Contents. 1. What is Medical coding? (page 1) 2. Medical coding as a career (page 2) 3. Certification exams in Medical coding (page 3-5)

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2 Thank you for subscribing. This ebook is not too long but I am sure you love the content of every page. If for people who are passionate towards learning medical codes and make a beautiful career in medical coding. This ebook has content, which I learnt through my experience in medical coding. I am a CPC certified coder trying to help professional who are serious towards making a career in medical coding. This ebook will take you through some of the basic things, which one should know as a medical coder. Hope this ebook will help you in increasing your knowledge about medical coding. Contents 1. What is Medical coding? (page 1) 2. Medical coding as a career (page 2) 3. Certification exams in Medical coding (page 3-5) 4. What is CPT and ICD codes(page 6) 5. Radiology Facility coding (page 7) 6. Surgery Facility Coding (page 8-11)

3 Page 1 What is Medical Coding? Medical coding is field where medical codes are coded for procedures and diagnosis. The patient with diagnosis is given ICD 9 code and for procedure is given CPT codes. The medical codes define the diagnosis and procedures. These codes are universal codes and used all US in Healthcare and insurance. So, let us learn in short how the whole cycle or the procedure for medical coding takes place. In US, every citizen has a health insurance. The patient when comes to physician never pays to physician, the physician gets paid for the insurance company or payer. The patient comes to physician tells the problem and the physician treats him. This conversation between patient and physician is recorded and converted in text file through medical transcribers. This text files are then forward to medical coders who given codes for diagnosis (problem) and procedure (treatment) given by the physician. The codes are coded in a claim, the claim is submitted to insurance company and once it is cleared, the physician is paid from the insurance company. So, medical coders work in between payer and physician. We have ICD 9 and CPT books available for coding medical codes. There are online software as well to search and fin d these codes. Before coding these codes, one has to be very clear with coding guidelines. Guidelines are given in the beginning of the books and in every chapter. So, to be a good coder he or she should know in and out about guidelines. In addition, these codes are updated every year, so the coders should remain updated while coding medical charts. Along with CPT and ICD9 codes, we also use modifiers with CPT codes. Modifiers are used to modifier any procedure in any procedure is done incomplete or reduced or extra work is done etc. Modifiers are little tricky to use but are very important in medical coding. If they are used incorrectly with CPT codes, if the claim is denied the physician or the doctor will not be get paid. Hence, one should know how to you these modifier along with CPT codes. Below are few modifiers we use regularly- 52- Reduced services 59- Distinct procedures 76- Same procedure done on same day by same physician 77- Same procedure done on same day by different physician

4 26- Professional component Page 2 Medical Coding as a Career Since last decade, this field has grown very fast. I am form India and I have seen the amount of companies has entered into insurance department especially in Medical coding. In addition, the pay or salary is great for life science professional. This field is unique if one is interested in learning new thing every day. Being myself a medical coder, I come across everyday with different medical charts and some charts are very challenging. The amount of knowledge you get is terrific. If you are coding a surgery charts, then you have to think as if you the physician and you are the one operating this surgery. So, the knowledge you get is equal to a doctor. The amount of medical coders has increased significantly in last decade. In India only, Chennai city itself has around five thousands coder, which is quite huge, and it is still increasing. In US also, the medical coders and increasing significantly and if you are AAPC certified coder you can check the AAPC website how many coders are being certified every month. So, it s great if you take medical coding as career. If you are certified a medical coder you have more opportunity to excel in this field. Now, few of the countries are growing medical coding like Philippines, UAE, and India etc. The amount of work outsourced from US to these countries is great. In healthcare, people are going to have disease especially old age so the amount of work will increase exponentially. In addition, US people are more prone to chronic disease like diabetes, hypertension etc. so these disease will be there for whole life. Hence, such patients will have to take medicine every day. So, the whole idea here is the healthcare domain will never sink. The work will keep on increasing and people will get work in the field. So, if you are a medical coder, you will get work every day because people are falling sick and have to take medicine. So, even if there is recession healthcare field won t get affected like other domain. All and all I would suggest to go ahead join a training program on medical coding and enter into this world of medical codes. Also, there are different facilities if one is interested in coding Radiology, Emergency department, surgery, outpatient, inpatient etc. So, we have choices but the difficulty level increase for some facility. But, I will just say that if you are passionate towards working in a field where you will learn every day new things I would suggest to ahead and take medical coding as you career.

5 Page 3 Medical Coding career and AAPC Certification Exams What is Medical coding? In US healthcare the patient are not required to pay any money to there physician for any treatment. The physician is paid by the Insurance company for its fees which are also called payer. So, the whole process is go through a revenue cycle in this healthcare setting and medical coding is a part of the cycle. Now, in US healthcare the patient treatment process is documented in a transcription report by medical transcriptionist and this is followed to medical coders. Now, the medical coders gives specific numeric codes to the diagnosis patient got and the Procedure (like x-ray, CT, MRI etc) performed by the physician. Hence, the coder coding medical charts are called medical coders in the field of medical coding. Codes given for the diagnosis are ICD-9 codes (International Classification of Diseases) and the Procedure codes are called CPT code (Current Procedural Terminology). Now, the question why we are using numeric codes for diagnosis as well as for the procedure performed. To keep the patient information and his demographic report confidential such codes help a lot, since the codes can be understood only by the people having knowledge about medical codes nobody can be able to understand this numeric codes. Also, such numeric codes have particular dollar value, so when the medical coders give some specific code like for one view of chest x-ray, this procedure has some corresponding dollar value which will be paid by the insurance company to the physician. To take medical coding as a career, one to pass a certification exam to become a certified coder. AAPC also called American Academy of Professional Coders ( conduct the exam every year for the fresher and students to become certified coders. The exam have centers around the globe which will help them to take exam in there own country or might in there own city. Exam for Medical coders The basic exam for the medical coder to pass is CPC (Certified Professsional Coder). The exam has 150 mutiple choice questions to finish within a time of 5 hours 30 minutes. The exam results comes within few days after giving the exam. The results can be seen online once you have become the member of AAPC. It has one more attempt free if you failed to pass the exam. After passing the exam the member or the professional having not enough experience are given Apprentice certificate as CPC-A. Once you have gain the required the

6 experience one can send the experience document to AAPC to remove the Apprentice from CPC-A to CPC. CPC exam is mostly focused on outpatient coding hence it is comparatively more easy to pass. Also, many hospitals and healthcare firms prefer mostly CPC certified coders to join there company. Now, one more exam similar to CPC is CPC-H. Most of the things are same in CPC-H except they ask question more on medical billing as well along with medical coding. Hence, medical billing knowledge should also be there while giving this exam. CPC-H certified coders are mostly preferred by the hospital since they have hospital coding which mostly requires CPC- H certified coders. For Interventional Radiology coders, AAPC conduct CIRCC (Certified Interventional Radiology Cardiovascular Coder) exam. CIRCC is basically for coders interested in coding Percutaneous Surgery procedures. This exam also has 150 multiple choice questions but it is one of the tough exam to clear. So, a coder having in and out knowledge about interventional radiology and have experience in coding live charts on these procedure should always go with this exam. CIRCC has more preference and value over CPC and CPC- H since they know the amount of knowledge required to code surgery charts. Along with AAPC there is one more organisation which conduct exams for medical coders called as AHIMA(Americal Health Information Management Association) ( AHIMA has been recognised one the best organization for Coding professional because of the exam they conduct. Exam conducted by AHIMA have more value and recognition than AAPC. One of the exam mostly coders prefer to given from AHIMA is CCS (Certified Coding Specialist). CCS is one the tough exam I have come through to pass in one attempt. The exam has both objective as well as subjective questions. Hence, one cannot do any guess work here to get the write answer like in AAPC exam. CCS is mainly conducted for Inpatient coders but anyone can give this exam. CCS certified coders are always required by hospitals and healthcare firms. In between AHIMA has banned this exam in ASIA continent due to some reasons but now it has again started conducting this exam around the globe. CCS have questions from both outpatient and inpatient background hence one has to have in and out knowledge about the codes and the coding guidelines. Now, after giving you the brief knowledge about these exams I hope coders can go for the exam of there speciality and get certified. Also, let me just add that while preparing these exam coders should not forget about the main coding guidelines given in the beginning of

7 the Coding books. So, always follow the book you will always reach to the correct code. Also, while giving the exam, don't forget to manage your time, because time management is one of the biggest factor during the exam. The time runs like anything while giving the exam, and we are not able to attempt the all questions. Always attempt all the questions mainly in AAPC exams because there no negative marking for wrong answers. I would like to you attempt these exam as soon as possible since with the coming of ICD-10 codes the exam pattern may change and coders have learn many new codes. ICD-10 has alphanumeric codes and number of codes have also been increased significantly. So, to learn these new codes will take time, hence I would suggest to apply for any of these exam before the implementation of the ICD-10.

8 Page 6 CPT and ICD Coding CPT codes are codes for procedures or the treatment given to patient by the physician. There are lot of CPT codes for X-rays, CT, MRI etc.the cpt codes are five digit numerical codes. These codes have a dollar value for each procedure. So, coding an incorrect CPT codes will increase or decrease the dollar value and hence one should be very accurate while coding CPT codes. Cpt Codes are updated every year and coders should always be updated with new CPT codes. ICD codes are used for coding diagnosis codes. The diagnosis codes tell about the final problem the patient was having. Currently we are using ICD 9 codes and are going to use ICD 10 code form October So, slowly we are transition from ICD 9 to ICD 10 codes. The icd 9 codes are all numerical codes but ICD 10 codes are alphanumerical codes. The amount of codes have increased significantly in icd 10 codes. ICD 10-code awareness has already been started and after too much delayed it is going to be used from October ICD codes should be used very carefully. Since, there are particular guidelines for few codes when to used them primary and secondary dx. Always read the book properly. If you know, you book as a friend you can reach out to any code. This will help in clearing certification exam as well since time really matter during exam. Coding CPT and ICD codes are very necessary to get you claim to be paid. Wrong icd and CPT codes lead to denial of the claim. Also, medical coders should follow all the coding guidelines for coding CPT and ICD codes. Coding guidelines are given is CPT and ICD code book. For clearing certification exam, original books for CPT and ICD code book are required. So, always try to code using books not software this will tell which code you have find and how in code book. If you are confident, enough in searching code then you can go ahead and appear for certification exam. CPT and icd codes carry about 80 to 85% question in certification exams, if you answer all these correct you can easily clear these exams.

9 Page 7 Radiology Facility coding Radiology facility consists of procedures like X-ray, CT, MRI, nuclear medicine etc. So, these are very common and performed in almost every patient by the physician. The CPT codes are easy to find in CPT codebook. The amounts of codes are huge but if you are regular radiology coder, you can easily learn these codes. Few example of radiology codes are below Chest x-ray single view Ultrasound Abdomen complete CT lower extremity without contrast MRI upper extremity joint, without contrast Bone scan whole body, Nuclear medicine Duplex scan, venous, extremity, unilateral In radiology, we have CPT code unilateral and bilateral procedure. We can use LT and RT modifier for unilateral procedure to denote the anatomic site. There are some combined codes used in radiology for some anatomic site. For example, we use for abdominal series with one view of chest. Also we have for bilateral ribs with one view of chest. Sample Report of Radiology. CHEST SINGLE VIEW RADIOGRAPH: VIEWS: One views INDICATION: chest pain. FINDINGS: Lungs: Calcified granuloma left midlung. Right basilar density is unchanged. Heart: The cardiac silhouette is normal in size. The thoracic aorta is normal in caliber. Osseous Structures: The osseous structures are unremarkable.support Catheters: Right internal jugular venous catheter tip near the cavoatrial junction. There is no pneumothorax.

10 IMPRESSION:1. No change in right basilar findings. CPT ICD Page 8 Surgery Coding (How to Code different types of Repair) Laceration Repair: CPT Codes are: Simple repair of superficial wounds Intermediate repair of wounds Complex repair of wounds HCPCS Level II Code(s): G0168 Wound closure utilizing tissue adhesive(s) only CPT Definition: The repair of wounds of the skin and subcutaneous tissue utilizing sutures, staples, or tissue adhesives in CPT is classified as simple, intermediate, or complex. One or more of the above mentioned repair materials could be used for the repair. Simple: Superficial wounds of the epidermis, dermis, or subcutaneous tissue without significant involvement of deeper structures. It requires simple one layer closure or suturing. Intermediate: Wounds that require layered closure of one or more of the deeper layers of subcutaneous tissue and superficial (non-muscle) fascia, in addition to the skin closure described under simple repair. Single-layer closure of heavily contaminated wounds requiring extensive cleaning or removal of particulate matter is included under intermediate repair. Complex: Wounds requiring more than layered closure, for instance scar revision, debridement, extensive undermining, stents or retention sutures. Complex repair may include creation of the defect and necessary preparation for its repair or the debridement and repair of complicated lacerations. HCPCS Level II Definition: Wound closure utilizing tissue adhesive only. SUPPORTING DOCUMENTATION:

11 History and physical: The history should describe how and when the wound occurred. The physical examination should include a description and location of all wounds including their measurements in centimeters (cm) and their depth. The following table of inches and the metric equivalents may be helpful if the wound length is documented in inches. The conversion to centimeters is necessary for the proper CPT code assignment. 1 inch = 2.5 cm /16 inches = cm /16 inches = cm 4 15/ /8 inches = cm 7 15/ /16 inches = cm 11 14/16 inches = over 30.0 cm CODING AND COMPLIANCE ISSUES: When multiple wounds are repaired, add together the lengths of those of the same type of repair, and from all anatomic sites that are grouped together. Report the sum of these lengths as a single code. For example, a patient had three superficial lacerations of the following sites: 3.0-cm cheek wound, 6.5-cm scalp wound, and 3.5-cm neck wound as well a 4.5 cm scalp wound requiring layered closure. The length of the superficial scalp and neck wounds would be added together because these are the same group of sites and the same type of repair making it a 10.0-cm simple repair. Although the second scalp wound would belong to the same group of sites, its length is not added to the other two lacerations because it falls into a different repair classification (intermediate). The cheek laceration would be coded separately because it is in a different group of sites than the other simple repairs. The repair codes assigned in this case are 12032, and The repair of simple wounds using tissue glue/adhesive such as Derma bond should be coded to appropriate repair code. ( ). Wound closure utilizing adhesive strip(s) as the only repair material should be coded using the appropriate E/M code. Simple exploration of nerves, blood vessels, or tendons exposed in an open wound is considered part of the essential treatment of the wound unless appreciable dissection is required. CPT Asst April Integumentary vs. Musculoskeletal Lesions Repairs, specifies simple closures are included in the excision of benign and malignant skin lesions. If an intermediate

12 closure (codes ) or complex closure (codes ) is required, it should be separately reported.complex repairs, codes may be reported with codes for excision of soft tissue tumors if extensive undermining or other techniques are used to close a defect created by the tumors excision. Bone Marrow Aspiration and Bone Marrow Biopsy: CPT Code are as below: Bone marrow aspiration Bone marrow biopsy, needle or trocar G0364 Bone marrow aspiration and biopsy through the same incision on the same date of service Definition: A bone marrow aspiration is the suction removal of fluid and cells from the bone marrow using a needle with the center portion in place (stylet or trocar). A small skin incision is made and the aspiration needle is inserted. When the needle comes in contact with the bone it is rotated slowly clockwise and counterclockwise until the bone marrow cavity is penetrated. Once the cavity has been entered the stylet/trocar is removed, a syringe is attached to the needle and bone marrow is aspirated by withdrawing the plunger of the syringe. A bone marrow biopsy is the removal of a small piece of the bone marrow tissue using a needle with the center portion (stylet/trocar) removed. The approach for the bone marrow biopsy is the same as for the aspirate. As the needle is rotated through the bone, into the bone marrow cavity, a core is cut which is retained inside the needle. The most common site used for a bone marrow aspirate or biopsy is the posterior ilium (pelvic bone) because it is readily accessible from the lower back and is frequently marked by small dimples on either side of the spine. Other sites that may be used are the anterior (front) pelvic bone, or the sternum, although needle biopsy should not be performed on the sternum due to the risk of cardiac injury. SUPPORTING DOCUMENTATION: History and Physical: A full history and physical should be obtained from the referring physician detailing the signs, symptoms and conditions that deem the biopsy and/or aspirate necessary. The physician should be aware of all medications the patient may be taking.

13 Final Note/Summary: The final note should indicate the procedure(s) performed, the site of the aspirate and/or biopsy, and the final pathology findings. Follow up and treatment options should also be documented. Indications / Associated Pathology: Anemia Fever of unknown origin Infection Abnormal blood test results Bone marrow fibrosis Blood cell disorders (leukopenia, leukocytosis, thrombocytopenia, thrombocytosis, etc.) Myeloma Lymphoma Leukemia Bone grafting