Practical Application Workbook—Instructor
2012Medical Coding Training: CPC Practical Application Workbook—Instructor
DisclaimerThis course was current when it was published. Every reasonable effort has been made to assure the accuracy of theinformation within these pages. The ultimate responsibility lies with readers to ensure they are using the codes, andfollowing applicable guidelines, correctly. AAPC employees, agents, and staff make no representation, warranty, orguarantee that this compilation of information is error-free, and will bear no responsibility or liability for the resultsor consequences of the use of this course. This guide is a general summary that explains guidelines and principles inprofitable, efficient health care organizations.Notice Regarding Clinical Examples Used in this BookAAPC believes it is important in training and testing to reflect as accurate a coding setting as possible to students andexaminees. All examples and case studies used in our study guides, exams, and workbooks are actual, redacted officevisit 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 notesto the stringent grammatical or stylistic standards found in the text of our products. Some minor changes have beenmade for clarity or to correct spelling errors originally in the notes, but essentially they are as one would find them ina coding setting.US Government RightsThis product includes CPT , which is commercial technical data and/or computer data bases and/or commercialcomputer software and/or commercial computer software documentation, as applicable, which was developed exclusively 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/orcomputer data bases and/or computer software and/or computer software documentation are subject to the limitedrights restrictions of DFARS 252.227-7015(b)(2) (November 1995), as applicable, for U.S. Depart ment of Defenseprocurements and the limited rights restrictions of FAR 52.227-14 (June 1987) and/or subject to the restricted rightsprovision of FAR 52.227-14 (June 1987) and FAR 52.227-19 (June 1987), as applicable, and any applicable agency FARSupplements, for non-Department of Defense Federal procurements.AMA DisclaimerCPT 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, arenot part of CPT , and the AMA is not recommending their use. The AMA does not directly or indirectly practicemedicine 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 AAPC2480 South 3850 West, Suite B, Salt Lake City, Utah 84120800-626-CODE (2633), Fax 801-236-2258, www.aapc.comRevised 091211. All rights reserved.ISBN# 978-1-935809-73-9CPC , CPC-H , CPC-P , CIRCC , CPMA , and CPCO are trademarks of AAPC.ii2012 Medical Coding Training: CPC Practical Application Workbook—InstructorCPT copyright 2011 American Medical Association. All rights reserved.
AcknowledgementsAuthors:Katherine Abel, CPC, CPMA, CPC-I, CRMSDebra A. Apfel, RN, BA, CPC, CPMACarrie Bosela, CPC, CPC-IRhonda Buckholtz, CPC, CPC-I, CPMA, CGSC, CPEDC, COBGC, CENTCMarcella Bucknam, CPC, CPC-H, CPC-P, CPC-I, CCC, COBGCShelly Cronin, CPC, CPMA, CANPC, CGIC, CGSCKelly Dennis, CPC, CPC-I, CANPCMary Divine, CPC, CPC-H, CPC-I, CUCBrad Ericson, MPC, CPC, COSCRaemarie Jimenez, CPC, CPMA, CPC-I CANPC, CRHCBetty Johnson, CPC, CPC-H, CPC-I, CPCDDolly Perrine, CPC, CPMA, CPC-I, CUCJean Pryor, CPC, CPMA, CPC-I, CIMCDorothy Steed, CPC-H, CPMA, CPC-I, CEMC, CFPCKate Tierney, CPC, CPC-P, CEDC, CEMC, CGSC, COBGCG. John Verhovshek, MA, CPCSusan Ward, CPC, CPC-H, CPC-I, CEMC, CPCD, CPRCReviewers: Lynn Anderanin, CPC, CPC-I, COSCNicole Benjamin, CPC, CPC-I, CEDCGlade B. Curtis, MD, MPH, FACOG, CPC, CPC-I, COBGCJennifer Hume, CPC, CPMA, CEMCLindsay-Anne McDonald Jenkins, CPC, CPC-H, CPC-I, CPMA, CANPC, CIRCC, RN, CRNA (retired)Vandna Kejariwal, CPC, CPC-H, CPC-I, CEDCBarbara Pross, CPC, CPMA, CPC-I, CEDC, CEMC, COBGCCarrie Lynn Rawlings, CPC, CPMA, CPC-I, CCVTC, CEMCAlice Reybitz, RN, BA, CPC, CPC-H, CPC-I, CHICarrie Severson, CPC, CPC-H, CPC-P, CPMA, CPC-IKathy Skolnick, CPC, CPC-ICharleen Yamasato, CPC, CPC-IProduction: Dianne Allred, Designer, Desktop PublishingTina M. Smith, Desktop PublishingCPT copyright 2011 American Medical Association. All rights reserved.www.aapc.comiii
ContentsThe Business of Medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.1Exercise 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.1Medical Terminology and Anatomy Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.1Questions 1–10 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.1–2.2Introduction to ICD-9-CM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.1Exercise 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.1ICD-9-CM Coding Chapters 1–9 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.1Case 1–Case 10 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.1–4.11ICD-9-CM Coding Chapters 10–19 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.1Case 1–Case 10 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.1–5.11Introduction to CPT , Surgery Guidelines, HCPCS, and Modifiers . . . . . . . . . . . . 6.1Exercise 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6.1Exercise 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6.3Integumentary System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7.1Case 1–Case 10 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7.1–7.17Musculoskeletal System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8.1Case 1–Case 10 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8.1–8.19Respiratory, Hemic, Lymphatic, Mediastinum, and Diaphragm . . . . . . . . . . . . . . 9.1Case 1–Case 10 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9.1–9.12Cardiovascular System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10.1Case 1–Case 10 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10.1–10.15Digestive System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11.1Case 1–Case 10 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11.1–11.12CPT copyright 2011 American Medical Association. All rights reserved.www.aapc.comv
Urinary System and Male Genital System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12.1Case 1–Case 10 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12.1–12.15Female Reproductive System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13.1Case 1–Case 10 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13.1–13.15Endocrine and Nervous System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14.1Case 1–Case 10 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14.1–14.19Eye and Ocular Adnexa, Auditory Systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15.1Case 1–Case 10 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15.1–15.14Anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16.1Case 1–Case 10 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16.1–16.13Radiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17.1Case 1–Case 10 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17.1–17.13Pathology and Laboratory . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18.1Case 1–Case 10 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18.1–18.12Evaluation and Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19.1Case 1–Case 10 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19.1–19.21Medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20.1Case 1–Case 10 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20.1–20.11vi2012 Medical Coding Training: CPC Practical Application Workbook—InstructorCPT copyright 2011 American Medical Association. All rights reserved.
Chapter1The Business of MedicineExercise 11. What type of profession might a skilled coder enter?Answer: Consultants, educators, medical auditors2. What is the difference between outpatient and inpatient coding?Answer: Outpatient coders will focus on learning CPT , HCPCS Level II, and ICD-9-CMcodes volumes 1 and 2. They will work in physician offices, outpatient clinics, andfacility outpatient departments. Outpatient facility coders will also work with Ambulatory Payment Classifications (APCs).Inpatient hospital coding focuses on a different subset of skills, where coders willwork with ICD-9-CM volumes 1, 2, and 3. These coders also will assign MS-DRGs forreimbursement. Outpatient coders usually will have more interaction throughoutthe day, and must communicate well with physicians; inpatient coders tend to haveless interaction throughout the day.3. What is a mid-level provider?Answer: Mid-level providers include physician assistants (PA) and nurse practitioners (NP). Mid-level providers are known also as physician extenders because theyextend 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 inskilled nursing facilities, hospice care, and home health care. Medicare Part B helps to cover medically-necessary doctors’ services, outpatientcare, and other medical services (including some preventive services) not coveredunder Medicare Part A. Medicare Part B is an optional benefit for which thepatient must pay a premium, and which generally requires a yearly co-pay. Codersworking in physician offices will mainly deal with Medicare Part B. Medicare Part C, also called Medicare Advantage, combines the benefits ofMedicare Part A, Part B, and—sometimes—Part D. The plans are managed byprivate insurers approved by Medicare, and may include Preferred ProviderOrganizations (PPOs), Health Maintenance Organizations (HMOs), and others.CPT copyright 2011 American Medical Association. All rights reserved.www.aapc.com1.1
The Business of MedicineChapter 1 Medicare Part D is a prescription drug coverage program available to all Medicarebeneficiaries. Private companies approved by Medicare provide the coverage.5. Evaluation and management services are often provided in a standard formatsuch as SOAP. What does SOAP represent?Answer:S—Subjective—The patient’s statement about his or her health, includingsymptoms.O—Objective—The provider assesses and documents the patient’s illness usingobservation, palpation, auscultation, and percussion. Tests and other servicesperformed may be documented here as well.A—Assessment—Evaluation and conclusion made by the provider. This is usuallywhere 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 unlessthere are further defined diagnoses or additional diagnoses found in the body orfindings of the operative report. If a pathology report is available, use the findings from the pathology report for the diagnosis.2. Start with the procedures listed—For the coder who is new to coding a procedure, one way of quickly starting the research process is by focusing on theprocedures listed in the header. Read the note in its entirety to verify the procedures performed. Procedures listed in the header may not be listed correctly andprocedures documented within the body of the report may not be listed in theheader at all; however, it will help a coder with a place to start.3. Look for key words—Key words may include locations and anatomical structuresinvolved, surgical approach, procedure method (debridement, drainage, incision,repair, etc.), procedure type (open, closed, simple, intermediate, etc.), size andnumber, and the surgical instruments used during the procedure.4. Highlight unfamiliar words—Words you are not familiar with should be highlighted and researched for understanding.5. Read the body—All procedures reported should be documented within thebody of the report. The body may indicate a procedure was abandoned orcompli cated, possibly indicating the need for a different procedure code or thereporting of a modifier.1.22012 Medical Coding Training: CPC Practical Application Workbook—InstructorCPT copyright 2011 American Medical Association. All rights reserved.
Chapter 1The Business of Medicine7. What is medical necessity and what tool can you refer to for the medicalnecessity of a service?Answer: The term “medical necessity” relates to whether a proce dure or service isconsidered appropriate in a given circumstance. Tools to determine medical necessity include National Coverage Determinations (NCDs), Local Coverage Determinations (LCD), and commercial Medical Policies.8. What are some common reasons Medicare may deny a procedure or service?Answer: Medicare does not pay for the procedure/service for the patient’s condition Medicare does not pay for the procedure/service as frequently as proposed Medicare does not pay for experimental procedures/services9. Under the Privacy Rule, the minimum necessary standard does not apply towhat type of disclosures?Answer: Disclosures to or requests by a health care provider for treatment purposes. Disclosures to the individual who is the subject of the information. Uses or disclosures made pursuant to an individual’s authorization. Uses or disclosures required for compliance with the HIPAA AdministrativeSimplification Rules. Disclosures to the U. S. Department of Health and Human Services (HHS) whendisclosure of information is required under the Privacy Rule for enforcementpurposes. Uses or disclosures that are required by other law.10. What are the seven key actions of an internal compliance plan?Answer: Conduct internal monitoring and auditing through the performance of periodic audits.Implement compliance and practice standards through the development ofwritten standards and procedures.Designate a compliance officer or contact(s) to monitor compliance efforts andenforce practice standards.Conduct appropriate training and education on practice standards andprocedures.Respond appropriately to detected violations through the investigation ofallegations and the disclosure of incidents to appropriate government entities.CPT copyright 2011 American Medical Association. All rights reserved.www.aapc.com1.3
The Business of MedicineChapter 1 Develop open lines of communication, such as (1) discussions at staff meetingsregarding how to avoid erroneous or fraudulent conduct and (2) communitybulletin boards, to keep practice employees updated regarding complianceactivities. Enforce disciplinary standards through well-publicized guidelines.1.42012 Medical Coding Training: CPC Practical Application Workbook—InstructorCPT copyright 2011 American Medical Association. All rights reserved.
Chapter2Medical Terminology and Anatomy Review1. Diagnosis: Calcification left basal ganglia.Where are the basal ganglia located?Answer: Cerebral Cortex2. Diagnosis: Vesicoureteral reflux.What is this a reflux of?Answer: Urine backflow from bladder into ureters.3. Documentation: The posterior vaginal fornix and outer cervical os were preppedwith a cleansing solution.In this statement, what does “os” stand for?Answer: Ostium (Opening)4. Hysterosalpingogram report: “Right cornual contour abnormality.”What is the cornua referred to?Answer: The cornua is where the fallopian tubes connect to the fundus.5. Surgical Procedure: MyringotomyWhat anatomic location is being operated on?Answer: Ear6. Documentation: There was no cleft of the uvula or sub mucosal palate by visualand palpable exam.What is being examined?Answer: Oral cavity7. Documentation: Recession of left inferior rectus muscle, 5 mm.What anatomic location is being operated on?Answer: Eye8. Diagnosis: KyphosisWhat anatomic location does this diagnosis refer to?Answer: Thoracic SpineCPT copyright 2011 American Medical Association. All rights reserved.www.aapc.com2.1
Medical Terminology and Anatomy ReviewChapter 29. Documentation: Suprapatellar recess showed no evidence of loose bodies or jointpathology.What anatomic location does this refer to?Answer: Knee (above the patella)10. Colles’ FractureWhat anatomic location does this refer to?Answer: Wrist2.22012 Medical Coding Training: CPC Practical Application Workbook—InstructorCPT copyright 2011 American Medical Association. All rights reserved.
Chapter3Introduction to ICD-9-CMExercise 1Directions: Using the ICD-9-CM coding manual, locate the diagnosis codes for thefollowing conditions.1. FeverAnswer: 780.60Rationale: From the Index to Diseases, look up Fever. There is no additional information provided. The default code is 780.60. Review the code in the Tabular List toverify code accuracy.2. Migraine headacheAnswer: 346.90Rationale: From the Index to Diseases, look up
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-
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5.1 Customizing Your SWMOR-Alt Workbook . To begin customizing your SWMOR -Alt workbook, refer to Chapter 1 for instructions on accessing and opening a blank copy of an MOR workbook. Save a blank copy of the workbook on your desktop. After you open the workbook, select [Enable Content
Microsoft Excel Basic 1. Setting up a workbook Creating Workbooks o Excel Terminology o Excel Environment o Customizing Quick Access Toolbar o Creating a New Workbook o Entering Data into Workbook o oSaving a workbook o Open a workbook o Zoom o Insert a new worksheet o Renaming a new worksheet o 3.Changing the tab colour of worksheet
