Preface TO THE STUDENT

Transcription

1 Welcome to The Complete Procedure Coding Book! This book is part of a three-book series that instructs students on how to become proficient in medical coding a health care field that continues to be in high demand. The Bureau of Labor Statistics notes the demand for health information management professions (which includes coders) will continue to increase incredibly through 2018 and beyond. This series of books was written to speak directly to the medical coding student using step-by-step instructions and conversational language to maximize understanding. Built into the structure of these texts are many opportunities for students to practice coding and apply what they have learned. Students will also have the chance to practice abstracting with real-world health professionals documentation and accurately translating these facts into the best, most accurate codes. TO THE STUDENT Your medical coding classes introduce you to the skills you will need to work in the health information management field. A fundamental role of an insurance coding and medical billing specialist s job is to work with the insurance companies that will reimburse the health care facility for the services and treatments provided to patients. You may be employed by a hospital, clinic, doctor s office, health maintenance organization, mental health care facility, insurance company, government agency or long-term care facility. Your career will be challenging, interesting, and one of the top ten fastest-growing Allied Health professions. Before you begin your adventure, here are some tips to help you succeed: First, take a deep breath. Coding is complex and is not like anything else you have tackled before. Remember that you are learning a new skill! Give yourself some time to become proficient. Second, never code directly from the alphabetic index. Always look the code up in the tabular list before deciding on a code. If you remember this rule, you will always head in the right direction. Third, when you encounter a word or abbreviation that you don t understand, stop and look it up in your medical dictionary. Your instructor can recommend a medical dictionary for you, or you can purchase McGraw-Hill s Medical Dictionary for Allied Health (ISBN: ). Fourth, after you finish coding the case studies, scenarios, or whatever you are coding, put it all aside. Then, later or the next day, go back and do back coding. In the tabular list, look up each code x

2 you came up with and match the code description carefully with the case study or scenario words. This is a very effective way to double-check your answers. Your fresh eyes will enable you see words and notations you may have missed before. Finally, reevaluate your work by checking each and every question to make certain you understand how you found your answer. When you find you have gotten an exercise, test question, or other activity wrong, try to figure out what happened. Make sure you ask your instructor for help when you need it! Good luck on your medical coding journey! TO THE INSTRUCTOR Shelley Safian s Medical Coding Series includes three books: The Complete Diagnosis Coding Book (ISBN: ) The Complete Procedure Coding Book (ISBN: ) You Code It! Abstracting Case Studies Practicum (ISBN: ) These books are designed to give your students the medical coding experience they need in order to pass their first medical coding certification exams, such as CCS/CCS-P or CPC/CPC-H. The books offer students a variety of practice opportunities by reinforcing the learning outcomes set forth in every chapter. The chapter materials are organized in short bursts of text followed by practice keeping students active and coding throughout! Instructor Resources McGraw-Hill offers extensive resources on the Online Learning Center for our textbooks. After obtaining the instructor username and password from your McGraw-Hill sales representative, access our instructor resources here: Online Learning Center Features Instructor s Manual this manual includes the answers to the endof-chapter exercises as well as a chapter outline with overviews, discussion activities and additional resources. Instructor s PowerPoint slides organized by the chapter learning outcomes, these slides help reinforce the text content and make your course prep a breeze! Test Bank our test bank is available in both EZ-Test Online and Word document formats. Organized by chapter, learning outcome, level of difficulty, and Bloom s taxonomy, this test bank is sure to help with assessment. LearnSmart: Medical Insurance Billing and Coding McGraw-Hill s LearnSmart diagnoses students skill levels to determine what they know and what they don t, and delivers customized learning content based on their strengths and weaknesses. Visit learnsmart and to try it yourself! xi

3 WHAT S NEW IN OUR SECOND EDITION The Complete Procedure Coding Book, second edition, has been revised to include a greater number of realistic scenarios and case studies for students to gain hands-on learning with the popular Let s Code It! scenarios and You Code It! case studies. Keys to Coding a new feature for this edition make it easier for students to connect learning concepts and specific official guidelines to critical thinking. And, of course, we have added an entire new chapter covering ICD-10-PCS (using the 2010 code set version). Another new feature, Bridge to ICD-10, prepares students for transition to ICD-10. Throughout the book, more anatomy and physiology descriptions, as well as more information on inclusive signs and symptoms, enhance your comprehension of the procedure coding process. The entire text has been updated using 2011 CPT, 2011 ICD-9-CM, and 2011 HCPCS Level II. The instructor s manual will have a 2011-compliant answer key to all end-of-chapter tests: Chapter Reviews (multiple-choice questions), You Code It! Practice (short scenarios), and end of chapter You Code It! Simulation (full physician s notes/operative reports). Chapter-by-Chapter Updates Chapter 1: Legal and Ethical Issues Key Terms include several additional terms paths and guidance New sections on National Correct Coding Initiative, compliance programs, and federal False Claims Act Updated AHIMA Standards of Ethical Coding Updated AAPC Code of Ethical Standards Chapter 2: Introduction to Coding and CPT Key Terms include several additional terms Expanded section on the Seven Steps to Accurate Coding Updated section on Coding from Physician s Notes New subsection on CPT Resequencing Initiative New feature: Bridge To ICD-10-CM New feature: Bridge To ICD-10-PCS xii

4 Chapter 3: Introduction to Modifiers Updated section on Procedure Code Modifiers New section on Sequencing Multiple Modifiers Additional Let s Code It! scenario and examples Chapter 4: Evaluation and Management Codes, Part 1 Key Terms include additional terms Revised and expanded explanations on E/M coding elements: location, level of patient history, level of physical examination, and level of decision-making New subsections on counseling, face-to-face time, unit/floor time, and non face-to-face time Chapter 5: Evaluation and Management Codes, Part 2 Key Terms include additional terms New sections on E/M in the Global Surgical Package, Inpatient Neonatal and Pediatric Critical Care, and Intensive Care Services New subsections on Newborn Care Services and Delivery/Birthing Room Attendance and Resuscitation Services Chapter 6: Anesthesia Coding Reformatted for easier comprehension and flow of information New subsections on Time Reporting, Qualifying Circumstances Codes, Conscious Sedation, Unusual Anesthesia, and Same Provider New figure Chapter 7: Surgery Coding, Part 1 New section on Types of Surgical Procedures New subsections on Diagnostic and Therapeutic Procedures; Noninvasive, Minimally-Invasive, and Open Procedures; Global Period Timeframes; Incision and Drainage; and Debridement Revised section on Destruction Several new examples, figures/tables, and an additional Let s Code It! activity Chapter 8: Surgery Coding, Part 2 New subsections on Open or Closed Treatment; Spinal Fusion; Sinus Endoscopy; Central Venous Access Procedures; Maternity Care and Delivery; and Tympanostomy Revised sections on the Male Genital System and the Auditory System xiii

5 Chapter 9: Radiology Coding New sections on Screening versus Diagnostic, Mammography and Breast Imaging, and Bone and Joint Studies Expanded sections on Procedures with or without Contrast and Nuclear Medicine Chapter 10: Pathology and Laboratory Coding Expanded section on Microbiology Additional Let s Code It! activity Chapter 11: Medicine Coding Expanded section on Injections and Infusions and Dialysis New subsection on Implantable and Wearable Cardiac Device Evaluations Chapter 12: Category II and Category III Coding Updated Category II codes New subsection on Alphabetic Measure Index of Performance Measures Updated Category III codes Nine new You Code It! Practice scenarios Chapter 13: HCPCS Level II Coding: Introduction and Guidelines Updated section on HCPCS Level II Categories Updated section on Alphanumeric Listing Chapter 14: Coding Medical Supplies, Durable Medical Equipment (DME), Pharmaceutical, and Ambulance and Other Transportation Services General updates Chapter 15: ICD-9-CM Volume 3 Procedure Codes General updates Two new You Code It! Simulation case studies Chapter 16: ICD-10-PCS New Chapter! New section on the Objectives for ICD-10-PCS New section on the ICD-10-PCS Code Descriptions New section on the Structure of ICD-10-PCS Codes New section on the ICD-10-PCS Book New section on General Equivalence Mapping (GEM) Chapter 17: Procedure Coding Practicum New note formatting makes reading easier, allowing more time for practice xiv

6 CODEITRIGHTONLINE : YOUR ONLINE CODING TOOL So that your students can gain experience with the use of an online coding tool, they will have access for a 14-day period to CodeitRightOnline, produced by Contexo Media, a division of Access Intelligence. CodeitRightOnline offers a comprehensive search function for CPT, HCPCS Level II, and ICD-9-CM codes, along with ICD-10-CM/PCS code sets. It includes helpful tools like search indexing for easy reference, and offers newsletter articles and other coding resources. For more information about the features of CodeitRightOnline and how to sign up for a trial, visit ACKNOWLEDGMENTS Book Reviews Many instructors reviewed the first and second editions and provided valuable feedback that directly affected the books development. Their contributions are greatly appreciated. Bobette Anderson, CPC MedVance Institute Darlene Boschert, CPC, CPC-H Career Institute of Florida Gerry Brasin, AS Premier Education Group Lisa G. Bynoe, BS, MBA ASA Institute Christine M. Cole, CCA Williston State College Rosalind Collazo, BS, MS ASA Institute Christine M. Enz, BA, M.Ed. Rochester Business Institute Theresa Errante-Parrino, AS, BS Indian River Community College Kristina Ferry, MAEd Heritage College Janet Hunter, MBA, MS Northland Pioneer College Judy Hurtt East Central Community College Carol Lee Jarrell, MLt, AHI Brown Mackie College Jennifer Lame, MPH, BS, RHIT Southwest Wisconsin Technical College Martha Luebke, AA, BA High Tech Institute Pat Moeck, PhD, MBA, BA University of North Texas Della Moon, AA San Jacinto College John E. Nurge, M.Ed. CCI Training Center, Inc. Sheba Schlaikjer, BA, RHIT Colorado Tech University Shirley Eittrein Shaw, MA Northland Pioneer College Anna M. Slaski, JD International Institute of the Americas Jim Wallace, MHSA Maric College Technical Editing/Accuracy Panel A panel of instructors completed a technical edit and review of all content in the book page proofs to verify its accuracy, along with the supplements. Jennifer de Zayas Carmean, MBA, CPC, CPC-H, CCS-P American InterContinental University Betty Haar, BS, RHIA Kirkwood Community College Lucinda S. Neville, RN, CPC DuBois Business College Debbie Milton, CPC Northern Maine Community College Kimberly S. Poag, MHA Ed, CMA, CPC Baker College Sheba Schlaikjer, BA, RHIT Colorado Technical University xv