Overview. A Note from the Authors on Why They Wrote This Book PREFACE

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1 PREFACE Overview Medical Coding Certification Exam Preparation is designed to aid in the review for the Certified Professional Coder (CPC) exam. However, much of the information included in this text will also assist the coder in preparation for other coding certification exams. While not intended to be an introduction to medical coding, this text provides an extensive review of the topics students need to know for the CPC exam, including coverage of anatomy, medical terminology, and pathophysiology, as well as the concepts, guidelines, and rules of medical coding. Based on their significant teaching experience and affiliations with AAPC, authors Cynthia Stewart and Cynthia Ward bring a fresh approach to preparing for the exam. The book is organized around the principle that students need the means to learn how to analyze cases and how to then translate services, procedures, and diagnoses from those cases into codes. The importance of understanding and knowing how to locate and use the guidelines inherent to the ICD, CPT, and HCPCS coding manuals is emphasized throughout the book with the use of Spotlights and Mentor Coding Tips. Each chapter contains questions similar to those found on the CPC exam. In addition, each of the five units of the book ends with a Unit Exam, meant to be a cumulative review. Finally, the book concludes with a comprehensive practice exam on the use of ICD-9-CM codes. (An ICD-10-CM exam is also available to help prepare students for the ICD-10-CM proficiency exam in development by AAPC.) Additional practice is available through Connect Plus, McGraw- Hill s online assignment and assessment tool. A Note from the Authors on Why They Wrote This Book We began our journey with this text because we felt there was a need to look at preparing coders for the exam and their future career in medical coding in a different way. In our experience as instructors, we found that practicing for the exam by routinely going through numerous cases studies did not benefit the coder in truly understanding why the codes selected were correct or how the codes are supported by the provider s documentation. During our tenure as instructors, we have learned that our students needed the tools to understand how to break the case down and translate services, procedures, and diagnoses into codes. Our purpose in writing this text is to aid the instructor and coder in bringing all of the individually learned pieces together to complete the process of medical coding. xi

2 How to Use the Book As stated in the overview, this book is not designed as, or intended to be used as, an introduction to medical coding. The reader should have an understanding of and foundation in medical coding. Instead, this book is designed to aid in review for the CPC exam. While preparing for the exam with this text, you will also need: Current CPT manual standard or professional edition (professional edition is author-recommended). Current ICD-9-CM manual. ICD-10-CM manual (optional). Current HCPCS manual. A medical dictionary. A comprehensive anatomy text. Throughout this text, instructions identify certain areas, guidelines, or notes within the coding manuals that you should highlight or otherwise flag to remind yourself of the information and to access it quickly when you are taking the exam. To this end, you are encouraged to work through this text with each of the coding manuals open and to use them as additional resources, thus reinforcing the information available to you during the exam. Organization of Medical Coding Certification Exam Preparation Here is an overview of the five units of the book: UNIT COVERAGE 1. Fundamental Coding Guidelines Discusses coding as a career and the many reasons to become certified. This unit reviews ICD-9-CM and ICD-10-CM coding formats and guidelines. ICD chapterspecific guidelines on conditions such as HIV, septicemia, neoplasms, and diabetes are also found within this unit, along with CPT coding applications. 2. Coding for Evaluation/ Management (E/M), Anesthesia, and Surgery 3. Coding for Surgical Procedures on Integumentary, Musculoskeletal, Respiratory, and Cardiovascular/ Lymphatic Systems Provides a review of evaluation and management coding. Specific guidelines along with valuable coding tips for anesthesia procedures and general surgery are included as well. Serves as a comprehensive guide to anatomy, medical terminology, and ICD and CPT coding for the integumentary, musculoskeletal, respiratory, and cardiovascular/lymphatic systems. The use of modifiers with codes for each of these systems is also reviewed. 4. Coding for Surgical Procedures on Digestive, Urinary, Male and Female Reproductive Systems, Maternity Care, Nervous System, and Eyes, Ears, and Endocrine System 5. Coding for Radiology, Pathology/ Laboratory, General Medicine, HCPCS, Category II and III, and Practice Management Gives an in-depth overview of the urinary, male reproductive, female reproductive, nervous, and endocrine systems anatomy, ICD and CPT coding, and appropriate use of modifiers with codes for these systems. Coding information is also included for the eyes, ears, and adnexa. Details medical terms, types of procedures, and coding guidelines and their application for radiology, pathology/laboratory, and general medicine services and procedures. Coding foundations for such services as diagnostic imaging, nuclear medicine, drug testing, surgical microscopic exams, immunizations, cardiac procedures, and dialysis are provided. A review of HCPCS coding guidelines, as well as category II and category III code definitions, is found here. This unit also provides a review of practice management issues such as ABNs, compliance, and HIPAA and their effect on coding. xii PREFACE

3 Key Points about the Book The importance of understanding the guidelines inherent to the ICD, CPT, and HCPCS coding manuals and knowing how to locate and use them is stressed throughout this text by the frequent use of special-feature boxes: Spotlights within each chapter refer the coder to or provide additional information and direction on specific procedures, conditions, guidelines, and practice management issues. Mentor Coding Tips are tips and shortcuts the authors have accumulated over the years and learned from other experienced coders in the trenches. These tips aid the coder in breaking down and retaining information necessary for the exam and everyday coding. While all of the chapters in this text are presented differently from what you might find in other review guides, four chapters in particular should be noted: C hapter Two, Foundations of ICD-9-CM, and Chapter Three, Foundations of ICD-10-CM These chapters began as a single chapter. However, due to the complications of teaching two similar yet conceptually different coding systems, as well as medical coders potential need to prepare for the upcoming ICD-10-CM proficiency exam, the authors were prompted to divide these code sets into individual chapters. The intent is for one or the other of these two chapters to be reviewed, depending on the examinee s need. Information about the ICD-10-CM code set is included in Chapters 9 through 20 to help coders gain familiarity with these codes. Chapter Four, ICD Chapter-Specific Guidelines This chapter includes the four ICD-9-CM coding guidelines that the authors have found to be the most difficult for students and coders to interpret and use: those pertaining to human immunodeficiency virus; septicemia, systemic inflammatory response syndrome (SIRS), sepsis, severe sepsis, and septic shock; neoplasms; and diabetes mellitus. Chapter-specific guidelines pertaining to other ICD chapters are included in the relevant CPT surgery subsection chapters, Chapters 9 through 20. Chapter Eight, Surgery This chapter begins the Surgery section of CPT. Included is a step-by-step process of documentation analysis. This series of questions maps out many of the thought processes that experienced coders engage in when reviewing operative reports and other documentation. Walking through this process for each case study will help instill this approach in the coder. It is important to note that not everything within the CPT, ICD, and HCPCS coding manuals is addressed in this text. The authors did address concepts and guidelines that in their experience as instructors tended to be difficult for examinees and new coders to master. Taking into account the various learning types, they created and added decision trees for a few of the most difficult coding concepts: pregnancy trimester episode of care, human immunodeficiency, and sepsis, SIRS, and septicemia. Each chapter contains tables that outline the sections of the ICD-9-CM and CPT code sets. Also included in Chapters 9 through 20 are tables comparing ICD-9-CM and ICD-10-CM code sets. From a pedagogical standpoint, a variety of methods have been included for students to practice applying and developing their skills: review exercises at the end of each chapter section, end-of-chapter reviews and cases studies utilizing the documentation analysis tool where appropriate, and a cumulative unit exam at the end of each unit, designed to prepare students for the final PREFACE xiii

4 exam at the end of the book (covering ICD-9-CM). The questions in both the unit exams and the final exam are presented in the style of the actual CPC exam questions. In addition, to help prepare coders for the upcoming ICD-10-CM proficiency exam, the authors have also prepared a final exam covering ICD-10-CM. At the time that this practice exam was developed, very little information regarding the format of the AAPC ICD-10-CM proficiency exam was known. Therefore, the proficiency exam is formatted in a style similar to that of the ICD-9-CM practice exam included in this book. Key Content Highlights Pedagogy Learning outcomes and key terms are listed at the beginning of each chapter to set the stage for the content to come. Major chapter heads are structured to reflect the numbered learning outcomes. Key terms are defined in the margins for easy reference, and they are also listed in the Glossary near the end of the book. Tips, Spotlights, and Examples help students navigate through the material. Chapter summaries, organized by learning outcomes, are presented in a tabular, step-by-step format to help with review of the material. End-of-chapter elements are tagged with corresponding learning-outcome numbers. The Chapter Review section includes: Using Terminology matching questions with key terms and definitions. Checking Your Understanding multiple-choice questions. Applying Your Knowledge case studies. Chapter by Chapter Chapter One: the language and roles of medical coding, benefits of credentialing your knowledge, and CPC exam format and test-taking skills. Chapter Two: ICD-9-CM manual format, abbreviations, coding conventions, and punctuation; ICD-9-CM chapter, general, section and chapterspecific guidelines; and translation of provider terminology to diagnostic codes. Chapter Three: ICD-10-CM manual format, abbreviations, coding conventions, and punctuation; ICD-10-CM chapter, general, section and chapterspecific guidelines; and new conventions in ICD-10-CM default codes, extenders, and placeholders. Chapter Four: ICD chapter-specific general guidelines related to human immunodeficiency virus (HIV) infections; septicemia, systemic inflammatory response syndrome (SIRS), sepsis, severe sepsis, and septic shock; neoplasms; and diabetes mellitus. Chapter Five: CPT format, conventions, instructional notes, guidelines, and symbols; CPT modifiers; CPT and ICD linkage; and translation of provider documentation to codes. Chapter Six: Evaluation and management (E/M) guidelines, modifiers, and types of services; and components and levels of an E/M code. xiv PREFACE

5 Chapter Seven: anesthesia reimbursement formula and terminology; physical status, qualifying-circumstance modifiers, and HCPCS Level II modifiers; and locating of anesthesia terms in the CPT manual index. Chapter Eight: general guidelines and format of the Surgery section of the CPT manual; global surgical package and Surgery section modifiers; and use of the index to locate codes for surgical procedures. Chapter Nine: anatomy of the integumentary system; ICD-9-CM and CPT guidelines for diseases of the skin and subcutaneous tissue; Integumentary subsection modifiers; and common medical and procedural terms used in operative reports. Chapter Ten: anatomy of the musculoskeletal system; ICD-9-CM and CPT guidelines for diseases of the musculoskeletal system; musculoskeletal system modifiers; and common medical and procedural terms used in operative reports. Chapter Eleven: anatomy of the respiratory system; ICD-9-CM and CPT guidelines for diseases of the respiratory system; respiratory system modifiers; and common medical and procedural terms used in operative reports. Chapter Twelve: anatomy of the cardiovascular and lymphatic systems; ICD-9-CM and CPT guidelines for diseases of the cardiovascular system; ICD-9-CM and CPT guidelines for diseases of the lymphatic system; cardiovascular and lymphatic system modifiers; and common medical and procedural terms used in operative reports. Chapter Thirteen: anatomy of the digestive system; ICD-9-CM and CPT guidelines for diseases of the digestive system; digestive system modifiers; and common medical and procedural terms used in operative reports. Chapter Fourteen: anatomy of the urinary and male reproductive system; ICD-9-CM and CPT guidelines for diseases of the urinary system; ICD-9-CM and CPT guidelines for diseases of the male reproductive system; urinary and male reproductive system modifiers; and common medical and procedural terms used in operative reports. Chapter Fifteen: anatomy of the female reproductive system; ICD guidelines and format for complications of pregnancy, childbirth, and the puerperium; CPT guidelines for the female genital system and maternity care and delivery; subsection modifiers; and common medical and procedural terms used in operative reports. Chapter Sixteen: anatomy of the nervous system; ICD-9-CM and CPT guidelines for diseases of the nervous system; nervous system modifiers; and common medical and procedural terms used in operative reports. Chapter Seventeen: anatomy of the endocrine system, eye, ocular adnexa, and auditory system; ICD-9-CM guidelines for diseases of the eye, ocular adnexa, and auditory system; CPT guidelines for diseases of the endocrine system, eye, ocular adnexa, and auditory system; endocrine system, eye, ocular adnexa, and auditory system modifiers; and common medical and procedural terms used in operative reports. Chapter Eighteen: CPT guidelines for the Diagnostic Imaging, Ultrasound, Mammography, and Bone/Joint Studies subsection of the Radiology section; CPT guidelines for the Radiation Oncology and Nuclear Medicine subsections. Chapter Nineteen: CPT guidelines for pathology/laboratory coding; modifiers most commonly used with codes in the Pathology/Laboratory section of CPT; and common medical and procedural terms used in lab and operative reports. PREFACE xv

6 Chapter Twenty: CPT guidelines for the Medicine section; medical and procedural terms; and modifiers most commonly used with codes in the Medicine section. Chapter Twenty-One: HCPCS II guidelines and modifiers; common abbreviations and acronyms used in HCPCS Level II; CPT guidelines and format of category II and category III codes. Chapter Twenty-Two: AAPC professional code of ethics; definitions of providers and payers, including Medicare, Medicaid, TRICARE, and managed care entities; regulations and the parties responsible for maintaining and enforcing the regulations. Medical Coding Certification Exam Preparation in the Digital World: Supplementary Materials for the Instructor and Student Instructors, McGraw-Hill knows how much effort it takes to prepare for a new course. Through focus groups, symposia, reviews, and conversations with instructors like you, we have gathered information about what materials you need in order to facilitate successful courses. We are committed to providing you with high-quality, accurate instructor support. Knowing the importance of flexibility and digital learning, McGraw-Hill has created multiple assets to enhance the learning experience no matter what the class format: traditional, online, or hybrid. This product is designed to help instructors and students be successful, with digital solutions proven to drive student success. A one-stop spot to present, deliver, and assess digital assets available from McGraw-Hill: McGraw-Hill Connect Medical Coding Certification Exam Preparation McGraw-Hill Connect Medical Coding Certification Exam Preparation provides online presentation, assignment, and assessment solutions. It connects your students with the tools and resources they ll need to achieve success. With Connect you can deliver assignments, quizzes, and tests online. A robust set of questions and activities, including all of the end-of-section and end-of-chapter questions, all of the unit exams, multiple full practice exams (the ICD-9-CM exam from the book plus additional exams, as well as ICD- 10-CM exams), interactives, and test bank questions, are presented and aligned with the textbook s learning outcomes. As an instructor, you can edit existing questions and author entirely new problems. Connect enables you to track individual student performance by question, by assignment, or in relation to the class overall with detailed grade reports. You can integrate grade reports easily with Learning Management Systems (LMSs), such as Blackboard, Desire2Learn, or ecollege and much more. Connect Plus Medical Coding Certification Exam Preparation provides students with all the advantages of Connect Medical Coding Certification Exam Preparation plus 24/7 online access to an ebook. This media-rich version of the textbook is available through the McGraw-Hill Connect platform and allows seamless xvi PREFACE

7 integration of text, media, and assessments. To learn more, visit connect.mcgraw-hill.com. A single sign-on with Connect and your Blackboard course: McGraw-Hill Higher Education and Blackboard Blackboard, the web-based course management system, has partnered with McGraw-Hill to better allow students and faculty to use online materials and activities to complement face-to-face teaching. Blackboard features exciting social learning and teaching tools that foster active learning opportunities for students. You ll transform your closed-door classroom into communities where students remain connected to their educational experience 24 hours a day. This partnership allows you and your students access to McGraw-Hill s Connect and Create right from within your Blackboard course all with a single sign-on. Not only do you get single sign-on with Connect and Create, but you also get deep integration of McGraw-Hill content and content engines right in Blackboard. Whether you re choosing a book for your course or building Connect assignments, all the tools you need are right where you want them inside Blackboard. Gradebooks are now seamless. When a student completes an integrated Connect assignment, the grade for that assignment automatically (and instantly) feeds into your Blackboard grade center. McGraw-Hill and Blackboard can now offer you easy access to industry leading technology and content, whether your campus hosts it or we do. Be sure to ask your local McGraw-Hill representative for details. Create a textbook organized the way you teach: McGraw-Hill Create With McGraw-Hill Create, you can easily rearrange chapters, combine material from other content sources, and quickly upload content you have written, such as your course syllabus or teaching notes. Find the content you need in Create by searching through thousands of leading McGraw- Hill textbooks. Arrange your book to fit your teaching style. Create even allows you to personalize your book s appearance by selecting the cover and adding your name, school, and course information. Order a Create book and you ll receive a complimentary print review copy in 3 to 5 business days or a complimentary electronic review copy (ecomp) via in minutes. Go to today and register to experience how McGraw-Hill Create empowers you to teach your students your way. Record and distribute your lectures for multiple viewing: My Lectures Tegrity McGraw-Hill Tegrity records and distributes your class lecture with just a click of a button. Students can view it anytime and anywhere via computer, ipod, or mobile device. It indexes as it records your PowerPoint presentations and anything shown on your computer, so students can use keywords to find exactly what they want to study. Tegrity is available as an integrated feature of McGraw-Hill Connect Medical Coding Certification Exam Preparation and as a stand-alone. PREFACE xvii

8 Introducing CodeitRightOnline Curriculum! You know that the future starts with education and the new CodeitRightOnline Curriculum is designed specifically for the coding student. Using the same user friendly online medical coding and billing application offered in the market today through CodeitRightOnline, the Curriculum version presents all of the essential coding information that students and faculty need. CodeitRightOnline Curriculum is offered to students and faculty for up to 12 months, depending on your subscription. You ll get: ICD-9-CM: all three volumes, guidelines, and notes CPT codes, modifiers, guidelines, and notes HCPCS Level II codes, modifiers, guidelines, and notes ICD-10-CM and PCS codes and guidelines, and notes Ability to add notes E/M Guidelines accessible from the library ICD-9-CM official guidelines accessible from the library All the searching tools we have in the system The ability to make codes a favorite Anatomy and physiology games ICD-10-CM information from Contexo Curriculum packages include a subscription for 3 months, 6 months, or 12 months. For a limited time, experience CodeitRightOnline Curriculum and all that it has to offer through a free 29-day trial! Simply visit mcgraw-hill to register for a free trial. Curriculum Pricing: 3 months: $ months: $ months: $99.95 To learn more about CodeitRightOnline Curriculum, visit codeitrightonline.com. CPT is a registered trademark of the American Medical Association. xviii PREFACE

9 Instructor Resources You can rely on the following materials to help you and your students work through the material in this book. All of these resources are available on the book s website, (instructors can request a password through their sales representative): SUPPLEMENT Instructor s Manual (organized by learning outcomes) PowerPoint Presentations (organized by learning outcomes) Electronic Test Bank Tools to Plan Course FEATURES Lesson plans Answer keys for all exercises, with tagging for learning outcomes, level of difficulty, and level of Bloom s taxonomy Key terms Key concepts Teaching notes EZ Test Online (computerized) Word version Questions with tagging for learning outcomes, level of difficulty, level of Bloom s taxonomy, feedback, ABHES, CAAHEP, CAHIIM, and estimated time of completion Correlations of the learning outcomes to accrediting bodies such as ABHES CAAHEP, and CAHIIM Sample syllabi Asset Map a recap of the key instructor resources, as well as information on the content available through Connect Plus Need help? Contact McGraw-Hill s Customer Experience Group (CXG). Visit the CXG website at Browse our FAQs (frequently asked questions) and product documentation and/or contact a CXG representative. CXG is available Sunday through Friday. Want to learn more about this product? Attend one of our online webinars. To learn more about the webinars, please contact your McGraw-Hill sales representative. To find your McGraw-Hill representative, go to and click Find My Sales Rep. PREFACE xix