Let's Code It! 2022-2023 Code Edition

Let’s Code It! provides a 360-degree learning experience for anyone interested in the field of medical coding, with strong guidance down the path to coding certification. It is designed to give your students the medical coding experience they need in order to pass their first medical coding certification exams, such as the CCS/CCS-P or CPC/COC. This product is part of a multipart series that instructs students on how to become proficient in medical coding—a health care field that continues to be in high demand. Cover Let’s Code It!: 2022–2023 CODE EDITION About the Authors Brief Contents Contents Guided Tour Preface Acknowledgments Part I: Medical Coding Fundamentals Chapter 1: Introduction to the Languages of Coding 1.1: The Purpose of Coding 1.2: Diagnosis Coding 1.3: Procedure Coding 1.4: Equipment and Supplies Chapter Summary and Review Chapter 2: Abstracting Clinical Documentation 2.1: For Whom You Are Reporting 2.2: The Process of Abstracting 2.3: Deconstructing Diagnostic Statements 2.4: Identifying Manifestations, Co-morbidities, and Sequelae 2.5: Reporting External Causes 2.6: Deconstructing Procedural Statements 2.7: How to Query Chapter Summary and Review Chapter 3: The Coding Process 3.1: The Coding Process Overview 3.2: The Alphabetic Indexes 3.3: The Tabular List, Main Section, Tables, and Alphanumeric Section 3.4: The Official Guidelines 3.5: Confirming Medical Necessity Chapter Summary and Review Part II: Reporting Diagnoses Chapter 4: Introduction to ICD-10-CM 4.1: Introduction and Official Conventions 4.2: ICD-10-CM Official Guidelines for Coding and Reporting 4.3: The Alphabetic Index and Ancillaries 4.4: The Tabular List 4.5: Which Conditions to Code 4.6: Putting It All Together: ICD-10-CM Basics Chapter Summary and Review Chapter 5: Coding Infectious Diseases 5.1: Infectious and Communicable Diseases 5.2: Bacterial Infections 5.3: Viral Infections 5.4: Parasitic and Fungal Infections 5.5: Infections Caused by Several Pathogens 5.6: Immunodeficiency Conditions 5.7: Septicemia and Other Blood Infections 5.8: Antimicrobial Resistance Chapter Summary and Review Chapter 6: Coding Neoplasms 6.1: Screening and Diagnosis 6.2: Abstracting the Details about Neoplasms 6.3: Reporting the Neoplastic Diagnosis 6.4: Neoplasm Chapter Notes 6.5: Admissions Related to Neoplastic Treatments Chapter Summary and Review Chapter 7: Coding Conditions of the Blood and Immunological Systems 7.1: Reporting Blood Conditions 7.2: Coagulation Defects and Other Hemorrhagic Conditions 7.3: Conditions Related to Blood Types and the Rh Factor 7.4: Disorders of White Blood Cells and Blood-Forming Organs 7.5: Disorders Involving the Immune System Chapter Summary and Review Chapter 8: Coding Endocrine Conditions 8.1: Disorders of the Thyroid Gland 8.2: Diabetes Mellitus 8.3: Diabetes-Related Conditions 8.4: Other Endocrine Gland Disorders 8.5: Nutritional Deficiencies and Weight Factors 8.6: Metabolic Disorders Chapter Summary and Review Chapter 9: Coding Mental, Behavioral, and Neurologic Disorders 9.1: Conditions That Affect Mental Health 9.2: Mood (Affective) and Nonmood (Psychotic) Disorders 9.3: Anxiety, Dissociative, Stress-Related, Somatoform, and Other Nonpsychotic Mental Disorders 9.4: Physiological Conditions Affecting the Central Nervous System 9.5: Physiological Conditions Affecting the Peripheral Nervous System 9.6: Pain Management Chapter Summary and Review Chapter 10: Coding Dysfunction of the Optical and Auditory Systems 10.1: Diseases of the External Optical System 10.2: Diseases of the Internal Optical System 10.3: Other Conditions Affecting the Eyes 10.4: Dysfunctions of the Auditory System 10.5: Causes, Signs, and Symptoms of Hearing Loss Chapter Summary and Review Chapter 11: Coding Cardiovascular Conditions 11.1: Heart Conditions 11.2: Cardiovascular Conditions 11.3: Hypertension 11.4: Manifestations of Hypertension 11.5: CVA and Cerebral Infarction 11.6: Sequelae of Cerebrovascular Disease Chapter Summary and Review Chapter 12: Coding Respiratory Conditions 12.1: Underlying Causes of Respiratory Disease 12.2: Disorders of the Respiratory System 12.3: Pneumonia and Influenza 12.4: Chronic Respiratory Disorders 12.5: Reporting Tobacco Involvement 12.6: Respiratory Conditions Requiring External Cause Codes Chapter Summary and Review Chapter 13: Coding Digestive System Conditions 13.1: Diseases of Oral Cavity and Salivary Glands 13.2: Conditions of the Esophagus and Stomach 13.3: Conditions Affecting the Intestines 13.4: Dysfunction of the Digestive Accessory Organs and Malabsorption 13.5: Reporting the Involvement of Alcohol in Digestive Disorders Chapter Summary and Review Chapter 14: Coding Integumentary Conditions 14.1: Disorders of the Skin 14.2: Disorders of the Nails, Hair, Glands, and Sensory Nerves 14.3: Lesions 14.4: Prevention and Screenings Chapter Summary and Review Chapter 15: Coding Muscular and Skeletal Conditions 15.1: Arthropathies 15.2: Dorsopathies and Spondylopathies (Conditions Affecting the Joints of the Spine) 15.3: Soft Tissue Disorders 15.4: Musculoskeletal Disorders from Other Body Systems 15.5: Pathological Fractures Chapter Summary and Review Chapter 16: Coding Injury, Poisoning, and External Causes 16.1: Reporting External Causes of Injuries 16.2: Traumatic Injuries 16.3: Using Seventh Characters to Report Status of Care 16.4: Using the Table of Drugs and Chemicals 16.5: Adverse Effects, Poisoning, Underdosing, and Toxic Effects 16.6: Reporting Burns 16.7: Abuse, Neglect, and Maltreatment 16.8: Complications of Care Chapter Summary and Review Chapter 17: Coding Genitourinary, Gynecology, Obstetrics, Congenital, and Pediatrics Conditions 17.1: Renal and Urologic Malfunctions 17.2: Diseases of the Male Genital Organs 17.3: Sexually Transmitted Diseases 17.4: Gynecologic Care 17.5: Routine Obstetrics Care 17.6: Pregnancies with Complications 17.7: Neonates and Congenital Anomalies Chapter Summary and Review Chapter 18: Factors Influencing Health Status (Z Codes) 18.1: Preventive Care 18.2: Early Detection 18.3: Genetic Susceptibility 18.4: Observation 18.5: Continuing Care and Aftercare 18.6: Organ Donation 18.7: Resistance to Antimicrobial Drugs 18.8: Z Codes as First-Listed/Principal Diagnosis 18.9: Social Determinants of Health Chapter Summary and Review Chapter 19: Inpatient (Hospital) Diagnosis Coding 19.1: Concurrent and Discharge Coding 19.2: Official Coding Guidelines 19.3: Present-On-Admission Indicators 19.4: Diagnosis-Related Groups 19.5: Uniform Hospital Discharge Data Set Chapter Summary and Review Chapter 20: Diagnostic Coding Capstone Part III: Reporting Physician Services and Outpatient Procedures Chapter 21: Introduction to CPT 21.1: Abstracting for Procedure Coding 21.2: CPT Code Book 21.3: Understanding Code Descriptions 21.4: Notations and Symbols 21.5: Official Guidelines 21.6: Category II and Category III Coding Chapter Summary and Review Chapter 22: CPT and HCPCS Level II Modifiers 22.1: Modifiers Overview 22.2: Personnel Modifiers 22.3: Anesthesia Physical Status Modifiers 22.4: Ambulatory Surgery Center Hospital Outpatient Use Modifiers 22.5: Anatomical Site Modifiers 22.6: Service-Related Modifiers 22.7: Sequencing Multiple Modifiers 22.8: Supplemental Reports Chapter Summary and Review Chapter 23: CPT Evaluation and Management Coding 23.1: What Are E/M Codes? 23.2: Location Where the E/M Services Were Provided 23.3: Relationship Between Provider and Patient 23.4: Types of E/M Services 23.5: Preventive Medicine Services 23.6: Abstracting the Physician’s Notes 23.7: E/M in the Global Surgical Package 23.8: E/M Modifiers and Add-On Codes 23.9: Special Evaluation Services 23.10: Coordination and Management Services Chapter Summary and Review Chapter 24: CPT Anesthesia Section 24.1: Types of Anesthesia 24.2: Coding Anesthesia Services 24.3: Anesthesia Guidelines 24.4: Time Reporting 24.5: Qualifying Circumstances 24.6: Special Circumstances 24.7: HCPCS Level II Modifiers Chapter Summary and Review Chapter 25: CPT Surgery Section 25.1: Types of Surgical Procedures 25.2: The Surgical Package 25.3: Global Period Time Frames 25.4: Unusual Services and Treatments 25.5: Integumentary System 25.6: Musculoskeletal System 25.7: Respiratory System 25.8: Cardiovascular System 25.9: Digestive System 25.10: Urinary System 25.11: The Genital Systems: Male and Female 25.12: Nervous System 25.13: The Optical and Auditory Systems 25.14: Organ Transplantation 25.15: Operating Microscope Chapter Summary and Review Chapter 26: CPT Radiology Section 26.1: Types of Imaging 26.2: Purposes for Imaging 26.3: Technical vs. Professional 26.4: Number of Views 26.5: Procedures With or Without Contrast 26.6: Diagnostic Radiology 26.7: Mammography 26.8: Bone and Joint Studies 26.9: Radiation Oncology 26.10: Nuclear Medicine Chapter Summary and Review Chapter 27: CPT Pathology & Lab Section 27.1: Specimen Collection and Testing 27.2: Testing Methodology and Desired Results 27.3: Panels 27.4: Blood Test Documentation 27.5: Clinical Chemistry 27.6: Molecular Diagnostics 27.7: Immunology, Microbiology, and Cytopathology 27.8: Surgical Pathology 27.9: Modifiers for Laboratory Coding 27.10: Pathology and Lab Abbreviations Chapter Summary and Review Chapter 28: CPT Medicine Section 28.1: Immunizations 28.2: Injections and Infusions 28.3: Psychiatry, Psychotherapy, and Biofeedback 28.4: Dialysis and Gastroenterology Services 28.5: Ophthalmology and Otorhinolaryngologic Services 28.6: Cardiovascular Services 28.7: Pulmonary 28.8: Allergy and Clinical Immunology 28.9: Neurology and Neuromuscular Procedures 28.10: Physical Medicine and Rehabilitation 28.11: Acupuncture, Osteopathic, and Chiropractic Treatments 28.12: Other Services Provided Chapter Summary and Review Chapter 29: Physicians’ Services Capstone Part IV: DMEPOS & Transportation Chapter 30: HCPCS Level II 30.1: HCPCS Level II Categories 30.2: The Alphabetic Index 30.3: The Alphanumeric Listing Overview 30.4: Symbols and Notations 30.5: Appendices Chapter Summary and Review Chapter 31: DMEPOS and Transportation Capstone Part V: Inpatient (Hospital) Reporting Chapter 32: Introduction to ICD-10-PCS 32.1: The Purpose of ICD-10-PCS 32.2: The Structure of ICD-10-PCS Codes 32.3: The ICD-10-PCS Book 32.4: ICD-10-PCS General Conventions 32.5: Selection of Principal Procedure Chapter Summary and Review Chapter 33: ICD-10-PCS Medical and Surgical Section 33.1: Medical/Surgical Section/Body Systems: Characters 1 and 2 33.2: Medical/Surgical Root Operations: Character 3 33.3: Medical/Surgical Body Parts: Character 4 33.4: Medical/Surgical Approaches: Character 5 33.5: Medical/Surgical Devices: Character 6 33.6: Medical/Surgical Qualifiers: Character 7 33.7: Multiple and Discontinued Procedures in Medical and Surgical Cases 33.8: Medical/Surgical Coding: Putting It All Together Chapter Summary and Review Chapter 34: Obstetrics Section 34.1: Obstetrics Section/Body System: Characters 1 and 2 34.2: Obstetrics Root Operations: Character 3 34.3: Obstetrics Body Parts: Character 4 34.4: Obstetrics Approaches: Character 5 34.5: Obstetrics Devices: Character 6 34.6: Obstetrics Qualifiers: Character 7 34.7: Obstetrics Coding: Putting It All Together Chapter Summary and Review Chapter 35: Placement through Chiropractic Sections 35.1: Reporting Services from the Placement Section 35.2: Reporting Services from the Administration Section 35.3: Reporting Services from the Measurement and Monitoring Section 35.4: Reporting Services from the Extracorporeal or Systemic Assistance and Performance Section 35.5: Reporting Services from the Extracorporeal or Systemic Therapies Section 35.6: Reporting Osteopathic Services 35.7: Reporting from the Other Procedures Section 35.8: Reporting Inpatient Chiropractic Services 35.9: Sections 2–9: Putting It All Together Chapter Summary and Review Chapter 36: Imaging, Nuclear Medicine, and Radiation Therapy Sections 36.1: Reporting from the Imaging Section 36.2: Reporting from the Nuclear Medicine Section 36.3: Reporting from the Radiation Therapy Section 36.4: Sections B, C, and D: Putting It All Together Chapter Summary and Review Chapter 37: Physical Rehabilitation and Diagnostic Audiology through New Technology Sections 37.1: Reporting Services from the Physical Rehabilitation and Diagnostic Audiology Section 37.2: Reporting Services from the Mental Health Section 37.3: Reporting from the Substance Abuse Treatment Section 37.4: Reporting from the New Technology Section 37.5: Sections F–X: Putting It All Together Chapter Summary and Review Chapter 38: Inpatient Coding Capstone Part VI: Reimbursement, Legal, and Ethical Issues Chapter 39: Reimbursement 39.1: The Role of Insurance in Health Care 39.2: Types of Insurance Plans 39.3: Methods of Compensation 39.4: NCCI Edits and NCD/LCD 39.5: Place-of-Service and Type-of-Service Codes 39.6: Organizing Claims: Resubmission, Denials, and Appeals Chapter Summary and Review Chapter 40: Introduction to Health Care Law and Ethics 40.1: Sources for Legal Guidance 40.2: Rules for Ethical and Legal Coding 40.3: False Claims Act 40.4: Health Insurance Portability and Accountability Act (HIPAA) 40.5: Health Care Fraud and Abuse Control Program 40.6: Codes of Ethics 40.7: Compliance Programs Chapter Summary and Review Appendix Glossary Index