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2 Medical Coding Specialist s Exam Review Physician, Second Edition Lynette Olsen Vice President, Editorial: Dave Garza Director of Learning Solutions: Matthew Kane Executive Editor: Rhonda Dearborn Managing Editor: Marah Bellegarde Product Manager: Meghan Orvis Editorial Assistant: Lauren Whalen Vice President, Marketing: Jennifer Baker Marketing Director: Wendy Mapstone Senior Marketing Manager: Nancy Bradshaw Marketing Coordinator: Erica Ropitzky Production Director: Carolyn Miller Production Manager: Andrew Crouth Senior Content Project Manager: Stacey Lamodi Senior Art Director: Jack Pendleton Technology Project Manager, New Media: Chris Catalina 2011, 2006, 1999, 1994, 1989 Delmar, Cengage Learning ALL RIGHTS RESERVED. No part of this work covered by the copyright herein may be reproduced, transmitted, stored or used in any form or by any means graphic, electronic, or mechanical, including but not limited to photocopying, recording, scanning, digitizing, taping, Web distribution, information networks, or information storage and retrieval systems, except as permitted under Section 107 or 108 of the 1976 United States Copyright Act, without the prior written permission of the publisher. For product information and technology assistance, contact us at Cengage Learning Customer & Sales Support, For permission to use material from this text or product, submit all requests online at cengage.com/permissions Further permissions questions can be ed to permissionrequest@cengage.com Library of Congress Control Number: ISBN-13: ISBN-10: Delmar 5 Maxwell Drive Clifton Park, NY USA Cengage Learning is a leading provider of customized learning solutions with office locations around the globe, including Singapore, the United Kingdom, Australia, Mexico, Brazil, and Japan. Locate your local office at: international.cengage.com/region Cengage Learning products are represented in Canada by Nelson Education, Ltd. To learn more about Delmar, visit Purchase any of our products at your local college store or at our preferred online store NOTICE TO THE READER Publisher does not warrant or guarantee any of the products described herein or perform any independent analysis in connection with any of the product information contained herein. Publisher does not assume, and expressly disclaims, any obligation to obtain and include information other than that provided to it by the manufacturer. The reader is expressly warned to consider and adopt all safety precautions that might be indicated by the activities described herein and to avoid all potential hazards. By following the instructions contained herein, the reader willingly assumes all risks in connection with such instructions. The publisher makes no representations or warranties of any kind, including but not limited to, the warranties of fitness for particular purpose or merchantability, nor are any such representations implied with respect to the material set forth herein, and the publisher takes no responsibility with respect to such material. The publisher shall not be liable for any special, consequential, or exemplary damages resulting, in whole or part, from the readers use of, or reliance upon, this material. Printed in the United States of America

3 Chapter 1 INTRODUCTION Objectives (1) Evaluate your preparedness for the national exam. (2) Gain a realistic perspective of what to expect on the national exam. (3) Understand the history and orientation of the coding books. (4) Learn about the history, structure, role, and application process of national coding organizations. Key Terms American Academy of Professional Coders (AAPC) American Health Information Management Association (AHIMA) Certified Coding Associate (CCA) Certified Coding Specialist Physician (CCS-P) Centers for Medicare & Medicaid Services (CMS) Certified Professional Coder (CPC) Certified Professional Coder Hospital (CPC-H) Current Procedural Terminology (CPT) Health care Common Procedure Coding System (HCPCS) International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) This book contains the recommendations and experiences of many people, including myself, who have taken the national exams or who have worked for many years in the field of coding. Throughout the years, I have listened closely to my colleagues and students. This book is filled with their experiences and recommendations, not just mine. This is not an introductory course in coding. This is a supplement to other courses and books. It focuses on information needed for the national coding exams and preparation for them. If you find this book difficult, you may not be ready for the national exam, and you should consider taking courses in coding. There are differences between coding for inpatient hospital billing and coding for outpatient/physician billing. This book focuses on preparation for outpatient/ physician-based coding and billing. So some rules that apply here do not apply to inpatient hospital coding. CODING BOOKS Three coding books are required for the physicianbased national coding exams: ICD-9-CM, CPT, and HCPCS. INTERNATIONAL CLASSIFICATION OF DISEASES, NINTH REVISION, CLINICAL MODIFICATION A form of ICD-9-CM has been around since 1900, and the World Health Organization has been responsible for its development since The current International Classification of Diseases, Ninth Revision (ICD-9) was created by the World Health Organization (WHO) in Versions are updated by October 1 of every year, with clarifications and explanations provided routinely; these can be accessed through the

4 2 Chapter 1 Federal Register. These codes were originally intended to provide statistical information for morbidities and mortalities. However, they have been revised in the United States to be used for reimbursement purposes. The United States revision (as modified by the National Center for Health Statistics, NCHS) is known as ICD- 9-CM (International Classification of Diseases, Ninth Revision, Clinical Modification). The CM in ICD- 9-CM denotes that this is the revision for reimbursement purposes in the United States. Whereas the ICD-9 book contains three-digit codes, the ICD-9-CM requires codes with additional fourth and fifth digits. In other words, you cannot use a three-digit code when a fourth or fifth digit exists. It is critical in coding to list the highest degree of specificity (i.e., fourth and fifth digits). Some ICD-9-CM books provide notation that a fourth or fifth digit is required; these books are useful during the exams. So there is no valid reason to make the mistake of leaving off fourth or fifth digits. The ICD-9-CM is composed of three volumes. The first volume contains the actual codes for disease and injuries. It includes appendixes and supplementary classifications, such as V codes and E codes. V codes encompass a wide array of circumstances for a patient s visit other than a disease or injury, such as personal histories or vaccinations. E codes are for external causes of injuries or diseases; they are not required on the national coding exams. There is also a separate alphabetic index for E codes. The appendixes include listings of morphology codes and the classifications of drugs. The second volume is the alphabetical index. The third volume lists the procedural codes that are used for inpatient hospital coding and are not included on national coding exams for physician billing. HEALTH CARE COMMON PROCEDURE CODING SYSTEM AND CURRENT PROCEDURAL TERMINOLOGY The Centers for Medicare & Medicaid Services (CMS), formerly known as the Health Care Financing Administration (HCFA), first created the procedural system for reporting medical services and procedures in It is called the Health care Common Procedure Coding System (HCPCS). The two levels of HCPCS are as follows: Level I is the Current Procedural Terminology (CPT), as incorporated from the American Medical Association (AMA). Level II consists of the national codes for supplies and materials. HCPCS and CPT codes, like ICD-9-CM codes, are used not only for billing but also for statistical and management purposes. Level I HCPCS contains CPTs that are produced yearly by the AMA. CPT codes are used in coding for physicians, outpatient hospital services, and ambulatory surgery centers. The process of changing codes is ongoing and published yearly in the annual CPT book, which is available in October. The CPTs are five-digit codes that can have two-digit modifiers appended to them. The book begins with Evaluation and Management (E/M) codes, then continues with Anesthesia, Surgery, Radiology, Pathology/Laboratory, and Medicine. The book contains an index and appendixes, including a list of modifiers and yearly changes. Level II HCPCS, known as the national codes, are produced by CMS. They are alphanumeric codes used to report in detail the use of supplies and materials that are nonphysician services, such as durable medical equipment and medications. Temporary codes are available in sections G, K, and Q. An index is also provided. Modifiers are also available, which are either alphanumeric or letters. THE NATIONAL ORGANIZATIONS Two national organizations provide coding certification, with some major differences in their exams and in their organizational structure. AMERICAN HEALTH INFORMATION MANAGEMENT ASSOCIATION The American Health Information Management Association (AHIMA) is a national organization that has certified health information specialists for over 75 years. AHIMA was begun in 1928 by the Association of Record Librarians of North America to standardize and professionalize the field of health information, such as medical records in hospitals and other medical institutions. The headquarters are in Chicago. There are currently more than 60,000 members, some of whose certifications are familiarly known today as Registered Health Information Technicians (RHITs) and Registered Health Information Administrators (RHIAs). These national certifications are often required for various administrative positions in hospitals or large clinics. AHIMA is governed by a Board of Directors elected by AHIMA members. As of 2010, the board consists of 13 members, including the CEO.

5 Introduction 3 The House of Delegates assists in the governance of AHIMA through the performance of their duties, as outlined in the AHIMA bylaws. The delegates are either appointed or elected from each of the 50 states, Washington D.C., and Puerto Rico. In addition, AHIMA now offers certifications for management of privacy and security programs within medical practices. These certifications are known as Certified in Health care Privacy and Security (CHPS) and Certified Health care Data Analyst (CHDA). Most importantly from the perspective of this book, AHIMA provides coding certifications for both physician (Certified Coding Specialist Physician-Based, CCS-P) and hospital (Certified Coding Specialist, CCS, for inpatient and outpatient hospital coding). In addition, there is certification for entry-level coders (Certified Coding Associate, CCA). You must be a high school graduate or have an equivalent educational background to be eligible to take the coding exams. It is also recommended that you have several years experience in the coding and billing fields before taking the CCS-P and CCS exams. AHIMA can be contacted through their Web site ( where applications, forms, and information are provided. In addition, the Web site provides sample tests, descriptions of available references, a listing of AHIMA-certified educational resources, correspondence material, and various other coding-related information. Materials can be purchased for a home study course in coding, but not for RHIT or RHIA. Check out: APPLICATION INFORMATION The information contained in this book reflects current practices of AHIMA, which AHIMA can change at any time. So check their current information thoroughly. You can either register online or complete a paperwork application and submit it by mail. In 2010, the cost of the exam was $299 for AHIMA members and $329 for nonmembers. Be sure to review the handbook for the exam because it contains important dates, rules, and directions about the exam. If you do not follow the directions, points will be deducted from the exam. Within AHIMA, the Commission on Certification for Health Informatics and Information Management (CCHIIM) is charged with the responsibility of ensuring the competency of the certification exams. An outside company, Prometric, a global test design and delivery company, administers the computerized exam. It can therefore be scheduled at your convenience and usually within your city or a nearby city. Once AHIMA has confirmed your application, it sends you a letter that confirms your application and testing information. As of 2010, you have four months to schedule your exam at a local or nearby Prometric Center, which are located widely throughout the country. You may change the dates of your testing if adequate notice is given, as indicated in the application materials. Check out: WITHDRAWAL You may withdraw from the exam but must meet deadlines, and you must send a written request. A refund will be issued, less a fee charged for processing. Occasionally, AHIMA will allow withdrawal after deadlines due to emergencies. However, official documentation, such as a physician s statement, must be completed and submitted within 30 days after the scheduled exam date. CERTIFED CODING ASSOCIATE AHIMA offers an apprentice-level certification, which is known as the Certified Coding Associate (CCA). This exam tests basic entry-level coding skills. The purpose in establishing this certification is to provide a career ladder for coders, due in part to the large demand for certified coders. This certification provides an individual with the opportunity to enter the coding field despite a lack of experience. You must have a diploma, or its equivalent, from a high school in the United States. It is recommended that you attend a quality coding program or work six months as a coder. AMERICAN ACADEMY OF PROFESSIONAL CODERS The American Academy of Professional Coders (AAPC) was formed in It provides national coding certifications for both physician coding (Certified Professional Coder, CPC) and outpatient coding for the hospital (Certified Professional Coder Hospital, CPC-H, outpatient hospital coding only). AAPC is composed of a national advisory board with members selected from state organizations, and the Academy is supported by a national physician advisory board. There are now more than 998,000 members throughout 250 local chapters. State and local groups provide educational opportunities and meetings for its members.

6 4 Chapter 1 AAPC can be contacted at their Web site ( where forms, dates, applications, and information are provided. In addition, this Web site provides sample tests, descriptions of available references, a listing of AAPC-certified educational resources, correspondence material, and various other coding-related information. Coursework can be purchased for a home study course. The exam dates are also available in AAPC s publication, The Coding Edge, or by calling the national office. The locations and dates of exams are determined by local AAPC chapters. Check out: APPLICATION INFORMATION The information contained in this book reflects the current practices of AAPC, which the AAPC can change at any time. So check their current information thoroughly. You can obtain an application either online or by ordering one from AAPC. The application must be mailed and received four weeks before the exam date. The cost of the exam in 2010 was $300. You have to be an AAPC member in order to take the exam; membership costs $120 per year. It is recommended that you have several years experience in the coding and billing fields before taking the exam. Two letters of recommendation must accompany the application. The letters should address your coding qualifications and professionalism, and they should document that you have two years of coding experience. One year may be waived for completion of a coding course that is at least 80 hours in length. Appropriate people to write recommendation letters are supervisors, instructors, physicians, or colleagues who are knowledgeable of your experience and/or education. Remember to contact AAPC or the proctor as early as possible before the exam if you have not received any information or confirmation. APPRENTICE CERTIFICATION In the absence of any coding experience, the applicant can apply for apprentice certification by filling out the apprentice application. Upon completion of the required one or two years of experience in the medical coding field, apprentices are officially certified as CPCs as long as they remain in good standing with AAPC and maintain the certification each year. RESOURCES A multitude of resources are available in health administration and coding. GOVERNMENT WEB SITES Centers for Disease Control and Prevention Centers for Medicare & Medicaid Services Federal Register Federal Statistics Health Resources and Services Administration Medicare National Center for Health Statistics National Committee on Vital and Health Statistics National Institutes of Health Occupational Safety and Health Administration Office of Inspector General for Health Administration Information Social Security Administration TRICARE U.S. Bureau of Labor Statistics U.S. Department of Health & Human Services U.S. Department of Veterans Affairs ORGANIZATIONS WEB SITES American Medical Association Agency for Health care Research and Quality American College of Health Care Administrators American College of Health care Executives American Hospital Association

7 Introduction 5 American Society for Quality Blue Cross Blue Shield Association Coding and Reimbursement Network Health care Information and Management Systems Society National Association for Health care Quality National Committee for Quality Assurance National Uniform Billing Committee National Uniform Claim Committee Resource-Based Relative Value System The Joint Commission RESEARCH WEB SITES American National Standards Institute Advance Health Administration magazine HIPAA INFORMATION Administrative Simplification Provisions of the Health Insurance Portability and Accountability Act HIPAA Privacy and Security Administration ANNUAL ICD-9-CM UPDATES AND REVISIONS National Correct Coding Initiative ICD-9htm#guidelines SUMMARY Evaluate your preparedness for taking the national coding exams because the exams are difficult. If you are not fully ready, you can prepare yourself in several ways. One important way is to familiarize yourself with the national organizations that provide certification. This step is particularly important with regard to regulations and the application process, as well as your continued participation as a certified member once you have successfully passed the exam.

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