The next step advanced medical coding and auditing, 2014

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Go to evolve.elsevier.com/html/shop-promo.html to search and browse for products * Evolve Student Resources are provided free with each NEW book purchase only iii 2014 THE NEXT STEP ADVANCED MEDICAL CODING and AUDITING Carol J Buck MS, CPC, CPC-H, CCS-P Former Program Director Medical Secretary Programs Northwest Technical College East Grand Forks, Minnesota 3251 Riverport Lane St Louis, Missouri 63043 THE NEXT STEP: ADVANCED MEDICAL CODING AND AUDITING, 2014 EDITION ISBN: 978-1-4557-5897-5 Copyright © 2014, 2013, 2012, 2011, 2010, 2009, 2008, 2006, 2004 by Saunders, an imprint of Elsevier Inc All rights reserved No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher Details on how to seek permission, further information about the Publisher’s permissions policies and our arrangements with organizations such as the Copyright Clearance Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions This book and the individual contributions contained in it are protected under copyright by the Publisher (other than as may be noted herein) NOTE: Current Procedural Terminology, 2014, was used in updating this text Current Procedural Terminology (CPT) is copyright 2013 American Medical Association All Rights Reserved No fee schedules, basic units, relative values, or related listings are included in CPT The AMA assumes no liability for the data contained herein Applicable FARS/DFARS restrictions apply to government use Notices Knowledge and best practice in this field are constantly changing As new research and experience broaden our understanding, changes in research methods, professional practices, or medical treatment may become necessary Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds, or experiments described herein In using such information or methods they should be mindful of their own safety and the safety of others, including parties for whom they have a professional responsibility With respect to any drug or pharmaceutical products identified, readers are advised to check the most current information provided (i) on procedures featured or (ii) by the manufacturer of each product to be administered, to verify the recommended dose or formula, the method and duration of administration, and contraindications It is the responsibility of practitioners, relying on their own experience and knowledge of their patients, to make diagnoses, to determine dosages and the best treatment for each individual patient, and to take all appropriate safety precautions To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors, assume any liability for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein Library of Congress Cataloging-in-Publication Data Buck, Carol J., author   The next step : advanced medical coding and auditing / Carol J Buck.—2014    p ; cm   Includes index   ISBN 978-1-4557-5897-5 (pbk : alk paper)   I Title   [DNLM: Clinical Coding—Problems and Exercises W 18.2] R728.8 616.001’2—dc23 Content Strategy Director: Jeanne R Olson Associate Content Development Specialist: Helen O’Neal Publishing Services Manager: Pat Joiner Project Manager: Lisa A P Bushey Senior Designer: Amy Buxton Printed in Canada Last digit is the print number:  9  8  7  6  5  4  3  2  2013020953 To all the students, whose abilities to surmount tremendous obstacles to achieve their goals have been a source of unending inspiration To the teachers, who give of their talent, time, and knowledge to help the students who enter their classrooms, may this work make your load just a little lighter as we travel the same road, toward the same goal To my husband, Dennis, for understanding the mission, supporting the journey, and keeping the faith Carol J Buck This page intentionally left blank Index Cardiovascular system (Continued) E/M codes for, 222–224, 264 ejection fraction in, 234 hospital services for auditing reports, 259–261b cardiac cases, 243–244, 248–249 pacemakers for definition of, 226 follow-up notes, 228b implantation of, 233 insertion of, 226f types of, 226–233 procedures of angioplasty, 241 CABGs, 224–225, 225f cardioversion, 251, 252b catheterization, 241–245, 251 stenting, 241, 245 thromboendarterectomy, 253b Cardioversion atrial fibrillation case, 252b description of, 92, 251 respiratory failure case, 92b Cardioverter-defibrillator, 227 Carotid artery, 89–90b, 90–91b Cataracts audit report for, 491–492 operative reports for, 479–480b, 479b removal of, 491–492 types of, 479 Catheters anesthesia-related, 495 angioplasty, 241 balloon tip, 241 Swan-Ganz, 103 types of, 112 Cecectomy, 298–301b Centers for Medicare & Medicaid Services (CMS) diagnostic test guidelines, 18–19 ICD coding guidelines, excerpts, 18b Central nervous system assessments/tests, 93–94 divisions of, 450 psychological-associated CPT codes, 93–94 Cerebral hemorrhage, 46 Cerebrovascular disease, 89 Certified registered nurse anesthetist (CRNA) services of concurrency scenarios, 497t dual performance, 496 in hospital setting, 499–500 medical direction, 496 modifiers, 496 responsibilities of, 494 Cesarean section anesthesia for, 498 audit report for, 446 characterization of, 433–438 complicated pregnancy case, 442 macrosomia case, 435 membrane rupture case, 436–438b Chargemaster, 111 Chemistry tests cardiac cases, 246–247 codes for, 149–151 CTP coding of, 150–151b Chemotherapy administration of, 95 diagnosis coding for, 95 Z/V codes for, 30 Chiropractic, doctor of, 99 Cholecystectomy characterization of, 285–290 laparoscopic, 286f operative report, 286b Cholecystitis, 289–290 Chromatography, 151 Chronic obstructive pulmonary disease (COPD), 385f bronchitis illustration of, 385f pulmonary function study for, 360–361b Chronic renal failure characterization of, 390 diagnosis coding of, 390 Chronic renal insufficiency, 50 Cine-pharyngoesophagram, 115 Circumcision, 401, 401b Clinical brachytherapy, 129–131 Clinical treatment planning, 128 Closed fractures, 315 CMV See Cytomegalovirus (CMV) Coagulation, 156–157, 157b Cold agglutinin, 159 Colonoscopy audit reports for, 309, 310 characterization of, 271 operative reports for cancer case, 309 cytomegalovirus colitis case, 282 polyp case, 310 Colons, 305f Color-flow Doppler echocardiography, 229 Colposcopy, 420 Complete ROS, Complex wound repair, 193 Complications ICD codes for, 87 reporting of, 87 Component codes, 358 Comprehensive-focused history, Computed axial tomography (CAT or CT) abdomen cases, 119b, 120–121b, 121–122b, 122b audit reports, 139, 140 brain cases, 116b, 124b characterization of, 116–123 chest cases, 118b, 119–120b, 120–121b code divisions, 111 guidance with, 123 kidney biopsy case, 123b pelvis cases, 119b, 120–121b, 122b reconstructions with, 117 sinuses cases, 117b, 118b surgical navigation with, 453 Concurrent care, 17 Conduction anesthesia, 494 Congenital cysts, 392 Congestive heart failure, 49–50, 117 Conjunctivoplasty, 491 Consultation services audit reports, 72–74, 75–76 cardiac cases, 235–238b, 239–240b cardiology cases, 222, 223–224b cardiothoracic case, 237–238 567 568 Index Consultation services (Continued) cerebral palsy case, 460 clinical pathology, 164, 165b digestive cases, 265–266b, 304 inpatient, 38 OB/GYN, 439–443 orthopedic cases supracondylar fracture, 332–333b tennis elbow, 316b thigh pain, 331 outpatient, 37–38 overview of, 37–39 peptic ulcer case, 40–41b postmenopausal bleeding, 393–394b preoperative diabetes management, 27 pulmonary edema case, 357–358b renal failure case, 42–44b respiratory cases lung lesion, 364–365 pulmonary edema, 357–358b tracheostomy, 356–357b uterine carcinoma case, 422–423 varicose veins case, 39–40b Consulting physicians discharge services and, 17 role of, 37 Coombs, 156 Coordination of care, 14 COPD, See Chronic obstructive pulmonary disease (COPD) Coronary arteries, 120 Coronary artery bypass grafts (CABGs), 225f audit report of, 260 case of, 225–226b description of, 224–225 illustrations of, 224f, 225f Costovertebral tumor audit report for, 343–344 excision case, 320–321b Counseling, 14 CPT See Current procedural terminology (CPT) codes Cranioplasty, 457, 457b Craniotomy audit report for, 474–475 brain tumor case, 456–457b characterization of, 451 glioblastoma multiforme case, 455b intracranial clot case, 454b osteoplastic, 506b subarachnoid hemorrhage case, 456b subdural hematoma case, 453b Critical care services, 38 anesthesia, 499 cardiopulmonary arrest, 50–53b characterization of, 38 hypotension case, 48–50b hypotension/respiratory failure case, 54b tachypnea case, 44–46b Crohn’s disease characterization of, 296 diagnosis of, 296 Cryoablation, 407, 407–408b Current procedural terminology (CPT) codes anesthesia services base unit values, 501f divisions of, 495 moderate sedation, 499 Current procedural terminology (CPT) codes (Continued) modifiers for, 495 operative reports and, 495 qualifying circumstances, 497 surgeon administered, 495 chemistry tests, 149–151 chemotherapy administration, 95 cranioplasty, 457 echography, 432–433 fracture repairs, 328 HCPCS modifiers with, 100–104, 315 hydration, 81 integumentary-associated breast procedures, 207 keratosis, 185 lesion excision, 185 modifier-59, 195 nails, 191 rearrangements, 199 special services, 99–104 wound repair, 193–195 interventional radiology, 135–138 keratosis, 185 lymphatic system, 304–305 pathology- and laboratory-associated body fluids, 159–160 chemistry, 149–151 chromatography, 151 coagulation, 156–157 consultations, 164 drug testing, 161–162 evocative/suppression testing, 162 hematology, 153 immunohematology, 157 immunology, 158–159 microbiology, 163 molecular pathology, 149 organ- or disease-oriented panels, 145 panels, 145 therapeutic drug assays, 147–148 urinalysis, 148–149 psychological-associated central nervous system, 93–94 cognitive function, 88 radiology-associated contrast, 110–111 CT scans, 116–123 global component, 109 interventional, 135–138 reconstructions, 117 ultrasound, 92, 127 requisition forms, 143 skin tags, 184 thyroid gland, 408 vaccines, 79 Cystometrogram (CMG), 393–395 Cystoscopy audit report for, 416 case of, 397b Cysts acquired, 392 congenital, 392 ganglion, 322b urinary, 392 Cytomegalovirus (CMV), 281 Cytopathology and cytogenetic studies, 165, 165b Index D D&C See Dilation and curettage Data reviews, 22 Debridement audit reports for, 218, 219, 473 characterization of, 181 fat necrosis excision case, 182b frozen shoulder case, 336b leg case, 183–184b normal, 194 pressure ulcer case, 206b Decubitus positions, 106, 108f Delivery See Labor and delivery Dementia characterization of, 93–94 cognitive function assessment for, 94b reporting of, 90–91b Detailed history, Diabetes diagnostic codes for, 85 ICD codes for, 85 preoperative management of, 27 Diabetic ketoacidosis, 20 Diagnosis levels, questions for, 22 noninvasive vascular studies, 89–90 radiological, 111–115 Diagnostic tests See also specific procedures incidental findings, 18–19 reason for, 18, 19 Dialysis, 84–87 Digestive system See also Gastrointestinal tract audit report, 283 characterization of, 263–302 conditions of abdominal pain, 274–276, 275–278b anal fissure, 311 anal fistula case, 267b cholecystitis, 289–290 CMV, 281 Crohn’s disease, 296 duodenitis, 270 gastritis, 270 hemorrhoids, 268 hernia, 271, 302, 302–303b intersphincteric abscess case, 267b intestinal obstructions, 264 ulcers, 289–290 consultations for colon resection case, 275–276 gastric ulcer case, 287 infectious disease case, 280–281 surgical case, 265–266b E/M codes for, 264 hospital services for digestive distress case, 278–284b hernia case, 294, 302–303 procedures for abnormal findings, 273 appendectomy, 285b catheters, 269, 269–270b cecectomy case, 298–301b cholecystectomy, 285–290 endoscopy, 270 esophagogastroduodenoscopy, 271b Digestive system (Continued) external, 266 gastrojejunostomy case, 296–297b, 301–302b hemicolectomy, 280, 293–294b incisional surgical, 292 polypectomy, 310 rectal, 271–272 sigmoidoscopy case, 273b, 274b tracheostomy case, 296–297b stomach parts, 291f Dilation and curettage, 430b Direct coombs, 156, 157 Direct inguinal hernias, 271 Discectomy, 468–469b Discharge services See Hospital discharge services Distal position, 106, 107f Donor sites, 202 Doppler echocardiography audit report for, 261 case of, 239b characterization of, 229 principles of, 251f Doppler ultrasound, 124–125 Dorsal positions, 106 Dosimetry, 129 Drug testing case, 162b diagnoses coding, 161–162 qualitative, 161 DUB See Dysfunctional uterine bleeding (DUB) Duodenal ulcers, 290 Duodenitis, 270 Duplex carotid artery study, 89–90b, 90–91b Duplex venous exam, 104 Dysfunctional uterine bleeding (DUB), 429 E Ear, external, 485f Echo Doppler See Doppler echocardiography Echocardiography, 470–471b, 470b See also Doppler echocardiography; Stress tests auditing report, 259 cases of, 230b, 246–248b characterization of, 229 Echography, 432 Ectropion, 481, 482b EEG See Electroencephalography Effusion, 346 EIA See Enzyme immunoassay (EIA) Ejection fraction, 234 Electroencephalogram, 103 Electroencephalography, 469, 469b Electrolyte imbalance, 85 Emergency department services audit reports, 74 cardiac cases, 243 female genital disorder case, 418–419b gastric ulcer case, 288 vomiting case, 25b EMG (electromyographic) electrodes, 393–395 End Stage Renal Disease (ESRD), 84 Endemic bladder stones, 397 Endocrine system overview of, 408 thyroidectomy, 410f 569 570 Index Endocrinologist, 408 Endometriosis characterization of, 426 pelvic pain case, 425–428b polyps in, 438f Endoscopy, 270 Endotracheal intubation, 61 ENT physician See Otolaryngologists Entropion audit report for, 492 clinical progress note, 482b definition of, 481–482 Enzyme immunoassay (EIA), 347 Epidural anesthesia administration of, 494 labor-associated, 498 pain management with, 498 postoperative pain-associated, 495 Epiphora, 482, 483b Established patient, Estimated date of delivery (EDD), 431 ESWL (extracorporeal shock wave lithotripsy) audit report for, 415–416 case of, 394b Ethmoidectomy, 373b, 374b Evaluation and Management (E/M) codes cardiovascular system, 222–224 components of, 2–8 consultation services, 37–39 craniotomy, 451 critical care services, 38 debridement, 181 diagnosis coding, 17–20 diagnostic radiology, 111–115 dialysis, 84–87 digestive system, 264 female genital system, 418 hemangiomas, 400 history, 3–7 history level of, 21–22 hospital inpatient services, 16–17 immunization, 78–79 inpatient consultations, 38 labor and delivery, 431 late effects, 90 MDM in, 11–13 neonatal care services, 59–60 neonatal critical care services, 60–61 newborn care services, 60–61 observation services, 57 physical medicine and rehabilitation, 97 prolonged services, 38–39 psychiatry, 82 respiratory system, 346–359 standby services, 39 three factors of, Evocative/suppression testing, 162, 163b Examinations audit form elements, 10f body areas, definition of, 7–8 elements of, 22 example of, general constitutional OS, 8–9 newborn record, 62f Excisional biopsy, 207 Expanded problem-focused history, Extend ROS, Extracapular cataract extraction (ECCE), 479 Extractable nuclear antigen (ENA 1), 158 Eye systems audit reports, 490–492b blepharoplasty, 489 conditions of cataracts, 479, 479–480b, 479b common, 477 ectropion, 481, 482b entropion, 481–482, 482b epiphora, 482, 483b examinations of clinic progress notes, 478b description, 477 visual acuity charts, 477f impairment levels, 477f photocoagulation in, 480, 481b F Face-to-face time, 16 Female genital system See also Labor and delivery; Maternity care audit reports, 445–448b disorders of DUB, 429 endometriosis, 426 menopausal/postmenopausal, 419, 420–425b pelvic pain, 425 symptoms, 418 E/M codes for, 418 overview of, 418–429 procedures of cholecystectomy, 422 colposcopy, 420 D&C, 430b hysterectomy, 425–428b, 427 hysteroscopy, 421–422 sonogram, 434 sterilizations, 432b surgical, 419 Fetus gestation of, 61, 431 heart monitoring, 433 Field block, 494 Fistula cases of, 267b definition of, 266 Fixations application/removal of, 316 types of, 316 Foraminotomies characterization of, 462 herniated disc case, 462–463b radiculopathy case, 463–464b Fracture repairs closed reduction case, 330b supracondylar fracture, 332–333b types of, 315, 328 Fractures, types of, 328f Full-thickness graft, 201 G Gastric bypass, 519–520 Gastric ulcers characterization of, 290 consultation for, 287, 288–289 operative report for, 289–290 Index Gastritis, 270 Gastroenterologists, 263, 266 Gastrointestinal tract organs, 263, 263f Gastrojejunostomy case of, 296–297b tube placement, 301–302b General anesthesia, 494 Genital systems See Female genital system; Male genital system Gestation See Short gestation Global radiology services, 109 Glomerular disease, primary, 138f Gram conversion, 66 Growth, 189f Gynecologists, 418, 419 H Halo applications audit report for, 343 description of, 317b vest replacement, 468b HCPCS See Healthcare Procedural Coding System (HCPCS) Head injury, 103f Health and behavior assessment, 95, 95b Healthcare Procedural Coding System (HCPCS) anatomical modifiers of, 100–104 clinical progress notes, 101 modifier-59 use, 79 office procedures case, 100–101b radiological contrasts, 110 vaccine codes, 79 Hemangioma, 390–399 Hematology, 153, 155–156b Hemic/lymphatic system bone marrow biopsy of, 307b characterization of, 305 characterization of, 304 coding of, 304–305 neoplasms of, 305 nodes codes for, 304–305 dissection case, 305–306b repair of, 305 spleen, 305 splenectomy case, 306–307b Hemicolectomy characterization of, 276 operative report, 277, 293 Hemodialysis catheter placement, 111, 135b progress report, 84–85b reporting of, 84 services for, 84 Hemoptysis, 346–347 Hemorrhoids, 268–269b Hep B surface antigen, 159 Hernia characterization of, 302 inpatient services for, 294 operative report on, 302–303b types of, 271 Heterophile antibody screen, 159 High complexity diagnosis, 12, 13 High severity problem, 14 History audit forms, 8f definition of, elements of, History (Continued) indicators of, 5b levels of, review of systems, 4–6 History of present illness (HPI) audit form, 4f definition of, 3–4 elements of, 21 HIV test, 159 Holter monitor case of, 231–233b characterization of, 231 Hospital admission services cardiac cases, 243–244, 246, 248–249 cecectomy, 298–299 cesarean section case, 436–438 labor and delivery, 431 Hospital discharge services adenocarcinoma case, 424–425 bases of, 24 cerebral palsy case, 461–462 cesarean section case, 436 chronic duodenal ulcer case, 36b distended small bowel case, 295–296 endometriosis case, 428 femur nailing case, 332 gastric ulcer case, 292 mastectomy case, 212–213 pneumonia case, 352 pulmonary edema case, 356 reporting of, 17 spontaneous delivery case, 432 stroke case, 298–299 tendon rupture case, 325 Hospital inpatient services audit review, 72 code assignments, 19–20 diagnosis coding, 17–20 discharge services, 17, 24 distended small bowel case, 292 initial care, 17, 23–24b nausea case, 278–280 overview of, 16–17 residents’ notes, 348, 348–352b subsequent care, 17 Hospital observation services case, 57–59b codes for, 57 Hyaline membrane disease, 63–64 Hydration, 81 Hydrocele, 403, 403b Hydronephrosis, 397 Hyperbilirubinemia, 66 Hypertension pulmonary, 50 renal failure and, 85 Hypertensive chronic kidney disease, 85 Hyperthermia, 129 Hypoxemia, 117–119 Hysterectomy audit reports for, 445–448 characterization of, 419 endometriosis case, 427 Hysteroscope, 420 Hysteroscopy anesthesia for, 506b audit reports for, 445–446 571 572 Index I Immune globulins diagnosis coding for, 79 ICD codes for, 79 Immunization See also Vaccines active, 78 passive, 78 types of, 78 Immunohematology, 157 audit report, 179 Immunology, 158–159, 159b Incidental findings, 18–19 Indicators, 143 Indirect coombs, 156 Indirect inguinal hernias, 271 Infections, 138f Infratentorial burr holes, 450 Infusions case for, 96b CPT codes for, 81 Initial hospital care, 17 abdominal pain case, 26–28b emergency services, 25b hypertriglyceridemia case, 33b pancreatitis case, 28–30b, 35–36b symptomatic bradycardia case, 30–33b vomiting case, 23–24b Injections chart notes, 82b CPT codes for, 81–82 Inpatient coder reports by, 19–20 skill building steps, 20 Inpatients, Integumentary system breast procedures characterization of, 207 expander removal case, 215b mammoplasty cases, 213–214b, 215b modified radical mastectomy case, 211–213b needle localization biopsy case, 209–210b segmental mastectomy case, 210b surgical biopsy cases, 207–208b, 208–209b debridement of characterization, 181 fat necrosis excision case, 182b leg case, 183–184b pressure ulcer case, 206b lesion excision of basal cell case, 199–201b characterization, 185 epithelioma case, 188b histolytic case, 195–196b keratosis, 185, 189b lipoma case, 187b melanoma cases, 189b, 190–191b nevus case, 188b operative report, 185b operative reports, 185b, 187b squamous cell case, 190b modifier-59, 195 nails, 191, 192–193b pressure ulcers, 206, 206b rearrangements in, 199 skin grafts in abdominal case, 205b characterization of, 201–202 Integumentary system (Continued) composite case, 204b full-thickness case, 202–203b muscle flap cases, 202–203b, 204b post case, 205–206b split-thickness case, 202b skin tags, 184 wound repair in characterization of, 193–195 laceration case, 194b scar revision case, 197b, 198b umbilicoplasty case, 196–197b Intermediate wound repair, 193 International Classification of Disease CMS memorandum excerpts, 18b ICD-10-CM asthma, 21 atherosclerosis, 222 cerebral hemorrhage, 46 cesarean section, 435 complications, 87 diabetes, 85 diabetic ketoacidosis, 20 fractures, 315 gastric ulcers, 290 gastritis, 271 hemorrhoids, 268 late effects, 327 live born infants, 61 macrosomia, 435 macrosomia/cesarean, 435 nonspecific abnormal findings, 362 respiratory symptoms, 361 urinary cysts, 392 valve insufficiencies, 229 wound repair, 194 ICD-9-CM asthma, 21 atherosclerosis, 223 cerebral hemorrhage, 46 complications, 87 diabetes, 85 diabetic ketoacidosis, 20 facility specifics, 111 fractures, 315 gastric ulcers, 290 gastritis, 270, 271 hemorrhoids, 268 hernias, 271 hypertensive chronic kidney disease, 85 immune globulins, 79 late effects, 327 live born infants, 61 nonspecific abnormal findings, 362 respiratory symptoms, 361 sprains and strains, 323 urinary cysts, 392 vaccinations, 79 valve insufficiencies, 229 reporting of, 17–18 Interventional radiology audit report, 139 characterization of, 110 coding of, 135–138 gastrojejunostomy catheter case, 136b, 137b hemodialysis catheter case, 135b Intestinal obstructions, 264 Index Intracapsular cataract extraction (ICCE), 479 Intracerebral hemorrhage, 46 Intramuscular administration, 78 Intraperitioneal catheters, 269, 269–270b Intussusception, 264, 265f K Keratosis, 185 Kidney failure acute, characterization of, 34–35 chronic (See Chronic renal failure) etiology of, 138f Kilogram conversion, 66 Knee arthroscopy meniscus tear case, 336–337b patellar dislocation case, 339b portals for, 341 L Labor and delivery anesthesia for, 498 cesarean section characterization of, 433–438 ICD codes for, 435 macrosomia case, 435 membrane rupture case, 436–438b malposition/malpresentation, 435f marcrosomia, 435 normal, 431 overview of, 431 Laboratory use only section, 153, 154f Lacerations artery laceration case, 256–257b audit report, 220 wound repair case, 194b Laminotomy characterization of, 462 herniated disc case, 462–463b Laparoscopic procedures audit report for, 312, 519–520 description of, 270 hysterectomy with, 419 lymph node repair with, 305 operative report of, 295 Larynx carcinoma sign, 217f Last menstrual period (LMP), 431 Late effects Alzheimer’s disease, 93b code assignment in, 90 fracture-related, 327 Lateral positions, 106 Left lateral decubitus position, 106, 107f Lesion excision basal cell case, 199–201b carbuncle case, 319b case, 185b characterization of, 185 costovertebral tumor case, 320–321b, 344 epithelioma case, 188b ganglion cyst case, 322b histolytic case, 195–196b keratosis, 185, 189b lipoma case, 187b lymphatic tissue case, 319b melanoma case, 189b, 190–191b nevus case, 188b, 320b Lesion excision (Continued) operative reports, 185b, 187b shoulder case, 321b, 322b size calculation, 185f squamous cell case, 190, 190b Leukemia, 305 Ligation audit report for, 414–415 simple, 194 Lithotripsy, 415 Local anesthesia, 494 Low birth weight, 61 Low complexity diagnosis, 12, 13 Low severity problem, 14 Ludwig’s angina, 217f Lumbar punctures, 458, 459b Lymph nodes codes for, 304–305 dissection case, 305–306b pathology report, 306 repair of, 305 Lymphadenectomy audit report for, 414 operative report for, 406–407b M Magnetic resonance imaging (MRI) description of, 111 lumbar spine case, 466–467 Male genital system audit reports, 414–416b disorders of balanitis, 401 hemangioma, 400 hydrocele, 403, 403b overview of, 400–407 procedures for circumcision, 401, 401b epididymectomy, 403b lymphadenectomy, 406–407b prostate volume determination, 391 prostatectomy, 406–407b, 406b, 413f PSA test, 404 resection, 400b vasectomy, 402, 402b prostate cancer, 405 Manipulative treatment, 99, 328 Mastectomy, 207 Maternity care See also Labor and delivery complicated pregnancy amniocentesis for, 441 biophysical profile for, 440 cesarean section for, 442 consultations for, 439–443 Doppler umbilical arterial for, 440 duplex venous exam for, 439 reporting guidelines, 438 ultrasound for, 440, 441, 442 echography, 432–433 overview of, 431–438 routine obstetric, 431 MDM See Medical decision making (MDM) Meatotomy, 399b Medical decision making (MDM) anesthesia medical direction, 496 audit form section, 13f, 14f complexity of, 11–13, 22 573 574 Index Medical decision making (Continued) contributory factors, 14–16 head injury management, 103f management options, 11 risk levels, examples, 13t Medical nutrition therapy, 99 Medical supervision, 496 Meniscetomy, 342 Meniscus tear, 336–337, 342 Menopausal disorders, 419 Microbiology, 163, 164b Migrant bladder stones, 397 Minimal problem, 14 Mitral valves, 229 Moderate complexity diagnosis, 12, 13 Moderate severity problem, 14 Modifier-59 arthroscopy use of, 334 arthrocentesis use of, 315 integumentary use of, 195 Molecular pathology, 149 Monitored Anesthesia Care (MAC), 494–495 Mono test, 159 Monocytic leukemia, 305 Musculoskeletal system arthroscopy in characterization of, 334–335 knee case, 336–337b, 339b knee portals, 335f patella case, 339–340b rotator cuff case, 338 shoulder case, 335b tibia approach, 335f auditing reports, 342–344b common complaints of, 314 conditions of fractures, 315 late effects, 327, 327b sprains/strains, 323–327 fixations in application/removal of, 316 types of, 316 fracture repair in closed reduction case, 330b femur case, 330b supracondylar fracture, 332–333b types of, 328 lesion excision in carbuncle case, 319b costovertebral tumor case, 320–321b description of, 318 ganglion cyst case, 322b lymphatic tissue case, 319b nevus case, 320b shoulder case, 321b, 322b orthopedic consultations, 316b procedures for acromioplasty, 337–338b amputation, 334, 334b arthrocentesis, 314–315 arthroplasty case, 326b chondroplasty case, 339–340b halo application, 317b hardware removal, 317–318b menisectomy case, 337–338b, 339–340b reconstructions, 323, 323b revisions, 323 Musculoskeletal system (Continued) sprain/strain repair, 323–327, 324–325b, 325–326b stealthy surgery, 453 Myeloid leukemia, 305 Myocardial perfusion scans, 234–236 Myringotomy, 484–485 N Nails clinical progress note, 191, 192–193b common conditions of, 191 fracturing case, 342 Nasogastric tube, 113 Neoplasms hematopoietic, 305 lymphatic, 305 Nephrologists, 390 Nephrons, 390 Nephrostomy tubes, 391 Nervous system audit reports, 473–475b cerebrum, 452f conditions of cerebral palsy case, 460–462b subdural hematomas, 451–452 division of, 450 parasympathetic, 450f procedures of bard port removal, 461 burr holes, 450 cranioplasty, 457, 457b craniotomy, 451, 453b, 454b, 455b, 456–457b, 456b discectomy, 468–469b EEG, 469, 469b, 470–471b, 470b foraminotomies, 462, 462–463b, 463–464b halo vest replacement, 468b laminotomy, 462, 462–463b lumbar puncture, 458, 459b pump implantation, 459, 459b spinal fusion, 467, 467b stealth surgery, 453 ventriculostomy, 451, 469f shunts for, 458, 458b sympathetic, 450f Neuraxial anesthesia See Epidural anesthesia Neuroadiologist, 117 Neurologists, 450 Neurosurgeon, 450 New patient definition of, office visits, 55 Newborn care services case for, 61b codes for, 60–61 critical care, 60–61, 62–67b diagnosis codes, 61 neonatal, 59–60 Newborns definition of, 59 examination records of, 62f status considerations for, 59–60 Noninvasive vascular diagnostic studies, 89–90 Nuclear medicine characterization of, 133–134 lung scan case, 134b pulmonary function study, 134b Nurse anesthetist See Certified registered nurse anesthetist (CRNA) Index O Oblique positions, 108f, 109 Obstructive disease, 138f Occult blood, 149 Odontoid position, 109 Office visits annual case, 70b HCPCS for, 100–101b hypothyroidism case, 55b infant checkup case, 70b lymphadenitis case, 55–56b new patients, 55 Pap exam case, 68–69b, 71b testing during, 160, 161b Onychetomy definition of, 191 illustration of, 192f Open fractures, 315 Ophthalmologists, 477 Organ systems audit form section, 11f general, 8–9 Organ- and disease-oriented panels, 145, 146b Osteopathy, doctor of, 99 Otolaryngologists, 483 Outpatients coder for, 19–20 definition of, services for, 37–38 Oxygen desaturation overnight, 386 walking, 386 P Pacemakers definition of, 226 implantation of, 233 insertion of, 226f types of, 226–233 Pain management, 498 Paralytic ileus, 264 Parasympathetic nervous system, 450f Passive immunization, 78 Patent ductus arteriosus, 67 Pathology and laboratory services anatomic pathology, 164, 164b audit reports, 178–179b body fluid, 159–160, 160b calculations, 151, 152f chemistry, 149–151, 150–151b chromatography, 151 coagulation, 156–157, 157b consultations, 164, 165b cytology, 377, 384 cytopathology and cytogenetic studies bone marrow case, 165b lung biopsy case, 378 subsection of, 165 thoracentesis case, 378 disease-oriented panels, 145 drug testing, 161–162, 162b evocative/suppression testing, 162, 163b hematology, 153, 155–156b immunohematology, 157 immunology, 158–159, 159b lab use only section, 153, 154f microbiology, 163, 164b Pathology and laboratory services (Continued) miscellaneous testing, 166, 167b molecular pathology, 149 office testing, 160, 161b organ-oriented panels, 145 requisition forms, 143, 144f section review, 167–176b surgical, 165–166, 166b therapeutic drug assays, 147–148, 147–148b throat cultures, 347b transfusion medicine, 163 types of, 143 urinalysis, 148 urine/stool analysis, 148 Pathology reports appendix case, 298 audit review, 178 carotid tumor case, 411–412 colon adenocarcinoma case, 277–278 complicated pregnancy case, 443 costovertebral tumor case, 321 DUB case, 430 endometriosis case, 427–428 gastric ulcer case, 290–292 hernia case, 303 lung mass case, 366, 378 meningioma case, 454 node dissection case, 306 polyp cases, 273, 274 shoulder mass case, 321 spleen case, 307 throat cultures, 347b Patients See also Outpatients analgesia controlled by, 499–500 established, history of, 3–7 new, positioning of, 497 spirometry initiated by, 359 status of, PDT See Photodynamic therapy (PDT) PE (pressure equalization) tube audit report for, 492 illustration of, 485f removal of, 485b, 486b, 492 Peptic ulcers, 290 Percutaneous transluminal coronary angioplasty (PTCA) case study of, 245 definition of, 241 Perforated ulcers, 290, 291f Peritoneal dialysis case for, 86–89b characterization of, 86 self-administered, 86f PFSH (past, family, social history) audit form section for, 6f definition of, 6–7 items included in, 5b Pharyngitis clinical progress notes for, 483–484b diagnosis of, 347, 347b Well Child Care case, 483–484b Photocoagulation, 480, 481b Photodynamic therapy (PDT) audit report, 104 case, 96b characterization of, 96 575 576 Index Physical medicine and rehabilitation cerebral palsy case, 97–99b codes for, 97 knee repair case, 97b Physicians attending, 17 consulting, 17, 37 education of, 348 Pinch graft, 201 Place of service, Plate removal, 473 Pleural effusion, 120 Plexus blocks, 494 Polycystic ovarian disease (PCOD), 429 Polypectomy audit reports for, 310, 311 definition of, 310 Polyps characterization of, 272 endometrial, 438f pathology reports, 272, 274 ureteral, 392 Porfimer sodium, 96 Posteroanterior (PA) position, 106, 107f Postmenopausal disorders, 419 Postpartum care, 431 Pregnancy tests, 149 Presenting problems, 14 Pressure ulcers, 206, 206b Preventive medicine services, 67–68 Problem-focused history, Problem-focused ROS, Proctosigmoidoscopy, 271 Professional radiology services, 109 Prolonged services examples of, 38 subheadings, 38 Prone position, 108f Prostate cancer characterization of, 177f cryoablation for, 407, 407–408b staging of clinical, 177f definition of, 406 TNM, 405f Whitmore-Jewett staging of, 405f Prostate-specific antigen (PSA) test, 160, 404 Prostatectomy operative report, 406–407b, 406b radical, 413f Proton beam treatment delivery, 129 Proximal position, 106, 107f PSA See Prostate-specific antigen (PSA) Psychiatry auditing reports, 103 case, 83b evaluation codes, 82 PTCA See Percutaneous transluminal coronary angioplasty (PTCA) Pulmonary function study audit report for, 386 COPD case, 360–361b hypoxemia case, 134b Pulmonary hypertension, 50 Pump implantation, 459, 459b Q Qualifying circumstances, 497 R Radiation oncology See also Nuclear medicine characterization of, 128–132 clinical brachytherapy, 129–131 clinical treatment planning, 128 dosimetry for, 129 hyperthermia, 129 proton beam delivery, 129 simulation, 128–129 treatment, 129 delivery, 132 management, 129 notes, 130–133b Radiculopathy, 463 Radiologists, 106, 109–110 Radiology See also specific imaging techniques characterization of, 106 cine-pharyngoesophagram, 115 clinical services, 110 contrasts, 110–111 diagnostic, 111–115 facility specifics, 111 hemodialysis catheter placement, 111, 113b interventional, 110, 135–138 line placement, 112b positions and placement, 107f, 126 Radiology reports abdomen case, 113b abdominal pain case, 28 chest imaging breathing case, 350 lung mass case, 367 neoplasm case, 113b palpitations case, 250 pleural effusion case, 379 pneumonia case, 368 pneumothorax case, 379 pulmonary edema case, 354, 355 sinus case, 237 femur case, 114b herniated disc case, 464 knee case, 114b KUB case, 115b nephrostogram case, 391–392 pacemaker implantation case, 231–233 perfusion scan case, 234 shoulder case, 114–115b video swallow case, 115b Rapid plasma reagin (RPR), 159 Reagents, definition of, 148–149 Rearrangements See Adjacent tissue transfers Reconstructions CT scan-associated, 117 musculoskeletal-associated, 323 rotator cuff case, 323b Rectal procedures, 271–272 Recumbent position, 106 Regional anesthesia, 494 Renal calculus, 393 Requisition forms, 143, 144f See also specific services Resection (penile), 400b Respiratory system conditions of bronchospasm, 359 COPD, 385f ill-defined, 361 Index Respiratory system (Continued) pulmonary edema case, 352–356b shortness of breath case, 348–352b symptoms, 361–362 consultations for, 356–357b, 357–358b diagnostic procedures for EIA, 347 pulmonary function, 360–361b, 363b E/M codes for, 346–359 function of, 346 hospital services for, 348–352b medicine services for, 358 procedures for antrostomy, 374b bronchoscopy, 382–383b, 383–384b endoscopic, 372–373 ethmoidectomy, 373b, 374b septoplasty, 369, 370b, 373b thoracentesis, 347, 371, 371b tonsillectomy, 370b tracheostomy, 372, 372b turbinoplasty, 373b residency programs for, 348 sleep studies description of, 361 oxygen desaturation case, 378 somnolence case, 362–363b spirometry procedures agents with, 360 basic, 359 bronchodilator-associated, 359 patient-initiated, 359 performance of, 359 report assessments, 359 Review of systems (ROS) audit form section for, 4f definition of, 4–6 elements of, 21 examples of, levels requiring, 6, 7f recognized, 5b Revisions (musculoskeletal), 323 Rheumatoid factor, 158 Right lateral decubitus position, 107f Risk levels, 13t ROS See Review of systems (ROS) S Secondary bladder stones, 397 Self-limited problem, 14 Septoplasty audit report for, 387–388 definition of, 369 septal deviation case, 373b sleep apnea case, 370b Short gestation case for, 22 codes for, 61 Shoulders arthroscopy for, 335b debridement of, 336b lesion excision case, 321b, 322b Shunts audit report for, 475 definition of, 458 replacement of, 475 Shunts, 458b Sick sinus syndrome, 227–228 Sigmoidoscopy, 271 Simple exploration, 194 Simulations, 128–129 Single nerve blocks, 494 Skin grafts abdominal case, 205b characterization of, 201–202 composite case, 204b full-thickness case, 203b muscle flap cases, 202–203b, 204b post case, 205–206b split-thickness case, 202b Skin tags, 184, 185b Sleep studies audit report for, 387 multiple latency, 363b performance of, 361 Small bowel resection audit report for, 309–310 Somnolence, 361 Sonogram, 434 Sore throats See Pharyngitis Special services, 99–104 Spinal anesthesia, 494 Spinal fusion, 467, 467b Spirometry agents with, 360 basic, 359 patient-initiated, 359 performance of, 359 report assessments, 359 Spleen, 305 Splenectomy, 306–307b Split graft, 201 Sprains and strains coding of, 323–327 tendon repair case, 324–325b, 325–326b Squamous cell case audit report, 218–219 case study of, 190b characterization of, 218 Standby services, 39 Stein-Leventhal syndrome, 429 Stem cells, 305 Stenting auditing report, 260 case of, 245 characterization of, 241 illustration of, 242f Sterilization audit report for, 448 operative report of, 432b post-labor, 431 Z/V codes for, 402, 437 Stomach parts, 291f Straightforward diagnosis, 12 Stress incontinence, 395 Stress tests audit report for, 261 case of, 234–235b characterization of, 233 Strictures See Urethral strictures Subarachnoid hemorrhage, 46 Subcutaneous administration, 78, 81 577 578 Index Subdural hematomas audit report for, 518–519 causes of, 451–452 image of, 452f surgical procedures for, 500f Submandibular abscess, 217f Subsequent hospital care, 17 Superbills See Requisition forms Supine position, 108f Supine positions, 106 Supratentorial burr holes, 450 Surgical pathology, 165–166, 166b Swan-Ganz catheter, 103 Sympathetic nervous system, 450f Syphilis test, 159 T Tangential position, 109, 109f Technical radiology services, 109 Therapeutic drug assays, 147–148, 147–148b Thoracentesis, 371, 371b Thrombocytopenia, 66 Thromboendarterectomy, 253b Thyroid gland CPT codes for, 408 tumor removal case, 408–409b Thyroidectomy, 393f, 410f Tibia, posterolateral approach to, 335f Time critical care services, 38 incorporation of, 14–16 measures of, 16 Times urine test, 149 TNM staging, 405f Tonsillectomy anesthesia for, 503–504b audit report for, 387–388 auditory-related, 486b operative report for, 370b Tracheostomy audit report for, 388 definition of, 372 feeding tube case of, 296–297b respiratory failure case, 372b Transesophageal echocardiography (TEE), 229, 252b Transfusion medicine, 163 audit report, 179 Transthoracic echocardiography, 229 Tricuspid valves, 229 Tubular disease, primary, 138f Turbinates audit report for, 387–388 definition of, 369 illustration of, 369f reduction of, 370b, 387–388 Turbinoplasty, 373b Twist drill See Burr holes Tympanostomy, 484–485 audit report for, 490 Type of service, U Ulcers See Gastric ulcers Ultrasound appendix case, 125b audit reports, 140, 141 cesarean case, 433b characterization of, 92 Ultrasound (Continued) codes for, 124 for complicated pregnancy, 440, 441, 442 Doppler, 124–125 fetal heart monitoring, 433 gallbladder case, 125b, 126b guidance, 127 hemithorax case, 128b lower extremities case, 93b modes of, 124–127 prostate volume determination, 404–405b renal cases, 126b, 127b retroperitoneal case, 127b scans of, 124–127 Umbilical vein, 61 Unit/floor time, 16 Ureteral polyps, 392 Ureteral strictures, 399 Ureterocele, 392 Urethral strictures, 399 Urethropexy audit report for, 416 case of, 396b Urinalysis, 148–149 Urinary system audit reports, 414–416b conditions of bladder rupture, 396, 396–397b bladder stones, 397, 398b chronic renal failure, 390 congenital abnormalities, 392 cysts, 392 hydronephrosis, 397 hypertensive kidney disease, 85 renal calculus, 393 stress incontinence, 395 urethral strictures, 399 overview of, 390–399 procedures for cystoscopy, 397b ESWL, 394b meatotomy, 399b nephrectomy, 392, 393–394b nephrostomy tube placement, 391, 391–392b renal biopsy case, 390b stent insertion, 398–399b Turp, 398–399b urethropexy, 396b urodynamics, 393–395, 395b subcategories of, 392 Urine/stool analysis, 148–149 Urodynamics, 393–395, 395b Urologists, 390 V Vaccines See also Immunization administration of, 78 chart notes, 80b, 81b definition of, 78 Vaginal approach hysterectomy, 419 Valve insufficiencies, 229 Varicocele ligation, 414–415 Vascular disease, 138f Vasectomies, 402, 402b Ventriculostomy audit report for, 473–474 operative report, 451 procedure illustration, 469f Index Verteporfin, 96 Visual acuity chart, 477f Voiding pressure study (VCUG), 393–395 Volvulus, 264 W Whitmore-Jewett staging, 405f Wound repair characterization of, 193–195 laceration case, 194b Wound repair (Continued) scar revision case, 197b, 198b umbilicoplasty case, 196–197b Z Z/V codes chemotherapy, 30 general use of, 67–68 physical therapy, 97 sterilization, 402, 437 579 This page intentionally left blank ~StormRG~ ... RHIA, CCS, CCS-P* Coding and Consulting Services Abingdon, Maryland *Coauthor of ICD-9-CM Coding: Theory and Practice with ICD-10, 2013 /2014 Edition, and ICD-10-CM/PCS Coding: Theory and Practice,... vein The guidewire then directs the placement of the electrode into the heart while the surgeon views the progression using a fluoroscope The electrode is then attached to the pulse generator The. .. 3251 Riverport Lane St Louis, Missouri 63043 THE NEXT STEP: ADVANCED MEDICAL CODING AND AUDITING, 2014 EDITION ISBN: 978-1-4557-5897-5 Copyright © 2014, 2013, 2012, 2011, 2010, 2009, 2008, 2006,