after admission, code it as an additional diagnosis. 54 Medical Coding 2

58 Coding Guidelines for Respiratory Disease Diagnoses 1. Code 481 lobar pneumonia only when specified by the physician. 2. When the two types of aspiration pneumonia are present in the same patient, code both the 507 category code and the code from categories Code COPD as 496 chronic airway obstruction, NEC only when assignment of a more specific code isn t possible. 4. An admission for acute exacerbation of COPD should be assigned code chronic obstructive bronchitis with acute exacerbation. 5. When a patient is admitted with acute bronchitis and COPD with acute exacerbation, assign code obstructive chronic bronchitis with acute bronchitis. Don t assign code acute bronchitis as an additional code because it s implicit in category Assign respiratory failure as the principal diagnosis if it brings the patient to the hospital and is caused by a respiratory condition. 7. Don t code respiratory failure as the principal diagnosis if the patient is admitted with respiratory failure due to an acute nonrespiratory condition. Code the nonrespiratory condition as principal diagnosis, followed by a secondary code for the respiratory failure. 8. When a patient is admitted in respiratory failure due to/associated with a chronic nonrespiratory condition, code the respiratory failure as principal followed by the chronic nonrespiratory condition as secondary. Now let s practice the principles for this section. Proceed to the practical coding exercise for more information. Lesson 1 55

59 Practice Exercise 3D Books Needed: Clinical Coding Workout: Practice Exercises for Skill Development ICD-9-CM coding book In your Clinical Coding Workout: Practice Exercises for Skill Development, complete exercises , Respiratory System, starting on page 17. When you re finished, check your answers at the back of this study guide. Once you re confident you understand the coding principles for this section, move on to the next section. 56 Medical Coding 2

60 Assignment 3 Quiz Books Needed: Clinical Coding Workout: Practice Exercises for Skill Development ICD-9-CM coding book Directions: Each assignment quiz is divided into two parts. Part A contains multiple-choice coding questions, whereas Part B requires you to code the information from a coding scenario found in your Clinical Coding Workout: Practice Exercises for Skill Development book. Complete all required and relevant codes for each given scenario. When you re comfortable with your answers for both parts, submit this quiz to your instructor for grading. Part A: Complete the following multiple-choice questions. 1. Conditions such as myocardial infarction and angina pectoris are included in which code category range? A C B D A myocardial infarction that occurred three weeks ago should be coded to category A C B D Don t assign code 412 as a secondary code when A. current ischemic heart disease is present. B. the physician documents healed MI. C. a previous heart attack is indicated by an electrocardiogram (EKG) and physician documentation. D. a past MI is causing no problems for the current admission. 4. Which of the following is the appropriate coding and sequencing (if applicable) for a diagnosis of dementia without behavioral disturbance due to Alzheimer s disease? A C , B , D (Continued) Lesson 1 57

61 Assignment 3 Quiz One of the patient s diagnoses is listed as alcoholism in remission. Which of the following codes should be reported for this condition? A C B D. V A right-handed patient has right-sided hemiplegia from a current, unspecified CVA that clears before patient discharge. Which of the following could be the correct code assignment(s) and sequencing (if applicable)? A. 436 C B. 436, D , Bacterial meningitis due to pneumococcus infection should be categorized to A. one code. B. two codes. C. three codes. D. no codes until the physician is queried for more information. 8. Code seizures and convulsions to category A C B D. Need more information 9. Which of the following are examples of codes that can be assigned to the same patient for the same encounter? A and C. 496 and B and D and When a patient is admitted in respiratory failure due to an acute, nonrespiratory condition, which of the following actions should the coder take? A. Code respiratory failure as the principal diagnosis and sequenced first. B. Code acute, nonrespiratory condition as the principal diagnosis and sequenced first. C. Code respiratory condition causing the respiratory failure as the principal diagnosis and sequenced first. D. Query the physician for appropriate sequencing. (Continued) 58 Medical Coding 2

62 Assignment 3 Quiz Part B: Complete the following exercises in your Clinical Coding Workout: Practice Exercises for Skill Development book: Exercises , Disorders of the Cardiovascular System, starting on page 95 Exercises , Behavioral Health Conditions, starting on page 109 Exercises , Disorders of the Nervous and Sense Organs, starting on page 116 Exercises , Disorders of the Respiratory System, starting on page 121 Lesson 1 59

63 NOTES 60 Medical Coding 2

64 ANSWER SHEET FOR YOUR INSTRUCTOR S USE GRADE GRADED BY STUDENT NUMBER: PLEASE PRINT ASSIGNMENT 3 QUIZ Medical Coding 2 NAME ADDRESS CITY STATE/PROVINCE ZIP/POSTAL CODE Check if this is a new address PHONE INDICATE YOUR ANSWER TO EACH QUESTION BY MARKING AN X IN THE APPROPRIATE SQUARE. EXAMPLE: A B C D Part A X CUT ALONG THIS LINE 1. A B C D A B C D A B C D A B C D A B C D 10. A B C D A B C D A B C D A B C D A B C D Part B HAVE YOU ENTERED YOUR STUDENT NUMBER IN THE SPACE PROVIDED?

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66 ASSIGNMENT 4: DIGESTIVE SYSTEM/DISEASES OF THE GENITOURINARY SYSTEM/ DISEASES OF THE SKIN AND SUBCUTANEOUS TISSUE Review the kidney and nephron diagrams on the first page of Chapter 10 (p. 193) Diseases of the Genitourinary System in the Tabular List of your ICD-9-CM coding book. Review the skin and subcutaneous layer diagram on the first page of Chapter 12 (p. 227) Diseases of the Skin and Subcutaneous Tissue in the Tabular List of your ICD-9-CM coding book. Digestive System (Categories ) Diseases of the digestive system are listed in Chapter 9 and are classified to code categories Gastrointestinal Hemorrhage Gastrointestinal (GI) hemorrhage can manifest itself in several ways: NOTES: There s no additional reading assignment for the Digestive System. Assign code category 578 when the physician notes that GI bleeding is due to a non-gi condition. Hematemesis (vomiting of blood) may indicate upper GI hemorrhage Melena (dark-colored blood in stool) may indicate upper or lower GI hemorrhage Occult blood (microscopic blood in stool) may indicate upper or lower GI hemorrhage Gastric ulcers, intestinal ulcers, and intestinal diverticular disease are the most common causes of upper GI hemorrhage. When hemorrhage is present for these conditions, there s one combination code that covers both the condition and the hemorrhage. For example, acute gastritis with hemorrhage code (covers both the condition and the bleeding). Lesson 1 63

67 Diverticulosis versus Diverticulitis Diverticulosis indicates the presence of pouchlike herniations (diverticula) throughout the intestine. Diverticulitis is inflammation of the diverticula. NOTES: Diverticula can be found on any hollow, tubular organ (such as intestine, esophagus, bladder). When diverticulosis isn t otherwise specified, it s assumed to be of the colon (code [without hemorrhage]). The terms stone and calculus are synonymous and may be used interchangeably in documentation. When removal of stones is performed, don t code incision of the cystic duct as a separate procedure because it s implicit in the basic procedure code. When both diverticulosis and diverticulitis are documented, code only the diverticulitis because the condition assumes the presence of the pouchlike herniations (from diverticulosis). For example, for diverticulosis with diverticulitis of the duodenum code diverticulitis of the small intestine (without mention of hemorrhage). Diverticula can be acquired or congenital. For certain sites (such as colon), diverticula are assumed to be congenital. For other sites (such as espophagus), diverticula are assumed to be acquired unless otherwise documented. Pay close attention to medical record documentation and coding notes in your coding book so that you ll assign the appropriate code for these distinctions. Cholecystitis, Cholelithiasis, and Choledocholithiasis This section deals with diseases of the gallbladder. The function of the gallbladder is to store excess bile until it s needed to break down fat. Cholecystitis is acute or chronic inflammation of the gallbladder. Cholelithiasis is the presence of gallstones in the gallbladder. If there are abnormally high levels of bile salts or, more commonly, cholesterol, stones can form. Choledocholithiasis is a condition of stones in the common bile duct. Choledocholithiasis may also be referred to as biliary calculus or gallstones. In ICD-9-CM classification, there are codes that allow for these three related conditions to be coded as one combination code. There are classification groups (code category 574) based on location of the calculus. The fourth digit within the category indicates if there s associated cholecystitis and if it s acute. Fifth digits indicate any presence of obstruction. Cholecystectomy, or removal of the gallbladder, is a procedure that can be performed as total or partial via either an open approach ( ) or a laparoscopic approach ( ). 64 Medical Coding 2

68 Adhesions and Hernia Adhesions are bands of scar tissue that bind together internal surfaces that are normally separate. Adhesions most commonly form in the abdomen after abdominal surgery. Adhesions are classified to codes (peritoneal adhesions; postoperative, post-infective) and (intestinal or peritoneal adhesions with obstruction; postoperative, post-infective). Adhesions are treated by lysis (destruction/dissolution of the scar tissue) and coded by the following approaches: Laparoscopic lysis of peritoneal adhesions code Other lysis of peritoneal adhesions code Hernia is a protrusion or projection of an organ through an abnormal opening. In ICD-9-CM, hernias are classified by type and site. For hernia repair, make sure that the diagnostic code for hernia matches the procedure code. For example, if a diagnosis of unilateral hernia is coded, it isn t possible for a bilateral hernia procedure to be coded. Errors in coding such as this will result in denial of payment for the institution. Coding Guidelines for Digestive System Diagnoses 1. Code category 578 (gastrointestinal hemorrhage) is assigned only when the physician states GI bleeding is caused by a condition other than GI. 2. Assign GI conditions with hemorrhage to the appropriate combination code. NOTES: A patient may have minor adhesions that don t cause issues. When these adhesions are lysed during another procedure, don t code the adhesions or the lysis. Code these adhesions only when they re so extreme that the surgeon must stop the other procedure in order to lyse the adhesions. As always, query the physician for clarification when needed. It isn t possible for a bilateral repair to be performed for a unilateral hernia. However, it s possible for a unilateral repair to be done for a bilateral hernia if repair for one of the hernias is necessary but not for the other. 3. Obstruction of gallbladder code and obstruction of bile duct code should be assigned only when there s obstruction but no calculi. 4. Calculus of the gallbladder and bile duct with both acute and chronic cholecystitis should be coded to 574.8X. 5. When coding postcholecystectomy syndrome code don t code a postoperative complication code (categories ). 6. With femoral and inguinal hernias, use the fifth-digit subclassification to indicate if the hernia is unilateral or bilateral and whether it s recurrent. 7. Code incarcerated or strangulated hernias as obstructed. Lesson 1 65

69 8. Code functional diarrhea as (564.4 if it follows GI surgery). Coding Guidelines for Digestive System Procedures NOTES: Infectious diarrhea with organism is assigned to Chapter 1, Infectious and Parasitic Diseases (code categories ). When no condition/cause is identified, code diarrhea as a sign/symptom code (787.91). For the code 47.0X guideline, the appendix doesn t need to show pathologic changes on tissue examination for this to be coded. 1. When coding cholecystectomy, look for the following additional performed procedures and assign additional codes if present: removal of stones (51.41), other relief of obstruction (51.42), intraoperative cholangiogram (87.53). 2. When removal of stones is performed during a cholecystectomy, don t code incision of the cystic duct as a separate procedure because it s implicit in the basic procedure code. 3. When simple or minor adhesions are lysed during another procedure, don t code the adhesions or the lysis. 4. For appendectomy, assign code 47.1X, incidental appendectomy, when an appendix is removed as a routine measure during the course of other abdominal surgery. 5. For an appendix removed during exploratory laparoscopic surgery (with no other therapeutic procedure), code 47.0X with no code for the approach. Now let s practice the principles for this section. Proceed to the practical coding exercise for more information. Practice Exercise 4A Books Needed: Clinical Coding Workout: Practice Exercises for Skill Development ICD-9-CM coding book In your Clinical Coding Workout: Practice Exercises for Skill Development, complete exercises , Digestive System, starting on page 19. When you re finished, check your answers at the back of this study guide. Once you re confident you understand the coding principles for this section, move on to the next section. 66 Medical Coding 2

70 Genitourinary System (Code Categories ) Chapter 10 in the ICD-9-CM book categorizes diseases of the genitourinary system (code categories ). Genitourinary refers to the organs and/or functions of both the genitals and urinary system together. Genitourinary is also called urogenital. Urinary Tract Infections Urinary tract infections (UTIs) may be one of the most commonly coded conditions from this chapter. A urinary tract infection (UTI) is an infection of one or more structures in the urinary system. UTIs are most commonly found in women and commonly caused by gram-negative bacteria. Types of urinary tract infections include Cystitis inflammation of the bladder and ureters Pyelonephritis inflammation of the renal pelvis of the kidney Urethritis inflammation of the urethra Codes for urinary tract infections include both combination codes and single codes. Combination codes will use one code to cover both the infection and the organism causing the infection. Many of these codes are reclassified to a chapter other than the genitourinary system chapter. For example, gonococcal cystitis (bladder) code is reclassified to Chapter 1, Infections and Parasitic Disease, to indicate the organism Neisseria gonorrhoeae as the infective agent causing the cystitis. When coding urinary tract infections to Chapter 10, use two codes: infection code (coded first); organism code. For example, in acute cystitis due to Escherichia coli code as follows: acute cystitis code (assigned first); E. coli (assigned as secondary code). When the specific location of the UTI isn t documented, code urinary tract infection, NOS. If the organism is identified, use a secondary code following NOTES: If cystitis and pyelonephritis are documented, look up the actual disease mentioned (that is, cystitis) in the Alphabetic Index. Starting with the term infection may take you to the wrong coding information. The code is used commonly by coders. Many times a specific location/organism may not be mentioned. Lesson 1 67

71 Hematuria and Incontinence NOTES: Incontinence actually refers to the inability to control urination or defecation. For the purpose of this chapter, we re discussing incontinence related specifically to urination. Unspecified renal failure is coded to 586. Hematuria, or blood in the urine, is a symptom of certain conditions. The hematuria code (599.7) should be assigned only when the condition causing it isn t identified. In some cases (for example, after urinary procedures), some amount of hematuria is expected and shouldn t be coded. If documentation indicates that hematuria after a procedure is excessive, query the physician to determine if it should be coded as a postoperative condition or secondary diagnosis. Incontinence refers to the inability to control urination due to anatomic, physiologic, or pathologic conditions. Stress incontinence is due to physical strain such as occurs when a person coughs, sneezes, or laughs. Stress incontinence in women is coded to and in men to code Renal Disease Renal disease is classified to code categories , with the exception of that related to pregnancy/labor (reclassified to Chapter 11). Renal failure is a result of other diseases and can be acute or chronic. Acute kidney failure is the sudden cessation of renal function (584.X). Chronic kidney disease, or CKD (585.X), is the inability of the kidneys to function adequately on a long-term basis. According to the Clinical Practice Guidelines for CKD by the National Kidney Foundation ( CKD is defined as kidney damage or greater than or equal to three months. Kidney damage is pathologic abnormalities or markers of damage (including abnormalities in blood or urine tests or imaging studies). The ICD-9-CM coding book provides fourth digits to cover all stages of kidney disease (Stage I V and then End Stage ). Chronic kidney disease includes chronic renal disease, chronic renal failure NOS, and chronic renal insufficiency, which are all included in code If applicable, an additional code (V42.0) should be used to identify the kidney transplant status. As discussed in the circulatory system chapter, ICD-9-CM assumes a relationship between hypertension and kidney disease (reclassified to categories 403 or 404). However, acute 68 Medical Coding 2

72 renal failure isn t assumed to be caused by hypertension. In this case, assign first the code for acute renal failure (584.9) followed by the code for hypertension (401.9). Don t use codes from categories 403 or 404 if the following scenarios exist: Acute renal failure exists with hypertension. Hypertension is described as secondary. Renal disease is specifically stated due to another cause (other than hypertension). Renal disease with diabetes (or diabetic nephropathy) is also coded to another chapter code 250.4X diabetes with renal manifestation. Assign an additional code to indicate a manifestation (for example, renal failure, glomerulosclerosis). Coding Guidelines for Genitourinary System Diagnoses 1. When a UTI is due to the presence of an implant, graft, or device (for example, indwelling catheter), code complication code category 996.6X. 2. Code the symptom hematuria (599.7) only when it isn t implicit in other conditions or when the related condition isn t identified. 3. Regarding laboratory reports, code blood in urine as hemoglobinuria only if the physician documents clinical significance. 4. When the underlying cause is known for incontinence, code the underlying cause first followed by the incontinence code. 5. Code both chronic renal failure and end-stage renal disease to category Code renal insufficiency to unspecified disorder of the kidney and ureter. 7. When renal disease results from both hypertension and diabetes mellitus, two combination codes from categories 403/404 and subcategory 250.4X are assigned (sequence either code as principal diagnosis). However, don t assign a code from codes with this scenario. Lesson 1 69

73 8. When the patient is admitted for dialysis, code V56.0 extracorporeal dialysis (hemodialysis) or V56.8 other dialysis (peritoneal) as the principal diagnosis. Coding Guidelines for Genitourinary System Procedures 1. When a patient is admitted for dialysis, also code the insertion of venous catheter (38.95) or totally implantable vascular access device (86.07). Code for the associated dialysis. 2. Don t code cystoscopy used for diagnosing and treating urinary conditions as a separate code. The procedures include the cystoscopy in the code. 3. For prostate surgery, the approach (for example, perineal, retropubic, transurethral) determines the code assignment. Note that code 60.5 is for radical prostatectomy regardless of approach used. Now let s practice the principles for this section. Proceed to the practical coding exercise for more information. Practice Exercise 4B Books Needed: Clinical Coding Workout: Practice Exercises for Skill Development ICD-9-CM coding book In your Clinical Coding Workout: Practice Exercises for Skill Development, complete exercises , Genitourinary System, starting on page 21. When you re finished, check your answers at the back of this study guide. Once you re confident you understand the coding principles for this section, move on to the next section. 70 Medical Coding 2

74 Skin and Subcutaneous Tissue (Code Categories ) Skin and subcutaneous tissue conditions are covered in Chapter 12, code categories ( ). They re subdivided into the following categories: Infections ( ) Other inflammatory conditions ( ) Other disease of skin/subcutaneous tissue ( ) Cellulitis Cellulitis is an acute infection of the skin and subcutaneous tissue. Symptoms of cellulitis may range from localized heat, redness, pain, and swelling to fever, chills, malaise, and headache. Individuals who have diabetes, poor circulation, or damaged skin are more prone to cellulitis. NOTES: This chapter includes conditions of the nails, sweat glands, hair, and hair follicles. Cellulitis can occur in other areas (aside from skin/subcutaneous tissue). In those cases, code the cellulitis to the appropriate chapter. Skin Ulcers Decubitus ulcer, or pressure sore/ulcer, is a sore or ulcer that occurs most frequently at pressure points, especially those when the patient is lying down for long periods of time. Elderly and debilitated patients are at a higher risk for decubitus ulcers. For example, elderly or paralyzed individuals who lie or sit in one position for long periods may develop decubitus ulcers on their sacral/buttock area. Code these ulcers to 707.0X. Lesson 1 71

75 NOTES: Excisional debridements may be carried out at the patient s bedside or in an operating room. However, just because a physician is performing the debridement doesn t make it excisional. Nonexcisional debridements performed by personnel other than physicians shouldn t be coded. Abscess and lymphangitis are included in the code for cellulitis. Simple excision involves only the skin. Debridement Debridement is a procedure done to remove damaged tissue, debris, and foreign objects from a wound or burn to prevent infection and promote healing. There are two important distinctions for debridement when coding this procedure; excisional debridement of the skin includes cutting away of the tissue and is performed only by a physician. Code is a nonoperative (nonexcisional) procedure that includes terms like brushing, irrigating, scrubbing, or other methods to remove tissue or foreign material. Coding Guidelines for Skin and Subcutaneous Tissue Diagnoses 1. Code cellulitis due to a superficial injury, burn, or frostbite to two codes one for the injury and one for cellulitis. Sequencing in this case depends on the circumstances of admission. 2. For abscess and/or lymphangitis with cellulitis, assign only the appropriate code for cellulitis. Assign an additional code for the causative organism. 3. Assign cellulitis as a complication of a chronic skin ulcer to code category 707 with a secondary code to identify the cellulitis. Sequencing depends on the circumstances for admission. 4. Code gangrenous cellulitis due to injury/ulcer to gangrene as a secondary diagnosis with the injury/ulcer sequenced as principal diagnosis. 72 Medical Coding 2

76 Coding Guidelines for Skin and Subcutaneous Tissue Procedures 1. Code simple excision of lesions to category 86.3 (includes local excision and method of destruction). 2. Code 86.4 for a radical or wide excision. 3. Nonexcisional debridements performed by personnel other than physicians shouldn t be coded. NOTE: Radical or wide excision involves underlying/adjacent tissue. Now let s practice the principles for this section. Proceed to the practical coding exercise for more information. Practice Exercise 4C Books Needed: Clinical Coding Workout: Practice Exercises for Skill Development ICD-9-CM coding book In your Clinical Coding Workout: Practice Exercises for Skill Development, complete exercises , Skin and Subcutaneous Tissue, starting on page 24. When you re finished, check your answers at the back of this study guide. Once you re confident you understand the coding principles for this section, move on to the next section. Lesson 1 73

77 Assignment 4 Quiz Books Needed: Clinical Coding Workout: Practice Exercises for Skill Development ICD-9-CM coding book Directions: Each assignment quiz is divided into two parts. Part A contains multiple-choice coding questions, and Part B requires you to code the information from a coding scenario found in your Clinical Coding Workout: Practice Exercises for Skill Development book. Complete all required and relevant codes for each given scenario. When you re comfortable with your answers for both parts, submit this quiz to your instructor for grading. Part A: Complete the following multiple-choice questions. 1. Vomiting of blood may indicate which of the following types of hemorrhage? A. Acute upper GI C. Upper or lower GI B. Chronic upper GI D. Lower GI 2. Which of the following conditions is/are the most common causes of upper GI bleed? A. Gastric ulcers C. Intestinal diverticular disease B. Intestinal ulcers D. All of the above 3. A patient is admitted with a small pouch extending from the duodenum. The coder will probably report category A diverticulitis. C duodenal ulcer. B diverticulosis. D acute gastric ulcer. 4. When minor adhesions are lysed as part of another procedure, how should you code the lysis of adhesions? A. As an additional procedure B. As an incision C. Don t code the lysis of adhesions. D. Depends on the approach used (Continued) 74 Medical Coding 2

78 Assignment 4 Quiz How should the presence of hematuria after a urinary tract procedure or prostatectomy be coded? A B C D. It shouldn t be coded unless directed by the physician. 6. When a patient has both hypertension and renal disease, a relationship is presumed and coded as one code together except in the case of A. acute renal failure. C. renal disease with heart disease. B. chronic renal failure. D. acute renal disease. 7. Which of the following factors most likely determines the appropriate procedure code assignment for prostatectomies? A. The approach C. The age of the patient B. The case-mix index D. The presence of secondary diseases 8. A sacral decubitus ulcer with gangrene is coded and sequenced (if applicable) as codes A C B , D , How many codes should be assigned for cellulitis as a complication of chronic skin ulcers? A. One B. Two C. Three D. Unsure, need to query physician 10. Any skin debridement performed by a physician should be coded to which of the following procedure codes? A B C D. Need more information; must query physician for type of debridement used (Continued) Lesson 1 75

79 Assignment 4 Quiz Part B: Complete the following exercises in your Clinical Coding Workout: Practice Exercises for Skill Development workbook. Exercises , Disorders of the Digestive System, starting on page 98 Exercises , Disorders of the Genitourinary System, starting on page 105 Exercises , Disorders of the Skin and Subcutaneous Tissue, starting on page Medical Coding 2

80 ANSWER SHEET FOR YOUR INSTRUCTOR S USE GRADE GRADED BY STUDENT NUMBER: PLEASE PRINT ASSIGNMENT 4 QUIZ Medical Coding 2 NAME ADDRESS CITY STATE/PROVINCE ZIP/POSTAL CODE Check if this is a new address PHONE INDICATE YOUR ANSWER TO EACH QUESTION BY MARKING AN X IN THE APPROPRIATE SQUARE. EXAMPLE: A B C D Part A X CUT ALONG THIS LINE 1. A B C D A B C D A B C D A B C D A B C D 10. A B C D A B C D A B C D A B C D A B C D Part B HAVE YOU ENTERED YOUR STUDENT NUMBER IN THE SPACE PROVIDED?

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82 ASSIGNMENT 5: DISEASES OF THE MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE/ COMPLICATIONS OF PREGNANCY, CHILDBIRTH, AND PUERPERIUM/NEWBORN (PERINATAL)/CONGENITAL ANOMALIES Review the diagram for Chapter 13 (p. 237) Diseases of the Musculoskeletal System and Connective Tissue in the Tabular List of your ICD-9-CM coding book. Read Section 11 Complications of Pregnancy, Childbirth, and Puerperium (pp ) in the Coding Guidelines of your ICD-9-CM coding book. Read Section 15 Newborn (Perinatal) Guidelines (pp ) in the Coding Guidelines of your ICD-9-CM coding book. Read Section 18, Letter d, Number 11 Obstetrics and related conditions (p. 23), and Number 12 Newborn, infant, and child (p. 23) in the Coding Guidelines of your ICD-9-CM coding book. NOTE: There s no additional reading assignment for congenital anomalies. Musculoskeletal System and Connective Tissue (Code Categories ) Chapter 13 lists codes for the musculoskeletal system and connective tissue (code categories ). Many of the categories for this chapter have fifth-digit subclassifications that indicate the site involved. Follow notes in your ICD-9-CM coding book for the appropriate fifth-digit assignment. Arthritis Arthritis is an inflammatory condition of the joints that causes pain, redness, swelling, and also limits movement. Arthritis may occur alone or as a manifestation of another disease. Lesson 1 79

83 In these cases, assign the appropriate dual codes. Some common examples of arthritis are osteoarthritis (code category 715) and rheumatoid arthritis (code category 714). NOTES: The fifth digit indicates the site. Remember, fractures due to injuries (traumatic) are coded to Chapter 17 Injury and Poisoning. Back pain associated with the herniation of an intervertebral disc is included in the herniation code (no separate code for back pain is assigned). Pathologic Fractures Pathologic fractures are breaks in the bone caused by a weakness in the bone tissue. If a fracture is described as spontaneous, it s a pathologic fracture and coded to category 733.1X. Coding Guidelines for Musculoskeletal System and Connective Tissue Diagnoses 1. Code back pain in the following way: first code to site of pain; lumbago, or low back pain 724.2; back pain, NOS 724.5; cervicalgia, or neck pain Many back disorder codes make a distinction for those persons with or without myelopathy (functional disturbance and/or pathologic change in the spinal cord). Follow the medical record documentation for appropriate assignment. 3. A pathologic fracture (733.1X) is sequenced as principal diagnosis only when admission is for treatment of the fracture and no other underlying condition exists. 4. Never assign traumatic fracture and pathologic fracture of the same bone together. 5. Assign code V43.6 joint replacement status as an additional code if the presence of the replacement is significant for the patient s current episode of care. Coding Guidelines for Musculoskeletal System and Connective Tissue Procedures 1. When a laminectomy is performed with excision of a herniated disc, don t code the laminectomy separately (because it s the approach). When a laminectomy is performed for the sole purpose of exploration or decompression of the spinal canal, use code Medical Coding 2

84 2. Assign replacement of joint lower extremities to code 81.5X and upper extremities to code 81.8X. 3. When joint replacement also involves bone growth stimulator, code the stimulator to 78.9X as an additional procedure code. 4. When a bilateral replacement of a joint is performed, use the joint replacement code twice to indicate both locations. 5. Code revision or replacement of a joint replacement of lower extremity to 81.5X. NOTE: The guideline for Number 5 is used after the joint has been replaced the initial time. Don t assign this code for the first (initial) joint replacement. Now let s practice the principles for this section. Proceed to the practical coding exercise for more information. Practice Exercise 5A Books Needed: Clinical Coding Workout: Practice Exercises for Skill Development ICD-9-CM coding book In your Clinical Coding Workout: Practice Exercises for Skill Development, complete exercises , Musculoskeletal System and Connective Tissue, starting on page 26. When you re finished, check your answers at the back of this study guide. Once you re confident you understand the coding principles for this section, move on to the next section. Pregnancy, Childbirth, Puerperium (Code Categories ) Chapter 11 codes Complications of Pregnancy, Childbirth, and the Puerperium are classified to code categories Any condition that arises during a pregnancy, childbirth, or puerperium is considered a complication and should be coded as such unless otherwise specified from the physician. The following two guidelines are important to remember when assigning codes from categories : 1. These codes are used only for reporting diagnoses in the mother s record and never coded in the newborn s record. Lesson 1 81

85 2. These codes have sequencing priority over codes from other chapters. Chapter 11 is divided into the following sections: Ectopic and molar pregnancies: code categories NOTES: Puerperium is the time after childbirth approximately six weeks in which a woman s anatomic and physiologic changes from the pregnancy resolve. Antepartum means occurring or existing before birth. This stage is often referred to as prenatal. Postpartum means occurring after birth. Other pregnancies with abortive outcomes: code categories Complications mainly related to pregnancy: code categories Normal delivery (and other indications for care): code categories Complications occurring mainly during labor and delivery: code categories Complications of the puerperium: code categories Fifth digit subclassifications used for code categories and provide more information. Pay close attention to notes and guidelines for using these fifth digits. Fifth digits can be assigned only at certain periods, and many can t be assigned to the same episode. The fifth digits are 0 Unspecified as to episode of care or not applicable 1 Delivered, with or without mention of antepartum condition 2 Delivered, with mention of postpartum complication 3 Antepartum condition or complication when delivery hasn t occurred 4 Postpartum condition or complication when delivery occurred during a previous episode of care Other Conditions Some conditions classified to other chapters (for example, hypertension, diabetes, anemia) are reclassified to Chapter 11 when they affect or complicate a pregnancy, delivery, or puerperium. For example, during these periods benign hypertension is coded to categories (Chapter 11) instead of to the normal code (Chapter 7). 82 Medical Coding 2

86 Coding Guidelines for Pregnancy, Childbirth, and Puerperium Diagnoses 1. When an encounter is for a condition unrelated to the pregnancy, code the condition for admission first followed by V22.2 pregnant state, incidental. 2. Fifth digits 1 and 2 can be used together for the same episode, but not with any other fifth digits (from other codes in this chapter). 3. For complications, fifth digits 3 (antepartum) and 4 (postpartum) can t be used together or with any other fifth digit. 4. Assign a secondary category code V27.X to the mother s record to indicate the outcome of delivery (for example, single birth, multiple births, alive, stillborn) for the current episode of care. 5. Code 650 normal delivery only when the delivery is normal with a single liveborn outcome. Criteria: head/ occipital delivery; antepartum complication resolved before admission; no labor/delivery abnormalities; no postpartum complications; outcome assigned V27; no procedures other than episiotomy without forceps, episiorrhaphy, amniotomy, manual delivery (no forceps), administration of analgesia/anesthesia, fetal monitoring, sterilization 6. When a patient is admitted for obstetric care other than delivery, the principal diagnosis should be coded to the pregnancy complication. NOTES: Look up Outcome of delivery (V27.X) in the Alphabetic Index, V code section, of your ICD-9-CM code book to find these codes. Code 650 is always coded as principal diagnosis and can t be coded with any other codes from Chapter 11. Don t use codes V22.0 and V22.1 with any codes from Chapter For routine prenatal visits (no complications), code V22.0 surpervision of normal first pregnancy or V22.1 supervision of other normal pregnancy as the reason for the encounter. 8. When the patient delivers outside of the hospital and no complications are present, code V24.0 postpartum care and examination immediately after delivery as the principal diagnosis. 9. Code from categories 655 and 656 only when the fetal condition is responsible for modifying the mother s care. Lesson 1 83

87 NOTES: Diagnoses can t be assigned based solely on elevated blood pressure, abnormal albumin level, or edema. Complications are considered postpartum if they occur within six weeks after delivery. Don t forget to also assign a procedure code for a contraceptive management visit when appropriate. If sterilization is performed during the same admission as the delivery, assign code V25.2 as the secondary diagnosis. Code includes repair of episiotomy, so there s no need for an additional code. 10. Always code preexisting hypertension (category 642) as a complication in pregnancy, delivery, or puerperium. 11. The physician must specify pre-eclampsia or eclampsia before these conditions can be coded. 12. Postpartum complications that occur during the admission for delivery are assigned a fifth digit of 2. Postpartum complications that occur after discharge are assigned a fifth digit of Code perineal lacerations to categories 664.0X 664.3X. 14. Assign a code from category V25 as the principal diagnosis when the admission/outpatient encounter is for contraceptive management. 15. Assign code V25.2 (covers both male and female) when the admission/encounter is solely for contraceptive sterilization. Coding Guidelines for Pregnancy, Childbirth, and Puerperium Procedures 1. Assign additional codes for procedures that assist delivery: artificial rupture of membranes (73.01), cervical dilation (73.1), artificial rupture of membranes (after labor has begun) (73.09), forceps rotation of fetal head (72.4), manual rotation of fetal head (73.51). 2. Episiotomies are coded to category 73.6 (without forceps delivery) or category 72.1 (low forceps delivery). 3. Repair of perineal lacerations are coded to category Cesarean sections are coded as 74.0 (classical), 74.1 (low cervical), or 74.2 (extraperitoneal). 5. Code female contraceptive/sterilization procedures to categories 66.2 and 66.3; code male contraceptive/ sterilization procedures to Now let s practice the principles for this section. Proceed to the practical coding exercise for more information. 84 Medical Coding 2

88 Practice Exercise 5B Books Needed: Clinical Coding Workout: Practice Exercises for Skill Development ICD-9-CM coding book In your Clinical Coding Workout: Practice Exercises for Skill Development, complete exercises , Pregnancy, Childbirth, and the Puerperium, starting on page 22. When you re finished, check your answers at the back of this study guide. Once you re confident you understand the coding principles for this section, move on to the next section. Congenital Anomalies (Categories ) Congenital means present at birth; therefore, a congenital anomaly is a condition or disease that a baby is born with. Congenital anomalies are represented in Chapter 14 of the ICD-9-CM coding book, code categories Many anomalies occur as a set of symptoms or multiple abnormalities. Because of the large amount of congenital anomalies present in the medical field, it s difficult to provide a code for each and every anomaly. Sometimes the anomaly will be specified even though there s no specific ICD-9-CM code to match. In these cases, code other specified anomaly of the specific type/site. When a specific anomaly code isn t available, code instead each of the manifestations present for the anomaly. NOTE: Some congenital perinatal conditions are coded to Chapter 15 (instead of Chapter 14). Follow coding notes in your ICD-9-CM coding book for the correct code assignment. Even though codes from this chapter are described as perinatal, they can be assigned to patients of any age. Many congenital anomalies persist throughout a person s lifetime and have an impact on health and treatments. Coding Guidelines for Congenital Anomaly Diagnoses 1. When the anomaly is specified but there s no specific ICD-9-CM code to match, code instead other specified anomaly of the specific type/site with manifestation codes of the anomaly. Lesson 1 85

89 2. Conditions due to birth injuries are reclassified to perinatal conditions, birth trauma, code category 767 (Chapter 15). NOTES: Newborn congenital conditions are reported even if they re not treated/evaluated during the current admission. This policy is an exception to the coding guideline for reporting additional diagnoses. There s no separate coding exercise for the congenital anomaly section. Congenital anomalies have been grouped with the next section. Follow information in the coding book for correct assignment of fourth- and fifth-digit subdivisions of categories V30 V39. Codes from categories 764 and 765 should be assigned based on physician documentation and not just on gestational age and/or birth weight. The physician must document prematurityrelevant conditions to be coded. 3. Code a newborn with a congenital anomaly to code category V30 V39 as principal diagnosis followed by the additional anomaly code from Chapter When a renal cyst isn t specified as congenital or acquired, code the cyst as congenital. Certain Conditions Originating in the Perinatal Period (Code Categories ) Conditions originating in the perinatal period appear in Chapter 15, code categories Perinatal refers to the time period around and including the process of being born or giving birth. The newborn (perinatal) period begins at birth and lasts through the 28th day following birth. Classification of Newborns When coding births, assign a code from categories V30 V39 according to the type of birth and any other significant secondary diagnoses originating in the perinatal period. Codes from categories V30 V39 are assigned to the medical record as principal diagnosis and only one time to the newborn record at the time of birth. Prematurity and Fetal Growth Retardation A premature infant is one who is born before 37 weeks gestation and hasn t fully developed or matured. Fetal growth retardation means that the infant is smaller than expected at a specific gestational age. Codes for premature infants and/or fetal growth retardation are assigned to code categories 764 and 765 with a fifth digit to indicate birth weight. 86 Medical Coding 2

90 Coding Guidelines for Perinatal Diagnoses 1. When coding the birth of an infant, assign to the newborn record a code from category V30 V39 according to type of birth. 2. Don t code from category V30 39 when a newborn has been transferred from another institution. Code instead the condition responsible for the transfer as principal diagnosis (with no V30 V39 series coded). 3. Don t code categories V33, V37, and V39 for acute care hospitals (sufficient information should be provided to code elsewhere). 4. Assign a V29 category code as secondary diagnosis when a healthy newborn is evaluated for a suspected condition that s (after study) not present. Assign the V30 category code as principal diagnosis. 5. Code a secondary diagnosis from category 766 for a long gestation or unusually high birth weight. 6. Code fetal distress and asphyxia only when the condition has been specifically identified and documented by the physician. Don t codes these conditions based on scores or tests. 7. Code from categories 760 and 763 maternal causes of perinatal morbidity to the newborn record only when the maternal condition is the cause for morbidity or mortality. 8. Assign routine vaccination of newborns as V05.3 (viral hepatitis) and V05.4 (varicella). 9. Assign a code from category V20 health supervision of infant/child for routine encounters when no problem has been identified. Coding Guidelines for Perinatal Procedures NOTES: When the signs/ symptoms of a suspected condition are present, code instead the sign or symptom (and not the V29 category code). A code from V29 can be assigned as principal diagnosis for readmission or when V30 is no longer appropriate. 760 and 763 codes are assigned to newborn records only when the maternal condition has adversely affected the newborn. Code V20.2 is assigned for routine examinations (for example, well baby clinic) at clinics/offices but not for hospital admissions. For routine newborn vaccinations, assign procedure code Now let s practice the principles for this section. Proceed to the practical coding exercise for more information. Lesson 1 87

91 Practice Exercise 5C Books Needed: Clinical Coding Workout: Practice Exercises for Skill Development ICD-9-CM coding book In your Clinical Coding Workout: Practice Exercises for Skill Development, complete exercises , Newborn/Congenital Disorders, starting on page 27. When you re finished, check your answers at the back of this study guide. Once you re confident you understand the coding principles for this section, move on to the next section. 88 Medical Coding 2

92 Assignment 5 Quiz Books Needed: Clinical Coding Workout: Practice Exercises for Skill Development ICD-9-CM coding book Directions: Each assignment quiz is divided into two parts. Part A is composed of multiplechoice coding questions, and Part B requires you to code the information from a coding scenario found in your Clinical Coding Workout: Practice Exercises for Skill Development book. Complete all required and relevant codes for each given scenario. When you re comfortable with your answers for both parts, submit this quiz to your instructor for grading. Part A: Complete the following multiple-choice questions. 1. When coding back disorders, which of the following conditions should always be considered for inclusion in the code? A. Degeneration C. Herniation B. Myelopathy D. Arthritis 2. Laminectomy when performed with excision of herniated disc shouldn t be coded separately because this procedure is A. a closure and inherent in the code. B. an operative approach and inherent in the code. C. an invasive surgical procedure. D. never covered by third-party payers. 3. A code such as can be assigned as principal diagnosis only when A. the physician lists it first on the admission sheet with no other conditions. B. there s no underlying condition that s being treated. C. there s an underlying condition that s coded as secondary. D. it has been ruled out as the secondary diagnosis. (Continued) Lesson 1 89

93 Assignment 5 Quiz Which of the following is the correct coding and sequencing if applicable for bilateral total hip replacement? A C , B D , Codes from Chapter 11 refer to codes for A. the mother only. C. the baby only. B. the mother and baby. D. pregnancy conditions only. 6. The only circumstance for which code V27 can be assigned is on the A. newborn s record for birth in the hospital during the current episode of care. B. newborn s record to indicate birth on subsequent episodes of care. C. mother s record for delivery in hospital during current episode of care. D. mother s record to indicate delivery on subsequent episodes of care. 7. Which of the following scenarios would be assigned the code for normal delivery on the mother s record? A. Live birth, full term, cephalic presentation with episiotomy repair B. Live birth, full term, cephalic presentation, postpartum breast abscess C. Live birth, full term, breech presentation, rotated by version before delivery D. Live birth, full term, vertex presentation, low forceps 8. A scenario in which categories V30 V39 are assigned is once, as the diagnosis to the record at the time of birth. A. principal, newborn C. secondary, newborn B. principal, maternal D. secondary, maternal 9. A valid documentation for codes 764 or 765 would be physician documentation stating A. gestational age as 35 weeks. C. low birth weight for 37 weeks. B. fetal growth retardation. D. prematurity. 10. Which of the following are all category codes that could be assigned for acute-care hospitals? A. V20, V29, V37 C. V27, V29, V30 B. V27, V29, V33 D. V33, V37, V39 (Continued) 90 Medical Coding 2

94 Assignment 5 Quiz Part B: Complete the following exercises in your Clinical Coding Workout: Practice Exercises for Skill Development workbook: Exercises , Disorders of the Musculoskeletal System and Connective Tissue, starting on page 110 Exercises , Newborn/Congenital Disorders, starting on page 117 Exercises , Conditions of Pregnancy, Childbirth, and the Puerperium, starting on page 120 Lesson 1 91

95 NOTES 92 Medical Coding 2

96 ANSWER SHEET FOR YOUR INSTRUCTOR S USE GRADE GRADED BY STUDENT NUMBER: PLEASE PRINT Assignment 5 Quiz Medical Coding 2 NAME ADDRESS CITY STATE/PROVINCE ZIP/POSTAL CODE Check if this is a new address PHONE INDICATE YOUR ANSWER TO EACH QUESTION BY MARKING AN X IN THE APPROPRIATE SQUARE. EXAMPLE: Part A X A B C D CUT ALONG THIS LINE 1. A B C D A B C D A B C D A B C D A B C D 10. A B C D A B C D A B C D A B C D A B C D Part B HAVE YOU ENTERED YOUR STUDENT NUMBER IN THE SPACE PROVIDED?

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98 Lesson 1 ICD-9-CM Hospital Inpatient Coding When you feel confident that you have mastered the material in Lesson 1, submit your answers by attachment to edserv@pennfoster.com. On the subject line of the , write Exam , then Medical Coding 2. Follow the directions given for submitting assignment quizzes. If you don t have access to , you can mail in your exam. Submit your answers for this examination as soon as you complete it. Do not wait until another examination is ready. Send your completed exam to Penn Foster Student Service Center 925 Oak Street Scranton, PA EXAMINATION NUMBER Whichever method you use in submitting your exam answers to the school, you must use the number above. Questions 1 25: Select the one best answer to each question. Record your answers on the answer sheet for this examination. Part A: Multiple-Choice Questions 1. A patient is admitted to undergo chemotherapy for cancer of the sigmoid colon that was previously treated with resection. Which code is sequenced first? A C. V58.1 B D. V10 2. A patient was admitted to the hospital for chest pain due to tachycardia. While in the hospital, the patient was also treated for type 1 diabetes. Upon further review, the coder noted that the documentation and EKG didn t provide further evidence of the type of tachycardia or underlying cardiac condition(s). What should the coder report as the principal diagnosis? A. Chest pain B. Tachycardia, NOS C. Insulin-dependent diabetes mellitus D. Cardiac disease, NOS Examination 95

99 3. Dr. Smith recorded the following diagnoses on the patient s discharge sheet: gastrointestinal bleeding due to acute gastritis and angiodysplasia. The principal diagnosis is coded as A. GI bleeding. B. acute gastritis. C. angiodysplasia. D. either acute gastritis or angiodysplasia. 4. A patient was admitted with extreme fatigue and lethargy. Upon discharge, the physician documents: fatigue due to either depression or hypothyroidism. Which of the following are correct codes and sequencing for the scenario? A , 311, C , 311 B. 311, 249.9, D Of the following, which code would take precedence over the other? A over C. 486 over 480 B over D over Upon discharge, the physician documents the following on the patient s discharge sheet:?hiv infection. As the inpatient coder, your next step should be to A. code the HIV infection as if it exists (according to UHDDS guidelines) and report it as the principal diagnosis. B. review the UHDDS guidelines for assigning possible HIV infection codes versus AIDS codes. C. query the physician and request that the statement be amended with a positive (or negative) confirmation of the HIV infection. D. wait to code the patient s record until a positive finding on the serology report confirms the HIV diagnosis. 7. For which of the following scenarios would it be appropriate to query the physician for more information before coding and/or sequencing? A. A patient was admitted with severe abdominal pain. At discharge, the physician documents: abdominal pain due to either hiatal hernia or diverticula. B. A patient was admitted with congestive heart failure (treated with IV furosemide) and unstable angina (treated with nitrates). C. A patient has low potassium levels noted on the laboratory report (treated with orally administered potassium). D. A patient is admitted with dysuria with no cause found. 96 Examination, Lesson 1

100 8. Which of the following statements is true? A. A patient has diabetes and an ulcer. Code the ulcer as diabetic. B. A pregnant patient has diabetes. Code diabetes as complicating the pregnancy. C. A patient has diabetes and cardiomyopathy. Code the cardiomyopathy as a diabetic complication. D. A patient has diabetes and cataracts. Code diabetic cataracts. 9. A patient was admitted for metastatic carcinoma from the breast to several lymph node sites. Two years ago she had a double mastectomy. Which of the following is the correct code assignment for this case? A , V10.3 C , 174.9, B , D , 174.9, V One of the secondary diagnoses listed on the patient s discharge sheet is seizures. As a coder, your next step is probably A. coding seizures to B. coding seizures to 345. C. not reporting the code because it s a symptom. D. querying the physician for more information/clarification. 11. A patient was discharged with the diagnosis of acute bronchitis with chronic obstructive asthma. Which of the following is the correct coding and sequencing (if applicable) for this patient? A C , B , 496 D Code can be listed as principal diagnosis in which of the following cases? A. For an outpatient encounter when the cause has been determined B. For an inpatient encounter when the cause hasn t been determined C. When it s listed with a contrasting diagnosis D. It can never be listed as principal diagnosis. 13. Which of the following codes should not be listed as principal diagnosis? A C. E812.0 B. V30.00 D Choose the correct code and sequencing for the following scenario: Reduction of right humerus fracture with cast. A C , B D , Examination, Lesson 1 97

101 15. Read the following excerpt from medical record documentation and determine the correct code(s) for coding. The physician writes: noted burn on the arm skin with redness. Patient complained of tenderness to the touch. A C B D A patient was admitted in a coma from intentionally ingesting an entire bottle of sedatives. Which of the following is the correct coding and sequencing assignment? A , C , E950.2 B , 967.8, E950.2 D , , E Which of the following situations would allow the assigning of a V code for a principal diagnosis? A. Mother admitted for birth of infant, no complications B. Patient admitted for dialysis C. Patient admitted for metastatic breast cancer with a history of ovarian cancer D. Patient admitted for poisoning has a history of alcoholism 18. A patient was admitted for nausea and vomiting due to gastroenteritis. Which of the following is the correct code reporting and sequencing? A , , C , B , , D A physician lists positive findings on a purified protein derivative (PPD) test as a secondary diagnosis on the patient s discharge sheet. How should this listing be coded? A B C D. This listing shouldn t be coded. 20. A physician lists urosepsis as a secondary diagnosis on a patient s discharge sheet. How would you code this diagnosis? A. Code it to C. Code it to B. Code it to D. Code 599.0, A patient is admitted for metastatic adenocarcinoma of the sacrum from the prostate. A prostatectomy was performed 11 months ago. Which of the following should be reported as the principal diagnosis for this patient? A. V10 C B. 185 D Examination, Lesson 1

102 22. A patient was discharged with a diagnosis of diabetes with nephropathy and chronic renal failure. How many codes would be reported for this patient? A. One B. Two C. Three D. Need more information on the type of diabetes 23. If the physician describes the patient as presently in a manic phase, but has experienced depression in the past, this condition may be coded as A X C X B X D. Need more information 24. Codes 331.9, 332.0, are conditions affecting the A. central nervous system. C. gastrointestinal system. B. peripheral nervous system. D. cardiovascular system. 25. A patient was admitted with an acute exacerbation of chronic obstructive bronchitis and found to be in respiratory failure. Which of the following is the correct coding and sequencing for this case? A , C , 496 B , D , 496, Part B: Coding Record Scenarios In your Clinical Coding Workout: Practice Exercises for Skill Development book, code the following health record scenarios. Record your answers on the answer sheet for this examination. In some cases, you ll select codes from a multiple-choice list. In other cases, you ll be assigning the actual diagnosis and procedure codes. When assigning codes, be sure to report them on the answer sheet in the order that you would sequence them (if appropriate). Be sure to read the directions on pages (Case Studies from Inpatient Health Records) before beginning these exercises. Coding Inpatient Records Complete the following exercises from Level III Advanced Coding Exercises: 7.1 (p. 190), 7.5 (p. 196), 7.6 (p. 196), 7.8 (p. 196), 7.9 (p. 197), 7.11 (p. 199), 7.13 (p. 203), 7.14 (p. 206), 7.15 (p. 207), 7.19 (p. 217), 7.22 (p. 221), 7.25 (p. 224), 7.27 (p. 226), 7.28 (p. 227), 7.31 (p. 231), 7.34 (p. 234), 7.36 (p. 237), 7.40 (p. 246), 7.41 (p. 246), 7.45 (p. 250) Examination, Lesson 1 99

103 NOTES 100 Examination, Lesson 1

104 ANSWER SHEET FOR YOUR INSTRUCTOR S USE GRADE GRADED BY STUDENT NUMBER: PLEASE PRINT EXAMINATION NUMBER Lesson 1: Inpatient Coding NAME Medical Coding 2 ADDRESS CITY STATE/PROVINCE ZIP/POSTAL CODE Check if this is a new address PHONE INDICATE YOUR ANSWER TO EACH QUESTION BY MARKING AN X IN THE APPROPRIATE SQUARE. EXAMPLE: X A B C D CUT ALONG THIS LINE Part A 1. A B C D 10. A B C D A B C D 11. A B C D A B C D 12. A B C D A B C D 13. A B C D A B C D 14. A B C D A B C D 15. A B C D A B C D 16. A B C D A B C D 17. A B C D A B C D A B C D A B C D A B C D A B C D A B C D A B C D A B C D A B C D Part B HAVE YOU ENTERED YOUR STUDENT NUMBER IN THE SPACE PROVIDED?

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106 RESEARCH PROJECT Background Some hospitals, organizations, and physicians now outsource, or hire contract coders, to perform their coding. There are commercial coding companies that engage pools of coders to meet these outsourcing needs. Procedure Use the internet to research coding companies. Select two and provide the following information for each company: Part A Company Information 1. Company Name 2. URL (Web address) Part B Questions Lesson 1 GRADED PROJECT NUMBER How long has the company been in business? 2. List the range of services the company provides. 3. What kind of health care providers does the company work with? 4. What are the requirements (educational, certification, experience, and so on) to work for this company? 5. Would you like to work for this company? Why or why not? What additional skills would you need to acquire before working for this company? Graded Project 103

107 Goal Your goal is to become aware of these coding companies, the health care providers they work with, and the skills and experience coders must have to work for individual companies. Writing Guidelines Type your submission, double-spaced, in a standard, size 12 print font. Use a standard document format with one-inch margins. (Don t use any fancy or cursive fonts.) Include the following information at the top of your paper: Name and address Student number Course title and number (Medical Coding 2 HIT 204) Research project number ( ) Read the assignment carefully and answer each question. Be specific. Limit your submission to the questions asked and issues mentioned. Include a reference page that lists Web sites, journals, or any other references used in preparing the submission. Proofread your work carefully. Check for correct spelling, grammar, punctuation, and capitalization. Grading Criteria You re researching two companies. The information for each company is worth 50 percent. Your responses for each company count as follows: Part A 5% Part B Question 1 5% Questions % each 104 Graded Project

108 The questions will be evaluated according to the following criteria: Content The student Provides clear answers to the assigned question(s) Answers the question(s) in complete sentences, not just simple yes or no statements Supports his or her opinion by citing specific information from the assigned Web sites and other references used Stays focused on the assigned issues Writes in his or her own words and uses quotation marks to indicate direct quotations Written Communication The student As necessary, answers each question in a complete paragraph that includes an introductory sentence, at least four sentences of explanation, and a concluding sentence Uses correct grammar, spelling, punctuation, and sentence structure Provides clear organization by using words like first, however, on the other hand, and so on, consequently, since, next, and when Makes sure the paper contains no typographical errors Format The paper is double-spaced and typed in font size 12. It includes the student s Name and address Student number Course title and number (Medical Coding 2 HIT 204) Research project number ( ) Graded Project 105

109 Submitting Your Project After you complete your research project, submit it as an attachment to On the subject line, write Research Project, then the project number, , then Medical Coding 2. In the body of the , be sure to include your full name and student number. If you re unable to send in your research project as an attachment, you may use the answer sheet provided. Attach it to the project and mail the project to this address: Penn Foster Student Service Center 925 Oak Street Scranton, PA Be sure to include your full name, your student number, the project number and your complete mailing address. 106 Graded Project

110 ANSWER SHEET FOR YOUR INSTRUCTOR S USE GRADE GRADED BY STUDENT NUMBER: PLEASE PRINT EXAMINATION NUMBER Graded Project NAME Medical Coding 2 ADDRESS CITY STATE/PROVINCE ZIP/POSTAL CODE Check if this is a new address PHONE Company 1 Part A Company Information (5 points) Score CUT ALONG THIS LINE Part B Questions Question 1 (5 points) Question 2 (10 points) Question 3 (10 points) Question 4 (10 points) Question 5 (10 points) Score Score Score Score Score Company 2 Part A Company Information (5 points) Part B Questions Question 1 (5 points) Question 2 (10 points) Question 3 (10 points) Question 4 (10 points) Question 5 (10 points) Score Score Score Score Score Score Comments: Final Grade

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112 Inpatient/Outpatient Procedure Coding/ Physician Coding/ HCPCS Level II ASSIGNMENT 6: HOSPITAL (ACUTE CARE) INPATIENT AND AMBULATORY (OUTPATIENT) PROCEDURE CODING Read Section IV Diagnostic Coding and Reporting Guidelines for Outpatient Services (p ) in the Coding Guidelines of your ICD-9-CM coding book. Read the Introduction (pp. xiv xvii) in your Current Procedural Terminology: CPT coding book. INTRODUCTION In this lesson you ll learn about general coding guidelines for inpatient and outpatient procedures and physician office coding using ICD-9-CM, HCPCS Level I, and HCPCS Level II procedure coding. ICD-9-CM procedure codes are found in volume 3 of the ICD-9-CM coding book and are used to code acute-care hospital inpatient and outpatient procedures. Volume 3 (Index to Procedures) is arranged mainly by specific body system. HCPCS Level I (CPT) is found in your CPT 2011 coding book arranged in six sections by numeric order. The HCPCS Level II list from CMS is arranged alphanumerically. Most HCPCS Level II coding books are arranged by code letter section (for example, all A codes are in one section, and B codes are in a separate section). Note: You don t have a HCPCS Level II textbook. Instead, you ll use the lists you downloaded earlier from the CMS Web site. For this section, you ll focus on hospital inpatient and outpatient procedure coding guidelines. Lesson 2 109

113 NOTES: There s one exception to the numeric order E/M codes ( ) are listed at the beginning of the CPT 2011 coding book. The UHDDS doesn t apply to the coding of outpatient procedures. The CPT system (from the AMA) is the classification system that determines reporting guidelines for outpatient procedures along with the CMS. You may also hear the term encounter used for an outpatient s visit or an inpatient stay at the hospital. Coding Inpatient Procedures For reimbursement and reporting, medical coders are required by the UHDDS to code hospital inpatient procedures. The UHDDS (to refresh your memory, the Uniform Hospital Discharge Data Set) requires that all significant procedures be reported. A significant procedure has the following characteristics: Surgical in nature Has an anesthetic risk Has a procedural risk Requires specialized training to perform Remember, hospital inpatient procedures are reported using the codes from Volume 3 (Index to Procedures) of the ICD-9-CM coding book. You learned about guidelines for some of these procedures when working through the different body systems in Lesson 1. Coding Outpatient Procedures An outpatient is defined as an individual who receives hospital services and isn t expected to be admitted to the hospital or remain in the hospital over a period of 24 hours. Outpatient care may also be referred to as ambulatory care. The CMS requires that outpatient procedures be reported using HCPCS Level I (CPT) codes. ICD-9-CM procedure codes aren t required for reporting; however, the administrators of some hospitals and other health care institutions may choose to have the coder report both the HCPCS Level I (CPT) code and the ICD-9-CM procedure code for internal tracking or statistical purposes. 110 Medical Coding 2

114 Coding Inpatient versus Outpatient Procedures Two major differences exist between coding inpatient versus outpatient records. 1. The UHDDS definition of principal diagnosis applies only to inpatients (acute care hospitals). 2. Inconclusive diagnoses (probably, suspected, likely) aren t coded for outpatients. Instead, the highest level of certainty is coded. This means that there may be times when you re coding a symptom as the reason for an outpatient encounter. Acute-Care Hospital Inpatient Procedural Coding Hospital inpatient procedures are coded using ICD-9-CM procedure codes (categories ) found in Volume 3 of the ICD-9-CM coding book. Just as there s a principal diagnosis in inpatient coding, there s also a principal procedure. A principal procedure is performed for definitive treatment (rather than diagnostic/exploratory) or treatment necessary to take care of a complication. If there are two or more procedures performed, then the one that most closely relates to the principal diagnosis should be sequenced first as the principal procedure. NOTES: This outpatient scenario is different than that for inpatient guidelines wherein you may code probable, suspected, and likely as if the condition exists. There may be times when your principal procedure and principal diagnosis aren t related. Make sure that you have adequate documentation for the codes assigned so that reimbursement isn t denied. Basic Guidelines for Coding Inpatient Procedures 1. Code Also For some ICD-9-CM procedures, you ll see an instructional note that says Code Also. Code also means that an additional procedure should be coded if performed. If two code assignments are needed, the index will often indicate this by using slanted brackets [ ] around the additional code(s). In this case, the additional codes must be assigned and sequenced as indicated. Example: Cardiotomy and pericardiotomy Code also cardiopulmonary bypass [extracorporeal circulation][heart-lung machine] (39.61) 2. Omit Code The omit code instruction means that no code for that category is to be assigned. Lesson 2 111

115 3. Excision of Organ or Lesion Excision of organs (or lesions) may also be listed under the term resection. 4. Bilateral Procedures Bilateral procedures indicate that the procedure was performed at two locations/sides. Assign the procedure code twice for bilateral procedures (unless otherwise indicated by the code). NOTES: The operative approach is coded when the opening is followed only by a diagnostic procedure (for example, a biopsy). There are a few exceptions for coding laparoscopic/thoracoscopic approaches separately. Follow coding instructions in the coding book closely. Category V64 can t be assigned as a principal diagnosis. 5. Approaches and Closures Operative approaches/closures (for example, incisions and stitching up) and laparoscopic/thoracoscopic approaches are usually considered an integral part of the procedure and aren t coded as separate codes. 6. Other Endoscopic Approaches Endoscopic approaches are coded unless directed otherwise by the Alphabetic Index, and/or a procedure was performed with the endoscopy. When an endoscopy is performed on more than one body cavity, the code assignment should indicate the most distant site reached. 7. Biopsies Closed biopsies are performed percutaneously (by needle), by aspiration, or by endoscopy. The biopsy is coded according to the procedure used. For example, when an endoscopic approach is used, code the endoscopy and biopsy with the endoscopy (the most intensive procedure) coded first. For example, a colonoscopy of the large intestine with biopsy is coded to (ICD-9-CM) (CPT). Open biopsies are performed by an incision. Because the incision is implicit in the biopsy procedure, code only the biopsy. When an open biopsy is performed with another procedure, code both the biopsy and the procedure, with the procedure sequenced first. 8. Canceled Procedures When a procedure has been canceled after a patient admission, code only ICD-9-CM diagnosis code category V64 persons encountering health services for specific procedures, not carried out as a secondary diagnosis with no procedure code assigned. 112 Medical Coding 2

116 9. Incomplete Procedures When coding incomplete procedures (procedures that weren t completed for a reason), follow these guidelines: Incision only performed: code to the site of incision Endoscopic approach unable to reach site: code endoscopy only Cavity or space entered: code to exploration of site 10. Failed procedures If a procedure didn t achieve the needed results, it may be considered as having failed. Code the full procedure as normal. Review medical record documentation and/or query the physician if questions arise. 11. Stents Stents are implants used to restore flow of fluid and are usually performed with other procedures. Code both the procedure and the insertion of the stent. Now let s practice the principles for this section. Proceed to the practical coding exercise for more information. Lesson 2 113

117 Practice Exercise 6A Books Needed: Clinical Coding Workout: Practice Exercises for Skill Development ICD-9-CM coding book CPT coding book In your Clinical Coding Workout: Practice Exercises for Skill Development, complete exercises , ICD-9-CM Procedure Coding, starting on page 36. When you re finished, check your answers at the back of this study guide. Once you re confident you understand the coding principles for this section, move on to the next section. NOTES: Observation patients aren t technically considered inpatients until they ve been admitted as such. Physicians may assign this observation status to patients for determining the need for treatment or review of a condition or postsurgical complication. For outpatient records, don t code approaches and closures (just as in ICD-9-CM). Level I HCPCS (CPT) Procedural Coding Hospital Outpatient Procedural Coding Outpatient procedures usually include ambulatory surgeries performed in an operating room, on-site clinic, surgical suite, or ambulatory surgery center. In addition, all claims for emergency room visits and patient visits with the status of observation must be submitted with HCPCS codes. Often new coders and sometimes even experienced coders have difficulty trying to determine which items to code. When reviewing a medical record, the amount of information can be overwhelming, and sometimes the tendency may be to code everything as a safety net. When coding outpatients (and surgical reports of inpatients), it may be easier to review operative reports and look for terms such as the following: incision, excision, endoscopy, exploration. These words can help you to narrow down the procedures that should be coded. 114 Medical Coding 2

118 Guidelines for Assigning HCPCS Level I (CPT) Codes For hospital outpatients, the following information is required by the CMS for reporting: Diagnoses ICD-9-CM diagnosis codes Procedures HCPCS Level I (CPT) codes Note: Some hospitals still use ICD-9-CM procedure codes for statistical reporting purposes. Follow these steps in assigning a HCPCS Level I (CPT) procedure code: 1. Determine the procedure, test, or service to be coded. Remember, look for such action terms as excision and incision. 2. Locate the main term in the CPT index (check under the following categories: procedure, anatomic site, condition, synonym, eponym, service, or abbreviation). NOTE: Never code directly from the CPT index. If the procedure or service isn t listed in the alphabetic index, locate the organ/anatomic site, condition/diagnosis, or synonym/eponym instead. Also, follow coding book notes/directions. For example, reconstruction may be listed under revision. 3. Review/select the subterms (indented below main term). 4. Follow cross-references. 5. Find the code in the main list section. 6. Review all notes for the selected code. 7. If applicable for the particular setting, select the appropriate modifier. Using the CPT Book The CPT book is divided into six sections: (1) evaluation and management, (2) anesthesia, (3) surgery, (4) radiology, (5) pathology, and (6) laboratory medicine. Because we re discussing hospital ambulatory (outpatient) guidelines in this lesson, you ll be focusing on the surgery and laboratory medicine sections of CPT here. You ll learn about the other CPT sections in the next section that deals with physician office Lesson 2 115

119 coding. However, let s take a moment and explain why the other sections for hospital ambulatory guidelines aren t discussed here. NOTES: You may also hear the chargemaster referred to as the charge description master. It s very important to use the most current coding book. Using codes and/or coding books from previous years could result in incorrect statistics and possibly denial of reimbursement for payment. Coding and the Chargemaster In the hospital setting, the chargemaster automates the billing of services such as pathology, laboratory, and radiology. A chargemaster is a computerized list of service codes and descriptions that automatically matches charges with these specific service codes. When one of the service codes is performed for a patient, the hospital computer system automatically assigns the code and applies the charge for that service to the patient s bill. So, you may be wondering how you know what to code and what s assigned automatically by the chargemaster? Well, this task can be tricky for a new coder. A good rule when coding hospital records inpatient or outpatient is to remember that you don t need to assign codes for procedures or items such as laboratory tests, X-rays, needle sticks, and equipment. These assignments are all done automatically via the chargemaster. In a hospital setting, you need to focus only on diagnoses and procedures as defined in previous sections. HCPCS Level I (CPT) Ambulatory Surgery Coding As previously discussed, HCPCS Level I most commonly referred to as CPT is a listing of codes that physicians and other health care providers use to report medical services and procedures performed. Hospitals are required to report HCPCS Level I (CPT) codes for all outpatients. Basic Coding Guidelines for Hospital Outpatient Services When coding for ambulatory surgery, ICD-9-CM codes for diagnoses are also required. 116 Medical Coding 2

120 HCPCS Level I (CPT) Codes for Procedures Some common rules and guidelines to remember when coding for ambulatory surgery are as follows: 1. The appropriate diagnosis code(s) from V82.9 must be used to identify diagnoses or reason(s) for the encounter/visit. 2. Codes that describe symptoms and signs are acceptable for reporting purposes when an established diagnosis hasn t been confirmed by the physician. 3. List first the ICD-9-CM code for the diagnosis or reason for the encounter/visit shown in the medical record to be chiefly responsible for the services provided. List any additional ICD-9-CM diagnosis codes that describe any coexisting conditions. 4. Don t code diagnoses documented as probable, suspected, questionable, or rule out. Code the condition(s) that have been established to the highest degree of certainty for that encounter/visit. Such information as symptoms, signs, abnormal test results, or other reasons for the visit should be included. NOTES: This process for outpatient surgery coding runs contrary to the coding practices used by hospitals and health information management (medical records) departments for coding the diagnoses of hospital inpatients. History codes (V10 V19) may be used as secondary codes if the historical condition or family history has an impact on current care or influences treatment. 5. Chronic diseases treated on an ongoing basis may be coded and reported as many times as the patient receives treatment and care. 6. Code all documented conditions that coexist at the time of the encounter/visit and require or affect patient care, treatment, and management. 7. Don t code conditions that were previously treated and no longer exist. 8. For patients receiving diagnostic services only, sequence first the diagnosis, condition, problem, or other reason for the encounter/visit. Codes for other diagnoses (for example, chronic conditions) can be sequenced as additional diagnoses. The only exception to this rule is that for patients receiving chemotherapy, radiotherapy, or rehabilitation, the appropriate V code for the service is listed first, and the diagnosis or problem for which the service is being performed is listed second. Lesson 2 117

121 NOTES: If the patient is just admitted for observation status and meets observation guidelines, then follow the observation/outpatient guidelines for coding. 9. For patients receiving preoperative evaluations only, sequence a code from category V72.8X other specified examinations to describe the preoperative consultations. Assign a code for the condition to describe the reason for the surgery as an additional diagnosis. Code also any findings related to the preoperative evaluation. 10. For ambulatory surgery, code the diagnosis for which the surgery was performed. If the postoperative diagnosis is known to be different from the preoperative diagnosis at the time the diagnosis is confirmed, select the postoperative diagnosis for coding. 11. When a patient is admitted as an inpatient for a complication due to an outpatient procedure, code the principal diagnosis as the condition that required the inpatient admission, followed by the condition for the procedure/ surgery, and the procedure code. Example. An outpatient tonsillectomy is performed for chronic tonsillitis with postoperative bleeding noted. The patient was admitted to the hospital for control of the bleeding. Code as follows: Principal diagnosis: Postoperative bleeding Secondary: Chronic tonsillitis Procedure: Tonsillectomy Now let s practice the principles for this section. Proceed to the practical coding exercise for more information. 118 Medical Coding 2

122 Practice Exercise 6B Books Needed: Clinical Coding Workout: Practice Exercises for Skill Development CPT coding book Note: Even though in a hospital outpatient setting a coder would sometimes code both the ICD-9-CM diagnosis codes (for internal reporting) and the HCPCS Level I (CPT) procedure codes, for the purpose of this exercise you only need to be concerned with coding the HCPCS Level I (CPT) procedure codes. In your Clinical Coding Workout: Practice Exercises for Skill Development book, complete the following exercises: 2.56 (p. 51); 2.62 (p. 51); 2.69 (p. 52); 2.79 (p. 53); 2.83 (p. 54); 2.93 (p. 55); (p. 56); (p. 59); (p. 59); (p. 60); (p. 60); (p. 62); (p. 63); (p. 64); (p. 66); (p. 66); (p. 67); (p. 69) When you re finished, check your answers at the back of this study guide. Once you re confident you understand the coding principles for this section, move on to the next section. Category III/Unlisted Procedures in HCPCS Level I (CPT) Unlisted/Category III CPT Procedure Codes A group of unlisted five-digit alphanumeric CPT (Category III) procedure codes that bear T endings provide a way of reporting codes for new technologies and procedures. These codes are temporary codes that should be used only as a last resort because they re often automatically flagged for review from the payer (and may frequently be denied for reimbursement). The payer will require additional, supportive documentation when a claim is submitted. NOTE: The first four positions of these Category III codes will be numeric, with the alpha character in the fifth position. These Category III codes should not be confused with HCPCS Level III codes, which have alpha characters in the first position, followed by four numeric digits. Lesson 2 119

123 Unlisted HCPCS Procedures Codes These Category III codes have the following characteristics: Allow coders to assign a code to a procedure that s not listed in the CPT coding book Should be assigned only as a last resort (that is, check HCPCS Levels II and III codes first) NOTE: A complete list of these unlisted procedure codes appears in the index of the CPT coding book under Unlisted Services and Procedures. Must be accompanied by supporting documentation (for example, operative reports) According to AMA guidelines, any Category III code that hasn t been added as a permanent CPT code after five years is archived. In 2011, for the first time, they re using recycled Category III codes. There are three T-codes that have been used in the past for other code descriptions. The symbol indicating a recycled code is (an open circle). Now let s practice the principles for this section. Proceed to the practical coding exercise for more information. Practice Exercise 6C Books Needed: Clinical Coding Workout: Practice Exercises for Skill Development CPT coding book In your Clinical Coding Workout: Practice Exercises for Skill Development, complete exercises , Category III Codes, starting on page 80. When you re finished, check your answers at the back of this study guide. Once you re confident you understand the coding principles for this section, move on to the next section. 120 Medical Coding 2

124 Assignment 6 Quiz Books Needed: Clinical Coding Workout: Practice Exercises for Skill Development ICD-9-CM coding book CPT coding book Directions: Each assignment quiz is divided into two parts. Part A is composed of multiplechoice coding questions, and Part B requires you to code the information from a coding scenario found in your Clinical Coding Workout: Practice Exercises for Skill Development. Complete all required and relevant codes for each given scenario. When you re comfortable with your answers for both parts, submit this quiz to your instructor for grading. Part A: Complete the following multiple-choice questions. 1. Which of the following is an example of a HCPCS Level I code? A C B D. Q Hospital inpatient procedures and interventions are reported using A. Volume 3 of ICD-9-CM. B. Volume 3 of ICD-9-CM and HCPCS Level I. C. HCPCS Level I. D. HCPCS Level II. 3. For outpatient procedures, the CMS requires reporting codes using A. Volume 3 of ICD-9-CM. B. Volume 3 of ICD-9-CM and HCPCS Level I. C. HCPCS Level I. D. HCPCS Level II. (Continued) Lesson 2 121

125 Assignment 6 Quiz The UHDDS definition for principal diagnosis applies to A. inpatients. C. inpatients and outpatients. B. outpatients. D. all coded information. 5. Which rule is correct when an outpatient is seen for chemotherapy? A. List first the diagnosis, followed by the chemotherapy V code. B. List first the chemotherapy V code, followed by the diagnoses. C. List only the V code for chemotherapy. D. List only the code for the diagnosis. 6. Review the following ICD-9-CM coding instruction excerpt: Cardiotomy and pericardiotomy Code also cardiopulmonary bypass [extracorporeal circulation][heart-lung machine] (39.61) According to this excerpt, how many ICD-9-CM procedure codes should be assigned? A. 0 C. 2 B. 1 D. Need more information 7. For an outpatient with gallstones who had a laparoscopic cholecystectomy performed, how many codes are required for reporting? A. 1 C. 3 B. 2 D What happens when an inpatient procedure is canceled after a patient has been admitted? A. Code V64.X as the secondary diagnosis with no procedure code assigned B. Code V64.X as the principal diagnosis with no procedure code assigned C. Code V64.X as secondary diagnosis with the procedure coded as completed D. Code V64.X as principal diagnosis with the procedure coded as completed 9. If you were looking for corneal reconstruction in the CPT Index, what term gets you to the right code? A. Cornea C. Revision B. Eye D. Reconstruction (Continued) 122 Medical Coding 2

126 Assignment 6 Quiz HCPCS Level III codes A. identify emerging technology, services, and procedures for which there are no codes yet. B. are those local codes that have been phased out. C. list frequently unused procedures. D. require AMA approval for use and assignment. Part B: Complete the following exercises in your Clinical Coding Workout: Practice Exercises for Skill Development book: Note: Read the directions for coding the ambulatory health record case studies found on page 125 of the Clinical Coding Workout book. Exercises 5.1 (p. 126); 5.11 (p. 129); 5.22 (p. 136); 5.45 (p. 142); 5.55 (p. 144); 5.61 (p. 147); 5.65 (p. 148); 5.70 (p. 150); 5.74 (p. 151); 5.77 (p. 153) Lesson 2 123

127 NOTES 124 Medical Coding 2

128 ANSWER SHEET FOR YOUR INSTRUCTOR S USE GRADE GRADED BY STUDENT NUMBER: PLEASE PRINT ASSIGNMENT 6 QUIZ Medical Coding 2 NAME ADDRESS CITY STATE/PROVINCE ZIP/POSTAL CODE Check if this is a new address PHONE INDICATE YOUR ANSWER TO EACH QUESTION BY MARKING AN X IN THE APPROPRIATE SQUARE. EXAMPLE: A B C D Part A X CUT ALONG THIS LINE 1. A B C D 6. A B C D 2. A B C D 7. A B C D 3. A B C D 8. A B C D 4. A B C D 9. A B C D 5. A B C D 10. A B C D Part B HAVE YOU ENTERED YOUR STUDENT NUMBER IN THE SPACE PROVIDED?

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130 ASSIGNMENT 7: PHYSICIAN OFFICE CODING Read Evaluation and Management (E/M) Service Guidelines (pp. 4 10) in your Current Procedural Teminology: CPT coding book. Coding for Physician Offices You probably remember from your reading in Appendix A that physicians are required to report ICD-9-CM codes for diagnoses and HCPCS codes for procedures and services. When coding for physician office services and care, it s important to ask what the physician (or practitioner) is doing when providing care. As a coder, this awareness will help you assign the most accurate and inclusive code possible for the services. In these sections, you ll learn about how to code from the physician office perspective. Let s take a look at an example of how a hospital coder reports codes versus how a physician coder reports codes. Example. On June 23, 2005, a patient was admitted to the hospital for a total abdominal hysterectomy due to endometriosis of the uterus. Codes Hospital ICD-9-CM diagnosis code Hospital ICD-9-CM procedure code 68.4 NOTE: Don t let the physician office perspective confuse you. Remember, physicians work in a variety of settings (for example, hospitals, outpatient centers, clinics, personal offices). In this lesson, we re focusing on how the physician codes and bills for different services no matter the setting. Whether a physician offers services in an office or at a hospital, the physician services provided will still need to be coded. Physician office ICD-9-CM diagnosis code Physician office CPT procedure code Reasoning The hospital coder will report and bill for the facility s services and charges for the hysterectomy procedure using the ICD-9-CM procedure code of The physician office coder will bill the surgeon s charges on a CMS-1500 form using the CPT code for the hysterectomy procedure. Both the hospital and the physician s office will report the patient s diagnosis using the same ICD-9-CM diagnosis code of endometriosis of the uterus. Let s review some different areas of coding for physician offices. Lesson 2 127

131 HCPCS Level I (CPT) Evaluation and Management Codes for Physician Office Coding Introduction Evaluation and management or E/M codes are used by physicians to report a significant portion of the services they provide. E/M codes encompass the wide variation in skill, effort, time, responsibility, and medical knowledge that s required for the promotion of optimal health and the prevention or diagnosis and treatment of an illness or injury. Examples of some physician services covered by E/M codes include the following: Consultations Skilled nursing visits Office visits Hospital inpatient visits NOTE: In this subsection, you re learning about coding only as it relates to reimbursement. However, it s important to remember that the reporting of codes serves other important functions such as statistical compilation of diseases and treatments; thus, coding has an impact beyond reimbursement. E/M codes are represented by CPT codes and appear at the front of the CPT coding book. Coders working in physician offices report these E/M codes for payment of services rendered by the physicians. Coders working in acute-care hospitals hospitals that provide short-term care for patient aren t required to report E/M codes. However, don t confuse this with the work that physicians do during an inpatient, acute-care setting. Acute-care hospital coders will code the appropriate ICD-9-CM diagnosis and procedure codes for a hospital admission. This is how the hospital gets paid (that is, reimbursed from providers such as insurance companies). However, the physician s office will separately code his or her time and services for treating the patient while in the hospital. This is how the physician gets reimbursed. 128 Medical Coding 2

132 Let s look at an E/M coding example to help you better understand the process. Example. An emergency department physician provides critical care services (including CPR) to a cardiac arrest patient for more than two hours. Codes cardiac arrest critical care and evaluation and management of the critically ill or critically injured patient; first 30 to 74 minutes 99292, critical care and evaluation and management of the unstable critically ill or unstable critically injured patient, requiring the constant attendance of the physician; each additional 30 minutes list separately in addition to code for primary service NOTE: The outpatient coder for the hospital would code as the diagnosis and cardiopulmonary resuscitation as the CPT procedure. Reasoning The physician will report the ICD-9-CM diagnosis code and then the appropriate E/M codes that cover this level of service. Basics of E/M Codes E/M codes have the following characteristics: Begin with 99 Identify the place or type of service (for example, outpatient service, physician office, initial/subsequent care) Define the extent of service (for example, detailed history or examination) Describe the nature of the presenting problem (for example, moderate severity) Identify the time typically required to provide a service Lesson 2 129

133 Documentation for E/M Codes An evaluation and management (E/M) service has seven specific components. The first three of these components are considered to be key or essential for providing any E/M service in any location. Seven E/M Components 1. History: Key Component The patient s history includes the following information: Chief complaint (CC) Reason for the encounter History of the present illness (HPI) a chronologic description of the development of the patient s illness/problem Review of systems (ROS) an inventory of the body systems obtained through a series of questions Past, family, and/or social history (PFSH) a review of the patient s past experiences with illnesses, injuries, and treatments; a review of medical events in the patient s family; an age-appropriate review of past and current activities 2. Examination: Key Component The extent of the physical examination of the patient depends on the clinician s judgment as well as the nature of the presenting problem(s)/illness. The levels of E/M services are based on four types of examinations that are documented by specific items. Problem focused a limited examination of the affected body area or organ system Expanded problem focused a limited examination of the affected body area or organ system and other symptomatic or related organ system(s) 130 Medical Coding 2

134 Detailed an extended examination of the affected body area(s) and other symptomatic or related organ system(s) Comprehensive a general multisystem or complete examination of a single organ system and other symptomatic or related body area(s) or organ system(s) 3. Medical Decision Making: Key Component Medical decision making refers to establishing and/or selecting management options as determined by the number of possible diagnoses and/or the number of management options that must be considered; amount and/or complexity of medical records, diagnostic tests, and/or other information that must be obtained, reviewed, and analyzed; and the risk of significant complications, morbidity, and/or mortality as well as comorbidities associated with the patient s presenting problem(s), diagnostic procedure(s), and/or the possible management options. The levels of E/M services recognize four types of medical decision making: straightforward, low complexity, moderate complexity, and high complexity. 4. Counseling Counseling involves discussing with a patient and/or family members one or more of the following: Diagnostic results, impressions, and/or recommended diagnostic studies Prognosis Risks and benefits of treatment Instructions for treatment and/or follow-up 5. Coordination of Care: Patient management with other health care professionals 6. Nature of the Presenting Problem The nature of the presenting problem or illness is the sign, symptom, or condition (that is, reason for the encounter) with or without a diagnosis being established. The nature Lesson 2 131

135 of a presenting problem can be a disease, condition, illness, injury, symptom, sign, finding, complaint, or other reason for the encounter. The nature of the presenting problem drives the E/M encounter. It establishes the necessity for the type of history to be taken; it determines the detail and content of an appropriate examination to be done; it defines the rationale for the medical decisionmaking process; and it establishes the necessity for any counseling or coordination of care. Documentation in the medical record should include terms or phrases such as Stable Recovering Responding poorly Significant complication(s) Unstable Urgent evaluation needed Life-threatening problem Presenting problems can be defined as Minimal severity a problem that may not require the presence of a physician, but a service is provided under the physician s supervision Self-limited or minor severity a problem that runs a definite and prescribed course, is transient in nature, and isn t likely to permanently alter the patient s health status or has a good prognosis with management (that is, treatment) Low severity a problem where the risk of morbidity without treatment is low or there s little to no risk of mortality without treatment and a full recovery is expected without functional impairment Moderate severity a problem for which the risk of morbidity without treatment is moderate, there s a moderate risk of mortality without treatment, there s an uncertain prognosis, or there s an increased probability of prolonged functional impairment 132 Medical Coding 2

136 7. Time High severity a problem for which the risk of morbidity without treatment is high to extreme and there s a moderate-to-high risk of mortality without treatment or there s a high probability of severe, prolonged functional impairment The inclusion of time in the definition of the levels of E/M services should be recognized as representing averages, and therefore this component represents a range of times that may be higher or lower, depending on actual clinical circumstances. All three key or essential components are required for the following: Initial hospital care Emergency department Office new patient Office and hospital consultations E/M Two of the three key or essential components are required for the following: Subsequent hospital Office established patient E/M services Levels of E/M Codes Various levels of E/M codes describe different items such as skill, effort, time, responsibility, and so forth. Each E/M level includes the following: Examinations Evaluations Treatment Conferences with or concerning patients Preventive pediatric or adult health supervision Other, similar medical services Lesson 2 133

137 It s also important to understand that within each category the levels aren t the same. For example, code New Patient requires the documentation of all three key components: (1) an expanded problem-focused history; (2) an expanded problem-focused examination; and (3) straightforward medical decision-making level. Code Established Patient requires two of the three key components: (1) a problem-focused history; (2) a problemfocused examination; and (3) straightforward medical decision making. Assigning E/M Codes To help in assigning E/M codes, ask the following questions: What type of service is the patient receiving? What s the place of service? Is the patient a new or established patient? A new patient is one who hasn t been seen by any clinician of the same specialty within the previous three years. For a new-patient encounter, all three of the E/M key components (history, examination, and medical decision making) must be documented. An established patient is one who has been seen by the clinician or by another clinician of the same specialty within the past three years. For an established-patient encounter, two of the three E/M key components (history, examination, and medical decision making) must be documented in the patient record. The following CPT code ranges are the E/M codes that provide distinctions between new and established patients Office/other outpatient services Domiciliary, rest home, or custodial services Home services Preventive medicine services 134 Medical Coding 2

138 These steps should be taken when selecting an E/M service. 1. Identify the category or subcategory of the service provided (for example, new patient, established patient, consultation) 2. Review the reporting instructions for the selected category or subcategory. 3. Review the level of E/M service descriptors and examples in the selected category. 4. Determine the extent of history obtained. 5. Determine the extent of examination performed. 6. Determine the complexity of medical decision making. 7. Select the appropriate level of E/M service CMS Final Rule in Regard to Consultations As of January 2010, CMS will no longer reimburse for consultations. This doesn t mean the codes for consultations will be deleted from the CPT manual. As a coder, you ll still have to know how to code consultations. However, for billing purposes, you must pay attention to the patient s primary insurer. If the primary insurer is Medicare in a consultation situation, you must instead code an appropriate initial visit E/M code as outlined in the following. Inpatient Consultations Inpatient consultations are normally coded to the code set Now, the consultant should use the code set initial hospital care. An admitting physician would use these codes for the initial admission encounter for a patient. Normally, these codes are used only once per admission and only to admit the patient. Now, to differentiate between the admission encounter and any subsequent consultations, the admitting physician is required to append a new modifier AI to these codes. Consultants don t append any modifiers to these codes when they re used to represent consultations on an inpatient. However, it s important that Lesson 2 135

139 consultants identify their specialties on their claims, because multiple claims carrying the code set won t be denied, but inquiry is possible if it s not clear that these consultations were done by separate specialties. If the admitting physician doesn t append the modifier, any subsequent claims submitted for that admission with these initial codes on them will be subject to review. Outpatient Consultations Outpatient consultations for Medicare should now be coded to the appropriate new patient ( ) or established patient ( ) E/M encounters. No modifiers are needed for any of these codes to indicate that they re consultations. Ramifications Some physicians are concerned about the lower reimbursement rates associated with the codes to be substituted for consultation codes. CMS has raised the reimbursement for all of these codes, but minimally, so they still don t compete with the past rates reimbursed for consultations. Practices with high rates of consultations are facing significant reductions in revenue. Of course, we have yet to see if other insurance companies will follow the lead of CMS, as they usually do. Before that happens, however, another problem has yet to be worked out. What happens for inpatients with a commercial secondary payer? If a consultant codes an initial visit for a consultation, as required by Medicare, and the secondary carrier doesn t recognize this process, the secondary payment (20 percent of the total) will likely be denied for all consultations. This will have to be written off by the physician or billed to the patients, depending on the requirements of the secondary insurance. Neither option is likely to be popular. This issue will be interesting to follow in the coming years, and it will impact the work you ll be doing as you become a coder. Now let s practice the principles for this section. Proceed to the practical coding exercise for more information. 136 Medical Coding 2

140 Practice Exercise 7A Books Needed: Clinical Coding Workout: Practice Exercises for Skill Development CPT coding book In your Clinical Coding Workout: Practice Exercises for Skill Development, complete exercises , Evaluation and Management (E/M) Services, starting on page 47. When you re finished, check your answers at the back of this study guide. Once you re confident you understand the coding principles for this section, move on to the next section. Code Modifiers Modifiers are two-digit alphanumeric, numeric, or alpha codes that are appended to the end of HCPCS Level I (CPT) and HCPCS Level II codes. A modifier indicates that a service or procedure was altered by specific circumstances. Modifiers are reported only by physicians and Medicare Part B providers and not by hospitals. The use of modifiers allows more specific and accurate reporting. In many cases, modifiers allow physicians to bill for the additional charges that are represented. Modifiers for HCPCS Level I (CPT) are two-digit numeric codes. Examples of CPT (HCPCS Level I) modifiers include the following: -25 Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service -50 Bilateral procedure NOTES: Appendix A in the CPT coding book provides a list of currently used modifiers for both HCPCS Level I (CPT) and HCPCS Level II. HCPCS Level II modifiers may be used with any level of HCPCS codes. You ll learn more about HCPCS Level II modifiers in the next section. Let s take a look at an example of coding HCPCS Level I (CPT) with a modifier. Example. The patient underwent a bilateral needle core breast biopsy. Procedure Codes : Biopsy of breast; percutaneous, needle core, not using imaging guidance (separate procedure) bilateral Lesson 2 137

141 Reasoning is the CPT (HCPCS Level I) code for the breast biopsy. The modifier -50 indicates that the procedure is bilateral. HCPCS Level II modifiers are either alphanumeric or two letters. Examples of HCPCS Level II modifiers include the following: -RC Right coronary artery -RT Right side (used to identify a procedure performed on the right side of the body) -T1 Left foot, second digit NOTE: Appendix A of the CPT manual contains a comprehensive list of the Level I modifiers with definitions for correct use. Use of the CPT guidelines and Appendix A is critical to the appropriate use of modifiers. Modifiers are important to ensure appropriate and timely payment. If you understand when and how to use them, you ll likely reduce the problems caused by third-party payer denials and also help expedite the processing of claims. It s important to note that modifiers can t be used with all HCPCS codes. For example, some modifiers may be used only with E/M codes (for example, -24 or -25), and others are used only with procedure codes (for example, -58 or -79). At the beginning of each section of the CPT, guidelines appear that list or describe the modifiers that may be used with the codes in that section. Place of Service Codes For every physician service coded, you ll need to indicate where that service was provided. The majority of physician services will probably be performed in the office (site of service modifier). Sometimes the physician will see a patient at the hospital or some other setting outside the office. This is indicated by using a different place of service code. Appropriate Use of Modifiers Modifiers are reported only by physicians (and other Medicare Part B providers) when they submit claims for services. Modifiers aren t used for outpatient hospital services. You can ask some general questions when determining if you should code modifiers. If the answer to any of the following questions is yes, then it s appropriate to use the applicable modifier. 138 Medical Coding 2

142 1. Will the modifier add more information regarding the anatomic site of the procedure? Example. Cataract Surgery on the Right or Left Eye 2. Will the modifier help eliminate the appearance of duplicate billing? Examples. Use modifier -77 to report the same procedure performed more than once by different physicians. Use modifier -25 to report significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service. Use modifier -58 to report staged or related procedure or service by the same physician during the postoperative period. Use modifier -78 to report a return to the operating room for a related procedure during the postoperative period. Use modifier -79 to report an unrelated procedure or service by the same physician during the postoperative period. 3. Would a modifier help eliminate the appearance of unbundling? Example. CPT codes (Infusion therapy, using other than chemotherapeutic drugs, per visit) and (Introduction of needle or intracatheter, vein). If procedure was performed for a reason other than as part of the IV infusion, modifier -59 would be appropriate (for a code of ). Let s look at an example to help you understand the differences in coding physician services using modifiers and outpatient services. NOTE: Unbundling means reporting multiple codes for a procedure when one procedure would be sufficient to cover all the services mentioned. Unbundling can be considered a fraudulent practice to gain a higher reimbursement. Example. Patient received bilateral reduction of inguinal hernia as a hospital outpatient. Procedure Codes (Physician claim) 49505, (Hospital claim) Lesson 2 139

143 Reasoning is reported on the physician claim with the 50 to indicate the bilateral procedure is coded twice on the hospital claim to indicate that the procedure was performed bilaterally. Now let s practice the principles for this section. Proceed to the practical coding exercise for more information. Practice Exercise 7B Books Needed: Clinical Coding Workout: Practice Exercises for Skill Development CPT coding book In your Clinical Coding Workout: Practice Exercises for Skill Development, complete exercises , Modifiers, starting on page 78. When you re finished, check your answers at the back of this study guide. Once you re confident you understand the coding principles for this section, move on to the next section. HCPCS Level I (CPT) Medicine Coding for Physician Offices NOTES: When the immunization is the only service provided during an encounter, the physician can also bill for a minimal level of service (for example, 99211) plus the immunization code. Medicine includes a wide variety of specialties and services. Medicine encompasses CPT codes It s important to remember that some procedures or services listed in this section may be performed in conjunction with other services and procedures listed in other CPT sections. Pay close attention to coding guidelines and notations in the CPT coding book for correct coding assignment. Modifiers Used with Medicine Codes There s an extensive list of medicine code modifiers. Pay special attention to the notes in your CPT coding book regarding the use of medicine code modifiers. 140 Medical Coding 2

144 Basic CPT Coding Guidelines for Medical Services and Procedures 1. Code series for active and passive immunization. 2. For procedures requiring prolonged intravenous infusion with the presence of a physician, code (first hour of infusion) and (each additional hour up to eight hours). Codes are other specific infusion codes. 3. Therapeutic or diagnostic injections should be coded to series Code psychiatric services to series Services related to end-stage renal disease, hemodialysis, and peritoneal dialysis should be coded to series Ophthalmologic medical services should be coded to series Code cardiovascular diagnostic and therapeutic services to series Code the administration of chemotherapy to series Code can be used for physician supplies and materials. HCPCS Level I (CPT) Anesthesiology Coding for Physician Offices Anesthesia services cover general, regional, or local anesthesia. The anesthesia section covers codes ; these codes are arranged by body site and then by specific surgical procedure performed. When looking up the codes in the CPT index, reference under the terms anesthesia and analgesia. NOTES: For Medicare cases, the appropriate Level II HCPCS code list is also required for identification of a specific drug. For other payers, code may be used. Shunts, cannulas, and fistulas for hemodialysis are coded to the surgery section. The definitions for new and established patients apply for ophthalmologic codes. For Medicare cases, a code from the HCPCS Level II code list identifying the specific drug must also be reported. For other payers, code can be reported. For Medicare cases, a more specific code may exist in the HCPCS Level II codes for reporting the supply. Anesthesia codes aren t reported by acute-care hospitals. For physician reporting, the anesthesiologist determines the physical status modifier, and supportive information should be documented in the medical record. Lesson 2 141

145 General Guidelines 1. Anesthesia services are reported based on time. Time begins when the anesthesiologist begins preparing the patient to receive anesthesia and ends when the anesthesiologist is no longer in personal attendance. 2. All anesthesia services require a physical status modifier. This modifier indicates the patient s condition at the time of anesthesia and identifies the complexity of services provided. NOTES: Conscious sedation codes are found in the Medicine Section of the CPT manual and aren t reported in conjunction with anesthesia codes. Procedures marked with include conscious sedation, so it can t be coded separately. Modifier -47 (Anesthesia by surgeon) is never used with anesthesia CPT codes (series ). 3. Report a qualifying circumstance as an additional code when anesthesia services are provided during situations or circumstances that make the administration of anesthesia more difficult. Example. Anesthesia for total knee replacement for 72-year-old patient with mild systemic disease. Codes P2 Anesthesia for open procedures on knee joint; total knee arthroplasty (physical status modifier) E/M code for anesthesia for patient of extreme age, that is, under 1 year and over age Standard modifiers are applicable to this section. Modifiers Commonly Used with Anesthesia Services -22 Unusual procedural services -23 Usual anesthesia -32 Mandated services -51 Multiple procedures -53 Discontinued procedure -59 Distinct procedural service The modifiers listed here are those most commonly used with anesthesia. This doesn t mean that coders can t assign other appropriate modifiers with anesthesia codes. 142 Medical Coding 2

146 Now let s practice the principles for this section. Proceed to the practical coding exercise for more information. Practice Exercise 7C Books Needed: Clinical Coding Workout: Practice Exercises for Skill Development CPT coding book In your Clinical Coding Workout: Practice Exercises for Skill Development, complete exercises , Anesthesia Services, starting on page 50. When you re finished, check your answers at the back of this study guide. Once you re confident you understand the coding principles for this section, move on to the next section. HCPCS Level I (CPT) Radiology Coding for Physician Offices Most physicians don t have radiologic equipment in their offices. In many cases, the physician refers patients for radiologic procedures to hospitals or other radiologic centers. In this case, the physician office coder doesn t assign radiology codes unless the physician provides radiologic supervision and interpretation. HCPCS Level I (CPT) radiology codes have several subsections. Diagnostic Radiology (diagnostic imaging) Diagnostic Ultrasound Radiologic Guidance Breast, Mammography Bone/Joint Studies NOTES: The radiology codes are coded/reported by the office of the radiologist performing the services. If the radiologic procedure is performed in the hospital, the hospital coder won t code it. Instead, the radiologic procedure is assigned a HCPCS code automatically through the hospital s computerized chargemaster system. Radiation Oncology Nuclear Medicine Lesson 2 143

147 Modifiers Commonly Used with Radiology -22 Unusual procedural services -26 Professional component -51 Multiple procedures -52 Reduced services -53 Discontinued procedures -59 Distinct procedural service -RT & -LT Bilateral radiology procedures for Medicare claims (and other payers as directed) The modifiers listed here are those most commonly used with radiology. This doesn t mean that coders can t assign other modifiers with radiology codes. NOTES: Radiologic supervision and interpretation codes don t apply to codes (radiation oncology). Radiology procedures can be referenced in the CPT book by looking up the main term. Terms such as X-ray, MRI, and MRA should be referenced by their full term name. An important point to remember when coding radiologic procedures is that there are different codes if a contrast material is used. Radiologic Supervision and Interpretation Many radiology codes include radiological supervision and interpretation. These are codes that describe the procedure performed by two physicians. If one physician performs both the supervision and interpretation and the actual procedure, then two codes are assigned. These codes include a radiology code and procedure code (for example, surgery). Let s take a closer look with an example. Example. A patient had a unilateral lymphangiography of the extremity (complete procedure) all performed by the same physician. Codes Reasoning Code identifies the radiology procedure, including interpretation. Code identifies the lymphangiography injection. 144 Medical Coding 2

148 Diagnostic Radiology Diagnostic radiology, or diagnostic imaging, is covered under codes The codes are subdivided by anatomic site and then again by specific type of procedure performed. Diagnostic radiology procedures include X-rays, computed axial tomography (CAT) scans, magnetic resonance images MRIs, and magnetic resonance angiograms MRAs. Contrast materials are radiopaque substances that help make the structure(s) being viewed show up. Examples of contrast agents include the following: NOTE: The CPT medicine section contains ultrasound procedure codes for arterial, venous, cerebrovascular arterial, visceral/penile vascular, and echocardiography (heart) studies. Barium (Gastrografin) Iohexol Iopamidol Hypaque Renografin You may see contrast materials used with the following examinations/procedures: Barium enema Angiography Cystogram Endoscopic retrograde cholangiopancreatography Intravenous pyelogram Urogram Lymphangiography Cholecystogram Contrast materials may or may not be used with CT scans and MRIs. Lesson 2 145

149 Diagnostic Ultrasound Diagnostic ultrasound procedures use high-frequency sound waves to visualize internal structures of the body. They re commonly performed for evaluation of the abdomen, pelvis, and heart. These procedures cover codes by anatomic site. When looking up diagnostic ultrasound procedures in the CPT coding book index, reference terms like ultrasound or echocardiography. Radiation Oncology Radiation oncology, codes , is the medical field in which radiation is used to treat diseases like tumors and malignancies. Some of these conditions are Neoplastic tumors Hodgkin s disease Small cell lung cancer Head and neck cancers NOTE: When these tests are performed for cardiovascular stress testing, use the appropriate code from categories Modifier -51 is used with the following nuclear medicine diagnostic procedures codes: 78306, 78320, 78803, 78806, and Radiation can be used internally or externally. External radiation is the delivery of ionizing radiation from an external source through the patient s skin to the tumor. Internal radiation, also known as brachytherapy, applies a radioactive material inside the patient s body or in close proximity to the patient. Nuclear Medicine Nuclear medicine is the administration of radioactive elements (that is, radioisotopes) to help diagnose disease. Nuclear medicine codes are covered in Now let s practice the principles for this section. Proceed to the practical coding exercise for more information. 146 Medical Coding 2

150 Practice Exercise 7D Books Needed: Clinical Coding Workout: Practice Exercises for Skill Development CPT coding book In your Clinical Coding Workout: Practice Exercises for Skill Development, complete exercises , Radiology Services, starting on page 71. When you re finished, check your answers at the back of this study guide. Once you re confident you understand the coding principles for this section, move on to the next section. HCPCS Level I (CPT) Pathology and Laboratory Coding for Physician Offices The Pathology and Laboratory sections cover CPT code ranges Laboratory services encompass clinical laboratory settings and services that are equipped for testing and analysis. Pathology services are those that focus on microbiology, immunopathology, blood/transfusion medicine, chemical pathology, cytogenetics, hematology, coagulation, toxicology, and medical microscopy. Modifiers Commonly Used with Pathology and Laboratory -22 Unusual procedural services -26 Professional component NOTES: Remember that in the hospital setting the chargemaster automates the codes for the billing of laboratory and pathology services. Therefore, as a hospital coder, you wouldn t code these services. Some physicians now send the sample/specimen to a freestanding or hospital-based laboratory for processing. In this case, the coder who works for the physician can code only the collection/ handling of the specimen. -32 Mandated services -52 Reduced services -53 Discontinued procedures -59 Distinct procedural service -90 Reference (outside) laboratory Lesson 2 147

151 The modifiers listed here are those most commonly used with pathology and laboratory. This doesn t mean that coders can t assign other modifiers with codes from this section. Laboratory Services Medicare and CMS have often changed the rules surrounding the coding and billing of laboratory services. As a result, even if you aren t a new coder, you may have some questions about choosing the appropriate codes. Here are some general guidelines for coding laboratory physician services: NOTE: Medicare and other insurers want you to use the panel codes as much as possible instead of billing the tests separately. However, each test in the panel must be necessary for the diagnosis and/or treatment of the patient. 1. Each laboratory test billed must be medically necessary. 2. Determine if the physician performed the complete procedure (or only part of it). 3. If all the tests in a panel aren t being performed, code the individual tests separately. 4. Individual chemistry tests not performed as part of the automated multichannel tests should be coded to series Hematology and coagulation (complete blood count, bone marrow aspiration/biopsy, and so forth) should be coded to series Pathology Services Surgical pathology, codes , involves specimens (tissues or samples) that are taken from a patient during surgery and examined for diagnosis. When two or more specimens are obtained from the same patient, use separate codes to report the specimens. Now let s practice the principles for this section. Proceed to the practical coding exercise for more information. 148 Medical Coding 2

152 Practice Exercise 7E Books Needed: Clinical Coding Workout: Practice Exercises for Skill Development CPT coding book In your Clinical Coding Workout: Practice Exercises for Skill Development, complete exercises , Pathology/Laboratory Services, starting on page 73. When you re finished, check your answers at the back of this study guide. Once you re confident you understand the coding principles for this section, move on to the next section. Lesson 2 149

153 Assignment 7 Quiz Books Needed: Clinical Coding Workout: Practice Exercises for Skill Development ICD-9-CM coding book CPT coding book Directions: Each lesson quiz is divided into two parts. Part A is multiple-choice coding questions, whereas Part B requires you to code the information from a coding scenario found in your Clinical Coding Workout: Practice Exercises for Skill Development book. Complete all required and relevant codes for each given scenario. When you re comfortable with your answers for both parts, submit this quiz to your instructor for grading. Part A: Complete the following multiple-choice questions. 1. Which of the following is the correct set of coding guidelines that physicians are required to report? A. ICD-9-CM codes for diagnoses and HCPCS codes for procedures and services B. ICD-9-CM codes for diagnoses, HCPCS and ICD-9-CM codes for procedures C. Only HCPCS and ICD-9-CM procedure codes D. Only HCPCS procedure and service codes 2. In a physician s office, coding and billing is done for which of the following categories? A. Only physician office services B. Only services the physician perform in hospitals C. Only services performed in outpatient centers D. All physician services performed, no matter where the service occurred 3. A significant portion of the services that physicians provide are reported by codes. A. E C. E/M B. V D. Q/T 4. Which of the following codes requires the use of modifiers? A. ICD-9-CM procedures C. ICD-9-CM diagnosis codes B. HCPCS D. Varies according to the setting (Continued) 150 Medical Coding 2

154 Assignment 7 Quiz Using two or more codes when one code would be sufficient to represent all services is an example of A. unbundling. C. Code Also. B. bundling. D. inclusion. 6. A Medicare patient had a benign lesion measuring 0.5 cm removed from his back at his physician s office. Which of the following codes is correct? A C B D What is the proper modifier to use for referring to services performed by a physician who repaired a broken leg and a broken arm at the same operative session? A. -51 C. -62 B. -59 D Which code is appropriate for a radiologist s report on a 23-year-old patient who had an X-ray of the left and right forearms? A C LT, RT B D , How does a physician ensure that each laboratory test performed in his/her office is reimbursed? A. Assign a separate code for each test B. Report the appropriate panel code for the tests. C. Make sure that each test is documented D. Only order and report medically necessary tests 10. What is the correct code for IV infusion for therapy/diagnosis, administered by physician or under direct supervision of physician up to one hour? A C B D (Continued) Lesson 2 151

155 Assignment 7 Quiz Part B: Complete the following exercises in your Clinical Coding Workout: Practice Exercises for Skill Development workbook. Exercises 6.1 (p. 160) 6.6 (p. 162) 6.11 (p. 163) 6.16 (p. 166) 6.23 (p. 167) 6.28 (p. 168) 6.33 (p. 170) 6.38 (p. 171) 6.41 (p. 172) 6.53 (p. 175) 152 Medical Coding 2

156 ANSWER SHEET FOR YOUR INSTRUCTOR S USE GRADE GRADED BY STUDENT NUMBER: PLEASE PRINT ASSIGNMENT 7 QUIZ Medical Coding 2 NAME ADDRESS CITY STATE/PROVINCE ZIP/POSTAL CODE Check if this is a new address PHONE INDICATE YOUR ANSWER TO EACH QUESTION BY MARKING AN X IN THE APPROPRIATE SQUARE. EXAMPLE: A B C D Part A X CUT ALONG THIS LINE 1. A B C D A B C D A B C D A B C D A B C D 10. A B C D A B C D A B C D A B C D A B C D Part B HAVE YOU ENTERED YOUR STUDENT NUMBER IN THE SPACE PROVIDED?

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158 ASSIGNMENT 8: HCPCS LEVEL II CODING Introduction Level II codes are five-digit alphanumeric codes that describe products, supplies, and services not included in the HCPCS Level I (CPT) codes. Level II codes include items and services such as Ambulance services Durable medical equipment Prosthetics Orthotics Pharmaceuticals Supplies Procedures Tests In 2000, the Health Insurance Portability and Accountability Act (HIPAA) requirement for standardized coding systems named HCPCS Level II codes as the standardized coding system for health care equipment and supplies that aren t identified by the HCPCS Level I (CPT) codes. Level II codes are developed and maintained by the CMS with quarterly updates. HCPCS Level II codes are made up of one alpha character (a letter from A V, excluding S), followed by four numeric digits. Examples of Level II codes include Q0084 Chemotherapy administration by IV infusion J9190 Fluorouracil, 500 mg A4367 Ostomy belt, each P9021 Red blood cells, each unit HCPCS Level II has modifiers that may either be alphanumeric or two alpha characters. Also, the modifiers found in this level may also be used in HCPCS Level I (CPT) when appropriate. Be sure to follow coding guidelines when assigning modifiers. Lesson 2 155

159 NOTE: All codes beginning with D are dental codes copyrighted by the American Dental Association. The HCPCS Level II codes aren t found in the CPT book. If you haven t already done so, you can download these codes from the CMS Web site. You ll find directions for the download process in a later section. HCPCS Level II Sections HCPCS Level II codes are broken into sections based on the alpha character at the beginning of the code. These sections include the following: A codes: A0021 A9999 Transportation services, including ambulance, chiropractic, medical and surgical supplies, and miscellaneous B codes: B4034 B9999 Enteral and parenteral therapy C codes: C1178 C1900 Pass-through items used only by hospital outpatient claims D codes: D0120 D9999 Dental procedures E codes: E0100 E8002 Durable medical equipment G codes: G0008 G8628 Procedures/professional services (not found in CPT); G9001 G9143 Coordination of care/demonstration project items and services H codes: H0001 H2037 Alcohol and drug abuse treatment services J codes: J0120 J9999 Drugs administered, including oral and chemotherapy drugs (drugs require both Level I and Level II codes) K codes: K0001 K0899 Durable medical equipment, prosthetics, orthotics, supplies L codes: L0100 L9900 Orthotic and prosthetic procedures, devices M codes: M0064 M0301 Medical services P codes: P2028 P9615 Pathology and laboratory services Q codes: Q0035 Q9968 Miscellaneous services (temporary codes) R codes: R0070 R0076 Radiology services S codes: S0012 S9999 Temporary national codes (nonmedical) 156 Medical Coding 2

160 T codes: T1000 T5999 National codes established for state Medicaid agencies V codes: V2020 V5364 Vision, hearing, and speechlanguage pathology services Types of HCPCS Level II Codes Permanent National Codes Permanent national codes are used by all private and public health insurers to provide standardized coding for claims submission and processing. Dental Codes Dental codes (D codes) are a separate category of national codes. The Current Dental Terminology (CDT) is a publication copyrighted by the American Dental Association (ADA) that lists codes used for billing related to dental procedures and supplies that are included in HCPCS Level II. Miscellaneous Codes HCPCS Level II includes categories for miscellaneous or not otherwise classified codes. These codes are used when there s no existing code for an item or service (that is, new services/ items or services/items that are rarely used). Temporary National Codes Temporary HCPCS Level II codes are assigned by the CMS to cover immediate needs regarding items and services that have no codes (that is, before the next annual update is published). For example, G codes designate procedures and services being reviewed before inclusion in CPT, and S codes are assigned for private payers). NOTES: Miscellaneous codes should be used sparingly by the coder. Claims with miscellaneous codes are manually reviewed by the payer. The item or service being billed must be clearly described, and pricing information must be provided along with documentation to explain why the beneficiary needs the item or service. Because S codes are assigned for private payers, they re not recognized by Medicare. For annual updates, some temporary codes may be replaced with permanent codes. This change is reflected in the annual update by deleting the temporary code and redirecting the coder to the cross-referenced permanent code. Lesson 2 157

161 NOTES: C codes are used exclusively for HOPPS purposes and are valid only for Medicare claims submitted by hospital outpatient departments. The Medicaid program also uses these codes, but they re not payable by Medicare. T codes aren t used by Medicare but can be used by private insurers. Level II modifiers apply whether Medicare is the primary or secondary payer. Types of Temporary HCPCS Codes C codes are for items that could be billed under the hospital outpatient prospective payment system (HOPPS). G codes are used to identify professional health care procedures and services that should be added to Level I (CPT). Q codes identify services that are needed for claims processing but wouldn t be classified as Level I (CPT) and aren t identified by Level II. K codes are used by the durable medical equipment regional carriers (DMERCs) when the currently existing permanent Level II codes don t include the codes needed to implement a DMERC medical review policy. S codes are used by private insurers to report drugs, services, and supplies for which there are Level II codes, but for which codes are needed by the private sector to implement policies, programs, or claims processing for private insurance processing. H codes are used by those state Medicaid agencies that are mandated by state law to establish separate codes for identifying mental health services such as alcohol and drug treatment services. T codes are used by state Medicaid agencies to establish codes related to items for which there are no permanent Level II codes and for which codes are necessary to meet a national Medicaid program operating need. Code Modifiers Level II HCPCS modifiers are either composed of alphanumeric characters or two alpha characters. When coding Medicare cases, HCPCS Level II modifiers may be used with Level I (CPT) or Level II HCPCS codes. If more than one Level II modifier applies, the HCPCS code is repeated on another line with the additional and appropriate Level II modifier. Example. Code drainage of finger abscess; simple; on the left thumb and second finger would be coded as follows: FA F1 158 Medical Coding 2

162 As just mentioned, some situations require Level I (CPT) codes and modifiers to be combined with Level II codes and modifiers. This process may be referred to as multilevel coding. Let s look at an example to help you understand better. Example. A Medicare patient has tendon surgery on the right palm and left middle finger. Codes F RT Reasoning The F2 is a CPT code that reports excision of tendon, palm, flexor, single (separate procedure), each, and the modifier F2 reports the third digit, left hand. The RT is a CPT code that reports excision of tendon, finger, flexor (separate procedure), and each tendon. The Level I (CPT) modifier -59 reports that this is a separate procedure. The Level II modifier -RT reports that this was performed on the right hand. The code is reported first because this surgery has a higher reimbursement value. However, you shouldn t worry about reimbursement value at this point. You ll learn much more about sequencing correctly for reimbursement in the course on reimbursement. Guidelines for Coding HCPCS Level II Codes For the HCPCS Level II exercises in your study guide and your coding workbook, you should use the following link to download the current list of HCPCS Level II codes (provided by the CMS for free). If you haven t done so already, be sure to download the HCPCS Level II code list before you go any further. Follow these steps to access the HCPCS Level II codes: 1. Go to the CMS Web site ( HCPCSReleaseCodeSets/ANHCPCS/list.asp). 2. Scroll down and click on 2011 Alpha-Numeric HCPCS File. 3. Click on 2011 Alpha-Numeric HCPCS File (ZIP, 805KB). NOTES: Although a HCPCS Level II coding book isn t required for this course, you ll have a separate book if you re coding these types of services in your job. Unlike CPT, HCPCS Level II codes aren t copyrighted by a private organization (with the exception of D codes). Therefore, there are several different publishers that produce HCPCS Level II coding books. The guidelines listed next are the same guidelines that are followed when coding with a HCPCS Level II coding book. Lesson 2 159

163 4. Click Open on the pop-up box. 5. Double-click on 11anweb_V3.xls (an Excel file) or 11anweb_V3.txt (a text file) to read the codes. 6. Repeat these steps to download the 2011 Alpha- Numeric Index (PDF, 166KB) and the 2011 Table of Drugs. The guidelines for assigning HCPCS Level II codes from a HCPCS Level II coding book are basically the same as the guidelines for using your CPT coding book. When assigning HCPCS Level II codes from a HCPCS Level II book, you should follow the following basic steps: 1. Identify the services and/or procedures the patient received. 2. Look up the appropriate term in the Index. 3. Note the code from the Index. 4. Locate the code in the appropriate section. 5. Determine if modifiers should be assigned with the code. NOTES: Q codes are used for chemotherapy administration. Thus, J drug codes are used for coding chemotherapy drugs, and Q codes are used for coding chemotherapy administration. Level II HCPCS codes are updated on a quarterly basis. The annual updates appear on the CMS Web site in late November or early December. The Web site address is listed in the previous section and in the Instructions section of this study guide. Coding HCPCS Level II Drugs HCPCS Level II drugs are listed under the J codes. J drug codes cover the range from J0120 J9999. Drugs administered include oral and chemotherapy drugs. Chemotherapy drugs are listed within the range J8999 J9999. For an oncology office aside from the temporary G codes for Medicare drug administration the most important section of HCPCS Level III is the J code section. The J codes describe most of the drugs and injectable products that are administered in the health care field. It s important to get a new HCPCS Level II coding book each year, because new drugs are developed and approved each year. Furthermore, the definition of a J code can change in terms of dosage or billing units. If you aren t aware of the changes, you could bill incorrectly for drugs administered. For instance, if the unit definition of a J code changes from 20 mg to 5 mg, and you re billing for a 100 mg dosage, that unit definition change makes a big difference in billing increments. 160 Medical Coding 2

164 J codes describe not only a particular drug, but also a particular amount (for example, dosage, container quantity) of that drug. The coder is also responsible for calculating the appropriate number of units to bill. Now let s practice the principles for this section. Proceed to the practical coding exercise for more information. Practice Exercise 8A Books Needed: Clinical Coding Workout: Practice Exercises for Skill Development HCPCS Level II list from the CMS Web site (see download directions on page 159) Complete exercises , Drugs, starting on page 85 of your Clinical Coding Workout: Practice Exercises for Skill Development. Please note that for J codes, the workbook uses generic names for drugs, whereas the HCPCS code list uses generic drug names. Thus, when you work on these exercises, you ll need a reference source for cross-checking (for example, the Internet, Physicians Desk Reference). When you re finished, check your answers at the back of this study guide. Once you re confident you understand the coding principles for this section, move on to the next section. Coding HCPCS Level II Supplies Medical and surgical supplies are covered under HCPCS Level II series codes A4206 A8999. An example of a medical/ surgical supply may be a sterile needle (A4215). Coding supplies can be a tricky and confusing process because many supplies are included within the code for the office visit or the procedure performed. Payment for many physician office medical supplies is considered included in the allowable amount for the service being billed to Medicare and other insurers using the Medicare fee schedule. Separate payment for supplies used incidental to the physician s service may be made by some payers if you use CPT code (supplies and materials provided by the physician over and above those usually included with the office visit or other services rendered) or A4550 (surgical trays). NOTE: A good rule of thumb to remember when coding HCPCS Level II supplies is: If the physician s office provides additional supplies when performing a procedure (that is, above and beyond the supplies customarily used for the type of procedure), then a HCPCS Level II code should be assigned to report the proper use of resources and for the physician to receive proper reimbursement. Lesson 2 161

165 NOTE: Medicare doesn t allow separate payment for supplies or surgical trays. Billing for Surgical Trays (HCPCS A4550) For certain procedures, billing for supplies in addition to the procedure itself is allowed. When a separate payment is allowed, use HCPCS code A4550 for a surgical supply tray used during the course of a procedure. Only one tray can be billed for regardless of the number used. Now let s practice the principles for this section. Proceed to the practical coding exercise for more information. Practice Exercise 8B Books Needed: Clinical Coding Workout: Practice Exercises for Skill Development HCPCS Level II list from the CMS Web site (see download directions on page 159) In your Clinical Coding Workout: Practice Exercises for Skill Development workbook, complete exercises , Supplies, starting on page 86. When you re finished, check your answers at the back of this study guide. Once you re confident you understand the coding principles for this section, move on to the next section. Coding HCPCS Level II Ambulance/Transportation HCPCS Level II ambulance/transportation codes are listed under series A0021 A0999. Ambulance transport services are reported based on mileage (per mile). Ambulance waiting time is measure in 30-minute (half-hour) increments. Ambulance (transportation) services have special singlecharacter modifiers that indicate both the origin and destination of the services. These modifiers include -H: Hospital -P: Physician s office -R: Residence 162 Medical Coding 2

166 When coding transportation services, two modifiers are assigned. The first indicates the origin of the transportation (pickup), and the second indicates the destination (drop-off). For example, if a patient was picked up at a physician s office and dropped off at a hospital, the modifier -PH is assigned to the appropriate HCPCS Level II code. Definitions: Level of Service There are levels of service that are used with this category of codes; each service must be deemed medically necessary to be reimbursed. Basic Life Support (BLS). Basic life support (BLS) services include the establishment of a peripheral intravenous (IV) line. Advanced Life Support, Level 1 (ALS1). This level includes assessment by an advanced life support (ALS) provider and/or one or more ALS interventions. Advanced Life Support, Level 2 (ALS2). This level is defined as the administration of at least three different medications and/or one or more of the following ALS procedures: Manual defibrillation/cardioversion Endotracheal intubation Establishment of a central venous line Cardiac pacing Chest decompression Establishment of a surgical airway Establishment of an intraosseous line Specialty Care Transport (SCT). A level of interfacility service provided for a critically injured/ill patient that s beyond the scope of paramedic service. NOTES: An ALS provider is trained to the level of the emergency medical technician (EMT) intermediate or paramedic. That is, an ALS intervention is beyond the scope of an EMT Basic. Specialty Care Transport is necessary when a patient s condition requires ongoing care that must be provided by one or more health professionals in an appropriate specialty area (nursing, medicine, respiratory care, cardiovascular care, or a paramedic with additional training). Lesson 2 163

167 NOTES: Sometimes fixed-wing air ambulance may be necessary because the geographic point of pickup is inaccessible by land vehicle; in other situations, great distances or other obstacles make fixedwing air ambulance necessary. Rotary-wing air ambulance may be necessary when the point of pickup is inaccessible by land vehicle; in other situations, great distances or other obstacles make rotary-wing air ambulance necessary. Paramedic Intercept (PI). PI provides ALS services to a patient who has been transported by ambulance staffed by personnel not qualified to administer such services. Fixed-Wing Air Ambulance (FW). This level of service is provided when the patient s medical condition is so severe that transportation by either basic or advanced life support ground ambulance isn t appropriate. Rotary Wing Air Ambulance Rotary-Wing Air Ambulance (RW). Provided when the patient s medical condition is such that transportation by either basic or advanced life support ground ambulance isn t appropriate. Now let s practice the principles for this section. Proceed to the practical coding exercise for more information. Practice Exercise 8C Books Needed: Clinical Coding Workout: Practice Exercises for Skill Development HCPCS Level II list from the CMS Web site (see download directions on page 159) In your Clinical Coding Workout: Practice Exercises for Skill Development workbook, complete exercises , Ambulance, starting on page 87. When you re finished, check your answers at the back of this study guide. Once you re confident you understand the coding principles for this section, move on to the next section. 164 Medical Coding 2

168 Coding HCPCS Level II Durable Medical Equipment Durable medical equipment is covered under HCPCS Level II E codes. The code ranges include E0100 E0159: Ambulatory devices E0160 E0175: Commodes and accessories E1500 E1699: Artificial kidney machines and accessories Durable medical equipment (DME) is defined by Medicare as equipment that meets the following specifications: Serves a medical purpose Can be used repeatedly Is used in a patient s home Isn t used if the patient didn t have the illness/injury Examples of durable medical equipment are canes, crutches, walkers, commode chairs, wheelchairs, and blood glucose monitors. The equipment is supplied to patients by durable medical equipment, prosthetic, and orthotic supplies dealers. Durable medical equipment regional carriers (DMERC) cover this type of equipment. Now let s practice the principles for this section. Proceed to the practical coding exercise for more information. NOTE: Remember that modifiers may be used with HCPCS Level I or II codes. Practice Exercise 8D Books Needed: Clinical Coding Workout: Practice Exercises for Skill Development HCPCS Level II list from the CMS Web site (see download directions on page 159) In your Clinical Coding Workout: Practice Exercises for Skill Development workbook, complete exercises , Durable Medical Equipment, starting on page 88. When you re finished, check your answers at the back of this study guide. Once you re confident you understand the coding principles for this section, move on to the next section. Lesson 2 165

169 Coding HCPCS Level II Procedures/Services G0008 G9142 are temporary codes that cover procedures and professional services. Other outside factors that influence coding assignments are the transmittals and program memos that the CMS issues on a regular basis. These codes are often changed to CPT codes within a given time period and should be reviewed and updated annually. The codes often include coding guidance, instructions on the use of temporary HCPCS Level II G codes versus CPT procedure codes, and documentation criteria that must accompany claims. Now let s practice the principles for this section. Proceed to the practical coding exercise for more information. Practice Exercise 8E Books Needed: Clinical Coding Workout: Practice Exercises for Skill Development HCPCS Level II list from the CMS Web site (see download directions on page 159) Complete exercises , Procedures/Services, starting on page 89 of your Clinical Coding Workout: Practice Exercises for Skill Development. When you re finished, check your answers at the back of this study guide. Once you re confident you understand the coding principles for this section, move on to the next section. 166 Medical Coding 2

170 Assignment 8 Quiz Books Needed: Clinical Coding Workout: Practice Exercises for Skill Development ICD-9-CM coding book CPT coding book Directions: Each lesson quiz is divided into two parts. Part A is multiple-choice coding questions, and Part B requires you to code the information from a coding scenario found in your Clinical Coding Workout: Practice Exercises for Skill Development book. Complete all required and relevant codes for each given scenario. When you re comfortable with your answers for both parts, submit this quiz to your instructor for grading. Part A: Complete the following multiple-choice questions. 1. Which of the following would be coded within the HCPCS Level II series code range of A4206 A8004? A. Ambulance ride to an emergency department B. Artificial kidney machine C. Commode chair D. Sterile needle 2. HCPCS Level II drugs are listed mainly in which of the following coding sections? A. A codes C. J codes B. F codes D. Q codes 3. HCPCS Level II modifiers may be used with A. Level I or Level II HCPCS codes. C. CPT codes only. B. Level I, II, or III HCPCS codes. D. CPT and ICD-9-CM procedure codes. 4. Services like transportation and wheelchairs are reported under A. ICD-9-CM. C. HCPCS Level I codes. B. CPT. D. HCPCS Level II E codes. (Continued) Lesson 2 167

171 Assignment 8 Quiz An ambulance picks up a patient at her sister s house. Which of the following is the correct modifier for this type of service? A. -H C. -R B. -P D. -RH 6. The code A4642 is classified under which of the following categories? A. Drug C. Ambulance service B. Supply D. Durable medical equipment 7. What is the corresponding HCPCS Level II code for HCPCS Level I code 96360? A. S9373 C. S9376 B. S9374 D. S In what category do you code administration of Procrit if not identified by Levels I or II? A. A codes C. J codes B. G codes D. Q codes 9. Which of the following is the HCPCS Level II code for a single-use chemotherapy pump? A. E0781 C. A9270 B. G0361 D Which of the following is a true statement about HCPCS Level II supplies? A. They re often included within the procedure code. B. They re always coded separately. C. They re covered under unlisted procedure codes. D. They re covered under HCPCS Level I. (Continued) 168 Medical Coding 2

172 Part 2 Coding Record Scenarios Assignment 8 Quiz Part B: Complete the following exercises by using the appropriate codes. Report the codes on your answer sheet. Directions: Code only the HCPCS Level II code or codes (plus modifiers, if applicable) for each example. Use the lists that you downloaded from the CMS. 1. Physician s professional component of interpreting an abnormal Pap smear 2. Five surgical team members meet with the patient to determine a treatment course 3. Annual flu vaccine at a local grocery store 4. Infusion, albumin (human), 5%, 50 ml 5. Gastrostomy tubing 6. Heavy-duty folding walker with a seat and wheels 7. Psychiatrist screens a patient to determine eligibility for an alcohol and drug program 8. Transportation of a portable EKG to a physician s office for a patient 9. Anterior chamber intraocular lens 10. TLSO corset front Lesson 2 169