medical coding 1 - 1 study guide 1

Study Guide

Medical Coding, Part 1

INSTRUCTIONS TO STUDENTS 1

LESSON ASSIGNMENTS 7

LESSON 1: CODING FUNDAMENTALS 9

LESSON 2: CPT BASICS AND EVALUATION AND MANAGEMENT 21

LESSON 3: ANESTHESIA AND GENERAL SURGERY 27

EXAMINATION—LESSONS 1, 2, AND 3 29

LESSON 4: THE INTEGUMENTARY SYSTEM AND ORTHOPEDICS 37

TEXTBOOK EXERCISE ANSWERS 41

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INTRODUCTIONThe health care industry is growing at an amazing rate, and

many insurance companies, physicians’ offices, hospitals,

and other health care organizations urgently need qualified

staff to manage the workload. Among other duties, medical

office personnel are often responsible for generating and pro-

cessing medical claims. This crucial task involves translating

diagnoses, symptoms, procedures, and other health-related

information into numerical or alphanumeric codes. This

conversion process is commonly referred to as coding.

This part of your program provides you with detailed instruc-

tions to walk you through the coding process. The material

will lead you step-by-step through a wide range of coding

procedures, offering invaluable tips and suggestions along

the way. Your textbook also offers quite a number of practi-

cal exercises to assist you in mastering the fine points of the

coding process. At the same time, you’ll have a chance to

become familiar with a broad variety of medical terms, fur-

ther increasing your skill.

The material related to medical coding might seem complicated

at first—after all, you’re being asked to learn a new “language.”

As you proceed, however, you’ll find yourself growing more

and more comfortable with the terms and procedures used

by health care professionals every day. By the time you

finish the course, you’ll have gained many of the skills you

need to land a great job in the health care industry!

OBJECTIVESWhen you complete this part of your program, you’ll be able to

n Discuss the differences between ICD-9-CM, CPT, and

HCPCS Level II codes

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

CPT manuals

n Accurately review medical records to identify diagnoses

and procedures

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Instructions to Students2

n Properly code services, conditions, and procedures using

ICD-9-CM and CPT specifications

n Describe the basic procedures involved in evaluation and

management and primary care

n Discuss common services associated with general surgery

n Identify common medical terms and treatments

KNOW YOUR TEXTBOOKThe textbook for this part of your program is Understanding

Medical Coding. Your textbook provides a complete overview of

ICD-9-CM and CPT coding procedures. The book is divided into

16 chapters. This study guide, Medical Coding, Part 1, focuses

on the first eight chapters of the textbook. Your next study

guide, Medical Coding, Part 2, will continue through the second

eight chapters of the textbook.

The contents, found on pages v–xi of Understanding Medical

Coding, outlines the topics presented in each chapter. Take a

few moments now to examine the table of contents to get a

feel for the topics and concepts you’ll be learning.

Next, read the preface of Understanding Medical Coding

(pages xiii–xvi), which will give you a basic idea of the range

and purpose of the material presented. The preface also

introduces the workbook, StudyWARE software, and Web

Tutor program. These supplemental tools are designed to

increase your knowledge and skill as you progress through

the material.

Now, look through the rest of your textbook. You’ll see that

every chapter begins with a set of learning objectives, followed

by a brief introduction to the topic to be explored. A bar above

the learning objectives lists key terms that you’ll focus on

throughout the chapter. In addition to reading the objectives

and key terms before you work through the textbook material,

you should review the list of key terms and learning objectives

after you complete each chapter, to make sure you’ve fully

grasped the material. Each chapter concludes with a short

summary of essential points, followed by a list of books and

articles for further study.

Instructions to Students 3

As you proceed through the text, you’ll see that each chapter

includes a series of coding exercises. These exercises typically

follow the presentation of new information, and are designed

to provide you with an immediate and practical means of

applying what you’ve learned. Complete each exercise in

the order in which it appears.

The back portion of Understanding Medical Coding includes

several helpful study resources. The textbook’s glossary

(pages 593–605) provides an alphabetical listing of important

terms, accompanied by their definitions. A detailed index of

the subjects discussed in your textbook can be found on

pages 607–619. Once you’re done studying Understanding

Medical Coding, you can use these resources to refer back

to any topic you wish to review.

Each of your textbook assignments is geared to assist you in

developing a solid working knowledge of coding procedures and

medical terms. A great deal of technical information will be

presented to you, so take your time absorbing all the details.

You’ll need to dedicate both time and concentration to work

through the textbook exercises. To get the most out of this

essential part of your program, it’s a good idea to schedule sev-

eral study periods throughout each week. As you proceed

through the program, you’ll soon discover the rewards of the

effort you put into your study.

YOUR STUDY GUIDEThis study guide is a companion to your textbook and pro-

vides a study plan of lessons that will help you explore the

fundamentals of medical coding quickly and easily. This

study guide is divided into four lessons, each of which pro-

vides a practical overview of the subjects covered, as well as

several study assignments. As noted earlier, each reading

assignment in Understanding Medical Coding includes a series

of practical coding exercises, which you’ll need to complete

as you work through the textbook assignments. At the end of

Lessons 3 and 6, you’ll be asked to complete a multiple-choice

examination. Submit each examination for grading as soon

as you complete it. There will also be a final examination at

the end of Part 2.


PROGRAM MATERIALSThis part of your program provides you with the following

materials:

1. This study guide, which includes an introduction to your

textbook, plus

n A lesson assignment page, which lists the schedule

of the study assignments in your textbook and

lesson exams

n Explanatory material, which emphasizes the main

points in the instructional part of each lesson

n Answers to the exercises found in Understanding

Medical Coding

2. Your program textbook Understanding Medical Coding,

which contains your assigned readings and exercises

3. ICD-9-CM 2010 manual, Volumes 1, 2, and 3

4. CPT 2010 manual

5. Healthcare Common Procedure Coding System (HCPCS) Level II Code List (from the Centers for Medicare andMedicaid Services Web site)

You should ensure that you have all of these materials before

starting the course. For your HCPCS Level II exercises in this

study guide, you should use the following link to print out the

current list of HCPCS Level II codes (provided by the CMS for

free). Print the HCPCS Level II codes from the following Web site:

http://www.cms.hhs.gov/HCPCSReleaseCodeSets/ANHCPCS

Scroll down to the list of files, click on the 2010 link to the

left of 2010 Alpha-Numeric HCPCS File, then click on 2010

Alpha-Numeric HCPCS File (ZIP, 863KB). Read the License

Agreement and click Accept. Then, click Save and choose a

location to save the zip file to your hard drive. Once you’ve

saved the zip file, you can open either the Excel spreadsheet

(10anweb.xls) or the text file (10anweb2.txt) to access the

HCPCS Level II codes.

http://www.cms.hhs.gov/HCPCSReleaseCodeSets/ANHCPCS

Instructions to Students 5

A STUDY PLANWork through this study guide one assignment at a time. Keep

your ICD-9-CM and CPT manuals on hand as you make your

way through your lessons, as you’ll need them to complete the

exercises in each assignment.

Once you’ve finished all of the assignments included in each

lesson, you’ll be ready to complete the examination. Before

you attempt to complete this exam, make sure you’ve read all

of the assigned material and have completed all the assigned

exercises. To get the most out of your studies, follow these

steps to completing your assigned work:

Step 1: Carefully note the pages where your assigned reading

begins and ends. These pages are identified in the

Lesson Assignments section of this study guide.

Step 2: Skim through the assigned pages (in both the study

guide and the textbook) to get a general idea of their

content. Try to develop an overall perspective on the

concepts and skills being taught and practiced in

each assignment.

Step 3: Carefully read through the study guide’s assigned

pages. These pages contain background information

about the material covered in each textbook module.

Step 4: Read the assigned pages in your textbook, and take

notes on any important points or terms that you feel

are especially significant.

Step 5: When you feel you’ve mastered all of the material

presented in each assignment, proceed to your next

study guide assignment. Repeat steps 1–4 for the

remaining assignments in each lesson.

Step 6: Once you’ve finished all the assignments and self-

checks, proceed to the next section. If the next

item in your study guide is an examination, care-

fully complete it. Take your time with the exam. As

you work, feel free to refer to your textbook, the

study guide, and any notes you may have taken.

Repeat steps 1–6 for the remaining lessons in your

study guide.


Remember, at any point in your studies, you can e-mail

your instructor for further information or clarification.

Your instructor can answer questions, provide additional

information, and further explain any of your study materials.

You should find your instructor’s guidance and suggestions

very helpful.

Now look over your lesson assignments and begin your study

of medical coding with Lesson 1, Assignment 1.

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

page. Your instructor may post additional resources that you can

access to enhance your learning experience.

7

Lesson 1: Coding Fundamentals

For: Read in the Read in

study guide: the textbook:

Assignment 1 Pages 9–10 Pages 1–10



Lesson 2: CPT Basics and Evaluation and Management





Lesson 3: Anesthesia and General Surgery




Examination 38189701 Material in Lessons 1, 2, and 3

Lesson 4: The Integumentary System and Orthopedics





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Lesson Assignments8

NOTES

Coding FundamentalsYour first lesson begins with an overview of coding concepts,

terms, and procedures. You’ll learn about the different levels

of standardized codes, as well as why accurate coding is

an essential element of reporting medical conditions and

treatments. You’ll begin to work directly with the ICD-9-CM

manual, looking up codes and using them to create medical

reports. You’ll also be introduced to the HCPCS Level II man-

ual, an essential part of the coding arsenal.

ASSIGNMENT 1Read through the following material in your study guide. After

you’ve read the study guide commentary, read pages 1–10 of

your textbook Understanding Medical Coding.

Introduction to CodingMedical coding is a process of converting medical terms into

standardized numeric and alphanumeric equivalents that

are defined by national and international health agencies.

Reliance on standardized coding systems greatly expedites

the processing of health insurance claims, so patients and

health care practitioners can be reimbursed more quickly.

Proper coding also helps prevent the submission of erroneous

or fraudulent insurance claims, while providing a wide

range of health care organizations with accurate statistics

on disease, mortality, and treatments.

Health care employees responsible for coding are expected

to be familiar with two different coding systems:

n The Health Care Financing Administration Common

Procedural Coding System (commonly referred to

as HCPCS ), made up of two manuals: the Current

Procedural Terminology (CPT) and National Coding

Manual

n The International Classification of Diseases, 9th Revision,

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

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A career in medical coding can involve many jobs, from

coding for doctors’ offices and hospitals to educating new

coders. It’s therefore likely that you’ll hold more than one

kind of coding position during your career. Opportunities

in this field will increase in the coming years.

Most coders have a combination of formal education and

on-the-job experience. Although not all coders are required

to be certified, certification is recommended and leads to

more opportunities and higher pay. Three institutions offer

certification for coders. The organization you choose will

depend on what you want from your career. However,

choosing one organization doesn’t prevent you from

choosing another in the future.

Computer skills are necessary for today’s coding environment.

Though you’ll receive training on the job for the particular

billing program used by each office, a familiarity with basic

applications and the Internet will make your learning process

much easier. Knowledge of medical terminology, anatomy,

and physiology is also helpful in this field.

Insurance fraud and abuse are partly responsible for increased

premiums and rising health care costs. The Health Insurance

Portability and Accountability Act (HIPAA) and the Omnibus

Budget Reconciliation Act (OBRA) both have detection and

penalty measures in place to help prevent fraud and abuse.

The only way to avoid even the appearance of wrongdoing is

to follow meticulous record-keeping practices and to continu-

ously update your knowledge of current coding regulations.

Purchasing updated coding materials every year, participating

in continuing-education seminars, reading coding newsletters

and Internet sites regularly, and scrupulously documenting

patient charts are crucial to this job.




ICD-9-CMAssignment 2 focuses primarily on the ICD coding system,

which was originally created by the World Health Organization

for collecting and analyzing statistics relating to diseases and

treatments. The system is currently in its ninth revision, with

a tenth revision due for publication in the near future. Now

regularly used to track diagnoses and procedures performed

in a hospital setting, ICD-9-CM codes provide the highest

degree of specificity in describing medical conditions and

procedures.

The ICD-9-CM system is contained in three separate volumes.

Volume 1 consists of a tabular numerical listing of diagnostic

codes, while Volume 2 provides an alphabetical listing of

diagnostic codes. Volume 3 consists of both a tabular and

alphabetical lists of medical procedures, most of which

are performed in a hospital setting. All three volumes are

contained in one book.

Hospital patients may present a variety of symptoms and

conditions upon admission. The first—and most important—

step in ICD-9-CM coding therefore involves determining the

primary condition that led a patient to seek hospital care.

This primary condition is commonly referred to as the principal

diagnosis, while the process of distinguishing the principal

diagnosis is known as sequencing.

Once you’ve determined the principal diagnosis, you can find

the appropriate ICD-9-CM code by looking up the main term

of the diagnosis in Volume 2 of the ICD-9-CM manual. The

main term represents the most basic aspect of a disease or

condition. For example, the main term of a diagnosis involving

a broken arm would be “fracture.” The anatomical location

of a diagnosed condition—in this case, “arm”—is never used

as a main term.

Lesson 1 11

You can really grasp the specificity of ICD-9-CM when you

examine the number and variety of subterms and modifiers

associated with most main terms. Subterms provide more

precise details about main term conditions. For example, the

list of subterms associated with main term “fracture” covers

several pages, and includes a wide assortment of locations,

causes, and related conditions. In most cases, you’ll find the

appropriate ICD-9-CM code listed alongside a subterm of the

main term.

After you locate the correct ICD-9-CM code in the alphabetical

index, verify the code in the tabular list in Volume 1 of the

ICD-9-CM manual. The tabular list is divided into 17 sections,

while the codes themselves are broken down into categories,

subcategories, and subclassifications.

n Category codes consist of three digits, and may represent

either the main term of a single disease or condition or a

group of several similar diseases.

n Subcategory codes, which consist of four digits, provide

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

or condition.

n Subclassification codes consist of five digits, representing

the most specific level of detail regarding a particular dis-

ease or condition.

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

conventions and formats used in the ICD-9-CM manual. Be

sure to complete each of the practice exercises that accompany

each section of your reading assignment.

Particular attention is given to diagnosing tumors or growths,

which medical professionals commonly refer to as neoplasms.

Accuracy is crucial when coding neoplasms, because incor-

rectly listing a tumor as malignant or cancerous on a patient’s

medical record can negatively affect that patient’s insurance

coverage. You’ll also be working with injuries, fractures,

burns, and poisonings.

Several special areas of concern are covered in Assignment 2,

including E codes, which are special secondary codes used to

describe external causes of injury. Two ranges of codes are


Lesson 1 13

new in 2010: E000 codes for external cause status and

E001–E030 for activity codes. Both sets of codes add speci-

ficity to external causes of injury. For example, in 2009 the

E-code for a soldier injured by falling from a cliff during a

mountain-climbing training session would have been E884.1.

Beginning in 2010, you would use three E-codes for this sce-

nario: E000.1 to indicate that the injury happened during a

military activity, E004.0 to indicate the mountain climbing,

and E884.1 to indicate the fall. Not all E-coding will require

these extra codes, but it’s a good idea to review these new

categories (E000–E030) so you’ll know when to add them.

In addition, many complications resulting from surgical pro-

cedures or implanted medical devices, such as pacemakers,

require special codes located in the 996–999 series of ICD-9-

CM codes. You’ll also learn about coding late effects, a term

used to describe side effects or conditions that appear after

the acute phase of an illness or injury has passed. Late effects

can sometimes present months or years after the termination

of a primary disease or injury. Assignment 2 concludes with

an exciting preview of ICD-10 codes, which are due to be

released in the very near future.

The ICD-10-CM project has been delayed for several years.

The manual is such a significant departure from the ICD-9-

CM that the transition is expected to be difficult. Personnel

training, computer program updating, and the printing of edu-

cational materials represent only part of the tasks necessary

for transition to this new system.

The codes in the ICD-10-CM will be alphanumeric (like the

current “V” and “E” codes). The 21 chapters will provide more

detailed descriptions of every known disease and variation

thereof. There will be far fewer NOS (Not Otherwise Specified)

and NEC (Not Elsewhere Classified) codes. Coding in the

future will be even more specific than it is now.

The procedure index currently included in the ICD-9-CM (for

inpatient coding procedures) will be a separate manual known

as the ICD-10-PCS. The codes in this manual will be extended

to seven alphanumeric characters.



you’ve read the study guide commentary, read pages 85–101 in

Understanding Medical Coding.

HCPCS Level II OverviewThe second level of HCPCS coding, the manual most people

refer to as “HCPCS,” is a very important and often over-

looked part of the billing system. There was a third level to

this billing system, but it was phased out in 2003.

HCPCS Level II codes, contained in the National Coding

Manual, were designed initially for use with Medicare and

Medicaid claims. The use of Level II codes is mandatory for

most supplies and services provided to Medicare and Medicaid

patients. National codes are not used to report inpatient ser-

vices. Inpatient health care facilities use ICD-9-CM Volume 3

codes to report inpatient services and procedures provided to

Medicare patients.

The material in Assignment 2 mentioned that the CPT coding

system doesn’t cover all patient services. For example, certain

health care professionals—including ambulance personnel,

orthodontists, and dentists—aren’t included in the CPT coding

system. To better ensure accuracy in reporting, many insur-

ance companies have begun requiring health care providers

to use Level II codes even on bills submitted for non-Medicare

patients.

Certain kinds of medical supplies, such as drugs and durable

medical equipment, aren’t covered under the CPT system,

either. Durable medical equipment (DME) includes a wide range

of items, such as walkers and wheelchairs, used by patients

suffering from chronic disabling conditions. Claims for DME

and related supplies can be paid only if the items meet the

Medicare definition of covered DME and are medically neces-

sary. Documentation provided by a physician is typically

required to determine medical necessity. Such documentation

may include medical records, plans of care, discharge plans,

and prescriptions. Forms specifically designed to certify med-

ical necessity—commonly referred to as Certificates of Medical

Necessity (CMN)—may also be submitted as documentation.

Lesson 1 15

You’ll also have to check whether your Medicare carrier

accepts HCPCS Level II codes. Sometimes these claims are

paid separately by the Durable Medical Equipment Regional

Carrier (DMERC).

HCPCS Code StructureUnlike CPT codes, HCPCS Level II codes are alphanumeric.

The first item in the code consists of one of the following

letters: A, B, D, E, G, H, J, K, L, M, P, Q, R, or V. A string of

four numbers follows the initial letter.

Codes that begin with the Q, G, or K are temporary codes, and

indicate that a more exact decision regarding the service or

supply will be provided later on. Q codes are used to identify

temporary assignments for procedures, services, and supplies.

G codes identify temporary assignments only for procedures

or services. K codes identify temporary assignments only for

durable medical equipment.

HCPCS Level II uses J codes to identify medications, as well

as the administered dosages. J codes are rarely used to

code orally administered medications, which are typically

purchased by the patient after a visit to a health care provider.

In addition, most J codes refer to the medications by their

generic titles, rather than by brand or trade names.

To assist you in locating the correct names and their

associated codes, the HCPCS manual provides a Table

of Drugs. The Table of Drugs includes a column labeled

“Route of Administration.” This column lists the most

common methods of administering specific medications,

which are abbreviated as follows:

IT Intrathecal

IV Intravenous

IM Intramuscular

SC Subcutaneous

INH Inhalant solution

VAR Various routes

OTH Other routes

Intravenous administration includes all methods, such as

gravity infusion, injections, and timed pushes. When several

routes of administration are listed, the first listing is the most

common method. A VAR posting denotes various routes of

administration and is used for drugs commonly administered

into joints, cavities, or tissues, as well as topical applications.

Listings posted with OTH alert the coder to other administra-

tion methods, such as suppositories or catheter injections.

A dash (—) in a column signifies that no information is

available for that particular listing.

HCPCS Level II provides an even higher degree of specificity

through the use of alphanumeric modifiers that may be

appended to the five-digit national code. These modifiers

may be used to identify service providers, anatomic sites, or

other pertinent details. For example, the modifier -T1 is used

to specify the second toe of the left foot. The modifier -QN

identifies ambulance services provided directly by a service

provider. You can find a partial list of HCPCS Level II

modifiers in Appendix A of the CPT manual.

Using the HCPCS ManualIn addition to HCPCS codes and the Table of Drugs, the

HCPCS manual includes a set of general guidelines for coding,

as well as an index. The index is organized in alphabetical

order and includes main terms and subterms. When you

look up a code, be aware that the item or service you need

may be listed under more than one index entry. If you’re

looking for the appropriate code for dialysis kits, for example,

you can look for either the heading “Dialysis” or “Kits.”

Index entries cover a wide range of items, including tests,

services, supplies, durable medical equipment, prostheses,

drugs, therapies, and certain types of medical and surgical

procedures. Note that many of the headings in the HCPCS

index are followed by a range of codes available for the

associated service or supply. As shown in Figure 1, two

separate code ranges follow the heading “Wheelchair.” One

range begins with E0950 and ends with E1298. The other,

which represents a temporary assignment, begins with

K0001 and ends with K0109.


Lesson 1 17

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

descriptive subheadings are listed immediately below the main

heading. These subheadings provide more detailed information

about the type of supplies or services provided, and are

followed by a specific code to be used when submitting a

claim. To avoid errors in coding, be sure to review all the

subheadings found under the main index entry.

Once you locate a term in the index, you’ll need to verify the

code number and description in the alphanumeric listing,

to be sure that you’ve selected the correct code that

describes the item you’re coding. The alphanumeric listing

also provides more detailed information about the code, to

help you in determining that you’ve selected the proper code.

Though you don’t receive a HCPCS manual with your program,

the material you’ve just covered in Assignment 3 (in your

study guide and textbook) will give you sufficient informa-

tion to complete the following self-check.

Once you’ve studied the material in Assignment 3, com-

plete the HCPCS self-check that follows. If you’re unsure

of an answer, take a few minutes to go back and reread

the material in this study guide.

Wheelchair, E0950–E1298, K0001–K0108accessories, E0192, E0950–E1001,

E1065–E1069, E2211–E2230,E2300–E2399

cushions, E2601–E2619High Profile, 4-inch, E0965Low Profile, 2-inch, E0963

tray, K0107

FIGURE 1—An Exampleof the HCPCS Level IIIndex Format


HCPCS Self-Check

Check your understanding of what you’ve learned about HCPCS codes by completing the

self-check below.

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

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

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

a. HCPCS codes may consist of three or more numbers.b. HCPCS codes begin with a letter.c. Modifiers may not be used with HCPCS codes.d. HCPCS codes end with a letter.

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

a. OTH c. CAVb. JOI d. VAR

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

a. five-digit c. alphanumericb. alphabetical d. three-digit

5. HCPCS drug codes begin with a

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

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

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

Check your answers with those on the next page.

After you’ve finished Lesson 1, take the time to review all the

study assignments. Then, proceed to Lesson 2.

Lesson 1 19

HCPCS Self-Check Answers

1. b

2. b

3. d

4. c

5. d

6. b


NOTES

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CPT Basics and Evaluationand ManagementChapters 4 and 5 make up Lesson 2. In these chapters, you’ll

learn how to use the CPT manual in general and then delve

into the knowledge needed for Evaluation and Management

coding. E/M coding, as it’s often referred to, has become very

important in the industry. Almost every physician and health

care provider who sees patients uses these codes in practice.

Like the HCPCSII, the CPT manual holds codes to which fees

are linked. It’s essential to the financial health of the practice

and to compliance with coding regulations to be able to choose

accurate and appropriate codes.

ASSIGNMENT 4

Read through the following material in your study guide.After you’ve read the study guide commentary, readpages 103–124 of your textbook Understanding MedicalCoding.

Current Procedural Terminology (CPT) BasicsIn Chapter 4, you’ll work with CPT codes, which are found

in the manual of Current Procedural Terminology (CPT).

Updated and published annually by the American Medical

Association, the CPT manual is used to describe and report

medical procedures and services performed by physicians

and other health care professionals. Note that CPT codes

focus specifically on procedures rather than diagnoses or

conditions. Unlike ICD-9-CM, the purpose of CPT coding

is to describe the activities of the provider, rather than the

status of the patient.

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The CPT manual is the Level I coding manual for the HCPCS

system of coding. This manual is divided into three categories:

Category I Established procedures/services

Category II Data research/performance tracking

Category III Emerging technology

The codes in the CPT manual are grouped by specialty. You’ll

find that, when coding for a specialty, the majority of the

codes you use will be in one or two sections of the manual.

Although you may occasionally stray from these sections,

most physicians use many of the same codes over and over

again and usually stay within the codes in their specialties.

Just about everyone uses E/M codes, but besides these,

ophthalmologists mainly stick to the Eye and Ocular Adnexa

section (65091–68899), radiologists use the codes ranging

from 70010–79999, and anesthesiologists stick to codes

starting with “0” (00100–01999). Go through your CPT man-

ual and see if you can identify the specialties that go with

each section.

The CPT manual uses many symbols, and knowing what they

mean is crucial to accurate coding. These symbols will alert

you to extended definitions of a code, revised or new codes,

and special circumstances related to a service or procedure.

One new symbol you’ll see in 2010 is #. This symbol indicates

that a code is listed out of numerical sequence. For the 2010

manual, some codes were moved so they could be grouped

with similar procedures. Instead of renumbering many items,

they simply moved the procedure codes and inserted clear

notes where the code was moved to and from. Be on the look-

out for these. An example is code 46220.

Guidelines and descriptions are found at the beginning of

many sections of the CPT manual. It’s very important to read

this information before coding within a section, since it

explains the codes listed and sometimes may help refine a

search or lead to a more appropriate code.

Lesson 2 23

CPT categories II and III are much less frequently used, but

they’re still important. Neither replaces Category I codes.

Category II codes can be added to a claim with other codes

to denote a specific type of care given. For example, a regular

E/M code could be given to a visit with a patient being evalu-

ated for asthma. The insurer would pay according to the level

of visit billed, but adding the code 1005F to the claim allows

the insurer to determine the total number of clients at the

facility with asthma and to track how often they’re treated.

Category II codes can be found in the CPT manual following

the Category I codes, before the Appendix section. Detailed

information about these codes is located in Appendix H.

Category III codes, listed after Category II, are for emerging

treatment modalities. They may be used instead of an

“unlisted” code when a treatment isn’t yet FDA approved

or is used as an experimental treatment. These codes are

updated semiannually in February and July. If the physician

is using new treatments or you find that you’re coding

unlisted procedures frequently, you should look into using

Category III codes instead.

Another important update to the CPT is the errata (errors)

list. Despite careful scrutiny, it’s inevitable that errors find

their way into the CPT manual each year. Check the AMA

Web site after you receive your book every year. Note the

corrections in your book next to each affected code and in

your billing program to prevent errors in billing throughout

the year.

The index of the CPT manual provides an alphabetical listing

of procedures you may be looking for. Before using a code,

it’s very important that you find the name of the procedure

or service in the index and then follow up by finding the code

number in the main section for a full description. You may

find when you look up a code as directed by the index that

there’s a better one referenced within that code description.

Never code by the index listing alone.

Once you’ve mastered the material in Assignment 4

and have completed all of the textbook exercises in

Chapter 4 of your textbook, you can proceed to

Assignment 5.



you’ve read the study guide commentary, read pages 125–180

of your textbook Understanding Medical Coding.

Evaluation and ManagementCPT Evaluation and Management (E/M) codes are used pri-

marily to describe procedures associated with a physician’s

first encounter with a patient. The first encounter can occur

in a wide variety of settings, including hospitals, medical

offices, nursing homes, and clinics. Evaluation codes describe

initial procedures used to provide a framework for under-

standing a patient’s condition. Management codes, meanwhile,

describe the procedures used to diagnose and treat specific

complaints or problems.

Several factors are involved in determining E/M codes. The

first of these factors, commonly referred to as history, is an

account of medical, emotional, psychological, environmental,

and other related details that may have contributed to the

patient’s condition. The level of detail achieved in obtaining

a patient’s history will often have a significant impact on the

level of service provided by the physician.

Other important factors influencing the assignment of E/M

codes include examination and medical decision making. The

term examination refers to the various tests performed in

an effort to obtain objective data about a patient’s condition.

These tests can range from obtaining simple measurements,

such as body temperature and blood pressure, to more com-

plex procedures, such as X-ray and ultrasound scans. The

term medical decision making refers to the process of arriving

at a diagnosis based on history and examination.

Several less critical factors will also contribute to the accurate

determination of E/M codes. For example, a certain amount

of counseling is typically required to ensure patients under-

stand both the nature of their conditions and their own role

in the treatment program. Another factor, referred to as

coordination of care, involves various activities such as writing

Lesson 2 25

prescriptions, consulting other doctors, and instructing office

personnel to arrange referrals to specialists.

The severity of the presenting problem also contributes to

the level of service provided by a physician. In general, the

more severe the presenting problem is, the higher the level of

service will be. Similarly, the time required to obtain a history,

perform examinations, counsel patients, and coordinate care

will also have a bearing on the level of service provided—and

consequently, on the determination of appropriate E/M codes.

After you’ve finished Lesson 2, take the time to review all of

the study assignments. Then, you can proceed to Lesson 3.


NOTES

27

Anesthesia and General SurgeryLesson 3 examines the CPT codes used to describe procedures

involving anesthesia and general surgical treatments. This

fascinating section of your course provides you with the tools

you need to code anesthesia and general surgery procedures,

as well as a valuable overview of various anatomical systems

of the human body. Although later lessons will take a deeper

look at procedures associated with specific anatomical sites

and systems, Lesson 3 gives you a head start on learning

specialized medical terminology.




Coding Anesthesia and General Surgery ProceduresUsed in a medical context, the term anesthesia refers to the

administration of pharmacological drugs aimed at suppressing

nerve functions. Anesthesia is often administered prior to sur-

gery, according to three different categories. Local anesthesia

numbs a specific part of the body. Regional anesthesia sup-

presses feeling in a wider anatomical area, such as the leg,

arm, or face. General anesthesia is administered in cases that

require suppression of the patient’s entire nervous system.

Conscious sedation is a form of anesthesia that’s being used

more often. While under conscious sedation, the patient is

pain-free but still able to respond to instructions from the

medical team. Codes located in the Anesthesia section of the

CPT manual are used to report the administration of all cate-

gories of anesthesia by anesthesiologists and other qualified

or supervised physicians.

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General surgery is a term used to describe operations on a

wide range of anatomical systems. These include the respira-

tory, cardiovascular, lymphatic, auditory, ocular, nervous, and

digestive systems, as well as the male and female reproductive

systems. Surgical procedures associated with each system are

grouped together in separate sections of the CPT manual.

Each of these sections is organized into subsections identifying

the various organs that make up a particular system, as

well as the surgical procedures performed on each organ.

For example, the Respiratory System/Surgery section of the

CPT manual is divided into four subsections: Nose, Larynx,

Trachea and Bronchi, and Lungs and Pleura. The Nose sub-

section is subdivided into a variety of surgical categories,

including incision, excision, removal of a foreign body, and

repair. Within each surgical category, you’ll find a list of

specific procedures, along with the appropriate codes.

HCPCS Level II modifiers are frequently used when reporting

general surgical procedures, to provide an additional level of

detail. Accuracy and specificity are especially important when

filing claims for general surgery. To report unilateral proce-

dures performed on the lungs, for example, you’ll need to

append the left side (-LT) and right side (-RT) modifiers to

each instance of the surgical code. Otherwise, an insurance

company or other third-party payer may incorrectly deny a

claim on the supposition that duplicate procedures have

been reported.

After you’ve finished Lesson 3, take the time to review all of the study assignments. Then, take the examination forLessons 1, 2, and 3.

29

Lessons 1, 2, and 3Medical Coding 1

Exam 1

When you feel confident that you have mastered the material

in Lessons 1, 2, and 3, go to http://www.takeexamsonline.com

and submit your answers online. If you don’t have access to

the Internet, you can phone in or mail in your exam. If you’re

unable to take the exam by telephone or online, please call

Student Services and request the special answer sheet and mail

in your exam. Submit your answers for this examination as soon

as you complete it. Do not wait until another examination is ready.

Note: When you receive your examination evaluation after sub-

mitting your answers for grading, “Book 1” will refer to your

Understanding Medical Coding textbook. “Book 2” will refer to

your ICD-9-CM manual. “Book 3” will refer to your CPT manual.

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

1. Which of the following types of examination is limited to an affected body area or organ system and other related organ systems?

A. Problem focused C. DetailedB. Expanded problem focused D. Comprehensive

2. What code should you use for an office visit for an estab-lished patient if the level of history and examination isdetailed and the decision making is of moderate complexity?

A. 99203 C. 99213B. 99204 D. 99214

EXAMINATION NUMBER:

38189701Whichever method you use in submitting your exam

answers to the school, you must use the number above.

For the quickest test results, go to

http://www.takeexamsonline.com

Exa

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Examination, Lessons 1, 2, and 3 30

3. What convention in the Alphabetic Index tells you to look elsewhere before assigning a code?

A. Note C. SummaryB. Cross-reference term D. Abbreviation

4. The letter _______ designates a temporary HCPCS Level II code for durable medicalequipment only.

A. G C. KB. Q D. J

5. The reason given by a patient for seeking health care is referred to as the

A. chief complaint. C. brief history.B. primary diagnosis. D. morbidity factor.

6. Which one of the following items must be included in a general multisystem examination of a constitutional system?

A. Vital signs C. Auscultation of the lungsB. Inspection of teeth and gums D. Palpation of lymph nodes

7. The abbreviation NOS is used

A. when a separate code for a specific condition isn’t provided in the classification system.

B. when the medical record doesn’t provide enough information to permit assignmentof a more specific code.

C. to indicate that another code may describe the condition more completely or specifically.

D. to provide assurance that the code is correct by listing various terms that are covered by the code.

8. In the Alphabetic Index to Procedures of the ICD-9-CM manual, locate the correct codefor “ligation and stripping of varicose veins in the lower limb.” Verify the code in theTabular List. The code is

A. 38.50. C. 38.58.B. 38.53. D. 38.59.

9. One of the factors used to determine CABG procedure codes is the number of _______ involved.

A. catheters C. vesselsB. organs D. physicians


10. Which of the following codes is used for the diagnosis “closed dislocation of the sternum”?

A. 839.61 C. 839.71B. 839.8 D. 839.9

11. A 50-year-old new female patient has had a sore throat and head congestion for fivedays. The physician performs an expanded problem-focused history and examinationand straightfoward medical decision making. What is the correct code for this service?

A. 99201 C. 99212B. 99202 D. 99213

12. A discharge summary contains the diagnosis “acute ethmoidal sinusitis.” Which of thefollowing codes represents the correct entry for this diagnosis?

A. 461.2 C. 473.2B. 461.9 D. 473.9

13. Which one of the following subcategories of the E/M section has separate codes fornew and established patients?

A. Office or Other Outpatient ServicesB. Hospital Observation ServicesC. Initial Inpatient ConsultationD. Emergency Department Services

14. Which of the following initial inpatient consultation codes is used in situations involving an expanded problem focused history and examination and straightforward medicaldecision making?

A. 99251 C. 99253B. 99252 D. 99254

15. Which of the following E codes take priority over all other E codes?

A. Cataclysmic events C. Suicide and self-inflicted injuryB. Transport accidents D. Child or adult abuse

16. Single braces are used in the Tabular List to

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


17. An operative report shows “open reduction of humerus for separation of epiphysis, withinternal fixation.” Identify the correct code in the Alphabetic Index to Procedures andverify it in the Tabular List.

A. 79.3 C. 79.5B. 79.31 D. 79.51

18. The chief complaint, a brief history of present illness, and a problem-specific review ofsystems are documented in what type of history level for E/M coding?

A. Detailed C. Expanded problem focusedB. Brief D. Comprehensive

19. An attending physician asks a specialist to see a patient about a specific problem andto advise him regarding treatment. This situation is called a

A. confirmatory consultation. C. transfer of care.B. referral. D. consultation.

20. When coding late effects, the code for the _______ is usually sequenced first.

A. original cause C. modifierB. residual condition D. complication

21. Provide a code for the following situation: initial admission to hospital for observationcare with a detailed history and examination and moderate decision making.

A. 99217 C. 99219B. 99218 D. 99220

22. What is the main term in the diagnosis “pituitary gland hypofunction”?

A. Ablation C. GlandB. Pituitary D. Hypofunction

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

A. 99254 C. 99244B. 99255 D. 99245

24. Provide the ICD-9-CM and CPT codes for a history and physical examination of a singleliveborn delivered in hospital by caesarian section.

A. V30.00, 99430 C. V30.02, 99432B. V30.01, 99460 D. V30.03, 99433


25. _______ are used to indicate factors influencing health status and contact with health services.

A. Manifestation codes C. E codesB. Cross-reference codes D. V codes

26. In the Tabular List, where would you find alternative terms and explanatory phrases?

A. In square brackets C. In double bracesB. After a colon D. In parentheses

27. The minimum examination level required to code 99203 is

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

28. According to the Tabular List for code 463, which one of the following conditions isexcluded from the code?

A. Follicular tonsillitis C. Septic sore throatB. Acute viral tonsillitis D. Septic tonsillitis

29. Which of the following range of codes is located in the Evaluation and Managementsection of the CPT manual?

A. 90001–90699 C. 89000–89999B. 99201–99450 D. 80600–88999

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

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

31. The _______ medical decision-making category includes minimal diagnoses, minimalcomplexity of data, and minimal risk of complications.

A. straightforward C. low complexityB. simple D. uncomplex

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

A. When a manifestation code is givenB. When no fifth-digit subcategory codes are in that categoryC. When the cross reference tells you to do soD. When there are no nonessential modifiers


33. Which of the following ICD-9-CM and CPT codes would you use to describe physician supervision only of a cardiovascular stress test on a patient with an abnormal electrocardiogram?

A. 794.31, 93016 C. 787.1, 93012B. 793.40, 93000 D. V70.01, 93014

34. Which of the following codes is used for initial neonatal critical care?

A. 99477 C. 99468B. 99469 D. 99472

35. When coding, you should always use the Tabular List to

A. verify the codes you’ve located in the Alphabetic Index.B. locate codes not found in the Alphabetic Index.C. find the range of codes for a particular disease.D. determine if there are any cross references for the code.

36. How many bulleted topics must be included in documentation relating to a detailedpsychiatric analysis?

A. 1–5 C. 7B. 6 D. Any 12

37. Which of the following categories is used to code heart conditions caused by hypertension?

A. 429 C. 402B. 425 D. 405

38. Which of the following codes would be used for a one-hour initial therapeutic intravenous infusion under the supervision of a physician?

A. 96365 C. 96367B. 96366 D. 96369

39. In the Alphabetic Index to Procedures in the ICD-9-CM manual, locate the correct codefor “open drainage of the chest by incision.” Verify the code in the Tabular List.

A. 34.09 C. 34.04B. 34.05 D. 34.01

40. Which of the following range of codes is used to report Emergency Department Services?

A. 99271–99280 C. 99289–99297B. 99281–99288 D. 99298–99305

41. Which of the following physical status modifiers would be used to code a patient with amild systemic disease?

A. P1 C. P3B. P2 D. P4


42. What is the code for the unlisted surgery procedure for the inner ear?

A. 25999 C. 58999B. 43499 D. 69949

43. Anesthesia procedure codes are grouped according to

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

44. Which of the following code ranges is used to report a coronary bypass graft usingveins only?

A. 33510–33516 C. 33517–33523B. 33533–33545 D. 33533–33536

45. Which of the following HCPCS Level II modifiers is used to indicate a procedure performed on the thumb of the left hand?

A. -FA C. -FTB. -F1 D. -L1

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

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

47. Which of the following range of codes is used to describe laparoscopic removal ofthe gallbladder?

A. 47562–47564 C. 56340–56342B. 47611–47620 D. 56345–56347

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

A. ICCE C. ERCPB. PEG D. UPPP

49. In addition to the CPT codes, _______ are frequently used when reporting generalsurgical procedures to provide better detail.

A. modifiers C. physician signaturesB. ICD-9-CM codes D. anesthesiologist reports

50. Which of the following procedures involves inserting an endoscope past the third partof the duodenum?

A. ERCP C. EGDB. Esophagoscopy D. Ileoscopy


NOTES

37

The Integumentary Systemand OrthopedicsIn Lesson 4, you’ll begin using both the ICD-9-CM and

the CPT manuals to describe diagnoses and procedures.

By focusing on specific anatomical systems, your textbook

assignments are designed to ease you gradually into the

process of using both manuals to code reports. Your first

area of exploration will be the integumentary system, which

is comprised of the skin, nails, hair, sebaceous glands, and

sweat glands. After you’ve thoroughly familiarized yourself

with the terms, procedures, and codes associated with this

system, you’ll have a chance to learn about conditions and

procedures associated with the musculoskeletal system.

ASSIGNMENT 7Read through the following material in your study guide.

After you’ve read the study guide commentary, read pages

209–243 of your textbook Understanding Medical Coding.

The Integumentary SystemProcedures involving the integumentary system are located

at the beginning of the Surgery section of the CPT manual.

A brief glance through this part of the manual shows that

the Integumentary subsection is divided into the following

five subheadings:

n Skin, Subcutaneous and Accessory Structures

n Nails

n Repair

n Destruction

n Breast

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Each subheading contains several categories that describe

procedures appropriate to each subheading of the integu-

mentary system. Under the Destruction subheading, for

example, you’ll find the following categories:

n Destruction, Benign or Premalignant Lesions

n Destruction, Malignant Lesions, Any Method

n Mohs Microscopic Surgery

n Other Procedures

The codes listed in each category are used to report specific

variations of the procedure described by the category head-

ing. For example, CPT code 17260 is used to describe the

destruction of malignant lesions measuring 0.5 cm or less in

diameter, while 17261 is used to report the destruction of

lesions measuring between 0.6 and 1.0 cm in diameter.

Most of the diagnostic codes associated with the skin,

subcutaneous tissue, hair, and nails are grouped together

in Chapter 12 of the ICD-9-CM manual. Bear in mind, though,

that certain integumentary system conditions may be listed

in other chapters of the manual dealing with larger categories

of illness or injury. ICD-9-CM codes for burns and cuts, for

example, are located in the Injury and Poison chapter (17),

while skin and subcutaneous tissue conditions caused by

neoplasms are located in the Neoplasm chapter (2).

Lesson 4 39




OrthopedicsUnlike other types of procedures, CPT codes for reporting

musculoskeletal system procedures are often determined on

the basis of treatment method. An open treatment of a radial

shaft fracture, for example, involves surgical opening of the

fracture site. The associated CPT code is 25515. A closed

treatment of the same type of fracture, which is accomplished

without surgically entering the fracture site, would be coded

25500 if no manipulation were necessary, and 25505 if the

physician needed to manipulate the bone.

Several other aspects need to be considered when determining

the appropriate code for orthopedic procedures. For example,

procedures performed on soft tissue—such as excision of a

ganglion cyst—are located in different areas of the Musculo-

skeletal section of the CPT manual than procedures performed

on bone.

Since treatments for traumatic injury are usually coded

differently than treatments for medical conditions, the reason

for treatment will also play a decisive role. The code for hip

replacement to alleviate osteoarthritis, for instance, is located

under the Repair, Revision and/or Reconstruction category of

the Pelvis and Hip Joint subheading of the Musculoskeletal

subsection of the CPT manual. By contrast, the code for hip

replacement performed as a result of fracture is located under

the Fracture and/or Dislocation category.

You’ll also want to be sure you’ve identified the most specific

anatomical site on which a procedure was performed.

Vertebral treatments, for example, are coded differently

depending on whether the procedure was performed on the

lumbar, thoracic, or cervical vertebrae. In addition, when

coding procedures performed on multiple sites in the same

area—such as repairing fractures to several fingers—you

must either indicate the number of specific sites treated or


enter the code multiple times. The method will depend on

the code itself. Different codes require different procedures.

A final factor to consider is whether treatment required the

insertion of pins, screws, or wires to immobilize an area—

a procedure commonly referred to as fixation—or grafting.

Some procedures, such as reconstruction of the midface,

specifically list bone grafts. When grafting or fixation isn’t

specifically identified, you may need to list the appropriate

code separately.

Note: Exercise 8-3 in your textbook lists spaces for the

numbers of codes in each category. The code expansions

have affected question 2 in that exercise. This question

now requires two ICD-9-CM codes, one ICD-9-CM Volume 3

code, and two CPT codes.

After you’ve finished Lesson 4, take the time to review all the

study assignments. Then, move on to Lesson 5 in Medical

Coding, Part 2. The examination for Lesson 4 is included in

that study guide.

41

TEXTBOOK EXERCISE ANSWERS

Chapter 1

Exercise 1-1

Research only

Exercise 1-2

Research only

Exercise 1-3

Research only

Chapter 2

Exercise 2-1

1. Senile cataract

2. Carcinoma of the breast

3. Mitral valve prolapse

4. Urinary cystitis

5. Hypertensive cardiovascular disease (can be located

under either main term)

6. Sudden infant death syndrome

7. Nontoxic thyroid goiter

8. Sickle cell anemia (can be located under either

main term)

9. Acute situational depression

10. Upper respiratory tract infection

11. Sore throat

12. Migraine headache

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Answers42

13. Chronic lower back pain

14. Rectal mass

15. Left ureteral calculus

Exercise 2-2

1. 346.90

2. 428.0

3. 250.03

4. 410.11

5. 820.8

6. 558.9

7. 530.20

8. 411.89

9. 351.0

10. 244.9

11. 788.20

12. 331.0

13. 042

14. 780.2

15. 339.10

16. 463

17. 729.5

18. 784.7

19. 300.02

20. 710.3

Exercise 2-3

1. 51.22 (open) or 51.23 (laparoscopic). The coder should

review the medical record to determine whether this was

an open or laparoscopic procedure.

2. 45.13

Answers 43

3. 86.59

4. 53.14 (The laparotomy isn’t coded because it’s an

operative approach.)

5. 85.21 (The coder should review the pathology report

to see whether this is a benign or malignant lesion.)

6. 50.11

7. 60.29

8. 89.52

9. 06.2

10. 51.23

Exercise 2-4

1. Diagnoses: 218.9, 617.1

Procedures: 68.49, 65.29

2. Diagnosis: 722.10

Procedure: 80.51

Question for physician: Findings indicated an osteo-

arthritic spur. Is this significant enough to code?

3. Diagnoses: 574.00, V64.41

Procedure: 51.22

Exercise 2-5

1. Sign

2. Symptom

3. Sign

4. Sign

5. Sign

6. Sign

7. Symptom

8. Sign

9. Symptom

10. Sign

Answers44

Exercise 2-6

1. 794.31

2. 786.50

3. 780.60

4. 795.5

5. 783.21

6. 794.2

7. V08

8. 795.19

9. 790.22

10. 795.39

Exercise 2-7

1. Diagnoses: 430 (the cause of the CVA is coded, so code

436 isn’t coded), 342.90 (since the aphasia had cleared, it

wouldn’t normally be coded). The hemiplegia is present

on discharge and will require home care, so it should

be coded.

2. Diagnoses: 574.00, 401.9, 714.0, 250.00, V45.81, 51.23

(This previous bypass “Status Post CABG” is significant,

especially since the patient is having surgery.)

3. Diagnoses: 042, 276.51, 558.9

4. Diagnoses: 042, 481, 176.0

5. Diagnoses: 038.42, 599.0, 041.4

Question for physician: Renal insufficiency (593.9) is

noted as positive in the ER findings but isn’t mentioned

in the remainder of the discharge summary. Should it

be coded?

6. Diagnoses: 410.21, 412 (The patient had a previous

infarction three years ago that’s separate from the cur-

rent illness, but does have an impact on treatment at

this time, so it’s normally coded.)

Answers 45

Exercise 2-8

1. 250.70 785.4

2. 250.80 707.9

3. 250.40 581.81

4. 250.53 366.41

5. 250.41 581.81

6. 250.50 362.01

7. 250.11

8. 648.80

9. 648.00 250.00

10. 251.0

Exercise 2-9

1. V70.3

2. V16.0

3. V01.82

4. V25.02

5. V17.3

6. V14.0

7. V22.2

8. V72.31, V76.47

9. V04.81

10. V20.2

11. V82.81

12. V01.81

13. V61.10

14. V15.85

15. V70.4

Answers46

Exercise 2-10

1. Diagnosis: V23.2, supervision of high-risk pregnancy

with history of miscarriage

Question for physician: Are there any current problems

such as bleeding, contractions, and so forth that should

be coded?

2. Diagnoses: 751.61, 774.5 (The coder should review the

radiology report to determine the type of procedure

performed and the proper code.)

3. Diagnoses: V30.1, 765.18, 765.28

4. Diagnoses: 666.22, V27.0

Exercise 2-11

1. Diagnosis: 153.5

Procedures: 47.09, 45.72

2. Diagnoses: 185, 198.5. Sequencing of these two

malignancies would depend on the circumstances

of admission.

3. Diagnosis: 201.90 (This code is for an unspecified site of

Hodgkin’s disease. The coder should review the medical

record and biopsy results to determine whether a more

specific code can be used.)

Procedure: 40.11

4. Diagnosis: 188.9

5. Diagnoses: 162.9, 198.3 (Sequencing of these two

malignancies would depend on the circumstances

of admission.)

6. Diagnosis: 233.1

7. Diagnoses: 174.5, 197.0 (Sequencing depends on

circumstances.)

8. Diagnosis: 210.1

9. Diagnosis: 141.9


circumstances.)


circumstances.)

Answers 47

12. Diagnoses: 174.9, 196.3, 197.0 (Sequencing depends on

circumstances.)




16. Diagnosis: 174.9 (The coder should review the pathology

report and other documentation in the medical record to

determine a more exact location of the carcinoma within

the breast.)

Procedure: 85.43

Exercise 2-12

1. 850.9, E819.0

2. 873.42, E916, E908.9

3. 883.0, E920.5

Exercise 2-13

1. 826.0

2. 733.13, 733.01

3. 808.41, 250.00

4. 821.29

5. 802.5

6. 813.23, 873.42, E819.1, E849.5

Exercise 2-14

1. 944.20, 944.10, E924.0

2. 947.0, 947.2, 948.00

3. 692.71

4. 945.06, E898.1

5. 941.12

Answers48

Exercise 2-15

1. 983.9, E864.3

2. 964.2, E858.2, 459.0

3. 969.0, E854.0, 780.4

Exercise 2-16

1. 276.8, E944.3

2. 708.0, E930.4

3. 780.09, E933.0

4. 785.0, E933.0

5. 995.0, E930.0

Exercise 2-17


2. Diagnoses: 558.1, 153.9, E879.2

Exercise 2-18

1. 138

2. 438.21

3. 716.17, 824.8

4. 389.12, 139.8 (late effect of disease classifiable to code

055.9)

5. 348.9, 326, 324.0

Chapter 3

Exercise 3-1

1. E1231–E1238

2. A5105, A5112

Answers 49

3. Notice the index lists many medications for the term

Depo. The index doesn’t always list the brand name

(Depo-Provera), and you may need to use the Table of

Drugs, the Physicians’ Desk Reference, or the package

insert of the medication.

a. To select the code, you need documentation to sup-

port contraceptive versus other medical indication.

b. For Provera, review J1051 and J1055.

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

bols, guiding to obtain the policy and/or the ABN

prior to rendering the medication. This code is used

as a quantity 1 per 150 mg, so for the additional

dose given to this patient, the unit quantity is 2

(150 + 50 mg). Read the descriptions carefully for

the dose.

d. Answer, J1055 × 2. Injection medroxyprogesterone

acetate for contraceptive use, 150 mg.

Exercise 3-2

1. G0107 Colorectal cancer screening, fecal occult blood

test 1–3 simultaneous determinations

Exercise 3-3

The amount of medication that’s rendered must be

documented, and the medical necessity is required for

reimbursement purposes. Certainly, who/licensure,

where, and how rendered would be better charting

for medical standards. To select the code, we must

have the amount that’s given each date of service.

Rocephin 1 Gm injection IM, RUQ, csm is much

better documentation.

Exercise 3-4

1. J0150 × 2 (The code quantity is per 6 mg. Since dosage

is more than 6 mg, use × 2 for quantity.)

2. J0152

Answers50

3. J2353 × 180 (The quantity is reported per amount given,

even if the payer has limitations for the amount.)

4. J1890

Exercise 3-5

IA Intra-arterially

IV Intravenous

IM Intramuscular

IT Intrathecal

SC Subcutaneously

INH Inhaled solution via IPPB

INJ Injection not otherwise specified

VAR Variously, into joint, cavity tissue or topical

OTH Into catheter or suppositories

Oral Oral per drops

Chapter 4

Exercise 4-1

False

Exercise 4-2

1. Semicolon (;)—Used to save space in the description to

avoid repetition in the descriptor portion of the code.

Example: 99238

2. Plus sign (+)—Used for add-on codes. Example: 01953

3. Revised code ( )—Description of the code has changed

from the previous year. Example: 67901

4. New code (•)—New code for the current year. Example:

50592

5. New or revised wording ( )—Alerts to wording or

content change. Frequently seen in Guidelines.

Example: 76394

Answers 51

6. Reference to CPT publications ( )—Alerts to any changes

recently published in other books or newsletters. Example:

11021

7. Modifier 51 exempt ( )—Normally added to second and

subsequent surgeries. The symbol means the code may be

listed as a secondary code without the use of a modifier.

Example: 35600

8. Moderate sedation ( )—Included in the performance of

a procedure. An additional conscious sedation code isn’t

selected. Example: 44360

Exercise 4-3

The surgical guidelines are listed on page 52 of the

2010 AMA CPT. They’re usually located just after CPT

code 01999 for non-AMA publications.

Exercise 4-4

The term separate procedure means a procedure is com-

monly part of another code. Don’t report in addition to

the code that it may be considered an integral part of

the code. If the procedure is independently performed,

unrelated, or distinct, modifier -59 is attached to the

code. Select modifier -59 for a different session, different

encounter, different procedure, different site or organ

system, separate incision/excision, separate lesion, or

separate injury.

Exercise 4-5

1. A modifier is selected to indicate special circumstances

or variances from the description of the base code.

2. Modifiers are placed following the CPT code. An example

is 99215-25. The hyphen isn’t typically entered on the

claim and is used just for visual clarification.

Exercise 4-6

57105 Biopsy of the vaginal mucosa; extensive requiring

suture (including cysts) is selected. If the procedure is

performed using a colposcopy, a different code would be

selected. If the cyst is excised in its entirety, a different

code would be selected.

Answers52

Exercise 4-7

1. Laparoscopy, surgical; with bilateral total pelvic lym-

phadenopathy and periaortic lymph node sampling

(biopsy), single or multiple.

2. The codes are 99201–99499, located in the front of

the AMA/CPT, in the Evaluation/Management section

of the CPT.

Chapter 5

Exercise 5-1

No answers; research practice only.

Exercise 5-2

1. A new patient is one who hasn’t received any professional

services from the physician or another physician of the

same specialty who belongs to the same group practice

within the past three years.

2. An established patient is one who has received profes-

sional service from the physician or another physician of

the same specialty who belongs to the same group practice

within the past three years. (The on-call paragraph states

that you use the same code “as the absent physician”

would use. In other words, if the patient is established,

while on call, select established, not new patient.)

3. History, exam, and decision making

4. Counseling, coordination of care, nature of presenting

problem, and time

5. The chief complaint typically contains a concise statement

describing the symptom, problem, condition, diagnosis, or

other factor that’s the reason for the encounter, usually in

the patient’s own words.

6. History of present illness

7. Location, quality, severity, timing, context, modifying

factors, and associated signs and symptoms related to

today’s problem

Answers 53

8. No, only information significantly related is considered

for code selection.

9. Review of systems

10. ROS data define the problem, clarify the differential

diagnoses, and identify testing of baseline data that

might affect management options.

11. Chief complaint, brief history, and present illness

12. CC, HPI, and problem-pertinent system review

13. Expanded problem-focused history. The ROS is two

systems: constitutional and genitourinary. There are

no further questions regarding musculoskeletal, neuro-

logical, skin, for example, that may influence testing and

diagnosing. Past history and family and social history

aren’t stated. (AMA/CPT, 1995, and 1997)

14. Detailed history

15. Complete history

Exercise 5-3

1. Exam of the ENMT limited, Lymph limited affected, and

Respiratory limited asymptomatic is performed. AMA/CPT

and 1995=EPF; OR 1997 CMS Exam of oropharynx. Exam

of lymph neck doesn’t meet criteria as only the neck is

examined, and the criteria require two areas. Exam

Auscultation of the lungs, two elements are completed. PF

exam for 1997. OR 1997 ENT specialty exam oropharynx,

lymph, respiratory for three elements completed, PF exam.

2. AMA/CPT and the 1995 are single-specialty complete

examinations of the ENMT examinations. 1997 CMS exam

oropharynx, otoscopic, lymph doesn’t meet criteria, respi-

ratory auscultation, cardiac auscultation, skin. Exam of

ENMT, Lymph, Respiratory, Cardiac, Skin, no credit for

Temp; Extended exam affected area, plus additional symp-

tomatic, Detailed. 1995 is also Detailed, however, credit

is given for the Temp as Constitutional exam. 1997 CMS

Oropharynx, otoscopic, lymph doesn’t meet criteria, respi-

ratory auscultation, cardiac auscultation, skin is history

not defined in the exam as noted today, Temp is only one

of three vitals, so criteria aren’t met. Four elements are

Answers54

met, PF exam. 1997 ENT oropharynx, otoscopic, lymph,

respiratory, cardiac, skin is history, Temp is only one,

requires three vitals. Five elements met, PF exam. In

reality, the physician probably did assess the skin when

the mother described the rash the day prior; however,

this information isn’t documented. If the skin assess-

ment was documented, the examination would have

increased a level to an EPF exam, meeting six elements

for the ENT exam.

3. AMA/CPT and the 1995 are single-specialty complete

examinations of the ENMT examinations. 1997 CMS exam

oropharynx, otoscopic, lymph doesn’t meet the criteria,

respiratory auscultation, cardiac auscultation, skin,

Temp is only one of three vitals, so criteria aren’t met.

Five elements are met, PF exam. 1997 ENT oropharynx,

otoscopic, lymph respiratory, cardiac, skin, Temp is only

one, requires three vitals. Six elements met, EPF exam.

The statement of noncontributory doesn’t satisfy the 1997

examination elements, so it doesn’t affect the selection.

Exercise 5-4

1. Number of diagnoses or management options, amount

and/or complexity of data to be reviewed, risk of compli-

cations and/or morbidity or mortality. Two of three

components of decision making must match in selecting

the correct level.

2. No

3. a. The 50 percent coordination of care rule applies.

No history, exam, or decision making needs to

be charted.

b. 99214

Exercise 5-5

New patient:

1. 99201

2. 99203

3. 99202

Established patient:

1. 99214

Answers 55

Exercise 5-6

1. The code is 99233 because you need only two of three

components to meet or exceed the requirements, and the

history and exam meet the level 3 requirements.

2. 99214. For second-day observation services, use “office

or other outpatient services” codes for an established

patient.

3. 99234

Exercise 5-7

1. 99221

2. N/A (Level of history not high enough even to code

level 1 initial inpatient visit.)

3. 99221

4. 99231

Exercise 5-8

1. Opinion requested by another physician, regarding

a specific problem, initiate care only, written report

advising care recommendations

2. 99243

3. 99253

Exercise 5-9

1. 99282. If the ER doctor already saw the patient, he

would code for the ER visit. Another doctor coming in

to see him can code only for an established patient out-

patient visit.

2. 99213

Exercise 5-10

99291 × 1

99292 × 2

Answers56

Exercise 5-11

99441–99443, depending on the time it took. Note: You

can’t code for this at all if the patient has seen the doc-

tor in the past seven days or will see the doctor in the

next 24 hours.

Exercise 5-12

1. 99396

2. 99396, 99213-25

Chapter 6

Exercise 6-1

1. B

2. E

3. C

4. F

5. A

6. D

Exercise 6-2

Items 1–6: All of these forms of sedation are covered by

codes 99143–99150. The code is determined by the age

of the patient and the length of time sedated.

Exercise 6-3

1. 00832-P2

2. 01220-P1

3. 00172, 99100

4. 00944-P2

5. 01622-P2

Answers 57

Exercise 6-4

1. 30901

2. 30903

3. 30110-50

4. 31238

5. 31535

6. 31622

7. 32422

8. 31090

9. 31530

10. 32420

Exercise 6-5

1. 45380

2. 42821

3. 46221

4. 43456

5. 49505-RT (You can’t code separately for mesh implanta-

tion for an inguinal hernia repair—only for ventral or

incisional hernia repair.)

6. 47562

7. 47605

8. 44960

9. 45385

10. 43263

Exercise 6-6

1. 55706

2. 55250

3. 66984-LT

4. 69210

Answers58

5. 69090

6. 69420

7. 54520

8. 50590

9. 61760

10. 63030

Chapter 7

Exercise 7-1

ICD-9-CM 702.0

CPT 11442

Select excision benign rather than biopsy because the

entire lesion is removed by the surgeon obtaining the

biopsy. The entire margin is added together for a total

of 1.5 cm. Always use the margin dictated by the sur-

geon, as the pathology specimen may be smaller due

to tissue shrinkage.

Exercise 7-2

ICD-9-CM 705.83

CPT 11450

Exercise 7-3

CPT 12005-LT (total of 16.5 cm)

ICD-9-CM: 891.0 open wound leg; 881.00, open

wound forearm; 882.0, open wound hand; E007.3

playing baseball

Exercise 7-4

CPT 12032

ICD-9-CM: 890.0 open wound thigh; E928.8 “other”

accident

Answers 59

Exercise 7-5

Preoperative: 707.9 (Lesions can be coded as neoplasms

only after a pathology determination. As a preoperative

diagnosis, you must code it as an ulcerative lesion of

the skin.)

Postoperative: 173.2

Lesion site measurement 1.3 cm × 1 cm × 1.5 cm =

1.95 cm

Adjacent tissue measurement 1.5 cm × 2 cm = 3.0 cm

Total square cm code selection 4.95 cm

CPT code 14060—no cartilage or derma fascia grafting

is provided. The tissue transfer code includes the exci-

sion of the lesion.

ICD-9-CM 173.2

Exercise 7-6

ICD-9-CM 873.30 (The description of “complicated”

includes delayed healing. There’s no entry for “skin

of nose,” so you have to indicate “unspecified site.”)

CPT 15120

Exercise 7-7

ICD-9-CM 174.4

CPT 19290, 19125

Chapter 8

Exercise 8-1

1. 812.01, 79.11, 23675

2. 825.22, 825.23, 79.27, 28465 q=2 (This CPT code can be

used for cuboid, navicular, or any of the three cuneiform

bones. Code once for each bone treated.)

3. 813.41, 79.02, 78.13, 25606

4. 836.3, 79.76, 27552

5. 733.19, 733.00, 79.09, 27194

6. 820.21, 81.52, 27236

Answers60

Exercise 8-2

1. 711.01, 041.7, 80.13, 80.11, 23031, 25031

2. 717.41, 80.6, 80.7, 80.86, 29881

3. 203.00, 713.2, 77.62, 23184

4. 715.26, 715.25, 278.01, 81.54, 27447-50

5. 717.9, 719.16, 80.16, 27301

Exercise 8-3

1. 721.1, 80.51, 63075

2. 722.10, 724.02, 03.09, 63047, 63048 (This CPT code

is for each segment, not interspace, so you need two

codes: 63047 for C1 and 63048 for C2.)

3. 738.4, 81.04, 22810, 22846

4. 721.2, 721.3, 722.11, 80.51, 03.09, 81.05, 77.79,

63046, 22610, 22614, 20930

Exercise 8-4

1. 996.40, 81.08, 77.79, 22630, 20931

2. 730.03, 041.4, 77.03, 83.49, 20005, 24136

medical coding 1 - 1 study guide 1

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