2012 Medical Coding Training: CPC ® Practical Application Workbook—Instructor Disclaimer This course was current when it was published. Every reasonable effort has been made to assure the accuracy of the information within these pages. The ultimate responsibility lies with readers to ensure they are using the codes, and following applicable guidelines, correctly. AAPC employees, agents, and staff make no representation, warranty, or guarantee that this compilation of information is error-free, and will bear no responsibility or liability for the results or consequences of the use of this course. This guide is a general summary that explains guidelines and principles in profitable, efficient health care organizations. Notice Regarding Clinical Examples Used in this Book AAPC believes it is important in training and testing to reflect as accurate a coding setting as possible to students and examinees. All examples and case studies used in our study guides, exams, and workbooks are actual, redacted office visit and procedure notes donated by AAPC members. To preserve the real world quality of these notes for educational purposes, we have not re-written or edited the notes to the stringent grammatical or stylistic standards found in the text of our products. Some minor changes have been made for clarity or to correct spelling errors originally in the notes, but essentially they are as one would find them in a coding setting. US Government Rights This product includes CPT®, which is commercial technical data and/or computer data bases and/or commercial computer software and/or commercial computer software documentation, as applicable, which was developed exclu- sively at private expense by the American Medical Association, 515 North State Street, Chicago, Illinois, 60610. U.S. Government rights to use, modify, reproduce, release, perform, display, or disclose these technical data and/or computer data bases and/or computer software and/or computer software documentation are subject to the limited rights restrictions of DFARS 252.227-7015(b)(2) (November 1995), as applicable, for U.S. Depart¬ment of Defense procurements and the limited rights restrictions of FAR 52.227-14 (June 1987) and/or subject to the restricted rights provision of FAR 52.227-14 (June 1987) and FAR 52.227-19 (June 1987), as applicable, and any applicable agency FAR Supplements, for non-Department of Defense Federal procurements. AMA Disclaimer CPT® copyright 2011 American Medical Association. All rights reserved. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT®, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. CPT® is a registered trademark of the American Medical Association. © 2011 AAPC 2480 South 3850 West, Suite B, Salt Lake City, Utah 84120 800-626-CODE (2633), Fax 801-236-2258, www.aapc.com Revised 091211. All rights reserved. ISBN# 978-1-935809-73-9 CPC®, CPC-H®, CPC-P®, CIRCC®, CPMA®, and CPCO™ are trademarks of AAPC. ii 2012 Medical Coding Training: CPC Practical Application Workbook—Instructor CPT ® copyright 2011 American Medical Association. All rights reserved. Acknowledgements Authors: Katherine Abel, CPC, CPMA, CPC-I, CRMS Debra A. Apfel, RN, BA, CPC, CPMA Carrie Bosela, CPC, CPC-I Rhonda Buckholtz, CPC, CPC-I, CPMA, CGSC, CPEDC, COBGC, CENTC Marcella Bucknam, CPC, CPC-H, CPC-P, CPC-I, CCC, COBGC Shelly Cronin, CPC, CPMA, CANPC, CGIC, CGSC Kelly Dennis, CPC, CPC-I, CANPC Mary Divine, CPC, CPC-H, CPC-I, CUC Brad Ericson, MPC, CPC, COSC Raemarie Jimenez, CPC, CPMA, CPC-I CANPC, CRHC Betty Johnson, CPC, CPC-H, CPC-I, CPCD Dolly Perrine, CPC, CPMA, CPC-I, CUC Jean Pryor, CPC, CPMA, CPC-I, CIMC Dorothy Steed, CPC-H, CPMA, CPC-I, CEMC, CFPC Kate Tierney, CPC, CPC-P, CEDC, CEMC, CGSC, COBGC G. John Verhovshek, MA, CPC Susan Ward, CPC, CPC-H, CPC-I, CEMC, CPCD, CPRC Reviewers: Lynn Anderanin, CPC, CPC-I, COSC Nicole Benjamin, CPC, CPC-I, CEDC Glade B. Curtis, MD, MPH, FACOG, CPC, CPC-I, COBGC Jennifer Hume, CPC, CPMA, CEMC Lindsay-Anne McDonald Jenkins, CPC, CPC-H, CPC-I, CPMA, CANPC, CIRCC, RN, CRNA (retired) Vandna Kejariwal, CPC, CPC-H, CPC-I, CEDC Barbara Pross, CPC, CPMA, CPC-I, CEDC, CEMC, COBGC Carrie Lynn Rawlings, CPC, CPMA, CPC-I, CCVTC, CEMC Alice Reybitz, RN, BA, CPC, CPC-H, CPC-I, CHI Carrie Severson, CPC, CPC-H, CPC-P, CPMA, CPC-I Kathy Skolnick, CPC, CPC-I Charleen Yamasato, CPC, CPC-I Production: Dianne Allred, Designer, Desktop Publishing Tina M. Smith, Desktop Publishing CPT ® copyright 2011 American Medical Association. All rights reserved. www.aapc.com iii Contents The Business of Medicine . 1 1. Exercise 1 . 1.1 Medical Terminology and Anatomy Review . 2 1. Questions 1–10 . 2.1–2.2 Introduction to ICD-9-CM . 3 1. Exercise 1 . 3.1 ICD-9-CM Coding Chapters 1–9 . .4 1. Case 1–Case 10 . .4.1–4.11 ICD-9-CM Coding Chapters 10–19 . 5 1. Case 1–Case 10 . 5.1–5.11 Introduction to CPT®, Surgery Guidelines, HCPCS, and Modifiers . 6 1. Exercise 1 . 6.1 Exercise 2 . 6.3 Integumentary System . 7 1. Case 1–Case 10 . 7.1–7.17 Musculoskeletal System . 8 1. Case 1–Case 10 . .8.1–8.19 Respiratory, Hemic, Lymphatic, Mediastinum, and Diaphragm . 9 1. Case 1–Case 10 . 9.1–9.12 Cardiovascular System . 10 1. Case 1–Case 10 . 10.1–10.15 Digestive System . 11 1. Case 1–Case 10 . 11.1–11.12 CPT ® copyright 2011 American Medical Association. All rights reserved. www.aapc.com v Urinary System and Male Genital System . 12 1. Case 1–Case 10 . .12.1–12.15 Female Reproductive System . 13 1. Case 1–Case 10 . 13.1–13.15 Endocrine and Nervous System . 14 1. Case 1–Case 10 . 14.1–14.19 Eye and Ocular Adnexa, Auditory Systems . 15 1. Case 1–Case 10 . 15.1–15.14 Anesthesia . 16 1. Case 1–Case 10 . 16.1–16.13 Radiology . 17 1. Case 1–Case 10 . 17.1–17.13 Pathology and Laboratory . 18 1. Case 1–Case 10 . 18.1–18.12 Evaluation and Management . 19 1. Case 1–Case 10 . 19.1–19.21 Medicine . .20 1. Case 1–Case 10 . 20.1–20.11 vi 2012 Medical Coding Training: CPC Practical Application Workbook—Instructor CPT ® copyright 2011 American Medical Association. All rights reserved. Chapter 1 The Business of Medicine Exercise 1 1. What type of profession might a skilled coder enter? Answer: Consultants, educators, medical auditors 2. What is the difference between outpatient and inpatient coding? Answer: Outpatient coders will focus on learning CPT®, HCPCS Level II, and ICD-9-CM codes volumes 1 and 2. They will work in physician offices, outpatient clinics, and facility outpatient departments. Outpatient facility coders will also work with Ambu- latory Payment Classifications (APCs). Inpatient hospital coding focuses on a different subset of skills, where coders will work with ICD-9-CM volumes 1, 2, and 3. These coders also will assign MS-DRGs for reimbursement. Outpatient coders usually will have more interaction throughout the day, and must communicate well with physicians; inpatient coders tend to have less interaction throughout the day. 3. What is a mid-level provider? Answer: Mid-level providers include physician assistants (PA) and nurse practitio- ners (NP). Mid-level providers are known also as physician extenders because they extend the work of a physician. 4. Discuss the different parts of Medicare and what each program covers. Answer: Medicare Part A helps to cover inpatient hospital care, as well as care provided in skilled nursing facilities, hospice care, and home health care. Medicare Part B helps to cover medically-necessary doctors’ services, outpatient care, and other medical services (including some preventive services) not covered under Medicare Part A. Medicare Part B is an optional benefit for which the patient must pay a premium, and which generally requires a yearly co-pay. Coders working in physician offices will mainly deal with Medicare Part B. Medicare Part C, also called Medicare Advantage, combines the benefits of Medicare Part A, Part B, and—sometimes—Part D. The plans are managed by private insurers approved by Medicare, and may include Preferred Provider Organizations (PPOs), Health Maintenance Organizations (HMOs), and others. CPT ® copyright 2011 American Medical Association. All rights reserved. www.aapc.com 1 1. The Business of Medicine Chapter 1 Medicare Part D is a prescription drug coverage program available to all Medicare beneficiaries. Private companies approved by Medicare provide the coverage. 5. Evaluation and management services are often provided in a standard format such as SOAP. What does SOAP represent? Answer: S—Subjective—The patient’s statement about his or her health, including symptoms. O—Objective—The provider assesses and documents the patient’s illness using observation, palpation, auscultation, and percussion. Tests and other services performed may be documented here as well. A—Assessment—Evaluation and conclusion made by the provider. This is usually where the diagnosis(es) for the services are found. P—Plan—Course of action. Here, the provider will list the next steps for the patient, whether it is ordering additional tests, or taking over the counter medications, etc. 6. What are five tips for coding operative reports? Answer: 1. Diagnosis code reporting—Use the post-operative diagnosis for coding unless there are further defined diagnoses or additional diagnoses found in the body or findings of the operative report. If a pathology report is available, use the find- ings from the pathology report for the diagnosis.