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 FREE CODING OVERVIEW

A. Coder background: Coding generally requires a good background in medicine,

but it doesn’t entirely exclude those who have little or no background. Coding is
generally done by a variety of staff in the provider’s office, but most do not have the
background in medical terminology to allow good fundamental judgment in utilization
of codes. Since few prospective employees have the needed background, most must
receive some kind of training which is generally hit and miss resulting in errors in
billing (and in horrendous liability to the provider). Hospitals have a higher volume
of billing dollar volume, and information requiring coding, so they generally have a
more conscientious training process, but still have a difficult time finding good
candidates to train and often unreliable methods for supervision.

B. Coding Manuals: The coder should have the coding manuals needed: A
current CPT code book (these are updated annually with the addition and deletion of
codes) and the ICD (ICD-9-CM) manual, which is generally provided in combined
volumes 1 and 2 (and 3). This combined volume is all that will be needed for the
physician or outpatient office. We provide the AMA CPT book and the Easy Coder in
our training program rather than the multivolume sets, which are more cumbersome
to use. These codebooks are included in the course Meditec provides.

Hospitals and standalone surgery clinics, as well as private practices, use the ICD
Volume 3, which describes procedures in a 2-digit format, with 2 digits to the right of
the decimal. Also, coders will use HCPCS (Health Care Finance Administration)
codes, which describe durable goods, supplies, and provide more definition on some
of the CPT codes. These books may be ordered through most large bookstores, state
Blue Cross offices, the American Medical Association (800-621-8335). If you have
any trouble finding or ordering the books, let us know (www://meditec.com).

C. Here are some coding exercises for you to try to see how it all works.

Let’s start with wounds, fractures, burns and surgery codes (CPT codes).

Wounds are classified as Simple, Intermediate or Complex. Simple repair is for

superficial wounds involving the epidermis or dermis or subcutaneous tissue without
significant involvement of deeper structures and require one layer closure. This closure
includes anesthesia and chemical or electrocautery of the wound. For our purposes, we
will be practicing using only the simple codes. A couple types of fractures are noted,
as well as treatment for burns. A few surgical codes are listed for reference.

CPT CODES: These are procedure or service codes.

Examples:

Code Description Size

12001* Simple repair of wound of scalp, neck, axillae, external genitalia, trunk
and/or extremities (including hands and feet) 2.5 cm or less

12002* Same 2.6 cm to 7.5 cm

12004* Same 7.6 cm to 12.5 cm
12005 Same 12.6 cm to 20.0 cm
Fractures - Examples:

27530 Closed treatment of tibial fracture, proximal, without manipulation

27535 Open treatment of tibial fracture, proximal plateau, unicondylar, with or
without internal or external fixation

Burns - Local Treatment - Examples:

16010 Dressings and/or debridement, initial or subsequent, under anesthesia

16020 * Same as 16010 without anesthesia, office or hospital, small

Surgery - Examples:

44950 Appendectomy; (incidental appendectomy during intra-

abdominal surgery does not usually warrant a separate
identification. If necessary add modifier -52 or 09952)
47562 Laparoscopy, surgical; cholecystectomy (any method)
47563 As in 47562 with cholangiography
58150 Total abdominal hysterectomy (corpus and cervix)

As you now know, the above codes are CPT codes. In order for you to do the
exercises, you need some ICD codes as well. Listed here are enough codes to do the
coding exercise reports. The actual ICD books have thousands of codes and, of course,
are not reproduced here. The diagnoses are arranged in alphabetic order by condition
similar to ICD-9-CM Volume II. When actually doing coding, the alphabetic listing is
first located, then checked in Volume I (numeric code listing) to make certain it is the
most correct numeric code option. If you are in our Coding Course, you will be using a
one-volume Easy Coder.

EXAMPLES ICD CODES (ALPHA): These are the diagnosis codes.

Burn
leg 945.00
second degree 945.20
Cellulitis
leg, except foot 682.6
Cholelithiasis 574.5#
 Note: Use the fifth digit subclassifcation = 0 (547.50) without mention of
obstruction or
1 =574.51) with obstruction
with cholecystitis (chronic) 574.4
acute 574.3
Dehydration 276.5
Diabetes 250.0
Fracture, tibia, open 823.90
Hypertension
essential, unspecified 401.9
Injury, superficial, head, (and other part(s) of face, neck, or scalp, except eye) 910
Keratosis 702.##
seborrheic 702.11
Ketoacidosis 276.2
diabetic 250.1
Noninflammatory disorders of ovary, fallopian tube and broad ligament 620
620.2 Other and unspecified ovarian cyst (serous)
Pain, chest (central) 786.50
wall (anterior) 786.52
Pyelonephritis 590.80
acute 590.10
Scoliosis (acquired)(postural) 737.30
Sprain/strain
ankle 845.00
Tonsillitis (acute) 463
Urinary tract infection 599.0
Wound, open, scalp 873.0
complicated 873.0

CODE THE REPORTS

Now, read the following reports and check the above code listings to find the answers
by selecting the appropriate CPT (treatment/procedure) and ICD (diagnosis) codes
from the previous sections. Then check your answers against the one provided.

Report 1. The patient is a 7-year-old male who has not been seen in our office before
who fell off a bicycle, hit his head and sustained a 3 cm scalp laceration. The wound is
linear through the skin and subcutaneous tissue. The child was examined and the
wound cleansed with Hibicleans. The area around the wound was infiltrated with 1%
xylocaine with epinephrine. It was repaired with #1-0 chromic and a dressing was
placed. The stitches will be removed in 10 days.

Code the laceration repair ____________

Code the diagnosis: ____________

Answer: Report 1 Answers:

Repair of laceration: 12002 / ICD Diagnosis code: 873.0

Report 2. The patient is an 8-year-old female with a sore throat. Examination

showed acute tonsillitis and she was started on penicillin. She has had these bouts
in the past for which I have prescribed medication, primarily Pen-Vee K. We will do
a culture and let mom know the results.

Code the diagnosis: ____________________

Answer: 463
___________________________________________________________________

Report 3. The patient has ankle pain and is seen in the physician’s office. He has
not been in before. He is examined and diagnosed as having an ankle sprain.

Code the diagnosis: ______________

Answer: 845.00

Report 4. The patient is a 16 Y/O male not seen by me before with itching
problems on his back. On exam, seborrheic keratoses are noted. Will treat with
anti-inflammatory salve and plan on surgical intervention.

Code the Diagnosis: _____________

Answer: 702.11

Report 5. The patient is a 14 Y/O female who has noted back pain. She was
referred here by Dr. Frame. On examination a beginning scoliosis is noted. She is
referred for x-rays and will counsel with parents when those return with a treatment
plan.

Code the Diagnosis: ______________

Answer: 737.30

Report 6. This is a 62 Y/O gentleman who noted anterior chest wall pain this a.m.
It has subsided some throughout the day. Will send him for chest x-ray and EKG
this afternoon, talk to his regular attending physician and see him back tomorrow.
On this one, we will add the office call (CPT) code and charge. The office code is
99204 (described as an office or other outpatient visit for the evaluation and
management of a new patient).

Office Call code: _____________ Diagnosis ______________

Answer: CPT = 99204 ICD = (implied new patient) ICD: 786.52

Report 7. This is a visit for a patient with an ankle sprain. There is swelling and
redness. She had her ankle wrapped, to use crutches, ice and elevate. Darvocet
was prescribed for pain.

has decreased; however, is not entirely gone. She is to continue on crutches, ice
and elevate it and return here in one week.

CPT code: _____________ (office code is the same as in Report 6.

ICD code: ______________

Anwer: CPT = 99204 ICD = 845.00

___________________________________________________________________

Report 8. Ms Gardner comes in for recheck on her hypertension. BP is 190/110.

Also her blood sugar was a little elevated; will change her insulin to 40 units a.m.
and see her back in a week. A followup office visit for a known patient (has been
seen before) is dependent on the complexity. In this case, it is limited to the 2
problems of blood pressure and diabetes. We will assign it a a 99213 (followup office
visit about medium range in complexity).

CPT code: _____________

ICD code: ______________

Answer: 99213 CPT, ICD = 250.0

Report 9. Patient has a second degree burn on the leg; I debrided the wound and
applied a dressing. She was also started on penicillin and gentamicin. The heparin
was titrated to maintain a PT between 1 and 1/2 and 2 1/2 x control. She will
return here for followup in 2 days.

Code the debridement CPT: ____________________

Code the diagnosis ICD: _______________________

You could also code the heparin lab code.

Answer: CPT debridement = 16020, ICD = 945.20

Report 10. Patient has abdominal pain and burning on urination; her urine was
checked and she has a urinary tract infection.

ICD code: __________________

Answer: 599.0
___________________________________________________________________
Report 11. Patient came to the emergency room with a tibial fracture; he was
treated for an open tibial plateau fracture, proximal end without any manipulation
since it wasn’t displaced.

CPT code: ______________________

ICD code: ______________________

Answer: CPT: 27530 ICD: 823.90

Those exercises should give you some idea of what is involved in the coding process.
The codes selected will be reproduced on standard insurance forms, and at times the
same detail is provided on the statements to the patient.

It is an interesting process, requires a good medical terminology background.

Obviously precision is a useful skill too. Transposing code numbers, as you can
imagine, would be a serious problem.

If you did well, seriously consider enrolling in the coding training.