Med Coding

INTRODUCTION As the healthcare industry continues to grow at an amazing rate, and with the Affordable Care Act (ACA) being signed into law in March 2010, many insurance companies, physicians’ offices, hospitals, and other healthcare organizations urgently need qualified medical coders. Medical coders play a key role in the healthcare industry for several reasons. First, medical coders optimize physician and hospital reimbursement through precise coding that adheres to coding guidelines and reflects the content of a patient’s medical record. Second, because medical coders must ask questions to clarify any areas of ambiguity in the medical record prior to selecting their codes, they help keep the medical record up to date. As questions are clarified, the record is updated with documents that explain the areas questioned by the medical coder. Third, medical coders assign codes that reflect new diseases, disorders, therapies, treatments, and medical devices. Medical coders select codes that are also used for statistical research on diseases and disorders. These codes are used to gauge the effectiveness of medical treatments throughout the United States.

In this course, you’ll learn how to assign diagnosis and pro- cedure codes using ICD-10-CM and ICD-10-PCS. You’ll also learn about the HCPCS Level I and Level II code set, which is used to assign codes for physician reimbursement in the out- patient setting. You’ll learn about assigning codes for office visits, surgeries, radiology procedures, medical devices, equipment, injections, supplies, and many other outpatient services.

OBJECTIVES When you complete this course, you’ll be able to

� Describe the purpose of coding and the documentation used in coding

� Assign ICD-10 codes using the ICD-10 coding manual

� Correctly apply coding guidelines using ICD-10

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� Assign codes to different body systems using ICD-10

� Review coding for ICD-10

� Assign codes for services and procedures using CPT and HCPCS Level II

� Describe the relationship between HCPCS Level I and HCPCS Level II

� Outline the types of services and procedures described in the CPT

� Describe the types of patients seen in the outpatient setting

YOUR TEXTBOOK The textbook for your Medical Coding course is Step-by-Step Medical Coding. This textbook gives an overview of ICD-10- CM and ICD-10-PCS. It also covers CPT coding. Your textbook is divided into chapters. The table of contents, found on pages xxiii–xxx of Step-by-Step Medical Coding, out- lines the topics presented in each chapter. Take a few moments now to examine the table of contents to get a better feel for the topics and concepts you’ll be learning about. Next, read the preface on pages ix–xiv, which describes the depth, range, and purpose of the material presented. Now, look through the rest of your textbook. You’ll see that every chap- ter begins with a set of chapter topics and learning objectives, followed by a brief introduction to the topics you’ll explore. Read the learning objectives twice: once before you read each chapter, and again after you finish reading. This two-step learning approach reinforces your understanding of the major concepts covered in the chapter, and also confirms that you truly understand the material.

Instructions to Students2

CPT stands for Current Procedural Terminology. ICD stands for International Classification of Diseases. The number following the acronym ICD refers to the version. For example, ICD-10 is the tenth revision.

The back portion of Step-by-Step Medical Coding includes several helpful study resources. The textbook’s glossary on pages 755–769 defines important terms. You’ll find a detailed index on pages 787–802.

If you’re ever unsure about where to find specific codes that are referenced in the chapters, use the handy Coder’s Index on pages 775–786. This index lists the pages where you can find specific codes referenced in each of the chapters. The references to the ICD-10-CM codes begin on page 782.

Once you’ve explored the Step-by-Step Medical Coding text- book, you can use the textbook’s resources to refer to any topic that you want to review. Your textbook’s companion website provides Encoder practice exercises, extra coding cases, and an extra chapter on nursing homes, durable medical equipment (DME), and home health. Go to the intro- ductory pages of your textbook or click the link on your student portal for more information.

Please note that the textbook goes into much more detail about the ICD-10 coding system than we’ll be covering in the study guide. Remember to code to the highest level of speci- ficity when assigning your ICD-10 codes. The ICD-10 codes are listed in the answer section of the study guide.

In the later part of your course, you’ll turn your attention to HCPCS Level I and Level II. Take a few minutes now to review the chapters listed in Unit 3, the area of the text that covers CPT and HCPCS coding. Take some extra time to review the concepts and the guidelines for coding presented in this course. It will be well worth it in the long run! Re-read the chapters in your textbook until you feel certain that you understand every CPT guideline presented.

There are three types of exercises in the textbook: Quick Checks, Exercises, and Chapter Reviews. You should com- plete Quick Checks and Exercises as you come upon them during your reading. You can find Quick Check answers in Appendix C (pages 744–747) and Exercise answers in Appendix B (pages 723–743). You’ll be instructed on when to complete the Chapter Reviews in the instructions for each lesson assignment in this study guide. Answers to the Chapter Reviews are given at the end of this study guide.