MEDICAL CODING FUNDAMENTALS

Transcription

1 Medical Coding Fundamentals Goldsmith, Susan ISBN-13: Table of Contents MEDICAL CODING FUNDAMENTALS CHAPTER 1: MEDICAL TERMINOLOGY, ANATOMY, AND PHYSIOLOGY Word Elements Root Words Combining Vowels and Combining Forms Prefixes Suffixes Eponyms, Abbreviations, and Acronyms Eponyms Abbreviations and Acronyms Anatomy and Physiology Integumentary System Musculoskeletal System Cardiovascular System Lymphatic System Respiratory System Digestive System Urinary System Reproductive System Nervous System Endocrine System Hemic System ICD-10-CM and Medical Terminology PART I: ICD-9-CM AND ICD-10-CM CHAPTER 2: INTRODUCTION TO ICD-9-CM The Structure of the ICD-9-CM Manual Using Volumes 1 and 2 to Determine Diagnosis Codes Volume 2: Alphabetic Index of Diseases

2 Volume 1: Tabular List of Diseases Volume 3: Tabular List and Alphabetic List for Procedure Codes ICD-9-CM Conventions Abbreviations Punctuation Use Additional Code Instruction Code First Underlying Disease Instruction Update Notations Additional Digit Specificity Indicator Diagnosis Code-Specific Color Highlights Age Conflict Edits Sex Conflict Edits Hospital Acquired Condition (HAC) Indicator Other and Unspecified Codes "See" and "See Also" Instructions Signs and Symptoms Combination Codes Outpatient Coding Principles Specific Guidelines for Coding Outpatient Encounters CHAPTER 3: ICD-9-CM CHAPTER-SPECIFIC GUIDELINES, PART I: CHAPTERS 1-10 Coding Diseases and Disorders, Chapters 1-3 Chapter 1: Infectious and Parasitic Diseases ( ) Chapter 2: Neoplasm ( ) Chapter 3: Endocrine, Nutritional, and Metabolic Diseases and Immunity Disorders ( ) Coding Diseases and Disorders, Chapters 4-6 Chapter 4: Diseases of Blood and Blood-forming Organs ( ) Chapter 5: Mental Disorders ( ) Chapter 6: Diseases of Nervous System and Sense Organs ( ) Coding Diseases, Chapters 7-8 Chapter 7: Diseases of the Circulatory System ( ) Chapter 8: Diseases of the Respiratory System ( ) Coding Diseases, Chapters 9-10 Chapter 9: Diseases of the Digestive System ( ) Chapter 10: Diseases of the Genitourinary System ( ) CHAPTER 4: ICD-9-CM CHAPTER-SPECIFIC GUIDELINES, PART II: CHAPTERS 11-19

3 Coding Conditions and Complications of Pregnancy, Chapter 11 Chapter 11: Pregnancy, Childbirth and the Puerperium ( ) Coding Diseases, Chapters Chapter 12: Diseases of Skin and Subcutaneous Tissue ( ) Chapter 13: Diseases of the Musculoskeletal System and Connective Tissue ( ) Coding Abnormalities and Unusual Conditions, Chapters Chapter 14: Congenital Anomalies ( ) Chapter 15: Certain Conditions Originating in the Perinatal Period ( ) Chapter 16: Symptoms, Signs, and Ill-Defined Conditions ( ) Chapter 17: Injury and Poisoning ( ) V-Codes and E-Codes, Chapters Chapter 18: Supplemental Classification of Factors Influencing Health Status and Contact With Health Services (V01-V91) Chapter 19: Supplemental Classification of External Causes of Injury and Poisoning (E000-E030, E800-E999) CHAPTER 5: INTRODUCTION TO ICD-10-CM Transitioning to the ICD-10-CM Coding System General Equivalence Mapping Diagnosis Code Structure Laterality Trimesters Initial Treatment, Subsequent Encounter and Sequelae Structure of the ICD-10-CM Manual ICD-10-CM Conventions and General Guidelines Conventions General Guidelines Introduction to ICD-10-PCS Breakdown of Sections PART II: CPT AND HCPCS CHAPTER 6: INTRODUCTION TO CPT Structure of the CPT Manual Code Sections Code Format and Additional Information Indented Code Structure Symbols Parenthetical Notes

4 Modifiers Separate Procedure Other Information Included in the CPT Manual Index Appendices Introductory Pages Information Listed Inside Front and Back Covers Reporting Category II Codes and Using Category II Modifiers Format of Category II Codes Types of Category II Performance Measurement Codes Reporting Category III Codes CHAPTER 7: MODIFIERS The Function and Use of Modifiers Services Provided During the Global Period Modifier 24 Modifier 25 Modifier 57 Modifier 58 Modifier 76 and 77 Modifier 78 Modifier 79 Reporting Portions of a Procedure or Service Professional and Technical Components Surgical Procedure Components Reporting Multiple Services on the Same Date Modifier 50 Modifier 51 Modifier 59 Modifier 91 Identifying Additional Providers Involved in Procedures Modifiers 80, 81, and 82 Modifier 62 Modifier 66 Reporting Procedures Involving Significantly More or Less Work Than Is Typical Reporting Procedures Involving More Work Than Typical

5 Reporting Procedures Involving Less Work Than Typical Reporting Mandatory Services, Physical Status and Genetic Tests Mandatory Services Physical Status Modifiers P1 through P6 Genetic Modifiers HCPCS Modifiers Anatomical Modifiers Ambulance Modifiers Equipment Modifiers CHAPTER 8: EVALUATION AND MANAGEMENT SERVICES, PART I: STRUCTURE AND GUIDANCE Categories and Subcategories of E/M Services Subcategories of E/M Services Defining Key Terms in E/M Coding New vs. Established Patient Chief Complaint Concurrent Care and Transfer of Care Counseling Family History History of Present Illness (HPI) Nature of the Presenting Problem Past History Review of Systems Physical Examination Medical Decision Making Social History Time Unlisted Services Special Report Selecting the Level of E/M Service Working with Histories Elements of History The Physical Examination The Complexity of Medical Decision Making Selecting the Correct Level of E/M Services

6 Determining Coding Requirements Special Situations CHAPTER 9: EVALUATION AND MANAGEMENT SERVICES, PART II: CODE SELECTION Outpatient Services Coding for New or Established Patients New Patient ( ) Established Patient ( ) Categories and Suncategories of Hospital Services Hospital Observation Services Hospital Inpatient Services Observation or Inpatient Care Services (IncludinSubcategoriesnd Discharge) Hospital Discharge Services Consultation Services Office or Other Outpatient Consultations ( ) Inpatient Consultations ( ) Emergency Department Services E/M Services for New or Established Patients ( ) Other Emergency Services (99288) Reporting Critical Care Services Services Included in Critical Care Reporting E/M Codes in Other Settings Nursing Facility Services Domiciliary, Rest Home (e.g., Boarding Home), or Custodial Care Services Home Services New Patient ( ) Established Patient ( ) Prolonged Services and the Time Factor Prolonged Physician Service with Direct Patient Contact ( ) Prolonged Physician Service Without Direct Patient Contact ( ) Physician Standby Services (99360) Case Management and Care Plan Oversight Services Case Management Services Care Plan Oversight Services Preventative Medicine Services New Patient ( ) Established Patient ( )

7 Counseling Risk Factor Reduction and Behavior Change Intervention ( ) Special E/M Services Telephone Services ( ) Online Medical Evaluation (99444) Other Special E/M Services Coding E/M Services for Pediatric Patients Newborn Services Inpatient Neonatal Intensive Care and Pediatric/Neonatal Critical Care CHAPTER 10: ANESTHESIA SERVICES Selecting Anesthesia CPT Codes Based on the Surgical Procedure Anesthesia Time Units Secondary Aspects of Anesthesia Coding Physical Status Modifiers Modifiers Identifying Professional Credentials of Anesthesia Providers Modifiers Describing Reasons for Monitored Anesthesia Care (MAC) Qualifying Circumstances Add-on Codes Calculating Total Anesthesia Units Selecting Anatomy-Based Anesthesia CPT Codes Head ( ) Neck ( ) Thorax (Chest Wall and Shoulder Girdle) ( ) Intrathoracic Region ( ) Spine and Spinal Cords ( ) Upper Abdomen ( ) Lower Abdomen ( ) Perineum ( ) Pelvis (Except Hip) ( ) Upper Leg (Except Knee) ( ) Knee and Popliteal Area ( ) Lower Leg (Below Knee, Includes Ankle and Foot) ( ) Shoulder and Axilla ( ) Upper Arm and Elbow ( ) Forearm, Wrist and Hand ( ) Coding for Specific Procedures Radiological Procedures ( )

8 Burn Excisions or Debridement ( ) Obstetric Anesthesia ( ) Other Procedures ( ) CHAPTER 11: RADIOLOGY SERVICES Positions, Projections and Planes Reporting Radiology Services Unlisted Codes Modifiers Radiology CPT Coding Diagnostic Radiology (Diagnostic Imaging) ( ) Diagnostic Ultrasound ( ) Radiologic Guidance ( ) Mammography Services ( ) Bone/Joint Studies ( ) Radiation Oncology ( ) Nuclear Medicine ( ) CHAPTER 12: SURGICAL PROCEDURES Introduction Follow-up Care Multiple Procedures and "Separate Procedures" Structure of the Surgical Section of the CPT Module 12.1 General and Integumentary System Reporting Procedures of the Skin and Subcutaneous Tissues Wound Repair (Closure) Skin Repair Procedures Destruction of Lesions Procedures on the Breast Anesthesia Associated with Procedures on the Integumentary System Module Review Module 12.2 Musculoskeletal System Musculoskeletal System Treatments General Codes and Codes Describing Procedures on the Head, Neck, Thorax, Back and Flank Codes Describing Procedures on the Back and Flank, Spinal Column and Abdomen Codes Describing Procedures on the Extremeties and Joints Casting, Strapping, Endoscopy and Arthroscopy

9 Anesthesia Associated with Procedures on the Musculoskeletal System Module Review Module 12.3 Respiratory System; Cardiovascular System; Hemic and Lymphatic Systems; Mediastinum and Diaphragm Procedures on the Respiratory System ( ) Procedures on the Heart and Pericardium ( ) Procedures on the Arteries and Veins ( ) Procedures on the Hemic and Lymphatic System, Mediastinum, and Diaphragm Anesthesia for Procedures in the Series Module Review Module 12.4 Digestive System Procedures on the Mouth and Throat Procedures on the Gastrointestinal Tract from the Esophagus to the Anus Procedures on Organs Connected to the Digestive Tract Anesthesia for Procedures in the Series Module Review Module 12.5 Urinary System, Male and Female Genital Systems, and Maternity Care and Delivery Procedures on the Urinary System ( ) Procedures on the Male Genital System ( ) Procedures on the Female Genital System ( ) Maternal Care and Delivery ( ) Anesthesia for Procedures in the Series Module Review Module 12.6 Endocrine, Nervous, Ocular, and Auditory Systems Endocrine System ( ) Procedures on the Skill, Meninges, and Brain ( ) Procedures on the Spine and Spinal Cord ( ) Procedures on Extracranial Nerves, Peripheral Nerves and the Autonomic Nervous System ( ) Procedures on Ocular Structures Procedures on the Auditory System ( ) Anesthesia for Procedures in the Series Module Review CHAPTER 13: PATHOLOGY AND LABORATORY SERVICES Organ or Disease-Oriented Panels ( ) Lab Tests Involving Drugs or Medicines

10 Drug Testing ( ) Therapeutic Drug Assay ( ) Evocative/Suppression Testing ( ) Reporting Other Lab Tests Consultation (Clinical Pathology) ( ) Urinalysis ( ) Chemistry ( ) Hematology and Coagulation ( ) Immunology ( ) Transfusion Medicine ( ) Microbiology ( ) Pathology Services Anatomic Pathology ( ) Cytopathology ( ) and Cytogenetic Studies ( ) Surgical Pathology ( ) In Vivo Laboratory Procedures ( ) Reproductive Medicine Procedures ( ) CHAPTER 14: MEDICINE SERVICES Medicine Chapter Structure and General Guidelines Multiple Procedures Add-on Codes Separate Procedures Unlisted Service or Procedure Materials Supplied by Physician Immune Globulins; Immunization Administration for Vaccines/Toxoids; Vaccines, Toxoids Immune Globulins ( ) Immunization Administration for Vaccines/Toxoids ( ) Vaccines, Toxoids ( ) Psychiatry, Biofeedback, Dialysis, Gastroenterology, Ophthalomology, and Otorhinolaryngological Services Psychiatry ( ) Biofeedback (90901 and 90911) Dialysis ( ) Gastroenterology ( ) Ophthalmology ( ) Special Otorhinolaryngologic Services ( )

11 Cardiovascular, Immunological, and Neurological Services Cardiovascular ( ) Noninvasive Vascular Diagnostic Studies ( ) Pulmonary ( ) Allergy and Clinical Immunology ( ) Endocrinology ( ) Neurology and Neuromuscular Procedures ( ) Medical Genetics and Genetic Counseling Services (96040) Central Nervous System Assessments/Tests ( ) Health and Behavior Assessment/Intervention ( ) Injections and Infusions; Therapeutic Services; Rehabilitation; Moderate Sedation; Home Health and Medication Therapeutic Management Services Hydration, Therapeutic Injections and Infusions, and Chemotherapy Photodynamic Therapy ( ) Special Dermatological Procedures ( ) Physical Medicine and Rehabilitation ( ) Medical Nutrition Management ( ) Acupuncture ( ) Osteopathic Manipulative Treatment ( ) Chiropractic Manipulative Treatment ( ) Education and Training for Patient Self-Management ( ) Non-Face-to-Face Non-Physician Services ( ) Special Services, Procedures and Reports ( ) Qualifying Circumstances for Anesthesia (99100, 99116, 99135, and 99140) Moderate Sedation ( ) Home Health Procedures/Services ( ) Medication Therapy Management Services ( ) CHAPTER 15: HCPCS HCPCS Codes Functions of HCPCS Codes Uses of HCPCS Codes Index and Tabular List of Services Calculating Multiple Units of Service Identifying Services Described by Each Category of HCPCS Codes HCPCS A, B, C, D, and E Codes A Codes: Transportation Services Including Ambulance; Medical & Surgical Supplies; Administrative, Miscellaneous & Investigational

12 B Codes: Enteral and Parenteral Therapy C Codes: Outpatient HCPCS Codes E Codes: Durable Medical Equipment HCPCS G, H, J, K, L, and M Codes G Codes: Procedures/Professional Services (Temporary); Physician's Voluntary Reporting Program Codes; Last Minute Additions H Codes: Alcohol and Drug Abuse Treatment Services J Codes: Drug Administered Other than Oral Method K Codes: Temporary Codes L Codes: Orthotic and Prosthetic Procedures (L0112-L9900) Other Medical Services HCPCS P, Q, R, S, T, and V Codes P Codes: Pathology and Laboratory Services (P2028-P9615) Q Codes: Miscellaneous Services (Temporary) R Codes: Diagnostic Radiology Services S Codes: Temporary National Codes (Non-Medicare) T Codes: National T Codes Established for State Medicaid Agencies (T1000-T5999) V Codes: Vision Services, Hearing Services & Speech-Language Pathology Services HCPCS Modifiers and HCPCS Manual Appendices Anatomic Modifiers DME and Other Equipment Modifiers Radiology Modifiers Place of Service Modifier Appendices PART III: PRACTICUM CHAPTER 16: PUTTING IT ALL TOGETHER Coding Scenarios