Study Guide

Medical Coding By

Sheila McCray

About the Author

Sheila D. McCray, MS, CCS, CCS-P, has worked in the healthcare industry since 1987 as a medical claims examiner, medical tran- scriptionist, medical transcription quality assurance editor, medical coder, healthcare instructional designer, and healthcare subject matter expert. She has also worked as an online adjunct professor for several online universities, teaching a variety of healthcare courses.

As a healthcare instructional designer, Sheila regularly writes, reviews, and revises courses about healthcare topics. She’s the owner of Avidity Medical Design, an instructional design consulting practice specializing in curriculum development for the healthcare sector.

Copyright © 2016 by Penn Foster, Inc.

All rights reserved. No part of the material protected by this copyright may be reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, or by any information storage and retrieval system, without permission in writing from the copyright owner.

Requests for permission to make copies of any part of the work should be mailed to Copyright Permissions, Penn Foster, 925 Oak Street, Scranton, Pennsylvania 18515.

Printed in the United States of America

All terms mentioned in this text that are known to be trademarks or service marks have been appropriately capitalized. Use of a term in this text should not be regarded as affecting the validity of any trademark or service mark.

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INSTRUCTIONS TO STUDENTS 1

LESSON ASSIGNMENTS 7

LESSON 1: DIAGNOSIS CODING WITH ICD-10-CM 9

LESSON 2: PROCEDURE CODING WITH ICD-10-PCS 31

LESSON 3: EVALUATION AND MANAGEMENT AND ANESTHESIA CODING 51

LESSON 4: SURGICAL CPT CODING, PART 1 63

LESSON 5: SURGICAL CPT CODING, PART 2 73

LESSON 6: SURGICAL CPT CODING, PART 3 81

LESSON 7: SIMILARITIES AND DIFFERENCES BETWEEN HCPCS LEVEL II AND CPT 89

GRADED PROJECT 95

CHAPTER REVIEW ANSWERS 101

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.

Instructions to Students 3

Instructions to Students

Note: The questions found in the Chapter Reviews may include directions to find ICD-9-CM codes for diagnoses. Because ICD-10 has replaced ICD-9 as the standard coding system, you won’t have an ICD-9 book in which to find these codes; therefore, code for CPT and ICD-10 codes only.

YOUR STUDY GUIDE Use this study guide as a companion to your textbook. The study guide also includes a lesson study plan that helps you explore ICD-10 fundamentals quickly and easily.

This study guide is divided into lessons, each with a practical overview of the topic, and several study assignments. Each reading assignment in Step-by-Step Medical Coding includes a series of practical coding exercises, which you’ll need to com- plete as you work through the textbook assignments. At the end of each lesson, you must complete an online, multiple- choice examination. Submit each examination for grading as soon as you complete it.

COURSE MATERIALS This part of your program includes the following materials:

1. This study guide, which offers an introduction to your textbook, plus

� A lesson assignments page, which lists the study assignments in your textbook and lesson exams

� Explanatory material, which emphasizes the main points of the instruction to support the chapter material covered in Step-by-Step Medical Coding

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Important: If you don’t fully understand ICD-10 coding concepts

now, you won’t be able to apply the concepts later on when you start

to assign medical codes to diagnoses and procedures using each of

these code sets. Therefore, it’s very important that you take the time

to learn each concept before moving on to the next.

Instructions to Students 5

2. Your program textbook, Step-by-Step Medical Coding, which contains your assigned readings, exercises and answers

3. ICD-10-CM Professional Edition for Physicians

4. ICD-10-PCS

5. CPT

Make sure you have all of these materials before starting the course.

A STUDY PLAN Take the time to review the material as many times as you need to. Your effort will be well worth it in the long run!

Each of your textbook assignments helps you develop a solid foundation in diagnosis and procedural coding. Using codes for both diagnosis of diseases and the procedures used to treat them facilitates payment for health services, research into quality and cost, and planning for future healthcare needs. You’ll learn a great deal of technical information, so take your time as you move through each chapter.

To get the most out of this course, you’ll need to schedule several study periods over the course of the week. Devote at least one to three hours each day to reading, learning, and mastering each set of coding concepts. Again, it’ll be well worth it! If you devote the time to your studies now, as you move through the course, you’ll feel less stressed and frus- trated when you start to code. You’ll also begin to gain confidence for the intermediate and advanced medical coding scenarios that will come later.

Work through this study guide one assignment at a time. Keep your ICD-10-CM and ICD-10-PCS references handy as you review each lesson. You’ll need them to complete the lesson exercises. Once you’ve finished all of the assignments included in each lesson, you’ll be ready to complete the exam.

Instructions to Students6

To get the most out of your studies, follow these steps to complete your assignments:

Step 1: Carefully note the pages where your assigned reading begins and ends. These pages are iden- tified in the Lesson Assignments section of this study guide.

Step 2: Skim through the assigned pages (in both the study guide and the textbook) for a general idea of their content. Try to develop an overall per- spective on the concepts and skills being taught and practiced in each assignment.

Step 3: Carefully read through the study guide’s assigned pages. These pages contain back- ground information about the material covered in the textbook.

Step 4: Read the assigned pages in your textbook, and take notes on any important concepts or terms.

Step 5: When you’ve mastered all of the material for each assignment, proceed to your next study guide assignment. Repeat steps 1–4 for the remaining assignments in each lesson.

Step 6: Once you’ve finished all the assignments, Quick Checks, Exercises, and Chapter Reviews in each lesson, proceed to the examination. Take your time with the exam. As you work, feel free to refer to your textbook, the study guide, and any notes you’ve taken.

Step 7: Repeat steps 1–6 for the remaining lessons in your study guide.

Remember: At any point in your studies, you can email your instructor for additional clarification. Now look over your les- son assignments and begin your study of medical coding with Lesson 1, Assignment 1.

Remember to regularly check your student portal. Your instructor may

post additional resources that you can access to enhance your learn-

ing experience.

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Lesson 1: Diagnosis Coding With ICD-10-CM For Read in the Read in the

study guide textbook

Assignment 1 12–16 Pages xviii-xxii

Assignment 2 17–22 Chapter 2, pages 26–40

Assignment 3 22–25 Chapter 2, pages 41–50

Assignment 4 25–27 Chapter 3

Assignment 5 27–29 Chapter 4

Examination 480822 Material in Lesson 1

Lesson 2: Procedure Coding With ICD-10-PCS For Read in the Read in the

study guide textbook

Assignment 6 31–47 Chapters 5–7

Assignment 7 47–50 Chapter 27

Examination 480823 Material in Lesson 2

Lesson 3: Evaluation and Management and Anesthesia Coding For Read in the Read in the

study guide textbook

Assignment 8 Pages 54–56 Chapter 8

Assignment 9 Pages 56–57 Chapter 10

Assignment 10 Pages 58–60 Chapter 11

Assignment 11 Page 61 Chapter 12

Examination 480824 Material in Lesson 3

Lesson 4: Surgical CPT Coding: Part 1 For: Read in the Read in the

study guide: textbook:

Assignment 12 Page 64 Chapter 13

Assignment 13 Page 65 Chapter 14

Assignment 14 Pages 66–67 Chapter 15

Lesson Assignments8

Assignment 15 Pages 67–68 Chapter 16

Assignment 16 Pages 68–72 Chapter 17

Examination 480825 Material in Lesson 4

Lesson 5: Surgical CPT Coding: Part 2 For: Read in the Read in the

study guide: textbook:

Assignment 17 Pages 74–75 Chapter 18

Assignment 18 Page 75 Chapter 19

Assignment 19 Pages 76–77 Chapter 20

Assignment 20 Pages 78–80 Chapter 21

Examination 480826 Material in Lesson 5

Lesson 6: Surgical CPT Coding: Part 3 For: Read in the Read in the

study guide: textbook:

Assignment 21 Pages 82–83 Chapter 22

Assignment 22 Pages 83–84 Chapter 23

Assignment 23 Page 85 Chapter 24

Assignment 24 Page 86 Chapter 25

Assignment 25 Pages 87–88 Chapter 26

Examination 480827 Material in Lesson 6

Lesson 7: Similarities and Differences between HCPCS Level II and CPT For: Read in the Read in the

study guide: textbook:

Assignment 26 Pages 90–93 No Readings

Graded Project 48082800 Materials in Lessons 1-7

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Diagnosis Coding with ICD-10-CM Medical coders review the documents in the patient’s medical record and abstract (collect clinical data) or retrieve informa- tion from specific documents. They then assign numeric or alphanumeric codes to each piece of data they retrieve.

Medical coders must use their skills in research, reasoning, and interpretation of medical coding guidelines to ensure that physicians and hospitals are reimbursed accurately and com- pletely for the services that they provide.

This part of your program will introduce you to this exciting field. You’ll learn all about ICD-10 medical coding and the steps involved in assigning diagnosis and procedure codes using this code set. The material that follows will lead you step-by-step through a wide range of ICD-10 coding exam- ples, offering invaluable tips and suggestions that you can use along the way. You’ll also find Quick Checks and Exercises in your textbook. Be sure to complete all of these additional practice tools to help you fine-tune your coding skills, master the fine points of ICD-10 coding, and learn about a wide range of medical terms. Doing so will further sharpen your skills, strengthen your ability to accurately interpret these terms, and, in turn, translate these terms into accurate code.

By choosing to learn medical coding, you’re embarking on a journey that essentially means learning a new language. Although this new language may seem a bit complicated and overwhelming at first, it becomes easier once you learn the basics of ICD-10 coding (and with lots and lots of practice). Your confidence will increase as you learn the basics and then apply what you learn to basic coding scenarios.

The important thing to remember is that you don’t ever have to feel lost. The coding steps, along with the coding guide- lines, tell you exactly what you need to do. If you do feel yourself getting off track though, connect with other students in the program on the Medical Billing and Coding Academic Space on the Penn Foster Community. You can see if other students are encountering the same difficulties and learn

Medical Coding10

how they’ve overcome these difficulties. You can also create study groups and find study buddies to help make your learning experience even better.

Your instructor is also a valuable resource. You can connect with your instructor on the Medical Billing and Coding Academic Space. It’s always much better to ask for help, rather than become frustrated and try to figure things out on your own. As you move forward, you’ll find yourself becoming more comfortable with the medical terms, processes, and pro- cedures that coders use every day. Just remember not to put too much pressure on yourself to master coding overnight. When you begin to code, don’t expect to get every single code right—you won’t. The key to learning medical coding is being willing to make mistakes. Experienced coders had to make many coding errors along the way to gain the experience they now have. When you make an error in your code selection, retrace your steps and find out where you went wrong, so the next time you’ll be less likely to make the same mistake. Remember that a mistake is never a mistake if you learn from it! Keep this in mind as you move forward through your coding courses.

By the time you finish Medical Coding, you’ll have gained many of the skills you need to accurately assign ICD-10 codes.

As a medical coder, you’ll use the ICD-10-CM (often called ICD-10 or I-10), to assign different codes depending on the circumstances surrounding the patient encounter. The patient encounter is the episode of care that takes place on one or more specific dates, when the physician evaluates the patient and provides treatment. During the encounter, the patient relates the symptoms or chief complaint that brought the patient to the office, clinic, or hospital. Based on the patient’s reported symptoms, as well as the results of any examinations, x-rays, laboratory reports, or specialist consul- tations, the physician will determine the most likely cause of the patient’s symptoms, or diagnosis. If the patient comes in complaining of coughing, sneezing, and congestion, the physician may ultimately determine that the patient has influenza. As a coder, you’d assign the diagnosis code for flu, along with codes that pertain to the service or treatment pro- vided in relation to the patient’s flu. Likewise, if the patient is

Lesson 1 11

seen because of difficulty walking due to a swollen ankle, an x-ray may reveal a fracture, in which case the physician’s diagnosis would be ankle fracture. The physician may also determine that the patient has more than one diagnosis, in addition to the one that brought him or her to the office. The physician may determine that in addition to the fractured ankle, the patient has several chronic conditions that require treatment. Examples of chronic conditions include hyperten- sion, diabetes mellitus, and any conditions that require ongoing treatment or monitoring and regularly prescribed medication. You’d assign diagnosis codes for the fractured ankle and the chronic conditions that require ongoing treatment.

As a medical coder, you’ll use the ICD-10-CM to look up the patient’s diagnosis (or diagnoses if there’s more than one). After you find the diagnosis, you’ll review the code descrip- tions, follow any additional instructions that are provided in the ICD-10-CM regarding code assignment, and then assign your code. You’ll then follow the same process to assign sub- sequent diagnosis codes. If you’re working as an inpatient coder, you’ll also use the ICD-10-CM to assign procedure codes for inpatient surgical procedures.

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

� Define the process of medical coding

� Explain the tools used by medical coders

� Outline the skills necessary for a successful career in medical coding

� Summarize examples of medical coding certifications

� Describe other careers in medical coding

� Summarize the history of medical coding

� Explain the process of general equivalence mapping

� Summarize how to use ICD-10-CM

Medical Coding12

� Explain the guidelines for the first-listed diagnosis

� Explain the steps for accurate coding

� Locate and assign codes in ICD-10-CM

� Summarize key concepts of multiple coding, acute and chronic condition coding, and laterality coding

ASSIGNMENT 1 Read through the following material in your study guide. Then, read the Introduction in your textbook, Step-by-Step Medical Coding.

Introduction to Medical Coding Recent changes in healthcare have created a great demand for medical coders. An older population; advances in techno – logy; an increased demand for healthcare services; and an increase in the number of medical tests, treatments, and pro- cedures means that the number of people seeking healthcare services has increased. Additionally, the increased use of outpatient facilities means that the government is exerting greater control and becoming more involved with services provided to Medicare and Medicaid patients. These changes in healthcare have resulted in an increased demand for certi- fied medical coders.

Prominent healthcare organizations in the field of medical coding include the American Health Information Management Association (AHIMA) and the American Academy of Professional Coders (AAPC). Both of these organizations offer credentials in medical coding. Certifications offered by both organizations are nationally recognized and accepted by healthcare employ- ers worldwide. Most coders choose to sit for one of four certifications: the CPC-A, CPC, CCS, or CCS-P.

The CPC-A and the CPC are both offered by the AAPC. CPC (Certified Professional Coder) indicates that you’ve completed the necessary educational requirements and now have experi- ence in the field. In CPC-A, the A stands for apprentice. The CPC-A demonstrates that you’ve completed the necessary

Lesson 1 13

educational requirements for a career in coding, but haven’t yet obtained the required experience in reviewing, abstract- ing, interpreting, and correctly assigning codes. After you earn the required two years of full-time coding experience, the A is dropped from the credential and you become a CPC.

CCS and CCS-P are certifications offered by AHIMA. CCS (Certified Coding Specialist) demonstrates that you’ve gained proficiency in assigning codes to inpatient as well as outpatient medical records. CCS-P indicates that a coder is adept at coding medical records in the outpatient setting, such as in the physician’s office, emergency room, or clinic. Although many coders do, it isn’t necessary to earn more than one credential to demonstrate proficiency in a certain area of coding. At least one credential is needed to gain entry into the field of medical coding.

Success in medical coding means being able to convert medical terms into standardized numeric and alphanumeric codes for physician and hospital reimbursement. The rule of thumb for medical coding is: If it wasn’t documented, it wasn’t done.

While coders are primarily concerned with correct interpreta- tion of coding guidelines, accurate code assignment, and optimized reimbursement for physicians and hospitals, medical coding also involves ethical concerns. Medical coders must ensure that the codes they select accurately reflect what’s in the patient’s medical record. All diagnosis and procedure codes should be assigned based strictly on the content of the medical record.

Coders use standardized code sets to assign codes for diag- noses, procedures, drugs, medical devices, supplies, and equipment. (You’ll learn more about the code set used for drugs, medical devices, supplies, and equipment later in Medical Coding). Accurate and complete coding helps mini- mize turnaround in terms of medical claims processing, and as a result, it helps expedite reimbursement for physicians and hospitals. In addition to increasing the likelihood of faster claims turnaround, accurate and complete coding also minimizes the likelihood of fraud. Medical coders are required by law to assign codes based only on the documentation in the medical record. Assigning codes that aren’t supported by

Medical Coding14

the medical record to increase reimbursement constitutes fraud and can result in civil and criminal penalties for healthcare facilities.

Proficiency in medical coding means learning both how to determine the specific piece of data that requires a code assignment and the rules for assigning your codes.

Coders use two types of tools to assign codes: textbooks and encoders. Encoders are coding software programs that you can use to locate and assign diagnosis and procedure codes. However, when you test for a medical coding certification such as the CPC-A, you’ll be required to use your coding textbooks to assign codes. The textbooks that you’ll use in this course are

� The International Classification of Diseases, 10th Revision, Clinical Modification (commonly referred to as ICD-10-CM)

� The International Classification of Diseases, 10th Revision, Procedure Coding System (commonly referred to as ICD-10-PCS)

Being a Coder To be successful in medical coding, you must be

� Detail oriented. In medical coding, the old adage “little things mean a lot” is especially true. The descriptions for two codes may be identical except for one word. That one word may be the difference in choosing code A vs. code B. If you’re good at picking up on the little things, then you’ll enjoy coding.

� A detective. If you like being a sleuth and researching coding guidelines to understand how, when, and where you should assign a specific code, then you’ll like med- ical coding.

Note: As you proceed through your assigned reading, be sure to

complete the Quick Checks and Exercises, which will reinforce the

reading material.

Lesson 1 15

� A good storyteller. Much of coding involves reading the medical record and then painting a mental picture in your mind of what took place, as if you were right there in the doctor’s office or emergency room. If you can visualize what occurred based on what you read in the medical record, you’ll love medical coding.

� Analytical. If you’re good at analyzing pieces of infor- mation from different documents in the same record and finding contradictory information, then medical coding is a great career choice for you. Maybe you’re working on a medical chart for a patient who was admitted to the hospital. Dr. Brown’s report indicates that the patient has diabetes, which is well controlled on insulin, but Dr. Smith’s report indicates that the patient has diabetes, but it isn’t well controlled on insulin. These are two dif- ferent doctors saying two different things about the same patient’s diabetes, and hence, these two statements would translate into two different diabetes codes for the same admission. You would need to determine which statement is correct so that you can assign the right code.

In the previous example, you’d need to send a query to the hospital to determine whether the patient’s diabetes is con- trolled or out of control. You’d then assign your diabetes code based on the answer you receive from the hospital, and the answer would be placed in the patient’s medical record so that the record is kept up to date.

You develop each of these skills as you proceed through Medical Coding, as well as the courses that follow.

In addition to being able to accurately review and abstract clinical data from the medical record, good computer skills are essential to your success as a medical coder for several reasons.

1. If you work from home, you’ll need to set up a connec- tion to your employer’s office or the hospital client to which you’re assigned in order to access medical charts.

Your company’s IT department or the hospital’s technical support department will help you do this. You may need to access and navigate specific websites and download certain programs to sign in to the system and begin to

Medical Coding16

code your charts. The setup process should be relatively simple, but you’ll need to be able to follow the directions provided by the IT person to set up the website links on your computer and begin coding.

2. On a daily basis, you’ll log in to the website provided by your company, retrieve charts, open reports within each chart, and review the documents to locate your codes.

3. You’ll also need to go online to research medical or surgical terms that pertain to a specific diagnosis or pro- cedure. This is why it’s important to complete courses in medical terminology, anatomy, and physiology in addi- tion to your coursework in medical coding.

Once you start working as a coder, you’ll find that the oppor- tunities in coding are plentiful, from coding for doctors’ offices and hospitals to educating new coders. You’ll likely have more than one kind of coding position during your career. You might initially start working as a medical coder and later become a medical coding auditor, for example. A medical coding auditor reviews the charts coded by the med- ical coders, pinpoints errors, and provides feedback on making corrections. The auditor also provides references to supplemental coding documents to help coders improve their accuracy. You might become a medical coding supervisor, overseeing a team of medical coders and assigning accounts. Or, you may choose to specialize in one particular area of medical coding, such as cancer registry, where you review medical records and capture diagnoses for cancer patients, and obtain a medical coding certification in cancer registry.

Now that you’ve completed Assignment 1, it’s time to review the Introduction to Step-by-Step Coding. As you review the Introduction, you’ll learn more about the anticipated job growth in the medical coding field, as well as the salaries for credentialed medical coders, categorized by region, job responsibility, workplace, work setting, and job level.

Lesson 1 17

ASSIGNMENT 2 Read through the following material in your study guide. Then, read Chapter 2, pages 26–40, of your textbook, Step-by-Step Medical Coding.

History of ICD-10 Medical Coding In order to understand the history of ICD-10-CM in relation to medical coding, it’s necessary to understand how ICD-10 evolved and why it’s necessary for accurate coding.

The United States started using ICD-10 to report mortality in 1999, but didn’t fully adopt ICD-10 until October 1, 2015. However, the United Kingdom actually began using the ICD-10 in 1995, along with 200 other countries, that used all or part of ICD-10. The World Health Organization (WHO) still main- tains the ICD, although they stopped supporting the ICD-9 in 2012. The Centers for Medicare and Medicaid Services (CMS) along with the American Hospital Association (AHA) and the National Center for Health Statistics (NCHS) are responsible for maintaining the ICD-10-CM and ICD-10-PCS. ICD-10-PCS replaced ICD-9-CM Volume 3 as the component used to assign procedure codes for patients having surgery in the hospital. We’ll cover ICD-10-PCS later in this course.

ICD-10-CM was created for several reasons. First, ICD-9-CM had run out of room to expand. New diseases and new disor- ders are constantly being discovered, and the ICD-9-CM code set didn’t have room for any new codes. Since the ICD-9-CM code structure didn’t include sufficient detail about the patient’s condition, these codes needed to be revised for greater specificity and more comprehensive coverage of each element of the patient’s diagnosis.

ICD-10 is a new and improved version of the old ICD-9 code set. The ICD-10 is like a huge rubber band that can stretch to put more detail into each code, thereby eliminating the need for multiple codes while simultaneously improving specificity. The reason that more information can be packed into each ICD-10 code is because of its revised structure. ICD-10 incorporates common fourth- and fifth-character sub- classifications in one code. For example, a patient who is

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diagnosed with abusing alcohol and also having mood disor- ders because of the alcohol abuse can now be assigned to one code in ICD-10, rather than two codes in ICD-9. Each ICD-10 code can accommodate six characters, and even expand to seven characters, whereas ICD-9 codes only con- tained four digits and could only expand to a maximum of five characters. In a case involving a patient with complications resulting from diabetes mellitus, for example, the coder would have had to assign two codes: one for the diabetes mellitus and one for the complication resulting from it. However, ICD-10 can expand to combine everything in one code.

Symptoms can be combined with the diagnosis in the same code. Injury codes can be expanded to include more details, such as whether the patient is being seen the first time for the injury, whether it’s a subsequent visit, or whether the visit is due to a sequel, an aftereffect of a disease or injury.

The structure of ICD-10-CM is similar to the structure of the old ICD-9-CM, but the new ICD-10 code set includes two additional chapters: one pertaining to diseases of the eye, and one pertaining to diseases of the ear. ICD-10 also adds infor- mation pertaining to ambulatory and managed care visits.

In summary, improvements offered with ICD-10-CM include

� Adding information that pertains to ambulatory and managed care visits

� Expanded codes pertaining to injury

� Extensive injury code expansion to increase the speci- ficity of each code

� Combining diagnoses and symptoms in one code, thereby reducing the number of codes required to report a condition

� Adding a sixth character to the diagnosis code

� Incorporating subclassifications of fourth and fifth characters

� Updating codes for diabetes mellitus and making them more specific

� Making code assignment more specific

Lesson 1 19

Unlike ICD-9-CM, the category codes in the ICD-10-CM begin with a letter. The following sample illustrates the structure of the ICD-10-CM system:

Chapter 1: Certain Infectious and Parasitic Diseases (A00-B99)

Chapter 2: Neoplasms (C00-D49)

Chapter 3: Diseases of the Blood and Blood-Forming Organs (D50-D89)

Chapter 4: Endocrine, Nutritional and Metabolic Diseases (E00-E89)

Chapter 5: Mental, Behavioral and Neurodevelopmental Disorders (F01-F99)

General Equivalence Mapping (GEM) You may wonder how to confirm whether you have the cor- rect ICD-10-CM equivalent code that matches the code that you would have chosen in the earlier ICD-9-CM code set. The general equivalence mapping (GEM) files were developed to help you map ICD-10 codes back to the old ICD-9 code set and vice-versa. General equivalence mapping is bidirectional, meaning that you can map the new ICD-10 codes back to the original ICD-9 codes, and map the original ICD-9 codes to the new ICD-10 codes.

Mapping ICD-9 codes to ICD-10 codes is called forward mapping. When you map ICD-10 codes back to their original ICD-9 codes, the process is called backward mapping. One thing to keep in mind: when you review the GEM files to determine the equivalent mapping codes, you’ll notice that the GEM files don’t include decimals. Remember this when you map your codes. You’ll have to mentally insert the deci- mal point so that you understand the code that you’re seeing in the GEM file. For example, in ICD-9-CM, the diagnosis code for salmonella meningitis was 003.21. When you locate this ICD-9-CM code in your GEM file, you’ll see 00321, with- out the decimal. The new equivalent ICD-10-CM code is A02.21. So the old ICD-9-CM code 003.21 maps directly to the new ICD-10-CM code, which is A02.21. This is an

Medical Coding20

example of forward mapping. If you found the ICD-10-CM code first, and then found the old ICD-9-CM code second, you would have done backward mapping.

There’s one GEM file for forward mapping and one GEM file for backward mapping. The GEM file for forward mapping has three columns in this order: ICD-9, ICD-10, and Flag. The GEM file for backward mapping also has three columns: ICD-10, ICD-9, and Flag. It all depends on the direction that you’re going in terms of mapping your codes.