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Table of ConTenTs vii
In Vivo (e .g ., Transcutaneous) Medical Genetics and Genetic Part V: Insurance

Laboratory Procedures . . . . . . .756 Counseling Services . . . . . . . . . .791
Other Procedures . . . . . . . . . . . . . .757 Central Nervous System
and Reimbursement
Reproductive Medicine Assessments/Tests (e .g ., Overview 807
Procedures . . . . . . . . . . . . . . . . .757 Neuro-Cognitive, Mental
Status, Speech Testing) . . . . . . .791 Chapter 19: Insurance and
Proprietary Laboratory Analyses . .758
Health and Behavior Assessment/ Reimbursement 808
Chapter 18: CPT Medicine 765 Intervention . . . . . . . . . . . . . . . . .792 Third-Party Payers . . . . . . . . . . . 811
Overview of Medicine Section . .766 Hydration, Therapeutic, Prophylactic, Health Insurance Marketplace . . . . 815
Diagnostic Injections and Types of Third-Party Payers . . . . . 817
Medicine Section Guidelines . . .766 Infusions, and Chemotherapy and
Other Highly Complex Drug or Health Care Reimbursement
Add-On Codes . . . . . . . . . . . . . . . .767
Highly Complex Biologic Agent Systems . . . . . . . . . . . . . . . . . . . 823
Separate Procedures . . . . . . . . . . .767
Administration . . . . . . . . . . . . . .792 Prospective Payment Systems, Fee
Unlisted Service or Procedure . . . .767
Photodynamic Therapy . . . . . . . . .796 Schedules, and Exclusions . . . . .823
Special Report . . . . . . . . . . . . . . . .767
Special Dermatological Case-Mix Analysis, Severity of
Imaging Guidance . . . . . . . . . . . . .768 Illness (SI), and Intensity of
Procedures . . . . . . . . . . . . . . . . .796
Supplied Materials . . . . . . . . . . . . .768 Services (IS) Systems . . . . . . . . .838
Physical Medicine and
Medicine Subsections . . . . . . . .768 Physician Documentation for
Rehabilitation . . . . . . . . . . . . . . . .796
Immune Globulins, Serum or Medical Necessity of Medicare
Medical Nutrition Therapy . . . . . . .797
Recombinant Products . . . . . . .769 Part A Hospital Inpatient
Acupuncture . . . . . . . . . . . . . . . . . .797 Admissions . . . . . . . . . . . . . . . . .839
Immunization Administration for
Vaccines/Toxoids . . . . . . . . . . . .770 Osteopathic Manipulative Critical Pathways . . . . . . . . . . . . . .840
Treatment . . . . . . . . . . . . . . . . . . .797
Vaccines, Toxoids . . . . . . . . . . . . .770 Revenue Cycle Management . . . . .840
Chiropractic Manipulative Impact of HIPAA on
Psychiatry . . . . . . . . . . . . . . . . . . . .771 Treatment . . . . . . . . . . . . . . . . . . .798
Biofeedback . . . . . . . . . . . . . . . . . .773 Reimbursement . . . . . . . . . . . . . 846
Education and Training for Patient
Dialysis . . . . . . . . . . . . . . . . . . . . . .773 Self-Management . . . . . . . . . . . .798 Health Care Access, Portability,
Gastroenterology . . . . . . . . . . . . .776 and Renewability . . . . . . . . . . . . .846
Non-Face-to-Face Nonphysician
Ophthalmology . . . . . . . . . . . . . . . .777 Services . . . . . . . . . . . . . . . . . . . .798 Preventing Health Care Fraud
and Abuse . . . . . . . . . . . . . . . . . .847
Special Otorhinolaryngologic Special Services, Procedures, and
Services . . . . . . . . . . . . . . . . . . . .778 Administrative Simplification . . . . .855
Reports . . . . . . . . . . . . . . . . . . . .799
Cardiovascular . . . . . . . . . . . . . . . .779 Privacy and Security Rules . . . . . .860
Qualifying Circumstances for
Noninvasive Vascular Anesthesia . . . . . . . . . . . . . . . . . .799 Medical Liability Reform . . . . . . . .862
Diagnostic Studies . . . . . . . . . . .785 Moderate (Conscious) Sedation . .799
Pulmonary . . . . . . . . . . . . . . . . . . .786 Other Services and Procedures . .800 Appendix I: E/M CodeBuilder 869
Allergy and Clinical Immunology . .786 Home Health Procedures/ Bibliography 874
Endocrinology . . . . . . . . . . . . . . . .787 Services . . . . . . . . . . . . . . . . . . . .800
Neurology and Neuromuscular Medication Therapy Management
Glossary 875
Procedures . . . . . . . . . . . . . . . . .788 Services . . . . . . . . . . . . . . . . . . . .800 Index 905
Ischemic Muscle Testing and
Guidance for Chemodenervation 789
02809_fm_ptg01.indd 7 11/1/18 12:03 PM

LIST OF TABLES
Table 1-1 Professional Associations Table 10-7 Sample Coding Rules Associated with
Table 1-2 Internet-Based Discussion Boards (Listservs) Intrathoracic Subsection Anesthesia Codes
Table 2-1 ICD-10-CM Tabular List of Diseases and Injuries Table 10-8 Sample Coding Rules Associated with Spine
and Spinal Cord Subsection Anesthesia Codes
Table 2-2 ICD-10-CM Index to Diseases and Injuries
Table 10-9 Sample Coding Rules Associated with Upper
Table 2-3 Value Assigned to Each Character in a Abdomen Subsection Anesthesia Codes
7-Character ICD-10-PCS Code
Table 10-10 Sample Coding Rules Associated with Lower
Table 4-1 Portion of Chapter-Specific Coding Abdomen Subsection Anesthesia Codes
Guidelines Table of Contents from
ICD-10-CM Official Guidelines for Table 10-11 Sample Coding Rules Associated with
Coding and Reporting Perineum Subsection Anesthesia Codes
Table 4-2 Organisms Table 10-12 Sample Coding Rules Associated with
Radiological Procedures Subsection
Table 5-1 Medical and Surgical Section Root Anesthesia Codes
Operations and Definitions
Table 10-13 Sample Coding Rule Associated with Burn
Table 6-1 Medical Specialties Excisions or Debridement Subsection
Table 6-2 Freestanding, Hospital-Based, and Anesthesia Codes
Hospital-Owned Ambulatory Facilities Table 10-14 Sample Coding Rule Associated with
Table 7-1 Categories of HCPCS Level II Temporary Codes Obstetric Subsection Anesthesia Codes
Table 8-1 CPT Modifiers in a Quick View Format Table 10-15 Sample Coding Rules Associated with Other
Procedures Subsection Anesthesia Codes
Table 8-2 Organization of CPT Modifiers According
to Reporting Similarity Table 11-1 Subheadings Typically Organized Below
CPT Surgery Subsections
Table 8-3 Partial Listing of National Correct Coding
Initiative (NCCI) Edits Table 11-2 Integumentary Procedures and Definitions
Table 9-1 History Elements, Definitions, and Examples Table 11-3 Medical Terms for Adjacent Tissue Transfer/
Rearrangement, Flap, and Graft Procedures
Table 9-2 Physical Examination Elements and Examples
Table 11-4 Adjacent Tissue Transfer or Tissue
Table 9-3 Complexity of Medical Decision Making
Rearrangement Methods and Definitions
Table 9-4 Critical Care Services: Total Duration
Table 11-5 Types of Codes for Tissue Rearrangement,
of Critical Care and Codes
Free Skin Grafts, and Flaps
Table 9-5 Prolonged Services Without Direct
Table 12-1 Types of Fractures, Joint Injuries, and
Patient Contact: Total Duration of Services
Fracture Treatment
and Codes
Table 13-1 Coding Central Venous Access Catheters
Table 9-6 Psychiatric Collaborative Care Management
and Devices
Services: Total Duration of Care and Codes
Table 16-1 Type of Radiologic Guidance and the
Table 10-1 Sample Portion of Anesthesia Base Unit Values
Purpose of Each
Table 10-2 Sample Portion of Modifying Units and
Table 18-1 Gastroenterology Procedures and Services
Relative Values
Table 19-1 Claims and Coding Systems According to
Table 10-3 Sample Portion of Locality-Specific
Type of Health Care Setting
Anesthesia Conversion Factors
Table 19-2 Prospective Payment Systems and
Table 10-4 Sample Coding Rules Associated with Head
Fee Schedules, Year Implemented,
Subsection Anesthesia Codes
and Prospective Rate Type
Table 10-5 Sample Coding Rules Associated with Neck
Table 19-3 Resource Utilization Groups (RUGs) Categories
Subsection Anesthesia Codes
Table 19-4 Sample Hospice Payment System Rates
Table 10-6 Sample Coding Rules Associated with
Thorax (Chest Wall and Shoulder Girdle) Table 19-5 National Correct Coding Initiative (NCCI)
Subsection Anesthesia Codes Terms and Definitions
viii
02809_fm_ptg01.indd 8 11/1/18 12:03 PM

PREFACE
Introduction
Accurate coding is crucial to the successful operation of any health care facility or provider’s office because
reported codes determine the amount of reimbursement received. The annual (and sometimes more frequent)
revision of coding guidelines and payer requirements serve to challenge coders. Those responsible for assigning
and reporting codes in any health care setting require thorough instruction in the use of the ICD-10-CM, ICD-10-
PCS, CPT, and HCPCS level II coding systems. Students who are completing formal coursework as part of an
academic program and experienced coders who are already employed in the health care field will find that 3-2-1
Code It! provides the required information in a clear and comprehensive manner.
Due to the comprehensive nature of the 3-2-1 Code It! textbook, instructors may choose to cover its content
in more than one course.
●● Chapters 1 through 6 could be taught in an ICD-10-CM and ICD-10-PCS coding course.
●● Chapters 7 through 18 could be taught in a CPT and HCPCS level II coding course.
●● Chapter 19 could be included as required reading in an insurance and reimbursement course, either as an
introductory or summary chapter.
Instructors for medical assistant (MA) and medical office administration (MOA) programs may choose to
cover the following chapters only in their coding course(s):
●● Chapters 2 through 4, and 7 in an ICD-10-CM, and HCPCS level II coding course (ICD-10-PCS is not used
for outpatient or physician office coding.)
●● Chapters 8 through 9, selected sections of 11 through 15, and 16 through 18 in a CPT coding course
NOTE:
Your academic program’s community of interest (e.g., employers of graduates) will determine which sections of Chapters 11 through
15 (CPT Surgery) should be covered in your CPT coding course. Likewise, if your graduates obtain employment assigning and
submitting CPT Anesthesia codes, your course should include Chapter 10. If your graduates do not assign radiology or pathology/
laboratory codes during their employment, Chapters 16 and 17 can be excluded from your CPT coding course.
Instructors can refer to the Instructor’s Manual for sample course syllabi that organize textbook content into
one or two courses. For example, the syllabus for a one-semester course includes content from 3-2-1 Code It!
appropriate for an introductory course.
The 3-2-1 Code It! text requires users to have access to paper-based coding manuals (ICD-10-CM, ICD-10-
PCS, HCPCS level II, and CPT) because they are used as references when coding rules are explained and for
completing exercises and reviews in each chapter.
NOTE:
Dental codes (D codes) are copyrighted by the American Dental Association. Purchase of a separate Current Dental Terminology
(CDT) coding manual is required to assign dental codes.
The intended use of 3-2-1 Code It! is for:

●● Academic programs in coding and reimbursement, health information management, medical assisting,
medical office administration, and so on
ix
02809_fm_ptg01.indd 9 11/1/18 12:03 PM

x PrefaCe
●● In-service education programs in health care facilities (e.g., physicians’ offices, hospitals, nursing
facilities, home health agencies, hospices), health insurance companies, quality improvement organizations,
and so on
●● Individuals who want to use it for self-instruction to learn how to code or to update their coding skills
●● Health care professionals who need a comprehensive coding reference to assist them in accurately
assigning codes
It is recommended that students complete the following course work before they begin and/or during the
same time they are learning concepts presented in 3-2-1 Code It!:
●● Essentials of health information management
●● Medical terminology
●● Anatomy and physiology
●● Essentials of pharmacology
●● Human diseases/pathophysiology
Organization of This Textbook

This textbook is organized into 19 chapters and one appendix.
NOTE:
Content about long-term care, home health care, and hospice coding is located at the textbook’s Student Companion Site at
http://login.cengage.com.
●● Chapter 1 includes an overview of coding systems used to report inpatient and outpatient diagnoses
and procedures and services to health plans. It also focuses on coding career opportunities in health
care, the importance of joining professional organizations and obtaining coding credentials, the
impact of networking with other coding professionals, and the development of opportunities for career
advancement. Computer-assisted coding (CAC) is also covered.
The corresponding workbook chapter contains high level Bloom’s taxonomy assignments about
validating ICD-10-CM/PCS codes, computer-assisted coding, face validity of data management reports,
physician query process, determining medical necessity, and SNOMED CT.
●● Chapters 2 and 3 cover general ICD-10-CM/PCS coding concepts and provide coding practice. Chapter
3 covers ICD-10-CM official coding guidelines.
●● Chapter 5 is specific to inpatient coding concepts (and not typically covered by academic programs
that focus on outpatient and physician coding), and Chapter 6 is specific to outpatient coding concepts.
Inpatient coding concepts apply to acute care hospitals, and the chapters include ICD-10-CM and ICD-
10-PCS official coding guidelines. Outpatient coding concepts covered include the physicians’ office, and
hospital emergency and outpatient departments. ICD-10-CM/PCS chapters are sequenced before HCPCS
level II and CPT chapters in this textbook because diagnosis codes are reported to justify the medical
necessity of procedures and/or services provided.
●● Chapter 7 covers the HCPCS level II national coding system, which was developed by the Centers for
Medicare & Medicaid Services.
●● Chapters 8 through 18 cover CPT coding concepts. Each CPT section has its own chapter, except for the
Surgery section, which requires five separate chapters.
02809_fm_ptg01.indd 10 11/1/18 12:03 PM

PrefaCe xi
●● Chapter 19 contains a detailed discussion of insurance and reimbursement concepts. (For comprehensive
coverage of third-party payers and reimbursement methodologies, refer to Cengage’s Understanding
Health Insurance: A Guide to Billing and Reimbursement, by Michelle A. Green.)
●● Appendix I contains the E/M CodeBuilder, which can also be downloaded from the Student Companion
Site at http://login.cengage.com and printed for use with Chapter 9 cases to select evaluation and
management (E/M) service codes.
Features of the Textbook

Each textbook chapter contains the following elements:
●● List of topics
●● Key terms
●● Chapter objectives
●● Introduction
●● Exercises
●● Internet links
●● Summary
●● Study checklist
●● Review
Textbook features include:
●● Key terms and learning objectives located at the beginning of each chapter to help organize the material
●● Boldfaced terms throughout each chapter to assist students in learning the technical vocabulary associated
with coding systems
●● Coding tips and notes that highlight important concepts presented in each chapter
●● Exercises after each chapter section that reinforce content presented
●● Multiple choice and coding practice reviews that allow for mastery of coding concepts
New to This Edition

●● The textbook and its ancillaries have been updated to include the latest ICD-10-CM, ICD-10-PCS, CPT, and
HCPCS level II code sets, conventions, and guidelines.
●● Textbook and workbook coding assignments, examples, exercises, and reviews have been updated to
include the most recent ICD-10-CM, ICD-10-PCS, CPT, and HCPCS level II codes. .
●● Answer keys have been updated in the Instructor’s Manual to Accompany 3-2-1 Code It!, which is located
at the Instructor Companion Site (http://login.cengage.com).
●● Chapter 1 includes updated content about professional associations, professional credentials, and
computer-assisted coding (CAC). Exercises about Documentation as a Basis for Coding: Determining
Medical Necessity and Other Classifications, Databases, and Nomenclatures: SNOMED CT were created
for the corresponding chapter in the workbook.
●● Chapter 2 was revised to update ICD-10-CM and ICD-10-PCS content. Content about encoders and
computer-assisted coding (CAC) was revised and expanded. Content about ICD-9-CM as a legacy
classification system content was also updated.
●● Chapter 3 includes updated content about coding conventions in ICD-10-CM and ICD-10-PCS, and examples
allow educators and students to compare the use of conventions in the classification systems. Examples,
exercises, and the chapter review have also been updated.
02809_fm_ptg01.indd 11 11/1/18 12:03 PM

xii PrefaCe
●● Chapter 4 includes updated content about the ICD-10-CM Official Guidelines for Coding and Reporting.
Exercises and the chapter review have also been updated. New examples have been added throughout
content about ICD-10-CM chapter coding guidelines.
●● Chapter 5 includes updated content about inpatient ICD-10-CM diagnosis coding guidelines and
inpatient ICD-10-PCS procedure coding guidelines. Examples, exercises, and the chapter review were
also updated.
●● Chapter 6 contains updated content about outpatient ICD-10-CM diagnosis coding guidelines.
Examples, exercises, and the chapter review have also been updated.
●● Chapter 7 contains updated content about HCPCS level II coding. Examples, exercises, and the chapter
review have also been updated.
●● Chapter 8 contains updated introductory content about CPT coding. Examples, exercises, and the chapter
●● Chapter 9 contains updated content about CPT’s evaluation and management (E/M) section. Examples,
exercises, and the chapter review have also been updated.
●● Chapter 10 contains updated content about CPT’s Anesthesia section. Examples, exercises, and the
chapter review have also been updated.
●● Chapters 11 through 15 contain updated content about CPT’s Surgery section. Examples, exercises, and
the chapter review have also been updated.
●● Chapter 16 contains updated content about CPT’s Radiology section. Examples, exercises, and the
●● Chapter 17 contains updated content about CPT’s Pathology and Laboratory section. Examples, exercises,
and the chapter review have also been updated.
●● Chapter 18 contains updated content about CPT’s Medicine section. Examples, exercises, and the chapter
●● Chapter 19 contains updated content about insurance and reimbursement. Examples, exercises, and the
●● Appendix I contains an E/M CodeBuilder (also available on the Student Companion Site), which can be
used with Chapter 9 to assign evaluation and management codes.
Supplements
The following supplements accompany this text:
●● Instructor Companion Site ●● Student Companion Site at
●● Student Workbook http://login .cengage .com
●● MindTap at http://login .cengage .com
Instructor Companion Site

Spend less time planning and more time teaching with Cengage’s Instructor Companion Site to Accompany the
Seventh Edition of 3-2-1 Code It! As an instructor, you will have access to all of your resources online, anywhere
and at any time. All instructor resources can be accessed by going to http://login .cengage .com to create a
unique user login. Contact your sales representative for more information. Online instructor resources at the
Instructor Companion Site are password-protected and include the following:
●● The Instructor’s Manual consists of seven sections:
o Section I—Instructor’s Resources
o Section II—Answer Keys to Textbook Chapter Exercises and Reviews
02809_fm_ptg01.indd 12 11/1/18 12:03 PM

PrefaCe xiii
o Section III—Answer Keys to Workbook Assignments and Reviews
o Section IV—Answer Keys to Coding Patient Records (Workbook Appendices A–D)
o Section V—Answer Key to Mock Certified Professional Coder (CPC) Certification Examination (Workbook
Appendix E)
o Section VI—Answer Key to Mock Certified Coding Specialist—Physician (CCS-P) Certification
Examination (Workbook Appendix F)
o Section VII—Answer Key to Mock Certified Coding Specialist (CCS) Certification Examination (Workbook
Appendix G)
●● Cengage Learning Testing Powered by Cognero, a flexible, online system that allows you to author, edit,
and manage test bank content from multiple Cengage Learning solutions; you can also create multiple
test versions in an instant, and deliver tests from your learning management system (LMS), classroom, or
elsewhere.
●● Customizable instructor support slide presentations in PowerPoint® format focus on the most important points
for each chapter.
●● Insurance Billing & Coding Curriculum Guide helps you plan your course using 3-2-1 Code It! and other
coding resources, and also maps content to certification exams.
●● Conversion grids, map the seventh edition to the sixth edition and to competing texts to make adapting
your course to 3-2-1 Code It! a snap.
●● Access to all free student supplements, including additional textbook content.
Student Workbook
(ISBN: 978-1-337-90281-6)
The workbook follows the chapter organization of the text and contains higher-level Bloom’s taxonomy
assignments (that comply with academic program accreditation organization requirements, such as CAHIIM
competencies), including numerous diagnosis/procedure statements and case studies so that students can
practice coding. Each assignment contains a list of objectives, an overview of content relating to the assignment,
and instructions for completing the assignment. The last assignment in each workbook chapter contains review
questions in multiple-choice format to emulate credentialing exam questions. The workbook also contains actual
patient records and mock CPC, CCS-P, and CCS certification examinations.
Student Companion Site

Additional textbook resources for students and instructors can be found online at http://login .cengage .com.
All resources located on the Student Companion Site to accompany 3-2-1 Code It! are free to textbook
users. Student resources include:
●● Revisions to textbook and workbook due to coding changes as they become available
●● E/M Codebuilder (also found in Appendix I of the textbook)
●● Tutorials for how to code patient records (to assist in coding patient records found in Appendices A-D of the
workbook)
●● Extra content about related coding topics, including long-term care, home health care, and hospice
coding
02809_fm_ptg01.indd 13 11/1/18 12:03 PM

xiv PrefaCe
MindTap
(ISBNs: 2-Year Instant Access Code: 9781337902861
2-Year Printed Access Code: 9781337902878
4-Year Instant Access Code: 9781337902885
4-Year Printed Access Code: 9781337902892)
Green’s 3-2-1 Code It! Seventh Edition on MindTap is the first of its kind in an entirely new category: the Personal
Learning Experience (PLE). This personalized program of digital products and services uses interactivity and
customization to engage students, while offering instructors a wide range of choice in content, platforms,
devices, and learning tools. MindTap is device agnostic, meaning that it will work with any platform or learning
management system and will be accessible anytime, anywhere: on desktops, laptops, tablets, mobile phones,
and other Internet-enabled devices.
NOTE:
The numbering of textbook review case studies matches MindTapTM numbering.
This MindTap includes:

●● An interactive eBook with highlighting, note-taking (integrated with Evernote), and more
●● Flashcards for practicing chapter terms
●● Computer-graded activities and exercises
o Self-check and application activities, integrated with the eBook
o Case studies with videos

●● Easy submission tools for instructor-graded exercises
●● Medical Coding Trainer software for a real-world interactive coding experience
●● Computer-assisted coding (CAC) cases
Optum360TM EncoderPro.com
Go to www .EncoderPro .com to register for a 30-day free trial of EncoderPro.com Expert, which automates the
ICD-10-CM, ICD-10-PCS, CPT, and HCPCS level II coding manuals. (ICD-10-CM and ICD-10-PCS crosswalks for
ICD-9-CM codes are also included.)
Students should not register for the 30-day free trial until instructed to do so by faculty. Students should use
paper-based coding manuals to learn how to assign codes. Then, www .EncoderPro .com software can be used
to assign codes for exercises as assigned by the instructor.
A Note About CPT Coding

Manual Editions
Every attempt is made to make the material within this textbook and its ancillary products (e.g., Workbook,
Instructor’s Manual) as current as possible by updating to CPT 2019 just prior to publication.
02809_fm_ptg01.indd 14 11/1/18 12:03 PM

ABOUT THE AUTHOR
Michelle A. Green, MPS, RHIA, FAHIMA, CPC, has been a college

professor since 1984. She taught traditional classroom-based
courses until 2000 at Alfred State College, when she transitioned
all of the health information management and coding courses to
an Internet-based format. In 2016, she began teaching for the
health information management program at Mount Wachusett
Community College, Gardner, Massachusetts. In 2017, she also
began teaching for the health information technology program
at Mohawk Valley Community College, Utica, New York. Prior to
1984, she worked as a director of health information management
at two acute care hospitals in Florida’s Tampa Bay area. Both
positions required her to assign codes to inpatient cases. Upon
becoming employed as a college professor, she routinely spent
the semester breaks coding for a number of health care facilities
so that she could further develop her inpatient and outpatient
coding skills.
xv
02809_fm_ptg01.indd 15 11/1/18 12:03 PM

REVIEWERS
Content Reviewers
Monica Carmichael, MHSA, MHRM, CPC Patricia King, MA, BS, RHIA
Director of Business Management and Online HIM Faculty
International Trade Sullivan University
Medical Billing and Coding/Miller Motte Louisville, KY
Technical College
North Charlston, NC Cheryl A Miller MBA/HCM
Assistant Professor/Program Director
Carol Dantzler Westmoreland County Community College
Instructor Youngwood, PA
HIT/HCC
Donna Sue M . Shellman EdS, CPC
Judy Hurtt Program Coordinator, Medical Programs & Instructor,
Instructor, East Central Community College Office Systems Technology
Decatur, MS Gaston College
Dallas, NC
Natunya D . Johnson
Ed .S, MBA, CPC
Department Chair of Business and Office Technology
Holmes Community College
Ridgeland, MS
Technical Reviewer
Marsha Diamond, CCS, CPC, COC, CPMA
Instructor
City College
Altamonte Springs, Florida
and
Manager
Coding Compliance, Physician/Outpatient Services
Medical Audit Resource Services, Inc.
Orlando, Florida
xvi
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ACKNOWLEDGMENTS
In memory of my son, Eric, who always kept me “on task” by asking, “How much did you get finished in the
chapter today, Mom?” Thank you for truly understanding my need to pursue my passion for teaching and writing.
You always proudly introduced me as your mom, the teacher and writer. You remain forever in my heart, Eric. A
special thank you to my brother, Dave Bartholomew, for his encouragement and help. You are my rock!
To my students, located throughout the world! You always ask me the toughest coding questions, and you
also make me want to find the answers. You are truly critical thinkers!
To my technical reviewer, Marsha Diamond, thank you for your incredible attention to detail!
To Kaitlin Schlicht, Instructional Designer, for her invaluable support, patience, and guidance!
To Stephen Smith, Product Team Manager, for patiently listening to all of my concerns about the revision
process!
To the incomparable Kara DiCaterino, Senior Content Manager, what can I say? You are simply the best!
To my mom, Alice B. Bartholomew, for her support and assistance. Between writing real-life case studies for
my textbooks and having originally helped me select a health care career, your guidance is appreciated beyond
words.
Special appreciation is expressed to Optum360 Publishing Group for granting permission to reprint selected
images, tables, and pages from:
●● Coder’s Desk Reference for Diagnoses
●● Coders Desk Reference for Procedures
●● Coding & Payment Guide for Anesthesia Services
●● EncoderPro.com
●● HCPCS Level II Professional
●● ICD-10-CM Professional
●● ICD-10-PCS Professional
Michelle A. Green, MPS, RHIA, FAHIMA, CPC
Feedback
Contact the author at michelle .ann .green@gmail .com with questions, suggestions, or comments about the
text or its supplements. Please realize that the publisher (www .cengage .com) authorizes the release of the
Instructor’s Manual (with coding answers) to educators only. The publisher also posts an AAPC CEU exam on the
Student Companion Site.
xvii
02809_fm_ptg01.indd 17 11/1/18 12:03 PM

CHAPTE
2
R
Introduc
tio
HOW TO USE THIS TEXT ICD-10-C n to
M
ICD-10-P and
CS Codi
ng
Chapter Outline and Key Terms Chapter
Outline
Overview
The Chapter Outline organizes the chapter material of ICD-10-
CM and IC
ICD-10-C D-10-PCS
at a glance. The Key Terms list represents new M Tabula
r List of D Official IC
ICD-10-C iseases an D-10-CM
M Index to d Injuries and ICD-1
vocabulary in each chapter. Each term is highlighted Diseases for Codin
g and Rep 0-PCS G
uidelines
ICD-10-P and Injurie ICD-9-CM or ting
CS Index s
in color in the chapter, where it is also defined and and Tables Legacy C
oding Sys
tem
used in context. A complete definition of each term Chapter
Objectiv
appears in the Glossary at the end of the textbook. At the conc
es
lusion o f this cha
1. Define pter, the
key terms student s
Objectives 2. Explain
the purpos
related to
the introd
uction of
hould be
able to:
3. Locate e of assign ICD-10-C
ing ICD-1 M and IC
The Objectives list the outcomes expected of 4. Assign
main term
s for diagnostic 0- CM an d ICD-10- D -10-PCS co
diagnosis statemen PCS code ding.
the learner after a careful study of the chapter. Tabular Li codes us
st of Disea
ing the IC
ts using th
e ICD-10-
CM Index
s.
D-10-CM
5. Assign ses and In Index to D to Disease
Read the objectives before reading the chapter procedur
e codes us
juries. iseases an
d Injuries
s and Inju
ries.
6. Explain ing the IC and the IC
content. When you complete the chapter, the import D-10-PCS D-10-CM
and repo an ce of appl In dex
rting. ying ICD-1 an d Tables.
0-CM and
read the objectives again to see if you can 7. Use ge
neral equi ICD-10-P
CS guidel
valence m ines for co
say for each one, “Yes, I know that.” If you Key Term
appings (G
EMs) as pa ding
rt of the IC
cannot say this about an objective, go back s D-9-CM
legacy co
ding syst
category em.
to the appropriate content and reread. These cooperat ICD-10 C
ing parties oordinatio
n
outcomes are critical to a successful career as for the IC
D-10-CM
/
and Maint
enance Medicare
Prescriptio
PCS Committee Drug, Impr n Official IC
an insurance specialist. encoder Index to D and Moderni
ovement, D-10-
Guidelines PCS
iseases an zation for Codin
In ju d Ac t (MMA)
CHAPTER 2: Introduction to ICD-10-CM encoand unteICD-10-PCS
r Coding 47 ries and Repor
ting
g
essential Internatio morbidity placeholde
mod na l C lassificatio r
ng Guid ifi
eline er
s 103 of Diseases n
M Codi mortality subcateg
CHA PTER 4: ICD-10-C etiology (ICD)
Introduction general eq
legacy cla
ssification
sy st
nonessen
tia
subterm
ory
uiva
one le legacy co em l modifier
sec tion s and nc e Ta
anized into four mClassification
International apping (G ding system Official IC bular List
There are two related classifications of diseases
for Coding and Rep
with similar
orting aretitles.
orgThe EM) of Diseases D-10- of Disease
(ICD) -10-CM Offi
is published theGui
bycial delines
World Health Organization in Cha used5.)to classify mortality (death) data from ain term
is pter
m Guidelines CM and Injurie s
The ICD
ure cod ing guid elines are (WHO)
located and
ly to the and Repor
for Codin
g
s
death certificates.
ix. (ICD -10- PCS WHO proced
published the tenth revision of ICD in 1994 with a new
eral name,
guid elin es that app Statistical
International tin
app end sification and gen g
s of the clas
ventionProblems, they are arra nged in
Classification ofude Diseases
s the struand e and con
cturRelated Health and reorganized the cha pters ascategories.
its 3-digit (Although the
●● Section I incl ic guid
ecifthe that correspond to
elinesabbreviation
name of the sific publication
atio n and was
cha pter -sp
changed, familiar ICD was kept.)
entire clas
Theclas
the sification. Classification of Diseases, Tenthcipa
International Revision,
l diagnos Clinical
is for nonModification settings.
outpatient (ICD-10-CM) was developed Introduction
elin es fortosele n of the prin
ctioand facilities , hom e hea lth care agencies,
in●●the United States
Section II includes guid
and is used code classify morbidity
-term care (disease) data from inpatient and outpatient
records, including
tpatient settphysician ude acu
ings incloffice te care
records.
hos pita ls, long
ICD-10-CM is anos is is disc
closed ussed in Cha
classification pter
system
5.)
that is used in the United The Introduction provides a brief
(Nonou
(The sele ction of principal diag ns, comeachplications)
Statesnursto ingclassify and so on.)which
homes,diagnoses, means that ICD-10-CM provides
es (e.g., just
coexist conditio
oneingplace to classify condition. overview about major topics covered in
add ition al diag nos
guidelin for reporting
es ICD-10-CM ed in Chapter 5.)
●● All
Sechealth caredes
tion III inclu settings use to reportdiag noses is disc
diagnoses. Theuss International Classification of Diseases,
nt sett ings . (The coding of additional . (Ou tpat ient diag nosis coding is the chapter. The introduction (and the
Tenth outpatie
Revision,
in non Procedure Classification System (ICD-10-PCS) ing and reporting
is used to code and classify procedure data
for outp
elinesonly. atient diagnosis cod
from hospital inpatient
●● Section IV incl
udes guidrecords (ICD-10-CM and ICD-10-PCS are abbreviated as ICD-10-CM/PCS.)
is discussed in
objectives) provides a framework for your
6.)
discussed in Chapter elines. (POA reporting
ent on adm issio n (POA) reporting guid study of the content.
●● App NendOT : udes pres
ixEI incl
urate
Chapter 19.) g complete and acc
the coder is essential to achievin were
andICD-10-CM
vider use guidelines
Provider offices and health care hea
A
procedures. rt betw
joint effo(Provider een the facilities
lth
offices and outpatient
(e.g., pro
care
ent, and health
hospitals)
of diaguse
care settings
reporting
to code diagnoses. Hospitals
es and
nosCPT pro ced ures .
and HCPCS level II to code
The
tifying diagnoses and
useing
cod ICD-10-PCS
procedurespro andced
to code
ures that
services.)
inpatient
Notes
e assignm
umentation,
docICD-10-CM and cod
ICD-10-PCS are abbreviated as ICD-10-CM/PCS.r and the coder in iden is crucial
ass ist both the health care provide ume ntat ion in the patient record Notes appear throughout the text and
develop ed to sistent, complet e doc rd must
The importance of con ition, the entire reco
are to be reported. be achieved. In add
ntat ion, acc urate coding cannot ns trea ted. (The term encounter serve to bring important points to your
Overview of ICD-10-CM and ICD-10-PCS
because without suc
h doc ume
rmine the specific reas
on for the encounter
and the con ditio
g inpatient hospital
admissions. The term
be reviewed to dete sett ings , incl udin ner who is lega lly attention. The notes clarify content,
ing guid elines for all health care or any qualifiedofhea
lth care practitio
is used in the
ICD-10-CM is acodclinical modificationelin of WHO’s mea n physician Classification
International Diseases, Tenth Revision (ICD-10). The
use d in the coding guid es to refer you to reference material, provide
term vider is is
proclinical used to emphasizepati theent’modification’s
s diag nos is.)intent. This means that the coding system serves as a useful
e for establis hing the
toolacc thetabl
inoun classification of morbidity data for indexing of patient records, reviewing quality of care, and compiling
more background for selected topics, or
basic health statistics. Used to describe the clinical picture of the patient, ICD-10-CM and ICD-10-PCS codes are
more precise
HIPAthan A Ale thosert!needed for statistical groupings and trends analysis. ty payers, including Medicare emphasize exceptions to rules.
s and third-par
ic tran sactions require provider g. Thus, a viola-
ICD-10-CM is divided latio nsinto
for two main
electron parts: for Coding and Reportin
The HIPA A regu
adh ere to the Official Guidelines and MACs do not
-party payers codes,
●● Index
admto inist rative conand
Diseases tractors
ing guid eline
(MA
s is
Cs),
tech
to
Injuries, which is an
nica lly a alphabetical
HIPA A viola tionlist
. of
Bec aus e
termssomande third
corresponding
iate
ropr Causesreim burs eme
and
nt for sub mit-includes HIPAA Alerts
tion of the cod
a Neoplasm Table, Table of Drugs and Chemicals, HIPA A provand
isionan obtaintoapp
, toIndex External lation that
und erst and ) this ision s in the regu
appearList
●● Tabular to beof Diseases
(or
aware of and Injuries, which ismay a sequential,
prov
t out specific list of codes divided
need to poinalphanumeric e and medical care ) cod
into es
chapters The HIPAA Alert feature highlights issues
(and ICD
CMsystem -10-PCS) codes, you ounter for other aftercar
based on -10-
ted ICD body or condition example, the Z51 (Enc and MACs deny
reference the cod ing guid eline s. For
nt care. If third -par ty pay ers related to the privacy and security of
as a first -listed code for outpatie office (located at CMS)
ICD-10-PCS is divided into two
in ICD-10-CM can be repo
rted main parts: or HIPA A enforcement personal health information.
rt Z51 cod es conoftact the regional CMS office
●● Index, which
claims that repo
is an alphabetic list procedures according to general type of procedure (e.g., resection), or a
more resolution. used term (e.g., appendectomy), and includes the first three or four values of the code (or
forcommonly
directs the user to see another term)
●● Tables, which are organized according to sections that contain rows that specify valid combinations of
code values
xviiiExercisand Official Guidelines

– ICD-10-CM (ICD-10-CM/PCS)
ICD-10-CM e 4.1ICD-10-PCS
ding anof Reporti
d Diseases, ng
for Co
The International Classification Tenth Revision, Clinical Modification (ICD-10-CM) and the International
h statement.
plete eacProcedure Coding System (ICD-10-PCS)the are___
abbreviated for ICD-
Classification oftru
Ins
Diseases,
ctions:TenthComRevision, d by _________as ___ICD-10-CM/PCS.
ICD-10-CM/PCS also enhances accurate payment forRep
ing and services are approve
ortingrendered and sfacilitates evaluation ofvide
pro medical in
d withprocesses
Gui deli nes for Cod and inst ruct ions
1. The Official
plem ial convention
officintent,
ent theLearning.
and outcomes. The termto
clinical
acc omp emphasizes
any
Copyright and2020 the
com modification’s
Cengage which
All is to: Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-203
Rights
10-CM
. sett ings,precise g inpatient
includinthan
●● Describe the -10-CMpicture
ICDclinical of the patient, which means___ the
for all health
codes carebe
must more those
elin es use the term ____________ (continues)
needed 2. only for
Codingstatistical
guid groupings and trend analysis.
pita l adm issio ns.
●● Serve as a hosuseful tool in the area of classification of morbidity data for indexing of medical records, medical
care review, and ambulatory and other medical care programs, as well as for basic health statistics.
02809_fm_ptg01.indd 18 11/1/18 12:03 PM

646 PA RT IV: Cu
rre nt Pro ce du
ral Te rm ino log
y (CP T ) Co din g
86 ste m
PART II: ICD-10-CM and ICD-10-PCS Coding Systems
Sy
●● Partial proced
ure: Removal
Complete pr of less than
●●
ocedure: Re 80 percent of
moval of grea the vulvar ar
When an op ICD-10 Alert! ter than 80 pe ea
rcent of the
en sling oper
sling operat ICD-10-PCS doesatnot
ion is perform ion is pe
containrfoinclusion
rmed foterms.
vulvar arHOW
ea TO USE THIS TE X T xix
ed, report co r stress incon
de 51992 fro tinence, repo
m the Urinary rt co de 57288. W
System subs hen a laparos
ection. copic
Coding Tips Codin gT
Lists of ip
inclusion terms are included below certain codes in the ICD-10-CM tabular list. The inclusion terms indicate
Make sure some of the conditions for which that code may be assigned. They may be synonyms with the code title, or, in the
The Coding Tips feature caseyouofre“other
ad CPspecified”
T code decodes,
procedure, scriptiothe terms may also provide a list of various conditions included within a code. The list
of th at otherterms
inclusion in the
uretabular listnsis ca
notreexhaustive.
fully. WhenThe
the index
provides recommendations and repair of cysto proced is not reported code may provide additional terms that may also be assigned
description sta
cele wi
to a given code.
th or without re separately if it tes “with or wi
pair of urethro is pe
70rformed (e.g., thout” another
hints for selecting codes and for The ICD-10-CM disease
57 cele, incsupplement
index is an important luding cystoto the
PA II: IC 57
RT tabular 24
list0,because
-C M an ter itcocontains many
an d ICior
S Codin g
uctio n to ICD-1 0-CM and ICD-10-PC
diagnostic terms that do not appear in the tabular list. The inclusion ro ureth D-10
scoplisted lporrh aptabular
hy, list
CHAP TER 2: Introd terms y, when below
performed).in Co
codes
D-10 -P CS the
the correct use of the coding are not meant to be exhaustive, and additional terms found only in the disease index may also be assigned tos
din g Sy st em
A pelvic to orn This concept is called trust the index, because when you find a term and a code in the
manuals. GORY CODES: Go toifFigur
e 2-2, refer extheaamtabular
Diso
un of newb
rderslist
der an code.
(P07es.3)th
and ia
M CATEGORY AND SUBCATE
pe4-ch
the rfoarac
rmed ter subc
se ategory code
disease
pa ra index, andes is a ro
the term is ut
not
inerepeated
evaluationin the tabular list (below a category or subcategory), that code can
EXAMP LE 1: ICD- 10-C
tion and fetal growth (P05
–P08) secti on, and locat e
is not reporte still be assigned. te ly. This proc
Theed ure islist
tabular incwould
luded be
Exercise
of the surgica
too cumbersome tol use if all disease index terms were included below
related to length of gesta d se pa rately when in all major an 2.6 – ICD
field, and it is repo
the 5-charac ter subc ateg ory code (P07.30). su rg ical procedcategories pe
and subcategories.rformed durin d mos Intstmru -9-CM Le
rted with co
de 57410
ure. g the same
op
inoctr io
gynnes:co
Ulog
se ica
thel pr gacy Cod
En do sc
to the Poiso opy code s
ning by, adve rse effec ts of and erative sess
ion as another fe diagno
ocedures, an
sis GEMd it ing Syste
Examples M 6-CH ARACTER COD
ES: Go to Figur e 2-2, refer
)an aton,
omand l site es (e.r to
icalocat
ar
the 6-charac e reported fo
ter subc ateg ory
r exam
male genital
syste
depicted m
in the tabl
EXAMPLE 2: ICD-10-C gical substances (T36 –T50
secti
EXAMPLE
g.allow
, vulvafor future1: ICD-10-CM ination
TABULAR LISTanOF
dm DISEASES AND INJURIES—INCLUSION TERMS: The following m
inclusion e below to
ing of drug s, medicaments and biolo h also (e.
cont g.
ain, “x”
ca as a placeholde
ncer , va gin
T36 a, ceTabular ag nif ica tio IC complete
unde rdos T36. 0x4, and T36.0x5) , whic
d ,
to tu m
each or s, fromare
terms
code categ ory
located in the rvix utList
er i,of Diseases
an and Injuries n,
forIC an d
diagnosis co code
de M54.5, Low D -9 pain:
back -C M eac
0x3, adde human papi d oviduct/ova D-9-CM Di s distinguis to ICD -10-
Examples appear throughout the text
codes (T36.0x1, T36. 0x2,
e
T36.
the seventh char acter s (A, D, and S), one of whicex h is
am
(e.g.,
to be
ina
T36. tion). and mag
0x1A llo ma virus [HPV ry). Abnorm
ali
ag nosis Code h am ong C M Gener
al
expansion . Then , locat
the condition is a sequ ela)
ut
●● Loin pain
nification. Fo ], and pruritu 07 an
ties of the fe d Descrip Equivalen
unte r or whet her er i (Figure 15-9 r example, s) 8. 81
are com Epidemic m ale genital ntio ce Map
to promote understanding of presented
(depending on status of
enco
). Lumbago NOS ●● laparoscopy
/hysteroscop
monly diag venortigo
sed and tre
system ICD-10-CM ping
When dilation code T36.0x1 Poisoning
078.y 82
is Ep
peidrfo ated with Diagnosis
and referofto th emrm Code and De
concepts. LDER “X” IN
Go to Figur
ICD-10-CM COD approach pr
ES: e 2-2,
holde ocin the 5th-c hara
ecter
vaposit
ginion.
a orThus
ce, rvix is pe 078.88 Othe
edmto
ic vo vissyua
iting ndliz
roemethe corpus A88.1 Epid
emic vertigo sc
PLAC EHO
EXAMPLE 3: USE OF
r
T36.0x1A requires “x”anesth position) is anur
as a place ed e, do code, which is
rformed durin r specified
by penicillins, accidenta
l (unintentional). Code r in the 5th-characteresia is perfoinvalid not report the dilation pr g the same
op er at ive
diseases du
e
R11.11 Vom
01A (with out the “x” place holde
co nt. rm ed
EXAMPLE
during the sa2: ICD-10-CM oc
TABULAR ed ure separate
LIST OF DISEASES AND07 8. se
INJURIES—INCLUSION
89 ss
Other specion as anothe TERMS to Ch
(conditions classified
lamyd e to iti ng without naus
reporting the code as T36. for third-par ty paye r reim for eme
de burs the dilation an me opercodes): ly. Whe ginalcode ia ea
results in a denied claim “other
d cuspecified” subcategory ative seIf the
ss provider documents n a peas
polyalgia lvictheexpatient’s ases dureva
ified disecondition, assign M79.89 A74.89 Othe
incorrect if reported and
In the Cervix even
rettage on
though the codely.description indicates ition is
as a dilation
an other specified an d
code.
cu
aminatio n undetor viruses r chlamydia
l di se as
Uteri heading re ttage (Figure A98.3 Marbu es
with codes 57 , conization 15-10), repo rg virus dise
procedures
520– 57522.
Co nizuri
Inj ationescodes include Exercises
of the cervix
(re moval of a co
rt the A9 8. 4 Eb ola virus di
ase
o sbean pedrformed th
caea se
n als ne-shaped pie sease
Lis52t2).of Dis fulguration, 1. ICD B33.8 Othe
erc ise 2.2 – ICD -10-CM Tabular(57 Make sure yo EXAMPLE rough usINDEX
3: ICD-10-CM e of aExercises
TO DISEASES AND dilatINJURIES
ion an
reinforce d -9-CTABULAR
AND
cu re chapter
M codeLIST
tta
ce of tissue)
07 content.
OF DISEASESis reAND
po INJURIES—
rte d
r specified
viral diseas
Ex u re view the oper
TRUSTriptio
THEnsINDEX: ative re
Locate thepo
co ld
index entry for knife or lasfisher2.tapeworm,
IC52
D-9
ge , and re828.
Then,pa m
toap
goir. thesniz
Co toatICion es
Instructions: Com
plete each stateme
nt.
nges codes andcode desc in rt carefully infection,
to
(57 0)-Corlarval
Mthco B70.1.
ro deh07
ug 8.
loo 81
tabular Dlist to verify
-10- CM code
of Diseases and Injur ies arra B70.1, where you will notice that infection as
due sig
to fish
n 3.
tapeworm,
theICap D-9 larval is not listed p
as ele
m
an inclusion
ap
ct rosde
to term. The coder has __ __ ___________.
____ ____ ____ ___ dise ases and injur ies. pr-C
op Mria te de
co code ex
IC Dcis
-1ion
0-CM code
1. The ICD-10-CM chapters that classify to trust theters
index and assign code B70.1 for the documented condition. 07.8.88 m __________
r, and it contains 21 encoun 4. ICD-10- aps to ICD
alphanumerical orde reported for patient CM code -10-CM co _____.
list codes that are A74.89 m
cha pter of ICD-10-CM tabular ume nted (loca ted in Table 2-1) 5. IC ap de ______
_________.
2. The last dise ase or injury is doc D-10-CM s to ICD-9
when a circumstanc
e othe r than
tact with Health Serv ices code B33 -CM code
encing Health Stat us and Con .8 maps to IC ____________
are called Factors Influ D-9-CM co
de ______
___.
codes. subdivisions.
or _______________ which has no further _________.
3. I10 is an example
of a ________ ____ ___ cod e,
___________ if the Exercise 3.9 – Inclusion Terms
4th, 5th, 6th,
al characters are ____
4. Subcategory cod
es that require addition
Summar
Instructions: Assign an ICD-10-CM code to each statement. Make sure that you appropriately
and/or 7th charact
cha
er(s)
ract
are
ers
abse
of
nt.
“x” in code O40.1xx0 are
___.
called ____________ interpret the use of inclusion terms in the ICD-10-CM tabular list. y
5. The 5th and 6th The Inte
________________ 1. Acute amebic dysenteryrnational C
Intern lassificatio
________________ ational Cla
2. Disseminated blastomycosis n of Disea
ICD-10-C n of Dis ssifica tio ses, 10th
Revision,
as es and Injurie s
________________ 3. Megakaryocytic M/PCS,
(thrombocytic) replacedacute eases, 10th Revisio
leukemia, Clinical M
-C M Inde
Summary x to Dise Hea lth Organ ICD-9-CM n, Proced odification
(ICD-10-C
ICD-10 is an alph abetical list of
________________
main term s and their 4. GM2 gangliosidosis,
m an juvenile
y more co
iz ation’s Inte
rn ational Cla
ef fective O
ctober 20
15
ure Codin
g System
(ICD-1
M) and th
e
(Figu re 2-3) Injuries indented below
qualifiers are de sstype of he . IC s and appl ification of D-10-CM 0-PCS), ab
x to Diseases and , and subterms and ________________ 5. Congenital toxoplasmosis ies to mor Diseases, is a clinical b
The ICD-10-CM Inde The Summary at the end of each chapter recaps the
Main terms are prin
ted in boldfaced type
parts (Table 2-2): ICD-10-C
alth care
encounte e users th
an ICD-9-C
Ninth Rev
ision (ICD modificatio
n of
corresponding codes. sub divid ed into two M Ta bular List r (e.g ., in patient, ou M because -9). ICD-10-C
CM index is Chemicals
main term s. The ICD
key points of the chapter. The summary also serves as a
-10-
includes a Table of
Neoplasms and a Tabl e of Drug s and w ithin chap
ters base
of Diseases
and Injurie
tp atient, ho
spice, hom
it is designed
to collect
M /PCS
●● Index to Diseases
and Injuries, which categorie d on body s contains e health ca data o
s, subcat system or
review aid when preparing for tests.
Cau ses of Injur ies mea ns hyp hen s m ost are fo eg or ie s, and co co nd iti on, and co
21 chapte
rs. It is a sequen
re, and lo
ng -t erm ca
●● Index to External
are listed in alphabe
FI GUhRE
tical order, whic 15 -9al La pa ro llowed by des. ICD-1 des are th tial list of
96 Diseases and Injuries When numeric sc opy/ hystto Diseases a decimal 0-CM dise en organi codes c
PART II: ICD-10-CM and
Main terms in the Inde
x to ICD-10-PCS Coding Systems n term is not ignored. e listed nex t to a er os copy and Inju point and ase and in zed within
but a sing le space within a mai l orde r. A cod qu rie s entries ar be tw ee ju ry co m aj or
within main terms are
igno red, listed in alphabe tica
condition alifiers, an e organize n one and des cons topic h
main term, they are t e for the
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❏● Read this chapter and highlight key concepts. Study Checklist al
❏● Create an index card for each key term. The Study Checklist appears toward the end of
❏● Access the chapter Internet links to learn more about concepts. each chapter and directs you to other learning and
❏● Complete the chapter exercises and review, verifying answers with your instructor. application aids. Completing each of the items in
❏● Complete Workbook chapter, verifying answers with your instructor. the checklist will help you to gain confidence in
your are
❏● Go to http://login.cengage.com to access the Student Companion Web Site. Login instructions understanding of the key concepts and in
located in the Preface.
your ability to apply them correctly.
❏● Form a study group with classmates to discuss chapter concepts in preparation for an exam.
Review
Review Each chapter Review includes multiple-choice
questions and coding practice cases that will test
Matching – ICD-10-CM
your understanding of chapter content and critical
Instructions: Match the format in Column 2 with each line of the ICD-10-CM Index to Diseases and Injuries
entries in Column 1. thinking ability.
ICD-10-CM Index to Diseases and Injuries Format
________ 1. Abnormal, abnormality, abnormalities (see a. 2nd qualifier
________ 2. also Anomaly) b. 3rd qualifier
c. Continuation line
________ 3. Copyright
chromosome, chromosomal
2020 Cengage Q99.9
Learning. All Rights d. Main
Reserved. May not be copied, term or duplicated, in whole or in part. WCN 02-200-203
scanned,
________ 4. sex Q99.8 e. Subterm
________ 5. female phenotype Q97.9
Multiple Choice – ICD-10-CM

02809_fm_ptg01.indd 19Instructions: Circle the most appropriate response. 11/2/18 10:08 AM
NOTES
02809_fm_ptg01.indd 20 11/1/18 12:03 PM

CHAPTER : 1
PA R T
Coding Overview
1: Overview of Coding, 2
02809_ch01_ptg01.indd 1 11/1/18 10:48 AM

CHAPTER
1 Overview of Coding
Chapter Outline
Career as a Coder Other Classification Systems and Databases
Professional Associations Documentation as Basis for Coding
Coding Systems and Processes Health Data Collection
Chapter Objectives
At the conclusion of this chapter, the student should be able to:
1. Define key terms related to the overview of coding.
2. Summarize the training, job responsibilities, and career path for a coder.
3. Differentiate among types of professional associations for coders, health insurance specialists,
and medical assistants.
4. Summarize coding systems and processes.
5. Identify other classification systems and databases.
6. Identify how documentation serves as the basis for assigning codes.
7. Describe health data collection for the purpose of reporting hospital and physician office data.
Key Terms
application service classification system concurrent coding discharge note
provider (ASP) clearinghouse continuity of care documentation
Assessment (A) CMS-1450 Current Procedural document imaging
assumption coding CMS-1500 Terminology (CPT) downcoding
automated case code database electronic health record
abstracting software demographic data (EHR)
coder
automated record Diagnostic and Statistical electronic medical
coding
Centers for Medicare Manual of Mental record (EMR)
coding system
& Medicaid Services Disorders (DSM) encoding
(CMS) computer-assisted
diagnostic/management evidence-based coding
coding (CAC)
claims examiner plan
02809_ch01_ptg01.indd 2 11/1/18 10:48 AM

CHAPTER 1: Overview of Coding 3
evidence-verification International internship supervisor progress notes

coding Classification of jamming provider
HCPCS level II Diseases, Ninth
listserv resident physician
Revision, Clinical
HCPCS national codes Logical Observation RxNorm
Modification
health care (ICD-9-CM) Identifiers Names and scanner
clearinghouse Codes (LOINC)
International sectionalized record
Healthcare Common Classification of manual record
source-oriented record
Procedure Coding Diseases, Tenth medical assistant (SOR)
System (HCPCS) Revision, Clinical
medical coding process specialty coders
health care provider Modification
(ICD-10-CM) medical management Subjective (S)
health data collection software
International Systematized
Health Insurance medical necessity
Classification of Nomenclature of
Portability and
Diseases, Tenth medical nomenclature Medicine Clinical
Accountability Act
Revision, Clinical medical record Terms (SNOMED CT)
of 1996 (HIPAA)
Modification/Procedure teaching hospital
health insurance National Drug Codes
Coding System
specialist (NDC) teaching physician
(ICD-10-CM/PCS)
health plan Objective (O) therapeutic plan
International
hospitalist Classification of online discussion board third-party administrator
Diseases, Tenth overcoding (TPA)
hybrid record
Revision, Procedure third-party payer
indexed patient education plan
Coding System
patient record transfer note
initial plan (ICD-10-PCS)
physician query process UB-04
integrated record International
Classification of Plan (P) unbundling
International
Classification of Functioning, Disability problem list Unified Medical Language
Diseases for Oncology, and Health (ICF) System (UMLS)
problem-oriented record
Third Edition (ICD-O-3) internship upcoding
(POR)
Introduction
This chapter focuses on coding career opportunities in health care, the importance of joining professional
associations and obtaining coding credentials, the impact of networking with other coding professionals, and
the development of opportunities for career advancement. It also provides a coding overview that explains
clinical documentation improvement, the physician query process, and the use of computer-assisted coding
(CAC) and encoder software. Documentation as a basis for coding includes patient record formats and the
importance of establishing medical necessity. Health data collection covers the reporting of hospital and
physician office data using abstracting software, medical practice management software, and CMS-1500 and
UB-04 claims.
NOTE:
This chapter does not require the use of ICD-10-CM, ICD-10-PCS, CPT, or HCPCS level II coding manuals. However, later chapters in
this textbook do require them (because learning how to code is easier when you use paper-based coding manuals). Students should
also learn how to use encoder and computer-assisted coding (CAC) software.
02809_ch01_ptg01.indd 3 11/1/18 10:48 AM

4 PART I: Coding Overview
NOTE:
The following additional content is located on the Student Companion Site at http://login.cengage.com:
● Documentation Requirements for Teaching Physicians 2012
● History of Medical Classification and Coding Systems
● Alternate Health Care Coding Systems
Career as a Coder
A coder acquires a working knowledge of coding systems (e.g., CPT, HCPCS level II, ICD-10-CM, ICD-10-PCS),
coding conventions and guidelines, government regulations, and third-party payer requirements to ensure that all
diagnoses (conditions), services (e.g., office visits), and procedures (e.g., surgery, x-rays) documented in patient
records are coded accurately for reimbursement, research, and statistical purposes. Excellent interpersonal skills
are required of coders because they communicate with providers about documentation and compliance issues
related to the appropriate assignment of diagnosis and procedure/service codes.
NOTE:
Although graduates of medical assistant and medical office administration programs typically do not become employed as full-time
coders, they often are responsible for the coding function in a physician’s office or medical clinic. This chapter provides the following
resources for students pursuing any health-related academic program that includes coding as a job function:
● Professional associations that offer coding and other certification exams
● Internet-based discussion boards that cover coding and other topics
● Impact of HIPAA federal legislation on coding and reimbursement
● Coding references and other resources that facilitate accurate coding
● Physician query process as a way to prevent assumption coding
● Manual and automated patient record formats and health data collection
Training
Training methods for those interested in pursuing a coding career include college-based programs that contain
coursework in medical terminology, anatomy and physiology, health information management, pathophysiology,
pharmacology, ICD-10-CM, ICD-10-PCS, HCPCS level II, and CPT coding, and reimbursement methodologies.
Many college programs also require students to complete a nonpaid internship (e.g., 120 hours) at a health care
facility. Professional associations (e.g., the American Health Information Management Association) offer noncredit-
based coding training, usually as distance learning (e.g., Internet-based), and some health care facilities develop
internal programs to retrain health professionals (e.g., nurses) who are interested in a career change.
NOTE:
Pharmacology plays a significant role in accurate and complete coding. Coders review the medication administration record (MAR)
to locate medications administered that impact diagnosis coding. For example, upon review of the MAR the coder notices that
the patient received a course of Librium (chlordiazepoxide) during inpatient hospitalization. Librium is classified as an antianxiety
medication, but it can be also used to counteract alcohol withdrawal symptoms. If the latter is the reason that the patient received
the Librium (based on physician documentation), the coder can assign an appropriate alcohol dependence diagnosis code as well as
alcohol detoxification procedure codes.
02809_ch01_ptg01.indd 4 11/1/18 10:48 AM

CHAPTER 1: Overview of Coding 5
Coding Internship
The coding internship benefits the student and the facility that accepts the student for placement. Students
receive on-the-job experience prior to graduation, and the internship assists them in obtaining permanent
employment. Facilities benefit from the opportunity to participate in and improve the formal education process.
Quite often, students who complete professional practice experiences (or internships) are later employed by the
facility at which they completed the internship.
The internship supervisor is the person to whom the student reports at the site. Students are often required
to submit a professional résumé to the internship supervisor and to schedule an interview prior to being accepted
for placement. While this experience can be intimidating, it is excellent practice for the interview process that the
student will undergo prior to obtaining permanent employment. Students should research the résumé writing and
interview technique services available from the college’s career services office. This office will review résumés
and will provide interview tips. (Some even videotape mock interviews for students.)
NOTE:
Breach of patient confidentiality can result in termination from the internship site, failure of the internship course, and even possible
suspension and/or expulsion from your academic program. Make sure you check out your academic program’s requirements
regarding this issue.
The internship is on-the-job training even though it is nonpaid, and students should expect to provide proof
of immunizations (available from a physician) and possibly undergo a preemployment physical examination and
participate in facility-wide and department-specific orientations. In addition, because of the focus on privacy and
security of patient information, the facility will likely require students to sign a nondisclosure agreement (to protect
patient confidentiality), which is kept on file at the college and by the professional practice site.
During the internship, students are expected to report to work on time. Students who cannot attend the
internship on a particular day (or who arrive late) should contact their internship supervisor and program faculty.
Students are also required to make up any lost time. Because the internship is a simulated job experience,
students are to be well groomed and should dress professionally. Students should show interest in all aspects
of the experience, develop good working relationships with coworkers, and react appropriately to criticism
and direction. If any concerns arise during the internship, students should discuss them with their internship
supervisor and/or program faculty.
Credentials
The American Health Information Management Association (AHIMA) and the AAPC (previously called the
American Academy of Professional Coders) offer certification in coding. Credentials available from AHIMA include
the following:
●● Certified Coding Associate (CCA)
●● Certified Coding Specialist (CCS)
●● Certified Coding Specialist—Physician-based (CCS-P)
The AAPC offers the following core coding certification exams:
●● Certified Professional Coder (CPC)
●● Certified Inpatient Coder (CIC)
●● Certified Outpatient Coder (COC)
●● Certified Risk Adjustment Coder (CRC)
The AAPC also offers specialty certifications in response to a demand for specialty coders who have
obtained advanced training in medical specialties and who are skilled in compliance and reimbursement areas,
such as the Certified Ambulatory Surgical Center Coder (CASCC) credential.
02809_ch01_ptg01.indd 5 11/1/18 10:48 AM

Another random document with
no related content on Scribd:
entfernt, tauchte eine hohe, kegelförmige Spitze auf. Cesca
behauptete, es sei der Monte Amiata.
Ueber den frisch gewaschenen, blauen Lenzhimmel hin zogen
sich die letzten Reste der Regenwolken fort, schwer und
silberverbrämt, vor der Sonne zerfließend; das Unwetter flüchtete
westwärts, dunkel drohend, dorthin, wo die etrurische Hochebene
sich braunschwarz und einsam zum fernen, weißgelben
Glanzstreifen des Mittelmeeres herabsenkte.
Oede, groß und streng war das Land weithin, wie eine
Hochgebirgslandschaft daheim, trotz der grauen Olivenhaine und
Weinranken, die sich zwischen den Reihen der Ulmen auf den
grünen Hügeln am See hinzogen.
In den kleinen Anlagen oben rings um die Burgruine warfen die
Steineichen ihre eisenschwarzen alten Blätter von den Zweigen ab,
die schon neue Knospen trugen. Hier waren Hecken von einer Art
immergrünen Buschwerks mit lederartigem Laub. Das junge neue
von diesem Frühling glänzte in unnatürlichem Goldgrün.
Gemeinsam mit ihr hatte er sich in den Schutz der Hecke
gehockt und seine Jacke vorgehalten, damit sie sich eine Zigarette
anzünden könnte. Der Lenzwind blies eisig scharf und rein hier
oben, so daß sie in ihren nassen Kleidern leicht erschauerte. Ihre
Wangen waren rot und die Sonne glänzte auf dem feuchten,
goldenen Haar, das sie sich mit der freien Hand aus den Augen
strich.
Dort hinauf wollte er reisen. Morgen schon.
Dort wollte er den Lenz grüßen, den frierenden, nackten,
erwartungsvollen Lenz, dessen Blütenaugen ringsum geblendet sind
von Nässe, vor Kälte im Winde zittern und dennoch blühen.
Der Lenz und sie — sie waren jetzt eins für ihn. O Gott — sie, die
dort oben stand und fror und lachte, in dem unbeständigen Wetter,
und alle Blumen in ihrem Schoße sammeln wollte.
„Ach, du meine kleine Jenny, du konntest nicht all die Blumen
pflücken, wie du gewollt, deine Träume erblühten nie — und jetzt
träume ich sie.
Wenn ich dann lange genug gelebt habe, so daß mich Sehnsucht
erfüllt wie einst dich — vielleicht tue ich dann wie du und spreche zu
meinem Schicksal, gib mir einige Blüten nur, ich begnüge mich mit
weit Geringerem, als ich ersehnte, da ich mein Leben begann. Und
dennoch sterbe ich nicht, wie du gestorben bist, denn dir konnte es
doch nicht genügen. Ich behalte nur die Erinnerung an dich, küsse
deine Perle und dein goldenes Haar und denke, nein, sie konnte
nicht leben, wenn sie nicht die Beste sein und das Beste als ihr
Recht fordern durfte. Dann sage ich vielleicht, dem Himmel sei
Dank, daß sie lieber den Tod wählte, als so weiterzuleben.
Aber heute Nacht gehe ich hinaus auf den Petersplatz und
lausche des Springbrunnens ekstatischer Musik, die niemals
schweigt und träume meinen eigenen Traum.
Ja, Jenny, denn nun bist du mein Traum, niemals habe ich einen
anderen gehabt. —
Ach, Träume, Träume.
Wenn dein Kind gelebt hätte, Jenny, so wäre es nicht geworden,
wie du es dir geträumt hattest, als du den Knaben in deinen Armen
hieltest und ihm deine Brust reichtest. Gut und schön hätte er
werden können — oder schlecht und häßlich — nur wie du ihn
erträumtest, so wäre er nicht geworden. —
Keine Frau hat je das Kind geboren, von dem sie träumte, als sie
schwanger ging. Kein Künstler hat je das Werk geschaffen, das er in
der Stunde der Eingebung vor sich sah. Wir erleben Sommer auf
Sommer, aber keiner ist wie der, den wir herbeisehnten, als wir uns
niederbeugten und die ersten nassen Blüten unter den
Sturmschauern des Lenzes pflückten.
Keine Liebe wurde so, wie sie zwei erträumten, die einander zum
ersten Male küßten. Hätten wir, du und ich, zusammen gelebt — wir
hätten glücklich oder auch unglücklich mit einander werden können;
wir konnten einander unsagbare Freude oder unsagbares Leid
zufügen. Jetzt aber werde ich niemals erfahren, wie unsere Liebe
geworden wäre, wenn du mir angehört hättest. Das Einzige, was ich
weiß, ist: so, wie ich sie erträumte in jener Nacht, als ich mit dir
zusammenstand, und der Springbrunnen im Mondenschein
plätscherte — so wäre unsere Liebe nicht geworden. Und das ist
bitter. — —
Dennoch. —
Herr mein Gott — ich wünsche nicht, daß ich diesen Traum nie
geträumt hätte. Und ich möchte den Traum nicht missen, dem ich
mich jetzt hingebe.
Jenny, mein Leben wollte ich opfern, könntest du mir droben auf
der Bergklippe begegnen wie einst, könntest du mich küssen, mir
nahe sein — einen Tag nur, eine Stunde. — Ständig, unablässig
muß ich daran denken, wie unser beider Leben sich gestaltet hätte,
wenn du nicht von mir gegangen, wenn du mein eigen geworden
wärest. Ach Jenny, ein grenzenloses Glück ist verspielt. Du bist nicht
mehr und hast mich so arm, so arm gemacht. Nur meine armseligen
Träume umweben dich und irren ruhelos umher, dich zu suchen. —
Und dennoch. Messe ich meine Armut an der Anderen Reichtum, so
dünkt sie mich überwältigend reich und strahlend. Sollte ich sie auch
mit meinem Leben bezahlen, so würde ich doch nimmer meine Liebe
zu dir, meine Träume und meinen Gram um dich, wie er mich jetzt
zerreißt, hingeben ....“
Gunnar Heggen wußte nicht, daß er in seines Herzens

grenzenlosem Aufruhr seine Arme gen Himmel streckte und halblaut
vor sich hinflüsterte. Die Anemonen, die er gepflückt, hielt er noch
immer in seinen Händen, aber er wußte es nicht.
Die Soldaten auf der Kasernenmauer lachten über ihn, aber er
sah es nicht. Er preßte die Blumen gegen seine Brust und murmelte
leise vor sich hin, während er sich von dem Sonnenschein, der über
dem Grabe lag, langsam dem dunklen Zypressenhain zuwandte.
Ende.
In demselben Verlage erschienen:
HARALD BERGSTEDT
Alexandersen
Eine Pilgerfahrt
Roman
327 Seiten
Preis: broschiert M. 27.—
geb. in starkem Pappband M. 32.—
Hamburger Correspondent v. 1. 3. 21:

.... Lukians köstliche Lügen der milesischen Märchen,
Swift Gullivers Reisen, Wielands Abderiten und nicht zuletzt
Andersens Mär vom fliegenden Teppich scheinen Vorbilder
zum Bau dieser prächtigen Pilgerfahrt gewesen zu sein.
Doch es scheint nur so. Das Buch ist ganz Eigenart — tief
und voll abgeklärter Weltanschauung. ....
Welt am Montag v. 20. 12. 20:

.... Gedankentiefe Symbolik, gelegentlich mit heiterer
Satire gewürzt, projiziert Welt und Zeit, in der wir leben, in
ein Märchenreich. Der Skandinavier H a r a l d B e r g s t e d t
wird in Deutschland bald zu den bekanntesten Autoren
zählen. ....
W—r.
Vossische Zeitung v. 12. 6. 21:

.... Dieser Roman ist mit einem ganz brillanten Witz, mit
einer ungewöhnlich scharfen Satire erzählt, mit barocken
Zwischenstrophen durchsetzt. In überraschender Fülle
drängt sich Bild an Bild. Man liest in atemloser Spannung,
kommt aus dem Lachen nicht heraus, und überlacht doch
niemals den Ernst des Ganzen. Das ist die ergötzlichste
Universal-Zivilisationskarikatur, die mir seit langem
vorgekommen ist. Dieser dänische Küsterssohn hat in
seiner kleinen Provinzstadt — Saeby — ein Buch von
europäischer Geltung geschrieben. ....
JOHANNES BUCHHOLTZ
Egholms Gott
Roman
224 Seiten
München-Augsburger Ztg. v. 19. 5. 21:

.... Tragik und schneidender satirischer Humor
verbinden sich in erschütternder Weise. ....
Welt am Montag v. 20. 12. 20:

.... In „Egholms Gott“ lernen wir einen Erzähler kennen,
der mit naturalistischer Schärfe die Tragödie des
proletarischen Phantasten schildert. ....
Weser-Zeitung v. 12. 2. 21:

.... In dem starken Werk, das ein Familienschicksal aus
der Tiefe der sozialen Schichtung schildert, einen sich
tiefernste Tragik und satirisch schneidender Humor in
ergreifender Weise.
ur.
Neues Wiener Tageblatt v. 27. 4. 21:

.... Buchholtz setzt die Linie der großen
skandinavischen Erzähler einer älteren Generation fort. Die
Gestalt dieses Egholm, eines Typus des nordischen
Menschen, ist mit Meisterhand gezeichnet, wie überhaupt
der Roman von hohem, dichterischem Können Zeugnis
gibt. Kein falsches Wort stört, und keine Konzession an
sentimentale Herzen, und er ist von einer
weltabgewandten, in sich ruhenden Gedanklichkeit
durchströmt.
Dr. H u g o G r e i n z .
LAURIDS BRUUN
OANDA
Roman
277 Seiten
Hamburger Correspondent v. 6. 4. 21:

.... alle diese Schilderungen zeugen von
unübertrefflicher Gestaltungskraft. „Oanda“ ist ein sozialer
Roman im besten Sinne des Wortes, in eigentümlicher
Weise verklärt durch die fast märchenhaft anmutende
Gestalt der Heldin selbst. Die musterhafte Übersetzung und
die ausgezeichnete äußere Ausstattung erhöhen noch den
Wert des Buches.
Dr. N a g e l .
Vorwärts v. 5. 6. 21:
.... Wer Laurids Bruuns frühere Bücher, insbesondere
sein van Zantens Buch kennt, weiß, daß der Verfasser von
einem Utopia der Menschengüte träumt, weiß auch, daß er
seinen Träumen Gestalt zu geben versteht. ....
Literarisches Echo, 23. Jahrgang, Heft 13:

Aus den Romanen Laurids Bruuns, die wie sonnige
glückliche Inseln im trüben Meer unserer literarischen
Erinnerungen liegen, kehren manche vertrauten, edlen
Menschen in diesem Buche wieder, so daß wir alsbald in
ihm heimisch sind und die Vorgänge sofort Relief und
Perspektive bekommen. ....
EJNAR MIKKELSEN
Sachawachiak
der Eskimo
Ein Erlebnis aus Alaska
180 Seiten
Deutsche Allgemeine Zeitung v. 8. 5. 21:

.... Dieses Buch hätte niemand schreiben können, der
nicht selbst eine Zeit seines Lebens fern von der Kultur,
dem Abenteuer hingegeben, Entbehrungen und Gefahren
auf sich genommen hat; aber der wagemutige Forscher
allein hätte es ebensowenig zustande gebracht. Es gibt in
der Erzählung einige Partien, etwa die Schilderung der
rasenden Jagd, in der Sachawachiak seinen Peiniger
verfolgt, die an die grobe Volksepik, an alte Heldenlieder
erinnern, an Gogols „Taras Bulba“ oder Selma Lagerlöfs
„Gösta Berling“. ....
Weser-Zeitung v. 5. 2. 21:
.... Da sind Urlaute, da pulst — trotz Schnee und Eis —
ein wildes Leben. Die Fabel ist eigentlich nur Mittel zum
Zweck. Gewiß: die Zertrümmerung einer primitiven Kultur
durch Branntwein und Syphilis soll sich gestalten, in der
Hauptsache aber will der Verfasser, der als arktischer
Forscher einen guten Namen hat, den eigenartigen
Daseinsrhythmus jener nördlichen Himmelsstriche, wo
Menschen wohnen, vergegenwärtigen. ....
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