Let’s Code It!

Let’s Code It!

Shelley C. Safian, PhD, RHIA

MAOM/HSM/HI, CCS-P, COC, CPC-I,
AHIMA-Approved ICD-10-CM/PCS Trainer

Mary A. Johnson, MBA-HM-HI, CPC

Central Carolina Technical College
LET’S CODE IT!
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Library of Congress Cataloging-in-Publication Data
Names: Safian, Shelley C., author. | Johnson, Mary A. (Medical record coding
program manager) author.
Title: Let’s code it! / Shelley C. Safian, PhD, RHIA, MAOM/HSM, CCS-P, CPC-H,
CPC-I, AHIMA-Approved ICD-10-CM/PCS Trainer, Mary A. Johnson, CPC, Central
Carolina Technical College.
Description: First edition. | New York, NY : McGraw-Hill Education, [2019] |
Includes index.
Identifiers: LCCN 2017025623 | ISBN 9781259828737 (alk. paper)
Subjects: LCSH: Nosology—Code numbers.
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 ABOUT THE AUTHORS

Shelley C. Safian
Shelley Safian has been teaching medical coding and health information management
for more than 15 years, at both on-ground and online campuses. In addition to her
regular teaching responsibilities at University of Central Florida and Berkeley College
Online, she often presents seminars sponsored by AHIMA and AAPC, writes regu-
larly about coding for the Just Coding newsletter, and has written articles published in
AAPC’s Healthcare Business Monthly, SurgiStrategies, and HFM (Healthcare Finan-
cial Management) magazine. Safian is the course author for multiple distance educa-
tion courses on various coding topics, including ICD-10-CM, ICD-10-PCS, CPT, and
HCPCS Level II coding.
Safian is a Registered Health Information Administrator (RHIA) and a Certified
Coding Specialist–Physician-based (CCS-P) from the American Health Information
Management Association and a Certified Outpatient Coder (COC) and a Certified Courtesy of Shelley C. Safian
Professional Coding Instructor (CPC-I) from the American Academy of Professional
Coders. She is also a Certified HIPAA Administrator (CHA) and has earned the desig-
nation of AHIMA-Approved ICD-10-CM/PCS Trainer.
Safian completed her Graduate Certificate in Health Care Management at Keller
Graduate School of Management. The University of Phoenix awarded her the
Master of Arts/Organizational Management degree and a Graduate Certificate in
Health Informatics. She earned her Ph.D. in Health Care Administration with a focus
in Health Information Management.

Mary A. Johnson
Mary Johnson is currently the Medical Record Coding Program Director at Central
Carolina Technical College, Sumter, South Carolina. Her background includes cor-
porate training as well as on-campus and online platforms. Johnson also designs and
implements customized coding curricula. Johnson received her Bachelor of Arts dual
degree in Business Administration and Marketing from Columbia College, and earned
a Masters of Business Administration with a dual focus in Healthcare Management
and Health Informatics from New England College. Johnson is a Certified Profes-
sional Coder (CPC) credentialed through the American Academy of Professional Cod-
ers and is ICD-10-CM proficient.

Acknowledgments
—This book is dedicated to all of those who have come into my life sharing encour-
agement and opportunity to pursue work that I love; for the benefit of all of my stu- Courtesy of Mary A. Johnson
dents: past, present, and future.—Shelley

—This book is dedicated in loving memory of my parents, Dr. and Mrs. Clarence
J. Johnson Sr., for their love and support. Also, to those students with whom I have
had the privilege to work and to those students who are beginning their journey into
the world of medical coding.—Mary
 BRIEF CONTENTS

Guided Tour  xii

Preface  xvi

PART I:  Medical Coding Fundamentals  1

  1 Introduction to the Languages of Coding  2
  2 Abstracting Clinical Documentation  22
  3 The Coding Process  39

PART II:  Reporting Diagnoses  53

  4 Introduction to ICD-10-CM  54
  5 Coding Infectious Diseases  101
  6 Coding Neoplasms  145
  7 Coding Conditions of the Blood and Immunological Systems  173
  8 Coding Endocrine Conditions  198
  9 Coding Mental, Behavioral, and Neurological Disorders  228
10 Coding Dysfunction of the Optical and Auditory Systems  263
11 Coding Cardiovascular Conditions  294
12 Coding Respiratory Conditions  329
13 Coding Digestive System Conditions  356
14 Coding Integumentary Conditions  382
15 Coding Muscular and Skeletal Conditions  406
16 Coding Injury, Poisoning, and External Causes  429
17 Coding Genitourinary, Gynecology, Obstetrics, Congenital, and Pediatrics Conditions  470
18 Factors Influencing Health Status (Z Codes)  519
19 Inpatient (Hospital) Diagnosis Coding  541
20 Diagnostic Coding Capstone  568

PART III:  Reporting Physician Services and Outpatient

Procedures  577
21 Introduction to CPT  578
22 CPT and HCPCS Level II Modifiers  602
23 CPT Evaluation and Management Coding  641
24 CPT Anesthesia Section  691
25 CPT Surgery Section  717
26 CPT Radiology Section  797
27 CPT Pathology & Lab Section  828
28 CPT Medicine Section  859
29 Physicians’ Services Capstone  895

PART IV:  DMEPOS & Transportation  905

30 HCPCS Level II  906
31 DMEPOS and Transportation Coding Capstone  941

PART V:  Inpatient (Hospital) Reporting  949

32 Introduction to ICD-10-PCS  950
33 ICD-10-PCS Medical and Surgical Section  975
34 Obstetrics Section  1015
35 Placement through Chiropractic Sections  1040
36 Imaging, Nuclear Medicine, and Radiation Therapy Sections  1087
37 Physical Rehabilitation and Diagnostic Audiology through New Technology
Sections  1111
38 Inpatient Coding Capstone  1140

PART VI:  Reimbursement, Legal, and Ethical Issues  1155

39 Reimbursement  1156
40 Introduction to Health Care Law and Ethics  1185

Appendix  1216
Glossary  1218
Index  1229

Let’s Code It! is the comprehensive title in a series of four books. The other titles are:
Let’s Code It! ICD-10-CM: includes Parts 1, 2 and 6
Let’s Code It! ICD-10-CM, ICD-10-PCS: includes Parts 1, 2, 5 and 6
Let’s Code It! Procedure: includes Parts 1 and 3-6

viii   BRIEF CONTENTS

 CONTENTS

Guided Tour  xii PART II:  Reporting Diagnoses  53

Preface  xvi
4  INTRODUCTION TO ICD-10-CM  54
PART I:  Medical Coding 4.1 Introduction and Official Conventions  54
Fundamentals  1 4.2 ICD-10-CM Official Guidelines for Coding
1   INTRODUCTION TO THE LANGUAGES OF and Reporting  63
CODING  2 4.3 The Alphabetic Index and
Ancillaries  72
1.1 The Purpose of Coding  2
4.4 The Tabular List  78
1.2 Diagnosis Coding  4
4.5 Which Conditions to Code  84
1.3 Procedure Coding  9
4.6 Putting It All Together: ICD-10-CM
1.4 Equipment and Supplies  16
Basics  88
Chapter Summary and Review  19
Chapter Summary and Review  91
2   ABSTRACTING CLINICAL DOCUMENTATION  22
2.1 For Whom You Are Reporting  22 5  CODING INFECTIOUS DISEASES  101
2.2 The Process of Abstracting  23 5.1 Infectious and Communicable
2.3 Deconstructing Diagnostic Diseases  101
Statements  25 5.2 Bacterial Infections  104
2.4 Identifying Manifestations, 5.3 Viral Infections  109
Co-morbidities, and Sequelae  28 5.4 Parasitic and Fungal Infections  116
2.5 Reporting External Causes  30 5.5 Infections Caused by Several
2.6 Deconstructing Procedural Pathogens  119
Statements  31 5.6 Immunodeficiency Conditions  122
2.7 How to Query  34 5.7 Septicemia and Other Blood
Chapter Summary and Review  35 Infections  128
5.8 Antimicrobial Resistance  133
3   THE CODING PROCESS  39 Chapter Summary and Review  137
3.1 The Coding Process Overview  39
3.2 The Alphabetic Indexes  41 6  CODING NEOPLASMS  145
3.3 The Tabular List, Main Section, 6.1 Screening and Diagnosis  145
Tables, and Alphanumeric 6.2 Abstracting the Details About
Section  43 Neoplasms  149
3.4 The Official Guidelines  45 6.3 Reporting the Neoplastic
3.5 Confirming Medical Necessity  47 Diagnosis  151
Chapter Summary and Review  49 6.4 Neoplasm Chapter Notes  156
6.5 Admissions Related to Neoplastic 9.4 Physiological Conditions Affecting the
Treatments  160 Central Nervous System  244
Chapter Summary and Review  164 9.5 Physiological Conditions Affecting the
Peripheral Nervous System  249
7  CODING CONDITIONS OF THE BLOOD AND 9.6 Pain Management  251
IMMUNOLOGICAL SYSTEMS  173 Chapter Summary and Review  255
7.1 Reporting Blood Conditions  173
7.2 Coagulation Defects and Other 10  CODING DYSFUNCTION OF THE OPTICAL AND
Hemorrhagic Conditions  178 AUDITORY SYSTEMS  263
7.3 Conditions Related to Blood 10.1 Diseases of the External Optical
Types and the Rh Factor  182 System  263
7.4 Disorders of White Blood Cells 10.2 Diseases of the Internal Optical
and Blood-Forming Organs  185 System  267
7.5 Disorders Involving the Immune 10.3 Other Conditions Affecting the Eyes  273
System  188 10.4 Dysfunctions of the Auditory System  278
Chapter Summary and Review  190 10.5 Causes, Signs, and Symptoms of Hearing
Loss  280
8  CODING ENDOCRINE CONDITIONS  198 Chapter Summary and Review  284
8.1 Disorders of the Thyroid Gland  198
8.2 Diabetes Mellitus  203 11  CODING CARDIOVASCULAR CONDITIONS  294
8.3 Diabetes-Related Conditions  208 11.1 Heart Conditions  294
8.4 Other Endocrine Gland Disorders  210 11.2 Cardiovascular Conditions  301
8.5 Nutritional Deficiencies and Weight 11.3 Hypertension  305
Factors  212 11.4 Manifestations of Hypertension  311
8.6 Metabolic Disorders  216 11.5 CVA and Cerebral Infarction  316
Chapter Summary and Review  218 11.6 Sequelae of Cerebrovascular Disease  319
Chapter Summary and Review  320
9  CODING MENTAL, BEHAVIORAL, AND
NEUROLOGICAL DISORDERS  228 12  CODING RESPIRATORY CONDITIONS  329
9.1 Conditions That Affect Mental Health  228 12.1 Underlying Causes of Respiratory
9.2 Mood (Affective) and Nonmood Disease  329
(Psychotic) Disorders  236 12.2 Disorders of the Respiratory System  333
9.3 Anxiety, Dissociative, Stress-Related, 12.3 Pneumonia and Influenza  336
Somatoform, and Other Nonpsychotic 12.4 Chronic Respiratory Disorders  340
Mental Disorders  241 12.5 Reporting Tobacco Involvement  343

x   CONTENTS
12.6 Respiratory Conditions Requiring External 16  CODING INJURY, POISONING, AND EXTERNAL
Cause Codes  345 CAUSES  429
Chapter Summary and Review  347 16.1 Reporting External Causes
of Injuries  429
13  CODING DIGESTIVE SYSTEM CONDITIONS  356 16.2 Traumatic Injuries  432
13.1 Diseases of Oral Cavity and Salivary 16.3 Using Seventh Characters to Report
Glands  356 Status of Care  439
13.2 Conditions of the Esophagus and 16.4 Using the Table of Drugs and
Stomach  360 Chemicals  440
13.3 Conditions Affecting the Intestines  364 16.5 Adverse Effects, Poisoning, Underdosing,
13.4 Dysfunction of the Digestive Accessory and Toxic Effects  444
Organs and Malabsorption  370 16.6 Reporting Burns  450
13.5 Reporting the Involvement of Alcohol in 16.7 Abuse, Neglect, and Maltreatment  457
Digestive Disorders  373 16.8 Complications of Care  458
Chapter Summary and Review  374 Chapter Summary and Review  460

14  CODING INTEGUMENTARY CONDITIONS  382 17  CODING GENITOURINARY, GYNECOLOGY,

14.1 Disorders of the Skin  382 OBSTETRICS, CONGENITAL, AND PEDIATRICS
14.2 Disorders of the Nails, Hair, Glands, and CONDITIONS  470
Sensory Nerves  387 17.1 Renal and Urologic Malfunctions  470
14.3 Lesions  393 17.2 Diseases of the Male
14.4 Prevention and Screenings  396 Genital Organs  479
Chapter Summary and Review  397 17.3 Sexually Transmitted Diseases  482
17.4 Gynecologic Care  485
15  CODING MUSCULAR AND SKELETAL 17.5 Routine Obstetrics Care  488
CONDITIONS  406 17.6 Pregnancies with Complications  495
15.1 Arthropathies  406 17.7 Neonates and Congenital Anomalies  499
15.2 Dorsopathies and Spondylopathies Chapter Summary and Review  508
(Conditions Affecting the Joints of the
Spine)  411 18  FACTORS INFLUENCING HEALTH STATUS
15.3 Soft Tissue Disorders  415 (Z CODES)  519

15.4 Musculoskeletal Disorders from Other 18.1 Preventive Care  519

Body Systems  418 18.2 Early Detection  521
15.5 Pathological Fractures  419 18.3 Genetic Susceptibility  523
Chapter Summary and Review  421 18.4 Observation  524
18.5 Continuing Care and Aftercare  525 22.4 Ambulatory Surgery Center Hospital
18.6 Organ Donation  527 Outpatient Use Modifiers  611
18.7 Resistance to Antimicrobial Drugs  528 22.5 Anatomical Site Modifiers  613
18.8 Z Codes as First-Listed/Principal 22.6 Service-Related Modifiers  615
Diagnosis  531 22.7 Sequencing Multiple Modifiers  628
Chapter Summary and Review  532 22.8 Supplemental Reports  631
Chapter Summary and Review  632
19  INPATIENT (HOSPITAL) DIAGNOSIS
CODING  541 23  CPT EVALUATION AND MANAGEMENT
19.1 Concurrent and Discharge Coding  541 CODING  641
19.2 Official Coding Guidelines  544 23.1 What Are E/M Codes?  641
19.3 Present-On-Admission Indicators  545 23.2 Location Where the E/M Services Were
19.4 Diagnosis-Related Groups  550 Provided  642
19.5 Uniform Hospital Discharge Data Set  552 23.3 Relationship between Provider and
Chapter Summary and Review  553 Patient  644
23.4 Types of E/M Services  647
20  DIAGNOSTIC CODING CAPSTONE  568 23.5 Preventive Medicine Services  667
23.6 Abstracting the Physician’s Notes  669
PART III:  Reporting Physician 23.7 E/M in the Global Surgical
Services and Outpatient Package  671
Procedures  577 23.8 E/M Modifiers and Add-On Codes  672
23.9 Special Evaluation Services  676
21  INTRODUCTION TO CPT  578
23.10 Coordination and Management
21.1 Abstracting for Procedure Coding  578
Services  677
21.2 CPT Code Book  579
Chapter Summary and Review  680
21.3 Understanding Code Descriptions  581
21.4 Notations and Symbols  583 24  CPT ANESTHESIA SECTION  691
21.5 Official Guidelines  587 24.1 Types of Anesthesia  691
21.6 Category II and Category III Coding  590 24.2 Coding Anesthesia Services  694
Chapter Summary and Review  593 24.3 Anesthesia Guidelines  698
24.4 Time Reporting  701
22  CPT AND HCPCS LEVEL II MODIFIERS  602 24.5 Qualifying Circumstances  702
22.1 Modifiers Overview  602 24.6 Special Circumstances  703
22.2 Personnel Modifiers  606 24.7 HCPCS Level II Modifiers  705
22.3 Anesthesia Physical Status Modifiers  609 Chapter Summary and Review  707

xii   CONTENTS
25  CPT SURGERY SECTION  717 27  CPT PATHOLOGY & LAB SECTION  828
25.1 Types of Surgical Procedures  718 27.1 Specimen Collection and Testing  828
25.2 The Surgical Package  720 27.2 Testing Methodology and Desired
25.3 Global Period Time Frames  724 Results  830
25.4 Unusual Services and 27.3 Panels  833
Treatments  725 27.4 Blood Test Documentation  835
25.5 Integumentary System  728 27.5 Clinical Chemistry  838
25.6 Musculoskeletal System  739 27.6 Molecular Diagnostics  839
25.7 Respiratory System  747 27.7 Immunology, Microbiology, and
25.8 Cardiovascular System  749 Cytopathology  840
25.9 Digestive System  759 27.8 Surgical Pathology  843
25.10 Urinary System  762 27.9 Modifiers for Laboratory Coding  848
25.11 The Genital Systems: Male and 27.10 Pathology and Lab Abbreviations  849
Female  765 Chapter Summary and Review  851
25.12 Nervous System  769
25.13 The Optical and Auditory 28  CPT MEDICINE SECTION  859
Systems  773 28.1 Immunizations  859
25.14 Organ Transplantation  779 28.2 Injections and Infusions  862
25.15 Operating Microscope  784 28.3 Psychiatry, Psychotherapy, and
Chapter Summary and Review  786 Biofeedback  865
28.4 Dialysis and Gastroenterology
26  CPT RADIOLOGY SECTION  797 Services  867
26.1 Types of Imaging  797 28.5 Ophthalmology and Otorhinolaryngologic
26.2 Purposes for Imaging  801 Services  870
26.3 Technical vs. Professional  803 28.6 Cardiovascular Services  872
26.4 Number of Views  805 28.7 Pulmonary  876
26.5 Procedures With or Without 28.8 Allergy and Clinical Immunology  877
Contrast  807 28.9 Neurology and Neuromuscular
26.6 Diagnostic Radiology  809 Procedures  879
26.7 Mammography  813 28.10 Physical Medicine and Rehabilitation  880
26.8 Bone and Joint Studies  814 28.11 Acupuncture, Osteopathic, and
26.9 Radiation Oncology  815 Chiropractic Treatments  882
26.10 Nuclear Medicine  818 28.12 Other Services Provided  884
Chapter Summary and Review  819 Chapter Summary and Review  886
29  PHYSICIANS’ SERVICES CAPSTONE  895 33.5 Medical/Surgical Devices: Character 6  993
33.6 Medical/Surgical Qualifiers:
PART IV:  DMEPOS & Character 7  995
TRANSPORTATION  905 33.7 Multiple and Discontinued Procedures in
30  HCPCS LEVEL II  906 Medical and Surgical Cases  996
33.8 Medical/Surgical Coding: Putting It All
30.1 HCPCS Level II Categories  906
Together  999
30.2 The Alphabetic Index  908
Chapter Summary and Review  1003
30.3 The Alphanumeric Listing Overview  910
30.4 Symbols and Notations  923 34  OBSTETRICS SECTION  1015
30.5 Appendices  931 34.1 Obstetrics Section/Body System:
Chapter Summary and Review  932 Characters 1 and 2  1015
34.2 Obstetrics Root Operations:
31  DMEPOS AND TRANSPORTATION
Character 3  1016
CODING CAPSTONE  941
34.3 Obstetrics Body Parts: Character 4  1021
PART V:  Inpatient (Hospital) 34.4 Obstetrics Approaches:
Reporting  949 Character 5  1022
34.5 Obstetrics Devices: Character 6  1024
32  INTRODUCTION TO ICD-10-PCS  950
34.6 Obstetrics Qualifiers: Character 7  1024
32.1 The Purpose of ICD-10-PCS  950 34.7 Obstetrics Coding: Putting It All
32.2 The Structure of ICD-10-PCS Codes  950 Together  1028
32.3 The ICD-10-PCS Book  959 Chapter Summary and Review  1030
32.4 ICD-10-PCS General Conventions  964
32.5 Selection of Principal Procedure  967 35  PLACEMENT THROUGH CHIROPRACTIC
Chapter Summary and Review  968 SECTIONS  1040
35.1 Reporting Services from the Placement
33  ICD-10-PCS MEDICAL AND SURGICAL Section  1040
SECTION  975 35.2 Reporting Services from the
33.1 Medical/Surgical Section/Body Systems: Administration Section  1046
Characters 1 and 2  975 35.3 Reporting Services from the Measurement
33.2 Medical/Surgical Root Operations: and Monitoring Section  1050
Character 3  978 35.4 Reporting from the Extracorporeal
33.3 Medical/Surgical Body Parts: or Systemic Assistance and
Character 4  987 Performance Section  1054
33.4 Medical/Surgical Approaches: 35.5 Reporting Services from the Extracorporeal
Character 5  989 or Systemic Therapies Section  1058

xiv   CONTENTS
35.6 Reporting Osteopathic Services  1063 38  INPATIENT CODING CAPSTONE  1140
35.7 Reporting from the Other Procedures
Section  1066 PART VI:  Reimbursement, Legal, and
35.8 Reporting Inpatient Chiropractic Ethical Issues  1155
Services  1070
39  REIMBURSEMENT  1156
35.9 Sections 2–9: Putting It All
39.1 The Role of Insurance in
Together  1074
Health Care  1156
Chapter Summary and Review  1076
39.2 Types of Insurance Plans  1158
36  IMAGING, NUCLEAR MEDICINE, AND 39.3 Methods of Compensation  1163
RADIATION THERAPY SECTIONS  1087 39.4 NCCI Edits and NCD/LCD  1165
39.5 Place-of-Service and Type-of-Service
36.1 Reporting from the Imaging Section  1087
Codes  1167
36.2 Reporting from the Nuclear Medicine
39.6 Organizing Claims: Resubmission,
Section  1092
Denials, and Appeals  1172
36.3 Reporting from the Radiation Therapy
Chapter Summary and Review  1180
Section  1096
36.4 Sections B, C, and D: Putting It All 40  INTRODUCTION TO HEALTH CARE LAW AND
Together  1101 ETHICS  1185
Chapter Summary and Review  1104
40.1 Sources for Legal Guidance  1185
37  PHYSICAL REHABILITATION AND DIAGNOSTIC 40.2 Rules for Ethical and Legal Coding  1190
AUDIOLOGY THROUGH NEW TECHNOLOGY 40.3 False Claims Act  1193
SECTIONS  1111 40.4 Health Insurance Portability and
Accountability Act (HIPAA)  1195
37.1 Reporting Services from the Physical
Rehabilitation and Diagnostic Audiology 40.5 Health Care Fraud and Abuse Control
Section  1111 Program  1205
37.2 Reporting Services from the Mental 40.6 Codes of Ethics  1206
Health Section  1115 40.7 Compliance Programs  1208
37.3 Reporting from the Substance Abuse Chapter Summary and Review  1209
Treatment Section  1119 Appendix  1216
37.4 Reporting from the New Technology Glossary  1218
Section  1123 Index  1229

37.5 Sections F–X: Putting It All

Together  1128
Chapter Summary and Review  1132
GUIDED TOUR
Let’s Code It! was developed with student success in mind: success in college, success taking the certifi-
cation exam, and success in their future health care career.
1.2 Diagnosis Co
When a person goes to see a h
health-related reason. After all
ably wouldn’t make an appoint
Revised Pages

paperwork just to say, “hello.”

Chapter Openers thing more serious, there is alwa

Each chapter begins by clearly identifying the 1 Introduction to the written or dictated, recounting
Languages of Codingstatement, in these notes will ex
The physician’s notes explai
Learning Outcomes students need to master along Key Terms
Classification Systems
Learning Outcomes
The notes may document a sp
with the Key Terms that they need to learn. Condition After completing this chapter, the student should be able to:
Diagnosis LO 1.1 Explain the four purposes of medical coding. a yet-unnamed problem, or an
Eponym
LO 1.2 Identify the structure of the ICD-10-CM diagnosis coding
External Cause
Inpatient
Medical Necessity
manual. service. As a coding specialist,
LO 1.3 Differentiate between the types of procedures and the
Nonessential Modifiers
Outpatient
various procedure coding manuals. nosis code (or codes) so that ev
LO 1.4 Examine the HCPCS Level II coding manual used to report
Procedure
Reimbursement
Services
the provision of equipment and supplies.
particular patient at a particular
Treatments
The International Classificat
1.1 The Purpose of Coding
CODING BITES (ICD-10-CM) code book cont
Around the world, languages exist to enable clear and accurate communication
We use the concept of
“languages” to help you report the reason why the healt
between individuals in similar groups or working together in similar functions. The
purpose of using health care coding languages is to enable the sharing of information,
in a specific and efficient way, between all those involved in health care. 
cific encounter.
relate medical coding—
and its code sets—to Coding languages are constructed of individual codes that are more precise than
an idea you already words. (You will discover this as you venture through this textbook.) By communicat-
understand. In the health ing using codes rather than words, you can successfully convey to others involved (1)
care industry, however, exactly what happened during a provider-patient encounter and (2) why it occurred.

Overview of the Interna

the various code sets, You, as the professional coding specialist, have the responsibility to accurately inter-
such as ICD-10-CM pret health care terms and definitions (medical terminology) into numbers or num-
or HCPCS Level II, ber-letter combinations (alphanumeric codes) that specifically convey diagnoses and
procedures. 
Revision – Clinical Modi
are referred to as
Classification Systems. Why is it so critical to code diagnoses and procedures accurately? The coding lan-
guages, known as classification systems, communicate information that is key to vari-
Classification Systems ous aspects of the health care system, including

The ICD-10-CM code book (w

The term used in health care
∙ Medical necessity

CPT © 2017 American Medical Association. All rights reserved.

to identify ICD-10-CM, CPT,
ICD-10-PCS, and HCPCS ∙ Statistical analyses

tions. Here is an overview of its

Level II code sets. ∙ Reimbursement
∙ Resource allocation

Coding Bites
CODING BITES
A diagnosis explains
WHY the patient CODING BITES
Medical Necessity
sections to determine the most
requires the attention of
a health care provider encounter occurred.
The diagnosis codes that you report explain the justification for the procedure, service,
or treatment provided to a patient during his or her encounter. Every time a health
and a procedure
explains WHAT the
This is just an overview
These appear throughout the text to highlight key
physician or health care
provider did for the to help you orient your- Index to Diseases and In
patient.
self to the structure of
concepts and tips to further support understanding the code book. You will
The Alphabetic Index [Index t
terms used by the physician to
2

and learning. learn, in depth, how

from a health care professional
to use the ICD-10-CM
The Alphabetic Index lists al
code set to report any
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their basic description alphabet

and all of the reasons
tions are listed by
why a patient needs the
care of a health care ∙ Condition (e.g., infection, fr
professional in Part II: ∙ Eponym (e.g., Epstein-Barr
Reporting Diagnoses.
∙ Other descriptors (e.g., perso
Condition
The state of abnormality or Abnormal, abnormality, abno
dysfunction. - acid-based balance (mixed)
Eponym - albumin R77.0
A disease or condition named - alphafetoprotein R77.2
for a person. - alveolar ridge K08.9
- anatomical relationship Q89
- apertures, congenital, diaph
- auditory perception H93.29
-- diplacusis — see Diplacusis
xvi -- hyperacusis — see Hyperac
 the suffix -oma means
Pathology reports may also provide
known toinformation
be malignant on or
thebenign.
grading and/or staging of the
tumor.
tumor. Grading a tumor is the microscopic
Often, analysis
when you of the
looktumor cellsof
up one and tissuespecific
these to describe
neoplasm terms in the
how abnormal they appear. Staging, however, evaluates the
betic Index, it will provide yousize andwith
location
someofspecific
the tumor,
information about the
as well as determination of any Let’s
signs take
or evidence
a look inofthemetastasis.
ICD-10-CM In some cases, you
Alphabetic will
Index under the term written
need to know the grade of a patient’s tumor. .so. you can determine the correct code.
physician
Fibroxanthoma (see also Neoplasm, connective tissue, benign)
EXAMPLES atypical — see Neoplasm, connective tissue, uncertain behavior

Examples, Let’s Code It! Scenarios,

C82.07 Follicular lymphomamalignant
grade 1,— see
spleenNeoplasm, connective tissue, malignant
C82.16 Fibroxanthosarcoma — see
Follicular lymphoma Neoplasm,
grade II, intrapelvic lymph nodes connective tissue malignant
You can see that while you might not know if a fibroxanthoma is malignant or b
These two codes are examples of those with code descriptions that require you to

and You Code It! Case Studies

the Alphabetic Index will tell you.
check the physician’s documentation and pathology reports to identify the grade
of the tumor.

ICD-10-CM
LET’S CODE IT! SCENARIO
CHAPTER
Abby Shantner, a 41-year-old female, comes to see Dr. Branson to get the results 6 | CODING
of her biopsy. NEOPLA
Dr. Bra
Examples are included throughout each chapter to help explains that Abby has an alpha cell adenoma of the pancreas. Dr. Branson spends 30 minutes discussing t
ment options.

students make the connection between theoretical and Let’s Code It!
Rev

practical coding. Let’s Code It! Scenarios walk students

Dr. Branson has diagnosed Abby with an alpha cell adenoma of the pancreas. You have been working w
Dr. Branson as hiscoder for a while, so you know that an adenoma is a neoplasm, but what kind of neoplasm
saf28735_ch06_145-172.indd 147

it—benign or malignant? To help you determine this, instead of going to neoplasm, let’s see if there is a listing

through abstracting and the coding process, step-by- the Alphabetic Index under adenoma. When you find adenoma, the book refers you to
Adenoma (see also Neoplasm, benign, by site)

step, to determine the correct code. And You Code It! This tells you an adenoma is a benign tumor. Or you can continue down this list to the indented term, and find
EXAMPLE
Adenoma
Case Studies provide students with hands-on practice alpha-cell, 
pancreas D13.7
N30 Cystitis
Also,
Use additional read
code the next
to identify notation
infectious carefully:
agent (B95-B97)

coding scenarios and case studies throughout each Turn to the Tabular List and read the complete description of code category D13:
D13
Very often, the ICD-10-CM will tell you that you will need this second code
Benign neoplasmtify the specific
of other
Use additional code to identify any fam
pathogen.
and ill-defined parts of digestive system
chapter. In addition, You Interpret It! questions present The note does not relate to this patient’s diagnosis for this encounter, so continue rea
ICD-10-CM reminds you that an additional
ing down the column to review all of the choices for the required fourth character.
factor for the screening is not age but family
opportunities for students to use critical-thinking skills YOUD13.7 Benign neoplasm of endocrine pancreas
INTERPRET IT!
That matches Dr. Branson’s diagnosis.  in the patient’s past bloodline had been diag
to identify details needed for accurate coding.
Check the top of this subsection and the head of this chapter in ICD-10-CM. There are several NOTES. Re
What is the mode of transmission for eachand ofitAbby?
condition?
carefully. Do any relate to Dr. Branson’s diagnosis is known
No. Turnthat
to thethis places
Official theandpatient
Guidelines a
read Secti
1. 1.c.2.
Hepatitis
There B ___________
is nothing specifically applicable here, either. 4. Insect bites ___________
2. Measles
Good job! ___________ 5. Influenza ___________
3. Cholera ___________
EXAMPLE
You would report code:
5.2 Bacterial
Malignant Primary Infections
The termof
Types primary
Bacteria Z80.42
indicates Family
the anatomical history
site (the ofthe
place in malignan
body) whe
malignant neoplasm was first seen and identified. If the physician’s notes do no
Bacteria Bacteria areor single-celled
ify primary secondary, organisms
in addition
then the site named by
tomentioned
code Z12.5their shape
for an
is primary. (see Figure
encoun
Single-celled microorganisms shaped bacteria, called bacilli, are responsible for the development of d
that cause disease. a screening
tetanus, and tuberculosis, prostate
among others. exam
Spirilla, because
bacterial organismshis
shaf
150 PART II | REPORTING DIAGNOSES with prostate cancer, dramatically increa
GUIDANCE
Guidance Connections CONNECTION
A personal history code (Z85.-) shoul
Read the ICD-10-CM receive screening tests more frequently tha
Official Guidelines
saf28735_ch06_145-172.indd 150 for tory of breast cancer may get mammogram 07/08/1

Each of these boxes connects the concepts Coding and Reporting, personal history of breast cancer code will
section I. Conventions, in the frequency of testing.
students are learning in the chapter to the General Coding Guide-

related, specific Official Guidelines in order lines and Chapter

(a) Specific Guidelines,
EXAMPLE
(c)

to further students’ knowledge and under- subsection C. Chapter-

Specific Coding Guide-
You would report code:

standing of coding resources. lines, chapter 21.

Z85.3 Personal history of malign
Factors influencing in addition to code Z12.31 Encounter fo
health status and neoplasm of breast for an encounter wh
contact with health screening mammogram every 6 months,
services (Z00-Z99), sub- the fact that she had a malignant neoplas
section c.4) History (of). cally increases her risk for a recurrence.

(b) The(d)Z12 code category also carries an

difference
FIGURE 5-1 Types of bacteria: (a) coccus, (b) bacillus, between
(c) spirillum, and (d)avibrio
diagnostic test, Carr;
(a) Source: CDC/Janice whic
signs or symptoms, and a screening test, wh
(b) Source: CDC/Janice Carr; (c) ©MELBA PHOTO AGENCY/Alamy Stock Photo RF; (d) Source: CDC/Janice Carr

detection of disease without signs or symp

104 PART II | REPORTING DIAGNOSES
encounter for diagnostic

EXAMPLE
saf28735_ch05_101-144.indd 104 You would report code: 07

N63.- Unspecified lump in breast

for an encounter when a 62-year-old fem
she felt a lump in her breast during her m
confirmed it was suspicious.

Confirming a Diagnosis
Once the patient exhibits signs, such as a
or an abnormality identified during a scree
essence of the neoplasm. This is the only w
cells and malignant cells.

146 PART II | REPORTING DIAGNOSES

saf28735_ch06_145-172.indd 146
 Revised Pages

End-of-Chapter Reviews CHAPTER 39 REVIEW

CHAPTER 39 REVIEW
Reimbursement Enhance your learning by
completing these exercises and
more at connect.mheducation.com!

Let’s Check it! Terminology

Most chapters end with the following assess- Match each term to the appropriate definition.

Part I
ment types to reinforce the chapter learning 1. LO 39.2 A physician, typically a family practitioner or an internist, who serves
as the primary care physician for an individual. This physician is
A. Automobile Insurance

outcomes: Let’s Check It! Terminology; Let’s

B. Capitation Plans
responsible for evaluating and determining the course of treatment or
C. Centers for Medicare
services, as well as for deciding whether or not a specialist should be
& Medicaid Services

Check It! Concepts; Let’s Check It! Guide-

involved in care.
(CMS)
2. LO 39.1 A type of health insurance coverage that controls the care of each sub-
D. Dependents
scriber (or insured person) by using a primary care provider as a cen-

lines; Let’s Check It! Rules and Regulations; tral health care supervisor. E. Disability
Compensation
3. LO 39.2 A type of health insurance that uses a primary care physician, also
known as a gatekeeper, to manage all health care services for an F. Discounted FFS

and You Code It! Basics. individual.

4. LO 39.2 A policy that covers loss or injury to a third party caused by the insured
G. Episodic Care
H. Fee-for-Service (FFS)
or something belonging to the insured. Plans
5. LO 39.1 The total management of an individual’s well-being by a health care I. Gatekeeper
professional. J. Health Care  
6. LO 39.3 An insurance company pays a provider one flat fee to cover the entire K. Health Maintenance
course of treatment for an individual’s condition. Organization (HMO)
7. LO 39.2 The agency under the Department of Health and Human Services L. Insurance Premium
(DHHS) in charge of regulation and control over services for those
M. Liability Insurance
covered by Medicare and Medicaid.
N. Managed Care
8. LO 39.3 Payment agreements that outline, in a written fee schedule, exactly how
much money the insurance carrier will pay the physician for each treat-
ment and/or service provided.
9. LO 39.3 An extra reduction in the rate charged to an insurer for services pro-
vided by the physician to the plan’s members.
10. LO 39.1 The amount of money, often paid monthly, by a policyholder or
insured, to an insurance company to obtain coverage.
11. LO 39.2 Auto accident liability coverage will pay for medical bills, lost wages,
and compensation for pain and suffering for any person injured by the
insured in an auto accident.
12. LO 39.3 Agreements between a physician and a managed care organization that
pay the physician a predetermined amount of money each month for
each member of the plan who identifies that provider as his or her pri-
mary care physician.
13. LO 39.2 A plan that reimburses a covered individual a portion of his or her income
that is lost as a result of being unable to work due to illness or injury.
14. LO 39.2 Individuals who are supported, either financially or with regard to
insurance coverage, by others.

Revised Pages

CHAPTER 39 | REIMBURSEMENT 1181

CHAPTER 6 REVIEW

saf28735_ch39_1155-1184.indd 1181 09/15/17 04:48 AM

7. Follicular grade III lymphoma lymph nodes of 11. Malignant odontogenic tumor, upper jaw bone:

Real Abstracting Practice with You Code It! Practice, You

inguinal region and lower limbs: a. main term: _____ b. diagnosis: _____
a. main term: _____ b. diagnosis: _____ 12. Secondary malignant neoplasm of vallecula:

Code It! Application, and Capstone Case Studies Chapters

8. Acral lentiginous, right heel melanoma: a. main term: _____ b. diagnosis: _____
a. main term: _____ b. diagnosis: _____ 13. Carcinoma in situ neoplasm of left eyeball:
9. Lipoma of the kidney: a. main term: _____ b. diagnosis: _____
a. main term: _____ b. diagnosis: _____ 14. Benign neoplasm of cerebrum peduncle:
10. Primary malignant neoplasm of right male breast, a. main term: _____ b. diagnosis: _____
upper-outer quadrant: 15. Myelofibrosis with myeloid metaplasia:

Gain real-world experience by using ac- a. main term: _____ b. diagnosis: _____ a. main term: _____ b. diagnosis: _____

tual patient records (with names and other

identifying information changed) to prac- ICD-10-CM
YOU CODE IT! Practice
tice ICD-10-CM, ICD-10-PCS, CPT, and Using the techniques described in this chapter, carefully read through the case studies and determine the most
accurate ICD-10-CM code(s) and external cause code(s), if appropriate, for each case study.
HCPCS Level II coding for both inpatients 1. George Donmoyer, a 58-year-old male, presents today with a sore throat, persistent cough, and earache.
Dr. Selph completes an examination and appropriate tests. The blood-clotting parameters, the thyroid function
and outpatients. You Code It! Practice studies, as well as the tissue biopsy confirm a diagnosis of malignant neoplasm of the extrinsic larynx.
2. Monica Pressley, a 37-year-old female, comes to see Dr. Wheaten today because she has been having diarrhea
exercises give students the chance to prac- and abdominal cramping and states her heart feels like its quavering. The MRI scan confirms a diagnosis of
benign pancreatic islet cell adenoma. 
tice coding with short coding scenarios. 3. Suber Wilson, a 57-year-old male, was diagnosed with a malignant neoplasm of the liver metastasized from
the prostate; both sites are being addressed in today’s encounter. 
You Code It! Application exercises give 4. William Amerson, a 41-year-old male, comes in for his annual eye examination. Dr. Leviner notes a benign

students the chance to review and abstract

right conjunctiva nevus. 
5. Edward Bakersfield, a 43-year-old male, presents with shortness of breath, chest pain, and coughing up

physicians’ notes documenting real patient blood. After a thorough examination, Dr. Benson notes stridor and orders an MRI scan. The results of the
MRI confirm the diagnosis of bronchial adenoma. 

encounters in order to code those scenarios. 6. Elizabeth Conyers, a 56-year-old female, presents with unexplained weakness, weight loss, and dizziness.
Dr. Amos completes a thorough examination and does a work-up. The protein electrophoresis (SPEP) and

Both of these types of exercises can be quantitative immunoglobulin results confirm the diagnosis of Waldenström’s macroglobulinemia. 
7. James Buckholtz, a 3-year-old male, is brought in by his parents. Jimmy has lost his appetite and is los-
found at the end of most chapters. Capstone ing weight. Mrs. Buckholtz tells Dr. Ferguson that Jimmy’s gums bleed and he seems short of breath.
Dr. Ferguson notes splenomegaly and admits Jimmy to Weston Hospital. After reviewing the blood tests,

Chapters come at the end of Parts II–V and MRI scan, and bone marrow aspiration results, Jimmy is diagnosed with acute lymphoblastic leukemia. 
8. Kelley Young, a 39-year-old female, presents to Dr. Clerk with the complaints of sudden blurred vision, dizzi-
include 15 additional real-life outpatient ness, and numbness in her face. Kelley states she feels very weak and has headaches. Dr. Clerk admits Kelley
to the hospital. After reviewing the MRI scan, her hormone levels from the blood workup, and urine tests,
and inpatient case studies to help stu- Kelley is diagnosed with a primary malignant neoplasm of the pituitary gland. 
9. Ralph Bradley, a 36-year-old male, comes to see Dr. Harper because he is weak, losing weight, and vomiting
dents synthesize and apply what they have and has diarrhea with some blood showing. Ralph was diagnosed with HIV 3 years ago. Dr. Harper completes
an examination noting paleness, tachycardia, and tachypnea. Ralph is admitted to the hospital. The biopsied
learned through hands-on coding practice tissue from an endoscopy confirms a diagnosis of Kaposi’s sarcoma of gastrointestinal organ. 

with each code set.

168 PART II | REPORTING DIAGNOSES

xviii

saf28735_ch06_145-172.indd 168
 CHAPTER 4 REVIEW
15. Paul Plum, an 8-month-old male, is brought in by his mother to see Dr. Wallace, Paul’s pediatrician. Paul’s
stomach feels hard and he is also having some diarrhea and vomiting. Dr. Wallace notes Paul is failing to
thrive and hospitalizes him. After blood tests and a hydrogen breath test are completed, Paul is diagnosed
with congenital lactase deficiency. 

In addition, all of the exercises in the ICD-10-CM

YOU CODE IT! Application
Chapter Review can be assigned through The following exercises provide practice in abstracting physician documentation from our health care facility,

Connect. Of particular note are the You

Prader, Bracker, & Associates. These case studies are modeled on real patient encounters. Using the techniques
described in this chapter, carefully read through the case studies and determine the most accurate ICD-10-CM

Code It! Practice exercises, which offer

code(s) for each case study. Remember to include external cause codes, if appropriate.

our unique CodePath option. In Connect, PRADER, BRACKER, & ASSOCIATES

A Complete Health Care Facility
students are presented with a series of 159 Healthcare Way • SOMEWHERE, FL 32811 • 407-555-6789

questions to guide them through the PATIENT: Kassandra, Kelly

ACCOUNT/EHR #: KASSKE001
critical thinking process to determine the DATE: 09/16/18

correct code. Attending Physician: Oscar R. Prader, MD

S: Pt is a 19-year-old female who has had a sore throat and cough for the past week. She states that
she had a temperature of 101.5 F last night. She also admits that it is painful to swallow. No OTC medi-
cation has provided any significant relief.
O: Ht 5′5″ Wt. 148 lb. R 20. T 101 F. BP 125/82. Pharynx is inspected, tonsils enlarged. There is pus
noted in the posterior pharynx. Neck: supple, no nodes. Chest: clear. Heart: regular rate and rhythm
without murmur.
A: Acute pharyngitis
P: 1. Send pt for Strep test
2. Recommend patient gargle with warm salt water and use OTC lozenges to keep throat moist
3. Rx if needed once results of Strep test come back
4. Return in 2 weeks for follow-up

ORP/pw D: 9/16/18 09:50:16 T: 9/18/18 12:55:01

Determine the most accurate ICD-10-CM code(s).

WESTON HOSPITAL
629 Healthcare Way • SOMEWHERE, FL 32811 • 407-555-6541
PATIENT: DAVIS, HELEN
ACCOUNT/EHR #: DAVIHE001
DATE: 10/21/18
Attending Physician: Renee O. Bracker, MD

CHAPTER 4 | INTRODUCTION TO ICD-10-CM 97

saf28735_ch04_053-100.indd 97 07/05/17 06:23 PM

 PREFACE

Welcome to Let’s Code It! This product is part of a multipart series that instructs
students on how to become proficient in medical coding—a health care field that con-
tinues to be in high demand. The Bureau of Labor Statistics notes the demand for
health information management professionals (which includes coders) will continue to
increase incredibly through 2024 and beyond.
Let’s Code It! provides a 360-degree learning experience for anyone interested in
the field of medical coding, with strong guidance down the path to coding certification.
Theory is presented in easy-to-understand language and accompanied by lots of exam-
ples. Hands-on practice is included with real-life physician documentation, from both
outpatient and inpatient facilities, to promote critical thinking analysis and evaluation.
This is in addition to determination of accurate codes to report diagnoses, procedures,
and ancillary services. All of this is assembled to support the reader’s development of
a solid foundation upon which to build a successful career after graduation.
The Safian/Johnson Medical Coding series includes the following products:
Let’s Code It!
Let’s Code It! ICD-10-CM
Let’s Code It! ICD-10-CM/PCS
Let’s Code It! Procedure
You Code It! Abstracting Case Studies Practicum, 3e
The different solutions are designed to fit the most common course content selections.
Let’s Code It! is the comprehensive offering with coverage of ICD-10-CM, ICD-10-
PCS, CPT, and HCPCS Level II.
These products are further designed to give your students the medical coding experi-
ence they need in order to pass their first medical coding certification exams, such as the
CCS/CCS-P or CPC/COC. The products offer students a variety of practice opportuni-
ties by reinforcing the learning outcomes set forth in every chapter. The chapter materi-
als are organized in short bursts of text followed by practice—keeping students active
and coding! These products were developed based on the 2017 code sets, with 2018
updates implemented as much as possible prior to publication. Updates will be made to
the answer keys and Connect exercises on an annual basis.

Here’s What You Can Expect from Let’s Code It!

∙ Each of the six parts of this product includes an Introduction to provide students
with an overview of the information within that part and how they can use this
knowledge.
∙ Part I: Medical Coding Fundamentals
∙ Part II: Reporting Diagnoses
∙ Part III: Reporting Physicians Services and Outpatient Procedures
∙ Part IV: DMEPOS & Transportation
∙ Part V: Inpatient (Hospital) Reporting
∙ Part VI: Legal, Ethical, and Reimbursement Issues
 ∙ Part I: Medical Coding Fundamentals helps students build a strong theoretical founda-
tion regarding the various code sets. The chapters teach students how and when each
code set is used and how to abstract documentation. These chapters also teach them
how to use a solid coding process, including the importance of queries, how to write a
legal query, exposure to the Official Guidelines, and confirmation of medical necessity.
∙ Part II: Reporting Diagnoses provides students with an incremental walkthrough
of the ICD-10-CM code set.
∙ Part III: Reporting Physicians Services and Outpatient Procedures provides stu-
dents with a progressive learning experience for using CPT® procedure codes.
∙ Part IV: DMEPOS & Transportation gives students insight into, and hands-on
practice using, the HCPCS Level II code set to report the provision of durable med-
ical equipment, prosthetics, orthotics, and other medical supplies.
∙ Part V: Inpatient (Hospital) Reporting shows students how to build an accurate
ICD-10-PCS code to report inpatient procedures, services, and treatments.
∙ The coding chapters in Parts II–V all include real-life scenarios, as well as physi-
cian documentation mainly in the form of procedure notes and operative reports
(both inpatient and outpatient) for students to practice abstracting and coding.
∙ Let’s Code It! Scenarios provide step-by-step instruction so students can learn
to use their critical-thinking skills throughout the coding process to determine
the correct code.
∙ You Code It! Case Studies provide students with hands-on practice coding sce-
narios and case studies throughout each chapter.
∙ You Interpret It! questions present additional opportunities for students to use
critical-thinking skills to identify details required for accurate coding.
∙ Chapter Reviews include assessments of chapter concepts:
∙ Let’s Check It! Terminology
∙ Let’s Check It! Concepts
∙ Let’s Check It! Guidelines
∙ Let’s Check It! Rules and Regulations
∙ You Code It! Basics
∙ You Code It! Practice Case Studies
∙ You Code It! Application Case Studies
∙ Examples are included throughout each chapter to help students make the connec-
tion between theoretical and practical coding.
∙ Coding Bites highlight key concepts and tips to further support understanding and
learning.
∙ Guidance Connection features point to the specific Official Guideline applicable
for the concept being discussed.
∙ Capstone Chapters come at the end of Parts II–V with 15 additional real-life outpa-
tient and inpatient case studies to help students synthesize and apply what they have
learned through hands-on coding practice with each code set.
∙ Part VI: Legal, Ethical, and Reimbursement Issues provides a concise overview
connecting these broad topics to a professional coding specialist’s job requirements.
∙ Examples again take students through real-life scenarios to help them understand
how they will use this information.
∙ Coding Bites provide tips and highlight key concepts.
∙ This part also includes material to teach students how to access credible resources
on the Internet.

xxii   PREFACE
∙ Codes of Ethics from both AHIMA and AAPC are included as well as information
on compliance plans.
∙ You Interpret It! questions present students with opportunities to use critical-thinking
skills to identify details required for accurate job performance.
∙ Chapter Reviews include assessments of chapter concepts:
∙ Let’s Check It! Terminology
∙ Let’s Check It! Concepts
∙ Let’s Check It! Which Type of Insurance?
∙ Let’s Check It! Rules and Regulations
∙ You Code It! Application Case Studies
 McGraw-Hill Connect® is a highly reliable, easy-to-
use homework and learning management solution
that utilizes learning science and award-winning
adaptive tools to improve student results.

Homework and Adaptive Learning

Connect’s assignments help students

contextualize what they’ve learned through
application, so they can better understand the
material and think critically.
Connect will create a personalized study path
customized to individual student needs through
SmartBook®.
SmartBook helps students study more efficiently
by delivering an interactive reading experience
through adaptive highlighting and review.

Over 7 billion questions have been

answered, making McGraw-Hill Using Connect improves retention rates
by 19.8 percentage points, passing rates
Education products more intelligent, by 12.7 percentage points, and exam
reliable, and precise. scores by 9.1 percentage points.

73% of instructors
who use Connect
Quality Content and Learning Resources require it; instructor
satisfaction increases
Connect content is authored by the world’s best subject by 28% when Connect
matter experts, and is available to your class through a is required.
simple and intuitive interface.
The Connect eBook makes it easy for students to
access their reading material on smartphones
and tablets. They can study on the go and don’t
need internet access to use the eBook as a
reference, with full functionality.
Multimedia content such as videos, simulations,
and games drive student engagement and critical
thinking skills. ©McGraw-Hill Education
Robust Analytics and Reporting

Connect Insight® generates easy-to-read

reports on individual students, the class as a
whole, and on specific assignments.
The Connect Insight dashboard delivers data
on performance, study behavior, and effort.
Instructors can quickly identify students who ©Hero Images/Getty Images

struggle and focus on material that the class

has yet to master.
Connect automatically grades assignments
and quizzes, providing easy-to-read reports
on individual and class performance.

More students earn

As and Bs when they
use Connect.
Trusted Service and Support

Connect integrates with your LMS to provide single sign-on and automatic syncing
of grades. Integration with Blackboard®, D2L®, and Canvas also provides automatic
syncing of the course calendar and assignment-level linking.
Connect offers comprehensive service, support, and training throughout every
phase of your implementation.
If you’re looking for some guidance on how to use Connect, or want to learn
tips and tricks from super users, you can find tutorials as you work. Our Digital
Faculty Consultants and Student Ambassadors offer insight into how to achieve
the results you want with Connect.

www.mheducation.com/connect
 CONNECT FOR YOU CODE IT!
McGraw-Hill Connect for You Code It! will include:
∙ All end-of-chapter questions
∙ CodePath versions of You Code It! practice questions, in which students are pre-
sented with a series of questions to guide them through the critical thinking process
to determine the correct code
∙ Interactive Exercises, such as Matching, Sequencing, and Labeling activities
∙ Testbank questions
∙ Lecture-style videos, which will provide additional guidance on challenging coding
questions

INSTRUCTORS’ RESOURCES
You can rely on the following materials to help you and your students work through
the material in the book; all are available in the Instructor Resources under the Library
tab in Connect (available only to instructors who are logged in to Connect).

Supplement Features
Instructor’s Manual (organized by Learning ∙  Lesson plans
Outcomes) ∙  Answer keys for all exercises
PowerPoint Presentations (organized by ∙  Key terms
Learning Outcomes) ∙  Key concepts
∙  Accessible
Electronic Testbank ∙  Computerized and Connect
∙  Word version
∙ Questions are tagged with learning out-
comes; level of difficulty; level of Bloom’s
taxonomy; feedback; and ABHES,
CAAHEP, and CAHIIM competencies.
Tools to Plan Course ∙ Correlations by learning outcomes to
accrediting bodies such as ABHES,
CAAHEP, and CAHIIM
∙  Sample syllabi
∙ Asset map—recap of the key instructor
resources as well as information on the
content available through Connect

Want to learn more about this product? Attend one of our online webinars. To learn
more about them, please contact your McGraw-Hill learning technology representa-
tive. To find your McGraw-Hill representative, go to www.mheducation.com and click
“Contact,” then “Contact a Sales Rep.”
Need help? Contact the McGraw-Hill Education Customer Experience Group
(CXG). Visit the CXG website at www.mhhe.com/support. Browse our fre-
quently asked questions (FAQs) and product documentation and/or contact a CXG
representative.

xxvi   PREFACE
 ACKNOWLEDGMENTS

Board of Advisors
A select group of instructors participated in our Coding Board of Advisors. They pro-
vided timely and focused guidance to the author team on all aspects of content devel-
opment. We are extremely grateful for their input on this project.
Christine Cusano, CMA (AAMA), CPhT, Tatyana Pashnyak, CHTS-TR, Bainbridge
Lincoln Technical Institute State College
Gerry Gordon, BA, CPC, CPB, Daytona Patricia Saccone, MA, RHIA, CCS-P,
College Waubonsee Community College
Shalena Jarvis, RHIT, CCS Stephanie Scott, MSHI, RHIA, CDIP,
CCS, CCS-P, Moraine Park Technical
Jan Klawitter, AS, CPC, CPB, CPC-I, College
San Joaquin Valley College

Reviews
Many instructors reviewed the manuscript while it was in development and provided
valuable feedback that directly affected the product’s development. Their contribu-
tions are greatly appreciated.
Julie Alles-Grice, MSCTE, RHIA Rashmi Gaonkar, BS, MS, MHA/
Informatics, ASA College
Alicia Alva, AS, San Joaquin Valley
College Savanna Garrity, MPA, CPC,
Madisonville Community College
Kelly Berge, MSHA, CPC, CCS-P,
Berkeley College Deborah Gilbert, RHIA, MBA, CMA,
Dalton State College
Valerie Brock, EdS, MBA, RHIA, CDIP,
CPC, Tennessee State University Terri Gilbert, MS, ECPI University
William Butler, MHA, UNC Gerry Gordon, BA, CPC, CPB, Daytona
Healthcare College
Heather Copen, RHIA, CCS-P, Ivy Tech Michelle A. Harris, CPC, CPB, CPC-I,
Community College Bossier Parish Community College
Gerard Cronin, MS, DC, Salem Susan Hernandez, B.S.B.A., San Joaquin
Community College Valley College
Christine Cusano, CMA (AAMA), Judith Hurtt, MEd, East Central
CPhT, Lincoln Technical Institute Community College
Patti Fayash, CCS, ICD-10-CM/PCS Beverlee Jackson, BA, RHIT, CCS,
AHIMA Approved Trainer, Luzerne AHIMA Ambassador, Central Oregon
County Community College Community College
 Shalena Jarvis, RHIT, CCS Melissa Oelfke, RHIA, HIT Program
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Sciences
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County Community College
College
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Carolina Technical College

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York University
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xxviii   ACKNOWLEDGMENTS
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College CPC, CCS-P, RMA

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Judith Hurtt, MEd, East Central Waubonsee Community College
Community College
Shalena Jarvis, RHIT, CCS
Let’s Code It!
PART I
MEDICAL CODING FUNDAMENTALS
INTRODUCTION
Coding is not like anything you have ever studied before. No courses that you expe-
rienced in elementary, middle, or high school have prepared you for learning this
skill. Biology and your science classes began your education that your anatomy and
physiology class continued. Other courses you are taking as part of this program also
typically connect to something, in some way, you have previously learned.
As you begin this educational journey, you will use your critical thinking skills as
well as some experiences you may have had as a patient yourself (or as the loved one
of a patient). For the most part, though, this will be different, so prepare yourself for a
new learning experience.
In Part I, the chapters Introduction to the Languages of Coding, Abstracting Clini-
cal Documentation, and The Coding Process share an overview of the concepts and
skills you will apply in the chapters that follow. You will be introduced to the tools you
have and will need to use as a professional coding specialist. Together, these three
chapters create the foundation, the first layer, of a multilayered approach to learning
coding. Then, the remaining Parts will share with you, one by one, the best practices
for how to use each of these tools correctly. You will then be given many opportunities
for hands-on practice so that you can build your skills and reinforce the knowledge
you have obtained.
 1
Key Terms
Introduction to the
Languages of Coding
Learning Outcomes
Classification Systems
Condition After completing this chapter, the student should be able to:
Diagnosis LO 1.1 Explain the four purposes of medical coding.
Eponym
External Cause
LO 1.2 Identify the structure of the ICD-10-CM diagnosis coding
Inpatient manual.
Medical Necessity LO 1.3 Differentiate between the types of procedures and the
Nonessential Modifiers ­various procedure coding manuals.
Outpatient LO 1.4 Examine the HCPCS Level II coding manual used to report
Procedure the provision of equipment and supplies.
Reimbursement
Services
Treatments

1.1  The Purpose of Coding

CODING BITES Around the world, languages exist to enable clear and accurate communication
We use the concept of between individuals in similar groups or working together in similar functions. The
“languages” to help you purpose of using health care coding languages is to enable the sharing of information,
relate medical coding— in a specific and efficient way, between all those involved in health care. 
and its code sets—to Coding languages are constructed of individual codes that are more precise than
an idea you already words. (You will discover this as you venture through this textbook.) By communi-
understand. In the health cating using codes rather than words, you can successfully convey to others involved
care industry, however, (1) exactly what happened during a provider-patient encounter and (2) why it
the various code sets, occurred. You, as the professional coding specialist, have the responsibility to accu-
such as ICD-10-CM rately interpret health care terms and definitions (medical terminology) into numbers
or HCPCS Level II, or number-letter combinations (alphanumeric codes) that specifically convey diagnoses
are referred to as and procedures. 
Classification Systems. Why is it so critical to code diagnoses and procedures accurately? The coding lan-
guages, known as classification systems, communicate information that is key to vari-
Classification Systems ous aspects of the health care system, including
The term used in health care
∙ Medical necessity
CPT © 2017 American Medical Association. All rights reserved.
to identify ICD-10-CM, CPT,
ICD-10-PCS, and HCPCS ∙ Statistical analyses
Level II code sets. ∙ Reimbursement
∙ Resource allocation
CODING BITES
A diagnosis explains
WHY the patient Medical Necessity
requires the attention of The diagnosis codes that you report explain the justification for the procedure, service,
a health care provider or treatment provided to a patient during his or her encounter. Every time a health
and a procedure
explains WHAT the
physician or health care
provider did for the
patient.

2
 care professional provides care to a patient, there must be a valid medical reason. Diagnosis
Patients certainly want to know that health care professionals performed procedures A physician’s determination of
or provided care for a specific, justified purpose, and so do third-party payers! This is a patient’s condition, illness,
referred to as medical necessity. Requiring medical necessity ensures that health care or injury.
providers are not performing tests or giving injections without a good medical reason. Procedure
Diagnosis codes explain why the individual came to see the physician and support the Action taken, in accordance
physician’s decision about what procedures to provide. with the standards of care, by
Medical necessity is one of the reasons why it is so very important to code the diag- the physician to accomplish
nosis accurately and with all the detail possible. If you are one number off in your code a predetermined objective
selection, you could accidentally cause a claim to be denied because the diagnosis, (result); a surgical operation.
identified by your incorrect code, does not justify the procedure. Medical Necessity
Let’s analyze an example:  The determination that the
health care professional was
acting according to standard
EXAMPLE practices in providing a
Dr. Justini performs a colonoscopy on Shoshanna because a lab test identified particular procedure for an
that she had blood in her feces (melena). individual with a particular
diagnosis. Also referred to as
medically necessary.
A colonoscopy involves the insertion of a camera, with surgical tools, into the patient’s
anus, rectum, and up through the large intestine. If you are Shoshanna, or if you are
the one paying for this procedure, you want to make certain that this colonoscopy was CODING BITES
done to support Shoshanna’s good health and not any other reason. This is clearly The WHY justifies the
communicated when you report the code: K92.1 Melena (the presence of blood in WHAT.
feces). Now, whether for resource allocation or reimbursement, it is understood that
Dr. Justini was caring properly for Shoshanna and her good health.

Statistical Analyses
Research organizations and government agencies statistically analyze the data pro-
vided by codes to develop programs, identify research areas, allocate funds, and write
public health policies that will best address areas of concern for the health of our
nation. For example, we can only know that a disease such as Alzheimer’s needs diag-
nostic tests, treatments, and possibly a vaccine or a cure by studying statistics to see
what individual signs and symptoms are being identified and treated around the coun-
try and around the world. Reimbursement
The process of paying for
health care services after they
Reimbursement have been provided.
In most cases, there are three parties involved in virtually every encounter: the health
care provider, the patient, and the person or organization paying for the care provided
(frequently, a health care insurance company). However, the insurance company is not CODING BITES
CPT © 2017 American Medical Association. All rights reserved.

always an actual insurance company, so the broader term “third-party payer” is used. In most cases, there are
Third-party payers use our coding data to determine how much they should pay health three parties involved in
care professionals for the attention and services they provide patients. This is the role reimbursement:
that coding plays in the reimbursement process. The codes make it easier for the
organizations involved to evaluate and manage all their data. • The health care
provider = First party
• The patient =
Resource Allocations
Second party
Whether a health care facility is a one-physician office or a large hospital, there are • The insurance
not unlimited resources available. Administrators and managers must ensure that all company or other
resources are employed in the most efficient and effective manner. Computer pro- organization
grams can easily and quickly organize data (the codes) to identify the largest patient financially
population’s diagnoses and the most frequently provided treatments and services. With responsible =
these details, staff members, equipment, and money can be directed to those patients Third-party payer
and locations that need them the most.

CHAPTER 1  | 
 1.2  Diagnosis Coding
When a person goes to see a health care provider, he or she must have a reason—a
health-related reason. After all, as much as you might like your physician, you prob-
ably wouldn’t make an appointment, sit in the waiting room, and go through all the
paperwork just to say, “hello.” Whether the reason is a checkup, a flu shot, or some-
thing more serious, there is always a reason why. The physician will create notes, either
written or dictated, recounting the events of the visit. The diagnosis, or diagnostic
statement, in these notes will explain the reason why the patient was seen and treated.
The physician’s notes explain, in writing, the reasons why the encounter occurred.
The notes may document a specific condition or illness, the signs or symptoms of
a yet-unnamed problem, or another reason for the encounter, such as a preventive
­service. As a coding specialist, it is your job to translate this explanation into a diag-
nosis code (or codes) so that everyone involved will clearly understand the issues of a
particular patient at a particular time.
The International Classification of Diseases – 10th Revision – Clinical Modification
(ICD-10-CM) code book contains all of the codes from which you will choose to
report the reason why the health care professional cared for the patient during a spe-
cific encounter.

Overview of the International Classification of Diseases – 10th

Revision – Clinical Modification (ICD-10-CM) Code Book Sections
The ICD-10-CM code book (whether paper or electronic) is made up of several sec-
tions. Here is an overview of its parts and how you will utilize the information in these
CODING BITES sections to determine the most accurate code or codes to report the reasons why an
encounter occurred.
This is just an overview
to help you orient your- Index to Diseases and Injuries [aka Alphabetic Index]
self to the structure of
The Alphabetic Index [Index to Diseases and Injuries] lists, in alphabetic order, the
the code book. You will
terms used by the physician to describe the reasons why the patient required attention
learn, in depth, how
from a health care professional.
to use the ICD-10-CM
The Alphabetic Index lists all diagnoses and other reasons to provide health care by
code set to report any
their basic description alphabetically from A to Z (see Figure 1-1). Diagnostic descrip-
and all of the reasons
tions are listed by
why a patient needs the
care of a health care ∙ Condition (e.g., infection, fracture, and wound)
professional in Part II: ∙ Eponym (e.g., Epstein-Barr syndrome and Cushing’s disease)
Reporting Diagnoses.
∙ Other descriptors (e.g., personal history, family history)
Condition
The state of abnormality or Abnormal, abnormality, abnormalities (see also Anomaly)
CPT © 2017 American Medical Association. All rights reserved.
dysfunction. - acid-based balance (mixed) E87.4
Eponym - albumin R77.0
A disease or condition named - alphafetoprotein R77.2
for a person. - alveolar ridge K08.9
- anatomical relationship Q89.9
- apertures, congenital, diaphragm Q79.1
- auditory perception H93.29-
-- diplacusis — see Diplacusis
-- hyperacusis — see Hyperacusis
-- recruitment — see Recruitment, auditory
-- threshold shift — see Shift, auditory threshold
- autosomes Q99.9

FIGURE 1-1  ICD-10-CM Alphabetic Index, partial listing under main term Abnormal

4   PART I  |  MEDICAL CODING FUNDAMENTALS

 So, whichever type of words you read in the documentation, you should be able to
find them in the Alphabetic Index in one form or another. 
The Alphabetic Index can only suggest a possible code to report the patient’s diag-
nosis, and you will use this suggestion to guide you to the correct page or subsection
in the Tabular List (see the next subsection of this text, Tabular List of Diseases and
Injuries). The Official Guidelines require you to always find a suggested code in the
Tabular List to confirm it is accurate, or to find another code that might be better. 

Tabular List of Diseases and Injuries

The Tabular List provides you with each and every available code in the ICD-10-CM CODING BITES
code book, in order of the code characters—alphanumeric order. You need to care-
Notations in the Tabular
fully read the descriptions, beginning at the top of the three-character code category.
List help make your
When you begin reading at this point, you can make certain that you find the best
coding process more
code, to the highest level of specificity, according to the physician’s documentation.
accurate and a bit
You will find that the Tabular List section shows all ICD-10-CM codes, first in
easier. For example,
alphabetic order and then in numeric order: A00 through Z99.89 (see Figure 1-2), along
as you can see in
with additional details (notations and symbols) that guide you to the accurate code.
Figure1-2, the condition
Ancillary Sections of ICD-10-CM represented by code
category B67 is
Neoplasm Table Echinococcosis. Now,
The Neoplasm Table (Figure 1-3) itemizes all of the anatomical sites in the human read the note
body that may develop a tumor (neoplasm). Columns in this table further describe directly below B67; it
the type of neoplasm and suggest a code that may be accurate. As with other codes reads . . .
suggested by the Alphabetic Index, you will need to go to the Tabular List to look up hydatidosis. This
any code found on the Neoplasm Table to confirm accuracy, additional characters notation lets you know
required, and other details before you can determine the accurate code to report. that, if the physician
You will learn how to use the Neoplasm Table to report diagnoses of benign, malig- wrote “echinococcosis”
nant, and other types of neoplasms in the Coding Neoplasms chapter. or “hydatidosis” in the
documentation, this
Table of Drugs and Chemicals is the correct code
The Table of Drugs and Chemicals (Figure 1-4) lists pharmaceuticals and chemicals category. 
that may cause poisoning or adverse effects in the human body. The multiple columns In ICD-10-CM, the
in this table categorize the intent of how or why the patient became ill from the drug note provides
or chemical to suggest a possible code. As with all of these, this suggested code must you with alternative
words or phrases
that the physician
B67 Echinococcosis might use that mean
the same condition.
   hydatidosis
In English, they are
   B67.0 Echinococcus granulosus infection of liver known as synonyms.
In ICD-10-CM, they are
CPT © 2017 American Medical Association. All rights reserved.

   B67.1 Echinococcus granulosus infection of lung

known as nonessential
   B67.2 Echinococcus granulosus infection of bone modifiers.
You will learn
   B67.3 Echinococcus granulosus infection, other and multiple sites
more about notations
B67.31 Echinococcus granulosus infection, thyroid gland in the Introduction to
ICD-10-CM chapter.
B67.32 Echinococcus granulosus infection, multiple sites
B67.39 Echinococcus granulosus infection, other sites
Nonessential Modifiers
   B67.4 Echinococcus granulosus infection, unspecified Descriptors whose inclusion in
the physician’s notes are not
Dog tapeworm (infection)
absolutely necessary and that
are provided simply to further
FIGURE 1-2  ICD-10-CM Tabular List, partial list of codes included in code clarify a code description;
­category B67 Echinococcosis optional terms.

CHAPTER 1  | 
 Malignant Malignant Ca in Uncertain Unspecified
Primary Secondary situ Benign Behavior Behavior
Neoplasm, neoplastic C80.1 C79.9 D09.9 D36.9 D48.9 D49.9
-abdomen, abdominal C76.2 C79.8- D09.8 D36.7 D48.7 D49.89
--cavity C76.2 C79.8- D09.8 D36.7 D48.7 D49.89
--organ C76.2 C79.8- D09.8 D36.7 D48.7 D49.89
--viscera C76.2 C79.8- D09.8 D36.7 D48.7 D49.2
--wall—see also Neoplasm, C44.509 C79.2- D04.5 D23.5 D48.5 D49.2
­abdomen, wall, skin
---connective tissue C49.4 C79.8- - D21.4 D48.1 D49.2
---skin C44.509
----basal cell carcinoma C44.519 - - - - -
----specified type NEC C44.599 - - - - -
----squamous cell carcinoma C44.529 - - - - -

FIGURE 1-3  The Neoplasm Table from ICD-10-CM, listings for abdominal neoplasms

Poisoning, Poisoning,
Accidental Intentional Poisoning, Poisoning, Adverse
Substance (Unintentional) Self-harm Assault Undetermined Effect Underdosing
Acefylline piperazine T48.6X1 T48.6X2 T48.6X3 T48.6X4 T48.6X5 T48.6X6
Acemorphan T40.2X1 T40.2X2 T40.2X3 T40.2X4 T40.2X5 T40.2X6
Acenocoumarin T45.511 T45.512 T45.513 T45.514 T45.515 T45.516
Acenocoumarol T45.511 T45.512 T45.513 T45.514 T45.515 T45.516
Acepifylline T48.6X1 T48.6X2 T48.6X3 T48.6X4 T48.6X5 T48.6X6
Acepromazine T43.3X1 T43.3X2 T43.3X3 T43.3X4 T43.3X5 T43.3X6
Acesulfamethoxypyridazine T37.0X1 T37.0X2 T37.0X3 T37.0X4 T37.0X5 T37.0X6
Acetal T52.8X1 T52.8X2 T52.8X3 T52.8X4 — —
Acetaldehyde (vapor) T52.8X1 T52.8X2 T52.8X3 T52.8X4 — —
- liquid T65.891 T65.892 T65.893 T65.894 — —
P-Acetamidophenol T39.1X1 T39.1X2 T39.1X3 T39.1X4 T39.1X5 T39.1X6
Acetaminophen T39.1X1 T39.1X2 T39.1X3 T39.1X4 T39.1X5 T39.1X6

FIGURE 1-4  The Table of Drugs and Chemicals from ICD-10-CM, listings from Acefylline piperazine to Acetaminophen 

CPT © 2017 American Medical Association. All rights reserved.

Source: ICD-10-CM Official Guidelines for Coding and Reporting, The Centers for Medicare and Medicaid Services (CMS) and the National Center for Health Statis-
tics (NCHS)

be reviewed in the Tabular List to ensure completeness and accuracy before you can
report it.
You will learn how to use the Table of Drugs and Chemicals in the chapter Coding
Injury, Poisoning, and External Causes.

Index to External Causes

External Cause The Index to External Causes (Figure 1-5) lists the causes of injury and poisoning.
An event, outside the body, These codes are used to explain how a patient got injured and where (place of occur-
that causes injury, poisoning, rence) he or she was when the injury happened. 
or an adverse reaction. As with the other content in the Alphabetic Index, the code or codes shown here are
only suggestions and must be confirmed in the Tabular List before you are permitted
to report them. You will learn about the importance of reporting these codes as you

6   PART I  |  MEDICAL CODING FUNDAMENTALS

 Abandonment (causing exposure to weather conditions) (with intent to injure or
kill) NEC X58
Abuse (adult) (child) (mental) (physical) (sexual) X58
Accident (to) X58
- aircraft (in transit) (powered) — see also Accident, transport, aircraft
-- due to, caused by cataclysm — see Forces of nature, by type
- animal-rider — see Accident, transport, animal-rider
- animal-drawn vehicle — see Accident, transport, animal-drawn vehicle occupant
- automobile — see Accident, transport, car occupant
- bare foot water skier V94.4
- boat, boating — see also Accident, watercraft
-- striking swimmer
-- powered V94.11
-- unpowered V94.12
- bus — see Accident, transport, bus occupant
- cable car, not on rails V98.0

FIGURE 1-5  The Index to External Causes, first listings including main terms
Abandonment, Abuse, and Accident

progress through your learning experience, particularly in the chapter Coding Injury,
Poisoning, and External Causes.

The Format of ICD-10-CM Codes

A complete, valid ICD-10-CM code will always begin with a 3-character code cat-
egory: a letter of the alphabet followed by a minimum of 2 characters (either letters or
numbers).
E54 Ascorbic acid deficiency (scurvy)
O9A Maternal malignant neoplasms, traumatic injuries, and abuse
A majority of the codes will require additional characters to communicate more
specific information about the patient’s condition. When an additional character is CODING BITES
needed to complete the code, a symbol to the left of the code in the Tabular List When additional
will  identify that additional characters are necessary. The symbol may be a bullet characters are required,
or it may be a box with a check mark , depending upon the publisher of your those codes with fewer
code book. You will find a legend to explain the meaning of each symbol at the bot- characters are invalid.
tom  of  the page  in your  code book. As you evaluate the options available for the The need for additional
additional ­character, make certain to place a dot (period) between the third and fourth characters is mandatory,
CPT © 2017 American Medical Association. All rights reserved.

characters. not a suggestion.

Let’s take a look at an example together:
M17 Osteoarthritis of knee
    M17.0 Bilateral primary osteoarthritis of knee
The symbol to the left of code M17 alerts you that this code requires a 4th character.
In looking at the second line of this example (M17.0), you can see that this fourth
character shares additional, important information about the patient’s condition. It is
not enough to communicate that the patient has been diagnosed with osteoarthritis of
the knee. You must explain the specific location (from our example, bilateral = both
knees) and specific type of condition (from our example, primary osteoarthritis).
ICD-10-CM codes can be as short as three (3) characters and can add additional
characters containing more specificity about the patient’s condition . . . up to a total of
seven (7) characters. These additional characters ensure that as much detail as possible
about the patient’s condition is communicated accurately and completely.

CHAPTER 1  | 
 EXAMPLE
The Tabular List shows you which details to abstract from the documentation. All you
have to do is keep reading. The portion of the ICD-10-CM Tabular List below shows
options for additional characters and the information these characters convey.
S43.3 Subluxation and dislocation of other and unspecified parts of shoulder
girdle
CODING BITES    S43.30 Subluxation and dislocation of unspecified parts of shoulder girdle
    Dislocation of shoulder girdle NOS
You will learn many
    Subluxation of shoulder girdle NOS
more details about
reporting diagnoses     S43.301 Subluxation of unspecified parts of right shoulder girdle
in Part II: Reporting     S43.302 Subluxation of unspecified parts of left shoulder girdle
Diagnoses, with more     S43.303 Subluxation of unspecified parts of unspecified shoulder girdle
in-depth introduction to     S43.304 Dislocation of unspecified parts of the right shoulder girdle
ICD-10-CM as well as     S43.305 Dislocation of unspecified parts of the left shoulder girdle 
details by body system.     S43.306 Dislocation of unspecified parts of unspecified shoulder girdle

ICD-10-CM
LET’S CODE IT! SCENARIO
MCGRAW GENERAL HOSPITAL
DATE OF ADMISSION: 05/27/18
DATE OF DISCHARGE: 05/28/18
PATIENT: YOUNG, MATTHEW JAMES
HISTORY: Neonate is male, delivered 05/27/2018 at 1915 hours by C-section due to previous C-section. Mother is:
•  gravida 2, para 2, AB 1
•  blood type B positive
•  GBS negative
•  hepatitis B surface antigen negative
•  rubella immune
•  VDRL nonreactive 

VITAL SIGNS:
Weight: 6 pounds 9 ounces
Height: 10-1/2 inches

CPT © 2017 American Medical Association. All rights reserved.

Head circumference: 14 inches
GENERAL:
APGAR = 10 @1 min., 10 @5 min
SKIN: Portwine nevus on right ankle
NEUROLOGIC: Alert, vigorous cry, good tone, nonfocal
DISPOSITION:
The neonate was discharged to his mother. I instructed the mother to phone me PRN. I told her that I want to see both
in my office in 10 days for a follow-up.

Let’s Code It!

Dr. Michaels delivered Matthew James Young and examined him. Being born is the confirmed reason why
the baby needed Dr. Michael’s time and expertise. You need to translate the reason why into an ICD-10-CM

8   PART I  |  MEDICAL CODING FUNDAMENTALS

 diagnosis code. So, begin in the Alphabetic Index of your ICD-10-CM manual. What should you look up? Mat-
thew needed to be examined right after being born, so let’s look up: 
Birth . . . nothing here that matches. 
Next, try: Newborn. We have a match!
Newborn (infant) (liveborn) (singleton) Z38.2
Turn in the Tabular List to this code and begin by reading at the three-character code category:
 Z38 Liveborn infants according to place of birth and type of delivery
NOTE: This category is for use as the principal code on the initial record of a newborn baby. It is to be used
for the initial birth record only. It is not to be used on the mother’s record.
You know that Matthew was just born, so this note confirms you are in the right place in the code book. Notes,
notations, symbols, and other marks in the code book are there to help point you in the right direction and to
support your determination of the correct code.
Our next step is to look at the mark to the left of the code . . . it may be a box with a check mark , it may be a
dot , or the following lines may just be indented. However your copy of the code book alerts you, it is clear . . .
this code needs an additional character. And this is not a suggestion; it is mandatory.
There are three options for a fourth character:
Z38.0 Single liveborn infant, born in hospital
Z38.1 Single liveborn infant, born outside hospital
Z38.2 Single liveborn infant, unspecified as to place of birth
You can see in the record above that Matthew was born in McGraw General Hospital and, therefore, Z38.0 is the
most accurate. 
But we aren’t done yet. There is a symbol to the left of code Z38.0. It is telling you that an additional character is
required. Let’s look at the two options:
Z38.00 Single liveborn infant, delivered vaginally
Z38.01 Single liveborn infant, delivered by cesarean
Go back to the documentation and read the information provided by the doctor. He noted that Matthew was
born via a C-section (the C stands for cesarean).
There are no more symbols or notations here in the Tabular List. Next, double-check the Official Guidelines, Section 1C.
Chapter 21, subsection 12) Newborns and Infants as well as Chapter 16, subsection 6) Code all clinically signifi-
cant conditions. It appears that there are no further details or codes needed . . . so this is the code.
Good job! You were able to determine that code Z38.01 most accurately reports Matthew’s birth. You did it!
CPT © 2017 American Medical Association. All rights reserved.

1.3  Procedure Coding

Once the physician has determined the patient’s condition or problem, he or she can
then establish a treatment plan. Generally, there are three terms used to describe
actions that the physician can take to support a patient’s good health or to improve a
current condition:
Procedures are actions, or a series of actions, taken to accomplish an objective Services
(result). For example, surgically removing a mole or resectioning the small intestine. Spending time with a patient
Services are actions that will most often involve counseling, educating, and advis- and/or family about health
ing the patient, such as discussing test results or sharing recommendations for risk care situations.
reduction. Treatment
Treatments are typically an application of a health care service, such as radiation The provision of medical care
treatments for tumor reduction or acupuncture. for a disorder or disease.

CHAPTER 1  | 
 These actions provided by the physician, or other health care professional, are done for
one of three reasons:
Diagnostic tests or procedures are performed to provide the physician with addi-
tional information required to determine a confirmed diagnosis.
Preventive procedures and services are provided to keep a healthy patient healthy.
In other words . . . to avoid illness or injury. These also include early detection test-
ing, known as screenings.
Therapeutic procedures, treatments, and services are performed with the intention
of removing, correcting, or repairing an abnormality or condition.
There are three different code sets available for you to use to translate health care
procedures, services, and treatments into codes. These three code sets are
Current Procedural Terminology (CPT)
International Classification of Diseases – 10th Revision – Procedure Coding System
(ICD-10-PCS)
Healthcare Common Procedure Coding System (HCPCS) Level II

Current Procedural Terminology (CPT)

CPT codes are used to describe procedures performed by a physician in any location.
These services range from speaking with a patient about test results to performing
surgery or determining a treatment plan. In addition, CPT codes are used to report the
Outpatient contribution made by outpatient facilities (a physician’s office, a clinic, an ambulatory
An outpatient is a patient surgical center, or the emergency department of a hospital) such as a sterile procedure
who receives services for a room, trained nursing and support staff, etc.
short amount of time (less
than 24 hours) in a physician’s The Organization of the CPT Code Book
office or clinic, without being
The CPT book has two parts, which in turn have many sections.
kept overnight. An outpatient
facility includes a hospital
The CPT book (see Figure 1-6) has six sections, which are generally presented in
emergency room, ambulatory numeric order by code number:
care center, same-day surgery ∙ Evaluation and Management: 99201–99499
center, or walk-in clinic.
∙ Anesthesia: 00100–01999 and 99100–99140
∙ Surgery: 10021–69990
∙ Radiology: 70010–79999
∙ Pathology and Laboratory: 80047–89398
CODING BITES ∙ Medicine: 90281–99199, 99500–99607
CPT codes and sections The second part of the CPT book also contains several sections, including
run, generally, in
∙ Category II codes: used for supplemental tracking of performance measurements.
CPT © 2017 American Medical Association. All rights reserved.
numeric order; however,
there are exceptions These codes are not reimbursable but support research on specific physician actions
throughout. Bottom line taken on behalf of a patient’s health.
. . . read carefully and ∙ Category III codes: temporary codes used to report emerging technological proce-
completely. dures. Technology and health care are innovating and improving every day. These
codes enable tracking physician adoption and the frequency of use to identify what
should stay and what will be deleted.
∙ Appendixes A–M: modifiers and other relevant additional information.
CODING BITES
∙ Alphabetic Index: all the CPT codes in alphabetical order by code description,
More information
­presented in four types of entries (see Figure 1-7):
about Category II and
Category III codes a.  Procedures or services, such as bypass, decompression, insertion.
will be covered in the b. Anatomical site or organ, such as brain stem, spinal cord, lymph nodes.
chapter Introduction to
c. Condition, such as pregnancy, fracture, abscess.
CPT.
d. Eponyms, synonyms, or abbreviations, such as Potts-Smith Procedure or EEG.

10   PART I  |  MEDICAL CODING FUNDAMENTALS

 pancreas, 49180 for abdominal or retroperitoneal mass,
50200 for kidney, 54500 for testis, 54800 for epididymis, Incision and Drainage
60100 for thyroid, 62267 for nucleus pulposus,
(For excision, see 11400, et seq)
intervertebral disc, or paravertebral tissue, 62269 for
spinal cord) 10040 Acne surgery (eg, marsupialization, opening or removal of
multiple milia, comedones, cysts, pustules)
(For evaluation of fine needle aspirate, see 88172, 88173) CPT Assistant Fall 92:10, Feb 08:8
10060 Incision and drainage of abscess (eg, carbuncle,
Integumentary System suppurative hidradenitis, cutaneous or subcutaneous
abscess, cyst, furuncle, or peronychia); simple or single
CPT Assistant Sep 12:10
Skin, Subcutaneous, and Accessory 10061 complicated or multiple
Structures CPT Assistant Sep 12:10
10080 Incision and drainage of pilonidal cyst; simple
Introduction and Removal CPT Assistant Fall 92:13, Dec 06:15, May 07:5

10030 Image-guided fluid collection drainge by catheter (eg. 10081 complicated

abscess, hematoma, seroma, lymphocele, cyst), soft CPT Assistant Fall 92:13, Dec 06:15. May 07:5
tissue (eg. extremity, abdominal wall, neck), (For excision of pilonidal cyst, see 11770-11772)
percutaneous
CPT Changes: An Insider’s View 2014 10120 Incision and removal of foreign body, subcutaneous
tissues: simple
CPT Assistant Fall 13:6, May 14:3, 9
Clinical Examples in Radiology Summer 14:9 CPT Assistant Sep 12:10, Apr 13:10, Dec 13:16

(Report 10030 for each individual collection drained with 10121 complicated
a separate catheter) CPT Assistant Spring 91:7, Dec 06:15. Sep 12:10, Dec 13:16

(Do not report 10030 in conjunction with 75989, 76942, (To report wound exploration due to penetrating trauma
77002, 77003, 77012, 77021) without laparotomy or thoracotomy, one 20100-20103, as
appropriate)

FIGURE 1-6  CPT main section, showing codes 10030–10121  Source: American Medical
Association, CPT Professional Manual

The Formats of CPT Codes

The codes listed in the various CPT sections each have different structures:
CPT codes (Category I codes) are five-digit codes. They have all numbers (no letters,
no punctuation). Example: 51100 Aspiration of bladder; by needle.
Category II codes are five-character codes, with four numbers followed by the
­letter “F.” Example: 2001F Weight recorded.
Category III codes are five-character codes. These codes also have four numbers;
however, Category III codes are followed by the letter “T.” Example: 0208T Pure tone
audiometry (threshold), automated; air only.
Modifiers (listed in Appendix A of your CPT code book) are two characters: two
numbers, two letters, or one letter and one number. Modifiers are appended to CPT

Activity, Glomerular Procoagulant Alanine Transaminase

Activity, Glomerular Procoagulant Labial Adult T Cell Leukemia Lymphoma

See Thromboplastin Lysis. . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . .56441 Virus I
Liver See HTLV-I
Acupuncture Lysis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58660
with Electrical Stimulation . . . . . . . . . .97813, 97814 Lungs Advanced Life Support
without Electrical Stimulation. . . . . . . .97810, 97811 Pneumonolysis. . . . . . . . . . . . . . . .32174, 32940 Physician/Health Care Professional Direction 99288
Nose
Acute Poliomyelitis Lysis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30560 Advancement
See Polio Genioglossus. . . . . . . . . . . . . . . . . . . . . . . . . . . 21199
CPT © 2017 American Medical Association. All rights reserved.

Pelvic
Acylcarnitines . . . . . . . . 82016, 82017 Lysis. . . . . . . . . . . . . . . . . . . . . . . .58660, 58740 Tendon
Penile Tibia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .28238
Adamantinoma, Pituitary Lysis
See Craniopharyngioma Post-circumcision. . . . . . . . . . . . . . . . . . .54162
Advancement Flap
See Skin, Adjacent Tissue Transfer
Preputial
Addam Operation
See Dupuytren's Contracture
Lysis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54450 Aerosol Inhalation
Urethral See Pulmonology, Therapeutic
Adductor Tenotomy of Hip Lysis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53500 Pentamidine. . . . . . . . . . . . . . . . . . . . . . . . . . . 94642
See Tenotomy. Hip, Adductor
Adipectomy AFB
Adenoidectomy See Lipectomy See Acid-Fast Bacilli (AFB)
Index

See Adenoids. Excision

ADL Afferent Nerve
Adenoids See Activities of Daily Living See Sensory Nerve
Excision. . . . . . . . . . . . . . . . . . . . . . . . .42830, 42836
with Tonsils. . . . . . . . . . . . . . . . . . .42820, 42821
Administration AFP
Immunization See Alpha-Fetoprotein (AFP)
Unlisted Services and Procedures. . . . . . . . . .42999
Each Additional Vaccine/Toxoid 90472, 90474
Adenoma with Counseling. . . . . . . . . . . . . . . . . . . .90461 After Hours Medical Services. . 99050
Pancreas One vaccine/Toxoid. . . . . . . . . . . . .90471, 90473
with Counseling. . . . . . . . . . . . . . . . . . . 90460
Agents, Anticoagulant
Excision . . . . . . . . . . . . . . . . . . . . . . . . . . . .48120
Occlusive Substance. . . . . . . . . . . . . . . . . . . . . 31634 See Clotting Inhibitors
Parathyroid
Localization Pharrnacologic Agent. . . . . . . . . . . . . . . . . . . .93463 Agglutinin
Injection Procedure. . . . . . . . . . . . . . . . .78808 Cold. . . . . . . . . . . . . . . . . . . . . . . . . . . . 86156, 86157
Thyroid Gland Excision. . . . . . . . . . . . . . . . . . 60200
ADP
See Adenosine Diphosphate Febrile. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86000

FIGURE 1-7  CPT Alphabetic Index, partial listings from Activity, Glomerular
­Procoagulant to Agglutinin  Source: American Medical Association, CPT Professional Manual

CHAPTER 1  | 
 CPT
LET’S CODE IT! SCENARIO
Corey Carter, a 55-year-old male, came to the McGraw Ambulatory Surgery Center, an outpatient facility, so Dr.
Lucano could perform a percutaneous core needle biopsy on his thyroid. Corey’s primary care physician referred
him to Dr. Lucano after noting a lump on his thyroid during an annual physical.

Let’s Code It!

Open your CPT book to the Alphabetic Index. Which term should you look up? Let’s dissect the scenario:
Biopsy = the procedure
Percutaneous core needle = the type of biopsy
Thyroid = the anatomical site
Let’s begin by finding Biopsy in the Alphabetic Index:
Biopsy
See Brush Biopsy; Needle Biopsy
Abdomen. . . . . . . . . . . . . . . . . . 49000, 49321
Notice that Abdomen is the beginning of a long list of anatomical sites on which a biopsy can be done. Read
down the list to find:
Thyroid. . . . . . . . . . . . . . . . . . . . . . . . . . . 60100
Now, turn into the Main Section of CPT to find code 60100. You can see:
60100 Biopsy thyroid, percutaneous core needle
This matches Dr. Lucano’s documentation perfectly—you can report this procedure code with confidence!

codes under special circumstances, such as the use of unusual anesthesia, two sur-
CODING BITES geons working on the same patient at the same time, or a multipart procedure per-
You will learn many formed over time. When required, a modifier is added after the main CPT code with a
more details about hyphen. Example: 47600-54 Cholecystectomy, surgical care only.
reporting procedures
in Part III: Reporting International Classification of Diseases – 10th Revision –
­Physicians Services and ­Procedure Coding System (ICD-10-PCS)
Outpatient Procedures.
The International Classification of Diseases – 10th Revision – Procedure Coding Sys-
tem (ICD-10-PCS) codes are used to describe the contribution made by the hospital to
inpatient a procedure provided to an inpatient (a patient admitted into an acute care facility).
These are known as “facility charges” because they report what the hospital provided
CPT © 2017 American Medical Association. All rights reserved.
A patient admitted into a
hospital for an overnight stay during a specific procedure, service, or treatment, such as the skilled nursing staff, the
or longer. operating room, the equipment, and whatever else is required.
ICD-10-PCS contains an Alphabetic Index and a Tables section (Figure 1-8).
The  Alphabetic Index is used in the same way you use this part of the other code
books—to get an idea of where in the Tables section to find codes. However, the
Tables section of this code set is very different. Rather than a listing of the codes in
numeric or alphanumeric order, you will find Tables listing various characters and
their meanings. Then, you will actually build the code, according to the physician’s
documentation.

The Format of ICD-10-PCS Codes

ICD-10-PCS codes have seven (7) characters and are alphanumeric (both letters
and numbers). Each of the seven positions in the code represents a specific piece of
information relating to a procedure, service, or treatment provided. These meanings

12   PART I  |  MEDICAL CODING FUNDAMENTALS

 Section 0 Medical and Surgical
Body System 2 Heart and Greater Vessels
Operation 5 Destruction: Physical eradication of all or a portion of a body part by the direct use of energy,
force, or a destructive agent
Body Part Approach Device Qualifier
4 Coronary Vein 0 Open Z No Device Z No Qualfier
5 Atrial Septum 3 Percutaneous
6 Atrium, Right 4 Percutaneous Endoscopic
8 Conduction Mechanism
9 Chordae Tendineae
D Papillary Muscle
F Aortic Valve
G Mitral Valve
H Pulmonary Valve
J Tricuspid Valve
K Ventricle, Right
L Ventricle, Left
M Ventricular Septum
N Pericardium
P Pulmonary Trunk
Q Pulmonary Artery, Right
R Pulmonary Artery, Left
S Pulmonary Vein, Right
T Pulmonary Vein, Left
V Superior Vena Cava
W Thoracic Aorta
7 Atrium, Left 0 Open Z No Device K Left Atrial Appendage
3 Percutaneous Z No Qualfier
4 Percutaneous Endoscopic

FIGURE 1-8  Table 025, one of the tables from ICD-10-PCS Tables section
CPT © 2017 American Medical Association. All rights reserved.

change for each section of the codebook. But don’t worry. No memorization is
required . . . the code book provides you with what you need to know. All you have to
do is read carefully.
For example, in the Medical and Surgical Section, each character reports the:
1. Section of the ICD-10-PCS code set.
2. Body system upon which the procedure or service was performed.
3. Root operation, which explains the category or type of procedure.
4. Body part, which identifies the specific anatomical site involved in the procedure.
5. Approach, which reports which method was used to perform the service or
treatment.
6. Device, which reports, when applicable, what type of device was involved in the
service or procedure.
7. Qualifier, which adds any additional detail.

CHAPTER 1  | 
 EXAMPLE
0DQ48ZZ Repair of the esophagogastric junction, via natural opening
endoscopic
0RRJ0J6 Replacement of shoulder joint humeral surface with synthetic
­substitute, right side, open approach

Whereas in the Imaging Section, each character reports the:

1. Section of the ICD-10-PCS code set.
2. Body system upon which the procedure or service was performed.
3. Root type, which explains the type of imaging, such as MRI or CT scan.
4. Body part, which identifies the specific anatomical site imaged and recorded.
5. Contrast, which reports if contrast materials were used in the imaging process
6. Qualifier, which adds any additional detail.
7. Qualifier, which adds any additional detail.

EXAMPLE
B31M110 Intraoperative fluoroscopy of the spinal arteries, low osmolar
­contrast, laser
BB24ZZZ Bilateral CT scan of lungs, no contrast

ICD-10-PCS
LET’S CODE IT! SCENARIO
Marlena Takamoto, a 37-year-old female, contracted hepatitis seven years ago. The disease severely damaged her
liver. She was admitted to Carolina Brookdale Hospital today so Dr. Lewis and his team can perform a liver trans-
plantation, open approach. The liver donor was killed in a car accident early this morning.

Let’s Code It!

The physicians will transplant a liver, using an open approach, from the donor to Marlena. The coder who works
for Dr. Lewis will use CPT codes to report his services provided to Marlena. You work as the coder for Carolina
Brookdale Hospital, so you need to use ICD-10-PCS to report the hospital’s contribution in this surgery (the
operating room, the support staff [surgical nurses, technicians, etc.], and other equipment).
The procedure is a transplant, so let’s start by looking in the Alphabetic Index in ICD-10-PCS for transplant. In
the index, we find
Transplantation
CPT © 2017 American Medical Association. All rights reserved.
Liver 0FY00Z-
In this particular case, the Alphabetic Index provides you with the first six of the required seven characters. In
other cases, you may find the Alphabetic Index will only provide you with three or four characters. Regardless,
you must find this Table in the Tables section to complete the seven (7) characters. Using the first three charac-
ters provided by the Alphabetic Index, turn in the Tables section to the Table that begins with 0FY (see below):

Section 0 Medical and Surgical

Body System F Hepatobiliary System and Pancreas
Operation Y Transplantation: Putting in or on all or a portion of a living body part taken from
another individual or animal to physically take the place and/or function of all or a
portion of a similar body part

14   PART I  |  MEDICAL CODING FUNDAMENTALS

 Body Part Approach Device Qualifier
0 Liver 0 Open Z No Device 0 Allogeneic
G Pancreas 1 Syngeneic
2 Zooplastic

Now, with all of this information, let’s build the correct code:
1.  Section of the ICD-10-PCS code set = Medical and Surgical 0
2.  Body system upon which the procedure was performed = Hepatobiliary F
Remember, the liver is an organ that is part of the Hepatobiliary System.
3.  Root operation: the type of procedure = Transplantation Y
4.  Body part: the specific anatomical site involved in the procedure = Liver 0
5.  Approach: method used to perform the transplant = Open 0
6.  Device, when applicable = No Device Z
7.  Qualifier: any additional detail = Allogeneic 0
Before reporting this code . . . check the Official Guidelines, specifically B3.16 Transplantation vs. Administration.
This confirms that you used the correct root operation term of Transplantation.
Good job! Now you have built the ICD-10-PCS code for this procedure: 0FY00Z0.

It would not be unusual for one patient encounter, for a patient admitted into
the  hospital, to ultimately require interpretation into all three coding languages: CODING BITES
­ICD-10-CM, CPT, and ICD-10-PCS.
Use a medical
dictionary whenever
EXAMPLE you do not know the
Injured in an accident, Terence McCarthy was admitted into McGraw General meaning of a term:
Hospital with a major contusion of the spleen. Terence was brought into the Allogeneic means
­operating room, he was placed in the supine position, and general anesthesia coming from a different
was administered by Dr. London. Dr. Berring performed a total splenectomy. individual of the same
Together, let’s review all of the codes that will be reported for this surgical species.
procedure: Syngeneic means
• The professional coding specialist for Dr. Berring, the surgeon, will report: coming from a genetic
identical, such as from
S36.021A Major contusion of spleen, initial encounter an identical twin.
38100 Splenectomy; total Zooplastic means
• The professional coding specialist for Dr. London, the anesthesiologist, will report: the tissue or organ is
CPT © 2017 American Medical Association. All rights reserved.

coming from a donor of

S36.021A Major contusion of spleen, initial encounter another species into a
00790-P1 Anesthesia for intraperitoneal procedures in upper abdomen human.
including laparoscopy; not otherwise specified
• The professional coding specialist for McGraw General Hospital, the facility,
will report:

S36.021A Major contusion of spleen, initial encounter CODING BITES

07TP0ZZ Splenectomy, open approach You will learn many
more details about
HCPCS Level II Procedure Codes reporting inpatient
procedures in Part V:
In some cases, you might determine that the CPT code set does not contain a code that Inpatient (Hospital)
accurately and completely reports a procedure or service. It is possible that a HCPCS Reporting.
Level II code may do the job.

CHAPTER 1  | 
 HCPCS (pronounced “hick-picks”) is the abbreviation for Healthcare Common
Procedure Coding System.
∙ HCPCS Level I codes are actually called CPT codes. While CPT codes are main-
tained by the American Medical Association (AMA), this code set was adopted by
our industry as the first level of HCPCS.
∙ HCPCS Level II codes are referred to as HCPCS Level II codes.
For the most part, health care services are listed in the HCPCS Level II section
titled Procedures/Professional Services (Temporary) G0008–G0151 [but not exclu-
sively, so be certain to check the Alphabetic Index first]. As always, reading carefully
and completely is required. However, as you scan the codes and their descriptions
in this section of HCPCS Level II, you may find some are very close to CPT code
descriptions. But . . . not exactly. Let’s look at the simple repair of a 2.1 cm superficial
laceration on the patient’s left hand being repaired with tissue adhesive.
In CPT, under REPAIR (CLOSURE), the in-section guidelines state: “Use the
codes in this section to designate wound closure utilizing sutures, staples, or tissue
adhesives, either singly or in combination with each other or in combination with
adhesive strips.”
The definition in CPT of a simple repair includes “. . . requires simple one layer
closure.” With this scenario, this would lead to code
12001 Simple repair of superficial wounds of scalp, neck, axillae,
­external genitalia, trunk and/or extremities (including hands
and feet); 2.5 cm or less
Compare this with the most appropriate HCPCS Level II code:
G0168 Wound closure utilizing tissue adhesive(s) only
Which code reports the repair more accurately? You must go back to the documenta-
tion and read carefully, looking for the additional details included in the definition
of Simple Repair in CPT. Was a one-layer closure performed? Was local anesthesia
used? Was anything else done by the physician in addition to the application of the
tissue adhesive?
If the answer to any of these questions is Yes, then you need to report the CPT code
12001. If the answers to all of these questions are No, then report G0168. 
Let’s look at an example that is perhaps a bit less complex. Compare and contrast
these two codes, both of which are used for reporting speech therapy services:
92507 Treatment of speech, language, voice, communication, and/or
auditory processing disorder; individual
CODING BITES S9128 Speech therapy, in the home, per diem

Learn about the other These two codes report similar services: speech therapy provided to an individual.
CPT © 2017 American Medical Association. All rights reserved.
types of HCPCS However, they differ with regard to location, length of the session, and possibly the pro-
Level II codes in the fessional providing the therapy. Be certain to read the CPT in-section Guidelines related
section Equipment and to the reporting of 92507 (and other codes in this subsection) before you decide. And, of
Supplies in this chapter. course, you need to carefully abstract the details within the documentation from which
And learn more you are coding and compare the specifics to each of the code descriptions, and perhaps
about the HCPCS to any others available. Then, and only then, can you determine which code to report.
Level II code set in the Don’t worry . . . one item, one detail, one concept at a time. It will take time, but we
chapter HCPCS Level II. are confident you will be able to understand, learn, and master coding for health care
services.

1.4  Equipment and Supplies

A large number of components of health care extend beyond what are usually referred
to as procedures, services, and treatments you learned about earlier in Section 1.3

16   PART I  |  MEDICAL CODING FUNDAMENTALS

 of this chapter. This includes equipment that is provided for a patient’s use at home,
supplies that are not already included in other codes, and transportation services not
described in the CPT book at all. HCPCS Level II also contains codes you can use to
report them.
HCPCS Level II codes cover specific aspects of health care services, including
∙ Durable medical equipment (e.g., a wheelchair or a humidifier).
∙ Pharmaceuticals administered by a health care provider (e.g., a saline solution or a
chemotherapy drug).
∙ Medical supplies provided for the patient’s home use (e.g., an eye patch or gradient
compression stockings).
∙ Dental services (e.g., all services provided by a dental professional).
∙ Transportation services (e.g., ambulance services).
∙ Vision and hearing services (e.g., trifocal spectacles or a hearing aid).
∙ Orthotic and prosthetic procedures (e.g., scoliosis brace or prosthetic arm).
HCPCS Level II codes are listed in sections, grouped by the type of service, the
type of supply item, or the type of equipment they represent. However, you should
not assume that a particular item or service is located in a specific section. Use the
Alphabetic Index (Figure 1-9) to direct you to the correct section or subsection in the
Alphanumeric Listing of the code book. One type of service or procedure might be
located under several different categories depending upon the details.
Medicare and Medicaid want you to use HCPCS Level II codes; however, not all
insurance carriers accept these codes. It is your responsibility, as a coding specialist,
to find out whether each third-party payer with which your facility works will permit
the reporting of HCPCS Level II codes on a claim form. If not, you should ask for the
payer’s policies on reporting the services and supplies covered by HCPCS Level II so
you don’t have a claim delayed or denied.

The Format of HCPCS Level II Codes

The codes listed in the HCPCS Level II code book are all structured the same way:
one letter followed by four numbers. No dots, no dashes (Figure 1-10).
A0225 Ambulance service, neonatal transport, base rate, emergency
transport, one way
E0130 Walker, rigid (pickup), adjustable or fixed height
J3480 Injection, potassium chloride, per 2 mEq
L0130 Cervical, flexible, thermoplastic collar, molded to patient
V5050 Hearing aid, monaural, in the ear
CPT © 2017 American Medical Association. All rights reserved.

Cyclosporine, J7502, J7515, J7516

Cytarabine, J9100
Cytarabine liposome, J9098
Cytomegalovirus immune globulin (human), J0850
D
Dacarbazine, J9130
Daclizumab, J7513
Dactinomycin, J9120

FIGURE 1-9  HCPCS Level II Alphabetic Index, partial listing from Cyclosporine to
Dactinomycin

CHAPTER 1  | 
 2017 HCPCS Level II J7628

Drugs Administered Other Than Oral method

J7512 Prednisone, Immediate release or delayed release, oral, 1 mg J7611 Albuterol, inhalation solution, FDA-approved final product,
noncompounded, administered through DME, unit dose, 1
J7513 Daclizumab, parenteral, 25 mg
mg
Use this code for Zenapax.
Use this code for Acouneb, Proventil, Respirol, Ventelin.
CMS: 100-2,15,50.5; 100-4, 17, 80.3
AHA: 20, ’08, 10; 20, ’07, 10
AHA: 20, ’05, 11
J7612 Lavalbuterol, inhalation solution, FDA-approved final
J7515 Cyclosporine, oral, 25 mg
product, noncompounded, administered through DME, unit
Use this code for Neoral, Sandimmune, Gengraf, Sangcya. dose, 0.5 mg
CMS: 100-4, 17, 80.3 Use this code for Xopenex.
J7516 Cyclosporine, parenteral, 250 mg CMS: 100-3, 200.2
Use this code for Neoral, Sandimmune, Gengral, Sangcya. AHA: 20, ’08, 10; 20, ’07, 10
CMS: 100-4, 17, 80.3
J7615 Levalbuterol, inhalation solution, compounded product,
J7517 Mycophenolate mofetil, oral, 250 mg administered through DME, unit dose, 0.5 mg
Use this code for CeliCept. CMS: 100-3, 200.2
CMS: 100-4, 17, 80.3 J7620 Albuterol, up to 2.5 mg and ipratropium bromide, up
J7518 Mycophenolic acid, oral, 180 mg to 0.5 mg, FDA-approved final product, noncompounded,
Use this code for Mytoxtic Delayed Release. administered through DME
CMS: 100-4, 17, 80, 3.1
J7622 Betclomethasone, inhalation solution, compounded
AHA: 20, ’05, 11 product, administered through DME, unit dose form, per mg
J7520 Sirolimus, oral, 1 mg Use this code for Beclovent, Beconase.
Use this code for Rapamune. AHA: IQ, ’02, 5
CMS: 100-2, 15, 50.5; 100-4, 17, 80.3 J7624 Betamethasone, inhalation solution, compounded
J7525 Tacrolimus, parenteral, 5 mg product, administered through DME, unit dose form, per mg
Use this code for Prograt. AHA: IQ, ’02, 5
CMS: 100-2, 15, 50.5; 100-4, 17, 80.3 J7626 Budesonide, inhalation solution. FDA-approved final
J7527 Everolimus, oral, 0.25 mg product, noncompounded, administered through DME, unit
Use this code for Zortress, Afinitor. dose form, up to 0.5 mg
Use this code for Pulmicort, Pulmicort Flexhaler, Pulmicort Respules,
J7599 Immunosuppressive drug, not otherwise classified Vanceril.
Determine if an alternative HCPCS Level II or a CPT code Better describes AHA: IQ, ’02, 5
the service being reported. This code should be used only if a more specific
code is unavailable. J7627 Budesonlde, Inhalation solution, compounded product,
CMS: 100-2, 15, 50.5; 100-4, 17, 80.3 administered through DME, unit dose form, up to 0.5 mg

J7512 — J7628
CODING BITES AHA: 2Q, ’13, 3 J7628 Bitolterol mesylate, inhalation solution, compounded
product, administered through DME, concentrated form, per mg
Inhalation Drugs
You will learn many J7604 Acetylcysteine, Inhalation solution, compounded product,
administered through DME, unit dose form, per g
more details about J7605 Arformoterol, inhalation solution, FDA approved final product,
using the HCPCS noncompounded, administered through DME, unit dose form,
15 mcg
Level II code set in
Part IV: DMEPOS &
Transportation. FIGURE 1-10  One page from the HCPCS Level II Alphanumeric Listing, showing
codes J7512–J7628  Center for Medicare and Medicaid Services (CMS)

HCPCS Level II
LET’S CODE IT! SCENARIO
Rita Widden, a 92-year-old female, was being transferred from Hampton Medical Center to the Sunflower Nursing
Home across town. Cosentti Ambulance Service provided nonemergency transportation prepared with basic life
support (BLS) services.

Let’s Code It!

Cosentti Ambulance Service provided nonemergency BLS (basic life support) transportation for Rita. After look-
ing carefully in your CPT and ICD-10-PCS code books, you find that this type of service is not represented.

CPT © 2017 American Medical Association. All rights reserved.

Therefore, you need to look in the HCPCS Level II code set.
Begin in the Alphabetic Index, and find:
Transportation
  Ambulance, A0021–A0999

This code set often will require some patience as you read through all of the code options, which were sug-
gested by the Alphabetic Index, until you find the one that matches the services for which you are reporting:
A0428 Ambulance service, basic life-support, nonemergency transport, (BLS)
Good work! You got it!

18   PART I  |  MEDICAL CODING FUNDAMENTALS

 Chapter Summary

CHAPTER 1 REVIEW
Essentially, the process of coding begins with the physician’s documentation stating
why the patient needed care and what was done for this patient during this visit. As
a professional coding specialist, you will interpret the documentation in the patient’s
record from medical terminology into codes: diagnosis codes to explain why, along
with how and where if the patient is injured; and procedure codes to report what the
physician or facility did for the patient during this encounter. You will need to confirm
that the diagnosis code or codes support medical necessity for the procedures, ser-
vices, and treatments provided. As you proceed through this textbook, read carefully
and completely. Coding is like nothing you have experienced before, and you want to
learn how to be proficient.

CODING BITES
ICD-10-CM . . . Diagnosis Codes
• Used by all health care providers and facilities
• Report WHY the patient needed care [medical necessity]
• ICD-10-CM diagnosis codes = A12.3K5A (up to 7 alphanumeric)
CPT . . . Procedure Codes
• Used by physicians to report services provided at any/all facilities
• Also used by outpatient care facilities [i.e., ambulatory surgery centers, hospital
emergency rooms, hospital outpatient surgery centers, etc.]
• Report WHAT was done for the patient
• CPT procedure codes = 12345 (five numbers always)
ICD-10-PCS . . . Procedure Codes
• Used only by hospitals for reporting facility services to inpatients
• ICD-10-PCS procedure codes = 012B4LZ (seven characters always)
HCPCS Level II  . . . Services and Supplies Codes
• Used to report services and supplies not already represented by a code in CPT
[i.e., transportation, drugs administered by a health care professional, durable
medical equipment, etc.]
• Used by any facility or provider
• Not all third-party payers accept the use of HCPCS Level II codes
• HCPCS Level II codes = A1234 (one letter, four numbers always)
CPT © 2017 American Medical Association. All rights reserved.

CHAPTER 1 REVIEW
Enhance your learning by

Introduction to the Languages of Coding completing these exercises and

more at connect.mheducation.com!

A. Classification System 
Let’s Check It! Terminology B. Condition
Match each key term to the appropriate definition. C. Diagnosis
1. LO 1.3  The provision of medical care for a disorder or disease. D. Eponym
2. LO 1.2  The state of abnormality or dysfunction.  E. External Causes

CHAPTER 1  | 
 3. LO 1.1  The determination that the health care professional was acting according F. Inpatient
CHAPTER 1 REVIEW

to standard practices in providing a particular procedure for an individ- G. Medical Necessity

ual with a particular diagnosis.  
H. Outpatient
4. LO 1.1  The process of paying for health care services after they have been provided. 
I. Procedure
5. LO 1.2  The explanation of how a patient became injured or poisoned, as well
J. Reimbursement
as other necessary details about the event; a health concern caused by
something outside of the body.    K. Services
6. LO 1.1  A physician’s determination of a patient’s condition, illness, or injury. L. Treatment
7. LO 1.1  Action taken, in accordance with the standards of care, by the physician
to accomplish a predetermined objective (result); a surgical operation. 
8. LO 1.1  The category term used in health care to identify ICD-10-CM, CPT,
ICD-10-PCS, and HCPCS Level II code sets. 
9. LO 1.3  A patient admitted into a hospital for an overnight stay or longer. 
10. LO 1.3  Spending time with a patient and/or family about health care situations.
11. LO 1.3  Health care services provided to individuals without an overnight stay in
the facility.
12. LO 1.2  A disease or condition named for a person.

Let’s Check It! Concepts

Choose the most appropriate answer for each of the following questions.
1. LO 1.1  Coding languages communicate information that is key to which of the following aspect(s) of the health
care system? 
a. medical necessity b. reimbursement c. resources allocation d. all of these
2. LO 1.1  Coding is accurately interpreting health care terms and definitions into ___________ that specifically
convey diagnoses and procedures.
a. letter combinations b. number combinations
c. number-letter combinations d. numbers or number-letter combinations
3. LO 1.1  A diagnosis explains
a. what the provider did for the patient. b. who the policyholder is.
c. why the patient requires attention of the provider. d. where the patient was seen by the provider.
4. LO 1.1  A procedure explains
a. where the patient was seen by the provider. b. what the provider did for the patient.
c. why the patient requires attention of the provider. d. who the policyholder is.
5. LO 1.2  Which code book contains all of the codes to report the reason why the health care provider cared for the
patient during a specific encounter? CPT © 2017 American Medical Association. All rights reserved.

a. ICD-10-CM code book b. ICD-10-PCS code book

c. CPT code book d. HCPCS Level II code book
6. LO 1.2  What part of the ICD-10-CM code book do you use to confirm that a diagnostic code is accurate?
a. the Alphabetic Index b. the Index to External Causes
c. the Tabular List d. the Neoplasm Table
7. LO 1.2  Diagnostic descriptions are listed by 
a. conditions such as fractures. b. eponyms such as Epstein-Barr syndrome.
c. other descriptors such as family history. d. all of these.
8. LO 1.2  Which of the following would be an example of an eponym?
a. infections b. wounds
c. Arnold-Chiari disease d. family history

20   PART I  |  MEDICAL CODING FUNDAMENTALS

 9. LO 1.2  The Index to External Causes lists the causes of

CHAPTER 1 REVIEW
a. injuries and poisoning b. diseases and syndromes
c. injuries d. poisoning
10. LO 1.2  An example of an ICD-10-CM code is
a. H2031 b. 85460 c. H61.022 d. 08NTXZZ
11. LO 1.1  When ICD-10-CM codes support medical necessity, this means that
a. there was a valid medical reason to provide care.
b. a preexisting condition was treated.
c. the patient was seen in a hospital.
d. a licensed health care professional was involved.
12. LO 1.1  The why justifies the
a. who b. where c. what d. when
13. LO 1.3  Surgical removal of a skin tag is an example of a
a. treatment b. procedure c. service d. diagnosis
14. LO 1.3  ___________ tests or procedures are performed to provide the physician with additional information to
support the determination of a confirmed diagnosis.
a. Diagnostic b. Preventive c. Therapeutic d. Conditional
15. LO 1.3  The code set(s) available for the coding specialist to use to translate health care procedures, services, and
treatments into codes is/are
a. CPT code book. b. ICD-10-PCS code book.
c. HCPCS level II code book. d. all of these.
16. LO 1.3  The main body of the CPT book has ___________ sections.
a. 5 b. 6 c. 7 d. 8
17. LO 1.3  An example of a Category II code is
a. 89398 b. 1134F c. V95.9 d. 0241T
18. LO 1.3  The code set used for hospital facility reporting of procedures, services, and treatments provided to a
patient who has been admitted as an inpatient is
a. ICD-10-CM code book. b. CPT code book.
c. ICD-10-PCS code book. d. HCPCS Level II code book.
19. LO 1.4  HCPCS Level II codes are presented as
a. five numbers. b. one letter followed by four numbers.
c. four numbers followed by two letters. d. one letter, a dash, and four numbers.
CPT © 2017 American Medical Association. All rights reserved.

20. LO 1.4  An example of a HCPCS Level II code is

a. J3285 b. D7056ZZ c. 58940 d. T84.010D

Let’s Check It! Rules and Regulations

Please answer the following questions from the knowledge you have gained after reading this chapter.
1. LO 1.1  Explain what is meant by a third-party payer. 
2. LO 1.2  Describe the Tabular List of Diseases and Injuries, including its format and why it is important. 
3. LO 1.3  Explain the difference between diagnostic testing, preventive procedures, and therapeutic procedures. 
4. LO 1.1  Discuss medical necessity and its importance.  
5. LO 1.4  Do all insurance carriers accept HCPCS Level II codes and what is the responsibility of the coding
­specialist in regards to billing third-party payers? 

CHAPTER 1  | 
 2
Key Terms
Abstracting Clinical
Documentation
Learning Outcomes
Abstracting After completing this chapter, the student should be able to:
Assume
Co-morbidity LO 2.1 Identify which health care professional for whom you are
Demographic coding.
Interpret LO 2.2 Describe the process of abstracting physician documenta-
Manifestation tion and operative notes.
Query LO 2.3 Recognize the terms used to describe diagnoses in
Sequela documentation.
Signs
Symptoms LO 2.4 Distinguish between co-morbidities, manifestations, and
sequelae.
LO 2.5 Determine those conditions that require external cause
codes to be reported.
LO 2.6 Recognize the terms used to describe procedures, services,
and treatments provided.
LO 2.7 Create a legal query to obtain documentation about a miss-
ing, ambiguous, or contradictory component in the existing
documentation.

2.1  For Whom You Are Reporting

Most people do not realize how many coders are involved in reporting one
patient’s surgical procedure or other type of encounter. Let’s look at a scenario
and dissect it:
Carly Camden, a 27-year-old female, was admitted into the hospital to have sur-
gery on her broken leg.
∙ The surgeon will have a coder to report what he does for Carly.
∙ The anesthesiologist will have a coder to report administration of anesthesia.

CPT © 2017 American Medical Association. All rights reserved.

∙ The facility will have a coder to report what the hospital did for Carly (providing
the nursing and other support staff, equipment, and room, etc.). In this case, the
facility is an acute care hospital. In other cases, the facility may be a same day
surgery center, a skilled nursing facility, an imaging center, or another health
care organization.
∙ The radiologist will have a coder to report for any imaging (e.g., x-rays, MRI, CT
scan, etc.).
∙ The pathologist will have a coder to report for any blood work or lab tests
provided.

22
 Therefore, the first question you, as the professional coder, will need to ask is . . .
for whom are you reporting? Only then will you know which key terms to look for as CODING BITES
you abstract the operative notes, the physician’s notes, and the reports. Patient = Who is pro-
There may also be many professionals providing different types of care for one vided with care
patient for different reasons. For example . . . Physician = Who is the
Allen Davidson, a 59-year-old male, was admitted to the hospital due to a myocar- health care provider you
dial infarction (heart attack). Allen has type 2 diabetes mellitus. are representing
∙ A cardiologist (heart specialist) will diagnose and treat Allen’s heart problem. Diagnosis = Why the
∙ An endocrinologist will diagnose and treat Allen’s diabetes mellitus. provider is caring for
this individual during
∙ The facility, such as a hospital, will provide care for Allen and all of his health this encounter
concerns.
External Cause = How
For all professionals involved in the care of a patient, the reason or reasons why and Where the patient
(diagnosis code or codes) care was required are critical to establishing medical neces- became injured
sity for the what (specific procedures, services, and treatments) provided. Yet, in a Procedure = What the
location, such as an acute care facility (hospital), there may be many issues for you to provider did for the
evaluate and connect. individual
Facility = Where the ser-
2.2  The Process of Abstracting vices were provided

You are learning that documentation about the encounter between physician and
patient will be your primary source for details that you will use to determine the most Abstracting
accurate codes to report. Physicians, though, do not write their documentation solely Identifying the key words or
terms needed to determine
for coding; therefore, there will be pieces of information included that you will not use
the accurate code.
in your coding process. Reading the entire patient record and pulling out the details
necessary for determining the correct codes is known as abstracting. Assume
Suppose to be the case, with-
Assume or Interpret out proof; guess the intended
details.
Always keep in mind the professional coding specialists’ motto: “If it isn’t docu-
mented, it didn’t happen. If it didn’t happen, you can’t code it!” Interpret
If it is documented appropriately, there is no reason for you to assume any details; Explain the meaning of; con-
vert a meaning from one lan-
you only need to interpret what is documented.
guage to another.
One of the most challenging aspects of coding is the very fine line between assum-
ing and interpreting. Yes, professional coding specialists must interpret the physician’s
documentation. This does not include assuming in any way. Assuming is making up CODING BITE
details, filling in the blanks with your own specifics, guessing, or substituting your Keep a medical dictionary
own knowledge for missing facts. Interpreting is an exact science; it involves chang- by your side so that the
ing information from one language to another. Just like casa = house (Spanish-to- minute you come upon
English), fine needle aspiration = 10021 (medical terminology-to-CPT). This is why a word you don’t under-
coding can be so challenging. We are responsible for not only translating from one stand for an absolute fact,
CPT © 2017 American Medical Association. All rights reserved.

language (medical terminology) to another (medical codes) but also for accurately you can look it up right
figuring out into which language (CPT or ICD-10-CM or ICD-10-PCS or HCPCS away. If you don’t under-
Level II) medical terminology must be translated. Another major factor is that no one stand what you are read-
is a natural-born speaker of medical terminology, so you are required to learn a new ing, you will not be able
language to understand the languages of medical coding. Imagine if you were born to interpret it accurately.
speaking English, but you had to learn to speak French before achieving your ultimate
goal of interpreting French words into Spanish. EXCELLENT RESOURCE:
MedlinePlus, an online
Source Documents medical dictionary and
encyclopedia, is an excel-
The patient’s health care record is at the center of health information management lent and reliable source
in general as well as the primary focus for you, as the professional coding specialist. created and maintained
Within this record, whether it is written on paper or typed into an electronic health by the US National
record (EHR), are several important components that you will use to gather details Library of Medicine.
necessary to determine the correct code or codes.

CHAPTER 2  | 
 Virtually every patient record should include all, or most, of these pages or sections:
∙ Patient’s Registration Form: This document or section includes the patient’s
Demographic ­demographic information, as well as health insurance policy numbers and the
Demographic details include name of the individual who will be financially responsible for the patient’s care.
the patient’s name, address,
∙ Referral Authorization Form: If another physician or health care provider referred
date of birth, and other per-
sonal details, not specifically
this patient for a consultation, you will need to know this to determine the correct
related to health. evaluation and management code.
∙ Physician’s Notes/Operative Reports: Written documentation of what occurred
during the encounter between physician and patient is also known as clinical doc-
umentation. The physician’s notes or operative reports are your most important
source for details required to determine the most accurate code or codes. Your job
is to interpret the words—medical terminology—into codes. Your ability to inter-
pret accurately is dependent upon your knowledge of anatomy and physiology, as
well as medical terminology.
∙ Pathology and Laboratory Reports: Results of testing performed on blood, tissue,
and other specimens hold important keys to the patient’s condition. The results can
provide you with important details necessary for you to determine a specific, accu-
rate code.
∙ Imaging Reports: Similar to pathology reports, these are reports written by a radi-
ologist containing his or her interpretations of images taken of the patient [e.g.,
x-ray, CT scan, MRI, etc.].
∙ Medication Logs: If the facility is residential, such as an acute care hospital, skilled
nursing facility, long-term care facility, etc., the nursing staff must record every
time they administer a medication to a patient, including the drug name, dosage,
time administered, and route used for administration. All data must be reported.
∙ Allergy List: This list is included for the patient’s safety so health care professionals
can avoid giving the patient any substance to which he or she may be allergic.
∙ History and Physical (H&P): Essentially, this document, written by the admitting
physician, explains the background and current issues used to make the decision to
admit the patient into the hospital.
∙ Consultations Reports: When a specialist is asked by an attending physician to
evaluate a patient’s condition, a report is written and sent over to be included in the
patient’s medical record in the requesting physician’s files, as well as those belong-
ing to the consulting physician.
∙ Discharge Summary: At the time a patient is released from a facility, such as a hos-
pital, the Discharge Summary provides the conclusions and results of the patient’s
stay in the facility in addition to follow-up advice.

CODING BITE CPT © 2017 American Medical Association. All rights reserved.
Principles of Documentation for Medical Records
Adapted from the Centers for Medicare and Medicaid Services
. The documentation of each patient encounter should include:
1
∙ the date;
∙ the reason for the encounter;
∙ appropriate history and physical exam in relationship to the patient’s chief
complaint;
∙ review of lab, x-ray data, and other ancillary services, where appropriate;
∙ assessment; and
∙ a plan for care (including discharge plan, if appropriate).
2. Past and present diagnoses should be accessible.

24   PART I  |  MEDICAL CODING FUNDAMENTALS

 3. The reasons for—and results of—x-rays, lab tests, and other ancillary services
should be documented or included in the medical record.
4. Relevant health risk factors should be identified.
5. The patient’s progress, including response to treatment, change in treatment,
change in diagnosis, and patient noncompliance, should be documented.
6. The written plan for care should include, when appropriate:
∙ treatments and medications, specifying frequency and dosage;
∙ any referrals and consultations;
∙ patient/family education; and
∙ specific instructions for follow-up.
7. The documentation should support the intensity of the patient evaluation and/
or the treatment, including thought processes and the complexity of medical
decision making as it relates to the patient’s chief complaint for the encounter.
8. All entries to the medical record should be dated and authenticated.
9. The CPT/ICD-10-CM/ICD-10-PCS/HCPCS Level II codes reported on the claim
form should be supported by the documentation in the medical record.

Abstracting the Documentation

CODING BITE
Abstracting is the first step in the coding process. You must read all clinical docu- One suggestion is to
mentation related to the specific encounter all the way through, slowly and carefully. use scrap paper so you
Whether the encounter was a short visit in a physician’s office, an hours-long surgical can jot down details as
procedure documented in operative reports, or a five-day stay in a hospital, you cannot you read them, which
expect that one sentence will give you a clear and complete picture of what occurred may point toward why
(the procedures or services) and why they were provided (the diagnosis or diagnoses). the patient required
You learned about understanding the why and what in the Introduction to the Lan- the attention of the
guages of Coding chapter. You are required to code all conditions documented to be physician (e.g., signs,
relevant during this encounter or hospital stay, not just those in the official diagnostic symptoms, confirmed
statement. The same stands for the procedures. diagnoses), as well as
what was provided (e.g.,
Reasons That Are Not Illness; Procedures specific procedures, ser-
That Are Not Actions vices, and treatments).

There are times when an individual comes to see a health care provider without hav-
ing a particular illness or injury. In such cases, you might assign a diagnosis code that
explains why the patient was seen that is not a current health condition or injury. A
healthy person might go to see a physician for preventive care, for routine and admin-
istrative exams, or for monitoring care and screenings for someone with a personal CODING BITE
CPT © 2017 American Medical Association. All rights reserved.

history or family history of a condition. As you read through the documentation, you Every health care
may discover that the reason why the encounter was necessary may be wellness, rather professional/patient
than illness or injury. encounter must have
In the same fashion, the description of what the physician provided may not be a at least one reportable
procedure, service, or treatment. It may be advice or a second opinion. The physician [codeable] reason why
and patient may meet to discuss previously done test results, a recommendation for a and at least one report-
specific treatment plan, suggestions for risk-factor reduction (e.g., stop smoking), or a able [codeable] explana-
referral to another physician or facility. tion of what.

2.3  Deconstructing Diagnostic Statements

Diagnosis codes, for either reimbursement or statistical purposes, will report only
those conditions addressed by the provider during a specific encounter  and  not the
patient’s entire health history. When there is no confirmed diagnosis to provide

CHAPTER 2  | 
 medical necessity for a procedure, service, or treatment performed, determining the
diagnosis code to report will vary slightly, depending on whether you are coding for
an inpatient or outpatient encounter. 
∙ In an outpatient encounter, if there is no confirmed diagnostic statement, you will
Signs code the patient’s signs and/or symptoms that led to the physician’s decision for the
Measurable indicators of a next step in care.
patient’s health status.
∙ When an inpatient (admitted into the hospital) is being discharged with-
Symptoms out a ­confirmed diagnosis, you will code the suspected conditions listed on the
A patient’s subjective descrip- discharge summary as if they were confirmed. You will not code the signs and
tion of feeling. symptoms.

Dissect the Diagnostic Statement

Now that you have identified all of the statements in the documentation that explain
why the patient was cared for, take each statement apart to determine which word
identifies the disease, illness, condition, or primary reason for the visit (also known
as the “main term”). Separate this term from any words that may simply describe the
type of condition or the location of the condition (anatomical site/body site). Keep a
medical dictionary close by so you can look up any terms you don’t clearly understand.
Remember, if you do not completely understand the terms, how can you possibly inter-
pret them?
Why is the physician caring for the patient? Many diagnostic statements are made
up of multiple words, with each providing additional information. As you analyze the
examples below, dissect the condition for which the physician is seeing the patient and
separate out those terms used to provide more detail about that condition.
∙ Herpes zoster . . . The disease is “herpes” and “zoster” is the type of herpes.
∙ Acute bronchospasm .  .  . The condition is a “spasm” (muscle contraction) of the
bronchus (a part of the lungs) and the term “acute” (which means severe) describes
what type of bronchospasm the patient has.
∙ Personal history of lung cancer . . . The issue of concern is “history”—why the
patient is being seen. The type of history is “personal” and the secondary descriptor
is “malignant neoplasm of the lung (lung cancer)” to explain “a history of what?”
∙ Myocardial infarction . . . The condition is “infarction” (area of dead tissue) and
“myocardial” (heart muscle) is the anatomical site of the infarction.
∙ Congenital pneumothorax . . . The condition is “pneumothorax” (air in the chest
cavity) and the term “congenital” (present at birth) describes the cause of the
condition.
∙ Family history of renal failure .  .  .  The issue of concern is “history”—why the
patient is being seen. The type of history is “family” and the secondary descriptor
is “renal failure” (loss of function of the kidneys) to explain “a history of what?” CPT © 2017 American Medical Association. All rights reserved.

CODING BITE
A diagnostic term might have a suffix like:
Dermatitis derma = skin + -itis = inflammation (a condition)
Acrophobia acro = heights + -phobia = fear (a condition)
A procedural term might have a suffix like:
Pancreatectomy pancreat = pancreas + -ectomy = to surgically remove
(an action)
Conjunctivoplasty conjunctivo = conjunctiva (part of the eye) + -plasty = to
repair (an action)

26   PART I  |  MEDICAL CODING FUNDAMENTALS

 LET’S CODE IT! SCENARIO
Dr. Olivera diagnosed Kathleen Belsara with ulcerative blepharitis of the right upper eyelid. He treated her with an
injection of gentamicin 80mg, IM and gave her a prescription for gentamicin ointment 0.3% q.i.d. for 7 to 10 days.

Let’s Code It!

Why did Dr. Olivera care for Kathleen? ulcerative blepharitis of the right upper eyelid.

The condition is: blepharitis

The type of blepharitis: ulcerative

Anatomical site affected: right upper eyelid

NOTE: These first three steps will get you started when it comes to determining the correct diagnosis code in
ICD-10-CM. You will learn more about this beginning in the chapter Introduction to ICD-10-CM.

Also . . .

What did Dr. Olivera do for Kathleen? an injection of gentamicin 80mg, IM

The drug: gentamicin

The dosage: 80mg

The route of administration: IM (intramuscular) injection

NOTE: These first three steps will get you started when it comes to determining the correct drug code in
HCPCS Level II. You will learn more about this beginning in the chapter HCPCS Level II.

Recognize Inclusive Signs and Symptoms

As you abstract the documentation, you will need to identify any signs and symp-
toms that are already part of the description of a confirmed diagnosis. Physicians
are trained in medical school to add all of the data (history, signs, symptoms, test
results, etc.) together, almost like a math equation, to arrive at a diagnosis. This sign +
that symptom = this diagnosis. These equations are based on the standards of care
accepted by the health care industry around the world.
Think about it: John comes to see Dr. Finch. John complains of chest congestion,
runny nose, sneezing, headaches, being achy all over. Dr. Finch examines John, does
CPT © 2017 American Medical Association. All rights reserved.

a quick lab test, and tells John he has the flu.

It is a fact that “chest congestion, runny nose, sneezing, headaches, being achy
all over” are signs and symptoms of the flu. Therefore, when you report the code
for the flu, there is no reason to also code the signs and symptoms of the flu . . . it is
redundant.

GUIDANCE CONNECTION
Read the ICD-10-CM Official Guidelines for Coding and Reporting, section
I. Conventions, General Coding Guidelines and Chapter Specific Guidelines;
subsections
• B.4 Signs and Symptoms
• B.5 Conditions that are an integral part of a disease ­process
• B.6 Conditions that are not an integral part of a disease process

CHAPTER 2  | 
 LET’S CODE IT! SCENARIO
Ralph Carbonna, a 61-year-old male, came into the Emergency Department of McGraw General Hospital. Earlier
in the day, Ralph felt lightheaded and a little dizzy. In addition, he complained that his heart was beating so wildly
that he thought he may have had a heart attack. When interviewed by the nurse, Ralph revealed his previous diag-
nosis of type 1 diabetes mellitus, prompting Dr. Geller to order a blood glucose test. Dr. Geller also ordered an EKG
(ECG) to check Ralph’s heart. After getting the results of the tests, Dr. Geller determined that Ralph’s lightheadedness
and dizziness were a result of his abnormal glucose level. He spoke with Ralph about how to bring his diabetes
­mellitus under control and informed Ralph that the EKG was negative [normal], meaning there were no signs of a
heart attack.

Let’s Code It!

Dr. Geller confirmed that Ralph’s type 1 diabetes mellitus, specifically his abnormal glucose level, caused his
feelings of dizziness. Diabetes seems to be the only confirmed diagnosis in Dr. Geller’s notes. You can report
this with confidence, and this condition justifies performing the blood glucose test.
Dr. Geller also ordered an EKG (ECG). A diagnosis for diabetes does not provide any medical rationale for
doing an EKG. In addition, the test was negative and, therefore, provided no diagnosis.
You still need a diagnosis code to report that there was a medical necessity to run the EKG. Why did Dr. Geller
order the EKG? Because Ralph complained of a rapid heartbeat. A rapid heartbeat provides the medical neces-
sity for performing the EKG.
Before you confirm any codes, be certain to read all notations and symbols and check the Official Guidelines.
Now, you can continue with confidence.
For the encounter, you have one confirmed diagnosis (the diabetes) and one symptom unrelated to the con-
firmed diagnosis (rapid heartbeat).

GUIDANCE CONNECTION
Read the ICD-10-CM Official Guidelines for Coding and Reporting, section I. Con-
ventions, General Coding Guidelines and Chapter Specific Guidelines; subsection
B.18. Use of Sign/Symptom/Unspecified Codes. “If a definitive diagnosis has not
been established by the end of the encounter, it is appropriate to report codes for
sign(s) and/or symptoms in lieu of a definitive diagnosis.”
Section II. Selection of Principal Diagnosis, subsection H. Uncertain
­Diagnosis. “If the diagnosis documented at the time of discharge is qualified as
‘probable’, ‘suspected’, ‘likely’, ‘questionable’, ‘possible’, or ‘still to be ruled out’, or
other similar terms indicating uncertainty, code the condition as if it existed or was
established.” NOTE: This guideline is applicable only to inpatient admissions to CPT © 2017 American Medical Association. All rights reserved.
short-term, acute, long-term care, and psychiatric hospitals.

2.4  Identifying Manifestations,

Co-morbidities, and Sequelae
Manifestations
Manifestation There are some diseases (also known as underlying conditions) that actually cause
A condition that develops as patients to develop other conditions. This second condition, directly the result of the
the result of another, underly- first condition, is known as a manifestation. In these cases, scientific evidence proves
ing condition. that the patient would not have the manifested disease or problem if the first condition

28   PART I  |  MEDICAL CODING FUNDAMENTALS

 had not already been present. The cause-and-effect relationship between the two con-
ditions must be documented by the physician and supported by medical research to be CODING BITES
coded as a manifestation. The underlying condi-
A manifestation is a second condition CAUSED by a first condition. Let’s use dia- tion is known as the
betes mellitus as an example. Diabetes is known to cause problems with patients’ eyes. etiology—the original
The physician determined that the patient has diabetic retinopathy with macular edema. source or cause for the
This documentation confirms that diabetes CAUSED the retinopathy to develop. You development of a dis-
will often find combination codes in ICD-10-CM. These codes report both the underly- ease or condition.
ing condition and the manifestation. In our example, the combination code is
E11.351 Type 2 diabetes mellitus with proliferative diabetic retinopathy
with macular edema
This one code, E11.351, tells the whole story about this patient’s condition. How-
ever, not all conditions and their manifestations have combination codes from which
to choose. When an appropriate combination code is not available, you will need to
select two codes (or more) to clearly communicate the complete story of a patient’s
diagnosis. One example is a patient who is admitted to the hospital with pulmonary
histoplasmosis, a documented manifestation of the patient’s HIV-positive status. In
this case, there is no combination code, so two codes are needed to tell the whole story
of this patient’s condition.
B20 Human immunodeficiency virus
B39.0 Acute pulmonary histoplasmosis capsulati 

Co-morbidities
A co-morbidity is a condition that is present in the same body at the same time as Co-morbidity
another problem or disease, but the two conditions are unrelated—there is no docu- A separate diagnosis exist-
mented cause-and-effect relationship. These “other diagnoses” may be referred to in the ing in the same patient at the
physician’s documentation. However, only those conditions that the physician has spe- same time as an unrelated
cifically evaluated, treated, or ordered additional testing for or those requiring additional diagnosis.
monitoring, nursing care, or more time in the hospital should be reported with a code.

EXAMPLE
Lindsey, 28 weeks pregnant, fell and broke her leg. So, the pregnancy and the
fracture are co-morbidities—they are two conditions present in the same patient
at the same time. You know that being pregnant does not cause a fracture and a
fracture does not cause pregnancy.

Which code will you report first? The code that is the reason for the encounter with
CPT © 2017 American Medical Association. All rights reserved.

the physician. You are coding for Dr. Kessler, an orthopedist, and Lindsey comes in
because her leg hurts. Dr. Kessler confirms her leg is fractured, so the fracture will be
reported first because this is Dr. Kessler’s primary concern—caring for the fracture.
However, Dr. Kessler MUST take the pregnancy into consideration because pregnancy
is a systemic condition and will impact the treatment plan for the fracture. The preg-
nancy code will also be reported (after the fracture code).

EXAMPLE
Mary-Ellen’s history includes asthma. She is here to see the dermatologist to have
a benign mole removed from her arm. Dr. Callen does not ask about Mary-Ellen’s
asthma. The asthma does not have any relationship at all to the benign mole or
the care/treatment of the mole. You will only determine the correct diagnosis code
for the benign mole. The asthma will NOT be reported at all.

CHAPTER 2  | 
 GUIDANCE EXAMPLE
CONNECTION Paul’s history includes asthma. He is here to see Dr. Hannah, his family physician,
Read the ICD-10-CM for his annual checkup. Dr. Hannah asks Paul about his asthma and writes a pre-
Official Guidelines for scription for a refill for his inhaler. In addition to the annual exam code, you will
Coding and Reporting, also need to report the code for the asthma because the physician paid attention
section III. Reporting to it during this encounter.
Additional Diagnoses.

Sequelae
Sequela A sequela is the residual impact of a previous condition or injury that may need the
A cause-and-effect relation- attention of a physician. When the patient has come to see the health care professional
ship between an original con- for the treatment of a sequela (also known as a late effect), you must code the particu-
dition that has been resolved lar problem as a sequela only in the following situations:
with a current condition; also
known as a late effect. ∙ Scarring
∙ Nonunion of a fracture
∙ Malunion of a fracture
∙ When the connection is specifically documented by the physician or health care
professional confirming the new condition as a sequela (a late effect) of a previous
condition
Coding a sequela requires at least two codes, in the following order:
1. The sequela condition, which is the condition that resulted and is being treated,
such as a scar or paralysis.
2. The sequela (late effect) or original-condition code with the seventh character “S.”

EXAMPLE
Jenna Malaletto, an 18-year-old female, was using a hydrofluoric acid mixture to
etch glass for an art class last spring and got some on her left forearm, causing
a corrosion burn of the third degree. She came in today to see Dr. Rosen to dis-
cuss treatment options for the adherent scarring.
CODING BITES Dr. Rosen is discussing treatment options of the scars that were left behind
after the third-degree corrosion burn had healed. This is known as a sequela, and
You will learn a lot
it is the reason for this encounter. However, as you learned, you will also need to
more about reporting
report what caused the scar—the corrosion burn.
co-­morbidities, manifes-
tations, and sequelae L90.5 Scar conditions and fibrosis of skin (adherent scar)
in Part II: Reporting T22.712S Corrosion of third degree of left forearm, sequela

CPT © 2017 American Medical Association. All rights reserved.

Diagnoses.

2.5  Reporting External Causes

You learned in the Introduction to the Languages of Coding chapter that in addition to
the why and the what, if a patient is injured, you will need to abstract details about how
and where the patient became injured. As you learn more about determining external
cause codes, you will discover that a simple statement such as “the patient was hurt in
a car accident” does not contain enough information to determine the accurate exter-
nal cause code. The details of the accident are very important. For example:
∙ Was the patient the driver, a passenger, or outside of the vehicle?
∙ Was the vehicle a car, a pick-up truck, a van, or a heavy transport vehicle?
∙ Did the vehicle collide with another vehicle, a nonmotor vehicle, or a stationary object?
∙ Was this a traffic accident or a nontraffic accident?

30   PART I  |  MEDICAL CODING FUNDAMENTALS

 ICD-10-CM
LET’S CODE IT! SCENARIO
Victor Lamza, a 13-year-old male, was brought into the Emergency Department complaining of pain after he banged
his head. Dr. Farxia diagnosed him with a contusion of the scalp. When asked by Dr. Farxia what he was doing imme-
diately before he got hurt, he reluctantly admitted that he had made a bet with his friends at Space Camp. They
wanted to see who could stay the longest in the weightlessness simulator; Victor was in there for 6 hours.

Let’s Code It!

Dr. Farxia documented that Victor’s staying too long in the weightlessness simulator caused the contusion of his
scalp. You will need to code why Dr. Farxia cared for Victor (his injury), how he became injured, and where he
was when the injury occurred.
S00.03XA Contusion of scalp, initial encounter
X52.XXXA Prolonged stay in weightless environment, initial encounter
Y92.838 Other recreation area as the place of occurrence of the external cause
Y93.89 Activity, other specified
Y99.8 Other external cause status (recreation or sport)

There are thousands of different ways a patient can become injured, and there is
a different code for almost every incident: the typical, the silly, the unusual, and the
surprising.
ICD-10-CM provides a separate Index to External Causes, usually found between
the Index to Diseases and Injuries (Alphabetic Index) and the beginning of the Tabular
List. This index will point you to the correct subsection in the Tabular List, within the
code range of V00–Y99.
You will learn more details about how to code external causes later in this textbook
in the chapter Coding Injury, Poisoning, and External Causes.

2.6  Deconstructing Procedural Statements

In addition to abstracting the terms from the documentation related to the diagnosis
code or codes, you will also need to identify those terms that relate to what was done
for the patient.
Due to the structure of medical terminology, you might find that the word or term
mentioned in the documentation describing what was done for the patient is a com-
bination term identifying both the action taken and the anatomical site on which the
action was performed.
CPT © 2017 American Medical Association. All rights reserved.

EXAMPLES
i. Neuroplasty: neuro = nerves + -plasty = repair
ii. Thrombolysis: thrombo = blood clot + -lysis = dissolving
iii. Gastrectomy: gastr = stomach + -ectomy = surgical removal
CODING BITE
Other times, the procedure will be identified by its name. This name may be Only the procedures,
∙ a description of the action, such as ablation, debridement, or injection services, and treatments
actually provided dur-
∙ an eponym (named after the individual who invented it), such as Abbe-Estlander
ing a specific encounter,
procedure, Swan-Ganz catheter, or Dupuy-Dutemps operation
by a specific physician,
∙ an abbreviation or acronym, such as ECG = electrocardiography; GTT = glucose health care professional,
tolerance test; PET = positron emission tomography; TAVR = transcatheter aortic or facility, will be coded.
valve replacement

CHAPTER 2  | 
 Review and practice your medical terminology and keep a medical dictionary close
at hand. As you gain more experience, the process of deconstructing the statements
in the various types of documentation will become easier (not really easy, but easier).
You learned about the part of this career that involves interpreting and you cannot
interpret the words if you don’t know what they mean.

Interpreting for Each Code Set

You will find that you not only need to understand medical terminology overall to
interpret the physician’s documentation into codes; each code set may require you to
interpret them differently.

CPT ICD-10-PCS
LET’S CODE IT! SCENARIO
McGRAW HILL HOSPITAL
DATE OF PROCEDURE: 08/18/2018
PATIENT: Christine Gordon
PREOPERATIVE DIAGNOSIS: Acute right lower abdominal pain.
POSTOPERATIVE DIAGNOSIS: Acute appendicitis.
OPERATION PERFORMED: Laparoscopic appendectomy.
SURGEON: Charles E. Manchester, MD
SEDATION: General endotracheal anesthetic.

PROCEDURE:
This 47-year-old female presented with signs and symptoms consistent with acute appendicitis. Preoperative
CT scan indicates an inflamed appendix, rupture not probable. Patient signed written consent for a laparoscopic
appendectomy.

Let’s Code It!

The documentation created by Dr. Manchester clearly provides us with the details of what occurred during
this encounter with this patient, Christine Gordon. She was having lower right side abdominal pain, which was
determined to be appendicitis (why reported with ICD-10-CM code K35.80 Acute Appendicitis Not Otherwise
Specified) and the doctor performed a surgical laparoscopic appendectomy (what). Seems very straightforward,
doesn’t it?
A good place to begin is the CPT Alphabetic Index; look up:
Appendectomy
Appendix Excision. . . . . . . . . . . . . . 44950, 44955, 44960
Laparoscopic. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44970 CPT © 2017 American Medical Association. All rights reserved.

Turn to the Main Section of CPT to find code 44970 because Dr. Manchester specifically documented that the
appendectomy was done laparoscopically. So, now you have found the correct code to report for Dr. Manches-
ter’s work:
44970 Laparoscopy, surgical, appendectomy

*-*-*
Now, if you were the coder for the hospital at which the surgery occurred, you would need to report this same
procedure using the ICD-10-PCS code set.

32   PART I  |  MEDICAL CODING FUNDAMENTALS

 Dr. Manchester performed this surgical procedure on Christine Gordon in the hospital. The hospital provided
the support staff (nurses, technicians, etc.), as well as the equipment, the room, etc. You learned earlier that the
hospital’s coder would use ICD-10-PCS codes to report their participation and care for this patient. Let’s look at
the documentation again . . .
“the doctor performed a surgical laparoscopic appendectomy”
In the ICD-10-PCS code book’s Alphabetic Index, you will see:
Appendectomy
see Excision, Appendix 0DBJ
see Resection, Appendix 0DTJ
Which is correct? The ICD-10-PCS code book includes the definitions right in the front of the code book:
Excision: Cutting out or off, without replacement, a portion of a body part
Resection: Cutting out or off, without replacement, all of a body part
You learned in medical terminology class that appendectomy = surgical removal of the appendix. Therefore, you
have documentation that the entire appendix was surgically removed, and this is called “Resection” by ICD-10-
PCS. Terrific! Now we will turn to the 0DT Table in ICD-10-PCS.
First character: Section: Medical and Surgical
This is correct because this was a surgical procedure.
Second character: System: Gastrointestinal System
You know this is correct because you learned in anatomy class that the appendix is part of the gastrointestinal
system.
Third character: Root Operation: Resection
You confirmed this by reading the root operation term definition for “resection” and comparing it with the physi-
cian’s documentation.
Fourth character: Body Part: Appendix
The documentation clearly states the appendix is the body part that was removed.
Fifth character: Approach: Percutaneous Endoscopic
The documentation states that this procedure was performed laparoscopically. A laparoscope is an endoscope
passed through the skin of the abdomen using small slits (percutaneously). Therefore, you know that this proce-
dure was done using a percutaneous endoscopic approach.
Sixth character: Device: None
CPT © 2017 American Medical Association. All rights reserved.

Seventh character: Qualifier: None

Great! So, if you were the coder for the hospital where Dr. Manchester performed surgery, you would report ICD-
10-PCS code
0DTJ4ZZ Resection of the appendix, via percutaneous endoscope
Good work!
You can see how the two procedure code sets, CPT and ICD-10-PCS, use different terms to describe and report
the same procedure. Use your resources, like a medical dictionary, and you will be able to interpret all of the
terms correctly.

CHAPTER 2  | 
 2.7  How to Query
Once you have completed abstracting the documentation, you may find that details
needed to determine a specific code are not included. Should this happen, you
Query should query the physician who wrote the documentation to ask him or her to provide
To ask; an official request to clarification or additional specifics. Every day, coders and health information man-
the attending physician for agement specialists find documentation with information that is
more specific information
related to a patient’s condition ∙ Missing or incomplete
or treatment. ■ for example, What specific type of fracture?
∙ Ambiguous or inconsistent
■ for example, Procedure notes state a single lead pacemaker was inserted; how-
ever, the equipment list states the pacemaker was dual lead.
∙ Contradictory
■ for example, In first paragraph, notes state, “Patient denies any cough or chest
congestion.”; however, last paragraph states patient was prescribed Tessalon (a
cough suppressant).
In Section 2.2 The Process of Abstracting, you learned the difference between
assuming and interpreting. Therefore, you will need to ask the physician to add the
details you need to the patient’s record so you can move forward and determine the
correct code. This process is known as creating a query, and it must be done in a very
specific manner so as not to break the law.

Writing the Query

Remember that one important use of codes is to determine reimbursement. Different
codes are paid at different amounts. [You will learn more about this in the Reimburse-
ment chapter.] When writing a query, the law does not permit you to prompt or pro-
mote a specific response so you don’t inadvertently influence the physician to opt for
the higher-paying detail rather than the truth. This means you must ask for the details
in a nonleading manner. Asking open-ended questions or providing multiple options
for the answer are the best approaches.

EXAMPLE
Dr. Osage saw Jose Ramirez and documented him to have a displaced fracture of
the metatarsal bone of the right foot.
After rereading the operative notes again, and reviewing the entire patient
record, you discover that the detail of which specific bone was fractured is miss-
ing. Therefore, you need to query Dr. Osage.
Open-ended query: CPT © 2017 American Medical Association. All rights reserved.

Which metatarsal bone was fractured? 

Multiple-choice query:
Which metatarsal bone was fractured?
A.  First
B.  Second
C.  Third
D.  Fourth
E.  Fifth
*-*-*

34   PART I  |  MEDICAL CODING FUNDAMENTALS

 Dr. Stabler performed a total hysterectomy on Melinda Blaudon. CODING BITE
After rereading the operative notes again, and reviewing the entire patient
Before using an
record, you discover that the detail of which approach was used to perform the
unspecified diagnosis
hysterectomy is missing. Therefore, you need to query Dr. Stabler.
code, query the physi-
Open-ended query: cian to gain the details
needed to use a more
What approach was used in the surgery? 
specific code. Unspeci-
Multiple-choice query: fied or NOS (not other-
What approach was used in the surgery? wise specified) codes
should only be used as
A.  Open a last resort when the
B.  Percutaneous endoscopic [Laparoscopic] physician cannot be
C.  Via natural orifice contacted.

The query you write to request the specific details needed should be accompanied
by the pertinent clinical information from the patient’s chart. You want to make it
clear to the physician what you need clarified or supported with more details. There
are many query templates available and often larger organizations have their own ver-
sions, already approved by attorneys.

Query Pathways
The specific details will need to be added to the chart in a time-efficient man-
ner; therefore, the way you deliver the query to the physician is important. Most
facilities have an existing process for delivering a query to the attending physician.
Certainly, in a physician’s office or small clinic, it may be easier than in a hospital
to connect with the physician to ask a question or questions and obtain a response
or responses. 
Some electronic health record software programs include a query feature. Alter-
natively, using a secure, encrypted e-mail system can provide a swift route for ask-
ing for the details required as well as a written response. Remember our creed: “If
it’s not documented, it didn’t happen. If it didn’t happen, you cannot code it!” This
reinforces the importance of obtaining those additional specifics in writing from
the physician.
For those facilities still using paper patient records, query notes should be attached
to the front of charts, so all relevant information about that patient, for that encounter,
is at hand and easy for the physician to reference and annotate.
CPT © 2017 American Medical Association. All rights reserved.

Chapter Summary
In preparation for you to learn the process of determining the specific code or codes,
you must be able to gather the required information from the clinical documentation.
You must read through the clinical documentation in the patient’s record and under-
stand everything you read so you can collect the specifics you need. If details are
missing, ambiguous, or conflicting, you will need to query the physician to have the
documentation amended. This is your responsibility and a critical part of the coding
process.

CHAPTER 2  | 
 CHAPTER 2 REVIEW
CHAPTER 2 REVIEW

Abstracting Clinical Documentation Enhance your learning by

completing these exercises and
more at connect.mheducation.com!

Let’s Check It! Terminology

Match each key term to the appropriate definition.
1. LO 2.2  Suppose to be the case, without proof; guess the intended details. A. Abstracting
2. LO 2.3  A patient’s subjective description of feeling. B. Assume
3. LO 2.7  To ask; an official request to the attending physician for more specific C. Co-morbidity
information related to a patient’s condition or treatment. D. Demographic
4. LO 2.3  Measurable indicators of a patient’s health status. E. Interpret
5. LO 2.2  The patient’s name, address, date of birth, and other personal details, not F. Manifestation
specifically related to health.
G. Query
6. LO 2.2  Explain the meaning of; convert a meaning from one language to another.
H. Sequela
7. LO 2.4  A cause-and-effect relationship between an original condition that has
I. Signs
been resolved with a current condition; also known as a late effect.
J. Symptoms
8. LO 2.4  A condition that develops as the result of another, underlying condition.
9. LO 2.2  Identifying the key words or terms needed to determine the accurate code.
10. LO 2.4  A separate condition or illness present in the same patient at the same
time as another, unrelated condition or illness.

Let’s Check It! Concepts

Choose the most appropriate answer for each of the following questions.
1. LO 2.1  The first question you, as the professional coder, will need to ask is
a. does the patient have health insurance? b.  is there a preexisting condition?
c. for whom are you reporting? d.  is this encounter to treat a sequela?
2. LO 2.1  The _____ will have a coder to report for any imaging procedures.
a. anesthesiologist b.  radiologist  c.  cardiologist d.  pathologist
3. LO 2.1  Which of the following is an acute care facility?
a. The physician’s office b.  A nursing facility  c.  A hospital d.  An assisted living facility

CPT © 2017 American Medical Association. All rights reserved.

4. LO 2.2  Converting a meaning from one language to another is called
a. assuming. b.  interpreting.  c.  querying. d.  supposing.
5. LO 2.2  The most important source for details required for the coding specialist to determine the most accurate
code or codes is found in which part of the patient’s record?
a. Patient’s Registration Form b.  Referral Authorization Form
c.  Physician’s Notes/Operative Reports d.  Imaging Reports
6. LO 2.2  What is the best way to begin abstracting clinical documentation?
a. Listen to the nurse explain the encounter.
b. Read all the way through the clinical documentation for the specific encounter.

36   PART I  |  MEDICAL CODING FUNDAMENTALS

 c. Talk to the technician.

CHAPTER 2 REVIEW
d. Read the patient’s registration form.
7. LO 2.2  Every patient encounter must have at least _____ reportable [codeable] reason why and at least _____
reportable [codeable] explanation of what.
a. 1, 1 b.  2, 1  c.  1, 2 d.  3, 1
8. LO 2.3  All of the following would be considered a diagnostic “main term” except
a. herpes. b.  acute.  c.  spasm. d.  infarction.
9. LO 2.3  The patient has been diagnosed with hypersecretion of thyroid stimulating hormone. Identify the
condition.
a. hormone b.  thyroid  c.  stimulating d.  hypersecretion
10. LO 2.3  Which official guideline is concerned with conditions that are an integral part of a disease process?
a. Section 1.B.4 b.  Section 1.B.5 c.  Section 1.B.6 d.  Section 1.B.7
11. LO 2.4  A manifestation is a _____ condition caused by the _____condition.
a. first, second b.  third, fourth c.  second, first d.  second, third
12. LO 2.4  Coding a sequela requires at least _____ codes.
a. 1 b.  2 c.  3 d.  4
13. LO 2.5  External causes explain _____ and _____ the patient became injured.
a. why, what b.  what, where c.  how, where d.  why, how
14. LO 2.5  Which of the following would be an example of an external causes code?
a.  H26.053 b.  M62.831 c.  S00.03A d.  Y92.838
15. LO 2.6  The suffix -plasty means
a. to dissolve. b.  to repair. c.  to crush. d.  to remove.
16. LO 2.6  The abbreviation ECG stands for
a. electrocardiography. b.  electroencephalography.
c.  electroconvulsive therapy. d.  electrocautery.
17. LO 2.7  When you find missing or incomplete information in the physician’s notes, you should
a. place the file at the bottom of the pile.
b. figure out the information yourself; you should know what the doctor is thinking.
c. ask a coworker.
d. query the physician.
18. LO 2.7  Before using an unspecified or NOS (not otherwise specified) code(s), you should
a. code the case as unspecified and move to the next file.
CPT © 2017 American Medical Association. All rights reserved.

b. assume what the missing information is.

c. query the physician to gain the details needed to use a more specific code.
d. leave it for your coworker to do.
19. LO 2.3  Tom is diagnosed with herpes zoster, conjunctivitis. Which ICD-10-CM diagnosis code would you
assign? 
a. B02.9 b.  B02.31 c.  B02.0 d.  B02.1
20. LO 2.6  Judith presents for a unilateral mammography. Which procedural (CPT) code would you assign?
a. 77053 b.  77054 c.  77065 d.  77066

CHAPTER 2  | 
 Let’s Check It! A Diagnosis or Procedure
CHAPTER 2 REVIEW

First, identify the following statements as a diagnosis or a procedure, and then identify the main term.
Example: Factitial dermatosis:
a. diagnosis or procedure: diagnosis  b. main term: dermatosis

1. LO 2.3  Sprained wrist, left, initial encounter: 

a. diagnosis or procedure:         b. main term:        
2. LO 2.6  Tympanic neurectomy: 
a. diagnosis or procedure:         b. main term:        
3. LO 2.3  Acute bronchitis:
a. diagnosis or procedure:         b. main term:        
4. LO 2.6  Cerebral thrombolysis: 
a. diagnosis or procedure:         b. main term:        
5. LO 2.3  Newborn circulatory failure: 
a. diagnosis or procedure:         b. main term:        
6. LO 2.6  Laryngeal web laryngoplasty:
a. diagnosis or procedure:         b. main term:        
7. LO 2.3  Cutaneous abscess of chest wall, initial encounter: 
a. diagnosis or procedure:         b. main term:        
8. LO 2.6  Planned tracheostomy: 
a. diagnosis or procedure:         b. main term:        
9. LO 2.3  Stenosis of the esophagus:
a. diagnosis or procedure:         b. main term:        
10. LO 2.6  Ulna osteomyelitis: 
a. diagnosis or procedure:         b. main term:        

Let’s Check It! Rules and Regulations

Please answer the following questions from the knowledge you have gained after reading this chapter.

1. LO 2.2  What is the professional coding specialists’ motto?

2. LO 2.2  Explain the difference between assuming and interpreting.
3. LO 2.3  Explain the ICD-10-CM Official Guidelines concerning Signs and Symptoms—Section 1.B.4; include
where the guideline directs you. CPT © 2017 American Medical Association. All rights reserved.

4. LO 2.4  Discuss the ICD-10-CM Official Guidelines concerning Sequela—Section 1.B.10; include where the
guideline directs you.
5. LO 2.4  Discuss co-morbidity and the correct coding sequence for the encounter.

38   PART I  |  MEDICAL CODING FUNDAMENTALS

 The Coding Process
Learning Outcomes
After completing this chapter, the student should be able to:
LO 3.1 Implement the six actions of the coding process.
3
Key Terms
LO 3.2 Locate main terms in the Alphabetic Index. Alphabetic Index
LO 3.3 Confirm the accurate code in the Tabular List, Main Section, Alphanumeric
or Tables. Coding Process
Linking
LO 3.4 Apply the Official Guidelines to ensure accurate code
Main Section
determination. Notations
LO 3.5 Analyze documentation and code selection to confirm medi- Official Guidelines
cal necessity. Symbols
Tables
Tabular List

3.1  The Coding Process Overview

There are six specific actions that you should take as part of the coding process. As Coding Process
you gain experience, it will take you less time to go through these tasks. However, The sequence of actions
remember that time is not the number one consideration when coding—no matter required to interpret physician
what anyone says, accuracy is the most important factor. Following all of these actions documentation into the codes
every time you code will support your development of habits that will maintain accu- that accurately report what
occurred during a specific
racy throughout your career.
encounter between health
care professional and patient.
Action 1. Abstract the documentation
∙ Read completely through the documentation for the encounter, from beginning to end.
∙ Then, reread the documentation and identify the main words regarding the diagno-
ses (why) and procedures (what) of the encounter.
∙ Remember, if the patient was injured, you will need to identify the external causes
(how and where) as well.

Action 2. Query, if necessary

∙ Make a list of any questions you have regarding unclear or missing information
necessary to code the encounter. Query the health care provider who cared for the
patient. Never assume or guess. You are only allowed to code what you know from
CPT © 2017 American Medical Association. All rights reserved.

actual documentation. If it is not documented, it did not happen. If it didn’t happen,

you cannot code it!
∙ Create a query using nonleading questions, with open-ended or multiple-option
formatting, to have the physician amend the documentation, so you can use those
added details to determine the accurate code or codes. NOTE: In school, your que-
ries should go to your instructor.
 Action 3. Code the diagnosis or diagnoses
∙ Code each diagnosis and/or appropriate signs or symptoms describing why the
health care provider treated this patient during this encounter, as documented in the
notes, to tell the whole story. Use the best, most accurate code or codes available
based on that documentation.
∙ Read the symbols and notations around the code in the Tabular List.
∙ Go to the Official Guidelines to review any coding rules with which you must
comply.
NOTE: Part II: Reporting Diagnoses of this textbook will share with you everything
you need to know to determine the accurate diagnosis code or codes.
CODING BITES
One diagnosis code can Action 4. Code the procedure or procedures
provide the explana-
tion of medical neces- ∙ Determine for whom you are reporting: physician, outpatient facility, or inpatient
sity for more than one facility. This way, you will know which code set to use: CPT or ICD-10-PCS.
procedure code. One ∙ Code each procedure, service, or treatment, as stated in the notes, describing what
procedure code may be the provider did for the patient during this encounter. You should not code any
provided to treat more procedures that are simply recommended, suggested, or ordered; you can only
than one diagnosis, but code those that have already been provided to the patient during the encounter for
there must be at least which you are reporting. Use the best, most accurate codes available based on the
one diagnosis code to documentation.
explain why each pro- ∙ Read the symbols and notations around the code in the Main Section. Check for
cedure was medically Guidelines (in front of this section as well as in the subsection) to review any cod-
necessary. ing rules with which you must comply.
For inpatient set- ∙ In some cases, you will also need to report a code or codes using the HCPCS
tings, the admission into Level II code set. You will learn more about this code set in Part IV: DMEPOS &
the facility must also Transportation.
be justified—explained
by a diagnosis code or NOTE: Part III: Reporting Physician Services and Outpatient Procedures will share
codes. You will learn with you everything you need to know to determine the accurate procedure code or
more about this later in codes. This chapter is just an introduction.
this chapter, subsection
3.5 Confirming Medical
Necessity
Action 5. Confirm medical necessity
∙ Ensure that each and every procedure code is supported by at least one diagnosis
code to verify medical necessity.
CODING BITES
Begin to build the habit, Action 6. Double-check your codes
CPT © 2017 American Medical Association. All rights reserved.
right now, of reading
You, as the professional coding specialist, have a responsibility to ensure that you are
slowly, carefully, and
submitting only accurate, truthful information, supported by the physician’s documen-
completely. There are
tation. Yet, we are all human and anyone can make a mistake. Now is the time to build
so many times, when
the habit of double-checking your work before you hit that submit button.
reviewing a coding
error, we have heard, ∙ Go back into the code books you have used and reread the full descriptions, all
“Oh, I can’t believe I notations, and symbols for the codes you have assigned. Compare these details,
didn’t read that!” It is once more, with the original documentation—just to be certain you did not misread
better for you to find anything.
and correct your own ∙ Read carefully, one letter at a time, one number at a time, so you can catch and cor-
mistakes than have rect any typos before your work becomes official.
anyone else find your
mistakes and suffer the Taking action to code precisely will result in a greater number of your claims get-
consequences. ting paid quickly and your reports will represent accurate data. You owe this to your
facility, your patients, and yourself.

40   PART I  |  MEDICAL CODING FUNDAMENTALS

 3.2  The Alphabetic Indexes
Once you have abstracted the main terms that describe the diagnosis (why) and the pro-
cedure (what) from within the physician documentation or operative reports, the next
action is to determine the codes that accurately report these details. You will begin by
matching those main terms to an entry in the appropriate code book’s Alphabetic Index. Alphabetic Index
In the Introduction to the Languages of Coding chapter, you learned to connect the The section of a code book
details you abstracted from the medical documentation to the correct code set: showing all codes, from
A to Z, by the short code
Diagnoses (why) = ICD-10-CM code set descriptions.
Physicians services (what) = CPT code set
Outpatient facility services (what) = CPT code set
Inpatient (hospital) facility services (what) = ICD-10-PCS code set
Transportation, equipment, drugs (what) = HCPCS Level II code set
Each of these code set books includes a section, or part, that is called the Alpha-
betic Index. Each Alphabetic Index lists all of the main terms that are represented by
codes within its set, in alphabetic order (A to Z). So . . .
In ICD-10-CM’s Alphabetic Index, you will see terms such as:
Abscess
Carcinoma
Hyperemia
Pneumonia
Shock
Ulcer
In CPT’s Alphabetic Index, you will see terms such as:
Angioplasty
Bypass
Discography
Insertion
Psychotherapy
Reconstruction
In ICD-10-PCS’s Alphabetic Index, you will see terms such as:
Cannulation
Detachment
Extraction
CPT © 2017 American Medical Association. All rights reserved.

Laryngoplasty
Repair
Supplement
In HCPCS Level II’s Alphabetic Index, you will see terms such as:
Commode
IPPB machine
Nebulizer
Wheelchair
Once you find the main term that matches the word or words that you abstracted
from the medical documentation, you may find an indented list containing adjectives
providing more detail about that specific main term. It may be an additional descrip-
tion, such as chronic or laparoscopic, or it may be the anatomical site that was involved.
 EXAMPLES
ICD-10-CM: ABDOMINAL ABSCESS
Abscess
Abdominal
CPT: INSERTION OF A GASTROSTOMY TUBE
Insertion
Gastrostomy Tube
ICD-10-PCS: REPAIR OF MAXILLA
Repair
Maxilla
HCPCS LEVEL II: NEBULIZER FILTER
Nebulizer
Filter

Often, you will find that further details will be necessary, and options will be pro-
vided in another list, indented from the previous indented list.

EXAMPLES
ICD-10-CM: ABSCESS IN THE WALL OF THE ABDOMINAL CAVITY
Abscess
Abdominal
Cavity
Wall
CPT: PERCUTANEOUS INSERTION OF GASTROSTOMY TUBE
Insertion
Gastrostomy Tube
Laparoscopic
Percutaneous
ICD-10-PCS: REPAIR OF THE RIGHT MAXILLA
Repair
Maxilla
Left
Right
HCPCS LEVEL II: NON-DISPOSABLE NEBULIZER FILTER
Nebulizer

CPT © 2017 American Medical Association. All rights reserved.

Filter
Disposable
Non-disposable

You are required to keep making choices, matching the documentation, all the way
to the most specific detail. Once at the most specific level, you will see that the Alpha-
betic Index will suggest a code or codes.

EXAMPLES
ICD-10-CM: ABSCESS IN THE WALL OF THE ABDOMINAL CAVITY
Abscess
Abdominal
(continued)

42   PART I  |  MEDICAL CODING FUNDAMENTALS

 Cavity K65.1 CODING BITES
Wall L02.211 The Main Section and
CPT: PERCUTANEOUS INSERTION OF GASTROSTOMY TUBE Tabular List of the code
Insertion books all contain addi-
Gastrostomy Tube tional symbols and
Laparoscopic 43653 notations to help you
Percutaneous 43246 determine the most
accurate code. The
ICD-10-PCS: REPAIR OF THE RIGHT MAXILLA book actually can help
Repair you determine the accu-
Maxilla rate code or codes!
Left 0NQV More about these
Right 0NQT in chapters later in this
HCPCS LEVEL II: NON-DISPOSABLE NEBULIZER FILTER book.
Nebulizer
Filter
Disposable A7013 Symbols
Non-disposable A7014 Marks, similar to emojis, that
provide additional direction
to use codes correctly and
You are not done with the coding process yet. These codes will guide you to find accurately.
the suggested code in the Main Section, Tabular List, or Tables of that code book. You
Notations
are not permitted, by law, to report a code from the Alphabetic Index without first con-
Alerts and warnings that sup-
firming that it is the best possible option in the Tabular List, Main Section, or Tables. port more accurate use of
codes in a specific code set.
3.3  The Tabular List, Main Section, Tables, Tabular List of Diseases and
and Alphanumeric Section Injuries
The section of the ICD-10-CM
Think of the Alphabetic Index as a very cheap GPS mapping app. You cannot count on code book listing all of the
it to give you accurate information because it is not designed to get you to your precise codes in alphanumeric order.
destination. Sometimes, yes, it will get you to the correct front door. Sometimes, however, Main Section
it will mistakenly take you to the house down the block, and you will have to look at all The section of the CPT code
of the houses and all of the addresses in the area to see which one is correct. You begin book listing all of the codes in
with a suggested code from the Alphabetic Index to get you to the correct neighborhood. numeric order.
However, you cannot report this code until you have confirmed it is correct and complete,
Tables
using the ICD-10-CM’s Tabular List, CPT’s Main Section, ICD-10-PCS’s Tables sec-
The section of the ICD-10-
tion, or HCPCS Level II’s Alphanumeric Section of the appropriate code book.
PCS code book listing all of
These sections list all of the codes available in that code set, only this time, they the codes in alphanumeric
are listed in numeric or alphanumeric order by the code first, followed by the words order, based on the first three
describing exactly what that code represents. Here, you will find several things to help characters of the code.
CPT © 2017 American Medical Association. All rights reserved.

you get to absolute accuracy.

Alphanumeric Section
The section of the HCPCS
Full Code Descriptions Level II code book listing all
In these sections, you will be able to read the full code description, not the shortened of the codes in alphanumeric
version used in the Alphabetic Index. Let’s continue with our examples from the previ- order.
ous section, 3.2 The Alphabetic Indexes: alphanumeric
Containing both letters and
EXAMPLE numbers.

ICD-10-CM
The Alphabetic Index gave you:
Abscess, Abdominal, Cavity K65.1
Abscess, Abdominal, Wall L02.211 (continued)
 Rev. Confirming Pages

The Tabular List gives you:

K65.1 Peritoneal abscess (mesenteric abscess)
L02.211 Cutaneous abscess of abdominal wall
CPT
The Alphabetic Index gave you:
Insertion, Gastrostomy Tube, Laparoscopic 43653
Insertion, Gastrostomy Tube, Percutaneous 43246
In the Main Section, you will read:
43653 Laparoscopy, surgical; gastrostomy, without construction of gastric tube
(e.g. Stamm procedure)
43246 Esophagogastroduodenoscopy, flexible, transoral; with directed place-
ment of percutaneous gastrostomy tube
ICD-10-PCS
The Alphabetic Index gave you:
Repair, Orbit, Left 0NQQ
Repair, Maxilla, 0NQR
In the Tables Section, you must build the code out to seven (7) characters based
on the additional details in the operative notes:
0NQQ0ZZ Repair of orbit, left side, open approach
0NQRXZZ Repair of maxilla, external approach
HCPCS LEVEL II
The Alphabetic Index gave you:
Nebulizer, Filter, Disposable A7013
Nebulizer, Filter, Non-disposable A7014
In the Alphanumeric List, you will read:
A7013 Filter, disposable, used with aerosol compressor or ultrasonic generator
A7014 Filter, non-disposable, used with aerosol compressor or ultrasonic
generator

Look at all the additional details provided in the complete code descriptions. As
you can see with just our few examples, there are specifics that may require you to go
back to the documentation to confirm these additional details are still accurate. While
you are here, you also need to read the complete code descriptions for all of the other
codes in this code category. It is not uncommon that you may find another code that is CPT © 2017 American Medical Association. All rights reserved.

a better match for the documentation.

Conventions (Notations and Symbols)

In addition to full code descriptions, you will also find conventions (notations and
symbols) in the Tabular List (ICD-10-CM) and Main Section (CPT) that include tips
and hints pointing you toward the correct code. This section is a preview of more in-
depth discussions about symbols that will come in future chapters. So, for now, just a
little glance.

ICD-10-CM
In the Tabular List above K65.1 is a notation that states:
Use additional code to identify infectious agent
K65.1 Peritoneal abscess (mesenteric abscess)

44   PART I  |  MEDICAL CODING FUNDAMENTALS

saf28735_ch03_039-052.indd  44 10/29/18 09:49 AM

 Rev. Confirming Pages

A “Use additional code” notation reminds you that you will need to include a second
code reporting the detail identified in the notation. This notation helps you ensure you CODING BITES
are reporting complete information about a patient’s diagnosis that will support medi- You will learn more
cal necessity for the appropriate treatment. about ICD-10-CM con-
ventions, notations, and
CPT symbols in the chapter
In the Main Section to the left of code 97803 is a star symbol: titled Introduction to
⋆97803  Medical nutrition therapy; re-assessment and intervention, individual, ICD-10-CM.
face-to-face with the patient, each 15 minutes
Both at the bottom of the page in CPT and in the “Introduction” in the front of the CPT
code book, you can see that this symbol ⋆ informs you, the coder, that if this service CODING BITES
was provided using audio/video synchronous equipment (i.e., Skype, FaceTime), you You will learn more
will need to append modifier 95 to this code. This small symbol helps you avoid com- about CPT conventions,
mitting fraud. notations, and symbols
in the chapter titled
ICD-10-PCS Introduction to CPT.
The majority of the codes suggested in the Alphabetic Index of ICD-10-PCS are not
complete codes. This fact will not let you forget that you have to go into the Tables sec-
tion to build the code out to seven (7) characters (based on the additional details in the
operative notes). To report a complete, valid code, you must go into the Tables section. CODING BITES
0NQQ0ZZ Repair of orbit, left side, open approach You will learn more
about ICD-10-PCS con-
0NQRXZZ Repair of maxilla, external approach
ventions in the chapter
NOTE: Even in those occasions when the Alphabetic Index provides you with all titled Introduction to
seven characters for the code, you still should go to the appropriate Table to confirm. ICD-10-PCS.
It will only take a few seconds, and you can be certain you are reporting the complete
and accurate code.

HCPCS LEVEL II CODING BITES

In the Alphanumeric Section, to the left of code J8705 is a symbol: You will learn more
about HCPCS Level II
   J8705 Topotecan, oral, 0.25mg
conventions, notations,
The symbol  , in some versions of the HCPCS Level II book, alerts you that this code and symbols in the
description includes a specific quantity. When seeing this, you should confirm the chapter titled HCPCS
quantity documented with the quantity in the code description. The code may need to Level II.
be reported multiple times.

3.4  The Official Guidelines

CPT © 2017 American Medical Association. All rights reserved.

With all these code sets and all these codes, you can see that the process to get from
documentation to code is more complicated than simply finding a word here and a
code there. Coding is important work, so you want to get it accurate every time. To
accomplish this, it is essential to have help and support exactly when you need it.
And you have that help right at your fingertips within each code set’s book. Always
there, just the turn of a few pages, is the guidance from those who created these code
sets and who oversee their legal and correct use. These are the published Official Official Guidelines
Guidelines with which you must comply. You don’t need to memorize them; you A listing of rules and regula-
just need to remember they are there and refer to them every time you are working to tions instructing how to use a
determine a code. specific code set accurately.

ICD-10-CM
Usually in the front of this code book, you will find the section titled “ICD-10-CM
Official Guidelines for Coding and Reporting.”

saf28735_ch03_039-052.indd  45 10/29/18 09:52 AM

 CPT
In the front of each individual main section, you will find the guidelines applicable
to that part of the CPT codes. So, in front of the Evaluation and Management (E/M)
Services codes are the pages containing the Evaluation and Management (E/M) Ser-
vices Guidelines; in front of the Anesthesia code section are the Anesthesia Guide-
lines; etc.
In addition, it is important to note that the CPT book also includes official guide-
lines within the sections, at some subsections, with advice and direction for accurate
coding of just those procedures, services, and treatments. This means you must get
in the habit of reading from the beginning of each section and the beginning of the
subsection before determining a code. It only takes a few seconds and it can make the
difference between accuracy and fraudulent reporting.

ICD-10-PCS
Usually in the front of this code book, you will find the section titled “ICD-10-PCS
Official Guidelines for Coding and Reporting.”

Guidance Connection
Throughout this book, you will see special boxes titled GUIDANCE CONNEC-
TION that will point you to a specific guideline in that particular code set directly
related to whatever concept or aspect is being discussed. Take a minute and turn to
that Guideline in your personal code book and read it, think about it, and identify how
you would apply this guideline to your work as a professional coding specialist. There
is no need to memorize these details because they will always be there for you, right
inside your code book, at your fingertips.

CPT
LET’S CODE IT! SCENARIO
DATE OF PROCEDURE: 08/18/2018
PATIENT: ARTHUR FERGUSON
PREOPERATIVE DIAGNOSIS: Acute upper abdominal pain
POSTOPERATIVE DIAGNOSIS: Liver tumor
OPERATION PERFORMED: Diagnostic laparoscopy; Laparoscopic ablation, using radiofrequency
SURGEON: Harrison Brusk, MD
SEDATION: General endotracheal anesthetic
ESTIMATED BLOOD LOSS: Minimal.
COMPLICATIONS: None. CPT © 2017 American Medical Association. All rights reserved.

INDICATIONS FOR PROCEDURE:

This 57-year-old male presented with signs and symptoms consistent with liver malfunction. Laparoscopic investiga-
tion to confirm suspected liver tumor, and if so, ablation. The informed consent form was signed.
DESCRIPTION OF OPERATION:
The patient was brought to the operating room and placed in a supine position on the operating table. After adminis-
tration of general anesthetic, I prepped and draped the upper abdomen in the usual sterile fashion.
A small incision was made into the umbilicus through which a bladeless 11 mm trocar was inserted without dif-
ficulty. After the pneumo-peritoneum was established, the patient was moved into the Trendelenburg position. Two
additional 5 mm trocar insertions were made. The liver was visualized and two tumors were identified, one on the

(continued)

46   PART I  |  MEDICAL CODING FUNDAMENTALS

 distal portion of the liver and one on the proximal surface. The diagnostic laparoscopy was then converted to a sur-
gical procedure so we could remove the tumors. Using radiofrequency techniques, both tumors were successfully
ablated.

Let’s Code It!

The documentation created by Dr. Brusk clearly provides us with the details of what occurred during this encoun-
ter with this patient, Arthur Ferguson. He was having upper abdominal pain that was determined to be two liver
tumors (why reported with ICD-10-CM code D13.4 Benign neoplasm of liver) and the doctor performed a diag-
nostic laparoscopy, followed by a surgical laparoscopic ablation of liver tumors (what). Seems very straightfor-
ward, doesn’t it?
A good place to begin: in the CPT Alphabetic Index, look up:
Ablation
Liver (Tumor)
Cryosurgical............................. 47381, 47383
Laparoscopic........................... 47370, 47371
Radiofrequency....................... 47380-47382

Turn to the Main Section of CPT to find code 47370 because Dr. Brusk specifically documented that the abla-
tion was done laparoscopically. Directly above code 47370 are some official guidelines that provide important
direction:

“Surgical laparoscopy always includes diagnostic laparoscopy. To report a diagnostic laparoscopy (perito-
neoscopy) (separate procedure), use 49320.”

Without this direction, you might have gone to the trouble to report both 49320 and 47370. So, now you
saved yourself some time and found the correct code to report for Dr. Brusk’s work:

47370 Laparoscopy, surgical, ablation of 1 or more liver tumor(s); radiofrequency

If you had reported both codes, this could constitute overcoding—which would be fraud.

See . . . the Guidelines help you code accurately, and legally.

Good work!

3.5  Confirming Medical Necessity

No one believes physicians or other health care professionals should be permitted to
CPT © 2017 American Medical Association. All rights reserved.

do whatever they want to a patient without a valid reason. In our industry, this valid
reason is known as medical necessity, and you learned about it in the Introduction to
the Languages of Coding chapter. The code or codes that you report to identify the
reasons why the patient required the attention of a health care professional justify what
the physician or health care professional did to the patient or for the patient . . . but
only when they are in accordance with the standards of care.

Outpatient Settings
In an outpatient setting, once you have determined the accurate diagnosis codes and
procedure codes, you must confirm that you are reporting at least one diagnosis code Linking
to identify medical necessity by linking it to at least one procedure code. Multiple Confirming medical necessity
procedure codes can link to one diagnosis code, and multiple diagnosis codes can by pairing at least one diagno-
link to one procedure code. But there must be at least one of each to support the sis code to at least one proce-
encounter. dure code.
 You must take this action to ensure that the diagnosis codes you are reporting accu-
rately represent the documented reasons why the physician made the decisions he or
she made and provided care to this patient, based on those reasons. You must make
certain you did not miss anything in the documentation. You must make certain you
did not jot down, or enter, the code incorrectly [a typo?].

CPT
LET’S CODE IT! SCENARIO
Ahmed Obodeh, a 23-year-old male, came in to see Dr. Starkey because he hit his head on a cabinet and has had a
headache for 2 days nonstop. Dr. Starkey examined Ahmed and ordered an MRI of his brain to be taken. Just before
the nurse took him down to imaging, Ahmed told Dr. Starkey that he also banged his left knee and was having pain
when walking. So Dr. Starkey told the nurse to have radiology take an x-ray of his left knee while he was there. After-
wards, Dr. Starkey gave Ahmed instructions for care of a mild concussion, and suggested an ace bandage for his
knee and over-the-counter pain relievers for 1 week.

Let’s Code It!

Dr. Starkey diagnosed Ahmed with a mild concussion and provided an MRI of the brain and an x-ray of the left
knee. Let’s analyze this. The concussion is a traumatic impact of the brain and skull. This matches with the MRI
of the brain. Perfect.
But there is no diagnosis to justify the x-ray of the knee. Did Dr. Starkey order an unnecessary test? Was he
trying to cheat the insurance company and take advantage of Ahmed? No. He is a good doctor and he was
doing a good job by ordering the x-ray of Ahmed’s knee. How will you communicate that he was properly caring
for his patient?
Go back to the documentation. What was written about Ahmed’s knee? “was having pain when walking”
The report of pain by a patient is a symptom and a valid reason for the provision of an x-ray. Therefore, you will
determine the diagnosis code to explain that pain in the knee was the medical necessity.
Diagnosis Procedure
Brain concussion [S06.0X0A] –Links to– MRI brain [70551]
Pain in left knee [M25.562] –Links to– X-ray of knee, left [73560-LT]

You are really learning!

Inpatient Setting
In an inpatient setting, the diagnosis code or codes reported must support the medical
necessity for the patient to require acute care in a hospital setting—24-hour care from
trained health care professionals.
CPT © 2017 American Medical Association. All rights reserved.
For example, uncomplicated mild intermittent asthma [J45.20], occasional narrow-
ing of the bronchi causing diminished breathing, relieved with a prescription inhaler,
is not a reason to admit a patient into the hospital to receive round-the-clock care;
however, mild intermittent asthma with status asthmaticus [J45.22], a life-threatening
asthma attack that is not responding to normal treatments such as an inhaler or nebu-
lizer, certainly might be.

ICD-10-CM
LET’S CODE IT! SCENARIO
DATE OF ADMISSION: 09/18/2018
ADMITTING DIAGNOSIS: Suspected bowel obstruction
CHIEF COMPLAINT: Severe abdominal pain, vomiting, bloating (continued)

48   PART I  |  MEDICAL CODING FUNDAMENTALS

 HISTORY OF PRESENT ILLNESS: Patient is a 29-year-old male with a history of Crohn’s disease of the large intestine.
The patient came to the ER for an episode of vomiting, continuous, 36 hours. Patient states crampy abdominal pain
and bloating. Abdominal ultrasound shows thickening of the bowel wall resulting in acute stricture of the descending
colon. Patient is admitted with suspected Crohn’s disease with bowel obstruction. Consult with gastroenterology is
requested.

Let’s Code It!

The admitting diagnosis appears to be clear:
K50.112 Crohn’s disease of large intestine with intestinal obstruction
You could see the problem getting reimbursed for this hospital stay if, by mistake, this code was reported:
K50.10 Crohn’s disease of large intestine without complications
The little details are important!

Chapter Summary
In this chapter, you learned how to take the data culled from the physician’s documen-
tation and interpret the data into another language, a medical code (ICD-10-CM, CPT,
HCPCS Level II, or ICD-10-PCS). Following each and every one of the six actions
required will help you ensure that you are accurately interpreting what occurred
between physician and patient during a specific encounter or during a patient’s stay
in a hospital. In the next part of this book, you will delve more deeply into diagnosis
coding using the language of ICD-10-CM.

CODING BITES
Action 1. Abstract the documentation
Action 2. Query, if necessary
Action 3. Code the diagnosis or diagnoses
Action 4. Code the procedure or procedures
Action 5. Confirm medical necessity
Action 6. Double-check your codes
CPT © 2017 American Medical Association. All rights reserved.
 CHAPTER 3 REVIEW
CHAPTER 3 REVIEW

The Coding Process Enhance your learning by

completing these exercises and
more at connect.mheducation.com!

Let’s Check It! Terminology

Match each key term to the appropriate definition.
1. LO 3.2  The section of a code book showing codes, from A to Z, by the short A. Alphabetic Index
code descriptions. B. Alphanumeric
2. LO 3.3  The section of the ICD-10-PCS code book listing all of the codes in C. Coding Process
alphanumeric order, based on the first three characters of the code.
D. Official Guidelines
3. LO 3.1  The sequence of actions required to interpret physician documentation
into the codes that accurately report what occurred during a specific E. Linking
encounter between health care professional and patient. F. Main Section
4. LO 3.3  A code consisting of both numbers and letters. G. Notations
5. LO 3.5  Confirming medical necessity by pairing at least one diagnosis code to H. Symbols
at least one procedure code. I. Tables
6. LO 3.3  The section of the CPT code book listing all of the codes in numeric order. J. Tabular List
7. LO 3.4  A listing of rules and regulations instructing how to use a specific code
set accurately.
8. LO 3.2  Alerts and warnings that support more accurate use of codes in a spe-
cific code set.
9. LO 3.2  Marks, similar to emojis, that provide additional direction to use codes
correctly and accurately.
10. LO 3.3  The section of the ICD-10-CM code book listing all of the codes in
alphanumeric order.

Let’s Check It! Concepts

Choose the most appropriate answer for each of the following questions.
1. LO 3.1  There are _____ specific actions that you should take to construct your proper coding process.
a. 3 b.  4 c.  5 d.  6
2. LO 3.1  The most important factor in coding is
a. speed of the coding process. b.  accuracy of codes.
c.  level of codes d.  quantity of codes.
CPT © 2017 American Medical Association. All rights reserved.
3. LO 3.1  Abstract the documentation is Action _____ in the coding process.
a. 1 b.  2 c.  3 d.  4
4. LO 3.1  Action 5 in the coding process is to
a. code the diagnosis or diagnoses. b.  code the procedure or procedures.
c.  confirm medical necessity. d.  double-check your codes.
5. LO 3.1  Every encounter between patient and health care professional must have at least _____ diagnosis code(s)
and at least _____ procedure code(s).
a. 2, 2 b.  1, 2 c.  1, 1 d.  2, 1
6. LO 3.2  After abstracting the main terms, a coder will go next to the
a. External cause codes. b.  Tabular listings.
c.  Alphabetic Index. d.  Appendix C.

50   PART I  |  MEDICAL CODING FUNDAMENTALS

 7. LO 3.2  Pneumonia would be an example of a term found in which Alphabetic Index?

CHAPTER 3 REVIEW
a. ICD-10-CM b.  CPT
c.  ICD-10-PCS d.  HCPCS Level II
8. LO 3.2  IPPB machine would be an example of a term found in which Alphabetic Index?
a. ICD-10-CM b.  CPT
c.  ICD-10-PCS d.  HCPCS Level II
9. LO 3.2  The Main Section and Tabular List of the code books all contain additional _____ and _____ to help you
determine the most accurate code.
a. notations, modifiers b.  symbols, notations
c.  figures, icons d.  transformers, symbols
10. LO 3.3  Which of the following code books lists the codes in numeric order?
a. ICD-10-CM b.  HCPCS Level II c.  CPT d.  ICD-10-PCS
11. LO 3.3  Which of the following is a full code description?
a. Carbuncle of trunk L02.23 b.  Furuncle of trunk L02.22
c.  Cutaneous abscess of chest wall L02.213 d.  Impetigo L01.0
12. LO 3.3  In the ICD-10-CM Tabular List above code K70.31 there is a notation. What is the notation?
a. Use additional code to identify alcohol abuse and dependence
b.  Code first underlying diseases
c.  Code also, if applicable, viral hepatitis
d.  Code first poisoning due to drug or toxin, if applicable
13. LO 3.3  If you see this symbol in the CPT code book’s main section beside a code, it tells you that
a. the code is a revised code. b.  moderate sedation is included in this code.
c.  the code is an add-on code. d.  the code is a new code.
14. LO 3.3  Which code set requires you, the coder, to build the code out to seven characters?
a. ICD-10-CM b.  HCPCS Level II
c.  CPT d.  ICD-10-PCS
15. LO 3.3  What is the correct ICD-10-PCS code for the Repair of maxilla, left side, open approach?
a. 0NQT0ZZ b.  0NQRXZZ
c.  0NQR0ZZ d.  0NQV0ZZ
16. LO 3.3  What is the correct CPT code for a Laparoscopy, surgical; gastrostomy, without construction of gastric
tube?
a. 43246 b.  43653
CPT © 2017 American Medical Association. All rights reserved.

c.  48001 d.  43246

17. LO 3.4  Official _____ are a listing of rules and regulations instructing you how to use a specific code set
accurately.
a. guidelines b.  linking
c.  tables d.  appendix
18. LO 3.4  The official guidelines for ICD-10-CM can usually be found in the
a. back of the code book. b.  Alphabetic Index.
c.  Tabular List. d.  front of the code book.
19. LO 3.5  The why justifies the _____
a. where. b.  who.
c.  what. d.  when.
 20. LO 3.5  _____ confirm(s) medical necessity by pairing at least one diagnosis code to at least one procedure code.
CHAPTER 3 REVIEW

a. Tables b.  Linking

c.  Guidelines d.  Appendix

Let’s Check It! Guidelines

Part I
Refer to the ICD-10-CM Official Guidelines and match each section number to the
corresponding guideline.
1. Diagnostic Coding and Reporting Guidelines for Outpatient Services. A. Section I
2. Selection of Principal Diagnosis. B. Section II
3. Conventions, general coding guidelines and chapter specific guidelines. C. Section III
4. Reporting Additional Diagnoses. D. Section IV
Part II
Refer to the ICD-10-CM Official Guidelines and match each section number to the
corresponding guideline.
1. LO 3.4  Sequela (Late Effects) A. Section 1.A.2
2. LO 3.4  Format and Structure B. Section 1.A.4
3. LO 3.4  Abbreviations – Tabular List abbreviations C. Section 1.A.6.b
4. LO 3.4  Etiology/manifestation convention (“code first”, “use additional code” D. Section 1.A.13
and “in diseases classified elsewhere” notes)
E. Section 1.A.17
5. LO 3.4  “Code Also” note
F. Section 1.B.4
6. LO 3.4  Conditions that are an integral part of a disease process
G. Section 1.B.5
7. LO 3.4  Placeholder character
H. Section 1.B.6
8. LO 3.4  Conditions that are not an integral part of a disease process
I. Section 1.B.10
9. LO 3.4  Signs and symptoms
J. Section 1.B.13
10. LO 3.4  Laterality

Let’s Check It! Rules and Regulations

Please answer the following questions from the knowledge you have gained after reading this chapter.
1. LO 3.1  List the six Actions of the coding process and explain each action in your own words.
2. LO 3.2  Discuss the Alphabetic Index and the role it plays in the coding process. CPT © 2017 American Medical Association. All rights reserved.

3. LO 3.3  Explain the ICD-10-CM Tabular List, how the codes are listed, and why it is important.
4. LO 3.4  Describe what the Official Guidelines are, why they are important, where they are located, and if you are
required to comply with these guidelines.
5. LO 3.5  Discuss the importance of linking a diagnosis code to a procedure code.

52   PART I  |  MEDICAL CODING FUNDAMENTALS

PART II
REPORTING DIAGNOSES
INTRODUCTION
For the second layer of your learning, you will focus on interpreting and reporting the
key terms and details about the diagnoses, signs, and symptoms—the reasons why the
physician provided care to the patient during a specific encounter. As you learned in
Part I of this book, this is known as medical necessity.
The concept of medical necessity is as simple as it sounds—the determination that
a medical procedure, service, or treatment needed to be provided to a patient because
of an identified health care issue or concern. Overall, the industry uses the accepted
standards of care by which to measure the rationale—the justification—for every
action taken on behalf of an individual patient. 
For example, atrial fibrillation [irregular heart beats in the upper chambers of the
heart] may be a diagnosis that supports the insertion of a pacemaker; however, ven-
tricular fibrillation [irregular heart beats in the lower chambers of the heart] does not.
A diagnosis of dysphasia [problems with speech] justifies the provision of a speech
evaluation; however, a diagnosis of dysphagia [problems with swallowing] does not.
The physician’s confirmation of a hydrocele [collection of fluid in tunica vaginalis,
spermatic cord, or testis] can only be diagnosed in a male patient and the determina-
tion of a hematometra [accumulated blood in the uterus] can only be diagnosed in a
female.
When you think about it—why would anyone pay for, or accept, the provision of
medical treatment to patients who do not need treatment? The way you will explain
that the physician’s actions were reasonable and correct is by reporting the accurate
diagnosis code or codes.
 4
Key Terms
Introduction to
ICD-10-CM
Learning Outcomes
Acute After completing this chapter, the student should be able to:
Adverse Effect
Alphabetic Index
LO 4.1  Explain the official conventions used in ICD-10-CM.
Anatomical Site LO 4.2  Translate the Official Guidelines and how they impact the
Chronic  way codes are reported.
Condition LO 4.3  Use the Alphabetic Index in ICD-10-CM properly.
Confirmed LO 4.4  Employ the information within the Tabular List to determine
Differential Diagnosis the accurate code to report.
Eponym
External Cause
LO 4.5  Distinguish which conditions mentioned in the documenta-
First-Listed tion to report.
Index to External LO 4.6  Utilize what you learned in this chapter to determine the cor-
Causes rect diagnosis code to report.
Inpatient Facility
Manifestation
Neoplasm Table
Nonessential Modifiers
Not Elsewhere Clas- Remember, you need to follow along in
sifiable (NEC)   STOP! your ICD-10-CM code book for an optimal
ICD-10-CM

Not Otherwise Speci- learning experience.

fied (NOS)
Other Specified
Outpatient Services
Principal Diagnosis 4.1  Introduction and Official Conventions
Sequela (Late Effect)
Systemic Condition
In the chapters Introduction to the Languages of Coding and The Coding Process, you
Table of Drugs and
were provided with a brief overview of the various code sets. Now, let’s begin to dig
Chemicals
deeper into the specifics of the ICD-10-CM code set and how to implement it as part
Tabular List of Dis-
of the coding process.
eases and Injuries
Underlying Condition
Introduction
Unspecified In the very front of the ICD-10-CM code book is the Introduction. Here you can learn
about the history of ICD-10-CM and how we got to this tenth revision. The use of
codes to describe the reasons why a patient would need the care of a health care pro-
fessional is an ever-evolving process. These codes, and coding overall, will continue
to change throughout your career as a professional coder, so you will need to learn to
adapt and change as the needs of health care progress.

ICD-10-CM Official Conventions

The Official Conventions are a very important part of the ICD-10-CM code set. You
need to learn the specifics of how codes are presented, and what symbols and nota-
tions mean, so you can use them accurately.
Throughout the ICD-10-CM code book, directions, tips, symbols, and helpful nota-
tions are available to guide you to the accurate code for a patient encounter. Let’s go
through common notations and abbreviations, with examples, so you can develop a
clear understanding of their meanings.

54
Punctuation
CODING BITES
Punctuation in ICD-10-CM adds information and helps you further your quest for the
best, most appropriate code. NOTE: This code set is
maintained by the U.S.
Brackets [ ] federal government;
however, there are
Found in the Tabular List, brackets will show you alternate terms, alternate phrases, and/
many different publish-
or synonyms to provide additional detail or explanation to the description. In the follow-
ers. Each publisher may
ing example, the provider may have diagnosed the patient with food-borne intoxication
present the symbols
due to either Clostridium perfringens or C. welchii. In either case, A05.2 would be the
and notations in its own
correct code. The same for our other examples: If the documentation reads either “benign
way. Don’t worry. The
recurrent meningitis” or “Mollaret’s,” code G03.2 can be reported, and if either “third
conventions section in
nerve palsy” or “palsy of the oculomotor nerve” is documented, code H49.02 is valid.
the very front of your
code book, in Section
1.A of the Official Guide-
EXAMPLES lines, as well as the leg-
A05.2 Food-borne Clostridium perfringens [Clostridium welchii] intoxication end along the bottom of
G03.2 Benign recurrent meningitis [Mollaret] every page will always
H49.02 Third [oculomotor] nerve palsy, left eye explain what means
what. All you have to do
is read.
Italicized or Slanted Brackets [  ]
Italicized, or slanted, brackets, used in the Alphabetic Index, will surround an addi-
tional code or codes (i.e., secondary codes) that must be included with the initial code.
It is the Alphabetic Index’s way of telling you that you may need to report more than
one code, as well as in what order to sequence these codes.
The italic brackets tell you that if the patient has been diagnosed with schistosomia-
sis due to granuloma, you have to use two codes: first, B65.9 for the underlying condi-
tion (the schistosomiasis) and, second, G07 for the granuloma itself.

EXAMPLE
Granuloma L92.9
brain (any site) G06.0
schistosomiasis B65.9 [G07]

Parentheses (  )
Throughout the code set, parentheses show you additional terms or phrases that are
also included in the description of a particular code. The additional terms are called
nonessential modifiers. The modifiers can be used to provide additional defini- Nonessential Modifiers
tion but do not change the description of the condition. The additional terms are not Descriptors whose inclusion in
required in the documentation, so if the provider did not use the additional term, the the physician’s notes are not
code description is still valid. absolutely necessary and that
Take a look at the first example below. Whether the physician wrote the diagnosis as are provided simply to further
clarify a code description;
“malaria,” “malarial,” or “malarial fever,” code B54 would still be a valid suggestion.
optional terms.
In the Tabular List example, code H18.52 would be valid for a diagnosis written by
the physician as “epithelial corneal dystrophy” or “juvenile corneal dystrophy.”

EXAMPLES
In the Alphabetic Index:
Malaria, malarial (fever) B54
Injury, thyroid (gland) NEC S19.84 (continued)
 In the Tabular List:
H18.52 Epithelial ( juvenile) corneal dystrophy
H44.631 Retained (old) magnetic foreign body in lens, right eye

Colon :
A colon (two dots, one on top of the other), used in the Tabular List, emphasizes that
one or more of the following descriptors are required to make the code valid for the
diagnosis.

CODING BITES EXAMPLE

Health care is an indus- venous embolism and thrombosis (of):
try that uses many, cerebral (I63.6, I67.6)
many abbreviations and coronary (I21–I25)
acronyms. Keep a medi-
You would read these as:
cal dictionary close at
venous embolism and thrombosis (of), cerebral (I63.6, I67.6)
hand so you can look up
venous embolism and thrombosis (of), coronary (I21–I25)
any with which you are
not familiar.
Abbreviations
NEC
Not Elsewhere Classifiable Not elsewhere classifiable (NEC), or not elsewhere classified, indicates that the phy-
(NEC) sician provided additional details of a condition but that the ICD-10-CM book did not
Specifics that are not include those extra details in any of the other codes in the book. NEC may appear in
described in any other code either the Alphabetic Index or the Tabular List, as you can see in our examples here.
in the ICD-10-CM book; also Before reporting a code with NEC in its description, you want to check and double-
known as not elsewhere
check that there is not another code with a more complete description that matches the
classified.
details documented in the physician’s notes.

EXAMPLES
K72.-  Hepatic failure, not elsewhere classified
Infection, coronavirus NEC B34.2

NOS
Not Otherwise Specified Not otherwise specified (NOS) means that the physician did not document any addi-
(NOS) tional details that are identified in any of the other available code descriptions. On
The absence of additional occasion, you may find an NOS in the Alphabetic Index, but most often, you will see
details documented in the these notations in the Tabular List.
notes. Before reporting a code with NOS in the description, you need to reread the phy-
sician’s documentation and complete patient chart to make certain the specifics you
need to report a more complete code are not there. And, even then, you should query
the physician to obtain the details, as you learned in the chapter Abstracting Clinical
Documentation. An NOS code should be a very last resort to report.

EXAMPLES
R10.811 Right upper quadrant abdominal tenderness NOS
Z30.09 Encounter for other general counseling and advice on contraception
(Encounter for family planning advice NOS)

56   PART II  |  REPORTING DIAGNOSES

General Notes
GUIDANCE
Includes, Excludes1, and Excludes2 CONNECTION
Let’s begin the explanations of , , and  notations with an
example. Turn, in the ICD-10-CM Tabular List, to code F31: Read the ICD-10-CM
Official Guidelines for
F31 Bipolar disorder Coding and Reporting,
section I. Conven-
manic-depressive illness
tions, General Coding
manic-depressive psychosis
Guidelines and Chapter
manic-depressive reaction
bipolar disorder, single manic episode (F30.-) Specific Guidelines,
major depressive disorder, single episode (F32.-) subsection A. Con-
major depressive disorder, recurrent (F33.-) ventions for the ICD-
cyclothymia (F34.0) 10-CM, paragraph 6.
Abbreviations.
These notations are in the Tabular List to help you determine the correct code. They
provide you with additional terms as well as alternate codes that you might find better
match what the physician wrote. Notations are all designed to make the coding process
easier and more accurate.
INCLUDES
The notation provides you with additional terms and diagnoses that are
included in the above code (this code’s description). These notations provide you with
additional terms, and variations of descriptors, that expand the meaning of this code’s
description, making it easier to match what the physician wrote in the documentation.
Take a look at our example: The notation explains to you that diagnoses of
bipolar disorder, manic-depressive illness, manic-depressive psychosis, and manic-
depressive reaction are all reported from code category F31.
EXCLUDES1
There are times when two diagnostic statements may be close to each other, yet actu-
ally conflict with each other. The notation identifies codes that cannot be
used together on the same health claim form with the originally listed code. The nota-
tion explains that the two codes
∙ Are contradictory to each other.
∙ Cannot coexist in the same person at the same time.
∙ Are redundant.
Using our example above, this notation tells you that F32 Major-depressive disorder,
single episode is mutually exclusive to (cannot be reported with) F31 Bipolar disorder.

EXAMPLE
Turn in your ICD-10-CM code book, Tabular List, and find code:
J99 Respiratory disorders in diseases classified elsewhere
respiratory disorders in:
amebiasis (A06.5)
blastomycosis (B40.0–B40.2)
You would read the excluded diagnoses as . . .
respiratory disorders in ambeiasis (A06.5)
respiratory disorders in blastomycosis (B40.0–B40.2)

EXCLUDES2
An notation is a warning to STOP AND DOUBLE- CHECK THE DOCUMENTA-
TION so you don’t report the code above the notation when a code shown in the notation
 may be more accurate. You will see specific conditions listed in the notation that are
GUIDANCE not a part of the code above and a suggestion for an alternate code that may be a more
CONNECTION accurate match to the physician’s notes. In some cases, the  notation may be
Read the ICD-10-CM
alerting you that an additional code may be needed to complete telling the story about
Official Guidelines for
the patient’s condition. Using our example, you can see that the notation
Coding and Report-
tells you that F34.0 Cyclothymia is not the same as F31 Bipolar disorder. Now you can
ing, section I. Con-
go back to the physician’s notes, double-check the information, and determine which
ventions, General
is the more accurate code to report, or if you need to report both codes.
Coding Guidelines
and Chapter Specific EXAMPLE
Guidelines, subsection
Turn in your ICD-10-CM Tabular List to:
A. Conventions for
the ICD-10-CM, para- M66.1 Rupture of synovial cyst
graphs 10. Includes  rupture of popliteal cyst (M66.0)
notes; 11. Inclusion
The   notation alerts you to STOP AND DOUBLE-CHECK THE DOCUMENTATION to
terms; and 12. Excludes
confirm which type of cyst the physician documented. If the documentation states
notes.
a synovial cyst, then continue determining the correct additional characters for
M66.1. If the documentation states that the cyst was a popliteal cyst, then you
need to report M66.0 to be more accurate.

Code First
Certain conditions and diseases can cause other problems in the body. Individuals
with diabetes, for example, are known to have problems with their eyes or circulation,
just to name a few, as a direct result of having diabetes. Patients found to be HIV-
positive are prone to conditions such as pneumonia, again as a direct result of the fact
that they have human immunodeficiency virus infection. In these examples, diabetes
Underlying Condition and HIV are what are known as underlying conditions. The resulting conditions (e.g.,
One disease that affects circulation problems, pneumonia) are called manifestations.
or encourages another The Code first notation is a reminder that you are going to need another code to
condition. identify the underlying disease that caused the diagnosed condition. This notation
Manifestation also tells you the sequence in which to report the two codes: the underlying condition
A condition caused or devel- first followed by the manifestation (see Figure 4-1). Often, the notation will reference
oped from the existence of the most common underlying diseases for a manifestation (along with their codes)!
another condition. Cool!

13. Etiology/manifestation convention (“code first”, “use additional code”, and

“in diseases classified elsewhere” notes)
Certain conditions have both an underlying etiology and multiple body system
manifestations due to the underlying etiology. For such conditions, ICD-10-CM has
a coding convention that requires the underlying condition to be sequenced first,
if applicable, followed by the manifestation. Wherever such a combination exists,
there is a “use additional code” note at the etiology code, and a “code first” note
at the manifestation code. These instructional notes indicate the proper sequenc-
ing order of the codes, etiology followed by manifestation.
In most cases the manifestation codes will have the code title, “in diseases
classified elsewhere.” Codes with this title are a component of the etiology/mani-
festation convention. The code title indicates that it is a manifestation code. “In
diseases classified elsewhere” codes are never permitted to be used as first-listed
or principal diagnosis codes. They must be used in conjunction with an underlying
condition code and they must be listed following the underlying condition. See
category F02, Dementia in other diseases classified elsewhere, for an example of
this convention.

58   PART II  |  REPORTING DIAGNOSES

 There are manifestation codes that do not have “in diseases classified else-
where” in the title. For such codes, there is a “use additional code” note at the
etiology code and a “code first” note at the manifestation code and the rules for
sequencing apply.
In addition to the notes in the Tabular List, these conditions also have a specific
Alphabetic Index entry structure. In the Alphabetic Index both conditions are listed
together with the etiology code first followed by the manifestation codes in brack-
ets. The code in brackets is always to be sequenced second.
An example of the etiology/manifestation convention is dementia in Parkinson’s
disease. In the Alphabetic Index, code G20 is listed first, followed by code F02.80
or F02.81 in brackets. Code G20 represents the underlying etiology, Parkinson’s
disease, and must be sequenced first, whereas codes F02.80 and F02.81 repre-
sent the manifestation of dementia in diseases classified elsewhere, with or with-
out behavioral disturbance.
“Code first” and “Use additional code” notes are also used as sequencing rules
in the classification for certain codes that are not part of an etiology/manifestation
combination.
See Section I.B.7. Multiple coding for a single condition.

FIGURE 4-1  ICD-10-CM Convention I.A.13. Etiology/manifestation convention. 

Source: CDEC.gov

The Code first notation is ICD-10-CM’s way of informing you that

1. You may need to report another code in addition to the code above to accurately tell
the whole story of a diagnosis.
2. This other code should be reported first,  before the code above the Code
first notation.

EXAMPLE CODING BITES

I26.01 Septic pulmonary embolism with acute cor pulmonale 
An underlying condi-
Code first underlying infection tion must come first and
This notation tells you that then a manifestation
develops from it. Think
1. You need to report both code I26.01 and a code for an infection (see the physi-
of an underlying condi-
cian’s notes to determine the exact infection).
tion as the trunk of a
2. You need to report the code for the infection first, followed by I26.01. tree and a manifestation
as a branch that grows
out from that trunk. If
Use Additional Code
the tree trunk didn’t
Similar to the Code first notation, the Use additional code notation is ICD-10-CM’s exist, there would be no
way of informing you that branch.
1. You may need to report another code in addition to the code above to accurately tell
the whole story of a diagnosis. 
2. This extra (additional) code should be reported after the code above the Use
additional code notation.

EXAMPLE
G00.2 Streptococcal meningitis
Use additional code to further identify the organism (B95.0–B95.5)
(continued)
 This notation tells you that
1. You need to report both code G00.2 and a code from the range B95.0-B95.5
(as per the physician’s notes).
2. You need to report G00.2 first, followed by the code from B95.0-B95.5.

Code Also
The  Code also notation is similar to the Code first and Use additional code nota-
tions, just without the predetermination of sequencing. ICD-10-CM is alerting you that
GUIDANCE the physician’s notes may contain some additional condition or issue that should be
CONNECTION reported with a separate code, in addition to the code above this notation. This nota-
Read the ICD-10-CM tion leaves it up to you to decide whether or not the additional code is needed to tell
Official Guidelines for the whole story. If it is needed, you will need to use the Official Guidelines, Sections
Coding and Report- II and III, to determine the reporting order.
ing, section I. Con-
ventions, General
Coding Guidelines EXAMPLE
and Chapter Specific H18.041 Kayser-Fleischer ring, right eye
Guidelines, subsection
Code also any associated Wilson’s disease (E83.01)
A. Conventions for the
ICD-10-CM, paragraph This Code also notation alerts you to check the documentation to see if there is a
17. “Code also note.” diagnosis of Wilson’s disease mentioned in connection with the Kayser-Fleischer
ring of the patient’s right eye. 
If so, then . . .
1. You need to report both code H18.041 and code E83.01 (as per the physi-
CODING BITES cian’s notes).
Sometimes notations 2. You need to determine from the physician’s documentation, and using the Offi-
appear under the three- cial Guidelines, Section II. Selection of Principal Diagnosis, and Section III.
character code at the Reporting Additional Diagnoses, which code to report first.
top of a category but are
not repeated after each
additional code in its
Category Notes
section. This is another
reason why it is impor- Occasionally, you may see informational notes under the description of a three-
tant to start reading at character code or at the top of a subsection in the Tabular List.  These notes share
the three-character code, important information and clarifications that you need to know before you determine
even when the Alpha- the code or codes to report.
betic Index directs you to
a code with more char-
acters. You don’t want to EXAMPLES
miss any important direc-
tives, such as , I69 Sequelae of cerebrovascular disease
, Code first, or Note: Category I69 is to be used to indicate conditions in I60–I67 as the cause of
Use additional code sequelae. The “sequelae” include conditions specified as such or as residuals that
notations. may occur at any time after the onset of the causal condition.
*-*-*
Chapter 15. Pregnancy, Childbirth and the Puerperium (O00–O9A)
Sequela
A cause-and-effect relation- Note: Codes from this chapter are for use only on maternal records, never on
ship between an original con- newborn records. Codes from this chapter are for use for conditions related to or
dition that has been resolved aggravated by the pregnancy, childbirth, or by the puerperium (maternal causes or
with a current condition; also obstetric causes).
known as a late effect.

60   PART II  |  REPORTING DIAGNOSES

And
GUIDANCE
The guidelines for the accurate use of ICD-10-CM instruct you to interpret the use
of the word and in a code description as “and/or.” Therefore, if the physician’s notes
CONNECTION
include only one part of a code description but not the other, the code may still be Read the ICD-10-CM
correct. Official Guidelines for
Coding and Report-
ing, section I. Con-
EXAMPLE ventions, General
Coding Guidelines
J38.01 Paralysis of vocal cords and larynx, unilateral and Chapter Specific
You would be correct to report code J38.01 on the basis of physician’s notes that Guidelines, subsection
confirm a diagnosis of paralysis of the vocal cords only, paralysis of the larynx A. Conventions for the
only, or paralysis of both the vocal cords and larynx. ICD-10-CM, paragraph
14. “And.”

With
The term “with” can be seen in both the Alphabetic Index and the Tabular List, and GUIDANCE
you should read this as a connection confirmed by the physician. A phrase you may
CONNECTION
see in the physician’s documentation is “associated with.” To use a combination code
containing “with,” you do not need the physician to document the connection between Read the ICD-10-CM
the two diagnoses. The Official Guidelines direct us to avoid using a combination Official Guidelines for
code when the physician’s documentation specifies that the conditions are not related Coding and Report-
or associated with each other. ing, section I. Con-
ventions, General
Coding Guidelines
EXAMPLE and Chapter Specific
Lorrie Demming, a 31-year-old female, G1, P0, came to see Dr. Southland because Guidelines, subsection
of bleeding. She is in her third trimester and very worried about the baby. Dr. A. Conventions for the
Southland confirmed the hemorrhage was associated with her placenta previa. ICD-10-CM, paragraph
15. “With.”
O44.13 Placenta previa with hemorrhage, third trimester

Confirmed
Other Specified Found to be true or definite.
The phrase other specified means the same thing as NEC: The physician specified Other Specified
additional information that the ICD-10-CM book doesn’t have in any of the other Additional information the
codes in the category. physician specified that isn’t
included in any other code
description.
EXAMPLE
Dr. Josephs diagnosed Allen Halverson with portal cirrhosis of the liver. Turn to the
ICD-10-CM Tabular List code category: 
K74 Fibrosis and cirrhosis of liver
K74.3 Primary biliary cirrhosis
K74.4 Secondary biliary cirrhosis
K74.6 Other and unspecified cirrhosis of liver
K74.60 Unspecified cirrhosis of liver
K74.69 Other cirrhosis of liver
You can see that Portal cirrhosis of the liver is not specified in codes K74.3 or
K74.4. You cannot honestly report K74.60 because the physician DID specify the
type of cirrhosis. Therefore, to be accurate, you must report K74.69 Other
cirrhosis of liver.
 Unspecified
Unspecified Unspecified has the same meaning as NOS, explaining that the physician did not
The absence of additional provide more details in his or her notes. Query the physician for specifics so you can
specifics in the physician’s avoid using an unspecified code. Using these codes should always be a last resort.
documentation.

EXAMPLES
K64.9 Unspecified hemorrhoids
Tumor, yolk sac, unspecified site, male C62.90

See
CODING BITES In the Alphabetic Index of ICD-10-CM, you may look up a term and notice that the
Before choosing any book instructs you to see another term. This is an instruction in the index that the
code with NOS or information you are looking for is listed under a different term. 
unspecified in the
description, double-
check the notes and EXAMPLES
patient record to be
Entamoeba, entamebic—see Dysentery, amebic
certain you cannot
Dysentery, dysenteric
find specific details to
amebic (see also Amebiasis) A06.0
support a specific code.
acute A06.0
If not, then query the
chronic A06.1
provider and ask for
the additional details  *-*-*
you need to determine Glue
a more accurate code. sniffing (airplane)—see Abuse, drug, inhalant
An unspecified or NOS Abuse
code should always be drug
a last resort. inhalant F18.10

See Also
GUIDANCE
In other places in the Alphabetic Index, you may see that the instruction see also is
CONNECTION next to the term you are investigating. See also explains that additional details may be
Read the ICD-10-CM found under a different term. The index is providing you with an alternate main term
Official Guidelines for that may show descriptions more accurate to the physician’s documentation.
Coding and Report-
ing, section I. Con-
ventions, General EXAMPLE
Coding Guidelines Angiofibroma (see also Neoplasm, benign, by site)
and Chapter Specific juvenile
Guidelines, subsection
A. Conventions for specified site—see Neoplasm, benign, by site
the ICD-10-CM, para- unspecified site D10.6
graph 16. “See” and You can see that the See Also notation provides you with an additional path to get
“See Also.” to the correct code.

See Condition
The Alphabetic Index may also point you in a less concrete way, such as when you look
up a term and the notation tells you to see condition. This can be confusing. The index
Anatomical Site is not telling you to look up the term condition. What it is instructing you to do is to
A specific location within the find the term that describes the health-related situation involved with this diagnosis and
anatomy (body). look up that term. You will see this most often next to the listing for an anatomical site.

62   PART II  |  REPORTING DIAGNOSES

 EXAMPLE
Heart—see condition
Leg—see condition
Patellar—see condition 

This instruction comes back to the reason you are looking for a code in the first
place. Remember, you are looking for a code to explain why the physician cared for the
patient during the encounter. Using our example, having a heart is not a reason for a
physician to meet with a patient. Everyone has a heart. Therefore, the index is telling
you to look, instead, for the term that describes the condition of this patient’s heart—
the problem or concern about his or her heart that brought the patient together with the
physician at this time. So, as an example, instead of heart, cervix, or lung, you need to
look up atrophy, fracture, or deformity . . . whatever the reason why the patient would
need the care of a health care professional.

Additional Characters Required

Box with a Checkmark and Number 
A box with a checkmark and number located to the left of a code in the Tabular List
is a symbol that notifies you that an additional character is required. The number tells
you which character—fourth, fifth, sixth, or seventh—is needed. Some publishers of
ICD-10-CM code books use a bullet ∙ rather than a box. In addition, some versions of
the ICD-10-CM book will use a , alerting you to the need for a placeholder—the
letter x—to be used prior to the 7th character.

EXAMPLE
H20 Iridocyclitis
H20.0 Acute and subacute iridocyclitis
H20.01 Primary iridocyclitis
H20.013 Primary iridocyclitis, bilateral
You can see that, as each additional character is added to the code, more specific
details are included in the code description. As a professional coding specialist, it
is your obligation to always report the most detail possible. This is referred to as
the “highest level of specificity.” Therefore, when the ICD-10-CM code book directs
you to keep reading to find an additional character, you are required to do this.

Hyphen -
A hyphen is used in the Alphabetic Index to indicate that additional characters are
required. This alerts you to an incomplete code.

EXAMPLES
Cogan’s syndrome H16.32-
Discontinuity, ossicles, ear H74.2-
Fahr Volhard disease (of kidney) I12.-

4.2  ICD-10-CM Official Guidelines for Coding

and Reporting
As you work your way through this content, you may be thinking, “How can I pos-
sibly remember all of this information?” Here is the good news . . . you don’t have to
 memorize because your code book contains the important information you need to
CODING BITES code accurately. All you have to do is read carefully and completely.
If you ever forget what In the front of your code book are the rules and directions for accurate reporting of
one of these symbols, diagnosis codes. You don’t have to memorize them. All you have to do is remember
abbreviations, or nota- that they are available, right at your fingertips, so you can make certain that the codes
tions means, look you report (1) are presented in the legal manner and (2) support clear communications
for the pages in your with all parties involved in the care and reimbursement of patients. (See Figure 4-2.)
ICD-10-CM book titled
ICD-10-CM Official
a. Diabetes mellitus
Guidelines for Coding
and Reporting, Sec- The diabetes mellitus codes are combination codes that include the type of
tion 1. A. Conventions diabetes mellitus, the body system affected, and the complications affecting
for the ICD-10-CM. On that body system. As many codes within a particular category as are necessary
these pages, you will to describe all of the complications of the disease may be used. They should
find the explanation for be sequenced based on the reason for a particular encounter. Assign as many
all of the footnotes, sym- codes from categories E08-E13 as needed to identify all the associated condi-
bols, instructional notes, tions that the patient has.
and conventions used. 1) Type of diabetes
In addition, most
The age of a patient is not the sole determining factor, though most type 1
versions of ICD-10-CM
diabetics develop the condition before reaching puberty. For this reason
include a legend across
type 1 diabetes is also referred to as juvenile diabetes.
the bottom of the pages
throughout the Tabu- 2) Type of diabetes mellitus not documented
lar List with the sym- If the type of diabetes mellitus is not documented in the medical record the
bols used and a brief default is E11.–, Type 2 diabetes mellitus.
description.
3) Diabetes mellitus and the use of insulin
If the documentation in a medical record does not indicate the type of
diabetes but does indicate that the patient uses insulin, code E11, Type 2
diabetes mellitus, should be assigned. Code Z79.4, Long-term (current) use
of insulin, or Z79.84, Long-term (current) use of oral hypoglycemic drugs,
should also be assigned to indicate that the patient uses insulin or oral
hypoglycemic drugs. Code Z79.4 should not be assigned if insulin is given
temporarily to bring a type 2 patient’s blood sugar under control during an
encounter.

FIGURE 4-2  An excerpt from the Official Guidelines for Coding and Reporting,
section 1.C. Chapter-Specific Coding Guidelines, chapter 4. Endocrine, Nutritional,
and Metabolic Diseases (E00-E89), subsection a. Diabetes Mellitus, parts
1 through 3  Source: ICD-10-CM Official Guidelines for Coding and Reporting The Centers for Medicare and
Medicaid Services (CMS) and the National Center for Health Statistics (NCHS)

Section I. Conventions, General Coding Guidelines and

Chapter-Specific Guidelines
As you can tell from this header, Section 1 has three parts:
A. Conventions for the ICD-10-CM
B. General Coding Guidelines
C. Chapter-Specific Coding Guidelines
This section contains the rules and guidelines for determining and reporting accurate,
valid diagnosis codes. Take a moment and review the information in A and B. You
will discover that most of these reiterate what you read in the Introduction and Official
Conventions section. These may describe each of the items differently, so be certain to
read both to ensure that you understand the guidelines. 

64   PART II  |  REPORTING DIAGNOSES

 There are a few additional elements that are important and, therefore, emphasized
here. GUIDANCE
CONNECTION
Section I.A. Conventions for the ICD-10-CM and Section I.B.
Read the ICD-10-CM
General Coding Guidelines Official Guidelines for
Multiple and Additional Codes Coding and Reporting,
If the patient has several conditions or concerns, the physician might possibly indicate section I. Conven-
more than one diagnosis. Sometimes, the doctor will list the diagnoses, making it tions, General Coding
easier for you to know which additional codes are needed. Guidelines and Chapter
Specific Guidelines,
HOW MANY CODES DO YOU NEED? subsection B. General
A professional coding specialist’s job is to tell the whole story about the encounter coding guidelines, para-
between the health care provider and the patient. With diagnosis codes, you relate the graph 7. Multiple
whole story about why the physician provided the services, treatments, and procedures to coding for a single
the patient at this time. You must support medical necessity for all of these procedures. condition.
Let’s use a scenario as an example:
Jenna Wilson, a 29-year-old female, came to a walk-in clinic complaining of a
terrible headache in her forehead and pain in her cheeks. She stated that this
is the third time over the last few months she has had this pain. Dr. Jackson
evaluated her, did a physical exam, and took a culture from her nasal cavity. The
in-house lab identified the cause of her sinusitis as Streptococcus pneumoniae.
Dr. Jackson diagnosed Jenna with acute recurrent frontal sinusitis due to Strep-
tococcus pneumoniae and gave her a prescription for Amoxicillin.
So, how many codes do you need?
You need as many codes as necessary to tell the whole story about why Jenna
required Dr. Jackson’s care at this visit. Why did Dr. Jackson examine Jenna, take the
culture, perform the lab test, and then write a prescription? Because Jenna has acute
frontal sinusitis caused by Streptococcus pneumoniae. When you look for Sinusitis,
Acute, in the Alphabetic Index, it leads you to the Tabular List at code category

J01 Acute Sinusitis

J01.10 Acute frontal sinusitis, unspecified
J01.11 Acute recurrent frontal sinusitis

Dr. Jackson noted that Jenna’s sinusitis was recurrent, leading you to J01.11 as the
correct code. However, this does not tell the WHOLE story, does it? You need to also
explain the cause of the sinusitis. 
Take a look at the notations beneath J01:
Use additional code (B95–B97) to identify infectious agent
This tells you that the second code to report will explain the cause of the sinusitis. You
are already using what you have learned in just this short amount of time. You can find
the correct second code by turning in your Tabular List to B95 and read all of the code
descriptions in these code categories carefully. Did you find: CODING BITES
The sinusitis is con-
B95.3  treptococcus pneumoniae as the cause of diseases classified
S
sidered a “disease
elsewhere
classified elsewhere”
So, you will report: because it is a condition
that is reported with a
J01.11 Acute recurrent frontal sinusitis
B95.3 Streptococcus pneumoniae as the cause of diseases classified code from elsewhere in
elsewhere this code set. The word
“classified” is used to
Now you can see that, with these two codes, you and anyone reading these codes mean assigned a code
clearly can understand that Dr. Jackson cared for Jenna because she had a recurring in this code set.
acute frontal sinus infection caused by Streptococcus pneumoniae. Without BOTH
 codes, you don’t have the whole story. So, for every case, every encounter, every sce-
nario, you are responsible for telling the WHOLE STORY about the encounter.
CODE SEQUENCING
When more than one diagnosis code is required to tell the whole story of the encounter
accurately, you then must determine in which order the codes should be listed. [Yes, it
does matter!] The code reporting the most important reason for the encounter is called
Principal Diagnosis the principal diagnosis.
The condition, after study, that Sometimes the ICD-10-CM book will tell you which code should come first and
is the primary, or main, reason which should come second with the Code first and Use additional code notations.
for the admission of a patient Section II and Section III of the Official Guidelines will help you with those instances
to the hospital for care; the when there are no notations to guide you with sequencing.
condition that requires the
largest amount of hospital
resources for care. EXAMPLE
Carl Rossen was diagnosed with myocarditis due to E. coli. You will find notations
directing you on how to sequence these two codes.
I40.0 Infective myocarditis 
Use additional code (B95–B97) to identify infectious agent
I41 Myocarditis in diseases classified elsewhere 
Code first underlying disease, such as: typhus (A75.0–A75.9)

In cases when there are multiple confirmed diagnoses identified, the guidelines
CODING BITES instruct you to list the codes in order of severity from the most severe to the least
If two (or more) diagno- severe. Take a look at the encounter Dr. Jackson documented with Jenna Wilson. You
ses are of equal sever- knew to report B95.3 AFTER J01.11 because the notation beneath J01 directed you
ity, then report them to Use additional code, providing you with the detail that you (1) needed a second
in order of anatomical code to complete your explanation of why Jenna required treatment and that (2) clari-
site—head to toe. fied the order in which to place the codes.

Acute and Chronic Conditions

If a patient has a health concern diagnosed by a physician as being both acute (severe) and
chronic (ongoing) and the condition offers you separate codes for the two descriptors, you
should report the code for the acute condition first, as directed by the guidelines. Remem-
ber, from your medical terminology lessons—acute is more serious than chronic.

ICD-10-CM
YOU CODE IT! CASE STUDY
Lorraine Pankow has acute lymphoblastic leukemia and chronic lymphocytic leukemia of B-cell type, now in remis-
sion. She is seeing Dr. Huang today for a checkup of this condition.

You Code It!

Can you determine the correct codes for Lorraine’s visit with Dr. Huang?
Step #1: Read the case carefully and completely.
Step #2: Abstract the scenario. Which main words or terms describe why the physician cared for the patient dur-
ing this encounter? 
Step #3: Are there any details missing or incomplete for which you would need to query the physician? [If so, ask
your instructor.]
Step #4: Check for any relevant guidance, including reading all of the symbols and notations in the Tabular List
and the appropriate sections of the Official Guidelines.

66   PART II  |  REPORTING DIAGNOSES

 Step #5: Determine the correct diagnosis code or codes to explain why this encounter was medically necessary.
Step #6: Double-check your work.
Answer:
Did you determine the correct codes?
C91.01   Acute lymphoblastic leukemia, in remission
C91.11   Chronic lymphocytic leukemia of B-cell type in remission
Great job!

Combination Codes
If one code exists with a description that includes two or more diagnoses identified in
one patient at the same time, you must choose the code that includes as many condi-
tions as available. You may not code each separately.
When the physician’s notes indicate that the patient suffered with both acute respi- Acute
ratory failure and chronic respiratory failure, you must use the code J96.2-. You are Severe; serious.
not allowed to use J96.0- and J96.1-, even though, technically, you are reporting the Chronic
patient’s conditions accurately. It is required that you use the combination code, as Long duration; continuing over
discussed in the Official Guidelines. an extended period of time.

EXAMPLES
J96.0- Acute respiratory failure GUIDANCE
J96.1- Chronic respiratory failure CONNECTION
J96.2- Acute and chronic respiratory failure
Read the ICD-10-CM
Official Guidelines for
Also, there are combination codes throughout ICD-10-CM that enable you to report Coding and Reporting,
an underlying condition along with a manifestation.  section I. Conven-
tions, General Coding
Guidelines and Chapter
EXAMPLES Specific Guidelines,
E10.21 Type 1 diabetes mellitus with diabetic nephropathy subsection B. General
. . . This one code reports two diagnoses: type 1 DM + diabetic nephropathy. Coding Guidelines,
I73.01 Raynaud’s syndrome with gangrene paragraphs 8. Acute
. . . This one code reports two diagnoses: Reynaud’s syndrome + gangrene. and Chronic Conditions
and 9. Combination
K55.21 Angiodysplasia of colon with hemorrhage
Code.
. . . This one code reports two diagnoses: Angiodysplasia of colon + hemorrhage.

Two or More Conditions—Only One Confirmed Diagnosis

There may be cases where the physician documents treatment of two (or more) com-
plaints and only one is identified by a confirmed diagnosis.

ICD-10-CM
LET’S CODE IT! SCENARIO
Cahlen Achmed, a 61-year-old male, came to see Dr. Miller. Earlier in the day, he was lightheaded and a little
dizzy. In addition, he complained that his heart was beating so wildly that he thought he was having a heart attack.

(continued)
 Due to his previous diagnosis of type 1 diabetes, Dr. Miller ordered a blood glucose test. He also performed an EKG to
check Cahlen’s heart. After getting the results of the tests, Dr. Miller determined that Cahlen’s lightheadedness and dizziness
were a result of his glucose being too high and administered a shot of insulin subq, 5U. He spoke with Cahlen about how to
bring his diabetes under control. He also told him that the EKG was negative and that there were no signs of a heart attack.

Let’s Code It!

Dr. Miller confirmed that Cahlen’s type 1 diabetes mellitus was the cause of his lightheadedness and dizziness.
Turn to the Alphabetic Index and find:
Diabetes
Turn to the Tabular List and see:
E10 Type 1 diabetes mellitus
  E10.9 Type 1 diabetes mellitus without complications

CODING BITES
Cahlen Achmed’s case illustrates that sometimes asking yourself, “Why did the physician provide a specific
test, treatment, or service?” can help you find the necessary diagnostic key words for an encounter.

Type 1 diabetes mellitus seems to be the only confirmed diagnosis in Dr. Miller’s notes. However, the doctor
performed an EKG. A diagnosis for diabetes does not provide any medical necessity for doing an EKG. In addi-
tion, the test was negative and, therefore, provided no diagnosis. So you still need a diagnosis code to report
the medical necessity for running the EKG. Why did Dr. Miller perform the EKG? Because Cahlen complained of a
rapid heartbeat. The Alphabetic Index suggests:
Rapid, heart (beat) R00.0
The Tabular List confirms
R00 Abnormalities of heart beat
  R00.0 Tachycardia, unspecified

CODING BITES
An electrocardiogram may be referred to as either an ECG or an EKG. Tachycardia is the medical term for
rapid heartbeat.

For the encounter, you have one confirmed diagnosis (the diabetes) and one symptom (rapid heartbeat). 
Check the top of this subsection and the head of this chapter in ICD-10-CM. There is a NOTE, an 
notation, and an notation. Read carefully. Do any relate to Dr. Miller’s diagnosis of Cahlen? No. Turn
to the Official Guidelines and read Section 1.c.4, particularly a. Diabetes mellitus. There is nothing specifically
applicable here either.
The guidelines state that a confirmed diagnosis should precede a sign or symptom, so you will list the diabe-
tes code first and then the tachycardia.
E10.9 Type 1 diabetes mellitus without complications
R00.0 Tachycardia, unspecified

Differential Diagnosis
When the physician indicates
Differential Diagnosis
that the patient’s signs and
symptoms may closely lead to In the case where a provider indicates a differential diagnosis by using the word
two different diagnoses; usu- versus or or between two diagnostic statements, you need to code both as if they were
ally written as “diagnosis A vs. confirmed, and either may be listed first. This means that the physician has deter-
diagnosis B.” mined that the patient’s signs and symptoms lead equally to two different diagnoses.

68   PART II  |  REPORTING DIAGNOSES

 ICD-10-CM
YOU CODE IT! CASE STUDY
Gilbert Albun, a 57-year-old male complaining of chest pain and shortness of breath, was seen by his family physi-
cian. Dr. Pressman admitted him into the hospital with a differential diagnosis of congestive heart failure versus
pleural effusion with respiratory distress.

You Code It!

Review the notes of the encounter between Dr. Pressman and Gilbert Albun, and determine the applicable diag-
nosis code(s).
Step #1: Read the case carefully and completely.
Step #2: Abstract the scenario. Which main words or terms describe why the physician cared for the patient dur-
ing this encounter? 
Step #3: Are there any details missing or incomplete for which you would need to query the physician? [If so, ask
your instructor.]
Step #4: Check for any relevant guidance, including reading all of the symbols and notations in the Tabular List
and the appropriate sections of the Official Guidelines.
Step #5: Determine the correct diagnosis code or codes to explain why this encounter was medically necessary.
Step #6: Double-check your work.
Answer:
Did you determine the correct codes?
I50.9 Congestive heart failure, unspecified
J90 Pleural effusion, not elsewhere classified
R06.00 Dyspnea, unspecified

Other Current Conditions

Another important issue that needs to be coded is a current condition that might be
subtly addressed by the physician. It might be the writing of a prescription refill or a
short discussion on the state of the patient’s well-being as the result of ongoing therapy
for a matter other than that which brought the patient to see the physician today.

ICD-10-CM
YOU CODE IT! CASE STUDY
Deanna Franklin, a 45-year-old female, came to see Dr. Carter for a follow-up on a previous diagnosis of paroxysmal
atrial fibrillation. Dr. Carter examined Deanna and did a blood test to monitor the effectiveness of the prescription
medication Coumadin, a blood thinner. Dr. Carter told Deanna he was very pleased with her progress and that she
was doing well. Before leaving, Deanna asked Dr. Carter for a refill of trinalin, her allergy medication. This time of
year typically provoked her allergy to pollen, which caused a lot of inflammation and irritation in her nose (rhinitis).
Dr. Carter wrote the refill prescription.

You Code It!

Read Dr. Carter’s notes regarding this encounter with Deanna, and determine the correct diagnostic code or codes.
Step #1: Read the case carefully and completely.
Step #2: Abstract the scenario. Which main words or terms describe why the physician cared for the patient dur-
ing this encounter? 

(continued)
 Step #3: Are there any details missing or incomplete for which you would need to query the physician? [If so, ask
your instructor.]
Step #4: Check for any relevant guidance, including reading all of the symbols and notations in the Tabular List
and the appropriate sections of the Official Guidelines.
Step #5: Determine the correct diagnosis code or codes to explain why this encounter was medically necessary.
Step #6: Double-check your work.
Answer:
Did you determine the correct codes?
I48.0 Paroxysmal atrial fibrillation
J30.1 Allergic rhinitis, due to pollen (hayfever)
Z79.01 Long-term (current) use of anticoagulants
The code for the atrial fibrillation supports the office visit and exam, the code for long-term use of the Coumadin
(an anticoagulant) justifies the blood test, and the code for the allergic rhinitis supports the medical necessity for
the trinalin prescription.

Placeholder Character
There are times when a fifth, sixth, or seventh character is required, yet there are no
fourth, fifth, or sixth characters. In these cases, ICD-10-CM uses a placeholder char-
GUIDANCE acter, the letter “x,” so the following characters will fall into their correct locations.
CONNECTION The symbols in the Tabular List will lead you to filling out your code accurately. Just
pay attention to each character as well as in what position each character belongs. Let’s
Read the ICD-10-CM look at   as an example. This symbol tells you that you will need to add a place-
Official Guidelines for holder x in the fifth position and a placeholder x in the sixth position before determin-
Coding and Report- ing which of the seventh character options to place at the end of the code.
ing, section I. Conven-
tions, General Coding
EXAMPLES
Guidelines and Chapter
Specific Guidelines, sub- S02.611A Fracture of condylar process of right mandible, initial encounter
section A. Conventions T47.2x2D Poisoning by stimulant laxatives, intentional self-harm, subsequent
for the ICD-10-CM, para- encounter
graph 4. Placeholder W89.1xxS Exposure to tanning bed, sequela
character.
W85.xxxA Exposure to electric transmission lines, initial encounter
As you can see, all of these codes require a seventh character, yet the initial
codes were shorter. These codes are examples of how the placeholder character
GUIDANCE “x” is used so that all of the characters fall into their proper placement.
CONNECTION
Seventh Character
Read the ICD-10-CM
Official Guidelines for
Some ICD-10-CM codes require a seventh character. Different subsections of the code
Coding and Report-
book use this position—the seventh character—to add varying types of information.
ing, section I. Con-
Most often, the character choices are listed at the top of the code category to be used
ventions, General
for all codes within that category. With this in mind, you must always begin reading at
Coding Guidelines
the top of the code category or subsection for this information.
and Chapter Specific
The Tabular List contains all the details you need. All you have to do is read the
Guidelines, subsection
options and determine which is the most accurate, as per the physician’s documentation.
A. Conventions for the
Section I.C. Chapter-Specific Coding Guidelines
ICD-10-CM, paragraph
5. 7th Characters. This subsection of the Official Guidelines is further divided and sorted by the chap-
ters in the Tabular List. The process of determining the code or codes for a specific

70   PART II  |  REPORTING DIAGNOSES

encounter will lead you to various places throughout the ICD-10-CM code set. It is
important to always reference these chapter-specific official guidelines to ensure you CODING BITES
are considering all of the facets of this complex job before you report a code on an Inpatient coding calls
assessment in class or on a claim form or report when you are on the job. the most serious diag-
nosis code, the code
Section II. Selection of Principal Diagnosis and Section III. that is reported first, as
Reporting Additional Diagnoses the principal diagnosis
code.
Earlier in this chapter, you learned about reporting multiple diagnosis codes and about
Outpatient coding
the basics of sequencing codes. It might seem straightforward right now, but there
calls the most serious
are times when sequencing and reporting multiple codes become more complicated.
diagnosis code the first-
Determining the sequencing of the diagnosis codes reported is very important, so you
listed diagnosis code.
want to get it right every time. With the Official Guidelines readily available for you to
reference while you are coding, you can report codes with confidence.

Section IV. Diagnostic Coding and Reporting Guidelines for Principal Diagnosis
The condition, after study, that
Outpatient Services is the primary, or main, reason
This section of the Official Guidelines covers specific differences when reporting for for the admission of a patient
to the hospital for care; the
an outpatient service, including a hospital emergency department, same-day surgical
condition that requires the
center, walk-in clinic, or physician’s office. largest amount of hospital
Essentially, the guidelines for inpatient and outpatient coding are the same or simi- resources for care.
lar when it comes to reporting the reasons why a patient needs care except for one main
difference—unconfirmed diagnoses. First-Listed
“First-listed diagnosis” is used,
Unconfirmed Diagnoses when reporting outpatient
encounters, instead of the
The Official Guidelines are different for reporting unconfirmed diagnoses for patients
term “principal diagnosis.”
who are treated as outpatient versus inpatient.
Outpatient
Outpatient Services An outpatient is a patient who
The guideline Section IV.H, Uncertain diagnosis states that you are to use the code receives services for a short
or codes that identify the condition to its highest level of certainty. This means that amount of time (less than 24
you code only what you know for a fact. You are not permitted to assign an ICD- hours) in a physician’s office
or clinic, without being kept
10-CM diagnosis code for a condition that is described by the provider as probable,
overnight. An outpatient
suspected, possible, questionable, or to be ruled out. If the health care professional facility includes a hospital
has not been able to confirm a diagnosis, then you must code the signs, symptoms, emergency room, ambulatory
abnormal test results, or other element stated as the reason for the visit or service. care center, same-day surgery
center, or walk-in clinic.
EXAMPLE
Ellyn Cragen, a 27-year-old female, came to see Dr. Jenisha in his office because
of nausea and absence of her period for 2 months. After doing a thorough exami- GUIDANCE
nation, Dr. Jenisha suspects that Ellyn may be pregnant, so he orders a blood test. CONNECTION
If the blood test comes back positive to confirm her pregnancy (after the physician
documents it in the file), you would use the following code: Read the ICD-10-CM
Official Guidelines for
Z32.01 Encounter for pregnancy test, result positive Coding and Reporting,
If the blood test comes back negative, this confirms that Ellyn is not pregnant. section IV. Diagnostic
Therefore, you would need to report what you know to be true: Coding and Report-
ing Guidelines for
N91.2 Amenorrhea, unspecified Outpatient Services,
R11.0 Nausea paragraph H. Uncertain
Z32.02 Encounter for pregnancy test, results negative Diagnosis.

Inpatient Services
The rules for coding uncertain diagnoses for patients of an inpatient facility are dif-
ferent from those for outpatients. As directed by the guideline Section II.H, Uncertain
Inpatient Facility diagnosis, if the diagnosis is described as probable, possible, suspected, likely, or still
An establishment that pro- to be ruled out at the time of discharge, you must code that condition as if it existed.
vides health care services to This directive applies only when you are coding services provided in a short-term,
individuals who stay overnight acute, long-term care, or psychiatric hospital or facility. It is one of the few circum-
on the premises.
stances in which you will find the guidelines differ between coding for outpatient and
inpatient services.

ICD-10-CM
YOU CODE IT! CASE STUDY
Howard Tamar, a 61-year-old male, was admitted to the hospital for observation after he complained of having
severe chest pain radiating to his left shoulder and down his left arm. After 24 hours in the telemetry unit, Dr. Norwalk
discharged him with a diagnosis of suspected variant angina pectoris.

You Code It!

As the hospital’s coder, go through the steps of coding and determine the diagnosis code or codes that should
be reported for this encounter between Dr. Norwalk and Howard Tamar.
Step #1: Read the case carefully and completely.
Step #2: Abstract the scenario. Which main words or terms describe why the physician cared for the patient dur-
ing this encounter?
Step #3: Are there any details missing or incomplete for which you would need to query the physician? [If so, ask
your instructor.]
Step #4: Check for any relevant guidance, including reading all of the symbols and notations in the Tabular List
and the appropriate sections of the Official Guidelines.
Step #5: Determine the correct diagnosis code or codes to explain why this encounter was medically necessary.
Step #6: Double-check your work.
Answer:
Did you determine this to be the code?
I20.1   Angina pectoris with documented spasm (variant angina)
Good job!

Appendix I. Present-On-Admission Reporting Guidelines

You will learn more about Present-On-Admission (POA) indicators in the chapter
Inpatient (Hospital) Diagnosis Coding. These indicators are only used for report-
ing diagnoses for patients treated in a hospital as an inpatient. The Appendix
I rules about how to use POA indicators will come in very handy later in your
GUIDANCE learning.
CONNECTION
Read the ICD-10-CM 4.3  The Alphabetic Index and Ancillaries 
Official Guidelines for
Coding and Reporting, In the Abstracting Clinical Documentation chapter, you learned how to identify the
section II. Selection of diagnosis-related main words abstracted from the physician’s notes (the terms that
Principal Diagnosis, explain why the physician needed to care for the patient during the encounter). Let’s
paragraph H. Uncertain practice looking for the main term or terms in the Alphabetic Index of your ICD-
Diagnosis. 10-CM code book [also titled ICD-10-CM Index to Diseases and Injuries] (see Figure
4-3), as well as the ancillary sections of the code set.

72   PART II  |  REPORTING DIAGNOSES

 A
Aarskog’s syndrome Q87.1
Abandonment—see Maltreatment
Abasia (-astasia) (hysterical) F44.4
Abderhalden-Kaufmann-Lignac syndrome (cystinosis) E72.04
Abdomen, abdominal—see also condition
- acute R10.0
- angina K55.1
- muscle deficiency syndrome Q79.4
Abdominalgia—see Pain, abdominal
Abduction contracture, hip or other joint—see Contraction, joint

FIGURE 4-3  Example from ICD-10-CM Alphabetic Index: Main terms Aarskog’s
syndrome through Abduction contracture, hip or other joint  Source: ICD-10-CM Official
Guidelines for Coding and Reporting The Centers for Medicare and Medicaid Services (CMS) and the National Center
for Health Statistics (NCHS)

Index to Diseases and Injuries (aka Alphabetic Index)

Index to Diseases and Injuries, most often referred to as the Alphabetic Index, is the Alphabetic Index
part of the code book that lists all of the diagnoses and other reasons to provide health The section of a code book
care by their main word or term, alphabetically from A to Z. showing all codes, from
You will use the Alphabetic Index to guide you to the correct page or area in the A to Z, by the short code
Tabular List. Codes in the Alphabetic Index are only suggested codes. Often, the code descriptions.    
shown in the Index will require additional characters, will need to be coupled with Condition
another code, or will be the wrong interpretation altogether.  The state of abnormality or
Conditions are shown in the Alphabetic Index by: dysfunction.
∙ Condition (e.g., infections, fractures, and wounds) Eponym
∙ Eponyms (e.g., Epstein-Barr syndrome and Cushing’s disease) A disease or condition named
for a person.
∙ Other descriptors (e.g., history, family history)
After you abstract the documentation and open the Alphabetic Index, you will real- CODING BITES
ize that looking for a main word of a diagnosis in the Alphabetic Index may, some-
Find the condition or
times, be easy and direct, and you will be able to determine the code right away!
issue (“main term”) in
For example, suppose you read that “Dr. Gaseor diagnosed Belinda Alfonzo with
the ICD-10-CM Alpha-
Tourette’s disorder.”
betic Index.
Turning in the Alphabetic Index in your codebook, you will find (Figure 4-4):
If you cannot identify
The Alphabetic Index’s suggestion is clear: a “main term” from all
Tourette’s syndrome F95.2 the words in the diag-
There are times, however, when finding the suggested code requires a bit more nostic statement, just
work. Consider this diagnostic statement, “Dr. Mulford noted that Charlie has suffered look up all the words,
an abrasion on his chin.” Did you determine the main term to be “abrasion”? Good one at a time, in the
job! Let’s find this term in the Alphabetic Index (Figure 4-5). ICD-10-CM Alphabetic
This is not as straightforward, is it? Notice that the long list indented below the Index. You will get to
main term Abrasion (and you can see in your ICD-10-CM book that it is much longer the correct “main term”
than what is shown here) is a list, in alphabetic order, of anatomical sites: abdomen, and find the suggested
alveolar, ankle, etc. Go back to the diagnostic statement: “Dr. Mulford noted that code. Write the sug-
Charlie has suffered an abrasion on his chin.” On what anatomical site was Charlie’s gested code down on a
abrasion? His chin. Now read down the long list and find the suggested code: piece of scratch paper
and move to the next
Abrasion, chin S00.81
step.
Good work! You are really learning.
 Torture, victim of Z65.4
Torula, torular (histolytica) (infection)—see Cryptococcosis
Torulosis—see Cryptococcosis
Torus—see (mandibularis) (palatinus) M27.0
- fracture—see Fracture, by site, torus
Touraine’s syndrome Q79.8
Tourette’s syndrome F95.2
Tourniquet syndrome—see Constriction, external, by site
Tower skull Q75.0
- with exophthalmos Q87.0
Toxemia R68.89
- bacterial—see Sepsis
- burn—see Burn

FIGURE 4-4  ICD-10-CM, Alphabetic Index, partial, from Torture to Toxemia  Source:
ICD-10-CM Official Guidelines for Coding and Reporting The Centers for Medicare and Medicaid Services (CMS) and
the National Center for Health Statistics (NCHS)

Abrasion T14.8
- abdomen, abdominal (wall) S30.811
- alveolar process S00.512
- ankle S90.51-
- antecubital space—see Abrasion, elbow
- anus S30.817
- arm (upper) S40.81-
- auditory canal—see Abrasion, ear
- auricle—see Abrasion, ear
- axilla—see Abrasion, arm
- back, lower S30.810
- breast S20.11- 
- brow S00.81
- buttock S30.810
- calf—see Abrasion, leg
- canthus—see Abrasion, eyelid
- cheek S00.81
-- internal S00.512
- chest wall—see Abrasion, thorax
- chin S00.81
- clitoris S30.814
- cornea S05.0-
- costal region—see Abrasion, thorax
- dental K03.1
- digit(s)
-- foot—see Abrasion, toe
-- hand—see Abrasion, finger
- ear S00.41-
- elbow S50.31-
- epididymis S30.813
- epigastric region S30.811
- epiglottis S10.11
- esophagus (thoracic) S27.818
-- cervical S10.11
- eyebrow—see Abrasion, eyelid
(continued)

74   PART II  |  REPORTING DIAGNOSES

 - eyelid S00.21-
- face S00.81
- finger(s) S60.41-
-- index S60.41-
-- little S60.41-
-- middle S60.41-
-- ring S60.41-
- flank S30.811
- foot (except toe(s) alone) S90.81-
-- toe—see Abrasion, toe
- forearm S50.81-
-- elbow only—see Abrasion, elbow
- forehead S00.81

FIGURE 4-5  ICD-10-CM Alphabetic Index, partial, from Abrasion to Abrasion, fore-
head  Source: ICD-10-CM Official Guidelines for Coding and Reporting The Centers for Medicare and Medicaid
Services (CMS) and the National Center for Health Statistics (NCHS)

It is important for you to remember that the ICD-10-CM code book has informa-
tion that can really help you do your job well. Consider Dr. Johnson, a pediatrician,
caring for Melinda, who has a problem with her right eye. Dr. Johnson documents
that Melinda has “pink eye.” Pink eye is not actually a medical term. It is a common
term. But this is all you have to go on, so let’s take a chance with this in the Alphabetic
Index. Eye is an anatomical site, so you know that having an eye is not a reason to see
the physician. Look for the term “pink” and find, not a suggested code, but a reference
(see Figure 4-6).
The ICD-10-CM Alphabetic Index actually tells you the medical term for “pink
eye” and that you need to look this up using this term. Turn in the Alphabetic Index to
find the main term, Conjunctivitis (see Figure 4-7).
Similar to the situation with Abrasion, you see a long list indented beneath
this main term, meanin, you need more details from the documentation, or in this
case, the previous Alphabetic Index notation. Check back to what you read when
you looked at  Pink, eye—see Conjunctivitis, acute, mucopurulent. Now, read the
indented list beneath Conjunctivitis carefully and find  acute. Then, indented
beneath that, find:
Conjunctivitis, acute, mucopurulent H10.02-
You may find that a medical dictionary can also help you find synonyms for terms
used in the physician documentation that does not match an item in the Alphabetic
Index. Build the habit to use all of your resources to help you determine the accurate
code.

Pinhole meatus (see also Stricture, urethra) N35.9

Pink
- disease—see subcategory T56.1
- eye—see Conjunctivitis, acute, mucopurulent
Pinkus’ disease (lichen nitidus) L44.1

FIGURE 4-6  ICD-10-CM Alphabetic Index, partial, from Pinhole meatus through
Pinkus’ disease  Source: ICD-10-CM Official Guidelines for Coding and Reporting The Centers for Medicare
and Medicaid Services (CMS) and the National Center for Health Statistics (NCHS)
 CODING BITES Conjunctiva—see condition
Never, never, never Conjunctivitis (staphylococcal) (streptococcal) NOS H10.9
code only from the - Acanthamoeba B60.12
Alphabetic Index. You - acute H10.3-
are required to check -- atopic H10.1-
every code in the Tabu- -- chemical (see also Corrosion, cornea) H10.21-
lar List. Only then can -- mucopurulent H10.02-
you read the entire --- follicular H10.01-
code description and all -- pseudomembranous H10.22-
notations to determine -- serous except viral H10.23-
the most accurate code. --- viral—see Conjunctivitis, viral
-- toxic H10.21-
- adenoviral (acute) (follicular) B30.1
- allergic (acute)—see Conjunctivitis, acute, atopic
-- chronic H10.45
--- vernal H10.44
- anaphalactic—see Conjunctivitis, acute, atopic
- Apollo B30.3
- atopic (acute)—see Conjunctivitis, acute, atopic
CODING BITES - Béal’s B30.2
Neoplasm Table: A - blennorrhagic (gonococcal) (neonatorum) A54.31
table that lists the - chemical (acute) (see also Corrosion, cornea) H10.21-
suggested codes for
benign and malignant FIGURE 4-7  ICD-10-CM Alphabetic Index, partial, Conjuctiva to Conjunctivitis,
neoplasms (tumors). chemical  Source: ICD-10-CM Official Guidelines for Coding and Reporting The Centers for Medicare and Medic-
The list is organized in aid Services (CMS) and the National Center for Health Statistics (NCHS)
alphabetic order by the
anatomical location of
the neoplasm.
Neoplasm Table
Neoplasm Table The Neoplasm Table is a breakout section of the Alphabetic Index, listing the sug-
The Neoplasm Table lists all gested codes for benign and malignant neoplasms. These pages are set up as a seven
possible codes for benign (7) column table (Figure 4-8) organized by the information in column 1—the ana-
and malignant neoplasms, in tomical location of the tumor, in alphabetic order. Moving to the right, the following
alphabetic order by anatomi- six columns show the suggested code in the following order:
cal location of the tumor.
Malignant, Primary
Malignant, Secondary

Malignant Malignant Uncertain Unspecified

Primary Secondary Ca in situ Benign Behavior Behavior
Neoplasm, neoplastic C80.1 C79.9 D09.9 D36.9 D48.9 D49.9
- abdomen, abdominal C76.2 C79.8- D09.8 D36.7 D48.7 D49.89
-- cavity C76.2 C79.8- D09.8 D36.7 D48.7 D49.89
-- organ C76.2 C79.8- D09.8 D36.7 D48.7 D49.89
-- viscera C76.2 C79.8- D09.8 D36.7 D48.7 D49.89
-- wall—see also Neoplasm, abdomen, C44.509 C79.2- D04.5 D23.5 D48.5 D49.2
wall, skin

FIGURE 4-8  Excerpt from the Neoplasm Table, partial listing for Abdominal neo-
plasm  Source: ICD-10-CM Official Guidelines for Coding and Reporting The Centers for Medicare and Medicaid
Services (CMS) and the National Center for Health Statistics (NCHS)

76   PART II  |  REPORTING DIAGNOSES

 Ca in situ
Benign
Uncertain Behavior
Unspecified Behavior
As you have learned, there are many different variations of diseases, especially neo-
plasms. When the documentation uses one of these alternate terms, you can still look
up the main term used by the physician, and, again, the ICD-10-CM Alphabetic Index
will help you find your way in the code book.
Adenosarcoma—see Neoplasm, malignant, by site
You will learn more about this Table in the chapter on Coding Neoplasms.

Table of Drugs and Chemicals

Similar to the Neoplasm Table, the seven (7) columns in the Table of Drugs and Table of Drugs and
Chemicals section (see Figure 4-9) provide suggested codes related to the cause of a Chemicals
patient being poisoned or of having an adverse reaction to a medication. This table’s The section of the ICD-10-CM
first column shows a list of most drugs and chemicals with which a patient might inter- code book listing drugs,
act, listed in alphabetic order. The six columns that follow, to the right, are: chemicals, and other bio-
logicals that may poison a
Poisoning, Accidental (unintentional) patient or result in an adverse
Poisoning, Intentional Self-Harm reaction.

Poisoning, Assault
Poisoning, Undetermined CODING BITES
Adverse Effect Table of Drugs and
Chemicals : A table that
Underdosing lists pharmaceuticals
Later in this book, the chapter titled Coding Injury, Poisoning, and External Causes and chemicals that may
will provide you with full explanations for using this table. cause poisoning or
adverse effects in the
Index to External Causes human body. 
To make it easier to determine the correct code or codes to report how the patient
became injured or poisoned, and where the patient was (Place of Occurrence) when Adverse Effect
An unexpected bad reaction
to a drug or other treatment.

Poisoning, Poisoning, Poisoning,

Accidental Intentional Poisoning, Undeter- Adverse Under-
Substance (unintentional) Self-Harm Assault mined Effect dosing
Acetomorphine T40.1X1 T40.1X2 T40.1X3 T40.1X4 — —
Acetone (oils) T52.4X1 T52.4X2 T52.4X3 T52.4X4 — —
- chlorinated T52.4X1 T52.4X2 T52.4X3 T52.4X4 — —
- vapor T52.4X1 T52.4X2 T52.4X3 T52.4X4 — —
Acetonitrile T52.8X1 T52.8X2 T52.8X3 T52.4X4 — —
Acetophenazine T43.3X1 T43.3X2 T43.3X3 T43.3X4 T43.3X5 T43.3X6
Acetophenetedin T39.1X1 T39.1X2 T39.1X3 T39.1X4 T39.1X5 T39.1X6
Acetophenone T52.4X1 T52.4X2 T52.4X3 T52.4X4 — —
Acetorphine T40.2X1 T40.2X2 T40.2X3 T40.2X4 — —
Acetosulfone (sodium) T37.1X1 T37.1X2 T37.1X3 T37.1X4 T37.1X5 T37.1X6

FIGURE 4-9  Excerpt from Table of Drugs and Chemicals, Acetomorphine through
Acetosulfone (sodium).  Source: ICD-10-CM Official Guidelines for Coding and Reporting The Centers for
Medicare and Medicaid Services (CMS) and the National Center for Health Statistics (NCHS)
 Fall, falling (accidental) W19
- building W20.1
-- burning (uncontrolled fire) X00.3
- down
-- embankment W17.81
-- escalator W10.0
-- hill W17.81
-- ladder W11
-- ramp W10.2
-- stairs, steps W10.9
- due to
– bumping against
CODING BITES --- object W18.00
Index to External ---- sharp glass W18.02
Causes : The alphabetic ---- specified NEC W18.09
list with short descrip- ---- sports equipment W18.01
tions of the external
causes of injury and
FIGURE 4-10  An excerpt from the Index to External Causes, main term Fall  Source:
poisoning. ICD-10-CM Official Guidelines for Coding and Reporting The Centers for Medicare and Medicaid Services (CMS) and
the National Center for Health Statistics (NCHS)

Index to External Causes the injury or poisoning occurred, you can use the Index  to External Causes (see
The alphabetic listing of the Figure 4-10) to find a suggested code for the main terms you abstract from the physi-
external causes that might cian’s documentation.
cause a patient’s injury, poi- Later in this book, the chapter titled Coding Injury, Poisoning, and External Causes
soning, or adverse reaction. 
will provide you with full explanations for using this index.
External Cause
An event, outside the body,
that causes injury, poisoning, 4.4  The Tabular List
or an adverse reaction.
Once you have a suggested code from the Alphabetic Index, Neoplasm Table, Table of
Drugs and Chemicals, and/or the Index to External Cause Codes, you will need to find
Tabular List of Diseases and that code in the Tabular List  of Diseases and Injuries. Remember, you may never
Injuries report a code directly from the Alphabetic Index without checking it in the Tabular List.
The section of the ICD-10-CM This suggested code will point you to a section or subsection inside a chapter of the
code book listing all of the Tabular List (see Table 4-1 for a list of the Tabular List chapters). 
codes in alphanumeric order.     Beginning at the top of each chapter and subchapter, you will need to carefully read
all associated code descriptions. This part of the process helps you ensure that you
determine the most accurate code to the highest level of specificity:
∙ Matching the details in the physician’s documentation
∙ Regarding only one particular encounter 
∙ In compliance with the rules and guidelines
The Tabular List section of the ICD-10-CM book lists every code and its complete
description in alphanumeric order by code. Starting at A00, the codes go all the way through
to Z99.89 (see Figure 4-11). Let’s investigate the various components of this section.

Tabular List Chapter Heads

Many of the 21 chapters within the Tabular List start out with valuable information that
will support your determination of the accurate code to report. For example, Chapter 1
(Figure 4-12) begins with several instructions that will affect your code decisions. As
you practice your coding process, be certain to include checking the very beginning of
the chapter so you can benefit from these important notations. 

78   PART II  |  REPORTING DIAGNOSES

TABLE 4-1  Chapters in ICD-10-CM Tabular List

Chapter Code Range Title

 1 A00–B99 Certain Infectious and Parasitic Diseases
 2 C00–D49 Neoplasms
 3 D50–D89 Diseases of the Blood and Blood-forming Organs and Certain Disorders Involving the Immune
Mechanism
 4 E00–E89 Endocrine, Nutritional, and Metabolic Diseases
 5 F01–F99 Mental, Behavioral, and Neurodevelopmental Disorders
 6 G00–G99 Diseases of the Nervous System
 7 H00–H59 Diseases of the Eye and Adnexa
 8 H60–H95 Diseases of the Ear and Mastoid Process
 9 I00–I99 Diseases of the Circulatory System
10 J00–J99 Diseases of the Respiratory System
11 K00–K95 Diseases of the Digestive System
12 L00–L99 Diseases of the Skin and Subcutaneous Tissue
13 M00–M99 Diseases of the Musculoskeletal System and Connective Tissue
14 N00–N99 Diseases of the Genitourinary System
15 O00–O9A Pregnancy, Childbirth, and the Puerperium
16 P00–P96 Certain Conditions Originating in the Perinatal Period
17 Q00–Q99 Congenital Malformations, Deformations, and Chromosomal Abnormalities
18 R00–R99 Symptoms, Signs, and Abnormal Clinical and Laboratory Findings, Not Elsewhere Classified
19 S00–T88 Injury, Poisoning, and Certain Other Consequences of External Causes
20 V00–Y99 External Causes of Morbidity
21 Z00–Z99 Factors Influencing Health Status and Contact with Health Services

Source: ICD-10-CM Official Guidelines for Coding and Reporting The Centers for Medicare and Medicaid Services
(CMS) and the National Center for Health Statistics (NCHS)

CODING BITES
The Alphabetic Index will suggest a possible diagnosis code. Then you must find
the code suggested by the Alphabetic Index in the Tabular List. This step is not
a suggestion—it is mandatory. The Tabular List provides more detail in the code
description as well as additional notations such as includes and excludes notes and
directives for the requirement of additional characters and codes. NEVER, NEVER,
NEVER code from the Alphabetic Index.

CODING BITES
Different publishers do things differently. So, your specific version of the ICD-
10-CM code book may provide you with the meanings of the symbols in other
ways, and other places. Be certain to spend a few minutes becoming familiar
with YOUR code book and where things are placed. Inserting tabs on specific
pages may help you find quick access to the details you need when you need
them.
 B68 Taeniasis
  cysticercosis (B69.-)
  B68.0 Taenia solium taeniasis
   Pork tapeworm (infection)
  B68.1 Taenia saginata taeniasis
   Beef tapework (infection)
   Infection due to adult tapeworm Taenia saginata
  B68.9 Taeniasis, unspecified
B69 Cysticercosis
  cysticerciasis infection due to larval form of Taenia solium
  B69.0 Cysticercosis of central nervous system
  B69.1 Cysticercosis of eye
  B69.8 Cysticercosis of other sites
   B69.81 Myositis in cysticercosis
   B69.89 Cysticercosis of other sites
  B69.9 Cysticercosis, unspecified
B70 Diphyllobithriasis and sparganosis
  B70.0 Diphyllobothriasis
   Diphyllobothrium (adult) (latum) (pacificum) infection
   Fish tapeworm (infection)
  larval diphyllobothriasis (B70.1)
B70.1 Sparganosis

FIGURE 4-11  Example of a page from ICD-10-CM Tabular List: code categories
B67 through B70  Source: ICD-10-CM Official Guidelines for Coding and Reporting The Centers for Medicare
and Medicaid Services (CMS) and the National Center for Health Statistics (NCHS)

Chapter 1
Certain infectious and parasitic diseases (A00-B99)
 diseases generally recognized as communicable or transmissible
Use additional code to identify resistance to antimicrobial drugs (Z16.-)
certain localized infections—see body system-related chapters
carrier or suspected carrier of infectious disease (Z22.-)
infectious and parasitic diseases complicating pregnancy, childbirth,
and the puerperium (O98.-)
infectious and parasitic diseases specific to the perinatal period
(P35-P39)
influenza and other acute respiratory infections (J00-J22)

FIGURE 4-12  ICD-10-CM Tabular List, chapter 1 opening notations  Source: ICD-10-CM

Official Guidelines for Coding and Reporting The Centers for Medicare and Medicaid Services (CMS) and the National
Center for Health Statistics (NCHS)

The Legends
Across the bottom of every page throughout the Tabular List you will find short expla-
nations for many of the symbols you will see among the codes and their descriptions.
These legends are an abbreviation of the more complete explanations of each symbol
in the front of your code book, found on the pages titled  Overview of ICD-10-CM
Official Conventions and Additional Conventions. Once you become familiar with

80   PART II  |  REPORTING DIAGNOSES

each symbol and notation, the legends will provide you with a quick reference to con-
firm you are making the correct interpretation.

Using the Tabular List

Earlier in this chapter, in 4.3 The Alphabetic Index and Ancillaries , you learned to
use the Alphabetic Index to find suggested codes that matched diagnostic statements.
Let’s take each of these to the next step . . . confirming the code in the Tabular List.

Case #1 Tourette’s Disorder

The first scenario you worked with in the previous section The Alphabetic Index and
Ancillaries was “Dr. Gaseor diagnosed Belinda Alfonzo with Tourette’s disorder.”
And you found code F95.2 suggested by the Alphabetic Index. In your ICD-10-CM
code book, turn to code category F95 in the Tabular List.
F95 Tic disorder
F95.0 Transient tic disorder       
  Provisional tic disorder
F95.1 Chronic motor or vocal tic disorder
F95.2 Tourette’s disorder     
  Combined vocal and multiple motor tic disorder [de la Tourette]     
  Tourette’s syndrome
F95.8 Other tic disorders
F95.9 Tic disorder, unspecified       
  Tic NOS
It appears that, at this point, F95.2 is the correct code to report this diagnosis. You
are not done yet. Now, backtrack to the subchapter header to see if there are any
notations that may apply to this case. [HINT: It is directly above code F90. See
Figure 4-13.]
This is good information but has no impact to this specific encounter. Next, back-
track to the very beginning of this ICD-10-CM chapter 5 (see Figure 4-14) to check for
any notations that you need to apply in reporting Belinda’s diagnosis.

Behavioral and emotional disorders with onset usually occurring in childhood

and adolescence (F90-F98)
Note: Codes within categories F90-F98 may be used regardless of the age
of a patient. These disorders generally have onset within the childhood and
adolescent years, but may continue throughout life or not be diagnosed until
adulthood.

FIGURE 4-13  Example of a subchapter section note, from above code F90  Source:
ICD-10-CM Official Guidelines for Coding and Reporting The Centers for Medicare and Medicaid Services (CMS) and
the National Center for Health Statistics (NCHS)

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

 disorders of psychological development
symptoms, signs, and abnormal clinical laboratory findings, not classi-
fied elsewhere (R00-R99)

FIGURE 4-14  Chapter opening notations, example from chapter 5  Source: ICD-10-CM
Official Guidelines for Coding and Reporting The Centers for Medicare and Medicaid Services (CMS) and the National
Center for Health Statistics (NCHS)
 Again, good information, but none of these notations related to reporting Belinda’s
diagnosis. One more step to take—check the ICD-10-CM Official Guidelines for
Coding and Reporting, Section 1.c.5. Mental, Behavioral, and Neurodevelopmen-
tal Disorders (F01-F99). Read all of the guidelines in this section to see if there is any
guidance you need to properly report code F95.2. No? Great.
Now . . . you can report code F95.2 with confidence that it is accurate and correct to
report why Dr. Gaseor cared for Belinda during this encounter. Good work!

Case #2 Abrasion
Let’s look at the second case we covered in the section The Alphabetic Index and Ancil-
laries, “Dr. Mulford noted that Charlie has suffered an abrasion on his chin.” And
you found code Abrasion, chin S00.81. Turn in your ICD-10-CM Tabular List to the
code category:
S00 Superficial injury of head
 diffuse cerebral contusion (S06.2-)
focal cerebral contusion (S06.3-)
injury of eye and orbit (S05.-)
open wound of head (S01.-)
The appropriate 7th is to be added to each code from category S00.
A Initial encounter
D Subsequent encounter
S Sequela
None of these diagnoses in the notation relate to Charlie’s case; however, it
is a good thing you started reading here because there is a box containing the available
seventh characters for you to use in this code category.
Read down through all of the available fourth characters in this code category to
ensure you don’t find something more accurate than that suggested by the Alphabetic
Index:
S00.0 Superficial injury of scalp
S00.1 Contusion of eyelid and periocular area
S00.2 Other and unspecified superficial injuries of eyelid and periocular area
S00.3 Superficial injury of nose
S00.4 Superficial injury of ear
S00.5 Superficial injury of lip and oral cavity
S00.8 Superficial injury of other parts of the head
S00.9 Superficial injury of unspecified part of head
It looks like the Alphabetic Index was sending us in the right direction. S00.8 is the
best option. A fifth character is needed. Read all of the options carefully. Did you
determine this?
S00.81 Abrasion of other part of head
You see how different this code description is from what you read in the Alphabetic
Index? This is one reason why it is important to use both the Alphabetic Index and the
Tabular List. Each has its own details to share. Good. However, one thing the Alpha-
betic Index didn’t let you know is that this code must have a seventh character. Turn
back to that box at the beginning of this subsection. Which is the correct character to
report for Charlie’s encounter with Dr. Mulford for care related to his abrasion?
The appropriate 7th is to be added to each code from category S00.
A Initial encounter
D Subsequent encounter
S Sequela

82   PART II  |  REPORTING DIAGNOSES

 Chapter 19. Injury, Poisoning and Certain Other Consequences of External
Causes (S00-T88)
Note: Use secondary code(s) from Chapter 20, External causes of morbidity, to
indicate cause of injury. Codes within the T section that include the external cause
do not require an additional external cause code.
Use additional code to identify any retained foreign body, if applicable (Z18.-)
birth trauma (P10-P15)
obstetric trauma (O70-O71)
Note: The chapter uses the S-section for coding different types of injuries related
to single body regions and the T-section to cover injuries to unspecified body
regions as well as poisoning and certain other consequences of external causes.

FIGURE 4-15  ICD-10-Tabular List, chapter 19 opening notations  Source: ICD-10-CM

Official Guidelines for Coding and Reporting The Centers for Medicare and Medicaid Services (CMS) and the National
Center for Health Statistics (NCHS)

Did you abstract from the scenario that this was the first encounter? And you
noticed that you will need to insert a placeholder letter x after the fifth character, so
that the seventh character A lands in the correct spot.
S00.81xA Abrasion of other part of head, initial encounter
Look back to the beginning of this ICD-10-CM chapter to check for any notations
that you might need to consider before you report this code (see Figure 4-15).
This is important information, but none of it relates to Charlie’s abrasion.
One more step, check the ICD-10-CM Official Guidelines for Coding and
Reporting, Section 1.c.19. Injury, Poisoning, and Certain Other Consequences of
External Causes (S00-T88). Read all of the guidelines in this section to see if there
is any guidance you need to properly report code S00.81xA. No? Great. Good work!

Case #3 Pink Eye (Conjunctivitis)

Our third scenario in the section The Alphabetic Index and Ancillaries was from Dr.
Johnson’s care for Melinda’s pink eye. You used the Alphabetic Index properly to lead
you to the suggested code:
Conjunctivitis, acute, mucopurulent H10.02-
In this case, the Alphabetic Index did notify you that an additional character is required
by including the hyphen after the first five characters. In your ICD-10-CM’s Tabular
List, find the code category
H10 Conjunctivitis
keratoconjunctivitis (H16.2-)
This is a match for the alternate term provided by the Alphabetic Index, and
the notation is not related to Melinda’s case, so continue reading down to investigate
the fourth character options. Did you determine which one matches best?
H10.0 Mucopurulent conjunctivitis
You are making good progress! A fifth character is required, so read carefully and
determine which you should use:
H10.02 Other mucopurulent conjunctivitis
This is the best because there was nothing about the pink eye diagnosis that stated it
could be acute follicular conjunctivitis.
As you read the options for the sixth character, you should notice that you need a new
piece of information . . . which eye was diagnosed? Right? Left? Or both (bilateral)?
 Chapter 7. Diseases of the Eye and Adnexa (H00-H59)
Note: Use an external cause code following the code for the eye condition, if
applicable, to identify the cause of the eye condition
  certain conditions originating in the perinatal period (P04-P96)
  certain infectious and parasitic diseases (A00-B99)
  complications of pregnancy, childbirth, and puerperium (O00-O9A)
 congenital malformations, deformations, and chromosomal
  abnormalities (Q00-Q99)
 diabetes mellitus related eye conditions (E09.3-, E10.3-, E11.3-,
  E13.3-)
  endocrine, nutritional and metabolic diseases (E00-E88)
  injury (trauma) of eye and orbit (S05.-)
 injury, poisoning, and certain consequences of external causes
  (S00-T88)
  neoplasms (C00-D49)
 symptoms, signs and abnormal clinical and laboratory findings, not
  elsewhere classified (R00-R94)
  syphilis related eye disorders (A50.01, A50.3-, A51.43, A53.71)

FIGURE 4-16  Tabular List, chapter 7, Diseases of the Eye and Adnexa, opening
notations  Source: ICD-10-CM Official Guidelines for Coding and Reporting The Centers for Medicare and Medic-
aid Services (CMS) and the National Center for Health Statistics (NCHS)

Go back to the documentation and read: “Dr. Johnson . . . caring for Melinda, who has
a problem with her right eye.”
H10.021 Other mucopurulent conjunctivitis, right eye
Good work! Check the beginning of the subsection. There are no notations at all. Now,
check the very beginning of this ICD-10-CM chapter (see Figure 4-16).
A lot of good information here, yet it is not related to Melinda’s diagnosis, so you
have only one more place to check: the ICD-10-CM Official Guidelines for Coding
and Reporting, Section 1.c.7. Diseases of the Eye and Adnexa (H00-H59). Read
GUIDANCE all of the guidelines in this section to see if there is any guidance you need to properly
CONNECTION report code H10.021. No? Great. You can now report H10.021 Other mucopurulent
conjunctivitis, right eye with confidence.
Read the ICD-10-CM
Official Guidelines for
Coding and Reporting,
section I. Conven-
4.5  Which Conditions to Code
tions, General Coding As you abstract the provider’s notes, you are looking for the information that will
Guidelines and Chapter direct you to those codes that explain or describe the answer to the question, “Why did
Specific Guidelines, this health care provider care for and treat this individual during this encounter?” That
subsection B. General is it. The codes do not report the individual’s complete medical history.
coding guidelines, spe-
cifically subsections Unrelated Conditions
4. Signs and symptoms,
5. Conditions that are The attending physician may include information in his or her documentation that
an integral part of a reports a condition or diagnosis that is unrelated to this encounter. Remember that
disease process, and the physician does not write the notes just for you to code from. The notes have other,
6. Conditions that are important purposes, such as documenting past history. You must learn to distinguish
not an integral part of a among notations. You will code only those diagnoses, signs, and/or symptoms related
disease process. to procedures, services, treatments, and/or medical decision making occurring dur-
ing this visit. ICD-10-CM guidelines specifically direct you to omit (do not code) any

84   PART II  |  REPORTING DIAGNOSES

diagnoses or conditions from a patient’s history that have no impact on the current
treatment or service. So, you will have to read carefully.
Keep in mind, in some situations, the attention to a condition may be subtle. For
example, the physician may renew a previous prescription for a chronic condition. You
will need to report that condition to support the writing of the prescription, even if it is
not the principal reason the patient is being cared for at this encounter. Systemic Condition
A condition that affects the
Systemic Conditions entire body and virtually all
body systems, therefore
If a patient has a systemic condition, this means that this condition affects the entire requiring the physician to con-
body, for example, diabetes mellitus, hypertension, or pregnancy. The physician, sider this in his or her medical
therefore, must take this into consideration in the medical decision making for virtu- decision making for any other
ally any other condition. condition.

ICD-10-CM
LET’S CODE IT! SCENARIO
MaeBelle Abernathy, a 29-year-old female, came to see Dr. Cypher complaining of severe pain in her shoulder. She
stated that she was working in the garden and a loose branch fell out of her magnolia tree onto her left shoulder.
MaeBelle is 15 weeks pregnant. Normally, Dr. Cypher would have sent MaeBelle for an x-ray. However, because
she is pregnant, he decided to examine her, diagnosed her with a sprained corahumeral shoulder, and strapped her
shoulder and arm. He also double-checked the pain medication he prescribed to ensure that it was safe for preg-
nant women.

Let’s Code It!

Dr. Cypher diagnosed MaeBelle with a sprained shoulder. Turn to the Alphabetic Index and look up sprain,
shoulder.
Sprain, shoulder joint S43.40-
In the Tabular List, begin reading at code category S43 and read the and notes carefully.
There is nothing here that relates to this patient, so continue reading.
S43 Dislocation and sprain of joints and ligaments of shoulder girdle
You can see that you need additional characters, so continue reading down the column. Match the terms to the
physician’s notes. The fact is that Dr. Cypher did not provide any further specifics, so the most accurate code is:
S43.412A Sprain of left corahumeral (ligament), initial encounter
This is the only diagnosis confirmed by Dr. Cypher at this encounter. However, the notes clearly indicate that
MaeBelle’s pregnancy influenced the way the doctor treated her. Therefore, the codes need to tell that part
of the story. The code for the pregnancy must be included to accurately report this visit. The Alphabetic Index
suggests
Pregnancy incidental finding Z33.1
In the Tabular List you will find:
Z33 Pregnant state
Keep reading to review the fourth-character choices. The most accurate is
Z33.1 Pregnant state, incidental
This code explains the situation perfectly. MaeBelle is pregnant and that pregnancy was involved in the treat-
ment of her shoulder injury, but it was not the principal reason she came to see Dr. Cypher. This code means

(continued)
 that her pregnancy was a factor included in the patient’s treatment plan but not a part of the principal diagnosis.
Perfect!
Do you remember when you read the chapter Abstracting Clinical Documentation that you will need external
cause codes for this encounter between MaeBelle and Dr. Cypher because she was injured? Therefore, you
would also include three other codes:
W20.8xxA Other cause of strike by thrown, projected or falling object
Y93.H2 Activity, gardening and landscaping
Y99.8 Other external cause status (leisure activity)
[Don’t worry . . . more details about determining external cause codes are in the upcoming chapter titled Cod-
ing Injury, Poisoning, and External Causes.]
Check the top of each subsection and the head of each chapter in ICD-10-CM. There are notations at the
beginning of this chapter: an notation, a Use Additional Code note, an  notation, and an
notation. Read carefully. Do any relate to Dr. Cypher’s diagnosis of MaeBelle? No. Turn to the Official
Guidelines and read Section 1.c.19, 1.c.20, and 1.c.21. There is nothing here that will change what you have
already determined, this time.
The bottom line . . . there will be five codes to report the reasons why Dr. Cypher needed to care for MaeBelle
at this encounter:
S43.412A Sprain of left corahumeral (ligament), initial encounter
Z33.1 Pregnant state, incidental
W20.8xxA Other cause of strike by thrown, projected or falling object
Y93.H2 Activity, gardening and landscaping
Y99.8 Other external cause status (leisure activity)

In some encounters you will not report a condition, just because there was a men-
tion of it in the documentation.

ICD-10-CM
LET’S CODE IT! SCENARIO
Arthur Fleurs, a 47-year-old male, came to Dr. Davenport at the clinic because he was having a nosebleed that
wouldn’t stop. Arthur was in a single-car accident and his airbag expanded, hitting him in the nose, causing it to
bleed. He is otherwise healthy with a history of allergic asthma. Dr. Davenport examined Arthur’s nasal passages
and packed the nostrils. The doctor then told Arthur to go home and rest and return the next day for a follow-up.

Let’s Code It!

Arthur came to see Dr. Davenport because he had a nosebleed. Turn to the Alphabetic Index and look up the
diagnosis.
Nosebleed R04.0
Surprised it was that easy? Well, sometimes it is. Check the code in the Tabular List, and you will see
R04   Hemorrhage from respiratory passages
The nose is on the head, so you are in the correct category. Continue reading down the column to review your
choices for the fourth-digit:
R04.0 Epistaxis
Hemorrhage from nose; nosebleed

(continued)

86   PART II  |  REPORTING DIAGNOSES

 Yes. I guess it was easy. Is that all you need to code? The notes state that Arthur has a history of asthma.
However, it has nothing to do with the reason he came to the doctor, and it did not affect the way Dr. Davenport
treated Arthur. Therefore, you will not code it for this encounter because it had nothing to do with this visit.
Check the top of this subsection and the head of this chapter in ICD-10-CM. There is a NOTE and an
notation. Read carefully. Do any relate to Dr. Davenport’s diagnosis of Arthur? No. Turn to the Official Guidelines
and read Section 1.c.18. There is nothing specifically applicable here either.
Now you can report R04.0 with confidence.

Screenings and Other Preventive Services

When a screening test is performed (patient has no signs, symptoms, or diagnosis of
a condition), you will still need to report a code to explain the reason why Fiona had
her annual mammogram or Roger, after his 50th birthday, had a colonoscopy. Many
times, you can identify such instances because they are usually determined not by the
patient’s feelings, signs, symptoms, or other active health issue, but by the calendar.

EXAMPLES
Z00.00 Encounter for general adult medical examination without abnormal
findings 
. . . this code reports what is commonly known as an annual physical, which is
an encounter prompted by the calendar to ensure preventive measures and
early detection testing are employed to support good health.
Z02.1 Encounter for pre-employment examination
. . . some employers require a candidate to have a physical prior to being offi-
cially hired. This code is used to report this reason why the individual would
see the physician.
Z12.31 Encounter for screening mammogram for malignant neoplasm of
breast
. . . every woman over the age of 40 should be doing this annually, or every
other year, to identify the presence of a malignancy at the earliest possible
time, when treatment is less invasive, less intensive, and less costly. This code
explains that this woman has no signs or symptoms; she and her physician just
want to be smart about her health.

Test Results
Even though you didn’t go to medical school, you still need to know the difference
between a positive test result and a negative test result. However, you are not permitted
to affirm a diagnosis from a test result without the physician’s documentation. This rule
applies to laboratory tests, x-rays and other imaging, pathology, and any other screening
or diagnostic testing done for a patient. In such cases, especially when the health care pro-
fessional has ordered additional tests based on an abnormal finding, you should query, or
ask, the physician whether or not you should document the results. Be certain to get your
answer in writing in the patient’s record. If it’s not in writing, you can’t code it!

EXAMPLE
Laboratory report in patient’s file shows:
Glucose  155  Norm Range: 65–105 mg/dL
You can see that the patient’s glucose is abnormally high. However, you cannot code
hyperglycemia without a physician’s written interpretation and diagnostic statement.
 If a physician or other health care professional has already interpreted the test
results and the final report has been placed in the patient’s file with a diagnostic state-
ment, you should include the code.

EXAMPLE
Report from radiology states: “X-ray shows an open fracture of the anatomical
neck of the humerus, right arm. Signed: Flor Rodriquez, MD, Chief of Radiology.”
The report, signed by a physician, includes a specific diagnostic statement that
should be coded. However, you should always check with the attending physician
and permit him or her the opportunity to update the patient’s chart with the con-
firmed diagnosis. You should do this as a sign of respect.

Preoperative Evaluations
Whenever a patient is scheduled for a surgical procedure (on a nonemergency basis),
there are typical tests that must be done to ensure that the patient is healthy enough to
have the operation. Cardiovascular, respiratory, and other examinations are often done
a couple of days prior to the date of surgery. Often these tests do not necessarily relate
directly to the diagnostic reason the surgery will be performed. Therefore, they will
need a different diagnosis code to report medical necessity.
Coding those encounters carries a specific guideline. In such cases, the principal, or
first-listed, diagnosis code will be from the following category:
Z01.8   Encounter for other specified special examinations
Follow that code with the code or codes that identify the condition(s) documented as
the reason for the upcoming surgical procedure.

EXAMPLE
Kenzie Hannon was diagnosed with carpal tunnel syndrome in her right wrist. Dr.
Isaacs recommended a surgical solution. Because of her history of atrial fibrilla-
tion, Kenzie was required to get approval from her cardiologist before she could
have the procedure.
G56.01, Carpal tunnel syndrome, right upper limb, is the code that will be used
to report the medical necessity for the surgery on Kenzie’s wrist. However, it will
not support the examination performed by her cardiologist. Think about it . . . who
would agree to pay for a cardiologist to examine a patient with a diagnosis of car-
pal tunnel syndrome? The cardiologist is not qualified to do the job; that is better
suited for an orthopedist.
GUIDANCE Z01.810, Encounter for preprocedural cardiovascular examination will support
the cardiologist’s time and expertise to clear Kenzie for the procedure on her
CONNECTION wrist.
Read the ICD-10-CM
Official Guidelines for
Coding and Reporting, Preoperative/Postoperative Diagnoses
section II. Selection of You may have already noticed that procedure and operative reporting usually include
Principal Diagnosis and both a preoperative diagnosis and a postoperative diagnosis. For cases where the two
section III. Reporting statements differ, the guidelines state that you should code the postoperative diagnosis
Additional Diagnoses. because it is expected that it is the more accurate of the two.

4.6  Putting It All Together: ICD-10-CM Basics

Now that you have learned about how to use all of the parts of the ICD-10-CM code
book, let’s put all your new knowledge to the test.

88   PART II  |  REPORTING DIAGNOSES

 ICD-10-CM
LET’S CODE IT! SCENARIO
Michael Smithstone, a 45-year-old male, came in to see Dr. Opell, his internist. He complains of a fever, sweating,
headaches, and pain in his muscles, joints, and back. He stated that he has also felt fatigued. Dr. Opell documents
that Michael has just returned from working for a week at a goat farm in an impoverished area. He said that he was
supposed to stay longer but came home early because of his illness, “whatever it is.”
Dr. Opell ordered a CBC and other blood tests, which revealed that Michael was suffering from Cypress Fever, a
bacterial infection caused by Brucella abortus. Dr. Opell gave Michael a prescription for Doxycycline, 100mg PO q
12 hr on the first day, then once daily for 6 weeks; and another for Rifampin, 600mg BID for 6 weeks.

Let’s Code It!

First, let’s identify the confirmed diagnosis of the bacterial infection:
  Cypress Fever, caused by Brucella abortus
Next, which word is the main term . . . the reason why Michael needed Dr. Opell’s care. You can always look
up all of the words; however, as you gain more experience in identifying the main term, it will save you time. For
this case, the main term is Fever.
Open your ICD-10-CM code book to the Index to Diseases and Injuries—more commonly referred to as the
Alphabetic Index—and find the main term in bold: FEVER.

Fever (inanition) (of unknown origin) (persistent) (with chills) (with rigor) R50.9
- abortus A23.1
- Aden (dengue) A90
- African tick-borne A68.1
- American
-- mountain (tick) A93.2
-- spotted A77.0
- aphthous B08.8
- arbovirus, arboviral A94
-- hemorrhagic A94
-- specified NEC A93.8
- Argentinian hemorrhagic A96.0
- Assam B55.0
- Australian Q A78
- Bangkok hemorrhagic A91
- Barmah forest A92.8
- Bartonella A44.0
- bilious, hemoglobinuric B50.8
- blackwater B50.8
- blister B00.1
- Bolivian hemorrhagic A96.1
- Bonvale dam T73.3
- boutonneuse A77.1
- brain—see Encephalitis
- Brazilian purpiric A48.4
- breakbone A90
- Bullis A77.0
- Bunyamwera A92.8
- Burdwan B55.0
- Bwamba A92.8

(continued)
 - Cameroon—see Malaria
- Canton A75.9
- catarrhal (acute) J00
-- chronic J31.0
- cat-scratch A28.1
- Central Asian hemorrhagic A98.0
- cerebral—see Encephalitis
- cerebrospinal meningococcal A39.0
- Chagres B50.9
- Chandipura A92.8
- Changuinola A93.1
- Charcot’s (biliary) (hepatic) (intermittent)—see Calculus, bile duct
- Chikungunya (viral) (hemorrhagic) A92.0
- Chitral A93.1
- Colombo—see Fever, paratyphoid
- Colorado tick (virus) A93.2
- congestive (remittent)—see Malaria
- Congo virus A98.0
- continued malarial B50.9
- Corsican—see Malaria
- Crimean-Congo hemorrhagic A98.0
- Cyprus—see Brucellosis
- dandy A90
- deer fly—see Tularemia
- dengue (virus) A90
-- hemorrhagic A91

You can see the long, long list of types of fevers that a person can have. Notice these additional terms are
shown in alphabetic order, so . . . what kind of fever did Michael have? Cypress Fever. Read carefully down the
long list and see if you can find Cypress.
Fever
  - Cyprus—see Brucellosis
Still in the Alphabetic Index, turn to find the main term, Brucellosis.

Bruce sepsis A23.0

Brucellosis (infection) A23.9
- abortus A23.1
- canis A23.3
- dermatitis A23.9
- melitensis A23.0
- mixed A23.8
- sepsis A23.9
-- melitensis A23.0
-- specified NEC A23.8
- suis A23.2
Bruck-de Lange disease Q87.1

There are several choices here as well. Go back to Dr. Opell’s notes. Are there any terms that will help with
this decision? 

(continued)

90   PART II  |  REPORTING DIAGNOSES

 . . . a bacterial infection caused by Brucella abortus
Therefore, Brucellosis abortus leads you to a suggested code A23.1—good. Now you have a suggested code
to work with.
Turn in the Tabular List of your ICD-10-CM code book and find the code category A23. Remember, you must
always begin reading in the Tabular List at the three-character code category. 

A23 Brucellosis
Malta fever
   Mediterranean fever
   undulant fever
     A23.0 Brucellosis due to Brucella melitensis
     A23.1 Brucellosis due to Brucella abortus
     A23.2 Brucellosis due to Brucella suis
     A23.3 Brucellosis due to Brucella canis
     A23.8 Other brucellosis
     A23.9 Brucellosis, unspecified

Check the notation. This does not relate to this case. Check for any other notations. There are none.
Do you need a second code to identify the specific bacteria that caused Michael’s infection? No, because this is
a combination code and it already includes that detail.
One final step . . . turn to the ICD-10-CM Official Guidelines for Coding and Reporting, Section 1.c.1. Certain
Infectious and Parasitic Diseases (A00-B99). Read through the subsections. Are there any related to Cypress
Fever or Brucellosis? No. 
Terrific! Now you can feel confident that reporting A23.1 Brucellosis due to Brucella abortus will justify
Dr. Opell’s care for Michael.
Good job! You are really learning.

Chapter Summary
As you look back over this chapter, you should notice one very important thing: The
ICD-10-CM book will almost always guide you to the correct code. The Alphabetic
Index will guide you to the correct chapter and subsection in the Tabular List, so you
can read all of the notations and symbols, evaluate all the options, and determine the
best, most accurate code. If no codes seem to match the attending physician’s notes, CODING BITES
just go back and keep looking.
ICD-10-CM CODE
Two principles important to becoming a good ICD-10-CM coder:
BOOK CONTENTS
1. Abstract the main term(s) from the physician’s documentation so that you can deter- Introduction
mine the best, most accurate code or codes. Official Conventions
2. In case of an injury, poisoning, or adverse effect, you will need to add an external Official Guidelines
cause code.   for Coding and
Reporting
The Official Coding Guidelines are always there, at your fingertips in the book for The Alphabetic Index
you to reference—no memorization! All the information can point you in the right The Neoplasm Table
direction toward the best, most accurate code. Just look and read. And when the time The Table of Drugs
comes, you will have no problem transitioning from student to professional coding   and Chemicals
specialist. The Index to External
The ICD-10-CM code book will lead you, step-by-step, to the correct, complete   Causes
code to report medical necessity—why the health care provider cared for the patient— The Tabular List
for this encounter with the highest level of specificity. However, not all diagnostic
 statements follow a straight line. Sometimes, you have to really read carefully and use
CHAPTER 4 REVIEW

your critical thinking skills to interpret accurately. Other times, you may have to use
alternate terms from those used in the notes to determine the correct code description.
A medical dictionary will help you, so it is recommended that you keep one by your
side (especially now, while you are early in your learning). Familiarize yourself with
the terms used as well as the critical thinking and interpretation skills that are part of
the coding process.

CHAPTER 4 REVIEW
Introduction to ICD-10-CM Enhance your learning by
completing these exercises and
more at connect.mheducation.com!

Let’s Check It! Terminology

Match each key term to the appropriate definition.

Part I
1. LO 4.4  The section of the ICD-10-CM code book listing all of the codes in A. Alphabetic Index        
alphanumeric order.     B. Index to External
2. LO 4.3  The section of a code book showing all codes, from A to Z, by the short Causes
code descriptions.   C. Neoplasm Table 
3. LO 4.3  The section of the ICD-10-CM code book listing drugs, chemicals, D. Table of Drugs and
and other biologicals that may poison a patient or result in an adverse Chemicals   
reaction. 
E. Tabular List of Diseases
4. LO 4.3  A list of all possible codes for benign and malignant neoplasms, in and Injuries
alphabetic order by anatomical location of the tumor.
5. LO 4.3  The alphabetic listing of the multitude of external causes that might
result in a patient’s injury.

Part II
1. LO 4.1  A specific location or part of the human body. A. Adverse Effect
2. LO 4.1  Found to be true or definite. B. Anatomical Site
3. LO 4.3  A condition named after a person. C. Condition
4. LO 4.5  A condition that affects the entire body and virtually all body systems, D. Confirmed
therefore requiring the physician to consider this in his or her medical E. Eponym
decision making for any other condition.
F. External Cause
5. LO 4.2  An establishment that provides acute care services to individuals who
G. Inpatient Facility
stay overnight on the premises.
H. Outpatient Services
6. LO 4.1  Cause-and-effect relationship between an original condition, illness, or
injury and an additional problem caused by the existence of that original I. Sequela (Late Effect)
condition. J. Systemic Condition  
7. LO 4.2  Health care services provided to individuals without an overnight stay in
the facility.
8. LO 4.3  The state of abnormality or dysfunction.
9. LO 4.3  An unexpected, bad result.
10. LO 4.3  An event, outside the body, that causes injury, poisoning, or an adverse
reaction.

92   PART II  |  REPORTING DIAGNOSES

Part III

CHAPTER 4 REVIEW
1. LO 4.1  Descriptors that are not absolutely necessary to have been included in A. Acute
the physician’s notes and are provided simply to further clarify a code B. Chronic 
description; optional terms.
C. Differential Diagnosis
2. LO 4.1  Specifics that are not described in any other code in the ICD-10-CM
D. Manifestation 
book.
E. Nonessential Modifier 
3. LO 4.2  Long duration; continuing over a long period of time.
F. Not Elsewhere Classifi-
4. LO 4.1  A condition caused or developed from the existence of another
able (NEC)
condition.
G. Not Otherwise Speci-
5. LO 4.1  One disease that affects or encourages another condition.
fied (NOS)
6. LO 4.1  The absence of additional specifics in the physician’s documentation.
H. Other Specified
7. LO 4.1  Additional information that the physician specified and isn’t included in
I. Principal Diagnosis
any other code description.
J. Underlying Condition
8. LO 4.2  The condition that is the primary, or main, reason for the encounter. 
K. Unspecified
9. LO 4.1  An indication that more detailed information is not available from the
physician’s notes.
10. LO 4.2  Severe; serious.
11. LO 4.2  When the physician indicates that the patient’s signs and symptoms may
closely lead to two different diagnoses. 

Let’s Check It! Concepts

Choose the most appropriate answer for each of the following questions.
1. LO 4.4  Which code range identifies the diseases of the digestive system?
a. E00-E89 b. G00-G99
c. K00-K95 d. R00-R99
2. LO 4.1  Turn to Hypertension in the ICD-10-CM Alphabetic Index. All of the following are listed as nonessential
modifiers except
a. accelerated. b. benign.
c. idiopathic. d. organic.
3. LO 4.2  Refer to the ICD-10-CM Official Guidelines Section II. What is section II’s title?
a. Conventions, General Coding Guidelines and Chapter Specific Guidelines
b. Selection of Principal Diagnosis
c. Reporting Additional Diagnoses
d. Diagnostic Coding and Reporting Guidelines for Outpatient Services
4. LO 4.2  The ICD-10-CM Official Guidelines I.A.16 are guidelines with instructions concerning which word(s)?
a. “And” b. “With” 
c. “See” and “See Also” d. “Code Also” note
5. LO 4.1  A code surrounded within italicized, or slanted, brackets
a. is optional. b. must be included.
c. is a previously deleted code. d. is a manifestation.
6. LO 4.1  NEC means
a. the hospital didn’t provide more details.
b. the physician didn’t provide more details.
 c. the ICD-10-CM book didn’t provide a code with more details.
CHAPTER 4 REVIEW

d. the patient didn’t provide more details.

7. LO 4.3  An example of a condition is
a. Cushing’s disease. b. Danlos syndrome.
c. Beck’s. d. a wound.
8. LO 4.6  The correct code for acute and chronic respiratory failure with hypoxia is
a. J96.01 b. J96.12
c. J96.21 d. J96.92
9. LO 4.5  Which of the following would not be considered a systemic condition?
a. diabetes mellitus b. sprain of left corahumeral
c. pregnancy d. hypertension
10. LO 4.6  Steve is starting a new job and is required to complete a preemployment examination. Dr. Rogers com-
pleted the exam and signs the paperwork. How is this encounter coded? 
a. Z02.1 b. Z00.00
c. Z12.31 d. Z02.2

Let’s Check It! Guidelines

Refer to the Official Guidelines and fill in the blanks according to the Conventions and General Coding Guidelines
Section I, subsections A and B.
Tabular  3 Neoplasms  separate
reported Diseases  Excludes2  right
first highest placeholder Drugs
acute discharge Alphabetic  same
related External Causes both not
verify once expansion confirmed
left invalid Excludes1  established
unspecified insufficient

1. The ICD-10-CM is divided into the _____ Index, an alphabetic list of terms and their corresponding code, and the
______ List, a structured list of codes divided into chapters based on body system or condition. 
2. The Alphabetic Index consists of the following parts: the Index of _____ and Injury, the Index of _____  of Injury,
the Table of _____, and the Table of _____ and Chemicals.
3. All categories are _____ characters.
4. A code that has an applicable seventh character is considered _____ without the seventh character.
5. The “x” is used as a _____ at certain codes to allow for future _____.
6. Codes titled _____ are for use when the information in the medical record is _____ to assign a more specific
code.
7. A type _____ note is a pure excludes note. It means “NOT CODED HERE!”
8. A type _____ note represents “Not included here.”
9. To select a code in the classification that corresponds to a diagnosis or reason for a visit documented in a medical
record, _____ locate the term in the Alphabetic Index, and then _____ the code in the Tabular List.
10. Diagnosis codes are to be used and _____ at their _____ number of characters available.
11. Codes that describe symptoms and signs, as opposed to diagnoses, are acceptable for reporting purposes when a
_____ definitive diagnosis has _____ been _____ (confirmed) by the provider.

94   PART II  |  REPORTING DIAGNOSES

 12. If the same condition is described as both acute (subacute) and chronic, and

CHAPTER 4 REVIEW
_____ subentries exist in the Alphabetic Index at the _____ indentation level,
code _____ and sequence the _____ code first.
13. Each unique ICD-10-CM diagnosis code may be reported only _____ for an
encounter.
14. If no bilateral code is provided and the condition is bilateral, assign separate
codes for both the _____ and _____ side.
15. If the provider documents a “borderline” diagnosis at the time of _____, the
diagnosis is coded as _____, unless the classification provides a specific entry
(e.g., borderline diabetes).

Let’s Check It! Rules and Regulations

Please answer the following questions from the knowledge you have gained after read-
ing this chapter.
1. LO 4.2  Explain the difference in the guidelines between coding for outpatient
services and coding for inpatient services.                         
2. LO 4.3  When is it appropriate to code from the Alphabetic Index?        
3. LO 4.1  Explain a code first notation.                                            
4. LO 4.4  Explain the importance of the Tabular List. 
5. LO 4.5  When the preoperative and the postoperative diagnoses differ, which
diagnosis is coded and why?

ICD-10-CM

YOU CODE IT! Basics

First, identify the main term in the following diagno- 8. Adrenal fibrosis:
ses; then code the diagnosis. a. main term: _____ b. diagnosis: _____
Example: Factitial dermatosis:  9. Upper respiratory infection, chronic:
a. main term: dermatosis  b. diagnosis: L98.1 a. main term: _____ b. diagnosis: _____
10. Acute conjunctivitis, right:
1. Acute cystitis without hematuria: 
a. main term: _____ b. diagnosis: _____
a. main term: _____ b. diagnosis: _____
11. Ulcer of lower limb, left calf with muscle
2. Pulmonary necrosis:
necrosis:
a. main term: _____ b. diagnosis: _____
a. main term: _____ b. diagnosis: _____
3. Fibrocystic disease of the pancreas:
12. Aortic endocarditis:
a. main term: _____ b. diagnosis: _____
a. main term: _____ b. diagnosis: _____
4. Chronic daily headache:
13. Tuberculous cystitis:
a. main term: _____ b. diagnosis: _____
a. main term: _____ b. diagnosis: _____
5. Inflammation of the jaw:
14. Acute appendicitis:
a. main term: _____ b. diagnosis: _____
a. main term: _____ b. diagnosis: _____
6. Mobile kidney:
15. Systemic lupus erythematosus with lung
a. main term: _____ b. diagnosis: _____ involvement:
7. Lymphoid interstitial pneumonia: a. main term: _____ b. diagnosis: _____
a. main term: _____ b. diagnosis: _____
CHAPTER 4 REVIEW

ICD-10-CM
YOU CODE IT! Practice
Using the techniques described in this chapter, carefully read through the case studies and determine the most
accurate ICD-10-CM code(s) and external cause code(s), if appropriate, for each case.
1. Ralph Flower, a 27-year-old male, presents today for his annual flu vaccination.           
2. Erina Castles, a 43-year-old female, presents today with a few pimples on her chest. Dr. Moss noted some
slight redness and swelling in the area and orders blood tests. The results of the blood tests confirm the diag-
nosis that Erina is a carrier of staphylococcal, methicillin resistant (MRSA). 
3. Herman Carson, a 32-year-old male, presents with a severe headache and occasional nosebleeds. Dr. Wells
completed an examination recording a blood pressure reading of 180/110. Herman is hospitalized, where an
ECG and echocardiogram confirm the diagnosis of malignant hypertension. 
4. Anna Blanks, a 68-year-old female, presents with a cyst on the anterior wall of her vagina. After an examina-
tion, Dr. Hervey takes a tissue biopsy and orders a CT scan. Anna is diagnosed with a primary malignant neo-
plasm of the Skene’s gland. 
5. Jan McKenzie, a 68-year-old female, presents today to see Dr. McLeod due to restlessness and being anxious.
Jan retired 3 months ago. Dr. McLeod notes Jan is having difficulty adjusting to retirement. 
6. Margaret Carll, a 28-year-old female, presents today with the complaint of feeling dizzy and has some head-
aches. Dr. Dithomas notes a fever and completes an ECG, which shows an ST depression. PMH and PFH are
noncontributory. Margaret is admitted to the hospital, where further blood tests, a chest CT scan, and a venti-
lation scan confirm the diagnosis of hyperventilation (tetany). 
7. Elizabeth Hagun, a 35-year-old female, spent yesterday afternoon outside in the full sun; now she is experi-
encing severe itching. She comes to see Dr. Jerod, who completes an examination and notes skin redness and
blistering. Elizabeth is diagnosed with acute dermatitis due to solar radiation. Code the dermatitis. 
8. Audrey Harkey, a 33-year-old female, comes to see Dr. Blankenship. Audrey is accompanied by her husband,
Henry. Audrey complaints of fever, a stiff neck, and headaches. Henry states he is concerned because he has
noticed some confusion. Audrey is admitted to the hospital, where a lumbar puncture is performed; 5 ml of
cerebrospinal fluid is drawn. Test results confirm Dr. Blankenship’s diagnosis of tuberculous meningitis.
9. Gloria Leugers, a 37-year-old female, comes to see Dr. Lewis with a fever, weakness, and abdominal pain.
Blood tests reveal a hemoglobin of 8.6 and UA is positive for blood. Gloria is admitted to Weston Hospital
and diagnosed with schistosomiasis disorder in the kidney. 
10. Lauren Wheatle, a 68-year-old female, presents today with chest discomfort when resting. Dr. Billings com-
pletes an examination with ECG. The ECG reveals an elevated ST segment. Lauren is admitted to the hospital,
where blood tests show elevated cardiac enzymes and a cardiac echo confirms the diagnosis of variant angina. 
11. Carolyn Mann, a 34-year-old female, presents today with intense itching and a burning sensation of her anus.
Dr. Neal completes an examination and diagnoses her with pruritus ani, stage 2. 
12. Sylvia McCray, a 17-year-old female, presents today with a headache and dull facial pain between and behind
her eyes. Dr. Clayton orders a CT scan, which confirms the diagnosis of acute ethmoidal sinusitis, infection
due to staphylococcus. 
13. Shawn Phillips, a 6-year-old male, is brought in by his parents to see Dr. Smoak, his pediatrician. Shawn
was eating his lunch and swallowed a piece of chicken bone, which is stuck in his throat. Shawn is having
difficulty breathing. Dr. Smoak notes that the bone is causing tracheal compression. Dr. Smoak was able to
remove the bone and Shawn’s breathing returned to normal. 
14. Christopher Crawford, a 47-year-old male, presents today with swollen, red gums that are painful to touch,
but are not bleeding. Dr. Hubert diagnosed Christopher with acute gingivitis, non-plaque induced. 

96   PART II  |  REPORTING DIAGNOSES

 CHAPTER 4 REVIEW
15. Paul Plum, an 8-month-old male, is brought in by his mother to see Dr. Wallace, Paul’s pediatrician. Paul’s
stomach feels hard and he is also having some diarrhea and vomiting. Dr. Wallace notes Paul is failing to
thrive and hospitalizes him. After blood tests and a hydrogen breath test are completed, Paul is diagnosed
with congenital lactase deficiency. 

ICD-10-CM
YOU CODE IT! Application
The following exercises provide practice in abstracting physician documentation from our health care facility,
Prader, Bracker, & Associates. These case studies are modeled on real patient encounters. Using the techniques
described in this chapter, carefully read through the case studies and determine the most accurate ICD-10-CM
code(s) for each case study. Remember to include external cause codes, if appropriate.

PRADER, BRACKER, & ASSOCIATES

A Complete Health Care Facility
159 Healthcare Way • SOMEWHERE, FL 32811 • 407-555-6789
PATIENT: Kassandra, Kelly
ACCOUNT/EHR #: KASSKE001
DATE: 09/16/18
Attending Physician: Oscar R. Prader, MD
S: Pt is a 19-year-old female who has had a sore throat and cough for the past week. She states that
she had a temperature of 101.5 F last night. She also admits that it is painful to swallow. No OTC medi-
cation has provided any significant relief.
O: Ht 5′5″ Wt. 148 lb. R 20. T 101 F. BP 125/82. Pharynx is inspected, tonsils enlarged. There is pus
noted in the posterior pharynx. Neck: supple, no nodes. Chest: clear. Heart: regular rate and rhythm
without murmur.
A: Acute pharyngitis
P: 1. Send pt for Strep test
  2. Recommend patient gargle with warm salt water and use OTC lozenges to keep throat moist
  3. Rx if needed once results of Strep test come back
  4. Return in 2 weeks for follow-up

ORP/pw  D: 9/16/18 09:50:16  T: 9/18/18 12:55:01

Determine the most accurate ICD-10-CM code(s).

WESTON HOSPITAL
629 Healthcare Way • SOMEWHERE, FL 32811 • 407-555-6541
PATIENT: DAVIS, HELEN
ACCOUNT/EHR #: DAVIHE001
DATE: 10/21/18
Attending Physician: Renee O. Bracker, MD
CHAPTER 4 REVIEW

Patient, an 82-year-old that presents today to see Dr. Newson. Dr. Newson saw this patient 10 days ago
in office, where she was diagnosed with a UTI and prescribed nitrofurantoin po. Today she presents
with the complaints of dysuria, low back pain, abdominal pain, nausea, and diarrhea. After a positive UA
she was admitted to Weston Hospital.
PE: Ht: 5′3″, Wt: 112 lb., T: 97.3, P: 70, R: 19, BP: 133/62, O2 sat 97%. Dr. Newson notes LLQ tender-
ness and poor nutritional intake. Blood work results: WBC-16.5, RBC-5.70, HCT-50.5 indicating infec-
tion. Urine culture showed Staphylococcus. CT scan of abdomen and pelvis reveals mild diverticulitis.
Chest clear, lungs clear—sounds bilaterally S1 & S2 heard. Active bowel sound. Strong muscle strength
in all extremities. Pulse is regular. Skin is intact, noted redness in coccyx area. Mucous membrane is
moist and pink. Functioning independently.
Laboratory results:
Sodium—133 (L); Potassium—4.7
Chloride—95 (L); CO2—23
Glucose-Serum—122 (H); BUN—16
Creatinine—0.8; Protein—8.2
Albumin—4.7; Total Bilirubin—1.3
WBC—15.5 (H); RBC—5.70 (H)
HGB—15.9; HCT—50.5 (H)
Platelet—326; Neutrophils—65.4
Lymphocytes—27.0; Monocytes—6.3
Eosinophils—0.4; Basophils—0.9
ALT—13; AST—31; Alkaline Phosphatase—106
Patient was started on Vancomycin 200mg/IV q 6 hr, Docusate sodium 100mg/hr, and Zofran 24mg po.
Patient responded to treatment and is alert & oriented x 3. If she continues to improve, she will be dis-
charged home tomorrow.
Dx: Staphylococcal UTI, Large intestine diverticulitis

ROB/pw  D: 10/21/18 09:50:16  T: 10/25/18 12:55:01

Determine the most accurate ICD-10-CM code(s).

PRADER, BRACKER, & ASSOCIATES

A Complete Health Care Facility
159 Healthcare Way • SOMEWHERE, FL 32811 • 407-555-6789
PATIENT: HOBARTH, CHANTEL
ACCOUNT/EHR #: HOBACH001
DATE: 08/11/18
Attending Physician: Oscar R. Prader, MD

98   PART II  |  REPORTING DIAGNOSES

 CHAPTER 4 REVIEW
S: Pt is a 45-year-old female diagnosed with bladder cancer 4 years ago. She underwent chemotherapy
and radiation treatments and is now malignant-free for 18 months. Since being malignant-free she
comes in for an abdominal scan every 6 months. Pt has no signs or symptoms indicating a return of the
malignancy.
O: Ht 5′5″. Wt. 137 lb. R 18. T 99. BP 128/81. Abdomen appears to be normal upon manual examina-
tion. Results of CT scan indicated no abnormalities.
A: Personal history of bladder cancer
P: Pt to return PRN

ORP/pw  D: 08/11/18 09:50:16  T: 08/13/18 12:55:01

Determine the most accurate ICD-10-CM code(s).

PRADER, BRACKER, & ASSOCIATES

A Complete Health Care Facility
159 Healthcare Way • SOMEWHERE, FL 32811 • 407-555-6789
PATIENT: ROMANO, JOSEPH
ACCOUNT/EHR #: ROMAJO001
DATE: 07/11/18
Attending Physician: Renee O. Bracker, MD
S: Pt is a 32-year-old male who works at local restaurant. While at work he was preparing a chicken and
cut the back of his right index finger. He states he stopped the bleed with pressure, but now he can’t
extend his finger. Pt. had last tetanus toxoid administered last year. He has no past history of serious ill-
nesses, operations, or allergies. Social history and family history are noncontributory.
O: Examination reveals a 3.6-cm laceration, dorsum of right index finger, with laceration of extensor
tendon, proximal to the interphalangeal joint. The patient cannot extend the finger. Pt was prepped, and
a digital nerve block using 1% Carbocaine was administered. When the block was totally effective, the
wound was irrigated with normal saline. The joint capsule was repaired with two sutures of 5-0 Dexon.
The tendon repair was then carried out using 4-0 nylon. Dressings were applied, and a splint was
applied holding the interphalangeal joint in neutral position, in full extension. The Pt tolerated the proce-
dure well.
A: 3.6-cm laceration, dorsum of right index finger
P: 1. Rx Percocet, q4h prn for pain
  2. Rx Augmentin, 250mg tid
  3. Follow-up in 3 days

ROB/pw  D: 07/11/18 09:50:16  T: 07/13/18 12:55:01

Determine the most accurate ICD-10-CM code(s) for the laceration.

CHAPTER 4 REVIEW

WESTON HOSPITAL
629 Healthcare Way • SOMEWHERE, FL 32811 • 407-555-6541
PATIENT: FLORA, VINCENT
ACCOUNT/EHR #: FLORVI001
DATE: 11/19/18
Attending Physician: Oscar R. Prader, MD
S: Pt is a 37-year-old female who was on vacation with friends. On a wager she parachuted from a plane
and landed in a tree. She hit her head against a rock when she fell from the tree and lost consciousness
for approximately 5 minutes. She says she has a headache and is a bit nauseated.
O: Ht 5′6″ Wt. 130 lb. R 18. T 98.1. BP 122/83. HEENT unremarkable. PERRLA. Dr. Prader notes slight
slurred speech. EEG shows indication of a head trauma. CT scan confirmed the brain concussion.
Patient was admitted to the hospital for observation.
A: Concussion with brief loss of consciousness
P: 1. Watch for 24 hours
2. Discharge home if no further complications.

ORP/pw  D: 11/19/18 09:50:16  T: 11/23/18 12:55:01

Determine the most accurate ICD-10-CM code(s) for the concussion.

100   PART II  |  REPORTING DIAGNOSES

Coding Infectious
Diseases
Learning Outcomes
5
Key Terms
After completing this chapter, the student should be able to: Acute
Asymptomatic
LO 5.1 Interpret the details required to report an accurate code for Bacteria
an infection. Chronic
LO 5.2 Clarify the details about bacterial infections. Fungi
LO 5.3 Determine the specifics needed to report viral infections. Human Immunodefi-
LO 5.4 Translate information about parasitic and fungal infections ciency Virus (HIV)
Infection
into diagnosis codes.
Infectious
LO 5.5 Abstract documentation to identify important details about Inflammation
the specific pathogen causing a diagnosis. Nosocomial
LO 5.6 Ascertain the correct code or codes to report immunodefi- Parasites
ciency conditions. Pathogen
LO 5.7 Apply the guidelines for reporting blood infections. Sepsis
Septic Shock
LO 5.8 Analyze the documentation to identify the code or codes
Septicemia
required to report antimicrobial resistance. Severe Sepsis
Systemic
Systemic
­Inflammatory
Response Syn-
Remember, you need to follow along in
drome (SIRS)
  STOP! your ICD-10-CM code book for an optimal
ICD-10-CM

Tuberculosis
learning experience. Viruses

5.1  Infectious and Communicable Diseases Infectious

A condition that can be transmit-
Many conditions and illnesses can be disseminated from one individual to another.
ted from one person to another.
Infectious diseases are spread by personal contact, such as a handshake or the
exchange of bodily fluids, while other diseases can be spread by the touch of a door- Tuberculosis
knob that has been handled by someone else. Some of these conditions, such as menin- An infectious condition that
gitis, hepatitis, tuberculosis, and human immunodeficiency virus (HIV), have been causes small rounded swell-
in the media, and others you may never have heard of before. This chapter will help ings on mucous membranes
you understand how to report all of these diseases using ICD-10-CM codes. throughout the body.

Human Immunodeficiency
Infections and Inflammation Virus (HIV)
A condition affecting the
There are wars going on constantly throughout your body as pathogens (vehicles of immune system.
disease) insert themselves into your cells and multiply. There are many types of patho-
gens and each carries its own threat to your health. Infection happens once a patho- Pathogen
gen successfully invades the body and begins to replicate. This multiplication of the Any agent that causes dis-
organism, known as colonization, causes damage to cell structures and can remain ease; a microorganism such
localized in one area (such as an infected toe), spread to a larger area (such as infection as a bacterium or virus.
of the foot and leg), or become systemic (spreading throughout the entire body). The Infection
human body is designed to alert the individual and the doctor to the existence of infec- The invasion of pathogens
tion by exhibiting specific signs and symptoms: into tissue cells.
Systemic ∙ Increased body temperature (commonly known as a fever)
Spread throughout the entire ∙ Increased white blood cell count
body.
∙ Increase (tachycardia) or decrease (bradycardia) in heart rate  
Asymptomatic
∙ Increase (hyperventilation) or decrease (dyspnea) in respiratory rate  
No symptoms or
manifestations. In some cases, a patient might not be aware that there is an infection in his or
Acute
her body. This is known as a subclinical or asymptomatic infection. In other cases,
Severe; serious. the condition can become acute (severe) and a specific area may show signs of
­inflammation. When located in the epidermis, inflammation can be visible; it causes
Inflammation signs and symptoms, such as erythema (reddening), swelling, warmth to the touch,
The reaction of tissues to and often pain. When located internally, the inflammation can cause lack of func-
infection or injury; character- tion, especially when found within a joint. When inflammation is left untreated, or if
ized by pain, swelling, and
­treatment is ineffective, the condition can become chronic (ongoing). Any of these
erythema.
details may be required to determine an accurate code. You will know by reading the
Chronic complete code descriptions in the Tabular List.
Long duration; continuing over
an extended period of time.

EXAMPLE
CODING BITES A39.2 Acute meningococcemia
Keep references close B39.1 Chronic pulmonary histoplasmosis capsulati
at hand. Bookmark Z21 Asymptomatic human immunodeficiency virus [HIV] infection status
or mark as a favorite
reliable sources such
as the MedlinePlus
online medical ency- Communicable Diseases
clopedia. This will help
People interact in society, and, therefore, the transmission of pathogens cannot be
you increase your
avoided. The level of interaction and the severity of the pathogen (how aggressive it
understanding of any
may be) will impact how many individuals are infected. There are many ways that
infectious disease, and
patients can be exposed to an infection and become ill.
its inclusive signs and
Health care–acquired infections (HAIs), also known as nosocomial infections,
symptoms, that you
are those conditions that are contracted solely due to interactions with a health
encounter in physician
care facility, during which exposure to various types of pathogens occurs. Take
documentation.
note that HAIs are infections that occur in hospitals, nursing homes, and other
health care provider locations. HAIs are not just the concern of inpatient acute
Nosocomial
care facilities. 
A hospital-acquired condition; A cough or a sneeze may send pathogens into the air, and a doorknob or a tele-
a condition that develops as a phone receiver easily transfers pathogens to the skin that touches it next—these are
result of being in a health care methods of transportation for bacteria or viruses to travel from an infected person
facility. to another soon-to-be-infected person. Some diseases require more intimate con-
tact, such as the exchange of bodily fluids (during sex, exposure to blood, or contact
with mucus).
∙ Touch exposure: Physical interaction with blood, bodily fluids, nonintact skin, and
mucous membranes can enable a long list of bloodborne pathogens to make their
way from one person to another.
∙ Airborne exposure: Some pathogens travel in small particles that remain contagious
CODING BITES in the air, such as chickenpox. Measles can live in the air of a room for 2 hours after
Later on, in the chapter the infected person leaves. Breathing in contaminated air by merely entering an
titled Inpatient (­Hospital) examination room or patient area can expose someone to the disease.
Diagnosis Coding, you
∙ Droplet exposure: Some diseases, such as influenza, can be dispersed in large drop-
will learn how to use
lets, such as those transmitted by coughing, spitting, talking, and sneezing.
Present-On-Admission
indicators to report nos- ∙ Contact exposure: As with touch exposure, some infections, such as herpes simplex
ocomial conditions. virus, are communicated by skin-to-skin contact or skin to other surfaces (e.g., coun-
tertops, paper).

102   PART II  |  REPORTING DIAGNOSES

 ∙ Needlestick/sharps injury exposure: Bloodborne pathogens, including HIV, hepatitis
B, and hepatitis C, can be highly contagious when contaminated needles or other sharp CODING BITES
objects (e.g., scalpels, dental wire) penetrate the protective outer layer of the skin. Remember, inclusive
∙ Insect bites: Mosquitoes, deer ticks, fleas, and other insects/parasites spread dis- signs and symptoms are
ease as well. Zika is transmitted by mosquitoes, deer ticks transmit Lyme disease, not coded separately.
and fleas spread the plague. This is why you need
∙ Food and water: There are many diseases, such as E. coli or cholera, that are spread to learn what they are
by ingestion of substances. for each illness or dis-
ease so you know what
should not and what
Reporting the Infectious Agent should be coded.
In some cases, the code you determine to report an infection may be complete with
the specific type of pathogen, such as tuberculosis, which is only caused by Mycobac-
terum tuberculosis or Mycobacterium bovis. This means that the specific pathogen is
included in the diagnostic statement and therefore the code.

EXAMPLE
Tuberculosis (A15-A19)
infections due to Mycobacterium tuberculosis and Mycobacterium bovis

Sometimes, you will find a combination code that includes the name of the patho-
gen in the code description.

EXAMPLE
J02.0 Streptococcal pharyngitis
J09.x3 Influenza due to identified novel influenza A virus with gastrointesti-
nal manifestations
These code descriptions are known as combination codes because they include
both the condition and the specific pathogen.

Other times, an infection might be caused by any one of several different pathogens.
In these cases, you will need to report a second code to specify the bacterial or viral
infectious agent. 

EXAMPLES
B95.2 Enterococcus as the cause of diseases classified elsewhere
B96.3 Hemophilus influenzae [H. influenzae] as the cause of diseases clas-
sified elsewhere
B97.11 Coxsackievirus as the cause of diseases classified elsewhere
These code descriptions identify the specific pathogen to be reported along with
the code describing the condition caused.

The part of the code description that states “diseases classified elsewhere” means
that the condition has its own code within this code set. This underscores the fact that
this is not a combination code and you will need two codes to report the condition.

CHAPTER 5 
 EXAMPLE
N30 Cystitis
Use additional code to identify infectious agent (B95-B97)
Very often, the ICD-10-CM will tell you that you will need this second code to iden-
tify the specific pathogen.

YOU INTERPRET IT!

What is the mode of transmission for each condition?

1. Hepatitis B ___________ 4. Insect bites ___________
2. Measles ___________ 5. Influenza ___________
3. Cholera ___________

5.2  Bacterial Infections

Types of Bacteria
Bacteria Bacteria are single-celled organisms named by their shape (see Figure 5-1). Rod-
Single-celled microorganisms shaped bacteria, called bacilli, are responsible for the development of diphtheria,
that cause disease. tetanus, and tuberculosis, among others. Spirilla, bacterial organisms shaped like a

(a) (c)

(b) (d)

FIGURE 5-1  Types of bacteria: (a) coccus, (b) bacillus, (c) spirillum, and (d) vibrio  (a) Source: CDC/Janice Carr;
(b) Source: CDC/Janice Carr; (c) ©MELBA PHOTO AGENCY/Alamy Stock Photo RF; (d) Source: CDC/Janice Carr

104   PART II  |  REPORTING DIAGNOSES

spiral, may cause cholera or syphilis, while dot-shaped bacteria known as cocci cause
gonorrhea, tonsillitis, scarlet fever, and bacterial meningitis.

EXAMPLE
A05.4 Foodborne Bacillus cereus intoxication
A27.9 Leptospirosis, unspecified
A49.1 Streptococcal infection, unspecified site
This is a great example of why professional coders-to-be need to know these
details . . . so you can recognize the name of a bacterium in diagnostic terms and
phrases. Until you learn them, use your medical dictionary to confirm.

Conditions Caused by Bacteria

Impetigo
Impetigo is a common illness affecting children, caused by either a streptococcal or a
staphylococcal pathogen. This means that MRSA (methicillin-resistant Staphylococ-
cus aureus) is a real concern. This disease spreads through contact with fluid oozing
from a bullous—or blister. Visually, impetigo is evidenced by the appearance of rings
that can range from pea-size to large rings. They may itch. These blisters may ooze
yellow or honey-colored fluid and then crust. Of course, the itching may result in the
patient scratching, which then spreads the rash. The physician may also document
swollen lymph nodes, particularly in the body areas close to the infection site. Impe-
tigo is often reported with a code from code category L01 with additional required
characters to provide additional specificity.

EXAMPLE
A specific, complete diagnostic statement is required to determine an accurate
code for a case of impetigo:
L01.01 Non-bullous impetigo
L01.02 Brockhart’s impetigo
L01.03 Bullous impetigo
L01.09 Other impetigo [ulcerative impetigo]
Yet, notice . . . not all impetigo diagnoses are reported from this one code
­category . . .
L40.1 Generalized pustular psoriasis [impetigo herpetiformis]

Foodborne Illness
Some bacterial infections that you will encounter in a typical health care facility are
those that are foodborne, commonly called food poisoning. Do not let the word “poison-
ing” fool you. These diagnoses are not poisonings; they are actually infections. Some of
the most frequently seen bacterial infections, and their sources, are shown in Table 5-1.

EXAMPLES
Clostridium botulinium is the bacterium that causes A05.1 Botulism food poisoning
Foodborne Clostridium perfringens, the bacterium that causes enteritis necroti-
cans, is reported with code A05.2
(continued)

CHAPTER 5 
 Foodborne staphylococcal intoxication is reported with A05.0
Salmonella foodborne intoxication and infection are reported from code category
A02, which requires additional information related to the infection resulting from
this bacterium.
Listeriosis [listerial foodborne infection] is reported from code category A32 and
requires additional detail about the patient’s condition.

TABLE 5-1  Common Bacterial Infections, Their Sources, and Their Codes

Name  Source Code

Campylobacter From foods including raw poultry, raw meat, untreated milk A04.5
Listeria Untreated milk, dairy products, raw salads and vegetables A32.-
Salmonella Raw poultry, eggs, raw meat, untreated milk and dairy products A02.9
Shigella Untreated water, milk and dairy products, raw vegetables and sal- A03.-
ads, shellfish, turkey, apple cider
Vibrio Raw and lightly cooked shellfish A00.-
Clostridium perfringens Animal and human excreta, soil, dust, insects, raw meat B96.7
Escherichia coli (E. coli 0157) Human and animal gut, sewage, water, raw meat A49.8

Almost all infections shown in Table 5-1 induce symptoms of diarrhea, abdominal
pain, nausea, fever, and vomiting. Other serious effects include dehydration, head-
ache, and kidney damage or failure. Therefore, you must be careful not to report
unnecessary codes for signs and symptoms that are actually included in a definitive
diagnosis that has been made.

ICD-10-CM
LET’S CODE IT! SCENARIO
Francie Holland, a 23-year-old female, came to see Dr. Kensington due to severe abdominal pain. She had a fever
and stated that she has had bloody diarrhea for the past 2 days. Dr. Kensington’s examination revealed that she was
dehydrated as well. Francie stated she ate at a new restaurant at the beach where she had a salad and a vegetable
plate. After taking some tests, he diagnosed Francie with Shigella dysenteriae (bacillary dysentery).

Let’s Code It!

Dr. Kensington found Francie to be suffering from Shigella dysenteriae. Turn to the Alphabetic Index and find
Shigella (dysentery) (see Dysentery, bacillary)
Dysentery, bacillary A03.9
Turn to the Tabular List, and check the code’s complete description:
A03  Shigellosis
There are no notations or directives, so read down the column to review all of the choices for the required fourth
character. The code suggested by the Alphabetic Index:
A03.9  Shigellosis, unspecified
Is this the most accurate code? You will note that the other fourth-character code choices want specifics on
which group (A, B, C, or D) of the Shigella infection is present. Do you know? Dr. Kensington did specify in the
notes—Shigella dysenteriae, which matches the description for

106   PART II  |  REPORTING DIAGNOSES

 A03.0  Shigellosis due to Shigella dysenteriae
Check the top of this subsection and the head of this chapter in ICD-10-CM. There are notations at the begin-
ning of this chapter: an notation, a Use Additional Code note, an notation, and an
notation. Read carefully. Do any relate to Dr. Kensington’s diagnosis of Francie? No. Turn to the Official Guide-
lines and read Section 1.c.1. There is nothing specifically applicable here either.
Therefore, A03.0 is the most accurate code available. Excellent!!

Cellulitis
Cellulitis is a serious infection of the skin that may be either a staph infection (the
staphylococcal bacteria) or a strep infection (the streptococcal bacteria). These patho-
gens typically enter the body through an abnormal opening in the epidermal layer of
the skin—for example, a burn, puncture wound, abrasion (also known as a scrape), or
even a bite—either animal or human. 
Cellulitis begins with the typical signs of inflammation: erythema (redness), heat
arising from the area of infection, pain, and edema (swelling). Vesicles or bullae may
appear in the infected area. In addition, the patient may develop a fever with chills,
experience tachycardia (a rapid heartbeat), suffer a headache, have hypotension (low
blood pressure), and, at times, become mentally confused.
Report a diagnosis of cellulitis with a code—in many cases—from code category
L03. You will need specific information on the precise anatomical site affected by the
condition.

EXAMPLES
L03.012 Cellulitis of left finger
L03.113 Cellulitis of right upper limb
L03.314 Cellulitis of groin
These are examples of the need to identify the specific anatomical site of the cel-
lulitis to determine an accurate code.

There is an notation beneath L03.211, the code used to report cellulitis

of the face. This long list of specific anatomical sites that might normally be included
within the face are actually reported with different codes from different areas of the
ICD-10-CM code book . . . such as cellulitis of the ear, reported with code H60.1, or
cellulitis of the mouth, which is reported with code K12.2. As always, you must read
all of the notations, carefully and completely.
L03.31—the code used to report cellulitis of the trunk—also has a list of specific
anatomical sites located on the torso that are reported with codes from other chapters,
such as cellulitis of anal and rectal regions, which is reported with a code from the K61 CODING BITES
Abscess of anal and rectal regions code category, or cellulitis of the breast, which is
When the documen-
reported from code category N61 Inflammatory disorders of the breast. tation states that an
external cause, such as
Tetanus (Lockjaw) an animal bite, provided
You are probably more familiar with the tetanus vaccine than you are with the disease. entry for the pathogen,
Tetanus is an infection of the nervous system and is caused by the entry of bacteria external cause codes
into the body through a break in the skin. It causes death in about 11% of all cases. The may be required. More
illness can be prevented by the administration of the tetanus toxoid, included in the about these in the
DTaP, DT, and Td vaccines. chapter Coding Injury,
When a patient has come for inoculation with the tetanus toxoid only, you will use ­Poisoning, and Exter-
Z23. However, read the notes carefully. If the development of tetanus is a complication nal Causes.
arising from the vaccination, use code T88.1. If tetanus is a result of an incident, such

CHAPTER 5 
 as stepping on a rusty nail, report it with code A35 plus an external cause code. Should
this disease occur with or following an abortion or ectopic pregnancy, then you will
report it as a complication of pregnancy, using A34 or O08.89. And in cases where the
tetanus is affecting a neonate, it will be reported with code A33.

Tuberculosis
Mycobacterium tuberculosis, the causative agent of tuberculosis (TB), is a bacte-
rial infection that is transmitted through the air. One version of TB is called latent
tuberculosis infection (LTBI) because it is dormant and may not show symptoms
right away. Not everyone who has been infected is symptomatic, so a test is required
to confirm the diagnosis. Most types of TB and LTBI are successfully treated with
medication.
There is a specific cultural group of people who will get a positive result to the skin
test but not actually have the disease. A simple chest x-ray confirms that situation.
Should you have a patient in such a circumstance, you will use this code:
R76.11 Nonspecific reaction to tuberculin skin test without active
tuberculosis
When the documentation confirms a diagnosis of TB, you will choose the best, most
appropriate code from the range A15–A19 Tuberculosis based on the specific anatomi-
cal site affected. 

EXAMPLE
A15.0 Tuberculosis of lung
A17.1 Meningeal tuberculoma
A18.81 Tuberculosis of thyroid gland
A19.1 Acute miliary tuberculosis of multiple sites
The codes in these four code categories illustrate the extensive list of anatomical
sites that may be affected with TB. Read the documentation and diagnosis care-
fully (as always).

As you look through the section, you will notice that TB is a disseminated disease.
While most people think of TB as a pulmonary infection, infiltrating only the lungs, it
can actually leach throughout the body and be identified in many different anatomical
sites. You have to abstract which anatomical site is infected with the TB bacterium so
that you can find the most accurate code. 

ICD-10-CM
YOU CODE IT! CASE STUDY
Audra Swenson was brought into the emergency department (ED) by ambulance because she was having suprapu-
bic pain, pain in her lower back, and nocturia. Dr. Balthazar diagnosed Audra with renal tuberculosis, also known as
urogential TB, confirmed histologically, with pyelonephritis.

You Code It!

Go through the steps of coding, and determine the diagnosis code or codes that should be reported for this
encounter between Dr. Balthazar and Audra Swenson.
Step #1: Read the case carefully and completely. 
Step #2: Abstract the scenario. Which main words or terms describe why the physician cared for the patient dur-
ing this encounter?

108   PART II  |  REPORTING DIAGNOSES

 Step #3: Are there any details missing or incomplete for which you would need to query the physician? [If so, ask
your instructor.] 
Step #4: Check for any relevant guidance, including reading all of the symbols and notations in the Tabular List
and the appropriate sections of the Official Guidelines. 
Step #5: Determine the correct diagnosis code or codes to explain why this encounter was medically necessary.. 
Step #6: Double-check your work.
Answer:
Did you determine the correct code?
A18.11 Tuberculosis of kidney and ureter (Pyelitis tuberculous)
Terrific!

5.3  Viral Infections 

Types of Viruses
There are a large number of viral infectious diseases that you may have to code, Infectious
depending upon the type of facility that employs you, combined with geographic and A condition that can be trans-
other factors.  mitted from one person to
Viruses are tiny microorganisms that are not easily treated with medication because another.
they embed themselves within their host’s cells and are, therefore, difficult to isolate Viruses
(see Figure 5-2). These invaders can remain dormant (latent) for long periods of time.  Microscopic particles that initi-
ate disease, mimicking the
characteristics of a particular
EXAMPLE cell; viruses can reproduce
only within the body of the
A85.0 Enteroviral encephalitis cell that they have invaded.
B18.0 Chronic viral hepatitis B with delta-agent
B33.21 Viral endocarditis
Sometimes, the code description identifies the viral pathogen involved in a diag-
nosis. When a combination code is available, you will need to report it, as long as
it matches the physician’s documentation.

(a) (b) (c)

FIGURE 5-2  Types of viruses: (a) influenza, (b) hepatitis, and (c) warts  (a) Source: CDC/F.A. Murphy; (b) ©BSIP/UIG/Universal
Images Group/Getty Images; (c) ©James Cavallini/Science Source

CHAPTER 5 
 Wart (due to HPV) (filiform) (infectious) (viral) B07.9
- anogenital region (venereal) A63.0
- common B07.8
- external genital organs (venereal) A63.0
- flat B07.8
- Hassal-Henle’s (of cornea) H18.49
- Peruvian A44.1
- plantar B07.0
- prosector (tuberculosis) A18.4
- seborrheic L82.1
-- inflamed L82.0
- senile (seborrheic) L82.1
-- inflamed L82.0
- tuberculosis A18.4
- venereal A63.0

FIGURE 5-3  ICD-10-CM Alphabetic Index, partial listing under the main term
Wart  Source: ICD-10-CM Official Guidelines for Coding and Reporting The Centers for Medicare and Medicaid Ser-
vices (CMS) and the National Center for Health Statistics (NCHS)

Conditions Caused by Viruses

Viral Warts
Viral warts are most common in children and are rarely seen in the elderly. This virus
can be spread from person to person during sexual contact or an individual with a viral
wart can see it spread from one anatomical site to another.
There are several different types of warts, as you can see in Figure 5-3, so it is impor-
tant that the specifics are documented. Take a look at the suggested codes, here in the
Alphabetic Index: A63.0, B07.9, H18.49, L82.0 . . . located in several different chapters
throughout the Tabular List. You must read the documentation carefully, including the
pathology report, to point you toward the correct codes from which to choose.

Viral Hepatitis
Hepatitis (hepat = liver; -itis = inflammation) actually refers to several different viral
infections. According to the Centers for Disease Control and Prevention (CDC), viral
hepatitis is the most prevalent cause of malignant neoplasms of the liver. As you know,
prevention is a much better path than treatment. For those coming to your facility to
get a hepatitis vaccine, you will report one of these codes:
Z20.5 Contact with or (suspected) exposure to other viral hepatitis
Z22.330 Carrier of Group B Streptococcus
Z23 Encounter for immunization
For those who are already infected with one of the strains of hepatitis, it’s critical to
understand the different types in order to code the encounter(s) correctly.

Viral Hepatitis, Type A

The CDC estimates that an additional 25,000 people each year become infected with
viral hepatitis, type A, a viral infection of the liver caused by the hepatitis A virus
(HAV). The virus can travel from person to person by personal contact, as with other
infections. However, in addition, one can become infected through exposure to con-
taminated water or ice. Shellfish harvested from sewage-contaminated water as well
as fruits, vegetables, and other foods that have been contaminated and eaten uncooked
may also carry the hepatitis A virus. 

110   PART II  |  REPORTING DIAGNOSES

 In some cases, a patient may develop hepatic encephalopathy (hepatic coma). This
occurs when, because of the infection, the liver is unable to remove toxins from the
blood, resulting in a loss of brain function.
Viral hepatitis A is reported with either:
B15.0 Hepatitis A with hepatic coma
or
B15.9 Hepatitis A without hepatic coma

Viral Hepatitis, Type B

Caused by the hepatitis B virus (HBV), viral hepatitis, type B is transmitted through
contact with infected bodily fluids, such as blood or semen. The infection can also be
spread by the use of equipment that has been contaminated with the virus, which is
why when getting a tattoo, body piercing, or even a fingernail application one must be
careful that the needles and files have been sterilized properly. The CDC estimates
43,000 new cases of hepatitis B are diagnosed each year. 
To determine the most accurate code, you have to abstract these details from the
documentation:
∙ Is the patient documented as in a hepatic coma?
∙ Is the condition identified as acute (code category B16) or chronic (code category B18)?
∙ Is hepatitis D (also known as hepatitis delta, or delta-agent) involved?

B16.0 Acute hepatitis B with delta-agent with hepatic coma

B16.1 Acute hepatitis B with delta-agent without hepatic coma
B16.2 Acute hepatitis B without delta-agent with hepatic coma
B16.9 Acute hepatitis B without delta-agent and without hepatic coma

Viral Hepatitis, Type C

The hepatitis C virus (HCV) infection is estimated by the CDC to chronically affect
3.2 million people in the United States. It is considered to be the most widespread
chronic bloodborne infection. Those individuals at the highest risk for infection are
those using injected drugs. Each year, it is believed that an additional 17,000 indi-
viduals become hepatitis C positive. Report this diagnosis with one of these codes:
B17.11 Acute hepatitis C with hepatic coma
B18.2 Chronic hepatitis C
B17.10 Acute hepatitis C without hepatic coma
B19.20 Unspecified viral hepatitis C without hepatic coma

Viral Hepatitis, Type D

Also known as hepatitis delta, this is a serious liver disease that requires the HBV (hepa-
titis B virus) to replicate itself. This condition is not seen often in the United States. Hepa-
titis D is transmitted through direct contact with infected blood, similar to how hepatitis B
is passed from one person to another. Currently, there is no vaccine for hepatitis D. Hepati-
tis D is referred to as hepatitis delta in the code descriptions, and reported with this code:
B17.0 Acute delta-(super) infection of hepatitis B carrier

Viral Hepatitis, Type E

Occurrences of hepatitis E in the United States are rare; it is known to be common in
countries with poor sanitation and contaminated water supplies. This liver disease,
caused by the hepatitis E virus (HEV), does not lead to chronic infection. There is no
vaccine currently approved by the FDA for hepatitis E. Report this diagnosis with
B17.2 Acute hepatitis E

CHAPTER 5 
 ICD-10-CM
LET’S CODE IT! SCENARIO
David Tranccione, a 55-year-old white male, came into our office. He complains that he feels tired all the time, no
matter how much he sleeps. His muscles are sore, his stomach is upset, and he has experienced frequent bouts of
diarrhea. He made an appointment with his regular physician, Dr. Cameron, when he noticed his urine was dark. 
Dr. Cameron ordered blood tests, and the pathology report confirmed the diagnosis of acute hepatitis B virus.

Let’s Code It!

Dr. Cameron confirmed that David has acute hepatitis B virus. Open your ICD-10-CM code book to the Alpha-
betic Index to:
Hepatitis K75.9
Before you turn to this code category in the Tabular List, read down the long list indented beneath, just to see if
you can find a listing that is more specific and in agreement with Dr. Cameron’s documentation.
Hepatitis K75.9
B B19.10
with hepatic coma B19.11
acute B16.9
Four different listings and three very different codes. It is a good thing you keep reading. Turn to code category
B16 in the Tabular List:
B16 Acute hepatitis B
Read the four options for the required fourth character. What details do you need from the documentation to
choose: with or without delta-agent and with or without hepatic coma. Go back to the scenario. There is no men-
tion of either delta-agent or hepatic coma, so you can report:
B16.9   Acute hepatitis B without delta-agent and without hepatic coma
Check the top of this subsection, which has an and an notation. Neither relates to David’s
case this time, so next, check the head of this chapter in ICD-10-CM. Above code A00, you will find an
notation, a Use additional code note, an  notation, and an notation. Read carefully. Do any
relate to Dr. Cameron’s diagnosis of David? No. Turn to the Official Guidelines and read Section 1.c.1. There is
nothing specifically applicable here either.
Now you can report B16.9 for David’s diagnosis with confidence.
Good coding!

Influenza
There is a reason why so much commotion is made annually about individuals getting
their flu shots. A seemingly ordinary infection, influenza (commonly called the flu)
can be deadly. It is caused by the influenza A or B virus and can be transmitted by
casual contact, such as a handshake or touching a contaminated doorknob. It is esti-
mated that as many as 36,000 people die in the United States each year from influenza.
The most common symptoms of the flu are
∙ Body or muscle aches
∙ Chills
∙ Cough
∙ Fever
∙ Headache
∙ Sore throat

112   PART II  |  REPORTING DIAGNOSES

The diagnosis of influenza will be reported with a code from these categories:
J09 Influenza due to certain identified influenza viruses
J10 Influenza due to other identified influenza viruses
J11 Influenza due to unidentified influenza viruses
The required additional characters will enable you to report the specific virus, such as
novel influenza A, as well as manifestations of this virus.

EXAMPLE
J09.X1 Influenza due to identified novel influenza A virus with pneumonia
J10.2 Influenza due to other identified influenza virus with gastrointestinal
manifestations
J11.1 Influenza due to unidentified influenza virus with other respiratory
manifestations
The physician’s documentation, along with the pathology report, should provide
you with the details you need.

Varicella
Varicella, commonly known as chickenpox, is generally not perceived to be serious,
most particularly for children. Complications from varicella, however, may include
pneumonia in adults and bacterial infections of the skin and soft tissue in affected
children. The infections can be severe and can lead to septicemia, toxic shock syn-
drome, necrotizing fasciitis, osteomyelitis, bacterial pneumonia, and septic arthritis. CODING BITES
There may also be a connection between varicella and development of herpes zoster, Varicella is commonly
also known as shingles, later in life. The availability of the varicella vaccine has made called chickenpox.
the risk of contracting the infection almost nil.
Code varicella from B01.- if the patient has been diagnosed. If the patient has come
to receive a varicella vaccine, then use code Z23. However, if the patient has been
exposed to varicella, the code will change to Z20.820.

Rubeola
The risk of catching the childhood illness of rubeola, commonly referred to as mea-
sles, is very low because of the success of the measles vaccine. Your coding experience
relating to measles should be limited to office visits for administering the vaccine.
When an individual has come to get vaccinated against rubeola only, code the
encounter using Z23. However, a patient who is seeing a health care professional
because of having been exposed to rubeola will be reported with Z20.828. A diagnosis
of rubeola (measles) should be reported with code B05.-.

ICD-10-CM
YOU CODE IT! CASE STUDY
Gregg Espinoza brought his 3-year-old son, Raymond, to his pediatrician, Dr. Nunez, with complaints of a 102
degree F fever for 3 days’ duration. The boy was coughing, had signs of a runny nose, and had conjunctivitis in both
eyes. Upon examination, Dr. Nunez notes Koplik’s spots inside his checks and lips. Also noted are small, generalized,
maculopapular erythematous rashes on his scalp. When asked, the father agreed that the boy had been scratching
his head and he had been tugging at his ears. 
Dr. Nunez confirmed that Raymond had measles keratoconjunctivitis.
(continued)

CHAPTER 5 
 You Code It!
Read the scenario carefully and determine the diagnosis code or codes to report for this encounter with Dr.
Nunez.
Step #1: Read the case carefully and completely.
Step #2: Abstract the scenario. Which main words or terms describe why the physician cared for the patient dur-
ing this encounter? 
Step #3: Are there any details missing or incomplete for which you would need to query the physician? [If so, ask
your instructor.]
Step #4: Check for any relevant guidance, including reading all of the symbols and notations in the Tabular List
and the appropriate sections of the Official Guidelines.
Step #5: Determine the correct diagnosis code or codes to explain why this encounter was medically necessary.
Step #6: Double-check your work.
Answer:
Did you determine this to be the code?
B05.81 Measles keratitis and keratoconjunctivitis
Good job!

Rubella
Rubella, an acute viral disease that can affect anyone of any age, is thought of by
many to be a children’s disease known as the German measles. While the symptoms
are most often not more than a mild rash, the health danger of rubella can be serious
to a pregnant woman in her first trimester. When contracted during the early months
of pregnancy, rubella can be associated with a condition known as congenital rubella
syndrome (CRS). CRS may cause any of a large number of birth defects, including
deafness and possibly fetal death. The rubella vaccine has almost eliminated CRS.
Rubella is coded with B06.- when it has been diagnosed. For those cases in which
a patient is being vaccinated against rubella alone, you will use Z23, and if the patient
has been exposed to rubella, report this with code Z20.4.

Herpes Simplex Virus

The herpes simplex virus, often referred to by the abbreviation HSV, is transmitted by
direct contact between individuals. Small vesicles (fluid-filled lesions) appear on reddened
skin in clusters or groups, particularly in the mucous membranes. HSV type 1 may be
associated with orofacial disease and type 2 is associated with infections in the genitalia.
B00 is the code category dedicated to reporting herpes simplex infections—with
the exception of congenital herpesviral infection—reported with code P35.2.

EXAMPLE
B00 Herpesviral [herpes simplex] infections
 congenital herpesviral infections (P35.2)
 anogenital herpesviral infection (A60.-)
gamaherpesviral mononucleosis (B27.0-)
herpangina (B08.5)

114   PART II  |  REPORTING DIAGNOSES

 Specific documentation is critical to determine an accurate code. You want to avoid
reporting B00.9 Herpesviral infection NOS, so be certain to query your physician if you
need more details to determine which of these codes to report.

Herpes Zoster
Herpes zoster or postherpetic neuralgia is commonly known as shingles. Herpes zos-
ter is an infection of the varicella zoster virus—the same pathogen that causes chick-
enpox. Those patients who actually had chickenpox previously are at the greatest risk
for developing this painful disease. Patients will feel a burning sensation or shooting
pain, accompanied often by tingling or itching on only one side of the body.
Finding shingles in the ICD-10-CM Alphabetic Index will require you to search
for Herpes, zoster .  .  . reported with a code from code category B02. The required
additional characters will identify specific details about the anatomical location and
activity of the virus.

EXAMPLE
 B02 Zoster [herpes zoster]
 shingles
zona
B02.0 Zoster encephalitis
B02.24 Postherpetic myelitis

You may be aware of the shingles vaccine, made recently available. For those
patients coming to your health care facility to take advantage of this preventive medi-
cine, the likely ICD-10-CM diagnosis code to provide medical necessity will be
Z86.19 Personal history of other infectious and parasitic diseases.
Of course, the specific disease would be varicella—commonly known as chicken- GUIDANCE
pox. The documentation will need to specify this personal history to support the provi- CONNECTION
sion of this vaccine. Also, make note of any other qualifiers set forth by third-party
Read the ICD-10-CM
payers. Some require the patient to be aged 65 or over.
Official Guidelines for
Coding and Reporting,
Zika Virus Infections section I. Conven-
When a physician documents a confirmed diagnosis of the Zika virus, you are going tions, General Coding
to report code A92.5 Zika virus disease. However, if the physician includes any terms Guidelines and Chapter
of doubt, such as describing this diagnosis as “suspected” or “possible,” do not report Specific Guidelines,
the A92.5 code. Instead, you must report either: subsection C. Chapter-
Specific Coding Guide-
∙ the codes for the specific symptoms that are included in the documentation, such as lines, chapter 1. Certain
joint pain, fever, etc. Infectious and Parasitic
or Diseases, subsection
f. Zika virus infections.
∙ Z20.828 Contact with and (suspected) exposure to other viral communicable diseases

YOU INTERPRET IT!

Is the infection bacterial or viral? 

6.  Strep throat (a) Bacteria (b) Virus   9.  Measles (a) Bacteria (b) Virus
7.  The Flu (a) Bacteria (b) Virus 10.  Staph infection (a) Bacteria (b) Virus
8.  Plantar wart (a) Bacteria (b) Virus

CHAPTER 5 
 5.4  Parasitic and Fungal Infections
Parasitic Infestations
Parasites Parasites are tiny living things that can invade and feed off other living things—like
Tiny living things that can humans. They are one-celled organisms (protozoa), insects (lice and mites), and worms
invade and feed off other liv- (helminths) among others (see Figure 5-4) that can interfere with a healthy body. Tape-
ing things. worms, hookworms, and pinworms are internal parasites. Parasites can be transmitted
in food (e.g., protozoa like Giardia intestinalis and Cyclospora cayetanensis); spread
by mosquitoes and other insects through the bloodstream (as in malaria and leishmani-
asis); or ingested in contaminated water (as in amebiasis and schistosomiasis).

EXAMPLE
B86 Scabies
B71.9 Cestode infection, unspecified
B87.2 Ocular myiasis
Diagnoses with a pathogen that is parasitic may not always be clearly defined.
Keep that medical dictionary close at hand.

(a)

(d)

(b)

(e)

FIGURE 5-4  Parasitic worms: (a) tapeworms and (b) Trichinella. Parasitic
insects: (c) mosquitoes, (d) deer ticks, and (e) mites  (a) ©Mediscan/Alamy Stock
Photo; (b) ©Dickson Despommier/Science Source; (c) Source: CDC/James Gathany; (d) ©Svetoslav Radkov/
(c) Shutterstock.com RF; (e) Source: USDA/Scott Bauer

116   PART II  |  REPORTING DIAGNOSES

 FIGURE 5-5  Angiostrongyli-
asis due to Parastrongylus
cantonensis, reported with
code B83.2 ©Michael S. Duffy

Protozoal diseases are caused by a single-celled, microscopic organism. There are CODING BITES
several types of diagnoses that fall into this category:
These terms from Greek
 B50-B54 Malaria and Latin can be com-
 B57 Chagas’ disease (infection due to Trypanosoma cruzi) plex. However, physi-
 B58 Toxoplasmosis (infection due to Toxoplasma gondii) cians are more likely
Helminths (from the Greek word for worms) are large organisms that grow to be to use these terms in
visible with the naked eye. (See Figure 5-5.) Platyhelminths (flatworms) are com- documentation. There-
monly called tape worms, like acanthocephalins, which seek out the gastrointestinal fore, keep that medical
tract. Ascariasis is the medical term used to describe a case of roundworm infection. dictionary close at hand.
You will need the sup-
B68.1 Taenia saginata taeniasis (infection due to adult port and accuracy of the
tapeworm Taenia saginata) definitions to help you
 B76 Hookworm diseases determine the correct
 B77 Ascariasis (roundworm infection) code.
B85.3 Phthiriasis (infestation by crab-louse)

ICD-10-CM
YOU CODE IT! CASE STUDY
Michael McCarthey brought his 6-year-old daughter, Johannah, to see Dr. Benzzoni, complaining that his daughter
keeps scratching her head. After a thorough exam, Dr. Benzzoni explains that Johannah has a case of head lice.
He instructs Michael to buy Nix, an over-the-counter permethrin, and provides an instruction sheet on how to rid his
child and their household of the parasites.

You Code It!

Step #1: Read the case carefully and completely. 
Step #2: Abstract the scenario. Which main words or terms describe why the physician cared for the patient dur-
ing this encounter?
Step #3: Are there any details missing or incomplete for which you would need to query the physician? [If so, ask
your instructor.] 
Step #4: Check for any relevant guidance, including reading all of the symbols and notations in the Tabular List
and the appropriate sections of the Official Guidelines. 
(continued)

CHAPTER 5 
 Step #5: Determine the correct diagnosis code or codes to explain why this encounter was medically necessary.
Step #6: Double-check your work.
Answer:
Did you determine the correct code?
B85.0 Pediculosis due to Pediculus humanus capitis [head louse infestation]
Great work!

Fungal Infections
Fungi There are many versions of fungi (the plural form of fungus) in our lives. Mushrooms
Group of organisms, includ- on your pizza or in your salad and yeast in your bread or beer are tasty. Mold, a form
ing mold, yeast, and mildew, of fungus, can be delicious when it is called blue cheese or feta cheese, and it can
that cause infection; fungus be helpful when developed in a pill containing penicillin. Then there are fungi that
(singular). cause illness, such as Aspergillus, which may cause lower respiratory tract dysfunc-
tion, or Candida albicans, which causes infection in the oral mucosa and the walls of
the vagina. Onychomycosis is the most common nail fungal infection.

EXAMPLE
P37.5 Neonatal candidiasis
B44.81 Allergic bronchopulmonary aspergillosis
B40.3 Cutaneous blastomycosis
With fungal infections, it may not be easy or straightforward from reading the diagnos-
tic statement. You may need to do some research, or check in your medical dictionary.

Except in patients with compromised immune systems, fungal infections are not
life-threatening.
 B35 Dermatophytosis
Ectoparasites are organisms that attach, or burrow, into the epidermis and dermis and
remain there, such as ticks, fleas, lice, and mites. Often, the medical term “tinea” is
used in the diagnostic statement, such as tinea pedis (commonly known as athlete’s
foot) or tinea cruris (also known as jock itch).
 B44 Aspergillosis
There can be serious concerns with a fungal infection when it affects the pulmonary
organs, skin, or adrenal glands, known as histoplasmosis.
 B38.0 Acute pulmonary coccidioidomycosis (also known as Valley Fever, this is
an infection of the lungs)
 B39.3 Disseminate histoplasmosis capsulati

YOU INTERPRET IT!

How are these diseases transmitted?

11. Lyme disease    (a) Parasite   (b) Fungus 4. Aspergillus     (a) Parasite   (b) Fungus
1
12. Candida albicans  (a) Parasite   (b) Fungus 15. Blastomycosis    (a) Parasite   (b) Fungus
13. Zika        (a) Parasite   (b) Fungus 16. Ring worm      (a) Parasite   (b) Fungus

118   PART II  |  REPORTING DIAGNOSES

5.5  Infections Caused by
Several Pathogens
Up to this point, you have been reading about infectious and communicable diseases
that are known to be caused by either a bacterium, virus, or other specific pathogen.
However, there are some diagnoses that can be caused by a virus, a bacterium, or even
a fungus. This means that you must abstract not only the name of the condition but
also the specific type of underlying pathogen to determine an accurate code. Lab tests
are required to confirm a diagnosis. Therefore, reading the pathology reports in the
patient’s chart can provide these details.

Pneumonia
Pneumonia is not an uncommon infection of the lungs. Actually, it is estimated that CODING BITES
more than 3 million diagnoses of pneumonia are made each year in the U.S. Yet, as The incidence of
a professional coder, you need to know the specific type of pathogen that caused this pneumonia is also cat-
infection before you can accurately determine the code. egorized by the envi-
ronment in which the
Types of Pneumonia patient may have con-
tracted this condition. 
Several different types of pathogens can result in fluid and pus filling the air sacs
Community-acquired
(­alveoli)—the underlying cause of pneumonia. Integral signs and symptoms include
pneumonia (CAP) identi-
cough with phlegm or pus, fever, chills, and difficulty breathing. When you look
fies that pneumonia has
under the main term PNEUMONIA in the ICD-10-CM Alphabetic Index, you can
developed in a patient
see the very long list of additional descriptors needed to get to a specific code
who has not recently
recommendation. 
been in the hospital
or another health care
Bacterial Pneumonia facility such as a nursing
The  Streptococcus pneumoniae bacterium, also known as  pneumococcus, causes home or rehab facility. 
the most common type of pneumonia. Atypical pneumonia, commonly referred to as Hospital-acquired
walking pneumonia, is also caused by bacteria, but different bacteria, including Legi- pneumonia identifies
onella pneumophila, Mycoplasma pneumoniae (M. pneumoniae), and Chlamydophila those patients who con-
pneumoniae. tract pneumonia while in
Aspiration pneumonia is a bacterial infection that develops after the patient has a residential health care
inhaled food, a liquid, or vomit. The particles deteriorate and bacteria grow, causing facility.
the infection and inflammation.

ICD-10-CM
LET’S CODE IT! SCENARIO
Anna Carland, an 81-year-old female, was admitted to the hospital with pneumonia. She was placed on oxygen to
help her breathe while labs were done to determine the type of pneumonia. Dr. Premin diagnosed her with strepto-
coccal pneumonia. The pathology report specifies Streptococcus pneumoniae group B.

Let’s Code It!

Anna was diagnosed with streptococcal pneumonia by Dr. Premin. Turn to the Alphabetic Index in your ICD-
10-CM code book and find the main term:
Pneumonia (acute) (double) (migratory) (purulent) (septic) (unresolved) J18.9
Read carefully down the long, indented list beneath and find

(continued)

CHAPTER 5 
 Pneumonia
in (due to)
all the way down this list to . . .
   Streptococcus J15.4
    group B J15.3
    pneumoniae J13
    specified NEC J15.4
Knowing that Anna has “Streptococcus pneumoniae” is not enough. Remember that we are required to always
code to the greatest specificity, and the code book is reminding you that you need additional details. Go back
to the documentation, not only the physician’s notes but the pathology report, too. Aha! The pathology report
specifies “Streptococcus group B.” Now, turn to the Tabular List to the code category J15.
J15 Bacterial pneumonia, not elsewhere classified
Code First associated influenza, if applicable (J09.X1, J10.0-, J11.0-)
Code Also associated lung abscess, if applicable (J85.1)
chlamydial pneumonia (J16.0)
congenital pneumonia (P23.-)
Legionnaires’ disease (A48.1)
spirochetal pneumonia (A69.8)
Read these notations carefully and determine if any of them relate to Anna’s case. Not this time. Good! So, read
down all of the fourth-character options and determine which matches Dr. Premin’s documentation.
J15.3 Pneumonia due to streptococcus, group B
Check the head of this chapter in ICD-10-CM. There are notations at the beginning of this chapter: a NOTE, a
Use Additional Code notation, and an notation. Read carefully. Do any relate to Dr. Premin’s diagno-
sis of Anna? No. Turn to the Official Guidelines and read Section 1.c.1. There is nothing specifically applicable
here either.
Now you can report J15.3 for Anna’s diagnosis with confidence.
Good coding!

Viral Pneumonia
There are some viruses that are known to cause inflammation and swelling in the
lungs. The influenza A and B viruses, as well as Hemophilus influenzae (H. influ-
enzae), can develop into viral pneumonia if not treated quickly. Cytomegalovirus
(CMV) is most often seen in patients with a suppressed immune system, such
as one going through chemotherapy or one suffering with an immunodeficiency
condition.

EXAMPLES
J11.0 Influenza due to unidentified influenza virus with pneumonia
J12 Viral pneumonia not elsewhere classified
J14 Pneumonia due to Hemophilus influenzae

120   PART II  |  REPORTING DIAGNOSES

Fungal Pneumonia
The fungus Pneumocystis jiroveci is the cause of a fungal pneumonia, previously known
as Pneumocystis carini or PCP pneumonia, in patients whose immune system is dimin-
ished. This is a known manifestation in those diagnosed with advanced HIV infection.
Pneumonia due to Aspergillus is the result of inhaling this form of mold.

Secondary Pneumonia
There are some diseases that can manifest a case of pneumonia. These conditions
include rheumatic fever, schistosomiasis, and Q fever. There is a difference between
this type of pneumonia and those we have just been discussing, so read carefully and
possibly query the physician. This diagnosis is reported with the following code:
J17 Pneumonia in diseases classified elsewhere

Meningitis
Meningitis is the inflammation of the meningeal membranes of the brain and/or the
spinal cord. Meningitis can be caused by a bacterial pathogen, such as Meningococ-
cus; however, it is more often the result of a viral infection. When meningitis is caught
early, the prognosis is good and complications are rare.
In order to code a diagnosis of meningitis, you have to know the specific virus or
bacterium at the core of the inflammation. This will typically be found in the patholo-
gist’s report as well as the physician’s documentation.

EXAMPLES
Some bacterial causes of meningitis would be reported with
A39.0 Meningococcal meningitis
A54.81 Gonococcal meningitis
G00.2 Streptococcal meningitis
Use additional code to further identify organism
(B95.0-B95.5)

EXAMPLES
Some viral causes of meningitis would be reported with
A87.1 Adenoviral meningitis
A87.0 Echoviral meningitis
B26.1 Mumps (virus) meningitis

In some cases, ICD-10-CM will identify the requirement of a second code.

EXAMPLES
Meningitis due to poliovirus A80.9 [G02]
A80.9 Acute poliomyelitis, unspecified
G02 Meningitis in other infectious and parasitic diseases
classified elsewhere
G00.2 Streptococcal meningitis
Use additional code to further identify organism (B95.0-B95.5)

CHAPTER 5 
 CODING BITES 5.6  Immunodeficiency Conditions
In some states, infor- Some conditions cause the body’s immune system to stop working, meaning that infec-
mation in the patient’s tion and pathogens cannot be fought off effectively. You may remember learning about
record relating to HIV T cells, B cells, and lymphoid tissues from your physiology class. A defect involv-
testing (positive or ing any of these is known as a primary (congenital) immunodeficiency condition. A
negative result), HIV secondary (acquired) immunodeficiency is a manifestation caused by something that
AIDS status, sexually is blocking the proper immune response or depressing the response to an ineffective
transmitted diseases, level. There are some viruses that trigger secondary immunodeficiency, such as with
genetic information acquired immunodeficiency syndrome (AIDS). However, there are a number of poten-
(such as the results of tial external causes of secondary immunodeficiency, ranging from exposure to an
any genetic testing), infection, a toxic chemical, or radiation to suffering severe burns. 
mental health condi- Primary immunodeficiency disorders include
tions, and substance ∙ X-linked agammaglobulinemia (XLA)
abuse is categorized as
superconfidential infor-
∙ Common variable immunodeficiency (CVID)
mation. This information ∙ Severe combined immunodeficiency (SCID), also known as “boy in a bubble”
has additional legal disease
protection, above the ∙ Alymphocytosis (deficiency of lymphocytes in the blood)
requirements of HIPAA,
with regard to disclo-
Secondary immunodeficiency conditions include
sure and use. Be certain ∙ AIDS
to find out if your state ∙ Leukemia and other cancers of the immune system
has this additional pro-
tection for patients as
∙ Viral hepatitis and other immune-complex diseases
well as the requirements ∙ Multiple myeloma (a cancer of the plasma cells)
for compliance.
Human Immunodeficiency Virus
Human immunodeficiency virus (HIV) infection is a serious illness. Sadly, as if
GUIDANCE this illness were not enough for a patient to deal with, it also carries a huge societal
stigma. Therefore, whether you are coding for an inpatient facility (an exception
CONNECTION
to the guideline discussed earlier) or an outpatient facility, you will code this ill-
Read the ICD-10-CM ness only when it has been clearly specified in the physician’s notes that the patient
Official Guidelines for is HIV-positive.
Coding and Reporting, Anyone possibly exposed to HIV should be tested. Similar to so many other con-
section I. Conven- ditions, like malignancies, the earlier a diagnosis is made, the sooner treatment can
tions, General Coding begin. Early treatment translates into a longer, better-quality life for the patient.
Guidelines and Chapter
Specific Guidelines, Coding HIV Testing, Test Results, and Symptoms
subsection C. Chapter-
Specific Coding Guide-
Documenting Medical Necessity of HIV Testing
lines, chapter 1. Certain When an individual with no symptoms comes to a health care facility to be tested for
Infectious and Parasitic a condition, you will need a diagnosis code to provide medical necessity for the test.
Diseases, subsections As with other preventive health care encounters, you will use a Z code to document the
a. Human immuno- need for HIV testing. For a first office visit to discuss possible exposure to HIV, you
deficiency virus (HIV) will use this code:
infections and a.2)(h) Z20.6 Contact with and (suspected) exposure to human
Encounters for testing ­immunodeficiency virus [HIV]
for HIV.
For the diagnosis code used to support the actual test, generally, you will use this
code:
Z11.4 Encounter for screening for human immunodeficiency virus [HIV]
However, if the patient is documented by the physician as a member of a known high-
risk group, you may use one of these codes:

122   PART II  |  REPORTING DIAGNOSES

 Z72.5- High-risk sexual behavior
Z72.8- Other problems related to lifestyle CODING BITES
Remember, until there is a specific diagnostic statement in the physician’s notes, NEVER report a code
you are not to report anything connected to HIV. If the patient is tested because of for HIV infection or ill-
specific signs and/or symptoms, you will code those signs and symptoms, rather than ness without a specific
any of the above. physician diagnostic
statement—a confirmed
diagnosis.

ICD-10-CM
LET’S CODE IT! SCENARIO
Michael Callahan got drunk and had unprotected intercourse last night. He comes to Dr. Ansara’s office to discuss
his concerns about possible exposure to HIV.

Let’s Code It!

Michael went to see Dr. Ansara because he was concerned that he had been exposed to HIV. Let’s turn to the
Alphabetic Index and look up exposure:
Exposure (to)
  human immunodeficiency virus (HIV) Z20.6
Confirm the complete code description in the Tabular List; start reading at the top of the chapter subsection titled
Persons with potential health hazards related to communicable diseases (Z20-Z29)
Be certain to read the and notes. While these excluded diagnoses do not relate to our cur-
rent case of Michael’s visit to Dr. Ansara, always reading up and down and around the code that was suggested
by the Alphabetic Index is a critical habit that you need to build. This time, the notes do not apply, but next time,
they might. Continue reading down the column.
Z20 Contact with or (suspected) exposure to communicable diseases
This fits the documentation, which notes that Michael is concerned that he has been “exposed.” Keep reading
down the column to find that required fourth digit. You will see this code:
Z20.6 Contact with and (suspected) exposure to human immunodeficiency virus [HIV]
Directly beneath this code is another notation:
Asymptomatic human immunodeficiency virus [HIV] infection status (Z21)
This reminds you that contact or exposure is not the same as a positive status asymptomatic HIV diagnosis.
Check the top of this subsection and the head of this chapter in ICD-10-CM. There is a NOTE at the beginning
of this chapter. Read carefully. Does it relate to Dr. Ansara’s diagnosis of Michael? No. Turn to the Official Guide-
lines and read Section 1.c.1. There is nothing specifically applicable here, either.
Now you can report code Z20.6 with confidence!

Test Negative
There are rapid HIV tests using oral swabs or finger sticks that can provide results in
minutes. Other HIV tests may take several days to provide an answer. Therefore, a
return visit to the health care provider will sometimes be required.

CHAPTER 5 
 The entire experience of being tested and then having to wait for the results can be psy-
chologically difficult, even when the news is good and the test is negative. It is the health
care professional’s responsibility to counsel the patient on how to prevent future risk.
Therefore, when an individual returns to get the results of an HIV test, even when the results
are negative, counseling should be provided. For that reason, when documented, report:
Z71.7 Human immunodeficiency virus [HIV] counseling

Test Inconclusive
CODING BITES It can happen that the serology (pathology testing) comes back inconclusive for HIV.
Once a patient has There can be no specific diagnosis for HIV or any direct manifestations of the illness
been diagnosed with because there is nothing to confirm or deny HIV-positive status. In such cases, you
manifestations of HIV- have to use this code:
positive status, you are R75 Inconclusive laboratory evidence of human immunodeficiency virus [HIV]
no longer permitted to
use code Z21, even Test Positive but Asymptomatic
when the manifestations
Thanks to research and the development of new drug therapies, patients who have HIV
are no longer present.
are living longer and with a better quality of life. Therefore, testing positive for HIV is
not quite as devastating as it was years ago. When a patient comes to receive the HIV
test results that are positive but the patient has no signs, symptoms, or manifestations,
Asymptomatic the patient is asymptomatic. You will assign this code:
No symptoms or
manifestations. Z21 Asymptomatic human immunodeficiency virus [HIV] infection status
When the physician provides counseling for the patient, discusses therapeutic treat-
ments, and/or any other elements of dealing with the disease, you should report the
counseling code as well.
CODING BITES
Test Positive with Symptoms or Manifestations
Positive status means
that laboratory tests Once the individual has been diagnosed and exhibits any manifestations associated
have confirmed that the with HIV, the code to report the condition will change from Z21 to
patient does have the B20 Human immunodeficiency virus [HIV] disease
virus in his or her sys-
tem (positive status). Code B20 includes a diagnosis of acquired immune deficiency syndrome (AIDS),
Asymptomatic means which is essentially HIV with manifestations. When you use code B20, you have to
that the patient is cur- follow it with a code or codes to identify the specific manifestations, such as pneu-
rently not exhibiting any monia or HIV-2 infection. There is a notation in the ICD-10-CM book, below code
signs or symptoms of B20’s description in the Tabular List, reminding you to do this. If the patient is seen
the disease. for a condition or illness directly related to his or her HIV-positive status, list code B20
first, followed by the code or codes for the conditions.

ICD-10-CM
LET’S CODE IT! SCENARIO
Alfredo Zimoso has been HIV-positive for 10 years. He comes to see Dr. Chang because of severe headaches and
vision problems. After a complete physical examination (PE) and appropriate tests, Dr. Chang diagnoses Alfredo with
noninfectious acute disseminated encephalomyelitis, secondary to HIV.

Let’s Code It!

Alfredo has been diagnosed with noninfectious acute disseminated encephalomyelitis, secondary to HIV. Do
you know whether the noninfectious acute disseminated encephalomyelitis is an HIV-related manifestation?
There are two ways to tell. First, the physician’s notes state that the condition is secondary to HIV. This means

124   PART II  |  REPORTING DIAGNOSES

that not only are the two conditions related to each other but that the HIV is also the underlying condition (it
came first). The second way to tell is shown in the Tabular List. Let’s first go to the Alphabetic Index to find
encephalomyelitis. The indented descriptions of encephalomyelitis include terms used by the physician in her
notes.
Encephalomyelitis
  acute disseminated (ADEM) (postinfectious) G04.01
Notice that this description also includes the term postinfectious. Alfredo was diagnosed with noninfectious
encephalomyelitis. Keep reading down and find:
Encephalomyelitis, acute disseminated, noninfectious G04.81
That seems to match the doctor’s notes, so now, let’s turn to the Tabular List and read the complete descriptions.
Start reading at
G04 Encephalitis, myelitis, and encephalomyelitis
This code category contains , , and notes, which you need to read carefully. Is there
anything that leads you away from this code category? No, there isn’t, so you need to read down the column to
find the most accurate, required fourth digit:
G04.8 Other causes of encephalitis, myelitis, and encephalomyelitis
None of the other descriptions match Dr. Chang’s notes, so this looks like the best option. Take a look at your
choices for the required fifth digit:
G04.81 Other encephalitis and encephalomyelitis
G04.89 Other myelitis
Check the notes and you will see that Alfredo was diagnosed with encephalomyelitis, leading you directly
to code:
G04.81 Other encephalitis and encephalomyelitis; noninfectious acute disseminated
encephalomyelitis (noninfectious ADEM)
That matches Dr. Chang’s notes exactly.
Now you need the code for Michael’s HIV-positive status. You know that the encephalomyelitis is a manifesta-
tion of that status and you should be clear as to what the code should be. In the Alphabetic Index, find:
Human immunodeficiency virus (disease) (infection) B20
  asymptomatic status Z21
Which one should you follow? You know from the notes that Alfredo does have symptoms and has manifested a
secondary illness. Therefore, turn to the Tabular List to confirm:
B20 Human immunodeficiency virus [HIV] disease
You now have two codes to report the reasons Dr. Chang cared for Alfredo at this encounter. Which gets listed
first? The notation below the description reminds you to “use additional code(s) to identify all manifestations of
HIV.” This tells you that B20 is listed first. 
Check the top of this subsection and the head of this chapter in ICD-10-CM. There are notations at the begin-
ning of this chapter: an notation, a Use additional code note, an  notation, and an
notation. Read carefully. Do any relate to Dr. Chang’s diagnosis of Alfredo? No. Turn to the Official Guidelines and
read Section 1.c.1. Read subsection (a) Human Immunodeficiency virus (HIV) infections, particularly (2) Selection
and sequencing of HIV codes, (a) Patient admitted for HIV-related condition.
So your report for Dr. Chang’s encounter with Alfredo will show:
B20 Human immunodeficiency virus [HIV] disease
G04.81 Other causes of encephalitis, noninfectious acute disseminated encephalomyelitis
Good job!

CHAPTER 5 
 HIV Status with Unrelated Conditions
GUIDANCE
An individual who is HIV-positive can still be affected by conditions, illnesses, or inju-
CONNECTION ries that have nothing to do with his or her HIV status. As you have learned, the first-
Read the ICD-10-CM listed code should answer the question, “Why did the health care provider care for the
Official Guidelines for patient at this encounter?” Therefore, the code for the condition that caused the patient
Coding and Reporting, to visit the physician should come first. Because HIV is a systemic disease, affecting
section I. Conven- the entire body, you have to include a code for that condition as well. Even if it has
tions, General Coding nothing to do with the services or treatment provided by the physician, it will have an
Guidelines and Chapter impact on the physician’s decision making and therefore must be included.
Specific Guidelines,
subsection C. Chapter- GUIDANCE CONNECTION
Specific Coding Guide-
lines, chapter 1. Certain Read the ICD-10-CM Official Guidelines for Coding and Reporting, section I. Conven-
Infectious and Parasitic tions, General Coding Guidelines and Chapter Specific Guidelines, subsection C.
Diseases, subsec- Chapter-Specific Coding Guidelines, chapter 1. Certain Infectious and Parasitic Dis-
tion a. 2)(f) Previously eases, subsection a.2)(b): “If a patient with HIV disease is admitted for an unrelated
diagnosed HIV-related condition (such as a traumatic injury), the code for the unrelated condition (e.g., the
illness. nature of injury code) should be the principal diagnosis. Other diagnoses would be
B20 followed by additional diagnosis codes for all reported HIV-related conditions.”

EXAMPLE
Gayle Robbins came to see Dr. Tigliano because she slipped on the ice this morn-
ing and hurt her ankle. Dr. Tigliano examined her and took x-rays that confirmed
a sprain of the deltoid ligament of the left ankle. Gayle was diagnosed with HIV 2
years ago and is asymptomatic.
S93.422A Sprain, of deltoid ligament of left ankle, initial encounter
Z21 Asymptomatic human immunodeficiency virus [HIV]

EXAMPLE
Yuri Kastachen fell off a ladder and hurt his lower back. Dr. Lang determined that Yuri
had a fractured coccyx. Last year, Yuri was hospitalized with HIV-related pneumonia.
S32.2xxA Fracture of coccyx, initial encounter
B20 Human immunodeficiency virus [HIV] disease

HIV Status in Obstetrics

When a woman with HIV-positive status is pregnant, giving birth, or in the postpar-
tum period, the systemic disease must be a consideration in determining her care.
Therefore, whether or not she has symptoms or manifestations of the HIV condition,
the first-listed code must be
O98.7- Human immunodeficiency virus [HIV] disease complicating pregnancy,
childbirth, or the puerperium
This should be followed by the appropriate HIV-positive status code: Z21 or B20.

ICD-10-CM
YOU CODE IT! CASE STUDY
Maureen Dunbar, a 27-year-old female, 23 weeks pregnant, was playing tennis when she felt a pain in her right knee.
She went to see her physician, Dr. Rummur, who diagnosed her problem as a derangement of the anterior horn of the
lateral cystic meniscus. Maureen has been HIV-positive and asymptomatic for 5 years.

126   PART II  |  REPORTING DIAGNOSES

 You Code It!
Go through the steps of coding, and determine the diagnosis code(s) to be reported for this encounter between
Dr. Rummur and Maureen Dunbar.
Step #1: Read the case carefully and completely. 
Step #2: Abstract the scenario. Which main words or terms describe why the physician cared for the patient dur-
ing this encounter?
Step #3: Are there any details missing or incomplete for which you would need to query the physician? [If so, ask
your instructor.] 
Step #4: Check for any relevant guidance, including reading all of the symbols and notations in the Tabular List
and the appropriate sections of the Official Guidelines. 
Step #5: Determine the correct diagnosis code or codes to explain why this encounter was medically necessary. 
Step #6: Double-check your work.
Answer:

Did you determine the correct codes?

M23.041 Cystic meniscus, anterior horn of lateral meniscus, right knee
O98.712 Human immunodeficiency virus [HIV] disease complicating pregnancy, childbirth, or the
puerperium, antepartum condition, second trimester
Z21 Asymptomatic human immunodeficiency virus [HIV] infection status
Good job!

Are you wondering why the knee condition is listed first when the guideline for
HIV infection in pregnancy states the O98.7- code category should be listed first? In
this case, you have two guidelines that need to be followed:
Section I.C.1.a.2)(b) Patient with HIV disease admitted for unrelated condition
Section I.C.1.a.2)(g) HIV infection in pregnancy, childbirth, and the puerperium
To break the tie, let’s look at one more guideline, either
Section II. Selection of Principal Diagnosis (for inpatient encounters)
or
 ection IV. Diagnostic Coding and Reporting Guidelines for Outpatient Services,
S
Subsection H (for outpatient encounters)
Whether you are coding for outpatient or inpatient services, the guidelines agree that
the principal, or first-listed, diagnosis code should be the condition “chiefly responsible”
for the encounter. In Maureen’s case, the reason she went to the doctor for care was the
pain in her knee—not the pregnancy and not the HIV. Then why code them at all? Because
Dr. Rummur must take Maureen’s pregnant status and her HIV status into consideration
in his medical decision-making process to determine the best way to treat her knee.

YOU INTERPRET IT!

Which condition code is sequenced first [principal diagnosis]?

17. HIV-positive patient admitted with fractured leg  _____
18. Patient admitted with pneumocystis carinii, HIV-positive since 2015  _____
19. Patient, 38 weeks pregnant, HIV-positive, delivers  _____
20. Patient seen for type 1 diabetes, HIV-positive  _____

CHAPTER 5 
 5.7  Septicemia and Other Blood Infections
Blood infections are very dangerous, as you might imagine, because of their poten-
tial effect on the entire body. Blood circulates through the body and touches all the
cells and organs in some fashion. So you can understand that if the blood circulat-
ing through the body is carrying a disease, it can have the potential to cause serious
problems. There are several types of blood infections, and each needs to be coded
Septicemia differently.
Generalized infection spread
through the body via the
bloodstream; blood infection. Septicemia
Systemic Inflammatory Essentially, septicemia is identified as the presence of a microorganism or toxin in the
Response Syndrome (SIRS) bloodstream. The organism might be a virus, a fungus, a bacterium, or another patho-
A definite physical reaction, logic substance. Septicemia is very serious. A physician may refer to this condition as
such as fever, chills, etc., to an bacteremia; however, they are really not the same. Bacteremia may not be clinically
unspecified pathogen. significant, but septicemia is always significant.
The code used for a diagnosis of septicemia may be taken from category
A41.9 Sepsis, unspecified sepsis (Septicemia NOS)
GUIDANCE
CONNECTION You will need to determine a more accurate code by the pathogen or toxin found in the
blood, such as streptococcus or staphylococcus.
Read the ICD-10-CM A diagnosis of systemic inflammatory response syndrome (SIRS) is used when
Official Guidelines for the basic cause, or pathogen, is unknown. The human body is amazing and is designed
Coding and Reporting, to fight any and all intruders (disease or infection). The system’s response to infection
section I. Conven- may be
tions, General Coding
Guidelines and Chapter
∙ Increased body temperature.
Specific Guidelines, ∙ Change in heart rate.
subsection C. Chapter- ∙ Change in respiratory rate.
Specific Coding Guide- ∙ Increased white blood cell count.
lines, chapter 1. Certain
Infectious and Parasitic Systemic inflammatory response syndrome (SIRS) of non-infectious origin
Diseases, subsection d. R65.10
Sepsis, severe sepsis, Systemic inflammatory response syndrome (SIRS) of non-infectious origin with
and septic shock. acute organ dysfunction R65.11

ICD-10-CM
YOU CODE IT! CASE STUDY
Priscilla Christopher, a 17-year-old female, was brought by her mother to see Dr. Fasold. Priscilla claimed that her
muscles ache, she has been sweating, and she has chills at the same time. She stated that she has been cough-
ing and short of breath for several days. After running some tests, Dr. Fasold diagnosed Priscilla with sepsis due to
Hemophilus influenzae.

You Code It!

Go through the steps of coding, and determine the diagnosis code or codes that should be reported for this
encounter between Dr. Fasold and Priscilla.
Step #1: Read the case carefully and completely. 
Step #2: Abstract the scenario. Which main words or terms describe why the physician cared for the patient dur-
ing this encounter?

128   PART II  |  REPORTING DIAGNOSES

 Step #3: Are there any details missing or incomplete for which you would need to query the physician? [If so, ask
your instructor.] 
Step #4: Check for any relevant guidance, including reading all of the symbols and notations in the Tabular List
and the appropriate sections of the Official Guidelines. 
Step #5: Determine the correct diagnosis code or codes to explain why this encounter was medically necessary. 
Step #6: Double-check your work.
Answer:

Did you determine the correct code?

A41.3   Sepsis due to Hemophilus influenzae
Terrific!

Sepsis Sepsis
Condition typified by two or
When an individual exhibits two or more systemic responses or when the presence of more systemic responses
a specific pathogen has been identified in the bloodstream, the diagnosis is typically to infection; a specified
sepsis. pathogen.
Reporting a diagnosis of sepsis will begin with the identification of the underlying
systemic infection—the pathogen that initiated the septic condition. This code will
come from category A40.- or A41.-. You may find this detail in the physician’s docu- GUIDANCE
mentation or the pathology report.
On occasion, a physician might diagnose a patient with urosepsis. This is not a syn- CONNECTION
onym for sepsis and cannot be coded as sepsis. Should you find this term used in the Read the ICD-10-CM
documentation, you will need to query the physician for clarification. Official Guidelines for
A patient may be diagnosed with sepsis and acute organ failure during the same Coding and Reporting,
encounter, without a relationship (or cause and effect) between the two. In these situ- section I. Conven-
ations, the organ failure is a co-morbidity and is reported separately from the sepsis. tions, General Coding
Guidelines and Chapter
Specific Guidelines,
EXAMPLE subsection C. Chapter-
Bernard Madison was in the hospital and diagnosed with group A streptococcus Specific Coding Guide-
sepsis. lines, chapter 1. Certain
A40.0 Sepsis due to streptococcus, group A Infections and Parasitic
Diseases, subsec-
tion d.3) Sequencing
Severe Sepsis of severe sepsis, which
warns you that a code
When left untreated, sepsis may become severe and cause an organ to fail—a life- from subcategory
threatening condition. In some cases, this can occur when treatment is provided but R65.2 Severe sepsis is
is ineffective. A diagnosis of sepsis in combination with acute organ failure due to the never permitted to be
septic condition is reported as severe sepsis. The physician’s notes that contain a diag- the first-listed or prin-
nosis of severe sepsis will be reported with cipal diagnosis code
∙ First: the code for the underlying systemic infection, such as streptococcus or other reported.
bacteria (e.g., a code from A40.- or A41.-). If the organism is not known, you may
report A41.9 Sepsis, unspecified organism.
Severe Sepsis
∙ Followed by: a code from subcategory R65.2 Severe sepsis. An additional char-
Sepsis with signs of acute
acter is required to report whether or not the physician has documented that the organ dysfunction.
patient is in “septic shock.”
∙ Followed by: a code to report the specific organ failure caused by the septic condi-
tion. To remind you, code subcategory R65 has a Use additional code notation.

CHAPTER 5 
 ICD-10-CM
LET’S CODE IT! SCENARIO
Dr. Kahanni admitted Burton Chapel with acute renal failure due to severe sepsis resulting from pneumonia.

Let’s Code It!

Dr. Kahanni diagnosed Burton with “acute renal failure due to severe sepsis resulting from pneumonia.” Remem-
ber the Official Guideline at Section l.c.1.d(1)(b): The coding of severe sepsis requires first a code for the underly-
ing systemic infection, followed by a code from R65.2-, and then the code for the acute organ dysfunction. Turn
to the Alphabetic Index and find

  Sepsis
   Pneumococcal A40.3
Turn to the Tabular List to confirm this code:

A40 Steptococcal sepsis

Read the fourth-character choices and find

A40.3 Sepsis due to Streptococcus pneumoniae (Pneumococcal sepsis)

Next, let’s turn to R65.2- and see what will accurately report Dr. Kahanni’s diagnosis for Burton.

R65.2 Severe sepsis

Read the fifth-character descriptions, and determine which one matches:

R65.20 Severe sepsis without septic shock

The notations above this code help you further. They remind you to “Code first underlying infection,” which you
have done already with the pneumococcal sepsis code. The second notation directs you to

Use additional code to specify acute organ dysfunction, such as: acute kidney failure (N17.-)

Next, confirm the code for the acute renal (kidney) failure:

N17 Acute kidney failure

Carefully read the Code also and notes. There is no relevance here to Burton’s diagnosis at this
encounter, so read down the column to review all of your choices for the required fourth character. With no docu-
mentation of any lesions on Burton’s kidneys, the best choice is

N17.9 Acute renal failure, unspecified

Check the top of this subsection and the head of this chapter in ICD-10-CM. There are notations at the beginning
of this chapter: an notation, a Use additional code note, an  notation, and an nota-
tion. Read carefully. Do any relate to Dr. Kahanni’s diagnosis of Burton? No. Turn to the Official Guidelines and
read Section 1.c.1, particularly d. Sepsis, severe sepsis, and septic shock. 
Now you can report, with confidence, these codes in the order specified by the guidelines: A40.3,
R65.20, N17.9 . . .
Good job!

Septic Shock Septic Shock

Severe sepsis with hypoten-
sion; unresponsive to fluid Should a patient also develop hypotension (low blood pressure) in addition to having
resuscitation. severe sepsis, the diagnosis becomes septic shock. Septic shock cannot be present

130   PART II  |  REPORTING DIAGNOSES

without the existence of severe sepsis—and it all must be documented. When coding
septic shock, report the codes in the following order: CODING BITES
1. The code for the systemic infection (e.g., A40.-). The code for septic
shock may not be the
2. The code for the severe sepsis with septic shock (e.g., R65.21). principal or first-listed
3. The code for the organ dysfunction. diagnosis.

Sepsis and Septic Shock Relating to

Pregnancy or Newborns GUIDANCE
CONNECTION
Sepsis during Labor
Read the ICD-10-CM
During the process of giving birth, a woman might develop a septic infection. In this
Official Guidelines for
case, code O75.3 Other infection during labor (Sepsis during labor) is reported. A
Coding and Reporting,
code from B95–B97 Bacterial and viral infectious agents should follow to specify the
section I. Conven-
pathogen causing the infection.
tions, General Coding
Guidelines and Chapter
Puerperal Sepsis Specific Guidelines,
Puerperal sepsis, also known as postpartum sepsis,puerperal peritonitis, or puerperal subsection C. Chapter-
pyemia, results from an infection that develops in a woman’s reproductive organs and Specific Coding Guide-
that was initiated during or following miscarriage or childbirth. This diagnosis is lines, chapter1. Certain
reported with code O85 Puerperal sepsis. Infectious and Parasitic
In addition, a code from B95-B97 Bacterial and viral infectious agents is required to Diseases, subsection d.
specify the pathogen causing the infection. If severe sepsis is documented, a code from 2) Septic shock.
R65.2- should also be reported.

Neonatal Sepsis
A fetus may contract an infection in utero, during the birth process (delivery),
or during the first 28 days after birth. In these cases, when a neonate is diag-
nosed with sepsis, the code will be reported from category P36 Bacterial sepsis of
newborn. An additional character is required to identify the pathogen that caused
the infection. If severe sepsis is documented, a code from R65.2- should also be
reported.

Septic Condition Resulting from Surgery GUIDANCE

Should a patient develop sepsis from an infection as a complication of a surgical pro- CONNECTION
cedure, you will list a code for that situation first. In the Alphabetic Index, find
Read the ICD-10-CM
Sepsis, postprocedural T81.4 Official Guidelines for
In the Tabular List, find Coding and Reporting,
section I. Conven-
T81.4xx- Infection following a procedure tions, General Coding
You can see, included with other non-essential modifiers Sepsis following a procedure Guidelines and Chapter
is listed. Specific Guidelines,
Read the note. You will see that there are three diagnoses that would be subsection C. Chapter-
easy to code incorrectly from this subcategory: Specific Coding Guide-
lines, chapter 1. Certain
obstetric surgical wound infection (O86.0) Infectious and Parasitic
postprocedural fever NOS (R50.82) Diseases, subsection d.
postprocedural retroperitoneal abscess (K68.11) 5) Sepsis due to a post-
procedural infection.
This is a great example of why it is so important to read carefully.

CHAPTER 5 
 Next, carefully read the three diagnoses listed in the note.
bleb associated endophthalmitis (H59.4-)
infection due to infusion, transfusion and therapeutic injection (T80.2-)
infection due to prosthetic devices, implants and grafts (T82.6-T82.7, T83.5-
T83.6, T84.5-T84.7, T85.7)
Don’t forget the Use Additional Code notations, also:
Use additional code to identify infection
Use additional code (R65.2-) to identify severe sepsis, if applicable
Then, continue with the usual coding sequence for sepsis, as reviewed earlier in this
section. Remember to refer to the physician’s documentation and the pathology report
to gather all of the details you need to code accurately.

ICD-10-CM
YOU CODE IT! CASE STUDY
Gregory Parrale, a 31-year-old male, had his appendix taken out last week. He comes to Dr. Gorman’s office for his
postsurgical follow-up visit. Dr. Gorman finds the surgical wound is erythematous, swollen, and painful to the touch.
He takes a swab of the fluid oozing from the site. The lab confirms a postoperative staph infection.

You Code It!

Go through the steps of coding, and determine the diagnosis code(s) to be reported for this encounter between
Dr. Gorman and Gregory Parrale.
Step #1: Read the case carefully and completely. 
Step #2: Abstract the scenario. Which main words or terms describe why the physician cared for the patient dur-
ing this encounter?
Step #3: Are there any details missing or incomplete for which you would need to query the physician? [If so, ask
your instructor.] 
Step #4: Check for any relevant guidance, including reading all of the symbols and notations in the Tabular List
and the appropriate sections of the Official Guidelines. 
Step #5: Determine the correct diagnosis code or codes to explain why this encounter was medically necessary. 
Step #6: Double-check your work.
Answer:

Did you determine the correct codes?

T81.4xxA Infection following a procedure, initial encounter
B95.8 Unspecified staphylococcus as the cause of diseases classified elsewhere
Good job!

Systemic Inflammatory Response Syndrome (SIRS)

without Infection
Systemic inflammatory response syndrome (SIRS) can develop in patients who have
not developed an infection. Instead the reaction may occur due to the presence of

132   PART II  |  REPORTING DIAGNOSES

a burn or other trauma, a malignant neoplasm, or the presence of pancreatitis. In
such cases, coding the condition will change slightly. You will code the following GUIDANCE
sequence: CONNECTION
1. The code for the underlying condition (e.g., T22.311- Third-degree burn of right Read the ICD-10-CM
forearm). Official Guidelines for
2. The code for SIRS from the subcategory R65.1- Systemic inflammatory response Coding and Reporting,
syndrome (SIRS) of non-infectious origin. section I.Conventions,
General Coding Guide-
3. The code for the acute organ dysfunction, when applicable. lines and Chapter
If the documentation indicates that the patient later developed an infection, you will Specific Guidelines,
code the diagnosis for the infection as shown earlier in this section, along with the subsection C. Chapter-
additional code for the underlying trauma or condition. Specific Coding Guide-
lines, chapter 18.
Symptoms, signs,
and abnormal clinical
5.8  Antimicrobial Resistance laboratory findings,
There are individuals who go to the doctor or clinic demanding a prescription for an not elsewhere classi-
antibiotic for the slightest sniffle. Touch a cart at the supermarket? Wipe antimicrobial fied, subsectiong. SIRS
gel on your hands. Unfortunately, there is an ongoing war on germs and, it turns out, due to non-infectious
the pathogens are winning. A natural phenomenon of adaptation to survive is one of process.
the reasons why antimicrobial drugs are no longer working. Biologists call this “adap-
tive immunity” . . . a concept similar to the process of vaccinations affording a patient
ultimate resistance to the effects of a specific pathogen. Only, in this case, it is the
pathogen building its own immunity.
In 1928, bacteriologist Alexander Fleming realized that a mold growing on a
culture plate actually had antibacterial benefit. The mold became known as “peni-
cillin” and it was found to be very effective against staphylococci bacteria—a seri-
ous and life-threatening human infection. This discovery saved millions of lives
as penicillins and other antibiotics were able to kill infection and prevent patients
from dying. More than eight decades later, antibiotics are no longer halting the
spread of infectious disease. And, in one perspective, they may actually be contrib-
uting to the spread.
The World Health Organization (WHO) defines “antimicrobial resistance (AMR)”
as the “. . . resistance of a micro-organism to an antimicrobial medicine to which it
was originally sensitive.” In addition to adaptive immunity, AMR is caused by the
overuse of antibiotics. In the United States, antibiotics are prescribed for patients
who actually do not need them an estimated 50% of the time. The Centers for Dis-
ease Control and Prevention (CDC) recommends that physicians wait for the results
of cultures and lab tests  before writing that prescription to ensure the bacteria or
virus proven to cause the patient’s infection can be fought off with the most effective
drug. And these tests will also identify when no prescription is in the patient’s best
interests, saving the money that would have been spent on medication that would not
work anyway.
Both inpatient and outpatient facilities are guilty of having less than effective infec-
tion control and prevention—the third underlying cause of AMR. The invisibility of
these tiny organisms makes it difficult for some individuals to believe and remember
to wash up or, at least, access antibacterial gel/foam.
Several codes are available to you to report AMR.

Coding for AMR

The CDC identified three pathogens as urgent threats: Clostridium difficile (C. diff),
carbapenem-resistant Enterobacteriaceae, and drug-resistant Neisseria gonorrhoeae.
Let’s look at some details about these three concerns.

CHAPTER 5 
 Primarily, one code category is used to report AMR. There is a note and a notation
for you:
 Z16 Resistance to antimicrobial drugs
CODING BITES NOTE: The codes in this category are provided as Use additional codes to iden-
A Physician’s Desk Ref- tify the resistance and non-responsiveness of a condition to antimicrobial drugs.
erence (PDR) or a Drug Code first the infection.
Guide can help you
connect the name of a
specific drug to a fam-
Clostridium difficile (C. diff)
ily name of drugs. For C. diffis a spore-forming, gram-positive anaerobic bacillus that causes life-­threatening
example, the quinolones diarrhea and that has been documented as causing about 250,000 infections each year,
are a family of synthetic which have resulted in about 14,000 deaths. Of those patients aged 65 and older infected
broad-spectrum antibi- with C. diff, more than 90% died. In total, C. diff costs us an estimated $1  ­billion
otics. Ciprofloxacin, also in excess health care costs. At greatest risk for contracting C. diff are hospitalized
known as Cipro, and patients, those who have been recently hospitalized, and those who have recently
levofloxavin, also known received medical care with a course of antibiotic therapy.
as Levaquin, are part of The CDC is calling for more data as they track these AMRs. ICD-10-CM gives us
the quinolones family of the tools to collect and submit these details. For example, these codes may be reported
drugs. for a patient with C. diff who is not responding to antibiotics:
Z16.23 Resistance to quinolones and fluoroquinolones
Z16.24 Resistance to multiple antibiotics

Carbapenem-Resistant Enterobacteriaceae (CRE)

CRE refers to a collection of microorganisms that have developed resistance to
antibiotics. This grouping, or family, includes Klebsiella species and Escherichia
coli (E. coli). Carbapenem antibiotics are beta-lactam antibiotics used as a last
resort for many bacterial infections (brand names include Invanz®, Primaxin®, and
­Merrem®); however, increased resistance to these antibiotics has made them virtu-
ally ineffective.
Klebsiella pneumoniae carbapenemase (KPC) and New Delhi Metallo-beta-­lactamase
(NDM), both types of CRE, are the enzymes responsible for rendering carbapenems
ineffective. CRE causes a variety of diseases, ranging from pneumonia to urinary tract
infections to serious bloodstream or wound infections. Patients who are ill, exposed
to hospital environments, and in long-term care facilities are most susceptible to CRE
infection.
Z16.19 Resistance to other specified beta lactam antibiotics

Neisseria gonorrhoeae Bacterial Infection

Gonorrhea is caused by the Neisseria gonorrhoeae bacterium and is most often
transmitted by sexual contact. This microorganism replicates easily in the warm,
moist areas of the reproductive tract, as well as in the mouth, throat, eyes, and anus.
Approximately 30% of gonorrhea infections are found to be drug resistant and, often,
patients infected with drug-resistant Neisseria gonorrhoeae do not exhibit any signs
or symptoms. This disease can have long-lasting effects on the patient, including pel-
vic inflammatory disease that can result in infertility in women and epididymitis (an
inflammation of the structure within the testis that stores sperm and transports the
sperm to the vas deferens) in men. A patient who has contracted gonorrhea is more
susceptible to contracting the human immunodeficiency virus (HIV).
When the physician’s documentation states the patient is resistant to one of these
antibiotics, normally prescribed to combat a diagnosis of Neisseria gonorrhoeae,
report one of these codes in addition to the code for the infection (based on the ana-
tomical site). Code Z16.19 or Z16.29 explains why the physician prescribed a differ-
ent antibiotic.

134   PART II  |  REPORTING DIAGNOSES

 Z16.19 Resistance to other specified beta lactam antibiotics (resistance to
cephalosporins)
Z16.29 Resistance to other single specified antibiotic (resistance to macro-
lides) (resistance to tetracyclines)

Methicillin-Resistant Staphylococcus aureus Infection

Methicillin-resistant Staphylococcus aureus (MRSA) is a bacterial (staph) infection
that is essentially unaffected by certain antibiotics. MRSA is spread from one person
to another by direct contact with the infection, such as touching a skin bump or infec-
tion that is draining pus. MRSA can be spread directly, for example, by touching an
infected person’s rash, or it can be spread indirectly, such as by touching a used ban-
dage contaminated with MRSA or by sharing a towel or razor that has come in contact
with infected skin. One of the most frequent anatomical sites of MRSA colonization is
the nose; bacteria can be found in nasal secretions.
To properly report these diagnoses, code the current infection due to MRSA and the
MRSA infection separately with codes:
A49.02 Methicillin resistant Staphylococcus aureus infection, unspecific
site GUIDANCE
B95.62 Methicillin resistant Staphylococcus aureus infection as the cause CONNECTION
of diseases classified elsewhere
Read the ICD-10-CM
Official Guidelines for
Combination Codes Coding and Reporting,
There are some infections commonly known to be caused by the patient’s current section I. Conven-
MRSA status. In these cases, ICD-10-CM provides a combination code that can be tions, General Coding
used—the one code instead of two different codes. Two examples of these combina- Guidelines and Chapter
tion codes are Specific Guidelines,
subsection C. Chapter-
A41.02 Sepsis due to Methicillin resistant Staphylococcus aureus
Specific Coding Guide-
J15.212 Pneumonia due to Methicillin resistant Staphylococcus aureus
lines, chapter 1. Certain
Notice that the code descriptions include both the MRSA and another infection: septi- Infectious and Parasitic
cemia in the first code and pneumonia in the second. Diseases, subchapter
e. Methicillin resistant
Staphylococcus aureus
(MRSA) conditions.
EXAMPLE
Sally Hayes-Meyer was diagnosed with acute cystitis due to MRSA.
N30.00 Acute cystitis without hematuria
B95.62 Methicillin resistant Staphylococcus aureus infections as the causes
of diseases classified elsewhere

Methicillin-Resistant Staphylococcus aureus Colonization

When a patient is documented as having a MRSA screening or nasal swab test that is
positive yet there is no current illness, this is called colonization. Colonization indi-
cates that the patient is a carrier. When this is the case, report either
Z22.321 Carrier or suspected carrier, Methicillin susceptible Staphylococcus
aureus (MSSA)
or
Z22.322 Carrier or suspected carrier, Methicillin resistant Staphylococcus
aureus (MRSA)

CHAPTER 5 
 The coding guidelines state that it is possible for one patient to be a MRSA carrier
and have a current MRSA infection at the same encounter. When this is the case, you
are permitted to report code Z22.322 and a code for the MRSA infection.

ICD-10-CM
YOU CODE IT! CASE STUDY
REFERRING PHYSICIAN: Audra Starch, MD
REASON FOR CONSULTATION: MRSA pneumonia, fever.
HISTORY OF PRESENT ILLNESS: This 77-year-old male has a history of recent stroke. Garden Nursing Home, where
he is a resident, requested a consultation due to his increased cough, along with some pulmonary congestion. Dr.
Starch prescribed an extended spectrum penicillin (Zosyn, 4.5g q 6hr via IV bedside) for the patient’s low-grade
fever. Sputum cultures evidenced MRSA, leading to the request for this consultation. 
Patient is post-CVA aphasic. Daughter is present and serves as primary relator. Nurse’s notes document that the
patient has been aspirating in conjunction with the increasing frequency of cough. Overall status has decreased due
to these situations. At this time, the patient appears to be resting comfortably without any complaints. 
ASSESSMENT AND PLAN:
1. Pathology report shows: positive sputum cultures with methicillin-resistant Staphylococcus aureus.  
2. Fever, most likely secondary to pneumonia.
RX: Vancomycin, 500mg q 6hr IV x 10 days to treat MRSA
ceftriazone, 2 g q 12, IM x 7 days to treat UTI/E. coli

You Code It!

Read Dr. Starch’s documentation about this patient’s condition and determine the accurate diagnosis code or
codes. 
Step #1: Read the case carefully and completely. 
Step #2: Abstract the scenario. Which main words or terms describe why the physician cared for the patient dur-
ing this encounter?
Step #3: Are there any details missing or incomplete for which you would need to query the physician? [If so, ask
your instructor.] 
Step #4: Check for any relevant guidance, including reading all of the symbols and notations in the Tabular List
and the appropriate sections of the Official Guidelines. 
Step #5: Determine the correct diagnosis code or codes to explain why this encounter was medically
necessary. 
Step #6: Double-check your work.
Answer:
Did you determine this to be the correct code?
J15.212 Pneumonia due to methicillin resistant Staphylococcus aureus
Good job!
NOTE: The fever is not reported separately because it is an inclusive sign of the pneumonia.

136   PART II  |  REPORTING DIAGNOSES

Chapter Summary

CHAPTER 5 REVIEW
The contagious nature of infectious diseases makes them very serious. The coding of
such conditions, and their treatments, has statistical significance, in addition to the
importance of reimbursement.
Ordinary day-to-day activities, such as sneezing, coughing, having sex, or play-
ing baseball, may pass an infectious disease from one person to another. Health care
advancements have enabled the use of vaccines to prevent such conditions as measles,
mumps, varicella, or human papillomavirus (HPV). Other conditions require behav-
ioral or lifestyle changes to prevent their spread.
In any case, the health care industry is charged with helping patients, and it is, or
will be, your job to code all of these infectious diseases correctly.

CODING BITES
Did you know . . .?
• Number of visits to physician offices for infectious and parasitic diseases: 20.2
million (2012)
• Number of new tuberculosis cases: 9,582 (2013)
• Number of new salmonella cases: 50,634 (2013)
• Number of new Lyme disease cases: 36,307 (2013)
• Number of new meningococcal disease cases: 556 (2013)

You Interpret It! Answers

1. Needlestick, 2. Airborne, 3. Drinking water, 4. Insect bites, 5. Droplets, 6. Bacteria
(streptococcus bacteria), 7. Virus (influenza virus A or B), 8. Virus (human p­ apillomavirus
(HPV)), 9.Virus (measles virus), 10. Bacteria (staphylococcus bacteria), 11. Parasite (deer
tick), 12. Fungus (bodily fluid exchange), 13. Parasite (mosquito), 14. Fungus (airborne,
contaminated water), 15. Parasite (lice), 16. Fungus (­microsporum), 17. Fracture, 18. HIV,
19. Complication of pregnancy, 20. Type 1 diabetes

CHAPTER 5 REVIEW
Coding ­Infectious Diseases Enhance your learning by
completing these exercises and
more at connect.mheducation.com!

Let’s Check It! Terminology

Match each key term to the appropriate definition.

Part I A. Acute
1. LO 5.1  A hospital-acquired condition.  B. Asymptomatic
2. LO 5.2  A singxle-celled microorganism that causes disease. C. Bacteria
3. LO 5.1  A condition that can be transmitted from one person to another.  D. Chronic
4. LO 5.1  Long-lasting; ongoing.  E. Fungi
5. LO 5.1  A condition affecting the immune system.  F. Human Immunodefi-
6. LO 5.4  Group of organisms, including mold, yeast, and mildew, that cause infection.  ciency Virus (HIV)
7. LO 5.1  Severe.  G. Infection 
8. LO 5.1  The invasion of pathogens into tissue cells.  H. Infectious
9. LO 5.1  No symptoms or manifestations.  I. Inflammation
10. LO 5.1  The reaction of tissues to infection or injury; characterized by pain, J. Nosocomial
swelling, and erythema. 

CHAPTER 5 
 Part II
CHAPTER 5 REVIEW

1. LO 5.3  Microscopic particles that initiate disease, mimicking the characteris- A. Parasites 
tics of a particular cell, and can reproduce only within the body of the
B. Pathogen 
cells that they have invaded. 
C. Sepsis 
2. LO 5.4  Tiny living things that can invade and feed off of other living things. 
D. Septic Shock 
3. LO 5.1  Any agent that causes disease; a microorganism such as a bacterium or
virus.  E. Septicemia 
4. LO 5.7  Generalized infection spread through the body via the bloodstream; F. Severe Sepsis 
blood infection.  G. Systemic 
5. LO 5.7  Sepsis with signs of acute organ dysfunction.  H. Systemic Inflammatory
6. LO 5.7  A definite physical reaction, such as fever, chills, etc., to an unspecified Response Syndrome
pathogen.  (SIRS) 
7. LO 5.1  Spread throughout the entire body. I. Tuberculosis 
8. LO 5.2  An infectious condition that causes small rounded swellings on mucous J. Viruses 
membranes throughout the body. 
9. LO 5.7  Condition typified by two or more systemic responses to infection; a
specified pathogen. 
10. LO 5.7  Severe sepsis with hypotension; unresponsive to fluid resuscitation.

Let’s Check It! Concepts

Choose the most appropriate answer for each of the following questions.
1.LO 5.1  The body’s response to an infection may include the sign or symptom of
a. rash. b.  blurred vision. c.  increased body temperature. d.  reduced body temperature.
2. LO 5.2  _____ is a serious infection of the skin that may be either a staph infection (staphylococcal bacteria) or a
strep infection (streptococcal bacteria).
a. Impetigo b.  Cellulitis c.  Hepatitis d.  Meningitis
3. LO 5.3  Grant Harris, a 19-year-old male, is diagnosed with herpes zoster keratoconjunctivitis. How is this
coded?
a. B02.30 b.  B02.31 c.  B02.32 d.  B02.33
4. LO 5.4  All of the following are parasites except
a. lice. b.  mites. c.  warts. d.  worms.
5. LO 5.5  Aspiration pneumonia is a
a. viral infection. b.  bacterial infection. c.  fungal infection. d.  parasitic infection.
6. LO 5.6  A woman with HIV-positive status is pregnant and in her second trimester. What must be the first-listed
code?
a. O98.7 b.  O98.71 c.  O98.711 d.  O98.712
7. LO 5.6   Exposure to HIV will be coded with which code?
a. Z20.4 b.  Z20.5 c.  Z20.6 d.  Z20.7
8. LO 5.7  When coding for SIRS in a patient who has not developed an infection, you would code in which
sequence?
a. the code for the acute organ dysfunction, the code for SIRS, the code for the underlying condition
b. the code for SIRS, the code for the acute organ dysfunction, the code for the underlying condition
c. the code for the underlying condition, the code for SIRS, the code for the acute organ dysfunction
d. none of these

138   PART II  |  REPORTING DIAGNOSES

 9. LO 5.7  The code for septic shock may be all of the following except

CHAPTER 5 REVIEW
a. the first-listed diagnosis code.
b. an additional code.
c. used to identify the inclusion of hypotension.
d. added to the codes required for severe sepsis.
10. LO 5.8  Methicillin-resistant Staphylococcus aureus (MRSA) is spread from one person to another by
a. direct contact.
b. indirect contact.
c. both direct and indirect contact.
d. none of these.

Let’s Check It! Guidelines

Refer to the Official Guidelines and fill in the blanks according to the Chapter 1, Certain Infectious and Parasitic Dis-
eases, Chapter-Specific Coding Guidelines.
I.C.16.f R65.2  infection  synonymous 
informed  confirmed  diagnosis  underlying 
Septic  B95.62  2 inconclusive 
unrelated  documentation  sepsis  organ 
R75  severe  urosepsis  Z71.1 
postprocedural  queried  principal 
1. Code only _____ cases of HIV infection/illness. This is an exception to the hospital inpatient guideline _____.
2. If a patient with HIV disease is admitted for an _____ condition, the code for the unrelated condition should be
the _____ diagnosis.
3. Patients with _____ HIV serology, but no definitive _____ or manifestations of the illness, may be assigned code
_____. 
4. When a patient returns to be _____ of his/her HIV test results and the test is negative, use code _____. 
5. The term _____ is a nonspecific term. It is not to be considered _____ with sepsis. Should a provider use this
term, he/she must be _____ for clarification.
6. The coding of severe sepsis requires a minimum of _____ codes: first code for the _____ systemic infection, fol-
lowed by a code from subcategory _____, Severe sepsis.
7. _____ shock generally refers to circulatory failure associated with _____ sepsis, and therefore, it represents a type
of acute _____dysfunction. 
8. As with all _____ complications, code assignment is based on the provider’s _____ of the relationship between
the _____ and the procedure. 
9. Newborn _____ See Section _____. Bacterial sepsis of Newborn.
10. When there is documentation of a current infection due to MRSA, and that infection does not have a
combination code that includes the causal organism, assign the appropriate code to identify the condition along
with code _____.

Let’s Check It! Rules and Regulations

Please answer the following questions from the knowledge you have gained after reading this chapter.
1. LO 5.2/5.3  Explain the difference between a bacterial infection and a viral infection, and give examples of each.
2. LO 5.4  What is the difference between a parasitic and a fungal infection? Include an example of each in your answer.

CHAPTER 5 
 3. LO 5.1  What is a nosocomial infection, and where do such infections occur? 
CHAPTER 5 REVIEW

4. LO 5.7  Discuss the difference between septicemia and SIRS. 

5. LO 5.8  What is MRSA and how is it spread? 

ICD-10-CM
YOU CODE IT! Basics
First, identify the main term in the following diagno- 8. Kaposi’s sarcoma of the lymph nodes: 
ses; then code the diagnosis. a. main term: _____ b. diagnosis: _____
Example: Neonatal candidiasis:  9. Cellulitis of upper right limb: 
a. main term: candidiasis   b. diagnosis: P37.5 a. main term: _____ b. diagnosis: _____
10. Generalized blastomycosis: 
1. Allergic bronchopulmonary aspergillosis:
a. main term: _____ b. diagnosis: _____
a. main term: _____ b. diagnosis: _____
11. Acute disseminated, noninfectious,
2. Chronic active hepatitis: 
encephalomyelitis: 
a. main term: _____ b. diagnosis: _____
a. main term: _____ b. diagnosis: _____
3. Sepsis, streptococcal, group B: 
12. Laryngeal diphtheria: 
a. main term: _____ b. diagnosis: _____
a. main term: _____ b. diagnosis: _____
4. Pulmonary cryptococcosis:  
13. Retroperitoneal tuberculosis: 
a. main term: _____ b. diagnosis: _____
a. main term: _____ b. diagnosis: _____
5. Herpes zoster meningitis:
14. Shigellosis, group C: 
a. main term: _____ b. diagnosis: _____
a. main term: _____ b. diagnosis: _____
6. Chronic otitis media, right ear: 
15. Ringworm honeycomb: 
a. main term: _____ b. diagnosis: _____
a. main term: _____ b. diagnosis: _____
7. Jungle yellow fever: 
a. main term: _____ b. diagnosis: _____

ICD-10-CM
YOU CODE IT! Practice
Using the techniques described in this chapter, carefully read through the case studies and determine the most
accurate ICD-10-CM code(s) and external cause code(s), if appropriate, for each case.
1. Ben Kenton, a 49-year-old male, presents today with a high fever, chills, nausea, and diarrhea. After an exam-
ination and reviewing the results of the blood tests, Dr. Daniels diagnoses Ben with West Nile fever. 
2. Robin Pullen, a 36-year-old female, comes to see Dr. Ditolla because she is running a fever and has a sore
throat and overall body aches. Test results are positive for H1N1. Robin is diagnosed with swine influenza. 
3. Joan Kenney, a 27-year-old female, is having difficulty breathing. Dr. Aung documents a fever of 101 F and
facial edema. Joan recently returned home from a trip to Asia. Joan said they were contending with some sort
of larval infestation in Asia. Joan is diagnosed with nasopharyngeal myiasis.

140   PART II  |  REPORTING DIAGNOSES

 CHAPTER 5 REVIEW
4. Babbs Fisher, a 48-year-old female, just returned from an African vacation. Babbs is brought in by her ­husband,
George, who noticed she was acting confused. Dr. Carla notes a low fever. Babbs states she feels tired and has
a sore throat. She started vomiting this morning and admits to abdominal pain. Dr. Carla examines Babbs and
orders an enzyme-linked immunosorbent assay (ELISA) test, which confirms the diagnosis of Ebola virus.
Babbs is admitted to Weston Hospital for treatment.  
5. Steven Jordan, a 51-year-old male, comes to see Dr. Kolb because he is experiencing nausea and vomiting
and his stool is unusually light in color. Steven is accompanied by his wife, Sally. Sally says her husband
seems confused and less alert lately. Upon examination, Dr. Kolb notes hepatosplenomegaly, jaundice, and
RUQ tenderness. Steven is admitted to the hospital, where blood test results confirm the presence of IgG anti-
HAV antibodies. Steven is diagnosed with acute hepatitis A. 
6. John Brennen, a 7-year-old male, is brought in by his parents. Johnny has developed a hard cough and
says his sides hurt. Dr. Travis, Johnny’s pediatrician, completes blood work and takes a CXR and
­nasopharyngeal specimen. A subconjunctival hemorrhage is noted in the left eye. Test results confirm a
diagnosis of whooping cough due to Bordetella pertussis with pneumonia. Johnny is admitted to Weston
Hospital. 
7. Frances Lowder is having difficulty breathing. She also admits to a bad headache, sore throat, and no appe-
tite. She is 28 weeks pregnant and was diagnosed with HIV 3 years ago. Dr. Mabry notes a temperature of
102 F and papules over her upper body. Blood tests confirm the diagnosis of varicella with pneumonia. Fran-
ces is admitted to Weston Hospital.  
8. Jenny Cassidy, a 4-year-old female, is brought in by her parents to see her pediatrician, Dr. Harmon. Jenny
has a fever and a rash on her back. Dr. Harmon notes a “strawberry tongue.” The completed CBC test con-
firms a diagnosis of scarlet fever. 
9. Lee Greenwalt, a 9-year-old male, is brought in by his parents. Lee is not feeling well and is losing weight.
Mrs. Greenwalt states Lee seems to be sweating at night. Dr. Moon documents a bitonal cough, a temperature
of 100 F, and a general weakening. Lee is admitted to Weston Hospital. Test results confirm a diagnosis of
tuberculosis of tracheobronchial lymph nodes. 
10. Donald Rampey, a 72-year-old male, was admitted to the hospital with severe sepsis due to streptococcus,
group B. Donald developed acute hepatic failure. 
11. Mendenhall Aguirre, a 37-year-old male, presents today with a burning sensation during urination.
Dr. Boykin collects a penile swab specimen for a microscopic examination, which confirms trichomonal
prostatitis. 
12. Gayle Cassels, a 12-year-old female, is brought in by her mother to see Dr. Kellum. Gayle has had a fever for
3 days with a head cold. Dr. Kellum notes conjunctivitis, an erythematous rash on the head and neck, as well
as Koplik’s spots on the inside of Gayle’s mouth. The salivary measles-specific IgA test confirmed the diag-
nosis of measles. 
13. Steven Crooks, a 16-year-old male, presents today with a sore throat. Dr. Hoffman notes acute pharyngitis
with a low-grade fever, as well as petechiae on the roof of the mouth. A serological test confirms the diagno-
sis of Epstein–Barr infectious mononucleosis. 
14. Donna Burgess, a 33-year-old female, comes to see Dr. Freeman today with a headache, fever, and chest pain.
The ELISA serological test confirms a diagnosis of Coxsackie B virus infection with pericarditis. 
15. Victor Lockhart, a 29-year-old male, presents today with a fever of 100.6 F. He says 1 minute he is sweating
and the next he is shivering and his stomach hurts. Dr. Osterlund documents paleness and tenderness in the
right hypochondria region. Victor is admitted to Weston Hospital, where blood tests, a liver function test, and
a CT scan confirm the diagnosis of amebic liver abscess due to Entamoeba histolytica.

CHAPTER 5 
CHAPTER 5 REVIEW

ICD-10-CM
YOU CODE IT! Application
The following exercises provide practice in abstracting physicians’ documentation from our textbook’s health care
facility, Prader, Bracker, & Associates. These case studies are modeled on real patient encounters. Using the tech-
niques described in this chapter, carefully read through the case studies and determine the most accurate ICD-10-
CM code(s) for each case study.

WESTON HOSPITAL
629 Healthcare Way • SOMEWHERE, FL 32811 • 407-555-6541
PATIENT: GALEANA, ROBERT
ACCOUNT/EHR #: GALERO001
DATE: 09/16/18
Attending Physician: Oscar R. Prader, MD
This 33-year-old male was admitted for a high fever, abdominal pain, and a noted moderate decrease in
alertness. Robert has been on oral antibiotics for a left ear infection for approximately 7 days. I last saw
the patient in the office four days ago when his left ear spontaneously drained.
PE: Ht: 5’ 11”, Wt: 194, T: 101.2, R: 19, BP: 134/86. Pt seems confused. Left ear drainage continues.
CSF analysis reveals normal pressure, a slightly thicker viscosity with a cloudy appearance. Results of
CSF exam showed 6875 WBC, 35 g/L protein, and 23 mg/dL glucose.
Arbovirus is identified in two blood cultures. Pt responds positively to antimicrobial therapy.
DX: Meningitis due to arbovirus, urban yellow fever; acute suppurative otitis media.

ORP/pw  D: 09/16/18 09:50:16  T: 09/18/18 12:55:01

Determine the most accurate ICD-10-CM code(s).

WESTON HOSPITAL
629 Healthcare Way • SOMEWHERE, FL 32811 • 407-555-6541
PATIENT: MURPHY, ADRIENNE
ACCOUNT/EHR #: MURPAD001
DATE: 08/11/18
Attending Physician: Renee O. Bracker, MD
Pt is admitted with a chief complaint of shortness of breath of approximately 7 to 10 days duration and
a feeling of uneasiness and discomfort. Pt was found to be HIV-positive in May 2014, and diagnosed
with AIDS in February 2016. Patient also complains of vision loss. She states she can’t see and it hurts
when you touch her eyes and face.
PE: Ht: 5’4”, Wt: 126, T: 101.6. The physician notes pustules on forehead, right eye, and bridge of nose.
A Tzanck smear with methylene blue stain was performed; results positive.
DX: Herpesviral keratoconjunctivitis (simplex), secondary to AIDS
Plan: Acyclovir, IV: 10mg/kg q 8 hr

ROB/pw  D: 08/11/18 09:50:16  T: 08/13/18 12:55:01

Determine the most accurate ICD-10-CM code(s).

142   PART II  |  REPORTING DIAGNOSES

 CHAPTER 5 REVIEW
PRADER, BRACKER, & ASSOCIATES
A Complete Health Care Facility
159 Healthcare Way • SOMEWHERE, FL 32811 • 407-555-6789
PATIENT: LUPO, THERESA
ACCOUNT/EHR #: LUPOTH001
DATE: 09/16/18
Attending Physician: Renee O. Bracker, MD
Pt presented to office with a laceration to the left knee that occurred approximately 10 days ago. The-
resa states that she fell as she was getting up from a chair in her backyard. She cleaned the area and
put an OTC antibiotic ointment on the bandage before applying it to the wound. She has changed the
bandage daily.
PE: Ht: 5”2”, Wt: 120, T: 99.6, R: 18, BP: 128/78. After removing the bandage, a widely infected wound was
found with small pieces of gravel, with resulting cellulitis to the knee. Extensive irrigation and debridement
using sterile water were performed, but closure was not attempted pending resolution of the infection.
Culture of the wound revealed streptococcus D.
1,200 units of Bicillin CR IM was given.
Rx for oral antibiotics was given to Pt.
Pt to return in 3 days for follow-up.

ROB/pw  D: 09/16/18 09:50:16  T: 09/18/18 12:55:01

Determine the most accurate ICD-10-CM code(s).

PRADER, BRACKER, & ASSOCIATES

A Complete Health Care Facility
159 Healthcare Way • SOMEWHERE, FL 32811 • 407-555-6789
PATIENT: PLATTENBAUM, BENJAMIN
ACCOUNT/EHR #: PLATBE001
DATE: 08/11/18
Attending Physician: Oscar R. Prader, MD
Pt, a 32-year-old male, presents with continued complaints of nasal drainage, pressure behind his eyes,
and a sore throat. I last saw Ben two weeks ago when he was diagnosed with acute frontal sinusitis due
to Staphylococcus aureus. Prescription for amoxicillin 250mg q 8 hr. was given.
PE: Ht: 6’ 2”, Wt: 210, T 100.1, R 20, BP: 134/86. Nasal endoscopy confirms the diagnosis that acute
sinusitis is still present. MRSA, specifically to penicillins, is apparent. IV injection levofloxacin, 500 mg.
Rx: Levofloxacin, 250 mg q 24 hr x 10 days
Recommendation for bed rest, lots of fluids. Pt to return prn.

ORP/pw  D: 08/11/18 09:50:16  T: 08/13/18 12:55:01

Determine the most accurate ICD-10-CM code(s).

CHAPTER 5 
CHAPTER 5 REVIEW

WESTON HOSPITAL
629 Healthcare Way • SOMEWHERE, FL 32811 • 407-555-6541
PATIENT: SAMUELS, BERNARD
ACCOUNT/EHR #: SAMUBE001
DATE: 09/16/18
Attending Physician: Oscar R. Prader, MD
This 82-year-old male was admitted to the hospital with high fever, myalgia, headache, rhinitis, and a
nonproductive cough. He also shows signs of confusion.
PE: Ht: 5’9”, Wt: 173, T: 103.2, R: 22, BP: 90/59. Pt’s condition deteriorated with definite signs of septic
shock, pneumonia, and hypotension. He is now in acute renal failure.
DX: Influenza with pneumonia due to E. coli; septic shock, acute renal failure.

ORP/pw  D: 09/16/18 09:50:16  T: 09/18/18 12:55:01

Determine the most accurate ICD-10-CM code(s).

144   PART II  |  REPORTING DIAGNOSES

Coding Neoplasms

Learning Outcomes
6
Key Terms
After completing this chapter, the student should be able to: Benign
Carcinoma
LO 6.1 Identify the medical necessity for screenings and diagnostic Ectopic
testing for malignancies. Functional Activity
LO 6.2 Discern the various types of neoplasms. Malignant
LO 6.3 Interpret the Table of Neoplasms accurately. Mass
LO 6.4 Employ the directions provided in the Chapter Notes at the Metastasize
Morphology
head of the Neoplasms section of the Tabular List.
Neoplasm
LO 6.5 Apply the guidelines for sequencing admissions due to com- Overlapping
plications of neoplasms and/or their treatments. Boundaries
Topography

Remember, you need to follow along in GUIDANCE

ICD-10-CM

  STOP! your ICD-10-CM code book for an optimal CONNECTION

learning experience. Read the ICD-10-CM
Official Guidelines for
Coding and Reporting,
6.1  Screening and Diagnosis section I. Conven-
tions, General Coding
Screenings Guidelines and Chapter
Specific Guidelines,
You may already know about screenings. Screenings are provided with the intention of
subsection C. Chapter-­
identifying a disease or abnormality as early as possible. When a neoplasm is detected
Specific Coding Guide-
and treated early in its formation, the treatment is less intense, making the process
lines, chapter 21.
easier on the patient and less costly. Also important is the proven fact that the earlier
Factors influencing
a malignancy is dealt with, the better the chances of recovery and survival. Patients
health ­status and
with no signs or symptoms are typically scheduled for various screenings based on
contact with health
guidelines related to age, family history, or personal history.
services (­Z00-Z99),
When you are coding for a patient encounter for a screening for a possible malignant neo-
­subsection c.5)
plasm, such as a mammogram or a colonoscopy, you will report a code from this category:
Screening
Z12 Encounter for screening for malignant neoplasms

EXAMPLE
You would report code:
Z12.5 Encounter for screening for malignant neoplasm of prostate
for an encounter when a 59-year-old man goes in for a screening prostate exam,
as per recommendations for men aged 55 to 69 years of age.

Read the notation directly below the Z12 code category:

Screening is the testing for disease or disease precursors in asymptomatic indi-
viduals so that early detection and treatment can be provided for those who
test positive for the disease.
 Also, read the next notation carefully:
Use additional code to identify any family history of malignant neoplasm (Z80.-)
ICD-10-CM reminds you that an additional code should be reported when the prompting
factor for the screening is not age but family history. Family history means that someone
in the patient’s past bloodline had been diagnosed with the condition being screened for,
and it is known that this places the patient at a higher risk for developing the condition.

EXAMPLE
You would report code:
Z80.42 Family history of malignant neoplasm of prostate
in addition to code Z12.5 for an encounter when a 44-year-old man goes in for
a screening prostate exam because his father and brother were both diagnosed
with prostate cancer, dramatically increasing his risk.
GUIDANCE
CONNECTION
A personal history code (Z85.-) should be reported for those patients who may
Read the ICD-10-CM receive screening tests more frequently than others. For example, a woman with a his-
Official Guidelines for tory of breast cancer may get mammograms every 6 months rather than annually. The
Coding and Reporting, personal history of breast cancer code will support medical necessity for this increase
section I. ­Conventions, in the frequency of testing.
General Coding Guide-
lines and ­Chapter
Specific Guidelines, EXAMPLE
subsection C. Chapter-­ You would report code:
Specific Coding Guide-
Z85.3 Personal history of malignant neoplasm of breast
lines, chapter 21.
Factors influencing in addition to code Z12.31 Encounter for screening mammogram for m ­ alignant
health status and neoplasm of breast for an encounter when a 57-year-old female goes in for a
contact with health screening mammogram every 6 months, instead of the usual (once a year), because
services (Z00-Z99), sub- the fact that she had a malignant neoplasm of her breast a few years ago dramati-
section c.4) History (of). cally increases her risk for a recurrence.

The Z12 code category also carries an notation to remind you of the
difference between a diagnostic test, which is performed when a patient does exhibit
signs or symptoms, and a screening test, which is performed with the intention of early
detection of disease without signs or symptoms.
encounter for diagnostic examination—code to sign or symptom

EXAMPLE
You would report code:
N63.- Unspecified lump in breast
for an encounter when a 62-year-old female goes in for a mammogram because
she felt a lump in her breast during her monthly self-check and her gynecologist
confirmed it was suspicious.

Confirming a Diagnosis
Once the patient exhibits signs, such as a lump found during a physical examination
or an abnormality identified during a screening test, a pathologist must determine the
essence of the neoplasm. This is the only way to factually distinguish between benign
cells and malignant cells.

146   PART II  |  REPORTING DIAGNOSES

 Generally, specimens may be provided to the laboratory in various forms: blood
(capillary or vein), urine, semen, sputum, swabs (that carry tissue cells, pus, or other CODING BITES
excretion), or tissue specimens (surgical samples taken during a biopsy). Most often The only way to confirm
with neoplasms, a biopsy is necessary. You will need to ensure that an accurate ICD- a diagnosis of a malig-
10-CM diagnosis code is presented with the specimen to confirm medical necessity nancy is for the physi-
for the diagnostic testing, such as signs and symptoms. cian to perform a biopsy
(surgical removal of all or
part of the tumor tissue)
EXAMPLES
and submit that tissue for
R91.8 Other nonspecific abnormal finding of lung field (mass on lung)  pathological examina-
R93.1 Abnormal findings on diagnostic imaging of heart and coronary tion. Therefore, you can
circulation understand why report-
Abnormal findings of diagnostic tests justify the need for additional tests and ing a malignancy and not
procedures. specifying the anatomi-
cal location of the tumor
would be unlikely.
Blood tests can also provide important information with regard to malignancies in the
body. For example, an increased white blood cell (WBC) count, also known as leukocyto-
sis, may be a sign that neoplastic cells have been produced in the bone marrow and released
into the bloodstream—common in conditions such as leukemic neoplasia and other myelo-
proliferative disorders. Many types of pathological and imaging tests can provide critical
information to the physician seeking to confirm, or deny, a diagnosis of a malignancy. Tests
available depend upon the anatomical site and the type of malignancy (see Table 6-1).

Test Results
You will see pathology reports in the patient’s chart, whether you work in a hospital or
a physician’s office. Some examples of reports include
∙ Histopathology: A punch biopsy of the overlying skin reveals an adenocarcinoma
with diffuse involvement of the dermis and extensive invasion of the dermal lym-
phatics. The adenocarcinoma is composed of irregular nests with some areas form-
ing tubercles. Mitotic figures, including atypical forms, are seen. The tumor was
ER −, PR −, Her2 +, CK7 +, and CK 20 −.
∙ Tissue biopsy culture: Negative for any growth
∙ Lumbar puncture: negative for organisms
∙ Blood culture: 2/2 positive for Neisseria meningitidis
∙ Labs: WBC: 8.6, Hgb/Hct: 9.4/26.3, Platelets: 222, BUN: 71, Creatinine: 6.8, U/A:
2+ protein, 3+ blood, ANA: negative, Hepatitis B surface antigen: negative, Hepatitis
C antibody: negative, Serum cryoglobulins: negative, HIV: negative, cANCA: posi-
tive (1:1280), Tissue culture: negative, Initial blood cultures: negative, CXR: bilat-
eral opacities.
Pathology reports may also provide information on the grading and/or staging of the
tumor. Grading a tumor is the microscopic analysis of the tumor cells and tissue to describe
how abnormal they appear. Staging, however, evaluates the size and location of the tumor,
as well as determination of any signs or evidence of metastasis. In some cases, you will
need to know the grade of a patient’s tumor so you can determine the correct code.

EXAMPLES
C82.07 Follicular lymphoma grade 1, spleen
C82.16 Follicular lymphoma grade II, intrapelvic lymph nodes
These two codes are examples of those with code descriptions that require you to
check the physician’s documentation and pathology reports to identify the grade
of the tumor.
 TABLE 6-1  Some Common Tests Performed When Various Types of Malignan-
cies Are Suspected
Malignant Neoplasm of the Cervix
∙ Abdominal ultrasound
∙ Cervical biopsy
∙ Colposcopy
∙ CT scan of the abdomen and pelvis
Malignant Neoplasm of the Colon and Rectum
∙ Barium enema
∙ Carcinoembryonic antigen (CEA)
∙ Colonoscopy
∙ Stool for occult blood
Leukemia/Lymphoma
∙ Blood smear
∙ Bone marrow biopsy
∙ Cell surface immunophenotyping
∙ Cryoglobulins
Malignant Neoplasm of the Lung
∙ Alpha-1 antitrypsin
∙ Bone scan
∙ Bronchoscopy
∙ Chest x-ray
∙ Lung biopsy
Malignant Neoplasm of the Ovary
∙ CA-125
∙ Laparoscopy
∙ Paracentesis
∙ Pyelography
Malignant Neoplasm of the Prostate
∙ Acid phosphatase
∙ CT scan of the pelvis
∙ Cystoscopy
∙ MRI of the prostate
∙ Prostate specific antigen (PSA)

TABLE 6-2  Cancer Stages

Tumor Stage What the Stage Describes

Stage 0 Abnormal cells are present but have not spread to nearby tissue. Also
known as carcinoma in situ, or CIS. CIS is not malignant, but it may
evolve into malignancy.
Stage I, Malignant cells are present. The higher the number, the larger the
Stage II, ­malignant tumor and the more it has metastasized to nearby tissues.
Stage III
CODING BITES Stage IV Malignant cells have metastasized to distant parts of the body.
Find out more about Source: cancer.gov
Cancer Registries at
https://www.cdc The pathologist will also stage the tumor tissue specimen (see Table 6-2 for more details
.gov/cancer/npcr/value/ on the stages of cancer).
index.htm Physicians, most often oncologists, use tumor grading in addition to staging, a
patient’s age, and overall health to determine a prognosis and create a treatment plan.

148   PART II  |  REPORTING DIAGNOSES

Cancer registries collect population-based cancer incidence data, as required under
federal law, to support research and government funding to support the impact of can-
cer on a community.

YOU INTERPRET IT!

Is this order for a screening or a diagnostic test?

1. Susie’s annual mammogram (a) Screening (b) Diagnostic
2. Dr. McFadden felt a lump in Arthur’s arm. Dr. McFadden did a biopsy. (a) Screening (b) Diagnostic
3. Edith told her doctor she is coughing, is wheezing, and suffers (a) Screening (b) Diagnostic
from unexplained weight loss. Her doctor ordered a lung CT.
4. At Roger’s annual checkup, Dr. Concord ordered a PSA test to be (a) Screening (b) Diagnostic
completed.

6.2  Abstracting the Details About Neoplasms

When normal cells mutate, they may create a neoplasm, also known as a tumor. Neoplasm
A  tumor is an overgrowth or abnormal mass of tissue, and it may be either benign Abnormal tissue growth; tumor.
or malignant (cancerous). In all cases, a physician should check the abnormality and Mass
determine a course of action. Abnormal collection of tissue.
Once a diagnosis is confirmed, you will need to accurately report it with the spe-
cific code or codes. Begin by ensuring you understand the details. Carcinoma
A malignant neoplasm or
In some cases, you will see the term mass used to describe a patient’s condition.
­cancerous tumor.
Mass is not the same as a neoplasm. More often, mass is used to identify a cyst or
other thickening of tissue. Malignant
While many people think that neoplasm and cancer are synonymous, they are not. Invasive and destructive
Cancer is the common term for carcinoma (see Figure 6-1). characteristic of a neoplasm;
possibly causing damage
Terms Used to Identify Neoplasms or death.

Neoplasms might be malignant or benign or have aspects of both characteristics. In Benign

diagnoses, neoplasms may also be defined by an individual name. The physician’s Nonmalignant characteristic
of a neoplasm; not infec-
notes may state a different term. Some examples of these terms are
tious or spreading.
∙ Adenoma
∙ Melanoma
∙ Leukemia
∙ Papilloma

(a) (b) (c)

© Biophoto Associates/Science Source © Biophoto Associates/Science Source © James Stevenson/Science Source

FIGURE 6-1  Types of skin cancer: (a) squamous cell carcinoma, (b) basal cell carcinoma, and (c) malignant melanoma
 When the physician uses a term such as adenoma, melanoma,  or other specific
CODING BITES name rather than the more generic term of neoplasm, it is more efficient for you to
In medical terminology, look for that specific term in the Alphabetic Index first, before looking under the term
the suffix -oma means neoplasm. At the very least, the Alphabetic Index can tell you if that type of tumor is
tumor. known to be malignant or benign.
Often, when you look up one of these specific neoplasm terms in the Alpha-
betic Index, it will provide you with some specific information about the tumor.
Let’s take a look in the ICD-10-CM Alphabetic Index under the term written by the
physician . . .
Fibroxanthoma (see also Neoplasm, connective tissue, benign)
  atypical — see Neoplasm, connective tissue, uncertain behavior
  malignant — see Neoplasm, connective tissue, malignant
Fibroxanthosarcoma — see Neoplasm, connective tissue malignant
You can see that while you might not know if a fibroxanthoma is malignant or benign,
the Alphabetic Index will tell you.

ICD-10-CM
LET’S CODE IT! SCENARIO
Abby Shantner, a 41-year-old female, comes to see Dr. Branson to get the results of her biopsy. Dr. Branson
explains that Abby has an alpha cell adenoma of the pancreas. Dr. Branson spends 30 minutes discussing treat-
ment options.

Let’s Code It!

Dr. Branson has diagnosed Abby with an alpha cell adenoma of the pancreas. You have been working with
Dr. Branson as his coder for a while, so you know that an adenoma is a neoplasm, but what kind of neoplasm is
it—benign or malignant? To help you determine this, instead of going to neoplasm, let’s see if there is a listing in
the Alphabetic Index under adenoma. When you find adenoma, the book refers you to
Adenoma (see also Neoplasm, benign, by site)
This tells you an adenoma is a benign tumor. Or you can continue down this list to the indented term, and find
Adenoma
   alpha-cell, 
    pancreas D13.7
Turn to the Tabular List and read the complete description of code category D13:
D13 Benign neoplasm of other and ill-defined parts of digestive system
The note does not relate to this patient’s diagnosis for this encounter, so continue read-
ing down the column to review all of the choices for the required fourth character.
D13.7   Benign neoplasm of endocrine pancreas
That matches Dr. Branson’s diagnosis. 
Check the top of this subsection and the head of this chapter in ICD-10-CM. There are several NOTES. Read
carefully. Do any relate to Dr. Branson’s diagnosis of Abby? No. Turn to the Official Guidelines and read Section
1.c.2. There is nothing specifically applicable here, either.
Good job!

Malignant Primary
The term primary indicates the anatomical site (the place in the body) where the
malignant neoplasm was first seen and identified. If the physician’s notes do not spec-
ify primary or secondary, then the site mentioned is primary.

150   PART II  |  REPORTING DIAGNOSES

Malignant Secondary
CODING BITES
The term secondary identifies the anatomical site to which the malignancy
­metastasized. One very strange thing about cancerous cells is that they travel Always begin with the
through the body and do not necessarily spread to adjoining body parts. Cancer can terms the physician
be identified in the breast as the primary site and metastasize to the liver without writes in his or her
actually affecting anything in between. Notes will state that a site is “secondary to” notes. Then, only when
(primary site), “metastasized from” (primary site), or (primary site) “metastasized that does not bring you
to” (­secondary site). to a suggested code,
The terms disseminated cancer, generalized cancer, or widely metastatic would you can look up alter-
indicate that the malignancy has infiltrated the body throughout and affects all or most nate terms. This rule of
of the patient’s anatomy. This would be coded as a malignant neoplasm without speci- thumb will save you a
fication of site (code C80.0). In such cases, it is not that the physician forgot to specify lot of time.
the site. It is that there are too many sites to list.

Ca in Situ Metastasize
To proliferate, reproduce, or
The term Ca in situ indicates that the tumor has undergone malignant changes but is spread.
still limited to the site where it originated (i.e., it has not spread). Ca is short for carci-
noma, and you can remember situ as in the word situated. So think of it as a cancerous
tumor that is staying in place. CODING BITES
To determine the code
Benign to report a neoplasm,
The term benign means there is no indication of invasion of adjacent cells. Essentially, you need to know
benign means not cancerous. 1. Where in the body
(specifically, which
Uncertain anatomical site) is the
The classification uncertain indicates that the pathologist is not able to specifically deter- neoplasm located?
mine whether a tumor is benign or malignant because indicators of both are present. 2. Is the neoplasm
benign, malignant,
Unspecified Behavior in situ, or uncertain?
Choose codes that describe “Unspecified Behavior” when the physician’s notes do Uncertain is a patho-
not include any specific information regarding the nature of the tumor. Before choos- logic determination
ing one of these codes, please query the physician and make certain that a laboratory and is not the same
report is not available or on its way with the information you need. as unspecified.
3. If the neoplasm is
malignant, is this
YOU INTERPRET IT! the first diagnosis of
malignancy for this
patient? If so, this
What type of neoplasm is this: benign or malignant; primary or secondary?
is the primary site.
5. Metastatic lung cancer ___________ If not, this is a sec-
6. Melanoma ___________ ondary malignancy
7. Squamous cell carcinoma ___________ because it metas-
8. Pancreatic lymph gland neoplasm ___________ tasized from the
9. Adenoma ___________ primary.

CODING BITES
6.3  Reporting the Neoplastic Diagnosis
If you turn to the term
Once you have determined the anatomical location and type of tumor that has been Neoplasm in the Alpha-
documented, you will need to find a suggested code in the ICD-10-CM Neoplasm betic Index in the regu-
Table, found directly after the Alphabetic Index. lar alphabetic order, you
The Neoplasm Table is a seven-column table set in alphabetic order by the ana- will see the notation (see
tomical site (the part of the body where the tumor is located), shown in the first also Table of Neoplasms).
column. To the right of the first column, there are six columns across: Malignant
 Malignant Malignant Uncertain Unspecified
Primary Secondary Ca in situ Benign Behavior Behavior
Neoplasm, neoplastic C80.1 C79.9 D09.9 D36.9 D48.9 D49.9
- abdomen, abdominal C76.2 C79.8- D09.8 D36.7 D48.7 D49.89
-- cavity C76.2 C79.8- D09.8 D36.7 D48.7 D49.89
-- organ C76.2 C79.8- D09.8 D36.7 D48.7 D49.89
-- viscera C76.2 C79.8- D09.8 D36.7 D48.7 D49.89
-- wall — see also Neoplasm, C44.509 C79.2- D09.5 D23.5 D48.5 D49.2
abdomen, wall, skin
--- connective tissue C49.4 C79.8- — D21.4 D48.1 D49.2
--- skin C44.509
---- basal cell carcinoma C44.519 — — — — —
---- specified type NEC C44.599 — — — — —
---- squamous cell carcinoma C44.529 — — — — —
- abdominopelvic C76.8 C79.8- — D36.7 D48.7 D49.89

FIGURE 6-2  The Neoplasm Table, in part, showing codes for various abdominal neoplasms and abdominopelvic
neoplasms

Primary, Malignant Secondary, Ca in situ, Benign, Uncertain Behavior, and Unspeci-

fied Behavior (see Figure 6-2) . . . the types of neoplasms you read about previously in
this chapter. It is here, in this Table, that you can find the suggested code to report the
specific type and location of the tumor documented by the physician.
After abstracting the physician’s documentation to identify the anatomical
site of the tumor, turn to the Neoplasm Table and find that anatomical site in the
first column in the Table. Remember to carefully review indented lists below the
main term of the anatomical site so you can determine the code for the greatest
specificity.

EXAMPLE
Epiglottis
anterior aspect or surface
cartilage
free border (margin)
junctional region
posterior (laryngeal) surface
You can see in this one example that knowing the anatomical site of the tumor—
the epiglottis—is not enough information. You need to identify, from the documen-
tation, where the tumor is located on the epiglottis.

Once you have found the most specific match for the anatomical site identified
as the location of the tumor in the documentation, go back to the physician’s notes.
This time, look for the type of neoplasm in the diagnosis: Malignant Primary, Malig-
nant Secondary, Ca in situ, Benign, Uncertain, or Unspecified Behavior. Now, back
in the Neoplasm Table, read straight across to the right of the anatomical site line.
At the top of the page, each of these six columns has a title. Find which column has
the title that matches the diagnosis, and then go down until you hit the conjunction
of the anatomical site line and the type of neoplasm in question. This is your sug-
gested code.

152   PART II  |  REPORTING DIAGNOSES

 EXAMPLE
Dr. Tomlinsonn diagnosed Elsa with a malignant neoplasm of the abdominal viscera, noted as Ca in situ.

Malignant Malignant Uncertain Unspecified

Primary Secondary Ca in situ Benign Behavior Behavior
Neoplasm, neoplastic C80.1 C79.9 D09.9 D36.9 D48.9 D49.9
- abdomen, abdominal C76.2 C79.8- D09.8 D36.7 D48.7 D49.89
-- cavity C76.2 C79.8- D09.8 D36.7 D48.7 D49.89
-- organ C76.2 C79.8- D09.8 D36.7 D48.7 D49.89
-- viscera C76.2 C79.8- D09.8 D36.7 D48.7 D49.89
-- wall — see also Neoplasm, C44.509 C79.2- D04.5 D23.5 D48.5 D49.2
abdomen, wall skin

In the Neoplasm Table, in the first column, find Abdomen, then indented below that the specific site -- viscera.
Then, across to the right you can see suggested codes for each type of tumor. For Elsa’s diagnosis, code D09.8
is suggested.

Next, turn in the Tabular List to check this code, and all of the notations. Because
the Neoplasm Table is a part of the Alphabetic Index, the rule still applies . . . never,
never report a code directly from here. You must check the suggested code in the
Tabular List, read the symbols and notations, read the complete code description and
all of the options, and check the Official Guidelines before you can confirm and report
a code.

ICD-10-CM
LET’S CODE IT! SCENARIO
Aaron Docker, a 65-year-old male, returns to see Dr. Cabrera. The results of his colonoscopy and laboratory tests on
the biopsy have come back. Dr. Cabrera confirms Aaron has a benign neoplasm of the ascending colon.

Let’s Code It!

Dr. Cabrera confirmed Aaron has a benign neoplasm of the ascending colon. Turn to the Neoplasm Table in your
ICD-10-CM code book. Go down the list of anatomical sites until you reach colon. There is a notation that directs
you to “see also Neoplasm, intestine, large.” The ascending colon is actually the portion of the large intestine
that goes from the cecum to the transverse colon. Indented under colon are the words and rectum. Go back to
Dr. Cabrera’s notes. His diagnosis does not include the rectum, so follow the book’s advice and turn to the listing
for intestine, large, and read what is shown there.
Continue through the list until you get to intestine, intestinal. Beneath the term intestine, you will find the
word large indented. Indented under large is colon. Indented under colon, you see ascending. This matches
Dr. Cabrera’s diagnosis of Aaron’s neoplasm exactly! Now, read across the table to the right to the “Benign” col-
umn. Here, the code D12.2 is suggested. Remember the rule: Never, never code from the Alphabetic Index, and
that includes the Neoplasm Table, so turn to the Tabular List to confirm this suggested code. Start reading at the
three-character code category:
D12  Benign neoplasm of colon, rectum, anus, and anal canal
The note does not relate to this patient’s diagnosis for this encounter, so continue reading down the
column to review all of the choices for the required fourth character.
D12.2  Benign neoplasm of ascending colon

(continued)
 Check the top of this subsection and the head of this chapter in ICD-10-CM. There are several NOTES at the
beginning of this chapter. Read carefully. Do any relate to Dr. Cabrera’s diagnosis of Aaron? No. Turn to the Offi-
cial Guidelines and read Section 1.c.2. There is nothing specifically applicable here, either.
Now you can report D12.2 for Aaron’s diagnosis with confidence.
Good coding!

A Pregnant Patient with a Malignancy

Conditions that may complicate a pregnancy have their very own chapter in ICD-
10-CM. You will learn about this in depth in the chapter Coding Genitourinary,
­Gynecology, Obstetrics, Congenital, and Pediatrics. However, when a pregnant
woman is ­diagnosed with a malignancy, a code from code subcategory O9A.1- Malig-
nant neoplasm complicating pregnancy, childbirth, and the puerperium will be reported
as the principal diagnosis, followed by the code for the primary malignancy. To rein-
force this, you can see the notation beneath this code subcategory that reminds you to
Use additional code to identify neoplasm.

EXAMPLE
Fran has been diagnosed with malignant melanoma on her right shoulder. She is
CODING BITES 21 weeks pregnant.

Professional coding O9A.112 Malignant neoplasm complicating pregnancy, second trimester

specialists must be
C43.61 Malignant melanoma of right upper limb, including shoulder
cautious when deter-
mining the difference Z3A.21 21 weeks gestation of pregnancy
between a patient in
remission and a patient
with a personal his- Malignancies in Remission or Relapse
tory of a condition. If
the documentation is There are certain types of malignancies, such as multiple myeloma (malignancy of the
not absolutely clear on plasma cells in the bone marrow) or leukemia (malignancy of the bone marrow and
this, you must query bone-forming tissues), that may be described differently. For example:
the physician for clari- C90.00 Multiple myeloma not having achieved remission
fication. There is a big C90.01 Multiple myeloma in remission
difference between C90.02 Multiple myeloma in relapse
these two diagnostic
identifications. These categorizations are not available for all malignancies; however, when they are,
you already know to match the code description to the documentation.

ICD-10-CM
LET’S CODE IT! SCENARIO
PATIENT: Roberta Wolfe
DATE OF CONSULTATION: 05/25/2018
CONSULTING PHYSICIAN: Oliver Cannon, MD
REQUESTING PHYSICIAN: Theresa Calabressi, MD
Thank you for referring the patient for medical oncology consultation.

154   PART II  |  REPORTING DIAGNOSES

HISTORY OF PRESENT ILLNESS: The patient is a 29-year-old female with noninvasive left breast cancer. The patient
had a screening mammogram 4 months ago, which revealed a left upper outer breast abnormality. Stereotactic
biopsy previously confirmed ductal carcinoma in situ. The patient underwent needle localization excision with pathol-
ogy confirming ductal carcinoma in situ grade 2, ER positive, PR positive. She received ipsilateral breast radiation.
Her course has been complicated by apparent incision site infection, which has resulted in persistent low-grade
­oozing of blood and occasional extrusion of pus. She has been treated with several courses of antibiotics. However,
the scant bloody discharge continued. Over the past 1 week, she has noted increasing tenderness at the site of
bleeding and apparent infection. She otherwise offers no complaints.
PAST MEDICAL HISTORY: Remarkable for anemia attributed to iron deficiency for which she takes iron supplements.
Unremarkable for hypertension, diabetes, hypercholesterolemia, or prior cardiac, pulmonary, or hepatic dysfunction.
Normal monthly cycles; however, the last cycle has been particularly prolonged at 9 days.
MEDICATIONS: She takes no regular prescription medications.
ALLERGIES: NO KNOWN ALLERGIES.
FAMILY HISTORY: Remarkable for sister with diagnosis of breast cancer at age 43, presently 51, in remission. No
other known family history of breast or ovary cancer. Father died at age 82 of cardiac disease, mother aged 79 with
history of heart disease; 2 brothers, 3 sons, and 2 daughters are healthy.
SOCIAL HISTORY: Married. Denies cigarettes, alcohol, drugs.
REVIEW OF SYSTEMS: Denies fever, chills, sweats, headaches, seizures, syncope, blurred vision, dysphagia, cough,
chest pain, shortness of breath, abdominal pain, nausea, vomiting, diarrhea, constipation, melena, hematochezia, dysuria,
hematuria, flank pain, back pain, abnormal bleeding, bruising, lymph node swelling, or focal paresthesias or weakness.

PHYSICAL EXAMINATION
GENERAL: The patient is well developed, well nourished, in no acute distress.
VITAL SIGNS: Temperature 98.8, heart rate 63, blood pressure 110/81, weight 135.4 pounds, and height 57 inches.
SKIN: Skin clear. No visible rash, ecchymosis or petechia.
HEENT: Normocephalic. No scleral icterus. No mucosal lesions.
NECK: Supple without thyromegaly.
LYMPH NODES: No secondary neck, axillary, or inguinal nodes.
BREASTS: Without dominant mass bilaterally. There is moderate induration of approximately 2.8 cm across, underly-
ing the left upper outer quadrant incision. There is no fluctuance or erythema and patient denies significant tender-
ness to the area.
CHEST: Clear to auscultation and percussion.
CARDIAC: Regular rate and rhythm. No murmur, rub, or gallop.
ABDOMEN: Soft and nontender. No masses or hepatosplenomegaly.
RECTAL AND GENITAL: Deferred.
EXTREMITIES: No clubbing, cyanosis, or edema.
MUSCULOSKELETAL: No back tenderness. No bony or joint deformity.
NEUROLOGIC: Alert and oriented. Cranial nerves, sensory and motor system, and gait are normal. 
IMPRESSION: Ductal carcinoma in situ, left breast, stage 0 (Tis N0 M0), ER positive, PR positive, status post lumpec-
tomy to negative surgical margins and has set up breast radiation. Overall prognosis is excellent with estimated risk
of local recurrence in the 5% range. Risk of systemic metastasis is negligible. Thus, adjuvant systemic therapy is not
warranted. She is, of course, at increased risk for second malignancy; thus tamoxifen chemoprevention would be a
reasonable option.
RECOMMENDATIONS AND PLAN: Diagnosis, prognosis, and management options were discussed in detail with
the patient and questions were answered. Tamoxifen chemoprevention was discussed in detail and she, at this time,
appears agreeable to initiation of therapy. I provided a prescription for tamoxifen 20 mg daily. On the assumption that
(continued)
 she desires continuing oncologic follow-up, any follow-up appointment will be made in 6 months. Alternatively, if she
should decline tamoxifen chemoprevention or if her gynecologic physician, Dr. Calabressi, would be willing to prescribe
tamoxifen and provide continuing oncologic follow-up, then medical oncology follow-up will be on an as-needed basis.

Let’s Code It!

Dr. Cannon examined and evaluated Roberta Wolfe with regard to her post-procedural condition for breast can-
cer. Read the entire documentation. Can you find his conclusion or impression of her condition? In the section
marked IMPRESSIONS, he documents, “Ductal carcinoma in situ, left breast.”
Turn in your ICD-10-CM Alphabetic Index, Table of Neoplasms. What is the anatomical site of this neoplasm?
“breast, duct.” Find this in the first column:
breast (connective tissue) (glandular tissue) (soft parts)
Read all of the specific components of the breast shown in the indented list below this. Can you find “duct”?
Neither can I. However, you know that this is the location within the breast that has the neoplasm. Hmm. Read
across to the third column to the right, titled Ca in situ. Notice that the majority of these have the same code
category suggested: D05. Perhaps we can find a more specific description for the duct in the Tabular List. Turn
to find D05 in the Tabular List.
D05 Carcinoma in situ of breast
Check the notation. None of these diagnoses relate to Roberta’s diagnosis, so read down and review
the four options you have for a fourth character. One seems to be what you are looking for:
D05.1 Intraductal carcinoma in situ of breast
Read the three options for the required fifth character. Which one matches Dr. Cannon’s documentation?
D05.12 Intraductal carcinoma in situ of left breast
However, before you can report this code, you must check the top of this subsection and the note
above code D00. Next, check the notations at the head of this chapter in ICD-10-CM. There are notations at the
beginning of this chapter; you will learn more about these specific notations in the next part of this chapter. Read
carefully. Do any relate to Dr. Cannon’s diagnosis of Roberta? No. Turn to the Official Guidelines and read Sec-
tion 1.c.2. There is nothing specifically applicable here either.
Now you can report D05.12 for Roberta’s diagnosis with confidence.
D05.12 Intraductal carcinoma in situ of left breast
Good work!

6.4  Neoplasm Chapter Notes

In the ICD-10-CM Tabular List, take a look at the beginning of Chapter 2: Neoplasms
(directly above code C00). There are four notes here to help you determine the most
accurate neoplasm code.

Functional Activity
The functional activity of a neoplasm notes whether or not the tumor is causing the
secretion of hormones. This would be documented in the pathology report and may
need to be reported.
The first note in the Neoplasms chapter of ICD-10-CM helps you when certain
Functional Activity neoplasms require an additional code to report functional activity. This note states: 
Glandular secretion in abnor-
mal quantity. “All neoplasms are classified in this chapter, whether they are functionally active
or not. An additional code from chapter 4 may be used to identify such func-
tional activity associated with any neoplasm.” 

156   PART II  |  REPORTING DIAGNOSES

 Chapter 4 of the ICD-10-CM Tabular List is titled: Endocrine, nutritional, and met-
abolic diseases (E00–E89). The note beneath the heading for Chapter 4 (directly above
code E00) reminds you of this detail:
Note: All neoplasms, whether functionally active or not, are classified in
­Chapter 2. Appropriate codes in this chapter (i.e. E05.8, E07.0, E16–E31,
E34.-) may be used as additional codes to indicate either functional activity
by neoplasms and ectopic endocrine tissue or hyperfunction and hypofunc-
tion of endocrine glands associated with neoplasms and other conditions
classified elsewhere.
What this note means is that if a patient has been diagnosed with a neoplasm affecting
the individual’s glandular function, you have to identify the functional activity (of the
gland) with an additional code.
For example, take a look beneath code category C56 Malignant neoplasm of ovary.
There is a notation that says:
Use additional code to identify any functional activity
This note regarding functional activity also appears under the following terms:
Benign neoplasm of ovary
Malignant neoplasm of endocrine glands
Benign neoplasm of endocrine glands
Malignant neoplasm of islets of Langerhans
Benign neoplasm of islets of Langerhans
Malignant neoplasm of the testis
Benign neoplasm of the testis
Malignant neoplasm of thyroid glands
Benign neoplasm of thyroid glands

EXAMPLES
Catecholamine-producing malignant pheochromocytoma of thyroid
C73 Malignant neoplasm of thyroid gland
E27.5 Adrenomedullary hyperfunction
Ovarian carcinoma, right side, with hyperestrogenism
C56.1 Malignant neoplasm of right ovary
E28.0 Estrogen excess
Basophil adenoma of pituitary with Cushing’s disease
C75.1 Malignant neoplasm of pituitary gland
E24.0 Pituitary-dependent Cushing’s disease

LET’S CODE IT! SCENARIO

ICD-10-CM

Daniel Coleman, a 41-year-old male, came to see Dr. Lucano for a checkup. He was diagnosed with functioning thy-
roid carcinoma. Dr. Lucano reviews with Daniel the results of his latest thyroid scan, TSH and TRH stimulation tests,
and an ultrasonogram. Dr. Lucano informs Daniel that he has developed hyperthyroidism.
(continued)
 Let’s Code It!
Dr. Lucano has diagnosed Daniel with functioning thyroid carcinoma and hyperthyroidism. The hyperthyroidism
is the functional activity of the thyroid carcinoma. Turn to the Alphabetic Index and look for
Carcinoma — see also Neoplasm, by site, malignant
Look down the list. Neither the term functioning nor the term thyroid is shown here, so you will need to turn to
the Neoplasm Table and find
Neoplasm, thyroid, malignant, primary C73
Let’s go to the Tabular List, to confirm:
C73 Malignant neoplasm of thyroid gland
Use additional code to identify any functional activity
This code is correct, and the ICD-10-CM book is telling you that you need an additional code to report the
functional activity. The only other detail Dr. Lucano included in her diagnostic statement is hyperthyroidism. Turn
back to the Alphabetic Index and look up hyperthyroidism:
Hyperthyroidism (latent) (preadult) (recurrent) E05.90
Turn to the Tabular List to confirm this suggested code.
E05 Thyrotoxicosis [hyperthyroidism]
The note mentions nothing that relates to this encounter for our patient, so read down the column to
review the choices for the required fourth character.
E05.9 Thyrotoxicosis unspecified
This matches the notes, so you are in the correct place. The symbol to the left of the code tells you that an addi-
tional character is required.
E05.90 Thyrotoxicosis unspecified without mention of thyrotoxic crisis or storm
Did you notice that this code is located in Chapter 4 and is describing the functional activity of the neo-
plasm? Great! 
Check the top of this subsection and the head of this chapter in ICD-10-CM. A  NOTE and an 
notation are shown at the beginning of this chapter. Read carefully. Do any relate to Dr. Lucano’s diagnosis of
­Daniel? Yes. Both chapters have NOTES regarding the coding of neoplasms and functional activity. Double-
check to make certain you are complying with these directions. Next, turn to the Official Guidelines and read
both ­Sections 1.c.2 and 1.c.4. There is nothing specifically applicable here either.
Now, you can report C73 and E05.90 for this encounter with Daniel with confidence.
Good coding!

Morphology (Histology)
The second note at the top of Chapter 2 relates to the classifications of neoplasms.
Topography Chapter 2 classifies neoplasms primarily by site (topography) with broad group-
The classification of neo- ings for behavior, malignant, in situ, benign, etc. The Table of Neoplasms should
plasms primarily by anatomi- be used to identify the correct topography code. In a few cases, such as for
cal site. malignant melanoma and certain neuroendocrine tumors, the morphology (histo-
Morphology
logic type) is included in the category and codes.
The study of the configura- In addition to the code for a neoplasm, you may be required to include a separate code
tion or structure of living with additional information about the tumor’s morphology. “Morphology of Neo-
organisms. plasms” is available as a separate book, the International Classification of Diseases

158   PART II  |  REPORTING DIAGNOSES

for Oncology (ICD-O). Morphology codes are not structured like the other diagno-
sis codes. The codes always begin with the letter “M,” which is followed by four char-
acters, a slash (/), and a single character. A neoplasm’s histology is described by the
first four characters of the M code.
M codes are used for providing specific data about the site (topography) and the
histology (morphology) of the affected tissue to tumor and cancer registries. Patholo-
gists may also use the codes to provide more detail about a particular tissue sample.
Normally, M codes are not used for reimbursement and are not placed on insurance
claim forms. Cancer registries use them in their cataloging of data.

Primary Malignant Neoplasms Overlapping Site Boundaries

The third note here, at the head of Chapter 2, Neoplasms, in ICD-10-CM, is concerned
with primary malignant tumors that overlap anatomical sites.
A primary malignant neoplasm that overlaps two or more contiguous (next to
each other) sites should be classified to the subcategory/code 8 (“overlapping CODING BITES
lesion”), unless the combination is specifically indexed elsewhere. For multiple The phrase “subcat-
neoplasms of the same site that are not contiguous, such as tumors in different egory/code .8” refers to
quadrants of the same breast, codes for each site should be assigned. the fourth character of 8.
The nature of a malignant neoplasm includes its potential to spread to adjoining tissue.
As you learned earlier in this chapter, you code malignancies by their anatomical site
in the order in which the malignancy developed: primary and secondary. However,
there are cases where the condition of the patient involves more than one code subcat-
egory. Neoplasms with overlapping boundaries, also known as contiguous, may blur Overlapping Boundaries
anatomical descriptors. Multiple sites of carcinoma
without identifiable borders.

EXAMPLE
C05.8 Malignant neoplasm of overlapping sites of palate
C17.8 Malignant neoplasm of overlapping sites of small intestine
C57.8 Malignant neoplasm of overlapping sites of female genital organs

For cases in which the physician cannot identify a specific site, usually because
the malignancy has metastasized so dramatically, the code category C76 enables you
to report the malignancy by identifying only the section of the patient’s body, such as
head, abdomen, or lower limb.

EXAMPLE
C76.0 Malignant neoplasm of head, face, and neck
C76.51 Malignant neoplasm of right lower limb

Malignant Neoplasms of Ectopic Tissue

The last note at the head of Chapter 2 in the Tabular List states:
Malignant neoplasms of ectopic tissue are to be coded to the site men-
tioned, e.g., ectopic pancreatic malignant neoplasms are coded to pancreas,
unspecified (C25.9)
This notation provides you with direction on how to determine the code for a case Ectopic
when the neoplasm is located in an unusual and hard-to-determine location in the Out of place, such as an organ
body. The term ectopic means outside of an organ. Therefore, if the diagnostic state- or body part.
ment describes the tumor as being ectopic, report the condition to the nearest, identi-
fied organ.
 EXAMPLE
Dr. Laveign documented that Evan’s biopsy confirmed that he has an ectopic
malignant neoplasm of the prostate. 
Report this with the following code:
C61 Malignant neoplasm of prostate

6.5  Admissions Related to Neoplastic

Treatments
When you are coding encounters with a patient who has been diagnosed with a neo-
plasm, whether benign or malignant, the same rule for identifying the principal diag-
nosis still applies.
Why did the health care professional care for this patient today?

Admission for Treatment of Malignancy

If a patient’s encounter is only for therapeutic treatment of a malignancy, such as the
administration of chemotherapy, immunotherapy, or radiation therapy, then the princi-
pal (first-listed) code will report this fact, followed by a code or codes to report details
about the malignancy being treated.
One of these codes would be reported as the principal diagnosis code:
Z51.0 Encounter for antineoplastic radiation therapy
Z51.11 Encounter for antineoplastic chemotherapy
Z51.12 Encounter for antineoplastic immunotherapy
Note that there is a notation for the Z51 code category that reminds you to
Code also condition requiring care
This would be the code or codes with the details about the malignancy, the rea-
son why the patient would need this radiation, chemotherapy, or immunotherapy
treatment.

EXAMPLE
Warren Spencer was admitted to McGraw Hospital for his third chemotherapy
infusion . . . treatment for the malignant neoplasm on the tail of his pancreas.
Z51.11 Encounter for antineoplastic chemotherapy
C25.2 Malignant neoplasm of tail of pancreas
Because Warren was admitted for the purpose of receiving his chemotherapy
treatment, his chemotherapy is reported first (the principal diagnosis code), fol-
lowed by the reason Warren needs this chemotherapy—pancreatic cancer.

Excised Malignancies/Personal History

Thanks to modern medical science and technology, health care professionals are
more successful than ever at getting rid of certain neoplasms (tumors), often by excis-
ing them (surgically cutting them out). Postoperatively, the patient no longer has the
anatomical site where the malignancy was located. Therefore, the patient can no lon-
ger have that condition. At that time, the code will change from a malignancy code
(­C00–C96) to a personal history of a malignancy code (category Z85).

160   PART II  |  REPORTING DIAGNOSES

 EXAMPLE GUIDANCE
Martha Peterson was diagnosed with a malignant neoplasm of the upper-inner CONNECTION
quadrant of the right breast. The diagnosis code was Read the ICD-10-CM Offi-
C50.211 Malignant neoplasm of upper-inner quadrant of right female breast cial Guidelines for Coding
and Reporting, section
She underwent a mastectomy, a surgical procedure to remove her breast. I. Conventions, Gen-
Once the anatomical site (her breast) that contained the malignant neoplasm eral Coding Guidelines
was removed, she no longer had the disease, and no additional treatment was and Chapter Specific
needed. From this point on, the diagnosis code is Guidelines, subsec-
Z85.3 Personal history of malignant neoplasm, breast tion C. Chapter-­Specific
Coding Guidelines,
chapter 2. Neoplasms,
Suppose a patient has a primary site of malignancy and the disease has already subsection d. Primary
metastasized to a second location. If the primary site is removed, the secondary malig- malignancy previously
nancy is still coded as secondary but listed first. Confusing? Let’s look at an example. excised.

EXAMPLE
GUIDANCE
Ronald Albertson was diagnosed with prostate cancer. It spread to his liver before
he was able to have surgery. The diagnosis codes, in this sequence, are
CONNECTION
Read the ICD-10-CM Offi-
C61 Malignant neoplasm of the prostate
cial Guidelines for Coding
C78.7 Secondary malignant neoplasm of liver, and intrahepatic bile duct
and Reporting, section
Dr. Isaacson removes Ronald’s prostate successfully. He no longer required any I. Conventions, General
treatment. The new codes are Coding Guidelines and
Chapter Specific Guide-
C78.7 Secondary malignant neoplasm of liver, and intrahepatic bile duct
lines, subsection C.
Z85.46 Personal history of malignant neoplasm, prostate
Chapter-­Specific Coding
Once Ronald has the site of his primary malignancy removed, his prostate condi- Guidelines, chapter 2.
tion becomes “history.” The code for his secondary malignancy in the liver moves Neoplasms, subsection
up in order, but it will always be the secondary site at which Ronald developed a b. Treatment of second-
malignancy. ary site.

ICD-10-CM
YOU CODE IT! CASE STUDY
Frederick Westchester, a 53-year-old male, came to see Dr. Henner, his dermatologist, for an annual checkup.
Two  years ago, Dr. Henner removed a malignant melanoma from Frederick’s left forearm. The malignancy was
totally removed, but he comes to see his physician for a checkup once a year.

You Code It!

Go through the steps of coding, and determine the diagnosis code or codes that should be reported for this
encounter between Dr. Henner and Frederick.
Step #1: Read the case carefully and completely.
Step #2: Abstract the scenario. Which main words or terms describe why the physician cared for the patient
during this encounter? 
Step #3: Are there any details missing or incomplete for which you would need to query the physician? [If so, ask
your instructor.]
Step #4: Check for any relevant guidance, including reading all of the symbols and notations in the Tabular List
and the appropriate sections of the Official Guidelines.
(continued)
 Step #5: Determine the correct diagnosis code or codes to explain why this encounter was medically necessary.
Step #6: Double-check your work.
Answer:
Did you determine the following diagnosis code?
Z85.820 Personal history of malignant melanoma of skin
Good job!

Complications and Complications of Treatment

You probably are aware that some of the most frequently used treatments to eradicate
malignant cells, such as chemotherapy and radiation, manifest other conditions. 
In those cases where the patient is admitted for therapy (radiation, chemotherapy,
or immunotherapy) and develops complications during the encounter, report the
Z51.0, Z51.11, or Z51.12 as the principal diagnosis code, followed by the code or
codes to report the specific complications, such as uncontrolled nausea and vomiting
or dehydration.
When the patient is admitted for treatment of anemia that is a manifestation of the
GUIDANCE
malignancy, and only the anemia is treated during this stay, report the code for the neo-
CONNECTION plasm as the principal diagnosis followed by code D63.0 Anemia in neoplastic disease.
Read the ICD-10-CM However, if the patient is admitted for treatment of anemia that is the result of the
Official Guidelines for neoplastic treatment (chemotherapy or immunotherapy), you will report a code for the
Coding and Reporting, anemia first, followed by code T45.1x5- Adverse effect of antineoplastic and immuno-
section I. ­Conventions, suppressive drugs [seventh character is required to identify the encounter].
General Coding Guide- Anemia that is manifested as an effect from radiation treatments is reported a bit
lines and ­Chapter differently. For this patient, the code to report the anemia is reported as the principal
Specific ­Guidelines, diagnosis, followed by the code explaining the neoplasm for which the radiation was
subsection C. Chapter-­ administered, followed by code Y84.2 Radiological procedure and radiotherapy as the
Specific Coding cause of abnormal reaction of the patient, or of later complication, without mention of
Guidelines, chapter 2. misadventure at the time of the procedure.
Neoplasms, subsection When the patient is admitted for treatment of dehydration, manifestation from the
c. Coding and sequenc- malignancy, and only the dehydration is treated during this stay, report the code for the
ing of complications. dehydration as the principal diagnosis followed by the code for the neoplasm that was
the reason the treatment was needed.

GUIDANCE Treatment of Secondary Site Only

CONNECTION There are instances where a physician may treat only the secondary site of malignancy
Read the ICD-10-CM for a patient in a given encounter. In this case, you would report the secondary site as
Official Guidelines for the principal diagnosis and the primary site malignancy after this.
Coding and ­Reporting,
section I. Conventions,
General Coding Guide-
EXAMPLE
lines and Chapter Marvin’s prostate cancer has spread to his lungs. Today, he has come to see Dr. Dunbar,
Specific Guidelines, a pulmonologist specializing in lung cancer, for evaluation and treatment.
subsection C. ­Chapter- Report the codes in this order:
Specific Coding Guide- . Secondary lung cancer
1
lines, chapter 2. Neo-
2. Primary prostate cancer
plasms, subsection
l. Sequencing of Note that the primary cancer site is still identified and coded as “primary” even
neoplasm codes. though it is the second code reported.

162   PART II  |  REPORTING DIAGNOSES

 ICD-10-CM
YOU CODE IT! CASE STUDY
Eric Swanson is a 43-year-old male with a malignant neoplasm of the laryngeal cartilage. He has become dehy-
drated due to the course of radiation therapy treatments. Dr. Leistner admitted Eric today to receive rehydration
therapy.

You Code It!

Abstract the details related to the reasons why Dr. Leistner met with Eric.
Step #1: Read the case carefully and completely.
Step #2: Abstract the scenario. Which key words or terms describe why the physician cared for the patient
during this encounter?
Step #3: Are there any details missing or incomplete for which you would need to query the physician? [If so, ask
your instructor.]
Step #4: Check for any relevant guidance, including reading all of the symbols and notations in the Tabular List
and the appropriate sections of the Official Guidelines. 
Step #5: Determine the correct diagnosis code or codes to explain why this encounter was medically necessary.
Step #6: Double-check your work.
Answer:
Did you determine these to be the correct codes?
E86.0   Dehydration
C32.3   Malignant neoplasm of laryngeal cartilage

Prophylactic Organ Removal

Advances in science have given us genetic predisposition testing and other identifi-
cation exams. The information these tests provide, along with personal and family
histories, enables patients and health care professionals to predict an individual’s
risk for cancer and other diseases more accurately. Studies show, for example, that
a woman who has inherited a mutation in the BRCA1 or BRCA2 gene faces a dra-
matically higher risk for developing breast cancer by age 65. A strong family his-
tory of colon cancer may lead an individual to be tested for a variant in the APC
gene. There are many genes that can now be tested for various hereditary or famil-
ial conditions.
Prophylactic, or preventive, surgery can reduce risk of cancer in these situations
by as much as 90%. In the case of breast cancer, preventive action would mean hav-
ing a double mastectomy (the surgical removal of both breasts) while a patient is still
healthy and without any signs or symptoms of carcinoma.
As a coder, the question becomes: How do you code a diagnosis for a surgical pro-
cedure on a healthy anatomical site? You will use a code from this sub-category:
Z40.0- Encounter for prophylactic surgery for risk factors related to malig-
nant neoplasms (Admission for prophylactic organ removal) 
Use additional code to identify risk factor
For those patients who have had genetic testing with a confirmed abnormal gene,
you will also use a second code from category Z15 Genetic susceptibility to disease.
If the reason for the preventive surgery is due to a family history of cancer, you will
add another code from the Z80 Family history of primary malignant neoplasm category.
 ICD-10-CM
YOU CODE IT! CASE STUDY
Angelina Constantine, a 27-year-old female, was admitted today for the prophylactic removal of her breasts. Her
grandmother, mother, and sister have all had breast cancer, so she had genetic testing performed. It indicated that
she did have a genetic susceptibility to breast cancer. She elected to have the surgery instead of taking chances
with her health.

You Code It!

Go through the steps of coding, and determine the diagnosis code or codes that should be reported for
­Angelina’s surgery.
Step #1: Read the case carefully and completely.
Step #2: Abstract the scenario. Which main words or terms describe why the physician cared for the patient
during this encounter? 
Step #3: Are there any details missing or incomplete for which you would need to query the physician? [If so, ask
your instructor.]
Step #4: Check for any relevant guidance, including reading all of the symbols and notations in the Tabular List
and the appropriate sections of the Official Guidelines.
Step #5: Determine the correct diagnosis code or codes to explain why this encounter was medically necessary.
Step #6: Double-check your work.
Answer:
Did you determine the following diagnosis codes?
Z40.01 Prophylactic removal of breast
Z15.01 Genetic susceptibility to malignant neoplasm of breast
Z80.3 Family history of malignant neoplasm, breast
Good job!

Chapter Summary
In this chapter, you learned how to identify the key words in physicians’ documen-
tation and test results reports that can guide you toward the most accurate code
or codes. You learned the differences in the types of neoplasms and the proper
sequencing of codes. In addition, you reviewed the correct way to sequence the
codes when a patient has had a malignant site excised or been admitted for treat-
ment or a complication.
There have been, and continue to be, incredible advancements made in the treat-
ments of all types of neoplasms, as well as modifications to sociological behaviors
to help prevent the development of those insidious health concerns. As a professional
coding specialist, your ability to properly code the medical necessity for diagnostic
tests and therapeutic procedures used in the care of individuals can open many job
opportunities for you.

You Interpret It! Answers

1. (a) Screening, 2. (b) Diagnostic, 3. (b) Diagnostic, 4. (a) Screening, 5. Malignant,
secondary, 6. Malignant, primary, 7. Malignant, primary, 8. Malignant, secondary,
9. Benign

164   PART II  |  REPORTING DIAGNOSES

 CHAPTER 6 REVIEW
CODING BITES
Did you know that medical coders have foundational knowledge to become
­Cancer Registrars?
Run by the CDC, the National Program of Cancer Registries (NPCR) collates
data amassed by local cancer registries. This important health information pro-
vides public health professionals with the ability to assess and make plans for
ways to alleviate the cancer burden on patients, families, and the community more
effectively. 
According to the National Cancer Registrars Association (NCRA), “cancer reg-
istrars capture a complete summary of the history, diagnosis, treatment, and dis-
ease status for every cancer patient. Registrars’ work leads to better information
that is used in the management of cancer, and ultimately, cures.”
Cancer registrars work in hospitals, state and regional cancer registries, federal
government agencies, pharmaceutical companies, and other locations working
with these data.

CHAPTER 6 REVIEW
Coding Neoplasms Enhance your learning by
completing these exercises and
more at connect.mheducation.com!

Let’s Check It! Terminology

Match each key term to the appropriate definition.
1. LO 6.2  Invasive and destructive characteristic of a neoplasm; possibly causing A. Benign
damage or death. B. Carcinoma
2. LO 6.4  Glandular secretion in abnormal quantity. C. Ectopic
3. LO 6.2  Nonmalignant characteristic of a neoplasm; not infectious or spreading. D. Functional Activity
4. LO 6.2  A malignant neoplasm or cancerous tumor. E. Malignant
5. LO 6.2  Abnormal tissue growth; tumor. F. Mass
6. LO 6.2  To proliferate, reproduce, or spread. G. Metastasize
7. LO 6.4  Out of place, such as an organ or body part. H. Morphology
8. LO 6.4  The classification of neoplasms primarily by anatomical site. I. Neoplasm
9. LO 6.4  Multiple sites of carcinoma without identifiable borders. J. Overlapping
10. LO 6.2  Abnormal collection of tissue. Boundaries
11. LO 6.4  The study of the configuration or structure of living organisms. K. Topography

Let’s Check It! Concepts

Choose the most appropriate answer for each of the following questions.
1. LO 6.2  A neoplasm is the same as a
a. tumor. b.  cancer. c.  malignancy. d.  metastasis.
2. LO 6.2  Different types of neoplasms include all of the following except
a. adenoma. b.  melanoma. c.  papilloma. d.  chemotherapy.
 3. LO 6.2  The term _____ indicates that the tumor has undergone malignant changes but is still limited to the site
CHAPTER 6 REVIEW

where it originated.
a. uncertain b.  Ca in situ c.  benign d.  secondary
4. LO 6.4  Morphology codes are used
a. for reimbursement. b.  to describe treatment.
c. to describe the topography and histology of the neoplasm.
d. for identification of manifestations.
5. LO 6.5  At subsequent encounters after the surgical removal of a neoplasm and no additional treatment, the diag-
nosis code changes to a
a. personal history of malignancy code. b.  malignancy code.
c. late effects code. d.  co-morbidity code.
6. LO 6.5  When a patient is admitted for chemotherapy to treat a malignant neoplasm and that is the extent of treat-
ment, the first code listed is the code for
a. the primary malignancy. b.  the secondary malignancy.
c. the chemotherapy. d.  observation in a hospital.
7. LO 6.5  When a patient is admitted for treatment for a complication, such as anemia or dehydration, as the result
of a neoplastic treatment, the code for this complication should be listed
a. after the primary malignancy. b.  first.
c. after the chemotherapy or radiation code. d.  as a Z code.
8. LO 6.3  The correct code for a solitary plasmacytoma in remission is
a. C90.3 b.  C90.30 c.  C90.31 d.  C90.32
9. LO 6.1  All of the following are common diagnostic tests for a suspected malignancy of the lung except
a. alpha-1 antitrypsin. b.  CA-125 c.  bronchoscopy. d.  bone scan.
10. LO 6.2  When coding a neoplasm, you must know
a. the anatomical site. b.  whether it is primary or secondary.
c. whether it is benign or malignant. d.  all of these.

Let’s Check It! Guidelines

Refer to the Official Guidelines and fill in the blanks according to the Chapter 2, Neoplasms, Chapter-Specific Coding
Guidelines.
benign  Z85 anemia  primary 
Z51.11 principal  extent Z51.12
first-listed  malignancy  properly  M84.5 
pathological  metastasis dehydration  first
excised  principal/first-listed  Z51.0
1. To _____ code a neoplasm it is necessary to determine from the record if the neoplasm is _____, in-situ, malig-
nant, or of uncertain histologic behavior. 
2. If the treatment is directed at the malignancy, designate the malignancy as the _____ diagnosis. 
3. When a patient is admitted because of a _____ neoplasm with _____ and treatment is directed toward the second-
ary site only, the secondary neoplasm is designated as the principal diagnosis even though the primary malig-
nancy is still present.

166   PART II  |  REPORTING DIAGNOSES

 4. When admission/encounter is for management of an _____ associated with the malignancy, and the treatment is

CHAPTER 6 REVIEW
only for anemia, the appropriate code for the malignancy is sequenced as the principal or _____ diagnosis fol-
lowed by the appropriate code for the anemia.
5. When the admission/encounter is for management of _____ due to the malignancy and only the dehydration is
being treated (intravenous rehydration), the dehydration is sequenced first, followed by the code(s) for the _____. 
6. When a primary malignancy has been previously _____ or eradicated from its site and there is no further treat-
ment directed to that site and there is no evidence of any existing primary malignancy, a code from category
_____, Personal history of malignant neoplasm, should be used to indicate the former site of the malignancy.
7. If a patient admission/encounter is solely for the administration of chemotherapy, immunotherapy, or radiation
therapy assign code _____, Encounter for antineoplastic radiation therapy, or _____, Encounter for antineoplastic
chemotherapy, or _____, Encounter for antineoplastic immunotherapy as the first-listed or principal diagnosis.
8. When the reason for admission/encounter is to determine the _____ of the malignancy or for a procedure such as
paracentesis or thoracentesis, the primary malignancy or appropriate metastatic site is designated as the principal
or first-listed diagnosis, even though chemotherapy or radiotherapy is administered.
9. If the reason for the encounter is for treatment of a primary malignancy, assign the malignancy as the _____
diagnosis.
10. When an encounter is for a _____ fracture due to a neoplasm, and the focus of treatment is the fracture, a code
from subcategory _____, Pathological fracture in neoplastic disease, should be sequenced _____, followed by the
code for the neoplasm.

Let’s Check It! Rules and Regulations

Please answer the following questions from the knowledge you have gained after reading this chapter.
1. LO 6.2  Explain the difference between benign and malignant. 
2. LO 6.2  What is the difference between primary, secondary, Ca in situ, uncertain, and unspecified behavior?
3. LO 6.4  Explain what overlapping boundaries are, and give another term for overlapping boundaries. 
4. LO 6.4  What is morphology, and why is it important? 
5. LO 6.5  Discuss prophylactic organ removal, its advantage, and how this should be coded.

ICD-10-CM
YOU CODE IT! Basics
First, identify the main term in the following diagno- 3. Papillary adenocarcinoma, intraductal, left
ses; then code the diagnosis. breast:
Example: Malignant primary neoplasm of lung, right a. main term: _____ b. diagnosis: _____
upper lobe: 4. Malignant carcinoid tumor of the colon:
a. main term: neoplasm b. diagnosis C34.11 a. main term: _____ b. diagnosis: _____
5. Hemangioma of intra-abdominal structures:
1. Acute megakaryocytic leukemia in relapse: 
a. main term: _____ b. diagnosis: _____
a. main term: _____ b. diagnosis: _____
6. Adenoma of the liver cell:
2. Benign neoplasm of uterine ligament, broad: 
a. main term: _____ b. diagnosis: _____
a. main term: _____ b. diagnosis: _____
CHAPTER 6 REVIEW

7. Follicular grade III lymphoma lymph nodes of 11. Malignant odontogenic tumor, upper jaw bone:
inguinal region and lower limbs: a. main term: _____ b. diagnosis: _____
a. main term: _____ b. diagnosis: _____ 12. Secondary malignant neoplasm of vallecula:
8. Acral lentiginous, right heel melanoma: a. main term: _____ b. diagnosis: _____
a. main term: _____ b. diagnosis: _____ 13. Carcinoma in situ neoplasm of left eyeball:
9. Lipoma of the kidney: a. main term: _____ b. diagnosis: _____
a. main term: _____ b. diagnosis: _____ 14. Benign neoplasm of cerebrum peduncle:
10. Primary malignant neoplasm of right male breast, a. main term: _____ b. diagnosis: _____
upper-outer quadrant: 15. Myelofibrosis with myeloid metaplasia:
a. main term: _____ b. diagnosis: _____ a. main term: _____ b. diagnosis: _____

ICD-10-CM
YOU CODE IT! Practice
Using the techniques described in this chapter, carefully read through the case studies and determine the most
accurate ICD-10-CM code(s) and external cause code(s), if appropriate, for each case study.
1. George Donmoyer, a 58-year-old male, presents today with a sore throat, persistent cough, and earache.
Dr. Selph completes an examination and appropriate tests. The blood-clotting parameters, the thyroid function
studies, as well as the tissue biopsy confirm a diagnosis of malignant neoplasm of the extrinsic larynx.
2. Monica Pressley, a 37-year-old female, comes to see Dr. Wheaten today because she has been having diarrhea
and abdominal cramping and states her heart feels like its quavering. The MRI scan confirms a diagnosis of
benign pancreatic islet cell adenoma. 
3. Suber Wilson, a 57-year-old male, was diagnosed with a malignant neoplasm of the liver metastasized from
the prostate; both sites are being addressed in today’s encounter. 
4. William Amerson, a 41-year-old male, comes in for his annual eye examination. Dr. Leviner notes a benign
right conjunctiva nevus. 
5. Edward Bakersfield, a 43-year-old male, presents with shortness of breath, chest pain, and coughing up
blood. After a thorough examination, Dr. Benson notes stridor and orders an MRI scan. The results of the
MRI confirm the diagnosis of bronchial adenoma. 
6. Elizabeth Conyers, a 56-year-old female, presents with unexplained weakness, weight loss, and dizziness.
Dr. Amos completes a thorough examination and does a work-up. The protein electrophoresis (SPEP) and
quantitative immunoglobulin results confirm the diagnosis of Waldenström’s macroglobulinemia. 
7. James Buckholtz, a 3-year-old male, is brought in by his parents. Jimmy has lost his appetite and is los-
ing weight. Mrs. Buckholtz tells Dr. Ferguson that Jimmy’s gums bleed and he seems short of breath.
Dr. ­Ferguson notes splenomegaly and admits Jimmy to Weston Hospital. After reviewing the blood tests,
MRI scan, and bone marrow aspiration results, Jimmy is diagnosed with acute lymphoblastic leukemia. 
8. Kelley Young, a 39-year-old female, presents to Dr. Clerk with the complaints of sudden blurred vision, dizzi-
ness, and numbness in her face. Kelley states she feels very weak and has headaches. Dr. Clerk admits Kelley
to the hospital. After reviewing the MRI scan, her hormone levels from the blood workup, and urine tests,
Kelley is diagnosed with a primary malignant neoplasm of the pituitary gland. 
9. Ralph Bradley, a 36-year-old male, comes to see Dr. Harper because he is weak, losing weight, and vomiting
and has diarrhea with some blood showing. Ralph was diagnosed with HIV 3 years ago. Dr. Harper completes
an examination noting paleness, tachycardia, and tachypnea. Ralph is admitted to the hospital. The biopsied
tissue from an endoscopy confirms a diagnosis of Kaposi’s sarcoma of gastrointestinal organ. 

168   PART II  |  REPORTING DIAGNOSES

 CHAPTER 6 REVIEW
10. Ben Jameson, a 31-year-old male, was admitted today for the prophylactic removal of his prostate. Both Ben’s
father and brother have prostate cancer that has spread to the lungs and liver. Ben decides to have a laparo-
scopic radical prostatectomy while he is still healthy. 
11. Phillip DeLorne, a 21-year-old male, presents with a sore on his left ear of approximately 5-weeks duration.
Philip says it just won’t get well. Dr. Duruy notes a pink lump on Philip’s pinna and a biopsy is taken, which
confirms a diagnosis of melanoma in situ of the left external ear. 
12. Mitchell Lane, a 48-year-old male, presents with the complaints of night sweats and weight loss. Dr. Clark
completes an examination noting hemoptysis and takes a chest x-ray, which reveals a mass. Mitchell is admit-
ted to Weston Hospital where a CT-guided needle biopsy is then performed. Mitchell is diagnosed with a
malignant primary neoplasm of the posterior mediastinum. 
13. Raykeem McFadden, a 63-year-old female, was last seen in this office 6 months ago for her annual checkup;
no concerns were noted at that time. She presents today because of excessive itching after a warm bath. She
also complains of a burning sensation in her arms, especially her left arm. Dr. Dingle completes a physical
exam and notes aphasia, hepatosplenomegaly, and some loss of physical coordination. Raykeem is admitted
to the hospital. The laboratory tests and bone marrow aspiration confirm a diagnosis of polycythemia vera. 
14. Terry Shelton, a 33-year-old female, had chemotherapy 3 days ago, for gallbladder cancer. She presents today
to see Dr. China due to extreme weakness and chest pain. Dr. China notes an irregular heartbeat and a CBC
reveals a hemoglobin of 8.3 g/dL. Terry is diagnosed with anemia due to antineoplastic chemotherapy and
admitted to Weston Hospital for treatment of her anemia.
15. Kewane Childs, a 44-year-old female, has a history of smoking cigarettes for 15 years; she quit last year.
Kewane sees Dr. Cope for a dry cough, hoarse voice, and coughing up blood. Dr. Cope notes crepitation and
dyspnea. Kewane is admitted to the hospital. The MRI scan and lung function tests confirm a diagnosis of
neoplasm of the trachea, malignant primary. 

ICD-10-CM
YOU CODE IT! Application
The following exercises provide practice in abstracting physicians’ documentation from our health care facility,
Prader, Bracker, & Associates. These case studies are modeled on real patient encounters. Using the techniques
described in this chapter, carefully read through the case studies and determine the most accurate ICD-10-CM
code(s) and external cause code(s), if appropriate, for each case study.

WESTON HOSPITAL 
629 Healthcare Way • SOMEWHERE, FL 32811 • 407-555-6541
PATIENT: KAHN, SERENA
ACCOUNT/EHR #: KAHNSE001
DATE: 09/16/18
Attending Physician: Oscar R. Prader, MD
HPI: This patient is being admitted to Weston Hospital for wide excision of a level 2 melanoma, right
side of the face. She was referred from Dr. Robinson. Patient states she has had the lesion forever.
Dr. Robinson found it disturbing and decided to take a biopsy; results, melanoma, level 2.
This lesion is located just anterior to the ear on the right zygomatic region; we should get a reasonably
good margin.
PAST MEDICAL HISTORY: Hypothyroidism and takes thyroid replacement medication.
CHAPTER 6 REVIEW

PAST SURGICAL HISTORY: The patient had carcinoma of the breast and underwent a left mastectomy in
2012. She had a hysterectomy for benign ovarian tumors in 2015.
ALLERGIES: NKA
SOCIAL HISTORY: Nonsmoker. Drinks alcohol socially.
FAMILY HISTORY: The patient’s sister is diabetic.
ROS: Negative.
PHYSICAL EXAMINATION: Ht: 5’6”, Wt: 142, T: 98.6, R: 18, BP 170/70. HEENT: Head is atraumatic, nor-
mocephalic; there is a pigmented lesion just anterior to the right ear over the zygomatic region, which
is slightly irregular in shape and different shades of brown. Biopsied site is noted and healing within
normal limits. 
NECK: Negative.
CHEST: Clear and symmetrical
HEART: Regular rhythm, no murmurs 
ABDOMEN: Soft, nontender, no masses or organomegaly
EXTREMITIES: No cyanosis, clubbing, or edema
NEUROLOGIC: Grossly intact
IMPRESSION: Melanoma of the right cheek, level 2
PLAN: Wide excision with flap advancement closure
ORP/pw  D: 9/16/18 09:50:16  T: 9/18/18 12:55:01

Determine the most accurate ICD-10-CM codes.

WESTON HOSPITAL
629 Healthcare Way • SOMEWHERE, FL 32811 • 407-555-6541
PATIENT: DAWSON, WILSON
ACCOUNT/EHR #: DAWSWI001
DATE: 08/11/18
Attending Physician: Renee O. Bracker, MD
Pt is a 47-year-old male with left breast carcinoma, terminal stage, metastatic to the brain and liver.
­Wilson is undergoing chemotherapy and has become dehydrated, showing signs of confusion and dis-
orientation. He is admitted to Weston Hospital for rehydration. Procalamine 3%, IV, 50mL/hr was given
for 12 hours. Patient stabilized and was discharged home with no other treatment.
ROB/pw  D: 08/11/18 09:50:16  T: 08/13/18 12:55:01

Determine the most accurate ICD-10-CM codes.

170   PART II  |  REPORTING DIAGNOSES

 CHAPTER 6 REVIEW
WESTON HOSPITAL
629 Healthcare Way • SOMEWHERE, FL 32811 • 407-555-6541
PATIENT: OAKWOOD, QUENTIN
ACCOUNT/EHR #: OAKWQU001
DATE: 09/16/18
Attending Physician: Oscar R. Prader, MD
Pt is a 63-year-old male who was diagnosed with prostate cancer 3 years ago. 18 months ago he had
a radical prostatectomy. 1 year ago he was diagnosed with bone and liver metastasis. Patient has a
high level of pain associated with his liver cancer and is being admitted for an insertion of a tunneled
centrally inserted port-a-cath VAD (venous access device) with a sub q port for delivery of pain control
medication.
ORP/pw  D: 9/16/18 09:50:16  T: 9/18/18 12:55:01

Determine the most accurate ICD-10-CM codes.

PRADER, BRACKER, & ASSOCIATES

A Complete Health Care Facility
159 Healthcare Way • SOMEWHERE, FL 32811 • 407-555-6789
PATIENT: CHARLES, KAREN
ACCOUNT/EHR #: CHARKA001
DATE: 08/11/18
Attending Physician: Renee O. Bracker, MD
Patient, a 43-year-old female, presents today to discuss pathological findings of recent exploratory
laparotomy. Patient is 4 days’ status post lysis of adhesions; total abdominal hysterectomy; bilateral
salpingo-­oophorectomy; partial omentectomy; excision of small and large bowel implants; pelvic-
abdominal peritoneal stripping; placement of intraperitoneal port-a-cath; and enterolyses.
The ovaries were found to be poorly differentiated; serous carcinoma extended to the left fallopian
tube. The right fallopian tube was found to have serosal fibrosis consistent with tubo-ovarian adhesion.
A broad-based endometrial polyp was found in the endometrium while the myometrium showed leiomy-
omata, adenomyosis, and multifocal serosal implants of poorly differentiated ovarian serous carcinoma.
The specimen from the omentum was found to be metastatic adenocarcinoma consistent with ovarian origin.
Lastly, the specimens from both the small and large bowel were positive for metastatic, poorly differenti-
ated ovarian serous carcinoma.
The histomorphologic features of poorly differentiated ovarian serous carcinoma closely resemble that
of a poorly differentiated fallopian tube primary adenocarcinoma. The bilateral ovarian involvement sup-
ports the primary ovarian origin of the neoplasm.
ASSESSMENT: Metastatic adenocarcinoma of the omentum; metastatic carcinoma of the small and large
intestines.
ROB/pw  D: 08/11/18 09:50:16  T: 08/13/18 12:55:01

Determine the most accurate ICD-10-CM codes.

CHAPTER 6 REVIEW

WESTON HOSPITAL
629 Healthcare Way • SOMEWHERE, FL 32811 • 407-555-6541
PATIENT: BENTONN, VERNON
ACCOUNT/EHR #: BENTVE001
DATE: 09/16/18
Attending Physician: Oscar R. Prader, MD
PREOP DIAGNOSIS: Lower extremity ischemia with rest pain and gangrene of the right third toe, prob-
able atheroembolic disease to the right lower extremity.
POSTOP DIAGNOSIS: Atheroembolic disease to the right lower extremity.
PROCEDURE: Right, axillary femoral-femoral bypass utilizing an 8.0-mm ringed Gore-Tex axillary-to-
femoral graft and a 6.0-mm ringed Gore-Tex femoral cross-over graft, right third toe amputation.
OPERATIVE INDICATIONS: This is a 69-year-old male, presenting with local rectal carcinoma, recurrent,
with miliary metastases to the liver. 
PATHOLOGICAL FINDINGS: Specimen: Third right toe consistent with ischemic necrosis.
PLAN/RECOMMENDATIONS: At this time, given known early liver metastases and extensive local
regional recurrence in the pelvis, I do not feel that further antineoplastic therapy will be of great benefit.
Specifically, patient has had chemotherapy up until September of this year and this disease has
recurred. In addition, he has a history of full radiotherapy to the pelvis.
Secondly, evidence-based medicine for recurrent colorectal cancer has shown that secondline chemo-
therapy has been of little to no value.
Pain management: I would recommend continuing his Duragesic patch, advise the addition of a low
dose of Elavil to help reduce neurogenic pain. Efforts will be made to improve mobility. 
ORP/pw  D: 9/16/18 09:50:16  T: 9/18/18 12:55:01

Determine the most accurate ICD-10-CM codes.

172   PART II  |  REPORTING DIAGNOSES

Coding Conditions of the
Blood and Immunological
Systems
7
Learning Outcomes Key Terms
After completing this chapter, the student should be able to: Agglutination
Antibodies
LO 7.1 Differentiate between various blood conditions and how this Antigen
affects the determination of the code. Blood
LO 7.2 Determine the codes to report coagulation defects and hem- Blood Type
orrhagic conditions accurately. Coagulation
LO 7.3 Identify the different types of blood and the importance of Rh Hematopoiesis
Hemoglobin
factoring involved in malfunction.
(hgb or Hgb)
LO 7.4 Interpret the details of white blood cell disorders and dis- Hemolysis
eases of the spleen. Hemostasis
LO 7.5 Evaluate the factors involved in immunodeficiency disorders. Plasma
Platelets (PLTs)
Red Blood Cells
(RBCs)
Remember, you need to follow along in Rh (Rhesus) Factor
Transfusion
ICD-10-CM
  STOP! your ICD-10-CM code book for an optimal White Blood Cells
learning experience. (WBCs)

Blood
7.1  Reporting Blood Conditions Fluid pumped throughout
the body, carrying oxygen
As with any other part of the body, malfunction of the blood-forming organs, the and nutrients to the cells and
blood itself, or one of its components can result in problems affecting the entire body.  wastes away from the cells.
Blood is actually a type of connective tissue consisting of red blood cells (RBCs), Red Blood Cells (RBCs)
white blood cells (WBCs), and platelets (PLTs)—all contained within liquid Cells within the blood that con-
plasma. It is the transportation system used to deliver oxygen (nourishment) for cells tain hemoglobin responsible
throughout the body and to carry carbon dioxide (cell waste products) so it can be for carrying oxygen to tissues;
expelled from the body. The average adult has between 5 and 6 liters of blood con- also known as erythrocytes.
stantly circulating throughout.
White Blood Cells (WBCs)
Cells within the blood that help
The Formation of Blood to protect the body from patho-
Blood is created in the red bone marrow (see Figure 7-1) during a series of steps called gens; also known as leukocytes.
hematopoiesis. During gestation, blood cells originate in the yolk sac from the mesen- Platelets (PLTs)
chyme (the section of the embryo in which blood, lymphatic vessels, bones, cartilage, Large cell fragments in the bone
and connective tissues form). As the fetus continues to develop, the liver, spleen, and marrow that function in clotting;
thymus begin to produce blood cells. Then, at about the 20th week of gestation, the red also known as thrombocytes.
bone marrow also begins to contribute to production. Once the baby is born, blood cell
formation becomes the responsibility of the red bone marrow only, specifically in the Plasma
The fluid part of the blood.
sternum, ribs, and vertebrae. Red bone marrow produces red blood cells (erythrocytes)
through a process called erythropoiesis and white blood cells (leukocytes) through a Hematopoiesis
process called leukopoiesis. The formation of blood cells.
 Epiphyseal plates
Articular cartilage
Proximal
Spongy bone epiphysis
Space containing
red marrow

Compact bone
Medullary cavity

Yellow marrow

Periosteum Diaphysis

Distal
epiphysis

Femur

FIGURE 7-1  Bone marrow  Source: David Shier et al., Hole’s Human Anatomy & Physiology, 12/e. ©2010
McGraw-Hill Education. Figure 7.2, p. 194. Used with permission.

How many blood cells does a healthy body need? Normal counts (per microliter of
blood) are
∙ Red blood cell count: 4 to 6 million cells.
Hemoglobin (hgb or Hgb) ∙ White blood cell count: 4,000 to 11,000 cells.
The part of the red blood cell
that carries oxygen. ∙ Platelet count: 150,000 to 400,000 platelets.
Too many cells or too few cells may indicate a problem. This is why one of the first
diagnostic tests run when a physician is trying to figure out what is wrong with the
patient is a complete blood count (CBC).
CODING BITES
While professional cod-
Blood Roles
ing specialists are not Blood’s primary job is transporting oxygen from the lungs and delivering it to tissue
permitted to diagnose cells throughout the body. As the oxygen passes from the lungs to the blood, it binds
a patient, understand- to the red blood cells and the hemoglobin (hgb or Hgb) inside those RBCs (see
ing these details from a Figure 7-2), so it can travel through the heart and out through the body via the arteries.
pathology or lab report After delivering the oxygen (O2) to the cells, the blood picks up carbon dioxide (CO2)
can support your under- and carries it back to the lungs for expulsion from the body.
standing of the docu-
mentation or explain Anemias
medical necessity—or
it may alert you, as the While many believe anemia is the result of an iron deficiency, this is only one cause
coder, to query the phy- of an abnormally low count of hemoglobin, hematocrit, and/or RBCs. The low volume
sician about missing or of RBCs reduces the amount of oxygen being transported, causing tissue hypoxia (low
ambiguous notes. levels of oxygen). Blood loss, lack of red blood cell production, and high rates of red
blood cell destruction are the three most common causes of anemia. Classic signs and
symptoms include tachycardia, dyspnea, and sometimes fatigue.

174   PART II  |  REPORTING DIAGNOSES

 Lung
External alveoli
respiration

Pulmonary CO2 O2 Pulmonary

artery vein

Red blood cells

Pulmonary circuit

Systemic Systemic circuit Systemic

veins Red blood cells arteries

CO2 O2

Internal
respiration

Tissue cells

FIGURE 7-2  Oxygen and carbon dioxide exchanging in blood

Nutritional anemia, reported with a code from the D50–D53 range, is caused by an
insufficient intake or absorption into the body of certain key nutrients. For example,
pernicious anemia is a genetic condition that causes dysfunction of the ileum so it
cannot properly absorb vitamin B12; iron deficiency anemia may be caused by a diet
lacking iron-rich foods.

EXAMPLES
D50.0 Iron deficiency anemia secondary to blood loss (chronic)
D51.0 Vitamin B12 deficiency anemia due to intrinsic factor deficiency
(pernicious (congenital) anemia)
D52.0 Dietary folate deficiency anemia
D53.2 Scorbutic anemia
Specific details about the underlying cause of the anemia are required to report
an accurate code.

CHAPTER 7  | 
 Hemolytic anemia (codes D55–D59) results from an insufficient number of healthy
red blood cells due to abnormal or premature destruction, thereby retarding the deliv-
ery of oxygen to the tissues throughout the body. This premature destruction of the
red blood cells may be caused by a genetic defect, an infection, or exposure to certain
toxins. Hemolytic anemia can also be caused by a mismatched blood transfusion. 

EXAMPLES
D55.1 Anemia due to other disorders of glutathione metabolism
D56.4 Hereditary persistence of fetal hemoglobin
Sickle-cell disorders are included in this subsection. See upcoming section for
more on these diagnoses.

Aplastic anemia (code category D61) is the inability of the bone marrow to manu-
facture enough new blood cells required by the body for proper function. 

EXAMPLES
D61.01 Constitutional (pure) red blood cell aplasia
D61.2 Aplastic anemia due to other external agents
Code first, if applicable, toxic effects of substances chiefly non-
medicinal as to source (T51-T65)
Sickle-cell disorders are included in this subsection. See upcoming section for
more on these diagnoses.

Hemorrhagic anemia, also called blood loss anemia or posthemorrhagic anemia

(code D62 Acute posthemorrhagic anemia), can occur after the patient has lost a great
deal of blood. This can be after a traumatic injury or internal bleeding, such as an
untreated gastric ulcer.

ICD-10-CM
LET’S CODE IT! SCENARIO
Carter McMannus, an 18-month-old male, was brought by his mother to Dr. Hampshire, a pediatrician specializing
in hematologic (blood) disorders. Dr. Hampshire noted jaundice, an enlarged spleen on palpation, and other signs
of failure to thrive. Dr. Hampshire recognized these signs and symptoms and confirmed with blood tests a diagnosis
of Cooley’s anemia.

Let’s Code It!

Dr. Hampshire diagnosed Carter with Cooley’s anemia. Turn to the Alphabetic Index and find
Anemia
Are you surprised by the long indented list of different types of anemia? Read down the list and find
Anemia
  Cooley’s (erythroblastic) D56.1
Now let’s go to the Tabular List to confirm this code. Remember, always begin reading at the three-character
category.
D56  Thalassemia

176   PART II  |  REPORTING DIAGNOSES

 Thalassemia is an inherited group of hemolytic anemias (hemo = blood + -lytic = involving lysis, the decompo-
sition of a cell). Cooley’s anemia, also known as thalassemia major, is one type of beta thalassemia, the most
common form of this condition.
Read down the fourth-character choices and find
D56.1  Beta thalassemia (Cooley’s anemia)
Check the top of this subsection and the head of this chapter in ICD-10-CM. There is an notation at
the beginning of this chapter. Read carefully. Does this relate to Dr. Hampshire’s diagnosis of Carter? No. Turn to
the Official Guidelines and read Section 1.c.3. Interesting, there are no guidelines for this chapter.
Now you can report D56.1 for Carter’s diagnosis with confidence.
Good job!

Sickle Cell Disease and Sickle Cell Trait

Sickle cell disease (SCD) is not actually one diagnosis, but represents several genetically
passed disorders of the red blood cells (RBCs). Normal RBCs are round, whereas an
individual with SCD develops red blood cells that are a C-shape and are unusually firm
and sticky. The shape of these abnormal cells resembles a tool known as a sickle, leading
to the name for this condition. In addition to the shape and nature of these cells, they have
a shorter life span, resulting in a continuing shortage of RBCs. The sticky texture of these
cells also increases the opportunity for the cells to stick to the walls of the blood vessels,
manifesting obstructions and an ineffective delivery of oxygen via the hemoglobin.
SCD can be diagnosed in utero or in newborn blood screenings. The earlier the
diagnosis, the sooner treatments can be implemented.
As a professional coder, you will need to know more than a diagnosis of SCD; you
will need to know specifics about the condition, as well as any manifestations. CODING BITES
Be certain to read the
Hb-SS notation at the code cat-
egory of D57 Sickle-
D57.00 Hb-SS disease with crisis, unspecified cell disorders, which
D57.01 Hb-SS disease with acute chest syndrome directs you to
D57.02 Hb-SS disease with splenic sequestration Use additional code
Hb-SS disease is a condition in which the patient has inherited two sickle cell genes for any associated
(“S”), one from each parent. Commonly referred to as sickle cell anemia, this is typi- fever (R50.81)
cally the most acute form of this condition.

Hb-C, HB-S, or HB-SC

D57.20 Sickle-cell/Hb-C disease without crisis
D57.211 Sickle-cell/Hb-C disease with acute chest syndrome
D57.212 Sickle-cell/Hb-C disease with splenic sequestration
D57.219 Sickle-cell/Hb-C disease with crisis, unspecified
Sometimes known as Hb-SC or Hb-S disease, this patient has inherited a sickle cell
gene (“S”) from one parent and a gene for abnormal hemoglobin called “C” from the
other parent. 

HbS Beta Thalassemia

D57.40 Sickle-cell thalassemia without crisis
D57.411 Sickle-cell thalassemia with acute chest syndrome
D57.412 Sickle-cell thalassemia with splenic sequestration
D57.419 Sickle-cell thalassemia with crisis, unspecified

CHAPTER 7  | 
 This form of SCD manifests when the patient inherits one sickle cell gene (“S”) from
one parent and the gene for beta thalassemia from the other parent. 

HbSD and HbSE

D57.80 Other sickle-cell disorders without crisis
D57.811 Other sickle-cell disorders with acute chest syndrome
D57.812 Other sickle-cell disorders with splenic sequestration
D57.819 Other sickle-cell disorders with crisis, unspecified
When a patient inherits one sickle cell gene (“S”) and one gene with an abnormal
type of hemoglobin (“D,” “E,” or “O”) it would be documented as Hb-SD, Hb-SE, or
Hb-S. 

Sickle Cell Trait

D57.3 Sickle-cell trait
Sickle-cell trait (SCT) develops when the patient has inherited one sickle cell gene
(“S”) from one parent and a normal gene (“A”) from the other parent. Individuals diag-
nosed with SCT do not typically exhibit any signs or symptoms of the disease. When
this patient considers having children, this should be noted because this can be passed
along to future children. 

Hematologic Malignancies
Both lymphomas and leukemias are included in this category. Leukemia is the pres-
ence of malignant cells within the bone marrow that produces blood cells (hema-
topoietic tissues), causing a reduction in the production of RBCs, WBCs, and
platelets. This anemic state makes the patient very susceptible to infections and
hemorrhaging. 
There are several types of leukemia reported from several ICD-10-CM code
categories:
code category C92 Myeloid leukemia
code category C93 Monocytic leukemia
code category C94 Other leukemia of specified cell type
code category C95 Leukemia of unspecified cell type
The aspiration of bone marrow (known as a bone marrow biopsy) is typically taken
from the posterior superior iliac spine. This specimen is tested to quantify the white
blood cells. When a rapid reproduction of immature WBCs is evidenced, this confirms
a diagnosis of acute leukemia. In addition, the results of a differential leukocyte count
can specifically identify the type of cell and a lumbar puncture (aka spinal tap) can
reveal whether or not there is involvement of the meninges.

7.2  Coagulation Defects and Other

­Hemorrhagic Conditions
Hemostasis In addition to transporting oxygen, blood also controls hemostasis (stopping the
The interruption of bleeding. bleeding process) via coagulation (clotting).
Essentially, there are two types of clotting disorders: hemostatic and thrombotic.
Coagulation
Clotting; the change from A hemostatic disorder is a failure in the system to repair a damaged blood vessel.
a liquid into a thickened Because there is no clot to stop it, the vessel continues to bleed. These coagulation
substance. deficiencies—where clotting does not occur as it should (see Figure 7-3)—may
be seen with bleeding into the muscles, joints, and viscera or with the appearance

178   PART II  |  REPORTING DIAGNOSES

 Vasoconstriction

Vessel Collagen
injury fibers
Endothelial cells Platelet plug Blood clot Fibroblasts

(a) Blood vessel spasm (b) Platelet plug formation (c) Blood clotting (d) Fibrinolysis

FIGURE 7-3  The four main events in hemostasis

of purpura (dysfunction of blood vessels). Hemophilia is a common hemostatic

condition, reported with code D66 Hereditary factor VIII deficiency (Classical
hemophilia). 
Thrombotic disorders are the opposite: The blood clots without purpose, forming
thrombi (blood clots) within the vessels, causing a blockage. Beyond the dangers from
the thrombi themselves, should a clot dislodge (embolus) and travel through the blood
vessels, it might get caught going through the lungs or heart, causing a blockage that
could be deadly. Thrombophilia is an example of a thrombotic condition, reported
with, for example, ICD-10-CM code D68.59 Other primary thrombophilia (Hyperco-
agulable state NOS).

Hemophilia
Hemophilia is a genetic mutation that establishes a deficiency lacking a protein (clot-
ting factor) in the blood necessary in the clotting process. Therefore, the patient’s
blood will not clot when needed to prevent hemorrhaging. The lower the quantity of
the clotting factor, the higher the probability that the patient might hemorrhage and
have it become life-threatening.
The majority of patients diagnosed with hemophilia have a deficiency of either fac-
tor VIII or factor IX.

Types of Hemophilia
There are four types of Hemophilia: A, B, C, and Acquired.

Hemophilia A (Classic Hemophilia) . . . deficiency of clotting factor VIII. This is

reported with one of two codes:
D66 Hereditary factor VIII deficiency
(Hemophilia A)
(Deficiency factor VIII with functional defect)
D68.0 Von Willebrand’s disease
(factor VIII deficiency with vascular defect)
Hemophilia B (Christmas Disease) . . . deficiency of clotting factor IX.
D67 Hereditary factor IX deficiency
(Hemophilia B)
(Deficiency factor IX with functional defect)
(Christmas disease)

CHAPTER 7  | 
 Hemophilia C (Rosenthal’s Disease) . . . deficiency of clotting factor XI.
D68.1 Hereditary factor XI deficiency
(Hemophilia C)
Plasma thromboplastin antecedent [PTA} deficiency
(Rosenthal’s disease)
Acquired hemophilia (secondary hemophilia) . . . actually an autoimmune disease that
occurs when antibodies are created that mistakenly attack healthy tissue, specifically
clotting factor VIII. In these cases, the bleeding pattern is quite different from classi-
cal hemophilia. With acquired hemophilia, spontaneous hemorrhaging moves into the
muscles, skin, soft tissue, and mucous membranes. Bleeding episodes are frequently
acute and can become life-threatening.
D68.311 Acquired hemophilia
(Secondary hemophilia)
D68.4 Acquired coagulation factor deficiency
(Deficiency of coagulation factor due to liver disease)
(Deficiency of coagulation factor due to vitamin K deficiency)

ICD-10-CM
LET’S CODE IT! SCENARIO
Dr. Victor ordered a coagulation profile, including a partial thromboplastin time (PTT) and prothrombin time (PT), to
be done on Louis Langer prior to scheduling his surgery. The pathology report showed an abnormally prolonged
PTT. The surgery will be delayed until Dr. Victor can confirm the cause.

Let’s Code It!

The lab report identified an abnormal coagulation profile, and Dr. Victor did not provide any confirmed diagnosis.
Therefore, this is all you know for a fact, and this is what must be reported. Turn to the Alphabetic Index and find
Abnormal

This is going to take some analysis. There is no listing under Abnormal for Test or Coagulation. Think about this.
What is the body’s reason for coagulation? To stop bleeding. Look for Blood or Bleeding. Did you find
Abnormal
  Bleeding time R79.1

Now let’s go into the Tabular List to check this out. Remember, always begin reading at the three-character
category.
R79 Other abnormal findings of blood chemistry

Read down the fourth-character choices and find

R79.1 Abnormal coagulation profile (abnormal or prolonged partial thromboplastin time [PTT])

Read the and notations directly below this code.

Check the top of this subsection; there is an notation. Read it carefully to see if any of those condi-
tions apply. At the head of this chapter in ICD-10-CM, you will find a long NOTE and an  notation. Read
carefully. Do any relate to Dr. Victor’s diagnosis of Louis? Yes, so confirm that there is no more specific diagnosis
that can be reported instead. There is not. Now, turn to the Official Guidelines and read Section 1.c.18. There is
nothing specifically applicable here either.
Now you can report R79.1 for Louis’s diagnosis with confidence.
Good job!

180   PART II  |  REPORTING DIAGNOSES

Thrombocytopenia
This is a low platelet count most often due to increased platelet destruction, decreased
platelet production, or malfunctioning platelets. Underlying conditions might include
splenomegaly (enlarged spleen); destruction of bone marrow by medication, chemo-
therapy, or radiation therapy; or aplastic anemia. The condition will be reported most
often with a code from ICD-10-CM code category D69 Purpura and other hemor-
rhagic conditions, although not exclusively. For example, postpartum puerperal
thrombocytopenia is reported with code O72.3 Postpartum coagulation defects and
neonatal, transitory thrombocytopenia is reported with code P61.0 Transient neonatal
thrombocytopenia.

ICD-10-CM
YOU CODE IT! CASE STUDY
Marissa Rubine, a 27-year-old female, came to see Dr. Post with complaints of bruising “suddenly appearing” on her
arms and legs. She states she had two recent episodes of epistaxis but denies any other bleeding. She denied tak-
ing any drugs or smoking, and states she has no risk factors for HIV. Physical examination revealed the spleen was
not palpable. Petechiae are noted scattered on her legs bilaterally. 
Blood work results: 
•  hemoglobin (138 g/L)—normal 
•  white cell count—normal
•  platelet count of 10 × 109/L—low (normal >150 × 109/L)
•  erythrocyte sedimentation rate was 6 mm/h
•  direct Coombs’ test—negative
•  antinuclear—absent 
•  DNA-binding antibodies—absent
•  rheumatoid factor—absent

Bone marrow aspiration: high number of normal megakaryocytes but otherwise normal
Dx: Immune thrombocytopenia purpura
She is placed on a short course of prednisolone.

You Code It!

Go through the steps of coding, and determine the code or codes that should be reported for this encounter
between Dr. Post and Marissa.
Step #1: Read the case carefully and completely.
Step #2: Abstract the scenario. Which main words or terms describe why the physician cared for the patient dur-
ing this encounter?
Step #3: Are there any details missing or incomplete for which you would need to query the physician? [If so, ask
your instructor.]
Step #4: Check for any relevant guidance, including reading all of the symbols and notations in the Tabular List
and the appropriate sections of the Official Guidelines.
Step #5: Determine the correct diagnosis code or codes to explain why this encounter was medically necessary.
Step #6: Double-check your work.

(continued)

CHAPTER 7  | 
 Answer:
Did you determine this to be the correct code?
D69.3 Immune thrombocytopenic purpura

Great work!

7.3  Conditions Related to Blood Types

and the Rh Factor
Antigens on Red Blood Cells
Antigen Antigens sit on the surface of red blood cells, while antibodies are located within the
A substance that promotes blood plasma. Antigens are proteins that cause antibodies to form, and each antibody
the production of antibodies. can connect with only one specific type of antigen. Antigens that are located on RBCs
Antibodies are categorized in two ways: blood type and Rh factor.
Immune responses to
antigens. Blood Type
You may know what blood type you have: type A, type B, type AB, or type O. This is
Blood Type
something that is inherited from your parents.
A system of classifying blood
based on the antigens pres- ∙ An individual with type A blood has only antigen A on his or her red blood cells.
ent on the surface of the indi-
∙ An individual with type B blood has only antigen B on his or her red blood cells.
vidual’s red blood cells; also
known as blood group. ∙ An individual with type AB blood has both antigens—A and B.
∙ An individual with type O blood has neither antigen—neither A nor B.

Rh Factor
Another antigen that may or may not be present on the surface of a red blood cell is
Rh (Rhesus) Factor called Rh (Rhesus) factor. This is also an inherited situation.
An antigen located on the
red blood cell that produces ∙ An individual identified as Rh-negative does not have the Rh antigen.
immunogenic responses in ∙ An individual identified as Rh-positive does have the Rh antigen.
those individuals without it.
Because Rh factor is inherited, there is concern about additional complications if
an Rh-negative woman becomes pregnant with a Rh-positive fetus (the father is Rh-
positive). The good news is, often, the placenta will prevent the mother’s blood from
mixing with the baby’s blood, keeping both mother and baby safe. 

EXAMPLE
O36.012 Maternal care for anti-D (Rh) antibodies, second trimester
Z31.82 Encounter for Rh incompatibility status
When the mother is seen so Rh compatibility can be determined and, if necessary,
dealt with, these codes are examples for reporting why the encounter was medi-
cally necessary.

When the mother is Rh-negative and her body makes antibodies to her fetus’s Rh-
positive blood cells, and the antibodies cross the placenta, it can result in Rh incom-
patibility, resulting in a large number of red blood cells in the fetus’s bloodstream that
may be destroyed, known as hemolytic disease of the newborn.

182   PART II  |  REPORTING DIAGNOSES

 EXAMPLES
P55.0 Rh isoimmunization of newborn [hemolytic disease (newborn)]
P55.1 ABO isoimmunization of newborn
A neonate affected by the Rh factor may be diagnosed with a hemolytic disease.

When proper precautions have not been taken while the baby is in utero, hydrops
fetalis due to hemolytic disease, also known as immune hydrops fetalis, can develop.
This is a known complication of Rh incompatibility and leads the neonate’s entire
body to swell, interfering with the proper function of body organs and systems.
P56.0 Hydrops fetalis due to isoimmunization

ICD-10-CM
LET’S CODE IT! SCENARIO
Neonate Alvarez, male, was born vaginally yesterday, 09/05/2018, at 15:25 without incident. Apgar scores: 1 min.—
10, 5 min.—10. 
Four hours later, extensive purpura became visible on his abdomen, arms, and legs. No jaundice was observed.
His 29-year-old mother was given a blood transfusion for a postpartum hemorrhage after her first pregnancy 3
years earlier. The mother’s serum was found to contain IgG antibodies to the father’s platelets and to some of a
panel of platelets from normal, unrelated donors. These antibodies were typed as specific anti-HPA-1A antibodies
and had been incited by the previous pregnancy and transfusion. 
These antibodies crossed the placenta, manifesting as alloimmune thrombocytopenia in this neonate. Addition-
ally, the neonate was found to have red cell incompatibility. 
An exchange transfusion was performed to compensate for hemolysis. While it is unusual for an ABO incompat-
ibility to require an exchange transfusion, it worked. The neonate’s platelet count returned to normal quickly due to
free reactant antibody to platelets having been removed by the exchange.
We kept the neonate for observation for another 48 hours and then discharged him to his mother. She was told
to follow up in 1 week at the office or phone PRN.

Let’s Code It!

The baby was born and diagnosed with alloimmune thrombocytopenia. In the Alphabetic Index, let’s find our
key term:
Thrombocytopenia
As you read down the indented list, there are two choices that may pop out at you:
Thrombocytopenia
  Congenital D69.42
  Neonatal, transitory P61.0
   Due to
    Exchange transfusion P61.0

Congenital means “present at birth,” and this condition was. However, the patient is a neonate, and the docu-
mentation states that this condition is due to the exchange with his mother. One thing to always remember: You
can always look up both terms in the Tabular List. So let’s do just that—take a look at them both:
D69.42 Congenital and hereditary thrombocytopenia purpura
P61.0 Transient neonatal thrombocytopenia

(continued)

CHAPTER 7  | 
 Let’s go back to the documentation. The physician notes that the baby contracted this condition as a result
of the transfusion his mother received previously. So, this is not actually inherited because it is not the result
of genetics; it is the result of circumstances. In addition, the treatment worked, so the baby no longer has the
blood problem, meaning the thrombocytopenia was temporary (transient). This points us toward the accurate
code of
P61.0 Transient neonatal thrombocytopenia

Check the top of this subsection as well as the head of this chapter in ICD-10-CM. You will find a NOTE, an
notation, and an  notation at the beginning of this chapter. Read carefully. Do any relate to this
neonate’s diagnosis? No. Turn to the Official Guidelines and read Section 1.c.16. There is nothing specifically
applicable here either.
Now you can report P61.0 for baby boy Alvarez’s diagnosis with confidence.
Good work!

Transfusions
Due to the existence of antigens located on the surface of the patient’s red blood cells,
Transfusion any time a patient requires a transfusion of blood, it must be checked for compatibil-
The provision of one person’s ity with regard to type and Rh factor; otherwise, serious consequences could occur.  
blood or plasma to another People with type O blood have neither antigen; anyone can accept this blood type.
individual. Individuals with type O blood are known as universal donors. So, a patient with type
A blood can receive a transfusion of only type A or type O blood. An individual with
type B blood can receive only type B or type O blood. Those with type AB blood
have both types of antigens, so they can receive type A blood, type B blood, or type O
blood. For this reason, they are known as universal recipients.
However, attention must still be paid to Rh factor compatibility. A patient with Rh-
positive blood can receive either Rh-positive or Rh-negative blood. However, patients
with Rh-negative blood should only receive Rh-negative blood. Because of these facts,
Agglutination in an emergency, when time cannot be taken to test the patient’s blood, Rh-negative
The process of red blood cells blood is used.
combining together in a mass The concern about both blood type and Rh factor compatibility arises from the
or lump. dangers that can happen when the correct antibodies and antigens are not in place.
Hemolysis For example, if an Rh-negative patient receives Rh-positive blood, anti-Rh antibodies
The destruction of red blood would be created, causing red blood cell agglutination and hemolysis. Agglutina-
cells, resulting in the release tion occurs when antibodies merge with antigens, causing red blood cells to clump
of hemoglobin into the together. Hemolysis is the process of cells rupturing—destroying red blood cells and
bloodstream. releasing hemoglobin into the bloodstream.

EXAMPLES
Complications of incompatibility can occur when a transfusion is administered
without a valid match to the patient. Because this condition is a complication of
the transfusion, this diagnosis is not reported from Chapter 3 in ICD-10-CM. As the
result of an External Cause, this is reported from the following code category:
T80 Complications following infusion, transfusion, and therapeutic
injection
T80.411A Rh incompatibility with delayed hemolytic transfusion reaction, ini-
tial encounter
T80.310A ABO incompatibility with acute hemolytic transfusion reaction 
T80.A10A Non-ABO incompatibility with acute hemolytic transfusion reaction

184   PART II  |  REPORTING DIAGNOSES

7.4  Disorders of White Blood Cells
and Blood-Forming Organs
White Blood Cell Disorders
Remember from when you took anatomy class, there are five major types of white
blood cells, each of which can malfunction and be unable to perform its job keeping
the body working properly.
∙ Neutrophils contain enzymes that work to destroy parts of bacterial pathogens that
have been consumed by phagocytes.
∙ Lymphocytes are critical in the immune response.
∙ Monocytes are large blood cells that travel throughout the body and destroy dam-
aged red blood cells.
∙ Eosinophils destroy some parasites in addition to controlling inflammation and
allergic reactions.
∙ Basophils create heparin, a blood-thinning agent that prevents inappropriate blood
clotting, and create histamines, involved in allergic reactions.

Neutropenia
Neutropenia is a condition when the patient’s bone marrow produces an abnormally
low number of white blood cells. This may be an ineffective number of cells being
created or a loss of neutrophils at a rate faster than they can be replaced by new cells.
Remember that white blood cells fight infection. Once created in the bone marrow,
these cells are released into the bloodstream, so they can move about the body to
wherever they are needed. 
A diagnosis of neutropenia may be a congenital condition, an adverse reaction to
chemotherapy or other medications, or a malfunction of the hematopoiesis process.
D70.0 Congenital agranulocytosis
(congenital neutropenia)
(Kostmann’s disease)
D70.1 Agranulocytosis secondary to cancer chemotherapy
Code also underlying neoplasm
Use additional code for adverse effect, if applicable, to identify
drug (T45.1X5)
D70.2 Other drug-induced agranulocytosis
Use additional code for adverse effect, if applicable, to identify
drug (T36-T50 with fifth or sixth character 5)
D70.3 Neutropenia due to infection
D70.4 Cyclic neutropenia

Leukopenia and Leukocytosis

In leukopenia, the body is not producing the required number of leukocytes.
D72.810 Lymphocytopenia
D72.819 Decreased white blood cell count, unspecified
Of course, while an insufficient quantity of cells is not going to accomplish what
is needed by the body, too many can also cause havoc. In leukocytosis, the body cre-
ates too many leukocytes. This may be a correct action because these cells are part of
the immune response to certain pathogens. In that case, the elevated white blood cell
count would be a sign that an infection is present, and not reported separately. Without
a reason stated, this may be a malfunction, and its own condition.
D72.820 Lymphocytosis (symptomatic)
D72.829 Elevated white blood cell count, unspecified

CHAPTER 7  | 
 Monocytic, Eosinophilic, and Basophilic Conditions
CODING BITES It is logical that the malfunctions causing too few, or too many, neutrophils and leuko-
Leukemia is a malig- cytes might also occur to the other types of white blood cells.
nancy of the white
blood cells, resulting in D72.818 Other decreased white blood cell count
the bone marrow pro- (Basophilic leukopenia)
ducing abnormal white (Eosinophilic leukopenia)
blood cells that do not (Monocytopenia)
function as needed. This D72.821 Monocytosis (symptomatic)
is why it is reported from D72.823 Leukemoid reaction
the Neoplasms section (Basophilic leukemoid reaction)
of ICD-10-CM, specifi- (Monocytic leukemoid reaction)
cally the C91–C95 code (Neutrophilic leukemoid reaction)
categories.
Splenic Dysfunction
The spleen is part of the lymphatic system, but it contains white blood cells that work
to fight infection. Damage to this organ can be caused by disease or trauma. Problems
with the spleen caused by pathogens are reported from this section of ICD-10-CM. 

EXAMPLES
D73.0 Hyposplenism (Atrophy of spleen)
D73.3 Abscess of spleen
A pathogen or other disease that interferes with the proper function of the spleen
is reported from this chapter of ICD-10-CM.

However, an injury to the spleen caused by a traumatic event would be reported

from the Injury, Poisoning, and Certain Other Consequences of External Causes
chapter of ICD-10-CM.

EXAMPLES
S36.021A Major contusion of spleen, initial encounter
S36.030A Superficial (capsular) laceration of spleen, initial encounter
Even though the spleen is part of the immune system, traumatic injuries are still
reported from the appropriate chapter in ICD-10-CM.

When the problem with the spleen is a congenital anomaly, the appropriate codes
will be found in the Congenital Malformations, Deformations, and Chromosomal
Abnormalities chapter of ICD-10-CM.

EXAMPLES
Q89.01 Asplenia (congenital)
Q89.09 Congenital malformations of spleen
These codes explain that the malfunction of this organ (the spleen) occurred in utero.

Manifestations of Other Diseases

When a condition causes a malfunction in the blood system and/or the blood-forming
organs, it might be a manifestation. If this is the case, the underlying condition will be
reported first, followed by this code:
D77 Other disorders of blood and blood-forming organs in diseases classi-
fied elsewhere

186   PART II  |  REPORTING DIAGNOSES

 ICD-10-CM
 YOU CODE IT! CASE STUDY
PATIENT: Frank Copeland
DISCHARGE SUMMARY
DATE OF ADMISSION: 03/15/2018
DATE OF DISCHARGE: 03/21/2018
ADMISSION DIAGNOSIS: Neutropenic fever.
DISCHARGE DIAGNOSES:
1.  Neutropenic fever.
2.  Acute myelogenous leukemia, status post induction and three cycles of high-dose Ara-C.
3.  Thrombocytopenia.

PROCEDURES PERFORMED:
1.  Two-view chest x-ray.
2.  One unit of PRBC transfusion.
HOSPITAL COURSE: The patient is a very pleasant 54-year-old male with acute myelogenous leukemia who has
undergone three cycles of high-dose Ara-C. He was transferred here after he presented to an outside facility with a
1-day onset of fevers and chills. He had a measured temperature at the outside hospital at that time of 102 degrees.
He was transferred to this facility and admitted to the oncology service.
He was initially placed on cefepime, and blood cultures were drawn. All cultures throughout the course of his hos-
pitalization turned out to be negative. He, however, remained febrile for the majority of his hospitalization. Upon
presentation, he did complain of 1-day onset of profuse watery diarrhea that was extremely foul smelling. Of note, he
was on p.o. prophylactic Levaquin due to his neutropenia. He was also on prophylactic acyclovir. Due to his being on
antibiotics and history of diarrhea, a stool PCR was collected but resulted negative. Before the stool PCR resulted, he
was placed on Flagyl as empiric coverage for suspected C. diff colitis. After the stool PCR resulted negative, Flagyl
was discontinued.

During the short 24 hours when he was on Flagyl, he seemed to have defervesced, and his fever curve trended
down. However, after the Flagyl was discontinued, he started having worsened diarrhea and the fevers went back
up again. For this reason, a C. diff PCR was ordered and the Flagyl was resumed. The C. diff PCR was also negative.
Until that point, he remained on cefepime and the Flagyl was also decided to be continued since the patient seemed
to improve with it. The thinking was that he may have had some colitis that was not related to C. diff.

Six days into his hospitalization, he continued to have fever. At this juncture, vancomycin was added to see if this
would help. Repeat blood cultures were negative. Cultures were even drawn from the port that he had. There was
some discussion as to whether his fevers may have been caused by the cefepime. The cefepime was discontin-
ued. At this time, however, his fever curve had already started slightly trending down. Over the next 48 hours, he
remained afebrile.

The vancomycin and Flagyl were discontinued the day before discharge, and he remained afebrile that night. His
diarrhea had resolved over the last 4 to 5 days of his hospitalization and he received Imodium for this. The remainder
of his hospitalization was unremarkable and he felt well. Of note, he did complain of poor appetite. We advised him
to try to eat as much as he can and at the very least remain hydrated with Gatorade, and he understood that it may
take some time for his appetite to completely return to normal.

He did frequently have hypokalemia and hypomagnesemia. This was presumed to be secondary to the diarrhea.
Both of these electrolytes were replaced appropriately. However, even after the diarrhea resolved, he continued
to have hypokalemia despite replacement. He later notified us that this issue is not new and that he actually takes
potassium supplementation at home. He reported that he had p.o. potassium chloride at home and that he did not
need medication or a refill for this. He could not, however, recall the dosage. We do not know the etiology of his

(continued)

CHAPTER 7  | 
 hypokalemia as this was not worked up while he was inpatient due to again thinking that his hypokalemia was a
result of his diarrhea.

On the day of discharge, he was also instructed to resume his prophylactic Levaquin and acyclovir.

DISCHARGE MEDICATIONS:
1.  Acyclovir 400 mg p.o. b.i.d.
2.  HCTZ 25 mg p.o. daily.
3.  Lopressor 25 mg p.o. b.i.d.
4.  Pravastatin 10 mg p.o. at bedtime.
5.  Norethindrone 5 mg p.o. daily.
6.  Levaquin 500 mg p.o. daily.
7.  Zofran 4 mg sublingually q.8 hours p.r.n. nausea.
8.  Norco 5/325 one tablet p.o. q.4 hours p.r.n. pain.

FOLLOWUP APPOINTMENT: Dr. Constantine Revorsky in 1 week for followup for chemotherapy.
FOLLOWUP LABS AND STUDIES: CBC, CMP before appointment with Dr. Revorsky.
DISCHARGE DIET: Regular as tolerated.
DISCHARGE ACTIVITY: As tolerated.

You Code It!

Read this Discharge Summary for Frank Copeland and determine only the principal diagnosis code.
Step #1: Read the case carefully and completely.
Step #2: Abstract the scenario. Which main words or terms describe why the physician cared for the patient dur-
ing this encounter?
Step #3: Are there any details missing or incomplete for which you would need to query the physician? [If so, ask
your instructor.]
Step #4: Check for any relevant guidance, including reading all of the symbols and notations in the Tabular List
and the appropriate sections of the Official Guidelines.
Step #5: Determine the correct diagnosis code or codes to explain why this encounter was medically necessary.
Step #6: Double-check your work.
Answer:
Did you determine this to be the principal diagnosis code?
D70.9 Neutropenia, unspecified

Antibodies 7.5  Disorders Involving the Immune System

Immune responses to The immune system is the armed forces network that develops special forces, known
antigens.
as antibodies, produced by plasma cells in the blood to protect the body from patho-
Antigen gens and other invaders (antigens) that may disrupt proper function. In the previous
A substance that promotes section, you learned about the role that the different types of white blood cells play in
the production of antibodies. guarding the good health of the body . . . your immune system.

188   PART II  |  REPORTING DIAGNOSES

 Researchers continue to study and learn more about the actual mechanisms in place,
to employ in the development of more effective and efficient treatments when the CODING BITES
body cannot fight alone. The integration of technology and the greater availability of Generally, allergies are
genetic details support these efforts to eliminate past and current illness and disease, reported by either the
and to fight off or prevent new conditions from evolving.   substance or object
to which the patient
Immunodeficiencies is allergic or by the
response suffered by
Immunodeficiency disorders are conditions when the patient’s immune response is the patient.
diminished or totally ineffective. Typically, immunodeficiency disorders occur when T
or B lymphocytes (special white blood cells) do not work properly. Immunodeficiency K52.2-  Allergic and
disorders may be inherited (genetically passed from parent to child) or acquired, an dietetic gastroenteritis
adverse effect to another illness, such as HIV-positive status or some malignancies; and colitis
long-term use of certain medications, such as corticosteroids; chemotherapy treat- J30.1  Allergic rhinitis
ments; or a manifestation of a splenectomy (the surgical removal of the spleen). due to pollen
∙ Hereditary hypogammaglobulinemia, also known as autosomal recessive agamma- J30.81  Allergic rhinitis
globulinemia, is an inherited immunodeficiency disorder often causing pulmonary and due to animal (cat) (dog)
digestive disorders—reported with code D80.0 Hereditary hypogammaglobulinemia hair and dander
∙ Agammaglobulinemia with immunoglobulin-bearing B-lymphocytes is a nonfa-
milial (acquired) defect in the body’s antibodies—reported with code D80.1 Nonfa-
milial hypogammaglobulinemia

Allergies
An allergy is actually an immune system false alarm, responding to something as if it
were a pathogen able to harm the body, when, in reality, it is not. In medical terminol-
ogy, this is known as a hypersensitivity reaction. These reactions are divided into four
classes. Classes I, II, and III are caused by antibodies, IgE or IgG, which are produced
by B cells in response to an allergen. Class IV reactions are caused by T cells. In these
cases, the T cells might turn traitor and cause damage to the body, or they may ignite
macrophages and eosinophils, which, in turn, may damage host cells.

Sarcoidosis
The specific etiology of sarcoidosis is still unknown; however, most researchers believe it
is a combination of a genetic susceptibility with a certain exposure to something that trig-
gers the immune system to release chemicals that are ineffective at combating inflamma-
tion. Instead, the cells clump together and become granulomas (tumors that result from an
ulcerated infection) situated within certain organs throughout the body, such as the lungs,
liver, or skin. This diagnosis is reported with a code from category D86 Sarcoidosis.

EXAMPLES
D86.0 Sarcoidosis of lung
D86.3 Sarcoidosis of skin
D86.84 Sarcoidosis pyelonephritis
As you can see from these three examples, you will need to know the specific
anatomical site of the sarcoidosis before you can determine an accurate code.

Wiskott-Aldrich Syndrome
When a patient suffers from Wiskott-Aldrich syndrome, this genetic mutation causes
white blood cells to malfunction, increasing the body’s susceptibility to inflammatory
diseases and other immunodeficiency disorders. Eczema, thrombocytopenia, and pyo-
genic infections often develop and put the patient at a higher-than-normal risk of autoim-
mune diseases. This condition is reported with code D82.0 Wiskott-Aldrich syndrome.

CHAPTER 7  | 
 ICD-10-CM
YOU CODE IT! CASE STUDY
Carol-Anne Nieman, a 41-year-old female, came in complaining of discomfort and tenderness under her arms and
in her neck. Dr. Rothenberg performed a physical exam, revealing swollen lymph nodes. Lab work showed she was
suffering with sarcoidosis of her lymph nodes.

You Code It!

Go through the steps of coding, and determine the code or codes that should be reported for this encounter
between Dr. Rothenberg and Carol-Anne.
Step #1: Read the case carefully and completely.
Step #2: Abstract the scenario. Which main words or terms describe why the physician cared for the patient dur-
ing this encounter? 
Step #3: Are there any details missing or incomplete for which you would need to query the physician? [If so, ask
your instructor.]
Step #4: Check for any relevant guidance, including reading all of the symbols and notations in the Tabular List
and the appropriate sections of the Official Guidelines.
Step #5: Determine the correct diagnosis code or codes to explain why this encounter was medically necessary.
Step #6: Double-check your work.
Answer:
Did you determine this to be the correct code?
D86.1 Sarcoidosis of lymph nodes
Great work!

CODING BITES Chapter Summary

• One-third (about Blood flows through your arteries and veins, transporting oxygen (O2) to nourish tis-
33%) of people with sues and carrying away the waste (CO2) from those cells. Production of the compo-
DVT/PE will have a nents of the blood, including red blood cells, white blood cells, and platelets, occurs
recurrence within 10 within the red bone marrow, specifically, within the sternum, ribs, and vertebrae in the
years. adult. Since blood is systemic (traveling throughout the entire body), blood tests are
• Approximately 5 to an excellent diagnostic tool because the minor invasiveness of venipuncture can yield
8% of the U.S. popu- massive amounts of information about the health of the body. When the blood system
lation has one of malfunctions, serious health consequences result.
several genetic risk
factors, also known
as inherited throm-
bophilia, in which a
genetic defect can
be identified that
increases the risk for
thrombosis.
Source: http://www.cdc.
gov/ncbddd/dvt/data.
html

190   PART II  |  REPORTING DIAGNOSES

CHAPTER 7 REVIEW

CHAPTER 7 REVIEW
Coding Blood Conditions Enhance your learning by
completing these exercises and
more at connect.mheducation.com!

Let’s Check It! Terminology

Match each key term to the appropriate definition.
1. LO 7.3  A system of classifying blood based on the antigens present on the sur-
face of the individual’s red blood cells.
2. LO 7.1  Cells within the blood that help to protect the body from pathogens.
A. Agglutination
3. LO 7.3  The process of red blood cells combining together in a mass or lump.
B. Antibody
4. LO 7.3  Immune responses to antigens.
C. Antigen
5. LO 7.2  Clotting; the change from a liquid into a thickened substance.
D. Blood
6. LO 7.2  The interruption of bleeding.
E. Blood Type
7. LO 7.3  An antigen located on the red blood cell that produces immunogenic
responses in those individuals without it. F. Coagulation
8. LO 7.3  The provision of one person’s blood or plasma to another individual. G. Hematopoiesis
9. LO 7.1  Fluid pumped throughout the body, carrying oxygen and nutrients to the H. Hemoglobin
cells and wastes away from the cells. I. Hemolysis
10. LO 7.1  The fluid part of the blood. J. Hemostasis
11. LO 7.1  Cells within the blood that contain hemoglobin responsible for carrying K. Plasma
oxygen to tissues. L. Platelets (PLTs)
12. LO 7.1  The part of the red blood cell that carries oxygen. M. Red Blood Cells
13. LO 7.3  The destruction of red blood cells resulting in the release of hemoglobin (RBCs)
into the bloodstream. N. Rh Factor
14. LO 7.1  Large cell fragments in the bone marrow that function in clotting. O. Transfusion
15. LO 7.1  The formation of blood. P. White Blood Cells
16. LO 7.3  A substance that promotes the production of antibodies. (WBCs)

Let’s Check It! Concepts

Choose the most appropriate answer for each of the following questions.
1. LO 7.1  Blood is composed of all of the following except
a. RBCs. b. WBCs. c. Plats. d. HCT.
2. LO 7.1  Red bone marrow produces white blood cells through which process? 
a. erythrocytes c. lymphocytes
b. leukopoiesis d. erythropoiesis
3. LO 7.3  An individual with blood type B− can receive only which type(s) of blood in a transfusion?
a. type B− c. type O+
b. type B+ d. type B− or type O−
4. LO 7.4  _____create heparin, a blood thinning agent that prevents inappropriate blood clotting, and create hista-
mines, involved in allergic reactions.
a. Neutrophils b. Lymphocytes c. Eosinophils d. Basophils

CHAPTER 7  | 
 5. LO 7.1  Which type of anemia results from an insufficient number of healthy red blood cells due to abnormal or
CHAPTER 7 REVIEW

premature destruction?
a. aplastic anemia c. nutritional anemia
b. hemolytic anemia d. hemorrhagic anemia
6. LO 7.2  _____ is a low platelet count most often due to increased platelet destruction, decreased platelet produc-
tion, or malfunctioning platelets.
a. Pancytopenia  c. Thrombocytopenia
b. Leukocytopenia d. Erythrocytopenia
7. LO 7.1  Donny Cobin, a 19-year-old male, has been diagnosed with sickle-cell thalassemia with acute chest syn-
drome. How would you code this?
a. D57.40 b. D57.411 c. D57.811 d. D57.812
8. LO 7.3  Antigens are _____ that sit on the surface of red blood cells. 
a. proteins b. sugars c. markers d. chromosomes
9. LO 7.5  Typically, immunodeficiency disorders occur when _____ do not work properly.
a. T lymphocytes c. T or B lymphocytes
b. B lymphocytes d. None of these
10. LO 7.5  The genetic mutation causing white blood cells to malfunction, increasing the body’s susceptibility to
inflammatory diseases and other immunodeficiency disorders, is known as _____.
a. Clarke-Hadfield Syndrome c. Wiskott-Aldrich Syndrome 
b. Heubner-Herter Syndrome d. Lennox-Gastaut Syndrome

Let’s Check It! Rules and Regulations

Please answer the following questions from the knowledge you have gained after reading this chapter.
1. LO 7.1  Discuss what blood is, how it is created, and what it consists of; include how many blood cells are needed
for a healthy body.
2. LO 7.2  Explain the two types of clotting disorders.
3. LO 7.3  When a patient requires a transfusion of blood, it must first be checked for compatibility. What does this
mean? 
4. LO 7.4  Discuss the difference between neutropenia, leukopenia, and leukocytosis.
5. LO 7.5  What are immunodeficiency disorders and are they inherited or acquired?

ICD-10-CM
 YOU CODE IT! Basics
First, identify the main term in the following diagnose; 2. Purpura fulminans:
then code the diagnosis. a. main term: _____ b. diagnosis: _____
Example: Posthemorrhagic anemia, chronic  3. Anemia due to vitamin B12 intrinsic factor
deficiency:
a. main term: anemia   b. diagnosis D50.0
a. main term: _____ b. diagnosis: _____
1. Hemoglobin H disease:
a. main term: _____ b. diagnosis: _____

192   PART II  |  REPORTING DIAGNOSES

 CHAPTER 7 REVIEW
4. Cyclic hematopoiesis: 10. Congenital neutropenia: 
a. main term: _____ b. diagnosis: _____ a. main term: _____ b. diagnosis: _____
5. Antineoplastic chemotherapy–induced 11. Sickle-cell Hb-C with crisis disease: 
pancytopenia: a. main term: _____ b. diagnosis: _____
a. main term: _____ b. diagnosis: _____ 12. Agranulocytosis due to infection: 
6. Minor alpha thalassemia: a. main term: _____ b. diagnosis: _____
a. main term: _____ b. diagnosis: _____ 13. Hemolytic-uremic syndrome: 
7. Medullary hypoplasia: a. main term: _____ b. diagnosis: _____
a. main term: _____ b. diagnosis: _____ 14. Polycythemia due to erythropoietin:
8. Infantile pseudoleukemia:  a. main term: _____ b. diagnosis: _____
a. main term: _____ b. diagnosis: _____ 15. Non-Langerhans cell histiocytosis: 
9. Deficiency factor VIII:  a. main term: _____ b. diagnosis: _____
a. main term: _____ b. diagnosis: _____

ICD-10-CM
YOU CODE IT! Practice
Using the techniques described in this chapter, carefully read through the case studies and determine the most ac-
curate ICD-10-CM code(s) and external cause code(s), if appropriate, for each case study.
1. James Abney, a 7-month-old male, is brought in by his parents to see Dr. Fay, his pediatrician. Dr. Fay notes
a temperature of 106 F, jaundice, and generalized weakness and admits James to Weston Hospital for a full
work-up. The CBC and Coombs’ test results confirm the diagnosis of favism anemia. 
2. Sam Goodman, a 9-year-old male, presents today for a sports physical in order to play on his school baseball
team. Dr. Inabinet notes splenomegaly. The results from the CBC test and peripheral blood smear confirm a
diagnosis of Hb-C disease. 
3. Arthur Hylton, a 45-year-old male, presents today with the complaint of general weakness and overall tiredness.
Arthur works for an industrial factory and has been exposed to a large quantity of benzene. Dr. Burger completes
an examination, noting an irregular heartbeat and hand tremors. Arthur is admitted to the hospital. The results of
the bone marrow biopsy confirm a diagnosis of aplastic anemia due to accidental poisoning by benzene.
4. Rosalyn Burkett, a 37-year-old female, presents today with the complaint of migraines and blurred vision.
After an examination and a review of the laboratory tests, Dr. Flick diagnoses Rosalyn with Lupus anticoagu-
lant syndrome. 
5. Tilley Cabe, a 9-month-old female, is brought in to see Dr. Peterson, her pediatrician. Tilley has had a per-
sistent low-grade fever for 4 days that has not diminished. Dr. Peterson notes a temperature of 100.2 and
splenomegaly. Tilley is not thriving. Dr. Peterson admits her to the hospital. The laboratory results reveal
Tilley has a low natural killer cell activity and cytopenia, which confirm the diagnosis of hemophagocytic
lymphohistiocytosis (HLH). 
6. Glenn Carballero, a 15-year-old male, presents today with the complaint of weakness and generalized muscu-
lar pains. Dr. Douglass notes an erythematous periorofacial macular rash. After a thorough examination and
laboratory tests are completed, Glenn is diagnosed with biotinidase deficiency.
7. Sadie Thompson, an 18-month-old female, was born with TAR syndrome (thrombocytopenia with absent
radius). Sadie is brought in today by her mother with the complaint of excessive bruising without significant
trauma. After an examination and the laboratory tests are completed, Dr. Dotson diagnosis Sadie with con-
genital thrombocytopenia purpura. 

CHAPTER 7  | 
CHAPTER 7 REVIEW

8. Victor Motts, a 6-month-old male, is brought in by his mother to see his pediatrician, Dr. Stewart. Victor
experienced a type of spasm. Dr. James notes skeletal abnormalities and cyanosis as well as some hearing
difficulties and admits him to Weston Hospital. A fluorescence in situ hybridization (FISH) blood test
confirms a diagnosis of Di George’s syndrome. 
9. Lindsey Williams, a 33-year-old female, has not been feeling well and is seen by Dr. Goldburg, who notes
jaundice. Lindsey admits to feeling weak and being dizzy. Blood tests return a hemoglobin of 6.3 g/dL.
Lindsey is admitted to the hospital for a blood transfusion; while there, a peripheral blood smear was
performed that showed echinocytes, confirming a diagnosis of pyruvate kinase deficiency anemia. 
10. Antonio Scott, a 47-year-old male, presents today with the complaint of a cough, runny nose, and a sore
throat. Dr. Benton completes an examination and reviews the results of the CBC test and diagnoses Stanley
with lymphocytopenia. 
11. Ivory Presnell, a 75-year-old female, comes in today complaining of fever, chills, and night sweats. She says she
feels tired and has lost 5 lbs. within a week. Dr. Shirley notes nail clubbing and completes an in-house CBC test;
results: hemoglobin of 7.9 g/dL. Ivory is admitted to Weston Hospital, where a tissue biopsy is taken, returning
a positive reading for extra-pulmonary tuberculosis. Ivory is diagnosed with anemia due to tuberculosis. 
12. Buddy Dent, a 59-year-old male with chronic kidney disease, stage 4, comes to see Dr. Wilberly complaining
of extreme weakness. Dr. Wilberly completes a full blood workup and notes the following results:
hemoglobin—8.2 g/dL, creatinine—52 mg/dL, and BUN—102 mg/dL. Buddy is diagnosed with anemia due
to chronic kidney disease and is scheduled for a transfusion. 
13. Juanita Ilderton, a 41-year-old female, received a blood transfusion 12 hours ago; now she is experiencing
fever, chills, and dizziness. A direct Coombs’ test is performed, which confirms a diagnosis of acute Rh blood
transfusion incompatibility after a transfusion. 
14. Richard Greene, 33-year-old male, comes to see Dr. Walter with the complaints of tiredness and weakness.
Dr. Walter completes bloodwork and a bone marrow biopsy. Richard is diagnosed with chronic lymphocytic,
B-cell type leukemia. 
15. Billy Stevenson, a 10-year-old-male, is brought in by his father to see Dr. Loveichelle. Billy has developed
a cough and fever. Billy says he feels really tired. Mr. Stevenson also stated they can’t get Billy to eat.
Dr. Loveichelle completes an examination and an in-house CBC. Billy’s hemoglobin is 7.4 g/dL. Billy is
admitted to the hospital for a full workup. Once all the laboratory results have been reviewed, Billy is
diagnosed with hookworm anemia. 

ICD-10-CM
YOU CODE IT! Application
The following exercises provide practice in abstracting physicians’ documentation from our health care facility,
Prader, Bracker, & Associates. These case studies are modeled on real patient encounters. Using the techniques
described in this chapter, carefully read through the case studies and determine the most accurate ICD-10-CM
code(s) and external cause code(s), if appropriate, for each case study.

PRADER, BRACKER, & ASSOCIATES

A Complete Health Care Facility
159 Healthcare Way ∙ SOMEWHERE, FL 32811 • 407-555-6789

PATIENT: KRIESEL, BROOKE
ACCOUNT/EHR #: KRIEBR001
DATE: 09/23/18

194   PART II  |  REPORTING DIAGNOSES

 CHAPTER 7 REVIEW
Attending Physician: Oscar R. Prader, MD
Brooke Kriesel, a 41-year-old female, presents today with the complaint of fatigue—2 weeks duration.
She admits to moderate shortness of breath with exertion; denies chest pain with exertion or at rest.
No bright red blood per rectal exam or melena. She has had heavy menstrual periods—1 year duration.
PAST MEDICAL HISTORY: Noncontributory 
FAMILY HISTORY: Noncontributory
OTC medication—aspirin, 81 mg daily—3 month duration.
PHYSICAL EXAM:
General appearance: Pale, no acute distress.
Vital signs: Ht: 5’ 7’, Wt: 146, T: 99.8, R: 15, HR: 81 and regular, BP: 128/81. Pale conjunctiva; mucous
membranes, moist with no apparent lesions; chest, clear; heart, regular rate and rhythm, no murmurs,
rubs, or gallops. The abdomen—soft, nontender, and nondistended; no hepatosplenomegaly; rectal
examination—no masses and heme negative, brown stool is present.
Hemoglobin level—7.4 g/dL. There is evidence of marked microcytosis and hypochromia with a
decreased hemoglobin level.
DIAGNOSIS: Anemia due to iron deficiency

ORP/pw  D: 09/25/18 09:50:16  T: 09/25/18 12:55:01

Determine the most accurate ICD-10-CM code(s).

PRADER, BRACKER, & ASSOCIATES

A Complete Health Care Facility
159 Healthcare Way • SOMEWHERE, FL 32811 • 407-555-6789
PATIENT: LAKEMONT, CALEB
ACCOUNT/EHR #: LAKECA001
DATE: 10/03/18
Attending Physician: Oscar R. Prader, MD
Calib Lakemont, a 29-year-old male, came to see me with complaints of bruising easily and prolonged
nosebleeds. He also showed me a rash, nonpainful/nonitchy, on his ankles and shins. He denies mak-
ing any recent changes in body soap or household detergents. Dr. Prader notes bruises on his arms and
trunk; patient denies any type of trauma that would cause bruising.
PE: Ht: 5’ 11”, Wt: 185, T: 98.4, R: 13, HR: 57, BP: 115/79. No lymphadenopathy or hepatosplenomeg-
aly. Stool sample testing is guaiac positive.
Lab results: CBC and peripheral smear confirm patient is thrombocytopenic. There is no evidence of a
coagulation disorder.
DIAGNOSIS: Autoimmune thrombocytopenia (ITP)

ORP/pw  D: 10/05/18 09:50:16  T: 10/05/18 12:55:01

Determine the most accurate ICD-10-CM code(s).

CHAPTER 7  | 
CHAPTER 7 REVIEW

WESTON HOSPITAL
629 Healthcare Way • SOMEWHERE, FL 32811 • 407-555-6541
PATIENT: FUENTES, ERIN
ACCOUNT/EHR #: FUENER001
DATE: 09/16/18
Attending Physician: Renee O. Bracker, MD
Pt is a 9-year-old female brought in by her parents to see Dr. Bracker. I last saw Erin 6 months ago, at
which time she was thriving. Erin has experienced several nosebleeds over the last week. After ques-
tioning Erin, she admits she gets tired easily and doesn’t feel much like eating.
PE: Ht: 52.5”, Wt: 60 lb., T: 101.2, R: 18, HR: 81, BP: 125/70. Dr. Bracker notes that Erin is having dif-
ficulty focusing and articulating. Weight loss of 3 lb. since last visit. A CBC is performed; results show a
hemoglobin of 6.8 g/dL. Erin is admitted.
CV: Normal S1, S2, regular.
Pulm: Unlabored respiration, clear, bilaterally.
Abd: Soft, nontender, nondistended, without organomegaly or mass.
Extr: Warm, well perfused, no edema, notable for several 3 cm ecchymoses on the forearms and thighs
bilaterally; in addition, there is a petechial rash over the ankles and feet bilaterally. 
Neuro: Alert and oriented 
Laboratory results:
Hemoglobin—6.7 g/dL
Platelet count—35 × 10/L
Leukocyte count–3.1 × 10/L
Neutrophil count—1.4 × 10/L
INR—1.5
PT—16.2
Bone marrow aspirate was performed—20% promyelocytes. 
Dx: Acute promyelocytic leukemia (APL) 
P: Chemotherapy with ATRA

ROB/pw  D: 09/16/18 09:50:16  T: 09/18/18 12:55:01

Determine the most accurate ICD-10-CM code(s).

WESTON HOSPITAL
629 Healthcare Way • SOMEWHERE, FL 32811 • 407-555-6541
PATIENT: FLOWERS, CATLYNNE
ACCOUNT/EHR #: FLOWCA001
DATE: 09/16/18

196   PART II  |  REPORTING DIAGNOSES

 CHAPTER 7 REVIEW
Attending Physician: Renee O. Bracker, MD
S: Catlynne Flowers, a 22-year-old female, presents to the emergency room today with dyspnea and cough.
O: Ht: 5’ 3”, Wt: 131 lb., R: 30, T: 101.2, BP: 110/67. Catlynne was diagnosed with sickle-cell disease
3 years ago. Patient appears to be in crisis. Chest x-ray confirms pulmonary infiltration. A broncho-alveolar
lavage was performed; specimen was taken for culture, which confirmed the diagnosis.
A: Sickle-cell/Hb-C crisis with acute chest syndrome ACS
P: Admit to inpatient

ROB/pw  D: 09/16/18 09:50:16  T: 09/18/18 12:55:01

Determine the most accurate ICD-10-CM code(s).

WESTON HOSPITAL
629 Healthcare Way • SOMEWHERE, FL 32811 • 407-555-6541
PATIENT: ARNOLD, CAMERON
ACCOUNT/EHR #: ARNOCA001
DATE: 08/11/18
Attending Physician: Oscar R. Prader, MD
Cameron Arnold, a 39-year-old female, comes in to see Dr. Prader with complaints of weakness and
several spontaneous nosebleeds that last approximately 10 minutes—10 days duration. She states that
she bruises easily without any injury—3 times in the last month alone—and her menstrual periods have
been notably heavier. Dr. White, the referring physician, asks that we rule out coagulopathy. PMH: non-
contributory. PFH: no history of family bleeding.
Preliminary laboratory results reveal a hemoglobin of 6.7 g/dL. The mean corpuscular volume (MCV) is
71 fl. PT and APTT are within normal range.
A von Willebrand factor antigen assay, a von Willebrand factor activity assay, and factor VIII measure-
ment were ordered; results confirm the diagnosis of von Willebrand disease.

ORP/pw  D: 08/11/18 09:50:16  T: 08/13/18 12:55:01

Determine the most accurate ICD-10-CM code(s).

CHAPTER 7  | 
 8
Key Terms
Coding Endocrine
Conditions
Learning Outcomes
Cushing’s Syndrome After completing this chapter, the student should be able to:
Diabetes Mellitus
(DM) LO 8.1 Identify the various disorders affecting the thyroid gland.
Dyslipidemia LO 8.2 Evaluate the details about a diabetes mellitus diagnosis to
Gestational Diabetes determine the correct code.
Mellitus (GDM) LO 8.3 Assess the relationship between diabetes mellitus and its
Hyperglycemia manifestations.
Hypoglycemia LO 8.4 Interpret the documentation related to the reporting of other
Hypoglycemics
Hypothyroidism endocrinologic diseases.
Parathyroid Glands LO 8.5 Identify the aspects of nutrition and weight required for accu-
Polydipsia rate code determination.
Polyuria LO 8.6 Analyze the details related to metabolic disorder diagnoses
Secondary Diabetes to determine the correct code.
Mellitus 
Thyroid Gland
Type 1 Diabetes
Mellitus Remember, you need to follow along in
Type 2 Diabetes
Mellitus
ICD-10-CM

  STOP! your ICD-10-CM code book for an optimal

learning experience.

8.1  Disorders of the Thyroid Gland

Thyroid Gland
Thyroid Gland The thyroid gland is located in the neck. Each of its two lobes reaches around the
A two-lobed gland located in trachea laterally; they connect anteriorly by an isthmus (see Figure 8-1).
the neck that reaches around The anterior pituitary gland transmits thyroid-stimulating hormone (TSH) to the
the trachea laterally and con- thyroid, which then extracts iodine from the blood system to create two hormones.
nects anteriorly by an isthmus. The two hormones secreted by this gland—triiodothyronine (T3) and thyroxine (T4)—
The thyroid gland produces
are collectively known as thyroid hormone (TH). Thyroid hormone is responsible for
hormones used for metabolic
function.
stimulating the production of proteins in virtually every tissue in the body, controlling
the body’s metabolic rate, and increasing the quantity of oxygen used by each cell.
In addition, calcitonin is produced here from the C cells located in the follicles. This
hormone, secreted in response to hypercalcemia (too much calcium in the blood), pro-
motes the deposit of calcium and works in the formation of bone.

EXAMPLES
E03.1 Congenital hypothyroidism without goiter
E07.81 Sick-euthyroid syndrome
Parathyroid Glands
Four small glands situated
on the back of the thyroid
Parathyroid Glands
gland that secrete parathyroid In the posterior aspect of the thyroid gland are four partially embedded parathy-
hormone. roid glands. When stimulated by hypocalcemia (too little calcium in the blood), they

198
Pharynx
(posterior view)

Thyroid gland

Parathyroid
glands

Esophagus

Trachea FIGURE 8-1  The thyroid gland,

illustrated as part of the anatomi-
cal sites within the neck 
©McGraw-Hill Education

produce parathyroid hormone (PTH). PTH works in the opposite way of how calcito-
nin (produced by the thyroid) works.

EXAMPLES
E20.1 Pseudohypoparathyroidism
E21.0 Primary hyperparathyroidism

Hypothyroidism (Adults)
Hypothyroidism is caused by an insufficient production of thyroid hormone (TH). Hypothyroidism
When a patient has hypothyroidism, the thyroid converts energy more slowly than A condition in which the thy-
normal, resulting in an otherwise unexplained weight gain and fatigue. In addition, roid converts energy more
hypercholesterolemia, unexplained increase in weight, forgetfulness, and even unusual slowly than normal, resulting
sensitivity to colder temperatures may be evidence of early signs of this condition. in an otherwise unexplained
weight gain and fatigue.
This might be the result of irradiation therapy, infection, Hashimoto’s disease
(chronic autoimmune thyroiditis), or pituitary failure to produce the required amount
of thyroid-stimulating hormone (TSH).
To confirm this diagnosis, radioimmunoassay and/or lab tests are performed to look
at the levels of TSH. Lab tests can identify the patient’s TSH levels; however, refer-
ence ranges may fluctuate depending upon the patient’s age and family history. Treat-
ment for hypothyroidism includes medication, such as levothyroxine, to replace TH.

EXAMPLES
E03.1 Congenital hypothyroidism without goiter
E03.2 Hypothyroidism due to medicaments and other exogenous
substances
 ode first poisoning due to drug or toxin, if applicable (T36-T65
C
with fifth or sixth character 1-4 or 6)
Use additional code for adverse effect, if applicable, to identify
drug (T36-T50 with fifth or sixth character 5)
(continued)

CHAPTER 8  | 
 CODING BITES E03.3 Postinfectious hypothyroidism
If you recognize a As you can see, the underlying cause of the hypothyroidism is key to determining
patient’s condition from an accurate code.
a lab report, but the
physician did not docu-
ment a confirmed diag- Hyperthyroidism
nosis, you must query
the physician. You may Hyperthyroidism, also known as thyrotoxicosis, is a condition in which the thyroid
not code from the lab secretes too many hormones, more than the body needs to function properly. Inter-
report. estingly, hyperthyroidism is most often a manifestation of another disease, including
Graves’ disease or thyroiditis.
Signs and symptoms include unexplained weight loss, rapid heart rate, and sensitivity
to heat. Also, because the body systems are faster due to the excess of these hormones,
irritability, trouble sleeping, hand tremors, and mood swings may also be exhibited.

EXAMPLES
E05.00 Thyrotoxicosis with diffuse goiter without thyrotoxic crisis or storm
(Graves’ disease)
E05.11 Thyrotoxicosis with toxic single thyroid nodule with thyrotoxic crisis
or storm
E05.20 Thyrotoxicosis with toxic multinodular goiter without thyrotoxic crisis
or storm
As you can see from these few examples, the term thyrotoxicosis is used by the
code descriptions, rather than the more common term hyperthyroidism.

Graves’ Disease
Graves’ disease (toxic diffuse goiter) is an autoimmune disorder. This malfunction of
the immune system creates an antibody called thyroid stimulating immunoglobulin
(TSI) that affixes itself to thyroid cells. TSI then accelerates the overproduction of the
thyroid hormone.

Thyroid Nodules
Thyroid nodules are adenomas, benign neoplasms that grow in the thyroid. These nod-
ules may stimulate the thyroid to become overactive. A toxic multinodular goiter is an
accumulation of several thyroid nodules multiplying the effects, and the quantity of
thyroid hormone that is overproduced.

Thyroiditis
Thyroiditis is an inflammation of the thyroid that causes thyroid hormone stored
within the thyroid gland to leak out. Initially, the leakage can be identified by
increased hormone levels showing in the blood. If the leak continues, this can cause
hyperthyroidism.
E06.0 Acute thyroiditis
(Abscess of thyroid)
(Pyogenic thyroiditis)
Use additional code (B95–B97) to identify infectious agent
E06.1 Subacute thyroiditis
(de Quervain thyroiditis)
(Giant cell thyroiditis)
: autoimmune thyroiditis (E06.3)

200   PART II  |  REPORTING DIAGNOSES

 E06.2 Chronic thyroiditis with transient thyrotoxicosis
: autoimmune thyroiditis (E06.3)
E06.3 Autoimmune thyroiditis
(Hashimoto’s thyroiditis)
(Lymphocytic thyroiditis)
E06.4 Drug-induced thyroiditis
 se additional code for adverse effect, if applicable, to identify
U
drug (T36-T50 with fifth or sixth character 5)
E06.5 Other chronic thyroiditis
(Chronic fibrous thyroiditis)
(Ligneous thyroiditis)
(Riedel thyroiditis)
Postpartum thyroiditis develops during the postpartum period.
O90.5 Postpartum thyroiditis

Other Disorders of the Thyroid

Additional disorders of the thyroid include
∙ Nontoxic goiter, reported from code category E04
∙ Hashimoto’s thyroiditis, reported with code E06.3
∙ Myxedema, a type of hypothyroidism, is reported with code E03.9

ICD-10-CM
LET’S CODE IT! SCENARIO
PATIENT: Angela Tanner
Preprocedural Diagnosis: Right thyroid tumor
Postprocedural Diagnosis: Benign tumor of right thyroid
Procedure: Isthmectomy, Right thyroidectomy
Surgeon: Samuel Rodriguez, MD
DESCRIPTION OF OPERATION: The patient was intubated with a Xomed nerve monitor endotracheal tube. The
neck was extended with a shoulder roll and a transverse cervical incision was made along the skin crease, leaning
to the right side. The skin incision was made and the platysma was divided. A superior flap was developed to the
thyroid notch and inferior flap to the sternal notch. Crossing jugular veins were ligated with 2-0 and 3-0 silk ties. The
strap muscles were separated in the midline. The right strap muscles were then lifted off of a markedly enlarged right
thyroid gland. The lateral border of the gland was identified. The middle thyroid vein and its branches were doubly
ligated with 3-0 silk ties and divided. The recurrent laryngeal nerve was identified at the base of the neck and we
traced this superiorly. The inferior thyroid vascular bundle was noted to be quite anterior to this. We doubly ligated
this with 2-0 silk ties and divided it as it entered the thyroid gland. The inferior right parathyroid gland was identified.
It was noted to be adherent to the thyroid gland. We separated the two glands and placed the right inferior parathy-
roid gland in the base of the neck. We then identified the superior pole of the right thyroid gland. The superior thyroid
vascular bundle was doubly ligated with 2-0 silk ties and divided. The right upper parathyroid gland was separated
from the thyroid gland. This was also adherent to the thyroid gland. We then mobilized the gland medially. A small
amount of thyroid tissue was left behind in the upper pole. The stump was doubly ligated with 2-0 silk ties and
divided. This allowed us to mobilize the thyroid gland medially, and we slowly separated the nerve from the posterior
surface of the thyroid gland. This nerve was adherent to the thyroid gland. The gland was left intact as we separated
the thyroid gland from it, and then we lifted the thyroid gland off of the trachea. Dissection was then carried beyond
the isthmus, and with the right thyroid gland in the isthmus lifted off of the trachea, we then clamped the medial
(continued)

CHAPTER 8  | 
 aspect of the right thyroid lobe and we then excised the specimen. The stump was then suture ligated with running
2-0 silk stitch. Specimen was sent for pathology, and on analysis, there was no evidence of a malignancy. The thy-
roid stump was inspected. No bleeding was noted. No bleeding was noted from the right upper or lower parathyroid
glands. The recurrent laryngeal nerve was noted to be functional throughout its course, and the inferior and superior
vascular bundles were noted to be hemostatic. With assurance of hemostasis, the strap muscles were closed with
running 4-0 Vicryls, platysma was closed with interrupted 4-0 Vicryls, and 5-0 Monocryls were used for subcuticular
skin closure. Local anesthesia was infiltrated. The patient tolerated the procedure well. Sponge and needle counts
were correct. Blood loss was minimal. The patient was extubated and taken to the recovery room in stable condition.

Let’s Code It!

Dr. Rodgriquez operated on Angela to remove her right thyroid because there was a tumor on it. How do you
know that the tumor was benign? The documentation states, “Specimen was sent for pathology, and on analy-
sis, there was no evidence of a malignancy.”
Turn to the Neoplasm Table in your ICD-10-CM code book and find Thyroid in the first column . . .
Thyroid (gland)
Carefully read across, on that same row, to the fourth column to the right, the column titled, “Benign.” Code D34
is suggested.
Now turn in the Tabular List to:
D34 Benign neoplasm of thyroid gland
This matches. But wait, there is a notation beneath this code:
Use additional code to identify any functional activity
Hmm. There is nothing in the procedure note about functional activity, and there would not be. This would be
noted in the diagnostic statement. In real life, you would need to look at the other parts of the patient’s record,
or query the physician about this detail. For now, consider that there is documentation in the patient’s medical
record that the functional activity with this tumor is corticoadrenal insufficiency.
Turn back to the Alphabetic Index and find
Insufficiency, insufficient
. . . read all the way down the list to find the indented . . .
   corticoadrenal E27.40
    --primary E27.1
In the Tabular List, find
E27 Other disorders of adrenal gland
   E27.1 Primary adrenocortical insufficiency
E27.4 Other and unspecified adrenocortical insufficiency
    E27.40 Unspecified adrenocortical insufficiency
Before you report these codes, be certain to check the top of this subsection; there is an notation
above code E20. This has no relation to this case. At the beginning of the chapter, you will find a NOTE and an 
notation. Read carefully. Do any relate to Dr. Rodriguez’s diagnosis of Angela? No. Turn to the Official
Guidelines and read Section 1.c.4. There is nothing specifically applicable here either.
Now you can report these two codes for Angela’s diagnosis, evidencing the medical necessity for this proce-
dure, with confidence.
D34 Benign neoplasm of thyroid gland
E27.40 Unspecified adrenocortical insufficiency
Good work!

202   PART II  |  REPORTING DIAGNOSES

 ICD-10-CM
YOU CODE IT! CASE STUDY
Emily Benko, a 2-month-old female, was having dyspnea and her cry sounded hoarse. In addition, Dr. Jenkins
noticed her skin color was jaundiced. Her mother, Danielle, stated that she is a good baby and sleeps all the time.
After running a TSH blood test and performing a thyroid scan, Dr. Jenkins diagnosed Emily with infantile cretinism,
also known as congenital hypothyroidism. Dr. Jenkins also noted mild cognitive impairment, which is associated with
the cretinism. He explained to Emily’s mother that the mental impairment is likely to be progressive.

You Code It!

Go through the steps of coding, and determine the code or codes that should be reported for this encounter
between Dr. Jenkins and Emily.
Step #1: Read the case carefully and completely.
Step #2: Abstract the scenario. Which main words or terms describe why the physician cared for the patient dur-
ing this encounter?
Step #3: Are there any details missing or incomplete for which you would need to query the physician? [If so, ask
your instructor.]
Step #4: Check for any relevant guidance, including reading all of the symbols and notations in the Tabular List
and the appropriate sections of the Official Guidelines.
Step #5: Determine the correct diagnosis code or codes to explain why this encounter was medically necessary.
Step #6: Double-check your work.
Answer:
Did you determine these to be the correct codes?
E03.1 Congenital hypothyroidism without goiter
G31.84 Mild cognitive impairment, so stated

Good for you!

8.2  Diabetes Mellitus

Diabetes Mellitus
Diabetes mellitus (DM) is a chronic disease and a result of insulin deficiency or resis- Diabetes Mellitus (DM)
tance due to a malfunction of the pancreatic beta cells. The body has a difficult time A chronic systemic disease
metabolizing carbohydrates, proteins, and fats. It is estimated that 16 million people that results from insulin defi-
ciency or resistance and
have DM; however, many (possibly as many as 50%) do not know it yet.
causes the body to improperly
A physician can diagnose diabetes with a glucose lab test and the presence of the metabolize carbohydrates,
following signs and symptoms: proteins, and fats.
∙ Excessive thirst (polydipsia) Polydipsia
∙ Excessive appetite Excessive thirst.
∙ Increased urination (polyuria) Polyuria
∙ Unusual weight change (loss or gain) Excessive urination.
∙ Fatigue
∙ Nausea, vomiting
∙ Blurred vision

CHAPTER 8  | 
 ∙ Frequent vaginal infections (females)
∙ Yeast infections (both males and females)
∙ Dry mouth
∙ Slow-healing sores or cuts
∙ Itchy skin, especially in the groin or vaginal area
Measures for detecting diabetes include a glucose tolerance test (GTT) and evaluation
of the results. Diabetes may be indicated by
∙ A casual plasma glucose value greater than or equal to 200 mg/dL
∙ A fasting plasma glucose level greater than or equal to 126 mg/dL
∙ A plasma glucose value in the 2-hour sample of the oral glucose tolerance test
greater than or equal to 200 mg/dL
(Note: Normal blood glucose levels are less than 110 mg/dL)
There are four types of diabetes mellitus:
Type 1 Diabetes Mellitus ∙ Type 1 DM: The malfunction of the pancreatic beta cells, resulting in no production
A sudden onset of insulin of insulin naturally, is the underlying cause of type 1 (juvenile) diabetes mellitus,
deficiency that may occur at although there is no documented known etiology for idiopathic DM. Therapeuti-
any age but most often arises cally, type 1 DM patients must administer insulin every day in addition to follow-
in childhood and adoles- ing specific diet and exercise programs. Implanted insulin pumps may be used for
cence; also known as insulin-­
those requiring multiple dose regimens. This diagnosis will be reported from ICD-
dependent diabetes mellitus
(IDDM), juvenile diabetes,
10-CM code category E10 with additional characters required to identify specific
or type I. information about complications (manifestations).
∙ Type 2 DM: In type 2 patients, the pancreatic beta cells do produce insulin; however,
Type 2 Diabetes Mellitus
the glucose transport is ineffective, thereby failing to deliver the required amount
A form of diabetes mellitus
with a gradual onset that may
to the rest of the body. Type 2 diabetics often suffer pathologic effects, including
develop at any age but most increased body fat (obesity), especially when the individual does not exercise regu-
often occurs in adults over the larly. Family history of DM, co-morbidities of hypertension or dyslipidemia, or a
age of 40; also known as non- personal history of gestational DM will increase the likelihood of developing this
insulin-dependent diabetes condition. In addition, patients of African-American, Latino, or Native American
mellitus (NIDDM) or type II. heritage are found to have a high risk. Diet and exercise are the first level of treat-
ment and may resolve the condition. However, oral antidiabetic medications, such
Dyslipidemia
Abnormal lipoprotein
as sulfonylureas, may be prescribed to stimulate pancreatic beta cell function if diet
metabolism. and exercise fail to show sufficient improvement. Some type 2 DM patients require
the administration of insulin. A type 2 diagnosis will be reported from ICD-10-CM
code category E11 with additional characters required to identify specific informa-
tion about complications (manifestations).
Secondary Diabetes Mellitus ∙ Secondary DM: Certain drugs or chemicals can negatively affect the pancreatic
Diabetes caused by medica- beta cells and may prevent them from producing the required amount of insulin.
tion or another condition or Also, other diseases and conditions, such as Cushing’s syndrome, can cause the
disease. patient to develop diabetes mellitus. This diagnosis is reported from code category
E08 Diabetes mellitus due to underlying condition, E09 Drug or chemical induced
diabetes mellitus, or E13 Other specified diabetes mellitus; additional characters
are required to provide specific information about complications. The underlying
condition, drug, or chemical causing the secondary DM will be reported first, and
any codes required to identify specific manifestations will be reported following
the E08, E09, or E13 code.
Gestational Diabetes Mellitus
(GDM) ∙ Gestational DM (GDM): When a woman is pregnant, the weight gain, along with
Usually a temporary diabe- the higher levels of estrogen and the increase of placental hormones, may retard the
tes mellitus occurring during production of insulin. This is considered a temporary type of DM due to the fact
pregnancy; however, such that, typically, the problem with the pancreatic beta cells resolves itself after the
patients have an increased baby is delivered. Report this with a code from the ICD-10-CM code subcategory
risk of later developing type 2 O24.4 Gestational diabetes mellitus, with an additional character to report addi-
diabetes. tional details.

204   PART II  |  REPORTING DIAGNOSES

Diabetic Manifestations GUIDANCE
Due to its involvement with the blood system as well as muscle and fat tissue, there CONNECTION
can be serious manifestations—the development of other illnesses and conditions—
caused by suffering with DM long term, especially when the condition goes untreated. Read the ICD-10-CM
Official Guidelines
Ophthalmic Manifestations for Coding and
Reporting, section I.
The problems that diabetics frequently experience with their eyes are actually related
­Conventions, General
to vascular concerns. Diabetic retinopathy, one of the leading causes of irreversible
Coding ­Guidelines
blindness, may be one of several types:
and ­Chapter Specific
∙ Background retinopathy: blood vessel damage with no current vision problems. ­Guidelines, subsec-
∙ Maculopathy: damage to the macula part of the eye, resulting in a considerable loss tion C. ­Chapter-Specific
of vision. ­Coding Guidelines,
chapter 4. Endocrine,
∙ Proliferative retinopathy: a microvascular complication of diabetes in which the
Nutritional, and Meta-
small vessels of the eye become diseased as a result of diminishing oxygen.
bolic Diseases (E00-
∙ Other eye problems often suffered by diabetics: diabetic cataracts and macular edema. E89), subsection a.
Diabetic retinopathy is evidenced by microcirculatory changes in the eye that inter- Diabetes mellitus,
fere with the blood supply and therefore the health of the eye. Nonproliferative diabetic and chapter 15. Preg-
retinopathy is seen in the blood vessels of the retina leaking plasma or fatty substances, nancy, childbirth, and
resulting in diminished blood flow. Proliferative diabetic retinopathy encourages neovas- the puerperium, sub-
cularization (the growth of new blood vessels) in the vitreous of the eye; these vessels sections g. Diabetes
then rupture, causing a hemorrhage and sudden loss of vision. Without treatment, this mellitus in pregnancy
can cause blindness. A diagnosis of type 1 diabetic retinopathy would be reported with a and i. Gestational
code from ICD-10-CM code subcategory E10.3 Type I diabetes mellitus with ophthalmic (pregnancy induced)
complications, with the required additional characters determined by the specifics (pro- diabetes.
liferative/nonproliferative, with/without macular edema, mild/moderate/severe).

Neurologic Manifestations
Uncontrolled diabetes can cause damage to the patient’s nerves, causing diabetic
neuropathy—in particular, sensory diabetic neuropathy, or a lack of feeling. Sensory
diabetic neuropathy can be dangerous because the damaged nerves do not transmit
feelings of heat, cold, or pain. Such a patient might be burned or cut and not know it.
The injuries might become infected, causing additional health problems. In addition,
the nerve damage can retard healing, making additional complications more viable.

Renal Manifestations
Diabetic nephropathy develops due to the reduced control of blood sugar. Almost 30%
of diabetics develop diabetic nephropathy (kidney disease) or other kidney-related
problems, such as bladder infections and nerve damage to the bladder. The nephrons
within the kidneys thicken, and the scarring that forms results in leakage of albumin
(protein) into the urine. Quantitative lab tests examine the levels of albumin in the
patient’s urine (microalbuminuria), as well as other levels such as blood urea nitrogen
(BUN) and serum creatinine. Diabetic kidney disease can cause severe illness and
possibly death. Therefore, early diagnosis and treatment to prevent the progression of
the condition are important. Angiotensin-converting enzyme (ACE) inhibitors as well
as angiotensin receptor blockers (ARB) are considered the best medications in these
cases. A diagnosis of type 2 diabetic nephropathy is reported from ICD-10-CM sub-
category E11.2 Type 2 diabetes mellitus with kidney complications, with an additional
character to report a chronic or other condition.
You may need a second code to identify the exact nature of the renal complication,
such as the stage of the chronic kidney failure. Type 2 diabetes–related chronic kidney
disease may be reported with E11.22 Type 2 diabetes mellitus with diabetic chronic
kidney disease; diabetic nephropathy may be reported with E10.21 Type 1 diabetes
mellitus with diabetic nephropathy.

CHAPTER 8  | 
 Circulatory Manifestations
Peripheral vascular disease is another likely complication because diabetes mellitus
disturbs the blood flow, increasing the development of ulcers. It is estimated that as
many as 10% of diabetics develop foot ulcers. Gangrene, a condition by which necrosis
(tissue death) occurs as a result of lack of blood, is another relatively common mani-
festation. When gangrene is not caught early enough, the resulting treatment to stop
the spread of the necrosis is often amputation. You might report one of these diagnoses
with code E09.52 Drug or chemical induced diabetes mellitus with diabetic peripheral
angiopathy with gangrene or E11.51 Type 2 diabetes mellitus with diabetic peripheral
angiopathy without gangrene.

ICD-10-CM
LET’S CODE IT! SCENARIO
Brittany Hatthaway, a 53-year-old female, came to see Dr. DeRupo for her annual checkup. She is a type 1 insulin-
dependent diabetic and has been feeling fine. There are no diabetic-related manifestations noted.

Let’s Code It!

Dr. DeRupo’s notes state that Brittany has type 1 diabetes mellitus with no complications. When you turn to the
Alphabetic Index, you see
Diabetes, diabetic (mellitus) (sugar) E11.9
When you turn to the Tabular List, you confirm:
E11 Type 2 diabetes mellitus
Oh, wait a minute. This code category is for type 2 diabetes. Dr. DeRupo’s notes document that Brittany has type
1 diabetes. Turn the pages and review this whole section to see if you can find a more accurate code category.
Did you find this code category?
E10 Type 1 diabetes mellitus
There is an note as well as an notation listing several diagnoses. Take a minute to review
them and determine if any apply to Brittany’s condition. No, none of them do, so continue down and review all of
the fourth-character choices. Which matches Dr. DeRupo’s notes?
E10.9 Type 1 diabetes mellitus without complications
Perfect!

CODING BITES Long-Term Drug Use

The code for long- Long-Term Insulin Use
term insulin use is not There are cases where a patient, who has been diagnosed with type 2 diabetes, gesta-
reported for patients tional diabetes, or secondary diabetes, has been prescribed insulin on a regular basis.
with type 1 diabetes This is not a standard of care, so you will have to include a code stating this fact:
mellitus. Remember,
type 1 DM is known Z79.4 Long-term (current) use of insulin
as insulin-dependent You can see the notation at the beginning of the E11 Type 2 diabetes mellitus code
diabetes, making Z79.4 category to remind you:
unnecessary.
Use additional code to identify control using:
insulin (Z79.4)
oral antidiabetic drugs (Z79.84)
oral hypoglycemic drugs (Z79.84)

206   PART II  |  REPORTING DIAGNOSES

Long-Term Hypoglycemic Use
There are now several new drugs, known as hypoglycemics. These medications are Hypoglycemics
not insulin; however, they work to lower a patient’s glycemic level. You may see names Prescription, non-insulin medi-
of drugs such as Orinase, Glucotrol, Avandia, or Glucophage in the physician’s docu- cations designed to lower a
mentation. When a diabetic patient has been using one of these medications for a patient’s glycemic level.
while, you will need to add a code:
      Z79.84 Long term (current) use of oral hypoglycemic drugs
Be careful not to confuse code Z79.84 with code Z79.4. Insulin and hypoglycemic
drugs are different. And remember, both of these codes report that the use of the insu-
lin or hypoglycemic drug is not a one-time or temporary treatment.

GUIDANCE CONNECTION
Read the ICD-10-CM Official Guidelines for Coding and Reporting, section I.
­Conventions, General Coding Guidelines and Chapter Specific Guidelines,
subsection C. Chapter-Specific Coding Guidelines, chapter 4. Endocrine,
­Nutritional, and Metabolic Diseases (E00–E89), subsection a.3) Diabetes
­mellitus and the use of insulin and oral hypoglycemics and a.6)(a) Secondary
diabetes mellitus and the use of insulin or hypoglycemic drugs.

ICD-10-CM
YOU CODE IT! CASE STUDY
Alec Kustra, a 37-year-old male, was diagnosed with type 2 diabetes a year ago. Dr. Lockhart had prescribed tolbu-
tamide to stimulate his pancreatic insulin release. However, 6 months ago, he became concerned that the medica-
tion was not working and started Alec on a regime of insulin injections. Alec is here today for Dr. Lockhart to check
his insulin levels.

You Code It!

Go through the steps of coding, and determine the code or codes that should be reported for this encounter
between Dr. Lockhart and Alec Kustra.
Step #1: Read the case carefully and completely.
Step #2: Abstract the scenario. Which main words or terms describe why the physician cared for the patient dur-
ing this encounter?
Step #3: Are there any details missing or incomplete for which you would need to query the physician? [If so, ask
your instructor.]
Step #4: Check for any relevant guidance, including reading all of the symbols and notations in the Tabular List
and the appropriate sections of the Official Guidelines.
Step #5: Determine the correct diagnosis code or codes to explain why this encounter was medically necessary.
Step #6: Double-check your work.
Answer:
Did you determine these to be the correct codes?
E11.9 Type 2 diabetes mellitus without complications
Z79.4 Long-term (current) use of insulin

CHAPTER 8  | 
 8.3  Diabetes-Related Conditions

Hyperglycemia Hyperglycemia and Hypoglycemia

Abnormally high levels of A patient with hyperglycemia is not diagnosed with diabetes. Hyperglycemia, just
glucose. like hypoglycemia, is a separate condition.
Hypoglycemia Chronic hyperglycemia may impair one’s resistance to infection, resulting in dia-
Abnormally low glucose betic skin problems and urinary tract infections. A diabetic patient that has hypoglyce-
levels. mia may have administered too much insulin or antidiabetic medication.

ICD-10-CM
LET’S CODE IT! SCENARIO
Jessica Gundersen, a 61-year-old female, has been feeling excessively tired and irritable. She tells Dr. Vickers
that she has felt edgy and nervous while experiencing cold sweats and trembling. Dr. Vickers performs a glucose-­
screening test using a reagent strip, resulting in a reading of less than 45 mg/dL. He orders a lab test to confirm a
diagnosis of reactive hypoglycemia and provides Jessica with a diet to follow and a referral to a nutritionist.

Let’s Code It!

Jessica has been diagnosed with reactive hypoglycemia. Let’s turn to the Alphabetic Index and look it up:
Hypoglycemia (spontaneous) E16.2
Read all the way down the indented list to find
Reactive (not drug-induced) E16.1
The Tabular List describes the code as
E16 Other disorders of pancreatic internal secretion
There are no notations or directives, so keep reading down the column.
E16.1 Other hypoglycemia
E16.2 Hypoglycemia, unspecified
How do you decide between these two codes? Let’s think about this. Dr. Vickers did specify the type of hypo-
glycemia that Jessica has, so you cannot report that this detail was “unspecified.” This eliminates E16.2 and
confirms that E16.1 Other hypoglycemia is accurate.
Notice that the note under code E16.1 states that neither hypoglycemia in infant of diabetic mother
(P70.1) nor neonatal hypoglycemia is to be reported with this code. Does it apply to Jessica’s case? Dr. Vickers
indicated that Jessica is an adult; therefore, it does not apply.
The correct diagnosis code for the encounter between Dr. Vickers and Jessica is this:
E16.1 Other hypoglycemia
Excellent!

Insulin Pumps
Technology has provided patients with an easier and more controlled manner by which
to get their insulin: an insulin pump. However, nothing is perfect, so there may be a
concern with the patient as a result of the insulin pump not working correctly.

Underdose of Insulin
It can be very dangerous for a patient to receive less than the proper amount of insulin,
as prescribed by the physician, on schedule. If that occurs and is the reason the physi-
cian is caring for the patient at the encounter, your first-listed code should be this:

208   PART II  |  REPORTING DIAGNOSES

 T85.614A Breakdown (mechanical) of insulin pump, initial encounter
GUIDANCE
Follow that code with the proper diabetes mellitus code and any other appropriate
CONNECTION
codes, including codes for any effects, or conditions, caused by the insulin underdose.
If the patient’s ill health is caused by an underdose of insulin that the patient injects Read the ICD-10-CM Offi-
by hand (not using a pump), meaning that the patient is not taking the correct amount cial Guidelines for Coding
as often as it was prescribed, you might use the following code: and Reporting, section
I. Conventions, Gen-
Z91.120 Patient’s intentional underdosing of medication regimen due to
eral Coding Guidelines
financial hardship
and Chapter Specific
Also note that beneath code Z91.12 and Z91.13 is a notation: Guidelines, subsection C.
Chapter-­Specific Cod-
Code first underdosing of medication (T36-T50) with fifth or sixth character 6
ing Guidelines, chapter
This T code will enable you to report which specific medication was underdosed. So, 4. Endocrine, Nutritional,
in this example, you would also report this code: and Metabolic Diseases
(E00-E89), subsection
T38.3x6D Underdosing of insulin and oral hypoglycemic (antidiabetic) drugs,
a.5) Complications
subsequent encounter
due to insulin pump
malfunction.

ICD-10-CM
YOU CODE IT! CASE STUDY
Tori Anderson, a 19-year-old female, was diagnosed with type 1 diabetes 2 years ago. Starting college, Tori
kept forgetting to take her insulin as prescribed. She comes into the University Health Center because she feels
dizzy, weak, and confused. Dr. Griffith, the on-call physician, finds her to have poor skin turgor and dry mucous
membranes. He diagnoses her with dehydration caused by insulin deficiency and diabetes mellitus, type 1,
uncontrolled.

You Code It!

Go through the steps of coding, and determine the code or codes that should be reported for this encounter
between Dr. Griffith and Tori Anderson.
Step #1: Read the case carefully and completely.
Step #2: Abstract the scenario. Which main words or terms describe why the physician cared for the patient dur-
ing this encounter?

Step #3: Are there any details missing or incomplete for which you would need to query the physician? [If so, ask
your instructor.]

Step #4: Check for any relevant guidance, including reading all of the symbols and notations in the Tabular List
and the appropriate sections of the Official Guidelines.

Step #5: Determine the correct diagnosis code or codes to explain why this encounter was medically
necessary.

Step #6: Double-check your work.

Answer:

Did you determine these to be the correct codes?

E86.0 Dehydration
E10.9 Type 1 diabetes mellitus without complications
T38.3x6A Underdosing of insulin and oral hypoglycemic (antidiabetic) drugs, initial encounter
Z91.138 Patient’s unintentional underdosing of medication regimen for other reason

CHAPTER 8  | 
 Overdose of Insulin
Patients with an insulin pump that malfunctions can dose with a higher quantity of
insulin than prescribed by the attending physician. For such a case, you will use the
following code (which is the same as the code for an underdose):
T85.614A Breakdown (mechanical) of insulin pump, initial encounter
Follow that code with a poisoning code, for example:
T38.3x1A Poisoning by insulin and oral hypoglycemic (antidiabetic) drugs,
accidental (unintentional), initial encounter
Follow that code with the appropriate diabetes mellitus code and any other appropri-
ate codes, including the codes identifying the reaction or conditions caused by the
overdose.
If the patient delivers a dose of insulin manually and suffers an overdose,
you will code it the same way you do any other poisoning, including the deter-
mination of the cause of the overdose (such as accident, attempted suicide, or
assault). Unless the health concern with the patient is an adverse reaction to the
insulin and not related to the actual dosage, you will not use the code reporting
therapeutic usage.

8.4  Other Endocrine Gland Disorders

Diabetes Insipidus
Another type of diabetes that few people have heard of is diabetes insipidus (DI). DI
is a disorder of water metabolism that is the result of an antidiuretic hormone (ADH)
deficiency. Intracranial neoplastic or metastatic lesions, hypophysectomy or other neu-
rosurgery, or skull fractures or other head trauma that damages the neurohypophyseal
structures can all incite DI. The condition can also result from infection. Diabetes
insipidus is also known as pituitary diabetes insipidus and is coded using E23.2 from
the subsection for disorders of the pituitary gland.
Nephrogenic diabetes insipidus, another form of DI, is a very rare congenital dis-
turbance of water metabolism resulting from a renal tubular resistance to vasopressin.
Interestingly, it is not coded from the congenital anomalies but is reported using code
N25.1 Nephrogenic diabetes insipidus.

ICD-10-CM
YOU CODE IT! CASE STUDY
Roy Holvang, a 25-year-old male, comes to see Dr. Fletcher with complaints of extreme thirst and muscle weakness.
During examination, Dr. Fletcher identifies that Roy has poor tissue turgor, dry mucous membranes, and hypoten-
sion. UA results show urine of low osmolality at 75 mOsm/kg. Dr. Fletcher diagnoses Roy with diabetes insipidus and
prescribes vasopressin IM qid.

You Code It!

Go through the steps of coding, and determine the code or codes that should be reported for this encounter
between Dr. Fletcher and Roy Holvang.
Step #1: Read the case carefully and completely.
Step #2: Abstract the scenario. Which main words or terms describe why the physician cared for the patient dur-
ing this encounter?

210   PART II  |  REPORTING DIAGNOSES

 Step #3: Are there any details missing or incomplete for which you would need to query the physician? [If so, ask
your instructor.]
Step #4: Check for any relevant guidance, including reading all of the symbols and notations in the Tabular List
and the appropriate sections of the Official Guidelines.
Step #5: Determine the correct diagnosis code or codes to explain why this encounter was medically necessary.
Step #6: Double-check your work.
Answer:
Did you determine this to be the correct code?
E23.2 Diabetes insipidus

Good job!

Cushing’s Syndrome
Cushing’s syndrome is caused by excessive production of corticotropin (ACTH) in Cushing’s Syndrome
the hypothalamus and too much secretion from the adenohypophysis (pituitary gland). A condition resulting from the
This may be caused by a tumor in another organ affecting this process—possibly a hyperproduction of corticoste-
bronchogenic tumor or a malignant neoplasm of the pancreas. Approximately 30% of roids, most often caused by
such cases are the result of a benign neoplasm of the adrenal gland. an adrenal cortex tumor or a
Cushing’s syndrome may cause diabetes mellitus, hypokalemia (low potassium in tumor of the pituitary gland.
the blood), pathologic fractures, slow wound healing, hypertension, irritability, and
other conditions. Lab tests for plasma steroid levels measured by 24-hour urine sam-
ples can be used to confirm a diagnosis of Cushing’s syndrome. An adrenal tumor
can be seen on an ultrasound, CT scan, or angiography, while MRI and CT scans can
illuminate the presence of a pituitary tumor.
Administration of radiation therapy, drug therapy with a medication such as
aminoglutethimide, or surgery to remove the tumor can be successful to control or
reverse the effects of Cushing’s syndrome. ICD-10-CM code category E24 Cushing’s
­syndrome requires an additional character to provide more specific information about
the condition.

EXAMPLES
E24.0 Pituitary-dependent Cushing’s disease
E24.2 Drug-induced Cushing’s disease
Use additional code for adverse effect, if applicable, to identify
drug (T36-T50 with fifth or sixth character 5)
E24.4 Alcohol-induced pseudo-Cushing’s disease CODING BITES
As you can see, you will need to abstract additional details related to the diagno- The postprocedural time
sis of Cushing’s disease in order to determine a specific code. frame is generally con-
sidered the time from
the surgical procedure’s
Postprocedural Endocrine System Complications conclusion until the
physician releases the
Due to the incredible connections between all aspects of the human body, there are patient from care. This
times when a procedure employed to treat one condition results in a malfunction else- typically aligns with the
where in the body. global period standard
Should a malfunction in the endocrine system be a documented postprocedural for the specific proce-
complication, you must report this using a designated code category: E89 Postproce- dure provided.
dural endocrine and metabolic complications and disorders, not elsewhere classified.

CHAPTER 8  | 
 EXAMPLES
E89.0 Postprocedural hypothyroidism
E89.3 Postprocedural hypopituitarism
E89.5 Postprocedural testicular hypofunction
These complications may be predictable. For example, it would be expected, after
the surgical removal of the patient’s thyroid, that hypothyroidism would develop.
However, this is not always the case.

8.5  Nutritional Deficiencies and Weight

Factors
Nutritional Deficiencies
My mother said it a thousand times, as do physicians and the media . . . eat good food
so you can get all your vitamins. Even with the large number of supplements available
on the market, individuals still lack certain vitamins and other vital nutrients required
for a healthy body.
Vitamin A deficiencies can manifest with diagnosed ophthalmological conditions. You
will need to know this when reporting the vitamin A deficiency diagnosis. Two examples:
E50.0 Vitamin A deficiency with conjunctival xerosis
E50.4 Vitamin A deficiency with keratomalacia
Niacin, riboflavin, calcium, magnesium . . . and so many more deficiencies are
reported from the subsection of the Endocrine, Nutritional, and Metabolic Diseases
chapter in ICD-10-CM.
E52 Niacin deficiency [pellagra]
E56.0 Deficiency of vitamin E
E61.1 Iron deficiency

CODING BITES
Remember, in earlier chapters you learned the difference between a manifestation
and a sequela. When a patient is diagnosed with a sequela of malnutrition or other
nutritional deficiency, report the condition (the sequela) first, followed by a code
from the E64 code category:
E64.0 Sequela of protein-calorie malnutrition
E64.1 Sequela of vitamin A deficiency
E64.2 Sequela of vitamin C deficiency
E64.3 Sequela of rickets
E64.8 Sequela of other nutritional deficiencies

ICD-10-CM
YOU CODE IT! CASE STUDY
Shakeia and Robert Malabwa just adopted Benjamin, a 3-year-old male, from an orphanage in Africa. They brought
him in to see Dr. D’Onofrio, a pediatrician, for this first American checkup. After reviewing what was available about
his history, and a complete physical examination, Dr. D’Onofrio diagnosed Ben with moderate protein-energy mal-
nutrition. They sat together and discussed a treatment plan and diet to help him improve. Lactose intolerance can
manifest, so he suggested that they avoid foods with lactose.

212   PART II  |  REPORTING DIAGNOSES

 You Code It!
Go through the steps of coding, and determine the code or codes that should be reported for this encounter
between Dr. D’Onofrio and Benjamin Malabwa.
Step #1: Read the case carefully and completely.
Step #2: Abstract the scenario. Which main words or terms describe why the physician cared for the patient dur-
ing this encounter?
Step #3: Are there any details missing or incomplete for which you would need to query the physician? [If so, ask
your instructor.]
Step #4: Check for any relevant guidance, including reading all of the symbols and notations in the Tabular List
and the appropriate sections of the Official Guidelines.
Step #5: Determine the correct diagnosis code or codes to explain why this encounter was medically necessary.
Step #6: Double-check your work.
Answer:
Did you determine the correct diagnosis code?
E44.0 Moderate protein-calorie malnutrition

Obesity
The definitions of overweight, obese, and morbidly obese can get lost in societal
norms and self-perception. Of course, the health care industry has its own official
determinations of these conditions, further specified by reporting the patient’s body
mass index (BMI).
Overweight merely means weighing too much. This can be a reference to the indi-
vidual’s muscles, bones, fat, or fluid retention when calculated along with the person’s
height. This condition is calculated as a BMI of 25 to 29.9.
Obesity is a condition calculated as a body mass index of 30 to 38.9. Typically, a
person becomes obese when more calories are consumed than expended. While some
critics believe extra pounds are caused only by eating too much and not exercising
enough, the facts are that one’s genetics and current medications (including herbal
supplements) can also influence this condition.
Being diagnosed as obese is a true health condition that not only can result in self-
esteem problems and social anxiety but also may increase the risk of developing dia-
betes, heart disease, arthritis, stroke, and even certain malignancies.
Morbid obesity is diagnosed when a patient’s current overweight status increases
to the extent that it actually interferes with normal, daily activities. This condition is CODING BITES
calculated as a BMI over 39.
Several different types
of health care profes-
EXAMPLES sionals, such as a dieti-
code category E66 Overweight and obesity tian or a nutritionist,
may be involved in the
Use additional code to identify Body Mass Index (BMI) if known (Z68.-)
care of a patient deter-
E66.01 Morbid (severe) obesity due to excess calories mined to be overweight,
E66.09 Other obesity due to excess calories obese, or morbidly
E66.1 Drug-induced obesity obese. However, the
E66.2 Morbid (severe) obesity with alveolar hypoventilation first time this diagnosis
E66.3 Overweight code is reported, it may
E66.8 Other obesity be coded only from phy-
E66.9 Obesity, unspecified sician documentation.

CHAPTER 8  | 
 As you can see, ICD-10-CM reminds you to use an additional code to specify the
patient’s BMI.

Body Mass Index

It is important for health care professionals to determine specifically what is a
healthy amount of body fat and what falls or rises to an unhealthy level. Body
mass index (BMI) is a calculation using an individual’s actual weight and current
height to determine a workable measure of body fat. However, some people, such
as athletes, may have a BMI that indicates he or she is overweight even though
there is no excess body fat. This can occur because BMI does not actually measure
body fat but instead determines a ratio with which to work. BMI is just an indi-
cator of potential health risks related to an individual’s being outside the normal
weight range.
BMI ranges are listed differently for adults than they are for children and teens.
The pediatric ranges, used for individuals aged 2 to 20 years, are based on the growth
charts of the Centers for Disease Control and take into account the normal differences
in body fat for various ages as well as differences between boys and girls.
Z68 Body Mass Index [BMI]
Adult BMI codes range from Z68.1–Z68.45. The pediatric BMI code is
Z68.5- Body Mass Index [BMI] pediatric

Underweight
With all the discussion regarding how many people in the United States are over-
weight or clinically obese, the opposite—being underweight—can also cause health
concerns. Unlike the codes for overweight conditions, codes for reporting an abnormal
weight loss or underweight condition are listed in the Symptoms, Signs, and Abnor-
mal Clinical and Laboratory Findings section of ICD-10-CM. In certain cases, the
BMI will also need to be reported.

EXAMPLES
R63.4 Abnormal weight loss
R63.6 Underweight
 se additional code to identify Body Mass Index (BMI) if
U
known (Z68.-)

CODING BITES
While you may see
issues of overweight When a patient is diagnosed with anorexia, you may need more information from
status accompany- the physician before determining the correct code.
ing diagnoses such as
diabetes mellitus or R63.0 Anorexia
hypertension, in cases (This is used when the cause of the anorexia has not been determined as organic [phys-
of underweight patients, iological] or nonorganic [psychological].)
be alert to initial or
additional diagnoses of F50.0- Anorexia nervosa
malnutrition. F50.2 Bulimia nervosa
F50.8- Other eating disorders

214   PART II  |  REPORTING DIAGNOSES

 ICD-10-CM
YOU CODE IT! CASE STUDY

PATIENT: ERIC MICOH

REASON FOR CONSULTATION: Preoperative evaluation for bariatric surgery.
HISTORY OF PRESENT ILLNESS: The patient is a 47-year-old morbidly obese male with a BMI of 46.3 and multiple
medical problems including hypertension, diabetes, and dyslipidemia. He has been overweight most of his life. The
patient was considering bariatric surgery and he is planning to go for a lap band procedure. He says that snoring
is not a very common complaint of his wife. He snores mainly when he drinks; otherwise, it could be soft snoring
or sometimes no snoring at all. There was no mention of witnessed apneas. He does not wake himself up choking
or gasping for air. He is a very quiet sleeper with not much tossing and turning. He wakes up feeling refreshed for
the most part, unless he sleeps for 5 hours or so. He goes on with his day with no difficulty as far as excessive day-
time sleepiness or fatigue. He is only tired if he had a really busy long day. His Epworth sleepiness score today was
between 5 and 6. He has never fallen asleep behind the wheel or got himself in an accident. His weight has been
steady. He has been overweight since he was 15 years old. He never had any symptoms suggestive of cataplexy,
sleep paralysis, or hypnagogic or hypnopompic hallucinations. He denies any symptoms of restless legs. No symp-
toms of parasomnia. No sleep onset or sleep maintenance insomnia.
ASSESSMENT AND PLAN:
1. Even though this patient does not have any of the cardinal symptoms of obstructive sleep apnea including snor-
ing, witnessed apneas, or excessive daytime sleepiness, he does have physical features that increase the risk for
sleep apnea including obesity, large neck circumference, crowded airway with a high Mallampati class, as well as
his multiple associated cardiovascular and metabolic disorders including hypertension that is not very well con-
trolled on different blood pressure medicines, diabetes, and dyslipidemia.
2. I had a long discussion with him today about the need for a sleep study to rule out obstructive sleep apnea,
even though he does not have the classic symptoms. I also explained to him the risks in the perioperative
period for patients with obstructive sleep apnea that has not been treated. At this point, he wants to wait and
think about it as well as talk it over with the bariatric surgery team. He does not think he has sleep apnea. He
does not think he would be able to perform the sleep study, as he will have a hard time sleeping outside his
house.
3. I explained to him the risks involved with untreated moderate-to-severe obstructive sleep apnea, including wors-
ening cardiovascular disease, arrhythmias, risk of stroke, and increased overall mortality.
4. I also mentioned to him that there is a possibility of doing a portable sleep study at home if that would be some-
thing he is willing to pursue.
5. In the meantime, he should continue to lose weight, avoid alcohol and sedatives, exercise routinely, and avoid
driving if drowsy.
6. We will follow up with him as needed if he is willing to pursue this further.

You Code It!

Read this evaluation of Eric Micoh and determine the diagnosis code or codes to report.
Step #1: Read the case carefully and completely.
Step #2: Abstract the scenario. Which main words or terms describe why the physician cared for the patient dur-
ing this encounter?
Step #3: Are there any details missing or incomplete for which you would need to query the physician? [If so, ask
your instructor.]
Step #4: Check for any relevant guidance, including reading all of the symbols and notations in the Tabular List
and the appropriate sections of the Official Guidelines.

(continued)

CHAPTER 8  | 
 Step #5: Determine the correct diagnosis code or codes to explain why this encounter was medically necessary.
Step #6: Double-check your work.
Answer:
Did you determine these to be the correct codes?
E66.01 Morbid (severe) obesity due to excess calories
E11.9 Type 2 diabetes mellitus without complications
I10 Essential (primary) hypertension
E78.5 Hyperlipidemia, unspecified
Z68.42 Body mass index [BMI] 45.0-49.9, adult

8.6  Metabolic Disorders

When you eat, it is your metabolism that processes nutrition into energy. The chemi-
cals in the digestive system portion out glucose and acids from the carbohydrates, fats,
and proteins in the food. This process is known as metabolization. The energy created
by this process can be used right away—for example, when someone eats before tak-
ing a test or running a race. If the body doesn’t need the energy at this time, the tissues
in the liver and the muscular system, as well as the adipose (body fat), can store it for
future use.
Dysfunction of the metabolic processes can interfere with the various systems of
the body getting what they need to work properly. This may be realized as too little
of a chemical needed, such as when the pancreas cannot create enough insulin (a
condition known as diabetes mellitus). You have already learned about what havoc
can be caused in the other organs and systems when this disorder continues. Meta-
bolic disorders can also result in too much of a chemical being present in the body.
For example, hyperchloremia is an excessive level of chloride anion in the blood and
can cause tachycardia (rapid heartbeat), hypertension, dyspnea (shortness of breath),
and agitation.
The long list of metabolic diagnoses includes:
∙ Acid lipase disease
∙ Amyloidosis
∙ Barth’s syndrome
∙ Central pontine myelinolysis
∙ Farber’s disease
∙ G6PD deficiency
∙ Gangliosidoses
∙ Hunter’s syndrome
∙ Hyperoxaluria
∙ Lesch-Nyhan syndrome
∙ Lipid storage diseases
∙ Metabolic myopathies
∙ Mitochondrial myopathies
∙ Mucolipidoses
∙ Mucopolysaccharidoses (MPS)
∙ Oxalosis
∙ Pompe’s disease

216   PART II  |  REPORTING DIAGNOSES

 ∙ Trimethylaminuria
∙ Type I glycogen storage disease
∙ Urea cycle disorder
Let’s take a look at some of the more common metabolic conditions, and review the
details required to accurately code them.

Cystic Fibrosis
Cystic fibrosis (CF) is a hereditary malfunction of the secretory glands. Many lay-
people think of this as a malfunction of the pulmonary system. However, as you can
see by the code descriptions, the effects of this genetic condition reach to other body
systems as well.
A defect in the CFTR gene affects the glands that produce mucus and sweat, result-
ing in the creation of thick, sticky mucus and very salty sweat. There are manifesta-
tions that can develop in the respiratory, digestive, and reproductive systems, as well
as other maladies.
E84.0 Cystic fibrosis with pulmonary manifestations
 se additional code to identify any infectious organism present,
U
  such as Pseudomonas (B96.5)
E84.11 Meconium ileus in cystic fibrosis 
E84.19 Cystic fibrosis with other intestinal manifestations
E84.8 Cystic fibrosis with other manifestations
Other manifestations, reported with E84.8, include male neonates born without a vas
deferens or females who may have an overproduction of mucus blocking the cervix.
Dehydration may result due to the large loss of salt in the CF patient’s perspiration;
clubbing and low bone density may both occur later in life.

ICD-10-CM
YOU CODE IT! CASE STUDY
Rachel Ward brought her 3-year-old son Ethan to his pediatrician, Dr. Inger. She was very distressed because Ethan
had eruptions on his arms, legs, and face that appeared after he had spent the day at the beach. She had also
noticed that his urine appeared to be reddish in color. Dr. Inger examined Ethan and discovered that he had sple-
nomegaly (enlargement of the spleen). The blood test came back positive for hemolytic anemia. Both of these con-
ditions are signs of erythropoietic porphyria, also known as Gunther’s disease. Dr. Inger diagnosed Ethan with this
condition.

You Code It!

Go through the steps of coding, and determine the code or codes that should be reported for this encounter
between Dr. Inger and Ethan Ward.
Step #1: Read the case carefully and completely.
Step #2: Abstract the scenario. Which main words or terms describe why the physician cared for the patient dur-
ing this encounter?
Step #3: Are there any details missing or incomplete for which you would need to query the physician? [If so, ask
your instructor.]
Step #4: Check for any relevant guidance, including reading all of the symbols and notations in the Tabular List
and the appropriate sections of the Official Guidelines.
Step #5: Determine the correct diagnosis code or codes to explain why this encounter was medically necessary.

(continued)

CHAPTER 8  | 
 Step #6: Double-check your work.
Answer:
Did you determine this to be the correct code?
E80.0 Hereditary erythropoietic porphyria

Good job!

Lactose Intolerance
If you know anyone with a lactose intolerance, you understand how challenging this
can be to quality of life. While the symptoms of this condition evidence in the diges-
tive system, this is a metabolic disorder because a lactose intolerance develops after
the small intestine is unable to digest lactose due to abnormally low production of
lactase (also known as lactase deficiency).
As you have learned many times, while this sounds like a complete diagnostic state-
ment, you will need to abstract the type of lactase deficiency before you will be able to
determine the accurate code.
∙ Congenital lactase deficiency is an extremely rare, genetic disorder in which there
is a failure of the small intestine to produce any, or enough, of the lactase enzyme.
This diagnosis is reported with code E73.0 Congenital lactase deficiency.
∙ Secondary lactase deficiency manifests when an infection or disease causes the
small intestine to malfunction in this way. These cases can be reversed with success-
ful treatment of the underlying disease. This diagnosis is reported with code E73.1
Secondary lactase deficiency.
∙ Other lactose intolerance may be prompted by developmental lactase deficiency,
a short-term condition seen in premature neonates, or primary lactase deficiency
(lactase nonpersistence), the most frequently seen type of lactase deficiency. Typi-
cally, in these patients, the small intestine’s production of lactase begins to decline
around 2 years of age. Any of these diagnoses are reported with code E73.8 Other
lactose intolerance.

Chapter Summary
The glands of the endocrine system produce and release various types of hormones
that are used by numerous organs throughout the body—all a part of the function of a
healthy body. When a component of this system does not function properly, the harm
can cascade and reveal itself as signs and symptoms evident with other body systems,
such as the urinary system or reproductive system. Diabetes mellitus is probably the
most common of the conditions and diseases affecting the endocrine system. From the
hypothalamus of the brain to the genitals, every part of this system, like all of the oth-
ers that make up the human body, can malfunction or become diseased.

218   PART II  |  REPORTING DIAGNOSES

Hypothalamus
Antidiuretic hormone (ADH)
Oxytocin (OT)
Regulatory hormones
Pineal gland
Pituitary gland Melatonin
Anterior pituitary secretes:
Adrenocorticotropic hormone (ACTH) Parathyroid glands
Follicle-stimulating hormone (FSH) Thyroid gland (posterior surface of thyroid)
Growth hormone (GH) Calcitonin (CT) Parathyroid hormone (PTH)
Luteinizing hormone (LH) Thyroid hormone
Melanocyte-stimulating hormone (MSH) (T3 and T4)
Prolactin (PRL)
Thyroid-stimulating hormone (TSH)
Posterior pituitary releases:
Antidiuretic hormone (ADH) Thymus
Oxytocin (OT) Thymopoietin
Thymosin
Heart
Atrial natriuretic peptide
Gastrointestinal (GI) tract
Adrenal glands Cholecystokinin (CCK)
Cortex: Gastric inhibitory peptide (GIP)
Aldosterone Gastrin
Cortisol Secretin
Medulla: Vasoactive intestinal peptide (VIP)
Epinephrine (E)
Norepinephrine (NE)
Pancreatic islets
Kidney Glucagon
Calcitriol Insulin
Erythropoietin (EPO)
Renin

Testes (male)
Testosterone

Ovaries (female)
Estrogen
Progesterone

CHAPTER 8  | 
 CHAPTER 8 REVIEW
CHAPTER 8 REVIEW

Coding ­Endocrine Conditions Enhance your learning by

completing these exercises and
more at connect.mheducation.com!

Let’s Check It! Terminology

Match each key term to the appropriate definition.
1. LO 8.2  A form of diabetes mellitus with a gradual onset. A. Cushing’s Syndrome
2. LO 8.2  A chronic systemic disease that results from insulin deficiency or resis- B. Diabetes Mellitus
tance and causes the body to improperly metabolize carbohydrates, pro- C. Dyslipidemia
teins, and fats.
D. Gestational Diabetes
3. LO 8.2  A temporary diabetes mellitus occurring during pregnancy. Mellitus (GDM)
4. LO 8.3  Abnormally high levels of glucose. E. Hyperglycemia
5. LO 8.2  Excessive thirst. F. Hypoglycemia
6. LO 8.2  Diabetes caused by medication or another condition or disease. G. Hypoglycemics
7. LO 8.2  Excessive urination. H. Hypothyroidism
8. LO 8.2  Abnormal lipoprotein metabolism. I. Parathyroid Glands
9. LO 8.3  Abnormally low glucose levels. J. Polydipsia
10. LO 8.1  A condition in which the thyroid converts energy more slowly than nor- K. Polyuria
mal, resulting in an otherwise unexplained weight gain and fatigue.
L. Secondary DM
11. LO 8.2  A sudden onset of insulin deficiency.
M. Thyroid gland
12. LO 8.4  A condition resulting from the hyperproduction of corticosteroids, most
N. Type 1 DM
often caused by an adrenal cortex tumor or a tumor of the pituitary gland.
O. Type 2 DM
13. LO 8.1  Four small glands situated on the back of the thyroid gland that secrete
parathyroid hormone.
14. LO 8.1  Two lobes located in the neck that reach around the trachea laterally and
connect anteriorly by an isthmus.
15. LO 8.3  Prescription, non-insulin medications designed to lower a patient’s
­glycemic level.

Let’s Check It! Concepts

Choose the most appropriate answer for each of the following questions.
1. LO 8.3  Daniel Gupta is seen at his doctor’s office with a previous lab test result of positive for hyperglycemia.
Dr. Ansewa writes in his chart that his diagnosis is suspected diabetes mellitus. The correct diagnosis
code would report
a. diabetes mellitus with unspecified complication.
b. hyperglycemia.
c. hyperglycemia; diabetes mellitus uncomplicated.
d. diabetes mellitus with specified complication.
2. LO 8.2  Karin is diagnosed with diabetes mellitus, type 2 with Kimmelstiel-Wilson disease. What is the correct
code for this diagnosis?
a. E11.00 b.  E11.01 c.  E11.21 d.  E11.29

220   PART II  |  REPORTING DIAGNOSES

 3. LO 8.2  Diabetic retinopathy may be manifested in all of the following except

CHAPTER 8 REVIEW
a. background. b.  maculopathy. c.  proliferative. d.  neurologic.
4. LO 8.2  Gestational diabetes is a condition that can affect only an individual
a. over the age of 65. b.  under the age of 4. c.  who is pregnant. d.  with hypertension.
5. LO 8.5  What are the correct codes for a patient with type 1 DM who is overweight and has been diagnosed with
Refsum’s disease?
a. E10.51, E66.00, G60.8
b. E11.9, E66.3, G60.2
c. E11.49, E66.01, G60.0
d. E10.9, E66.3, G60.1
6. LO 8.1  Amanda is being seen today for her hypothyroidism, which was induced when she took sulfonamide as
prescribed by her physician, initial encounter. What is/are the correct code(s) for this condition? 
a. E03.2, T37.0X1A b.  T37.0X5A, E03.2 c.  E03.2, T37.0X5A d.  T37.0X5A
7. LO 8.1  When a patient has _____, the thyroid converts energy more slowly than normal, resulting in an other-
wise unexplained weight gain and fatigue.
a. hypothroidism b.  myxedema c.  hyperthyroidism d.  thyroidits
8. LO 8.4  Which of the following conditions is a disorder of water metabolism that is the result of an ADH
deficiency?
a. Type I DM b.  Diabetes insipidus c.  Secondary DM d.  Gestational DM
9. LO 8.5  When the patient is diagnosed with obesity, his or her body mass will be between
a. 20 and 24.9 b.  25 and 29.9 c.  30 and 38.9 d.  40 and 45.0
10. LO 8.6  Which of the following is a metabolic diagnosis?
a. G6PD deficiency b.  Mucopolysaccharidoses c.  Hyperoxaluria d.  All of these

Let’s Check It! Guidelines

Refer to the Official Guidelines and fill in the blanks according to the Chapter 4, Endocrine, Nutritional and Meta-
bolic Diseases, Chapter-Specific Coding Guidelines.

T85.6- not T85.6-  E08–E13 

body system  E13 T38.3x6- age

E09 T38.3x1-  combination  Z79.4

puberty  E89.1 temporarily  E11.-

Z79.84 type E08 

1. The diabetes mellitus codes are _____ codes that include the type of diabetes mellitus, the _____ affected, and the
complications affecting that body system.
2. Assign as many codes from categories _____ as needed to identify all of the associated conditions that the patient
has.
3. The _____ of a patient is not the sole determining factor, though most type 1 diabetics develop the condition
before reaching _____.
4. If the _____ of diabetes mellitus is not documented in the medical record, the default is _____, type 2 diabetes
mellitus.

CHAPTER 8  | 
 5. An underdose of insulin due to an insulin pump failure should be assigned to a code from subcategory _____,
CHAPTER 8 REVIEW

Mechanical complication of other specified internal and external prosthetic devices, implants and grafts, that
specifies the type of pump malfunction, as the principal or first-listed code, followed by code _____, Underdosing
of insulin and oral hypoglycemic [antidiabetic] drugs. 
6. The principal or first-listed code for an encounter due to an insulin pump malfunction resulting in an overdose of
insulin should also be _____, Mechanical complication of other specified internal and external prosthetic devices,
implants and grafts, followed by code _____, Poisoning by insulin and oral hypoglycemic [antidiabetic] drugs,
accidental (unintentional).
7. Codes under categories _____, Diabetes mellitus due to underlying condition, _____, Drug or chemical induced
diabetes mellitus, and _____, Other specified diabetes mellitus, identify complications/manifestations associated
with secondary diabetes mellitus.
8. For patients who routinely use insulin or hypoglycemic drugs, code _____, Long-term (current) use of insulin, or
_____, Long term (current) use of oral hypoglycemic drugs should also be assigned.
9. Code Z79.4 should _____ be assigned if insulin is given _____ to bring a patient’s blood sugar under control dur-
ing an encounter.
10. For postpancreatectomy diabetes mellitus (lack of insulin due to the surgical removal of all or part of the pan-
creas), assign code _____, Postprocedural hypoinsulinemia.

Let’s Check It! Rules and Regulations

Please answer the following questions from the knowledge you have gained after reading this chapter.
1. LO 8.1  Discuss Graves’ disease. When you look up Graves’ disease in the Alphabetic Index, where does it send
you?

2. LO 8.2  Explain the difference between diabetes mellitus type 1 and diabetes mellitus type 2; include the ICD-
10-CM category code for each.

3. LO 8.3  How would you code an overdose of insulin caused by a malfunction of an insulin pump?

4. LO 8.4  Explain Cushing’s syndrome, including the ICD-10-CM code category as well as an example of another
diagnosis that may result from having Cushing’s.

5. LO 8.6  What is cystic fibrosis and what gene is defective? Include an example of where manifestations can
appear.

ICD-10-CM
YOU CODE IT! Basics
First, identify the main term in the following diagno- 3. Abscess of the thyroid:
ses; then code the diagnosis. a. main term: _____ b. diagnosis: _____
Example: Diabetes mellitus, type 1, with dermatitis:  4. Type I glycogen storage disease:
a. main term: diabetes   b. diagnosis E10.620 a. main term: _____ b. diagnosis: _____
1. Endemic hypothyroid cretinism: 5. Urea cycle metabolism disorder:
a. main term: _____ b. diagnosis: _____ a. main term: _____ b. diagnosis: _____
2. Diabetes mellitus with hyperglycemia: 6. Thyroid nodules with thyrotoxicosis:
a. main term: _____ b. diagnosis: _____ a. main term: _____ b. diagnosis: _____

222   PART II  |  REPORTING DIAGNOSES

 CHAPTER 8 REVIEW
7. Hashimoto’s disease: 12. Cystic fibrosis with intestinal manifestations:
a. main term: _____ b. diagnosis: _____ a. main term: _____ b. diagnosis: _____
8. 5-alpha-reductase deficiency: 13. Respiratory acidosis:
a. main term: _____ b. diagnosis: _____ a. main term: _____ b. diagnosis: _____
9. Wernicke’s encephalopathy: 14. Postprocedural hypoparathyroidism:
a. main term: _____ b. diagnosis: _____ a. main term: _____ b. diagnosis: _____
10. Hartnup’s disease: 15. Dysmetabolic syndrome X:
a. main term: _____ b. diagnosis: _____ a. main term: _____ b. diagnosis: _____
11. Beta hyperlipoproteinemia:
a. main term: _____ b. diagnosis: _____

ICD-10-CM
YOU CODE IT! Practice
Using the techniques described in this chapter, carefully read through the case studies and determine the most
accurate ICD-10-CM code(s) and external cause code(s), if appropriate, for each case study.
1. Jason Peak, a 33-year-old male, comes to see Dr. James with the complaint that he is having difficulty sleep-
ing, is sweating a lot, and has diarrhea. Dr. James completes an examination and notes muscle weakness and
skin warmth with moistness. Dr. James also notes eyelid retraction with exophthalmos. Jason is diagnosed
with Graves’ disease. 
2. Pauline Allyson, a 2-week-old female, is brought in by her mother to see her pediatrician, Dr. Goldburg.
Pauline is having feeding difficulties with vomiting. She also has diarrhea. Dr. Goldburg notes the child is
failing to thrive, as well as hepatosplenomegaly and abdominal distention. Pauline is admitted to the hos-
pital, where lab tests confirm the absence of lysosomal lipase acid (LIPA). Pauline is diagnosed with Wol-
man’s disease.
3. Joyce Meadows, a 42-year-old female, was found unconscious by her husband, George, who rushed his wife
to the nearest ED. Dr. Herald asked about her medical history and George said she was diagnosed with type
2 diabetes about 3 years ago. After lab work, Joyce is admitted in a diabetic hypoglycemic coma.
4. Richard Sullivan, a 12-year-old male, presents with the complaint of tiredness. Richard is accompanied by his
mother. Mrs. Sullivan tells Dr. Gilbert that Richard has been clumsy lately and seems confused. After a thor-
ough examination, Dr. Gilbert notes slight muscle stiffness and Kayser–Fleischer rings bilaterally. Richard is
admitted to Weston Hospital, where a liver biopsy confirmed the diagnosis of Wilson’s disease.
5. April Sundell, a 48-year-old female, presents today with the complaint of generally being “out of sorts” or
a feeling of uneasiness. Dr. Loveichelle notes muscle weakness and mild hyperventilation. The laboratory
results confirm the diagnosis of hyperkalemia. 
6. Latoya Nexsen, a 61-year-old female with diabetes type 1, presents today with the complaint that her left
lower leg is cold and she has a sore that won’t heal. Dr. Benson notes gangrene in Latoya’s left extrem-
ity and admits her to Weston Hospital. After a thorough physical exam, lab workup, and an angiography,
Latoya is diagnosed with atherosclerosis and gangrene of the left lower extremity due to type 1 diabetes
mellitus.

CHAPTER 8  | 
CHAPTER 8 REVIEW

7. Lee Summers, a 3-year-old male, is brought in by his parents for a checkup. The parents have no specific
concerns. Lee does have a history of ear infections and colds. Dr. Shirley, his pediatrician, notes a prominent
forehead, a flattened nose bridge, and a slightly enlarged tongue. Dr. Shirley completes a urine test, which
reveal the presence of mucopolysaccharides. Lee is admitted to the hospital, where further laboratory tests
confirm the diagnosis of Hunter’s syndrome.
8. Loretta Sims, a 14-year-old female, presents today with the complaint of abdominal bloating and cramps with
vomiting. Mrs. Sims, her mother, says this usually occurs shortly after Loretta has drunk milk or eaten yogurt.
Dr. Albany completes an examination and the hydrogen breath test confirms the diagnosis of primary lactose
intolerance.
9. Billy Siau, an 8-month-old male with a congenital cataract, was referred to an ophthalmologist by his pedia-
trician, Dr. Wilberly. Billy and his mother present today to discuss the results of Billy’s tests. Dr. Wilberly
also notes that Billy has hypotonia and below-normal reflexes. The ophthalmologist’s report confirms glau-
coma. Dr. Wilberly diagnoses Billy with Lowe’s syndrome.
10. Anita Kucherin, a 27-year-old female, is at 29 weeks gestation. This is Anita’s first baby and she has not felt
the baby move all day, so she presents to the ED. Anita was diagnosed with diabetes type 2 approximately
3 years ago. Anita states she has tried to keep her diabetes under control. Anita is admitted to the hospital
for observation.
11. James Bucklew, a 38-year-old male, presents for the results of the blood tests taken last week. Dr. Walter
documents central obesity, hypertension, decreased serum HDL cholesterol (fasting), elevated serum triglyc-
eride level (fasting), and pre-diabetes. James’s BMI is 35.4. Dr. Walter diagnoses James with Dysmetabolic
syndrome X.
12. Diana Gamble, a 56-year-old female, had her pancreas removed and is now experiencing headaches, blurred
vision, and weight loss. Diana admits she has not been taking her medications as prescribed. Dr. Caldwell
notes a blood sugar of 305 mg/dL postprandial and admits Diana. After a complete workup, Diana is diag-
nosed with postpancreatectomy hyperglycemia.
13. Mark Hennecy, a 32-year-old male, presents today with the complaints of feeling tired all the time, difficulty
concentrating, and abdominal pain. Dr. Mather notes mild jaundice. After a thorough examination and review
of the laboratory results, Mark is diagnosed with Gilbert’s syndrome.
14. Erica Lamotte, a 63-year-old female, has been diagnosed with insulin-dependent (type 1) diabetic nephropa-
thy and chronic renal failure, stage 4. She is now requiring regular dialysis treatments.
15. Sue Pittman, a 46-year-old female, presents today with the complaints of tiredness and numbness. Sue was
diagnosed with hypertension 2 years ago. Dr. Charmers notes muscle weakness with slight paralysis. Sue is
admitted to the hospital, where blood tests reveal a high level of calcium. After a complete workup, Sue is
diagnosed with familial aldosteronism, type I.

ICD-10-CM
YOU CODE IT! Application
The following exercises provide practice in abstracting physicians’ documentation from our health care facility,
Prader, Bracker, & Associates. These case studies are modeled on real patient encounters. Using the techniques
described in this chapter, carefully read through the case studies and determine the most accurate ICD-10-CM
code(s) and external cause code(s), if appropriate, for each case study.

224   PART II  |  REPORTING DIAGNOSES

 CHAPTER 8 REVIEW
PRADER, BRACKER, & ASSOCIATES
A Complete Health Care Facility
159 Healthcare Way • SOMEWHERE, FL 32811 • 407-555-6789
PATIENT: FUENTES, GILES
ACCOUNT/EHR #: FUENGI001
DATE: 09/16/18
Attending Physician: Renee O. Bracker, MD
This 61-year-old male returns today to review the results of his blood tests, ordered last week. Patient
had come in with complaints of hyperactive deep tendon reflexes, muscle cramps, and carpopedal
spasm.
Pathology report shows abnormally decreased blood calcium levels. I discussed the details of this con-
dition and reviewed treatment options. He wants to discuss this with his wife, and he will call within the
next few days.
DX: Hypocalcemia

ROB/pw  D: 09/16/18 09:50:16  T: 09/18/18 12:55:01

Determine the most accurate ICD-10-CM code(s). 

PRADER, BRACKER, & ASSOCIATES

A Complete Health Care Facility
159 Healthcare Way • SOMEWHERE, FL 32811 • 407-555-6789
PATIENT: MOLINAZZI, JAMES
ACCOUNT/EHR #: MOLIJA001
DATE: 09/16/18
Attending Physician: Oscar R. Prader, MD
S: Pt is a 52-year-old male, comes in for a 6-week follow-up since his diagnosis of secondary diabetes
mellitus due to hyperthyroidism. Patient states he has been taking his methimazole, as prescribed.
O: H: 6’0”, W: 168, T: 99.1, BP: 125/82; HEENT: unremarkable. Heart rhythm is regular and steady. Lung
sounds are also normal. EKG unremarkable. I emphasized the importance of medication and diet. I
reviewed the plan to control the secondary diabetes with diet and exercise as first treatment choice.
A: Hyperthyroidism with secondary diabetes mellitus
P: 1. Rx: Propranolol to manage tachycardia. Methimazole continued
    2. Rx: TSH blood test. Patient to go to lab for test within the week.
   3. Patient to return in 10–14 days.
ORP/pw  D: 09/16/18 09:50:16  T: 09/18/18 12:55:01

Determine the most accurate ICD-10-CM code(s). 

CHAPTER 8  | 
CHAPTER 8 REVIEW

PRADER, BRACKER, & ASSOCIATES

A Complete Health Care Facility
159 Healthcare Way • SOMEWHERE, FL 32811 • 407-555-6789
PATIENT: CARTER, KIMBERLY
ACCOUNT/EHR #: CARTKI001
DATE: 09/16/18
Attending Physician: Renee O. Bracker, MD
Pt, a 61-year-old female, comes in for her regular checkup. She has insulin-dependent diabetes mellitus,
type 2, with bilateral, mild, nonproliferative retinal edema and chronic kidney disease, stage I. In addition,
she suffers from hypertensive heart disease with episodes of congestive heart failure. After the exam,
some time is spent talking about her day-to-day activities, her diet and overall eating habits, whether or
not she is engaging in regular exercise, and her overall mental attitudes as well as physical well-being.
The patient states it can be difficult to get around by herself due to the problems with her eyes, and she
is finding it more and more difficult to give herself the insulin injections. I provided her with some informa-
tion about an insulin pump and she states she will go over it and discuss it with her son.
ROB/pw  D: 09/16/18 09:50:16  T: 09/18/18 12:55:01

Determine the most accurate ICD-10-CM code(s).

PRADER, BRACKER, & ASSOCIATES

A Complete Health Care Facility
159 Healthcare Way • SOMEWHERE, FL 32811 • 407-555-6789
PATIENT: WILLRODT, VICTORIA
ACCOUNT/EHR #: WILLVI001
DATE: 09/16/18
Attending Physician: Oscar R. Prader, MD
S: Pt is a 28-year-old female complaining of discoloration of her right lower eyelid. She states the discol-
oration is of 4 weeks duration with no evidence of healing despite multiple home remedies and over-
the-counter treatments. Pt is a type 1 diabetic for 10 years.
O: Wt: 146 lb, Ht: 5′5″ T: 98.6, BP: 131/58; HEENT: unremarkable. Dr. Prader notes premature graying
of the right eyelashes and eyebrows and discoloration of the right lower eyelid. Ultraviolet light treat-
ment and micropigmentation are discussed as treatment options.
A: Type 1 diabetes; Vitiligo
P: RX: 0.1% Tacrolimus ointment, b.d
    Pt to return in 2 weeks for follow-up 
ORP/pw  D: 09/16/18 09:50:16  T: 09/18/18 12:55:01

Determine the most accurate ICD-10-CM code(s).

226   PART II  |  REPORTING DIAGNOSES

 CHAPTER 8 REVIEW
WESTON HOSPITAL
629 Healthcare Way • SOMEWHERE, FL 32811 • 407-555-6541
PATIENT: HAWKINS, TYRONE
ACCOUNT/EHR #: HAWKTY001
DATE: 09/16/18
Attending Physician: Renee O. Bracker, MD
S: Patient is a 46-year-old male with insulin-dependent type 2 diabetic nephropathy and end-stage
renal disease. He presents today for an arteriovenous shunt for dialysis. Tyrone complains of shortness
of breath and extreme fatigue.
PE: H: 5’10”, Wt: 164, T: 99.2, R: 24, P: 106, BP: 175/63. Dr. Bracker notes some confusion and admits
Tyrone for an emergency hemodialysis treatment. Once patient was stabilized, a Cimino-type direct
arteriovenous anastomosis is performed by incising the skin of the left antecubital fossa. Vessel clamps
are placed on the vein and adjacent artery. The vein is dissected free, and the downstream portion
of the vein is sutured to an opening in the artery using an end-to-side technique. The skin incision is
closed in layers.
ROB/pw  D: 09/16/18 09:50:16  T: 09/18/18 12:55:01

Determine the most accurate ICD-10-CM code(s).

CHAPTER 8  | 
 9 Coding Mental,
Behavioral, and
Neurological Disorders
Key Terms Learning Outcomes
Abuse After completing this chapter, the student should be able to:
Acute
Anxiety LO 9.1 Determine underlying conditions that affect mental health.
Behavioral LO 9.2 Distinguish mood and nonmood disorders.
Disturbance LO 9.3 Apply the guidelines for reporting nonpsychotic mental
Chronic conditions.
Dependence LO 9.4 Identify conditions affecting the central nervous system.
Depressive LO 9.5 Interpret details regarding peripheral nervous system
Manic
Phobia ­conditions into accurate codes.
Schizophrenia LO 9.6 Assess the diagnosis of pain and report it with accurate codes.
Somatoform Disorder
Use

Remember, you need to follow along in

ICD-10-CM

  STOP! your ICD-10-CM code book for an optimal

learning experience.

9.1  Conditions That Affect Mental Health

Mental and behavioral disorders have long been a mystery to the average person, and
the lack of understanding has fed fear of patients with these disorders. The dysfunc-
tion of a person’s brain is often the result of many of the same things that cause other
bodily health concerns, including genetics, congenital anomalies, traumatic injury, or
the invasion of a pathogen. Any of these, along with other conditions and circum-
stances, have the ability to impact the health and function of the brain. Scientific
research has evidenced shared signs and symptoms between psychiatric illness and
neurological illness.
The accepted understanding of mental illness is a condition that negatively affects
an individual’s thoughts, emotions, behaviors, ability to maintain effective social inter-
actions, and ability to appropriately carry out the activities of daily living.

Mental Disorders Due to Known Physiological Conditions

In some cases, a mental disorder is caused by another condition in the body. The phys-
iological condition may be any of various diagnoses, including an infarction of the
brain, hypertensive cerebrovascular disease, or a disease such as Creutzfeldt-Jakob dis-
ease, Parkinson’s disease, or trypanosomiasis (a condition commonly known as sleep-
ing sickness). Moreover, some endocrine disorders, exogenous hormones, and toxic
substances can cause cognitive and/or intellectual malfunction, including signs and
symptoms of problematic memory, impaired judgment, and diminished intellect.

228
 Dementia is included in this subsection of the chapter on mental and behavioral dis-
orders in ICD-10-CM. This diagnosis can be identified by evidence of both neurologic
and psychological signs and symptoms, such as differences in personality, altered
thoughts and feelings, and behavioral changes.
When it comes to reporting diagnoses for mental disorders that are manifestations
of physiological conditions, you need to identify from the documentation the specific
known etiology in cerebral disease, brain injury, or other insult leading to this cerebral
dysfunction.

Vascular Dementia
A patient may develop vascular dementia after having experienced an infarction of
the brain that is known to be a manifestation of a previously existing vascular disease.
In ICD-10-CM, code category F01 also includes a diagnosis of hypertensive cerebro-
vascular disease as well as arteriosclerotic dementia. A cerebrovascular disease and
ischemic or hemorrhagic brain injury can often result in cognitive impairment known
as vascular dementia.

EXAMPLE
At the code category F01, you can see the definition, along with some important
notations:
F01 Vascular dementia
Vascular dementia as a result of infarction of the brain due to vascular disease,
including hypertensive cerebrovascular disease.
arteriosclerotic dementia
Code first the underlying physiological condition or sequelae of cerebrovas-
cular disease.

Therefore, the notation to “Code first the underlying physiological condition or

sequelae of cerebrovascular disease” logically supports your correct sequencing of
codes that may be involved in the reporting of this diagnosis.

EXAMPLES
F01.50 Vascular dementia without behavioral disturbance
F01.51 Vascular dementia with behavior disturbance
Use additional code, if applicable, to identify wandering in vascular demen-
tia (Z91.83)

As you read down this code category listing, you can see that, in addition to identi-
fying the underlying physiological condition, you will also need to identify whether or
not the patient is documented as having behavioral disturbance. If so, has the patient Behavioral Disturbance
also been documented as having episodes of “wandering”? These details will guide A type of common behavior
you toward the correct code or codes to accurately report this patient’s condition. that includes mood disorders
(such as depression, apathy,
Amnestic Disorder Due to Known Physiological Condition and euphoria), sleep disorders
(such as insomnia and hyper-
Reporting amnestic disorder due to known physiological condition will take you to somnia), psychotic symptoms
code category F04 Amnestic disorder, with the additional descriptions of Korsakov’s (such as delusions and hallu-
psychosis and Syndrome, nonalcoholic. You can see that the Code first underlying cinations), and agitation (such
condition notation requires that the underlying condition be physiological, thereby as pacing, wandering, and
eliminating any psychological underlying conditions from qualifying for this code. aggression).

CHAPTER 9  | 
 Note that ICD-10-CM reporting of this diagnosis has an notation. An
notation identifies other diagnoses that are mutually exclusive to the diag-
nosis above the notation (in this case, F04). This is the absolute statement that the
excluded code can never be used at the same time because the two conditions cannot
occur together in one patient at one time.
amnesia NOS (R41.3)
anterograde amnesia (R41.1)
dissociative amnesia (F44.0)
retrograde amnesia (R41.2)
F04 also carries an notation identifying several amnestic disorders that are
not included in F04, therefore requiring either a different code or an additional code:
alcohol-induced or unspecified Korsakov’s syndrome (F10.26,
F10.96)
Korsakov’s syndrome induced by other psychoactive substances
(F13.26, F13.96, F19.16, F19.26, F19.96)

Mood Disorder Due to Known Physiological Condition

A mood disorder is a daily issue of dealing with one’s emotional state. This category
of mental illnesses includes major depressive disorder, dysthymic disorder, and
bipolar disorder. Code subcategory F06.3- differentiates itself from other diagno-
ses under “Mood [affective] disorders,” which includes bipolar disorder (F30–F39),
because this diagnosis (reported with F06.3-) includes a documented physiological
underlying cause.

EXAMPLES
F06.30 Mood disorder due to known physiological condition, unspecified
F06.31 Mood disorder due to known physiological condition, with depres-
sive features
F06.32 Mood disorder due to known physiological condition, with major
depressive-like episode
F06.33 Mood disorder due to known physiological condition, with manic
features
F06.34 Mood disorder due to known physiological condition, with mixed
features
As you abstract documentation related to a mood disorder, you must be alert to
mentions of any additional signs and symptoms.
Depressive features include decrease in interest in hobbies or favorite activi-
ties, hypersomnia, or insomnia virtually every day.
Manic features are identified by documented episodes of intensely disruptive
and exaggerated behaviors of heightened mood.
Mixed features refer to documented and regular (virtually every day within 1 week)
meeting of the criteria of both depressive and manic features. Also known as
roller-coastering.

Beneath F06.3 is an notation, indicating specific diagnoses that are not

included in this subcategory:
mood disorders due to alcohol and other psychoactive substances
(F10-F19 with .14, .24, .94)
mood disorders, not due to known physiological condition or unspec-
ified (F30-F39)

230   PART II  |  REPORTING DIAGNOSES

Personality and Behavioral Disorders Due to Known
Physiological Condition
There have been known physiological conditions that manifest personality changes
or behavioral disorders. Traumatic brain injury—specifically, damage to the patient’s
frontal lobe—can be evidenced by apathy, a lack of ability to formulate plans, emo-
tional bluntness, and inability to perform abstract thinking. In this code category, you
will find a Code first underlying physiological condition notation applicable to all
codes within.
Beneath F07.0 are two notations, which further clarify which diagnoses are
reported with this code and which require the coder to look elsewhere in the code set:

EXAMPLE
F07.0 Personality change due to known physiological condition (Fron-
tal lobe syndrome) (Organic pseudopsychopathic personality)
(Postleucotomy syndrome)
Code first underlying physiological condition
mild cognitive impairment (G31.84)
postconcussional syndrome (F07.81)
postencephalitic syndrome (F07.89)
signs and symptoms involving emotional state (R45.-)
specific personality disorder (F60.-)

F07.81 Postconcussion syndrome (Postcontusion syndrome or encepha-

lopathy) (Posttraumatic brain syndrome, nonpsychotic)
Use additional code to identify associated post-traumatic
headache, if applicable (G44.3-)
Current concussion (brain) (S06.0-)
Postencephalitic syndrome (F07.89)

Remember that an notation in ICD-10-CM identifies diagnoses that are

mutually exclusive—that cannot be reported for the same patient at the same time.
Also, don’t forget to read the notation at the top of this code category, directly
beneath F07 . . . this applies to all codes within this code category.

Code first underlying physiological condition

ICD-10-CM
LET’S CODE IT! SCENARIO
Eboni O’Neal, a 37-year-old female, came with her husband, Carl, to see Dr. Annikah, a psychiatrist, on a referral
from her regular physician. She complains about unusual fatigue and problems remembering things. Her husband
has complained that she has been unusually irritable. Carl stated that he has found Eboni wandering the neighbor-
hood several times over the last few weeks. Eboni admitted to being on a new dairy-free, animal product–free diet.
After a complete physical examination, Dr. Annikah performed a complete psychology exam and ordered blood
work, which confirmed his diagnosis of dementia caused by vitamin B12 deficiency.
(continued)

CHAPTER 9  | 
 Let’s Code It!
Dr. Annikah diagnosed Eboni with dementia caused by vitamin B12 deficiency. You also read that she did have
incidents of wandering. When you turn to the Alphabetic Index, you see
Dementia (degenerative (primary)) (old age) (persisting) F03.90
  In (due to)
   Vitamin B12 deficiency E53.8 [F02.80]
    With behavioral disturbance E53.8 [F02.81]
You should remember from the chapter The Coding Process that the second code, in italicized brackets, tells you
that you will need two codes for this diagnosis and in which order to report these two codes. Turn to the Tabular
List to read the first suggested code:
E53 Deficiency of other B group vitamins
Read down and review all of the fourth-character choices to determine the most accurate code:
E53.8 Deficiency of other specified B group vitamins
Next, you know that you will need to follow this code with a code from F02—either F02.80 or F02.81. Let’s take
a look at both codes and see what exactly is meant by behavioral disturbance:
F02.80 Dementia in other diseases classified elsewhere without behavioral disturbance
F02.81 Dementia in other diseases classified elsewhere with behavioral disturbance
Did you notice the notation beneath F02.81?
Use additional code, if applicable, to identify wandering in dementia in conditions classified elsewhere
(Z91.83)
Aha! This tells you that “wandering” is considered a behavioral disturbance. Dr. Annikah documented that Eboni
had been wandering, so you will need one more code:
Z91.83 Wandering in conditions classified elsewhere
Good job! You determined the three codes required to accurately report Dr. Annikah’s encounter with Eboni.
Check the top of all three chapters in ICD-10-CM. Check them all for an notation, a Use additional
code note, an  notation, and an notation. Read carefully. Do any relate to Dr. Annikah’s diag-
nosis of Eboni? No. Turn to the Official Guidelines and read Section 1.c.4, 1.c.5, and 1.c.21. There is nothing
specifically applicable here either.
Now you can report these three codes with confidence.
E53.8 Deficiency of other specified B group vitamins
F02.81 Dementia in other diseases classified elsewhere with behavioral disturbance
Z91.83 Wandering in conditions classified elsewhere
Good coding!

Mental and Behavioral Disorders Due

to Psychoactive Substance Use
Reporting Alcohol-Related and Drug-Related Disorders
When a patient is diagnosed with an alcohol- or drug-related disorder, the diagnosis is
often more complex, as such conditions are susceptible to both psychological and phys-
iological signs, symptoms, manifestations, and co-morbidities. Alcohol use doesn’t
damage the actual brain cells, but it does damage the ends of neurons, which are called
dendrites. This results in problems conveying messages between the neurons.

232   PART II  |  REPORTING DIAGNOSES

 EXAMPLES
NOTE: All codes in this example require additional characters.
F10.1 Alcohol abuse
F10.2 Alcohol dependence
F10.9 Alcohol use, unspecified
F11.1 Opioid abuse
F11.2 Opioid dependence
F11.9 Opioid use, unspecified
F12.1 Cannabis abuse
F12.2 Cannabis dependence
F12.9 Cannabis use, unspecified Sedative
F13.1 Sedative, hypnotic or anxiolytic-related abuse A tranquilizer; a drug used to
F13.2 Sedative, hypnotic or anxiolytic-related dependence calm or soothe.
F13.9 Sedative, hypnotic or anxiolytic-related use, unspecified
Hypnotic
F14.1 Cocaine abuse A drug that induces sleep.
F14.2 Cocaine dependence
F14.9 Cocaine use, unspecified Anxiolytic
A drug used to reduce anxiety.

The first thing you might notice about these codes is that details are required from
the documentation to identify use of,  abuse of, or dependence on the psychoactive
substance. Also, there are codes for specifically reporting the use of alcohol and drugs
that enable the tracking of the patient’s behavior, which often will ultimately have a
negative impact on his or her health. These details can give providers and researchers
a great deal of useful information as they look for better ways to care for patients and
their maladies.
What is the clinical difference between these terms?
Use: Consumption of a substance without significant clinical manifestations. Use
Abuse: Ongoing, regular consumption of a substance with resulting clinical Occasional consumption of
a substance without clinical
manifestations.
manifestations.
Dependence: Ongoing, regular consumption of a substance with resulting signifi-
cant clinical manifestations and a dramatic decrease in the effect of the substance Abuse
with continued use, therefore requiring an increased quantity of the substance to Regular consumption of a sub-
achieve intoxication. In addition, the patient will require continued consumption of stance with manifestations.
the substance to avoid withdrawal symptoms and other serious behavioral effects, Dependence
occurring at any time in the same 12-month period. Ongoing, regular consump-
tion of a substance with
All of these codes require additional characters to identify details from the documen-
resulting significant clinical
tation about manifestations and co-morbidities. Let’s take alcohol abuse as an exam- manifestations, and a dramatic
ple of what details you may need to abstract from the clinical documentation. decrease in the effect of the
substance with continued
use, therefore requiring an
EXAMPLES increased quantity of the sub-
F10.1 Alcohol abuse stance to achieve intoxication.
F10.10 Alcohol abuse, uncomplicated
F10.120 Alcohol abuse with intoxication, uncomplicated
F10.121 Alcohol abuse with intoxication delirium
F10.14 Alcohol abuse with alcohol-induced mood disorder
F10.150 Alcohol abuse with alcohol-induced psychotic disorder with delusions
F10.180 Alcohol abuse with alcohol-induced anxiety disorder
F10.181 Alcohol abuse with alcohol-induced sexual dysfunction
F10.182 Alcohol abuse with alcohol-induced sleep disorder
F10.188 Alcohol abuse with other alcohol-induced disorder

CHAPTER 9  | 
 As you can see, ICD-10-CM requires an understanding of the psychological and
behavioral impacts of the use, abuse, or dependence. Signs, symptoms, manifestations,
GUIDANCE and co-morbidities such as delirium, mood disorder, and hallucinations will be reported
with one combination code from this subsection.
CONNECTION
In the subcategories for alcohol use and dependence, you will also find codes
Read the ICD-10-CM including a state of withdrawal, again providing one combination code to report this
Official Guidelines for condition.
Coding and Reporting,
section I. Conven-
tions, General Coding EXAMPLE
Guidelines and Chapter
F10.231 Alcohol dependence with withdrawal delirium
Specific Guidelines,
subsection C. Chapter-
Specific Coding Guide-
The extended descriptions and combination-code choices include those codes used
lines, chapter 5. Men-
to report the use of other nontherapeutic substances as well. Take, for example, caf-
tal, Behavioral, and
feine use, hallucinogens, and inhalant use.
Neurodevelopmental
disorders (F01–F99),
subsection b. ­Mental
and behavioral dis- EXAMPLES
orders due to psy- F15.120 Other stimulant abuse with intoxication, uncomplicated
choactive substance F15.920 Other stimulant use, unspecified with intoxication, uncomplicated
use, 2) Psychoactive F16.1- Hallucinogen abuse
substance use, abuse F16.2- Hallucinogen dependence
and dependence and F16.9- Hallucinogen use, unspecified
3) Psychoactive sub- F18.1- Inhalant abuse
stance use. F18.9- Inhalant use, unspecified

ICD-10-CM code descriptions separate inhalant abuse and dependence into its
own specific code category (F18), and caffeine (yes, this is considered a substance)
is included in the “Other” code category, now combined with amphetamine-related
disorders.
As with the previous code categories in this subsection, the additional characters
required for these ICD-10-CM codes include abstracting documentation for details
on accompanying intoxication, delirium, perceptual disturbance, mood disorder, psy-
Anxiety chotic disorder with delusions or hallucinations, anxiety disorder, flashbacks, and
The feelings of apprehension other manifestations.
and fear, sometimes mani- One more addition to this subsection of ICD-10-CM’s Chapter 5, Mental, ­Behavioral,
fested with physical manifes- and Neurodevelopmental disorders, is code category F17 Nicotine dependence.
tations such as sweating and The note reminds you that nicotine dependence is not the same d­ iagnosis
palpitations.
as tobacco use (Z72.0) or history of tobacco dependence (Z87.891). Therefore, the
documentation will need to specifically discern between tobacco use and nicotine
dependence.

EXAMPLES
F17.210 Nicotine dependence, cigarettes, uncomplicated
F17.211 Nicotine dependence, cigarettes, in remission
F17.213 Nicotine dependence, cigarettes, with withdrawal
F17.218 Nicotine dependence, cigarettes, with other nicotine-induced
disorders
F17.220 Nicotine dependence, chewing tobacco, uncomplicated
F17.221 Nicotine dependence, chewing tobacco, in remission

234   PART II  |  REPORTING DIAGNOSES

 F17.223 Nicotine dependence, chewing tobacco, with withdrawal
F17.228 Nicotine dependence, chewing tobacco, with other nicotine-
induced disorders
F17.290 Nicotine dependence, other tobacco product, uncomplicated
F17.291 Nicotine dependence, other tobacco product, in remission
F17.293 Nicotine dependence, other tobacco product, with withdrawal
F17.298 Nicotine dependence, other tobacco product, with other nicotine-
induced disorders

The bottom line is that ICD-10-CM has organized these codes in a logical and effi-
cient order and provided you with many combination codes.

ICD-10-CM
LET’S CODE IT! SCENARIO
Jason Hurst, a 63-year-old male, has been a salesman for the last 30 years. He travels throughout the Midwest
and has had a less-than-stellar career. Very often, he has come close to being fired for not making quota, but his
supervisor takes pity on him because he has been with the company for so long. He is at the medical office today by
court order after being arrested for his third DUI in the last 6 months. Seeking treatment is part of his plea deal so he
doesn’t lose his driver’s license. He needs to be able to drive to see his customers.
Jason states he has tried to stop drinking but can’t because it is part of his job. He must take customers out for
a drink. And when he is back at his office, all the guys go out for drinks after work. When he is on the road, he finds
nothing to do in the motel at night, so he drinks away the loneliness. The one time he tried to quit drinking, he got
really sick. The only thing that helped him feel better was a little “hair of the dog.”
He states that at times he is very sad and hopeless, while other times, especially when he is with clients, he is the
life of the party and knows some of the best jokes. He pleads for help and begins to cry.
Dr. Walkowicz diagnoses Jason with alcohol dependence with alcohol-induced mood disorder.

Let’s Code It!

Dr. Walkowicz diagnosed Jason with alcohol dependence with alcohol-induced mood disorder. Turn in the
Alphabetic Index to find
Dependence (on) (syndrome) F19.20
  Alcohol (ethyl) (methyl) (without remission) F10.20
   With
    Mood disorder F10.24
Now let’s turn to find this suggested code in the Tabular List:
F10 Alcohol related disorder
Use additional code for blood alcohol level, if applicable (Y90.-)
This is not applicable in Jason’s case, so continue reading to review all of the options for the required fourth
character. Did you choose this code?
F10.2 Alcohol dependence
Don’t skip over the and notations. You must read them all carefully, and then determine
whether they apply to the specific case you are coding. In this case, they do not. Keep reading all of the fifth-
character choices to determine the most accurate code. You can see the code that matches Dr. Walkowicz’s
notes perfectly!
F10.24 Alcohol dependence with alcohol-induced mood disorder
Good work!

CHAPTER 9  | 
 In Remission
GUIDANCE
The determination of whether a patient who has been diagnosed with a mental or
CONNECTION behavioral disorder due to the use of a psychoactive substance is in remission is in the
Read the ICD-10-CM judgment of the attending physician. Therefore, report the appropriate character iden-
Official Guidelines for tifying the state of remission only when the physician has specifically documented
Coding and Reporting, this condition.
section I. Conven-
tions, General Coding
Guidelines and Chapter EXAMPLES
Specific Guidelines, F11.21   Opioid dependence, in remission
subsection C. Chapter-­ F14.21   Cocaine dependence, in remission
Specific Coding
Guidelines, chapter 5.
Mental, Behavioral, and
Neurodevelopmental
9.2  Mood (Affective) and Nonmood
disorders (F01–F99), (Psychotic) Disorders
subsection b. Mental
and behavioral disor- Mood (Affective) Disorders
ders due to psychoac-
tive substance use, 1)
Bipolar Disorders
In remission. The etiology of bipolar disorders is uncertain and complex. The strongest evidence
leads to the belief that many factors act together to activate the signs and symptoms.
While some evidence exists that the condition tends to have familial connections,
there have been studies of identical twins in which only one twin is affected.
Bipolar disorder is categorized as a “mood disorder” identified by acute swings
exhibited by the patient, ranging from euphoria and hyperactivity to depression and
Manic lethargy. An overly elated or overexcited state is called a manic episode, and an acute
An emotional state that sad or hopeless state is known as a depressive episode. Bipolar disorder may also be
includes elation, excitement, present in a mixed state, during which the patient experiences both mania and depres-
and exuberance. sion simultaneously.
Depressive Bipolar disorder is a chronic illness, therefore requiring long-term, continuous
An emotional state that treatment to control symptoms. Mood stabilizers (e.g., lithium carbonate), atypical
includes sadness, hopeless- antipsychotics (e.g., clozapine), and antidepressants are most commonly prescribed in
ness, and gloom. combination.
This diagnosis is categorized into two types: Type I bipolar disorder is identified
as alternating between manic episodes and depressive episodes, while type II bipolar
patients deal with recurring depressive episodes with occasional mania.

EXAMPLES
F31 Bipolar disorder
F31.0 Bipolar disorder, current episode hypomanic
F31.11 Bipolar disorder, current episode, manic without psychotic features,
mild
F31.12 Bipolar disorder, current episode, manic without psychotic features,
moderate
F31.13 Bipolar disorder, current episode, manic without psychotic features,
severe
F31.2 Bipolar disorder, current episode, manic, severe, with psychotic
features
F31.31 Bipolar disorder, current episode, depressed, mild
F31.32 Bipolar disorder, current episode, depressed, moderate
F31.4 Bipolar disorder, current episode, depressed, severe, without psy-
chotic features

236   PART II  |  REPORTING DIAGNOSES

 F31.5 Bipolar disorder, current episode, depressed, severe, with psychotic
features
F31.6- Bipolar disorder, current episode, mixed
F31.81 Bipolar II disorder
F31.89 Other bipolar disorder (recurrent manic episodes NOS)
When you abstract the documentation regarding a current episode, you need to
be on the lookout for details regarding the aspects:
• Manic means that the patient reports periods of high energy and an inability
to sleep.
• Depressed mood regards periods of low energy, disinterest in favorite activi-
ties, and feeling sad for no apparent reason.
• Psychotic features include the patient experiencing either auditory or visual
hallucinations.

The categorization of those patients in partial or full remission is also available, so

you will need to check the documentation for this detail or query the physician.

EXAMPLES
F31.7- Bipolar disorder, currently in remission
F31.71 Bipolar disorder, in partial remission, most recent episode hypomanic
F31.72 Bipolar disorder, in full remission, most recent episode hypomanic
F31.73 Bipolar disorder, in partial remission, most recent episode manic
F31.74 Bipolar disorder, in full remission, most recent episode manic
F31.75 Bipolar disorder, in partial remission, most recent episode depressed
F31.76 Bipolar disorder, in full remission, most recent episode depressed
F31.77 Bipolar disorder, in partial remission, most recent episode mixed
F31.78 Bipolar disorder, in full remission, most recent episode mixed
A patient in full remission has not experienced any significant mood fluxuataion for
at least 2 months, virtually always during treatment.
A patient in partial remission has experienced reduced episodes or has had no
episodes for less than 60 days.

Major Depressive Disorder

Everyone feels sad or depressed at times. It is part of life. However, major depressive
disorder causes patients to feel hopeless, guilty, and worthless. The typical activities
of life (work, study, sleep, and fun) become difficult and, for some, nearly impossible.
Some patients may experience ongoing (recurrent) episodes, while others suffer only
a one-time (single) episode. Additional diagnostic terms used by some psychiatrists
include agitated depression, depressive reaction, major depression, psychogenic
depression, reactive depression, and vital depression.
Major depressive disorder may be mild, moderate, or severe and may be described
as with or without psychotic features. Patients diagnosed with this illness may also
experience partial or full remission. As the professional coding specialist, it is your job
to ensure that your physician documents all of these details.

EXAMPLES
F32.- Major depressive disorder, single episode
F33.- Major depressive disorder, recurrent
(continued)

CHAPTER 9  | 
 You will need an additional character to identify the current episode as mild, mod-
erate, severe without psychotic features, or severe with psychotic features.
F32.4 Major depressive disorder, single episode, in partial remission
F33.41 Major depressive disorder, recurrent, in partial remission
A patient in partial remission has experienced reduced episodes or has had no
episodes for less than 60 days.
F32.5 Major depressive disorder, single episode, in full remission
F33.42 Major depressive disorder, recurrent, in full remission
A patient in full remission has not experienced any significant depressive symp-
toms for at least 2 months, virtually always during treatment.

ICD-10-CM
YOU CODE IT! CASE STUDY
Sherri L., a 23-year-old female, came in to see Dr. Keel, a psychiatrist. She has a very demanding and high-stress
life, being a second-year law student. In addition, she is clerking for a judge, and she is planning her wedding for this
coming summer. She states that she has always been highly motivated to achieve her goals. After graduating with
top honors from college, she went on to achieve a 3.95 GPA in her first year in law school. She admits that she can
be very self-critical when she is not able to achieve perfection, even though, intellectually, she knows that perfec-
tion is not necessary for success. Recently, she has been struggling with considerable feelings of worthlessness and
shame due to her inability to perform as well as she has in the past.
For the past few weeks, Sherri has noticed that she is constantly feeling fatigued, no matter how much she has slept.
She also states that it has been increasingly difficult to concentrate at work and pay attention in class. Her best friend,
RaeAnn, who works with her at the courthouse, stated that, recently, Sherri is irritable and withdrawn, not at all her typi-
cal upbeat and friendly disposition. While she has always prided herself on perfect attendance at school and at work,
Sherri has called in sick on several occasions. On those days she stayed in bed all day, watching TV and sleeping.
At home, Sherri’s fiancé has noticed changes in her as well. He states that, in the last 6 months, it seems that she
has lost interest in sex despite a very healthy sex life during the previous 2 years they had been together. He also
has noticed that she has had difficulties falling asleep at night. Her tossing and turning for an hour or two after they
go to bed has been keeping him awake. He confesses that he overheard her having tearful phone conversations
with RaeAnn and her sister that have worried him. When he tries to get her to open up, she denies anything is wrong,
emphatically stating, “I’m fine,” and walking away.
Sherri states that she has found herself increasingly dissatisfied with her life. She admits to having frequent
thoughts of wishing she was dead, yet denies ever considering suicide. She gets frustrated with herself because she
feels that she has every reason to be happy yet can’t seem to shake the sense of a heavy dark cloud enshrouding
her. Dr. Keel diagnosed Sherri with major depressive disorder, single episode, moderate severity.

You Code It!

Go through the steps of coding, and determine the code or codes that should be reported for this encounter
between Dr. Keel and Sherri.
Step #1: Read the case carefully and completely.
Step #2: Abstract the scenario. Which main words or terms describe why the physician cared for the patient dur-
ing this encounter?
Step #3: Are there any details missing or incomplete for which you would need to query the physician? [If so, ask
your instructor.]
Step #4: Check for any relevant guidance, including reading all of the symbols and notations in the Tabular List
and the appropriate sections of the Official Guidelines.

238   PART II  |  REPORTING DIAGNOSES

 Step #5: Determine the correct diagnosis code or codes to explain why this encounter was medically necessary.
Step #6: Double-check your work.
Answer:
Did you determine this to be the correct code?
F32.1 Major depressive disorder, single episode, moderate

Nonmood (Psychotic) Disorders

Schizophrenia
There is no known cause of schizophrenia (a psychotic disorder); however, evidence Schizophrenia
does exist that it may have an etiology of genetic, biological, cultural, and/or psycho- A psychotic disorder with no
logical foundations. The belief of a genetic predisposition is supported with statistical known cause.
research showing that the close relatives of a schizophrenic are 50 times more likely to
develop the condition. There is also a widely held belief of a biochemical imbalance,
specifically excessive activity of dopaminergic synapses, encouraging the signs and
symptoms of schizophrenia. Five types of schizophrenia are recognized by psychiatric
professionals:
∙ Paranoid, also known as paraphrenic schizophrenia [F20.0]
∙ Disorganized, also known as hebephrenic schizophrenia or hebephrenia [F20.1]
∙ Catatonic, also known as schizophrenic catalepsy, catatonia, or flexibilitas
cerea [F20.2]
∙ Undifferentiated, also known as atypical schizophrenia [F20.3]
∙ Residual, also known as restzustand [F20.5]
The signs and symptoms of schizophrenia are generally categorized into three
groups: positive symptoms, negative symptoms, and cognitive symptoms. The spe-
cific behaviors related to this diagnosis will vary depending upon the type and phase
of the disorder.

EXAMPLES
F20.0 Paranoid schizophrenia
F20.1 Disorganized schizophrenia
F20.2 Catatonic schizophrenia
F20.3 Undifferentiated schizophrenia (Atypical schizophrenia)
F20.5 Residual schizophrenia
F20.81 Schizophreniform disorder
F20.89 Other schizophrenia (Simple schizophrenia)
F21 Schizotypal disorder (Latent schizophrenia)
F25.0 Schizoaffective disorder, bipolar type
F25.1 Schizoaffective disorder, depressive type
F25.8 Other schizoaffective disorders

Coders working with health care professionals caring for patients diagnosed with
schizophrenia should be aware of the known adverse effects of the antipsychotic drugs
most often used to treat this condition. Also known as neuroleptic drugs, antipsychot-
ics (such as haloperidol) are known to result in a high incident rate of extrapyramidal
effects, including

CHAPTER 9  | 
 ∙ Drug-induced parkinsonism [G21.11] with signs of propulsive gait, stooped posture,
muscle rigidity, tremors
∙ Drug-induced acute dystonia [G24.02] showing signs of severe muscle contractions
∙ Drug-induced akathisia [G25.71] showing signs of restlessness and pacing
Some low-potency drugs in this category have been known to cause orthostatic
hypotension [I95.2]—a sudden drop in blood pressure when the patient changes posi-
tion quickly, such as standing up. A development of malignant neuroleptic syndrome
[G21.0] has been reported in as many as 1% of patients taking antipsychotics.
Remember that when these adverse effects have been diagnosed, you will need to
include an external cause code to identify the “drug taken for therapeutic purposes” as
the reason for this condition. You would choose a code from category T43 Poisoning
by, adverse effect of and underdosing of psychotropic drugs, not elsewhere classified in
ICD-10-CM.

Schizoid Personality Disorder

There may appear to be some overlap in the signs and symptoms of schizophrenia (a
psychotic disorder) and schizoid personality disorder; however, they are very different
conditions.
Patients diagnosed with schizoid personality disorder exhibit a limited range of
emotions and an aversion to social relationships and personal interactions. These
patients have little to no interest in sex and are indifferent to both praise and criti-
cism. Overall, these patients have a flat affect. Report this diagnosis with code F60.1
­Schizoid personality disorder.

ICD-10-CM
YOU CODE IT! CASE STUDY
Gary R., a 20-year-old male, is a junior at a state university. Over the past month, his parents have noticed that his
behavior has become quite peculiar. Several times, his mother has overheard him speaking in a quiet yet angry
tone, even though no one was in the room with him. Over the past 7 to 10 days, Gary has refused to answer or
make calls on his cell phone, stating that he knows if he uses the phone, it will activate a deadly chip that has been
implanted in his brain by evil men from space.
Gary’s parents, as well as his brother and his best friend, have attempted to convince him to join them at an
appointment with a psychiatrist for an evaluation, but he adamantly refused, until today. Several times, Gary has
accused his parents of conspiring with the aliens to steal his brain. He no longer attends classes and will soon flunk
out unless he can get some help.
Other than a few beers with his friends, Gary denies abusing alcohol or drugs. There is a family history of psychiatric
illness; an estranged aunt has been in and out of psychiatric hospitals over the years due to erratic and bizarre behavior.
Dr. Zavakos diagnosed Gary with paranoid schizophrenia.

You Code It!

Go through the steps of coding, and determine the code or codes that should be reported for this encounter
between Dr. Zavakos and Gary.
Step #1: Read the case carefully and completely.
Step #2: Abstract the scenario. Which main words or terms describe why the physician cared for the patient
during this encounter?
Step #3: Are there any details missing or incomplete for which you would need to query the physician? [If so, ask
your instructor.]
Step #4: Check for any relevant guidance, including reading all of the symbols and notations in the Tabular List
and the appropriate sections of the Official Guidelines.

240   PART II  |  REPORTING DIAGNOSES

 Step #5: Determine the correct diagnosis code or codes to explain why this encounter was medically necessary.
Step #6: Double-check your work.
Answer:
Did you determine this to be the correct code?
F20.0 Paranoid schizophrenia

9.3  Anxiety, Dissociative, Stress-Related,

Somatoform, and Other Nonpsychotic
Mental Disorders
Phobias
Are you terrified of something, with no real rationale? The definition of a phobia is Phobia
the excessive and irrational fear of an object, activity, or situation. Of course, a slight Irrational and excessive fear of
fear of a spider or of flying would not typically result in a physician encounter or docu- an object, activity, or situation.
mented diagnosis. Therefore, for the most part, the code categories for phobias will be
used to report the condition in which this fear has risen to the level at which it actually Somatoform Disorder
interferes with daily life and, therefore, requires treatment. The sincere belief that one is
suffering an illness that is not
present.
EXAMPLES
F40.0- Agoraphobia
F40.1- Social phobia GUIDANCE
F40.23- Blood, injection, injury type phobia CONNECTION
F41.0 Panic disorder [episodic paroxysmal anxiety]
F41.1 Generalized anxiety disorder Read the ICD-10-CM
Official Guidelines for
Coding and Reporting,
Somatoform Disorders section I. Conven-
The term somatoform disorders may be new to you; however, you have probably heard tions, General Coding
of one type, hypochondria (hypochondriacal disorder), in which patients have an ongoing Guidelines and Chapter
belief that they have an illness that they do not have. This group of psychological disorders Specific Guidelines,
causes the patient to exhibit, or believe he or she exhibits, physical signs and symptoms. subsection C. Chapter-­
Specific Coding
Guidelines, chapter 5.
EXAMPLES Mental, Behavioral, and
F45.0 Somatization disorder (Multiple psychosomatic disorder) Neurodevelopmental
F45.22 Body dysmorphic disorder disorders (F01–F99),
F45.41 Pain disorder exclusively related to psychological factors subsection a. Pain dis-
F45.42 Pain disorder with related psychological factors orders related to psy-
  Code also associated acute or chronic pain (G89.-) chological factors.

ICD-10-CM
YOU CODE IT! CASE STUDY
Brian B., a 52-year-old divorced father of two teenagers, states he has a successful, financially rewarding career.
He has been with this company for the last 15 years, the last 5 as vice president of his division. Even though his job
performance evaluations are good and he has been lauded by his boss, he is overwrought with worry constantly
(continued)

CHAPTER 9  | 
 about losing his job and being unable to provide for his children. This worry has been troubling him for about the last
8 or 9 months. Despite really trying, he can’t seem to shake the negative thoughts.
Over these last months, he noticed that he feels restless, tired, and stressed out. He often paces in his office
when he’s alone, especially when not deeply engaged in tasks. He’s found difficulty in expressing himself and has
been humiliated in a few meetings when this has occurred. At night, when attempting to go to sleep, he often finds
that his brain won’t shut off. Instead of resting, he finds himself obsessing over all the worst-case scenarios, includ-
ing losing his job and ending up homeless.
Dr. Burnett diagnoses Brian with generalized anxiety disorder and discusses a treatment plan with him.

You Code It!

Go through the steps of coding, and determine the code or codes that should be reported for this encounter
between Dr. Burnett and Brian.
Step #1: Read the case carefully and completely.
Step #2: Abstract the scenario. Which main words or terms describe why the physician cared for the patient dur-
ing this encounter?
Step #3: Are there any details missing or incomplete for which you would need to query the physician? [If so, ask
your instructor.]
Step #4: Check for any relevant guidance, including reading all of the symbols and notations in the Tabular List
and the appropriate sections of the Official Guidelines.
Step #5: Determine the correct diagnosis code or codes to explain why this encounter was medically necessary.
Step #6: Double-check your work.
Answer:
Did you determine this to be the correct code?
F41.1 Generalized anxiety disorder

Stress-Related Disorders
Post-traumatic stress disorder (PTSD) is a condition in which a horrible experience
leaves a lasting imprint on the patient’s sense of danger. Normally, when an individual
senses danger, a “fight or flight” response initiates feelings of worry and fear. For
those suffering from PTSD, the harmful or dangerous situation is gone, yet the sensa-
tion of fear continues.
Situations that may ignite PTSD can affect more individuals than just our wonderful
military personnel returning from the horrors of war. Sadly, it has become far too typical
to read about a shooting at a school or restaurant, rape, abuse (child, spouse, elder), trans-
portation accidents (car, truck, train, airplane), natural disasters (­hurricane, ­earthquake,
flood), or other terrifying ordeals occurring in an all-­American ­neighborhood. As health
information management professionals and professional coding specialists, we should
be aware, empathetic, and accurate. PTSD affects an estimated 7.5 million adults in the
United States.
Signs and symptoms typically appear within 3 months of the event; however, in
some cases, they can be internalized and take longer to recognize. Flashbacks, hyper-
arousal (overreactions), and avoidance are the most frequently experienced behaviors.
When the symptoms are acute but then dissipate after a few weeks, this may be diag-
nosed as acute stress disorder (ASD), reported with ICD-10-CM code F43.0 Acute
stress reaction, also known as crisis state or psychic shock.
When the patient experiences at least one flashback or “re-experiencing” symp-
tom (including diaphoresis (sweating) and tachycardia (rapid heart rate)), at least

242   PART II  |  REPORTING DIAGNOSES

two hyperarousal symptoms (patients may feel edgy, easily startled, or overly ner-
vous), and at least three avoidance symptoms (avoid locations that are reminiscent CODING BITES
of the event) that last longer than  1 month, it may be PTSD. Additionally, these NOTE: There is a dif-
patients often experience depression and anxiety as well as frequent attempts to ference between acute
self-medicate, resulting in substance abuse. PTSD is reported with one of these PTSD and chronic
ICD-10-CM codes: PTSD. If the documen-
F43.10 Post-traumatic stress disorder, unspecified tation is ambiguous
F43.11 Post-traumatic stress disorder, acute or unclear, query the
F43.12 Post-traumatic stress disorder, chronic physician.

When reporting PTSD, remember to include external cause codes to explain

the specifics about the traumatic event. This is important to both treatment and
reimbursement.
∙ Cause of the injury, such as an earthquake or a multicar accident.

EXAMPLES
All of these codes require additional characters to complete a valid code.
X34.xxx- Earthquake
X37.0xx- Hurricane (storm surge) (typhoon)
X96.3xx- Assault by fertilizer bomb
X99.1xx- Assault by knife
Y36.- Operations of war
Y37.- Military Operations

∙ Place of the occurrence, such as the park or the kitchen.

EXAMPLES
Y92.133 Barracks on military base as the place of occurrence of the external
cause
Y92.212 Middle school as the place of occurrence of the external cause
Y92.26 Movie house or cinema as the place of occurrence of the external
cause
Y92.821 Forest as the place of occurrence of the external cause

∙ Activity during the occurrence, such as almost drowning while SCUBA diving or
being involved in a construction accident.

EXAMPLE
Y93.15 Activity, underwater diving and snorkeling
Y93.34 Activity, bungee jumping
Y93.H3 Activity, building and construction

∙ Patient’s status, such as paid employment, on-duty military, or leisure activity.

The patient’s status at the time must also be included in analysis for research
­purposes, in addition to the determination of financial liability for treatment. For
example, reporting Y99.0 Civilian activity done for income or pay would connect to a
workers’ compensation liability, while Y99.1 Military activity would tie the diagnosis to
military service.

CHAPTER 9  | 
 9.4  Physiological Conditions Affecting the
Central Nervous System
Inflammatory Conditions of the Central Nervous System
Bacteria and viruses can invade the nervous system and cause infection, malfunction,
and, in some cases, death. Examples include encephalitis (inflammation of the brain
tissue), myelitis (inflammation of the spinal cord), intracranial abscess, and, probably
the most well-known condition, meningitis.
Meningitis is an inflammatory disease of the CNS. However, as a professional
coder, you must know more than the fact that the patient is diagnosed with meningitis.
Meningitis can be caused by a virus or a bacterial invader that you will need to identify
from the documentation; this may be a virus such as enterovirus, herpes zoster, or lep-
tospira or a bacteria such as Haemophilus influenzae, streptococcus, pneumococcus,
staphylococcus, or E. coli, to name just a few. Each specific detail may lead you to a
different code or require a second code.

EXAMPLES
G00.1 Pneumococcal meningitis
G00.8 Other bacterial meningitis (Meningitis due to Escherichia coli)
G03.0 Nonpyogenic meningitis

ICD-10-CM
LET’S CODE IT! SCENARIO
Lamonte Millwood went to see Dr. Vaughn after returning home from college on spring break. He stated that
his new dorm room is a small suite and he has three roommates. He said that the last couple of days before he
left to come home, two of his roommates were coughing and sneezing. Lamonte tells Dr. Vaughn that he has
been nauseous and vomiting, he has become very sensitive to light, and he feels a bit confused, having trou-
ble concentrating on his school work. Tests confirmed Dr. Vaughn’s diagnosis of bacterial meningitis caused by
Neisseria meningitidis.

Let’s Code It!

Dr. Vaughn confirmed Lamonte’s diagnosis of “bacterial meningitis caused by Neisseria meningitidis,” so let’s
begin with the first part and turn to the Alphabetic Index to look up “Meningitis.” You can see a long, long list
of additional descriptors indented below this entry. Take a minute to review the elements listed to see if any of
them match what the physician wrote in the documented diagnosis.
Meningitis
  bacterial G00.9
Now, there is another indented list beneath the term “bacterial” that offers many different names of bacteria . . .
except Neisseria meningitidis (N. meningitidis). There are many possibilities including: gram-negative [G00.0]
and specified organism NEC [G00.8]. Do you know if N. meningitidis is gram-negative or gram-positive?
According to the Centers for Disease Control and Prevention,  Neisseria meningitidis is a gram-negative
bacterium.
Let’s go to the Tabular List and begin reading at the three-character code category suggested here:
G00 Bacterial meningitis, not elsewhere classified

244   PART II  |  REPORTING DIAGNOSES

 Read the and notations directly below this code. You are good to continue reading down and
review the two choices:
G00.8 Other bacterial meningitis
Use additional code to further identify organism (B96.-)
G00.9 Bacterial meningitis, unspecified (Meningitis due to gram-negative bacteria, unspecified)
Even though G00.9 includes gram-negative bacteria, which is accurate for Lamonte’s diagnosis, it is not true that
the bacterium is unspecified. It was specified as Neisseria meningitidis. So, you cannot honestly and accurately
report G00.9.
Turn to B96 in your Tabular List to see if you can find a code to specify that Neisseria meningitidis is the spe-
cific bacterium involved. It appears that the only code that could be used truthfully would be
B96.89 Other specified bacterial agents as the cause of diseases classified elsewhere
This doesn’t quite add any details, does it? Not really. Before you make a decision, check one more time in the
Alphabetic Index under meningitis, only this time check for any mention of Neisseria meningitidis.
Meningitis
  Neisseria A39.0
This points us to a code in the Infectious diseases chapter of ICD-10-CM. Let’s take a look at it.
A39 Meningococcal infection
  A39.0 Meningococcal meningitis
Two choices to report this diagnosis: A39.0 or G00.8, B96.89
And still you are unable to provide the specific details you know are important. Therefore, you should append
a special report, such as the pathology report, with this claim to provide these additional details.
Check the head of this chapter in ICD-10-CM. There is an notation. Read carefully. Do any relate to
Dr. Vaughn’s diagnosis of Lamonte? No. Turn to the Official Guidelines and read Section 1.c.6. There is nothing
specifically applicable here either.
For this encounter between Dr. Vaughn and Lamonte, you can confidently report these codes:
G00.8 Other bacterial meningitis
B96.89 Other specified bacterial agents as the cause of diseases classified elsewhere
Great job!

Hereditary and Degenerative Diseases

of the ­Central ­Nervous System
Some nervous system conditions that affect the function of the CNS are linked to
genetics or degeneration but not trauma. The patient may have a condition that is well
known, such as Alzheimer’s disease or dementia, or a lesser-known condition such as
parkinsonism or Huntington’s chorea.
As you have seen before, a diagnosis may seem to be complete but actually may not
include enough information for a professional coder. For example, it is not enough to
know the patient was diagnosed with dementia. To determine the most accurate code,
you need more details, such as
Frontotemporal dementia (Pick’s disease) G31.01
Dementia with Lewy bodies (Lewy body dementia) G31.83
You may remember we discussed coding some forms of dementia in the Conditions
That Affect Mental Health section of this chapter. The good news here is that the cod-
ing process you learned will help you get to the correct ICD-10-CM chapter, know
which specific descriptors to look for in the documentation, and then lead you directly
to the most accurate code.

CHAPTER 9  | 
 ICD-10-CM
LET’S CODE IT! SCENARIO
Nate Mercado, an 81-year-old male, came to see Dr. Bronson with complaints of increasing forgetfulness and dif-
ficulty remembering new information. He states virtually no ability to focus or concentrate. His presentation confirms
a deterioration in personal hygiene, and his appearance is somewhat disheveled. Nate’s daughter insisted that he
come to the doctor. After a neurologic exam, psychometric testing, a PET scan, and an EEG, Dr. Bronson diagnosed
Nate with late-onset Alzheimer’s disease.

Let’s Code It!

Dr. Bronson diagnosed Nate with Alzheimer’s disease. Let’s turn to the Alphabetic Index in the ICD-10-CM book
and find
Disease
  Alzheimer’s G30.9 [F02.80]
Read the list of additional descriptors indented below this. The specific code to report will change on the basis
of documentation of behavioral disturbance, early onset, and/or late onset. What did Dr. Bronson document?
Disease
  Alzheimer’s G30.9 [F02.80]
   late onset G30.1 [F02.80]
Dr. Bronson stated nothing about behavioral disturbances, so this matches the notes. Let’s turn to the Tabular
List and begin reading at the three-character code:
G30 Alzheimer’s disease
Take a look at the note here, which identifies Alzheimer’s dementia senile and presenile forms, as well as
the Use additional code notation, which directs you to the second code suggested in the Alphabetic Index list-
ing, and an note citing three diagnoses that are not reported from this code category. Do you see any
of these diagnoses included in Dr. Bronson’s documentation? No. Read all of the choices for the fourth character
available in this code category and determine which one best matches what Dr. Bronson wrote in Nate’s notes:
G30.1 Alzheimer’s disease with late onset
This matches the documentation exactly! Good job! Now you must go and investigate the second code sug-
gested by the Alphabetic Index: F02.80. Remember, even though the Alphabetic Index gave us five characters,
you must always begin reading at the three-character level:
F02 Dementia in other diseases classified elsewhere
Directly below this entry, you can see a notation to Code first the underlying physiological condition, such as
Alzheimer’s disease. This is a great confirmation that you will need these two codes, and now you know the
order in which to report them: G30.1 first, followed by the F02 code. Also, read carefully both the and
notations. For Nate’s encounter with Dr. Bronson, none of these apply. However, the next case you
code may involve one of these diagnoses. Now is the best time to establish good coding habits.
Review the fourth-character choices. You will notice there is only one:
F02.8 Dementia in other diseases classified elsewhere
Now review the fifth-character choices. You have two. Which one matches Dr. Bronson’s notes about Nate? Dr.
Bronson makes no mention at all about any behavioral disturbance.
F02.80 Dementia in other diseases classified elsewhere without behavioral disturbance
You have done a great job determining the two codes to report for Dr. Bronson’s diagnosis of Nate:
G30.1 Alzheimer’s disease with late onset
F02.80 Dementia in other diseases classified elsewhere without behavioral disturbance

246   PART II  |  REPORTING DIAGNOSES

Hydrocephalus
When too much CSF accumulates in the ventricles of the brain, and the body cannot
absorb it back into the vascular system fast enough, the brain tissues can be damaged
and lose the ability to function properly. This can occur in infants (a congenital anom-
aly: ICD-10-CM code category Q03 Congenital hydrocephalus), or it can develop in
adults (code category G91 Hydrocephalus).
You will find that, again, a diagnostic statement of “hydrocephalus” is insufficient
to determine an accurate code, as there are several different types, each with its own
specific code.
Communicating hydrocephalus, also referred to as secondary normal pressure
hydrocephalus, is a condition in which the CSF is still able to flow out of the ventricles
but then encounters an obstruction preventing it from moving further. This results in
a flooding of the brain tissues in and around the ventricles. This is reported with code
G91.0 Communicating hydrocephalus.
Noncommunicating hydrocephalus, also referred to as obstructive hydrocephalus,
most commonly is caused by aqueductal stenosis, a narrowing of one or more of the
aqueducts (narrow passageways) that connect the ventricles. This is reported with
code G91.1 Obstructive hydrocephalus.
(Idiopathic) normal pressure hydrocephalus (NPH) is an abnormal increase in the
quantity of CSF flowing into the ventricles. This is reported with code G91.2 (Idio-
pathic) normal pressure hydrocephalus.
Post-traumatic hydrocephalus, also known as hydrocephalus ex-vacuo, is the result
of damage to the brain after a cerebrovascular accident (CVA) or a traumatic injury,
such as traumatic brain injury (TBI). This is reported with code G91.3 Post-traumatic
hydrocephalus, unspecified.
Hydrocephalus may also occur as a manifestation of another condition, such as a
neoplasm or congenital syphilis. As you have learned in these situations before, you
will need to report that underlying condition’s code first, followed by code G91.4
Hydrocephalus in diseases classified elsewhere.

Migraine Headaches
Medical researchers have been trying to determine the cause of migraine headaches
for quite a long time. According to the U.S. National Library of Medicine, cur-
rently the theory is that genes related to the control of some brain cell function are
the cause.
While the genetic potential for having migraines may be congenital, generally, this
pain is not constant, but caused by specific actions or events in one’s life. These are
known as triggers, and they include
∙ Stress or anxiety
∙ Insufficient sleep
∙ Lack of food
∙ Fluctuations in hormone levels (specifically in females)
There are several different types of migraine headaches, and these details should be
available to you when you abstract the documentation.
Aura: The aura connected with a migraine is actually a sequence of neurologic
symptoms that occur within the hour prior to the onset of the migraine itself (in adults).
These experiences may affect their vision, such as the appearance of dark or colored
spots; their physical sensations, such as tingling or numbness, possibly vertigo; or
their senses, such as difficulty with speech or hearing.
Intractable: An intractable migraine may also be described in the documentation as
pharmacologically resistant, treatment resistant, medically induced (refractory), and/
or poorly controlled by treatment.

CHAPTER 9  | 
 Status migrainosus: This term is used to identify that the patient’s migraine head-
ache has lasted more than 72 continuous hours.
Chronic: A diagnosis of chronic migraine is documented as the patient reporting
more than 15 headache days within a 30-day period, with more than half of these
described as migraines.
Other types of migraines: There are many more categories of migraine headaches
that you may abstract from the documentation, such as cyclical vomiting, abdomi-
nal, or menstrual. Each of these has its own specific code within code category G43
Migraine.
Be alert to these terms, in connection with a migraine diagnosis. The absence of
a term, such as aura or intractable, can be used as an indicator that the patient was
“without” that aspect of the condition. What this means is that, if the physician does
not specifically document that the patient had aura with his or her migraine, you are
permitted to use a code that states, “without aura.” It is not expected that the physician
would necessarily document elements that are not present. However, if the detail is
documented, a code that includes that detail must be reported.

ICD-10-CM
LET’S CODE IT! SCENARIO
Jeffrey Himes was referred to Dr. Jonas, a neurosurgeon, after his last brain MRI came back showing signs of an
abundance of cerebrospinal fluid (CSF) in the ventricles of his brain. After taking a full history and examination,
Dr.  Jonas determined that there was malabsorption of CSF in the brain—an official diagnosis of communicating
hydrocephalus. Dr. Jonas discussed the treatment options with Jeffrey and his family.

Let’s Code It!

Dr. Jonas diagnosed Jeffrey with hydrocephalus. Let’s turn to the Alphabetic Index in the ICD-10-CM book
and find

Hydrocephalus (acquired) (external) (internal) (malignant)

(noncommunicating) (obstructive) (recurrent) G91.9

This seems to match the notes, except included in the parenthetical nonessential modifiers is the term noncom-
municating. When you look back at the notes, you can see that Dr. Jonas diagnosed Jeffrey with communicating—­
the opposite. So, you know that this code cannot be correct. There is still a long list of additional modifying
terms indented below hydrocephalus. Read through all of the choices and see if you can determine which one
matches the documentation. Did you find this?

Hydrocephalus
  communicating G91.0

This matches the notes, so let’s turn to the Tabular List and begin reading at the three-character code:

G91 Hydrocephalus

Carefully read the note that identifies acquired hydrocephalus and the note citing three diag-
noses that are not reported from this code category. Do you see any of these diagnoses included in Dr. Jonas’s
documentation? No. Read all of the choices for the fourth character available in this code category and deter-
mine which one best matches what Dr. Jonas wrote in Jeffrey’s notes:

G91.0 Communicating hydrocephalus

This matches the documentation exactly! Good job!

248   PART II  |  REPORTING DIAGNOSES

9.5  Physiological Conditions Affecting
the Peripheral Nervous System
Disorders that affect the peripheral nervous system may interfere with only one nerve,
or multiple nerves. In an earlier chapter, you learned that conditions such as diabe-
tes mellitus may cause the development of manifestations affecting the peripheral
nervous system, such as diabetic neuropathy. There are various types of underlying
causes, such as infection, compression, or injury.

Dominant and Nondominant Sides

Are you right-handed? If so, the right side of your body is considered your dominant
side. Individuals who are left-handed have the left side of their bodies considered the GUIDANCE
dominant side. Then there are those who are ambidextrous (use both hands equally). CONNECTION
Patients suffering with hemiplegia (paralysis of one side of the body) or hemipare-
Read the ICD-10-CM
sis (weakness of one side of the body)—code category G81—will need documentation
Official Guidelines for
of whether the dominant side or nondominant side is affected. The same is required
Coding and Reporting,
for a patient diagnosed with monoplegia (paralysis of one extremity, e.g., one arm or
section I. Conven-
one leg)—code category G83.
tions, General Coding
You may have no memory of a physician ever asking you whether you are right- or
Guidelines and Chapter
left-handed—I don’t. While neurologists are trained to consider this, you may find this
Specific Guidelines,
detail missing from the documentation. For such cases, querying the physician may
subsection C. Chapter-­
not help because he or she may not know. ICD-10-CM Official Guidelines are here to
Specific Coding
help you determine the correct code when the affected (weakened or paralyzed) side is
Guidelines, chapter
documented yet there is no indication of whether or not this is the patient’s dominant
6. Diseases of the
side. Here is how the guidelines direct you:
Nervous System, sub-
∙ If the documentation states the right side is affected—report as dominant. section a. Dominant/
∙ If the documentation states the left side is affected—report as nondominant. nondominant side.

For those patients documented to be ambidextrous, whichever side is documented as

affected should be reported as the patient’s dominant side.

EXAMPLES
G81.12 Spastic hemiplegia affecting left dominant side
G83.14 Monoplegia of lower limb affecting left nondominant side
Remember that the laterality refers to the patient’s right or left, not that of the
writer of the documentation.

Carpal Tunnel Syndrome

Many people know about carpal tunnel syndrome, when the nerve that feeds through
the carpal tunnel within the wrist becomes painful, and sometimes incapacitating.
The ligaments and tendons become swollen and compress the nerves threaded through
the tunnel from the hand to the arm. In addition to having a confirmed diagnostic
statement, you will need documentation of laterality to determine a specific code:
G56.01 Carpal tunnel syndrome, right upper limb or G56.02 Carpal tunnel syndrome,
left upper limb or G56.03 Carpal tunnel syndrome, bilateral upper limbs.

Plexus Disorders
Many plexus disorders are the result of a specific point in the peripheral neural path-
way for that plexus becoming compressed. Typically, something causes the nerve to
be pinched between muscle and bone, such as the thoracic outlet syndrome (­brachial

CHAPTER 9  | 
 plexus disorder) occurring from the muscles of the neck and shoulder squeezing
CODING BITES down on the nerve. See code G54.0 Brachial plexus disorders or G54.1 Lumbosacral
Four nerve plexuses plexus disorders.
branch from the spinal
cord off into the periph- Complex Regional Pain Syndrome
eral nerve network:
After a traumatic injury, complex regional pain syndrome (CRPS) may develop in the
• The cervical plexus damaged extremity (arm/hand, leg/foot). Signs and symptoms include chronic (ongo-
branches nerves to ing) pain; dramatic changes to the color, texture, or temperature of the epidural sur-
the head, neck, and face; a burning sensation; and edema and stiffness in involved joints, which often
shoulder. results in decreased mobility.
• The brachial plexus There are two types of CRPS: CRPS-I and CRPS-II.
branches nerves to CRPS-I used to be called reflex sympathetic dystrophy syndrome. Physicians clas-
the chest, shoulders, sify this diagnosis when the patient denies the occurrence of any nerve injury.
upper arms, fore-
G90.511 Complex regional pain syndrome I of right upper limb
arms, and hands.
G90.512 Complex regional pain syndrome I of left upper limb
• The lumbar plexus G90.513 Complex regional pain syndrome I of upper limb, bilateral
branches nerves to G90.521 Complex regional pain syndrome I of right lower limb
the back, abdomen, G90.522 Complex regional pain syndrome I of left lower limb
groin, thighs, knees, G90.523 Complex regional pain syndrome I of lower limb, bilateral
and calves.
• The sacral plexus CRPS-II has been previously documented as causalgia, for patients who have a
branches nerves to confirmed nerve injury prior to this diagnosis.
the pelvis, buttocks, G56.41 Causalgia of right upper limb
genitals, thighs, G56.42 Causalgia of left upper limb
calves, and feet. G56.43 Causalgia of bilateral upper limbs
G57.71 Causalgia of right lower limb
G57.72 Causalgia of left lower limb
G57.73 Causalgia of bilateral lower limbs

ICD-10-CM
YOU CODE IT! CASE STUDY
Simon Clossberg is a 37-year-old architect. While on a business trip to Los Angeles, Simon and guys on his
team decided to have some fun and rented some motorcycles. Taking a turn too wide, Simon was involved in a
one-vehicle motorcycle accident. In the accident, Simon was pinned and slid between the bike and the pave-
ment, ultimately landing on his back. A police officer witnessed the accident and immediately called for medical
assistance.
EMTs arrived within minutes and immediately immobilized Simon’s neck and secured him to a rigid board prior
to transporting him to the emergency department of the nearest hospital. Upon arrival at the ED, Simon was con-
scious and complained of pain in his lower back. ED physician Dr. NeJame examined Simon and found numer-
ous ­abrasions and contusions, in addition to a loss of both sensation and motor control of his legs. After he was
stabilized, Dr. NeJame admitted Simon and called for a neurologic consult. Dr. Cheslea completed the neurologic
assessment.
The neurologic exam revealed the following: Simon demonstrated normal or near normal strength in flexing and
extending his elbows, in extending his wrists, and when flexing his middle finger and abducting his little finger on
both hands. However, he exhibited no movement when medical personnel tested his ability to flex his hips, extend
his knees, and dorsiflex his ankles.
Stretch reflexes involving the biceps, brachioradialis, and triceps muscles were found to be normal, while those
involving the patella and ankle were absent. In addition, Simon was found to have normal sensitivity to pin prick
and light touch in areas of his body above the level of his inguinal (groin) region, but not below that region of
the body.
Dr. Cheslea diagnosed Simon with lumbosacral plexus disorder.

250   PART II  |  REPORTING DIAGNOSES

 You Code It!
Go through the steps of coding, and determine the code or codes that should be reported for this encounter
between Dr. Cheslea and Simon.
Step #1: Read the case carefully and completely.
Step #2: Abstract the scenario. Which main words or terms describe why the physician cared for the patient
during this encounter?
Step #3: Are there any details missing or incomplete for which you would need to query the physician? [If so,
ask your instructor.]
Step #4: Check for any relevant guidance, including reading all of the symbols and notations in the Tabular List
and the appropriate sections of the Official Guidelines.
Step #5: Determine the correct diagnosis code or codes to explain why this encounter was medically
necessary.
Step #6: Double-check your work.
Answer:
Did you determine this to be the correct code?
G54.1 Lumbosacral plexus disorder
Good work!

9.6  Pain Management

Neurologists are among the health care professionals who most often treat pain because
neurologic conditions involve the nerve endings and electrical impulses within the
nervous system. There are physicians who specialize in pain management, although
specialized training is not mandatory. Acute pain is determined by  the severity of Acute
the pain and its impact on the patient’s ability to function. The most common types Severe; serious.
of chronic pain include headache, low back pain, ­cancer pain, arthritis pain, neuro-
Chronic
genic pain, and psychogenic pain. There is no specific time measurement to determine Long duration; continuing over
chronic pain. Therefore, the judgment of the physician, as stated in the documentation, an extended period of time.
is what differentiates acute pain from chronic pain. You must be careful not to assume
a diagnosis of chronic pain syndrome. This condition is different from chronic pain,
and its diagnosis may  be reported (code G89.4) only when the attending physician
specifically documents this condition.
Pain can be a very difficult thing to deal with clinically because it is not the
same for every patient. Medically speaking, pain is an unpleasant sensation often
initiated by tissue damage that results in impulses being transmitted to the brain
via specific nerve fibers. It can be challenging for the patient to describe the
level of intensity, and each individual patient’s ability to cope with pain will vary
greatly. Clinically speaking, pain can be diagnosed as acute, chronic, or both acute
and chronic.
Most health care facilities use some type of pain scale from 0 to 10 (see Table 9-1)
to help improve communication with patients. The zero indicates no pain at all, and
the scale increases up to the number 10, representing excruciating, intolerable pain.
Some facilities use a scale that includes illustrations to help patients accurately com-
municate what they are feeling.

CHAPTER 9  | 
 TABLE 9-1  Numeric Rating Scale for Pain

Numeric Rating Meaning

0 No pain
1–3 Mild pain (nagging, annoying, interfering little with ADLs)
4–6 Moderate pain (interferes significantly with ADLs)
7–10 Severe pain (disabling; unable to perform ADLs)

Source: National Institutes of Health

Reporting Pain Separately

When the physician has documented a confirmed diagnosis and this condition is the
underlying cause of the pain, pain should not be reported with a separate code. In
these circumstances, the pain is considered to be an inclusive symptom. The excep-
tions to this guideline occur when
∙ The principal purpose of the encounter is pain management and the encounter does
not include treatment or management of the underlying condition.
∙ The pain is noted as acute and/or chronic, documenting that the pain suffered by
the patient is above and beyond the level typical of the underlying condition.
ICD-10-CM provides code category G89 Pain, not elsewhere classified, from which
to choose an appropriate code.

EXAMPLES
1. Megan slipped during ice skating practice and broke her right ankle. After
x-­raying the ankle and applying the cast, Dr. Hustey gave her a prescription
for pain medication. In this case, only the fractured ankle would be reported
(S82.64xA, Nondisplaced fracture of lateral malleolus of right fibula, i­nitial
encounter for closed fracture). The pain is an inclusive symptom of the fracture.
2. Megan came back to Dr. Hustey 10 days later complaining of unbearable pain
and stating that the prescribed medication was not “doing the trick.” Dr. Hustey
discussed with Megan several management treatments for the acute pain, and
she agreed to try a different medication. This encounter was only for pain man-
agement. Dr. Hustey did not attend to the fracture at all. Therefore, this encoun-
ter would be reported with two codes:
G89.11 Acute pain due to trauma
S82.64xD Nondisplaced fracture of lateral malleolus of right fibula, sub-
sequent encounter for fracture with routine healing
A code from category G89 is reported to add details about the reason for this
encounter with Dr. Hustey. The code for the fracture explains why Megan had pain.
3. Phillip is diagnosed with chronic tension headaches due to the extreme
­pressures of his job. He told the doctor he could not stand the pain anymore and
he needed help. This diagnosis would be reported with both of these codes:
G89.29 Other chronic pain
G44.229 Chronic tension-type headache, not intractable

The official guidelines state that if the pain is not specifically documented as
acute or chronic, it should not be reported separately. The exceptions to this guide-
line include

252   PART II  |  REPORTING DIAGNOSES

 ∙ Post-thoracotomy pain: G89.12 Acute post-thoracotomy pain (post-thoracotomy
pain NOS); G89.22 Chronic post-thoracotomy pain. GUIDANCE
∙ Postprocedural pain: G89.18 Other acute postprocedural pain (postprocedural CONNECTION
pain NOS); G89.28 Other chronic postprocedural pain. Read the ICD-10-CM
∙ Neoplasm-related pain: G89.3 Neoplasm related pain (acute) (chronic). Official Guidelines for
∙ Central pain syndrome: G89.0 Central pain syndrome. Coding and Reporting,
section I. Conven-
In these four situations, the code from category G89 should be reported in addition to tions, General Coding
any other conditions related to the encounter. Guidelines and Chapter
Specific Guidelines,
Postprocedural Pain subsection C. Chapter-­
Specific Coding
As stated above, postprocedural pain would be reported with either G89.18 or G89.28,
Guidelines, chapter 6.
depending upon the physician’s documentation of the pain as either acute or chronic.
Diseases of the Nervous
One of these codes may be reported only when the pain is documented as
­System, ­subsection b.
∙ More intense or lasting longer than the expected level of pain that is considered Pain—category G89.
normal immediately after a surgical procedure.
∙ Not related to a detailed complication of the surgical procedure.

Site-Specific Pain Codes

There are many other code categories within ICD-10-CM used to report pain
located in a specific anatomical site. Code category G89 Pain, not elsewhere classi-
fied, does not include any site-specific information. Anatomical site-specific code
categories include
M54.5 Low back pain (lumbago)
M79.602 Pain in left arm
M79.672 Pain in left foot

Sequencing Pain Codes with Other Codes

To determine the proper sequencing of a code from category G89 with codes for site-­
specific pain or underlying conditions, the first question to be answered from the documen-
tation is, “Why was this encounter necessary?” If the answer is for pain management, the
code from category G89 should be first-listed or the principal diagnosis reported. If
the encounter is for any other reason and the attention to pain management is secondary
to the purpose for the encounter, then the first-listed or principal diagnosis code would
report that other reason and the code from category G89 would be reported afterward.

ICD-10-CM
LET’S CODE IT! SCENARIO
Patti Moscowicz came in to see Dr. Levine with complaints of extreme pain in her head. She stated that she was nau-
seous and irritable and that light made the pain even worse. Patti stated that these headaches seemed to happen
every month, right before she got her menstrual period, and she couldn’t take it anymore. She begged for something
to help with the pain. After a full examination, Dr. Levine diagnosed her with chronic premenstrual migraine.

Let’s Code It!

Dr. Levine diagnosed Patti with premenstrual migraine headaches, and pain management was the purpose of
this visit to the physician. Let’s turn to the ICD-10-CM Alphabetic Index and find
Migraine (idiopathic) G43.909

(continued)

CHAPTER 9  | 
 There is a list of additional descriptors indented below this. Go back to the physician’s notes. Did he describe the
migraine with more detail? Yes, he stated her migraine was premenstrual. So look down the list and see if you
can find a suggested code:
Migraine (idiopathic) G43.909
  Premenstrual—see Migraine, menstrual
  Menstrual G43.829
Perfect! Now, let’s turn to code category G43 in the Tabular List:

G43 Migraine

Did you notice the notation below this code?

Use additional code for adverse effect, if applicable, to identify drug (T36-T50 with fifth or
sixth ­character 5)

There is no mention of any drugs or adverse reactions in Dr. Levine’s documentation, so let’s continue. Read the
and notes. Nothing there matches the physician’s notes, so continue down the column and
review all of the choices for the mandatory fourth character. Which one matches what Dr. Levine wrote?

G43.8 Other migraine

There are fifth-character choices listed below this code, so you will have to look down the column and find the
box containing the fifth-character choices. You will see the box directly below the three-character code category.
Review the four choices. Which one matches?

G43.82 Menstrual migraine, not intractable

Good. There was no mention that Patti was having an intractable migraine. Read the notation beneath this code
classification:

Code also associated premenstrual tension syndrome (N94.3)

There was no mention of this in Dr. Levine’s notes on Patti. Review the choices for the sixth character:

G43.829 Menstrual migraine, not intractable, without mention of status migrainosus

Do you also need to include a code from the G89 code category? Check the Official Guidelines, specifically
Section 1.c.6.b.1)(b), Use of category G89 codes in conjunction with site specific pain codes. You will
see that it states, “If the code describes the site of the pain, but does not fully describe whether the pain
is acute or chronic, then both codes should be assigned.” Terrific! Dr. Levine documented that Patti’s pain
was chronic, and code G43.829 does not include that specific detail. That’s the answer to that question,
so go and review all of the possible codes from code category G89 to determine the most accurate code
to report:

G89.29 Other chronic pain

You have one last task to complete. Now that you have two codes to report Dr. Levine’s reasons for caring
for Patti during this encounter, you need to determine the correct sequence in which to report these codes.
Refer again to that guideline, and the next part tells you, “If the encounter is for pain control or pain man-
agement, assign the code from category G89 followed by the code identifying the specific site of pain.”
You know from the notes that the reason for this encounter was pain management, so now you know the
correct codes and the correct order in which to report the reason why Dr. Levine cared for Patti during this
encounter:
G89.29 Other chronic pain
G43.829 Menstrual migraine, not intractable, without mention of status migrainosus
Good job!

254   PART II  |  REPORTING DIAGNOSES

Chapter Summary

CHAPTER 9 REVIEW
Due to an increase in available care, more patients are receiving treatment for mental
and behavioral disorders. Therefore, it is important for professional coding specialists
to understand both psychological and physiological concerns. Through education and
understanding, these patients can receive treatment and their providers can receive
accurate reimbursement.
Many different circumstances and situations can be the cause of malfunction any-
where in the nervous system. As with any other organ system or diagnosis, professional
coding specialists should never assume. Everything you need to report these conditions
accurately is in the physician’s documentation. If it is not, you must query the physician.

CODING BITES
Did you know there are hundreds of named phobias . . . such as
Acrophobia = fear of high places
Aerophobia = fear of air travel
Apiphobia = fear of bees
Bromidrosiphobia = fear of body odor
Claustrophobia = fear of enclosed places
Gephyrophobia = fear of bridges
Haemophobia = fear of blood
Kakorrhaphiaphobia = fear of failure
Linonophobia = fear of string
Phasmophobia = fear of ghosts
Scotophobia = fear of the dark
Taphephobia = fear of being buried alive
Triskaidekaphobia = fear of the number 13

CHAPTER 9 REVIEW
Coding Mental, Behavioral, Enhance your learning by
completing these exercises and
more at connect.mheducation.com!

and Neurological Disorders

Let’s Check It! Terminology
Match each key term to the appropriate definition.
1. LO 9.2  An emotional state that includes sadness, hopelessness, and gloom.
2. LO 9.1  Ongoing, regular consumption of a substance with resulting significant A. Abuse
clinical manifestations, and a dramatic decrease in the effect of the sub- B. Anxiety
stance with continued use, therefore requiring an increased quantity of
C. Behavioral Disturbance
the substance to achieve intoxication.
D. Dependence
3. LO 9.2  An emotional state that includes elation, excitement, and exuberance.
E. Depressive
4. LO 9.1  The feelings of apprehension and fear, sometimes manifested with phys-
ical manifestations such as sweating and palpitations. F. Manic
5. LO 9.3  The sincere belief that one is suffering an illness that is not present. G. Phobia
6. LO 9.1  Consumption of a substance without significant clinical manifestations. H. Schizophrenia
7. LO 9.1  Common behaviors include mood disorders, sleep disorders, psychotic I. Somatoform Disorders
symptoms, and agitation. J. Use

CHAPTER 9  | 
 8. LO 9.3  Irrational and excessive fear of an object, activity, or situation.
CHAPTER 9 REVIEW

9. LO 9.1  Ongoing, regular consumption of a substance with resulting clinical

manifestations.
10. LO 9.2  A psychotic disorder with no known cause.

Let’s Check It! Concepts

Choose the most appropriate answer for each of the following questions.
1. LO 9.1  When a patient is diagnosed with an alcohol- or drug-related disorder,
such condition is susceptible to _____ signs, symptoms, manifestations, and
co-morbidities.
a. psychological b.  physiological
c. psychological and physiological d.  none of these
2. LO 9.2  All of the following are mood disorders except
a. depression. b.  apathy. c.  euphoria. d.  hallucinations.
3. LO 9.1  Pete smokes marijuana on a regular basis and it takes a little more each
time to achieve the full effect. Pete is beginning to have some problems with his
memory and gets irritable when he doesn’t smoke pot. Pete is _____ marijuana.
a. using b.  abusing c.  dependent on d.  withdrawing from
4. LO 9.3  Which of the following is a somatoform disorder?
a. panic disorder b.  bipolar disorder
c. hypochondriacal disorder d.  schizophreniform disorder
5. LO 9.2  The patient has been diagnosed with Bipolar disorder, current episode,
manic, severe, with psychotic features. The correct code is
a. F31 b.  F31.2 c.  F31.4 d.  F31.5
6. LO 9.4  Huntington’s chorea is an example of a(n)
a. inflammatory disease of the CNS. b.  trauma of the CNS.
c. hereditary disease of the CNS. d.  disease of the PNS.
7. LO 9.4  The Official Guidelines state that if the pain is not specifically docu-
mented as acute or chronic, it should not be reported separately. The exceptions
to this guideline include all of the following except
a. neoplasm-related pain. b.  tension headaches.
c. central pain syndrome. d.  post-thoracotomy pain.
8. LO 9.3  _____ is a condition in which a horrible experience leaves a lasting
imprint on the patient’s sense of danger.
a. Fear b.  Anxiety
c. Post-traumatic stress disorder d.  Reactive depression
9. LO 9.5  The _____ plexus branches nerves to the chest, shoulders, upper arms,
forearms, and hands.
a. brachial b.  cervical c.  lumbar d.  sacral
10. LO 9.6  To determine the proper sequencing of a code from category G89 with
codes for site-specific pain or underlying conditions, the first question to be
answered from the documentation is
a. Where did the encounter take place? b.  How was the service provided?
c. When did the encounter take place? d.  Why was the encounter necessary?

256   PART II  |  REPORTING DIAGNOSES

Let’s Check It! Guidelines

CHAPTER 9 REVIEW
Refer to the Official Guidelines and fill in the blanks according to the Chapter 5, Mental, Behavioral, and
­Neurodevelopmental Disorders, and Chapter 6, Diseases of the Nervous System, Chapter-Specific Coding
Guidelines.
G89 default G89.2 cancer psychological
relationship one acute pain associated 
G89.4 G89.0 F45.41  G89.3 only
documentation  F45.42 mental appropriate

1. Assign code _____, for pain that is exclusively related to _____disorders. As indicated by the Excludes 1 note
under category G89, a code from category G89 should not be assigned with code F45.41.
2. Code _____, Pain disorders with related psychological factors, should be used with a code from category _____,
Pain, not elsewhere classified, if there is documentation of a psychological component for a patient with acute or
chronic pain.
3. The _____ codes for “in remission” are assigned only on the basis of provider _____ (as defined in the Official
Guidelines for Coding and Reporting).
4. When the provider documentation refers to use, abuse and dependence of the same substance, only _____ code
should be assigned to identify the pattern of use.
5. The codes are to be used only when the psychoactive substance use is _____ with a _____ or behavioral disorder,
and such a _____ is documented by the provider.
6. Codes in category G89, Pain, not elsewhere classified, may be used in conjunction with codes from other catego-
ries and chapters to provide more detail about acute or chronic _____ and neoplasm-related pain, unless otherwise
indicated below.
7. The _____ for post-thoracotomy and other postoperative pain not specified as acute or chronic is the code for the
_____ form.
8. Chronic pain is classified to subcategory _____.
9. Code _____ is assigned to pain documented as being related, associated or due to _____, primary or secondary
malignancy, or tumor.

10. Central pain syndrome _____ and chronic pain syndrome _____ are different than the term “chronic pain,” and
therefore codes should _____ be used when the provider has specifically documented this condition.

Let’s Check It! Rules and Regulations

Please answer the following questions from the knowledge you have gained after reading this chapter.
1. LO 9.1  What is the clinical difference between use, abuse, and dependence?

2. LO 9.2  Explain schizoid personality disorder.

3. LO 9.3  What is a phobia?

4. LO 9.4  Differentiate between an inflammatory and a hereditary/degenerative type of disease of the nervous
­system. Give an example of each type.

5. LO 9.5  Why is it important to know which side is dominant when coding weakness or paralysis? How do the
guidelines help us if the dominant side is not documented in the patient’s chart? How do the guidelines
direct the coder for a patient who has been documented as being ambidextrous?

CHAPTER 9  | 
CHAPTER 9 REVIEW

ICD-10-CM
YOU CODE IT! Basics
First, identify the main term in the following diagno- 8. Infantile autism:
ses; then code the diagnosis. a. main term: _____ b.  diagnosis: _____
Example: Korsakoff’s alcoholic psychosis 9. Bacterial meningitis, E. coli:
a. main term: psychosis b.  diagnosis F10.96 a. main term: _____ b.  diagnosis: _____
10. Acute disseminated encephalitis:
1. Nicotine dependence:
a. main term: _____ b.  diagnosis: _____
a. main term: _____ b.  diagnosis: _____
11. Early-onset cerebellar ataxia:
2. Generalized anxiety disorder:
a. main term: _____ b.  diagnosis: _____
a. main term: _____ b.  diagnosis: _____
12. Amyotrophic lateral sclerosis:
3. Vascular dementia:
a. main term: _____ b.  diagnosis: _____
a. main term: _____ b.  diagnosis: _____
13. Postencephalitic parkinsonism:
4. Mild cognitive impairment:
a. main term: _____ b.  diagnosis: _____
a. main term: _____ b.  diagnosis: _____
14. Generalized idiopathic epilepsy:
5. Cocaine abuse:
a. main term: _____ b.  diagnosis: _____
a. main term: _____ b.  diagnosis: _____
15. Congenital dystonic cerebral palsy:
6. Schizoaffective manic type disorder:
a. main term: _____ b.  diagnosis: _____ a. main term: _____ b.  diagnosis: _____
7. Delirium with multiple etiologies:
a. main term: _____ b.  diagnosis: _____

ICD-10-CM
YOU CODE IT! Practice
Using the techniques described in this chapter, carefully read through the case studies and determine the most
accurate ICD-10-CM code(s) and external cause code(s), if appropriate, for each case study.
1. Albert Goings, a 54-year-old male, presents today with abdominal cramping and diarrhea. Albert had knee
surgery 6 months ago and the surgeon prescribed oxycodone for pain control. Albert has stopped taking the
medication but is having difficulty. Dr. Kenneth documents dilated pupils as well as goose bumps. Albert is
diagnosed with oxycodone dependence, uncomplicated.
2. Charles Homer, a 6-year-old male, is brought in by his parents to see his pediatrician, Dr. Freibert. Mrs.
Homer is concerned because Charles has been eating dirt and sand and he has tried to eat paper for approxi-
mately 1 month. Dr. Freibert completes a thorough examination and notes paleness and failure to thrive.
Charles is admitted to Weston Hospital for a full workup. After reviewing the laboratory and developmental
test results, Charles is diagnosed with pica.
3. Kelley Dumont, a 19-year-old female, comes in to see Dr. Molusky. Kelley complains that she feels powerless
and depressed. Kelley is accompanied by her mother. Mrs. Dumont states that Kelley has given up activi-
ties and has become fearful. Dr. Molusky completes a psychological examination and diagnoses Kelley with
chronic paranoid reaction.
4. Kevin Genutis, a 24-year-old male, presents with the complaint of experiencing early orgasm and ejacula-
tion, usually a minute or two after beginning sexual activity. Dr. Fox completes an examination and diagnoses
Kevin with premature ejaculation.

258   PART II  |  REPORTING DIAGNOSES

 CHAPTER 9 REVIEW
5. April Carter, a 56-year-old female, was brought to the emergency department by a friend who found her in
a stupor. After Dr. Hoogenboom completed a thorough examination and after documenting posturing, echola-
lia, and echopraxia, April is admitted for further psychological testing. After reviewing the test results,
Dr. Hoogenboom diagnoses April with schizophrenic catatonia.
6. Brent Brooke, an 18-year-old male, presents for immunizations before joining the army. Brent passes out
when given an injection. Dr. Meetze diagnoses Brent with fear of injections.
7. Melissa Roxburgh, a 21-year-old female, presents for a checkup. Melissa states she is deliberately trying to
lose weight, exercises strenuously, and uses appetite suppressants. Dr. Fritz documents a BMI of 16.5, hypo-
tension, and tachycardia as well as Melissa’s inability to concentrate. Dr. Fritz decides to admit Melissa. After
reviewing the laboratory results and a psychological evaluation, Melissa is diagnosed with anorexia nervosa,
restricting type.
8. Gregory Abreu, a 37-year-old male, was previously diagnosed with African rhodesiense trypanosomiasis
infection due to Trypanosoma bruceri. Greg presents today with the complaint of a severe headache and a
stiff neck. Greg says he feels so bad that it actually hurts to walk. Dr. Crumpler notes a fever of 102F and
shivering. Greg is admitted to Weston Hospital, where the results of a lumbar puncture confirm an elevated
CSF pressure of 24 cm H2O. Gregory is diagnosed with meningitis.
9. Carol Abuelo, a 39-year-old female, presents today with general restlessness. Dr. Sabbagha documents unin-
tentional and uncontrollable movements as well as slowed saccadic eye movements. Carol is admitted. An MRI
scan reveals atrophy of the caudate nuclei and genetic tests confirmed the diagnosis of Huntington’s chorea.
10. Harold Darden, a 5-month-old male, is brought in by his parents for a checkup. Dr. Hottel notes muscle
weakness and a weak cry. Mrs. Darden says that Harold seems to have some difficulty swallowing. Harold is
admitted to Weston Hospital. The genetic blood tests, EMG, and NCV all confirm a diagnosis of infantile spi-
nal muscular atrophy, type I.
11. Ruby Jenkins, a 26-year-old female, presents with popping or clicking sounds in her ears. After a thorough
examination and the appropriate tests, Dr. Thompson diagnoses Ruby with palatal myoclonus.
12. Joe Frances, a 47-year-old male, presents with weakness and a numb feeling in his legs. Dr. Wigley notes
hypertonia and orders an MRI, which reveals a thoracic spinal cord lesion. Joe is diagnosed with acute trans-
verse myelitis.
13. Daniela Wiebenga, an 11-year-old female, is brought in by her mother. Mrs. Wiebenga is concerned because
Daniela is starting to knock over objects and drop things, mostly in the morning. Daniela says it’s hardest in
the morning and seems to get better as the day progresses. Dr. Jefferson orders an EEG, which reveals spikes
and waves, and admits Daniela. After a full workup, Daniela is diagnosed with juvenile absence epilepsy.
14. Eric Lewter, a 56-year-old male, presents with the feeling of tiredness but has been sleeping a lot over the last
3 to 4 months. Eric is accompanied by his wife, Peggy, who states she has noticed some mild mood changes
as well. Dr. Shealy completes a thorough examination and the appropriate tests and diagnoses Eric with
Kleine-­Levin syndrome (KLS).
15. Paige Henderson, a 42-year-old female, comes in today with the complaint of numbness in her left little fin-
ger. Dr. McKenna notes Paige has difficulty performing fine motor movements with her left hand and fingers.
After an examination and the appropriate tests, Dr. McKenna diagnoses Paige with tardy ulnar nerve palsy,
left arm.

ICD-10-CM
YOU CODE IT! Application
The following exercises provide practice in abstracting physicians’ notes and learning to work with documentation
from our health care facility, Prader, Bracker, & Associates. These case studies are modeled on real patient encoun-
ters. Using the techniques described in this chapter, carefully read through the case studies and determine the most
accurate ICD-10-CM code(s) and external cause code(s), if appropriate, for each case study.

CHAPTER 9  | 
CHAPTER 9 REVIEW

PRADER, BRACKER, & ASSOCIATES

A Complete Health Care Facility
159 Healthcare Way • SOMEWHERE, FL 32811 • 407-555-6789
PATIENT: PORTER, KELSEY
ACCOUNT/EHR #: PORTKE001
DATE: 10/16/18
Attending Physician: Oscar R. Prader, MD
Kelsey is a straight “A” student at the state university. He is well liked and respected, handsome, tall, and
personable. However, he is finding it increasingly difficult to socialize with his friends without the need
to, unobtrusively, wash his hands for fear of contamination. He began carrying antibacterial wipes for
those occasions when he could not get to a sink. He had difficulty tolerating medication to help defuse
these feelings, and he has found talk therapy to be of little benefit. He stated that he came to my office
with his parents, desperately hoping to get some relief.
After a thorough 2½-hour evaluation, I diagnosed Kelsey with OCD.
Diagnosis: Obsessive-compulsive disorder (OCD).

ORP/pw  D: 10/16/18 09:50:16  T: 10/18/18 12:55:01

Determine the most accurate ICD-10-CM code(s).

PRADER, BRACKER, & ASSOCIATES

A Complete Health Care Facility
159 Healthcare Way • SOMEWHERE, FL 32811 • 407-555-6789
PATIENT: MYRICK, JULIE
ACCOUNT/EHR #: MYRIJU001
DATE: 10/16/18
Attending Physician: Oscar R. Prader, MD
S: Julie, a 47-year-old female, came to see me because her youngest son was getting married, leaving
her alone. She stated that, over the last several weeks, she had begun having panic attacks whenever
she thought about the upcoming separation. Patient has tried cognitive behavioral therapy and different
medications without success.
O: CBC results showed the size of her red blood cells (MCV) was slightly abnormal. The range was
80–100, and she was 101. Evidence-based medicine has documented an elevated MCV could indicate
a B12 deficiency, so I had Julie do a Schilling test, which was positive.
A: Panic disorder without agoraphobia, vitamin B12 deficiency.
P: Rx B12 injections; patient to return in 10–14 days.

ORP/pw  D: 10/16/18 09:50:16  T: 10/16/18 12:55:01

Determine the most accurate ICD-10-CM code(s).

260   PART II  |  REPORTING DIAGNOSES

 CHAPTER 9 REVIEW
PRADER, BRACKER, & ASSOCIATES
A Complete Health Care Facility
159 Healthcare Way • SOMEWHERE, FL 32811 • 407-555-6789
PATIENT: FALCONE, ANTONIO
ACCOUNT/EHR #: FALANT001
DATE: 10/16/18
Attending Physician: Renee O. Bracker, MD
Antonio, a 43-year-old male, was referred by his therapist of 3 years, Ms. Benton, for psychiatric evalu-
ation and consideration of medication to treat worsening depression. At the initial interview, Antonio’s
wife, Marie, an attorney, was present to provide some history and perceptions. She was quite coopera-
tive yet strangely detached. She answered all of the questions that I asked in a genuine manner. All
pathological causes of sadness have been ruled out. A complete workup is performed.
It gradually became clear that the source of Antonio’s persistent depression was his wife’s lack of
accountability and responsibility in the marriage. She was frequently late for sessions, with no notice.
Antonio always wanted to be a family man. Marie refuses to work at the marriage, crushing Antonio’s
expectations of a satisfying marriage.
Antonio checked into a hotel 500 miles away from home and threatened suicide 2 days ago. When
Antonio returned, he came directly to my office. This episode was due to his wife’s lack of therapy
participation. Antonio stated he feels like a failure because he can’t make the marriage work. Suicide
seemed to be a viable exit strategy from the pain.
My recommendations were that an environment change was needed to recover from the suicidal ide-
ation. Antonio was experiencing continued depression caused by this environment in which his level of
control over the outcome was minimal. This led to more severe and frequent depression. I advised him
to stay out of the house.
Diagnosis: Major depressive disorder, recurrent, moderate

ROB/pw  D: 10/16/18 09:50:16  T: 10/18/18 12:55:01

Determine the most accurate ICD-10-CM code(s).

WESTON HOSPITAL
629 Healthcare Way • SOMEWHERE, FL 32811 • 407-555-6541
PATIENT: LYNCH, VICTOR
ACCOUNT/EHR #: LYNVIC001
DATE: 10/16/18
Attending Physician: Renee O. Bracker, MD
S: This is a 3-year-old male who is recovering from a mild case of the Flu and suddenly began vomit-
ing. The babysitter may have given him aspirin by accident instead of acetaminophen. Luke’s mother
brought him to the ED for unexplained irritability and restlessness. He later develops convulsions, which
are treated with anticonvulsants. He is admitted to PICU.

CHAPTER 9  | 
CHAPTER 9 REVIEW

O: T: 36.7, P: 102, R 48, BP 115/69, oxygen saturation 99% in room air. Height, weight, and head cir-
cumference are all at the 50th percentile. PERRLA. No signs of external trauma. Sclera nonicteric. EOMs
cannot be fully tested, but they are conjugate. TMs are normal. Neck reveals no adenopathy. He is agi-
tated and uncooperative. Heart regular without murmurs or gallops. Lungs are clear. Abdomen—normal
bowel sounds. No definite tenderness. No inguinal hernias are present. He moves all extremities.
LABS: Serum bilirubin: normal. Serum AST and ALT: increased. Serum ammonia: increased. Prothrombin
time: prolonged. A CT scan of the brain shows cerebral edema. Neurologic symptoms rapidly deterio-
rate and he becomes unresponsive. Patient is intubated and put on mechanical ventilation and IV fluid
is started. A liver biopsy reveals diffuse, small lipid deposits in the hepatocytes (microvesicular steatosis)
without significant necrosis or inflammation.
A: Reye’s syndrome.
P: Continue to follow and treat.

ROB/pw  D: 10/16/18 09:50:16  T: 10/18/18 12:55:01

Determine the most accurate ICD-10-CM code(s).

WESTON HOSPITAL
629 Healthcare Way • SOMEWHERE, FL 32811 • 407-555-6541
PATIENT: YAN, MARANDA
ACCOUNT/EHR #: YANMAR001
DATE: 10/16/18
Attending Physician: Oscar R. Prader, MD
S: This is a 23-year-old female who presents with a chief complaint of clumsiness and blurred vision.
Patient states she had been feeling fine until about 10 days ago when she noticed some numbness and
weakness in her right leg, and suddenly her vision became blurry.
O: VS are normal. She is alert but subdued, afebrile with some ataxia noted. HEENT exam is notable for
severe visual loss and pale optic discs on funduscopy. Her heart, lungs, and abdomen are normal. She
is noted to have a hyporeflexive paraparesis noted on the right.
I decided to admit her to the hospital. An MRI scan shows multiple lesions in the periventricular white
matter and cerebellum. Pattern visual evoked responses showed markedly delayed latencies. Cortico-
steroids are prescribed. Prognosis—a full recovery within 10–14 days.
A: Multiple sclerosis (MS)
P: Continue to follow and treat with traditional medication.

ORP/pw  D: 10/16/18 09:50:16  T: 10/18/18 12:55:01

Determine the most accurate ICD-10-CM code(s).

262   PART II  |  REPORTING DIAGNOSES

Coding Dysfunction of
the Optical and Auditory
Systems
10
Learning Outcomes Key Terms
After completing this chapter, the student should be able to: Accommodation
Blepharitis
LO 10.1 Identify conditions affecting the external eye. Bulbar Conjunctiva
LO 10.2 Interpret the details documented about diseases of the inter- Cataract
nal optical system to report accurate code. Choroid
LO 10.3 Determine the accurate code to report other conditions of Ciliary Body
the eye. Cone
Conjunctivitis
LO 10.4 Abstract documentation accurately to report conditions
Cornea
affecting the auditory system. Corneal Dystrophy
LO 10.5 Enumerate the causes, signs, and symptoms of hearing loss. Dacryocystitis
Extraocular Muscles
Glands of Zeis
Glaucoma
Iris
Remember, you need to follow along in Keratitis
  STOP! your ICD-10-CM code book for an optimal
ICD-10-CM

Lacrimal Apparatus
learning experience. Lens
Meibomian Glands
Moll’s Glands
Orbit
10.1  Diseases of the External Palpebrae
Palpebral Conjunctiva
Optical System Proptosis
The Exterior of the Eye Pupil
Retina
The palpebrae (eyelids) cover the eyeballs to protect them from injury and envi- Retinal Detachment
ronmental invaders as well as to maintain the proper level of moisture. Some peo- Retinopathy
ple think eyelids are made of epidermis, like regular skin; however, they are really Rod
composed of connective tissue. The levator palpebrae muscle superioris (levator = Sclera
lift; palpebrae = eyelids; muscle; superioris = above) is responsible for opening Uveal Tract
and closing the upper eyelid, while the fascia behind the orbicularis oculi muscle Vitreous Chamber
(the orbital septum) creates a barrier between the lids and the orbit. There is a
thin mucous membrane that lines the inside of the eyelid, known as the ­palpebral
Palpebrae
­conjunctiva; this lines the eyelid internally, creasing over at the fornix, and covers The eyelids; singular palpebra.
the surface of the eyeball. At that point, it becomes known as the bulbar ­conjunctiva
(see ­Figure 10-1). Orbit
Within the palpebrae (eyelids), there are three types of glands: The bony cavity in the skull
that houses the eye and
∙ Moll’s glands: ordinary sweat glands. its ancillary parts (muscles,
∙ Meibomian glands: sebaceous glands that secrete a tear film component that pre- nerves, blood vessels).
vents tears from evaporating so that the area stays moist. Palpebral Conjunctiva
∙ Glands of Zeis: altered sebaceous glands that are connected to the eyelash A mucous membrane that
follicles. lines the palpebrae.
 Upper eyelid
Upper lacrimal
punctum Pupil
Superior Limbus
canaliculus Iris
Lacrimal sac
Sclera
Inferior canaliculus
Lower eyelid
Lower lacrimal
punctum
Nasolacrimal duct

FIGURE 10-1  The anatomical components of the external eye

Bulbar Conjunctiva
A mucous membrane on the EXAMPLES
surface of the eyeball. H00.024 Hordeolum internum left upper eyelid
H00.15 Chalazion left lower eyelid
Moll’s Glands
H01.112 Allergic dermatitis of right lower eyelid
Ordinary sweat glands.
H02.031 Senile entropion of right upper eyelid
Meibomian Glands H02.131 Senile ectropion of right upper eyelid
Sebaceous glands that
You may be thinking, “Hey, wait a minute. You just taught us that palpebra is the med-
secrete a tear film compo-
nent that prevents tears from ical term for eyelid. And yet here in the code descriptions, they each state ‘eyelid,’ the
evaporating so that the area English word.” That’s very true. However, the reason you need to learn that the term
stays moist. palpebra means eyelid is because when your physician is writing operative notes or
procedure notes, he or she may use the term palpebra, and if you’re not familiar
Glands of Zeis with that and you don’t know what it means, you won’t know how to code this.
Altered sebaceous glands that
are connected to the eyelash
follicles. Blepharitis
Blepharitis Staphylococcal blepharitis, also known as ulcerative blepharitis, is a condition in
Inflammation of the eyelid. which the rims of the eyelids become inflamed and appear red. Most often, this condi-
tion is chronic and affects bilaterally, as well as simultaneously to the upper and lower
lids. In addition to the redness, dry scales and ulcerations may form. 
Squamous blepharitis is similar, with inflammation of the glands of Zeis. Signs
and symptoms include itching, burning, photophobia, mucous discharge, and a crusty
formation on the eyelids.
As you abstract documentation with a confirmed diagnosis of blepharitis, you will
need to confirm the specific eye involved (right or left) as well as the specific lid
(upper or lower). Code subcategory H01.0- Blepharitis.

ICD-10-CM
YOU CODE IT! CASE STUDY
Rosemary Seaborn, a 25-year-old female, came to see Dr. Spencer, an ophthalmologist, with complaints of itching
and a burning sensation in both of her eyes. She stated her upper eyelids looked like they had “dandruff” with a
crusty appearance, and she noted an increased sensitivity to light. After examinations and testing, Dr. Spencer docu-
mented a confirmed case of bilateral squamous blepharitis on her upper palpebrae.

264   PART II  |  REPORTING DIAGNOSES

 You Code It!
Review the details of this documentation, and determine the accurate code or codes to report Dr. Spencer’s
diagnosis for Rosemary.
Step #1: Read the case carefully and completely.
Step #2: Abstract the scenario. Which main words or terms describe why the physician cared for the patient dur-
ing this encounter? 
Step #3: Are there any details missing or incomplete for which you would need to query the physician? [If so, ask
your instructor.]
Step #4: Check for any relevant guidance, including reading all of the symbols and notations in the Tabular List
and the appropriate sections of the Official Guidelines.
Step #5: Determine the correct diagnosis code or codes to explain why this encounter was medically necessary.
Step #6: Double-check your work.
Answer:
Did you determine these to be the correct codes?
H01.021 Squamous blepharitis right upper eyelid
H01.024 Squamous blepharitis left upper eyelid

Exophthalmic Conditions
Exophthalmos, also known as proptosis, is an abnormal displacement of the eyeball. Proptosis
Most often, ophthalmic Graves’ disease is the underlying condition that results in the Bulging out of the eye; also
eyeball bulging outward while the eyelids retract backward, bilaterally. Trauma, such as known as exophthalmos.
ethmoid bone fracture, may cause a unilateral diagnosis. Edema, hemorrhage, throm-
bosis, or varicosities may also cause exophthalmos, either unilaterally or bilaterally.
As you abstract the documentation, note the difference between the displacement of
CODING BITES
the orbit, or eyeball, and whether or not the exophthalmos is constant, intermittent, or
pulsating so you can determine the accurate code: NOTE: All of these
codes [in the H05 code
H05.21- Displacement (lateral) of globe  category] require a sixth
H05.24- Constant exophthalmos character to specify
H05.25- Intermittent exophthalmos right eye, left eye, or
H05.26- Pulsating exophthalmos bilateral (both eyes)
involved.
Disorders of the Lacrimal Apparatus
The lacrimal glands, the upper canaliculi, the lower canaliculi, the lacrimal sac, and
the nasolacrimal duct are together known as the lacrimal apparatus. Tears are cre- Lacrimal Apparatus
ated in the main lacrimal gland and then flow through several excretory ducts, pass A system in the eye that con-
through the canaliculi and the lacrimal sac, and continue down the nasolacrimal duct sists of the lacrimal glands,
into the nasal cavity—the nose. This is why when you cry, your nose runs. the upper canaliculi, the lower
Signs and symptoms of an obstructed lacrimal apparatus include recurring conjunc- canaliculi, the lacrimal sac,
and the nasolacrimal duct
tivitis (pink eye), discharge of pus or mucus from the eyelids and/or the conjunctiva,
blurred vision, and excessive tearing.
Congenital nasolacrimal duct anomalies: A neonate may be born with a duct
abnormality, an obstruction, or a lacrimal apparatus that is not fully developed. This is
reported with one of these codes: 
Q10.4 Absence and agenesis of lacrimal apparatus 
or

CHAPTER 10  | 
 Q10.5 Congenital stenosis and stricture of lacrimal duct
or
Q10.6 Other congenital malformations of lacrimal apparatus
Neonatal lacrimal duct (passages) obstruction: An infant born with a healthy lac-
rimal apparatus may still develop an obstruction of the nasolacrimal duct. As you are
abstracting the documentation, confirm that this condition is acquired and not con-
genital so you can determine the accurate code:
H04.531 Neonatal obstruction of right nasolacrimal duct
or
H04.532 Neonatal obstruction of left nasolacrimal duct
or
H04.533 Neonatal obstruction of bilateral nasolacrimal ducts
Dacryops, also known as lacrimal gland cyst or lacrimal duct cyst, is reported with
one of these codes: 
H04.111 Dacryops of right lacrimal gland
or
H04.112 Dacryops of left lacrimal gland
or
H04.113 Dacryops of bilateral lacrimal glands

Dacryocystitis
Dacryocystitis Dacryocystitis is lacrimal gland inflammation (dacry/o = lacrimal sac or duct + cyst =
Lacrimal gland inflammation. sac + itis = inflammation). This may be a manifestation of a nasolacrimal duct obstruc-
tion and can be acute and/or chronic. Research shows that Staphylococcus aureus—
or, on occasion, beta-hemolytic streptococci—is the pathogen responsible for acute
dacryocystitis inflammation, whereas the chronic condition is more often caused by
Streptococcus pneumoniae or, on occasion, a fungal infection such as Actinomyces or
Candida albicans.
Signs and symptoms include pain, redness, and swelling over the inner aspect of the
lower eyelid and epiphora. As you are abstracting the documentation, confirm whether
the patient is a neonate or not, so you can determine the accurate code:
H04.321 Acute dacryocystitis of right lacrimal passage
or
H04.322 Acute dacryocystitis of left lacrimal passage
or
H04.323 Acute dacryocystitis of bilateral lacrimal passages
or
P39.1 Neonatal conjunctivitis and dacryocystitis 

ICD-10-CM
YOU CODE IT! CASE STUDY
Raven Mercado, a 27-year-old female, came in to see Dr. Garner complaining of swelling, pain, and redness on her
left eyelid. She was pretty certain it was a stye, but it was so painful, she had to ask for help. Dr. Garner examined her
and confirmed a diagnosis of hordeolum externum of the left lower eyelid (commonly known as a stye).

266   PART II  |  REPORTING DIAGNOSES

 You Code It!
Go through the steps of coding, and determine the code or codes that should be reported for this encounter
between Dr. Garner and Raven.
Step #1: Read the case carefully and completely.
Step #2: Abstract the scenario. Which main words or terms describe why the physician cared for the patient dur-
ing this encounter? 
Step #3: Are there any details missing or incomplete for which you would need to query the physician? [If so, ask
your instructor.]
Step #4: Check for any relevant guidance, including reading all of the symbols and notations in the Tabular List
and the appropriate sections of the Official Guidelines.
Step #5: Determine the correct diagnosis code or codes to explain why this encounter was medically necessary.
Step #6: Double-check your work.
Answer:
Did you determine this to be the correct code?
H00.015 Hordeolum externum left lower eyelid

10.2  Diseases of the Internal Optical System

Interior of the Eye
The organ that is commonly referred to as the eye (see Figure 10-2) consists of the eye-
ball, the optic nerves, the extraocular muscles, the cranial nerves, the blood vessels, Extraocular Muscles
orbital adipose (fat), and the lacrimal system. The muscles that control the
eye.
Disorders of the Conjunctiva
Conjunctivitis, commonly known as pink eye, actually refers to an inflammation of Conjunctivitis
the conjunctiva of the eye. The most common signs and symptoms include swelling, Inflammation of the
itching, burning, and redness of the conjunctiva as well as the palpebral conjunctiva conjunctiva.
(lining of the eyelids).
A pathogen (bacterium or virus), allergic reactions, environmental irritants, a
contact lens product, eyedrops, or eye ointments may all be an underlying cause of
conjunctivitis. This condition is highly contagious (easily spread from one person to
another). Viral conjunctivitis is reported from the infectious disease chapter of ICD-
10-CM. You will need to check the pathology report to determine an accurate code:
B00.53 Herpesviral conjunctivitis 
B30.1 Conjunctivitis due to adenovirus
B30.3 Acute epidemic hemorrhagic conjunctivitis (enteroviral)
Conjunctivitis due to coxsackievirus 24
Conjunctivitis due to enterovirus 70
Hemorrhagic conjunctivitis (acute) (epidemic)
B30.8 Other viral conjunctivitis
Newcastle conjunctivitis
Mucopurulent conjunctivitis is evident by mucus and pus produced by the inflam-
mation, whereas atopic conjunctivitis is most often caused by allergies. Yet, be careful:

CHAPTER 10  | 
 Ora serrata
Ciliary muscle
Hyaloid canal Ciliary body
Ciliary process
Lacrimal sac
Central retinal
artery and vein

Limbus
Scleral venous sinus
CN II (optic) (canal of Schlemm)
Suspensory ligament
Lens
Iris
Cornea
Optic disc (blind spot)
Pupil
Fovea centralis

Vitreous chamber (posterior cavity)

Retina Anterior chamber

Anterior cavity
Posterior chamber
Choroid
Sclera

FIGURE 10-2  The anatomical components of the orbital septum (view from the right side)

Vernal conjunctivitis is the result of an allergic reaction to seasonal allergens, such as

pollen or mold. Abstract the specific details about the conjunctivitis, as well as the
laterality for the eye involved (right, left, or bilateral), from the documentation.
H10.01- Acute follicular conjunctivitis
H10.02- Other mucopurulent conjunctivitis
H10.1- Acute atopic conjunctivitis
Acute papillary conjunctivitis
H10.21- Acute toxic conjunctivitis
H10.22- Pseudomembranous conjunctivitis
H10.23- Serous conjunctivitis, except viral
NOTE: All of the codes in code category H10 Conjunctivitis require a fifth or sixth
character to report laterality.

Sclera Disorders of the Sclera, Cornea, Iris, and Ciliary Body

The membranous tissue
that covers all of the eyeball The portion of the sclera at the medial anterior aspect (the middle of the front) of the
(except the cornea); also eyeball is called the cornea. It is a curved, multilayer, transparent, and avascular (no
known as the white of the eye. blood vessels) segment of this structure (see Figure 10-3). The cornea’s only function
Cornea within the eye is to refract light rays. There are five layers that make up the cornea:
Transparent tissue covering ∙ Epithelium: the location of sensory nerves.
the eyeball; responsible for
focusing light into the eye and ∙ Bowman’s membrane: the location of epithelial cells.
transmitting light. ∙ Stroma: the supporting tissue that makes up 90% of the corneal structure.

268   PART II  |  REPORTING DIAGNOSES

 Limbus
Scleral venous sinus
(canal of Schlemm)
Suspensory ligament
Lens
Iris
Cornea

Pupil

Anterior chamber
Anterior cavity
Posterior chamber

FIGURE 10-3  An illustration showing the sclera, iris, and cornea

∙ Descemet’s membrane: elastic fibers.

∙ Endothelium: cells that help to maintain proper hydration of the cornea to keep it
moist.
The posterior (back) surface of the cornea is coated in an aqueous humor that keeps
intraocular pressure at a consistent volume and rate of outflow.
Keratitis, an inflammation and ulceration of the cornea, may be instigated by any Keratitis
type of pathogen: bacterium, virus, or fungus. You will need to abstract two additional An inflammation of the
details from the documentation: the location of the ulcer on the cornea, as well as the ­cornea, typically accompanied
laterality affected (right, left, bilateral). by an ulceration.

H16.11- Macular keratitis

H16.12- Filamentary keratitis
H16.13- Photokeratitis
H16.14- Punctate keratitis
NOTE: All of the codes in code subcategory H16.1 Other and unspecified superficial
keratitis without conjunctivitis require a fifth or sixth character to report laterality.
When reporting a corneal ulcer, you will need to abstract two additional details
from the documentation: the location of the ulcer on the cornea, as well as the lateral-
ity affected (right, left, bilateral). CODING BITES
H16.01- Central corneal ulcer Hypopyon is an inflam-
H16.02- Ring corneal ulcer mation in the anterior
H16.03- Corneal ulcer with hypopyon chamber of the eye.
H16.04- Marginal corneal ulcer Mooren’s ulcer is also
H16.05- Mooren’s corneal ulcer known as peripheral
H16.06- Mycotic corneal ulcer ulcerative keratitis.
H16.07- Perforated corneal ulcer Mycotic corneal ulcer
is also known as fungal
NOTE: All of the codes in code subcategory H16.0 Corneal ulcer require a fifth or ulcerative keratitis.
sixth character to report laterality.

CHAPTER 10  | 
 When caused by herpes simplex virus, type 1, the diagnosis is dendritic corneal
ulcer (herpesviral keratitis). Typically it is a unilateral condition, and initial signs and
symptoms include reduced visual clarity, tearing, photophobia, and varying levels of
pain (anywhere from mild discomfort to acute pain). As you can see, there are several
different viruses that cause keratitis. You should find this detail in the documentation
and the pathology report.
B00.52 Herpesviral keratitis
B01.81 Varicella keratitis
B02.33 Zoster keratitis
Corneal Dystrophy Corneal dystrophy occurs when one or more parts of the cornea develop an accu-
Growth of abnormal tissue on mulation of cloudy material, resulting in the loss of normal clarity. There are over
the cornea, often related to a 20 varieties of corneal dystrophies, all of which share several characteristics:
nutritional deficiency.
∙ Genetic (inherited)
∙ Bilateral
∙ Not the result of external causes, such as injury or diet
∙ Develop gradually
∙ Onset limited to a single layer of the cornea, with the disorder spreading later to the
others
Some of the most common corneal dystrophies include Fuchs’ dystrophy (endothe-
lial corneal dystrophy), keratoconus, lattice dystrophy, and map-dot-fingerprint (epi-
thelial corneal) dystrophy.
H18.51 Endothelial corneal dystrophy
Fuchs’ dystrophy
H18.52 Epithelial ( juvenile) corneal dystrophy
H18.53 Granular corneal dystrophy
H18.54 Lattice corneal dystrophy
H18.55 Macular corneal dystrophy

ICD-10-CM
LET’S CODE IT! SCENARIO
Jessica Harvey, a 41-year-old female, came in to see Dr. Loughlin with complaints of pain in her left eye upon blink-
ing, photophobia, and increased tearing. She has also noticed some blurring. She states she hasn’t been able to put
her contact lenses in for several days. Dr. Loughlin examined Jessica and dropped fluorescein dye into the conjuncti-
val sac, which stained the outline of the ulcer, the entire outer rim of the cornea. Dr. Loughlin diagnosed Jessica with
a ring corneal ulcer of the left eye.

Let’s Code It!

Dr. Loughlin diagnosed Jessica with a ring corneal ulcer of the left eye. In the Alphabetic Index, let’s look at the
main term—ulcer:
Ulcer, ulcerated, ulcerating, ulceration, ulcerative
Find the term cornea in the long list below. Then, in the list indented beneath cornea, determine the most accu-
rate match to Dr. Loughlin’s notes:
Ulcer, ulcerated, ulcerating, ulceration, ulcerative
- Cornea H16.00-
-- Ring H16.02-

270   PART II  |  REPORTING DIAGNOSES

 Now to the Tabular List—let’s check out the top of the code category:
H16 Keratitis
Are you in the wrong place? Remember that earlier, when you learned about keratitis, you learned it is an inflam-
mation and ulceration of the cornea. Double-check, though, to be certain. Do you see a confirmation that you
are in the correct location?
H16.0 Corneal ulcer

Whew! Now review the options for the fifth and sixth characters to see if you can determine an accurate
code:
H16.022 Ring corneal ulcer, left eye
That matches perfectly!
Check the top of this subsection and the head of this chapter in ICD-10-CM. There are notations at the begin-
ning of this chapter: a NOTE and an notation. Read carefully. Do any relate to Dr. Loughlin’s diagnosis
of Jessica? No. Turn to the Official Guidelines and read Section 1.c.7. There is nothing specifically applicable
here either.
Now you can report H16.022 for Jessica’s diagnosis with confidence.
Good coding!

Disorders of the Lens

The lens of the eye is located at the anterior of the vitreous chamber (see Lens
­Figure  10-3). The lens is a semipermeable membrane that is transparent, avascu- A transparent, crystalline
lar (contains no blood vessels), and biconvex. The lens goes through what’s called segment of the eye, situated
accommodation, which is the process of changing shape to accomplish seeing directly behind the pupil, that
objects both near and far. To view objects that are close (near vision), the lens is responsible for focusing
light rays as they enter the
reshapes to a spherical body, the pupil contracts, and the eyes converge (come
eye and travel back to the
toward the middle). When looking at something at a distance (far vision), the lens retina.
flattens out, the eyes straighten, and the pupils dilate (open wider). As individuals
get older, the lens gets tired of accommodating and is not as flexible as it used to Vitreous Chamber
be. This makes it more likely the lens may get stuck in the near-vision shape, mean- The interior segment of the
ing the individual is nearsighted and may need corrective lenses (eyeglasses or eye that contains the vitreous
contact lenses) to enable him or her to see far away. When somebody is farsighted, body.
the lens gets stuck in the flattened position and the individual will need corrective Accommodation
lenses to see close up. Adaptation of the eye’s lens
A cataract is the gradual opacity (clouding) of the lens or lens capsule of the to adjust for varying focal
eye, which causes a reduction of vision. Many individuals perceive this to be a distances.
condition of the elderly; however, cataracts can occur at any age, including being Pupil
present at birth. Patients with diabetes mellitus are especially prone to developing The opening in the center of
cataracts. Complicated cataracts are most often an idiopathic condition, caused by the iris that permits light to
a preexisting condition such as diabetes mellitus or hypoparathyroidism. However, enter and continue on to the
this condition can also be caused by trauma, especially after a foreign body has lens and retina.
injured the lens.
Cataract
Ophthalmoscopy examination, or a slit-lamp exam, can be used to confirm the pres-
Clouding of the lens or lens
ence of a cataract by enabling the observation of a dark area in the normally consistent capsule of the eye.
red reflex of the lens. 
H25.11 Age-related nuclear cataract, right eye
H26.012 Infantile and juvenile cortical, lamellar, or zonular cataract, left eye
Q12.0 Congenital cataract

CHAPTER 10  | 
 ICD-10-CM
YOU CODE IT! CASE STUDY
Nicholas McCord, a 45-year-old male, was tightening the rope holding a load on the bed of his pickup truck
when the rope broke suddenly. His fist, clenching the rope, snapped backward, hitting him in the right eye. The
pain was difficult for him to deal with, so his friends brought him to the emergency department. After examina-
tion, Dr. Espinal diagnosed Nicholas with an anterior dislocation of his right eye lens. He was taken up to the
procedure room.

You Code It!

Go through the steps of coding, and determine the code or codes that should be reported for this encounter
between Dr. Espinal and Nicholas.
Step #1: Read the case carefully and completely.
Step #2: Abstract the scenario. Which main words or terms describe why the physician cared for the patient dur-
ing this encounter?
Step #3: Are there any details missing or incomplete for which you would need to query the physician? [If so, ask
your instructor.]
Step #4: Check for any relevant guidance, including reading all of the symbols and notations in the Tabular List
and the appropriate sections of the Official Guidelines.
Step #5: Determine the correct diagnosis code or codes to explain why this encounter was medically necessary.
Step #6: Double-check your work.
Answer:
Did you determine this to be the correct code?
H27.121 Anterior dislocation of lens, right eye

Uveal Tract Disorders of the Choroid and Retina

The middle layer of the eye,
consisting of the iris, ciliary The Uveal Tract
body, and choroid. The uveal tract is the middle layer of the eye; it has three sections: the iris (in the
Iris
anterior), followed by the ciliary body, and the choroid in the posterior. Together, the
The round, pigmented muscu- parts of the uvea improve the contrast of the image created by the retina. The uvea
lar curtain in the eye. accomplishes this by reducing the light reflected within the eye while absorbing out-
side light as it is transmitted. The uvea is also responsible for providing nutrition to the
Ciliary Body eye structure and exchanging gases (see Figure 10-4).
The vascular layer of the eye
that lies between the sclera
and the crystalline lens. The Retina
Choroid The retina, the area of the eye that contains nerve endings, is responsible for
The vascular layer of the eye receiving visual images and forwarding these images to the brain for analysis (see
that lies between the retina ­Figure 10-4). The choroid is lightly attached to the retinal pigment epithelium (RPE)
and the sclera. and is adjacent to the rods and cones that function as light receptors. The rods are
Retina located throughout the retina and are responsible for detecting movement so that you
A membrane in the back of can see when something in front of you is moving. There are three types of cones
the eye that is sensitive to that, together, provide designation for up to 150 shades of color: one type of cone
light and functions as the sen- reacts to red light, one to blue-violet light, and the third to green light. Isn’t it amaz-
sory end of the optic nerve. ing that you can go into a paint store and see 500 different colors, yet the eye can

272   PART II  |  REPORTING DIAGNOSES

 Fibrous tunic
Sclera
Cornea

Vascular tunic
Iris
Ciliary body
Choroid

Neural tunic
Retina

FIGURE 10-4  The anatomical components of the interior of the eye 

really only interpret up to 150? The eye combines the light wavelengths to enable rod
perception of a multitude of colors. An elongated, cylindrical cell
Retinal detachment is the separation of the outer RPE from the neural retina, cre- within the retina that is photo-
ating a space immediately beneath the retina. This subretinal space then fills with fluid sensitive in low light.
(liquid vitreous) and obstructs the flow of choroidal blood (which supplies oxygen and Cone
nutrients to the retina). Signs and symptoms include floaters (floating black spots) as A receptor in the retina that is
well as photopsia (recurring flashes of light).  responsible for light and color.
H33.012 Retinal detachment with single break, left eye Retinal Detachment
H33.021 Retinal detachment with multiple breaks, right eye A break in the connection
H33.21 Serous retinal detachment, right eye between the retinal pigment
epithelium layer and the neu-
ral retina.

10.3  Other Conditions Affecting the Eyes Glaucoma

The condition that results
when poor draining of fluid
Glaucoma causes an abnormal increase
Glaucoma is a malfunction of the fluid pressure within the eye; the pressure rises to in pressure within the eye,
a level that can cause damage to the optic disc and nerve. Glaucoma is essentially cat- damaging the optic nerve.
egorized as either open angle or closed angle:
GUIDANCE
∙ Open angle: a slowly developing, chronic condition that typically has no signs or
symptoms until very advanced. CONNECTION
∙ Closed angle: a painful condition with a sudden onset and rapidly progressing Read the ICD-10-CM
vision loss. Official Guidelines for
Coding and Report-
In addition to abstracting the documented diagnosis of glaucoma, you will need
ing, section I. Con-
to confirm the current stage of development of this condition to accurately report the
ventions, General
seventh character: 
Coding Guidelines
∙ mild stage (evidence of changes in the aqueous outflow system of the eye) and ­Chapter Specific
∙ moderate stage (elevated intraocular pressure) Guidelines, subsec-
tion C. ­Chapter-Specific
∙ severe stage (atrophy of the optic nerve and loss of the visual field) 
Coding Guidelines,
∙ indeterminate stage  (for unusual circumstances, when the physician documented ­chapter 7. Diseases
being unable to determine the stage; this is not the same as unspecified)  of the Eye and
Adnexa, subsection
H40.1113 Primary open-angle glaucoma, right eye, severe stage a. Glaucoma.
H40.2221 Chronic angle-closure glaucoma, left eye, mild stage

CHAPTER 10  | 
 ICD-10-CM
YOU CODE IT! CASE STUDY
PATIENT NAME: Peter Calvern
DATE OF OPERATION: 10/05/2018
PREOPERATIVE DIAGNOSIS: Narrow-angle glaucoma, right eye.
POSTOPERATIVE DIAGNOSIS: Narrow-angle glaucoma, right eye.
OPERATION PERFORMED: Laser iridotomy, right eye.
SURGEON: JoAnn Hannigan, MD
ANESTHESIA: Topical proparacaine.
INDICATIONS FOR PROCEDURE: The patient is a 67-year-old male with a history of narrow-angle glaucoma, at high
risk for blindness or angle-closure glaucoma, diagnosed on physical examination by gonioscopy. Risks, benefits, and
alternatives of laser iridotomy were discussed with the patient preoperatively. The patient agreed and signed appro-
priate consent preoperatively.
DESCRIPTION OF PROCEDURE: On the day of the procedure, the right eye was identified as the operative eye.
The patient received 3 sets q. 5 minutes of the following drops: proparacaine, pilocarpine, and Iopidine. Appropri-
ate constriction and anesthesia were achieved. The patient was then brought back to the laser suite, where first
the argon laser was used to pretreat the iris superiorly in an area that was covered by the lid with the following set-
tings: 800 milliwatts, 0.06 second duration and 50 micron spot size. Then, the YAG laser was used to complete the
iridotomy with the following settings: 5 millijoules, 2 pulses and a total of 2 pulses applied. Good flow of aqueous
was noted from the posterior chamber to the anterior chamber and a patent iridotomy was obtained. The patient
was given the following postoperative instructions: No bending, coughing, lifting, straining, or sneezing. Return to
the clinic for further followup care, and the patient is to use prednisolone acetate 1 drop, left eye, 4 times a day
for 1 week.

You Code It!

Review this documentation about the procedure that Dr. Hannigan performed on Peter, and determine the cor-
rect code or codes to report the reason why this procedure was medically necessary.
Step #1: Read the case carefully and completely.
Step #2: Abstract the scenario. Which main words or terms describe why the physician cared for the patient dur-
ing this encounter? 
Step #3: Are there any details missing or incomplete for which you would need to query the physician? [If so, ask
your instructor.]
Step #4: Check for any relevant guidance, including reading all of the symbols and notations in the Tabular List
and the appropriate sections of the Official Guidelines.
Step #5: Determine the correct diagnosis code or codes to explain why this encounter was medically necessary.
Step #6: Double-check your work.
Answer:
Did you determine this to be the correct code?
H40.031 Anatomical narrow angle, right eye

Good work!

274   PART II  |  REPORTING DIAGNOSES

Diabetic Retinopathy
Patients diagnosed with diabetes mellitus are at risk for ophthalmic manifestations of
their improper glucose levels. Diabetic retinopathy is the most common; it is a condi- Retinopathy
tion that causes damage to the tiny blood vessels inside the retina (retina + -pathy = Degenerative condition of the
disease). Signs and symptoms include retina.

∙ Blurry or double vision.

∙ Rings around lights.
∙ Flashing lights.
∙ Blank spots.
∙ Dark or floating spots (commonly known as floaters).
∙ Pain in one or both eyes.
∙ Sensation of pressure in one or both eyes.
∙ Difficulty in seeing things peripherally (out of the corners of the eyes).
∙ Macular edema, which occurs when fluid and protein deposits collect on or beneath
the macula (a central area of the retina), resulting in swelling (edema). The swelling
then causes the macula to thicken, distorting the person’s central vision.
Diabetic retinopathy progresses through four stages of development:
1. Mild nonproliferative retinopathy (microaneurysms).
2. Moderate nonproliferative retinopathy (blockage in some retinal vessels).
3. Severe nonproliferative retinopathy (more vessels are blocked, depriving the retina
of blood supply).
4. Proliferative retinopathy (most advanced stage).
When diagnosis and treatment are implemented in the early stages, vision loss can
be reduced. Therefore, individuals with diabetes mellitus are encouraged to get regu-
lar eye exams. Diabetic retinopathy is one of the leading causes of blindness in U.S.
adults, affecting more than 4 million Americans.

EXAMPLES
E10.321 Type 1 diabetes mellitus with mild nonproliferative diabetic retinop-
athy with macular edema
E11.36 Type 2 diabetes mellitus with diabetic cataract
Remember, whenever a combination code is available that includes the underlying GUIDANCE
condition and the manifestation in one code, you must use this to report the diag-
nosis. If no combination code is accurate, then you will probably need to report
CONNECTION
multiple codes to provide the whole picture. Read the ICD-10-CM
Official Guidelines for
Coding and Report-
Hypertensive Retinopathy ing, section I. Conven-
tions, General Coding
Patients with hypertension (high blood pressure) can develop damage to the retina
Guidelines and ­Chapter
because of the unusually high pressure of the blood traveling through the vessels.
Specific ­Guidelines,
This condition is known as hypertensive retinopathy. The higher the pressure and the
­subsection C.
longer this condition has been ongoing, the more severely the retina may be harmed.
­Chapter-Specific
Signs and symptoms most evident for those with hypertensive retinopathy include
Coding Guidelines,
∙ Double vision ­chapter 9. Diseases of
∙ Dimmed vision the ­Circulatory System,
subsection a. 5) Hyper-
∙ Blindness (vision loss)
tensive retinopathy.
∙ Headaches

CHAPTER 10  | 
 EXAMPLES
H35.031 Hypertensive retinopathy, right eye
H35.032 Hypertensive retinopathy, left eye
Did you notice that, with diabetic retinopathy, the combination codes are available
to you in the subsection for the underlying condition, diabetes mellitus? However,
with hypertensive retinopathy, these combination codes are with the ophthalmic
codes—the manifestation. You always need to read carefully and completely.

ICD-10-CM
LET’S CODE IT! SCENARIO
PATIENT’S NAME: Arlene Masconetti
MRN: ALMAS0122
DATE OF PROCEDURE: 07/22/2018
PRE/POSTOPERATIVE DIAGNOSIS: Cataract, traumatic and mature, right eye.
PROCEDURE PERFORMED: Phacoemulsification and implantation of intraocular lens, right eye.
SURGEON: Jason Britemann, MD
ANESTHESIA: MAC with retrobulbar
PREPROCEDURE: Patient is a 37-year-old female who had been playing softball with co-workers and got hit by a ball
in the right eye, causing a total traumatic cataract. She tried to ignore the discomfort, but it was interfering with her
doing her work, and she was afraid to drive. Patient was given the complete information on this procedure, possible
outcomes, and projected outcomes, and she signed consent. Prior to bringing the patient to the operating room, the
patient received three sets of topical dilating, antibiotic drops.
DESCRIPTION OF OPERATION: The patient was brought to the procedure room and placed in a supine position on
the operating table, and was prepped and draped in a sterile manner. She was sedated and retrobulbar injection of
0.75% Marcaine and 1% lidocaine was made. No complications were evident. A lid speculum was inserted to part
the eyelid. A paracentesis was made infratemporally. The anterior chamber was filled with air and then indocyanine
green to stain the anterior capsule. The cataract was noted to be extremely mature. A small capsulorrhexis was initi-
ated. Immediately, milky white fluid extruded from the capsulorrhexis opening. A 27-gauge cannula was then used
to aspirate this fluid. The cystotome was then used to complete the capsulorrhexis. The nucleus was gently rocked
to facilitate mobility. The phacoemulsification apparatus was introduced into the eye. The nucleus was phacoemulsi-
fied and removed without any complications. The remaining cortex was removed with irrigation and aspiration. An
SA60 AC 21-diopter lens was placed in the bag and the remaining viscoelastic was removed. One interrupted 10-0
nylon suture was placed in the cornea. The patient tolerated the procedure well. The lid speculum was removed.
One drop of Betadine, one drop of Ciloxan, and bacitracin ointment were placed into the eye and patch and shield
were applied. The patient was returned to postanesthesia care in satisfactory condition. The patient was instructed to
take the eye patch off at 6 p.m. and use the topical Vigamox and Pred Forte eye drops every 2 hours until bedtime.

Let’s Code It!

Dr. Britemann performed cataract surgery on Arlene to treat her traumatic and mature cataract of her right eye.
Open your ICD-10-CM code book to the Alphabetic Index and find
Cataract (cortical) (immature) (incipient) H26.9
Hmm. The first thing you might notice is that this included a nonessential modifier of “immature,” and Dr.
Britemann documented that Arlene’s cataract is mature. What is the difference? This is why it is always such
a great idea to have a medical dictionary nearby. A mature cataract is one that produces swelling and opac-
ity of the entire lens. In this case, mature is not the same as senile (an age-related cataract). As you look down
the indented list, notice there is no specific listing for Cataract, mature. However, keep reading and you will find:

276   PART II  |  REPORTING DIAGNOSES

 Cataract (cortical) (immature) (incipient) H26.9
  traumatic H26.10-
Let’s take a look at this code and see what additional information the Tabular List might offer. You can always
come back here to the Alphabetic Index.
H26 Other cataract
     congenital cataract (Q12.0)
Before you review the fourth character options, scan this entire subsection, code categories H25, H26, H27, and
H28. Do you see any description that suits Dr. Britemann’s diagnosis of Arlene? Neither do I, so continue investi-
gating the options available within H26.
H26.1 Traumatic cataract
   Use additional code (Chapter 20) to identify external cause
The required fifth character will explain if the trauma was localized, partially resolved, or total. Go back to the
documentation and determine which is the accurate character:
H26.13 Total traumatic cataract
You are making good progress. The sixth character will report which eye, or both eyes, are injured.
H26.131 Total traumatic cataract, right eye
Check the top of this subsection and the head of this chapter in ICD-10-CM. A NOTE and an nota-
tion are at the head of this chapter. Read carefully. Do any relate to Dr. Britemann’s diagnosis of Arlene?
No.  Turn to the Official Guidelines and read Section 1.c.7. There is nothing specifically applicable here,
either.
Now you can report H26.131 for Arlene’s diagnosis with confidence.
H26.131 Total traumatic cataract, right eye
Wait one minute. You are not done yet. Remember the Use Additional Code notation? External cause codes are
required. Turn to the Index to External Causes. Arlene was hit, or struck, by a ball. So, find
Struck (accidentally) by
   ball (hit) (thrown) W21.00-
    softball W21.07-
Now, turn in the Tabular List, to find:
W21 Striking against or struck by sports equipment
  assault with sports equipment (Y08.0-)
                  striking against or struck by sports equipment with subsequent fall (W18.01)
W21.0 Struck by hit or thrown ball
  W21.07   Struck by softball
You will learn more about external cause codes in this book’s chapter Coding Injury, Poisoning, and External
Causes.
H26.131 Total traumatic cataract, right eye
W21.07 Struck by softball
Y93.64 Activity, baseball (activity, softball)
Y99.8 Other external cause status
Good coding!

CHAPTER 10  | 
 10.4  Dysfunctions of the Auditory System
Auditory Diseases
Otitis media is the inflammation of the middle ear. There are various types of this
condition: suppurative and nonsuppurative, acute and chronic. While otitis media
is common in children, it is not exclusively a childhood condition. Interestingly, the
cases of this diagnosis increase during the winter, while there is an increase of otitis
externa (inflammation of the external ear) in the summer. ICD-10-CM code category
H66.- Suppurative and unspecified otitis media requires additional characters to report
details including acute or chronic, suppurative or nonsuppurative, and with or without
rupture of the eardrum, as well as laterality.
Endolymphatic hydrops (Ménière’s disease) is a dysfunction of the labyrinth (semicir-
cular canals). Signs and symptoms include vertigo, sensorineural hearing loss, and tinnitus.
A feeling of fullness within the ear is not uncommon. Report this diagnosis with ICD-
10-CM code H81.0- Ménière’s disease, with an additional character to identify laterality.

ICD-10-CM
LET’S CODE IT! SCENARIO
Kaitlyn Logan, a 27-year-old female, was at a club and met a guy doing ear piercings. She got a piercing through
the cartilage of her upper left ear. Now, 3 days later, her ear is erythematous (red), swollen, and painful to the touch.
Dr. Sweeting examined her ear and diagnosed her with acute perichondritis of the left pinna. He prescribed fluoro-
quinoline with a semisynthetic penicillin and told her to come back in 2 weeks.

Let’s Code It!

Dr. Sweeting diagnosed Kaitlyn with acute perichondritis of the left pinna. Let’s turn in the Alphabetic Index
to find
Perichondritis
Read down the indented list, and you will see that pinna is listed:
Perichondritis
  Pinna — see Perichondritis, ear
However, this is giving us a directive, not a code, to look back up the list to
Perichondritis
  Ear (external) H61.00
   Acute H61.01-
   Chronic H61.02-
OK, now we have a suggested code to get us started. Turn to the three-digit code category suggested here:
H61 Other disorders of external ear
You remember from earlier in this chapter that the pinna is a part of the external ear, so this may be the correct
code category. Go ahead and review the fourth and fifth characters available and see if any match Dr. Sweeting’s
diagnosis.
H61.0 Chondritis and perichondritis of external ear
H61.01 Acute perichondritis of external ear
That is great. Now review the choices for the sixth character, and determine the complete code to report for Dr.
Sweeting’s encounter with Kaitlyn.
H61.012 Acute perichondritis of left external ear
Good job!

278   PART II  |  REPORTING DIAGNOSES

 Otosclerosis is a condition of increasing growth of spongy bone in the otic capsule.
This growth interferes with the travel of sound vibrations from the tympanic mem-
brane to the cochlea, causing a progressive deterioration of hearing. This condition is
seen most frequently in adults between the ages of 18 and 35, and it is more prevalent
in females. Report this condition with ICD-10-CM code category H80.- Otosclerosis,
with additional characters to identify the specific location within the ear as well as
laterality. 

ICD-10-CM
LET’S CODE IT! SCENARIO
Alexis Acosta, a 33-year-old female, was having a terrible time with dizziness. She states that she has also had
a problem keeping her balance. A complete examination by Dr. McQuaig confirmed a diagnosis of bilateral aural
vertigo.

Let’s Code It!

Dr. McQuaig confirmed a diagnosis of bilateral aural vertigo. Turn to the Alphabetic Index and find
Vertigo R42
Wait. Before you turn to the Tabular List, review the additional terms shown in the indented list.
Vertigo R42
  Aural H81.31-
This matches the diagnosis documented by Dr. McQuaig much closer, doesn’t it? Let’s check this out in the Tabu-
lar List, of course, beginning at the code category:
H81 Disorders of vestibular function
Directly below this is an notation. Does either of these diagnoses relate to Dr. McQuaig’s notes about
Alexis? No. Good. Continue reading to review the available choices for the fourth and fifth characters. Did you
find this?
H81.31 Aural vertigo
Perfect! Just one more thing: Take a look at Dr. McQuaig’s documentation and determine which ear or ears are
affected. Now you can report with confidence that Alexis’s diagnosis is
H81.313 Aural vertigo, bilateral
Good work!

Tumors of the ear canal include osteomas and sebaceous cysts and can grow large
enough to interfere with hearing. Should the growth become infected, the patient may
develop a fever and other signs of inflammation, including pain. While these tumors
rarely become malignant, pain might indicate a malignancy. Examination with an oto-
scope can typically confirm this diagnosis, although a biopsy would be required to
confirm benign or malignant status.

EXAMPLES
C30.1 Malignant neoplasm of middle ear (malignant neoplasm of inner ear)
C44.212 Basal cell carcinoma of skin of right ear and external auricular canal
D14.0 Benign neoplasm of middle ear, nasal cavity and accessory sinuses
D23.22 Other benign neoplasm of skin of left ear and external auricular canal

CHAPTER 10  | 
 Labyrinthitis  is an infection within the inner ear’s labyrinth. The most evident
symptom is incapacitating vertigo that may last as long as 5 days. Sensorineural hear-
ing loss may also occur. Viral labyrinthitis can be a manifestation of some upper respi-
ratory tract infections, or caused by trauma or toxic drug ingestion. In some cases,
cholesteatoma may form on the bone of the labyrinth and erode it. Labyrinthitis may
be described as circumscribed, destructive, diffused, latent, purulent, or suppurative.
Report H83.0- Labyrinthitis with an additional character to identify laterality.

ICD-10-CM
YOU CODE IT! CASE STUDY
Rebekka Keith, a 9-year-old female, was brought to her pediatrician, Dr. Granberry, because her right ear was very
painful and inflamed, and there was presence of both blood and fluid in her ear canal. She had suffered with the Flu
(upper respiratory infection), which had resolved last week. Physical examination revealed blebs and evidence that
one or two had ruptured spontaneously causing the presence of fluid and blood. Culture identified the pathogen as
Haemophilus influenzae. Dr. Granberry diagnosed Rebekka with acute infectious bullous myringitis of the right ear
and prescribed antibiotic ear drops.

You Code It!

Go through the steps of coding, and determine the diagnosis code or codes that should be reported for this
encounter between Dr. Granberry and Rebekka.
Step #1: Read the case carefully and completely.
Step #2: Abstract the scenario. Which main words or terms describe why the physician cared for the patient dur-
ing this encounter? 
Step #3: Are there any details missing or incomplete for which you would need to query the physician? [If so, ask
your instructor.]
Step #4: Check for any relevant guidance, including reading all of the symbols and notations in the Tabular List
and the appropriate sections of the Official Guidelines.
Step #5: Determine the correct diagnosis code or codes to explain why this encounter was medically necessary.
Step #6: Double-check your work.
Answer:
Did you determine these to be the correct codes?
H73.011 Acute bullous myringitis, right ear
B96.3 Hemophilus influenzae (H. influenzae) as the cause of diseases classified elsewhere 

10.5  Causes, Signs, and Symptoms

of ­Hearing Loss
There are several things that might contribute to loss of hearing: genetics and congeni-
tal anomalies, pathogens, and external causes that may be traumatic or environmental.

Signs and Symptoms of Hearing Loss

While each individual will notice loss of hearing in a different way, these are the most
common complaints:
∙ Hearing speech and other sounds as muffled.
∙ Having difficulty understanding conversations, particularly when in a crowd or in a
noisy place (e.g., a restaurant).

280   PART II  |  REPORTING DIAGNOSES

 ∙ Frequently asking others to speak more slowly, clearly, and loudly.
∙ Turning up the volume of the television or radio.
∙ No longer engaging in conversation.
∙ Avoiding some social settings.
The degrees of hearing loss are measured in decibels (dB). This part of the assess-
ment identifies the volume heard—from soft sounds to loud. The horizontal lines of
the audiogram track the patient’s acknowledged sounds. Audiologists tend to measure
volumes from zero dB (soft sounds) up to 120 dB (extremely loud sounds). Hearing
loss is classified in degrees of hearing from normal to profound. This determination
is evaluated using the standard hearing thresholds—the softest a sound was heard at a
specific frequency (see Table 10-1).

TABLE 10-1  Degrees of Hearing Loss

Indication of Hearing Loss Hearing Threshold (dB)

Normal hearing 0–20
Mild hearing loss 21–40
Moderate hearing loss 41–55
Moderately severe hearing loss 56–70
Severe hearing loss 71–90
Profound hearing loss 91 and above
http://www.hopkinsmedicine.org/hearing/hearing_testing/understanding_audiogram.html
Source: “Understanding Your Audiogram” Johns Hopkins Medicine, The Johns Hopkins University, hopkinsmedi-
cine.org

EXAMPLES
Z01.10 Encounter for examination of ears and hearing without abnormal
findings
Z13.5 Encounter for screening for eye and ear disorders
Here are two examples of code you might report to explain the reason why the
physician or audiologist met with the patient for this encounter.

Genetics and Congenital Anomalies Causing Hearing Loss

During gestation, some infections, such as rubella, herpes, or toxoplasmosis, are
known to possibly cause deafness in the fetus. In addition, congenital anomalies may
cause a malformation of any of the ear structures, and there are over 400 genetic
conditions that have been identified as causing genetic hearing loss. Most often, these
circumstances result in sensorineural hearing loss.

EXAMPLES
P00.2 Newborn (suspected to be) affected by maternal infectious and
parasitic diseases
Q16.5 Congenital malformation of inner ear
H91.1- Presbycusis
H93.25 Central auditory processing disorder (Congenital auditory
imperception)

CHAPTER 10  | 
 Psychogenic (Hysterical) Hearing Loss
Sometimes a traumatic event can be so upsetting to an individual that it results in neu-
rologic symptoms that have no organic cause. This is a psychiatric disorder that was
formerly called “hysteria.”

EXAMPLE
F44.6 Conversion disorder with sensory symptom or deficit (psychogenic
deafness)

Idiopathic Causes of Hearing Loss

Cerumen (earwax) serves an important function within the ear canal. It protects
the skin of the ear canal; protects the middle ear from bacteria, fungi, insects, and
water; and enables cleaning and lubrication. However, too much cerumen can build
up in the canal and form an obstruction, blocking the entrance of sound waves
and causing sudden conductive hearing loss. Recurrent ear infections can result in
scarring of the tympanic membrane, reducing its ability to transmit sounds into the
middle ear.
Presbycusis is the deterioration of the ability to hear that naturally occurs for about
a third of adults as they get into their late 60s to mid 70s. Report this diagnosis from
code category H91.1 with a fifth character to report laterality.

EXAMPLES
H61.22 Impacted cerumen, left ear
H91.21 Sudden idiopathic hearing loss, right ear

ICD-10-CM
YOU CODE IT! CASE STUDY
Tatiana Clayton, a 39-year-old female, felt something in her ear. She was having problems hearing in her left ear
and felt very uncomfortable. When Dr. Silver asked her, she stated that it felt like something was inside her ear. Upon
inspection with the otoscope, Dr. Silver diagnosed a polyp in her middle ear.

You Code It!

Go through the steps of coding, and determine the code or codes that should be reported for this encounter
between Dr. Silver and Tatiana.
Step #1: Read the case carefully and completely.
Step #2: Abstract the scenario. Which main words or terms describe why the physician cared for the patient dur-
ing this encounter? 
Step #3: Are there any details missing or incomplete for which you would need to query the physician? [If so, ask
your instructor.]
Step #4: Check for any relevant guidance, including reading all of the symbols and notations in the Tabular List
and the appropriate sections of the Official Guidelines.
Step #5: Determine the correct diagnosis code or codes to explain why this encounter was medically necessary.

282   PART II  |  REPORTING DIAGNOSES

 Step #6: Double-check your work.
Answer:

Did you determine this to be the correct code?

H74.42 Polyp of left middle ear
Terrific!

Traumatic (External) Causes of Hearing Loss

The ear is well protected, for the most part, by the skull; however, trauma can still
damage it and interfere with the proper transmission of sound. Fireworks set off too
close to a person’s ear, explosions, and even standing too close to the amplifiers at a
rock concert can result in a loss of hearing. A skull fracture might also cause injury to
the ear structures or nerves. While you might not have thought about this, some medi-
cations and drugs can result in ototoxic hearing loss. Ototoxic medications—including
gentamicin (an aminoglycoside antibiotic) and cisplatin and carboplatin (both cancer
chemotherapy drugs)—may cause permanent hearing loss. Others—such as aspirin
and other salicylate pain relievers, quinine (which is used to treat malaria), and some
loop diuretics—are known to result in temporary hearing loss.

EXAMPLES
H83.3x1 Noise effects on right inner ear
H91.03 Ototoxic hearing loss, bilateral
S09.21xA Traumatic rupture of right ear drum

Remember, whenever an external cause is documented, you must include the addi-
tional codes to explain how the injury or poisoning occurred.

EXAMPLES
T36.8x5A Adverse effect of other systemic antibiotics, initial encounter
W36.1xxA Explosion and rupture of aerosol can, initial encounter

Sound Levels Causing Hearing Loss

Walk down the street and you can hear construction equipment or the siren from a
passing ambulance that may cause you to cover your ears to lessen the discomfort.
Your neighbor revs his motorcycle as he drives past your house, or you go to the airport
to see your parents off on a flight for vacation and you wait as the jet takes off into the
sky. What is “loud”? And what is so loud that it could damage your hearing? Take a
look at Table 10-2 to see the decibel (dB) levels of some of the sounds of everyday life.

EXAMPLE
When the physician documents that sound has caused the patient’s hearing loss,
you may report an external cause code from the W42 Exposure to noise code
category.

CHAPTER 10  | 
TABLE 10-2  Common Sounds
Sound Noise Level (dB) Effect
Boom cars 145
Jet engines (near) 140
Shotgun firing 130
Jet takeoff (100–200 ft)
Rock concerts (varies) 110–140 Threshold of pain begins around 125 dB.
Oxygen torch 121
Discotheque/boom box  120 Threshold of sensation begins around 120 dB.
Thunderclap (near)
Stereos (over 100 watts) 110–125
Symphony orchestra 110 Regular exposure to sound over 100 dB for more
Power saw (chainsaw) than 1 minute risks permanent hearing loss.
Pneumatic drill/jackhammer
Snowmobile 105
Jet flyover (1,000 ft.) 103
Electric furnace area  100 No more than 15 minutes of unprotected exposure rec-
Garbage truck/cement mixer ommended for sounds between 90 and 100 dB.
Farm tractor 98
Newspaper press 97
Subway, motorcycle (25 ft) 88 Very annoying.
Lawn mower, food blender  85–90 85 dB is the level at which hearing damage
Recreational vehicles, TV 70–90 (8 hr) begins.
Diesel truck (40 mph, 50 ft) 84
Average city traffic  80 Annoying; interferes with conversation; constant
Garbage disposal ­exposure may cause damage.
Washing machine 78
Dishwasher 75
Vacuum cleaner, hair dryer 70 Intrusive; interferes with telephone conversation.
Normal conversation 50–65
Source: Decibel table developed by the National Institute on Deafness and Other Communication Disorders, National Institutes of Health. January 1990.
nidcd.nih.gov

GUIDANCE
CONNECTION
Chapter Summary
Read the ICD-10-CM Offi-
cial Guidelines for Coding One of the five senses, vision is involved in virtually every aspect of one’s life.
and Reporting, section I. This incredible complex organ system captures light and transmits it via inter-
Conventions, General active anatomical sites to the optic nerve and into the brain for evaluation and
Coding Guidelines and interpretation. Even though it is protected by the skull, the optical system is still
Chapter Specific Guide- susceptible to the invasions of pathogens (bacteria, viruses, fungi); can be dam-
lines, ­subsection C. aged by trauma; and can be impacted by other environmental issues, such as UV
Chapter-­Specific light rays from the sun.
Coding Guidelines, The auditory (hearing) system enables the human body to hear—one of only two
­chapter 20. External senses that have their own organ systems. The auditory system passes along sound
Causes of Morbidity. vibrations captured by the external ear, through the middle ear and the inner ear, to the
cerebellum for interpretation.

284   PART II  |  REPORTING DIAGNOSES

 CHAPTER 10 REVIEW
CODING BITES
There are many abbreviations related directly to the optical and auditory systems
that may be used by your health care providers in their documentation. Some of
the most common abbreviations are shown below:
Optical System–Related Abbreviations
OD = right eye
OS = left eye
OU = each eye
ACC = accommodation
PERRLA = pupils equal, round, reactive to light and accommodation
VA = visual acuity
VF = visual field
REM = rapid eye movements
ARMD = age-related macular degeneration
Audiology-Related Abbreviations
AD = right ear
AS = left ear
AC audiometry = air conduction audiometry
BC audiometry = bone conduction audiometry
dB = decibel
dBHL = decibel hearing level
dBSPL = decibel sound pressure level
dBHTL = decibel hearing threshold level
HF = high frequency
HL = hearing level
Hz = hertz (and kHz: kilohertz)
LF = low frequency
PTA = pure tone audiometry

CHAPTER 10 REVIEW
Coding ­Dysfunction of the Enhance your learning by
completing these exercises and
more at connect.mheducation.com!

Optical and Auditory Systems

Let’s Check It! Terminology
Match each key term to the appropriate definition.

Part I
1. LO 10.2  A membrane in the back of the eye that is sensitive to light and A. Choroid
­functions as the sensory end of the optic nerve. B. Cones
2. LO 10.2  An elongated, cylindrical cell within the retina that is photosensitive in C. Cornea
low light.
D. Iris
3. LO 10.2  A receptor in the retina that is responsible for light and color.
E. Lens
4. LO 10.2  The membranous tissue that covers the entire eyeball (except the cor-
nea); also known as the white of the eye.
5. LO 10.2  Transparent tissue covering the eyeball; responsible for focusing light
into the eye and transmitting light.

CHAPTER 10  | 
 6. LO 10.2  The vascular layer of the eye that lies between the retina and the sclera. F. Orbit
CHAPTER 10 REVIEW

7. LO 10.1  A transparent, crystalline segment of the eye, situated directly behind G. Pupil
the pupil, that is responsible for focusing light rays as they enter the eye H. Retina
and travel back to the retina.
I. Rod
8. LO 10.2  The opening in the center of the iris that permits light to enter and con-
J. Sclera
tinue on to the lens and retina.
9. LO 10.1  The bony cavity in the skull that houses the eye and its ancillary parts
(muscles, nerves, and blood vessels).
10. LO 10.2  The round, pigmented muscular curtain in the eye.

Part II
1. LO 10.1  The eyelids. A. Accommodation
2. LO 10.1  Sebaceous glands that secrete a tear film component that prevents tears B. Bulbar Conjunctiva
from evaporating so that the area stays moist. C. Ciliary body
3. LO 10.2  The vascular layer of the eye that lies between the sclera and the crys- D. Extraocular Muscles
talline lens.
E. Glands of Zeis
4. LO 10.2  The interior segment of the eye that contains the vitreous body.
F. Lacrimal Apparatus
5. LO 10.1  Altered sebaceous glands that are connected to the eyelash follicles.
G. Meibomian Glands
6. LO 10.1  A system in the eye that consists of the lacrimal glands, the upper cana-
H. Moll’s Glands
liculi, the lower canaliculi, the lacrimal sac, and the nasolacrimal duct.
I. Palpebral Conjunctiva
7. LO 10.1  A mucous membrane that lines the palpebrae.
J. Palpebrae
8. LO 10.1  Adaptation of the eye’s lens to adjust for varying focal distances.
K. Uveal Tract
9. LO 10.1  Ordinary sweat glands.
L. Vitreous Chamber
10. LO 10.2  The muscles that control the eye.
11. LO 10.1  A mucous membrane on the surface of the eyeball.
12. LO 10.2  The middle layer of the eye, consisting of the iris, ciliary body, and
choroid.

Part III
1. LO 10.1  Inflammation of the eyelid.  A. Blepharitis
2. LO 10.3  Degenerative condition of the retina.  B. Conjunctivitis 
3. LO 10.2  A break in the connection between the retinal pigment epithelium layer C. Corneal Dystrophy
and the neural retina.  D. Dacryocystitis 
4. LO 10.2  An inflammation of the cornea, typically accompanied by an E. Glaucoma 
ulceration.
F. Keratitis 
5. LO 10.1  Bulging out of the eye; also known as exophthalmos.
G. Proptosis 
6. LO 10.2  Inflammation of the conjunctiva. 
H. Retinal Detachment
7. LO 10.1  Lacrimal gland inflammation. 
I. Retinopathy 
8. LO 10.3  The condition that results when poor draining of fluid causes an abnor-
mal increase in pressure within the eye, damaging the optic nerve. 
9. LO 10.2  Growth of abnormal tissue on the cornea, often related to a nutritional
deficiency. 

286   PART II  |  REPORTING DIAGNOSES

Let’s Check It! Concepts

CHAPTER 10 REVIEW
Choose the most appropriate answer for each of the following questions.
1. LO 10.1  All of the following are layers of the cornea except
a. epithelium. b.  conjunctiva. c.  stroma. d.  endothelium.
2. LO 10.1  Tears are created in the main
a. lacrimal gland. b.  upper canaliculi. c.  lacrimal sac. d.  lower canaliculi.
3. LO 10.2  _____ is commonly known as pink eye.
a. Keratitis b.  Dacryocystitis c.  Conjunctivitis d.  Blepharitis
4. LO 10.2  The muscles that control the eye are known as
a. intraocular. b.  palpebrae. c.  vitreous. d.  extraocular.
5. LO 10.3  What is the correct diagnosis code for intermittent angle-closure glaucoma, left eye?
a. H40.23 b.  H40.231 c.  H40.232 d.  H40.233
6. LO 10.3  Signs and symptoms of diabetic retinopathy include all of the following except
a. double vision. b.  flashing lights. c.  rings around lights. d.  headaches.
7. LO 10.4  Auditory dysfunction of the labyrinth is known as
a. otitis media. b.  otosclerosis.
c. endolymphatic hydrops. d.  tumors of the ear canal.
8. LO 10.4  ________ is an infection within the inner ear’s labyrinth.
a. Labyrinthitis b.  Otitis media c.  Chondritis d.  Perichondritis
9. LO 10.5  Too much cerumen can build up in the canal and form an obstruction, blocking the entrance of sound
waves and causing sudden
a. inner ear hearing loss. b.  sensorineural hearing loss. 
c. organ of Corti hearing loss. d.  conductive hearing loss.
10. LO 10.5  The hearing threshold for moderately severe hearing loss is
a. 20 dB and below. b.  40 to 55 dB. c.  56 to 70 dB. d.  90 dB and above.

Let’s Check It! Guidelines

Refer to the Official Guidelines and fill in the blanks according to the Chapter 7, Diseases of the Eye and Adnexa,
Chapter-Specific Coding Guidelines.
glaucoma different seventh
highest each admitted
laterality H40 clinical
4 bilateral progresses
stage one both type

1. Assign as many codes from category _____, Glaucoma, as needed to identify the type of _____, the affected eye,
and the glaucoma stage.
2. When a patient has _____ glaucoma and both eyes are documented as being the same type and _____, and there is
a code for bilateral glaucoma, report only the code for the type of glaucoma, bilateral, with the seventh character
for the stage.

CHAPTER 10  | 
 3. When a patient has bilateral glaucoma and _____ eyes are documented as being the same _____ and stage, and
CHAPTER 10 REVIEW

the classification does not provide a code for bilateral glaucoma report only _____ code for the type of glaucoma
with the appropriate seventh character for the stage.
4. When a patient has bilateral glaucoma and each eye is documented as having a _____ type or stage, and the
classification distinguishes _____, assign the appropriate code for _____ eye rather than the code for bilateral
glaucoma.
5. If a patient is _____ with glaucoma and the stage _____ during the admission, assign the code for _____ stage
documented.
6. Assignment of the _____ character “_____” for “indeterminate stage” should be based on the _____
documentation.

Let’s Check It! Rules and Regulations

Please answer the following questions from the knowledge you have gained after reading this chapter.
1. LO 10.1  What are the three types of glands within the palpebrae, including their function? 
2. LO 10.2  Explain the difference between rods and cones. 
3. LO 10.3  What is hypertensive retinopathy? Include some of the most common signs and symptoms. 
4. LO 10.4  Explain otosclerosis, including the ICD-10-CM category code.
5. LO 10.5  List five signs and symptoms of hearing loss. 

ICD-10-CM
YOU CODE IT! Basics
First, identify the condition in the following diagnoses; 8. Chronic perichondritis of external ear, left:
then code the diagnosis. a. main term: _____ b. diagnosis: _____
Example: Hordeolum externum, left upper eye 9. Labyrinthine dysfunction, right ear:
a. main term: Hordeolum b. diagnosis: H00.014 a. main term: _____ b. diagnosis: _____
10. Bullous keratopathy, left ear:
1. Stenosis of lacrimal sac, bilateral: 
a. main term: _____ b. diagnosis: _____
a. main term: _____ b. diagnosis: _____
11. Mechanical entropion of eyelid, right lower:
2. Transient ischemic deafness, bilateral:
a. main term _____ b. diagnosis: _____
a. main term: _____ b. diagnosis: _____
12. Total attic perforation of tympanic membrane,
3. Retinal telangiectasis, bilateral:
right ear:
a. main term: _____ b. diagnosis: _____
a. main term: _____ b. diagnosis: _____
4. Ulcerative blepharitis, right upper eyelid:
13. Recurrent bilateral mastoiditis:
a. main term: _____ b. diagnosis: _____
a. main term: _____ b. diagnosis: _____
5. Cholesteatoma of attic, left ear:
14. Senile ectropion of eyelid, left lower:
a. main term: _____ b. diagnosis: _____
a. main term: _____ b. diagnosis: _____
6. Subluxation of lens, left eye:
15. Vestibular neuronitis, left ear:
a. main term: _____ b. diagnosis: _____
a. main term: _____ b. diagnosis: _____
7. Granuloma of right orbit:
a. main term: _____ b. diagnosis: _____

288   PART II  |  REPORTING DIAGNOSES

 CHAPTER 10 REVIEW
ICD-10-CM
YOU CODE IT! Practice
Using the techniques described in this chapter, carefully read through the case studies and determine the most ac-
curate ICD-10-CM code(s) and external cause code(s), if appropriate, for each case study.
1. George McKeown, a 65-year-old male, presents with pain around his right eye and sensitivity to bright light.
Dr. Zabawa notes redness of the eye and sagging skin around the lower eyelid. George is diagnosed with
entropion of the right eye, lower eyelid.
2. Sheila Friday, a 17-year-old female, presents with the complaint that her left upper eyelid is swollen but
doesn’t hurt. This is the third time it has happened. Dr. Moss completes a thorough examination and diagno-
ses Sheila with blepharochalasis, left upper eyelid.
3. John Di Toma, a 10-month-old male, was diagnosed with congenital bilateral cataracts several weeks ago.
John is admitted today for the surgical removal of the cataracts.
4. Robert Gould, a 42-year-old male, presents today complaining of pain and lack of vision in his left eye.
­Robert states that he was playing in a baseball game at the local baseball field and was accidentally struck
in the face by the ball. Dr. Beck notes visual acuity of 20/200 (OS), a protruding eyeball, and an intraocular
pressure of 42 mm Hg. Normal right eye exam. Robert is admitted, where the CT scan confirms the diagnosis
of subarachnoid hematoma.
5. Fred Grossman, a 36-year-old male, presents with the complaint of blurred vision and difficulty seeing at
night. Dr. Cole, an ophthalmologist, takes a complete medical history and completes a thorough exami-
nation. The results of the slit lamp examination of the cornea confirm a diagnosis of stable keratoconus,
right eye.
6. Jill Pruitt, a 9-year-old female, is brought in today by her mother. Jill was jumping on her bed in her bedroom
at home when she fell off and struck her head on the floor; now she is seeing double. Dr. Brownder completes
an examination and decides to admit Jill for observation. After CT scan results were reviewed, Jill is diag-
nosed with temporary diplopia.
7. Donald McShane, a 32-year-old male, presents with the complaints of headaches, blurred vision, and eye
pain. Dr. Clayton notes redness of the eyes and irregular pupils. Don has been having recurrent episodes and
his condition has worsened. The oral steroid treatment does not seem to be effective. After an examination,
Dr. Clayton makes the decision to admit Don for a complete workup. Don is diagnosed with acute recurrent
iridocyclitis, bilaterally.
8. Streeta Frederick, a 31-year-old female, presents with the complaints of headaches, hearing loss, and dizzi-
ness. Dr. Molair completes an examination and admits Streeta. The MRI confirms a diagnosis of primary
malignant neoplasm of inner ear, left.
9. Micah Fullmore, a 17-year-old male, comes in today with a swollen left ear lobe that is painful. Dr. Wiccetta
notes a red pus-filled lump and, after an examination, Micah is diagnosed with furuncle of external left ear.  
10. Rosa Fuller, a 24-year-old female, presents with ear pain. Dr. Rider documents a thick greyish-white matter.
After a thorough examination, Rosa is diagnosed with diffuse otomycosis, external ear.
11. Mark Gamble, a 57-year-old male, presents with a low fever and right ear pain. Dr. Martin completes an
examination with otoscope, which confirmed a moderately bulging, nonperforated, right tympanic membrane;
left tympanic membrane is noted to be within normal limits. Dr. Martin also notes this is the third bout this
year. Mark is diagnosed with acute suppurative otitis media, recurrent, right ear.
12. Latoya Simpkins, a 36-year-old female, presents with the complaint of right ear pain. Dr. Herauf also docu-
ments a low-grade fever, cough, and nasal drainage. Dr. Herauf completes an examination with otoscope,
which visualizes a cloudy bulging eardrum with blisters. Latoya is diagnosed with bullous myringitis.
13. Ken Medlock, a 37-year-old male, presents today with the complaint of ringing in his ears and the feel-
ing of being unbalanced. Ken also states he is having difficulty with his hearing and has pressure in both
ears. Dr. Burgos completes an examination and decides to admit Ken for a full workup. Sensorineural

CHAPTER 10  | 
CHAPTER 10 REVIEW

hearing loss is verified by audiometry; MRI scan and electrocochleography confirm the final diagnosis of
bilateral Ménière’s disease.
14. Tamika Robinson, a 12-year-old female, is having difficulty hearing at school. Dr. Zaprzalka uses an otoscope
to visualize the tympanic membrane, noting left and right are within normal range without indication of
inflammation. The results of audiometry suggest conductive hearing loss. The CT scan confirms the diagno-
sis of cochlear otosclerosis, right ear.
15. Rodney Sabido, a 49-year-old male, is suddenly having difficulty with his hearing. Rod describes it as the
pitch is higher in one ear than the other. Dr. Butterfield completes an examination and the audiometry con-
firms a diagnosis of diplacusis, right ear.

ICD-10-CM
YOU CODE IT! Application
The following exercises provide practice in abstracting physicians’ notes and learning to work with documenta-
tion from our health care facility, Prader, Bracker, & Associates. These case studies are modeled on real patient
encounters. Using the techniques described in this chapter, carefully read through the case studies and determine
the most accurate ICD-10-CM code(s) and external cause code(s), if appropriate, for each case study.

WESTON EYE CENTER

658 Healthcare Way • SOMEWHERE, FL 32811 • 407-555-7892
PATIENT: OLDENBERG, KYLE
ACCOUNT/EHR #: OLDEKY001
DATE: 10/17/18
Attending Physician: Renee O. Bracker, MD
Kyle Oldenberg, 65-year-old male, presents today with the complaints of gradual loss of vision OD of a
2-month duration. Kyle states it doesn’t hurt, “just getting to where I can’t see.” Kyle saw his ophthalmol-
ogist and was diagnosed with angle closure glaucoma and was referred to us for treatment.
PMH: Healthy, no medications
FH: Noncontributory with no history of glaucoma
SH: Drinks alcohol socially and denies use of tobacco.
Eye Exam:
∙ Best corrected visual acuities: 20/20 OS, barely hand motion vision OD.
∙ Pupils: >2.9 LU RAPD OD
∙ EOM: full OU
∙ IOP: 17 mmHg OS, 66 mmHg OD
∙ DFE: retina exam—normal macula, vessels, and periphery OU. Optic nerves: 0.3 C/D OS, complete
cup OD.
Gonioscopy: moderately open angles OD. (+) Sampaolesi’s line OD.
Dx: Pseudoexfoliation glaucoma, moderate stage
P: Selective laser trabeculoplasty (ALT or SLT).

ROB/pw D: 10/17/18 09:50:16  T: 10/19/18 12:55:01

Determine the most accurate ICD-10-CM code(s).

290   PART II  |  REPORTING DIAGNOSES

 CHAPTER 10 REVIEW
PRADER, BRACKER, & ASSOCIATES
A Complete Health Care Facility
159 Healthcare Way • SOMEWHERE, FL 32811 • 407-555-6789
PATIENT: TRUDELL, LEONARD
ACCOUNT/EHR #: TRUDLE001
DATE: 10/17/18
Attending Physician: Renee O. Bracker, MD
S: Leonard presents today with a red, irritated right eye and decreased vision.

O: History of Present Illness: A 69-year-old male presented to our office with a 1-day history of conjunc-
tival injection and mild discomfort in his right eye (OD). He had a known history of pigmentary glaucoma
that was treated with PCIOL and trabeculectomy with mitomycin C in the right eye 5 years earlier. His
visual acuity had decreased from 20/120 to 20/250 OD.

Past Ocular History: Pigmentary glaucoma (OD), age-related macular degeneration in both eyes (OU).
The patient had suffered a severe retinal detachment in the left eye (OS).
Medical History: Hypertension, thyroidectomy.
Medications: Latanoprost OD qhs, Synthroid, and Buspar.
Family History: Noncontributory.
Social History: The patient denies alcohol and tobacco use.
Exam, Ocular:
∙ Visual acuity, with correction: OD—20/250; OS—Light perception.
∙ Intraocular pressure: OD—8 mmHg.
∙ External and anterior segment examination, OD: Conjunctival hyperemia with papillary reaction.
There were 4+ cells (per high-power field) visible in the anterior chamber with a small (0.75-mm)
hypopyon. The right eye had an elevated, thin avascular bleb with a small infiltrate visible within
the bleb. The bleb had a positive Seidel test.
∙ Dilated fundus exam (DFE), OD: 3+ vitreous cell with a hazy view. Visible retina appeared to be
normal.
Course: Performed aqueous and vitreous taps; administered intravitreal vancomycin and ceftazidime;
and prescribed hourly topical, fortified gentamycin and vancomycin drops.
The patient responded well to treatment. His visual acuity has returned to baseline, and the bleb leak
resolved in 6 weeks.
A: Bleb-related endophthalmitis
P: Next appointment 2 months or earlier prn
ROB/pw D: 10/17/18 09:50:16  T: 10/18/18 12:55:01

Determine the most accurate ICD-10-CM code(s).

CHAPTER 10  | 
CHAPTER 10 REVIEW

WESTON HOSPITAL
629 Healthcare Way • SOMEWHERE, FL 32811 • 407-555-6541
PATIENT: SIMONSON-WALKER, SIERRA
ACCOUNT/EHR #: SIMOSI001
DATE: 10/17/18
Attending Physician: Oscar R. Prader, MD
S: Sierra Simonson-Walker, a 61-year-old woman, presented with left ear discharge with some bleeding.
Sierra has a 4-year history of progressive hearing loss in the left ear. She denied any pain, numbness, or
weakness.
O: Upon examination, her right ear is within normal limits and the left ear canal is completely blocked
with skin debris not consistent with cerumen. An attempt was made to remove the debris in the office,
but the patient could not tolerate the severe discomfort.
Medical History: Progressive hearing loss, no ear surgery, no reoccurring ear infections, no prolonged
exposure to sun, no head and neck malignancies.
Family History: Noncontributory
Social History: The patient denies alcohol and tobacco use.
Maximum conductive hearing loss on the left and normal hearing on the right is verified by the
audiometry.
CT scan showed opacification of the external ear canal with no evidence of bone erosion.
The patient is admitted and taken to the operating room; the debris is visualized to be flaky and kerati-
naceous. A portion of this was traced back to the anterior portion of the cartilaginous ear canal, where
it appeared to be adherent to the skin. This lesion was removed en block and sent to frozen pathology,
resulting in no identified carcinoma. There was also some irregular-appearing tissue along the tympanic
membrane, which was also removed and sent with the specimen. The patient underwent a tympano-
plasty without complication.
Final pathology, however, shows squamous cell carcinoma. The patient was then taken for a lateral tem-
poral bone resection and external ear canal closure.
A: Squamous cell carcinoma of the external ear canal, left
P: Will continue to follow patient closely

ORP/pw  D: 10/16/18 09:50:16  T: 10/18/18 12:55:01

Determine the most accurate ICD-10-CM code(s).

WESTON HOSPITAL
629 Healthcare Way • SOMEWHERE, FL 32811 • 407-555-6541
PATIENT: RIVERA, WALTER
ACCOUNT/EHR #: RIVEWA001
DATE: 10/16/18
Attending Physician: Renee O. Bracker, MD

292   PART II  |  REPORTING DIAGNOSES

 CHAPTER 10 REVIEW
S: Walter Rivera, a 57-year-old male, presents today with ear pain and loss of hearing. Dr. Wiccetta
notes some facial paralysis and slurred speech. Walter is admitted for a full workup.
O: H: 5.10”, Wt: 176, T: 97.3 F, HR: 86, R: 25, BP: 176/92. Patient is in obvious pain. Right pupil is 2.6
mm and left is 3.1 mm. Left auricle shows erythematous and is tender and swollen; tympanic membrane
is not visible. Chest is clear; heart is regular without murmurs, rubs, or gallops; abdomen is soft and
nontender; normal bowel sounds; no hepatosplenomegaly. Extremities are within normal range; skin is
clear. Patient is alert and oriented.
Laboratory results:
Sodium 135 mEq/L, potassium 4.6 mEq/L, chloride 91 mEq/L, creatinine 0.6 mg/dL, glucose 274 mg/dL,
calcium 9.3 mg/dL, total protein 6.7 g/dL, albumin 3.6 g/dL, total bilirubin 0.7 mg/dL, hemoglobin 15.3
g/dL, WBC 22.4 × 103/μL, hematocrit 48.0, platelet count 288 × 103/μL.
CT scan shows thickened tissue of the external auditory canal. Brain appears normal from MRI scan.
A: Diabetes, type 2, and malignant otitis externa, right.
P: Antipseudomonal therapy

ROB/pw D:10/16/18 09:50:16  T: 10/18/18 12:55:01

Determine the most accurate ICD-10-CM code(s).

PRADER, BRACKER, & ASSOCIATES

A Complete Health Care Facility
159 Healthcare Way • SOMEWHERE, FL 32811 • 407-555-6789
PATIENT: BARDARO, LYNNE
ACCOUNT/EHR #: BARDLY001
DATE: 10/16/18
Attending Physician: Renee O. Bracker, MD
S: Lynne, a 37-year-old female, presents today with the complaint that her right ear is throbbing.
O: T: 101, BP: 137/83, R: 21, P: 78. PERRLA. Lynne is in moderate discomfort. She admits to a pain level
of 4 on a scale of 0–10.
Past medical history: noncontributory.
Review of systems: negative.
Medications: none.
Ear exam: Left is within normal range. Right pinna: a lump is noted, as well as swelling and inflammation. It
appears to be a localized pool of blood. Dr. Bracker evacuates the blood and applies a pressure bandage.
A: Auricle hematoma
P: Rx: antibiotics
Follow up with patient in 10–14 days.

ROB/pw D: 10/16/18 09:50:16  T: 10/18/18 12:55:01

Determine the most accurate ICD-10-CM code(s).

CHAPTER 10  | 
 11
Key Terms
Coding Cardiovascular
Conditions
Learning Outcomes
Angina Pectoris After completing this chapter, the student should be able to:
Atherosclerosis
Atrium LO 11.1 Abstract the documentation accurately to report heart
Cerebral Infarction dysfunction.
Cerebrovascular Acci- LO 11.2 Discern the specifics of cardiovascular disease.
dent (CVA) LO 11.3 Evaluate documentation to determine details about abnormal
Edema blood pressure diagnoses.
Elevated Blood LO 11.4 Identify known manifestations of hypertension.
Pressure
Embolus LO 11.5 Interpret the details of cerebrovascular disease.
Gestational LO 11.6 Distinguish the sequelae of cerebrovascular disease and
Hypertension report them accurately.
Hypertension
Hypotension
Infarction
Myocardial Infarction Remember, you need to follow along in
(MI)
  STOP! your ICD-10-CM code book for an optimal
ICD-10-CM

NSTEMI
Secondary learning experience.
Hypertension
STEMI
Thrombus
Vascular 11.1  Heart Conditions
Ventricle At the center of your body is the heart. Like the engine in a car, this small organ
pumps oxygen-rich blood through your arteries to every cell in your body, from your
head to your toes. The heart beats approximately once every second (60 beats per min-
ute). Each beat is a compression—the heart contracting to force blood through it and
out through the aorta to travel through the body delivering oxygen (see Figure 11-1).

Heart Disorders
Cardiac Arrest
Cardiac arrest means the heart actually stops beating. Typically, this happens suddenly.
The key factor that you need to know about this condition is that it must be caused
by something else. Possible causes of cardiac arrest include an underlying condition
such as a myocardial infarction (dead tissue within the heart), an arrhythmia (abnormal
heartbeat), electric shock (such as from wiring or lightning), a drug interaction, a drug
overdose, a medical procedure, or a trauma. Therefore, along with abstracting this spe-
cific diagnosis, you will also need to look for the underlying cause (Figure 11-2).
There are several codes available to report this condition, specifying the underlying
cause; here are some of the codes shown in the Tabular List:
I46.2 Cardiac arrest due to underlying cardiac condition
  Code first underlying cardiac condition
I46.8 Cardiac arrest due to other underlying condition
  Code first underlying condition
I97.710 Intraoperative cardiac arrest during cardiac surgery

294
 I97.711 Intraoperative cardiac arrest during other surgery
I97.120 Postprocedural cardiac arrest during cardiac surgery CODING BITES
I97.121 Postprocedural cardiac arrest during other surgery In reality, there is a code
O75.4 Other complications of obstetric surgery and procedures available with no spe-
cific underlying cause:
As you can interpret from these code descriptions, you would have to go back to the I46.9  Cardiac arrest,
physician’s documentation and specifically identify the underlying condition (that caused cause unspecified
As you learned in
Abstracting Clinical
Documentation, you
are required to query
Superior vena cava the physician to obtain
Aorta the details about the
Aortic valve cause of this patient’s
Left pulmonary
artery cardiac arrest to be
Right pulmonary added to the documen-
artery Pulmonary trunk
Left pulmonary tation so the code you
veins report is accurate.
Branches of Left atrium
right pulmonary
veins
Bicuspid (mitral) valve
Right atrium
Chordae tendineae

Left ventricle
Opening of coronary
sinus Papillary muscle

Tricuspid valve
Septum
Right ventricle
Inferior vena cava

FIGURE 11-1  The anatomical components of the heart  David Shier et al., HOLE’S HUMAN
ANATOMY & PHYSIOLOGY, 12/e. ©2010 McGraw-Hill Education. Figure 15.6b, p. 558. Used with permission.

Arrest, arrested
- cardiac I46.9
-- complicating
--- abortion — see Abortion, by type, complicated by, cardiac arrest
--- anesthesia (general) (local) or other sedation — see Table of Drugs and
Chemicals, by drug,
---- in labor and delivery O74.2
---- in pregnancy O29.11-
---- postpartum, puerperal O89.1
--- delivery (cesarean) (instrumental) O75.4
-- due to
--- cardiac condition I46.2
--- specified condition NEC I46.8
-- intraoperative I97.71-

FIGURE 11-2  ICD-10-CM, Alphabetic Index, partial, from Cardiac Arrest to Intra-
operative Arrest  Source: ICD-10-CM Official Guidelines for Coding and Reporting The Centers for Medicare
and Medicaid Services (CMS) and the National Center for Health Statistics (NCHS)

CHAPTER 11  | 
 the cardiac arrest). You need this information so you can determine which of these two
GUIDANCE codes to report, and so you will know what that other (principal) diagnosis code should be.
CONNECTION
Dysrhythmia/Arrhythmia
Read the ICD-10-CM
Dysrhythmia, or arrhythmia, refers to an irregular heartbeat. Signs include tachycar-
Official Guidelines for
dia (rapid heartbeat, more than 100 beats per minute) or bradycardia (abnormally slow
Coding and Reporting,
heartbeat, less than 60 beats per minute). A short-term version of tachycardia may be pal-
section II. Selection of
pitations, a condition in which the patient feels a very rapid heartbeat that lasts only a
Principal Diagnosis,
few minutes. Palpitations are a temporary condition that may be caused by another con-
as well as section III.
dition, such as anxiety, whereas tachycardia is an ongoing malfunction of the heart.
Reporting Additional
Diagnoses. R00.0 Tachycardia, unspecified
R00.1 Bradycardia, unspecified
I49.8 Other specified cardiac arrhythmias
I49.9 Cardiac arrhythmia, unspecified
I97.89 Other postprocedural complications and disorders of the circulatory
system, not elsewhere classified
When you search for dysrhythmia or arrhythmia, the ICD-10-CM Alphabetic Index
directs you to I49.9. You can see that there are no codes specific to dysrhythmia.
Notice that other codes are suggested when this condition is diagnosed in a newborn or
occurring postoperatively. These details are a tip for you to go back to the documenta-
tion and check the patient’s age or if the patient was in the postoperative period when
the dysrhythmia occurred. Essentially, this diagnosis is vague, as it expresses what is
wrong (irregular heartbeat) but does not relate the reason or reasons why the heartbeat
is abnormal. You will need more specific information about the patient’s condition,
from either the documentation or the physician, to determine the correct code(s).
Mitral Valve Prolapse
Mitral valve prolapse is a rather common abnormality that prevents the mitral valve
Atrium from closing properly (the mitral valve is the gateway between the left atrium and the
A chamber that is located in left ventricle). A prolapse may develop or be influenced by other conditions, including
the top half of the heart and hyperthyroidism, congenital heart lesions, or Marfan syndrome.
receives blood. In the Alphabetic Index, find
Ventricle Prolapse, prolapsed
A chamber that is located in mitral (valve) I34.1
the bottom half of the heart
and receives blood from the When you turn to the code category in the Tabular List, you will see
atrium.
I34 Nonrheumatic mitral valve disorders
  I34.1 Nonrheumatic mitral (valve) prolapse
The inclusion of the term “nonrheumatic” is a tip to go back into the documentation to
ensure that the physician did not state that the patient’s condition was caused by rheu-
matic fever. Rheumatic fever can manifest heart inflammation as well as affect joints
and other parts of the body. Rheumatic fever with heart involvement as well as chronic
rheumatic heart diseases are reported from code categories I01– I09.
Atrial Fibrillation
Atrial fibrillation is a condition in which atria shudder or tremble in the heart instead
of contracting to push blood through to the ventricles. This results in incomplete emp-
tying of the atria, leaving blood to collect and sometimes clot. Episodes of paroxysmal
atrial tachycardia (PAT), a rapid heart rate that can go as high as 150 or 200 beats per
minute, can occur. Anticoagulants (drugs that prevent clotting) and/or thrombolytics
(clot-dissolving drugs) are often prescribed.
I48.2 Chronic atrial fibrillation
I47.1 Supraventricular tachycardia (Atrial (paroxysmal) tachycardia)

296   PART II  |  REPORTING DIAGNOSES

 When the atrial fibrillation is chronic and the patient is prescribed anticoagulants
or antithrombotics, this additional information may need to be reported. The following
diagnosis codes explain the medical necessity for more frequent blood tests or office
visits.
Z79.01 Long term (current) use of anticoagulants
Z79.02 Long term (current) use of antithrombotics/antiplatelets
Z79.82 Long term (current) use of aspirin
And when the reason, or one of the reasons, for the encounter is regular blood testing,
you will also need to report:
Z51.81 Encounter for therapeutic drug level monitoring

ICD-10-CM
LET’S CODE IT! SCENARIO
Sara Cohen, a 73-year-old woman, was brought to the ED via ambulance after a witnessed cardiac arrest at the local airport. 
Past medical history included hypertension, elevated cholesterol, and obstructive sleep apnea. She wore CPAP
nightly but continued to experience daytime somnolence. She has smoked half a pack of cigarettes a day for the past
40 years and drank no alcohol. She had a chronic daily cough. She walked 2 miles daily without dyspnea or other
limitation. She had never experienced chest pain, palpitations, presyncope, or syncope and had no known history of
CAD. Current medications included nifedipine 30 mg orally once daily and simvastatin 20 mg orally once daily.
On the day of presentation, she was at the airport waiting for a flight to visit her grandchildren. Bystanders at the
airport reported that they saw her suddenly drop to the floor while walking in the terminal. At a subsequent interview,
the first lay responder described that the woman collapsed abruptly without any vocalization and was found to be
unresponsive, pulseless, and without respirations. This lay responder, along with another bystander who was a nurse
without formal training in advanced resuscitation, began CPR. This particular airport had recently instituted a policy of
providing public access defibrillators in the terminals. Bystanders notified airport security staff, who brought a defibril-
lator to the scene and also called the EMTs. The woman was revived and brought to the hospital.
After examination, Dr. Troy diagnosed Sara with sudden cardiac arrest. He admitted her to the hospital for further
testing to determine the cause of this event.

Let’s Code It!

Dr. Troy diagnosed Sara with sudden cardiac arrest. Turn in your ICD-10-CM Alphabetic Index and find
Arrest, arrested
cardiac I46.9
There is no mention of “sudden,” but the rest matches, so let’s turn in the Tabular List to find this code, and we
can read from there.
 I46 Cardiac arrest
 cardiogenic shock (R57.0)
I46.2 Cardiac arrest due to underlying cardiac condition
  Code first underlying cardiac condition
I46.8 Cardiac arrest due to other underlying condition
  Code first underlying condition
I46.9 Cardiac arrest, cause unspecified
Let’s go back and read Dr. Troy’s documentation carefully. Did he identify the cause of Sara’s cardiac arrest? No,
actually he specifically stated that he was admitting Sara with the express purpose of determining the underlying
condition. Therefore, this is the code you must report:
I46.9 Cardiac arrest, cause unspecified
Good work!

CHAPTER 11  | 
 Heart Failure
CODING BITES
To determine the diag-
A diagnosis of heart failure is serious; however, it does not mean the heart has totally
nosis code for heart fail-
“failed” to function. This condition, also known as congestive heart failure (CHF),
ure, you need to know:
is characterized by the inability of an individual’s heart to pump a sufficient quantity
of blood throughout the body. Congestive heart failure can cause fluid to back up into
• What type of heart the lungs, resulting in respiratory problems such as shortness of breath and fatigue. In
failure? addition, fluid might build up in the lower extremities, causing edema (swelling) in the
• Is it acute or chronic? feet, ankles, and legs. In some patients, the edema can become so acute (severe) that
they may have pain and trouble walking.
The National Heart, Lung, and Blood Institute reported in November 2015 that
approximately 5.7 million people in the United States currently have a diagnosis of
heart failure. The institute estimates that this condition contributes to as many as
30,000 deaths each year.

The Types of Heart Failure

Left heart failure, also known as pulmonary edema or cardiac asthma, indicates an
insufficiency of the heart’s left ventricle. This malfunction results in the accumula-
tion of fluid in the lungs. When this happens, patients may also develop respiratory
problems.

I50.1 Left ventricular failure, unspecified

Right heart failure, secondary to left heart failure, is diagnosed when the heart
cannot pump and circulate the blood needed throughout the body. Patients with this
diagnosis may develop hypertension, congestion, edema, and fluid collection in the
lungs.

I50.814 Right heart failure (due to left heart failure)

Systolic heart failure occurs when the contractions of the ventricles are too weak to
push the blood through the heart. The documentation should include the specific detail
Secondary Hypertension that the condition is acute, chronic, or acute on chronic.
The condition of hypertension
caused by another condition I50.21 Acute systolic (congestive) heart failure
or illness. I50.22 Chronic systolic (congestive) heart failure
I50.23 Acute on chronic systolic (congestive) heart failure

Diastolic heart failure is the result of a ventricle of the heart being unable to fill as
CODING BITES it should. The documentation should include the specific detail that the condition is
When a condition, such acute, chronic, or acute on chronic.
as right heart failure,
causes the patient I50.31 Acute diastolic (congestive) heart failure
to develop another I50.32 Chronic diastolic (congestive) heart failure
condition, such as I50.33 Acute on chronic diastolic (congestive) heart failure
hypertension, that
other condition may be Combined systolic and diastolic heart failure means that the function of the heart
referred to as a second- is weak and unable to process blood properly. The documentation should include the
ary condition. specific detail that the condition is acute, chronic, or acute on chronic.
For example, if Ralph
developed hypertension I50.41 Acute combined systolic (congestive) and diastolic (congestive)
due to his right heart fail- heart failure
ure, you would report the I50.42 Chronic combined systolic (congestive) and diastolic (congestive)
hypertension as second- heart failure
ary hypertension. I50.43 Acute on chronic combined systolic (congestive) and diastolic
(congestive) heart failure

298   PART II  |  REPORTING DIAGNOSES

 ICD-10-CM
YOU CODE IT! CASE STUDY
Judith Patriko, a 78-year-old female, came to see her cardiologist, Dr. Fillmari, to follow up on her CHF. The edema
(swelling) of her legs has improved, but she continues to have dyspnea (shortness of breath) with mild exertion. No
syncope (fainting) at this time. Dx: Chronic diastolic congestive heart failure.

You Code It!

Look at Dr. Fillmari’s notes for Judith Patriko, and determine the best, most appropriate code or codes.
Step #1: Read the case carefully and completely.
Step #2: Abstract the scenario. Which main words or terms describe why the physician cared for the patient dur-
ing this encounter?
Step #3: Are there any details missing or incomplete for which you would need to query the physician? [If so, ask
your instructor.]
Step #4: Check for any relevant guidance, including reading all of the symbols and notations in the Tabular List
and the appropriate sections of the Official Guidelines.
Step #5: Determine the correct diagnosis code or codes to explain why this encounter was medically necessary.
Step #6: Double-check your work.
Answer:

Did you determine this to be the diagnosis code?

I50.32 Chronic diastolic (congestive) heart failure
Good job!

Myocardial Infarction (MI)

Myocardial Infarction Malfunction of the heart due
When a part of the heart muscle deteriorates, or actually dies, that muscle can no longer to necrosis or deterioration of
function properly. This malfunction within a person’s heart, known as a myocardial a portion of the heart muscle;
infarction (MI), will cause persistent pain in the chest, left arm, jaw, and neck; fatigue; also known as a heart attack.
nausea; vomiting; and shortness of breath. A preliminary diagnosis of MI, based on STEMI
these signs and symptoms, can be confirmed by an electrocardiogram (EKG or ECG), An ST elevation myocardial
blood tests measuring the serial serum enzyme levels, and/or an echocardiogram. infarction—a heart event dur-
An ST elevation myocardial infarction (STEMI) is a heart event during which the ing which the coronary artery
coronary artery is completely blocked by a thrombus or embolus. The ST segment is completely blocked by a
is a specific range seen in an EKG (ECG). A nontransmural ST elevation myocar- thrombus or embolus.
dial infarction (NSTEMI) indicates that only a portion of the artery is occluded Thrombus
(blocked). A blood clot in a blood vessel;
To determine the code for a diagnosis of MI, you will need to know plural = thrombi.
∙ What specific part of the heart was affected by the infarction? Embolus
∙ Has this patient been treated for an MI before? If so, how long ago? A thrombus that has broken
free from the vessel wall and
∙ Is this infarction a STEMI or an NSTEMI? is traveling freely within the
vascular system.
Anatomical Site of the AMI NSTEMI
An infarction can occur in almost any location within the heart, and it is impor- A nontransmural elevation
tant that you identify the specific site from the documentation to support the accu- myocardial infarction—a
rate code to report. You will see that the individual codes in the code category for heart event during which the
STEMI infarctions include different locations, specifically identified by the fourth coronary artery is partially
character: occluded (blocked).

CHAPTER 11  | 
 GUIDANCE CODING BITES
CONNECTION A thrombus is a blood clot that has attached itself to the wall of a blood vessel. If
Read the ICD-10-CM Offi- left untreated, it may cause a blockage, preventing blood from flowing through
cial Guidelines for Coding the artery or vein. In addition, there is always concern that the clot will detach and
and Reporting, section float through the vessel and pass through an organ. A detached clot is known
I. Conventions, General as an embolus; it can get stuck as it passes through an organ and can com-
Coding Guidelines and pletely prevent blood from moving through. The greatest danger occurs when an
Chapter Specific Guide- embolus travels into the lung or the heart, potentially causing death.
lines, subsection C.
Chapter-Specific Cod- I21.01 ST elevation (STEMI) myocardial infarction involving left main coronary
ing Guidelines, chapter artery
9. Diseases of the Circu- I21.02 ST elevation (STEMI) myocardial infarction involving left anterior
latory System, subsec- descending coronary artery
tion e. Acute myocardial I21.11 ST elevation (STEMI) myocardial infarction involving right coronary artery
infarction (AMI). I21.21 ST elevation (STEMI) myocardial infarction involving left circumflex
coronary artery
CODING BITES Subsequent MI
If the physician docu- Another important aspect of a diagnosis of MI is whether or not this is the first time a
ments this encounter patient has experienced this event. When a patient is documented as having had an acute
has focused on the myocardial infarction (AMI) within the last 4 weeks (28 days) and is at your facility for
patient’s subsequent or a second event, this current MI is reported with a code describing a “subsequent” MI:
second MI and the . . .
I22.0 Subsequent ST elevation (STEMI) myocardial infarction of anterior wall
• Previous MI was I22.1 Subsequent ST elevation (STEMI) myocardial infarction of inferior wall
within the last 4 I22.2 Subsequent non-ST elevation (NSTEMI) myocardial infarction
weeks = code from I22.8 Subsequent ST elevation (STEMI) myocardial infarction of other sites
category I22
When the previous MI is documented either as a “healed MI” or as a past MI with-
• Previous MI was out any current signs or symptoms, it is reported with this code:
more than 4 weeks
ago = code I25.2 I25.2 Old myocardial infarction

GUIDANCE CONNECTION
Read the ICD-10-CM Official Guidelines for Coding and Reporting, section I.
Conventions, General Coding Guidelines and Chapter Specific Guidelines, sub-
section C. Chapter-Specific Coding Guidelines, chapter 9. Diseases of the Circu-
latory System, subsection e. Acute myocardial infarction (AMI), 4) Subsequent
acute myocardial infarction.

ICD-10-CM
YOU CODE IT! CASE STUDY
Mark is sitting in the stands watching his son play softball when all of a sudden he feels a severe pain in his chest.
He is having difficulty taking a breath, and the pain is radiating down his left arm. He arrives at the ED via ambu-
lance, and Dr. Constantine and nurses work on him, taking blood and doing an EKG. Dr. Constantine determines that
Mark had an ST elevation myocardial infarction (STEMI) of the inferolateral wall. Once he is stabilized, Mark is admit-
ted into the hospital and transferred to the ICU.

You Code It!

Go through the steps of coding, and determine the code or codes that should be reported for this encounter
between Dr. Constantine and Mark.
Step #1: Read the case carefully and completely.

300   PART II  |  REPORTING DIAGNOSES

 Step #2: Abstract the scenario. Which main words or terms describe why the physician cared for the patient dur-
ing this encounter?
Step #3: Are there any details missing or incomplete for which you would need to query the physician? [If so, ask
your instructor.]
Step #4: Check for any relevant guidance, including reading all of the symbols and notations in the Tabular List
and the appropriate sections of the Official Guidelines.
Step #5: Determine the correct diagnosis code or codes to explain why this encounter was medically necessary.
Step #6: Double-check your work.
Answer:
Did you determine this to be the correct code?
I21.19 ST elevation (STEMI) myocardial infarction involving other coronary artery of inferior wall
(Inferolateral transmural (Q wave) infarction (acute))

11.2  Cardiovascular Conditions

The circulatory (cardiovascular) system (Figure 11-3) includes the heart, arteries, and
veins. It has the job of circulating blood to carry oxygen to cells throughout the body
and to move waste products away from those cells. The circulatory network touches
and affects every area of the body, from hair and tissues to organ function.
Circulatory conditions are very serious because they affect the flow of blood and,
therefore, the delivery of oxygen. While problems with circulation can affect a patient
of any age, older individuals are more susceptible to such conditions. As the body
ages, the strength and elasticity of blood vessels decrease and they become less effi-
cient. In addition, long-term poor nutrition and insufficient cardiovascular exercise
take their toll and contribute to the circulatory system’s inability to do its job.

Carotid
artery Superior
vena cava CODING BITES
Jugular
vein
Cardiovascular: car-
Pulmonary dio = heart + -vascu-
Heart trunk
lar = vessels (veins and
Brachial
Aorta arteries)
artery Arteries = blood
Femoral vessels that carry oxy-
Inferior artery and genated blood from the
vena vein
cava heart to the tissues and
cells throughout the
body.
Veins = blood ves-
sels that carry deoxy-
genated blood, along
with carbon dioxide and
cell waste, away from
the tissues and cells
throughout the body
FIGURE 11-3  The cardiovascular system, highlighting major vessels  Booth et al., Medi- and back to the heart.
cal Assisting, 5e. Copyright ©2013 by McGraw-Hill Education. Figure 22-6b, p. 479. Used with permission.

CHAPTER 11  | 
 Deep Vein Thrombosis
Earlier in this chapter, you learned about thrombi and emboli—blood clots that develop
within the blood vessels. Deep vein thrombi can block the blood flow, causing venous
insufficiency and affecting the ability of oxygen to get to the tissues throughout the body.
A lack, or reduction, of blood flow can cause edema, congestion, necrosis, and pain. In
addition, there is the danger that the blood clot can break loose and travel within the
veins and arteries (embolism), causing damage to internal organs, blocking oxygen from
the lungs (pulmonary embolism), or blocking off blood flow through the heart.
Reporting a diagnosis of deep vein thrombosis (DVT) [the presence of a blood clot
attached to the wall of an interior vein] will require you to know a few specifics to
determine the most accurate code:
∙ Is the condition identified as acute or chronic?
∙ Where (the specific anatomical site) has the thrombus been located?
I82.412 Acute embolism and thrombosis of left femoral vein
I82.543 Chronic embolism and thrombosis of tibial vein, bilateral

ICD-10-CM
YOU CODE IT! CASE STUDY
Dr. Victorelli examined Carter Franchez and diagnosed him with a chronic thrombosis of the right popliteal vein. 

You Code It!

Review the notes about why Dr. Victorelli provided care to Carter Franchez and determine the accurate diagno-
sis code or codes.
Step #1: Read the case carefully and completely.
Step #2: Abstract the scenario. Which main words or terms describe why the physician cared for the patient dur-
ing this encounter?
Step #3: Are there any details missing or incomplete for which you would need to query the physician? [If so, ask
your instructor.]
Step #4: Check for any relevant guidance, including reading all of the symbols and notations in the Tabular List
and the appropriate sections of the Official Guidelines.
Step #5: Determine the correct diagnosis code or codes to explain why this encounter was medically necessary.
Step #6: Double-check your work.
Answer:
Did you determine this to be the accurate code?
I82.531 Chronic embolism and thrombosis of right popliteal vein
Good job!

Atherosclerosis and Coronary Artery Disease (CAD)

Atherosclerosis Atherosclerosis, also known as arteriosclerosis, is a stricture or stenosis of an artery
A condition resulting from (e.g., code  I70.0 Atherosclerosis of aorta) that may require the placement of a stent
plaque buildup on the interior (a wire mesh tube inserted to support the walls of the artery and to keep them open).
walls of the arteries, caus- You have probably heard about this in some commercials on television that talk about
ing reduced blood flow; also the buildup of plaque in the arteries and the damage that may result. Atherosclerosis
known as arteriosclerosis.
(athero = artery + sclerosis = hardening) is the medical term for plaque-lined arteries.
You may also see the abbreviation ASHD (arteriosclerotic heart disease). The plaque
builds up on the inner walls of the arteries, thereby narrowing the passageway and
reducing the flow of blood. Remember that arteries carry oxygenated blood from the
heart to the tissues and cells throughout the body.

302   PART II  |  REPORTING DIAGNOSES

 In coronary artery disease (CAD), plaque collects specifically within the coronary
arteries (arteries within the heart); the heart itself becomes oxygen-deprived. This
means there will be a greater potential for a stroke (cerebrovascular accident [CVA]),
a heart attack, or death. According to the National Heart, Lung, and Blood Institute,
CAD is the number-one cause of death in the United States.
When you look in the ICD-10-CM Alphabetic Index, you will read:
Disease, diseased
- coronary (artery) — see Disease, heart, ischemic, atherosclerotic
Angina Pectoris
- heart (organic) I51.9
Chest pain.
-- ischemic (chronic or with a stated duration of over 4 weeks) I25.9
--- atherosclerotic (of) I25.10
---- with angina pectoris — see Arteriosclerosis, coronary (artery) GUIDANCE
---- coronary artery bypass graft — see Arteriosclerosis, coronary (artery)
CONNECTION
A patient may first be alerted to reduced flow of blood to the heart muscle by
Read the ICD-10-CM
angina. Angina pectoris is an event of acute chest pain caused by an insufficient supply
Official Guidelines for
of oxygen to an area of the heart. This condition may be treated with drugs categorized
Coding and Report-
as vasodilators, such as Isordil or Nitrostat (sublingual nitroglycerin), that dilate arterial
ing, section I. Con-
walls, making it easier for blood to flow smoothly. When hypertension is also present, a
ventions, General
calcium channel blocker, such as Norvasc or Vascor, may be prescribed instead. Report
Coding Guidelines
angina pectoris with a code from category  I20.- Angina pectoris, with a required addi-
and Chapter Specific
tional character for the specific type of angina, and be certain to pay attention to the nota-
Guidelines, subsec-
tion directly above this code category that applies to this whole range of codes I20–I25:
tion C. Chapter-Specific
Use additional code to identify presence of hypertension (I10-I16) Coding Guidelines,
chapter 9. Diseases of
In addition to diet and exercise modification, antilipemic drugs, such as Lipitor
the Circulatory Sys-
or Zocor, may be prescribed to decrease the lipid (fat) blood level. If these actions
tem, subsection b. Ath-
are not sufficient, a percutaneous transluminal coronary angioplasty (PTCA) may be
erosclerotic coronary
performed. During a PTCA, a catheter is threaded through the artery to the site of
artery disease with
the plaque buildup. A balloon on the tip of the catheter is expanded, compacting the
angina.
plaque against the walls of the artery, thereby reducing the blockage.

ICD-10-CM
YOU CODE IT! CASE STUDY
PATIENT: Basti, Carl
REASON FOR CONSULTATION: Surgical evaluation for coronary artery disease.
HISTORY OF PRESENT ILLNESS: The patient is a 47-year-old male who has a known history of coronary artery
disease. He underwent previous PTCA and stenting procedures in December and most recently in August. Since
that time, he has been relatively stable with medical management. However, in the past several weeks, he started to
notice some exertional dyspnea with chest pain.
For the most part, the pain subsides with rest. For this reason, he was reevaluated with a cardiac catheterization.
This demonstrated 3-vessel coronary artery disease with a 70% lesion to the right coronary artery; this was a proximal
lesion. The left main had a 70% stenosis. The circumflex also had a 99% stenosis. Overall left ventricular function was
mildly reduced with an ejection fraction of about 45%. The left ventriculogram did note some apical hypokinesis. In
view of these findings, surgical consultation was requested and the patient was seen and evaluated by Dr. Isaacson.
PAST MEDICAL HISTORY:
1.  Coronary artery disease as described above with previous PTCA and stenting procedures. 
2.  Dyslipidemia.
3.  Hypertension.
ALLERGIES: None.
(continued)

CHAPTER 11  | 
 MEDICATIONS: Aspirin 81 mg daily, Plavix 75 mg daily, Altace 2.5 mg daily, metoprolol 50 mg b.i.d., and Lipitor 10 mg q.h.s.
SOCIAL HISTORY: He quit smoking approximately 8 months ago. Prior to that time, he had about a 35- to 40-pack-
per-year history. He does not abuse alcohol.
FAMILY MEDICAL HISTORY: Mother died prematurely of breast cancer. His father died prematurely of gastric carcinoma.
REVIEW OF SYSTEMS: There is no history of any CVAs, TIAs, or seizures. No chronic headaches. No asthma, TB, hemop-
tysis, or productive cough. There is no congenital heart abnormality or rheumatic fever history. He has no palpitations.
He notes no nausea, vomiting, constipation, diarrhea, but immediately prior to admission, he did develop some diffuse
abdominal discomfort. He says that since then, this has resolved. No diabetes or thyroid problem. There is no depression
or psychiatric problems. There are no musculoskeletal disorders or history of gout; no hematologic problems or blood
dyscrasias; no bleeding tendencies; and no recent fevers, malaise, changes in appetite, or changes in weight.
PHYSICAL EXAMINATION: His blood pressure is 120/70; pulse is 80. He is in a sinus rhythm on the EKG monitor.
Respirations are 18 and unlabored. Temperature is 98.2 degrees Fahrenheit. He weighs 260 pounds and is 5 feet
10 inches. In general, this was a pleasant male who currently is not in acute distress. Skin color and turgor are good.
Pupils were equal and reactive to light. Conjunctivae clear. Throat is benign. Mucosa was moist and noncyanotic.
Neck veins not distended at 90 degrees. Carotids had 2+ upstrokes bilaterally without bruits. No lymphadenopathy
was appreciated. Chest had a normal AP diameter. The lungs were clear in the apices and bases; no wheezing or
egophony appreciated. The heart had a normal S1, S2. No murmurs, clicks, or gallops. The abdomen was soft, non-
tender, nondistended. Good bowel sounds present. No hepatosplenomegaly was appreciated. No pulsatile masses
were felt. No abdominal bruits were heard. His pulses are 2+ and equal bilaterally in the upper and lower extremi-
ties. No clubbing is appreciated. He is oriented x3. Demonstrated a good amount of strength in the upper and lower
extremities. Face was symmetrical. He had a normal gait.
IMPRESSION: This is a 47-year-old male with significant multivessel coronary artery disease. The patient also has a left
main lesion. He has undergone several PTCA and stenting procedures within the last year to year and a half. At this point,
in order to reduce the risk of any possible ischemia in the future, surgical myocardial revascularization is recommended.      
PLAN: We will plan to proceed with surgical myocardial revascularization. The risks and benefits of this procedure
were explained to the patient. All questions pertaining to this procedure were answered.
Vaughn Pronder, MD
You Code It!
Carefully review Dr. Pronder’s documentation after his evaluation of Carl Basti, and determine the correct diag-
nosis code or codes to report.
Step #1: Read the case carefully and completely.
Step #2: Abstract the scenario. Which main words or terms describe why the physician cared for the patient dur-
ing this encounter?
Step #3: Are there any details missing or incomplete for which you would need to query the physician? [If so, ask
your instructor.]
Step #4: Check for any relevant guidance, including reading all of the symbols and notations in the Tabular List
and the appropriate sections of the Official Guidelines.
Step #5: Determine the correct diagnosis code or codes to explain why this encounter was medically necessary.
Step #6: Double-check your work.
Answer:
Did you determine these to be the correct codes?
I25.10 Atherosclerotic heart disease of native coronary artery without angina pectoris
I10 Essential (primary) Hypertension
Z87.891 Personal history of nicotine dependence
Z79.82 Long term (current) use of aspirin
Good work!

304   PART II  |  REPORTING DIAGNOSES

11.3  Hypertension
The average adult has approximately 10 pints (5 liters) of blood in his or her cardiovas-
cular system. Together, the components of the cardiovascular system will pump these
10 pints through the body every minute. The level of pressure at which the blood trav-
els through the vessels is very important.

Blood Pressure
The force with which blood travels through your veins and arteries must create enough
pressure to ensure the cycle of oxygenation and carbon dioxide is maintained properly.
Blood pressure that is too low—a condition known as hypotension (hypo = low or Hypotension
under +  tension = pressure)—can result in organs and tissue cells being unable to Low blood pressure; systolic
function. In hypotension, the patient has lower-than-normal blood pressure. Low blood blood pressure below
pressure indicates an inadequate flow of blood and, therefore, inadequate oxygen to 90 mmHg and/or diastolic
the brain, heart, and other vital organs. Lightheadedness and dizziness can occur in measurements of lower than
60 mmHg.
a person with hypotension. Some medications, such as antianxiety drugs and diuret-
ics, can cause hypotension, as can alcohol and narcotics. Conditions such as advanced
diabetes, dehydration, or arrhythmia can also result in a patient suffering from hypo-
tension. Code category I95 will provide you with the details you will need to abstract
from the documentation about this diagnosis:

I95.0 Idiopathic hypotension

I95.1 Orthostatic hypotension
I95.2 Hypotension due to drugs
Use additional code for adverse effect, if applicable, to identify drug
I95.3 Hypotension of hemodialysis
I95.81 Postprocedural hypotension
I95.89 Other hypotension

Hypertension  (hyper = high or over +  tension = pressure) is a condition when Hypertension

blood pressure is too high. The increased force of the blood’s pressure moving through High blood pressure, usually a
the vessels can actually damage organs and tissues as the blood rushes through. chronic condition; often identi-
A health care professional will use a sphygmomanometer (blood pressure machine) fied by a systolic blood pres-
to measure a patient’s blood pressure and will document the results in two numbers. sure above 140 mmHg and/
or a diastolic blood pressure
For example: A patient’s blood pressure is documented in the chart as 125/85. The
above 90 mmHg.
number 125 represents the systolic pressure and the number 85 is the diastolic pres-
sure (see Table 11-1).
Systolic pressure (SP) is the measure of the maximum push of blood being forced
into an artery from the ventricle during a cardiac contraction. This is the top number
of a reported blood pressure.

TABLE 11-1  Blood Pressure Levels

Systolic/Diastolic Measurement (mmHg) Diagnosis

< 90/60 Hypotension
90–120/60–80 Normal
120–139/80–89 Prehypertension
140–159/90–99 Hypertension stage 1
160–179/100–109 Hypertension stage 2
180–209/110–119 Hypertension stage 3
210/120 + Hypertension stage 4

CHAPTER 11  | 
 Diastolic pressure (DP) is the measure of the pressure of blood left in the arteries
in between ventricular contractions. This is the bottom number of a reported blood
pressure.
Hypertension is a condition that millions of people must deal with every day and is
a major cause of death. According to the Centers for Disease Control and Prevention
(CDC), 29% of all American adults—70 million people—have high blood pressure.
These numbers include more women than men and a greater prevalence in individu-
als over 65 years of age. There are estimates that only about one-third of hypertensive
people have been officially diagnosed and are getting treatment. It is believed that as
many as 50% of all people over age 60 are included in these numbers.
The CDC also determined that high blood pressure was a primary or contributing
cause of death for more than 360,000 people in the United States in 2013. The risk of
heart disease is increased 300% by the presence of hypertension, and the risk of stroke
is increased 700%. Research also proves that African-Americans are at a much higher
risk of hypertension and its effects than any other racial or ethnic group.

Elevated Blood Pressure

Elevated Blood Pressure Elevated blood pressure is not the same as a diagnosis of hypertension. Almost any-
An occurrence of high blood one might have a single measure above the norm. Some individuals get nervous when
pressure; an isolated or infre- visiting a health care facility, while others may have just eaten something with a great
quent reading of a systolic deal of salt, causing an unusual measure one time. For his or her own reasons, the
blood pressure above physician may want to document a reading of elevated blood pressure and therefore
140 mmHg and/or a diastolic
include this as a diagnosis to be reported.
blood pressure above
90 mmHg. R03.0 Elevated blood-pressure reading, without diagnosis of hypertension
Hypertension is a chronic state of elevated blood pressure. Therefore, without the
specific diagnosis of hypertension, you, as the professional coder, cannot report a code
for hypertension.

Primary Hypertension
Hypertension frequently shows no signs and symptoms, other than continuous high
Vascular blood pressure measurements, until the condition alters vascular function in the heart,
Referring to the vessels (arter- brain, and/or kidneys. This effect is similar to what would happen if the pressure level
ies and veins). at which water flows through the pipes in your home increased: High pressure can
break a dish in your kitchen sink and make a mess. Patients with high blood pres-
sure specifically diagnosed as hypertension are known to suffer manifestations of this
condition, including damage to the heart and kidneys. Hypertension causes the heart
to work harder than normal and can result in left ventricular hypertrophy, which can
subsequently cause left-sided heart failure or right-sided heart failure as well as pul-
Edema monary edema (excess fluid in the tissues).
An overaccumulation of fluid There are many risk factors that promote the development of hypertension. Here are
in the cells of the tissues. a few of the most common:
∙ An underlying disorder such as renal disease or Cushing’s syndrome
∙ Chronic emotional stress
∙ A sedentary lifestyle
∙ Excessive sodium in diet
∙ Family history of hypertension
∙ Postmenopausal state
∙ Advancing age
∙ Excessive use of alcohol
∙ Obesity
∙ African-American ancestry

306   PART II  |  REPORTING DIAGNOSES

 A diagnosis will typically come from trending—charting the blood pressure read-
ings over time (an excellent tool in most electronic health record software programs). CODING BITES
In addition, a physician can support a diagnosis of hypertension with other data Hypertension is a sys-
derived from a variety of sources: temic disease, meaning
∙ Auscultation (listening to sounds with a stethoscope) over the abdominal aorta it can affect every part
as well as the carotid, renal, and femoral arteries may reveal bruits (an abnormal of the body, throughout
sound created by blood flowing past an obstruction; also known as turbulent flow). the patient’s entire sys-
tem. With this in mind, a
∙ Ophthalmoscopy (examination of the interior of the eye) may reveal arteriovenous diagnosis of hyperten-
nicking. sion will affect treatment
∙ Patient history may include a family history of hypertension. of almost any other
∙ Chest x-ray may reveal cardiomegaly (enlargement of the heart). condition, disease, or
∙ Echocardiography may show left ventricular hypertrophy (hyper = high or over + injury. Therefore, a code
-trophy = growth). for the hypertension is
almost always included,
∙ Electrocardiogram (ECG or EKG) may show ischemia (shortage of oxygen due to regardless of the reason
reduced or restricted blood flow). for the encounter and
When the documentation includes a specific diagnosis of hypertension, you, the even if treatment of the
coder, will need more information to accurately report this diagnosis. hypertension is not per-
formed directly.
Essential Hypertension
Essential (primary) hypertension is the usual type of hypertension. Code category I10
is used for any diagnosis written by the physician that is stated as high blood pressure,
arterial hypertension, benign hypertension, malignant hypertension, primary hyper-
tension, or systemic hypertension.
Most often, essential hypertension can be kept under control with diet (including
avoiding high-sodium foods) and medication (e.g., angiotensin-converting enzyme, or
ACE, inhibitors, diuretics, and beta-blockers).

ICD-10-CM
LET’S CODE IT! SCENARIO
Anna Epstein, a 63-year-old female, came to see Dr. Tanner. She was complaining of occasional dizziness and a
headache. After a complete examination, Dr. Tanner diagnosed Anna with idiopathic systemic hypertension.

Let’s Code It!

Dr. Tanner diagnosed Anna with idiopathic systemic hypertension. Let’s turn to the Alphabetic Index and find
the main term hypertension and begin reading. If you look down the alphabetic listing under hypertension, you
will see no listing for idiopathic or systemic. So go back to the very first entry for this key term, “Hypertension,
hypertensive,” and read the words shown in parentheses following that entry.
Do you see the words (idiopathic) and (systemic) included? Both of the adjectives used by Dr. Tanner in his
diagnostic statement are in the listing. Therefore, the diagnosis code for Anna’s current diagnosis is I10. Turn to
the Tabular List to double-check.
One more stop: Let’s turn to the Official Guidelines and check chapter 9. Diseases of the Circulatory System
(I00-I99), subsection a. Hypertension. There don’t seem to be any guidelines that relate to Dr. Tanner’s diagnosis
for Anna.
I10 Essential (primary) hypertension
high blood pressure
hypertension (arterial) (benign) (essential) (malignant) (primary) (systemic)
Perfect!

CHAPTER 11  | 
 Secondary Hypertension
There are occasions when another condition or a medication may cause hypertension
instead of hypertension causing other conditions (manifestations) in the patient. Medica-
tions, such as corticosteroids (e.g., prednisone), antidepressants (e.g., Sinequan), and hor-
mones (e.g., Estrace), or diseases, such as Cushing’s syndrome or scleroderma, may trigger
a hypertensive condition. When the hypertensive condition is generated by, or secondary
Secondary Hypertension to, another disease or medication, the condition is called secondary hypertension.
The condition of hypertension The involvement of renal disease as an underlying cause of hypertension, also
caused by another condition known as renovascular hypertension, may be diagnosed as a result of testing including:
or illness.
∙ Urinalysis, which shows protein levels and red and white blood cells indicating
glomerulonephritis (inflammation of small blood vessels in the kidneys).
∙ Excretory urography, which reveals renal atrophy (wasting away of a kidney),
pointing to chronic renal disease, or a shortening of one kidney, which may indicate
unilateral renal disease.
∙ Blood tests for serum potassium levels (measuring the levels of potassium in the
blood), which show levels below the normal measure of 3.5 mEq/L, which can indicate
primary hyperaldosteronism (hyper = high or over + aldosterone = a hormone pro-
duced by the adrenal cortex that prompts the kidney to preserve sodium and water).
Hypertension is coded as secondary when the physician uses terms such as “due
to” an underlying disease, “resulting from” another condition, or other descriptors that
GUIDANCE point to another disease or condition. In such cases, you will need two codes:
CONNECTION 1. The underlying condition
Read the ICD-10-CM 2. The type of secondary hypertension (I15.x)
Official Guidelines for
There is a notation to “Code also underlying condition.” Note that sequencing is
Coding and Report-
not identified in this notation. Therefore, you will need to report the two codes based
ing, section I. Con-
on the sequencing guidelines in the Official Guidelines, Section II, which will guide
ventions, General
you in determining the principal diagnosis code. So the order in which you will list the
Coding Guidelines
two codes is determined by the answer to the question, “Why did the patient come to
and Chapter Specific
see the physician today?”
Guidelines, subsec-
tion C. Chapter-Specific
Coding Guidelines, EXAMPLES
chapter 9. Diseases I15.0 Renovascular hypertension
of the Circulatory I15.1 Hypertension secondary to other renal disorders
System, subsection I15.2 Hypertension secondary to endocrine disorders
a.6) Hypertension, I15.8 Other secondary hypertension
secondary. I15.9 Secondary hypertension, unspecified

ICD-10-CM
LET’S CODE IT! SCENARIO
Breanna Payne, a 67-year-old female, came to see Dr. Lebonna in his office. She was having headaches and bouts
of dizziness. After a physical examination, a urinalysis, and blood work, he diagnosed her with benign hyperten-
sion. Dr. Lebonna’s notes stated that Breanna’s hypertension was the result of her existing diagnosis of pituitary-
dependent Cushing’s disease.

Let’s Code It!

Dr. Lebonna diagnosed Breanna with benign hypertension due to pituitary-dependent Cushing’s disease. This
means that Cushing’s disease caused Breanna’s hypertension. First, go to the Alphabetic Index and look

308   PART II  |  REPORTING DIAGNOSES

 under hypertension. Look down the indented column until you see “due to” (which is the same as “result of”
stated in the physician’s notes). Now, look at the indented listing under “due to”; you will see no listing for “Cush-
ing’s disease.” So “specified disease” is a strong consideration. You can also keep looking down the column until
you see “secondary” specified disease NEC I15.8. Both paths take you to the same suggested code:
Hypertension
  Due to
   Endocrine disorders I15.2

Now let’s check this code in the Tabular List:

I15.2 Hypertension secondary to endocrine disorders
Did you remember that the pituitary gland is a component of the endocrine system? Now, one more thing: Is
there a notation beneath I15 alerting you that something is missing?
Code also underlying condition

That’s right—a code for the Cushing’s disease. In the Alphabetic Index, you see the following under Cushing’s:
Cushing’s
  Syndrome or disease E24.9
   Pituitary-dependent E24.0

In the Tabular List, you will see

E24 Cushing’s syndrome

Next, there is an   note:

 congenital adrenal hyperplasia (E25.0)
Just because Breanna is 67 years old does not mean this isn’t a congenital condition. However, Dr. Lebonna pro-
vides no documentation stating that her Cushing’s disease is congenital, so this   note does not apply
to this patient for this encounter.
E24.0 Pituitary-dependent Cushing’s disease
Check for any relevant guidance, including reading all of the symbols and notations in the Tabular List and the
appropriate sections of the Official Guidelines. Nothing is directed to this specific case, so you will report these
two codes for this encounter between Dr. Lebonna and Breanna:
I15.2 Hypertension secondary to endocrine disorders
E24.0 Pituitary-dependent Cushing’s disease
How should these codes be sequenced? List the hypertension first (I15.2) because it was the symptoms of the
hypertension (headaches, dizziness) that brought Breanna to Dr. Lebonna’s office for this encounter.

Hypertensive Crisis
Code category I16 provides three codes for reporting a hypertensive crisis. This is
when a patient suffers an acute and dramatic increase in blood pressure, measuring
approximately 180/120. This situation can result in blood vessels becoming dam-
aged and leaking, as well as dysfunction of the heart’s ability to pump blood through
the body.
A hypertensive crisis is categorized as either urgent or emergency.

CHAPTER 11  | 
 ∙ I16.0 Hypertensive urgency identifies a patient with an extremely high spike of
CODING BITES blood pressure, with the belief that the vessels have not yet been damaged.
Code category I16 ∙ I16.1 Hypertensive emergency documents that the patient’s extraordinarily high
includes a notation blood pressure has caused damage to blood vessels and/or organs. This diagnosis
applicable to all codes can be associated with life-threatening complications.
in this category: ∙ I16.9 Hypertensive crisis, unspecified is a code that should rarely be reported.
Code also any identi- Instead, as you have learned, you should query the physician to determine what
fied hypertensive dis- type of crisis it is and have the documentation amended.
ease (I10-I15)
Hypertension and Pregnancy
When a pregnant woman has a diagnosis of hypertension, you will first need to determine
from the documentation whether she developed hypertension before or after conception.
A woman with a preexisting diagnosis of hypertension who then becomes pregnant
will be reported with the appropriate code from the  O10 Pre-existing hypertension
complicating pregnancy, childbirth, and the puerperium code category. A code from the
Gestational Hypertension O10 code category reports this situation clearly with additional details, provided by
Hypertension that devel- the fourth character, to report the specific hypertensive manifestation, if any:
ops during pregnancy and
typically goes away once the O10.0- Pre-existing essential hypertension complicating pregnancy, child-
pregnancy has ended. birth, and the puerperium
O10.1- Pre-existing hypertensive heart disease complicating pregnancy,
childbirth, and the puerperium
GUIDANCE O10.2- Pre-existing hypertensive chronic kidney disease complicating preg-
CONNECTION nancy, childbirth, and the puerperium
O10.3- Pre-existing hypertensive heart and chronic kidney disease compli-
Read the ICD-10-CM cating pregnancy, childbirth, and the puerperium
Official Guidelines for O10.4- Pre-existing secondary hypertension complicating pregnancy, child-
Coding and Report- birth, and the puerperium
ing, section I. Con-
ventions, General However, if the hypertension is diagnosed as  gestational hypertension, or tran-
Coding Guidelines sient hypertension, you will report a code from  O13 Gestational [pregnancy-induced]
and Chapter Specific hypertension without significant proteinuria. This is not unusual and generally means
Guidelines, subsec- that the hypertension will go away after the baby is born.
tion C. Chapter-Specific O13.1 Gestational [pregnancy-induced] hypertension without significant
Coding Guidelines, proteinuria, first trimester
chapter 9. Diseases O13.2 Gestational [pregnancy-induced] hypertension without significant
of the Circulatory proteinuria, second trimester
System, subsec- O13.3 Gestational [pregnancy-induced] hypertension without significant
tion a.7) Hypertension, proteinuria, third trimester
transient.
Should the woman’s diagnosed hypertension cause problems directly related to the
pregnancy or complicating the pregnancy, you will choose the best, most appropriate code
from ICD-10-CM’s Chapter 15, Pregnancy, Childbirth, and the Puerperium (O00–O9A).

ICD-10-CM
LET’S CODE IT! SCENARIO
Zena Browning, a 23-year-old female, is 20 weeks pregnant. Dr. Shinto diagnoses her with gestational hyperten-
sion. Even though there is no evidence of proteinuria, he is concerned about the effect of the condition on her preg-
nancy and writes a prescription.

Let’s Code It!

Zena Browning has gestational hypertension. Her hypertensive condition is complicating her pregnancy. Turn
to the term hypertension in the Alphabetic Index and look down the column of adjectives below the primary
term hypertension. You see

310   PART II  |  REPORTING DIAGNOSES

 Hypertension
  complicating
   pregnancy
    gestational (pregnancy-induced) (transient) (without proteinuria) O13.-
That matches Dr. Shinto’s notes. Now you must turn to the Tabular List to confirm the code and determine the
correct fourth character:
O13 Gestational [pregnancy-induced] hypertension without significant proteinuria
Now turn to the first page of Chapter 15 in ICD-10-CM to see the definitions of the trimesters. You can see the
information:
1st trimester—less than 14 weeks, 0 days
2nd trimester—14 weeks, 0 days to less than 28 weeks, 0 days
3rd trimester—28 weeks, 0 days until delivery
Zena is in her 20th week, so she is in her 2nd trimester. This points us to the correct fourth character of 2. The
code to be used for this visit between Dr. Shinto and Zena Browning is
O13.2 Gestational [pregnancy-induced] hypertension without significant proteinuria, second
trimester
Before you report this code, be certain to carefully check for any relevant guidance, including reading all of the
symbols and notations in the Tabular List and the appropriate sections of the Official Guidelines. Confirmed!
Good job!

GUIDANCE
11.4  Manifestations of Hypertension CONNECTION
Read the ICD-10-CM
Hypertensive Heart Disease Official Guidelines for
When a patient has heart disease or heart failure and also has hypertension, you must Coding and Reporting,
carefully examine the words used by the physician in the description. section I. Conven-
tions, General Coding
1. Heart condition due to hypertension
Guidelines and Chapter
2. Hypertensive heart condition Specific Guidelines,
3. Heart condition with hypertension subsection C. Chapter-
Specific Coding Guide-
If the physician states that the patient has both hypertension and heart disease,
lines, chapter 9. Dis-
a combination code from code category I11 Hypertensive heart disease must be
eases of the Circulatory
recorded.
System, subsection
I11.0 Hypertensive heart disease with heart failure a.1) Hypertensive with
Use additional code to identify type of heart failure (I50.-) heart disease.
I11.9 Hypertensive heart disease without heart failure

Hypertensive Heart Disease with Heart Failure CODING BITES

In cases where a physician states that a patient has heart failure due to hypertension, Determine what type of
you will need to heart failure the patient
has so you can report it
1. Use the appropriate fourth character, as shown in the Tabular List under category with an additional code.
I11. You learned about the dif-
2. Use additional code to specify the type of heart failure from category I50.-. ferent types of heart fail-
ure earlier in this chapter.
ICD-10-CM includes a notation directing you to “Use additional code to identify
type of heart failure (I50.-)” to remind you.

CHAPTER 11  | 
 EXAMPLE
Acute congestive heart failure due to benign hypertension  
You will report two codes, in this sequence: I11.0, I50.31
I11.0 Hypertensive heart disease with heart failure
I50.31 Acute diastolic (congestive) heart failure

ICD-10-CM
LET’S CODE IT! SCENARIO
Colin Fahey, a 53-year-old male, was diagnosed with chronic diastolic congestive heart failure due to benign hyper-
tension. Dr. Engman wrote a prescription for medication and scheduled follow-up tests.

Let’s Code It!

Colin was diagnosed with congestive heart failure due to benign hypertension.
Turn in the Alphabetic Index to find
Failure, failed
  heart (acute) (senile) (sudden) I50.9
   hypertensive—see Hypertension, heart
OK, turn to . . .
Hypertension, hypertensive (accelerated) (benign) (essential) (idiopathic) (malignant) (systemic) I10
  heart (disease) (conditions in I51.4-I51.9 due to hypertension) I11.9
Remember from earlier in this chapter that when the diagnostic statement is written “heart condition due to hyper-
tension,” the guidelines state that only one code, from category I11, is used. Turn to the Tabular List for I11:
I11 Hypertensive heart disease 
any condition in I51.4-I51.9 due to hypertension
This description fits perfectly. Now we must look at the fourth character. Dr. Engman wrote “congestive heart
failure,” bringing us to
I11.0 Hypertensive heart disease with heart failure
  Use additional code to identify type of heart failure (I50.-)
Does the documentation identify the specific type of heart failure? Yes, Dr. Engman indicated that Colin has con-
gestive heart failure. Let’s turn to
I50 Heart failure
Read the notation under the code:
Code first:
  heart failure due to hypertension (I11.0)
This is the book’s way of reinforcing the guideline as well as the notation that you found beneath I11. Continue
reading, and you see that the second code you need to include for Colin’s diagnosis is this:
I50.32 Chronic diastolic (congestive) heart failure
Be certain to check for any relevant guidance, including reading all of the symbols and notations in the Tabular
List and Section 1.c.9 of the Official Guidelines. There is nothing that alters the determination of these codes.
You need to show both codes for the visit between Colin and Dr. Engman:
I11.0 Hypertensive heart disease with heart failure
I50.32 Chronic diastolic (congestive) heart failure
Good work!

312   PART II  |  REPORTING DIAGNOSES

Hypertensive Chronic Kidney Disease
When a diagnosis of hypertensive chronic kidney disease is documented, you will
CODING BITES
report a combination code, as appropriate. In such cases, a cause-and-effect relation-
ship between the hypertension and the kidney disease does not need to be specifically If you can’t find the
stated by the physician. The mere existence of both conditions in the same body at information in the docu-
the same time is enough to report them together. You will need the documentation to mentation as to what
specify the stage of the chronic kidney disease to determine the correct code in ICD- stage of kidney disease
10-CM. Code category I12 is to be used for reporting a patient with a diagnosis of the patient has, query
hypertensive chronic kidney disease. the doctor.

 I12 Hypertensive chronic kidney disease

The fourth-character choices are

GUIDANCE
I12.0 Hypertensive chronic kidney disease with stage 5 chronic kidney
disease or end stage renal disease CONNECTION
Use additional code to identify the stage of chronic kidney disease Read the ICD-10-CM
(N18.5, N18.6) Official Guidelines for
I12.9 Hypertensive chronic kidney disease with stage 1 through stage Coding and Reporting,
4 chronic kidney disease or unspecified chronic kidney disease section I. Conven-
Use additional code to identify the stage of chronic kidney disease tions, General Coding
(N18.1-N18.4, N18.9) Guidelines and Chapter
You can see that beneath each of these codes is a notation: Specific Guidelines,
subsection C. Chapter-
∙ Beneath I12.20: Specific Coding
Use additional code to identify the stage of chronic kidney disease Guidelines, chapter 9.
(N18.5, N18.6) Diseases of the Circula-
tory System, subsec-
∙ Beneath I12.29:
tion a.2) Hypertensive
Use additional code to identify the stage of chronic kidney disease chronic kidney disease.
(N18.1-N18.4, N18.9)

ICD-10-CM
YOU CODE IT! CASE STUDY
Matthew Spencer, a 69-year-old male, is admitted to Franklin General Hospital for observation with a diagnosis of
stage 3 chronic renal disease due to benign hypertension.

You Code It!

Go through the steps of coding, and determine the code or codes that should be reported for Matthew Spen-
cer’s admission into the hospital.
Step #1: Read the case carefully and completely.
Step #2: Abstract the scenario. Which main words or terms describe why the physician cared for the patient dur-
ing this encounter?
Step #3: Are there any details missing or incomplete for which you would need to query the physician? [If so, ask
your instructor.]
Step #4: Check for any relevant guidance, including reading all of the symbols and notations in the Tabular List
and the appropriate sections of the Official Guidelines.
Step #5: Determine the correct diagnosis code or codes to explain why this encounter was medically necessary.
Step #6: Double-check your work.

(continued)

CHAPTER 11  | 
 Answer:
Did you determine these to be the diagnosis codes?

I12.9 Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease or
unspecified chronic kidney disease
N18.3 Chronic kidney disease, stage 3 (moderate)

Hypertensive Heart and Chronic Kidney Disease

If the patient is diagnosed with both hypertensive heart disease and hypertensive chronic
kidney disease, you will choose one combination code from category I13. Now, great
emphasis has been placed on the fact that you should never assume. You are permitted
to code only what you know for a fact from the documentation. But, as you know, every
GUIDANCE rule has an exception, and this is it. The Official Guidelines state that you “may assume
CONNECTION the relationship between the hypertensive heart disease and hypertensive renal disease
even if the physician does not state this relationship in the diagnosis.”
Read the ICD-10-CM
You will still need to confirm that a cause-and-effect relationship is specified for
Official Guidelines for
the hypertension and the heart condition, even though the cause-and-effect relation-
Coding and Reporting,
ship between the hypertension and the kidney disease does not have to be specified.
section I. Conven-
The additional-character choices for code I13 will identify whether the patient is docu-
tions, General Coding
mented to have
Guidelines and Chapter
Specific Guidelines, ∙ Heart failure or not
subsection C. Chapter- ∙ Stage 1, 2, 3, or 4 chronic kidney disease or unspecified stage
Specific Coding Guide-
∙ Stage 5 chronic kidney disease, or ESRD
lines, chapter 9. Dis-
eases of the Circulatory In addition to using this code, you will also need a code for the specific type of heart
System, subsection failure and another to report the stage of the kidney disease. ICD-10-CM includes
a.3) Hypertensive heart notations under code I13 to remind you of the additional coding:
and chronic kidney
Use additional code to identify type of heart failure (I50.-)
disease.
Use additional code to identify stage of chronic kidney disease (N18.-)

ICD-10-CM
YOU CODE IT! CASE STUDY
Clarissa Bennelli, a 71-year-old female, is seen at Weston Hospital with a diagnosis of acute systolic congestive
heart failure due to hypertensive heart disease. Ms. Bennelli responds positively to Lasix therapy. She is also diag-
nosed with stage 1 chronic renal disease.

You Code It!

Go through the steps of coding, and determine the code or codes that should be reported for Clarissa Bennelli’s
admission into the hospital.
Step #1: Read the case carefully and completely.
Step #2: Abstract the scenario. Which main words or terms describe why the physician cared for the patient dur-
ing this encounter?
Step #3: Are there any details missing or incomplete for which you would need to query the physician? [If so, ask
your instructor.]

314   PART II  |  REPORTING DIAGNOSES

 Step #4: Check for any relevant guidance, including reading all of the symbols and notations in the Tabular List
and the appropriate sections of the Official Guidelines.
Step #5: Determine the correct diagnosis code or codes to explain why this encounter was medically necessary.
Step #6: Double-check your work.
Answer:
Did you determine these to be the diagnosis codes?
I13.0 Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage
4 chronic kidney disease or unspecified chronic kidney disease
I50.21 Acute systolic (congestive) heart failure
N18.1 Chronic kidney disease, stage 1
Good job!

Hypertensive Retinopathy GUIDANCE

Retinopathy is a degenerative disease of the eye, most specifically the retina. The con- CONNECTION
dition can be caused by diabetes, hypertension, or other circumstances. In cases where
the patient is diagnosed with hypertensive retinopathy due to hypertension, you will Read the ICD-10-CM
need two codes to thoroughly report the patient’s condition. Official Guidelines for
Your first code is from the subcategory  H35.03- Hypertensive retinopathy. This Coding and Report-
code requires a sixth character to identify which eye is affected: ing, section I. Conven-
tions, General Coding
H35.031 Hypertensive retinopathy, right eye Guidelines and Chapter
H35.032 Hypertensive retinopathy, left eye Specific Guidelines, sub-
H35.033 Hypertensive retinopathy, bilateral section C. Chapter-
Then you will need an additional code to identify the type of hypertension that caused Specific Coding
the retinopathy. Choose that code from the I10–I15 range. There is a reminder notation Guidelines, chapter 9.
for you, shown beneath code H35.0: Diseases of the Circula-
tory System, subsec-
Code also any associated hypertension (I10.-) tion a.5) Hypertensive
retinopathy.
Hypertensive Cerebrovascular Disease
Patients diagnosed with cerebrovascular disease due to hypertension will have two
codes assigned. The first code will report the cerebrovascular disease, a code from the
I60–I69 range. The second code will identify the hypertension, using the appropriate
code from the I10–I15 range. Both the guidelines and a notation under the category
heading shown directly above code I60 remind you of the necessity for a second code.
You can see that the notation also instructs you as to in which order to place the codes:
Use additional code to identify presence of hypertension (I10-I15)

ICD-10-CM
YOU CODE IT! CASE STUDY
Denise Argudin, a 53-year-old female, came to see Dr. Fenwick because she was experiencing headaches and
problems with her vision. Denise was diagnosed with essential benign hypertension 3 years ago. After a thorough
physical examination and further questioning about her visual disturbances, Dr. Fenwick ordered a CT scan of her
head and a few other tests. The test results indicate that Denise has hypertensive encephalopathy.

(continued)

CHAPTER 11  | 
 You Code It!
Carefully review Dr. Fenwick’s notes on his visit with Denise, along with the test results. Determine the best, most
appropriate diagnosis code or codes.
Step #1: Read the case carefully and completely.
Step #2: Abstract the scenario. Which main words or terms describe why the physician cared for the patient dur-
ing this encounter?
Step #3: Are there any details missing or incomplete for which you would need to query the physician? [If so, ask
your instructor.]
Step #4: Check for any relevant guidance, including reading all of the symbols and notations in the Tabular List
and the appropriate sections of the Official Guidelines.
Step #5: Determine the correct diagnosis code or codes to explain why this encounter was medically necessary.
Step #6: Double-check your work.
Answer:

Did you determine these to be the diagnosis codes?

I67.4 Hypertensive encephalopathy
I10 Essential hypertension
Good job!

GUIDANCE 11.5  CVA and Cerebral Infarction

CONNECTION While arteries and veins run through the entire body, special attention is paid to those
that service the brain—the cerebellum—the cerebrovascular system.
Read the ICD-10-CM
Official Guidelines for
Coding and Report- CODING BITES
ing, section I. Con-
Cerebrovascular = cerebro = cerebellum (brain)
ventions, General
Coding Guidelines +
and Chapter Specific -vascular = blood vessels
Guidelines, subsec-
tion C. Chapter-Specific
A  cerebrovascular accident (CVA) is technically considered a condition of the
Coding Guidelines,
neurologic system, yet this diagnosis is reported with codes included in this subsection
chapter 9. Diseases of
(codes I60–I67) because a CVA is the result of an obstruction in a cerebral blood ves-
the Circulatory System,
sel. A cerebrovascular accident, also referred to as a stroke, is the result of a thrombus
subsection a.4) Hyper-
or embolism getting lodged in a cerebral vessel and preventing blood from flowing
tensive cerebrovascu-
through the area.
lar disease.
There are times when the blockage (occlusion) resolves quickly, either on its own or
from the administration of blood-thinning/clot-busting medication (tPA), making the
event short-lived. This is known as an ischemic attack (code categories I63, I65, and
Cerebrovascular Accident
I66) (Figure 11-4).
(CVA)
In some cases, the obstruction causes a backup of blood that subsequently bursts
Rupture of a blood vessel
causing hemorrhaging in the through the vessel wall and a hemorrhage floods the area of the brain. This is known
brain or an embolus in a blood as a hemorrhagic attack (code categories I60, I61, I67) (see Figure 11-5).
vessel in the brain causing a While a cerebrovascular accident is not technically the same as a cerebral infarction,
loss of blood flow; also known the term CVA is frequently used to indicate a cerebral infarction. An infarction occurs
as stroke. when the occlusion created by the thrombus deprives surrounding tissue of oxygen and the
cells die (necrosis).

316   PART II  |  REPORTING DIAGNOSES

 Cerebral Infarction
An area of dead tissue (necro-
sis) in the brain caused by a
blocked or ruptured blood
vessel.

Infarction
Tissue or muscle that has
deteriorated or died (necrotic).

FIGURE 11-4  Illustration highlighting the position of an embolus causing an isce-

mic stroke

GUIDANCE
CONNECTION
Read the ICD-10-CM
Official Guidelines for
Coding and Report-
ing, section I. Con-
ventions, General
Coding Guidelines
and Chapter Specific
Guidelines, subsec-
tion C. Chapter-Specific
Coding Guidelines,
chapter 9. Diseases of
the Circulatory System,
subsection c. Intraop-
erative and postproce-
dural cerebrovascular
accident.
FIGURE 11-5  Illustration highlighting an aneurysm causing a hemorrhagic stroke 

CHAPTER 11  | 
 You will need specific details about the patient’s condition, abstracted from the
documentation, to determine the correct code category, and then the correct code to
report:
∙ Was the attack a result of a hemorrhage from a cerebral aneurysm or an obstruction
from a thrombus or embolism?
∙ What is the specific anatomical site of the attack?
I61.- Nontraumatic intracerebral hemorrhage
I63.- Cerebral infarction (occlusion and stenosis of cerebral arteries,
resulting in cerebral infarction)
I65.- Occlusion and stenosis of precerebral arteries, not resulting in cere-
bral infarction
I66.- Occlusion and stenosis of cerebral arteries, not resulting in cerebral
infarction
It can happen that a cerebrovascular hemorrhage or infarction is brought about by a
GUIDANCE medical procedure, most typically surgery. When the procedure is plainly identified as
the cause of the infarction, you have to use two codes. The first code will be
CONNECTION
I97.810 Intraoperative cerebrovascular infarction during cardiac surgery
Read the ICD-10-CM I97.811 Intraoperative cerebrovascular infarction during other surgery
Official Guidelines for I97.820 Postprocedural cerebrovascular infarction following cardiac surgery
Coding and Reporting, I97.821 Postprocedural cerebrovascular infarction following other surgery
section I. Conven-
tions, General Coding As noted below code I97.8, you will need an additional code to identify the exact
Guidelines and Chapter complication. The second code will identify the exact nature of the infarction, and you
Specific Guidelines, will choose it from the I60–I67 range, as appropriate, according to the documentation.
subsection C. Chapter-
Specific Coding Guide- NIH Stroke Scale
lines, chapter 18.
Symptoms, signs, and
The National Institutes of Health Stroke Scale (NIHSS) is used to assess a patient’s
abnormal clinical and
cerebral activity and function after a cerebrovascular accident (CVA—also known as a
laboratory findings, not
stroke). The assessment tool provides health care professionals with a numeric (quan-
elsewhere classified,
tifiable) way to measure impairment.
subsection i. NIHSS
Code category R29.7 National Institutes of Health Stroke Scale (NIHSS) score pro-
Stroke Scale.
vides you with 43 codes from which to choose to accurately report the score. Notice
that this code is reported after the code to report the type of cerebral infarction (code
category I63).

ICD-10-CM
YOU CODE IT! CASE STUDY
Ruben Sackheim, a 55-year-old male, was brought into the recovery room after having a craniectomy for the drain-
age of an intracranial abscess. Dr. Turner’s notes indicate that Ruben had a postoperative cerebrovascular infarc-
tion with intracranial hemorrhage and an acute subdural hematoma.

You Code It!

Look at Dr. Turner’s notes for Ruben, and determine the best, most appropriate code or codes.
Step #1: Read the case carefully and completely.
Step #2: Abstract the scenario. Which main words or terms describe why the physician cared for the patient dur-
ing this encounter?
Step #3: Are there any details missing or incomplete for which you would need to query the physician? [If so, ask
your instructor.]

318   PART II  |  REPORTING DIAGNOSES

 Step #4: Check for any relevant guidance, including reading all of the symbols and notations in the Tabular List
and the appropriate sections of the Official Guidelines.
Step #5: Determine the correct diagnosis code or codes to explain why this encounter was medically necessary.
Step #6: Double-check your work.
Answer:

Did you determine these to be the diagnosis codes?

I97.821 Postprocedural cerebrovascular infarction following other surgery
I62.01 Nontraumatic acute subdural hemorrhage
Good job!

11.6  Sequelae of Cerebrovascular CODING BITES

Disease There is a NOTE in the
Tabular List, directly
The sequelae, or late effects, of cerebrovascular disease are coded differently from under code I69, that
other sequelae. reads:
ICD-10-CM provides a series of combination codes in category  I69 Sequela of
NOTE: Category I69 is
cerebrovascular disease. It is not unusual for patients who are status post CVA to
to be used to indicate
suffer with neurologic deficits that last past the initial onset of the condition. In such
conditions in I60–I67 as
cases, the physician must connect the dots and specifically identify the current condi-
the cause of sequelae.
tion as a sequela, or late effect, of the cerebrovascular issue.
The “sequelae” include
Should the patient be diagnosed with neurologic deficits from both a previous cere-
conditions specified as
brovascular condition and a current CVA, you are permitted to use both a code from
such or as residuals
the I60–I67 range and a code from the I69 category.
which may occur at any
time after the onset of
the causal condition.
EXAMPLES
Sometimes a deficit, known as a sequela from a CVA, includes:
• Cognitive deficit
• Speech and language deficit including aphasia, dysphasia, dysarthria, and flu-
ency disorders GUIDANCE
• Monoplegia (paralysis) of a limb (arm or leg)
CONNECTION
• Hemiplegia and hemiparesis (paralysis of one side of the body)
Read the ICD-10-CM
Official Guidelines for
Coding and Reporting,
When there are no neurologic deficits present and the patient has a personal history section I. Conven-
of cerebrovascular disease, you should use a code from subcategory Z86.7- Personal tions, General Coding
history of diseases of the circulatory system, and not code I69. Remember, you will Guidelines and Chapter
only code that history when it has been documented that the physician addressed the Specific Guidelines,
condition during the current encounter. subsection C. Chapter-
You will see similar notes in other locations as well. Sometimes, they can be confus- Specific Coding Guide-
ing to understand. What the note above means is this: When you read in the patient’s lines, chapter 9.
chart that he or she was previously diagnosed with a condition that was originally Diseases of the Circula-
reported with any of the codes in the range I60–I67 and, during this visit, the doctor tory System, subsection
documents that the patient currently has a neurologic deficit, such as paralysis or dys- d. Sequelae of cerebro-
phasia, that is a result of that earlier condition, you will use a code from category I69 vascular disease.
to report the new condition—the neurologic deficit.

CHAPTER 11  | 
 ICD-10-CM
LET’S CODE IT! SCENARIO
Arlene Williams goes to see Dr. McGovern. She was diagnosed with a cerebral embolism 3 months ago that has now
been resolved. She explains that she has been having difficulty putting words together to make a sentence and it
seems to be getting worse. After examination, Dr. McGovern diagnoses her with post-cerebral embolic dysphasia.

Let’s Code It!

Arlene has been diagnosed with post-cerebral embolic dysphasia. This is one way the physician may state that
the dysphasia is a late effect of the cerebral embolism she had before.
Turn to the ICD-10-CM Alphabetic Index and look up the term dysphasia.
There is one code suggested: R47.02. In the Tabular List, find the beginning of this code category:
R47 Speech disturbances, not elsewhere classified
Dysphasia is a speech disturbance—a problem speaking—so that is OK, so far. There is nothing in the  note
that relates to this patient. As you read down, you see that fourth and fifth characters are required, so continue
reading the column until you get to
R47.0 Dysphasia and aphasia
R47.02 Dysphasia
This is where the Alphabetic Index pointed you, so look closely at this code. Below it is another   note,
which tells you that this code does not include a diagnosis of dysphasia due to a late effect of cerebrovascular
accident and directs you to the codes in the I69 code category.
dysphasia following cerebrovascular disease (I69. with final characters -21)
Go back to the physician’s notes (the scenario). The documentation doesn’t state that Arlene had cerebrovascu-
lar disease; it states that she had a cerebral embolism. Is this the same thing, or is it unrelated to this notation?
This is the same thing: A cerebral embolism is a type of CVA. When you look it up, you will see that a cerebral
embolism is reported with code I66.9, clearly in the range of I60–I67. This means you will report the dysphasia
from a code in the I69 category.
Therefore, this  note applies to this encounter, and you must turn to code I69 to determine the
correct code to report Arlene’s diagnosis. The notation directly under  I69 Sequelae of cerebrovascular dis-
ease confirms that you are in the right place now. Read down and determine the code:
I69.821 Dysphasia following other cerebrovascular disease
Before you report this code, remember to check for any relevant guidance, including reading all of the symbols
and notations in the Tabular List and the appropriate sections of the Official Guidelines. No additional direction
is there and you can now report this code with confidence!
Good work!

CODING BITES
Read carefully! Dysphasia (ending in “sia”) means impaired speech and dyspha-
gia (ending in “gia”) means difficulty swallowing. Another word that is close is dys-
plasia, which means abnormal cell growth. Big difference!

Chapter Summary
Cardiovascular conditions may initially be treated within the specialty of a cardiologist.
However, the manifestations of heart failure and heart disease can affect the patient any-
where in the body—from the brain to the feet. Blood vessels extend throughout the body,
from the large aorta to the tiny capillaries, delivering oxygen and transporting carbon

320   PART II  |  REPORTING DIAGNOSES

dioxide back to the lungs so it can be released. When something goes awry, the health of

CHAPTER 11 REVIEW
the entire body, as well as the patient’s quality of life, can be negatively affected.
Hypertension is a condition that you may encounter as a professional coder while work-
ing for a family physician, an internist, a gerontologist, or a cardiologist. It can be a very
dangerous condition and can cause many co-morbidities and manifestations. As complex
as the condition is, so is the coding of the diagnosis. As with all other situations, it must be
diagnosed and documented by the attending physician. Read the notes carefully, and query
the physician when necessary to get all the specifics that you need to code accurately.

Source: http://www.cdc.gov/vitalsigns/heartdisease-stroke/infographic.html

CHAPTER 11 REVIEW
Coding Cardiovascular Conditions Enhance your learning by
completing these exercises
and more at connect.mheducation.com!

Let’s Check It! Terminology

Match each key term to the appropriate definition.

Part I
1. LO 11.2  Chest pain. A. Angina Pectoris
2. LO 11.3  An occurrence of high blood pressure; an isolated or infrequent reading B. Atherosclerosis
of a systolic blood pressure above 140 mmHg and/or a diastolic blood C. Atrium
pressure above 90 mmHg.
D. Cerebral Infarction
3. LO 11.5  A stroke.
E. Cerebrovascular
4. LO 11.5  An area of dead tissue (necrosis) in the brain caused by a blocked or Accident (CVA)
ruptured blood vessel.
F. Edema
5. LO 11.2  A  condition resulting from plaque buildup on the interior walls of the
G. Elevated Blood
arteries, causing reduced blood flow.
Pressure
6. LO 11.1  A thrombus that has broken free and is traveling freely within the vas-
H. Embolus
cular system.
7. LO 11.1  A chamber that is located in the top half of the heart and receives blood.
8. LO 11.3  An overaccumulation of fluid in the cells of the tissues.

Part II
1. LO 11.1  A chamber that is located in the bottom half of the heart and receives A. Gestational
blood from the atrium. Hypertension
2. LO 11.3  High blood pressure, usually a chronic condition; often identified by a B. Hypertension
systolic blood pressure above 140 mmHg and/or a diastolic blood pres-
sure above 90 mmHg.

CHAPTER 11  | 
 3. LO 11.3  Hypertension that develops during pregnancy and typically goes away C. Hypotension
CHAPTER 11 REVIEW

once the pregnancy has ended. D. Infarction

4. LO 11.1  A heart event during which the coronary artery is partially occluded E. Myocardial Infarction
(blocked). (MI)
5. LO 11.1  A heart event during which the coronary artery is completely blocked F. NSTEMI
by a thrombus or embolus.
G. Secondary
6. LO 11.1  A blood clot in a blood vessel. Hypertension
7. LO 11.1  A heart attack H. STEMI
8. LO 11.3  The condition of hypertension caused by another condition or illness. I. Thrombus
9. LO 11.5  Tissue or muscle that has deteriorated or died (necrotic). J. Vascular
10. LO 11.3  Referring to the vessels (arteries and veins). K. Ventricle
11. LO 11.3  Low blood pressure; systolic blood pressure below 90 mmHg and/or
diastolic measurements of lower than 60 mmHg.

Let’s Check It! Concepts

Choose the most appropriate answer for each of the following questions.
1. LO 11.2  _____ are blood vessels that carry oxygenated blood from the heart to the tissues and cells throughout
the body.
a. Arteries b.  Veins c.  Venules d.  Cardiovascular
2. LO 11.5  The patient is diagnosed with a cerebral infarction due to thrombosis of left anterior cerebral artery.
How is this coded?
a. I63.321 b.  I63.322 c.  I63.323 d.  I63.329
3. LO 11.1  _____ refers to an irregular heartbeat.
a. Angina b.  Dyspnea c.  Dysrhythmia d.  Edema
4. LO 11.4  If the patient has a diagnosis of heart failure due to hypertension, you will need to
a. use the appropriate fourth character, as shown in the Tabular List under category I11.
b. use an additional code to specify the type of heart failure from category I50.
c. use code I10.
d. use both the appropriate fourth character, as shown in the Tabular List under category I11, and an additional
code to specify the type of heart failure from category I50.
5. LO 11.1  A heart event during which the coronary artery is completely blocked by a thrombus or embolus is
called a(n)
a. myocardial infarction.
b. thrombus.
c. nontransmural myocardial infarction.
d. ST elevation myocardial infarction.
6. LO 11.3  A diagnosis of secondary hypertension means you will code
a. the underlying condition only.
b. the hypertension only.
c. the underlying condition code and the hypertension code.
d. the hypertension code first and then the underlying condition code.
7. LO 11.3  When a pregnant woman is diagnosed with hypertension, you must determine
a. if it is gestational hypertension. b.  if it is an infarction.
c. if it is transient hypertension. d.  if it is familial.

322   PART II  |  REPORTING DIAGNOSES

 8. LO 11.6  The code for a patient with no neurologic deficits and who had a previous diagnosis of cerebrovascular

CHAPTER 11 REVIEW
disease (which has since resolved) should be reported from
a. the I60–I69 range. b.  the I69 code category.
c. the Z86.7- code subcategory. d.  none of these.
9. LO 11.3  According to ICD-10-CM Official Guidelines section I.C.9.a.7 “Assign code _____, Elevated blood
pressure reading without diagnosis of hypertension, unless patient has an established diagnosis of
hypertension.”
a. R03.1 b.  I15.1 c.  R03.0 d.  I10
10. LO 11.3  A physician can support a diagnosis of hypertension with all of the following data except
a. auscultation over the abdominal aorta. b.  EKG.
c. chest x-ray. d.  ACE.

Let’s Check It! Guidelines

Refer to the Official Guidelines and fill in the blanks according to the Chapter 9, Diseases of the Circulatory System,
Chapter-Specific Coding Guidelines.
I13 current Two
site I60-I69 AMI
I69 STEMI before
hypertension secondary deficits
evolves admitted underlying
subendocardial first N18
combination  I15 Uncontrolled
1. The appropriate code from category _____ should be used as a _____ code with a code from category I12 to iden-
tify the stage of chronic kidney disease.
2. The codes in category _____, Hypertensive heart and chronic kidney disease, are _____ codes that include hyper-
tension, heart disease, and chronic kidney disease.
3. For hypertensive cerebrovascular disease, _____ assign the appropriate code from categories _____, followed by
the appropriate _____ code.
4. Secondary hypertension is due to an underlying condition. _____ codes are required: one to identify the _____
etiology and one from category _____ to identify the hypertension. Sequencing of codes is determined by the rea-
son for admission/encounter.
5. _____ hypertension may refer to untreated hypertension or hypertension not responding to current therapeutic regimen.
6. If a patient with coronary artery disease is _____ due to an acute myocardial infarction (AMI), the AMI should be
sequenced _____ the coronary artery disease.
7. Codes from category _____ may be assigned on a health care record with codes from I60-I67, if the patient has a
_____ cerebrovascular disease and _____ from an old cerebrovascular disease.
8. The ICD-10-CM codes for acute myocardial infarction (AMI) identify the _____, such as anterolateral wall or
true posterior wall.
9. If NSTEMI _____ to STEMI, assign the _____ code.
10. If an _____ is documented as nontransmural or subendocardial, but the site is provided, it is still coded as a _____ AMI.

Let’s Check It! Rules and Regulations

Please answer the following questions from the knowledge you have gained after reading this chapter.

1. LO 11.3  Differentiate between systolic pressure and diastolic pressure.

CHAPTER 11  | 
 2. LO 11.3  What is the difference between hypertension and elevated blood pressure?
CHAPTER 11 REVIEW

3. LO 11.3  What is gestational hypertension?

4. LO 11.1  Explain the difference between STEMI and NSTEMI.
5. LO 11.4   Read the ICD-10-CM Official Guidelines for Coding and Reporting, section I. Conventions, General
Coding Guidelines and Chapter Specific Guidelines, subsection C. Chapter-Specific Coding Guide-
lines, chapter 9. Diseases of the Circulatory System, subsection a.1) Hypertensive with heart disease.
Explain the coding guideline.

ICD-10-CM
YOU CODE IT! Basics
First, identify the main term in the following diagno- 8. Chronic embolism of superior vena cava:
ses; then code the diagnosis. a. main term: _____ b. diagnosis: _____
Example: Acute rheumatic myocarditis:  9. Rupture of pulmonary vessels:
a. main term: myocarditis b. diagnosis: I01.2 a. main term: _____ b. diagnosis: _____
10. Nonrheumatic pulmonary valve stenosis:
1. Acute diastolic (congestive) heart failure:
a. main term: _____ b. diagnosis: _____
a. main term: _____ b. diagnosis: _____
11. Arteriosclerotic endocarditis:
2. Secondary hypertension due to
pheochromocytoma: a. main term: _____ b. diagnosis: _____
a. main term: _____ b. diagnosis: _____ 12. Giant cell myocarditis:
3. Left posterior fascicular block: a. main term: _____ b. diagnosis: _____
a. main term: _____ b. diagnosis: _____ 13. Cardiac arrest due to cardiac condition:
4. Aneurysm of heart, 6 weeks’ duration: a. main term: _____ b. diagnosis: _____
a. main term: _____ b. diagnosis: _____ 14. Ventricular fibrillation:
5. Ischemic cardiomyopathy: a. main term: _____ b. diagnosis: _____
a. main term: _____ b. diagnosis: _____ 15. Neurogenic orthostatic hypotension:
6. Chronic total occlusion of coronary artery: a. main term: _____ b. diagnosis: _____
a. main term: _____ b. diagnosis: _____
7. Atherosclerosis of bypass graft of coronary artery
of transplanted heart:
a. main term: _____ b. diagnosis: _____

ICD-10-CM
YOU CODE IT! Practice
Using the techniques described in this chapter, carefully read through the case studies and determine the most
accurate ICD-10-CM code(s) and external cause code(s), if appropriate, for each case study.
1. Kitty Hearn, a 63-year-old female, presents today with the complaint of chest tightness. She also states that her left
jaw and shoulder hurt. Dr. Kickey notes diaphoresis. Kitty has smoked cigarettes for 40 years. Dr. Kickey com-
pletes an examination and reviews blood test results, which reveal a high level of creatine phosphokinase (CPK).
Kitty is admitted to the hospital, where a coronary angiography confirms the diagnosis of crescendo angina.
2. Calvin Ballew, an 8-year-old male, is brought in by his parents with the complaint that Calvin has been
“out of sorts” for the last day or two and has not been eating well. Dr. Barfield notes a cough and labored

324   PART II  |  REPORTING DIAGNOSES

 CHAPTER 11 REVIEW
breathing. After a thorough examination, Dr. Barfield decides to admit Calvin to Weston Hospital. The blood
tests reveal an increased erythrocyte sedimentation rate (ESR) and ECG confirms a diagnosis of chronic
rheumatic myocarditis.
3. Judith Raj, a 49-year-old female, has been diagnosed with hypertension heart disease and stage II chronic
kidney disease. Dr. Bennett documents the fact that Judith is not in heart failure at this time.
4. Kay Risinger, a 57-year-old female, presents today with chest pain and shortness of breath on exertion. Kay
also admits that it is difficult to breathe at night when lying in bed. Dr. Tate notes a cough and completes
a thorough examination. The echocardiogram confirms a diagnosis of rheumatic aortic regurgitation with
mitral valve disease.
5. Johnette Barrett, a 27-year-old female, is brought in by her husband, who is concerned because Johnette
has been very confused. Johnnette says her chest hurts and it feels like her heart is racing. Dr. Bakker notes
labored breathing. Patient is admitted to the hospital, where test results confirm the diagnosis of paroxysmal
atrial fibrillation.
6. Richard Grimm, a 57-year-old male, suffered a cerebral infarction 3 months ago due to an occlusion of the
left anterior cerebral artery. Richard is having difficulty with his speech and is finding it hard to write.
Dr. McManus diagnoses Richard with aphasia due to the cerebral infarction.
7. Vanessa Dostoimov, a 67-year-old female, had a pericardiotomy 6 weeks ago. Dr. Baker last saw Vanessa
2 weeks ago for a fever and chest pain. Today, Dr. Baker notes patient is experiencing similar symptoms today
and documents a pericardial rub, tachycardia, and hepatomegaly. Vanessa is admitted to the hospital for a
possible pericardiocentesis. After a thorough examination and review of the test results, Vanessa was diag-
nosed with postcardiotomy syndrome.
8. Jessie Jacobs, a 48-year-old female, presents today with the complaint of shortness of breath and weakness.
During the examination, Jessie experiences severe chest pain. Dr. Raley completes an ECG, which confirms a
diagnosis of acute transmural myocardial infarction ST elevated inferior diaphragmatic wall. Jessie is admit-
ted to Weston Hospital for stabilization and treatment.
9. Ben Jamison, a 51-year-old obese male, was diagnosed with a chronic embolism of the left subclavian vein.
10. James Tedder, a 62-year-old male, complains of chest tightness with physical activity. Jim also says he has a
funny feeling in his neck. Dr. Franklin notes tachycardia and admits him to Weston Hospital. A cardiac CT
scan and stress ECG confirm a diagnosis of silent myocardial ischemia.
11. Shirley Hatfield, a 59-year-old female, presents today with the complaint of a tender swollen left leg. Dr. Neal
documents a nonpressure ulceration left ankle limited to skin breakdown. After an examination and a Doppler
sonography were completed, Shirley was diagnosed with chronic total arterial occlusion of left extremity with
atherosclerosis of arteries of the left extremity.
12. Gary Allen, a 59-year-old male, presents today with chest pain and cough. Upon examination, Dr. Rogers
documents a low-grade fever, dyspnea, tachypnea, and a pleural friction rub. The decision is made to admit
Gary to Weston Hospital, where he is diagnosed with a saddle embolus of pulmonary artery with acute cor
pulmonale.
13. Earline Hodges, a 57-year-old female, has a sharp sudden chest pain. Dr. Harper notes a pericardial rub. The
laboratory results confirm infective pericarditis due to retrovirus.
14. Donald Ross, a 49-year-old male, presents today with numbness in his fingers and toes. Dr. Jones notes pale
coloration in the ring finger of his right hand. Don also states that the numbness is worse with temperature
changes. Dr. Jones completes a thorough examination and reviews the laboratory results, which confirm a
diagnosis of Raynaud’s syndrome without gangrene.
15. Dedrick Andrews, a 43-year-old male, presents today with a cough, fever, and night sweats. Dr. Jamerson
completes an examination, the appropriate laboratory tests, and a chest x-ray. Dedrick is diagnosed with sep-
tic arterial embolism of thoracic aorta with lung abscess due to MSSA.

CHAPTER 11  | 
CHAPTER 11 REVIEW

ICD-10-CM
YOU CODE IT! Application
The following exercises provide practice in abstracting physicians’ notes and learning to work with documenta-
tion from our health care facility, Prader, Bracker, & Associates. These case studies are modeled on real patient
encounters. Using the techniques described in this chapter, carefully read through the case studies and determine
the most accurate ICD-10-CM code(s) and external cause code(s), if appropriate, for each case study.

PRADER, BRACKER, & ASSOCIATES

A Complete Health Care Facility
159 Healthcare Way • SOMEWHERE, FL 32811 • 407-555-6789
PATIENT: PETERS, CHARLENE
ACCOUNT/EHR #: PETECH001
DATE: 08/11/18
Attending Physician: Renee O. Bracker, MD
S: Pt is a 68-year-old female who suffered a cerebral infarction 3 weeks ago. Her son is concerned
about the patient’s dysarthria, which doesn’t seem to be getting any better. The patient understands but
is having difficult pronouncing her words. Dr. Bracker also notes a low degree of audibility.
O: Ht. 5′4″, Wt. 146 lb., R 18, T 99.6, BP 138/95. Physical examination: unremarkable.
A: Dysarthria, following a cerebral infarction.
P: 1. Pt to return PRN
  2. Referral to speech therapist

ROB/pw  D: 08/11/18 09:50:16  T: 08/13/18 12:55:01

Determine the most accurate ICD-10-CM code(s).

WESTON HOSPITAL
629 Healthcare Way • SOMEWHERE, FL 32811 • 407-555-6541
PATIENT: CROWDER, CHRISTOPHER
ACCOUNT/EHR #: CROWCH001
DATE: 11/04/18
ATTENDING PHYSICIAN: Oscar R. Prader, MD
ADMITTING DIAGNOSES: Deep venous thrombosis (DVT) right leg
                                    Urinary tract infection (UTI)
                                 Parkinson’s disease
FINAL DIAGNOSES: Acute DVT, right
                      UTI
                      Parkinson’s disease
HOSPITAL COURSE: The patient presented to the office with left leg pain, and uneasiness as well as
cloudy urine. He was evaluated, and Doppler studies of the leg confirmed DVT. Urinalysis reveals infec-
tion and the patient was started on Levaquin and Lovenox subcu 1 mg per kg twice a day; after 3 days
patient asymptomatic for both with his urinary symptoms and calf pain. Patient’s vital signs are stable.
He is afebrile. Lungs clear. Heart rhythm regular.

326   PART II  |  REPORTING DIAGNOSES

 CHAPTER 11 REVIEW
Neurologic examination: Tremors and rigidity secondary to Parkinson’s disease. Rest is unremarkable.
His Doppler studies were positive for left popliteal vein thrombosis and flow abnormalities in superficial
femoral vein. The results of the pelvic sonogram reveal an enlarged prostate and questionable intralu-
minal. Right kidney, normal. Left kidney, cyst lower pole.
PT, INR on the day of discharge was 13.5 and 0.9 His UA was positive for blood, negative for leukocyte
esterase, nitrites, and WBC. His CHEM-7 showed sodium of 135, potassium 3.8, chloride 98, CO2 29,
sugar 126, BUN 18 mg/dL, and creatinine 1.1. WBC 6,500, H&H 17.2 and 52. Platelets 150,000. He
was discharged home.
DISPOSITION: Arrange for home health.
Follow-up with his primary physician in 7 to 10 days. Arrange for patient evaluation for repeat urinalysis
and urology consultation for possible BPH and bladder mass.

ORP/pw  D: 11/04/18 09:50:16  T: 11/07/18 12:55:01

Determine the most accurate ICD-10-CM code(s).

PRADER, BRACKER, & ASSOCIATES

A Complete Health Care Facility
159 Healthcare Way • SOMEWHERE, FL 32811 • 407-555-6789
PATIENT: NOLAN, SHERYESSE
ACCOUNT/EHR #: NOLASH001
DATE: 08/21/18
Attending Physician: Oscar R. Prader, MD
S: Pt is a 53-year-old female who comes in today complaining of fainting, chest pain, and difficulty
breathing of approximately 1 week duration. Patient was diagnosed 3 years ago with hypertension.
Hypertension has been under control with diet and exercise.
O: Ht. 5′5″, Wt. 153 lb., R 19, T 98.4, BP 148/89. Results of blood tests, UA, CBC, ECG, and echocardio-
gram indicate the development of renal sclerosis (stage 4) with benign hypertension. Tests also reveal
left ventricular failure and acute systolic heart failure.
A: Renal sclerosis with benign hypertension; left ventricular failure and acute systolic heart failure
P: 1. Pt to return PRN
  2. Referral for renal dialysis evaluation

ORP/pw  D: 08/21/18 09:50:16  T: 08/23/18 12:55:01

Determine the most accurate ICD-10-CM code(s).

PRADER, BRACKER, & ASSOCIATES

A Complete Health Care Facility
159 Healthcare Way • SOMEWHERE, FL 32811 • 407-555-6789
PATIENT: GUZMANN, EVAN
ACCOUNT/EHR #: GUZMEV001
DATE: 08/23/18

CHAPTER 11  | 
CHAPTER 11 REVIEW

Attending Physician: Renee O. Bracker, MD

S: Pt is a 68-year-old male returning to discuss test results done 2 days ago at our imaging center.
Patient is accompanied by his wife, Angie.
O: Ht. 5′10″, Wt. 184 lb., R 20, T 98.9, BP 134/86. I explain to the patient and his wife that the test
results show a narrowing of the basilar, carotid, and vertebral arteries on his right side, which we believe
to be the cause of the symptoms experienced by Mr. Guzmann that we discussed in our last encounter.
These arterial strictures account for the headaches, dizziness, and reduced mental acuity. There is cur-
rently no cerebral infarction. We discussed a variety of treatment options, and they both agreed to a
surgical consultation referral to explore the possibility of a shunt insertion.
A: Stenosis of precerebral arteries, including the basilar, carotid, and vertebral arteries
P: 1. Pt to return PRN
  2. Referral for surgical consult for shunt placement
ROB/pw  D: 08/23/18 09:50:16  T: 08/28/18 12:55:01

Determine the most accurate ICD-10-CM code(s).

WESTON HOSPITAL
629 Healthcare Way • SOMEWHERE, FL 32811 • 407-555-6541
PATIENT: WEINER, PHILLIP
ACCOUNT/EHR #: WEINPH001
DATE: 08/03/18
Attending Physician: Oscar R. Prader, MD
Pt is a 73-year-old male who was admitted to the hospital because of asthenia, xerostomia, fatigue. The
patient states he is very weak, drinks a lot of water, but has not been urinating much. His blood pressure
was 165/91, and he has been having pain in the left jaw and neck.
PMH: 2003 he had bladder suspension operation and has a history of PVCs.
The patient has had trouble with some edema of the ankles and feet.
The electrocardiogram shows a sinus rhythm with premature ventricular contractions.
FH: Father died of CVA. Mother died of stomach cancer.
CURRENT MEDICATIONS: Inderal; Ativan; Zestril
ALLERGIES: NKA
FINAL DIAGNOSES:
1.  Acute myocardial infarction—anterior wall
2.  Systemic arterial hypertension
3.  Cardiomegaly with chronic systolic CHF
4.  Cardiac arrhythmia

ORP/pw  D: 08/03/18 09:50:16  T: 08/05/18 12:55:01

Determine the most accurate ICD-10-CM code(s).

328   PART II  |  REPORTING DIAGNOSES

Coding Respiratory
Conditions
Learning Outcomes
12
Key Terms
After completing this chapter, the student should be able to: Chronic Obstructive
Pulmonary Disease
LO 12.1 Discern the various underlying causes of respiratory (COPD)
disorders. Exacerbation
LO 12.2 Report the different types of respiratory disorders. Influenza
LO 12.3 Determine the correct way to report cases of pneumonia and Pneumonia
influenza. Pneumothorax
Respiratory Disorder
LO 12.4 Analyze the details required to report chronic respiratory
Status Asthmaticus
conditions.
LO 12.5 Accurately code any involvement of tobacco in the patient’s
respiratory disorder.
LO 12.6 Identify the appropriate use of external cause codes when
applicable to respiratory conditions.

Remember, you need to follow along in

  STOP!  your ICD-10-CM code book for an optimal
ICD-10-CM

learning experience.

12.1  Underlying Causes of Respiratory Disease

Respiratory disorders can be caused by many things, including trauma, genetics, environ- Respiratory Disorder
mental concerns, congenital anomalies, and infection. Regardless of the underlying cause, A malfunction of the organ
having difficulty bringing oxygen into the lungs and getting carbon dioxide out of the body system relating to respiration.
can interfere with the patient’s quality of life—and, actually, the ability to live life at all.

Congenital Anomalies
Respiratory distress and cyanosis are the two most frequent manifestations of congeni-
tal anomalies of the lungs and are usually identified within the child’s first 24 months.
The most common congenital respiratory disorder is pulmonary hypoplasia, a situa-
tion in which the lung does not form completely or forms improperly. When you are
reporting this condition, ICD-10-CM requires you to determine from the documenta-
tion whether the pulmonary hypoplasia is a result of short gestation (i.e., prematu-
rity) or not. If the gestation is short, it is reported with code P28.0 Primary atelectasis
of newborn (pulmonary hypoplasia associated with short gestation). If it is not, it is
reported with code Q33.6 Congenital hypoplasia and dysplasia of lung.
The most common cause of neonate mortality is respiratory distress syndrome (RDS)
and it is seen most often in premature births. RDS can be fatal within 72 hours if not
treated. Mechanical ventilation improves patient outcomes. Idiopathic RDS is reported
with code P22.0 for a newborn or code J80 for acute RDS in a child or adult patient.
Remember, the definition of a neonate (newborn) is one who is age 28 days or younger.
 Genetic Disorders
CODING BITES
Congenital anomalies
Alpha-1 antitrypsin deficiency is a genetic condition that may cause respiratory dysfunc-
occur during gestation.
tion as well as liver disease. Individuals with an alpha-1 antitrypsin deficiency often will
However, the problem
develop emphysema, with the first signs and symptoms appearing in adulthood (between
may not be diagnosed
ages 20 and 50). Cystic fibrosis is another genetic condition that causes malfunction of the
until later on in the
mucous glands and results in progressive damage to the lungs. A mutation of the BMPR2
patient’s life.
gene causes pulmonary arterial hypertension, a genetic condition with extremely high
hypertension specifically in the pulmonary artery. Dyspnea and fainting are symptoms
of this condition. Primary pulmonary arterial hypertension is reported with code I27.0,
while secondary pulmonary arterial hypertension is reported with code I27.21.

Manifestations of Another Disease

Measles, as well as the adenovirus, may cause obliterative bronchiolitis (J44.9). Left-
sided heart failure can cause pulmonary edema (J81.0 or J81.1), an accumulation of
fluid in the lung. The administration of diuretics will help reduce the fluid, while
vasodilators are given to decrease vascular resistance. High concentrations of oxygen,
via cannula or facemask, will help improve the delivery of oxygen into the tissues.
Pleurisy, an inflammation of the parietal and visceral pleurae, is usually a com-
plication of another condition, such as pneumonia, lupus erythematosus, pulmonary
infarction, trauma to the chest, or tuberculosis. Tuberculous pleurisy, for example, is
reported with combination code A15.6.

Trauma
Car accidents and other activities can result in trauma to the chest, throat, or nose that
can interfere with a patient’s ability to breathe. Traumatic pneumothorax (S27.0xx-)
may result from a penetrating chest wound or can occur due to a medical misadven-
ture during the insertion of a central venous line or during thoracic surgery. During
a pneumothorax, air accumulates between the parietal and visceral pleurae, reducing
the space in the chest cavity and thereby limiting the room the lungs have to expand
during inhalation. When the lungs cannot expand properly, oxygen cannot be brought
down into the lungs far enough, so breathing becomes difficult and the exchange of
gases (oxygen and carbon dioxide) is hindered. Blunt trauma to the chest, or a pen-
etrating wound, can also cause hemothorax, in which blood (instead of air, as in pneu-
mothorax) fills the pleural cavity. Report this condition with code J94.2 Hemothorax.

ICD-10-CM
LET’S CODE IT! SCENARIO
Vincent Perdimo, a 17-year-old male, decided he wanted to audition for the State Fair. After watching some videos
online, he decided that he could do a fire-eating act. As he was practicing in his backyard, he accidentally aspirated
some of the isopropyl alcohol he poured in his mouth. After he began having problems breathing, his parents took
him to the ED. Dr. Van Hooven documented that Vincent had severe pulmonary complications, and appeared to
have pneumonitis with partial respiratory insufficiency. After a workup and testing, Vincent was admitted into the
hospital with a diagnosis of acute respiratory distress syndrome.

Let’s Code It!

Dr. Van Hooven diagnosed Vincent with acute respiratory distress syndrome.
In your ICD-10-CM code book, turn to the Alphabetic Index, and find
Syndrome
Read all the way down this long list and find

330   PART II  |  REPORTING DIAGNOSES

 Syndrome
   respiratory
     distress
       acute J80
         adult J80
This is a great start. Turn to J80 in the Tabular List.
J80 Acute respiratory distress syndrome
respiratory distress syndrome in newborn (perinatal) (P22.0)
This code’s description matches Dr. Van Hooven’s documentation perfectly. And the  note does not
apply because Vincent is not a newborn.
Check the top of this subsection and the head of this chapter in ICD-10-CM. There are no notations at the
beginning of this subsection; however, there are notations at the beginning of this chapter: a NOTE, a Use
additional code note, and an notation. Read carefully. Do any relate to Dr. Van Hooten’s diagnosis
of Vincent? No. Turn to the Official Guidelines and read Section 1.c.10. There is nothing specifically applicable
here, either.
Now you can report J80 for Vincent’s diagnosis with confidence. Hold it! Vincent’s respiratory distress syn-
drome did not just occur; it was the result of an external cause. Turn to the ICD-10-CM Index to External Causes.
What should you look up? Do you think it has a listing for fire-eating? You never know, so take a look. Nope. Dr.
Van Hooten documented that this happened because Vincent “aspirated” isopropyl alcohol. Try looking up Aspi-
ration. Isopropyl alcohol is definitely not food, not a foreign body, and not vomitus. Hmm. What now?
As you think about what actually happened to Vincent, it was the isopropyl alcohol in his lungs that caused
the problem. Perhaps this should be reported as a poisoning because this is a chemical. Turn in the Table of
Drugs and Chemicals and find
Alcohol
   isopropyl
Look across on this line to the first column. It is documented that this was an accident, so the code T51.2x1 is
suggested. Turn to the Tabular List to this code category:
T51 Toxic effect of alcohol
Read all of the fourth character options and you will see:
T51.2 Toxic effect of 2-Propanol (Toxic effect of isopropyl alcohol)
   T51.2x Toxic effect of 2-Propanol (Toxic effect of isopropyl alcohol)
     T51.2x1 Toxic effect of 2-Propanol (Toxic effect of isopropyl alcohol), accidental (unintentional)
Look back up to the top of this code category. There is a box containing the options for the seventh character.
This was the first time Dr. Van Hooven cared for Vincent for this respiratory condition, so use the seventh char-
acter: A = Initial encounter.
Now you know, with confidence, what codes to report for Vincent’s diagnosis:
J80 Acute respiratory distress syndrome
T51.2x1A Toxic effect of 2-Propanol (Toxic effect of isopropyl alcohol), accidental (unintentional),
­initial encounter
Good coding!

Environment
Respiratory dysfunction can be caused by elements in the world around us. Those
­elements can be natural, like volcanic dust from an erupting volcano or dander from
cats, or human-made, such as asbestos in the ceiling (J61). Legionnaires’ disease, an

CHAPTER 12  | 
 aerobic Gram-negative bacillus, is transmitted through the air—for example, through
air-conditioning systems (J67.7). Men are more susceptible than women. Administra-
tion of antibiotics, specifically erythromycin, is the primary treatment, along with
fluid replacement and oxygen administration, if necessary. When a patient is diag-
nosed with coal worker’s pneumoconiosis, another environmentally caused lung dis-
ease, this is reported with code J60 Coal worker’s pneumoconiosis, along with code
Y92.64 Mine or pit as the place of occurrence of the external cause and Y99.0 Civilian
activity done for income or pay.
Some patients may suffer respiratory problems from air contaminants at work, which
would be reported with a subsequent code; for example: Z57.31 Occupational expo-
sure to environmental tobacco smoke; Z57.39 Occupational exposure to other air con-
taminants; Z77.110 Contact with and (suspected) exposure to air pollution; or  Z77.22
Contact with and (exposure to) environmental tobacco smoke (acute) (chronic).

Lung Infections
Both bacteria and viruses can cause respiratory disorders. Bacterial pneumonia
(J15.-), community-acquired pneumonia, nosocomial (originating in a hospital) pneu-
monia, viral pneumonia (J12.-), and opportunistic pneumonia (affecting individuals
with compromised immunities) are common examples of respiratory infection. In
addition, bronchitis (inflammation of the bronchi) (J20.-) and influenza (J09.- or J10.-)
are also frequently seen, particularly in children and the elderly. Viruses affecting the
pulmonary parenchyma result in interstitial pneumonia (J84.9). Mycobacterium tuber-
culosis, acquired by inhaling aerosols, has been seen more often in the last several
years, especially in patients who are HIV-positive and have developed AIDS. When an
HIV-positive patient is diagnosed with tuberculosis affecting the lungs, this condition
would be reported with code B20 HIV, followed by code A15.0 Tuberculosis of the lung.

Lifestyle Behaviors
Smoking cigars and cigarettes is known to cause respiratory disorders, including lung
cancer. In addition, sedentary lifestyles can encourage the creation of thrombi in the
legs. What does that have to do with the lungs? A dislodged thrombus becomes an
embolus that can travel through the pulmonary artery into the lungs, becoming a pul-
monary embolus. An acute pulmonary embolism NOS is reported with code I26.99;
however, several other details are required for a complete code.

GUIDANCE CONNECTION
At the very beginning of this chapter in ICD-10-CM, there is a Use additional code
notation. It states:
Use additional code, where applicable, to identify:
exposure to environmental tobacco smoke (Z77.22)
exposure to tobacco smoke in the perinatal period (P96.81)
history of tobacco use (Z87.891)
occupational exposure to environmental tobacco smoke (Z57.31)
tobacco dependence (F17.-)
tobacco use (Z72.0)
This applies to all codes in this chapter of ICD-10-CM, which makes sense, right?
It has been proven that inhaling tobacco has a negative effect on the pulmonary
system. If the physician’s documentation is not clear on this detail, you must query
the physician to have it added, if applicable, so you can report this code, as well
as the specific respiratory diagnosis.
See more details about this later in this chapter, in the section Reporting
Tobacco Involvement.

332   PART II  |  REPORTING DIAGNOSES

 ICD-10-CM
YOU CODE IT! CASE STUDY
Baby boy Luciano was born vaginally at 33 weeks. Complete physical exam performed. No anomalies were noted
with the exception of a perforated nasal septum. He is admitted into the NICU (Neonatal Intensive Care Unit). Dr.
Aronson, a pediatrician specializing in congenital respiratory disorders, was called in for a consultation.

You Code It!

What ICD-10-CM code or codes will you use to report baby boy Luciano’s diagnosis?
Step #1: Read the case carefully and completely.
Step #2: Abstract the scenario. Which main words or terms describe why the physician cared for the patient dur-
ing this encounter? 
Step #3: Are there any details missing or incomplete for which you would need to query the physician? [If so, ask
your instructor.]
Step #4: Check for any relevant guidance, including reading all of the symbols and notations in the Tabular List
and the appropriate sections of the Official Guidelines.
Step #5: Determine the correct diagnosis code or codes to explain why this encounter was medically necessary.
Step #6: Double-check your work.
Answer:
Did you determine this to be the code?
Q30.3 Congenital perforated nasal septum

12.2  Disorders of the Respiratory System

Pleural Disorders
The pleura is made up of two membranes: the visceral pleura, a thin membrane that coats
the outside of the lung, and the parietal pleura, a membrane that lines the inside of the tho-
racic (chest) cavity. Pleurisy, also known as pleuritis, identifies the presence of inflamma-
tion on one or both of the pleural membranes. This condition can cause pain to the patient
with each breath. A virus is most often the cause. To report pleurisy, the Alphabetic Index
provides a long list of possibilities that lead to a surprisingly short number of codes:
A15.6 Tuberculous pleurisy
J10.1 Influenza due to other identified influenza virus with other
­respiratory manifestations
R09.1 Pleurisy
J90 Pleurisy with effusion, not elsewhere classified
S27.63XA Injury to the pleura, laceration of pleura, initial encounter
(Note: Of course, you remember that with code S27.63XA, an external cause code should
be reported to identify how the injury happened, as well as the place of occurrence.)
The very narrow space between the two pleural membranes is referred to as the
pleural space or pleural cavity. Normally, this space contains a tiny amount of fluid,
just enough to enable the visceral pleura and the parietal pleura to move and function
without irritation. If excess air or fluid gets into this space, it can cause pressure on the
lung and prevent the patient from inhaling because the lung does not have the room
required to expand as the oxygen is brought in. Pleural space disorders include pleural
effusion, pneumothorax, and hemothorax:

CHAPTER 12  | 
 ∙ Pleural effusion: The presence of excess fluid in the pleural cavity, frequently a
manifestation of congestive heart failure.
J94.0 Chylous effusion
J91.0 Malignant pleural effusion
P28.89 Newborn pleural effusion
Pneumothorax ∙ Pneumothorax: The presence of excess air or gases in the pleural space, typi-
A condition in which air or gas cally caused by respiratory disease such as chronic obstructive pulmonary disorder
is present within the chest (COPD) or tuberculosis (TB).
cavity but outside the lungs.
J93.81 Chronic pneumothorax
J86.9 Pyothorax without fistula (empyema) [an infection within the
­pleural space]
∙ Hemothorax: An accumulation of blood in the pleural cavity, most often caused by
an injury to the thoracic cavity (the chest).
J94.2 Hemothorax

Pulmonary Embolism
As you probably remember, an embolus is the medical term for a blood clot (thrombus)
CODING BITES or other tiny piece of bone marrow fat (most often created by high cholesterol) that
Why is a hemothorax travels within the bloodstream. During its passage through the body, this embolus can
coded as a type of pleu- get stuck in an artery and block the flow of blood through that area. When this occurs
ral effusion? Remember in the lungs, it is called a pulmonary embolism.
that a pleural effusion The presence of a pulmonary embolism can create serious problems for the patient,
is the accumulation of including dyspnea (shortness of breath), pain, and/or hemoptysis (coughing up blood).
excessive fluid in the Over the course of time, a pulmonary embolism can result in permanent damage to the
pleural space. Blood is a lung as well as damage to the organs being denied oxygen because of the blockage. A
type of fluid. pulmonary embolism can also cause an infarction (necrotic tissue) due to the lack of oxy-
gen to the cells. A large clot, or cluster of several clots, can result in the patient’s death.
I26.02 Saddle embolus of pulmonary artery with acute cor pulmonale
I27.82 Chronic pulmonary embolism

ICD-10-CM
LET’S CODE IT! SCENARIO
Fawn Springwater, a 3-year-old female, was brought to her pediatrician, Dr. Canterberg, with an odd-sounding
cough and chest congestion. She had the measles just a short time prior. After a complete PE and the appropriate
tests, Dr. Canterberg diagnosed Fawn with the croup.

Let’s Code It!

Fawn was diagnosed with the croup. Let’s turn to the Alphabetic Index:
Croup, croupous (catarrhal) (infective) (inflammatory) (nondiphtheritic) J05.0
The Tabular List confirms:
J05 Acute obstructive laryngitis [croup] and epiglottitis
You can see a Use additional code notation beneath this code category directing you to “identify the infectious
agent.” Notice that croup is included, in brackets. This is the common term for the medical diagnosis of acute
obstructive laryngitis. However, this is not what Fawn was diagnosed with, so keep reading down the column to
review the choices for the required fourth character:
J05.0 Acute obstructive laryngitis
Good job!

334   PART II  |  REPORTING DIAGNOSES

Respiratory Syncytial Virus Infections
While most adults and teenagers suffer only mild symptoms (similar to a cold), respiratory
syncytial virus infection (RSV) can cause serious problems for infants. Similar to other
infectious diseases, RSV can be spread from person to person by touching an infected per-
son or by coming in contact with an infected object like a toy or a tabletop. Upon infection,
infants can have difficulty breathing, stuffy noses, and fever. RSV is actually the pathogen
that causes respiratory illness in young children such as pneumonia or acute bronchitis.
B97 Viral agents as the cause of diseases classified elsewhere
Read down the column to review your choices for the required fourth character.
B97.4 Respiratory syncytial virus (RSV) as the cause of diseases classi-
fied elsewhere
This code looks perfect except for one thing. Did you read the note directly above code
B95 that states:
NOTE: These categories are provided for use as supplementary or additional
codes to identify the infection agent(s) in diseases classified elsewhere.
So, if the notes state that the child has pneumonia due to RSV, you would first list the
pneumonia followed by B97.4.

Pulmonary Fibrosis
Fibrosis is the creation of extra fibrous tissue (also known as scar tissue) in response to
inflammation or irritation. When this abnormal process occurs in the lungs, it is called
pulmonary fibrosis. This development of thickened tissue reduces the flexibility of
the lung sac, making it harder for the lungs to expand with inspiration and contract
for expiration. Idiopathic pulmonary fibrosis may also be referred to as cryptogenic
fibrosing alveolitis, diffuse interstitial fibrosis, idiopathic interstitial pneumonitis, and
Hamman-Rich syndrome.
Pulmonary fibrosis may be caused by another disease, such as tuberculosis, or
develop as a result of debris inhaled from an environment, such as the dust that may
be breathed in by sand blasters or coal miners during their work. Pulmonary fibrosis is
also associated as a side effect of certain medications.
J84.10 Pulmonary fibrosis, unspecified

ICD-10-CM
YOU CODE IT! CASE STUDY
Hans Surgesson, a 47-year-old male, has been suffering with chronic inflammation of his left bronchus. He admits to
previous crack cocaine use but denies current use. He complains of a dry, hacking, paroxysmal cough and occasional
dyspnea lasting at least 5 months. Chest x-ray and pulmonary function tests lead Dr. Mellville to diagnose Hans with
idiopathic pulmonary fibrosis due to mucopurulent chronic bronchitis. Hans is placed on oxygen therapy immediately.

You Code It!

Go through the steps of coding, and determine the diagnosis code or codes that should be reported for this
encounter between Dr. Mellville and Hans.
Step #1: Read the case carefully and completely.
Step #2: Abstract the scenario. Which main words or terms describe why the physician cared for the patient dur-
ing this encounter? 

(continued)

CHAPTER 12  | 
 Step #3: Are there any details missing or incomplete for which you would need to query the physician? [If so, ask
your instructor.]
Step #4: Check for any relevant guidance, including reading all of the symbols and notations in the Tabular List
and the appropriate sections of the Official Guidelines.
Step #5: Determine the correct diagnosis code or codes to explain why this encounter was medically necessary.
Step #6: Double-check your work.
Answer:
Did you determine these to be the correct codes?
J84.112 Idiopathic pulmonary fibrosis
J41.1 Mucopurulent chronic bronchitis

Terrific!

GUIDANCE Respiratory Failure

CONNECTION Respiratory failure identifies that a patient’s lungs are not working efficiently. The
result may be a reduced intake of oxygen or an excess of carbon dioxide that is not
Read the ICD-10-CM thoroughly being expelled from the lungs, or both. You have learned throughout this
Official Guidelines for chapter about the problems that can occur in the body when it does not get enough
Coding and Report- oxygen, a condition called hypoxemic respiratory failure, or when there is too much
ing, section I. Con- carbon dioxide, a condition called hypercapnic respiratory failure.
ventions, General Respiratory failure can be a manifestation of a respiratory disease, such as COPD.
Coding Guidelines In addition, certain injuries can affect a patient’s ability to breathe. For example, a
and Chapter Specific spinal cord injury may involve damage to the nerves that control breathing. A drug
Guidelines, subsec- or alcohol overdose can also have an impact on the nervous system in a manner that
tion C. Chapter-Specific affects the nervous system’s ability to properly control respiration. Code choices
Coding Guidelines, include
chapter 10. Diseases
of the Respiratory Sys- J96.0- Acute respiratory failure
tem, subsection b. Acute J96.1- Chronic respiratory failure
Respiratory Failure. J96.2- Acute and chronic respiratory failure
The physician may diagnose the patient with acute respiratory failure as a primary
diagnosis when it meets the requirements to be first-listed as directed in the Official
Guidelines. More typically, you will find that respiratory failure will be a secondary
diagnosis, as mentioned previously.

12.3  Pneumonia and Influenza

Pneumonia
Pneumonia Pneumonia is a serious infection of the lung parenchyma (tissue) and typically hin-
An inflammation of the lungs. ders the exchange of gases. When an individual with normal, healthy lungs contracts
pneumonia, the expectation of a complete recovery is good. However, early treatment
is important. Even with this good news, pneumonia is one of the top 10 leading causes
of death in the United States. A virus, bacterium, fungus, or other type of protozoan
can cause pneumonia. You have to know which type of pneumonia the patient has
contracted in order to code it accurately.

336   PART II  |  REPORTING DIAGNOSES

Viral Pneumonia
∙ Influenza
∙ Adenovirus
∙ Respiratory syncytial virus
∙ Measles (rubeola)
∙ Chickenpox (varicella)
∙ Cytomegalovirus
Bacterial Pneumonia
∙ Streptococcus (Streptococcus pneumoniae)
∙ Klebsiella
∙ Staphylococcus
Protozoan Pneumonia
∙ Pneumocystis carinii
Aspiration pneumonia is a specific type of condition that results from the patient vom-
iting and then inhaling gastric or oropharyngeal contents into the trachea and/or lungs.

GUIDANCE
EXAMPLES
CONNECTION
J12.0 Adenoviral pneumonia
J15.0 Pneumonia due to Klebsiella pneumoniae Read the ICD-10-CM
Official Guidelines
Note that these examples of pneumonia codes are both combination codes,
for Coding and
reporting both the condition (pneumonia) and the pathogen (adenovirus or Kleb-
Reporting, section I.
siella). Not all pneumonia codes are combination codes, so you may need to
­Conventions, General
remember to use an additional code to identify the pathogen.
Coding Guidelines
and Chapter Specific
Pneumonia as a Manifestation of HIV Guidelines, subsec-
tion C. ­Chapter-Specific
In some cases, pneumonia may be a manifestation of HIV infection. Therefore, if the ­Coding Guidelines,
notes report that the patient has also been diagnosed with HIV-positive status, you chapter 10. ­Diseases
have to include of the Respiratory
B20 Human immunodeficiency virus (HIV) disease ­System, subsec-
tion c. Influenza due
Code B20 should be listed first, followed by the appropriate pneumonia code. There to certain identified
are other types of pneumonia that may have other underlying diseases. Read the nota- ­influenza viruses.
tions carefully.

ICD-10-CM
LET’S CODE IT! SCENARIO
Craig Alaksar, a 13-year-old male, came to see Dr. Winston with a complaint of a sore throat, fever, cough, chills,
and malaise. Dr. Winston examined Craig, took a chest x-ray, and did a WBC count. After reviewing the results of the
exam and tests, Dr. Winston diagnosed Craig with adenovirus pneumonia.

Let’s Code It!

Dr. Winston identified Craig’s health concern as adenovirus pneumonia. The Alphabetic Index will direct you to
Pneumonia
  Adenoviral J12.0

(continued)

CHAPTER 12  | 
 Will the Tabular List confirm that it is the correct code? Turn to
J12 Viral pneumonia, not elsewhere classified
There are no notations or directions, so keep reading to review all of the choices for the required fourth character:
J12.0 Adenoviral pneumonia
You will remember that when there is an infectious organism involved, you must code it. Dr. Winston’s notes
identify it as the adenovirus. Should you use an additional code or not?
Professional coding specialists are responsible for relating the entire story with all specific details applicable
to the diagnosis. This one combination code tells both the condition and the infectious organism. There is no
reason to provide a second code to repeat the same information. Therefore, the code on Craig’s claim form will
be J12.0 alone.

GUIDANCE Ventilator-Associated Pneumonia

CONNECTION When a patient needs help breathing because of a malfunction in the respiratory sys-
tem, he or she may be placed on a ventilator, a machine that will essentially complete
Read the ICD-10-CM respiration. While the patient is hooked up to the machine, which uses a tube placed
Official Guidelines for into the patient’s throat, pathogens can travel directly into the patient’s lungs, poten-
Coding and Report- tially resulting in the development of ventilator-associated pneumonia (VAP). The
ing, section I. Con- attending physician must specifically document the diagnosis of VAP before you can
ventions, General report code J95.851. Only the physician can link the ventilator with the infection. If the
Coding Guidelines documentation is not clear, you must query the physician for clarification.
and Chapter Specific Beneath this code is a Use additional code notation reminding you that you will need to
Guidelines, subsec- report a second code to identify the specific organism responsible for this infection. Also,
tion C. Chapter-Specific an notation directs you to report code P27.8 instead if the patient is a newborn.
Coding Guidelines,
chapter 10. Diseases
of the Respiratory Influenza
System, subsection Influenza, the formal term for what is commonly known as the Flu or the grippe, is a
d. Ventilator associated highly contagious and serious illness. It is a respiratory tract infection that can affect
Pneumonia. individuals of all ages, but it is most dangerous to young children, the elderly, and
those who have chronic diseases because these individuals have immune systems that
Influenza are more sensitive and more susceptible. 
An acute infection of the The signs and symptoms that are inclusive in a diagnosis of influenza include
respiratory tract caused by the
influenza virus. ∙ Achy feeling in the muscles, or overall body ache
∙ Chills
CODING BITES ∙ Fever
Do you know the dif-
∙ Headache
ference between a ∙ Cough
cold and the Flu? Colds ∙ Sore throat
rarely cause a fever or
headaches. To code a diagnosis of influenza correctly, you have to know what virus is involved:
Do you know that J09.X- Influenza due to identified novel influenza A viruses
what is commonly known [Avian influenza] [Bird influenza] [Swine influenza]
as the “stomach flu” is J10.- Influenza due to other identified influenza virus
actually gastroenteritis— J11.- Influenza due to unidentified influenza virus
inflammation in the
stomach and small As you abstract the documentation, you will need to look for mention of any mani-
intestines? festations, such as respiratory, gastrointestinal, encephalopathy, myocarditis, or otitis
media, for example. You will need these details to determine the fifth character.

338   PART II  |  REPORTING DIAGNOSES

 ICD-10-CM
YOU CODE IT! CASE STUDY
Andrea Ignitto, a 21-year-old female, came into the University Clinic with complaints of nasal congestion, cough, sore
throat, fatigue, and overall aches. She states that she has had bouts of mild diarrhea for the last 2 days. She indicates
that her roommate and about five others on her dorm floor were sick with similar symptoms. She has a low grade
fever, chills, and nausea but denies vomiting. She claims loss of appetite and feeling weak with generalized aches
and pains. Her cough is mostly nonproductive. She denies chest pain or shortness of breath.
PAST MEDICAL HISTORY: Right knee surgery. [She is a soccer captain.]
CURRENT MEDICATIONS: Birth control pills
ALLERGIES: Sulfa
SOCIAL HISTORY: The patient drinks a couple of beers per week.
REVIEW OF SYSTEMS: Essentially as in the HPI.
OBJECTIVE:
VITAL SIGNS: Blood pressure 116/82, pulse 100, temperature 100.4F, respiratory rate is 18. Pain is 7/10. Saturation
is 97% on room air.
GENERAL: The patient is looking unwell, but in no acute distress.
HEENT: Atraumatic and normocephalic. Pupils are equal, round, reactive to light, and accommodation. Extraocular
movements are intact. There is no icterus, cyanosis, or pallor of the conjunctivae. Tympanic membranes are dull but
not inflamed bilaterally. Nasal turbinates are congested with clear exudates. Sinuses are uncomfortable to percus-
sion. Posterior pharynx is minimally erythematous. No exudates are noted.
CHEST: Air entry is adequate bilaterally with occasional scattered rhonchi. No crackles are appreciated.
HEART: Sounds 1 and 2 are heard and are normal. Regular rate and rhythm, somewhat tachycardic, but no murmurs,
gallops, or rubs.
ABDOMEN: Soft and nontender. Bowel sounds are present but somewhat hyperactive. There is no hepatosplenomegaly.
SKIN: Clear, slight pallor.
EXTREMITIES: Without edema, cyanosis, or clubbing.
Specimen taken and tested in our office lab. Novel A influenza virus is confirmed.
ASSESSMENT: Influenza with gastrointestinal manifestations.
PLAN:
1.  The patient will be put on Phenergan with Codeine 5 mL p.o. t.i.d. for 7 days.
2.  Zyrtec 10 mg p.o. daily for 10 to 14 days.
3. She is instructed to take Tylenol p.r.n. for aches and pains, to drink a lot of liquids, and to stay in the dorm, in bed
if possible, and rest.
4.  She has been given a note for her coach and any professors.
5.  If she does not get any better, she will come back.
Gary H. Mulder, MD

You Code It!

Read carefully about Dr. Mulder’s diagnosis of Andrea and determine the correct diagnosis code or codes.
Step #1: Read the case carefully and completely.
Step #2: Abstract the scenario. Which main words or terms describe why the physician cared for the patient
­during this encounter? 

(continued)

CHAPTER 12  | 
 Step #3: Are there any details missing or incomplete for which you would need to query the physician? [If so, ask
your instructor.]
Step #4: Check for any relevant guidance, including reading all of the symbols and notations in the Tabular List
and the appropriate sections of the Official Guidelines.
Step #5: Determine the correct diagnosis code or codes to explain why this encounter was medically necessary.
Step #6: Double-check your work.
Answer:
Did you determine this to be the code?
J09.X3 Influenza due to identified novel influenza A virus with gastrointestinal manifestations

12.4  Chronic Respiratory Disorders

Chronic Obstructive Pulmonary Disease
Chronic Obstructive One of the most common respiratory disorders that you may code is chronic
­Pulmonary Disease (COPD) ­obstructive pulmonary disease (COPD). It is estimated that as much as 10% of the
An ongoing obstruction of the world population over age 40 has a lung disorder that is on a par with COPD. COPD is
airway. distinguished by restricted airflow. It is not fully reversible and, therefore, is a leading
cause of disability and death. Clinically, there are three types of COPD:
∙ Chronic bronchitis
∙ Emphysema
∙ Asthma

EXAMPLES
J40 Bronchitis, not specified as acute or chronic
J41.- Simple and mucopurulent chronic bronchitis
J42 Unspecified chronic bronchitis
J43.- Emphysema
J44.- Other chronic obstructive pulmonary disease
J45.- Asthma

Diagnoses in the COPD section can be particularly complex. You will need to be
very diligent as you read the terms in the physician’s notes and those included in the
code descriptions. It is, as always, crucial that you refer to the index and then verify
the code in the Tabular List.
Let’s look at some of the diagnostic statements that might be used in the documen-
tation, by reading through the note under J44.
 J44 Other chronic obstructive pulmonary disease
asthma with chronic obstructive pulmonary disease
chronic asthmatic (obstructive) bronchitis
chronic bronchitis with airways obstruction
chronic bronchitis with emphysema

340   PART II  |  REPORTING DIAGNOSES

 chronic emphysematous bronchitis
chronic obstructive asthma CODING BITES
chronic obstructive bronchitis Never, never, never,
chronic obstructive tracheobronchitis never code out of
There is also an note that will remind you to read very carefully. You the Alphabetic Index.
can see that chronic obstructive bronchitis is INCLUDED in the J44 code category, Always confirm the
while chronic bronchitis is EXCLUDED. This is the ICD-10-CM book’s way of code by reading the
reminding you that one word—“obstructive”—makes a big difference as to which complete description in
code to report. the Tabular List.

ICD-10-CM
LET’S CODE IT! SCENARIO
Tiffany Burnstein, a 57-year-old female, quit smoking 2 years ago after a two-pack-a-day habit that lasted 40 years.
She came to see Dr. Mercado with an insidious onset of dyspnea, tachypnea, and malaise. PE showed use of her
accessory muscles for respiration. Dr. Mercado took a chest x-ray, EKG, RBC count, and pulmonary function test. The
results directed a diagnosis of panlobular emphysema.

Let’s Code It!

Dr. Mercado diagnosed Tiffany with panlobular emphysema. The Alphabetic Index shows
Emphysema
   Panlobular J43.1
Go to the Tabular List to confirm this code:
J43 Emphysema
Read the Use additional code notation carefully, as well as the note. Does either of them relate to
Tiffany’s condition? Yes, the note to Use additional code for “history of tobacco use” applies. First, keep reading
and review all of the choices for the required fourth character:
J43.1 Panlobular emphysema
Now let’s follow the lead to the code for “history of tobacco use.” Turn to code Z87:
Z87 Personal history of other diseases and conditions
Z87.891 Personal history of nicotine dependence
Now you have two codes to report the story of why Dr. Mercado cared for Tiffany:
J43.1 Panlobular emphysema
Z87.891 Personal history of nicotine dependence

Exacerbation and Status Asthmaticus

You may notice that some of the codes in this section have the designation for acute
exacerbation of asthma, COPD, or other related condition. It is a clinical term and can Exacerbation
be assigned only by the attending physician. An increase in the severity of
Acute exacerbation of asthma indicates an increase in the severe nature of a a disease or its symptoms.
patient’s asthmatic condition. The patient may be suffering from wheezing or short-
ness of breath, commonly called an asthma attack. Status asthmaticus, however, is a Status Asthmaticus
life-threatening condition and is a diagnosis indicating that the patient is not respond- The condition of asthma that
ing to therapeutic procedures. If a patient is diagnosed with status asthmaticus and is life-threatening and does
COPD or acute bronchitis, the status asthmaticus should be the first-listed code. As a not respond to therapeutic
life-threatening condition, it is considered to be the diagnosis with the greatest severity treatments.

CHAPTER 12  | 
 and follows the sequencing rules that you learned earlier. In addition, status asthmati-
CODING BITES cus, being the more severe condition, will override an additional diagnosis of acute
If both diagnoses are exacerbation of asthma.
included in the notes—
status asthmaticus and
acute exacerbation of
asthma—use only one GUIDANCE CONNECTION
asthma code, for status
Read the ICD-10-CM Official Guidelines for Coding and Reporting, section I.
asthmaticus. Do not use
Conventions, General Coding Guidelines and Chapter Specific Guidelines,
two asthma codes.
subsection C. Chapter-Specific Coding Guidelines, chapter10. Diseases of the
Respiratory System, subsection a. Chronic Obstructive Pulmonary Disease
[COPD] and Asthma.

ICD-10-CM
LET’S CODE IT! SCENARIO
Isabella LaVelle, a 41-year-old female, has a history of intermittent dyspnea and wheezing. She comes today to see
Dr. Slater with complaints of tachypnea, chest tightness, and a cough with thick mucus. The results of Dr. Slater’s PE,
the chest x-ray, sputum culture, EKG, pulmonary function tests, and an arterial blood gas analysis indicate moderate,
persistent asthma with COPD, with exacerbation.

Let’s Code It!

Dr. Slater’s diagnosis of Isabella’s condition is moderate, persistent asthma with COPD, with exacerbation. This
is also referred to as chronic obstructive asthma. Let’s turn to the Alphabetic Index and look up
Asthma
  With
   Chronic obstructive pulmonary disease J44.9
    With
     Exacerbation (acute) J44.1
That’s great, it matches perfectly. Turn in the Tabular List to
J44 Other chronic obstructive pulmonary disease
You can see “chronic obstructive asthma” in the list. Also notice the instruction to Code also type of
asthma, if applicable (J45.-).
J44.0 Chronic obstructive pulmonary disease with acute lower respiratory infection
J44.1 Chronic obstructive pulmonary disease with (acute) exacerbation
J44.9 Chronic obstructive pulmonary disease, unspecified
You can see that J44.1 matches. Terrific! Now let’s turn to J45 to determine the additional code for the asthma.
Go back to Dr. Slater’s notes and determine if Isabella’s asthma is documented as mild, moderate, or severe
and if her condition is intermittent or persistent. Then match all of the options within code category J45 to deter-
mine which code is accurate:
J45.41 Moderate persistent asthma with (acute) exacerbation
One more detail to address: Certainly you saw the Use additional code notation regarding tobacco exposure,
use, dependence, or history. Is there documentation that Isabella was a smoker? No! Good for her (and good for
you). Now you have the codes to report this encounter:
J44.1 Chronic obstructive pulmonary disease with (acute) exacerbation
J45.41 Moderate persistent asthma with (acute) exacerbation
Good job!

342   PART II  |  REPORTING DIAGNOSES

 ICD-10-CM
YOU CODE IT! CASE STUDY
Oliver Rockwell, a 61-year-old male, was brought into the emergency department (ED) by ambulance because he
was having a severe asthma attack. His wife, Karolyn, stated that he was diagnosed with asthma about 2 years
prior. This attack began 5 days ago and has not responded to his inhaler, his regular asthma pills, or any other treat-
ment. Dr. Pressman diagnosed Oliver with acute exacerbation of late-onset severe, persistent asthma with status
asthmaticus.

You Code It!

Go through the steps of coding, and determine the diagnosis code or codes that should be reported for this
encounter between Dr. Pressman and Oliver.
Step #1: Read the case carefully and completely.
Step #2: Abstract the scenario. Which main words or terms describe why the physician cared for the patient dur-
ing this encounter? 
Step #3: Are there any details missing or incomplete for which you would need to query the physician? [If so, ask
your instructor.]
Step #4: Check for any relevant guidance, including reading all of the symbols and notations in the Tabular List
and the appropriate sections of the Official Guidelines.
Step #5: Determine the correct diagnosis code or codes to explain why this encounter was medically necessary.
Step #6: Double-check your work.
Answer:

Did you determine this to be the correct code?

J45.52 Severe persistent asthma with status asthmaticus

You are really getting good at this!

12.5  Reporting Tobacco Involvement

One set of elements that has become required is the reporting of tobacco use, abuse,
and/or dependence. For example, at the start of ICD-10-CM Chapter 10, Diseases of
the Respiratory System (J00–J99), there is a notation that applies to all codes within:
Use additional code, where applicable, to identify:
  Exposure to environmental tobacco smoke (Z77.22)
  Exposure to tobacco smoke in the perinatal period (P96.81)
  History of tobacco use (Z87.891)
  Occupational exposure to environmental tobacco smoke (Z57.31)
  Tobacco dependence (F17.-)
  Tobacco use (Z72.0)
Surely you know that tobacco use can be a risk factor to the development of respi-
ratory illness. ICD-10-CM makes it easier to collect data on tobacco use. To do so,
you need to understand what the terms exposure, use, abuse, dependence, and history
really mean.
∙ Exposure means that the patient has been in contact with, or in close proxim-
ity to, a source of tobacco smoke in such a way that the harmful effects of this

CHAPTER 12  | 
 agent may impact the patient. When it comes to health care issues, this would
apply to an individual who does not use tobacco products but lives or works
with someone who smokes, resulting in the patient’s breathing in secondhand
tobacco smoke on an ongoing basis. If this individual develops a respiratory
disease as a result of this environment, you would include a code to report this
exposure.

EXAMPLE
Z77.22 Contact with and (suspected) exposure to environmental tobacco
smoke (acute) (chronic) [Exposure to second hand tobacco smoke]

∙ Use is the term that identifies that the patient smokes tobacco on a regular basis,
taken by his or her own initiative, even though the substance is known to be a detri-
ment to one’s health. There are no obvious clinical manifestations.

EXAMPLE
Z72.0 Tobacco use

∙ Abuse describes the patient’s habitual smoking of tobacco, taken by his or her own
initiative, even though the substance is known to be a detriment to one’s health.
Clinical manifestations are evident as signs and symptoms develop. The patient
deals with a daily fixation on obtaining and smoking tobacco with virtually every-
thing else in life becoming secondary.

EXAMPLE
F17.218 Nicotine dependence, cigarettes, with other nicotine-induced
disorders

∙ Dependence indicates the patient’s compulsive, continuous smoking of tobacco

that has resulted in significant clinical manifestations as well as the physiologi-
cal need for the substance to function normally. Any interruption results in signs
and symptoms of withdrawal, occurring within a continuous 12-month time
frame.

EXAMPLE
F17.220 Nicotine dependence, chewing tobacco, uncomplicated

∙ History describes a patient who has successfully quit using tobacco products.

EXAMPLE
Z87.891 Personal history of tobacco dependence

344   PART II  |  REPORTING DIAGNOSES

 ICD-10-CM
YOU CODE IT! CASE STUDY
Evan Pattison has been smoking cigarettes for more than 10 years. He has tried to quit several times, unsuccess-
fully. Evan tells the doctor that he has been very stressed and smoking much more than usual and now his throat
hurts and his voice is hoarse. Dr. Dieter evaluates Evan and determines acute laryngitis due to tobacco dependence.

You Code It!

Read the scenario and determine what code or codes you need to report why Dr. Dieter cared for Evan.
Step #1: Read the case carefully and completely.
Step #2: Abstract the scenario. Which main words or terms describe why the physician cared for the patient dur-
ing this encounter? 
Step #3: Are there any details missing or incomplete for which you would need to query the physician? [If so, ask
your instructor.]
Step #4: Check for any relevant guidance, including reading all of the symbols and notations in the Tabular List
and the appropriate sections of the Official Guidelines.
Step #5: Determine the correct diagnosis code or codes to explain why this encounter was medically necessary.
Step #6: Double-check your work.
Answer:

Did you determine these to be the codes?

J04.0 Acute laryngitis
F17.210 Nicotine dependence, cigarettes, uncomplicated

12.6  Respiratory Conditions Requiring

­External Cause Codes
Earlier in this text, you learned about external cause codes and how to determine
whether they are necessary. There are respiratory conditions that may require external
cause codes to explain how, and sometimes where, an external condition was involved
in causing this health problem. Some of these conditions are
J39.8: Cicatrix of trachea might need an external cause code to identify it as a late GUIDANCE
effect of an injury or poisoning. CONNECTION
J67.0: Farmer’s lung might need an external cause code for a workers’ compensa-
Read the ICD-10-CM
tion claim.
Official Guidelines for
J68.-: Respiratory conditions due to inhalation of chemicals, gases, fumes, and
Coding and Report-
vapors would need an external cause code to identify the chemical.
ing, section I. Con-
J70.-: Respiratory conditions due to other external agents would need an external
ventions, General
cause code to identify the external cause of the condition.
Coding Guidelines
J95.811: Postprocedural pneumothorax would need an external cause code to
and Chapter Specific
identify that it was a postoperative condition.
Guidelines, subsec-
tion C. Chapter-Specific
External Cause Codes Coding Guidelines,
chapter 20. External
When a patient has been injured traumatically, has been poisoned, has had an adverse Causes of Morbidity.
reaction, has been abused or neglected, or has experienced other harm as a result of

CHAPTER 12  | 
 an external cause, you will need to report the details of the event so that you tell the
CODING BITES whole story. In addition to reporting the other codes, you will also need to report codes
Refer back to that explain
the Abstracting Clinical ∙ Cause of the injury, such as a car accident or a fall off a ladder.
Documentation chapter
to remind yourself about ∙ Place of the occurrence, such as the park or the kitchen.
reporting external cause ∙ Activity during the occurrence, such as playing basketball or gardening.
codes whenever you ∙ Patient’s status, such as paid employment, on-duty military, or leisure activity.
are reporting an injury
or poisoning.

ICD-10-CM
LET’S CODE IT! SCENARIO
Amanda Bleigh, a 33-year-old female, works in a veterinary clinic. After a very sick stray animal was brought in, she
was instructed by her boss to disinfect the floor of the clinic by mopping it with straight bleach. It was cold outside,
so all the doors and windows were closed tightly. Amanda began to have trouble breathing. She went immediately
to Dr. Litzkom’s office, where, after examination and tests, he diagnosed her with acute chemical bronchitis.

Let’s Code It!

Dr. Litzkom diagnosed Amanda with acute chemical bronchitis. In the Alphabetic Index:
Bronchitis
  Acute
   chemical (due to gases, fumes, or vapors) J68.0
Will the Tabular List confirm this suggested code?
J68 Respiratory conditions due to inhalation of chemicals, gases, fumes, and vapors
Did you notice that there are two notations: Code first (T51–T65) to identify cause and Use additional code to
report the associated respiratory condition. Keep reading down the column to
J68.0 Bronchitis and pneumonitis due to chemicals, gases, fumes, and vapors (chemical bronchi-
tis (acute))
Next, you must report how and where Amanda was exposed to the chemical. Let’s go to the Alphabetic Index for
external cause codes and look up how Amanda was injured by the bleach—she inhaled the chemical:
Inhalation
  gases, fumes, or vapors NEC T59.9-
   specified agent—see Table of Drugs and Chemicals, by substance
Turn to the Table of Drugs and Chemicals and look down the first column to find bleach:
Bleach NEC
Reading across this line, in the column titled “Poisoning, Accidental,” you will see the suggested poisoning
code. Remember: If the condition was not an adverse reaction to properly prescribed and taken medication, it is
reported as a poisoning. The code suggested on the line for bleach is T54.91.
Now turn to the Tabular List to confirm the most accurate code. Let’s begin with the poisoning code:
T54 Toxic effect of corrosive substances
There are no notations or directives, so keep reading to find the most accurate fourth, fifth, and sixth
characters:

346   PART II  |  REPORTING DIAGNOSES

 T54.91xA Toxic effect of unspecified corrosive substance, accidental (unintentional), initial encounter
This does look like the best choice.
In addition, Amanda was at work when the exposure happened, so you will need an external cause code to
report where she was at the time of her injury. The External Cause Code Alphabetic Index will direct you:
Place of occurrence
     hospital Y92.239
            cafeteria Y92.233
            corridor Y92.232
There is no specific listing for veterinary clinic. However, hospital does come the closest. Let’s turn to the code
in the Tabular List and check the description:
Y92.232 Corridor of hospital as the place of occurrence of the external cause
Well, that really does hit the target. Remember, the code is being included to explain that Amanda was hurt at
work; such information is most often required to support a workers’ compensation claim.
These are the three codes on Amanda’s report:
J68.0 Bronchitis and pneumonitis due to chemicals, gases, fumes and vapors (chemical
­bronchitis (acute))
T54.91xA Toxic effect of unspecified corrosive substance, accidental (unintentional), initial encounter
Y92.232 Corridor of hospital as the place of occurrence of the external cause

Chapter Summary
Sadly, most people take breathing for granted . . . until they cannot do it without
difficulty or pain. You have to know how to code respiratory conditions accurately
whether you are working for a family physician, a pediatrician, respiratory therapist,
or a pulmonologist. In addition, respiratory conditions might be present in a patient of
an immunologist; allergist; or ear, nose, and throat (ENT) specialist.

CODING BITES
Did you know . . . ?
• The average healthy adult’s respiration rate is 12 to 15 per minute. Adult men
breathe more slowly than adult women. Neonates breathe 30 to 60 times per
minute. 
• The entire surface area of both lungs combined is approximately the same sur-
face area as a tennis court.
• Expiration (breathing out) not only expels carbon dioxide from the body, but
water as well—an estimated 12 ounces a day.
• A yawn is an autonomic response when your brain determines the body needs
more oxygen.
• The left lung is smaller than the right lung to accommodate the placement of the
heart in the thoracic cavity.

CHAPTER 12  | 
 CHAPTER 12 REVIEW
CHAPTER 12 REVIEW

Coding Respiratory Conditions Enhance your learning by

completing these exercises and
more at connect.mheducation.com!

Let’s Check It! Terminology

Match each key term to the appropriate definition.
1. LO 12.4  An increase in the severity of a disease or its symptoms. A. Chronic Obstructive
2. LO 12.3  An acute infection of the respiratory tract caused by the influenza Pulmonary Disease
virus. (COPD)
3. LO 12.4  An ongoing obstruction of the airway. B. Exacerbation
4. LO 12.1  A malfunction of the organ system relating to respiration. C. Influenza
5. LO 12.3  An inflammation of the lungs. D. Pneumonia
6. LO 12.4  The condition of asthma that is life-threatening and does not respond to E. Pneumothorax
therapeutic treatments. F. Respiratory Disorder
7. LO 12.2  A condition in which air or gas is present within the chest cavity but G. Status Asthmaticus
outside the lungs.

Let’s Check It! Concepts

Choose the most appropriate answer for each of the following questions.
1. LO 12.4  COPD stands for 
a. chronic obstructive pneumonia dyspnea.
b. chronic olfactory pharyngitis disease.
c. chronic other pneumonic disease.
d. chronic obstructive pulmonary disease. 
2. LO 12.4  One of the three types of COPD is
a. sinusitis. b.  pneumonia. c.  emphysema. d.  pharyngitis.
3. LO 12.3  When the cause of pneumonia is an underlying disease such as HIV, the codes should be sequenced
a. pneumonia first, underlying disease second.
b. pneumonia only.
c. underlying disease only.
d. underlying disease first, pneumonia second. 
4. LO 12.1  Respiratory disorders can be
a. genetic. b.  environmental. c.  congenital. d.  all of these.
5. LO 12.3  When a known infectious organism is involved in a respiratory condition,
a. code only the infectious organism.
b. code both the known organism and the respiratory condition.
c. code only the respiratory condition.
d. use a personal history code. 
6. LO 12.4  If the diagnostic statement includes both status asthmaticus and acute exacerbation of asthma,
a. code only the status asthmaticus.
b. code only the acute exacerbation of asthma.

348   PART II  |  REPORTING DIAGNOSES

 c. code both status asthmaticus and acute exacerbation with two codes.

CHAPTER 12 REVIEW
d. these two diagnoses cannot be in the same patient at the same time. 
7. LO 12.2  Jake Phillipson, a 59-year-old male, presents with dyspnea, tachypnea, and chest pain. After an exami-
nation, Jake is diagnosed with a saddle embolus of pulmonary artery with acute cor pulmonale. How
would this be coded?
a. I26.09 b.  Z86.711 c.  I26.92 d.  I26.02
8. LO 12.6  Respiratory conditions need external cause codes
a. never. b.  sometimes.
c. always. d.  only if there is an external cause for the condition.
9. LO 12.5  _____ is the term that identifies that the patient smokes tobacco on a regular basis, taken by his or her
own initiative, even though the substance is known to be a detriment to one’s health. There are no obvi-
ous clinical manifestations.
a. Exposure b.  Use c.  Abuse d.  Dependence
10. LO 12.3  Code the diagnosis of pneumonitis due to inhalation of lubricating oil, unintentional, initial encounter.
a. T52.0X1A b.  J69.1 c.  T52.0X1A, J69.1 d.  J69.1, T52.0X1A

Let’s Check It! Guidelines

Refer to the Official Guidelines and fill in the blanks according to the Chapter 10, Diseases of the Respiratory System,
Chapter-Specific Coding Guidelines.
secondary principal documentation mechanical

all J95.851 not J96.0 

J96.2 exacerbation confirmed one

admission

1. An acute _____ is a worsening or a decompensation of a chronic condition.

2. A code from subcategory _____, Acute respiratory failure, or subcategory _____, Acute and chronic respiratory
failure, may be assigned as a principal diagnosis when it is the condition established after study to be chiefly
responsible for occasioning the admission to the hospital, and the selection is supported by the Alphabetic Index
and Tabular List.
3. Respiratory failure may be listed as a _____ diagnosis if it occurs after admission, or if it is present on admission,
but does not meet the definition of _____ diagnosis.
4. Code only _____ cases of influenza due to certain identified influenza viruses (category J09), and due to other
identified influenza virus (category J10). 
5. As with _____ procedural or postprocedural complications, code assignment is based on the provider’s _____ of
the relationship between the condition and the procedure.
6. Code _____, Ventilator associated pneumonia, should be assigned only when the provider has documented venti-
lator associated pneumonia (VAP). 
7. Code J95.851 should _____ be assigned for cases where the patient has pneumonia and is on a _____ ventilator
and the provider has not specifically stated that the pneumonia is ventilator-associated pneumonia.
8. A patient may be admitted with _____ type of pneumonia (e.g., code J13, Pneumonia due to Streptococcus pneu-
monia) and subsequently develop VAP. In this instance, the principal diagnosis would be the appropriate code
from categories J12-J18 for the pneumonia diagnosed at the time of _____.

CHAPTER 12  | 
 Let’s Check It! Rules and Regulations
CHAPTER 12 REVIEW

Please answer the following questions from the knowledge you have gained after reading this chapter.
1. LO 12.2  What is pleural effusion? What is the correct ICD-10-CM code for malignant pleural effusion? 
2. LO 12.3  Explain what ventilator-associated pneumonia is. Include the correct ICD-10-CM code you would use
to report VAP. 
3. LO 12.4  Differentiate between exacerbation and status asthmaticus. 
4. LO 12.5  In relation to tobacco involvement, explain the difference between exposure,use,abuse,dependence, and
history.
5. LO 12.6  Explain why a respiratory condition might require an external cause code. Include an example. 

ICD-10-CM
YOU CODE IT! Basics
First, identify the condition in the following diagnoses; 8. Bronchitis due to rhinovirus:
then code the diagnosis. a. main term: _____ b. diagnosis: _____
Example: Acute nasopharyngitis: 9. Cellulitis of nose: 
a. main term: Nasopharyngitis b. diagnosis: J00 a. main term: _____ b. diagnosis: _____
10. Polypoid sinus degeneration: 
1. Vasomotor rhinitis:
a. main term: _____ b. diagnosis: _____
a. main term: _____ b. diagnosis: _____
11. Adenoid vegetations: 
2. Nasal catarrh, acute:
a. main term: _____ b. diagnosis: _____
a. main term: _____ b. diagnosis: _____
12. Abscess of lung:
3. Acute recurrent empyema of sphenoidal sinus: 
a. main term: _____ b. diagnosis: _____
a. main term: _____ b. diagnosis: _____
13. Bronchiectasis with exacerbation: 
4. Hypertrophy of tonsils:
a. main term: _____ b. diagnosis: _____
a. main term: _____ b. diagnosis: _____
14. Seropurulent pleurisy with fistula: 
5. Obstructive laryngitis:
a. main term: _____ b. diagnosis: _____
a. main term: _____ b. diagnosis: _____
15. Pulmonary gangrene: 
6. Chronic laryngotracheitis:
a. main term: _____ b. diagnosis: _____
a. main term: _____ b. diagnosis: _____
7. Aspiration pneumonia due to solids and liquids:
a. main term: _____ b. diagnosis: _____

ICD-10-CM
YOU CODE IT! Practice
Using the techniques described in this chapter, carefully read through the case studies and determine the most ac-
curate ICD-10-CM code(s) and external cause codes, if appropriate, for each case study.
1. Fred Draper, a 39-year-old male, is HIV-positive, asymptomatic. Fred was just admitted with organic
pneumonia. 
2. Rebecca Key, a 21-year-old female, presents with a fever and sore throat. Dr. Brice notes large lymph nodes.
The throat culture confirms a diagnosis of streptococcal pharyngitis. 

350   PART II  |  REPORTING DIAGNOSES

 CHAPTER 12 REVIEW
3. Larry Ligon, a 58-year-old male, presents today with severe chest congestion. Dr. Snell also notes ­difficulty
breathing and wheezing. Larry is admitted to the hospital, where further laboratory tests confirm the
­diagnosis of streptococcus, group B, pneumonia. 
4. Sally Griffith, a 13-year-old female, was brought to the ED by her mother. Sally had a cough and fever, and
her eyes were tearing. She was complaining that her eyes were itchy and burning. After a thorough exami-
nation and chest x-ray, Dr. Minister diagnosed her with an upper respiratory infection with bilateral acute
conjunctivitis.
5. Chris Fravel, a 13-year-old male, is brought in by his mother with the complaints of sore throat, fever, and
that it hurts when he swallows. Dr. Dennis documents white pus-filled spots on the tonsils and large lymph
nodes. After completing an examination and an optical fiber endoscopy, Chris is diagnosed with chronic
­tonsillitis and adenoiditis. 
6. Allison Mabry, a 6-year-old female, is brought in by her parents with a fever and hoarseness. Allison says
it hurts when she swallows and it’s hard to breath. Dr. Macon completes an examination noting drooling;
­culture is positive for haemophilus influenza. Allison is diagnosed with acute epiglottitis.
7. Benjamin Fulkenbury, a 46-year-old male, comes in today with cough, runny nose, sneezing, and body
aches. Dr. Pruessner completes a thorough examination and notes a temperature of 104 F. Ben is admit-
ted, where a CXR and laboratory tests confirm the diagnosis of influenza virus A/H5N1 with pleural
effusion. 
8. Sandra Busbee, a 43-year-old female, comes in today with a cough and chest pain. Dr. Lindsey completes a
thorough examination, the appropriate tests, and a chest x-ray. Sandra is diagnosed with acute bronchitis due
to parainfluenza virus. 
9. Dale Hunter, a 52-year-old male, was diagnosed with chronic bronchitis 3 months ago and is on medication.
This morning, he came to see Dr. Teasdale because he began to cough and is having difficulty breathing.
Dr. Teasdale admitted him into the hospital with a diagnosis of chronic obstructive pulmonary disease with
acute exacerbation. 
10. Monica Adams, a 65-year-old female, comes in today with hoarseness and neck pain. Dr. Fazio completes a
thorough examination and the appropriate tests and notes that Monica smokes cigarettes. Monica undergoes a
laryngoscopy, which confirms the diagnosis of vocal cord nodules. 
11. Caitlyn Joy, a 12-year-old female, comes in today with a nosebleed. She was playing a pickup game of bas-
ketball at the local sports area and was struck in the face by the basketball. After an examination, Dr. Jordan
diagnoses Caitlyn with a deviated nasal septum. 
12. Randy Prescott, a 56-year-old male, presents today with a cough and shortness of breath. Dr. Holden docu-
ments notable weight loss from Randy’s last visit 6 months ago. Randy admits to joint aches and some
chest pain. After a thorough examination and the appropriate tests, Dr. Holden diagnoses Randy with
berylliosis. 
13. Larry Crosstree, a 29-year-old male, presents today concerned about vocal pitch changes he has been expe-
riencing for approximately 2 weeks. Dr. Leonard notes the frequent need for breath while Larry is speaking
as well as hoarseness. Larry is admitted to the hospital, where an MRI scan of the neck and chest confirms a
diagnosis of complete bilateral paralysis of the laryngeal nerve. 
14. Nakeisha Dittman, a 27-year-old female, presents today with a cough, fever, shortness of breath, and night
sweats, 2 weeks duration. Dr. Mokeba completes a thorough examination and decides to admit Nakeisha
to the hospital. Further laboratory tests confirm the diagnosis of eosinophilic pneumonia with secondary
­spontaneous pneumothorax. 
15. Beth Northing, a 25-year-old female, was diagnosed 6 months ago with asthma. She presents today with the
complaint of shortness of breath and a tight chest. Dr. Hayden completes an examination, noting cyanosis of
the lips and confusion. Dr. Hayden diagnoses Beth with a severe persistent asthma attack and admits her into
the hospital. 

CHAPTER 12  | 
CHAPTER 12 REVIEW

ICD-10-CM
YOU CODE IT! Application
The following exercises provide practice in abstracting physicians’ notes and learning to work with documentation
from our health care facility, Prader, Bracker, & Associates. These case studies are modeled on real patient encoun-
ters. Using the techniques described in this chapter, carefully read through the case studies and determine the most
accurate ICD-10-CM code(s) and external cause code(s), if appropriate, for each case study.

WESTON HOSPITAL
629 Healthcare Way • SOMEWHERE, FL 32811 • 407-555-6541
PATIENT: YOUNG, ELIAS
ACCOUNT/EHR #: YOUNEL001
DATE: 07/16/18
Attending Physician: Oscar R. Prader, MD
Elias Young, a 71-year-old male, is brought to the ED by EMS. Elias is on ACUD mode on ventilator with
a respiration of 11 breaths per minute. No cyanosis is noted. Pt is currently alert and oriented and able
to answer some questions. Dr. Prader notes as time progresses patient is showing signs of confusion
and disorientation. He is admitted to the hospital.
The patient’s blood gases showed a compensated respiratory acidosis, VS are stable, and patient is
afebrile. BP: 148/83. Sinus tachycardia on the monitor at about 131 beats per minute. Lung fields are
clear to auscultation and percussion.
DIAGNOSES: 1. Respiratory failure, chronic
       2. Sinus tachycardia

PLAN/RECOMMENDATIONS:
       1.  100% ventilator support for the time being
       2.  Nutrition with PulmoCare at 60 cc an hour
       3.  Follow up laboratory

ORP/pw  D: 07/16/18 09:50:16  T: 07/18/18 12:55:01

Determine the most accurate ICD-10-CM code(s).

PRADER, BRACKER, & ASSOCIATES

A Complete Health Care Facility
159 Healthcare Way • SOMEWHERE, FL 32811 • 407-555-6789
PATIENT: NADER, ERICK
ACCOUNT/EHR #: NADEER001
DATE: 08/11/18
Attending Physician: Oscar R. Prader, MD

352   PART II  |  REPORTING DIAGNOSES

 CHAPTER 12 REVIEW
S: Erick Nader, an 18-month-old male, is brought in today by his parents because of shortness of breath
and a cough that has grown worse over the last 24 hours.
O: H: 32.5”, W: 25 lb., T: 103 F, P: 138, R: 37, SpO2: 96% on room air, BP: 95/62. A “bark-like” cough is
noted and upon auscultation stridor is heard. A lateral neck x-ray is taken.
A: Stridulous croup
P: 0.5 mL of racemic epinephrine via small volume nebulizer is administered

ORP/pw  D: 08/11/18 09:50:16  T: 08/13/18 12:55:01

Determine the most accurate ICD-10-CM code(s).

WESTON HOSPITAL
629 Healthcare Way • SOMEWHERE, FL 32811 • 407-555-6541
PATIENT: SMUTH, SARAH
ACCOUNT/EHR #: SMUTSA001
DATE: 07/16/18
Attending Physician: Renee O. Bracker, MD
Sarah Smuth, a 52-year-old female, underwent total knee replacement surgery 5 days ago. Patient is
alert and oriented, but began to complain of chest pain and dyspnea 3 days after surgery. Laboratory
tests reveal a WBC of 15, HR: 101, R: 20 and shallow, P: 56, BP: 135/85, T: 98.9 F, SpO2 is 95% receiv-
ing oxygen via nasal cannula at 2 Lpm. VS have remained stable. Diminished sounds and fine crackles
are noted on auscultation. Post-op day 3—CXR confirms atelectasis; pneumonia is ruled out. Post-op
day 4—patient has not improved; a repeat CXR shows no improvement of atelectasis and a bronchos-
copy was performed and mucus plugs were removed. Post-op day 5—patient begins to show improve-
ment and full resolution is expected.

A: Atelectasis, post-op complication

P: Albuterol nebulizer every 4 hours and prn

    Deep breathing exercises and coughing. Monitor via continuous capnography. 

ROB/pw  D: 07/16/18 09:50:16  T: 07/18/18 12:55:01

Determine the most accurate ICD-10-CM code(s).

CHAPTER 12  | 
CHAPTER 12 REVIEW

WESTON HOSPITAL
629 Healthcare Way • SOMEWHERE, FL 32811 • 407-555-6541
PATIENT: ALBERTSON, JONAH
ACCOUNT/EHR #: ALBEJO001
DATE: 09/15/18
Attending Physician: Renee O. Bracker, MD
Jonah Albertson, a 62-year-old male, was transported to the ED by EMS after an MVA. Patient was
involved in a three-car accident while driving home. Patient does not appear to have any injuries.
Patient denies any pain or discomfort at this time. Patient is alert and oriented, but appears anxious.
VS: H: 6’ 1”, W: 192 lb., P: 94, R: 24, T: 99.1 F, BP: 90/60, SpO2 100% on room air.
Laboratory results 25 minutes after arrival: 
pH: 7.5
PaO2: 195 mmHg
PaCO2: 32 mmHg
SaO2: 90%
HCO3: 20 mEq
Hgb: 13.9 gms
COHgb: 11.2% 
With the level of carbon monoxide on the hemoglobin, the patient is placed on a nonrebreathing
mask. COHgb has decreased to 7.1% and patient is breathing comfortably 4 hours after arrival. Patient
is admitted for observation. 
Three hours later, respiration becomes more rapid and labored. Patient shows extreme fatigue. Auscul-
tation reveals fine crackles throughout both lungs. CXR shows bilateral infiltrates extending into all four
lung quadrants.
Arterial blood gases are rechecked:
pH: 7.31
PaO2: 71 mmHg 
PaCO2: 43 mmHg
SaO2: 89% 
HCO3: 22 mEq
COHgb: 3.9% 

Heart Rate: 79
Blood Pressure: 88/57 

Dx: ARDS 
P: Intubation and mechanical ventilation

ROB/pw  D: 09/15/18 09:50:16  T: 09/17/18 12:55:01

Determine the most accurate ICD-10-CM code(s).

354   PART II  |  REPORTING DIAGNOSES

 CHAPTER 12 REVIEW
PRADER, BRACKER, & ASSOCIATES
A Complete Health Care Facility
159 Healthcare Way • SOMEWHERE, FL 32811 • 407-555-6789
PATIENT: MASHEN, CYRUS
ACCOUNT/EHR #: MASHCY001
DATE: 11/25/18
Attending Physician: Oscar R. Prader, MD
S: This new Pt is a 57-year-old male complaining of a stabbing chest pain and shortness of breath.
Patient states the pain is worse when he breathes in.
PMH: Noncontributory
PFH: Noncontributory
O: VS: within normal range. Chest: Pleural rub on auscultation. Dullness upon percussion. Chest x-ray
shows approximately 2.75 liters of fluid in the pleural space.
A: Interlobar pleurisy
P: Schedule aspiration of pleural fluid

ORP/pw  D: 11/25/18 09:50:16  T: 11/27/18 12:55:01

Determine the most accurate ICD-10-CM code(s).

CHAPTER 12  | 
 13 Coding Digestive
System Conditions
Learning Outcomes
Key Terms
Accessory Organs After completing this chapter, the student should be able to:
Anus
LO 13.1 Analyze the documentation for applicable details needed
Ascending Colon
Cecum to report diseases affecting the mouth and salivary glands
Cholelithiasis accurately.
Common Bile Duct LO 13.2 Interpret documentation to determine necessary details
Descending Colon to report conditions affecting the esophagus and stomach
Duodenum correctly.
Edentulism
LO 13.3 Apply your knowledge to identify main terms relating to
Esophagus
Fundus intestinal disorders.
Gallbladder LO 13.4 Evaluate the specifics from the documentation related to
Gangrene digestive accessory organs and malabsorption disorders
Hemorrhage accurately.
Hernia LO 13.5 Determine when additional codes are required to report the
Ileum
involvement of alcohol.
Jejunum
Liver
Mesentery
Obstruction
Oral Cavity
Pancreas Remember, you need to follow along in
Pancreatic Islets
ICD-10-CM

  STOP! your ICD-10-CM code book for an optimal

Perforation learning experience.
Rectum
Salivary Glands
Sigmoid Colon
Sphincter
Stomach 13.1  Diseases of Oral ­Cavity
Teeth
Transverse Colon
and Salivary Glands
Vermiform Appendix Oral Cavity
Virtually all nourishment enters the body at the mouth, also referred to as the
oral cavity. The components within this area include the lips, cheeks, tongue, lingual
Oral Cavity tonsils, hard and soft palates, uvula, palatine tonsils, pharyngeal tonsils, and teeth
The opening in the face that (Figure 13-1).
begins the alimentary canal Teeth are components of the mouth, required for proper digestion. Typically,
and is used for the input of as you probably know from your own experiences, they have their very own
nutrition; also known as the ­specialists, dentists, to care for them. Teeth are small, calcified protrusions
mouth. consisting of multiple tissues of varying density and hardness. Rooted in the jaws
Teeth (maxillary [upper jaw] and mandibular [lower jaw]), the bases of the teeth are
Small, calcified protrusions protected and secured by the gums. Their job  is to grind and crush food and food
with roots in the jaw. (singular: particles so they can combine with saliva for easier movement through the rest of the
Tooth) digestive system.

356
 Lip

Hard palate

Soft palate

Uvula

Palatine tonsils

Tongue

Vestibule

Lip

FIGURE 13-1  An illustration of the anatomical components of the oral cavity

(human mouth)  David Shier et al., HOLE’S HUMAN ANATOMY & PHYSIOLOGY, 12/e. ©2010 McGraw-Hill Edu-
cation. Figure 17.5, p. 657. Used with permission.

EXAMPLE
Perry brought his 8-month-old son, Benjamin, to Dr. Reddington, his pediatrician,
because he had been crying all night long. It seemed nothing he or his wife did
calmed him. After examination, Dr. Reddington diagnosed Benjamin with teething
syndrome and provided Perry with several ways to help the family through this
experience. This diagnosis is reported with the following code:
K00.7 Teething syndrome

Diagnoses, related to the teeth, range from everything from baby’s first tooth to
dental caries (commonly known as a dental cavity) to issues of the surrounding tissue,
such as gingivitis and other periodontal diseases, to edentulism (tooth loss). Edentulism
When you are abstracting the documentation regarding acquired loss of teeth, you Absence of teeth.
will need to identify three specified details from the notes:
1. Is the loss complete or partial?
K08.1 Complete loss of teeth
K08.4 Partial loss of teeth
2. What is the cause of this loss?
K08.11 Complete loss of teeth due to trauma
K08.12 Complete loss of teeth due to periodontal diseases
K08.13 Complete loss of teeth due to caries
K08.41 Partial loss of teeth due to trauma
K08.42 Partial loss of teeth due to periodontal diseases
K08.43 Partial loss of teeth due to caries

CHAPTER 13  | 
 3. What class classification is documented?
∙ Class I describes the stage of edentulism believed to have the best prognosis to have
successful treatment using conventional prosthodontic techniques.
∙ Class II identifies a patient with deterioration of the gums and other supporting
structures, along with systemic disease interactions, soft tissue concerns, as well as
patient management and/or lifestyle considerations affecting the prognosis of the
treatment.
∙ Class III establishes the existence of other factors significantly affecting the out-
comes of treatment and the need for surgical revision of the supporting structures
(gums and bone) to create an opportunity for prosthodontics.
∙ Class IV reports a severely compromised condition of the supporting structures
requiring surgical reconstruction. If due to the patient’s health, personal prefer-
ences, past dental history, along with financial considerations, a customized prosth-
odontic technique may need to be created for an acceptable outcome.
Remember that ICD-10-CM diagnosis codes provide the explanation of why a par-
ticular procedure, treatment, or service is provided. You can see that the descriptions
of each of these class classifications provides the justification for the treatment plan.

ICD-10-CM
LET’S CODE IT! SCENARIO
Hannah Kim, a 49-year-old female, comes in to see her dentist, Dr. Morrison. She knew that she had periodontitis
for a while, but now the teeth on the lower right side of her mouth are really bothering her. Dr. Morrison did a full
evaluation and found that five teeth on the lower right were so loose that they came out with little encouragement.
Dr. Morrison determined that Hannah has partial loss (edentulism) of teeth due to periodontal disease, class I.

Let’s Code It!

Hannah lost five teeth due to periodontal disease. Let’s turn to the Alphabetic Index and find the key term of the diagnosis:
Edentulism — see Absence, teeth, acquired
Turn to:
Absence
  teeth, tooth (congenital) K00.0
   acquired (complete) K08.109
   partial K08.409
    class I K08.401
    class II K08.402
    class III K08.403
    class IV K08.404
Also take note of the listings within this long list for the loss of teeth due to caries (dental cavities), periodontal
disease, trauma, or another specified cause. These will take you to other specific codes.
Refer to the physician’s documentation and read that Hannah was diagnosed with partial class I edentulism,
so let’s turn to the Tabular List and find
K08 Other disorders of teeth and supporting structures
Read the notation carefully. Does it have anything to do with this encounter? No! Great, so now review
all the choices for the required fourth character and determine which one most accurately reports the diagnosis:
K08.4 Partial loss of teeth
There are and notes here. Read them carefully, and reread Dr. Morrison’s documentation.
Nothing there matches. Next, you must review the options for the fifth character.

358   PART II  |  REPORTING DIAGNOSES

 K08.42 Partial loss of teeth due to periodontal diseases
Check the documentation. Dr. Morrison wrote that Hannah’s loss of teeth was caused by the periodontitis, and it
was class I. Review all of the choices, and determine the most accurate code:
K08.421 Partial loss of teeth due to periodontal diseases, class I
Good work!

Salivary Glands
As the teeth and tongue are breaking down food in preparation for the journey down
the alimentary canal, three sets of major salivary glands (the parotid, submandibu- Salivary Glands
lar, and sublingual glands) secrete saliva to moisten and bind the food particles. This Three sets of bilateral exo-
begins the chemical digestion of carbohydrates, dissolves foods so their flavor can crine glands that secrete
be appreciated, and helps enable swallowing of the food particles. In addition, saliva saliva: parotid glands, sub-
helps to clean the teeth and mouth after the particles leave the oral cavity. maxillary glands, and sublin-
gual glands.
As with almost any other part of the body, these glands can become infected. The
salivary glands may be negatively impacted by either a bacterium or a virus, so be
alert to check the pathology report.
Sialoadenitis, also known as parotitis, is described as acute, acute recurrent, or
chronic. Note that chronic means  ongoing (typically lasting more than 3 months),
whereas acute recurrent means that the condition is severe, it clears up, and everything
is fine for a while, but then it comes back again.
K11.21 Acute sialoadenitis
K11.22 Acute recurrent sialoadenitis
K11.23 Chronic sialoadenitis

ICD-10-CM
YOU CODE IT! CASE STUDY
Isaac McNealy, a 37-year-old male, came in with complaints of pain in his face and mouth. He states that the pain
becomes worse just before and during meals. He also claims that he has trouble swallowing and when he went to
the dentist, he couldn’t open his mouth very wide at all. Dr. Randolph did an ultrasound of Isaac’s face and neck and
confirmed that he was suffering with calculus of the salivary duct.

You Code It!

Read this documentation, and determine the correct ICD-10-CM diagnosis code or codes to report Dr. Randolph’s
diagnosis of Isaac’s condition.
Step #1: Read the case carefully and completely.
Step #2: Abstract the scenario. Which main words or terms describe why the physician cared for the patient dur-
ing this encounter?
Step #3: Are there any details missing or incomplete for which you would need to query the physician? [If so, ask
your instructor.]
Step #4: Check for any relevant guidance, including reading all of the symbols and notations in the Tabular List
and the appropriate sections of the Official Guidelines.
Step #5: Determine the correct diagnosis code or codes to explain why this encounter was medically necessary.
Step #6: Double-check your work.

(continued)

CHAPTER 13  | 
 Answer:
Did you determine this to be the code?
K11.5   Sialolithiasis
   (Calculus of salivary gland or duct)

13.2  Conditions of the ­Esophagus

and Stomach
Esophagus
The tubelike structure that connects the hypopharynx to the stomach is known as the
Esophagus esophagus. As you can see in Figure 13-2, the esophagus lies parallel and posterior
The tubular organ that con- to the trachea. Just as the epiglottis blocks food and liquid from entering the trachea,
nects the pharynx to the the esophagus has its own gateway, called the upper esophageal sphincter, to restrict
stomach for the passage of the entrance of air into the stomach. A sphincter is a circular muscle that can open or
nourishment. close an opening. There are several sphincters along the alimentary canal.
Sphincter A second esophageal sphincter is located at the juncture between the esophagus and
A circular muscle that con- the stomach (the lower esophageal sphincter). This sphincter is designed to prevent
tracts to prevent passage of the contents of the stomach from splashing back up into the esophagus. When this
liquids or solids. sphincter does not function properly, the patient might experience chronic heartburn,
nausea, and possibly a sore throat. This may lead to a diagnosis of gastroesophageal
reflux disease (GERD).

Gastroesophageal Reflux Disease (GERD)

Heartburn may not seem like a big concern; however, for many patients with persistent
heartburn, one of the first symptoms of GERD (gastroesophageal reflux disease) is an
increased intensity of that burning or painful sensation when bending down, lying

Epiglottis

Esophagus
Trachea

Bronchi
Lung

Diaphragm
Gastroesophageal
junction Stomach

FIGURE 13-2  An illustration showing the anatomical sites from the epiglottis to
the gastroesophageal junction

360   PART II  |  REPORTING DIAGNOSES

down, or vigorously exercising. Dysphagia (difficulty with swallowing) and/or esopha-
gitis may also occur.
GERD may be caused by a slacking lower esophageal sphincter, which s­ eparates
the stomach from the esophagus and is designed to prevent backflow from the
stomach upward.

EXAMPLES
K21.0 Gastro-esophageal reflux disease with esophagitis
K21.9 Gastro-esophageal reflux disease without esophagitis

Stomach
The next organ along the alimentary canal is the stomach. As stated earlier, the stom- Stomach
ach connects to the esophagus at the lower esophageal sphincter in the cardiac region A saclike organ within the
of the stomach, also known as the cardia. To the left, the stomach curves upward, alimentary canal designed to
creating the fundic region, or fundus. A fundus is defined as a domed portion of a contain nourishment during
hollow organ that sits the farthest from, above, or opposite an opening. As you can see the initial phase of the diges-
tive process.
in Figure 13-3, the fundus of the stomach is located superior to (above) the opening to
the esophagus. Fundus
The lining of the stomach, a mucous membrane, contains gastric glands that The section of an organ far-
secrete gastric juices. As with the function of saliva in the processing of food in thest from its opening.
the mouth, the gastric juices support the extraction of nutritional elements in the
contents that entered from the esophagus. Mucous cells coat the internal wall of the
stomach to prevent the gastric juices from digesting it. When this coating is flawed,
the patient might develop a gastric (peptic) ulcer, a condition in which the acids in
the stomach actually eat a hole in the lining and wall of the stomach. This diagnosis
is reported with code K25.9 Gastric ulcer, unspecified as acute or chronic, without
hemorrhage or perforation.
As the shape of the stomach’s body curves downward, the inside of the curve on the
side of the cardia is referred to as the lesser curvature, and the outside curve, coming
down from the fundus, is referred to as the greater curvature. The lower portion of the
stomach narrows as it nears the duodenum and connects to the small intestine. The
pyloric sphincter is located here to control the emptying of the contents of the stomach
into the lower half of the digestive system.
Lower esophageal
(cardiac) sphincter
Fundus
Esophagus

Cardiac region
of stomach

Pyloric sphincter Body region

of stomach
Duodenum
Rugae

Pyloric canal
Pylorus

FIGURE 13-3  An illustration identifying the specific anatomical sites of the stomach 
David Shier et al., HOLE’S HUMAN ANATOMY & PHYSIOLOGY, 12/e. ©2010 McGraw-Hill Education. Figure 17.17,
p. 666. Used with permission.

CHAPTER 13  | 
 EXAMPLES
K31.1 Adult hypertrophic pyloric stenosis
K31.3 Pylorospasm, not elsewhere classified

Perforation
An atypical hole in the wall of
an organ or anatomical site.
Ulcers
Hemorrhage
Excessive or severe bleeding. An ulcer is a sore or hole in the tissue. Ulcers can occur externally, such as a decubitus
ulcer, or they can form internally. The terms used to document an internal ulcer in the
digestive system may include
∙ Ulcer of esophagus
CODING BITES ∙ Gastric ulcer (in the lining of the stomach)
If a medication caused
∙ Duodenal ulcer
the ulcer, an external
cause code will be ∙ Gastrojejunal ulcer
required to identify the You will notice that these descriptors identify the location of the ulcer, such as the
specific drug and whether esophagus, the stomach, or the jejunum.
or not it was taken for Further description of these ulcers may include known complications resulting
therapeutic purposes. from an ulcer in this segment of the upper digestive system: perforation and
hemorrhage.

ICD-10-CM
LET’S CODE IT! SCENARIO
Pauline Ochoa had been taking aspirin several times a day every day for pain in her knees. Her husband, John,
came home and found her lying on the kitchen floor. Emergency medical services (EMS) brought her to the ED. Tests
revealed an acute perforated, hemorrhaging peptic ulcer due to chronic use of aspirin.

Let’s Code It!

Pauline was diagnosed with an acute perforated, hemorrhaging peptic ulcer, so let’s turn to the Alphabetic Index
of ICD-10-CM and find
Ulcer, ulcerated, ulcerating, ulceration, ulcerative
There is a very long list of additional terms indented beneath this main listing, so read through it and find
Ulcer, ulcerated, ulcerating, ulceration, ulcerative
  peptic (site unspecified) K27.9

Beneath peptic is another indented list. Is there anything here that matches the physician’s notes?
Ulcer, ulcerated, ulcerating, ulceration, ulcerative
  peptic (site unspecified) K27.9
   with
   hemorrhage K27.4
   and perforation K27.6
  acute K27.3
   with
   hemorrhage K27.0
   and perforation K27.2

362   PART II  |  REPORTING DIAGNOSES

 Hmmm. The good news is that all of these choices are within one code category, K27, so let’s turn to the Tabular
List and begin reading at

K27 Peptic ulcer, site unspecified

Use additional code to identify alcohol abuse and dependence (F10.-)
Read the and notes, as well as the Use additional code notation. Then read down and review
all of the choices for the required fourth character. Which one matches the physician’s notes the best?
K27.2 Acute peptic ulcer, site unspecified, with both hemorrhage and perforation
Excellent!
Are you done? No. Remember that notation beneath the code category?
Use additional code to identify alcohol abuse and dependence (F10.-)
Was there any mention of alcohol abuse or alcohol dependence in the documentation? No. However, you do
know that aspirin caused this ulcer. There is no notation, but remember that your job is to tell the whole story. So
you will need to find an external cause code to report which drug caused Pauline’s peptic ulcer. Aspirin is a drug,
so let’s turn to the Table of Drugs and Chemicals and find the name of the drug that caused Pauline’s peptic ulcer
in the first column (“Substance”): aspirin. Look across the line to the code listed in the column under “Adverse
Effect.” Remember that Pauline was taking the aspirin for therapeutic use—a medical reason. This shows code
T39.015.
Let’s turn to the T codes in the Tabular List and begin reading at
T39 Poisoning by, adverse effect of and underdosing of nonopioid analgesics,
antipyretics and antirheumatics
Notice that beneath this code category is a notation:
The appropriate 7th character is to be added to each code from category T39
   A initial encounter
   D subsequent encounter
   S sequela
Remember, this is here for reference later. But first you need the fourth, fifth, and sixth characters. Read down
and review all of the choices. Which one matches most accurately?
T39.015- Adverse effect of aspirin
Great! Now you need that seventh character. Go back to the documentation. Is this the first time that Pauline is
being treated by this physician for this diagnosis? She is in the emergency department, so, yes, this is the initial
encounter. Now you have two codes to report Pauline’s condition:
K27.2 Acute peptic ulcer, site unspecified, with both hemorrhage and perforation
T39.015A Adverse effect of aspirin, initial encounter

Hernia
Hernias A condition in which one
A hernia is a condition that is created when a tear or opening in a muscle permits anatomical structure pushes
a part of an internal organ to push through. Due to the nature of one anatomical through a perforation in the wall
part squeezing through a hole in another site, the blood supply can be cut off to of the anatomical site that nor-
the section stuck in that opening. When that happens, the tissue might become mally contains that structure.
necrotic (deteriorate and die) and/or develop gangrene. In addition, this condition Gangrene
can create an obstruction in the structure or organ, preventing the normal flow of Necrotic tissue resulting from
material. a loss of blood supply.

CHAPTER 13  | 
Obstruction There are several types of hernias, or anatomical sites that can be susceptible to
A blockage or closing. herniation:
∙ Hiatal (esophageal) hernia may occur when a portion of the stomach pokes
CODING BITES through an opening in the diaphragm; congenital diaphragmatic hernias are con-
If an activity, such as lifting sidered birth defects and reported from the congenital malformations section of
something very heavy, ICD-10-CM.
causes an inguinal hernia, ∙ Umbilical hernia may occur when the muscle around the navel (belly button) does
or if a surgical procedure not close completely, permitting an internal organ to protrude.
causes an incisional her- ∙ Incisional hernia is a defect that may occur at the site of a previous abdominal sur-
nia, additional codes may gical opening (scar tissue).
be required to tell the
∙ Inguinal hernias, more common in men, appear in the groin area.
whole story.
∙ Femoral hernias, more common in women, appear in the upper thigh.

ICD-10-CM
YOU CODE IT! CASE STUDY
Jeffrey Gilberts, a 3-hours-old male, is brought in for Dr. Gensin to surgically repair his diaphragmatic hernia. He was
born with this abnormal fistula in the diaphragm, diagnosed at 28 weeks gestation, but it was determined that he
was not a candidate for in utero surgery.

You Code It!

Go through the steps of coding, and determine the code or codes that should be reported for this encounter
between Dr. Gensin and Jeffrey Gilberts.
Step #1: Read the case carefully and completely.
Step #2: Abstract the scenario. Which main words or terms describe why the physician cared for the patient dur-
ing this encounter?
Step #3: Are there any details missing or incomplete for which you would need to query the physician? [If so, ask
your instructor.]
Step #4: Check for any relevant guidance, including reading all of the symbols and notations in the Tabular List
and the appropriate sections of the Official Guidelines.
Step #5: Determine the correct diagnosis code or codes to explain why this encounter was medically necessary.
Step #6: Double-check your work.
Answer:
Did you determine this to be the correct code?

Q79.0   Congenital diaphragmatic hernia

Good job!

13.3  Conditions Affecting the Intestines

Small Intestine
Duodenum The inferior aspect of the pyloric sphincter is the duodenum, the first segment of the
The first segment of the small small intestine. The duodenum curves around like the letter “C,” with the pancreas
intestine, connecting the tucked in the center. The hepatopancreatic sphincter, also called the sphincter of Oddi,
stomach to the jejunum. is the connection point between the duodenum, the pancreatic duct, and the common
bile duct that comes from the gallbladder and the liver.

364   PART II  |  REPORTING DIAGNOSES

 EXAMPLES CODING BITES
K29.80 Duodenitis without bleeding Be careful to not con-
K31.5 Obstruction of duodenum fuse ileum (with an e),
the end of the small
intestine, with ilium (with
As the duodenum trails into that last portion, at the bottom of the “C,” it curves an i), the widest portion
around and becomes the jejunum, the segment of the small intestine that twists and of the pelvic bones.
turns throughout the abdomen (see Figure 13-4). The mesentery is a membrane that
connects to the jejunum like a spider web filled with blood vessels, nerves, and lym- ∙ ileum is the end of
phatic vessels to provide nourishment to the intestine. On the anterior side of the the small intestine.
abdominal cavity, coming from the greater curvature of the stomach down to the ante- Connect ileum with
rior of the jejunum like a protective curtain, is a double fold of the peritoneum called end.
the greater omentum. ∙ ilium is a portion of
The last segment of the small intestine is the ileum. The ileum connects to the the hip bone. Think
cecum, the bridge to the large intestine via the ileocecal sphincter. This sphincter con- of the i in hip.
trols the passage of material from the small intestine into the large intestine.
Jejunum
Gastrojejunal Ulcer The segment of the small
A lesion that develops in the small intestine can be quite problematic because it may intestine that connects the
duodenum to the ileum.
interfere with the absorption of nutrients in the digestive process. As you review docu-
mentation for a diagnosis of a gastrojejunal ulcer, you will need to abstract some key Mesentery
details: A fold of a membrane that car-
ries blood to the small intes-
1. Is the ulcer identified as acute or chronic? tine and connects it to the
K28.0–K28.3 Acute gastrojejunal ulcer . . . posterior wall of the abdomi-
K28.4–K28.7 Chronic gastrojejunal ulcer . . . nal cavity.

2. Is the ulcer hemorrhaging? Ileum

The last segment of the small
K28.0 Acute gastrojejunal ulcer with hemorrhage intestine.
K28.4 Chronic or unspecified gastrojejunal ulcer with hemorrhage
Cecum
A pouchlike organ that con-
nects the ileum with the large
intestine; the point of con-
Stomach nection for the vermiform
appendix.

Duodenum

Jejunum

Ascending colon

Cecum
Mesentery
Appendix

Ileum

FIGURE 13-4  An illustration identifying the anatomical sites of the lower

­alimentary canal from the stomach to the cecum  David Shier et al., HOLE’S HUMAN ANATOMY
& PHYSIOLOGY, 12/e. ©2010 McGraw-Hill Education. Figure 17.31, p. 680. Used with permission.

CHAPTER 13  | 
 3. Has the ulcer perforated the wall of the small intestine?
K28.1 Acute gastrojejunal ulcer with perforation
K28.5 Chronic or unspecified gastrojejunal ulcer with perforation
4. Are hemorrhage and perforation both documented?
K28.2 Acute gastrojejunal ulcer with both hemorrhage and perforation
K28.6 Chronic or unspecified gastrojejunal ulcer with both hemorrhage and
perforation
5. Has either hemorrhage or perforation been documented individually? If not . . .
K28.3 Acute gastrojejunal ulcer without hemorrhage or perforation
K28.7 Chronic or unspecified gastrojejunal ulcer without hemorrhage or
perforation

Of course, be certain to read the notations at the top of this code category:
Use additional code to identify alcohol abuse and dependence (F10.-)
primary ulcer of small intestine (K63.3)
Read the documentation carefully, again, to determine if the physician noted whether
the patient suffers with alcohol abuse or alcohol dependence. If so, you will need to
code this, as well.
The jejunum is one specific part of the small intestine. The small intestine includes
the duodenum, jejunum, mesentery, ileum, and cecum.

ICD-10-CM
YOU CODE IT! CASE STUDY
Bernadette Bowers, a 29-year-old female, came to see Dr. Grandem with symptoms of persistent diarrhea and
ongoing right lower quadrant (RLQ) abdominal pain. Lab work showed an increased white blood cell count and
erythrocyte sedimentation rate. A barium enema showed string sign. A biopsy confirmed a diagnosis of Crohn’s
disease of the jejunum.

You Code It!

Go through the steps of coding, and determine the code or codes that should be reported for this encounter
between Dr. Grandem and Bernadette.
Step #1: Read the case carefully and completely.
Step #2: Abstract the scenario. Which key words or terms describe why the physician cared for the patient dur-
ing this encounter?
Step #3: Are there any details missing or incomplete for which you would need to query the physician? [If so, ask
your instructor.]
Step #4: Check for any relevant guidance, including reading all of the symbols and notations in the Tabular List
and the appropriate sections of the Official Guidelines.
Step #5: Determine the correct diagnosis code or codes to explain why this encounter was medically necessary.
Step #6: Double-check your work.
Answer:

Did you determin e this to be the correct code?

K50.00   Crohn’s disease of the small intestine without complications

Good job!

366   PART II  |  REPORTING DIAGNOSES

Large Intestine
The colon is also known as the large intestine. As you look at the illustration (see
­Figure 13-5), you might wonder why it is considered large when the small intestine
seems to be so much longer. This distinction has nothing to do with length; the large
intestine has a larger diameter.
You may notice that the two terms colon and large intestine are used almost inter-
changeably. In reality, they are technically not the same thing. The large intestine con-
sists of the cecum, the vermiform appendix, the colon, the rectum, and the anus. The
colon represents the majority of the large intestine. Let’s take a look at the parts of the
large intestine. Ascending Colon
Starting at the cecum, the colon frames the abdomen almost like the beltway around The portion of the large intes-
Washington, D.C., and is referred to in four segments. tine that connects the cecum
The ileum of the small intestine connects to the ascending colon on the right side of to the hepatic flexure.
the large intestine at the cecum. The vermiform appendix, a rounded tubular append- Vermiform Appendix
age, protrudes from the end of the cecum. The ascending colon stretches upward from A long, narrow mass of tissue
the cecum to just below the liver in the superior aspect of the abdomen. At this point, attached to the cecum; also
this tubular structure makes a sharp left turn, known as the hepatic flexure (named called appendix.

Muscular layer

Mucous membrane
Serous layer
Transverse colon

Ascending colon
Tenia coli

Ileum
Descending colon
Ileocecal sphincter

Orifice of appendix

Haustra
Cecum

Vermiform appendix

Rectum Sigmoid colon

Anal canal

FIGURE 13-5  An illustration identifying the anatomical sites of the large intestine  David Shier et al., HOLE’S HUMAN ANAT-
OMY & PHYSIOLOGY, 12/e. ©2010 McGraw-Hill Education. Figure 17.43, p. 687. Used with permission.

CHAPTER 13  | 
Transverse Colon because of the proximity to the liver) and runs across to the left side. This section is
The portion of the large known as the transverse colon because it traverses across the abdomen (transverse
­intestine that connects the = across). On the left side, the colon turns downward at a curve known as the splenic
hepatic flexure to the splenic flexure (named because of the proximity to the spleen), becoming the descending
flexure.
colon. It continues down until it slightly curves, just above the pelvis, and becomes the
Descending Colon sigmoid colon.
The segment of the large The large intestine turns again, downward. This area is called the rectum (rectal
intestine that connects the vault), and it leads directly into the anal canal. At the distal end of the anal canal, the
splenic flexure to the sigmoid internal and external anal sphincters form the anus—the opening to the outside.
colon.

Sigmoid Colon
The dual-curved segment of EXAMPLES
the colon that connects the K51.20 Ulcerative (chronic) proctitis without complications
descending colon to the rec- K56.41 Fecal impaction of the intestine
tum; also referred to as the K35.3 Acute appendicitis with localized peritonitis
sigmoid flexure.

ICD-10-CM
YOU CODE IT! CASE STUDY
Gerald Candahar, a 51-year-old male, was brought into the procedure room so Dr. Avalino could remove his anal
polyps.

You Code It!

Go through the steps of coding, and determine the code or codes that should be reported for this encounter
between Dr. Avalino and Gerald.
Step #1: Read the case carefully and completely.
Step #2: Abstract the scenario. Which key words or terms describe why the physician cared for the patient
during this encounter?
Step #3: Are there any details missing or incomplete for which you would need to query the physician? [If so, ask
your instructor.]
Step #4: Check for any relevant guidance, including reading all of the symbols and notations in the Tabular List
and the appropriate sections of the Official Guidelines.
Step #5: Determine the correct diagnosis code or codes to explain why this encounter was medically necessary.
Step #6: Double-check your work.
Answer:
Did you determine this to be the correct code?
K62.0   Anal polyp
Good job!

Rectum Ulcerative Colitis

The last segment of the large
intestine, connecting the sig-
An inflammation of the lining of the colon is known as ulcerative colitis. This is often
moid colon to the anus. a chronic illness and believed to be a malfunction in the immune response within the
mucosa. Studies have shown a familial tendency. Signs and symptoms include bloody
Anus diarrhea with asymptomatic periods of time between attacks. Abdominal pain, irrita-
The portion of the large intes- bility, weight loss, weakness, nausea, and vomiting are also indicators.
tine that leads outside the body. Manifestations, such as pancolitis, proctitis, rectosigmoiditis, and inflammatory
polyps in the colon are not uncommon. In addition, the presence of rectal bleeding,
obstruction within the intestinal tract, fistulae, and abscesses must be included in the
code or codes, as documented.

368   PART II  |  REPORTING DIAGNOSES

 The terms you need to abstract from the documentation will lead you to the correct
fourth character to identify the manifestations:
K51.0 Ulcerative (chronic) pancolitis
K51.2 Ulcerative (chronic) proctitis
K51.3 Ulcerative (chronic) rectosigmoiditis
K51.4 Inflammatory polyps of colon
K51.5 Left sided colitis
K51.8 Other ulcerative colitis
Then, fifth and sixth characters will identify the presence of rectal bleeding, intestinal
obstruction, fistula, abscess, or other complication.

Diverticular Disease of the Intestine

Since the first page of this book, you have learned that you must read carefully
and completely, and this habit will be especially important when determining the
code for a patient diagnosed with diverticular disease. There are two conditions,
which are very different, reported from code category K57 Diverticular disease of
intestine:
∙ Diverticulosis: small pouches develop and protrude outward through the intestine
∙ Diverticulitis: when these pouches become inflamed or infected
While abstracting the documentation, you will also need to determine:
1. Is the small intestine, the large intestine, or both affected?
2. Is there mention of perforation, abscess, or bleeding?

ICD-10-CM
YOU CODE IT! CASE STUDY
Lisa Begas, a 63-year-old female, came in complaining of a low-grade fever with chills for 3 days, nausea and vomit-
ing, and cramps. Dr. Allendale did a CT scan of her abdomen and pelvis, and determined that she had diverticulitis
without perforation or bleeding of the colon.

You Code It!

Read the scenario of Dr. Allendale’s encounter with Lisa, and determine the accurate diagnosis code or codes.
Step #1: Read the case carefully and completely.
Step #2: Abstract the scenario. Which main words or terms describe why the physician cared for the patient
during this encounter?
Step #3: Are there any details missing or incomplete for which you would need to query the physician? [If so, ask
your instructor.]
Step #4: Check for any relevant guidance, including reading all of the symbols and notations in the Tabular List
and the appropriate sections of the Official Guidelines.
Step #5: Determine the correct diagnosis code or codes to explain why this encounter was medically necessary.
Step #6: Double-check your work.
Answer:
Did you determine this to be the code?

K57.32   Diverticulitis of large intestine without perforation or abscess without bleeding

CHAPTER 13  | 
 13.4  Dysfunction of the Digestive Accessory
Organs and Malabsorption
Accessory Organs
Organs that assist the diges- The digestive accessory organs play a role in the way the body processes food
tive process and are adja- and water so that each tissue and organ system has the fuel to function. These
cent to the alimentary canal: organs secrete enzymes, alkalis, and other substances that are required for the
the gallbladder, liver, and process of digestion, and they include the gallbladder, liver, and pancreas. The
pancreas. accessory organs connect to the alimentary canal and support it, but they are not
a part of it.
Gallbladder
A pear-shaped organ that
stores bile until it is required Gallbladder
to aid the digestive process.
In the top left corner of Figure 13-6, the pear-shaped pouch is the gallbladder. This
Common Bile Duct sac is a storage tank for bile, a yellow-green liquid created by the liver and used by
The juncture of the cystic duct the body to assist in the digestive process. When required, the gallbladder contracts
of the gallbladder and the
to release bile into the duodenum via the common bile duct and the hepatopancreatic
hepatic duct from the liver.
ampulla. The common bile duct is the juncture where the hepatic duct (which comes
from the liver) meets the cystic duct (which comes from the gallbladder). At the hepa-
topancreatic sphincter, both the common bile duct and the pancreatic duct meet to
CODING BITES continue into the duodenum.
Due to the interactive
nature of the anatomical
organs in this small area EXAMPLES
of the body, you may
K81.0 Acute cholecystitis
notice long, complex
medical terms used in K82.3 Fistula of gallbladder
diagnostic statements.
Don’t be intimidated;
just use your knowledge Right hepatic duct Left hepatic duct
from medical terminol- Cystic duct Common hepatic duct
Common
ogy class and parse bile duct
the terms. For example: Gallbladder
choledocholithiasis: Pancreatic duct
chole = bile + docho
Pyloric sphincter
= common bile duct +
lith = calculus + iasis =
Minor duodenal
pathologic condition. papilla

Duodenum
Tail of pancreas
Major duodenal Common Pancreatic
papilla bile duct duct

Sphincter muscles

Head of pancreas

Duodenal papilla

Intestinal lumen

Hepatopancreatic Hepatopancreatic
ampulla sphincter

FIGURE 13-6  An illustration identifying the anatomical sites within the accessory
organs  David Shier et al., HOLE’S HUMAN ANATOMY & PHYSIOLOGY, 12/e. ©2010 McGraw-Hill Education.
Figure 17.23, p. 672. Used with permission.

370   PART II  |  REPORTING DIAGNOSES

Cholecystitis
Cholecystitis is the medical term for inflammation of the gallbladder (chole = bile +
cyst = fluid-filled sac + -itis = inflammation). In cases where the disease affects the
bile duct rather than the gallbladder, the diagnosis is cholangitis.
Calculi can accumulate in this area and harden into small rocks (stones) that may
block the flow of bile from the gallbladder. This condition is known as cholelithiasis. Cholelithiasis
This may occur with or without cholecystitis, changing the code used to report the Gallstones.
condition.

EXAMPLES
K80.70 Calculus of gallbladder and bile duct without cholecystitis without
obstruction
K81.1 Chronic cholecystitis

Pancreas
Situated posterior to the stomach, tucked inside a curve of the duodenum, is the
­pancreas. The section of the pancreas adjacent to the duodenum, called the head of Pancreas
the pancreas, extends to the center section (the body of the pancreas), which extends to A gland that secretes insulin
the tail of the pancreas, which forms almost a fingerlike shape. The pancreatic islets and other hormones from the
(the islets of Langerhans) create glucagon and insulin, as well as other hormones, and islet cells into the bloodstream
secrete them into the bloodstream. Similar to the gallbladder, the pancreas manufac- and manufactures digestive
enzymes that are secreted
tures certain digestive enzymes that pass into the duodenum via the pancreatic duct
into the duodenum.
(see Figure 13-6).
Malfunction of the pancreas may lead to various health problems, including pancre- Pancreatic Islets
atic cancer, pancreatitis, cystic fibrosis, and diabetes mellitus. One of the most danger- Cells within the pancreas that
ous concerns about the impact on the body of conditions of the pancreas is that signs secrete insulin and other hor-
and symptoms are few and nonspecific, making diagnosis difficult. For example, there mones into the bloodstream.
is actually a treatment for pancreatic cancer. However, due to lack of signs and symp- Liver
toms that typically promote early identification and treatment, diagnosis is not often The organ, located in the
realized until the malignancy has metastasized to other organs and cannot be halted. upper right area of the
abdominal cavity, that is
Pancreatitis responsible for regulating
Acute pancreatitis occurs suddenly and usually goes away in a few days with treat- blood sugar levels; secret-
ing bile for the gallbladder;
ment. However, when you are determining the correct code for this diagnosis, you
metabolizing fats, proteins,
must abstract the underlying cause of the pancreatitis: and carbohydrates; manufac-
K85.0- Idiopathic acute pancreatitis turing some blood proteins;
K85.1- Biliary acute pancreatitis and removing toxins from the
K85.2- Alcohol-induced acute pancreatitis blood.
K85.3- Drug-induced acute pancreatitis
CODING BITES
Note that alcohol-induced acute pancreatitis and alcohol-induced chronic pancreatitis
are reported from different code categories. The medical root hepa-
or hepat- is used in
K86.0 Alcohol-induced chronic pancreatitis most diagnoses and
other descriptive terms
Liver to refer to the liver as
the anatomical site
The liver is an almost triangular-shaped organ (see Figure 13-7) located in the right involved. For example,
upper quadrant (RUQ) of the abdominal cavity, beneath the diaphragm, anterior to the the term hepatic failure
stomach and pancreas. As the largest gland in the body, it performs many functions, identifies a condition
including regulating blood sugar levels and aiding the digestive process by secreting that has rendered the
bile to the gallbladder. The liver cleans the blood of toxins; metabolizes proteins, fats, liver ineffective.
and carbohydrates; and manufactures some blood proteins.

CHAPTER 13  | 
 Inferior
Right lobe vena cava Left lobe

FIGURE 13-7  An illustration

Falciform identifying the anatomical sites
ligament
of the liver (anterior view)  Michael
Round ligament McKinley and Valerie O’Loughlin, HUMAN
CODING BITES of liver ANATOMY, 1/e. ©2006 McGraw-Hill
Education. Figure 26.19, p. 815. Used with
You will need to deter- Gallbladder permission.
mine from the documen-
tation if the use (abuse)
Hepatitis
of alcohol has contrib-
uted to the diagnosis Hepatitis (hepa- = liver + -itis = inflammation or disease) is a swelling of the liver
because this may affect that causes a reduction in function. Most often, hepatitis is caused by a virus, result-
the determination of ing in a diagnosis that includes the specific type of inflammation, such as hepatitis
the correct code or the A, hepatitis B, and so on. (For more details on this condition, see the chapter Coding
need for an additional Infectious Diseases).
code. At code category There are cases when drugs and alcohol can lead to this same diagnosis. Identified
K70, Alcoholic liver as acute or chronic nonviral hepatitis, most patients will exhibit signs and symptoms
disease, is a notation to very similar to viral hepatitis, including nausea, vomiting, and jaundice (yellowing of
remind you: the skin). Take a look at the Use additional code notation beneath code category:

Use additional code K70   Alcoholic liver disease

to identify alcohol     Use additional code to identify: alcohol abuse and dependence (F10.-)
abuse and depen-
dence (F10.-)
EXAMPLES
B18.2 Chronic viral hepatitis C
K70.10 Alcoholic hepatitis without ascites
K76.4 Peliosis hepatis

Cirrhosis
After a person suffers with chronic hepatic disease, fibrotic tissue may form on hepatic
cells causing scarring, known as cirrhosis of the liver. This condition may be caused
by injury as well. The scar tissue impairs the normal function of the liver and can
result in easy bruising or bleeding, abdominal swelling, lower extremity edema, and
possibly kidney failure. There is evidence that approximately 5% of patients suffering
with cirrhosis will develop liver cancer.

EXAMPLES
K74.3 Primary biliary cirrhosis
K74.69 Other cirrhosis of liver

ICD-10-CM
YOU CODE IT! CASE STUDY
After struggling to deal with a sharp pain that went from his stomach area straight through to his back, Saul Braver-
man went to see Dr. Spiegel. After a full examination and an ultrasound, Dr. Spiegel confirmed Saul’s cholelithiasis
and they discussed plans for surgery.

372   PART II  |  REPORTING DIAGNOSES

 You Code It!
Abstract this documentation about the encounter between Dr. Spiegel and Saul.
Step #1: Read the case carefully and completely.
Step #2: Abstract the scenario. Which main words or terms describe why the physician cared for the patient dur-
ing this encounter?
Step #3: Are there any details missing or incomplete for which you would need to query the physician? [If so, ask
your instructor.]
Step #4: Check for any relevant guidance, including reading all of the symbols and notations in the Tabular List
and the appropriate sections of the Official Guidelines.
Step #5: Determine the correct diagnosis code or codes to explain why this encounter was medically necessary.
Step #6: Double-check your work.
Answer:
Did you determine this to be the code?

K80.20   Calculus of gallbladder without cholecystitis without obstruction

Celiac Disease
While you may see a great deal in the news and advertisements about gluten-free
products, the facts support that celiac disease, also known as gluten enteropathy, is
uncommon. This condition is suffered by twice as many women than men, and has
been seen to be familial (common in families).
Recurrent attacks of diarrhea, abdominal distention due to flatulence, stomach
cramps, and weakness are some of the most frequently experienced signs and symp-
toms. When diagnosed in adults, celiac disease may be the underlying cause of mul-
tiple ulcers forming within the lining of the small intestine. Biopsies from the small
bowel, identifying histologic changes, would confirm this diagnosis.

EXAMPLE
K90.0 Celiac disease
  Use additional code for associated disorders including:
   dermatitis herpetiformis (L13.0)
   gluten ataxia (G32.81)
  Code also exocrine pancreatic insufficiency (K86.81) CODING BITES
In some cases, through-
out the ICD-10-CM Tab-
13.5  Reporting the Involvement of Alcohol ular List will remind you
in Digestive Disorders that the involvement of
alcohol abuse must also
Alcohol abuse can increase the risk of developing several serious disorders of the be reported:
digestive system. When the documentation includes a connection of alcohol abuse in K05  Gingivitis and
the diagnosis, you will need to report this with an additional code. periodontal diseases
When reading the documentation for digestive system disorders, be aware of these
 Use additional code
diagnoses which are known to be connected to alcohol abuse. If there is any indica-
to identify:
tion, you might need to query the physician.
alcohol abuse and
∙ Mouth cancer and gum disease: Alcohol abuse increases the risk, second only to dependence (F10.-)
tobacco abuse.

CHAPTER 13  | 
 ∙ GERD and gastritis: Excessive use of alcohol can damage the sphincter between
the esophagus and the stomach, permitting stomachs acids to backwash into the
esophagus. The lining of the stomach can also become irritated.
∙ Malabsorption and malnutrition: The consistent and excessive intake of alcohol
can interfere with the body’s ability to absorb nutrients.
∙ Pancreatitis: Alcohol abuse can cause inflammation in the pancreas and interfere
with the proper function of the digestive process.
∙ Alcoholic liver disease: Alcohol abuse can cause this condition, a precursor to
cirrhosis.

ICD-10-CM
YOU CODE IT! CASE STUDY
Noel Cooper, a 43-year-old male, came to see Dr. Briscow with complaints of epigastric discomfort, nausea, and
indigestion, over the last several days. He admits to drinking alcohol at lunch and dinner daily. He states he often
has a couple in the evening as well. A gastroscopy was performed, and Dr. Briscow confirmed a diagnosis of acute
gastritis due to alcohol abuse.

You Code It!

Review the details of this encounter between Dr. Briscow and Noel Cooper.
Step #1: Read the case carefully and completely.
Step #2: Abstract the scenario. Which main words or terms describe why the physician cared for the patient dur-
ing this encounter?
Step #3: Are there any details missing or incomplete for which you would need to query the physician? [If so, ask
your instructor.]
Step #4: Check for any relevant guidance, including reading all of the symbols and notations in the Tabular List
and the appropriate sections of the Official Guidelines.
Step #5: Determine the correct diagnosis code or codes to explain why this encounter was medically necessary.
Step #6: Double-check your work.
Answer:
Did you determine these to be the codes?
K29.00 Acute gastritis without bleeding
F10.188 Alcohol abuse with other alcohol-induced disorder
Good job!!

Chapter Summary
The organs included in the digestive system run from the head to the bottom of the
torso. Therefore, several different health care specialists may be involved in car-
ing for patients with digestive disorders, depending upon where the abnormality is
located. Health care issues within the digestive system can occur as the result of a
congenital anomaly, a traumatic event, or dietary influence. This means that there
may be times when an external cause code is required to be included so that you can
tell the whole story about the reasons why (the medical necessity) this patient was
cared for.

374   PART II  |  REPORTING DIAGNOSES

 CHAPTER 13 REVIEW
CODING BITES
Health Conditions Connected to Poor Oral Hygiene
Disease of the gums of the mouth, known as periodontal disease, has been
shown to affect the health of other organs throughout the body. Some exam-
ples include:
Cardiovascular system •  Increased risk of stroke
•  Increased risk of fatal heart attack
•  Increased risk of cardiovascular disease
•  Increased risk of clotting disorder
Respiratory system Bacteria from mouth, dental plaque buildup, and
throat can contribute to pneumonia and other lung
diseases.
Musculoskeletal system Increased risk of osteopenia.
Endocrine system Interference with control of diabetes mellitus.
Reproductive system • During gestation, mothers with advanced peri-
odontitis are at increased risk for premature and/
or underweight neonates.
• Microbes from periodontitis can cross through
the placenta and expose the fetus to infection.

CHAPTER 13 REVIEW Enhance your learning by completing

Coding Digestive System Conditions these exercises and more at

connect.mheducation.com!

Let’s Check It! Terminology

Match each key term to the appropriate definition.

Part I
1. LO 13.1  Small, calcified protrusions with roots in the jaw. A. Anus
2. LO 13.4  Cells within the pancreas that secrete insulin and other hormones into B. Duodenum
the bloodstream. C. Esophagus
3. LO 13.4  A large gland responsible for creating digestive enzymes. D. Ileum
4. LO 13.3  The last segment of the small intestine. E. Jejunum
5. LO 13.2  A saclike organ within the alimentary canal designed to contain nour- F. Liver
ishment during the initial phase of the digestive process.
G. Pancreas
6. LO 13.3  A long, narrow mass of tissue attached to the cecum; also called
H. Pancreatic Islets
appendix.
I. Rectum
7. LO 13.3  The last segment of the large intestine, connecting the sigmoid colon to
the anus.
8. LO 13.2  The tubular organ that connects the pharynx to the stomach for the pas-
sage of nourishment.
9. LO 13.4  The organ, located in the upper right area of the abdominal cavity, that
is responsible for regulating blood sugar levels; secreting bile for the
gallbladder; metabolizing fats, proteins, and carbohydrates; manufac-
turing some blood proteins; and removing toxins from the blood.

CHAPTER 13  | 
 10. LO 13.3  The portion of the large intestine that leads outside the body. J. Stomach
CHAPTER 13 REVIEW

11. LO 13.3  The first segment of the small intestine, connecting the stomach to the K. Teeth
jejunum. L. Vermiform Appendix
12. LO 13.3  The segment of the small intestine that connects the duodenum to the ileum.

Part II
1. LO 13.3  A pouchlike organ that connects the ileum with the large intestine; the A. Ascending Colon
point of connection for the vermiform appendix. B. Cecum
2. LO 13.3  The segment of the large intestine that connects the splenic flexure to C. Common Bile Duct
the sigmoid colon.
D. Descending Colon
3. LO 13.3  The portion of the large intestine that connects the hepatic flexure to
E. Oral Cavity
the splenic flexure.
F. Salivary Glands
4. LO 13.4  The juncture of the cystic duct of the gallbladder and the hepatic duct
from the liver. G. Sigmoid Colon
5. LO 13.3  The portion of the large intestine that connects the cecum to the hepatic H. Transverse Colon
flexure.
6. LO 13.3  The dual-curved segment of the colon that connects the descending
colon to the rectum.
7. LO 13.1  The opening in the face that begins the alimentary canal and is used for
the input of nutrition; also known as the mouth.
8. LO 13.1  Three sets of bilateral exocrine glands that secrete saliva: parotid
glands, submaxillary glands, and the sublingual glands.

Part III
1. LO 13.2  A blockage or closing. A. Accessory Organs
2. LO 13.2  An atypical hole in the wall of an organ or anatomical site. B. Cholelithiasis
3. LO 13.4  Organs that assist the digestive process and are adjacent to the alimen- C. Edentulism
tary canal: the gallbladder, liver, and pancreas. D. Fundus
4. LO 13.4  Gallstones. E. Gallbladder
5. LO 13.3  A fold of a membrane that carries blood to the small intestine and con- F. Gangrene
nects it to the posterior wall of the abdominal cavity.
G. Hemorrhage
6. LO 13.2  A circular muscle that contracts to prevent passage of liquids or solids.
H. Hernia
7. LO 13.4  A pear-shaped organ that stores bile until it is required to aid the
I. Mesentery
­digestive process.
J. Obstruction
8. LO 13.2  The section of an organ farthest from its opening.
K. Perforation
9. LO 13.1  Absence of teeth.
L. Sphincter
10. LO 13.2  A condition in which one anatomical structure pushes through a perforation
in the wall of the anatomical site that normally contains that structure.
11. LO 13.2  Necrotic tissue resulting from a loss of blood supply.
12. LO 13.2  Excessive or severe bleeding.

Let’s Check It! Concepts

Choose the most appropriate answer for each of the following questions.
1. LO 13.2  The correct code for a diaphragmatic hernia with obstruction without gangrene is
a.  K44 b.  K44.0 c.  K44.1 d.  K44.9

376   PART II  |  REPORTING DIAGNOSES

 2. LO 13.3  The duodenum, jejunum, and ileum are all parts of the

CHAPTER 13 REVIEW
a. esophagus. b.  liver. c.  small intestine. d.  large intestine.
3. LO 13.1  When you are abstracting the documentation regarding acquired loss of teeth: Class _____ establishes
the existence of other factors significantly affecting the outcomes of treatment and the need for surgical
revision of the supporting structures (gums and bone) to create an opportunity for prosthodontics.
a. I b.  II c.  III d.  IV
4. LO 13.4  Cirrhosis of the liver can be caused by
a. abuse of alcohol. b.  trauma. c.  disease. d.  all of these.
5. LO 13.2  A hiatal hernia occurs at the
a. esophagus. b.  small intestine. c.  surgical site. d.  groin.
6. LO 13.3  What is the correct code for an acute appendicitis with localized peritonitis?
a. K35.2 b.  K35.3 c.  K35.8 d.  K35.89
7. LO 13.3  The transverse colon lies between the
a. ascending colon and the hepatic flexure. b.  hepatic flexure and the splenic flexure.
c. splenic flexure and the sigmoid colon. d.  sigmoid colon and the anus.
8. LO 13.4  Cholelithiasis is commonly known as
a. disease of the liver. b.  disease of the colon. c.  gallstones. d.  pancreatic cancer.
9. LO 13.2  Necrotic tissue resulting from a loss of blood supply is known as
a. obstruction. b.  hemorrhage. c.  perforation. d.  gangrene.
10. LO 13.5  All of the following are known be diagnoses that could be connected to alcohol abuse except
a. GERD. b.  pancreatitis.
c. malabsorption and malnutrition. d.  all of these could be connected to alcohol abuse.

Let’s Check It! Rules and Regulations

Please answer the following questions from the knowledge you have gained after reading this chapter.
1. LO 13.1  When you are abstracting the documentation regarding acquired loss of teeth, you will need to identify
three specified details from the notes. What are the three details?
2. LO 13.2  Explain the condition of GERD.
3. LO 13.3  What are some of the key details you will need to abstract from the documentation when coding a gas-
trojejunal ulcer?
4. LO 13.4  Which is the largest gland in the body? Where is it located, and what is its function?
5. LO 13.5  Discuss how alcohol abuse can affect the digestive system.

ICD-10-CM
YOU CODE IT! Basics
First, identify the condition in the following 2. Acute generalized periodontitis severe:
diagnoses; then code the diagnosis. a.  main term: _____ b.  diagnosis: _____
Example: Acute pulpitis 3. Odontogenic cyst:
a.  main term: Pulpitis    b.  diagnosis: K04.0 a.  main term: _____ b.  diagnosis: _____
4. Exfoliative cheilitis:
1. Dental caries on pit and fissure surface, penetrat-
ing into dentin: a.  main term: _____ b.  diagnosis: _____
a.  main term: _____ b.  diagnosis: _____

CHAPTER 13  | 
CHAPTER 13 REVIEW

5. Leukoplakia of oral mucosa: 11. Inguinal hernia with gangrene:

a.  main term: _____ b.  diagnosis: _____ a.  main term: _____ b.  diagnosis: _____
6. Hypertrophy of tongue papillae: 12. Inflammatory polyps of colon with abscess:
a.  main term: _____ b.  diagnosis: _____ a.  main term: _____ b.  diagnosis: _____
7. Eosinophilic esophagitis: 13. Chronic ischemic colitis:
a.  main term: _____ b.  diagnosis: _____ a.  main term: _____ b.  diagnosis: _____
8. Acute gastric ulcer: 14. Rectal prolapse:
a.  main term: _____ b.  diagnosis: _____ a.  main term: _____ b.  diagnosis: _____
9. Alcoholic gastritis: 15. Radiation proctitis:
a.  main term: _____ b.  diagnosis: _____ a.  main term: _____ b.  diagnosis: _____
10. Hyperplasia of the appendix:
a.  main term: _____ b.  diagnosis: _____

ICD-10-CM
YOU CODE IT! Practice
Using the techniques described in this chapter, carefully read through the case studies and determine the most
accurate ICD-10-CM code(s) and external cause code(s), if appropriate, for each case study.
1. Dorothea Greig, a 26-year-old female, presents with the complaint of persistent pain in her lower left abdo-
men, 1 week duration. Dorothea says she has also experienced nausea and vomiting. Dr. Hendrix notes
weakness and a temperature of 102.2 F. The decision is made to admit the patient. Following a review of the
laboratory tests, liver function tests, and the CT scan, Dorothea is diagnosed with diverticulitis of both the
small and large intestines; abscess is noted.
2. Kent Rhodes, a 28-month-old male, is brought in by his parents for a checkup. Dr. Washington notes Kent’s
deciduous teeth are smaller than normal and widely spaced with notches on the biting surface. Kent is diag-
nosed with Hutchinson’s teeth.
3. Leigh Norman, a 37-year-old female, comes in today with the complaint of shortness of breath. Dr. Schimek
notes tachypnea, tachycardia, and cyanosis. Upon auscultation, bowel sounds are heard in the chest area.
Leigh is admitted to Weston Hospital. After reviewing the arterial blood gases, laboratory results, and CT
scan, Leigh is diagnosed with a diaphragmatic hernia with obstruction. Surgery is scheduled.
4. John Bandings, a 53-year-old male, presents today with fever and jaundice. John admits to drinking alcohol for
decades. After reviewing the test results, Dr. Fong diagnoses John with alcoholic cirrhosis of the liver with ascites.
5. Maxine Weber, a 42-year-old female, comes in today with the complaint of severe pain in the right side of her
lower abdomen. Maxine also says she has vomited. Dr. Jefferson documents a temperature of 101 F. Maxine is
admitted to the hospital, where a CT scan confirms the diagnosis of acute appendicitis with localized peritonitis.
6. Archie Blume, a 41-year-old male, presents with the complaint of swollen tender gums and bleeding after he
brushes his teeth. Dr. Day notes Archie uses tobacco. After an examination and x-rays, Archie is diagnosed
with acute gingivitis, non-plaque induced.
7. Allen Klebb, a 36-year-old male, comes in today complaining of diarrhea and vomiting. Allen just finished his
radiation treatments for his hand malignancy. Dr. Ard diagnoses Allen with gastroenteritis due to radiation.
8. Paula Dent, a 3-year-old female, is diagnosed with a congenital trachea-esophageal fistula with atresia of the
esophagus. Paula is admitted to Weston Hospital for surgical repair.
9. Walter Logan, a 59-year-old male, presents today with a yellow brownish tongue. Walter admits to a bad taste
in his mouth. Dr. Roche completes an examination, noting hypertrophy of the central dorsal tongue papillae.
The biopsy confirms a diagnosis of black hairy tongue.

378   PART II  |  REPORTING DIAGNOSES

 CHAPTER 13 REVIEW
10. Robert Thomas, an 82-year-old male, presents today with severe epigastric pain. Robert also has been expe-
riencing sharp chest pain that radiated to the left side of the neck and arm. Robert is admitted to the hospital,
where an upper GI series confirms the diagnosis of volvulus of the colon with perforation.
11. Michelle Toatley, a 51-year-old female, presents with the complaints of stomach pain and bloating. Michelle
admits to vomiting. Dr. Mobley notes patient has a history of heartburn and current alcohol abuse. The EGD
confirms a diagnosis of acute gastric ulcer.
12. Harry Wisemann, a 46-year-old male, comes in today with the complaint of long-lasting heartburn and pain
under his breastbone. Harry admits to taking aspirin several times a day for many years. Dr. Camut diagnoses
Harry with an ulcer of the esophagus due to ingestion of aspirin.
13. C.E. Molyneaux, a 34-year-old male, comes in today with the complaint of a lump in his groin area. Dr. Wil-
liams completes a physical examination of the groin region and notes a bulge on the right side when C.E. is
standing erect. A CT scan confirms a diagnosis of a femoral hernia, unilateral. C.E. is admitted to the hospi-
tal for surgical repair.
14. Carla Jett, a 45-year-old female, presents today with bloody diarrhea and weakness. Carla states this has been
going on over the last few weeks. Dr. Edenton completes a thorough examination, noting a small ulcer on
Carla’s left leg and a temperature of 102.1 F. Carla is admitted to the hospital for a full workup. After review-
ing the laboratory tests and the MRI scan, Carla is diagnosed with ulcerative pancolitis with rectal bleeding
and pyoderma gangrenosum.
15. Jonathan Stutts, a 41-year-old male, comes in today with the complaint of abdomen pain with some diarrhea
and bloating. Dr. Dresdner completes a thorough examination with the appropriate laboratory tests. Jonathan
is diagnosed with idiopathic sclerosing mesenteric fibrosis.

ICD-10-CM
YOU CODE IT! Application
The following exercises provide practice in abstracting physicians’ notes and learning to work with documentation
from our health care facility, Prader, Bracker, & Associates. These case studies are modeled on real patient encoun-
ters. Using the techniques described in this chapter, carefully read through the case studies and determine the most
accurate ICD-10-CM code(s) and external cause code(s), if appropriate, for each case study.

WESTON HOSPITAL
629 Healthcare Way • SOMEWHERE, FL 32811 • 407-555-6541
PATIENT: UMBRELL, MORGAN
ACCOUNT/EHR #: UMBRMO001
DATE: 09/16/18
Attending Physician: Renee O. Bracker, MD
S: Patient is a 41-year-old female complaining of localized pain in the upper right quadrant radiating to
the right scapular tip. Pain usually begins postprandial and is intense for approximately a 5-hour dura-
tion and then subsides. Pain is not relieved by emesis, flatus, or position change.
O: H: 5’3”, Wt: 146 lb., R: 19, HR: 125, BP: 135/73, T: 102.4 F. Dr. Bracker notes diaphoresis, slight jaundice,
as well as hypoactive bowel sound. CT scan confirms a bile duct calculus. Morgan is admitted for surgery.
A: Choledocholithiasis, acute with cholangitis, and obstruction
P: Laparoscopic cholecystectomy

ROB/pw  D: 09/16/18 09:50:16  T: 09/16/18 12:55:01

Determine the most accurate ICD-10-CM code(s).

CHAPTER 13  | 
 YOU CODE IT! Practice
CHAPTER 13 REVIEW

PRADER, BRACKER, & ASSOCIATES

A Complete Health Care Facility
YOU CODE IT! Application
159 Healthcare Way • SOMEWHERE, FL 32811 • 407-555-6789
PATIENT: SEQUEN, EUGENE
ACCOUNT/EHR #: SEQUEU001
Determine the most accurate ICD-10-CM code(s).
DATE: 09/16/18
Attending Physician: OscarDetermine the most accurate ICD-10-CM code(s).
R. Prader, MD
Patient is a 49-year-old male diagnosed with chronic acid reflux. Barium swallow fluoroscopy, esopha-
Determine the most accurate ICD-10-CM code(s).
geal pH probe, esophageal manometry, and esophagoscopy were completed. He presents today to
discuss the results of those tests.
Determine the most accurate ICD-10-CM code(s).
I explain that the test results indicate that he has GERD. The first course of treatment is to adopt a low-
fat, high-fiber diet. The second course would be surgical repair. Patient was instructed not to eat at least
2 hours before going to bed, and the head of the bed should be elevated 6 to 8 inches while in supine
position.
Patient was informed that surgery may be necessary if diet and positioning do not relieve symptoms.

ORP/pw  D: 09/16/18 09:50:16  T: 09/16/18 12:55:01

Determine the most accurate ICD-10-CM code(s).

PRADER, BRACKER, & ASSOCIATES

A Complete Health Care Facility
159 Healthcare Way • SOMEWHERE, FL 32811 • 407-555-6789
PATIENT: HERMAN, CONNIE
ACCOUNT/EHR #: HERMCO001
DATE: 10/16/18
Attending Physician: Oscar R. Prader, MD
S: This 43-year-old female comes in with complaints of hematemesis and epigastric pain.
O: Esophageal tears are visualized during a fiberoptic endoscopy.
A: Mallory-Weiss syndrome, confirmed.
P: The options of electrocoagulation therapy for hemostasis and surgery to suture the esophageal lac-
erations if the condition did not resolve itself were discussed.

ORP/pw  D: 10/16/18 09:50:16  T: 10/18/18 12:55:01

Determine the most accurate ICD-10-CM code(s).

380   PART II  |  REPORTING DIAGNOSES

 CHAPTER 13 REVIEW
PRADER, BRACKER, & ASSOCIATES
A Complete Health Care Facility
159 Healthcare Way • SOMEWHERE, FL 32811 • 407-555-6789
PATIENT: GRAILLE, VAN
ACCOUNT/EHR #: GRAIVA001
DATE: 09/16/18
Attending Physician: Oscar R. Prader, MD
S: Patient is a 27-year-old male complaining of abdominal pain with alternating diarrhea and constipa-
tion. Abdominal distention is evident.
O: Complete history is obtained, including psychological profile. Sigmoidoscopy is completed.
A: Irritable bowel syndrome with diarrhea, confirmed.
P: Patient is asked to keep a food diary in order to identify foods that aggravate the condition.
  Follow-up appointment 10–14 days

ORP/pw  D: 09/16/18 09:50:16  T: 09/16/18 12:55:01

Determine the most accurate ICD-10-CM code(s).

PRADER, BRACKER, & ASSOCIATES

A Complete Health Care Facility
159 Healthcare Way • SOMEWHERE, FL 32811 • 407-555-6789
PATIENT: ELLISON, THERESA
ACCOUNT/EHR #: ELLITH001
DATE: 09/16/18
Attending Physician: Renee O. Bracker, MD
S: Patient is a 36-year-old female complaining of regular epigastric pain beginning in the umbilical
region and radiating toward her spine. Last night the pain was so severe she vomited.
O: Examination reveals crackles in lower lobe at the base of the lung, tachycardia, and a temperature
of 102 F. Lab results show increased serum lipase levels and increased polymorphonuclear leukocytes.
Ultrasound shows enlarged pancreas.
A: Acute pancreatitis
P: Admit to hospital.

ROB/pw  D: 09/16/18 09:50:16  T: 09/16/18 12:55:01

Determine the most accurate ICD-10-CM code(s).

CHAPTER 13  | 
 14
Key Terms
Coding Integumentary
Conditions
Learning Outcomes
Blister After completing this chapter, the student should be able to:
Bulla
Carbuncle LO 14.1 Apply the guidelines for reporting conditions of the skin.
Cyst LO 14.2 Analyze disorders of the nails, hair, glands, and sensory
Decubitus Ulcer nerves.
Dermis LO 14.3 Determine the specific characteristics of a lesion as they
Epidermis relate to coding.
Furuncle LO 14.4 Abstract the reasons for preventive care and report them
Gangrene
Hair accurately to support medical necessity.
Hair Follicle
Macule
Nevus
Nodule
Papule Remember, you need to follow along in
Patch
Phalanges
ICD-10-CM

  STOP! your ICD-10-CM code book for an optimal

learning experience.
Pressure Ulcer
Pustule
Scale
Skin
Subcutaneous 14.1  Disorders of the Skin
Ulcer
The Skin
Skin The average person has roughly 2 square yards (5,184 inches) of skin surface area. As
The external membranous the largest organ in the human body, the skin does so much more than just keep all
covering of the body. your internal organs covered. Each of its layers, the epidermis and the dermis, plays
an important role in protecting the body.
Epidermis The dermis is a sturdy collagenous layer that connects the epidermis to the fatty
The external layer of the skin,
tissue layer. Blood vessels, nerves, glands, hair follicles, and lymph channels are all
the majority of which is squa-
mous cells.
located in this stratum of the skin. In Figure 14-1, you can see how all of the compo-
nents of the integumentary system work together—the skin (epidermis and dermis)
Dermis along with the accessory structures (hair, nails, glands, and sensory receptors). Notice
The internal layer of the skin; how the line between the epidermis and the dermis has hills and ridges, known as
the location of blood vessels, dermal papillae. Fingerprints are formed by these genetically prompted elevations and
lymph vessels, hair follicles, valleys, which are then altered further during formation as a fetus presses against the
sweat glands, and sebum.
wall of the uterus. This explains why no two people have the same fingerprints, not
Subcutaneous even identical twins.
The layer beneath the Fastening the skin to the underlying elements of the anatomy is the fatty tissue, also
dermis; also known as the known as the hypodermis (hypo = below + dermis = dermal) or the subcutaneous layer.
hypodermis.
Dermatitis
Dermatitis is technically an inflammation of the skin (derma = skin + -itis = inflam-
mation). However, it is not as simple as this; there are several types of dermatitis.
Atopic dermatitis (category L20) includes Besnier’s prurigo, flexural eczema, infan-
tile eczema, and intrinsic (allergic) eczema. Most often, this chronic inflammation

382
 Epidermis

Dermis

Subcutaneous
layer

FIGURE 14-1  An illustration identifying the layers of the skin  David Shier et al., Hole’s
Human Anatomy & Physiology, 12/e. ©2010 McGraw-Hill Education. Figure 6.2a, p. 172. Used with permission.

affects infants (1 month to 1 year of age) with family histories of atopic conditions
such as allergic rhinitis and bronchial asthma. Signs and symptoms include erythema-
tous areas on extremely dry skin, appearing as lesions on the forehead, cheeks, arms,
and legs. The pruritus nature of this condition results in scratching that induces scaling
and edema.
Seborrheic dermatitis (category L21) includes seborrhea capitis and seborrheic
infantile dermatitis, commonly affecting the scalp and face. Symptoms include itch-
ing, erythematous areas, and inflammation, characterized by lesions covered with
brownish gray or yellow scales in areas in which sebaceous glands are plentiful.
Diaper dermatitis (category L22), commonly referred to as diaper rash, is caused
by continuously wet skin. Often, this develops when diapers are not changed frequently
enough to permit the area to dry out.
Allergic contact dermatitis (category L23) is the result of the skin touching a mate-
rial or substance to which the patient is sensitive. In addition to erythematous areas,
vesicles develop that itch, scale, and may ooze.
Irritant contact dermatitis (category L24) is caused by exposure of the skin to
detergents, solvents, acids, or alkalis. Blisters and/or ulcerations may appear in the
area that came in contact with the chemical.
Exfoliative dermatitis (category L26) is an acute and chronic inflammation with
widespread erythema and scales. The loss of the stratum corneum (the outermost layer
of the epidermis) is at the heart of this condition, along with hair loss, fever, and
shivering.
Dermatitis due to substances taken internally (category L27) would include an
inflammatory eruption of the epidermis in reaction to medications, drugs, ingested
food, or other substances. It may be easy to think that this might be limited to a
response only to oral medicines, but, technically, a drug injected, infused, or delivered
via subcutaneous patch also places the pharmaceutical internally. Keep a watchful eye
on the Use additional code notations within this code category, which remind you to
include an external cause code.

CHAPTER 14  | 
 Psoriasis
Identified by epidermal erythematous papules and plaques covered with silvery scales,
psoriasis is a chronic illness. Exacerbations (flare-ups) can be treated to relieve the
symptoms. Patients can inherit the tendency to develop psoriasis because it is geneti-
cally passed from parent to child. Its pruritic nature can sometimes result in pain along
with itching in the areas covered with dry, cracked, encrusted lesions appearing on
the scalp, chest, elbows, knees, shins, back, and buttocks. The silver scales may flake
away easily or create a thickened cover over the lesion. There are several types of pso-
riasis, including the following:
Psoriasis vulgaris, also known as nummular psoriasis or plaque psoriasis, is the
most common type of psoriasis. It usually causes dry, red skin lesions (plaques)
covered with silvery scales. Reported with code L40.0 Psoriasis vulgaris.
Guttate psoriasis appears more often in young adults (under the age of 30) as well as
children. Lesions covered by a fine scale will typically develop as small, teardrop-
shaped sores on the scalp, arms, trunk, and legs. Reported with code L40.4 Guttate
psoriasis.
Psoriatic arthritis mutilans presents with pain, edema, and/or loss of flexibility
in at least one joint. When affecting the fingers or toes, the nails may show pit-
ting or begin to separate from the nail bed. Reported with code L40.52 Psoriatic
arthritis mutilans.

Pressure Ulcer Pressure Ulcers

An open wound or sore
caused by pressure, infection,
A pressure ulcer can be created in an area of skin when tissue breaks down. Also
or inflammation. known as a bedsore,plaster ulcer,pressure sore, or decubitus ulcer, it can occur if the
patient is unable to move or shift his or her own weight, such as when an individual is
Decubitus Ulcer confined to a wheelchair or bed, even for a short period of time. The constant pressure
A skin lesion caused by against the skin reduces the blood supply to that particular area, and the affected tis-
continuous pressure on one sue becomes necrotic (dies). You might have experienced this yourself with a pebble in
spot, particularly on a bony
your shoe or a simple fold of your sock within a tight shoe. The area where the pres-
prominence.
sure impacted your foot became more and more painful. If you took your shoe right
Blister off, you might have noticed a red area. If you waited a length of time before removing
A bubble or sac formed on the your shoe, you found a painful blister. The longer the pressure and irritation are main-
surface of the skin, typically tained, the worse the damage to the skin (see Figure 14-2).
filled with a watery fluid or The National Pressure Ulcer Advisory Panel (NPUAP) defines a pressure ulcer as
serum. “a localized injury to the skin and/or underlying tissue, usually over a bony promi-
nence, as a result of pressure, or pressure in combination with shear and/or friction.”
As a professional coding specialist, you will need to know two factors to determine
GUIDANCE the correct codes for a diagnosed pressure ulcer:
CONNECTION
∙ Anatomical location (where on the body the ulcer is).
Read the ICD-10-CM
∙ Depth of the lesion (also known as the stage of ulcer).
Official Guidelines for
Coding and Reporting, There are five codeable stages of pressure ulcers (see Figure 14-3):
section I. Conventions, ■ Stage 1 affects the epidermal layer and is recognized by persistent erythema
General Coding (redness). A stage 1 pressure ulcer is visualized as a reddened area on the skin
Guidelines and Chapter that, when pressed with the finger, is nonblanchable (does not turn white).
Specific Guidelines, ■ Stage 2 is a partial-thickness loss involving both the epidermis and the der-
subsection C. Chapter-
mis; sometimes a fluid-filled blister is evident. A stage 2 pressure ulcer shows
Specific Coding
visible blisters or forms an open sore. The tissue surrounding the sore may
Guidelines, chapter
be red and irritated like an abrasion, blister, or shallow crater with a red-pink
12. Diseases of the
wound bed.
Skin and Subcutaneous
Tissue, subsection
■ Stage 3 pressure ulcer involves skin loss through and including the subcutane-
a. Pressure ulcer stage ous tissue. A stage 3 pressure ulcer looks like a crater with visible damage to the
codes. tissue below the skin. Full-thickness tissue loss may expose subcutaneous fatty
tissue but not bone, tendon, or muscle.

384   PART II  |  REPORTING DIAGNOSES

 Pressure of bone
Bone against hard
surface

Soft
tissue
Pinching off of
Blood blood vessels
vessels

Skin
layers

Hard surface Friction of skin

(bed) against the surface
Normal

FIGURE 14-2  An illustration identifying the etiology of pressure ulcers including the layers of the skin affected

■ Stage 4 indicates the skin layers are necrotic and the ulcer reaches down into
muscle and possibly bone. Stage 4 pressure ulcers have become so deep that there
is damage to the muscle and bone, sometimes along with tendon and joint dam-
age. While the depth of the ulcer varies on the basis of the anatomical site, there
is full-thickness tissue loss with bone, tendon, or muscle exposed.
■ An unstageable ulcer is not an unspecified stage. There are times when slough
and eschar must be removed to reveal the base of the wound before the true
depth, or stage, can be accurately determined. The lesion may be inaccessible—
because it is covered by a wound dressing that has not been removed or by a GUIDANCE
sterile blister or because of some other documented reason. CONNECTION
ICD-10-CM has created combination codes, therefore requiring only one code to Read the ICD-10-CM
identify both the anatomical site and the stage of the ulcer. Official Guidelines for
Coding and Reporting,
section I. Conven-
EXAMPLE tions, General Coding
Holder Pronce has a stage 3 pressure ulcer on his left hip. Guidelines and Chapter
Specific Guidelines,
L89.223 Pressure ulcer of left hip, stage 3 subsection C. Chapter-
Specific Coding Guide-
lines, chapter 12. Dis-
Healing Pressure Ulcers eases of the Skin and
It is logical that a patient will be attended to by a health care professional during Subcutaneous Tissue,
the time the pressure ulcer is healing. Typically, the documentation will identify the subsection a.5) Patients
original stage and describe the ulcer as “healing.” For example, “Harvey Rhoden was admitted with pressure
seen today by Dr. Steelman to follow up on his stage 2 pressure ulcer. Dr. Steelman ulcers documented as
documented that the ulcer is healing nicely.” In this case, you would continue to code healing.
this as a stage 2 pressure ulcer.

CHAPTER 14  | 
 GUIDANCE
CONNECTION Skin
layers
Read the ICD-10-CM
Official Guidelines for Subcutaneous
Coding and Reporting, soft tissue
section I. Conven- Bone
tions, General Coding
Guidelines and Chapter
Stage 1 Stage 2
Specific Guidelines,
subsection C. Chapter-
Specific Coding Guide-
lines, chapter 12.
Diseases of the Skin
and Subcutaneous
Tissue, subsection
a.6) Patients admitted
with pressure ulcer
evolving into another
stage during the Stage 3 Stage 4
admission. FIGURE 14-3  An illustration showing each of the four pressure ulcer stages

At the time of discharge, if the patient’s pressure ulcer has healed, and is documented
as healed, you will need to report the stage and site of this ulcer as described in the
admissions documentation. This will provide the medical necessity for the treatment of
this condition while the patient was in the facility and resulted in the healed outcome.

Evolving Pressure Ulcers

Sadly, there are occasions when a patient is admitted into the hospital with a pressure
ulcer that, during his or her stay, gets worse and progresses into a higher stage of ulcer.
Should this happen, you will need to report two codes at discharge:
CODING BITES 1. Code for the site and stage of the pressure ulcer as documented when the patient
was admitted into the hospital.
Nonpressure ulcers are
reported with codes 2. Report an additional code for the site and stage of the ulcer as documented when
from the L97 and L98 the patient is discharged.
code categories. For
more details about Presence of Gangrene
these skin disorders, Notice the Code first notation beneath the code category L89 Pressure ulcer to report
see section Lesions in the code for any gangrenous condition associated with the ulcer by using code I96
this chapter. Gangrene, not elsewhere classified (Gangrenous cellulitis). You are directed by this
notation to list the gangrene code first, followed by the pressure ulcer code.
Did you notice that the code for gangrene is in the chapter of codes used to report
Gangrene diseases of the circulatory system? This makes sense because gangrene is necrosis, cell
Necrotic tissue resulting from death, and decay caused by insufficient blood supply to the affected cells. Remember
a loss of blood supply. that pressure ulcers are caused by the ongoing compression of the skin, often resulting
in the prevention of blood flow into the area. Look again at Figure 14-3.

ICD-10-CM
LET’S CODE IT! SCENARIO
After attempting to jump his motorcycle over five barrels and crashing on the other side, Hunter Massler ended up
in the hospital for 6 weeks with a left, closed, transverse fractured femur, shaft; a right, closed, oblique fractured

386   PART II  |  REPORTING DIAGNOSES

 femoral shaft; and three fractured ribs, left side. He was unable to move without extreme pain, so he lay in bed virtu-
ally motionless, except with help from the nurse. After several weeks, while changing the sheets, Nurse Kenesson
identified a pressure ulcer on each of his hips. Dr. Weiner staged the ulcers bilaterally as stage 2 and ordered wound
care immediately. While there, Dr. Weiner also checked Hunter’s progress on the healing of his fractures.

Let’s Code It!

Dr. Weiner came in to stage and treat Hunter’s pressure ulcers: bilateral hip pressure ulcers, both documented
as stage 2. Let’s turn to the Alphabetic Index and find
Ulcer, ulcerated, ulcerating, ulceration, ulcerative
   pressure (pressure area) L89.9-
    hip L89.2-
Perfect! Now let’s turn to L89 in the Tabular List and read completely.
L89 Pressure Ulcer
Read the , Code first, and notations. There is nothing here to direct you elsewhere, so con-
tinue reading and review all of the required fourth-character choices to determine the one that matches the
physician’s notes:
L89.2 Pressure ulcer of hip
This matches the notes, so you know you are in the right place. Next, you must determine the required fifth
character for this ulcer code. Check the documentation; is the pressure ulcer on his right hip or left hip? Both,
actually, so you will need two codes, one for each hip:
L89.21 Pressure ulcer of right hip
L89.22 Pressure ulcer of left hip
To identify the sixth characters, you will need to abstract from the documentation regarding the stage of each
ulcer. The documentation states stage 2 for both.
L89.212 Pressure ulcer of right hip, stage 2
L89.222 Pressure ulcer of left hip, stage 2
These pressure ulcer codes will be reported first because the ulcers are the principal reason Dr. Weiner came to
see Hunter for this encounter. Then follow these steps with the codes to report Hunter’s fractures, and you will
have the diagnosis codes to report this encounter:
L89.212 Pressure ulcer of right hip, stage 2
L89.222 Pressure ulcer of left hip, stage 2
S72.325D Nondisplaced transverse fracture of shaft of left femur, sub-
sequent encounter for closed fracture with routine healing
S72.334D Nondisplaced oblique fracture of shaft of right femur, subse-
quent encounter for closed fracture with routine healing
S22.42xD Multiple fractures of ribs, left side, subsequent encounter for
closed fracture with routine healing
Good work!

14.2  Disorders of the Nails, Hair, Glands,

and Sensory Nerves
Nails
Phalanges
As you can see in Figure 14-4, there are several components of nails—those hard, pro- Fingers and toes [singular:
tective layers at the ends of your phalanges (fingers and toes). The most well-known part phalange or phalanx].

CHAPTER 14  | 
 Stratum
corneum Radix
Unguis (nail) (cuticular fold) (nail root)

Stratum Corpus Eponychium

lucidum (nail (cuticle)
(free surface) body)

Phalanx
Stratum Nail (bone)
germinativum matrix
(nail bed)

FIGURE 14-4  An illustration identifying the anatomical sites of the basic parts
of a human nail: nail plate, lunula, root, sinus, matrix, nail bed, hyponychium, free
edge  Booth et al., Medical Assisting, 5e. Copyright ©2013 by McGraw-Hill Education. Figure 23-4, p. 501. Used
with permission.

of the nail is the nail plate, the main part of the nail, which lies upon a layer of skin (nail
bed). At the point where the nail plate goes beneath the skin [eponychium = nail fold +
cuticle (lunula)] of the finger (or toe) is the lunula, a white area shaped like a crescent
moon (therefore, the term lunula, from luna, meaning moon). As the nail grows over the
tip of the phalange, the area of epidermis beneath is called the hyponychium.

Nail Disorders
The human body has 20 nails—10 fingernails and 10 toenails—and as with any other
anatomical site, things can go wrong.
∙ Onycholysis: This is a detachment of the nail from the bed of the nail. Onset occurs
at either the distal or lateral attachment. Patients previously diagnosed with psoria-
sis or thyrotoxicosis are most often seen with this condition. Reported with code
L60.1 Onycholysis.
∙ Beau’s lines: These are deeply grooved, horizontal lines (from side to side) on either
a fingernail or a toenail. Previous infection, injury, or other disruption to the nail
fold, the location of nail formation, may be the cause. Reported with code L60.4
Beau’s lines.
∙ Yellow nail syndrome: A thickened nail that has become yellowed is typically seen
in patients previously diagnosed with a systemic disease, such as lymphedema or
bronchiectasis. This is reported with code L60.5 Yellow nail syndrome.
You have learned, with many diseases in various body systems, that a disease in one
location of the body may negatively impact another part of the body. This can happen
with the nails as well, so ICD-10-CM provides a specific code to report this:
L62 Nail disorders in diseases classified elsewhere
Code first underlying disease, such as: pachydermoperiostosis (M89.4-)

ICD-10-CM
LET’S CODE IT! SCENARIO
Priscilla Ablerts, an 83-year-old female, was brought in with toenails that had grown out of normal shape. It had got-
ten to the point that she could no longer wear closed shoes, and her daughter was concerned. After examination, Dr.
Terranzo diagnosed Priscilla with onychogryphosis.

388   PART II  |  REPORTING DIAGNOSES

 Let’s Code It!
Dr. Terranzo diagnosed Priscilla with onychogryphosis. Turn in the ICD-10-CM Alphabetic Index to find
Onychogryphosis, onychogryposis L60.2
Let’s turn in the Tabular List to the code category:
L60 Nail disorders
clubbing of nails (R68.3)
onychia and paronychia (L03.0-)
Neither of these conditions applies to Priscilla’s reason for seeing Dr. Terranzo for this encounter, so keep read-
ing down to evaluate all of the fourth-character options. Which is the most accurate?
L60.2 Onychogryphosis
This matches Dr. Terranzo’s documentation. However, you know that before you can report this code, you need
to check the note for this subsection (right above L60). This does not relate to this case. Now, check
the   note at the very beginning of this chapter in the ICD-10-CM Tabular List. Last stop at the Official
Guidelines, section 1.c.12. There seem to be no guidelines here that relate to Dr. Terranzo’s care for Priscilla, so
you can now report this code with confidence:
L60.2 Onychogryphosis
Good job!

Hair
Hair is a pigmented (colored), hard keratin that grows from the hair follicle—the Hair
location of the hair root. As you can see in Figure 14-5, the follicle is embedded in the A pigmented, cylindrical
dermis and fatty tissue of the skin layers. As you probably know from your own body, filament that grows out from
hair may grow externally, such as on your scalp, as well as internally, such as inside the hair follicle within the
the nasal or ear cavity. The hairs in the nose help to prevent certain particles from epidermis.
entering the respiratory system. Hair Follicle
A saclike bulb containing the
Disorders of the Hair hair root.
For some patients, a bad hair day can be much more serious than a cowlick or frizz.
∙ Alopecia mucinosa: This skin disorder may first be identified by erythematous
plaqueing of the skin without any hair growth. The flat patches of hairlessness may
occur on the scalp, face, or legs. Reported with code L65.2 Alopecia mucinosa.
∙ Trichorrhexis nodosa: Evidenced by a hair shaft defect that causes weak spots, this
disorder results in hair that easily breaks. Most often, this condition is caused by
environmental factors such as blow drying, permanent waves, or excessive chemi-
cal exposure. Reported with code L67.0 Trichorrhexis nodosa.
∙ Hirsutism: Women with this condition have excessive hair growth on anatomical
sites where hair does not typically occur, such as the chest or chin. It is believed
to be caused by an abnormal hormonal level, particularly male hormones such as
testosterone. Reported with code L68.0 Hirsutism.

Glands
Three different types of glands are located within the skin:
∙ Sebaceous glands produce an oil-rich element, known as sebum, that lies on the
outer surface of the epidermis and along the hair. The substance has a waterproof-
ing effect. Individuals with oily skin may have overly active sebaceous glands.

CHAPTER 14  | 
 Hair shaft

Sebaceous
gland

Hair root
(keratinized
cells)
Hair follicle

Region of
cell division
Hair papilla

FIGURE 14-5  An illustration identifying the anatomical parts of a hair; from papilla
to shaft  David Shier et al., Hole’s Human Anatomy & Physiology, 12/e. ©2010 McGraw-Hill Education.
Figure 6.7a, p. 178. Used with permission.

∙ Eccrine glands are sweat glands that are responsible for maintaining proper body
temperature by excreting sweat (water, salt, and wastes) via the pores in the skin. Pro-
duction of more sweat is the reaction to cool an overheated body (see Figure 14-6).
∙ Apocrine glands release  a discharge that is high in protein. Located in the axilla
(armpits), anal, and genital areas, bacteria interact with the protein and create an odor.

Eccrine Sweat Disorders 

As with any other anatomical site, the eccrine sweat glands can malfunction. One con-
dition is known as focal hyperhidrosis (excessive sweating). This is reported with a spe-
cific character to identify the region of the body affected (i.e., axillae, face, palms, or
soles). Primary hyperhidrosis is an idiopathic condition (no known etiology), whereas
secondary focal hyperhidrosis (also known as Frey’s syndrome) is often caused by dam-
age to the parotid glands, resulting in excessive salivation. Hypohidrosis (code L74.4),
also known as anhidrosis, is a condition in which the glands do not produce enough
perspiration. This may lead to hyperthermia, heat stroke, or heat exhaustion.
You can see that the ICD-10-CM code descriptions use the term miliaria, which is the
medical term for a skin disorder—the appearance of red bumps or blisters—caused by
blocked sweat ducts and trapped sweat beneath the skin. Laypeople call this heat rash.
L74.0 Miliaria rubra
L74.1 Miliaria crystallina
L74.2 Miliaria profunda
L74.4 Anhidrosis (Hypohidrosis)

390   PART II  |  REPORTING DIAGNOSES

 Sweat gland pore
Sweat

Sebaceous gland

Sweat gland duct

Sweat gland

FIGURE 14-6  An illustration identifying the anatomical sites of sweat glands  Booth
et al., Medical Assisting, 5e. Copyright ©2013 by McGraw-Hill Education. Figure 23-1, p. 497. Used with permission.

Apocrine Sweat Disorders 

One of the challenges in dealing with an apocrine sweat disorder is the potential for embar-
rassment due to the increase in body odor. Natural odors can be a natural attraction between
humans; however, when body odor is out of balance, this can cause both physiological and
psychological problems. Bromhidrosis (foul-smelling perspiration, code L75.0) or chrom-
hidrosis (pigmented perspiration, code L75.1) can be publicly humiliating to any adult.
L75.0 Bromhidrosis
L75.1 Chromhidrosis
L75.2 Apocrine miliaria (Fox-Fordyce disease)
L75.8 Other apocrine sweat disorders

ICD-10-CM
YOU CODE IT! CASE STUDY
Ellyn Pacard, a 41-year-old female, presents to Dr. Grall with what she believes to be nonscarring male-pattern
alopecia. Examination reveals small patches of scalp, with some limited mild erythema. “Exclamation point” hairs
are located on the periphery with some indication of new patches and regrowth. Explained to patient that complete
regrowth is possible in this diagnosis.
Diagnosis: alopecia capitis
Treatment plan: intralesional corticosteroid injections followed by minoxidil applications.

You Code It!

Read Dr. Grall’s notes on his encounter with Ellyn carefully, and code the visit.
Step #1: Read the case carefully and completely.
Step #2: Abstract the scenario. Which main words or terms describe why the physician cared for the patient
during this encounter? 

(continued)

CHAPTER 14  | 
 Step #3: Are there any details missing or incomplete for which you would need to query the physician? [If so,
ask your instructor.]
Step #4: Check for any relevant guidance, including reading all of the symbols and notations in the Tabular List
and the appropriate sections of the Official Guidelines.
Step #5: Determine the correct diagnosis code or codes to explain why this encounter was medically
necessary.
Step #6: Double-check your work.
Answer:
Did you determine this to be the correct code?
L63.0 Alopecia (capitis) totalis
Good work!

Sensory Nerves
In a part of the nervous system known as the somatic (relating to the body) sensory
system, sensory nerve endings are located in the layers of the skin to provide sensory
feedback—the sense of touch. These nerves enable you to feel pressure, pain, tempera-
ture (hot and cold), textures (rough and smooth), and more.
There is more about the nervous system in this book’s chapter titled Coding Men-
tal, Behavioral, and Neurological Disorders.

ICD-10-CM
LET’S CODE IT! SCENARIO
Serena Brynner is a 19-year-old female who came in to see Dr. Trenton with thickened, hardened skin and subcu-
taneous tissue on her forearms, bilaterally. Examination shows Addison’s keloid present. She is given a referral to a
plastic surgeon.

Let’s Code It!

Dr. Trenton diagnosed Serena with Addison’s keloid on both of her forearms. Let’s begin by finding this key term
in the Alphabetic Index:
Keloid, cheloid L91.0
   Addison’s L94.0
Let’s find this code category in the Tabular List:
L94 Other localized connective tissue disorders
The terms here don’t match exactly. Let’s check a medical encyclopedia to find out exactly what an Addison’s
keloid is:
Addison’s keloid is a skin disease consisting of patches of yellowish or ivory-colored hard, dry,
smooth skin. It is more common in females. Also known as morphea or circumscribed
scleroderma.
This helps a great deal. Read the complete code descriptions in this code category. Did you connect to this code?
L94.0 Localized scleroderma [morphea] (Circumscribed scleroderma)
Fantastic!

392   PART II  |  REPORTING DIAGNOSES

14.3  Lesions
Many people believe a lesion is a sore on the epidermis; however, lesions might also
occur internally. Skin lesions are categorized as primary or secondary and are patho-
logically determined to be benign or malignant. Even though the majority of lesions
are external, reporting them is not confined to the codes in the L00–L99 section,
Diseases of the Skin and Subcutaneous Tissue. Essentially, lesion codes are located
throughout the code set; they are most often found in the section related to the ana-
tomical location or by a specific term. Many skin lesions (see Figure 14-7) are identi-
fied by name or type, including
Cyst
∙ Cyst: a fluid-filled or gas-filled bubble in the skin.
A fluid-filled or gas-filled bub-
∙ Furuncle: a staphylococcal infection in the subcutaneous tissue; commonly known ble in the skin.
as a boil.
Furuncle
∙ Papule: a raised lesion with a diameter of less than 5 mm. A staphylococcal infection in
∙ Nodule: a tissue mass or papule larger than 5 mm. the subcutaneous tissue; com-
monly known as a boil.
∙ Macule: a flat lesion with a different pigmentation (color) when compared with the
surrounding skin. An ephelidis (freckle) is a small macule. Papule
∙ Nevus: an abnormally pigmented area of skin. A birthmark is an example. A raised lesion with a diam-
eter of less than 5 mm.
∙ Patch: a flat, small area of differently colored or textured skin; a large macule.
∙ Bulla: a large vesicle that is filled with fluid. Nodule
A tissue mass or papule larger
∙ Pustule: a swollen area of skin; a vesicle filled with pus. than 5 mm.
∙ Scale: flaky exfoliated epidermis; a flake of skin.
Macule
∙ Ulcer: an erosion or loss of the full thickness of the epidermis. A flat lesion with a different
pigmentation (color) when
EXAMPLE compared with the surround-
ing skin.
L02.32 Furuncle of buttock
Nevus
An abnormally pigmented
Let’s turn to the Alphabetic Index and find the key term lesion. Review the terms area of skin. A birthmark is an
shown in the indented list that follows, providing additional description for the type example.
of lesion documented. For the most part, these lesions are directly described by their
Patch
anatomical location, with no additional clinical terminology.
A flat, small area of differently
colored or textured skin; a
EXAMPLES large macule.
Lesion, aortic (valve) I35.9 (an internal lesion) Bulla
Lesion, lip K13.0 (an external lesion) A large vesicle that is filled
Lesion, basal ganglion G25.9 (an internal lesion) with fluid.
Lesion, eyelid H00.03- (an external lesion)
Pustule
A swollen area of skin; a vesi-
Often, a skin lesion is diagnosed with a specific name or by type. Therefore, the cle filled with pus.
most effective way to find the codes in the Alphabetic Index is to look up the exact
term that the physician used in the diagnostic statement first, before trying to general- Scale
ize by interpreting lesion and using that term. For example, carbuncles and furuncles, Flaky exfoliated epidermis; a
also known as boils (a type of pustule caused by an infection), are listed by the terms flake of skin.
carbuncle and furuncle, rather than under the main term of lesion, with the fourth Ulcer
character identifying the anatomical location of the skin condition. An erosion or loss of the full
thickness of the epidermis.
EXAMPLES Carbuncle
Carbuncle, chin L02.03 A painful, pus-filled boil due
Carbuncle, hand L02.53- to infection of the epidermis
Carbuncle, scalp L02.831 and underlying tissues, often
caused by staphylococcus.

CHAPTER 14  | 
 PRIMARY LESIONS

Flat, discolored, nonpalpable changes in skin color Elevation formed by fluid in a cavity

Macule Patch Vesicle Bulla Pustule

Elevated, palpable solid masses

Papule Plaque Nodule Tumor Wheal

SECONDARY LESIONS

Loss of skin surface

Erosion Ulcer Excoriation Fissure

Material on skin surface

Scale Crust Keloid

VASCULAR LESIONS

Cherry angioma Telangiectasia Petechiae Purpura Ecchymosis

FIGURE 14-7  An illustration showing the various types of skin lesions  Booth et al., Medical Assisting, 5e. Copyright ©2013 by
McGraw-Hill Education. Figure 23-2, p. 498. Used with permission.

Malignant Lesions
The majority of skin lesions diagnosed are benign. However, there are certain skin
lesions that are pathologically identified as malignant. 
Malignant melanoma is the most deadly type of skin malignancy, causing 80%
of all skin malignancy fatalities. The most frequently identified sites of melanoma

394   PART II  |  REPORTING DIAGNOSES

metastases are the lymph nodes, liver, lung, and brain. The ABCDE method is used
most often to evaluate a possible site, then confirmed by a biopsy. Confirmed diagno-
ses will be reported with a code from the category C43.- Malignant melanoma of skin,
with an additional character or characters based on the specific anatomical site.
Merkel cell carcinoma (also known as neuroendocrine carcinoma) is a rare diagno-
sis. Most often found on the face and neck, it can be recognized by a bluish-red or flesh-
colored nodule. This malignancy grows quickly and will metastasize quickly, meaning
that early diagnosis and treatment are an essential component of a positive outcome.
Report this confirmed diagnosis with a code from category C4A.- Merkel cell carci-
noma with an additional character or characters based on the specific anatomical site.
Squamous cell carcinoma is often pink and scaly with notched or irregular bor-
ders. It has the potential to become erythematous (reddened) or ulcerated with easy
bleeding. Metastasis is common, making early detection and treatment very impor-
tant.  Report this confirmed diagnosis with a code from category C44.- Other and CODING BITES
unspecified malignant melanoma of skin with an additional character or characters For more information on
based on the specific anatomical site. malignant neoplasms,
Basal cell carcinoma is the most frequently seen skin malignancy, with patients refer to the chapter
aged 80 or older at highest risk. Report this confirmed diagnosis with a code from titled Coding Neo-
category C44.- Other and unspecified malignant melanoma of skin with an additional plasms in this text.
character or characters based on the specific anatomical site.

ICD-10-CM
YOU CODE IT! CASE STUDY
Carlos Monteverde, a 63-year-old male, comes in to see Dr. Harris, complaining of an extremely painful spot on his
thigh. He states he has been very tired lately, especially since he noticed this bump. Patient history reveals a preex-
istent furunculosis.
Examination shows deep follicular abscess of several follicles with several draining points. CBC shows an ele-
vated white blood cell count. Wound culture identifies Staphylococcus aureus.
Area is cleaned thoroughly. Instructions given to patient to apply warm, wet compresses at home.
A: Carbuncle of the thigh, left
P: Rx for erythromycin, q8h and mupirocin ointment

You Code It!

Read Dr. Harris’s notes on his encounter with Carlos carefully, and code the visit.
Step #1: Read the case carefully and completely.
Step #2: Abstract the scenario. Which main words or terms describe why the physician cared for the patient
during this encounter? 
Step #3: Are there any details missing or incomplete for which you would need to query the physician? [If so,
ask your instructor.]
Step #4: Check for any relevant guidance, including reading all of the symbols and notations in the Tabular List
and the appropriate sections of the Official Guidelines.
Step #5: Determine the correct diagnosis code or codes to explain why this encounter was medically necessary.
Step #6: Double-check your work.
Answer:

Did you determine these to be the correct codes?

L02.436 Carbuncle of left lower limb
B95.61 Methicillin susceptible Staphylococcus aureus infection as the cause of diseases classified
elsewhere
Good job!

CHAPTER 14  | 
 14.4  Prevention and Screenings
The most frequently diagnosed malignancy in the United States is skin cancer. While
some individuals have a higher risk of developing this type of malignant neoplasm, the
truth is that anyone can find himself or herself with this diagnosis. 
The best way to prevent skin lesions is to avoid known causes. Of course, some sug-
gest staying out of the sun altogether, but this could decrease a patient’s exercise and out-
door activities, which are also good for one’s health. Therefore, protective clothing and
use of sunscreen with a sun protection factor (SPF) of 15 or higher is strongly recom-
mended prior to going out into the sun. Tanning beds also may cause an increased risk.
The Centers for Disease Control and Prevention (CDC) suggests ways to protect
yourself from UV rays that can cause harm:
∙ Stay in the shade as much as possible, especially during the hours of 10 a.m. through
4 p.m.
∙ Keep your extremities (arms and legs) covered with clothing.
∙ Use a wide-brimmed hat to shade and protect your head, face, neck, and ears.
∙ Wear sunglasses to protect your eyes (and reduce your risk for cataracts).
∙ Apply sunscreen with an SPF of 15 or higher.
∙ Avoid the use of any indoor tanning beds or booths including sunlamps.
Physicians are encouraged by the CDC to perform an annual exam of all patients,
especially those who are older and higher at risk. The scalp, ears, nasolabial folds, and
wrinkles are key points.

EXAMPLES
There can be other reasons for a healthy patient to see a physician about skin-
related issues:
Z12.83 Encounter for screening for malignant neoplasm of skin
Z20.7 Contact with and (suspected) exposure to pediculosis, acariasis
and other infestations
Z52.11 Skin donor, autologous
Z52.19 Skin donor, other
Z84.0 Family history of diseases of the skin and subcutaneous tissue
Z86.31 Personal history of diabetic foot ulcer
Z87.2 Personal history of disease of the skin and subcutaneous tissue
Z94.5 Skin transplant status
Z96.81 Presence of artificial skin

ICD-10-CM
YOU CODE IT! CASE STUDY
PATIENT NAME: Christopher Flemming
SUBJECTIVE: The patient is a 54-year-old male who presents for his annual preventive screening of moles. He has
no particular lesions he is concerned about, although he states his wife has told him that he has a lot of moles on his
back. He does not think any of them are changing. He did have an atypical nevus removed from one of the toes on
his left foot about 3 years ago. He did not require re-excision after the biopsy. He was told to have annual skin exams
and he just has not followed through with it. His other complaint is acne on his chest and back.
PAST MEDICAL HISTORY: Negative for skin cancer.
MEDICATIONS: None.

396   PART II  |  REPORTING DIAGNOSES

 ALLERGIES: NKDA.
FAMILY HISTORY: Negative for melanoma.
SOCIAL HISTORY: Moderate sun exposure. He does use sunscreen, when he remembers.
OBJECTIVE: Alert and oriented x3. Normal mood. Normal body habitus. Examined his face, neck, chest, abdomen,
back, upper extremities and lower extremities, hands and feet bilaterally. There were no lesions anywhere worrisome
for cutaneous malignancy; however, he does have an above-average number of pigmented macular nevi. These
range from 2–6 mm in diameter. The lesions appear similar to each other and are widely distributed on his chest,
abdomen, and back; few on his upper and lower extremities and face. On his upper back, there are scattered 2.5 mm
inflammatory papules and pustules.
ASSESSMENT:
1.  Mild truncal acne.
2.  Multiple nevi.
3.  History of solitary atypical nevus.
PLAN:
1. Reviewed ABCDs of pigmented lesions, sun protection. Discussed self-exam. Advised he return for skin examina-
tion annually as the mole pattern he has does put him at a higher lifetime risk of development of melanoma.
2.  He was given erythromycin solution to use b.i.d. for acne.
3.  Follow-up is scheduled in 1 year.

You Code It!

Review this documentation from Dr. Stirpe’s evaluation of Christopher, and determine the correct code or codes
to report the medical necessity for this encounter.
Step #1: Read the case carefully and completely.
Step #2: Abstract the scenario. Which main words or terms describe why the physician cared for the patient
during this encounter?
Step #3: Are there any details missing or incomplete for which you would need to query the physician? [If so,
ask your instructor.]
Step #4: Check for any relevant guidance, including reading all of the symbols and notations in the Tabular List
and the appropriate sections of the Official Guidelines.
Step #5: Determine the correct diagnosis code or codes to explain why this encounter was medically necessary.
Step #6: Double-check your work.
Answer:
Did you determine these to be the correct codes?
Z12.83 Encounter for screening for malignant neoplasm of skin
D22.5 Melanocytic nevi of trunk
L70.8 Other acne

Chapter Summary
With all the advertising about lotions to preserve youthful skin, shampoos and con-
ditioners for soft hair, and manicures and pedicures for nails, you may forget that
the elements of the integumentary system (skin, hair, nails) are not just cosmetic or

CHAPTER 14  | 
 decorative elements of our bodies. In addition, the glands embedded in the skin sup-
CHAPTER 14 REVIEW

port the ongoing proper function of the body.

CODING BITES
Early detection is the best, most effective way to deal with any malignancy, includ-
ing skin cancer. This means that a regular habit of self-examination is wise. The
CDC developed a five-point checklist to help you check yourself for melanoma. 
“A” stands for Asymmetrical. Does the mole or spot have an irregular shape
with two parts that look very different?
“B” stands for Border. Is the border irregular or jagged?
“C” is for Color. Is the color uneven? Do you see variations of brown, black,
blue, or white?
“D” is for Diameter. Is the mole or spot larger than the size of a pea (6 mm)?
“E” is for Evolving. Has the mole or spot changed during the past few weeks or
months?
If the answer to any of these steps is Yes, the patient should contact a dermatolo-
gist for a complete screening.

CHAPTER 14 REVIEW
Coding Integumentary Conditions Enhance your learning by
completing these exercises and
more at connect.mheducation.com!

Let’s Check It! Terminology

Match each key term to the appropriate definition.

Part I
1. LO 14.1  A bubble or sac formed on the surface of the skin, typically filled with A. Blister
a watery fluid or serum. B. Carbuncle
2. LO 14.1  An open wound or sore caused by pressure, infection, or inflammation. C. Decubitus Ulcer
3. LO 14.2  Death and decay of tissue due to inadequate blood supply. D. Dermis
4. LO 14.1  The layer beneath the dermis; also known as the hypodermis. E. Epidermis
5. LO 14.3  A painful, pus-filled boil due to infection of the epidermis and underly- F. Gangrene
ing tissues, often caused by staphylococcus.
G. Hair
6. LO 14.1  A skin lesion caused by continuous pressure on one spot, particularly
H. Hair Follicle
on a bony prominence.
I. Phalanges
7. LO 14.2  A saclike bulb containing the hair root.
J. Skin
8. LO 14.2  Fingers and toes.
K. Subcutaneous
9. LO 14.2  A pigmented, cylindrical filament that grows out from the hair follicle
within the epidermis. L. Pressure Ulcer
10. LO 14.1  The external layer of the skin, the majority of which is squamous cells.
11. LO 14.1  The internal layer of the skin; the location of blood vessels, lymph ves-
sels, hair follicles, sweat glands, and sebum.
12. LO 14.1  The external membranous covering of the body.

398   PART II  |  REPORTING DIAGNOSES

Part II

CHAPTER 14 REVIEW
1. LO 14.3  An erosion or loss of the full thickness of the epidermis. A. Bulla
2. LO 14.3  A large macule. B. Cyst
3. LO 14.3  A raised lesion with a diameter of less than 5 mm. C. Furuncle 
4. LO 14.3  An abnormally pigmented area of skin. A birthmark is an example. D. Macule
5. LO 14.3  A flat lesion with a different pigmentation (color) when compared with E. Nevus
the surrounding skin. F. Nodule
6. LO 14.3  A papule larger than 5 mm. G. Papule
7. LO 14.3  A fluid-filled or gas-filled bubble in the skin. H. Patch
8. LO 14.3  A boil. I. Pustule
9. LO 14.3  Flaky exfoliated epidermis. J. Scale
10. LO 14.3  A large vesicle that is filled with fluid. K. Ulcer
11. LO 14.3  A vesicle filled with pus.

Let’s Check It! Concepts

Choose the most appropriate answer for each of the following questions.
1. LO 14.1  The _____ is a sturdy collagenous layer that connects the _____ to the fatty tissue layer.
a. epidermis, dermis b.  dermis, epidermis
c. fatty tissue, dermis d.  subcutaneous, epidermis

2. LO 14.1  Seborrheic dermatitis is coded from category _____.

a. L20 b.  L21 c.  L22 d.  L23

3. LO 14.3  Latoya Gregson was diagnosed with a left hand nevus. The correct code would be 
a. D22.6 b.  D22.60 c.  D22.61 d.  D22.62

4. LO 14.2  Women with this condition have excessive hair growth on anatomical sites where hair does not typically
occur, such as the chest or chin. This condition is known as
a. trichotillomania. b.  hirsutism.
c. alopecia. d.  cilia.

5. LO 14.1  Kathy Harrington, a 17-year-old female, comes in today complaining of red, tender skin and having
chills. Kathy admits to sun bathing all day yesterday. After an examination, Dr. Dills diagnoses Kathy
with a 2nd degree sunburn. What is the correct code?
a. L55.9 b.  L55.0 c.  L55.1 d.  L55.2

6. LO 14.2  _____ are sweat glands that are responsible for maintaining proper body temperature by excreting sweat
(water, salt, and wastes) via the pores in the skin.
a. Sebaceous glands b.  Eccrine glands
c. Apocrine glands d.  Holocrine glands

7. LO 14.3  _____ is recognized by a bluish-red or flesh-colored nodule. 

a. Basal cell carcinoma b.  Malignant melanoma
c. Merkel cell carcinoma d.  Squamous cell carcinoma

CHAPTER 14  | 
 8. LO 14.1  When skin layers are lost through and including the subcutaneous tissue, this is a _____ pressure ulcer.
CHAPTER 14 REVIEW

a. stage 1 b.  stage 2 c.  stage 3 d.  stage 4

9. LO 14.1  _____ presents with pain, edema, and/or loss of flexibility in at least one joint. When affecting the fin-
gers or toes, the nails may show pitting or begin to separate from the nail bed. 
a. Psoriatic arthritis mutilans b.  Psoriasis vulgaris
c. Guttate psoriasis d.  Plaque psoriasis

10. LO 14.4  All of the following are ways to protect yourself from UV rays that can cause harm except
a. keep your extremities covered with clothing. 
b. use indoor tanning beds regularly.
c. use a wide-brimmed hat to shade and protect your head, face, neck, and ears.
d. wear sunglasses to protect your eyes (and reduce your risk for cataracts).

Let’s Check It! Guidelines

Refer to the Official Guidelines and fill in the blanks according to the Chapter 12, Diseases of the Skin and Subcuta-
neous Tissue, Chapter-Specific Coding Guidelines.
all site clinical documentation no
completely  highest progresses ulcer admitted
terms L89 healing stage two

1. Codes from category L89, Pressure _____, identify the _____ of the pressure ulcer as well as the stage of the
ulcer.
2. Assign as many codes from category _____ as needed to identify _____ the pressure ulcers the patient has, if
applicable.
3. When there is _____ documentation regarding the _____ of the pressure ulcer, assign the appropriate code for
unspecified stage (L89.--9).
4. Assignment of the pressure ulcer stage code should be guided by _____ documentation of the stage or documen-
tation of the _____ found in the Alphabetic Index.
5. No code is assigned if the documentation states that the pressure ulcer is _____ healed.
6. Pressure ulcers described as _____ should be assigned the appropriate pressure ulcer stage code based on the
_____ in the medical record. 
7. If a patient is _____ with a pressure ulcer at one stage and it _____ to a higher stage, _____ separate codes should
be assigned: one code for the site and stage of the ulcer on admission and a second code for the same ulcer site
and the _____ stage reported during the stay.

Let’s Check It! Rules and Regulations

Please answer the following questions from the knowledge you have gained after reading this chapter.
1. LO 14.1  What are two factors a professional coding specialist needs to know to determine the correct code(s) for
a diagnosed pressure ulcer? 
2. LO 14.1  List the stages of pressure ulcers, and explain how you differentiate among the stages. 
3. LO 14.1  Read the ICD-10-CM Official Guidelines for Coding and Reporting, section I. Conventions, General
Coding Guidelines and Chapter Specific Guidelines, subsection C. Chapter-Specific Coding Guidelines,
chapter 12. Diseases of the Skin and Subcutaneous Tissue, subsection a.2) Unstageable pressure ulcers.
Explain the guideline, including instructions concerning clinical documentation. 

400   PART II  |  REPORTING DIAGNOSES

 4. LO 14.2  Explain the different types of glands that are located within the skin. What is the function of each?

CHAPTER 14 REVIEW
5. LO 14.3  List two types of malignant lesions; describe each one, including the category code.

ICD-10-CM
YOU CODE IT! Basics
First, identify the condition in the following 8. Psoriasis vulgaris:
diagnoses; then code the diagnosis. a. main term _____ b. diagnosis: _____
Example: Bullous impetigo 9. Psoriatic arthritis mutilans: 
a. main term: impetigo b. diagnosis: L01.03 a. main term _____ b. diagnosis: _____
10. Lichen nitidus: 
1. Carbuncle of perineum: 
a. main term _____ b. diagnosis: _____
a. main term _____ b. diagnosis: _____
11. Telogen effluvium:
2. Acute lymphangitis:
a. main term _____ b. diagnosis: _____
a. main term _____ b. diagnosis: _____
12. Alopecia universalis: 
3. Coccygeal fistula with abscess: 
a. main term _____ b. diagnosis: _____
a. main term _____ b. diagnosis: _____
13. Acne conglobata: 
4. Pemphigus vulgaris:
a. main term _____ b. diagnosis: _____
a. main term _____ b. diagnosis: _____
14. Pilar cyst: 
5. Flexural eczema: 
a. main term _____ b. diagnosis: _____
a. main term _____ b. diagnosis: _____
15. Livedoid vasculitis: 
6. Seborrhea capitis:
a. main term _____ b. diagnosis: _____
a. main term _____ b. diagnosis: _____
7. Irritant contact dermatitis due to cosmetics:
a. main term _____ b. diagnosis: _____

ICD-10-CM

YOU CODE IT! Practice

Using the techniques described in this chapter, carefully read through the case studies and determine the most ac-
curate ICD-10-CM code(s) and external cause code(s), if appropriate, for each case study.
1. Angie Ullman, a 7-year-old female, is brought into the ER by her parents due to a painful rash on her legs.
The ER physician documents a temperature of 101 F and admits Angie to the hospital with the diagnosis of
severe poison ivy. Angie’s mother admitted she was walking their dog at the local park this morning and must
have come in contact with the poison ivy there. 
2. Anna Morris, a 22-year-old female, presents today with a blister on her left elbow. Her elbow is painful and
warm to the touch. After an examination, Dr. Lane diagnoses Anna with a pressure ulcer of the elbow, stage 2. 
3. A.G. Harrison, a 62-year-old male, complains of a deep sore on his right heel. After an examination, Dr.
Miles notes that the subcutaneous tissue is visible with necrosis and admits A.G. to the hospital. Dr. Miles
diagnoses A.G. with a decubitus ulcer of the heel, stage 3. 
4. George Bowden, a 34-year-old male, presents today with a painful pus-filled lump on the nape of his neck.
After an examination, Dr. Harris diagnoses George with a neck carbuncle. 
5. Maechearda McConico, a 23-year-old female, presents with a bleeding mole on her left eyebrow. After a thorough
examination and the appropriate tests, Dr. Ardis diagnoses Maechearda with a malignant melanoma in situ. 

CHAPTER 14  | 
CHAPTER 14 REVIEW

6. Matt Kicklighter, an 18-year-old male, presents today with fluid-filled blisters on his back. Matt states that
the blisters are easily broken. After an examination and testing, Dr. Gardener diagnoses Matt with staphylo-
coccal scalded skin syndrome with 14% exfoliation due to erythematosis. 
7. Judy Shirer, a 48-year-old female, comes in today with swollen, red, and painful skin on her face. Judy says
she also feels nauseous. Dr. Lee notes red streaking around the cheeks and eyes and a temperature of 103 F.
After examining Judy, Dr. Lee admits her to the hospital, where further laboratory test results confirm the
diagnosis of facial cellulitis, MRSA. 
8. Aaron Ragin, a 17-year-old male, presents today with a painful red lump on his chest. Dr. Godwin com-
pletes an examination and the appropriate laboratory tests. Aaron is diagnosed with a furuncle due to
staphylococcus. 
9. Harriett Mooney, a 6-year-old female, is brought in by her parents. Harriett has dry scaly skin. Dr. Lebrun
completes an examination and a patch test, which confirms the diagnosis of infantile eczema. 
10. Kathy Neal, a 56-year-old female, presents today with an itchy purple-colored lower lip. Dr. Grimsley notes
flat-topped papules intermingled with lacy white lines. Kathy is diagnosed with bullous lichen planus.  
11. Brenda Mets, a 32-year-old female, was diagnosed with basal cell carcinoma on her nose 10 days ago. Brenda
is admitted to the hospital today for electrodesiccation and curettage by Dr. Dease. 
12. Donald Ross, a 33-year-old male, presents today with raised bumps on his back. Dr. Margroff notes pustules.
Don admits to skin tenderness. Dr. Margroff completes an examination and diagnoses Donald with general-
ized pustular psoriasis. 
13. Beth Whitman, an 81-year-old female, presents with a sore on the medial side of her right calf. After examin-
ing the area and documenting edema and ulceration, Dr. Sanoski decides to admit Beth to the hospital. After a
workup, Beth is diagnosed with a venous stasis ulcer with muscle necrosis, right calf. A possible skin graft is
discussed with the patient. 
14. Eugene Sanford, a 49-year-old male, comes in today with the complaint of a small red prickly rash under his scro-
tum. Dr. Kimrey completes an examination and the appropriate tests. Eugene is diagnosed with apocrine miliaria. 
15. Gary Sanders, a 78-year-old male, comes in today with the complaint that the mole on his right ankle has
begun to rapidly change in shape and color. Dr. Jones completes an examination noting ABCD - asymmetry,
elevation above skin surface with an irregular border, blue-grey in color, firm to the touch, and a diameter of
8 mm and thickness of 1.63 mm. Gary is admitted to Weston Hospital. Skin and lymph node biopsies were
ordered as well as imaging studies and blood tests. After reviewing the results of the pathology report and
other tests, Gary is diagnosed with a malignant nodular melanoma. Excision of lesion is scheduled.    

ICD-10-CM

YOU CODE IT! Application

The following exercises provide practice in abstracting physicians’ notes and learning to work with documentation
from our health care facility, Prader, Bracker, & Associates. These case studies are modeled on real patient encoun-
ters. Using the techniques described in this chapter, carefully read through the case studies and determine the most
accurate ICD-10-CM code(s) and external cause code(s), if appropriate, for each case study.

PRADER, BRACKER, & ASSOCIATES

A Complete Health Care Facility
159 Healthcare Way • SOMEWHERE, FL 32811 • 407-555-6789
PATIENT: CHILDERS, AARON
ACCOUNT/EHR #: CHILAA001

402   PART II  |  REPORTING DIAGNOSES

 CHAPTER 14 REVIEW
DATE: 09/16/18
Attending Physician: Oscar R. Prader, MD
This 59-year-old male presents today with a rash on the bottom of his feet. Patient admits he is also
having trouble with his vision and has dysuria.
VS normal; on visual foot examination, rash has a cobblestone appearance. After a thorough examina-
tion and testing, patient is diagnosed with acquired keratoderma due to reactive arthritis of the foot joint
(Reiter’s disease).
Patient is given 5 mg IM, methotrexate
Rx: Methotrexate, 2.5 mg tab, PO, once a day, x 10 days
P: Return PRN

ORP/pw  D: 09/16/18 09:50:16  T: 09/16/18 12:55:01

Determine the most accurate ICD-10-CM code(s).

PRADER, BRACKER, & ASSOCIATES

A Complete Health Care Facility
159 Healthcare Way • SOMEWHERE, FL 32811 • 407-555-6789
PATIENT: STEEVANG, BRANDON
ACCOUNT/EHR #: STEEBR001
DATE: 10/16/18
Attending Physician: Oscar R. Prader, MD
S: This is a 39-year-old male with advanced human immunodeficiency virus infection who has pre-
sented to the emergency department with severe itching with a duration of approximately 10 days. On
a scale of 1 to 10, he rates the itching as 10 of 10 in severity. Patient states he has been compliant with
his antiretroviral therapy. He has been drinking excessively and taking diphenhydramine every 4 hours
for the last several days.
O: H: 6’1”, Wt: 176, T: 98.9, R: 19, P: 66, BP: 132/76. On examination, he is constantly scratching his
skin. There are spots of blood on his clothing. Xerosis is noted as well as several brown patches on his
extremities. The scrotum appears leathery and thickened. A skin scraping for scabies mite is performed
and sent to the lab for analysis.
A: Scabies, HIV
Rx: Permethrin, 5% cream, apply to all skin surfaces. Leave on for at least 9 hours, then wash off with
warm water.
P: Follow-up appointment with PCP

ORP/pw  D: 10/16/18 09:50:16  T: 10/18/18 12:55:01

Determine the most accurate ICD-10-CM code(s).

CHAPTER 14  | 
CHAPTER 14 REVIEW

PRADER, BRACKER, & ASSOCIATES

A Complete Health Care Facility
159 Healthcare Way • SOMEWHERE, FL 32811 • 407-555-6789
PATIENT: CHARLES, RICHARD
ACCOUNT/EHR #: CHARRI001
DATE: 09/16/18
Attending Physician: Renee O. Bracker, MD
S: This 35-year-old male came in after experiencing a severe episode with a prodrome of tingling of
his lip before the appearance of lesions. He has been diagnosed with recurrent herpes simplex labialis.
These episodes typically last between 1 and 2 weeks. He has no other medical problems and would
like some easy-to-follow recommendations to manage this chronic illness. 
O: VS normal. On visual examination, a small blister/sore on the lower lip is documented.
A: Recurrent herpes simplex labialis
Rx: Valacyclovir 2g, PO, followed by 2g in 12 hours
P: Return PRN

ROB/pw  D: 09/16/18 09:50:16  T: 09/16/18 12:55:01

Determine the most accurate ICD-10-CM code(s).

WESTON HOSPITAL
629 Healthcare Way • SOMEWHERE, FL 32811 • 407-555-6541
PATIENT: MEDINA, LEAH
ACCOUNT/EHR #: MEDILE001
DATE: 09/16/18
Attending Physician: Renee O. Bracker, MD
S: Leah Medina, a 6-year-old female, was at home helping her father clean out the attic when she was
bitten by a black spider. Her father, Jacob, thought quickly and captured the spider in an old jar. Leah
began to run a fever and vomited several hours later, so her father rushed her to the ED. 
O: H: 50.5”, Wt: 58.0 lbs., T: 102 F, R: 22, P: 90, BP: 127/88. Leah says she feels really tired and hurts all
over. She has constantly scratched the bite area since arriving at the ED. She appears lethargic; rash is
noted over body; heart is regular with no gallops or murmurs; lungs are clear; a dark blue/purple wound
is noted on the right thigh. PMH and FH are both noncontributory. Dr. Bracker was able to identify the
spider as a black widow spider and admits Leah to the hospital. 
A: Black widow spider bite 
P: Anitvenom 6000 units IV in 50 mL of normal saline over 15 minutes

ROB/pw  D: 09/16/18 09:50:16  T: 09/16/18 12:55:01

Determine the most accurate ICD-10-CM code(s).

404   PART II  |  REPORTING DIAGNOSES

 CHAPTER 14 REVIEW
WESTON HOPSITAL
629 Healthcare Way • SOMEWHERE, FL 32811 • 407-555-6541
PATIENT: CHABANNI, LORI
ACCOUNT/EHR #: CHABLO001
DATE: 09/16/18
Attending Physician: Renee O. Bracker, MD
S: This 46-year-old female with a 3-month history of ulcerations and abscesses involving both breasts
was admitted today. Patient states the ulcerations began to appear after breast reduction surgery,
approximately 2 weeks postop. The patient had no history of ulcerations before the breast reduction
surgery. She also states that her muscles and joints ache.
O: VS: T: 102 F, all other VS are within normal range; patient is in obvious distress. PMH: remarkable for
hypertension and quiescent ulcerative colitis. FH: Noncontributory. Deep ulcers under breast, bilaterally,
are noted with well-defined borders. Ulcer edges are worn and surrounding skin is red. Coloration of
ulcers is violet to blue. Incision and drainage of breast abscesses is scheduled.
A: Pyoderma gangrenosum. 
P: Pulse IV methylprednisolone, 500 mg daily for 3 consecutive days

ROB/pw  D: 09/16/18 09:50:16  T: 09/16/18 12:55:01

Determine the most accurate ICD-10-CM code(s).

CHAPTER 14  | 
 15
Key Terms
Coding Muscular
and Skeletal Conditions
Learning Outcomes
Arthropathy After completing this chapter, the student should be able to:
Articulation
Chondropathy LO 15.1 Code accurately arthropathic conditions of the muscles.
Dorsopathy LO 15.2 Determine the proper way to report dorsopathies and
Intervertebral Disc spondylopathies.
Laterality LO 15.3 Interpret the details required to report soft tissue disorders.
Myopathy LO 15.4 Identify the specifics of diseases that affect the musculoskel-
Site etal system reported from other areas of ICD-10-CM.
Spondylopathy
Vertebra LO 15.5 Report diagnoses related to pathological fractures
accurately.

Remember, you need to follow along in

ICD-10-CM

  STOP! your ICD-10-CM code book for an optimal

learning experience.

15.1  Arthropathies
As you can see in Figure 15-1, the entire skeleton appears to be wrapped with muscles
from top to bottom and all the way around. Each muscle has a specific function.
Injuries are not the only concern that can affect an individual’s musculoskeletal
health. Diseases, infections, and other problems can occur. There are pathogens (bac-
teria, viruses, and fungi) that directly attack the muscles of the body. The physician’s
Myopathy notes might identify the patient’s condition as myopathy, arthropathy, chondropathy,
Disease of a muscle [plural: dorsopathy, or spondylopathy. Some of these conditions are described in this list:
myopathies].

Arthropathy
Disease or dysfunction of a CODING BITES
joint [plural: arthropathies]. Myopathy: myo = muscle + -pathy = disease.
Chondropathy Arthropathy: arthro = joint + -pathy = disease.
Disease affecting the cartilage Chondropathy: chondro = cartilage + -pathy = disease.
[plural: chondropathies]. Dorsopathy: dorso = back + -pathy = disease.
Spondylopathy: spondylo = vertebra + -pathy = disease.
Dorsopathy
Disease affecting the
back of the torso [plural:
Rheumatoid arthritis (RA) is an autoimmune systemic inflammatory disease that
dorsopathies].
affects joints as well as the surrounding muscles, tendons, and ligaments. Report a
Spondylopathy code from category M05 Rheumatoid arthritis with rheumatoid factor or M06 Other
Disease affecting the verte- rheumatoid arthritis. To determine the complete valid code, you will need to iden-
brae [plural: spondylopathies]. tify, from the documentation, the specific anatomical site. Be alert because more than
one anatomical site may be involved, and ICD-10-CM provides you with combination
codes to report the complete story of this patient’s condition.

406
 Frontalis
Orbicularis Temporalis
oculi
Occipitalis
Zygomaticus
Masseter Sternocleidomastoid
Orbicularis oris
Trapezius Trapezius Infraspinatus
Sternocleido-
mastoid
Deltoid Rhomboid
Deltoid
Pectoralis Teres minor Latissimus
major dorsi
Serratus Teres major
anterior Biceps brachii Brachialis
Brachialis Triceps
External External
brachii
oblique oblique
Rectus Brachioradialis Gluteus
abdominis medius

Tensor Gluteus
maximus
fasciae
latae

Sartorius

Rectus femoris Gracilis

Biceps femoris Adductor
Adductor longus Vastus magnus
medialis Semitendinosus
Vastus lateralis Gracilis
Semimembranosus
Vastus
lateralis
Fibularis longus Gastrocnemius Sartorius

Tibialis anterior Gastrocnemius

Fibularis
Soleus
Extensor longus
Calcaneal tendon
digitorum longus
Soleus

FIGURE 15-1  An illustration identifying the muscles of the body: anterior and posterior  David Shier et al., Hole’s Human
Anatomy & Physiology, 12/e. ©2010 McGraw-Hill Education. Figure 9.23 and 9.24, p. 305–306. Used with permission.

EXAMPLES
CODING BITES
M05.151 Rheumatoid lung disease with rheumatoid arthritis of right hip
Many people confuse
M05.242 Rheumatoid vasculitis with rheumatoid arthritis of the left hand
RA (rheumatoid arthritis)
M05.361 Rheumatoid heart disease with rheumatoid arthritis of right knee
with OA (osteoarthritis).
M06.022 Rheumatoid arthritis without rheumatoid factor, left elbow
RA is a condition that
M06.071 Rheumatoid arthritis without rheumatoid factor, right ankle
affects the muscles,
and foot
joints, and/or connec-
tive tissue, whereas OA Rheumatoid factor (RF) is a test that quantifies the amount of the RF antibodies in
is the deterioration of the blood. A positive RF is the abnormal result indicating a higher number of anti-
cartilage within joints as bodies have been detected—confirmation of the autoimmune response mecha-
well as spinal vertebrae. nism. You would find the data on the pathology report.

CHAPTER 15  | 
 ICD-10-CM
YOU CODE IT! CASE STUDY
Gary Simmons, a 19-year-old male, came in with complaints of intense pain and swelling of his left elbow. Vital signs
evidence a low-grade fever. Gary states that he injured his forearm in hockey practice and it got infected, but he
was too busy with classes and practice to go to the medical clinic on campus. Now, all of a sudden, he has pain in
his elbow that he cannot ignore. Dr. Lannahan applied a local anesthetic and used fine needle aspiration to extract
some synovial fluid. Analysis shows gross pus and testing shows a high white blood cell count. The synovial fluid glu-
cose is 55 mg/dL. This confirmed a diagnosis of acute septic arthritis, due to gram-positive Staphylococcus aureus.

You Code It!

Go through the steps of coding, and determine the code or codes that should be reported for this encounter
between Dr. Lannahan and Gary.
Step #1: Read the case carefully and completely.
Step #2: Abstract the scenario. Which main words or terms describe why the physician cared for the patient dur-
ing this encounter? 
Step #3: Are there any details missing or incomplete for which you would need to query the physician? [If so, ask
your instructor.]
Step #4: Check for any relevant guidance, including reading all of the symbols and notations in the Tabular List
and the appropriate sections of the Official Guidelines.
Step #5: Determine the correct diagnosis code or codes to explain why this encounter was medically necessary.
Step #6: Double-check your work.
Answer:

Did you determine these to be the correct codes?

M00.022 Staphylococcal arthritis, left elbow
B95.61 Methicillin susceptible Staphylococcus aureus infection as the cause of diseases clas-
sified elsewhere
(Staphylococcus aureus infection NOS as the cause of diseases classified elsewhere)

Genu recurvatum, the backward curving of the knee joint, as well as other bowing
of the long bones of the leg, may be treated with braces, casting, and/or orthotics. Con-
genital genu recurvatum is reported with code Q68.2 Congenital deformity of knee.
When this condition is the sequela (late effect) of rickets, it is reported with M21.26-
Flexion deformity, knee, followed by code E64.3 Sequela of rickets.
Gout, also known as gouty arthritis, is the result of the buildup of uric acid in the
body; caused by either a malfunction that produces too much uric acid or an anomaly
that makes it difficult for the body to get rid of uric acid. The specific underlying cause
may be idiopathic or secondary, as a manifestation of renal impairment, adverse reaction
to a drug, or a toxic effect. Gout presents in the joints, most often a toe, knee, or ankle,
and begins with a throbbing or extreme pain in the middle of the night. The joint will
be tender, warm to the touch, and erythematous (red). The most common treatment is a
prescription for NSAIDs (nonsteroidal anti-inflammatory drugs). In ICD-10-CM, gout
is reported from code category M10- Gout or from code category M1A- Chronic Gout,
with additional characters required to report the underlying cause (i.e., drug-induced,
idiopathic, etc.) as well as the specific anatomical location (i.e., ankle, elbow, foot, etc.).
Osteoarthritis is a chronic degeneration of the articular cartilage simultaneous with
the formation of bone spurs on the underlying bone within a joint. The cause of the
osteoarthritis might be an idiomatic condition (such as code M17.11 Unilateral pri-
mary osteoarthritis, right knee); secondary to another underlying condition (such as

408   PART II  |  REPORTING DIAGNOSES

code M18.52 Other unilateral secondary osteoarthritis of first carpometacarpal joint, left
hand); or post-traumatic (such as code M19.172 Post-traumatic osteoarthritis, left ankle
and foot). Treatments typically begin with NSAIDs and/or corticosteroid injections. In
some cases, a brace or crutches may be helpful.

ICD-10-CM
LET’S CODE IT! SCENARIO
Timothy Metrosky, a 55-year-old male, came to see Dr. Weingard with complaints of acute pain in his left hip. He had
been diagnosed with stage 1 chronic kidney disease about 1 year ago, but it has been under control with medica-
tion. Dr. Weingard aspirated synovial fluid from his hip, and the pathology report confirmed that Timothy had devel-
oped secondary gout in his hip.

Let’s Code It!

Dr. Weingard diagnosed Timothy with gout in his left hip, secondary to his renal impairment. Turn to the Alpha-
betic Index, look up Gout, and read down the list. Hmmm.
Gout, gouty (acute) (attack) (flare) (see also Gout, chronic) M10.9
Was Timothy diagnosed with chronic gout? Check the notes. No. So, look down the indented list to find “second-
ary,” or something similar . . .
Gout, gouty
   in (due to) renal impairment M10.30
    hip M10.35-
Great! The terms “due to” and “secondary” both indicate the condition [gout] was caused by another condition
[kidney disease]. Now turn to the Tabular List and confirm the code.
Start reading at the code category
M10 Gout
Read the Use additional code notation carefully to see if it applies. None are applicable. Now check the
note. You have already confirmed that the patient does not have chronic gout; therefore, this does not apply either.
Continue reading to find the accurate fourth character:
M10.3 Gout due to renal impairment
There is a Code first notation that states you need to report Timothy’s renal impairment as the first code, fol-
lowed by this code for the gout. But, as long as you are here, keep reading down the column to review the fifth-
character and sixth-character options and determine which matches Dr. Weingard’s documentation:
M10.352    Gout due to renal impairment, left hip
Very good! Now go back to the Alphabetic Index and find
Disease, kidney, chronic, stage 1 N18.1
Double-check this code in the Tabular List.
N18 Chronic kidney disease (CKD)
Read the Code first and Use additional code notations carefully. Do they apply to this case? No. So, continue
down to find the accurate fourth character.
N18.1 Chronic kidney disease, stage 1
You have the two codes required to report Dr. Weingard’s diagnosis for Timothy. And remember that the Code
first notation directed you to the correct sequencing of these two codes.
N18.1 Chronic kidney disease, stage 1
M10.352 Gout due to renal impairment, left hip

(continued)

CHAPTER 15  | 
 Make certain to check the top of both subsections and the head of both chapters in ICD-10-CM. There are nota-
tions at the beginning: an notation, a Code first notation, a Use additional code notation, NOTEs at
the head of both chapters, and notations. Read carefully. Do any relate to Dr. Weingard’s diagnosis of
Timothy? No. Turn to the Official Guidelines and read Section 1.c.13 (for the musculoskeletal system) and 1.c.14
(for the renal disease). There is nothing specifically applicable here, either. Now you can report N18.1, M10.352
for Timothy’s diagnosis with confidence. Good coding!

Systemic lupus erythematosus (SLE) is an autoimmune disease affecting the joints, kid-
neys, brain, skin, and other organs. Interestingly, ICD-10-CM places this code category
within the musculokeletal system chapter. SLE may be an adverse effect of certain drugs.
When this is documented, you will code M32.0 Drug-induced systemic lupus erythemato-
sus, as well as an additional external cause code to identify the specific drug involved. If
the etiology of the SLE is unknown, you will need to abstract from the physician’s notes if
any organ or organ system is specifically affected. When this is documented, use a combi-
nation code from subcategory M32.1- Systemic lupus erythematosus with organ or system
involvement, with the fifth character naming that system or issue, such as
M32.11 Endocarditis in systemic lupus erythematosus
M32.13 Lung involvement in systemic lupus erythematosus

ICD-10-CM
LET’S CODE IT! SCENARIO
Manuel Daniels, a 43-year-old male, came to see Dr. Biehl complaining of pain and stiffness in his lower jaw. Upon
examination, Dr. Biehl noted swelling and erythema at the temporomandibular joint. Dr. Biehl diagnosed Manuel with
arthralgia of temporomandibular joint, right side.

Let’s Code It!

Dr. Biehl diagnosed Manuel with arthralgia of temporomandibular joint. In the Alphabetic Index, find
Arthralgia –
   Temporomandibular M26.62
Let’s turn to the Tabular List and locate the beginning of the code category:
M26 Dentofacial anomalies (including malocclusion)
Beginning at the code category was a good idea. There is an notation. Read it carefully and deter-
mine whether any of this guidance is applicable to this specific encounter. There is nothing here that relates to
Manuel’s condition, so review all of the choices for the fourth character to determine what matches Dr. Biehl’s
documentation about Manuel’s diagnosis:
M26.6 Temporomandibular joint disorders
There is an notation with two temporomandibular conditions listed. Again, read it carefully and determine
whether any of this guidance is applicable to this specific encounter. There is nothing here that relates to Manuel’s
condition, so review all of the choices for the fifth character to determine what matches Dr. Biehl’s documentation
about Manuel’s diagnosis. This part of the coding process is very important to determining the correct code to report.
Review the list of fifth characters. The documentation will bring you to this code:
M26.62 Arthralgia of temporomandibular joint
Very good. Now, a sixth character is required to report the laterality. Check the documentation, which side of
Manuel’s jaw was affected? The right side. Read through all of the sixth character options and determine the
correct code to report:
M26.621   Arthralgia of right temporomanibular joint
Good job!

410   PART II  |  REPORTING DIAGNOSES

15.2  Dorsopathies and Spondylopathies
(Conditions Affecting the Joints of the Spine)
Components of the Spine
From the neck, where the atlas (C1—the first cervical vertebra) articulates with the
skull, and all the way down the column to the coccyx, the spine is a long stack of indi-
vidual bones called vertebrae, separated by intervertebral discs. Vertebra
A bone that is a part of the
Vertebrae construction of the spinal col-
umn [plural: vertebrae].
An individual vertebra is more than just a bone—it is actually a complex segment
of the anatomical structure. In each of the sections of the vertebral column, the size Intervertebral Disc
and shape of the vertebrae change. The cervical, thoracic, and lumbar vertebrae are A fibrocartilage segment that
shaped slightly differently as the bones reconfigure on the basis of their position in lies between vertebrae of the
the column and the support that is necessary. The cervical vertebrae are the small- spinal column and provides
est of all, and the lumbar vertebrae are the largest. The various aspects of all the cushioning and support.
vertebrae, however, are the same. As you can see in Figure 15-2, the vertebral body
protects the spinal cord anteriorly, while the spinous process and pedicle protect it
posteriorly.
Vertebrae are identified by their location and position in each section of the spinal
column (see Figure 15-3):
∙ Cervical vertebrae: There are seven cervical vertebrae—beginning with the atlas
(the first cervical vertebra) followed by the axis (the second cervical vertebra)—
that run down the posterior (back) of the neck to the top of the shoulder area. These
vertebrae are identified as C1, C2, C3, C4, C5, C6, and C7.
∙ Thoracic vertebrae: There are 12 thoracic vertebrae that run along the posterior
segment of the torso (the thoracic cavity). The rib cage connects at these points.
These vertebrae are identified as T1, T2, T3, T4, T5, T6, T7, T8, T9, T10, T11,
and T12.
∙ Lumbar vertebrae: The five lumbar vertebrae are located at approximately the
waist/hips area and are identified as L1, L2, L3, L4, and L5.

Posterior
Anterior Posterior
Spinal cord
Spinous
process Spinal cord
Vertebral
foramen Transverse Facet of superior
process articular process
Intervetebral
Facet for head
disc
of rib
Facet of Vertebral arch:
superior
articular Lamina
Inferior articular
process process
Pedicle
Facet for
head of rib Body
Spinous process
Spinal nerve
Anterior exiting through
intervertebral Left posterolateral view
foramen of articulated vertebrae
Superior view

FIGURE 15-2  An illustration identifying the aspects of the vertebrae: anterior and posterior

CHAPTER 15  | 
 Cervical Cervical
curvature vertebrae

Vertebra
prominens

Rib facet
Thoracic Thoracic
curvature vertebrae

Intervertebral
discs

Intervertebral
Lumbar foramina Lumbar
curvature vertebrae

Sacrum
Pelvic
curvature
Coccyx
(a) (b)

FIGURE 15-3  An illustration identifying the anatomical sites of the spinal column
Source: David Shier et al., Hole’s Human Anatomy & Physiology, 12/e. ©2010 McGraw-Hill Education. Figure 7.32,
p. 219. Used with permission.

∙ Sacrum: This is a triangular-shaped bone that begins as five individual vertebrae,

which fuse together by the time the average person is in his or her mid-twenties.
The sacrum vertebrae may be identified as S1, S2, S3, S4, and S5.
∙ Coccyx: Also known as the tailbone, this bottommost tip of the spinal column
begins as three to five individual vertebrae, which fuse together in adulthood. For
the average person, this fusion begins in the mid-twenties, and the vertebrae have
completely fused into one bone by middle age.

Conditions Affecting the Spine

Kyphosis is a bending forward of the vertebral column, most often at the thoracic
vertebrae. This condition may be congenital or may be caused by poor posture or
other spinal disorder. Kyphosis used to be commonly referred to as “dowager’s hump.”
A brace and exercise are often the first course of treatment. Spinal arthrodesis may
relieve symptoms, and surgery may be done when neurologic function is impaired.
This condition is reported with code M40.04 Postural kyphosis, thoracic region. How-
ever, multiple codes are available for kyphosis determined by section of the spine as
well as underlying cause.
Scoliosis is similar to kyphosis, in that it results in a bending of the spinal column;
however, with scoliosis, the bend is sideways rather than forward. The spine might
resemble the letter S or C. Scoliosis is most often diagnosed in children aged 0–18,
and more likely in females than males. Uneven gait and unbalanced hips and/or shoul-
ders are signs that initiate further investigation.
Infantile idiopathic scoliosis is identified prior to the age of 4, equally in boys and
girls, and more than 90% of these cases resolve without medical treatment.

412   PART II  |  REPORTING DIAGNOSES

 Juvenile idiopathic scoliosis is diagnosed in children between the ages of 4 and 10,
and is found more frequently in males than females. The curve in these children is
often left-sided.
Adolescent idiopathic scoliosis is seen in patients aged 10–18 and may be evidenced
in as high as 4% of this portion of the population. Researchers believe there may be
a genetic connection; however, this has not yet been proven.

EXAMPLE
In all scoliosis diagnoses, you will need to abstract the specific region of the spine
affected.
M41.02 Infantile idiopathic scoliosis, cervical region
M41.115 Juvenile idiopathic scoliosis, thoracolumbar region
M41.127 Adolescent idiopathic scoliosis, lumbosacral region

ICD-10-CM
YOU CODE IT! CASE STUDY
Marci Wakefield started having pain in her back, after completing a full course of radiation treatments for a malig-
nant tumor. Dr. Diaz diagnosed her with scoliosis of the thoracic region as a result of the radiation.

You Code It!

Go through the steps of coding, and determine the code or codes that should be reported for this encounter
between Dr. Diaz and Marci.
Step #1: Read the case carefully and completely.
Step #2: Abstract the scenario. Which key words or terms describe why the physician cared for the patient dur-
ing this encounter?
Step #3: Are there any details missing or incomplete for which you would need to query the physician? [If so, ask
your instructor.]
Step #4: Check for any relevant guidance, including reading all of the symbols and notations in the Tabular List
and the appropriate sections of the Official Guidelines.
Step #5: Determine the correct diagnosis code or codes to explain why this encounter was medically necessary.
Step #6: Double-check your work.
Answer:
Did you determine these to be the correct codes?
M41.54 Other secondary scoliosis, thoracic region
Y84.2 Radiological procedure and radiotherapy as the cause of abnormal reaction of the patient,
or of later complication, without mention of misadventure at the time of the procedure

Spinal ankylosis is the fusion within a vertebral joint caused by disease. This is not
a procedure where the physician may fuse a joint. Code subcategory M43.2 Fusion of
spine requires a fifth character to report the specific region affected.
Ankylosing spondylitis (AS) is actually a type of inflammation within the vertebral
joint (arthritis). This may also be seen in the joints between the spine and the pelvic
girdle. AS affects men more than women. Code category M45 Ankylosing spondylitis
is used to report AS, with a fourth character to specify the region affected.
Intervertebral disc infection is caused by a pathogen and is different from the
inflammation of arthritis because it is suppurative (produces pus). Code subcategory

CHAPTER 15  | 
 CODING BITES
Why is Marci’s condition coded as secondary scoliosis and not . . .
M41.24   Other idiopathic scoliosis, thoracic region
Idiopathic means with no known cause. But the notes do state a cause of her
scoliosis—the radiation. So this cannot be correct.
What about this code:
Q67.5   Congenital deformity of spine (Congenital scoliosis)
Congenital means present at birth. But Marci was not born with scoliosis—it devel-
oped as a result of her having radiation treatments.
Secondary means that something else (other than nature or something
unknown) caused this condition. In this case, the radiation caused the scoliosis.
The radiation came first, and the scoliosis came second.

M46.3 Infection of intervertebral disc (pyogenic) requires a fifth character to identify

the specific region where the infection is located, as well as an additional code from
B95–B97 to identify the pathogen.

ICD-10-CM
LET’S CODE IT! SCENARIO
George Cornelius came to see Dr. Rymer with complaints of sudden-onset, severe low back pain. He states that the
pain is in the left side of his buttocks, his left leg, and sometimes his left foot. At times, he states that his leg seems
weak as well. Dr. Rymer takes a complete patient history, including specific times and actions that intensify the pain.
Then x-rays, followed by an MRI, are taken of George’s spine, showing a herniated (intervertebral) disc at L3–L4.

Let’s Code It!

Dr. Rymer diagnosed George with a herniated (intervertebral) disc. Turn to the Alphabetic Index, look up herni-
ated, and read down the list to find disc. Hmmm. It is not there. Try looking for intervertebral. Look down and see
Hernia, hernial (acquired) (recurrent) K46.9
   intervertebral cartilage or disc — see Displacement, intervertebral disc
OK, let’s turn to that in the Alphabetic Index:
Displacement, displaced
   intervertebral disc NEC
    lumbar region M51.26
You might ask, How do we know that it is the lumbar region? Look back at Dr. Rymer’s notes. He wrote that
the herniated disk is at L3–L4. The “L” means the lumbar vertebrae, and the notation L3–L4 indicates that the
affected intervertebral disc is between the third and fourth lumbar vertebrae. Now turn to the Tabular List and
confirm the code.
Start reading at
M51 Thoracic, thoracolumbar, and lumbosacral intervertebral disc disorders
There is an note that mentions disorders of the cervical and sacral discs. However, George’s lumbar
disc is what is dislocated, so you can keep reading down the column to review the fourth-character and fifth-
character options and determine which matches Dr. Rymer’s documentation:
M51.2 Other thoracic, thoracolumbar, and lumbosacral intervertebral disc displacement
    M51.26 Other intervertebral disc displacement, lumbar region

414   PART II  |  REPORTING DIAGNOSES

 Go back to Dr. Rymer’s notes and see that while this doesn’t match exactly, it does tell the story of why Dr.
Rymer cared for George. Terrific!
This code tells the whole story about George’s specific injury. Now ask yourself, Do I need to find the external
cause code(s) to explain how George’s injury happened? No. A herniated disc is not necessarily the result of a
traumatic event. Therefore, there is no need to report any external cause.
Good work!

15.3  Soft Tissue Disorders

Fibromyalgia, also known as myofibrositis, or fibromyositis, causes the patient to
experience tenderness on his or her extremities, as well as his or her neck and shoul-
ders, back, and hips. In addition, the patient will suffer headaches, trouble sleeping,
and sometimes forgetfulness and difficulties thinking. Code M79.7 Fibromyalgia.
Myositis identifies the inflammation of a muscle caused by a muscle strain. When
a diagnosis of infective myositis is documented, you will need to report a code from
subcategory M60.0 Infective myositis, with a fifth character to identify the specific
anatomical site (shoulder, upper arm, hand, thigh, etc.) and a sixth character to report
laterality. In addition to the M60.0-- code, you will need an additional code from
B95–B97 to report the specific pathogen.
Polymyositis is a systemic rheumatic disorder evidenced by inflammatory and
degenerative changes in the muscles. The signs and symptoms of muscle weakness,
discomfort, and tenderness appear suddenly, most often in the proximal muscles.
These symptoms interrupt the patient’s ability to perform activities of daily living
(ADL). To report this diagnosis accurately, you will need to abstract from the docu-
mentation the involvement of the respiratory system (M33.21), myopathy (M33.22),
or other specific organs being hampered by this condition (M33.29).
Dermatopolymyositis is a systemic rheumatic disorder characterized by inflam-
matory and degenerative changes in the skin and muscles. The first sign is often an
erythematous rash that appears on the face, neck, torso (front and back), and upper
extremities. In addition, there may be a heliotropic rash on the eyelids along with
periorbital edema. To report this diagnosis accurately, you will need to abstract from
the documentation the involvement of the respiratory system (M33.11), myopathy
(M33.12), or other specific organs being hampered by this condition (M33.19).
Juvenile dermatomyositis (JDM) is a systemic, autoimmune, inflammatory mus-
cle condition that often appears with vasculopathy in children 18 years of age or
younger. To report this diagnosis accurately, you will need to abstract from the docu-
mentation the involvement of the respiratory system (M33.01), myopathy (M33.02),
or other specific organs being hampered by this condition (M33.09).
Bursitis is a painful inflammation of a bursa, most often the result of recurring
trauma. Once you make your way to code category M71 Other bursopathies, you will
need to abstract from the physician’s notes the type of problem: Is there an abscess or
infection? If so, in addition to identifying the specific anatomical site (shoulder, elbow,
hand, etc.) and laterality, you will need to find the confirmation of the pathogen, so
you can accurately add a second code from B95.- or B96.- to report this detail as well.
Epicondylitis is an inflammation of the elbow joint that typically begins as a small
tear in the muscle and then is aggravated by activities. Lateral epicondylitis is com-
monly known as “tennis elbow,” while medial epicondylitis is commonly known as
“golfer’s elbow,” reported by codes M77.1 Lateral epicondylitis and M77.0 Medial epi-
condylitis, respectively. Both codes require a fifth character to identify the right or left
elbow.
Achilles tendon contracture is a shortening of the tendocalcaneus (heel cord), which is
caused by chronic poor posture, continual wearing of high-heeled shoes, or landing on the

CHAPTER 15  | 
 ball of the foot rather than the heel while jogging or is a manifestation of cerebral palsy or
poliomyelitis. Use code M67.0 Short Achilles tendon (acquired), with a fifth character to
identify the right or left ankle, or Q66.89 Other specified congenital deformities of feet.
Torticollis is a condition in which the sternocleidomastoid muscle becomes spasmed
(shortened), causing the head to bend to one side and the chin to the opposite side. This
condition may be acquired, reported with code M43.6 Torticollis, unless the documen-
tation states Q68.0 Congenital deformity of sternocleidomastoid muscle,  F45.8 Other
somatoform disorders, G24.3 Spasmodic torticollis, or other diagnosis shown in the nota-
tion beneath M43.6.
Muscle spasms, commonly known as muscle cramps, are involuntary twitches and
are often caused by myositis or fibromyositis. Sometimes these spasms are caused
by metabolic or mineral imbalances. Abstract the documentation to identify the ana-
tomical site. Use code M62.830 Muscle spasm of back, M62.831 Muscle spasm of calf
(Charley-horse), M62.838 Other muscle spasm, or R25.2 Cramp and spasm.
Type III traumatic spondylolisthesis of the axis (C2) is a displacement of the ver-
tebra anteriorly over the vertebra below it. An open reduction of the C2 vertebra fol-
lowed by a posterior spinal fusion with a pedicle lag screw is used to repair the injury.
Report this with code M43.12 Spondylolisthesis, cervical region.

ICD-10-CM
LET’S CODE IT! SCENARIO
Elliott Carlyle, a 17-year-old male, is believed to be an up-and-coming star on the golf course. He explains to Dr. Carole
that the pain in his left elbow has become severe and his ability to grasp the club is weakened. Physical exam included
flexion and pronation, confirming medial epicondylitis.

Let’s Code It!

Dr. Carole diagnosed Elliott with medial epicondylitis. In the ICD-10-CM Alphabetic Index, let’s turn to find the
documented term. . . . Find
Epicondylitis (elbow)
There are only two items on the indented list:
Epicondylitis (elbow)
   lateral M77.1-
   medial M77.0-
Check the scenario to confirm which diagnosis was documented. Let’s go to the Tabular List to check this code
category. Find
M77 Other enthesopathies
Check the diagnoses shown in the and notations. Do either of them relate to Elliott’s diagno-
sis? No, good. Now, read down and review all of the fourth-character options. Which matches the documentation?
M77.0 Medial epicondylitis
     M77.01 Medial epicondylitis, right elbow
     M77.02 Medial epicondylitis, left elbow
Therefore, the most accurate code is
M77.02 Medial epicondylitis, left elbow
Check the top of this subsection and the head of this chapter in ICD-10-CM. Both a NOTE and an notation
appear at the beginning of this ICD-10-CM chapter. Read carefully. Do any relate to Dr. Carole’s diagnosis of Elliott?
No. Turn to the Official Guidelines and read Section 1.c.13. There is nothing specifically applicable here, either.
Now you can report M77.02 for Elliott’s diagnosis with confidence.
Good coding! Good work!

416   PART II  |  REPORTING DIAGNOSES

 Osteochondrosis, also known as osteochondropathy or Osgood-Schlatter disease,
is a painful separation of the epiphysis of the tibial tubercle from the tibial shaft. This GUIDANCE
condition most often affects preteen and early teenage boys after a traumatic event. CONNECTION
Treatments include immobilization of the knee and rest. In severe cases, surgical Read the ICD-10-CM
repair may be required. One code example is M93.1 Kienbock’s disease of adults (adult Official Guidelines for
osteochondrosis of carpal lunates).
Coding and Report-
Osteitis deformans, also known as Paget’s disease, may cause severe and chronic ing, section I. Con-
pain as well as impaired movement due to abnormal bone growth on the spinal cord. ventions, General
The preferred first phase of treatment is pharmaceutical. Report this from code cat- Coding Guidelines
egory M88 Osteitis deformans (Paget’s disease of bone), with additional characters to and Chapter Specific
report the specific bone affected as well as laterality. Guidelines, subsec-
Osteoporosis is a disease that is believed to be the manifestation of slowing tion C. Chapter-Specific
bone formation that occurs simultaneously with an increase in the body’s reab- Coding Guidelines,
sorption of bone. One exception is post-traumatic osteoporosis, also known as chapter 13. Diseases
Sudeck’s atrophy. The existence of osteoporosis increases the patient’s susceptibil- of the Musculoskeletal
ity to fractures. The presence of a pathologic fracture will change the code deter- System and Connec-
mination in ICD-10-CM. Code category M80 reports osteoporosis with a current tive Tissue, subsection
pathologic fracture, while code category M81 reports osteoporosis without a cur- d. Osteoporosis.
rent pathologic fracture.

ICD-10-CM
LET’S CODE IT! SCENARIO
Everett Rotarine, a 43-year-old male, was having pain in his left thigh, which his orthopedist, Dr. Nixon, identified
as excessive bone resorption, the osteoclastic phase of Paget’s disease. X-rays and a urinalysis showing elevated
levels of hydroxyproline confirmed the osteoclastic hyperactivity. Everett comes in today to discuss the test findings
and treatment options.

Let’s Code It!

Dr. Nixon diagnosed Everett with Paget’s disease. You may remember that this is an eponym and will be shown
in the ICD-10-CM Alphabetic Index, so let’s turn to find the suggested code. Find
Paget’s disease
Notice the long list of additional descriptors of this condition indented beneath this listing. Look at the scenario
again.
Paget’s disease
   bone M88.9
    femur M88.85-
Let’s go to the Tabular List to check this code category. Find
M88 Osteitis deformans (Paget’s disease of bone)
Let’s keep reading:
M88.8 Osteitis deformans of other bones
   M88.85 Osteitis deformans of thigh
     M88.852 Osteitis deformans of left thigh
Therefore, the most accurate code is
M88.852 Osteitis deformans of left thigh
Good work!

CHAPTER 15  | 
 15.4  Musculoskeletal Disorders from Other
Body Systems
Acquired Conditions
Muscle tumors do not occur frequently and can often be malignant. Use code catego-
ries C49 Malignant neoplasm of other connective and soft tissue, C79.89 Secondary
malignant neoplasms of other specified sites, or D21 Other benign neoplasms of con-
nective and other soft tissue.
Duchenne’s muscular dystrophy (DMD) is caused by a mutation of the DMD gene
within the X chromosome, resulting in the body’s inability to create the dystrophin
protein within the muscles. Due to this, males are more likely to contract the condition
because females have an additional X chromosome that may counteract the mutated
gene, as long as the second X chromosome is not damaged as well. Initial signs and
symptoms of DMD include leg muscle weakness followed by weakness of the shoul-
der muscles. DMD is most often diagnosed in early childhood and may be terminal by
age 21 should the weakness spread to either heart or respiratory muscles. New trials
using gene therapy are hopeful. Use code G71.0 Muscular dystrophy.
Myasthenia gravis is a chronic autoimmune condition that causes muscle weak-
ness, primarily in the face and neck, due to the immune system incorrectly attacking
the muscle cells in the body. It may progress and involve additional weakness in the
muscles of the extremities (arms and legs). Use code G70.00 Myasthenia gravis with-
out (acute) exacerbation or G70.01 Myasthenia gravis with (acute) exacerbation.
Paralytic syndromes are conditions in which muscle control is reduced or non-
existent. Cerebral palsy (code category G80), hemiplegia and hemiparesis (code
category G81), and paraplegia (paraparesis) and quadriplegia (quadriparesis) (code
category G82) are some of the conditions that may interfere with the activities of
daily living.

Congenital Disorders
Congenital myopathies include minicore disease, nemaline myopathy, and fiber-type
disproportion. One code, G71.2, reports several muscle abnormalities diagnosed in a
neonate or infant. Most often, the infant will not meet normal developmental mile-
stones, particularly those involving muscular actions, such as sitting up or rolling over.
CODING BITES Such babies may also have problems feeding.
NOTICE that these Developmental dysplasia of the hip (DDH), also known as congenital hip dyspla-
conditions—congenital sia, is most common in a baby born breech, a large neonate, or a multiparity baby.
myopathies, muscular DDH is a condition in which the head of the femur is displaced from the acetabulum.
dystrophy, myasthe- Use code Q65.89 Other specified congenital deformities of hip (congenital acetabular
nia gravis, and para- dysplasia).
lytic syndromes—are Ectromelia or hemimelia can occur in either the upper or lower limb. Ectromelia
reported with codes is the congenital absence or imperfection of one or more limbs. Hemimelia is a con-
from the Diseases of genital abnormality affecting only the distal segment of either the upper or lower limb.
the Nervous System This condition is reported with code Q73.8 Other reduction defects of unspecified limb
chapter of ICD-10-CM. (ectromelia of limb NOS) (hemimelia of limb NOS).
Remember that the Klippel-Feil syndrome is a condition characterized by the development of a short,
nerves signal the wide neck due to either an abnormal number of cervical vertebrae or fused hemiverte-
muscles to function. brae (the incomplete development of one side of a vertebra). Use code Q76.1 Klippel-
Therefore, paralysis is Feil syndrome (cervical fusion syndrome).
actually a dysfunction of Spina bifida is a condition in which the bony encasement of the spinal cord fails to
the nerves that commu- close. Surgical repair is done as soon as possible in an effort to reduce serious handi-
nicate with the affected caps. There have been some successful cases of in utero surgical repair. This condition
specific muscles. is reported from code category Q05- Spina bifida, with an additional character to iden-
tify the specific area of the spine that is affected.

418   PART II  |  REPORTING DIAGNOSES

 ICD-10-CM
YOU CODE IT! CASE STUDY
Theda Granddura, a 37-year-old female, came to see Dr. Lyndon complaining of weakness in her arms and hands.
She stated that sometimes, she is unsteady on her feet, and her right eyelid was droopy. Two days ago, she tried
to pick up a glass and could not get her fingers to “work right.” An EMG was performed in the office, confirming a
diagnosis of myasthenia gravis.

You Code It!

Review the details in Dr. Lyndon’s documentation of this encounter with Theda to determine the accurate ICD-
10-CM code or codes to report her diagnosis.
Step #1: Read the case carefully and completely.
Step #2: Abstract the scenario. Which main words or terms describe why the physician cared for the patient dur-
ing this encounter?
Step #3: Are there any details missing or incomplete for which you would need to query the physician? [If so, ask
your instructor.]
Step #4: Check for any relevant guidance, including reading all of the symbols and notations in the Tabular List
and the appropriate sections of the Official Guidelines.
Step #5: Determine the correct diagnosis code or codes to explain why this encounter was medically necessary.
Step #6: Double-check your work.
Answer:

Did you determine this to be the correct code?

G70.00 Myasthenia gravis without (acute) exacerbation

15.5  Pathological Fractures

The skeleton of the human body (see Figure 15-4) provides the structure for both form
and function. The 206 bones in the adult body comprise a framework hinged together Articulation
at the articulations (joints) that is stabilized by muscles and connective tissues. A joint.
In your job as a professional coding specialist, it is important to abstract from the
documentation details regarding the site of the disease or injury (the specific bone) as
GUIDANCE
well as the laterality (right side or left side), when applicable.
Some conditions may affect any part of the skeletal system and therefore require CONNECTION
that the specific anatomical location be documented. For instance, when a long bone, Read the ICD-10-CM
such as an ulna or femur, is affected, you might find that knowing the name of the bone Official Guidelines for
is insufficient; you will also need to know the part of the bone, such as the shaft. When Coding and Report-
the segment of the bone that is diseased leads into, and participates in, the formation ing, section I. Con-
of a joint (articulation), read the documentation carefully. Even if the part of the bone ventions, General
affected is at the joint, you must report the bone as the diseased anatomical site. Coding Guidelines
Diseases and other conditions can create problems with the bones and may be and Chapter Specific
caused by a congenital malformation, pathology, or a traumatic event. As always, Guidelines, subsec-
these are important details for coders to know. tion C. Chapter-Specific
The bones are, typically, the strongest parts of our bodies. However, in some cases, Coding Guidelines,
disease can deteriorate the structure of a bone so much that it breaks under the slight- chapter 13. Diseases
est pressure. Even normal activity can result in the weakened part of the bone breaking of the Musculoskeletal
(fracture). When this happens, it is known as a pathological fracture. System and Connec-
The most common underlying cause of a pathological fracture is osteoporosis. tive Tissue, subsection
However, other health conditions, such as a bone cyst, an infection, genetic disorders, a. Site and laterality.
and malignancy, may do just as much harm.

CHAPTER 15  | 
Site Skull
The specific anatomical loca- Cranium
tion of the disease or injury. Spinal
column
Laterality Cervical Mandible
The right or left side of ana- vertebrae
Clavicle
tomical sites that have loca-
Scapula
tions on both sides of the
body; e.g., right arm or left Manubrium
Thoracic
arm; unilateral means one Ribs
vertebrae
side and bilateral means both Sternum
sides. Humerus
Ulna
Lumbar
Radius
vertebrae
GUIDANCE Sacrum
Pelvic girdle
Carpals
CONNECTION
Metacarpals
Read the ICD-10-CM
Official Guidelines for Coccyx Phalanges
Coding and Reporting,
section I. Conven-
tions, General Coding Femur
Guidelines and Chapter
Specific Guidelines, Patella
subsection C. Chapter- Tibia
Specific Coding
Fibula
Guidelines, chapter
13. Diseases of the
Musculoskeletal Sys- Tarsals
tem and Connective Metatarsals
Tissue, subsection a.1) Phalanges
Bone versus joint.
FIGURE 15-4  An illustration identifying the major bones of the human skeleton

Treatment for pathological fractures may be similar to that for a traumatic fracture.
GUIDANCE However, not always. In virtually all cases, the underlying condition is treated as well.
CONNECTION
Read the ICD-10-CM
Official Guidelines for EXAMPLES
Coding and Report- Pathological fractures are reported from these code subcategories:
ing, section I. Con-
M84.4- Pathological fracture, not elsewhere classified
ventions, General
M84.5- Pathological fracture in neoplastic disease
Coding Guidelines
M84.6- Pathological fracture in other diseases
and Chapter Specific
Guidelines, subsec-
tion C. Chapter-Specific When reporting a code for a pathologic fracture, you will need to assign a seventh
Coding Guidelines, character to identify the point in the treatment for this condition.
chapter 13. Diseases
of the Musculoskeletal A Use the seventh character A for the entire scope of time that the patient is receiving
System and Connec- active treatment for this fracture. This seventh character reports the status of “active
tive Tissue, subsection treatment,” not the relationship between physician and patient (new patient).
c. Coding of Pathologic D Once the patient has completed active treatment, this character should be reported to
Fractures. identify follow-up for routine healing.
G The seventh character G would be reported for subsequent care for a pathological
fracture with delayed healing.
K Subsequent care provided for a nonunion would be identified with a seventh charac-
ter of K.

420   PART II  |  REPORTING DIAGNOSES

P When a malunion occurs, the subsequent care would be reported with a seventh char-
acter of P.
S Care for any sequela (late effect) of the original pathological fracture is identified
with a seventh character of S.

GUIDANCE CONNECTION
Read the ICD-10-CM Official Guidelines for Coding and Reporting, section I.
Conventions, General Coding Guidelines and Chapter Specific Guidelines, sub-
section C. Chapter-Specific Coding Guidelines, chapter 13. Diseases of the Mus-
culoskeletal System and Connective Tissue, subsection c. Coding of Pathologic
Fractures, and chapter 2. Neoplasms, subsection l.6) Pathologic fracture due to
a neoplasm.

ICD-10-CM
YOU CODE IT! CASE STUDY
Deliah Livingston, a 49-year-old female, was diagnosed with breast cancer a year ago. She had a double mas-
tectomy 6 months ago. She came to see Dr. Wells for a checkup and he discovered that Deliah’s malignancy had
metastasized to the proximal portion of her right femur. Dr. Wells suggested surgery to insert a metal rod to support
the bone. She told him she would think about it. Yesterday, she was walking down her driveway and all of a sudden
her thighbone splintered and she fell. In the Emergency Department, Dr. Travers diagnosed Deliah with a pathologi-
cal fracture of the proximal femur, just below the hip joint, due to metastatic malignancy.

You Code It!

Abstract the documentation about this ED encounter between Deliah and Dr. Travers and determine how to
report the reasons for this visit.
HINT: You will need some of what you learned from the Coding Neoplasms chapter here.
Step #1: Read the case carefully and completely.
Step #2: Abstract the scenario. Which main words or terms describe why the physician cared for the patient dur-
ing this encounter?
Step #3: Are there any details missing or incomplete for which you would need to query the physician? [If so, ask
your instructor.]
Step #4: Check for any relevant guidance, including reading all of the symbols and notations in the Tabular List
and the appropriate sections of the Official Guidelines.
Step #5: Determine the correct diagnosis code or codes to explain why this encounter was medically necessary.
Step #6: Double-check your work.
Answer:
Did you determine these to be the correct codes?
M84.551A Pathological fracture in neoplastic disease, right femur, initial encounter for fracture
C79.51 Secondary malignant neoplasm of bone
Z85.3 Personal history of malignant neoplasm of breast

Chapter Summary
The entire body is wrapped from head to toe and all the way around by muscles: vol-
untary muscles that assist movement of the skeleton and involuntary muscles that are

CHAPTER 15  | 
 controlled by the nervous system. Each muscle has its specific function and they are
CHAPTER 15 REVIEW

all susceptible to injury, inflammation, and disease.

The 206 bones of the adult human skeleton provide the foundational structure for the
components of the body. These bones protect internal organs as well as enable certain
functions. Each bone is categorized by its shape: long bones, flat bones, short bones,
irregularly shaped bones, and sesamoid bones. Any of these bones can be afflicted
by malformation during gestation (congenital conditions), disease (pathologic condi-
tions), or injury (traumatic conditions).

CODING BITES
Interesting Facts about Human Muscles 
Longest muscle = Sartorious (thigh) muscle 
Smallest muscle = Stapedius (in the ear) 
Largest muscle = Gluteus maximus (buttocks) 
Strongest muscle = Masseter (chewing) 
Busiest muscles = Eye muscles 
Goosebump muscles = Tiny muscles in the hair root 
Smiling requires 17 facial muscles. 
Frowns require 42 facial muscles.

CHAPTER 15 REVIEW
Coding Muscular and Skeletal Enhance your learning by
completing these exercises and
more at connect.mheducation.com!

Conditions
Let’s Check It! Terminology
Match each key term to the appropriate definition.
1. LO 15.2  A fibrocartilage segment that lies between vertebrae of the spinal col- A. Articulation
umn and provides cushioning and support. B. Intervertebral Disc
2. LO 15.5  A joint. C. Laterality
3. LO 15.5  The specific anatomical location of the disease or injury. D. Site
4. LO 15.2  A bone that is a part of the construction of the spinal column. E. Vertebra
5. LO 15.5  The right or left side of anatomical sites that have locations on both
sides of the body.

Let’s Check It! Concepts

Choose the most appropriate answer for each of the following questions.
1. LO 15.2  Jane Timmerman was diagnosed with lower back strain, subsequent encounter. What is the correct code?
a. S39.002A b.  S39.012D c.  S39.022D d.  S39.092S
2. LO 15.1  ____ is an autoimmune systemic inflammatory disease that affects joints as well as the surrounding
muscles, tendons, and ligaments.
a. Duchenne’s muscular dystrophy b.  Nemaline myopathy
c. Rheumatoid arthritis d.  Myasthenia gravis
3. LO 15.1  A chronic degeneration of the articular cartilage simultaneous with the formation of bone spurs on the
underlying bone within a joint is known as
a. rheumatoid arthritis. b.  gout.
c. genu recurvatum. d.  osteoarthritis.

422   PART II  |  REPORTING DIAGNOSES

 4. LO 15.3  ____ is a condition in which the sternocleidomastoid muscles become spasmed (shortened), causing the

CHAPTER 15 REVIEW
head to bend to one side and the chin to the opposite side.
a. Bursitis b.  Epicondylitis
c. Achilles tendon contracture d.  Torticollis
5. LO 15.2  Sammie Blane was diagnosed with cervicothoracic postural kyphosis. How is this coded?
a. M40.209 b.  M40.202 c.  M40.03 d.  M40.12
6. LO 15.3  A systemic rheumatic disorder characterized by inflammatory and degenerative changes in the skin and
muscles is known as
a. myositis.
b. juvenile dermatomyositis.
c. osteochondrosis.
d. dermatopolymyositis.
7. LO 15.4  Myotonic muscular dystrophy is coded
a. G71.11 b.  G71.0 c.  G71.12 d.  G71.13
8. LO 15.4  ____ is a chronic autoimmune condition that causes muscle weakness, primarily in the face and neck,
due to the immune system incorrectly attacking the muscle cells in the body.
a. Duchenne’s muscular dystrophy
b. Myasthenia gravis
c. Ectromelia
d. Paralytic syndromes
9. LO 5.5  Ben Watson is diagnosed with a malunion. It will be reported with which seventh character?
a. A b.  G c.  P d.  K
10. LO 15.5  When disease deteriorates the structure of a bone so much that it breaks under the slightest pressure,
this is known as a ____ fracture.
a. malformation b.  traumatic
c. congenital d.  pathologic

Let’s Check It! Guidelines

Refer to the Official Guidelines and fill in the blanks according to the Chapter 13, Diseases of the Musculoskeletal
System and Connective Tissue, Chapter-Specific Coding Guidelines.

no laterality joint Z87.310 without

systemic history active A multiple
healed not site bone time
fracture affected current known musculoskeletal
represents traumatic one

1. Most of the codes within Chapter 13 have ____ and ____ designations. The site ____ the bone, joint or the mus-
cle involved.
2. For categories where ____ multiple site code is provided and more than ____ bone, joint or muscle is involved,
____ codes should be used to indicate the different sites involved.
3. For certain conditions, the bone may be affected at the upper or lower end (e.g., avascular necrosis of bone, M87,
Osteoporosis, M80, M81). Though the portion of the bone ____ may be at the ____, the site designation will be
the ____, not the joint.
4. Bone, joint, or muscle conditions that are the result of a ____ injury are usually found in Chapter 13. 
5. 7th character ____ is for use as long as the patient is receiving ____ treatment for the fracture.

CHAPTER 15  | 
 6. Osteoporosis is a ____ condition, meaning that all bones of the ____ system are affected.
CHAPTER 15 REVIEW

7. Category M81, Osteoporosis ____ current pathological fracture, is for use for patients with osteoporosis who do
____ currently have a pathologic fracture due to the osteoporosis, even if they have had a ____ in the past.
8. For patients with a ____ of osteoporosis fractures, status code ____, Personal history of (healed) osteoporosis
fracture, should follow the code from M81.
9. Category M80, Osteoporosis with ____ pathological fracture, is for patients who have a current pathologic frac-
ture at the ____ of an encounter.
10. A code from category M80, not a ____ fracture code, should be used for any patient with ____ osteoporosis who
suffers a fracture, even if the patient had a minor fall or trauma, if that fall or trauma would not usually break a
normal, healthy bone.

Let’s Check It! Rules and Regulations

Please answer the following questions from the knowledge you have gained after reading this chapter.
1. LO 15.1  What is arthropathy? Include ways that the physician might identify the patient’s condition; also include
an example of an arthropathic condition.
2. LO 15.2  List two conditions that affect the spine and explain each one.
3. LO 15.3  Explain the difference between osteochondrosis and osteoporosis.
4. LO 15.4  List an acquired musculoskeletal disorder and a congenital disorder and discuss each.
5. LO 15.5  Explain the difference between a traumatic fracture and a pathologic fracture. Why is it important to
know the difference?

ICD-10-CM
YOU CODE IT! Basics
First, identify the condition in the following diagnoses; 8. Osteomyelitis neonatal jaw: 
then code the diagnosis. a. main term: ____ b. diagnosis: ____
Example:  Trigger thumb, right: 9. Infantile idiopathic scoliosis, lumbosacral:
a. main term: Trigger b. diagnosis: M65.311 a. main term: ____ b. diagnosis: ____
10. Contracture of right ankle:
1. Infective myositis, left foot:
a. main term: ____ b. diagnosis: ____
a. main term: ____ b. diagnosis: ____
11. Atrophy of left lower leg:
2. Pyogenic arthritis, left knee:
a. main term: ____ b. diagnosis: ____
a. main term: ____ b. diagnosis: ____
12. Ankylosis of right wrist:
3. Foreign body granuloma of soft tissue, right thigh:
a. main term: ____ b. diagnosis: ____
a. main term: ____ b. diagnosis: ____
13. Abscess of tendon sheath, right forearm:
4. Juxtaphalangeal distal osteoarthritis:
a. main term: ____ b. diagnosis: ____
a. main term: ____ b. diagnosis: ____
14. Spinal stenosis, cervicothoracic region:
5. Nontraumatic rupture of muscle, left shoulder:
a. main term: ____ b. diagnosis: ____
a. main term: ____ b. diagnosis: ____
15. Calcific tendinitis, left pelvic region:
6. Hallux valgus, left foot:
a. main term: ____ b. diagnosis: ____
a. main term: ____ b. diagnosis: ____
7. Ischemic infarction of muscle, left hand:
a. main term: ____ b. diagnosis: ____

424   PART II  |  REPORTING DIAGNOSES

 CHAPTER 15 REVIEW
ICD-10-CM
YOU CODE IT! Practice
Using the techniques described in this chapter, carefully read through the case studies and determine the most
accurate ICD-10-CM code(s) and external cause code(s), if appropriate, for each case study.
1. Nancy Nottingham, a 52-year-old female, presents today with a severe burning pain and swelling in her upper
right arm and fingers. Dr. Olden notes edema and allodynia. After a thorough examination, Nancy is diag-
nosed with reflex sympathetic dystrophy (RSD).
2. Arturo Garwood, a 57-year-old male, comes in today with left shoulder pain and weakness. Arturo admits
that he struggles to raise his left arm above his head. Dr. Dow completes an examination and orders an MRI
scan. The MRI results confirm the diagnosis of incomplete rotator cuff tear.
3. Sharron Webster, a 3-year-old female, was brought in by her parents to see her pediatrician, Dr. Surrant, 4 days
ago. Sharron had a boil on her left thigh that Dr. Surrant incised and drained. Sharron is now running a fever of
102 F. Dr. Surrant decides to admit Sharron to Weston Hospital. The MRI scan revealed abscess of the vastus
intermedius muscle. A wound culture grew Staphylococcus aureus. Sharron is diagnosed with pyomyositis.
4. Tamara Gibbons, a 37-year-old female, presents today with pain on the inside of her right knee. Dr. Booker
completes a history and physical examination. After reviewing the MRI results, Tamara is diagnosed with
Plica syndrome.
5. Jay Lawson, a 13-year-old male, is brought in by his parents to see Dr. Bouknight, his pediatrician. Jay is
complaining of left hip pain and stiffness. Dr. Bouknight completes a physical examination and notes limited
left hip motion as well as soft tissue swelling. Jay is admitted to Weston Hospital. Aspiration of synovial fluid
reveals an elevated cell count of 136 cells/mL with 52% being polymorphonuclear leukocytes. Jay is diag-
nosed with intermittent hydrarthrosis.
6. Terrell Meddy, a 58-year-old male, comes in today to see Dr. McNair with the complaint his left elbow is
stiff, painful and feels warm. Terrell doesn’t remember hitting his elbow on anything. After an examination,
Dr. McNair diagnosed Terrell with olecranon bursitis of the elbow.
7. Shirley Moody, an 11-year-old female, is brought in by her mother. Mrs. Moody states that Shirley is experi-
encing severe muscle weakness. Dr. Bernstein completes a physical examination and notes heart arrhythmias,
aphasia, and dyspnea. Shirley says that the weakness seems to last about 4 hours and comes and goes. Dr.
Bernstein admits Shirley into the hospital and orders an electromyographic (EMG) test. The results of the
ECG, EMG, and muscle biopsy confirm the diagnosis of hypokalemic periodic paralysis.
8. Angie Dawson, a 4-year-old female, is brought in by her parents. Angie is having difficulty chewing her food
as well as having some speech problems. Dr. Hunt notes misalignment between the teeth of the dental arches
as Angie’s jaw closes. Dr. Hunt completes a thorough examination and the appropriate tests. Angie is diag-
nosed with malocclusion, Angle’s class II.
9. Ned Taylor, a 33-year-old male, presents today with severe weakness in his left hip. Dr. Louthan notes
enlarged neck lymph node, a rash, and high fever. Ned admits to some eye and chest pain with general leth-
argy. After a thorough examination, Dr. Louthan decides to admit Ned to the hospital. The laboratory test and
MRI confirmed the diagnosis of arthritis of the hip due to O’nyong-nyong fever.
10. Rykia Huffman, a 21-year-old female, presents today with the complaint of uneven hips and leg length. Dr.
Gamble completes a physical examination and orders a weight-bearing, full-length spine x-ray, AP, which
confirms the diagnosis of idiopathic scoliosis, lumbosacral region.
11. Kendall Everett, a 41-year-old female, comes in today with the complaint her right hand aches and itches.
Kendall also admits it has become harder to hold objects in her right hand. Dr. Inabinet completes an exami-
nation and a table top test, which was positive for Dupuytren’s disease.
12. Jason Okoro, a 46-year-old male, presents with pain in his right foot. Jason admits it hurts to walk. Dr. Denka
completes an examination and after reviewing the results of the MRI, Jason is diagnosed with a synovial cyst
rupture between the second and third metatarsal bones.

CHAPTER 15  | 
CHAPTER 15 REVIEW

13. Valerie Halsey, a 51-year-old female, complains of lower back pain and numbness. Valerie also admits it is
sometimes difficult to control her left leg. Dr. Spratt completes a physical examination and history of the
symptoms. Dr. Spratt has Valerie perform the straight leg raise test, which was positive for Lasegue’s sign.
Valerie is diagnosed with wallet sciatica, left side.
14. James Ard, a 31-year-old male, comes in today to see Dr. Smyth. Jim complains his head is tilting and he
can’t control it. He also admits to neck spasms and it seems to him that it is worse after he has taken his after-
noon run. After a thorough examination and testing, Dr. Smyth diagnoses Jim with spasmodic torticollis.
15. Marygrace Fuller, a 16-year-old female, participated in rhythmic gymnastics yesterday at the local gym. She
woke up this morning and her left ankle was stiff and aches. After an examination, Dr. Jefferson diagnosed
Marygrace with Achilles tendinitis.

ICD-10-CM
YOU CODE IT! Application
The following exercises provide practice in abstracting physicians’ notes and learning to work with documentation
from our health care facility, Prader, Bracker, & Associates. These case studies are modeled on real patient encoun-
ters. Using the techniques described in this chapter, carefully read through the case studies and determine the most
accurate ICD-10-CM code(s) and external cause code(s), if appropriate, for each case study.

PRADER, BRACKER, & ASSOCIATES

A Complete Health Care Facility
159 Healthcare Way • SOMEWHERE, FL 32811 • 407-555-6789
PATIENT: LOPEZ, JUANA
ACCOUNT/EHR #: LOPEJU001
DATE: 07/16/18
Attending Physician: Oscar R. Prader, MD
S: Patient is a 15-year-old female with complaints of dysphagia and occasional problems speaking. She
complains of dyspnea and finds it painful to raise her arms over her head. In the last couple of days, she
states that climbing stairs and even getting up from a chair are painful and challenging.
O: ROM indicates weakness in the proximal muscles, specifically shoulders and hips. Both MRI and
electromyography indicate polymyositis with myopathy. This was confirmed by autoimmune antibody
testing.
A: Polymyositis with myopathy
P: Rx: Prednisone
    Rx: Methotrexate

ORP/pw  D: 07/16/18 09:50:16  T: 07/17/18 12:55:01

Determine the most accurate ICD-10-CM code(s).

PRADER, BRACKER, & ASSOCIATES

A Complete Health Care Facility
159 Healthcare Way • SOMEWHERE, FL 32811 • 407-555-6789
PATIENT: MARCHEON, GABRIELLA

426   PART II  |  REPORTING DIAGNOSES

 CHAPTER 15 REVIEW
ACCOUNT/EHR #: MARCGA001
DATE: 07/16/18
Attending Physician: Renee O. Bracker, MD
Assessment: Derangement of anterior horn medial meniscus due to old tear, right knee.
Order for physical therapy:
     Moist heat, cryotherapy, muscle stimulation, whirlpool, massage
     ROM: active, active assistive, passive
     Exercise: isometric, isotonic ambulation training, as tolerated
     3 a week for 6 weeks.
Session # 3/6: Pain Level: 4/10
Pt states pain shooting down right medial lower leg and numbness in toes.
     Total time: 35 minutes
     10 min. Cold pack/right knee
     25 min. Therapeutic exercise . . . to increase strength and ROM
Symptoms began to return in right lower leg toward the end of the exercise. No new exercises added.

Donata R. Chen, MPT

DRC/pw  D: 07/16/18 09:50:16  T: 07/17/18 12:55:01

Determine the most accurate ICD-10-CM code(s).

PRADER, BRACKER, & ASSOCIATES

A Complete Health Care Facility
159 Healthcare Way • SOMEWHERE, FL 32811 • 407-555-6789
PATIENT: STRICK, JOSEPH
ACCOUNT/EHR #: STRIJO001
DATE: 09/16/18
Attending Physician: Oscar R. Prader, MD
On Sept. 10, the patient’s daughter noticed him walking on his toes, in obvious pain, and having trouble
moving his left foot. She insisted on him coming here to have me check, because she was worried.
PE: Patient states sharp pain is experienced during dorsiflexion of the left foot. ROM is limited. Circula-
tion good.
DX: Achilles tendon contracture, left
PLAN: Referral for physical therapy
 Rx for specialized series of shoes

ORP/mg  D: 9/16/18 09:50:16  T: 9/18/18 12:55:01

Determine the most accurate ICD-10-CM code(s).

CHAPTER 15  | 
CHAPTER 15 REVIEW

PRADER, BRACKER, & ASSOCIATES

A Complete Health Care Facility
159 Healthcare Way • SOMEWHERE, FL 32811 • 407-555-6789
PATIENT: LAO, HANNAH
ACCOUNT/EHR #: LAOHAN001
DATE: 09/16/18
Attending Physician: Oscar R. Prader, MD
Hannah Lao, a 59-year-old female, came to see Dr. Prader with pain, swelling, and erythema in her left
foot and ankle. She stated that she was diagnosed with open-angle glaucoma and prescribed acetazol-
amide (a diuretic) by Dr. Carson, her ophthalmologist. She stated she never mentioned she was using a
topical lotion of urea (a diuretic) prescribed by her dermatologist to hydrate her dry skin. Hannah stated
she didn’t think a lotion would count when asked about current medications.
Dr. Prader realized the combination of the two diuretics lowered her serum uric acid too quickly, causing
drug-induced gout.

ORP/pw  D: 9/16/18 09:50:16  T: 9/18/18 12:55:01

Determine the most accurate ICD-10-CM code(s).

PRADER, BRACKER, & ASSOCIATES

A Complete Health Care Facility
159 Healthcare Way • SOMEWHERE, FL 32811 • 407-555-6789
PATIENT: BRACKSLEY, NATASHA
ACCOUNT/EHR #: BRACNA001
DATE: 09/16/18
Attending Physician: Renee O. Bracker, MD
It has been 8 months since I saw this 67-year-old female. She states experiencing terrible “knee pain” in
both legs. Patient states taking extra-strength Tylenol around the clock (two tablets every 4 hours) with
little or no relief.
PE: She has Heberden’s and Bouchard’s nodes and deformity of the knee joints with decreased range
of motion. On the basis of the patient’s history and this examination, osteoarthritis is suspected. Patient
is taken to x-ray. AP, 2 views, x-rays of each knee confirm diagnosis of osteoarthritis. There are no other
findings.
DX: Osteoarthritis, bilateral
Rx: Tripod cane
Patient is advised to begin taking OTC glucosamine plus chondroitin sulfate. Patient to return prn

ROB/pw  D: 9/16/18 09:50:16  T: 9/18/18 12:55:01

Determine the most accurate ICD-10-CM code(s).

428   PART II  |  REPORTING DIAGNOSES

Coding Injury, Poisoning,
and External Causes
Learning Outcomes
16
Key Terms
After completing this chapter, the student should be able to: Abuse
Avulsion
LO 16.1 Analyze the documentation to determine when external Burn 
cause codes are required. Corrosion
LO 16.2 Apply guidelines for coding traumatic injuries. Dislocation
LO 16.3 Determine seventh characters for injury codes accurately. Extent
LO 16.4 Identify a suggested code from the Table of Drugs and First-Degree Burn 
Fracture
Chemicals.
Laceration
LO 16.5 Distinguish between poisonings and adverse effects. Malunion
LO 16.6 Abstract documentation to accurately report burns. Myalgia
LO 16.7 Demonstrate coding protocols for reporting abuse and neglect. Nonunion
LO 16.8 Evaluate documented complications of care to report them Physicians’ Desk Ref-
accurately. erence (PDR)
Rule of Nines
Second-Degree Burn 
Severity
Site 
Remember, you need to follow along in
Third-Degree Burn 
ICD-10-CM

  STOP! your ICD-10-CM code book for an optimal

learning experience.

16.1  Reporting External Causes of Injuries

When a patient has been injured traumatically, the first code or codes you need to
report will explain the specific injury, such as a fractured arm or a burned foot. We
will discuss those details as you move through this chapter. There are more codes
required for these circumstances to tell the whole story. This means that you also need CODING BITES
to report codes that explain the: An external cause code
∙ Cause of the injury, such as a car accident or a fall off a ladder. can never be a first-
listed code, and it can
∙ Place of the occurrence, such as the park or the kitchen.
never be the only code
∙ Activity during the occurrence, such as playing basketball or gardening. reported. External cause
∙ Patient’s status, such as paid employment, on-duty military, or leisure activity. codes are reported sec-
ondary to the codes that
That’s a lot of information. However, think of how important these details are to
report the injury itself.
the reimbursement process as well as to research studies. When you report that the
patient’s status was “civilian activity done for income or pay,” it will be clear that
this is a workers’ compensation case and not a claim to be sent to the patient’s health
insurance carrier. If the cause of the injury was “driver of pickup truck or van injured
in collision with heavy transport vehicle or bus in nontraffic accident,” this informa-
tion may direct the claim to the auto insurance company (not the health insurance
carrier), and there may be the possibility that the information can support any legal
action. Including a code to report a “fall into swimming pool” may help with getting
improved fencing and saving others.
 To begin the process of determining the appropriate external cause codes for a spe-
GUIDANCE cific encounter, you will start in the Alphabetic Index. However, these codes have a
CONNECTION separate index. You will not use the Alphabetic Index to Diseases, which you have
Read the ICD-10-CM
been using in previous chapters and cases. Instead, you will use the Alphabetic Index
Official Guidelines for
to External Causes, often located after the Alphabetic Index to Diseases, after the
Coding and Reporting,
Table of Drugs and Chemicals, and before the Tabular List.
section I. Conventions,
General Coding Cause of the Injury Code
Guidelines and Chapter When a part of the body meets with an external object and the result is injury, you
Specific Guidelines, must explain what that external object or force was, along with the code or codes
subsection C. Chapter-­ for the injury itself. The cause may be anything from being stepped on by a cow
Specific Coding (W55.29x-) to falling from scaffolding (W12.xxx-) to the forced landing of a (hot air)
Guidelines, chapter 20. balloon injuring the occupant (V96.02x-). Domestic violence, child abuse, and elder
External Causes of abuse are considered assault and may be the cause of a physical injury (code category
Morbidity, subsection Y07). Whatever it may have been, you need to determine from the documentation
a. General External what it was that caused the fracture, dislocation, sprain, or strain and report it with the
Cause Coding appropriate code or codes.
Guidelines.

Dislocation Place of the Occurrence Code

The movement of a muscle Where was the patient when he or she was injured? Code category Y92 Place of occur-
away from its normal position.
rence of the external cause provides you with many options so you can report, for
GUIDANCE example, that the swimming pool at which the patient slipped and tore his deltoid
muscle was at a single-family (private) house, a mobile home, a boarding house, a
CONNECTION nursing home, or another noninstitutional or institutional location. The codes are quite
Read the ICD-10-CM Offi- specific, so you need to ensure that your physicians understand the need to be equally
cial Guidelines for Coding specific in their documentation.
and Reporting, section
I. Conventions, General Activity Code
Coding Guidelines and
Chapter Specific Guide- Code category Y93 Activity codes provides you with many activities from which to
lines, subsection C. choose to identify what exactly the patient was doing when he or she became injured.
Chapter-Specific Coding Dancing, yoga, gymnastics, trampolining, cheerleading . . . each has its own code, and
Guidelines, chapter 20. this is just one subcategory!
External Causes of
Morbidity, subsection Patient’s Status
b. Place of Occurrence This sounds a bit obscure, certainly. What was the patient’s status at the time the injury
Guideline. occurred? There are four options within code category Y99 External cause status:
∙ Civilian activity done for income or pay—in other words, on the job for pay or
GUIDANCE other compensation, excluding on-duty military or volunteers.
CONNECTION ∙ Military activity, excluding off-duty status at the time.
Read the ICD-10-CM ∙ Volunteer activity.
Official Guidelines for ∙ Other external cause status, which includes leisure activities, student activities, and
Coding and Reporting, working on a hobby.
section I. Conven-
tions, General Coding As we discussed earlier in this section, this detail is important to the entire process,
Guidelines and Chapter including reimbursement as well as continuity of care.
Specific Guidelines,
subsection C. Chapter-­
GUIDANCE CONNECTION
Specific Coding Guide-
lines, chapter 20. Read the ICD-10-CM Official Guidelines for Coding and Reporting, section
External Causes of I. Conventions, General Coding Guidelines and Chapter Specific Guidelines,
Morbidity, subsection ­subsection C. Chapter-Specific Coding Guidelines, chapter 20. External Causes
c. Activity Code. of Morbidity, subsection k. External cause status.

430   PART II  |  REPORTING DIAGNOSES

 ICD-10-CM
LET’S CODE IT! SCENARIO
Phyllis Bush, a 27-year-old female, was learning to rock climb at her gym. As she was scaling the wall, her foot slipped
and Phyllis grabbed on with her right hand, pulling something in her shoulder. The severe pain caused her to stop by
her physician’s office on her way home. Dr. Dellin took x-rays and determined that she had an inferior dislocation of the
humerus, right side. Dr. Dellin put Phyllis’s arm into a sling and gave her a prescription for a pain reliever.

Let’s Code It!

Dr. Dellin diagnosed Phyllis with an inferior dislocation of the humerus, right side. Turn to the Alphabetic Index
and look up dislocation, humerus. Read down the list and see
Dislocation, humerus, proximal end — see Dislocation, shoulder
Even though Dr. Dellin’s notes didn’t specify proximal, that was necessary to get to inferior—anatomically:
Dislocation, shoulder
  humerus S43.00-
   inferior S43.03-
Perfect! Now, turn to the Tabular List and confirm the code. Start reading at
S43 Dislocation and sprain of joints and ligaments of shoulder girdle
There is a Code also note reminding you to also report a code for any associated open wound. Phyllis does not
have an open wound, so this does not apply. There is also an note that mentions a strain of muscle,
fascia, and tendon of the shoulder and upper arm (S46.-). However, Phyllis dislocated her humerus, so you can
keep reading down the column to review the fourth-character and fifth-character options and determine which
matches Dr. Dellin’s documentation:
S43.0 Subluxation and dislocation of shoulder joint
  S43.03 Inferior subluxation and dislocation of humerus
Go back to Dr. Dellin’s notes and see that this matches exactly. Terrific! Now a sixth character is required. Review
the options, check the documentation again, and determine
S43.034- Inferior dislocation of right humerus
Fantastic! A seventh character is required to explain where in the treatment path this encounter is. You can see
the options directly under the code category S43. This is the first time that Dr. Dellin is treating Phyllis’s disloca-
tion. Great! This leads you to the complete, most accurate code to report Phyllis’s injury:
S43.034A Inferior dislocation of right humerus, initial encounter
This code tells the whole story about Phyllis’s specific injury.
Now you need to find the external cause code(s) to explain how Phyllis’s injury happened. Turn to the External
Cause Code Alphabetic Index. Climb—no; exercise—no; fall—possibly. None of these listings really describes
how Phyllis got hurt. Actually, she was involved in an “activity,” so let’s take a look:
Activity (involving) (of victim at time of event) Y93.9
Keep reading down the long indented list below until you get to
climbing NEC Y93.39
  mountain Y93.31
  rock Y93.31
  wall climbing Y93.31

Perfect! That is exactly what she was doing. Let’s take a look in the Tabular List:

(continued)

CHAPTER 16  | 
 Y93 Activity codes
Y93.3 Activities involving climbing, rappelling, and jumping off
The note lists activities not related to Phyllis’s injury, so keep reading down the list:
Y93.31 Activity, mountain climbing, rock climbing and wall climbing
A code is needed to report the place of occurrence. Where was Phyllis when she got injured? At her gym.
Y92 Place of occurrence of the external cause
Y92.39 Other specific sports and athletic area as the place of occurrence of the external cause
(Gymnasium)
One more thing: What was Phyllis’s status, which you can describe using the codes within Y99 External cause
status? The wall climbing was a leisure activity for Phyllis, so you will report
Y99.8 Other external cause status (hobby not done for income)
Now you have all of the codes you need to tell the whole story about Phyllis’s injury and why Dr. Dellin treated
her:
S43.034A Inferior dislocation of right humerus, initial encounter
Y93.31 Activity, mountain climbing, rock climbing and wall climbing
Y92.39 Other specific sports and athletic area as the place of occurrence of the external cause
(Gymnasium)
Y99.8 Other external cause status (hobby not done for income)
Good work!

16.2  Traumatic Injuries

The term injury refers to traumatic damage to some aspect of the body, virtually
always caused by a fall, crash, weapon, or some other external cause. The damage may
be minor (superficial) or it may be life-threatening. It may occur during time at work
or while playing. It may be the result of an automobile accident or a fight. Or it may
occur during an indoor or outdoor activity.

Traumatic Fractures
Fracture Both bone and cartilage can break—that is, become fractured. Fractures can be the
Broken cartilage or bone. result of trauma, such as a fall or car accident, or they can be the result of a pathologic
condition (underlying disease), such as osteoporosis, that causes the bone to weaken so
much that it breaks. This is important information for you to abstract from the physi-
cian’s documentation because traumatic fractures and pathologic fractures are coded
differently. Actually, they have separate listings in the Alphabetic Index: Fracture,
pathological, and Fracture, traumatic.
When a fracture of a bone occurs, the coder must identify the segment of the bone
that was affected. For example: The sternal end of the clavicle is called this because it
is the end that connects to the sternum (ICD-10-CM code S42.011 Anterior displaced
fracture of sternal end of right clavicle). The acromial or lateral end of the clavicle con-
nects to the acromioclavicular joint (ICD-10-CM code S42.031 Displaced fracture of
lateral end of right clavicle).

Types of Fractures
One of the first factors needed for accurate coding of a fracture is whether the fracture
is open or closed (see Figure 16-1).

432   PART II  |  REPORTING DIAGNOSES

 Complex Incomplete Comminuted Greenstick

Simple (closed) Compound (open) Colles' Impacted

FIGURE 16-1  Illustrations of several different types of fractures

An open fractured bone is found in conjunction with an open wound through which
the bone may or may not extend. A closed, or simple, fracture has no accompany-
ing wound and remains within the confines of the body. Some types of fractures are
explained in the following paragraphs.
Avulsion fractures happen when a tiny bone piece breaks off at the point where a
ligament or tendon attaches to the bone. This is an occurrence of a piece of bone that
has broken away at a tubercle. When the fracture is not displaced, treatment is similar
to that for a soft tissue injury. In severe cases, surgery may be required to realign and
stabilize an affected growth plate.
Burst fractures occur when a vertebra has been crushed in all directions. This frac-
ture may be described as stable or unstable. Imaging (x-rays, CT scan, or MRI), as
well as physical and neurologic exams, typically will support a diagnosis. Stable burst
fractures may be treated with a molded turtle shell brace or a body cast. If neurologic
damage is identified, then the fracture is considered unstable and will require surgery.
An anterior or posterior approach may be used to insert internal fixation, a bone graft,
and/or fusion. The specific bone affected will determine the code.
Comminuted fracture identifies the breaking of the bone into several pieces.
A closed reduction may be required prior to immobilization by cast or splint. Internal
fixation may be necessary to correct an impacted fracture with an open reduction.
Depressed fracture indicates that the bone has been displaced inward. CODING BITES
Fatigue fractures occur most often in the second or third metatarsal shaft and are typi- Open fractures may
cally the result of continuous weight-bearing activities such as long-distance running, ballet also be documented as
dancing, or sports. An example is M48.4- Fatigue fracture of vertebra. Additional names for infected, missile, punc-
this type of fracture include march fracture, Deutschlander’s disease, and stress fracture— ture, compound, or with
reported from subcategory M84.3- Stress fracture (fatigue fracture) (march fracture). a foreign body.
Fissured (linear) fracture is a break that runs along the length of a long bone. Closed fractures
Greenstick fracture is one in which the fracture exists on one side of the bone while may also be docu-
the other side is not broken but bent. Example: S42.311A Greenstick fracture of shaft mented as comminuted,
of humerus, right arm, initial encounter for closed fracture. depressed, elevated,
Impacted fracture occurs when a fragment from the broken bone embeds itself into fissured, greenstick,
the body of another. impacted, linear, simple,
Infected fracture documents that there is presence of an infection at the fracture site. slipped epiphysis, or
This often will require additional codes to report the underlying bacterium or virus, as spiral.
well as the infection itself.

CHAPTER 16  | 
 Lateral mass fracture of the atlas (C1), as the name implies, involves the lateral
masses. These are the sturdiest sections of the C1 vertebra and include a superior facet
and an inferior facet. This fracture occurs at the point where the spine meets the base
of the cranium. A stable fracture means the transverse ligament is still intact, and a
cervical collar or cervicothoracic brace is the first course of treatment. For unstable
fractures, cranial traction will support a reduction of the displaced bone. After time, a
halo vest can be used. Fusion of C1–C3 may be required for more severe subluxation.
Use code S12.040 Displaced lateral mass fracture of first cervical vertebra or S12.041
Non-displaced lateral mass fracture of first cervical vertebra.
Maisonneuve’s fracture is a spiral fracture of the proximal portion of the fibula.
This type of fracture includes a disruption of ligaments. Stable fractures can be treated
with a long leg cast. Internal fixation may be required in more severe cases.
Oblique fracture is a fracture line that runs at an angle to the axis of the bone. Cast-
ing is the typical first course of treatment. In severe cases, an open reduction and pos-
sibly internal fixation will be used. Repair to surrounding ligaments may be required
as well.
Periosteal fractures occur below the periosteum (membrane covering the bone sur-
face) and are usually not displaced.
Pilon fracture is an oblique, comminuted fracture of the distal tibia. Treatment may
begin with stabilization, using external traction to permit the soft tissue injuries to heal
prior to surgical intervention. Open reduction with internal fixation, as well as external
fixation and percutaneous plating, may be used once the soft tissue has recovered.
Puncture fracture can identify that a puncture from outside the body penetrated
to cause the fracture or that the broken bone has punctured the skin after the fracture
occurred. Example: S91.231A Puncture wound without foreign body of right great toe
with damage to nail, initial encounter.
Segmental fracture is similar to the comminuted fracture; however, the broken
pieces of the bone separate. Internal fixation with open reduction is used to prevent
misalignment of the bone fragments. In some cases, bone cement is included in the
repair. Some surgical procedures also include attachment of external fixation.
Salter-Harris physeal fracture is a fracture of the epiphyseal plate (a thin layer of
bone; a growth plate, an area near the end of a long bone that contains growing tissue,
also known as the physis), and it is commonly found in children. ICD-10-CM sepa-
rately codes four of the nine types of Salter-Harris fracture: Salter-Harris type I is a
transverse fracture of the growth plate; type II is a fracture of the growth plate and the
metaphysis; type III is a fracture of the growth plate and the epiphysis; and type IV is a
fracture line that travels through all three: the growth plate, metaphysis, and epiphysis.
Closed reductions and traction can be used for less severe cases. Types III and IV more
GUIDANCE often will require surgical intervention using open reduction and internal fixation. For
CONNECTION example: S79.011A Salter-Harris type I physeal fracture of upper end of right femur,
Read the ICD-10-CM initial encounter for closed fracture.
Official Guidelines for Spiral fracture happens when a twisting force causes the bone to break around a
Coding and Reporting, long bone in a spiral direction. Example: S52.244A Nondisplaced spiral fracture of
section I. Conven- shaft of ulna, right arm, initial encounter for closed fracture.
tions, General Coding Torus fracture is also known as a buckle fracture; it is a compression of one side of
Guidelines and Chapter a bone’s protrusion, also known as the torus, while the other side is bent. This fracture
Specific Guidelines, is typically nondisplaced and, therefore, is correctable with a cast or splint.
subsection C. Chapter- Transverse fracture is a fracture line that runs across the bone; it may be an open or
Specific Guidelines, closed fracture. An open reduction with internal fixation may be required if the bone
chapter 19. Injury, has separated. A closed reduction might alternatively be employed. Casting is typical.
poisoning, and certain Transcondylar fracture is a fracture that runs through a condyle (a rounded knoblike
other consequences of prominence at the end of a bone). Such fractures are categorized as flexion or exten-
external causes, sub- sion fractures. Treatment can begin with immobilization for nondisplaced injury. How-
section c. Coding of ever, treatment for this type of fracture can be difficult due to the break’s location and
Traumatic Fractures. the lack of bone available for successful union. Example: S42.431A Displaced fracture
(avulsion) of lateral epicondyle of right humerus, initial encounter for closed fracture.

434   PART II  |  REPORTING DIAGNOSES

 Wedge compression fracture occurs when only the anterior portion of a vertebra
is crushed, which causes the vertebra to take on a wedge shape. Vertebroplasty will CODING BITES
stabilize the fracture and prevent further damage. Example: A wedge compression The Tabular List catego-
fracture of L3 would be reported with code S32.030A Wedge compression fracture of rizes the codes used
third lumbar vertebra, initial encounter for closed fracture. to report injuries first
by anatomical site (the
Skull Fracture location of the injury)
A skull fracture will first be qualified by the area injured, such as the vault of the and then by the specific
skull (frontal or parietal bone—code S02.0xxA) or the base of the skull (sphenoid or injury (contusion, insect
temporal bone—code S02.19xA). Note: A second code would report any intracranial bite, etc.).
injury, if applicable.
Fractures of the skull are characterized differently than others throughout the body
and include the following:
∙ Basal skull fracture is a break in the floor of the skull.
∙ Blowout fracture indicates a break in the floor of the orbit that is typically caused
by a severe blow to the eye.
∙ Depressed skull fracture identifies an inward displacement of one of the bones of
the skull.
∙ Stellate fracture is one with a clear central point of the fracture and with break
lines radiating from this central spot.

Maxillary Fracture
Facial trauma might result in a LeFort fracture, which is a bilateral maxillary frac-
ture with involvement of the surrounding bone, including the zygomatic bones. Such
fractures are identified by type: A LeFort I fracture (code S02.411-) is a downward
horizontal facial fracture and typically involves the maxillary alveolar rim and infe-
rior nasal aperture. A LeFort II fracture (code S02.412-) is more triangular, involving
the inferior orbital rim, the nasal bridge, and the frontal processes of the maxilla.
A LeFort III fracture (code S02.413-) is a transverse fracture, sometimes referred to
as a craniofacial dissociation. This fracture involves the zygomatic arch, the nasal
bridge, and the upper maxilla and extends along the orbit floor (posteriorly).

EXAMPLES
S02.402A Zygomatic fracture, unspecified side, initial encounter for closed
fracture
S02.413D LeFort III fracture, subsequent encounter for fracture with rou-
tine healing

Sequelae (Late Effects) of Fractures

Once a bone has been given the opportunity to heal, it may not heal properly. The most
common types of late effects of fractures are malunion and nonunion. A malunion
(mal = bad + union = together) of a fractured bone means that the pieces of the bone Malunion
healed back together but not in an effective way. Unfortunately, the most common A fractured bone that did not
treatment for a malunion is for the physician to rebreak the bone and set it again, heal correctly; healing of bone
hoping that it will heal properly the second time. When the parts of a broken bone do that was not in proper position
not heal back together at all, despite the proper treatment and time allotment, this is or alignment.
known as a nonunion (non = not + union = together). Nonunion
In ICD-10-CM’s Alphabetic Index, when you look up Fracture, malunion, you will A fractured bone that did not
see the notation “See Fracture, by site.” When you look up Fracture, nonunion, you heal back together; no mend-
will see the notation “See Nonunion, fracture.” At Nonunion, fracture, the notation ing or joining together of the
states, “See Fracture, by site.” broken segments.

CHAPTER 16  | 
Laceration Traumatic Wounds
Damage to the epidermal
and dermal layers of the skin Lacerations (Superficial Wounds)
made by a sharp object.
Each one of us has had a laceration at some time or another. Perhaps it was a paper
cut or a cut from a knife while chopping vegetables. This smooth slit or opening in the
GUIDANCE epidermal layer is typically superficial and does not bleed. A laceration caused by a
CONNECTION sharp object is generally a ragged wound (see Figure 16-2). Unlike a superficial cut,
a laceration is deeper, damaging the dermal layer of the skin. It penetrates the blood
Review the ICD-10-CM
vessels, resulting in bleeding. These more severe injuries may also be vulnerable to
Official Guidelines for
infection and pain. Depending upon the specific object or event that caused the lacera-
Coding and Report-
tion, the physician may order an x-ray to determine whether any foreign bodies, such
ing, section I. Conven-
as shards of glass or splinters from wood, are lodged within the wound.
tions, General Coding
Guidelines and Chapter
Contusions and Hematomas
Specific Guidelines, sub-
section C. Chapter- A contusion, commonly known as a bruise or “black-and-blue mark,” is an injury to
Specific Coding the body that typically does not break the skin but that does damage to the underlying
Guidelines, chapter blood vessels. The bleeding in the dermal layer is seen only through the epidermis as a
13. Diseases of the dark color. As the contusion heals, the colors change until the collected blood is dissi-
Musculoskeletal System pated and everything has healed. When the bleeding coagulates into a blood clot, this
and Connective Tissue, is called a hematoma. The seriousness of these injuries largely depends on the ana-
subsection b, Acute trau- tomical site where the bleeding and/or clot is located. A contusion or hematoma on the
matic versus chronic or leg or arm is typically a minor event that rarely requires a physician’s skill, whereas a
recurrent musculoskel- contusion to the brain or a subdural hematoma could be life-threatening.
etal conditions, in addi-
tion to chapter 19. Injury, Puncture Wounds
poisoning, and certain When a pointed, narrow object enters deeply into the visceral (inside) aspects of the
other consequences of body, the injury is known as a puncture wound (see Figure 16-2). A carpenter’s nail,
external causes, subsec- a knife, scissors, and a fishhook are just a few items that can cause an injury of this
tion b. Coding of Injuries. nature. Due to the characteristics of this type of wound, infection and internal damage

Contusion Incision Laceration

Puncture Abrasion

FIGURE 16-2  Illustrations of different types of wounds, including lacerations and puncture wounds  Booth et al., Medi-
cal Assisting, 5e. Copyright ©2013 by McGraw-Hill Education. Figure 57-7, p. 1191. Used with permission.

436   PART II  |  REPORTING DIAGNOSES

are possible. The physician may check for dirt, debris, or foreign objects within the
wound. He or she may also order blood tests to check for a pathogen that might cause
an infection. Stitches and possible surgery may be required, depending upon the spe-
cific depth and location of the injury.

Avulsions
The medical term avulsion describes a situation in which all layers of the skin (epidermis Avulsion
and dermis) are forcibly torn away from the body, typically a surface trauma. Due to the Injury in which layers of skin
pulling off of the dermal layers, the underlying structures, including adipose tissue, mus- are traumatically torn away
cles, tendons, and bone, become open to the outside. Rock climbers may suffer “flappers,” from the body.
an avulsion of the fingertip pad. When this occurs to a fingernail or toenail, it is known
as a nail avulsion—the nail plate is torn off the nail bed. Unlike the case with avulsions
at other anatomical sites, in nail avulsions the nail is not reattached. Instead, the fingertip
and nail bed are covered to protect the area until the keratin has formed a new nail.

Animal, Insect, or Human Bites

Animal bites and human bites can be a particular concern due to the potential spread
of bacteria and viruses via saliva transference. Insects may transmit their own fluids
and sometimes venom.

ICD-10-CM
LET’S CODE IT! SCENARIO
Nathan Kirchner, an 8-year-old male, was hiking in a public park with his Boy Scout troop when they came to a clearing
and he saw a foal and its mother looking over the fence in a corral in the northeast edge of the park. He reached out
his left hand to pet the foal, and the mother horse bit his thumb. His scout leader took him to the emergency room. After
examination and some tests, Dr. Clifton cleaned the wound, applied a sterile dressing, and gave Nathan an antibiotic.

Let’s Code It!

Dr. Clifton’s notes state that Nathan had been bitten on the thumb by a horse. When you turn to the Alphabetic
Index, you see
Bite(s) (animal)(human)
   thumb S61.05
Remember the Coding Tip from the beginning of this chapter? These codes are first categorized by the anatomi-
cal site and then by the specific injury.
When you turn to the Tabular List, you confirm
S61 Open wound of wrist, hand and fingers
Before you continue reading, be certain to pay attention to the notations here. There is a Code also if a wound
infection is documented; there is an notation with two diagnoses that do not relate to Nathan’s case;
and there are options for the required seventh character. You will need to come back to this after you determine
the correct code. So keep reading to determine the correct fourth character:
S61.0 Open wound of thumb without damage to nail
There is another notation. Has Dr. Clifton documented that the nail was also damaged? No. So con-
tinue reading to determine the correct fifth character:
S61.05 Open bite of thumb without damage to nail
There is another detail you need to abstract from the documentation: Nathan’s right or left thumb?
S61.052- Open bite of left thumb without damage to nail
Now you need to determine the correct seventh character. Go back to the beginning of this code category and
review your choices.

(continued)

CHAPTER 16  | 
 S61.052A Open bite of left thumb without damage to nail, initial encounter
Perfect! Yet you have not explained the whole story about why Dr. Clifton cared for Nathan. This code states he
was bitten on the left thumb, but not by whom or what. To report how Nathan got bitten and by what, you will
need external cause codes. Turn to the Alphabetic Index to External Causes and look up
Bite
   horse W55.11
Turn in the Tabular List to
W55 Contact with other mammals
Of course, you are going to read this code’s notation carefully. None of the exclusions apply to this
case. And there are your options for the seventh character. But, first, read down to determine the correct fourth,
fifth, and sixth characters:
W55.1 Contact with horse
  W55.11x- Bitten by horse
And now, go back up for the seventh character:
W55.11xA Bitten by horse, initial encounter
Terrific! You will also need to determine the codes to report the place of occurrence, activity, and the external
cause status. Try this on your own. Did you determine that these are the codes?
Y92.830 Public park as the place of occurrence of the external cause
Y93.01 Activity, walking, marching and hiking
Y99.8 Other external cause status
You are really getting to be a great coder!

Myalgia
Pain in a muscle. Traumatic Injury to the Muscles
A muscle injury is most often the result of some type of trauma or overexertion dur-
CODING BITES ing exercise or sports. Traumatic injuries to muscles may be described in a number of
Remember that when- ways:
ever you are reporting ∙ Strain is a tearing of the fibers of the muscle involved, most often the result of over-
an injury, you will also stretching the muscle during movement.
need to report external
∙ Sprain is a partially torn or overstretched ligament.
cause codes to explain
how the patient got ∙ Contusion is usually the result of a minor trauma to a muscle, causing a bruise.
injured and identify the ∙ Tear (muscle tear) is a separation within the muscle fibers. A bowstring tear, also
place of occurrence. To known as a bucket-handle tear, occurs longitudinally in the meniscus.
learn more, see the sec- ∙ Myalgia is the medical term for muscle pain.
tion Reporting External
∙ Rupture is the tear in an organ or tissue.
Causes of Injuries in this
chapter. Also, many of the
codes from ICD-10-CM
code book’s Chapter 19, EXAMPLES
Injury, poisoning, and S53.21xA Traumatic rupture of right radial collateral ligament, initial
certain other conse- encounter
quences of external S76.122A Laceration of left quadriceps muscle, fascia, and tendon, initial
causes require seventh encounter
characters for reporting S83.211A Bucket-handle tear of medial meniscus, current injury, right
the type of encounter. knee, initial encounter

438   PART II  |  REPORTING DIAGNOSES

 ICD-10-CM
YOU CODE IT! CASE STUDY
Theresa Flores experienced her first parachute jump with her boyfriend 3 months ago. She loved it and is now work-
ing on her certification for parachute jumping. On her last jump, she sprained the lateral collateral ligament of her
left knee after landing the wrong way. Dr. Hadden confirmed the injury and treated it.

You Code It!

Go through the steps of coding, and determine the code or codes that should be reported for this encounter
between Dr. Hadden and Theresa.
Step #1: Read the case carefully and completely.
Step #2: Abstract the scenario. Which main words or terms describe why the physician cared for the patient
during this encounter? 
Step #3: Are there any details missing or incomplete for which you would need to query the physician? [If so,
ask your instructor.]
Step #4: Check for any relevant guidance, including reading all of the symbols and notations in the Tabular List
and the appropriate sections of the Official Guidelines.
Step #5: Determine the correct diagnosis code or codes to explain why this encounter was medically necessary.
Step #6: Double-check your work.
Answer:
Did you determine these to be the correct codes?
S83.422A Sprain of lateral collateral ligament of left knee, initial encounter
V97.22xA Parachutist injured on landing, initial encounter
Y99.8 Other external cause status (leisure activity)

16.3  Using Seventh Characters to

Report Status of Care
Throughout the long list of codes available to report traumatic injury, you will see that
a majority require seventh (7th) characters. These characters report where the patient
is, at this encounter, in the treatment plan.

Character Description Meaning

A Initial Patient is receiving active treatment including evalu- CODING BITES
encounter ation and continuing treatment by any physician. When reporting an
D Subsequent Patient has completed active treatment and is encounter for sequela
encounter receiving routine care for the condition during the care, the principal (first-
healing process or the recovery phase. listed) code is the one
S Sequela Late effects, also known as residual effects, identifying the specific
of another condition, such as scar formation after sequela (i.e., scar, mal-
a burn. union of fractured bone,
etc.), followed by the
Seventh Characters for Fracture Care code that reports the
original injury or poison-
When reporting a code identifying that the patient has a fracture (more about this ing with a 7th character
in 16.2 Traumatic Injuries in this chapter), the definitions of the seventh characters of S.
change a bit to provide more details about the specific fracture.

CHAPTER 16  | 
 Skeletal Fractures
GUIDANCE
Character Description
CONNECTION
A Initial encounter for closed fracture
Read the ICD-10-CM Offi- B Initial encounter for open fracture
cial Guidelines for Coding D Subsequent encounter for fracture with routine healing
and Reporting, section
G Subsequent encounter for fracture with delayed healing
I. Conventions, Gen-
eral Coding Guidelines K Subsequent encounter for fracture with nonunion
and Chapter Specific P Subsequent encounter for fracture with malunion
Guidelines, subsection C. S Sequela
Chapter-Specific Cod-
ing Guidelines, chapter
19. Injury, poisoning, CODING BITES
and certain other con- Example of a subsequent encounter for fracture care might include a cast change,
sequences of external removal of a cast, x-ray to evaluate healing of a fracture, or adjusting a patient’s
causes, subsection a. medication.
Application of 7th Char-
acters in Chapter 19.
Fracture of Forearm, Femur, and Lower Leg (Including Ankle)
Character Description 
GUIDANCE A Initial encounter for closed fracture
CONNECTION B Initial encounter for open fracture type I or II (or NOS)
C Initial encounter for open fracture type IIIA, IIIB, or IIIC
Read the ICD-10-CM Offi-
cial Guidelines for Coding
D Subsequent encounter for closed fracture with routine healing
and Reporting, section E Subsequent encounter for open fracture type I or II with routine healing
I. Conventions, Gen- F Subsequent encounter for open fracture type IIIA, IIIB, or IIIC with
eral Coding Guidelines routine healing
and Chapter Specific G Subsequent encounter for closed fracture with delayed healing
Guidelines, subsection C. H Subsequent encounter for open fracture type I or II with delayed healing
Chapter-Specific Cod- J Subsequent encounter for open fracture type IIIA, IIIB, or IIIC with
ing Guidelines, chapter delayed healing
19. Injury, poisoning,
K Subsequent encounter for closed fracture with nonunion
and certain other con-
sequences of external M Subsequent encounter for open fracture type I or II with nonunion
causes, subsection c.1) N Subsequent encounter for open fracture type IIIA, IIIB, or IIIC wtih
Initial vs. Subsequent nonunion
Encounter for Fractures. P Subsequent encounter for closed fracture with malunion
Q  Subsequent encounter for open fracture type I or II with malunion
R Subsequent encounter for open fracture type IIIA, IIIB, or IIIC with
malunion
S Sequela

CODING BITES
Aftercare codes from ICD-10-CM’s Chapter 21 (Z codes) should NOT be reported
when the injury or poisoning code uses a 7th character. 

16.4  Using the Table of Drugs and Chemicals

Often located directly after the alphabetical listing is the Table of Drugs and Chemicals
(see Figure 16-3). (Note: Different published versions of the ICD-10-CM book may place
sections in a different order.) The Table of Drugs and Chemicals is used when a drug or
chemical caused an adverse reaction, poisoned the patient, or caused a toxic effect. Simi-
lar to the Neoplasm Table, the Table of Drugs and Chemicals is organized in columns.

440   PART II  |  REPORTING DIAGNOSES

 Poisoning, Poisoning,
Accidental Intentional Poisoning, Poisoning, Adverse
Substance (unintentional) self-harm Assault Undetermined Effect Underdosing
# – –
1-propanol T51.3X1 T51.3X2 T51.3X3 T51.3X4 – –
2-propanol T51.2X1 T51.2X2 T51.2X3 T51.2X4 – –
2,4-D (dichlorophen-
oxyacetic acid) T60.3X1 T60.3X2 T60.3X3 T60.3X4 – –
2,4-toluene dilsocyanate T65.0X1 T65.0X2 T65.0X3 T65.0X4 – –
2,4,5-T (trichloro-
phenoxyacetic acid) T60.1X1 T60.1X2 T60.1X3 T60.1X4 – –
14-hydroxydihyrdo-
morphinone T40.2X1 T40.2X2 T40.2X3 T40.2X4 T40.2X5 T40.2X6
A
ABOB T37.5X1 T37.5X2 T37.5X3 T37.5X4 T37.5X5 T37.5X6
Abrine T62.2X1 T62.2X2 T62.2X3 T62.2X4 – –
Abrus(seed) T62.2X1 T62.2X2 T62.2X3 T62.2X4 – –
Absinthe T51.0X1 T51.0X2 T51.0X3 T51.0X4 – –
- beverage T51.0X1 T51.0X2 T51.0X3 T51.0X4 – –
Acaricide T60.8X1 T60.8X2 T60.8X3 T60.8X4 – –
Acebutolol T44.7X1 T44.7X2 T44.7X3 T44.7X4 T44.7X5 T44.7X6
Acecarbromal T42.6X1 T42.6X2 T42.6X3 T42.6X4 T42.6X5 T42.6X6
Aceclidine T44.1X1 T44.1X2 T44.1X3 T44.1X4 T44.1X5 T44.1X6
Acedapsone T37.0X1 T37.0X2 T37.0X3 T37.0X4 T37.0X5 T37.0X6
Acetylline piperazine T48.6X1 T48.6X2 T48.6X3 T48.6X4 T48.6X5 T48.6X6
Acemorphan T40.2X1 T40.2X2 T40.2X3 T40.2X4 T40.2X5 T40.2X6
Acenocoumarin T45.511 T45.512 T45.513 T45.514 T45.515 T45.516
Acenocoumarol T45.511 T45.512 T45.513 T45.514 T45.515 T45.516
Acepifylline T48.6X1 T48.6X2 T48.6X3 T48.6X4 T48.6X5 T48.6X6
Acepromazine T43.3X1 T43.3X2 T43.3X3 T43.3X4 T43.3X5 T43.3X6
Acesulfamethoxypyrida-
zine T37.0X1 T37.0X2 T37.0X3 T37.0X4 T37.0X5 T37.0X6
Acetal T52.8X1 T52.8X2 T52.8X3 T52.8X4 – –
Acetaldehyde (vapor) T52.8X1 T52.8X2 T52.8X3 T52.8X4 – –
- liquid T65.891 T65.892 T65.893 T65.894 – –
P-Acetamidophenol T39.1X1 T39.1X2 T39.1X3 T39.1X4 T39.1X5 T39.1X6
Acetominaphen T39.1X1 T39.1X2 T39.1X3 T39.1X4 T39.1X5 T39.1X6
Acetalminosalol T39.1X1 T39.1X2 T39.1X3 T39.1X4 T39.1X5 T39.1X6
Acetanilide T39.1X1 T39.1X2 T39.1X3 T39.1X4 T39.1X5 T39.1X6
Acetarsol T37.3X1 T37.3X2 T37.3X3 T37.3X4 T37.3X5 T37.3X6
Acetazolamide T50.2X1 T50.2X2 T50.2X3 T50.2X4 T50.2X5 T50.2X6
Acetiamine T45.2X1 T45.2X2 T45.2X3 T45.2X4 T45.2X5 T45.2X6
Acetic
- acid T54.2X1 T54.2X2 T54.2X3 T54.2X4 – –

(continued)

CHAPTER 16  | 
 Poisoning, Poisoning,
Accidental Intentional Poisoning, Poisoning, Adverse
Substance (unintentional) self-harm Assault Undetermined Effect Underdosing
-- with sodium acetate
(ointment) T49.3X1 T49.3X2 T49.3X3 T49.3X4 T49.3X5 T49.3X6
-- ester (solvent) (vapor) T52.8X1 T52.8X2 T52.8X3 T52.8X4 – –
-- irrigating solution T50.3X1 T50.3X2 T50.3X3 T50.3X4 T50.3X5 T50.3X6
-- medicinal (lotion) T49.2X1 T49.2X2 T49.2X3 T49.2X4 T49.2X5 T49.2X6
- anhydride T65.891 T65.892 T65.893 T65.894 – –

FIGURE 16-3  ICD-10-CM Table of Drugs and Chemicals, in part, from 1-propanol through acetic anhydride  Source:
ICD-10-CM Official Guidelines for Coding and Reporting The Centers for Medicare and Medicaid Services (CMS) and the National Center for Health Statistics (NCHS)

GUIDANCE Drug and Chemical Names

CONNECTION The first column of the table lists the names of drugs and chemicals, in alphabetic
order. The list includes prescription medications, over-the-counter medications, house-
Read the ICD-10-CM hold and industrial chemicals, and many other items with a chemical basis. Aspirin,
Official Guidelines for indigestion relief medication, drugstore-brand allergy relievers, alcohol (for drinking
Coding and Reporting, or sterilization), window cleaner, battery acid, and lots of other similar substances are
section I. Conven- included, as well as medications prescribed by a physician.
tions, General Coding Sometimes, it is easy to find what you’re looking for. For example, Giselle had a
Guidelines and Chapter bad reaction to Nytol. Even though Nytol is the brand name of an over-the-counter
Specific Guidelines, sleep medication, you will find it easily in the list of substances in the first column of
subsection C. Chapter- the Table of Drugs and Chemicals.
Specific Coding Guide- Other times, it may not be this easy, and the name—whether brand name, generic
lines, chapter 19. Injury, name, or chemical name—that is documented in the physician’s notes may not be in
poisoning, and certain the table. If you don’t find it, you may have to do some research. Some of the drugs
other consequences of and chemicals are listed by their brand or common names, such as Metamucil or Nytol.
external causes, sub- Others are listed by their chemical or generic names, such as barbiturates (sedatives).
sections e. Adverse If you are not certain, consult a Physicians’ Desk Reference (PDR), a group of books
Effects, Poisoning, that list all the approved drugs, herbal remedies, and over-the-counter medications by
Underdosing and Toxic brand name, chemical name, generic name, and drug category.
Effects and e.1) Do not
code directly from the
Table of Drugs. EXAMPLE
Vesicare—the brand name.
Physicians’ Desk Reference Solifenacin succinate—the generic or chemical name.
(PDR) Muscarinic receptor antagonist—the drug category.
A series of reference books Anticholinergic—the general drug category.
identifying all aspects of pre-
scription and over-the-counter
In our example, you can see Vesicare is shown as the trade or brand name. The generic
medications, as well as herbal
or chemical name is solifenacin succinate. If a physician prescribed it for a patient, who
remedies.
then had an adverse reaction or took an overdose, you would most likely see one or the
other of those names in the notes. However, you will find neither of them listed in the
Table of Drugs and Chemicals. The next piece of information given to you by the PDR is
found in the description of the drug: muscarinic receptor antagonist. Unfortunately, there
is nothing in the table under muscarinic either. Because the patient either had an adverse
reaction or had taken an overdose, take a look at the following paragraphs from the PDR:
ADVERSE REACTIONS
. . . Expected side effects of antimuscarinic agents . . .
OVERDOSAGE
. . . Overdosage with Vesicare can potentially result in severe anticholinergic
effects . . .

442   PART II  |  REPORTING DIAGNOSES

 The two paragraphs provide us with two new descriptors for the drug: antimusca-
rinic and anticholinergic. Both of them are shown in the Table of Drugs and Chemi-
cals and, interestingly, lead you to the same codes.

ICD-10-CM
LET’S CODE IT! SCENARIO
Kurt Hershey found an unmarked barrel in the back of the warehouse where he works. He opened the top and
leaned over to see what was inside. Vapors from the benzene solvent being stored in that barrel overcame Kurt.
He had difficulty breathing because he accidentally inhaled the chemical. He was taken to the doctor immediately.
Dr. Blanchard diagnosed Kurt with respiratory distress syndrome, a toxic effect from inhaling the benzene.

Let’s Code It!

Kurt had a toxic effect from inhaling the benzene. The notes also state that Kurt had respiratory distress. You
learned that you need at least two codes: toxic effect + external cause code.
The first code identifies the chemical or substance and intent. In Kurt’s case, the substance was the vapor
from a barrel of benzene solvent. Turn to the Alphabetic Index’s Table of Drugs and Chemicals. Look down the
first column and find benzene:
Benzene
   homologues (acetyl) (dimethyl) (methyl) (solvent)
You know from the documentation that this was an accidental poisoning, so look across the line to the first col-
umn titled “Poisoning, Accidental (Unintentional)”:
Benzene T52.1x1
   homologues (acetyl) (dimethyl) (methyl) (solvent) T52.2x1
Hmm. It can be difficult to know what was in that barrel. You can get more information from the Tabular List and
see if that helps. Start at the three-character number and be certain to check any notations or directives:
T52 Toxic effect of organic solvents
Be sure to read the notation. Does it relate to Kurt’s diagnosis? No. Good! There are the seventh-
character options for later, but first you must determine the rest of the code, so keep reading down the
column:
T52.1 Toxic effects of benzene
T52.2 Toxic effects of homologues of benzene
Homologues are not mentioned in the documentation, so review the options for fifth and sixth characters under
T52.1:
T52.1x1 Toxic effects of benzene, accidental (unintentional)
Remember, you need to include the seventh character.
T52.1x1A Toxic effects of benzene, accidental (unintentional), initial encounter
Great! You now have the first-listed code for Kurt’s encounter.
The next code reports the effect that the benzene vapors had on Kurt.
The notes state he had respiratory distress. In the main section of the Alphabetic Index, find
Distress
   respiratory (adult) (child) R06.03
Look up the code in the Tabular List
R06.03 Acute respiratory distress

(continued)

CHAPTER 16  | 
 This matches!
Two more codes—remember, you also need external cause codes to report where the accident occurred
and Kurt’s status (why he was doing this). In the Index to External Causes, turn to “Place of occurrence.”
The notes state that Kurt was in a warehouse when this accident happened, so read down the list, and you
will see
Place of occurrence 
   warehouse Y92.59
Go to the Tabular List, beginning with the code category:
Y92 Place of occurrence of the external cause
Read down the column to review your choices for the required fourth and fifth characters.
Y92.59 Other trade areas as the place of occurrence of the external cause (warehouse as the
place of occurrence of the external cause)
Your last code will report Kurt’s status. You know he was at work, so you will use this code:
Y99.0 Civilian activity done for income or pay
This completes the report.

T52.1x1A Toxic effects of benzene, accidental (unintentional), initial encounter

R06.03 Acute respiratory distress
Y92.59 Other trade areas as the place of occurrence of the external cause (warehouse as
the place of occurrence of the external cause)
Y99.0 Civilian activity done for income or pay

You are really becoming a great coder!

16.5  Adverse Effects, Poisoning,

GUIDANCE Underdosing, and Toxic Effects
CONNECTION When an individual comes in contact with a drug or a chemical that has an unhealthy
Read the ICD-10-CM impact, it must be coded. The person might have had an unusual reaction to a medica-
Official Guidelines for tion prescribed by a health care professional or might have been exposed to something
Coding and Reporting, noxious. 
section I. Conven- The first step is for you to determine whether the patient was poisoned, suffering an
tions, General Coding adverse effect (or reaction), or experiencing a toxic effect.
Guidelines and Chapter
Specific Guidelines, Adverse Reaction
subsection C. Chapter-
When health care providers determine that a pharmaceutical substance may improve
Specific Coding Guide-
an individual’s health status, they will typically prescribe that medication for thera-
lines, chapter 19,
peutic use. A patient is diagnosed with an adverse effect, or reaction, when all of the
Injury, poisoning, and
following occur and the patient has a negative outcome anyway: 
certain other conse-
quences of external ∙ A health care professional correctly prescribes a drug for a patient. 
causes,subsection e. ∙ The correct patient receives the correct drug.
Adverse Effects, Poi-
∙ The correct dosage is given to the patient (or taken by the patient). [The correct dos-
soning, Underdosing
age includes the correct amount in the correct frequency.]
and Toxic Effects.
∙ The correct route of administration is used.           

444   PART II  |  REPORTING DIAGNOSES

 EXAMPLE CODING BITES
Dr. Levinson prescribed 10 mg of Lexapro, bid, po, for Terence Romulles for You might need more
anxiety. than one code to report
the negative effect of
Lexapro is the brand name of an anti-anxiety medication.
this medication on this
10 mg is the quantity (amount) of the dosage. 
patient. Remember, you
bid is the abbreviation meaning twice per day—the frequency.
need to tell the whole
po is the abbreviation meaning “by mouth”—the route of administration.
story in codes.

The patient then has an unexpected bad reaction to that drug. There may have been
no way to know the patient was allergic to this medication because he had never taken CODING BITES
it before. Unpredictable reactions to drugs can be prompted by genetic factors, other Think P.E. for Poison
conditions or diseases, allergies, or other issues. P = poison code is
When an adverse reaction has occurred, you will need a minimum of two codes.  reported first [the code
First, code for the effect. The code or codes will report exactly what the reaction suggested by the
was, such as a rash, vomiting, or unconsciousness. When you abstract the physician’s appropriate column of
documentation, you may find this is a confirmed diagnosis, or signs and symptoms the Table of Drugs and
experienced by the patient as a result of taking the medication. Chemicals]
Second, code for the external cause. The external cause code will explain that the
patient took the drug for therapeutic use. You can find this code in the Table of Drugs E = effect of the poison-
and Chemicals by first locating the name of the drug (either the brand name or the ing is reported next [the
generic name) in the first column and then reading across that row to the column under bad reaction the patient
the heading “Adverse Effect.”  had to the substance,
such as a rash, vomiting,
or unconsciousness]
EXAMPLE The effect of the poi-
Giana Roman took her prescription for amoxicillin exactly as the doctor and the soning might be a
pharmacist instructed. She broke out in a rash because it turned out she was aller- confirmed diagnosis
gic to this antibiotic and no one knew.  or documentation of
The “effect” is the rash “dermatitis due to drugs taken internally” = L27.0 Gen- signs and/or symptoms.
eralized skin eruption due to drugs and medicaments taken internally You may need more
than one code to tell
+
the whole story about
The external cause code explains “therapeutic use of amoxicillin” = T36.0x5A how this poisoning has
Adverse effect of penicillins, initial encounter affected the patient.

Poisoning GUIDANCE
Most people think of poisoning as something from a great detective novel or movie; CONNECTION
however, a poisoning can happen under many different circumstances. In reality, when
a person comes in contact with a drug (not prescribed by a physician or not taken as The ICD-10-CM guide-
prescribed) or a chemical and a health problem results, it is called a poisoning.  lines reduce the num-
The drug or substance might have been ingested, inhaled, absorbed through the ber of codes you will
skin, injected, or taken by some other method. Remember that this may be a drug, or need to report some
it may be a chemical, such as cleaning supplies, gasoline, or other type of poison or conditions. Codes in
toxic substance. Your first step is to abstract the name of the substance that poisoned categories T36–T65 are
the patient so you can look it up on the Table of Drugs and Chemicals. combination codes that
Next, you will need to discover the circumstances under which this patient came to include the substances
be poisoned. Was it . . .  related to adverse
effects, poisonings, toxic
∙ An accident (unintentional). Things happen, such as a child finding a bottle of effects, and underdos-
medication and thinking it’s candy or finding cleaning spray and thinking it would ing, as well as the exter-
be fun to wash his face with it. A patient mistakenly took the wrong amount of nal cause.
a medication or the clinician mistakenly administered the wrong quantity to the

CHAPTER 16  | 
 wrong patient (if this was a drug). Two substances could also be taken that contra-
GUIDANCE dicted each other.
CONNECTION ∙ A suicide attempt (intentional self-harm). Sadly, a person might take an overdose
Read the ICD-10-CM while trying to harm himself or herself, intentionally. 
Official Guidelines for ∙ An assault. This occurs when someone tries to cause intentional harm to someone
Coding and Report- else. It sounds like a scene from that detective movie, but it does happen in real life. 
ing, section I. Conven- ∙ Underdosing. Most often, this occurs when the patient cannot afford the medica-
tions, General Coding tion, so he or she takes less each time so one prescription will last longer. Or, this
Guidelines and Chapter may occur because a label is misread or an implanted medication pump malfunc-
Specific Guidelines, tions. In any of these situations, the patient is not receiving the quantity necessary
subsection C. Chapter- for therapeutic value and thus does not improve as expected due to the medication’s
Specific Coding Guide- ineffectiveness.
lines, chapter 19. Injury,
poisoning, and certain Underdosing and Patient Noncompliance
other consequences of
Sometimes, a patient has an adverse effect because he or she did not take the medica-
external causes, subsec-
tion as ordered by the physician or didn’t take the drugs at all. Some patients forget,
tion e.5)(b) Poisoning.
some are resistant to needing a drug, and some cannot afford the required number of
pills. When taking too little of the quantity prescribed (underdosing) is the patient’s
action, rather than an error on the part of a health care professional, this is considered
CODING BITES noncompliance and is reported with an additional code to explain:
Code subcategories
Z91.120 Patient’s intentional underdosing of medication regimen due to
Z91.12- and Z91.13-
financial hardship
both have a Code first
Z91.128 Patient’s intentional underdosing of medication regimen for other
notation, so you don’t
reason
have to wonder about
Z91.130 Patient’s unintentional underdosing of medication regimen due to
proper sequencing.
age-related debility
Z91.138 Patient’s unintentional underdosing of medication regimen for
other reason
CODING BITES Z91.14 Patient’s other noncompliance with medication regimen
The difference between
a poisoning and a toxic Toxic Effects
effect is the substance.
A toxic effect, such as irritation or carcinogenicity, may result from a part of the
A poisoning or adverse
human body interacting with a chemical or other nonmedicinal substance. When an
effect is a reaction to
individual comes in contact with a toxic substance, whether ingested (such as liquid
a natural or medicinal
window cleaner), inhaled (such as asbestos), or touched (such as acid), you will report
substance, whereas a
this using the same coding process as reporting a poisoning. The external cause code
toxic effect is a reaction
will come from a different range of codes, that’s all.
to a harmful substance.
T51-T65 Toxic effects of substances chiefly nonmedicinal as to source

ICD-10-CM
LET’S CODE IT! SCENARIO
Dr. Barry, a pediatrician, was called in to see Abigail Scanter, a 3-year-old female, brought in by her mother after she
discovered Abigail on the floor with part of a detergent pod in her mouth, half empty. Abigail was having difficulty
breathing; she had vomited; and her mouth, throat, and esophagus were erythmatous, swollen, and irritated. Dr.
Barry ordered blood tests and immediately began to pump Abigail’s stomach based on his diagnosis of a toxic effect
of the accidental ingestion of detergent.

Let’s Code It!

Dr. Barry confirmed that Abigail was ill due to the toxic effects of ingesting the detergent. 
Turn to the Table of Drugs and Chemicals to find “detergent” in the first column, “Substance”:

446   PART II  |  REPORTING DIAGNOSES

 Detergent
external medication
local
medicinal
nonmedicinal
specified NEC
Were you surprised to see so many different options? I was. Which fits this diagnosis? Let’s think this through:
Detergent
external medication — the problem here was not external
local — she swallowed the detergent, so it was not local
medicinal — definitely not
nonmedicinal — this fits!
specified NEC — possibly
Look across the row where nonmedicinal is listed to the first column to the right, the column “Poisoning, Acci-
dental (unintentional)” . . . you will see code T55.1x1 suggested. This is the same code suggested on the next
row for “specified NEC” so that will save some time.
Turn in the ICD-10-CM Tabular List to the code category
T55 Toxic effect of soaps and detergents
The fourth character requires you to determine if Abigail was affected by soap or detergent, leading you to
T55.1 Toxic effect of detergents
T55.1x Toxic effect of detergents
  T55.1x1 Toxic effect of detergents, accidental (unintentional)
You will find the seventh-character options in the box immediately below the code category. You can tell this is
the first time Dr. Barry is caring for Abigail for this reason, and this is the first time Abigail is receiving care for this
event, leading you to confirm this code:
T55.1x1A Toxic effect of detergents, accidental (unintentional), initial encounter
Good job! 

Substance Interactions
When the cause of the poisoning or toxic effect is the interaction between two sub-
stances (e.g., drugs and alcohol), then you will need to report both substances involved.
You will need one poisoning code for each substance causing the reaction, as well as
one or more codes to accurately report the effect of the interaction.
Interactions can occur between two or more drugs, drugs and alcohol or other
drinks, drugs and food, or many other combinations. For example, you might notice
a warning “Don’t take this drug with milk or other dairy products.” This is a warn-
ing provided to prevent an interaction—the mixture of two or more substances that
changes the effect of any of the individual substances.

ICD-10-CM
LET’S CODE IT! SCENARIO
Meryl Brighton was prescribed Zyprexa (olanzapine), a psychotropic, by her psychiatrist, Dr. Cauldwell, for treatment
of her bipolar disorder. Meryl mentioned that her family doctor, Dr. Wall, had her on Norvasc (amlodipine), an anti-
hypertensive, for her high blood pressure. Dr. Cauldwell told Meryl to stop taking the Norvasc while on the Zyprexa.
Meryl forgot and took both medicines at the same time. Meryl suffered a dangerous case of severe hypotension and
was rushed to the ED by ambulance.
(continued)

CHAPTER 16  | 
 Let’s Code It!
Meryl was diagnosed with severe hypotension as a result of taking both Zyprexa and Norvasc. She was told not
to take both medications, but she forgot and took them both anyway. This means that this was an accidental
drug interaction.
First, you will need to determine the codes for the substances and intent. Open your ICD-10-CM code book
to the Table of Drugs and Chemicals and look for
Zyprexa
Move across the row to find the suggested code in the first column for Poisoning, Accidental (Unintentional) . . .
T43.591
Turn in the Tabular List to code category 
T43 Poisoning by, adverse effect of and underdosing of psychotropic drugs, not elsewhere
classified
Carefully read the and notes. Do they have any connection to Meryl’s diagnosis? Not this
time, so read down and review all of the fourth-character options.
T43.5 Poisoning by, adverse effect of and underdosing of other and unspecified antipsychot-
ics and neuroleptics
Carefully read the note. Meryl did not become poisoned by rauwolfia, so continue reading to find the
appropriate fifth character.
T43.59 Poisoning by, adverse effect of and underdosing of other antipsychotics and
neuroleptics
Next, find the appropriate sixth character for Meryl’s accidental ingestion of Zyprexa.
T43.591 Poisoning by, adverse effect of and underdosing of other antipsychotics and neurolep-
tics, accidental (unintentional)
Almost done; find the appropriate seventh character. You will find the box with the options at the top of this sub-
section, right under the T43 code.
T43.591A Poisoning by, adverse effect of and underdosing of other antipsychotics and neuroleptics,
accidental (unintentional), initial encounter
Good job! Now, you need to go back to the Table of Drugs and Chemicals, and look for
Norvasc
It is not listed. So, use a PDR (Physicians’ Desk Reference) or the website [www.pdr.net] and learn that the
generic name for Norvasc is amlodipine besylate and it is an antihypertensive.
Antihypertensive drug NEC
Move across the row to find the suggested code in the first column for Poisoning, Accidental (Unintentional) . . . T46.5x1
Turn in the Tabular List to code category 
T46 Poisoning by, adverse effect of and underdosing of agents primarily affecting the cardio-
vascular system
Carefully read the note. Meryl did not become poisoned by metaraminol, so continue reading to find
the appropriate fourth character.
T46.5 Poisoning by, adverse effect of and underdosing of other antihypertensive drugs
Carefully read the  notes. Meryl did not become poisoned by any of these, so continue reading to find
the appropriate fifth character.

T46.5x Poisoning by, adverse effect of and underdosing of other antihypertensive drugs

448   PART II  |  REPORTING DIAGNOSES

 Next, find the appropriate sixth character for Meryl’s accidental ingestion of Norvasc.
T46.5x1 Poisoning by, adverse effect of and underdosing of other antihypertensive drugs
accidental (unintentional)
Almost done, find the appropriate seventh character. You will find the box with the options at the top of this sub-
section, right under the T46 code.
T46.5x1A Poisoning by, adverse effect of and underdosing of other antihypertensive drugs ac-
cidental (unintentional), initial encounter
Good job! One more code to go. You need to report the effect that this interaction had on Meryl. Turn to the
Alphabetic Index and find:
Hypotention (arterial) (constitutional) I95.9
with a list indented beneath. Stop and review the scenario again. What exactly caused Meryl’s hypotension? The
interaction of the two drugs. Therefore, it was drug-induced. Read down and find
Hypotention (arterial) (constitutional) I95.9
  drug-induced I95.2
Turn to the Tabular List, and begin at the code category . . .
I95 Hypotension
Carefully read the note. None of these apply to this encounter with Meryl, so continue reading to find
the appropriate fourth character.
I95.2 Hypotension due to drugs
Use additional code for adverse effect, if applicable, to identify drug (T36-T50 with fifth or
sixth character 5)
Does this turn your sequencing upside down? No. Read this carefully. In this case, for Meryl’s current issue, she
did not have an adverse effect. It was a poisoning. Great!
Now you can report, with confidence . . .
T43.591A Poisoning by, adverse effect of and underdosing of other antipsychotics and neurolep-
tics, accidental (unintentional), initial encounter
T46.5x1A Poisoning by, adverse effect of and underdosing of other antihypertensive drugs ac-
cidental (unintentional), initial encounter
I95.2 Hypotension due to drugs
Good coding!

YOU INTERPRET IT!

Identify if this is an accidental poisoning, an adverse effect, a suicide attempt, or an assault.

1. The EMTs brought Katherine into the ER. Her roommate found her unconscious
with an empty pill bottle by her side, along with a suicide note.
2. Harrison rushed his 3-year-old son into the ER. He had found him sitting on the
bathroom floor with his bottle of Synthroid, half empty.
3. Roger picked up his new prescription at the drug store. Within 30 minutes of
taking the first tablet, he began to break out in a rash.
4. Ellen was brought into the Urgent Care late one night by her friends. They were
out at a club and she suddenly lost consciousness. The blood tests showed that
someone at the club had put something in her drink.

CHAPTER 16  | 
 16.6  Reporting Burns
A patient can sustain a burn or corrosion to any part of the body in many different
ways. It can be the result of the skin coming near to or in actual contact with a flame,
such as a candle or the flame on a gas stove. A burn can happen when contact is made
with a hot object, such as a hot plate or curling iron. Chemicals, such as lye or acid,
can cause a corrosion upon contact with a person’s skin. As a professional coding spe-
CODING BITES cialist, you may need to code the diagnosis of a burn or corrosion.
When a patient has suffered a burn, virtually every case will require multiple codes to
A burn is caused by tell the whole story. So, we came up with a memory tip to help you remember the details
fire or heat, while a cor- you need, the minimum number of codes you need, and the sequencing of (the order in
rosion is caused by a which to report) the codes. To report these diagnoses correctly, you have to S/S.E.E. the
chemical. burn. You need at least three codes to properly report the diagnosis of a burn:
First-listed code(s): S/S = site and severity (from categories T20–T25)
Next-listed code: E = extent (from code category T31)
GUIDANCE Last-listed code(s): E = external cause code(s)
CONNECTION
Let’s look at these components and what they mean.
Read the ICD-10-CM
Official Guidelines for Site and Severity
Coding and Reporting,
section I. Conven- Site
tions, General Coding Your first-listed code or codes will be combination codes that report both the site and
Guidelines and Chapter severity of the injury. Site refers to the anatomical site that is affected by the burn.
Specific Guidelines, When you look at the descriptions for the codes in range T20–T28, you see that each
subsection C. Chapter- code category is first defined by a general part or section of the human body:
Specific Coding Guide-
T20 Burn and corrosion of head, face, and neck
lines, chapter 19. Injury,
T21 Burn and corrosion of trunk
poisoning, and certain
T22 Burn and corrosion of shoulder and upper limb, except wrist and hand
other consequences of
T23 Burn and corrosion of wrist and hand
external causes, sub-
T24 Burn and corrosion of lower limb, except ankle and foot
section d. Coding of
T25 Burn and corrosion of ankle and foot
Burns and Corrosions.
T26 Burn and corrosion confined to eye and adnexa
T27 Burn and corrosion of respiratory tract
T28 Burn and corrosion of other internal organs
GUIDANCE
CONNECTION EXAMPLE
Read the ICD-10-CM Offi- Hope Rockfield suffered a burn to her left knee. Lower limb is the general ana-
cial Guidelines for Coding tomical site, and knee is the specific site of the burn.
and Reporting, section
I. Conventions, General
Coding Guidelines and Severity
Chapter Specific Guide- The fourth character for each category (except categories T26–T28) identifies the severity.
lines, subsection C. Using the layers of the skin, the severity of a burn is identified by degree (see Figure 16-4):
Chapter-Specific Cod-
∙ First-degree burns are evident by erythema (redness of the epidural layer).
ing Guidelines, chapter
19. Injury, poisoning, ∙ Second-degree burns are identified by fluid-filled blisters in addition to the
and certain other con- erythema.
sequences of external ∙ Third-degree burns have damage evident in the epidermis, dermis, and fatty tis-
causes, subsections sue layers and can involve the muscles and nerves below.
d.2) Burns of the same ∙ Deep third-degree burned skin will show necrosis (death of the tissue) and at times
local site and d.5) Assign may result in the loss (amputation) of a body part.
separate codes for each
burn site. The fourth characters available in this section give you the ability to report the
documented severity of the burn or corrosion:

450   PART II  |  REPORTING DIAGNOSES

 Capillary Sweat pore
Burn
Injury by heat or fire.

Epidermis Dermis Subcutaneous

Corrosion
Superficial
A burn caused by a chemical;
(first-degree) burn Nerve endings chemical destruction of the
(epidermis damaged) Sebaceous (oil) skin.
Partial-thickness gland
Site
(second-degree) burn Hair follicle The specific anatomical loca-
(epidermis and part of
tion of the disease or injury.
dermis destroyed) Sweat gland
Fat Severity
Full-thickness
(third-degree) burn The level of seriousness.
Blood vessels
(all layers of skin
destroyed) First-Degree Burn
Redness of the epidermis
FIGURE 16-4  An illustration identifying the impact on the layers of skin for the dif- (skin).
ferent degrees of burns
Second-Degree Burn
.0 Unspecified degree Blisters on the skin; involve-
.1 Erythema (first degree) ment of the epidermis and the
.2 Blisters, epidermal loss (second degree) dermis layers.
.3 Full-thickness skin loss (third degree NOS) Third-Degree Burn
.4 Corrosion of unspecified degree Destruction of all layers of the
.5 Corrosion of first degree skin, with possible involve-
.6 Corrosion of second degree ment of the subcutaneous fat,
.7 Corrosion of the third degree muscle, and bone.

Specific Site
The fifth character gives you the opportunity to report additional details regarding the CODING BITES
anatomical site of the burn. Of course, these details will change in accordance with The code descriptions
the anatomical region of the code category. Let’s take a look at samples from code in this section all include
category T23 Burn and corrosion of wrist and hand: both the medical terms
T23.-1 Burn . . . of thumb (nail) (such as blisters) and
T23.-2 Burn . . . of single finger (nail) except thumb the degree (such as
T23.-3 Burn . . . of multiple fingers (nail), not including thumb second degree), so you
T23.-4 Burn . . . of multiple fingers (nail), including thumb can match either to the
T23.-5 Burn . . . of palm documentation.
T23.-6 Burn . . . of back of hand
T23.-7 Burn . . . of wrist
T23.-9 Burn . . . of multiple sites of wrist and hand CODING BITES
The description of the
EXAMPLE fifth character 0 (zero)
Troy was talking to his buddy and stepped back, hitting the back of his right calf on states “unspecified site.”
the hot tailpipe of his motorcycle. The doctor at the emergency room documented Use this character very,
second-degree burns. very rarely. Think about
it: How can a physi-
The first three characters = T24 Burn and corrosion of lower limb, except
cian diagnose and treat
ankle and foot.
a burn and not know
The fourth character = T24.2 Burn of second degree of lower limb, except
exactly where it is?
ankle and foot.
The fifth character = T24.23 Burn of second degree of lower leg.
The sixth character = T24.231 Burn of second degree of right lower leg.
The seventh character = T24.231A Burn of second degree of right lower leg,
initial encounter.
And there you have the complete code to report Troy’s injury. Of course, as you
remember, you will also need to report an external cause code to explain how
Troy’s leg became burned.

CHAPTER 16  | 
 ICD-10-CM
LET’S CODE IT! SCENARIO
Anthony, a 15-year-old male, was working on a school project in the basement and accidentally released the hot
glue gun onto the palm of his left hand. Dr. Clermont treated him for third-degree burns of the palm of his hand.

Let’s Code It!

Anthony was diagnosed with third-degree burns of the palm. Let’s turn to the Alphabetic Index and look up burns:
Burn
  palm(s) T23.059
Turn to the Tabular List, and read
T23 Burn and corrosion of wrist and hand
Notice the available seventh-character options listed directly beneath this code. You will need that information
later. First, you need to determine the other characters, so read through your choices for the fourth character:
T23.3 Burn of third degree of wrist and hand
That is much more specific and accurate. Now you have to review the fifth-character choices for code T23.3. Did
you notice that there is a character to specify that the burn was on his palm?
T23.35 Burn of third degree of palm
The choices for the sixth character clearly identify which palm:
T23.352 Burn of third degree of left palm
One more character—remember, the options for the seventh character for this code are shown directly beneath
the three-character code category. Is this the first time Dr. Clermont is seeing Anthony for this burn? Yes.
T23.352A Burn of third degree of left palm, initial encounter
This code tells the complete story, doesn’t it? Of course, you will need to also report the external cause code.

Multiple Sites Fall into the Same Code Category

When various sites fall into the same code category (the first three characters of the
code), you will report all of these sites with just one code. If the burns are of differ-
ent severity, use the fourth character that reports the most severe burn (determined by
severity), the highest degree.
Then identify that more than one specific site has been burned by using the fifth
character that reports “multiple sites,” such as T25.19- Burn of first degree of multiple
sites of ankle and foot.

ICD-10-CM
LET’S CODE IT! SCENARIO
Damien Connell opened the cover of the bar-b-que to see how the coals were doing. He decided to add some
lighter fluid to hurry it along, and the flames roared up into his face. Gina, his wife, rushed him to the emergency
department. After an exam, Dr. Hawks diagnosed Damien with a third-degree burn on his chin and second-degree
burns on his nose and cheek.

Let’s Code It!

Let’s begin by abstracting Damien’s condition. He has
Third degree burn on his chin
Second degree burn on his nose
Second degree burn on his cheek

452   PART II  |  REPORTING DIAGNOSES

 In the Alphabetic Index, turn to the term burn. You will notice that the long, long list of terms indented beneath
this main term all identify anatomical sites, the location on the body that has been burned. Find the suggested
codes for all three of Damien’s burns:
Burn, chin, third-degree T20.33
Burn, nose, second-degree T20.24
Burn, cheek, second-degree T20.26
Notice that the code category T20 is the same for all three sites: chin, nose, and cheek. Therefore, you use only
one code to report these burn sites. Turn to code T20 in the Tabular List:
T20 Burn and corrosion of head, face, and neck
Read carefully the listed diagnoses. None of them apply to Damien’s condition. Remember that your
seventh-character options are listed here as well, for later.
Go ahead and read down the column to review all of the choices for the required fourth character. Now you
need to determine which fourth character to use. The burn on his chin is a third-degree burn (fourth character 3),
but the burns on his nose and cheek are only second-degree burns (fourth character 2). Should you report both?
The guidelines direct you to report only one code, with the fourth character that reports the most severe of all
the burns, so you need to use the fourth character of 3:
T20.3 Burn of third degree of head, face, and neck
Notice that the Use additional external cause code notation is here to remind you that you need to do this next,
after you determine all of the appropriate codes to report the injury itself.
Review the fifth-character options in this subcategory:
The fifth character 3 reports his chin was burned.
The fifth character 4 reports his nose was burned.
The fifth character 6 reports his cheek was burned.
Again, the guidelines tell you that you must combine all of these into one accurate code. Take a look at the fifth
character 9, which reports multiple sites of face, head, and neck. Perfect!
Put it all together and get the most accurate code that tells the whole story:
T20.39- Burn of third degree of multiple sites of head, face, and neck
Look back up to the beginning of the code category to review your options for the seventh character. This is the
first time Dr. Hawks is caring for Damien’s burns. Now you have the complete code to report:
T20.39xA Burn of third degree of multiple sites of head, face, and neck, initial encounter
Excellent!

Extent
The next code you have to report indicates the extent, or percentage, of the body Extent
involved. The three-character category for reporting the extent of a burn is T31 and the The percentage of the body
extent of a corrosion is T32. Either of these codes requires a total of five characters to that has been affected by the
be valid, no matter what the extent of the burn or corrosion. burn or corrosion.

T31 Burns classified according to extent of body surface involved

T32 Corrosions classified according to extent of body surface involved
Turn to code T31 in the Tabular List. The required fourth character will identify
the percentage of the patient’s entire body that is affected by any and all burns, of all
degrees (severity). The code descriptions refer to this as percentage of body surface,
also known as total body surface area (TBSA).
The physician may specify the percentages directly in his or her notes. A statement
like “third-degree burns over 10% of the body” or “7% of the body burned” will give

CHAPTER 16  | 
 GUIDANCE 41/2% 41/2%
head and neck posterior trunk
CONNECTION 9% and buttocks
anterior trunk 18%
Read the ICD-10-CM 18%
Official Guidelines for
Coding and Reporting,
arms, hands,
section I. Conven- and shoulders
tions, General Coding 18% 18% 18%
Guidelines and Chapter
41/2% 41/2% 41/2% 41/2%
Specific Guidelines,
subsection C. Chapter-
Specific Coding Guide-
lines, chapter 19. Injury, 9% 9% 9% 9%
poisoning, and certain genitals
other consequences of 1%
anterior posterior
external causes, sub- legs and feet
legs and feet
section d.6) Burns and 18% 18%
Corrosions Classified
According to Extent of
Body Surface Involved.

Anterior Posterior

FIGURE 16-5  An illustration identifying the rule of nines, which can be used to
estimate the extent of burns

you the information you need to find the correct fourth character for code T31 or T32.
However, other times, the physician may not use a number, and you will have to calcu-
Rule of Nines late the percentage yourself. To calculate, you can use the rule of nines.
A general division of the whole The rule of nines is used to estimate the total body surface area that has been
body into sections that each affected by the burns. The body is divided into sections, each section representing 9%
represents 9%; used for esti- of the human body (see Figure 16-5):
mating the extent of a burn.
Head and neck 9%
Arm, right 9%
GUIDANCE Arm, left 9%
CONNECTION Chest 9%
Abdomen 9%
Read the ICD-10-CM
Official Guidelines for Upper back 9%
Coding and Reporting, Lower back 9%
section I. Conven- Leg, right, anterior (front) 9%
tions, General Coding
Leg, right, posterior (back) 9%
Guidelines and Chapter
Specific Guidelines, Leg, left, anterior (front) 9%
subsection C. Chapter- Leg, left, posterior (back) 9%
Specific Coding Guide- Genitalia 1%
lines, chapter 19. Injury,
poisoning, and certain As you read through the physician’s notes, be aware of the anatomical site, not only
other consequences of for your site code but also for your calculation of the extent of the body involved in
external causes, sub- the burns.
section d.1) Sequenc- Next, you must determine the most accurate fifth character for this code. The fifth
ing of burn and related character identifies the percentage of the patient’s body that is suffering with third-
condition codes. degree burns only. You can also use the rule of nines to calculate the percentage of
area affected by third-degree burns to find the best fifth character.

454   PART II  |  REPORTING DIAGNOSES

 Of course, these percentages are general—to be used for estimation purposes. As
you look at the code descriptions for the fourth and the fifth characters, you will see
that the choices for codes T31 and T32 all have descriptors that require you to know
the percentage of the body involved only within a 10% range. Therefore, you don’t
have to worry too much about narrowing down the number.
When you are determining the fourth and fifth characters for code T31 or T32, you
may have to add the percentages for several anatomical sites together.
While everyone knows that the rule of nines provides an estimate and is not expected
to be precise, it is a professional coder’s job to be as specific as possible. Therefore,
you want to adjust the percentage as appropriate.

EXAMPLE
Celia suffered third-degree burns on her lower back and the back of her left leg
and second-degree burns on her anterior forearm, wrist, and hand:
Lower back (9%) + left leg, back (9%) + anterior forearm (2%) + wrist and
hand (1%) = total body surface (21%)
T31.2 Burns involving 20%–29% of body surface
Only her back and leg had third-degree burns:
Lower back (9%) + left leg, back (9%) = 18%
T31.21 Burns involving 20%–29% of body surface with 10–19% third-
degree burns

ICD-10-CM
LET’S CODE IT! SCENARIO
Eli Glosyck, a 28-year-old male, was trying to start a campfire when the flames flared and burned him on the back
of his right hand, right forearm, and right elbow. He was rushed to the emergency room, where Dr. Compton deter-
mined that he had third-degree burns on his hand and forearm and second-degree burns on his elbow.

Let’s Code It!

Dr. Compton diagnosed Eli with third-degree burns on his hand and forearm and second-degree burns on his
elbow. Go to the Alphabetic Index and look up burn, hand. Find that listing and the others:
Burn, hand, third-degree T23.309
Burn, forearm, third-degree T22.319
Burn, elbow, second-degree T22.229
Does the Tabular List confirm the codes? Let’s check each one:
T23 Burn and corrosion of wrist and hand
You can see that a fourth character is required, so read down the column to
T23.3 Burn of third degree of wrist and hand
The burns on Eli’s hand were documented as third-degree, so that is correct. Now you need to determine the
required fifth and sixth characters. Read all of the choices and determine which is the most accurate.
T23.36 Burn of third degree of back of hand
  T23.361- Burn of third degree of back of right hand
Don’t forget the seventh character. The options are at the beginning of this code category.

(continued)

CHAPTER 16  | 
 T23.361A Burn of third degree of back of right hand, initial encounter
This code tells the whole story about the burn to Eli’s hand. Now look at the other codes suggested by the Alpha-
betic Index:
Burn, forearm, third degree T22.319
Burn, elbow, second-degree T22.229
Did you notice that both of these burns are reported using the same three-character code category, T22?
T22 Burn and corrosion of shoulder and upper limb, except wrist and hand
You have two codes with the same three-character code category. The guidelines state that you must combine
these into one code, T22, but which fourth character should you use? Remember, the guidelines also direct you
to use the character that reports the greatest severity (the highest degree) of the burn. Third degree is more
severe than second degree, so you will use
T22.3 Burn of third-degree of shoulder and upper limb, except wrist and hand
Read the fifth-character choices for this code category. Which one code can report the burn to both Eli’s forearm
and his elbow?
T22.39 Burn of third-degree of multiple sites of shoulder and upper limb, except wrist and hand
The sixth character will report which forearm and elbow were burned:
T22.391 Burn of third-degree of multiple sites of right shoulder and upper limb, except wrist
and hand
And the seventh character will report which encounter this is:
T22.391A Burn of third-degree of multiple sites of right shoulder and upper limb, except wrist
and hand, initial encounter
Good! Next, you need a code to report the extent of the burns. Eli was burned on the following sites:
Hand (part of the arm), 9%
Forearm (part of the same arm), 9%
Elbow (also part of the same arm), 9%
The rule of nines states that one arm represents 9%. Eli had burns on his hand, forearm, and elbow of the same
arm. You can see that it would not make sense to add 9% for each of these injuries, as it is still only one arm, so
you get a TBSA of 9%. Of this 9%, you must note that only an estimated 4% of his body (his hand and forearm)
suffered third-degree burns. Therefore, the next code on Eli’s chart will be:
T31.0 Burns involving less than 10% of body surface
The codes you have for Eli’s burns are T23.361A, T22.391A, and T31.10 (plus the external cause codes, of course!).
Good work!

GUIDANCE
CONNECTION
Read the ICD-10-CM
Official Guidelines for Infection in the Burn Site
Coding and Reporting,
section I. C. 19. Injury, If not treated properly, a burn site can become infected. This can happen because
poisoning, and certain the inner layers of the tissue are exposed, and it might be difficult to keep the
other consequences of wound clean and sterile. If an infection occurs, you should add a code for the spe-
external causes, subsec- cific pathogen. Sequence the infection code after the burn code but before the T31
tion d.4) Infected Burn. or T32 code.

456   PART II  |  REPORTING DIAGNOSES

Solar and Radiation Burns GUIDANCE
When a patient has been burned not by fire or chemicals but by some kind of radia- CONNECTION
tion, the injuries are not reported with codes from the T20–T28 range.
Even with all the ads promoting sunblock lotions and ointments to protect the Read the ICD-10-CM
skin, individuals still manage to get sunburns. These burns are also identified in three Official Guidelines for
degrees to report damage to the skin as a result of overexposure to the natural sun, and Coding and Report-
each degree has its own code: ing, section I. Conven-
tions, General Coding
L55.0 Sunburn of first degree Guidelines and Chapter
L55.1 Sunburn of second degree Specific Guidelines,
L55.2 Sunburn of third degree subsection C. Chapter-
Some individuals have a hypersensitivity to the sun, similar to an allergic reaction. Specific Coding Guide-
Actually, this can be diagnosed as a photoallergic or a phototoxic response to the sun. lines, chapter 19. Injury,
This type of severe reaction can be determined to be an effect of solar radiation and is poisoning, and certain
reported with one of the following codes: other consequences of
external causes, sub-
L56.0 Drug phototoxic response sections d.7) Encoun-
L56.1 Drug photoallergic response ters for treatment of
L56.2 Photocontact dermatitis (berloque dermatitis) late effects of burns and
L56.3 Solar urticaria d.8) Sequelae with a
In addition to physiological sensitivity to the sun, certain medications can cause a late effect code and cur-
patient to develop a sensitivity to the sun. When this is the case, you will need to add rent burn.
an external cause code to report the specific drug that caused this situation.
Abuse
Sequelae (Late Effects) of Burns and Corrosions This term is used in different
manners: (a) extreme use of
Often, a scar or contracture develops at the site of a healed burn or corrosion. There a drug or chemical; (b) violent
are times when this lasting condition requires treatment or a procedure. In these cases, and/or inappropriate treat-
you will report the original burn or corrosion code using the seventh character “S,” ment of another person (child,
for sequela, to identify that the care and treatment are directed at the late effect of the adult, elder).
burn or corrosion.
GUIDANCE
CONNECTION
16.7  Abuse, Neglect, and Maltreatment
Read the ICD-10-CM
Some people treat other people terribly. Such treatment may be physical or sexual Official Guidelines for
abuse, neglect, or abandonment. Often, people consider unacceptable behavior as Coding and Reporting,
being directed toward a child, yet adults also are abused, neglected, and maltreated. section I. Conven-
As our elder population increases, these adults are also vulnerable and need health tions, General Coding
care professionals to watch out for them and protect them. Guidelines and Chapter
T74- Adult and child abuse, neglect, and other maltreatment, confirmed Specific Guidelines,
T76- Adult and child abuse, neglect, and other maltreatment, suspected subsection C. Chapter-
O9A.3- Physical abuse complicating pregnancy, childbirth and the Specific Coding Guide-
puerperium lines, chapter 19. Injury,
O9A.4- Sexual abuse complicating pregnancy, childbirth and the puerperium poisoning, and certain
O9A.5- Psychological abuse complicating pregnancy, childbirth and the other consequences of
puerperium external causes, sub-
Z04.4- Encounter for examination and observation following alleged rape section f. Adult and
Z04.7- Encounter for examination and observation following alleged physi- child abuse, neglect
cal abuse and other maltreat-
ment, and chapter
The difference between categories T74 and T76 is important and is determined 20. External Causes
by the documentation: category T74 reports that the physician knows (confirms) of Morbidity, subsec-
this situation; category T76 records a suspicion. You know that suspected condi- tion g. Child and Adult
tions are generally not coded and reported. However, most states require health care Abuse Guidelines.

CHAPTER 16  | 
 professionals to report any instances of abuse or neglect, even if it is just a suspicion
at this point.
When applicable, the code from T74 or T76 should be the first-listed or principal
diagnosis, followed by the injury code and/or mental health code. For cases in which
the circumstances have been confirmed, a code to report the specific cause of the
injury should be included, most often from code range X92–Y08. In any case of abuse,
neglect, or maltreatment, if the perpetrator is known, an additional code from category
Y07 should be included.

ICD-10-CM
YOU CODE IT! CASE STUDY
Judah Messner, a 5-month-old male, was brought into the ED with third-degree burns on all five fingers of his left
hand and both second-degree and third-degree burns on the back of his left hand. His aunt brought him in after
visiting the home and seeing her sister’s boyfriend stick the baby’s hand into a pot of boiling water on the stove.
She states she quickly grabbed the baby from this man and rushed him here. She stated that she did not want to
risk staying on the premises awaiting the ambulance. When asked about the baby’s mother, the aunt stated she
just stood there, crying, and did not come with the child. The child was taken into treatment and the police were
notified.

You Code It!

Read this scenario, and determine the correct codes to report Judah’s injuries.
Step #1: Read the case carefully and completely.
Step #2: Abstract the scenario. Which main words or terms describe why the physician cared for the patient
during this encounter?
Step #3: Are there any details missing or incomplete for which you would need to query the physician? [If so,
ask your instructor.]
Step #4: Check for any relevant guidance, including reading all of the symbols and notations in the Tabular List
and the appropriate sections of the Official Guidelines.
Step #5: Determine the correct diagnosis code or codes to explain why this encounter was medically necessary.
Step #6: Double-check your work.
Answer:

Did you determine these to be the codes?

T23.342A Burn of third degree of multiple left fingers (nail), including thumb, initial
encounter
T23.362A Burn of third degree of back of left hand, initial encounter
T74.12xA Child physical abuse, confirmed, initial encounter
X12.xxxA Contact with other hot fluids, initial encounter

16.8  Complications of Care 

Even though medical procedures and the standards of care are heavily researched
and tested, things can go wrong. Complications can occur for any number of rea-
sons. Before a condition can be coded as a “complication of care,” the documenta-
tion must specifically identify the cause-and-effect relationship between the health
care procedure, service, or treatment and the current condition that is noted as a
complication.

458   PART II  |  REPORTING DIAGNOSES

 Pain caused by medical devices and grafts previously implanted is reported
with a code from categories T80–T88 (such as T82.847A Pain from cardiac pros- GUIDANCE
thetic devices, implants and grafts, initial encounter), along with either code G89.18 CONNECTION
Other acute postprocedural pain  or G89.28 Other chronic postprocedural pain, as
Read the ICD-10-CM
appropriate. Official Guidelines for
As you might imagine, transplanting an organ from one individual to another is a Coding and Reporting,
complex surgical accomplishment and saves thousands of lives. When a complication section I. Conven-
of the transplantation has been documented, a code from category T86 Complications tions, General Coding
of transplanted organs and tissue should be reported, followed by a second code to
Guidelines and Chapter
specify the complication itself. Specific Guidelines,
Not all intraprocedural or postprocedural complications are reported from code cat- subsection B.16. Docu-
egories T80–T88. They may be reported with codes from any chapter of the code set. mentation of Complica-
The Alphabetic Index will guide you. tions of Care, as well as
subsection C. Chapter-
Specific Coding Guide-
lines, chapter 19. Injury,
EXAMPLES poisoning, and certain
J95.2 Acute pulmonary insufficiency following non-thoracic other consequences of
surgery external causes, sub-
K91.840 Postprocedural hemorrhage of a digestive system organ or section g. Complica-
structure following a digestive system procedure tions of care.

ICD-10-CM
YOU CODE IT! CASE STUDY
Dr. Prentiss ordered 1 pint of A+ to be transfused into Sami Yariz in the postoperative area. The nurse was in a hurry
and did not read carefully when she grabbed the blood and hung it on the IV pole. A few hours later, the patient
began to complain of feeling very hot (temperature of 103 F) and pain in his back. At that time, one of the assistants
noticed that the patient was given AB+ blood. The patient was treated immediately for ABO incompatibility. Hemo-
lytic transfusion reaction was confirmed.

You Code It!

Review this scenario, and determine the correct ICD-10-CM code or codes to report.
Step #1: Read the case carefully and completely.
Step #2: Abstract the scenario. Which main words or terms describe why the physician cared for the patient
during this encounter? 
Step #3: Are there any details missing or incomplete for which you would need to query the physician? [If so,
ask your instructor.]
Step #4: Check for any relevant guidance, including reading all of the symbols and notations in the Tabular List
and the appropriate sections of the Official Guidelines.
Step #5: Determine the correct diagnosis code or codes to explain why this encounter was medically necessary.
Step #6: Double-check your work.
Answer:

Did you determine this to be the correct code?

T80.310A ABO incompatibility with acute hemolytic transfusion reaction, initial encounter

CHAPTER 16  | 
 Chapter Summary
CHAPTER 16 REVIEW

People injure themselves in many different ways under many different circumstances,
or others may harm someone—by accident or on purpose. Some patients may try to
hurt themselves. Whether a fractured bone, a third-degree burn, a pulled muscle, or an
adverse effect of a medication, when something like this happens, those of us working
in health care help them.
As professional coding specialists, you must remember that, in these situations, you
not only need to determine the code or codes to explain why the patient needs health
care services, you also must explain how the patient got hurt and where the injury
occurred. 

CODING BITES
External cause codes explain
• Cause of the injury, such as a car accident or a fall off a ladder.
• Place of the occurrence, such as the park or the kitchen.
• Activity during the occurrence, such as playing basketball or gardening.
• Patient’s status, such as paid employment, on-duty military, or leisure activity.

You Interpret It! Answers

1. Attempted suicide, 2. Accidental poisoning, 3. Adverse effect, 4. Assault

CHAPTER 16 REVIEW
Coding Injury, Poisoning, Enhance your learning by
completing these exercises and
more at connect.mheducation.com!

and External Causes

Let’s Check It! Terminology
Match each key term to the appropriate definition.

Part I
1. LO 16.2  Layers of skin traumatically torn away from the body. A. Avulsion
2. LO 16.5  Redness of the epidermis (skin). B. Burn
3. LO 16.5  A burn caused by a chemical;chemical destruction of the skin.  C. Corrosion
4. LO 16.5  Destruction of all layers of the skin, with possible involvement of the D. First-Degree Burn
subcutaneous fat, muscle, and bone. E. Laceration
5. LO 16.5  Injury by heat or fire.  F. Rule of Nines
6. LO 16.5  The level of seriousness. G. Second-Degree Burn
7. LO 16.5  Blisters on the skin; involvement of the epidermis and the dermis H. Severity
layers.
I. Site
8. LO 16.5  A general division of the whole body portioned out to each represent
J. Third-Degree Burn
9%; used for estimating the extent of a burn.
9. LO 16.2  Damage to the epidermal and dermal layers of the skin made by a
sharp object.
10. LO 16.5  The location on or in the human body; the anatomical part of the body.

460   PART II  |  REPORTING DIAGNOSES

Part II

CHAPTER 16 REVIEW
1. LO 16.6  This term is used in different manners: (a) extreme use of a drug or A. Abuse 
chemical; (b) violent and/or inappropriate treatment of another person.  B. Dislocation 
2. LO 16.5  The percentage of the body that has been affected by the burn or C. Extent 
corrosion.
D. Fracture
3. LO 16.2  A fractured bone that did not heal correctly; healing of bone that was
E. Malunion
not in proper position or alignment.
F. Myalgia
4. LO 16.1  The displacement of a limb, bone, or organ from its customary
position. G. Nonunion
5. LO 16.2  Broken cartilage or bone. H. Physicians’ Desk Refer-
ence (PDR) 
6. LO 16.2  Pain in a muscle.
7. LO 16.3  A series of reference books identifying all aspects of prescription and
over-the-counter medications, as well as herbal remedies.
8. LO 16.2  A fractured bone that did not heal back together; no mending or joining
together of the broken segments.

Let’s Check It! Concepts

Choose the most appropriate answer for each of the following questions.
1. LO 16.1  Karen Graysen, a 31-year-old female, lives in a mobile home. This morning she was working in her gar-
den and was injured. What is the correct external cause code for the place of occurrence?
a. Y92.015 b.  Y92.046 c.  Y92.027 d.  Y92.096
2. LO 16.2  _____ fracture identifies the breaking of the bone into several pieces.
a. Burst b.  Depressed c.  Comminuted d.  Fatigue
3. LO 16.2  A bruise or black and blue mark is known as a(n)
a. contusion. b.  avulsion. c.  puncture. d.  bite.
4. LO 16.2  How would you code an avulsion of the left eye, initial encounter?
a. S05.02XA b.  S05.72XA c.  S05.52XA d.  S05.92XA
5. LO 16.3  Drugs and chemicals are listed in the Table of Drugs and Chemicals in all of these manners except
a. the brand name. b.  the chemical name.
c. the drug category. d.  the size of the dose.
6. LO 16.3  The Table of Drugs and Chemicals does not include a specific listing for
a. adhesives. b.  lettuce opium.
c. marsh gas. d.  vodka.
7. LO 16.4  The columns in the ICD-10-CM Table of Drugs and Chemicals include
a. Intentional Self-Harm. b.  Malignant.
c. Toxin. d.  Ca in situ.
8. LO 16.5  An example of a late effect of a burn is
a. malunion. b.  contracture.
c. infection. d.  epidermal loss.
9. LO 16.5  A third-degree burn of the chin, subsequent encounter, would be coded
a. T20.33XD b.  S01.411A
c. S00.83XD d.  T20.33XS

CHAPTER 16  | 
 10. LO 16.6  Jennie James, a 28-year-old female, is pregnant and in her third trimester. Jennie presents today with the
CHAPTER 16 REVIEW

complaint that her right forearm hurts. Upon examination, bruises are noted. When asked how she got
the bruises, Jennie stated that her husband came home upset and twisted her arm because dinner was not
ready. What is the correct code for the physical abuse complicating the pregnancy?
a. O9A.311 b.  O9A.312 c.  O9A.313 d.  O9A.319

Let’s Check It! Guidelines

Part I
Refer to the Official Guidelines and fill in the blanks according to the Chapter 19, Injury, poisoning, and certain other
consequences of external causes, Chapter-Specific Coding Guidelines.
aftercare highest active local
extent Superficial separate first
primary acute 7th T31
degree minor external severity
Z initial late subsequent
T31 “S”

1. Most categories in chapter 19 have a _____ character requirement for each applicable code.
2. The aftercare _____ codes should not be used for _____ for conditions such as injuries or poisonings, where 7th
characters are provided to identify _____ care.
3. _____ injuries such as abrasions or contusions are not coded when associated with more severe injuries of the
same site.
4. When a primary injury results in _____ damage to peripheral nerves or blood vessels, the _____ injury is
sequenced _____ with additional code(s) for injuries to nerves and spinal cord (such as category S04), and/or
injury to blood vessels (such as category S15).
5. Traumatic fractures are coded using the appropriate 7th character for _____ encounter (A, B, C) for each encoun-
ter where the patient is receiving _____ treatment for the fracture.
6. Multiple fractures are sequenced in accordance with the _____ of the fracture.
7. When the reason for the admission or encounter is for treatment of _____ multiple burns, sequence first the code
that reflects the burn of the _____ degree.
8. Classify burns of the same _____ site (three-character category level, T20-T28) but of different _____ to the sub-
category identifying the highest degree recorded in the diagnosis.
9. Non-healing burns are coded as _____ burns.
10. When coding burns, assign _____ codes for each burn site.
11. Assign codes from category _____, Burns classified according to extent of body surface involved, or _____, Cor-
rosions classified according to _____ of body surface involved, when the site of the burn is not specified or when
there is a need for additional data. 
12. Encounters for the treatment of the _____ effects of burns or corrosions (i.e., scars or joint contractures) should
be coded with a burn or corrosion code with the 7th character _____ for sequela.

Part II 
Refer to the Official Guidelines and fill in the blanks according to the Chapter 19, Injury, poisoning, and certain other
consequences of external causes, Chapter-Specific Coding Guidelines.
external adverse many assault properly sequelae
improper toxic current Underdosing  Z04.71 complication 
confirmed correctly individually suspected source T36-T50

462   PART II  |  REPORTING DIAGNOSES

 1. When appropriate, both a code for a _____ burn or corrosion with 7th character “A” or “D” and a burn or corro-

CHAPTER 16 REVIEW
sion code with 7th character “S” may be assigned on the same record (when both a current burn and _____ of an
old burn exist).
2. An _____ cause code should be used with burns and corrosions to identify the _____ and intent of the burn, as
well as the place where it occurred.
3. Use as _____ codes as necessary to describe completely all drugs, medicinal or biological substances.
4. If two or more drugs, medicinal or biological substances are reported, code each _____ unless a combination code
is listed in the Table of Drugs and Chemicals.
5. When coding an _____ effect of a drug that has been _____ prescribed and _____ administered, assign the appro-
priate code for the nature of the adverse effect followed by the appropriate code for the adverse effect of the drug
(T36-T50).
6. When coding a poisoning or reaction to the _____ use of a medication (e.g., overdose, wrong substance given or
taken in error, wrong route of administration), first assign the appropriate code from categories _____.
7. _____ refers to taking less of a medication than is prescribed by a provider or a manufacturer’s instruction.
8. When a harmful substance is ingested or comes in contact with a person, this is classified as a _____ effect.
9. For cases of _____ abuse or neglect an external cause code from the _____ section (X92-Y09) should be added to
identify the cause of any physical injuries.
10. If a _____ case of abuse, neglect, or mistreatment is ruled out during an encounter code _____, Encounter for exami-
nation and observation following alleged physical adult abuse, ruled out, or code Z04.72, Encounter for examination
and observation following alleged child physical abuse, ruled out, should be used, not a code from T76. 
11. Intraoperative and postprocedural _____ codes are found within the body system chapters with codes specific to
the organs and structures of that body system.

Part III
Refer to the Official Guidelines and fill in the blanks according to the Chapter 20, External Causes of Morbidity,
Chapter-Specific Coding Guidelines.
A00.0-T88.9  never Y92 encounter
secondary assault data Y38.9
Y93 “S” full initial
completely Y99 once status

1. External cause codes are intended to provide _____ for injury research and evaluation of injury prevention
strategies. 
2. An external cause code may be used with any code in the range of _____, Z00-Z99, classification that is a health
condition due to an external cause. 
3. Assign the external cause code, with the appropriate 7th character (initial encounter, subsequent encounter or
sequela) for each _____ for which the injury or condition is being treated. 
4. Use the _____ range of external cause codes to _____ describe the cause, the intent, the place of occurrence, and
if applicable, the activity of the patient at the time of the event, and the patient’s status, for all injuries, and other
health conditions due to an external cause.
5. An external cause code can _____ be a principal (first-listed) diagnosis.
6. Codes from category _____, Place of occurrence of the external cause, are secondary codes for use after other
external cause codes to identify the location of the patient at the time of injury or other condition. 
7. Generally, a place of occurrence code is assigned only _____, at the _____ encounter for treatment.
8. Assign a code from category _____, Activity code, to describe the activity of the patient at the time the injury or
other health condition occurred. 

CHAPTER 16  | 
 9. Adult and child abuse, neglect, and maltreatment are classified as _____. 
CHAPTER 16 REVIEW

10. Sequela are reported using the external cause code with the 7th character _____ for sequela. 
11. Assign code _____, Terrorism, _____ effects, for conditions occurring subsequent to the terrorist event. 
12. Assign a code from category _____, External cause status, to indicate the work _____ of the person at the time
the event occurred. 

Let’s Check It! Rules and Regulations

Please answer the following questions from the knowledge you have gained after reading this chapter.
1. LO 16.2  Explain the difference between a traumatic fracture and a pathologic fracture. Why is it important to
know the difference?
2. LO 16.5  What does the acronym S/S.E.E. mean in relation to a burn? What details does it help you remember?
3. LO 16.5  How do you identify the severity of burns? Include the description of each stage.
4. LO 16.6  Turn to the Official Guidelines for Chapter 19. Injury, poisoning, and certain other consequences of
external causes—I.C.19.f. Discuss adult and child abuse, neglect, and other maltreatment as outlined in
the Chapter 19 guidelines; include reference to Abuse in a pregnant patient.
5. LO 16.4  Explain patient noncompliance and the different codes that represent noncompliance.

ICD-10-CM
YOU CODE IT! Basics
First, identify the condition in the following diagnoses; 8. Second degree burn of the right axilla, initial
then code the diagnosis. encounter: 
Example: Abrasion of scalp, initial encounter: a. main term: _____ b. diagnosis: _____
9. Displaced shaft fracture of the left clavicle (trau-
a. main term: Abrasion b. diagnosis: S00.01XA
matic), subsequent encounter for fracture with
1. Underdosing of succinimides, initial encounter:  malunion: 
a. main term: _____ b. diagnosis: _____ a. main term: _____ b. diagnosis: _____
2. External constriction of left eyelid, initial 10. Concussion with loss of consciousness of
encounter:  35 minutes, initial encounter: 
a. main term: _____ b. diagnosis: _____ a. main term: _____ b. diagnosis: _____
3. Laceration without foreign body of nose, initial 11. Contusion of left ear, subsequent encounter: 
encounter  a. main term: _____ b. diagnosis: _____
a. main term: _____ b. diagnosis: _____ 12. Crushing injury of larynx: 
4. Open bite of left cheek, subsequent encounter:  a. main term: _____ b. diagnosis: _____
a. main term: _____ b. diagnosis: _____ 13. Corrosion of third degree of left shoulder, initial
5. Corrosion of trachea, sequela:  encounter: 
a. main term: _____ b. diagnosis: _____ a. main term: _____ b. diagnosis: _____
6. Toxic effect of ethanol, assault, subsequent 14. Adverse effect of antimycobacterial drugs,
encounter: combination:
a. main term: _____ b. diagnosis: _____ a. main term: _____ b. diagnosis: _____
7. Puncture wound with foreign body of scalp, initial 15. Pathological fracture of right tibia due to neoplas-
encounter:  tic disease, delayed healing: 
a. main term: _____ b. diagnosis: _____ a. main term: _____ b. diagnosis: _____

464   PART II  |  REPORTING DIAGNOSES

 CHAPTER 16 REVIEW
ICD-10-CM
YOU CODE IT! Practice
Using the techniques described in this chapter, carefully read through the case studies and determine the most
accurate ICD-10-CM code(s) and external cause code(s), if appropriate, for each case study.
1. Richard Pittmon, a 22-year-old male, was playing baseball with some friends at the local park and as he was
crossing home plate, he was struck on his right leg by the baseball. The ED physician, Dr. Bonneville, took
a history of the injury and completed an examination and the appropriate tests. Richard is diagnosed with an
open shaft fracture type I, oblique, of the tibia. 
2. Jamie McIntyre, a 43-year-old female, presents today with a painful blister on her right hand. Jamie is trying
to get in shape and has begun to play handball. Dr. Brown completes an examination and diagnoses Jamie
with a superficial blister on the palm of her hand between the third and fourth metacarpals. 
3. Billy Ugro, a 7-year-old male, was brought in by his mother. Billy was playing this afternoon in his back-
yard on the sliding board and fell, scraping his left cheek. Dr. Tucker, his pediatrician, examines the area and
cleans and dresses the wound. Billy is diagnosed with a second-degree abrasion. 
4. Janie Walters, a 27-year-old female, presents today with burns on her left hand. Over the weekend, Janie was
at a campout and while toasting marshmallows over a bonfire, got too close to the flame, burning her left
fingers. Dr. Platzs thoroughly examines Janie’s hand and fingers, noting redness with blisters on the second,
third, and fourth phalanges. Janie is diagnosed with second-degree burns of the fingers, multiple sites. 
5. Jerry Ard, a 31-year-old male, presents today with a cut to his thigh. Jerry was dressing a piece of venison
when the knife slipped and cut his left thigh accidentally. Dr. Phillips examines the incised wound and cleans
the area, then closes with sutures. Jerry is diagnosed with a laceration to the thigh. 
6. Grace Fuller, a 16-year-old female, was brought into the ED by her parents. They found Grace extremely
drowsy. Dr. Rowell, the ED physician, notes slow heart rate and breathing. Dr. Rowell also notes constricted
pupils. Grace’s parents state she has been diagnosed with bipolar depression and has been taking cyclazocine.
Grace is drowsy; however, she will not respond to Dr. Rowell. Dr. Rowell completes a thorough examination
with the appropriate laboratory tests, which confirm an overdose of cyclazocine. Grace is admitted to Weston
Hospital for a full workup. 
7. Patricia Neil, a 34-year-old female, presents today with a painful left foot. Patricia accidentally hit her foot
on a desk this morning and is concerned she might have broken it. Dr. Dickerson examines Patricia’s foot and
notes swelling and discoloration. Dr. Dickerson orders an x-ray, which confirms no fractures. Patricia is diag-
nosed with a contusion, bruise harm score 1. 
8. Michael George, a 28-year-old male, presents today with a wound to his lower right leg. Michael stated this morn-
ing at home he accidentally stepped on his cat’s tail and the cat bit him. The cat has been vaccinated for rabies.
Dr. Coleman examines, cleans, and dresses the area and prescribes a round of antibiotics as a precaution. 
9. Kim Horton, a 4-year-old female, is brought in today by her father. Kim was playing with her father’s pocket
change and swallowed a nickel. Dr. Grebner, her pediatrician, notes labored breathing and orders an x-ray,
which shows the nickel is lodged in the oropharynx. Dr. Grebner is able to remove the nickel without difficulty. 
10. Dean Williams, a 5-year-old male, is brought into the ED by ambulance. Dean’s grandmother stated he was
playing in the yard where she has ornamental plants. One plant has mezereon berries and the birds were eat-
ing them, so Dean ate one too. Dean began to have a choking sensation. Dr. Adams completes a thorough
examination and the laboratory results confirmed the diagnosis of accidental poisoning.
11. Annie Froster, an 8-year-old female, was brought in by her mother to see her pediatrician, Dr. Benton. Annie
has been having difficulty swallowing. After an examination and the appropriate tests, Dr. Lukenson diag-
noses Annie with a lye stricture of the esophagus. Annie admitted that her stepfather forced her to drink lye,
confirmed by local police. 
12. Carolina Tanner, an 18-year-old female, came into the emergency department with a wrist sprain where a
baseball had hit her. She is on her school baseball team and was at a practice game being played on the school

CHAPTER 16  | 
CHAPTER 16 REVIEW

baseball field and got hit by the ball. She was in obvious pain, and the wrist was swollen and too painful upon
attempts to flex. After Dr. Rodgers reviewed the x-ray Carolina is diagnosed with a Salter-Harris, type II frac-
ture of the distal radius, left. 
13. Tricia Thornwell, a 68-year-old female, was going walking when she fell down the icy front steps of her
house; now she can’t bear weight on her right leg. She is brought into the ER by ambulance. After the ER
physician completed a thorough exam and reviewed the x-ray, he diagnosed her with a femoral neck base
fracture, nondisplaced. 
14. Paula Caine, a 41-year-old female, was deep-frying fish and the kettle fell over and burned her right thigh.
Paula was rushed to the ER by her husband, where the ER physician, Dr. Dinkins, diagnosed her with a sec-
ond degree burn on her right thigh. Dr. Dinkins dressed the wounds and sent her to the burn unit. 
15. Helen Carrizo, an 18-year-old female, presents to the ED with a painful left ankle. Helen is accompanied by
her mother. Helen had been rollerblading and tripped, falling on the sidewalk. Helen is unable to flex her ankle,
which has begun to swell. Dr. Webber gathered a brief history of the incident that caused the injury, as well
as any history relating to her legs and feet. He then performed a limited examination of her left leg, ankle, and
foot. The imaging confirmed a sprained calcaneofibular ligament and a sprained anterior tibiofibular ligament. 

ICD-10-CM
YOU CODE IT! Application
The following exercises provide practice in abstracting physicians’ notes and learning to work with documenta-
tion from our health care facility, Prader, Bracker, & Associates. These case studies are modeled on real patient
encounters. Using the techniques described in this chapter, carefully read through the case studies and determine
the most accurate ICD-10-CM code(s) and external cause code(s), if appropriate, for each case study.

WESTON HOSPITAL 
629 Healthcare Way • SOMEWHERE, FL 32811 • 407-555-6541
PATIENT: TRUMAN, HERBERT
ACCOUNT/EHR #: TRUMHE001
DATE: 07/16/18
Attending Physician: Oscar R. Prader, MD
S: Pt is a 47-year-old male brought in by ambulance accompanied by his wife. Wife states he has been
confused, dizzy, and vomiting all morning.
O: Ht. 5′11″, Wt. 187 lb., R 16. During the physical examination, the patient has a dramatic drop in vital
sign measurements and suffers cardiac arrest. The crash team takes over and patient is successfully
resuscitated. Blood work reveals overdose of digoxin. After Pt is stabilized, he states he was rushing to
get to work this morning and couldn’t remember if he had taken his medication, so he took it again.
A: Cardiac arrest due to overdose of digoxin, accidental
P: Admit for stabilization
    Oxygenation
    Hydration IV fluids
    Monitor electrolyte balance

ORP/pw  D: 07/16/18 09:50:16  T: 07/17/18 12:55:01

Determine the most accurate ICD-10-CM code(s).

466   PART II  |  REPORTING DIAGNOSES

 CHAPTER 16 REVIEW
PRADER, BRACKER, & ASSOCIATES
A Complete Health Care Facility
159 Healthcare Way • SOMEWHERE, FL 32811 • 407-555-6789
PATIENT: JANKOWSKI, HILDA 
ACCOUNT/EHR #: JANKHI001
DATE: 07/16/18
Attending Physician: Renee O. Bracker, MD
S: Patient, a 9-year-old female, was brought in by her mother. She had just returned from a school hik-
ing trip when her parents noticed a problem with her right shoulder. The patient states that her shoulder
started bothering her early Sunday morning, but by the time she arrived home Sunday evening, it was
much worse. Her mother called a nurse hotline and the nurse suggested an anti-inflammatory, so the
parents gave her 250 mg of Tylenol.
The patient is right-handed and noticed, upon waking this morning, that she could not move her arm
without a great deal of pain and that her hand was tingling, particularly her fingers. She denies any fall
or accident during the trip.
O: Exam revealed some muscle wasting, observed around the right scapula. Movements of the elbow
and wrist were both within normal range. However, abduction of her right arm was difficult. She denies
being able to extend the arm without support, and she required movement of her entire upper arm to
accomplish abduction of this arm.
Additional specific history about activities during the trip revealed that throughout the weekend, she
carried a heavy backpack. The left strap had broken, so the entire weight was supported by her right
shoulder and arm, creating a traction-countertraction force centered on the axilla and neck area, which
produced a stretching force. She stated that each day she carried this on her right shoulder for as long
as 10 or 12 hours.
A: Dislocation of the inferior acromioclavicular joint
P: Sling
    Rest and Ice packs
    Rx: Nonsteroidal anti-inflammatory
ROB/pw  D: 07/16/18 09:50:16  T: 07/17/18 12:55:01

Determine the most accurate ICD-10-CM code(s).

PRADER, BRACKER, & ASSOCIATES

A Complete Health Care Facility
159 Healthcare Way • SOMEWHERE, FL 32811 • 407-555-6789
PATIENT: ZIMMER, CYRUS 
ACCOUNT/EHR #: ZIMMCY001
DATE: 09/16/18
Attending Physician: Oscar R. Prader, MD

CHAPTER 16  | 
CHAPTER 16 REVIEW

S: This new Pt is a 56-year-old male who was involved in an accident when the motorcycle he was driv-
ing was struck by a car on a street near his house. Cyrus admits to riding motorcycles for recreation.
He is complaining about some neck pain. He has tingling into his hand and feet. He states that his left
arm hurts when he tries to pull it overhead. PMH is remarkable for kidney trouble. Past bronchoscopy,
laparoscopy, and kidney stone surgery, otherwise noncontributory as per the medical history form com-
pleted by the patient and reviewed this encounter.
O: Ht. 5′9″, Wt. 181 lb., R 18. On exam, the left shoulder demonstrates full passive motion. He has nor-
mal strength testing. He has no deformity. He has some tenderness over the trapezial area. The reflexes
are brisk and symmetric. X-rays of his chest 2 views and C spine AP/LAT are relatively benign, as are
complete x-rays of the shoulder.
A: Anterior displaced type II dens fracture of the second cervical vertebra, and an anterior dislocation of
the proximal end of the left humerus.
P: 1. Rx Naprosyn
  2. Referral to PT
  3. Referral to orthopedist

ORP/mg  D: 9/16/18 09:50:16  T: 9/18/18 12:55:01 

Determine the most accurate ICD-10-CM code(s).

PRADER, BRACKER, & ASSOCIATES

A Complete Health Care Facility
159 Healthcare Way • SOMEWHERE, FL 32811 • 407-555-6789
PATIENT: KIM, LINDA
ACCOUNT/EHR #: KIMLI001
DATE: 09/16/18
Attending Physician: Oscar R. Prader, MD
S: This new Pt is a 29-year-old female who presents with splatter burns on the back of her right hand
and her right cheek. She stated that she was deep-frying shrimp for a dinner party at her home in the
kitchen and the grease splattered unexpectedly.
O: Ht. 5′6″, Wt. 152 lb., R 20. Skin is red and blistered on both sites. There is some epidermal loss. Area
was cleansed with antiseptic, and ointment was applied before a clean gauze bandage was put on the
hand. The facial area was also cleansed and bandaged.
A: Second-degree burns to back of hand and face.
P: 1. Rx: Aspirin for pain, prn
    2. Return in 1 week for dressing change.

ORP/pw  D: 9/16/18 09:50:16  T: 9/18/18 12:55:01

Determine the most accurate ICD-10-CM code(s).

468   PART II  |  REPORTING DIAGNOSES

 CHAPTER 16 REVIEW
WESTON HOSPITAL
629 Healthcare Way • SOMEWHERE, FL 32811 • 407-555-6541
PATIENT: O’MALLEY, REGINA
ACCOUNT/EHR #: OMALRE001
DATE: 09/16/18
Attending Physician: Renee O. Bracker, MD
S: Pt is a 6-year-old female seen in our emergency facility. She was brought in by ambulance, accompa-
nied by her mother. Mother states that they were baking cookies when the phone rang; she turned to
answered it and when she returned, the child was unconscious on the kitchen (apartment) floor, a bottle
of wintergreen oil found empty next to the patient.
O: Pt is listless and unresponsive. Respiration labored, BP 80/65, P slow and erratic. Skin is pale and
moist. Stomach pumped. Pt responding to treatment.
A: Poisoning by overdose of wintergreen oil, accidental
P: Admit to pediatric unit.

ROB/pw  D: 9/16/18 09:50:16  T: 9/18/18 12:55:01

Determine the most accurate ICD-10-CM code(s).

CHAPTER 16  | 
 17 Coding Genitourinary,
Gynecology, Obstetrics,
Congenital, and
Pediatrics Conditions
Key Terms Learning Outcomes
Abortion After completing this chapter, the student should be able to:
Anemic
Anomaly LO 17.1 Identify the details required to accurately report renal and
Benign Prostatic urologic malfunctions.
Hyperplasia (BPH) LO 17.2 Explain the conditions affecting the male genital system.
Bladder Cancer LO 17.3 Abstract the components for reporting sexually transmitted
Chronic Kidney Dis- diseases accurately.
ease (CKD)
Clinically Significant
LO 17.4 Enumerate the reasons for gynecologic care.
Congenital LO 17.5 Apply the guidelines for coding routine obstetrics care.
Deformity LO 17.6 Determine the correct codes for reporting complications of
Genetic Abnormality pregnancy.
Gestation LO 17.7 Utilize the official guidelines for well-baby encounters and
Glomerular Filtration congenital anomalies.
Rate (GFR)
Gynecologist (GYN)
Low Birth Weight
(LBW)
Malformation Remember, you need to follow along in
Morbidity
  STOP! your ICD-10-CM code book for an optimal
ICD-10-CM

Mortality
Obstetrics (OB) learning experience.
Perinatal
Prematurity
Prenatal
Prostatitis
Puerperium 17.1  Renal and Urologic Malfunctions
Urea Components of the Urinary System
Urinary System
Urinary Tract Infection The components of the urinary system (see Figure 17-1) are the same in both men
(UTI) and women. This organ system is responsible for removing waste products (known
as urea) that are left behind by protein (food), excessive water, disproportionate
amounts of electrolytes, and other nitrogenous compounds from the blood and the
Urinary System
body. A failure to eliminate these wastes from the body in a timely fashion may actu-
The organ system responsible ally result in the body poisoning itself. The organ components of the urinary system
for removing waste products include
that are left behind in the ∙ Kidney (right and left), each leading to a
blood and the body.
∙ Ureter (right and left), each leading to the
Urea
A compound that is excreted
∙ Urinary bladder, which then passes urine through the
in urine. ∙ Urethra, to travel outside the body.

470
 Kidney

Renal
Renal artery
vein
Inferior
Hilum vena cava
Abdominal
aorta

Ureters

Urinary
bladder
Urethra

FIGURE 17-1  An illustration identifying the anatomical sites of the urinary sys-
tem  David Shier et al., Hole’s human anatomy & physiology, 12/e. ©2010 McGraw-Hill Education. Figure 20.1, p.
776. Used with permission. 

As with many body systems, diseases and illnesses, congenital anomalies,

medications, and pathogens can cause havoc within the urinary system. These
problems may require straightforward treatments, such as using antibiotics for a
urinary tract infection (UTI), or more complex treatments, such as dialysis or Urinary Tract Infection (UTI)
transplantation. Inflammation of any part of the
Renal malfunction affects every organ and body system, so physical examination urinary tract: kidney, ureter,
may alert the physician to a concern in this area. The skin’s color and texture can bladder, or urethra.
change, periorbital edema can modify vision, or the patient may develop difficulty
with muscle function, including gait and posture. Mental status can also be influenced.
Electrolyte imbalance can alter hypertension levels, while metabolic acidosis can
result in hyperventilation.

Diagnostic Tools
A patient history of hypertension, diabetes mellitus, and/or bladder infections may
also be indicative of urinary system conditions. Genetic predispositions can be identi-
fied with family histories that include glomerulonephritis or polycystic kidney disease.
Nephrotoxicity can be caused by the patient’s abuse of antibiotics or analgesics.
Blood tests can measure the levels of uric acid, creatinine, and blood urea nitro-
gen (BUN), providing insight into kidney function. Of course, urinalysis can add data
about pH as well as clarity, color, and odor of the specimen. Measurement of urine
output may require 24-hour specimen collection. Checking levels of antidiuretic hor-
mone (ADH), produced by the pituitary gland, and/or levels of aldosterone, a hormone
produced by the adrenal cortex, may also indicate kidney concerns.
Kidney-ureter-bladder (KUB) radiography can measure the size, shape, and posi-
tion of these organs, as well as identify any possible areas of calcification.
Ultrasonography, fluoroscopy, computerized tomography (CT) scans, and/or mag-
netic resonance imaging (MRI) of the urinary system may also be appropriate to sup-
port the confirmation of a diagnosis.
An intravenous pyelogram (IVP) records a series of x-ray images, taken rapidly, as
contrast material injected intravenously passes through the urinary tract. A retrograde
pyelogram also uses contrast material; however, this iodine-based fluid is injected
through the ureters to investigate a suspicion of an obstruction, such as kidney stones
(calculi).

CHAPTER 17  | 
 ICD-10-CM
LET’S CODE IT! SCENARIO
Nila Taglia, a 33-year-old female, just returned from her honeymoon in the islands. She is feeling a burning sensa-
tion and some pain on urination, so she came to see Dr. Slater. After exam and urinalysis, Nila was diagnosed with
acute cystitis due to E. coli.

Let’s Code It!

Dr. Slater’s notes state that Nila has acute cystitis. When you turn to the Alphabetic Index, you see
Cystitis (exudative) (hemorrhagic) (septic) (suppurative) N30.90
acute N30.00
When you turn to the Tabular List, you confirm
N30 Cystitis
Take a second to read the Use additional code and notations carefully. Do you know what the infec-
tious agent is so you can code it? Yes, you do. Dr. Slater included this detail (E. coli) in his notes. And Nila does
not have prostatocystitis. Great! But first, we must determine the code for the cystitis. Did you find
N30.0 Acute cystitis
There is an notation listing two diagnoses. Take a minute to review them and determine whether
either one applies to Nila’s condition. No, neither of them does, so continue down and review all of the fifth-
character choices. Which matches Dr. Slater’s notes?
N30.00 Acute cystitis without hematuria
Wait, you are not done yet. You still need to report the infectious agent. The Use additional code notation
referred you to code range B95–B97. Let’s turn to B95 in the Tabular List. Review all of the code descriptions in
this subsection. Did you find
B96.2 Escherichia coli [E. coli] as the cause of diseases classified elsewhere
That’s good. However, you need more information to determine the accurate fifth character. Did you realize
there was more than one type of E. coli? Hmm. Even though you have documentation that the infectious agent is
E. coli, it is not enough information. For this exercise, you will need to report the unspecified version. Once you
get on the job, you will need to double-check the pathology report to be more specific.
N30.00 Acute cystitis without hematuria
B96.20 Unspecified Escherichia coli [E. coli] as the cause of diseases classified elsewhere

Chronic Kidney Disease

Glomerular Filtration Rate
(GFR) The kidneys are so important to the extraction of waste within the body. Therefore,
The measurement of kidney when one or both malfunction, toxicity can form and the patient can become very ill.
function; used to determine Chronic kidney disease (CKD) can be caused by disease, trauma, or an adverse reac-
the stage of kidney disease. tion to medication.
GFR is calculated by the phy- In the section about the kidneys, you learned that glomerular filtration is an impor-
sician using the results of a tant process in removing wastes (creatinine) from the blood as it flows through the
creatinine test in a formula kidneys. The glomerular filtration rate (GFR) is measured by blood tests to check
with the patient’s gender, age,
the creatinine level. When kidney function is not at an optimum level, creatinine con-
race, and other factors; normal
GFR is 90 and above.
tinues to amass in the blood because it is not being removed as necessary. The National
Kidney Foundation identifies a normal GFR range as 90–120 mL/min. GFR decreases
Chronic Kidney Disease with age, so geriatric patients are likely to have lower levels. Actually, a 90-year-old
(CKD) patient may have kidney function at 50% solely due to age-related changes.
Ongoing malfunction of one Monthly tests would be performed to identify a chronic condition. Chronic kidney
or both kidneys. disease (CKD) may be indicated by the following lab results:

472   PART II  |  REPORTING DIAGNOSES

 ∙ Normal GFR: Kidney damage may exist even with a normal GFR—CKD stage 1,
code N18.1
∙ GFR of 60–89: CKD stage 2 (mild renal disease), code N18.2
∙ GFR of 30–59: CKD stage 3 (moderate renal disease), code N18.3
∙ GFR of 15–29: CKD stage 4 (severe renal disease), code N18.4
∙ GFR below 15: CKD stage 5, code N18.5
∙ End-stage renal disease (ESRD): CKD stage 5 requiring ongoing dialysis or trans-
plantation, code N18.6

ICD-10-CM
YOU CODE IT! CASE STUDY
Shane Moyet, a 41-year-old male, was tested as part of his annual physical. He came in today with his wife to get his
test results. Dr. Contreras diagnosed him with moderate chronic kidney disease. She sat and discussed treatment
options with Shane and his wife.

You Code It!

Go through the steps of coding, and determine the code or codes that should be reported for this encounter
between Dr. Contreras and Shane Moyet.
Step #1: Read the case carefully and completely.

Step #2: Abstract the scenario. Which key words or terms describe why the physician cared for the patient dur-
ing this encounter?

Step #3: Are there any details missing or incomplete for which you would need to query the physician? [If so,
ask your instructor.]

Step #4: Check for any relevant guidance, including reading all of the symbols and notations in the Tabular List
and the appropriate sections of the Official Guidelines.

Step #5: Determine the correct diagnosis code or codes to explain why this encounter was medically necessary.

Step #6: Double-check your work.

Answer:
Did you determine this to be the correct code?
N18.3 Chronic kidney disease, stage 3 (moderate)

CKD with Other Conditions

CKD can be caused by hypertension, diabetic neuropathy (diabetes mellitus), untreated
obstruction such as renal calculi (kidney stones), or a congenital anomaly such as poly-
cystic kidneys. CKD progresses slowly; therefore, early diagnosis and treatment pro-
vide the best prognosis.

Hypertensive Chronic Kidney Disease

When a patient is documented to have both hypertension and CKD, you are to
assume that there is a cause-and-effect relationship between the two conditions.
The physician does not have to specifically state that one caused the other in the
documentation. Report this with a code from category I12 Hypertensive chronic
kidney disease.

CHAPTER 17  | 
 Diabetes with Renal Manifestations
A patient who has been diagnosed with diabetes may develop problems with his or her
kidneys, such as chronic kidney disease, diabetic nephropathy, or Kimmelstiel-Wilson
syndrome. When this is documented, regardless of the specific reason for the encoun-
ter, you will report a code from one of the following code categories, depending upon
the type of diabetes mellitus:
E08.2- Diabetes mellitus due to underlying condition with kidney
complications
E09.2- Drug or chemical induced diabetes mellitus with kidney complications
E10.2- Type 1 diabetes mellitus with kidney complications
E11.2- Type 2 diabetes mellitus with kidney complications
E13.2- Other specified diabetes mellitus with kidney complications
In all of these code categories, if the patient’s kidney complication is CKD, you will
need to report an additional code to identify the stage of the disease. You will see the
Use additional code notation.

ICD-10-CM
LET’S CODE IT! SCENARIO
Sergio Prisma, a 21-year-old male, was diagnosed with type 1 diabetes mellitus when he was 7 years old. He has
been lax about testing his glucose and giving himself his insulin shots because he has been so busy with his courses
and activities at Hillgraw University. After a complete HPI and exam, Dr. Allenson performed a glucose test and a
urinalysis. The results showed the early signs of type 1 diabetic nephrosis.

Let’s Code It!

Dr. Allenson’s notes state that Sergio has type 1 diabetic nephrosis. When you turn to the Alphabetic Index, you see
Diabetes, diabetic (mellitus) (sugar) E11.9
The word nephrosis is not there, but “kidney complications” is shown, suggesting code E11.29. Let’s take a look
in the Tabular List:
E11 Type 2 diabetes mellitus
Oh, wait a minute. This code category is for type 2 diabetes. Dr. Allenson’s notes document that Sergio has type
1 diabetes. Turn the pages and review this whole section to see if you can determine a more accurate code
category. Did you find this code category:
E10 Type 1 diabetes mellitus
There is an note as well as an notation listing several diagnoses. Take a minute to review
them and determine whether any apply to Sergio’s condition. No, none of them do, so continue down and
review all of the fourth-character choices. Which matches Dr. Allenson’s notes?
E10.2 Type 1 diabetes mellitus with kidney complications
You remember that nephrosis is an abnormal condition of the kidney. Review the three potential fifth-character
options. Which do you believe most accurately reports Sergio’s condition?
E10.21 Type 1 diabetes mellitus with diabetic nephropathy
Nephropathy (nephro = kidney + -pathy = disease) means the same as nephrosis, so you have found the correct
code. Good job!

Anemic
Any of various conditions
Anemia in CKD
marked by deficiency in red The malfunction of the kidneys as they attempt to filter out the impurities in the body
blood cells or hemoglobin. may trigger an anemic condition in the body. This condition can leave the patient

474   PART II  |  REPORTING DIAGNOSES

weak, fatigued, and potentially short of breath because there is less oxygen carried
through the bloodstream to the cells. When the patient is documented with these two
conditions, you will need to
∙ Code first the underlying chronic kidney disease (CKD) (N18.-).
∙ Follow this with code D63.1 Anemia in chronic kidney disease.

Dialysis
There are two types of dialysis that may be used to treat a patient with renal malfunc-
tion: peritoneal dialysis and hemodialysis.
Peritoneal dialysis infuses a dialysate solution into the peritoneal cavity. Subse-
quently, the solution passes through the peritoneal membrane (which lines the abdom-
inal cavity), collecting waste. The solution is then drained and thereby removes the
waste.
Hemodialysis draws blood out of the body via an intravenous tube and passes the
blood through a machine that removes waste products and returns clean blood to the
body via a second intravenous connection.
When the patient is preparing for the dialysis treatments, you will need to know
which type of dialysis the patient will be receiving:
Z49.01 Encounter for fitting and adjustment of extracorporeal dialysis
catheter
or
Z49.02 Encounter for fitting and adjustment of peritoneal dialysis catheter
Plus, note the reminder directly beneath the code category:
Code also associated end stage renal disease (N18.6)
Within the first few weeks after beginning the series of dialysis treatments, the physician
will want to have the patient come in for an efficiency or adequacy test. The purpose of the
test is to measure the exchanges to ensure that the treatments are removing enough urea. The
test results enable the health care professionals to adjust the dose, or amount, of the dialysis
in each treatment. To report the reason for the encounter, report one of these codes:
Z49.31 Encounter for adequacy testing for hemodialysis
or
Z49.32 Encounter for adequacy testing for peritoneal dialysis
Most patients will need to receive dialysis several times each week, usually until a GUIDANCE
transplant is available. For each of these encounters, the diagnosis codes to report will CONNECTION
include this code: Read the ICD-10-CM
Z99.2 Dependence on renal dialysis (hemodialysis status) (peritoneal dialy- Official Guidelines for
sis status) (presence of arteriovenous shunt for dialysis) Coding and Reporting,
section I. Conven-
Sadly, some patients cannot deal with an ongoing need for treatment and may tions, General Coding
not come in for their sessions. As you learned, this can have a negative impact on Guidelines and Chapter
their health, and it must be documented. The diagnosis codes to report will include Specific Guidelines,
this: subsection C. Chapter-
Z91.15 Patient’s noncompliance with renal dialysis Specific Coding Guide-
lines, chapter 14.
Diseases of Genitouri-
Transplantation
nary System, subsec-
At the point when the kidney is so severely damaged that it cannot be rehabilitated, a tion a.2) Chronic kidney
transplant may be the only solution to improve the patient’s health and possibly save disease and kidney
his or her life. A patient receiving a transplant must deal with the challenge of need- transplant status.
ing lifelong medication as well as follow-up care. However, great success has been

CHAPTER 17  | 
 achieved in increasing transplant patients’ quality of life. Of course, there is always
CODING BITES the possibility that the patient’s body might reject the new organ, but the greatest road-
Code category T86 block for these patients is the long wait for a donor:
Complications of trans- Z76.82 Awaiting organ transplant status
planted organs and
tissue has a Use addi- Of course, a donor is needed. With kidney transplants, the donor may be either a live
tional code notation individual or a cadaver. If the donor is live, the individual will need this diagnosis
to remind you to also code to support medical necessity for the preoperative testing, the procedure itself to
report any other trans- remove the donated organ, and the postoperative care:
plant complications, Z52.4 Kidney donor
such as
Organ transplantation is an incredible health care procedural accomplishment, giv-
Graft-versus-host dis- ing thousands of individuals with previously terminal conditions a second chance to
ease (D89.81-) live a normal and productive life. Patients who have received an organ transplant will
Malignancy associated typically need to take antirejection medication and receive regular checkups. There-
with organ transplant fore, after the transplant has taken place, the patient’s posttransplant status may need
(C80.2-) to be reported:
Post-transplant lympho- Z94.0 Kidney transplant status
proliferative disorders
(PTLD) (D47.Z1) Transplanting an organ from one person into another person is not always a per-
fect cure. There may be several issues that may require additional treatment. In some
cases, the transplant does not eliminate all of the kidney disease. One kidney may
have a milder case of CKD and not need transplantation, whereas the other kidney
CODING BITES does. Therefore, it is acceptable to report both posttransplant status and current CKD
in the same patient at the same time when the physician documents both conditions
Infections can occur concurrently.
commonly, particularly When a transplanted organ begins to show signs of rejection, failure, infection, or
in an organ system that other complication, this will need to be treated and, in some cases, the transplanted
is open to the outside organ will need to be removed.
of the body. Conditions
such as a kidney infec- T86.11 Kidney transplant rejection
tion, cystitis (bladder T86.12 Kidney transplant failure
infection), or a urinary T86.13 Kidney transplant infection
tract infection (UTI) are   (use additional code to report specific infection)
certainly not exotic T86.19 Other complication of kidney transplant
infectious conditions. Z98.85 Transplanted organ removal status
In these cases, you will
need to
Acute Renal Failure
 se additional code
U
to identify organism. Acute renal failure (ARF) is a sudden malfunction of the kidney often caused by an
obstruction, a circulatory problem, or possible renal parenchymal disease. This condi-
You may have to check tion is often reversible with medical treatment.
the pathology report The most typical cause of ARF in critically ill patients and the cause of approxi-
to determine what the mately 75% of all cases of ARF is a condition known as acute tubular necrosis
organism is if it is not (ATN), also called acute tubulointerstitial nephritis (ATIN)—code N10. Nephro-
specified in the physi- toxic injury, such as that caused by the ingestion of certain chemicals, can cause
cian’s notes. ATN but is reversible when diagnosed and treated early. Ischemic ATN may be
the result of an injury to the glomerular epithelial cells causing cellular collapse
or injury to the vascular endothelium, resulting in cellular swelling and therefore
obstruction.
Report this condition with a code from category N17 Acute kidney failure, with an
additional character to identify accompanying tubular necrosis, acute cortical necrosis,
or medullary necrosis.
Treatment typically includes the provision of diuretics and fluids to flush the sys-
tem. Electrolyte and fluid balances must be maintained to avoid fluid overload. Some
cases require peritoneal dialysis.

476   PART II  |  REPORTING DIAGNOSES

 ICD-10-CM
YOU CODE IT! CASE STUDY
Frieda Sacks, an 81-year-old female, has been having problems with her kidneys for a while, with two kidney infec-
tions over the last 5 years. Dr. Cannon diagnosed her with acute renal insufficiency.

You Code It!

Go through the steps of coding, and determine the code or codes that should be reported for this encounter
between Dr. Cannon and Frieda.
Step #1: Read the case carefully and completely.
Step #2: Abstract the scenario. Which key words or terms describe why the physician cared for the patient dur-
ing this encounter?
Step #3: Are there any details missing or incomplete for which you would need to query the physician? [If so,
ask your instructor.]
Step #4: Check for any relevant guidance, including reading all of the symbols and notations in the Tabular List
and the appropriate sections of the Official Guidelines.
Step #5: Determine the correct diagnosis code or codes to explain why this encounter was medically necessary.
Step #6: Double-check your work.
Answer:
Did you determine this to be the correct code?

N28.9 Disorder of kidney and ureter, unspecified (renal insufficiency (acute))

Urinary Tract Infection

Cystitis and urethritis are both lower urinary tract infections (UTIs), which are often
resolved easily with treatment. Ten times more women than men are affected by one
of these conditions. In the elderly, a weakening of the bladder muscles may create a
foundation for bladder infections (cystitis). Children with a confirmed UTI should be
examined for a urinary tract abnormality. This condition would not only predispose
them to UTIs but may also present a greater likelihood for renal damage in the future.
Report this with a code from category N30 Cystitis, with an additional character to
report specifics.
Most UTIs are caused by a Gram-negative enteric bacterium. The pathology report
will identify which one. This is important to know because there is a Use additional
code notation to identify the infectious agent. Additionally, a urinary catheter, a neuro-
genic (neuromuscular dysfunction) bladder, or a fistula between the intestine and the
bladder might cause a UTI. Medicare may consider a UTI caused by a urinary catheter
to be a nonreimbursable hospital-acquired condition (HAC).
Urinalysis of a clean-catch midstream void will confirm this diagnosis and will
provide the specific name of the pathogen for coding.

Renal Calculi
Renal calculi, commonly known as kidney stones, might actually form anywhere
within the urinary system; however, formation in the renal pelvis or the calyces of the
kidneys is most common. While the precise cause of these uncomfortable formations
is not known, decreased urine production, infection, urinary stasis, and metabolic con-
ditions, such as gout, are considered predispositions. Code category N20 Calculus of

CHAPTER 17  | 
 kidney and ureter, N21 Calculus of lower urinary tract, or N22 Calculus of urinary tract
in diseases classified elsewhere would be appropriate for reporting this diagnosis.
When the individual stones are small, hydration is prescribed to enable natural
passage of the calculi. Larger stones may need to be removed surgically, most often
using a cystoscope or using lithotripsy to break up the larger pieces to permit natural
passage.

ICD-10-CM
YOU CODE IT! CASE STUDY
Brandon Markinson, a 51-year-old male, was in so much pain that he was doubled over. He went to the emergency
department at the hospital near his house. Dr. Deitz took an x-ray and determined that Brandon had nephrolithiasis.
She discussed treatment options with him.

You Code It!

Go through the steps of coding, and determine the code or codes that should be reported for this encounter
between Dr. Deitz and Brandon.
Step #1: Read the case carefully and completely.
Step #2: Abstract the scenario. Which key words or terms describe why the physician cared for the patient dur-
ing this encounter?
Step #3: Are there any details missing or incomplete for which you would need to query the physician? [If so,
ask your instructor.]
Step #4: Check for any relevant guidance, including reading all of the symbols and notations in the Tabular List
and the appropriate sections of the Official Guidelines.
Step #5: Determine the correct diagnosis code or codes to explain why this encounter was medically necessary.
Step #6: Double-check your work.
Answer:
Did you determine this to be the correct code?
N20.0 Calculus of kidney (Nephrolithiasis)

Malignant Neoplasm of the Bladder

Bladder Cancer Malignant neoplasm of the bladder, commonly known as bladder cancer, is the fourth
Malignancy of the urinary most frequently diagnosed cancer in men and the eighth most frequent in women.
bladder. While various types of malignant cells can invade this organ, transitional cell carci-
noma is seen most often and develops in the lining of the urinary bladder. This would
be reported with a code from category C67 Malignant neoplasm of the bladder, with
an additional character to report the specific location of the tumor (trigone, dome,
etc.). The definitive test to confirm this condition is a cystoscopy with biopsy.

ICD-10-CM
YOU CODE IT! CASE STUDY
Corneilus St. Augusteine contracted syphilis of his kidney, and now Dr. Acosta determines that an anterior urethral
stricture has developed as a result.

478   PART II  |  REPORTING DIAGNOSES

 You Code It!
Go through the steps of coding, and determine the code or codes that should be reported for this encounter
between Dr. Acosta and Corneilus.
Step #1: Read the case carefully and completely.
Step #2: Abstract the scenario. Which key words or terms describe why the physician cared for the patient dur-
ing this encounter?
Step #3: Are there any details missing or incomplete for which you would need to query the physician? [If so,
ask your instructor.]
Step #4: Check for any relevant guidance, including reading all of the symbols and notations in the Tabular List
and the appropriate sections of the Official Guidelines.
Step #5: Determine the correct diagnosis code or codes to explain why this encounter was medically necessary.
Step #6: Double-check your work.
Answer:
Did you determine these to be the correct codes?
N35.114 Post-infective anterior urethral stricture, not elsewhere classified, male
A52.75 Syphilis of kidney and ureter

17.2  Diseases of the Male Genital Organs

Due to the proximity of the prostate to the urethra and bladder (see Figure 17-2), the
most common underlying condition promoting UTI is prostatitis. In men, the prostate Prostatitis
is a gland that sits inferior to (below) the urinary bladder. It is shaped like a chestnut Inflammation of the prostate.
and wraps around the urethra as the urethra descends from the bladder to the outside
of the body. E. coli is the pathogen causing approximately 80% of these cases. A urine

Serous coat
Urinary bladder

Ureter

Vas
deferens

Seminal
vesicle

Prostate gland

Urethra

FIGURE 17-2  An illustration identifying the anatomical sites of the prostate  Booth et al., Medical Assisting, 5e. Copyright ©2013
by McGraw-Hill Education. Figure 31-6 (b), p. 616. Used with permission.

CHAPTER 17  | 
 culture of specimens collected using a four-step process known as the Meares and
Stamey technique provides the best data for a confirmed diagnosis. Antibiotics are the
standard-of-care treatment. Code category N41 Inflammatory diseases of the prostate
requires a fourth character to identify whether the inflammation is acute, chronic, an
abscess, or another issue.
Benign Prostatic Hyperplasia Benign prostatic hyperplasia (BPH), also known as benign prostatic hypertrophy,
(BPH) most often diagnosed in men over 50 years of age, is a condition in which the prostate
Enlarged prostate that results enlarges and results in depressing the urethra. This interferes with the flow of urine
in depressing the urethra. from the bladder to the outside. Code category N40 Enlarged prostate with a fourth
character would be used to report this condition. BPH can also result in urine reten-
tion, severe hematuria (blood in urine), or hydronephrosis. 
Hydrocele is a condition that occurs when fluid collects within the tunica vaginalis
of the scrotum, the testis, or the spermatic cord. The physician will not only diagnose
and treat this condition, but also needs to investigate to determine the underlying cause,
especially when associated with pathology that is considered clinically significant. As
you abstract the documentation, you will need to identify if the hydrocele is congeni-
tal, encysted, infected, or other type, as well as any identified underlying conditions.
N43.0 Encysted hydrocele
N43.1 Infected hydrocele
Use additional code (B95-B97), to identify infectious agent
N43.2 Other hydrocele
P83.5 Congenital hydrocele

ICD-10-CM
YOU CODE IT! CASE STUDY
PATIENT NAME: Walter Primiera
PREOPERATIVE DIAGNOSES:
1.  Left hydrocele, possible right.
2.  Urethral meatal stenosis.
POSTOPERATIVE DIAGNOSES:
1.  Left encysted hydrocele.
2.  Urethral meatal stenosis.
OPERATIONS PERFORMED:
1.  Left hydrocelectomy.
2.  Diagnostic laparoscopy.
3.  Urethral meatoplasty.
ANESTHESIA: General and caudal.
DESCRIPTION OF PROCEDURE: After informed consent was acquired, the patient was brought into the surgical
suite. The patient was placed on the table in a supine position, and prepped and draped in the usual sterile manner.
General anesthesia was accomplished, and a caudal block was administered. A left inguinal skin crease incision was
made and the dissection proceeded to expose the external oblique fascia. After placing self-retaining retractors, the
external oblique was opened in the direction of its fibers. The external ring was opened. The ilioinguinal nerve was
identified and moved away to avoid any injury. The cord was then isolated and a vessel loop placed around it. The
fibers of cord were separated and hydrocele sac was identified. This was carefully dissected away from the cord
structures, taking care to identify and avoid any injury to the vas or vessels.
Once the sac was completely isolated, bladder was doubly clamped and divided on the proximal aspect as well as
up to the internal ring. The sac was then opened, 5 mm laparoscopic trocar sheath was placed under vision into the
peritoneum, and a 2-0 silk stitch was secured in order to maintain the pneumoperitoneum. CO2 was then insufflated to

480   PART II  |  REPORTING DIAGNOSES

 a pressure of 10 mmHg. With the patient in Trendelenburg position, the contralateral internal ring was inspected with a
25 degree lens. The vas and vessels were seen exiting a closed internal ring. Thus, a repair on the right was required.
The scope was removed, pneumoperitoneum was released, and the trocar was removed. The hydrocele sac was
gathered in the right-angled clamp, twisted, and high ligation was performed with 3-0 Vicryl suture ligature and tied.
Attention was turned to the distal aspect of the sac and the testis was delivered. Tunica vaginalis was opened,
redundant tunica was excised, hydrocele fluid drained. A very small testicular appendage was also excised with cau-
tery. The testis was then returned to its normal scrotal location. The floor of the canal was inspected, and there was no
evidence of any weakness to suggest a direct hernia. The external oblique was then closed with a running 3-0 Vicryl,
taking care to avoid any injury to the nerve. The subcutaneous tissues were closed with interrupted 4-0 chromic, and
the skin with running 4-0 Monocryl. Steri-Strip and Tegaderm dressing were placed over the inguinal incision.
Attention was now turned towards the urethral meatus and the tissue in the ventral midline. The meatus was ste-
notic, so the tissue in the ventral midline was crushed with a mosquito clamp and then opened sharply with Westcott
scissors. A 7-0 Vicryl stitch was placed at the apex. Some redundant tissue was crimped and then excised along
either the left or right side. To make a normal appearance and help with avoiding interrupting the stream, this tissue
was excised. The edge of the urethral mucosa was attached to the glans skin. This was done also with 7-0 Vicryl
sutures. Bacitracin ointment was placed over the meatus. The patient was awakened. He was taken to the recovery
room in stable condition. All counts were correct. He tolerated the procedure well. There were no complications.
Signed: Stefan Olsen, MD

You Code It!

Review Dr. Olsen’s operative notes regarding this procedure performed on Walter. Then, determine the accurate
ICD-10-CM code or codes that will explain the medical necessity for this encounter.
Step #1: Read the case carefully and completely.
Step #2: Abstract the scenario. Which main words or terms describe why the physician cared for the patient
during this encounter? 
Step #3: Are there any details missing or incomplete for which you would need to query the physician? [If so,
ask your instructor.]
Step #4: Check for any relevant guidance, including reading all of the symbols and notations in the Tabular List
and the appropriate sections of the Official Guidelines.
Step #5: Determine the correct diagnosis code or codes to explain why this encounter was medically necessary.
Step #6: Double-check your work.
Answer:
Did you determine these to be the correct codes?
N43.0 Encysted hydrocele
N35.8 Other urethral stricture 

Oligospermia is a type of male infertility, commonly known as a low sperm count.

ICD-10-CM code options are combination codes that will include the general type of
underlying cause, so you will need to be alert for this when you are abstracting the
physician’s notes. In most cases, you will also need a second code to provide more
specifics about that underlying cause.
N46.11 Organic oligospermia
N46.121 Oligospermia due to drug therapy
N46.122 Oligospermia due to infection
N46.123 Oligospermia due to obstruction of efferent ducts
N46.124 Oligospermia due to radiation
N46.125 Oligospermia due to systemic disease
N46.129 Oligospermia due to other extratesticular causes

CHAPTER 17  | 
 Erectile dysfunction is broadcast in television and Internet ads as easily solved by
a little blue pill. However, whether or not it is that simple to cure, the reporting of the
diagnosis is complex. As you will discover turning to code category N52 Male erectile
dysfunction, you will need to determine, from the documentation, the underlying cause
because all of these code options are combination codes.
N52.01 Erectile dysfunction due to arterial insufficiency
N52.02 Corporo-venous occlusive erectile dysfunction
N52.03 Combined arterial insufficiency and corporo-venous occlusive erec-
tile dysfunction
N52.1 Erectile dysfunction due to diseases classified elsewhere
Code first underlying disease
N52.31 Erectile dysfunction following radical prostatectomy
N52.32 Erectile dysfunction following radical cystectomy
N52.33 Erectile dysfunction following urethral surgery
N52.34 Erectile dysfunction following simple prostatectomy
N52.39 Other and unspecified post-surgical erectile dysfunction

17.3  Sexually Transmitted Diseases

Age, employment status, income level, gender, number of sexual encounters . . . noth-
ing except taking proper precautions during sex shields someone from getting a sexu-
ally transmitted disease (STD). This is true for all types of sexual encounters in which
bodily fluids are exchanged—not just intercourse. The paragraphs below present an
overview of the STDs considered the most common by the Centers for Disease Con-
trol and Prevention (CDC).

Bacterial Vaginosis
Bacterial vaginosis (BV)—the most common vaginal infection in women 16 to 45
years of age, often affecting pregnant women—is caused by an overgrowth of bacteria.
Symptoms include odor, itching, burning, pain, and/or a discharge. Code N76.0 Acute
vaginitis would be reported, along with a second code to identify the infectious agent.

Chlamydia
Caused by a bacterium (Chlamydia trachomatis), chlamydia can result in infertility
or other irreversible damage to a woman’s reproductive organs. The symptoms are
mild or absent, so most women don’t know they have a problem unless their partner is
diagnosed. Chlamydia can cause a penile discharge in men. It is the most commonly
reported bacterial STD in the United States, according to the CDC. In ICD-10-CM,
code A55 Chlamydial lymphogranuloma (venereum) is reported for chlamydia that is
transmitted by sexual contact. Note: Do not confuse this with A70 Chlamydia psit-
taci infections, A74.0 Chlamydial conjunctivitis, A74.81 Chlamydial peritonitis, A74.89
Other chlamydial diseases, or A74.9 Chlamydial infection unspecified, all of which are
reported when chlamydia causes another disease.

Genital Herpes
Genital herpes is caused by one of the herpes simplex viruses: type 1 (HSV-1) or type
2 (HSV-2). In this STD, one or more blisters may appear on or in the genital or rectal
area. Once the blister bursts, it can take several weeks for the ulcer to heal. The virus
will remain in the body indefinitely, even though no more breakouts may be experi-
enced, because there is no cure. Treatment can reduce the number of outbreaks and
diminish the opportunity of transmission to a partner. To code from category A60
Anogenital herpesviral [herpes simplex] infections, you must know the specific ana-
tomical site, such as penis or cervix, to determine the additional characters required.

482   PART II  |  REPORTING DIAGNOSES

Gonorrhea
Gonorrhea, a bacterial STD, can develop in the reproductive organs of men (urethra)
and women (cervix, uterus, fallopian tubes, and urethra), in addition to the mouth,
throat, eyes, and anus. Symptoms in men include a burning sensation during urina-
tion, a penile discharge (white, yellow, or green), and/or swelling or pain in the tes-
tes. Women typically do not experience any symptoms. You will report this diagnosis
from ICD-10-CM code category A54 Gonococcal infection, which requires identifica-
tion of the specific anatomical site of the infection to determine additional characters.

Human Immunodeficiency Virus

Both types of human immunodeficiency virus (HIV)—HIV-1 and HIV-2—destroy
cells within the body that are responsible for helping fight disease (those that are part of
the immune system). Soon after the initial infection, some individuals may suffer flu-
like symptoms, while others will have no symptoms at all and feel fine. Current medi-
cations can help individuals continue to feel well and decrease their ability to transmit
the disease. HIV, especially untreated HIV, has known manifestations, including car-
diovascular, renal, and liver disease. In the late stages of the disease, when the patient’s
immune system is quite damaged, acquired immune deficiency syndrome (AIDS) may
develop. Currently, there is no cure for HIV or AIDS. You will report a confirmed
diagnosis of HIV with code B20 Human Immunodeficiency Virus [HIV] disease when
the patient has, or has had, manifestations or code Z21 Asymptomatic human immuno-
deficiency virus [HIV] infection status when the patient is asymptomatic.

Human Papillomavirus
There are over 40 different types of human papillomavirus (HPV) that can infect the gen-
ital regions, mouth, and/or throat of both men and women. This infection will not cause
any signs or symptoms; however, it is known to contribute to the development of genital
warts as well as cervical cancer (in women). A connection has also been made between
HPV and malignancies in the penis, anus, vulva, vagina, and oropharynx. A patient get-
ting a test to screen for HPV will be reported with code Z11.51 Encounter for screening
for human papillomavirus (HPV). Reporting for a female patient with a positive test result
will come from subcategory R87.8 Other abnormal findings in specimens from female
genital organs. Additional characters are required based on the anatomical location (cer-
vix or vagina) and on whether the patient is identified as high risk or low risk. Male and
female patients would both be reported with a code from subcategory R85.8 Other abnor-
mal findings in specimens from digestive organs and abdominal cavity for HPV-positive
results in the anus. A confirmed diagnosis for either a male or female patient would be
reported with A63.0 Anogenital (venereal) warts [due to (human) papillomavirus (HPV)].

Pelvic Inflammatory Disease

Pelvic inflammatory disease (PID) is often a complication of previous chlamydial,
gonococceal, or other STD infection, occurring when the bacterium moves from the
vagina into a woman’s uterus or fallopian tubes. It causes lower abdominal pain. Seri-
ous consequences of untreated PID include chronic pelvic pain, formation of abscesses,
ectopic pregnancy, and possible infertility. Use code A56.11 Chlamydial female pelvic
inflammatory disease or A54.24 Gonococcal female pelvic inflammatory disease, or
use a code from category N73 Other female pelvic inflammatory diseases or code N74
Female pelvic inflammatory disorders in diseases classified elsewhere.

Syphilis
In its early stages, syphilis, caused by a bacterium (Treponema pallidum), is easy
to cure. Signs and symptoms include a rash, particularly on the palmar and plantar

CHAPTER 17  | 
 surfaces, as well as a small, round, painless sore on the genitals, anus, or mouth. How-
ever, these symptoms mimic many other diseases, often resulting in delayed diagno-
sis. Code category A50 Congenital syphilis, A51 Early syphilis, A52 Late syphilis, or
A53 Other and unspecified syphilis would be reported when this condition is sexually
transmitted.

Trichomoniasis
Trichomoniasis (trich), a protozoan parasitic (Trichomonas vaginalis) STD, is more
common in older women than in men. Most individuals do not know they are infected
because only approximately 30% develop any symptoms, such as a genital discharge.
While the condition is curable, a person who has trich and goes without treatment
increases his or her risk of getting human immunodeficiency virus (HIV). Trich, when
present in a pregnant woman, can cause premature delivery of low-birth-weight neo-
nates. Code category A59 Trichomoniasis requires additional characters to identify the
specific anatomical site of the infection.

ICD-10-CM
YOU CODE IT! CASE STUDY
PATIENT: AMELIA MADISON
DATE OF OPERATION: 05/22/2018
PREOPERATIVE DIAGNOSES:
1.  Severe pelvic pain.
2.  History of pelvic inflammatory disease and pelvic adhesion.
3.  Probable left hydrosalpinx.
POSTOPERATIVE DIAGNOSES:
1.  Chronic pelvic inflammatory disease.
2.  Extensive pelvic adhesion and left hydrosalpinx.
PROCEDURES PERFORMED:
1.  Pelvic examination under anesthesia.
2.  Total abdominal hysterectomy.
3.  Bilateral salpingo-oophorectomy.
4.  Lysis of adhesions.
SURGEON: Gabriel Underwood, MD
ANESTHESIA: General.
ESTIMATED BLOOD LOSS: 100 mL.
COMPLICATIONS: None.
DESCRIPTION OF OPERATION: The patient was taken to the operating room, where general anesthesia was admin-
istered without complication. The patient was placed in the dorsal lithotomy position, and examination under anes-
thesia revealed a normal-appearing vagina and cervix. Bimanual exam reveals a normal-sized uterus with no right
adnexal pathology noted. There was an adnexal mass in the left adnexa of approximately 4–5 cm. The patient was
placed in the supine position. She was prepped and draped in the usual fashion.
A Pfannenstiel skin incision was performed and carried down to the fascial layer. The fascia was transected. The
rectus muscles were retracted laterally, and the peritoneum was entered under direct visualization. The pelvic cav-
ity was inspected, and there were extensive pelvic adhesions noted. The bowel was packed into the upper abdo-
men using moist laps. There was a large left hydrosalpinx present with bilateral tubal-ovarian adhesions. The left

484   PART II  |  REPORTING DIAGNOSES

 hydrosalpinx was first freed up using careful sharp dissection. The tube and ovary on the right side were likewise
mobilized with sharp dissection. The right round ligament was doubly clamped, cut, and tied with 0 Vicryl suture. The
visceroperitoneum was dissected free to the midline. The left round ligament was likewise doubly clamped, cut, and
tied and the visceroperitoneum was dissected free to the midline. The bladder was carefully dissected off the lower
uterine segment. The right infundibulopelvic ligament was clamped, cut, and doubly tied with 0 Vicryl suture. The left
infundibulopelvic ligament was likewise doubly clamped, cut, and doubly tied with 0 Vicryl suture. The right uterine
vessels and cardinal ligament were doubly clamped, cut, and doubly tied with 0 Vicryl suture. The left uterine vessels
and cardinal ligament were likewise clamped, cut, and doubly tied with 0 Vicryl suture. The bladder was retracted
inferiorly. The right uterosacral ligament was clamped, cut, and tied with 0 Vicryl suture. This step was repeated until
the specimen was mobilized on the right side. The left uterosacral ligament was likewise clamped, cut, and tied with
0 Vicryl suture. Again, the step was repeated until the specimen was mobilized on the left side.
The anterior aspect of the vagina was entered with a scalpel and heavy curved scissors were used to remove the
uterus, tubes, and ovaries, which were sent to pathology for microscopic examination. Angled sutures were placed on
either side of the vaginal cuff using 0 Vicryl suture. The vaginal cuff was closed with interrupted figure-of-eight sutures of
0 Vicryl. A thorough search was made to ensure that there was complete hemostasis. The pelvic peritoneum was reap-
proximated with 0 Vicryl suture. The instruments were removed from the abdomen. The sponge, needle, and instrument
counts were all correct. The parietal peritoneum was reapproximated with 2-0 Vicryl suture. The rectus muscles were
reapproximated with interrupted 0 Vicryl suture. The fascia was closed with 0 PDS suture. The subcutaneous tissue was
reapproximated with 3-0 Vicryl suture. The skin was closed with staples. A dry sterile dressing was placed over the inci-
sion. The patient was then awoken in the operating room and transferred to the recovery room in good condition.
DISPOSITION: The patient was taken to the recovery room in good condition at the end of the procedure.

You Code It!

Read these operative notes, written by Dr. Underwood, about Amelia’s procedure, and determine the correct
ICD-10-CM code or codes to explain the reason why the procedures were medically necessary.
Step #1: Read the case carefully and completely.
Step #2: Abstract the scenario. Which main words or terms describe why the physician cared for the patient
during this encounter?
Step #3: Are there any details missing or incomplete for which you would need to query the physician? [If so,
ask your instructor.]
Step #4: Check for any relevant guidance, including reading all of the symbols and notations in the Tabular List
and the appropriate sections of the Official Guidelines.
Step #5: Determine the correct diagnosis code or codes to explain why this encounter was medically necessary.
Step #6: Double-check your work.
Answer:
Did you determine these to be the codes?
N73.1 Chronic parametritis and pelvic cellulities
N73.6 Female pelvic peritoneal adhesions (post-infective)
N70.11 Chronic salpingitis
Good job!

17.4  Gynecologic Care Gynecologist (GYN)

A physician specializing in
Females of all ages may go to the gynecologist (GYN) for specialized health care. the care of the female genital
Sometimes, the physician is referred to as an OB/GYN, an abbreviation for the dual tract.

CHAPTER 17  | 
Obstetrics (OB) specialization of obstetrics (OB), which focuses on care during pregnancy and the
A health care specialty focus- puerperium, and gynecology. Concerns and disorders relating to other aspects of the
ing on the care of women female anatomy are not always related to pregnancy. Let’s investigate some of the most
during pregnancy and the common reasons a woman would seek the care of a gynecologist and how to report them.
puerperium.

Puerperium Routine Encounters

The time period from the
end of labor until the uterus Most women understand the importance of getting their annual well-woman exami-
returns to normal size, typi- nation. It may take place at the office of a specialized OB/GYN or be performed by
cally 3 to 6 weeks. a family or general practitioner. Typically, the visit includes a routine physical exam,
pelvic exam, and breast exam. Often, the visit also includes a Papanicolaou cervical
smear, better known as a Pap smear. The encounter is coded
Z01.411 Encounter for routine gynecological examination (general) (routine)
with abnormal findings
or
Z01.419 Encounter for routine gynecological examination (general) (routine)
without abnormal findings
These codes include a cervical Pap smear. However, when a vaginal Pap smear (which
is different from a cervical Pap smear and must be specified in the documentation) is
included in the visit, add a second code:
Z12.72 Encounter for screening for malignant neoplasm of vagina (vaginal
pap smear)

Endometriosis
Endometriosis (code category N80) is an inflammation or swelling of the tissue that lines
the uterus. The condition is estimated to affect 2% to 10% of women of childbearing age
in the United States. Although the disorder is identified as being within the uterus, endo-
metriosis can be observed in a woman’s ovary, cul-de-sac, uterosacral ligaments, broad
ligaments, fallopian tube, uterovesical fold, round ligament, vermiform appendix, vagina,
and/or rectovaginal septum. This means that a diagnosis of endometriosis is not sufficient
to determine the most accurate code. You have to know the specific site of the condition.

Uterine Fibroids
Also known as uterine leiomyoma or uterine fibromyoma, uterine fibroids (code cate-
gory D25 Leiomyoma of uterus) are tumors located in the female reproductive system.
Only about one-third of women with these tumors are actually diagnosed. Uterine
fibroids are not related to cancer, do not increase the patient’s risk of developing can-
cer later, and are found to be benign 99% of the time.

Pelvic Pain
Female pelvic and perineal pain (code R10.2) may be related to a specific genital
organ or an area around a genital organ or may be psychological in nature. The physi-
cian may be able to diagnose a particular cause, such as sexual intercourse or men-
struation, or the source of the pain may remain unknown.

ICD-10-CM
YOU CODE IT! CASE STUDY
Clarisse Battle, a 31-year-old female, came to see Dr. Legg with complaints of feeling bloated. She stated that she has
felt this way for over a month and cannot connect it to anything she has been eating. After taking a complete history,
doing an exam, and performing an ultrasound, Dr. Legg explained that Clarisse had a simple cyst on her right ovary.

486   PART II  |  REPORTING DIAGNOSES

 You Code It!
Go through the steps of coding, and determine the code or codes that should be reported for this encounter
between Dr. Legg and Clarisse.
Step #1: Read the case carefully and completely.
Step #2: Abstract the scenario. Which key words or terms describe why the physician cared for the patient dur-
ing this encounter?
Step #3: Are there any details missing or incomplete for which you would need to query the physician? [If so,
ask your instructor.]
Step #4: Check for any relevant guidance, including reading all of the symbols and notations in the Tabular List
and the appropriate sections of the Official Guidelines.
Step #5: Determine the correct diagnosis code or codes to explain why this encounter was medically necessary.
Step #6: Double-check your work.
Answer:
Did you determine this to be the correct code?
N83.291 Other ovarian cysts (simple cyst of ovary), right
You are really getting to be a great coder!

Procreative Management
A woman may want to see her doctor regarding her desire to have children now or in
the future. Code category Z31 Encounter for procreative management is used only
for testing conducted with anticipation of procreation (having children). Code subcat-
egory Z31.6 Encounter for general counseling and advice on procreation will provide
you with a few fifth-character options to include additional details.
Perhaps a patient comes in for a test to determine whether or not she is a carrier
of a genetic disease before getting pregnant. Most often, such a woman wants to be
aware of the possibilities of passing inherited diseases, such as sickle cell anemia
or Tay-Sachs, to her baby. The code or codes to report her encounter would be
code(s):
Z31.430 Encounter of female for testing for genetic diseases carrier status
for procreative management
and/or
Z31.438 Encounter for other genetic testing of female for procreative
management

Code Z31.5 Encounter for genetic counseling would be used after a genetic test has
been done and shown positive results.
With good news so far, our female patient may come in next time for fertility testing
or, perhaps, a pregnancy test:
Z31.41 Encounter for fertility testing
Z32.00 Encounter for pregnancy test, result unknown
Z32.01 Encounter for pregnancy test, result positive
Z32.02 Encounter for pregnancy test, result negative

CHAPTER 17  | 
 ICD-10-CM
LET’S CODE IT! SCENARIO
Priscilla Sharp, a 25-year-old female, came to see Dr. Trenton to have an intrauterine device (IUD) inserted. She and
her husband, Eli, want to wait a while before having children.

Let’s Code It!

Priscilla came to get an IUD. The purpose of this visit is to prevent Priscilla from getting pregnant, also termed
contraception. Let’s go to the Alphabetic Index and look up contraception. Look down the list indented under
contraception and you see device. However, none of the terms indented under device seems to really match
Dr. Trenton’s notes. This is the first encounter relating to contraception, so perhaps “initial prescription” would
be a place to begin.
Contraception, contraceptive
  device (intrauterine) (in situ) Z97.5
    initial prescription Z30.014
Turn to the Tabular List and confirm that this is the best, most accurate code:
Z30 Encounter for contraceptive management
There are no notations or directives, so continue reading down the column to determine the most accurate
required fourth and fifth characters:
Z30.014 Encounter for initial prescription of intrauterine contraceptive device
Be sure to read further down the column to determine whether any other code descriptions may be more accu-
rate than this description. Sometimes, the Alphabetic Index gets us to only the best subsection of the Tabular
List.
Z30.430 Encounter for insertion of intrauterine contraceptive device
There it is! Good job!

17.5  Routine Obstetrics Care

Fertilization and Gestation
When a sperm fertilizes an oocyte, a zygote is created. This will typically occur while
the egg is still in the last portion of the fallopian tube. Each oocyte (egg) has 23 chro-
mosomes, and each sperm contains 23 chromosomes (in the nucleus in the head of the
sperm). When they combine during fertilization, the zygote then has the complete set
of 46 chromosomes. This may be confirmed by a pregnancy test; the medical neces-
sity for this visit is reported with a code such as Z32.01 Encounter for pregnancy tests,
result positive.
The embryonic period, from weeks 2 through 8 after fertilization, is the time during
which external structures and internal organs begin to form. Additionally, the placenta,
umbilical cord, amnion, yolk sac, and chorion are established during this time. At
week 8, the embryo, about 1 inch in length, is considered a fetus, and all organ systems
are in place.
Gestation Gestation, the length of the pregnancy, is measured in trimesters, beginning on the
The length of time for the first day of the last menstrual period (LMP). For coding purposes, ICD-10-CM pro-
complete development of a vides the following definitions:
baby from conception to birth;
on average, 40 weeks. ∙ First trimester: from the first day of the last menstrual period (LMP) to less than
14 weeks 0 days.
∙ Second trimester: 14 weeks 0 days to less than 28 weeks 0 days.

488   PART II  |  REPORTING DIAGNOSES

 ∙ Third trimester: 28 weeks 0 days until delivery.
GUIDANCE
∙ Preterm (premature) neonate: one with a gestation of 28 completed weeks or more
but less than 37 completed weeks (between 196 and 258 completed days). CONNECTION
∙ Postterm neonate: one with over 40 completed weeks up to 42 completed weeks of Read the ICD-10-CM
gestation. Official Guidelines for
∙ Prolonged gestation of a neonate: a gestational period that has lasted over 42 com- Coding and Reporting,
pleted weeks (294 days or more). section I. Conven-
tions, General Coding
Guidelines and Chapter
Weeks of Gestation Specific Guidelines,
Cases in which a complication has been identified require additional specificity, subsection C. Chapter-
beyond the current trimester of the pregnancy, and you will need to report the specific Specific Coding Guide-
number of weeks of gestation. Code category Z3A Weeks of gestation provides you lines, chapter 15. Preg-
with codes that specify the individual week, from 8 weeks to 42 weeks gestation. In nancy, Childbirth, and
addition, codes are available for less than 8 weeks and greater than 42 weeks. the Puerperium, sub-
When a pregnant patient is admitted and stays in the hospital for more than 1 week, sections a.3) Final
you should use the date of admission to determine the weeks of gestation. character for trimes-
ter, a.4) Selection of
trimester for inpatient
EXAMPLE admissions that encom-
pass more than one
Amy went into labor and ultimately delivered the baby. She and her husband were trimester, a.5) Unspeci-
very concerned because the baby was only at 33 weeks: fied trimester, and
O60.14X0 Preterm labor third trimester with preterm delivery third trimester, b.3) Episodes when no
single gestation delivery occurs.
Z3A.33 33 weeks gestation of pregnancy

Prenatal Visits CODING BITES

Code category Z3A
A woman often has three items noted in her chart: gravida (G) reports how many
codes are not reported
times the woman has been pregnant; para, or parity (P), reports how many babies this
in cases of
woman has given birth to (after 20 weeks of gestation); and abortus (A) identifies how
many pregnancies did not come to term or make it past the 20th week. Gravida and • Pregnancies with
para may be noted using an abbreviation, such as G2 P1. abortive outcomes
• Elective termination
of pregnancy
EXAMPLE • Postpartum
conditions
G1 P1 tells you that the woman has been pregnant once and given birth
once.
G1 P2 tells you that the woman has been pregnant once and given birth
twice—twins!
G2 P1 tells you that the woman has been pregnant twice and given birth
once. If she is pregnant now, this is her second pregnancy; if she is
not pregnant now, she may have had a miscarriage in the past.

Normal Pregnancy
Routine outpatient prenatal checkups are very important to the health and well-being Prenatal
of both the mother and the baby. For a healthy pregnant woman, the visits are typically Prior to birth; also referred to
scheduled at specific points throughout the pregnancy, as determined by the number as antenatal.
of weeks of gestation.
When coding routine visits, with the patient having no complications, you will
choose from the available Z codes. Remember that you will use a Z code when the

CHAPTER 17  | 
 patient is not encountering the health care provider because of any current illness or
GUIDANCE injury. A healthy, pregnant woman has neither a current illness nor a current injury.
CONNECTION
Z34.01 Encounter for supervision of normal first pregnancy, first trimester
Read the ICD-10-CM Z34.82 Encounter for supervision of other normal pregnancy, second
Official Guidelines for trimester
Coding and Report-
ing, section I. Con-
As you can see, you will need to determine which code to use on the basis of the physi-
ventions, General
cian’s notes on the woman’s gravida.
Coding Guidelines
High-Risk Pregnancy
and Chapter Specific
Guidelines, subsec- In cases where the pregnancy is considered to be medically high risk, you will use a
tion C. Chapter-Specific code from category O09 Supervision of high-risk pregnancy for the routine visit.
Coding Guidelines, You will determine the fourth digit for the O09 code according to the reason stated
chapter 15. Pregnancy, in the physician’s notes that the pregnancy is considered high risk. The reason might
Childbirth, and the be a history of infertility (O09.0-), a very young mother (O09.61-), an older mother
Puerperium, subsection (O09.51-), or another issue.
b.1) Routine outpatient The fifth or sixth character is used to report which trimester the patient is in at the
prenatal visits. encounter.

EXAMPLES
GUIDANCE O09.211 Supervision of pregnancy with history of pre-term labor, first trimester
CONNECTION O09.32 Supervision of pregnancy with insufficient antenatal care, second
trimester
Read the ICD-10-CM
Official Guidelines for
Coding and Report- Incidental Pregnant State
ing, section I. Con- You may be in an office when a pregnant woman comes in for services or treatment
ventions, General from a physician for a reason that has nothing to do with her pregnancy at all. Even
Coding Guidelines though the actual treatment or service is not related to her pregnancy, the fact that she
and Chapter Specific is pregnant will affect the way the doctor treats her condition. Therefore, you must
Guidelines, subsec- always include code Z33.1 Pregnant state, incidental, to indicate the pregnancy. It will
tion C. Chapter-Specific never be a first-listed code.
Coding Guidelines,
chapter 15. Pregnancy,
EXAMPLE
Childbirth, and the
Puerperium, subsec- Wendy Weingarter is 15 weeks pregnant and works at a bank. As she was walk-
tion b.2) Supervision of ing to her car, she slipped and fractured her toe. Dr. Stewart prescribed one pain
High-Risk Pregnancy. medication rather than another because Wendy was pregnant. He also took extra
precautions while x-raying her foot. You will report these codes:
S92.424A Nondisplaced fracture of distal phalanx of right great toe, initial
encounter
Z33.1 Pregnant state, incidental

ICD-10-CM
YOU CODE IT! CASE STUDY
Genesa Thurston, a 31-year-old female, G1 P0, came to see Dr. Mallard for her routine 20-week prenatal checkup.
Dr. Mallard noted that Genesa’s blood pressure was elevated and told her to come back in 10 days for a recheck.

You Code It!

Go through the steps of coding, and determine the code or codes that should be reported for this encounter
between Dr. Mallard and Genesa.

490   PART II  |  REPORTING DIAGNOSES

 Step #1: Read the case carefully and completely.
Step #2: Abstract the scenario. Which key words or terms describe why the physician cared for the patient dur-
ing this encounter?
Step #3: Are there any details missing or incomplete for which you would need to query the physician? [If so,
ask your instructor.]
Step #4: Check for any relevant guidance, including reading all of the symbols and notations in the Tabular List
and the appropriate sections of the Official Guidelines.
Step #5: Determine the correct diagnosis code or codes to explain why this encounter was medically necessary.
Step #6: Double-check your work.
Answer:
Did you determine these to be the correct codes?
Z34.02 Encounter for supervision of normal first pregnancy, second trimester
R03.0 Elevated blood pressure reading, without diagnosis of hypertension
Good job!

Labor and Delivery

The time has come for the baby to make its way into the world (see Figure 17-3). When
the event goes picture-perfectly, requiring minimal or very little assistance from the
obstetrician, everything is simpler, including the coding. On the mother’s chart, every
encounter that results in the birth of a baby requires at least two codes:
∙ The delivery itself.
∙ The outcome of that delivery—number of babies, alive or not (Z37.-).
Additional codes may be required if there are any complications.

Normal Delivery
When a baby comes by the old-fashioned route—spontaneous, full-term, vaginal, live-
born, single infant—and there are no current complications or issues related to the
pregnancy, your principal diagnostic code will be
GUIDANCE
O80 Encounter for full-term uncomplicated delivery
CONNECTION
Amniotic sac Read the ICD-10-CM
Official Guidelines for
Coding and Reporting,
Umbilical cord
section I. Conven-
tions, General Coding
Urethra Guidelines and Chapter
Specific Guidelines,
Vagina
subsection C. Chapter-
Placenta
Cervix Specific Coding Guide-
lines, chapter 15. Preg-
Rectum nancy, Childbirth, and
the Puerperium, sub-
sections b.4) When a
delivery occurs and
FIGURE 17-3  An illustration identifying the anatomical sites of a pregnant uterus n. Normal Delivery,
and related parts of the female anatomy  Roiger, Deborah, Anatomy & Physiology: Foundations for Code O80.
the Health Professions, 1/e. ©2013 McGraw-Hill Education. Figure 16.20, pg. 619. Used with permission.

CHAPTER 17  | 
 Vertex presentation Breech presentation

GUIDANCE Shoulder presentation

CONNECTION FIGURE 17-4  Illustrations of various birth presentations

Read the ICD-10-CM
Official Guidelines for Antepartum conditions may have been a concern; however, in order to use code O80,
Coding and Report- they must have been resolved prior to the big event.
ing, section I. Con- When a pregnant woman is admitted into the hospital and delivers the baby dur-
ventions, General ing this admission, the principal diagnosis code should be the reason documented for
Coding Guidelines admitting her, whether or not it is related to the delivery of the baby.
and Chapter Specific
Guidelines, subsec- Special Circumstances Related to Delivery
tion C. Chapter-Specific The process of labor and the ultimate delivery of a baby is a natural and joyous occa-
Coding Guidelines, sion. Of course, things don’t always happen as they should. There may be an issue that
chapter 15. Pregnancy, requires ongoing observation, admission into the hospital, or some other factor requir-
Childbirth, and the ing a change to the original delivery plan (see Figure 17-4). For example:
Puerperium, subsection
a.6) 7th character for O64.1xx- Obstructed labor due to breech presentation
Fetus Identification. O60.14xx- Preterm labor third trimester with preterm delivery third trimester
O69.0xx- Labor and delivery complicated by prolapse of cord

ICD-10-CM
LET’S CODE IT! SCENARIO
Annette Spearman, a 33-year-old female, G1 P0, is in the birthing room and in full labor, ready to give birth to her
baby vaginally. All of a sudden, Dr. Tatum tells her to stop pushing. The umbilical cord has prolapsed, and they can-
not seem to move it. Dr. Tatum immediately orders Annette into the OR, where he performs a c-section. Annette’s
baby girl was born without further incident.

Let’s Code It!

Dr. Tatum performed a c-section because the umbilical cord had prolapsed, endangering the baby’s well-being.
This is an example of a complication of childbirth. How should you look it up in the Alphabetic Index? Looking

492   PART II  |  REPORTING DIAGNOSES

 up the word complication won’t work, so let’s take a look at the key diagnostic words, the reason why Dr. Tatum
performed the c-section (the procedure)—prolapsed umbilical cord.
Prolapse, prolapsed
  umbilical cord
   complicating delivery O69.0
Let’s check this out in the Tabular List. You find
O69 Labor and delivery complicated by umbilical cord complications
There is a notation about the seventh character required. First, you must determine the first six characters, so
continue reading down. The code suggested by the Alphabetic Index is the first one:
O69.0xx- Labor and delivery complicated by prolapse of cord
Notice that the code requires a seventh character. Go back up to the list shown directly below the O69 category.
Which is the most accurate seventh character? A single baby was delivered:
O69.0xx0 Labor and delivery complicated by prolapse of cord, single gestation
Good job! You will also need to report an outcome-of-delivery code. Keep reading to learn all about this.

Outcome of Delivery
GUIDANCE
As stated earlier in this chapter, every time a patient gives birth during an encounter,
you have to code the birth process (the delivery code) and you have to report the result
CONNECTION
of that birth process (the outcome-of-delivery code). Read the ICD-10-CM
The very last code on the mother’s chart that will have anything to do with the baby Official Guidelines for
is a code chosen from the Z37 Outcome of delivery category. The fourth character for Coding and Report-
the code is determined by two elements: ing, section I. Con-
ventions, General
1. How many babies were born during this delivery.
Coding Guidelines
2. Live-born, stillborn (dead), or, if a multiple birth, a combination. and Chapter Specific
Guidelines, subsec-
CODING BITE tion C. Chapter-Specific
Coding Guidelines,
Once a baby is born, the baby gets his or her own chart. From that point forward,
chapter 15. Pregnancy,
anything having to do with the baby is coded for the baby and stays off the moth-
Childbirth, and the
er’s chart.
Puerperium, subsec-
Remember that the very last code directly relating to the baby that is placed
tion b.5) Outcome of
on the mother’s chart is a code from category Z37 Outcome of delivery. The very
delivery.
first code on the baby’s chart will be from code category Z38 Liveborn infants
according to place of birth and type of delivery. This Z code is used to report that
a newborn baby has arrived, and it is always the principal (first-listed) code. A code
from this category can be used only once, for the date of birth.

ICD-10-CM
LET’S CODE IT! SCENARIO
Shoshanna Betterman, a 29-year-old female, had some third-trimester bleeding, so she went to her doctor. Dr. Patterson
performed a pelvic examination and was concerned. A transvaginal ultrasound scan confirmed that she was suffer-
ing from total placenta previa. Because she is in her 36th week, Dr. Patterson arranged to do a c-section immediately.
Shoshanna’s baby girl was born without further incident.

(continued)

CHAPTER 17  | 
 Let’s Code It!
Dr. Patterson performed a c-section on Shoshanna because she had total placenta previa with bleeding. Go to
the Alphabetic Index and look up
Placenta, placental — see Pregnancy, complicated by (care of) (management affected by), specified
condition
So let’s turn to
Pregnancy
  complicated by (care of) (management affected by)
   placenta previa O44.0-
In the Tabular List, you confirm it is an appropriate code. Start reading at
O44 Placenta previa
There are no notations or directives, so keep reading down the column to determine the most accurate fourth
character:
O44.0- Complete placenta previa NOS or without hemorrhage
O44.1- Complete placenta previa with hemorrhage
Be certain not to go too fast, or you might miss that the first code, O44.0, states, “without hemorrhage.”
Shoshanna was hemorrhaging (bleeding). This makes O44.1 more accurate.
Now, you need to determine the required fifth character. As with all codes in this chapter of ICD-10-CM, you
will need to determine, from the documentation, which trimester Paula was in at this encounter. Dr. Patterson
stated, “some third-trimester bleeding.”
Put it all together and your code for this encounter is
O44.13 Complete placenta previa with hemorrhage, third trimester
That’s good. But coding for the encounter with Shoshanna is not complete.
Shoshanna is in only her 36th week of gestation. Therefore, you need to include this detail. Turn to the Alpha-
betic Index and look up weeks—nothing there. Try gestation—not there either. Let’s turn to
Pregnancy
  weeks of gestation
   36 weeks Z3A.36
Turn to the Tabular List to confirm, as is required by the Official Guidelines:
Z3A Weeks of gestation
  Z3A.36 36 weeks gestation
Terrific! You need one more code, to report the outcome of delivery. Shoshanna had one live-born baby.
Z37 Outcome of delivery
There are no notations or directives, so read down the column to determine the required fourth character that
will accurately report Shoshanna’s outcome of delivery:
Z37.0 Outcome of delivery, single live birth
Excellent!
O44.13 Placenta previa with hemorrhage, third trimester
Z3A.36 36 weeks gestation
Z37.0 Outcome of delivery, single live birth

494   PART II  |  REPORTING DIAGNOSES

 CODING BITES CODING BITES
The last code on the mother’s chart regarding the baby is a code from category Preterm labor is defined
Z37 Outcome of delivery. Once the baby is born, he or she will get his or her own as the spontaneous
chart. The first code on the baby’s chart is a code from category Z38 Liveborn onset of labor before
infants according to place of birth and type of delivery. More information about 37 completed weeks of
coding for the baby’s medical record is coming up later in this chapter. gestation.

ICD-10-CM
YOU CODE IT! CASE STUDY
Charles Wallace drove his wife, Angela, a 30-year-old female, to the hospital. She had gone into labor, but she was
only at 35 weeks gestation. Dr. Callahan assisted in the delivery of her twin girls. However, there was a problem, and
one of the twins was stillborn.

You Code It!

Review Dr. Callahan’s notes on this encounter with Angela and the birth process, and determine the most accu-
rate codes.
Step #1: Read the case carefully and completely.
Step #2: Abstract the scenario. Which key words or terms describe why the physician cared for the patient dur-
ing this encounter?
Step #3: Are there any details missing or incomplete for which you would need to query the physician? [If so,
ask your instructor.]
Step #4: Check for any relevant guidance, including reading all of the symbols and notations in the Tabular List
and the appropriate sections of the Official Guidelines.
Step #5: Determine the correct diagnosis code or codes to explain why this encounter was medically necessary.
Step #6: Double-check your work.
Answer:
Did you determine these to be the correct codes?
O60.14x1 Preterm labor third trimester with preterm delivery third trimester, fetus 1
O60.14x2 Preterm labor third trimester with preterm delivery third trimester, fetus 2
Z3A.35 35 weeks gestation
Z37.3 Outcome of delivery, twins, one liveborn and one stillborn
Good job!

17.6  Pregnancies with Complications

A complication of pregnancy is considered to be any condition or illness that may
∙ Threaten the pregnant state, such as an ectopic pregnancy or an abortion.
∙ Affect or threaten the health of the woman, such as hemorrhage or vomiting.
∙ Influence the manner in which the woman will be treated, such as preexisting car-
diovascular disease or chromosomal abnormality in the fetus.
A complication may be something as common as mild hyperemesis gravidarum (code
O21.0), commonly known as morning sickness, or something of concern, such as a
kidney infection (e.g., O23.03 Infections of kidney in pregnancy, third trimester).

CHAPTER 17  | 
 ICD-10-CM
YOU CODE IT! CASE STUDY
Vitalita Meadows, a 31-year-old female, G2 P1, is 17 weeks pregnant. Dr. Kramer is meeting with her to discuss her
lab test results, which indicate that Vitalita has anemia. Dr. Kramer is concerned about how the anemia will affect
her pregnancy.

You Code It!

Go through the steps of coding, and determine the code or codes that should be reported for this encounter
between Dr. Kramer and Vitalita.
Step #1: Read the case carefully and completely.
Step #2: Abstract the scenario. Which key words or terms describe why the physician cared for the patient dur-
ing this encounter?
Step #3: Are there any details missing or incomplete for which you would need to query the physician? [If so,
ask your instructor.]
Step #4: Check for any relevant guidance, including reading all of the symbols and notations in the Tabular List
and the appropriate sections of the Official Guidelines.
Step #5: Determine the correct diagnosis code or codes to explain why this encounter was medically necessary.
Step #6: Double-check your work.
Answer:
Did you determine this to be the correct code?
O99.012 Anemia complicating pregnancy, second trimester
Good work!

Preexisting Conditions Affecting Pregnancy

GUIDANCE
Some diseases and illnesses are coded differently when the only thing that has changed
CONNECTION is that the woman is now pregnant. Such cases most often involve conditions, such as
Read the ICD-10-CM diabetes mellitus or hypertension, that are systemic (involving the whole body) and,
Official Guidelines for therefore, will complicate the pregnancy, childbirth, or puerperium:
Coding and Report-
O10.01- Pre-existing essential hypertension complicating pregnancy
ing, section I. Conven-
O11- Pre-existing hypertension with pre-eclampsia
tions, General Coding
O24.01- Pre-existing diabetes mellitus, type 1, in pregnancy
Guidelines and Chapter
O24.11- Pre-existing diabetes mellitus, type 2, in pregnancy
Specific Guidelines, sub-
O24.81- Other pre-existing diabetes mellitus in pregnancy
section C. Chapter-
O98.7- HIV complicating pregnancy, childbirth, and the puerperium
Specific Coding Guide-
lines, chapter 15. Preg-
nancy, Childbirth, and Gestational Conditions
the Puerperium, sub- Other conditions solely related to pregnancy may make caring for a woman and her
sections c. Pre-existing unborn baby more challenging. Gestational conditions develop as a result of any of the
conditions versus condi- many changes a woman’s body goes through and are typically transient, meaning they
tions due to the preg- are expected to go away once the pregnancy is complete.
nancy, d. Pre-existing
hypertension in preg- O13- Gestational [pregnancy-induced] hypertension without significant
nancy, and g. Diabetes proteinuria
mellitus in pregnancy. O22.43 Hemorrhoids in pregnancy, third trimester
O24.4- Gestational diabetes mellitus

496   PART II  |  REPORTING DIAGNOSES

Multiple Gestations GUIDANCE
Code category O30 provides you with the code options available to report a multiple CONNECTION
gestation. In addition to determining the number of fetuses from the documentation,
you will also need to determine Read the ICD-10-CM
Official Guidelines for
∙ The number of placentae (monochorionic, dichorionic, or more). Coding and Report-
∙ The number of amniotic sacs (monoamniotic, diamniotic, or more). ing, section I. Con-
∙ The specific trimester the gestation is in during this encounter. ventions, General
Coding Guidelines
and Chapter Specific
EXAMPLES Guidelines, subsec-
O30.032 Twin pregnancy, monochorionic/diamniotic, second trimester tion C. Chapter-Specific
O30.111 Triplet pregnancy with two or more monochorionic fetuses, first Coding Guidelines,
trimester chapter 15. Pregnancy,
Childbirth, and the
Puerperium, subsec-
Fetal Abnormalities tion e. Fetal Conditions
When a woman is pregnant, all care for both her and the baby is provided to the woman Affecting the Manage-
herself. Therefore, if there is a change to the treatment or care plan of the mother that ment of the Mother.
is prompted by an issue with the fetus, it must be documented and reported. This may
be necessary to support medical necessity for admission to the hospital, for example.
Code categories O35 Maternal care for known or suspected fetal abnormality and
damage and O36 Maternal care for other fetal problems provide you with the options.

EXAMPLES
O36.593- Maternal care for other known or suspected poor fetal growth,
third trimester
This diagnosis would explain the medical necessity for the mother
being referred to a nutritionist for a special diet.
O35.3XX- Maternal care for (suspected) damage to fetus from viral disease
in mother
This diagnosis would explain the medical necessity for the mother
to have special laboratory tests or an amniocentesis.
Note: The seventh character reports which fetus is, or may be, damaged or abnor-
mal. The number 0 (zero) is used for a single gestation, the number 1 for the first
of a multiple gestation, the number 2 for the second fetus, and so on.

Seventh Character
You may have noticed that many pregnancy complication codes require a seventh
character. If the pregnancy is a single gestation, you will report a zero (0). However,
when there is more than one fetus, you will need to determine, from the documenta-
tion, which specific fetus is having the problem described by the code. For example:
O64.2xx3 Obstructed labor due to face presentation, fetus 3
O69.1xx2 Labor and delivery complicated by cord around neck, with com-
pression, fetus 2

Postpartum and Peripartum Conditions

After the birth, the woman’s body continues to go through changes. In some cases,
treatment of an antepartum condition extends into the postpartum period. On other
occasions, health care concerns develop during or after delivery. The postpartum
period begins at delivery and extends for 6 weeks. The peripartum period runs from
the beginning of the last month of pregnancy and ends 5 months after delivery.

CHAPTER 17  | 
 Routine postpartum care, just like routine prenatal care, is reported with a Z code:
GUIDANCE
CONNECTION Z39.0 Encounter for care and examination of mother immediately after
delivery
Read the ICD-10-CM Z39.1 Encounter for care and examination of lactating mother
Official Guidelines for Z39.2 Encounter for routine postpartum follow-up
Coding and Reporting,
section I. Conven- Whenever the health care concern arises—even if the diagnosis falls outside the
tions, General Coding 6-week period—if the physician’s notes document that it is a postpartum complica-
Guidelines and Chapter tion, or pregnancy-related, you are to code it as a postpartum condition.
Specific Guidelines,
subsection C. Chapter- Sequelae (Late Effects) of Obstetric Complications
Specific Coding Guide-
Late effects of obstetric complications, as identified by the attending physician in his
lines, chapter 15. Preg-
or her notes, are coded the same way as all other sequelae. The late effect code— O94
nancy, Childbirth, and
Sequelae of complication of pregnancy, childbirth, and the puerperium—is added
the Puerperium, sub-
when a condition begins during pregnancy but requires continued treatment. The code
section o. The Peripar-
is placed after the code describing the actual health condition. Notice the notation
tum and Postpartum
beneath this code:
Periods.
Code first condition resulting from (sequela) of complication of pregnancy, child-
birth, and the puerperium

ICD-10-CM
YOU CODE IT! CASE STUDY
Marjorie Ableman, a 31-year-old female, gave birth, vaginally, to a beautiful baby girl 3 weeks ago. She comes
today to see Dr. Beale because of feelings of fatigue. After exam and blood tests, Dr. Beale diagnoses her with post-
partum cervical infection caused by Enterococcus.

You Code It!

Go through the steps of coding, and determine the code or codes that should be reported for this encounter
between Dr. Beale and Marjorie.
Step #1: Read the case carefully and completely.
Step #2: Abstract the scenario. Which key words or terms describe why the physician cared for the patient dur-
ing this encounter?
Step #3: Are there any details missing or incomplete for which you would need to query the physician? [If so,
ask your instructor.]
Step #4: Check for any relevant guidance, including reading all of the symbols and notations in the Tabular List
and the appropriate sections of the Official Guidelines.
Step #5: Determine the correct diagnosis code or codes to explain why this encounter was medically necessary.
Step #6: Double-check your work.
Answer:
Did you determine these to be the correct codes?
O86.11 Cervicitis following delivery
B95.2 Enterococcus as the cause of diseases classified elsewhere
O94 Sequela of complication of pregnancy, childbirth, and the puerperium

498   PART II  |  REPORTING DIAGNOSES

Abortive Outcomes Abortion
The end of a pregnancy prior
The term abortion should not automatically start a political or religious discussion. to or subsequent to the death
Abortions can be spontaneous (caused by a biological or natural trigger) or be induced of a fetus.
(initiated by an artificial or therapeutic source). What is commonly known as a mis-
carriage is clinically known as an abortion. GUIDANCE
Many different situations can result in the loss of the fetus:
CONNECTION
O00.- Ectopic pregnancy
O01.- Hydatidiform mole Read the ICD-10-CM
O02.- Other abnormal products of conception Official Guidelines for
O03.- Spontaneous abortion Coding and Reporting,
O04.- Complications following (induced) termination of pregnancy section I. Conven-
O07.- Failed attempted termination of pregnancy tions, General Coding
Guidelines and Chapter
Specific Guidelines,
GUIDANCE CONNECTION subsection C. Chapter-
Read the ICD-10-CM Official Guidelines for Coding and Reporting, section I. Conven- Specific Coding Guide-
tions, General Coding Guidelines and Chapter Specific Guidelines, subsection C. lines, chapter 16.
Chapter-Specific Coding Guidelines, chapter 15. Pregnancy, Childbirth, and the Certain Conditions
Puerperium, subsection q. Termination of Pregnancy and Spontaneous Abortions. Originating in the Peri-
natal Period, subsection
a. General Perinatal
Rules.
EXAMPLE
Nellie, a 22-year-old female who was 10 weeks pregnant, was reading a text mes-
sage while driving her SUV in slow traffic and didn’t notice that the car in front of
her had stopped. She hit it. The steering wheel struck and severely bruised her
abdomen. This trauma caused her to hemorrhage, resulting in a complete miscar-
riage. You would report these codes:
O03.6 Delayed or excessive hemorrhage following complete or
unspecified spontaneous abortion
V47.5xxA Car driver injured in collision with fixed or stationary object in
traffic accident initial encounter

17.7  Neonates and Congenital Anomalies

Neonates
Once a baby is born, the baby gets his or her own chart. From that point forward, any-
thing having to do with the baby is coded for the baby and stays off the mother’s chart.
Remember that the very last code directly relating to the baby that is placed on the
mother’s chart is a code from category Z37 Outcome of delivery. The very first code
on the baby’s chart will be from code category Z38 Liveborn infants according to place
of birth and type of delivery. This Z code is used to report that a newborn baby has
arrived, and it is always the principal (first-listed) code. A code from this category can
be used only once, for the date of birth.

ICD-10-CM
LET’S CODE IT! SCENARIO
Tristan Allen Montegro was born via vaginal delivery in the McGraw Birthing Center at 10:58 a.m. on September
1. He weighed 8 pounds 5 ounces and was 21 inches long, with Apgar scores of 9 and 9. Dr. Grall, a pediatrician,
performed a comprehensive examination immediately following Tristan’s birth. Baby Tristan was sent home at 6:30
p.m. in the care of his mother, Arashala.
(continued)

CHAPTER 17  | 
 Let’s Code It!
Tristan was just born, and this is his first health care chart. As you learned, his very first code must be from the
Z38 range. As with all other cases, begin in the Alphabetic Index. What should you look up? Birth would be a
logical choice. However, when you turn to this term in the Alphabetic Index, you are going to see a long list of
adjectives, none of which applies to Tristan, or any other baby being born without a problem. As you look down
the list, you may notice this item:
Birth
There is nothing here that fits. Let’s go look up the term newborn.
Newborn (infant) (liveborn) (singleton) Z38.2
Check Dr. Smith’s notes. It is documented that Tristan was a single, liveborn baby.
Let’s go to the Tabular List and look at our choices. Begin with
Z38 Liveborn infants according to place of birth and type of delivery
As you read down, you can see that code Z38.2 reports Single liveborn infant, unspecified as to place of birth.
The documentation clearly indicates where Tristan was born—in the McGraw Birthing Center (not a part of a
hospital). So this code is not accurate. Keep reading. The answer from the documentation will bring you to the
correct code:
Z38.1 Single liveborn infant, born outside the hospital
Good work!

GUIDANCE Suspected Conditions Not Found

CONNECTION After a neonate comes into the world, there may be concerns requiring tests to be
run or for the baby to stay in the hospital longer. When there is good news, and it
Read the ICD-10-CM turns out the baby is healthy and all the tests are negative, how will you report the
Official Guidelines for medical necessity for the tests and extended stay in the hospital? You will report code
Coding and Reporting, Z05 Encounter for Observation and evaluation of newborns for suspected conditions
section I. Conven- ruled out to explain the circumstances.
tions, General Coding For a readmission to the hospital or an outpatient encounter, Z05 may be used as a
Guidelines and Chapter principal or first-listed diagnosis code.
Specific Guidelines,
subsection C. Chapter-
Specific Coding Guide-
Clinically Significant Conditions
lines, chapter 16. The guidelines state that you must code all clinically significant conditions noted on
Certain Conditions the baby’s chart during the standard newborn examination. You may be concerned
Originating in the Peri- about how you, as a coder, can determine what is clinically significant and what is
natal Period, subsection not. Good news! It is not your decision to make. Only the physician can determine and
b. Observation and document this. However, you must ensure that the documentation gives you the diag-
Evaluation of New- nostic conditions that support any of the following:
borns for Suspected
∙ Therapeutic treatments performed: For example, perhaps the baby is placed on a
Conditions not Found.
respirator.
∙ Diagnostic procedures done: For example, perhaps additional and specific blood
Clinically Significant tests are performed on the baby.
Signs, symptoms, and/or con-
ditions present at birth that ∙ Keeping the baby in the hospital longer than usual: Perhaps the physician is con-
may impact the child’s future cerned about an issue so he or she does not discharge the baby yet.
health status. ∙ Increased monitoring or nursing care: Perhaps the physician orders 24-hour
private-duty nursing care for continuous monitoring.

500   PART II  |  REPORTING DIAGNOSES

 ∙ Any implication that the child will need health care services in the future as a result Perinatal
of a condition, sign, or symptom that can be identified now: Perhaps there is evi- The time period from before
dence that there may be brain damage as a result of the birth process; however, this birth to the 28th day after
cannot be confirmed until the child is about 2 years old. birth.

When a congenital or perinatal condition has been resolved and no longer has an Prematurity
Birth occurring prior to the
impact on the child’s health and well-being, you will need to assign a code from the
completion of 37 weeks
range Z85–Z87, Personal history of . . . .
gestation.

Maternal Conditions Affecting the Infant Low Birth Weight (LBW)

A baby born weighing less
When the physician’s notes specify that a mother’s illness, injury, or condition had a than 5 pounds 8 ounces, or
direct impact on the baby’s health, you will include a code on the baby’s chart from the 2,500 grams.
subsection code range P00–P04 Newborn affected by maternal factors and by compli-
cations of pregnancy, labor, and delivery.
Conditions in the mother, such as nutrition, smoking, high blood pressure, the pres- GUIDANCE
ence of certain infections, or an abnormal uterus or cervix, can increase the possibili- CONNECTION
ties that the baby might be born prematurely and/or with a low birth weight (LBW). Read the ICD-10-CM
A mother’s heart, kidney, and/or lung problems might also affect the baby’s health. Official Guidelines for
While the reasons are not completely understood by physicians, a woman may Coding and Report-
experience spontaneous premature rupture of the membranes (PROM), which results ing, section I. Conven-
in spontaneous preterm labor. There is virtually nothing that can be done to prevent the tions, General Coding
situation that so often leads to the birth of a premature, LBW baby. Guidelines and Chapter
A preterm (premature) neonate is one who has been in gestation for at least 28 com- Specific Guidelines,
pleted weeks but less than 37 completed weeks (or between 196 and 258 completed subsection C. Chapter-
days). While the baby’s chart will almost always include a notation of the number of Specific Coding Guide-
weeks gestation at birth, you are permitted to code “prematurity” only when it is spe- lines, chapter 16.
cifically documented by the physician. Certain Conditions Orig-
A weight of less than 2,500 grams at birth is also an indicator of prematurity. When inating in the Perinatal
a fetus has not had the prescribed length of time to grow, the neonate can be suscep- Period, subsections a.6)
tible to certain health concerns, realized in the near or distant future. Code all clinically sig-
Premature, LBW babies are more likely to be at risk for developing certain condi- nificant conditions and
tions now and later in life. Incomplete growth of the fetus’s central nervous system c. Coding Additional
can result in feeding difficulties for the neonate/infant, recurrent apnea, and/or poor Perinatal Diagnoses.
vasomotor control. Testing for neonatal hyperbilirubinemia, especially when jaundice
is visible, can indicate that the liver did not develop sufficiently to create and excrete
bilirubin (a yellowish component of bile that is made by the liver). This is why it is so
important that the documentation and the coding accurately report the baby’s situation CODING BITES
from the beginning. Some of the most common conditions include these: Usually, the physician
will write the baby’s
∙ Breathing problems, including respiratory distress syndrome (RDS).
birth weight in grams.
∙ Periventricular and/or intraventricular hemorrhage (bleeding in the brain). However, you should
∙ Patent ductus arteriosus (PDA), a dangerous heart problem. learn how to convert
∙ Necrotizing enterocolitis (NEC), an intestinal problem that leads to difficulties in from pounds and
feeding. ounces to grams:
∙ Retinopathy of prematurity (ROP). 1 ounce = 28.350 gm
∙ Low body temperature (caused by a lack of body fat used by newborns to maintain 1 pound = 16 oz
normal body temperature), which promotes slow growth, breathing problems, and  = 453.6 gm
other complications.
∙ Apnea, an interruption in breathing.
∙ Jaundice, a result of incomplete liver development.
∙ Anemia.
∙ Bronchopulmonary dysplasia, also known as chronic lung disease.
∙ Infections, due to the inability of immature immune systems to fight off bacteria
and viruses.

CHAPTER 17  | 
Mortality Respiratory distress syndrome (RDS) is the leading cause of mortality and morbidity
Death. of premature neonates. The immature lungs have an insufficient quantity of surfactant—
Morbidity the secretion within the lungs that supports the alveoli and keeps them from collapsing.
Unhealthy. Maternal diabetes and neonatal asphyxia are known contributing factors. RDS causes
hypoxia, which can then lead to pulmonary ischemia, pulmonary capillary damage, and
fluid leaking inappropriately into the alveoli. Cyanosis, increased respiratory effort,
anoxia, and acidosis are signs and complications. Report a diagnosis of RDS with code
CODING BITES P22.0 Respiratory distress syndrome of newborn.
Codes from category You will find the codes needed to report an infant’s prematurity and/or LBW, as
P05 and category P07 well as long gestation and high birth weight, as documented in the physician’s notes,
may not be reported on within these code categories:
the same claim at the
same time. P05 Disorders of newborn related to slow fetal growth and fetal malnutrition
P07 Disorders of newborn related to short gestation and low birth weight,
not elsewhere classified
P08 Disorders of newborn related to long gestation and high birth weight

GUIDANCE CONNECTION
Read the ICD-10-CM Official Guidelines for Coding and Reporting, section I. Con-
ventions, General Coding Guidelines and Chapter Specific Guidelines, subsec-
tion C. Chapter-Specific Coding Guidelines, chapter 16. Certain Conditions
Originating in the Perinatal Period, subsections d. Prematurity and Fetal Growth
Retardation and e. Low birth weight and immaturity status.

ICD-10-CM
YOU CODE IT! CASE STUDY
Harper Anne Glosick was born today at 27 weeks 2 days gestation by cesarean section at Hillside Hospital. She
weighed 945 grams at birth, and her lungs are immature. Dr. McArthur admits Harper into the neonatal intensive
care unit (NICU) with a diagnosis of extreme immaturity.

You Code It!

Read through Dr. McArthur’s notes on Harper, and determine the correct diagnosis code or codes.
Step #1: Read the case carefully and completely.
Step #2: Abstract the scenario. Which key words or terms describe why the physician cared for the patient dur-
ing this encounter?
Step #3: Are there any details missing or incomplete for which you would need to query the physician? [If so,
ask your instructor.]
Step #4: Check for any relevant guidance, including reading all of the symbols and notations in the Tabular List
and the appropriate sections of the Official Guidelines.
Step #5: Determine the correct diagnosis code or codes to explain why this encounter was medically necessary.
Step #6: Double-check your work.
Answer:
Did you determine these to be the correct codes?
Z38.01 Single liveborn, infant, delivered by Cesarean
P07.03 Extremely low birth weight newborn, 750–999 grams
P07.26 Extreme immaturity of newborn, gestational age 27 completed weeks

502   PART II  |  REPORTING DIAGNOSES

Well-Baby Checks
CODING BITES
These encounters, just like adult physicals and other checkups, are scheduled by the
See the notation beneath
age of the child: 2 to 4 days, 1 month, 2 months, 4 months, 6 months, 9 months, 1 year,
code category P07:
15 months, 18 months, 2 years, 2.5 years, 3 years, and then annually. The age of the
child also influences which codes are reported for the well-baby encounter: Note: When both birth
weight and gestation-
Z00.110 Health examination for newborn under 8 days old
al age of the newborn
Z00.111 Health examination for newborn 8 to 28 days old
are available, both
Z00.121 Encounter for routine child health examination with abnormal
should be coded
findings
with birth weight
Use additional code to identify abnormal findings
sequenced before
Z00.129 Encounter for routine child health examination without abnormal
gestational age.
findings

ICD-10-CM
LET’S CODE IT! SCENARIO
Roseanna Glassman brought her 39-day-old daughter, Marisol, to Dr. Granger for her routine health check. During the
examination, Roseanna related that Marisol’s head accidentally was banged into the table and she was worried about
neurologic problems. Dr. Granger checked her head and found no bruise or laceration. To calm Roseanna, he took Mari-
sol down the hall to have a special neurologic screening for traumatic brain injury. Fortunately, the scan was negative.

Let’s Code It!

What key words in the notes provide you with the information you need to report this encounter? Why did
Dr. Granger care for Marisol? Marisol was brought in for her “routine health check”—her regular well-baby visit.
What will you look up in the Alphabetic Index? Routine? Nothing there. Well-baby? Nothing there. Try a term that
is not technically a diagnosis: examination. Take a look and find
Examination (for) (following) (general) (of) (routine) Z00.00
Read down the long list of additional descriptors and find
Child (over 28 days old) Z00.129
That sounds accurate. So let’s turn to the Tabular List and check it out:
Z00 Encounter for general examination without complaint, suspected or reported diagnosis
There are no notations or directives, so read down the column to determine the most accurate fourth character:
Z00.12 Encounter for routine child health examination
Read the notations beneath this code. First, notice that it states “Health check (routine) for child over 28 days
old.” How old is Marisol? She is 39 days, so this is the correct code. Carefully read the notation, and
ask yourself: Does this apply to Dr. Granger’s caring for Marisol during this encounter? No, it doesn’t. Read down
to review the sixth-character choices. The notes state that he did a neurologic screening because of the bang to
her head. You will need to check the documentation for the results of this screening so you can report “abnormal
findings” or not. The documentation states that “the scan was negative,” so you will report this code:
Z00.129 Encounter for routine child health examination without abnormal findings
You still need to report the neurologic screening. Go back to the Alphabetic Index and look up
Screening (for) Z13.9
  neurological condition Z13.89
That’s really the only suggested code, so let’s take a look at it in the Tabular List:
Z13 Encounter for screening for other diseases and disorders

(continued)

CHAPTER 17  | 
 Go back to the notes and see that Dr. Granger wrote “neurologic screening for traumatic brain injury.” There-
fore, you know that Z13.850 Encounter for screening for traumatic brain injury is accurate and matches what
Dr. Granger wrote in the notes.
One more code—remember, you need to report a code for the bang on the head because this led Dr. Granger
to do the screening. Check the notes and see that Dr. Granger found no bruises or lacerations and that Roseanna
did not report any other signs or symptoms, such as vomiting or seizure. The bang on the head will have to be
reported with an external cause code because it is an external factor that explains why Dr. Granger screened
Marisol for a TBI. Check the External Causes Code Alphabetic Index and look up strike, striking because Marisol’s
head struck the table (furniture). Code W22.03 is suggested. Let’s check the Tabular List:
W22 Striking against or struck by other objects
W22.03x- Walked into furniture
This cannot be accurate because Marisol is only 39 days old and she cannot walk yet. Review all of the other
codes in this subsection to determine the code that will report what happened:
W22.8xxA Striking against or struck by other objects, initial encounter
So for Marisol’s visit to Dr. Granger, you have three codes to report:
Z00.129 Encounter for routine child health examination without abnormal findings
Z13.850 Encounter for screening for traumatic brain injury
W22.8xxA Striking against or struck by other objects, initial encounter

ICD-10-CM
YOU CODE IT! CASE STUDY
Ines Nancy Mulle was born, full term, vaginally at Barton Hospital. Her mother has been an alcoholic for many years
and would not stop drinking during the pregnancy. Ines weighed only 1,575 grams, small for a full-term neonate.
After testing, she was diagnosed at birth with fetal alcohol syndrome and admitted into the NICU.

You Code It!

Read the notes on Ines, and determine the most accurate diagnosis code(s).
Step #1: Read the case carefully and completely.
Step #2: Abstract the scenario. Which main words or terms describe why the physician cared for the patient
during this encounter?
Step #3: Are there any details missing or incomplete for which you would need to query the physician? [If so,
ask your instructor.]
Step #4: Check for any relevant guidance, including reading all of the symbols and notations in the Tabular List
and the appropriate sections of the Official Guidelines.
Step #5: Determine the correct diagnosis code or codes to explain why this encounter was medically necessary.
Step #6: Double-check your work.
Answer:
Did you determine these to be the correct codes?

Z38.00 Single liveborn infant, delivered vaginally

P05.16 Newborn small for gestational age, 1500–1749 grams
Q86.0 Fetal alcohol syndrome (dysmorphic)
Terrific!

504   PART II  |  REPORTING DIAGNOSES

Genetics
Genetics is the study of diseases passed from parent to child, a process known as
hereditary transmission. There are more than 1,000 diseases that might be inherited.
A genetic disorder may be dominant—the result of one defective gene in a pair—or it
may be recessive—the result of both alleles being defective. Some examples of dom-
inant genetic disorders are familial hypercholesterolemia (code E87.8) and familial
retinoblastoma (code C69.2-). Examples of recessive genetic disorders include cystic
fibrosis (code E84.9) and Gaucher’s disease (code E75.22). Certain diseases that have
been correlated to genetics cause accelerated aging, such as Hutchinson-Guilford pro-
geria (code E34.8), an inherited endocrine disorder.
If the patient is diagnosed with a specific genetic condition, you will need to report
the code for the confirmed diagnosis. However, there are times when the patient does
not exhibit any signs or symptoms of the condition. In these cases, it may be important
to document the family history of the condition to support more frequent screenings or
other preventive or early detection services, such as Family history of alcohol abuse and
dependence, reported with code Z81.1.

Genetic Conditions versus Congenital Malformations

The term congenital anomaly means an abnormality present at birth and therefore refers Congenital
to any variation from the norm for a neonate. The abnormality may be genetic in nature or A condition existing at the
may be a malformation that occurred during gestation. A genetic condition may indicate time of birth.
that a chromosomal alteration has been inherited—passed down from parent to child via Anomaly
chromosomal and cell structures. Or the condition may be a congenital malformation, An abnormal, or unexpected,
or damage to a chromosome during formation. A congenital malformation means that condition.
something went awry during the gestational process. Such alterations can occur sponta-
neously or can be an adverse reaction to a pathogen, drug, radiation, or chemical. Malformation
An irregular structural
development.
EXAMPLES
Q91.2 Trisomy 18, translocation
Q93.3 Deletion of short arm of chromosome 4

Inherited Conditions
Your blue eyes and brown hair are the products of genetics—qualities in the chromo-
somes you received from your father and mother. Sadly, a genetic abnormality will
negatively affect the health of a child. An inherited mutation in the DNA causes a
permanent alteration that will affect each and every cell as it multiplies during the
GUIDANCE
maturation of the zygote to embryo to fetus to neonate. There is also a strong probabil-
ity that this person will pass this condition along to his or her children. CONNECTION
Read the ICD-10-CM
Congenital Anomalies Official Guidelines for
A congenital malformation, also known as a birth defect, is a permanent physical Coding and Reporting,
defect—the incomplete development of an anatomical structure—that is identified in section I. Conven-
a neonate. It may be the effect of a genetic mutation, or it may have been caused by tions, General Coding
a prenatal event. The fetal development of many organs, including the brain, heart, Guidelines and Chapter
lungs, liver, bones, and/or intestinal tract, may have been altered by alcohol or drugs Specific Guidelines,
used by the mother at a particular point during gestation, by exposure to an environ- subsection C. Chapter-
mental factor, or by an injury sustained during delivery. Specific Coding
Guidelines, chapter
EXAMPLES 17. Congenital malfor-
mations, deformations,
Q14.1 Congenital malformation of retina and chromosomal
Q64.4 Malformation of urachus abnormalities.

CHAPTER 17  | 
 Testing
Health care research has found ways to identify the presence or the likelihood of
genetic disorders and congenital anomalies.
Genetic testing can be performed prior to fertilization so the potential parents can
gain insights on the possibility of passing along certain diseases to their future chil-
dren. A family tree analysis, called a pedigree, is a diagram of the individual’s family
that includes diseases and causes of death. A geneticist (a physician specializing in
the study of genetics) can use this diagram to identify inheritance patterns and prob-
abilities. In addition, a blood test known as a karyotype can be used. During this test,
multiple staining techniques can illuminate each chromosomal band to enable visual-
ization of a mutation.
Prenatal blood and DNA tests can currently detect more than 600 genetic disorders
prior to the baby’s birth. This information can allow parents to make informed deci-
sions and to become prepared emotionally, intellectually, and financially for the birth
of a child with a genetic disorder. In addition, the physician can make certain appropri-
ate arrangements, such as method of delivery and timing of delivery, that may reduce
the severity or impact of the condition.
Amniocentesis is the process of collecting a sample of amniotic fluid via needle
aspiration from a pregnant uterus. Chorionic villus sampling is the process of obtain-
ing tissues from the placenta for prenatal testing by passing a catheter through the
vagina and threading it up to the placenta.
Genetic tests are not limited to potential or impending parents. Adults can use this
information as well. For example, many women are tested for the BRCA1 or BRCA2
gene that identifies a potential for the development of breast and/or ovarian cancer.

EXAMPLES
Z14.1 Cystic fibrosis carrier
Z15.01 Genetic susceptibility to malignant neoplasm of breast

Gene Therapy
Researchers continue to experiment with gene therapy to prevent or treat these types
of diseases. The goal is to find a safe and effective way to correct a malfunctioning
gene. Methods currently being investigated include
∙ Placing a normal gene into the genome in a nonspecific place so it can provide the
correct function of the nonfunctional gene.
∙ Using homologous recombination to remove the abnormal gene and replace it with
a normal gene.
∙ Using selected reverse mutation to actually repair the gene so it will function properly.
In such cases, the term placed or inserted does not mean the same as it typically does
in the context of other health care procedures. One method is to put the therapeutic
gene into a carrier molecule, known as a vector, which is a genetically altered virus.
Nonviral methods include the injection of the therapeutic gene directly into its target
cell. However, this can be accomplished only with a limited number of tissue types.
Studies are being conducted on the effectiveness of using an artificial liposome and/or
certain chemicals to achieve the successful delivery of the therapeutic gene.
Genetic Abnormality
An error in a gene (chromo- Genetic Disorders
some) that affects develop-
ment during gestation; also
Chromosomal Abnormalities
known as a chromosomal Down syndrome (trisomy 21) is a spontaneous genetic abnormality and is not inher-
abnormality. ited. Manifestations include mental retardation, unusual facial features including

506   PART II  |  REPORTING DIAGNOSES

slanted eyes and protruding tongue, and congenital heart defects, as well as respiratory
and related complications. Mosaicism is possible in a child with Down syndrome. This
is the occurrence of cells with two different genetic makeups within one person. The
possibility of having a child with Down syndrome increases with the age of the mother
at the time of delivery. Treatment of manifestations can improve the patient’s quality
of life and extend the life span. Use code category Q90 Down syndrome (trisomy 21),
with an additional character to report nonmosaicism, mosaicism, or translocation. An
additional code to identify specific physical and intellectual disabilities is required.
Klinefelter’s syndrome is a genetic abnormality that results in the inclusion of an
extra X chromosome in a male child. Testicular changes occur at puberty, including
eventual infertility due to the deterioration of the testicles. In addition, gynecomastia
may develop, learning disabilities may become apparent, facial hair may be sparse,
and reduced libido causing impotence will become evident. There is a mosaic form of
Klinefelter’s. Report this syndrome with a code from category Q98 Other sex chromo-
some abnormalities, male phenotype, not elsewhere classified.

Autosomal Recessive Inherited Diseases

Cystic fibrosis is seen most often in Caucasian children and rarely seen in black or
Asian populations. This disease causes chronic pulmonary disease and deficient exo-
crine pancreatic function, development of thickened mucus that can block bile flow
from the liver, and other manifestations. Use code category E84 Cystic fibrosis, with
an additional character to identify manifestations.
Tay-Sachs disease (Tay-Sachs amaurotic familial idiocy) is an inherited disease that
results in the child’s death before the age of 4. Symptoms include increasing deteriora-
tion of motor skills and mental acuity, identifiable in the infant at 6 to 10 months of
age. Genetic tests can screen potential parents. Report this disease with code E75.02
Tay-Sachs disease.
Phenylketonuria (PKU) is a genetic disorder that causes a gradual deterioration of
the patient’s mental faculties, often discernable by 1 year of age. Many hospitals per-
form a simple blood test for PKU as a part of the birth evaluation. This condition can
be treated with a semisynthetic diet. Outcomes improve with early detection. Report
PKU with code E70.0 Classical phenylketonuria or E70.1 Other hyperphenylalanin-
emias (maternal).
Sickle cell anemia is an inherited hemolytic anemia that develops as the result of a
defective hemoglobin molecule that causes the red blood cells to be misshapen. This
half-moon- (sickle-) shaped cell (instead of the rounded, button shape) interferes with
circulation and manifests itself as fatigue, dyspnea, and swollen joints. Pharmaceutical
treatments can reduce ill health. Sickle cell disorders are grouped into code category
D57 Sickle-cell disorders. You will need additional characters to identify the specific
type of sickle cell, possibly requiring a pathology report at some point, and to identify
whether the patient is having a crisis at this time or not. For example: D57.20 Sickle-
cell/Hb-C disease without crisis.

Multifactorial Abnormalities
Cleft lip and cleft palate are malformations of the upper lip and/or palate that occur
during the first 2 months of gestation. This deformity may be seen unilaterally or Deformity
bilaterally (medial is rare) and may extend into the nasal cavity and/or the maxilla A size or shape (structural
(upper jaw). Use code categories Q35 Cleft palate (additional character to identify hard design) that deviates from that
palate, soft palate, etc.),  Q36 Cleft lip (additional character to specify laterality), and which is considered normal.
Q37 Cleft palate with cleft lip (additional character to specify laterality).

X-Linked Inherited Diseases

Hemophilia is an inherited hemostatic disorder that causes difficulty with the occur-
rence of coagulation. The abnormal bleeding can be problematic, especially after an

CHAPTER 17  | 
 injury or surgical procedure. On occasion, spontaneous bleeding may occur, causing
damage to the brain, nerves, or muscle function, depending upon the location of the
hemorrhage. Treatment can extend life expectancy. Report code D66 Hereditary factor
VIII deficiency (hemophilia NOS).
Fragile X syndrome is the most frequently diagnosed underlying cause of inher-
ited mental retardation, and it affects both males and females. An accurate pedigree
would be important in predicting the likelihood of this condition because probabili-
ties increase with each generation. Males display profound mental retardation, while
females may or may not reveal this dysfunction. Use code Q99.2 Fragile X chromo-
some to report this condition.

Congenital Malformations
Spina bifida is a condition that results from an incomplete closure of the vertebral col-
umn, the spinal cord, or both. Presented often by a hole in the skin covering the area
of the spine, it is an abnormality in the development of the central nervous system.
In the 1990s, researchers discovered that folic acid (a B vitamin), when taken before
and during the first trimester of pregnancy, could actually prevent some cerebral and
spinal birth defects. In 1996, the U.S. Food and Drug Administration ordered that folic
acid be added into breads, cereals, and other grain products. The number of cases of
spina bifida dropped from 2,490 in 1995–1996 to 1,640 in 1999–2000. Spina bifida is
sometimes accompanied by hydrocephalus. Code category Q05 Spina bifida (aperta)
(cystica) requires an additional character to report the location on the spine (cervical,
thoracic, lumbar, sacral), as well as to report the presence or absence of hydrocepha-
lus. Spina bifida occulta is reported with Q76.0 Spina bifida occulta. This version of
spina bifida is evidenced by a tiny gap between vertebrae with no involvement of the
nervous system. It can be seen only on an x-ray of the affected area and generally has
no signs or symptoms.
Congenital hernia can occur in several locations in the body, just as with adult
hernias. The difference with reporting such conditions is the specification in the docu-
mentation that the hernia is congenital. Some of the codes include Q79.0 Congenital
diaphragmatic hernia, Q40.1 Congenital hiatus hernia, and Q79.51 Congenital hernia
of bladder.
Congenital heart defects have been determined by the CDC to affect close to
400,000 babies born in the United States each year. They are the most common type of
congenital anomaly and one of the most common causes of death in infants. Research
has proved a strong connection between cigarette smoking, especially during the first
trimester of gestation, and neonates with pulmonary valve stenosis and type 2 atrial
septal defects, among other congenital heart malformations. Code from categories
Q20 Congenital malformations of cardiac chambers and connections, Q21 Congeni-
tal malformations of cardiac septa, Q23 Congenital malformations of aortic and mitral
valves, and Q24 Other congenital malformations of heart. Additional characters are
required to provide specific details, such as Q21.1 Atrial septal defect and Q22.1 Con-
genital pulmonary valve stenosis.

Chapter Summary
The urinary system is designed to remove the urea from the blood, manufacture urine,
and perform waste removal by eliminating the urine. It supports many of the other
body systems by ensuring fluid balance and eliminating waste products to avoid tox-
icity. Understanding the components of this system and their functions will help you
correctly interpret the documentation to determine the most accurate code or codes.
Some conditions affecting organs in the urinary system are the manifestations of other
diseases, such as hypertension or diabetes, whereas others may be the result of an
infectious organism. Coders must read carefully (as always) to determine the correct
coding process.

508   PART II  |  REPORTING DIAGNOSES

 The anatomical sites included in the female genital system are the definition of the

CHAPTER 17 REVIEW
phrase “private places.” These organs have important functions and are susceptible to
disease and injury, as with other body systems. Female anatomy includes many organs
and anatomical sites that can be subject to health concerns. Well-woman exams and
preventive tests should be annual events in every woman’s life. Each time, a medical
necessity for the visit must be documented. Remember that staying healthy or catching
illness or disease early is a medical necessity.
Babies are precious and should always be treated with tender loving care. From the
moment they are born, babies receive a special version of health care services created
especially for them, due to their size and growth patterns. The guidelines for coding
the reasons for these services are very specific. Congenital anomalies, whether inher-
ited or caused by an interaction with a chemical, drug, or other environmental factor
during gestation, can have a lifelong effect on the child as well as the family. Con-
genital deficits can cause a minor inconvenience, present a challenge, require years of
health care treatments, or result in premature death.

CODING BITES
The Apgar test is named for Virginia Apgar, but it also has come to stand for the
following:
Activity (muscle tone)
Pulse rate (heart rate)
Grimace (reflex response)
Appearance (skin color)
Respiratory (breathing effort)
Apgar Scoring for Newborns
Score Interpretation
0–3 Baby needs immediate lifesaving procedures
4–6 Baby needs some assistance; requires careful monitoring
7–10 Normal

CHAPTER 17 REVIEW Enhance your learning by

Coding Genitourinary, Gynecology, completing these exercises and

more at connect.mheducation.com!

Obstetrics, Congential, and

Pediatrics Conditions
Let’s Check It! Terminology
Match each key term to the appropriate definition.

Part I
1. LO 17.1  The organ system responsible for removing waste products that are A. Anemic
left behind by protein, excessive water, disproportionate amounts of B. Benign Prostatic
electrolytes, and other nitrogenous compounds from the blood and the Hyperplasia (BPH)
body.
2. LO 17.1  Inflammation of any part of the urinary tract: kidney, ureter, bladder, or
urethra.

CHAPTER 17  | 
 3. LO 17.7  An error in a gene that affects development during gestation. C. Bladder Cancer
CHAPTER 17 REVIEW

4. LO 17.2  Enlarged prostate that results in depressing the urethra. D. Chronic Kidney Dis-
5. LO 17.1  Ongoing malfunction of one or both kidneys. ease (CKD)
6. LO 17.7  A size or shape that deviates from that which is considered normal.  E. Deformity
7. LO 17.1  Glomerular filtration rate, the measurement of kidney function; used to F. Genetic Abnormality
determine the stage of kidney disease. G. GFR
8. LO 17.2  Inflammation of the prostate. H. Malformation
9. LO 17.7  An irregular structural development. I. Prostatitis
10. LO 17.1  Malignancy of the urinary bladder. J. Urea
11. LO 17.1  A compound that results from the breakdown of proteins and is K. Urinary System
excreted in urine. L. Urinary Tract Infection
12. LO 17.1  Suffering from a low red blood cell count. (UTI)

Part II
1. LO 17.4  A health care specialty focusing on the care of women during preg- A. Abortion
nancy and the puerperium. B. Gestation
2. LO 17.4  A physician specializing in the care of the female genital tract. C. Gynecologist
3. LO 17.5  The length of time for the complete development of a baby from con- D. Obstetrics
ception to birth; on average, 40 weeks.
E. Prenatal
4. LO 17.4  The time period from the end of labor until the uterus returns to normal
F. Puerperium
size, typically 3 to 6 weeks.
5. LO 17.5  Prior to birth; also referred to as antenatal.
6. LO 17.6  The end of a pregnancy prior to or subsequent to the death of a fetus.

Part III
1. LO 17.7  An abnormal, or unexpected, condition. A. Anomaly
2. LO 17.7  A condition existing at the time of birth. B. Clinically Significant
3. LO 17.7  A baby born weighing less than 5 pounds 8 ounces, or 2,500 grams. C. Congenital
4. LO 17.7  Unhealthy, diseased. D. Low Birth Weight
5. LO 17.7  The time period from before birth to the 28th day after birth. (LBW)
6. LO 17.7  Birth occurring prior to the completion of 37 weeks gestation. E. Morbidity
7. LO 17.7  Signs, symptoms, and/or conditions present at birth that may impact F. Mortality
the child’s future health status. G. Perinatal
8. LO 17.7  Death. H. Prematurity

Let’s Check It! Concepts

Choose the most appropriate answer for each of the following questions.
1. LO 17.1  GFR below 15 is stage_____ CKD and would be coded _____.
a. 2, N18.2 b.  3, N18.3 c.  4, N18.4 d.  5, N18.5

2. LO 17.2  _____ is a condition that occurs when fluid collects within the tunica vaginalis of the scrotum, the testis,
or the spermatic cord.
a. Erectile dysfunction b.  Oligospermia
c. Hydrocele d.  Benign prostatic hyperplasia

510   PART II  |  REPORTING DIAGNOSES

 3. LO 17.3  The patient is diagnosed with endocarditis. Which ICD-10-CM code should be used?

CHAPTER 17 REVIEW
a. A51.9 b.  A52.06 c.  A52.03 d.  A51.2

4. LO 17.4  _____ are tumors located in the female reproductive system.

a. Uterine leiomyomas b.  Uterine fibromyomas
c. Uterine fibroids d.  All of these
5. LO 17.5  A woman noted to be G3 P2 has given birth
a. once. b.  never. c.  twice. d.  four times.
6. LO 17.5  You would use code Z33.1 for a pregnant woman who came to see the doctor for
a. a broken leg.
b. a regular first-pregnancy checkup.
c. a regular third-pregnancy checkup.
d. a regular pregnancy checkup for a woman 37 years old. 
7. LO 17.5  The encounter at which a woman gives birth will always have at least
a. one code. b.  four codes. c.  two codes. d.  three codes.
8. LO 17.6  All of the following would be considered a complication of a pregnancy except
a. hyperemesis gravidarum. b.  kidney infection.
c. hemorrhage. d.  sprained wrist.
9. LO 17.7  A congenital malformation is also known as a(n) 
a. inherited condition. b.  birth defect.
c. breech birth. d.  pediatric factor.
10. LO 17.7  A newborn has been diagnosed with sepsis due to Staphylococcus aureus. Which code should be used
to report this?
a. B95.61 b.  A41.01 c.  P36.8 d.  P36.2

Let’s Check It! Guidelines

Part I
Refer to the Official Guidelines and fill in the blanks according to the Chapter 14, Diseases of Genitourinary System,
Chapter-Specific Coding Guidelines.
mild 2 severe
query failure or rejection stage 1-5
based N18 CKD
sequencing severity  N18.3
3 relationship I.C.19.g
Z94.0 N18.4 N18.6
diabetes mellitus and hypertension  end-stage-renal disease (ESRD) chronic kidney disease (CKD)

1. The ICD-10-CM classifies CKD based on _____. 

2. The severity of CKD is designated by _____.
3. Stage _____, code N18.2, equates to _____ CKD.
4. Stage _____, code _____, equates to moderate CKD.
5. Stage 4, code _____, equates to _____ CKD. 
6. Code N18.6, End stage renal disease (ESRD), is assigned when the provider has documented _____.

CHAPTER 17  | 
 7. If both a stage of CKD and ESRD are documented, assign code _____ only.
CHAPTER 17 REVIEW

8. Patients who have undergone kidney transplant may still have some form of _____ because the kidney transplant may
not fully restore kidney function. Therefore, the presence of CKD alone does not constitute a transplant complica-
tion. Assign the appropriate _____ code for the patient’s stage of CKD and code _____, Kidney transplant status.
9. If a transplant complication such as _____ or other transplant complication is documented, see section _____ for
information on coding complications of a kidney transplant. If the documentation is unclear as to whether the
patient has a complication of the transplant, _____ the provider.
10. Patients with _____ may also suffer from other serious conditions, most commonly _____.
11. The _____ of the CKD code in _____ to codes for other contributing conditions is _____ on the conventions in
the Tabular List.

Part II
Refer to the Official Guidelines and fill in the blanks according to the Chapter 15, Pregnancy, Childbirth, and the
Puerperium, Chapter-Specific Coding Guidelines.
never fetus every complications
7th O09 “in childbirth” “unspecified trimester” 
prompted Z37 priority Z34
antepartum trimester insufficient maternal
no

1. Chapter 15 codes have sequencing _____ over codes from other chapters.
2. Chapter 15 codes are to be used only on the _____ record, _____ on the record of the newborn.
3. The majority of codes in Chapter 15 have a final character indicating the _____ of pregnancy.
4. Whenever delivery occurs during the current admission, and there is an “in childbirth” option for the obstetric
complication being coded, the _____ code should be assigned.
5. In instances when a patient is admitted to a hospital for _____ of pregnancy during one trimester and remains
in the hospital into a subsequent trimester, the trimester character for the _____ complication code should be
assigned on the basis of the trimester when the complication developed, not the trimester of the discharge.
6. The _____ code should rarely be used, such as when the documentation in the record is _____ to determine the
trimester and it is not possible to obtain clarification.
7. Where applicable, a _____ character is to be assigned for certain categories to identify the _____ for which the
complication code applies.
8. For routine outpatient prenatal visits when no complications are present, a code from category _____, Encounter
for supervision of normal pregnancy, should be used as the first-listed diagnosis.
9. For routine prenatal outpatient visits for patients with high-risk pregnancies, a code from category _____, Super-
vision of high-risk pregnancy, should be used as the first-listed diagnosis.
10. In episodes when _____ delivery occurs, the principal diagnosis should correspond to the principal complication
of the pregnancy which necessitated the encounter.
11. When an obstetric patient is admitted and delivers during that admission, the condition that _____ the admission
should be sequenced as the principal diagnosis.
12. A code from category _____, Outcome of delivery, should be included on _____ maternal record when a delivery
has occurred.

Part III
Refer to the Official Guidelines and fill in the blanks according to the Chapter 16, Certain Conditions Origination in
the Perinatal Period, Chapter-Specific Coding Guidelines.

512   PART II  |  REPORTING DIAGNOSES

perinatal condition type 28th

CHAPTER 17 REVIEW
life originate definitive once
place before newborn first
continue not default Z38
never clinically should

1. For coding and reporting purposes the perinatal period is defined as _____ birth through the _____ day following birth.
2. Codes in this chapter are _____ for use on the maternal record.
3. Codes from Chapter 15, the obstetric chapter, are never permitted on the _____ record.
4. Chapter 16 codes may be used throughout the _____ of the patient if the _____ is still present.
5. When coding the birth episode in a newborn record, assign a code from category _____, Liveborn infants accord-
ing to _____ of birth and _____ of delivery, as the principal diagnosis.
6. A code from category Z38 is assigned only _____, to a newborn at the time of birth.
7. Codes for signs and symptoms may be assigned when a _____ diagnosis has _____ been established.
8. If the reason for the encounter is a _____ condition, the code from Chapter 16 should be sequenced _____.
9. Should a condition _____ in the perinatal period, and _____ throughout the life of the patient, the perinatal code
should continue to be used regardless of the patient’s age.
10. If a newborn has a condition that may be either due to the birth process or community acquired and the documenta-
tion does not indicate which it is, the _____ is due to the birth process and the code from Chapter 16 should be used.
11. All _____ significant conditions noted on routine newborn examination _____ be coded.

Let’s Check It! Rules and Regulations

Please answer the following questions from the knowledge you have gained after reading this chapter.
1. LO 17.1  Turn to the Official Guidelines for Chapter 14. Diseases of Genitourinary System—I.C.14.a.2. Discuss
chronic kidney disease and kidney transplant status as outlined in the Chapter 14 guidelines.
2. LO 17.3  Discuss how sexually transmitted diseases (STDs) are spread. Include an example of an STD and how it
would be coded.
3. LO 17.5  Explain coding the birth, including what code category goes on the mother’s chart (and its sequence)
and what code category goes on the newborn’s chart, including its sequence and how many times this
code can be reported. 
4. LO 17.7  Explain the differences between genetic conditions and congenital malformations.
5. LO 17.4  Explain what procreative management is. Include the subcategory code for a general counseling and
advice encounter.

ICD-10-CM
YOU CODE IT! Basics
First, identify the condition in the following diagnoses, 2. Recurrent hematuria with membranoproliferative
then code the diagnosis. glomeruloephritis:
Example: Glaucoma of newborn: a. main term: _____ b. diagnosis: _____
3. Chronic interstitial nephritis, reflux associated:
a. main term: Glaucoma    b. diagnosis: Q15.0
a. main term: _____ b. diagnosis: _____
1. Acute nephritic syndrome with dense deposit
4. Stricture of ureter: 
disease: 
a. main term: _____ b. diagnosis: _____
a. main term: _____ b. diagnosis: _____

CHAPTER 17  | 
CHAPTER 17 REVIEW

5. Ovarian ectopic pregnancy:  11. Dehydration of newborn: 

a. main term: _____ b. diagnosis: _____ a. main term: _____ b. diagnosis: _____
6. Cervical shortening, third trimester:  12. Neonatal jaundice from breast milk inhibitor: 
a. main term: _____ b. diagnosis: _____ a. main term: _____ b. diagnosis: _____
7. Spontaneous abortion:  13. Classic hydatidiform mole: 
a. main term: _____ b. diagnosis: _____ a. main term: _____ b. diagnosis: _____
8. Embolism following molar pregnancy:  14. Hydrocephalus in newborn: 
a. main term: _____ b. diagnosis: _____ a. main term: _____ b. diagnosis: _____
9. Respiratory failure of newborn:  15. Thoracic spina bifida: 
a. main term: _____ b. diagnosis: _____ a. main term: _____ b. diagnosis: _____
10. Neonatal tachycardia: 
a. main term: _____ b. diagnosis: _____

ICD-10-CM
YOU CODE IT! Practice
Using the techniques described in this chapter, carefully read through the case studies and determine the most
accurate ICD-10-CM code(s) and external cause code(s), if appropriate, for each case study.
1. Sean Dollarson, an 8-year-old male, is brought in by his parents to see Dr. Greenburg, his pediatrician. Sean
has not been feeling well and has had some pinkish colored urine. Dr. Greenburg completed a physical exam
noting elevated blood pressure and periobrbital puffiness. Sean is admitted to the hospital. The laboratory
tests reveal azotemia, a BUN:Cr ratio of 18, proteinuria of 2.1 g/day, and that RBCs are dysmorphic. After
reviewing the results of the tests, Sean is diagnosed with chronic nephritic syndrome with diffused mesangial
proliferative glomerulonephritis. 
2. Sally Hyman, a 37-year-old female, presents with the complaint of restlessness, nausea, and vomiting. Sally
also admits to intermittent abdominal pain. Dr. Moye completes an examination and orders a noncontrast CT
scan followed by an intravenous contrast CT scan. The CT results confirmed the diagnosis of a staghorn cal-
culus of kidney. 
3. Murphy Jorganson, a 42-year-old male, presents with the complaint of frequent and painful urination. Dr. Reddy
completes a physical examination and notes swelling of the testicles. Murphy admits to some soreness and a
whitish discharge. Dr. Reddy inserts a cotton swab approximately 3.5 cm into the urethra and rotates it once.
Microscopic examination confirmed the diagnosis of non-gonococcal urethritis due to methicillin-resistant
Staphylococcus aureus.
4. Eugene Applewhite, a 5-year-old male, is brought in by his parents. Eugene is losing weight and his parents are
concerned because Eugene prefers drinking water to eating food. Eugene has also been wetting his bed. Dr. Ryant
completes a clinical examination and notes mild dehydration and decides to admit Eugene to the hospital. After
reviewing the MRI scan and laboratory results, Eugene is diagnosed with nephrogenic diabetes insipidus. 
5. Larry Tucker, a 24-year-old male, presents today to see Dr. Dawkins, a urologist, with the complaint of low
level of semen with ejaculation. Dr. Dawkins completes a medical history, a physical examination, and the
appropriate tests. Larry is diagnosed with azoospemia due to obstruction of efferent ducts. 
6. Pamela Cain, a 34-year-old female, presents today 23 weeks pregnant. Pamela has no complaints and states
she is feeling well. Pamela was diagnosed with essential hypertension 1 year ago. 
7. Gladys Shull, a 17-year-old female, comes in today to see Dr. Henson. Gladys thinks she may be pregnant.
Dr. Henson performs a pregnancy test, results positive. 

514   PART II  |  REPORTING DIAGNOSES

 CHAPTER 17 REVIEW
8. Jennifer Addis, a 23-year-old female, presents today with frequent urination and a burning sensation. Jennifer
is 25 weeks pregnant. Dr. Pizzuti completes an examination and orders a culture, which reveals Escherichia
coli. Jennifer is diagnosed with a urinary bladder infection due to E. coli.
9. Kreshella Goodpaster, a 29-year-old female, 17 weeks pregnant, presents with heavy vaginal bleeding.
Dr. Freedenberg admits Kreshella to the hospital with the diagnosis of antepartum hemorrhage.
10. Mazie Iablonovski, a 32-year-old female, 13 weeks pregnant, comes to see Dr. Minick, her OB-GYN. Mazie
states she is feeling well and has no complaints. Dr. Minick is concerned because Mazie has a history of mis-
carriages. Mazie is G3 P0. 
11. Judy Sovde, a 28-year-old female, gave birth to a beautiful baby girl today at Weston Hospital. Dr. Kibler
assisted in the full-term vaginal delivery. Dr. Kibler diagnoses baby Sovde with congenital entropion, right
eye. Code baby Sovde’s chart. 
12. Jason Eldridge was born today at Weston Hospital. Jason was delivered by cesarean section, full term, by
Dr. DeYoung. Jason’s laboratory results were positive for metabolic acidemia.
13. Paula Devan, a 2-week-old female, is brought by her parents to see her pediatrician, Dr. Langer, for a
checkup. Dr. Langer documents a pansystolic murmur. Paula is diagnosed with a congenital ventricular septal
defect (VSD). 
14. Dr. Jeffers, a neonatologist, was called in to treat Saddie Hawkins, born in this hospital 2 days ago. Saddie is
showing signs of hypoxia. Dr. Jeffers transferred Saddie to NICU, where the infant pneumogram confirms a
diagnosis of apnea of prematurity. 
15. Karen Sprague went into labor, and her husband, Allen, was driving her to the hospital when they got caught
in a traffic jam. Karen gave birth in the car, and Allen cut the umbilical cord with the utility knife he keeps in
the trunk. Upon arrival at the hospital, Dr. Parkerson performed a complete newborn examination and diag-
nosed the baby with tetanus neonatorum caused by the use of the nonsterile instrument during delivery. Code
baby Sprague’s chart. 

ICD-10-CM
YOU CODE IT! Application
The following exercises provide practice in abstracting physicians’ notes and learning to work with documenta-
tion from our health care facility, Prader, Bracker, & Associates. These case studies are modeled on real patient
encounters. Using the techniques described in this chapter, carefully read through the case studies and determine
the most accurate ICD-10-CM code(s) and external cause code(s), if appropriate, for each case study.

WESTON HOSPITAL 
629 Healthcare Way • SOMEWHERE, FL 32811 • 407-555-6541
PATIENT: OTTMAN, BELINDA
ACCOUNT/EHR #: OTTMBE001
DATE: 10/17/18
Attending Physician: Renee O. Bracker, MD
S: This 71-year-old female was diagnosed with end-stage renal disease requiring regular dialysis main-
tenance 6 months ago. She presents today with shortness of breath, nausea, hiccups, and overall weak-
ness. She admits to noncompliance with her dialysis plan.
O: Ht. 5′4″, Wt. 134 lb., P 81, R 28, BP 170/92. HEENT: unremarkable. Serum creatinine of 1.7 mg/dL,
GFR 14 mL/min/1.73 m, hemaglobin 6.4, edema pitting 2+.

CHAPTER 17  | 
CHAPTER 17 REVIEW

A: End-stage renal disease with regular dialysis, noncompliance; anemia due to ESRD
P: Admit to inpatient with immediate hemodialysis session and transfusion

ROB/pw  D: 10/17/18 09:50:16  T: 10/19/18 12:55:01

Determine the most accurate ICD-10-CM code(s).

PRADER, BRACKER, & ASSOCIATES

A Complete Health Care Facility
159 Healthcare Way • SOMEWHERE, FL 32811 • 407-555-6789
PATIENT: BANG, PARC
ACCOUNT/EHR #: BANGPA001
DATE: 10/17/18
Attending Physician: Renee O. Bracker, MD
S: This is a 64-year-old male who comes in today with frequent painful urination and feeling the consis-
tent need to void. He states that he smoked cigarettes for 10+ years but has been smoke-free for
2.5 years.
O: Ht. 6′2″, Wt. 215 lb., P 82, R 18, BP 141/83. HEENT: unremarkable, oxygen saturation 100% in RA.
Afebrile. Skin: warm and well perfused with no rash. Back exam: no deformities or defects. Neuro exam:
normal tone and strength. Urinalysis is positive for hematuria. Cystoscopy results positive for bladder
carcinoma.
A: Bladder cancer, anterior wall, primary.
P: Transurethral resection—discussed TUR option with patient. He will think about it and will return in
1 week.

ROB/pw  D: 10/17/18 09:50:16  T: 10/18/18 12:55:01

Determine the most accurate ICD-10-CM code(s).

PRADER, BRACKER, & ASSOCIATES

A Complete Health Care Facility
159 Healthcare Way • SOMEWHERE, FL 32811 • 407-555-6789
PATIENT: VANZELL, LEONORE
ACCOUNT/EHR #: VANZLE001
DATE: 10/17/18
Attending Physician: Oscar R. Prader, MD
S: This is a 58-year-old female who comes in today with concerns about tiredness and urinating during
the night. She states that recently she has had interrupted sleep because of being awakened with an
urgent need to void. The past 3–4 nights she has gotten up to void at least four times during the night.
Patient also admits that during the day she has to urinate a good bit and yesterday she counted voiding
9 times within a 24-hour period. She states that her fluid intake has not changed and she is not on any
medications. She denies any incontinence at this time.

516   PART II  |  REPORTING DIAGNOSES

 CHAPTER 17 REVIEW
O: Ht. 5′6″, Wt. 131 lb., P 72, R 16, BP 135/81. HEENT: unremarkable, oxygen saturation 100% in RA.
Afebrile. Patient history is noncontributory. Abdomen: flat, soft, nontender. Back exam: no deformities
or cutaneous defect. Neuro exam: normal tone, strength, and activity. Finger stick shows glucose lev-
els within normal range. UA is negative for hematuria and infection. Cystourethroscopy ruled out any
tumors and kidney stones. Patient denies any pain associated with micturition.
A: Detrusor muscle hyperactivity
P: Rx: Darifenacin
  Restrict fluid intake

ORP/pw  D: 10/17/18 09:50:16  T: 10/18/18 12:55:01

Determine the most accurate ICD-10-CM code(s).

WESTON HOSPITAL
629 Healthcare Way • SOMEWHERE, FL 32811 • 407-555-6541
PATIENT: TERRY, MARIANNA
ACCOUNT/EHR #: TERRMA001
DATE: 9/17/18
Operative Report
Preoperative DX: 1. First trimester missed abortion; 2. Undesired fertility
Postoperative DX: Same
Operation: 1. Dilation and curettage with suction; 2. Laparoscopic bilateral tubal ligation
using Kleppinger bipolar cautery
Surgeon: Oscar R. Prader, MD
Assistant: None
Anesthesia: General endotracheal anesthesia
Findings: Pt had products of conception at the time of dilation and curettage. She also had
normal-appearing uterus, ovaries, fallopian tubes, and liver edge.
Specimens: Products of conception to pathology
Disposition: To PACU in stable condition
Procedure: The patient was taken to the operating room, and she was placed in the dorsal supine posi-
tion. General endotracheal anesthesia was administered without difficulty. The patient was placed in
dorsal lithotomy position. She was prepped and draped in the normal sterile fashion. A red rubber tip
catheter was placed gently to drain the patient’s bladder. A weighted speculum was placed in the pos-
terior vagina and Deaver retractor anteriorly. A single-tooth tenaculum was placed in the anterior cervix
for retraction. The uterus sounded to 9 cm. The cervix was dilated with Hanks dilators to 25 French.
This sufficiently passed a #7 suction curet. The suction curet was inserted without incident, and the
products of conception were gently suctioned out. Good uterine cry was noted with a serrated curet. No
further products were noted on suctioning. At this point, a Hulka tenaculum was placed in the cervix for
retraction. The other instruments were removed.
Attention was then turned to the patient’s abdomen. A small vertical intraumbilical incision was made
with the knife. A Veress needle was placed through that incision. Confirmation of placement into the
abdominal cavity was made with instillation of normal saline without return and a positive handing drop
test. The abdomen was then insufflated with sufficient carbon dioxide gas to cause abdominal tympany.
The Veress needle was removed and a 5-mm trocar was placed in the same incision. Confirmation of

CHAPTER 17  | 
CHAPTER 17 REVIEW

placement into the abdominal cavity was made with placement of the laparoscopic camera. Another
trocar site was placed two fingerbreadths above the pubic symphysis in the midline under direct visual-
ization. The above-noted intrapelvic and intraabdominal findings were seen. The patient was placed in
steep trendelenburg. The fallopian tubes were identified and followed out to the fimbriated ends. They
were then cauterized four times on either side. At this point, all instruments were removed from the
patient’s abdomen. This was done under direct visualization during the insufflation. The skin incisions
were reapproximated with 4-0 Vicryl suture. The Hulka tenaculum was removed without incident.
The patient was placed back in the dorsal supine position. Anesthesia was withdrawn without difficulty.
The patient was taken to the PACU in stable condition. All sponge, instrument, and needle counts were
correct in the operating room.
ORP/pw  D: 9/17/18 09:50:16  T: 9/19/18 12:55:01

Determine the most accurate ICD-10-CM code(s).

PRADER, BRACKER, & ASSOCIATES

A Complete Health Care Facility
159 Healthcare Way • SOMEWHERE, FL 32811 • 407-555-6789
PATIENT: FAIRBANKS, GREGORY
ACCOUNT/EHR #: FAIRGR001
DATE: 09/17/18
Attending Physician: Renee O. Bracker, MD
Consultant: Vivian D. Pixar, MD
Reason for Consultation: Screening for retinopathy of prematurity
S: The patient was born on 08/19/18, with a birth weight of 2,740 grams, gestational age of 36 weeks;
given oxygen in NICU for the first 60 minutes of life. Child discharged third day postpartum with oxygen
saturation of 98%.
O: Retinal follow-up examination this date shows normal external exam, well-dilated pupils. Indirect
exam shows clear media, normal optic nerves both eyes, with normal right retinal vessel extension to
the periphery without evidence of retinopathy. Left retinal vessel extension shows a faint demarcation
line at the junction between the vascularized and avascular border.
A: Prematurity retinopathy, stage 1, left eye
P: Follow-up 1 week
ROB/mg  D: 09/17/18 09:50:16  T: 09/18/18 12:55:01

Determine the most accurate ICD-10-CM code(s).

518   PART II  |  REPORTING DIAGNOSES

Factors Influencing
Health Status (Z Codes)
Learning Outcomes
18
Key Terms
After completing this chapter, the student should be able to: Abnormal Findings
LO 18.1 Abstract details about preventive services to report their Allogeneic
medical necessity. Autologous
Carrier
LO 18.2 Determine the medical reasons for early detection testing.
Isogeneic
LO 18.3 Demonstrate how to report encounters related to genetic Preventive Care
susceptibility. Prosthetic
LO 18.4 Identify the reasons for observation services to determine Screening
the correct code or codes. Xenogeneic
LO 18.5 Apply the Official Guidelines for reporting aftercare and
follow-up care.
LO 18.6 Evaluate the specific services provided for organ donation
and report the medical necessity.
LO 18.7 Distinguish indications of antimicrobial drug resistance to
report this accurately.
LO 18.8 Employ Z codes accurately.

Remember, you need to follow along in Preventive Care

Health-related services
  STOP! your ICD-10-CM code book for an optimal
ICD-10-CM

designed to stop the develop-

learning experience. ment of a disease or injury.

GUIDANCE
18.1  Preventive Care CONNECTION
In several chapters throughout this textbook, you got an overview of Z codes, which Read the ICD-10-CM
are codes used to report a reason for a visit to a physician for something other than an Official Guidelines for
illness or injury. As you have learned, there must always be a valid, medical reason Coding and Reporting,
for a patient’s encounter with a health care professional. And there are occasions for section I. Conventions,
patients to seek attention even when they are not currently ill. These codes give you General Coding Guide-
the opportunity to explain. lines and Chapter
Science and research have provided us with a better understanding of disease and Specific Guidelines,
disease progression, as well as etiology (underlying cause of disease). This knowledge subsection C. Chapter-
has resulted in improved preventive care services to stop the onset of illness or injury. Specific Coding
The provision of preventive care services is likely to increase. The enacting of the Guidelines, chapter
Affordable Care Act enables more patients to take advantage of more preventive ser- 21. Factors influenc-
vices than ever before. Since September 2010, new health insurance policies must ing health status and
cover preventive services, with no copayment, no coinsurance payments, and no contact with health
requirement for deductible fulfillment. services, subsection
Reporting the provision of preventive care will require a Z code to explain the spe- c.2) Inoculations and
cific reason for the encounter, such as a flu shot or measles vaccination (Z23 Encoun- vaccinations.
ter for immunization).
 The physician or other health care professional may also be able to provide counsel-
ing for the patient and/or family members. This type of counseling is not the same as
that provided by a psychiatrist or psychologist; instead, the physician would take the
time to discuss options for preventing the development of disease or injury. Perhaps
this may include dietary counseling and surveillance (Z71.3) to prevent the onset of
hypertension, heart disease, obesity, or other nutrition-related conditions, or a discus-
sion about the patient’s tobacco use (Z72.0) could focus on various methodologies
available to quit smoking to prevent the patient from developing lung disease. Couples
may come in for genetic counseling (Z31.5) to prevent passing chromosomal abnor-
malities to their future children; for those who do not want to have children yet, gen-
eral counseling and advice on contraception (Z30.09) may be provided.

ICD-10-CM
LET’S CODE IT! SCENARIO
Bonnie Poggio, a 15-year-old female, came into the clinic with her mother. While searching for seashells at the
beach, she went up on the boardwalk barefooted to get ice cream and stepped on a nail, puncturing the sole of her
left foot. After checking the puncture wound, cleaning it, and dressing it, Dr. Baldwin gave Bonnie a tetanus shot as
a precaution.

Let’s Code It!

You are reviewing how to determine Z codes in this chapter, so here’s the first code for this encounter:
S91.332A Puncture wound without foreign body, left foot, initial encounter. Dr. Baldwin’s notes state that
Bonnie received a preventive tetanus shot. You have learned that, in medical terminology, this is known as an
immunization. When you turn to the Alphabetic Index, you see
Immunization — see also Vaccination
  Encounter for Z23
When you turn to the Tabular List, you confirm:
Z23 Encounter for immunization
This is great. However, the reason Bonnie went to see Dr. Baldwin was care for the wound. The tetanus shot was
secondary. So, you will not report Z23. But you do need an external cause code to explain why Bonnie needed
this immunization. Turn to the Alphabetic Index to External Causes. Did you find this?
Puncture, puncturing — see also Contact, with, by type of object or machine
Let’s turn to
Contact (accidental)
  with
   nail W45.0
Now let’s find code category W45 in the Tabular List:
W45 Foreign body or object entering through skin
That sounds right. First, read carefully the notation listing several diagnoses. Take a minute to review
them, and determine whether any apply to Bonnie’s condition. No, none of them do, so you are in the correct
location. Notice the seventh-character options here. You will need them for later. First, you need to determine
the first six characters, so continue down and review all of the fourth-, fifth-, and sixth-character choices. Which
matches Dr. Baldwin’s notes?
W45.0 Nail entering through skin
Perfect! And the seventh character? The choices are listed at the top of this code category:

520   PART II  |  REPORTING DIAGNOSES

 W45.0XXA Nail entering through skin, initial encounter
Next, you need the place of occurrence (the beach) and the status code. (Refer to the chapter Coding Injury,
Poisoning, and External Causes to remind yourself about reporting external cause codes whenever you are
reporting an injury or poisoning.)
Take a look. Did you find these codes:
Y92.832 Beach as the place of occurrence of the external cause
Y99.8 Other external cause status
Fantastic! You have determined all of the codes required for this encounter:
S91.332A Puncture wound without foreign body, left foot, initial encounter
W45.0XXA Nail entering through skin, initial encounter
Y92.832 Beach as the place of occurrence of the external cause
Y99.8 Other external cause status
You have got this!

18.2  Early Detection

The reason for routine and administrative exams is to ensure continued good health by
looking for signs of disease as early as detection may be possible, using a physician’s
knowledge and technological advancement. Commonly, these health care encounters
are known as annual physicals, well-baby checks, or well-woman exams. These rou-
tine encounters, most often prompted by the calendar rather than the way the patient
feels, are reported with Z codes, such as code Z00.00 Encounter for general adult
medical examination without abnormal findings or Z00.129 Encounter for routine child
health examination without abnormal findings.
Many schools and organizations require that a physician examine a child before the child
joins a sports team (Z02.5), companies may require preemployment exams (Z02.1), and
virtually all surgeons will order pre-procedural exams (Z01.81-) for the patient prior to
surgery. These are all considered administrative health encounters because they are deter-
mined by a specific circumstance, rather than the calendar or the way the patient feels.
Certain conditions, even after being resolved, may continue to identify the patient
as being at risk of a recurrence. The patient had a previous condition; however, pru-
dent health care standards require that the physician keep a watchful eye to catch and
treat a recurrent episode. Codes such as Z86.11 Personal history of tuberculosis and
Z87.11 Personal history of peptic ulcer may provide medical necessity for an extra
screening test or encounter.

ICD-10-CM
YOU CODE IT! CASE STUDY
Kathryn Rogers, a 49-year-old female, came in to see Dr. Apter to get a colonoscopy. Dr. Apter explained last week
that this was an important screening for malignant neoplasms of the colon and was recommended for all adults
aged 50 and over. After the screening, Dr. Apter told Kathryn she was fine and there were no abnormalities.

You Code It!

Go through the steps of coding, and determine the code or codes that should be reported for this encounter
between Dr. Apter and Kathryn.

(continued)

CHAPTER 18  | 
 Step #1: Read the case carefully and completely.
Step #2: Abstract the scenario. Which main words or terms describe why the physician cared for the patient dur-
ing this encounter?
Step #3: Are there any details missing or incomplete for which you would need to query the physician? [If so,
ask your instructor.]
Step #4: Check for any relevant guidance, including reading all of the symbols and notations in the Tabular List
and the appropriate sections of the Official Guidelines.
Step #5: Determine the correct diagnosis code or codes to explain why this encounter was medically necessary.
Step #6: Double-check your work.
Answer:
Did you determine this to be the correct code?
Z12.11 Encounter for screening for malignant neoplasm of colon

Screening A screening is a test or examination, such as routine lab work or imaging services,
An examination or test of administered when there are no current signs, symptoms, or related diagnosis. Report
a patient who has no signs a visit for a screening with a Z code such as code Z13.22 Encounter for screening for
or symptoms that is con- metabolic disorder or Z13.820 Encounter for screening for osteoporosis.
ducted with the intention The standards of care have established important examinations and tests to detect
of finding any evidence of
illnesses at the earliest possible time. However, these tests are typically recommended
disease as soon as possible,
thus enabling better patient
for specific population subgroups determined to be at the greatest risk, such as mammo-
outcomes. grams for women over 40 or prostate examinations for men over 50. These encounters
would be reported with a Z code such as code Z12.5 Encounter for screening for malig-
nant neoplasm of prostate or Z13.6 Encounter for screening for cardiovascular disorders.
Society, especially in the United States, is designed for interaction between indi-
viduals. Shopping malls, concert halls and festival venues, public transport sites, class-
rooms, playgrounds, and other locations draw friends, families, and strangers together
in close proximity to one another. Close physical proximity can put someone in contact
with a potential health hazard and facilitate (suspected) exposure to a communicable
disease. Think of this: Two children, Jane and Mary, were playing together, and the
next day Jane is diagnosed with rubella. This means that Mary was exposed. When
Mary’s mom takes her to the doctor, this visit will include code Z20.4 Contact with and
(suspected) exposure to rubella. Another example: Kenny works for County Animal
Control. As he was placing a wild raccoon into his vehicle, the raccoon bit him. Kenny
went to the emergency clinic immediately, and code Z20.3 Contact with and (suspected)
exposure to rabies was included on the claim.
With all these tests being done to confirm the patient’s good health, there are times
Abnormal Findings when the documentation includes abnormal findings, meaning the results indicate
Test results that indicate a something is wrong. This is not the same thing as a confirmed diagnosis, necessar-
disease or condition may be ily. It may be a signal that a condition is potential or that more extensive and specific
present. examinations must be done.

EXAMPLES
Z00.01 Encounter for general adult medical examination with abnormal
findings
Z01.411 Encounter for gynecological examination (general) (routine) with
abnormal findings

522   PART II  |  REPORTING DIAGNOSES

 GUIDANCE CONNECTION
Read the ICD-10-CM Official Guidelines for Coding and Reporting, section I.
Conventions, General Coding Guidelines and Chapter Specific Guidelines,
subsection C. Chapter-Specific Coding Guidelines, chapter 21. Factors influenc-
ing health status and contact with health services, subsections c.1) Contact/
exposure, c.4) History (of), c.5) Screening, and c.13) Routine and administrative
examinations, plus section IV. Diagnostic Coding and Reporting Guidelines for
Outpatient Services, subsection P. Encounters for general medical examinations
with abnormal findings.

ICD-10-CM
YOU CODE IT! CASE STUDY
Dallas Rossi, a 66-year-old male, came in to see his regular physician, Dr. DeGusipe, for his annual physical. Dallas
said he has been feeling great and working out about twice a week. During the digital rectal exam, Dr. DeGuisipe
noted a palpable nodule on the posterior of Dallas’s prostate. Dr. DeGuispe told Dallas that he appears in good
health except for the nodule. They discussed this and scheduled an appointment for a biopsy.

You Code It!

Go through the steps of coding, and determine the code or codes that should be reported for this encounter
between Dr. DeGusipe and Dallas.
Step #1: Read the case carefully and completely.
Step #2: Abstract the scenario. Which main words or terms describe why the physician cared for the patient
during this encounter?
Step #3: Are there any details missing or incomplete for which you would need to query the physician? [If so,
ask your instructor.]
Step #4: Check for any relevant guidance, including reading all of the symbols and notations in the Tabular List
and the appropriate sections of the Official Guidelines.
Step #5: Determine the correct diagnosis code or codes to explain why this encounter was medically necessary.
Step #6: Double-check your work.
Answer:
Did you determine these to be the correct codes?
Z00.01 Encounter for general adult medical examination with abnormal findings
N40.2 Nodular prostate without lower urinary tract symptoms
You did great!

18.3  Genetic Susceptibility

Carrier
A patient might be a carrier or suspected carrier of a disease. He or she needs to
An individual infected with a
know this so the condition is not unintentionally passed on. Or the patient may have disease who is not ill but can
an abnormal gene that may increase a patient’s chances of developing a disease. This still pass it to another person;
is of particular concern when there is a known family history for conditions that are, an individual with an abnormal
or may be, inherited. gene that can be passed to
In most cases, the documentation will note that the patient has a family history of a con- a child, making the child sus-
dition, such as code Z80.6 Family history of leukemia or Z83.3 Family history of diabetes ceptible to disease.

CHAPTER 18  | 
 mellitus. In these cases, no additional genetic testing may be done. However, the knowledge
GUIDANCE of family members with a particular condition could support more frequent screenings,
CONNECTION such as a patient getting a mammogram every 6 months instead of the standard annual test.
Read the ICD-10-CM
A patient may have reason to believe he or she is the carrier of a disease, such as
Official Guidelines for
diphtheria (Z22.2) or viral hepatitis B (Z55.51). A carrier is an individual who has
Coding and Report-
been infected with a pathogen yet has no signs or symptoms of the disease. Carriers,
ing, section I. Conven-
while not ill themselves, are still able to pass the condition to another person.
tions, General Coding
Guidelines and Chapter
EXAMPLE
Specific Guidelines, sub-
section C. Chapter- Cystic fibrosis, the result of mutations in the CFTR gene, is a common genetic dis-
Specific Coding Guide- ease. Due to its nature, both parents must each carry a copy of the mutated gene
lines, chapter 21. Fac- in order for the child to inherit and develop the disease. However, the parents may
tors influencing health not show any signs or symptoms.
status and contact with Risk is measured by family history and ethnic background. If the patient has a
health services, subsec- family history of CF, then the probability of being a carrier is increased above the
tions c.3), Status and risk based on ethnicity alone. The probability increases if the patient is a close
c.14) Miscellaneous Z relative of an individual with CF, such as a parent, sibling, or child.
codes—Prophylactic To report medical necessity to perform the genetic testing:
Organ Removal. Z84.81 Family history of carrier of genetic disease
Z13.71 Encounter for nonprocreative screening for genetic disease
carrier status
CODING BITES
or
Notice that these codes
are used when the phy- Z31.430 Encounter of female for testing for genetic diseases carrier
sician determines obser- status for procreative management
vation is required “to be
or
sure” and the result is
nothing is wrong [ruled Z31.440 Encounter of male for testing for genetic diseases carrier
out]. If the determina- status for procreative management
tion is that there is a
If the woman is currently pregnant and needs to be screened, use this code:
problem, you would
then report the code Z36.- Encounter for antenatal screening of mother
for the problem, not the
If the test is positive, report
observation.
Z14.1 Cystic fibrosis carrier

GUIDANCE
CONNECTION You may have heard about genetic susceptibility to malignant neoplasm of the breast
(Z15.01) and genetic susceptibility to malignant neoplasm of the ovary (Z15.02), iden-
Read the ICD-10-CM tified by the BRCA1 and BRCA2 tests. These tests may be used to confirm, or deny,
Official Guidelines for the presence of an abnormality in a gene that may have been inherited, which can
Coding and Reporting, serve as a prediction of the potential for developing a disease—in these cases, cancer.
section I. Conven- Some patients have opted for prophylactic (preventive) surgery after a positive finding
tions, General Coding of an abnormal gene. If a patient had this procedure, you would report it with code
Guidelines and Chapter Z40.01 Encounter for prophylactic removal of breast.
Specific Guidelines,
subsection C. Chapter-
Specific Coding Guide- 18.4  Observation
lines, chapter 21. Fac- There might be a reason that a physician suspects a patient may be ill despite the
tors influencing health absence of signs and symptoms. Code categories Z03 and Z04 enable you to report the
status and contact reason these types of encounters are medically necessary.
with health ser-
vices, subsection c.6) Z03 Encounter for medical observation for suspected diseases and
Observation. conditions ruled out
Z04 Encounter for examination and observation for other reasons

524   PART II  |  REPORTING DIAGNOSES

 Imagine that a mother brings her 2-year-old son into the emergency department
because she found him in her bathroom with her allergy pill bottle tipped over and pills
strewn about the floor. She does not know whether he ingested any of the pills and, if
he did, how many. After an examination showing no signs or symptoms of overdose
or poisoning, the doctor decides to keep the boy in the hospital for observation, just in
case. The next day, the boy appears to be fine, and his blood tests show no signs of the
allergy medication at all. He is discharged with a clean bill of health. You would report
this with code Z03.6 Encounter for observation for suspected toxic effect from ingested
substance, ruled out.

ICD-10-CM
YOU CODE IT! CASE STUDY
Tracey Morales, a 33-year-old male, was brought into the ED after an accident on his construction job site. He
tripped and hit his head against a pile of bricks. There was a 3 cm laceration on his temporal lobe scalp, but he did
not lose consciousness. CT scan of his head was inconclusive. After the laceration was stitched up with a simple
repair, Dr. Tribow placed Tracey into observation status so they could watch for signs of a concussion. After 20 hours
with normal vital signs and a normal neurologic exam, he was determined to not have suffered a concussion and
released.

You Code It!

Review Dr. Tribow’s documentation about Tracey’s stay in observation. Then, determine the correct ICD-10-CM
code or codes to report the reasons why Tracey needed care.
Step #1: Read the case carefully and completely.
Step #2: Abstract the scenario. Which main words or terms describe why the physician cared for the patient
during this encounter?
Step #3: Are there any details missing or incomplete for which you would need to query the physician? [If so,
ask your instructor.]
Step #4: Check for any relevant guidance, including reading all of the symbols and notations in the Tabular List
and the appropriate sections of the Official Guidelines.
Step #5: Determine the correct diagnosis code or codes to explain why this encounter was medically necessary.
Step #6: Double-check your work.
Answer:
Did you determine these to be the codes?
Z04.2 Encounter for examination and observation following work accident
S01.01xA Laceration without foreign body of scalp, initial encounter
W01.198A Fall on same level from slipping, tripping and stumbling with subsequent striking
against other object, initial encounter
Y92.61 Building [any] under construction as the place of occurrence of the external cause
Y99.0 Civilian activity done for income or pay

18.5  Continuing Care and Aftercare

Chronic illness may require long-term use of medication, known as drug therapy.
When a patient is taking any type of pharmaceutical on an ongoing basis, regular
monitoring can identify potential concerns, such as side effects or loss of potency.
Some individuals’ body chemistry can get used to certain drugs, making them less

CHAPTER 18  | 
 effective. When coding an encounter for such monitoring, you may begin with Z51.81
GUIDANCE Encounter for therapeutic drug level monitoring, along with a code to identify the
CONNECTION type of therapeutic drug, such as Z79.01 Long term (current) use of anticoagulants or
Z79.811 Long term (current) use of aromatase inhibitors.
Read the ICD-10-CM
Official Guidelines for
Of course, the physician-patient relationship in treating a specific illness or injury
Coding and Reporting,
does not end at the end of a surgical procedure or other type of therapeutic service.
section I. Conven-
A healing illness or injury may require aftercare, reported with a code such as Z47.1
Aftercare following joint replacement surgery, Z48.00 Encounter for change or removal
tions, General Coding
of nonsurgical wound dressing, or Z45.24 Encounter for aftercare following lung
Guidelines and Chapter
transplant.
Specific Guidelines,
subsection C. Chapter-
Patients with implanted medical devices may need more frequent encounters to
Specific Coding Guide-
check the device to ensure it is working properly, as is the case with a patient with a
lines, chapter 21. Fac-
cardiac pacemaker (Z45.01) or a patient with a cochlear implant (Z45.321).
tors influencing health
Follow-up examinations may be necessary for a condition that has already been
status and contact with
treated or no longer exists. Examples of such follow-ups include an encounter for the
health services, subsec-
removal of sutures (stitches), reported with code Z48.02, or an encounter after the
tion c.7) Aftercare.
patient has completed treatment for a malignant neoplasm (Z08), once the patient has
finished the chemotherapy or radiation treatment plan.

GUIDANCE CONNECTION
Read the ICD-10-CM Official Guidelines for Coding and Reporting, section I. Con-
ventions, General Coding Guidelines and Chapter Specific Guidelines, subsec-
tion C. Chapter-Specific Coding Guidelines, chapter 21. Factors influencing
health status and contact with health services, subsection c.8) Follow-up.

ICD-10-CM
LET’S CODE IT! SCENARIO
Adelina Plenner, a 43-year-old female, came in to see Dr. Buldar, her gastroenterologist. She had a colostomy
6 weeks ago, and this is a standard post-procedural follow-up. He noted that there was some irritation and he applied
some ointment and gave Adelina a prescription for more ointment. Dr. Buldar examined the area and told Adelina
to return prn.

Let’s Code It!

This encounter is a standard follow-up post-surgically to ensure all is well with the patient. Dr. Buldar was check-
ing Adelina’s condition post-colostomy.
In the ICD-10-CM Alphabetic Index, find
Aftercare (see also Care) Z51.89
Read all of the indented items. Hmm, there doesn’t seem to be anything that matches this encounter. Let’s try
this:
Care (of) (for) (following)
Wow, nothing here seems to fit, either. What about . . .
Encounter (with health service) (for) Z76.89
Not here, either! One more idea. . . . Dr. Buldar paid attention to Adelina’s stoma. Take a look at this:
Attention (to)
   artificial

526   PART II  |  REPORTING DIAGNOSES

 opening (of) Z43.9
     digestive tract NEC Z43.4
      colon Z43.3
Finally!!! Success!! This proves that you cannot give up. You must keep thinking and looking because it will
always be there . . . somewhere.
Turn in the ICD-10-CM Tabular List and find
Z43 Encounter for attention to artificial openings
Read carefully the diagnoses listed next to the , , and notations. Did you check the
artificial opening status only, without need for care (Z93.-)? Was there a need for care? The ointment could
support this. Did you check to see if this qualifies as a complication of external stoma . . . particularly K94.-?
When on the job, you could query the physician for confirmation. This documentation does not really describe
a complication, so let’s continue on to confirm this code:
Z43.3 Encounter for attention to colostomy
Good job!

18.6  Organ Donation

The number of organs and tissues that can be successfully transplanted has dramati-
cally increased over the years, and many can be provided by a living donor. Code
category Z52 Donors of organs and tissues includes various types of blood donors
(Z52.0-), skin donors (Z52.1-), and bone donors (Z52.2-). You will notice that all three
of these code subcategories require you, as the professional coder, to determine from
the documentation whether the donor is autologous or is providing another type of Autologous
graft or donation (see Table 18-1). It is not unusual for a patient to donate his or her The donor tissue is taken from
own blood prior to having a surgical procedure so that in the event he or she needs a different site on the same
a transfusion, his or her own blood will be used. When an injury to the skin is so individual’s body (also known
severe that a graft is needed, there are times when the surgeon will take the graft from as an autograft).
another part of the patient’s own body and transfer it to the injured site. Allogeneic
A kidney (Z52.4) and cornea (Z52.5) as well as a part of the liver (Z52.6) may come The donor and recipient are of
from a living donor. Fertility issues occur and some women donate their oocytes (eggs) the same species, e.g., human
for in vitro fertilization for themselves or someone else (Z52.81-). The donation of any of → human, dog → dog (also
these organs would almost always be used as an allogeneic donation to another individual. known as an allograft).
A donation from the recipient’s monozygotic twin is called isogeneic, while a Isogeneic
xenogeneic donation involves a donor and recipient who are of different species. The donor and recipient indi-
Synthetic organ and tissue replacements are referred to as prosthetics. viduals are genetically identi-
cal (i.e., monozygotic twins).
TABLE 18-1  Types of Grafts Xenogeneic
The donor and recipient are of
Autologous The donor tissue is taken from a different site on the same individual’s different species, e.g., bovine
body (also known as an autograft). cartilage → human (also known
as a xenograft or heterograft).
Isogeneic The donor and recipient individuals are genetically identical (i.e., mono-
zygotic twins). Prosthetic
Lost tissue that is replaced
Allogeneic The donor and recipient are of the same species, e.g., human → human,
with synthetic material such as
dog → dog (also known as an allograft).
metal, plastic, or ceramic, to
Xenogeneic The donor and recipient are of different species, e.g., bovine cartilage → take over the function of the
human (also known as a xenograft or heterograft). lost tissue.

Prosthetic Lost tissue is replaced with synthetic material such as metal, plastic, or
ceramic.

CHAPTER 18  | 
 ICD-10-CM
YOU CODE IT! CASE STUDY
Ilani Marhefka, a 31-year-old female, came in to donate her eggs. Her sister, Serita, had lesions on her ovaries and
had to have them removed many years ago. Dr. Stark is going to harvest eggs from Ilani to implant in Serita so she
and her husband, Jude, can have children. Ilani wanted to help her sister and brother-in-law by donating her eggs.

You Code It!

Go through the steps of coding, and determine the code or codes that should be reported for this encounter
between Dr. Stark and Ilani.
Step #1: Read the case carefully and completely.
Step #2: Abstract the scenario. Which main words or terms describe why the physician cared for the patient
during this encounter?
Step #3: Are there any details missing or incomplete for which you would need to query the physician? [If so,
ask your instructor.]
Step #4: Check for any relevant guidance, including reading all of the symbols and notations in the Tabular List
and the appropriate sections of the Official Guidelines.
Step #5: Determine the correct diagnosis code or codes to explain why this encounter was medically necessary.
Step #6: Double-check your work.
Answer:
Did you determine this to be the correct code?
Z52.811 Egg (oocyte) donor under age 35, designated recipient
Very good!

Of course, prior to the actual procedure to harvest the organ or tissue, an examina-
tion will need to be done, reported with code Z00.5 Encounter for examination for
potential donor of organ or tissue.

18.7  Resistance to Antimicrobial Drugs

You learned about antimicrobial resistance (AMR) in the chapter about coding infec-
tious diseases. Let’s review these codes again, just to reinforce how to report these
situations using Z codes.
Take a look at code category Z16 Resistance to antimicrobial drugs. You can see that
ICD-10-CM provides a note with some direction about the proper use of these Z codes:
NOTE: The codes in this category are provided for use as additional codes to
identify the resistance and non-responsiveness of a condition to antimicrobial
drugs.
And you can see the Code first the infection notation that provides sequencing
direction.
Z16.10 Resistance to unspecified beta lactam antibiotics
Z16.11 Resistance to penicillins (amoxicillin) (ampicillin)
Z16.12 Extended spectrum beta lactamase (ESBL) resistance
Z16.19 Resistance to other specified beta lactam antibiotics
(cephalosporins)

528   PART II  |  REPORTING DIAGNOSES

 Z16.20 Resistance to unspecified antibiotic (antibiotics NOS)
Z16.21 Resistance to vancomycin
Z16.22 Resistance to vancomycin related antibiotics
Z16.23 Resistance to quinolones and fluoroquinolones
Z16.24 Resistance to multiple antibiotics
Z16.29 Resistance to other single specified antibiotic (aminoglycosides)
(macrolides) (sulfonamides) (tetracylines)
Z16.342 Resistance to multiple antimycobacterial drugs
Z16.35 Resistance to multiple antimicrobial drugs
resistance to multiple antibiotics only (Z16.24)
Reporting these conditions is not exclusive to the Z code chapter. When a patient
is confirmed to have an infection that is resistant, you might report one of these codes
instead:
A41.02 Sepsis due to methicillin resistant Staphylococcus aureus
A49.02 Methicillin resistant Staphylococcus aureus infection, unspecified
site
B95.62 Methicillin resistant Staphylococcus aureus infection as the cause
of diseases classified elsewhere
J15.212 Pneumonia due to methicillin resistant Staphylococcus aureus
And remember, back in the chapter about infectious diseases, you learned about using
the additional codes to identify the bacterial or viral pathogen in a specific other infec-
tion, such as a urinary tract infection or infected laceration, by using an additional
code from B95–B97, including these:
B95.61 Methicillin susceptible Staphylococcus aureus infection as the
cause of diseases classified elsewhere
B95.62 Methicillin resistant Staphylococcus aureus infection as the cause
of diseases classified elsewhere
These code descriptions change the language a bit, so you will need to know the differ-
ence between “resistant” and “susceptible.” In this context:
∙ Resistant means that those certain antibiotics will not be effective in combating this
pathogen.
∙ Susceptible (also referred to as sensitive) means that the named antibiotic is
expected to be successful in killing off the infection.

ICD-10-CM
YOU CODE IT! CASE STUDY
PATIENT: Paulina Stohl
DATE OF CONSULTATION:011/09/2018
PHYSICIAN REQUESTING THE CONSULT: Ada Carole, MD
REASON FOR CONSULTATION: Resistant infection.
CHIEF COMPLAINT: Fatigue.
HISTORY OF PRESENT ILLNESS: The patient is a 57-year-old female with a history of type 2 diabetes mellitus, pan-
creatitis, and chronic hepatitis C who presented with complaints of fever and generalized malaise. She was seen and
evaluated by Dr. Koehler in the ED and subsequently admitted. Vital signs identified a low grade fever [99.8 F] and
blood cultures taken in ED were positive for gram-positive cocci. In addition, urinalysis was positive for MRSA. Patient
was given Zosyn, 3.375g q 6 hr. Infectious disease was requested in for a consultation.

(continued)

CHAPTER 18  | 
 At bedside, the patient stated a cystoscopy was performed by her urologist for chronic obstructive uropathy. The
following biopsy was negative for malignancy. A few days later, the patient began to experience generalized malaise
and then experienced fever and chills. The urine culture taken in ED was noted to be positive for MRSA and one of
two blood cultures was positive. Since admission 1 day ago, blood cultures were repeated, with positive results in
both tests for gram-positive cocci in clusters.
FAMILY HISTORY: No immune dysfunction other than diabetes.
ALLERGIES: No known drug allergies.
REVIEW OF SYSTEMS: A 14-system review is as per history of present illness, otherwise negative.
CURRENT MEDICATIONS: List is reviewed.
PHYSICAL EXAMINATION:
VITAL SIGNS: Upon my initial evaluation, patient has T 100.2 degrees Fahrenheit, pulse 104, respirations 20, and
blood pressure 120/70.
GENERAL: Patient is alert and oriented x3, in no apparent distress at rest.
HEENT: Head is normocephalic and atraumatic. Extraocular muscle movements are intact. No scleral icterus. Oro-
pharynx is clear.
NECK: Free of palpable adenopathy.
HEART: Regular at 100. No auscultated rub.
LUNGS: Clear to auscultation and percussion bilaterally. No rhonchi and no wheezing.
ABDOMEN: Positive bowel sounds, soft, nontender, and nondistended. No rebound, rigidity, or guarding.
EXTREMITIES: Lower extremities are without clubbing or cyanosis.
NEUROMUSCULAR: Neurologically, patient is nonfocal with normal cranial nerves. Muscle strength is normal in the
upper extremities.
LABORATORY STUDIES: A complete blood count, basic metabolic profile, full microbiologic database, all of which
have been reviewed.
IMPRESSION:
1. Methicillin-resistant Staphylococcus aureus urinary tract infection in a patient who has recently undergone a geni-
tourinary procedure for outlet obstruction.
2.  Type 2 diabetes mellitus with poor control.
3.  Fever.
RECOMMENDATIONS:
1.  Place the patient in contact isolation.
2.  Repeat blood cultures x2.
4.  Start vancomycin.
5.  Discontinue Zosyn [the extended-spectrum penicillin that has proved ineffective to patient’s MRSA].
Thank you for this interesting consult and allowing us to participate in this patient’s care.
Allen B. Dechante, MD
You Code It!
Read Dr. Dechante’s notes regarding his evaluation of Paulina Stohl and determine the accurate ICD-10-CM
diagnosis codes for this encounter.
Step #1: Read the case carefully and completely.

530   PART II  |  REPORTING DIAGNOSES

 Step #2: Abstract the scenario. Which main words or terms describe why the physician cared for the patient
during this encounter?
Step #3: Are there any details missing or incomplete for which you would need to query the physician? [If so,
ask your instructor.]
Step #4: Check for any relevant guidance, including reading all of the symbols and notations in the Tabular List
and the appropriate sections of the Official Guidelines.
Step #5: Determine the correct diagnosis code or codes to explain why this encounter was medically necessary.
Step #6: Double-check your work.
Answer:
Did you determine these to be the codes?
N39.0 Urinary tract infection, site not specified
B95.62 Methicillin resistant Staphylococcus aureus infection as the cause of diseases classified
elsewhere
E11.9 Type 2 diabetes mellitus without complication

18.8  Z Codes as First-Listed/Principal Diagnosis

During most encounters, a Z code may be the only code you report, or it may be
reported along with others, determined by the specific circumstances. Except for 20
of the Z codes, sequencing is determined by the facts of the encounter and the Official
Guidelines, as explained in Sections II and III. The other 20 Z codes are permitted to
be only first-listed or principal diagnosis codes:
Z00 Encounter for general examination without complaint, suspected or
reported diagnosis
Z01 Encounter for other special examination without complaint, sus-
pected or reported diagnosis
Z02 Encounter for administrative examination
Z03 Encounter for medical observation for suspected diseases and con-
GUIDANCE
ditions ruled out
Z04 Encounter for examination and observation for other reasons CONNECTION
Z33.2 Encounter for elective termination of pregnancy Read the ICD-10-CM
Z31.81 Encounter for male factor infertility in female patient Official Guidelines for
Z31.82 Encounter for Rh incompatibility status Coding and Reporting,
Z31.83 Encounter for assisted reproductive fertility procedure cycle section I. Conven-
Z31.84 Encounter for fertility preservation procedure tions, General Coding
Z34 Encounter for supervision of normal pregnancy Guidelines and Chapter
Z38 Liveborn infants according to place of birth and type of delivery Specific Guidelines,
Z39 Encounter for maternal postpartum care and examination subsection C. Chapter-
Z42 Encounter for plastic and reconstructive surgery following medical Specific Coding Guide-
procedure or healed injury lines, chapter 21: Fac-
Z51.0 Encounter for antineoplastic radiation therapy tors influencing health
Z51.1- Encounter for antineoplastic chemotherapy and immunotherapy status and contact with
Z52 Donors of organs and tissues health services, subsec-
Except: Z52.9, Donor of unspecified organ or tissue tion c.16) Z Codes
Z76.1 Encounter for health supervision and care of foundling That May Only be
Z76.2 Encounter for health supervision and care of other healthy infant Principal/First-Listed
and child Diagnosis.
Z99.12 Encounter for respirator [ventilator] dependence during power failure

CHAPTER 18  | 
 ICD-10-CM
LET’S CODE IT! SCENARIO
Alfredo “Al” Martinelli, a 43-year-old male, was admitted to the hospital today because he is donating one of his
kidneys to his son, Anthony. The surgery is scheduled for this afternoon.

Let’s Code It!

Even though he is perfectly healthy, Alfredo Martinelli is admitted into the hospital. Why? Because he is an organ
donor. You don’t have too much information here, so how will you look this up? Turn in the ICD-10-CM Alphabetic
Index to
Donor (organ or tissue) Z52.9
Read down the indented list beneath and find:
  kidney Z52.4
This appears to be very straightforward, so go to the code category in the Tabular List:
Z52 Donors of organs and tissues
Directly below this you will see and notations. Good that you saw these. Read them carefully.
Alfredo is definitely a living donor. Is this “autologous”? In transplantation, the term “autologous” means that the
donor and the recipient are the same person. This is not the case here because Alfredo is donating to his son.
Does this mean you cannot use a code from this code category? Remember that the term “and” also means
“and/or,” so because Alfredo is a living donor, this situation is included here. What about the nota-
tion? Is Alfredo here to be examined as a “potential” donor? No, it is evident that this has been done previously
because Alfredo is here to donate, and the surgery is scheduled. Good! So, you can now read all of the fourth-
character options and determine which is accurate for this encounter. . . .
Now you can report, with confidence, this code to specify the medical necessity for Alfredo’s admission into
the hospital.
Z52.4 Kidney donor
Good job!

Chapter Summary
As a professional coder, you are responsible to ensure that every physician-patient
encounter is supported as medically necessary. You probably know from your own
personal experience that there are legitimate reasons for a healthy person to seek the
attention of a physician or other health care professional. In ICD-10-CM, virtually all
of the codes used to explain these valid reasons are found in the Z code chapter. Here,
you will find codes to report the medical necessity for providing preventive care ser-
vices, performing a screening, observing a patient, and checking for the viability of a
potential organ donor.

CODING BITES
Free Preventive Services under Affordable Care Act
All marketplace plans and many other plans must cover the following list of pre-
ventive services without charging you a copayment or coinsurance. This is true
even if you haven’t met your yearly deductible. This applies only when these ser-
vices are delivered by a network provider.

532   PART II  |  REPORTING DIAGNOSES

 CHAPTER 18 REVIEW
1. Abdominal aortic aneurysm one-time screening for men of specified ages
who have ever smoked.
2. Alcohol misuse screening and counseling.
3. Aspirin use to prevent cardiovascular disease for men and women of certain ages.
4. Blood pressure screening for all adults.
5. Cholesterol screening for adults of certain ages or at higher risk.
6. Colorectal cancer screening for adults over 50.
7. Depression screening for adults.
8. Diabetes (type 2) screening for adults with high blood pressure.
9. Diet counseling for adults at higher risk for chronic disease.
10. HIV screening for everyone ages 15 to 65, and other ages at increased risk.
11. Immunization vaccines for adults—doses, recommended ages, and recom-
mended populations vary:
• Hepatitis A
• Hepatitis B
• Herpes zoster
• Human papillomavirus
• Influenza (flu shot)
• Measles
• Mumps
• Rubella
• Meningococcal
• Pneumococcal
• Tetanus
• Diphtheria
• Pertussis
• Varicella
12. Obesity screening and counseling for all adults.
13. Sexually transmitted infection (STI) prevention counseling for adults at higher risk.
14. Syphilis screening for all adults at higher risk.
15. Tobacco use screening for all adults and cessation interventions for tobacco
users.
Source: Preventive care benefits. https://www.healthcare.gov/what-are-my-preventive-care-benefits/

CHAPTER 18 REVIEW
Factors Influencing Health Enhance your learning by
completing these exercises and
more at connect.mheducation.com!

Status (Z Codes)
Let’s Check It! Terminology
Match each key term to the appropriate definition.
1. LO 18.6  The donor and recipient individuals are genetically identical.
2. LO 18.3  An individual infected with a disease who is not ill but can still pass A. Abnormal Findings
it to another person; an individual with an abnormal gene that can be B. Allogeneic
passed to a child, making the child susceptible to disease.

CHAPTER 18  | 
 3. LO 18.2  Test results that indicate a disease or condition may be present. C. Autologous
CHAPTER 18 REVIEW

4. LO 18.6  The donor and recipient are of different species. D. Carrier

5. LO 18.2  An examination or test of a patient who has no signs or symptoms that E. Isogeneic
is conducted with the intention of finding any evidence of disease as F. Preventive Care
soon as possible, thus enabling better patient outcomes.
G. Prosthetic
6. LO 18.6  Lost tissue that is replaced with synthetic materials such as metal, plas-
H. Screening
tic, or ceramic.
I. Xenogeneic
7. LO 18.6  The donor tissue is taken from a different site on the same individual’s body.
8. LO 18.1  Health-related services designed to stop the development of a disease
or injury.
9. LO 18.6  The donor and recipient are of the same species.

Let’s Check It! Concepts

Choose the most appropriate answer for each of the following questions.
1. LO 18.2  The patient, a 38-year-old adult, presents for an annual physical examination, without abnormal find-
ings. You would use code ________.
a. Z00.00 b.  Z01.00 c.  Z00.2 d.  Z00.70
2. LO 18.1  When the patient has a preventive care encounter, you will use a ________ code.
a. W b.  Z c.  X d.  Y
3. LO 18.6  If the donor and recipient are of different species, the graft is
a. isogeneic. b.  allogeneic.
c. xenogeneic. d.  autologous.
4. LO 18.2  Abnormal findings are
a. test results that indicate a disease or condition may be present.
b. test results that are negative.
c. test results showing that the donor and recipient are of the same species.
d. test results that are inconclusive.
5. LO 18.8  All of the following “Z” codes can be reported as the principal diagnosis except ________.
a. Z00 b.  Z33.2 c.  Z76.2 d.  Z46.0
6. LO 18.6  James Davis presents today to donate his bone marrow. How would you code this?
a. Z52.3 b.  Z52.21 c.  Z52.29 d.  Z52.20
7. LO 18.3  An individual has been found to be a typhoid carrier. How would you code this?
a. Z22.1 b.  A01.00 c.  A01.03 d.  Z22.0
8. LO 18.5  The patient presents today to have his surgical wound dressing changed. What code would you use?
a. Z48.00 b.  Z48.01 c.  Z48.02 d.  Z48.03
9. LO 18.4  If a patient is without signs or symptoms and is being watched for a suspected illness, then the patient is
under
a. preventive care. b.  observation.
c. continuous care. d.  aftercare.
10. LO 18.7  Ben Harris, an 8-year-old male, has an ear infection. Dr. Whitman prescribed a round of penicillin, but
Ben’s condition has not improved. Ben’s infection is resistant to penicillin. You would first code the
infection and then code ________.
a. Z16.10 b.  Z16.11 c.  Z16.21 d.  Z16.22

534   PART II  |  REPORTING DIAGNOSES

Let’s Check It! Guidelines

CHAPTER 18 REVIEW
Part I
Refer to the Official Guidelines and fill in the blanks according to the Chapter 21, Factors influencing health status and
contact with health services, Chapter-Specific Coding Guidelines.
first-listed secondary any
screening present past
potential Z carrier
procedure specifically higher
depending Family no
sequelae not
1. _____ codes are for use in _____ health care setting.
2. Z codes may be used as either a _____ (principal diagnosis code in the inpatient setting) or secondary code,
_____ on the circumstances of the encounter.
3. Z codes are _____ procedure codes.
4. A corresponding _____ code must accompany a Z code to describe any procedure performed.
5. Contact/exposure codes may be used as a first-listed code to explain an encounter for testing, or, more commonly,
as a _____ code to identify a potential risk.
6. Status codes indicate that a patient is either a _____ of a disease or has the _____ or residual of a past disease or
condition.
7. Personal history codes explain a patient’s _____ medical condition that _____ longer exists and is not receiving
any treatment, but that has the _____ for recurrence, and therefore may require continued monitoring.
8. _____ history codes are for use when a patient has a family member(s) who has had a particular disease that
causes the patient to be at _____ risk of also contracting the disease.
9. A _____ code may be a first-listed code if the reason for the visit is _____ the screening exam.
10. The observation codes are not for use if an injury or illness or any signs or symptoms related to the suspected con-
dition are _____.

Part II
Z40 routine support
surveillance continued living
multiple prophylactic inital
aftermath Z52 risk
1. Aftercare visit codes cover situations when the _____ treatment of a disease has been performed and the patient
requires _____ care during the healing or recovery phase, or for the long-term consequences of the disease.
2. The follow-up codes are used to explain continuing _____ following completed treatment of a disease, condition,
or injury.
3. A follow-up code may be used to explain _____ visits.
4. Codes in category _____, Donors of organs and tissues, are used for _____ individuals who are donating blood or
other body tissue.
5. Counseling Z codes are used when a patient or family member receives assistance in the _____ of an illness or
injury, or when _____ is required in coping with family or social problems.
6. The Z codes allow for the description of encounters for _____ examinations, such as, a general checkup, or, exam-
inations for administrative purposes, such as, a pre-employment physical.
7. For encounters specifically for _____ removal of an organ (such as prophylactic removal of breasts due to a
genetic susceptibility to cancer or a family history of cancer), the principal or first-listed code should be a code

CHAPTER 18  | 
 from category _____, Encounter for prophylactic surgery, followed by the appropriate codes to identify the associ-
CHAPTER 18 REVIEW

ated _____ factor (such as genetic susceptibility or family history).

Let’s Check It! Rules and Regulations

Please answer the following questions from the knowledge you have gained after reading this chapter.
1. LO 18.2  Why is early detection important? Include examples of early detection encounters.
2. LO 18.3  Why is it important for a patient to know if he or she has a genetic susceptibility?
3. LO 18.5  Why would a patient need continuing care or aftercare?
4. LO 18.6  Explain the difference between autologous, allogeneic, and xenogeneic.
5. LO 18.8  List 10 of the Z codes, including descriptions, that are permitted to be only first-listed or principal
codes.

ICD-10-CM
YOU CODE IT! Basics
First, identify the condition in the following diagnoses; 8. Encounter for procreative management:
then code the diagnosis. a. main term: _____ b. diagnosis: _____
Example: Awaiting organ transplant status: 9. Encounter for fitting and adjustment of external
right breast prosthesis:
a. main term: Status b. diagnosis: Z76.82
a. main term: _____ b. diagnosis: _____
1. Encounter for disability limiting activities:
10. Aftercare following explantation of knee joint:
a. main term: _____ b. diagnosis: _____
a. main term: _____ b. diagnosis: _____
2. Encounter for screening for human
11. Cornea donor:
papillomavirus:
a. main term: _____ b. diagnosis: _____
a. main term: _____ b. diagnosis: _____
12. High-risk bisexual behavior:
3. Personal history of leukemia:
a. main term: _____ b. diagnosis: _____
a. main term: _____ b. diagnosis: _____
13. Acquired absence of left upper limb below elbow:
4. Genetic susceptibility to malignant neoplasm:
a. main term: _____ b. diagnosis: _____
a. main term: _____ b. diagnosis: _____
14. Encounter for examination of blood pressure with-
5. Contact with and suspected exposure to rubella:
out abnormal findings:
a. main term: _____ b. diagnosis: _____
a. main term: _____ b. diagnosis: _____
6. Carrier of diphtheria:
15. Presence of heart assist device:
a. main term: _____ b. diagnosis: _____
a. main term: _____ b. diagnosis: _____
7. Encounter for surveillance of injectable
contraceptive:
a. main term: _____ b. diagnosis: _____

ICD-10-CM
YOU CODE IT! Practice
Using the techniques described in this chapter, carefully read through the case studies and determine the most ac-
curate ICD-10-CM code(s) and external cause code(s), if appropriate, for each case study.
1. Donald DuFour, an 8-month-old male, is brought in by his mother and Kent Fuller to determine if Kent is
the biological father. Don’s mother is applying for child support and social welfare benefits and needs proof

536   PART II  |  REPORTING DIAGNOSES

 CHAPTER 18 REVIEW
of the biological father before she can proceed. Dr. Sanderson completes a paternity test, results 99.99% that
Kent is the biological father.
2. Jane Ellerbe, a 36-year-old female, presents today to see Dr. Molly, her dentist. Dr. Molly’s dental hygienist
cleans Jane’s teeth and Dr. Molly completes a dental examination. Dr. Molly notes no abnormalities.
3. Charles Copeland, a 48-year-old male, presents today to see Dr. McElmurray. Charles is scheduled to have a
cardiac pacemaker implanted. Dr. McElmurray completes the pre-procedural cardiovascular examination and
clears Charles for the implant.
4. Betty Junketer, a 32-year-old female, was plugging in a light fixture at work when it shocked her badly. She
was taken to the ER by the office manager. After the appropriate tests were completed, Dr. Peterson, the ER
physician, put Betty under observation.
5. Tammy Coco, a 33-year-old female, went on a tour of 19th century buildings last week. The company that
conducted the tour just announced asbestos was found in some of these buildings. Tammy comes to see
Dr. Kiefer today because she is concerned she might have been exposed to asbestos. Dr. Kiefer completes the
appropriate tests, which return a negative result for asbestos exposure.
6. Kelly Richardson, a 46-year-old female, comes in today with the complaints of painful and burning urination.
Dr. Keyton completes the appropriate tests and diagnoses Kelly with a UTI due to Staphylococcus aureus; the
culture shows the UTI is resistant to vancomycin.
7. Connie Burton, a 63-year-old female, presents today for a screening for malignant neoplasm of the ovaries.
Connie’s mother died at age 58 of ovarian cancer. Dr. Bales performs the screening; results were negative.
8. Bennie Cantrell, a 45-day-old male, is brought in by his parents for a well-baby check. Dr. Davis notes that
Bennie’s heel prick is slow to coagulate and stop bleeding. After the appropriate tests, Dr. Davis diagnoses
Bennie with hemophilia A, symptomatic carrier.
9. Ross Risinger, a 47-year-old male, presents today for screening of a malignant neoplasm of the prostate. Ross’s
grandfather died of prostate cancer. Dr. Richardson completes the appropriate test; results were negative.
10. Nellie Preacher, a 27-year-old female, is in her second trimester of pregnancy, G2 P1. Nellie presents today
for her regular checkup. Dr. Williams notes no abnormalities and tells Nellie she is doing fine.
11. Alexandra Smith, a 31-year-old female, presents today to donate blood platelets for her child, who has been
diagnosed with thrombocytopenia.
12. Martha Henry, a 38-year-old female, was diagnosed with breast cancer. Martha had a mastectomy 1 month
ago and Dr. Martin chose to delay the breast reconstruction. Martha presents today for the breast reconstruc-
tion procedure.
13. Van Poteat, a 59-year-old male, was diagnosed with colon cancer and now has an end colostomy. Van comes
to see Dr. Holland, who inspects and cleans the colostomy opening. Dr. Holland tells Van he is doing well.
14. Edwina Henning, a 61-year-old female, was diagnosed with atrial fibrillation and her cardiologist,
Dr. Balestrero, prescribed heparin, an anticoagulant. Edwina is taking the heparin as prescribed and
presents today for therapeutic drug monitoring.
15. Andrew Medders, a 12-year-old male, is brought in by his parents to see Dr. Hearn, his pediatrician. Andrew
has been cross and having some temper tantrums. Dr. Hearn notes Andrew has yawned three times since he
has been in the examination room. Dr. Hearn also notes minor periorbital dark circles and slight periorbital
puffiness. Andrew admits he has not been sleeping well. Andrew is diagnosed with sleep deprivation.

ICD-10-CM
YOU CODE IT! Application
The following exercises provide practice in abstracting physicians’ notes and learning to work with documentation
from our health care facility, Prader, Bracker, & Associates. These case studies are modeled on real patient encoun-
ters. Using the techniques described in this chapter, carefully read through the case studies and determine the most
accurate ICD-10-CM code(s) and external cause code(s), if appropriate, for each case study.

CHAPTER 18  | 
CHAPTER 18 REVIEW

PRADER, BRACKER, & ASSOCIATES

A Complete Health Care Facility
159 Healthcare Way • SOMEWHERE, FL 32811 • 407-555-6789
PATIENT: ELLIOTT, ELLYN
ACCOUNT/EHR #: ELLIEL001
DATE: 10/16/18
Attending Physician: Oscar R. Prader, MD
S: Patient is a 27-year-old female who came in for a physical. I last saw this patient approximately 1
month ago when she received her annual flu shot. She is starting a new job on the first of next month
and is required by her employment contract to get a complete physical including blood pressure check,
cholesterol screening, blood glucose levels, tetanus-diphtheria and acellular pertussis (TdAP), and flu
vaccine.
O: Vital signs charted by the nurse, including BMI. Finger stick glucose test was normal, showing there
were no indications of patient being prediabetic. Cholesterol screening is within normal limits. The TdAP
immunization was administered on 5/24/2012. The flu vaccine was administered on 09/14/2018.
A: Preemployment examination.
P: Form completed, and attached the documentation showing the TdAP and flu administration dates,
and signed it.

ORP/pw  D: 10/16/18 09:50:16  T: 10/18/18 12:55:01

Determine the most accurate ICD-10-CM code(s).

WESTON HOSPITAL
629 Healthcare Way • SOMEWHERE, FL 32811 • 407-555-6541
PATIENT: GALLOP, MICHAEL
ACCOUNT/EHR #: GALLMI001
DATE: 10/16/18
Attending Physician: Renee O. Bracker, MD
S: Neonate was born 8 hours ago via spontaneous vaginal delivery, full-term, this hospital.
O: Newborn screening exam performed in the well-baby nursery included pulse oximetry showing
normal percentage of hemoglobin in his blood that is saturated with oxygen. However, the test for
hypothyroidism was positive. Prior to discharge, I met with the parents and explained this condition and
discussed thyroxine, the medication required so the baby can avoid problems such as slowed growth
and brain damage.
A: Congenital hypothyroidism without goiter
P: Rx: Thyroxine
Follow-up in office in 2 days

ROB/pw  D: 10/16/18 09:50:16  T: 10/18/18 12:55:01

Determine the most accurate ICD-10-CM code(s).

538   PART II  |  REPORTING DIAGNOSES

 CHAPTER 18 REVIEW
PRADER, BRACKER, & ASSOCIATES
A Complete Health Care Facility
159 Healthcare Way • SOMEWHERE, FL 32811 • 407-555-6789
PATIENT: BELLOW, SANDRA
ACCOUNT/EHR #: BELLSA001
DATE: 10/17/18
Attending Physician: Oscar R. Prader, MD
Patient and her husband, Wayne, are thinking about starting a family, so they came in to learn about
genetic screenings. They wanted to get all the information possible before Sandra gets pregnant so
preparations can be employed to have a healthy child. I counseled them and discussed many options.
Both Sandra and Wayne decided to complete a preconception genetic test, and family histories were
reviewed.

ORP/pw  D: 10/17/18 09:50:16  T: 10/18/18 12:55:01

Determine the most accurate ICD-10-CM code(s).

PRADER, BRACKER, & ASSOCIATES

A Complete Health Care Facility
159 Healthcare Way • SOMEWHERE, FL 32811 • 407-555-6789
PATIENT: LESZEK, OGLEV
ACCOUNT/EHR #: LESZOG001
DATE: 10/17/18
Attending Physician: Renee O. Bracker, MD
S: This 13-year-old male was last seen in this office for his back-to-school annual exam 3 months ago.
This exam revealed a healthy young man without any significant medical history.
Today Oglev presents complaining of a cough and a sore throat, of approximately 1 week duration. He
is accompanied by his mother. He and his mother deny fever, nasal congestion, or runny nose. He says
he feels more tired than usual, and his mom states that she can’t get him out of bed to go to school.
Oglev has been truant from school over the last 6 weeks. Patient states that his “mom won’t get off my
back.” He admits that his grades have been dropping and he quit the baseball team. Mom leaves the
room, and patient admits to smoking pot every day, sometimes several times a day, for the last month or
so. He denies any other drug use and states smoking pot is “no big deal.”
O: Physical examination is remarkable only for a mildly erythematous throat without petechiae. Lungs
are clear, and the rest of his exam is normal. Vital signs are also unremarkable.
COUNSELING: Patent is assured that doctor-patient confidentiality is secure. We discussed side
effects and risks of abusing pot. He states he has tried to quit but can’t make it through an entire
day without smoking. It is pointed out to him that his pot use is already having a negative impact on
his life. He understands that his parents need to know about this but that he must tell them himself.
We discussed options and methodologies for his quitting with reduced effects. He agrees to regular
surveillance.

CHAPTER 18  | 
CHAPTER 18 REVIEW

A: Marijuana abuse counseling

P: Refer to drug counselor

ROB/pw  D: 10/17/18 09:50:16  T: 10/18/18 12:55:01

Determine the most accurate ICD-10-CM code(s).

PRADER, BRACKER, & ASSOCIATES

A Complete Health Care Facility
159 Healthcare Way • SOMEWHERE, FL 32811 • 407-555-6789
PATIENT: MONETS, ARNOLD
ACCOUNT/EHR #: MONEAR001
DATE: 10/17/18
Attending Physician: Oscar R. Prader, MD
S: Patient is a 37-year-old male who came to our office for his annual physical exam. Blood was taken
and processed in our in-house lab while the rest of the exam was completed. The results of his blood
work revealed a random elevated transferrin saturation of 82%.
O: Past Medical History: Noncontributory
Family History: Noncontributory
Social History: Active; states he works out in the gym three times a week; apparently healthy; married
for 4 years to Valerie, no children. He states that his wife gives him a multivitamin daily, but he is not cer-
tain which one or its exact contents. His diet includes raw oysters on the half shell and sushi about once
a week; denies eating red meat or organ meat; drinks coffee, about three cups a day, but denies drink-
ing teas or caffeinated beverages.
Physical Exam: Unremarkable; Height: 6’1"; Weight: 215 lb.; Vital signs: within normal limits.
A: Hemochromatosis
P: Quantitative phlebotomy of 500 mL of whole blood per week for an estimated 5 months.
Regular monitoring via blood tests every month: serum ferritin, hemoglobin, and hematocrit over the
course of the phlebotomy treatments.
Dietary modifications, including elimination of all iron supplements and multivitamins containing iron, as
well as no more consumption of raw shellfish.

ORP/pw  D: 10/17/18 09:50:16  T: 10/19/18 12:55:01

Determine the most accurate ICD-10-CM code(s).

540   PART II  |  REPORTING DIAGNOSES

Inpatient (Hospital)
Diagnosis Coding
Learning Outcomes
19
Key Terms
After completing this chapter, the student should be able to: Co-morbidity
Complication
LO 19.1 Evaluate concurrent and discharge coding methodologies. Concurrent Coding
LO 19.2 Utilize the Official Guidelines specific for inpatient reporting. Diagnosis-Related
LO 19.3 Apply the Present-On-Admission (POA) indicators properly. Group (DRG)
LO 19.4 Determine the impact of diagnosis-related groups (DRGs) on Hospital-Acquired
the coding process. Condition (HAC)
Major Complication
LO 19.5 Recognize the importance of the Uniform Hospital Discharge
and Co-morbidity
Data Set (UHDDS). (MCC)
Present-On-
Admission (POA)
Uniform Hospital Dis-
charge Data Set
Remember, you need to follow along in (UHDDS)

  STOP! your ICD-10-CM code book for an optimal

ICD-10-CM

learning experience.

19.1  Concurrent and Discharge Coding

Some acute care facilities have patients who may spend weeks or months in the hospital.
In these cases, professional coding specialists may do what is called concurrent coding. Concurrent Coding
This means that coders actually go up to the nurse’s station on the floor of the hospital System in which coding pro-
and code from the patient’s chart while the patient is still in the hospital. Concurrent cesses are performed while
coding enables the hospital to gain reimbursement to date without having to wait until a patient is still in the hospital
the patient is discharged, improving cash flow for the facility. Figure 19-1 shows you an receiving care.
example of progress notes that might be found in a patient’s chart. A coder performing
concurrent coding would read these, as well as other documentation, to determine what
diagnoses to report.
Once a patient is discharged, you will go through the complete patient record. The
most important documentations to look for include:
∙ Discharge summary or discharge progress notes, signed by the attending physician.
∙ Hospital course, which is a summary of the patient’s hospital stay.
∙ Discharge instructions, a copy of which is given to the patient.
∙ Discharge disposition, which contains orders for the patient to be transferred home
with special services, transferred to another facility, etc.
∙ The death/discharge summary, which is used if the patient expired prior to
discharge.
All of these documents should be reviewed to provide you with a complete picture
of what procedures, services, and treatments were provided to the patient, along with
signs, symptoms, and diagnoses to support medical necessity.
 FIGURE 19-1  An example of a handwritten physician’s progress note

ICD-10-CM
LET’S CODE IT! SCENARIO
The attending physician, Raymond Morrison, MD, included this in the discharge summary:
Admission Diagnosis: Abdominal pain, status post appendectomy
Final Diagnosis: Abdominal pain, unknown etiology, status post appendectomy
Brief History: Patient underwent an appendectomy for perforated appendicitis 6 weeks ago. . . . Three days prior to
admission, she had a recurrent bout of diffuse, dull abdominal pain in the right upper quadrant with associated
nausea and anorexia. She was admitted to the hospital at the time for workup of this pain.
At this time, the patient has just had a regular meal without difficulty and feels like returning home. She will be dis-
charged home at this time and can follow up with her primary MD. We will see her on an as-needed basis.

542   PART II  |  REPORTING DIAGNOSES

Let’s Code It!
This discharge documentation provides you the information you need to code the diagnosis supporting this
patient’s stay in the hospital. (To code the procedures, you would have to review the complete record.)
You have the admitting diagnosis and the final diagnosis. Remember, the Official Guidelines state that
the principal diagnosis is “that condition established after study.” This tells you that the final diagnosis
would be used. You have two conditions to report: abdominal pain, unknown etiology, and status post
appendectomy.
As always, begin in the Alphabetic Index, and find
Pain(s) – see also Painful R52
  abdominal R10.9
Turn to the Tabular List to review the complete code description:
R10 Abdomen and pelvis pain
The and notations do not appear to include any diagnosis documented in these notes, so
continue reading down the column to determine the most accurate fourth character:
R10.1 Pain localized to upper abdomen
Virtually all of the choices you have for the fifth character are specific to the location of the pain in the abdomen.
Dr. Morrison did state that when the patient was admitted, she had “abdominal pain in the right upper quadrant,”
leading you to the fifth character 1. So, here is how this diagnosis code will be reported:
R10.11 Right upper quadrant pain
Are you done? Do you need to report that the patient was status post appendectomy? Yes, you do. It is not
known if the pain is related to the surgical procedure or the condition for which it was performed. So let’s turn
back to the Alphabetic Index and look up
Status (post) – see also Presence (of)

Appendectomy is not listed. What can you look up? Think about the patient status post: What exactly is an
appendectomy? Surgery. No, surgery is not listed in this index either. Hmmmm. Try looking at postsurgical.
Aha!
Status (post) – see also Presence (of)
  postsurgical (postprocedural) NEC Z98.890
(Postoperative NEC is also shown, leading to the same code.)
Let’s turn to the Z code section and check this code out:
Z98 Other postprocedural states
The notes don’t relate to this discharge summary, so continue reading down the column to find the
correct fourth character. No other fourth character is accurate to report postappendectomy, so let’s take a look
at what the Alphabetic Index suggested:
Z98.8 Other specified postprocedural status
  Z98.89 Other specified postprocedural states
   Z98.890 Other specified postprocedural states
When you review the other procedures included in this classification, none seem to relate to an appendectomy.
This code description is the most accurate of those available. Therefore, these are the diagnosis codes you will
report for this case:
R10.11 Right upper quadrant pain
Z98.890 Other specified postprocedural states
Good job!

CHAPTER 19  | 
 CODING BITES
What about the part of the diagnosis where Dr. Morrison wrote “Abdominal pain,
unknown etiology”? How is that reported? Notice that the code R10.11 for the
abdominal pain is located in Symptoms, signs, and abnormal clinical and labora-
tory conditions, not elsewhere classified (ICD-10-CM’s chapter 18). This is the
part that reports the physician could not determine the cause (etiology) of the
pain. Had the cause of the pain been identified, you would be reporting that with a
different code.

19.2  Official Coding Guidelines

In the front of your ICD-10-CM code book are the Official Coding Guidelines.
Included are some specific directions that focus on inpatient coding, rather than on
outpatient coding or both. They are always at your fingertips, right there in your code
book, but please become familiar with them, so you can gain confidence to use them
correctly.

Uncertain Diagnosis
Remember, you learned for outpatient coding (as shown in Section IV, Subsection H.
Uncertain diagnosis) that you are not permitted to ever code something identified by
the physician in his or her documentation as “rule out,” “probable,” “possible,” “sus-
pected,” or other similar terms of an unconfirmed nature. 
For inpatient coding, this guidance (as shown in Section II, Subsection H. Uncer-
tain diagnosis) is different.

GUIDANCE CONNECTION
Read the ICD-10-CM Official Guidelines for Coding and Reporting, section
II. Selection of Principal Diagnosis, subsection H. Uncertain diagnosis.

The guidance for inpatient coders is that you are permitted to “code the condi-
tion as if it existed or was established.” This is done so that medical necessity can be
reported for tests, observation, or other services and resources used to care for the
patient whether or not these efforts resulted in a confirmed diagnosis.

Patient Receiving Diagnostic Services Only

In the outpatient world, the guidelines instruct you to wait until the test results have
been determined and interpreted by the physician as documented in the final report
before coding. At that time, confirmed diagnoses, or the signs and symptoms that
were documented as the reason for ordering the test, are reported.

GUIDANCE CONNECTION
Read the ICD-10-CM Official Guidelines for Coding and Reporting, section
III. Reporting Additional Diagnoses, subsection B. Abnormal findings.

When you are coding for inpatient services, abnormal test results are not reported
unless the physician has documented the clinical significance of those results. Interest-
ingly, in this section of the guidelines, it is reiterated that if the coding professional

544   PART II  |  REPORTING DIAGNOSES

notices abnormal test results and documentation is unclear from the physician, it is
“appropriate to ask the provider whether the abnormal finding should be added.”

ICD-10-CM
YOU CODE IT! CASE STUDY
The attending physician, Thomas Talbott, MD, included this in the discharge summary:
Admission Diagnosis: Acute cervical pain, admitted through ED after MVA
Final Diagnosis: Acute cervical pain and radiculitis secondary to degenerative disc disease with posttraumatic acti-
vation of pain
Brief History: Patient is a 41-year-old male who was involved in a motor vehicle accident, admitted after being
brought to the ED by the ambulance that responded to the accident scene. Patient showed signs of neck and arm
pain associated with cervical radiculopathy, radiating into the shoulders along with constant headaches. He has
numbness and tingling into the hands and fingers.
Radiology: X-rays AP and lateral cervical spinal x-rays demonstrate evidence of significant degenerative disc dis-
ease at C5–6 and C6–7 levels. MRI of cervical spine demonstrates evidence of significant degenerative disc
disease at the C5–6 and C6–7 levels with osteophyte formation and canal compromise with the spinal canal
diameter reduced to approximately 9 mm. Lumbar spine MRI demonstrates mild degenerative disc disease; oth-
erwise normal.
Recommendation to patient is to undergo an anterior cervical diskectomy and fusion utilizing an autologous iliac
bone grafting and placement of anterior titanium plate. After reviewing with patient regarding risks and benefits of
surgery, the patient refused and requested to be discharged immediately.

You Code It!

In this case, the patient received only diagnostic services. Determine the most accurate diagnosis codes for this
inpatient encounter.
Answer:
Did you determine the accurate codes?
M50.122 Cervical disc disorder at C5-C6 level with radiculopathy
M50.123 Cervical disc disorder at C6-C7 level with radiculopathy
G89.11 Acute pain due to trauma
V43.92xA Unspecified car occupant injured in collision with other type car in traffic
accident, initial encounter
Good job!

19.3  Present-On-Admission Indicators

Present-On-Admission (POA) indicators are required for each diagnosis code Present-On-Admission (POA)
reported on UB-04 and 837 institutional claim forms. They are used to report addi- A one-character indicator
tional detail about the patient’s condition. reporting the status of the
Centers for Medicare and Medicaid Services (CMS), in CR5499, requires a POA diagnosis at the time the
indicator for every diagnosis appearing on a claim from an acute care facility. Claims patient was admitted to the
acute care facility.
are returned stamped “unpaid” to the facility if POA indicators are not included. Hos-
pitals are permitted to enter the POA indicators and refile the claim; however, think
about all the time and work wasted by having to do this.

GUIDANCE CONNECTION
Read the ICD-10-CM Official Guidelines for Coding and Reporting, Appendix
I. Present on Admission Reporting Guidelines.

CHAPTER 19  | 
 CODING BITES FIGURE 19-2  An example of an admitting history and physical (H&P) (Page 1 of 2)
A POA indicator is
required to be assigned
to the principal diagno- General Reporting Guidelines
sis codes as well as all According to CMS Publication 100-04, “Present on admission is defined as present
secondary diagnoses, at the time the order for inpatient admission occurs—conditions that develop during
including external cause an outpatient encounter, including emergency department, observation, or outpatient
of injury codes. surgery, are considered as present on admission.”
What does this mean? This means professional coders must carefully review the
admitting physician’s history and physical (H&P)—the documentation that supports
Hospital-Acquired Condition
(HAC)
the order to admit the patient into the hospital (see Figure 19-2 for an example)—
A condition, illness, or injury to determine whether or not the condition was identified at that time. Then you will
contracted by the patient dur- assign the POA indicator to report this fact: Yes—this diagnosis was present when the
ing his or her stay in an acute patient was admitted; No—it was not present; and so on.
care facility; also known as One reason for the importance of gathering POA data is to identify hospital-
nosocomial condition. acquired conditions (HACs). A hospital-acquired condition is exactly what it sounds

546   PART II  |  REPORTING DIAGNOSES

FIGURE 19-2  An example of an admitting history and physical (H&P) (Page 2 of 2)

like: an illness or injury that the patient contracted solely due to the fact that he or she
was in the hospital at the time. HAC data are used for many different purposes, includ-
ing evaluating patient safety directives and limiting payment to a facility for errors it
may have made that caused the problem.

GUIDANCE CONNECTION
Go to: 
www.cms.gov
> Medicare
. . . scroll down to . . .
  > Hospital-Acquired Conditions (Present on Admission Indicator)
(continued)

CHAPTER 19  | 
 On the next screen, on the left side, click on the link: Hospital-Acquired Con-
ditions and then click on ICD-10 HAC LIST for a current list of the conditions
included in this program.
https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalAcqCond/icd10_hacs.html
The ICD-10 HAC LIST actually shows you the diagnosis and then the procedures,
with ICD-10-PCS codes included. Very interesting!

POA Indicators
The POA indicators are used to clearly identify whether or not the signs, symptoms,
and diagnoses reported on the claim form were documented by the admitting physi-
cian at the time the patient was admitted into the hospital.

CODING BITES
POA indicators are not required for external cause codes unless the code is being
reported as an “other diagnosis.”

The indicators are Y, N, U, W, and 1:

∙ Y Yes This condition was documented by the admitting physician as
present at the time of inpatient admission.

EXAMPLE OF POA—“Y” INDICATOR

Felicia was admitted to the hospital from the emergency department with severe
angina (chest pains), dyspnea (shortness of breath), and paresthesia (tingling) in
her left arm. After all the tests were run, Dr. Gordon diagnosed her with an ST
elevation, acute myocardial infarction (AMI) of the anterior wall, left main coronary
artery; discussed diet, exercise, and medications; and discharged her. Reported
with I21.01 ST elevation (STEMI) myocardial infarction involving left main
coronary artery would be POA indicator Y because the signs and symptoms that
caused her admission to the hospital were those of an AMI. Her heart attack was
present on admission.

∙ N No This condition was not present at the time of inpatient admission.

CODING BITES
If any part of the diagnosis code description was NOT present at the time of
admission, report this with an N.

EXAMPLE OF POA—“N” INDICATOR

Porter was admitted with an esophageal ulcer that did not begin bleeding until
after admission. Reported with code K22.11 Ulcer of esophagus with bleeding is
POA indicator N because the entire description of this code was not present at
admission.

∙ U Unknown Documentation from the admitting physician is insuffi-

cient to determine if the condition is present on admission.

548   PART II  |  REPORTING DIAGNOSES

 EXAMPLE OF POA—“U” INDICATOR
David was admitted to the hospital to have his tonsils removed due to his chronic
tonsillitis. The second day, the physician noted a diagnosis of urinary tract infec-
tion (UTI) and ordered antibiotics. Upon discharge, code J35.01 Chronic tonsilli-
tis will get POA indicator Y; however, code N39.0 Urinary tract infection, site not
specified, would receive a U because the documentation is not clear whether the
UTI was not present and developed while he was in the hospital or was present
and not diagnosed when David was admitted.

CODING BITES
It is the responsibility of the physician or health care provider admitting the patient
into the hospital to clearly document which conditions are POA. However, it is the
professional coder’s responsibility to query the physician if the documentation is
incomplete with regard to this issue.

∙ W Clinically Provider is unable to clinically determine whether

Undetermined the condition was present on admission or not.

EXAMPLE OF POA—“W” INDICATOR

Torrie was admitted with diabetic gangrene. After a blood workup early on her
third day in the hospital, the physician documented an additional diagnosis of
septicemia. Upon discharge, the code for the diabetic gangrene (E11.52) would
be reported with a POA of Y; however, the septicemia (A41.9) would receive POA
indicator W because the physician documented that there is no way to be certain
clinically whether the septicemia was not present and developed while she was in
the hospital or present and not diagnosed when Torrie was admitted.

GUIDANCE CONNECTION
Read the ICD-10-CM Official Guidelines for Coding and Reporting, Appendix I,
Present on Admission Reporting Guidelines, subsection Condition is on the
“Exempt from Reporting” list.

∙ 1 Exempt
You can find a list of the conditions, and their diagnosis codes, that are exempt
from POA reporting in the Official Coding Guidelines in your ICD-10-CM book or on
the CMS website. (Note: Some third-party payers prefer this box remain blank instead
of using the numeral 1.)

EXAMPLE OF POA—“EXEMPT” DIAGNOSES

Belinda was admitted to the hospital in full labor and delivered a beautiful baby
boy the next morning. Upon discharge, both codes O80 Normal delivery and
Z37.0 Outcome of delivery, single liveborn, are reported with POA indicator 1.
You will notice that both of these codes are on the Categories and Codes Exempt
from Diagnosis Present on Admission Requirement list shown in the Official
Coding Guidelines in ICD-10-CM, Appendix I.

CHAPTER 19  | 
 CODING BITES
The CDC website has the detailed list of ICD-10-CM codes that are exempt from
(do not require) the use of a POA indicator:
ftp://ftp.cdc.gov/pub/Health_Statistics/NCHS/Publications/ICD10CM/2017/
The conditions on this exempt list represent categories and/or codes for cir-
cumstances regarding the health care encounter or factors influencing health
status that do not represent a current disease or injury or are always present on
admission.

ICD-10-CM
LET’S CODE IT! SCENARIO
Kimberly Byner was admitted into the hospital because she was suffering acute exacerbation of her obstructive
chronic bronchitis. After 2 days of treatment, while still in the hospital, she tried to get out of bed without help, fell,
and broke her left wrist.

Let’s Code It!

The reason Kimberly was admitted into the hospital was because she was having exacerbation of her bronchitis.
Therefore, the documentation (the physician’s H&P) identifies this as being present when she was admitted:
J44.1 Chronic obstructive pulmonary disease with (acute) exacerbation 
POA: Y
When she was discharged, Kimberly also had her wrist in a cast, due to the break suffered from her fall. This is
very clearly a condition she did not have when she was admitted:
S62.102A Fracture of unspecified carpal bone, left wrist, initial encounter
POA: N

19.4  Diagnosis-Related Groups

In addition to dealing with diagnosis and procedure codes, hospitals must work with
Diagnosis-Related Group diagnosis-related groups (DRGs) for Medicare reimbursement, under Medicare Part
(DRG) A—Hospital Insurance. To determine how much an acute care facility will be paid,
An episodic care payment the Inpatient Prospective Payment System (IPPS) was developed. Within IPPS, each
system basing reimburse- and every patient case is sorted into a DRG.
ment to hospitals for inpatient Each DRG has a payment weight assigned to it determined by the typical resources
services upon standards of
used to care for the patient in that case. This calculation includes the labor costs, such
care for specific diagnoses
grouped by their similar usage
as nurses and technicians, as well as nonlabor costs, such as maintenance for equip-
of resources for procedures, ment and supplies.
services, and treatments.
GUIDANCE CONNECTION
Go to: 
www.cms.gov
> Medicare
. . . scroll down to. . .
  > Acute Inpatient PPS
Here, along with the links on the left side, you will find up-to-date information on
the Inpatient Prospective Payment System.

550   PART II  |  REPORTING DIAGNOSES

 Typically, professional coding specialists do not have to worry about assigning the
DRG for a patient’s case. This is determined, most often, by a special software pro-
gram known as a “DRG grouper.”
Medicare-Severity Diagnosis-Related Groups (MS-DRGs) are a subset of 745 sub-
classifications used in the IPPS (Inpatient Prospective Payment System) that Medicare
uses to determine reimbursement for services provided to Medicare beneficiaries by
acute care health care facilities (hospitals). MS-DRGs are subdivided into three pay-
ment tiers based on the presence (or lack) of major complications and co-morbidities
(MCC) and/or complications and co-morbidities (CC).

EXAMPLE
There are several other versions of DRG systems that focus on different details:
APR-DRG = All-Patient Refined Diagnosis-Related Group
APS-DRG = All-Patient Severity-Adjusted DRG
MS-LTC-DRG = Medicare-Severity—Long-Term Care DRG
R-DRG = Refined DRG
AP-DRG = All Patient DRG
S-DRG = Severity DRG
IR-DRG = International-Refined DRG

Principal Diagnosis GUIDANCE

So why do you need to know all this? The principal diagnosis assigned is one of the CONNECTION
factors used to determine which DRG is most accurate. Particularly when it comes
to coding for reporting inpatient services to a Medicare beneficiary, the sequence in Read the ICD-10-CM
which you place the diagnosis codes can make a big difference in how accurately the Official Guidelines for
hospital will be reimbursed. Coding and Reporting,
Remember that the principal, or first-listed, diagnosis as defined by the guidelines is section II. Selection of
“that condition established after study to be chiefly responsible for occasioning the admis- Principal Diagnosis.
sion of the patient to the hospital for care.” This is the diagnosis that explains the most
serious reason for the patient to be in the hospital. This might be the reason for admission,
it might be the most serious condition, or it might be the condition that required the great-
est number of services, treatments, or procedures during the patient’s stay in the hospital.

Complications and Co-morbidities

As each diagnosis is evaluated for its standard of care, CMS understands that a patient
in a hospital may have multiple conditions or concerns (signs, symptoms, diagnoses)
that are interrelated and create a more complex need for care. These may be complica-
tions and/or co-morbidities (CCs).
In some cases, regardless of the precautions that may be taken, complications of Complication
a procedure or treatment may arise during the patient’s stay. Such a condition must An unexpected illness or
be coded and reported to support the medical necessity for the treatment provided to other condition that develops
resolve the concern. as a result of a procedure,
service, or treatment provided
during the patient’s hospital
stay.
EXAMPLE
Lori had surgery this morning and is now having a bronchospasm, a reaction to
the general anesthesia. This bronchospasm is a complication of the administration
of general anesthesia and must be coded and reported to identify the medical
necessity for the treatments to help alleviate this condition.

CHAPTER 19  | 
 You have learned that a patient may have, or end up with, several different condi-
tions treated during a stay in the hospital. The individual may also have preexisting
conditions that have nothing to do with the reason for admission but still need atten-
tion by hospital personnel.

EXAMPLE
Henry was admitted into the hospital with appendicitis. During his stay, the physi-
cian had to order and the nurses had to continue to give Henry his Lipitor, pre-
scribed for his preexisting hypercholesterolemia (high cholesterol). Even though
this condition has nothing to do with the appendicitis or the appendectomy
Co-morbidity (surgery to remove the infected appendix), this co-morbidity must be coded
A separate condition or illness and reported to support the medical necessity for the hospital supplying the
present in the same patient medication.
at the same time as another,
unrelated condition or illness.
Major Complications and Co-morbidities
Conditions, illnesses, and injuries come in all shapes and sizes, as well as severities,
Major Complication and and so do complications and co-morbidities. Typically, a major complication and co-
Co-morbidity (MCC) morbidity (MCC) is a condition that is systemic, making treatment for the principal
A complication or co-morbidity diagnosis more complex and/or making the health concern life-threatening.
that has an impact on the
treatment of the patient and
makes care for that patient
more complex.
EXAMPLES
MS-DRG 799 Splenectomy with MCC Weight: 4.7488
MS-DRG 800 Splenectomy with CC Weight: 2.7250
MS-DRG 801 Splenectomy without CC or MCC Weight: 1.7473
You can see how the presence, or absence, of MCC and/or CC alters the weight
applied to the reimbursement for this procedure.

GUIDANCE CONNECTION
Read the ICD-10-CM Official Guidelines for Coding and Reporting, section
III. Reporting Additional Diagnoses.

19.5  Uniform Hospital Discharge Data Set

Uniform Hospital Discharge The Uniform Hospital Discharge Data Set (UHDDS) is a collection of specific data
Data Set (UHDDS) gathered about hospital patients at discharge. No, this is not an invasion of privacy, nor
A compilation of data col- is it a collection of personal data. The information pulled from hospital claim forms is
lected by acute care facilities related to demographic and clinical details.
and other designated health Demographic data include
care facilities.
∙ Gender.
∙ Age.
∙ Race and ethnicity.
∙ Geographic location.
∙ Provider information, such as the hospital facility National Provider Identifier
(NPI) as well as attending and operating physician(s).
∙ Expected sources of payment, including primary and other sources of payment for
this care.

552   PART II  |  REPORTING DIAGNOSES

 ∙ Length of stay (LOS), determined by date of admission and date of discharge.

CHAPTER 19 REVIEW
∙ Total charges billed by the hospital for this admission (this will not include physi-
cian and other professional services billed).
Clinical data collected evaluate
∙ Type of admission, described as scheduled (planned in advance with preregistration
at least 24 hours prior) or unscheduled.
∙ Diagnoses, including principal and additional diagnoses.
∙ Procedures, services, and treatments provided during this admission period.
∙ External causes of injury, determined by the reporting of external cause codes.
Definitions of these, and other, categories as determined by the UHDDS are used
by ICD-10-CM in the Official Coding Guidelines. Over the years that the UHDDS
has been in place, these definitions have been used to assist the reporting of patient
data not only in acute care facilities (hospitals) but also for inpatient short-term care,
long-term care, and psychiatric hospitals. Outpatient providers including home health
agencies, nursing homes, and rehabilitation facilities also use these definitions for
their data.

Chapter Summary
The coding process remains the same for inpatient and outpatient services for which
coders are determining and reporting accurate diagnosis codes. The same code set,
ICD-10-CM, is used; the same guidelines are used (with the exception of the two spe-
cific guidelines). Therefore, with the additional knowledge provided in this chapter, a
professional coder can be successful in any type of facility.

CODING BITES
POA Reporting Options
Y = Yes
N = No
U = Unknown
W = Clinically undetermined
Unreported/Not used = Exempt from POA reporting

POA Reporting Definitions

Y = Present at the time of inpatient admission

N = Not present at the time of inpatient admission
U = Documentation is insufficient to determine if condition is present on admis-
sion
W = Provider is unable to clinically determine whether condition was present
on admission or not

CHAPTER 19 REVIEW
Inpatient (Hospital) Diagnosis Coding Enhance your learning by
completing these exercises and
more at connect.mheducation.com!

Let’s Check It! Terminology

Match each key term to the appropriate definition.

CHAPTER 19  | 
 1. LO 19.4  A complication or co-morbidity that has an impact on the treatment of A. Co-morbidity
CHAPTER 19 REVIEW

the patient and makes care for that patient more complex. B. Complication
2. LO 19.4  A separate condition or illness present in the same patient at the same C. Concurrent Coding
time as another, unrelated condition or illness.
D. Diagnosis-Related
3. LO 19.5  A compilation of data collected by acute care facilities and other desig- Group (DRG)
nated health care facilities.
E. Hospital-Acquired Con-
4. LO 19.1  System in which coding processes are performed while a patient is still dition (HAC)
in the hospital receiving care.
F. Major Complication
5. LO 19.3  A condition, illness, or injury contracted by the patient during his or and Co-morbidity
her stay in an acute care facility; also known as a nosocomial condition. (MCC)
6. LO 19.4  An unexpected illness or other condition that develops as a result of a G. Present-On-Admission
procedure, service, or treatment provided during the patient’s hospital (POA)
stay.
H. Uniform Hospital
7. LO 19.4  An episodic-care payment system basing reimbursement to hospitals Discharge Data Set
for inpatient services upon standards of care for specific diagnoses (UHDDS)
grouped by their similar usage of resources for procedures, services,
and treatments.
8. LO 19.3  A one-character indicator reporting the status of the diagnosis at the
time the patient was admitted to the acute care facility.

Let’s Check It! Concepts

Choose the most appropriate answer for each of the following questions.
1. LO 19.1  Which of the following is signed by the attending physician?
a. Hospital course
b. Discharge instructions
c. Discharge summary
d. Discharge disposition
2. LO 19.2  Martha Jameson was found to have a breast lump during a mammogram last month. She is admitted
today for a breast biopsy of her left breast. The pathology report returns with lower-inner quadrant
breast carcinoma of the left breast. Martha’s mother had breast cancer in her fifties. What is the correct
code assignment?
a. D05.12
b. D05.12, Z80.3
c. C50.312
d. C50.912, Z80.3
3. LO 19.3  All of the following are POA indicators except 
a. X.
b. Y.
c. W.
d. 1.
4. LO 19.5  The UHDDS is a new code set that will replace ICD-10-CM in 2020.
a. True
b. False

554   PART II  |  REPORTING DIAGNOSES

 5. LO 19.3  Bobby was admitted into the hospital with a compound fracture of the left femur head. Three days later,

CHAPTER 19 REVIEW
during his stay, he developed pneumonia. The POA indicator for the pneumonia is
a. Y.
b. 1.
c. W.
d. N.
6. LO 19.4  An example of a complication is a
a. known allergy to penicillin.
b. family history of breast cancer.
c. high-risk pregnancy.
d. postoperative wound infection.
7. LO 19.2  Inpatient coders are not permitted to ever code something identified in the physician’s notes as “sus-
pected” or “probable.”
a. True
b. False
8. LO 19.5  The UHDDS collects all of these data elements except 
a. gender.
b. credit card number.
c. geographic location.
d. age.
9. LO 19.1  Once a patient is discharged, the coder will go through the complete patient record. The most important
documentation to look for includes all of the following except
a. the discharge summary.
b. the hospital course.
c. the discharge disposition.
d. all of these documentations are important.
10. LO 19.4  DRGs are used for reimbursement from Medicare to
a. physician offices.
b. acute care facilities.
c. ambulatory surgical centers.
d. walk-in clinics.

Let’s Check It! Guidelines

Part I
Refer to the Official ICD-10-CM Guidelines and fill in the blanks according to Sections II and III.

inpatient diagnostic  Abnormal 

outside  one  principal 
admitted  complete discharge 
not unusual  worsens 
ask existed  established
equally overemphasized led 

CHAPTER 19  | 
 1. The circumstances of _____ admission always govern the selection of principal diagnosis.
CHAPTER 19 REVIEW

2. The principal diagnosis is defined in the Uniform Hospital Discharge Data Set (UHDDS) as “that condition
_____ after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care.”
3. The importance of consistent, _____ documentation in the medical record cannot be _____.
4. Codes for symptoms, signs, and ill-defined conditions from Chapter 18 are _____ to be used as _____ diagnosis
when a related definitive diagnosis has been established.
5. In the _____instance when two or more diagnoses _____ meet the criteria for principal diagnosis as determined
by the circumstances of admission, diagnostic workup and/or therapy provided, and the Alphabetic Index, Tabu-
lar List, or another coding guidelines does not provide sequencing direction, any _____ of the diagnoses may be
sequenced first.
6. If the diagnosis documented at the time of _____ is qualified as “probable,” “suspected,” “likely,” “questionable,”
“possible,” or “still to be ruled out,” or other similar terms indicating uncertainty, code the condition as if it _____
or was established.
7. When a patient is _____ to an observation unit for a medical condition, which either _____ or does not improve,
and is subsequently admitted as an inpatient of the same hospital for this same medical condition, the principal
diagnosis would be the medical condition which _____ to the hospital admission.
8. If the provider has included a diagnosis in the final _____ statement, such as the discharge summary or the face
sheet, it should ordinarily be coded.
9. _____ findings (laboratory, x-ray, pathologic, and other diagnostic results) are not coded and reported unless the
provider indicates their clinical significance.
10. If the findings are _____ the normal range and the attending provider has ordered other tests to evaluate the con-
dition or prescribed treatment, it is appropriate to _____ the provider whether the abnormal finding should be
added.

Part II
Go to www.cms.gov and click on the Medicare tab in the upper yellow navigation bar. In the right column, look for
Medicare Fee-for-Service Payment. Under this subtitle you will see Acute Inpatient PPS. Now click on it and fill in the
blanks accordingly.
(IPPS)  add-on approved prospectively
census diagnosis-related group unusually outlier
multiplied added divided low-income
inpatient qualify wage  ratio 
disproportionate prospective cost of living average

1. Section 1886(d) of the Social Security Act (the Act) sets forth a system of payment for the operating costs of
acute care hospital _____ stays under Medicare Part A (Hospital Insurance) based on _____ set rates.
2. This payment system is referred to as the inpatient _____ payment system _____.
3. Under the IPPS, each case is categorized into a _____ (DRG). Each DRG has a payment weight assigned to it,
based on the _____ resources used to treat Medicare patients in that DRG.
4. The base payment rate is _____ into a labor-related and nonlabor share.
5. The labor-related share is adjusted by the _____ index applicable to the area where the hospital is located, and if
the hospital is located in Alaska or Hawaii, the nonlabor share is adjusted by a _____ adjustment factor.
6. This base payment rate is _____ by the DRG relative weight.

556   PART II  |  REPORTING DIAGNOSES

 7. If the hospital treats a high-percentage of _____ patients, it receives a percentage _____ payment applied to the

CHAPTER 19 REVIEW
DRG-adjusted base payment rate.
8. This add-on, known as the _____ share hospital (DSH) adjustment, provides for a percentage _____ in Medicare
payment for hospitals that _____ under either of two statutory formulas designed to identify hospitals that serve a
disproportionate share of low-income patients.
9. Also if the hospital is an _____ teaching hospital it receives a percentage add-on payment for each case paid
through IPPS.
10. This add-on known as the indirect medical education (IME) adjustment, varies depending on the _____ of
residents-to-beds under the IPPS for operating costs, and according to the ratio of residents-to-average daily
_____ under the IPPS for capital costs.
11. Finally, for particular cases that are _____ costly, known as _____ cases, the IPPS payment is increased.
12. Any outlier payment due is _____ to the DRG-adjusted base payment rate, plus any DSH or IME adjustments.

Let’s Check It! Rules and Regulations

Please answer the following questions from the knowledge you have gained after reading this chapter.
1. LO 19.3  Define “Present-On-Admission” according to CMS Publication 100-04.
2. LO 19.2  What are the two instances in which the ICD-10-CM guidelines direct inpatient coders differently than
outpatient?
3. LO 19.4  Explain what DRG stands for and what it is.
4. LO 19.4  Differentiate between a co-morbidity and a complication.
5. LO 19.5  What does UHDDS stand for and what is its function? Include the type of data UHDDS collects.

ICD-10-CM
YOU CODE IT! Application
The following exercises provide practice in abstracting physicians’ notes and learning to work with documenta-
tion from our health care facility, Westward Hospital. These case studies are modeled on real patient encounters.
Using the techniques described in this chapter, carefully read through the case studies and determine the most
accurate ICD-10-CM code(s) and external cause code(s), if appropriate, for each case study.

WESTWARD HOSPITAL

591 Chester Road

Masters, FL 33955

DISCHARGE SUMMARY

PATIENT: FALSONE, LEWIS

DATE OF ADMISSION: 05/30/18

DATE OF SURGERY: 05/31/18

DATE OF DISCHARGE 06/01/18

CHAPTER 19  | 
CHAPTER 19 REVIEW

ADMITTING DIAGNOSIS: Right breast mass

DISCHARGE DIAGNOSIS: Malignant neoplasm of areola, right breast, estrogen receptor status negative;
postsurgical respiratory congestion

This 52-year-old African American male was admitted to the hospital with a palpable 2.25-cm
nodule in the right breast in the superficial aspect of the right breast in the 4 o’clock axis near the
periphery.

Excision of the right breast mass with an intermediate wound closure of 3 cm was accomplished. Patient
tolerated the procedure well; however, some respiratory complications were realized as a result of the
general anesthesia so the patient was kept in the facility for an extra day.

Patient is discharged home with his wife. Discharge orders instruct him to make a follow-up appoint-
ment with Dr. Facci, the oncologist, to discuss treatment.

Benjamin Johnston, MD

556839/mt98328: 06/01/18 09:50:16  T: 06/01/18 12:55:01

Determine the most accurate ICD-10-CM code(s).

WESTWARD HOSPITAL
591 Chester Road
Masters, FL 33955
DISCHARGE SUMMARY
PATIENT: FRIZZELLI, ALLISON
DATE OF ADMISSION: 07/15/18
DATE OF DISCHARGE: 08/01/18
ADMITTING DIAGNOSIS: Schizoaffective disorder
DISCHARGE DIAGNOSIS: Schizoaffective disorder; hypothyroidism; hypercholesterolemia; borderline
hypertension
The patient is a 34-year-old white female with a long history of schizoaffective disorder with numer-
ous hospitalizations, brought in by ambulance for increasing paranoia; increasing arguments with other
people; and, in general, an exacerbation of her psychotic symptoms, which had been worsening over
the previous 2 weeks.
She is now discharged to return to her home at the YMCA and also to return to her weekly psychiatric
appointments with Dr. Mulford. The patient also is advised to follow up with her medical doctor for her
hypertension.
The patient was advised during this admission to start on hydrochlorothiazide 12.5 mg daily, but she
refused.

558   PART II  |  REPORTING DIAGNOSES

 CHAPTER 19 REVIEW
She has been compliant with her medication until the recently refused hydrochlorothiazide. She is irrita-
ble at times, but overall she is redirectable and is considered to be at or close to her best baseline. She
is considered in no imminent danger to herself or to others at this time.

Roxan Kernan, MD
556848/mt98328: 08/01/18 09:50:16  T: 08/01/18 12:55:01

Determine the most accurate ICD-10-CM code(s).

WESTWARD HOSPITAL

591 Chester Road

Masters, FL 33955

DISCHARGE SUMMARY

PATIENT: TAPPEN, KENNETH

DATE OF ADMISSION: 03/05/18

DATE OF DISCHARGE: 03/17/18

ADMITTING DIAGNOSIS: Major depressive disorder

DISCHARGE DIAGNOSIS: Alcohol dependence; cocaine dependence; major depressive disorder, recur-
rent; HIV positive; hepatitis C; and history of asthma

This 39-year-old single male was referred for this admission, his second lifetime rehabilitation. The
patient has a history of alcohol and cocaine dependence since age 17.

During the course of admission, the patient was placed on hydrochlorothiazide 25 milligrams for hyper-
tension, to which he responded well. He participated in this rehabilitation program and worked rigor-
ously throughout.

On discharge, the patient is alert and oriented ×3. Mood is euthymic. Affect is full range. The patient
denies SI, HI, denies AH, VH. Thought process is organized. Thought content—no delusions elicited.
There is no evidence of psychosis. There is no imminent risk of suicide or homicide.

Benjamin Johnston, MD

556845/mt98328: 03/17/18 09:50:16  T: 03/17/18 12:55:01

Determine the most accurate ICD-10-CM code(s).

WESTWARD HOSPITAL

591 Chester Road

Masters, FL 33955

DISCHARGE SUMMARY

CHAPTER 19  | 
CHAPTER 19 REVIEW

PATIENT: ENGELS, WARREN

DATE OF ADMISSION: 01/15/18

DATE OF DISCHARGE: 01/17/18

ADMITTING DIAGNOSIS: Mass in bladder

DISCHARGE DIAGNOSIS: High-grade transitional cell carcinoma of the left bladder wall; low-grade tran-
sitional cell carcinoma in situ, bladder; underlying mild chronic inflammation,
bladder

This 59-year-old male was admitted with a suspicious mass identified in the lateral bladder wall. Biopsy
was performed, and upon pathology report of malignancy, a transurethral resection of the bladder
tumors was performed. Patient was kept overnight. Foley catheter removed second day, and dis-
charged with orders to make appointment to be seen in the office in about 2 weeks to start weekly BCG
bladder installation treatments for recurrent bladder tumors.

Kenzi Bloomington, MD

556839/mt98328: 01/17/18 09:50:16  T: 01/17/18 12:55:01

Determine the most accurate ICD-10-CM code(s).

WESTWARD HOSPITAL

591 Chester Road

Masters, FL 33955

DISCHARGE SUMMARY

PATIENT: BROCKTON, BRIAN

DATE OF ADMISSION: 10/07/18

DATE OF DISCHARGE: 10/09/18

ADMITTING DIAGNOSIS: Hematuria

DISCHARGE DIAGNOSIS: Benign prostatic hypertrophy; hematuria

This 51-year-old male had a transurethral resection of prostate 10 years ago, complicated by a post-
operative bleed as well as evaluation with an attempted ureteroscopy. This hematuria is secondary to
prostatic varices.

Flexible cystoscopy demonstrated a normal urethra and obstructed bladder outlet secondary to a very
large nodular regrowth of the prostate at the medium lobe.

A transurethral resection of prostate was performed with success.

Phillip Carlsson, MD

556845/mt98328: 10/09/18 09:50:16  T: 10/09/18 12:55:01

Determine the most accurate ICD-10-CM code(s).

560   PART II  |  REPORTING DIAGNOSES

 CHAPTER 19 REVIEW
WESTWARD HOSPITAL

591 Chester Road

Masters, FL 33955

DISCHARGE CLINICAL RESUME

PATIENT: LOGAN, PETER

DATE OF ADMISSION: 05/09/18

DATE OF DISCHARGE: 05/14/18

ADMITTING DIAGNOSES:

1. Dyspnea
2. Congestive heart failure (CHR) exacerbation
3. Hypertension
4. Heart murmur
5. Inferior vena cava filter placed July 2010 secondary to lower extremity deep venous thrombosis
(DVT)
6. Hypothyroidism with TSH 9.1
7. Peripheral vascular disease—peripheral arterial disease

DISCHARGE DIAGNOSES:

1. Dyspnea, resolved
2. Diastolic CHR, ejection fraction 70%
3. Hypertension, controlled
4. Aortic stenosis with insufficiency
5. Catheter placed secondary to deep venous thrombosis, on Coumadin, INR in 2 on discharge
6. Hypothyroidism
7. Peripheral vascular disease
8. Renal ultrasound with medical disease

HISTORY: A 76-year-old male was admitted with dyspnea. He was found with diastolic CHF exacerba-
tion. The patient was seen by Dr. Shah, vascular surgeon, who believed that he had some mild arterial
insufficiency and continued anticoagulation. He wants to see him in his office as an outpatient. During
admission, on and off he was having numbness in bilateral feet and hands and cyanosis that resolved
by themselves with no problems. Probably Raynaud phenomenon. During the admission he also was
seen by cardiologist, who diuresed the patient with no complications. He believes that the patient
needs to be started on 1 mg po Bumex. Weigh every day. If the weight gain is more than 3 pounds,
Bumex is to be increased by 1 mg po. The patient also was seen by Dr. Almeada, who believed that the
patient can go home and continue follow-up as an outpatient. Pulmonology saw the patient as well and
believed the same thing. The patient has been stable. Vital signs stable, afebrile, 98% O2 stat on room
air. He was complaining of some biting itching. The daughter had taken him to the dermatologist and
wants to continue follow-up with the dermatologist as an outpatient.

CHAPTER 19  | 
CHAPTER 19 REVIEW

RECOMMENDATIONS: Discharge patient home. Follow up with Dr. Yablakoff in the nursing home.

DISCHARGE MEDICATIONS

1. The patient is going with alendronate 70 mg every week, bumetanide 1 mg twice a day if the weight
gain is more than 3 pounds

2. Diovan 80 mg once a day

3. Levothyroxine was increased to 200 mcg every day, and check TSH in 4 weeks with Dr. Yablakoff
4. Metolazone 2.5 mg once a day
5. Potassium 20 mEq prn every day
6. Warfarin 5 mg every day. Check INR every day and let Dr. Yablakoff know if the INR is more than 2.5
7. Medrol Dosepak as directed
The outpatient care plan was discussed with the patient and his daughter. They understood, had no
questions, and agreed with the plan.

Keith Kappinski, MD

556842/mt98328 05/14/18 12:13:56 05/14/18 17:51:58

cc. Carole Yablakoff, MD

Determine the most accurate ICD-10-CM code(s).

WESTWARD HOSPITAL

591 Chester Road

Masters, FL 33955

DISCHARGE CLINICAL RESUME

PATIENT: DRYLER, ARTHUR

DATE OF ADMISSION: 06/03/18

DATE OF DISCHARGE: 06/06/18

ADMITTING DIAGNOSIS: Ischemia, transient ischemic attack, rule out myocardial infarction, arrythmia

DISCHARGE DIAGNOSES: Transient ischemic attack (TIA)

Hyperlipidemia
Coronary artery disease, status post coronary artery bypass graft and
cardioversion
Urinary tract infection

CONSULTATIONS: Dr. Jenson for neurology and Dr. Balmer for cardiology

562   PART II  |  REPORTING DIAGNOSES

 CHAPTER 19 REVIEW
PROCEDURES: Echocardiogram, TEE, Thallium stress test

COMPLICATIONS: None

INFECTIOUS: None

HISTORY: Eighty-one-year-old white male with significant history of coronary artery disease, status post
coronary artery bypass graft 3 years ago and cardioversion in February 2016, who presented with dif-
ficulty speaking. He stated that he had difficulty obtaining the right words when he spoke. This lasted
about 15 minutes; however, when the patient came to the emergency room he was completely okay.
He did not have any deficits. The patient was admitted and consultants were called in to provide evalu-
ation of possible TIA with rule out cardiac source. Carotid Doppler was done. Echocardiogram was
done. This showed dilated left ventricle, severe global left ventricular dysfunction, estimated ejection
fraction 20% and left atrial enlargement, mitral annular calcification with severe mitral regurgitation,
aortic sclerosis with moderate aortic insufficiency, and severe tricuspid regurgitation with estimated pul-
monary study pressure of 70 mm. Thallium stress test was uneventful. Persantine infusion protocol and
no clinical EKG changes of ischemia and radionuclide showed fixed defect anteroseptal, anteroapical,
and adjacent inferior wall with hypokinesis; no ischemia seen. The ejection fraction was calculated 40%.
CT of the brain showed white matter ischemic changes and atrophy, no acute intracranial abnormalities.
MRI showed extensive periventricular white matter ischemia changes. MRA was normal. EKG was within
normal limits, showing sinus bradycardia with average of 50 to 56.

The patient went to TEE to rule out cardiac source. The TEE was not conclusive and there was no hypo-
kinesis, as described in the previous echocardiogram, and it was considered the patient needs to have
lifetime Coumadin because of previous events.

The hospital course was uneventful. He never presented with any other new deficit or any new
symptoms.

Today, the patient is asymptomatic; vital signs are stable. Monitor shows sinus rhythm, and he is dis-
charged in stable condition to be followed by Dr. Curran in 1 week, by Dr. Jenson in 2 weeks, and by
Dr. Balmer in 2 weeks. He will have home health nurse to inject him Lovenox until PT and INR reach
therapeutic levels of 2/3. He will be on Coumadin 5 mg po qd, and home health nurse will draw PT and
INR daily until Dr. Roman thoroughly assesses the patient. He will receive the last dose of Bactrim today
for urine; however, urine culture has been negative.

Rudolph Langer, MD

556842/mt98328 06/06/18 1:23:36 06/06/18 10:11:59

cc. Karyn Curran, MD

Determine the most accurate ICD-10-CM code(s).

WESTWARD HOSPITAL

591 Chester Road

Masters, FL 33955

DISCHARGE DOCUMENT SUMMARY

CHAPTER 19  | 
CHAPTER 19 REVIEW

PATIENT: WESTCOTT, ROSEANNE

DATE OF ADMISSION: 02/09/18

DATE OF DISCHARGE: 02/10/18

ADMISSION DIAGNOSIS: Abdominal pain, status postappendectomy

DISCHARGE DIAGNOSIS: Abdominal pain, unknown etiology, status postappendectomy

BRIEF HISTORY: The patient is a 21-year-old female who, 6 weeks ago, underwent an appendec-
tomy for perforated appendicitis. About 3 weeks following that, she had episodes of nausea and
vomiting and diffuse abdominal pain. This was worked up at Kinsey Urgent Care Center, including
CT scan, Meckel scan, and laboratory, which were unremarkable. It resolved spontaneously over
a 3-day period. Three days prior to admission, she had a recurrent bout of diffuse, dull, abdominal
pain with associated nausea and anorexia. She was admitted to our hospital at the time for workup
of this pain.

CLINICAL COURSE: On examination, the patient was found to have a diffuse, mild tenderness with-
out any rebound or peritoneal signs. Plain radiographs of the abdomen were obtained, which were
within normal limits. A CT scan of the abdomen and pelvis was also obtained, which was unremark-
able. She was without leukocytosis. Dr. Pointer of GI saw the patient in consultation, and an upper
GI with small bowel follow-through was obtained. This was performed today and was found to be
normal.

At this time, the patient has just had a regular meal without difficulty and feels like returning home. She
will be discharged home at this time and can follow up with her primary MD. We will see her on an as-
needed basis.

Robyn Charne, MD

6582411/mt98328 02/10/18 12:13:56 02/10/18 17:51:58

Determine the most accurate ICD-10-CM code(s).

WESTWARD HOSPITAL

591 Chester Road

Masters, FL 33955

DISCHARGE DOCUMENT SUMMARY

PATIENT: ROMANSKI, CESAR

DATE OF ADMISSION: 08/01/18

DATE OF DISCHARGE: 08/22/18

FINAL DIAGNOSES:

1. Alcohol dependence, methamphetamine dependence

564   PART II  |  REPORTING DIAGNOSES

 CHAPTER 19 REVIEW
2. Major depressive disorder, recurrent, current episode severe

3. HIV

4. Tuberculosis of the lung, primary

5. Hepatitis C, chronic

DISCHARGE MEDICATIONS:

1. Zoloft 100 mg po qam

2. Seroquel 50 mg po qhs

3. Truvade 1 tab qam

4. Regataz 300 mg po qam

5. Norvir 100 mg po qam with breakfast

6. Dapsone 100 mg po qam

7. Hydrochlorothiazide 25 mg po qam

DISPOSITION: The patient will return to his residence at the Daylight Hotel. He will attend the hospital
continuing day treatment program.

PROGNOSIS: Guarded

HISTORY: He is noted to have significant immunosuppression related to his HIV. Currently there is no
stigmata of opportunistic infection.

During the course of admission, the patient was placed on hydrochlorothiazide 25 mg for hypertension,
which he responded well to.

CONDITION ON DISCHARGE: The patient is a 43-year-old single black male referred for his first BRU
admission, his second lifetime rehabilitation. The patient has a history of alcohol and methamphetamine
dependence since age 21. Prior to this admission, he had attained no significant period of sobriety
other than time spent incarcerated.

The patient participated in a 21-day MICA rehabilitation program. He worked rigorously throughout the entire
program. He had perfect attendance and participated well as a peer support provider. The patient attended
eight groups daily. He worked well in individual therapy with his nurse practitioner and social worker.

On discharge, the patient is alert and oriented ×3. Mood is euthymic. Affect is full range. The patient
denies SI, HI, denies AH, VH. Thought process is organized. Thought content—no delusions elicited.
There is no evidence of psychosis. There is no imminent risk of suicide or homicide.

Kelsey Berge, MD

517895221/mt98328 08/22/18 12:13:56 08/22/18 17:51:58

Determine the most accurate ICD-10-CM code(s).

CHAPTER 19  | 
CHAPTER 19 REVIEW

WESTWARD HOSPITAL

591 Chester Road

Masters, FL 33955

DISCHARGE CLINICAL RESUME

PATIENT: MORETTA, TERACIA

DATE OF ADMISSION: 11/05/18

DATE OF DISCHARGE: 11/18/18

This is a 36–37-week-old female neonate delivered to a 25-year-old, gravida 2, para 1, who was a
known breech presentation. Mother presented with complaint of vaginal bleeding, rupture of mem-
branes, and abdominal pain and cramping. On exam found to be complete with large fecal impaction.
Fetal heart rate 120 by monitor. To c-section room for disimpaction and cesarean section for breech.
Delivered precipitously immediately after impaction was removed, breech presentation. OB moved
baby to warmer. She was pale with no respiratory effort or heart rate. Ambu bagged with mask for
30 seconds. Intubation attempted. Code called. UAC was placed. ENT in place and bagged. No heart
rate, no breath sounds, pale, cyanotic. Reintubated with chest rise, heart rate about 60. Chest compres-
sion stopped when heart rate above 120, color improved. Apgar 0 at 1 minute, 1 at 5 minutes, and 4 at
10 minutes. No spontaneous respiratory effort. Received sodium bicarbonate, epinephrine, and calcium.
No grimace, no spontaneous movements. Pupils midpoint, nonreactive to light. NG placed for distended
abdomen. Cord pH 7.33. Mother noted to have 50% abruptio placenta. Transferred to Neo. UAC was
removed and replaced. UVC also placed.

Physical exam: weight 2,620 grams, pink, fontanelle soft, significant clonus of extremities, tone
decreased. Pupils 2 cm and round, nonreactive to light. No movement, no grimace, no suck, good chest
rise. Equal breath sounds, no murmur. Pulses 2+. Perfusion good. Abdomen soft and full. No masses.
Normal female genitalia externally. Anus patent. Extremities no edema. Skin—Mongolian spot sacrum
and both arms, single café-au-lait spot left flank 1.5 cm × 0.5 cm. Palate intact.

IMPRESSION:

1. 36–37 week AGA female

2. Status postcardiopulmonary arrest

3. Rule out sepsis

4. At risk for hypoxic ischemic encephalopathy

PHYSICAL EXAM: 23 days of age, weight 2,520 grams, head circumference 35, pink. Anterior fonta-
nelle soft. Heart—II/VI murmur radiating to the axilla. Chest clear. Abdomen soft, positive bowel sounds,
gastrostomy tube intact, wound is okay. Neuro—irritable. The infant has an anal fissure at 12 o’clock that
has caused some blood streaks in the stool.

FINAL DIAGNOSES:

1. 36–37 week appropriate for gestational age female

2. History post cardiac arrest

3. Respiratory arrest

566   PART II  |  REPORTING DIAGNOSES

 CHAPTER 19 REVIEW
4. Rule out sepsis

5. Hypoxic ischemic encephalopathy, mild

6. Seizures

7. Gastroesophageal reflux and feeding problems

8. Postoperative cesarean wound disruption

Nancy Odom, MD

2564821/mt98328 11/18/18 12:13:56 11/18/18 17:51:58

Determine the most accurate ICD-10-CM code(s).

CHAPTER 19  | 
20 Diagnostic Coding
Capstone
Learning Outcomes
After completing this chapter, the student should be able to:
LO 20.1 Apply the techniques learned, carefully read through the
case studies, and determine the accurate ICD-10-CM code(s)
and the external cause code(s), as required.

As you worked your way through the last 19 chapters, you have learned how to abstract
documentation and interpret the reasons WHY a physician needed to care for a patient—
known as the diagnosis—into ICD-10-CM codes. You also learned to distinguish signs
and symptoms, and other conditions, and when to code those—or not. Now, this chap-
ter provides you with case studies so you can get some hands-on practice.
For each of the following case studies, read through the documentation and:
∙ Determine what code or codes report these reasons, to their most specific level.
∙ Determine how many ICD-10-CM codes you will need to tell the whole story as to
WHY the patient required care.
∙ Identify external cause codes in cases of injury or poisoning.
∙ If more than one code is required, determine the sequence in which to report the codes.
Remember, the notations, symbols, and Official Guidelines are there to help you get
it correct.

YOU CODE IT! DIAGNOSIS CAPSTONE

CASE STUDY 1: JELYSA HANSON

JeLysa Hanson, a 41-year-old female, presents to the ED complaining of shortness

of breath and tightness in her chest. Following examination, she is discharged with a
diagnosis of musculoskeletal pain due to overexertion while practicing her new hobby,
kickboxing in her backyard.

CASE STUDY 2: HARRIS TEAL

Harris Teal, a 19-year-old male, reports to the hospital-based urgent care clinic for
headache and wheezing. Following examination, he is discharged with an acute frontal
sinus infection, recurrent, and exacerbated asthma due to environmental dust allergies.

CASE STUDY 3: ROGER GILL

Roger Gill, a 39-year-old retired professional athlete, comes in with complaints of inter-
mittent joint pain, particularly in his left shoulder. He was a pitcher on a AA league base-
ball team. He also states he feels tenderness at the outer aspect of the left shoulder,

568
most often when he raises his arm. He states that simply putting on his shirt is very
painful. Dr. Jeaneau asks Roger if he suffered any shoulder injuries while playing base-
ball. Roger admitted that his left proximal humerus was fractured when hit by a thrown
ball during a game. Roger quickly added that it healed OK. Dr. Jeaneau confirms a
diagnosis of abscess of the bursa of his shoulder.

CASE STUDY 4: ANGEL DUNBAR

Angel Dunbar, a 27-year-old male, presents to see his physician, Dr. Davison, with the
complaints of difficulty breathing, muscle weakness, and fatigue. Following a com-
plete examination, Dr. Davison notes ataxia and sudden muscle spasms in Angel’s
legs. The lab results are positive for lactic acidosis. CSF results show elevated protein
and the muscle biopsy is positive for ragged red fiber. Angel is diagnosed with MERRF
syndrome.

CASE STUDY 5: RENAY GRIFFITH

Renay Griffith, a 25-year-old female, recently returned from working for the Red Cross
overseas. She presents to the clinic for an evaluation of a rash. Dr. Leisom evaluates
the patient and diagnoses her with cutaneous leishmaniasis related to her recent
deployment to Iraq.

CASE STUDY 6: MARYBELLE OSTENKOWSKY

Patient: Marybelle Ostenkowsky

Physician: Fiona McNally, MD
December 17, 2018
History
This 87-year-old female has been a patient of the McGraw Health Center and Clinic
since 2005. Chronic conditions: pernicious anemia, osteoarthritis, and urinary incon-
tinency. She is fully functional and fully independent. She provides care for her home-
bound husband, who has severe COPD. They live in a home chosen because it was
“close to the hospital” to ensure access to house calls for her husband.
In September 2005, the husband died as a result of respiratory arrest. Her only rela-
tive is a niece who talks with her about once a month. In October 2007, her home was
broken into and our patient was raped and robbed. She was taken to a local hospital
specializing in rape. Here, she was distressed, delusional, and reported to be very emo-
tionally distraught.
Examination
I saw the patient about 3 weeks after the rape in a community nursing home, where
she was moved after a 4-day stay at the hospital. She was very distressed, delusional,
and confused. She slowly improved over 2 months and was discharged to a senior living
center.

CHAPTER 20  | 
 In March of 2018, the patient was seen in the office. She is still very emotionally
unstable. She is crying, depressed (not suicidal), and stressed about her new home.
She wants to move to a different Senior Housing unit because it would be on the bus
route, making it easier to get around. She has also hired a middle-aged woman as a
caregiver.
In November 2018, 9 months after moving to the new facility, she becomes acutely
ill with psychotic symptoms and severe paranoia. She hallucinates that men and women
are in her bed and calls others all hours of the day. I admitted her into a hospitalized
psychiatric unit and she shows improvement over about 14 days without antipsychotic
medication.
Today, 1 week following discharge from the hospital, symptoms rapidly recurred
when she returned to the senior apartment. She was disruptive and threatened with
eviction unless something was done rapidly. An emergency petition was prepared
because she refused medical care. With the help of her companion, we were finally
able to persuade her to take a neuroleptic drug (Haloperidol 0.025 – 1.0 mg/day)
for her recurrent incapacitating hallucinations. Initial injection was administered IM
5 mg. Our office nurse and staff called her later in the day to guide her through
the process of taking her medicines. She slowly but steadily improved and became
stabilized.
Diagnosis: Chronic Post Traumatic Stress Disorder
Rx: Haloperidol 0.025 – 1.0 mg/day

CASE STUDY 7: RAYONNETTA CALHOUN

Patient: Rayonnetta Calhoun

Physician: Robert Morgan, MD
ADMISSION to McGraw Hill Hospital
History
A fully functional, independent female who is nearly 89 years  old; lives with her two
sons. A history finds that she has
• high blood pressure
• CAD
• congestive heart failure
• cataracts
• hearing impairments
• knee osteoarthritis
Current Medications: lisinopril, furosemide, ASA, and metoprolol.
Examination
Patient develops abdominal pain increasing over 4 days; obstipation for 1 day. She is
acutely ill and appears uncomfortable and volume depleted. On exam, she has abdomi-
nal distention, she has hypoactive bowel sounds, and no mass is found. Her heart is
enlarged and no S3.
Laboratory findings:
• WBC . . . 13290
• HCT . . . 42

570   PART II  |  REPORTING DIAGNOSES

 • Na . . . 128
• K . . . 2.6
• Bun/creatinine . . . normal
An abdominal CT scan shows the cecum is very dilated to 13 cm and the left image
shows a possible mass in the descending colon.
Recognizing the seriousness of her illness, she was quickly stabilized with volume
repletion due to her hypertonic dehydration. She was in the emergency department
2 hours, then admitted to a non-intensive care surgical unit and cared for by a general
surgeon, Herman Canton, MD, and a geriatrician, Kyla Mondolano, MD.
Upon Admission
Protocol calls for endoscopy, but to do so would require a delay before surgery that is
clearly needed. There was an urgency to get her to surgery as delays would likely lead
to complications. Accordingly, no colonoscopy was performed. Prior to surgery, care-
ful anesthesia planning and intra-operative management were designed. A shortened
bowel prep was initiated.
A left hemicolectomy was performed on day 2 with pathology confirmation of malig-
nant neoplasm of the sigmoid colon. Pain was controlled with low doses of morphine
and fluid management was tightly managed. She was provided a single, quiet room and
a family member stayed with her continuously. The patient was discharged to subacute
rehabilitation on day 5, and then to home on day 10.

CASE STUDY 8: WINSTON WALLER

Patient: Winston Waller

Physician: Morris Johnston, MD
August 1, 2018
History:
This patient is a 73-year-old male nonsmoker with type 2 diabetes mellitus and hyper-
tension. He presented to this ED with shortness of breath and was found to have an
acute infarction of the anterior wall of his heart showing an ST elevation. He developed
several complications, including renal failure from a combination of cardiogenic shock
and toxicity from the dye used for emergency catheterization of his heart.
Hemodialysis was started during this hospitalization because of his renal failure.
After spending almost a month in the hospital and developing severe deconditioning,
he was discharged to a subacute rehabilitation facility.

Examination
While he was there he was noted to have symptoms consistent with mild depression,
as well as a prior history of a major depressive episode in 2016. Mirtazapine (Remeron)
25 mg/day was started.
He was transferred to a skilled nursing unit for another month of rehabilitation man-
agement of his medical conditions and then discharged home to the care of his wife. 

CHAPTER 20  | 
 CASE STUDY 9: GERALD YOUNG

Patient: Gerald Young

Physician: Hannah Cohen, MD
This 37-year-old man presents to the psychiatry emergency room for inappropriate
behavior and confusion. He works as a janitor and has had reasonably good work atten-
dance. His coworkers say that he has appeared “fidgety” for several years. They specifi-
cally mention jerky movements that seem to affect his entire body more recently. His
mother is alive and well, although his father died at age 28 in an auto accident.
On examination, he is alert but easily distracted. His speech is fluent without para-
phasias but is noted to be tangential. He has trouble with spelling the word “world”
backwards and serial seven’s, but recalls three objects at 3 minutes. His constructions
are good. When he walks, there is a lot of distal hand movement, and his balance is
precarious, although he can stand with both feet together. His reflexes are increased
bilaterally, and there is bilateral ankle clonus. A urine drug screen is negative.
Most likely diagnosis: Huntington disease.
Next diagnostic step: Genetic counseling and genetic testing for Huntington disease.
Review the history very carefully with patient and his relatives and assess medications—
either illicit or licit that could be responsible.
Molecular or genetic basis: Repeat CAG triplets present in a gene called hunting-
tin located on chromosome 4p16.3. Repeat lengths greater than 40 are nearly always
associated with clinical Huntington’s disease. Confirmed Huntington’s disease.

CASE STUDY 10: LORRAINE PARNETE

Patient: Lorraine Parnete

Physician: Jason Nuouri, MD
July 16, 2018
History
A well-established, 67-year-old female patient (since 1991) has controlled hypertension
with no complications. She is a smoker [cigarettes, about one pack a day] and takes
clonidine and HCTZ for her hypertension, and estrogen to address menopausal symp-
toms. Overall, she is well and fully active.
Examination
Patient presents with fatigue, about 1 month duration, associated with the withdrawal
from estrogen because of published data suggesting an increased risk of breast cancer
and other complications. Exam includes complete review of systems. CXR [chest x-ray]
and PPD (tuberculin skin test) are negative except for the following:
• cough with minimal sputum
• a low grade fever to about 100°F
• 5 pound weight loss
Plan
Order for CBC, glucose tolerance test, TSH.
Patient to return to discuss lab results.

572   PART II  |  REPORTING DIAGNOSES

CASE STUDY 11: BLAIZE MASTERS

PATIENT: Blaize Masters

IMPRESSION: This is a 49-year-old male who has significant multivessel coronary artery
disease. He has atypical anginal symptoms, suspected to be secondary to his type 1
diabetes mellitus. Still it is believed that he is at risk for ischemia. To reduce this risk,
surgical myocardial revascularization is recommended.
The patient is given complete details about the procedure, the risks, and the ben-
efits. We also discuss alternative treatments that may be viable. The patient signs the
informed consent and the surgery is scheduled.
PLAN: Proceed with coronary artery bypass graft operation utilizing the left internal
mammary artery as conduit to the left anterior descending. The remaining conduit will
come from the greater saphenous veins.

CASE STUDY 12: CAROLINA SPENCER

PATIENT: Carolina Spencer
REASON FOR ENCOUNTER: Assistance with tracheostomy management.
HISTORY OF PRESENT ILLNESS: The patient is a 73-year-old female admitted to McGraw
Hospital on July 17th with acute ischemic CVA and DKA. The patient has a very compli-
cated medical history, including respiratory failure, on prolonged mechanical ventilation.
She underwent tracheostomy placement on July 19th and was weaned from mechanical
ventilation within 12 hours. She was also diagnosed with hospital-acquired pneumonia,
multi-organism, and pulmonary embolism by CTPA. She is currently on heparin drip, while
started on Warfarin. She also has end-stage renal disease and is on hemodialysis.
PAST MEDICAL HISTORY: In addition to the above, the patient was found to have some
type of intracardiac shunt per echocardiogram, not otherwise defined; atherosclerosis
of the internal carotid arteries; positive lupus anticoagulants; and long-standing history
of diabetes mellitus, type II.
SOCIAL HISTORY: Tobacco and alcohol use are unknown.
MEDICATIONS: Sliding scale insulin, Reglan, Lantus insulin, diltiazem, Timentin, heparin
drip, Warfarin, Bactrim, Pepcid, and iron sulfate.
ALLERGIES: No known allergies.
REVIEW OF SYSTEMS: Not available.
FAMILY HISTORY: Not available.
PHYSICAL EXAMINATION:
GENERAL: She is an unresponsive female, in no acute distress.
VITAL SIGNS: Temperature is 98.6 degrees; respiratory rate is 21 to 25, somewhat
irregular; pulse is 102; blood pressure is 122/80; and pulse oximetry is 97% on 50%
cuffless tracheostomy.
HEENT: Unable to visualize posterior pharynx secondary to the patient’s resistance to
mouth opening. The patient does have some natural dentition anteriorly. No coating of
the tongue is appreciated. The patient has an eschar on the left upper lip, presumably
secondary to ET tube. Conjunctivae are clear. Gaze is conjugate. The patient has a size
8 Portex cuffless tracheostomy tube in the midline.
CHEST: The patient has a few crackles at the right base, few anterior coarse rhonchi.
No wheeze or stridor with the tracheostomy tube, patent. With finger occlusion of the

CHAPTER 20  | 
 cuffless #8 Portex, the patient does have stridor and increased respiratory rate. Unable
to adequately percuss the chest.
CARDIOVASCULAR: The patient has regular rate and rhythm. No murmur or gallop is
appreciated. No heaves or thrills.
ABDOMEN: Soft and obese. The patient has G-tube in position and normoactive bowel
sounds. No guarding.
EXTREMITIES: She has decreased pulse in lower extremities bilaterally. No discrepancy
in calf size is appreciated. No clubbing, cyanosis, or edema. 
NEUROLOGIC: The patient does withdraw, on the left side; grimaces to pain. She is not
cooperative with exam at this time.
LABORATORY DATA: BUN 16 and creatinine 3.3 on July 18th with venous CO2 of 24,
calcium 9.1, white count 9200, hemoglobin 9.2, and platelets 515,000. Chest x-ray is
not available for review.
IMPRESSION: The patient is a 73-year-old female, status post respiratory failure, pro-
longed mechanical ventilation, necessitating tracheostomy tube placement. She has
had multiple complications including pulmonary embolism, for which she is now antico-
agulated with heparin and reportedly intracardiac shunt, which would help explain her
Aa gradient. She also reported she had a right-sided cavitary lesion and had negative
AFB on bronchoalveolar lavage.
RECOMMENDATIONS:
1. Change to #8 Portex cuffless tracheostomy tube. Would not plan on downsizing,
capping tracheostomy at this time secondary to poor patient cough, decreased
mental status, and inability to protect airway. She does have some evidence with
occlusion of the tracheostomy of possible upper airway obstruction, and so, if her
ability to protect her airway improves, she may need evaluation of the upper airway
before considering progressing toward decannulation as well.
2. Repeat chest x-ray to evaluate right cavitary lesion and obtain films from the primary
care physician for comparison.

CASE STUDY 13: LINDA BROTHERS

This is a 33-year-old female, primigravida, who came in experiencing early labor. The
patient had been scheduled for a cesarean section due to breech presentation.
This patient has had no significant problems during first, second, or third trimes-
ter. The patient’s past medical history is noncontributory. The patient’s LMP was
06/22/2017, placing her EDC at 04/05/2018. Ultrasounds were performed throughout
the pregnancy and revealed adequate growth during the pregnancy and EDC remained
technically the same.
The patient’s initial blood work showed blood type to be A positive, VDRL was non-
reactive, rubella titer indicated immunity, hepatitis B surface antigen (HbsAg) was nega-
tive, HIV screen was negative, GC and Chlamydia cultures were negative. Pap smear
was normal. Her 1-hour glucose tolerance test was within normal parameters. The
patient’s blood count also remained well within normal parameters. Her quad screen
for maternal serum alpha-fetoprotein (MSAFP) was normal. Strep culture was likewise
negative at 34–35 weeks.
The patient, upon admission, was having contractions approximately every 4–5
minutes, moderate in intensity. The patient had no dilation; presenting part was still in
a breech presentation, per bedside ultrasound; and the patient was therefore made
ready for primary cesarean section.

574   PART II  |  REPORTING DIAGNOSES

 The patient was taken to surgery, where primary classical cesarean section was per-
formed with delivery of a breech infant from left sacral anterior positioning, male weigh-
ing 6 pounds 10 ounces with Apgars 8 and 8 at 1 and 5 minutes. Placenta delivered
intact. Membranes were removed. The patient tolerated the procedure quite well. Esti-
mated blood loss was less than 600 mL.
The patient has had an uneventful postoperative period. She is ambulating well and
moving well at this time. The patient is passing gas, moving her bowels, and urinating
well; moderate lochia is present; uterus is firm. The patient is discharged from the hospital,
being given careful instructions to avoid douching, intercourse, strenuous activity, going
up and down stairs, and traveling by car. She is to keep her incision clean with peroxide.
She was discharged with Darvocet-N 100 as needed for pain. She will be followed up in
1 week for staple removal. The patient was given information and instructions. Should she
experience unusual bleeding; difficulty urinating, voiding, or having a bowel movement;
or temperature elevation, she is to contact this physician. The patient’s baby is showing
some jaundice and may be kept for another 24–48 hours to evaluate bilirubin levels.

CASE STUDY 14: STEWART ALLEN

DATE OF ADMISSION: 11/15/2018

DATE OF DISCHARGE: 11/25/2018

DISCHARGE DIAGNOSES:
AXIS I:
. Bipolar disorder, depressed, with psychotic features, symptoms in remission.
1
2. Attention deficit hyperactivity disorder, symptoms in remission.
AXIS II: Deferred.
AXIS III: None.
AXIS IV: Moderate.
AXIS V: Global assessment of functioning 65 on discharge.
REASON FOR ADMISSION: The patient was admitted with a chief complaint of suicidal
ideation. The patient was brought to the hospital after his guidance counselor found a
note the patient wrote, which detailed to whom he was giving away his possessions
when he dies. The patient told the counselor that he hears voices telling him to hurt
himself and others. The patient reports over the last month these symptoms have exac-
erbated. The patient had a fight in school recently, which the patient blames on the
voices. Three weeks ago, he got pushed into a corner at school and threatened to
shoot himself and others with a gun. The patient was suspended for that remark.
PROCEDURES AND TREATMENT:
. Individual and group psychotherapy.
1
2. Psychopharmacologic management.
3. Family therapy with the patient and the patient’s family for the purpose of education
and discharge planning.
HOSPITAL COURSE: The patient responded well to individual and group psychotherapy,
milieu therapy, and medication management. As stated, family therapy was conducted.
DISCHARGE ASSESSMENT: At the time of discharge, the patient is alert and fully ori-
ented. Mood euthymic. Affect broad range. He denies any suicidal or homicidal ide-
ation. IQ is at baseline. Memory intact. Insight and judgment good.

CHAPTER 20  | 
 PLAN: The patient may be discharged as he no longer poses a risk of harm towards
himself or others.
The patient will continue on the following medications: Ritalin LA 60 mg q.a.m.,
Depakote 500 mg q.a.m. and 750 mg q.h.s., Abilify 20 mg q.h.s. Depakote level on date
of discharge was 110. Liver enzymes drawn were within normal limits.
The patient will follow up with Dr. Wallace for medication management and Dr. Deiter for
psychotherapy. All other discharge orders per the psychiatrist, as arranged by social work.

CASE STUDY 15: NOAH LOGAN

PATIENT: Noah Logan

PREOPERATIVE DIAGNOSIS: Midface deficiency.
POSTOPERATIVE DIAGNOSIS: Cleft hard palate with cleft soft palate
OPERATIVE PROCEDURE: LeFort I osteotomy with advancement. 
ANESTHESIA: General via nasal intubation.
BLOOD LOSS: 200.
FLUIDS: 600.
URINE OUTPUT: 125.
DRAINS: No drains.
COMPLICATIONS: No complications.
BRIEF HISTORY: The patient is an 8-month-old male who has been under the care of
Dr. Grayson for his pre-surgical orthodontics in order to address a midface deficiency.
He was also found to have a maxillary midline deficit of approximately 3 mm to his left
side. It was determined that he would benefit from a maxillary advancement of approxi-
mately 6 mm with rotation in order to set the midline straight.
OPERATIVE PROCEDURE: He was seen in the preop area, brought to the operating
room, placed in supine position. General anesthesia was induced. Head and neck were
prepped and draped in normal fashion. Time-out was performed. An NG was placed.
The external reference marks were made using the right and left medial canthal tendon
areas. The nasal width was also measured.
Next, a vestibular incision was made between the right and left first molars in the
maxilla. Subperiosteal dissection was performed, as well as dissection around the
piriform rim into the nasal fossa. Next, using a reciprocating saw, a standard LeFort
1 osteotomy was made. The osteotomy was taken posteriorly into the pterygomaxillary
junction. Next, using a series of guarded chisels, the osteotomies were completed. The
nasal septum was disarticulated as were the lateral nasal walls and finally pterygomaxil-
lary disjunction was completed with chisels. The maxilla was brought down quite easily
without any bleeding. All bony interferences were removed. The maxilla was then mobi-
lized appropriately.
Next, the maxilla was placed into intermaxillary fixation, and four 1.5 mm KLS plates
were placed across the right and left piriform rims as well as the zygomaticomaxillary
buttresses in order to plate the LeFort 1 osteotomy. Once this was done, the intermaxil-
lary fixation was released and the occlusion was found to be stable and repeatable.
This was approximately a 6-mm advancement move with about a 2-mm rotation to the
left. At this point, a V-Y closure of the upper lip was performed. An alar cinch suture was
also used to reestablish the alar width. The vestibular incision was then irrigated and
closed. The throat pack was removed. NG was maintained. The patient was extubated
and taken to the recovery room.

576   PART II  |  REPORTING DIAGNOSES

PART III
REPORTING PHYSICIAN SERVICES
AND OUTPATIENT PROCEDURES
INTRODUCTION
Now that you have learned to better understand the reasons why a patient may need
the attention and care from a physician or other health care provider, the next phase—
layer 2—of your learning will be about reporting what is done for this patient.
Procedures, services, and treatments are essentially all-inclusive to cover any-
thing and everything a health care provider can do to, or for, someone. These actions
may be preventive in nature, such as a vaccination; diagnostic such as an x-ray; or
therapeutic—something done to fix or repair an existing problem.
While you think of all the actions a physician may perform in care of the patient,
keep in mind that this includes advice and recommendations. Most of us rely on our
health care providers for guidance related to improving our health. As the professional
coder, a “service” might be conversation with the patient. This counts, too!
 21
Key Terms
Introduction to CPT
Learning Outcomes
After completing this chapter, the student should be able to:
LO 21.1 Recognize the main terms for procedure codes.
Category I Codes LO 21.2 Distinguish the various sections of CPT and how to use them.
Category II Codes LO 21.3 Analyze complete code descriptions.
Category III Codes
LO 21.4 Recall the meanings of notations and symbols within CPT.
Experimental
Outpatient LO 21.5 Interpret accurately the Official Guidelines, shown before
Procedure sections and in-section.
Service LO 21.6 Utilize category II and category III codes, as required.
Treatment
Unlisted Codes

Remember, you need to follow along in

CPT
  STOP! your CPT code book for an optimal
learning experience.

21.1  Abstracting for Procedure Coding

Procedure Procedures, services, and treatments are the terms used for anything and everything
Action taken, in accordance that occurs between a health care professional and a patient. Remember, you learned
with the standards of care, by about distinguishing what the provider did for the patient and reporting them in the
the physician to accomplish chapter Introduction to the Languages of Coding. CPT is one of the languages—the
a predetermined objective terminologies—we use to communicate these details.
(result); a surgical operation.
CPT stands for Current Procedural Terminology and lists services, procedures, and
Services treatments provided by all types of health care professionals. Services such as counsel-
Spending time with a patient ing, treatments such as the application of a cast, and procedures such as the surgical
and/or family about health removal of a mole are each assigned a special code to simplify reporting for pur-
care situations. poses of reimbursement and statistical analysis. In addition, ancillary services, such
Treatment as imaging (x-rays, CT scans, magnetic resonance imaging), pathology, and labora-
The provision of medical care tory (biopsy analysis, blood tests, cultures), are also reported using CPT codes. These
for a disorder or disease. services may range from intense surgical procedures, such as a heart transplant, to
everyday treatments or services, such as removing a splinter or providing professional
advice regarding a treatment plan or preventive service. CPT © 2017 American Medical Association. All rights reserved.
When you are coding for a physician or other health care professional, or on behalf
Outpatient of an outpatient facility, you will use CPT codes to report the actions taken for the
An outpatient is a patient who health and well-being of a patient.
receives services for a short An outpatient facility may be in the same building as a hospital, e.g., an emergency
amount of time (less than
room, ambulatory care center, or same-day surgery center, or it may be a free-standing
24 hours) in a physician’s
office or clinic, without being
facility, such as a physician’s office, a walk-in clinic, or an independent same-day sur-
kept overnight. gery center.

Outpatient Facility
EXAMPLES
An outpatient facility includes
a hospital emergency room, Outpatient Facilities
ambulatory care center, same- • Physicians’ offices
day surgery center, or walk-in • Urgent care and walk-in clinics
clinic.

578
 • Ambulatory care centers CODING BITES
• Same-day surgery centers
CPT codes explain what
• Emergency departments
the physician or health
care professional did to
When you are abstracting the physician’s documentation to collect the details, you or for the patient.
need to determine the codes that report what actions the physician accomplished for
the patient during this encounter. This is a different perspective from when you are
abstracting for diagnosis coding. As you read through the case, look for action verbs:
inserted; excised; administered; discussed; dilated; and many, many more. Then, you
will be able to identify which terms to interpret into CPT codes.

YOU INTERPRET IT!

CODING BITES
IMPORTANT: You are
Identify the term in the sentence that describes WHY the physician
only permitted to report
treated the patient and the term that describes WHAT the physician did codes for procedures,
for the patient. services, and treatments
1. Liam O’Connor fractured his thumb when building a bookshelf in his provided to the patient
house. Dr. Brazinski placed a cast on Liam’s hand. during the encounter. If
2. Emma Burgeron has been using tobacco for 20 years, and she wants the physician “orders”
to quit, once and for all. Dr. Spencer discussed with her several ways something to be done at
to help her. a later date or at a differ-
3. Jacob Treviani was found to have cholelithiasis (gallstones), so ent location, you are not
Dr. Myverson performed a cholecystectomy. permitted to report it.

21.2  CPT Code Book

The Organization of the CPT Book GUIDANCE
The CPT book has two parts, each of which has many sections. CONNECTION
1. The main body of the CPT book has six sections, presented in numeric order (gen- Read the CPT Introduc-
erally speaking) by code number: tion, subsection Instruc-
tions for Use of the
∙ Evaluation and Management: 99201–99499
CPT Codebook.
∙ Anesthesia: 00100–01999 and 99100–99140
∙ Surgery: 10021–69990
∙ Radiology: 70010–79999
CPT © 2017 American Medical Association. All rights reserved.

∙ Pathology and Laboratory: 80047–89398, 0001U-0017U

∙ Medicine: 90281–99199, 99500–99607
You may notice that, while each section within itself is in numeric order (for the
most part), the sections are also in numeric order, for the most part. Bottom line . . . CODING BITES
read carefully. Not all publishers of
CPT books present the
2. The second part of the CPT book contains several sections, including: information in this order.
∙ Category II codes: for supplemental tracking of performance measurement. This is an excellent time
∙ Category III codes: temporary codes for emerging technological procedures. to become familiar with
∙ Appendixes A–P: modifiers and other relevant additional information. the layout of your CPT
book and know where
∙ Alphabetic Index: all the CPT codes in alphabetical order by code description, you can find all of this
presented in four classes of entries: key information.
a. Procedures or services, such as removal, implantation, or debridement.
 b. Anatomical site or organ, such as heart, mouth, or pharynx.
c. Condition, such as miscarriage, cystitis, or abscess.
d. Eponyms, synonyms, or abbreviations, such as Baker’s cyst or EKG.
As you prepare to learn and improve your knowledge about medical procedures,
and build your skills for interpreting the documentation into CPT codes, you will find
that your education in medical terminology will be very useful.

YOU INTERPRET IT!

Identify the term that explains WHAT the physician did for the patient and from which SECTION that
would be reported.
4. Dr. Harper excised a mole from Katrina’s arm.
5. Dr. Aubrey administered general anesthesia prior to the beginning of the surgery.
6. Dr. Davine took and evaluated the MRI images of Lawrence’s head after the car accident.

CPT Resequencing Initiative

The American Medical Association (AMA) was faced with the challenge of fitting new
codes for evolving health care innovation and technology into a preexisting set of num-
bers. So, the AMA determined that resequencing codes would be easier, and less con-
fusing, than renumbering the entire code set. (That certainly would have caused havoc!)
Therefore, when new codes needed to be added to CPT and there were no more
available numbers in the correct sequence, the next available code number was
assigned. Different publishers of CPT books present this new information in various
ways.
In the AMA-published CPT book, the new code is listed in two places:
1. In its correct numeric sequence. The code is shown in the correct numeric sequence
with a notation that informs you where to find the code in its topic-related location.

EXAMPLE
Directly after code 46200 is code
46220   Code is out of numerical sequence. See 46200–46255
You can actually find code 46220 with its description between codes 46946 and
46230.

CPT © 2017 American Medical Association. All rights reserved.

2. In its correct topic-related location. The code is placed with the other codes that
report the same procedure or service based on the specific code description. This
is highlighted by a symbol to the left of the code number—# (the hashtag sign)—to
bring your attention to the fact that this code is not in numeric order.

EXAMPLES
The codes in the subsection for Anus, Excision are listed:
46221 Hemorrhoidectomy, internal, by rubber band ligation(s)
# 46945 Hemorrhoidectomy, internal, by ligation other than rubber band;
single hemorrhoid column/group
# 46946   2 or more hemorrhoid columns/groups

580   PART III  |  REPORTING PHYSICIAN SERVICES AND OUTPATIENT PROCEDURES

 As you can see, it makes much more sense for all of the hemorrhoidectomy codes
to be in the same place so that you can read through all of the code descriptions and GUIDANCE
choose the one that most accurately matches the physician’s notes. If the new codes CONNECTION
were just placed in numeric order, you would need to keep flipping back and forth. Read the CPT Intro-
duction, subsection
Instructions for Use of
21.3  Understanding Code Descriptions the CPT Codebook—
As you look through the CPT book, both the numeric listings and the Alphabetic Index Code Symbols, last
show their data in columns. Notice that some information is indented under other paragraph.
descriptions or terms. An indented description or term attaches to the description or
term that appears at the margin of the column above, or before, the indented words.

In the Alphabetic Index

The Alphabetic Index uses a list with an indented list as a space-saving format. Take
a look at this example:

EXAMPLE
Find “excision” in the Alphabetic Index:
Excision
Abdomen
   Tumor . . . . . . . . . . 49203-49205

Look at the words at the margin and those indented.

The term Excision, a type of procedure, is the heading of this part of the index. This
heading is at the margin of the column, in bold. Beneath this, also at the margin of the
column, is the word Abdomen, to indicate the anatomical site where the excision was
performed. Underneath this, indented, is the word Tumor, to report what specifically
was being excised, followed by a short range of suggested codes. Read backward and
you have Tumor, Abdomen, Excision. The physician’s notes are more likely to read:
Excision of a tumor in the abdomen
Just as with the descriptions in the numeric listing, you must be careful as you read
and connect the indented words and phrases. Using a ruler or other straight edge may
make it easier to see which words are indented and which are at the margins.
Notice that the CPT Alphabetic Index will not necessarily direct you toward one
code. Very often, there will be multiple or a range of codes suggested. Take a look
at the example for the Excision of an abdominal tumor; the Index suggests the range
CPT © 2017 American Medical Association. All rights reserved.

of codes 49203–49205. This means that you are required to investigate ALL of these
codes before making a decision as to which code will accurately report what the physi-
cian did.
As you compare these three code descriptions in the Main Section of CPT, you can
identify which additional specific detail or details you will need to abstract from the
documentation. Continue to the Main Section as you learn the steps to determine an
accurate CPT code.

In the Main Section (Numeric Listing)

Turn to the Main Section of CPT and find the first code suggested by the Alphabetic Index:
49203 Excision or destruction, open, intra-abdominal tumors, cysts, or endo-
metriomas, 1 or more peritoneal, mesenteric, or retroperitoneal pri-
mary or secondary tumors; largest tumor 5 cm diameter or less
 Look carefully. Do you see that this description is set at the inner margin of the col-
CODING BITES umn? The positioning indicates that it is the complete description of this code. Now,
Remember, the rule is let’s look right below this code, at the next two codes listed, which were included in
to read the part of the the Alphabetic Index’s suggested range.
code up to the semico- 49203 Excision or destruction, open, intra-abdominal tumors, cysts, or endo-
lon and then attach the metriomas, 1 or more peritoneal, mesenteric, or retroperitoneal pri-
indented description to mary or secondary tumors; largest tumor 5 cm diameter or less
it. The CPT book does 49204   largest tumor 5.1-10.0 cm diameter
this to save space. 49205   largest tumor greater than 10.0 cm diameter
You can see that the descriptions next to codes 49204 and 49205 are both indented,
not in line at the inner margin of the column. This means you must not only read
49204 or 49205’s description but also attach it to the description above. How do you
know what parts or how much? Look at the punctuation of the first code:
49203 Excision or destruction, open, intra-abdominal tumors, cysts, or endo-
metriomas, 1 or more peritoneal, mesenteric, or retroperitoneal pri-
mary or secondary tumors; largest tumor 5 cm diameter or less
Notice the semicolon (the dot over the comma) after the word tumors. The semico-
lon is very important. When you read the description for a code that has an indented
term or phrase, attach it to the description of the code above, but only the part of the
description up to the semicolon. Read it as shown by the colored text:
49203 Excision or destruction, open, intra-abdominal tumors, cysts, or endo-
metriomas, 1 or more peritoneal, mesenteric, or retroperitoneal pri-
mary or secondary tumors; largest tumor 5 cm diameter or less
49204   largest tumor 5.1-10.0 cm diameter
Putting both lines together means that the actual complete description of code
49204 is
49204 Excision or destruction, open, intra-abdominal tumors, cysts, or endo-
metriomas, 1 or more peritoneal, mesenteric, or retroperitoneal pri-
mary or secondary tumors; largest tumor 5.1-10.0 cm diameter
Now that you know the trick to reading these code descriptions, you can understand
the precise details reported by each of these three codes, and how they differ:
49203 Excision or destruction, open, intra-abdominal tumors, cysts, or endo-
GUIDANCE metriomas, 1 or more peritoneal, mesenteric, or retroperitoneal pri-
CONNECTION mary or secondary tumors; largest tumor 5 cm diameter
Read the CPT Introduc- 49204 Excision or destruction, open, intra-abdominal tumors, cysts, or endo-
tion, subsection Instruc- metriomas, 1 or more peritoneal, mesenteric, or retroperitoneal pri-
tions for Use of the CPT mary or secondary tumors; largest tumor 5.1-10.0 cm diameter
CPT © 2017 American Medical Association. All rights reserved.
Codebook—Format of 49205 Excision or destruction, open, intra-abdominal tumors, cysts, or endo-
the Terminology. metriomas, 1 or more peritoneal, mesenteric, or retroperitoneal primary
or secondary tumors; largest tumor greater than 10.0 cm diameter

ICD-10-CM
LET’S CODE IT! SCENARIO
Dr. Cragen performed a second pericardiocentesis on Lucy Brockton. Her initial procedure was 10 days ago.

Let’s Code It!

The procedure performed by Dr. Cragen was a pericardiocentesis. Let’s begin in the CPT Alphabetic Index, and read
Pericardiocentesis . . . . . . . . . . 33010, 33011

582   PART III  |  REPORTING PHYSICIAN SERVICES AND OUTPATIENT PROCEDURES

 Turn in the Main Section of CPT, and find these codes:
33010 Pericardiocentesis; initial
33011   subsequent
To determine the complete description for 33011, put it together, as you learned earlier. Remember, use the part
of the first code description up to the semicolon + the indented information:
33010 Pericardiocentesis; initial
33011 Pericardiocentesis; subsequent
Dr. Cragen documented that this was the second pericardiocentesis performed on this same patient, which
means it was subsequent to the first. Now, you know exactly which code to report!
33011 Pericardiocentesis; subsequent

Good job!

Unlisted Procedure or Service

On rare occasions, the physician for whom you are coding may perform a service or
procedure that does not yet have a designated CPT category I or CPT category III
code. When this is the case, you may find it necessary to report an unlisted code. Unlisted Codes
There is one of these codes at the end of almost every section or subsection. Codes shown at the end of
each subsection of the CPT
used as a catch-all for any
EXAMPLES procedure not represented by
an existing code.
You will typically find an unlisted procedure code at the end of each section or
subsection.
01999 Unlisted anesthesia procedure(s)
19499 Unlisted procedure, breast
78699 Unlisted nervous system procedure, diagnostic nuclear medicine

In these situations, report the unlisted code and attach a special report to the claim that
includes the specific details of the procedure or service. Make certain you, as the profes-
sional coder, have done everything possible, including querying the physician, to confirm
there are no other codes that will sufficiently or accurately report what was done.

21.4  Notations and Symbols

CPT © 2017 American Medical Association. All rights reserved.

Throughout the CPT book, you will see notations and symbols. Let’s review them
together.

See
A “see” reference is found under a heading in the Alphabetic Index. Let’s review again
an earlier example to better understand this reference.

EXAMPLE
Leukocyte
See White Blood Cell
 In this example, under the heading “Leukocyte,” the notation “See White Blood
Cell” provides an alternate term that the physician may have used in his or her notes.
The CPT book is suggesting that, if you cannot find a match to the documentation
under “Leukocyte,” you might find it under the heading “White Blood Cell.”

Plus Sign
GUIDANCE
CONNECTION The plus symbol ( ) identifies an add-on code. An add-on procedure is most often
performed with a main procedure. These services or treatments are in addition  to,
Read the CPT Introduc- and associated with, the main procedure and are never performed or reported alone
tion, subsection Instruc- (without the main procedure). Due to this relationship with the main procedure, add-
tions for Use of the on codes never use the modifier 51 Multiple Procedures. (You will learn all about
CPT Codebook—Add- modifiers later in this book.) All the add-on codes are grouped and listed in Appendix
on Codes. D for additional reference.

EXAMPLE
Add-On Code Listing—the Plus Symbol
22328 each additional fractured vertebra or dislocated segment (List sepa-
rately in addition to code for primary procedure)

(List Separately in Addition to Code for Primary Procedure)

This notation can be seen at the end of the description of an add-on code and reminds
you that the code represents a procedure that is done as a part of another procedure,
reported separately. Again, this should also remind you that this code cannot be used
by itself.

EXAMPLE
Add-On Code Listing—the Parenthetical Notations
22630 Arthrodesis, posterior interbody technique, including laminectomy
and/or discectomy to prepare interspace (other than for decom-
pression), single interspace; lumbar
22632 each additional interspace (List separately in addition to code for
primary procedure)
(Use 22632 in conjunction with 22612, 22630, or 22633 when performed at a
different level.)
CPT © 2017 American Medical Association. All rights reserved.

(Use . . . in Conjunction with . . .)

The notation “Use . . . in conjunction with . . .” is found below the description of an
add-on code. Here, the CPT book is going one step further. In addition to the sym-
bol and the notation “List separately,” the book states the primary procedure code or
codes with which the add-on code may be reported.

 Bullet Symbol
The bullet symbol ( ) identifies a new code, one that is in the CPT book for the first
time. During the annual update of the CPT book, various codes and guidelines are
added, deleted, or revised. The new, updated, printed version of CPT is effective every
January 1.

584   PART III  |  REPORTING PHYSICIAN SERVICES AND OUTPATIENT PROCEDURES

  Triangle Symbol
CODING BITES
The triangle symbol ( ) distinguishes a code whose description has been changed, or If a claim form is
revised, since the last edition of CPT. received listing codes
that have been deleted
EXAMPLE or changed, the claim
An Example of the  (Triangle) Symbol will be rejected for the
In the 2018 Code Book, see use of invalid codes.
95930 V
 isual evoked potential (VEP) checkerboard or flash testing, central
nervous system except glaucoma, with interpretation and report
GUIDANCE
In the 2017 Code book, see
CONNECTION
95930 Visual evoked potential (VEP) testing central nervous system, check-
erboard or flash Read the CPT Introduc-
The  alerts you to the change, so you can make the appropriate adjustments to tion, subsection Instruc-
your coding process. From January 1, 2018, going forward, you will need to check tions for Use of the
the physician’s notes. CPT Codebook—Code
Symbols. Also, be cer-
tain to check across the
 Double Sideways Triangles
bottom of each page
The double sideways triangles ( ) mark the beginning and end of text that has been revised throughout the book.
or is being shown for the first time in this year’s CPT book. This symbol may highlight code A legend will help
descriptions, guidelines, and/or instructional paragraphs throughout the CPT book. remind you about
the meaning for the
EXAMPLE symbols.
52000 Cystourethroscopy (separate procedure)
(Do not report 52000 in conjunction with 57240, 57260, 57265)

You can see that it is helpful to have this new notation here, should the physician
document an open procedure, and you ended up here, for the endoscopic proce-
dure, by mistake. Now, the CPT book tells you which code is more accurate.

Star Symbol
The star symbol ( ), new beginning with the 2017 edition of CPT, is placed to the left of
those procedure codes that are permitted to be reported when the service has been pro-
vided using synchronous telemedicine services, and appended with modifier 95. These
synchronous (real-time) telemedicine services engage physician and patient by use of
CPT © 2017 American Medical Association. All rights reserved.

equipment with functioning audio and video. These codes are listed in Appendix P.

EXAMPLE
 90832  Psychotherapy, 30 minutes with patient
The star lets you know that if this physician and patient met in person, you can
report this code. And if this physician and patient met via telemedicine (such as
FaceTime or Skype), you can report this same code, appended with modifier 95.
There will be more about modifiers in CPT and HCPCS Level II Modifiers.

 Open Circle with Slash

The symbol of a circle with a slash through it ( ), also called the Forbidden Sym-
bol, identifies codes that are not permitted to be appended with modifier 51 Multiple
 Procedures. These codes are procedures that are sometimes done at the same time
as another procedure (like an add-on code) but can also be performed alone (unlike
an add-on code). Consequently, when such a procedure is performed along with other
procedures, you are not allowed to attach the multiple procedure modifier. All codes
that are modifier 51 exempt are grouped and listed in Appendix E. There will be a lot
more about modifiers as you go through this text.

EXAMPLE
44500 Introduction of long gastrointestinal tube (eg, Miller-Abbott) (sepa-
rate procedure)

Hashtag
When you see this symbol, a hashtag ( ), to the left of a CPT code, this identifies a
code that has been added and placed into the code set out of numeric order. For more
on this, see the section on the CPT Resequencing Initiative in the section CPT Code
Book of this chapter.

 Open Circle
An open circle ( ) identifies a recycled or reinstated code, which is a code that was
CODING BITES previously deleted and now is found to be necessary, so it has been reactivated.
There is a legend across
the bottom of the pages Arrow in a Circle
throughout the CPT
code book to remind Some versions of the CPT book may also include a circle with an arrow symbol ( ). This
you what each symbol symbol ( ) points you toward an AMA-published reference that may be of additional guid-
represents, so you don’t ance. The notation may direct you toward a particular edition of either the CPT Assistant
have to worry about newsletter or the book CPT Changes: An Insider’s View. The American Medical Associa-
memorizing all of these tion (AMA) describes this subscription-only publication, CPT Assistant, as “instrumental
notations and symbols. to many in their appeal of insurance denials, validating coding to auditors, training their
staff and simply making answering day-to-day coding questions second nature.”

ICD-10-CM
LET’S CODE IT! SCENARIO
Kevin Kewly was in a fight with a member of his rival company’s softball team. The other player took out a knife and
stabbed him. When he arrived at the Emergency Department, Dr. Jarrenson repaired his 12 cm laceration, including
debridement and retention sutures, on his lower right arm.

Let’s Code It! CPT © 2017 American Medical Association. All rights reserved.

Dr. Jarrenson stitched a 12 cm laceration on Kevin’s arm. You learned in medical terminology class that this is
known in health care services as a wound repair. Turn to the Alphabetic Index in your CPT code book and find
Wound
Read down the list to find Repair, and indented beneath this, Arms.
Wound
Repair
  Arms
    Complex. . . . . . 13120-13122
    Intermediate. . . 12031, 12032, 12034-12037
    Simple. . . . . . . . 12001, 12002, 12004-12007

586   PART III  |  REPORTING PHYSICIAN SERVICES AND OUTPATIENT PROCEDURES

 Do you know whether Kevin’s wound required a simple repair, intermediate repair, or complex repair? Not yet
(you will learn), so for now, let’s turn to the first code—12001—and see what we can find out.
Look at the in-section Guidelines that are here, in the Repair (Closure) subsection, above code 12001. As you
read the descriptions of the three types of repairs, notice that debridement and retention sutures are mentioned
in both the case scenario and the description of Complex Repair.
Turn to the subsection Repair—Complex and find
13120 Repair, complex, scalp, arms and/or legs; 1.1 cm to 2.5 cm
13121   2.6 cm to 7.5 cm
13122   each additional 5 cm or less (List separately in addition to code for primary procedure)
Look back at the case scenario. It states the wound was 12 cm. You learned earlier in this chapter that that plus
sign ( ) means you will need two codes because code 13122 cannot be reported alone. So, you will have to do
some addition.
Code 13121 reports the first 7.5 cm and you will also need to report 13122 for the additional 4.5 cm to total
12 cm.
That completes the story. Now, you can report Dr. Jarrenson’s procedure performed on Kevin with
confidence . . .
13121 Repair, complex, scalp, arms and/or legs; 2.6 cm to 7.5 cm
13122   each additional 5 cm or less (List separately in addition to code for primary procedure)
Good job!

21.5  Official Guidelines

Section Guidelines
The Official Guidelines you will use to ensure that you are coding procedures cor-
rectly are presented right in your CPT. Notice the pages in front of each of the six
sections of the main part of the book.
∙ Evaluation and Management Guidelines
∙ Evaluation and Management Numerical Listings
∙ Anesthesia Guidelines
∙ Anesthesia Numerical Listings
CPT © 2017 American Medical Association. All rights reserved.

∙ Surgery Guidelines
∙ Surgery Numerical Listings
∙ Radiology Guidelines
∙ Radiology Numerical Listings
∙ Pathology and Laboratory Guidelines
∙ Pathology and Laboratory Numerical Listings
∙ Medicine Guidelines
∙ Medicine Numerical Listings
The guidelines identify important rules and directives that coders must follow when
assigning codes from each section—for example:
∙ Evaluation and management services guidelines include the definitions of com-
monly used terms.
 Surgery Guidelines
Guidelines to direct general reporting of services are other concomitant conditions is not included and may be
presented in the Introduction. Some of the listed separately.
commonalities are repeated here for the convenience of
hose referring to this section on Surgery. Other
definitions and items unique to Surgery are also listed.
Follow-Up Care for
Therapeutic Surgical
Services Procedures
Services rendered in the office, home, or hospital,
Follow-up care for therapeutic surgical procedures

Surgery
consultations, and other medical services are listed in the
includes only that care which is usually a part of the
Evaluation and Management Services section (99201-
surgical service. Complications, exacerbations, recurrence,
99499) beginning on page 11. “Special Services and
or the presence of other diseases or injuries requiring
Reports” (99000-99091) are listed in the Medicine
additional services should be separately reported.
section.

CPT Surgical Package Supplied Materials

Definition Supplies and materials (eg, sterile trays/drugs), over and
above those usually included with the procedure(s)
By their very nature, the services to any patient are rendered are reported separately. List drugs, trays,
variable. The CPT codes that represent a readily supplies, and materials provided. Identify as 99070 or
identifiable surgical procedure thereby include, on a specific supply code.
procedure-by-procedure basis, a variety of services. In
defining the specific services “included” in a given CPT
surgical code, the following services related to the surgery Reporting More Than One
when furnished by the physician or other qualified health
care professional who performs the surgery are included Procedure/Service
in addition to the operation per se:
When more than one procedure/service is performed on
Evaluation and Management (E/M) service(s) the same date, same session or during a post-operative
subsequent to the decision for surgery on the day before period (subject to the “surgical package” concept), several
and/or day of surgery (including history and physical) CPT modifiers may apply (see Appendix A for
Local infiltration, metacarpal/metatarsal/digital block definition).
or topical anesthesia
Immediate postoperative care, including dictating
operative notes, talking with the family and other Separate Procedure
physicians or other qualified health care professionals
Some of the procedures or services listed its the CPT
Writing orders
codebook that are commonly carried out as an integral
Evaluating the patient in the postanesthesia recovery component of a total service or procedure have been
area identified by the inclusion of the term “separate
Typical postoperative follow-up care procedure.” The codes designated as “separate procedure”
should not be reported in addition so the code for the

FIGURE 21-1  A portion of the Surgery Guidelines in the CPT code book, includ-
ing the CPT Surgical Package Definition  Source: CPT Professional Manual, American Medical
Association

∙ Surgery guidelines include a listing of services that are bundled into the surgical
package definition (see Figure 21-1).
∙ Medicine guidelines include instructions on how to code multiple procedures and
CPT © 2017 American Medical Association. All rights reserved.
the proper use of add-on codes.

In-Section Guidelines
There are additional guidelines and instructions throughout each section, shown in
paragraphs under various subheadings. These instructional notations, ranging from a
short sentence to several paragraphs, provide specific information regarding the proper
coding appropriate to that anatomical site or type of procedure. (See Figure 21-2.)

EXAMPLES
Instructional Notations in a Subsection
Biopsy

588   PART III  |  REPORTING PHYSICIAN SERVICES AND OUTPATIENT PROCEDURES

 Directly above code 11100 is a paragraph containing important information for
coders preparing to report a code from this subsection.
Cardiography
Above code 93000, critical coding guidelines in addition to important definitions
and descriptions are provided at the beginning of this subsection.

Stereotactic Radiation Therapy

Thoracic stereotactic body radiation therapy (SRS/SBRT)
is a distinct procedure which may involve collaboration
between a surgeon and radiation oncologist. The surgeon
identifies and delineates the target for therapy. The
radiation oncologist reports the appropriate code(s) for
clinical treatment planning, physics and dosimetry,
treatment delivery and management from the Radiation
Oncology section (see 77295, 77331, 77370, 77373,
77435). The same physician should not report target
delineation services with radiation treatment management
codes (77427-77499).
Target delineation involves specific determination of
tumor borders to identify tumor volume and relationship
with adjacent structures (eg, chest wall, intraparenchymal
vasculature and atelectatic lung) and previously placed
fiducial markers, when present. Target delineation also
includes availability to identify and validate the thoracic
target prior to treatment delivery when a fiducial-less
tracking system is utilized.
Do not report target delineation more than once per
entire course of treatment when the treatment requires
CPT © 2017 American Medical Association. All rights reserved.

greater than one session.

32701 Thoracic target(s) delineation for stereotactic body
radiation therapy (SRS/SBRT), (photon or particle
beam), entire course of treatment
CPT Changes: An Insider's View 2013

(Do not report 32701 in conjunction with 77261-77799)

(For placement of fiducial markers, see 31626, 32553)

FIGURE 21-2  In-section guidelines from the Surgery section of the CPT code
book related to reporting Stereotactic Radiation Therapy  Source: CPT Professional Manual,
American Medical Association
 Remember, the CPT code book will actually support your efforts to code accurately.
The Official Guidelines are right there at your fingertips, and it is your obligation to
read them before you confirm a code is ready to be reported. This is to your benefit . . .
as you will improve your accuracy!

YOU INTERPRET IT!

Identify the pre-section or in-section Guideline that you need to report the procedure accurately.
7. Dr. Singer documented that he debrided Jesse’s abdominal wall. What specific details do you need
to know to determine this code?
8. Dr. Trenton documented performing a sleep study with simultaneous recording of vital signs for
Kent Burlington. The CPT code description is
95807 Sleep study, simultaneous recording of ventilation, respiratory effort, ECG or heart
rate, and oxygen saturation, attended by a technologist
What does “attended by” mean?
9. Dr. Obatunda completed his documentation on his evaluation of Adam. To determine the correct
Evaluation and Management code, you must determine the level of history documented in the
notes. What exactly is included in a problem-focused history?

21.6  Category II and Category III Coding

In the chapter Introduction to the Languages of Coding, you learned about the three
Category I Codes categories of codes located in the CPT code book: Category I codes in the main text
The codes listed in the main of the CPT book, Category II codes, and Category III codes. Let’s briefly review
text of the CPT book, also how category II and category III codes are used.
known as CPT codes.

Category II Codes Category II Codes

Codes for performance mea-
surement and tracking. Category II codes are used for statistical purposes—to track and measure performance
and the quality of care provided in a health care facility.
Category III Codes While the number of Category II codes is small, these codes identify specific ser-
Codes for emerging vices that have been proven to be connected to quality patient care. Category II codes
technology. have five characters: four numbers followed by the letter F.

EXAMPLES
CPT © 2017 American Medical Association. All rights reserved.
0015F Melanoma follow-up completed (includes assessment of all of the
following components): history obtained regarding new or changing
moles, complete physical skin exam performed, and patient coun-
seled to perform a monthly self-skin examination.
1220F Patient screened for depression

As you can see from these examples, category II codes provide detailed informa-
tion about the encounter between physician and patient . . . details that are impor-
tant to research.

Each code’s description explains clinical fundamentals (such as vital signs), lab
test results, patient education, or other facets that might be provided within a typical
office visit. However, individually, these component services do not have any billable
value and, therefore, are not assigned a code from Category I CPT codes. Assigning

590   PART III  |  REPORTING PHYSICIAN SERVICES AND OUTPATIENT PROCEDURES

 Category II codes simply is a way for the health care researchers to specifically calcu-
late how often these services are being provided.

Merit-based Incentive Payment System (MIPS)

Beginning in 2017, the Merit-based Incentive Payment System (MIPS) was launched
by the Centers for Medicare and Medicaid Services (CMS) to provide a way to reward
participating providers with a performance-based payment adjustment to their earned
Medicare reimbursements. This program replaces the Physician Quality Reporting
System (PQRS) program. Coders are instructed to report when designated sets of
quality measures are provided by an eligible professional (EP), using CPT Category
II codes on a standard claim form, with a charged amount of $0.00 (zero) or $0.01
(zero dollars and one cent).

ICD-10-CM
LET’S CODE IT! SCENARIO
Michael Catapano, a 71-year-old male, comes to see Dr. Sheridan, his primary care physician for the last 5 years,
for his annual checkup. Michael has a family history of cardiac disease, so Dr. Sheridan takes extra care to examine
Michael and speak with him about angina (severe acute chest pain caused by inadequate supply of oxygen to part
of the heart). Dr. Sheridan documents that angina is absent.

Let’s Code It!

As the coder for Dr. Sheridan, you will report a preventive medicine evaluation and management (E/M) code
for the annual physical, along with codes for any specific tests or exams that she ordered to make certain Dr.
Sheridan is properly reimbursed for her work. Dr. Sheridan was a good health care professional taking the time
to discuss angina with Michael, and to carefully confirm that angina is not present. How can you, as the coder,
report this service to Medicare?
Turn to the Category II code section in your CPT book.
Under the heading Patient History, find the code that identifies this patient does not have angina. You will see
this code:
1012F Angina absent
So your report for this encounter will include two codes to tell the whole story about this encounter:
99397 Periodic comprehensive preventive medicine reevaluation and management of an individual
including an age and gender appropriate history, examination, counseling/participatory guid-
ance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures;
65 years and older
1012F Angina absent
CPT © 2017 American Medical Association. All rights reserved.

NOTE: You will learn more about annual physical exam coding in the chapter on CPT Evaluation and Manage-
ment Section, Section 23.5.

Category III Codes

Category III codes offer the opportunity to collect detailed information on the use of
new technological advancements, services, and procedures at their entry point into the
practice of health care throughout the United States. Each code identifies an innova-
tive procedure that is at the forefront of the health care industry but not yet widely
used or accepted as a standard of care. It is why the codes in this section of the CPT
book are considered temporary.
 Category III codes may eventually become Category I codes (the codes in the main
GUIDANCE text of the CPT book). New procedures and services are assigned a Category III code
CONNECTION so that actual usage can be accurately measured. They are placed in this section of the
Read the additional
CPT book and assigned a code that has five characters: four numbers followed by the
explanation in the
letter T (for temporary) in the fifth position.
guidelines directly
under the section head-
ing Category III Codes
EXAMPLES
in your CPT book. 0058T Cryopreservation; reproductive tissue, ovarian
0387T Transcatheter insertion or replacement of permanent leadless pace-
maker, ventricular

The use of Category III codes is mandatory, as appropriate, according to the physi-
cian’s notes. If there aren’t any accurate Category I codes in the CPT book to report the
physician’s services, you must check the Category III section for an appropriate code
Unlisted Codes before you are permitted to use a Category I unlisted code. The good news is that the
Codes shown at the end of CPT book will continue to help you. Category III codes are included in the Alphabetic
each subsection of the CPT Index. In addition, there are notations throughout the main sections that will direct you
used as a catch-all for any to a Category III code, if applicable.
procedure not represented by It is important that you are aware of the fact that Category III codes represent up-
an existing code.
and-coming technology. Because of this, the third-party payers from whom you seek
Experimental reimbursement may consider some services experimental. When you work in a health
A procedure or treatment that care facility that uses any procedures or services reported with a Category III code, it
has not yet been accepted by is critical that you determine the carrier’s rules and coverage with regard to the treat-
the health care industry as the ment or test. Should the carrier exclude it and refuse to pay, both the patient and your
standard of care. facility are better off knowing this as soon as possible.
Keep good communication open with the physicians for whom you code. There are
multiple benefits for this, including you finding out about a new technique or proce-
dure before it is provided to any patient. Then, you can determine if this procedure will
require a Category III code. Knowing this before a patient is involved will give you
time. You may be able to petition the payer to convince them of the medical necessity
and the cost efficiency of the new technology, and you may receive an approval after
all. Waiting for a denial notice is not an efficient way to handle the situation. That is
also not respectful to the patient.
A particular Category III code, once assigned, is reserved for 5 years, whether the
code is upgraded to a Category I code or deleted altogether. It allows for the fact that
certain technologies or procedures may take time to find acceptance.

YOU CODE IT! CASE STUDY CPT © 2017 American Medical Association. All rights reserved.
ICD-10-CM

Grace Emerson, a 55-year-old female, had a heart transplant 2 months ago. She has not been feeling well, so
Dr. Rasmussen performs a breath test for heart transplant rejection. This test is experimental, but it is noninvasive.

You Code It!

Go through the steps of coding, and determine the code(s) that should be reported for this test provided by
Dr. Rasmussen to Grace Emerson.
Step #1: Read the case carefully and completely.

Step #2: Abstract the scenario. Which key words or terms describe what service the physician provided to the
patient during this encounter?

592   PART III  |  REPORTING PHYSICIAN SERVICES AND OUTPATIENT PROCEDURES

 Step #3: Are there any details missing or incomplete for which you would need to query the physician? [If so,
ask your instructor.]
Step #4: Determine the correct CPT procedure code or codes to explain the details about what was provided
to the patient during this encounter.
Step #5: Check for any relevant guidance, including reading all of the symbols and notations.
Step #6: Do you need to append any modifiers to ensure complete and accurate information is provided?
Step #7: Double-check your work.
Answer:
Did you determine this to be the code?

0085T Breath test for heart transplant rejection

Good job!

Chapter Summary
In this chapter, you learned about the important role that coding plays in our health
care system, with specific focus on procedure codes used to report physician services
and outpatient facility services. As an up-and-coming professional coding specialist,
you must strive to accurately report the procedure, services, and treatments provided
to every patient using CPT codes. Health care professionals are responsible for ensur-
ing that the supporting documentation is complete so that you have the information
necessary to find the most accurate code or codes.

CODING BITES
Steps to Coding Procedures
Step #1: Read the case carefully and completely.
Step #2: Abstract the scenario. Which key words or terms describe what service
the physician provided to the patient during this encounter?
Step #3: Are there any details missing or incomplete for which you would need to
query the physician? [If so, ask your instructor.]
Step #4: Determine the correct CPT procedure code or codes to explain the
CPT © 2017 American Medical Association. All rights reserved.

details about what was provided to the patient during this encounter.
Step #5: Check for any relevant guidance, including reading all of the symbols and
notations.
Step #6: Do you need to append any modifiers to ensure complete and accurate
information is provided?
Step #7: Double-check your work.

You Interpret It! Answers

1. Fracture = diagnosis code reported to explain why; Cast = CPT code reported to
explain what Dr. Brazinski did for Liam. 2. Tobacco use = diagnosis code reported
to explain why; Discuss = CPT code reported to explain what Dr. Spencer did for
Emma. 3. Cholelithiasis = diagnosis code reported to explain why; Cholecystectomy
 = CPT code reported to explain what Dr. Myverson did for Jacob. 4. Excision = surgi-
CHAPTER 21 REVIEW

cal removal . . . report a code from the Surgery section. 5. Anesthesia . . . report a code
from the Anesthesia section. 6. MRI (Magnetic Resonance Imaging) = imaging . . .
report a code from the Radiology section. 7. Inside the Surgery section of CPT, above
the many codes available to report debridement, are in-section guidelines that include
Debridement. Wound debridements (11042–11047) are reported by depth of tissue that
is removed and by surface area of the wound.  8. 95807 Sleep study, simultaneous
recording of ventilation, respiratory effort, ECG or heart rate, and oxygen saturation,
attended by a technologist. What does “attended by” mean? The CPT book includes
this definition right there, along with in-section guidelines for Sleep Medicine Testing:
“Attended: a technologist or qualified health care professional is physically pres-
ent.” 9. Turn to the Evaluation and Management (E/M) Services Guidelines directly
in front of the Evaluation and Management code section in CPT and find this subsec-
tion: Determine the Extent of History Obtained. Problem focused: Chief complaint;
brief history of present illness or problem.

CHAPTER 21 REVIEW
Introduction to CPT Enhance your learning by
completing these exercises and
more at connect.mheducation.com!

Let’s Check It! Terminology

Match each term to the appropriate definition.
1. LO 21.1  The provision of care for a patient using advice, recommendations, or A. Category I
discussion. B. Category II
2. LO 21.1  A treatment or service provided by a health care professional. C. Category III
3. LO 21.1  A patient who receives services for short term (less than 1 day) in a D. Experimental
physician’s office or clinic, without being kept overnight.
E. Outpatient
4. LO 21.1  The provision of medical care for a disorder or disease.
F. Procedure
5. LO 21.6  Codes for performance measurement and tracking.
G. Service
6. LO 21.6  The codes listed in the main text of the CPT book, also known as CPT
H. Treatments
codes.
I. Unlisted Code
7. LO 21.6  Codes for emerging technology.
8. LO 21.6  A procedure or treatment that has not yet been accepted by the health
care industry as the standard of care.
9. LO 21.3  Codes shown at the end of each subsection of the CPT used as a catch-
all for any procedure not represented by an existing code.
CPT © 2017 American Medical Association. All rights reserved.

Let’s Check It! Concepts

Choose the most appropriate answer for each of the following questions.
1. LO 21.1  CPT stands for
a. Current Procedural Trailers.
b. Classification of Procedural Techniques.
c. Current Procedural Terminology.
d. Classification of Procedural Terms.
2. LO 21.2  The main body of the CPT book has _____ sections, presented in numeric order (for the most part) by
code number.
a. 2 b.  4 c.  6 d.  8

594   PART III  |  REPORTING PHYSICIAN SERVICES AND OUTPATIENT PROCEDURES

 3. LO 21.3  When reading a code description, the rule is to read the part of the code _____ and then attach the

CHAPTER 21 REVIEW
indented description to it.
a. up to the comma b.  up to the semicolon
c. up to the period d.  up to the hyphen
4. LO 21.5  CPT guidelines
a. must be memorized by professional coders.
b. can be found in the front of every CPT section.
c. can be found in a separate guidelines book.
d. change every 2 months.
5. LO 21.4  The plus symbol identifies
a. a new code. b.  a revised code.
c. an add-on code. d.  a code that includes conscious sedation.
6. LO 21.4  The star symbol identifies
a. a new code. b.  an add-on code.
c. a revised code. d.  a telemedicine encounter.
7. LO 21.4  The bullet symbol identifies
a. a new code. b.  an add-on code.
c. a revised code. d.  a code that includes conscious sedation.
8. LO 21.4  The hashtag symbol identifies
a. a reinstated or recycled code. b.  a product pending FDA approval.
c. an out-of-numeric-sequence code. d.  an exemption from modifier 51.
9. LO 21.3  An unlisted code should only be used when
a. an accurate Category I code is not available.
b. an accurate Category I code is not available and an accurate Category III code is not available.
c. an accurate Category III code is not available.
d. an accurate Category I code is not available or an accurate Category III code is not available.
10. LO 21.6  The _____ program provides for a bonus payment to those eligible professionals who meet the criteria
for successful reporting, and a negative payment adjustment is applied when reporting is not submitted
as required.
a. MIPS b.  AMA c.  RVU d.  PQRS

Let’s Check It! Symbols and Sections

CPT © 2017 American Medical Association. All rights reserved.

Part I
Match each symbol to the appropriate definition.
1. LO 21.4  Add-on code A.
2. LO 21.4  New or revised codes B.
3. LO 21.4  Telemedicine C.
4. LO 21.4  Out-of-numeric-sequence code D.
5. LO 21.4  New code E.
6. LO 21.4  Revised code F.
7. LO 21.4  Exempt from modifier 51 G.
8. LO 21.4  Reinstated or recycled code H.
 Part II
CHAPTER 21 REVIEW

The main body of the CPT book has six sections. Match the code range to the correct
A. 99201–99499
section name.
B. 00100–01999 and
1. LO 21.2  Surgery 99100–99140
2. LO 21.2  Pathology and Laboratory C. 10021–69990
3. LO 21.2  Evaluation and Management D. 70010–79999
4. LO 21.2  Medicine E. 80047–89398,
5. LO 21.2  Anesthesia 0001U-0017U
6. LO 21.2  Radiology F. 90281–99199,
99500–99607

Let’s Check It! Rules and Regulations

Please answer the following questions from the knowledge you have gained after reading this chapter.
1. LO 21.1  Explain what is meant by outpatient. Include three examples of an outpatient facility.
2. LO 21.2  Explain the CPT Resequencing Initiative.
3. LO 21.3  Discuss unlisted procedure or service codes, when it is appropriate to use them, and any attachment that
should be included.
4. LO 21.4  What does the arrow in a circle symbol identify?
5. LO 21.6  Differentiate between a CPT Category I code, Category II code, and Category III code, including any
special characteristics of how they are identified.

CPT
YOU CODE IT! Basics
First, identify the procedural main term in the follow- 8. Anesthesia for ear biopsy:
ing statements; then code the procedure or service. a. main term: _____ b. procedure: _____
Example: Drainage of eyelid abscess 9. Data analysis of implantable defibrillation, wear-
able device:
a. main term: Drainage b. procedure: 67700
a. main term: _____ b. procedure: _____
1. Ligation salivary ducts, intraoral:
10. Keratoplasty, anterior lamellar:
a. main term: _____ b. procedure: _____
a. main term: _____ b. procedure: _____
2. Carpal scaphoid fracture manipulation:
11. Lower arm x-ray:
a. main term: _____ b. procedure: _____
CPT © 2017 American Medical Association. All rights reserved.
a. main term: _____ b. procedure: _____
3. Cardiac massage:
12. Kidney cyst injection:
a. main term: _____ b. procedure: _____
a. main term: _____ b. procedure: _____
4. Ureter meatotomy:
13. Lithotripsy with cystourethroscopy:
a. main term: _____ b. procedure: _____
a. main term: _____ b. procedure: _____
5. Intraocular pressure monitoring for 36 hours:
14. Percutaneous spinal cord biopsy:
a. main term: _____ b. procedure: _____
a. main term: _____ b. procedure: _____
6. Tendon sheath incision, finger:
15. Pediatric gastroenteritis education, individual:
a. main term: _____ b. procedure: _____
a. main term: _____ b. procedure: _____
7. Immunoassay antigen detection influenza B:
a. main term: _____ b. procedure: _____

596   PART III  |  REPORTING PHYSICIAN SERVICES AND OUTPATIENT PROCEDURES

 CHAPTER 21 REVIEW
CPT
YOU CODE IT! Practice
Using the techniques described in this chapter, carefully read through the case studies and determine the most
accurate CPT code(s) for each case study.
1. Kelley Gaylord, a 7-year-old female, saw Dr. Roberts for a screening audiologic function test, pure tone, air
only, to check her hearing.
2. Marlene Carrington, a healthy 42-year-old female, was taken to the operating room (OR) for an anterior cer-
vical discectomy with decompression of a single interspace of the spinal cord and nerve roots and including
osteophytectomy.
3. Rosa Phillips, a 34-year-old female, presents today for a percutaneous breast biopsy, needle core.
4. Sandra Lewis, a 55-year-old female, has been experiencing pain in her lower left back that wraps around to
her inner thigh. Dr. Janson does a renal ultrasound, limited, real time with image documentation.
5. Hoyt Markum, a 78-year-old male, was taken to the OR for a single lung transplant with a cardiopulmonary
bypass. Dr. Cannelloni was concerned because Hoyt was not expected to survive without the transplant.
6. Sunshine Thomas, an otherwise healthy 24-year-old female, was taken to the OR for a total thyroidectomy to
remove a left thyroid mass.
7. Elaine Coker, an otherwise healthy 41-year-old female, was admitted to the same-day surgery center after
having an abnormal shoulder x-ray in the clinic the week before. Dr. Logan decided to do a diagnostic
arthroscopy.
8. Dr. Unentl inserted a nontunneled centrally inserted central venous catheter into Kevin Lorenzi, a 4-year-old male.
9. Anna Mourning, a 24-year-old female who is an amateur gymnast, was brought to the OR for the insertion of
a plate with screws to assist the healing of the malunion of a humeral shaft fracture, open treatment.
10. Viviana Shank, a 5-month-old female, was taken to the OR for an excision, radical resection, of a 1.3-cm
malignant neoplasm on the soft tissue of her left cheek right below her eye. It is expected that the carcinoma
was caught before any spread. The patient is in otherwise healthy condition.
11. Nancy Hansen, an 18-year-old female, was brought to the OR for a C-section. Anesthesia was administered.
She has type 1 diabetes that is currently under control. Dr. Klackson came to perform the cesarean delivery
only. Code Dr. Klackson’s procedure.
12. Ted Garrison, a 37-year-old male, was rushed to the hospital by ambulance and taken directly to the OR for
an appendectomy for a ruptured appendix and generalized peritonitis. The patient is otherwise healthy.
13. Dr. Simmons performed a spigelian hernia repair in the lower abdomen on Drew Avalino, a 7-month-old
male.
14. Barbara Cannin, an 18-year-old female, came to see her physician, Dr. Cordoba. She had something in her
eye, and it was irritating her. Nothing she did could get it out. Dr. Cordoba took a problem-focused history
CPT © 2017 American Medical Association. All rights reserved.

and examined the area. He then applied a topical anesthetic and removed the foreign body from the superfi-
cial conjunctiva of her eye. Code the removal of the foreign body only.
15. Michael Munsey, an 84-year-old male, was seen by his physician at an ambulatory surgical center for the
insertion of a temporary transvenous single-chamber cardiac electrode. The patient tolerated the procedure
well.

CPT

 YOU CODE IT! Application

The following exercises provide practice in the application of abstracting the physicians’ notes and learning to
work with SOAP notes from our textbook’s health care facility, Prader, Bracker, & Associates. These case studies
(SOAP notes) are modeled on real patient encounters. Using the techniques described in this chapter, carefully
read through the case studies and find the most accurate CPT code(s) for each case study.
CHAPTER 21 REVIEW

SOAP notes are a standardized documentation method used by health care providers to build a patient’s chart. The
SOAP note has 4 parts and each part will vary in length depending on the patient’s encounter for that day.
So, what does the acronym SOAP stand for?
S = subjective
O = objective
A = assessment
P = plan
What does the subjective portion of the SOAP note include?
The chief complaint, a short statement in the patient’s own words as to the reason for the encounter.
What does the objective portion of the SOAP note include?
The results of the physical examination and any measurable result; a few examples are vital signs, height,
weight, and lab and diagnostic results.
What does the assessment portion of the SOAP note include?
A brief summation of the physician’s diagnosis.
What does the plan portion of the SOAP note include?
The physician’s plan of care (treatment) for the patient’s encounter.

PRADER, BRACKER, & ASSOCIATES

A Complete Health Care Facility
159 Healthcare Way • SOMEWHERE, FL 32811 • 407-555-6789
PATIENT: MURRAY, CARMEL
ACCOUNT/EHR #: MURRCA001
DATE: 07/23/18
Attending Physician: Oscar R. Prader, MD
S: This new patient is a 32-year-old female who comes in with a complaint of severe neck pain and diffi-
culty turning her head. She states she was in a car accident 2 days ago; her car was struck from behind
when she was driving home from work.
O: PE reveals tightness upon palpitation of ligaments in neck and shoulders, most pronounced C3 to
C5. X-rays are taken of the cervical vertebrae, three views (AP, Lat, and PA). Radiologic review denies

CPT © 2017 American Medical Association. All rights reserved.

any fracture.
A: Anterior longitudinal cervical sprain
P: 1. Prescribed cervical collar to be worn during all waking
    2. Rx Vicodin (hydrocodone) 500 mg po prn
    3. 1,000 mg aspirin
    4. Pt to return in 2 weeks for follow-up
ORP/mg  D: 07/23/18 09:50:16  T: 07/24/16 12:55:01

Determine the most accurate CPT code(s) for the x-ray(s).

598   PART III  |  REPORTING PHYSICIAN SERVICES AND OUTPATIENT PROCEDURES

 CHAPTER 21 REVIEW
PRADER, BRACKER, & ASSOCIATES
A Complete Health Care Facility
159 Healthcare Way • SOMEWHERE, FL 32811 • 407-555-6789
PATIENT: AUSTIN, BRUCE
ACCOUNT/EHR #: AUSTBR001
DATE: 08/09/18
Attending Physician: Renee O. Bracker, MD
Preoperative Dx: Orbital mass, OD
Postoperative Dx: Herniated orbital fat pad, OD
Procedure: Excision of lesion and repair, right superior conjunctiva
Surgeon: Marc Zammarrelli, MD
Anesthesia: Local
PROCEDURE: After proparacaine was instilled in the eye, it was prepped and draped in the usual sterile
manner and 2 percent lidocaine with 1:200,000 epinephrine was injected into the superior aspect of
the right orbit. A corneal protective shield was placed in the eye. The eye was placed in down-gaze.
The upper lid was everted and the fornix examined. The herniating mass was viewed and measured at
0.75 cm in diameter. Westcott scissors were used to incise the fornix conjunctivae. The herniating mass
was then clamped, excised, and cauterized. It appeared to contain mostly fat tissue, which was sent to
pathology.
The superior fornix was repaired using running suture of 6-0 plain gut. Bacitracin ointment was applied
to the eye followed by an eye pad. The patient tolerated the procedure well and left the OR in good
condition.
ROB/mg  D: 08/09/16 09:50:16  T: 08/10/16 12:55:01

Determine the most accurate CPT code(s).

WESTON HOSPITAL
629 Healthcare Way • SOMEWHERE, FL 32811 • 407-555-6541
PATIENT: WOODARD, HOPE
CPT © 2017 American Medical Association. All rights reserved.

ACCOUNT/EHR #: WOODHO001
DATE: 3/19/18
Attending Physician: Oscar R. Prader, MD
The patient is a 54-year-old female with a very long history of schizoaffective disorder with numerous
hospitalizations who was brought in by ambulance due to increasing paranoia; increasing arguments
with other people; and, in general, an exacerbation of her psychotic symptoms, 14-day duration.
I am here to provide psychoanalysis.
Initially, the patient was very agitated and uncooperative. She refused medications. A 2PC* was done
and the patient had a court hearing that results in retention. Eventually, the patient agreed to a trial of
CHAPTER 21 REVIEW

a Risperdal; she fairly rapidly improved once she was started on Risperdal 2 mg twice daily. At the time
of discharge compared with admission, the patient is much improved. She is usually pleasant and coop-
erative, with occasional difficult moments and some continuing mild paranoia. She has no hallucinations.
She has no thoughts of harming herself or anyone else. She has been compliant with her medication
until she recently refused hydrochlorothiazide. She is irritable at times, but overall she is redirectable
and is considered to be at or close to her best baseline. She is considered no imminent danger to her-
self or to others at this time.
FINAL DX: Schizoaffective disorder; hypothyroidism; hypercholesterolemia; borderline hypertension.
Prescriptions for 30-day supplies were given:
Ativan 2 mg po tid; Celexa 40 mg po daily; Risperdal 2 mg po bid; Synthroid 0.088 mg po qam; Zocor
40 mg po qhs
ORP/mg  D: 03/19/18 09:50:16  T: 03/20/18 12:55:01

*2PC stands for “two physicians certify”—a medical certification testifying that an individual requires involuntary
treatment at a psychiatric facility.
Determine the most accurate CPT code(s).

PRADER, BRACKER, & ASSOCIATES

A Complete Health Care Facility
159 Healthcare Way • SOMEWHERE, FL 32811 • 407-555-6789
PATIENT: JOHNS, CHARLENE
ACCOUNT/EHR #: JOHNCH001
DATE: 08/09/18
Attending Physician: Renee O. Bracker, MD
S: This patient is a 34-year-old female who I have not seen in 6 months. She has a history of recurrent
sinus infections. She has been well until 6 days ago. She presents with fever, severe frontal headache,
facial pain, and runny nose. Patient states she has been having difficulty concentrating.
O: PE reveals: T 101.5º. HEENT: Tenderness over frontal and left maxillary sinuses. Nasal congestion
visible. CT scan of the maxillofacial area, without contrast, reveals opacification of both frontal, left max-
illary, and sphenoid sinuses and a possible large nonenhanced lesion in the brain.

CPT © 2017 American Medical Association. All rights reserved.

A: Epidural abscess with frontal lobe lesions caused by significant compression on frontal lobe.
P: Recommendation for surgery to evacuate the abscess. Patient will think about it and call in a day or
two.
Rx: Amoxil 875 mg q.12.h
   Sudafed 120 mg q.12.h
ROB/MG  D: 08/09/18 09:50:16  T: 08/10/18 12:55:01

Determine the most accurate CPT code(s) for the CT scan.

600   PART III  |  REPORTING PHYSICIAN SERVICES AND OUTPATIENT PROCEDURES

 CHAPTER 21 REVIEW
PRADER, BRACKER, & ASSOCIATES
A Complete Health Care Facility
159 Healthcare Way • SOMEWHERE, FL 32811 • 407-555-6789
PATIENT: PYKE, JOEL
ACCOUNT/EHR #: PYKEJO001
DATE: 05/26/18
Diagnosis: Primary cardiomyopathy with chest pain
Procedure: Arterial catheterization
Physician: Oscar R. Prader, MD
Anesthesia: Local
Procedure: The patient was placed on the table in supine position. Local anesthesia was administered.
Once we were assured that the patient had achieved no nervous stimuli, the incision was made and the
catheter was introduced percutaneously. The incision was sutured with a simple repair. The patient tol-
erated the procedure well and was transferred to the recovery room.
ORP/mg  D: 5/26/18 09:50:16  T: 05/27/18 12:55:010

Determine the most accurate CPT code(s).

CPT © 2017 American Medical Association. All rights reserved.
 22
Key Terms
CPT and HCPCS
Level II Modifiers
Learning Outcomes
Alphanumeric After completing this chapter, the student should be able to:
Ambulatory Surgery
Center (ASC) LO 22.1 Recognize the purpose of procedure code modifiers.
AMCC LO 22.2 Apply personnel modifiers per the guidelines.
Category II Modifiers LO 22.3 Correctly use anesthesia physical status modifiers.
Class A Finding LO 22.4 Implement ambulatory surgery center modifiers.
Class B Finding LO 22.5 Append anatomical site modifiers, as required.
Class C Finding LO 22.6 Identify circumstances that require a service-related modifier.
Clinical Laboratory
Improvement LO 22.7 Analyze the guidelines to correctly sequence multiple modifiers.
­Amendment (CLIA) LO 22.8 Determine when a supplemental report is necessary.
CPT Code Modifier
Early and ­Periodic
Screening,
­Diagnostic, and
Remember, you need to follow along in
­Treatment (EPSDT)
End-Stage Renal
CPT
STOP! HCPCS Level II
your CPT and HCPCS Level II code books
­Disease (ESRD) for an optimal learning experience.
HCPCS Level II
Modifier
Liters per Minute
(LPM) 22.1  Modifiers Overview
Locum Tenens
Physician In addition to the code for the specific procedure or service provided to the patient,
Modifier there may be times when you will have to append a modifier. Modifiers are
Nonphysician two-character codes that add clarification and additional details to the procedure
Parenteral Enteral code’s original description, as written in the main portion of the Current Procedural
Nutrition (PEN) Terminology (CPT) book. 
Personnel Modifier Sometimes, the modifier provides necessary explanation to the third-party payer
Physical Status that directly relates to the reimbursement that the facility or physician should receive.
Modifier It might explain that
Service-Related ∙ A service or procedure had both a professional component and a technical
CPT © 2017 American Medical Association. All rights reserved.
Modifier component.
Supplemental Report ∙ A service or procedure was performed by more than one physician.
Urea Reduction Ratio
(URR) ∙ A service or procedure was performed in more than one location.
∙ A service or procedure was not performed in total (only part of it was done).
Modifier ∙ The provider has special qualifications or training.
A two-character code that ∙ An optional extra service was performed.
affects the meaning of
∙ A bilateral procedure was performed.
another code; a code adden-
dum that provides more ∙ A service or procedure was performed more than once.
meaning to the original code. ∙ Unusual events arose.
One of the most important reasons to properly report a procedure code with a modi-
fier is to provide more information about that procedure—additional details that need
to be added to the code description to make certain you are completely and accurately

602
 reporting what was actually provided to the patient during the encounter. Some modifiers
GUIDANCE
will result in the physician or facility getting paid more money because the circumstances
resulted in their having to do more work than usual. For example, modifier 22 Increased CONNECTION
Procedural Service reports that the procedure was more complex than usual. Read the CPT Introduc-
Some modifiers will result in the physician or facility getting paid less money for tion, subsection Instruc-
the typical procedure but truthfully and accurately report that less work than usual was tions for Use of the CPT
provided. For example, modifier 52 Reduced Services reports fewer services were Codebook—Modifiers
provided. on how to properly use
Other modifiers will prevent a claim for reimbursement from being denied because modifiers.
it brings attention to the fact that unusual circumstances required unusual work. For
example, modifier 23 Unusual Anesthesia alerts that a procedure that typically only
uses a local anesthetic, for example, required general anesthesia. In these cases, you
will also need to provide a supplemental report to explain what those circumstances
were so that they will understand because you are telling the whole story. CODING BITES
As you go through the lists, you will find there are modifiers that have no effect Bookmark Appendix A
at all on reimbursement but provide specific details about the procedure that will be in your CPT code
important for continuity of care, as well as for research and statistics. An example is book. This is the sec-
modifier RC Right Coronary Artery to identify the specific anatomical site upon which tion containing the CPT
the procedure was completed. modifiers and their full
You will find many modifiers listed in Appendix A, their own section of the CPT descriptions. It is impor-
book. Listed in numeric order, each modifier is shown by category, accompanied by an tant that you reference
explanation of when and how you should use that modifier. The rest can be found in these prior to using any
the separate HCPCS Level II code book. modifier. Your HCPCS
Level II book has its own
Types of Modifiers section that lists those
There are five categories of modifiers: modifiers with their
complete descriptions.
∙ CPT code modifiers are two characters that can be attached to regular codes from
the main portion of the CPT book and to HCPCS Level II codes.
CPT Code Modifier
A two-character code that may
EXAMPLE: CPT Modifiers be appended to a code from
23 Unusual Anesthesia the main portion of the CPT
66 Surgical Team book to provide additional
information.

∙ Anesthesia Physical Status Modifiers consist of two characters and are Physical Status Modifier
­alphanumeric. They are used only with CPT codes reporting anesthesia services. A two-character alphanumeric
code used to describe the
condition of the patient at the
time anesthesia services are
CPT © 2017 American Medical Association. All rights reserved.

EXAMPLE: Physical Status Modifiers administered.

P1 A normal healthy patient Alphanumeric
P3 A patient with severe systemic disease Containing both letters and
numbers.
Ambulatory Surgery Center
∙ Ambulatory surgery center (ASC) hospital outpatient modifiers are two dig-
(ASC)
its and are used only when reporting services provided at this type of outpatient A facility specially designed
facility. to provide surgical treatments
without an overnight stay; also
known as a same-day surgery
EXAMPLE: ASC Modifiers center.

27 Multiple outpatient hospital E/M encounters on the same date

73 Discontinued outpatient procedure prior to anesthesia

CHAPTER 22  | 
HCPCS Level II Modifier ∙ HCPCS Level II modifiers are two characters and alphabetic or alphanumeric.
A two-character alphabetic They are used to provide additional information about services when appended to
or alphanumeric code that CPT and HCPCS Level II codes.
may be appended to a code
from the main portion of the
CPT book or a code from the
HCPCS Level II book. EXAMPLE: HCPCS Level II Modifiers
E1 Upper left eyelid
RT Right side (of body)

Category II Modifiers ∙ Category II modifiers are two characters: a number followed by the letter P. Only
Modifiers provided for use appended to Category II codes, these modifiers provide explanations as to why a
with Category II CPT codes particular service should not be included in the qualifications for a specific perfor-
to indicate a valid reason for mance measure.
a portion of a performance
measure to be deleted from
qualification.
EXAMPLES
1P Performance Measure Exclusion Modifier due to Medical Reasons
2P Performance Measure Exclusion Modifier due to Patient Reasons

Using Modifiers
CODING BITES
Using modifiers is, most often, a judgment that you, the coding specialist, will have
HCPCS Level II modi-
to make as you review the details of each case. As you analyze the descriptions of the
fiers can be appended
procedures performed, as documented by the physician, and compare them with the
to either CPT codes or
descriptions of the codes in the CPT book, you may find that there is more to the story
HCPCS Level II codes.
than the code description provides. This is important because it is a coding profes-
sional’s job to relate the whole story of the encounter. 

EXAMPLE
Dr. Kennedy determined that Patricia’s tear ducts were blocked. He dilated and
irrigated both the right and left eyes.
[Remember from medical terminology class, the medical term for the tear duct =
lacrimal punctum (plural = puncta). If you don’t remember, it is important to use
your medical dictionary to ensure you can determine the accurate code or codes.]

CPT Modifier Notation

CPT © 2017 American Medical Association. All rights reserved.

68801 Dilation of lacrimal punctum, with or without irrigation
(To report a bilateral procedure, use 68801 with modifier 50)

CODING BITES Modifier 50 is used to identify that a service or procedure was performed bilater-
ally (both sides). If the physician’s documentation states that this procedure was
On occasion, the CPT done on both sides, you can see that the code description does not include this
book will remind you of detail. Therefore, you must add a modifier . . . to tell the whole story.
a special circumstance
that requires a modifier.
However, most of the
time, it is you who must EXAMPLE
determine when to use
Jason has been deaf in his left ear since he was 16. Today, Dr. Sangar is perform-
a modifier and which
ing a Bekesy audiometry screening test on his right ear.
modifier or modifiers to
append to the code. 92560 Bekesy audiometry; screening

604   PART III  |  REPORTING PHYSICIAN SERVICES AND OUTPATIENT PROCEDURES

 Does this code report the test on one ear or two ears? It doesn’t state this impor-
tant detail. How do you know how to report this accurately? The CPT i­n-section
guidelines give you the answer.

CPT Instructional Paragraph

Paragraph above code 92550:
Audiologic Function Tests 
“. . . All services include testing of both ears. Use modifier 52 if a test is
applied to one ear instead of two ears . . . .” GUIDANCE
CONNECTION
Modifier 52 indicates that the service or procedure, as described, was not com-
pleted in full. If both ears are included in the code, but only one ear was tested, Read the in-section
then a reduced service was provided. This is why it is so very important to read all Official Guidelines, in
of these in-section guidelines, in addition to the those in the front of the section, to the subsection Repair
help you code accurately. Therefore, if the physician’s documentation states that (Closure), including para-
only one ear was examined during this encounter, you must append modifier 52 graph 2. When multiple
to tell the whole story. wounds are repaired.

CPT
LET’S CODE IT! SCENARIO
Dinah Chen, a 21-year-old female, came into the emergency clinic with two lacerations: one on her right hand and
the second on her right arm. Dr. Padmore debrided and provided a complicated repair of the 3.1 cm laceration on
her upper right arm and a layered closure of a 2.5 cm laceration on her right hand, proximal to the second digit.

Let’s Code It!

What exactly did Dr. Padmore do for Dinah Chen? A complicated repair of a laceration on her upper arm + a
layered repair on her hand. Begin in the CPT Alphabetic Index, and look up
Repair . . . Arm, Upper would make sense, but wait a minute. Dr. Padmore did not actually repair Dinah’s arm,
with regard to its muscles or tendons, etc. He repaired the laceration. Check this out . . .
Repair . . . Laceration does not work either. None of the anatomical sites listed beneath match arm or hand.
Pull out your medical dictionary and check the meaning of laceration: a wound or cut in the tissue. Let’s try . . .
Repair  .  .  . Wound—this has possibilities. The three terms showing—Complex, Intermediate, Simple—make
sense, and Dr. Padmore did provide a “complicated repair,” which could translate to Complex. The Alphabetic
Index suggests codes in the range 12001–13160. Turn in the CPT Main Section to find code 12001 Simple
repair. How do you know what actually constitutes a complex, intermediate, or simple repair?
CPT © 2017 American Medical Association. All rights reserved.

Directly above this first code, starting on the previous page, are Official Guidelines under the subheading Repair
(Closure). These in-section Guidelines explain the definitions of Simple Repair, Intermediate Repair, and
­Complex Repair, along with other important details that you need to report these repairs accurately.
The chapter CPT Surgery Section will provide you with more in-depth instruction about this.
For this chapter, on Modifiers, you want to focus on paragraph 2 of these in-section Guidelines. It tells you that,
when multiple wounds are repaired, reported with different levels of repair, you will need to append modifier 59
Distinct Procedural Service to the second code and all thereafter. This will help you understand that, to report
Dr. Padmore’s services to Dinah Chen, you will submit these codes:

13121 Repair, complex, scalp, arms, and/or legs; 2.6 cm to 7.5 cm

12041-59 Repair, intermediate, wounds of neck, hands, feet and/or external genitalia;
2.5 cm or less, distinct procedural service

CHAPTER 22  | 
 22.2  Personnel Modifiers
As you read through the descriptions of the modifiers, most of them will seem very
Personnel Modifier straightforward. Personnel modifiers explain special circumstances relating to the
A modifier adding informa- health care professionals involved in the treatment of the patient. These modifiers spe-
tion about the professional(s) cifically identify the qualifications of the health care professional who provided the
attending to the provision of service reported by the code to which this modifier is being attached, while other
this procedure or treatment modifiers identify the provider’s special training. You will note that some of the modi-
to the patient during this
fier descriptions also include a location as a part of their meaning.
encounter.

EXAMPLES: Personnel Modifier

62 Two Surgeons
66 Surgical Team
80 Assistant Surgeon
Nonphysician GF Non-physician services in a critical access hospital
A nonphysician can be a
AQ Physician providing a service in an unlisted health professional shortage
nurse practitioner, certified
area (HPSA)
registered nurse anesthetist,
certified registered nurse,
clinical nurse specialist, or
physician assistant. Modifier 62 Two Surgeons clearly is used when the operative notes indicate that
two surgeons worked side by side, both as primary surgeons, during a procedure. If
the modifier is not there to explain that there were two primary surgeons involved,
how else could the insurance carrier know that receiving two separate claim forms for
the same patient on the same day is legitimate? The insurance carrier would certainly
think that one of the physicians is fraudulently billing for work done by another. The
second claim filed, and possibly even the first one, might be denied or set aside for fur-
ther determination to find out why the second claim was submitted, and/or the carrier
may even initiate a fraud investigation. This little two-digit modifier tells the insurance
carrier that no one is cheating and both surgeons actually did provide for the patient.
The same scenario works for other CPT personnel modifiers:
∙ 66 Surgical Team
∙ 80 Assistant Surgeon
∙ 81 Minimum Assistant Surgeon
∙ 82 Assistant Surgeon (when qualified resident surgeon not available)
Using any of these modifiers, or any of the HCPCS Level II modifiers (see Table 22-1),
provides an explanation, very directly and simply, why more than one health care profes-
sional is claiming reimbursement for providing service to the same patient on the same CPT © 2017 American Medical Association. All rights reserved.
date, or the specific qualifications of that professional.

TABLE 22-1  HCPCS Level II Personnel Modifiers

AE Registered dietitian
AF Specialty physician
AG Primary physician
AH Clinical psychologist
AI Principal physician of record
AJ Clinical social worker

606   PART III  |  REPORTING PHYSICIAN SERVICES AND OUTPATIENT PROCEDURES

 AK Nonparticipating physician
AM Physician, team member service
AQ Physician providing service in unlisted HPSA
AR Physician provider services in a physician scarcity area
AS Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery
DA Oral health assessment by professional other than a dentist
GC Service performed in part by a resident under the direction of a teaching physician
GE Service performed by a resident without the presence of a teaching physician under the primary care exception
GF Non-physician services in a critical access hospital
GJ “Opt out” physician or practitioner emergency or urgent service
GV Attending physician not employed or paid under arrangement by the patient’s hospice provider
HL Intern
HM Less than bachelor degree level
HN Bachelors degree level
HO Masters degree level
HP Doctoral level
HT Multidisciplinary team
Q4 Service for ordering/referring physician that qualifies as a service exemption
Q5 Service furnished by a substitute physician under a reciprocal billing arrangement
Q6 Service furnished by a locum tenens physician
SA Nurse practitioner rendering service in collaboration with a physician
SB Nurse midwife
SD Services provided by registered nurse with specialized, highly technical home infusion training
SW Services provided by a certified diabetic educator
TD Registered nurse (RN)
TE Licensed practical nurse (LPN) or LVN

CPT
LET’S CODE IT! SCENARIO
CPT © 2017 American Medical Association. All rights reserved.

Valerie Ferguson, a 43-year-old female, has been diagnosed with endometriosis and is admitted to Midtown Hospi-
tal to have Dr. Lissard perform a vaginal, radical hysterectomy. While Valerie is in the operating room (OR) and under
anesthesia, Dr. Rasmussen is going to perform an open sling operation for stress incontinence on her bladder, and
Dr. Barlow is an assistant surgeon who is there to assist Dr. Lissard. She tolerates both procedures well and is taken
back to her room.

Let’s Code It!

The codes for these procedures are 58285 and 57288. You will learn more about how to determine these
codes in the following chapters. For now, let’s focus on the modifiers.
The CPT procedure codes explain what was done for Valerie during this procedure. Afterwards, Dr. Lissard’s
coder will submit a claim and send it to Valerie’s health insurance company, including the services provided for
both Dr. Lissard and Dr. Barlow. The coder forgets to append any modifiers.

(continued)

CHAPTER 22  | 
 Dr. Rasmussen’s coder sent the claim for her work performed for Valerie 2 days later. This claim also fails to
include any modifiers.
Now, Bernice Cannaloni, claims adjuster for Valerie’s health insurance company, looks at Dr. Rasmussen’s
claim. Wait a minute. We just paid a claim for two other physicians who stated a totally different surgical proce-
dure was provided to the same patient on the same date! Perhaps someone is trying to defraud this company!
An investigation begins, delaying payment by several months until it is all straightened out.
If there were modifiers that could explain what role each of these surgeons played, working side-by-side to
care for this patient, the entire fraud investigation and delay in payment could be prevented.
Open your CPT code book to Appendix A and read through the list of modifiers to see if any might enable
Dr. Lissard’s coder and Dr. Rasmussen’s coder to more clearly explain the whole story. Take a look at

62 Two Surgeons: When 2 surgeons work together as primary surgeons performing distinct
part(s) of a procedure, each surgeon should report his/her distinct operative work by adding
modifier 62 to the procedure code . . .
This looks perfect to explain this unusual situation, doesn’t it?
Now what about Dr. Barlow? How do we explain his role during this procedure? Review the modifiers in
Appendix A to determine if there are any that will help explain. Take a look at

80 Assistant Surgeon: Surgical assistant services may be identified by adding modifier 80 to the
usual procedure number(s).
So, Dr. Lissard’s coder would report this code:

58285-62 Vaginal hysterectomy, radical (Schauta type operation); two surgeons

And Dr. Rasmussen’s coder would report this code:

57288-62 Sling operation for stress incontinence; two surgeons

And Dr. Barlow’s coder would report this:

58285-80 Vaginal hysterectomy, radical (Schauta type operation); assistant surgeon

Good job!

Anesthesia Personnel Modifiers

The following modifiers (see Table 22-2), used only with anesthesia codes, are actu-
ally HCPCS Level II modifiers. You can see that they provide specific details about
the personnel administering the anesthetic to the patient. These details are important
for reimbursement as well as responsibility.

CPT © 2017 American Medical Association. All rights reserved.

TABLE 22-2  Anesthesia Personnel Modifiers

AA Anesthesia services that are performed personally by anesthesiologist

AD Medical supervision by a physician: more than four concurrent anesthesia procedures
G8 Monitored anesthesia care (MAC) for deep complex, complicated, or markedly invasive surgical procedure
G9 Monitored anesthesia care for patient who has history of severe cardiopulmonary condition
QK Medical direction of two, three, or four concurrent anesthesia procedures involving qualified individuals
QS Monitored anesthesia care (MAC) service
QX Qualified nonphysician anesthetist with medical direction by a physician
QY Medical direction of one qualified nonphysician anesthetist by an anesthesiologist
QZ CRNA service without medical direction by a physician

608   PART III  |  REPORTING PHYSICIAN SERVICES AND OUTPATIENT PROCEDURES

 CPT HCPCS Level II
YOU CODE IT! CASE STUDY
Dr. Charleston, an anesthesiologist, was asked to provide anesthesia care while Dr. Ablione performed a needle
biopsy of the pleura of Rosalind Bowman’s left lung. Gerald Mathinson, a CRNA, will administer the anesthesia for
this procedure, with Dr. Charleston’s supervision.

You Code It!

Gerald Mathinson is administering this anesthesia, but he is not an anesthesiologist. Dr. Charleston is not admin-
istering the anesthesia for this procedure; however, his presence and expertise are still needed. The procedure
code for this anesthesia service is this:
00522 Anesthesia for closed chest procedures; needle biopsy of pleura
Good. Now, you must find a way to explain that this was not an anesthesiologist who provided the service, but a
CRNA (Certified Registered Nurse Anesthetist), with direction by Dr. Charleston. The code description is correct.
You just need to clearly communicate what health care professionals were actually involved in this procedure. A
modifier can provide this additional explanation.
Answer:
Did you determine this to be the correct modifier?
00522-QX Anesthesia for closed chest procedures; needle biopsy of
pleura, CRNA service: with medical direction by a physician
Good job!!

22.3  Anesthesia Physical Status Modifiers

Anesthesia physical status modifiers are two-character alphanumeric codes: the letter
P followed by a number. These modifiers identify the condition of the patient at the
time anesthesia services were provided and highlight health circumstances that might
dramatically affect the anesthesiologist’s ability to successfully care for the patient.
An explanation of the patient’s health level at the time the anesthesiologist administers
the service helps the third-party payer get a better understanding of how hard this phy-
sician (anesthesiologist) had to work.
For example, if a patient has uncontrolled hypertension at the time anesthesia is GUIDANCE
administered, the anesthesiologist must monitor the patient more carefully, must per-
haps use a different type of anesthetic, and must watch for possible complications that CONNECTION
would not be an issue with an otherwise healthy patient. This status modifier, for the Read the anesthesia
most part, does not relate to the reason the patient is having the anesthesia adminis- physical status modifiers
CPT © 2017 American Medical Association. All rights reserved.

tered but is indicative of the patient’s overall health. You can see that, without under- and their descriptions in
standing the difference between treatment issue and overall health, it might be hard for the Official Guidelines
you to identify a patient as “P1 A normal healthy patient” when the person is in your located immediately
facility to have a diseased gallbladder removed. However, if the patient is otherwise prior to the Anesthesia
healthy, P1 is the correct status modifier. code section in the main
The Physical Status Modifiers, P1–P6, may be appended only to codes from the part of CPT and/or in
Anesthesia section of the CPT book, codes 00100–01999. Appendix A.
All anesthesia codes
and only anesthesia
EXAMPLE: Use of a Physical Status Modifier codes are appended
with a Physical Status
Anesthesia for a diagnostic arthroscopy of the knee on a 67-year-old male with Modifier, immediately
diabetes mellitus, controlled well with medication. following the anesthesia
      01382-P2 code.

CHAPTER 22  | 
 There may be a case when a CPT modifier must also be used with an anesthesia
code. When this is done, the Physical Status Modifier is to be placed closest to the
anesthesia code.

EXAMPLE: Using a Physical Status Modifier with a CPT Modifier

Anesthesia for a third-degree burn excision, 5% of total body surface area, for a
patient with uncontrolled diabetes. The procedure was discontinued due to sud-
den onset of arrhythmia.
01952-P3-53
Modifier P3 reports that this patient has a severe systemic disease [the uncon-
trolled diabetes mellitus]
Modifier 53 reports a Discontinued Procedure

You will read more about the anesthesia physical status modifiers in the chapter
CPT Anesthesia Section.

CPT
LET’S CODE IT! SCENARIO
Carson Crosby, a healthy and fit 18-year-old male, fell from a girder on a construction site, fracturing three ribs and
two vertebrae, and sustaining a hairline fracture of his pelvis. Dr. Pollack, an anesthesiologist, was brought in to
administer general anesthesia so the body cast could be applied by Dr. Abrams, an orthopedist.

Let’s Code It!

You are the professional coding specialist for Dr. Pollack, the anesthesiologist. Our focus in this case is the appli-
cation of anesthesia modifiers; however, you will need a code to which to append that physical status modifier.
So, let’s begin with the Alphabetic Index:
Anesthesia
The long list beneath includes mostly anatomical sites. Hmmm. You have two terms: body + cast, so try these.
There is listing for Body; however, there are two listings for Cast:
Cast
  Knee. . . . . . . . . . . . . . . . . . . . . 01420
Cast Application
  Forearm, Wrist, and Hand. . . 01860
  Leg. . . . . . . . . . . . . . . . . . . . . . 01490
  Pelvis . . . . . . . . . . . . . . . . . . . . 01130 CPT © 2017 American Medical Association. All rights reserved.
  Shoulder . . . . . . . . . . . . . . . . . 01680
Cast Application matches the documentation; however, none of these anatomical areas match. The scenario did
mention Carson’s pelvis being fractured, so let’s start with that code.
01130 Anesthesia for body cast application or revision
This is perfect! Now, you learned that all codes from the Anesthesia section require a Physical Status Modifier. So,
turn to Appendix A and find the heading Anesthesia Physical Status Modifiers [it is after modifier 99 Multiple
Modifiers]. Go back to the documentation and look for a description of Carson’s current health. This is in regard
to his overall health, not in relation to this specific issue. Did you read that the scenario states, “Carson Crosby,
a healthy and fit 18-year-old male”? Healthy and fit! Review all of the Physical Status Modifier descriptions and
determine which is most accurate about Carson’s condition during this encounter.
P1 A normal healthy patient

610   PART III  |  REPORTING PHYSICIAN SERVICES AND OUTPATIENT PROCEDURES

 Good job! Now put them together and you can report this, with confidence, to communicate what Dr. Pollack did
for Carson during this session:
01130-P1 Anesthesia for body cast application or revision; a normal healthy patient

22.4  Ambulatory Surgery Center Hospital

Outpatient Use Modifiers
When you are reporting the code or codes for procedures provided to a patient in
a same-day surgery center or outpatient surgery center, you might determine that a
modifier may be necessary. In these cases, you will append modifiers from those
provided specifically for these locations. The Ambulatory Surgery Center (ASC)
Hospital Outpatient Use Modifiers are shown in Appendix A of your CPT book, in
their own subsection. Some of the modifiers in this subheading are the same as the
CPT modifiers. However, there are three additional modifiers specifically for ASC
coders. Open your CPT book to Appendix A and read along as we review some of
these modifiers.
CODING BITES
Modifier 27 Many hospitals have
outpatient departments
27 Multiple Outpatient Hospital E/M Encounters on the Same Date: For hospi- providing same-day or
tal outpatient reporting purposes, utilization of hospital resources related to outpatient surgical pro-
separate and distinct E/M encounters performed in multiple outpatient hospital cedures. If the patient
settings on the same date may be reported by adding modifier 27 to each is “admitted” and “dis-
appropriate level outpatient and/or emergency department E/M code(s). This charged” the same
modifier provides a means of reporting circumstances involving evaluation and day, this is coded as an
management services provided by physician(s) in more than one (multiple) out- outpatient procedure,
patient hospital setting(s) (e.g., hospital emergency department, clinic). using CPT and, when
necessary, this group of
Using modifier 27 will not be a common occurrence, but still, it can be complex. So, modifiers.
let’s use an example scenario to work through together:

EXAMPLE
Alexandra Benson, a 41-year-old female, cut her hand and went to the Mulford
General Hospital clinic. After Dr. Williams evaluated her hand, he sent her to the
CPT © 2017 American Medical Association. All rights reserved.

emergency department (ED) because the cut was so deep it needed more intense
care. Dr. Kinsey evaluated the injury and repaired Alexandra’s laceration in the ED.
As the coding specialist for the hospital, you would be responsible for coding
the services provided in all your facilities, including the clinic as well as the ED.
Alexandra Benson was seen in two different facilities on the same day for the
same injury. First, you would code the services that Dr. Williams did—the E/M of
Alexandra’s injury and his decision to send her to the ED for a higher level of care.
Second, you would report the services that Alexandra received in the ED, which
certainly included additional evaluation and then the repair of her wound.
For Dr. Williams, report: 99201-27
For Dr. Kinsey, report: 99281-27
Without the use of modifier 27, you would have difficulty in getting the claim paid
because the third-party payer may think that this is a case of duplicate billing, an
error, or fraud.

CHAPTER 22  | 
 Modifiers 73 and 74
Occasionally, a planned surgical event is not performed due to circumstances that might
put the patient in jeopardy. In such cases, all the preparation was done, the team was
ready, and your facility needs to be reimbursed, even though you have not performed
the service or treatment. Modifiers 73 and 74 will identify these unusual circumstances.
73 Discontinued Outpatient Hospital/Ambulatory Surgery Center (ASC)
Procedure Prior to the Administration of Anesthesia: Due to extenuat-
ing circumstances or those that threaten the well-being of the patient, the
physician may cancel a surgical or diagnostic procedure subsequent to the
patient’s surgical preparation (including sedation when provided, and being
taken to the room where the procedure is to be performed), but prior to the
administration of anesthesia (local, regional block(s) or general). Under these
circumstances, the intended service that is prepared for but canceled can
be reported by its usual procedure number and the addition of modifier 73.
74 Discontinued Outpatient Hospital/Ambulatory Surgery Center (ASC)
Procedure After Administration of Anesthesia: Due to extenuating circum-
stances or those that threaten the well-being of the patient, the physician
may terminate a surgical or diagnostic procedure after the administration of
anesthesia (local, regional block(s) or general), or after the procedure was
started (incision made, intubation started, scope inserted, etc.). Under these
circumstances, the procedure started, but terminated can be reported by its
usual procedure number and the addition of modifier 74.
The extenuating circumstances mentioned are generally accepted situations that would
be reasonable to stop a procedure at this late point in time. Prior to the a­ dministration
of anesthesia, it might be that the nurse, while taking the patient’s vital signs, docu-
ments that the patient has a fever. It is the standard of care to avoid surgical procedures
on a patient with a fever, so the proper thing to do would be to postpone. Once the
patient is in the procedure room, and anesthesia has been administered, there may be a
need to stop the procedure, such as the patient experiencing a seizure or dramatic drop
in blood pressure. Make certain that you not only append one of these modifiers, when
appropriate, but also include a special report to explain exactly what happened to make
cancelling the procedure the right action to take.

CPT
LET’S CODE IT! SCENARIO
Cole Dennali, a 59-year-old male, was brought into Room 5 to be prepared for a bunionectomy. He changed into a
gown, he got into bed, and the nurse took his vital signs. Cole’s breathing was labored—it appeared he was having
an asthma attack. Dr. Fraumann ordered respiratory therapy to come in and provide a nebulizer treatment. Because
general anesthesia could not be administered, the bunionectomy was canceled. CPT © 2017 American Medical Association. All rights reserved.

Let’s Code It!

Dr. Fraumann and her team were prepared and ready to perform a bunionectomy. However, it is not wise to
administer general anesthesia to a patient having difficulty breathing, so the procedure had to be canceled in
the best interest of the patient. The facility still deserves to be reimbursed for its time, materials and supplies, and
efforts. Therefore, the facility will submit a claim form to Cole’s insurance carrier with the code for the bunionec-
tomy and the modifier 73 to indicate that the procedure was canceled prior to the administration of anesthesia:
28292-73 Correction, hallux valgus (bunionectomy), with sesamoidectomy, when
performed; with resection of proximal phalanx base, when performed, any
method, Discontinued Out-Patient Hospital/Ambulatory Surgery Center (ASC)
Procedure Prior to the Administration of Anesthesia

612   PART III  |  REPORTING PHYSICIAN SERVICES AND OUTPATIENT PROCEDURES

 22.5  Anatomical Site Modifiers
Anatomical site modifiers (see Table 22-3) provide additional specific detail about
the target of the service or procedure not provided by the code. These pieces of infor-
mation are important to include for those providing continuity of care as well as for
reimbursement purposes.
∙ E1–E4 identify right/left/upper/lower eyelids
∙ F1–FA identify each of the 10 fingers
∙ T1–TA identify each of the 10 toes
∙ LC–LD identify portions of the left coronary artery
∙ RC identifies the right coronary artery
∙ LT = left
∙ RT = right

EXAMPLE
28008 Fasciotomy, foot and/or toe

Adding a modifier such as T7 would include very important information for the
claim, especially if the patient had a preexisting condition involving a different toe.
T7 Right foot, third digit

Therefore, you would report: 28008-T7 Fasciotomy, right foot, third digit.

TABLE 22-3  Anatomical Sites Modifiers

E1 Upper left eyelid

E2 Lower left eyelid
E3 Upper right eyelid
E4 Lower right eyelid
FA Left hand, thumb
F1 Left hand, second digit
F2 Left hand, third digit
F3 Left hand, fourth digit
CPT © 2017 American Medical Association. All rights reserved.

F4 Left hand, fifth digit

F5 Right hand, thumb
F6 Right hand, second digit
F7 Right hand, third digit
F8 Right hand, fourth digit
F9 Right hand, fifth digit
LC Left circumflex coronary artery
LD Left anterior descending coronary artery
LT Left side (i.e., left side of the body)

(continued)

CHAPTER 22  | 
 TABLE 22-3  Anatomical Sites Modifiers  (continued)

RC Right coronary artery

RT Right side (i.e., right side of the body)
TA Left foot, great toe
T1 Left foot, second digit
T2 Left foot, third digit
T3 Left foot, fourth digit
T4 Left foot, fifth digit
T5 Right foot, great toe
T6 Right foot, second digit
T7 Right foot, third digit
T8 Right foot, fourth digit
T9 Right foot, fifth digit

CPT
YOU CODE IT! CASE STUDY
Beatrice Burmuda, a 37-year-old female, came to the Upton Ambulatory Surgery Center so that Dr. Thomas could
excise a benign tumor from her left foot’s big toe (known medically as the great toe). She tolerated the procedure
well and was discharged.

You Code It!

Go through the steps to determine the procedure code(s) that should be reported for this encounter between
Dr. Thomas and Beatrice Burmuda.
Step #1: Read the case carefully and completely.

Step #2: Abstract the scenario. Which key words or terms describe what service the physician provided to the
patient during this encounter?

Step #3: Are there any details missing or incomplete for which you would need to query the physician? [If so,
ask your instructor.]

Step #4: Determine the correct CPT procedure code or codes to explain the details about what was provided
CPT © 2017 American Medical Association. All rights reserved.
to the patient during this encounter.

Step #5: Check for any relevant guidance, including reading all of the symbols and notations.

Step #6: Do you need to append any modifiers to ensure complete and accurate information is provided?

Step #7: Double-check your work.

Answer:
The procedure code is 28108. Did you determine the correct modifier?
28108-TA Excision or curettage of bone cyst or benign tumor, phalanges of foot, left
foot, great toe
Terrific!

614   PART III  |  REPORTING PHYSICIAN SERVICES AND OUTPATIENT PROCEDURES

 22.6  Service-Related Modifiers
As you learn and expand your abilities to accurately report procedures, services, and
treatments provided to the patients of your facility, you will discover that to tell the
complete story about what was done, you may need to add a detail or two to the exist-
ing code description. Modifiers are created to enable this.

Telemedicine Synchronous Services

We live in a world integrated with technology, enabling us to improve patient care.
Now, Skype and other synchronous, interactive, audiovisual software programs permit
an encounter between physician and patient who are not in the same room—sometimes
not even in the same city. 
In Appendix P, you will find a list of 79 CPT codes permitted to be appended with
modifier 95 when the service is performed using synchronous electronic communica-
tions equipment. These codes are primarily located in the E/M and Medicine sections
of CPT, marked with a star (★) symbol to the left of the code.
The documentation for these encounters must confirm that the content of the physi-
cian/patient meeting is sufficient to meet the requirements for the code to be reported
whether the service was provided face-to-face or with the use of synchronous tele-
medicine services (as indicated by the appending of modifier 95).
95 Synchronous Telemedicine Service Rendered Via a Real-Time
­Interactive Audio and Video Telecommunications System: Synchro-
nous telemedicine service is defined as a real-time interaction between a
­physician or other qualified health care professional and a patient who is
located at a distant site from the physician or other qualified health care
professional. The totality of the communication of information exchanged
between the physician or other qualified health care professional and
the patient during the course of the synchronous telemedicine service
must be of an amount and nature that would be sufficient to meet the key
­components and/or other requirements of the same service when ren-
dered via a face-to-face interaction. Modifier 95 may only be appended to
the services listed in Appendix P. Appendix P is the list of CPT codes for
services that are typically performed face-to-face, but may be rendered
via a real-time (synchronous) interactive audio and video telecommunica-
tions system.

EXAMPLE
Dr. Lappin has been working with Louisa providing psychotherapy to help her deal
CPT © 2017 American Medical Association. All rights reserved.

with panic attacks. Today, they had a good, 30-minute session in the office.
90832 Psychotherapy, 30 minutes with patient
Dr. Lappin has been working with Louisa providing psychotherapy to help her
deal with panic attacks. Today, Louisa is on a plane, traveling to visit her parents in
another state. As she feels a panic attack coming on, she uses the airplane’s WiFi
system to Skype with Dr. Lappin. They spend 30 minutes talking things through
and helping Louisa get through.
90832-95 Psychotherapy, 30 minutes with patient, synchronous
telemedicine service rendered via a real-time interac-
tive audio and video telecommunications system
By appending modifier 95, you are clearly communicating the difference in
Dr. Lappin’s service to her patient.

CHAPTER 22  | 
 TABLE 22-4  Modifiers for Multiple Wounds

A1 Dressing for one wound

A2 Dressing for two wounds
A3 Dressing for three wounds
A4 Dressing for four wounds
A5 Dressing for five wounds
A6 Dressing for six wounds
A7 Dressing for seven wounds
A8 Dressing for eight wounds
A9 Dressing for nine or more wounds

Wound Care
Typically, a dressing change is required for a wound many times throughout the heal-
ing process. In addition, it is not unusual that a patient might have more than one
wound that needs care at the same time. Therefore, to make the coding process easier
and more efficient, one modifier can explain the extent of such care so that listing the
same code multiple times is not necessary. The list in Table 22-4 contains the modi-
fiers for multiple wounds.

CPT HCPCS Level II

LET’S CODE IT! SCENARIO
Ted Kercher, a 33-year-old male, is a firefighter who sustained partial-thickness burns the entire length of his right
arm when something exploded. He comes in to see Dr. Taggert to have the dressings changed on four wounds.

Let’s Code It!

Ted comes in to have his dressings changed on four burn wounds. First, you must find the CPT code for the pro-
cedure; second, you can address the modifier. Let’s go to the Alphabetic Index and look up dressings. You find
Dressings
Burns . . . . . . . . . . 16020–16030
Change
   Anesthesia. . . . . . . . . . . 15852
You know that Dr. Taggert is changing Ted’s dressings; however, there is nothing in the notes that states anes-
thesia was involved. In addition, Ted’s wounds are burns, so let’s turn to the numeric listing and carefully read the CPT © 2017 American Medical Association. All rights reserved.
descriptions for the codes shown next to burns. Do you agree that this is the best code?
16025 Dressings and/or debridement of partial-thickness burns,
initial or subsequent; medium (e.g., whole face or whole
extremity, or 5% to 10% total body surface area)
The notes indicate that Dr. Taggert changed the dressings for four wounds. So rather than just list this code four
times, we can use a modifier to communicate this fact: 16025-A4 tells the whole story clearly.
16025-A4 Dressings and/or debridement of partial-thickness burns, initial
or subsequent; medium (e.g., whole face or whole extremity, or
5% to 10% total body surface area); four wounds dressed
Good work!

616   PART III  |  REPORTING PHYSICIAN SERVICES AND OUTPATIENT PROCEDURES

 TABLE 22-5  ESRD/Dialysis Modifiers

CB Service ordered by a renal dialysis facility (RDF) physician as part of the beneficiary’s benefit is not part of the
composite rate and is separately reimbursable
CD AMCC test has been ordered by an ESRD facility or MCP physician that is part of the composite rate and is
not separately billable
CE AMCC test has been ordered by an ESRD facility or MCP physician that is a composite rate test but is beyond
the normal frequency covered under the rate and is separately reimbursable based on medical necessity
CF AMCC test has been ordered by an ESRD facility or MCP physician that is not part of the composite rate and
is separately billable
EM Emergency reserve supply (for ESRD benefit only)
G1 Most recent urea reduction ratio (URR) reading of less than 60
G2 Most recent URR reading of 60 to 64.9
G3 Most recent URR reading of 65 to 69.9
G4 Most recent URR reading of 70 to 74.9
G5 Most recent URR reading of 75 or greater
G6 ESRD patient for whom less than six dialysis sessions have been provided in a month

Ophthalmology/Optometry AMCC
Automated Multi-Channel
Sometimes, when ophthalmic or optometric services are provided, more detail is nec- Chemistry—Automated organ
essary to ensure proper reimbursement. Following are the HCPCS Level II modifiers disease panel tests performed
used with these services: on the same patient, by the
same provider, on the same day. 
AP Determination of refractive state was not performed in the course of diagnostic
­ophthalmologic examination 
Urea Reduction Ratio (URR)
LS FDA-monitored intraocular lens implant
A formula to determine the
PL Progressive addition lenses
effectiveness of hemodialysis
VP Aphakic patient treatment.

ESRD/Dialysis End-Stage Renal Disease

(ESRD)
Dialysis and other services for a patient with renal conditions, including those with Chronic, irreversible kidney
end-stage renal disease (ESRD), may involve extenuating circumstances requiring disease requiring regular
further explanation. The dialysis modifiers in Table 22-5 provide that information. treatments.

CPT HCPCS Level II

LET’S CODE IT! SCENARIO
CPT © 2017 American Medical Association. All rights reserved.

Amie Gander, a 39-year-old female, was diagnosed with ESRD. Dr. Linnger prescribed her treatments to begin on
May 29 at the Southside Dialysis Center (SDC). Code for the services provided at SDC for the month of May.

Let’s Code It!

End-stage renal disease (ESRD) services are billed on a monthly basis. However, Amie only received 3 days of
services during the month of May (May 29, May 30, and May 31) from Southside Dialysis Center. In the Alpha-
betic Index, you will find:
End-Stage Renal Disease Services
Dialysis. . . . . . . . . . . . . . . . . . . . . . . 90951-90970
  Inpatient . . . . 90935, 90937, 90945, 90947
  Home . . . . . . . . . . . . . . . . . . . . . . 90963-90966
  Outpatient . . . . . . . . . . . . . . . . . 90951-90962
Less Than a Full Month . . . . . . . . 90967-90970

(continued)

CHAPTER 22  | 
 After reading the complete code descriptions in the suggested range, you find the best procedure code to be this:
90970 End-stage renal disease (ESRD) related services (less than full month), per day; for patients
twenty years of age and over
This means you will have to list the code three times because the code description says per day. Are there any
modifiers than can help you communicate this situation?
G6 ESRD patient for whom less than six dialysis sessions have been provided in a month
The modifier that will complete this report is G6 because she has had fewer than six sessions in 1 month:
90970-G6; 90970-G6; 90970-G6 or 90970-G6 × 3.
Good job!

Habilitative and Rehabilitative Services

In the 2018 CPT code set, two modifiers were added:
96 Habilitative Services
97 Rehabilitative Services
These modifiers would most often be appended to codes from the Physical Medicine
and Rehabiliation subsection of the Medicine section. More about this in Chapter 28.

Pharmaceuticals
Pharmaceuticals, the industry term for medications, are items that must be monitored
very carefully: the purchase, the storage, and the dispensing. The modifiers in Table 22-6
provide important information that must be tracked.
Modifier RD Drug provided to beneficiary, but not administered “incident to” indi-
cates that a particular pharmaceutical was provided to the patient but not administered.
For example, the nurse brings the patient’s pills into his room to administer them when
she notices he has a rash. She notifies the physician on call and he orders the medica-
tion stopped to investigate if the patient is allergic. Once the pills have been taken out
of the pharmacy, they cannot be returned. If the patient does not take them, they must
be discarded but still accounted for in the system and billing.
Modifier SV Pharmaceuticals delivered to patient’s home but not utilized might
be used by a mail-order pharmaceutical service to show that the medications were
shipped and delivered to the patient’s house but have nothing to do with how, when, or
if the patient uses those drugs.

EXAMPLES
RD Drug provided to beneficiary, but not administered “incident to”
SV Pharmaceuticals delivered to patient’s home but not utilized

CPT © 2017 American Medical Association. All rights reserved.

TABLE 22-6  Pharmaceutical Modifiers
JW Drug amount discarded/not administered to any patient
KD Drug or biological infused through DME
KO Single drug unit dose formulation
Liters per Minute (LPM) KP First drug of a multiple drug unit dose formulation
The measurement of how
KQ Second or subsequent drug of a multiple drug unit dose formulation
many liters of a drug or chemi-
cal are provided to the patient QE Prescribed amount of oxygen is less than 1 liter per minute (LPM)
in 60 seconds. QF Prescribed amount of oxygen exceeds 4 LPM and portable oxygen is prescribed
QG Prescribed amount of oxygen is greater than 4 LPM
QH Oxygen-conserving device is being used with an oxygen delivery system
RD Drug provided to beneficiary, but not administered “incident to”
SL State-supplied vaccine
SV Pharmaceuticals delivered to patient’s home but not utilized

618   PART III  |  REPORTING PHYSICIAN SERVICES AND OUTPATIENT PROCEDURES

 TABLE 22-7  Items/Services Modifiers

AU Item furnished in conjunction with a urologic, ostomy, or tracheostomy supply

AV Item furnished in conjunction with a prosthetic device, prosthetic or orthotic
BA Item furnished in conjunction with parenteral enteral nutrition (PEN) services
BL Special acquisition of blood and blood products
BO Orally administered nutrition, not by feeding tube
EY No physician or other licensed health care provider order for this item or service
FX X-ray taken using film
GK Reasonable and necessary item/item associated with GA or GZ modifier
GL Medically unnecessary upgrade provided instead of standard item, no charge, no advance beneficiary
notice (ABN)
GY Item or service statutorily excluded or does not meet the definition of any Medicare benefit, not a con-
tract benefit
GZ Item or service expected to be denied as not reasonable and necessary
KS Glucose monitor supply for diabetic beneficiary not treated with insulin
KZ New coverage not implemented by managed care
Q1 Routine clinical service provided in a clinical research study that is in an approved clinical research study
QW Clinical Laboratory Improvement Amendment (CLIA) waived test
SC Medically necessary service or supply
SF Second opinion ordered by a professional review organization (PRO)
SM Second surgical opinion
SN Third surgical opinion
SQ Item ordered by home health

Clinical Laboratory Improve-

Items/Services ment Amendment (CLIA)
The modifiers in Table 22-7 cover a variety of circumstances relating to the provision Federal legislation created for
of an item or a service. the monitoring and regulation of
clinical laboratory procedures.

CPT HCPCS Level II

LET’S CODE IT! SCENARIO
CPT © 2017 American Medical Association. All rights reserved.

Oscar Barkley, a 57-year-old male, was diagnosed with type 2 diabetes mellitus. Dr. Habersham wants to try a new
medication to control Oscar’s blood glucose levels and delay, or avoid, putting him on insulin. Dr. Habersham gives
Oscar the prescription for the medication and a second prescription for a home blood glucose monitor.

Let’s Code It!

The code you will report for the provision of the home glucose monitor is this:
E0607 Home blood glucose monitor
Now, you need a way to explain that this monitor is for a patient who is a non-insulin-dependent diabetic. Sounds
like the perfect job for a modifier!
Did you determine this to be the correct modifier?
E0607-KS Home blood glucose monitor; Glucose monitor supply
for diabetic beneficiary not treated with insulin 

CHAPTER 22  | 
TABLE 22-8  Purchase/Rental Items Modifiers

BP The beneficiary has been informed of the purchase and rental options and has elected to purchase the item
BR The beneficiary has been informed of the purchase and rental options and has elected to rent the item
BU The beneficiary has been informed of the purchase and rental options and after 30 days has not informed the supplier
of his/her decision
KH DMEPOS item, initial claim, purchase or first month rental
KI DMEPOS item, second or third month rental
KJ DMEPOS item, parenteral enteral nutrition (PEN) pump or capped rental, months four to fifteen
KR Rental item, billing for partial month
LL Lease/rental (use when DME rental payments are to be applied against the purchase price)
MS Six-month maintenance and servicing fee for reasonable and necessary parts and labor not covered under any manu-
facturer or supplier warranty
NR New when rented
RR Rental DME

Purchase/Rental Items
Often, when durable medical equipment (DME) is supplied, the patient has a choice to
rent the equipment or purchase it outright. This will depend upon the patient’s personal
situation. A modifier (see Table 22-8) provides important details, especially to the payor.

CPT HCPCS Level II

YOU CODE IT! CASE STUDY
Darryl Rosen, an 81-year-old male, fell and broke his hip last winter. Even though it healed, Darryl is still experienc-
ing difficulty walking long distances. Dr. Sorrel prescribed a power wheelchair for him. Darryl decided to purchase a
lightweight, portable, motorized/power wheelchair from Hammermill Medical Supply Systems.

You Code It!

Go through the steps of coding, and determine the codes that should be reported for the supply of Darryl
Rosen’s new equipment. [NOTE: The wheelchair is reported with a HCPCS Level II code.]
Step #1: Read the case carefully and completely.
Step #2: Abstract the scenario. Which key words or terms describe what service the physician provided to the
patient during this encounter?
Step #3: Are there any details missing or incomplete for which you would need to query the physician? [If so,
CPT © 2017 American Medical Association. All rights reserved.
ask your instructor.]
Step #4: Determine the correct CPT procedure code or codes to explain the details about what was provided
to the patient during this encounter.
Step #5: Check for any relevant guidance, including reading all of the symbols and notations.
Step #6: Do you need to append any modifiers to ensure complete and accurate information is provided?
Step #7: Double-check your work.
Answer:
The code for the provision of the wheelchair is K0012. Did you determine this to be the correct modifier?
K0012-KH Lightweight portable motorized/power wheelchair; DMEPOS item, initial claim,
purchase or first month rental
Good work!

620   PART III  |  REPORTING PHYSICIAN SERVICES AND OUTPATIENT PROCEDURES

 TABLE 22-9  Claims and Documentation Modifiers

CC Procedure code change (used to indicate that a procedure code previously submitted was changed either for an admin-
istrative reason or because an incorrect code was filed)
GA Waiver of liability statement issued, individual case
GB Claim being resubmitted for payment because it is no longer covered under a global payment
KB Beneficiary requested upgrade for ABN, more than four modifiers identified on claim
KX Requirements specified in the medical policy have been met
QP Documentation is on file showing that the laboratory test(s) was ordered individually or ordered as a CPT-recognized
panel other than automated profile codes 80002–80019, G0058, G0059, and G0060

Deceased Patient
Should a patient expire (die) while services are in the process of being rendered, cer-
tainly the situation changes and there must be some indication of the death. The fol-
lowing modifiers are used in such circumstances:
CA Procedure payable only in the inpatient setting when performed emergently on an
outpatient who expires prior to admission
QL Patient pronounced dead after ambulance called

Claims and Documentation

The modifiers shown in Table 22-9 directly provide additional information relating to
the claims and documentation involved in certain health care encounters.

CPT HCPCS Level II

YOU CODE IT! CASE STUDY
Jonny Craig, a 45-year-old male, had a mass on his left upper eyelid. Dr. Neilsen performed a biopsy on the eyelid. The
pathology report determined it was a benign neoplasm. Gwen Sanders, the professional coding specialist, mistakenly
put code 68710-E1 on the claim form instead of 67810-E1. She didn’t realize this until the claim came back denied.

You Code It!

What additional modifier should Gwen append to code 67810-E1 on the second claim form, which she needs to
submit as a corrected claim?
Answer:
Did you determine this to be the correct code?
CPT © 2017 American Medical Association. All rights reserved.

67810-E1-CC Incisional biopsy of eyelid skin including lid margin; upper left, eyelid, Pro-
cedure code change because an incorrect code was filed
Good job!!

Family Services
Services provided under Medicaid’s Early and Periodic Screening, Diagnostic, and Early and Periodic Screening,
Treatment (EPSDT) program must be identified with the EP modifier, shown in Diagnostic, and Treatment
Table 22-10. In addition, other family services may benefit from further explanation (EPSDT)
by the use of one of the modifiers found in that list. A Medicaid preventive health
program for children under 21.
Treatments/Screenings
The modifiers shown in Table 22-11 are directly related to the provision of mammog-
raphy and infusion therapeutic services.

CHAPTER 22  | 
TABLE 22-10  Family Services Modifiers

EP Service provided as part of Medicaid early periodic screening diagnosis and treatment (EPSDT) program
FP Service provided as part of family planning program
G7 Pregnancy resulted from rape or incest or pregnancy certified by physician as life threatening
TL Early intervention/individualized family service plan (IFSP)
TM Individualized education plan (IEP)
TR School-based individualized education program (IEP) services provided outside the public school district
responsible for the student

TABLE 22-11  Treatments/Screenings Modifiers

GG Performance and payment of a screening mammogram and diagnostic mammogram on the same patient, same day
GH Diagnostic mammogram converted from screening mammogram on same day
SH Second concurrently administered infusion therapy
SJ Third, or more, concurrently administered infusion therapy

CPT HCPCS Level II

LET’S CODE IT! SCENARIO
Cheryl Baxett, a 41-year-old female, came into the hospital for her annual screening mammogram. Dr. Ogden ordered
the screening to be completed with computer-aided detection, due to a prior history of breast cancer. Later that day,
after the images were analyzed, Dr. Ogden diagnosed her with a considerable mass in her left breast.

Let’ Code It!

Cheryl came in for a screening mammogram with computer-aided detection on her left breast. Let’s go to the
Alphabetic Index of the CPT book and find the best, most appropriate procedure code:
77067 Screening mammography, bilateral (two view film study of each breast), includ-
ing computer-aided detection (CAD) when performed
Once the results of the mammogram became the basis for a decision to have surgery, the screening mammogram
became a diagnostic mammogram. Cheryl’s insurance carrier accepts HCPCS Level II codes and modifiers, so you
must adapt the definition of the mammogram from screening to diagnostic by appending a modifier: 77057-GH.
The GH modifier means that a diagnostic mammogram was converted from a screening mammogram on the
CPT © 2017 American Medical Association. All rights reserved.
same day.
77065-GH-LT Diagnostic mammography, including computer-aided detection (CAD) when performed;
unilateral, diagnostic mammogram converted from screening mammogram on same day,
left side
77067-52-RT Screening mammography, bilateral (two view film study of each breast), including
computer-aided detection (CAD) when performed, reduced services, right side
Great job!

622   PART III  |  REPORTING PHYSICIAN SERVICES AND OUTPATIENT PROCEDURES

 Transportation
Table 22-12 has the modifiers that provide additional details with relation to transpor-
tation services provided to patients.

Funded Programs
When a service or treatment is provided under the terms or conditions of a formal-
ized program or plan, the services must be identified so that statistical tracking can
be accomplished accurately and reimbursement is not received from two sources. The
modifiers shown in Table 22-13 enable such tracking.

TABLE 22-12  Transportation Modifiers

GM Multiple patients on one ambulance trip

LR Laboratory round trip

QM Ambulance service provided under arrangement by a provider of services

QN Ambulance service furnished directly by a provider of services

TK Extra patient or passenger, non-ambulance

TP Medical transport, unloaded vehicle

TQ Basic life support transport by a volunteer ambulance provider

TABLE 22-13  Funding Modifiers

GN Services delivered under an outpatient speech language pathology plan of care

GO Services delivered under an outpatient occupational therapy plan of care

GP Services delivered under an outpatient physical therapy plan of care

H9 Court-ordered

HA Child/adolescent program

HB Adult program, nongeriatric

HC Adult program, geriatric

HE Mental health program

HF Substance abuse program

CPT © 2017 American Medical Association. All rights reserved.

HG Opioid addiction treatment program

HH Integrated mental health/substance abuse program

HI Integrated mental health and mental retardation/developmental disabilities program

HJ Employee assistance program

HK Specialized mental health programs for high-risk populations

HU Funded by child welfare agency

(continued)

CHAPTER 22  | 
 TABLE 22-13  Funding Modifiers  (continued)

HV Funded by state addictions agency

HW Funded by state mental health agency
HX Funded by county/local agency
HY Funded by juvenile justice agency
HZ Funded by criminal justice agency
SE State and/or federally funded programs/services

TABLE 22-14  Individual/Group Modifiers

HQ Group setting
HR Family/couple with client present
HS Family/couple without client present
TJ Program group, child and/or adolescent
TT Individualized service provided to more than one patient in same setting
UN Two patients served
UP Three patients served
UQ Four patients served
UR Five patients served
US Six or more patients served

Individual/Group
Most often, modifiers for individuals or groups are going to be used in conjunction
with psychiatric and psychotherapeutic codes to clarify how many patients were
involved in the session. The modifiers shown in Table 22-14 relate to the number, and
sometimes the type, of patient(s) being helped at one time.

Prosthetics
When services are provided relating to the supply or adjustment of a prosthetic device,
you might have to include additional information by using one of the modifiers shown
in Table 22-15.

TABLE 22-15  Prosthetics Modifiers

K0 Lower extremity prosthesis functional level 0—does not have the ability or potential to ambulate or transfer safely with
CPT © 2017 American Medical Association. All rights reserved.
or without assistance and prosthesis does not enhance his or her quality of life or mobility
K1 Lower extremity prosthesis functional level 1—has the ability or potential to use a prosthesis for transfers or ambulation
on level surfaces at fixed cadence, typical of the limited and unlimited household ambulatory
K2 Lower extremity prosthesis functional level 2—has the ability or potential for ambulation with the ability to traverse low-
level environmental barriers such as curbs, stairs, uneven surfaces, typical of limited community ambulatory
K3 Lower extremity prosthesis functional level 3—has the ability or potential for ambulation with variable cadence. Typi-
cal of the commun­ity ambulatory who has the ability to traverse most environmental barriers and may have vocational,
therapeutic, or exercise activity that demands prosthetic utilization beyond simple locomotion
K4 Lower extremity prosthesis functional level 4—has the ability or potential for prosthetic ambulation that exceeds the
basic ambulation skills, exhibiting high impact, stress, or energy levels, typical of the prosthetic demands of the child,
active adult, or athlete
KM Replacement of facial prosthesis including new impression/moulage
KN Replacement of facial prosthesis using previous master model

624   PART III  |  REPORTING PHYSICIAN SERVICES AND OUTPATIENT PROCEDURES

 HCPCS Level II
LET’S CODE IT! SCENARIO
Sam Tanner, a 29-year-old male, returned home after being in a rehabilitation center for 3 months. He had a below-
knee amputation (BKA) after he was hurt in a rescue mission following a major hurricane. Alice Conner fitted him for
an initial, below-knee patellar tendon bearing (PTB) type socket prosthesis because he has the ability to walk on and
even maneuver over such low obstacles as sidewalk curbs and stairs.

Let’s Code It!

Alice Conner ordered and supplied an initial, below-knee PTB type socket prosthesis. In the HCPCS Level II
Alphabetic Index, you find
Prosthesis
   Fitting, L5400–L5460, L6380–L6388
The notes did say that Alice fitted him, so this should provide a good lead. When you get to this section, begin-
ning with L5400, you find a code whose description matches the notes very well:
L5500 Initial, below knee PTB type socket, non-alignable system, pylon, no
cover, SACH foot, plaster socket, direct formed
(Note: SACH stands for solid ankle, cushioned heel.)
You also have to support the service with a modifier to explain Sam’s abilities:
K2 Lower extremity prosthesis functional level 2—has the ability or poten-
tial for ambulation with the ability to traverse low-level environmental
barriers such as curbs, stairs, or uneven surfaces. Typical of the limited
community ambulator
And report this as
L5500-K2 Initial, below knee PTB type socket, non-alignable system,
pylon, no cover, SACH foot, plaster socket, direct formed, lower
extremity prosthesis functional level 2

Durable Medical Equipment

When the services relate to the provision of or adjustments to a piece of durable medi-
cal equipment (DME), a modifier from Table 22-16 may be needed to clarify a certain
condition or circumstance.
CPT © 2017 American Medical Association. All rights reserved.

TABLE 22-16  DME Modifiers

KA Add on option/accessory for wheelchair

KC Replacement of special power wheelchair interface
KF Item designated by FDA as Class III device
NB Nebulizer system, any type, FDA-cleared for use with specific drug
NR New when rented
NU New equipment
RA Replacement of a DME, orthotic, or prosthetic item
RB Replacement of a part of a DME, orthotic, or prosthetic item furnished as part of a repair
TW Backup equipment
UE Used durable medical equipment (DME)

CHAPTER 22  | 
 HCPCS Level II
YOU CODE IT! CASE STUDY
On January 5, a respiratory suction pump was provided to Teresa Christley, who was diagnosed with emphysema.
On January 6, another suction pump was delivered to Teresa. The first unit had to be replaced because of a defec-
tive piece.

You Code It!

Go through the steps, and determine the HCPCS Level II code(s) that should be reported for these services for
Teresa Christley.
Step #1: Read the case carefully and completely.
Step #2: Abstract the scenario. Which key words or terms describe what service the physician provided to the
patient during this encounter?
Step #3: Are there any details missing or incomplete for which you would need to query the physician? [If so,
ask your instructor.]
Step #4: Determine the correct CPT procedure code or codes to explain the details about what was provided
to the patient during this encounter.
Step #5: Check for any relevant guidance, including reading all of the symbols and notations.
Step #6: Do you need to append any modifiers to ensure complete and accurate information is provided?
Step #7: Double-check your work.
Answer:
The code for the provision of the pump is E0600. Did you determine the correct modifier for the second claim?
Jan 5: E0600     Respiratory suction pump, home model, portable or stationary, electric
Jan 6: E0600-RA  Respiratory suction pump, home model, portable or stationary, electric;
replacement of DME

Location
The following modifiers describe situations when you will need to clarify the location
at which services were provided:
PN Non-excepted service provided at an off-campus, outpatient, provider-based depart-
Class A Finding ment of a hospital
Nontraumatic amputation of PO Expected services provided at off-campus, outpatient, provider-based department
CPT © 2017 American Medical Association. All rights reserved.
a foot or an integral skeletal of a hospital
portion. SG Ambulatory surgical center (ASC) facility service
Class B Finding SU Procedure performed in physician’s office (i.e., to denote use of facility and equipment)
Absence of a posterior tibial TN Rural/outside providers’ customary service area
pulse; absence or decrease of
hair growth; thickening of the
nail, discoloration of the skin, Podiatric Care
and/or thinning of the skin
There are times when particular services are recategorized, determined by certain
texture; and/or absence of a
posterior pedal pulse. signs and/or symptoms that the patient may be exhibiting. The following list identifies
modifiers used to indicate some of these circumstances when a podiatrist provides
Class C Finding treatment to a patient:
Edema, burning sensation,
temperature change (cold feet), Q7 One class A finding
abnormal spontaneous sensa- Q8 Two class B findings
tions in the feet, and/or limping. Q9 One class B and two class C findings

626   PART III  |  REPORTING PHYSICIAN SERVICES AND OUTPATIENT PROCEDURES

 Recording
The following modifiers indicate the use of recording equipment as a part of the ser-
vice, treatment, or procedure provided to the patient:
QC Single-channel monitoring
QD Recording and storage in solid-state memory by a digital recorder
QT Recording and storage on tape by an analog tape recorder

Other Services
The modifiers shown in Table 22-17 do not seem to fit into any of the other categories
we have established. Review all the modifiers in the list, and see if you can come up
with examples of how and when they would be used.

Medicaid Services
Each state administers its own version of the federal Medicaid program and deter-
mines its own specific descriptions of the different levels of care. To maintain con-
sistency, HCPCS Level II has the modifiers shown in Table 22-18 that can be used
nationwide—even though the description of each modifier will change, as defined by
each state.

TABLE 22-17  Other Services Modifiers

AT Acute treatment (to be used only with 98940, 98941, 98942)

EJ Subsequent claims for a defined course of therapy
ET Emergency services
GQ Via asynchronous telecommunications system
GT Via interactive audio and video telecommunication systems
GW Service not related to the hospice patient’s terminal condition
Q2 HCFA/ORD demonstration project procedure/service
Q3 Live kidney donor surgery and related services
QJ Services/items provided to a prisoner or patient in state or local custody, however, the state or local government,
as applicable, meets the requirements in 42 CFR 411.4(b)
SK Member of high-risk population (use only with immunization codes)
ST Related to trauma or injury
CPT © 2017 American Medical Association. All rights reserved.

SY Persons who are in close contact with member of high-risk population (use with immunization codes only)
TC Technical component
TG Complex/high-tech level of care
TH Obstetrical treatment/services, prenatal or postpartum
TS Follow-up service
UF Services provided in the morning
UG Services provided in the afternoon
UH Services provided in the evening
UJ Services provided at night
UK Services provided on behalf of the client to someone other than the client (collateral relationship)

CHAPTER 22  | 
 TABLE 22-18  Medicaid Services Modifiers

U1 Medicaid level of care 1, as defined by each state

U2 Medicaid level of care 2, as defined by each state
U3 Medicaid level of care 3, as defined by each state
U4 Medicaid level of care 4, as defined by each state
U5 Medicaid level of care 5, as defined by each state
U6 Medicaid level of care 6, as defined by each state
U7 Medicaid level of care 7, as defined by each state
U8 Medicaid level of care 8, as defined by each state
U9 Medicaid level of care 9, as defined by each state
UA Medicaid level of care 10, as defined by each state
UB Medicaid level of care 11, as defined by each state
UC Medicaid level of care 12, as defined by each state
UD Medicaid level of care 13, as defined by each state

Special Rates
The following two modifiers are used to indicate that a service or procedure was provided
to a patient during an unusual time frame, that is, not during regular working hours:
TU Special payment rate, overtime
TV Special payment rates, holidays/weekends

22.7  Sequencing Multiple Modifiers

There may be circumstances where one case is so complex, unusual, or special that
you need more than one modifier to explain the whole scenario.

Two or Three Modifiers Needed

There are occasions when a particular procedure code will require the amendment
of more than one modifier. In these cases, you must place the modifiers in a particu-
lar order depending upon what each modifier represents. Let’s review a few different
situations.
CPT © 2017 American Medical Association. All rights reserved.
Generally, the CPT modifier that most directly changes, or modifies, the specific
code description will be placed closest to the procedure code. These are called service-
Service-Related Modifier related modifiers because they change, or alter, the description of the service (such
A modifier relating to a change as -23 Unusual Anesthesia or -32 Mandated services), rather than those modifiers that
or adjustment of a procedure explain personnel in attendance (such as -62 Two Surgeons) or an event (such as -57
or service provided. Decision for Surgery).

EXAMPLE
Dr. Weaver, and his surgical team, began the pancreatic transplantation procedure on
Kenneth. Once the incision had been made, the patient’s heartbeat became erratic
and could not be brought back under control, so the procedure was discontinued.
The procedure code reported requires two modifiers: 48554-53-66.

628   PART III  |  REPORTING PHYSICIAN SERVICES AND OUTPATIENT PROCEDURES

 Modifier 53 explains that the procedure was discontinued. This modifier relates
the fact that everyone involved, including the facility, prepared for the surgery and
began the procedure but had to stop. This will explain why, sometime down the
road, this same patient may again go through a pancreatic transplantation. In addi-
tion, this modifier will enable the health care professionals and the facility to get
some reimbursement to cover the cost of the services they did provide.
Modifier 66, on the other hand, explains that a surgical team was participating
in the surgery. This does not affect the specific code description of the procedure.
It explains why the third-party payer will need to reimburse more than one sur-
geon. This modifier may also help to prevent the claim for each of those additional
team members from being denied, or placed into determination, slowing the reim-
bursement process and avoiding an audit.

When a HCPCS Level II modifier is used in addition to a CPT modifier, the CPT
modifier is placed closest to the procedure code, and the HCPCS Level II modifier
follows.

EXAMPLE
24201-76-LT Removal of foreign body, upper arm or elbow area; deep,
repeat procedure by same physician, left side

There is an exception to this rule when reporting anesthesia services. The physical
status modifier always is reported closest to the anesthesia procedure code.

EXAMPLE
Dr. Cowles administered the general anesthesia when Dr. Dean had to take the
patient back into the surgery unexpectedly to attend to a problem with the replan-
tation procedure for the patient’s index finger of his right hand. For Dr. Cowles, the
code is 01810-P1-76.

CPT
LET’S CODE IT! SCENARIO
Dr. Tuders performed a bilateral osteotomy on the shaft of Arlis Richardson’s femur. Another surgeon performed the
same procedure on Jack 2 weeks ago but was unsuccessful, so Dr. Tuders repeated the procedure. As an expert in
CPT © 2017 American Medical Association. All rights reserved.

this procedure, he was brought in to perform the surgery only and will not be involved in any preoperative or post-
operative care of the patient.

Let’s Code It!

To accurately report Dr. Tuders’s surgical services to Arlis Richardson, you would need the following:
27448 Osteotomy, femur, shaft, or supracondylar; without fixation
-50 Modifier to report that it was a bilateral procedure
-54 Modifier to report Dr. Tuders was providing surgical care only
-77 Modifier to report that this is a repeat procedure by another physician
Therefore, the code you report will look like this:
27448-50-54-77

CHAPTER 22  | 
 More Than Three Modifiers Needed
The outpatient claim form, upon which you will record your chosen codes and other
information to request reimbursement from the third-party payer, has a limited amount
of space in which to place the necessary information, particularly when it comes to the
inclusion of modifiers. Some third-party payers do not permit multiple modifiers to be
listed on the same line as the CPT code. Therefore, should your case require three or
more modifiers to completely explain all of the circumstances involved, you can use
modifier 99.
99 Multiple Modifiers: Under certain circumstances two or more modifiers may
be necessary to completely delineate a service. In such situations modifier
99 should be added to the basic procedure, and other applicable modifiers
may be listed as part of the description of the service.

Sequencing Multiple Modifiers

When you need more than one modifier with a procedure or service code, you must
place the modifiers in order of specificity, with the most important, most precise mod-
ifier closest to the main code.

CPT
YOU CODE IT! CASE STUDY
Dr. Cabbot drained an abscess on Mark Swanson’s left thumb and another on his second finger. Both were simple
procedures.

You Code It!

Go through the steps of coding, and determine the codes that should be reported for this encounter between
Dr. Cabbot and Mark Swanson.
Step #1: Read the case carefully and completely.
Step #2: Abstract the scenario. Which key words or terms describe what service the physician provided to the
patient during this encounter?
Step #3: Are there any details missing or incomplete for which you would need to query the physician? [If so,
ask your instructor.]
Step #4: Determine the correct CPT procedure code or codes to explain the details about what was provided
to the patient during this encounter.

CPT © 2017 American Medical Association. All rights reserved.

Step #5: Check for any relevant guidance, including reading all of the symbols and notations.
Step #6: Do you need to append any modifiers to ensure complete and accurate information is provided?
Step #7: Double-check your work.
Answer:
The correct procedure code for the I&D of the abscess is 10060. Did you determine the correct modifiers?

10060-FA Incision and drainage of abscess, simple or single; left hand, thumb
10060-F1-59 Incision and drainage of abscess, simple or single; left hand, second digit;
separate procedure
Without the modifiers FA for left hand, thumb; F1 for left hand, second digit; and 59 for distinct procedural
­service, the claim form could not clearly communicate that Dr. Cabbot did work on two different fingers.

630   PART III  |  REPORTING PHYSICIAN SERVICES AND OUTPATIENT PROCEDURES

 22.8  Supplemental Reports
Remember, documentation is your watchword. It is the backbone of the health informa-
tion management industry. In many situations when a modifier is used, a supplemental Supplemental Report
report is needed for additional clarification. A letter or report written by
Generally, the modifier itself provides a certain amount of explanation; however, the attending physician or
the insurance carrier wants more details. You can be efficient and send the specific other health care professional
information along with the claim, or you can wait until the carrier requests additional to provide additional clarifica-
tion or explanation.
information. Either way, you will have to supply all the facts. However, if you wait to
be asked, you will be delaying payment to your facility.
You will need to use your judgment, so as you look at the modifiers you include to
tell the whole story, review the codes and modifiers to evaluate if there are any unan-
swered questions so you can use a supplemental report to answer them.

EXAMPLES
Just a few of the modifiers that might need a supplemental report to ensure com-
plete communications.
22 Increased Procedural Services . . . what was it that required the addi-
tional time and effort?
23 Unusual Anesthesia . . . why was this necessary?
52 Reduced Services . . . why couldn’t the physician complete the planned
procedure in full?
53 Discontinued Procedure . . . why did the physician have to stop?

CPT
LET’S CODE IT! SCENARIO
Aden Carrington, a 9-year-old boy, had a superficial cut, about 3.3 cm, on his left cheek, after being in a car accident
and hit by broken glass. Dr. Kern is ready to perform a simple repair of the wound, but she is very concerned. Aden
has Tourette’s syndrome, which causes him to jerk or move abruptly, especially when nervous. Although anesthe-
sia is not typically used for a simple repair of a superficial wound, Dr. Kern administers general anesthesia. Sharon
Haverty, a CRNA, assists Dr. Kern with monitoring Aden during the procedure.

Let’s Code It!

Dr. Kern performed a simple repair of Aden’s superficial wound on his face. Go to the Alphabetic Index in your
CPT code book and look up Repair. As you look down the list of anatomical sites, you do not see face or cheek
listed. You know that the repair was simple, and when you look at that listing, you note the direction “See Integu-
mentary System, Repair, Simple.” Once you go to that listing, you find the suggested codes 12001–12021.
Let’s take a look at the complete description in the numeric listing.
CPT © 2017 American Medical Association. All rights reserved.

12011 Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mu-
cous membranes; 2.5 cm or less
The basic description matches the notes exactly. However, several choices are determined by the size of the
wound. The notes state that Aden’s wound was 3.3 cm. This brings you to the correct code:
12013 Simple repair of superficial wounds of face, ears, eyelids,
nose, lips and/or mucous membranes; 2.6 cm to 5.0 cm
Great! Now, you have to address the fact that Dr. Kern gave Aden general anesthesia. This was done for a very
valid medical reason, and Dr. Kern (and her facility) should be properly reimbursed for the service. Anesthesia
is not included with code 12013 because it is not normally required. Aden’s case is unusual. Unusual circum-
stances often require modifiers, so let’s look at CPT’s Appendix A to see if there is an applicable modifier. Modi-
fier 23 seems to fit.
(continued)

CHAPTER 22  | 
 23 Unusual Anesthesia: Occasionally, a procedure, which usually requires either
no anesthesia or local anesthesia, because of unusual circumstances must be
done under general anesthesia. This circumstance may be reported by add-
ing modifier 23 to the procedure code of the basic service.
So modifier 23 should be appended, or attached, to the procedure code.
12013-23
You know that you have to code the anesthesia service as well.
00300 Anesthesia for all procedures on the integumentary system, muscles
and nerves of head, neck, and posterior trunk, not otherwise specified
Let’s look to see if there is an applicable CPT modifier to explain that an anesthesiologist was not involved. Modi-
fier 47 seems to fit.
47 Anesthesia by surgeon: Regional or general anesthesia provided by the
surgeon may be reported by adding modifier 47 to the basic service. (This
does not include local anesthesia.) Note: Modifier 47 would not be used as a
modifier for the anesthesia procedures.
Well, the note within the description of modifier 47 tells you that this modifier is necessary but that it cannot be
used with code 00300. You have to attach the modifier to the procedure code. Therefore, you submit the claim
with one CPT code and two modifiers: 12013-23-47. In addition, it is smart to include a supplemental report with
the claim to explain the use of general anesthesia. You are aware that the insurance company needs to know
the details before paying the claim.

Chapter Summary
Modifiers provide additional explanation to the third-party payer so that it can fully
appreciate any special circumstances that affected the procedures and services pro-
vided to the patient. In health care, as well as in so many other instances of our lives,
most things do not fit neatly into predetermined descriptions. By using modifiers
correctly, you provide an additional explanation and promote the efficient and more
accurate reimbursement of your facility.

CPT © 2017 American Medical Association. All rights reserved.

CODING BITES
CPT MODIFIER REFERENCES:
Inside the front cover of your CPT code book: CPT modifiers and short
descriptions
Appendix A: CPT modifiers, some Level II (HCPCS/National) Modifiers, and full
descriptions
HCPCS LEVEL II MODIFIER REFERENCE:
Appendix 2: Modifiers
[NOTE: Different publishers may place the Modifier listing in different locations of
the HCPCS Level II code book.]

632   PART III  |  REPORTING PHYSICIAN SERVICES AND OUTPATIENT PROCEDURES

 CHAPTER 22 REVIEW

CHAPTER 22 REVIEW
CPT and HCPCS Level II Modifiers Enhance your learning by
completing these exercises and
more at connect.mheducation.com!

Let’s Check It! Terminology

Match each key term to the appropriate definition.

Part I
1. LO 22.1  Containing both letters and numbers. A. Alphanumeric
2. LO 22.1  A two-character alphabetic or alphanumeric code that may be B. Ambulatory Surgery
appended to a code from the main portion of the CPT book or a code Center (ASC)
from the HCPCS Level II book. C. CPT Code Modifier
3. LO 22.8  A letter or report written by the attending physician or other health care D. HCPCS Level II
professional to provide additional clarification or explanation. Modifier
4. LO 22.1  A modifier relating to a change or adjustment of a procedure or service E. Modifier
provided.
F. Nonphysician
5. LO 22.2  A nurse practitioner, certified registered nurse anesthetist, certified reg-
G. Personnel Modifier
istered nurse, clinical nurse specialist, or physician assistant.
H. Physical Status
6. LO 22.1  A two-character code that affects the meaning of another code; a code
Modifier
addendum that provides more meaning to the original code.
I. Service-Related
7. LO 22.1  A facility specially designed to provide surgical treatments without an
Modifier
overnight stay; also known as a same-day surgery center.
J. Supplemental Report
8. LO 22.2  A modifier adding information about the professional(s) attending to
the provision of this procedure or treatment to the patient during this
encounter.
9. LO 22.1  A two-character code that may be appended to a code from the main
portion of the CPT book to provide additional information.
10. LO 22.1  A two-character alphanumeric code used to describe the condition of
the patient at the time anesthesia services are administered.

A. Automated Multi-
Part II Channel Chemistry
1. LO 22.6  Nontraumatic amputation of a foot or an integral skeletal portion. (AMCC)
CPT © 2017 American Medical Association. All rights reserved.

2. LO 22.6  A Medicaid preventive health program for children under 21. B. Class A Finding
3. LO 22.6  Nourishment delivered using a combination of means other than the gas- C. Class B Finding
trointestinal tract (such as IV) in addition to via the gastrointestinal tract. D. Class C Finding
4. LO 22.6  Edema, burning sensation, temperature change (cold feet), abnormal E. Clinical Laboratory
spontaneous sensations in the feet, and/or limping. Improvement
5. LO 22.6  Chronic, irreversible kidney disease requiring regular treatments. ­Amendment (CLIA)
6. LO 22.6  Absence of a posterior tibial pulse; absence or decrease of hair growth; F. Early and Periodic
thickening of the nail, discoloration of the skin, and/or thinning of the Screening, Diagnostic,
skin texture; and/or absence of a posterior pedal pulse. and Treatment (EPSDT)
7. LO 22.6  The measurement of how many liters of a drug or chemical are pro- G. End-stage renal disease
vided to the patient in 60 seconds. (ESRD)
8. LO 22.2  A physician who fills in, temporarily, for another physician. H. Locum Tenens Physician

CHAPTER 22  | 
 9. LO 22.6  Federal legislation created for the monitoring and regulation of clinical I. Liters Per Minute (LPM)
CHAPTER 22 REVIEW

laboratory procedures. J. Parenteral Enteral

10. LO 22.6  A formula to determine the effectiveness of hemodialysis treatment. Nutrition (PEN)
11. LO 22.6  Automated organ disease panel tests performed on the same patient, by K. Urea Reduction Ratio
the same provider, on the same day. (URR)

CPT

 
HCPCS Level II

Let’s Check It! Concepts

Choose the most appropriate answer for each of the following questions.

Part I
1. LO 22.1  A modifier explains
a. the reason a procedure was performed.
b. an unusual circumstance.
c. the date of service.
d. the level of education of the physician.
2. LO 22.1  CPT code modifiers are appended to
a. policy numbers. b. diagnosis codes. c. procedure codes. d. pharmaceuticalcodes.
3. LO 22.2  Service performed by a resident without the presence of a teaching physician under the primary care
exception is identified with modifier
a. AG b. AK c. GC d. GE
4. LO 22.3  A physical status modifier may only be appended to
a. surgical codes. b. radiology codes.
c. anesthesia codes. d. evaluation and management codes.
5. LO 22.1  An example of a HCPCS Level II modifier is
a. 23 b. LT c. P4 d. 99
6. LO 22.2  An example of a personnel modifier is
a. 81 b. 47 c. LC d. 57
7. LO 22.7  If a third-party payer limits your use of multiple modifiers, you should use
a. no modifiers b. 91 c. 51 d. 99
8. LO 22.3  P5 is an example of a
a. HCPCS Level II modifier.
b. CPT modifier.
c. physical status modifier. CPT © 2017 American Medical Association. All rights reserved.

d. personnel modifier.
9. LO 22.7  When appending both a CPT modifier and a HCPCS Level II modifier to a procedure code,
a. the HCPCS Level II modifier comes first.
b. the CPT modifier comes first.
c. it doesn’t matter which comes first.
d. use neither—they cancel each other out.
10. LO 22.8  A(n) _______ is a letter or report written by the attending physician or other health care professional to
provide additional clarification or explanation.
a. supplemental report b. service-related report
c. ambulatory surgery report d. personnel report

634   PART III  |  REPORTING PHYSICIAN SERVICES AND OUTPATIENT PROCEDURES

 Part II

CHAPTER 22 REVIEW
1. LO 22.6  Appending modifier A7 identifies a(n)
a. aphakic patient.
b. most recent URR reading of 65 to 69.9
c. state-supplied vaccine.
d. dressing for seven wounds.
2. LO 22.4  Discontinued outpatient hospital/ambulatory surgery center (ASC) procedure prior to the administration
of anesthesia is identified with modifier
a. 27 b. 73 c. 74 d. AJ
3. LO 22.6  LPM stands for
a. local procedure modality.
b. licensed practical medicine.
c. local patient median.
d. liters per minute.
4. LO 22.4  Multiple outpatient hospital E/M encounters on the same date are identified by modifier
a. 27 b. 73 c. 74 d. 82
5. LO 22.6  An example of DME is
a. an aspirin.
b. the administration of a vaccination.
c. a wheelchair.
d. the removal of a cyst.
6. LO 22.6  CLIA is identified with modifier 
a. BL b. QW c. SQ d. AV
7. LO 22.6  EPSDT for school-based individualized education program (IEP) services provided outside the public
school district responsible for the student is identified by 
a. TR b. EP c. G7 d. TM
8. LO 22.5  Dr. Fullmark repairs a laceration on Johnny’s left lower eyelid. What modifier would be appended?
a. E4 b. E3 c. E2 d. E1
9. LO 22.5  Which of the following modifiers identifies the right foot, third digit?
a. T2 b. T7 c. T8 d. T9
10. LO 22.8  Which of the following modifiers may need a supplemental report?
CPT © 2017 American Medical Association. All rights reserved.

a. 50 b. 57 c. 66 d. 53

Let’s Check It! Rules and Regulations

Please answer the following questions from the knowledge you have gained after reading this chapter.
1. LO 22.1  Why are modifiers used?
2. LO 22.3  Explain what an anesthesia physical status modifier is and why it is used.
3. LO 22.2  Explain what an anesthesia personnel modifier is and why it is important to use them. Include an
example.
4. LO 22.8  What is a supplemental report? Why would a supplemental report be needed, and when do you
submit it?
5. LO 22.6  Explain the difference between a Class A finding, a Class B finding, and a Class C finding.

CHAPTER 22  | 
CHAPTER 22 REVIEW

CPT HCPCS Level II

YOU CODE IT! Practice
Using the techniques described in this chapter, carefully read through the case studies and determine the most ac-
curate modifier(s) for each case study. Note: All insurance carriers and third-party payers for the patients accept
HCPCS Level II codes and modifiers.

Part I
1. Dr. Clayton removed Ricky Pujara’s gallbladder 10 days ago. Today, he comes to see Dr. Clayton because of a
problem with his knee. Which modifier should be appended to the encounter’s E/M code? 
2. Dr. Smyth performed an appendectomy on Lynda Lyman. However, the operation took twice as long as usual
because Lynda weighs 356 pounds. 
3. Dr. Julienne performed a biopsy on the left external ear of Ben Maas, a 69-year-old male. 
4. Christopher Slice, a 17-year-old male, was brought into the OR in the Bracker ASC to have a programmable
pump inserted into his spine for pain control. After the anesthesia was administered and Chris was fully
unconscious, Dr. Sutton made the first incision. Chris began to hemorrhage. The bleeding was stopped, the
incision was closed, and the procedure was discontinued. 
5. Glenda Roberts, a 61-year-old female, goes to see Dr. Zentz at the referral of her family physician,
Dr. Younts, for his opinion as to whether or not she should have surgery. After the evaluation and Glenda’s
agreement, Dr. Zentz schedules surgery for Thursday. Which modifier should be appended to Dr. Zentz’s
­consultation code for today’s evaluation? 
6. Patricia Harris, an 82-year-old female, is having Dr. Harmon remove a cyst from her left ring finger. 
7. Charles McBroom, a 4-week-old male, was rushed into surgery for repair of a septal defect. If the repair is not
completed successfully, he may not survive. What is the correct anesthesia physical status modifier? 
8. Dr. Shull is preparing to perform open-heart surgery on Fred Faulkner. Dr. Lowell is asked to assist because a
surgical resident is not available. Which modifier should be appended to the procedure code on Dr. Lowell’s
claim for services? 
9. Carolyn Lovett, a 37-year-old female, comes to see Dr. Richardson for a complete physical examination,
required by her insurance carrier. 
10. George Carlos, a 9-week-old male, was born prematurely and weighs 3.8 kg. Dr. Wilson performs a cardiac
catheterization on George. 
11. Dr. Kelley excised an abscess on Clyde Hawken’s great toe, right foot. 
12. Annie Mathewson, a 12-year-old female, has been complaining of hearing a constant ringing in her right ear.
Dr. Burwell performs an assessment for tinnitus in the right ear only. 
13. Dr. Maxwell performed a percutaneous transluminal coronary atherectomy, by mechanical method, on Ronald
Yates’s left circumflex artery. 
CPT © 2017 American Medical Association. All rights reserved.
14. John Davis, a 25-year-old male, came to Dr. Browne to have corrective surgery on both of his eyes. 
15. Tamara Connelly, a 16-year-old female, hurt her shoulder while camping. The clinic in the area took an x-ray
but did not have a radiologist, so Tamara brought the films to Dr. Evely for interpretation and evaluation.
Which modifier should Dr. Evely’s coder append to the code for the x-rays? 

Part II
1. Dr. White performed a blepharotomy on Vanetta Regis, draining the abscess on her upper left eyelid. 
2. Stacey Maxell, a nurse midwife, helped Janise Edge deliver her first baby, a girl. 
3. Wilfred Edmonds, a 67-year-old male diagnosed with terminal bone cancer, has been in the hospice facility
for 3 weeks and is showing signs of an ear infection. Dr. Johns was called in to attend Wilfred’s ear problem. 

636   PART III  |  REPORTING PHYSICIAN SERVICES AND OUTPATIENT PROCEDURES

 CHAPTER 22 REVIEW
4. Blake Gamble, an EMT, answered a call, with his partner, to Bracker Nursing Home. There was a small fire
in the laundry room, and two patients were overcome by smoke enough to require hospitalization. Blake
transported both patients at the same time in his ambulance and made one trip to the hospital.
5. Donnie Hentschell, a licensed psychotherapist, began the first of a series of court-ordered therapy sessions
with Sonia Jacobs. 
6. Dr. Rodriguez was called in to provide monitored anesthesia care for a procedure that will be performed on
Malaka Kinlaw. Malaka has a history of acute cardiopulmonary problems. 
7. Doon Jung, a registered nurse, works at the Bracker Nursing Facility. He changed the dressing on three
wounds that Sang Killingsworth had on her leg. 
8. Frank Wenami is the coding specialist for Bracker Dialysis Center. He is preparing the claim for services pro-
vided to Jenny Fortner, a patient with ESRD, who moved to the area just last week. Bracker Dialysis provided
four dialysis treatments for Jenny during the month. 
9. Cindy Kidman, one of the coding specialists at Weston Hospital, discovered that a claim had been submitted
with an incorrect code. She has corrected the procedure code and is resubmitting the claim.
10. Nancy Nemeir works at Bracker Medical Equipment Inc. She meets with Earl Hillier, who was recently pre-
scribed an electric wheelchair by Dr. Franks. Nancy explains the options of purchasing and renting the chair,
and Earl decides to purchase the wheelchair. 
11. Dr. Ott excised a lesion from Oliver Olden’s right thumb. 
12. Gwen Osby gave Frances Volkesberg, a 72-year-old female, a flu shot. 
13. Dr. Parker saw Barbara Gillins and provided service defined as level 3 by Medicaid in her state. 
14. Keren Haynes is a certified diabetic educator. She met with Bonnie Haversat to provide services. 
15. The peer review organization (PRO) ordered Dr. Dumont to provide a second opinion on the surgical options
for Maxine Nevradi.

CPT HCPCS Level II

YOU CODE IT! Application

The following exercises provide practice in abstracting the physician’s notes and learning to work with physician doc-
umentation for various types of situations that might require a modifier. These case studies are modeled on real pa-
tient encounters. Using the techniques described in this chapter, carefully read through the case studies and determine
the most accurate CPT code(s) and modifiers, if appropriate, to report the physician’s services for each case study.
Note: All insurance carriers and third-party payers for the patients accept HCPCS Level II codes and modifiers.

GREGORY SAME DAY SURGERY

CPT © 2017 American Medical Association. All rights reserved.

955 East Healthcare Boulevard • SOMEWHERE, FL 32811 • 407-555-1597

PATIENT: RISHER, BELVA
ACCOUNT/EHR #: RISHBE001
DATE: 10/03/18
Diagnosis: Fecal incontinence, diarrhea, constipation
Procedure: Total colonoscopy with hot biopsy destruction of sessile 3-mm mid-sigmoid colon polyp and
multiple cold biopsies taken randomly throughout the colon
Physician: Marion M. March, MD
Anesthesia: Demerol 50 mg and Versed 3 mg, both given IV

CHAPTER 22  | 
CHAPTER 22 REVIEW

PROCEDURE: Pt is a 43-year-old female. Patient was placed into position. Digital examination revealed
no masses. The pediatric variable flexion Olympus colonoscope was introduced into the rectum and
advanced to the cecum. A picture was taken of the appendiceal orifice and the ileocecal valve.
The scope was then carefully extubated. The mucosa looked normal. Random biopsies were taken from
the ascending colon, the transverse colon, the descending colon, the sigmoid colon, and the rectum.
There was a 3-mm sessile polyp in the mid-sigmoid colon that a hot biopsy destroyed.

IMPRESSION: Sigmoid colon polyp destroyed by hot biopsy

RECOMMENDATIONS: Follow-up in 7 days for biopsy results.

MMM/mg  D: 10/03/18 09:50:16  T: 10/05/18 12:55:01

Determine the most accurate CPT code(s) and necessary modifier(s).

GREGORY SAME DAY SURGERY

955 East Healthcare Boulevard • SOMEWHERE, FL 32811 • 407-555-1597
PATIENT: GILMORE, STEVEN
ACCOUNT/EHR #: GILMST001
DATE: 09/13/18
Diagnosis: Family history of colon cancer
Procedure: Colonoscopy
Physician: Marion M. March, MD
Anesthesia: Versed 4 mg, Demerol 75 mg
PROCEDURE: Pt is a 59-year-old male presenting for a colonoscopy. Pt receives educational material
and is informed of the risks. He acknowledges he understands the nature of the procedure, the risks,
and the consequences, and consents to the procedure.
The patient is placed in the left lateral decubitus position. The rectal exam reveals normal sphincter
tone and no masses. A colonoscope is introduced into the rectum and advanced to the distal sigmoid
colon. Further advancement is impossible due to the marked fixation and severe angulation of the rec-
tosigmoid colon. Procedure is discontinued.
On withdrawal, no masses or polyps are noted, and the mucosa is normal throughout. Rectal vault is

CPT © 2017 American Medical Association. All rights reserved.

unremarkable. The patient tolerates the procedure without difficulty.

IMPRESSION: Normal colonoscopy, only to the distal sigmoid colon

PLAN: Strong recommendation for a barium enema

MMM/mg  D: 09/13/18 09:50:16  T: 09/13/18 12:55:01

Determine the most accurate CPT code(s) and necessary modifier(s).

638   PART III  |  REPORTING PHYSICIAN SERVICES AND OUTPATIENT PROCEDURES

 CHAPTER 22 REVIEW
WESTON HOSPITAL
591 Chester Road • Masters, FL 33955
PATIENT: SCHERINI, STEPHANIE
ACCOUNT/EHR #: SCHEST001
DATE: 11/09/18
Diagnosis: Chronic obstructive lung disease
Procedure: Lung transplant, single, with cardiopulmonary bypass
Surgical Team: Marion M. March, MD, primary; Fredrick Avatar, MD; Gene Lavelle, MD
Anesthesia: General
PROCEDURE: Pt is a 37-year-old female brought into the OR, placed on the table, and draped in sterile
fashion. Anesthesia was administered. At thoracotomy, the left lung was removed by dividing the left
main stem bronchus at the level of the left upper lobe. The two pulmonary veins and single pulmonary
artery were divided distally. An allograft left lung was inserted. The recipient left main stem bronchus
and pulmonary artery were re-resected to accommodate the transplant. The recipient pulmonary veins
were opened into the left atrium. An end-to-end anastomosis of the recipient’s respective structures
(pulmonary artery, main stem bronchus, and left atrial cuffs) was made to the similar donor structures.
Two chest tubes were inserted. Bronchoscopy was performed in the OR. Cardiopulmonary bypass was
successfully completed.
Patient tolerated the procedure well and was taken to the recovery room.

MMM/mg  D: 11/09/18 09:50:16  T: 11/13/18 12:55:01

Determine the most accurate CPT code(s) and necessary modifier(s).

PRADER, BRACKER, & ASSOCIATES

A Complete Health Care Facility
159 Healthcare Way • SOMEWHERE, FL 32811 • 407-555-6789
PATIENT: WILBORN, AMANDA
ACCOUNT/EHR #: WILBAM001
DATE: 11/21/18
Attending Physician: Renee O. Bracker, MD
CPT © 2017 American Medical Association. All rights reserved.

Referring Physician: Valerie R. Reymond, MD

S: Pt is a 41-year-old female who was injured in a car accident. She presents today, at the recommenda-
tion of Dr. Reymond, for a fitting for a prosthetic spectacle.
O: HEENT is unremarkable. Monofocal measurements are taken, and data for the creation of an appro-
priate prosthesis are recorded.
A: Aphakia, left eye
P: Return in 2 weeks for final fitting

ROB/mg  D: 11/21/18 09:50:16  T: 11/23/18 12:55:01

Determine the most accurate CPT code(s) and necessary modifier(s).

CHAPTER 22  | 
CHAPTER 22 REVIEW

PRADER, BRACKER, & ASSOCIATES

A Complete Health Care Facility
159 Healthcare Way • SOMEWHERE, FL 32811 • 407-555-6789
PATIENT: HOLDER, ANDREW
ACCOUNT/EHR #: HOLDAN001
DATE: 12/10/18
Procedure Performed: CT brain w/o contrast
Radiologist: Michael B. Hawkins, MD
Clinical Information: Evaluation for VP shunt, postsurgical 
Attending Physician: Renee O. Bracker, MD
TECHNICAL INFORMATION: Contiguous 3-mm-thick axial images were obtained through the skull base
and posterior fossa structures followed by 7-mm-thick axial images through the remainder of the brain.
The examination was performed without the use of intravenous contrast material.
The scan was performed at an independent imaging center and sent to me via secured PACS system,
so I could interpret.
INTERPRETATION: Evaluation of the posterior fossa demonstrates bilateral vertebral artery calcification.
No abnormal intra- or extra-axial collections are noted. There is no evidence of midline shift.
Analysis of the region of the sella turcica demonstrates calcification, likely atherosclerotic involving the
cavernous carotid arteries bilaterally seen on series 2 image 7. 
Supratentorially, the lateral ventricles are prominent in size. A ventriculostomy catheter is seen coursing
from the region of the postcentral sulcus with its distal tip terminating within the frontal horn of the right
lateral ventricle abutting the septum pellucidum. Hypodensity is seen within the periventricular white
matter particularly abutting the frontal horns of the lateral ventricles bilaterally. There is a mild degree of
cerebral volume loss. No abnormal intra- or extra-axial collections are noted.
Evaluation of the visualized skull and paranasal sinuses demonstrates a right parietal burr hole defect
for placement of the patient’s ventriculostomy catheter. A subcutaneous ventriculostomy valve is seen
on series 3 image 26. 
RECOMMENDATIONS: There is mild prominence of the lateral ventricles bilaterally without evidence of
dilation of the cerebral aqueduct or fourth ventricle. 

MBH/mg  D: 12/10/18 09:50:16  T: 12/12/18 12:55:01

CPT © 2017 American Medical Association. All rights reserved.

Determine the most accurate CPT code(s) and necessary modifier(s).

640   PART III  |  REPORTING PHYSICIAN SERVICES AND OUTPATIENT PROCEDURES

 CPT Evaluation and
Management Coding
Learning Outcomes
23
Key Terms
After completing this chapter, the student should be able to: Anticipatory Guidance
Basic Personal
LO 23.1 Explain the purpose of E/M codes. Services
LO 23.2 Abstract the details for determining the location of the Care Plan Oversight
encounter. Services
LO 23.3 Interpret the relationship between physician and patient. Chief Complaint (CC)
LO 23.4 Analyze the documentation to accurately determine the Consultation
Critical Care Services
type of E/M service provided.
End-Stage Renal
LO 23.5 Ascertain the correct code for preventive care (annual ­Disease (ESRD)
physicals). Established Patient
LO 23.6 Cull the appropriate information from the documentation Evaluation and
related to E/M services. ­Management (E/M)
LO 23.7 Apply the rules of the Global Surgical Package. Global Surgical
Package
LO 23.8 Assign E/M modifiers and add-on codes accurately.
History of Present
LO 23.9 Determine the most accurate way to report special ­Illness (HPI)
­evaluation services. Hospice
LO 23.10 Validate and report the provision of coordination and Interval
­management services. Level of Patient
History
Level of Physical
Examination
Medical Decision
Remember, you need to follow along in Making (MDM)
CPT
  STOP! your CPT code book for an optimal New Patient
­learning experience. Nursing Facility
Past, Family, and
Social History
(PFSH)
23.1  What Are E/M Codes? Preventive
Problem-Pertinent
CPT © 2017 American Medical Association. All rights reserved.

Evaluation and Management (E/M) is the first section in the CPT book and lists codes System Review
numbered 99201–99499. These codes are used to report and reimburse physicians for Relationship
their expertise and thought processes involved in diagnosing and treating patients, Risk Factor Reduction
such as Intervention
∙ Talking with the patient and his or her family. Transfer of Care
∙ Reviewing data such as complaints, signs, symptoms, and examination results.
∙ Doing research in medical books and journals.
∙ Consulting with other health care professionals.
All these elements, including the training and education that this health care profes-
sional has had, go into the decision of what to do next for the patient—what advice,
what prescription, what test, what treatment, what procedure. E/M codes provide a
way to reimburse the health care professional for his or her assessment and supervision
of the patient and the determination of the best course for his or her care.
Preventive Evaluation and management (E/M) services go beyond those included in the typical
A type of action or service that office or hospital visit. Preventive medicine assessments—more commonly called
stops something from hap- annual physicals or wellness visits, evaluations of patients in short-term and long-term
pening or from getting worse. care facilities, counseling, and critical care—are just some of the areas of focus that
might be required of the attending physician. This chapter reviews these subcategories
GUIDANCE of E/M codes.
As you just read, E/M codes are used to describe specifically the physician’s exper-
CONNECTION tise and assessment that was provided during an encounter between him or her and a
When a specific code patient. There are many different types of E/M codes, as you will learn throughout
is approved for use this and the next chapter. Let’s begin by reviewing the pieces of information you will
in reporting services need to abstract from the physician’s documentation to code the E/M portion of the
provided using syn- encounter properly.
chronous, audiovisual,
telecommunications Face-to-Face (Office and Other Outpatient Visits)
equipment [indicated
by a star ( ) symbol to
You may have noticed the phrase face-to-face in the code description qualification
the left of the code],
about time. CPT is very specific about what is included in this element of E/M ser-
face-to-face may also
vices provided by a physician to a patient, such as the time it takes to collect health
occur electronically.
care–related history, perform the physical examination, and counsel the patient (as
Refer to the chapter
discussed previously).
CPT and HCPCS Level
Everyone understands that most physicians will spend time, before and after their
II ­Modifiers, where
encounters with patients, reviewing records, going over test results, conferencing with
you will find a section
other professionals and the patients by writing letters and reports, making phone calls,
on Service-Related
and performing other non–face-to-face tasks. Officially, these are not included in the
­Modifiers, ­specifically
time component of the E/M codes.
modifier 95.
Unit/Floor Time (Hospital and Other Inpatient Visits)
When a physician attends to a patient in a facility, such as a hospital or nursing home,
GUIDANCE the measure of time, for purposes of E/M coding, is described a bit differently than for
CONNECTION outpatient encounters.
In outpatient encounters, time is measured by face-to-face—the number of minutes
Read the additional spent with the patient. With inpatient services, in addition to the face-to-face time that
explanations in the the physician may spend at bedside examining the patient, there are additional com-
Evaluation and Manage- ponents included in the measure of time. These additional components are known as
ment (E/M) Services unit/floor time, which include
Guidelines, subhead
Time, paragraphs ∙ Meeting with nursing staff and other health care professionals.
­Face-to-face . . . and ∙ Speaking with family members.
Unit/floor time . . . , in ∙ Time the physician spends going over the patient’s chart and reviewing notes
your CPT book directly in by other professionals caring for the patient while the physician is still physically
front of the E/M section present in the hospital unit.
CPT © 2017 American Medical Association. All rights reserved.
that lists all the codes.

23.2  Location Where the E/M Services Were

Provided
The first element you must identify when coding E/M services is the location of the
encounter between the health care professional (physician) and the patient. Exactly
where did the provider see the patient: in an outpatient location (such as a physician’s
office), in the hospital, in a skilled nursing facility? Did they just speak on the phone,
or did the provider see the patient somewhere else?
Unlike when you are coding other procedures, it can be more efficient to go directly
to the E/M section of CPT rather than beginning with the Alphabetic Index. Know-
ing where this encounter took place between the provider and the patient will enable
you to narrow down the range of possible codes and get to the accurate one more

642   PART III  |  REPORTING PHYSICIAN SERVICES AND OUTPATIENT PROCEDURES

 effectively. In addition, going to the location subsection of the E/M section will let you
know what additional information you need to determine the right code. CODING BITES
For example, when the encounter occurs at the physician’s office, you will need to Should a patient be
know the level of history taken, the level of examination performed, and the complexity seen by the physician in
of medical decision making (MDM). However, when the encounter occurs on the tele- the office and then be
phone, you will need to know how long the physician was on the phone and the date of admitted into the hospi-
the most recent face-to-face E/M service. You will learn more about non-face-to-face tal on the same day by
encounters, such as telephone calls, later in this chapter and in the next chapter. that same physician, the
Take out your copy of the Current Procedural Terminology (CPT) code book so we entire encounter for the
can go through this together. Go to the Evaluation and Management (E/M) ­section day, including the office
of the CPT book. Look at the first subheading on the first page: Office or Other Out- visit, would be reported
patient Services. with a hospital code,
This header, like many others throughout the section, identifies the location of the under either Hospital
encounter—where the physician met with the patient. Observation Services or
Once you are in the subsection that identifies where the encounter happened, you Hospital Inpatient
can see what additional information you will need to gather from the physician’s notes ­Services—Initial
to determine the correct code. For example, in the Office or Other Outpatient Services ­Hospital Care.
subsection, you can see that the next piece of data you need to know is the relation-
ship between this provider and this patient—whether this patient is a new patient or
an established patient. However, under the Hospital Inpatient Services subsection, the Evaluation and Management
next piece of information you will need to cull from the documentation is whether this (E/M)
is the initial hospital care visit or a subsequent hospital care visit. Specific components of a
meeting between a health
care professional and a
patient.
EXAMPLES
Nicholas Marrin, a 59-year-old male, was brought into the emergency department
(ED) with sharp pain in his chest radiating downward into his left arm. The best,
most appropriate E/M code will be found in the 99281–99288 range of codes,
under Emergency Department Services.
Dr. Harman goes to the Sother Nursing Home to see his patient, Robin Farber,
a 93-year-old female. The best, most appropriate E/M code will be found in the
99304–99318 range of codes, under Nursing Facility Services.
Armani Belez, a 35-year-old female, comes to see Dr. Abrahams at his office. The
best, most appropriate E/M code will be found in the 99201–99215 range of
codes, under Office or Other Outpatient Services.

Location-Specific Headings in the E/M Section

The location-specific headings in the E/M section:
CPT © 2017 American Medical Association. All rights reserved.

Office or Other Outpatient Services

Hospital Observation Services
Hospital Inpatient Services
Office or Other Outpatient Consultations
Inpatient Consultations
Emergency Department Services
Nursing Facility
Nursing Facility Services
A facility that provides skilled
Domiciliary, Rest Home (e.g., Boarding Home), or Custodial Care Services nursing treatment and atten-
Domiciliary, Rest Home (e.g., Assisted Living Facility), or Home Care Plan ­Oversight tion along with limited medical
Services care for its (usually long-
term) residents, who do not
Home Services require acute care services
Non-Face-to-Face Services (hospitalization).

CHAPTER 23  | 
 CPT
LET’S CODE IT! SCENARIO
Suzette Kabole, an 87-year-old female, broke her hip 1 month ago. She has been a patient of Dr. Okine for several
years. Since her release from the hospital, Suzette has been homebound until her hip completely heals. Therefore,
Dr. Okine went to her home to check on her progress.

Let’s Code It!

Read the notes again, and look for the key words that tell you the location of the encounter and the relationship
between patient and physician.
The notes state that the doctor went to “her home.” That phrase tells us the location of the encounter. Look
through the E/M section of the CPT book, and find the group of E/M codes that report this location: Home
­Services . . . codes 99341–99350.

YOU INTERPRET IT!

Match the E/M subsection code range for each of these locations:
.
1 Preventive Medicine Services a. 99201–99205
2. Telephone with patient b. 99217–99226
3. Emergency Department c. 99381–99429
4. Hospital Observation d. 99441–99443
5. Walk-in Clinic e. 99281–99288

Relationship
23.3  Relationship between Provider
The level of familiarity
between provider and patient.
and Patient
Throughout the E/M section of the CPT book, subheadings identify the relationship
New Patient
between the provider and the individual. E/M codes use different types of relation-
A person who has not
received any professional ser-
ship for determining the best, most appropriate code. You may have to identify, from
vices within the past 3 years the documentation, if the relationship between the physician and patient is as a new
from either the provider or patient or established patient; if this is initial care or subsequent care; or if this
another provider of the same qualifies as a temporary relationship—a consultation.
specialty who belongs to the
same group practice. New or Established Patient
Established Patient In many cases, you must know the relationship between the patient and the provider so

CPT © 2017 American Medical Association. All rights reserved.

A person who has received that you can communicate an understanding of how familiar the physician is with the
professional services within patient; the patient’s personal history, social history, and family history; and other elements
the last 3 years from either this
that may affect the physician’s decisions regarding the patient’s health. Certainly you can
provider or another provider of
the same specialty belonging
understand that the first time they meet, the physician knows absolutely nothing about the
to the same group practice. patient. He or she must spend time asking questions to help collect the information that
will be critical to determining the correct diagnosis and course of treatment. When the
Consultation physician sees the patient again, however, all the doctor will need to do is quickly read
An encounter for purposes of a through the patient’s file to refresh his or her memory of past conditions and issues.
second physician’s opinion or
advice, requested by another New Patient
physician, regarding the man-
agement of a patient’s specific The CPT code set defines a new patient as “one who has not received any professional
health concern. A consultation services from the physician within the past three years.” This includes not only this
is planned to be a short-term specific physician but also any other group practice member who belongs to the exact
relationship between a health same specialty or subspecialty, whether they are a physician or another health care
care professional and a patient. professional.

644   PART III  |  REPORTING PHYSICIAN SERVICES AND OUTPATIENT PROCEDURES

 Established Patient
It is logical, then, to understand that an established patient is one who has received
professional services from this physician or another physician or health care profes-
sional in this same group practice who has the exact same specialty credentials, within
the last 3 years.
Some location subsections have different codes for a new patient and an established
patient, and others do not. You must read the descriptions at the beginning of each sub-
section to be certain whether this is a criterion for a particular E/M code. For example,
the subheading Emergency Department Services offers the same codes whether the GUIDANCE
individual is a new or an established patient. CONNECTION
Read the additional
EXAMPLE explanations in the
Evaluation and Man-
Leonora Lopez, a 25-year-old female, comes to see Dr. Poker at his office and
agement (E/M) Services
complains of severe pain in her right wrist and forearm. She just moved to the
Guidelines, subhead
area, and this is the first time Dr. Poker has seen her.
Definitions of Com-
“. . . at his office . . .” identifies the LOCATION of the encounter. monly Used Terms—
New and Established
“. . . this is the first time Dr. Poker has seen her” identifies the RELATIONSHIP
Patient, in your CPT
for this professional and this patient.
book directly in front of
Therefore, the E/M codes applicable for this encounter are now in the smaller the E/M section that lists
range of 99201–99205, Office or Other Outpatient Services, New Patient. all the codes.

Initial or Subsequent Care

For services located in hospitals, nursing facilities, intensive neonatal and pediatric criti-
cal care departments, and intensive care locations, you will need to identify whether
the encounter is the initial or a subsequent visit rather than if the relationship is new or
established. This distinction is similar to the new or established concept, as these two
terms describe how up-to-date the physician is on the current condition of this patient.
Initial care visits are reported for the first time a physician, the one for whom you
are coding, sees a patient at a location for a specific course of treatment or care.
Subsequent care visits are reported for the second time and all visits thereafter that
a physician sees a patient at a location during the course of the same treatment or care.

EXAMPLE
Barry Balmer is admitted to the hospital on Saturday after having a myocardial
infarction (MI) while playing tennis. His regular cardiologist, Dr. Hamilton, is out of
CPT © 2017 American Medical Association. All rights reserved.

town for the weekend, so Dr. Zenbar admits Barry to the hospital on Saturday and
checks in on his care on Sunday. Monday, when Dr. Hamilton returns, she goes to
see Barry in the hospital and takes charge of his care.
• On Saturday, an initial hospital care visit is reported for Dr. Zenbar because this
is his first time seeing Barry during this course of treatment at the hospital.
• On Sunday, a subsequent hospital care visit is reported for Dr. Zenbar because
this is his second time seeing Barry during this course of treatment at the hospital.
• On Monday, an initial hospital care visit is reported for Dr. Hamilton because
this is her first time seeing Barry during this course of treatment at the hospital,
even though it is Barry’s third day in the hospital.
• On Tuesday, a subsequent hospital care visit is reported for Dr. Hamilton
because this is her second time seeing Barry during this course of treatment at
the hospital.

CHAPTER 23  | 
 Consultations
There are times when the relationship between a patient and a health care provider is
expected to be temporary, typically lasting only one visit. In such cases, one physi-
cian or health care professional will ask another physician to meet with a patient and
evaluate a patient’s condition only to offer his or her own professional opinion about
the patient’s diagnosis and/or treatment options. This temporary relationship is known
GUIDANCE as a consultation.
When a patient goes to a physician for a consultation because the first physician is
CONNECTION merely seeking a second opinion from the consulting physician regarding diagnosis
Read the additional and/or treatment of the patient, it will be reported from the Consultations subsection
explanations in the of E/M. Different than other subsections, the consultation codes 99241–99255 are sep-
in-section guidelines arated into two parts on the basis of the location of where the consultation took place:
located within the Office and Other Outpatient Consultations and Inpatient Consultations.
­Evaluation and
­Management (E/M)
­section, subhead EXAMPLE
­Consultations, directly
Dr. Gail reviews Derita Beck’s lab tests and notices that her lipase level is very
above code 99241 in
high. This may indicate a problem with the patient’s pancreas. While Derita is
your CPT book.
healthy overall, Dr. Gail does not want to take any chances, so he refers Derita to
If the second opin-
Dr. Keith, a gastroenterologist, for a second opinion. Derita goes to see Dr. Keith,
ion is requested by the
who examines her, reviews the test results, and writes a letter to Dr. Gail agreeing
patient or a family mem-
with his assessment. Derita goes back to Dr. Gail and does not see Dr. Keith again.
ber instead of another
health care professional,
this is not reported as
a Consultation. It would The relationship between Dr. Keith and Derita Beck is not defined as new or
be reported as a New established but as a consultation—a second opinion requested by another physician.
Patient encounter. Therefore, Dr. Keith’s coder will report this one encounter from the Consultations
subsection, codes 99241–99255.

CPT
LET’S CODE IT! SCENARIO
Denny Rossman, a 49-year-old male, was having pain in his lower abdomen, especially when going to the bath-
room. His primary care physician, Dr. Lein, did a PSA and was not very concerned, so he told Denny to come back in
6–8 months for a follow-up. Denny did not feel comfortable about Dr. Lein’s decision and made an appointment for
a second opinion with Dr. Ellis, a urologist.

Let’s Code It!

The notes indicate that it was Denny, “the patient,” who “requested the consultation” with Dr. Ellis. Therefore, it is
coded as a new patient office visit, and you will find the correct code in the 99201–99205 range. CPT © 2017 American Medical Association. All rights reserved.

Referral or Consultation?
Referral and consultation are two terms that are commonly used and confused. When
one physician transfers the care and treatment for a patient (in total or for one par-
ticular issue) to another physician, this is a referral. The patient is merely being rec-
ommended to see another physician and is expected to become a patient of the other
physician. These visits are reported using the regular E/M codes, based on the loca-
tion of the encounter between the new physician (the specialist) and the patient—for
example, physician’s office 99201–99205, etc.
If the patient goes back to see the “consultant” again, this second E/M encounter will
be reported as an established patient encounter because this means that the “consultant”

646   PART III  |  REPORTING PHYSICIAN SERVICES AND OUTPATIENT PROCEDURES

 has accepted this individual as a patient for continued care. This is the same as when Transfer of Care
the first physician may refer the patient to another physician for continuing care and not When a physician gives up
just a second opinion. More commonly known as a referral, the industry term for this is responsibility for caring for
transfer of care. Transfer of the care of a patient can be complete, such as when a phy- a patient, in whole or with
regard to one specific condi-
sician is retiring, or just for one particular portion of a patient’s care, such as a primary
tion, and another physician
care physician sending a patient to a specialist for care of just the one issue. accepts responsibility for the
care of that patient.
EXAMPLE
Dr. Sanger has been Penny Condrel’s primary care physician for many years.
Today, Penny comes in complaining of a rash all over her legs. Dr. Sanger refers
Penny to Dr. Arias, a dermatologist, so that he can take over the diagnosis and
treatment of this skin condition. Dr. Arias agrees to take Penny on as his patient to
treat this rash. In this case, there has been a transfer of care for Penny’s rash from
Dr. Sanger to Dr. Arias.
For that first visit, the relationship between Dr. Arias and Penny is one of a new
patient, not a consultation, because Dr. Arias has accepted Penny as a patient
and the relationship is not a temporary one. This relationship will be ongoing until
Penny’s problem is resolved. However, Dr. Sanger will remain Penny’s primary
care physician.

23.4  Types of E/M Services

As you read through the documentation, you will also need to identify the specific
type of service provided by the physician. This detail will contribute to your ability
to determine which subsection of the E/M codes will provide you with accurate code
descriptions related to this specific encounter.
∙ Active Care
∙ Observation
∙ Critical Care
∙ Case Management
∙ Care Plan Oversight
∙ Preventive Medicine
∙ Non-Face-to-Face
∙ Special Services
∙ Newborn Care
∙ Delivery/Birthing Room
∙ Care Management Services
CPT © 2017 American Medical Association. All rights reserved.

Level of Service
While accurately reporting the level of expertise and knowledge used by the physician
during a visit may seem intangible, the Evaluation and Management (E/M) Services
Guidelines provide you with a checklist type of criteria—very specific and tangible
measurements to help you determine the appropriate level of service based on the doc-
umentation for the encounter. Let’s begin this step of E/M by discussing the elements
you need to determine what level of each component has been provided.
∙ Patient history taken
∙ Physical examination performed
∙ Medical decision making required to determine a diagnosis, or possible diagnoses,
and a treatment plan or next step

CHAPTER 23  | 
 Level of Patient History
As you look at the codes shown in the E/M Section of CPT, under the header Office or
Other Outpatient Services, you can see that included in the code description is a list
Level of Patient History with three bullets. Notice that the first key component (bullet) describes the level of
The amount of detail involved patient history taken during this encounter by the physician.
in the documentation of There are four levels of patient history. You can measure the level of patient history
patient history. taken by the physician by reading the notes and matching the documentation to this
list. Gathering information from the patient is an important part of the evaluation pro-
cess for the physician to complete. This is the portion of the visit where the physician
Chief Complaint (CC) asks the patient questions about his or her health and the situations surrounding the
The primary reasons why health concern that brought him or her to see this doctor.
the patient has come for this
encounter, in the patient’s Problem-Focused History
own words. a. A discussion of the patient’s chief complaint (CC)
History of Present Illness (HPI) b. A brief history of present illness (HPI) or concern
The collection of details Taking a problem-focused history from the patient is going to gather information about
about the patient’s chief
only the reason the patient came to this physician today. The physician and patient are
complaint, the current issue
that prompted this encounter:
not discussing anything else—no other concern, just this one aspect.
duration, specific signs and
symptoms, etc.
EXAMPLE: ANTONIO 1
Antonio goes to Dr. Grace because he has a cough. [Antonio’s chief complaint (CC)]
Dr. Grace documents that Antonio explained what type of cough (dry or wet),
how long he has been coughing, whether the cough is worse when lying down,
and the color of any mucus that may be coughed up. [Documentation of the
­history of Antonio’s present illness (HPI)]

Expanded Problem-Focused History

a. A discussion of the patient’s chief complaint
b. A brief history of this present illness or concern
Problem-Pertinent System c. A problem-pertinent system review
Review This means that the physician will expand the scope of the information he or she is
The physician’s collection of
gathering to extend through all of the systems throughout the entire body directly
details of signs and symptoms,
related to the chief complaint. The systems included in the CPT definition of a review
as per the patient, affecting
only those body systems con- of systems (ROS):
nected to the chief complaint.   1. Constitutional symptoms, such as fever, weight loss, etc.
  2. Eyes

CPT © 2017 American Medical Association. All rights reserved.

  3. Ears, mouth, nose, and throat
  4. Cardiovascular
  5. Respiratory
  6. Gastrointestinal
  7. Genitourinary
  8. Musculoskeletal
  9. Integumentary (skin and/or breast)
10. Neurologic
11. Psychiatric
12. Endocrine
13. Hematologic/lymphatic
14. Allergic/immunologic

648   PART III  |  REPORTING PHYSICIAN SERVICES AND OUTPATIENT PROCEDURES

 EXAMPLE: ANTONIO 2
In the visit between Antonio and Dr. Grace, in addition to the questions asked in
the problem-focused history, Dr. Grace may also document answers to whether
the cough comes from his throat or his chest, whether his throat is sore, and
whether he has sinus congestion. [Dr. Grace has expanded his investigation of
Antonio’s signs and symptoms to other anatomical sites within the respiratory
­system—the body system directly related to a cough.]

Detailed History
a. A discussion of the patient’s chief complaint.
b. An extended history of this present illness or concern.
c. A problem-pertinent system review extended to include some additional systems.
d. A pertinent past, family, and social history (PFSH). Past, Family, and Social
­History (PFSH)
Collection of details, related
CODING BITES to the chief complaint, regard-
ing possible signs, symptoms,
A PFSH has three key components that that you should be watching for while
behaviors, genetic connec-
abstracting that will help you differentiate a detailed history: Past history, Family
tion, etc.
history, and Social History.
Past History [Patient’s Medical History (PMH)]
• Prior major illnesses and injuries
• Prior operations
• Prior hospitalizations
• Current medications
• Allergies (e.g., drug, food)
• Age-appropriate immunization status
• Age-appropriate feeding/dietary status

Family History
• The health status or cause of death of parents, siblings, and children
• Specific diseases related to problems identified in the chief complaint, history
of present illness, and/or system review
• Diseases of family members that may be hereditary or place the patient at risk

Social History
• Marital status and/or living arrangements
CPT © 2017 American Medical Association. All rights reserved.

• Current employment
• Occupational history
• Use of drugs, alcohol, and tobacco
• Level of education
• Sexual history
• Other relevant social factors

EXAMPLE: ANTONIO 3
In addition to the previous questions for both problem-focused and expanded
problem-focused histories, the documentation for the visit between Antonio and
Dr. Grace may show information about whether Antonio ever had a cough like this
(continued)

CHAPTER 23  | 
 before; whether he has a history of sinus problems, heart problems, respiratory
problems, and/or throat problems; whether anyone in his family ever suffered a
cough like this; whether he smokes or lives/works/socializes with anyone who
smokes; and in what type of environment he works. [Dr. Grace is now asking
more questions, ­seeking a potential connection to a chronic problem (had this in
the past); genetics (anyone in the family have this); and social (behaviors that are
known to contribute to the chief complaint).]

Comprehensive History
CODING BITES a. A discussion of the patient’s chief complaint.
A complete PFSH would b. An extended history of this present illness or concern.
cover details about the c. A review of systems related to the problem.
patient’s health that cov-
ers all or most body sys- d. A review of all additional body systems.
tems and health-related e. A complete PFSH.
behaviors.

EXAMPLE: ANTONIO 4
In addition to the previous questions, the documentation for the visit between
Antonio and Dr. Grace may show information about Antonio’s complete medi-
cal history beyond those issues related to the respiratory system, to include his
entire body; about his allergies, vaccinations, vacations or other travel, general
GUIDANCE health, weight gain or loss, history of hypertension, diabetes; about the health of
his parents, siblings, etc. [Dr. Grace is now asking more questions, to get specific
CONNECTION knowledge about Antonio’s overall health as well as the health of his family. This
Read the additional broader understanding of Antonio’s health can provide important clues to his cur-
explanations in the rent diagnosis.]
Evaluation and Manage-
ment (E/M) Services
Guidelines, subhead
Table 23-1 may provide you with help to determine what level of history is
Determine the Extent
documented.
of History Obtained, in
your CPT book directly in Level of Physical Examination
front of the E/M section
that lists all the codes. The second key component (bullet) describes the level of physical examination
that was performed during an encounter with the physician. There are four levels of
physical examination. You can measure the level of examination performed by the
Level of Physical
Examination
physician by reading the notes and matching the documentation to the following list.
The extent of a physician’s CPT © 2017 American Medical Association. All rights reserved.
clinical assessment and Problem-Focused Examination
inspection of a patient. a. A limited examination of the affected body area or organ system.

TABLE 23-1  Determine Level of History Documented

Problem Focused (PF) Expanded PF Detailed Comprehensive

Chief complaint √ √ √ √
HPI (history of present illness) Brief Extended Extended Extended
System review None Problem-pertinent Extended problem-pertinent Complete
PFSH (past, family, and social
history) None None Pertinent Complete

650   PART III  |  REPORTING PHYSICIAN SERVICES AND OUTPATIENT PROCEDURES

 EXAMPLE: ANTONIO 5
Documentation of a problem-focused exam during the visit between Antonio and
Dr. Grace may indicate that Dr. Grace looked down Antonio’s throat, and perhaps
listened to his chest. [Dr. Grace only examines those anatomical sites directly
related to Antonio’s chief complaint.]

Expanded Problem-Focused Examination

a. A limited examination of the affected body area or organ system.
b. An examination of any other symptomatic or related body area(s) or organ system(s).

EXAMPLE: ANTONIO 6
An expanded problem-focused exam during the visit between Antonio and
Dr. Grace may indicate that Dr. Grace also looked up his nose, palpated his cheeks
(sinuses), and perhaps listened to his lungs. [Dr. Grace does a more in-depth exam
of those anatomical sites directly related to Antonio’s chief complaint.]

Detailed Examination
a. An extended examination of the affected body area(s) or organ system(s).
b. An examination of any other symptomatic or related body area(s) or organ system(s).

EXAMPLE: ANTONIO 7
In addition to looking at Antonio’s throat, nose, and lungs, Dr. Grace may also have
listened to his heart; manually palpated his lymph nodes and neck; and palpated
his abdomen, specifically the upper middle (stomach area). [Dr. Grace expands his
exam to include other anatomical sites that may relate to a cough.]

The CPT book categorizes 7 body areas and 11 organ systems in its determination
of the best, most appropriate level of physical examination. The CPT definitions of
each body area and each recognized organ system are a bit different than you learned
in anatomy class:

BODY AREAS
1. Head, including the face
CPT © 2017 American Medical Association. All rights reserved.

2. Neck
3. Chest, including breasts and axilla
4. Abdomen
5. Genitalia, groin, buttocks
6. Back
7. Each extremity (arms and legs)

ORGAN SYSTEMS
1. Eyes
2. Ears, mouth, nose, and throat
3. Cardiovascular

CHAPTER 23  | 
   4. Respiratory
GUIDANCE
  5. Gastrointestinal
CONNECTION
  6. Genitourinary
Read the additional   7. Musculoskeletal
explanations in the
Evaluation and Man-
  8. Skin
agement (E/M) Services   9. Neurologic
Guidelines, sub- 10. Psychiatric
head Determine the 11. Hematologic/lymphatic/immunologic
Extent of Examination
­Performed, in your CPT
Comprehensive examination
book directly in front of
the E/M section that lists a. A general, multisystem examination—or—
all the codes. b. A complete examination of a single organ system
Table 23-2 may provide you with help to determine what level of physical examina-
tion is documented.

EXAMPLE: ANTONIO 8
In addition to all of the above, Dr. Grace may have taken a chest x-ray, done a
respiratory efficiency test, and taken a sputum culture and/or throat cultures.

Level of Medical Decision Making

Medical Decision Making The third bullet describes the level of medical decision making (MDM) provided
(MDM) by the physician during this encounter. This can be the most challenging component
The level of knowledge and because, in essence, you need to determine from the documentation how hard the phy-
experience needed by the pro- sician had to think to determine what to do next to help this patient with this concern.
vider to determine the diagno- It may be that the physician writes a prescription, recommends a treatment or surgery,
sis and/or what to do next.
or orders some diagnostic tests to provide further information. Your understanding of
anatomy and physiology will help you with this portion of determining the most accu-
rate code. There are four levels of MDM.

Straightforward MDM
a. A small number of possible diagnoses
b. A small number of treatment or management options
c. A low to no risk for complications
d. Little to no data or research to be reviewed

CPT © 2017 American Medical Association. All rights reserved.

EXAMPLE: ANTONIO 9
If when Dr. Grace looked down Antonio’s throat he observed inflammation of his
tonsils, and if Antonio has no problematic history, then Dr. Grace’s decision making
may be very straightforward. Dr. Grace was trained to recognize tonsillitis and
knows exactly what to prescribe to help Antonio heal.

TABLE 23-2  Determine Level of Physical Examination Documented

Problem Focused (PF) Expanded PF Detailed Comprehensive

Affected body area or organ system Limited Limited Extended Complete
Other symptomatic or related organ system None √ √ Complete

652   PART III  |  REPORTING PHYSICIAN SERVICES AND OUTPATIENT PROCEDURES

 Low-complexity MDM
a. A limited number of possible diagnoses
b. A limited number of treatment or management options
c. A limited amount of data to be reviewed
d. A low risk for complications

EXAMPLE: ANTONIO 10
If Dr. Grace observed Antonio had a different type of inflammation (other than
­tonsillitis), such as some indication that his condition might be strep throat or
­pharyngitis, the process of determining what is best to do is slightly more complex.
If so, then a culture would need to be taken for a lab test.

Moderate-complexity MDM
a. A multiple number of possible diagnoses
b. A multiple number of treatment or management options
c. A moderate amount of data to be reviewed
d. A moderate level of risk for complications, possibly due to other existing diagnoses CODING BITES
or medications currently being taken Certain terms in the
physician’s notes may
indicate a more com-
plex process of MDM
EXAMPLE: ANTONIO 11 on the physician’s part.
In addition to the inflammation Dr. Grace observed, he also noted worrisome Orders for several tests
sounds in Antonio’s lungs. This complicates matters because the diagnosis with terms such as
possibilities now extend from tonsillitis to strep throat to asthma, bronchitis, or rule out, possible, and
pneumonia. Or perhaps Antonio has a history of asthma or previous bouts with likely might indicate the
pneumonia. Or perhaps Antonio has other known current illnesses, such as physician is looking for
­hypertension or diabetes, which may make diagnosing and treating this condition evidence of several pos-
much more complicated. sible diagnoses.

High-complexity MDM
a. A large number of possible diagnoses
b. A large number of treatment or management options
CPT © 2017 American Medical Association. All rights reserved.

c. A large amount of data and/or research to be reviewed

d. A high level of risk for complications, possibly due to other existing diagnoses and/or
medications currently being taken

EXAMPLE: ANTONIO 12
In highly complex cases, the documentation will show issues such as multiple
­co-morbidities (other conditions or diseases), current multiple medications that
may make determining the best treatment for a problem more dangerous for fear
of adverse interactions, perhaps allergies to medications under consideration, or
other factors that make the determination of the best course of treatment for the
patient incredibly complicated.

CHAPTER 23  | 
TABLE 23-3  Determine Level of Medical Decision Making Documented

Straightforward Low Complexity Moderate Complexity High Complexity

Number of possible diagnoses 1 or 2 Few Several Many
Number of management options 1 or 2 Few Several Many
Quantity of information to be
obtained, reviewed, analyzed (test
results, records, etc.) None, 1, or 2 Few Several Many
Risk of significant complications
(morbidity, mortality, interactions,
allergies, co-morbidities, systemic
underlying conditions, etc.) None, 1, or 2 Few Several Many

Table 23-3 may provide you with help to determine what level of MDM is
documented.

EXAMPLE
Bernard Clinton comes in to his physician’s office with a large shard of glass in his
hand. You can see that the number of potential diagnoses is very small: a foreign
body in his hand. There are a small number of treatment options: remove the
shard. There are no real health complications, and the physician should not have
GUIDANCE to research Bernard’s condition before deciding what to do. This is a straightfor-
CONNECTION ward level of MDM.
Read the additional
explanations in Evalua-
tion and Management
(E/M) Services Guide- EXAMPLE
lines, subhead Deter- Karen Potts comes to see her family physician, Dr. Seridan, and complains of mal-
mine the Complexity of aise and fatigue. She denies any major changes in her diet or lifestyle prior to the
Medical Decision Mak- onset of her symptoms. This is a complex situation that will take a lot of investiga-
ing, in your CPT book tion and knowledge on the part of the physician to determine Karen’s underlying
directly in front of the condition. There are numerous possible diagnoses and, therefore, a large number
E/M section that lists all of management options. Dr. Seridan may have to perform several diagnostic tests
the codes. to help him determine the problem. This is a highly complex case.

CPT © 2017 American Medical Association. All rights reserved.

CPT
YOU CODE IT! CASE STUDY
Dr. Sternan was asked by Dr. MacAndrews to provide a second opinion on Arthur Jankowski, a 17-year-old male. Arthur’s
pulmonary specialist, Dr. MacAndrews, wants to perform a lung transplant because of his diagnosis of cystic fibrosis.
Dr. Sternan examined Arthur’s respiratory system in his hospital room, reviewed the x-rays ordered by Dr. MacAndrews,
and wrote a report agreeing that Dr. MacAndrews should perform the surgery.

You Code It!

Go through the steps of E/M coding, and determine the E/M code that should be reported for this encounter
between Dr. Sternan and Arthur Jankowski.
Step #1: Read the case completely.
Step #2: Abstract the notes: Which key words can you identify relating to the E/M service performed?

654   PART III  |  REPORTING PHYSICIAN SERVICES AND OUTPATIENT PROCEDURES

 Step #3: What is the location?
Step #4: What is the relationship?
Step #5: What level of patient history was taken?
Step #6: What level of physical examination was performed?
Step #7: What level of MDM was required?
Step #8: What is the most accurate E/M code for this encounter?
Step #9: Double-check your work.
Answer:
Did you determine this to be the correct code?
99252 Inpatient consultation, expanded problem-focused
Good work!

Combining Multiple Levels into One E/M Code

GUIDANCE
Now that you have determined what level of history was taken, what level of physician
exam was performed, and what level of MDM was provided by this physician, this all
CONNECTION
needs to be put together into one code. When all three key components point to the Read the additional
same code, this is a piece of cake. explanations in the
Evaluation and Man-
agement (E/M) Services
EXAMPLE: ANTONIO 13 Guidelines, subhead
Antonio came to see Dr. Grace in Dr. Grace’s office because he had a cough. He had Instructions for Selet-
not ever seen Dr. Grace before. After carefully reviewing the documentation, you ing a Level of E/M
determine that Dr. Grace took an expanded problem-focused history, he performed an Serivce, in your CPT
expanded problem-focused physical exam, and the level of MDM was straightforward. book directly in front of
All three of these levels of key components point directly to code 99202. the E/M section that lists
all the codes.

CODING BITES
When the patient history, examination, and MDM are not performed at the same
level, the guidelines instruct you to choose the one code that identifies the required
key components that have been met or exceeded by the physician’s documentation.
CPT © 2017 American Medical Association. All rights reserved.

But what about when the three levels point toward different E/M codes? How do
you mesh them all into one code? The CPT guidelines state, “. . . must meet or exceed
the stated requirements to qualify for a particular level of E/M service.” Let’s use a
scenario to figure this out together.

CPT
LET’S CODE IT! SCENARIO
Sadie Adanson, an 89-year-old female, was admitted today into McGraw Skilled Nursing Facility (SNF) by Dr. Domino
for rehabilitation and care. She suffered a stroke 2 weeks ago and was just discharged from the hospital. Dr. Domino
documented a comprehensive level of history. She performed a detailed level of physical exam. Due to the patient’s
advanced age, co-morbidities, and long list of current medications, as well as the late effects of the stroke, Dr. Domino’s
MDM was of high complexity.
(continued)

CHAPTER 23  | 
 Let’s Code It!
First, identify the location where the encounter between Dr. Domino and Sadie Adanson occurred. The notes state,
“admitted into McGraw Skilled Nursing Facility.” Turn in the CPT book, E/M section, to Nursing Facility Services. This
subsection of E/M is divided into two parts: Initial Nursing Facility Care and Subsequent Nursing Facility Care.
The documentation states that Sadie was admitted today, so this must be the first time Dr. Domino is caring
for Sadie at this nursing home. Now you know that the correct code for Dr. Domino’s evaluation of Sadie for this
visit must be within the Initial Nursing Facility Care 99304–99306 range.
Next, you need to check the requirements for this range of codes. The code descriptions tell you that ALL
THREE key components—level of history, exam, and MDM—must be met or exceeded to qualify. In a full case,
you will go back and read through the physician’s notes to determine the level provided for each of the three
components, as you learned earlier in this chapter. This scenario is provided with a shortcut, indicating the levels
for you: “comprehensive history . . . detailed exam . . . MDM high complexity.”
Comprehensive history meets the descriptions for 99304, 99305, and 99306.
Detailed exam only meets the description of 99304. Codes 99305 and 99306 both require a comprehen-
sive exam to have been performed.
MDM high complexity meets the description of 99306 and exceeds (a higher level was actually docu-
mented) for codes 99304 and 99305.
You must find the one code that is satisfied by ALL THREE levels of care.
99304:
You have documentation that is equal to this level of history.
You have documentation that is equal to this level of exam.
You have documentation that is greater than this level of MDM.

99305:
You have documentation that is equal to this level of history.
You do NOT have documentation that is equal to this level of exam.
You have documentation that is greater than this level of MDM.

99306:
You have documentation that is equal to this level of history.
You do NOT have documentation that is equal to this level of exam.
You have documentation that is equal to this level of MDM.
The only code that has ALL THREE levels equal to or greater than its requirements is 99304, so this is the code
that must be reported.

Now, let’s take a look at another scenario that requires only two of the three
components. CPT © 2017 American Medical Association. All rights reserved.

CPT
LET’S CODE IT! SCENARIO
Patrick Chapman, a 77-year old male, has been living at Northside Assisted Living Facility for 6 months. Dr. Colon, his
primary physician since he moved in, comes in today to see Patrick because of a complaint of leg pain. Dr. Colon docu-
ments a problem-focused interval history, an expanded problem-focused exam, and MDM of moderate complexity.

Let’s Code It!

Read through the scenario, and identify the location where Dr. Colon provided his evaluation and management
services: “assisted living facility.”

656   PART III  |  REPORTING PHYSICIAN SERVICES AND OUTPATIENT PROCEDURES

 Let’s turn to the Domiciliary, Rest Home or Custodial Care Services subsection of E/M. Why? In the first
­ aragraph under this heading, you will see that CPT directs you to use this category of E/M codes “to report
p
evaluation and management services in an assisted living facility.”
This subsection is divided into New Patient and Established Patient, so go back to the scenario. It states,
“Dr. Colon, his primary physician since he moved in,” meaning that Patrick qualifies as an established patient.
This narrows down the choices to Established Patient 99334–99337.
These codes require TWO of the THREE key components. In a full case, you will go back and read through
the physician’s notes to determine the level provided for each of the three components, as you learned earlier in
this chapter. As we did before, this scenario is provided with a shortcut, indicating the levels for you:
Problem-focused interval history meets the requirement for 99334.
Expanded problem-focused exam meets the requirement for 99335 and exceeds the requirement
for 99334.
MDM moderate complexity meets the requirement for 99336 and exceeds the requirements for
99334 and 99335.
You must find the one level that is satisfied by at least TWO of the THREE levels of care.
99334:
You have documentation that is equal to this level of history.
You have documentation that is greater than this level of exam.
You have documentation that is greater than this level of MDM.

99335:
You have documentation that is NOT equal to this level of history.
You have documentation that is equal to this level of exam.
You have documentation that is greater than this level of MDM.

99336:
You have documentation that is NOT equal to this level of history.
You have documentation that is NOT equal to this level of exam.
You have documentation that is equal to this level of MDM.
Now, you must report the highest level of code that has at least TWO levels equal to or greater than its require-
ments. The only choice is 99335.

GUIDANCE CONNECTION
Read the list of these elements, body areas, and organ systems found in the Evalua-
CPT © 2017 American Medical Association. All rights reserved.

tion and Management (E/M) Services Guidelines, subhead Select the Appropriate
Level of E/M Services Based on the Following, in your CPT book directly in front of
the E/M section that lists all the codes.

CPT
YOU CODE IT! CASE STUDY
Daman Cordero, a 41-year-old male, came to see Dr. Decklin in her office for the first time because of a cough, fever,
excessive sputum production, and difficulty in breathing. He had been reasonably well until now. Dr. Decklin did an
expanded problem-focused exam of the patient’s respiratory system and took Daman’s personal, family, and social
history in detail. After a chest x-ray was taken to rule out pneumonia, Dr. Decklin’s straightforward MDM led her to
diagnose him with bronchitis and prescribe an antibiotic and a steroid.
(continued)

CHAPTER 23  | 
 You Code It!
Go through the steps of E/M coding, and determine the E/M code that should be reported for this encounter
between Dr. Decklin and Daman Cordero.
Step #1: Read the case completely.
Step #2: Abstract the notes: Which key words can you identify relating to the E/M service performed?
Step #3: What is the location?
Step #4: What is the relationship?
Step #5: What level of patient history was taken?
Step #6: What level of physical examination was performed?
Step #7: What level of MDM was required?
Step #8: What is the most accurate E/M code for this encounter?
Step #9: Double-check your work.
Answer:
Did you determine the correct code to be 99202? Good work!
You know, from the notes, that Daman saw the doctor “in her office.” This tells you the location. You also can
detect that Daman is a new patient because Dr. Decklin is seeing him “for the first time.”
You would need to use code 99203 because the physician documented “history in detail.” However, the level
of physical examination performed would better match code 99202 because she performed only “an expanded
problem-focused exam.” Code 99202 is also supported by the “straightforward medical decision making.” So when
you examine the requirements to meet or exceed the key components of code 99202, you consider the following:
• Expanded problem-focused history: Exceeded.
• Expanded problem-focused exam: Met.
• Straightforward decision making: Met.
The correct E/M code for this scenario is 99202.

Critical Care and Intensive Care Services

Critical Care Services Critical care services include the management and care of severely ill patients and
Care services for an acutely this takes a great deal of skill, knowledge, and time. Critically ill or injured patients
ill or injured patient with a have a high likelihood of developing a deteriorating life-threatening condition. E/M
high risk for life-threatening services reported include
developments.
CPT © 2017 American Medical Association. All rights reserved.
∙ Highly complex decision making to assess, manipulate, and support vital system
GUIDANCE function.
CONNECTION ∙ Treatment of single or multiple vital organ system failure.
∙ Efforts to avoid additional life-threatening decline of the patient’s condition.
Read the additional
explanations in the ∙ Interpretation of various vital function factors.
in-section guidelines ∙ Evaluation of advantages and disadvantages of using advanced technology.
located within the
The health care provider must document the amount of time spent so that you will
Evaluation and Man-
know how to code the encounter. The physician may spend his or her time
agement (E/M) section,
subhead Critical Care ∙ Reviewing test results and films at the nurses’ station.
Services, directly above ∙ Discussing the patient’s treatment and care with the other members of the medical team.
code 99291 in your
∙ Charting (writing in the patient’s chart).
CPT book.
∙ Attending to the patient at bedside.

658   PART III  |  REPORTING PHYSICIAN SERVICES AND OUTPATIENT PROCEDURES

 All such activities are a part of the time spent providing critical care.
Critical care services can be, but do not have to be, provided in a coronary care unit
(CCU), an intensive care unit (ICU), a respiratory care unit (RCU), or an emergency
care facility. CODING BITES
The codes you choose to report critical care services are determined by the services If a physician goes to
provided for the critically ill or injured patient and the total length of unit/floor time see a patient who is cur-
of the encounter. Use the following for coding physician services for the critically ill rently in the hospital and
or injured patient: given a bed in the CCU
99291 Critical care, evaluation and management of a critically ill or but who is not critically
­critically injured patient; first 30–74 minutes ill, you are not permitted
99292   each additional 30 minutes to use the critical care
codes 99291–99292.
(Note: If the physician spends less than 30 minutes of unit/floor E/M time with a criti- You have to code it as a
cally ill or critically injured patient, regular E/M inpatient codes should be reported. regular hospital visit.
Critical care codes do not become applicable until the 30th minute.)

CPT
LET’S CODE IT! SCENARIO
Rafael Soriano, a 17-year-old male, was brought into the ED by ambulance after being involved in a motorcycle
accident. He was not wearing a helmet, and his head hit a brick wall. After initial evaluation and testing by the ED
physician, Rafael was sent to the CCU and Dr. Haung spent 2 hours reviewing test results, performing a complete
physical exam of Rafael, and discussing a care management plan with the rest of the medical team.

Let’s Code It!

Dr. Haung spent “2 hours” managing the care of Rafael Soriano in the “­critical care unit.” Turn to the Critical
Care codes, and let’s look at the chart. Two hours equals 2 times 60 minutes, or 120 minutes. When you look
at the chart, you will see that 105–134 minutes (120 minutes is right in the middle of this range) is coded with
99291×1 and 99292×2 (read ×2 as reported twice). Look at the following complete description:
99291 Critical care, evaluation and management of the critically ill or critically
injured patient; first 30–74 minutes
99292   each additional 30 minutes
You know that Dr. Haung spent 120 minutes and that 120 minutes minus 74 minutes (which is represented by
code 99291) leaves 46 minutes unreported. Therefore, you must add 99292 to report an additional 30 minutes.
However, 16 minutes still remains. So you must include 99292 again to account for the leftover minutes. The
claim form that you complete will show 99291, 99292, 99292 or 99291, 99292 × 2. Great job!
CPT © 2017 American Medical Association. All rights reserved.

Inpatient Neonatal and Pediatric Critical Care

These services will most often be provided in sections of a hospital known as a neo-
natal intensive care unit (NICU) or pediatric intensive care unit (PICU), but these CODING BITES
codes are not exclusive to those designated areas. The guidelines included in the CPT If the same physician
directly above code 99468 contain a great deal of detail on the specific services that provides critical care
are included in these codes and not reported separately. services to the same
Determining the most accurate code in this subsection will require you to have two patient on the same
essential pieces of information: date as other E/M
services, codes from
∙ Age: Is the patient 28 days or younger, 29 days to 24 months, or 2 to 5 years of age? both subheadings may
∙ Initial or subsequent: Was this the first day of care for this baby or second/­additional be reported.
day of care by this physician for this newborn?

CHAPTER 23  | 
 Note that these code descriptions report a day of E/M service, not just history/exam/
GUIDANCE MDM or even time spent.
CONNECTION
Intensive Care Services—Child
Read the additional
explanations in the There is a difference between a patient who is critically ill and one who requires inten-
in-section guidelines sive care services, such as intensive observation, cardiac and respiratory monitoring,
located within the vital sign monitoring, and other services detailed in the guidelines for this subsection
Evaluation and Man- (shown above code 99477).
agement (E/M) section, Determining the most accurate code in this subsection will require you to have two
subhead Initial and essential pieces of information:
Continuing Intensive ∙ 99477 reports the initial hospital care for a neonate, 28 days of age or younger, who
Care Services, directly requires intensive care, as per those services identified in the guidelines.
above code 99477 in
∙ Subsequent intensive care codes 99478–99480 are distinguished by the present
your CPT book.
weight of the neonate.
Note that these code descriptions report a day of E/M service, not just history/exam/
MDM or even time spent.
GUIDANCE
CONNECTION Time
Read the additional Under certain circumstances, the correct E/M code is not determined by the key com-
explanations of these ponents of history, physical exam, and MDM but is based on the amount of time the
elements used to deter- physician spent evaluating the patient’s condition and managing his or her care. In
mine the most accurate these cases, the time shown in the last paragraph of the E/M code description is used
E/M code involving the as a guide. This detail can be found following the three bullets for the key compo-
measurement of time nents. You will see that the last sentence reads something like Typically, 20 minutes
spent with the patient are spent face-to-face with the patient and/or family (found in the last portion of the
in the Evaluation and code 99202 description). This gives you an approximate time frame that may be used
Management (E/M) Ser- instead of the other key components to determine the appropriate level. In order to
vices Guidelines, sub- use this guideline to choose a code, the documentation must contain the appropriate
head Time, in your CPT specific information.
book directly in front of
the E/M section that lists Counseling between Physician and Patient
all the codes.
If the physician spends more than half (51% or more) of the total time counseling the
patient, then time spent shall be used as the key element in determining the best, most
appropriate E/M code. This is not psychological counseling with a therapist (reported
with codes 90804–90857) but the physician’s discussing diagnosis and treatment with
the patient. It might be to review test results or to go over care options with a family
member. The CPT guidelines specify the following:
∙ The results of recommendations for diagnostic tests and/or the review of the results
of tests and impressions already gathered.
CPT © 2017 American Medical Association. All rights reserved.

EXAMPLE
The doctor writes, “I discussed with the patient that the MRI shows an area of
concern. . . .”

∙ The options of multiple treatments, including risks and benefits.

EXAMPLE
The doctor writes, “I explained to the patient that his condition can be treated
with medication or surgery. The research shows that this new drug has been quite
effective; however, there are some side effects. . . .”

660   PART III  |  REPORTING PHYSICIAN SERVICES AND OUTPATIENT PROCEDURES

 ∙ Directions to the patient for treatment and/or follow-up.

EXAMPLE
The doctor writes, “Prescription provided with instructions to take one tablet three
times a day. I want to see you in 1 week.”

∙ Emphasis on the importance of compliance with the agreed-upon treatment plan.

EXAMPLE
The doctor writes, “I informed the patient that she needs to take all of the pills in
this pack. Even if she is feeling better, I instructed her to keep taking them until
they are all gone.”

∙ Risk factor reduction.

GUIDANCE
EXAMPLE
CONNECTION
The doctor writes, “The test was negative this time. However, I discussed with the
patient how to prevent possible exposure in the future.” Read the additional
explanations in the
Evaluation and Man-
∙ Patient and family education. agement (E/M) Services
Guidelines, subhead
Counseling, in your CPT
EXAMPLE book directly in front of
The doctor writes, “I explained to the daughter that her mother is going to need the E/M section that lists
oxygen to treat her respiratory insufficiency. What this means is. . . .” all the codes.

Counseling and/or Risk Factor Reduction Intervention

A physician may see a patient at a visit, separate from the annual preventive medi-
cine evaluation, for the purposes of helping the patient learn about, understand, and/or
adopt better health practices, including
∙ Preventing injury or illness, such as the proper way to lift or the importance of test-
ing one’s blood glucose levels regularly.
∙ Encouraging good health, such as nutritional counseling or a new exercise regime.
GUIDANCE
CPT © 2017 American Medical Association. All rights reserved.

Services such as these are reported with codes from CONNECTION

99401–99404 Preventive medicine, individual counseling Read the additional
99411–99412 Preventive medicine, group counseling explanations in the
99429 Unlisted preventive medicine services in-section guidelines
located within the
Evaluation and Man-
agement (E/M) section,
EXAMPLE subhead Counseling
Dr. DeSalva meets a group of students from the local university to counsel them Risk Factor Reduction
on preventing sexually transmitted diseases. He speaks with them for an hour. It and Behavior Change
should be reported with code 99412 Preventive Medicine Counseling and/or Intervention, directly
risk factor reduction intervention(s) provided to individuals in a group setting; above code 99401 in
approximately 60 minutes. your CPT book.

CHAPTER 23  | 
 Long-Term Care Services
Specific codes are used to report E/M services provided to patients in residential care
facilities.
Use 99304–99318 and 99379–99380 for reporting services to patients in the
­following places:
∙ Skilled nursing facilities (SNF)
∙ Intermediate care facilities (ICF)
∙ Long-term care facilities (LTCF)
∙ Psychiatric residential treatment centers
Use 99324–99340 for reporting services to patients in locations where room, meals,
Basic Personal Services and basic personal services are provided, but medical services are not included:
Services that include washing/
bathing, dressing and undress-
∙ Assisted living facilities
ing, assistance in taking medi- ∙ Domiciliaries
cations, and assistance getting ∙ Rest homes
in and out of bed.
∙ Custodial care settings
∙ Alzheimer’s facilities

GUIDANCE EXAMPLE
CONNECTION Dr. Banks goes to see Peter Lister at the halfway house where he resides. Peter is
autistic, and Dr. Banks wants to examine him and adjust his medication for asthma.
Read the additional
You should report Dr. Banks’s visit to Peter with code 99334.
explanations in the
in-section guidelines
located within the
Evaluation and Man-
Care Plan Oversight Services
agement (E/M) section,
subhead Nursing Facil- When a physician provides care plan oversight services, you have to use the appro-
ity Services, directly priate code determined by the length of time involved and the type of facility in which
above code 99304 in the patient is located.
your CPT book. 99339–99340 for patients in assisted living or domiciliary facility
99374–99375 for home health care patients
99377–99378 for hospice patients
Care Plan Oversight Services
E/M of a patient, reported 99379–99380 for residents in a nursing facility—but only if the manage-
in 30-day periods, includ- ment of the patient involves repeated direction of therapy by the attending
ing infrequent supervision physician
CPT © 2017 American Medical Association. All rights reserved.
along with preencounter and
postencounter work, such
as reading test results and Admission to a Nursing Facility
assessment of notes. When a patient is admitted into a nursing facility as a continued part of an encounter
at the physician’s office or the emergency department (ED) (on the same day by the
same physician), you report only one code (from the Nursing Facility section of the
E/M codes) that will include all the services provided from all the locations on that
day. The admission to the hospital from the physician’s office or ED is reported all in
the one hospital admission E/M code. The same rule also applies to admission to a
nursing facility.
However, if the patient has been discharged from inpatient status on the same day
as being admitted to a nursing facility, you code the physician’s discharge services
separately from the admission.
Three key components, similar to other E/M codes, are used to determine the
­appropriate level of E/M service provided by the attending physician to a patient on

662   PART III  |  REPORTING PHYSICIAN SERVICES AND OUTPATIENT PROCEDURES

 the first day at a nursing facility. There is no differentiation made in this section of
codes between a new patient and an established patient.
Physicians use different methods and tools to assess a patient’s status and to create
and/or update an appropriate treatment plan for the ongoing care of the individual.
Such methods and tools include
∙ Resident assessment instrument (RAI)
∙ Minimum data set (MDS)
∙ Resident assessment protocols (RAP)

Subsequent Nursing Facility Care

Once the patient is in the facility, it is expected that the physician will continue to review
the patient’s chart, as well as assess test results and changes in the patient’s health status.
Notice that the code description for the history key component includes the term inter- Interval
val. The physician needs to evaluate the patient’s history only back to the last visit to The time measured between
gain a complete, up-to-date picture of the individual’s health. The continuing care type one point and another, such
of assessment is reported with the most appropriate code from the 99307–99310 range. as between physician visits.
If the physician does only an annual assessment of the patient in the nursing facility
(typically in cases where the patient is stable, progressing as expected, or recovering),
you use code
99318 Evaluation and management of a patient involving an
annual nursing facility assessment

CPT
LET’S CODE IT! SCENARIO
Mara Morietty, a 55-year-old female, was diagnosed with advanced pancreatic cancer and is being cared for at her
home by her family, with the help of a home health agency. Dr. Clarke is providing care plan oversight services for
the first month of care. The plan includes home oxygen, IV medications for pain control management, and diuretics
for edema and ascites control. Dr. Clarke also discusses end-of-life issues, living will directive, and other concerns
with the family, the nurse, and the social worker. Dr. Clarke includes documentation of his 45-minute assessment,
as well as notes on modifications to the care plan. Certifications of care from the nursing staff, the social worker, the
pharmacy, and the company supplying the durable medical equipment for support are also in the record.

Let’s Code It!

Dr. Clarke documented that he provided “care plan oversight services” for Mara Morietty. Turn to the Alphabetic
Index, and look up Care Plan Oversight Services. The index instructs you to see Physician Services. Turn to Phy-
sician Services, and you will see Care Plan Oversight Services.
As you look at the indented list below that phrase, note that you have to identify the location at which the
patient is being cared for. Mara is being cared for at home by a home health agency. This index entry suggests
CPT © 2017 American Medical Association. All rights reserved.

codes 99374 and 99375.

Physician services
Care Plan Oversight Services
     Home Health Agency Care. . . . . . . 99374, 99375

Now, let’s turn to code 99374 to read the entire code description:
99374 Physician supervision of a patient under care of home health agency (patient not
present) in home, domiciliary or equivalent environment requiring complex and multi-
disciplinary care modalities involving regular physician development and/or revision
of care plans; 15–29 minutes
99375   30 minutes or more
Dr. Clark’s notes report that he spent 45 minutes. Therefore, the correct code is 99375.

CHAPTER 23  | 
 GUIDANCE Case Management Services
CONNECTION If a patient has several or complex health issues or diagnoses, a team of health care
professionals may have to work together to provide proper management and treatment.
Read the additional The team may involve several physicians or the attending physician and a physical
explanations in the therapist, for example, conferencing together. To properly reimburse the health care
in-section guidelines professional for the time and expertise spent on the patient’s behalf with other profes-
located within the Evalu- sionals, you report such services using codes from ranges
ation and Management
(E/M) section, subheads 99366–99368 Medical Team Conferences
Case Management 99441–99443 Telephone Services
Services, directly above 99444 On-Line Medical Evaluation
code 99363, and Medi- 99446–99448 Interprofessional Telephone/Internet Consultations
cal Team Conferences,
directly above code
99366, in your CPT book.

CPT
YOU CODE IT! CASE STUDY
Scott Germain, an 81-year-old male, is still having pain and swelling in his hands. Dr. Daniels, an orthopedist, came
in to evaluate Scott 2 weeks ago, and Ira Hansrani’s last physical therapy session with Scott was yesterday.
Dr. Rubine, the gerontologist and primary care physician for Scott, reads the up-to-date notes and test results,
and sets up a meeting in the conference room with Ira Hansrani, the physical therapist, and Dr. Daniels to discuss
adjusting Scott’s therapy plan, based on current test results. The meeting lasts 45 minutes.

You Code It!

Go through the steps of coding, and determine the E/M code that should be reported for the encounter between
Dr. Rubine, Dr. Daniels, and Ira Hansrani.
Step #1: Read the case completely.
Step #2: Abstract the notes: Which key words can you identify relating to the E/M service performed?
Step #3: What is the location?
Step #4: Is this an “interdisciplinary team”?
Step #5: Is the patient or patient’s family present (on the call)?
Step #6: How long did the call last?
Step #7: Double-check your work.
Answer:
Did you determine these to be the correct codes? CPT © 2017 American Medical Association. All rights reserved.

Reported for Dr. Rubine:

99367 Medical team conference with interdisciplinary team, 30 minutes or more;
participation by physician
Reported for Dr. Daniels:
99367 Medical team conference with interdisciplinary team, 30 minutes or more;
participation by physician
Reported for Ira Hansrani, PT:
99368 Medical team conference with interdisciplinary team, 30 minutes or more;
participation by nonphysician qualified health care professional
Great work!

664   PART III  |  REPORTING PHYSICIAN SERVICES AND OUTPATIENT PROCEDURES

 Newborn and Pediatric E/M Care
CODING BITES
The E/M for a newborn or child may be performed by a neonatologist, pediatrician, or A newborn is described
other physician. This portion of the E/M section is divided into several parts: as a baby aged 28 days
old or younger.
Newborn Care
Determining the most accurate code in this subsection will require you to have two
essential pieces of information:
∙ Location: Hospital or birthing center, or other location. CODING BITES
∙ Initial or subsequent: Was this the first day of care for this newborn or the second/­ When a physician sees
additional day of care by this physician for this newborn? a newborn at an office
visit after seeing the
Note that these code descriptions report a day of E/M service, not just history/exam/
baby initially at the
MDM or even time spent.
hospital or other birth
location, the visit is
Delivery/Birthing Room Attendance and Resuscitation coded as an established
When requested by the delivering physician (most often the obstetrician), a neonatolo- patient visit (as long as
gist or pediatrician may need to be there in the delivery room to resuscitate and/or it is within 3 years, of
stabilize a baby immediately upon his or her birth. course).

EXAMPLE
Dr. Baldwin is a neonatologist. Dr. Matthews, an obstetrician, asked Dr. Baldwin to
be in attendance during the delivery of Anita Mescale’s baby because of a con-
cern over her excessive alcohol consumption during pregnancy. Dr. Baldwin was
there and stabilized the baby after birth. You would report Dr. Baldwin’s service
with code 99464.

Home Services
If a physician provides E/M services to a patient at his or her private residence, use
codes 99341–99350. Determine the most appropriate code by using the same key com-
ponents as those for E/M services provided in the physician’s office.
Some home health agencies employ physicians, some physicians may volunteer
to see homebound patients, while others visit only established patients who are
homebound.
When a health care professional other than the physician—such as a nurse or respi-
ratory therapist—cares for a patient at the patient’s home, report these services with a
CPT © 2017 American Medical Association. All rights reserved.

code from the range 99500–99602 in the Medicine section of CPT.

CPT
LET’S CODE IT! SCENARIO
Jules Paganto, a 39-year-old male, suffers from agoraphobia and cannot leave his home. Dr. Volente went to the
house to examine Jules because he was complaining of chest congestion. Dr. Volente took a problem-focused his-
tory, as this was the first time he had seen Jules. The doctor examined Jules’s HEENT and chest and concluded that
Jules had a chest cold. He told Jules to get some over-the-counter cold medicine and to call if the symptoms did not
go away within a week.

(continued)

CHAPTER 23  | 
 Let’s Code It!
You need to find the appropriate code to reimburse Dr. Volente for his E/M services to Jules Paganto. You know
that “Dr. Volente went to the house,” so the location section is titled Home Services. The notes say that “this
was the first time he had seen Jules,” meaning that Jules is a new patient, narrowing the choices to codes
99341–99345. The book tells us that a new patient home visit requires three key components: history, exami-
nation, and MDM. According to the notes, Dr. Volente
1.  Took a problem-focused history.
2. Examined the patient’s head, ears, eyes, nose, throat (HEENT), and chest: expanded problem-focused
because the doctor examined the affected body system and other related organ systems.
3. Concluded, without tests or additional resources: straightforward.
When you assess the levels and use the meet or exceed rule, the most accurate code for the visit is 99341.
Good job!

Non-Face-to-Face
Everyone is trying to work more efficiently by using the telephone or the Internet to
communicate with an established patient and/or the patient’s family, coordinate care,
discuss test results, or answer a question. This makes good sense.
To report E/M services provided by the physician over the telephone, a code from
the range 99441–99443 should be used. The different codes are distinguished by the
GUIDANCE
length of time of the call. However, before you report one of these codes, there are
CONNECTION restrictions. If the phone call is a follow-up to an E/M service provided for a related
Read additional expla- problem or concern that occurred within the previous 7 days, none of these codes can
nations in the in-section be reported because the phone call is considered part of that service. In the same light,
guidelines within if the phone call results in the decision for the patient to come in to see the physician
the Evaluation and as soon as possible, this phone call is considered a part of that future E/M service, so
­Management (E/M) one of these codes would not be used, either.
Services section, sub- Code 99444 is used to report an online E/M service to an established patient, a
head N­ on-Face-to-Face guardian, or a health care provider as a response to a patient’s question. Similar to
­Services, related to the restriction on the reporting of a telephone call, code 99444 should not be reported
codes 99441–99449 in when this e-mail or Internet communication is connected to an E/M service provided
your CPT book. for a related concern that occurred within the previous 7 days or within a surgical pro-
cedure’s postoperative period.

CPT © 2017 American Medical Association. All rights reserved.

ICD-10-CM
YOU CODE IT! CASE STUDY
Renay Miller, a 47-year-old female, had just seen the doctor during her annual physical 2 weeks earlier. Today she
phoned Dr. Reese to ask if she could travel out of the country, due to her condition. They spoke for about 7 minutes
regarding recommended precautions.

You Code It!

Go through the steps of coding, and determine the E/M code that should be reported for the encounter between
Dr. Reese and Renay Miller.
Step #1: Read the case completely.
Step #2: Abstract the notes: Which key words can you identify relating to the E/M service performed?
Step #3: What is the location?

666   PART III  |  REPORTING PHYSICIAN SERVICES AND OUTPATIENT PROCEDURES

 Step #4: Is this an “face-to-face” or “non-face-to-face” call?
Step #5: How long did the call last?
Step #6: Double-check your work.
Answer:
Did you determine this to be the correct code?
99441  Telephone evaluation and management service by a physician . . . provided to an established
patient . . . ; 5–10 minutes of medical discussion

23.5  Preventive Medicine Services

There may be times when the physician’s notes do not clearly identify all the individ-
ual components (for instance, history, exam, and medical decision making [MDM]) of
an encounter, such as when a patient comes in for an annual physical. In these cases,
you should be careful not to force the components or make them up. Instead, you
should look at other areas of the E/M section. For example, the Preventive Medicine
section, codes 99381–99429, may be more appropriate.
When provided at the same time as a comprehensive preventive medical examina-
tion, preventive medicine service codes 99381–99397 include
∙ Counseling
∙ Anticipatory guidance Anticipatory Guidance
∙ Risk factor reduction interventions Recommendations for behav-
ior modification and/or other
In regard to these preventive evaluations, the term counseling does not refer to a for- preventive measures.
malized relationship between a mental health counselor, psychologist, or psychiatrist
Risk Factor Reduction
but to the advice and guidance provided by a health care professional to his or her
Intervention
patient. From your own personal experience, you may be familiar with discussions Action taken by the attending
with your physician during your annual physical. The talks cover everything from physician to stop or reduce
quitting smoking to exercising more and perhaps having a better diet. These are all a behavior or lifestyle that
examples of counseling. is predicted to have a nega-
Anticipatory guidance refers to the physician’s offering suggestions for behavior tive effect on the individual’s
modification or other preventive measures related to a patient’s high risk for a condi- health.
tion. The concern may be based on specifics in a patient’s condition or history (or
perhaps a family history or an occupational hazard).
CPT © 2017 American Medical Association. All rights reserved.

EXAMPLE
Dr. Herbert provides anticipatory guidance to Kenneth Simons with regard to
being careful about protecting his respiratory health. Kenneth works at an auto-
mobile paint shop, and the fumes are very dangerous if a breathing mask is not
worn.

A physician prescribing a patch to help a patient quit smoking or referring a patient

to a registered dietitian to help him or her with a new diet—each of these is considered
a risk factor reduction intervention. It means the physician is taking action to intervene
with, or help stop, patient behaviors that put the patient at a higher risk for certain
­illnesses or conditions.

CHAPTER 23  | 
 Specific Preventive Medicine codes are determined first by New Patient or
­Established Patient, and second by the patient’s age:
∙ Infant (age younger than 1 year)
∙ Early childhood (age 1 through 4 years)
∙ Late childhood (age 5 through 11 years)
∙ Adolescent (age 12 through 17 years)
∙ 18–39 years
∙ 40–64 years
∙ 65 years and older
You may be familiar with the standards of care that have physicians check different
parts of the body in different ways, determined by the patient’s age, such as:
∙ Behavioral assessments for children ages 0 to 11 months, 1 to 4 years, 5 to 10 years,
11 to 14 years, and 15 to 17 years.
∙ Hearing screening for all newborns.
∙ Diabetes (type 2) screening for adults with high blood pressure.
If elements such as risk factor reduction intervention or counseling occur during
a separate visit (not at the same time as the physical examination), you have to code
them separately with a code from the 99401–99412 range.
If, during the course of the preventive medicine examination, the physician finds
something of concern that warrants special and extra attention involving the key com-
ponents of a problem-oriented E/M service, the extra work should be coded with a
separate E/M code appended with modifier 25. It is applicable only when the same
physician does the extra service on the same date.

CPT
LET’S CODE IT! SCENARIO
Kensie Hamilton, a 47-year-old female, comes to see her regular physician, Dr. Granger, for her annual physical. Dur-
ing the examination, Dr. Granger finds a mass in her abdomen that concerns him. After the exam, he sits and talks
with Kensie about past or current problems with her abdomen, including pain, discomfort, and other details regard-
ing her abdominal issue. He asks whether any family members have had problems in that area, as well as about
her alcohol consumption and sexual history as they relate to this concern. Dr. Granger then goes into his office to
analyze the multiple possibilities of diagnoses, evaluates the information in Kensie’s chart, and reviews the moder-
ate risk of complications that might occur due to her current list of medications. He orders an abdominal CT scan,
blood work, and a UA for further input.

Let’s Code It! CPT © 2017 American Medical Association. All rights reserved.

According to the notes, Dr. Granger performed an “annual physical exam,” also known as a preventive medicine
exam, on Kensie, a “47-year-old.” Go to the Alphabetic Index and look up Evaluation and Management, Preventive
Services, or go directly to the E/M section and look for the Preventive Medicine Services subheading. The phrase
“her regular physician” reveals that Kensie is an established patient, helping you to determine to report code
99396 Periodic comprehensive preventive medicine, established patient, 40–64 years
Dr. Granger’s notes also reveal that during the exam he found a mass in Kensie’s abdomen that he felt needed
further investigation. He spent additional time getting details about her personal, family, and social history
regarding abdominal problems; he reviewed concerns about multiple possible diagnoses, complications, and
treatments. As per the guidelines, this is extra work done on Dr. Granger’s part, and therefore he is entitled to
additional reimbursement, reported with a separate E/M code. As you review the notes, you should be able to

668   PART III  |  REPORTING PHYSICIAN SERVICES AND OUTPATIENT PROCEDURES

 determine the best, most appropriate E/M code for the additional service. Dr. Granger did a comprehensive
examination, and his MDM was certainly at a high level of complexity, leading you to the code
99215 Office or other outpatient visit with comprehensive exam and
medical decision making of high complexity
plus this modifier:
-25 Significant, separately identifiable evaluation and management service
The claim form for Dr. Granger’s encounter with Kensie will show 99396 and 99215-25. Good job!
Code 99396 will reimburse Dr. Granger for his time and services for the annual physical, and code 99215
will reimburse him for the extra work he did regarding the abdominal mass. The modifier -25 explains that, while
unusual, Dr. Granger did both of these services at the same encounter.
(Note: More information on E/M modifiers is provided later in this chapter.)

GUIDANCE
23.6  Abstracting the Physician’s Notes CONNECTION
You learned about abstracting clinical documentation in the chapter Abstracting Read additional explana-
Clinical Documentation. Abstracting for details regarding evaluation and manage- tions in the in-section
ment (E/M) is a bit different because you have to cull out details about the physi- guidelines located
cian’s thought processes, in addition to specifically what was done and why. Very within the Evaluation
rarely will physicians actually identify the level of MDM in their notes with a state- and ­Management (E/M)
ment such as “MDM was low complexity.” So, you really need to hone your inter- ­section, subhead Preven-
pretative skills. tive Medicine Services,
directly above code
99381 in your CPT book.

CPT
YOU CODE IT! CASE STUDY
Gloria Merro, a 33-year-old female, comes to see Dr. Feldner at his office with complaints of severe pain in her right
wrist and forearm. She just moved to the area, and this is the first time Dr. Feldner has seen her. Gloria sees Dr. Feldner
for a very specific concern. The doctor asks Gloria about any medical history she may have related to her arm
­(diagnosed osteoporosis, previous broken bones, etc.). Next, Dr. Feldner examines Gloria’s arm. He suspects that the
arm is broken and orders an x-ray to be taken.

You Code It!

Go through the steps to determine the E/M code that should be reported for this encounter between Dr. Feldner
CPT © 2017 American Medical Association. All rights reserved.

and Gloria Merro.

Step #1: Read the case completely.
Step #2: Abstract the notes: Which key words can you identify relating to the E/M service performed?
Step #3: What is the location?
Step #4: What is the relationship?
Step #5: What level of patient history was taken?
Step #6: What level of physical examination was performed?
Step #7: What level of MDM was required?
Step #8: What is the most accurate E/M code for this encounter?
Step #9: Double-check your work.
(continued)

CHAPTER 23  | 
 Answer:
Did you determine this to be the correct code?
99201 Office or other outpatient visit, new patient
Let’s carefully review the physician’s notes.
• Where did the encounter occur? Gloria went “to see Dr. Feldner at his office.” This will lead us to the first sub-
heading in the E/M section, Office or Other Outpatient Services.
• What is the relationship? The notes state, “She just moved to the area, and this is the first time Dr. Feldner has
seen her.” This brings us to the category of New Patient, and the code range 99201–99205.
• What is the level of history? The notes state, “The doctor asks Gloria about any medical history she may have
related to her arm,” meaning that all the history he took was problem-focused.
• What is the level of exam? You will see that “Dr. Feldner examines Gloria’s arm.” This means only one body
area (each extremity) or one organ system (musculoskeletal) was examined. That’s problem-focused.
• What is the level of MDM? In this case, did you analyze the situation and determine that the MDM was straight-
forward? However, you can see that the documentation supports the definition of this level: There is only
one diagnosis, the management options are limited (put a cast on it), there are very few complications, and
Dr. Feldner didn’t really have to do any research to recommend a course of treatment.
This brings you to the best, most appropriate E/M code: 99201.

Please understand that the physicians will not come right out and use the same
words as the code descriptions to describe what occurred during the encounter. Let’s
inspect various statements from patients’ charts and identify the key words that lead to
the correct E/M code.
1. George Semple, a 57-year-old male, was seen for the first time by Dr. Brieo in the
office for a contusion of his hand. Dr. Brieo asked questions about the bruise on
George’s hand and examined his hand thoroughly.
a. Location: Office tells us where the encounter took place.
b. Relationship: First time tells us this is a new patient.
c. Key components: History—problem-focused, physical examination—­problem-
focused, medical decision making—straightforward. Therefore, the correct
code is 99201.
2. Dr. Fein performed an initial observation at the hospital of Lois Martin, a 31-year-old
female. After asking about her personal medical history, including pertinent history
of stomach problems, digestive problems, and pertinent family and social history

CPT © 2017 American Medical Association. All rights reserved.

directly relating to her complaints, he examined Lois’s abdomen, chest, neck, and
back, which revealed lower right quadrant pain accompanied by nausea, vomiting,
and a low-grade fever. Dr. Fein made the straightforward decision to admit Lois
overnight to the hospital to rule out appendicitis.
a. Location: Initial observation at the hospital tells us this code is in the Hospital
Observation Services section.
b. Relationship: Observation at the hospital codes are the same for both new and
established patients.
c. Key components: History—detailed, physical examination—detailed, medical
decision making—straightforward, and overnight admission to the hospital all
lead us to the correct code of 99218.
3. Dr. Murphy, a general surgeon, saw Teena Harrison, a 46-year-old female, in her
office for a second opinion requested by Teena’s gynecologist, Dr. Enterez, regarding
a lump in her right breast. Dr. Murphy took a brief history of Teena’s present illness

670   PART III  |  REPORTING PHYSICIAN SERVICES AND OUTPATIENT PROCEDURES

 and a personal and family medical history relating to her hematologic and lymphatic
system, which was positive for breast cancer on her maternal side. After reviewing
the mammogram and performing a limited physical exam of her breasts and chest
area, the physician made the straightforward decision to advise a lumpectomy.
a. Location: In her office tells us where the encounter took place.
b. Relationship: Second opinion requested by a physician tells us this is a
consultation.
c. Key components: History—expanded problem-focused, physical examination—
expanded problem-focused, and medical decision making—straightforward lead
us directly to the correct code of 99242.
4. David Emerson, a 17-year-old male, presented at the ED with a painful, swollen
wrist. The patient stated he had been hurt at a softball game. Dr. Lubner took a brief
history and asked some key questions about David’s arm/hand. He then examined
David’s wrist and arm, checked his musculoskeletal system, and ordered x-rays to be
taken. It was rather simple to determine that David’s diagnosis was a sprained wrist.
a. Location: ED tells you the location.
b. Relationship: Codes in the Emergency Department Services section do not dif-
ferentiate between new and established patients.
c. Key components: History—expanded problem-focused, physical examination—
expanded problem-focused, and medical decision making—low complexity tell
us the extent of the encounter. The correct code is 99282.

23.7  E/M in the Global Surgical Package

As a part of the standard of care, there are certain E/M encounters that are already
included in the code for a surgical procedure. This is called the global surgical Global Surgical Package
­package. Specific details about this will be included in the CPT Surgery Section A group of services already
chapter. For now, let’s skip to the time frame, after the procedure is over and the included in the code for the
patient is discharged. operation and not reported
You are probably familiar with this: A patient is being discharged after a proce- separately.
dure, and the physician says, “I want to see you in my office in a week.” A physician
gets paid for performing surgery and for the time spent checking on the patient after
the surgery to make certain the body is healing correctly. When the follow-up visit in
the office (or wherever) occurs, you will not report this by using a regular E/M code
because the physician will not be paid separately. However, you do need to report that
this encounter occurred. Therefore, you will report a special services code from the
Medicine section of the CPT book. Take a look at this code:
99024 Postoperative follow-up visit, normally included in the surgi-
cal package to indicate that an evaluation and management
CPT © 2017 American Medical Association. All rights reserved.

service was performed during a postoperative period for a

reason(s) related to the original procedure

CHAPTER 23  | 
 CPT
YOU CODE IT! CASE STUDY
Ten days after Dr. Rollins performed a carpal tunnel revision on Nicole Letchin’s left hand, Nicole, a 23-year-old
female, came to see him in his office, as instructed when he discharged her. He asked how she was feeling, checked
the flexibility of the wrist, removed the stitches, and checked the healing of the incision. She was doing fine, so
Dr. Rollins told her to come in only if she needed anything.

You Code It!

Go through the steps of coding, and determine the E/M code that should be reported for the encounter between
Dr. Rollins and Nicole Letchin.
Step #1: Read the case completely.
Step #2: Abstract the notes: Which key words can you identify relating to the E/M service performed?
Step #3: What is the location?
Step #4: What is the relationship?
Step #5: Is this E/M service already included in the global surgical package?
Step #6: What is the most accurate E/M code for this encounter?
Step #7: Double-check your work.
Answer:

Did you determine this to be the correct code?

99024 Postoperative follow-up visit, normally included in the surgical package . . .
I knew you could do it!

23.8  E/M Modifiers and Add-On Codes

Several modifiers may be used in conjunction with an E/M code to provide additional
information about an encounter. Each modifier specifically explains an unusual cir-
cumstance that may justify the payment to the provider and helps you avoid having
to appeal a denied claim later on. CPT Level I modifiers are two-digit codes that are
listed in Appendix A of the CPT book. You first learned about these modifiers in the
chapter CPT and HCPCS Level II Modifiers in this textbook.
Open your CPT book to Appendix A and read along as we review some of these
CPT © 2017 American Medical Association. All rights reserved.
modifiers.
24 Unrelated evaluation and management service by the same physician dur-
ing a postoperative period. The physician may need to indicate that an evalu-
ation and management service was performed during a postoperative period
for a reason(s) unrelated to the original procedure. This circumstance may be
reported by adding modifier 24 to the appropriate level of E/M service.
As a part of the standard of care and the global surgical package, a physician gets paid
for performing surgery and for the time spent checking on the patient after the surgery to
make certain the body is healing correctly. Modifier 24 would explain that the physician
had to see the patient about a totally different concern during this time period.

672   PART III  |  REPORTING PHYSICIAN SERVICES AND OUTPATIENT PROCEDURES

 CPT
YOU CODE IT! CASE STUDY
Dr. Marple removed Christen Ellison’s gallbladder (cholecystectomy) on February 27. The global period for this
surgical procedure is 90 days. On March 15, Christen came to see Dr. Marple because he had been out in his garden
and developed a rash on his arms. The physician examined Christen’s arms and gave him an ointment for the rash.

You Code It!

Go through the steps of coding, and determine the E/M code that should be reported for the encounter between
Dr. Marple and Christen Ellison.
Step #1: Read the case completely.
Step #2: Abstract the notes: Which key words can you identify relating to the E/M service performed?
Step #3: What is the location?
Step #4: What is the relationship?
Step #5: What level of patient history was taken?
Step #6: What level of physical examination was performed?
Step #7: What level of MDM was required?
Step #8: What is the most accurate E/M code for this encounter?
Step #9: Do you need to clarify any detail or explain something with a modifier?
Step #10: Double-check your work.
Answer:
Did you determine the correct code to be 99212-24? Good for you!
Christen came to see Dr. Marple, meaning the encounter happened at the doctor’s office. Considering that
Dr. Marple just performed surgery on Christen 2 weeks ago, it is very reasonable to consider Christen an estab-
lished patient. Dr. Marple did a problem-focused examination (limited exam of the problem area) and his deci-
sion making was straightforward. This directs us to code 99212.
Ninety days from February 27 goes all the way to May 27. That means the visit for the rash, which is a
concern totally unrelated to the gallbladder surgery, occurred within the 90-day period. We must explain that
Dr. Marple should be compensated separately for the encounter because it has nothing to do with the surgery.
So our code will be 99212-24.

25 Significant, separately identifiable evaluation and management service

CPT © 2017 American Medical Association. All rights reserved.

by the same physician on the same day of the procedure of other ser-
vice. It may be necessary to indicate that on the day a procedure or service
identified by a CPT code was performed, the patient’s condition required a
significant, separately identifiable E/M service above and beyond the other
service provided or beyond the usual preoperative and postoperative care
associated with the procedure that was performed. A significant, separately
identifiable E/M service is defined or substantiated by documentation that
satisfies the relevant criteria for the respective E/M service to be reported.
The E/M service may be prompted by the symptom or condition for which
the procedure and/or service was provided. As such, different diagnoses
are not required for reporting of the E/M services on the same date. This
circumstance may be reported by adding modifier 25 to the appropriate
level of E/M service. Note: This modifier is not used to report an E/M ser-
vice that resulted in a decision to perform surgery. See modifier 57. For
significant, separately identifiable non-E/M services, see modifier 59.

CHAPTER 23  | 
 CODING BITES
In order for modifier 25 to be used correctly, it is best if the E/M code links or
relates to a different diagnosis from the procedure performed that day. So there
would be at least two diagnosis codes on the same claim form before you con-
sider using this modifier. Although different diagnoses are not required, there is
concern in the industry about overuse of modifier 25, so this may trigger an audit
without a separately identifiable diagnosis.

Certainly this happens quite frequently: A patient goes to see the doctor for a minor
procedure in the office. Then the patient says, “Oh, Doc, while I’m here, I want to talk
to you about . . . .” Should that happen, you have to append the E/M code with modi-
fier 25 to explain that there were two visits in one at this encounter.

CPT
LET’S CODE IT! SCENARIO
Gladys Topfer goes to see her dermatologist for a scheduled appointment to have a 1.5-cm mole removed from her
cheek. Once Dr. Assanti completes the procedure, Gladys asks the doctor to look at a cyst that has developed under
her arm. Dr. Assanti discusses the presence of the cyst with her (How long has it been there? Does it hurt? etc.), and
then he examines her underarm area and determines that the best course of action is to wait and see what happens
with the cyst. He advises Gladys to keep the area clean and to come back in 3 weeks if the cyst has not gone away.

Let’s Code It!

Gladys met with her dermatologist (documenting that she is an established patient), Dr. Assanti, at his office
(identifying an outpatient location). The notes document that Dr. Assanti did a problem-focused history (because
they discussed nothing else other than the cyst) and a problem-focused examination (because Dr. Assanti exam-
ined only the area where the cyst is located), and his decision making was straightforward (because he is very
knowledgeable about cysts and Gladys has no other conditions or medications that would cause more evalua-
tion). This directs you to code 99212.
But wait! The claim for this encounter is going to include the code for the surgical removal of the mole—a
totally different concern from the reason prompting the E/M of the patient. In essence, there were two encoun-
ters in one: the first for the removal of the mole and the second for the concern about the cyst. Therefore, the
correct code would be 99212-25 (plus the procedure code for the excision of the mole: CPT code 11312).

32 Mandated services: Services related to mandated consultation and/or

CODING BITES
CPT © 2017 American Medical Association. All rights reserved.
related services (e.g., third-party payer, governmental, legislative, or regu-
Modifier 32 can be used latory requirement) may be identified by adding modifier 32 to the basic
with both E/M codes procedure.
and procedure or treat-
ment codes. Modifier 32 indicates that a third-party payer, a governmental agency, or other regula-
tory or legislative action required the encounter, consultation, and/or procedure(s).

CPT
LET’S CODE IT! SCENARIO
Alene Morgen, a 49-year-old female, went to see Dr. Blume for a comprehensive physical assessment, as a require-
ment for her special coverage application. The insurance carrier would not consider the policy without the examina-
tion. She had never seen Dr. Blume before today’s visit.

674   PART III  |  REPORTING PHYSICIAN SERVICES AND OUTPATIENT PROCEDURES

 Let’s Code It!
Alene met with the physician at his office and had never seen Dr. Blume before, meaning that she is a new
patient. According to the notes, Dr. Blume did an initial comprehensive preventive medicine E/M of a 49-year-old
female. That directs you to code 99386.
Notice that the insurance carrier, a third-party payer, mandated the evaluation. Therefore, you must add the
modifier to the E/M code to get 99386-32 to explain this fact.

57 Decision for surgery. An evaluation and management service that

resulted in the initial decision to perform the surgery may be identified
by adding modifier 57 to the appropriate level of E/M service.
Documentation of an encounter may start off with the discussion between physician
and patient about test results and treatment options. If the two (physician and patient)
agree that a surgical procedure should be scheduled, then the E/M code should be
appended with modifier 57.

CPT
LET’S CODE IT! SCENARIO
Dr. Richards referred Timothy Dunne, a 67-year-old male, to Dr. Eliot for a consultation to determine whether he
needs a prostatectomy. After taking a comprehensive history, performing a comprehensive examination, and review-
ing all the previous test results, Dr. Eliot informs Timothy that he recommends the procedure. Timothy agrees, and
they select a date the following week for the surgery to be performed.

Let’s Code It!

Timothy met with Dr. Eliot at his office at the request of Dr. Richards for a consultation. According to the docu-
mentation, Dr. Eliot did a comprehensive history and a comprehensive examination. His medical decision making
was of moderate complexity. This directs you to code 99244. BUT this encounter ended in Timothy’s decision to
have Dr. Eliot perform the surgery. As you learned earlier in this chapter, this means there has been a transfer of
care in addition to the decision for surgery. Therefore, you must add the modifier 57 to the E/M code for a new
patient office visit: 99204-57.

Prolonged Services: 99354–99359

In some cases, patients require greater than the usual amount of attention from a phy-
sician, more time than would regularly be spent—either face-to-face or without direct GUIDANCE
contact—over the course of 1 day. CONNECTION
Prolonged service codes report E/M services that are at least 30 minutes longer than
CPT © 2017 American Medical Association. All rights reserved.

the amount of time represented by standard E/M codes. These codes may be reported Read the additional
in addition to standard E/M codes at any level, as appropriate. explanations in the
To determine the best, most appropriate code from this subcategory, you have to in-section guidelines
calculate the total number of minutes that the physician spent with, or on behalf of, the located within the Evalu-
patient, during one date of service. The codes will be calculated as follows: ation and ­Management
(E/M) section, subhead
∙ The first code would be the standard evaluation and management code (such as 99213). Prolonged Services,
∙ Then, depending upon how long the physician spent with the patient, you would directly above code
also report code . . . 99354 in your CPT book.
99354 or 99356 for the time spent lasting at least 30 minutes over the standard
evaluation and management service and includes time spent up to 74 minutes.
99355 or 99357 for each 30 minutes additionally spent, over the 74 minutes
reported by 99354 or 99356, until the total amount of time spent by the physi-
cian is represented.

CHAPTER 23  | 
 CODING BITES EXAMPLE
When the health care Dr. Alfredo spent a total of 2 hours, in his office, with Mona Catzer working with her
provider has spent more to stabilize her diabetes mellitus. The codes used to report this E/M encounter are
than the standard time
 99214 Office visit, established patient, detailed 25 min.
but less than 30 minutes
99354 Prolonged physician service in the office; first hour 60 min.
with the patient, it is not
99355   additional 30 minutes 30 min.
reported separately.
TOTAL 115 min

23.9  Special Evaluation Services

In cases when a patient is about to have a life insurance or disability certificate
issued, the insurer often requires the attending physician to provide an evaluation to
establish a baseline of data. The visit does not involve any actual treatment or man-
agement of the patient’s condition—it accounts for the time to create the appropriate
documentation. The codes in range 99450–99456 apply to both new and established
patients.
The three codes within this subsection are very specific as to which services are
included:
99450 Basic life and/or disability examination that includes:
∙ Measurement of height, weight, and blood pressure;
∙ Completion of a medical history following a life insurance pro forma;
∙ Collection of blood sample and/or urinalysis complying with “chain of
custody” protocols; and
∙ Completion of necessary documentation/certificates.
99455 Work related or medical disability examination by the treating physician
that includes:
∙ Completion of a medical history commensurate with the patient’s
condition;
∙ Performance of an examination commensurate with the patient’s condition;
∙ Formulation of a diagnosis, assessment of capabilities and stability, and
calculation of impairment;
∙ Development of future medical treatment plan; and
∙ Completion of necessary documentation/certificate and report.
99456 Work related or medical disability examination by other than the treating

CPT © 2017 American Medical Association. All rights reserved.

physician that includes:
CODING BITES ∙ Completion of a medical history commensurate with the patient’s condition;
Be aware of codes ∙ Performance of an examination commensurate with the patient’s condition;
99000–99091 in the ∙ Formulation of a diagnosis, assessment of capabilities and stability, and
Special Services, Pro- calculation of impairment;
cedures and Reports ∙ Development of future medical treatment plan; and
subsection of the
∙ Completion of necessary documentation/certificate and report.
Medicine section of
CPT—most specifically Be aware of the notation beneath code 99456:
99080. Read the notes
(Do not report 99455, 99456 in conjunction with 99080 for the completion of
carefully, as well as
Workman’s Compensation forms)
the descriptions of the
codes, to choose the 99080 Special reports such as insurance forms, more than the infor-
most accurate. mation conveyed in the usual medical communications or
standard reporting form

676   PART III  |  REPORTING PHYSICIAN SERVICES AND OUTPATIENT PROCEDURES

 23.10  Coordination and Management Services
Complex Chronic Care Coordination Services
Patients with chronic illnesses, such as diabetes mellitus or hypertension, need more
attention from their health care team. Code 99487 represents the first hour of clini- GUIDANCE
cal staff time for complex chronic care coordination directed by a physician or other CONNECTION
qualified health care professional with no face-to-face time. Code 99488 is used for a
face-to-face visit, and code 99489 is an add-on code for each additional 30 minutes of Read the additional
complex chronic care coordination. explanations in the
Numerous studies have proven that patients with chronic illnesses and conditions in-section guidelines
benefit from coordinated care across the many disciplines of physicians and other mem- located within the
bers of the clinical staff in addition to community service agencies. This specific subset Evaluation and Man-
of E/M codes focuses on support services and management of care provided to patients agement (E/M) sec-
who are living in their own homes, domiciliaries, rest homes, or assisted living facilities. tion, subhead Complex
These services are provided to patients who Chronic Care Manage-
ment Services, directly
∙ Require repeated hospital admissions or ED visits. above code 99487 in
∙ Are diagnosed with one or more chronic continuous or episodic medical and/or your CPT book.
psychiatric conditions lasting at least 1 year (12 months).
∙ Are at significant risk of death, acute exacerbation, decompensation, and/or func-
tional decline.
∙ Require continuing care from multiple health care specialties that need to be coor-
dinated for efficacy and efficiency of medical conditions, psychosocial conditions,
and activities of daily living (ADL).
∙ Require moderate or highly complex medical decision making during treatment.
Physicians and other qualified health care professionals must implement a docu-
mented care plan to coordinate multiple disciplines and agencies, which is shared with
the patient and/or family or caregiver.
With all of the services and activities involved with the care of a chronically ill
patient, CPT has specifically identified those services characteristically reported by
these codes, including
∙ Developing and maintaining a comprehensive care plan.
∙ Facilitating access to care and services needed by the patient and/or family.
∙ Assessing and supporting patient compliance with the treatment plan, including
schedule of medication.
∙ Educating the patient, family, and/or caregiver to enable and support self-management,
independent living, and ADL.
∙ Identifying community and health care resources available to the patient and/or
family.
CPT © 2017 American Medical Association. All rights reserved.

∙ Communicating with home health agencies and other community services available
and used by the patient.
∙ Communicating aspects of care to the patient, family, and/or caregiver.
∙ Collecting health outcomes data and registry documentation.
Services identified by code 99487 overlap longstanding E/M codes. Therefore, when
reporting 99487, (to set off clause) do not separately report the following:
∙ Care plan oversight services (CPT codes 99339, 99340, 99374–99378)
∙ Prolonged services without direct patient contact (99358, 99359)
∙ Anticoagulant management (99363, 99364)
∙ Medical team conferences (99366–99368)
∙ Education and training (98966–98968, 99441–99443)
∙ Online medical evaluation (98969, 99444)

CHAPTER 23  | 
 ∙ Preparation of special reports (99080)
∙ Analysis of data (99090, 99091)
∙ Transitional care management services (99495, 99496)
∙ Medication therapy management services (99605–99607)
Code 99487 should not be reported separately, nor should it include the time spent
when reporting the following:
∙ End-stage renal disease services (ESRD) (90951–90970) during the same month
∙ Postoperative care services during the global period
∙ E/M services (99211–99215, 99334–99337, 99347–99350)
∙ E/M services while patient is an inpatient or in observation (99217–99239,
99241–99255, 99291–99318)
∙ Transitional care management services (99495, 99496)
As you can see, 99487 would be reported only once per month by the physician or
health care professional who has taken on the role of coordinator for this patient for the
first 60–89 minutes of services.
Add-on code 99489 can be reported in conjunction with either 99487 to represent
time greater than 89 minutes during the month.

Transitional Care Management Services

GUIDANCE It can be a complex event to transfer the care and management of a patient’s ongoing
condition from one facility to another, especially when the new location will involve
CONNECTION a new care team. Code 99495 (transitional care management services) requires the
Read the additional physician to document the following elements:
explanations in the
∙ Communication (direct contact, telephone, electronic) with the patient and/or care-
in-section guidelines
giver within 2 business days of discharge.
located within the
Evaluation and Man- ∙ Medical decision making of at least moderate complexity during the service
agement (E/M) section, period.
subhead Transitional ∙ Face-to-face visit within 14 calendar days of discharge.
Care Management
Services, directly above
Code 99496 (transitional care management services) requires the following elements:
code 99495 in your ∙ Communication (direct contact, telephone, electronic) with the patient and/or care-
CPT book. giver within 2 business days of discharge.
∙ Medical decision making of high complexity during the service period.
∙ Face-to-face visit within 7 calendar days of discharge.

CPT © 2017 American Medical Association. All rights reserved.

Providers are often concerned that patients with multiple medical and/or psychoso-
cial issues may “slip through the cracks” when transferred from inpatient status to the
care of an assisted living facility, a domiciliary, or the patient’s own home. These two
codes provide an effective way to report the provision of these services to an estab-
lished patient by the physician or other qualified health care professional or licensed
clinical staff member under direction of the physician.
Transitional care management (TCM) includes one episode of face-to-face
­contact along with non-face-to-face services provided by the physician and clini-
cal staff. The period of TCM service begins on the date of discharge and runs for
29 consecutive days.
Within 48 hours (2 days) after discharge, the first TCM interactive contact between
the reporting physician and the patient must occur. This contact may be face-to-face,
over the telephone, or by use of electronic communication. The contact must encom-
pass the professional’s ability to promptly act upon patient needs and go beyond ­simply
scheduling follow-up care.

678   PART III  |  REPORTING PHYSICIAN SERVICES AND OUTPATIENT PROCEDURES

 When the provider documents two or more attempted contacts within the prescribed
time period and is unable to connect with the patient, family, and/or caregiver, the pro-
vider may still report TCM services as long as the other transitional care management
criteria have been met.
Reporting either of the two TCM codes requires at least one face-to-face visit, as
well as reconciliation of prescribed medication, with the patient. For patients requiring
highly complex medical decision-making services, the provider must meet with the
patient face-to-face within the first 7 calendar days after the patient is discharged from
inpatient status.
For patients requiring a moderate level of medical decision making, the first f­ ace-to-face
visit must occur during the first 14 calendar days of discharge. This first patient contact
is included in the TCM code and not reported separately. However, any additional E/M
services provided afterwards may be reported with a separate E/M code accordingly.
The CPT guidelines include specific services by the physician or other health care
professional included in TCM, as well as services provided by clinical staff under the
direction of that physician.
Services provided by the physician or other qualified health care professional include
∙ Obtaining and reviewing the discharge information.
∙ Reviewing the need for or follow-up on pending diagnostic tests and treatments.
∙ Educating the patient, family, and/or caregiver.
∙ Establishing (or reestablishing) referrals.
∙ Arranging for required community resources.
∙ Assisting in scheduling any required follow-up with community providers and
services.
∙ Interacting with other qualified health care professionals who will assume (or reas-
sume) care of the patient’s system-specific problems.
Services provided by clinical staff under the direction of the physician include
∙ Communicating about various aspects of care with the patient, family, caregiver,
and/or other professionals.
∙ Identifying available community and health resources.
∙ Assessing and supporting compliance with the treatment plan, including medica-
tion management.
∙ Communicating with home health agencies and other community services used by
the patient.
∙ Educating the patient, family, and/or caregiver to support self-management, inde-
pendent living, and ADL.
∙ Facilitating access to care and services required by the patient, family, and/or caregiver.
When reporting 99495 or 99496, do not separately report the following:
CPT © 2017 American Medical Association. All rights reserved.

∙ Care plan oversight services (CPT codes 99339, 99340, 99374–99380).

∙ Prolonged services without direct patient contact (99358, 99359).
∙ Anticoagulant management (99363, 99364).
∙ Medical team conferences (99366–99368).
∙ Education and training (98960–98962, 99071, 99078).
∙ Telephone services (98966–98968, 99441–99443).
∙ ESRD services (90951–90970). End-Stage Renal Disease
∙ Online medical evaluation (98969, 99444). (ESRD)
Chronic, irreversible kidney
∙ Preparation of special reports (99080). disease requiring regular
∙ Analysis of data (99090, 99091). treatments.
∙ Complex chronic care coordination services (99487–99489).
∙ Medication therapy management services (99605–99607).

CHAPTER 23  | 
 TCM may be reported only once within 30 days of discharge by only one health
care professional, even if there is a subsequent discharge within that time. This profes-
sional is permitted to report hospital or observation discharge services concurrently
with TCM services, but not within the global period of postoperative care.

Cognitive Assessment, Psychiatric Collaborative, and

General Behavioral Health Integration Care Management
Services
Health care professionals have gained greater understanding about those who may
benefit from cognitive, mental, or behavioral support. With this in mind, the 2018
CPT code set provides new codes for reporting these services from the appropriate
professionals:
99483 Assessment of and care planning for a patient with cognitive impairment
99492 Initial psychiatric collaborative care management
99493 Subsequent psychiatric collaborative care management
99494 Initial or subsequent psychiatric collaborative care management, each add’
l 30 mins
99484 Care management services for behavioral health conditions

Chapter Summary
Evaluation and management (E/M) codes report the energy and knowledge a health
care professional puts into gathering information, reviewing data, and determining the
best course of treatment for the patient’s current condition. Many health information
management professionals find these difficult to correctly determine due to the com-
plex formula of such codes. Don’t become overwhelmed. Once you get a job, you will
find that a particular portion of this section will become your main focus.

EXAMPLE
• If you work for a provider in a private medical office, most of your E/M codes will
be found under the Office heading on the first two pages of the section.
• If you work for a physician who cares for patients at a skilled nursing facility, you
will use codes from under the Nursing Facility Services heading.

So in the real world, most of the time, you will be using the same small set of codes
over and over again. But because you don’t know where you will be working in the

CPT © 2017 American Medical Association. All rights reserved.

future, you should learn the entire section.
In this chapter you learned that, for the key components of coding for services
rendered in a nursing home, a long-term care facility, or the patient’s home, you use a
different set of codes from those reporting physician services in an office or a hospital.
Understand that the elements of the distinct types of encounters, such as annual
physicals (preventive medical assessments) and case management services, also use
varying sets of parameters.
Your job as a professional coding specialist is to understand the variety of essentials
involved in coding E/M services properly and to report those services accurately.

680   PART III  |  REPORTING PHYSICIAN SERVICES AND OUTPATIENT PROCEDURES

 CHAPTER 23 REVIEW
CODING BITES
The steps to determining some E/M codes:
Step #1: Read the case completely.
Step #2: Abstract the notes: Which key words can you identify relating to the E/M
service performed?
Step #3: What is the location?
Step #4: What is the relationship?
Step #5: What level of patient history was taken?
Step #6: What level of physical examination was performed?
Step #7: What level of MDM was required?
Step #8: What is the most accurate E/M code for this encounter?
Step #9: Double-check your work.

You Interpret It! Answers

1. c (99381–99429), 2. d (99441–99443), 3. e (99281–99288), 4. b (99217–99226),
5. a (99201–99205)

CHAPTER 23 REVIEW
CPT Evaluation and Management Enhance your learning by
completing these exercises and
more at connect.mheducation.com!

Coding
Let’s Check It! Terminology
Match each key term to the appropriate definition.

Part I
1. LO 23.3  The level of familiarity between provider and patient. A. Chief Complaint
2. LO 23.3  An encounter for purposes of a second physician’s opinion or advice, B. Consultation
requested by another physician, regarding the management of a C. Established Patient
patient’s specific health concern.
D. Evaluation and
3. LO 23.4  The extent of a physician’s clinical assessment and inspection of a patient. ­Management (E/M)
4. LO 23.4  The collection of details about the patient’s chief complaint, the current E. History of Present
issue that prompted this encounter: duration, specific signs and symp-
CPT © 2017 American Medical Association. All rights reserved.

Illness
toms, etc.
F. Level of Patient History
5. LO 23.4  The level of knowledge and experience needed by the provider to
determine the diagnosis and/or what to do next. G. Level of Physical
Examination
6. LO 23.4  The amount of detail involved in the documentation of patient history.
H. Medical Decision
7. LO 23.4  Collection of details, related to the chief complaint, regarding possible
­Making (MDM)
signs, symptoms, behaviors, genetic connection, etc.
I. New Patient
8. LO 23.3  A person who has received professional services within the last 3 years
from either this provider or another provider of the same specialty
belonging to the same group practice.
9. LO 23.3  A person who has not received any professional services within the
past 3 years from either the provider or another provider of the same
specialty who belongs to the same group practice.

CHAPTER 23  | 
 10. LO 23.2  Specific characteristics of a face-to-face meeting between a health care J. PFSH
CHAPTER 23 REVIEW

professional and a patient. K. Problem-Pertinent

11. LO 23.4  The primary reasons why the patient has come for this encounter, in ­System Review
the patient’s own words. L. Relationship
12. LO 23.4  The physician’s collection of details of signs and symptoms, as per the
patient, affecting only those body systems connected to the chief complaint.

Part II
1. LO 23.7  A group of services already included in the code for the operation and A. Anticipatory Guidance
not reported separately. B. Basic Personal Services
2. LO 23.5  Action taken by the attending physician to stop or reduce a behavior or life- C. Care Plan Oversight
style that is predicted to have a negative effect on the individual’s health. Services
3. LO 23.4  An organization that provides services to terminally ill patients and D. Critical Care Services
their families. E. ESRD
4. LO 23.4  Services that include washing/bathing, dressing and undressing, assis-
F. Global Surgical
tance in taking medications, and getting in and out of bed.
Package
5. LO 23.1  A type of action or service that stops something from happening or
G. Hospice
from getting worse.
H. Interval
6. LO 23.2   A facility that provides skilled nursing treatment and attention along
with limited medical care for its (usually long-term) residents, who do I. Nursing facility
not require acute care services (hospitalization). J. Preventive
7. LO 23.4   The time measured between one point and another, such as between K. Risk Factor Reduction
physician visits. Intervention
8. LO 23.4   Services for a patient who has a life-threatening condition expected to L. Transfer of Care
worsen.
9. LO 23.10  Chronic, irreversible kidney disease requiring regular treatments.
10. LO 23.4   E/M of a patient, reported in 30-day periods, including infrequent
supervision along with pre-encounter and post-encounter work, such
as reading test results and assessment of notes.
11. LO 23.5   Recommendations for behavior modification and/or other preventive
measures.
12. LO 23.3   When a physician gives up responsibility for caring for a patient, in
whole or with regard to one specific condition, and another physician
accepts responsibility for the care of that patient.
CPT © 2017 American Medical Association. All rights reserved.

CPT

Let’s Check It! Concepts

Choose the most appropriate answer for each of the following questions.

Part I
1. LO 23.1  E/M codes enable the physician to be reimbursed for all of these services except
a. talking with the patient and his or her family. b. taking continuing education classes.
c. consulting with other health care professionals. d. reviewing data such as test results.
2. LO 23.2  Often, finding the correct E/M code begins with knowing
a. where the patient met with the physician.

682   PART III  |  REPORTING PHYSICIAN SERVICES AND OUTPATIENT PROCEDURES

 b. which credential is held by the provider.

CHAPTER 23 REVIEW
c. what type of insurance policy is held by the patient.
d. what the patient does for an occupation.
3. LO 23.3  A patient who has not seen a particular physician in the last 3 years is categorized as
a. an established patient. b. a referral.
c. a consultation. d. a new patient.
4. LO 23.4  The three key components of many E/M codes include all of these except
a. history. b. exam. c. chief complaint. d. MDM.

5. LO 23.4  Levels of patient history include all except

a. expanded problem-focused. b. comprehensive.
c. detailed. d. high complexity.
6. LO 23.4  Body areas that might be included in a physical examination include
a. eyes. b. each extremity. c. respiratory. d. neurologic.
7. LO 23.4  When services are provided at different levels, the guidelines state you should code to a level of
a. at least one of three key components achieved. b. all key components met or exceeded.
c. the number of minutes face-to-face. d. the number of diagnosis codes.
8. LO 23.4  If _____ of the time with the patient is spent counseling, you should use time rather than key compo-
nents to determine the level of service code.
a. 51% or more b. 45% or more c. 50% or less d. 25% or more
9. LO 23.3  A consultation is expected to be a(n) _____ relationship with the patient.
a. extended b. transferred c. temporary d. continuing
10. LO 23.3  A patient seen in the office and then admitted to the hospital the same day should be coded with E/M
codes from subsection(s)
a. Office Visit only. b. Office Visit and Initial Hospital Care.
c. Initial Hospital Care only. d. Emergency Department.

Part II
1. LO 23.5  A preventive medical E/M encounter may include any of these services except
a. counseling. b. admission into the hospital.
c. anticipatory guidance. d. risk factor reduction intervention.
2. LO 23.8  If the physician finds a health concern during a preventive medicine examination requiring additional
CPT © 2017 American Medical Association. All rights reserved.

E/M services and the extra service is performed by the same physician on the same day, then the extra
service should be coded with
a. the preventive medicine code only. b. the additional E/M code.
c. whichever code is reimbursable at a higher rate. d. a separate E/M code appended with modifier 25.
3. LO 23.4  E/M services provided to a patient in an assisted living facility are reported from the subsection
a. Nursing Facility.
b. Home Services.
c. Domiciliary, Rest Homes, and Custodial Care Settings.
d. Care Plan Oversight Services.
4. LO 23.4  If a patient is discharged from the hospital and admitted into a skilled nursing facility (SNF) on the
same day by the same physician, report the E/M services with

CHAPTER 23  | 
 a. an admission to the nursing facility E/M code only.
CHAPTER 23 REVIEW

b. a hospital discharge code and an admission to the nursing facility code.

c. one outpatient E/M services code.
d. a subsequent nursing facility E/M code.
5. LO 23.4  Care plan oversight services provided for a patient in a hospice setting are coded from the
a. 99339–99340 range. b. 99374–99375 range. c. 99377–99378 range. d. 99379–99380 range.
6. LO 23.4  Frank Brookshire goes to Dr. Corriher’s office for an appointment. After a full history, an exam, and compre-
hensive MDM, Dr. Corriher recommends that he be admitted into a psychiatric residential treatment center.
He takes him over and admits him into the facility that afternoon. You will code the E/M services with
a. one office visit code.
b. an admission to nursing facility code.
c. both an office visit code and an admission to nursing facility code.
d. a domiciliary, rest home, custodial care center code only.
7. LO 23.4  Arlen Flowers, a 5-day-old male, was admitted into the NICU for ­complications of his low birthweight status.
Dr. Hohman saw him ­yesterday and is in again today. You will code today’s E/M services from the
a. 99468–99469 range. b. 99478–99479 range.
c. 99307–99310 range. d. 99210–99215 range.
8. LO 23.4  Critical care codes are determined by
a. length of time. b. inpatient or outpatient status.
c. level of history, exam, and MDM. d. new or established patient.
9. LO 23.4  Conferencing with other health care professionals regarding ­management and/or treatment of a patient is
a. included in all E/M codes. b. coded as a consultation E/M code.
c. coded from 99366–99368. d. coded from 99201–99205.
10. LO 23.8  A modifier
a. explains an unusual circumstance. b. has five digits.
c. begins with the letter M. d. explains how a patient became injured.

Let’s Check It! Guidelines

Refer to the Official Evaluation and Management (E/M) Services Guidelines and fill in the blanks accordingly.
not history subspecialty
counseling Medical decision making hospital
CPT © 2017 American Medical Association. All rights reserved.
face-to-face chief complaint office
outpatient exact examination
five inpatient Concurrent care
coordination emergency department time

1. Solely for the purposes of distinguishing between new and established patients, professional services are those
_____ services rendered by physicians and other qualified health care professionals who may report evaluation
and management services reported by a specific CPT code(s).
2. An established patient is one who has received professional services from the physician/qualified health care
professional or another physician/qualified health care professional of the _____same specialty and _____ who
belongs to the same group practice, within the past 3 years.
3. A _____ is a concise statement describing the symptom, problem, condition, diagnosis, or other factor that is the
reason for the encounter, usually stated in the patient’s words.

684   PART III  |  REPORTING PHYSICIAN SERVICES AND OUTPATIENT PROCEDURES

 4. _____ is the provision of similar services (eg, hospital visits) to the same patient by more than one physician or

CHAPTER 23 REVIEW
other qualified health care professional on the same day.
5. Levels of E/M services are _____interchangeable among the different categories or subcategories of service.
6. The E/M codes recognize _____types of presenting problems.
7. Time is not a descriptive component for the _____ levels of E/M services because emergency department services
are typically provided on a variable intensity basis, often involving multiple encounters with several patients over
an extended period of time. Therefore, it is often difficult to provide accurate estimates of the time spent face-to-
face with the patient.
8. Intraservice times are defined as face-to-face time for _____ and other _____ visits and as unit/floor time for
_____ and other _____ visits.
9. The extent of the _____ is dependent upon clinical judgment and on the nature of the presenting problem(s).
10. The extent of the _____ performed is dependent on clinical judgment and on the nature of the presenting problem(s).
11. _____ refers to the complexity of establishing a diagnosis and/or selecting a management option.
12. When _____ and/or _____ of care dominates (more than 50%) the encounter with the patient and/or
­family ­(face-to-face time in the office or other outpatient setting or floor/unit time in the hospital or nursing ­facility),
then _____ shall be considered the key or controlling factor to qualify for a particular level of E/M services.

Let’s Check It! Rules and Regulations

Please answer the following questions from the knowledge you have gained after reading this chapter.
1. LO 23.2   List the location-specific headings in the E/M section.
2. LO 23.4   List the three components of an E/M code.
3. LO 23.5   Explain anticipatory guidelines.
4. LO 23.7   Explain a global surgical package.
5. LO 23.10  When transferring care and management of a patient to another facility, code 99495 requires the physi-
cian to document what elements?

CPT
YOU CODE IT! Basics
Using the techniques described in this chapter, carefully read through the case studies and determine the most
accurate E/M code(s) for each case study.
1. Makayla Sorensen, a 4-year-old female, sees Dr. Pitassin, a pediatrician, for the first time with itchy spots all
over her body. After a detailed history and a detailed examination, his MDM is of a low complexity. Dr. Pitassin
diagnoses her with chickenpox.
CPT © 2017 American Medical Association. All rights reserved.

2. Loretta Stabler, an 81-year-old female, comes to see Dr. Gilman for her semi-annual check-up Dr. Gilman notes
he last saw the patient 6 months ago for a regular checkup. Dr. Gilman completes a detailed interval history with
a comprehensive head-to-toe physical exam. He reviews and affirms the present medical plan of care. Loretta’s
condition is stable, her hypertension and diabetes (type 2) are in good control, and she has no new problems.
There are minimal data for Dr. Gilman to review and several diagnoses to consider. The MDM is moderate.
3. George Terazzo, an 81-year-old male, collapsed at church during services and was brought to the ED.
Dr. Horatio took a comprehensive history, performed a comprehensive examination, and made the decision to
admit George into the observation unit of the hospital due to an irregular heartbeat with an unknown cause.
MDM is of moderate complexity.
4. Sue Appleton, a 46-year-old female, was admitted this morning for observation after an MVA. Dr. Rhodes
documents a detailed history and a comprehensive exam with a straightforward MDM. Sue is doing fine; all
test results are within normal range. Dr. Rhodes discharges Sue the same afternoon.

CHAPTER 23  | 
CHAPTER 23 REVIEW

5. Reisa Haven, a 39-year-old female, was sent by Dr. Alfaya to Dr. Avery, an OB-GYN, for an office consultation.
She had been suffering with moderate pelvic pain, a heavy sensation in her lower pelvis, and marked discomfort
during sexual intercourse. In a detailed history, Dr. Avery noted the location, severity, and duration of her pelvic
pain and related symptoms. In the review of systems, Reisa had positive findings related to her gastrointestinal,
genitourinary, and endocrine body systems. Dr. Avery noted that her past medical history was noncontributory
to the present problem. The detailed physical examination centered on her gastrointestinal and genitourinary
systems with a complete pelvic exam. Dr. Avery ordered lab tests and a pelvic ultrasound in order to consider
uterine fibroids, endometritis, or other internal gynecologic pathology. MDM complexity was moderate.
6. Catalina King came into the ED with what appeared to be a wrist sprain that she sustained during a baseball
game when she slid into home base. She was in obvious pain, and the wrist was swollen and too painful upon
attempts to flex. Dr. Ervin performed an expanded problem-focused history and exam before he ordered
x-rays. Reports confirmed a simple fracture of the distal radius. MDM was low.
7. George Carter was discharged today from the Bracker Nursing Center after Dr. Mintz spent 25 minutes perform-
ing a final examination, discussing George’s stay, and providing instructions to George’s wife for continuing care.
8. Heather Swann, a 68-year-old female, in good health, is a new patient at Victors Boarding Home. Dr. Cannon
comes by to complete Heather’s evaluation and documents an expanded problem-focused history and exam
with an MDM of low complexity.
9. Marla Olden, a 38-year-old female, G2 P1, was admitted to Weston Hospital to deliver. Marla is considered a
high-risk delivery. Dr. Kucherin was on standby for 30 minutes in the event a c-section was necessary. Marla
delivered vaginally. Marla and baby are doing well. Code Dr. Kucherin’s services.
10. Loretta Reubens, an 18-month-old female, is admitted today by Dr. Smallerman into the pediatric critical care
unit because of severe respiratory distress.

CPT
YOU CODE IT! Practice
Using the techniques described in this chapter, carefully read through the case studies and determine the most
accurate E/M code(s) and modifier(s), if appropriate, for each case study.
1. Zena Awtrey, a 58-year-old female, sees Dr. Lunden for the first time for a variety of medical problems. She
was diagnosed 5 years ago with insulin-dependent diabetes mellitus with complicating eye and renal prob-
lems. In addition, she suffers from hypertensive heart disease with episodes of congestive heart failure. Her
peripheral vascular disease has worsened, and she can walk only a block before being crippled with extreme
leg pain. The patient reports that a new problem has surfaced: throbbing headaches with radiating neck pain.
Dr. Lunden and Zena thoroughly discuss her health concerns and issues. In order to manage and investigate
the multiplicity of problems, Dr. Lunden takes a complete PFSH. A complete review of systems (ROS) is CPT © 2017 American Medical Association. All rights reserved.
performed and comprehensive physical exam is completed. Dr. Lunden has to take a multitude of factors into
consideration, as the patient’s problems are highly complex.
2. Jamie Farmer, a 32-year-old male, goes to his family physician, Dr. Mitchell, for a tetanus shot after stepping
on a rusty nail at the beach. While there, he asks Dr. Mitchell to look at a cut on his left hand. Dr. Mitchell
examines the wound and tells him to keep the wound clean and bandaged. Dr. Mitchell documents a brief HPI
and performs a limited exam of the left hand, MDM straightforward. Code only the E/M.
3. Owen Unger, a 19-month-old male, is admitted to the hospital by his pediatrician, Dr. Curtis, after a chest
x-ray confirmed the child has pneumonia. Dr. Curtis and Mrs. Unger, Owen’s mother, discuss the child’s
fever, cough, and diarrhea. Mrs. Unger provides a pertinent PFSH. An extended problem-focused ROS is
completed and an extended examination of the cardiovascular and respiratory systems is performed. The
course of treatment planned by Dr. Curtis is straightforward as the child’s condition is of low severity.

686   PART III  |  REPORTING PHYSICIAN SERVICES AND OUTPATIENT PROCEDURES

 CHAPTER 23 REVIEW
4. Raymond Johnston, a 3-year-old male, showed no sign of improvement after 5 days of antibiotic therapy,
so Dr. Servina admits Raymond into the hospital with a diagnosis of bacterial pneumonia. At Raymond’s
admittance, his vitals showed a temperature of 38.3°C (101°F), with a mild rash on his torso. The following
day, Dr. Servina performed a problem-focused history and examination with MDM of low complexity. Code
Dr. Servina’s visit on the second day.
5. Tom Seihill, a 23-year-old male, was admitted into the hospital 2 days ago for bronchitis. While in the hos-
pital, Tom requested that his family physician, Dr. Selbiger, perform a circumcision, so Dr. Selbiger called in
Dr. Wacker, a urologist, for a consultation. Dr. Wacker discussed the request with Tom and took a brief his-
tory and performed a limited genitalia examination. Afterward, Dr. Wacker made a straightforward decision
and recommended that Raymond have the surgical procedure done at a later date as an outpatient procedure.
Code for Dr. Wacker’s services.
6. Dr. Modesta spent 2½ hours evaluating Carolina Tanner upon her admission into the ICU.
7. Howard Shires, a 78-year-old male, was diagnosed with advanced Alzheimer’s disease about 1 year ago
and has been in this facility for approximately 10 months. He was seen today by the nursing facility’s
­physician, Dr. Bowyer, over concern of the development of urinary and fecal incontinence, as well as a
number of other medical problems that have appeared to increase in severity. In addition to the detailed
interval history, the physician spoke with family members and the nursing staff. Then, Dr. Bowyer
reviewed the patient’s record to create an extended history necessary for an extended review of systems
(ROS). Dr. Bowyer performed a comprehensive physical exam to assess all body systems. Afterward, he
wrote all new orders due to the dramatic change in the patient’s physical and mental condition. A new
­complex treatment plan was created.
8. Royce Onoton’s legs have finally healed to the point that he can be discharged from the nursing facility,
where he has been for the last 6 weeks. Before he can go home, Dr. Zandi comes in for the final examination
and to provide continuing care instructions to Royce’s wife, who will be caring for Royce at home. Dr. Zandi
prepares the discharge records and writes a prescription for Royce for pain. This whole process takes Dr. Zani
about 45 minutes to complete.
9. Bernard Kristenson moved into the Prader Assisted Living Center today. Dr. Ramada, the center’s resident
physician, introduced himself to Bernard and then took an extended HPI and pertinent PFSH. Dr. Ramada
performed a comprehensive examination. After reviewing the results of the examination, Dr. Ramada found
management of Barnard’s case to be moderate complexity.
10. Dr. Harrington provided care plan oversight services for Verniece Dantini, one of her patients at the Bracker
Assisted Living Center. It took her 20 minutes.
11. Dr. Kaminsky spends approximately 1 hour in a meeting with an oncologist and a reconstructive surgeon. The
three professionals discussed treatments and options for Karyn Cassey, a 41-year-old female, who was recently
diagnosed with parosteal osteogenic sarcoma. Code the conference.
CPT © 2017 American Medical Association. All rights reserved.

12. Raymond Catertell, a 23-year-old male, is the son of two alcoholics. Dr. Lowen spends 40 minutes with him
providing risk factor reduction behavior modification techniques to help him avoid becoming an alcoholic
himself.
13. Premier Life & Health Insurance Company required David Harrison, a 39-year-old male, to get Dr. Dijohn,
his regular physician, to complete a certificate confirming that David’s current disability prevents him from
working at his regular job and makes him eligible for disability insurance.
14. Dr. Anderson works in a very small town in Ohio and travels up to 200 miles to see his patients in the sur-
rounding rural areas. His patient Brenda Viard gave birth at her home the previous day to a 6-lb 3-oz baby
girl, Alice Rose. Dr. Anderson sees Alice Rose for the first time today, does a complete history and exam, and
prepares her medical chart. Alice Rose is a healthy newborn.
15. Petula Carter, a 4-day-old female, currently weighs 2,000 grams and requires intensive cardiac and respiratory
monitoring. This is her third day in the NICU, and Dr. Wadhwa comes in to do his E/M of her condition.

CHAPTER 23  | 
CHAPTER 23 REVIEW

CPT
YOU CODE IT! Application
The following exercises provide practice in the application of abstracting the physicians’ notes and learning
to work with documentation from our health care facility, Prader, Bracker, & Associates. These case studies
are modeled on real patient encounters. Using the techniques described in this chapter, carefully read through
the case studies and determine the most accurate E/M code(s) and modifier(s), if appropriate, for each case
study.

WESTON HOSPITAL
629 Healthcare Way • SOMEWHERE, FL 32811 • 407-555-6541
PATIENT: TURNER, CHARLES
ACCOUNT/EHR #: TURNCH001
DATE: 10/01/18
Attending Physician: Renee O. Bracker, MD
S: This 27-year-old male was brought to the ED by ambulance after he was found unconscious on the
living room floor. He regained consciousness within several minutes but complained of a severe head-
ache and nausea. Pt states that the last thing he remembers he was on a ladder, changing a light bulb.
He believes he lost his balance trying to reach too far and fell, hitting his head on the end-table.
O: Ht 5’10”, Wt 195 lb., R 16. Head: Scalp laceration on the right posterior parietal bone. Bruise indi-
cates trauma to this area. Eyes: PERRLA. Neck: Neck muscles are tense; there is minor pain upon rota-
tion of the head. Musculoskeletal: All other aspects of the shoulders, arms, and legs are unremarkable.
X-rays of skull, two views, and soft tissue of the neck are all benign.
A: Concussion
P: 1. MRI to rule out subdural hematoma
  2. Repair laceration and bandage
ROB/mg  D: 10/01/18 09:50:16  T: 10/05/18 12:55:01

Determine the most accurate E/M code(s).

PRADER, BRACKER, & ASSOCIATES

A Complete Health Care Facility CPT © 2017 American Medical Association. All rights reserved.

159 Healthcare Way • SOMEWHERE, FL 32811 • 407-555-6789

PATIENT: BROMWELL, BRANDON
ACCOUNT/EHR #: BROMBR001
DATE: 10/18/18
Attending Physician: Oscar R. Prader, MD

688   PART III  |  REPORTING PHYSICIAN SERVICES AND OUTPATIENT PROCEDURES

 CHAPTER 23 REVIEW
S: Matthew is a 9-month-old male brought in today by his mother. I last saw this patient at his regular 6-month
checkup. He has been irritable lately and is tugging at his right ear. Brandon has been running a low-grade
fever since yesterday. There has been no cough. Pt has a history of problems with his ears and sinuses.
O: Ht 25”, Wt 26 lb., R 20, T 101.3. HEENT: Purulent nasal discharge, yellow-green in color, is noted.
Right TM is erythematous unilaterally, bulging, and with purulent effusions. Oropharynx is nonerythema-
tous without lesions. One tooth on the bottom. Tonsils are unremarkable. Neck: Neck is supple with
good range of motion (ROM). Positive cervical adenopathy. Lungs: Clear. Heart: Regular rate and rhythm
without murmurs.
A: Acute suppurative otitis media, right side
P: 1. Rx Augmentin 40 mg/kg divided tid 10 days
  2. Bed rest, lots of fluids
  3. Follow-up prn or if no improvement in 10 days
ORP/mg  D: 10/18/18 09:50:16  T: 10/23/18 12:55:01

Determine the most accurate E/M code(s).

PRADER, BRACKER, & ASSOCIATES

A Complete Health Care Facility
159 Healthcare Way • SOMEWHERE, FL 32811 • 407-555-6789
PATIENT: HENSLEY, ERNEST
ACCOUNT/EHR #: HENSER001
DATE: 09/29/18
Attending Physician: Benjamin L. Johnston, MD
Referring Physician: Oscar R. Prader, MD
S: Pt is a 35-year-old male, referred by Dr. Prader for a consultation regarding a sore on his left temple,
at the hairline. Pt states he is very involved in water sports. He knows the importance of sunscreen;
however, he does not always remember to put it on. He has not had any dermatologic concerns prior to
this. Patient states that his skin is occasionally dry and that he has adult onset acne.
O: Ht 6’1”, Wt 225 lb., R 17, T 98.6. After an examination of the skin along the hairline, as well as the
rest of the face and neck, a culture is taken of the lesion. The pathology report confirms a malignant
CPT © 2017 American Medical Association. All rights reserved.

melanoma of the skin of the scalp.

A: Malignant melanoma, scalp

P: 1. Discuss surgical and pharmaceutical options for treatment
  2. Report sent to Dr. Prader
ORP/mg  D: 09/29/18 09:50:16  T: 10/01/18 12:55:01

Determine the most accurate E/M code(s).

CHAPTER 23  | 
CHAPTER 23 REVIEW

PRADER, BRACKER, & ASSOCIATES

A Complete Health Care Facility
  159 Healthcare Way • SOMEWHERE, FL 32811 • 407-555-6789
PATIENT: SARGENT, ALEXANDER
ACCOUNT/EHR #: SARGAL001
DATE: 10/25/18
Attending Physician: Renee O. Bracker, MD
S: This 85-year-old male is seen today at Northside Assisted Living Center, where he has been living
for the last 6 months. The last time I saw this patient was right before he moved into the center. Nurse
Thomas states that he has been complaining of mild abdominal pain and some discomfort upon urina-
tion. Other than this issue, he has been well and stable.
O: Ht 5′6.5″, Wt 145 lb., R 18, P 73, BP 137/81. Abdomen is unremarkable. No masses or rigidity noted.
A: Suspected bladder infection
P: Order written for UA to rule out bladder infection.
ROB/mg D: 10/25/18 09:50:16 T: 10/28/18 12:55:01

Determine the most accurate E/M code(s) and modifier(s), if appropriate.

WESTON HOSPITAL
629 Healthcare Way • SOMEWHERE, FL 32811 • 407-555-6541
PATIENT: LEAMAN, HESTER
ACCOUNT/EHR #: LEAMHE001
DATE: 10/01/18
Attending Physician: Renee O. Bracker, MD
This 18-month-old female is being admitted to the pediatric critical care. Mother claims onset of symp-
toms was sudden. She states that she rushed the child to the ED immediately.
Child is unresponsive. Respiration is shallow. B/P 85/60 mmHg, T 102.

CPT © 2017 American Medical Association. All rights reserved.

Complete blood workup ordered: CBC with diff, tox screen, bilirubin, and basic metabolic panel. IV fluids
to keep hydrated.
Await test results.
ROB/mg D: 10/01/18 09:50:16 T: 10/03/18 12:55:01

Determine the most accurate E/M code(s) and modifier(s), if appropriate.

690   PART III  |  REPORTING PHYSICIAN SERVICES AND OUTPATIENT PROCEDURES

 CPT Anesthesia Section
Learning Outcomes
After completing this chapter, the student should be able to:
LO 24.1 Interpret the types of anesthesia provided.
24
Key Terms
LO 24.2 Determine the accurate code and physical status modifier for Anesthesia
the administration of anesthesia. Anesthesiologists
LO 24.3 Incorporate the Official Guidelines for reporting. Certified Registered
LO 24.4 Apply the formula for using time to report anesthesia Nurse Anesthetist
(CRNA)
services. Conscious Sedation
LO 24.5 Select the accurate qualifying circumstances add-on codes. General Anesthesia
LO 24.6 Identify special circumstances requiring a CPT modifier. Local Anesthesia
LO 24.7 Abstract the notes to append HCPCS Level II modifiers. Monitored Anesthesia
Care (MAC)
Regional Anesthesia
Topical Anesthesia

Remember, you need to follow along

in your CPT and HCPCS Level II
CPT
  STOP!  HCPCS Level II

code books for an optimal learning

experience.

24.1  Types of Anesthesia

Anesthesia is defined as the suppression of nerve sensations to relieve or prevent the Anesthesia
feeling of pain, usually by the use of pharmaceuticals. Essentially, it is more com- The loss of sensation, with or
monly described as the administration of drugs to enable a patient to avoid the feeling without consciousness, gener-
of pain. While there are many types of anesthesia, they are all primarily divided into ally induced by the administra-
three preliminary categories: topical/local, regional, and general. tion of a particular drug.

Topical and/or Local Anesthesia

Topical anesthesia refers to the numbing of surface nerves, whereas local anesthesia Topical Anesthesia
CPT © 2017 American Medical Association. All rights reserved.

refers to the dulling of feeling in a limited area of the body. The application of a drug to
Topical anesthesia is applied directly to the skin or mucous membranes, using a the skin to reduce or prevent
liquid or gel form. Typically, this is administered prior to very minor procedures on sensation in a specific area
the epidural layer of the skin, or the eye, anus, vagina, mouth, gums, eardrum, or nose. temporarily.
Local anesthetics are most often administered by injection, directly into the anatomi- Local Anesthesia
cal site that is the object or target of the procedure. Lidocaine is one of the frequently The injection of a drug to pre-
used anesthetics. vent sensation in a specific
portion of the body; includes
local infiltration anesthesia,
EXAMPLE digital blocks, and pudendal
Dr. Victors, a general dentist, rubbed a topical anesthetic onto Walter’s gum to blocks.
prevent him from feeling any pain from the injection of the local anesthetic. The
local anesthetic will prevent him from feeling pain while the doctor drills the cavity
that Walter has in his left, lower molar.
 Regional Anesthesia
CODING BITES
Topical: Think top, for
Regional anesthesia prevents a section of the body from transmitting pain and
the top layer of skin
includes epidural, caudal, spinal, axillary, stellate ganglion blocks, regional blocks,
Local: The effect of the
and brachial anesthesia.
anesthesia stays close
Regional anesthesia is most often used when the procedure
to the injection site ∙ Is focused on a specific region of the body.
Neither of these types ∙ Involves a larger area of the body than could be treated with a local injection.
of anesthesia is sepa- ∙ Does not require general anesthesia.
rately reported. They
are already included in In these cases, the chosen anesthetic is injected directly into a nerve, nerve plexis, or
the procedure code. the spinal cord. There are two types of regional anesthesia:
∙ Peripheral nerve blocks, which are typically used for procedures performed on the
Regional Anesthesia extremities: arms or legs, or the groin, or the face.
The administration of a drug
in order to interrupt the nerve ∙ Epidural and spinal anesthesia, which employs an anesthetic injected into the spinal
impulses without loss of cord, most often to numb the lower abdomen, pelvic area, or the lower extremities.
consciousness.

EXAMPLE
Dr. Carloni, an anesthesiologist, was paged to come to the maternity ward to
administer epidural anesthesia for Kimberly Saunders. After the epidural was
given, Kimberly was able to proceed with the birth of her baby without the pain of
childbirth. The loss of sensation was only from the waist down. She was otherwise
awake and alert.

General Anesthesia
General Anesthesia General anesthesia, also called surgical anesthesia, creates a total loss of conscious-
The administration of a drug in ness and sensation. General anesthesia is given to the patient by inhalation, intrave-
order to induce a loss of con- nous (IV) injection, or, on rare occasions, intramuscular (IM) injection.
sciousness in the patient, who Propofol is the drug most commonly used, administered by slow intravenous infu-
is unable to be aroused even sion. In some cases, a slow inhalation of anesthetic vapors is administered using a
by painful stimulation.
face mask.

EXAMPLE
Dr. Carver, an anesthesiologist, administered general anesthesia to Darnell Liberty
after he was brought into the operating room (OR) and positioned on the table.
Dr. Mendosa was preparing to remove Darnell’s gallbladder because of the collec-
CPT © 2017 American Medical Association. All rights reserved.
tion of stones in that organ, and everyone wanted to be certain that Darnell would
not feel anything during the surgical procedure.

Moderate (Conscious) Sedation

One additional type of anesthesia that you should know about when coding anesthetic
Conscious Sedation and surgical services is called conscious sedation. It is a form of ultralight general
The use of a drug to reduce anesthesia that affects the entire body.
stress and/or anxiety. With conscious sedation, the physician gives the patient medication to reduce
anxiety and stress. A short-acting benzodiazepine, such as midazolam (Versed),
either alone or in combination with an opioid analgesic, such as fentanyl, is most
often used for this purpose. The patient remains awake and aware of his or her sur-
roundings and what is going on. He or she can answer questions and respond to
verbal commands.

692   PART III  |  REPORTING PHYSICIAN SERVICES AND OUTPATIENT PROCEDURES

 Most often, conscious sedation is used for procedures that will not typically cause
pain but may be worrisome to patients, causing them to be nervous and frightened.
The services of an anesthesiologist are not required for the provision of conscious
sedation, so the physician performing the procedure, or a member of the nursing staff,
may administer this before the patient goes into the procedure room. This is one of the
reasons the codes for this service are not found in the Anesthesia section of CPT, but
in the Medicine section.
Codes 99151–99157 report the administration of moderate (conscious) sedation
and include
∙ Assessing the patient.
∙ Establishing IV access and fluids to maintain patency, when performed.
∙ Administering the drug.
∙ Maintaining the sedated level.
∙ Monitoring oxygen saturation, heart rate, and blood pressure.
∙ Observing and assessing the patient during recovery.
Coding for the administration of conscious sedation also has a few guidelines to help
you determine the best, most appropriate code:
1. Who is administering the sedation?
a. If the physician performing the procedure also administers the conscious seda-
tion, use a code from the 99151–99153 range (located in the Medicine section of
the CPT book).
b. If a different physician or other health care professional, other than the profes-
sional performing the procedure, administers the conscious sedation, use a code
from the 99155–99157 range (located in the Medicine section of the CPT book).
c. If an anesthesiologist administers the moderate sedation, this is known as
Monitored Anesthesia Care (MAC), which is reported from the Anesthesia sec- Monitored Anesthesia
tion of CPT (codes 00100-01999). Care (MAC)
The administration of seda-
2. The time spent with the patient under conscious sedation helps to determine the
tives, anesthetic agents, or
correct code or codes. Intraservice work is measured in an initial 15-minute seg- other medications to relax but
ment, followed by 15-minute segments. The clock starts when the physician admin- not render the patient uncon-
isters the sedative and stops when the patient is discharged and the physician is no scious while under the con-
longer required to supervise the patient. Total time is calculated only for the min- stant observation of a trained
utes the physician continuously spends face-to-face with the patient. anesthesiologist; also known
3. The patient’s age is the other factor that will lead you to the correct code. as “twilight” sedation.
4. Codes 99151–99153 require the presence of an independent qualified observer to
monitor the patient’s conscious status during the procedure. This is the sole respon-
sibility for this individual.
CPT © 2017 American Medical Association. All rights reserved.

EXAMPLES GUIDANCE
99151   Moderate sedation services provided by the same physician or CONNECTION
other qualified health care professional performing the diagnos- Read the additional
tic or therapeutic service that the sedation supports, requiring explanations in the
the presence of an independent trained observer to assist in the in-section guidelines
monitoring of the patient’s level of consciousness and physiologi- located within the
cal status; initial 15 minutes of intraservice time, patient younger Medicine section,
than 5 years of age subhead Moderate
99152     initial 15 minutes of intraservice time, patient age 5 years or older (Conscious) Sedation,
99153    each additional 15 minutes intraservice time (List separately in directly above code
addition to code for primary service) 99151 in your CPT book.
 CPT
LET’S CODE IT! SCENARIO
Caterina Zingler, a 41-year-old female, came into the same day surgery center to Certified Registered Nurse
have Dr. Freeman perform a hemorrhoidopexy by stapling. She was very nervous Anesthetist (CRNA)
because she had never had this procedure before. Raymond Elvers, a certified reg- A registered nurse (RN) who
istered nurse anesthetist (CRNA), administered Versed, IV, a sedative to relieve her has taken additional, special-
anxiety. The procedure is not really painful, so there was no need for a full anes- ized training in the administra-
thetic or painkiller. Raymond sat with Caterina throughout the procedure to ensure tion of anesthesia.
her safety and comfort level. Dr. Freeman accomplished the procedure in one stage,
taking 30 minutes.

Let’s Code It!

Raymond Elvers, a CRNA, administered Versed, a mild “sedative,” to Caterina before Dr. Freeman performed the
procedure. Read the complete description for the procedure code used to report the performing of a “hemor-
rhoidopexy by stapling” (46947). This includes all of the details about the procedure, except the administration
of the moderate sedation. Let’s go to the Alphabetic Index and find moderate sedation.

Moderate Sedation
See Sedation
Turn to Sedation, where you find:

Sedation
Moderate . . . . . . . . . . . 99151–99153, 99155–99157
  with independent observation. . . . . 99151–99153

Read, carefully, the complete descriptions of all of these codes in the Main Section of the CPT book and analyze
the details within each.
Code 99151 requires the physician who performed the procedure to administer the moderate sedation,
whereas 99155 requires another physician or health care professional. Which is correct? Go back to the docu-
mentation, which states, “Raymond Elvers, a certified registered nurse anesthetist (CRNA), administered Versed,
IV, a sedative to relieve her anxiety.” This would lead you to 99155.
You will see that code 99155 is the more accurate. This identifies moderate sedation, administered by a
different health care professional [Raymond Elvers, CRNA] than the professional who performed the
procedure [Dr. Freeman], initial 15 minutes intraservice, patient younger than 5 years of age.
Wait a minute; the documentation states the patient is “a 41-year-old female.” Take a look at code 99156
initial 15 minutes intraservice time, patient age 5 years or older. That’s more accurate.
Are you done? Not yet. Code 99156 only reports 15 minutes. The documentation states, “taking 30 minutes.”
You will need to also report code 99157 for the next 15 minutes, so Dr. Freeman and Raymond Elvers can be
accurately reimbursed for all of the time they spent.
CPT © 2017 American Medical Association. All rights reserved.
So, in addition to the code for the hemorrhoidopexy (46947), you need to include two additional codes for
the moderate sedation (99156 and 99157) on the report and claim form.
Good job!

24.2  Coding Anesthesia Services

When coding anesthesia services, you should follow these steps to find the best, most
appropriate code.
1. Confirm that the physician who performed the procedure for which the anesthe-
sia was required is a different professional from the person who administered the
anesthesia.

694   PART III  |  REPORTING PHYSICIAN SERVICES AND OUTPATIENT PROCEDURES

 On those occasions when the same physician who performs the procedure
also administers regional or general anesthesia, you must append modifier
47 Anesthesia by Surgeon to the appropriate procedure code. The modifier is
not attached to an anesthesia procedure code; it is added to the basic procedure
code. No additional code from the Anesthesia section will be used. See the sub-
section Special Circumstances later in this chapter to learn more about using
modifier 47.
2. Identify the anatomical site of the patient’s body upon which the surgical procedure
was performed.
3. Confirm the exact surgical procedure performed, as documented in the physician’s
notes (also known as the operative report).
4. Consult the Alphabetic Index of the CPT book, look under the heading of
Anesthesia, and read down the list to find the anatomical site shown below that
heading. Identify the suggested code or codes for this site.

EXAMPLE
Anesthesia
Skull. . . . . . . . 00190

5. Turn to the Main Section of the CPT book, Anesthesia section, and find the subsec-
tion identifying that anatomical site.

EXAMPLES
00212   Anesthesia for intracranial procedures; subdural taps
00216    vascular procedures

6. Read the descriptions written next to each code option suggested in the Alphabetic
Index carefully. Then compare them with the terms used by the physician in his or
her notes documenting the procedure. This will lead you to the best, most appropri-
ate code available.

CPT
LET’S CODE IT! SCENARIO
Dr. Fonda is called in to administer general anesthesia to Morgan Saffire, a 6-month-old female, diagnosed with
congenital tracheal stenosis. Dr. Caudwell performs a surgical repair of her trachea.
CPT © 2017 American Medical Association. All rights reserved.

Let’s Code It!

The notes indicate that Dr. Fonda administered the anesthesia and Dr. Caudwell performed a “surgical repair of
her trachea.” Remember, this means that an anesthesia code will be used, not a modifier appended to the pro-
cedure code. So let’s go ahead and find the best code for the anesthesia service.
Turn to the Alphabetic Index and look up anesthesia. Going down the alphabetic listing of the sites beneath
this heading, look for more than a page until you get to the correct anatomical site: Trachea.

Trachea . . . . . . . 00320, 00326, 00542

  Reconstruction. . . . . . . . . . . . . 00539

The physician’s notes state that Dr. Caudwell performed a “repair,” not a reconstruction, so focus on the codes
shown next to Trachea. Turn to the Main Section of the CPT book to find the codes 00320, 00326, and 00542.
 Read the descriptions written next to each code, as well as the others found in the subsection, in order to deter-
mine the best, most appropriate code available.

Neck
00320   Anesthesia for all procedures on esophagus, thyroid, larynx, trachea and lymphatic system of
neck; not otherwise specified, age 1 year or older
00322 Anesthesia for all procedures on esophagus, thyroid, larynx, trachea and lymphatic system of
neck; needle biopsy of thyroid
00326 Anesthesia for all procedures on the larynx and trachea in children less than 1 year of age
00542 Anesthesia for thoracotomy procedures involving lungs, pleura, diaphragm, and mediastinum
(including surgical thoracoscopy); decortication
As you review the code descriptions, you can identify which terms or words are most important in matching the
code to the physician’s documentation of the procedure. Look at the physician’s notes one more time and iden-
tify the key terms.
Dr. Fonda is called in to administer general anesthesia to Morgan Saffire, a 6-month-old female, diag-
nosed with congenital tracheal stenosis. Dr. Caudwell performs a surgical repair of her trachea.
The combination of all these terms matches only one of our available code descriptions, doesn’t it?

00326 Anesthesia for all procedures on the larynx and trachea in children younger than 1 year
of age

You found the best, most appropriate code for the administration of general anesthesia for Morgan’s surgery.

GUIDANCE Physical Status Modifiers

CONNECTION The American Society of Anesthesiologists (ASA) established six levels of measur-
ing the physical condition of a patient with regard to the administration of anesthesia.
Read the additional Each level, identified by the letter P and a number from 1 to 6, denotes issues that
explanations in the may increase the complexity of delivering anesthetic services and are measured at
Anesthesia Guide- the time the anesthetic is about to be administered. The anesthesiologist is the pro-
lines in your CPT book fessional who determines the correct Physical Status Modifier. However, you, as the
directly before the coding specialist, must be certain to look for the information and include it on the
Anesthesia section that claim form.
lists all the codes. Physical Status Modifiers are mandatory with every code from the Anesthesia sec-
tion of the CPT book and are placed directly after the five-digit CPT code (with a

CPT © 2017 American Medical Association. All rights reserved.

hyphen between the two). For example: 00000-P1. (Note: Physical Status Modifiers
are different from the regular CPT and HCPCS modifiers.)
Following are the Physical Status Modifiers that are to be used only with anesthesia
codes:
P1 (a normal healthy patient). Modifier P1 indicates that the patient to whom the
anesthetic was given had no medical concerns that would interfere with the
anesthesiologist’s responsibilities for keeping the patient sedated and safe.

EXAMPLE
Dr. Tristan administered general anesthesia to Austin Berger, a 15-year-old oth-
erwise healthy female gymnast, before Dr. Armaden performed an arthroscopic
extensive debridement of her shoulder joint. The correct code is 01630-P1.

696   PART III  |  REPORTING PHYSICIAN SERVICES AND OUTPATIENT PROCEDURES

 P2 (a patient with mild systemic disease). When a patient has a disease that may
affect the general workings of his or her body, it must be taken into consider-
ation with regard to administering anesthesia. However, if the disease is under
control, then its involvement is less of a concern.

EXAMPLE
Dr. Steiner administered general anesthesia to Venice Binle, a 41-year-old female
with controlled type 1 diabetes mellitus, for her radical mastectomy with internal
mammary node dissection, to be performed by Dr. Cabara. The correct code is
00406-P2.

P3 (a patient with severe systemic disease). In this case, the patient’s disease is seri-
ous throughout his or her body and is an important factor for the anesthesiolo-
gist to contend with, in addition to the reason for the procedure.

EXAMPLE
Dr. Jeffries administered general anesthesia to Wilson Meyers, a 62-year-old
male with benign hypertension due to Cushing’s disease. Wilson came today for
Dr. Ephron to perform a laparoscopic cholecystectomy with cholangiography for
acute cholecystitis. The correct code is 00790-P3.

P4 (a patient with severe systemic disease that is a constant threat to life). Modifier
P4 describes any patient having medical problems that have invaded or affected
multiple systems of the body. The large number of issues regarding the effects
of the disease, along with existing medications and treatments that have been
ongoing in the patient’s system, and the potential interactions with the anes-
thetic make it a very complex case.

EXAMPLE
Dr. Rockenbach administers general anesthesia to Ethan Vox, a 71-year-old male.
Ethan has advanced esophageal cancer that has metastasized throughout his
body. Dr. Glasser will be performing a partial esophagectomy. The correct code is
00500-P4.
GUIDANCE
P5 (a moribund patient who is not expected to survive without the operation). This CONNECTION
CPT © 2017 American Medical Association. All rights reserved.

is a life or death situation, but not necessarily an emergency. In such cases, the Read the additional
patient is in critical condition, and there are serious medical complications that explanations in the
make administering anesthesia more challenging. Anesthesia Guidelines,
subsection Anesthesia
Modifiers, in your CPT
EXAMPLE book directly in front of
Dr. Jeppapi administered general anesthesia to Zena Afronski, a 31-year-old the Anesthesia section
female with acute arteriosclerosis. Dr. Able was called back in from vacation to that lists all the codes,
perform a heart/lung transplant this morning. The correct code is 00580-P5. and read the entire
descriptions in
Appendix A, subsection
P6 (a declared brain-dead patient whose organs are being removed for donor pur- Anesthesia Physical
poses). This modifier is provided by the ASA for use with brain-dead patients. Status Modifiers in your
Individuals in this condition need to have anesthesia administered to slow CPT book.
bodily functions and give the transplant team time to harvest the viable organs.
 YOU INTERPRET IT!

Determine which Physical Status Modifier is most accurate from the descriptions below of the patients’
conditions.

1. Uma Koslozki, a 53-year-old female, with controlled hypertension. _____

2. Zachery Gregson is brought into the OR to have knee replacement surgery. He has _____
acute COPD.
3. Tyler Madison is brought in to have his tonsils out. He is a healthy 12-year-old male. _____

24.3  Anesthesia Guidelines

Anesthesia Guidelines
The Official Guidelines specifically intended for coding anesthesia services (general
and regional anesthesia) are shown at length on the pages at the beginning of the
Anesthesia section of the CPT book. Go through these guidelines and review how they
might help you determine the best, most appropriate anesthesia code.
∙ Time Reporting: You will learn more about this method sometimes used to report anes-
thesia services provided. Guidelines for this are included in this front part of the section.
∙ Supplied Materials: You might have questions if the anesthesiologist’s documenta-
tion includes the use of special drugs or equipment such as a surgical tray. These
guidelines include some direction.
∙ Separate or Multiple Procedures: When multiple procedures are performed during
the same operative session, but the anesthesia is continuous, the anesthesia should
be coded for the most complicated procedure only. These guidelines will provide
you with the correct way to report these situations on behalf of the anesthesiologist.
∙ Special Report: There are times when something unusual occurs, or a situation
where a less-than-common procedure is performed. How will this affect your
reporting for the anesthesiologist? Check these guidelines.
∙ Anesthesia Modifiers: You learned about these in the previous chapter on CPT and
HCPCS Level II Modifiers. They are repeated here for your convenience.
∙ Qualifying Circumstances: Later in this chapter, you will learn about these add-on
codes that are used to explain when an anesthesiologist has an additional challenge
keeping the patient sedated and safe. These are listed here, for your ease of reference.

CPT © 2017 American Medical Association. All rights reserved.

CPT HCPCS Level II
YOU CODE IT! CASE STUDY
Gerald Chang, a healthy 19-year-old male, was in a motorcycle accident. Today, Dr. Oliver, an anesthesiologist, was
called in to administer general anesthesia so Dr. Joshua could insert internal fixation on Gerald’s compound fracture
of the right distal ulna and radius, as well as complete an arthroscopic repair of the right rotator cuff.

You Code It!

You need to determine the correct code or codes to report Dr. Oliver’s work during this surgical event. He
administered general anesthesia while Dr. Joshua performed two procedures: insertion of internal fixation on a
compound fracture (01830) + repair of a rotator cuff injury (01630). Identify which Official Guideline will guide
you how to accurately code Dr. Oliver’s work in this case.

698   PART III  |  REPORTING PHYSICIAN SERVICES AND OUTPATIENT PROCEDURES

 Step #1: Read the case carefully and completely.
Step #2: Abstract the scenario. Which key words or terms describe what service the physician provided to the
patient during this encounter?
Step #3: Are there any details missing or incomplete for which you would need to query the physician? [If so, ask
your instructor.]
Step #4: Determine the correct CPT procedure code or codes to explain the details about what was provided to
the patient during this encounter.
Step #5: Check for any relevant guidance, including reading all of the symbols and notations.
Step #6: Do you need to append any modifiers to ensure complete and accurate information is provided?
Step #7: Double-check your work.
Answer:
Did you determine this to be the correct code to report and which Official Guideline did you use?
01830-P1-AA   Anesthesia for open or surgical arthroscopic/endoscopic procedures on distal radius,
distal ulna, wrist, or hand joints; not otherwise specified, healthy patient, anesthesia
administered by anesthesiologist
Two procedures were performed during this one anesthetic administration: the compound fracture is more com-
plex and severe than a rotator cuff injury. Therefore, in accordance with the Official Guidelines titled, “Separate
or Mulitple Procedures,” you will only report the one code for the “most complex procedure.”
Good work!

Anesthesia Code Package

All the codes within the Anesthesia section of the CPT book include activities that
are most often performed by anesthesiologists when they are preparing to administer Anesthesiologists
anesthesia to a patient. The following services are included in the anesthesia code Physicians specializing in the
package and are not coded separately. administration of anesthesia.

1. Usual preoperative visits. Most of the time, the anesthesiologist will stop in to
interview the patient, in addition to taking the time to thoroughly read the chart
and patient history, before administering the anesthesia. It gives the physician
the opportunity to discuss any potential reactions or other considerations with
CPT © 2017 American Medical Association. All rights reserved.

the patient.
2. Anesthesia care during the procedure. The time and expertise the anesthesiolo-
gist spends in addition to administering the actual anesthetic, including observing
the patient throughout the procedure, are very important parts of his or her job
responsibilities.
3. Administration of fluids. The anesthesiologist gives the patient fluids as well as
analgesics (liquid form) as needed during the procedure.
4. Usual monitoring services (such as ECG [electrocardiogram], temperature, BP
[blood pressure]). As a part of the natural course of the anesthesiologist’s duties,
he or she must monitor the patient’s vital signs throughout the procedure and make
certain that there are no unexpected effects from the anesthesia.
5. Usual postoperative visits. The anesthesiologist normally visits the patient while he
or she is in recovery to ensure that there are no lingering effects of the anesthesia
and there are no other concerns as a result of the anesthesia.
 CPT HCPCS Level II
YOU CODE IT! CASE STUDY
PATIENT: DARLENA ESKINE
DATE OF OPERATION: 02/17/2018
PREOPERATIVE DIAGNOSIS: Avascular necrosis, right hip.
POSTOPERATIVE DIAGNOSIS: Avascular necrosis, right hip.
OPERATION PERFORMED: Right total hip arthroplasty.
SURGEON: Arthur Hunter, MD
ANESTHESIOLOGIST: Samuel Samahdi, MD
INDICATIONS FOR OPERATION: The patient is an overall healthy 39-year-old former athlete, who presents for hip
arthroplasty having failed nonoperative treatment options. The risks, benefits, and treatment alternatives were dis-
cussed including, but not limited to, infection, bleeding, blood clots, nerve injury, dislocation, leg length inequal-
ity, prosthetic wear, loosening, need for further surgery, failure to relieve pain, etc. The patient’s questions were
answered, and the surgical plan was approved.
DESCRIPTION OF OPERATION: The patient was taken into the operating room, the appropriate extremity was iden-
tified, and the patient was positioned with appropriate padding to all pressure areas. After sterile skin preparation
and draping, a posterior incision was performed. The skin and subcutaneous tissues were divided to the level of the
fascia, which was then incised along the course of its fibers for a posterior approach. Leg lengths were measured
prior to dislocation and then the hip capsule was excised, and a femoral neck cut was made. The acetabulum was
then exposed and examined. No significant osteophytes were found. No significant acetabular defect was found.
The acetabulum was prepared. The last reamer used was 51 mm. No bone graft was used to reconstruct the
acetabular defect. The acetabular component, 52 mm Pinnacle, was positioned appropriately and impacted into
position, and mechanical stability was achieved. Supplemental screw fixation was not used. A neutral 36 liner was
then appropriately chosen and positioned and the device assembled. Femoral exposure was obtained and the femo-
ral canal was prepared. A trial reduction was performed and hip stability was assessed.
After the appropriate component position was determined, final canal preparation was completed. The compo-
nent was then impacted into position, and mechanical stability was achieved. A trial reduction was performed, leg
length and hip stability were assessed, and the appropriate neck length was chosen, and a +8.5 ceramic head was
impacted into position. The final reduction was performed, and hip stability was assessed. The hip was stable to
90 degrees of internal rotation, 20 degrees of abduction, 20 degrees of extension, 20 degrees of adduction, and
60 degrees of external rotation really with no tendency to dislocate.
The wound was irrigated profusely, a final inspection was performed, and bleeding was controlled and the wound
was closed in layers. The hip capsule was not sutured. A drain was not placed. Sterile dressings were applied, and
a radiograph was ordered. The components were found to be in appropriate alignment. The plan is for a routine
postoperative course with weightbearing as tolerated and ambulation. Sciatic nerve was explored at the end of the
procedure and found to be intact.

You Code It! CPT © 2017 American Medical Association. All rights reserved.

Read this operative report and determine what code or codes should be reported for Dr. Samadhi’s services.
Step #1: Read the case carefully and completely.
Step #2: Abstract the scenario. Which key words or terms describe what service the physician provided to the
patient during this encounter?
Step #3: Are there any details missing or incomplete for which you would need to query the physician? [If so, ask
your instructor.]
Step #4: Determine the correct CPT procedure code or codes to explain the details about what was provided to
the patient during this encounter.
Step #5: Check for any relevant guidance, including reading all of the symbols and notations.

700   PART III  |  REPORTING PHYSICIAN SERVICES AND OUTPATIENT PROCEDURES

 Step #6: Do you need to append any modifiers to ensure complete and accurate information is provided?
Step #7: Double-check your work.
Answer:
Did you determine this to be the correct code to report? 
01214-P1-AA   Anesthesia for open procedures involving hip joint; total hip arthoplasty, healthy
patient, anesthesia administered by anesthesiologist

24.4  Time Reporting

Time reporting may be used for billing general anesthesia services in certain areas or
by certain third-party payers instead of CPT codes. If this is the custom in your local
area, the clock begins when the anesthesiologist starts to prepare the patient for the
administration of the anesthetic drug in the OR and is typically measured in 15-minute
increments. The time ends when the anesthesiologist is no longer required to be pres-
ent, once the patient has been safely transferred to postoperative supervision. When
multiple procedures are completed during the same operative session, the time calcu-
lated should be the total time for all the procedures performed. A formula is used to
calculate the amount of compensation the anesthesiologist will receive. The formula is
Compensation = (B + T + M) × CF
where
  B = base unit
  T = time spent by the anesthesiologist with the patient GUIDANCE
  M = modifying factors CONNECTION
  CF = conversion factor
Read the additional
The base unit is assigned by the American Society of Anesthesiologists (ASA), as explanations in the
published in the annual Relative Value Guide. The unit includes reimbursement for Anesthesia Guidelines,
the usual time and services performed by the anesthesiologist preoperatively and post- subhead Time Report-
operatively. Modifying factors are any adjustments made to allow for the additional ing, in your CPT book
challenges presented by the physical status of the patient at the time anesthesia is directly before the
administered. The conversion factor is the number used to translate units into dollars. Anesthesia section that
Figure 24-1 is an example of an anesthesiologist’s sedation record showing the time lists all the codes.
log of service.
CPT © 2017 American Medical Association. All rights reserved.

YOU INTERPRET IT!

Here are the facts as reported by Dr. Haverall’s sedation record of general anesthesia administered to
Allen Dagmar for his perineal prostatectomy, performed by Dr. Kessler.
Base unit(s): 6
Time: 60 minutes [15 minutes × 4]
Modifying factors: None
Conversion factor: 21.9935
4. Determine the compensation the anesthesiologist should receive.
Remember . . . (B + T + M) × CF = Compensation
FIGURE 24-1  Anesthesiologist’s sedation record

24.5  Qualifying Circumstances

Sometimes special circumstances, also called qualifying circumstances, cause the
anesthetic process to be more complicated than usual. In these cases, a second—or
add-on—code is used to identify that circumstance.
The available add-on codes for qualifying circumstances are CPT © 2017 American Medical Association. All rights reserved.

99100   Patient of extreme age . . . younger than 1 year or older than 70 years
—This add-on code is not to be used when the code description already
includes an age definition, such as code 00326, 00834, or 00836.
99116 Anesthesia complicated by total body hypothermia
—Hypothermia is defined as extremely low body temperature, below
36.1°C (97°F). Because monitoring vital signs, including body temper-
ature, is an important part of the anesthesia process, a very low
body temperature would make the safe administration of anesthesia
more complex.
99135 Anesthesia complicated by controlled hypotension
—Hypotension is defined as abnormally low blood pressure. The critical
connection between blood pressure and heart rate makes this situation

702   PART III  |  REPORTING PHYSICIAN SERVICES AND OUTPATIENT PROCEDURES

 very intricate for the anesthesiologist. Controlled hypotension is utilized
during surgical procedures to reduce bleeding and the need for blood GUIDANCE
transfusions. This has become more popular, as it contributes to a satis- CONNECTION
factory bloodless surgical field.
Read the additional
99140 Anesthesia complicated by emergency conditions explanations in the
—An emergency is characterized as a situation in which the patient’s Anesthesia Guidelines,
life, or an individual body part, would be threatened if there were any subsection Qualifying
delay in providing treatment. In such a case, the anesthesiologist may Circumstances, in your
not have the time to get the patient history or other information neces- CPT book directly in front
sary to do his or her job most efficiently or effectively. of the Anesthesia section
that lists all the codes.

CPT
YOU CODE IT! CASE STUDY
Arlena Smithson, a 77-year-old female, comes to see Dr. Beele for a total knee arthroplasty due to acute arthritis.
Dr. Knight is called in to administer the general anesthesia for the procedure. Arlena is in otherwise good health.

You Code It!

Go through the steps, and determine the code(s) that should be reported for the anesthesia provided by
Dr. Knight to Arlena.
Step #1: Read the case carefully and completely.
Step #2: Abstract the scenario. Which key words or terms describe what service the physician provided to the
patient during this encounter?
Step #3: Are there any details missing or incomplete for which you would need to query the physician? [If so, ask
your instructor.]
Step #4: Determine the correct CPT procedure code or codes to explain the details about what was provided to
the patient during this encounter.
Step #5: Check for any relevant guidance, including reading all of the symbols and notations.
Step #6: Do you need to append any modifiers to ensure complete and accurate information is provided?
Step #7: Double-check your work.
Answer:
Did you determine these to be the correct codes?
01402-P1   Anesthesia for open or surgical arthroscopic procedures on knee joint; total knee
CPT © 2017 American Medical Association. All rights reserved.

arthroplasty; a normal healthy patient

99100 Anesthesia for patient of extreme age, younger than 1 year and older than 70

24.6  Special Circumstances

Unusual Anesthesia
Unusual circumstances might require the administration of general anesthesia for
a procedure that typically requires either local anesthesia or no anesthesia. In these
cases, the modifier 23 Unusual Anesthesia must be appended to the procedure code
for that basic service (not to the anesthesia code); you will not assign a code from the
Anesthesia section of CPT.
 Turn to Appendix A and read the CPT modifier description:
23   Unusual Anesthesia: Occasionally, a procedure, which usually requires either
no anesthesia or local anesthesia, because of unusual circumstances must be
done under general anesthesia. This circumstance may be reported by add-
ing modifier 23 to the procedure code of the basic service.

CPT
LET’S CODE IT! SCENARIO
Louisa Cabaña, a 61-year-old female, arrived for the insertion of a permanent pacemaker, atrial with transvenous
electrodes. Dr. Snyder, knowing that Louisa has been diagnosed with Parkinson’s disease, causing her to have
uncontrollable tremors, decided that conscious sedation (which is the standard of care) was insufficient to ensure
the patient’s safety. He called Dr. Corman to administer general anesthesia.

Let’s Code It!

Dr. Snyder decided that Louisa needed general anesthesia for this procedure, even though it is not the standard,
because her Parkinson’s disease made the procedure unsafe without it. He was inserting a permanent pace-
maker, atrial with transvenous electrodes. Dr. Corman, an anesthesiologist, administered the anesthesia.
The Alphabetic Index shows
Insertion
Pacemaker, Heart. . . . . . . . . . . . . . . . . . 33206–33208
  Pulse Generator Only. . . . . . . 33212, 33213, 3221
Look through the descriptions for the codes in the first range, 33206–33208. Do any of the descriptions match
the notes?
33206  Insertion of new or replacement of permanent pacemaker with transvenous electrode(s); atrial
Before you move on to the next section, remember that Dr. Snyder administered general anesthesia. You will
learn from experience that conscious sedation is the standard of care for this procedure. Generally, there is no
need for general anesthesia—the cost or the risk. General anesthesia is unusual. How will you ensure Dr. Snyder
and Dr. Corman get properly reimbursed for the administration of the anesthesia? This is what modifiers do—
identify unusual circumstances. Modifier 23 is specifically for a case when unusual anesthesia is used.
In this case, the correct code is 33206-23.
You would also include a Supplemental Report to explain the medical necessity for providing this patient with
general anesthesia, so the third-party payer and anyone one else will understand this was the right thing to do
for this patient.

GUIDANCE
CONNECTION
CPT © 2017 American Medical Association. All rights reserved.
Read the additional
Same Physician Administering Anesthesia and Performing
explanations in the
Anesthesia Guidelines, the Procedure
first column, last para- If the physician performing the procedure also administers either regional or general
graph, in your CPT book anesthesia, the modifier 47 Anesthesia by Surgeon must be appended to the procedure
directly before the code for that basic service (not to the anesthesia code). In such cases, an anesthesia
Anesthesia section that code would not be reported. However, it is permissible to report a code for the injec-
lists all the codes, and tion of the anesthetic drug.
read the entire descrip- Turn to Appendix A and read the CPT modifier description:
tion of modifier 47 in
Appendix A, subsection 47   Anesthesia by Surgeon: Regional or general anesthesia provided by the
Modifiers, in your surgeon may be reported by adding modifier 47 to the basic service.
CPT book. (This does not include local anesthesia.) NOTE: Modifier 47 would not be
used as a modifier for the anesthesia procedures.

704   PART III  |  REPORTING PHYSICIAN SERVICES AND OUTPATIENT PROCEDURES

 CPT
YOU CODE IT! CASE STUDY
Hallie Van Masters, a 27-year-old female, came to see Dr. Knowles for a repair of her extensor tendon in her right
wrist. Dr. Knowles administered a regional nerve block and then performed the repair.

You Code It!

Go through the steps, and determine the procedure code(s) that should be reported for this encounter between
Dr. Knowles and Hallie Van Masters.
Step #1: Read the case carefully and completely.
Step #2: Abstract the scenario. Which key words or terms describe what service the physician provided to the
patient during this encounter?
Step #3: Are there any details missing or incomplete for which you would need to query the physician? [If so, ask
your instructor.]
Step #4: Determine the correct CPT procedure code or codes to explain the details about what was provided to
the patient during this encounter.
Step #5: Check for any relevant guidance, including reading all of the symbols and notations.
Step #6: Do you need to append any modifiers to ensure complete and accurate information is provided?
Step #7: Double-check your work.
Answer:

Did you determine these to be the correct codes?

25270-47   Repair, tendon or muscle, extensor, forearm and/or wrist; primary, single, each tendon
or muscle, regional anesthesia administered by surgeon
64450 Injection, anesthetic agent; other peripheral nerve or branch

Excellent!

24.7  HCPCS Level II Modifiers

Specific HCPCS Level II modifiers are designated for use with anesthesia service
codes (see Table 24-1). These modifiers are used only if the insurance carrier, such as
Medicare, accepts HCPCS Level II codes and modifiers. It is your responsibility, as
CPT © 2017 American Medical Association. All rights reserved.

TABLE 24-1  HCPCS Level II Anesthesia-Related Modifiers

AA Anesthesia services performed personally by the anesthesiologist

AD Medical supervision by a physician: more than 4 concurrent anesthesia procedures
G8 Monitored anesthesia care (MAC) for deep complex, complicated, or markedly invasive surgical procedure
G9 Monitored anesthesia care (MAC) for a patient who has a history of a severe cardiopulmonary condition
QK Medical direction of 2, 3, or 4 concurrent anesthesia procedures involving qualified individuals
QS Monitored anesthesiology care services (can be billed by a qualified nonphysician anesthetist or a physician)
QX Qualified nonphysician anesthetist with medical direction by a physician
QY Medical direction of one qualified nonphysician anesthetist by an anesthesiologist
QZ CRNA without medical direction by a physician
 a professional coder, to know the rules for the different third-party payers with which
GUIDANCE you will work.
CONNECTION The QY modifier would be used to indicate that an anesthesiologist was available
Read the HCPCS
and oversaw the administration of anesthesia services provided by someone else, such
Level II code book, sub-
as a CRNA. The QY modifier is for the supervision of one case at a time. QK is used
section Level II National
for two to four cases at one time, and AD is for more than four cases at one time.
Modifiers.

CPT HCPCS Level II

LET’S CODE IT! SCENARIO
PATIENT: RANDOLPH BUTTERMAN
PREOPERATIVE DIAGNOSIS: Caries and tooth eruption disturbance.
POSTOPERATIVE DIAGNOSIS: Caries and tooth eruption disturbance.
SURGICAL PROCEDURE: Extraction of tooth and alveoplasty
#6, 7, 8, 9, 10, 11, 14, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32
IV FLUIDS: 1200 mL of normal saline.
ESTIMATED BLOOD LOSS: 20 cc.
INDICATIONS FOR PROCEDURE: Extractions of remaining teeth under general anesthesia due to severe periodon-
tal disease.
PROCEDURE IN DETAIL: The patient was identified in the preoperative holding area, at which time informed consent
was given by the patient after addressing risks, benefits, and alternatives, and answering all questions. The patient
was then transferred to the operating room. The patient was prepped and draped in a normal fashion.
The patient was anesthetized using general anesthesia due to the extensive nature of the procedure. Dr. Kendale,
an anesthesiologist, personally cared for this patient due to the patient’s uncontrolled type 2 diabetes mellitus.
A bite block was placed, a throat pack was placed, and attention was addressed to teeth #6, 7, 8, 9, 10, 11, 14,
18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32. These teeth were extracted using elevators and forceps.
A mucoperiosteal buccal flap was elevated along the maxilla and mandibular alveolus. The alveolus of the maxilla
and mandible (upper left, right, lower left, right) was trimmed and carved using ronguer forceps and bone files to
appropriately remove undercuts and sharp points. Specimens were sent to pathology. The surgical sites were irri-
gated thoroughly with normal saline. Gel foam was packed into the extraction sockets for hemostasis. The tissue was
closed with 3-0 chromic gut sutures.
Dentures were fitted and found to have adequate retention and occlusion. Gauze was then packed over dentures
for pressure hemostasis.

CPT © 2017 American Medical Association. All rights reserved.

Let’s Code It!
You are going to report Dr. Kendale’s services as the anesthesiologist during this surgery. First, the anesthesia
code. Turn to the Alphabetic Index in your CPT book, and find:
Anesthesia
There is a very long list beneath this main term. Look for teeth—no listing, extraction—no listing, . . . try . . .
Mouth . . . . . . . 00170, 00172
Turn to the Anesthesia section in the Main Part of CPT, and take a look:

00170  Anesthesia for intraoral procedures, including biopsy; not otherwise specified
00172 Anesthesia for intraoral procedures, including biopsy; repair of cleft palate

706   PART III  |  REPORTING PHYSICIAN SERVICES AND OUTPATIENT PROCEDURES

 There is no documentation that Randolph had a cleft palate, so 00172 cannot be reported. What about 00170?
Intraoral means within the oral cavity. That’s accurate. But what about the biopsy? There is no indication a biopsy
was performed during these extractions, or was it. Read again, the sentence “Specimens were sent to pathol-
ogy.” That supports the biopsy, so you now can confirm 00170 as the correct code.
Do you need any modifiers? You have already learned that every anesthesia code requires a Physical Status
Modifier. Is there anything in the documentation that will help you? Look at “the patient’s uncontrolled type 2
diabetes mellitus.” This sentence will lead you to Physical Status Modifier P3.
Do you need to report any other modifiers? Dr. Kendale is an anesthesiologist, and he personally admin-
istered the anesthesia for this procedure. Is there a modifier that can report this? Check the list. Modifier AA
explains this perfectly.
Now, you can report this code with these modifiers to clearly communicate Dr. Kendale’s work during this
procedure.
00170-P3-AA Anesthesia for intraoral procedures, including biopsy; not otherwise specified, patient
with severe systemic disease, anesthesia services performed personally by the
anesthesiologist
Good work!

Chapter Summary
For the most part, anesthesia coding is for the purposes of submitting health insurance
claim forms on behalf of the anesthesiologist or a member of his or her staff, such as
a CRNA.
To find the best, most appropriate code that accurately represents the anesthesia
services administered, you must first know which type of anesthesia was used. Then
you must determine the anatomical site upon which the procedure was performed and
exactly which procedure was provided to the patient. In addition, you must know who
administered the anesthesia to the patient: Was it the physician who also performed
that procedure, or was it a different health care professional? When using HCPCS
Level II modifiers, you also need to know whether the physician who administered the
anesthetic was an anesthesiologist.
Once you determine the best, most appropriate code for the dispensation of the
anesthesia, you also have to append the correct modifiers, when applicable.
CPT © 2017 American Medical Association. All rights reserved.

CODING BITES
Physical Status Modifiers

P1   A normal healthy patient

P2 A patient with mild systemic disease
P3 A patient with severe systemic disease
P4 A patient with severe systemic disease that is a constant threat to life
P5 A moribund patient who is not expected to survive without the
operation
P6 A declared brain-dead patient whose organs are being removed for
donor purposes
CHAPTER 24 REVIEW

Qualifying Circumstances Add-On Codes

99100   Patient of extreme age

99116 Anesthesia complicated by total body hypothermia
99135 Anesthesia complicated by controlled hypotension
99140 Anesthesia complicated by emergency conditions

You Interpret It! Answers

1. P2, 2. P4, 3. P1, 4. $527.84

CHAPTER 24 REVIEW
CPT Anesthesia Section Enhance your learning by
completing these exercises and
more at connect.mheducation.com!

Let’s Check It! Terminology

Match each key term to the appropriate definition.
1. LO 24.1  The administration of sedatives, anesthetic agents, or other medications A. Anesthesia
to relax but not render the patient unconscious while under the constant B. Anesthesiologists
observation of a trained anesthesiologist; also known as “twilight”
C. Certified Registered
sedation.
Nurse Anesthetist
2. LO 24.1  The loss of sensation, with or without consciousness, generally induced (CRNA)
by the administration of a particular drug.
D. Conscious Sedation
3. LO 24.1  The application of a drug to the skin to reduce or prevent sensation in a
E. General Anesthesia
specific area temporarily.
F. Local Anesthesia
4. LO 24.1  The administration of a drug in order to interrupt the nerve impulses
without loss of consciousness. G. Monitored Anesthesia
Care (MAC)
5. LO 24.1  The administration of a drug in order to induce a loss of consciousness
in the patient, who is unable to be aroused even by painful stimulation. H. Regional Anesthesia
6. LO 24.1  The use of a drug to reduce stress and/or anxiety. I. Topical Anesthesia
7. LO 24.3  Physicians specializing in the administration of anesthesia.
8. LO 24.1  A registered nurse (RN) who has taken additional, specialized training
in the administration of anesthesia.
CPT © 2017 American Medical Association. All rights reserved.
9. LO 24.1  The injection of a drug to prevent sensation in a specific portion of the
body; includes local infiltration anesthesia, digital blocks, and puden-
dal blocks.

CPT HCPCS Level II

Let’s Check It! Concepts
Choose the most appropriate answer for each of the following questions.
1. LO 24.1  The categories of anesthesia include all except
a. topical/local. b.  moderate sedation. c.  regional. d.  general.
2. LO 24.2  A normally healthy patient presents today for lens surgery. What would be the correct anesthesia code
for this procedure?
a. 00140-P1 b.  00142-P2 c.  00142-P1 d.  00144-P3

708   PART III  |  REPORTING PHYSICIAN SERVICES AND OUTPATIENT PROCEDURES

 3. LO 24.6  Unusual circumstances might require the administration of general anesthesia for a procedure that typi-

CHAPTER 24 REVIEW
cally requires either local anesthesia or no anesthesia. What modifier would be appended to the proce-
dure code in these circumstances?
a. 23 b.  QZ c.  47 d.  G9
4. LO 24.1  MAC is an acronym that stands for
a. medically administered care. c.  monitored anesthesia care.
b. mutually accessible care. d.  medical anesthetic characters.
5. LO 24.7  All of the following are HCPCS Level II modifiers except
a. AD    b.  G8    c.  57    d.  QX
6. LO 24.2  When the physician performing the procedure also administers regional or general anesthesia, modifier
47 should
a. be appended to the correct anesthesia code.
b. be appended to the correct procedure code.
c. be appended to either the correct anesthesia code or the correct procedure code.
d. not be used in this circumstance.
7. LO 24.3  The anesthesia code package includes all except
a. preoperative visits. c.  usual monitoring services.
b. postoperative visits. d.  home health follow-up.
8. LO 24.4  When reporting anesthesia services using time reporting, the formula used is
a. (B + T + M) × CF b.  (B + Q + CF) × T c.  (Q + T + CF) × B d.  (CF + B + T) × M
9. LO 24.5  Qualifying circumstances are conditions that might require more work on the part of the anesthesiolo-
gist, including all except
a. extreme age. c.  severe systemic disease.
b. emergency conditions. d.  total body hypothermia.
10. LO 24.2  A Physical Status Modifier describes issues that may increase the complexity of delivering anesthetic
services, including
a. emergency situations. c.  extreme age.
b. mild systemic disease. d.  controlled hypotension.

Let’s Check It! Guidelines

CPT © 2017 American Medical Association. All rights reserved.

Refer to the Anesthesia Guidelines and fill in the blanks accordingly.

five-digit over 99155, 99156, 99157 safely Medicine

minimal second All complex moderate
multiple ends anesthesia 99070 physical status modifier
plus total not facility deep
99151, 99152, 99153 nonfacility single above “P”
time separately monitored 1 to 6

1. Services involving administration of _____ are reported by the use of the anesthesia _____ procedure code plus
modifier codes.
2. To report _____ (conscious) sedation provided by a physician also performing the service for which conscious
sedation is being provided, see codes _____.
 3. When a second physician other than the health care professional performing the diagnostic or therapeutic services
CHAPTER 24 REVIEW

provides moderate (conscious) sedation in the _____ setting, the second physician reports the associated moderate
sedation procedure/service _____; when these services are performed by the second physician in the _____
setting, codes 99155, 99156, 99157 would _____ be reported.
4. Moderate sedation does not include _____ sedation (anxiolysis), _____ sedation, or _____ anesthesia care.
5. Anesthesia _____ begins when the anesthesiologist begins to prepare the patient for the induction of anesthesia
in the operating room and _____ when the anesthesiologist is no longer in personal attendance, that is, when the
patient may be _____ placed under postoperative supervision.
6. “Special Services and Reporting” are listed in the _____ section.
7. Supplies and materials provided _____ and _____ those usually included in the office visit or other services
rendered may be listed _____. Drugs, tray supplies, and materials provided should be listed and identified with
_____ or the appropriate supply code.
8. When _____ surgical procedures are performed during a _____ anesthetic administration, the anesthesia code
representing the most _____ procedure is reported. The time reported is the combined _____ for all procedures.
9. _____ anesthesia services are reported by use of the anesthesia five-digit procedure code _____ the addition of a _____.
10. Physical Status modifiers are represented by the initial letter _____ followed by a single digit from _____.

Let’s Check It! Rules and Regulations

HCPCS Level II

Please answer the following questions from the knowledge you have gained after reading this chapter.
1. LO 24.2  List the six steps to coding anesthesia.
2. LO 24.3  What is included in the anesthesia code package?
3. LO 24.4  Why is time important to coding anesthesia? When does the clock start and stop?
4. LO 24.5  List the qualifying circumstance add-on codes with their description.
5. LO 24.7  Explain the difference between HCPCS Level II modifiers QX, QY, and QZ.

CPT HCPCS Level II

YOU CODE IT! Basics
Using the techniques described in this chapter, carefully read through the case studies and determine the most
accurate anesthesia code(s) and modifier(s), if appropriate, for each case study.
1. Dr. Carey administers general anesthesia so Dr. Tucker can perform a transconjunctival blepharoplasty.
Patient has a diagnosis of controlled hypertension.

CPT © 2017 American Medical Association. All rights reserved.

2. Dr. Tumbokon administers anesthesia and performs a biopsy to rule out salivary duct carcinoma. Patient is
otherwise healthy.
3. Dr. Lynn administers anesthesia before performing a bone marrow aspiration on Mayra Magazine’s posterior
iliac crest. Mayra is a 36-year-old female who has been diagnosed with anemia and congestive heart failure.
4. Tierra, a healthy 29-year-old female, is taken to the OR, where Dr. Denmark administers spinal anesthesia
and performs a tubal ligation by bipolar coagulation method.
5. Geoffrey Foulks, an otherwise healthy 11-week-old male, is taken to the OR to repair his congenital cleft lip.
Geoffrey weights 12 lbs. and has a 10 g/dL hemoglobin. Dr. Fairbanks administers general anesthesia and Dr.
Olafson successfully performs the Millar procedure.
6. Paulette Milling, a 51-year-old female, has been diagnosed with a thyroid cyst. She presents today for a
needle biopsy of the thyroid cyst. Dr. Singletary administers general anesthesia because of her epilepsy. Oth-
erwise, she is healthy.

710   PART III  |  REPORTING PHYSICIAN SERVICES AND OUTPATIENT PROCEDURES

 CHAPTER 24 REVIEW
7. Brian, a healthy 13-month-old male, is brought to the OR, where Dr. Thomas administers general anesthesia
so Dr. Richardson, a pediatric urologist, can perform a laparoscopic orchipexy.
8. Jessica Hamilton, an otherwise healthy 12-year-old female, was playing in a treehouse when she fell approximately
6 feet, causing a tracheobronchial injury (TBI). Jessica was taken to the OR on an emergency basis, where Dr.
Mortimer administers general anesthesia so Dr. Skipper can perform the tracheobronchial reconstruction.
9. The patient is taken to the OR, where Dr. Sidney administers the general anesthesia so Dr. Weigle, an ortho-
pedic surgeon, can perform an ankle arthroplasty. Patient has an implanted pacemaker.
10. Dr. Benefield administers anesthesia and performs a vasectomy. Patient is otherwise healthy.
11. Dr. Simmons administers anesthesia and performs a thoracentesis, no imaging guidance.
12. Dr. Coleman administers anesthesia for Dr. Cho to harvest a liver from a brain-dead patient for
transplantation.
13. Dr. Caulkins administers anesthesia for pelvic body cast application revision. The patient is otherwise healthy.
14. Dr. Jones administers anesthesia for osteotomy of the humerus. Patient has been diagnosed with ongoing car-
diac ischemia.
15. Dr. Payne administers anesthesia for third-degree burn debridement; total body surface 5%. Patient has been
diagnosed with well-controlled DM/HTN.

CPT HCPCS Level II

YOU CODE IT! Practice
Using the techniques described in this chapter, carefully read through the case studies and determine the most ac-
curate anesthesia code(s) and modifier(s), if appropriate, for each case study.
1. Connie Huffman, a healthy 28-year-old female, received anesthesia before delivering her son at the hospital.
It was a vaginal delivery. Patient is otherwise healthy.
2. Dr. Masters administered general anesthesia to Ashton Hopkins, an otherwise healthy 32-year-old firefighter.
Dr. Woody performed a third-degree burn excision, followed by a skin grafting on Ashton’s chest, where 9%
of his body surface was burned while he was rescuing a little girl from a house fire.
3. David Wolff, a 53-year-old male, was previously diagnosed with benign hypertension due to morbid obesity.
Dr. Adams administers general anesthesia so that Dr. McKnight can perform a direct venous thrombectomy
on his lower left leg.
4. Dr. Carroll administered anesthesia to Margaret Lindler, a 41-year-old female, diagnosed with a malignant
CPT © 2017 American Medical Association. All rights reserved.

neoplasm of the uterus. Her gynecologist, Dr. Ramage, performed a vaginal hysterectomy.
5. Dr. Billingsworth administered anesthesia to Ralph Skipper, a 7-month-old male requiring a hernia repair
in the lower abdomen. Dr. Sims, the neonatologist, noted that, without the surgery, Ralph was not expected
to survive.
6. Martha Gantt, a 76-year-old female with a history of hypertension and diabetes mellitus, is brought into
the OR for Dr. Brunson to perform a corneal transplant. Dr. Williams, the anesthesiologist, administers the
anesthesia.
7. Dr. Elliston is preparing to perform a ventriculography with burr holes on Daniel Ewing, a 12-year-old male,
who fell off the monkey bars onto a cement floor yesterday. Dr. Hallbeck administers the anesthesia. Daniel is
otherwise healthy.
8. Dr. Hanh administers anesthesia so that Dr. Lindholm can perform a diagnostic lumbar puncture on Keith
Franklin, a 56-year-old male. Over the course of the last year, Keith, a construction worker, has developed
CHAPTER 24 REVIEW

essential hypertension, which is currently controlled by diet. This lumbar puncture is to confirm the suspected
diagnosis of bacterial meningitis.
9. Gerry Sherman, a healthy 28-year-old male, plays professional basketball and is given anesthesia by
Dr. Wallace before having a diagnostic arthroscopy of his right knee by Dr. Hook.
10. Carlton Dazquez, a 17-year-old male, was in a go-kart accident and fractured his upper arm 3 months ago.
Today, Dr. Hytower operated on him to repair the malunion of his humerus. Dr. Murphy administered the
anesthesia. Carl is otherwise healthy.
11. Trisha Moultrie brought her 3-year-old daughter, Tamara, into the emergency room with a deep laceration
of her scalp above her right ear, measuring 2.25 cm. Tamara was distraught, crying, and combative, kicking
at the physician and the nurse as they attempted to clean the wound. At the recommendation of Dr. White,
Trisha held Tamara in her lap, while the physician administered 1 mg of Versed, IM. Once the sedation took
effect, Dr. White was able to perform a layered repair of the laceration while the nurse monitored Tamara’s
vital signs. The entire procedure took 25 minutes. Code the moderate sedation only.
12. Regina Weyeneth, a healthy 23-year-old female, was given an epidural during labor, with the expectations of
a vaginal delivery. After a time, Dr. Bedenbaugh, her obstetrician, determined that the labor was obstructed
and notified the hospital staff, that they would have to do a cesarean (c-section).
13. Dr. Anderson administered anesthesia to Barbara Brooks, a 52-year-old female, in preparation of the breast
reconstruction with TRAM flap to be performed by Dr. Mocase. Barbara has a history of breast cancer and is
postmastectomy; she is otherwise healthy.
14. Dr. Solington brought Howard Chen, a 10-month-old male, into the OR for repair of his complete transpo-
sition of the great arteries under cardiopulmonary bypass. Pump oxygenation was used. Howard was not
expected to survive without the surgery. Dr. Misher, the anesthesiologist, administered the anesthesia.
15. Meredith Susswell, a 79-year-old female, was given anesthesia by Dr. Yabsley, the anesthesiologist, in prepa-
ration for the repair of her ventral hernia in her lower abdomen, to be performed by Dr. Carrouth. Meredith
has uncontrolled diabetes mellitus and essential hypertension.

YOU CODE IT! Application

CPT HCPCS Level II

The following exercises provide practice in the application of abstracting the physicians’ notes and learning to
work with documentation from our health care facility, Anytown Anesthesiology Associates. These case studies are
modeled on real patient encounters. Using the techniques described in this chapter, carefully read through the case
studies and determine the most accurate anesthesia code(s) and modifier(s), if appropriate, for each case study.

ANYTOWN ANESTHESIOLOGY ASSOCIATES

241 MAIN STREET • ANYTOWN, FL 32711 • 407-555-1234 CPT © 2017 American Medical Association. All rights reserved.

PATIENT: PERSILE, LORRAINE

ACCOUNT/EHR #: PERSLO001
DATE: 10/15/18
Preoperative DX: Locked right knee, rule out medial meniscus tear
Postoperative DX: 1. Grade 2 tear, anterior, cruciate ligament
2. Medial meniscus tear, anterior, horn
3. Grade 2 chondrosis, medial femoral condyle

712   PART III  |  REPORTING PHYSICIAN SERVICES AND OUTPATIENT PROCEDURES

 CHAPTER 24 REVIEW
Procedure: 1. Arthroscopy
2. Partial anterior cruciate ligament debridement
3. Partial medial meniscectomy
Attending Physician: Renee O. Bracker, MD
Anesthesia: General
Anesthesiologist: Lawrence Miller, MD
INDICATIONS: The patient is a 33-year-old female who was in her usual state of good health until about
10 days ago when she sustained a twisting injury to the right knee with inability to fully extend the knee,
with pain and swelling.
PROCEDURE: Estimated blood loss: None. Complications: None. Tourniquet time: See anesthesia notes.
Specimens: None. Drains: None. Disposition: To the recovery room in stable condition.
Pt was taken to surgery and placed on the OR table in the supine position. After adequate general
anesthesia was administered, she received a gram of intravenous Kefzol preoperatively. A proximal
thigh tourniquet was applied. Examination revealed no significant Lachman or drawer and a moderate
effusion. No varus or valgus instability. Distal pulses intact. The right lower extremity was placed in the
arthroscopic leg holder; shaved, prepped, and draped in the usual meticulously sterile fashion for lower
extremity surgery. Esmarch exsanguinations of the limb were performed, and the tourniquet was inflated.
Proximal medial, anteromedial, and anterolateral portals were fashioned. A systematic evaluation of the
knee was performed. The undersurface of the patella demonstrated normal tracking with no chondrosis.
The suprapatellar pouch, medial, and lateral gutters were well within normal limits, and in the notch a
grade 2 tear of the anterior cruciate ligament was identified. There were some bloody fragments of the
ACL that seemed to be impinging in the medial compartment. This was meticulously debrided. Approxi-
mately 50% of the ACL appeared to be intact. Attention was turned to the lateral compartment. The
articular surface of the meniscus was normal. On the medial side, a grade 2 lesion in medial femoral con-
dyle, lateral side, was noted. This was not debrided. Also, an anterior tear of the medial meniscus, which
was frayed and torn, was another potential source of impingement. This was meticulously debrided to
a smooth, stable mechanical limb, and the wound was irrigated and closed with 4-0 nylon simple inter-
rupted sutures. Xeroform, 4 × 4s, Webril and Ace bandage from the tips of the toes to the groin com-
pleted the sterile dressing. There were no intraoperative or immediate postoperative complications. The
prognosis is good, although it may be limited by potential for arthritis and instability in the future.

LM/mg  D: 10/15/18 09:50:16  T: 10/23/18 12:55:01

Determine the most accurate anesthesia code(s) and modifier(s), if appropriate.

CPT © 2017 American Medical Association. All rights reserved.

ANYTOWN ANESTHESIOLOGY ASSOCIATES

241 MAIN STREET • ANYTOWN, FL 32711 • 407-555-1234
PATIENT: HAMMOND, NEIL
ACCOUNT/EHR #: HAMMNE001
DATE: 10/21/18
Preoperative DX: C5–C6 and C6–C7 herniated nucleus pulposus
Postoperative DX: Same
Procedure: C5–C6 and C6–C7 anterior cervical diskectomy and fusion with cadaver bone and plate
CHAPTER 24 REVIEW

Attending Physician: Oscar R. Prader, MD

Anesthesia: General endotracheal
Anesthesiologist: Eric Keist, MD
INDICATIONS: The patient is a 35-year-old male with a history of neck and arm pain. MRI scan showed
disk herniation at C5–C6 and C6–C7. The patient failed conservative measures and was subsequently
set up for surgery. Patient has been diagnosed with DM/HTN, which is well under control.
PROCEDURE: The patient was taken to the OR. The patient was induced, and an endotracheal tube was
placed. A Foley catheter was placed. The patient was given preoperative antibiotics. The patient was
placed in slight extension. The left neck was prepped and draped in the usual manner. A linear incision
was made above the C6 vertebral body. The platysma was divided. Dissection was continued medial
to the sternocleidomastoid to the prevertebral fascia. The longus colli were cauterized and elevated.
The C5–C6 disk space was addressed first. A retractor was placed. A large anterior osteophyte was
removed with a large Leksell and drill. Distraction pins were then placed. The disk space was drilled
out. Large bone spurs were drilled posteriorly. The posterior longitudinal ligament was removed. A free
fragment was removed from beneath the ligament. The dura was visualized. A piece of bank bone was
measured and slightly countersunk. The C6–C7 disk space was then addressed. Distraction pins were
placed. A large anterior osteophyte was removed with a large Leksell and drill. The disk space was
drilled out. Large bone spurs were drilled posteriorly. The Kerrison punch was used to remove the pos-
terior longitudinal ligament. The dura was visualized. One piece of bank bone was in the C5, one in the
C6, and two in the C7 vertebral bodies. The locking screws were tightened. The wound was irrigated.
A drain was placed. The platysma was approximated with simple interrupted Vicryl. The dressing was
applied. The patient was placed in a soft collar. The patient tolerated the procedure without difficulty. All
counts were correct at the end of the case. The patient was extubated and transferred to recovery.

EK/mg  D: 10/21/18 09:50:16  T: 10/23/18 12:55:01

Determine the most accurate anesthesia code(s) and modifier(s), if appropriate.

ANYTOWN ANESTHESIOLOGY ASSOCIATES

241 MAIN STREET • ANYTOWN, FL 32711 • 407-555-1234
PATIENT: WAYMEN, MARK
ACCOUNT/EHR #: WAYMMA001
DATE: 11/07/18
Preoperative DX: Inguinal hernia, right
CPT © 2017 American Medical Association. All rights reserved.
Postoperative DX: Inguinal hernia, right, direct and indirect
Procedure: Repair of right inguinal hernia with mesh
Attending Physician: Oscar R. Prader, MD
Anesthesia: General
Anesthesiologist: Lawrence Miller, MD
PROCEDURE: The patient is a 41-year-old male who was taken to the OR and prepped in the usual
sterile fashion. After satisfactory anesthesia, a transverse incision was made above the inguinal liga-
ment and carried down to the fascia of the external oblique, which was then opened, and the cord was
mobilized. The ilioinguinal nerve was identified and protected. A relatively large indirect hernia was

714   PART III  |  REPORTING PHYSICIAN SERVICES AND OUTPATIENT PROCEDURES

 CHAPTER 24 REVIEW
found. However, there was an extension of the hernia, such that one could definitely tell there had been
a long-standing hernia here that probably had enlarged fairly recently. The posterior wall, however,
was quite dilated and without a great deal of tone and bulging as well, and probably fit the criteria for a
hernia by itself. Nonetheless, the hernia sac was separated from the cord structures, and a high ligation
was done with a purse string suture of 2-0 silk and a suture ligature of the same material prior to ampu-
tating the sac. The posterior wall was repaired with Marlex mesh, which was sewn in place in the usual
manner, anchoring two sutures at the pubic tubercle tissue, taking one lateral up the rectus sheath
and one lateral along the shelving border of Poupart’s ligament past the internal ring. The mesh had
been incised laterally to accommodate the internal ring. Several sutures were used to tack the mesh
down superiorly and laterally to the transversalis fascia. Then the two limbs of the mesh were brought
together lateral to the internal ring and secured to the shelving border of Poupart’s ligament. The mesh
was irrigated with Gentamicin solution. The subcutaneous tissue was closed with fine Vicryl, as was the
internal oblique. Marcaine was infiltrated in the subcutaneous tissue and skin. The wound was closed
with fine nylon. The patient tolerated the procedure well.

LM/mg  D: 11/07/18 09:50:16  T: 11/11/18 12:55:01

Determine the most accurate anesthesia code(s) and modifier(s), if appropriate.

ANYTOWN ANESTHESIOLOGY ASSOCIATES

241 MAIN STREET • ANYTOWN, FL 32711 • 407-555-1234
PATIENT: DRESSLER, SIMONE
ACCOUNT/EHR #: DRESSI001
DATE: 11/15/18
Preoperative DX: Chronic cholelithiasis
Postoperative DX: Chronic cholelithiasis; subacute cholecystitis
Procedure: Laparoscopic cholecystectomy; intraoperative cholangiogram
Attending Physician: Renee O. Bracker, MD
Anesthesia: General endotracheal
Anesthesiologist: Melinda Abruzzo, MD
PROCEDURE: The patient, a 57-year-old female, was taken to the OR. The patient was induced and an
endotracheal tube was placed. The patient was then placed in the supine position. The abdomen was
CPT © 2017 American Medical Association. All rights reserved.

prepped and draped in the usual fashion. The patient had several previous lower midline incisions and
right flank incision; therefore, the pneumoperitoneum was created via epigastric incision to the left of
the midline with a Verres needle. After adequate pneumoperitoneum, the 11-mm trocar was placed
through the extended incision in the left epigastrium just to the left of the midline, and the laparoscope
and camera were in place. Inspection of the peritoneal cavity revealed it to be free of adhesions, and
another 11-mm trocar was then placed under direct vision through a small infraumbilical incision. The
scope and camera were then moved to this position, and the gallbladder was easily visualized. The
gallbladder was elevated, and Hartmann’s pouch was grasped. Using a combination of sharp and
blunt dissection, the cystic artery was identified. The gallbladder was somewhat tense and subacutely
inflamed. Therefore, a needle was passed through the abdominal wall into the gallbladder, and the gall-
bladder was aspirated free until it collapsed. One of the graspers was held over this region to prevent
any further leakage of bile. Again, direction was turned to the area of the triangle of Calot. The cystic
duct was dissected free with sharp and blunt dissection. A small opening was made in the duct, and the
CHAPTER 24 REVIEW

cholangiogram catheter was passed. The cholangiogram revealed no stones or filling defects in the bile
duct system. The biliary tree was normal. There was good flow into the duodenum, and the catheter
was definitely in the cystic duct. The catheter was removed, and the cystic duct was ligated between
clips, as was the cystic artery. The gallbladder was then dissected free from the hepatic bed using
electrocautery dissection, and it was removed from the abdomen through the umbilical port. Inspection
of the hepatic bed noted that hemostasis was meticulous. The region of dissection was irrigated and
aspirated dry. The trocars were removed, and the pneumoperitoneum was released. The incisions were
closed with Steri-Strips, and the umbilical fascial incision was closed with 2-0 Maxon. The patient toler-
ated the procedure well; there were no complications. She was returned to the recovery room awake
and alert.

MA/mg  D: 11/15/18 09:50:16  T: 11/19/18 12:55:01

Determine the most accurate anesthesia code(s) and modifier(s), if appropriate.

ANYTOWN ANESTHESIOLOGY ASSOCIATES

241 MAIN STREET • ANYTOWN, FL 32711 • 407-555-1234
PATIENT: LYNDON, JAMES
ACCOUNT/EHR #: LYNDJA001
DATE: 12/01/18
Preoperative DX: Sensory deficit of common digital nerve; tendon laceration
Postoperative DX: Same
Procedure: Repair of digital nerve, right hand; repair of tendon laceration
Attending Physician: Renee O. Bracker, MD
Anesthesia: General
Anesthesiologist: Eric Keist, MD
INDICATIONS: The patient is a 23-year-old male who was stabbed in the right hand during a street fight.
Examination showed a sensory deficit of the thumb and index finger due to an injury to the common
digital nerve and a tendon laceration involving the abductor pollicis and first dorsal interosseous. He
was taken immediately to the OR for repair.
PROCEDURE: The patient was taken to the OR. General anesthesia was administered, a tourniquet was
applied, and the wound was explored. The common digital nerve to the thumb was identified and found
CPT © 2017 American Medical Association. All rights reserved.
to be divided at the level just proximal to the first metacarpal. The digital nerve to the radial aspect of
the index finger was also divided. The abductor pollicis and the first dorsal interosseous tendons were
then repaired with 3-0 Vicryl to the fascia.
Following this, both digital nerves were repaired by using interrupted 9-0 Nylon, suturing epineurium
to epineurium. When completed, the wound was thoroughly irrigated with saline solution and the skin
was closed with interrupted Ethilon. A dorsal splint was applied to the thumb and remains in IP flexion at
about 30 degrees and slight adduction. Tourniquet time totaled 190 minutes.

EK/mg  D: 12/01/18 09:50:16  T: 12/04/18 12:55:01

Determine the most accurate anesthesia code(s) and modifier(s), if appropriate.

716   PART III  |  REPORTING PHYSICIAN SERVICES AND OUTPATIENT PROCEDURES

 CPT Surgery Section

Learning Outcomes
25
Key Terms
After completing this chapter, the student should be able to: Allotransplantation
Arthrodesis
LO 25.1 Distinguish among the types of surgical procedures. Closed Treatment
LO 25.2 Determine which services are included in the global surgi- Complex Closure
cal package. Donor Area (Site)
LO 25.3 Interpret the impact on coding of the global time frames. Excision
LO 25.4 Identify unusual services and treatments and report them Fornix
Full-Thickness
accurately.
Global Period
LO 25.5 Abstract physician documentation of procedures on the Harvesting
integumentary system. Intermediate Closure
LO 25.6 Apply the guidelines, accurately, for coding procedures on Laminectomy
the musculoskeletal system. Manipulation
LO 25.7 Recognize the details required to accurately report proce- Open Treatment
Percutaneous Skeletal
dures on the respiratory system.
Fixation
LO 25.8 Identify guidelines to correctly report services to the car- Recipient Area
diovascular system. Saphenous Vein
LO 25.9 Distinguish the various procedures on the digestive Simple Closure
system. Standard of Care
LO 25.10 Ascertain the elements of coding services to the urinary Surgical Approach
Transplantation
system.
LO 25.11 Determine how to accurately report procedures on the
genital systems: male and female.
LO 25.12 Interpret documentation to accurately report procedures
on the nervous system.
LO 25.13 Recognize the necessary details to report procedures on
the eye, ocular adnexa, and auditory system.
LO 25.14 Report accurately the different services provided during an
organ transplant.
CPT © 2017 American Medical Association. All rights reserved.

LO 25.15 Demonstrate the proper way to report the use of an operat-

ing microscope with a CPT code.

Remember, you need to follow along in

CPT

  STOP! your CPT code book for an optimal

learning experience.
 25.1  Types of Surgical Procedures
Typically, a surgical procedure can be performed in any one of several locations: the
physician’s office, an ambulatory care center, or a hospital. Of course, the location
will most often be determined by the intensity or complexity of the procedure. You
certainly would not expect an entire operating room (OR) at the hospital to be used
for a physician repairing a simple laceration (cut), and no one could imagine agreeing
to have a heart transplant performed in a physician’s office. As a coding specialist,
your responsibilities will vary, depending upon where you work, when it comes to
coding surgical procedures. In addition, there may be more than one coding specialist
involved with reporting one procedure.

EXAMPLE
For a surgical procedure performed in a hospital operating room (OR), there may
be as many as three coders involved:
1. The hospital’s coder codes for the support personnel, facilities, and supplies.
2. The surgeon’s coder codes for his or her professional services.
3. The anesthesiologist’s coder codes for his or her professional services.

Coding operative reports and procedure notes becomes easier with experience
because the longer you work for a physician or facility, the more you will learn about
the procedures and services he or she performs. Experience will train you to decipher
which services are included in procedures and which are not. Throughout this chapter
and the next, the guidelines and specifications for coding the various types of surgical
and nonsurgical procedures are reviewed.
In CPT, the term surgery is not limited to only those services and treatments per-
formed in an operating room (OR) or even in a hospital. Within this section of the CPT
book, codes are listed that report
∙ Incision and drainage of a cyst
∙ Debridement
∙ Simple repair of a superficial wound
All these services can easily be performed in a physician’s office. In addition,
many procedures are now performed at an ambulatory surgical center or outpatient
department.
When hearing the word surgery, most people picture an all-white room with health
care professionals dressed in masks, gowns, and gloves and a patient under general
anesthesia. However, this is a very narrow perspective on surgical procedures. You, as
a professional coding specialist, need to understand the various types of surgical pro-
CPT © 2017 American Medical Association. All rights reserved.
cesses because this detail may be important for determining the most accurate code.

Prophylactic, Diagnostic, and Therapeutic Procedures

Under certain circumstances, the purpose of a procedure will affect the code you use
to report the service. Three key terms to watch for are prophylactic, diagnostic, and
therapeutic.
∙ A prophylactic treatment is one that is performed to prevent a condition from devel-
oping. This may be a surgical procedure, a series of injections, or a prescription.
∙ A diagnostic procedure or test is performed so that the physician can gather more
details about a condition or concern at issue. In other words, the reason for per-
forming the test or procedure is to get closer to an accurate diagnosis.
∙ A therapeutic procedure is provided, most often, to correct or fix a problem.

718   PART III  |  REPORTING PHYSICIAN SERVICES AND OUTPATIENT PROCEDURES

 EXAMPLES
27187 Prophylactic treatment (nailing, pinning, plating or wiring) with or with-
out methylmethacrylate, femoral neck and proximal femur
49320 Laparoscopy, abdomen, peritoneum and omentum, diagnostic, with Surgical Approach
or without collection of specimen(s) by brushing or washing (separate The methodology or tech-
procedure). nique used by the physician
50541 Laparoscopy, surgical; ablation of renal cysts to perform the procedure, ser-
vice, or treatment.

There are times when, for the safety of the patient, a procedure begins as a diag- GUIDANCE
nostic examination and turns into a therapeutic procedure. Generally, a therapeutic or CONNECTION
surgical procedure will include the diagnostic portion, thereby requiring only one code
when both are done during the same encounter. Read additional expla-
Above, in both of the two laparoscopic codes (49320 and 50541), CPT includes nations in the Surgery
the guideline “Surgical laparoscopy always includes diagnostic laparoscopy.” There- Guidelines, subheads
fore, if the physician performed a diagnostic laparoscopy solely to determine what was Follow-Up Care for
wrong with the patient, the correct code might be 49320. However, if while the physi- Diagnostic Proce-
cian was performing the diagnostic laparoscopy, he observed a renal cyst and decided dures and Follow-Up
to ablate the cyst at the same time, this would mean that a diagnostic procedure (to Care for Therapeutic
discover the cyst) and a therapeutic procedure (ablation of the cyst) were done at the Surgical Procedures, in
same time. In that case, only 50541 might be reported, as it is one code that includes your CPT book directly
both the diagnostic and therapeutic portions of the procedure. in front of the Surgery
section that lists all the
Surgical Approaches codes.

Procedure coding requires that you understand the various surgical approaches a Follow-Up Care for
physician can take to provide care for a patient: Diagnostic Procedures
When a diagnostic pro-
∙ A noninvasive, or external, procedure is one that does not enter the patient’s body;
cedure is performed,
these are procedures that are applied or performed directly to the skin without
the code includes only
physical entry into the visceral (internal) part of the body. An example of a nonin-
that care related to the
vasive procedure is a shave biopsy, a technique to acquire pathology specimens of
recovery from this pro-
an elevated growth on the skin by razor.
cedure, not any treat-
∙ Minimally invasive procedures are becoming more and more available as health ment for the condition
care researchers continue to find methods to diagnose and correct problems with identified. Care for the
the least amount of trauma to the patient. Although there is a big difference in our condition (therapeutic
perception between a patient being stabbed by a mugger and a patient being cut services) is not included.
open by a physician during a surgical procedure, the human body knows only that
it is being invaded by a sharp piece of metal. It is traumatic, and healing must occur Follow-Up Care for
at the point of the incision as well as to whatever was done to internal organs. Therapeutic Surgical
Procedures
CPT © 2017 American Medical Association. All rights reserved.

∙ The percutaneous approach uses instruments inserted into the body by way of a
puncture or small incision to access the intended anatomical site. Example: needle The code report-
biopsy. ing the provision of a
therapeutic procedure
∙ The percutaneous endoscopic approach uses instruments inserted into the body by
only includes the care
way of a puncture or small incision to access and visualize the intended anatomical
related to that proce-
site. Example: diagnostic anoscopy.
dure. Complications,
∙ The via natural or artificial opening approach involves instrumentation entered exacerbations, recur-
into the body through a natural opening (such as the vagina) or an artificial open- rence, or the presence
ing (such as a stoma) to visualize the intended anatomical site. Example: flexible of other diseases or
esophagoscopy. injuries requiring addi-
∙ The via natural or artificial opening endoscopic approach involves insertion of a tional services should
scope through a natural opening (such as the mouth) or an artificial opening (such be separately reported.
as a stoma) to visualize and aid in the performance of a procedure on the intended
anatomical site. Example: colonoscopy with polyp removal.
 ∙ Open approach procedures are fully invasive, as the surgeon cuts the body open
to enable access to internal tissues and organs. These procedures involve using a
scalpel or laser to cut through the skin, membranes, and body layers to access the
intended anatomical site.

EXAMPLES
Surgical procedures on a woman’s uterus can be performed using
• The vaginal canal as the entry point (endoscopic using a natural opening) to
avoid surgical entry through the abdomen, reported with
58262 Vaginal hysterectomy, for uterus 250g or less; with removal of
tube(s) and/or ovary(s)
• Laparoscopy (a minimally invasive procedure through the abdominal cavity) via
small incisions into the patient’s skin and muscle, reported with
58542 Laparoscopy, surgical, supracervical hysterectomy, for uterus
250g or less; with removal of tube(s) and/or ovary(s)
• Open procedure with a longer incision through the abdominal wall, reported
with
58150 Total abdominal hysterectomy (corpus and cervix), with or with-
out removal of tube(s), with or without removal of ovary(s)
You can see that all three of these codes accurately report a hysterectomy (the
surgical removal of the uterus) with the removal of the fallopian tubes and ovaries.
The difference between these codes is the surgical technique reported: 58150
reports an open abdominal procedure using an incision through the patient’s
abdominal wall, 58262 reports a procedure using a natural orifice (the vagina) so
that no surgical incision was required, and 58542 reports a laparoscopic proce-
dure that uses three tiny incisions in the patient’s abdomen. The information pro-
vided by the reporting of these different versions of this procedure includes not
only the level of work required by the physician to perform the procedure but also
the level of postoperative care that the patient will require.

YOU INTERPRET IT!

Interpret each of these procedural statements to determine the type of procedure being documented:
Diagnostic, Prophylactic, or Therapeutic.
1. Biopsy was performed to determine if mass is benign or malignant. _____________
CPT © 2017 American Medical Association. All rights reserved.
2. Lithotripsy to destroy kidney stones. _____________
3. Cholecystectomy. _____________
4. Pneumonia vaccine administered. _____________
Interpret each of these procedural statements to determine the type of surgical approach being docu-
mented: Open, Percutaneous, or Endoscopic/Laparoscopic.
5. A 7 cm incision was made. _____________
6. A needle-biopsy was performed. _____________
7. The scope was passed through the patient’s mouth into the stomach. _____________

25.2  The Surgical Package

One of the trickiest portions of coding surgical events is distinguishing between which
services and procedures are included in the code and which services and procedures

720   PART III  |  REPORTING PHYSICIAN SERVICES AND OUTPATIENT PROCEDURES

 might need to be coded separately for additional reimbursement. Whereas the services
included in each surgical protocol may vary with the procedure itself, some elements GUIDANCE
are already integrated in most CPT codes. CONNECTION
Read additional
Services Always Included explanations in the
Let’s begin by reviewing services that are always included in CPT surgical procedure Surgery Guidelines,
codes. subhead CPT Surgical
Once the physician and patient agree to move forward with the operation or proce- Package Definition, in
dure, the surgical package includes the following elements: your CPT book directly
in front of the Surgery
1. Evaluation and management (E/M) encounters provided after the decision to have section that lists all the
surgery. These visits may begin the day before the surgical procedure (for more codes.
complex procedures) or the day of the procedure (for minor procedures), as needed.
2. Local infiltration, metacarpal/metatarsal/digital block, or topical anesthesia. You
learned about the different types of anesthesia in the chapter CPT Anesthesia Section.
The surgical package includes specific types of local and regional anesthesia services CODING BITES
only when they are provided by the surgeon (the same professional who will be per- Remember that an
forming the procedure). encounter that ends
3. The operation itself, along with any services normally considered a part of the pro- with an agreement
cedure being performed. This would include supplies, as well as applying sutures, to have surgery is
bandages, casts, and so on to enable the patient to leave the OR safely after the reported with an E/M
procedure. code appended with
4. Immediate postoperative care. This includes assessing the patient in the recovery modifier 57 Decision
area; attending to any complications exhibited by the patient (not including any for Surgery. This is a
additional trips to the OR); dictating or writing the operative notes; talking with the notification of a surgical
patient, the patient’s family, and other health care professionals; and writing orders. package that will soon
begin.
5. Follow-up care. This care includes postoperative visits; care for typical complications
following surgery; pain management; dressing changes; removal of sutures, staples,
tubes, casts, and so on; and any other services considered to be the standard of care, Standard of Care
during the global period for the specific surgical procedure. However, be careful. The accepted principles of
Some procedures may require a longer period of postoperative care by the surgeon. conduct, services, or treat-
The period is determined by the accepted standard of care guidelines for each spe- ments that are established as
cific procedure and the details regarding the particular patient’s health. More about the expected behavior.
this in the section Global Period Time Frames. Global Period
6. Supplies provided in a physician’s office. With a few specific exceptions, included The length of time allotted for
supplies are determined by the insurance carrier. postoperative care included in
the surgical package, which is
generally accepted to be 90
Services Not Included days for major surgical proce-
dures and up to 10 days for
Some functions that are commonly performed when a patient is going to have, or has
CPT © 2017 American Medical Association. All rights reserved.

minor procedures.
had, surgery are not included in the surgical package. When such services and/or pro-
cedures are performed, you must code them separately.
1. Diagnostic tests and procedures. Tests or procedures that the physician needs to
confirm the medical necessity for the surgery or investigate other issues related to
the surgery are coded separately.

EXAMPLE
Diagnostic tests and procedures, such as biopsies, blood tests, and x-rays.

2. Postoperative therapies. Examples of postoperative therapies include immuno-

suppressive therapy after an organ transplant and chemotherapy after surgery to
remove a malignancy.
 3. A more comprehensive version of the original procedure. If the physician attempted
CODING BITES to use a less extensive procedure first that was not sufficient to treat the patient, the
For a surgical biopsy second, more extensive procedure would be coded separately, with its own surgical
followed by a surgical package; it is not an extension of the first procedure. Also, the CPT code for the
procedure in response second event would be appended with modifier 58.
to the results of that
biopsy, the surgical
procedure (not the EXAMPLE
biopsy) code would be Dr. Keystone performed a lumpectomy on Joan Calcanne’s left breast. The biopsy
appended with modifier of the tissue removed during the lumpectomy showed that the malignancy had
58 Staged or related spread farther through the breast. Dr. Keystone had to take Joan back into the OR
procedure or service 1 week later for a simple, complete mastectomy. The code for the mastectomy is
by the same physician appended with modifier 58.
during the postopera- 19301 Mastectomy, partial (e.g., lumpectomy, tylectomy, quadrantectomy,
tive period. segmentectomy)
19303-58 Mastectomy, simple, complete, more extensive procedure

4. Staged or multipart procedures. Each stage or operation has its own surgical pack-
CODING BITES age and global period for aftercare. You must add modifier 58 to the second proce-
There are some codes dure code and all additional procedure codes reported for the same encounter.
that are exempt from
58 Staged or Related Procedure or Service by the Same Physician During
using modifier 58.
the Postoperative Period. It may be necessary to indicate that the perfor-
Take a look at codes
mance of a procedure or service during the postoperative period was: (a)
67141–67229 for some
planned or anticipated (staged); (b) more extensive than the original proce-
examples. Notice that
dure; or (c) for therapy following a surgical procedure. This circumstance
each code’s descrip-
may be reported by adding modifier 58 to the staged or related procedure.
tion includes the phrase
“one or more sessions.”
EXAMPLE
Albert Rodgers, a 31-year-old male, suffered a fracture to his upper arm that
severely damaged the shaft of his right humerus. Dr. Curran decides to first do a
bone graft to support the healing process of the fracture and to follow that with a
second surgical procedure—an osteotomy—in about 4 weeks. This is a staged, or
multipart, surgical procedure.
24516 Treatment of humeral shaft fracture, with insertion of intramedul-
lary implant, with or without cerclage and/or locking screws
24400-58 Osteotomy, humerus, with or without internal fixation, staged pro-
cedure by the same physician during the postoperative period

5. Management of postoperative complications that require additional surgery. As CPT © 2017 American Medical Association. All rights reserved.
you may remember about the surgical package from Services Always Included
(earlier in this section), the physician’s attention to any postoperative complications
is included in the original package unless those complications require the patient to
return to the operating room. In such cases, you must use a modifier with the CPT
code for the procedure performed.
76 Repeat Procedure by the Same Physician. It may be necessary to indicate
that a procedure or service was repeated subsequent to the original proce-
dure or service. This circumstance may be reported by adding modifier 76
to the repeated procedure or service.
78 Unplanned Return to the Operating/Procedure Room by the Same Physi-
cian Following Initial Procedure for a Related Procedure During the Post-
operative Period. It may be necessary to indicate that another procedure
was performed during the postoperative period of the initial procedure

722   PART III  |  REPORTING PHYSICIAN SERVICES AND OUTPATIENT PROCEDURES

 (unplanned procedure following initial procedure). When this procedure is
related to the first, and requires the use of an operating/procedure room, it
may be reported by adding modifier 78 to the related procedure.

EXAMPLE
Lilly Drummond, a 14-year-old female, was burned on her left forearm when she
missed catching a flaming baton during cheerleading practice. Five days ago, Dr.
Cheng applied a skin allograft to the burned area. Lilly is admitted today because
the graft is not healing properly, and Dr. Cheng is going to apply a new allograft of
20 sq. cm.
15271-76 Application of skin substitute graft to trunk, arms, legs, total
wound surface area up to 100 sq. cm.; first 25 sq. cm. or less
wound surface area; repeat procedures by the same physician

77 Repeat Procedure by Another Physician. The physician may need to indi-

cate that a basic procedure or service performed by another physician had
to be repeated. This situation may be reported by adding modifier 77 to the
repeated procedure/service.

EXAMPLE
Ray DeVilldus, an 18-year-old male, was stabbed in the chest during a fight. Dr.
Swartz performed a complex repair of a 6-cm laceration of the chest. The next day,
Dr. Swartz left for a medical conference. The guy who stabbed Ray showed up at the
hospital, and Ray got out of bed, against doctor’s orders, and engaged in another
fight, ripping open his stitches. Dr. Tyson, filling in for Dr. Swartz, had to take Ray back
into the OR and redo the repair. Dr. Tyson will send the claim with the following code:
13101-77 Repair, complex, trunk; 2.6 cm to 7.5 cm; repeat procedure by
another physician

6. Unrelated surgical procedure during the postoperative period. If the same physician
must perform an unrelated surgical procedure during the postoperative period, you
have to include a modifier to explain that this procedure has nothing to do with the first.
79 Unrelated Procedure or Service by the Same Physician During the Post-
operative Period. The physician may need to indicate that the performance
of a procedure or service during the postoperative period was unrelated to
the original procedure. This circumstance may be reported by using modi-
fier 79.
CPT © 2017 American Medical Association. All rights reserved.

EXAMPLE
Judith Conchran, a 41-year-old female, had a gastric bypass performed by Dr.
Fellowes 10 days ago. She comes to see him today because she has a fever and
pain radiating across her abdomen. Dr. Fellowes examines her, calls an ambu-
lance, and takes her to the hospital and up to the operating room, where he
performs an appendectomy to remove her ruptured appendix. The global post-
operative period for a gastric bypass is 90 days. Dr. Fellowes performed Judith’s
appendectomy during the postoperative period for the bypass, and it had nothing
to do with the first procedure. Therefore, our correct code would be
44960-79 Appendectomy; for ruptured appendix with abscess or general-
izedperitonitis;unrelatedprocedureorservicebythesamephysicianduring
the postoperative period
 7. Supplies. In certain cases, for certain procedures performed in a physician’s office,
a separate code is permitted for supplies, such as a surgical tray, casting supplies,
splints, and drugs. You have to check the reimbursement rules for the specific third-
party payer.

EXAMPLE
Illea Beurus was prepped and ready for the procedure to begin. Dr. Hernandez
performed the closed manipulation of the fracture. Instead of the usual plaster
cast, fiberglass was used.
99070 Supplies and materials (except spectacles), provided by the physician
or other qualified health care professional over and above those usu-
ally included with the office visit or other services rendered (list drugs,
trays, supplies, or materials provided)

YOU INTERPRET IT!

Determine if the service or procedure provided in these statements is Included in the Surgical code
(package) or Reported with a separate code.
8. Jeanine came to see Dr. Kidmon in his office 1 week after he performed her hysterectomy, as he
instructed her to do. He wanted to check her sutures and healing progress. __________________
9. While at Dr. Kidmon’s office, Jeanine asked him to check her left breast because she felt a lump. He
was concerned and performed a biopsy on the lump. __________________
10. After Dr. Kidmon performed a mastectomy on Jeanine’s left breast, he explained to her that
they would need to complete a series of skin grafts. One graft would be done each month
for 3 months. All are part of the postoperative care for mastectomy patients. Jeanine agreed.
__________________

25.3  Global Period Time Frames

Essentially, all procedures have assigned global period time frames based on the stan-
dard of care for a treatment or service. These range from 0 (zero) for a very simple
procedure to 10 days for a minor procedure to 90 days for major surgery.
CPT © 2017 American Medical Association. All rights reserved.

Zero Day Postoperative Period

For procedures such as endoscopies and some minor procedures:
∙ No preoperative period
∙ No postoperative days
∙ Visit on day of procedure is generally not payable as a separate service

10-Day Postoperative Period

For other minor procedures, 10 days following the day of the surgery:
∙ No preoperative period 
∙ Visit on day of the procedure is generally not payable as a separate service 

724   PART III  |  REPORTING PHYSICIAN SERVICES AND OUTPATIENT PROCEDURES

 EXAMPLE GUIDANCE
Dr. Bartlett performed a diagnostic flexible esophagoscopy with a biopsy on CONNECTION
Wendy Crosek on April 5. The last day of the global period for this procedure will Refer to the Global
be April 15. Surgery Fact Sheet from
CMS:

90-Day Postoperative Period https://www.cms.gov/

Outreach-and-Educa-
For major procedures, the total global period is actually 92 days: 1 day before the day tion/Medicare-Learn-
of the surgery plus the day of surgery plus 90 days immediately following the day of ing-Network-MLN/
surgery. MLNProducts/
∙ One day preoperative included  downloads/
GloballSurgery-
∙ Day of the procedure is generally not payable as a separate service ICN907166.pdf
To find the official
EXAMPLE Global Surgery Period
for each CPT code,
Dr. Brennan saw Mira Sisto in his office on February 4 to confirm the arrangements
use the Physician Fee
and answer any last-minute questions for her intestinal allotransplantation surgery
Schedule Look-Up Tool:
the next day.
On February 5, Dr. Brennan performed the intestinal allotransplantation from a https://www.cms.gov/
cadaver donor to Mrs. Sisto. Medicare/Medicare-
The last day of the postoperative period is May 5. Fee-for-Service-
Payment/PFSlookup/
index.html
Scroll all the way down
YOU INTERPRET IT! the page to ACCEPT. This
will bring you to the next
Use your resources and good critical thinking to determine the global screen, where you will
surgery period for these procedures. specify the parameters
11. Metacarpal osteotomy [CPT code 26565] _______________ about the code you are
12. Initial pericardiocentesis [CPT code 33010] _______________ seeking information.
13. Cervical lymphadenectomy [CPT code 38724] _______________ Remember, CPT is also
known as HCPCS Level
14. Placement of seton [CPT code 46020] _______________
I, so in that field, you can
15. Cystourethroscopy, with biopsy [CPT code 52204] _______________
enter the CPT code. Click
SUBMIT.
On the next screen,
25.4  Unusual Services and Treatments be certain to click
“Show All Columns”
CPT © 2017 American Medical Association. All rights reserved.

Treatment Plan Provided by More Than One Physician

It is expected that the same physician will provide all of the surgical package’s ele-
ments. This is an umbrella that covers only one health care professional.
Occasionally, however, more than one physician will be involved in providing all
the necessary services for one patient having one operation. In such cases, modifiers
explain to the third-party payer who did what and when.
54 Surgical Care Only. You must add this modifier to the correct CPT surgical
procedure code when your physician is only going to perform the procedure
itself, and not provide or be involved in any preoperative or postoperative
care of the patient.
55 Postoperative Management Only. This modifier is added to the CPT code for
the surgical procedure included on a claim from the physician who only cares
for the patient after the operation.
 56 Preoperative Management Only. When a physician, other than the surgeon
who performed the procedure, cares for the patient from the decision to have
surgery up to but not including the operation itself, modifier 56 is appended
to the CPT code for the procedure.

CPT
LET’S CODE IT! SCENARIO
Nadia Forrester, a 37-year-old female, was on vacation, hiking through the mountains, when she fell over a log and
wrenched her knee very badly. She was flown to the nearest hospital and placed under the care of Dr. Petrone.
After the diagnostic tests were completed, Dr. Petrone recommended arthroscopic surgery to treat the knee. Dr.
Petrone called in Dr. Wellington, an orthopedic surgeon, to perform the procedure. Dr. Wellington performed a surgi-
cal arthroscopy and repaired the medial meniscus. Immediately after the surgery, Nadia flew home, and she went to
her family physician, Dr. Shields, for the follow-up appointments.

Let’s Code It!

The notes indicate that Dr. Petrone, Dr. Wellington, and Dr. Shields were all involved, to some extent, in caring for
Nadia during the procedure—surgical arthroscopy and repair of the medial meniscus. Let’s go to the Alphabetic
Index and look up the procedure.
Find arthroscopy. As you go down the list, you will see the subcategories Diagnostic and Surgical. You know
from the notes that this was surgical. Continue down and find the anatomical site for this procedure: Knee . . .
29871–29889. Indented under knee, you will find additional listings that don’t really match, so let’s look at the
suggested codes:
29871 Arthroscopy, knee, surgical; for infection, lavage and drainage
The description is correct, up to the semicolon. So continue down the page to find any additional information
that might be applicable to the case, according to our documentation. (Remember: Read up to the semicolon on
the code because it is at the margin, and then finish the description with each indented description.)
Continue reading until you see
29882   with meniscus repair (medial OR lateral)
The complete description of this code is
29882 Arthroscopy, knee, surgical; with meniscus repair (medial OR lateral)
This matches the notes exactly, doesn’t it? It does! Good job!
As you have learned, the surgical package for this procedure includes all the services and treatments that
Nadia received. However, instead of just one physician, Nadia actually had three doctors caring for her through-
out. Each physician will send his or her own claim form in an effort to get paid for the services he or she pro-
vided. You need to supply some explanation to the third-party payer so that it can understand receiving three
claim forms for one procedure provided to the one patient.

CPT © 2017 American Medical Association. All rights reserved.

Dr. Petrone will have the 29882-56 code with modifier to indicate he only provided the preoperative
care.
Dr. Wellington will have the 29882-54 code with modifier to indicate he only performed the surgery.
Dr. Shields will have the 29882-55 code with modifier to indicate she only provided the postoperative
care.

Increased Procedural Services

Every service and treatment or procedure has an industry standard of care. Included in
the assessment of each service is a calculation of how much work is involved and how
long it will take to complete the procedure. It is all part of the formula used by third-
party payers to determine how much to pay the health care professional. As you might
expect, though, particularly in health care, things do not always go exactly as planned.
There may be an issue with a patient that requires more work on the physician’s part.

726   PART III  |  REPORTING PHYSICIAN SERVICES AND OUTPATIENT PROCEDURES

 When this happens, the physician should receive additional compensation. Therefore,
you have to attach the modifier 22 to the procedure code to identify an unusual circum-
stance. You also have to attach documentation that fully explains the circumstances.
22 Increased Procedural Services. When the work required to provide a service
is substantially greater than typically required, it may be identified by add-
ing modifier 22 to the usual procedure code. Documentation must support
the substantial additional work and the reason for the additional work (i.e.,
increased intensity, time, technical difficulty of procedure, severity of patient’s
condition, physical and mental effort required). Note: The modifier should not
be appended to an E/M service.

CPT
YOU CODE IT! CASE STUDY
Fredrick Stiner, a 15-year-old male, is 5 ft. 6 in., 365 lb. Dr. Girst performs a partial colectomy with anastomosis. The
procedure, however, takes several hours longer than usual due to the fact that Frederick is morbidly obese.

You Code It!

Go through the steps, and determine the procedure code(s) that should be reported for this encounter between
Dr. Girst and Fredrick Stiner.
Step #1: Read the case carefully and completely.
Step #2: Abstract the scenario. Which key words or terms describe what service the physician provided to the
patient during this encounter?
Step #3: Are there any details missing or incomplete for which you would need to query the physician? [If so,
ask your instructor.]
Step #4: Determine the correct CPT procedure code or codes to explain the details about what was provided
to the patient during this encounter.
Step #5: Check for any relevant guidance, including reading all of the symbols and notations.
Step #6: Do you need to append any modifiers to ensure complete and accurate information is provided?
Step #7: Double-check your work.
Answer:
Did you determine this to be the correct code?
44140-22   Colectomy, partial; with anastomosis, increased procedural service
In addition to the code, you should attach a letter with the claim to explain the circumstance that complicated
the procedure.
CPT © 2017 American Medical Association. All rights reserved.

GUIDANCE
CODING BITES CONNECTION
Read the entire description of these modifiers, and all others, in your CPT book, Read the additional
Appendix A. explanations in the
Surgery Guidelines,
subhead Separate
Separate Procedure Procedure, in your CPT
book directly in front of
Throughout the CPT book, you will see code descriptions that include the notation “sep- the Surgery section that
arate procedure.” Such services and treatments are generally performed along with a lists all the codes.
group of other procedures. When this happens, you will be able to find a combination, or
 bundled, code that includes all the treatments together. However, this particular procedure
can also be performed alone. If so, you would use the code for the “separate procedure.”

CPT
LET’S CODE IT! SCENARIO
Dr. Capella performed a repair of the secondary tendon flexor in Bruce Roden’s right foot. He first performed an
open tenotomy and then did the repair with a free graft.

Let’s Code It!

The repair that Dr. Capella performed on Bruce Roden actually includes the tenotomy. Therefore, we will use the
one combination code for the entire procedure.
Go to the Alphabetic Index, and look up the procedure: repair. Under Repair, let’s find the anatomical site:
foot. Under foot, let’s find the part of the foot that was treated: tendon. The Alphabetic Index suggests the code
range 28200–28226, 28238. Let’s go to the first one.
28200 Repair, tendon, flexor, foot; primary or secondary, without free graft, each tendon
28202   secondary with free graft, each tendon (includes obtaining graft)
It seems we have found the code description that matches the physician’s notes.
28202 Repair, tendon, flexor, foot; secondary with free graft, each tendon (includes obtaining graft)
Great job!
Had Dr. Capella performed the tenotomy only, the correct code would be
28230 Tenotomy, open, tendon flexor; foot, single or multiple tendon(s) (separate procedure)
On occasion, you may find that the “separate procedure” is performed along with other procedures, not those
in the bundle. Should this be the situation, you have to add the modifier 59 to the “separate procedure” code.
Documentation must support these facts, as always.
59 Distinct Procedural Service. When the physician performs a procedure or service that is not nor-
mally performed with the other procedures or services, modifier 59 should be added to the second
procedure.

25.5  Integumentary System

The largest organ of the human body, the skin, is the main component of the integu-
mentary system, along with the hair and nails. Most people take this for granted. Yet
this is the body’s protective layer, the first line of defense for the anatomical organs
and systems within.

Incision and Drainage (I&D) CPT © 2017 American Medical Association. All rights reserved.
CODING BITES A cyst, an abscess, a furuncle (boil), or a paronychia (infected skin around a finger-
Remember: there is a nail or toenail) can harbor infection. When this happens, most often a physician will
difference between inci- perform an incision (cut into the tissue) and drainage (I&D) to extract the infectious
sion and excision. material.
Incision means cut into,
while excision means Debridement
cut out.
The process of carefully cleaning out a wound to encourage the healing process is
called debridement. The basis of this term comes from the word debris, meaning
wreckage or rubble, and relates to the process of taking away necrotic (dead or dying)
tissue that can impede the creation of new, healthy tissue. This may be necessary
for burn patients, for victims of penetrating wounds, and sometimes for patients with
complex wounds such as an open, penetrating fracture.

728   PART III  |  REPORTING PHYSICIAN SERVICES AND OUTPATIENT PROCEDURES

 EXAMPLE
11000 Debridement of extensive eczematous or infected skin; up to 10%
of body surface
11001   each additional 10% of the body surface, or part thereof

You can see, from the descriptions of the codes in this subsection, that you will
need to identify the total body surface area (TBSA) that was debrided, in order to
determine an accurate code.

Biopsies
Biopsies are performed, most often, for diagnostic purposes. These procedures are
done to obtain a sampling of cells or piece of tissue from the body that can then
be pathologically analyzed. Although a specimen of tissue may be excised, shave
removed, or lased and then sent to pathology for testing, this does not automatically
indicate the need for a separate biopsy code. The guidelines state that you should
use a biopsy procedure code only when the procedure is conducted individually, or
distinctly separate, from any other procedure or service performed at the same time.

EXAMPLE
Paula had a rash that would not go away. So, she went to see Dr. Denardo, a der-
matologist, who took a biopsy of one of the pustules in an effort to diagnose
the cause of her rash. Dr. Denardo closed the small defect with one stitch.
Dr. Denardo’s coder would report
11100 Biopsy of skin, subcutaneous tissue and/or mucous membrane
(including simple closure), unless otherwise listed; single lesion

There are many different types of biopsies, and you will need to know the details
(from the documentation) to help you determine the correct code: GUIDANCE
CONNECTION
∙ Fine-needle aspiration biopsy: the physician uses a thin needle to draw out—or
drain—a specimen (some fluid or gas) to be used for pathology testing. Read the additional
∙ Core-needle biopsy: the physician uses a hollow needle, a bit larger than the needle used explanations in the
during a fine-needle biopsy, to extract a cylindrical section of tissue to be analyzed. in-section guidelines
located within the
∙ Excisional biopsies and incisional biopsies: a sampling of tissue of the abnormal area;
Surgery section, sub-
an entire organ or tumor is taken during the procedure and sent to the pathology lab. 
head Biopsy, directly
∙ Endoscopic biopsy: during a percutaneous endoscopy or via a natural or artificial above code 11100 in
opening endoscopic procedure, a specimen of an abnormal or suspicious tissue is
CPT © 2017 American Medical Association. All rights reserved.

your CPT book.

obtained and sent to the lab.

CPT
LET’S CODE IT! SCENARIO
Seth Berensen, a 69-year-old male, came to see Dr. Tyner to get rid of some skin tags on his left cheek. After apply-
ing a local anesthetic, Dr. Tyner removed nine tags and sent them to the lab.

Let’s Code It!

Let’s go to the Alphabetic Index and find the key term for the procedure: removal. Now, what did the physician
remove? Skin tags. Find the term “skin tags” indented under Removal . . . skin tags . . . : the codes suggested

(continued)
 are 11200–11201. Turn to the numeric listing of the book, in the Surgery section, and look for those codes. You
will see
  11200 Removal of skin tags, multiple fibrocutaneous tags, any area; up to and including 15 lesions
11201   each additional 10 lesions or part thereof (list separately in addition to code for primary
  procedure)
  (Use 11201 in conjunction with 11200)
The next question is . . . How many skin tags (lesions) did the physician remove from Seth’s face? When you
reread the notes, you will see that he removed nine tags. This confirms the correct code is 11200.
The notes also indicate that the lesions were sent to pathology, meaning a biopsy. Should we add another
code for the biopsy? Remember that the guidelines state that a separate code for the biopsy is used only when
the biopsy is a procedure distinctly separate from other procedures and not a part of another service. In this
case, the biopsy is a part of the removal of the skin tags and does not require a second code.

Excisions
Excision When the physician removes a lesion from a patient, you must code the excision of each
The full-thickness removal of lesion separately. Codes for the excision, or full-thickness removal (Figure 25-1), of a
a lesion, including margins; lesion are determined first by the anatomical site from where the lesion was removed
includes (for coding purposes) and then by the size of the lesion removed. The code for the excision includes the
a simple closure. administration of a local anesthetic and a simple closure of the excision site, as men-
Full-Thickness tioned in the definition.
A measure that extends from To correctly measure what was excised, you must look at the dimensions of the
the epidermis to the connec- lesion itself plus a proper margin around the lesion. That will give you the total amount
tive tissue layer of the skin. actually excised by the physician and lead you to the correct code. In order to find the
correct size of the lesion excised, we must do the following: Add the size of the lesion
Simple Closure
A method of sealing an open- to the size of the margin doubled (margins all around mean that the diameter will have
ing in the skin (epidermis or a margin on each side).
dermis), involving only one The formula is
layer. It includes the admin-
Coded size of lesion = size of lesion + (size of margins × 2)
istration of local anesthesia
and/or chemical or electro- As always, you must read carefully. Some surgeons include the measurement of the
cauterization of a wound not margins in their operative notes. In other cases, you may need to review the patholo-
closed. gist’s report to determine an accurate measurement. And, typically, the measurements
will be presented in centimeters (cm). Just in case:
1 centimeter (cm) = 10 millimeters (mm) = 0.4 inch (in.)
1 millimeter (mm) = 0.1 centimeter (cm) = 0.04 inch (in.)
GUIDANCE
CPT © 2017 American Medical Association. All rights reserved.
1 inch (in.) = 2.54 cm
CONNECTION
Read the additional
explanations in the in-
section guidelines within
the Surgery section,
subheads Excision—
Benign Lesions, directly
above code 11400; Incision
Excision—Malignant Safety margin
of normal skin
Lesions, directly above
Skin lesion
code 11600; and Exci-
sion, directly above
code 19081, in your
CPT book. FIGURE 25-1  This illustration shows how you will determine the size of the lesion
for coding

730   PART III  |  REPORTING PHYSICIAN SERVICES AND OUTPATIENT PROCEDURES

 CPT
LET’S CODE IT! SCENARIO
Dr. Lanahan excised a lesion that measured 2.0 cm by 1.0 cm, with 0.2-cm margins all around, from Anson Hillam’s
neck. The pathology report confirmed that the lesion was benign.

Let’s Code It!

Let’s go to the Alphabetic Index and find the suggested code or codes. Look up excision for the procedure and
then neck for the anatomical site, right? Well, you will see that there is no listing for neck under excision. What
should you do now? Analyze what you see in the physician’s notes. Where exactly is the lesion? It isn’t really on
his neck; it is on his skin. So look at excision, skin. Aha! Under skin, you will see lesion. Good. And now, look for
benign, as per the notes, to find suggested codes 11400–11471.
When you go to the numeric listing, you will see the description for the first code in our range:
11400 Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk,
arms or legs; excised diameter 0.5 cm or less
The description for code 11400 matches our physician’s notes except for the mention of the anatomical sites:
trunk, arms, or legs. Our patient had the lesion on her neck. Continue looking down the listings, and take a look
at the description for code 11420.
11420 Excision, benign lesion including margins, except skin tag (unless listed elsewhere), scalp,
neck, hands, feet, genitalia; excised diameter 0.5 cm or less
This matches our physician’s notes! Next, you must determine the size of the lesion. Remember the formula:
Coded size of lesion = size of lesion + size of margins × 2
To the size of the lesion (2.0 cm, which is its largest measurement), we add the size of the margin (0.2 cm) times
2 (margins all around mean that the diameter will have a margin on each side). With the figures in place, our
formula becomes
Coded size of lesion = 2.0 cm + 0.2 cm × 2 = 2.4 cm
Therefore, the total size of the lesion excised is 2.4 cm. Now find the descriptions indented underneath 11420.
11423 Excision, benign lesion including margins, except skin tag (unless listed elsewhere), scalp,
neck, hands, feet, genitalia; excised diameter 2.1 to 3.0 cm
This matches exactly. You have found the code: 11423. Good work!

You may find that the physician’s notes indicate that the excision of the lesion was
complicated or unusual in some way. Should this be the situation, remember to add
modifier 22 Increased Procedural Services to the procedure code. The difficulty is
CPT © 2017 American Medical Association. All rights reserved.

related to the process of excising the lesion, not the closure.

CPT
LET’S CODE IT! SCENARIO
Dr. Samsune excised a lesion that measured 2.1 by 3.0 cm, with 0.5-cm margins on each side, from Sally Hardy’s
abdomen. Sally is diagnosed clinically obese and the excess fatty tissue around the lesion required a complex clo-
sure of the excision site. The pathology report confirmed that the lesion was malignant.

Let’s Code It!

The Alphabetic Index will direct you to a slightly different group of codes—excision, skin, lesion, malignant—
suggesting a code within the range of 11600–11646. Just as before, you will need to find the code in this range
that identifies the correct anatomical location of the lesion:

(continued)
 11600 Excision, malignant lesion including margins, trunk, arms or legs; excised diameter 0.5 cm or less
The abdomen is a part of the trunk, so this code is OK. Next, you will need to add up the size of the lesion.
Coded size of lesion = 3.0 cm + (0.5 cm × 2) = 4.0 cm
The answer 4.0 cm leads to the code
11604 Excision, malignant lesion including margins, trunk, arms or legs; excised diameter 3.1 to
4.0 cm
Excellent! Sally’s case was not as complicated as Anson’s, so modifier 22 will not be required. However, Dr. Samsune
did note that Sally’s procedure “required a complex closure of the excision site.” The guidelines tell you that only a
simple closure is included in the excision code. A complex closure, just like an intermediate closure, is coded in addi-
tion to the code for the excision. So let’s code it!
Let’s go back to the Alphabetic Index and find the key term closure. None of the indented descriptors seem to
match, so you should investigate the code range shown next to the word closure: 12001–13160.
You will notice the heading immediately above the first code in the range: 12001. It reads “Repair–Simple.”
But you are looking for a complex closure, so continue down the page. The next section, above code 12031, is
“Repair–Intermediate.” This is closer to what you need, but not exactly. Above code 13100 you find the heading
you have been looking for: “Repair–Complex.”
Remember that Sally’s lesion was located on her abdomen (trunk). Look at the codes in this section, and find
the best code for the complex closure of her excision site.
13100 Repair, complex, trunk; 1.1 cm to 2.5 cm
Excellent! You have found the correct level of closure (repair) for the correct anatomical site (trunk). Now, you
must find the correct size of the excision site. Your calculation totaled 4.0 cm, which brings you to the correct
code:
13101 Repair, complex, trunk; 2.6 cm to 7.5 cm
Excellent! You now know that, for this one procedure on Sally, the claim form will include these codes:
11604 Excision, malignant lesion including margins, trunk, arms or legs; excised diameter 3.1 to 4.0 cm
13101 Repair, complex, trunk; 2.6 cm to 7.5 cm
Good job!

Reexcision
When the pathology report indicates that the physician did not excise around the lesion
(the margins) widely enough to get all the malignancy, an additional excision proce-
Intermediate Closure
A multilevel method of sealing
dure may be needed.
CPT © 2017 American Medical Association. All rights reserved.
an opening in the skin involv- If the reexcision is performed during the same operative session, adjust the total
ing one or more of the deeper size of the lesion being coded to include the new total measurement. Report just the
layers of the skin. Single-layer one code, with the largest measurement shown in the operative or procedure notes.
closure of heavily contami- If the reexcision is performed during a subsequent encounter during the postopera-
nated wounds that required tive period, you should attach modifier 58 Staged Procedure to the procedure code for
extensive cleaning or removal that second excision. The reexcision to remove additional tissue around the original
of particulate matter also con- site during the postoperative period would directly apply to modifier 58’s description:
stitutes intermediate closure. (b) more extensive than the original procedure.
Complex Closure
A method of sealing an open- Repair (Closures)
ing in the skin involving a
multilayered closure and a Simple closure is included in the excision code. However, if the closure of the excision
reconstructive procedure such site becomes more involved and is described as an intermediate closure or a complex
as scar revision, debridement, closure, the repair is no longer included in the code for the excision procedure. You
or retention sutures. need to report an additional code.

732   PART III  |  REPORTING PHYSICIAN SERVICES AND OUTPATIENT PROCEDURES

 As you read the procedure notes or operative report, pay close attention to the
description documented as to how deep into the skin the physician worked. When you GUIDANCE
see a layered closure that involves the deeper layers of the subcutaneous tissue, the CONNECTION
superficial fascia, and the epidermal and dermal layers of the skin, you will report an Read the additional
intermediate repair. Also reported as an intermediate repair is a single-layer closure explanations in the
that first requires extensive cleaning or particulate matter removal before closing. in-section guidelines
When a complex repair has been performed, the documentation will include more located within the
than just a layered enclosure: Scar revision, traumatic laceration debridement, avul- Surgery section, sub-
sions, extensive undermining, stent insertion, or retention suture(s) all describe this head Repair (Closure),
more involved level of repair. directly above code
When multiple wounds are repaired with the same complexity on the same anatom- 12001 in your CPT
ical site(s) as indicated by the code descriptor, add all the lengths together to use one book.
code for the total repair. You may sometimes have more than one code to report repairs
performed at this encounter. In these cases, the codes should be listed in order from
the most complex to the simplest, then from head to toe. All procedure codes, after the
first, should have the modifier 59 Distinct Procedural Service appended.

GUIDANCE CONNECTION
In-section Guidelines (above code 12001 in the Surgery section)
The multiple wound repair guideline is different from the guideline for multiple
lesions. Remember that, with lesions, each lesion is coded separately. With
wounds, you will report one code for the total length of all wounds being repaired CODING BITES
on the same anatomical site with the same level of repair (simple, intermediate, Modifier 59 is used
complex). to report multiple
When more than one level of wound repair is used during the same encounter procedures that are
for the same patient, list the more complicated as the primary procedure and the performed at the same
less complicated as the secondary procedures, using modifier 59. encounter by the same
provider. This modifier is
appended to the codes
Debridement or decontamination of a wound is included in the code for the repair reporting the second
of that wound. However, if the contamination is so extensive that it requires extra time and additional services,
and effort, it should be coded separately. Also, if the debridement is performed and not the primary proce-
the wound is not closed or repaired during the same session, code the debridement dure code.
separately.

CPT
LET’S CODE IT! SCENARIO
Fiona Curtis, a 27-year-old female, got into a bar fight and sustained multiple wounds to her hand and arm.
CPT © 2017 American Medical Association. All rights reserved.

Dr. Rockville performed intermediate repair of a 5- by 2-cm wound and a 3.1- by 1-cm wound on Fiona’s right hand
and a simple repair to a 3.2- by 1-cm wound to her right forearm.

Let’s Code It!

You can see by Dr. Rockville’s notes that Fiona had two wounds, treated with intermediate closures, both on
her right hand, and one wound, with a simple repair, on her right forearm. Let’s go to the Alphabetic Index and
find repair, wound, intermediate (suggesting code range 12031–12057) and repair, wound, simple (suggesting
code range 12001–12021).
The intermediate repairs were done to the right hand, so let’s turn to the numeric listing for the code range
12031–12057 and find the best code for this anatomical site.
12041 Repair, intermediate, wounds of neck, hands, feet and/or external genitalia; 2.5 cm or less

(continued)
 There were two wounds on Fiona’s right hand (the first is 5 × 2 cm and the second 3.1 × 1 cm). The guide-
lines state that, because the wounds are on the same anatomical site as per the code description (hands) and
received the same level of repair (intermediate), you must add them together. Let’s add the two longest mea-
surements together (5 cm + 3.1 cm) for a total of 8.1 cm. This brings us to the correct code:
12044 Repair, intermediate, wounds of neck, hands, feet and/or external genitalia; 7.6 cm to
12.5 cm
Good job! Now, the last wound on Fiona’s forearm is different. It is a simple repair rather than an intermediate repair,
and the wound is on her arm, not her hand. Therefore, this wound repair will have its own code. Follow the code
descriptions and see if you can come up with the most accurate code. Did you determine this to be the correct code?
12002 Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or
extremities (including hands and feet); 2.6 cm to 7.5 cm
Now that you know the guideline regarding multiple wound repairs, do you think any adjustments should be
made to the claim form you are preparing for Dr. Rockville to be reimbursed for his work on Fiona? You need to
report them in the correct sequence and append a modifier:
12044 (The intermediate repair tells us this was the more severe or complicated procedure.
Therefore, this code is reported first.)
12002-59 (This was the simple repair of a smaller wound. This was less complicated and, therefore,
the code is listed second and appended with the modifier 59.)
That’s great! You did excellent work!

YOU CODE IT! CASE STUDY

CPT

A woman was screaming in a parking lot and calling for help. She had accidentally locked her keys in the car, along with
her infant son. It was a hot day, and she was quite concerned about her child. Alex Franklin came along and used a rock
to break a window on the other side of the car, reached in through the broken glass, and unlocked the door. Without
question, Alex is a hero, but he also cut his wrist on the broken glass. At the ED, Dr. Zander discovered that the subcu-
taneous tissue at the laceration site was littered with tiny shards of glass. Dr. Zander administered a local anesthetic. It
took Dr. Zander quite a long time to debride the 5.3- by 1.6-cm wound of all the glass before he was able to suture it.

You Code It!

Go through the steps, and determine the procedure code(s) that should be reported for this encounter between
Dr. Zander and Alex Franklin.
Step #1: Read the case carefully and completely. CPT © 2017 American Medical Association. All rights reserved.

Step #2: Abstract the scenario. Which key words or terms describe what service the physician provided to the
patient during this encounter?
Step #3: Are there any details missing or incomplete for which you would need to query the physician? [If so,
ask your instructor.]
Step #4: Determine the correct CPT procedure code or codes to explain the details about what was provided
to the patient during this encounter.
Step #5: Check for any relevant guidance, including reading all of the symbols and notations.
Step #6: Do you need to append any modifiers to ensure complete and accurate information is provided?
Step #7: Double-check your work.

734   PART III  |  REPORTING PHYSICIAN SERVICES AND OUTPATIENT PROCEDURES

 Answer:
Did you determine these to be the correct codes?
11042 Debridement, subcutaneous tissue (includes, epidermis and dermis, if performed); first
20 sq. cm or less
12002-51 Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or
extremities (including hands and feet); 2.6 cm to 7.5 cm; multiple procedures
Excellent! You are really learning how to code!

Adjacent Tissue Transfer and/or Rearrangement

When an excision is repaired with an adjacent tissue transfer or rearrangement, you
will see several terms in the procedure notes that are included in this code subcategory.
∙ Z-plasty is a double transposition flap, most often used to correct a skin web or
perform a scar revision.
GUIDANCE
∙ W-plasty uses several small, triangular-shaped flaps, alternating inversion, just like
the letter “W,” to break up a long scar. CONNECTION
∙ V-Y plasty uses a V-shaped flap that is next to the defect with surrounding skin Read additional expla-
raised up and brought into the wound. nations in the in-section
∙ Rotation flap is a raised subdermal plane, semicircular in shape, pivoted around guidelines located
into the defect. within the Surgery sec-
tion, subhead Adjacent
∙ Random island flap is a section of skin moved into the defect with its blood supply.
Tissue Transfer or
∙ Advancement flap involves a subdermal place of skin, longitudinally moved to the defect. Rearrangement, directly
The correct code to report a tissue transfer or rearrangement requires two elements above code 14000 in
from the physician’s notes: your CPT book.

∙ Anatomical site: The anatomical location of the primary defect—the skin opening
that needs to be repaired—as well as the location of the secondary defect—the skin
area from where the surgeon took the skin being transferred.
∙ Size of the defect: Add together the sizes of the primary defect and the secondary defect.
∙ For all defects over 30 sq. cm, all anatomical sites are reported with the same
codes—code 14301 with code 14302, depending upon the total size.

CPT
LET’S CODE IT! SCENARIO
CPT © 2017 American Medical Association. All rights reserved.

Larissa Cheek had a 2.5 cm × 1 cm contracted scar on the back of her hand, making it difficult to use her fingers
completely. Dr. Villa performed a Z-plasty tissue transfer to disrupt the scar tissue and elongate the transferred tis-
sues. He notes that the secondary defect was 3 sq. cm.

Let’s Code It!

Dr. Villa did a “Z-plasty tissue transfer” on Larissa. However, when you look in the CPT Alphabetic Index for
Z-plasty, you will find nothing. Take a look at the Alphabetic Index for transfer. There are a few items listed below,
but none of these seem to relate to the procedure on Larissa. So let’s take a look at the CPT Alphabetic Index
listings for tissue. Below this you will see:
Tissue
Transfer

(continued)
 Adjacent
Skin . . . . . . . . . . 14000–14350
As you review the guidelines in this subsection, shown above code 14000, you can see that Z-plasty is included
in this section, confirming that you are in the right area. Next, you can see that the code descriptions require you
to know the anatomical location of the procedure.
14000 Adjacent tissue transfer or rearrangement, trunk
14020 Adjacent tissue transfer or rearrangement, scalp, arms, and/or legs
14040 Adjacent tissue transfer or rearrangement, forehead, cheeks, chin, mouth, neck, axillae, genita-
lia, hands and/or feet
14060 Adjacent tissue transfer or rearrangement, eyelids, nose, ears, and/or lips
Go back to the scenario and identify the anatomical site: “on the back of her hand.” This leads you to code
14040. You must now choose between the following two codes determined by the size of the defects:
14040 Adjacent tissue transfer or rearrangement, forehead, cheeks, chin, mouth, neck, axillae, genita-
lia, hands and/or feet; defect 10 sq. cm or less
14041   defect 10.1 sq. cm to 30.0 sq. cm
How big was the defect? In the guidelines above code 14000, it says, “The primary defect resulting from the
excision and the secondary defect resulting from flap design to perform the reconstruction are measured
together to determine the code.”
Larissa’s original scar—the primary defect—is noted to be 2.5 cm × 1. Multiply these two numbers to get
2.5 sq. cm. The secondary defect, the source of the tissue transfer, is noted to be 3 sq. cm. Add 2.5 sq. cm to
3 sq. cm and get a total of 5.5 sq. cm. Compare this measurement to the measurements included in the code
descriptions for tissue transfers done on the hands. This confirms the correct code for the procedure Dr. Villa did
for Larissa:
14040 Adjacent tissue transfer or rearrangement, forehead, cheeks, chin, mouth, neck, axillae, genita-
lia, hands and/or feet; defect 10 sq. cm or less
Good job!

Skin Replacement Surgery and Flaps

The codes for skin grafts are determined by three things:
Recipient Area 1. The size of the recipient area (the size of the wound to be grafted).
The area, or site, of the body 2. The location of the recipient area (the anatomical site).
receiving a graft of skin or
3. The type of graft (pinch graft, split graft, full-thickness graft, and so on).
CPT © 2017 American Medical Association. All rights reserved.
tissue.
The codes include a simple debridement, or avulsion, of the recipient site. Through
Harvesting harvesting, grafts can be taken from another part of the patient’s body, another body
The process of taking skin or (a live donor), a cadaver (a deceased person), skin substitutes (such as neodermis, syn-
tissue (on the same body or thetic skin), or another species (for instance, a porcine graft). You have to know where
another). the graft came from in order to determine the best, most appropriate code.
It is not uncommon for skin grafts to be planned, from the beginning, to be done in
stages. When this is the case, the second and subsequent portions of the staged proce-
dure should be appended with modifier 58. This is directly described in CPT’s modi-
Donor Area (Site)
fier 58 description: (a) planned or anticipated (staged).
The area or part of the body If the donor area (site) requires a skin graft or a local flap to repair it, it should
from which skin or tissue is be coded as an additional procedure. When evaluating the size of the wound that has
removed with the intention of been grafted, the measurement of 100 sq. cm is used with patients aged 10 and older.
placing that skin or tissue in The code descriptor referring to a percentage of the body area applies only to patients
another area or body. under the age of 10.

736   PART III  |  REPORTING PHYSICIAN SERVICES AND OUTPATIENT PROCEDURES

 EXAMPLE GUIDANCE
15002 Surgical preparation or creation of recipient site by excision of open CONNECTION
wounds, burn eschar, or scar (including subcutaneous tissues), or Read additional expla-
incisional release of scar contracture, trunk, arms, legs; first nations in the in-section
100 sq cm or 1% of body area of infants and children guidelines located
within the Surgery
In the subheading relating to flaps and grafts, when the physician attaches a flap, section, subhead Skin
either in transfer or to the final site, the anatomical site identified in the code’s descrip- Replacement Surgery,
tion is the recipient site, not the donor site. directly above code
15002 in your CPT
EXAMPLE book.

15732 Muscle, myocutaneous, or fasciocutaneous flap; head and neck (e.g.,

temporalis, masseter muscle, sternocleidomastoid, levator scapulae)
GUIDANCE
When a tube is formed to be used later, or when “delay” of flap is done before the CONNECTION
transfer, the anatomical sites indicated in the code description refer to the donor site,
not the recipient site. Read the additional
explanations in the
in-section guidelines
EXAMPLE located within the Sur-
15620 Delay of flap or sectioning of flap (division and inset); at forehead, gery section, subhead
cheeks, chin, mouth, neck, axillae, genitalia, hands or feet Flaps (Skin and/or
Deep Tissues), directly
When extensive immobilization is performed, such as large plaster casts or traction, above code 15570 in
the application of the immobilization device should be coded as a separate proce- your CPT book.
dure. However, make note that the procedure codes in the range 15570–15738 already
include small or standard immobilization, such as a sling or splint.

CPT
YOU CODE IT! CASE STUDY
Evan Riggs, an 11-year-old male, had burn eschar on his face from an accident. Dr. Charne performed a surgical
preparation of the area. Two days later, Dr. Charne applied a dermal autograft to the 30-sq.-cm area.

You Code It!

Based on the notes, find the best, most appropriate procedure code(s) to report all of Dr. Charne’s work for
Evan’s injury.
Step #1: Read the case carefully and completely.
CPT © 2017 American Medical Association. All rights reserved.

Step #2: Abstract the scenario. Which key words or terms describe what service the physician provided to the
patient during this encounter?
Step #3: Are there any details missing or incomplete for which you would need to query the physician? [If so,
ask your instructor.]
Step #4: Determine the correct CPT procedure code or codes to explain the details about what was provided
to the patient during this encounter.
Step #5: Check for any relevant guidance, including reading all of the symbols and notations.
Step #6: Do you need to append any modifiers to ensure complete and accurate information is provided?
Step #7: Double-check your work.

(continued)
 Answer:
Did you determine the following codes?
15004 Surgical preparation or creation of recipient site by excision of open wounds, burn eschar,
or scar (including subcutaneous tissues), or incisional release of scar contracture, face,
scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; first
100 sq cm or 1% of body area of infants and children
15135-58 Dermal autograft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/
or multiple digits; first 100 sq cm or less, or 1% of body area of infants and children; staged
procedure
Great work!

Destruction
GUIDANCE
CONNECTION Destruction is the term used for the removal of diseased or unwanted tissue from the
body by surgical or other means, such as surgical curettement (also known as curet-
Read additional expla- tage), laser treatment, electrosurgery, chemical treatment, or cryosurgery. Ablation is
nations in the in-section the surgical destruction of tissue or a body part. When the tissue is destroyed rather
guidelines located than excised, there is nothing left. Therefore, there will be no specimens sent to pathol-
within the Surgery sec- ogy for analysis. The codes in the destruction subheading of the surgical section
tion, subhead Destruc- include the administration of local anesthesia.
tion, directly above There are several methods that a physician can use to destroy tissue.
code 17000 in your
CPT book. ∙ Cauterization is the process of destroying tissue with the use of a chemical or elec-
tricity to seal a wound and stop bleeding. Some cauterizations can be accomplished
with extreme heat or cold. For example, you might see physician’s notes document
the removal of an internal polyp with the use of hot forceps.
∙ Cryosurgical or cryotherapy techniques use liquid nitrogen or freezing carbon
dioxide to destroy the tissue of concern.
∙ Curettage is the method of using a special surgical tool, called a curette, to scrape
an organ, a muscle, or other anatomical site.
∙ Electrosurgical methods use high-frequency electrical current instead of a scalpel
to separate and destroy tissue. One example of this is electrolysis, which removes
hair by using electricity to destroy the hair follicle.
∙ Laser surgery uses light to cut, separate, or destroy tissue. The term laser is actu-
ally an acronym for “light amplification by stimulated emission of radiation.”

CPT © 2017 American Medical Association. All rights reserved.

CPT
LET’S CODE IT! SCENARIO
Derrick Franks, a 54-year-old male, came to see Dr. Johnston, his podiatrist, for the removal of a benign plantar wart
from the sole of his left foot. Dr. Johnston administered a local anesthetic and then destroyed the wart using a che-
mosurgical technique. A protective bandage was applied to the foot, and Frank was sent home with an appointment
to return in 1 week for a follow-up check.

Let’s Code It!

The notes indicate that Derrick had a benign plantar wart that Dr. Johnston destroyed using chemosurgery.
Let’s go to the Alphabetic Index and look up destruction.

738   PART III  |  REPORTING PHYSICIAN SERVICES AND OUTPATIENT PROCEDURES

 Under destruction, you will see an alphabetical list that includes both anatomical sites as well as skin condi-
tions, such as cysts and lesions. You know from the notes that Dr. Johnston destroyed a wart on Derrick’s foot.
There are no listings for foot or sole of foot. However, there is a listing for Warts, flat . . . 17110–17111. Do you
know if a plantar wart is a flat wart? Because this is the only choice here, let’s go to the codes suggested and see
if the numeric listing can provide more information.
The code descriptions read
17110 Destruction (e.g., laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curette-
ment), of benign lesions other than skin tags or cutaneous vascular proliferative lesions; up to
14 lesions
17111   15 or more lesions
These descriptions do not really answer our question about whether a plantar wart is a flat wart or a benign
lesion. But before you query the doctor, go to the beginning of this subsection and read down.
Directly below the description for code 17111 is a notation:
(For destruction of extensive cutaneous neurofibroma over 50-100 lesions, see 0419T, 0420T)
Directly below the description for code 17003 is a notation:
(For destruction of common or plantar warts, see 17110, 17111.)
This is an excellent example of how you must investigate all possibilities and really give the CPT book a chance
to point you toward the correct code.
Dr. Johnston destroyed with chemosurgery Derrick’s benign lesion that was not a skin tag or a cutaneous
vascular proliferative lesion, and he only had one. Code 17110 is perfect!

Mohs Micrographic Surgery GUIDANCE

The group of codes for Mohs micrographic surgery (17311–17315) will be used only CONNECTION
when you are coding for a physician who is specially trained in this type of procedure
because it requires one doctor to act as both surgeon and pathologist. If two different Read the additional
professionals perform these functions, these codes cannot be used. explanations in the
If a repair is performed during the same session, the repair procedures should be in-section guidelines
coded separately. located within the Sur-
If a biopsy is performed on the same day as the Mohs surgery because the physi- gery section, subhead
cian suspects that the patient has skin cancer, it should be reported separately as well, Mohs Micrographic
appended with modifier 59 Distinct Procedural Service. Surgery, directly above
code 17311 in your
CPT © 2017 American Medical Association. All rights reserved.

CPT book.
25.6  Musculoskeletal System
The musculoskeletal system subsection of codes reports procedures and treatments
performed on the bones, ligaments, cartilage, muscles, and tendons in the human body
(Figure 25-2).

Cast Application
Earlier in this chapter, you learned about the Surgical Package, and all of the services
it includes. In addition, codes in this subsection already include the application and
removal of a cast or traction device as a part of the procedure performed.
So, when would you report a code from the subsection Application of Casts and
Strapping, codes 29000 through 29799? There are times when no other procedure
is performed. When the only service provided is the cast application, this will be
reported from here.
FIGURE 25-2  These illustrations show some of the over 600 muscles and 206 bones in the human body

GUIDANCE EXAMPLES
CONNECTION Dr. Philphot performed a closed realignment, manipulating the fractured calcaneal
Read additional expla- bone back together, and applied a foot-to-knee plaster cast.
nations in the in-section • The application of this cast would be included in the code for the treatment of
guidelines located the fracture:
within the Surgery sec-
28405 Closed treatment of calcaneal fracture; with manipulation
tion, subhead Appli-
cation of Casts and Justine had fractured her ulna and radius after falling off her skateboard. She
Strapping, directly got caught in an unexpected rainstorm that drenched her, and her cast. Dr. Keller
above code 29000 in replaced the long-arm cast.
your CPT book.
• The application of this cast was the only service provided for the treatment of
Justine’s fracture; therefore, it would be reported separately.
29065 Application, cast; shoulder to hand (long arm)

Fracture Reduction
A fracture reduction is the process of returning the bone fragments back to their origi-
nal and correct location and configuration. The type of fracture will determine the CPT © 2017 American Medical Association. All rights reserved.
specific components of this procedure. For example, a simple fracture might possibly
be reduced with a closed treatment, while a multifragmentary fracture or one with
bone loss may require an open treatment with additional work, such as a bone graft or
internal fixation, to restore the bone to its previous length, alignment, and ability to
Manipulation rotate (such as with an articulation). Reduction or manipulation may be necessary to
The attempted return of a realign the bone pieces so that union can occur properly. This may be done externally
fracture or dislocation to its (closed reduction, known as manipulation) or surgically (open reduction).
normal alignment manually by Details from the CPT Coding Guidelines, found at the beginning of the Musculo-
the physician. skeletal System section of the Surgery section of CPT, remind you that
“Manipulation is used throughout the musculoskeletal fracture and dislocation
subsections to specifically mean the attempted reduction or restoration of a frac-
ture or joint dislocation to its normal anatomic alignment by the application of
manually applied forces.”

740   PART III  |  REPORTING PHYSICIAN SERVICES AND OUTPATIENT PROCEDURES

 This will support your determination for the correct code as you see that the codes
for treatment of either an open fracture or a closed fracture are categorized by the
method of reduction (manipulation) and fixation/immobilization used to stabilize the
realigned bone.
Certainly, you already know that the CPT procedure code will be determined, in
part, by which specific bone is fractured and therefore needs treatment.

EXAMPLES
23525 Closed treatment of sternoclavicular dislocation; with manipulation
27178 Open treatment of slipped femoral epiphysis; closed manipulation
with single or multiple pinning

The key terms you will need to identify from the documentation will also vary
depending upon the particular fractured bone that is being treated. For example:
Open treatment and/or reduction of vertebral fracture(s) and/or dislocation(s), pos-
terior approach, 1 fractured vertebra or dislocated segment;
Lumbar............................................................22325
Cervical...........................................................22326
Thoracic..........................................................22327
Additional fractured vertebra................. +22328
When the fractured bone is a segment of the spinal column, you will need to abstract
three key important pieces of information: the location of the bone on the vertebral
column (i.e., cervical, thoracic, lumbar), the number of fractured vertebrae reduced,
and the approach—posterior or anterior. The codes shown above (22325–22328) are
only to be reported when the physician used a posterior, or back, approach. When the
approach used to visualize and reduce the fracture was from the front—an anterior
approach—codes 63081–63091 are used instead.

Open or Closed Treatment

Procedures and services can be provided for various sites of the musculoskeletal sys-
tem as an open treatment or a closed treatment. These two words, open and closed, are
used for both the description of the fracture itself (in the diagnostic statement) and the
description of the procedure. Be careful not to confuse these identifiers because they
are NOT interrelated—that is, a compound (open) fracture is not automatically treated
with an open procedure. Be certain to differentiate the description of the fracture from
the description of the procedure. Let’s begin with understanding what CPT means by
open treatment or closed treatment.
CPT © 2017 American Medical Association. All rights reserved.

Open Treatment
CPT defines open treatment as a procedure provided to treat a fractured bone that is Open Treatment
either Surgically opening the frac-
ture site, or another site in the
Surgically opened, so that the fracture can be visualized and internal fixation may body nearby, in order to treat
be applied. the fractured bone.
or
Not opened surgically, but the fractured bone is opened remotely from the site to
enable the surgeon to insert an intramedullary nail.
Closed Treatment
The treatment of a fracture
Closed Treatment without surgically opening the
According to CPT, the closed treatment of a fracture is performed affected area.
 ∙ With or without manipulation.
GUIDANCE
∙ With or without traction.
CONNECTION
∙ Without the fracture being opened and visualized.
Read the additional
explanations in the
Penetrating Trauma Wounds
in-section guidelines
located within the Sur- The CPT book distinguishes between wounds and penetrating trauma wounds. A pen-
gery section, subhead etrating trauma wound requires
Musculoskeletal Sys-
1. Surgery to explore the wound.
tem, subsection Wound
Exploration—Trauma 2. Determination of the depth and complexity of the wound.
(e.g., Penetrating Gun- 3. Identification of any damage created by the penetrating object (such as the stabbing
shot, Stab Wound), from a knife or the wound from a bullet).
directly above code 4. Debridement of the wound to remove any particles, dirt, and foreign fragments.
20100 in your CPT
5. Ligation or coagulation of minor subcutaneous tissue, muscle fascia, and/or muscle
book.
(not severe enough to require a thoracotomy or laparotomy).
You will use codes 20100–20103 to report the exploration of such wounds. Then, code
whichever repair the physician actually performs, as documented in the notes.

Bone Grafts and Implants

Medical science and technology have progressed amazingly. Be certain to differ-
entiate between skin grafts (reported from the Integumentary System subsection
of CPT) and bone, cartilage, tendon, and fascia lata grafts that are coded from the
GUIDANCE Musculoskeletal System subsection.
CONNECTION If the code description does not specifically reference the harvesting of the graft or
implant (for example, code 20936 “includes harvesting the graft”), then the procedure
Read the additional for obtaining autogenous bone, cartilage, tendon, fascia lata grafts, or other tissues
explanations in the should be reported separately.
in-section guidelines
within the Surgery sec- Spine
tion, subhead Spine
(Vertebral Column), As you may remember from anatomy class, the human spine is referred to in sec-
directly above code tions: cervical (at or near the neck), thoracic (the chest area), lumbar (at the waist
22010 in your CPT and lower back), and sacral. References to the individual vertebrae are most often
book. identified by their alphanumeric identifiers, such as C1 (cervical vertebra number
1), L5 (lumbar vertebra number 5), or S3 (sacral vertebra number 3), as you can see
in Figure 25-3.

Laminotomy
CPT © 2017 American Medical Association. All rights reserved.
CODING BITES A laminotomy is a partial laminectomy used to treat lumbar disc herniation. Remov-
ing a portion of the lamina is often sufficient to access the affected nerve root. Then,
CPT describes a verte-
the disc herniation can be visualized and accessed from beneath the nerve root. This
bral interspace as the
procedure should be reported with the most accurate code, based on the details in the
nonbony compartment
documentation:
between two adjacent
vertebral bodies. This 63020 Laminotomy (hemilaminectomy), with decompression of nerve root(s),
space houses the including partial facetectomy, foraminotomy and/or excision of herni-
intervertebral disc and ated intervertebral disc, including open or endoscopically-assisted
includes the nucleus approach; one interspace, cervical
pulposus, the annulus 63030 Laminotomy (hemilaminectomy), with decompression of nerve root(s),
fibrosus, and two carti- including partial facetectomy, foraminotomy and/or excision of herni-
laginous endplates. ated intervertebral disc, including open or endoscopically-assisted
approach; one interspace, lumbar

742   PART III  |  REPORTING PHYSICIAN SERVICES AND OUTPATIENT PROCEDURES

 63035 each additional interspace, cervical or lumbar (List separately in C1 (Atlas)
additional to code for primary procedure) C2 (Atlas)
C3
Compare these two different codes. What’s the difference? C4
C5
C6
63020 63030 C7
T1
Laminotomy (hemilaminectomy) Laminotomy (hemilaminectomy) T2
T3
With decompression of nerve root(s) With decompression of nerve root(s) T4
T5
Including partial facetectomy Including partial facetectomy T6
foraminotomy and/or excision of herniated foraminotomy and/or excision of T7
intervertebral disc herniated intervertebral disc T8
including open or endoscopically-assisted including open or endoscopically- assisted T9
T10
approach approach
T11
One interspace, cervical One interspace, lumbar
T12

You can see that the only difference between the two code descriptions is the location L1
of the vertebra being treated. This is a piece of information you will need to determine L2
the correct code.
Then, depending upon how many discs were involved, you might add L3

63035 each additional interspace, cervical or lumbar L4

L5
Arthrodesis
Arthrodesis is the surgical immobilization of a joint so that the bones can heal, or Os sacrum
grow solidly, together. While this is most often performed on the spine, it can also be
done on any joint in the body, including ankle, elbow, shoulder, etc.
When coding arthrodesis, you will need to identify the approach technique used by Coccyx
the physician, such as
FIGURE 25-3  The verte-
∙ Lateral extracavitary technique.
brae of the spinal column
∙ Anterior transoral or extraoral technique. are numbered from the
∙ Anterior interbody technique. head to the coccyx Source:
www.boundless.com
∙ Posterior technique: craniocervical or atlas-axis.
∙ Posterior or posterolateral technique. Arthrodesis
∙ Posterior interbody technique with number of interspaces treated. The immobilization of a joint
using a surgical technique.
Arthrodesis can be performed alone or in combination with other procedures such
Laminectomy
as bone grafting, osteotomy, fracture care, vertebral corpectomy, or laminectomy.
The surgical removal of a ver-
When arthrodesis is done at the same time as another procedure, modifier 51 Multiple tebral posterior arch.
CPT © 2017 American Medical Association. All rights reserved.

Procedures should be appended to the code for the arthrodesis. This applies to almost
all procedures, with the exception of bone grafting and instrumentation. Modifier
51 Multiple Procedures is not used in those cases because bone grafts and instrumenta-
tion are never performed without arthrodesis.

CPT
LET’S CODE IT! SCENARIO
Caryn Philips, a 51-year-old female, was diagnosed with degenerative disc disease 3 months ago. She is admit-
ted today for Dr. Cheffer to perform a posterior arthrodesis of L5–S1 (transverse process), utilizing a morselized
autogenous iliac bone graft harvested through a separate fascial incision. Caryn tolerates the procedure well and is
returned to her hospital room after 2 hours in recovery.
(continued)
 Let’s Code It!
Pull out the description of the procedures that Dr. Cheffer performed. First, note the “posterior arthrodesis of
L5–S1” and then the “morselized autogenous iliac bone graft harvested through a separate fascial incision.”
Let’s begin in the Alphabetic Index with the listing for arthrodesis. The designation of L5–S1 tells you this
was done to Caryn’s spine. However, spine isn’t listed under arthrodesis. Keep reading and you will see vertebra
listed, lumbar underneath that, and posterior beneath that. However, the physician noted “transverse process,”
which is listed here as well. Let’s investigate code 22612, as suggested by the Alphabetic Index.
22612 Arthrodesis, posterior or posterolateral technique, single level; lumbar (with or without lat-
eral transverse technique)
This matches the physician’s notes.
Now, let’s move to the next procedure performed. Look in the Alphabetic Index under bone graft. Read
through the list until you reach the item that reflects what was done for Caryn: spine surgery. Indented below
that you will see autograft (the same as autogenous) and then morselized. The index suggests code 20937.
Turn to the numeric list and take a look at the code’s description:
20937 Autograft for spine surgery only (includes harvesting the graft); morselized (through sepa-
rate skin or fascial incision)
Notice the symbol to the left of code 20937: . The plus sign means this is an add-on code and it cannot be used
alone. However, the notation below 20937 indicates that you are permitted to use this code along with 22612.
In addition, the guidelines state that when arthrodesis is performed with another procedure, you need to add
modifier 51 to the arthrodesis code except when the other procedure is a bone graft. This is the case in Caryn’s
record, so the claim form for Caryn Phillip’s surgery will show procedure codes 22612 and 20937—with no
modifiers. Great job!

GUIDANCE
CONNECTION
Skeletal Fixation
Whether the fracture is open or closed, it may require fixation. Internal fixation is the
Read the additional
process of placing plates and screws, or pins, or other devices directly onto or around
explanations in the
the bone, inside of the patient. When external fixation is used, a device—such as a
in-section guidelines
brace, cast, or halo—prevents motion in a certain area of the body. The care for a frac-
within the Surgery sec-
ture may also include the external application of traction.
tion, subhead Spine,
It is not always necessary for the physician to visualize the specific fracture directly,
subsection Arthrodesis,
yet some type of immobilization is required to ensure proper healing. X-ray imaging
directly above code
is used to provide guidance so pins or other fixation can be accurately applied. This is
22532 in your CPT
known as percutaneous skeletal fixation because the procedure is not an open proce-
book.
dure, yet it is not completely closed either.

Percutaneous Skeletal CPT © 2017 American Medical Association. All rights reserved.
Fixation EXAMPLE
The insertion of fixation instru- 25606 Percutaneous skeletal fixation of distal radial fracture or epiphyseal
ments (such as pins) placed separation
across the fracture site. It may
be done under x-ray imaging
for guidance purposes. External fixation, as the name implies, is the attachment of skeletal pins along with
a device to provide stability and corrective action on either a permanent or temporary
basis. This is only reported separately when this portion of the process is not already
part of the procedure.

EXAMPLE
21454 Open treatment of mandibular fracture with external fixation

744   PART III  |  REPORTING PHYSICIAN SERVICES AND OUTPATIENT PROCEDURES

 Internal fixation is, most often, applied directly to the bone during an open proce-
dure or treatment.

EXAMPLE
29855 Arthroscopically aided treatment of tibial fracture, proximal (pla-
teau); unicondylar, includes internal fixation, when performed
(includes arthroscopy)

GUIDANCE CONNECTION
Read the additional explanations in the in-section guidelines located within the
Surgery section, subhead Spine (Vertebral Column), subsection Fracture and/or
Dislocation, directly above code 22310 in your CPT book.

CPT
LET’S CODE IT! CASE SCENARIO
Peter Kessler, a 17-year-old male, plays basketball on his high school team. While practicing in his driveway, he fell
and fractured the shaft of his tibia. Dr. Warden, the orthopedist on duty at the emergency room, is able to use a per-
cutaneous fixation using pins.

Let’s Code It!

Let’s turn to the Alphabetic Index. This time, we won’t look up the procedure by the type of treatment (percuta-
neous), but we will look at the condition that was treated: fracture. Under fracture, find the anatomical site of the
fracture—tibia—and then the percutaneous fixation. The index suggests code 27756. Let’s check the descrip-
tion in the numeric listing:
27756  Percutaneous skeletal fixation of tibial shaft fracture (with or without fibular fracture)
(e.g., pins or screws)
That’s exactly what Dr. Warden did. Great job!

Spinal Procedures
There are several procedures often performed on patients with spinal concerns:
∙ Arthrodesis is the surgical immobilization of a joint.
∙ Arthroplasty is the insertion of an artificial disc.
CPT © 2017 American Medical Association. All rights reserved.

∙ Discectomy is the surgical removal of an intervertebral disc, either a portion of the

disc or the entire component.
∙ Laminectomy is the surgical removal of the lamina (posterior arch) of the vertebra.
∙ Osteotomy is performed to remove, or cut out, a portion of a bone.
∙ Vertebroplasty and kyphoplasty may be performed surgically or percutaneously for
the purpose of repairing a vertebra that has been compromised by a compression
fracture.

Spinal Fusion
Spinal fusion permanently locks two or more spinal vertebrae together so that they
move as a single unit utilizing bone grafts, with or without screws, plates, cages, or
other devices. The bone grafts are placed around the problem area of the spine during
surgery. As the body heals itself, the graft helps join the bones together.
 Performed under general anesthesia, fusion of lumbar vertebrae is generally done
GUIDANCE using a posterior lumbar approach, whereas cervical vertebrae are accessed using an
CONNECTION anterior cervical approach. An anterior thoracic approach is normally used for fusion
Read the additional
of thoracic vertebrae.
explanations in the
Spinal fusion is known to diminish mobility because of the connections made
in-section guidelines
between the individual vertebrae involved in the procedure. This is one of the primary
located within the Sur-
reasons health care technology has been working diligently on an artificial interverte-
gery section, subhead
bral disc that can continue to permit individual vertebral motion. Artificial discs have
Spine (Vertebral Col-
been evidenced to allow for six degrees of freedom.
umn), subsection Spinal
After removing the ineffective or damaged disc, two metal plates are pressed into the
Instrumentation, directly
bony endplates above and below the interspace and held into place by metal spikes. A
above code 22840 in
plastic spacer, usually made of a polyethylene core, is inserted between the plates. The
your CPT book.
patient’s own body weight compresses the spacer after the surgery is complete.

CPT
YOU CODE IT! CASE STUDY
Allyssa Erickson, an 83-year-old female, fell and sustained a fracture to the C4 vertebral body. Due to the position of
the fracture, Dr. Rubbine was able to use a closed treatment without having to put her through a surgical procedure.
Dr. Rubbine then put Allyssa into a brace.

You Code It!

Go through the steps, and determine what procedure code(s) should be reported for this encounter between Dr.
Rubbine and Allyssa Erickson.
Step #1: Read the case carefully and completely.
Step #2: Abstract the scenario. Which key words or terms describe what service the physician provided to the
patient during this encounter?
Step #3: Are there any details missing or incomplete for which you would need to query the physician? [If so,
ask your instructor.]
Step #4: Determine the correct CPT procedure code or codes to explain the details about what was provided
to the patient during this encounter.
Step #5: Check for any relevant guidance, including reading all of the symbols and notations.
Step #6: Do you need to append any modifiers to ensure complete and accurate information is provided?
Step #7: Double-check your work.
Answer:
Did you find this to be the correct code? CPT © 2017 American Medical Association. All rights reserved.

22310  Closed treatment of vertebral body fracture(s), without manipulation, requiring and including
casting or bracing
Great job!

Lumbar Puncture (Spinal Tap)

When a patient exhibits certain signs and symptoms, the physician may decide to per-
form a lumbar puncture, commonly known as a spinal tap. In this procedure, a needle
is inserted into the spinal canal between two lumbar vertebrae to collect cerebrospinal
fluid (CSF).

746   PART III  |  REPORTING PHYSICIAN SERVICES AND OUTPATIENT PROCEDURES

 The two key procedure codes are differentiated by the reason the procedure is
performed—diagnostic or therapeutic.
62270 Spinal puncture, lumbar, diagnostic
62272 Spinal puncture, therapeutic, for drainage of cerebrospinal fluid (by
needle or catheter)

25.7  Respiratory System

GUIDANCE
The organs and tissues involved with bringing oxygen into the body and discharging
CONNECTION
gases make up the respiratory system. Procedures and treatments affecting this sector
are coded from the Respiratory System subsection. Read the additional
explanations in the
Sinus Endoscopy in-section guidelines
located within the Sur-
The upper respiratory system includes the nasal passages and sinus cavities. The gery section, subhead
standard for a nasal/sinus endoscopic procedure, performed for diagnostic purposes, Respiratory System,
includes assessment of the interior nasal cavity, the middle and superior meatus, the subsection Endoscopy,
turbinates, and the sphenoethmoid recess. Therefore, the inspection of all of these directly above code
areas is included in the diagnostic sinus endoscopy procedure code. 31231 in your CPT
When a surgical sinus endoscopy is provided, the code descriptions include both book.
the sinusotomy and a diagnostic endoscopy.

CPT
LET’S CODE IT! SCENARIO
Epharim Habbati, a 41-year-old male, had been diagnosed with chronic sinusitis many years ago and has tried
everything. He told Dr. Tolber that no medication has worked and the inflammation just won’t go away. Dr. Tolber
performed a nasal/sinus diagnostic endoscopy via the inferior meatus, with a maxillary sinusoscopy.

Let’s Code It!

The documentation explains that Dr. Tolber performed a “diagnostic endoscopy via the inferior meatus,
with a maxillary sinusoscopy,” so let’s turn to the CPT Alphabetic Index and find endoscopy. You can see a
long list of anatomical sites beneath. On what anatomical site did Dr. Tolber perform this endoscopy? The
notes state “nasal/sinus.” Find the term nose under endoscopy and you will see there are three choices:
Diagnostic, Surgical, and Unlisted Services and Procedures. Let’s go back to the notes and find out which
of these is most appropriate. The notes state specifically “diagnostic endoscopy.” The Alphabetic Index
suggests a range of codes: 31231–31235. Let’s turn to the Main Portion of CPT to read the complete code
CPT © 2017 American Medical Association. All rights reserved.

descriptions.
31231 Nasal endoscopy, diagnostic, unilateral or bilateral (separate procedure)
31233 Nasal/sinus endoscopy, diagnostic with maxillary sinusoscopy (via inferior meatus or canine
fossa puncture)
31235 Nasal/sinus endoscopy, diagnostic with sphenoid sinusoscopy (via puncture of sphenoidal face
or cannulation of ostium)
Let’s go back to the physician’s notes to confirm exactly what was done for Mr. Habbati.
diagnostic endoscopy . . . all three code choices include this term
via the inferior meatus . . . only code 31233 mentions the inferior meatus specifically
with a maxillary sinusoscopy . . . only code 31233 mentions the maxillary sinusoscopy
The code description for 31233 matches the notes and is our most accurate code to report.
 Pleural and Lung Biopsies
A biopsy of the pleural tissue or lung tissue may be accomplished in one of several
different ways.

Percutaneous Needle
When a percutaneous needle biopsy is performed, a hollow needle is inserted through
a tiny incision and directed toward the internal area, typically with the support of
imaging guidance. Only local anesthesia is used, and with only tiny incisions to mend,
getting back to normal daily activities is quick.
32400 Biopsy, pleura, percutaneous needle
32405 Biopsy, lung or mediastinum, percutaneous needle

Thoracotomy with Biopsy

When a thoracotomy is performed, along with a lung or pleural biopsy, the patient’s
chest is surgically opened (an open procedure rather than a percutaneous approach).
You will need to abstract, from the documentation, if the biopsy is performed to estab-
lish a diagnosis (diagnostic biopsy) or for therapeutic purposes (to surgically remove
the abnormal tissues).
32096 Thoracotomy, with diagnostic biopsy of lung infiltrate (e.g. wedge, inci-
sional), unilateral
32097 Thoracotomy, with diagnostic biopsy of lung nodule or masses
(e.g. wedge, incisional), unilateral
32098 Thoracotomy, with biopsy(ies) of pleura
NOTE: Other thoracotomy procedures can be reported with a code from the range of
32100–32160.

CPT
YOU CODE IT! CASE STUDY
Harrison Matthews, a 37-year old male, was having frequent nosebleeds. Finally, after all other methods failed to
provide relief, Dr. French performed an endoscopic surgical procedure to control his nasal hemorrhages.

You Code It!

Review the details of what Dr. French did for Harrison Matthews, and determine the CPT code or codes.
Step #1: Read the case carefully and completely.
Step #2: Abstract the scenario. Which key words or terms describe what service the physician provided to the
patient during this encounter?
Step #3: Are there any details missing or incomplete for which you would need to query the physician? [If so, CPT © 2017 American Medical Association. All rights reserved.

ask your instructor.]

Step #4: Determine the correct CPT procedure code or codes to explain the details about what was provided
to the patient during this encounter.
Step #5: Check for any relevant guidance, including reading all of the symbols and notations.
Step #6: Do you need to append any modifiers to ensure complete and accurate information is provided?
Step #7: Double-check your work.
Answer:
Did you determine this to be the procedure code?
31238 Nasal/sinus endoscopy, surgical; with control of nasal hemorrhage

748   PART III  |  REPORTING PHYSICIAN SERVICES AND OUTPATIENT PROCEDURES

 25.8  Cardiovascular System
Treatments and procedures on the heart as well as the entire network of veins, arteries,
and capillaries are coded from the Cardiovascular System subsection.

Pacemakers
When a physician inserts a standard pacemaker system (CPT codes 33202–33273), the
procedure includes the placement of a pulse generator into a subcutaneous envelope
that has been created beneath the abdominal muscles distally to the ribs or placement
in a subclavicular site. The generator itself contains a battery and one or more leads
(electrodes) that are inserted transvenously (through a vein) or epicardially (on the
surface of the heart). (See Figure 25-4.)
When the epicardial placement is used, a thoracotomy or thoracoscopy is necessary
to insert the electrodes accurately.
33202 Insertion of epicardial electrode(s); open incision (eg, thoracotomy,
median sternotomy, subxiphoid approach)
33203 Insertion of epicardial electrode(s); endoscopic approach (eg, thora-
coscopy, pericardioscopy)
When a physician inserts a single-chamber pacemaker system into a patient, it includes
the pulse generator and one electrode inserted into either the atrium or the ventricle.
When a dual-chamber pacemaker system is placed, the system includes the pulse
generator and one electrode into both the right atrium and the right ventricle.
When the pulse generator is inserted at the same encounter, report 33202 or 33203
in addition to
33212 Insertion of pacemaker pulse generator only; with existing single lead
33213 Insertion of pacemaker pulse generator only; with existing dual leads
33221 Insertion of pacemaker pulse generator only; with existing multiple
leads
In addition to the insertion method (epicardial or transvenous), coders must abstract
from the physician’s documentation the specific chamber or chambers of the heart
affected. These codes include the insertion of the pulse generator subcutaneously,
the transvenous placement of the electrode or electrodes, and moderate (conscious)
CPT © 2017 American Medical Association. All rights reserved.

Pacemaker

Pacemaker
leads

Right atrium

Right ventricle

FIGURE 25-4  An illustration showing the location of all of the components of an

implanted dual-lead pacemaker
 sedation. If, during the insertion process, the skin pocket requires revision, this is also
included in these codes (and all others from 33206 through 33249).
33206 Insertion of new or replacement of permanent pacemaker with trans-
venous electrode(s); atrial
33207 Insertion of new or replacement of permanent pacemaker with trans-
venous electrode(s); ventricular
33208 Insertion of new or replacement of permanent pacemaker with trans-
venous electrode(s); atrial and ventricular
You may notice that these code descriptions include the term replacement, insinuat-
ing that the patient already had a pacemaker in place. It is important to note that these
codes do not include the work to remove a previous system, only the insertion of a
new one. To report the physician’s services to remove a previous system and insert a
replacement system (pulse generator and transvenous electrode(s)) during the same
encounter, you will report
33233 Removal of permanent pacemaker pulse generator only

33234 Removal of transvenous pacemaker electrode(s); single lead system,
atrial or ventricular
or
33235 Removal of transvenous pacemaker electrode(s); dual lead system
One of these codes: 33206 or 33207 or 33208
When the physician documents that the patient has been upgraded from a single-
chamber system to a dual-chamber system, the removal of the existing pulse generator
and the insertion of the new dual-chamber system are reported with one code:
33214 Upgrade of implanted pacemaker system, conversion of single cham-
ber system to dual chamber system (includes removal of previously
placed pulse generator, testing of existing lead, insertion of new lead,
insertion of new pulse generator)
For some patients, the physician determines that an additional lead (electrode) inserted
into the left ventricle would be beneficial. This is known as biventricular pacing.
When this additional electrode is inserted, it is separately reported:
33224 Insertion of pacing electrode, cardiac venous system, for left ven-
tricular pacing, with attachment to previously placed pacemaker
or pacing cardioverter-defibrillator pulse generator (including revi-
sion of pocket, removal, insertion, and/or replacement of existing
generator)

CPT © 2017 American Medical Association. All rights reserved.

or
33225 Insertion of pacing electrode, cardiac venous system, for left ventricu-
lar pacing, at time of insertion of pacing cardioverter-defibrillator or
pacemaker pulse generator (eg. for upgrade to dual chamber system)
(List separately in addition to code for primary procedure)
Commonly referred to as replacing the battery in the pacemaker or cardioverter-
defibrillator, this procedure involves the removal of the old pulse generator and the
insertion of a new pulse generator. These two actions should be coded individually—
one code for the removal of the old and another code for the insertion of the new.
When this is documented, report the code determined by the number of leads (elec-
trodes) already in place:
33227 Removal of permanent pacemaker pulse generator with replacement
of pacemaker pulse generator; single lead system

750   PART III  |  REPORTING PHYSICIAN SERVICES AND OUTPATIENT PROCEDURES

 33228 Removal of permanent pacemaker pulse generator with replacement
of pacemaker pulse generator; dual lead system
33229 Removal of permanent pacemaker pulse generator with replacement
of pacemaker pulse generator; multiple lead system
After a length of time, some patients may develop an erosion of the dermal and subcu-
taneous tissues or an infection, at the location of the pulse generator. A situation of this
nature may require the physician to relocate the “pocket.” When this is documented,
report the physician’s services with this: GUIDANCE
33222 Relocation of skin pocket for pacemaker CONNECTION
Reporting the insertion and replacement of a pacing cardioverter-defibrillator (ICD) Read the additional
system is very similar, but often does require different codes from within this subsec- explanations in the
tion of CPT. in-section guidelines
33249 Insertion or replacement of permanent implantable defibrillator sys- located within the Sur-
tem, with transvenous lead(s), single or dual chamber gery section, subhead
33270 Insertion or replacement of permanent subcutaneous implantable Cardiovascular System,
defibrillator system, with subcutaneous electrode, including defibrilla- subsection Pacemaker
tion threshold evaluation, induction of arrhythmia, evaluation of sens- or Implantable Defibril-
ing for arrhythmia termination, and programming or reprogramming lator, directly above
of sensing or therapeutic parameters, when performed code 33202 in your
33271 Insertion of subcutaneous implantable defibrillator electrode CPT book.

Implantable Defibrillators
Pacing cardioverter-defibrillator systems are similar to pacemaker systems. While
they also consist of a pulse generator and electrodes, the units may use several leads
inserted into a single chamber (ventricle) or into dual chambers (atrium and ventricle)
(Figure 25-4). The system is actually a combination of antitachycardia pacing, low-
energy cardioversion, and/or defibrillating shocks to address a patient’s ventricular
tachycardia or ventricular fibrillation.
In some cases, an additional electrode may be needed to regulate the pacing of the
left ventricle, called biventricular pacing. When this occurs, the placement of the elec-
trode transvenously should be coded separately, just as the pacemaker is coded, with
either 33224 or 33225.

Leadless Pacemakers
An intracardiac pacemaker functions in much the same way as other pacemakers to
regulate heart rate. However, these newly FDA-approved units are self-contained, one-
inch-long devices that are implanted directly into the right ventricle chamber of the
CPT © 2017 American Medical Association. All rights reserved.

heart, and have no leads and no pockets. This pulse generator has an internal battery
and electrode and is inserted into a cardiac chamber by transfemoral catheter (through
an artery in the thigh). No incision or creation of a pocket reduces the opportunity
for infection and eliminates unsightly scars. No leads avoid the repercussions of lead
failure and result in no possible discomfort when moving, increasing mobility for the
patient.
These units are still considered new technology, so their codes will be found in the
Category III section of CPT.
These codes are used to report the evaluation of the patient so the physician can
determine if this type of pacemaker is feasible. This would be reported instead of a
typical E/M code, as long as this is the total focus of the encounter.
0390T Peri-procedural device evaluation (in person) and programming of
device system parameters before or after a surgery, procedure, or
test with analysis, review and report, leadless pacemaker system
 0391T Interrogation device evaluation (in person) with analysis, review, and
report, includes connection, recording and disconnection per patient
encounter, leadless pacemaker system
A code for insertion and/or replacement of this unit and a separate code for the removal
of the unit will report the specific services provided by this physician.
0387T Transcatheter insertion or replacement of permanent leadless pace-
maker, ventricular
0388T Transcatheter removal of permanent leadless pacemaker, ventricular
Leadless pacemakers use technology to direct their function, and the physician can ensure
that the unit is adjusted and set to provide the best possible outcomes for the patient.
0389T Programming device evaluation (in person) with iterative adjustment
of the implantable device to test the function of the device and select
optimal permanent programmed values with analysis, review and
report, leadless pacemaker system

Bypass Grafting
Saphenous Vein Venous Grafts
Either of the two major veins
in the leg that run from the When a venous graft is performed, use codes from the range 33510–33516. All these
foot to the thigh near the sur- codes include a saphenous vein graft.
face of the skin. However, if the graft is harvested from an upper extremity (arm) vein, you need to code
this separately, using code 35500, in addition to the code for the bypass procedure itself.
35500 Harvest of upper extremity vein, one segment for lower extremity or
CODING BITES coronary artery bypass procedure (List separately in addition to code
The same exceptions for primary procedure.)
apply as before: If the 35572 Harvest of femoropopliteal vein, one segment, for vascular recon-
graft is harvested from struction procedure (e.g., aortic, vena caval, coronary, peripheral
an upper extremity artery) (List separately in addition to code for primary procedure.)
artery, code it sepa-
rately from the bypass Combined Arterial-Venous Grafts
procedure, using code
When both venous grafts and arterial grafts are used during the same procedure, you
35600. And if the graft
will use two codes. First, code the combined arterial-venous graft from the range
is obtained from the
33517–33523. Just like the codes for the venous grafts, these include getting the graft
femoropopliteal vein,
from the saphenous vein. Second, code the appropriate arterial graft from the range
code it with 35572 in
33533–33536. Harvesting the arterial vein section is included in those codes.
addition to the code for
the bypass procedure.
Arterial Grafts
When an arterial graft is performed, use codes from the range 33533–33536. All these
CPT © 2017 American Medical Association. All rights reserved.
codes include the use of grafts from the internal mammary artery, gastroepiploic
GUIDANCE
artery, epigastric artery, radial artery, and arterial conduits harvested from other sites.
CONNECTION For example, examine the following code descriptions:
Read the additional 33533 Coronary artery bypass, using arterial graft(s); single arterial graft
explanations in the in- 33534 Coronary artery bypass, using arterial graft(s); 2 coronary arterial grafts
section guidelines within 33535 Coronary artery bypass, using arterial graft(s); 3 coronary arterial grafts
the Surgery section, 33536 Coronary artery bypass, using arterial graft(s); 4 or more coronary
subhead Cardiovascu- arterial grafts
lar System, subsection
Venous Grafting Only Use one of the following codes (in addition to the code for the bypass procedure) if
for Coronary Artery the graft is harvested from another site:
Bypass, directly above ∙ From an upper extremity artery, add code 35600.
code 33510 in your
∙ From an upper extremity vein, add code 35500.
CPT book.
∙ From the femoropopliteal vein, use code 35572.

752   PART III  |  REPORTING PHYSICIAN SERVICES AND OUTPATIENT PROCEDURES

 Composite Grafts
GUIDANCE
When two or more vein segments are harvested from a limb other than that part of the
body undergoing the bypass, you must use the best, most appropriate code from the range
CONNECTION
35681–35683 to report the harvesting and anastomosis of the multiple vein segments. Read the additional
explanations in the
35681 Bypass graft; composite, prosthetic and vein (List separately in addi-
in-section guidelines
tion to code for primary procedure.)
within the Surgery
35682 Bypass graft; autogenous composite, two segments of veins from two
section, subhead Car-
locations (List separately in addition to code for primary procedure.)
diovascular System,
35683 Bypass graft; autogenous composite, three or more segments of vein
subsection Combined
from two or more locations (List separately in addition to code for pri-
Arterial-Venous Graft-
mary procedure.)
ing for Coronary
A little confusing? Hopefully, Table 25-1 will help you organize all the rules for cod- Bypass, directly above
ing bypass grafts. code 33517 in your
CPT book.
Arteries and Veins
The primary vascular procedure codes 34001–37799 include
1. Ensuring both the inflow and the outflow of the arteries and/or veins involved
(Figure 25-5).
2. The operative arteriogram that is performed by the surgeon during the procedure.
3. Sympathectomy for aortic procedures.

TABLE 25-1  Bypass Grafts

Graft Harvested From Use Code(s)
Venous graft Saphenous vein Choose from 33510–33516
Venous graft Upper extremity vein Choose from 33510–33516;
+ 35500
Venous graft Femoropopliteal vein Choose from 33510–33516;
+ 35572
Arterial-venous Saphenous vein Choose from 33517–33523;
+ choose from 33533–33536
Arterial-venous Upper extremity vein Choose from 33510–33516;
+ choose from 33533–33536;
+ 35500
Arterial-venous Upper extremity artery Choose from 33510–33516;
+ choose from 33533–33536;
+ 35600
Arterial-venous Femoropopliteal vein Choose from 33510–33516;
CPT © 2017 American Medical Association. All rights reserved.

+ choose from 33533–33536;

+ 35572
Arterial graft Internal mammary artery Choose from 33533–33545
Gastroepiploic artery
Epigastric artery
Radial artery
Arterial conduits from other sites
Arterial graft Upper extremity vein Choose from 33533–33545;
+ 35500
Arterial graft Upper extremity artery Choose from 33533–33545;
+ 35600
Arterial graft Femoropopliteal vein Choose from 33533–33545;
+ 35572
Composite graft Two or more segments from another part of body + 35682 or 35683
 Common carotid arteries
GUIDANCE Brachiocephalic
CONNECTION artery
Right subclavian Internal jugular veins
Read the additional artery Left subclavian artery
explanations in the
Right subclavian Left subclavian vein
in-section guidelines vein Aortic arch
within the Surgery
Superior vena Pulmonary trunk
section, subhead Car- cava Left atrium
diovascular System,
Right axillary Ascending aorta
subsection Arterial vein Left axillary vein
Grafting for Coronary
Right atrium Left ventricle
Artery Bypass, directly
Right ventricle Descending aorta
above code 33533 in
Arterial and venous
your CPT book. Hepatic veins branches in abdominal
Inferior vena cava area
Common iliac arteries

Right internal
iliac artery

Right external Femoral veins

iliac artery

Femoral arteries
GUIDANCE
CONNECTION
Read the additional FIGURE 25-5  An illustration showing some of the arteries and veins of the body
information in the in-
section guidelines within
Endovascular Repair of Abdominal Aorta and/or Iliac Arteries
the Surgery section,
subhead Cardiovascu- There are many therapeutic procedures available to treat conditions affecting the
lar System, subsection abdominal aorta and/or iliac arteries. Often, this involves the insertion, positioning, or
Endovascular Repair of deployment of a device known as a covered stent (see Figure 25-6). You may find the
Abdominal Aortic and/ physician documentation may specify an endograft, endovascular graft, a stentgraft,
or Iliac Arteries, directly tube endograft, or endoprosthesis – all of which are variations of a stent.
above code 34701 in CPT codes 34701 through 34834 provide the details of these various procedures
your CPT book. from which you can determine that code which best reports where [which artery] as
well as what specifically was done for this patient.

YOU CODE IT! CASE STUDY

CPT © 2017 American Medical Association. All rights reserved.
CPT

Jason Antone, a 54-year old, was admitted to the hospital by Dr. Sabrina Jordan, for treatment of a chronic, contained
rupture of an aneurysm of the infrarenal aorta. Jason was prepped and draped in the usual manner, and the proce-
dure to deploy an aorto-bi-iliac endograft was performed.

You Code It!

Go through the steps, and determine the procedure code(s) that should be reported for this encounter between
Dr. Jordan and Jason Antone.
Step #1: Read the case carefully and completely.
Step #2: Abstract the scenario. Which key words or terms describe what service the physician provided to the
patient during this encounter?

(continued)

754   PART III  |  REPORTING PHYSICIAN SERVICES AND OUTPATIENT PROCEDURES

 Step #3: Are there any details missing or incomplete for which you would need to query the physician? [If so, ask
your instructor.]
Step #4: Determine the correct CPT procedure code or codes to explain the details about what was provided to
the patient during this encounter.
Step #5: Check for any relevant guidance, including reading all of the symbols and notations.
Step #6: Do you need to append any modifiers to ensure complete and accurate information is provided?
Step #7: Double-check your work.
Answer:
Did you determine this to be the correct code?
34705 Endovascular repair of infrarenal aorta and/or iliac artery(ies) by deployment of an aorto-
bi-iliac endograft . . .
Good job!

Narrowed artery with balloon catheter positioned.

Blood vessel Stent

Inflated balloon presses against arterial wall.

FIGURE 25-6  Illustrations of a balloon catheterization and the placement of a

stent

Catheterizations and Vascular Families

Understanding the vascular families can be useful to coders when reporting the
provision of a catheterization. Tables 25-2, 25-3, and 25-4 show some examples of
the vascular orders when reporting the catheterization of the aorta. The catheter-
ization of the femoral or carotid arteries would each have their own families, of
course. A full listing can be found in your CPT code book, Appendix L, Vascular
CPT © 2017 American Medical Association. All rights reserved.

Families.
A vascular family begins with the vessel that branches off from the aorta, femo-
ral artery, or carotid artery and continues to track all vessels that branch from that.
For example, in Table 25-2, in the first order (first column), you see the superior
mesenteric, which is one of the arteries that branch off the aorta. The middle colic,
interior pancreaticoduodenal, jejunal, ileocolic, appendicular, posterior cecal, ante-
rior cecal, marginal, and right colic arteries all branch off the superior mesenteric.
From this point, only the interior pancreaticoduodenal has additional vessels branch-
ing off it—the posterior inferior pancreaticoduodenal and the anterior inferior
pancreaticoduodenal.
 TABLE 25-2  Vascular Families: Superior Mesenteric

First Order Second Order Branch Third Order Branch

Middle colic
Posterior inferior
Inferior pancreaticoduodenal
pancreaticoduodenal Anterior inferior
pancreaticoduodenal
Jejunal
Superior mesenteric Ileocolic
Appendicular
Posterior cecal
Anterior cecal
Marginal
Right colic

TABLE 25-3  Vascular Families: Left Common Carotid

First Order Second Order Branch Third Order Branch

Left ophthalmic

Left posterior
communicating
Left internal carotid
Left middle cerebral

Left anterior cerebral

Left superior thyroid

Left common carotid
Left ascending pharyngeal

Left facial

Left lingual
Left external carotid Left occipital

Left posterior auricular

Left superficial temporal

Left internal maxillary

CPT © 2017 American Medical Association. All rights reserved.

CPT
LET’S CODE IT! SCENARIO
Lisa Westerly, an 11-week-old female, was diagnosed with ventricular septal defect (VSD) after her pediatrician, Dr.
Harris, ordered an echocardiography. A large VSD was identified in the septum. Due to the size of the defect, Dr.
Harris admitted Lisa into the hospital today to close the defect with a patch graft.

Let’s Code It!

Review the notes and abstract the key terms. Let’s go to the Alphabetic Index and look up closure, the proce-
dure being performed. Under the word closure, you will find septal defect, which suggests the code 33615.

756   PART III  |  REPORTING PHYSICIAN SERVICES AND OUTPATIENT PROCEDURES

 While we are in the Alphabetic Index, let’s try one other way to look up the code. Let’s go to heart, the anatomical
site where the procedure is being performed. When you read the column below heart, you will see closure, septal
defect, which again suggests code 33615. However, just out of curiosity, continue reading down the columns until you
get to repair (another word for the procedure being done). As you read everything listed under repair, keep going past
septal defect all the way to ventricular septum—33545, 33647, 33681–33688, 33692–33697, 93581. Ventricular
septum is a much better match to the physician’s notes than septal defect, isn’t it? Not certain? That’s great because
you need to let the actual code descriptions in the numeric listing give you more details before you make a decision.
This is where time and patience are important to the coding process. Read carefully through the description
of each code suggested by the Alphabetic Index. You will probably agree that the best, most appropriate code is
33681 Closure of single ventricular septal defect, with or without patch
Great job!

TABLE 25-4  Vascular Families: Common Iliac

First Order Second Order Branch Third Order Branch Beyond Third Order Branches

Iliolumbar
Lateral sacral
Superior gluteal
Umbilical
Superior vesical
Internal iliac Obturator
Inferior vesical
Middle rectal
Inferior rectal
Internal pudendal
Inferior gluteal
Cremasteric
Inferior epigastric
Common iliac External iliac Pubic
Deep circumflex iliac Ascending deep circumflex iliac

Medial descending

Perforating branches
Profunda femoris
Lateral descending
CPT © 2017 American Medical Association. All rights reserved.

Lateral circumflex
Deep external pudendal
Superficial external pudendal
Common femoral Ascending lateral circumflex femoral
Descending lateral circumflex femoral
Transverse lateral circumflex femoral
Geniculate
Popliteal
Superficial femoral Anterior tibial
Peroneal
Posterior tibial
 Central Venous Access Procedures
Venous access devices (VAD) can be challenging to report because of the various
types of procedures involved with their insertion as well as the multitude of purposes
for the procedure itself. According to the CPT guidelines, the tip of the VAD or cath-
eter must come to an end in the subclavian vein, brachiocephalic (innominate) vein,
iliac vein, superior or inferior vena cava, or right atrium of the heart to be considered
a central VAD or catheter.

Catheter or Device
A catheter is a tube that is used for various medical reasons. It may be inserted to
withdraw bodily fluids, as a urinary catheter collects urine from the bladder. Cath-
eters can also be used to deliver medications, such as an intravenous (IV) injection of
drugs directly into the patient’s veins. In addition, catheters can be used as a vehicle to
enable the insertion of a device such as a stent.
In this usage, a device is most often a subcutaneous pump or a subcutaneous port
designed to achieve ongoing access internally without the need to repeatedly obtain a
new entry site.
GUIDANCE
CONNECTION Entry Site: Centrally Inserted or Peripherally Inserted
Read the additional
For these procedures, it is important to the coding process that you read the physician’s
explanations in the
notes carefully to determine exactly where on the patient’s body the VAD or catheter
in-section guidelines
was inserted. A centrally inserted device enters the body at the jugular, subclavian, or
within the Surgery
femoral vein or the inferior vena cava. A VAD or catheter that enters the body at either
section, subhead Car-
the basilic vein or the cephalic vein is called a peripherally inserted central catheter,
diovascular System,
often referred to by its initials—a PICC line.
subsection Central
Nontunneled or Tunneled
Venous Access Proce-
dures, directly above A tunneled catheter does exactly as its name describes—it tunnels under the skin.
code 36555 in your These tubes are more flexible; they are inserted into a vein at one location, such as the
CPT book. neck, chest, or groin, and wended through beneath the skin to emerge at a separate site
in the body. A nontunneled catheter is inserted directly into the vein by venipuncture.

CPT
YOU CODE IT! CASE STUDY
Elias McGynty is a 54-year-old male who has significant multivessel coronary artery disease. He has atypical anginal
symptoms, which are probably secondary to his insulin-dependent (type 1) diabetes mellitus. Nonetheless, he is at
risk for ischemia, and in order to reduce this risk, surgical myocardial revascularization is recommended.
PROCEDURE: A coronary artery bypass graft operation utilizing the left internal mammary artery as conduit to the left
anterior descending. The remaining conduit will come from the greater saphenous veins. The risks and benefits of CPT © 2017 American Medical Association. All rights reserved.
this procedure were explained to the patient. He signed the informed consent. The patient tolerated the procedure
well and was brought into recovery conscious and aware.
Francis Lamiere, MD

You Code It!

Dr. Lamiere performed a coronary artery bypass graft on Elias McGynty. Determine the code or codes to report
this work.
Step #1: Read the case carefully and completely.
Step #2: Abstract the scenario. Which key words or terms describe what service the physician provided to the
patient during this encounter?

758   PART III  |  REPORTING PHYSICIAN SERVICES AND OUTPATIENT PROCEDURES

 Step #3: Are there any details missing or incomplete for which you would need to query the physician? [If so,
ask your instructor.]
Step #4: Determine the correct CPT procedure code or codes to explain the details about what was provided
to the patient during this encounter.
Step #5: Check for any relevant guidance, including reading all of the symbols and notations.
Step #6: Do you need to append any modifiers to ensure complete and accurate information is provided?
Step #7: Double-check your work.
Answer:
Did you determine these to be the correct codes?
33533 Coronary artery bypass, using arterial graft(s); single coronary arterial grafts
33517 Coronary artery bypass, using venous graft(s) and arterial graft(s); single venous graft

25.9  Digestive System

The digestive tract begins at the mouth and travels through the body all the way to the
anus. The organs along the pathway process food and nourishment so cells can absorb
nutrients and eliminate waste. The digestive tract is also referred to as the alimentary
canal or the gastrointestinal (GI) tract.

Endoscopic Procedures
There are times when a physician needs to visually examine and/or obtain a specimen
for pathologic testing of the interior of an organ, such as the throat, stomach, or blad-
der, in order to make a more accurate diagnosis. In these cases, an endoscope may be
used.
An esophagogastroduodenoscopy (EGD), more commonly known as an upper
endoscopy, enables the physician to view the patient’s esophagus, stomach, and duo-
denum without a surgical invasion of the body.
Endoscopic retrograde cholangiopancreatography (ERCP) uses a combination of
x-rays and the endoscope to enable visualization of the patient’s stomach, the duode-
num, and the bile ducts in the biliary tree and pancreas.
Sigmoidoscopy and colonoscopy are endoscopic procedures used to examine the
internal aspects of the lower digestive system. A sigmoidoscopy permits the physician
to visually investigate a patient’s anus, rectum, and sigmoid colon. A colonoscopy
CPT © 2017 American Medical Association. All rights reserved.

permits the physician to look at the entire large intestine: the anus, the rectum, the
descending (sigmoid) colon, the transverse colon, the ascending colon, and the cecum.
Endoscopy can be used for therapeutic procedures as well, as when Dr. Sanger
had to remove a penny (foreign body) from little Billy’s esophagus after he tried to
swallow the coin, code 43247 Esophagogastroduodenoscopy, flexible, transoral; with
removal of foreign body(s).

Gastric Intubation
The insertion of a nasogastric (NG) tube may be done for many reasons. The stomach
contents may need to be removed, pre-surgery, post-surgery, or to remove ingested
substances (commonly known as “pumping the stomach”). In other cases, the tube
may be required to deliver nutrition directly into the stomach. This may be done for
a patient after a surgical procedure on the esophagus or the esophogastric junction.
Alternately, the tube may be inserted through the mouth instead of the nose, known as
 oro-gastric tube placement, or percutaneously through the abdominal wall, known as
a gastrostomy tube.

EXAMPLES
43752 Naso- or oro-gastric tube placement, requiring physician’s skill and
fluoroscopic guidance (includes fluorosocpy, image documentation,
and report)
43753 Gastric intubation and aspiration(s), therapeutic, necessitating phy-
sician’s skill (eg. for gastrointestinal hemorrhage), including lavage if
performed

Hernia Repair
A hernia is a situation where an organ pushes through an abnormal opening within
a muscle or other structure that contains it. A hernia may occur in the inner groin
(inguinal hernia), outer groin (femoral hernia), umbilicus (umbilical hernia), between
the esophagus and stomach (hiatal hernia), and as the result of an incision (an inci-
sional hernia)
Of course, the procedure will be different to repair a hernia, as determined by the
anatomical location. As you can see by looking in the CPT Alphabetic Index, just
knowing the physician performed a hernia repair is not enough detail to determine the
code. You must identify, from the documentation, the specific anatomical site.
As with many other procedures, hernia repair can be done as an open procedure or
laparoscopically. With some types of hernias, you may also need to know the patient’s
age. Diaphragmatic, inguinal, and umbilicus hernias are known to occur in neonates
and children. And more specifics are needed about the hernia itself: initial or recur-
rent; incarcerated or strangulated. All of these details will also impact the determina-
tion of the code to report.

CPT
YOU CODE IT! CASE STUDY
Thomas Mouldare, 47-year-old male, was diagnosed with a diaphragmatic (hiatal) hernia that required surgery. Dr.
Wallabee performed a Nissen fundoplication, laparoscopically. The upper area of the stomach (gastric fundus) is
plicated (wrapped) around the distal portion of the esophagus. This is done to support and reinforce the effective-
ness of the lower esophageal sphincter. Then, the esophageal hiatus is sutured to narrow the opening back to the
correct width.

You Code It!

Review the details in this case study, and determine the code or codes required to accurately report Dr. Walla- CPT © 2017 American Medical Association. All rights reserved.

bee’s surgical procedure on Thomas Mouldare.

Step #1: Read the case carefully and completely.
Step #2: Abstract the scenario. Which key words or terms describe what service the physician provided to the
patient during this encounter?
Step #3: Are there any details missing or incomplete for which you would need to query the physician? [If so,
ask your instructor.]
Step #4: Determine the correct CPT procedure code or codes to explain the details about what was provided
to the patient during this encounter.
Step #5: Check for any relevant guidance, including reading all of the symbols and notations.

760   PART III  |  REPORTING PHYSICIAN SERVICES AND OUTPATIENT PROCEDURES

 Step #6: Do you need to append any modifiers to ensure complete and accurate information is provided?
Step #7: Double-check your work.
Answer:
Did you determine this to be the correct code?
43280   Laparoscopy, surgical, esophagogastric fundoplasty (eg. Nissen, Toupet procedures)

Bariatric Surgery
Bariatric surgical procedures may be performed on the stomach, the duodenum, the
jejunum, and/or the ileum and are most often provided to patients who have been diag-
nosed as morbidly obese. Consideration for performing this surgery may include the
physician’s evaluation of the candidate’s eating behaviors as well as the patient’s pre-
disposition for serious obesity-related co-morbidities such as coronary heart disease,
type 2 diabetes mellitus, and/or acute sleep apnea.
These surgeries may be performed as an open procedure or laparoscopically, and
this detail will affect the determination of the correct code. The four most common
versions of this surgery are
∙ Adjustable gastric band (AGB). See codes 43770–43774. AGB is a procedure
that places a small, adjustable band to create a proximal pouch, thereby limit-
ing the passage of food. The attending physician can increase or decrease the
size of the passage using saline solution to inflate or deflate as needed for the
patient’s situation.
∙ Roux-en-Y gastric bypass (RYGB). See codes 43846, 43847, 43644. RYGB lim-
its food intake by use of a small pouch that is similar in size to that created by
the adjustable gastric band. In addition, absorption of food in the digestive tract
is reduced by excluding most of the stomach, duodenum, and upper intestine
from contact with food by routing food directly from the pouch into the small
intestine.
∙ Biliopancreatic diversion with a duodenal switch (BPD-DS). See codes 43775 and
43843. BPD-DS, most often referred to as a “duodenal switch,” includes transection
of the stomach, a bypass to route digested material away from the small intestine, as
well as re-routing bile and other digestive juices that impair digestion.
∙ Vertical sleeve gastrectomy (VSG). See code 43775. A vertical sleeve gastrectomy
(VSG) is performed and connected to a very short segment of the duodenum, which
CPT © 2017 American Medical Association. All rights reserved.

is then directly connected to a lower part of the small intestine. A small portion
of the duodenum is untouched to provide passage for food and absorption of some GUIDANCE
vitamins and minerals. The distance between the stomach and colon is made much CONNECTION
shorter after this operation, resulting in malabsorption.
Read the additional
A VSG procedure includes the resectioning of the stomach and is most often per- explalnations in the
formed solely as the first stage of the multistaged BPD-DS on those patients deter- in-section guidelines
mined to be unable to go through such a long procedure at one encounter. VSG is not located within the
without benefits, as research has shown that some VSG patients report significant Surgery section, sub-
weight loss. Should a second-stage procedure be performed, that second procedure head Digestive System,
and any others in the sequence would be reported with the appropriate procedure code subsection Bariatric
appended by modifier 58 Staged Procedure. Surgery, directly above
During the postoperative period, adjustments of an adjustable gastric restric- code 43770 in your
tive device is included in the global surgical package and therefore not coded CPT book.
separately.
 CPT
LET’S CODE IT! SCENARIO
Justin Abernathy, a 61-year-old male, was suffering from fecal incontinence, diarrhea, and constipation. He came
to the Ambulatory Care Center so that his gastroenterologist, Dr. Minton, could perform a colonoscopy. First, Ellen
Brennon, RN, administered Demerol and Versed by IV, and the patient was brought into the examination room. The
variable flexion Olympus colonoscope was introduced into the rectum and advanced to the cecum. In the midsig-
moid colon, a 3-mm sessile polyp was destroyed. The procedure took about 30 minutes, and Justin tolerated the
procedure well.

Let’s Code It!

We know that the main procedure was a colonoscopy, so let’s look that up in the Alphabetic Index. When you
refer to the notes, what else was done for Justin in conjunction with the colonoscopy? A polyp was destroyed.
Find destruction beneath colonoscopy. Do you know whether a polyp is a lesion or a tumor? It happens to be
a lesion; however, you don’t have to know this because the index suggests the same code for both: 45388. Let’s
look at the complete description in the numeric listing.
45388 Colonoscopy, flexible; with ablation of tumor(s), polyp(s), or other lesion(s) (includes pre- and
post-dilation and guide wire passage, when performed)
You will also need to code the administration of the moderate sedation that was given to Justin (the Demerol
and Versed).
99156 Moderate sedation services provided by a physician or other qualified health care professional
other than the physician or other qualified health care professional performing the diagnos-
tic or therapeutic service that the sedation supports; initial 15 minutes of intraservice time,
patient age 5 years or older
99157  each additional 15 minutes of intraservice time (List separately in addition to code for pri-
mary service)
You have three codes to report the whole story as to what Dr. Minton did for Justin during this encounter:
45388, 99156, 99157. Great job!

25.10  Urinary System

The urinary system is responsible for maintaining the proper level and composition of
fluids in the body.

Urinary Catheterization
There are many reasons why a urinary catheter might need to be inserted: patients
CPT © 2017 American Medical Association. All rights reserved.
with incontinence, especially those who are chronically bedridden or those with lower
paralysis; those about to go through a surgical procedure, especially when general
GUIDANCE anesthesia is administered; as well as patients who suffer from reduced or blocked
urine flow, such as male patients with enlarged prostates or female patients with uter-
CONNECTION ine fibroid tumors. A patient with reduced renal function may require a catheterization
Read the additional so health care professionals can accurately monitor their urinary output.
explanations in the in- The documentation may include details, such as the type of catheter used, including
section guidelines within a Foley, a Robinson, a Carson, or a Tieman catheter. Each type performs differently
the Surgery with various features, determined by the specific issue being addressed.
section, subhead Uri-
nary System, subsection Urodynamics
Urodynamics, directly
above code 51725 in The codes listed for the procedures in the Urodynamics section, 51725–51798, include
your CPT book. the services of the physician to perform the procedure (or directly supervise the per-
formance of the procedure), as well as the use of all instruments, equipment, fluids,

762   PART III  |  REPORTING PHYSICIAN SERVICES AND OUTPATIENT PROCEDURES

 gases, probes, catheters, technician’s fees, medications, gloves, trays, tubing, and other
sterile supplies.
If the physician for whom you are coding did not actually perform the procedure
but only interpreted the results, then the appropriate procedure code from this section
should be appended with modifier 26 Professional Component.

CPT
YOU CODE IT! CASE STUDY
Rachel Naviga, a 39-year-old female, G3 P3, states she has been dealing with stress incontinence increasingly over
the last several years. She had three vaginal deliveries, with the largest infant weighing 7.5 lb. Rachel states that her
leakage frequency, volume, timing, and associated symptoms (urgency, stress, urinary frequency, nocturia, enuresis,
incomplete emptying, straining to empty, leakage without warning) have become bothersome and she wants to do
something about it.
Today she presents for a complex cystometrogram with voiding pressure study to confirm or deny the diagnosis
of stress urinary incontinence prior to the scheduling of surgery.

You Code It!

Go through the steps, and determine what procedure code(s) should be reported for the encounter with Rachel.
Step #1: Read the case carefully and completely.
Step #2: Abstract the scenario. Which key words or terms describe what service the physician provided to the
patient during this encounter?
Step #3: Are there any details missing or incomplete for which you would need to query the physician? [If so,
ask your instructor.]
Step #4: Determine the correct CPT procedure code or codes to explain the details about what was provided
to the patient during this encounter.
Step #5: Check for any relevant guidance, including reading all of the symbols and notations.
Step #6: Do you need to append any modifiers to ensure complete and accurate information is provided?
Step #7: Double-check your work.
Answer:
Did you determine this to be the correct code?
51728 Complex cystometrogram (ie. calibrated electronic equipment); with voiding pressure studies
(ie. bladder voiding pressure), any technique
CPT © 2017 American Medical Association. All rights reserved.

Transurethral Surgery
When a diagnostic or therapeutic cystourethroscopic intervention is performed, the
appropriate codes, 52204–52356, include the insertion and removal of a temporary
stent. Therefore, those services are not reported separately—when done at the same
time as the cystourethroscopy (Figure 25-7).
If the physician, however, inserts a self-retaining, indwelling stent during the diag-
nostic or therapeutic cystourethroscopic intervention, use one of the following:
1. Code 52332 with the modifier 51, along with the code for the cystourethroscopy for
a unilateral procedure.
2. Code 52332 with modifier 50 for a bilateral insertion of self-retaining, indwelling
ureteral stents.
Note that when the physician removes the self-retaining, indwelling ureteral stent, use
either 52310 or 52315 with modifier 58.
 Urinary Resectoscope
bladder Prostate in urethra

FIGURE 25-7  An illustration of a resectoscope inserted through the urethra of a

male patient

CPT
LET’S CODE IT! SCENARIO
Ena Colby, a 41-year-old female, is admitted today for the surgical removal of a kidney stone. The stone was too big
for her to pass, so Dr. Olympia decided to remove it surgically. The nephrolithotomy, with complete removal of the
calculus, went as planned, and Ena tolerated the entire procedure well.

Let’s Code It!

Dr. Olympia performed a nephrolithotomy, involving the removal of a kidney stone, also known as calculus. Let’s
try something direct and look up nephrolithotomy in the Alphabetic Index.
The Alphabetic Index suggests the code range 50060–50075. Let’s go to the numeric listing and read the
different code descriptions.
Do you agree that, according to the physician’s notes, the best, most appropriate code available is the following?
50060 Nephrolithotomy; removal of calculus
You are getting very good at this.

Percutaneous Genitourinary Procedures

Diagnostic procedures, such as a nephrostogram or a ureterogram, are most often per-
formed percutaneously, using some type of imaging to guide them. The most common CPT © 2017 American Medical Association. All rights reserved.
are ultrasound and fluoroscopy.
A patient may have a nephrostomy catheter inserted due to ureter stenosis or
obstruction preventing the flow of urine from the kidney to the bladder. A nephrosto-
GUIDANCE gram is done to confirm that the tube is positioned and working properly.
CONNECTION
50432 Placement of nephrostomy catheter, percutaneous, including diag-
Read the additional nostic nephrostogram and/or ureterogram when performed, imaging
explanations in the guidance (eg. ultrasound and/or fluoroscopy) and all associated radio-
in-section guidelines logical supervision and interpretation
within the Surgery sec-
Wondering if you should also report a second code for the injection of the contrast
tion, subhead Urinary
material, such as code 50430 or 50431? No worries, just read the guidelines beneath
System, and throughout
50432 and you will know exactly how to report this:
this subsection in your
CPT book. (Do not report 50432 in conjunction with 50430, 50431, 50432, 50694, 50695,
74425 for the same renal collecting system and/or associated ureter)

764   PART III  |  REPORTING PHYSICIAN SERVICES AND OUTPATIENT PROCEDURES

 This informs you that you cannot report 50430 or 50431 at the same time with 50432.
The guidelines are there to help you do this all correctly!

25.11  The Genital Systems: Male and Female

The Male Genital System
The male genital system is closely situated with the urinary bladder, so a urologist may
be the specialist most often performing procedures on this area of the male anatomy.

Penile Plaque
This type of plaque is a flat layer of scar tissue that can form on the inside of a thick
membrane called the tunica albuginea, which envelops the erectile tissues, and is known
as Peyronie disease. This is believed to begin as an inflammation, and the plaque is
benign, not contagious, and not sexually transmitted. However, it can cause discomfort
and pain in men with this condition. There are several ways to treat the problem.
Injections of steroids and chemotherapy agents, such as interferon, can be directly
delivered to the site of the plaque to work to reduce the effect. These procedures may
be reported with
54200 Injection procedure for Peyronie disease
54205 Injection procedure for Peyronie disease; with surgical exposure of
plaque
The plaque can be surgically removed. This procedure may be performed just to excise
the plaque, or it may include the grafting of material to replace tissue that was excised.
54110 Excision of penile plaque (Peyronie disease)
54111 Excision of penile plaque (Peyronie disease); with graft to 5 cm in
length
54112 Excision of penile plaque (Peyronie disease); with graft greater than
5 cm in length
Severe cases may require more extensive reconstruction and will be reported with code
54360 Plastic operation on penis to correct angulation

CPT
YOU CODE IT! CASE STUDY
Glenn Hagger, a 15-year-old male, came to see his regular physician, Dr. Carboni, for help. Glenn and his friends
were fooling around at his father’s construction company, and a staple gun went off, projecting a staple into his
scrotum. Dr. Carboni carefully removed the staple and applied some antibiotic ointment to prevent infection until the
CPT © 2017 American Medical Association. All rights reserved.

two small wounds healed.

You Code It!

Go through the steps, and determine the procedure code(s) that should be reported for this encounter between
Dr. Carboni and Glenn Hagger.
Step #1: Read the case carefully and completely.
Step #2: Abstract the scenario. Which key words or terms describe what service the physician provided to the
patient during this encounter?
Step #3: Are there any details missing or incomplete for which you would need to query the physician? [If so,
ask your instructor.]

(continued)
 Step #4: Determine the correct CPT procedure code or codes to explain the details about what was provided
to the patient during this encounter.
Step #5: Check for any relevant guidance, including reading all of the symbols and notations.
Step #6: Do you need to append any modifiers to ensure complete and accurate information is provided?
Step #7: Double-check your work.
Answer:
Did you determine this to be the correct code?
55120 Removal of foreign body in scrotum
This matches the physician’s description perfectly!

The Female Genital System

Vulvectomy
Sometimes physicians use direct terms in their notes, such as simple, partial, radical,
or complete, when describing vulvectomies. Such terms make finding the best code
easier. However, other physicians may be more descriptive in their notes regarding
the procedure. Therefore, you have to know what these terms mean. The CPT book
defines them as follows:
∙ Simple: The removal of skin and superficial subcutaneous tissues.
∙ Radical: The removal of skin and deep subcutaneous tissues.
∙ Partial: The removal of less than 80% of the vulvar area.
∙ Complete: The removal of more than 80% of the vulvar area.

GUIDANCE EXAMPLES
CONNECTION 56620 Vulvectomy, simple; partial
Read the additional
The description of this code represents a physician’s statement that he or she
explanations in the
removed less than 80% of the skin and superficial subcutaneous tissues of the
in-section guidelines
vulvar area.
within the Surgery sec-
tion, subhead Female 56633 Vulvectomy, radical; complete
Genital System, subsec-
The description of this code represents a physician’s statement that he or she removed
CPT © 2017 American Medical Association. All rights reserved.
tion Vulva, Perineum,
more than 80% of the skin and deep subcutaneous tissues of the vulvar area.
and Introitus, directly
above code 56405 in
your CPT book. Maternity Care and Delivery
The complete package of services provided to a woman for uncomplicated maternity
care includes the antepartum (prenatal) care, the delivery of the baby, and the post-
partum care of the mother. Similar to working with the services already provided in
the global surgical package, you must know the components of the maternity care
package. This is the only way you can determine what is already included and what
services should be reported separately.

Antepartum Care
∙ Initial patient history
∙ Subsequent patient history

766   PART III  |  REPORTING PHYSICIAN SERVICES AND OUTPATIENT PROCEDURES

 ∙ Physical examinations
∙ Documentation of weight, blood pressure, fetal heart tones, routine chemical
urinalysis
∙ Monthly visits from conception up to 28 weeks gestation
∙ Biweekly visits from 28 weeks to 36 weeks gestation
∙ Weekly visits from 36 weeks gestation to delivery

Delivery Services
∙ Admission to the hospital
∙ Admission history and physical examination (H&P)
∙ Management of uncomplicated labor
∙ Delivery: vaginal (with or without episiotomy, with or without forceps) or cesarean
section

Postpartum Care
∙ Hospital and office visits following the delivery
Should a physician provide one portion of the services, but not all, this will affect the
determination of the correct code.

EXAMPLE GUIDANCE
Dr. Barber provided antepartum care for Nancy Trainer. While on vacation in CONNECTION
Europe, Nancy suffered a miscarriage (spontaneous abortion) and lost the baby. Read the additional
Dr. Barber provided postpartum care for Nancy when she returned home. There- explanations in the
fore, instead of reporting in-section guidelines
59400 Routine obstetric care including antepartum care, vaginal delivery within the Surgery sec-
(with or without episiotomy, and/or forceps) and postpartum care tion, subhead Maternity
Care and Delivery,
or directly above code
59510 Routine obstetric care including antepartum care, cesarean delivery, 59000 in your CPT
and postpartum care book.

Dr. Barber’s complete care for Nancy will be reported with two codes:
59425 Antepartum care only; 4–6 visits
59430 Postpartum care only (separate procedure)
CPT © 2017 American Medical Association. All rights reserved.

CPT
LET’S CODE IT! SCENARIO
PATIENT: GLORIA VALDEZ 
DATE OF DISCHARGE: 05/30/2018
ADMITTING DIAGNOSIS: Intrauterine pregnancy at 36 weeks and 5 days estimated gestational age. Presented with
contractions and in latent labor.
DISCHARGE DIAGNOSIS: Status post normal spontaneous vaginal delivery at 36 weeks and 5 days estimated ges-
tational age.
HISTORY OF PRESENT ILLNESS/HOSPITAL COURSE: This patient is a 31-year-old G4, P 1-0-2-1 female for whom
I have been attending through all prenatal care. She is at 36 weeks and 5 days estimated gestational age who

(continued)
 presented with contractions and in latent labor. On vaginal examination, the patient was found to be 3 cm dilated,
70% effaced and –3 station. The fetal heart tracing at the time was in the 140s and reactive. The patient was admit-
ted to Labor and Delivery for antibiotics and epidural. The patient continued to have a good labor pattern and pro-
ceeded to deliver a viable female infant weighing 5 pounds 7 ounces over an intact perineum with Apgars of 9 and 9
at 1 and 5 minutes. There were no nuchal cords, no true knots, and the number of vessels in the cord were three. Her
postpartum course was uncomplicated and the patient was discharged to home in stable and satisfactory condition
on postpartum day #2.
PROCEDURES PERFORMED: Normal spontaneous delivery and repair of midline episiotomy in the usual fashion.
COMPLICATIONS: None.
FINAL DIAGNOSIS: Status post normal spontaneous vaginal delivery at 36 weeks and 5 days estimated gestational
age.
DISCHARGE INSTRUCTIONS: Call for increased pain, fever, or increased bleeding.
DIET: Advance as tolerated.
ACTIVITY: Pelvic rest for 6 weeks and nothing inserted into the vagina for 6 weeks, i.e., no tampons, douche, or
sex.

MEDICATIONS AND FOLLOWUP: Instructed patient to call me in the morning, or prn with any concerns. Then, I will
see her in the office in 1 week.
Felicia Washington, MD

Let’s Code It!

Dr. Washington has been caring for Gloria throughout this pregnancy and delivery. This is the big event, so turn
to the CPT Alphabetic Index to
Delivery
See Cesarean Delivery; Vaginal Delivery
Gloria has a vaginal delivery, so turn to
Vaginal Delivery . . . . . . . . . 59400, 59610-59614
Are there any items listed below this that match what Dr. Washington did for Gloria? Not exactly. So, turn to
review the full descriptions of these codes.
59400 Routine obstetric care including antepartum care, vaginal delivery (with or without episiotomy,
and/or forceps) and postpartum care
59610 Routine obstetric care including antepartum care, vaginal delivery (with or without episiotomy,
and/or forceps) and postpartum care, after previous cesarean delivery

CPT © 2017 American Medical Association. All rights reserved.

59612 Vaginal delivery only after previous cesarean delivery (with or without episiotomy and/or
forceps); 
59614 Vaginal delivery only after previous cesarean delivery (with or without episiotomy and/or for-
ceps); including postpartum care
Do any of these codes accurately and completely report what Dr. Washington provided to Gloria for this preg-
nancy and delivery?
59400 Routine obstetric care including antepartum care, vaginal delivery (with or without episiotomy,
and/or forceps) and postpartum care
Good work!

768   PART III  |  REPORTING PHYSICIAN SERVICES AND OUTPATIENT PROCEDURES

 25.12  Nervous System
Procedures performed on the nervous system organs (the brain, spinal cord, nerves,
and ganglia) and connective tissues are coded from the Nervous System subsection.
These components of the human body are responsible for sensory, integrative, and
motor activities.

Skull Surgery
The skull is, technically, the bone-shell that covers and protects the brain and organs
within. To cushion the tissues, blood vessels, and nerves, the dura mater, arachnoid
mater, and pia mater lie between the skull and these components (Figure 25-8).
The complexity of surgical treatment of skull base lesions often demands the skills
of more than one surgeon during the same session. When one surgeon provides one
portion of the procedure and another surgeon a different portion, each surgeon only
uses the code for the surgical procedure he or she performed.
Typically, the segments of the procedure include the following:
1. The approach describes the tactic of the procedure, such as craniofacial, orbitocra-
nial, or transcochlear:
a. Anterior cranial fossa, 61580–61586
b. Middle cranial fossa, 61590–61592
c. Posterior cranial fossa, 61595–61598
2. The definitive describes the procedure itself, such as resection, excision, repair,
biopsy, or transection:
a. Base of anterior cranial fossa, 61600–61601
b. Base of middle cranial fossa, 61605–61613
c. Base of posterior cranial fossa, 61615–61616
3. The repair/reconstruction identifies a secondary repair, such as
a. Extensive dural grafting
b. Cranioplasty

Skull

Pia mater
CPT © 2017 American Medical Association. All rights reserved.

Arachnoid
mater

Dura mater

FIGURE 25-8  The internal components of the head

 c. Local or regional myocutaneous pedicle flaps
CODING BITES d. Extensive skin grafts
If multiple treatments
are provided all in 1 If one surgeon performs more than one of the procedures, each segment should be
calendar day, then use reported separately, with the second (and third, if applicable) appended with modifier 51 to
code 62264. indicate that multiple procedures were performed at the same session by the same physician.
When a surgeon embeds a neurostimulator electrode array and performs microelec-
trode recording, the recording is included in the implantation code and shouldn’t be
coded separately.
GUIDANCE Code 62263 includes the following:
CONNECTION ∙ Percutaneous insertion of an epidural catheter.
Read the additional ∙ Removal of the catheter several days later.
explanations in the ∙ Procedure injections.
in-section guidelines
within the Surgery sec-
∙ Fluoroscopic guidance and localization.
tion, subhead Nervous ∙ Multiple adhesiolysis sessions over the course of 2 or more days.
System, subsection The code should be used only once to represent the entire series.
Surgery of Skull Base,
directly above code 62263 Percutaneous lysis of epidural adhesions using solution injection (e.g.,
61580 in your CPT hypertonic saline, enzyme) or mechanical means (e.g., catheter) includ-
book. ing radiologic localization (includes contrast when administered), mul-
tiple adhesiolysis sessions; 2 or more days
62264   1 day

Spinal Cord Injury Repair

Injury to the spinal cord is almost always the result of trauma. This damage can result
in changes to the patient’s strength, sensations, and other bodily functions that are
regulated by these nerves, impacting virtually every aspect of life. The extent of the
patient’s ability to control his or her limbs will be determined by the location (specific
site along the spine) and the severity of the damage. The location is identified by the
lowest (most distal) segment of the spine that is unaffected by the injury.
At this time, treatments of spinal cord injuries are directed at pain control and stabi-
lization of the spine to prevent additional irritation or damage to the nerves.
Methylprednisolone acetate (brand name Medrol) is an anti-inflammatory with
immunosuppressive properties. Some spinal cord injury patients find that it can reduce
the damage to the nerve cells as well as reduce inflammation near the site of the injury,
decreasing pain and discomfort. This is an off-label use of this drug but has been
found to be beneficial for these cases.
When the trauma causes something to press against the spinal cord, this com-
pression can interfere with the transmission of impulses within the nerves. Surgical

CPT © 2017 American Medical Association. All rights reserved.

decompression of a nerve is typically provided by a neurosurgeon performing a proce-
dure known as a neuroplasty. This procedure may be reported with, for example, CPT
code 64713 Neuroplasty, major peripheral nerve, arm, or leg, open; brachial plexus or
64714 Neuroplasty, major peripheral nerve, arm, or leg, open; lumbar plexus.
Functional electrical stimulation (FES), also termed neuromuscular electric stimu-
lation (NMES), may be used to support the restoration of neuromuscular function,
sensory function, or autonomic function (e.g., bladder, bowel, or respiratory function)
by employing electrical currents to activate damaged nerves within the spinal cord.
Procedures focused on the use of spinal neurostimulator systems, reported with CPT
codes 63650, 63655, and 63661–63664 (for insertion, revision, replacement, and/or
removal), include the implanted neurostimulator, an external controller, an extension,
and multiple contacts (also known as electrodes). These contacts may be located on a
lead, similar to a catheter, or on a plate-shaped or paddle-like surface. Percutaneous
stereotaxis (stereotactic surgery) may be used to stimulate the spinal cord by locating
specific points in the brain that may be identified for additional therapy. This would be

770   PART III  |  REPORTING PHYSICIAN SERVICES AND OUTPATIENT PROCEDURES

 TABLE 25-5  Numeric Rating Scale for Pain
0 = No pain
1–3 = Mild pain (nagging, annoying, interfering little with ADL*)
4–6 = Moderate pain (interferes significantly with ADL*)
7–10 = Severe pain (disabling; unable to perform ADL*)
*ADL = activities of daily living
Source: National Institute of Health.

reported with CPT code 63610 Stereotactic stimulation of spinal cord, percutaneous,
separate procedure not followed by other surgery.

Pain Management
Virtually everyone knows what pain feels like, and this is a very personal evaluation.
Medically speaking, pain is an unpleasant sensation often initiated by tissue damage,
resulting in impulses transmitted to the brain via specific nerve fibers. Most health
care facilities use some type of pain scale from 0 to 10, with 0 indicating no pain at
all and 10 representing excruciating, intolerable pain. In most instances, each number
on the scale is accompanied by an illustration to help patients accurately communicate
what they are feeling. This numeric scale (no illustrations), provided by the National
Institutes of Health, can help improve communication with patients (Table 25-5).
When the documentation indicates that an encounter is prompted by a patient’s
need for pain management, especially when the pain is noted as acute and/or chronic,
there are several options for treatment.

Electrical Reprocessing
Researchers are consistently searching for new ways to help patients manage their
pain. Transcutaneous electrical modulation pain reprocessing (TEMPR), also referred
to as scrambler therapy, administers electrical impulses designed to interrupt pain sig-
nals. Although this experimental procedure uses a type of transcutaneous electrical
nerve stimulation (TENS), it is not the same procedure. Each session lasts about an
hour, with the physician making adjustments approximately every 10 minutes. Each
treatment session is reported with Category III code 0278T.
0278T Transcutaneous electrical modulation pain reprocessing (eg. scrambler
therapy), each treatment session (includes placement of electrodes)

Epidural/Intrathecal Medication Administration

Medication administered intrathecally (directly into the cerebrospinal fluid via the
subarachnoid space in the spinal cord) may be used for chronic pain management.
CPT © 2017 American Medical Association. All rights reserved.

This methodology typically uses pumps, devices that can provide continual delivery
of the drug, biologicals, or genetically engineered encapsulated cells. This route of
administration has been found to be less invasive for the patient and enables treatment
of a larger portion of the central nervous system utilizing the cerebrospinal fluid circu-
lation pathways. Epidural administration tenders the medication into the dura mater of
the spinal cord rather than the subarachnoid space.

EXAMPLES
62350 Implantation, revision, or repositioning of tunneled intrathecal or
epidural catheter, for long-term medication administration via an
external pump or implantable reservoir/infusion pump; without
laminectomy
 CODING BITES 62360 Implantation or replacement of device for intrathecal or epidural
drug infusion; subcutaneous reservoir
Whenever you report
62362 Implantation or replacement of device for intrathecal or epidural
the administration of a
drug infusion; programmable pump, including preparation of pump,
drug, you will need the
with or without programming
code for the administra-
99601 Home infusion/specialty drug administration, per visit (up to 2 hours)
tion, such as implan-
tation of a pump or
infusion, as well as a
code to report the spe- Intravenous Therapy
cific drug that is admin-
This may be the administration route with which you are most familiar. The medica-
istered. Most often, the
tion enters the body via the patient’s vein, most often using a point inside the patient’s
codes used to report
antecubital fossa (elbow). If the condition is chronic, a peripherally inserted central
the specific drug come
catheter (PICC) line may be inserted and used for the administration of the medication
from the HCPCS Level II
for the duration of the therapy.
code set. See the chap-
ter HCPCS Level II in
this textbook for more
information on these EXAMPLE
codes.
96365 Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify
substance or drug); initial, up to 1 hour
36568 Insertion of peripherally inserted central venous catheter (PICC),
without subcutaneous port or pump; younger than 5 years
of age
36569 Insertion of peripherally inserted central venous catheter (PICC),
without subcutaneous port or pump; 5 years or older

CPT
LET’S CODE IT! SCENARIO
Gerald Rosen, a 63-year-old male, was admitted for the implantation of a cerebral cortical neurostimulator.
Dr. Grumman performed a craniotomy and then successfully implanted the electrodes.

Let’s Code It!

Dr. Grumman first performed a craniotomy. Let’s go to the Alphabetic Index and look. Below craniotomy, you
will see the listing for implant of neurostimulators. That matches our notes, so let’s go to the numeric listing and
check the descriptions for 61850–61875, as suggested. Read through the codes and their descriptions in this
section. Do you agree that the following matches our notes the best?

CPT © 2017 American Medical Association. All rights reserved.

61860 Craniectomy or craniotomy for implantation of neurostimulator electrodes, cerebral, cortical
It does!

Endovascular Therapy
Included in this category of neurologic procedures are balloon angioplasties and intra-
vascular stents. You learned about these types of procedures in the Cardiovascular
System section of this chapter. However, the codes here report these procedures when
done intracranially (within the skull) and not intracardially (within the heart).
An intra-arterial mechanical embolectomy or thrombectomy is most often per-
formed to treat an acute ischemic stroke (when a thrombus or embolus blocks blood
flow to the brain).

772   PART III  |  REPORTING PHYSICIAN SERVICES AND OUTPATIENT PROCEDURES

 CPT
LET’S CODE IT! SCENARIO
Alvin Bartholemew, a 71-year-old male, was admitted through the ED with signs of a stroke. He was taken into sur-
gery immediately and Dr. Newton performed a percutaneous transluminal mechanical thrombectomy in the anterior
parietal artery. Fluoroscopic guidance was used, and the thrombus was removed and Alteplase 0.9mg/kg (a throm-
bolytic agent) was injected.

Let’s Code It!

What did Dr. Newton do for Alvin? A transluminal mechanical thrombectomy was performed. Turn to the Alpha-
betic Index in your CPT code book to
Thrombectomy
There is a lengthy list below this term, so review them and read the scenario again and see if you can match any
words in common . . .
Thrombectomy
Percutaneous
Intracranial artery. . . . . . . . . . . . . . . . . 61645
Mechanical arterial. . . . . . . . . 37184-37186
These both match but are in very different subsections of the Surgery section. Let’s investigate these codes.
Remember, you must review all of them before you can determine which is the most accurate.
61645 Percutaneous arterial transluminal mechanical thrombectomy and/or infusion for thromboly-
sis, intracranial, any method, including diagnostic angiography, fluoroscopic guidance, catheter
placement, and intraprocedural pharmacological thrombolytic injection(s)
37184 Primary percutaneous transluminal mechanical thrombectomy, noncoronary, non-intracranial,
arterial or arterial bypass graft, including fluoroscopic guidance and intraprocedural pharmaco-
logical thrombolytic injection(s); initial vessel
[NOTE: Codes 37185 and 37186 are both add-on codes, so we can focus our analysis on this
first code in this series. Then, if 37184 is the right code for this procedure, we can come back and
analyze these add-on codes to determine if they are needed.]
Hmm. These two descriptions are very close. However, did you notice that code 61645 specifically states “intra-
cranial” whereas code 37184 specifically states “non-intracranial.”
Go back to the documentation. It does not state “intracranial” or “non-intracranial.” It does state the thrombec-
tomy was performed on the “anterior parietal artery.”
According to my medical dictionary, the anterior parietal artery is one of the branches of the middle cerebral
artery, distributed to the front or forward part of the parietal lobe of the brain.
OK, so if the thrombectomy was performed to remove a thrombus from the anterior parietal artery, and you
know that this artery is in the brain, this means that this procedure was “intracranial” [remember, the cranium is
the skull].
CPT © 2017 American Medical Association. All rights reserved.

Now, you know exactly which code to report for this procedure:
61645 Percutaneous arterial transluminal mechanical thrombectomy and/or infusion for thromboly-
sis, intracranial, any method, including diagnostic angiography, fluoroscopic guidance, cath-
eter placement, and intraprocedural pharmacological thrombolytic injection(s)
Good job!

25.13  The Optical and Auditory Systems

Optical System
Loss of sight, or even the reduction of vision, has both a social and an economic impact
on a patient and his or her family. In the United States, it is estimated that 14 million
 Sclera

Vitreous humor
Optic
disk
Iris
Optic
Cornea nerve
Pupil
Lens Fovea
centralis
Aqueous humor

Anterior Retina
chamber
Anterior
cavity Posterior
chamber Choroid

Ciliary body

FIGURE 25-9  An illustration of the components of the optical system

people aged 12 and over have some type of visual impairment, and about 61 million
adults are believed to be at high risk for acute vision loss.
There are two recesses in the human skull, each known as an orbit, or eye socket.
Within this bony conical orbit sits the contents of the eye and its ancillary parts (mus-
cles, nerves, blood vessels). The optical system is the most complex organ system of
the human body (Figure 25-9).
Ophthalmologists diagnose and treat problems and concerns of the eye and ocular
adnexa (anatomical parts and sites adjacent to an organ). Most commonly, cataracts
are corrected and foreign materials are removed.

Glaucoma Surgery
Glaucoma is a malfunction of the fluid pressure within the eye; the pressure rises to
a level that can cause damage to the optic disc and nerve. Treatment can successfully
prevent blindness or any vision loss from resulting. When eye drops, oral medication,
or laser treatments have failed to control the patient’s glaucoma condition, a trabecu-
lectomy may be performed. This procedure treats glaucoma with an incision into the
trabecular tissue of the eye to drain the excess fluid that has accumulated. In some
cases, a drainage tube is inserted.
CPT © 2017 American Medical Association. All rights reserved.

EXAMPLES
65850 Trabeculectomy ab externo 
66170 Fistulization of sclera for glaucoma; trabeculectomy ab externo in
absence of previous surgery

Vitrectomy
Patients diagnosed with diabetes mellitus are at risk for ophthalmic manifestations of
their abnormal glucose levels. Diabetic retinopathy is the most common; it is a condi-
tion that causes damage to the tiny blood vessels inside the retina. In cases where the
bleeding in the eye is severe, a vitrectomy, the surgical removal of vitreous gel from
the center of the eye, may be necessary.

774   PART III  |  REPORTING PHYSICIAN SERVICES AND OUTPATIENT PROCEDURES

 EXAMPLES
65810 Paracentesis of anterior chamber of eye (separate procedure); with
removal of vitreous and/or discission of anterior hyaloid membrane,
with or without air injection
67005 Removal of vitreous, anterior approach (open sky technique or lim-
bal incision); partial removal

Foreign Object in Eye

We all know . . . things happen. Tiny specks of dirt, gravel, debris, etc. can fly into
one’s eyes and may need to be surgically removed. In those cases where the foreign
body is difficult to remove, the patient may be admitted to the hospital to have a surgi-
cal extirpation. Read the documentation carefully to identify the specific part of the
eye from which the object is removed, as well as the direction of the approach.

EXAMPLES
65205 Removal of foreign body, external eye; conjunctival superficial
67413 Orbitotomy without bone flap (frontal or transconjunctival approach);
with removal of foreign body
67430 Orbitotomy with bone flap or window, lateral approach (eg, Kroen-
lein); with removal of foreign body
68530 Removal of foreign body or dacryolith, lacrimal passages

Dacryocystorhinostomy
Nasolacrimal duct (NLD) stenosis is a condition that may be congenital or acquired.
A patient may acquire an NLD stenosis as a result of a granulomatous disease, such
as sarcoidosis; a sinus condition; or the formation of dacryoliths (calculus in the lacri-
mal duct or sac). A dacryocystorhinostomy (DCR) is the standard of care for an NLD
obstruction. DCR can be performed using a percutaneous approach by way of a facial
incision or the approach may be via the natural opening of the nose endoscopically.
The procedure is designed to bypass the obstructed nasolacrimal duct and enable tear
drainage directly into the nose from the lacrimal sac.
Fornix
The conjunctival fornix is the
EXAMPLES area between the eyelid and
the eyeball. The superior for-
68801 Dilation of lacrimal punctum, with or without irrigation nix is between the upper lid
CPT © 2017 American Medical Association. All rights reserved.

68815 Probing of nasolacimal duct, with or without irrigation; with insertion and eyeball; the inferior fornix
of tube or stent is between the lower lid and
the eyeball. Plural: fornices

CPT
LET’S CODE IT! SCENARIO
Delores Leon was diagnosed with a herniated orbital mass, OD (right inferior orbit). Dr. Marconi performed an exci-
sion of the mass and repair. From his notes, “The lower lid was everted and the inferior fornix examined. The herniat-
ing mass was viewed and measured at 0.81 cm in diameter. Westcott scissors were used to incise the conjunctival
fornices. The herniating mass was then clamped, excised, and cauterized. It appeared to contain mostly fat tissue,
which was sent to pathology. The inferior fornix was repaired using running suture of 6-0 plain gut. Bacitracin oint-
ment was applied to the eye followed by an eye pad.”
(continued)
 Let’s Code It!
The procedure performed was “excision of the mass and repair, right inferior orbit.”
In the CPT Alphabetic Index, turn to excision and review the long list of anatomical sites below. What did Dr.
Marconi excise? Not the eye (that would be removal of the eyeball). He removed a “mass from the eye orbit” and
then “repaired the orbit.”
There is no listing for mass, but you should remember from medical terminology class (or look it up in a medi-
cal dictionary) that another term for mass is lesion. In the Alphabetic Index, find:
Excision . . . Lesion . . another long list. On your scratch pad, write down the codes suggested next to the word
Orbit—61333, 67412, 67420—so that you can check them out. However, while you are here, also write down
the codes suggested for Conjunctiva—68110–68130. Why? Because in the body of the notes, it states “incise
the conjunctival fornices.” This is why it is so important to read the complete notes and not just code from the
procedure statement at the top.
Now, let’s turn to the main portion of the CPT and find the complete code descriptions:
61333 Exploration of orbit (transcranial approach); with removal of lesion
67412 Orbitotomy without bone flap (frontal or transconjunctival approach); with removal of lesion
67420 Orbitotomy with bone flap or window, lateral approach (eg, Kroenlein); with removal of lesion
68110 Excision of lesion, conjunctiva; up to 1 cm
68115 Excision of lesion, conjunctiva; over 1 cm
68130 Excision of lesion, conjunctiva; with adjacent sclera
Which code description matches the physician’s notes accurately? 68110. Good work!

CPT
YOU CODE IT! CASE STUDY
Ronald Jackson, a 49-year-old male, was working in a metal shop. As he was trimming a steel bar, some metal splinters
got into his eye. Fortunately, Dr. Draman found that the metal pieces presented superficial damage and had not embed-
ded themselves in Ronald’s conjunctiva. Dr. Draman removed all the metal pieces and placed a patch over Ronald’s eye.

You Code It!

Go through the steps and determine the procedure code(s) that should be reported for this encounter between
Dr. Draman and Ronald Jackson.
Step #1: Read the case carefully and completely.
Step #2: Abstract the scenario. Which key words or terms describe what service the physician provided to the
patient during this encounter?
Step #3: Are there any details missing or incomplete for which you would need to query the physician? [If so,
ask your instructor.] CPT © 2017 American Medical Association. All rights reserved.

Step #4: Determine the correct CPT procedure code or codes to explain the details about what was provided
to the patient during this encounter.
Step #5: Check for any relevant guidance, including reading all of the symbols and notations.
Step #6: Do you need to append any modifiers to ensure complete and accurate information is provided?
Step #7: Double-check your work.
Answer:
Did you determine this to be the correct code?
65205 Removal of foreign body, external eye; conjunctival superficial
Good for you!

776   PART III  |  REPORTING PHYSICIAN SERVICES AND OUTPATIENT PROCEDURES

 The Auditory System
The auditory system of the human body is referenced in three sections (Figure 25-10).

The Outer Ear

∙ Auricle (pinna).
∙ External acoustic meatus (also known as the external auditory canal).
∙ Eardrum (the tympanic membrane).

EXAMPLES
69100 Biopsy external ear
69209 Removal impacted cerumen using irrigation/lavage, unilateral
69310 Recontruction of external auditory canal (meatoplasty) (eg. for steno-
sis due to injury, infection) (separate procedure)

The Middle Ear

∙ Auditory ossicles: malleus, incus, and stapes.
∙ Oval window.
∙ Eustachian tube (auditory tube) connects the middle ear to the nasopharynx (throat).

EXAMPLES
69421 Myringotomy, including aspiration and/or eustachian tube inflation
requiring general anesthesia
69535 Resection temporal bone, external approach

The Inner Ear

∙ Semicircular canals.
∙ Cochlea.

EXAMPLE
69801 Labyrinthotomy, with perfusion of vestibuloactive drug(s), transcanal
69820 Fenestration semicircular canal

Malleus Incus Stapes

Auricle
CPT © 2017 American Medical Association. All rights reserved.

Cochlea
Oval window
Tympanic Round window
membrane
Tympanic
(eardrum)
cavity
External
auditory Auditory
meatus tube

Pharynx

FIGURE 25-10  The auditory system

 Tympanostomy
When a patient has a middle ear infection (otitis media), pressure caused by the
build-up of fluid or pus in the middle ear compresses the eardrum, causing pain and
decreasing the patient’s ability to hear. A lack of treatment can result in a perforation
of the tympanic membrane. Tympanostomy (ear tube surgery) is a relatively common
procedure performed on about 2 million children each year in the United States. It
involves the insertion of a ventilating tube into the opening of the tympanum to relieve
the pressure.
When reporting a tympanostomy, you need to know what type of anesthesia was
provided to the patient: local or general anesthesia.
69433 Tympanostomy (requiring insertion of ventilating tube), local or topical
anesthesia
69436 Tympanostomy (requiring insertion of ventilating tube), general
anesthesia

These codes report the insertion of the tube into one ear only. When the physician
performs this for both ears at the same encounter, you will need to append modifier
50 Bilateral procedure to the correct procedure code.
Sometimes, over a period of time, the tubes naturally fall out. However, when the
physician must go in and surgically remove the tubes under general anesthesia, this
procedure will be reported separately:
69424 Ventilating tube removal requiring general anesthesia

CPT
YOU CODE IT! CASE STUDY
Anna Mendoza, a 33-year-old female, has been deaf since she was 11. She is admitted today for Dr. Eberhardt to
put a cochlear implant in her left ear. It is expected that Anna will gain back much of her hearing.

You Code It!

Go through the steps, and determine the procedure code(s) that should be reported for this encounter between
Dr. Eberhardt and Anna Mendoza.
Step #1: Read the case carefully and completely.
Step #2: Abstract the scenario. Which key words or terms describe what service the physician provided to the
patient during this encounter?

CPT © 2017 American Medical Association. All rights reserved.

Step #3: Are there any details missing or incomplete for which you would need to query the physician? [If so,
ask your instructor.]
Step #4: Determine the correct CPT procedure code or codes to explain the details about what was provided
to the patient during this encounter.
Step #5: Check for any relevant guidance, including reading all of the symbols and notations.
Step #6: Do you need to append any modifiers to ensure complete and accurate information is provided?
Step #7: Double-check your work.
Answer:
Did you determine this to be the correct code?
69930 Cochlear device implantation, with or without mastoidectomy

778   PART III  |  REPORTING PHYSICIAN SERVICES AND OUTPATIENT PROCEDURES

 25.14  Organ Transplantation
Lung Transplantation
Special guidelines help you report any lung transplant. However, as soon as you begin
to read the notation shown before codes 32850–32856, you will see that the editors of
the CPT book use the term lung allotransplantation in addition to transplantation. Allotransplantation
These words have a very similar meaning. The relocation of tissue from
A lung transplant requires three steps, which can be performed by a single physi- one individual to another
cian or a team of physicians, with each physician submitting his or her own claim. (both of the same species)
Each step has its own code. without an identical genetic
match.
Cadaver Donor Pneumonectomy
Transplantation
Because a human cannot live without lungs, the donor has to be deceased (a cadaver) The transfer of tissue from
prior to the harvesting of the organ. This portion of the transplant, or allotransplanta- one site to another.
tion, procedure should be identified with the code
32850 Donor pneumonectomy(s) (including cold preservation), from cadaver
donor GUIDANCE
CONNECTION
Backbench Work
Read the additional
The actual preparation of the cadaver lung allograft prior to the transplant procedure is
explanations in the
known as backbench work. The actual preparation of the cadaver donor lung allograft
in-section guidelines
prior to the transplant procedure is coded by using either of the following:
within the Surgery sec-
32855 Backbench stand preparation of cadaver donor lung allograft prior to tion, subhead Respira-
transplantation . . . ; unilateral tory System, subsection
or Lung Transplantation,
directly above code
32856 Backbench stand preparation of cadaver donor lung allograft prior to
32850 in your CPT
transplantation . . . ; bilateral
book.
Recipient Lung Allotransplantation
The final code for the entire operation identifies the placement of the allograft in the
patient (the recipient). The selection of a code from the range 32851–32854 is deter-
mined by whether the procedure is performed unilaterally or bilaterally and with or
without a cardiopulmonary bypass.
32851 Lung transplant, single; without cardiopulmonary bypass
32852   with cardiopulmonary bypass
32853 Lung transplant, double (bilateral sequential or en bloc); without car-
diopulmonary bypass
32854   with cardiopulmonary bypass
CPT © 2017 American Medical Association. All rights reserved.

CPT
LET’S CODE IT! SCENARIO
Abbey Reason, a 15-year-old female, was diagnosed 3 years ago with idiopathic pulmonary fibrosis, a chronic
interstitial pulmonary disease. Corticosteroid therapy has not improved her condition, so Dr. Flemming admitted her
today for a double-lung transplantation. The harvesting of the allograft and the preparation of the cadaver donor
double-lung allograft were done by Dr. Orenge. Dr. Flemming only performed the actual lung transplant, en bloc,
along with a cardiopulmonary bypass. Abbey tolerated the procedure well and has an excellent prognosis.

Let’s Code It!

The notes indicate that Dr. Flemming performed only one of the three steps. Therefore, you will have only one
code on his claim form for Abbey’s surgery.

(continued)
 Let’s go to the Alphabetic Index and look for transplant. Read down until you find lung. You know that Abbey
received a double-lung transplant, en bloc, with a bypass. That information leads to the suggested code 32854.
Now go to the numeric listing to check the complete code description.
32854 Lung transplant, double (bilateral sequential or en bloc); with cardiopulmonary bypass
Terrific! This code matches the notes.

Heart/Lung Transplantation
Similar to the components of the lung transplantation that we reviewed earlier, a heart
transplant, with or without a lung allotransplantation, requires three steps to be per-
formed by a single physician or a team of physicians. Each step has its own codes.

Cadaver Donor Cardiectomy with or without a Pneumonectomy

A human cannot live without a heart or lungs, so the donor has to be deceased (a cadaver)
prior to any organ harvesting. This portion of the transplant or allotransplantation proce-
dure is identified with the code 33930 (heart and lungs) or 33940 (heart alone):
33930 Donor cardiectomy-pneumonectomy (including cold preservation)
or
33940 Donor cardiectomy (including cold preservation)

Backbench Work
The actual preparation of the cadaver donor heart, or heart and lung, allograft prior
to the transplant procedure is known as backbench work. The second portion of the
transplant is coded by using either of the following:
33933 Backbench standard preparation of cadaver donor heart/lung allograft
to transplantation, including dissection of allograft from surrounding
soft tissues to prepare aorta, superior vena cava, inferior vena cava,
and trachea for implantation
or
33944 Backbench standard preparation of cadaver donor heart allograft to
transplantation, including dissection from surrounding soft tissues
to prepare aorta, superior vena cava, inferior vena cava, pulmonary
artery, and left atrium for implantation

Recipient Heart with or without Lung Allotransplantation

CPT © 2017 American Medical Association. All rights reserved.
The third code for the entire operation identifies the placement of the allograft into the
patient (the recipient). Select the code from either of the following:
33935 Heart-lung transplant with recipient cardiectomy-pneumonectomy
or
33945 Heart transplant with or without recipient cardiectomy
The codes for the insertion of the transplanted organs include the removal of the dam-
aged or diseased organs.

Liver Transplantation
Again, the components that we have reviewed for the other organ transplants are
involved with a liver allotransplantation.

780   PART III  |  REPORTING PHYSICIAN SERVICES AND OUTPATIENT PROCEDURES

 Donor Hepatectomy
A human can live without a portion of the liver, so the donor can be either deceased
(a cadaver) or living. The best code for this portion of the transplant process is deter-
mined by whether or not the donor is living, and if living, what percentage or portion
of the liver is donated.
47133 Donor hepatectomy (including cold preservation), from cadaver donor
or
47140 Donor hepatectomy (including cold preservation), from living donor;
left lateral segment only (segments II and III)
or
47141 Donor hepatectomy (including cold preservation), from living donor;
total left lobectomy (segments II, III, and IV)
or
47142 Donor hepatectomy (including cold preservation), from living donor;
total right lobectomy (segments V, VI, VII, and VIII)

Backbench Work
The actual preparation of the whole liver graft prior to the transplant procedure is
coded with
47143 Backbench standard preparation of cadaver donor whole liver graft
prior to allotransplantation, including cholecystectomy, if necessary,
and dissection and removal of surrounding soft tissues to prepare
the vena cava, portal vein, hepatic artery, and common bile duct for
implantation; without trisegment or lobe split
47144  with trisegment split of whole liver graft into 2 partial liver grafts (ie.
left lateral segment [segments II and III] and right trisegment [seg-
ments I and IV through VIII])
47145  with lobe split of whole liver graft into 2 partial liver grafts (ie.
left lobe [segments II, III, and IV] and right lobe [segments I and V
through VIII])
In certain cases, and almost always if the donor is living, some reconstruction of the
liver will be required prior to the transplantation. If the notes indicate that a venous
and/or arterial anastomosis was also performed, then you will need to use
47146 Backbench reconstruction of cadaver or living donor liver graft prior to
allotransplantation; venous anastomosis, each
CPT © 2017 American Medical Association. All rights reserved.

Recipient Liver Allotransplantation

The third code for the entire operation identifies the placement of the allograft in the
patient (the recipient): orthotopic (normal position) or heterotopic (other than normal
position).
47135 Liver allotransplantation; orthotopic, partial or whole, from cadaver or
living donor, any age

Pancreas Transplantation
Again, the components that we have reviewed for the other organ transplants are
involved with a pancreatic allotransplantation.

Cadaver Donor Pancreatectomy

A pancreas graft has to come from a deceased (a cadaver) donor.
 48550 Donor pancreatectomy (including cold preservation), with or without
GUIDANCE duodenal segment for transplantation
CONNECTION
Backbench Work
Read the additional
explanations in the When the preparation of the pancreas graft prior to the transplant procedure is routine,
in-section guidelines you use the following code:
within the Surgery sec- 48551 Backbench standard preparation of cadaver donor pancreas allograft
tion, subhead Diges- prior to transplantation, including dissection of allograft from sur-
tive System, subsection rounding soft tissues, splenectomy, duodenotomy, ligation of bile
Pancreas Transplanta- duct, ligation of mesenteric vessels, and Y-grafts arterial anastomoses
tion, directly above from iliac artery to superior mesenteric artery and to splenic artery
code 48550 in your
CPT book. However, in certain cases, some reconstruction of the pancreas will be required prior
to the transplantation. If the notes indicate that a venous and/or arterial anastomosis
was performed, then you have to use
48552 Backbench reconstruction of cadaver donor pancreas allograft prior to
allotransplantation; venous anastomosis, each

Recipient Pancreatic Allotransplantation

The final code for the entire operation identifies the placement of the allograft in the
patient (the recipient). For this, use the following code:
48554 Transplantation of pancreatic allograft

Renal (Kidney) Transplantation

The same three components exist for renal transplantation as for the other organ
transplants.

Donor Nephrectomy
A human can live without one kidney, so the donor can be either deceased (a cadaver)
or living.
50300 Donor nephrectomy (including cold preservation); from cadaver donor,
unilateral or bilateral
or
50320 Donor nephrectomy (including cold preservation); open, from living
donor
or
50547 Laparoscopy, surgical; donor nephrectomy (including cold preserva-
CPT © 2017 American Medical Association. All rights reserved.
tion), from living donor

Backbench Work
Performing the routine preparation of the allograft is coded differently, depending
upon whether the donor is living or a cadaver.
50323 Backbench standard preparation of cadaver donor renal allograft prior
to transplantation, including dissection and removal of perinephric fat,
diaphragmatic and retroperitoneal attachments, excision of adrenal
gland, and preparation of ureter(s), renal vein(s), and renal artery(s),
ligating branches, as necessary
or
50325 Backbench standard preparation of living donor renal allograft  prior
to transplantation, including dissection and removal of perinephric fat,

782   PART III  |  REPORTING PHYSICIAN SERVICES AND OUTPATIENT PROCEDURES

 diaphragmatic and retroperitoneal attachments, excision of adrenal
gland, and preparation of ureter(s), renal vein(s), and renal artery(s),
ligating branches, as necessary
In certain cases, some reconstruction of the kidney will be required prior to the trans-
plantation. If the notes indicate that a venous, arterial, and/or ureteral anastomosis was
performed, then you have to use one of the following codes:
50327 Backbench reconstruction of cadaver or living donor renal allograft
prior to allotransplantation; venous anastomosis, each
or
50328 Backbench reconstruction of cadaver or living donor renal allograft
prior to allotransplantation; arterial anastomosis, each
or
50329 Backbench reconstruction of cadaver or living donor renal allograft
prior to allotransplantation; ureteral anastomosis, each GUIDANCE
CONNECTION
Recipient Renal Allotransplantation
The final code for the entire operation identifies the placement of the allograft in the Read the additional
patient (the recipient). Choose the code by whether or not a recipient nephrectomy explanations in the
(the removal of the organ being replaced) is performed at the same time by the same in-section guidelines
physician: located within the Sur-
gery section, subhead
50360 Renal allotransplantation; implantation of graft; without recipient Urinary System, sub-
nephrectomy section Renal Trans-
or plantation, directly
above code 50300 in
50365 Renal allotransplantation; implantation of graft; with recipient your CPT book.
nephrectomy

CPT
YOU CODE IT! CASE STUDY
PATIENT: ETHAN NORWOOD, IV
PROCEDURE PERFORMED: Percutaneous kidney transplant biopsy.
DESCRIPTION OF PROCEDURE: After informed written consent was obtained from the patient, he was taken to the
ultrasound suite and placed in the supine position on the stretcher with the left side propped up slightly with towels
for optimal exposure of the transplant. The kidney transplant was localized in the left iliac fossa with ultrasound and
CPT © 2017 American Medical Association. All rights reserved.

a point overlying the lower pole was marked on the skin. The area was then prepped with Betadine and covered
with a sterile fenestrated drape. Lidocaine 1% was infiltrated at the mark superficially and then to less than 1 cm,
as indicated by ultrasound, to the surface of the kidney. A small incision was made at the anesthetized site with a
#11 blade. A 16 gauge Monopty biopsy gun was then introduced through the incision to a depth of less than 1 cm
and fired. A core tissue was obtained and placed in 10% formalin. The procedure was repeated once more, again
yielding a core tissue. It was divided between formalin and Michel’s solution. The procedure was then terminated.
Firm pressure was applied to the biopsy site after each pass including 5 minutes after the last pass. A Band-Aid
was then placed over the incision. A final ultrasound scan showed no obvious evidence of hematoma. A pressure
dressing was applied. The patient tolerated the procedure well. There were no apparent complications. He has
been returned to the floor in satisfactory condition and orders have been written for frequent vital signs, hematocrit,
exam parameters.
Ava Ferrer, MD

(continued)
 You Code It!
Read the details about the biopsy that Dr. Ferrer performed and determine the most accurate way to report it.
Step #1: Read the case carefully and completely.
Step #2: Abstract the scenario. Which key words or terms describe what service the physician provided to the
patient during this encounter?
Step #3: Are there any details missing or incomplete for which you would need to query the physician? [If so,
ask your instructor.]
Step #4: Determine the correct CPT procedure code or codes to explain the details about what was provided
to the patient during this encounter.
Step #5: Check for any relevant guidance, including reading all of the symbols and notations.
Step #6: Do you need to append any modifiers to ensure complete and accurate information is provided?
Step #7: Double-check your work.

Answer:
Did you determine these to be the codes?
50200 Renal biopsy; percutaneous, by trocar or needle
76942 Ultrasonic guidance for needle placement (eg biopsy, aspiration, injection, localization device),
imaging supervision and interpretation
Did you find the radiology code for the ultrasound, too? You will learn more about coding for radiology services
in our next chapter of this textbook. However, to get to this code, all you had to do is read the guideline notation
beneath code 50200
(For radiological supervision and interpretation, see 76942, 77002, 77012, 77021)
This notation not only told you how to report the ultrasound service for this biopsy, it also informed you that it
was not already included in the 50200 code.

25.15  Operating Microscope

When a surgeon performs microsurgery, he or she has to use an operating microscope.
In such cases, you must code the use of the microscope (69990) in addition to the pro-
cedure in which the microscope is used.

CPT © 2017 American Medical Association. All rights reserved.

69990 Microsurgical techniques, requiring use of operating microscope (List
separately in addition to code for primary procedure.)
There are two guidelines with regard to this add-on code:
1. Do not append modifier 51 Multiple Procedures to the code for the microscope. It is
not an additional procedure. Code 69990 indicates the use of a special technique or
tool, making modifier 51 incorrect.
2. There are some codes that already include the use of the operating microscope.
Therefore, adding code 69990 is redundant. The tough part here is that none of the
codes that already include use of the operating microscope include this information
in their description. Following, and in many CPT books above the code description,
is the list of codes to which you are not permitted to add code 69990 because it is
already included:

784   PART III  |  REPORTING PHYSICIAN SERVICES AND OUTPATIENT PROCEDURES

 15756-15758 31531 49906
15842 31536 61548 GUIDANCE
19364 31541 63075-63078 CONNECTION
19368 31545 64727
Read the additional
20955-20962 31546 64820-64823
explanations in the
20969-20973 31571 64912-64913
in-section guidelines
22551-22552 43116 65091-68850
within the Surgery sec-
22856-22861 43180 0184T
tion, subhead Operat-
26551-26554 43496 0308T
ing Microscope, directly
26556 46601 0402T
above code 69990 in
31526 46607
your CPT book.

EXAMPLE
19364 Breast reconstruction with free flap
(Do not report code 69990 in addition to code 19364.)

As you can see, the codes involved are throughout the Surgery section of the CPT.
You might want to go through and mark or highlight the codes, should you be coding
for a physician who works with an operating microscope.

CPT
LET’S CODE IT! SCENARIO
PATIENT: OLIVIA PRIMA
DATE OF PROCEDURE: 07/22/2018
PREOPERATIVE DIAGNOSIS: Right vocal cord lesion
POSTOPERATIVE DIAGNOSIS: Respiratory papilloma
PROCEDURE: Microscopic laryngoscopy with biopsy and papilloma shave
SURGEON: Serita Frapenstein, MD
ASSISTANT: Morris Bershic, MD
ANESTHESIA: General endotracheal
COMPLICATIONS: None
SPECIMENS REMOVED: Biopsy samples sent from the anterior commissure of the vocal cord
INDICATION FOR PROCEDURE: The patient is a 37-year-old female with a 6-month history of isolated hoarseness
with a vocal cord lesion on direct laryngoscopy, who presents for biopsy of the vocal cord lesion.
CPT © 2017 American Medical Association. All rights reserved.

DESCRIPTION OF PROCEDURE: The patient was brought to the operating room, and an appropriate plane of anes-
thesia was obtained via endotracheal intubation.
The head of the bed was turned 90 degrees. The Dedo laryngoscope was used to visualize the base of tongue, the
bilateral vallecula, both surfaces of the epiglottis, the aryepiglottic folds, the bilateral pyriform sinuses, and hypopharynx.
All of these areas were clear of any lesions or mucosal abnormalities. The true vocal cords were noted to have papilloma-
tous lesions on the right inferior aspect of the cord and the anterior commissure. The false cords and ventricles were clear.
The patient’s larynx was suspended via the laryngoscope. Biopsy samples were taken for frozen and perma-
nent specimens from the anterior commissure lesion. This came back to confirm papilloma. Next, the operating micro-
scope was brought into the field to obtain a detailed visualization of the vocal cord lesion. A straight shaver was then
utilized to remove the papillomatous tissue on the right vocal cord. Care was taken to preserve the mucosa on that
side and not injure the vocal cord. This was done unilaterally again on the right. Appropriate hemostasis was obtained.
The patient tolerated the procedure well. The operating microscope was removed from the field. The patient was
extubated and taken to recovery in stable condition with no immediate complications.
(continued)
 Let’s Code It!
As you read in the operative reports, Dr. Frapenstein performed a laryngoscopy using an operating microscope.
First, you must determine the code for the laryngoscopy. Find this in the CPT Alphabetic Index.
Laryngoscopy
with Operating Microscope or Telescope . . . . 31526, 31531, 31536, 31541, 31545, 31546, 31561, 31571
Turn to the main section and find the codes suggested. Remember, you are obligated to read ALL of these
code descriptions to determine which one is most accurate.
31526 Laryngoscopy direct, with or without tracheoscopy; diagnostic, with operating microscope or
telescope
31531 Laryngoscopy direct, operative, with foreign body removal; with operating microscope or
telescope
31536 Laryngoscopy direct, operative, with biopsy; with operating microscope or telescope
31541 Laryngoscopy direct, operative, with excision of tumor and/or stripping of vocal cords or epiglottis;
with operating microscope or telescope
31545 Laryngoscopy direct, operative, with operating microscope or telescope, with submucosal removal
of non-neoplastic lesion(s) of vocal cord; reconstruction with local tissue flap(s)
31546 Laryngoscopy direct, operative, with operating microscope or telescope, with submucosal removal
of non-neoplastic lesion(s) of vocal cord; reconstruction with graft(s) (includes obtaining autograft)
31561 Laryngoscopy direct, operative, with arytenoidectomy; with operating microscope or telescope
31571 Laryngoscopy direct, operative, with injection into vocal cord(s), thereapeutic; with operating
microscope or telescope
Now that you know, specifically, what these codes report, go back to the operative notes and abstract the
details, beyond laryngoscopy + operating microscope.
The documentation reads, “Biopsy samples were taken.” . . . This leads you to code 31536. However, the
documentation also states,
“A straight shaver was then utilized to remove the papillomatous tissue on the right vocal cord.”
[NOTE: Use your medical dictionary if you don’t already know that papillomatous tissue is benign.] 
. . . This might lead to code 31545 or 31546, except there is documentation that “Care was taken to preserve
the mucosa,” so you know that submucosal tissue was not removed. And there is no mention of a reconstruction
being performed.
So, you can confidently report code 31536. One more thing to check . . . do you need to report a second code
for the use of the operating microscope? Turn to code 69990 and read the guideline carefully. Code 31536 is
included in the “Do not report 69990” notation.
You also know that code 31536 includes the specific detail that an operating microscope was used, therefore
meaning that this tells the whole story and reporting 69990 would just be repetitive. Now, you know the accu-
rate way to report this procedure:

CPT © 2017 American Medical Association. All rights reserved.

31536 Laryngoscopy direct, operative, with biopsy; with operating microscope or telescope
Good job!

Chapter Summary
When coding surgical procedures, you have the challenge of determining which ser-
vices are included in the procedure code, which services are part of the global pack-
age, and which services must be coded separately.
In addition, it is important to remember that the Surgery section of the CPT book
not only includes codes for reporting services provided in an operating room under
general anesthesia but also includes codes for reporting simple and small procedures
such as removing a splinter.

786   PART III  |  REPORTING PHYSICIAN SERVICES AND OUTPATIENT PROCEDURES

 When reporting surgical procedures, it is important to (1) identify the components

CHAPTER 25 REVIEW
of the operation and (2) determine which services are included in the code’s descrip-
tion and which services require a separate code. The Surgery section of the CPT book
is divided into subsections identified by the body system upon which the technique
was performed.

CODING BITES
CPT Surgical Package
• Subsequent to the decision for surgery, one related E/M encounter on the date
immediately prior to or on the date of the procedure (including history and
physical).
• Local infiltration, metacarpal/metatarsal/digital block, or topical anesthesia.
• The procedure itself.
• Immediate postoperative care, including dictating operative notes and talking
with the family and other physicians/health care professionals.
• Writing orders.
• Evaluation of the patient in the post-anesthesia recovery area.
• Typical postoperative follow-up care.

You Interpret It! Answers

1. Diagnostic, 2. Therapeutic, 3. Therapeutic, 4. Prophylactic, 5. Open, 6. Percutane-
ous, 7. Endoscopic, 8. Included, 9. Not included; report separately, 10. Not included;
report separately, 11. 90 days, 12. Zero days, 13. 90 days, 14. 0 days, 15. Zero days

CHAPTER 25 REVIEW
CPT Surgery Section Enhance your learning by
completing these exercises and
more at connect.mheducation.com!

Let’s Check It! Terminology

Match each key term to the appropriate definition.

Part I
1. LO 25.2  The length of time allotted for postoperative care included in the surgi- A. Complex Closure
cal package, which is generally accepted to be 90 days for major surgi- B. Donor Area
cal procedures and up to 10 days for minor procedures.
CPT © 2017 American Medical Association. All rights reserved.

C. Excision
2. LO 25.5  The process of taking skin or tissue (on the same body or another).
D. Full-Thickness
3. LO 25.5  The area or part of the body from which skin or tissue is removed with
E. Global Period
the intention of placing that skin or tissue in another area or body.
F. Harvesting
4. LO 25.1  The methodology or technique used by the physician to perform the
procedure, service, or treatment. G. Intermediate Closure
5. LO 25.2  The accepted principles of conduct, services, or treatments that are
established as the expected behavior.
6. LO 25.5  A method of sealing an opening in the skin involving a multilayered
closure and a reconstructive procedure such as scar revision, debride-
ment, or retention sutures.
7. LO 25.5  The full-thickness removal of a lesion, including margins; includes (for
coding purposes) a simple closure.
 8. LO 25.5 The area, or site, of the body receiving a graft of skin or tissue. H. Recipient Area
CHAPTER 25 REVIEW

9. LO 25.5 A multilevel method of sealing an opening in the skin involving one I. Simple Closure
or more of the deeper layers of the skin. J. Standard of Care
10. LO 25.5 A method of sealing an opening in the skin (epidermis or dermis), K. Surgical Approach
involving only one layer. It includes the administration of a local
anesthesia and/or chemical or electrocauterization of a wound not
closed.
11. LO 25.5 A measure that extends from the epidermis to the connective tissue
layer of the skin.

Part II
1. LO 25.6 Surgically opening the fracture site, or another site in the body nearby, A. Allotransplantation
in order to treat the fractured bone. B. Arthrodesis
2. LO 25.6 The treatment of a fracture without surgically opening the affected area. C. Closed Treatment
3. LO 25.6 The insertion of fixation instruments (such as pins) placed across D. Fornix
the fracture site. It may be done under x-ray imaging for guidance
E. Laminectomy
purposes.
F. Manipulation
4. LO 25.6 The surgical removal of a vertebral posterior arch.
G. Open Treatment
5. LO 25.8 Either of the two major veins in the leg that run from the foot to the
thigh near the surface of the skin. H. Percutaneous Skeletal
Fixation
6. LO 25.14 The relocation of tissue from one individual to another (both of the
same species) without an identical genetic match. I. Saphenous Vein
7. LO 25.14 The transfer of tissue from one site to another. J. Transplantation
8. LO 25.6 The immobilization of a joint using a surgical technique.
9. LO 25.6 The attempted return of the fracture or dislocation to its normal align-
ment manually by the physician.
10. LO 25.13 The area between the eyelid and the eyeball.

CPT
  Let’s Check It! Concepts
Choose the most appropriate answer for each of the following questions.

Part I
1. LO 25.2  The global surgical package includes all except
a. preprocedure evaluation and management. b.  general anesthesia. CPT © 2017 American Medical Association. All rights reserved.

c. the procedure. d.  follow-up care.

2. LO 25.3  The global period is determined by
a. the type of anesthesia provided. b.  the size of the excision.
c. the location of the donor site. d.  the standard of care.
3. LO25.1  Which of the following is an example of a diagnostic test not included in the global package?
a. Closure b.  Local infiltration
c. Biopsy d.  Metacarpal block
4. LO 25.2  When a procedure is planned as a series of procedures, each service after the first should be appended
with the modifier
a. 76 b.  79 c.  58 d.  59

788   PART III  |  REPORTING PHYSICIAN SERVICES AND OUTPATIENT PROCEDURES

 5. LO 25.4  When a surgeon does not provide preoperative or postoperative care to the patient upon whom he or she

CHAPTER 25 REVIEW
operates, the procedure code should be appended with modifier
a. 54 b.  55 c.  56 d.  77
6. LO 25.5  Excision of lesions is reported
a. with total measurement of all lesions removed in one code.
b. with only the largest lesion coded.
c. with each lesion coded separately.
d. as a part of the total surgical procedure.
7. LO 25.5  The code for excision of a lesion includes this type of repair.
a. Intermediate b.  Complex
c. None d.  Simple
8. LO 25.5  If the surgeon performs a reexcision of a lesion during a later encounter with the patient, append the
procedure code with modifier
a. 58 b.  59 c.  51 d.  77
9. LO 25.5  If multiple wounds located on the same anatomical site are repaired with the same complexity, report
this procedure by
a. coding each wound separately.
b. coding only the largest wound.
c. adding all the lengths together and coding the total.
d. coding the average of all the wounds repaired.
10. LO 25.5  The elements of determining the most accurate code for a skin graft include all except
a. the size of the recipient area.
b. the type of donor.
c. the location of the recipient area.
d. the type of graft.

Part II
1. LO 25.6  Codes within the musculoskeletal subsection include
a. x-rays. b.  cast.
c.  medications. d.  shoes.
2. LO 25.13  Which of the following is/are part of the inner ear?
a. Auditory ossicles b.  Oval window
CPT © 2017 American Medical Association. All rights reserved.

c. Eustachian tube d.  Semicircular canals

3. LO 25.7  Thoracotomy, with biopsy of pleura, would be coded
a. 32096 b.  32097 c.  32098 d.  32400
4. LO 25.14  Backbench work during a transplant process is
a. the harvesting of an organ from a donor.
b. the implantation of the new organ.
c. the documentation of the surgery.
d. the preparation of the organ.
5. LO 25.8  When an arterial graft is performed, which of the following codes, in addition to the code for the bypass
procedure, would be assigned if the graft is harvested from the femoropopliteal vein? 
a. 35600 b.  35500 c.  35572 d.  35601
 6. LO 25.11  Vulvectomy, radical, partial; with unilateral inguinofemoral lymphadenectomy would be coded
CHAPTER 25 REVIEW

a. 56620 b.  56630 c.  56631 d.  56632

7. LO 25.8  The code for an endovascular repair of an iliac aneurysm includes all except
a. introduction of graft.
b. stent deployment.
c. balloon angioplasty.
d. pacemaker.
8. LO 25.9  A laparoscopy, surgical, gastric restrictive procedure; with gastric bypass and Roux-en-Y gastroenteros-
tomy of 145 cm would be coded
a. 43846 b.  43847 c.  43644 d.  43645
9. LO 25.12  Code 62263 includes all of the following except
a. percutaneous insertion of an epidural catheter.
b. extensive dural grafting.
c. procedure injections.
d. multiple adhesiolysis sessions over the course of 2 or more days.
10. LO 25.10  A physician who only interprets the results of a urodynamic procedure must append the code with
a. modifier 32 b.  modifier 26
c. modifier 53 d.  modifier 51

Let’s Check It! Guidelines

Refer to the Surgery Guidelines and fill in the blanks accordingly.
concomitant supervision session independently Follow-up
component Introduction technique therapeutic integral
usually guidelines “separate procedure” management guidance
59 date modifiers itself diagnostic
addition one Radiology Evaluation and Management surgical
designated only destruction separately post-operative
1. Guidelines to direct general reporting for services are presented in the _____.
2. Services rendered in the office, home, or hospital, consultations, and other medical services are listed in the
_____ Services section.
3. _____ care for diagnostic procedures includes _____ that care related to recovery from the diagnostic procedure
itself.
4. Care of the condition for which the _____ procedure was performed or of other _____ conditions is not included CPT © 2017 American Medical Association. All rights reserved.

and may be listed _____.

5. Follow-up care for _____ surgical procedure includes only that care which is _____ a part of the _____service.
6. When more than _____ procedure/service is performed on the same _____, same _____ or during a _____ period,
several CPT _____ may apply.
7. The codes designated as _____ should not be reported in _____ to the code for the total procedure or service of
which it is considered an _____ component.
8. However, when a procedure or service that is _____ as a “separate procedure” is carried out _____ or considered
to be unrelated or distinct from other procedures/services provided at that time, it may be reported by _____, or
in addition to other procedures/services by appending modifier _____ to the specific “separate procedure” code
to indicate that the procedure is not considered to be a _____ of another procedure, but is a distinct, independent
procedure.

790   PART III  |  REPORTING PHYSICIAN SERVICES AND OUTPATIENT PROCEDURES

 9. When imaging _____ or imaging _____ and interpretation is included in a surgical procedure, _____ for image

CHAPTER 25 REVIEW
documentation and report, included in the guidelines for _____ will apply.
10. Surgical _____ is a part of a surgical procedure and different methods of destruction are not ordinarily listed sepa-
rately unless the _____ substantially alters the standard _____ of a problem or condition.

Let’s Check It! Rules and Regulations

Please answer the following questions from the knowledge you have gained after reading this chapter.
1. LO 25.1 Explain the difference between prophylactic, diagnostic, and therapeutic treatments.
2. LO 25.4 What does the notation “Separate Procedure” tell a professional coder?
3. LO 25.5 What is the formula to find the correct coded size of an excised lesion?
4. LO 25.5 Differentiate between intermediate closure repair and complex closure repair.
5. LO 25.15 When a surgeon performs microsurgery, he or she has to use an operating microscope. What code
identifies the use of the microscope?

CPT

YOU CODE IT! Basics

First, identify the procedural main term in the follow- 8. Dr. Preston performs an arthroscopic repair of a
ing statements; then code the procedure or service. rotator cuff tear:
Example: Dr. Slaughter drains an ovarian cyst, vagi- a. main term: _____ b. procedure: _____
nal approach: 9. Roy has an implanted single-chamber pacemaker;
Dr. Terrence removes the existing pulse generator,
a. main term: Drainage b. procedure: 58800
tests the existing lead, and inserts a new dual-
1. Dr. Ladd performs a fine needle aspiration using chamber system for an upgrade:
ultrasound-guidance imaging: a. main term: _____ b. procedure: _____
a. main term: _____ b. procedure: _____ 10. Dr. Shumpert performs a infratentorial craniotomy
2. Dr. Dingle performs paring of six soft corn to remove a hematoma; intracerebellar:
lesions: a. main term: _____ b. procedure: _____
a. main term: _____ b. procedure: _____ 11. Dr. Wattel performs an epidermal facial chemical
3. Dr. Gunter removes 10 skin tags: peel:
a. main term: _____ b. procedure: _____ a. main term: _____ b. procedure: _____
4. Dr. Strobel performs an insertion of a nonbiode- 12. Dr. Rudner performs a breast reconstruction with
gradable drug delivery contraception implant: free flap:
a. main term: _____ b. procedure: _____ a. main term: _____ b. procedure: _____
CPT © 2017 American Medical Association. All rights reserved.

5. Dr. Amerson performs cryotherapy for acne: 13. Dr. Payton excises a malignant lesion from the
a. main term: _____ b. procedure: _____ neck that measured 2.9 cm with margins:
6. Mark Latham was accidentally shot in the arm; a. main term: _____ b. procedure: _____
Dr. Quattlebaum explores and enlarges the wound 14. Dr. Charne excises an ischial pressure ulcer with a
to remove the bullet. Code the exploration of the primary suture:
wound: a. main term: _____ b. procedure: _____
a. main term: _____ b. procedure: _____ 15. Dorothy Loman had a small partial-thickness burn
7. Dr. Hunter applies a uniplane external fixation on her hand. Dr. Beariman performed a debride-
device for temporary stabilization of a radial ment and dressing of the injury:
fracture: a. main term: _____ b. procedure: _____
a. main term: _____ b. procedure: _____
CHAPTER 25 REVIEW

CPT
YOU CODE IT! Practice
Using the techniques described in this chapter, carefully read through the case studies and determine the most ac-
curate surgery CPT code(s) and modifier(s), if appropriate, for each case study.
1. Jack Friedman, a 41-year-old male, was in a fight at a soccer game and was hit in the head with a bottle,
which caused some deep lacerations in his scalp. Dr. Girald performed a layered closure of the wounds: one
2.0 cm, one 4.5 cm, and two lacerations that were 1.0 cm each in length.
2. Bobby Sherman, a 36-year-old male, cut his left thumb at work on a construction site 2 weeks ago. He did not
get any treatment for the wound, which became infected. Today, Dr. Ravenell admitted Bobby to Westward
Hospital and amputated the thumb. The procedure is made more complicated by the spread of the infection to
the surrounding tissues, as Dr. Ravenell fights to save as much of the hand as possible.
3. Patricia Atkins, a 31-year-old female, has been diagnosed with pleural effusion. Patricia is having difficulty
breathing and is admitted to the hospital, where Dr. Jamison performs a percutaneous pleural drainage and
inserts an indwelling catheter. Dr. Jamison is aided by image guidance. Patricia tolerates the procedure well
and is breathing easier.
4. Kevin Benchley, a 52-year-old male, has been diagnosed with benign prostatic hyperplasia (BPH). Kevin and
Dr. Derek, his urologist, have discussed the options and Kevin has elected to proceed with a TURP. Kevin is
taken to the OR, where he is placed under general anesthesia and the transurethral electrosurgical resection of
prostate, complete is performed without complication. Code the TURP procedure.
5. Dr. Albertson performed a lumbar laminectomy for decompression on Grace James on September 15. One
month later, as originally planned, Dr. Albertson brought Grace back into the OR to implant an epidural drug
infuser with a subcutaneous reservoir. Code both procedures.
6. Bridgette Smith found a sore on her neck. The lab test identified it as a malignant lesion, and Dr. Payas
excised the lesion, which measured 2.9 cm with margins.
7. Alice Milton, a 39-year-old female, was diagnosed with an abdominal wall incisional hernia, which was
repaired using prosthetic mesh. Alice has had recurrent infections. Alice is taken to the OR, where Dr. Gilroy
debrides the infected subcutaneous tissue and removes the prosthetic mesh.
8. Samantha DaVita, a 74-year-old female, has a permanent subcutaneous implanted defibrillator system,
which is not functioning properly. Samantha is taken to the OR, where Dr. Meetze removes and replaces the
implanted defibrillator pulse generator and subcutaneous electrode; 25 minutes of moderate sedation was
achieved. The new defibrillator system is tested and is working within normal limits. The nurse monitored
Samantha’s vital signs during the procedure. Samantha tolerated the procedure well.
9. Having trouble hearing, Ruth Ann Marcelle, a 73-year-old female, came to see Dr. Assiss, an audiologist.
After examination, Dr. Assiss removed the impacted earwax from both ears. Ruth Ann was amazed at the
improvement in her hearing and left the office feeling much better.

CPT © 2017 American Medical Association. All rights reserved.

10. One week ago, Dr. Alden performed an ureteroneocystostomy with cystoscopy and ureteral stent placement
laparoscopically on Brad Vitalli. Brad is admitted to the hospital today because Dr. Alden must perform an
open procedure to drain a renal abscess that was discovered. Dr. Alden drained the abscess. Brad tolerated the
procedure well. Code the drainage of Brad’s renal abscess.
11. Frank Chestnut, a 17-year-old male, came to see Dr. Quartermain for the first time. He was in a fight at
school and got punched in the jaw, dislocating his temporomandibular joint. Dr. Quartermain performed
a closed treatment of the temporomandibular dislocation. The dislocation did not require any wiring or
fixation.
12. Dr. Quinn ordered a catheter aspiration with fiberscope of Stephan’s tracheobronchial tree. The procedure was
performed at Stephan’s bedside in his hospital room. The patient received 15 minutes of conscious sedation.
Stephan is a 34-year-old male.

792   PART III  |  REPORTING PHYSICIAN SERVICES AND OUTPATIENT PROCEDURES

 CHAPTER 25 REVIEW
13. Colleen Sizmauski, a morbidly obese 27-year-old female, was admitted for a gastric restrictive procedure. In
addition to the gastric bypass performed by Dr. Lafferty, Colleen’s small intestine was reconstructed to limit
absorption.
14. Dr. Macintosh performed the backbench preparation of a cadaver donor heart allograft prior to Dr. Gantt’s
performing the transplantation. Code for Dr. Mackintosh’s work.
15. Hannah Lopez, a 53-year-old female, hurt her eye in an accident. Dr. Dawson examined her and noticed that
her cornea was scratched. It was not a perforating laceration. Dr. Dawson repaired the laceration of the cornea
in the office.

    YOU CODE IT! Application

CPT HCPCS Level II

The following exercises provide practice in the application of abstracting the physicians’ notes and learning to work
with documentation from our health care facility, Prader, Bracker, & Associates. These case studies are modeled on
real patient encounters. Using the techniques described in this chapter, carefully read through the case studies and
determine the most accurate surgery CPT code(s) and modifier(s), if appropriate, for each case study.

PRADER, BRACKER, & ASSOCIATES

A Complete Health Care Facility
159 Healthcare Way • SOMEWHERE, FL 32811 • 407-555-6789
PATIENT: PENNETTA, OSCAR
ACCOUNT/EHR #: PENNOS001
Admission Date: 10/09/18
Discharge Date: 10/09/18
DATE: 10/09/18
Preoperative DX: Lacerations of arm, hand, and leg
Postoperative DX: Same
Procedure: Layered closure of leg laceration; simple closure of arm and hand lacerations
Surgeon: Gregg Wilson, MD
Assistant: None
Anesthesia: General
CPT © 2017 American Medical Association. All rights reserved.

INDICATIONS: The patient is a 4-year-old male brought to the emergency room by his mother. He was
helping his father install a new window when the window fell and shattered. Oscar suffered lacerations
on his left hand, left arm, and left leg.
PROCEDURE: The patient was placed on the table in supine position. Satisfactory anesthesia was
obtained. The area was prepped, and attention to the deeper laceration of the left thigh, right above the
patella, was first. A layered closure was performed, and the 5.1-cm laceration was closed successfully
with sutures. The lacerations on the upper extremity, a 2-cm laceration on the left hand at the base of
the fifth metacarpal and the 3-cm laceration on the left arm, just below the joint capsule in the posterior
position, were successfully closed with 4-0 Vicryl, as well. The patient tolerated the procedures well and
was transported to the recovery room.

GW/mg  D: 10/09/18 09:50:16  T: 10/09/18 12:55:01

CHAPTER 25 REVIEW

Determine the most accurate surgery CPT code(s) and modifier(s), if appropriate.

WESTON HOSPITAL
629 Healthcare Way • SOMEWHERE, FL 32811 • 407-555-6541
PATIENT: DRESDEN, NELDA
ACCOUNT/EHR #: DRESNE001
Admission Date: 11/01/18
Discharge Date: 11/01/18
DATE: 11/01/18
Preoperative DX: Toxic epidermal necrolysis
Postoperative DX: Same
Procedure: Xenogaft
Surgeon: William Dresser, MD
Assistant: None
Anesthesia: Local
INDICATIONS: The patient is a 29-year-old female with a diagnosis of toxic epidermal necrolysis as a
result of a reaction to procainamide, previously prescribed by a physician no longer in attendance.
PROCEDURE: The patient was placed on the table in supine position. Local anesthesia was adminis-
tered. As soon as patient stated a complete loss of feeling in the left forearm, the dermal xenograft pro-
ceeded. Procedure was repeated for right forearm.
A total of 150 sq. cm of grafting was successfully completed.
Bandages were applied. A prescription for Darvocet N100 po q4–6h prn was given to the patient
before discharge.
Follow-up appointment in office scheduled for 10 days.
WD/mg  D: 11/01/18 09:50:16  T: 11/01/18 12:55:01

Determine the most accurate surgery CPT code(s) and modifier(s), if appropriate.

WESTON HOSPITAL
629 Healthcare Way • SOMEWHERE, FL 32811 • 407-555-6541 CPT © 2017 American Medical Association. All rights reserved.

PATIENT: APPON, CYNTHIA

ACCOUNT/EHR #: APPOCY001
DATE: 09/23/18
Attending Physician: Regina Glasser, MD
Preoperative Diagnosis: C5 compression fracture
Postoperative Diagnosis: Same
Procedure: C5 corpectomy and fusion fixation with fibular strut graft and Atlantis plate

794   PART III  |  REPORTING PHYSICIAN SERVICES AND OUTPATIENT PROCEDURES

 CHAPTER 25 REVIEW
Anesthesia: General endotracheal
This is a 31-year-old female status post assault. The patient sustained a C5 compression fracture. MRI
scan showed compression with evidence of posterior ligamentous injury. The patient was subsequently
set up for the surgical procedure. The procedure was described in detail, including the risks. The risks
included but were not limited to bleeding, infection, stroke, paralysis, death, CSF leak, loss of bladder
and bowel control, hoarse voice, paralyzed vocal cord, death, and damage to adjacent nerves and tis-
sues. The patient understood the risks. The patient also understood that bank bone instrumentation
would be used and that the bank bone could collapse and the instrumentation could fail or break, or the
screws could pull out. The patient provided consent.
The patient was taken to the OR. The patient was induced. An endotracheal tube was placed. A Foley was
placed. The patient was given preoperative antibiotics. The patient was placed in slight extension. The
right neck was prepped and draped in the usual manner. A linear incision was made over the C5 verte-
bral body. The platysma was divided. Dissection was continued medial to the sternocleidomastoid to the
prevertebral fascia. This was cauterized and divided. The longus colli was cauterized and elevated. The
fracture was visualized. A spinal needle was used to verify the location using fluoroscopy. The C5 verte-
bral body was drilled out. The bone was saved. The disks above and below were removed. The posterior
longitudinal ligament was removed. The bone was quite collapsed and fragmented. Distraction pins were
then packed with bone removed from the C5 vertebral body prior to implantation. A plate was then placed
with screws in the C4 and C6 vertebral bodies. The locking screws were tightened. The wound was irri-
gated. Bleeding was helped with the bipolar. The retractors were removed. The incision was approximated
with simple interrupted Vicryl. The subcutaneous tissue was approximated, and skin edges were approxi-
mated subcuticularly. Steri-Strips were applied. A dressing was applied. The patient was placed back in an
Aspen collar. The patient was extubated and transferred to recovery.

RG/mgr  D: 09/23/18 12:33:08 PM  T: 09/25/18 3:22:54 PM

Determine the accurate surgery CPT code(s) and modifier(s), if appropriate.

WESTON HOSPITAL
629 Healthcare Way • SOMEWHERE, FL 32811 • 407-555-6541
PATIENT: WHEATON, MARLA
ACCOUNT/EHR #: WHEAMA001
Admission Date: 09/18/18
Discharge Date: 09/18/18
CPT © 2017 American Medical Association. All rights reserved.

DATE: 09/18/18
Preoperative DX: High-grade squamous intraepithelial lesion of the cervix
Postoperative DX: Same
Operation: Loop electrosurgical excision procedure (LEEP) and ECC (endocervical curettage)
Surgeon: Ralph L. Goff, MD
Assistant: None
Anesthesia: General by LMA
Findings: Large ectropion, large nonstaining active cervix essentially encompassing the entire active
cervix
CHAPTER 25 REVIEW

Specimens: To pathology
Disposition: Stable to recovery room
PROCEDURE: The patient was taken to the OR, where she was placed in the supine position and admin-
istered general anesthesia. She was then placed in candy cane stirrups and prepped and draped in the
usual fashion. Her vaginal vault was not prepped. The coated speculum was then placed and the cervix
exposed. It was then painted with Lugol and the entire active cervix was nonstaining with the clearly
defined margins where the stain began to be picked up. The cervix was injected with approximately
7 cc of lidocaine with 1% epinephrine. Using a large loop, the anterior cervix was excised, and then the
posterior loop was excised in separate specimens. Because of the size of the lesion, one piece in total
was not accomplished. Prior to the excision, the endocervical curettage was performed, and specimens
were collected. All specimens were sent to pathology. The remaining cervical bed was cauterized and
then painted with Monsel for hemostasis. The case was concluded with this. Instruments were removed.
The patient was taken down from candy cane stirrups, awakened from the anesthesia, and taken to the
recovery room in stable condition.

RLG/mgr  D: 09/23/18 12:33:08 PM  T: 09/25/18 3:22:54 PM

Determine the accurate surgery CPT code(s) and modifier(s), if appropriate.

WESTON HOSPITAL
629 Healthcare Way • SOMEWHERE, FL 32811 • 407-555-6541
PATIENT: UPTON, MAXINE
ACCOUNT/EHR #: UPTOMA001
DATE: 09/25/18
Diagnosis: Medulloblastoma
Procedure: Central Venous Access Device (CVAD) insertion
Physician: Vincent Hoyt, MD
Anesthesia: Conscious sedation
PROCEDURE: Patient is a 4-year-old female, with a recent diagnosis of malignancy. Due to an upcoming
course of chemotherapy, the CVAD is being inserted to ease administration of the drugs. The patient
was placed on the table in supine position and 1 mg of Versed was administered IM; moderate sedation
was achieved, 13 minutes. Maxine’s vital signs were monitored by the nurse. The incision was made to
CPT © 2017 American Medical Association. All rights reserved.
insert a central venous catheter, centrally. During the placement of the catheter, a short tract (nontun-
neled) was made as the catheter was advanced from the skin entry site to the point of venous cannula-
tion. The catheter tip was set to reside in the subclavian vein. The patient was gently aroused from the
sedation and was awake when transported to the recovery room.

VH/mg  D: 09/25/18 09:50:16  T: 09/25/18 12:55:01

Determine the accurate surgery CPT code(s) and modifier(s), if appropriate.

796   PART III  |  REPORTING PHYSICIAN SERVICES AND OUTPATIENT PROCEDURES

 CPT Radiology Section
Learning Outcomes
After completing this chapter, the student should be able to:
LO 26.1 Distinguish the different types of imaging.
26
LO 26.2 Abstract the different reasons for imaging services. Key Terms
LO 26.3 Identify the technical components from professional Angiography
components. Arthrography
LO 26.4 Apply the guidelines accurately regarding the number of Computed
views. ­Tomography (CT)
Computed
LO 26.5 Apply the guidelines to determine how to code the
­Tomography
­administration of contrast materials. ­Angiography (CTA)
LO 26.6 Recognize diagnostic radiologic services. Fluoroscope
LO 26.7 Interpret accurately into CPT codes to report Magnetic Resonance
­mammography services. Arthrography (MRA)
LO 26.8 Discern how to report bone and joint studies. Magnetic Resonance
Imaging (MRI)
LO 26.9 Decide when to code radiation treatments.
Nuclear Medicine
LO 26.10 Determine how to accurately report nuclear medicine Radiation
services. Sonogram
Venography

Remember, you need to follow along in

CPT
  STOP! your CPT code book for an optimal learning
experience.

26.1  Types of Imaging

Health care professionals use medical imaging technologies to see inside the body to
support medical decision making and accurate diagnostics. Radiologic services, also
known as interventional radiology, can be used to investigate a potential condition
(diagnostically), measure the progress of a disease or condition, or aid in the actual
CPT © 2017 American Medical Association. All rights reserved.

reduction or prevention of disease or other condition (therapeutically).

Many, many years ago, radiology was simply known as x-ray because this was the
extent of the equipment. Now, technology has made tremendous advancements in the
science of imaging, and health care professionals can screen, diagnose, monitor, and
treat patients much more effectively and efficiently. 

X-Rays (Radiography)
Radiography is the term that describes the use of x-rays to visualize the visceral aspects
(internal structures) of the human body. An x-ray tube emits a type of electromagnetic
radiation that is passed through and recorded on the opposite side of the anatomical
site being investigated by a digital detector (the digital version of film). Radiologists
can identify bone, muscle, and soft tissue on the image because each absorbs the radia-
tion at differing levels. The resulting contrast records a two-dimensional image for
evaluation and analysis.
 Clinical Applications
∙ Chest x-rays are most commonly used to analyze aspects of the lungs.
∙ Skeletal x-rays are frequently used to identify and diagnose fractures, dislocations,
and other abnormalities of the bones.
∙ Abdominal x-rays are used to determine obstructions in any organs within the cavity,
or to illuminate the presence of air or fluid.
∙ Dental x-rays are employed to detect abnormalities such as dental caries or abscesses.

Computed Tomography (CT) Scans

A computed tomography (CT) scanner is similar to radiography in that it is con-
structed of an x-ray tube and detectors. During a CT scan, an x-ray beam is emitted,
aimed through the anatomical site being studied, and recorded by the detectors, which
reconstruct the emissions in order to create a two- or three-dimensional image that
results in a cross-sectional slice through the patient at that point. Each consecutive
image is acquired at a slightly different angle, providing a more complete picture of
the internal aspects. 
Contrast media may be used to enable differentiation of the various structures of
similar density throughout the body. The contrast materials enable the identification of
various abnormalities, including hemorrhaging and malignant tissue.

Clinical Applications
∙ Brain function
∙ Neck/head
∙ Vascular system

Magnetic Resonance Imaging (MRI)

Magnetic resonance imaging (MRI) provides three-dimensional views of internal
body organs, in real time, with greater visibility of variations within soft tissues, mak-
ing visualization of brain, spine, muscles, joints, and other structures more informa-
tive. The images are captured utilizing a multiplanar modality (various body planes
without changing the position of the patient). Similarly to CT scans, contrast materials
may be used to illuminate specific visceral aspects.

Clinical Applications
∙ Measuring volumes of brain structures
∙ Measurement of brain tissue
∙ Soft tissue damage CPT © 2017 American Medical Association. All rights reserved.

Positron Emission Tomography (PET)

Unlike CT or MRI, PET studies metabolic activity and/or body function. A radioac-
tive medication is administered via IV enabling the areas of abnormal metabolism
as well as the detection of tumors and other dysfunctions, not typically detectable by
other means, to be captured. 

Clinical Applications
∙ Detection and staging of cancer
∙ Diagnosis of certain dementias such as Alzheimer’s disease
∙ Evaluation of coronary artery disease

798   PART III  |  REPORTING PHYSICIAN SERVICES AND OUTPATIENT PROCEDURES

 Nuclear Medicine
Nuclear medicine employs the administration of radioactive tracers to enable images
of internal organs. The radioactive tracer produces gamma radiation, enabling a
gamma camera to capture two-dimensional or three-dimensional images.
Nuclear medicine might also be used for therapeutic purposes. For instance, a larger
dose of therapeutic radiation (a radiopharmaceutical specific to the particular diagno-
sis) may be used to eradicate malignant cells.

Clinical Applications
∙ Assessing the metabolic activity of a skeletal structure
∙ Comparing blood flow to the myocardium at exercise and rest
∙ Determining renal perfusion and drainage
∙ Comparing pulmonary ventilation and perfusion
∙ Assessing the thyroid gland’s appearance and function

Fluoroscopy
Fluoroscopy also utilizes x-rays to visualize  internal organ structure and function.
The emission of the x-ray beams is continuous, producing a real-time, dynamic image.
High-density contrast agents, such as barium, might be administered to enable com-
parative data.

Clinical Applications
∙ Hysterosalphingography (HSG)
∙ Retrograde urethrogram
∙ Micturating cysto-urethrogram
∙ Fistulography
∙ Guidance for procedures, such as the reduction of a fracture

Ultrasound (Sonography)
Ultrasound, also known as sonography, uses high-frequency sound waves to capture
cross-sectional images of visceral organs, including the arteries, veins, and lymph
nodes. There are several different types of ultrasound:
∙ A-mode indicates a one-dimensional ultrasonic measurement procedure.
∙ M-mode is also a one-dimensional ultrasonic measurement procedure; however, it
includes the movement of the trace so that there can be a recording of both ampli-
CPT © 2017 American Medical Association. All rights reserved.

tude and velocity of the moving echo-producing structures.

∙ B-scan indicates a two-dimensional ultrasonic scanning procedure with a two-
dimensional display.
∙ Real-time scan indicates that a two-dimensional ultrasonic scanning procedure
with a display was performed, and included both the two-dimensional structure and
motion with time.
Ultrasound may also be used as a visual guide for percutaneous surgical procedures.

Clinical Applications
∙ Abdominal cavity
∙ Pelvic area [NOTE: codes are different for an obstetrical ultrasound vs. nonpreg-
nant pelvic area]
∙ Cardiovascular structures, i.e., echocardiography
 Angiography
During an angiography, x-rays are used to identify obstruction or stenosis of an artery
or vein, as well as other problems with the cardiovascular system. Contrast dyes may
be administered to illuminate a specific vessel to enable visualization of blood flow
and blockages.

Clinical Applications
∙ Tracking blood flow through arteries
∙ Identifying blood vessel malformations (thrombi, aneurysms)
∙ Discovering arteriosclerosis

CPT
LET’S CODE IT! SCENARIO
PATIENT: BONNIE SUZETT-ELLENTON
DATE OF STUDY: 06/08/2018
REFERRING PHYSICIAN: Lawrence Chorino, MD
RE: MRI OF THE LUMBAR SPINE
Comparison is made to an earlier exam.
TECHNIQUE: Multiplanar images were obtained using multiple pulse sequences to the lumbar spine. Because of the
postoperative nature of the lumbar spine, additional axial and sagittal postgadolinium T1-weighted images were obtained.
Plain films are not available for comparison; therefore, it will be assumed there is a normal complement of lumbar
vertebrae. Scanning was performed on 0.3-Tesla open bore scanner.
FINDINGS: The examination shows lumbar vertebrae to be in normal overall alignment with preservation in vertebral
body heights and normal signal within the marrow. For descriptive purposes of this study, fairly small disc is noted at
the S1-S2 interspace. The tip of the conus lies near the lower body of L1; we believe this nomenclature is the same
as that used on the prior exam.
Transaxial images show postsurgical changes from prior right semi-hemilaminectomy at the S1 vertebra. Examina-
tion does show the presence of a small annular disc bulge and perhaps some early annular spurring; however, the
traversing S1 nerve roots are unimpeded, and there is no evidence of recurrent focal disc herniation. There is some
normal enhancement seen involving the soft tissues, presumably of a postoperative nature.
At the L4-L5 level, there is likewise no evidence of focal disc herniation or significant central spinal stenosis.
The L3-L4 interspace shows trace annular bulging without focal disc herniation or stenosis. L1-L2 and L2-L3 inter-
spaces show a normal appearance on sagittal imaging.
IMPRESSION: MR examination of the lumbar spine with postsurgical changes from previous right semi-hemilaminectomy at
L5-S1 level on the right.
While there may be some minimal annular bulging and annular spurring at this level, there is no discrete focal disc CPT © 2017 American Medical Association. All rights reserved.
herniation, and traversing S1 nerve roots are not compromised.
The remainder of the lumbar interspaces may show some very minimal disc bulging; however, there is no focal
disc herniation or central spinal stenosis. The cause of the patient’s right lower extremity radicular symptoms cannot
easily be explained on the basis of findings.
Jason Kunerreth, MD
Chief of Radiology

Let’s Code It!

Dr. Kunerreth supervised and analyzed the MRI of Bonnie’s lumbar spine. Turn to the Alphabetic Index of CPT
and look for the term that MRI stands for . . .

800   PART III  |  REPORTING PHYSICIAN SERVICES AND OUTPATIENT PROCEDURES

 Magnetic Resonance Imaging (MRI)
Go back and read the documentation to determine if the MRI was done for diagnostic purposes or as guid-
ance for another procedure. This was to determine the patient’s current condition; therefore, it is a diagnostic
procedure.
Magnetic Resonance Imaging (MRI)
Diagnostic
  Spine
   Cervical . . . . . . . . . . . . 72141, 72142, 72156
   Lumbar . . . . . . . . . . . . 72148, 72149, 72158
   Thoracic . . . . . . . . . . . 72146, 72147, 72157
What part of Bonnie’s spine was examined? Her lumbar spine. Now, you need to turn to the Main Section and
check out all three of the suggested codes.
72148 Magnetic resonance (eg, proton) imaging, spinal canal and
contents, lumbar; without contrast material
72149 Magnetic resonance (eg, proton) imaging, spinal canal and
contents, lumbar; with contrast material
72158 Magnetic resonance (eg, proton) imaging, spinal canal and
contents, without contrast material, followed by contrast
material(s) and further sequences; lumbar
Does the documentation mention the use of contrast materials? Yes, it does. See the sentence in the section
titled TECHNIQUE:
“Because of the postoperative nature of the lumbar spine, additional axial and sagittal postgadolinium T1-
weighted images were obtained.”
Gadolinium is a contrast material. Postgadolinium means after the contrast material was introduced. “Additional
. . . images” tells you that both without contrast and with contrast images were captured.
Now you know how to report Dr. Kunerreth’s services . . .
72158 Magnetic resonance (eg, proton) imaging, spinal canal and
contents, without contrast material, followed by contrast
material(s) and further sequences; lumbar

26.2  Purposes for Imaging

Screening or Diagnostic
CPT © 2017 American Medical Association. All rights reserved.

Identifying whether an imaging service is performed as a screening or a diagnostic

tool can be important in determining the correct code for the procedure. This designa-
tion refers to the reason the physician ordered the test.
A screening image is typically performed as part of a regular preventive checkup.
This is ordered because the standard of care and the calendar have matched up. For
example, a screening mammogram will be ordered the same time every year for a
woman over the age of 50. There are no signs or symptoms that would prompt the test.
It is just the wise thing to do to make certain all is fine.
A diagnostic image is taken to assist in the identification and/or confirmation of a
suspected condition or diagnosis. In these cases, the physician would identify specific
signs or symptoms that led him or her to decide this test was needed.
There are times when an imaging session for a patient begins as a screening test and
becomes a diagnostic test while the patient is still there. With technology providing
instant imaging, the radiologist can review the images almost immediately after they
 have been taken, while the patient is still on the premises. This eliminates a patient’s
needing to come back at another time to retake an image that was not clear or the tech-
nician’s having to take additional views because the radiologist identified a suspicious
element. When a screening test turns into a diagnostic test, report only the diagnostic
imaging service because that will include the screening aspect of the procedure.

EXAMPLES
74261 Computed tomography (CT) colonography, diagnostic, including
image postprocessing; without contrast material
74263 Computed tomography (CT) colonography, screening, including
image postprocessing

Image Guidance
When a procedure is conducted percutaneously, the physician cannot see into the
body. Therefore, in order to ensure that the needle or scalpel finds the correct spot on
an internal organ, image guidance will be used. This may be as simple as a fine needle
aspiration to a biopsy to a more complex surgical procedure. 
In some cases, the CPT book will provide you with a code that includes the imaging
guidance; for example:
10021 Fine needle aspiration; without imaging guidance
10022   with imaging guidance
Often, the CPT book, will alert you to the need for a second code to report this
additional service with a notation below the code, such as
(For radiological supervision and interpretation, see 76942, 77002,
77012, 77021)
And more code options can be found in the Radiology section of CPT:
∙ Ultrasonic Guidance Procedures: 76930–76965, 76998
∙ Fluoroscopic Guidance: 77001–77003
∙ Computed Tomography Guidance: 77011–77014
∙ Magnetic Resonance Guidance: 77021–77022

YOU CODE IT! CASE STUDY CPT © 2017 American Medical Association. All rights reserved.
CPT

Every year, Margarette Sanchez gets a mammogram the week before her birthday. She feels fine and no lumps were
noted during her gynecologist’s manual exam. Margarette arrives at the Women’s Imaging Center for her annual
exam.

You Code It!

Determine the correct code or codes to report the provision of Margarette’s annual mammogram.
Step #1: Read the case carefully and completely.
Step #2: Abstract the scenario. Which key words or terms describe what service the physician provided to the
patient during this encounter?

802   PART III  |  REPORTING PHYSICIAN SERVICES AND OUTPATIENT PROCEDURES

 Step #3: Are there any details missing or incomplete for which you would need to query the physician? [If so, ask
your instructor.]
Step #4: Determine the correct CPT procedure code or codes to explain the details about what was provided to
the patient during this encounter.
Step #5: Check for any relevant guidance, including reading all of the symbols and notations.
Step #6: Do you need to append any modifiers to ensure complete and accurate information is provided?
Step #7: Double-check your work.
Answer:
Did you determine this to be the correct code?
77067 Screening mammography, bilateral (2-view study of each breast), including
computer-aided detection (CAD) when performed
Good job!

26.3  Technical vs. Professional

Essentially, there are two primary components of any radiologic procedure: the tech-
nical and the professional (referred to as supervision and interpretation in the CPT). CODING BITES
This is not to say that radiologic technicians are not professionals. The designation is You learned in medi-
merely to divide the services provided so that it can be determined which facility or cal terminology class
practitioner should be paid for what. that the suffix -graphy
means the recording of
an image and the suffix
EXAMPLE
-scopy means to look or
Jerod Paley, a 41-year-old male, was sent to the Kinsey Imaging Center to get an view. We tend to think
x-ray, three views, of his skull after he was hit in the head by a bat at a softball game. of all these procedures
The x-ray equipment is owned by the facility. Kris Chappel, the x-ray technician and services as radiol-
who will operate the equipment, is a member of the facility’s staff, and Dr. Briscoe, ogy. However, not all of
a board-certified radiologist who will interpret the films and send a report of this them are coded from
evaluation to Jerod’s physician, is also a staff member of the center. Therefore, the Radiology section of
Kinsey Imaging’s coding specialist will ask the insurance company for reimburse- the CPT book. 
ment for both the technical procedure (the use of the equipment, materials, and For example, car-
the staff to work and maintain that equipment) and the professional aspect (the diography is listed in
cost and work to supervise and interpret the films). For Jerod’s case, the code to
CPT © 2017 American Medical Association. All rights reserved.

the Medicine section.

be reported is 70250 Radiologic examination, skull; less than 4 views. Therefore, always use
the Alphabetic Index to
Purchasing (or leasing) and maintaining imaging equipment is very expensive and help point you toward
cannot be supported by every health care facility. In addition, physicians who are spe- the correct area of the
cially trained radiologists are not necessarily staff members of all health care facilities book. It will save you
with the equipment. Therefore, circumstances may arise when the technical procedure time in the long run.
and the professional service must be billed separately. In those cases, the coder who is
responsible for charging for the professional services must use modifier 26 to identify
the separation of the components.
26 Professional Component: Certain procedures are a combination of a
physician component and a technical component. When the physician
component is reported separately, the service may be identified by
adding modifier 26 to the usual procedure number.
 CODING BITES EXAMPLE
Technical component: Walter Wasser, a 31-year-old male, was brought into the emergency department
Coded to gain reim- of a small hospital near his farm after he fell off a ladder onto his back while work-
bursement for the ing in the barn. The physician sent Walter to radiology for x-rays of his entire
facility that owns and thoracic, lumbar, and sacral spine (two views). The hospital does not have a staff
maintains the equipment radiologist, so Dr. Chen is brought over to evaluate the x-rays and write the report
used, amortized cost of for the physician.
the machine, supplies, The hospital, which owns the equipment and pays the salary of the technician,
maintenance, overhead will bill the insurance carrier for the technical portion of the examination, using
(electricity and so on), code 72082-TC.
and the technician. Dr. Chen’s coding specialist will send in a claim for Dr. Chen’s interpretation
Professional compo- only, the professional services he provided. In order to make this clear on the
nent: Coded to gain reim- claim form, the modifier 26 Professional Component will be appended to the
bursement for the health code for the radiologic examination; the code that will be reported on his claim
care professional, radi- form will be 72082-26.
ologist, or physician who
supervises and interprets
the images taken.
As you have already learned, sometimes the CPT book will save you work. Certain
radiologic examination codes distinguish the technical component and professional
component of services for you. One of the easiest ways to identify such cases is by the
CODING BITES notation within the code’s description that specifies the code is for radiologic supervi-
If the third-party payer sion and interpretation only.
accepts HCPCS Level
II, append modifier TC
Technical Component
to the CPT code, when EXAMPLE
appropriate.
70015 Cisternography, positive contrast, radiological supervision and
interpretation
CODING BITES
Some third-party pay-
ers will determine the From the example, you can see that code 70015 excludes the technical component.
TC and PC components If you are coding for the physician’s services only, that makes it easy. If you are cod-
for payment without the ing for the facility for the technical aspect, you need to add modifier TC Technical
modifier by the place of ­Component. After a while, you will learn the details about the procedures performed
service code shown on by all of the professionals in your health care facility, and you will be able to identify
the claim form. the components easily. It just takes some practice.

LET’S CODE IT! SCENARIO CPT © 2017 American Medical Association. All rights reserved.
CPT HCPCS Level II

Roland Dellman, an 8-year-old male, is brought into the emergency department by ambulance. He was skateboard-
ing off a homemade ramp and fell on his neck and shoulder. Dr. Tyner suspects a broken clavicle and orders a com-
plete radiologic exam of the area. This facility does not have a radiologist on staff at this time, so the facility took the
x-ray and the digital images were electronically sent to Radiology Associates in another state. Dr. Neuman reads the
films and sends a report to Dr. Tyner confirming the fracture. Code for Dr. Neuman.

Let’s Code It!

The physician’s notes state that a radiologic exam of Roland’s clavicle was performed. Let’s turn to the Alpha-
betic Index under radiology. Note that the choices are not going to satisfy our needs. Therefore, let’s try an alter-
nate term for radiology: x-ray. Turn to x-ray, and you find a long list of anatomical sites. Next to the word clavicle
you see only one suggested code. Let’s go to the numeric listing and read the complete description:

804   PART III  |  REPORTING PHYSICIAN SERVICES AND OUTPATIENT PROCEDURES

 73000 Radiologic examination; clavicle, complete
This is exactly what Dr. Tyner ordered for Roland. And the facility only provided the technical component, so the
coder would report:
73000-TC Radiologic examination; clavicle, complete, technical component
The coder for Radiology Associates would report 73000-26 to be reimbursed for Dr. Neuman’s work.
Good job!

CPT
LET’S CODE IT! SCENARIO
Jalyssa Miland, a 35-year-old female, is 10 weeks pregnant. This is her first pregnancy, and twins run in her family.
In order to determine how many fetuses there are, Dr. Ruber orders a sonogram. Iona Appell is the technician at the
imaging center next door to Dr. Ruber’s office. The Kinsey Imaging Center performs Jalyssa’s real-time transabdomi-
nal exam and sends the documentation to Dr. Ruber so that he can read and interpret the results. A single fetus was
observed.

Let’s Code It!

You are Dr. Ruber’s coder, and his notes state that a sonogram of Jalyssa was performed at the imaging center.
We know that she is pregnant, and this is why she is having the test done, so the anatomical site of the examina-
tion is her pregnant uterus.
Turn to the Alphabetic Index under sonography, and the CPT book tells you to see echography, which is
the type of technology that sonograms use. Turn to echography (caution—not echocardiography; this is not of
Jalyssa’s heart), and find a list of anatomical sites. Looking for pregnant uterus, you see a range of suggested
codes. Let’s go to the numeric listing and read the complete description of the first one.
76801 Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal
evaluation, first trimester (<14 weeks 0 days), transabdominal approach; single or
first gestation
Great! The very first code seems to match the notes perfectly. However, to make certain you are using the best,
most appropriate code, you will want to read through all the suggested codes.
Remember, you are coding for Dr. Ruber. With regard to Jalyssa’s radiologic exam, he provided the
­interpretation—the professional component only. Therefore, the claim form you prepare should show this code
as 76801-26.
CPT © 2017 American Medical Association. All rights reserved.

26.4  Number of Views Sonogram

The use of sound waves to
Throughout the Radiology section of the CPT book, radiologic examinations are record images of internal
often described by the number of views taken by the technician. organs and tissues; also
called an ultrasound.

EXAMPLE
73060 Radiologic examination, humerus, minimum of two views

The “two views” refers to the number of angles, or perceptions, from which the
images were taken, such as anterior and posterior. Such codes represent the norm, or
standard, in imaging when it comes to these certain anatomical sites.
 The most common angles, or pathways, of imaging include:
AP Anteroposterior: Front to back.
PA Posteroanterior: Back to front.
O Oblique: At an angle.
RAO Right anterior oblique: At an angle from the right front.
LAO Left anterior oblique: At an angle from the left front.
LPO Left posterior oblique: At an angle from the left back.
Lat Lateral (lat): From one side to the other side.
In those cases when the radiologist takes fewer than the minimum number of views
included in the description, you have to append the radiologic code with modifier 52
Reduced Services.
52 Reduced Services: Under certain circumstances a service or procedure
is partially reduced or eliminated at the physician’s discretion. Under
these circumstances, the service provided can be identified by its usual
procedure number and the addition of modifier 52, signifying that the
service is reduced. This provides a means of reporting reduced services
without disturbing the identification of the basic service.

CPT
YOU CODE IT! CASE STUDY
Carly-Ann Price, an 18-month-old female, is brought into the office of her pediatrician, Dr. Lattel. She fell off the
couch onto a hard tile floor and it appears that her hip is painful to her. Dr. Lattel has his staff take an x-ray of the
pelvis and hip to determine if there is a fracture. He orders only the anteroposterior view to be taken. He does not
subject his patients to radiology exposure unnecessarily, and he believes that the one view will tell him what he
needs to know. The x-ray confirms a hairline fracture, and he applies a cast.

You Code It!

Go through the steps, and determine the code(s) that should be reported for the radiologic service Dr. Lattel
provided to Carly-Ann.
Step #1: Read the case carefully and completely.
Step #2: Abstract the scenario. Which key words or terms describe what service the physician provided to the
patient during this encounter?
Step #3: Are there any details missing or incomplete for which you would need to query the physician? [If so,
ask your instructor.]
Step #4: Determine the correct CPT procedure code or codes to explain the details about what was provided CPT © 2017 American Medical Association. All rights reserved.

to the patient during this encounter.

Step #5: Check for any relevant guidance, including reading all of the symbols and notations.
Step #6: Do you need to append any modifiers to ensure complete and accurate information is provided?
Step #7: Double-check your work.
Answer:
Did you determine this to be the correct code?
73501 Radiologic examination, hip, unilateral, with pelvis when performed; 1 view
Good job!

806   PART III  |  REPORTING PHYSICIAN SERVICES AND OUTPATIENT PROCEDURES

 26.5  Procedures With or Without Contrast GUIDANCE
Some imaging examinations use contrast materials to gain a clearer picture of an CONNECTION
organ or anatomical site. The phrase “with contrast” means that the technician or phy-
Read the additional
sician gave the patient a substance to enhance the image. For example, arthrography is
explanations in
used to identify abnormalities that may be present within a joint (wrist, hip, shoulder,
the Radiology Guide-
knee). Gadolinium is injected into the joint that is to be visualized to provide better-
lines (Including Nuclear
quality images of the patient’s condition. In other procedures, different substances are
Medicine and Diagnos-
injected. For example, when myelography is done to examine a patient’s spinal cord
tic Ultrasound), sub-
and nerves, an injection of x-ray dye may be used to more clearly visualize a patient’s
head Administration of
disc herniation, bone spurs, or vertebral stenosis.
Contrast Material(s), in
1. When radiographic arthrography is performed, use an additional code for the your CPT book directly
supervision and interpretation of the appropriate joint. This includes the use of a in front of the Radiology
fluoroscope. section that lists all the
codes.

EXAMPLE
Dr. Horace, a radiologist, supervised a radiographic arthrography of Porter Arthrography
­Maison’s ankle; later the interpreted results were reported with this code: The recording of a picture of
an anatomical joint after the
73615 Radiologic examination, ankle, arthrography, radiological administration of contrast
supervision and interpretation material into the joint capsule.

Fluoroscope
2. Imaging “with contrast” has some guidelines that you have to know in order to A piece of equipment that
code accurately. emits x-rays through a part
of the patient’s body onto a
a. If the code description includes the term “with contrast,” such as computed fluorescent screen, causing
tomography (CT) with contrast, computed tomography angiography (CTA) the image to identify various
with contrast, magnetic resonance arthrography (MRA) with contrast, or aspects of the anatomy by
magnetic resonance imaging (MRI) with contrast, the injection of the contrast density.
materials, when administered intravenously, is already included in the code and
Computed Tomography (CT)
should not be reported separately.
A specialized computer scan-
b. If the contrast material is injected intra-articularly (into a joint) or intrathe- ner with very fine detail that
cally (into a tendon or sheath), an additional code is reported for the appropriate records imaging of internal
injection. anatomical sites; also known
c. Providing contrast materials orally and/or rectally alone does not constitute an as computerized axial tomog-
raphy (CAT).
exam “with contrast.”
Computed Tomography
­Angiography (CTA)
EXAMPLE A CT scan using contrast
Dr. Groder injected Vincent Speck’s elbow intrathecally with contrast materials to materials to visualize arteries
CPT © 2017 American Medical Association. All rights reserved.

do a radiographic arthrography for his tennis elbow. This is reported with these and veins all over the body.
codes: Magnetic Resonance
73085 Radiologic examination, elbow, arthrography, radiological Arthrography (MRA)
supervision and interpretation MR imaging of an anatomical
joint after the administration of
20550 Injection(s); single tendon sheath, or ligament, aponeurosis
contrast material into the joint
(eg. plantar “fascia”)
capsule.

Magnetic Resonance Imaging

3. When a CT or MR arthrography is performed without radiographic arthrography, (MRI)
you will need three different codes: A three-dimensional radiologic
a. A code for the injection of the contrast material into the specific joint. technique that uses nuclear
technology to record pictures
b. A code for the appropriate CT or MR.
of internal anatomical sites.
c. A code for the imaging guidance (fluoroscopy) of the placement of the needle to
inject the contrast material.
 EXAMPLE
Felicia Hanson is experiencing pain in her pelvic region. Dr. Alvarez orders an
MRA of her hip/pelvis with contrast. The material is injected intra-articularly. This is
reported using these codes: 
27093 Injection procedure for hip arthrography; without anesthesia
72198 Magnetic resonance angiography, pelvis; with or without contrast
material(s)
77002 Fluoroscopic guidance for needle placement (eg. biopsy, aspira-
tion, injection, localization device)

Other types of radiologic procedures include

∙ Positron emission tomography (PET): Uses a variety of radiopharmaceuticals that
mimic natural sugars, water, proteins, and oxygen and collect in various tissues and
organs. It is a time-exposure picture of cellular biologic activities.
∙ Bone density scan (DEXA): Used most often for osteoporosis screenings; enables
assessment of bone minerals in spine, hip, and other skeletal sites.
∙ Nuclear medicine scan: Used to assess organ system function.

CPT
LET’S CODE IT! SCENARIO
Mark Silver, an 81-year-old male, has been having problems with his memory and his walking. After an extensive
examination, his neurologist, Dr. Chernuchin, orders an MRI, brain, with and without contrast, to determine if Mark is
suffering from hydrocephalus.

Let’s Code It!

This is very straightforward. Mark had an MRI of his brain taken. Let’s go to the Alphabetic Index and look this up.
Under magnetic resonance imaging (MRI), you see the list of anatomical sites, including brain, which suggests
code range 70551–70553. (Note: Intraoperative, indented below brain, means that the MRI was performed dur-
ing surgery. This was not the case for Mark, according to the physician’s notes.) Let’s go to the numeric listing
and read the descriptions.
70551 Magnetic resonance (e.g., proton) imaging, brain (including brain stem); without
contrast material
70552   with contrast material(s)
70553   without contrast material, followed by contrast material(s) and further

CPT © 2017 American Medical Association. All rights reserved.

sequences
Dr. Chernuchin’s notes state that the MRI is with and without contrast. That means both types of imaging were
done. Code 70551 describes without contrast, and code 70552 includes the contrast. When you keep reading,
you see that code 70553 is the correct code because, as the notes state, it includes both sequences: without
the contrast followed by with contrast materials. Of course, you will also add the appropriate HCPCS Level II
codes to report the contrast materials used.

CODING BITES
Appropriate HCPCS Level II codes from the range Q9951–Q9969, based on the
number of units, should be assigned to report the contrast materials supplied.

808   PART III  |  REPORTING PHYSICIAN SERVICES AND OUTPATIENT PROCEDURES

 26.6  Diagnostic Radiology
Diagnostic Angiography
The coding of the process of imaging the body’s blood vessels, diagnostic angiography, Angiography
carries certain guidelines affecting the use of the codes. The imaging of blood vessels
after the injection of contrast
1. In some cases, interventional coding guidelines don’t permit you to report a diag- material.
nostic angiography when it is performed at the same time as a therapeutic interven-
tional procedure. This rule applies when the patient has already been diagnosed
and has scheduled a therapeutic intervention to correct the problem. As you have
already learned, you must read the guidelines and the code descriptions carefully.

EXAMPLE
Dr. Victoria performed a left internal and external carotid arterial angiography to
check for blockage and immediately performed an intervention procedure. You
would report this by using codes 
36224 Selective catheter placement, internal carotid artery, unilateral,
with angiography of the ipsilateral intracranial carotid circulation
and all associated radiological supervision and interpretation,
includes angiography of the extracranial carotid and cervicocer-
ebral arch, when performed
36227 Selective catheter placement, external carotid artery, unilateral,
with angiography of the ipsilateral external carotid circulation
and all associated radiological supervision and interpretation (List
separately in addition to code for primary procedure)

2. In other cases, the diagnostic angiography should be coded separately even though
it is done at the same session as an interventional procedure. This is true if one of
the following conditions has been met:
a. A full diagnostic study is done, no prior catheter-based angiographic study is
available, and the decision to intervene is determined by the diagnostic study.
b. The patient’s condition has changed since a previously done study. GUIDANCE
c. The patient’s condition changes during the interventional procedure that requires CONNECTION
a diagnostic procedure to look at vessels outside of the area. Read the additional
d. The prior diagnostic angiography did not show the applicable anatomy and/or explanations in the
pathology being treated at the session. in-section guidelines
within the Radiol-
ogy section, subhead
CPT © 2017 American Medical Association. All rights reserved.

EXAMPLE Vascular Procedures,

Thelma Hadid had a diagnostic angiography of her adrenal gland 1 year ago. subsection Aorta and
Since then, her condition has deteriorated. Therefore, Dr. Carnicki first performs a Arteries, directly above
diagnostic procedure. Because this shows changes, at the same session, he per- code 75600 in your
forms an interventional procedure. CPT book.

3. Diagnostic angiography is included with the code for an interventional procedure

and should not be coded separately when that diagnostic angiography is performed
for any of the following:
a. Vessel measurement.
b. Postangioplasty or stent angiography.
c. Contrast injections, angiography, road mapping, and/or fluoroscopic guidance
for the interventional procedure.
 CPT
LET’S CODE IT! SCENARIO
Alene Ransom, a 61-year-old female, has had two mild heart attacks in the past 2 years. Today, Alene is at the Bey-
ers Ambulatory Surgical Center for a diagnostic angiography to quantify the degree of blockage suspected in her
left renal artery. Dr. Black performs the procedure, which includes placing the catheter directly in the renal artery.
Later that day, Dr. Black dictates a report indicating that Alene’s left renal artery is 50% blocked.

Let’s Code It!

The notes indicate that a left renal angiography was performed on Alene. Let’s go to the Alphabetic Index and
look up angiography. You know that Alene’s renal artery was examined, and the Alphabetic Index suggests
codes 36251–36254. Let’s check the complete descriptions in the numeric listings:
36251 Selective catheter placement (first-order), main renal artery and any accessory
renal artery(s) for renal angiography, including arterial puncture and catheter
placement(s), fluoroscopy, contrast injection(s), image postprocessing, perma-
nent recording of images, and radiological supervision and interpretation, in-
cluding pressure gradient measurements when performed, and flush aortogram
when performed; unilateral
36252   bilateral
The difference between these two code descriptions is that 36251 is for a unilateral procedure and 36252 is
for a bilateral procedure. Alene had only her left renal artery examined. One side is unilateral, leading us to the
correct code of 36251.

Diagnostic Venography
Venography The codes for reporting diagnostic venography have guidelines similar to those for
The imaging of a vein after the diagnostic angiography.
injection of contrast material.
1. Some interventional procedure codes include the diagnostic venography when
done at the same time as the procedure. You must read the descriptions carefully to
determine if this is the case.
2. Diagnostic venography done at the same time as an interventional procedure should
be coded separately if one of the following conditions has been met:
a. A full diagnostic study is done, no prior catheter-based venographic study is
available, and the decision to intervene is determined by this diagnostic study.
GUIDANCE
CPT © 2017 American Medical Association. All rights reserved.
b. The patient’s condition has changed since a previously done study.
CONNECTION c. The patient’s condition changes during the interventional procedure and requires
Read the additional a diagnostic procedure to look at vessels outside of the area.
explanations in the d. The prior diagnostic venography did not show the applicable anatomy and/or
in-section guidelines pathology being treated at the session.
within the Radiology 3. Diagnostic venography is included with the code for an interventional procedure
section, subhead and should not be coded separately when that diagnostic venography is performed
­Vascular Procedures, for any of the following:
subsection Veins and
Lymphatics, directly a. Vessel measurement.
above code 75801 in b. Postangioplasty or stent venography.
your CPT book. c. Contrast injections, venography, road mapping, and/or fluoroscopic guidance for
the interventional procedure.

810   PART III  |  REPORTING PHYSICIAN SERVICES AND OUTPATIENT PROCEDURES

 LET’S CODE IT! SCENARIO
CPT

Charles Baseman, a 55-year-old male, flew in yesterday from Australia, a 26-hour airplane ride. Since getting off
the plane, he has been having pain in his right calf. Dr. Vernon performed a diagnostic venography to determine if
Charles has deep vein thrombosis (DVT). After completing the procedure, he wrote a report with his interpretation,
which was sent to Charles’s internist.

Let’s Code It!

Dr. Vernon performed a diagnostic venography of Charles’s right leg. Let’s go to the Alphabetic Index and find
venography. Beneath venography, you see the anatomical site leg with the suggested code range 75820–
75822. Let’s look at the code descriptions in the numeric listings:
75820 Venography, extremity, unilateral, radiological supervision and interpretation
75822 Venography, extremity, bilateral, radiological supervision and interpretation
The difference between these two codes is that 75820 is a unilateral procedure and 75822 is a bilateral procedure.
Charles had only his right leg examined, making it a unilateral procedure and making 75820 the correct code.

GUIDANCE
Transcatheter Procedures
CONNECTION
Therapeutic transcatheter radiologic supervision and interpretation codes, when asso-
ciated with intervention, already include Read the additional
explanations in the
1. Vessel measurement. in-section guidelines
2. Postangioplasty or stent venography. within the Radiology
3. Contrast injections, angiography/venography, road mapping, and/or fluoroscopic section, subhead
guidance for the interventional procedure. Vascular Procedures,
subsection Transcathe-
Transcatheter therapeutic radiologic and interpretation services are separately report- ter Procedures, directly
able from diagnostic angiography/venography done at the same time unless they are above code 75894 in
specifically included in the code descriptor. your CPT book.

CPT
LET’S CODE IT! SCENARIO
Dr. Grubman is in the OR today to perform a transcatheter placement of an intravascular stent, percutaneously, in
Olivia Samuel’s common iliac.

Let’s Code It!

CPT © 2017 American Medical Association. All rights reserved.

You are Dr. Grubman’s coding specialist, so you are going to code only the radiologic supervision and interpreta-
tion of the transcatheter procedure, as well as the placement of the stent itself. Let’s go to transcatheter in the
Alphabetic Index. You will notice that, if you go to placement under transcatheter, you see intravascular stents
indented below. Here, the Alphabetic Index suggests some Category III codes (0075T, 0076T) along with code
ranges 37215–37218, 37236–37239, and 92928–92929.
When you turn to the codes, you realize that they are in the Surgery section, not Radiology. However, they
are the only codes offered by the Alphabetic Index, so let’s take a look at them all. Notice
37236 Transcatheter placement of an intravascular stent(s) (except lower extremity, artery(s) for occlusive
disease, cervical carotid, extracranial vertebral or intrathoracic carotid, intracranial or coronary),
open or percutaneous, including radiological supervision and interpretation and including all an-
gioplasty within the same vessel, when performed; initial artery

(continued)
 But we are coding for Dr. Grubman’s radiologic supervision and interpretation for the procedure as well as
the stent placement. Notice that the description for code 37236 includes “radiological supervision and
interpretation.”
Perfect!

Diagnostic Ultrasound
When reporting diagnostic ultrasound services, you need to abstract specific details
CODING BITES about the anatomical sites viewed. As the coding specialist, you must read the report
and pay attention to whether the exam was “complete” or “limited” and choose the
If the reason that an
correct code. The description of an ultrasound exam as being “complete” is deter-
organ was not visible
mined by the specific number of elements, such as organs or areas, that are surveyed
is documented in the
during the test. However, sometimes the full list is not visualized. For example, an
patient’s record, you are
organ may have been previously removed surgically, or another organ may be blocking
permitted to code this
the view. The report that is submitted for the patient’s record, after the exam, should
as “complete.”
note everything that was studied—as well as those elements that should have been but
were not, along with why they were not.
You will find information regarding what is included in a complete exam in
the guidelines shown below each of the ultrasound subheadings: Abdomen and
­Retroperitoneum, Pelvis—Obstetrical, Pelvis—Non-obstetrical.
Should an ultrasound exam be performed without a thorough evaluation of an organ
or anatomical region and recording of the image and a final, written report, you are
GUIDANCE not permitted to code the procedure separately.
CONNECTION
Read the additional
explanation in the in- EXAMPLE
section guidelines within
Abdomen and Retroperitoneum
the Radiology section,
subhead Diagnostic A complete ultrasound examination of the abdomen (76700) consists of real-time
Ultrasound, directly scans of the liver, gallbladder, common bile duct, pancreas, spleen, kidney, and
above code 76506 in the upper abdominal aorta and inferior vena cava including any demonstrated
your CPT book. abdominal abnormality.

Let’s say an ultrasound examination is done on Herman Smith’s abdomen. The doc-
umentation includes the physician’s (radiologist’s) interpretation of all organs except
the gallbladder. The patient had his gallbladder removed 1 year prior to this ultrasound
exam. As long as this fact is also documented, code 76700 for a complete ultrasound
examination of the abdomen is accurate. CPT © 2017 American Medical Association. All rights reserved.
You already know that an ultrasound may be called a sonogram. However, other
definitions are important for you to know so that you can determine the best, most
appropriate code. The following terms identify the type of scan:
∙ A-mode indicates a one-dimensional ultrasonic measurement procedure.
CODING BITES
∙ M-mode is also a one-dimensional ultrasonic measurement procedure; however, it
Ultrasound services are includes the movement of the trace so that there can be a recording of both ampli-
especially dangerous tude and velocity of the moving echo-producing structures.
to code from superbills
instead of notes. Make
∙ B-scan indicates a two-dimensional ultrasonic scanning procedure with a two-
certain you get the com-
dimensional display.
plete documentation ∙ Real-time scan indicates that a two-dimensional ultrasonic scanning procedure
before choosing a code. with a display was performed and included both the two-dimensional structure and
motion with time.

812   PART III  |  REPORTING PHYSICIAN SERVICES AND OUTPATIENT PROCEDURES

 If the report indicates that a Doppler evaluation of vascular structures, or another
diagnostic vascular ultrasound study, was performed, it should be coded separately
with the codes from the Noninvasive Vascular Diagnostic Studies subsection, codes
93880–93990.

CPT
YOU CODE IT! CASE STUDY
Eriq Taleni, a 57-year-old male, was sent to the Kinsey Imaging Center by Dr. Rayman to have an ophthalmic biom-
etry by ultrasound echography, A-scan. After performing the exam, Dr. Turner, the radiologist, wrote in his report that
a second test using intraocular lens power calculation might be necessary to further clarify the condition of the eye.
Dr. Rayman determined that Eriq should wait before having the second test.

You Code It!

Go through the steps, and determine the codes that should be reported for the service provided to Eriq Taleni
by Dr. Turner.
Step #1: Read the case carefully and completely.
Step #2: Abstract the scenario. Which key words or terms describe what service the physician provided to the
patient during this encounter?
Step #3: Are there any details missing or incomplete for which you would need to query the physician? [If so,
ask your instructor.]
Step #4: Determine the correct CPT procedure code or codes to explain the details about what was provided
to the patient during this encounter.
Step #5: Check for any relevant guidance, including reading all of the symbols and notations.
Step #6: Do you need to append any modifiers to ensure complete and accurate information is provided?
Step #7: Double-check your work.
Answer:
Did you determine this to be the correct code?
76516 Ophthalmic biometry by ultrasound echography, A-scan
Good job!

26.7  Mammography
CPT © 2017 American Medical Association. All rights reserved.

Until researchers can find a way to prevent breast cancer, the best weapon in the health
care arsenal is early detection—finding the malignancy when it is tiny and easier to
eradicate. Mammography, low-dose radiology, is considered the best method for iden-
tifying a small, otherwise undetectable lump or microcalcification. Mammography
employs low-energy x-rays specifically designed to take and record images of breast
tissue for the discovery of breast lesions. 
77065 Diagnostic mammography, including computer-aided detec-
tion (CAD) when performed; unilateral
77066 Diagnostic mammography, including computer-aided detec-
tion (CAD) when performed; bilateral
77067 Screening mammography, bilateral (2-view film study of each
breast), including computer-aided detection (CAD) when
performed
 At times, computer-aided detection (CAD) is used in conjunction with the x-ray
imaging. CAD transitions the x-ray image into a digital image, which is then scanned
by a computer, searching for anything that might be abnormal. 

CPT
YOU CODE IT! CASE STUDY
Every year, Donna Simmons, 47-year-old female, came in for her annual well-woman exam, and then would go over
to the Imaging Center for her screening mammogram. This year, Dr. Douglas felt a lump during Donna’s manual
exam, so he ordered a diagnostic mammogram for the left breast and a screening mammogram for the right. These
mammograms were provided the next day at the Imaging Center.

You Code It!

Read the case study of Donna’s encounter at the Imaging Center, and determine the correct code or codes.
Step #1: Read the case carefully and completely.
Step #2: Abstract the scenario. Which key words or terms describe what service the physician provided to the
patient during this encounter?
Step #3: Are there any details missing or incomplete for which you would need to query the physician? [If so,
ask your instructor.]
Step #4: Determine the correct CPT procedure code or codes to explain the details about what was provided
to the patient during this encounter.
Step #5: Check for any relevant guidance, including reading all of the symbols and notations.
Step #6: Do you need to append any modifiers to ensure complete and accurate information is provided?
Step #7: Double-check your work.
Answer:
Did you determine these to be the correct codes?
77065 Diagnostic mammography, including computer-aided detection (CAD) when
performed; unilateral
77067-52 Screening mammography, bilateral (2-view film study of each breast),
including computer-aided detection (CAD) when performed, reduced
services
Good job!

26.8  Bone and Joint Studies CPT © 2017 American Medical Association. All rights reserved.
There are many reasons a physician may need information about a patient’s bone
structure and strength, and several imaging techniques that could be used to provide
the most accurate data.
∙ Bone age studies enable the physician to identify the degree of maturation of a
child’s bones.
∙ CT scanography has surpassed orthoroentgenogram in the last decade to determine
leg length discrepancies.
∙ Osseous survey is a radiologic procedure used to identify fractures, tumors, and
degenerative conditions of the bone.
∙ Bone mineral density (BMD) scanning, also called dual-energy x-ray absorptiom-
etry (DXA or DEXA) or bone densitometry, is an enhanced form of x-ray technol-
ogy that is used to measure bone loss.

814   PART III  |  REPORTING PHYSICIAN SERVICES AND OUTPATIENT PROCEDURES

 GUIDANCE CONNECTION
The United States Preventive Services Task Force recommends screening for
osteoporosis in women aged 65 years and older and in younger women whose
fracture risk is equal to or greater than that of a 65-year-old white woman who has
no additional risk factors. 

CPT
YOU CODE IT! CASE STUDY
Rachel VanHeusen, a 65-year-old female, arrived at the Kinsey Imaging Center to have a DEXA bone density study,
both axial and appendicular skeleton. Dr. Underwood, the staff radiologist, analyzed the images and wrote a report.

You Code It!

The Kinsey Imaging Center performed a DEXA bone density study, for both the axial and appendicular skeleton
of Rachel VanHeusen. Review the details, and determine the code or codes for this service.
Step #1: Read the case carefully and completely.
Step #2: Abstract the scenario. Which key words or terms describe what service the physician provided to the
patient during this encounter?
Step #3: Are there any details missing or incomplete for which you would need to query the physician? [If so,
ask your instructor.]
Step #4: Determine the correct CPT procedure code or codes to explain the details about what was provided
to the patient during this encounter.
Step #5: Check for any relevant guidance, including reading all of the symbols and notations.
Step #6: Do you need to append any modifiers to ensure complete and accurate information is provided?
Step #7: Double-check your work.
Answer:
Did you accurately determine these to be the codes?
77080 Dual-energy X-ray absorptiometry (DXA), bone density study, 1 or more sites; axial
skeleton (eg. hips, pelvis, spine)
77081-59 Dual-energy X-ray absorptiometry (DXA), bone density study, 1 or more sites; appen-
dicular skeleton (peripheral) (eg. radius, wrist, heel), Distinct procedural service
CPT © 2017 American Medical Association. All rights reserved.

26.9  Radiation Oncology

Radiation oncology is performed to treat malignant neoplasms and other carcinomas, Radiation
commonly known as cancer. The high-speed discharge
The codes in this subsection already include certain services: and projection of energy
waves or particles.
∙ Initial consultation.
∙ Clinical treatment planning.
∙ Simulation.
∙ Medical radiation physics.
∙ Dosimetry (the determination of the correct dosage).
 ∙ Treatment devices.
GUIDANCE
∙ Special services.
CONNECTION
∙ Clinical treatment management procedures.
Read the additional ∙ Normal follow-up care during treatment and for 3 months following the completion
explanations in the of the treatment.
in-section guidelines
within the Radiology Radiation oncology services may be provided in varying degrees of intensity and
section, subhead Radia- are usually determined in the planning process. Therefore, the preparation for the
tion Oncology, directly sequence of treatments must be coded accurately. Some professionals may describe
above code 77261 in the planning as simple, intermediate, or complex. However, others may provide the
your CPT book. detail, leaving you to match the components performed with the level of service.
Here are the specifics involved in each level:
∙ Simple planning involves one treatment area with one port, or parallel opposed
ports, with simple or no blocking.
CODING BITES
∙ Intermediate planning involves two separate treatment areas, three or more con-
Interventional radio-
verging ports, multiple blocks, or special time–dose constraints.
logic services, such as
radiation oncology, are ∙ Complex planning involves three or more separate treatment areas, highly com-
typically provided in a plex blocking, custom shielding blocks, tangential ports, special wedges or com-
series over a span of pensators, rotational or special beam consideration, or a combination of therapeutic
time. Make certain to methods.
code dates of service Just to keep you on your toes, you will find the same terms (simple, intermediate,
accurately. complex) also used to describe the simulation applied, with different definitions. The
good news is that the same terms relate to the same elements involved in the process. 
With simulation, there is one additional descriptor:
∙ Simple simulation: a single treatment area with either a single port or parallel
opposed ports. Simple or no blocking.
∙ Intermediate simulation: three or more converging ports, two separate treatment
areas, multiple blocks.
∙ Complex simulation: tangential portals, three or more treatment areas, rotation or
arc therapy, complex blocking, custom shielding blocks, brachytherapy source veri-
fication, hyperthermia probe verification, any use of contrast materials.
∙ Three-dimensional computer-generated: reconstruction of the size and mass of the
tumor and the normal tissues that surround the tumor site.
If you work in a facility that provides proton beam treatments and/or clinical brachy-
therapy for patients, you will note that the CPT book has different definitions for the
same three terms: simple, intermediate, and complex.

CPT © 2017 American Medical Association. All rights reserved.

CPT
LET’S CODE IT! SCENARIO
PATIENT: CRAIG BENNINGTON
DATE OF PROCEDURE: 09/25/2018
PREOPERATIVE DIAGNOSIS: Adenocarcinoma of the prostate
POSTOPERATIVE DIAGNOSIS: Adenocarcinoma of the prostate
PROCEDURE PERFORMED: Prostate brachytherapy
SURGEON: Carlos Arias, MD

816   PART III  |  REPORTING PHYSICIAN SERVICES AND OUTPATIENT PROCEDURES

 ANESTHESIA: General anesthesia via LMA
COMPLICATIONS: None
DRAINS: One 18-French Foley catheter per urethra
INDICATIONS FOR PROCEDURE: This patient has a new diagnosis of adenocarcinoma of the prostate diagnosed
due to a very slowly rising PSA. His current PSA level is only 2.0, but prostate ultrasound biopsies were performed
showing adenocarcinoma of the prostate at the left base of the prostate, and two biopsies were positive out of eight
with a Gleason score of 6. Treatment options have been discussed, and he wishes to proceed with prostate brachy-
therapy. Informed consent has been obtained.
DESCRIPTION OF PROCEDURE: The patient was placed on the operating table in the supine position. General
anesthesia was administered via LMA. He was then placed in the dorsal lithotomy position and sterilely prepped and
draped in the usual fashion. The prostate ultrasound was inserted. The prostate was visualized using the preplanned
study as a guide. Intracavitary application of prostate brachytherapy was performed. The patient tolerated the proce-
dure well and had no immediate intraoperative or postoperative complications.
We implanted a total of 54 iodine-125 radioactive seeds through 12 needles with each seed containing 0.373
millicurie per seed. During the procedure, the patient received 4 mg of Decadron IV and 400 mg of Cipro IV. Subse-
quent fluoroscopy showed good distribution of the seeds throughout the prostate. The patient will have a CAT scan
of the pelvis and simulation for his seed localization. Total target dose is 14,500 cGy.
The patient will be discharged with prescriptions for Cardura 1 mg a day for a month with two refills; Tylenol No.
3 one t.i.d. p.r.n. for pain, a total of 20; Pyridium Plus one b.i.d. for 10 days; Cipro 500 mg b.i.d. for 5 days; and pred-
nisone 10 mg t.i.d. for a week.
Discharge instructions were explained to the patient and his wife. He will return to see Dr. Ferguson, his oncolo-
gist, in 2 weeks and Dr. Victors, his urologist, in 4 weeks for a followup.

Let’s Code It!

Dr. Arias performed brachytherapy, so turn to this term in the CPT Alphabetic Index.
Brachytherapy
Read down the listing of the types of brachytherapic methods. Notice the documentation states, “Intracavitary
application of prostate brachytherapy was performed,” which leads you to
Intracavitary Application . . . . . 0395T, 77761-77763

Now, look up each of these codes and read each complete description to find the one that matches:

0395T High dose rate electronic brachytherapy, interstitial or intracavitary treatment,

per fraction, includes basic dosimetry, when performed
77761 Intracavitary radiation source application; simple
77762 Intracavitary radiation source application; intermediate
CPT © 2017 American Medical Association. All rights reserved.

77763 Intracavitary radiation source application; complex

Analyze each of these codes’ descriptions. Code 0395T cannot be accurate for this encounter because there is
no mention of electronic brachytherapy being used. Codes 77761, 77762, and 77763 are essentially the same
except for the level of intensity: simple, intermediate, or complex. 
Do you know which level is described in the documentation? No, so you need to query the physician. The
physician responds by adding a notation in the patient’s chart that this was a low-dose (simple) application. Now
you have what you need to report:
77761 Intracavitary radiation source application; simple
Good work!
 26.10  Nuclear Medicine
Nuclear Medicine Nuclear medicine uses tiny quantities of radioactive material, also known as tracers,
Treatment that includes the in conjunction with a scintillation or gamma camera to record the emissions from the
injection or digestion of tracers to create an image of the anatomical site. Several types of nuclear medicine
isotopes. tests are used to identify a health concern:
∙ Bone scans are used to investigate injuries (fractures, sprains, and strains) as well
as tumors.
∙ Thyroid uptake scans are used to assess thyroid function and record the structure of
the gland.
∙ Heart scans are used to measure heart function, evaluate the existence and extent
of heart muscle damage after a heart attack, and gauge the blood flow to the heart
muscle.
∙ Lung scans are used to determine the presence of blood clots. In addition, scans can
be valuable to calculate the flow of air into and out of the lungs.
∙ Hepatobiliary scans can provide information to evaluate the function of the liver
and the gallbladder.
∙ Gallium scans can be used to identify the presence of infection and some types of
tumors.
In addition to the diagnostic benefits of nuclear medicine, this methodology can
also be used therapeutically to treat hyperthyroidism and thyroid cancer and to help to
correct blood imbalances.
One important point that you have to know as a coding specialist working with
nuclear medicine procedures is that the codes presented in the CPT book do not
include diagnostic or therapeutic radiopharmaceuticals (the drugs or isotopes used in
the treatments). Therefore, you have to code them separately. If the insurance carrier
accepts HCPCS Level II codes, you will use them. You will learn all about HCPCS
Level II codes in Part IV of this textbook.
Radiopharmaceutical therapy, the administration of nuclear drugs, whether given
to the patient orally, intravenously, intracavitarily, interstitially, or intra-arterially, are
reported with codes 79005–79999.
Also note that any chemical pathology or chemical analysis done in connection
with the provision of nuclear medicine treatments should be coded separately from the
Pathology and Laboratory section of the CPT book.

CPT
YOU CODE IT! CASE STUDY
CPT © 2017 American Medical Association. All rights reserved.
Nadya Bartlett, a 43-year-old female, had gained a great deal of weight recently, with no change in her diet or
exercise regimen. After a thorough examination, Dr. Posner ordered nuclear imaging of her thyroid, with uptake.
Radiopharmaceuticals were administered intravenously. The report came back to Dr. Posner with the multiple deter-
minations of Nadya’s exam.

You Code It!

Go through the steps of coding, and determine the radiology code or codes that should be reported for this
encounter between Dr. Posner and Nadya Bartlett.
Step #1: Read the case carefully and completely.

818   PART III  |  REPORTING PHYSICIAN SERVICES AND OUTPATIENT PROCEDURES

 Step #2: Abstract the scenario. Which key words or terms describe what service the physician provided to the
patient during this encounter?
Step #3: Are there any details missing or incomplete for which you would need to query the physician? [If so,
ask your instructor.]
Step #4: Determine the correct CPT procedure code or codes to explain the details about what was provided
to the patient during this encounter.
Step #5: Check for any relevant guidance, including reading all of the symbols and notations.
Step #6: Do you need to append any modifiers to ensure complete and accurate information is provided?
Step #7: Double-check your work.
Answer:
Did you determine this to be the correct code?
78014 Thyroid imaging (including vascular flow, when performed); with single or multiple
uptake(s) quantitative measurement(s) (including stimulation, suppression, or
­discharge, when performed)
Great job!

Chapter Summary
Health care technology has advanced tremendously in the area of radiology and imag-
ing. It is important that, as a coding specialist, you understand the differences among
the types of radiologic methods, as well as the components of each. Procedures with
contrast and without contrast, CT scans, MRIs, sonograms, and so many more enable
professionals to look inside the patient in a noninvasive manner, and it is your job to
obtain the correct reimbursement for every procedure.

CODING BITES
Isotopes Used in Nuclear Medicine

Lutetium-177 A therapeutic radioisotope with just

enough gamma to enable imaging. 
Yttrium-90 Treatment of cancer, particularly non-
CPT © 2017 American Medical Association. All rights reserved.

Hodgkin’s lymphoma and liver cancer, and

it is being used more widely, including for
arthritis treatment.
Iodine-131 Treats thyroid for malignancy and other
abnormal conditions such as hyperthyroid-
ism (overactive thyroid).
Phosphorus-32 Controls an excess of red blood cells (RBC).
Caesium-131, Used for brachytherapy.
Palladium-103,
Iodine-125, and
Radium-223
 CHAPTER 26 REVIEW
CHAPTER 26 REVIEW

CPT Radiology Section Enhance your learning by

completing these exercises and
more at connect.mheducation.com!

Let’s Check It! Terminology

Match each key term to the appropriate definition.

1. LO 26.6    The imaging of a vein after the injection of contrast material. A. Angiography
2. LO 26.3   The use of sound waves to record images of internal organs and tis- B. Arthrography
sues; also called an ultrasound. C. Computed Tomography
3. LO 26.6    The imaging of blood vessels after the injection of contrast material. (CT)
4. LO 26.5   A piece of equipment that emits x-rays through a part of the patient’s D. Computed Tomography
body onto a fluorescent screen, causing the image to identify various Angiography (CTA)
aspects of the anatomy by density. E. Fluoroscope
5. LO 26.5   A three-dimensional radiologic technique that uses nuclear technol- F. Magnetic Resonance
ogy to record pictures of internal anatomical sites. Arthrography (MRA)
6. LO 26.5   A specialized computer scanner with very fine detail that records G. Magnetic Resonance
imaging of internal anatomical sites. Imaging (MRI)
7. LO 26.9    The high-speed discharge and projection of energy waves or particles. H. Nuclear Medicine
8. LO 26.5   The recording of a picture of an anatomical joint after the administra- I. Radiation
tion of contrast material into the joint capsule.
J. Sonogram
9. LO 26.10  Treatment that includes the injection or digestion of isotopes.
K. Venography
10. LO 26.5   MR imaging of an anatomical joint after the administration of con-
trast material into the joint capsule.
11. LO 26.5   A CT scan using contrast materials to visualize arteries and veins all
over the body.

CPT

Let’s Check It! Concepts

Choose the most appropriate answer for each of the following questions.
1. LO 26.3  The professional component of radiologic services includes
a. repair of the equipment. b.  interpretation of the imaging.
c. supplies. d.  training.
2. LO 26.1  Interventional radiologic services are provided with the intent of all except CPT © 2017 American Medical Association. All rights reserved.

a. diagnosing a condition.
b. preventing the spread of a disease.
c. measuring the progress of a disease.
d. testing the equipment.
3. LO 26.10  Dani Thompson presents for a thyroid carcinoma metastases imaging; limited area (neck and chest
only). What radiology code would you assign?
a. 78012      b.  78013      c.  78014      d.  78015

820   PART III  |  REPORTING PHYSICIAN SERVICES AND OUTPATIENT PROCEDURES

 4. LO 26.5  The phrase “with contrast” means that the technician or radiologist

CHAPTER 26 REVIEW
a. administered a substance to enhance the image.
b. used a black background behind the patient.
c. took the image a second time, to compare to the first.
d. used a blue background beneath the patient.
5. LO 26.4  If the code description includes the phrase “two views” and the ­radiology reports show that only one
view was taken, you should code the service
a. with that code alone.
b. with that code plus the modifier 52
c. with that code plus the modifier 53
d. with that code plus the modifier 22
6. LO 26.6  Therapeutic transcatheter radiologic supervision and interpretation codes, when associated with inter-
vention, include all of the following except
a. vessel measurement.
b. postangioplasty or stent venography.
c. catheter placement.
d. contrast injections, angiography/venography, road mapping, and/or f­ luoroscopic guidance for the interven-
tional procedure. 
7. LO 26.4  RPO stands for
a. right procedure operation. b.  regional protocol obstetric.
c. right posterior oblique. d.  right preventive oblique.
8. LO 26.9  Radiation for the treatment of a malignant neoplasm is most often used for
a. diagnostic purposes. b.  therapeutic purposes.
c. research purposes. d.  prevention purposes.
9. LO 26.1  An x-ray is the same as
a. a CTA.      b.  a CT.       c.  an MRI.      d.  a radiologic exam.

10. LO 26.10  Nuclear medicine uses tiny quantities of radioactive material, also known as _____, in conjunction
with a scintillation or gamma ­camera to record the emissions from the _____ to create an image of the
­anatomical site.
a. isotopes, tracers  b.  tracers, isotopes
c. tracers, tracers d.  tracers, drugs
CPT © 2017 American Medical Association. All rights reserved.
 Let’s Check It! Guidelines
CHAPTER 26 REVIEW

Refer to the Radiology Guidelines and fill in the blanks accordingly.

Imaging joint  arthrography new 
contrast  surgical not Medicine
injection analog  MR integral
access  “with contrast” rarely enhancement 
descriptors intravascular signed without
qualify stated needle service 

1. A service that is _______ provided, unusual, variable, or _______ may require a ­special report.
2. _______ may be required during the performance of certain procedures or certain imaging procedures may
require surgical procedures to _______ the imaged area.
3. Many services include image guidance, which is _______ separately reportable and is so _______ in the
­descriptor or guidelines.
4. When imaging is not included in a _______ procedure or procedure from the _______ section, image guid-
ance codes or codes labeled “radiological ­supervision and interpretation” may be reported for the portion of the
_______ that requires imaging.
5. The phrase _______ used in the codes for procedures performed using contrast for imaging _______ represents
contrast material administered intravascularly, intra-articularly, or intrathecally.
6. For intra-articular injection, use the appropriate _______ injection code.
7. If radiographic _______ is performed, also use the arthrography supervision and interpretation code for the
appropriate joint.
8. If computed tomography or magnetic resonance arthrography are performed _______ radiographic arthrography,
use the appropriate joint _______ code, the appropriate CT or _______ code, and the appropriate imaging
­guidance code for _______ placement for contrast injection.
9. Injection of _______ contrast material is part of the “with contrast” CT, ­computer tomographic angiography,
magnetic resonance imaging and magnetic resonance angiography procedure.
10. Oral and/or rectal _______ administration alone does not _______ as a study “with contrast.”
11. A written report _______ by the interpreting individual should be considered an _______ part of a radiology
­procedure or interpretation.
12. With regard to CPT _______ for radiography services, “images” refer to those acquired in either an _______ or
digital manner.
CPT © 2017 American Medical Association. All rights reserved.

Let’s Check It! Rules and Regulations

Please answer the following questions from the knowledge you have gained after ­reading this chapter.
1. LO 26.3   Differentiate between the technical component and professional ­component including modifiers that
represent each. 
2. LO 26.2   What is the difference between a screening image and a diagnostic image? Why is it important for the
­professional coder to know the difference?
3. LO 26.2   When a screening test turns into a diagnostic test, what service(s) should be reported? 
4. LO 26.9   What is radiation oncology? What do the codes in this subsection already include? 
5. LO 26.10  What are the types of nuclear medicine tests that are used to identify a health concern? 

822   PART III  |  REPORTING PHYSICIAN SERVICES AND OUTPATIENT PROCEDURES

 CHAPTER 26 REVIEW
CPT

YOU CODE IT! Basics

First, identify the procedural main term in the following 7. Dr. Roof completes PET imaging of a heart:
statements; then code the procedure or service. a. main term: _____ b. procedure: _____
Example: Dr. Bradford performs a CT scan of the 8. Dr. Darby performs a ureteral reflux study:
brain without contrast material: a. main term: _____ b. procedure: _____
a. main term: CT b. procedure: 70450 9. Dr. Allister takes a unilateral x-ray of ribs, 2 views:
a. main term: _____ b. procedure: _____
1. Dr. Gray takes an eye x-ray for detection of
­foreign body: 10. Dr. Alexander completes kidney imaging
morphology:
a. main term: _____ b. procedure: _____
a. main term: _____ b. procedure: _____
2. Dr. Robertson takes a CT scan of the pelvis with
contrast: 11. Dr. Steiner performs a DXA scan, hips:
a. main term: _____ b. procedure: _____ a. main term: _____ b. procedure: _____
3. Dr. Banks performs a renal ultrasound, complete, 12. Dr. Smyth completes a radiopharmaceutical local-
real-time with image documentation: ization of inflammatory process; whole body:
a. main term: _____ b. procedure: _____ a. main term: _____ b. procedure: _____
4. Dr. Hicks takes a panoramic x-ray: 13. Dr. Benton performs radiopharmaceutical therapy
by intra-articular administration:
a. main term: _____ b. procedure: _____
a. main term: _____ b. procedure: _____
5. Dr. Louche administers brachytherapy, intracavi-
tary radiation, 8 sources: 14. Dr. Gilbert completes an angiography, extrem-
ity (arm), bilateral, radiological supervision and
a. main term: _____ b. procedure: _____
interpretation:
6. Dr. Pullets performs a liver SPECT (single photon
a. main term: _____ b. procedure: _____
emission computed tomography) with vascular
flow tomography: 15. Dr. Johannson performs an MRI, spinal canal and
contents, lumbar; without contrast material.
a. main term: _____ b. procedure: _____
a. main term: _____ b. procedure: _____

CPT HCPCS Level II

YOU CODE IT! Practice
Using the techniques described in this chapter, carefully read through the case studies and determine the most
­accurate radiology CPT code(s) and modifier(s), if appropriate, for each case study.
CPT © 2017 American Medical Association. All rights reserved.

1. Edith Shapin, a 24-year-old female, is pregnant for the first time and is at approximately 11 weeks
­gestation. She is brought into the diagnostic center for a fetal biophysical profile with nonstress testing. 
2. William Browne, a 15-year-old male, is brought into Dr. Jenkins’s office with severe right leg pain. Dr. Jenkins
takes x-rays of his right femur, AP and PA, to determine whether or not Bill’s leg is fractured.
3. Martha Lightfood, an 82-year-old female, was brought into Dr. Morrison’s office by her daughter because
Martha was complaining of a sharp pain in her chest. After a negative EKG, Dr. Morrison had a quantitative
differential pulmonary perfusion and ventilation study performed, which confirmed a pulmonary embolism.
Martha was taken immediately by ambulance to the hospital. Code the quantitative differential pulmonary
perfusion and ventilation study only. 
4. Dr. Logan saw Jason Miolo, a 38-year-old male, with a swollen right eye and loss of vision. Dr. Logan
ordered a CT with contrast of the right eye and area, which revealed marked proptosis of the right orbit,
thrombosis, and enlargement of the right superior ophthalmic vein. 
CHAPTER 26 REVIEW

5. Carl Gadsden, a 66-year-old male, was diagnosed with intrinsic laryngeal cancer, supraglottic T1 tumor. With
the tumor confined to one subsite in the supraglottis, Dr. Yoshihashi provided radiation treatment delivery,
with a single port, simple block, of 4.5 MeV. 
6. Olivia Kane, a 33-year-old female, came into Kinsey Imaging Center for her annual screening mammogram.
Due to her family history of malignant neoplasms of the breast (both her mother and sister have been diag-
nosed), the mammogram was ordered with computer-aided detection (CAD). 
7. Brianna Haralson, a 24-year-old female, is brought into Dr. Duncan’s office with sharp pains in her lower
right abdomen, shooting across to the left side. Dr. Duncan ordered some blood work and an MRA to confirm
the suspected diagnosis of acute appendicitis. Code the MRA. 
8. Charles Gresham, a 40-year-old male, was in training at Cape Canaveral when he hit his head in a weightless-
ness simulator, causing him to lose consciousness for 3 minutes. Charles was transported to the nearest hos-
pital, where Dr. Neumours, the ED on-call physician, took a skull x-ray, three views, and did an MRI without
contrast of Charles’s brain. 
9. Jonelle Graybar, a 73-year-old female, was experiencing pain in her back that radiated around her trunk. She
was also suffering with spastic muscle weakness. Dr. Maxwell ordered a radioisotope bone scan of Jonelle’s
lumbar spinal area. The scan identified a metastatic invasion of L1–L3. 
10. Maxine Zeigleman, newly diagnosed with metastatic lumbar spinal tumors, has been referred to Dr. Appleton
for the creation of a simple radiation therapy plan. 
11. Vernon Unger had been diagnosed with a malignancy and came today for intravenous radiopharmaceutical
therapy. 
12. Before beginning a series of treatments, Anna Hogan came to the Diagnostic Imaging Center for a metabolic
evaluation PET scan of her brain. 
13. Ira Morgan, a 16-month-old male, was brought to radiology for a real-time, limited, static ultrasound of his hips.
14. Xavier Pollack, a 62-year-old male, arrived at the Kinsey Imaging Center to have a SPECT (single photon
emission computed tomography) performed on his left kidney. 
15. Dr. Astrone performed a complete ultrasound evaluation of Alden Roberts’s pelvis. The procedure included
evaluation and measurement of Alden’s urinary bladder, evaluation of his prostate and seminal vesicles, and
pathology of his enlarged prostate.

CPT HCPCS Level II

YOU CODE IT! Application

The following exercises provide practice in the application of abstracting the physicians’ notes and learning to work
with documentation from our Kinsey Imaging Center. These case studies are modeled on real patient encounters. Using
the techniques described in this chapter, carefully read through the case studies and determine the most accurate radiol-

CPT © 2017 American Medical Association. All rights reserved.

ogy CPT code(s) and modifier(s), if appropriate, for each case study. You are coding for the radiologist.

KINSEY IMAGING CENTER

951 SYDNEY STREET • SOMEWHERE FL 32811 • 407-555-3573

PATIENT: SAVOY, MARCELLA
ACCOUNT/EHR#: SAVOMA001
DATE: 09/17/18
Procedure Performed: MRI, Spinal canal, thoracic, 3 views
CT, abdomen/pelvis

824   PART III  |  REPORTING PHYSICIAN SERVICES AND OUTPATIENT PROCEDURES

 CHAPTER 26 REVIEW
Radiologist: Keith Robbins, MD
Referring Physician: Oscar R. Prader, MD
INDICATIONS: Probable metastatic disease, T1–T3, asymptomatic; metastatic mucinous adenocarci-
noma of unknown primary
IMPRESSIONS: MRI scans also showed edema at T1, T2, and T3, but no obvious metastatic disease.
In the course of her evaluation, a CT of the abdomen and pelvis showed some mild common bile duct
dilation, but no obvious primary malignancy.

Keith Robbins, MD
KR/mg  D: 09/17/18 09:50:16  T: 09/20/18 12:55:01

Determine the most accurate radiology CPT code(s) and modifier(s), if appropriate.

KINSEY IMAGING CENTER

951 SYDNEY STREET • SOMEWHERE FL 32811 • 407-555-3573
PATIENT: JAQUARD, JOEL
ACCOUNT/EHR#: JAQUJO001
DATE: 10/01/18
Procedure Performed: X-rays, skull, two views
CT, soft tissue of neck, with contrast
MRI, brain stem
Radiologist: Robyn Campbell, MD
Referring Physician: Renee O. Bracker, MD
INDICATIONS: Concussion, after fall from ladder
IMPRESSIONS: 1. Full muscle and tendon retraction of the supraspinatus and infraspinatus structures.
2. Bruising and possible microfractures to the skull at occipital base.
3. Other partial tearing of the superior aspect of the semispinalis capitis
RC/mg  D: 10/01/18 09:50:16  T: 10/02/18 12:55:01

Determine the most accurate radiology CPT code(s) and modifier(s), if appropriate.
CPT © 2017 American Medical Association. All rights reserved.

KINSEY IMAGING CENTER

951 SYDNEY STREET • SOMEWHERE FL 32811 • 407-555-3573

PATIENT: BURMAN, CECILIA
ACCOUNT/EHR#: BURMCE001
DATE: 10/17/18
Procedure Performed: MRI, brain, no contrast
MRA, brain, no contrast
MRA, neck, no contrast
CHAPTER 26 REVIEW

Radiologist: Eryn Alberts, MD
Clinical Information: Evaluate for VP shunt
No prior studies available for a comparison
TECHNICAL INFORMATION: The examination was performed without the use of intravenous contrast material.
INTERPRETATION: Evaluation of the posterior fossa demonstrates hydrocephalus versus low pressure
communicating hydrocephalus.

Eryn Alberts, MD
EA/mg  D: 10/17/18 09:50:16  T: 10/20/18 12:55:01

Determine the most accurate radiology CPT code(s) and modifier(s), if appropriate.

KINSEY IMAGING CENTER

951 SYDNEY STREET • SOMEWHERE FL 32811 • 407-555-3573

PATIENT: TREMONT, GARETT
ACCOUNT/EHR#: TREMGA001
DATE: 11/05/18 
EXAMINATION: Chest and abdomen 
CLINICAL HISTORY: Fever
CHEST: AP supine and lateral films demonstrate no evidence of alveolar infiltrate or consolidation or
pleural effusion. The mediastinal structures are not enlarged. There is very mild increase in central bron-
chovascular markings. There is no evidence of focal destructive bone lesion.
IMPRESSION: No infiltrate.
ABDOMEN: Supine and erect films demonstrate mild to moderate dilatation of loops of small bowel with
short air/fluid levels on the erect film. The large bowel is within normal limits in size but is visualized to
the level of the splenic flexure. There is no air visualized in the remainder of the colon. The findings are
not specific but consistent with ileus. Further clinical correlation is advised. There is no evidence of focal
destructive bone lesion. There is no suspicious calcification in the upper abdomen.
IMPRESSIONS: Abdominal bowel pattern, not specific, consistent with ileus.

Milton Harrison, MD

CPT © 2017 American Medical Association. All rights reserved.

MH/mg  D: 11/05/18 09:50:16  T: 11/07/18 12:55:01

Determine the most accurate radiology CPT code(s) and modifier(s), if appropriate.

KINSEY IMAGING CENTER

951 SYDNEY STREET • SOMEWHERE FL 32811 • 407-555-3573

PATIENT: WILLARD, NADINE
ACCOUNT/EHR#: WILLNA001
DATE: 09/29/18

826   PART III  |  REPORTING PHYSICIAN SERVICES AND OUTPATIENT PROCEDURES

 CHAPTER 26 REVIEW
Procedure Performed: CT angiography of the head, without contrast and with contrast
Radiologist: Kevin Linnard, MD
Referring Physician: Renee O. Bracker, MD
INDICATIONS: Left CVA
IMPRESSIONS: The current study is compared with the previous one of 05-25-14.
Compared with the previous study, there is a focal area of hypodensity present in the right posterior
cerebral arterial distribution adjacent to the falx, a finding suspicious for a small acute infarction, non-
hemorrhagic, most likely the parieto-occipital branch.
No other abnormality detected. There are no intra- or extra-axial hemorrhages. There is no significant
midline shift or hydrocephalus.
Small new area as described above is suspicious for an area of acute infarction in the right posterior
cerebral arterial distribution, likely the occipital branch. Please clinically correlate.

Kevin Linnard, MD
KL/mg  D: 09/29/18 09:50:16  T: 09/30/18 12:55:01

Determine the most accurate radiology CPT code(s) and modifier(s), if appropriate.
CPT © 2017 American Medical Association. All rights reserved.
 27
Key Terms
CPT Pathology & Lab
Section
Learning Outcomes
Cytology After completing this chapter, the student should be able to:
Etiology
Gross Examination LO 27.1 Recognize key factors involved in pathology testing.
Laboratory LO 27.2 Identify testing methodologies and sources.
Microscopic LO 27.3 Report panel codes when qualified.
Examination LO 27.4 Analyze blood test reports to ensure accurate reporting.
Pathology LO 27.5 Discern clinical chemistry studies.
Qualitative LO 27.6 Interpret details about molecular diagnostic testing.
Quantitative
Specimen LO 27.7 Distinguish immunologic, microbiologic, and cytopathologic
Surgical Pathology testing.
LO 27.8 Abstract the correct details to report surgical pathology
testing.
LO 27.9 Append the correct modifier, when required.
LO 27.10 Accurately interpret the abbreviations used most often in
pathology and laboratory reports.

Remember, you need to follow along in

CPT

  STOP! your CPT code book for an optimal learn-

ing experience.

27.1  Specimen Collection and Testing

As physicians and health care professionals work to help their patients, very often they
need medical science to guide them. The guidance frequently comes from tests per-
CPT © 2017 American Medical Association. All rights reserved.
Laboratory formed by professionals working in a laboratory, studying the evolution of a patient’s
A location with scientific disease. This type of study is called pathology, which includes etiology.
equipment designed to per- Pathology and lab testing help detect the early presence of disease, ruling out or
form experiments and tests. confirming conditions that might have similar symptoms yet need to be treated dif-
Pathology ferently. The results of these tests also may predict the occurrence of disease in the
The study of the nature, etiol- future. You probably already know from your own experiences the importance of
ogy, development, and out- such work. Your annual physical has possibly included blood tests to measure your
comes of disease. cholesterol. Physicians order blood work to confirm pregnancy or a urinalysis to
determine if a symptom could be the result of an infection. Testing takes time and the
Etiology
The original source or cause
expertise of professionals educated in interpreting the results. It also takes materials
for the development of a dis- and resources.
ease; also, the study of the A specimen sent to the lab for testing may be from any number of different sources:
causes of disease. ∙ Blood
∙ Urine

828
 ∙ Other bodily fluids, such as
■ sputum
■ sperm
■ mucus
∙ Tissue
∙ An organ
CODING BITES
When you code pathol-
CODING BITES ogy and laboratory
Every pathology or lab test requires specimens to examine. In some cases, you work, you may be
may need to report the collection of the specimen separately. reporting the work
For example: provided by the profes-
sional performing the
36415   Collection of venous blood by venipuncture test and interpreting the
83930   Osmolality; blood results (the pathologist)
Be alert to the fact that the collection of the specimen may be provided at a sepa- or you may be reporting
rate facility from the lab, in which case, each facility would report the code for the for the facility that pro-
part performed. vided the testing.

As a coding specialist, you may work for a health care organization that has a labo- Specimen
ratory within its facilities, a billing company that codes everything, or an independent A small part or sample of any
facility that does nothing other than taking and analyzing specimens. In any case, you substance obtained for analy-
should understand the different aspects of pathology and lab testing and procedures, as sis and diagnosis.
well as the guidelines involved in coding the services.

CPT
LET’S CODE IT! SCENARIO
Cynthia Cardamen, a 33-year-old female, was not feeling well, so she went to see her family physician, Dr. Slater.
After talking with her and performing an exam, Dr. Slater began to suspect that Cynthia had diabetes mellitus, type
2. Reagan Dram, the nurse, obtained a specimen of capillary blood from Cynthia’s left index finger and took it to
Abbey Carmichael, who ran their in-house lab, for a glucose test to be performed. She used a reagent strip to per-
form the test and delivered the results to Dr. Slater.

Let’s Code It!

There are two steps to this test: the collection of the specimen and the testing of that blood to determine Cyn-
thia’s glucose level.
Let’s turn to the CPT Alphabetic Index, and find
CPT © 2017 American Medical Association. All rights reserved.

Collection and Processing

Specimen
  Capillary Blood............... 36416
Now, turn to the Main Section of CPT and find

36416   Collection of capillary blood specimen (eg. finger, heel, ear stick)
Now, we must report the test that Abbey will perform on this blood specimen. Dr. Slater ordered a blood glucose
test. Turn in the Alphabetic Index to
Glucose
Blood Test................. 82947, 82948, 82950

(continued)

CHAPTER 27  | 
 This time, we have three different codes to investigate.
82947   Glucose; quantitative, blood (except reagent strip)
82948   Glucose; blood, reagent strip
82950   Glucose; post glucose dose (includes glucose)
Compare the details in these code descriptions to the details you have in the documentation. Code 82948
matches.
36416   Capillary blood, collection
82948   Glucose; blood, reagent strip
Good work!

27.2  Testing Methodology and Desired

Results
Although no one expects you, as the coding specialist, to be completely knowledge-
able about the details of laboratory and pathology testing, you will need certain infor-
mation about how the tests are performed in order to code them correctly. This may
begin with exactly what type of properties are needed, going beyond just the name of
the test itself.

Types of Test Results

Quantitative Two of the types of results that lab tests can evidence are quantitative and
The counting or measurement qualitative. These details can support a physician’s medical decision making, espe-
of something. cially when trying to determine an accurate diagnosis or identify the success of a
Qualitative treatment, or lack of success of a treatment.
The determination of charac- For example, serum calcium tests are used to assess parathyroid function and cal-
ter or essential element(s). cium metabolism. The quantitative results (total amount of calcium in the blood) can
also be used to check on patients with renal failure.
Other tests you may be familiar with are white blood cell (WBC) count (quanti-
tative) and differential count (qualitative and quantitative) tests. These tests are part
of routine blood testing. The quantitative totals can provide important diagnostic
details—for example, an increased white blood cell count usually identifies the pres-
ence of an infection, inflammation, tissue necrosis, or leukemic neoplasia, while a
decreased total white blood cell count can be present due to bone marrow failure,
indicating a potential immunocompromised patient.
CPT © 2017 American Medical Association. All rights reserved.

EXAMPLES
Calcium
82310 Calcium; total
82330 Calcium; ionized
82331 Calcium; after calcium infusion test
82340 Calcium; urine quantitative, timed specimen

White Blood Cell

85004 Blood count; automated differential WBC count
85007 Blood count; blood smear, microscopic examination with manual
differential WBC count

830   PART III  |  REPORTING PHYSICIAN SERVICES AND OUTPATIENT PROCEDURES

 85008 Blood count; blood smear, microscopic examination without man-
ual differential WBC count
85009 Blood count; manual differential WBC count, buffy coat

The guidelines tell you that, if the documentation does not specify, you may assume
that the examination performed was quantitative. However, remember that documenta-
tion is absolute in the health care industry. Therefore, it is recommended that you query
the lab technician or pathologist and request that the report include this important detail.

Testing Methodologies
For other testing, you might see the details about the methodology of the testing. Some
of the terms you will notice in test descriptions and their codes include
∙ By dipstick
∙ Automated or nonautomated
∙ With or without microscopy
∙ Visual or gross inspection
These terms refer to the methods that the lab technicians use to test the specimen and
obtain the results.

CPT
LET’S CODE IT! SCENARIO
Margaret O’Hanahan came to see Dr. Marinson. She states that she has been feeling a stinging pain when she
urinates. She confirms some lower back aches but denies hematuria. Dr. Marinson asks Margaret to go into the
bathroom and provide a urine sample, which is then tested in the office by dipstick, automated without microscopy.

Let’s Code It!

Dr. Marinson is performing a urinalysis, by dipstick, automated. Turn to urinalysis in your CPT Alphabetic Index.

Urinalysis................81000-81099
Automated................81001, 81003
CPT © 2017 American Medical Association. All rights reserved.

These two listings fit the details according to the documentation, so turn to the Main Section and read these
code descriptions.
81000   Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes,
nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; non-
automated, with microscopy
81001 Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes,
nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; automated,
with microscopy
81002 Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes,
nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; non-
automated, without microscopy

(continued)

CHAPTER 27  | 
 81003 Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes,
nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; automated,
without microscopy
81005 Urinalysis; qualitative or semiquantitative, except immunoassays
81007 Urinalysis; bacteriuria screen, except by culture or dipstick
81015 Urinalysis; microscopic only
81020 Urinalysis; 2 or 3 glass test
81025 Urine pregnancy test, by visual color comparison methods
81050 Volume measurement for timed collection, each
81099 Unlisted urinalysis procedure

Go back to the scenario and abstract the details about the test. The documentation states, “dipstick, automated
without microscopy.” When you read all of these code descriptions, you can see that only one accurately reports
this specific test:
81003 Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leuko-
cytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents;
automated, without microscopy
Good work!

In addition to how the test is performed, you must also know the type of specimen
CODING BITES involved in the testing and, sometimes, how many specimens or sources are involved.
All the details regarding The type of specimen being tested may change the code. Consider a physician order-
the specimen and the ing a potassium test. Let’s go to the Alphabetic Index for potassium.
testing are important.
There are times when
the code descriptions EXAMPLE
include the type of test,
Potassium................84132
the type of specimen,
or both. Urine............................ 84133

The first code in the example, listed next to the word potassium, is code 84132, but
it does not contain any additional descriptors. However, the second code, listed under
potassium, indicates that it would be the code used if the potassium were tested from
the patient’s urine rather than blood (serum). When you look at the codes’ complete
descriptions in the numeric listing, you see the details shown.
CPT © 2017 American Medical Association. All rights reserved.

EXAMPLE
84132 Potassium; serum, plasma, or whole blood
84133   urine

The listings clearly show that there is a difference as to which code is correct based
on the source of the specimen.
In certain circumstances, an analysis may be performed on multiple specimens col-
lected at different times or from different sources. In these cases, the guidelines tell
you to code each source and each specimen separately. However, be certain to always
read the code descriptions carefully. Some codes already include multiple tests and/or
multiple sources.

832   PART III  |  REPORTING PHYSICIAN SERVICES AND OUTPATIENT PROCEDURES

 CPT
LET’S CODE IT! SCENARIO
Gilian Morrison, RN, performs a rapid influenza test using a commercial test kit in the office to determine if Hester
Childs has the virus. This way the results can be provided while Hester is still in with Dr. Alberts. When complete,
Nurse Morrison visually reads the result as positive.

Let’s Code It!

For this scenario, you are going to focus only on reporting the provision of the rapid influenza test. The first place
you look in the CPT Alphabetic Index is under the word Test. However, there is nothing there, so let’s look up the
term Influenza. There are several choices. Let’s analyze them.
The first two choices are titled Influenza A and Influenza B. There is nothing in the notes about which this
might be. Before querying the nurse or doctor, let’s keep reading.
The next listing is Influenza Vaccine. There is nothing in the notes stating that Hester was given a vaccination,
so this is not applicable to this encounter.
The last listing category is titled Influenza Virus. This could be possible because the notes state the test was
given to “determine if Hester has the virus.” Two codes are suggested here:
Antibody................................................................................................................ 86710
Detection
   by Immunoassay with Direct Optical Observation..............................87804
   by Nucleic Acid.............................................................................. 87501-87503
Let’s turn to the Main Section of CPT, look for these two possible codes in the Pathology and Laboratory sec-
tion, and read the complete code descriptions.
86710 Antibody; influenza virus
87804 Infectious agent antigen detection by immunoassay with direct optical observation; influenza
When you read the scenario and the complete code description, you can see how code 87804 matches
accurately.

27.3  Panels
A pathology report, such as the one shown in Figure 27-1, will typically itemize the
tests performed for the patient along with the results of each test.
CPT © 2017 American Medical Association. All rights reserved.

FIGURE 27-1  Sample lab report showing the tests run as part of a lipid profile

CHAPTER 27  | 
 When you turn to the Pathology and Laboratory section of the CPT book, you will
CODING BITES notice that many codes include a long list of tests within one code’s description. These
Remember that the groupings of tests commonly performed at the same time are called panels.
codes for testing a
specimen do not include
collecting the specimen.
Collection, such as per- EXAMPLE
forming a biopsy, veni- 80051 Electrolyte panel
puncture, or fine-needle This panel must include the following:
aspiration, is coded
separately by the coder Carbon dioxide (82374)
for the professional who Chloride (82435)
performed the collection. Potassium (84132)
Sodium (84295)

CODING BITES
When all the included
tests of a panel are per- This example shows you that, in order for you to report code 80051 legally and
formed, you must use accurately, the lab must have performed all four tests: carbon dioxide, chloride, potas-
the panel code. Coding sium, and sodium.
the tests individually is If the lab performed fewer than all the tests listed in a panel, you must report the
considered unbundling. code for each test separately; you are not permitted to use the panel code.
Unbundling is unethical Again, the CPT book will help you. Should you have to code any of the tests
and illegal. If fewer tests separately, each test code is given in parentheses right next to the name of the test
are performed, using listed there. From our example, next to carbon dioxide, you can see the number
a panel code with the 82374. Turn to code 82374, and you will see that it is the code for testing carbon
modifier 52 Reduced dioxide alone.
Services is not permit- Let’s say, instead of fewer tests than those listed in a panel, the lab performs more
ted. You must code the tests. The guidelines state that you are to report those additional tests, those not
tests individually. included in the panel code, separately and additionally.

CPT
LET’S CODE IT! SCENARIO
Concerned that Keisha Evans, a 51-year-old female, might be suffering from hypercholesterolemia, Dr. Rawlins
ordered blood work, including a total cholesterol serum test, lipoprotein (direct measurement of high-density lipopro-
tein), and triglycerides. He also added a potassium serum test to the order.

Let’s Code It!

The lab performed four tests: total cholesterol serum test, lipoprotein (direct measurement of high-density lipo-
protein), triglycerides, and potassium serum. When you look up the tests individually, you are directed to codes CPT © 2017 American Medical Association. All rights reserved.
for each. However, when it comes to pathology and laboratory coding, you must take an extra step.
Turn to the numeric listings at the beginning of the Pathology and Laboratory section, where you find the
standardized panels listed. Review the list of tests included in each of the panels and match it with the list of
tests Dr. Rawlins ordered. You see that code 80061 Lipid Panel includes three of the four tests performed.
80061   Lipid Panel
Since none of the panels includes all four tests, you use the lipid panel code and code the potassium test addi-
tionally, code 84132.
84132   Potassium; serum, plasma, or whole blood
Therefore, you have two codes for the lab work’s claim: 80061 and 84132.
Good job!

834   PART III  |  REPORTING PHYSICIAN SERVICES AND OUTPATIENT PROCEDURES

 GUIDANCE CONNECTION
Read the additional explanations in the in-section guidelines located within the
Pathology and Laboratory section, subhead Organ or Disease-Oriented Panels,
directly above code 80047 in your CPT book.

CODING BITES
Experience and practice will help you learn the components of panels. After work-
ing at a lab or for a facility with a lab, you will recognize the lab tests that are typi-
cally performed together and possibly have a panel code grouping them. Should a
test not be in a panel, the Alphabetic Index will direct you to the correct individual
code for that test.

27.4  Blood Test Documentation CODING BITES

Determining the code for a blood test can be complex, as you are learning in this chap- Remember, you are
ter. The lab report (see Figure 27-2) is an important part of the documentation you will only permitted to report
have to report the performing of the tests. a code, legally, when
you are coding for the
∙ Bicarbonate: Kidneys and lungs keep bicarbonate balanced to maintain homeo- individual or facility that
static pH levels (ensure a balance of acid and alkali levels). Abnormal levels can actually did the work.
indicate dysfunction of these organs (kidneys and lungs). When a physician
∙ Blood culture: This test measures the presence of bacteria or yeast in the blood, documents ordering a
which is used to confirm (or deny) a suspected infection or sepsis. test to be done (by an
∙ Blood differential (Diff): This test measures numbers of WBCs, which are used to outside lab), this is part
identify presence of infection. Normal is less than 20%. of the E/M service.
∙ Blood urea nitrogen (BUN): This test measures kidney function. A low count
might indicate malnutrition, while a high count may identify the presence of heart
failure, kidney disease, or liver disease. Normal range: 7–20 milligrams per decili-
ter (mg/dL).
∙ Creatinine: This test measures levels of this chemical excreted by the kidneys. It is
used to determine muscle damage, dehydration, and/or kidney dysfunction. Normal
range: 0.8–1.4 mg/dL.
∙ Glucose: This test measures the level of sugar in the blood. Low levels may indicate
hypoglycemia or liver disease, whereas high levels may indicate hyperglycemia
(diabetes) or hyperthyroidism. Normal range: 70–99 mg/dL.
CPT © 2017 American Medical Association. All rights reserved.

∙ Erythrocyte sedimentation rate (ESR): This test measures the speed with which
red blood cells cling together, fall, and settle in the bottom of a glass tube within
60 minutes. It is used to detect inflammatory, neoplastic, infectious, and necrotic
processes. When inflammation is present, the higher the rate, the greater the amount
of inflammation. Normal range: male = up to 15 millimeters per hour (mm/h);
female = up to 20 mm/h.
∙ Hematocrit (HCT): This test identifies the percentage of RBCs, which is used to
identify anemia. Low counts may indicate bone marrow damage or vitamin defi-
ciency, while high counts may indicate congenital heart disease, renal problems, or
pulmonary disease. Normal range: 34%–45%.
∙ Hemoglobin (Hgb): This test measures oxygen being carried by the RBCs. Low
counts may indicate bone marrow damage or vitamin deficiency, while high counts
may indicate congenital heart disease, renal problems, or pulmonary disease. Nor-
mal range: 11.5–15.5 grams per deciliter (g/dL).

CHAPTER 27  | 
 Mon Mar 31 10:10:27 2020

Augusta, GA. Oriando, Tampa, FL

Tel: Tel: Tel:
L A B O R ATO R I E S Fax: Fax: Fax:

Patient: Collecting Time: 03/26/20 08:27 PHYSICIAN P96

DOB: Age: Yrs Sex: Log in DT/TM: 03/27/20 00:57 550
PID: Report DT/TM: 03/27/20 05:02
Phone: Reprint DT/TM: 03/31/20 10:07
Episode: FASTING: Y Priority: R Physician:
Notes:
Copy to:

TEST NAME RESULT UNITS REF RANGE LAB

COMPREHENSIVE METABOLIC PANEL WITH eGFR ORL

Sodium 139 mEq/L (133–146)
Potassium 3.9 mEq/L (3.5–5.4)
Chloride 101 mEq/L (97–110)
Carbon Dioxide 31 mEq/L (21–33)
Anion Gap 7.0 mEq/L (5.0–15.0)
Glucose 96 mg/dL (65–100)
BUN 11 mg/dL (8–25)
Creatinine 0.64 mg/dL (0.6–1.4)
eGFR African American 113 mL/min (>60)
eGFR Non-African Am. 98 mL/min (>60)
BUN/Creatinine Ratio 17 (6–28)
Calcium 9.3 mg/dL (8.2–10.6)
Total Protein 7.2 g/dL (6.0–8.3)
Albumin 4.5 g/dL (3.5–5.7)
Globulin 2.7 g/dL (1.6–4.2)
A/G Ratio 1.7 (0.9–2.5)
Bilirubin Total 0.5 mg/dL (0.1–1.30
Alkaline Phosphatase 87 U/L (35–126)
AST (SGOT) 17 U/L (5–43)
ALT (SGPT) 11 U/L (7–56)

TSH 4.199 ulU/mL (0.550–4.780) ORL

Free T4 1.16 ng/dL (0.89–1.76) ORL

LIPID PANEL
Cholesterol H 243 mg/dL (80–199)
Triglycerides 188 mg/dL (30–150)

CPT © 2017 American Medical Association. All rights reserved.

HDL Cholesterol 55 mg/dL (40–110)
LDL Cholesterol Calc 141 mg/dL (30–130)
VLDL Cholesterol Calc 28 mg/dL (10–60)
Risk Ratio (CHOL/HDL) 3.6 Ratio (0.0–5.0)
Non-HDL Cholesterol 145 mg/dL

Cholesterol/HDL Ratio Interpretation:

Gender CVD Risk Category
Female
Average Risk 4.4
Twice Average Risk 71

Printed at:03/31/20 10:07 “CONTINUED REPORT”

FIGURE 27-2  Pathology report showing a list of all of the individual blood tests run for the patient, including
results and reference ranges

836   PART III  |  REPORTING PHYSICIAN SERVICES AND OUTPATIENT PROCEDURES

 ∙ Mean corpuscular hemoglobin (MCH): This test measures the amount of hemo-
globin in RBCs. A low number may indicate an iron deficiency, whereas a high
number may indicate a vitamin deficiency. Normal range: 27–34 picograms (pg).
∙ Mean corpuscular volume (MCV): This test identifies the average size of the RBCs.
Small size may indicate an iron deficiency, whereas a large reading may indicate a
vitamin deficiency. Normal range: 80–100 femtoliters (fL).
∙ Partial thromboplastin time (PTT): This test measures factors I (fibrinogen), II
(prothrombin), V, VIII, IX, X, XI, and XII. Inadequate quantities of these factors
cause the PTT to be prolonged, a delay in the clotting of the blood that increases the
opportunity for the patient to hemorrhage. Normal PTT: 60–70 seconds.
∙ Platelet count: Low platelet counts can indicate a clotting disorder, putting the
patient at risk for hemorrhage. Low levels may indicate pernicious anemia, lupus,
or a viral infection, while high levels may identify leukemia. Normal range: 150–
400 thousand per microliter (K/mcL).
∙ Potassium: This test measures levels of potassium in the blood. Low potassium
levels can cause muscle cramps and/or weakness; abnormal levels (too high or low)
can result in an abnormal heartbeat. Low levels can identify use of corticosteroids
or diuretics, while high levels may signify kidney failure, diabetes, or Addison’s
disease. Normal range: 3.7–5.2 milliequivalents per liter (mEq/L).
∙ Prothrombin time (PT): This test evaluates the clotting ability of factors I (fibrino-
gen), II (prothrombin), V, VII, and X. Low quantities of these clotting factors result
in a prolonged PT. PT results include the use of the international normalized ratio
(INR) value as well as absolute numbers. Normal PT result: 85%–100% in 11–12.5
seconds and an INR of 0.8–1.1.
∙ Sodium: This test determines if the balance between sodium and liquid in the
blood is at the correct proportion. Low levels of sodium can identify the use of
diuretics or adrenal insufficiency, while high levels may indicate dehydration or
kidney dysfunction. High levels of sodium can lead to hypertension. Normal range:
136–144 mEq/L.

CPT
YOU CODE IT! CASE STUDY
Rosalyn Alvarez, an 84-year-old female, complained to Dr. Files that she was having severe cramps in her legs and
hands. She said it has been getting worse the last few months. In Rosalyn’s chart, it notes that she has been on
diuretics, so Dr. Files orders blood work to quantify her creatinine levels to check on her kidney function. Thelma
Brooks, RN, performed the venipuncture and sent the blood specimen to the lab.
CPT © 2017 American Medical Association. All rights reserved.

You Code It!

Determine the code for the pathology lab testing Rosalyn’s blood to quantify the potassium levels.
Step #1: Read the case carefully and completely.
Step #2: Abstract the scenario. Which key words or terms describe what service the physician provided to the
patient during this encounter?
Step #3: Are there any details missing or incomplete for which you would need to query the physician? [If so,
ask your instructor.]
Step #4: Determine the correct CPT procedure code or codes to explain the details about what was provided
to the patient during this encounter.

(continued)

CHAPTER 27  | 
 Step #5: Check for any relevant guidance, including reading all of the symbols and notations.
Step #6: Do you need to append any modifiers to ensure complete and accurate information is provided?
Step #7: Double-check your work.
Answer:
Did you determine this to be the code?
82565   Creatinine; blood
Good job!

GUIDANCE 27.5  Clinical Chemistry

CONNECTION The lab tests that are most commonly performed use chemical processes to distinguish
qualities and quantities of elements in the specimens provided. Typically, the speci-
Read the additional
mens are samples of a patient’s blood or urine. Tests with which you might be familiar
explanations in the
include the following:
in-section guidelines
located within the ∙ Blood glucose (sugar) is used to diagnose conditions such as diabetes mellitus
Pathology and (hyperglycemia) or hypoglycemia.
Laboratory section, sub-
head Chemistry, directly ∙ Electrolytes are used to diagnose metabolic or kidney disorders.
above code 82009 in ∙ Enzymes can be released into the bloodstream by a damaged or diseased organ.
your CPT book. The presence of creatine kinase can indicate damage after a heart attack, or
amylase and lipase elevations may be a sign of cancer of the pancreas and/or
pancreatitis.
∙ Hormones, such as cortisol, in quantities too high or too low might indicate the
malfunction of the patient’s adrenal glands.
∙ Lipids (fatty substances) can signal coronary heart disease or liver disease.
∙ Metabolic substances, such as uric acid, at incorrect levels can identify the pres-
ence of gout.
∙ Proteins identified at the wrong levels on electrophoresis can point to malnutrition
or certain infections.

Many tests can be easily performed in the physician’s office with a small amount

CPT © 2017 American Medical Association. All rights reserved.

of blood or urine. Companies have created kits that make measuring such elements as
simple as dipping a little slip of special paper into the patient’s specimen. It means that
you have a much greater opportunity to code any number of tests.

CPT
YOU CODE IT! CASE STUDY
Charles Endicott, a 31-year-old male, is an up-and-coming stockbroker who does not pay much attention to a proper
diet. He came to see his physician, Dr. Falacci, because he has been experiencing episodes of light-headedness.
Dr. Falacci asks his assistant, Carla Falco, to do a quantitative blood glucose test. Carla takes a blood sample, goes
to the back, and checks the specimen. The results indicate that Charles has hypoglycemia.

838   PART III  |  REPORTING PHYSICIAN SERVICES AND OUTPATIENT PROCEDURES

 You Code It!
Go through the steps, and determine the pathology/lab code(s) that should be reported for this encounter.
Step #1: Read the case carefully and completely.
Step #2: Abstract the scenario. Which key words or terms describe what service the physician provided to the
patient during this encounter?
Step #3: Are there any details missing or incomplete for which you would need to query the physician? [If so,
ask your instructor.]
Step #4: Determine the correct CPT procedure code or codes to explain the details about what was provided
to the patient during this encounter.
Step #5: Check for any relevant guidance, including reading all of the symbols and notations.
Step #6: Do you need to append any modifiers to ensure complete and accurate information is provided?
Step #7: Double-check your work.
Answer:
Did you determine this to be the correct code?
82947   Glucose; quantitative, blood (except reagent strip)
Good work!

27.6  Molecular Diagnostics

Molecular diagnostic tests investigate infectious disease, oncology concerns (malig-
nant neoplasms), hematology (the study of blood and its disorders), neurology, and
inherited disorders (genetics).
Specifically, genetic testing involves the analysis of specimens to identify any pres-
ence of a genetic disorder. Research and technology have developed testing method-
ologies for more than 2,000 diseases that can be performed to provide peace of mind,
or early detection of diseases and conditions that are passed from parents to child via
their genes.
The ability for parents-to-be to determine if they have any conditions that might
be passed on to their future children has been found to be an important part of family
planning. After conception, embryos and fetuses can be tested to reassure parents, to
enable physicians to treat some conditions in utero, or to enable the family to be pre- GUIDANCE
CPT © 2017 American Medical Association. All rights reserved.

pared with accommodations before the baby arrives.

CONNECTION
Adults with a family or personal history of a genetic disorder may be tested to pro-
vide the option for preventive health care services or treatment as early as possible. Read the additional
explanations in the
Pharmacogenomic Testing in-section guidelines
located within the
Physicians are trained to determine the correct medication and dosage to prescribe for Pathology and
their patients based on several factors, including age, weight, personal history, gen- Laboratory section,
eral health, and allergies/sensitivities. In recent years, researchers have discovered that subhead Molecular
an individual’s genes may also affect the efficacy of a specific drug, explaining why Pathology, on the
one version of a drug may really help one patient while having no or little benefit to pages directly before
another. Evolving from these discoveries has been the development of pharmacoge- code 81170 in your
nomic tests to provide specific information that will assist the physician with a more CPT book.
accurate and effective prescription.

CHAPTER 27  | 
 CPT
YOU CODE IT! CASE STUDY
Parker Thomasini, a 4-year-old male, has a cousin who was diagnosed with cystic fibrosis last year. Recently, he has
been wheezing and has a dry, nonproductive cough. The fact that his cousin has cystic fibrosis means that Parker
has a 25% chance of carrying the disease. Therefore, Dr. Preston ordered a molecular diagnostic test for the muta-
tion of delta F 508 deletion in his DNA by sequencing, single segment.

You Code It!

Go through the steps, and determine the pathology/lab code(s) that should be reported for this encounter.
Step #1: Read the case carefully and completely.
Step #2: Abstract the scenario. Which key words or terms describe what service the physician provided to the
patient during this encounter?
Step #3: Are there any details missing or incomplete for which you would need to query the physician? [If so,
ask your instructor.]
Step #4: Determine the correct CPT procedure code or codes to explain the details about what was provided
to the patient during this encounter.
Step #5: Check for any relevant guidance, including reading all of the symbols and notations.
Step #6: Do you need to append any modifiers to ensure complete and accurate information is provided?
Step #7: Double-check your work.
Answer:
Did you determine this to be the correct code?
81220  CFTR (cystic fibrosis transmembrane conductance regulator) (e.g., cystic fibrosis) gene
analysis; common variants (e.g., ACMG/ACOG guidelines)
Good job! 

GUIDANCE 27.7  Immunology, Microbiology,

CONNECTION and Cytopathology
Read the additional Immunology
explanations in the
in-section guidelines Immunology is the study of the body’s immune system—how it works and what can
located within the go wrong. Immunologic tests identify problems that may occur when a disease causes
CPT © 2017 American Medical Association. All rights reserved.
Pathology and Labora- the body’s defense system to attack itself (called an autoimmune disease) or when a
tory section, subhead disease causes a malfunction of the body’s immune system (called an immunodefi-
Microbiology, directly ciency disorder). The tests can also evaluate the compatibility of tissues and organs for
above code 87003 in transplantation.
your CPT book. Conditions and diseases that you may be familiar with, which fall into this cate-
gory, include rheumatoid arthritis, allergies, and, of course, human immunodeficiency
virus (HIV).

CPT
LET’S CODE IT! SCENARIO
Nigel Winthrope, a 19-year-old male, was diagnosed with hemophilia many years ago. As a result of a blood trans-
fusion, he contracted HIV. He has come today for lab work to check on his T-cell count, an indicator of whether the
HIV is progressing.

840   PART III  |  REPORTING PHYSICIAN SERVICES AND OUTPATIENT PROCEDURES

 Let’s Code It!
Nigel is having a test to determine the count of T cells in his blood. Let’s turn to the Alphabetic Index to the
letter T.
Are you surprised at the many listings with T cell in the heading? Read through them all carefully. Remember
that Nigel does not have leukemia; he has HIV. Keep going down the list to T Cells, under which you see Count,
with the suggested code 86359.
The complete code description in the numeric listing shows us
86359   T cells; total count
Good job!

Microbiology
Microbiologic tests use many different methods to study bacteria, fungi, parasites,
and viruses. The specimens used in the tests might be blood, urine, sputum (mucus,
also called phlegm), feces (stool), cerebrospinal fluid (CSF), and other bodily fluids.
Blood cultures are used to diagnose bacterial infections of the blood, sputum cultures
can identify respiratory infections like pneumonia, and stool cultures can confirm the
presence of pinworms and other parasites.
Code descriptions in this subsection may include some specific terms, such as
∙ Presumptive identification. This is the pathologic identification of colony morphol-
ogy; growth on selective media (such as a culture or slide); gram stains; or other
tests such as catalase, oxidase, indole, or urease. For example: 87081 Culture, pre-
sumptive, pathogenic organisms, screening only.
∙ Definitive identification. This is the pathologic identification of the genus or spe-
cies that requires additional testing, such as biochemical panels or slide cultures.
For example: 87106 Culture, fungi, definitive identification, each organism, yeast.

CPT
LET’S CODE IT! SCENARIO
Sally Tong, a 5-year-old female, went to a picnic at the park with her playgroup and had a hamburger, cooked very
rare. Later that evening, her parents rushed her to the hospital because she was vomiting and had severe diarrhea.
Dr. Warner ordered an infectious agent antigen enzyme immunoassay for E. coli O157. Fortunately, the test was
negative, and it turned out that she just had eaten too much ice cream and milk.
CPT © 2017 American Medical Association. All rights reserved.

Let’s Code It!

Dr. Warner ordered “an infectious agent antigen enzyme immunoassay” for Sally to determine if she was suf-
fering from Escherichia coli (E. coli). Let’s go to the Alphabetic Index to immunoassay and find infectious agent
below it, with the suggested codes 86317–86318, 87449–87451. Let’s go to the numeric listings and read the
complete code descriptions.
86317  Immunoassay for infectious agent antibody, quantitative, not otherwise specified (For
immunoassay techniques for antigens, see 83516, 83518, 83519, 83520, 87301–87450,
87810–87899)
The code description states antibody, but the notes say antigen. Luckily, the CPT book is guiding you via the
parenthetical notation below the code description, which directs you to a long list of codes. The descriptions for

(continued)

CHAPTER 27  | 
 83516, 83518, 83519, and 83520 do not come any closer to Dr. Warner’s notes. Let’s turn to the next set of
suggested codes:
87301  Infectious agent antigen detection by immunoassay technique (eg. enzyme immunoassay
[EIA], enzyme-linked immunosorbent assay [ELISA], immunochemiluminometric assay [IMCA]),
qualitative or semiquantitative, multiple-step method; adenovirus enteric types 40/41
Read down the list a little farther:
87335    Escherichia coli O157
When you read the complete description, you get the following:
87335  Infectious agent antigen detection by immunoassay technique (eg. enzyme immunoassay
[EIA], enzyme-linked immunosorbent assay [ELISA], immunochemiluminometric assay [IMCA]),
qualitative or semiquantitative, multiple-step method; Escherichia coli O157
Sometimes, even with the CPT book pointing at codes, it may take a lot of reading to be certain you have the
best, most appropriate code.

Cytopathology and Cytogenetic Studies

Cytology Cytology is the study of one cell at a time to discover abnormal cells present in tissue
The investigation and identifi- or bodily fluids. Cytologic testing is used to detect cancer cells and infectious organ-
cation of cells. isms and to screen for fetal abnormalities.
Specimens used in cytopathologic testing are obtained by fine-needle aspirations
(as in amniocentesis), scraping of tissue surfaces (as in Pap smears), and collection of
bodily fluids (as with sputum or seminal fluid, or sperm).

CPT
LET’S CODE IT! SCENARIO
Rosalie Panesca, a 47-year-old female, came to see Dr. Sizemore for her annual well-woman checkup. In addition to
the examination, Dr. Sizemore took a Pap smear, to be examined using the Bethesda reporting system with manual
screening. Rosalie’s examination showed she was completely healthy.

Let’s Code It!

Dr. Sizemore took a smear of tissue for a cytopathologic examination of Rosalie’s cervical cells using the
Bethesda reporting system.
Let’s go to the Alphabetic Index to cytopathology, smears, cervical or vaginal, with the suggested codes

CPT © 2017 American Medical Association. All rights reserved.

88141–88167 and 88174–88175. However, in this case, you can also go to Pap smears and see the sug-
gested codes 88141–88155, 88164–88167, and 88174–88175. Note that there is a difference: Codes 88160,
88161, and 88162 are not included in the listing under Pap smears. Let’s go to the Main Section and read the
complete code descriptions.
Before you begin reading all the code descriptions, read the paragraph of instructions directly before code
88141. You will note that these instructions tell you to “Use codes 88164–88167 to report Pap smears that are
examined using the Bethesda System of reporting.” That saves you quite a lot of time. Reading that one small
paragraph directs you to the four best codes:

88164 Cytopathology, slides, cervical or vaginal (the Bethesda System); manual screening under
physician supervision
88165 Cytopathology, slides, cervical or vaginal (the Bethesda System); with manual screening
and rescreening and under physician supervision

842   PART III  |  REPORTING PHYSICIAN SERVICES AND OUTPATIENT PROCEDURES

 88166 Cytopathology, slides, cervical or vaginal (the Bethesda System); with manual screening
and computer-assisted rescreening under physician supervision
88167 Cytopathology, slides, cervical or vaginal (the Bethesda System); with manual screening and
computer-assisted rescreening using cell selection and review under physician supervision
Which of these four codes most accurately describes the pathology test done for Rosalie? No rescreening or
computer-assisted rescreening is documented. This means the most accurate code for this test is

88164 Cytopathology, slides, cervical or vaginal (the Bethesda System); manual screening under
physician supervision
Great job!

27.8  Surgical Pathology

When a biopsy is taken during a surgical procedure (or is the surgical procedure itself),
the specimen is sent to the lab for testing. The testing, typically performed immedi-
ately upon receipt from the OR, is called surgical pathology. Its purpose, much like Surgical Pathology
that of other testing and studies, is to provide the information necessary to diagnose a The study of tissues removed
disease or condition and to set forth a treatment plan. In such cases, all the steps (tak- from a living patient during a
ing the specimen, testing, diagnosis, and treatment) may occur during one surgical surgical procedure.
session. The benefit of this quick and immediate process is that there is less trauma
for the patient, who has to undergo anesthesia and an invasive procedure only once. In
addition, it saves money for the patient, the facility, and the third-party payer.
Codes 88300–88309 represent six levels of surgical pathologic testing. The codes
include accession, the testing itself, and the written report from the pathologist. The
codes (with the exception of 88300) also include both gross examination (also known Gross Examination
as macroscopic examination) of the specimen and microscopic examination. The visual study of a speci-
The first level, code 88300, is applicable for any and all specimens that are exam- men (with the naked eye).
ined only by visual, or gross, examination. It means that the sample has not been Microscopic Examination
looked at under a microscope. The study of a specimen
using a microscope (under
88300   Level I—Surgical pathology, gross examination only
magnification).
Codes 88302–88309 recognize the various amounts of work required by the pathol-
ogist or physician doing the examination to determine the accurate condition of the
specimen. Don’t worry—you don’t have to study pathology to decide which level to
GUIDANCE
use properly to represent the work done. Each code level is determined by the anatomi- CONNECTION
CPT © 2017 American Medical Association. All rights reserved.

cal site from where the specimen was taken. Under each, the sites are listed in alpha- Read the additional
betic order. However, you have to know what happened in the OR to find the correct explanations in the
code because that will change the level involved. in-section guidelines
located within the
Reading the Lab Report Pathology and Labora-
tory section, subhead
You may find a report, such as the one shown in Figure 27-3, that shows the results of
Surgical Pathology,
the surgical pathology along with the pathologist’s interpretation.
directly above code
The physician’s operative report may state a tissue biopsy was taken; however,
88300 in your
you may need more details from the pathologist’s report so you can code this accu-
CPT book.
rately. Remember, when you are reporting a code or codes from the Pathology and
Laboratory section of CPT, you are reporting for the pathologist, not the surgeon.
The code from the Surgery section of CPT will report the collection of the specimen,
while the code from the Pathology and Laboratory section will report the testing of
the specimen.

CHAPTER 27  | 
 HILL MCGRAW PATHOLOGY LABORATORIES INC.
Warren R. Mulford, MD,. Director
123 Learning Way • Academia, FL 12345

PATIENT INFORMATION PHYSICIAN INFORMATION

Name: NICOLE GABRINI JOSE MARKETTEN, MD
Sex: Female 456 Healing Lane
D.O.B: 09/07/01 Suite 505
Patient ID: 55899 Academia, FL 12345
Patient Phone: 555-456-5555 555-399-5555

SPECIMEN INFORMATION

COLLECTED: 04/29/16 Accession # IF_16_6971

Reported: 05/01/16 Other Accession (IC):
Received: 04/30/16
PATHOLOGY REPORT

CLINICAL INFORMATION

A. Right upper extremity—Scabies vs Eczema

B. Left lower extremity—Scabies vs Eczema
C. Right lower extremity—Scabies vs Eczema
Terrell Rodriguez, PA-C

SPECIMEN DATA

GROSS DESCRIPTION:
A. The specimen is a punch biopsy received in immunofluorescence transport medium that measures 0.1 × 0.4 × 0.1 cm. The
specimen is flash frozen and multiple 4 micron sections are cut for manual immunofluorescence staining. The sections are
probed with fluorescein labeled antihuman antibodies against IgG, IgA, IgM, C3, C5b-9, and fibrinogen.
B. Received is a 0.2 cm punch biopsy of skin, submitted complete. The specimen is received in formalin.
C. Received is a 0.2 cm punch biopsy of skin, submitted complete. The specimen is received in formalin.
MICROSCOPIC DESCRIPTION:
All positive and negative controls stained appropriately as required.

RESULTS
DIAGNOSIS:
A. DIRECT IMMUNOFLUORESCENCE, RIGHT UPPER EXTREMITY—NEGATIVE (See Note)
Note: There is no IgG, IgA, IgM, C3, C5b-9, and fibrinogen deposition seen in this specimen. There is no immunofluorescence
evidence of connective tissue, vasculitis, dermatitis herpetiformis, porphyria cutanea tarda, pseudoporphyria, or autoimmune
blistering disease; however, clinical histologic and, if pertinent, serologic correlation is recommended. Multiple immunoreactant
dilutions and sections were performed.
B. PUNCH BIOPSY, LEFT LOWER EXTREMITY—STASIS ECZEMA, TRAUMATIZED AND IMPETIGINIZED

CPT © 2017 American Medical Association. All rights reserved.

Note: PAS is negative for fungus. Multiple deepersections have been reviewed and no mite or mite elements identified. There is
an impetiginized ulcer with bacterial colonization of the stratum corneum containing neutrophils and serum exudate. The papillary
dermis contains a capillary proliferation, a few neutrophils, rare eosinophils and dermal cicatrix. These histopathologic features
are consistent with traumatized and impetiginized stasis eczema. There is no evidence of scabies.
C. PUNCH BIOPSY, RIGHT LOWER EXTREMITY—STASIS ECZEMA, TRAUMATIZED AND IMPETIGINIZED Note: PAS is negative for
fungus. Multiple deeper sections have been reviewed and no mite or mite elements identified. There is an impetiginized ulcer
with bacterial colonization of the stratum corneum containing neutrophils and serum exudate. The papillary dermis contains a
capillary proliferation, a few neutrophils, rare eosinophils and dermal cicatrix. These histopathologic features are consistent with
traumatized and impetiginized stasis eczema. There is no evidence of scabies.

Dermatopathologist (electronic signature)

FINAL REPORT

FIGURE 27-3  Sample pathology report showing details and analysis of a surgical specimen

844   PART III  |  REPORTING PHYSICIAN SERVICES AND OUTPATIENT PROCEDURES

 CPT
YOU CODE IT! CASE STUDY
Hildy French, an 11-year-old female, was taken to the OR to have her tonsils removed. However, due to addi-
tional symptoms, Dr. Anachino did a biopsy and sent a specimen of Hildy’s tonsils to the lab for surgical pathologic
examination. The report came back from the lab that Hildy had a malignant neoplasm of her tonsils. Dr. Anachino
surgically removed additional sections to be certain that the entire tumor had been removed. Hildy tolerated the
procedure well and was taken to the recovery room.

You Code It!

Go through the steps, and determine the pathology/lab code(s) that should be reported for this encounter.
Step #1: Read the case carefully and completely.
Step #2: Abstract the scenario. Which key words or terms describe what service the physician provided to the
patient during this encounter?
Step #3: Are there any details missing or incomplete for which you would need to query the physician? [If so,
ask your instructor.]
Step #4: Determine the correct CPT procedure code or codes to explain the details about what was provided
to the patient during this encounter.
Step #5: Check for any relevant guidance, including reading all of the symbols and notations.
Step #6: Do you need to append any modifiers to ensure complete and accurate information is provided?
Step #7: Double-check your work.
Answer:

Did you determine this to be the correct code?

88305   Level IV; Tonsil, Biopsy
Good work!

Pathologic Testing on Bone Marrow

Medical Necessity for Bone Marrow Testing
Although not performed as commonly as blood tests or urinalysis (because obtain-
CPT © 2017 American Medical Association. All rights reserved.

ing the specimen is complex), pathologic examination of a patient’s bone marrow has
many possible uses, including:
∙ To serve as a diagnostic tool for suspected myeloma, leukemia, myelodysplastic
syndromes, and myeloproliferative disorders.
∙ To assess a current diagnosis of thrombocytopenia, anemia, or leukopenia.
∙ To measure quantities of stored iron and marrow cellularity.
∙ To determine neoplasm, infection, fibrosis, or other infiltrative bone disease.
∙ To enable staging of lymphoma and/or other malignant neoplasms.
A patient may have abnormal blood counts for which an explanation has yet to be
identified, or the patient may have other abnormal cells evidenced in circulating
blood. These, as well as a current diagnosis of a bone marrow–related disease (such
as lymphoma) or indications that a malignancy has metastasized into the marrow, are
standard-of-care justifications to obtain and study a bone marrow specimen.

CHAPTER 27  | 
 Collection of the Specimen
Typically, the specimen is taken from the posterior superior iliac spine of the pel-
vis to acquire a sampling of the blood-forming cells in the marrow space. Evaluation
of a specimen taken by biopsy is considered to be more accurate than one obtained
by aspiration because the quantity of material gathered is greater and therefore more
likely to provide a representative sampling of a wider scope.
When coding for bone marrow biopsy, the first procedure to be reported is for
obtaining the specimen, using either 38220 Bone marrow; aspiration only or 38221
Bone marrow, biopsy, needle or trocar.
Note that the abstraction of bone marrow from a patient is not performed solely for
the lab. Therefore, it is very important to identify, from the documentation, not only
how the bone marrow was taken but also for what purpose. For example, bone marrow
aspiration for platelet-rich stem cell injections are not reported with 38220 but with
code 0232T Injection(s), platelet-rich plasma, any site, including image guidance, har-
vesting and preparation when performed. Harvesting bone marrow for transplantation
is reported with either 38230 Bone marrow harvesting for transplantation; allogeneic
or 38232 Bone marrow harvesting for transplantation; autologous.
When both a bone marrow biopsy and a bone marrow aspiration are performed on
a Medicare beneficiary during the same encounter, do not report code 38220. Instead,
use code G0364 Bone marrow aspiration performed with bone marrow biopsy through
the same incision on the same date of service.

Pathologic Testing
Next, the specimen will be sent to the laboratory for analysis. A bone marrow speci-
men, obtained by either biopsy or aspiration, can enable a hematologist/pathologist to
investigate the patient’s hematopoiesis (the process of forming blood cells), as well as
the shape, size, and quantity of red and white blood cells and megakaryocytes (very
large bone marrow cells that produce blood platelets). Blood cell formation is primar-
ily the responsibility of the red bone marrow, specifically in the sternum, ribs, and
iliac bones (pelvis).
Code 88305 Level IV Surgical pathology, gross and microscopic examination reports
both evaluation of the bone marrow biopsy specimen by the naked eye (gross exami-
nation) and visualization of the specimen using a microscope. When the documenta-
tion states that the specimen was obtained by aspiration, instead of 88305, the analysis
is reported with 85097 Bone marrow; smear interpretation.
It is not uncommon for a decalcification procedure and/or iron staining to be per-
formed at the same time as the surgical pathologic examination. When documenta-
tion confirms this, report these procedures separately using 88311 Decalcification
procedure (list separately in addition to code for surgical pathology examination) and/
or 88313 Special stain including interpretation and report; Group II, all other (e.g., iron,
trichrome) except stain for microorganisms, stains for enzyme constituents, or immuno-
cytochemistry and immunohistochemistry. CPT © 2017 American Medical Association. All rights reserved.
Per CPT parenthetical instruction, you should report one unit of 88313 for each
special stain on each surgical pathologic block, cytologic specimen, or hematologic
smear. Check documentation or query the pathologist performing the testing to ensure
that the notes are clear as to how many blocks, specimens, or smears are tested so that
you can report the accurate number of codes.
Immunophenotyping by flow cytometry provides the identification of cell-specific
antibodies, enabling a more accurate determination of cell percentages as well as iden-
tification of abnormal cell patterns. Report this test using 88184 Flow cytometry, cell
surface, cytoplasmic, or nuclear marker, technical component only; first marker and
88185 each additional marker, as appropriate.
Because 88184 and 88185 are specifically limited to the technical component
only, you will need a code to report the interpretation service separately. Note that no

846   PART III  |  REPORTING PHYSICIAN SERVICES AND OUTPATIENT PROCEDURES

 modifiers (neither TC nor 26) are necessary because these details are already included
in the code descriptors, as follows:

88187   Flow cytometry, interpretation; 2 to 8 markers

88188 Flow cytometry, interpretation; 9 to 15 markers
88189 Flow cytometry, interpretation; 16 or more markers

Fluorescent in situ hybridization (FISH) analysis (88365 In situ hybridization [eg,

FISH], per specimen; initial single probe stain procedure) is usually performed after the
analysis of the bone marrow, the results of which will direct the specific DNA probes
to be conducted. FISH analysis is better than an overall karyotype test because it can
find smaller pieces of chromosomes that may be missing or may have extra copies.

CPT
YOU CODE IT! CASE STUDY
Danielle Lee, a 37-year-old female, has a history of chronic myeloid leukemia (CML) and came to our facility today
for a bone marrow aspiration, right side posterior iliac crest. Dr. Hansen used a 15-gauge needle to obtain the aspi-
rate including an aspirate clot. The patient tolerated the procedure well.

You Code It!

Part 1: Go through the steps of coding, and determine the code or codes that should be reported for this
encounter between Dr. Hansen and Danielle Lee.
Step #1: Read the case carefully and completely.
Step #2: Abstract the scenario. Which key words or terms describe what service the physician provided to the
patient during this encounter?
Step #3: Are there any details missing or incomplete for which you would need to query the physician? [If so,
ask your instructor.]
Step #4: Determine the correct CPT procedure code or codes to explain the details about what was provided
to the patient during this encounter.
Step #5: Check for any relevant guidance, including reading all of the symbols and notations.
Step #6: Do you need to append any modifiers to ensure complete and accurate information is provided?
Step #7: Double-check your work.
Answer:
Did you determine this to be the correct code for obtaining the bone marrow specimen?
CPT © 2017 American Medical Association. All rights reserved.

38220   Diagnostic bone marrow; aspiration(s)

Part 2: Dr. Uker, a certified pathologist, wrote this report after testing the bone marrow.
PATHOLOGY REPORT:
The following specimens were reviewed:
• peripheral smear of bone marrow aspirate and clot section
• iron stain
Determine the code or codes that should be reported for Dr. Uker.

(continued)

CHAPTER 27  | 
 Answer:
Did you determine these to be the correct codes for the pathology testing?

85097 Bone marrow; smear interpretation

88313 Special stain including interpretation and report; Group II, all other (e.g., iron, trichrome)
except stain for microorganisms, stains for enzyme constituents, or immunocytochemistry
and immunohistochemistry

27.9  Modifiers for Laboratory Coding

If your health care facility uses an outside laboratory that bills your office, you include
the charges for the lab work on the claim form that you file. In such instances, you
must append the CPT code for the lab test with modifier 90. If the outside lab bills the
patient’s insurance directly, you will not include the test code or modifier on the claim
form you submit.

90  Reference (Outside) Laboratory: When laboratory procedures are per-

formed by a party other than the treating or reporting physician, the pro-
cedure may be identified by adding modifier 90 to the usual procedure
number.

Also on occasion, you may find that a lab test has to be repeated, on the same day
for the same patient, in order to get several readings of a level or measurement. When
this is documented, append modifier 91:

91  Repeat Clinical Diagnostic Laboratory Test: In the course of treatment of

the patient, it may be necessary to repeat the same laboratory test on the
same day to obtain subsequent (multiple) test results. Under these circum-
stances, the laboratory test performed can be identified by its usual proce-
dure number and the addition of modifier 91. (Note: This modifier may not
be used when tests are rerun to confirm initial results; due to testing prob-
lems with specimens or equipment; or for any other reason when a normal,
one-time, reportable result is all that is required. This modifier may not be
used when other code[s] describe a series of test results [e.g., glucose toler-
ance tests, evocative/suppression testing]. This modifier may only be used
for laboratory test[s] performed more than once on the same day on the
same patient.) CPT © 2017 American Medical Association. All rights reserved.

The use of testing kits is increasing in health care facilities because they make
it easier to obtain fast, accurate results. When a testing kit is being used, append
modifier 92.

92  Alternative Laboratory Platform Testing: When laboratory testing is being

performed using a kit or transportable instrument that wholly or in part
consists of a single use, disposable analytical chamber, the service may
be identified by adding modifier 92 to the usual laboratory procedure
code (HIV testing 86701-86703, and 87389). The test does not require
permanent dedicated space, hence by its design may be hand carried or
transported to the vicinity of the patient for immediate testing at that site,
although location of the testing is not in itself determinative of the use of
this modifier.

848   PART III  |  REPORTING PHYSICIAN SERVICES AND OUTPATIENT PROCEDURES

 CPT
YOU CODE IT! CASE STUDY
Dr. Georges is implementing a new treatment protocol for Priscilla Roper. He ordered that qualitative urinalysis be
performed first thing in the morning, again at noon, and again at 5:00 p.m. Erline Cutter, RN, collected the specimens
from Priscilla’s catheter and sent them to the lab for each of the tests.

You Code It!

Review the scenario, and report the appropriate code or codes for the pathology lab’s work.
Step #1: Read the case carefully and completely.
Step #2: Abstract the scenario. Which key words or terms describe what service the physician provided to the
patient during this encounter?
Step #3: Are there any details missing or incomplete for which you would need to query the physician? [If so,
ask your instructor.]
Step #4: Determine the correct CPT procedure code or codes to explain the details about what was provided
to the patient during this encounter.
Step #5: Check for any relevant guidance, including reading all of the symbols and notations.
Step #6: Do you need to append any modifiers to ensure complete and accurate information is provided?
Step #7: Double-check your work.
Answer:

Did you determine this to be the code?

81005-91x3 Urinalysis; qualitative or semiquantitative, except immunoassays, repeat clinical diag-
nostic laboratory test, three tests

27.10  Pathology and Lab Abbreviations

Abbreviations for pathology and laboratory tests are used in reports from labs all over
the country. Some of the most common are shown in Table 27-1.

TABLE 27-1  Abbreviations and Acronyms for Most Common Diagnostic and
Laboratory Tests

ABG Arterial blood gases

CPT © 2017 American Medical Association. All rights reserved.

ACE Angiotensin-converting enzyme

ACT Activated clotting time
AFP Alpha-fetoprotein
A/G Albumin/globulin ratio
AIT Agglutination inhibition test
ALP Alkaline phosphatase
ALT Alanine aminotransferase
AMA Antimitochondrial antibody
ANA Antinuclear antibody

(continued)

CHAPTER 27  | 
 APTT Activated partial thromboplastin time
AST Aspartate aminotransferase
BASO Basophiles
BMC Bone mineral content
BMD Bone marrow density
BST Blood serologic test
BUN Blood urea nitrogen
CBC Complete blood count
CEA Carcinoembryonic antigen
CK Creatine kinase
CMV Cytomegalovirus
CO2 Carbon dioxide
CPK Creatine phosphokinase
DIC Disseminated intravascular coagulation
DIFF Differential
EIA Enzyme immunoassay
EOS Eosinophil count
ESR Erythrocyte sedimentation rate
FBS Fasting blood sugar
GTT Glucose tolerance test
HCT Hematocrit
HDL High-density lipoprotein
HGB Hemoglobin
HPF High-power field
INR International normalization ratio
LD Lactic dehydrogenase
LDL Low-density lipoprotein
LFT Liver function tests
LPF Low-power field
LYMPHS Lymphocytes CPT © 2017 American Medical Association. All rights reserved.

MCH Mean corpuscular hemoglobin

MCHC Mean corpuscular hemoglobin concentration
MCV Mean corpuscular volume
MONO Monocyte count
MPV Mean platelet volume
NEUT Neutrophils
PAP Prostatic acid phosphatase
PH Hydrogen ion concentration
PLT Platelet

850   PART III  |  REPORTING PHYSICIAN SERVICES AND OUTPATIENT PROCEDURES

 PSA Prostate-specific antigen
PT Prothrombin time
PTT Partial thromboplastin time
RBC Red blood cells
RDW Red cell distribution width
RF Rheumatoid factor
RPR Rapid plasma reagin test
SEGS Segmented neutrophils
SGOT Serum glutamicoxaloacetic transaminase
SGPT Serum glutamicpyruvic transaminase
SMA Sequential multiple analyzer
SP GRAV Specific gravity
STS Serologic test for syphilis
T&C Type and crossmatch
TSH Thyroid-stimulating hormone
UA Urinalysis
WBC White blood cell

Chapter Summary
Pathology and laboratory tests provide health care professionals with definitive evi-
dence as to the condition that may be interfering with a patient’s good health. That
proof will help direct the physician toward a more accurate diagnosis and a beneficial
treatment plan. Lab tests are an invaluable part of the health care toolbox and must be
coded accurately.

CODING BITES
Common Abbreviations Used in Pathology Testing
CPT © 2017 American Medical Association. All rights reserved.

PT = Prothrombin time, which is used to evaluate bleeding and clotting

disorders
CBC = Complete blood count, which includes the following tests:
WBC = White blood cell count
RBC = Red blood cell count
PLT = Platelet count, which is used to diagnose or monitor bleeding and
clotting disorders
HCT = Hematocrit
HGB = Hemoglobin concentration, which is the concentration of the
oxygen-carrying pigment in red blood cells
DIFF = Differential blood count
Remember that the CBC includes the WBC, RBC, HCT, HGB, platelet count, and
differential count. Therefore, you are not to code those tests separately.

CHAPTER 27  | 
 CHAPTER 27 REVIEW
CHAPTER 27 REVIEW

CPT Pathology & Lab Section Enhance your learning by

completing these exercises and
more at connect.mheducation.com!

Let’s Check It! Terminology

Match each key term to the appropriate definition.
1. LO 27.7  The investigation and identification of cells. A. Cytology
2. LO 27.2  The counting or measurement of something. B. Etiology
3. LO 27.8  The study of tissues removed from a living patient during a surgical C. Gross Examination
procedure. D. Laboratory
4. LO 27.8  The study of a specimen using a microscope (under magnification). E. Microscopic
5. LO 27.1  A location with scientific equipment designed to perform experiments Examination
and tests. F. Pathology
6. LO 27.1  The study of the nature, etiology, development, and outcomes of G. Qualitative
disease.
H. Quantitative
7. LO 27.8  The visual study of a specimen (with the naked eye).
I. Specimen
8. LO 27.1  The study of the causes of disease.
J. Surgical Pathology
9. LO 27.1  A small part or sample of any substance obtained for analysis and
diagnosis.
10. LO 27.2  The determination of character or essential element(s).

CPT
Let’s Check It! Concepts
Choose the most appropriate answer for each of the following questions.
1. LO 27.10  What is the correct abbreviation for a liver function test?
a. INR b.  LDL c.  LPF d.  LFT
2. LO 27.7  What code(s) would you assign for a blood compatibility test by incubation technique, 2 units?
a. 86920 b.  86921, 86921
c. 86921 d.  86922, 86921
3. LO 27.1  A specimen can be
a. blood. b.  urine.
CPT © 2017 American Medical Association. All rights reserved.

c. sputum. d.  all of these.
4. LO 27.3  When not all of the tests listed in a panel are performed, you should
a. code the panel with modifier 52.
b. code the panel alone.
c. code the tests individually.
d. code the panel with modifier 53.
5. LO 27.2  The guidelines tell you that, if the documentation does not specify, you may assume that the examina-
tion performed was _____.
a. qualitative b.  measured
c.  quantitative d.  none of these

852   PART III  |  REPORTING PHYSICIAN SERVICES AND OUTPATIENT PROCEDURES

 6. LO 27.5  The lab test most commonly performed using a chemical process to identify hyperglycemia uses

CHAPTER 27 REVIEW
a. hormones. b.  blood glucose.
c.  electrolytes. d.  lipids.
7. LO 27.9  What modifier would you append to a CPT code for a lab test that has to be repeated, on the same day
for the same patient, in order to get several readings of a level or measurement?
a. 99 b.  90 c.  92 d.  91
8. LO 27.4  This test identifies the percentage of RBCs, which is used to identify anemia.
a. BUN b.  ESR c.  Hgb d.  HCT
9. LO 27.8  Surgical pathology may include
a. gross examination.
b. microbiology.
c. genetic testing.
d. nuclear medicine.
10. LO 27.6  _____ testing involves the analysis of specimens to identify any presence of a genetic disorder.
a. Infectious
b. Oncology
c. Genetic
d. Hematology

Let’s Check It! Guidelines

Refer to the Pathology and Laboratory Guidelines and fill in the blanks accordingly.
multiple rarely same
definition technologists special
separate effort 85999
extent may physician

1. Services in Pathology and Laboratory are provided by a physician or by _____ under responsible supervision of a
_____.
2. It is appropriate to designate _____ procedures that are rendered on the _____ date by _____ entries.
3. Unlisted hematology and coagulation procedure is represented by code _____.
4. A service that is _____ provided, unusual, variable, or new _____ require a _____ report.
5. Pertinent information should include an adequate _____ or description of the nature, _____, and need for the pro-
CPT © 2017 American Medical Association. All rights reserved.

cedure; and the time, _____, and equipment necessary to provide the service.

Let’s Check It! Rules and Regulations

Please answer the following questions from the knowledge you have gained after reading this chapter.
1. LO 27.1  Differentiate between pathology and etiology.
2. LO 27.2  What is the difference between quantitative and qualitative?
3. LO 27.7  What is cytopathology? What is cytologic testing used for, and how are specimens obtained?
4. LO 27.8  What is the purpose and benefit of surgical pathology?
5. LO 27.9  If your health care facility uses an outside laboratory that bills your office, and you include the charges
for the lab work on the claim form, what modifier must you append?

CHAPTER 27  | 
CHAPTER 27 REVIEW

CPT

YOU CODE IT! Basics

First, identify the procedural main term in the follow- 7. Dr. Campos performs a HBsAg (hepatitis B sur-
ing statements; then code the procedure or service. face antigen) immunoassay test:
Example: Dr. Gleason performs a definitive drug test a. main term: _____ b. procedure: _____
for barbiturates: 8. Dr. Hearon performs a forensic necropsy:
a. main term: Drug Assay   b. procedure: 80345 a. main term: _____ b. procedure: _____
9. Dr. Busby completes a mature oocytes
1. Dr. McElory completes a drug monitoring of total
cryopreservation:
digoxin:
a. main term: _____ b. procedure:_____
a. main term: _____ b. procedure: _____
10. Dr. Klausing performs a blood cell count with
2. Dr. Gavin performs a bleeding time test:
automated differential WBC count:
a. main term: _____ b. procedure:_____
a. main term: _____ b. procedure: _____
3. Dr. Kaufmann completes a tuberculosis skin
11. Dr. Reilly completed a creatine kinase, total:
test:
a. main term: _____ b. procedure:_____
a. main term: _____ b. procedure: _____
12. Dr. Flemington performs a RPR syphilis test:
4. Dr. Lovece performs an HLA crossmatch test, first
dilution: a. main term: _____ b. procedure: _____
a. main term: _____ b. procedure: _____ 13. Dr. Jensen completes a CMV (cytomegalovirus)
antibody IgM:
5. Dr. Sox completes a blood typing compatibility
test by spin technique: a. main term: _____ b. procedure: _____
a. main term: _____ b. procedure:_____ 14. Dr. Vance performs a bilirubin, total; direct test:
6. Dr. Dickenson performs a urine bacterial culture a. main term: _____ b. procedure:_____
quantitative colony count: 15. Dr. Humphrey completes a direct Coombs test:
a. main term: _____ b. procedure:_____ a. main term: _____ b. procedure: _____

CPT

YOU CODE IT! Practice

Using the techniques described in this chapter, carefully read through the case studies and determine the most ac-
curate pathology and laboratory CPT code(s) and modifier(s), if appropriate, for each case study.
1. Walter Winegarten, a 42-year-old male, was feeling rundown and tired all the time. So, Dr. Stevenson, think-
ing that Walter might have anemia, ordered a complete CBC, automated with an automated differential WBC
count. CPT © 2017 American Medical Association. All rights reserved.

2. Deidra Lowe, a 23-year-old female, has been living on the street and in shelters and comes to the free clinic
for a checkup because she is 5 months pregnant. Dr. Ashton orders a complete CBC, automated and appro-
priate manual differential WBC count, hepatitis B surface antigen, rubella antibody, qualitative syphilis test,
RBC antibody screening, blood typing ABO, and Rh factor.
3. Vivian Praxis, a 3-year-old female, is at the office of her pediatrician, Dr. Ashley, for her regular checkup.
Dr. Ashley notices that Vivian is very small for her age and orders a growth hormone stimulation panel to be
done.
4. Jay Zeeman, a 36-year-old male, went to the shore with his friends and feasted on raw oysters and beer. About
7 hours later, after getting home, he began to cough and vomit, and he found blood in his stool. He went to
the walk-in clinic, where Dr. Lanahan ran a smear test for ova and parasites, particularly Anisakis.

854   PART III  |  REPORTING PHYSICIAN SERVICES AND OUTPATIENT PROCEDURES

 CHAPTER 27 REVIEW
5. Gregg Abernathy, a 41-year-old male, was diagnosed with prostate cancer last week. Before beginning
radiation treatments, which will make him unable to have children, he comes today to submit his sperm for
cryopreservation.
6. Rudy Porter, a 71-year-old male, has a history of gastrointestinal problems, including intestinal polyps. After
taking a special kit home, he submits fecal specimens for an occult blood test by immunoassay.
7. Tiffany Matheson, a 28-year-old female, just got a new job with the space industry. As a condition of her
employment, she came to the lab today for a presumptive drug test for alcohol, amphetamines, and barbitu-
rates. The test was performed and the results were read by direct optical observation; they confirmed negative
outcomes for all drugs.
8. Caitlyn Deloach, a 21-year-old female, was found unconscious by her roommate and brought into the emer-
gency department by ambulance. The roommate stated that Caitlyn was very depressed, and she feared that
Caitlyn might have taken an overdose of her medication. Dr. Leroy ordered a therapeutic drug assay for
phenobarbital.
9. Rulon Cutler, a 25-year-old male, is overweight, bordering on obese, and Dr. Jacobs is concerned that he may
be developing diabetes, so he orders an insulin tolerance panel for adrenocorticotropic hormone (ACTH)
insufficiency.
10. Shawn McCully, a 51-year-old female, goes to her physician, Dr. Kahlil, for her annual checkup, which
includes a nonautomated urinalysis with microscopy for glucose, ketones, and leukocytes. Dr. Kahlil’s assis-
tant, Donna, performs the test, by dipstick, in the office. The results are normal.
11. Margaret Calhoun, a 23-year-old female, got drunk at a party and had unprotected sex. She came into the
clinic today for an HIV-1 and HIV-2 single assay test.
12. At the doctor’s suggestion, Margaret Calhoun (previous scenario) was also tested for syphilis, qualitative
(VDRL).
13. Georgia Stuart, a 37-year-old female, is pregnant for the first time. Dr. Ferguson performed an amniocentesis
to do a chromosome analysis, count 15 cells, 1 karyotype, with banding. The results showed that the baby is
fine.
14. Sean Olin, a 61-year-old male, was in the operating room for Dr. Tanger to perform a subtotal resection of his
pancreas. Surgical pathology showed no malignancy.
15. Chad Snell, a 22-day-old male, was born at 33 weeks gestation, and there is concern that he may have hyper-
bilirubinemia. Therefore, Dr. Bateman performed a total transcutaneous bilirubin.

CPT
YOU CODE IT! Application
The following exercises provide practice in the application of abstracting the physicians’ notes and learning to work
with documentation from our health care facility, Millard Pathology & Diagnostic Labs. These case studies are
CPT © 2017 American Medical Association. All rights reserved.

modeled on real patient encounters. Using the techniques described in this chapter, carefully read through the case
studies and determine the most accurate pathology and laboratory CPT code(s) and modifier(s), if appropriate, for
each case study. You are coding for the pathologist.

MILLARD PATHOLOGY & DIAGNOSTIC LABS

753 LITTLE WEST RD • SOMEWHERE, FL 32811 • 407-555-9371

PATIENT: MEDFORD, ROBERT
ACCOUNT/EHR #: MEDFRO001
DATE: 10/17/18

CHAPTER 27  | 
CHAPTER 27 REVIEW

Procedure Performed: Comprehensive metabolic panel

Pathologist: Derrick Castel, MD
Referring Physician: Oscar R. Prader, MD
INDICATIONS: Routine physical exam
IMPRESSIONS:
Albumin 3.9
Bilirubin Small*
Calcium 8.9
Carbon dioxide (CO2) 28
Chloride 96 L C
Creatinine 1.2
Glucose 102
Phosphatase, alkaline 90
Potassium 3.9
Protein, total 30*
Sodium 138
Transferase, alanine amino (ALT) (SGPT) 30
Transferase, aspartate amino (AST) (SGOT) 29
Urea nitrogen (BUN) 18
* = Abnormal, L = Low, H = High

Derrick Castel, MD
DC/mg  D: 10/17/18 09:50:16  T: 10/20/18 12:55:01

Determine the most accurate pathology and laboratory CPT code(s) and modifiers, if appropriate.

MILLARD PATHOLOGY & DIAGNOSTIC LABS

753 LITTLE WEST RD • SOMEWHERE, FL 32811 • 407-555-9371 CPT © 2017 American Medical Association. All rights reserved.

PATIENT: INGER, TERRENCE

ACCOUNT/EHR #: INGETE001
DATE: 09/29/18
Procedure Performed: Tissue, skin, head, mutation identification
Pathologist: Peter Havner, MD
Referring Physician: Oscar R. Prader, MD
INDICATIONS: Suspected melanoma

856   PART III  |  REPORTING PHYSICIAN SERVICES AND OUTPATIENT PROCEDURES

 CHAPTER 27 REVIEW
IMPRESSIONS: Abnormal cells present, by surgical pathology, gross and microscopic examination

Peter Havner, MD
PH/mg  D: 09/29/18 09:50:16  T: 09/30/18 12:55:01

Determine the most accurate pathology and laboratory CPT code(s) and modifiers, if appropriate.

MILLARD PATHOLOGY & DIAGNOSTIC LABS

753 LITTLE WEST RD • SOMEWHERE, FL 32811 • 407-555-9371
PATIENT: WALLER, FELIX
ACCOUNT/EHR #: WALLFE001
DATE: 11/15/18
Procedure Performed: Surgical pathology, gallbladder, gross and microscopic examination
Pathologist: Peter Havner, MD
Referring Physician: Renee O. Bracker, MD
INDICATIONS: R/O malignancy
IMPRESSIONS: All tissues unremarkable
Surgical pathology, gross and microscopic examination of gallbladder

Peter Havner, MD
PH/mg  D: 11/15/18 09:50:16  T: 11/20/18 12:55:01

Determine the most accurate pathology and laboratory CPT code(s) and modifiers, if appropriate.

MILLARD PATHOLOGY & DIAGNOSTIC LABS

753 LITTLE WEST RD • SOMEWHERE, FL 32811 • 407-555-9371
PATIENT: DALTON, ANGELA
ACCOUNT/EHR #: DALTAN001
DATE: 09/23/18
CPT © 2017 American Medical Association. All rights reserved.

Procedure Performed: Rectal biopsies, gross and microscopic examination

Pathologist: Walter Alchemy, MD
Referring Physician: Matthew Appellet, MD
INDICATIONS: Inflammatory bowel disease
IMPRESSIONS: All tissues normal
    Surgical pathology, gross and microscopic examination, colon biopsy

Walter Alchemy, MD
WA/mg  D: 09/23/18 09:50:16  T: 09/25/18 12:55:01

Determine the most accurate pathology and laboratory CPT code(s) and modifiers, if appropriate.

CHAPTER 27  | 
CHAPTER 27 REVIEW

MILLARD PATHOLOGY & DIAGNOSTIC LABS

753 LITTLE WEST RD • SOMEWHERE, FL 32811 • 407-555-9371

PATIENT: PRIMERO, GINO
ACCOUNT/EHR #: PRIMGI001
DATE: 06/17/18
Procedure Performed: Mass (fat tissue), upper eyelid gross and microscopic examination
Pathologist: Derrick Castel, MD
Referring Physician: Renee O. Bracker, MD
INDICATIONS: Herniated orbital fat pad, OD
IMPRESSIONS: Carcinoma in situ
    Surgical pathology, gross and microscopic examination, soft tissue tumor, extensive
resection

Derrick Castel, MD
DC/mg  D: 06/17/18 09:50:16  T: 06/20/18 12:55:01

Determine the most accurate pathology and laboratory CPT code(s) and modifiers, if appropriate.

CPT © 2017 American Medical Association. All rights reserved.

858   PART III  |  REPORTING PHYSICIAN SERVICES AND OUTPATIENT PROCEDURES

 CPT Medicine Section
Learning Outcomes
After completing this chapter, the student should be able to:
LO 28.1 Interpret the guidelines for coding the administration of
28
Key Terms
immunizations. Ablation
LO 28.2 Apply the guidelines to accurately report injections and Catheter
infusions. Duplex Scan
LO 28.3 Determine the correct coding parameters for reporting psy- Immunization
chiatric services. Infusion
Injection
LO 28.4 Abstract physicians’ notes to accurately report dialysis and
Ophthalmologist
gastroenterology services. Optometrist
LO 28.5 Identify specifics to correctly report ophthalmology and oto- Otorhinolaryngology
rhinolaryngologic services. Push
LO 28.6 Determine how to accurately report cardiovascular services.
LO 28.7 Recognize the details required for accurately reporting pul-
monary function testing.
LO 28.8 Report accurately the provision of immunology services.
LO 28.9 Interpret the specifics for accurately reporting neurologic
services.
LO 28.10 Abstract the required details for reporting physical medical
and rehabilitation services.
LO 28.11 Employ the guidelines to accurately report alternative medi-
cine services: acupuncture, osteopathic, and chiropractic
treatments. GUIDANCE
LO 28.12 Abstract documentation for reporting special and other CONNECTION
services.
Read the additional
explanations in the
in-section guidelines
located within the Medi-
Remember, you need to follow along in cine section, subheads
ICD-10-CM
  STOP! your CPT code book for an optimal Immune Globulins,
learning experience. Serum, or Recombinant
CPT © 2017 American Medical Association. All rights reserved.

Products, directly above

code 90281; Immuni-
zation Administration
28.1  Immunizations for Vaccines/Toxoids,
directly above code
Immunizations, also known as vaccinations, are developed to train a patient’s immune
90460; and Vaccines,
system against a specific pathogen. Immunization sera work to build immune memory
Toxoids, directly above
by creating antibodies, similar to special forces, that are ready to battle should a spe-
code 90476, all in your
cific bacterium or virus invade. This system is designed to prevent, or at least limit,
CPT book.
the damage done by invading pathogens. Immunization of a patient includes two parts:
the medication itself and the administration of the medication. Each part is coded
separately. Immunization
The medication may be an immune globulin, an antitoxin, a vaccine, or a toxoid. To make someone resistant
Codes 90281–90399 and 90476–90749 are available for you to identify specific drugs. to a particular disease by
You must be diligent and read all of the options for the specific vaccines because there vaccination.
 may be several choices with small differences that are still important to accuracy. For
example, there are actually 23 different codes (90653–90688) to report an influenza
virus vaccine, each identifying a different version. The physician’s documentation
should provide you with the specifics you need to identify the version that was used. If
not, you must query so you can report the correct code.

CPT
LET’S CODE IT! SCENARIO
Phillip Landstone, a 21-year-old male, came in so Dr. Micah can administer a flu vaccine before he starts volunteer-
ing at Community Hospital. Dr. Micah documents that the vaccine was trivalent, split virus, 0.5 mL dosage, adminis-
tered IM.

Let’s Code It!

The documentation states that Dr. Micah administered a trivalent, split virus influenza vaccination to Phillip. Turn
to the CPT Alphabetic Index and find
Vaccination
Vaccine Administration
  See Immunization Administration
Vaccines and Toxoids
  See Vaccines and Toxoids
This is great! The Alphabetic Index is reminding you that, when reporting the administration of a vaccination
(or other injection), you will need two codes: one for the administration + one for the serum (what is inside that
syringe).
As long as you are here, let’s find the suggestion(s) for the serum—the influenza vaccine itself.
Vaccines and Toxoids
Read down the list until you find something that matches what you abstracted from the documentation. Do you
see . . .
Influenza
Read down the indented list below Influenza to find
Influenza
  Trivalent, Split Virus (IIV3)..................................90654-90658, 90660, 90673
   for Intradermal Use..................................................................................... 90654
   for Intramuscular Use...................................................................90655-90658
   with Increased Antigen Content.............................................................. 90662
The documentation states, “trivalent, split virus, administered IM.” This matches, so turn to the suggested codes

CPT © 2017 American Medical Association. All rights reserved.

to read the entire code descriptions.
90655 Influenza virus vaccine, trivalent (IIV3), split virus, preservative free, 0.25 mL dosage, for
intramuscular use
90656 Influenza virus vaccine, trivalent (IIV3), split virus, preservative free, 0.5 mL dosage, for intra-
muscular use
90657 Influenza virus vaccine, trivalent (IIV3), split virus, 0.25 mL dosage, for intramuscular use
90658 Influenza virus vaccine, trivalent (IIV3), split virus, 0.5 mL dosage, for intramuscular use
As you read these four code descriptions, you can see that there are two differences: preservative free or not
+ the dosage. There is no mention that the vaccine was preservative free, so this narrows down the options to
90657 and 90658. What was the dosage? The documentation states, “0.5 mL dosage.” Now, you can determine
the accurate code for this vaccine is
90658 Influenza virus vaccine, trivalent (IIV3), split virus, 0.5 mL dosage, for intramuscular use

860   PART III  |  REPORTING PHYSICIAN SERVICES AND OUTPATIENT PROCEDURES

 Now, you need to go back to the Alphabetic Index, this time to the main term “Immunization Administration.”
Immunization Administration
Each Additional Vaccine/Toxoid.................................90472, 90474
  with Counseling.........................................................................90461
One Vaccine/Toxoid.......................................................90471, 90473
  with Counseling.........................................................................90460
Dr. Micah documented only one vaccine was administered; there is no documentation of any counseling. Turn to
the Main Section to code 90471 so you can read the entire code description:
90471 Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramus-
cular injections); 1 vaccine (single or combination vaccine/toxoid)
90473 Immunization administration by intranasal or oral route; 1 vaccine (single or combination vac-
cine/toxoid)
Go back to the documentation to check what route of administration was used. The documentation states,
“administered IM.” IM is the abbreviation for intramuscular. This fact eliminates 90473 as an option, and you
know what code to report.
Good job! You now can report codes 90471 and 90658 for Dr. Micah’s service to Phillip with confidence!

If more than one vaccine was administered during the same encounter, there may be
a combination code available for those vaccinations that are typically provided together,
such as the MMR (Measles, Mumps, Rubella) or the DTaP (Diphtheria, Tetanus tox-
oids, and Acellular Pertussis vaccines). It is illegal to report these vaccines individually
if they are administered in a combination.
Medications can be given, or administered, to the patient in several different ways: per-
cutaneous, intradermal, subcutaneous (SC), or intramuscular (IM) injections; intranasal
(INH) or oral (ORAL); intra-arterial (IA) or intravenous (IV). The method of administra-
tion will help you find the correct administration codes 90460–90461 and 90471–90474.
When more than one vaccine is provided on the same date, use the add-on codes for
the administration of the additional injections. You will find that most of the codes are
offered in sets: the first injection, administration, or hour and then the add-on code for
each additional injection, administration, or hour.

CPT
LET’S CODE IT! SCENARIO
Isaac Nelson, a 5-year-old male, came to Dr. Rubino for his MMR vaccine so that he can start kindergarten next
CPT © 2017 American Medical Association. All rights reserved.

month. Dr. Rubino administered an injection subcutaneously. Dr. Rubino met face-to-face with Isaac’s mother and
discussed the importance of the vaccine, as well as indications of a reaction that she should watch for. Isaac chose
a red balloon as his prize for being a good patient.

Let’s Code It!

Dr. Rubino gave Isaac one subcutaneous injection of the MMR vaccine. Do you know what MMR stands for? Even
if you don’t know that it is an acronym for measles, mumps, and rubella, you can look it up in the Alphabetic Index
under MMR shots. The suggested code is 90707. The numeric listing confirms
90707 Measles, mumps, and rubella virus vaccine (MMR), live, for subcutaneous use
The description matches Dr. Rubino’s notes exactly. However, the code will reimburse Dr. Rubino’s office only
for the drug itself, not Dr. Rubino’s time and expertise in administering the injection and counseling the family.

(continued)
 You could go back to the Alphabetic Index, or you could read the instructional paragraph at the beginning of the
Vaccines, Toxoids subsection (where you found the code 90707). You will see that this paragraph tells you that
you must use these codes “in addition to an immunization administration code(s) 90460–90474.” Let’s turn to
the first code, 90460, and read the description:
90460 Immunization administration through 18 years of age via any route of administration, with
counseling by physician or other qualified health care professional; first or only component
of each vaccine or toxoid administered
90461  each additional vaccine or toxoid component administered (list separately in addition to
code for primary procedure)
Now, you have the codes to reimburse Dr. Rubino for the MMR vaccine, as well as his time and expertise in
administering the injection and talking with Isaac’s mother. Remember, the MMR vaccine is a combination vac-
cine with three components. So, you will need to report four codes:
90707, 90460, 90461, 90461
Good job!!
NOTE: If Dr. Rubino had not spent time face-to-face with Isaac and his mother, 90460 would not be used. Instead
you would use codes 90471, 90472, 90472, which do not include the phrase “when the physician counsels
the patient/family” in the code description.

CODING BITES 28.2  Injections and Infusions

When a drug is provided The administration of fluids (such as saline solution to hydrate a patient suffering from
to a patient, two types of dehydration), pharmaceuticals (such as medications for treatment or preventive pur-
codes are reported: one poses), or dyes (such as those used for diagnostic testing) is coded from the Injections
for the administration— and Infusions subsection, which includes codes 96360–96379.
being discussed here— Some of these terms may sound familiar to you because we discussed them ear-
plus one for the drug lier when reviewing the various ways drugs can be administered into the body. In
itself—discussed in the Figure 28-1, do you see how the needle illustrating an intradermal injection has its
chapter HCPCS Level II. tip pointing into the dermis (intra = within + dermal = dermis)? The injection that

(b) Intramuscular (c) Subcutaneous

(IM) (subcut)

(a) Intradermal
(ID)

CPT © 2017 American Medical Association. All rights reserved.

Epidermis
(d) Intravenous
(IV)
Dermis

Subcutaneous

FIGURE 28-1  An illustration showing various injection routes  Source: Booth et al., Medical Assisting, 5e. Copyright ©2013 by McGraw-Hill
Education. Figure 53-5, p. 1081.

862   PART III  |  REPORTING PHYSICIAN SERVICES AND OUTPATIENT PROCEDURES

 is delivered subcutaneously has the tip of the needle all the way down into the fatty Infusion
tissue layer. And the intramuscular (intra = within + muscular = muscle) injection The introduction of a fluid into
leads down to the layer of muscle that lies below the fatty tissue layer. a blood vessel.
The infusion and injection codes include certain standard parts involved in admin- Injection
istering liquids. Services included and therefore not reported separately are Compelling a fluid into tissue
or cavity.
∙ The administration of a local anesthetic.
∙ The initiation of the IV.
∙ Accessing an indwelling IV, subcutaneous catheter, or port.
CODING BITES
∙ Flushing the line at the completion of the infusion.
The administration of
∙ The appropriate supplies: tubing, syringes, and so on.
chemotherapy drugs
The guidelines for coding injections and infusions provide further direction when is not coded from the
coding these services: Injections and Infusions
subsection, but from the
∙ When more than one infusion is provided into one IV site, report only the first
Chemotherapy Admin-
service.
istration subsection,
∙ Should more than one IV site be used, report the appropriate services for each site. codes 96401–96549.
∙ Report different drugs or materials and that service separately.
∙ Report infusion time as the actual time the fluid is provided.
An IV or intra-arterial push is described by the CPT guidelines as Push
The delivery of an additional
∙ An injection administered to the patient and then observed continuously by the drug via an intravenous line
health care professional who administered the drug. over a short period of time.
or
∙ An infusion that lasts 15 minutes or less.

Multiple Administrations
When more than one injection or infusion is provided to a patient at the same encoun-
ter, there is a specific order in which you need to report the codes. The sequencing
guidelines are different for those reporting physician services than for those reporting
for the facility.
When you are reporting for the physician’s, or other health care professional’s, ser-
vices, you must read the notes carefully to determine the main diagnosis or reason for
GUIDANCE
the treatment. The primary reason for the injection or infusion should be reported first, CONNECTION
as the “initial” service, no matter in what order the injections were administered. Read the additional
explanations in the
in-section guidelines
EXAMPLE located within the Medi-
CPT © 2017 American Medical Association. All rights reserved.

Wendy comes to see her physician because she has been vomiting a lot over the cine section, subheads
last several days. Dr. Kilmer identifies that she has become dehydrated due to this Hydration, directly
excessive vomiting. Dr. Kilmer gives Wendy an intramuscular (IM) injection of an above code 96360,
antiemetic (a drug to stop vomiting) and then gives her an IV infusion, 45 minutes, and Therapeutic, Pro-
of normal saline for hydration. The primary reason for the encounter is Wendy’s phylactic, Diagnostic
excessive vomiting; therefore, the injection of the antiemetic is the “initial” service, Injections and Infu-
followed by the hydration infusion service. sions (Excludes Che-
motherapy and Other
96372 Therapeutic, prophylactic, or diagnostic injection; subcutaneous or
Highly Complex Drug
intramuscular
or Highly Complex
96360 Intravenous infusion, hydration; initial, 31 minutes to 1 hour
Biologic Agent Admin-
NOTE: Remember, you will also need an additional code for the specific anti- istration), directly above
emetic medication that was inside that injection, as well as an additional code for code 96365, both in
the saline. your CPT book.
 When you are reporting services on behalf of a facility rather than the providing
professional, the order is determined by the type of service provided as well as the
reason for that service:
1. Chemotherapy service
2. Therapeutic, prophylactic, and diagnostic services
3. Hydration services
Then, the specific service hierarchy is
1. Infusions
2. Pushes
3. Injections

CPT
LET’S CODE IT! SCENARIO
Melissa Fusion, a 51-year-old female, postmastectomy for malignant neoplasm of the breast, has been having che-
motherapy treatments. She was seen today for nausea and vomiting as a result of this therapy. Dr. Saludo ordered
an antiemetic 10 mg IV push and another antiemetic IV infusion over 30 minutes.

Let’s Code It!

Melissa received two medications via two different routes of administration: IV push and IV infusion. Therefore,
you need two codes.
The notes report that an intravenous push, which is an injection given intravenously, was given. Let’s turn to
the Alphabetic Index and look up injection, intravenous.
Injection
Intravenous...............................................96379
Keep reading below that and you will see
Injection
Intravenous push...................... 96374-96376
That looks perfect. Turn to the numeric listing and read the complete descriptions. You see that 96374 matches
the notes:
96374 Therapeutic, prophylactic or diagnostic injection (specify substance or drug); intravenous
push, single or initial substance/drug
You also know that Melissa was given an infusion, intravenously, and that it was for therapeutic reasons—to elim-
inate her nausea and vomiting. Let’s go to the Alphabetic Index and look up infusion, intravenous, therapeutic.

CPT © 2017 American Medical Association. All rights reserved.

Infusion
Intravenous
  Diagnostic/Prophylactic/Therapeutic...................................... 96365-96368, 96379
  Hydration.......................................................................................................96360, 96361
When you turn to the numeric listing to check the code descriptions, you see that codes 96360–96361 are for
hydration only. Look through the complete descriptions for the next grouping, 96365–96368, and you see that
the best, most accurate code is
96367 Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug);
additional sequential infusion of a new drug/substance, up to 1 hour
The notes indicate that Melissa was given the infusion after the first (sequentially) for 30 minutes. Excellent!
Therefore, the claim form for this encounter with Melissa will show 96374 and 96367.
Great job!

864   PART III  |  REPORTING PHYSICIAN SERVICES AND OUTPATIENT PROCEDURES

 Chemotherapy Administration GUIDANCE
Codes 96401–96549 cover the different methods of chemotherapy dispensation that CONNECTION
may be used with one patient. Each method (such as steroidal agents and biologic
agents) and/or each technique (such as infusion or IV push) should be coded sepa- Read the additional
rately. The codes include the following services: explanations in the
in-section guidelines
∙ The administration of a local anesthetic. located within the Medi-
∙ The initiation of the IV. cine section, subhead
∙ Accessing an indwelling IV, subcutaneous catheter, or port. Chemotherapy and
Other Highly Complex
∙ Flushing the line at the completion of the infusion.
Drug or Highly Com-
∙ The appropriate supplies: tubing, syringes, and so on. plex Biologic Agent
∙ The preparation of the chemotherapy agent(s). Administration, directly
above code 96401 in
your CPT book.

CPT
YOU CODE IT! CASE STUDY
Andrew Gitner is admitted today for his chemotherapy, which consists of an antineoplastic drug, 500 mg IV infusion
over 3 hours. Dr. Munch is in attendance during Andrew’s treatment.

You Code It!

Go through the steps, and determine the code(s) that should be reported for this encounter between Dr. Munch
and Andrew Gitner.
Step #1: Read the case carefully and completely.
Step #2: Abstract the scenario. Which key words or terms describe what service the physician provided to the
patient during this encounter?
Step #3: Are there any details missing or incomplete for which you would need to query the physician? [If so,
ask your instructor.]
Step #4: Determine the correct CPT procedure code or codes to explain the details about what was provided
to the patient during this encounter.
Step #5: Check for any relevant guidance, including reading all of the symbols and notations.
Step #6: Do you need to append any modifiers to ensure complete and accurate information is provided?
Step #7: Double-check your work.
Answer:
CPT © 2017 American Medical Association. All rights reserved.

Did you determine these to be the correct codes?

96413 Chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial
substance/drug
96415  each additional hour (List separately in addition to code for primary procedure) [for sec-
ond hour]
96415  each additional hour (List separately in addition to code for primary procedure) [for third hour]

28.3  Psychiatry, Psychotherapy,

and Biofeedback
Sometimes we become so focused on physical health care issues that we forget the
health care professionals who treat mental health concerns. This area is a great
 opportunity for coding specialists because more and more health care plans cover
GUIDANCE psychotherapy and psychiatric services. Codes 90785–90911 provide details on such
CONNECTION services.
Read the additional Psychiatry services are categorized as:
explanations in the ∙ Interactive Complexity
in-section guidelines
located within the Medi-
∙ Psychiatric Diagnostic Procedures
cine section, subhead ∙ Psychotherapy
Psychiatry, directly ∙ Psychotherapy for Crisis
above code 90785 in ∙ Other Psychotherapy, Services, or Procedures
your CPT book
Once the type of therapy is determined, the next factor to consider is how much
time the provider spent face-to-face with the patient.
There is a difference between psychiatric E/M and medical E/M, so, lastly, you
must abstract from the documentation whether the physician or therapist provided
medical E/M services in addition to the therapy session at the same time or on the
same day.
When medical E/M services are provided at the same time or on the same date,
and are documented as separately identified—specifically different than those issues
covered by the therapy—then a code from the Evaluation and Management (E/M)
section of the CPT book may be appropriate.

CPT
LET’S CODE IT! SCENARIO
Taylor Loeb, a 32-year-old male, was sent to Dr. Panjab for psychotherapy to deal with anger management issues.
Dr. Panjab spent 45 minutes with Taylor in her office.

Let’s Code It!

Taylor saw Dr. Panjab in her office for psychotherapy for 45 minutes. Let’s look in the Alphabetic Index under
psychotherapy, beneath which you see family or group as choices. The notes indicate that Taylor had an indi-
vidual psychotherapy session. The Alphabetic Index suggests codes 90832–90834 and 90836–90838. Let’s
look at the numeric listing and see which of these matches Dr. Panjab’s notes.
90834 Psychotherapy, 45 minutes with patient
90836 Psychotherapy, 45 minutes with patient when performed with an evaluation and
management service (List separately in addition to the code for primary procedure)
The next issue to consider is whether Dr. Panjab provided medical E/M services at the same time. According to
her notes, she did not. This means that code 90834 is the code to report.

CPT © 2017 American Medical Association. All rights reserved.

Great job!

Telemedicine Synchronous Services

Several codes within the Psychiatry subsection qualify to be provided using telemedi-
cine synchronous services, as noted by the star ( ) symbol to the left of the code: 90791,
90792, 90832, 90833, 90834, 90836, 90837, 90838, 90845, 90846, 90847, and 90863.
As you learned in the chapter CPT and HCPCS Level II Modifiers in the section
Service-Related Modifiers, the documentation for these encounters must confirm
that the content of the physician/patient meeting is sufficient to meet the requirements
for the code to be reported whether the service was provided face-to-face or with the
use of synchronous telemedicine services (as indicated by appending modifier 95).

866   PART III  |  REPORTING PHYSICIAN SERVICES AND OUTPATIENT PROCEDURES

 CPT
YOU CODE IT! CASE STUDY
Adam has been acting out, often losing his temper and getting violent, since his parents divorced. After individual
sessions, Dr. Eisenberg holds a family psychotherapy session with Adam and his parents. As Adam’s mother had
moved about 1 hour away, and Adam’s father was at work, Dr. Eisenberg used Skype to connect the whole family for
the 50-minute session. Dr. Eisenberg’s notes indicate good progress was made.

You Code It!

Dr. Eisenberg used technology to have one session with an entire family. Determine the appropriate code to
report this service.
Step #1: Read the case carefully and completely.
Step #2: Abstract the scenario. Which key words or terms describe what service the physician provided to the
patient during this encounter?
Step #3: Are there any details missing or incomplete for which you would need to query the physician? [If so,
ask your instructor.]
Step #4: Determine the correct CPT procedure code or codes to explain the details about what was provided
to the patient during this encounter.
Step #5: Check for any relevant guidance, including reading all of the symbols and notations.
Step #6: Do you need to append any modifiers to ensure complete and accurate information is provided?
Step #7: Double-check your work.
Answer:
Did you determine this to be the correct code?
90847-95 Family psychotherapy (conjoint psychotherapy) (with patient present), 50 minutes,
synchronous telemedicine service rendered via a real-time interactive audio and video
telecommunications system

28.4  Dialysis and Gastroenterology Services

Dialysis
Dialysis is an artificial process used to clean the blood by removing excess water and
waste products when the individual’s body cannot do this. In addition to hospitals
providing this service, independent centers and home health agencies help patients
CPT © 2017 American Medical Association. All rights reserved.

receive treatment. The correct code for reporting dialysis service is determined by the
patient’s age, where the services are provided, and the level of physician services dur-
ing the encounters.
Physician services provided during a dialysis month included in these codes are
∙ Determination of the dialysis cycle
∙ Outpatient E/M of the dialysis visits
∙ Telephone calls
∙ Patient management
∙ Face-to-face visit with the patient

Hemodialysis
Hemodialysis is a process that uses a mechanical dialyzer to extract blood via an
intravenous catheter to filter out waste products and excess fluids, and returns the
 “cleaned” blood back into the patient via an intra-arterial catheter. Typically, three
GUIDANCE sessions a week are provided.
CONNECTION Prior to beginning ongoing hemodialysis treatments, the nephrologist will order
Read the additional
the insertion of either an arteriovenous fistula (AVF) or an arteriovenous graft
explanations in the
(AVG). For more information on these procedures, see the additional explanations
in-section guidelines
in the in-section guidelines located within the Surgery section, subhead Dialysis
located within the Medi-
Circuit, directly above code 36901 in your CPT book.
cine section, subhead
Hemodialysis procedures are reported with one of two codes determined by the
Dialysis, subsections
number of evaluations provided by the physician during the encounter:
Hemodialysis, directly 90935 Hemodialysis procedure with single evaluation by a physician or
above code 90935; other qualified physician or other health care professional
Miscellaneous Dialysis 90937 Hemodialysis procedure requiring repeated evaluation(s) with or
Procedures, directly without substantial revision of dialysis prescription
above code 90945; and
End-Stage Renal Dis-
When the hemodialysis services are performed by a nonphysician health care profes-
ease Services, directly
sional in the patient’s residence, including a private home, assisted living center, group
above code 90951, all
home, nontraditional provider home, custodial care facility, or a school, use this code:
in your CPT book. 99512 Home visit for hemodialysis
When hemodialysis is provided via an AV fistula, graft, or catheter, there are Category
II codes to report this service:
4052F Hemodialysis via functioning arteriovenous (AV) fistula [ESRD]
4053F Hemodialysis via functioning arteriovenous (AV) graft [ESRD]
4054F Hemodialysis via catheter [ESRD]
Access flow studies may be provided to determine the effectiveness of the dialysis
process.
90940 Hemodialysis access flow study to determine blood flow in grafts
and arteriovenous fistulae by an indicator method
93990 Duplex scan of hemodialysis access (including arterial inflow, body
of access and venous outflow)

Other Renal Therapies

There are other types of dialysis provided to patients with renal failure, including
∙ Peritoneal dialysis, which uses a catheter connected to the abdominal cavity, using
the peritoneal membrane to filter the blood.
∙ Hemofiltration, which is a process that uses mechanical filtration circuit to clean
the blood of waste products and excess fluid using a convection process.
These types of renal therapies are reported with one of two codes:
90945 Dialysis procedure other than hemodialysis, with single evalua- CPT © 2017 American Medical Association. All rights reserved.

tion by a physician or other qualified physician or other health care

professional
90947 Dialysis procedure other than hemodialysis, requiring repeated
evaluation(s) by a physician or other qualified health care
professional, with or without substantial revision of dialysis
prescription
When these services are provided at the patient’s home by a nonphysician profes-
sional, use these:
99601 Home infusion/specialty drug administration, per visit (up to
2 hours)
99602  each additional hour (List separately in addition to code for primary
procedure)

868   PART III  |  REPORTING PHYSICIAN SERVICES AND OUTPATIENT PROCEDURES

 End-Stage Renal Disease (ESRD)
When a patient is diagnosed with end-stage renal disease (ESRD), dialysis services are
reported on a monthly basis, rather than for each individual encounter, with a code from
the range 90951–90966. The correct code for reporting dialysis service is determined by
∙ Patient’s age: Grouped into ranges: younger than 2 years of age; 2–11 years of age;
12–19 years of age; and 20 years of age and older
∙ Where the services are provided: Outpatient facility or home dialysis
∙ Level of physician services: Number of face-to-face visits by a physician
If a facility does not provide a full month of services to a patient, for whatever reason,
then you should use one code from the range 90967–90970, determined by the age of
the patient, multiplied by each day of service.

CPT
LET’S CODE IT! SCENARIO
Glory Anders, a 61-year-old female, was diagnosed with ESRD 6 months ago. She has just moved to Springfield to
be closer to her daughter and began her daily dialysis on June 20 at the Southside Dialysis Center. Prepare the
claim for dialysis services for June.

Let’s Code It!

Glory has ESRD and has received dialysis as an outpatient from Southside Dialysis Center. Let’s look up dialysis
in the Alphabetic Index. You can see the listing for end-stage renal disease, with the suggested code range
of 90951–90970. When you turn to the numeric listing, you read that codes 90951–90966 are only for a full
month of treatment. Glory received 11 days of treatment from the facility (June 20 through June 30 is 11 days),
so you have to find the code to report each day of service to Glory. Codes 90967–90970 are chosen by the
patient’s age. Glory is 61 years old, bringing us to the following code:
90970 End-stage renal disease (ESRD) related services for dialysis less than a full month of service,
per day; for patients twenty years of age and over
Great! So the code will read 90970 × 11.

Gastroenterology Services
A limited number of tests and services for the gastroenterological system—from the patient’s
mouth down the esophagus to the stomach through the intestinal tract to the rectum—are
included in the Medicine section of the CPT book. The Alphabetic Index will guide you to
the best, most appropriate code in the best section, depending upon the service provided.
CPT © 2017 American Medical Association. All rights reserved.

CPT
YOU CODE IT! CASE STUDY
Paulina Porter, a 39-year-old female, has been battling with indigestion for over a year. After trying virtually every
over-the-counter medication possible, she came to see Dr. Dahl, who decided to administer an esophageal acid
reflux test. The test was administered in the office using a nasal catheter intraluminal impedance electrode. The
45-minute test was recorded and analyzed and interpreted by Dr. Dahl.

You Code It!

Go through the steps, and determine the procedure code(s) that should be reported for the test provided by
Dr. Dahl to Paulina Porter.
Step #1: Read the case carefully and completely. (continued)
 Step #2: Abstract the scenario. Which key words or terms describe what service the physician provided to the
patient during this encounter?
Step #3: Are there any details missing or incomplete for which you would need to query the physician? [If so,
ask your instructor.]
Step #4: Determine the correct CPT procedure code or codes to explain the details about what was provided
to the patient during this encounter.
Step #5: Check for any relevant guidance, including reading all of the symbols and notations.
Step #6: Do you need to append any modifiers to ensure complete and accurate information is provided?
Step #7: Double-check your work.
Answer:
Did you determine this to be the correct code?
91037 Esophageal function test, gastroesophageal reflux test with nasal catheter intraluminal
impedance electrode(s) placement, recording, analysis and interpretation

28.5  Ophthalmology and

Ophthalmologist
A physician qualified to diag-
Otorhinolaryngologic Services
nose and treat eye disease Ophthalmology
and conditions with drugs, sur-
gery, and corrective measures. Ophthalmologists are commonly called eye doctors or vision specialists. However,
be careful not to confuse them with optometrists, who are eyeglass specialists.
Optometrist The Ophthalmology subsection of the CPT book reports services provided by an
A professional qualified to ophthalmologist. General services, codes 92002–92014, are divided in two ways:
carry out eye examinations
and to prescribe and supply 1. The relationship between the patient and the physician: new patient or established
eyeglasses and contact lenses. patient. Remember this from E/M coding? As a reminder, a new patient is one who
has not received any services or treatments from the ophthalmologist (or any other
physician with the same specialty in the same group practice) within the last 3 years.
CODING BITES 2. The level of service: intermediate or comprehensive. An intermediate service is
Codes for ophthalmo- similar to a problem-focused evaluation. That is, the patient has a new or existing
logic services include specific condition to be addressed by the physician. The comprehensive service is
attention to both eyes. more of a general evaluation of the patient’s entire visual system.
Therefore, if only one It is important to remember that these general services include both technical exam-
CPT © 2017 American Medical Association. All rights reserved.
eye is addressed by the inations and medical decision-making services. Therefore, it is not appropriate to code
physician, you should any of those services separately.
include modifier 52 However, special services may be coded separately if provided at the same time as
Reduced Services with general services or E/M services. The documentation must be specific in its identifica-
the code. tion of the additional services. (Of course, special services can be provided alone and
coded as such.) Codes 92015–92499 are used to report other ophthalmologic services.

CPT
LET’S CODE IT! SCENARIO
Warren Preston, a 61-year-old male, has been having a problem with blurred vision and pain in his eyes. His father
has glaucoma, which makes Warren at high risk for the disease. Therefore, Dr. Coreley is going to perform a bilateral
visual field examination and a serial tonometry with multiple measurements. None of these services is done as a
part of a general ophthalmologic service provided to Warren.

870   PART III  |  REPORTING PHYSICIAN SERVICES AND OUTPATIENT PROCEDURES

 Let’s Code It!
Dr. Coreley is giving Warren a “bilateral visual field examination and a serial tonometry” today. Let’s go to the
Alphabetic Index and look at visual field exam. The Alphabetic Index suggests codes 92081–92083. Let’s take
a look at the numeric listing’s code description:
92081 Visual field examination, unilateral or bilateral, with interpretation and report; limited exami-
nation (e.g., tangent screen, Autoplot, arc perimeter, or single stimulus level automated test,
such as Octopus 3 or 7 equivalent)
It matches the notes. Now, you need to code the second test, the tonometry. You see that the Alphabetic Index
shows tonometry, serial and suggests code 92100. Let’s take a look at the complete code description:
92100 Serial tonometry (separate procedure) with multiple measurements of intraocular pressure
over an extended time period with interpretation and report, same day (e.g., diurnal curve or
medical treatment of acute elevation of intraocular pressure)
That’s great! You are ready to create the claim form for Warren’s tests: codes 92081 and 92100. Good job!

GUIDANCE CONNECTION
Read the additional explanations in the in-section guidelines located within the Medi-
cine section, subhead Ophthalmology, directly above code 92002 in your CPT book.

Otorhinolaryngologic Services
In the Special Otorhinolaryngologic Services portion of the Medicine section are
codes for special services that are not usually included in an office visit or evaluation
encounter in the field of otorhinolaryngology. Otorhinolaryngology
Throughout the listings for codes 92502–92700, you will see all types of tests and The study of the human
services that can help health care professionals diagnose and treat conditions relating ears, nose, and throat (ENT)
to a patient’s ears, nose, and throat and their functions. systems.

CPT
YOU CODE IT! CASE STUDY
Darlene Watson came with her husband, Albert, to see Dr. Hudman because of the problems Albert has been hav-
ing sleeping. Darlene noticed that Albert snores terribly during the night and has, at times, abruptly stopped making
noise. She is concerned that he may have actually stopped breathing during one of his episodes. Dr. Hudman per-
formed a nasopharyngoscopy with an endoscope to check Albert’s adenoids and lingual tonsils. The results of the
exam indicated that Albert is suffering from sleep apnea.
CPT © 2017 American Medical Association. All rights reserved.

You Code It!

Go through the steps, and determine the code(s) that should be reported for this test provided by Dr. Hudman
to Albert Watson.
Step #1: Read the case carefully and completely.
Step #2: Abstract the scenario. Which key words or terms describe what service the physician provided to the
patient during this encounter?
Step #3: Are there any details missing or incomplete for which you would need to query the physician? [If so,
ask your instructor.]
Step #4: Determine the correct CPT procedure code or codes to explain the details about what was provided
to the patient during this encounter.

(continued)
 Step #5: Check for any relevant guidance, including reading all of the symbols and notations.
Step #6: Do you need to append any modifiers to ensure complete and accurate information is provided?
Step #7: Double-check your work.
Answer:
Did you determine this to be the correct code?
92511 Nasopharyngoscopy with endoscope (separate procedure)
That is exactly what Dr. Hudman did. In addition, he did not perform it as a part of any other service, so it was a
separate procedure. Excellent!

GUIDANCE CONNECTION
Read the additional explanations in the in-section guidelines located within the
Medicine section, subhead Special Otorhinolaryngologic Services, directly above
code 92502 in your CPT book.

28.6  Cardiovascular Services

When reporting cardiovascular services from the Medicine section of CPT, you will
find both diagnostic and therapeutic services for conditions of the heart and its vessels.
As you look through the descriptions of the codes in this section, you might think that
some appear to be surgical in nature (an atherectomy), while others appear to be imag-
ing (radiologic), such as an echocardiogram. Regardless of what you think, the CPT
book is structured the way it is, and it is your job as a coding specialist to find the best,
most appropriate code to represent the service or treatment provided by the physician
or other health care professional for whom you are reporting. Again, this is why it is so
important that you take nothing for granted, read all notations and instructions care-
fully, and use the Alphabetic Index to guide you through the numeric listings.

Cardiovascular Therapeutic Services

A variety of procedures relating to the heart are included in the Cardiovascular subsec-
tion Therapeutic Services and Procedures that might seem more appropriate for other
places in the CPT book. For example, the inclusion of intravascular ultrasound and per-
cutaneous transluminal coronary balloon angioplasty illustrates the importance of using
the Alphabetic Index to locate the correct range of codes for the procedures performed.

CPT © 2017 American Medical Association. All rights reserved.

CPT
YOU CODE IT! CASE STUDY
Ransom Sweeney was in Dr. Plenmen’s office when Ransom went into cardiac arrest. Dr. Plenmen immediately
performed cardiopulmonary resuscitation (CPR). The nurse called 911, and Ransom was taken to the hospital after
regaining consciousness and being stabilized.

You Code It!

Go through the steps, and determine the code(s) that should be reported for the service provided by Dr. Plenmen
for Ransom Sweeney.
Step #1: Read the case carefully and completely.

872   PART III  |  REPORTING PHYSICIAN SERVICES AND OUTPATIENT PROCEDURES

 Step #2: Abstract the scenario. Which key words or terms describe what service the physician provided to the
patient during this encounter?
Step #3: Are there any details missing or incomplete for which you would need to query the physician? [If so,
ask your instructor.]
Step #4: Determine the correct CPT procedure code or codes to explain the details about what was provided
to the patient during this encounter.
Step #5: Check for any relevant guidance, including reading all of the symbols and notations.
Step #6: Do you need to append any modifiers to ensure complete and accurate information is provided?
Step #7: Double-check your work.
Answer:
Did you determine this to be the correct code?
92950 Cardiopulmonary resuscitation (e.g., in cardiac arrest)
It matches the notes perfectly. Good work!

Cardiography
The electronic measurement of heart rhythms very often uses an electrocardiograph
(ECG, also called an EKG, machine). Services involving an electrocardiogram are
coded from the Cardiography subsection.

EXAMPLE
Deliah Munroe experienced a rapid heartbeat and mild pain in her chest. Dr.
Donaldson took a 12-lead routine ECG to rule out a heart attack. He interpreted
the tracing and wrote a report for the file. The code is
93000 Electrocardiogram, routine ECG with at least 12 leads; with inter-
pretation and report

Implantable and Wearable Cardiac Device Evaluations

Technology has provided physicians with the ability to monitor a person’s heart func-
tion under various circumstances. You learned how to code the implantation of these
devices in the CPT Surgery Section chapter of this book, subsection Cardiovascular
System.
CPT © 2017 American Medical Association. All rights reserved.

These incredible measuring devices must be programmed, and then data must be
gathered by using in-person and/or remote transmission and interpreted by the physi-
cian. The codes in this subsection report these services.

EXAMPLE
Henriette had a dual-lead pacemaker implanted 3 days ago by Dr. Rasmussen.
She is here to have him do the evaluation and programming.
93286 Peri-procedural device evaluation (in person) and programming of
device system parameters before or after a surgery, procedure, or
test with analysis, review and report by a physician or other quali-
fied health care professional; single, dual, or multiple lead pace-
maker system
 Echocardiography
Echocardiography is different from electrocardiography. As the name indicates, an
echocardiogram uses ultrasound (sound waves to produce an echo), rather than a mea-
surement by electronic impulses, as with the ECG.
When coding echocardiography, the codes already include
∙ The exam (the recording of the images of the organ or anatomical areas being
studied).
∙ The interpretation and report of the findings.
You are not permitted to use these codes for echocardiograms that have been taken
when no interpretation or report has been done.

Cardiac Catheterization
The codes available for reporting cardiac catheterization include the following:
Catheter ∙ The introduction of the catheter(s).
A thin, flexible tube, inserted ∙ The positioning and repositioning of the catheter(s).
into a body part, used to inject
fluid, to extract fluid, or to ∙ Recording of the intracardiac and intravascular pressure.
keep a passage open. ∙ Obtaining blood samples for the measurement of blood gases, dilution curves, and/
or cardiac output with or without electrode catheter placement.
∙ Final evaluation and report of the procedure.

CODING BITES
The provision of a cardiac catheterization may require as many as five codes. The
determination of how many of these codes you are responsible for reporting will
depend upon for whom you are coding (which professional or facility):
. The professional service for the catheterization . . . procedure code + modifier 26.
1
2. The administration of the dye . . . procedure code + modifier 51.
3. The radiologist’s supervision and interpretation for the guidance for the injec-
tion of the dye . . . procedure code + modifier 26.
4. The procedure itself, such as coronary artery angiography.
5. The radiologist’s supervision and interpretation of the images.

CPT
LET’S CODE IT! SCENARIO
Mason Franks, a 4-month-old male, was experiencing cyanotic episodes, known as “blue” spells. Dr. Zahn, his pedi-
atrician, performed a transthoracic echocardiogram, which identified a ventricular septal defect and hypertrophied CPT © 2017 American Medical Association. All rights reserved.
walls of the right ventricle. He then performed a right cardiac catheterization that confirmed a diagnosis of a tetral-
ogy of Fallot.

Let’s Code It!

Dr. Zahn performed two tests on little Mason: first, a transthoracic echocardiogram and, second, a right cardiac
catheterization. Let’s go to the Alphabetic Index and look for the echocardiogram. Beneath it, you see transtho-
racic with a series of suggested codes. But before you go on, take a look at the indented listing below transtho-
racic for congenital anomalies. Mason is only 4 months old, and his heart problems are congenital; therefore,
those are likely the more accurate codes. Let’s take a look at the complete descriptions in the numeric listing for
the suggested codes 93303–93304.

874   PART III  |  REPORTING PHYSICIAN SERVICES AND OUTPATIENT PROCEDURES

 93303 Transthoracic echocardiography for congenital cardiac anomalies; complete
This matches the notes. Now, we must code the catheterization. In the Alphabetic Index, under catheterization,
you find cardiac, and indented below that you find right heart. And look what is indented below that: congenital
cardiac anomalies. Let’s take a look at the complete description:
93530 Right heart catheterization, for congenital cardiac anomalies
Excellent. Now, you can see how terms you learned from coding the first procedure—congenital cardiac anomalies—
make coding the second procedure easier. It is a small example of how practice and experience will make the entire
coding process go more smoothly for you.

Electrophysiologic Procedures
Intracardiac electrophysiologic studies (EPS) codes include
∙ The insertion of the electrode catheters (usually performed with two or more
catheters).
∙ The repositioning of the catheters.
∙ Recording of electrograms both before and during the pacing or programmed stim-
ulation of multiple locations of the heart.
∙ Analysis of the recorded electrograms.
∙ Report of the procedure and the findings.
There are cases when a diagnostic EPS is followed by treatment (ablation) of the Ablation
problem at the same encounter. When ablation is done at the same time as an EPS, you The destruction or eradication
must code it separately. of tissue.

GUIDANCE CONNECTION
Read the additional explanations in the in-section guidelines located within
the Medicine section, subhead Cardiovascular, subsections Cardiography,
directly above code 93000; Cardiovascular Monitoring Services, directly
above code 93224; Implantable and Wearable Cardiac Device Evaluations,
directly above code 93279; Echocardiography, directly above code 93303;
Cardiac Catheterization, directly above code 93451; and Intracardiac Elec-
trophysiological Procedures/Studies, directly above code 93600, all in your
CPT book.
CPT © 2017 American Medical Association. All rights reserved.

Noninvasive Vascular Studies CODING BITES

If the device used does
Codes 93880–93998 are provided for reporting noninvasive vascular studies of the not record the test,
arteries and veins of a patient and include the following: then you may not use
∙ Preparation of the patient for the testing. a separate code for the
service.
∙ Supervision of the performance of the tests.
∙ Recording of the study.
∙ Interpretation and report of the findings. Duplex Scan
An ultrasonic scanning proce-
Codes are chosen by the type of study done: noninvasive physiologic, transcranial dure to determine blood flow
Doppler (TCD), or duplex scan. and pattern.
 CPT
YOU CODE IT! CASE STUDY
Dr. Robbins was giving Teena Salazar her annual physical examination. She had a low-grade fever and swelling
and cyanosis was evident on her lower right leg. Concerned that she might have deep-vein thrombophlebitis, he
performed a duplex Doppler ultrasonogram to study the arteries in her leg.

You Code It!

Go through the steps, and determine the code(s) that should be reported for this test performed on Teena
Salazar.
Step #1: Read the case carefully and completely.
Step #2: Abstract the scenario. Which key words or terms describe what service the physician provided to the
patient during this encounter?
Step #3: Are there any details missing or incomplete for which you would need to query the physician? [If so,
ask your instructor.]
Step #4: Determine the correct CPT procedure code or codes to explain the details about what was provided
to the patient during this encounter.
Step #5: Check for any relevant guidance, including reading all of the symbols and notations.
Step #6: Do you need to append any modifiers to ensure complete and accurate information is provided?
Step #7: Double-check your work.
Answer:
Did you determine this to be the correct code?
93926 Duplex scan of lower extremity arteries or arterial bypass grafts; unilateral or limited study
Good job!

28.7  Pulmonary
Codes 94002–94799 in the Pulmonary subsection identify procedures and tests on
the pulmonary system and include
∙ The exam and/or laboratory procedure.
∙ Interpretation of the findings.

Pulmonary Function Testing

CPT © 2017 American Medical Association. All rights reserved.
Pulmonary function testing is performed to measure the ability of the patient’s lungs to
inspire (bring air into the lungs) and expire (expel gases from the body) as well as mea-
sure the efficacy of the lungs to transfer oxygen into the circulatory system of the body.

Spirometry
Spirometry, the basis of pulmonary function testing, measures the quantity of airflow
during expiration (exhaling), as well as the speed of this action. The results of this
assessment can provide indications of a wide range of lung diseases.
94010 Spirometry, including graphic record, total and timed vital capacity,
expiratory flow rate measurement(s), with or without maximal volun-
tary ventilation
94060 Bronchodilation responsiveness, spirometry as in 94010, pre- and
post-bronchodilator administration

876   PART III  |  REPORTING PHYSICIAN SERVICES AND OUTPATIENT PROCEDURES

 Lung Volume Measurement
GUIDANCE
Measurement of lung volumes can be done in several ways:
CONNECTION
∙ Plethysmography is used to determine total lung capacity, residual volume, func-
Read the additional
tional residual capacity, and airway resistance.
explanations in the
∙ Helium dilution and/or nitrogen washout are used to measure lung volumes, distri- in-section guidelines
bution of ventilation, and closing volume. located within the Medi-
cine section, subhead
Diffusing Capacity Pulmonary, subsection
A test for diffusing capacity uses an inhaled tracer gas, and is measured during expira- Pulmonary Diagnostic
tion. The comparison between the amount of gas acquired during inspiration and the Testing and Therapies,
amount exhaled evidences the effectiveness of air and gases moving from the lungs directly above code
into the blood. 94010 in your CPT
94729 Diffusing capacity (eg. carbon monoxide, membrane) book.

CPT
YOU CODE IT! CASE STUDY
Carmine Allen, a 2-day-old male, was born at 35 weeks gestation, with a birth weight of 1,450 g. After exhibiting
hypotension, peripheral edema, and oliguria, Carmine was diagnosed by Dr. Yanger with respiratory distress syn-
drome. Dr. Yanger performed the initiation of continuous positive airway pressure ventilation (CPAP).

You Code It!

Go through the steps, and determine the code(s) that should be reported for this treatment provided to Carmine.
Step #1: Read the case carefully and completely.
Step #2: Abstract the scenario. Which key words or terms describe what service the physician provided to the
patient during this encounter?
Step #3: Are there any details missing or incomplete for which you would need to query the physician? [If so,
ask your instructor.]
Step #4: Determine the correct CPT procedure code or codes to explain the details about what was provided
to the patient during this encounter.
Step #5: Check for any relevant guidance, including reading all of the symbols and notations.
Step #6: Do you need to append any modifiers to ensure complete and accurate information is provided?
Step #7: Double-check your work.
Answer:
CPT © 2017 American Medical Association. All rights reserved.

Did you determine this to be the correct code?

94660 Continuous positive airway pressure ventilation (CPAP) initiation and management
Excellent!

28.8  Allergy and Clinical Immunology

Codes 95004–95199 cover allergy and clinical immunology procedures. Allergies
can be responsible for many different reactions in the human body. Beyond the typi-
cal sneezing and watery eyes, outcomes can cause anything from hives and rashes to
behavioral problems, sleeplessness, and even death.
Often, when there is concern or suspicion that a patient may be suffering from an
allergic reaction, the physician will begin with allergy sensitivity tests. In these cases,
 small yet potent samples of the suspected allergen are given to the patient in one of
CODING BITES a number of methods: percutaneously (scratch, puncture, or prick), intracutaneously
The process of desen- (intradermal), inhalation, or ingestion. Then the patient is watched, and the body’s
sitizing can take weeks, reaction to the allergen is documented. The results of the tests tell the physician to
months, or years, so pay which elements the patient is considered allergic.
close attention to the Once an allergy is identified, immunotherapy may be provided. The therapy is a
dates of service. way of retraining the patient’s immune system, or desensitizing it, so that the body no
longer views the particles as a threat.

EXAMPLE
Dr. Bagg conducted percutaneous scratch testing with immediate reactions on
Shelley to identify the cause of her asthma. He tested her for a dozen common
allergens. Report this with 95004 Percutaneous tests × 12 tests.

CPT
LET’S CODE IT! SCENARIO

PATIENT: MARINA LOUONGO

REASON FOR VISIT: Skin testing to environmental allergens.
HISTORY OF PRESENT ILLNESS: The patient was a long-standing patient of Dr. Yeager in Masonville, her previ-
ous hometown in the north side of the state, and had received immunotherapy for the past several years. She was
referred to us by her new neighbor.
She had been getting injections for grass/ragweed/plantain, cat/dog/mold, dust mite, and trees. She states she
has been having some difficulty with local reactions and swelling to the tree injection. She is using Tylenol before
and after injections along with ice, which has helped somewhat. She gets injections every 3 weeks. Patient states
she had an episode one time where her arms swelled significantly and she required oral prednisone. She typically
has allergy symptoms in February, March, November, and December with rhinitis, congestion, and itchy eyes. She
was going to get dust covers for her pillow and mattress but hasn’t gotten around to it. Her bedroom is carpeted. She
denies smoking.
CURRENT MEDICATIONS: Flonase and Clarinex prior to injections.
PHYSICAL EXAMINATION: She is a healthy-appearing, well-nourished, well-developed 27-year-old female in no
acute distress.
Skin testing via prick was positive to birch 2+, beech 2+, ash 0/1+, hickory 1+, mite DF 2+, mite DP 2+ and hista-
mine 3+, grass 3+, mugwort 1+, birch 3+, oak 4+, maple 3+.
IMPRESSION: Seasonal and perennial allergic rhinitis.
RECOMMENDATIONS:

CPT © 2017 American Medical Association. All rights reserved.

1. Continue immunotherapy here with birch/oak/maple, mite DF/DP, grass/mugwort.
2. Continue Flonase two sprays per nostril daily during the spring and fall.
3. Environmental control measures regarding dust and pollen.
4. Report was sent to Dr. Yeager, along with patient’s signed Release of Information form so we can get copies of her
previous medical records.
Alvin Birchwood, MD

Let’s Code It!

Dr. Birchwood did percutaneous skin prick testing on Marina. Turn in the CPT Alphabetic Index and find
Allergy Tests
Skin Tests
  Allergen Extract............................ 95004, 95024, 95027

878   PART III  |  REPORTING PHYSICIAN SERVICES AND OUTPATIENT PROCEDURES

 Turn to the Main Section of CPT and read carefully the complete code descriptions for all three of these
suggestions.
95004 Percutaneous tests (scratch, puncture, prick) with allergenic extracts, immediate type reac-
tion, including test interpretation and report, specify number of tests
95024 Intracutaneous (intradermal) tests with allergenic extracts, immediate type reaction, includ-
ing test interpretation and report, specify number of tests
95027 Intracutaneous (intradermal) tests, sequential and incremental, with allergenic extracts for
airborne allergens, immediate type reaction, including test interpretation and report, specify
number of tests
Which of these is supported by Dr. Birchwood’s documentation? Did you determine . . .
95004 Percutaneous tests (scratch, puncture, prick) with allergenic extracts, immediate type reac-
tion, including test interpretation and report, specify number of tests
Correct! Now, how many tests were performed? The documentation states: “birch, beech, ash, hickory, mite DF,
mite DP and histamine, grass, mugwort, birch, oak, maple.”
A total of 12 tests were performed, so you can report 95004 × 12 with confidence. Good work!

GUIDANCE
28.9  Neurology and Neuromuscular CONNECTION
Procedures Read the additional
As with so many other headings in this section, the neurology and neuromuscular pro- explanations in the
cedure codes (95803–96020) include the recording of the test as well as the physician’s in-section guidelines
interpretation and report of the findings. located within the Medi-
Acronyms often seen in this arena of health care services include: cine section, subhead
Neurology and Neuro-
EEG Electroencephalogram
muscular Procedures,
EMG Electromyogram
directly above code
EOG Electrooculogram
95803 in your CPT book.
MEG Magnetoencephalography

CPT
LET’S CODE IT! SCENARIO
Ian Ellington, a 47-year-old male, was having a hard time staying awake during the day and asleep during the night.
Dr. Bruse sent him down the hall to have a polysomnography, with three additional parameters, to rule out sleep
CPT © 2017 American Medical Association. All rights reserved.

apnea.

Let’s Code It!

Dr. Bruse ordered a polysomnography on Ian to see if he has sleep apnea. Let’s turn to the Alphabetic Index
and find
Polysomnography.......................95782, 95783, 95808–95811
As you read through the complete code descriptions in the numeric listing, you will see that, because Dr. Bruse
ordered three additional parameters, the best code is
95808 Polysomnography; any age, sleep staging with 1–3 additional parameters of sleep, at-
tended by a technologist
Excellent!
 Central Nervous System Assessments
When a patient exhibits problems with cognitive processes, testing may evaluate the
extent of the condition so that a treatment plan can be established. It is expected that
the results of the tests in the Central Nervous System subsection (codes 96101–96127)
will be formulated into a report to be used in the creation of a treatment plan.

GUIDANCE CONNECTION
Read the additional explanations in the in-section guidelines located within the
Medicine section, subhead Central Nervous System Assessments/Tests (e.g.,
Neuro-Cognitive, Mental Status, Speech Testing), directly above code 96101 in
your CPT book.

CPT
YOU CODE IT! CASE STUDY
Oliver Gates, a 3-year-old male, does not appear to be meeting certain milestones. Dr. Saunders performed a devel-
opmental test known as an Early Language Milestone Screening. Once the test was interpreted, he sent his report
and contacted a speech therapist to consult on a treatment plan.

You Code It!

Go through the steps, and determine the code(s) that should be reported for this screening test performed on
Oliver.
Step #1: Read the case carefully and completely.
Step #2: Abstract the scenario. Which key words or terms describe what service the physician provided to the
patient during this encounter?
Step #3: Are there any details missing or incomplete for which you would need to query the physician? [If so,
ask your instructor.]
Step #4: Determine the correct CPT procedure code or codes to explain the details about what was provided
to the patient during this encounter.
Step #5: Check for any relevant guidance, including reading all of the symbols and notations.
Step #6: Do you need to append any modifiers to ensure complete and accurate information is provided?
Step #7: Double-check your work.
Answer:
Did you determine this to be the correct code?
96111 Developmental testing, (includes assessment of motor, language, social, adaptive, and/or CPT © 2017 American Medical Association. All rights reserved.

cognitive functioning by standardized developmental instruments) with interpretation and

report
Good work!

28.10  Physical Medicine and Rehabilitation

Physiatrists are health care professionals who specialize in physical medicine and reha-
bilitation, focusing their skills and knowledge to evaluate and treat traumatic injuries,
illnesses, and resulting disabilities affecting components of the nervous system and
musculoskeletal systems. The goals of these health care encounters are most often cen-
tered around maximizing the patient’s physical function and improving quality of life.

880   PART III  |  REPORTING PHYSICIAN SERVICES AND OUTPATIENT PROCEDURES

 Physical therapy focuses on working with patients who have been injured or dis-
abled by an illness, with the goal of helping them restore their mobility. These sessions CODING BITES
educate patients with methodologies to manage their physical situations, promote Codes 97010–97762
healing, and prevent further deterioration of physical abilities. are used to report each
Occupational therapy connects patients with activities they can participate in to distinct procedure pro-
improve their quality of life, and sometimes independence. The positive outcomes of vided to the patient.
these therapies include disabled students gaining inclusion in school and social events, Modifier 51 cannot be
as well as working with patients to function despite cognitive or physical changes. used with any of these
Throughout the Physical Medicine and Rehabilitation subsection and its compo- codes.
nents, note that some groups of codes require the provider to have direct (face-to-face)
contact with the patient during the course of the treatment and others do not.

CPT
YOU CODE IT! CASE STUDY

DATE OF PHYSICAL THERAPY EVALUATION: 05/31/2018

DATE OF INJURY: 03/18/2018
HISTORY OF PRESENT ILLNESS: The patient is a 19-year-old male who was the driver in an MVA. He was struck
from behind by a tractor trailer, causing his car to fishtail, landing beneath the truck’s trailer. He is single and lives with
his parents while he finishes college. His injuries have halted his education for now, but he is determined to reenroll
at a future date. He depends, right now, on someone to transport him to our facility.
ASSESSMENT AND PLAN: The patient is a 19-year-old male, status post multiple trauma.
For full assessment notes, including exam and clinical presentation of characteristics, see attached notes.
1. Rehabilitation: Toe-touch weightbearing, left lower extremity. Weightbearing as tolerated, left upper extremity. PT,
OT, speech language pathology, therapeutic recreation, and psychology to see and treat.
2. Deep venous thrombosis prophylaxis: The patient is on Fragmin. The patient is to have his Dopplers repeated.
3. Gastrointestinal prophylaxis: The patient is not on anything but complains of systemic nausea. We will start Pepcid
20 mg b.i.d.
4. Bowel and bladder: Overflow urinary incontinence. We will place Foley and start Urecholine 12.5 mg p.o. t.i.d.
5. Pain: Not well controlled. Start Oramorph 15 mg with Percocet for breakthrough and schedule before
therapies.
DISPOSITION: The patient will likely be discharged to home with any equipment and modifications PRN.

You Code It!

Dr. Gerald Foxglove was called in to perform a predischarge physical therapy evaluation.
Step #1: Read the case carefully and completely.
CPT © 2017 American Medical Association. All rights reserved.

Step #2: Abstract the scenario. Which key words or terms describe what service the physician provided to the
patient during this encounter?
Step #3: Are there any details missing or incomplete for which you would need to query the physician? [If so,
ask your instructor.]
Step #4: Determine the correct CPT procedure code or codes to explain the details about what was provided
to the patient during this encounter.
Step #5: Check for any relevant guidance, including reading all of the symbols and notations.
Step #6: Do you need to append any modifiers to ensure complete and accurate information is provided?
Step #7: Double-check your work.

(continued)
 Answer:
Did you determine this to be the correct code?
97163 Physical therapy evaluation; high complexity, requiring these components: a history of pres-
ent problem with 3 or more personal factors and/or comorbidities that impact the plan of
care, an examination of body systems using standardized tests and measures addressing a
total of 4 or more elements from any of the following: body structures and functions, activity
limitations, and/or participation restrictions; a clinical presentation with unstable and unpre-
dictable characteristics; and clinical decision-making of high complexity using standardized
patient assessment instrument and/or measurable assessment of functional outcome.

GUIDANCE 28.11  Acupuncture, Osteopathic, and

CONNECTION Chiropractic Treatments
Read the additional Acupuncture
explanations in the
in-section guidelines The health care industry is always evolving and incorporating new techniques into its
located within the Medi- accepted methods for helping patients. The techniques of acupuncture (codes 97810–
cine section, subhead 97814) are thousands of years old but are newly accepted by Western medicine and
Acupuncture, directly health insurance payers.
above code 97810 in Acupuncture services are measured in 15-minute increments of direct provider-
your CPT book. patient contact. While the needles may be in place for a longer period of time, you are
permitted to report only the time actually spent with the patient.

CPT
LET’S CODE IT! SCENARIO
Josie Rossini, a 57-year-old female, was having a problem with menopause. Because of the reported concerns
about hormone replacement therapy (HRT), she decided to try acupuncture. After discussing her symptoms and a
treatment plan, Dr. Kini inserted several needles. The needles were removed 20 minutes later. Dr. Kini reviewed the
follow-up plan and made an appointment for Josie’s next visit. Dr. Kini spent 30 minutes in total face-to-face with
Josie, who reported marked improvement.

Let’s Code It!

Dr. Kini’s treatment of Josie included 30 minutes face-to-face time and several needles during the acupuncture
treatment. Let’s turn to the Alphabetic Index and look up acupuncture.

CPT © 2017 American Medical Association. All rights reserved.

Acupuncture
With Electrical Stimulation..........................97813-97814
Without Electrical Stimulation....................97810-97811
There is no mention of electrical stimulation being used in Josie’s treatment, so turn to the codes recommended
for without electrical stimulation.
97810 Acupuncture, 1 or more needles; without electrical stimulation, initial 15 minutes of person-
al one-on-one contact with the patient
97811  without electrical stimulation, each additional 15 minutes of personal one-on-one con-
tact with the patient, with reinsertion of needles(s) (List separately in addition to code for
primary procedure.)
The first code, 97810, reports Dr. Kini’s services, but only for the first 15 minutes. You have to add the second code,
97811, to report the remainder of the time so that the doctor can be reimbursed for the total 30 minutes for the session.

882   PART III  |  REPORTING PHYSICIAN SERVICES AND OUTPATIENT PROCEDURES

 Osteopathic Manipulative Treatments GUIDANCE
Codes 98925–98929, to report osteopathic manipulative treatments (OMT), are CONNECTION
defined by the number of body regions involved in the encounter. Ten regions are
identified with the codes: Read the additional
explanations in the
∙ Head in-section guidelines
∙ Cervical located within the Medi-
∙ Thoracic cine section, subhead
Osteopathic Manipula-
∙ Rib cage
tive Treatment, directly
∙ Upper extremities above code 98925 in
∙ Lumbar your CPT book.
∙ Sacral
∙ Abdominal/visceral
∙ Pelvic
∙ Lower extremities

Chiropractic Manipulative Treatment

Similar to the osteopathic treatment codes, chiropractic manipulative treatment
(CMT) codes 98940–98943 are determined by the number of regions treated during
an encounter. The codes use spinal or extraspinal descriptions and are identified as
follows:

Spinal Regions
∙ Cervical, including atlanto-occipital joint
∙ Thoracic, including costovertebral and costotransverse joints
∙ Lumbar
GUIDANCE
∙ Sacral
CONNECTION
∙ Pelvic, including the sacroiliac joint Read the additional
explanations in the
Extraspinal Regions in-section guidelines
located within the Medi-
∙ Head, including temporomandibular joint (but not the atlanto-occipital) cine section, subhead
∙ Upper extremities Chiropractic Manipula-
tive Treatment, directly
∙ Rib cage, excluding costotransverse and costovertebral joints
above code 98940 in
∙ Abdomen your CPT book.
∙ Lower extremities
CPT © 2017 American Medical Association. All rights reserved.

CPT
YOU CODE IT! CASE STUDY
Evan LaVelle, a 37-year-old male who is 6 ft 6 in. tall, has pain in his neck and spine. Dr. Eisenberg, a chiropractor,
provides CMT to his cervical, thoracic, lumbar, sacral, and pelvic regions to alleviate Evan’s pain.

You Code It!

Go through the steps, and determine the code(s) that should be reported for this CMT encounter.
Step #1: Read the case carefully and completely.

(continued)
 Step #2: Abstract the scenario. Which key words or terms describe what service the physician provided to the
patient during this encounter?
Step #3: Are there any details missing or incomplete for which you would need to query the physician? [If so,
ask your instructor.]
Step #4: Determine the correct CPT procedure code or codes to explain the details about what was provided
to the patient during this encounter.
Step #5: Check for any relevant guidance, including reading all of the symbols and notations.
Step #6: Do you need to append any modifiers to ensure complete and accurate information is provided?
Step #7: Double-check your work.
Answer:
Did you determine this to be the correct code?
98942 Chiropractic manipulative treatment (CMT); spinal, five regions
Good job!

28.12  Other Services Provided

Education and Training for Patient Self-Management
Technological and other health care treatment and pharmaceutical advancements have
made it easier for the average patient to care for him- or herself or for a caregiver to
administer treatments formerly provided exclusively by a physician. Of course, this is
not something that should be done without guidance, so it is important that the patient
or caregiver is taught how to administer treatment properly. Education and training for
patient self-management are reported by using codes 98960–98962.

EXAMPLE
∙ Teaching a diabetic patient how to self-administer insulin injections.
∙ Teaching a caregiver how to change a dressing.

Non-Face-to-Face Nonphysician Services

CPT © 2017 American Medical Association. All rights reserved.
GUIDANCE Nurses and allied health care professionals extend the ability of a physician to com-
municate with patients. When a qualified nonphysician member of the health care
CONNECTION team provides an assessment and management service to an established patient via
Read the additional telephone or online electronic contact, this service is reported with a code from
explanations in the 98966–98969.
in-section guidelines
located within the Medi- Special Services, Procedures, and Reports
cine section, subhead
Non-Face-to-Face There are times when a health care professional is required to provide a service
Nonphysician Services, or write a report that is outside the normal realm of his or her responsibilities or
directly above code outside of the scope of other codes in the CPT book. In those cases, match the
98966 in your CPT circumstance to one of the descriptions in the Special Services, Procedures, and
book. Reports subsection (codes 99000–99091). Each code identifies a different special
situation.

884   PART III  |  REPORTING PHYSICIAN SERVICES AND OUTPATIENT PROCEDURES

 EXAMPLE GUIDANCE
Dr. Schnering comes into the office to meet Jason Carter on Thanksgiving CONNECTION
because Jason was bitten by his nephew’s pet snake and Dr. Schnering has the Read the additional
only antidote for that species. You would use the following code in addition to the explanations in the
codes needed to report the specific services Dr. Schnering provided: in-section guidelines
99050 Services provided in the office at times other than regularly sched- located within the Medi-
uled office hours, or days when the office is normally closed (e.g., cine section, subhead
holidays, Saturday or Sunday), in addition to basic service Special Services, Pro-
cedures and Reports,
directly above code
99000 in your CPT
Medication Therapy Management Services book.
When a patient is prescribed multiple medications, especially when ordered by mul-
tiple providers, a pharmacist may step in to assess the list and intervene as necessary.
The pharmacist can provide insights into potential drug interactions and duplications
caused by secondary ingredients.
Medication Therapy Management Services (MTMS) codes can be reported
when the following has been documented:
∙ Review of the pertinent patient history.
∙ Review of the medication profile for prescription and nonprescription drugs and
herbal supplements.
∙ Specific recommendations for improving patient health outcomes.
∙ Recommendations to support the patient’s treatment compliance.
The codes available to report these services are
99605 Medication therapy management service(s) provided by a pharma-
cist, individual, face-to-face with patient, with assessment and inter-
vention, if provided; initial 15 minutes, new patient
99606 Medication therapy management service(s) provided by a pharma-
cist, individual, face-to-face with patient, with assessment and inter-
vention, if provided; initial 15 minutes, established patient
99607  each additional 15 minutes (List separately in addition to code for
primary service)
As stated in the CPT guidelines, these codes should not be used to report the provision
of product-specific information at the time the product is provided to the patient or any
other routine dispensing-related activities.

Home Health Procedures/Services

CPT © 2017 American Medical Association. All rights reserved.

In the chapter CPT Evaluation and Management Coding, you learned about codes
99341–99350 for services provided by a physician at the patient’s home. However,
occasionally a health care professional in your facility other than the physician pro- GUIDANCE
vides services to a patient at his or her home. The person may be a nurse or ther- CONNECTION
apist, for example. For nonphysician clinical professionals, you must use the codes Read the additional
99500–99602 from the Home Health Procedures/Services subsection in the explanations in the
Medicine section. in-section guidelines
located within the Medi-
cine section, subhead
EXAMPLE Home Health Proce-
Shawn Webber, RN, stopped by Beatrice Mulligan’s home to give her an injection dures/Services, directly
of morphine sulfate, 10 mg, IM, for pain management. Report Nurse Webber’s visit above code 99500 in
with 99506 Home visit for intramuscular injections. your CPT book.
 CPT
YOU CODE IT! CASE STUDY
Eliot Sharpton is a Certified Diabetes Educator (CDE) and is meeting today with Robyn Wu. She was just diagnosed
with type 2 diabetes mellitus. Eliot spends 30 minutes with her, using the standardized curriculum, to help Robyn
adjust her diet, get some exercise in her routine, and answer questions about her medication.

You Code It!

Determine the correct code or codes to report Eliot Sharpton, CDE’s training of Robyn Wu.
Step #1: Read the case carefully and completely.
Step #2: Abstract the scenario. Which key words or terms describe what service the physician provided to the
patient during this encounter?
Step #3: Are there any details missing or incomplete for which you would need to query the physician? [If so,
ask your instructor.]
Step #4: Determine the correct CPT procedure code or codes to explain the details about what was provided
to the patient during this encounter.
Step #5: Check for any relevant guidance, including reading all of the symbols and notations.
Step #6: Do you need to append any modifiers to ensure complete and accurate information is provided?
Step #7: Double-check your work.
Answer:
Did you determine this to be the code?
98960 Education and training for patient self-management by a qualified, nonphysician health care
professional using a standardized curriculum, face-to-face with the patient (could include
caregiver/family) each 30 minutes; individual patient
Fantastic!

Chapter Summary
Many services provided by physicians, therapists, chiropractors, and other trained
health care professionals deserve to receive reimbursement. The Medicine sec-
tion contains information about these services. The variety of services included in
the Medicine section emphasizes the fact that finding the correct code begins in the
Alphabetic Index and culminates in the numeric listings.
CPT © 2017 American Medical Association. All rights reserved.

CODING BITES
The Medicine section of the CPT book has codes for services that are supplied
by health care professionals but not represented in any other sections. Services
reported using codes from the Medicine section include these:
• Flu shots
• Vaccinations for the kids to go back to school
• Allergy shots
• Chiropractic services
• Psychotherapy
• Dialysis

886   PART III  |  REPORTING PHYSICIAN SERVICES AND OUTPATIENT PROCEDURES

 CHAPTER 28 REVIEW
• Hearing evaluations
• Vision checks
• Chemotherapy
• Acupuncture
Wherever you work as a coding specialist, there is an excellent chance you will be
using this section. Let’s go through it together.

CHAPTER 28 REVIEW
CPT Medicine Section Enhance your learning by
completing these exercises and
more at connect.mheducation.com!

Let’s Check It! Terminology

Match each key term to the appropriate definition.
1. LO 28.2  The introduction of a fluid into a blood vessel. A. Ablation
2. LO 28.6  The destruction or eradication of tissue. B. Catheter
3. LO 28.2  The delivery of an additional drug via an intravenous line over a short C. Duplex scan
period of time. D. Immunization
4. LO 28.6  A thin, flexible tube, inserted into a body part, used to inject fluid, to E. Infusion
extract fluid, or to keep a passage open.
F. Injection
5. LO 28.5  A professional qualified to carry out eye examinations and to prescribe
G. Ophthalmologist
and supply eyeglasses and contact lenses.
H. Optometrist
6. LO 28.2  Compelling a fluid into tissue or cavity.
I. Otorhinolaryngology
7. LO 28.5  A physician qualified to diagnose and treat eye disease and conditions
with drugs, surgery, and corrective measures. J. Push
8. LO 28.6  An ultrasonic scanning procedure to determine blood flow and pattern.
9. LO 28.5  The study of the human ears, nose, and throat (ENT) systems.
10. LO 28.1  To make someone resistant to a particular disease by vaccination.

CPT
  Let’s Check It! Concepts
Choose the most appropriate answer for each of the following questions.
CPT © 2017 American Medical Association. All rights reserved.

1. LO 28.1  When an immunization is given, you will need

a. one code for administering the immunization.
b. two codes: one for the administration and one for the drug.
c. one code for the medication or drug.
d. one HCPCS Level II code.
2. LO 28.2  When a patient receives infusion therapy via more than one IV site, code
a. only the first site.
b. all appropriate services for each site.
c. infusion time instead of number of sites.
d. only when chemotherapy is infused.
 3. LO 28.3  Psychotherapy services are coded first by
CHAPTER 28 REVIEW

a. a category of service.
b. relationship of the patient.
c. type of therapy.
d. qualifications of the treating health care professional.
4. LO 28.4  Dialysis codes are reported by
a. the patient’s age.
b. the number of days treated.
c. the location of treatment (inpatient or outpatient).
d. all of these.
5. LO 28.5  An optometrist is qualified to
a. diagnose and treat serious eye diseases.
b. supply glasses and contact lenses.
c. write prescriptions for the treatment of serious eye diseases.
d. perform surgery.
6. LO 28.6  What code would you assign for a duplex scan of the left radial artery?
a. 93925 b.  93926
c. 93930 d.  93931
7. LO 28.12  Medication Therapy Management Services (MTMS) codes can be reported when all of the following
have been documented except
a. review of the pertinent patient examination.
b. review of medication profile for prescription and nonprescription drugs and herbal supplements.
c. specific recommendations for improving patient health outcomes.
d. recommendations to support the patient’s treatment compliance.
8. LO 28.11  Chiropractic treatment codes are chosen by
a. the time spent face-to-face with the patient.
b. the total number of treatments in a month.
c. the number of regions treated.
d. the age of the patient.
9. LO 28.9  Kinney Harris, a 41-year-old male, was in an automobile accident and was transported to the nearest
hospital, unconscious. The ED physician, Dr. Alexander, attempted to awaken Kinney with stimulants
without success. Dr. Alexander performs an EEG due to Kinney’s comatose condition. What is the cor-
rect code for the EEG? CPT © 2017 American Medical Association. All rights reserved.

a. 95812
b.  95816
c. 95822
d.  95824
10. LO 28.10  Betty Cannon receives an acupuncture treatment, two needles, for a total of 45 minutes of face-to-face
time with Dr. Hamilton. What is/are the correct code(s) for this procedure?
a. 97810
b.  97810, 97811
c. 97813, 97814
d.  97810, 97811, 97811

888   PART III  |  REPORTING PHYSICIAN SERVICES AND OUTPATIENT PROCEDURES

 Let’s Check It! Guidelines

CHAPTER 28 REVIEW
Refer to the Medicine Guidelines and fill in the blanks accordingly.
99070 not Medicine assessment
add-on identified itself 16 minutes
“Special Report” “separate procedure” independent
independently 59 integral
99600 Introduction supply
nomenclature “Unlisted Procedure” exempt
1. In addition to the definitions and commonly used terms present in the _____, several other items unique to this
section on _____ are defined or identified here.
2. All _____ codes found in the CPT codebook are _____ from the multiple procedure concept.
3. Add-on codes in the CPT codebook can be readily _____ by specific descriptor _____ which includes phrases
such as “each additional” or “(List separately in addition to primary procedure).”
4. The codes designated as _____ should not be reported in addition to the code for the total procedure or service of
which it is considered an _____ component.
5. However, when a procedure or service that is designated as a “separate procedure” is carried out _____ or considered
to be unrelated or distinct from other procedures/services provided at the time, it may be reported by _____, or in
addition to other procedures/services by appending modifier _____ to the specific “separate procedure” code to indi-
cate that the procedure is not considered to be a component of another procedure, but is a distinct, _____ procedure.
6. Supplies and materials over and above those usually included with the procedure(s) rendered are reported sepa-
rately using code _____ or a specific _____ code.
7. A service or procedure may be provided that is _____ listed in this edition of the CPT code book. When reporting
such a service, the appropriate _____ code may be used to indicate the service, identifying it by _____.
8. Unlisted home visit service or procedure is reported with code _____.
9. The psychotherapy services codes 90832-90838 include ongoing _____ and may include informants in the treat-
ment process.
10. Do not report psychotherapy of less than _____ duration.

Let’s Check It! Rules and Regulations

Please answer the following questions from the knowledge you have gained after reading this chapter.

1. LO 28.1  List five ways medication can be administered to a patient.

2. LO 28.2  Explain the standard parts included in infusion and injection codes.
3. LO 28.3  What are the categories of psychotherapy?
CPT © 2017 American Medical Association. All rights reserved.

4. LO 28.4  What physician services are included in the codes during a dialysis month?
5. LO 28.6  What do the available codes for reporting a cardiac catheterization include?

CPT

YOU CODE IT! BASICS

First, identify the procedural main term(s) in the fol- 1. Dr. Jameson performs a psychotherapy session
lowing statements; then code the procedure or service. with the patient, 45 minutes:
Example: Alan Capshaw, PA completes a home visit a. main term: _____ b. procedure: _____
for mechanical ventilation care. 2. Dr. Graban completes a therapeutic repetitive transcra-
nial magnetic stimulation (TMS), initial treatment:
a. main term: Ventilation Assist b. procedure:
99504 a. main term: _____ b. procedure: _____
CHAPTER 28 REVIEW

3. Dr. Kantsiper performs biofeedback training, 10. Dr. McKee completes nitric oxide expired gas
anorectal: determination:
a. main term: _____ b. procedure: _____ a. main term: _____ b. procedure: _____
4. Dr. Abernethy completes a diagnostic transcutane- 11. Dr. Middleton performs an unattended sleep study
ous electrogastrography: with simultaneous recording of heart rate, oxygen
a. main term: _____ b. procedure: _____ saturation, respiratory analysis, and sleep time:
5. Dr. Shutter fits a contact lens for management of a. main term: _____ b. procedure: _____
keratoconus, initial fitting: 12. Dr. Trezevant completes a manual muscle testing
a. main term: _____ b. procedure: _____ with report of extremity:
6. Dr. Sanning completes a positional nystagmus a. main term: _____ b. procedure: _____
test: 13. Dr. Reese performs a chemotherapy administra-
a. main term: _____ b. procedure:_____ tion, intra-arterial; infusion technique, 45 minutes:
7. Dr. Foldings performs a tympanometry and reflex a. main term: _____ b. procedure:_____
threshold measurements: 14. Dr. Kemper performs an anogenital (perineum)
a. main term: _____ b. procedure: _____ examination, magnified in childhood for suspected
trauma:
8. Dr. Edge completes a right heart catheterization
including measurement of oxygen saturation and a. main term: _____ b. procedure: _____
cardiac output: 15. Dr. Guinyard completes a home visit for prenatal
a. main term: _____ b. procedure: _____ monitoring and assessment including fetal heart
rate and nonstress test:
9. Dr. Pugh performs a duplex scan of lower extrem-
ity arteries; complete bilateral study: a. main term: _____ b. procedure: _____
a. main term: _____ b. procedure:_____

CPT

YOU CODE IT! Practice

Using the techniques described in this chapter, carefully read through the case studies and determine the most ac-
curate Medicine section CPT code(s) and modifier(s), if appropriate, for each case study.
1. Marlene Overton, a 59-year-old female, has been suffering from bronchitis off and on for 2 years. Dr. Turner
has ordered a pulmonary stress test for her. Dr. Turner notes that he wants her CO2 and O2 uptake measured
during the test as well as an electrocardiogram to be recorded.
2. Grant Hughes, a 74-year-old male, has uncontrolled diabetes and comes into the emergency department com-

CPT © 2017 American Medical Association. All rights reserved.

plaining of signs of hyperglycemia. Dr. Hawkins gives him insulin subcutaneous and IV push to bring his
blood sugar down. Code injection administration only.
3. After finding relief nowhere else, Rasheem Conner, a 42-year-old female, goes to Dr. Johnston, an acupunc-
turist, for treatment of her osteoarthritic knee. Dr. Johnston spends 15 minutes with the patient reviewing
history and symptoms, palpating, and locating the points to treat, and inserts the needles and applies electri-
cal stimulation. Rasheem is asked to rest. Dr. Johnston comes back in about 10 minutes later and spends 5
minutes monitoring the patient and restimulating the needles. Ten minutes later, Dr. Johnston sees that the
pain and swelling in Rasheem’s knee have reduced, removes the needles, and instructs Rasheem on home care
measures. Dr. Johnston spent a total of 30 minutes in direct contact with Rasheem.
4. Darlene Overton, an 8-year-old female, is brought to Dr. Mackinaw by her mother after a referral from the
school counselor and her pediatrician. Darlene is having difficulties with classwork. Mrs. Overton also tells
Dr. Mackinaw that Darlene has a problem understanding speech in noisy environments. Darlene may have a

890   PART III  |  REPORTING PHYSICIAN SERVICES AND OUTPATIENT PROCEDURES

 CHAPTER 28 REVIEW
hearing deficiency that has not shown up in hearing tests before, and it may account for her declining work in
class. Dr. Mackinaw performs a central auditory function evaluation, which takes 1 hour, with report.
5. Kent Egerton, a 13-year-old male, suffered from a severe asthma attack while at the playground. He was
rushed to the clinic, where he was given a nebulizer treatment (nonpressurized inhalation).
6. Kenya Cantrell, a 41-year-old female, broke out in a rash, which would not go away. After trying multiple
over-the-counter treatments, she went to Dr. Beech, who did a series of 11 allergenic extract scratch tests to
see if he could identify an allergen. The tests pointed to an allergy to her new kitten.
7. Kenya (previous scenario) didn’t want to give away her new kitten, so Dr. Beech prepared the allergenic
extract and began immunotherapy injections. She received the first injection today.
8. Paul Kensington, a 51-year-old male, is beginning chemotherapy today with the administration of methotrex-
ate, via IV push.
9. Darren Pinchot, a 24-year-old male, is a lifeguard at the beach and came into the emergency clinic with
uncontrolled nausea and vomiting. Darren told Dr. Valentine that he was on the beach for 12 hours straight
with no breaks because his replacement didn’t show up. Dr. Valentine diagnosed him with severe dehydration
and ordered 20 minutes of Zofran, IV infusion, and then saline for 4 hours.
10. Robin Gerstein, a 32-year-old female, comes to Duane Nettles, a licensed massage therapist, as prescribed by
Dr. Luellen. Robin is pregnant and has been suffering from acute lower back pain for over a month. Duane
performs therapeutic massage with effleurage on the left side and kneading on the iliac band, nerve stroking,
and light compression on the gluteus for a total of 15 minutes.
11. Robert Kini, a 9-day-old male, was born prematurely, and Dr. Martin is concerned about Robert’s heart. He
performs a combined right heart catheterization and transseptal left heart catheterization through the intact
septum, in order to measure the blood gases and record Robert’s intracardiac pressure. Dr. Martin provides
conscious sedation, 15 minutes, while the nurse monitors Robert’s status during the procedure.
12. Felicia Gardener, a 6-year-old female, comes to see Dr. Kaplan for an evaluation of her cochlear implant. Dr.
Kaplan reprograms the implant to improve Felicia’s reception.
13. Alice Heath, a 73-year-old female, came to see Dr. Browne, her ophthalmologist, for an annual checkup of
her eyes. Dr. Browne does a comprehensive evaluation of Alice’s complete visual system.
14. Jalal Kalisz, a 68-year-old male, came to see Dr. McDaniel because he was having chest pain. Dr. McDaniel
performed a routine ECG with 15 leads. After talking with Jalal and reviewing the ECG results, Dr. McDaniel
determined that Jalal was having a bout of indigestion.
15. Cecil Rossini, an 18-year-old female, is a professional gymnast who pulled a muscle in her shoulder. Today,
Dr. Salton measured her range of motion in the shoulder to confirm that the area has healed completely. Dr.
Salton then wrote and signed the report.
CPT
YOU CODE IT! Application
CPT © 2017 American Medical Association. All rights reserved.

The following exercises provide practice in the application of abstracting the physicians’ notes and learning to
work with documentation from our health care facilities. These case studies are modeled on real patient encounters.
Using the techniques described in this chapter, carefully read through the case studies and determine the most ac-
curate Medicine section CPT code(s) and modifier(s), if appropriate, for each case study.

WESTON HOSPITAL
629 Healthcare Way • SOMEWHERE, FL 32811 • 407-555-6541
PATIENT: HAUPTON, NICHOLAS
ACCOUNT/EHR #: HAUPNI001
DATE: 10/13/18
CHAPTER 28 REVIEW

Attending Physician: Jessica P. Turner, MD

PATIENT SERVICES:
  IV fluid replacement for dehydration, intravenous, 58 minutes
  Continuous pulse oximetry
  Therapeutic warm water enema for intussusception

Robin P. Moss, RN
RPM/mg  D: 10/13/18 09:50:16  T: 10/15/18 12:55:01

Determine the most accurate Medicine section CPT code(s) and modifier(s), if appropriate.

SPELLING CHIROPRACTIC CENTER

A Complete Health Care Facility
159 Healthcare Way • SOMEWHERE, FL 32811 • 407-555-6789
PATIENT: CARMICHAEL, ABIGAIL
ACCOUNT/EHR #: CARMAB001
DATE: 10/21/18
Attending Physician: Philip M. Osburn, DC
Diagnosis: Lumbar stenosis, sciatica
Procedure: CMT; traction, manual
PROCEDURE: The patient was placed on the table.
  Chiropractic manipulative treatment: spinal, thoracic
  Chiropractic manipulative treatment: lower extremity, left
  Manual traction: cervical & lumbar regions × 30 minutes
PMO/mg  D: 10/21/18 09:50:16  T: 10/25/18 12:55:01

Determine the most accurate Medicine section CPT code(s) and modifier(s), if appropriate.

CPT © 2017 American Medical Association. All rights reserved.

NORTHSIDE PHYSICAL THERAPY CENTER
955 East Main Ave. • SOMEWHERE, FL 32811 • 407-555-1191
PATIENT: TRAULER, CASIE
ACCOUNT/EHR #: TRAUCA001
DATE: 09/30/18
Attending Physician: Laverne Aspiras, MD
Physical Therapist: Harvey Shaw
DX: Postsurgical carpal tunnel (CT) release LT

892   PART III  |  REPORTING PHYSICIAN SERVICES AND OUTPATIENT PROCEDURES

 CHAPTER 28 REVIEW
TYPE OF THERAPY: Occupational therapy (hand) BIW × 3 weeks
VISIT # 1/6:
Reported Pain Level: 6/10
Patient reports: “I am still having pain in my hand and fingers.”
1.  Ultrasound for 10 minutes, 3 mgHz, 0.4 u/cm2 100% to scar at LT CT area
2.  Massage: Retrograde, 4 minutes to LT hand
3.  Manual therapy: soft tissue mobilization, 7 minutes to scar at LT wrist
4.  AROM and stretching, 4 minutes
5. Therapeutic exercise: 12 minutes, tendon glides, joint blocking, digit extension, median nerve glides,
and desensitization with cold towels (tolerated up until #5)
Pain level: 4–5/10. Pt still with heavy scar tissue adhesions in CT area. Pt still having pain in fingertips
and numbness, reportedly up arm and into his neck.

Harvey Shaw
HS/mg  D: 09/30/18 09:50:16  T: 09/30/18 12:55:01

Determine the most accurate Medicine section CPT code(s) and modifier(s), if appropriate.

PRADER, BRACKER, & ASSOCIATES

A Complete Health Care Facility
159 Healthcare Way • SOMEWHERE, FL 32811 • 407-555-6789
PATIENT: PASTNERNAC, ELSA
ACCOUNT/EHR #: PASTEL001
DATE: 10/07/18
Attending Physician: Walter P. Henricks, MD
Referring Physician: Renee O. Bracker, MD
Pt is a 69-year-old female who recently had a stroke. She is here on referral from Dr. Bracker for an
assessment of her aphasia.
CPT © 2017 American Medical Association. All rights reserved.

Assessment of expressive and receptive speech and language function; language comprehension,
speech production ability, reading, spelling, writing, using Boston Diagnostic Aphasia Examination.
Interpretation and report to follow.
Total time: 60 minutes

Walter P. Henricks, DC
WPH/mg  D: 10/07/18 09:50:16  T: 10/09/18 12:55:01

Determine the most accurate Medicine section CPT code(s) and modifier(s), if appropriate.
CHAPTER 28 REVIEW

RAILS RADIOLOGY
A Complete Health Care Facility
159 Healthcare Way • SOMEWHERE, FL 32811 • 407-555-6789
PATIENT: CRESSENA, FRANCIE
ACCOUNT/EHR #: CRESFR001
DATE: 10/15/18
Attending Physician: James I. Cipher, MD
Radiologist: Rhonda E. Beardall, MD
Reason for Exam: MD order—pre-op clearance
EXAMINATION:
1.  Chest two views
   Chest—AP and lateral views.
   Clinical history states evaluation: kidney stone with obstruction.
  Slightly elongated thoracic aorta. Prominent left ventricle. No pulmonary vascular congestion. No
acute inflammatory infiltrates in the lungs.
2.  ECG, 12 leads
   Unremarkable.
Rhonda E. Beardall, MD
REB/mg  D: 10/15/18 09:50:16  T: 10/17/18 12:55:01

Determine the most accurate Medicine section CPT code(s) and modifier(s), if appropriate.

CPT © 2017 American Medical Association. All rights reserved.

894   PART III  |  REPORTING PHYSICIAN SERVICES AND OUTPATIENT PROCEDURES

 Physicians’ Services
Capstone
Learning Outcomes
After completing this chapter, the student should be able to:
LO 29.1 Determine the correct procedure codes, using the CPT code
29
set, for these case studies.

Patients come to a physician for help to feel better, or to maintain good health. You
have learned that CPT codes are one of three code sets used to report WHAT the
physician did for the patient during a specific encounter. Now, this chapter provides
you with case studies so you can get some hands-on practice using CPT to report
physician services.
For each of the following case studies, read through the documentation, and determine:
∙ Which code or codes report WHAT the physician did for this patient.
∙ If any modifiers are necessary, and if so, which modifiers, and in what order.
∙ If more than one code is required, the sequence in which to report the codes.
Remember, the notations, symbols, and Official Guidelines—both before each sec-
tion as well as those in some subsections—are there to help you get it correct.

CPT HCPCS Level II

CASE STUDY #1: PAUL HENDRICKS

Marlena Hendricks brought her 13-year-old son, Paul, into my office as a walk-in. Paul
stated that he fell through a sliding glass door, while chasing his brother, and sustained
three lacerations: left knee, right knee, and left hand.
After physical examination, Dr. Smyth determined that the wounds of both knees
and left hand required debridement and suture repair using 1% lidocaine for topical
anesthetic.
Left knee: 5.5 cm laceration involving deep subcutaneous tissue and fascia, repaired
with layered closure. Some debridement was performed.
CPT © 2017 American Medical Association. All rights reserved.

Right knee: 7.2 cm laceration repaired with a single-layer closure.

Left hand: 2.5 cm laceration of the dermis, repaired with simple closure.
Plan: Instructions for keeping bandages and area clean, and change of bandages
provided to Mrs. Hendricks. Follow-up in 10 days for suture removal. Call office PRN
any problems or complications.

CASE STUDY #2: MARIA CURRY

Maria Curry, a 39-year-old female, status post right knee arthroplasty, was referred to
our rehabilitation clinic for a physical therapy evaluation by Dr. Hanson, her orthopedic
surgeon. Patient was diagnosed with degenerative osteoarthritis approximately 2 years
 ago. As part of my evaluation, I completed a range of motion measurement on both
legs. The physician was provided with a copy of my evaluation and a written report was
developed.

CASE STUDY #3: SABRINA BARBARA

Sabrina Barbara, a 23-year-old gravida 1 para 1 by cesarean delivery, presented to the

emergency department in active labor. She is at 38 weeks gestation and was visiting
her parents here in town. She lives 250 miles away in another state. Patient delivered
vaginally in the elevator on the way up to obstetrics. The emergency services physi-
cian, Dr. Zebbria, delivered the baby. The patient will follow up with her obstetrician for
postpartum care.

CASE STUDY #4: ROGER FORCHETTA

Roger Forchetta, a 33-year-old male, came in to our ophthalmology office today. I last
saw him 6 years ago when he had a corneal ulcer on his right eye. This is now cleared.
He states that over the last few weeks, his vision is “a bit off.”
I began with a complete, interval history. He denied any specific trauma or problems
with his eyes prior to this latest concern. Overall, this patient is a healthy male with an
admitted diet filled with a great deal of fast food and restaurant food.
His external ocular and adnexal areas were unremarkable, free from injury or infec-
tion. The patient has a normal corneal anterior chamber and iris but with very slow dilat-
ing pupils. Ophthalmoscopy shows there is no pseudoexfoliation, but there are dense
juvenile nuclear cataracts on both eyes, the right greater than the left.
I counseled him regarding cataract surgery of this right eye first, and then the left
eye; the need for postop correction; a 4- to 6-week recovery time; and the type of
procedure. He agreed to schedule the procedure for next Friday. Kathy, my assistant,
obtained the appropriate consent form signatures.

CASE STUDY #5: CAMILLE FIELDS

Camille Fields, a 67-year-old female, came into our Allergy & Immunology Clinic with

CPT © 2017 American Medical Association. All rights reserved.

urticarial rash over a large portion of her body.
Patient has a history of hysterectomy at age 35. She has current diagnoses of gen-
eralized osteoporosis, severe bone pain, and risk of bone fractures. After failure of
prior treatments for osteoporosis (bisphosphonates, alendronate, and risedronic acid)
and experiencing major side effects—gastrointestinal erosion with biphosphonates
and alendronate, and severe gastrointestinal bleeding, severe muscle and joint pain,
fever, flu symptoms, conjunctivitis, episcleritis, and uveitis with risedronic acid—she
was referred to Dr. Lantana for alternate therapies of her condition. All symptoms were
intense and persistent. Dr. Lantana prescribed denosumab. He administered Prolia,
60mg subq into abdomen and told her to come back in 6 months.
On the day after the first administration of denosumab, the patient developed a gen-
eralized urticarial rash (thighs, abdomen, bilateral breast area, back) accompanied by
bilateral facial angioedema and pruriginous injuries in the area of drug administration
(the abdomen). The symptoms started 2 h after the first administration and resolved

896   PART III  |  REPORTING PHYSICIAN SERVICES AND OUTPATIENT PROCEDURES

 completely after 15 days with the administration of antihistamines and oral corticoids
and the application of local corticoids.
She came here, to our office, to determine if the denosumab was the instigator of the
allergic reaction, or if other sources were to blame. She agreed to a skin prick test (SPT)
with denosumab, along with house dust mites, cat and dog dander, olive, grass pollen,
and latex, which we performed today.
A positive reaction was defined as a wheal with a diameter at least 3 mm larger than
that obtained by a negative control, shown at the test spot of denosumab.
We discussed a rapid desensitization protocol and she agreed. We began with an
initial subcutaneous dose of 0.005 mg, which will gradually be increased in an 8-hour
cycle until a cumulative dose of 60 mg.

CASE STUDY #6: BELINDA PETTAWAY

Oscar Pettaway brought his unconscious 3-year-old daughter, Belinda, into the emer-
gency department after finding her on the floor of the bathroom. An empty bottle of his
wife’s thyroid medication, Synthroid, was lying by her side. Oscar told the physician on
call, Dr. Rubinstein, that his wife had just refilled the prescription.
Dr. Rubinstein immediately evaluated Belinda’s condition and, after obtaining per-
mission from Oscar, ordered a gastric aspiration and lavage be done immediately, due
to the poisoning.

CASE STUDY #7: JOSEPH GREESON

PATIENT: Joseph Greeson

S: The last time I saw this 29-year-old male was 6 months ago for his annual checkup. He
came in today stating that he has been feeling feverish × 3 days and noticed increased
redness on his arm last night and this morning. He denies joint pain. He explained that
yesterday he was playing with his girlfriend’s new dog and it bit him on the right fore-
arm. The dog is a stray and has had no shots, and the patient states that he believes he
accidentally provoked the dog by getting too rough with it.
O: Temp 99.2 degrees, pulse 68, resp 20, weight 142. Right arm reveals four puncture
wounds with secondary cellulitis around the area. The area is warm to the touch and is
erythematous.
CPT © 2017 American Medical Association. All rights reserved.

A: Infected dog bite.

P: Patient is given 1 gram of Rocephin IM today. Follow up in 24 hours. A bandage was
applied. He was given a rabies immune globulin (Rlg), human, IM. Tylenol is recom-
mended PRN for pain. The patient is given a prescription for Erythromycin 333 mg t.i.d.
for 10 days.

CASE STUDY #8: MONIQUE KENNARD

Monique Kennard, a 17-year-old female, came into our office today. She is accompa-
nied by her mother, who is very worried about her daughter. Patient states she has been
experiencing wheezing × 10 days. She states the symptoms are worse at night. She

CHAPTER 29  | 
 was seen a week ago at this clinic and started on a 5-day course of azithromycin with-
out improvement. Yesterday she was seen at an urgent care clinic and prescribed an
albuterol inhaler, amoxicillin/clavulonic acid, and methylprednisolone. Symptoms con-
tinued to worsen throughout the day. Patient reports chest pain attempting to swallow
the amoxicillin/clavulonic acid tablets. Chest pain involves her left upper chest; it does
not radiate. The quality is “heavy.”
VS: 97.9°F, HR 85, RR 25, BP 144/101, SaO2 97%
HEAD/NECK: She is awake and alert, NAD (no apparent distress), HEENT (head, eyes,
ears, nose, throat), NC/AT (normocephalic and atraumatic), EOMI (extraocular move-
ments intact). Left EAC (external auditory canal) is swollen shut; right is occluded with
cerumen. Oropharynx is pink and moist.
HEART: RRR (regular rate and rhythm)
LUNGS: No wheezing, but patient is stridorous
ABDOMEN: Benign/unremarkable
EXTREMITIES: Normal pulses × 4 CN II–XII grossly intact
INTEGUMENTARY: Dermatologic exam reveals no rash
ALLERGIES: NKDA (no known drug allergies)
PMHx (Past Medical History): Unremarkable
SocHx (Social History): Patient denies EtOH (ethanol, alcohol). Denies smoking but
states positive for secondhand tobacco exposure
PLAN: Orders written for CXR (chest x-ray) to be done at imaging center across the road.
Nurse to perform venipuncture for specimens for comprehensive metabolic panel; CBC
complete, automated; and automated differential WBC count.
Patient to return once results are in.

CASE STUDY #9: HARRISON PARKER

Harrison Parker, a 69-year-old right-handed male, was referred to me for a neurologic

evaluation by his internist, Dr. Brady, for a tremor that has been present for approxi-
mately 20 years.
Patient states that the tremor began insidiously and has progressed gradually. It now
involves both hands and affects his handwriting, drinking coffee and other liquids with a
cup, and general work that requires manual dexterity. Other people occasionally notice
a tremor in his head.

CPT © 2017 American Medical Association. All rights reserved.

He is otherwise healthy, although he feels his balance is not quite as good as it used
to be. A glass of beer or wine markedly decreases the tremor severity. His mother and
daughter also have tremor. Patient denies smoking.
On examination, he has a rather regular tremor of approximately 8 cycles per sec-
ond (Hz) with his hands extended and also on finger-nose-finger maneuver. Mild regu-
lar “waviness” is seen when writing or drawing spirals. His tone is normal, although
when performing voluntary movements with one hand there is a “ratchety” quality felt
in the tone of the contralateral arm. Occasional tremor is also noted in the head and
voice.
Diagnosis: Probable essential tremor (ET)
Next diagnostic step: MRI of brain and cervical spine + Labs (CBC + TSH) done in
our facility today.
Nurse Montana drew blood specimens.
Next step in therapy: Primidone or propranolol

898   PART III  |  REPORTING PHYSICIAN SERVICES AND OUTPATIENT PROCEDURES

 CASE STUDY #10: TORI BENSIO

PATIENT: Tori Bensio

Preop Diagnosis: Acute cholecystitis, cholelithiasis
Postop Diagnosis: Acute cholecystitis, cholelithiasis
Procedure: Laparoscopic cholecystectomy
Surgeon: Anthony DeTaglia, MD
Assistant: Robyn Acculo, MD
Anesthesiologist: Benjamin Sullivan, MD
Anesthesia: General endotracheal
Findings at Surgery: Pericholecystic adhesions, large gallstones
DESCRIPTION OF OPERATION: This otherwise healthy patient was brought to the OR
and after the induction of general endotracheal anesthesia, the patient’s abdomen was
prepped and draped in the usual sterile manner and a small infraumbilical incision was
made in the skin and carried down to the linea alba, which was grasped with a clamp
and incised in a vertical manner. The peritoneum was entered under direct vision. Stay
sutures were placed in the fascia. The Hasson introducer was placed. Pneumoperito-
neum was established, and following this, three additional trocars were placed in the
abdomen: one in the left epigastrium and two in the right upper quadrant, all 5 mm.
Following this, the gallbladder was grasped with cephalad retraction of the gallbladder
fundus and lateralward retraction of the gallbladder infundibulum. The dissector was
employed to take down the peritoneum overlying the gallbladder infundibulum and cys-
tic duct junction. When this was well delineated on both the anterior and posterior sur-
faces of the cystic duct, the 5-mm endoscopic clip applier was inserted and two clips
were placed on the patient’s side, on the gallbladder side of the cystic duct, which was
transected. Further dissection in the triangle of Calot revealed the cystic artery, which
was handled in an identical manner. The remainder of the dissection was performed
by using the Bovie spatula cautery, and the liver bed was dry. A 10- to 15-mm camera
change-out was performed, and the camera was inserted into the left epigastric port. A
toothed clamp was passed through the umbilicus to grasp the gallbladder, which was
then removed through the umbilicus in a standard manner. Following this, the operative
field was copiously irrigated with saline and the return was clear. All three upper abdomi-
nal ports were seen to exit the abdomen under direct vision, and with the Hasson intro-
ducer removed, the fascial incision was closed with a 2-0 Vicryl figure-of-eight suture.
The skin at the umbilicus was closed with a 4-0 Maxon subcuticular suture. Steri-strips
were applied at all sites. The patient tolerated the procedure well.
ADDENDUM: There were three cystic artery branches; each was doubly clipped and
CPT © 2017 American Medical Association. All rights reserved.

transected.
Code for both Dr. DeTaglia and Dr. Sullivan.

CASE STUDY #11: ENID REYNOLDS

EMERGENCY DEPARTMENT
HISTORY OF PRESENT ILLNESS: The patient came in today for possible reaction
to immunotherapy. She has been seeing Dr. Oligby for allergic rhinitis and asthma.
She states that she is currently building on immunotherapy and yesterday received

CHAPTER 29  | 
 injections with oak/birch/maple 100 PNU 0.3 mL, grass and ragweed 100 BAU 0.3 mL,
cat/dog 50 BAU 0.3 mL, and mite and mold mix 100 units 0.3 mL. The patient tells
me after the immunotherapy, she went home and within hours felt some chest tight-
ness. The patient used her albuterol inhaler, but the chest tightness got worse and
she ended up taking her Symbicort 160/4.5 two puffs as well as some Claritin. She
continued to feel lethargic and out of breath. She also had an itchy area on her left arm
where she received the cat/dog injection. She was able to go to sleep that night but
woke twice due to wheezing and used her albuterol inhaler and went back to sleep.
When she woke up this morning, she was very tired and dizzy and could not catch
her breath. She used her albuterol inhaler once or twice this morning as well as the
Symbicort and took a tablet of Zyrtec. Then, around 9 or 9:30, when she was at work,
she felt her tongue swelling. During this time, she felt she couldn’t breathe normally.
The albuterol inhaler did not have any benefit; neither did the other medications she
tried. She tells me she had no rash, hives, or vomiting and is not coughing. She tells
me she has not been sick this week. No fever. She has been off of her Symbicort since
November because she felt her asthma is fine. She has had no recent trouble with
asthma. No recent exposure to animals, dust, or other allergens. She is on no new medi-
cations. She has no pets at home and continues to avoid turkey and chicken and has
no new foods during this time. She has a history of anxiety and panic attacks and does
feel she is having one now.
MEDICATIONS: Topamax for migraine headaches, Lexapro
ALLERGIES: NKDA
PHYSICAL EXAMINATION:
GENERAL: The patient is a healthy-appearing, well-nourished, well-developed 45-year-
old female in no acute distress but does appear to be breathing heavy and very shaky
and panicky.
VITAL SIGNS: Height is 63 inches. Weight is 132 pounds. Blood pressure is 106/70.
HEENT: Tympanic membranes are normal. Throat is clear. I did not appreciate any swell-
ing of the tongue or angioedema.
NECK: Supple without adenopathy
LUNGS: Completely clear
HEART: Regular rate and rhythm without murmur
STUDIES: I administered spirometry when she was a little bit more relaxed and achieved
an FEV1 of 3.1 liters or 88% of predicted, FEF25–75 is 118% of predicted. Graphic
record was placed in patient’s chart.
IMPRESSION:
CPT © 2017 American Medical Association. All rights reserved.
1. The patient appears to be having some anxiety and panic now. It is hard to say
whether this started with some mild asthma symptoms as a result of her immuno-
therapy or if this is purely an anxiety issue.
2. Allergic asthma
3. Allergic rhinitis
RECOMMENDATIONS:
1. We recommend a cutback of the dose of immunotherapy at the next visit to oak/
birch/maple 100 PNU at 0.2 mL, grass and ragweed 100 BAU at 0.2 mL,
cat/dog 50 BAU at 0.2 mL, and mite and mold mix 100 units at 0.2 mL
2. Restart Symbicort 160/4.5 two puffs twice daily
3. Zyrtec 10 mg daily for the next week and prior to immunotherapy

900   PART III  |  REPORTING PHYSICIAN SERVICES AND OUTPATIENT PROCEDURES

 4. Albuterol two puffs every 4 hours as needed
5. The patient should follow up if symptoms do not clear in the next day or two
6. Report to be sent to Dr. Oligby
7. Patient discharged at 16:55

CASE STUDY #12: ARNOLD TITLEMAN

OPERATION: Colonoscopy to the cecum

DESCRIPTION OF PROCEDURE: The patient was taken to the outpatient endoscopy
suite where he was monitored for pulse oximetry and blood pressure monitoring. He
was turned to the left side and given 50 mg of Demerol with 2 mg of Versed, IV, titrated
during the procedure; the nurse monitored Arnold’s vital signs for a total of 28 minutes.
An Olympus video colonoscope was inserted in the patient’s anus and directed up
to the rectum, sigmoid colon, descending colon, around the splenic flexure, through the
transverse colon, around the hepatic flexure, ascending colon, and cecum. The ileoce-
cal area was inspected and appeared grossly normal.
Terminal ileum was cannulated, appeared grossly normal. The scope was then slowly
withdrawn back through the entire colon, rectum, and anus and no gross abnormality
or lesion was identified. Mucosa pattern appeared normal. The patient tolerated the
procedure well. He will be discharged home with instructions to follow up for a surveil-
lance colonoscopy.

CASE STUDY #13: DARLIN EVERSTANG

OPERATIONS:
. Flexible bronchoscopy
1
2. Cervical mediastinoscopy with biopsy and thyroid isthmusectomy

PROCEDURE: This otherwise normally healthy patient was brought to the operative
suite and placed in supine position. After satisfactory induction of general endotracheal
anesthesia, a flexible Olympus bronchoscope was passed through the endotracheal
tube visualizing the distal trachea, carina, and right and left main stem bronchi of the
CPT © 2017 American Medical Association. All rights reserved.

primary and secondary divisions. No evidence of any endobronchial tumor was noted.
The scope was then withdrawn.
The patient was then prepped and draped in the usual sterile fashion. A shoul-
der roll was placed. A curvilinear incision was made above the suprasternal notch
in the line of a skin crease. Dissection was carried down through the subcutaneous
tissue down through the platysma muscle. The strap muscles were next identified
and laterally retracted. We continued our dissection down to the pretracheal space. A
thyroid isthmusectomy was done without any problems; this gave me clear access to
the pretracheal space. A pretracheal plane was next developed. A mediastinoscope
was placed. I saw multiple, firm right paratracheal lymph nodes. After first aspirating
these structures to make sure they are not vascular in nature, generous biopsies were
taken and sent to pathology for examination. Frozen section analysis revealed these
to be consistent with lymphoma. Excellent hemostasis was obtained. The wound was

CHAPTER 29  | 
 irrigated using warm antibiotic saline solution. The wound was then closed in layers
using Vicryl sutures. Dressings were applied. Marcaine 0.25% was used as a regional
block. The patient tolerated the procedure and was sent to the recovery room in sta-
ble condition.

CASE STUDY #14: DAVIDA PRAGER

PROCEDURE: Needle-localized biopsy, right breast

DESCRIPTION OF PROCEDURE: After proper consent was obtained, the patient
(48-year-old female) was brought to the operating room and placed on the table in a
supine position. Patient was given 2 mg of midazolam HCL, IV, titrated during the proce-
dure; the nurse monitored Davida’s vital signs for a total of 15 minutes.
The right breast area was prepped and draped in a sterile manner. Plain Marcaine
0.5% solution was injected for local anesthesia in the perioperative region. A curvilin-
ear incision was made medial to the insertion site of the wire, as the wire was noted
to pass medially in the breast. The preoperative localization films were reviewed, not-
ing that the clip was posterior to the wire. The dissection was carried out with cau-
tery to remove a core of tissue around the wire, being more generous on the posterior
aspect around the wire and especially near the end of the wire, taking a very generous
area of tissue posteriorly; in fact, it was all the way down to the pectoralis fascia at
that site. The specimen was removed, noting that the wire was within the mid portion
of removed tissue with a large amount of surrounding tissue. This was submitted for
radiographic analysis and the wire was noted to be within the large specimen. How-
ever, the clip could not be visualized. For this reason, the operative area was inspected
with fluoroscopy with diligence and there was no evidence of any residual clip within
the right breast tissue or within the drapes around the right breast. The Ray-Tec
sponge was also evaluated with fluoroscopy and direct inspection and no clip was
noted. The suction canister and tubing were also evaluated with fluoroscopy and no
clip was noted. At this point, due to the generous size of the biopsy specimen, deci-
sion was made to not blindly remove any further breast tissue. I suspect that the clip
may have become stuck to a Ray-Tec sponge or other instrument during this proce-
dure and came out of the wound and fell out of the field of dissection. The opera-
tive area was irrigated, noted to hemostatic, and closed in layers using interrupted
#3-0 Vicryl suture to close deep dermis and running #4-0 subcuticular Vicryl suture
to close the skin. Benzoin, Steri-Strips, and sterile gauze dressings were placed. The
patient had her sedation stopped and she was taken to the recovery area.

CPT © 2017 American Medical Association. All rights reserved.

CASE STUDY #15: HENRY SYSTONA

OPERATION: Orbitotomy on the right with biopsy of right lacrimal gland

DESCRIPTION OF OPERATION: The patient was brought to major operating room
where general endotracheal anesthesia was induced. Lateral lid crease of the right eye
was marked, and I marked the incision to extend lateral to the lateral canthus in case a
lateral orbitotomy became necessary, pending the biopsy. The area of the lateral upper
lid, beyond the lateral canthus, was injected with approximately 5 cc of 50:50 mix of 2%

902   PART III  |  REPORTING PHYSICIAN SERVICES AND OUTPATIENT PROCEDURES

 Xylocaine with 1:100,000 epinephrine, 0.75% Marcaine with 1:100,000 epinephrine.
He was prepped and draped in the usual manner for sterile oculoplastic surgery.
Attention was turned to the right upper lid. A lateral lid crease incision was made
with a 15 blade. Dissection was carried down through the orbicularis to the superior
orbital rim using the Colorado needle. The periosteum of the superior and lateral orbital
rim was incised with the Colorado needle. Freer elevator was then used to reflect the
periorbital off the lateral orbital wall and lateral orbital roof. Prior to proceeding with
the orbital dissection, a 4-0 silk suture was placed on the insertion of the lateral rectus
muscle for traction to better identify lateral rectus if an orbitotomy became necessary.
It was obvious, as the periorbital and lacrimal gland were lifted off the superotem-
poral orbit, that the lacrimal gland was enlarged with an infiltrative mass. Periosteum
was opened near the posterior third of the mass and a modest biopsy was taken. It was
then opened at the anterior edge and a biopsy was taken from this portion. Clinically,
the biopsies looked like a lymphomatous infiltrate. These were sent for frozen section,
and frozen section did reveal lymphomatous infiltrate consistent with non-Hodgkin lym-
phoma. Because of the need for special studies, more tissue was excised and pretty
much as much of the infiltrative mass that was safely excisable was excised.
Bleeders were cauterized with the Colorado needle and the use of cottonoids
saturated with 1:100,000 epinephrine. After adequate hemostasis was obtained, the
4-0 silk was removed from the lateral rectus muscle. The periosteum was closed with
2 interrupted 5-0 Vicryl, and the skin was closed with a running 5-0 fast-absorbing gut.
Polysporin ointment was placed in the right eye and along the wound. He was awak-
ened and taken to the recovery room in good condition. Estimated blood loss less than
10 cc. He tolerated the procedure well without complications.
CPT © 2017 American Medical Association. All rights reserved.

CHAPTER 29  | 
Part IV
DMEPOS & TRANSPORTATION
There is another portion to the procedure coding system that professional coding spe-
cialists use to report services and treatments. HCPCS (pronounced “hick-picks”) is the
acronym for Healthcare Common Procedure Coding System. You have learned about
the CPT codes used to report physician services and outpatient facility services. This
part of this textbook will give you the opportunity to learn about HCPCS Level II
codes (referred to as HCPCS codes).
DMEPOS is a combination abbreviation that stands for
∙ DME = Durable Medical Equipment
∙ P = Prosthetics
∙ O = Orthotics
∙ S = Supplies
Transportation refers to moving a patient from one point to another, such as ambu-
lance services.
30
Key Terms
HCPCS Level II

Learning Outcomes
Advanced Life After completing this chapter, the student should be able to:
Support (ALS)
Basic Life Support LO 30.1 Abstract physician’s notes to identify the category of HCPCS
(BLS) Level II codes needed.
Chelation Therapy LO 30.2 Employ the Alphabetic Index to find suggested HCPCS
DMEPOS Level II codes.
Durable Medical LO 30.3 Distinguish the types of services, products, and supplies
Equipment (DME) reported with HCPCS Level II codes.
Durable Medical
Equipment LO 30.4 Follow the directions supplied by the notations and symbols.
Regional Carrier LO 30.5 Utilize the additional information provided by Appendices.
(DMERC)
Enteral
Not Otherwise
Specified (NOS)
Orthotic Remember, you need to follow along in
Parenteral
Prosthetic
HCPCS Level II
  STOP! your HCPCS Level II code book for an
optimal learning experience.
Self-Administer
Specialty Care
Transport (SCT)

30.1  HCPCS Level II Categories

HCPCS Level II codes and modifiers are listed in their own book and are used to
report services, procedures, and supplies that are not properly described in the CPT
book. There are almost 5,000 HCPCS codes, each represented by five characters: one
letter followed by four numbers.

EXAMPLES
C9460   Injection, cangrelor, 1mg
R0076   Transportation of portable EKG to facility or location, per patient

HCPCS Level II codes cover specific aspects of health care services, including
∙ Durable medical equipment
e.g., a wheelchair or a humidifier
■

∙ Pharmaceuticals administered by a health care provider

e.g., a saline solution or a chemotherapy drug
■

∙ Medical supplies provided for the patient’s own use

e.g., an eye patch or gradient compression stockings
■

∙ Dental services
e.g., all services provided by a dental professional
■

906
 ∙ Transportation services
■ e.g., ambulance services
∙ Vision and hearing services
■ e.g., trifocal spectacles or a hearing screening
∙ Orthotic and prosthetic procedures Orthotic
A device used to correct
■ e.g., scoliosis braces or postsurgical fitting or improve an orthopedic
Not all insurance carriers accept HCPCS Level II codes, but Medicare and Med- concern.
icaid want you to use them. It is your responsibility as a coding specialist to find out Prosthetic
whether each third-party payer with which your facility works accepts HCPCS Level Fabricated artificial replace-
II codes. If not, you have to ask for the payer’s policies on reporting the services and ment for a damaged or miss-
supplies covered by HCPCS Level II. ing part of the body.

EXAMPLES
Medicare accepts HCPCS Level II codes and therefore requires you to code an
injection of tetracycline, 200 mg, with two codes (for administration of the shot
and the drug inside the syringe).
96372 Therapeutic, prophylactic or diagnostic injection (specify substance
or drug injected); subcutaneous or intramuscular
J0120 Injection, tetracycline, up to 250 mg
Yankee Health Insurance does not accept HCPCS Level II codes. This payor
includes reimbursement for the drug in the CPT code for the actual injection.
Therefore, you would only report the one code to get paid for both the service
(the giving of the shot) and the material (the drug inside the syringe).
96372 Therapeutic, prophylactic or diagnostic injection (specify substance
or drug injected); subcutaneous or intramuscular CODING BITES
A physiatrist is a health
care professional who
The process for using HCPCS Level II codes is the same as coding from the CPT uses physical method-
book. You abstract the key words from the physician’s notes regarding the services and ologies to treat illness
procedures, look those key words up in the Alphabetic Index of the appropriate book or injury.
(CPT or HCPCS), confirm the code in the numeric listing, and report the service using These methodolo-
that code. You know how to do this already! However, there are specific elements gies include electrical
unique to HCPCS Level II coding that you need to know. stimulation, heat/cold,
Understanding how to use HCPCS codes accurately will open new employment light, water, exercise,
opportunities for you. In addition to hospitals, physician’s offices, and outpatient clin- manipulation, and
ics, nursing homes, home health care agencies, health care equipment and supply com- mechanical devices.
panies, and other facilities use these codes quite extensively.

HCPCS Level II
LET’S CODE IT! SCENARIO
Carole Shelton, a 47-year-old female, came to see Dr. Giardino, a podiatrist recommended by her primary care
physician, complaining of acute pain in the ball of her left foot. She states that the pain has been ongoing for about
2 months. After examination, and an x-ray of the foot, two views, Dr. Giardino took a walking boot, non-pneumatic,
from the storage room and placed it on her foot. He instructed Carole to wear the boot at all times, except while in
bed, for 6 weeks, and return for a follow-up evaluation.

(continued)
 Let’s Code It!
Review the information in the scenario and abstract the services that Dr. Giardino provided: he evaluated her
condition, took x-rays, and provided her with the boot (durable medical equipment).
You have learned about CPT coding, so you can determine that these two codes will be reported for this
encounter:
99202   Office visit, new patient, problem-focused
73620   Radiologic examination, foot; 2 views
Now, you need to report the provision of the boot. It is only right that Dr. Giardino be reimbursed for providing
this to the patient for her use at home. Turn in your HCPCS Level II code book to the Alphabetic Index, and find:
Walking Boot
custom, L4386
off-the-shelf, L4387
Go back to the documentation, which states, “walking boot.” Terrific! Turn in the Main Section of HCPCS Level II
so you can read the complete code descriptions.
L4386   W
 alking boot, non-pneumatic, with or without joints, with or without interface material, pre-
fabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to
fit a specific patient by an individual with expertise.
L4387  Walking boot, non-pneumatic, with or without joints, with or without interface material, pre-
fabricated, off-the-shelf
Go back to the documentation. Is there any mention of customization, as mentioned in the description for code
L4386? No, there is not. And the documentation does state that the boot came right out of Dr. Giardino’s stor-
age room.
Now, you can report the three codes for this encounter with confidence: the two CPT codes + this one
HCPCS Level II code.
L4387-LT  Walking boot, non-pneumatic, with or without joints, with or without interface material,
prefabricated, off-the-shelf, left foot
Good work!

CODING BITES 30.2  The Alphabetic Index

Never, never, never, Like the other coding books, the HCPCS Level II book has an Alphabetic Index as
never, never code from well as an Alphanumeric Listing.
the Alphabetic Index. The Alphabetic Index lists the Level II code descriptions in alphabetic order from
Always confirm the code A to Z. After abstracting the key terms from the provider’s notes, you can look up key
in the Alphanumeric words in the Alphabetic Index by using the following:
Listing before deciding
which code to report. ∙ Brand name of the drug
∙ Generic name of the drug
∙ Medical supply item
∙ Orthotic
∙ Prosthetic
∙ Service
∙ Surgical supply

908   PART IV  |  DMEPOS & TRANSPORTATION

 The Alphabetic Index will suggest a code or a range of codes, similarly to CPT’s
Alphabetic Index. Then, as you have done before, you look the suggestions up in the
Alphanumeric Listing, read the complete description(s) and all of the symbols and
notations, and determine the best, most accurate code. (NOTE: The Alphabetic Index
in the HCPCS Level II book does not list all the codes included in the Alphanumeric
Listing. So if you can’t find what you are looking for in the Alphabetic Index, you
might want to find something closely related to get you to the appropriate section of
the book and then look around.)
This index includes many alternate terms identified by notations in the Alphanu-
meric Listings:

EXAMPLE
In the Alphabetic Index, you will see
Abciximab, J0130
ReoPro, J0130
In the Alphanumeric Listing, you will see:
J0130   Injection, abciximab, 10 mg
      Use this code for ReoPro

Deleted code descriptions are not included in the Alphabetic Index. However, the
new code(s) that are to be used instead of the deleted code are listed:

EXAMPLE
In the Alphabetic Index, you will see
Ventilator
  home
   used with invasive interface, E0465
In the Alphanumeric Listing, you will see:
E0465 Home ventilator, any type, used with invasive interface, (e.g. trache-
ostomy tube)

The Alphanumeric Listing shows a notation to use one code with another code.

EXAMPLE
In the Alphanumeric Listing, you will see
D2953 Each additional indirectly fabricate post–same tooth
To be used with D2952

HCPCS Level II codes are listed in sections, grouped by the type of service, the
type of supply item, or the type of equipment they represent. However, you should not
assume that a particular item or service is located only in that specific section. Use the
 Alphabetic Index to direct you to the correct category in the Alphanumeric Listing of
the book. One type of service or procedure might be located under several different
categories depending upon the details.

EXAMPLE
Transportation services may be identified by A, Q, R, S, T, or V codes.
Transportation
  Ambulance, A0021–A0999
  Corneal tissue, V2785
  EKG (portable), R0076
  Waiting time, T2007

30.3  The Alphanumeric Listing Overview

The Alphanumeric Listing presents the codes in alphabetic order by the first letter and
then numeric order beginning with the first number of that code. Let’s go through all
the sections together so you can get a general idea of the procedures, services, and sup-
plies that are reported using these codes.

A0000–A0999 Transportation Services Including Ambulance

If a severely ill or injured individual must be moved, whether from home or an acci-
dent scene, to a health care facility or from one health care facility to another, trans-
portation arrangements are made. The patient may need to be lying down or receiving
continuous IV therapy. The health care professional may have to monitor the patient’s
vital signs and other issues constantly. The room for additional personnel, the ability
to keep special equipment secure and functional, and the configuration of the seating
so that everyone involved can be kept safe during the ride are all concerns that demand
more than the average vehicle.
HCPCS Level II codes A0021–A0999 report the following transportation services:
∙ Ground ambulances
Advanced Life Support (ALS)
Life-sustaining, emergency ∙ Air ambulances (often a helicopter but not exclusively)
care provided, such as airway ∙ Nonemergency transportation, such as a special van, a taxi cab, a car, or even a bus
management, defibrillation,
∙ Additional or secondary related costs and fees
and/or the administration of
drugs.
Coding Components
Basic Life Support (BLS)
The provision of emergency The transportation section codes are determined by the answers to these questions:
CPR, stabilization of the 1. What type of vehicle was used to transport the patient?
patient, first aid, control of
bleeding, and/or treatment of ∙ Ground (ambulance, taxi, bus, minibus, van, etc.)
shock. ∙ Air—fixed wing (such as an airplane)
Specialty Care Transport ∙ Air—rotary wing (such as a helicopter)
(SCT) 2. What type of services did the patient need?
Continuous care provided by
one or more health profes-
∙ Emergency
sionals in an appropriate spe- ∙ Nonemergency
cialty area, such as respiratory ∙ Advanced life support (ALS)
care or cardiovascular care,
or by a paramedic with addi- ∙ Basic life support (BLS)
tional training. ∙ Specialty care transport (SCT)

910   PART IV  |  DMEPOS & TRANSPORTATION

 3. Did the ambulance have to wait?
GUIDANCE
4. How many miles did the ambulance have to travel from origin to destination?
CONNECTION
5. Were extra personnel required?
Read the guidelines
Determining the answers to these five questions from the documentation will direct within section A, sub-
you to the best, most appropriate code or codes needed to properly report transporta- head Transportation
tion services for a patient. Services Including
Ambulance A0000–
A0999 in your HCPCS
EXAMPLE Level II book.
EMTs Garret Tyson and Peter Gromine were asked by Jason Aeronson to travel
over the state line to the Morrison Nursing Center and transport his mother,
Melinda Donner, a 93-year-old female, to the Bramington Nursing Center back
near their home base and Jason’s home. Ms. Donner requires ALS services during
the ambulance transport. Upon arrival at Morrison Nursing Center, they had to wait
30 minutes for the staff to process Melinda out and release her to their care. The
round trip was 52 miles. Pre-approval from Medicaid was documented.
A0021x52 Ambulance service, outside state per mile, transport, 52 miles
round trip
A0420 Ambulance waiting time (ALS or BLS), one-half hour
increments

HCPCS Level II
LET’S CODE IT! SCENARIO
Priscilla DeLucca, an emergency medical technician (EMT), was called in as an extra ambulance attendant for the
ALS ground transportation of Willow Lawarence, a 12-year-old autistic female.

Let’s Code It!

Priscilla was called in as an extra ambulance attendant. When you look in the Alphabetic Index of the HCPCS
Level II book, notice that this does not match any of the listings under Ambulance or Attendant. So let’s turn to
the range shown next to the term Ambulance in the index: A0021–A0999.
Although reading down the listing will take time, sometimes it is the best way to find the code you need. For-
tunately, you won’t have to read too far to reach:
A0424 Extra ambulance attendant, ground (ALS or BLS) or air (fixed or rotary winged); (requires
medical review)

Transportation Codes in Other Sections

A few transportation codes in the HCPCS Level II book are in sections other than the
A codes. This, of course, is an excellent example of why you should use the Alphabetic
Index to find the best code in the Alphanumeric Listing—because there may be a bet-
ter, more appropriate code in a section you might not otherwise examine. In all cases
of temporary codes, you must confirm the acceptance of the temporary code by the
third-party payer to whom you are billing.
The S series (S0000–S9999) consists of temporary codes and is not accepted by
Medicare, according to the HCPCS Level II book. Medicaid programs and some pri-
vate insurers, such as Blue Cross and Blue Shield Association, do accept S codes.
 You must check with the organization or association in your state to confirm the accep-
tance of S codes. Here are two of the S codes that relate to transportation:
S0215 Nonemergency transportation; mileage, per mile
S9992 Transportation costs to and from trial location and local transporta-
tion costs (e.g., fares for taxicab or bus) for clinical trial participant
and one caregiver/companion

The T codes (T1000–T9999) are used by Medicaid state agencies to report services,
procedures, and other items for which there are no permanent national codes. You must
communicate with the third-party payer to whom you are sending the claim to ensure
that it accepts T codes. Here are some transportation services that may be reported
using T codes:
T2001 Non-emergency transportation; patient attendant/escort
T2002 Non-emergency transportation; per diem
T2003 Non-emergency transportation; encounter/trip
T2004 Non-emergency transport; commercial carrier, multi-pass
T2005 Non-emergency transportation; stretcher van
T2007 Transportation waiting time, air ambulance and non-emergency vehi-
cle, one-half (1/2) hour increments
T2049 Non-emergency transportation; stretcher van, mileage; per mile

HCPCS Level II
LET’S CODE IT! SCENARIO
Barry Camacho, a 79-year-old male, had a stroke 3 weeks ago. He has now improved sufficiently to be discharged
from the hospital. However, he is not completely well. Barry is being transferred to a short-term rehabilitation facility
to help him regain use of his legs and right arm. Ira Waxen, from Flomenhoff Ambulance Services, drove the wheel-
chair van to take Barry from McGraw Hospital to Flowers Nursing and Rehabilitation Center, a 12-mile ride.

Let’s Code It!

Ira, the driver, will submit the documentation to you. He noted that he drove a wheelchair van to transport Barry
from the hospital to the nursing facility. The notes also indicate that Barry is being discharged from the hospital
and there is no indication that this is an emergency. In addition, the wheelchair van does not contain emergency
equipment, so we know that this is a non-emergency trip.
Let’s go to the Alphabetic Index and turn to Wheelchair. Go down the list to the indented term van, non-
emergency transport, mileage, S0209. Turn to the Alphanumeric Listing to check out the complete description
of the first code:

A0130   Non-emergency transportation: wheelchair van

This matches Ira’s documentation, doesn’t it? Yes. In addition, it is the only code shown for that portion of
the service. However, you might also look in the Alphabetic Listing under Transportation, non-emergency,
A0080–A0210, T2001–T2005. Once you review the complete descriptions of the suggested codes, you will
see rather quickly that A0130 is the most specific and accurate.
Now, you must include a code for the mileage traveled by the van. Under Wheelchair, van, non-emergency,
mileage, you get the suggestion for code S0209, and while under Transportation, non-emergency, mileage, you
see S0215. Let’s examine both codes:
S0209 Wheelchair van, mileage, per mile
S0215 Non-emergency transportation; mileage, per mile

912   PART IV  |  DMEPOS & TRANSPORTATION

 You also might notice:
A0380 BLS mileage (per mile)
A0390 ALS mileage (per mile)
A0425 Ground mileage, per statute mile
Five different codes appear applicable to report the mileage component of the service. Look at S0209 versus
S0215 versus A0380, A0390, and A0425. You can see that the descriptions of A0380 and A0390 do not match
your notes and would be considered upcoding! S0209 is more accurate and more specific in its description of
the type of vehicle involved in the transportation. Therefore, as long as the insurance carrier accepts S codes,
the claim form should show these codes:
A0130 Non-emergency transportation: wheelchair van
S0209 Wheelchair van, mileage, per mile;
Number of miles: twelve (12)
Great job!

Ambulance Origin/Destination
When reporting transportation services to insurance carriers, you have to identify the
origin of service and the destination of service. The most common modifiers for the
origin and the destination of service are one-letter codes that categorize locations.

D Diagnostic or therapeutic site other than “P” or “H” when these are used
as origin codes
E Residential, domiciliary, custodial facility (other than 1819 facility)
G Hospital-based ESRD facility
H Hospital
I Site of transfer (e.g. airport or helicopter pad) between modes of ambu-
lance transport
J Free standing ESRD facility
N Skilled nursing facility (SNF) (1819 facility)
P Physician’s office
R Residence
S Scene of accident or acute event
X Intermediate stop at physician’s office on way to hospital (destination
code only)
Durable Medical Equipment
(DME)
A4206–A8004 Medical and Surgical Supplies Apparatus and tools that
and A9150–A9999 Administrative, Miscellaneous, help individuals accommo-
date physical frailties, deliver
and Investigational pharmaceuticals, and provide
These codes cover medical supplies, surgical supplies, and some services related to other assistance that will last
durable medical equipment (DME). for a long time and/or be used
In almost every health care encounter, materials and supplies are used. The paper to assist multiple patients
used to cover the examination table and the disposable cover on the digital thermome- over time.
ter are good examples. Such medical supplies are used by the health care facility itself. Self-Administer
However, they are not the types of medical and surgical supplies to which the HCPCS To give medication to oneself,
Level II book refers. The codes in the HCPCS Level II book are for reporting supplies such as a diabetic giving her-
given to a patient to self-administer health care at home. self an insulin injection.
 A Codes and B Codes
Let’s begin by reviewing the subheadings throughout the A code and B code sections
to get a good idea of which items are covered.
∙ Miscellaneous Supplies: The supplies used by a physician in the course of treatment
(syringes, alcohol wipes, urine test strips, and so on) are included in the amount
reimbursed for the provision of that treatment or service. The codes in miscella-
neous supplies (HCPCS Level II) are used to report, and be reimbursed for, sup-
plies provided to patients for their own use at home. For example, if a diabetic
patient requires a daily insulin shot at home, he or she would need to have syringes
available.
∙ Vascular Catheters: These codes report the use of a disposable drug delivery system
(DDS) as well as implantable access catheters. The codes are not for reporting the
physician’s work to implant the catheter but for the facility to be reimbursed for the
cost of the catheter itself.
∙ Incontinence Appliances and Care Supplies and External Urinary Supplies: The
sections Incontinence Appliances and Care Supplies and External Urinary Supplies
cover urinary supplies that a patient uses when he or she has been diagnosed with
permanent, or chronic, incontinence.
∙ Ostomy Supplies: Patients who have had surgery to create an ostomy need supplies
every day to make their medical situation easier to deal with and to enable them to
live their lives more normally.

EXAMPLES
A4245 Alcohol wipes, per box
A4452 Tape, waterproof, per 18 sq in.
A4490 Surgical stocking above knee length, each
A4637 Replacement, tip, cane, crutch, walker, each

You will also find codes in this section for

∙ Nonprescription drugs (also known as over-the-counter drugs)
∙ Exercise equipment
∙ Radiopharmaceutical diagnostic imaging agents
∙ Noncovered items and services
(NOTE: An item or service may be noncovered with regard to national standards but
covered by your state or other third-party carrier. Never take anything for granted.
Always ask!)

EXAMPLES
A9280 Alert or alarm device, not otherwise classified
A9505 Thallium T1-201, thallous chloride diagnostic, per millicurie

HCPCS Level II
LET’S CODE IT! SCENARIO
Teresa Baum, a 55-year-old female, has been diagnosed with malignant neoplasm of the liver. She has lost all her
hair because of the chemotherapy and radiation treatments. Dr. Colter prescribed a wig to help lift her spirits and
self-esteem.

914   PART IV  |  DMEPOS & TRANSPORTATION

 Let’s Code It!
You have to submit a claim to Medicare for the wig. Let’s go to the Alphabetic Index of the HCPCS Level II book
and find the W section. Beneath this, find
Wig, A9282
Go to the Alphanumeric Listing to confirm it is the best code:
A9282   Wig, any type, each

B4034–B9999 Enteral and Parenteral Therapy

The B codes cover supplies, formulas, nutritional solutions, and infusion pumps for
enteral and parenteral therapy. These codes report the supply of items related to Enteral
providing nutrition to a patient by alternate means—other than by mouth and/or the Within, or by way of, the gas-
digestive tract. trointestinal tract.
Parenteral
By way of anything other
than the gastrointestinal tract,
EXAMPLES such as intravenous, intra-
B4083 Stomach tube–Levine type muscular, intramedullary, or
B9006 Parenteral nutrition, infusion pump, stationary subcutaneous.

C1000–C9999 CMS Hospital Outpatient Payment System

Codes from the Temporary Hospital Outpatient PPS category are used to report drugs,
biologicals, devices for transitional pass-through payments for hospitals, and items GUIDANCE
classified in new-technology ambulatory payment classifications. CONNECTION
Read the guidelines
within section C, sub-
EXAMPLES head CMS Hospital
Outpatient Payment
C1724 Catheter, transluminal atherectomy, rotational System (C1000–
C2636 Brachytherapy linear source, nonstranded, palladium 103, per 1 mm C9999) in your HCPCS
C9364 Porcine implant (Permacol), per square cm Level II book.

D0000–D9999 Dental Procedures

The Dental Procedures category is the Dental Procedures and Nomenclature (CDT)
code set, copyrighted by the American Dental Association.
The codes are used to report dental services, such as x-rays (Figure 30-1).

EXAMPLES
D0240 Intraoral–occlusal film
D1110 Prophylaxis–adult
FIGURE 30-1  An x-ray
D3310 Endodontic therapy, anterior tooth (excluding final restoration)
showing a full-mouth view
NOTE: Prophylaxis is also known as a dental cleaning, and anterior (excluding final is one type of dental
restoration) is one of the codes that can be used to report root canal therapy. service  ©Stockbyte/Getty
Images RF
 HCPCS Level II
LET’S CODE IT! SCENARIO
Alvin Tunney, an 81-year-old male, came to Dr. Kahn for a complete maxillary denture. His old one was broken
beyond repair, so Alvin needed something immediately.

Let’s Code It!

Dr. Kahn provided Alvin with a complete maxillary denture. Let’s go to the HCPCS Level II Alphabetic Index:

Dentures D5110–D5899

As you read the full list, you see that the reference matches Dr. Kahn’s notes. Next, turn to the Alphanumeric List-
ing to see which code is the most accurate.

D5110 Complete denture—maxillary

D5120 Complete denture—mandibular
D5130 Immediate denture—maxillary
D5140 Immediate denture—mandibular

Is there additional information in the notes that will help us determine the best code? They state that Alvin
needed the denture immediately. It leads us directly to this code:

D5130   Immediate denture—maxillary

Excellent!

E0100–E1841 Durable Medical Equipment

The E codes are used to identify certain pieces of durable medical equipment (DME)
provided to a patient.
Science and technology have provided our society with great innovations that make
life easier and more functional. Canes, walkers, and wheelchairs, among other items,
help individuals move from one place to another without further assistance. Porta-
ble oxygen, humidifiers, vaporizers, and other equipment assist breathing, and pace-
makers and electrical nerve stimulators help keep a heart beating. Some items are so
commonplace that we take them for granted, yet only 10 years ago, patients would
be forced to stay home all day every day. Other products, such as wheelchairs, have
evolved into more convenient and accommodating pieces of equipment. Each item and
every accessory costs money to build. Therefore, the health care facility or company
should be reimbursed for giving, renting/leasing, or selling equipment. HCPCS Level
II codes for DME are used in the reimbursement process.

Durable Medical Equipment

Durable medical equipment (DME) includes such items as canes, wheelchairs, and
ventilators. However, to be accurate, Medicare has four qualifiers to determine
whether an item can be classified as DME. These qualifiers are

1. The item can withstand repeated use.

2. The item is primarily used for medical purposes.
3. The item is used in the patient’s home (rather than only in a health care facility).
4. The item would not be used if the individual were not ill or injured.

916   PART IV  |  DMEPOS & TRANSPORTATION

 Most often, DMEPOS dealers supply DME to the patient. Such companies submit DMEPOS
their claims not to Medicare or the state’s Medicare fiscal intermediary (FI) but to Durable medical equipment,
their assigned durable medical equipment regional carrier (DMERC), which is prosthetic, and orthotic
contracted by Centers for Medicare and Medicaid Services (CMS). supplies.

Durable Medical Equipment

HCPCS E Code Subheadings Regional Carrier (DMERC)
The DME E code section, codes E0100–E8002, is divided into subheadings. It is A company designated by the
not the only section in the HCPCS Level II book having codes related to DME ser- state or region to act as the
vices and supplies; however, it is the section dedicated to them. Take a minute to look fiscal intermediary for all DME
through its subheadings, and you should gain a clearer understanding of the items and claims.
services included here.

EXAMPLES
• Canes
• Crutches
• Walkers

CODING BITES
Be careful not to confuse the HCPCS Level II E codes with ICD-10-CM E codes,
which report endocrinological illnesses.

E0980   Safety vest, wheelchair

Letter followed by four numbers (from HCPCS Level II)
E09.8  Drug or chemical induced diabetes mellitus with unspecified
complications CODING BITES
Letter followed by two numbers, a period, and possibly additional numbers or Remember that a cod-
letters (from ICD-10-CM) ing specialist’s job is to
report with the greatest
specificity. There will
be times when you will
EXAMPLES need a code from this
E0105 Cane, quad, or 3-prong, includes canes of all materials, adjustable section because it pro-
or fixed, with tips vides more specificity
E0156 Seat attachment, walker than a code from
E0242 Bathtub rail, floor base the CPT.

G0000–G9999 Temporary Procedures/ CODING BITES

Professional Services Within section G, sub-
head Physician Quality
Codes from this section are used to report services and procedures that do not have an
Reporting Indicator
accurate code description in the main portion of the CPT book.
Code (PQRI) in your
HCPCS Level II book are
additional guidelines
EXAMPLES for reporting these ser-
G0102 Prostate cancer screening; digital rectal examination vices. “If appropriate
G0151 Services of physical therapist in home health or hospice setting, each Category II codes are
15 minutes not available, HCPCS
G0268 Removal of impacted cerumen (one or both ears) by physician on Level II G-codes may
same date of service as audiologic function testing be used.”
 H0001–H9999 Substance Abuse Treatment Services
When alcohol and drug treatment, as well as some other mental health services, is
provided, some state Medicaid agencies will have you use codes from the Alcohol and
Drug Abuse Treatment Services category.

EXAMPLES
H0005 Alcohol and/or drug services; group counseling by a clinician
H0038 Self-help/peer services, per 15 minutes
H2020 Therapeutic behavioral services, per diem

J0100–J8999 Drugs Other Than Chemotherapy Drugs

As the title so clearly states, the Drugs Administered category provides you with codes
to identify drugs that are given to the patient by a health care professional in any
way. This includes immunosuppressive drugs, inhalation solutions, and other miscel-
laneous drugs and solutions.

EXAMPLES
J0207 Injection, amifostine, 500 mg
J7100 Infusion, dextran 40, 500 mL
J7610 Albuterol, inhalation solution, compounded product, administered
through DME, concentrated form, 1 mg

You will find that drugs identified in the code descriptions are most often the chem-
ical, or generic, name of the pharmaceutical. At times the brand, or trade, name is
listed in the Alphabetic Index and/or in the Table of Drugs in an appendix of your
HCPCS Level II book. If your provider notes refer to a name that you cannot find in
this book, you might need to look in the Physician’s Desk Reference (PDR) to find an
alternate name for the drug.

EXAMPLE
Dr. Valentine asked the nurse to administer a 250 mg tablet, CellCept, PO, to
Benjamin Rudon.
CellCept, generic name mycophenolate mofetil, is classified as an
immunosuppressant.
• Neither name is listed in the Alphabetic Index of HCPCS.
• CellCept is listed in the Table of Drugs.
• Mycophenolate mofetil is listed in the Table of Drugs.
J7517   Mycophenolate mofetil, oral, 250 mg

In the chapter CPT Medicine Section, you learned about coding for the administra-
tion of pharmaceuticals (drugs). Those codes are used for reporting the services—
the labor—of the health care professional who gives the patient the drug. You may
remember that the different methods of administering drugs include
IA Intra-arterial administration
IV Intravenous administration (e.g., gravity infusion, injections, and
timed pushes)

918   PART IV  |  DMEPOS & TRANSPORTATION

 IM Intramuscular administration
IT Intrathecal
SC Subcutaneous administration
INH Inhaled solutions
VAR Various routes for drugs that are commonly administered into
joints, cavities, tissues, or topical applications, as well as other par-
enteral administrations
ORAL Administered orally
OTH Other routes of administration, such as suppositories or catheter
injections

The codes in HCPCS Level II enable you to report and gain reimbursement for the
actual drug or medication, as well as the syringe or IV bag used. The codes cover the
pharmaceutical materials only—not the administration of the drug.
In some cases, you may find DME has been supplied to the patient to provide medi-
cation, or drugs. When the equipment is made available to an individual, it may need
to be reported separately from the drug itself.

HCPCS Level II
LET’S CODE IT! SCENARIO
Janine Howell, a 55-year-old female, came in for her chemotherapy treatment. She is given Myocet, 30 mg/m2 daily
for 3 days, as treatment for metastatic breast neoplasms. This is day 2. The IV infusion takes 51 minutes. She toler-
ates the treatment well, and is discharged home.

Let’s Code It!

You learned in the CPT Medicine Section chapter that you will need one code for the administration of this drug
therapy and a second code from HCPCS Level II to identify the specific drug administered.
Let’s begin determining the code for the Myocet. Open your HCPCS Level II code book to the Table of Drugs.
Did you find it listed? It is not there. Check the HCPCS Level II code book’s Alphabetic Index. It is not there either.
You know there must be a code for this, so Myocet may be an alternate name. You will need to check the PDR.
[NOTE: If you do not have access to the PDR, you can use Drugs.com.]
You will see in the listing for Myocet that:
Therapeutic Classification: Antineoplastic
Common Name: Doxorubicin hydrocholoride
Go back to the HCPCS Level II code book’s Table of Drugs. Can you find it using the common name?
Doxorubicin HCL 10 MG IV J9000
Now, let’s go into the Alphanumeric Listing and find the specific code and its full description.
J9000 Injection, doxorubicin HCL, 10 mg
Perfect! However, this code only reports the provision of 10 mg. The documentation states, “30 mg.” Therefore,
you will need a multiplier.
J9000x3 Injection, doxorubicin HCL, 10 mg × 3
If you have your CPT code book nearby, try to determine the code for the administration of this medication. Did
you determine this to be the correct code?
96413 Chemotherapy administration, intravenous infusion technique; up to 1 hour, single or
initial substance/drug
Good work!
 K0000–K9999 Temporary Codes Assigned to DME Regional
Carriers
Durable Medical Equipment The K codes were developed for durable medical equipment regional carriers
Regional Carrier (DMERC) (DMERCs) to report services that are not currently identified by other codes.
A company designated by the
state or region to act as the
fiscal intermediary for all DME
claims. EXAMPLES
K0001 Standard wheelchair
K0462 Temporary replacement for patient-owned equipment being
repaired, any type

L0100–L4999 Orthotics and L5000–L9999 Prosthetics

The codes included in the Orthotic Procedures and Devices and Prosthetic Procedures
and Devices categories identify orthotic devices, orthopedic shoes, prosthetic devices,
prosthetic implants, and scoliosis equipment.
An orthotic is a device used to correct or improve the function of a musculoskeletal
concern or abnormality, whereas a prosthetic is an artificial replacement for a dam-
aged or missing part of the body (see Figure 30-2).

FIGURE 30-2  A U.S.

veteran uses his
prosthetic leg and
becomes a world-class
athlete  ©615 collection/
Alamy Stock Photo

920   PART IV  |  DMEPOS & TRANSPORTATION

 EXAMPLES
Orthotics
L0170 Cervical, collar, molded to patient model
L0984 Protective body sock, prefabricated, off-the-shelf, pair
L3809 Wrist-hand-finger orthosis, without joint(s), prefabricated, off-the-
shelf, any type
Prosthetics
L5100 Below knee, molded socket, shin, SACH foot
L6100 Below elbow, molded socket, flexible elbow hinge, triceps pad
L8020 Breast prosthesis, mastectomy form
SACH = Solid-Ankle Cushioned Heel

M0000–M0301 Other Medical Services

The codes in the Office and Other Medical Services category cover cellular therapy,
prolotherapy, intragastric hypothermia, intravenous chelation therapy, and fabric Chelation Therapy
wrapping of an abdominal aneurysm (MNP). The use of a chemical com-
pound that binds with metal in
the body so that the metal will
EXAMPLES lose its toxic effect. It might
M0075 Cellular therapy be done when a metal disc
M0301 Fabric wrapping of abdominal aneurysm or prosthetic is implanted in
a patient, eliminating adverse
reactions to the metal itself as
P0000–P9999 Laboratory Services a foreign body.

HCPCS Level II codes in the Temporary Laboratory and Pathology Services category
include codes for services not listed in the CPT book, including chemistry, toxicology,
microbiology, screening Papanicolaou (Pap) procedures, and numerous blood products.

EXAMPLES
P2031 Hair analysis (excluding arsenic)
P7001 Culture, bacterial, urine; quantitative, sensitivity study
P9051 Whole blood or red blood cells, leukocytes reduced, CMV-negative,
each unit

CODING BITES
Q0000–Q9999 Temporary Codes Assigned by CMS
Remember that you
The Q codes replace the less specific codes that you may find elsewhere in the coding must always choose the
process for casting and splinting supplies when a health care professional cares for a code with the greatest
patient with a fracture. The section also includes codes for certain drugs and services specificity.
having nothing to do with the management of a fracture.

EXAMPLES
Q0113 Pinworm examination
Q2017 Injection, teniposide, 50 mg
Q4049 Finger splint, static

R0000–R9999 Diagnostic Radiology Services

The codes in the Diagnostic Radiology Services section are used to report the hauling
of portable radiologic equipment.
 EXAMPLES
R0070 Transportation of portable x-ray equipment and personnel to home
or nursing home, per trip to facility or location, one patient seen
R0075 Transportation of portable x-ray equipment and personnel to home
or nursing home, per trip to facility or location, more than one
patient seen
R0076 Transportation of portable EKG to facility or location, per patient

S0000–S9999 Temporary National Codes (Non-Medicare)

CODING BITES The Temporary National Codes section was developed by the Health Insurance
Be certain to ask the Association of America (HIAA) and the Blue Cross Blue Shield Association (BCBSA)
third-party payer if they for use by the Medicaid program and other third-party payers. The codes cover sup-
accept “S” codes and, plies, services, and drugs for which there are no other codes.
if not, ask how to report
these services and
provisions. EXAMPLES
S0081 Injection, piperacillin sodium, 500 mg
S0317 Disease management program; per diem
S2060 Lobar lung transplantation
S9024 Paranasal sinus ultrasound

T1000–T9999 Temporary National Codes Established

by Medicaid
Planned for use by state agencies that administer Medicaid programs, the T codes
are used to report services not otherwise described by any other code. Services rep-
resented in this category include nursing facility and home health–related services,
substance abuse treatment, and training-related procedures.

EXAMPLES
T1013 Sign language or oral interpretive services, per 15 minutes
T2022 Case management, per month
T2045 Hospice general inpatient care; per diem

V0000–V9999 Vision, Hearing, Speech-Language Pathology

Services
V0000–V2999 Vision Services
If not represented by any other codes, ophthalmic and optometric services and sup-
plies may be coded from this V code category, including contact lenses, intraocular
lenses, miscellaneous lenses, prostheses, spectacles, and other vision-related supplies.

EXAMPLES
V2118 Aniseikonic lens, single vision
V2321 Lenticular lens, per lens, trifocal
V2530 Contact lens, scleral, gas impermeable, per lens

922   PART IV  |  DMEPOS & TRANSPORTATION

V5000–V9999 Hearing and Speech-Language Pathology Services
Services related to hearing and speech-language pathology are included in this V code
category and cover hearing tests, repair of augmentative communicative system, speech-
language pathology screenings, and other hearing test–related supplies and equipment.

EXAMPLES
V5008 Hearing screening
V5100 Hearing aid, bilateral, body worn
V5364 Dysphagia screening

HCPCS Level II
YOU CODE IT! CASE STUDY
Alfonzo Doyle, a 20-year-old male, lost his eye in a skiing accident and has come to see Dr. Durran to receive his
prosthetic eye. It is a custom-made, plastic prosthesis. Code for the prosthesis only.

You Code It!

Go through the steps of coding, and determine the code(s) that should be reported for the prosthetic provided
by Dr. Durran to Alfonzo Doyle.
Step #1: Read the case carefully and completely.
Step #2: Abstract the scenario. Which key words or terms describe what service the physician provided to the
patient during this encounter?
Step #3: Are there any details missing or incomplete for which you would need to query the physician? [If so, ask
your instructor.]
Step #4: Determine the correct HCPCS Level II code or codes to explain the details about what was provided to
the patient during this encounter.
Step #5: Check for any relevant guidance, including reading all of the symbols and notations.
Step #6: Do you need to append any modifiers to ensure complete and accurate information is provided?
Step #7: Double-check your work.
Answer
Did you find this to be the correct code?

V2623   Prosthetic eye, plastic, custom

Good job!

30.4  Symbols and Notations

Throughout many versions of a HCPCS Level II code book, you may see notations GUIDANCE
that will help you use the codes correctly and determine the best, most appropriate CONNECTION
code available. Check the front of your code book for meanings. Read the guidelines in
the Introduction and
Symbols HCPCS Level II Use and
Convention sections
Bullet in your HCPCS Level II
A large bullet ( ), or solid circle, shown next to a code indicates that it is the first year book.
that the code is included in this code set. That is, it marks a new code.
 EXAMPLES
J0604 Cinacalcet, oral, 1mg (for ESRD on dialysis)
J0606 Injection, etelcalcetide, 0.1 mg

Solid Triangle
A solid triangle ( ) shown next to a code lets you know that the code’s description
has been changed or adjusted since last year or that a rule or guideline regarding the
code has changed.

EXAMPLES
G8400 Patient with central dual-energy x-ray absorptiometry (DXA)
results not documented, reason not given
L1902 Ankle orthosis, ankle gauntlet or similar, with or without joints,
prefabricated, off-the-shelf

Open Circle
An open circle ( ) next to a code identifies that the code had been deleted but now has
been restored (reinstated).

EXAMPLES
J3090 Injection, tedizolid phosphate, 1 mg
CODING BITES J3380 Injection, vedolizumab, 1 mg

In CPT, the symbol

means that the code Circle with Slash
may not be used with A circle with a slash through it ( ), also known as the Forbidden Symbol in the
modifier 51. In HCPCS HCPCS Level II book, identifies a code that is not covered under the skilled nursing
Level II, this same sym- facility (SNF) prospective payment system (PPS).
bol means not covered
under SNFPPS.
EXAMPLES
L5970 All lower extremity prostheses, foot, external keel, SACH foot
CODING BITES
L7367 Lithium ion battery, rechargeable, replacement
Should the provider
administer less than
the amount in the code Box with Check Mark
descriptor, report the
A check mark inside a square box ( ) marks a code description that identifies a spe-
code.
cific quantity of material or supply. It is a reminder for you to check the detail in the
When more than
notes and report the code not only for the item it represents but for the amount as well.
the quantity in the
code description is
indicated, report the EXAMPLES
appropriate code in
the proper number. For J0894 Injection, decitabine, 1 mg
example, the provider K0073 Caster pin lock, each
gave the patient 2 mg
of decitabine, report
Male Symbol
J0894 ×2 to indicate
two units. The male symbol ( ) is placed next to codes that identify procedures, services, and
equipment that can only be performed or used on a male patient.

924   PART IV  |  DMEPOS & TRANSPORTATION

 EXAMPLES
L3219 Orthopedic footwear, man’s shoes, Oxford, each
L8330 Truss, addition to standard pad, scrotal pad

Female Symbol
The female symbol ( ) identifies codes used to report procedures, services, and equip-
ment that can only be performed or used on a female patient.

EXAMPLES
A4286 Locking ring for breast pump, replacement
L8600 Implantable breast prosthesis, silicone or equal

Capital Letter A
The symbol highlights the fact that a code is used only for procedures, services, and
equipment that are performed or used on a patient of a certain age group. Read the
code description carefully to ensure the age limitation of the code matches the patient.

EXAMPLES
A4280 Adhesive skin support attachment for use with external breast
prosthesis, each
A4561 Pessary, rubber, any type

Capital Letter M
The symbol is used to remind you that the code describes maternity procedures,
services, and equipment that are performed or used on a pregnant female 12–55 years
of age.

EXAMPLES
A4284 Breast shield and splash protector for use with breast pump,
replacement
S9001 Home uterine monitor with or without associated nursing services

Z1111 Any Code with a Line Through It

A line through the center of a code and its description means that the code has been
deleted and may no longer be used.

EXAMPLES
G6018 Ileoscopy, through stoma; with transendoscopic stent placement
(includes predilation)
S9015 Automated EEG monitoring

Notations
Just as in the CPT book, you will find notations (below code descriptions in the Alpha-
numeric Listing) that guide you on the proper use of HCPCS Level II codes.
 Always Report Concurrent to the xxx Procedure
This notation directs you to always report this code with a code for another specific
procedure. The notation is similar to the “code also” instruction found in CPT or
ICD-10-CM.

EXAMPLE
A4262 Temporary, absorbable lacrimal duct implant, each
Always report concurrent to the implant procedure.

A4263 Permanent, long-term, non-dissolvable lacrimal duct implant, each

Always report concurrent to the implant procedure.

In the previous example, the “A” code is for the implant itself, and the note reminds
you that you have to code the physician’s services for putting the implant into the
patient.

See Also Code Z1111

The see also code notation cross-references this code with another code that may be
similar in description. The notation serves as a reminder for you to double-check that
you are using the most accurate code.

EXAMPLES
A4450 Tape, non-waterproof, per 18 square inches
See also code A4452
A4452 Tape, waterproof, per 18 square inches
See also code A4450

Clarifications of Coverage
Clarifications of coverage notations are worded differently from code to code but
indicate when to use or not use the code. However, always check with the specific
payer to whom you will be sending the claim.

EXAMPLES
A4570 Splint
Dressings applied by a physician are included as part of the
professional service.
A6260 Wound cleansers, any type, any size
Surgical dressings applied by a physician are included as part of
the professional service. Surgical dressings obtained by the patient
to perform homecare as prescribed by the physician are covered.

Report in Addition to Code Z1111

When one code is to be reported with other codes, a notation Report in addition to
(a particular code) will identify those circumstances. It not only tells you the circum-
stances but also tells you which code to use. You may notice that it is similar to an
add-on code in CPT.

926   PART IV  |  DMEPOS & TRANSPORTATION

 EXAMPLE
D2953 Each additional indirectly fabricated post—same tooth
Report in addition to code D2952

To Report, See Code Z1111

When a code has been deleted, you may find a notation that directs you to another
HCPCS Level II code that can be used instead.

EXAMPLES
J0560 Injection, penicillin G benzathine, up to 600,000 units
To report, see J0561
C9026 Injection, vedolizumab, 1 mg
To report, see J3380

See Code(s): 00000

The notation See (a particular code) refers you to a CPT code for a description that is
potentially better and may be more specific for reporting what was actually done or
given to the patient.

EXAMPLES
E1130 Standard wheelchair; fixed full-length arms, fixed or swing-away,
detachable footrests
See code(s): K0001

E1086 Hemi-wheelchair detachable arms, desk or full-length, swing-

away, detachable footrests
See code(s): K0002

Determine If an Alternative HCPCS Level II or a CPT Code Better

Describes . . .
You will see the notation Determine if an alternative HCPCS Level II or a CPT code
better describes beneath each miscellaneous, unlisted, unclassified, not otherwise
classified (NOC), not otherwise listed, or not otherwise specified (NOS) code. The Not Otherwise Specified
notation serves as a warning to you to make certain that there is no better or more spe- (NOS)
cific code in either the CPT or elsewhere in this HCPCS Level II book that correctly An indication that more
reports the services or procedures performed. detailed information is not
available from the physician’s
notes.
EXAMPLES
L0999 Addition to spinal orthosis, not otherwise specified
Determine if an alternative HCPCS Level II or a CPT code better
describes the service being reported. This code should be used
only if a more specific code is unavailable.

J8999 Prescription drug, oral, chemotherapeutic, NOS

Determine if an alternative HCPCS Level II or a CPT code better
describes the service being reported. This code should be used
only if a more specific code is unavailable.
 Use This Code for . . .
The notation Use this code for provides you with alternative names, brand names, and
other terms that are also represented by the code’s description.

EXAMPLES
J0585 Injection, onabotulinumtoxinA, 1 unit
Use this code for Botox, Botox Cosmetic
J1160 Injection, digoxin, up to 0.5 mg
Use this code for Lanoxin

Pertinent Documentation to Evaluate Medical Appropriateness

Should Be . . .
Some procedures are not automatically accepted as being medically necessary. The
notation Pertinent documentation to evaluate medical appropriateness should be
warns you up-front that you should include the proper documentation along with the
claim the first time you submit it, rather than wait to be asked by the third-party payer,
which would delay payment.

EXAMPLES
D2980 Crown repair, by report
Pertinent documentation to evaluate medical appropriateness
should be included when this code is reported.
V2399 Specialty trifocal (by report)
Pertinent documentation to evaluate medical appropriateness
should be included when this code is reported.

Do Not Use This Code to Report . . .

The notation Do not use this code to report warns you of circumstances when you are
not permitted to use a code.

EXAMPLE
D3220 Therapeutic pulpotomy (excluding final restoration)—removal of
pulp coronal to the dentinocemental junction and application of
medicament
Do not use this code to report the first stage of root canal therapy.

Medicare Covers . . .
Throughout the HCPCS Level II book, you will see notations giving you information
about coverage, particularly Medicare and Medicaid coverage. You should note that
the book covers the entire nation and that both programs are state-administered. This
means that you should still confirm the terms and policies of what is covered with
your own state’s fiscal intermediary (FI)—the agency or organization that is in charge
of reimbursement for your state’s program. Also check with other third-party payers to
see if they will cover this item or service.

928   PART IV  |  DMEPOS & TRANSPORTATION

 EXAMPLES
E0607 Home blood glucose monitor
Medicare covers home blood-testing devices for diabetic patients
when the devices are prescribed by the patient’s physicians.
Many commercial payers provide this coverage to non–insulin
dependent diabetics as well.
Q0174 Thiethylperazine maleate, 10 mg, oral, FDA approved prescription
antiemetic, for use as a complete therapeutic substitute for an IV
antiemetic at the time of chemotherapy treatment, not to exceed a
48-hour dosage regimen
Medicare covers at the time of chemotherapy if regimen doesn’t
exceed 48 hours. Submit on the same claim as the chemotherapy.

Code with Caution

When you see the notation Code with caution beneath a code, you need to go back and
double-check the provider’s notes carefully. If this is what was actually done, then be
certain to attach documentation explaining why that method was used instead of the
newer technique because it is surely going to be questioned. CODING BITES
When you determine
EXAMPLES from the documentation
that a different code
M0301 Fabric wrapping of abdominal aneurysm may be more accurate
Code with caution: This procedure has largely been replaced with than one indicated
more effective treatment modalities. Submit documentation. by the physician, you
should query the physi-
P2028 Cephalin flocculation, blood cian to have him or her
Code with caution: This test is considered obsolete. Submit document complete
documentation. accurate details.

HCPCS Level II
YOU CODE IT! CASE STUDY
Dr. Principe modified Miriam Collins’s left orthopedic shoe by inserting a between-sole metatarsal bar wedge to
accommodate Miriam’s shrinking Achilles tendon. Dr. Principe checked off the code L3649 on the superbill. As the
professional coding specialist, is this the best code available?

You Code It!

Go through the steps of coding, and determine the code(s) that should be reported for this product between
Dr. Principe and Miriam Collins.
Step #1: Read the case carefully and completely.
Step #2: Abstract the scenario. Which key words or terms describe what service the physician provided to the
patient during this encounter?
Step #3: Are there any details missing or incomplete for which you would need to query the physician? [If so,
ask your instructor.]
Step #4: Determine the correct HCPCS Level II code or codes to explain the details about what was provided
to the patient during this encounter.

(continued)
 Step #5: Check for any relevant guidance, including reading all of the symbols and notations.
Step #6: Do you need to append any modifiers to ensure complete and accurate information is provided?
Step #7: Double-check your work.
Answer
Did you find this to be the correct code?

L3410   Metatarsal bar wedge, between sole

Now that’s a much more specific code. Good job!

HCPCS Level II
LET’S CODE IT! SCENARIO
Rita Warren came with her husband, Ryan, to see Dr. Capshaw because of the problems Ryan was having sleep-
ing. Dr. Capshaw had performed a nasopharyngoscopy and diagnosed Ryan with sleep apnea. At this encounter,
Dr. Capshaw provided Ryan with an apnea monitor, complete with a recording feature, so that more data could be
collected and Dr. Capshaw could further evaluate his condition.

Let’s Code It!

Dr. Capshaw has supplied Ryan with an apnea monitor with a recording feature. This machine is considered
durable medical equipment (DME). Ryan’s insurance carrier accepts HCPCS Level II codes. Therefore, we have
determined the code so that Dr. Capshaw can be reimbursed for the machine. Let’s go to the Alphabetic Index
and look up the word monitor because that is the key word that best describes this item. Beneath the word
monitor, indented slightly, you see the word apnea, and the suggestion for the codes E0618 and E0619. This
seems to be exactly what Dr. Dean described in his notes, so let’s turn to the Alphanumeric Listing to read the
complete description of the codes.

E0618   Apnea monitor, without recording feature

This matches the notes with one big exception. The code description specifically states without recording feature.
Dr. Capshaw documented giving Ryan a monitor with a recording feature. Let’s look at the other suggested code:

E0619   Apnea monitor, with recording feature

Excellent! It matches perfectly.

HCPCS Level II
LET’S CODE IT! SCENARIO
Dr. Bettesh provided Lauren Martins, a 79-year-old female, with a quad cane, after putting on a new handgrip. Code
for the supply only.

Let’s Code It!

When you pull out the key words that describe the items for which Dr. Bettesh should be reimbursed, you see
that Lauren was provided with a quad cane and new handgrip.

930   PART IV  |  DMEPOS & TRANSPORTATION

 It wouldn’t be out of line to think that the codes are automatically going to be listed in the Durable Medical
Equipment section, codes E0100–E9999. If you turned to that section directly, you would find the code for the
quad cane rather quickly. It’s right in the front. However, you could examine and search through the entire listing
of 9,899 possible codes in the section and never find the correct code for the replacement handgrip. When you
look these key words up in the Alphabetic Index first, you see very quickly, and more efficiently, that the codes
you need are these:
E0105 Cane, quad or 3-prong, includes canes of all materials, adjustable or fixed, with tips
A4636 Replacement, handgrip, cane, crutch, or walker, each
It’s great when the process works, isn’t it? You bet!

30.5  Appendices CODING BITES

The HCPCS Level II book provides you with additional information in the back of the NOTE: The content of
book to help you code more accurately. [See Figure 30-1] appendices may vary
depending upon the
TABLE 30-1  List of most common Appendices found in HCPCS Level II code books. publisher of the HCPCS
Level II book used.
Appendices Description
Table of Drugs This is an alphabetic listing of drug names, along with the stan-
dard unit of administration, a particular method of administration,
and a reference to its HCPCS Level II code.
CODING BITES
The list in Abbrevia-
Modifiers This is an alphabetic list of all HCPCS Level II modifiers. You
tions and Acronymns
will learn more about these modifiers in Appendix B of this text.
appendix is not inclusive
Abbreviations and Abbreviations and acronyms are used throughout the health care of all abbreviations and
Acronymns industry. This appendix lists those used in HCPCS Level II descrip- acronyms used in the
tions to help you better understand the meaning of the codes. health care industry. It
is a good idea to keep
CMS References Certain components of the coding system change from time to
a medical dictionary
time. Up-to-date manuals and information can be found online in
close by to reference
the Centers for Medicare and Medicaid Services (CMS) manual
those abbreviations
system found at www.cms.hhs.gov/manuals. Included in each
not included in this
annual edition of some printed HCPCS Level II books are refer-
appendix.
ences to national coverage determinations made just prior to publi-
cation. As a student, this may be outside the scope of your studies.
As you mature in your career, this reference will be very handy.
New, Changed, This appendix lists all HCPCS Level II codes that have expe-
Deleted, and rienced a change since the previous year’s printed book. As a
Reinstated HCPCS student, this will have little relevance for you. But when the new
Codes book comes out, it serves as an excellent reference for someone
who may use the same code or codes over and over again.
Place of Service and This appendix offers you a thorough explanation of each place of
Type of Service Codes service (POS) and type of service (TOS) code required for boxes
24B and 24C of the CMS 1500 claim form.
Deleted Code This is a list of all deleted codes from last year to this, and includes
Crosswalk the new codes to use to report the service, when available.
Glossary Key terms used throughout this code set are listed here, along
with their definitions.
Physician Quality This appendix provides up-to-date details about codes used in
Reporting System this program.
(PQRS)
CHAPTER 30 REVIEW

CODING BITES Chapter Summary

Some of the Health
HCPCS Level II codes are updated quarterly and are officially effective January 1
Care Services/Items
of each year, with no grace period. Most printed versions of the book are published
Reported with HCPCS
with those codes posted by the Centers for Medicare and Medicaid Services (CMS)
Level II Codes
as of November 1. Read the following notation in the introduction of the HCPCS
Level II book:
• Patient Transportation “Because of the unstable nature of HCPCS Level II codes, everything has been done
• Enteral and Paren- to include the latest information available at print time. Unfortunately, HCPCS Level
teral Therapy II codes, their descriptions, and other related information change throughout the year.
• Durable Medical Consult the patient’s payer and the CMS website to confirm the status of any HCPCS
Equipment Level II code. The existence of a code does not imply coverage under any given pay-
ment plan.”
• Pharmaceuticals
Administered by a
Health Professional
• Orthotics
• Prosthetics

CHAPTER 30 REVIEW
HCPCS Level II Enhance your learning by
completing these exercises and
more at connect.mheducation.com!

Let’s Check it! Terminology

Match each key term to the appropriate definition.
1. LO 30.3  The provision of emergency CPR, stabilization of the patient, first aid, A. Advanced Life Support
control of bleeding, and/or the treatment of shock. (ALS)
2. LO 30.3  A company designated by the state or region to act as the fiscal inter- B. Basic Life Support
mediary for all DME claims. (BLS)
3. LO 30.3  By way of anything other than the gastrointestinal tract, such as intra- C. Chelation Therapy
venous, intramuscular, intramedullary, or subcutaneous. D. Durable Medical
4. LO 30.4  An indication that more detailed information is not available from the Equipment (DME)
physician’s notes.
E. Durable Medical
5. LO 30.1  A device used to correct or improve an orthopedic concern. Equipment Regional
6. LO 30.3  Life-sustaining, emergency care is provided, such as airway manage- Carrier (DMERC)
ment, defibrillation, and/or the administration of drugs. F. Enteral
7. LO 30.3  Apparatus and tools that help individuals accommodate physical frail-
G. Not Otherwise
ties, provide pharmaceuticals, and provide other assistance that will
Specified (NOS)
last for a long time and/or be used to assist multiple patients over time.
H. Orthotic
8. LO 30.3  Within, or by way of, the gastrointestinal tract.
I. Parenteral
9. LO 30.1  Fabricated artificial replacement for a damaged or missing part of the
body. J. Prosthetic
10. LO 30.3  The use of a chemical compound that binds with metal in the body so K. Specialty Care
that the metal will lose its toxic effect. It might be done when a metal Transport
disc or prosthetic is implanted in a patient, eliminating adverse reac-
tions to the metal itself as a foreign body.
11. LO 30.3  Continuous care provided by one or more health professionals in an
appropriate specialty area, such as respiratory care or cardiovascular
care, or by a paramedic with additional training.

932   PART IV  |  DMEPOS & TRANSPORTATION

 CHAPTER 30 REVIEW
HCPCS Level II Let’s Check It! Concepts
Choose the most appropriate answer for each of the following questions.

1. LO 30.4  The symbol of a circle with a line through it means

a. a new code.
b. a revised code.
c. a code exempt from a particular modifier.
d. a service not covered under the skilled nursing facility payment system.
2. LO 30.4  The little box with a check mark in it indicates a code description that
a. includes a quantity measurement.
b. is always covered by Medicare.
c. is approved for reimbursement at a higher rate.
d. includes refills.
3. LO 30.3  The J codes are used to bill insurance carriers for
a. prescription drugs patients get at the drugstore.
b. drugs administered by a health care professional.
c. nothing. They are deleted codes.
d. items not accepted by Medicaid in any state for any reason.
4. LO 30.1  HCPCS Level II codes are used, most often, to report all except
a. drugs used for treatment of a patient.
b. equipment provided to a patient.
c. anesthesia administered by an anesthesiologist.
d. dental services.
5. LO 30.3  The acronym DME stands for
a. determination of medical effectiveness.
b. durable medical equipment.
c. donated medical equipment.
d. diluted medicine equivalent.
6. LO 30.1  HCPCS Level II codes are presented as
a. five numbers.
b. one letter followed by four numbers.
c. four numbers followed by one letter.
d. five letters.
7. LO 30.1  HCPCS is an acronym that stands for
a. Health Care Professional Classification Systems.
b. Health and Caretaker Providers Coding Series.
c. Home Care Providers Coding System.
d. Healthcare Common Procedure Coding System.
8. LO 30.3  The code D1110 is an example of a
a. HCPCS Level I code, also known as a CPT code.
b. HCPCS Level II code.
c. HCPCS Level III code.
d. HCPCS Level IV code.
CHAPTER 30 REVIEW
9. LO 30.3  The D0000–D9999 codes are created and maintained by the
a. American Medical Association.
b. American Dental Association.
c. Centers for Medicare and Medicaid Services.
d. Department of Health and Human Services.
10. LO 30.2  You can look up key words in the HCPCS Alphabetic Index by using which of the following?
a. Generic name of the drug b.  Medical supply item
c. Orthotic d.  All of these
11. LO 30.3  The E codes shown in the HCPCS Level II book are
a. an expansion of the E codes in the ICD-10-CM book.
b. used to identify DME provided to a patient.
c. not accepted by Medicaid.
d. always first listed on a claim form.
12. LO 30.3  An example of DME is
a. an injection of Demerol. b.  a prosthetic ankle.
c. a three-prong cane. d.  home infusion therapy.
13. LO 30.4  A deleted code in the HCPCS Level II book means
a. the procedure is obsolete.
b. the service is no longer reimbursable.
c. the code is reinstated.
d. the code is no longer available to represent the service or item.
14. LO 30.3  Alcohol intervention treatment might be coded in the range
a. H0001–H2037   b.  H5000–H9999   c.  F1000–F9999   d.  G0000–G9999
15. LO 30.4  A code with a capital “A” or next to it means that
a. a drug was administered intravenously.
b. the machine can only be used for infusion therapy.
c. the service is limited to a specific age group.
d. the equipment is illegal in some states.

Let’s Check It! Symbols and Notations

Part I
Match each HCPCS Level II symbol to the appropriate HCPCS Level II description
1. LO 30.4  The female symbol. A.
2. LO 30.4  Indicates that it is the first year that the code is included in this code set. B.
3. LO 30.4  Lets you know that the code’s description has been changed or adjusted C.
since last year or that a rule or guideline regarding the code has changed. D.
4. LO 30.4  Means that the code has been deleted and may no longer be used.
5. LO 30.4  Identifies that the code had been deleted but now has been restored
(reinstated).

934   PART IV  |  DMEPOS & TRANSPORTATION

 6. LO 30.4  Reminds you that the code describes maternity procedures, services, E.

CHAPTER 30 REVIEW
and equipment that are performed or used on a pregnant female F.
12–55 years of age.
G.
7. LO 30.4  The male symbol. H.
8. LO 30.4  Identifies a specific quantity of material or supply. It is a reminder for I.
you to check the detail in the notes and report the code not only for the
J. Z1111
item it represents but for the amount as well.
9. LO 30.4  Highlights the fact that a code is used only for procedures, services,
and equipment that are performed or used on a patient of a certain age
group.
10. LO 30.4  Identifies a code that is not covered under the skilled nursing facility
(SNF) prospective payment system (PPS).

Part II
Match each HCPCS Level II notation to the appropriate notation description.
1. LO 30.4  This notation cross-references this code with another code that may A. Always report
be similar in description. The notation serves as a reminder for you to concurrent to the xxx
double-check that you are using the most accurate code. procedure
2. LO 30.4  Refers you to a CPT code for a description that is potentially better and B. See also code . . .
may be more specific for reporting what was actually done or given to C. Clarifications of
the patient. coverage
3. LO 30.4  When one code is to be reported with other codes, a notation to D. Report in addition to
“Report in addition to” (a particular code) will identify those circum- code . . .
stances. It not only tells you the circumstances but also tells you which
E. See code(s): . . .
code to use.
F. Determine if an
4. LO 30.4  This notation directs you to always report this code with a code for
alternative HCPCS
another specific procedure.
Level II or a CPT code
5. LO 30.4  This notation indicates when to use or not use the code. better describes . . .
6. LO 30.4  Serves as a warning to you to make certain that there is no better or G. Use this code for . . .
more specific code in either the CPT or elsewhere in this HCPCS Level H. Pertinent documenta-
II book that correctly reports the services or procedures performed. tion to evaluate medical
7. LO 30.4  This notation warns that you need to go back and double-check appropriateness should
the provider’s notes carefully. If this is what was actually done, then be . . .
be certain to attach documentation explaining why that method was I. Do not use this code to
used instead of the newer technique because it is surely going to be report . . .
questioned.
J. Medicare covers . . .
8. LO 30.4  Warns you of circumstances when you are not permitted to use a code. K. Code with caution
9. LO 30.4  Provides you with alternative names, brand names, and other terms that
are also represented by the code’s description.
10. LO 30.4  This notation giving you information about coverage, particularly
Medicare and Medicaid coverage.
11. LO 30.4  Warns you up-front that you should include the proper documentation
along with the claim the first time you submit it, rather than wait to be
asked by the third-party payer, which would delay payment.
CHAPTER 30 REVIEW
Let’s Check It! Rules and Regulations
Please answer the following questions from the knowledge you have gained after reading this chapter.
1. LO 30.1  List four HCPCS Level II codes specific to aspects for health care services.
2. LO 30.1  Do all insurance carriers accept HCPCS Level II codes? What is the responsibility of the coding spe-
cialist with regards to billing third-party payers?
3. LO 30.2  List five ways to look up the key words after abstracting them from the provider’s notes.
4. LO 30.3  What HCPCS Level II codes represent Procedures and Professional Services (Temporary)?
5. LO 30.4  What does the notation “Use this code for. . .” indicate?

HCPCS Level II
YOU CODE IT! Basics
First, identify the HCPCS Level II main term in the 7. Nonemergency transportation by stretcher van:
following statements; then code the procedure or a. main term: _____ b. procedure: _____
service.
8. A 200-mg injection IM of chloroquine
Example: Airlift by helicopter, one-way: hydrochloride:
a. main term: Ambulance b. procedure: A0431 a. main term: _____ b. procedure: _____
9. An injection SC of 30 mg of codeine phosphate:
Example: A 5 ml injection, IM, of Robaxin:
a. main term: _____ b. procedure: _____
a. main term: Robaxin    b. procedure: J2800
10. Dr. Longwell ordered Fosphenytoin, with an ini-
1. A bottle of 50 blood glucose reagent strips: tial dose of 50 mg:
a. main term: _____ b. procedure: _____ a. main term: _____ b. procedure: _____
2. Johannsen Health Care delivered 1000 mL of dis- 11. A 25-mg injection of lepirudin:
tilled water for use with nebulizer: a. main term: _____ b. procedure: _____
a. main term: _____ b. procedure: _____ 12. A seat attachment for a Starke’s walker:
3. Youth-sized disposable incontinence brief, one: a. main term: _____ b. procedure: _____
a. main term: _____ b. procedure: _____ 13. One heel protector:
4. Arterial blood tubing: a. main term: _____ b. procedure: _____
a. main term: _____ b. procedure: _____ 14. Portable non-invasive ventilator:
5. Neonate ambulance transport, one-way, base rate: a. main term: _____ b. procedure: _____
a. main term: _____ b. procedure: _____ 15. Prostate cancer screening, antigen test:
6. Ambulance ride with oxygen administered along a. main term: _____ b. procedure: _____
with other advanced life support (ALS) services:
a. main term: _____ b. procedure: _____

HCPCS Level II
YOU CODE IT! Practice
Using the techniques described in this chapter, carefully read through the case studies and find the most accurate
HCPCS Level II code(s) and modifier(s) if appropriate for each case study.
Note: All insurance carriers and third-party payers for the patients accept HCPCS Level II codes and modifiers.
1. Daisha Kurucz, a 23-year-old female, has severe asthma. Dr. Benton ordered a nebulizer, with compressor, for
her to use at home. Code for the home health agency that supplied the equipment.

936   PART IV  |  DMEPOS & TRANSPORTATION

 CHAPTER 30 REVIEW
2. Daniel Hair, a 56-year-old male with end-stage renal disease (ESRD), was fitted for a reciprocating peritoneal
dialysis system. Code the supply of the equipment.
3. Due to his condition, Daniel Hair (previous case study) had an unscheduled dialysis treatment at the nearest
hospital outpatient department; this hospital is not certified as an ESRD facility.
4. Muddy Hambaugh, a 27-year-old female with a history of bipolar disorder, was given an injection IM of
Thorazine, 45 mg. Code for the drug.
5. Allen Jeter, a 48-year-old male, was being prepared for his kidney transplant. The nurse administered 100 mg
of Zenapax, IV, parenteral. Code the drug.
6. After Allen Jeter (previous case study) received his kidney transplant, the nurse gave him an oral dose of
250 mg of CellCept (mycophenolate mofetil) in the hospital. Code the drug.
7. Shirley Loveichelle, an 82-year-old female, was having trouble eating for such a long period of time that she
was exhibiting signs of malnutrition. Therefore, Dr. Milliner ordered enteral formula (Ensure) to be adminis-
tered through a feeding tube at 500 calories per day. Code for the nutritional supplement only.
8. Keith Pawley, a 34-year-old male, came to see Dr. Praylow, his dentist, for an implant-supported porcelain
crown on his back tooth.
9. Johnette Potash, a 13-year-old female, lost her retainer at camp. She is at Dr. Rivera’s office to get a
replacement.
10. Clifton Beckman, a 15-year-old male, sat in poison ivy while camping in the woods. Dr. Gregg prescribed a
portable sitz bath for him to use at home.
11. Roberta Henthorne, a 52-year-old female, was recuperating from surgery to repair a complex fracture of her
tibia and a compound fracture of her ankle. To help her be more comfortable, Dr. Locklear ordered a fixed-
height hospital bed, without side rails and with a mattress, for her to use at home. Code for the DME only.
12. Kenneth Paynter, a 68-year-old male, was on complete bed rest while recuperating from surgery. Because his
skin was very sensitive, he was particularly prone to decubitus ulcers. Dr. Roche prescribed a lamb’s wool
sheepskin pad to help prevent any ulcers from forming.
13. Dr. Sloan provided a complete set of dentures, maxillary and mandibular, for Cheryl Delaney.
14. Dennis Lederrick, a 39-year-old male, had surgery on his left foot. To enable him to take a shower safely,
Dr. Willrodt gave him a tub stool to sit on.
15. Scott Zamcho came home from serving in the Marines a double amputee, having had both legs damaged
badly in a suicide bomber’s attack. Dr. Lovell supplied him with an amputee wheelchair, desk height, with
detachable arms and no footrests or leg rests.

HCPCS Level II

YOU CODE IT! Application

On the following pages, you will see physicians’ notes documenting encounters with patients at our textbook’s
health care facility, Prader, Bracker, & Associates. Carefully read through the notes, and find the best code or
codes from the HCPCS Level II book for each of the cases.
Note: All insurance carriers and third-party payers for the patients accept HCPCS Level II codes and modifiers.

PRADER, BRACKER, & ASSOCIATES

A Complete Health Care Facility
159 Healthcare Way • SOMEWHERE, FL 32811 • 407-555-6789
PATIENT: ADDLER, ANNETTE
ACCOUNT/EHR #: ADDLAN001
CHAPTER 30 REVIEW

Date: 12/21/18
Representative: Elizabeth Alexander
Attending Physician: Renee O. Bracker, MD
The Pt is a 27-year-old female who recently returned from working in Africa. She was diagnosed with
variola and has been on a gastric feeding tube to increase her fluids, electrolytes, and calories because
the pharyngeal lesions make swallowing difficult. Nasogastric tubing without a stylet was supplied for
this patient.
A: Variola
P: Service number given to caregiver

Elizabeth Alexander
EA/mg  D: 12/21/18 09:50:16  T: 12/22/18 12:55:01

Determine the best, most appropriate HCPCS Level II code(s).

BRACKER DURABLE MEDICAL EQUIPMENT

A Complete Health Care Facility
159 Healthcare Way • SOMEWHERE, FL 32811 • 407-555-6789
PATIENT: CARLYLE, JOY
ACCOUNT/EHR #: CARJAY001
Date: 11/05/18
Representative Technician: LuAnn Hallmark
Attending Physician: Renee O. Bracker, MD
The Pt is a 72-year-old female diagnosed with adult kyphosis caused by poor posture. Dr. Bracker
prescribed bed rest on a firm mattress with pelvic traction attached to the footboard. At 5:00 p.m. on
this date, I delivered a bed board and the traction frame to Ms. Carlyle’s home. I placed the bed board
underneath the existing mattress in order to create a firm surface upon which the patient could sleep. I
then attached the traction frame to the footboard of the existing bed. I spent 45 minutes instructing the
patient, her family, and caretaker on the proper use of the equipment, how to properly get into and out
of the traction, and the expected sensations.
A: Adult kyphosis
P: Follow up in 2 weeks to see if patient has any questions or concerns.

LuAnn Hallmark
LH/mg  D: 11/05/18 09:50:16  T: 11/08/18 12:55:01

Determine the best, most appropriate HCPCS Level II code(s).

938   PART IV  |  DMEPOS & TRANSPORTATION

 CHAPTER 30 REVIEW
PRADER ONCOLOGY
A Complete Health Care Facility
159 Healthcare Way • SOMEWHERE, FL 32811 • 407-555-6789
PATIENT: BALMORAL, MARK
ACCOUNT/EHR #: BALMAR001
Date: 10/26/18
Attending Physician: Oscar R. Prader, MD
Pt is a 61-year-old male with metastatic testicular tumors. He comes in today for the administration of
cisplatin solution, IV, 20 mg. It is the first of five treatments he will receive this week.
IV infusion given over 7 hours.
Patient reports mild nausea. Refuses any pharmaceutical treatment for that side effect of this treatment.
Patient discharged at 4:15 p.m.

ORP/mg  D: 10/26/18 09:50:16  T: 10/27/18 12:55:01

Determine the best, most appropriate HCPCS Level II code(s).

VICTORS AMBULANCE SERVICE

654 Healthcare Way • SOMEWHERE, FL 32811 • 407-555-6789
PATIENT: CUTTER, WILIMENA
ACCOUNT/EHR #: CUTTWI001
Date: 10/15/18
Attending Physician: Renee O. Bracker, MD
EMT/Attendant: Lance H. Reynoso, EMT
Pt is a 78-year-old female who appears to have suffered a myocardial infarction in her nursing home’s
day room. Pt complained of numbness and tingling in the left arm and sharp pains in her chest. EKG
showed abnormal activity. Pulse and respiration were abnormal.
While preparing the patient for transport, she went into arrest. Defibrillator restored heartbeat. ALS1-
emergency services were administered, and patient was transported immediately to Barton Hospital.
Routine disposable supplies were used.
Total Mileage: 4.5

Lance H. Reynoso, EMT

LHR/mg  D: 10/15/18 09:50:16  T: 10/17/18 12:55:01

Determine the best, most appropriate HCPCS Level II code(s).

CHAPTER 30 REVIEW

PRADER, BRACKER, & ASSOCIATES

A Complete Health Care Facility
159 Healthcare Way • SOMEWHERE, FL 32811 • 407-555-6789
PATIENT: VANCE, TOMIKA
ACCOUNT/EHR #: VANTOM001
Date: 12/09/18
Attending Physician: Salvatore L. Bloome, MD
Indications: Ulcerative enterocolitis
Procedure: Colonoscopy
Instrument: Olympus video colonoscope CF 100L
Anesthesia: Versed 4 mg; Demerol 75 mg MAC < 30 min
HISTORY: This is a 71-year-old female admitted to the ambulatory surgical center for a colonoscopy.
Due to her chronic enterocolitis, she is at high risk for a malignancy of the colon, and, therefore, this
screening is being done. She has been informed of the nature of the procedure, the risks, and the con-
sequences, as well as told of alternative procedures. She consents to the procedure.
PROCEDURE: The patient is placed in the left lateral decubitus position. The rectal exam reveals normal
sphincter tone and no masses. A colonoscope is introduced into the rectum and advanced to the distal
sigmoid colon. Due to a marked fixation and severe angulation of the rectosigmoid colon, the scope
could not be advanced any further and the procedure was aborted. On withdrawal, no masses or polyps
are noted, and the mucosa is normal throughout. Retroflexion in the rectal vault is unremarkable.
DISPOSITION: The patient tolerated the procedure and was discharged from the minor operating
department in satisfactory condition.
IMPRESSIONS: Normal colonoscopy, only to the distal sigmoid colon
PLAN: Strong recommendation for a barium enema

Salvatore L. Bloome, MD
SLB/mg  D: 12/09/18 09:50:16  T: 12/11/18 12:55:01

Determine the best, most appropriate HCPCS Level II code(s).

940   PART IV  |  DMEPOS & TRANSPORTATION

DMEPOS and
Transportation Capstone
Learning Outcomes
31
After completing this chapter, the student should be able to:
LO 31.1 Determine the correct codes for these case studies using the
HCPCS Level II code set.

The health care team extends beyond the physician’s office or hospital. Home care ser-
vices are on the increase as a greater number of patients prefer care in their residences,
whenever possible. The provision of these services enables patients greater comfort
and lowers costs, especially for those with chronic conditions.
In addition, transportation of patients should be recorded and reported for reim-
bursement purposes, as well as the provision of orthotics and prosthetics. And, as you
learned in previous chapters about CPT coding, the provision of medication (drugs) by
a health care professional also must be recorded and reimbursed.
For each of the following case studies, read through the documentation and
determine
∙ What medical supply, equipment, or other item or service was provided to this
patient. Do not code the procedure.
∙ Whether any modifiers are necessary, and, if so, which modifiers and in what order.
∙ Whether more than one code is required, and, if so, the sequence in which to report
the codes.
Remember, read carefully and completely.

CASE STUDY #1: RHONDA SYNCOWSKI

Rhonda Syncowski is a 64-year-old female with a long-standing history of a seizure

disorder. She also has hypertension (high blood pressure) and chronic obstructive pul-
monary disease (COPD). She is no stranger to the hospital because of her health issues.
At home, she takes a number of medications, including three for her COPD and three—
levetiracetam, lamotrigine, and valproate sodium—to help control seizures.
The patient went to see Dr. Bushera, her family physician, last week because she
was wheezing and having trouble breathing. Dr. Bushera conducted a physical exami-
nation that yielded signs of an acute worsening of her COPD—including FEV1 of less
than 50% predicted value plus respiratory failure.
PLAN: Orders written for flunisolide 160 mcg, b.i.d. via nebulizer; portable oxygen
(gaseous) with 1-month supply. Follow up with physician in 3 weeks, or PRN.
Joshua Medical Supplies and Equipment was called by the patient to provide the
equipment and medications to the patient’s home. As per physician’s orders:
. Nebulizer with compressor
1
2. Flunisolide inhalation solution 1 mg
3. Portable oxygen system (gaseous), rental, cannula
4. Portable O2 contents, gaseous, 1 unit
 CASE STUDY #2: RYAN MCNAULTY

Ryan McNaulty, a 6-year-old male with a defect in bowel function, was hospitalized for
severe constipation. He was given a dose of neostigmine methylsulfate 0.4 mg, IM.
Code for the drug, one date of service, only.

CASE STUDY #3: NADIYA LONGSTEP

Nadiya Longstep was rescued from her apartment building, which was engulfed in a
two-alarm fire. The firemen carried her out and she was handed over to the EMTs, who
immediately began to examine the burns on 45% of her body. She was having trouble
breathing and was given oxygen. She lost consciousness. CPR was started immediately,
followed by external defibrillation at 200 joules until normal sinus rhythm was rees-
tablished. Orders came through to take her to the MacHill Burn Center unit of Mulford
Hospital immediately.

CASE STUDY #4: SONIA GRASSO

Sonia Grasso, an 11-year-old female, was diagnosed with idiopathic adolescent

scoliosis.
Joshua Medical Supplies and Equipment was referred by Dr. Karpel, her orthope-
dist, to provide a Milwaukee brace: cervical/thoracic/lumbar/sacral orthotic.

CASE STUDY #5: DANIEL BISHOP

Daniel Bishop, an 18-year-old male, was in an MVA and subsequently diagnosed with
whiplash, resulting in pain in C2–C4. Dr. Samman recommended traction for his cervical
region, which he could attach to the headboard of his bed at home. Dr. Samman told
Daniel to spend at least 5 hours each night in the traction device for 3 weeks. Follow-up
appointment in 2 weeks.

CASE STUDY #6: MALIK HUMISTON

Malik Humiston, a 16-year-old male, suffered a displaced (comminuted) fracture of the

right tibial shaft during his high school football game. Dr. Peterson prescribed articulat-
ing, spring-assisted underarm crutches for him upon post-surgical discharge. Joshua
Medical Supplies and Equipment provided him with a pair and spent approximately 30
minutes fitting him and teaching him how to use them properly.

942   PART IV  |  DMEPOS & TRANSPORTATION

CASE STUDY #7: ZIVAH MASTRIANI

Zivah Mastriani, a 41-year-old female, was diagnosed with type 2 diabetes mellitus,
and Dr. Ross wrote a prescription for her to obtain a home glucose disposable monitor.
Zivah brought the order to Roxone Home Medical Supplies, where a monitor and test
strips were provided. Harold Carter spent about 20 minutes teaching her how to use it
correctly.

CASE STUDY #8: VICTOR JEFFRIES

Victor Jeffries, a 71-year-old male, weighs 320 pounds and is currently bedridden due
to a fractured hip. In an effort to prevent any pressure ulcers or decubitus ulcer devel-
opment, Dr. Abreen ordered an air pressure mattress pad for his bed at home.

CASE STUDY #9: ANNA CHENG

Anna Cheng, an 83-year-old female, has been exhibiting dysphagia (problems swallow-
ing), resulting in her no longer wanting to eat. Dr. Baldwin inserted a standard gastros-
tomy/jejunostomy tube to enable enteral nutrition for 10 days.

CASE STUDY #10: CECIL DENOSO

Cecil Denoso, a 27-year-old male, was admitted to the Masters Behavioral Health Cen-
ter due to his current manic state. Dr. Levine ordered Haloperidol 5 mg IM t.i.d. Code for
the drug, one date of service, only.

CASE STUDY #11: COURTNEE CALLAHAN

SUBJECTIVE FINDINGS: This patient is a 55-year-old white female with pain in her
lumbosacral spine, extending into her buttocks bilaterally. She describes the pain
as being sharp and sometimes intense. She states it diminishes to an achy feeling.
She rates its intensity at 10/10 at its worst. Normally, she states it is 6–7/10. She
describes the pain as being ever-present, varying in intensity, increasing with activities
and decreasing with rest. She is using pain medications currently and is able to sleep
through the night.
HISTORY: This patient initially injured her back by catching a falling bookcase. She
had immediate pain that was disabling. The pain was resolved with occasional recur-
rence. She sought intervention last year from doctors, who diagnosed degenerative
disc disease and arthritis. She had a course of physical therapy with some resolution,

CHAPTER 31  | 
 but recurrence of pain occurred in June secondary to bending over while washing her
hands. She was referred here.
OBJECTIVE FINDINGS:
Observation: This patient appears as a normally developed white female of stated age.
She reports moving with forward flexed posture and an occasional antalgic gait on the
right when the pain is increasing. She currently postures and moves normally.
Palpation: Positive over L5 and S1 and paravertebral muscles at that same level.
Lumbosacral range of motion: Forward flexion 35 degrees with pain at the end of range.
Right side bending 30 degrees with pain at the end of range. Left side bending 35
degrees. Extension 0 degree with pain at the end of range.
Resisted motion: Positive in all directions
DTRs: Hyperreflexive bilaterally
Lasègue’s sign: Positive at 25 degrees bilaterally
Cram test: Positive at 25 degrees bilaterally
Cervical range of motion:
1. Right side bending: Within normal limits, painful
2. Left side bending: Within normal limits
3. Forward flexion: 45 degrees with pain at the end of range
4. Extension: Within normal limits
Radiculopathy: Positive with pain down the left arm and occasional tingling and
numbness
TREATMENT PLAN: We would like to see the patient three times per week to initiate
exercises and modalities to decrease pain and increase range of motion and function.
GOALS: The purpose of physical therapy intervention is to
. Increase range of motion to normal limits.
1
2. Decrease pain to zero.
3. Increase strength and function to normal.
RECOMMENDATION: I discussed with the patient the benefit of using a transcutaneous
electrical nerve stimulation device on her lumbar area. I suggested that she rent the unit
from us to give her the opportunity to try it out and see if it helps to reduce pain at L5–S1.
She agreed, and we provided her with a 2-lead unit. Instructions were for her to use it
every day, 15 minutes, b.i.d., first thing in the morning after getting out of bed and immedi-
ately prior to bed. Richard Penuto, my associate, taught her how to apply the leads and use
the machine. Appointment made for her to return in 2 weeks for evaluation.
Code for the provision of the transcutaneous electrical nerve stimulation device only.

CASE STUDY #12: ARTHUR PAIGE

HISTORY OF PRESENT ILLNESS: This patient is a 43-year-old male with pain in his cer-
vical spine. He states that the pain extends over the entire posterior neck and into the
right shoulder, including the upper trapezius. He rates that at a level of 7–8 on a scale
of 10 currently. He states that at its least it is 3–4 on a scale of 10. The patient is using
a cervical collar with good results. He also uses ibuprofen at night.
This patient was involved in an MVA 5 years ago resulting in a fracture of C5. He
had manipulation approximately 3 years ago resulting in pain for approximately

944   PART IV  |  DMEPOS & TRANSPORTATION

5 months. He had neck pain develop again approximately 18 months ago resulting in
bilateral shoulder surgery. The pain has remained the same, although the numbness is
better for approximately 1 year. He currently has complaints of a radial distribution into
his left hand, which caused him enough concern to seek intervention from Dr. Furmenn.
The patient was then referred here.
PHYSICAL EXAMINATION:
Observation: This patient is a normally developed male of stated age. He gaits normally
without apparent guarding or splinting.
Palpation: Positive over the right upper trapezius
Range of motion: Right rotation is 50 degrees, left rotation is 45 degrees, right side
bending 30 degrees with pain at the end of range, left side bending 30 degrees, for-
ward flexion 35 degrees, and extension 25 degrees.
Resisted motion: Negative
Radiculopathy: Positive in the left shoulder extending down to the left hand into his
thumb and digits 2 and 3.
Sensation: Some decreased sensation over the left hand to pinprick, particularly over
the radial digits.
TREATMENT PLAN: We would like to see the patient three times per week as per
instructions for cervical traction and exercises.
GOALS: The purpose of physical therapy intervention is to
. Increase range of motion to normal limits.
1
2. Increase pain-free function to normal.
3. Decrease pain generally to zero.
RECOMMENDATION: To encourage healing, I discussed with the patient using trac-
tion equipment at home, for beneficial outcomes in between appointments. Petra Zoz-
trev, our trainer, worked with Arthur to show him how to set up the equipment, put it
on, and take it off. Instructions for use are every night to sleep in the equipment until
we determine he has made sufficient progress. I also gave him a sheet with exercises—
diagrammed out, for him to do at home also. Petra helped him carry the box out to his car.
Code for the provision of the traction equipment only.

CASE STUDY #13: WILLETTA FREEDMAN

HISTORY: The patient is a 23-year-old black female professional athlete who, last month,
fell on her left elbow while reaching for a ball during a tennis game, sustaining a left distal
humerus fracture. The patient states the following day she had surgery to stabilize the
fracture. The patient was unsure if the surgery performed was for plates and screws.
PAST MEDICAL HISTORY: The patient fractured her right wrist approximately a year ago.
CHIEF COMPLAINT: The patient reports left elbow pain, currently 8/10, at best 7/10,
and at worst 10/10. The patient states she is taking her pain medications, which pro-
vide minimal relief but affect her performance on the court. The patient reports she
does have numbness in the left upper extremity, along the ulnar nerve distribution. The
patient states she does use some ice or heat; it provides minimal relief. The patient is
left-hand dominant.
PHYSICAL EXAMINATION: Left elbow AROM 35–120 degrees. Left elbow PROM
30–135 degrees. Left shoulder AROM within normal limits. Left wrist AROM within

CHAPTER 31  | 
 functional limits. Left elbow strength 3–/5. Left shoulder strength grossly 4/5. Left wrist
strength grossly 4/5. Left grip strength is 30 pounds. Right grip strength is 55 pounds.
Palpation: The patient is tender to palpation in the posterolateral aspect of the left
elbow. The incision is healed. No signs of infection. No swelling in the left elbow, no
bruising.
GOALS:
. Increase left elbow AROM and PROM to within normal limits.
1
2. Increase left elbow strength to within normal limits.
3. Eliminate pain.
4. Independent with home exercise program.
5. Return function to normal.

TREATMENT PLAN: We would like to see the patient three times a week to initiate and
advance range of motion, stretching and strengthening program to left elbow; may use
modalities as needed for pain control.
RECOMMENDATIONS: To ensure progress to help this patient recover more com-
pletely, I recommend a static progressive stretch elbow device with a range of motion
adjustment for her use at home. I discussed a workout plan, using the equipment, with
Willetta and her coach. They left with the device and instructions. Appointment is made
for her to return in 1 week to begin regular treatment.
Code for the provision of the device only.

CASE STUDY #14: GARY ELLIOTT

SUBJECTIVE FINDINGS: The patient said that he slept well last night.
OBJECTIVE FINDINGS:
General: The patient is a well-developed, obese male in no apparent distress.
Vital signs: Temperature 98.6 degrees, pulse 72, respirations 18, and blood pressure
158/80.
HEENT: Head is normocephalic
Neck: Supple to palpation
Extremities: Examination of the extremities shows incision site to be healing well with-
out any sign of infection or skin breakdown. Peripheral pulses are intact. Minimal edema
in the left lower extremity. Homans sign is absent.
FUNCTIONAL STATUS: Functionally, the patient is able to demonstrate improvement with
full range of motion, −5 to 80 degrees of flexion actively and 86 degrees passively. His
functional gait has advanced 200 feet with the use of front-wheel walker with supervision.
He is supervised level with his bedside commode transfers and contact guard assistance
with shower chair transfers. He is modified independent level with his eating and set up with
his grooming skills. He requires moderate assistance with lower body dressing.
IMPRESSION:
. Polyarthritis
1
2. Left total knee arthroplasty
3. Status post coronary artery bypass graft
4. Chronic obstructive pulmonary disease

946   PART IV  |  DMEPOS & TRANSPORTATION

PLAN: We provided the patient with a Continuous Positive Airway Pressure (CPAP)
machine with headgear and instructed both Gary and his wife on how to use it properly.
Instructions are provided in writing. I emphasized the importance of using the CPAP
machine every night. Continue with current treatment program. We will continue to
monitor the patient’s hypertension, which is still out of control.
Code for the provision of the CPAP machine with headgear.

CASE STUDY #15: PAULA BARKIN

Paula, a 4-year-old female, was referred for speech therapy by her school after discus-
sion about parents’ concerns over her difficulties pronouncing certain speech sounds.
These irregular pronunciations were making it challenging for those outside her family
to understand Paula when she spoke to them. Paula had suffered from hearing loss and
had grommets inserted at age 3.
An initial assessment was performed to look at her current speech profile and to pro-
vide information as to whether intervention was needed and, if so, what kind. Assess-
ment results revealed that Paula had difficulties with the ‘t’ and ‘d’ sounds and was
replacing these with ‘k’ and ‘g,’ so ‘letter’ was ‘lekker’ and ‘bed’ was ‘beg’. I explained to
the parents that this is called ‘backing,’ whereby sounds that should be produced at the
front of the mouth are produced at the back of the mouth instead. This is not a process
found in typically developing speech and therefore would be targeted in therapy.
Paula also showed difficulties with other early developing sounds ‘s’ and ‘v.’ These
sounds that are produced with a long flow of air were being cut short so ‘f’ was
‘p’—therefore, ‘fish’ was ‘pish.’ This process is called stopping, which is expected to
have resolved by the age of 3 years and so was also targeted in therapy.
Paula was set up for individual therapy sessions at her home, by me, for 30 min-
utes each visit. The sessions will be focused on developing Paula’s awareness and pro-
duction of the above speech sounds and processes. For each sound, visual materials
including a picture card with the grapheme and cued articulation (similar to a gesture/
sign) are used to help Paula learn them. Before asking Paula to produce any of the
sounds she had difficulties with, Paula was provided with many opportunities to hear
these sounds being produced correctly (this is known as auditory bombardment). Paula
then completed tasks in which she had to discriminate between a target sound, e.g., ‘t,’
and the sound that she replaced it with, e.g., ‘k,’ to ensure she could tell the two apart.
Therapy will then move to production. How each of the sounds is produced in the
mouth will be explained to Paula using words accompanied by diagrams. The first step
is to get Paula to try to produce her new sounds in isolation (e.g., ‘t’) and then com-
bined with a vowel (e.g., ‘tee’). The next steps are to practice new sounds at the start of
words (e.g., ‘tiger’), followed by at the end of words (e.g., ‘boat’) and then in the middle
of words (e.g., ‘bottle’) and finally onto sentences. These will be incorporated into fun
games. Parents will be given activities to practice in between weekly sessions; in addi-
tion, advice on how to support Paula’s new speech sounds in natural conversations
will also be provided. For example, if Paula made an error with one of her new speech
sounds, others will be able to provide her with options, e.g., is it a ‘kiger’ or a ‘tiger,’
emphasizing the correct sound.
PLAN: In addition to the 30-minute sessions at her home, I supply software with
30 minutes of prerecorded sounds and messages so the parents can work with her in
between our sessions.
Code for the one 30-minute home visit by the speech-language pathologist + the
speech software.

CHAPTER 31  | 
PART V
INPATIENT (HOSPITAL) REPORTING
Reporting inpatient (hospital) and outpatient encounters requires the same founda-
tional knowledge and skill: anatomy, physiology, and medical terminology. Part V of
this text provides you with the next layer of your learning about coding health care.
In these chapters, you will learn how to employ ICD-10-PCS (International Clas-
sification of Diseases, 10th revision, Procedure Coding System), the code set used
to report the procedures, services, and treatments provided by the acute care facility
(hospital) to inpatients (those who have been admitted).
32
Key Terms
Introduction to
ICD-10-PCS
Learning Outcomes
Approach After completing this chapter, the student should be able to:
Axis of Classification
Body Part LO 32.1 Explain the purpose of ICD-10-PCS codes.
Body System LO 32.2 Identify the structure of ICD-10-PCS codes.
Device LO 32.3 Recognize the proper ways to use the Alphabetic Index and
Qualifier Tables in ICD-10-PCS.
Root Operation Term LO 32.4 Discern the general conventions for using ICD-10-PCS.
LO 32.5 Determine the principal ICD-10-PCS code and proper
sequencing for multiple procedure codes.

Remember, you need to follow along in

ICD-10-PCS
  STOP! your ICD-10-PCS code book for an
optimal learning experience.

32.1  The Purpose of ICD-10-PCS

The International Classification of Diseases–10th revision–Procedure Coding Sys-
tem (ICD-10-PCS) was implemented in the United States on October 1, 2015, for the
reporting of procedures, services, and treatments provided to a patient who has been
admitted into an inpatient facility.
Earlier in Part III of this book, you learned how to use the CPT code set to report
physician’s services in any facility. And you learned that CPT codes are also used to
report services provided by an outpatient facility, during the care of the patient. Now,
you will learn to use the ICD-10-PCS code set to report the inpatient facility’s partici-
pation in providing these services.
When patients are provided with room and food, in addition to medical care, and
stay overnight in the facility, they are considered “inpatients.” This means that acute
care hospitals, as well as skilled nursing facilities, long-term care facilities, and short-
term care facilities may use this code set.
The structure of this code set is very different, as you will learn in this and the next
few chapters. Rather than looking up the code and determining the correct choice from
a list, you will build the code from the details shown in the tables of ICD-10-PCS (see
Figure 32-1). Each table contains details about procedures pertaining to that particular
type of procedure and that particular body system and body part.

32.2  The Structure of ICD-10-PCS Codes

The main purpose of creating the International Classification of Diseases–10th
Revision–Procedure Coding System (ICD-10-PCS) was to give you, the professional
coder, an easier way to determine the best, most accurate, and most specific code to
report procedures, services, and treatments provided to an inpatient (a patient admitted

950
 Section 0 Medical and Surgical
Body System 2 Heart and Great Vessels
Operation 4 Creation: Putting in or on biological or synthetic material to
form a new body part that to the extent possible replicates
the anatomic structure or function of an absent body part

Body Part Approach Device Qualifier

F Aortic Valve 0 Open 7 Autologous Tissue Substitute J Truncal

Valve
8 Zooplastic Tissue
J Synthetic Substitute
K Nonautologous Tissue Substitute

G Mitral Valve 0 Open 7 Autologous Tissue 2 Common

Atrioventricu-
J Tricuspid 8 Zooplastic Tissue
lar Valve
Valve
J Synthetic Substitute
K Nonautologous Tissue Substitute

FIGURE 32-1  An example from the Medical and Surgical Tables of 2018 ICD-10-PCS

to an acute care hospital or other inpatient facility). That purpose has led to a new
structure for the codes. In this code set, you will actually build the code. CODING BITES
ICD-10-PCS codes
Seven Characters may include any letter
of the alphabet except
Every ICD-10-PCS code is made up of seven (7) alphanumeric characters, and each the letters O and I. This
character position has its own specific meaning—a specific piece of information relat- is done to avoid any
ing to the procedure, service, or treatment provided. You must read carefully because confusion between the
each section has its own particular use for the character. As always, in coding, you can letter O and the number
never assume! 0 (zero), as well as any
Let’s begin with the first, and largest, section of the ICD-10-PCS code set . . . Medical mix-up between the let-
and Surgical section, just as an example. You will learn all the details about this and all ter I and the number
of the other code set sections in the chapters that follow this one. In this section, the seven 1 (one).
characters describe, in order, the:
1. Section of the ICD-10-PCS code set.
2. Body system upon which the procedure or service was performed.
3. Root operation, which explains the category or type of procedure.
4. Body part, which identifies the specific anatomical site involved in the procedure.
5. Approach, which reports which method was used to perform the service or
treatment.
6. Device, which reports, when applicable, the type of device involved in the service
or procedure.
7. Qualifier, which adds any additional detail.
Let’s go through each of these character positions, one by one, to understand what
each represents. To help illustrate these data points, we are going to use a snippet from
an operative report and build the code as an ongoing example:
Laparoscopic bypass, radial vein to ulnar vein, left, using autologous tissue
substitute

CHAPTER 32 
 Using this short statement as an example to work with, you are going to build the ICD-
CODING BITES 10-PCS code as you make your way through this chapter. You will learn how each
Using our example . . . character reports a part of the whole story about the specific procedure or service. This
Laparoscopic bypass should then help you understand how to build a code on your own.
You can tell from the
description that this is Section (First Character)
a surgical procedure, The first character in the seven-character sequence identifies the section of the ICD-
so this code is reported 10-PCS code set in which the procedure is listed. There are 17 section titles:
from within the Medical
and Surgical section of 0 Medical and Surgical
ICD-10-PCS. 1 Obstetrics
First character = 0 2 Placement
 0 Medical and 3 Administration
Surgical 4 Measurement and Monitoring
5 Extracorporeal or Systemic Assistance and Performance
6 Extracorporeal or Systemic Therapies
7 Osteopathic
8 Other Procedures
9 Chiropractic
B Imaging
C Nuclear Medicine
D Radiation Therapy
F Physical Rehabilitation and Diagnostic Audiology
G Mental Health
H Substance Abuse Treatment
X New Technology

EXAMPLES
An ankle x-ray is an imaging procedure—Section B
A breech extraction is an obstetrics procedure—Section 1
An amputation is a surgical procedure—Section 0

Body System (Second Character)

Body System The second character of the code reports the body system upon which the procedure,
The physiological system, service, or treatment was performed. The classes you took in anatomy will be very
or anatomical region, upon important to your accuracy in determining the correct character to report. Plus, you
which the procedure was need to pay careful attention due to greater specificity than typically defined by stan-
performed. dard anatomy classifications. There are 31 body systems used for clarification and
identification by the second character of codes reporting a medical or surgical proce-
dure or service:
0 Central Nervous System and Cranial Nerves
1 Peripheral Nervous System
2 Heart and Great Vessels
3 Upper Arteries
4 Lower Arteries
5 Upper Veins
6 Lower Veins

952   PART V  |  INPATIENT (HOSPITAL) REPORTING

 7 Lymphatic and Hemic Systems
8 Eye
9 Ear, Nose, Sinus
B Respiratory System
C Mouth and Throat
D Gastrointestinal System
F Hepatobiliary System and Pancreas
G Endocrine System
H Skin and Breast
J Subcutaneous Tissue and Fascia
K Muscles
L Tendons
M Bursae and Ligaments
N Head and Facial Bones
P Upper Bones
Q Lower Bones
R Upper Joints
S Lower Joints
T Urinary System
U Female Reproductive System
V Male Reproductive System
W Anatomical Regions, General
X Anatomical Regions, Upper Extremities
Y Anatomical Regions, Lower Extremities
The other sections of the code set describe the body systems that are appropriate to
those services. Take a look at Table 32-1, The Sections of ICD-10-PCS and Their Body
Systems.

CODING BITES
Using our example . . . radial vein to ulnar vein
Remember learning this in anatomy class? Don’t worry if you don’t; use that anat-
omy resource now. Then, you will know, for certain, that these veins are located
in the arm (upper extremity). Therefore, your second character will report a proce-
dure that was performed on the patient’s upper veins.
First character = 0
Second character = 5
0 Medical and Surgical
  5 Upper veins

CHAPTER 32 
TABLE 32-1  The Other Sections of ICD-10-PCS and Their Body Systems

SECTION BODY SYSTEM(S)

1 Obstetrics 0 Pregnancy
2 Placement W Anatomical Regions
Y Anatomical Orifices
3 Administration 0 Circulatory
C Indwelling Device
E Physiological Systems & Anatomical Regions
4 Measurement and Monitoring A Physiological Systems
B Physiological Devices
5 Extracorporeal or Systemic Assistance and Performance A Physiological Systems
6 Extracorporeal or Systemic Therapies A Physiological Systems
7 Osteopathic W Anatomical Regions
8 Other Procedures C Indwelling Device
E Physiological Systems & Anatomical Regions
9 Chiropractic W Anatomical Regions
B Imaging [See Medical and Surgical body systems]
C Nuclear Medicine [See Medical and Surgical body systems]
D Radiation Therapy [See Medical and Surgical body systems]
F Physical Rehabilitation and Diagnostic Audiology 0 Rehabilitation*
1 Diagnostic Audiology
G Mental Health Z None
H Substance Abuse Z None
X New Technology 2 Cardiovascular Systems
H Skin, Subcutaneous Tissue, Fascia and Breast
K Muscles, Tendons, Bursae and Ligaments
N Bones
R Joints
W Anatomical Regions
Y Extracorporeal
*The Rehabilitation and Diagnostic Audiology section identifies the body system with the fourth character rather than the second as with other sec-
tions. The same 31 body systems used for the Medical and Surgical section apply here, as well.

Root Operation (Third Character)

Root Operation Term The third character in the ICD-10-PCS code reports the root operation term—the
The category or classification central aspect of the procedure or service being provided. Just as you learned when
of a particular procedure, ser- reporting procedures using CPT, you are essentially looking for the term that describes
vice, or treatment. WHAT the physician did for the patient. You can see that these terms are, for the most
part, familiar to you. Notice that once again the Medical and Surgical section has 31
different root operations.

954   PART V  |  INPATIENT (HOSPITAL) REPORTING

 0 Alteration J Inspection
1 Bypass K Map
2 Change L Occlusion
3 Control M Reattachment
4 Creation N Release
5 Destruction P Removal
6 Detachment Q Repair
7 Dilation R Replacement
8 Division S Reposition
9 Drainage T Resection
B Excision U Supplement
C Extirpation V Restriction
D Extraction W Revision
F Fragmentation X Transfer
G Fusion Y Transplantation CODING BITES
H Insertion In ICD-10-PCS, the word
operation has nothing
This is a long list. But don’t worry. You will learn about each of these root operation to do with surgery.
terms, and more used in other sections, in the upcoming chapters. Most importantly,
they are in your code book, along with their descriptions. So, no memorization is
required . . . just reading carefully and completely.
The other sections may use some of the same terms as the Medical and Surgical
section in addition to some terms specific to their area. Try not to get overwhelmed by
all these terms. You have time to learn about these procedures, look them up in a med-
ical dictionary, and become familiar with them. And remember, they are always right
there, at your fingertips, in the ICD-10-PCS code book.

CODING BITES
Using our example . . . bypass
Yes, sometimes it really is this easy. The physician uses the same term for the pro-
cedure as the ICD-10-PCS code book does.
First character = 0
Second character = 5
Third character = 1
0 Medical and Surgical
  5 Upper veins
   1 Bypass
NOTE: They are not all this easy. More to help you interpret root operation terms
in the upcoming chapters.

Body Part (Fourth Character)

Body Part
The fourth character of the ICD-10-PCS code provides information regarding the spe- The anatomical site upon
cific body part, anatomical site, or body region upon which the procedure, service, or which the procedure was
treatment was performed. These characters, and what they represent, vary, determined performed.

CHAPTER 32 
 by the section and body system. This is one of the reasons the Alphabetic Index will
not usually reach this level of specificity.

CODING BITES
Using our example . . . radial vein to ulnar vein, left
You can see how the details are built into the code.
The radial and ulnar veins are both specifically grouped into the category of
brachial veins. Again, If you did not know this offhand, don’t worry. Check your
medical dictionary or anatomy reference. This is one of the wonderful aspects of
being a coder; you can always use your resources to ensure accuracy.
Character 4 will provide the more specific detail, including laterality (right or left).
First character = 0
Second character = 5
Third character = 1
Fourth character = A
0 Medical and Surgical
5 Upper veins
1 Bypass
  A Brachial vein, left

Approach (Fifth Character)

Approach The term approach, as reported by the fifth character, reports the technique or method-
The specific technique used ology used during the procedure, such as open or laparoscopic. This character explains
for the procedure. how the physician got to the anatomical site upon which the procedure was performed.
NOTE: Other sections use this character position (character 5) to report a different
detail, such as single or multiple duration for extracorporeal therapy. The Imaging
section uses this position to report the use of contrast materials. Again, don’t worry;
the ICD-10-PCS code book will share this information with you. All you have to do is
read carefully and completely.

CODING BITES
Using our example . . . Laparoscopic
This detail must be provided by the physician in his or her operative notes. The
words may not be identical, so you will have to understand the meaning so you
can interpret.
A laparoscope is an endoscope inserted through an incision in the abdominal
wall (percutaneously), used to visualize the interior of the peritoneal cavity. There-
fore, you would interpret this as a PERCUTANEOUS ENDOSCOPIC approach.
First character = 0
Second character = 5
Third character = 1
Fourth character = A
Fifth character = 4
0 Medical and Surgical
5 Upper veins
1 Bypass
  A Brachial vein, left
   4 Percutaneous endoscopic
More about the specific approaches coming up in the following chapters.

956   PART V  |  INPATIENT (HOSPITAL) REPORTING

Device (Sixth Character)
Some of the sections use the sixth character to identify a device used in the procedure. Device
To some, this term may conjure up pictures of hard, metal equipment. However, in The identification of any mate-
ICD-10-PCS, the term device is used in a more general sense to mean any item that rials or appliances that may
will remain in or with the body after the procedure is complete. So it might mean remain in or on the body after
equipment, such as a pacemaker, or it may report the use of a graft. the procedure is completed.

CODING BITES
Using our example . . . using autologous tissue substitute
For the sixth character, you need to read the notes to determine if any devices,
substances, or other components were used. First, check your ICD-10-PCS sec-
tion to familiarize yourself with what type of details this character, in this table, will
report. Then, you will know what to look for in the documentation.
Here, in our example code, you have already determined that you are work-
ing with the 051 Table in ICD-10-PCS. In this table, the sixth character reports a
device, something that will remain in, or with, the patient after the procedure is
completed. Look at the options you have for the sixth character in this table: tissue
substitutes of various origins. Autologous tissue substitute was used during the
bypass to support the rerouting of the vein.
First character = 0
Second character = 5
Third character = 1
Fourth character = A
Fifth character = 4
Sixth character = 7
0 Medical and Surgical
5 Upper veins
1 Bypass
  A Brachial vein, left
   4 Percutaneous endoscopic
    7 Autologous tissue substitute
Some sections of ICD-10-PCS, such as the Administration section, will have you
report a category of substance, such as anti-inflammatory or antineoplastic, with
the sixth character. When you are working in that section, keep your pharmacol-
ogy reference close at hand.
More about this in the following chapters.

Qualifier (Seventh Character)

The seventh character of the ICD-10-PCS code, the qualifier, is like a wild card, report- Qualifier
ing whatever additional information may be needed. Because the coding system is Any additional feature of the
designed for future expansion, there will be cases where a specific procedure does not procedure, if applicable.
currently have the details to require all seven characters. In such cases, the letter Z is
used to indicate that nothing in that position was applicable to the particular procedure.

CODING BITES
Using our example . . . to ulnar vein
In this case, there is one more detail that must be explained . . . to what anatomical
site was the radial vein rerouted, or bypassed “to”—a different upper vein.
(continued)

CHAPTER 32 
 As you have seen throughout this textbook, GUIDANCE CONNECTION icons
direct you to official guidelines that will help you make accurate determinations
for each character. For this case, Guideline B3.6a directs you to specify the body
part bypassed from for the fourth character and the body part bypassed to for the
seventh character. In this table, you only have one choice. However, there may be
occasions in the future where this reminder will come in handy. Good thing these
guidelines are always right there, in the front of your code book.
First character = 0
Second character = 5
Third character = 1
Fourth character = A
Fifth character = 4
Sixth character = 7
Seventh character = Y
0 Medical and Surgical
5 Upper veins
1 Bypass
  A Brachial vein, left
   4 Percutaneous endoscopic
    7 Autologous tissue substitute
     Y Upper vein
Again, you will need to look at the table within the section of ICD-10-PCS first to
discover what detail or type of detail this character of this code will report. As you
read earlier, sometimes there is nothing left to share, so you will use the letter
Z No Qualifier.
Don’t worry. More about this all coming in the next chapters.

Placeholder Characters
The letter Z means “not applicable” or “none.” The Z placeholder will be used most
often as the seventh character; however, it can be used in any of the seven character
positions, when needed. It can also be used in multiple positions in one code.

EXAMPLE
Dr. McCoy performed a biopsy on Clark’s neck. The ICD-10-PCS code to report
this would be 0WB6XZX . . .
0 = Medical and Surgical
W = Anatomical regions, general
B = Excision
6 = Neck
X = External
Z = No device
X = Diagnostic
There is no device, so there is nothing to report in the sixth character position. But
you can’t leave that part of the code out. So you put a Z in that spot and report
that there is no device.

EXAMPLE
Dr. Rothwell used a percutaneous endoscope in an attempt to control post-­
procedural bleeding in Isaac’s colon, after several polyps had been removed. The
ICD-10-PCS code to report this would be 0W3P4ZZ . . .

958   PART V  |  INPATIENT (HOSPITAL) REPORTING

 0 = Medical and Surgical
W = Anatomical regions, general
3 = Control
P = Gastrointestinal tract
4 = Percutaneous endoscope
Z = No device
Z = No qualifier
There is no device, so there is nothing to report in the sixth character position.
There is no qualifier, so there is nothing to report in the seventh character position
either. By placing a Z in both positions, you are explaining exactly that. By the way,
this is not a decision you have to make. In this subsection of ICD-10-PCS tables,
Z No Device and Z No Qualifier are the only choices on the chart for those two
character positions.

32.3  The ICD-10-PCS Book

The ICD-10-PCS book is divided into two parts: the Alphabetic Index and the Tables.
[NOTE: Some publishers add a third section, which is a listing of all of the possible
ICD-10-PCS codes, similar to the other code books. Therefore, if one does not want
to “build” a code from the Tables, it can be looked up.]

The Alphabetic Index

The Alphabetic Index’s entries are primarily sorted by root operation terms.
∙ Root operation term
A root operation term identifies the specific service or type of treatment that is the
basis of the entire procedure.

EXAMPLES
Root operation terms include bypass, drainage, excision, and insertion.

After you find the root operation term, as stated in the documentation, there are
subentries listed by the following:
∙ Body system

EXAMPLES
Digestive system
Musculoskeletal system

∙ Body part

EXAMPLES
Arm, leg, hand, foot

∙ Common procedure names and eponyms

The Alphabetic Index also lists common terms for some procedures and eponyms.

CHAPTER 32 
 EXAMPLES
Hysterectomy is listed and then cross-referenced to resection (a root operation
term) and female reproductive system (body system).
Roux-en-Y operation is listed and then cross-referenced to bypass (a root
operation term) and gastrointestinal system or hepatobiliary system and pancreas
(both are body systems).

The Alphabetic Index will usually give you only the first three or four characters of
the seven-character procedure code. You then must go to the Tables to find the addi-
tional characters. You won’t have to be reminded to never code from the Alphabetic
Index with ICD-10-PCS. Often, you won’t be able to code from the Alphabetic Index
alone anymore!

EXAMPLE
Fragmentation
Of the Bladder 0TF8-

For the most part, you will find that the Alphabetic Index will include information
relating to the first three characters. This information will enable you to turn to the
correct page in the Tables and determine the rest of the characters for the code. As
you have seen, virtually all of the sections are consistent with the first three elements.
However, as you get to the last four characters, the information represented by these
characters may change, depending upon what type of procedure was performed or
upon what body system a procedure was performed. This is a major aspect of the flex-
ibility of the ICD-10-PCS system.

The Tables
The Tables are divided by body systems. Of course, like all the other code sets, each
section is in order by the first character in the code. Within each section’s body sys-
tem division, the list continues in order by the root operation term for that procedure.
Each section of the list has a grid that specifies the assigned meaning to each letter
or number along with its position in the seven-character code. (See an example in
Figure 32-2.)
You will go through the grid and construct the correct code based on the physi-
cian’s notes. As you have already learned, all ICD-10-PCS codes are seven characters.
Therefore, you will build the code in this order, as directed by the grid.
∙ First character: Section (such as Medical and Surgical, Mental Health, or
Imaging)
∙ Second character: Body system
∙ Third character: Root operation
∙ Fourth character: Body part or region
∙ Fifth character: Approach
∙ Sixth character: Device
∙ Seventh character: Qualifier
Therefore, when you review the information in Figure 32-2, you can see that the cor-
rect ICD-10-PCS code for Dilation of one site of a Coronary Artery, using an open
approach with an Intraluminal device is 02700DZ.

960   PART V  |  INPATIENT (HOSPITAL) REPORTING

 Section 0 Medical and Surgical
Body System 2 Heart and Great Vessels
Operation 7 Dilation: Expanding an orifice or the lumen of a tubular body part
Body Part Approach Device Qualifier
0 Coronary Artery, One Artery 0 Open 4 Intraluminal Device, Drug-eluting 6 Bifurcation
1 Coronary Artery, Two Arteries 3 Percutaneous 5 Intraluminal Device, Drug-eluting, Z No
2 Coronary Artery, Three Arteries 4 Percutaneous Endoscopic two Qualifier
3 Coronary Artery, Four or More 6 Intraluminal Device, Drug-eluting,
Arteries Three
7Intraluminal Device, Drug-eluting,
Four or More
D Intraluminal Device
E Intraluminal Device, Two
F Intraluminal Device, Three
G Intraluminal Device, Four or More
T Intraluminal Device, Radioactive
Z No Device
F Aortic Valve 0 Open 4 Intraluminal Device, Drug-eluting Z No
G Mitral Valve 3 Percutaneous D Intraluminal Device Qualifier
H Pulmonary Valve 4 Percutaneous Endoscopic Z No Device
J Tricuspid Valve
KVentricle, Right
P Pulmonary Trunk
Q Pulmonary Artery, Right
S Pulmonary Vein, Right
T Pulmonary Vein, Left
V Superior Vena Cava
W Thoracic Aorta, Descending
X Thoracic Aorta, Ascending/Arch

R Pulmonary Artery, Left 0 Open 4 Intraluminal Device, Drug-eluting T Ductus

3 Percutaneous D Intraluminal Device Arteriosus
4 Percutaneous Endoscopic Z No Device Z No
Qualifier

FIGURE 32-2  Table 027 from the Medical and Surgical Section 2018 ICD-10-PCS

ICD-10-PCS
LET’S CODE IT! SCENARIO
Jahlil Browne was playing football in the park with his friends. A player on the other team hit him at full force in the
chest when he ran to catch a pass. Jahlil was taken to the ED by ambulance and admitted into the hospital with an
open fracture of the third rib, right side. Dr. Wolf operated on Jahlil to insert an internal fixation device, using a per-
cutaneous endoscopic approach to secure the bone together so it can heal properly.

Let’s Code It!

What did the doctor do for Jahlil? Dr. Wolf inserted an internal fixation device on Jahlil’s fractured rib. It is always
wise to begin with the actual term that the physician used in his or her notes, so let’s go to the Alphabetic Index
and look up the term insertion.

(continued)

CHAPTER 32 
 Below the main term, insertion, is a list. None of these terms seem to go with this situation. Wait a minute.
Right below this is a main term that does fit: Insertion of device in. Beneath this is a list of anatomical sites. What
anatomical site did the fixation device go onto? Rib. Find
Insertion of device in
   Rib
    Left 0PH2
    Right 0PH1
These four characters are a good start. Remember, all ICD-10-PCS codes require seven (7) characters. You must
go to the Tables to confirm this is correct.
In the Tables, turn to the Medical and Surgical section: 0PH. Look carefully at the second row.
Section 0 Medical and Surgical
Body System P Upper Bones
Operation H Insertion
Body Region Approach Device Qualifier
1 Ribs, 1 to 2 0 Open 4 Internal Fixation Z No Qualifier
2 Ribs, 3 or more 3 Percutaneous Device
3 Cervical Vertebra 4 Percutaneous
4 Thoracic Vertebra Endoscopic
5 Scapula, Right
6 Scapula, Left
OK, let’s build a code:
The section: 0 Medical and Surgical (Dr. Wolf performed surgery on Jahlil)
The body system: P Upper Bones (the ribs are in the upper half of the body)
The root operation: H Insertion (Dr. Wolf inserted a fixation device)
The body part: 1 Ribs, 1 to 2 (as per the physician’s documentation)
The approach: 4 Percutaneous Endoscopic (the documentation states this approach)
The device: 4 Internal Fixation Device (this equipment will stay on Jahlil’s rib after the procedure
until it is healed)
The qualifier: Z No Qualifier
The ICD-10-PCS code to report the repair of Jahlil’s rib is 0PH144Z.
Good job!

ICD-10-PCS
LET’S CODE IT! SCENARIO
Montell was in a car accident and his right knee hit against the steering column. He was admitted into the hospital
and Dr. Tompkins took a high osmolar x-ray of his knee.

Let’s Code It!

What did Dr. Tompkins do for Montell? He x-rayed his knee.
In the Alphabetic Index, look up x-ray. The Alphabetic Index suggests
X-ray—see Plain Radiography
OK, so turn to Plain Radiography in the Alphabetic Index. Beneath this main term is a long list of anatomical sites,
so read down and find

962   PART V  |  INPATIENT (HOSPITAL) REPORTING

 Plain Radiography
   Knee
     Left BQ08
     Right BQ07
The Alphabetic Index provided only four of the seven needed characters of this suggested code, so turn to the
Tables to complete the code and confirm its correctness.
In the Tables, turn to the Imaging section: BQ0.
Section B Imaging
Body System Q Non-Axial Lower Bones
Type 0 Plain Radiology: Planar display of an image developed from the capture of external ion-
izing radiation on photographic or photoconductive plate
Body Region Approach Device Qualifier
0 Hip, Right 0 High Osmolar Z None Z None
1 Hip, Left 1 Low Osmolar
Y Other Contrast
0 Hip, Right Z None Z None 1 Densitometry
1 Hip, Left Z None
3 Femur, Right Z None Z None 1 Densitometry
4 Femur, Left Z None
7 Knee, Right 0 High Osmolar Z None Z None
8 Knee, Left 1 Low Osmolar
G Ankle, Right Y Other Contrast
H Ankle, Left Z None
D Lower leg, Right Z None Z None Z None
F Lower leg, Left
J Calcaneus, Right
K Calcaneus, Left
L Foot, Right
M Foot, Left
P Toe(s), Right
Q Toe(s), Left
V Patella, Right
W Patella, Left
X Foot/Toe Joint, Right 0 High Osmolar Z None Z None
Y Foot/Toe Joint, Left 1 Low Osmolar
Y Other Contrast

OK, let’s build the code:

The section: B Imaging (you know that x-rays are a type of imaging)
The body system: Q Non-axial lower bones (non-axial means away from the central part of the body,
and you know that the knee is a lower bone)
The root operation: 0 Plain Radiography (also known as x-ray)
The body part: 7 Knee, Right (as per the physician’s notes)
The contrast: 0 High Osmolar (as per the physician’s notes)
The qualifier: Z None
The qualifier: Z None

The ICD-10-PCS code to report the x-ray of Montell’s knee is BQ070ZZ.

Good work!

CHAPTER 32 
 Appendices
The information shared in the appendices of your ICD-10-PCS code book can be very
valuable as you abstract documentation to interpret to the correct character as you
build your code. In addition to the definitions for each of the major components of the
ICD-10-PCS code, there are also examples, which may help your understanding. And
. . . they are right there in the back of your ICD-10-PCS code book!
Appendices
Components of the Medical and Surgical Approach Definitions
Root Operation Definitions
Comparison of Medical and Surgical Root Operations
Body Part Key
Body Part Definitions
CODING BITES Device Key and Aggregation Table
Device Definitions
Various publishers of
Substance Key/Substance Definitions
the ICD-10-PCS code
Sections B-H Character Definitions
book may present these
Hospital Acquired Conditions
appendices in a differ-
Answers to Coding Exercises
ent order. Don’t worry.
Procedure Combination Tables
The titles should stay
the same. Use the information in these appendices to support your determination of the accurate
characters and the correct ICD-10-PCS code.

32.4  ICD-10-PCS General Conventions

The ICD-10-PCS code set has its own set of guidelines, of course. The following list con-
tains the general conventions of how the codes are constructed and how to use the Tables.
Read through these guidelines to get a strong start to accurately reporting inpatient
procedures. But don’t worry about memorizing them because they are right there, in
the front of your code book.
A1. ICD-10-PCS codes are composed of seven characters. Each character is an
Axis of Classification axis of classification that specifies information about the procedure per-
A single meaning within the formed. Within a defined code range, a character specifies the same type of
code set; providing a detail. information in that axis of classification.
This convention is explaining that all ICD-10-PCS codes must have seven (7)
characters—no more, no less—and that each character position (axis of classification)
has a specific meaning.

EXAMPLE
The third character of the code specifies the root operation term.
GUIDANCE
CONNECTION A2. One of 34 possible values can be assigned to each axis of classification in
the seven-character code: they are the numbers 0 through 9 and the letters
In the front of your ICD- of the alphabet (except I and O because they are easily confused with the
10-PCS code book, numbers 1 and 0). The number of unique values used in an axis of classifica-
look for the page titled tion differs as needed.
ICD-10-PCS OFFICIAL
GUIDELINES FOR COD- When this convention refers to “34 possible values,” it is referring to the fact that
ING AND REPORTING. this code set uses letters of the American alphabet (letters A to Z minus O and I, so
Then, follow along as 26 letters minus 2 = 24 possible letters) plus 10 possible numbers (0–9) = 34 possibili-
we discuss the first sec- ties for each position in each code. And while there may be 34 possibilities, only what
tion, Conventions. is needed is used at this time. This means that this code set has lots of room to grow
and include new codes as they become a part of our standards of care.

964   PART V  |  INPATIENT (HOSPITAL) REPORTING

 EXAMPLE
Where the fifth character specifies the approach, seven different approach values
are currently used to specify the approach.

A3. The valid values for an axis of classification can be added to as needed.
This convention means that this code set has lots of room to grow and include new
codes as they become a part of our standards of care.

EXAMPLE
If a significantly distinct type of device is used in a new procedure, a new device
value can be added to the system.

A4. As with words in their context, the meaning of any single value is a combina-
tion of its axis of classification and any preceding values on which it may be
dependent.
This convention tells you to interpret each meaning, not only according to each spe-
cific character’s definition, but also in combination with the meanings of the other
characters that are in that table, in that row. It is the total meaning that you must
look at, as well as each individual character. So, if once you put all seven characters
together, something doesn’t make sense, you need to read again.

EXAMPLE
The meaning of a body part value in the Medical and Surgical section is always
dependent on the body system value. The body part value 0 in the Central Ner-
vous body system specifies Brain; the body part value 0 in the Peripheral Nervous
body system specifies Cervical Plexus.

A5. As the system is expanded to become increasingly detailed, over time more
values will depend on preceding values for their meaning.
This convention means that they will continue to expand the system and ensure that
new characters added will not overlap or duplicate the meanings of characters that
already exist in that table, in the row.

EXAMPLE
In the Lower Joints body system:
• Under the root operation Insertion: Table 0SH
Device character 6: value 3 specifies “Infusion Device”
• Under the root operation Replacement: Table 0SR
Device character 6: value 3 specifies “Synthetic Substitute, Ceramic”

A6. The purpose of the Alphabetic Index is to locate the appropriate table that
contains all information necessary to construct a procedure code. The PCS
tables should always be consulted to find the most appropriate valid code.
Essentially, this convention is telling you what you may have learned when coding from
other code sets. Never report a code from the Alphabetic Index. Always refer to the tables
and double-check the meaning for each and every character in that table, in that row.

CHAPTER 32 
 A7. It is not required to consult the Index first before proceeding to the Tables
to complete the code. A valid code may be chosen directly from the Tables.
This takes convention A6 a little further in telling you that you are NOT required to
ever look in the Alphabetic Index. As you gain more experience, and you are on the
job, you may learn your way through this code set. So, if you are coding for the labor
and delivery services to a pregnant woman, you can go directly to the Obstetrics
tables without looking in the Alphabetic Index if you don’t need the suggestion. And
if you are coding for a psychiatrist providing care to a patient in a behavioral health
hospital, you can go directly to the Mental Health tables.
A8. All seven characters must be specified to be a valid code. If the documenta-
tion is incomplete for coding purposes, the physician should be queried for
the necessary information.
Every character in every code must report the facts, as supported by the physician’s
documentation. If any detail is missing, and you are not able to determine the correct
character, then you must query the physician to have the documentation amended. You
can never assume and never guess.
A9. Within a PCS Table, valid codes include all combinations of choices in char-
acters 4 through 7 contained in the same row of the table. In the example
below, 0HTWXZZ is a valid code, and 0HTW0ZZ is not a valid code.
Section 0 Medical and Surgical
Body System H Skin and Breast
Operation T Resection: Cutting out or off, without replacement, all
of a body part
Body Part Approach Device Qualifier
Q Finger Nail X External Z No Device Z No Device
R Toe Nail
W Nipple, Right
X Nipple, Left
T Breast, Right 0 Open Z No Device Z No Device
U Breast, Left
V Breast, Bilateral
Y Supplemental Breast

This convention tells you how to read the table to build your code. Once you find the
table with the correct first three characters (section, body system, root operation term),
then go down the column to find the correct 4th character. Once you determine this
accurate character, you can only go across in that one row. If you determine that the
procedure was done on the right nipple (character W in the first row), then you only
have one option for the approach: X External. If the documentation states an open
approach was used, then you cannot put 0 Open with W Nipple, Right because they
are on two different rows. This would highlight to you that you need to go back to the
documentation because you can’t build this code from more than one row.
A10. “And,” when used in a code description, means “and/or.”
Take a look at an example: Knee Bursa and Ligament. You would interpret this as
Knee Bursa and Ligament
Knee Bursa
Knee Ligament

EXAMPLE
Lower Arm and Wrist Muscle means lower arm and/or wrist muscle.

966   PART V  |  INPATIENT (HOSPITAL) REPORTING

 A11. Many of the terms used to construct PCS codes are defined within the
system. It is the coder’s responsibility to determine what the documenta-
tion in the medical record equates to in the PCS definitions. The physician
is not expected to use the terms used in PCS code descriptions, nor is the
coder required to query the physician when the correlation between the
documentation and the defined PCS terms is clear.
This convention tells you, directly, that it is your responsibility to interpret the terms
and phrases used by the physician in the documentation. For example, if the physi-
cian documents that he performed a biopsy, you, as the coder, must interpret that to
the ICD-10-PCS root operation term excision and if the physician documents that she
manipulated the dislocated shoulder back into position, you, as the coder, must inter-
pret this into the ICD-10-PCS root operation term reposition.

EXAMPLE
When the physician documents “cauterization,” the coder can independently cor-
relate “cauterization” to the root operation “destruction” without querying the phy-
sician for clarification.

32.5  Selection of Principal Procedure

Similar to CPT and HCPCS Level II coding, ICD-10-PCS has its guidelines for deter-
mining the sequencing when reporting more than one procedure provided during an
encounter. This is always going to be determined in coordination with the diagnosis
codes being reported to identify the medical necessity for performing these proce-
dures. Here are the Official Guidelines for ICD-10-PCS code sequencing:
The following instructions should be applied in the selection of principal procedure
and clarification on the importance of the relation to the principal diagnosis when
more than one procedure is performed:
1. Procedure performed for definitive treatment of both principal diagnosis and sec-
ondary diagnosis.
a. Sequence procedure performed for definitive treatment most related to principal
diagnosis as principal procedure.
2. Procedure performed for definitive treatment and diagnostic procedures performed
CODING BITES
for both principal diagnosis and secondary diagnosis.
a. Sequence procedure performed for definitive treatment most related to principal You learned about the
diagnosis as principal procedure. different types of pro-
3. A diagnostic procedure was performed for the principal diagnosis and a procedure cedures in the chapter
is performed for definitive treatment of a secondary diagnosis. Introduction to the Lan-
a. Sequence diagnostic procedure as principal procedure, since the procedure guages of Coding, the
most related to the principal diagnosis takes precedence. section titled Procedure
4. No procedures performed that are related to principal diagnosis; procedures per- Coding.
formed for definitive treatment and diagnostic procedures were performed for sec-
ondary diagnosis.
a. Sequence procedure performed for definitive treatment of secondary diagnosis
as principal procedure, since there are no procedures (definitive or nondefinitive GUIDANCE
treatment) related to principal diagnosis. CONNECTION
Source: ICD-10-PCS Official Guidelines for Coding and Reporting, 2018.
Read the ICD-10-PCS
As you read through these four guidelines to determine how multiple ICD-10-PCS OFFICIAL GUIDELINES
procedure codes should be sequenced, notice that you must refer to the diagnosis FOR CODING AND
codes, and the sequencing of those codes, as part of your decision-making process. In REPORTING, section
addition, you must understand why each procedure was performed—not only for the Selection of Principal
intended outcome, but also to understand if the procedure was done for diagnostic or Procedure.
therapeutic purposes.

CHAPTER 32 
 Chapter Summary
CHAPTER 32 REVIEW

CODING BITES
Additional information The purpose of this chapter is to provide an overview of ICD-10-PCS, giving you an
about ICD-10-PCS can idea of what to expect, and to help you establish a comfort level so that you are not
be found at: apprehensive about the new system. This chapter shared with you the distinct benefits
https://www.cms. of this code set. Then, step by step, the chapter differentiated the way the codes look
gov/Medicare/Coding/ and are constructed. The notations and explanations, exclusive to ICD-10-PCS, are all
ICD10/2018-ICD-10- reviewed. Examples are provided to illustrate the concepts and elements throughout
PCS-and-GEMs.html the chapter.

CHAPTER 32 REVIEW
Introduction to ICD-10-PCS Enhance your learning by
completing these exercises and
more at connect.mheducation.com!

Let’s Check It! Terminology

Match each key term to the appropriate definition.
1. LO 32.3  The identification of any materials or appliances that may remain in or A. Approach
on the body after the procedure is completed. B. Axis of Classification
2. LO 32.3  The category or classification of a particular procedure, ­service, or C. Body Part
treatment.
D. Body System
3. LO 32.3  The anatomical site upon which the procedure was performed.
E. Device
4. LO 32.3  Any additional feature of the procedure, if applicable.
F. Qualifier
5. LO 32.3  The physiological system, or anatomical region, upon which the pro-
G. Root Operation Term
cedure was performed.
6. LO 32.3  The specific technique used for the procedure.
7. LO 32.4  A single meaning within the code set; providing a detail.

Let’s Check It! Concepts

Choose the most appropriate answer for each of the following questions.
1. LO 32.1  In ICD-10-PCS, the initials PCS stand for
a. Popular Coding System. b.  Procedure Coding System.
c. Possible Coding Solutions. d.  Proper Coding System.
2. LO 32.2  The Alphabetic Index’s entries are primarily sorted by
a. root operation terms. b.  the approach.
c. the device. d.  the body system.
3. LO 32.2  The structure of ICD-10-PCS codes includes
a. three numbers. b.  five numbers.
c. seven characters. d.  up to nine characters.
4. LO 32.2  ICD-10-PCS codes include
a. only numbers. b.  only letters.
c. one letter followed by numbers. d.  letters and numbers.
5. LO 32.2  An example of a root operation term is
a. bypass. b.  x-ray.
c. obstetrics. d.  hysterectomy.

968   PART V  |  INPATIENT (HOSPITAL) REPORTING

 6. LO 32.2  Digestive system is an example of a

CHAPTER 32 REVIEW
a. body part. b.  root operation term.
c. medical procedure. d.  body system.
7. LO 32.2  The 17 sections of ICD-10-PCS are identified by
a. numbers 1–17. b.  numbers 0–9, then letters B–H and X.
c. letters A–Z. d.  alphabetic order by the name of the section.
8. LO 32.2  Placeholders are indicated in ICD-10-PCS with
a. the number 0. b.  the letter X.
c. the letter Z. d.  the number 9.
9. LO 32.2  An example of an approach is
a. open. b.  ileostomy.
c. pacemaker. d.  ventricular.
10. LO 32.2  An example of a device, for purposes of ICD-10-PCS coding, is
a. ablation. b.  laparoscopy.
c. pacemaker. d.  allotransplantation.
11. LO 32.2  The ICD-10-PCS code for the provision of a cesarean section would be found in
a. Section 2 Placement. b.  Section 1 Obstetrics.
c. Section B Imaging. d.  Section 6 Extracorporeal Therapies.
12. LO 32.2  Coding a chiropractic manipulative treatment would begin in
a. Section 0 Medical and Surgical.
b.  Section 4 Measurement and Monitoring.
c. Section 7 Osteopathic.
d.  Section 9 Chiropractic.
13. LO 32.2  What is the letter or number that represents the device in code 2W22X4Z?
a. 2 b.  W
c. 4 d.  X
14. LO 32.2  What is the letter or number that represents the approach in code 3E00X3Z?
a. E b.  X
c. 0 d.  Z
15. LO 32.2  What is the letter or number that represents the root operation in code 3E1S38Z?
a. 1 b.  S
c. 8 d.  E
16. LO 32.2  What is the letter or number that represents the section in code 2W10X7Z?
a. 2 b.  W
c. 1 d.  0
17. LO 32.2  What is the letter or number that represents the qualifier in code 3E0Y70M?
a. 0 b.  Y
c. 7 d.  M
18. LO 32.3  The Alphabetic Index will usually give you only the first ________ or ________ characters of the
seven-character procedure code.
a. one, two b.  two, three
c. three, four d.  five, six

CHAPTER 32 
 19. LO 32.4  Which ICD-10-PCS general convention states that within a PCS table, valid codes include all combina-
CHAPTER 32 REVIEW

tions of choices in characters 4 through 7 contained in the same row of the table?
a. A1 b.  A3
c. A6 d.  A9
20. LO 32.5  ICD-10-PCS does not have guidelines for determining the sequencing when reporting more than one
procedure provided during an encounter.
a. True b.  False

Let’s Check It! Rules and Regulations

Please answer the following questions from the knowledge you have gained after reading this chapter.
1. LO 32.2  ICD-10-PCS codes may include any letter of the alphabet except the letter(s) ________; include why
these letters are avoided.
2. LO 32.2  List the related pieces of information for the seven ICD-10-PCS character positions.
3. LO 32.3  How are the ICD-10-PCS tables divided?
4. LO 32.4  What are the 11 ICD-10-PCS General Convention guidelines? Include a brief description of each.
5. LO 32.5  What are the instructions for selection of the principal procedure when more than one procedure is
performed?

ICD-10-PCS
YOU CODE IT! Application
The following exercises provide practice in abstracting physicians’ notes and learning to work with documentation
from our health care facility, Westward Hospital. These case studies are modeled on real patient encounters. Using
the techniques described in this chapter, carefully read through the case studies and determine the most accurate
answers for each case study.

WESTWARD HOSPITAL
591 Chester Road
Masters, FL 33955
PATIENT: WELLINGTON, ALISHA
DATE OF ADMISSION: 03/13/18
DATE OF SURGERY: 03/13/18
DATE OF DISCHARGE 03/14/18
PRE-OPERATIVE DX: Right ureteral obstruction secondary to colon cancer
POST-OPERATIVE DX: Same
PROCEDURE: Cystoscopy
Right retrograde pyelogram
Removal and replacement of double-J stent
ANESTHESIA: General
HISTORY/INDICATIONS: This is a 39-year-old female with a history of colon cancer and secondary right
ureteral obstruction who had a stent inserted a number of months ago. At this time, she is in the hospital
and it is time for a stent change. Consequently, the patient presents for the procedure.

970   PART V  |  INPATIENT (HOSPITAL) REPORTING

 CHAPTER 32 REVIEW
PROCEDURE: The patient was taken to the operating room and there she was given general anesthetic,
positioned in the dorsal lithotomy position, the genitalia scrubbed and prepped with Betadine. Sterile
towels and sheets were utilized to drape the patient in the usual fashion. A cystoscope was introduced
into the bladder. The ureteral catheter was identified. It was grabbed and removed without any difficulty.
Subsequently, the cystoscope was reinserted into the bladder and the right ureteral orifice was identi-
fied over a Pollack catheter. A glide wire was inserted into the right collecting system. Some contrast
was injected and a hydronephrotic right side was noted. Then, the wire was placed through the Pol-
lack catheter. With the wire in position, over the wire a 7 French 26 cm double-J stent was inserted.
Excellent coiling was noted fluoroscopically in the kidney and distally with a cystoscope. The bladder
was then drained and again it was inspected prior to removal. There was no evidence of any tumors or
lesions in the bladder. The stent was in good position. The cystoscope was removed and the patient
was taken to the recovery room awake and in stable condition.

Benjamin Johnston, MD—2222

556839/mt98328: 03/15/18 09:50:16  T: 03/15/18 12:55:01

In Dr. Johnston’s documentation of Alisha Wellington’s procedure, what is/are the root operation term(s)?
a. Replacement
b. Fluoroscopy
c. Replacement and fluoroscopy
d. Removal

WESTWARD HOSPITAL
591 Chester Road
Masters, FL 33955
PATIENT: FIELDING, STEPHEN
DATE OF ADMISSION: 07/15/18
DATE OF SURGERY: 07/15/18
DATE OF DISCHARGE: 07/16/18
PRE-OPERATIVE DX: Superior canalicular laceration 
POST-OPERATIVE DX: Same
PROCEDURE: Superior canalicular repair
This patient is a 3-year-old male who is admitted into the Pediatric Unit with a dog bite to left side of face.
HPI: Approximately 3 hours ago, patient was playing with a large dog, the pet of a neighbor. Family wit-
nessed the dog make a single lunge at the boy’s face. Due to the adults’ attempts to intervene, only the
top jaw made contact. The dog did not attack further, and the incomplete bite to the left face was the
only injury sustained. Ophthalmology called in for consult.
POH/PMH/SH: No past ocular history. No past medical history. No current medications or allergies.
Well-adjusted preschool child lives at home with both parents. Childhood immunizations are up-to-date,
according to the mother.
OCULAR EXAM:
• VA 20/25 OD and OS without correction

CHAPTER 32 
CHAPTER 32 REVIEW

• Extraocular motility and IOP were normal, OU

• CVF: Full OD, OS
• Lids: Right side—Normal
• Lids: Left side—2 lacerations on the left upper lid, the larger and deeper of the lacerations passes just
medial to the upper punctum. Initial exploration of laceration raises concerns for probable canalicu-
lar involvement, but further detailed examination in this anxious pediatric patient was unable to be
accomplished.
• Continuation of the examination in the operating suite revealed that the remainder of the anterior
segment examination and DFE were normal.
TREATMENT: Primary surgical repair of the lacerated or avulsed canaliculus using pigtail probes is per-
formed immediately. The patient was taken to the operating suite for examination under general anes-
thesia (EUA) and laceration repair, likely to include canalicular repair.
DX: Superior canalicular laceration

Roxan Kernan, MD—4444

556848/mt98328: 07/17/18 09:50:16  T: 07/17/18 12:55:01

In Dr. Kernan’s documentation of the procedure on Stephen Fielding, what is the root operation term?
a. Repair
b. Eyelid
c. Canalicular
d. Bite

WESTWARD HOSPITAL
591 Chester Road
Masters, FL 33955
PATIENT: O’LEARY, KEVIN
DATE OF ADMISSION: 03/05/18
DATE OF DISCHARGE: 03/17/18
PRE-OPERATIVE DX: Third-degree burn, neck
POST-OPERATIVE DX: Same
PROCEDURE: Skin graft
ANESTHESIA: General
This patient is a 43-year-old male who works as a county firefighter. He is recovering from third-degree
burns on his neck. He was admitted today for the first session of skin grafting. Patient is brought into the
surgical suite and general anesthesia is administered by Dr. Rambeau. Once the patient is unconscious,
he is prepped and draped in the usual, sterile fashion. A split-thickness autograft, which contains the
dermis with only a portion of the epidermis, is taken from a donor site on the patient’s inner thigh, left.
The graft harvested is 11/1000ths of an inch in thickness, using a derma-tome. The graft is carefully
spread on the bare area and held in place with surgical staples. Plasmatic imbibition is initiated. The
graft is meshed with lengthwise rows of short, interrupted cuts, each a few millimeters long, with each

972   PART V  |  INPATIENT (HOSPITAL) REPORTING

 CHAPTER 32 REVIEW
row offset by half a cut length. The area is covered with derma-surgical gauze. Patient is awakened and
taken to recovery.
Benjamin Johnston, MD—2222
556839/mt98328: 03/15/18 09:50:16  T: 03/15/18 12:55:01

What is/are the root operation term(s), as documented in Dr. Johnston’s procedure notes for Kevin O’Leary?
a. Excision
b. Excision and replacement
c. Replacement and neck
d. Neck

WESTWARD HOSPITAL
591 Chester Road
Masters, FL 33955
PATIENT: SWANSONN, HANS
DATE OF ADMISSION: 05/23/18
DATE OF DISCHARGE: 05/23/18
PRE-OPERATIVE DX: Rule out bladder tumor
POST-OPERATIVE DX: Same
PROCEDURE: Cystoscopy, biopsy, and fulguration of bladder
ANESTHESIA: Spinal
INDICATIONS: The patient is a 67-year-old male with a history of grade II superficial transitional cell
carcinoma of the bladder. Cystoscopy showed a suspicious erythematous area on the right trigone. He
presented today for cystoscopy, biopsy, and fulguration. Findings: The urethra was normal; the bladder
was 1+ trabeculated; the mid and right trigone areas were slightly erythematous and hypervascular. No
papillary tumors were noted; no mucosal abnormalities were noted.
PROCEDURE: The patient was placed on the table in supine position. Satisfactory spinal anesthesia was
obtained. He was placed in dorsal lithotomy position and prepped sterilely with Hibiclens and draped in
the usual manner. A #22 French cystoscopy sheath was passed per urethra in atraumatic fashion. The
bladder was resected with the 70-degree lens with findings as noted above. Cup biopsy forceps were
placed and three biopsies were taken of the suspicious areas of the trigone. These areas were fulgu-
rated with the Bugby electrode; no active bleeding was seen. The scope was removed; the patient was
returned to recovery having tolerated the procedure well. Estimated blood loss was minimal.

PATHOLOGY REPORT: Chronic cystitis (cystica) with squamous cell metaplasia.

Roxan Kernan, MD—4444
556848/mt98328: 05/24/18 09:50:16  T: 05/24/18 12:55:01

What is the root operation term identified in Dr. Kernan’s procedure notes about Hans Swansonn?
a. Diagnostic
b. Excision
c. Bladder
d. Endoscopic

CHAPTER 32 
CHAPTER 32 REVIEW

WESTWARD HOSPITAL
591 Chester Road
Masters, FL 33955
PATIENT: ZANDER, MARISSA
DATE OF ADMISSION: 02/16/18
DATE OF DISCHARGE: 02/18/18
PRE-OPERATIVE DX: Delivery
POST-OPERATIVE DX: Same
PROCEDURE: Cesarean section, classical
In the 40th week of her first pregnancy, a 29-year-old female arrived at labor and delivery at 0830 for a
planned induction of labor due to mild, pregnancy-induced hypertension. After intra-vaginal placement
of misoprostol, the nurse observed her briefly and, at 1100, discharged her from the unit. She went for
a walk with her husband in a park next to the hospital. Patient’s membranes spontaneously ruptured
and she readmitted to the labor and delivery unit. The nurse admitted the patient, took her vital signs,
and checked the fetal heart rate. The mother’s blood pressure was 176/95, but the nurse thought this
was related to nausea, vomiting, and discomfort from the contractions. The resident examined the
mother, determined that her cervix was 5–6 cm, 90 percent effaced, and the vertex was at 0 station.
An internal fetal heart monitor was placed because the mother’s vomiting and discomfort caused her to
move around too much in the bed, making it hard to record the fetal heart rate with an external moni-
tor. The internal monitor revealed a steady fetal heart rate of 120 and no decelerations. The mother
continued to complain of painful contractions and requested an epidural. Shortly after placement of
the epidural, the monitor recorded a prolonged fetal heart rate deceleration. The heart rate returned
slowly to the baseline rate of 120 as the nurse repositioned the mother, increased her intravenous
fluids, and administered oxygen by mask. An epidural analgesia infusion pump was started. The fetal
heart rate strip indicated another deceleration that recovered to baseline. The nurse informed the resi-
dent, who checked the tracing and told her to “keep an eye on things.” The primary nurse noted in the
labor record that the baseline fetal heart rate was “unstable, between 100–120,” but she did not report
this to the resident. The nurse recorded that the fetal heart rate was “flat, no variability.” As the nurse
was documenting this as a non-reassuring fetal heart rate pattern, the patient expressed a strong urge
to push and the nurse called for an exam. A resident came to the bedside, examined the mother, and
noted that she was fully dilated with the caput at +1. A brief update was written in the chart, but the cli-
nician who had performed the exam was not noted. The mother was repositioned and began pushing.
The fetal heart rate suddenly dropped and remained profoundly bradycardic for 11 minutes. The resi-
dent was called and attempted a vacuum delivery since the fetal head was at +2 station. The attending
then entered and attempted forceps delivery. An emergency classical cesarean delivery was performed;
the baby was stillborn. The physician identified a uterine rupture that required significant blood replace-
ment. Whole blood transfusion, nonautologous, was performed, via peripheral vein.
Roxan Kernan, MD—4444
556848/mt98328: 07/17/18 09:50:16  T: 07/17/18 12:55:01

In Dr. Kernan’s documentation on the procedure performed on Marissa Zander, identify the root operation term(s).
a. Extraction
b. Transfusion
c. Percutaneous
d. Extraction and transfusion

974   PART V  |  INPATIENT (HOSPITAL) REPORTING

ICD-10-PCS Medical and
Surgical Section
Learning Outcomes
33
Key Terms
After completing this chapter, the student should be able to: Approach
Character
LO 33.1 Identify the section and body systems used in Medical and Root Operation Term
Surgical Section codes.
LO 33.2 Interpret the procedure to determine the accurate root oper-
ation term used in Medical and Surgical Section codes.
LO 33.3 Utilize knowledge of anatomy to determine the body part
treated to be used in Medical and Surgical Section codes.
LO 33.4 Identify the approach used to accomplish the procedure
used in Medical and Surgical Section codes.
LO 33.5 Distinguish the type of device implanted, when applicable,
for Medical and Surgical Section codes.
LO 33.6 Select the appropriate qualifier character for Medical and
Surgical Section codes.
LO 33.7 Determine the correct way to report multiple and discontin-
ued procedures for Medical and Surgical Section codes.
LO 33.8 Analyze all of the details to build an accurate seven-charac-
ter code for Medical and Surgical Section codes.

Remember, you need to follow along in

ICD-10-PCS
  STOP! your ICD-10-PCS code book for an
optimal learning experience.

33.1  Medical/Surgical Section/Body

Systems: Characters 1 and 2
As you learned earlier, every ICD-10-PCS code has seven characters, and each character Character
position has a meaning. While all of these codes have the same number of characters, each A letter or number component
section uses each character position differently. So let’s review the meanings for the Medi- of an ICD-10-PCS code.
cal and Surgical Section characters:

Character Position Character Meaning

1 Section of the ICD-10-PCS book
2 Body system being treated
3 Root operation term
4 Body part (specific anatomical site)
5 Approach used by physician
6 Device
7 Qualifier
 Character Position 1: Medical and Surgical Section 0 (Zero)
Character Position Character Meaning
1 Section of the ICD-10-PCS book
2 Body system being treated
3 Root operation term
4 Body part (specific anatomical site)
5 Approach used by physician
6 Device
7 Qualifier
All of the codes reporting a medical or surgical procedure will begin with a zero.
Medical and Surgical is the first section of the Tables, after the Alphabetic Index.
When you look up a procedure in the Alphabetic Index and see that the suggested code
begins with a zero, you will know immediately that you will find the rest of this code
in the Medical and Surgical Tables.

Character Position 2: Body System

Character Position Character Meaning
1 Section of the ICD-10-PCS book
2 Body system being treated
3 Root operation term
4 Body part (specific anatomical site)
5 Approach used by physician
6 Device
7 Qualifier
In this code set, the body systems are broken down into further detail than the organ
systems you learned in your anatomy and physiology course. The body systems and
their corresponding characters are:
0 Central Nervous System and Cranial Nerves
1 Peripheral Nervous System
2 Heart and Great Vessels
3 Upper Arteries
4 Lower Arteries
5 Upper Veins
6 Lower Veins
7 Lymphatic and Hemic Systems
8 Eye
9 Ear, Nose, Sinus
B Respiratory System
C Mouth and Throat
D Gastrointestinal System
F Hepatobiliary System and Pancreas
G Endocrine System
H Skin and Breast
J Subcutaneous Tissue and Fascia
K Muscles
L Tendons
M Bursae and Ligaments
N Head and Facial Bones
P Upper Bones

976   PART V  |  INPATIENT (HOSPITAL) REPORTING

 Q Lower Bones
R Upper Joints
GUIDANCE
S Lower Joints CONNECTION
T Urinary System Read the ICD-10-PCS
U Female Reproductive System Official Guidelines for
V Male Reproductive System Coding and Reporting,
Medical and Surgical
W Anatomical Regions, General
Section Guidelines
X Anatomical Regions, Upper Extremities (Section 0), subhead
Y Anatomical Regions, Lower Extremities B2. Body system,
Notice that, in this list, there is a 0 (zero) and a number 1 (one) but no letter O or letter paragraphs B2.1a
I. The creators of this code set did this purposely to avoid confusion. and B2.1b.
Take a look at body system 5 Upper Veins and 6 Lower Veins. As explained in the
guidelines, the imaginary transverse line is at the diaphragm, dividing the body into
top (upper) and bottom (lower). A procedure performed on the brachial vein, located
in the arm, will be reported with body system character 5, and a procedure performed
on the gastric vein, located in the stomach, is reported with body system character 6.
Similarly, the same applies for characters 3 and 4 (Upper and Lower Arteries), P and Q
(Upper and Lower Bones), and R and S (Upper and Lower Joints).
Now, let’s look at body system characters W, X, and Y, which report anatomical
regions instead of a specific body section or system. These should be used only when
the documentation identifies that the procedure was performed on an anatomical cav-
ity rather than an individual body part. You must read carefully to distinguish the
details. To illustrate this, let’s look at a case of a patient diagnosed with ascites (a
buildup of fluid in the abdominal cavity). The physician drains this excess fluid from
the abdominal cavity; therefore, it will require a character of W for the body system:
Anatomical Regions, General.
You do not need to worry about remembering that the liver is part of the hepatobili-
ary system or that a pacemaker generator is inserted into the subcutaneous tissue and
fascia and its leads are inserted into the heart. The Alphabetic Index will help you, as
will the listings for body part (character position 4).

EXAMPLES
Dr. Franklin inserted a neurostimulator lead into Matthew Short’s cerebrum, during
an open procedure.
The Body System is reported: Central Nervous System and Cranial Nerves with
a 0 (zero) character.

YOU INTERPRET IT!

Identify which body system this anatomical site would report for the second character.
1. Umbilical artery: _____
2. Cervical lymph node: _____
3. Cornea: _____
4. Pharynx: _____
5. Stomach: _____
6. Deltoid muscle: _____
7. Zygomatic process of frontal bone: _____
8. Coccyx: _____
9. Elbow Joint: _____
10. Trachea: _____

CHAPTER 33  | 
 33.2  Medical/Surgical Root Operations:
Character 3
Character Position Character Meaning
1 Section of the ICD-10-PCS book
2 Body system being treated
3 Root operation term
4 Body part (specific anatomical site)
5 Approach used by physician
6 Device
7 Qualifier

Root Operation Term The Medical and Surgical Section uses 31 root operation terms to describe what
The category or classification procedure was performed for the patient during this encounter. Don’t worry—the defi-
of a particular procedure, ser- nitions are listed in the ICD-10-PCS code book. However, you still need to learn and
vice, or treatment. understand them so that you can abstract the operative report or procedure notes accu-
rately and completely from the documentation. Remember that you are required to use
the ICD-10-PCS term definition in its entirety. Also, just as in reporting with CPT pro-
cedure codes, it is important that you understand all of the components of a specific root
operation or procedure. You don’t want to code inclusive components separately or miss
a second code because a component is not part of that procedure automatically. Using
GUIDANCE the root operation term is the most efficient way of using the Alphabetic Index as well.
CONNECTION
Read the ICD-10-PCS Alteration
Official Guidelines for Alteration: Modification of a natural anatomic structure of a body part without
Coding and Reporting, affecting the function of the body part . . . Character: 0 (zero)
Medical and Surgical
Section Guidelines
(Section 0), sub- EXAMPLE
head B3. Root Opera- Alteration is a procedure most often performed for cosmetic purposes, to improve
tion, paragraphs B3.1a the patient’s appearance, such as a face lift.
through B3.16. Rhytidectomy (face lift surgery) is a procedure performed to alter the look of
the skin on the face. Liposuction and breast augmentation are also examples of
this type of procedure.
0J013ZZ Alteration of subcutaneous tissue and fascia, face, percutaneous
approach

Bypass
GUIDANCE Bypass: Altering the route of the contents of a tubular body part . . . Character: 1
CONNECTION Bypass procedures are coded by identifying the body part bypassed “from,” identified
Read the ICD-10-PCS by character 4 (Body Part), and the body part bypassed “to,” identified by character 7
Official Guidelines for (Qualifier).
Coding and Reporting,
Medical and Surgical EXAMPLE
Section Guidelines
A bypass can be performed only on a tubular body part, such as a vein or an artery, the
(Section 0), subhead
esophagus, or the intestines. A colostomy formation is another example of a bypass.
Bypass Procedures,
paragraphs B3.6a, 02114Z8 Coronary artery bypass, one site, percutaneous endoscopic
B3.6b, and B3.6c. approach, rerouted to internal mammary, right side

978   PART V  |  INPATIENT (HOSPITAL) REPORTING

Change
Change: Taking out or off a device from a body part and putting back an identical
or similar device in or on the same body part without cutting or puncturing the
skin or a mucous membrane . . . Character: 2

EXAMPLE
Change is a root operation only used when a device is involved in the procedure—
a device that stays with the patient after the procedure is complete. A urinary cath-
eter change or gastronomy tube change are good examples. Often, this term will
actually be used in the documentation.
0020X0Z Changing a drainage device in the brain, external approach

Control GUIDANCE
CONNECTION
Control: Stopping, or attempting to stop, postprocedural or other acute bleeding
. . . Character: 3 Read ICD-10-PCS
Official Guidelines for
The root operation term Control is used only when the only action taken during this Coding and Reporting,
procedure is the intent to stop the hemorrhage. If this attempt was unsuccessful and Medical and Surgical
another procedure was performed to accomplish this task, such as excision or resec- Section Guidelines
tion, then report the code for that root operation instead of Control. You will not report (Section 0), sub-
both. head Control vs. More
Definitive Root Opera-
tions, paragraph B3.7.
EXAMPLE
Control is a procedure to stop massive bleeding (hemorrhaging).
0W3B0ZZ Control post-procedural bleeding in the pleural cavity, left side,
open approach

Creation
Creation: Putting in or on biological or synthetic material to form a new body part
that to the extent possible replicates the anatomic structure or function of an
absent body part . . . Character: 4
This procedure is used when the physician actually makes a new structure, such as
creation of an artificial vagina during a male-to-female procedure in a gender reas-
signment surgery, procedures to correct congenital anomalies, or replacement of a
dysfunctional heart valve.

EXAMPLES
Creation of a body part, such as a penis or a heart valve, is reported with this root
operation term.
0W4N0J1 Creation of an artificial penis using synthetic substitute, open
approach
024G082 Creation of a mitral valve using zooplastic tissue, open approach

Destruction
Destruction: Physical eradication of all or a portion of a body part by the direct
use of energy, force, or a destructive agent . . . Character: 5

CHAPTER 33  | 
 Several methodologies are reported as destruction, such as fulguration, the application
of high-frequency electrical current, also known as electrofulguration, when it is used
to destroy tissue (typically malignant neoplasm). Chemical agents, such as salicylic
acid, can also be used to destroy tissue.

EXAMPLE
Destruction is used to describe when the tissue is no longer in existence, and
there is no specimen to send to pathology.
Terms that may be used in the documentation include fulguration, cauteriza-
tion, and cryosurgery.
0U5B8ZZ Fulguration of endometrium, vaginal endoscopic approach

Detachment
Detachment: Cutting of all or a portion of the upper or lower extremities . . .
Character: 6
This is the root operation term for amputation of an arm or a leg, in whole or in part.

EXAMPLE
Detachment is only used to report the amputation of an arm or leg, no other body
part.
0Y6J0Z1 Amputation, directly below knee, left leg, open approach

Dilation
Dilation: Expanding an orifice or the lumen of a tubular body part . . . Character: 7
Remember, an orifice is a natural body opening (such as vagina or anus) and the lumen
of a tubular body part (lumen = “space within the tube”). Blood vessels are tubular
body parts, as are a woman’s fallopian tubes.

EXAMPLES
Dilation is the process of opening a closed tubular body part.
037H34Z Dilation of right common carotid artery, with drug-eluting intralu-
minal device, percutaneous approach
0U7C7ZZ Dilation of the cervix, via natural opening

Division
Division: Cutting into a body part, without draining fluids and/or gases from the
body part, in order to separate or transect a body part . . . Character: 8

EXAMPLE
Division is the separation of body parts.
An episiotomy, an osteotomy, and spinal cordotomy are all good examples.
0K820ZZ Division of sternocleidomastoid muscle, right side, open
approach

980   PART V  |  INPATIENT (HOSPITAL) REPORTING

Drainage
Drainage: Taking or letting out fluids and/or gases from a body part . . . Character: 9

EXAMPLE
Drainage is, as it sounds, the process of helping gases or fluids escape.
0W9B30Z Drainage of excess air from left pleural cavity, percutaneous
approach

Excision
GUIDANCE
Excision: Cutting out or off, without replacement, a portion of a body part . . . CONNECTION
Character: B
Read the ICD-10-PCS
Pay close attention to this description of excision. This term has a narrower meaning Official Guidelines for
in ICD-10-PCS than it does in CPT and in many physicians’ notes. Excision is used in Coding and Report-
ICD-10-PCS only when a segment is cut out. This includes obtaining a tissue biopsy, ing, Medical and
performing a lumpectomy, and cutting out a bone spur. However, if the entire organ or Surgical Section
body part is removed, the root operation term used is Resection (even if the physician Guidelines (Section
documents that an organ was excised—you must interpret it). 0), subheads Exci-
sion vs. Resection,
EXAMPLE paragraph B3.8, and
Excision for Graft,
Excision is the surgical removal of a part or portion of a body part, not the entire
paragraph B3.9.
organ.
0FB13ZX Excision, liver, right lobe, percutaneous approach, diagnostic
procedure

Extirpation
Extirpation: Taking or cutting out solid matter from a body part . . . Character: C
This reference to “solid matter” may indicate a blood clot or gallstones when surgi-
cally removed.

EXAMPLE
Extirpation is the surgical removal of a solid formation from within the body.
Some good examples are thrombectomy (surgical removal of a blood clot attached
to the wall of a vein or artery) and cholelithotomy (surgical removal of gallstones).
04CL0ZZ Extirpation of thrombus, femoral artery, left side, open approach

Extraction
Extraction: Pulling or stripping out or off all or a portion of a body part by the use
of force . . . Character: D

EXAMPLE
Extraction may be done by scraping (curettage), pulling, suction, or other process.
Vein stripping, D&C (dilation and curettage), and a cesarean section (extracting
a baby from the womb) are all good examples.
0UDB8ZZ Suction extraction of endometrium, via natural opening, endo-
scopic approach

CHAPTER 33  | 
 Fragmentation
Fragmentation: Breaking solid matter in a body part into pieces . . . Character: F
An example of fragmentation is lithotripsy—the use of shock waves to break kidney
stones (renal lithiasis) into smaller pieces with the hope that the body will be able to
pass them naturally.

EXAMPLE
Fragmentation is the process of breaking up something in the body into smaller
pieces, such as the procedure of lithotripsy.
0TFCXZZ Fragmentation of stones in the bladder neck, using external
approach

GUIDANCE
CONNECTION Fusion
Read the ICD-10-PCS Fusion: Joining together portions of an articular body part rendering the articular
Official Guidelines for body part immobile . . . Character: G
Coding and Reporting, Arthrodesis, the surgical immobilization of a joint, such as of the spine, is one type of
Medical and Surgical fusion (articular = “joint”).
Section Guidelines
(Section 0), sub-
head Fusion Proce- EXAMPLE
dures of the Spine, Fusion is a procedure that is opposite of division.
paragraphs B3.10a,
0RG40A0 Fusion of cervicothoracic vertebral joint, open procedure,
B3.10b, and B3.10c.
anterior approach, anterior column, using an interbody fusion
device

Insertion
Insertion: Putting in nonbiological appliance that monitors, assists, performs, or
prevents a physiological function but does not physically take the place of a
body part . . . Character: H
This is another opportunity for reading very carefully. In ICD-10-PCS, this root oper-
ation applies only to the placement into the body of a medical device, such as a pace-
maker, that will remain in the body after the procedure is completed.

EXAMPLE
Insertion is the placing of a device into the body.

GUIDANCE 05H933Z Insertion of catheter (infusion device) into right brachial vein,
percutaneous approach
CONNECTION
Read the ICD-10-PCS
Official Guidelines for
Inspection
Coding and Report- Inspection: Visually and/or manually exploring a body part . . . Character: J
ing, Medical and
This root operation term is limited to the physician’s looking at the body part.
Surgical Section
Guidelines (Section
0), subhead Inspec- EXAMPLE
tion Procedures, para- Inspection in this case is just like the English word . . . to look at.
graphs B3.11a, B3.11b,
and B3.11c. 09JEXZZ Inspection of the left inner ear, external approach

982   PART V  |  INPATIENT (HOSPITAL) REPORTING

Map
Map: Locating the route of passage of electrical impulses and/or locating func-
tional areas in a body part . . . Character: K
Cardiac conduction mapping and brain mapping are two illustrations of this root oper-
ation. Note that this root operation term reports the examination only.

EXAMPLE
Map is a methodology that enables the physician to obtain a record of the func-
tion of a specific anatomical part.
00K03ZZ Mapping of brain function, percutaneous approach

GUIDANCE
Occlusion CONNECTION
Occlusion: Completely closing an orifice or lumen of a tubular body part . . . Char- Read the ICD-10-PCS
acter: L Official Guidelines for
There are times when an opening, such as a fistula, or a tubular body part, such as a Coding and Reporting,
fallopian tube, is purposely closed off or blocked. Medical and Surgical
Section Guidelines
(Section 0), sub-
EXAMPLE head Occlusion vs.
Occlusion is the opposite of dilation. Restriction for Vessel
Embolization Proce-
0VLH4ZZ Occlusion of spermatic cords, bilaterally, percutaneous endo- dures, paragraph B3.12.
scopic approach, no device

Reattachment
Reattachment: Putting back in or on all or a portion of a separated body part to
its normal location or other suitable location . . . Character: M
This word is the same as the term most often used by physicians for this procedure,
such as reattaching a finger after it has been severed during an accident.

EXAMPLE
Reattachment is reported for anatomical sites only.
0XMP0ZZ Reattachment of left index finger, open approach

Release GUIDANCE
CONNECTION
Release: Freeing a body part from an abnormal physical constraint by cutting or
by use of force . . . Character: N Read the ICD-10-PCS
Official Guidelines for
The procedure reported with this root operation term involves cutting or separation Coding and Report-
only, such as tendon lengthening, in order to free a body part from some type of ing, Medical and
restriction. Surgical Section
Guidelines (Section
EXAMPLE 0), subheads Release
Procedures, para-
Release is similar to division, so be careful to read the descriptions and the docu-
graph B3.13, and
mentation very carefully.
Release vs. Division,
0LNS0ZZ Release of right ankle tendon, open approach paragraph B3.14.

CHAPTER 33  | 
 Removal
Removal: Taking out or off a device from a body part . . . Character: P
Read this carefully: As the description specifically states “device,” this can be used
only for this type of procedure—to remove a previously inserted device. As you
abstract the physician’s notes, be cautious of the use of this term in documentation.
The removal of a mole, for example, is really an excision, not a removal.

EXAMPLE
Removal is only used when a device has been removed.
0QP304Z Removal of internal fixation device from left pelvic bone, open
approach

Repair
Repair: Restoring, to the extent possible, a body part to its normal anatomic
structure and function . . . Character: Q

EXAMPLE
Repair is often the therapeutic process of correcting an abnormality.
0CQV8ZZ Repair of left vocal cord, via natural opening, endoscopic
approach

Replacement
Replacement: Putting in or on biological or synthetic material that physically takes
the place and/or function of all or a portion of a body part . . . Character: R
Essentially, this is the placement of a prosthetic device, such as a hip replacement or a
prosthetic heart valve.

EXAMPLE
Replacement is directly related to the use of internal prosthetics.
02RG0JZ Replacement of mitral valve with synthetic prosthesis, open
approach

GUIDANCE Reposition
CONNECTION Reposition: Moving to its normal location or other suitable location all or a por-
tion of a body part . . . Character: S
Read the ICD-10-PCS
Official Guidelines for
Coding and Reporting, EXAMPLE
Medical and Surgical Reposition is the correction that is usually employed with a patient who has a
Section Guidelines dislocation.
(Section 0), sub-
head Reposition for 0PSFXZZ Reposition humeral shaft, right side, external approach
Fracture Treatment,
paragraph B3.15. Resection
Resection: Cutting out or off, without replacement, all of a body part . . .
Character: T

984   PART V  |  INPATIENT (HOSPITAL) REPORTING

Remember how this differs from excision. When the entire body part is surgically
removed, it is reported as a resection. If only a portion of the body part is removed, it GUIDANCE
is reported as an excision. CONNECTION
Read the ICD-10-PCS
EXAMPLE Official Guidelines for
Coding and Report-
Resection is the root operation term used for the surgical removal of an entire
ing, Medical and
organ.
Surgical Section
0FT44ZZ Resection of gallbladder, percutaneous endoscopic approach Guidelines (Section
0), subhead Excision
vs. Resection,
Restriction paragraph B3.8.
Restriction: Partially closing an orifice or lumen of a tubular body part . . .
Character: V
Compare this with the root operation term occlusion. Restriction is a partial closure
and occlusion is a complete closure.

EXAMPLE
Restriction is a surgical methodology for limiting the function, or malfunction, of an
anatomical site.
0DV44CZ Restriction of esophagogastric junction, using extraluminal
device, percutaneous endoscopic approach

Revision
Revision: Correcting, to the extent possible, a portion of a malfunctioning device
or the position of a displaced device . . . Character: W
Again, pay careful attention to the word device. This root operation term can only be
used when a medical device is being fixed.

EXAMPLE
Revision is correcting the internal positioning of a device.
02WA0MZ Revision of cardiac lead, open approach

Supplement
Supplement: Putting in or on biological or synthetic material that physically
reinforces and/or augments the function of a portion of a body part . . .
Character: U
Note: In the Tables section, supplement is in alphabetic order by its character U, not by
the term supplement, so it falls between resection and restriction.

EXAMPLES
Supplement, just as in English, is something that provides support.
0TUB4JZ Supplementation of bladder, percutaneous endoscopic
approach, using synthetic mesh
0YUA47Z Use of autologous tissue substitute mesh to repair an inguinal
hernia laparoscopically, bilateral

CHAPTER 33  | 
 Transfer
Transfer: Moving, without taking out, all or a portion of a body part to another
location to take over the function of all or a portion of a body part . . . Charac-
ter: X

EXAMPLE
Transfer is the process when the body part transferred still remains connected to
its original vascular and nervous supply.
0JX03ZB Transfer of skin and subcutaneous tissue, scalp, percutaneous
approach

Transplantation
GUIDANCE
Transplantation: Putting in or on all or a portion of a living body part taken from
CONNECTION another individual or animal to physically take the place and/or function of all
Read the ICD-10-PCS or a portion of a similar body part . . . Character: Y
Official Guidelines for ICD-10-PCS uses this term in the same manner that physicians do. However, this
Coding and Reporting, includes more than just organ transplant procedures. 
Medical and Surgical
Section Guidelines
(Section 0), sub- EXAMPLE
head Transplantation Transplantation is the implanting of a donor body organ into a recipient.
vs. Administration,
paragraph B3.16. 0TY00Z0 Transplant of an allogeneic right kidney, open approach

Adjusting Your Interpretations

As you abstract the physician’s documentation, you may need to adjust some of your
interpretative processes for reporting procedures using ICD-10-PCS. The root opera-
tion term is based on the objective of the procedure. You are seeking the word describ-
ing the action, such as excision or drainage. Combination terms with which you are
very familiar, such as colonoscopy, liver biopsy, or appendectomy, may describe the
procedure; however, these terms do not specifically explain the action of the physi-
cian, or do they? Let’s take a closer look at these terms and interpret them into the root
operation terms:
Colonoscopy: colon = “large intestine” (anatomical site) + -oscopy = “to view”
In ICD-10-PCS, you would use the root operation term Inspection: Visually and/or
manually exploring a body part.
Liver biopsy: liver = anatomical site + biopsy = “excision of tissue for diagnostic
purposes”
In ICD-10-PCS, you would use the root operation term Excision: Cutting out or off,
without replacement, a portion of a body part. In just a bit, you will learn about adding
a qualifier in the character 7 position to include the detail that this was a diagnostic
excision.
Appendectomy: append = “appendix” (anatomical site) + -ectomy = “surgical
CODING BITES removal”
Review Appendix: Root In ICD-10-PCS, you would use the root operation term Resection: Cutting out or off,
Operation Definitions without replacement, all of a body part.
in the back of your ICD- With some procedures, you will use your knowledge of the specific procedure and
10-PCS code book. what it is expected to accomplish. For example, you will need to remember that lith-
otripsy is performed for Fragmentation: Breaking solid matter in a body part into

986   PART V  |  INPATIENT (HOSPITAL) REPORTING

pieces, which is done when a patient has kidney stones. Another example is thoracen-
tesis (thora = “thorax [chest]” + -centesis = “puncture”), performed for Drainage:
Taking or letting out fluids and/or gases from a body part.

YOU INTERPRET IT!

Practice interpreting from the common procedure terms used to reference the ICD-10-PCS root opera-
tion term. The Root Operation Definitions Appendix may help you.
11. Colostomy formation: _____
12. Cautery of skin lesion: _____
13. Transluminal angioplasty: _____
14. Choledocholithotomy: _____
15. Free skin graft: _____
16. Adhesiolysis: _____
17. Fallopian tube ligation: _____
18. Diagnostic arthroscopy: _____
19. Ankle arthrodesis: _____
20. Total nephrectomy: _____
21. Esophagogastric fundoplication: _____

33.3  Medical/Surgical Body Parts:

Character 4
Character Position Character Meaning
1 Section of the ICD-10-PCS book
2 Body system being treated
3 Root operation term
4 Body part (specific anatomical site)
5 Approach used by physician
6 Device
7 Qualifier

The fourth character position identifies the specific body part that is the focus of a
procedure. The operative report or the procedure notes should be clear about these
details. However, sometimes it can be a challenge to match the documentation to the
choices offered in the tables. Following are some guidelines to help you determine the
accurate code in ICD-10-PCS.

General Guidelines
There may be times when the notes are more specific than the code character specifics.
If the physician documents that the procedure was performed on a specific anatomical
site, such as the biceps femoris muscle, yet the listing of body parts under Muscles (Body
System character K) does not provide this detail, you will need to code to the body part
that includes this anatomical site. In this case, you would report Upper Leg Muscle.

Bilateral Procedures
If the documentation identifies that a procedure was performed on both a right body
part and a left body part, and a Body Part code character is available to report the

CHAPTER 33  | 
 bilateral procedure, that is the one code to report. However, if there is no code char-
acter available to report a bilateral procedure, then you will need to report two codes:
one for each procedure.

EXAMPLES
0HRV3KZ Replacement of breasts, bilateral, percutaneous approach
0CNT8ZZ Release of right vocal cord, via natural opening endoscopic
0CNV8ZZ Release of left vocal cord, via natural opening endoscopic

Coronary Arteries
While the coronary arteries are represented by one code character, there are additional
characters to report when more than one site is treated in this one set of arteries.

EXAMPLE
Dr. Forreau performed an angioplasty in the left anterior descending coronary
artery in two distinct sites with two intraluminal, drug-eluting stents placed.
02713DZ Dilation of coronary artery, two sites, percutaneous approach
with intraluminal device, drug-eluting

Joints and Muscles

Many body systems provide individual code characters for body parts specific to a
joint or a muscle. There are some cases when the Body Part characters may not be as
specific as the physician’s notes. The guidelines provide direction in determination of
a code character to report the body part. When a procedure is performed on the skin,
the subcutaneous tissue, or the fascia that is lying over a joint,
∙ Shoulder is reported as Upper Arm.
∙ Elbow is reported as Lower Arm.
∙ Wrist is reported as Lower Arm.
GUIDANCE
∙ Hip is reported as Upper Leg.
CONNECTION
∙ Knee is reported as Lower Leg.
Read the ICD-10-PCS ∙ Ankle is reported as Foot.
Official Guidelines for
Coding and Reporting, When a body system does not include a separate Body Part code character for fin-
Medical and Surgical gers or toes,
Section Guidelines, ∙ Finger is reported as Hand.
subhead B4. Body
Part, paragraphs B4.1a ∙ Toe is reported as Foot.
through B4.8.
Gastrointestinal Body System
Certain areas within the gastrointestinal Body System tables group the individual
body parts of the intestinal tract into upper and lower. For these cases, the Upper Intes-
CODING BITES tinal Tract includes the esophagus, stomach, and small intestine, up to and including
Review Appendix: Body the duodenum. The Lower Intestinal Tract includes the jejunum, ileum, cecum, and
Part Key and Appendix: large intestine, all the way to and including the anus.
Body Part Definitions The Body Part Key Appendix in ICD-10-PCS can also help you when a specific
in the back of your ICD- anatomical site is documented and the Body Part components are not as specific. For
10-PCS code book. instance, Stensen’s duct is reported as the parotid duct, and the superior gluteal nerve
is described in ICD-10-PCS as the lumbar plexus.

988   PART V  |  INPATIENT (HOSPITAL) REPORTING

 YOU INTERPRET IT!

Practice using the Body Part Key Appendix and fill in the descriptions used by ICD-10-PCS for coding.
22. Superior olivary nucleus: _____
23. Sigmoid vein: _____
24. Right suprarenal vein: _____
25. Ulnar notch: _____
26. Ventricular fold: _____
27. Sweat gland: _____
28. Optic disc: _____
29. Oropharynx: _____
30. Nasal concha: _____
31. Manubrium: _____
32. Ischium: _____

33.4  Medical/Surgical Approaches:

Character 5 GUIDANCE
Character Position Character Meaning CONNECTION
1 Section of the ICD-10-PCS book Read the ICD-10-PCS
2 Body system being treated Official Guidelines for
3 Root operation term Coding and Reporting,
4 Body part (specific anatomical site) Medical and Surgical
Section Guidelines
5 Approach used by physician
(Section 0), sub-
6 Device head B5. Approach,
7 Qualifier paragraphs B5.2,
B5.3a, B5.3b, and
As you continue to build a code, you can see that you are telling a story. The first four
B5.4.
characters explain what the physician did and the anatomical site upon which he or she
worked. Now, with the fifth character, you are going to explain how the physician got
to the anatomical site to perform the procedure. This is known as the approach, and Approach
seven approaches are used within the Medical and Surgical Section. The path the physician took
to access the body part upon
which the treatment or proce-
Open dure was targeted.
Open: Cutting through the skin or mucous membrane and any other body layers
necessary to expose the site of the procedure . . . Character: 0
An open procedure is the traditional approach when the physician makes an incision
into the body to access an internal organ. The operative notes should include the details
of the incision, providing open access to the internal organ that needs the treatment.

EXAMPLES
You might see documentation that states:
“. . . Attention was then turned to the patient’s lower abdomen. Incision was
made from symphysis pubis to umbilicus, midline. The incision was carried
down through the dermis, subcutaneous fat, and linea alba using electro-
cautery. Preperitoneal fat was incised using electrocautery. Peritoneum was
grasped with pickups. . . .”
(continued)

CHAPTER 33  | 
 GUIDANCE You can see that the physician describes the incision made, cutting through the
CONNECTION subcutaneous and adipose layers to the peritoneum (the membrane that lines the
abdominal cavity).
Read the ICD-10-PCS
Official Guidelines for “. . . The patient was taken to the operating room after being administered
Coding and Reporting, an epidural anesthetic, placed in the supine position, prepped and draped
Medical and Surgical in a sterile fashion with a wedge under the right hip. A Pfannenstiel skin inci-
Section Guidelines sion was made and carried down through layers along the old incision
(Section 0), sub- line. . . .” 
head Open Approach In this excerpt from an operative report, the physician states this process more
with Percutaneous simply, but you can still understand that the patient is being cut into.
Endoscopic Assistance,
paragraph B5.2.
Percutaneous
Percutaneous: Entry, by puncture or minor incision, of instrumentation through
the skin or mucous membrane and any other body layers necessary to reach
the site of the procedure . . . Character: 3
When a percutaneous approach is used, the physician cannot see inside the body.
Often, a radiologist will provide imaging guidance (which would be reported sepa-
rately). A needle aspiration and needle biopsy are good illustrations of a percutaneous
approach.

EXAMPLE
You might see documentation that states:
“. . . The patient was prepped and draped in the usual fashion. A long, thin
needle is inserted through the patient’s abdominal wall, periumbilical quadrant,
passed into the amniotic sac. Ultrasound guidance is used. When puncture
into the sac is confirmed, a small sample of amniotic fluid is extracted and sent
to the lab. . . .”
A needle is inserted through the dermis (percutaneously) all the way into the amni-
otic sac. The fact that ultrasound guidance was used supports the fact that the
physician could not see where the point of the needle was going (no scope to see
inside; no internal visualization).

Percutaneous Endoscopic
Percutaneous Endoscopic: Entry, by puncture or minor incision, of instrumenta-
tion through the skin or mucous membrane and any other body layers neces-
sary to reach and visualize the site of the procedure . . . Character: 4
In this type of approach, a scope is placed through the incision or puncture. A laparo-
scopic procedure is a good example.

EXAMPLES
You might see documentation that states:
“. . . The patient was positioned supine on the operating room table. . . . A small
umbilical incision allowed for introduction of the Veress needle and inflation
of the abdomen to 15 cm of water pressure using carbon dioxide gas. The 0
degree, 5 mm laparoscope was introduced through a 5 mm port at the umbilicus
and 3 additional ports were placed in the usual anatomic positions. The liver
was found to be markedly enlarged. . . .”

990   PART V  |  INPATIENT (HOSPITAL) REPORTING

 A percutaneous endoscopic approach can also be described as a laparoscopic
procedure. This approach can also be recognized by the description of a “small”
incision, which only needs to be large enough to fit the endoscope through, typi-
cally about one inch long (2.54 cm).

Via Natural or Artificial Opening

Via Natural or Artificial Opening: Entry of instrumentation through a natural or
artificial external opening to reach the site of the procedure . . . Character: 7
The natural openings to the body include the nose, mouth, ear, vagina, urethra, and anus.
An artificial opening includes a stoma (an opening that has been surgically created).

EXAMPLE
“. . . A weighted speculum was placed in the posterior vaginal wall and the
right-angle retractor used to visualize the cervix. The cervix was grasped
across the anterior lip with a single-toothed tenaculum. . . . The cervix was cir-
cumferentially excised with the scalpel. . . .”
This excerpt is from the operative notes for a vaginal hysterectomy. Just the name
tells you that the approach was via the patient’s vagina, but you know that the name
is insufficient upon which to support a code. As you read the description of what the
physician did, you know you have the documentation to support the reporting of this
hysterectomy being performed using a vaginal (natural opening) approach.

Via Natural or Artificial Opening Endoscopic

Via Natural or Artificial Opening Endoscopic: Entry of instrumentation through a
natural or artificial external opening to reach and visualize the site of the pro-
cedure . . . Character: 8
Note that the difference between this approach and “via natural or artificial opening”
is the use of an endoscope to visualize the anatomical site upon which the procedure
will be performed.

EXAMPLES
You might see documentation that states:
“. . . The patient was placed in the dorsolithotomy position on a cystoscopy
table, prepped and draped in the usual fashion. A #21 French cystoscope
was passed through the urethra into the bladder. . . .”
The urethra is the anatomical tube that leads from the urinary bladder to the out-
side of the body. This is a natural opening into visceral organs, such as the blad-
der, ureters, and kidneys. The insertion of the cystoscope through the urethra is a
endoscope being used to see inside the body via a natural opening.
“. . . The patient was brought to the operative suite, placed in the supine posi-
tion. After satisfactory induction of general endotracheal anesthesia, a flexible
Olympus bronchoscope was passed through the endotracheal tube, visualizing
the distal trachea, carina, right and left main stem bronchus with primary and
secondary divisions. . . .”
Your understanding of anatomy will help you identify this natural opening—the
pharynx is the medical term for the throat. The bronchoscope was threaded
through the patient’s mouth, down the throat, into the bronchi. 

CHAPTER 33  | 
 Via Natural or Artificial Opening with Percutaneous Endo-
scopic Assistance
Via Natural or Artificial Opening with Percutaneous Endoscopic Assistance: Entry
of instrumentation through a natural or artificial external opening and entry,
by puncture or minor incision, of instrumentation through the skin or mucous
membrane and any other body layers necessary to aid in the performance of
the procedure . . . Character: F
This approach is kind of a combination endoscopic (laparoscopic) approach along
with the use of a natural or artificial opening.

EXAMPLE
You might see documentation that states:
“. . . The endoscope is inserted into the esophagus and down into the esopho-
gastric junction. The anterior aspect of the gastric lining is visualized. A 2.5 cm
incision is made into the right lateral aspect of the abdominal wall to allow for
GUIDANCE the insertion of the gastrostomy tube. . . .”
CONNECTION
This excerpt from the documentation of the placement of a feeding tube (also
Read the ICD-10-PCS known as a G-tube) uses a percutaneous endoscopic gastrostomy (PEG) approach
Official Guidelines for along with the natural opening approach of the mouth for the esophagogastro-
Coding and Report- duodenoscope (EGD).
ing, Medical and
Surgical Section
Guidelines (Section External
0), subhead Exter-
External: Procedure performed directly on the skin or mucous membrane and
nal Approach, para-
procedures performed indirectly by the application of external force through
graphs B5.3a and
the skin or mucous membrane . . . Character: X
B5.3b.

EXAMPLES
CODING BITES You might see documentation that states:
As you abstract the “. . . Used the McIvor mouth gag to retract the tongue and endotracheal
documentation and tube inferiorly, giving good exposure to the oropharynx. The tonsils were
interpret the way the visualized. . . .”
physician describes
As you read this physician’s description, it clearly indicates that the patient’s
how the procedure was
mouth was held open so the tonsils were visualized . . . seen by the naked eye.
performed, you may find
There were no incisions or penetrations through the tissues, neither was any type
Appendix: Components
of scope used.
of the Medical and
Surgical Approach Def- “. . . Upper eyelid incision was performed in the skin with 15 blade scalpel. . . .”
initions in your ICD-10-
The eyelid is right there, on the outside (external) part of the body. Again, no inci-
PCS code book helpful.
sions, penetrations through the tissues, or any type of scope was necessary.

YOU INTERPRET IT!

Practice using the Medical and Surgical Approach Definitions Appendix and fill in the approach used
by ICD-10-PCS for coding.
33. Liposuction: _____
34. Sigmoidoscopy: _____

992   PART V  |  INPATIENT (HOSPITAL) REPORTING

 5. Laparoscopic hysterectomy: _____
3
36. Fracture manipulation (closed): _____
37. Traditional cholecystectomy: _____
38. Foley catheter placement: _____
39. Lumbar puncture: _____
40. Breast biopsy with guidance: _____
41. Endoscopy: _____
42. Cesarean section: _____
43. Blepharotomy: _____

33.5  Medical/Surgical Devices: Character 6

Character Position Character Meaning
1 Section of the ICD-10-PCS book
2 Body system being treated
3 Root operation term
4 Body part (specific anatomical site)
5 Approach used by physician
6 Device
GUIDANCE
7 Qualifier CONNECTION
As you can see, a character placed in the sixth position will identify a device that will Read the ICD-10-PCS
remain with the patient after the procedure has been completed. ICD-10-PCS qualifies Official Guidelines for
these generalized types of devices: Coding and Reporting,
∙ Grafts Medical and Surgical
Section Guidelines
∙ Prostheses
(Section 0), subhead
∙ Implants B6. Device, paragraphs
∙ Simple or mechanical appliances B6.1a, B6.1b, B6.1c,
∙ Electronic appliances and B6.2.

Reading through the Medical and Surgical Section, with a focus on some of the
options for the sixth character, you will find a limited number of descriptors. Let’s take
a closer look at these:
GUIDANCE
Grafts CONNECTION
  Autologous Tissue . . . Character: 7
  Autologous Venous Tissue . . . Character: 9 Read the ICD-10-PCS
  Autologous Arterial Tissue . . . Character: A Official Guidelines for
Coding and Report-
This refers to a graft made with tissue from the patient’s own body. ing, Medical and
  Synthetic Substitute . . . Character: J Surgical Section
Guidelines (Section 0),
This explains that the graft material may be carbon fibers, polypropylene, or other subhead B6. Device:
nonhuman substance. General Guidelines,
  Nonautologous Tissue Substitute . . . Character: K paragraphs B6.1a,
B6.1b, and B6.1c, as
This graft is made from materials other than the patient’s own tissue. well as subhead Drain-
  Zooplastic Tissue . . . Character: 8 age Device, paragraph
B6.2, for more details.
This identifies that the graft was made with tissue from a species other than human.

CHAPTER 33  | 
 Simple or Mechanical Appliances
Drainage Device . . . Character: 0
Monitoring Device . . . Character: 2
Monitoring Device, Pressure Sensor . . . Character: 0
Infusion Device . . . Character: 3
Extraluminal Device . . . Character: C
Intraluminal Device . . . Character: D
Intraluminal Device, Two . . . Character: E
Intraluminal Device, Three . . . Character: F
Intraluminal Device, Four or More . . . Character: G
Intraluminal Device, Drug-Eluting . . . Character: 4
Intraluminal Device, Drug-Eluting, Two . . . Character: 5
Intraluminal Device, Drug-Eluting, Three . . . Character: 6
Intraluminal Device, Drug-Eluting, Four or More . . . Character: 7
Bioactive Intraluminal Device . . . Character: B
Intraluminal Device, Radioactive . . . Character: T
Implants and Electronic Appliances
Stimulator (Cardiac) Lead . . . Character: M
Cardiac Lead, Pacemaker . . . Character: J
Intracardiac Pacemaker . . . Character: N
Implantable Heart Assist System . . . Character: Q
External Heart Assist System . . . Character: R
Radioactive Element . . . Character: 1
No Device . . . Character: Z
In operative reports and procedure notes, when a device is placed into the patient,
CODING BITES the notes will identify the brand name and details, rather than “synthetic substitute”
or “intraluminal device.” For instance, an AxiaLIF® System is an interbody fusion
Review Appendix:
device used in lower joints, or Ultrapro plug is a synthetic substitute. Don’t panic. You
Device Key and Aggre-
don’t have to memorize these brand names. Just bookmark Appendix: Device Key
gation Table and
and Aggregation Table in your ICD-10-PCS code book.
Appendix: Device Defi-
nitions in the back of
your ICD-10-PCS code EXAMPLES
book. How can you determine if a device was implanted into the patient? The documen-
tation will state something like one of these surgical notes excerpts.
“. . . A Kapandji technique was also used for intrafocal pinning, taking a
0.062 K-wire in both the radial and ulnar aspects of the distal fragment and
elevating it, followed by reducing it, controlling the distal fragment. . . .”
“. . .  A Palmaz Blue Genesis stent, 6 x 80 mm was used. It was deployed
across the left renal artery stenosis in good position. . . .”
“. . . A stylet (a thin wire) is inserted inside the center channel of the pace-
maker lead to make it more rigid, and the lead-stylet combination is then
inserted into the sheath and advanced under fluoroscopy to the appropriate
heart chamber. . . .”

YOU INTERPRET IT!

Practice using the Device Key Appendix and fill in the device description used by ICD-10-PCS for coding.
44. Bovine pericardial valve: _____
45. Acuity Steerable Lead: _____

994   PART V  |  INPATIENT (HOSPITAL) REPORTING

 6. Embolization coil(s): _____
4
47. Tissue bank graft: _____
48. Pump reservoir: _____
49. Lap-Band® Adjustable Gastric Banding System: _____
50. Prestige cervical disc: _____
51. Versa: _____
52. Novacor Left Ventricular Assist Device: _____
53. EndoSure® sensor: _____
54. Brachytherapy seeds: _____

33.6  Medical/Surgical Qualifiers: Character 7

Character Position Character Meaning
1 Section of the ICD-10-PCS book
2 Body system being treated
3 Root operation term
4 Body part (specific anatomical site)
5 Approach used by physician
6 Device
7 Qualifier

This seventh character is required. In many cases, there may be no more details to
add, so you will use the placeholder Z No Qualifier—the equivalent of “not applicable.”
You will find that, depending on the procedure provided, you may need to check the
documentation for applicable details. For instance, when an excision is performed, you
may find a Qualifier character option to explain that this was a biopsy (for diagnostic
purposes . . . character X).
Earlier in this chapter, in the section that discussed root operation terms, you learned
that bypass procedures are coded by identifying the body part bypassed “from,” iden-
tified by character 4 (Body Part), and the body part bypassed “to,” identified by the
character 7 (Qualifier). This is just a reminder that, in some cases, the Qualifier char-
acter will partner with the Body Part character to explain the whole story about the
procedure.

EXAMPLE
0D164JA Gastric bypass, percutaneous endoscopic approach, rerouted
from stomach to jejunum

ICD-10-PCS
LET’S CODE IT! SCENARIO
Callie MacDonald, a 2-year-old female, was admitted to the hospital by her ophthalmologist, Dr. Epps. Her right
lacrimal duct was occluded. After sedation was administered, Dr. Epps probed her nasolacrimal duct and inserted
a transluminal balloon catheter to expand the duct. The balloon was deflated and removed. She tolerated the pro-
cedure well.
(continued)

CHAPTER 33  | 
 Let’s Code It!
Let’s go through the steps of coding for ICD-10-PCS and determine the code or codes that should be reported
for this encounter between Dr. Epps, an ophthalmologist, and Callie MacDonald.
First character: Section: Medical and Surgical . . . 0
Second character: Body System: Eye . . . 8
What root operation term would be most accurate? Read through the scenario carefully. Dr. Epps “expanded”
the duct. The description of the term “dilation” is to expand an orifice or the lumen of a tubular body part.
Third character: Root Operation: Dilation . . . 7
Now, which “tubular body part” was dilated? The scenario states, “Her right lacrimal duct . . .”
You may have been tempted to think “eye”; however, when you get to the table for Eye, Dilation . . . 087, you
will see that “eye” is the Body System and not an option for Body Part.
Fourth character: Body Part: Lacrimal Duct, Right . . . X
Dr. Epps inserted the catheter directly into the duct (this opening is how our tears flow from our eyes). Therefore,
he used a natural opening.
Fifth character: Approach: Via Natural or Artificial Opening . . . 7
Dr. Epps inserted a transluminal balloon catheter; however, then the documentation states, “The balloon was
deflated and removed.” Therefore, there is no Device reported in this position.
Sixth Character: Device: No Device . . . Z
Seventh Character: Qualifier: No Qualifier . . . Z
The ICD-10-PCS code you will report is
087X7ZZ   Dilation, lacrimal duct, right, via natural or artificial opening
Good job!!

33.7  Multiple and Discontinued Procedures

in Medical and Surgical Cases
Multiple Procedures
GUIDANCE
CONNECTION Just because the physician performs more than one procedure does not necessarily
mean you will report more than one code. The Official Guidelines provide four illus-
Read the ICD-10-PCS trations of cases when you will report multiple procedures:
Official Guidelines for
Coding and Reporting, 1. The same root operation is performed on different body parts as defined by dis-
Medical and Surgical tinct values of the body part character. Two codes are reported.
Section Guidelines 2. The same root operation is repeated at different body sites that are included in the
(Section 0), sub- same body part value. You will report the same code twice. It is recommended that
head Multiple Proce- a report to explain is appended.
dures, paragraph B3.2. 3. Multiple root operations with distinct objectives are performed on the same body
part. Two codes are reported, one for each root operation.
4. The intended root operation is attempted using one approach but is converted to a
different approach. One code will report what was actually accomplished with the
first approach, and a second code will report the second approach.

996   PART V  |  INPATIENT (HOSPITAL) REPORTING

 ICD-10-PCS
LET’S CODE IT! SCENARIO
Ronald Markum, a 21-year-old male, was riding his motorcycle when he skidded out. The bike fell on top of him and
his left ankle was dislocated. He was admitted into the hospital and Dr. Traub tried to manually realign the tarsal
bone to its rightful position. Unfortunately, he was unable to accomplish this and had to take Ronald to the OR to
perform an open procedure.

Let’s Code It!

Let’s go through the steps of coding for ICD-10-PCS and determine the code or codes that should be reported
for this encounter between Dr. Traub and Ronald Markum.
First code:
First character: Section: Medical and Surgical . . . 0
What is the body system? The documentation states, “tarsal bone.” That is in the ankle . . . therefore, Lower Bones.
Second character: Body System: Lower Bones . . . Q
What did the physician actually do? The documentation states, “manually realign the tarsal bone to its rightful
position.” Read the definitions of the root operation terms. This matches Reposition.
Third character: Root Operation: Reposition . . . S
What body part was treated? The documentation states, “his left ankle” + “the tarsal bone.”
Fourth character: Body Part: Tarsal, Left . . . M
What was the approach? Did the physician go into the body? No, treatment was done from the outside.
Fifth character: Approach: External . . . X
Was any device inserted into the patient and left there? There is no mention of this.
Sixth Character: Device: No Device . . . Z
No details left to report.
Seventh Character: Qualifier: No Qualifier . . . Z
The ICD-10-PCS code you will report is
0QSMXZZ Reposition, left tarsal bone, externally
Remember the guideline about multiple procedures, B3.2, part d. You will need a second code to report the sec-
ond attempt to realign Ronald’s ankle. Notice the differences between the first attempt and the second attempt.
The only difference is that the procedure was changed from an EXTERNAL approach to an OPEN approach.
Second code:
First character: Section: Medical and Surgical . . . 0
Second character: Body System: Lower Bones . . . Q
Third character: Root Operation: Reposition . . . S
Fourth character: Body Part: Tarsal, Left . . . M
Fifth character: Approach: Open . . . 0
Sixth character: Device: No Device . . . Z
Seventh character: Qualifier: No Qualifier . . . Z
The ICD-10-PCS code you will report is
0QSM0ZZ Reposition, left tarsal bone, open approach
Finally, consider in what sequence you will report these two codes. The rule is that the most intense procedure
will be reported first, so you should report the open procedure first, followed by the external approach.
0QSM0ZZ Reposition, left tarsal bone, open approach
0QSMXZZ Reposition, left tarsal bone, externally
Good job!

CHAPTER 33  | 
 Discontinued Procedures
It has happened: The physician begins a procedure and for some reason must stop
before accomplishing the goal originally planned. Should this occur, you are directed
to report those root operations that were actually done.

GUIDANCE CONNECTION
Read the ICD-10-PCS Official Guidelines for Coding and Reporting, Medical and
Surgical Section Guidelines (Section 0), subhead Discontinued Procedures,
paragraph B3.3, for more details.

EXAMPLE
Dr. Zander has planned a laparoscopic cholecystectomy. The incisions are made
and the scope is inserted. The gallbladder can be visualized. However, before the
organ can be surgically removed, the patient has a seizure. Dr. Zander stops the
procedure and closes the incisions.
0FJ44ZZ Inspection of gallbladder, percutaneous endoscopic approach

ICD-10-PCS
YOU CODE IT! CASE STUDY
Nita Yessa has been in the hospital with a compound fracture of the leg and she was brought into the procedure
room to have her two-lead pacemaker replaced. Dr. Balthazar was able to remove her current pacemaker easily.
However, there was a problem with the new device and he did not want to insert it. He closed the incision and sent
Nita back to her room. He told Rita Holsman, his assistant, to notify him as soon as a new pacemaker was available.

You Code It!

Dr. Balthazar intended to replace Nita’s pacemaker, but he couldn’t complete the procedure. Using your ICD-10-
PCS code book, determine the correct code to report this procedure.
Step #1: Read the case carefully and completely.
Step #2: Abstract the scenario. Which key words or terms describe what service the physician provided to the
patient during this encounter?
Step #3: Are there any details missing or incomplete for which you would need to query the physician? [If so,
ask your instructor.]
Step #4: Build the correct ICD-10-PCS procedure code or codes to explain the details about what was pro-
vided to the patient during this encounter.
Step #5: Check for any relevant guidance.
Step #6: Double-check your work.
Answer:
Did you determine this to be the correct code?
02PA3QZ Removal of implantable heart assist system, percutaneous approach

As Guideline B3.3 directs you, when an intended procedure is discontinued, you need to code for what was
actually completed. Dr. Balthazar was able to remove the old pacemaker, so you must code for the removal. You
cannot code for the insertion of the new pacemaker because this was not done.
Good work!

998   PART V  |  INPATIENT (HOSPITAL) REPORTING

33.8  Medical/Surgical Coding:
Putting It All Together

ICD-10-PCS
LET’S CODE IT! SCENARIO
PATIENT: Randolph Joy
HISTORY OF PRESENT ILLNESS: Patient was admitted to the Medical/Surgical floor last evening with acute upper
abdominal pain and dyspnea. Blood work results were inconclusive, as was x-ray. Today, we are going to perform
an EGD to investigate further.
PROCEDURE PERFORMED: Esophagogastroduodenoscopy
MEDICATIONS: Fentanyl 50 mcg, Versed 4 mg.
DESCRIPTION OF PROCEDURE: Informed consent was obtained. The patient was then placed in the left lateral
decubitus position. IV sedation was started in a sequential fashion until the appropriate level of consciousness was
achieved. Hurricaine spray was applied to the back of the throat and the endoscope was then advanced under
direct visualization over the tongue, the esophagus, stomach, and duodenum. It was slowly withdrawn and the
mucosa was carefully evaluated. Duodenal mucosal abnormalities were not visualized. Antegrade and retrograde
views of the stomach did demonstrate some mild nonerosive gastritis, predominantly in the antrum. Portal gastropa-
thy was noted throughout the gastric body, cardia, and fundus. Thickened gastric folds were noted and biopsied.
Retroflexed view as well demonstrated no signs of a gastric varix; no coffee grounds or red blood was seen in the
gastric lumen either. The scope was then withdrawn through the GE junction and careful examination did dem-
onstrate shallow esophageal ulceration distally; biopsies were obtained. The suspicion of Barrett’s esophagus
noted with two salmon tongues of mucosa emanating 1 cm proximal to the GE junction. Careful examination of the
remainder of the esophagus did demonstrate a hyperemic esophagus without further ulceration. The scope was
then withdrawn from the patient and the procedure terminated. It was well tolerated and there were no immediate
complications. 
POST-PROCEDURE DIAGNOSES: 
1. Probable Barrett’s esophagus
2. Distal esophageal ulceration
3. Thickened hypertrophied gastric folds
4. Portal gastropathy and nonerosive gastritis
IMPRESSION AND PLAN: I suspect this patient’s upper GI bleed is likely related to the ulcerations noted on this
examination. As we await results of biopsies, I will change his proton pump inhibitor from an IV drip to oral and be-
gin oral feeding as well. Hemoglobin and hematocrit will continue to be followed and, if stable, discharge may take
place tomorrow.

Let’s Code It!

Dr. Ferrante performed an EGD to visually inspect Randolph’s interior stomach to determine the cause of the
pain and respiratory issues.
First character: Section: Medical and Surgical . . . 0
An esophagogastroduodenoscopy was performed. What body system does this involve? You learned about this
in medical terminology class. Esopha- = esophagus + -gastro- = stomach + -duoden- = duodenum. To what
body system do these anatomical sites belong? 
Second character: System: Gastrointestinal System . . . D
Dr. Ferrante performed an EGD to visually inspect Randolph’s interior stomach to determine the cause of the
pain. This would point to the root operation term inspection. However, then tissue biopsies were taken, which

(continued)

CHAPTER 33  | 
 points to the root operation term excision. Do you report two ICD-10-PCS codes? Let’s analyze this. They are two
different reasons for the procedure; however, while an inspection could be done without any excisions, the fact
is that the biopsies could not be acquired without the inspection. Therefore, you only need one code, using the
root operation term Excision.
Third character: Root Operation: Excision . . . B
From what anatomical site were the biopsies taken? The documentation states, “esophageal ulceration distally;
biopsies were obtained.” 
Fourth character: Body Part/Region: Esophagus, Lower . . . 3
How did Dr. Ferrante get to the distal (lower) esophagus? The documentation states, “the endoscope was then
advanced under direct visualization. . . .”
Fifth character: Approach: Via Natural or Artificial Opening Endoscopic . . . 8
Sixth character: Device: No Device . . . Z
Our last character will explain the essential reason for this procedure. Was it to gather details to support a diag-
nosis (i.e., diagnostic)? Or was it to repair or fix a problem (i.e., therapeutic)?
Seventh character: Qualifier: Diagnostic . . . X
Now, you can put all of these characters together to report the ICD-10-PCS code, with confidence:
0DB38ZX Esophagogastroduodenoscopy, with biopsies, diagnostic
Good work!

ICD-10-PCS
LET’S CODE IT! SCENARIO
PATIENT: GARY SALTON
PREOPERATIVE DIAGNOSIS: Subdural hematoma, traumatic
HISTORY OF PRESENT ILLNESS: This is a 17-year-old male, legally blind since birth, admitted after an assault.
During the assault, he suffered extensive subarachnoid hemorrhage, LeFort fracture of the face, right arm venous
phlebitis, and subdural hematoma. He was maintained on SICU, prophylaxis Dilantin, because of extensive sub-
arachnoid hemorrhage. He went to the OR for facial ORIF. His course was complicated by ventricular tachycardia,
but he was ruled out for MI at that time. He was started on amiodarone for the rate control. He also suffered a
mandibular fracture so PEG was placed because of his inability to eat. No mention is made of acute seizure in this
patient. There is no report of MRIs anywhere in the documentation. Preadmission summary states intracerebral
hemorrhage and subdural hematoma, although they do not state where. He had to be emergently intubated due
to hypoxemia. Other complications, during his hospital course, include cellulitis around the trach site, FUOs, and
sinusitis. He has phlebitis in his right forearm. Repeat head CT showed increased bilateral frontal subdural hygroma
and subarachnoid hemorrhage. He also developed hyphema of the right eye.
PAST MEDICAL HISTORY: Hypertension
FAMILY HISTORY: Hypertension and stroke
SOCIAL HISTORY: He smokes a pack a day and occasional alcohol. Otherwise, independent prior to the
admission.
MEDICATIONS: Prednisone, bacitracin topical cream, amiodarone, vancomycin, methadone b.i.d., dalteparin subcu
daily, BuSpar 10 mg b.i.d., metoprolol 50 mg b.i.d., Pepcid, and Percocet.
PROCEDURE: Patient was taken to the OR for excision of frontal subdural hygroma and subarachnoid hemor-
rhage for evacuation. Once endotracheal administration of anesthesia was accomplished, patient was prepped

1000   PART V  |  INPATIENT (HOSPITAL) REPORTING

and draped in the usual fashion, in a supine position. Using the drill, one small hole was made in the skull to relieve
pressure and allow blood and fluids to be drained from the anterior cerebral vein. This was accomplished, and suc-
tion was applied to ensure the area was cleaned thoroughly. The area was bandaged and the patient was aroused
successfully.
Scott Taucher, MD
Let’s Code It!
Dr. Taucher drained Gary Salton’s anterior cerebral vein. Let’s analyze the documentation and build the code.
First character: Section: Medical and Surgical . . . 0
What specific body system was operated upon? The documentation states, “anterior cerebral vein.” The body
system, therefore, would be the cerebrovascular system. However, there is not one character to cover this.
Instead, you have four: 3 Upper Arteries; 4 Lower Arteries; 5 Upper Veins; and 6 Lower Veins. In which of these
does the “anterior cerebral vein” fit? Cerebral indicates the brain, and, therefore, Upper Veins.
Second character: System: Upper Veins . . . 5
What did Dr. Taucher actually do in this procedure? The documentation states, “allow blood and fluids to be
drained.”
Third character: Root Operation: Drainage . . . 9
Now, turn to the 059 Table in the Tables section. Read carefully through the options listed for the fourth charac-
ter. Can you find “anterior cerebral vein”? You can see it with a broader descriptor . . .
Fourth character: Body Part: Intracranial Vein . . . L
Do you see the specific type of approach used in this procedure? The documentation states, “Using the drill, one
small hole was made in the skull.”
Fifth character: Approach: Open . . . 0
Go back to the notes. Was a device placed into the patient and left there after the procedure ended?
Sixth character: Device: No Device . . . Z
Did Dr. Taucher do this to gather information to determine a diagnosis, or was this to fix or repair a problem?
Seventh character: Qualifier: No Qualifier . . . Z
Now you can put all of these characters together to report this ICD-10-PCS code, with confidence:
059L0ZZ Drainage of intracranial vein, open approach
Good work!

ICD-10-PCS
LET’S CODE IT! SCENARIO
PATIENT: ANABELLE PRESTON
DATE OF OPERATION: 10/18/2018
PREOPERATIVE DIAGNOSIS: Bilateral urolithiasis
POSTOPERATIVE DIAGNOSIS: Bilateral urolithiasis
OPERATIONS PERFORMED:
1. Cystoscopy
2. Right retrograde pyelogram
(continued)

CHAPTER 33  | 
 3. Right ureteral stent placement
4. Right percutaneous nephrolithotripsy
SURGEON: Sonia Petrosky, MD
ANESTHESIA: Laryngeal mask general
ANESTHESIOLOGIST: Matthew Sorensten, MD
ESTIMATED BLOOD LOSS: Minimal
IV FLUIDS: 2.5 liters crystalloid
DRAINS: A #5-French x 28 cm right double-pigtail ureteral stent and #18-French Foley catheter
COMPLICATIONS: None
INDICATIONS: The patient is a 63-year-old female, admitted last night through the ED with acute right flank pain,
who denies prior history of kidney stones. She underwent parathyroidectomy 3 years ago. She stated that over
the past few weeks she had intermittent right flank pain. An ultrasound showed mild dilation of the right collecting
system with an 11-mm stone. Smaller stones were noted in the left kidney without any hydronephrosis. This was
confirmed on her KUB showing an 11-mm stone in the right mid kidney and three stones on the left measuring
3–6 mm. She has had followup testing showing a 24-hour urine calcium output of only 90 mg. Her serum calcium
level is normal.
DESCRIPTION OF THE PROCEDURE: The patient was brought to the lithotripsy suite. After induction of laryngeal
mask general anesthesia, she was placed in dorsal lithotomy position. Perineum and introitus were prepped and
draped. A #22-French rigid cystoscope was passed per urethra with obturator. The bladder was drained and then
inspected with 12- and 70-degree lenses. She has a central cystocele. Both orifices appear normal. Minimal squa-
mous metaplasia in the bladder neck area and no suspicious mucosal changes elsewhere. No trabeculation noted.
Pollack catheter was threaded into the right ureter and dilute contrast was used to perform segmental pyelogram
images on the right. Distally, multiple pelvic calcifications are lateral to the ureter consistent with phleboliths. No
obvious filling defects seen. There is mild dilation of the majority of the collecting system above the pelvic brim. The
stone appeared to be free floating within the renal pelvis.
Sensor guidewire was threaded up into the kidney. The Pollack catheter was inserted over the wire and the ure-
teral length was estimated. The contrast in the kidney was also allowed to drain to improve visualization of the stone
for lithotripsy. The guidewire was then replaced and the Pollack catheter removed. A #5-French x 28 cm Polaris dou-
ble-pigtail stent was then inserted with good pigtail formation on both ends. Cystoscope was removed and replaced
with an #18-French Foley catheter. 
Next, we performed a percutaneous nephrolithotripsy on the right kidney stone in the ureteropelvic junction. The
stone appeared to fragment well. Periodic AP and oblique fluoroscopy was used. The patient was awakened, extu-
bated, and transported to the recovery room in stable condition.

Let’s Code It!

Dr. Petrosky completed two procedures on Annabelle during this session: insertion of a stent + the percutane-
ous nephrolithotripsy. Let’s begin with the nephrolithotripsy:
First character: Section: Medical and Surgical . . . 0
These procedures were performed on Annabelle’s kidneys. Therefore, the body system is the
Second character: System: Urinary System . . . T
What exactly does a nephrolithotripsy do? This procedure is performed to remove kidney stones by breaking
them up. A good clue is in the documentation, where it states, “The stone appeared to fragment well.”
Third character: Root Operation: Fragmentation . . . F
Read the options listed in the Body Part (character 4) column of this Table. The documentation states, “in
the ureteropelvic junction.” There is an additional descriptor under Kidney Pelvis, which also matches the

1002   PART V  |  INPATIENT (HOSPITAL) REPORTING

 documentation, which states, “The stone appeared to be free floating within the renal pelvis” and “on the right
kidney stone.”
Fourth character: Body Part/Region: Kidney Pelvis, Right . . . 3
What approach was used to access the kidney stone to fragment it? The documentation states, “percutaneous.”
Fifth character: Approach: Percutaneous . . . 3
The options for the sixth and seventh characters are straightforward.
Sixth character: Device: No Device . . . Z
Seventh character: Qualifier: No Qualifier . . . Z  
Now, you can put all of these characters together to report this ICD-10-PCS code, with confidence:
0TF33ZZ Nephrolithotripsy, percutaneous, kidney pelvis, right.
Good work!

Chapter Summary
This chapter showed you that building a code in ICD-10-PCS may require you to
become familiar with a different perspective and way of interpreting the physician’s
notes. However, it all fits together, even though you will be using your knowledge in a
slightly different way. 
The ICD-10-PCS is used for reporting procedures performed in hospital inpatient
health care settings only. And the Medical and Surgical Section code components are
necessary for the largest percentage of procedures provided to patients while admitted
to a hospital. 

CODING BITES
Medical and Surgical Section character positions and their meanings:

Character Position Character Meaning

1 Section of the ICD-10-PCS book
2 Body system being treated
3 Root operation term
4 Body part (specific anatomical site)
5 Approach used by physician
6 Device
7 Qualifier

You Interpret It! Answers

1. Lower Arteries, 2. Lymphatic and Hemic Systems, 3. Eye, 4. Mouth and Throat,
5. Gastrointestinal System, 6. Muscles, 7. Head and Facial Bones, 8. Lower Bones, 9.
Upper Joints, 10. Respiratory System, 11. Bypass, 12. Destruction, 13. Dilation, 14.
Extirpation, 15. Replacement, 16. Release, 17. Occlusion, 18. Inspection, 19. Fusion,
20. Resection, 21. Restriction, 22. Pons, 23. Inferior Mesenteric Vein, 24. Inferior
Vena Cava, 25. Radius, 26. Larynx, 27. Skin, 28. Retina, 29. Pharynx, 30. Nasal 

CHAPTER 33  | 
 Turbinate, 31. Sternum, 32. Pelvic Bone, 33. Percutaneous, 34. Via Natural or Arti-
CHAPTER 33 REVIEW

ficial Opening Endoscopic, 35. Via Natural or Artificial Opening with Percutaneous
Endoscopic Assistance, 36. External, 37. Open, 38. Via Natural or Artificial Opening,
39. Percutaneous, 40. Percutaneous, 41. Via Natural or Artificial Opening Endoscopic,
42. Open, 43. External, 44. Zooplastic Tissue, 45. Cardiac Lead, 46. Intraluminal
Device, 47. Nonautologous Tissue Substitute, 48. Infusion Device, Pump, 49. Extralu-
minal Device, 50. Synthetic Substitute, 51. Pacemaker, Dual Chamber, 52. Implant-
able Heart Assist System, 53. Monitoring Device, Pressure Sensor, 54. Radioactive
Element

CHAPTER 33 REVIEW
ICD-10-PCS Medical and Surgical Section Enhance your learning by
completing these exercises and
more at connect.mheducation.com!

Let’s Check It! Terminology

Match each key term to the appropriate definition.
1. LO 33.1  A letter or number component of an ICD-10-PCS code. A. Approach
2. LO 33.4  The path the physician took to access the body part upon which the B. Character
treatment or procedure was targeted. C. Root Operation Term
3. LO 33.2  The term used to describe the function or purpose of the procedure.

ICD-10-PCS

Let’s Check It! Concepts

Choose the most appropriate answer for each of the following questions.
1. LO 33.1  Character position 4 represents which of the following?
a. The body system being treated b.  The approach used by the physician
c. The body part (specific anatomical site) d.  A device
2. LO 33.1  Character position 2: Body Systems: The endocrine system is identified by what number or letter?
a. 2 b.  G
c. 7 d.  S
3. LO 33.1  What letters are not found in the list of body systems?
a. B and H b.  C and W
c. K and Q d.  O and I
4. LO 33.2  According to the Official Guidelines for Coding and Reporting paragraph B2.1a, the example “Control
of postoperative hemorrhage” is coded to the _____ “Control” found in the general anatomical regions
body systems.
a. root operation b.  approach
c. device d.  qualifier
5. LO 33.1  According to the Official Guidelines for Coding and Reporting paragraph B2.1b, the example “Vein
body parts above the diaphragm” is found in the _____ body system.
a. Heart and Great Vessels b.  Upper Veins
c. Anatomical Regions, Upper Extremities d.  Upper Arteries
6. LO 33.2  Which character position does the root operation term represent?
a. 1 b.  3
c. 5 d.  7

1004   PART V  |  INPATIENT (HOSPITAL) REPORTING

 7. LO 33.2  Creation of an artificial female perineum using a synthetic substitute, open approach, would be coded

CHAPTER 33 REVIEW
with which of the following?
a. 0W4M0J1 b.  0W4N0Z0
c. 0W4N0J0 d.  0W4N071
8. LO 33.2  According to the Official Guidelines for Coding and Reporting paragraph B3.7, the example “Resection
of spleen to stop post-procedural bleeding” is coded to
a. resection. b.  control.
c. excision. d.  incision.
9. LO 33.2  Extraction of the right cornea, external approach, would be coded with which of these?
a. 08D9XZX b.  08D83ZZ
c. 08DKXZX d.  08D8XZZ
10. LO 33.2  The complete closing of an orifice or a lumen of a tubular body part is known as
a. map. b.  occlusion.
c. fusion. d.  detachment.
11. LO 33.2  According to the Official Guidelines for Coding and Reporting paragraph B3.14, the example “Severing
a nerve root to relieve pain” is coded to the root operation term
a. release. b.  reposition.
c. division. d.  restriction.
12. LO 33.2  A diagnostic arthroscopy would be interpreted as
a. bypass. b.  extirpation.
c. resection. d.  inspection.
13. LO 33.2  An esophagogastric fundoplication would be interpreted as
a. fusion. b.  restriction.
c. resection. d.  dilation.
14. LO 33.1  The ileum is part of which body system?
a. Upper Intestinal Tract b.  Upper Leg
c. Lower Intestinal Tract d.  Lower Leg
15. LO 33.3  The appendix that helps you when a specific anatomical site is documented and the body part compo-
nents are not as specific is entitled
a. Definition Key. b.  Body Part Key.
c. Device Key. d.  Device Aggregation Table.
16. LO 33.4  The approach to a procedure was entry, by puncture or minor incision, of instrumentation through the
skin or mucous membrane and any other body layers necessary to reach the site of the procedure and is
identified with the character 3. What type of approach was used?
a. Open b.  External
c. Percutaneous d.  Via natural or artificial opening
17. LO 33.4  Endoscopic repair of the urethra via natural opening would be coded with which of these?
a. 0TQC8ZZ b.  0TQD7ZZ
c. 0TQD4ZZ d.  0TQD8ZZ
18. LO 33.5  A cardiac lead, pacemaker implant device is represented by what sixth character?
a. M b.  J
c. K d.  R

CHAPTER 33  | 
 19. LO 33.6  A diagnostic qualifier is identified by what letter?
CHAPTER 33 REVIEW

a. X b.  Z
c. B d.  F
20. LO 33.5  Single upper tooth drainage device implant, open approach, would be coded with which of the
following?
a. 0C9W000 b.  0C9XX02
c. 0C9W0Z1 d.  0C9W001

Let’s Check It! Guidelines

Refer to the Official ICD-10-PCS Medical and Surgical Section Guidelines and fill in the blanks accordingly.
only  Open Percutaneous
root operations  overlapping  Release
Inspection  device  coded
after deepest not
Reposition  separate autograft 
fused  freed External 
indirectly drainage bypassed 

1. Biopsy procedures are coded using the _____ Excision, Extraction, or Drainage and the qualifier Diagnostic.
2. If the root operations Excision, Repair or Inspection are performed on _____ layers of the musculoskeletal sys-
tem, the body part specifying the _____ layer is coded.
3. If multiple coronary arteries are _____, a separate procedure is coded for each coronary artery that uses a differ-
ent device and/or qualifier.
4. If an _____ is obtained from a different procedure site in order to complete the objective of the procedure, a sepa-
rate procedure is coded.
5. If multiple vertebral joints are _____, a separate procedure is coded for each vertebral joint that uses a different
device and/or qualifier.
6. _____ of a body part(s) performed in order to achieve the objective of a procedure is not coded separately.
7. In the root operation _____, the body part value coded is the body part being _____ and not the tissue being
manipulated or cut to free the body part.
8. Reduction of a displaced fracture is coded to the root operation _____ and the application of a cast or splint in
conjunction with the Reposition procedure is _____ coded separately.
9. If a body system does not contain a _____ body part value for fingers, procedures performed on the fingers are
coded to the body part value for the hand.
10. Procedures performed using the open approach with percutaneous endoscopic assistance are coded to the
approach _____.
11. Procedures performed _____ by the application of external force through the intervening body layers are coded to
the approach _____.
12. Procedures performed percutaneously via a _____ placed for the procedure are coded to the approach _____.
13. A device is coded only if a device remains _____the procedure is completed.
14. Procedures performed on a device _____and not on a body part are specified in the root operations Change, Irri-
gation, Removal and Revision, and are _____ to the procedure performed. 
15. A separate procedure to put in a _____ device is coded to the root operation Drainage with the device value
Drainage Device.

1006   PART V  |  INPATIENT (HOSPITAL) REPORTING

Let’s Check It! Rules and Regulations

CHAPTER 33 REVIEW
Please answer the following questions from the knowledge you have gained after reading this chapter.
1. LO 33.1  List the seven character positions of an ICD-10-PCS Medical and Surgical section code, include each
character’s meaning.
2. LO 33.3  If the notes state a bilateral procedure was performed and there is no code character available to report a
bilateral procedure, how would you report this procedure accurately? 
3. LO 33.3  What is the title of the appendix that helps you when a specific anatomical site is documented and the
body part components are not as specific? 
4. LO 33.4  List the seven approaches used within the Medical and Surgical section; explain each approach. 
5. LO 33.7  The Official Guidelines provide four illustrations of cases when you will report multiple procedures.
What are the four cases? 

Let’s Check It! Anatomical Term: ICD-10-PCS Value 

Refer to the ICD-10-PCS Appendix entitled “Body Part Key” and identify the ICD-10-PCS value for each anatomical term.
Example: Abdominal aortic plexus:  
a. ICD-10-PCS value: Abdominal Sympathetic Nerve
1. Apneustic center:
a.  ICD-10-PCS value: _________________________
2. Columella:
a.  ICD-10-PCS value: _________________________
3. Dural venous sinus:
a.  ICD-10-PCS value: _________________________
4. Fifth cranial nerve:
a.  ICD-10-PCS value: _________________________
5. Gastroduodenal artery:
a.  ICD-10-PCS value: _________________________
6. Genitofemoral nerve:
a.  ICD-10-PCS value: _________________________
7. Inferior cardiac nerve:
a.  ICD-10-PCS value: _________________________
8. Mammillary body:
a.  ICD-10-PCS value: _________________________
9. Palatine gland:
a.  ICD-10-PCS value: _________________________
10. Recurrent laryngeal nerve:
a.  ICD-10-PCS value: _________________________
11. Stylopharyngeus muscle:
a.  ICD-10-PCS value: _________________________

CHAPTER 33  | 
 12. Tympanic nerve:
CHAPTER 33 REVIEW

a.  ICD-10-PCS value: _________________________

13. Ventricular fold:
a.  ICD-10-PCS value: _________________________
14. Xiphoid process:
a.  ICD-10-PCS value: _________________________
15. Zygomaticus muscle:
a.  ICD-10-PCS value: _________________________

ICD-10-PCS
YOU CODE IT! Practice
Using the techniques described in this chapter, carefully read through the case studies and determine the most ac-
curate ICD-10-PCS code(s) for each case study.
1. Theron Patel, a 12-year-old male, is experiencing obstructive sleep apnea. Dr. Pascal admits Theron to the
hospital and performs an adenoidectomy, open approach. 
2. Juanita Keane, a 38-year-old female, was admitted to Westwood Hospital yesterday. Dr. Chavez performs a
laparoscopic cholecystectomy today. 
3. Tom Gilbert, a 29-year-old male, is admitted to Weston Hospital due to severe hypertension. Dr. Benton notes
left kidney atrophy and performs an endoscopic left renal artery biopsy. 
4. Bella Cable, a 62-year-old female, has severe pain in her right foot when she walks. Upon examination her
right big toe has turned toward the second toe. Bella is admitted to the hospital, where Dr. Meltzer performs a
bunionectomy, open approach, with a soft tissue correction. 
5. Richard McMillan, a 26-year-old male, has had a bad cough for the last 3 months. Therefore, Dr. Skenes
admitted him into the hospital and performed a diagnostic fiberoptic bronchoscopy with hopes of determining
the cause of the irritation. 
6. Merle Sims, a 34-year-old female, is a professional runner and has won three marathons. Today, she is admit-
ted to the hospital for a total arthroplasty (replacement) of her right knee, nonautologous tissue substitute,
open approach. 
7. Carolyn Bulwark, a 21-year-old female, feels she has “big ears.” Carolyn was admitted to the hospital, where
her external ears were altered bilaterally, percutaneous approach. 
8. Harry Matthews, a 48-year-old male, was admitted to Westwood Hospital yesterday. Harry was diagnosed
with esophageal cancer. A middle esophagus bypass, percutaneous endoscopic approach, rerouted to stomach,
was performed today. 
9. John Andrews, a 46-year-old male, was admitted to the hospital, where he underwent urinary bladder surgery
2 days ago. Today, John’s urinary bladder drainage device is changed, external approach. 
10. Annie Campbell, a 28-year-old female, was admitted to Westwood Hospital. The patient closed the car door
on her foot and severely injured her left foot. Annie’s left 5th toe is completely amputated.
11. Wilburn Backwinkel, a 54-year-old male, has had left upper quadrant pain radiating to his back. Dr. Dix
admits Wilburn to Westwood Hospital, where he performs an endoscopic (via natural opening) inspection of
the pancreatic duct. 
12. Lynda Dibble, a 39-year-old female, gave birth to her 4th child 6 months ago. The patient presents today
requesting tubal ligation. Lynda is admitted to Westwood Hospital, where Dr. Connell performs a bilateral
fallopian tube ligation, percutaneous endoscopic approach. 

1008   PART V  |  INPATIENT (HOSPITAL) REPORTING

 CHAPTER 33 REVIEW
13. Mike Raval, a 53-year-old male, underwent an abdominal procedure this morning at Westwood Hospital.
After the procedure was completed, Mike began to hemorrhage. Dr. Scott performed a control of postopera-
tive bleeding in the abdominal wall, open approach. 
14. Lee Spigner, an 83-year-old male, cannot swallow his food and has lost a substantial amount of weight. Lee
is admitted to the hospital, where Dr. Ubaldo inserts a feeding device in Lee’s stomach, percutaneous endo-
scopic approach. 
15. Vickie Turner, a 24-year-old female, has a history of uncontrolled motor movements and some uncontrolled
eye movement. Vickie is admitted to the hospital, where Dr. Allen performs a mapping of Vickie’s basal gan-
glia signals, percutaneous approach. 

YOU CODE IT! Application

ICD-10-PCS

The following exercises provide practice in abstracting physicians’ notes and learning to work with documentation
from our health care facility, Westward Hospital. These case studies are modeled on real patient encounters. Using
the techniques described in this chapter, carefully read through the case studies and determine the most accurate
ICD-10-PCS code(s), if appropriate, for each case study.

WESTWARD HOSPITAL
591 Chester Road
Masters, FL 33955
OPERATIVE REPORT
PATIENT: FASCHEL, MARTIN
DATE OF ADMISSION: 11/15/18
DATE OF SURGERY: 11/16/18
DATE OF DISCHARGE: 11/19/18
ADMITTING DIAGNOSIS: Uncontrolled epilepsy
DISCHARGE DIAGNOSIS: Uncontrolled epilepsy
PROCEDURE PERFORMED: Left vagal nerve stimulator insertion.
SURGEON: Kevin Mulford, MD
ASSISTANT: Denny Granger, MD
ANESTHESIA: General endotracheal
ESTIMATED BLOOD LOSS: Less than 10 mL
COMPLICATIONS: None
DRAINS: None
OPERATIVE FINDINGS: A model 102 generator with 2 mm electrodes was utilized.
INDICATION FOR PROCEDURE: The patient is a 6-year-old child who was found to have progressive
epilepsy. It was recommended that a vagal nerve stimulator be placed. We discussed the options, the
risks, and benefits with the child’s parents, and their questions were welcomed and answered. The pro-
cedure and potential risks of surgery include, but are not limited to, vagal nerve injury, vascular damage,

CHAPTER 33  | 
CHAPTER 33 REVIEW

stroke, inoperability, malfunction, the need for continuous monitoring and evaluations, the possible
need for further surgical interventions, among others. With the family’s understanding and permission,
the child was brought to the operating room for this procedure.
DESCRIPTION OF PROCEDURE: After suitable general endotracheal anesthesia was obtained, the
patient was placed in the supine position and the head immobilized in a donut. The skin was pre-
pared using Betadine scrub and solution and a suitable surgical drape. Marcaine with epinephrine was
infiltrated.
Initially, we made a 2.5 cm incision along the neck crease, and the platysma muscle was divided. The
sternocleidomastoid muscle was retracted and dissected medially, and we identified the carotid sheath.
The carotid sheath was opened and we identified the vagal nerve. This was then isolated with vessel
loops.
We then attached the two electrodes in the grounding mechanism using 2 mm size coils. These were
found to be securely placed and a small loop was left for anchoring.
We then prepared the pocket while making a 6 cm curvilinear incision just medial to the axilla. A sub-
cutaneous pocket was created over the pectoralis muscle, and the area was irrigated.
We then used the tunneling device from the cervical to the chest incisions, and the electrodes were
placed in the subcutaneous tunnel. The model 102 generator was then connected to the electrodes. An
impedance test was done and was found to be 1.
The electrode in the subclavian was left with a small loop for growth, and this was anchored to the
fascia using a Vicryl suture.
Subsequently, the generator was turned on at the 0.25 mA at 30 Hz, on 30 seconds, off for 5 min-
utes, with a magnet strength of 0.5 for 60 seconds.
The wounds were then irrigated and subsequently painted with Betadine solution. They were then
closed using 3-0 Vicryl sutures for the deep layer. The skin was approximated using 4-0 Vicryl suture
in a running subcuticular fashion. Steri-Strips were applied, and the patient was awakened and trans-
ported to the recovery room, having tolerated the procedure well.
We discussed the operation, the findings, and the potential implications and complications with the
patient’s family. Their questions were welcomed and answered, and they expressed understanding of
the situation.

556839/mt98328: 06/01/18 09:50:16  T: 06/01/18 12:55:01

Determine the most accurate ICD-10-PCS code(s).

WESTWARD HOSPITAL
591 Chester Road
Masters, FL 33955
OPERATIVE REPORT
PATIENT: TUTTLE, BARBIE
DATE OF ADMISSION: 05/07/18
DATE OF SURGERY: 05/08/18
DATE OF DISCHARGE: 05/11/18
ADMITTING DIAGNOSIS: Avascular necrosis with severe collapse, total head involvement, left hip.
DISCHARGE DIAGNOSIS: Avascular necrosis with severe collapse, total head involvement, left hip.
OPERATION PERFORMED: Left total hip arthroplasty.

1010   PART V  |  INPATIENT (HOSPITAL) REPORTING

 CHAPTER 33 REVIEW
SURGEON: Gerard Brighton, MD
ASSISTANT: Peter Alfredson, MD
ANESTHESIA: General.
INDICATIONS FOR OPERATION: This 55-year-old female was noted to have progressively worsening
hip pain. She was noted to have on x-ray avascular necrosis with severe collapse and loss of spheric-
ity of the femoral head, Ficat grade 4. The risks and benefits of total hip arthroplasty were discussed in
detail, and the patient signed surgical consent.
DESCRIPTION OF OPERATION: The surgical site was signed. The patient was prepped and draped in
a routine sterile manner. The IV antibiotics were given prior to the procedure. The surgical team used
space suits for added sterility. A posterolateral approach to the hip was made. The fascia was identified
and split in line of its fibers. The short external rotators were identified. A T-capsulotomy was performed.
The hip was dislocated. The femoral neck was cut using a reciprocating saw. The cut was made based
on intraoperative and preoperative templating.
Once the neck was cut, the patient’s anteversion was noted, and bone wax was placed on the neck
cut to decrease bleeding. The acetabular retractors were placed, a cobra retractor anteriorly, and a
posterior-inferior retractor placed into the obturator foramen after an inferior radial capsulotomy. The
acetabulum was exposed. The soft tissues, including the labrum and pulvinar, were removed from the
acetabulum, and then the acetabulum was progressively reamed from a size 50 up to a size 56. A
57 mm Converge cup was then impacted into place at position of 45 degrees of abduction and
20 degrees of anteversion. The overhanging osteophytes were removed. The 38 mm liner was
snapped into the cup. A lap sponge was used to protect the cup.
The acetabular retractors were removed. A proximal femoral retractor was placed. The proximal
femur was machined first with a cookie cutter osteotome, then a lateralizing reamer, and then progres-
sive broaches. The broaches were taken up to a size 13.5. This initially had good fit. X-rays were taken
with a 13.5 mm stem and a neutral ball.
Of note, intraoperative x-rays did note that there was residual room at the lateral aspect of the femur.
This was likely secondary to scarred bone from her prior cord decompression. The trial stem was then
removed, and using a large curette, the lateral bone was removed. We then again machined from a size
13.5 up to a size 16.25 stem. The 16.25 had excellent fit, kept the equal leg length at the same level as
the intraoperative x-ray, taken with the 13.5, but had better canal fill. The real stem was then placed. A
neutral ball was placed.
The hip was then tested for range of motion, noted to be quite stable with flexion to 90 degrees,
internal rotation to 70, and no instability with extension, external rotation. The capsule was then
repaired with #2 FiberWire. The short external rotators were repaired with #2 FiberWire to the trochan-
ter. The fascia was closed with 0 PDS, the subcutaneous tissue was closed with 0 Vicryl, a running 3-0
Monocryl was placed at the subcuticular region. Dermabond was placed at the skin.
The patient was taken to recovery room in stable condition. Estimated blood loss was 150 mL.
Sponge and needle counts were correct.

556848/mt98328: 08/01/18 09:50:16  T: 08/01/18 12:55:01

Determine the most accurate ICD-10-PCS code(s).

WESTWARD HOSPITAL
591 Chester Road
Masters, FL 33955
OPERATIVE REPORT

CHAPTER 33  | 
CHAPTER 33 REVIEW

PATIENT: LATCHMAN, VICTOR

DATE OF ADMISSION: 03/05/18
DATE OF DISCHARGE: 03/17/18
ADMITTING DIAGNOSIS: Dislocation, right humeroulnar joint
PROCEDURE: Open repair
Patient is a 31-year-old male, admitted via the ED with acute pain in his right arm. Patient is a land-
scaper and tree trimmer and was hit by a falling tree limb. X-rays show dislocation of the humeroulnar
joint, right side.
Patient was taken into the operating room and placed in the supine position. General anesthesia was
administered. The area was opened with a 9 cm incision point to the distal aspect of the joint. Once the
dislocation was visualized, manipulation was employed to reconfigure the tendons, muscles, and bones
back to normal position.
The incision was closed using 4.0 silk; bandage and cast were applied. The patient was taken into the
recovery room, having tolerated the procedure well.
Benjamin Johnston, MD—2222
556845/mt98328: 03/17/18 09:50:16  T: 03/17/18 12:55:01

Determine the most accurate ICD-10-PCS code(s).

WESTWARD HOSPITAL
591 Chester Road
Masters, FL 33955
OPERATIVE REPORT
PATIENT: MAGGUIOTT, FELIX
DATE OF ADMISSION: 01/15/18
DATE OF DISCHARGE: 01/17/18
ADMITTING DIAGNOSIS: Inguinal hernia, left
PROCEDURE: Herniorrhaphy, with synthetic substitute
OPERATION: Left inguinal hernia repair with mesh.
DESCRIPTION OF OPERATION: The patient was taken to the operating room and placed supine on
the operating room table. After general anesthesia was induced, the left inguinal area was prepped
with Betadine solution and sterilely draped in the usual manner for procedure in this area. The skin and
subcutaneous tissues of the left inguinal area were anesthetized, and an incision beginning at the left
pubic tubercle and extending laterally along natural skin lines was created. The incision was extended
through the subcutaneous tissues to the aponeurosis of the external oblique. Hemostasis was obtained
with the Bovie cautery. The subaponeurotic tissues were anesthetized.
The aponeurosis of the external oblique was incised along the length of its fibers. Care was taken to
avoid the ilioinguinal nerve. At the level of the pubic tubercle, the spermatic cord was bluntly dissected
from its surrounding structures and encircled with a 0.25 inch Penrose drain. The direct hernia sac was
dissected off of the cord structures and invaginated into the preperitoneal space. A search for an indi-
rect component proved fruitless.

1012   PART V  |  INPATIENT (HOSPITAL) REPORTING

 CHAPTER 33 REVIEW
A large Marlex mesh “plug” was placed in the preperitoneal space, reducing the direct inguinal her-
nia. It was anchored to the conjoint tendon and the shelving edge of the Poupart’s ligament and the
pubic tubercle with 2-0 PDS sutures. The onlay portion was placed over the floor of the inguinal canal,
while it was anchored to the shelving edge of the Poupart’s ligament to the conjoint tendon and later-
ally to the internal oblique with interrupted 2-0 PDS sutures. The Marlex mesh plug was attached to the
onlay portion with a 3-0 Prolene suture. The aponeurosis of the external oblique was closed with a run-
ning suture of 3-0 PDS. Subcutaneous tissues were approximated with interrupted sutures of 3-0 PDS.
The skin was closed with subcuticular suture of 4-0 PDS. A 0.5-inch Steri-Strip tape was applied. A ster-
ile occlusive dressing was applied over this.
The patient tolerated the procedure well and was transferred to the recovery room in stable condi-
tion. Estimated blood loss was 5 cc. Sponge, needle, and instrument counts were correct.

Kenzi Bloomington, MD—7777

556839/mt98328: 01/17/18 09:50:16  T: 01/17/18 12:55:01

Determine the most accurate ICD-10-PCS code(s).

WESTWARD HOSPITAL
591 Chester Road
Masters, FL 33955
OPERATIVE REPORT
PATIENT: KENSINGTON, LOUIS
DATE OF ADMISSION: 10/07/18
DATE OF DISCHARGE: 10/09/18
ADMITTING DIAGNOSIS: Chronic anal fissure and anal stenosis.
DISCHARGE DIAGNOSIS: Chronic anal fissure and anal stenosis.
OPERATIONS:
1. V-Y anoplasty.
2. Lateral internal sphincterotomy with fissurectomy.
3. Flexible sigmoidoscopy.
ESTIMATED BLOOD LOSS: 30 mL.
SPECIMENS: No specimens.
DRAINS: A 0.25-inch Penrose to the flap.
COMPLICATIONS: None.
DESCRIPTION OF OPERATION: After informed consent was obtained, the patient was taken to the OR.
He was placed in the prone jackknife position and IV sedation was given by the anesthesiologist. The
buttocks were taped laterally, exposing the perianal area. I began with the lubricated scope. The video-
scope was inserted into the rectum and advanced through the colon to about 40 cm. At 40 cm, there
was some angulation and some looping of the scope, and I elected not to proceed beyond this point. I
then began to slowly withdraw the scope, carefully inspecting the lumen. The prep was adequate up to
this point. I withdrew the scope. I noted no tumors or polyps. There was no evidence of colitis or proc-
titis and no diverticular disease was noted. I then desufflated the colon and rectum and removed the
scope.

CHAPTER 33  | 
CHAPTER 33 REVIEW

The perianal area was then prepped with Betadine and draped in the usual fashion. I then used a
solution of 0.5% Marcaine with epinephrine and injected about 30 mL perianally as well as intramuscu-
larly to achieve some relaxation of the sphincter muscles. After adequate analgesia was obtained, the
small Ferguson retractor was inserted and the anal canal was inspected. The anterior fissure was very
chronic appearing and measured about 1 × 0.5 cm in size. The anal canal was rather small and there
seemed to be spasm of the distal edge of the internal sphincter muscle.
I then inserted the Buie retractor and opened it to expose the right lateral anal canal. An incision was
made over the anoderm in the right lateral position and then I dissected down to the distal edge of the
internal sphincter muscle, which was easily palpable as a tight band. I used a hemostat to dissect under-
neath it and elevated and divided it for a length of less than 1 cm. This did achieve relaxation of the
sphincter muscle.
Then at this point, I was able to remove the Buie retractor and inserted the Chelsea-Eaton retractor.
There was a definite release of the spasm of the sphincter muscle. However, there was also now obvi-
ous evidence of stenosis of the anal canal and there was no way to bring the mucosal edges together
to cover the sphincterotomy wound without putting tension on the anal canal. Because of this, I did
elect to go ahead with the anoplasty.
I used a marking pen to outline a house-shaped flap on the perianal skin in the right lateral position.
I then anesthetized this area. I used a #15 blade scalpel to incise the skin edges. I then mobilized the
flap by dissecting laterally to give the flap a very broad base. With the lateral dissection, I was then able
to mobilize the flap down into the anal canal to cover up the lateral internal sphincterotomy wound.
The area was irrigated. Then the flap was sewed into place using interrupted sutures, using com-
bination of #3-0 Vicryl and #4-0 Vicryl sutures, using the #3-0 Vicryl primarily on the tension points of
the flap. Once the proximal edge of the flap was sewed to the dentate line, I then came up the anterior
and posterior sides of the flap, suturing again in an interrupted fashion to the cut mucosal edges. I then
used a scalpel to make a small incision in the right posterior position about 1 centimeter or 2 away from
the flap and then used the stab incision to bring a 0.25-inch Penrose through the skin and positioned
it underneath the flap. It was sutured to the skin with a single #3-0 Vicryl suture. The excess drain was
then cut away, leaving about 2 or 3 cm protruding and the remainder positioned underneath the flap.
I then used #2-0 Vicryl and a mattress suture to perform the long portion of the Y of the flap. This was
done on the distal edge of the incision, bringing the two skin edges together with two of these mattress
sutures to form the Y.
At this point, I now just had the remainder of the bottom of the Y portion of the flap to close and this
was done again using a combination of interrupted #3-0 and #4-0 Vicryl sutures. At this point, I had
good hemostasis throughout the flap and the flap appeared to be viable. There was no tension on it.
There was a good color with no blanching noted.
I then directed my attention back toward the anal fissure in the anterior position. The small anterior
tag was excised. That was a small hypertrophied anal papilla. I then mobilized the mucosal side of the
fissure, elevating the mucosa, and a very small amount of muscle as well and then used a #4-0 Vicryl
suture to bring this mucosal edge about halfway up the fissure to partially cover it and facilitate the
healing process. There was a small amount of bleeding that was controlled with the #3-0 Vicryl figure-
of-eight suture.
At this point, I had good release of the anal stenosis and good hemostasis throughout. On further
examination, there was a very small posterior anal fissure, which was simply coagulated with the elec-
trocautery. At this point, the retractor was removed. A roll of Gelfoam was placed in the anal canal and
then a fluffy gauze dressing was placed over the Gelfoam.
The patient was then returned to the supine position and taken to the recovery area in stable condition.
Phillip Carlsson, MD—1111
556845/mt98328: 10/09/18 09:50:16  T: 10/09/18 12:55:01

Determine the most accurate ICD-10-PCS code(s).

1014   PART V  |  INPATIENT (HOSPITAL) REPORTING

Obstetrics Section

Learning Outcomes
34
Key Terms
After completing this chapter, the student should be able to: Abortifacient
Laminaria
LO 34.1 Recognize the details reported in the Obstetrics Section of Products of
ICD-10-PCS. Conception
LO 34.2 Interpret the procedure to determine the accurate Obstetrics
root operation term.
LO 34.3 Employ your knowledge of anatomy to determine the body
part treated in Obstetrics coding.
LO 34.4 Determine the approach used for the Obstetrics procedure.
LO 34.5 Identify any devices that will stay with the body after an
Obstetrics procedure.
LO 34.6 Utilize the details required to report the correct qualifier for
an Obstetrics code.
LO 34.7 Analyze all of the details to build an accurate seven-
character Obstetrics code.

Remember, you need to follow along in

ICD-10-PCS
  STOP! your ICD-10-PCS code book for an opti-
mal learning experience.

34.1  Obstetrics Section/Body System:

Characters 1 and 2
Obstetrics is the medical specialty that focuses on the care of pregnant women. The GUIDANCE
relationship between the physician—the obstetrician—and the patient often begins CONNECTION
prior to conception and lasts all the way through gestation through delivery to the
postpartum period. The entire scope of this care is not an issue for coders in a hospital. Read the ICD-10-PCS
However, there will be times when a pregnant woman might be admitted into a hospital Official Guidelines for
requiring acute care. These are the procedures and services reported from this section. Coding and Report-
So let’s review the meanings for the Obstetrics Section characters: ing, Obstetrics Section
Guidelines (Section
Character Position Character Meaning 1), subhead C. Obstet-
rics Sections, para-
1 Section of the ICD-10-PCS book graphs C1 and C2.
2 Body system being treated (Pregnancy)
3 Root operation term
4 Body part (Products of Conception)
5 Approach used by physician
6 Device
7 Qualifier
 At this time, there are only two Official Guidelines to support your reporting
from the Obstetrics Section in ICD-10-PCS. You should become familiar with
them both.

Character Position 1: Obstetrics Section 1

Character Position Character Meaning
1 Section of the ICD-10-PCS book
2 Body system being treated (Pregnancy)
3 Root operation term
4 Body part (Products of Conception)
5 Approach used by physician
6 Device
7 Qualifier

All of the codes reporting an obstetrics procedure provided to a pregnant woman who
has been admitted into a hospital will begin with the number one (1).

Character Position 2: Body System: 0

Character Position Character Meaning
1 Section of the ICD-10-PCS book
2 Body system being treated (Pregnancy)
3 Root operation term
4 Body part (Products of Conception)
5 Approach used by physician
6 Device
7 Qualifier

In this section there is only one body system, that is, the gestational term:
Pregnancy . . . Character: 0
From conception to delivery, procedures, services, and treatments provided to the
products of conception within a woman who is pregnant and has been admitted into a
hospital are reported with codes from this section to report the hospital (facility) care.
Before conception or after the baby is born, the services will be reported from a differ-
ent section of this code set.

34.2  Obstetrics Root Operations: Character 3

Character Position Character Meaning
1 Section of the ICD-10-PCS book
2 Body system being treated (Pregnancy)
3 Root operation term
4 Body part (Products of Conception)
5 Approach used by physician
6 Device
7 Qualifier

1016   PART V  |  INPATIENT (HOSPITAL) REPORTING

The Obstetrics Section uses 12 root operation terms to describe the specific proce-
dure provided during this encounter. Some interpretation may be necessary so you
can understand what terms to abstract from the operative report or procedure notes
accurately and completely. Using the root operation term is the most efficient way of
using the Alphabetic Index, as well.
As you learned in previous chapters, the root operation term is based on the objec-
tive of the procedure. You are seeking the word describing the action, such as extrac-
tion or delivery. Terms with which you are very familiar, such as cesarean section
(c-section) or amniocentesis, may name the procedure; however, these terms do not
specifically explain the action of the physician, or do they? Let’s take a closer look at
these two terms, as examples, and interpret them into the root operation terms:
Cesarean section: What precisely is this procedure? The extraction of the baby via
surgical incision. This explanation leads you to the root operation term used in
ICD-10-PCS, extraction.
Amniocentesis: What specifically is done during this procedure? Using a needle,
the physician takes out (drains) some of the amniotic fluid. Understanding this,
you can interpret that the root operation term drainage describes this perfectly.
With some procedures, you will use your knowledge of the specific procedure and
what it is expected to accomplish. For example, you will need to remember that the
physician supporting the natural process of a vaginal delivery is reported with the root
operation term delivery. That one works very well in translation, doesn’t it?
Now, let’s go over each of the 12 root operation terms used in this section of
ICD-10-PCS and look at some examples, to help you understand what each reports.

Abortion
Abortion: Artificially terminating a pregnancy . . . Character: A
GUIDANCE
Note, this is not typically reporting a voluntary abortion. Those are most often CONNECTION
performed on an outpatient basis. This root operation term refers to a procedure
performed for medical necessity only. Read the ICD-10-PCS
Official Guidelines for
Coding and Report-
EXAMPLES ing, Obstetrics Section
Deena Wolff has been in a coma for a week, as a the result of being raped and Guidelines (Section 1),
beaten. Blood work shows she is pregnant and her injuries make the pregnancy subhead C2. Proce-
not viable. Dr. Owens performed an abortion, vaginal approach, using a vacum dures Following Deliv-
method. ery or Abortion.
10A07Z6 Abortion of products of conception via natural or artificial open-
ing using vacuum
The patient was pregnant with monochorionic twins (twins that share a common
placenta) and there was a problem. Evidence of unbalanced flow of blood from
one twin to the other twin caused twin–twin transfusion syndrome. Because she
was only at 13 weeks, a pregnancy termination was determined to be the best
option for the mother’s health and a future opportunity to get pregnant again. He
performed a dilation and curettage.
10A08ZZ Abortion of products of conception via natural or artificial
opening

Change
Change: Taking out or off a device from a body part and putting back an identical
or similar device in or on the same body part without cutting or puncturing the
skin or a mucous membrane . . . Character: 2
 EXAMPLE
Two days ago, Dr. Conners inserted a fetal scalp electrode on Jenna’s 27-gestational-
week-old fetus. Today, Jenna is admitted into the hospital to monitor her and the
fetus, and to change the current electrode to a new one.
102073Z Changing a monitoring device for the products of conception via
natural or artificial opening

GUIDANCE Delivery
CONNECTION Delivery: Assisting the passage of the products of conception from the genital
canal . . . Character: E
Read the ICD-10-PCS
Official Guidelines for
Coding and Report- EXAMPLE
ing, Obstetrics Section The patient is a 31-year-old G2, P0 female at 38 weeks and 5 days estimated
Guidelines (Section 1), gestational age who presented in labor. On vaginal examination, the patient was
subhead C2. Proce- found to be 4 cm dilated, 70% effaced, and –3 station, and the fetal heart tracing
dures Following Deliv- at that time was in the 140s with minimal long-term variability. She was admitted
ery or Abortion. to Labor and Delivery for Pitocin augmentation and amniotomy. She continued to
have a good labor pattern and proceeded to deliver a viable 6-pound, 12-ounce
male infant over an intact perineum with Apgars of 8 and 9 at 1 and 5 minutes.
There were no nuchal cords, no true knots, and the number of vessels in the cord
was three. Her postpartum course was uncomplicated, and the patient was dis-
charged to home in stable and satisfactory condition.
10E0XZZ Delivery of a neonate (products of conception), external
approach
NOTE: The administration of the Pitocin, IV, would be reported separately (you will
learn about these codes in the Placement through Chiropractic Sections (2–9)
chapter, section Reporting Services from the Administration Section.

Drainage
Drainage: Taking or letting out fluids and/or gases from a body part . . . Character: 9

EXAMPLES
Maria Lettio was 39 years old when Dr. Platt confirmed she was pregnant. Today,
she has been admitted into the hospital for a gastroesophageal fundoplication.
While here, Dr. Lowenthal performed an amniocentesis to check the fetus for
genetic abnormalities.
10903ZU Drainage of amniotic fluid, percutaneous approach, for diagnos-
tic purposes
Concern for the existence of alloimmune thrombocytopenia, fetal blood sampling
to assess the baby’s platelet count is performed.
10903Z9 Drainage, fetal blood sampling, percutaneously
The patient’s uterus is compressing due to an overabundance of amniotic fluid.
Therefore, today we will perform an amnioreduction to decompress the womb
to prevent preterm delivery. A needle is inserted into the amniotic cavity and the
excess fluid is removed. 
10903ZC Drainage of amniotic fluid, percutaneous approach, for thera-
peutic purposes

1018   PART V  |  INPATIENT (HOSPITAL) REPORTING

Extraction GUIDANCE
Extraction: Pulling or stripping out or off all or a portion of a body part by the use CONNECTION
of force . . . Character: D
Read the ICD-10-PCS
A great example of an extraction is a cesarean section, which is not a separate root Official Guidelines for
operation because the intention is to extract the baby from the mother’s body. How- Coding and Report-
ever, it is not the only type of procedure reported with this root operation. ing, Obstetrics Section
Guidelines (Section 1),
subhead C2. Proce-
EXAMPLES
dures Following Deliv-
Dr. Traucher determined that Petricka’s pregnancy was ectopic. He used an endo- ery or Abortion.
scopic method, via her vagina, to remove the fertilized egg from her fallopian tube.
10D28ZZ Extraction of ectopic products of conception via natural or artifi-
cial opening endoscopic
The patient was admitted on the morning of her scheduled surgery. Detailed
informed consent was again reobtained. All consents were signed. Under spinal
anesthesia, uncomplicated repeat low transverse cesarean section was per-
formed. A viable male infant with Apgars of 9 and 9 with birth weight of 8 pounds
6 pounds was delivered. The patient’s postoperative course was uneventful.
10D00Z1 Extraction of products of conception, open approach, using a
low cervical incision

Insertion
Insertion: Putting in nonbiological appliance that monitors, assists, performs, or
prevents a physiological function but does not physically take the place of a
body part . . . Character: H
This is another opportunity for reading very carefully. In ICD-10-PCS, this root opera-
tion, insertion, applies only to the placement into the body of a medical device, such
as a monitoring device, that will remain in the body after the procedure is completed.

EXAMPLE
Concerned about the fetus’s sustainability, Dr. Franklin placed a scalp electrode
while Mei Lynn was still in the hospital for another issue.
10H073Z Insertion of monitoring electrode via natural or artificial opening

Inspection
Inspection: Visually and/or manually exploring a body part . . . Character: J
This root operation term is limited to the physician’s looking.

EXAMPLE
Using a scope via a percutaneous incision, Dr. Klotzky viewed the fetus’s position
using an operative fetoscopy.
10J04ZZ Inspection of productions of conception, percutaneous endo-
scopic approach

Removal
Removal: Taking out or off a device from a body part . . . Character: P
 Read this carefully: As the description specifically states “device,” this can only
be used for this type of procedure, to remove a previously inserted device. As you
abstract the physician’s notes, be cautious of the use of this term in documentation.
The removal of a mole, for example, is really an excision, not a removal.

EXAMPLE
After gathering the data he needed, Dr. Abernathy removed the electrode that
had been placed on the fetus’s scalp.
10P003Z Removal of monitoring electrode, open approach

Repair
Repair: Restoring, to the extent possible, a body part to its normal anatomic
structure and function . . . Character: Q

EXAMPLES
Dr. Atlante determined that Geena Simpson’s fetus has indications of spina bifida.
He performed a repair of the skin over the spinal opening, in utero, with hopes of
enabling the child to be born without disability.
10Q03ZQ Repair of skin, percutaneous approach
Aortic stenosis may be relieved in utero by performing an aortic balloon valvu-
loplasty. This is accomplished by inserting a needle into the fetal heart through
which the balloon catheter is passed.
10Q03ZF Repair of cardiovascular system, percutaneous approach

Reposition
Reposition: Moving to its normal location or other suitable location all or a por-
tion of a body part . . . Character: S

EXAMPLE
Rae-Ann was in the last stage of labor and ready to deliver when Dr. Bornstine
realized the baby was breech. Externally, he manually manipulated the position of
the baby, and a 7 lb. 3 oz. boy was delivered a short time later.
10S0XZZ Reposition of fetus, external approach

Resection
Resection: Cutting out or off, without replacement, all of a body part . . . Character: T
Remember how this differs from excision. When the entire body part is surgically
removed, it is reported as a resection. If only a portion of the body part is removed, it
is reported as an excision.

EXAMPLE
Dr. Peterson determined that Ursula’s fertilized egg was stuck in her left fallopian
tube and was growing. He had to surgically remove the fallopian tube before it burst.
10T28ZZ Resection of fallopian tube for ectopic products of conception,
via natural or artificial opening endoscopic

1020   PART V  |  INPATIENT (HOSPITAL) REPORTING

Transplantation
Transplantation: Putting in or on all or a portion of a living body part taken from
another individual or animal to physically take the place and/or function of all
or a portion of a similar body part . . . Character: Y
ICD-10-PCS uses this term in the same manner that physicians do, when a donor
organ is placed in lieu of a natural organ that is malformed or dysfunctional. Technol-
ogy has enabled some organ transplants to be performed on a fetus (in utero).

EXAMPLE
A percutaneous bone marrow transplant was performed on a 25-gestational-
week-old fetus.
10Y03ZG Transplantation, percutaneous, lymphatics and hemic

YOU INTERPRET IT!

Practice interpreting from the common term used to reference the ICD-10-PCS root operation term.
1. Amniocentesis: _______
2. Chorionic villus sampling: _______
3. Surgical treatment of ectopic pregnancy: _______
4. Cerclage of cervix during pregnancy: _______
5. Intrauterine cordocentesis (percutaneous umbilical cord blood sampling): _______
6. Fetal shunt placement: _______
7. Induced abortion, by dilation and curettage: _______
8. Uterine evacuation and curettage: _______
9. In utero fetal kidney transplant: _______
10. Vaginal delivery: _______
11. Hysterorrhaphy: _______

34.3  Obstetrics Body Parts: Character 4

Character Position Character Meaning
1 Section of the ICD-10-PCS book
2 Body system being treated (Pregnancy)
3 Root operation term
4 Body part (Products of Conception)
5 Approach used by physician
6 Device
7 Qualifier

The only procedures reported from this section are those performed on the products Products of Conception
of conception: zygote, embryo, or fetus, as well as the amnion, umbilical cord, and The zygote, embryo, or fetus,
placenta.  as well as the amnion, umbili-
When a sperm fertilizes an oocyte (egg), a zygote is created. Two weeks later (after cal cord, and placenta.
fertilization), the zygote becomes an embryo. At week 8, the embryo, about 1 inch in
length, is considered a fetus.
 The Obstetrics Section focuses on three body parts, which are not specific ana-
tomical sites with which you are familiar:

GUIDANCE Products of conception . . . Character: 0 (zero)

Products of conception, retained . . . Character: 1
CONNECTION Products of conception, ectopic . . . Character: 2
Read the ICD-10-PCS In the simplest terms, the products of conception are fertilized ova (zygote, embryo, or
Official Guidelines for fetus) along with the components that accompany, including amnion (the inmost mem-
Coding and Report- brane, also known as the amniotic sac, that encloses the fetus in utero and the amniotic
ing, Obstetrics Section fluid), umbilical cord, and placenta. The change in the character will designate if these
Guidelines (Section 1), components are ectopic (outside of the uterus) or retained (still inside).
subhead C1. Products There are times when placental tissue remnants or fetal tissue may remain inside
of Conception. the uterus after a miscarriage, planned pregnancy termination, or a successful deliv-
ery. This is known as retained products of conception (RPOC).
A zygote (fertilized egg) usually travels through the fallopian tube and plants itself
into the wall of the uterus to begin to grow. When there is a narrowing or other block-
age preventing the completion of the journey into the uterus, the zygote may begin to
develop outside the uterus. This condition can be life-threatening to the mother and is
known as an ectopic pregnancy.

34.4  Obstetrics Approaches: Character 5

Character Position Character Meaning
1 Section of the ICD-10-PCS book
2 Body system being treated (Pregnancy)
3 Root operation term
4 Body part (Products of Conception)
5 Approach used by physician
6 Device
7 Qualifier

As you continue to build a code, you can see that you are telling a story. The first four
characters explain what the physician did and the anatomical site upon which he or she
worked. Now, with the fifth character, you are going to explain how the physician got
to the anatomical site to perform the procedure. You learned in previous chapters that
this is known as the approach.

Open
Open: Cutting through the skin or mucous membrane and any other body layers
necessary to expose the site of the procedure . . . Character: 0
An open procedure is the traditional approach when the physician makes an incision
into the body to access an internal organ.

EXAMPLE
10D00Z1 Cesarean section, low cervical, open incision

Percutaneous
Percutaneous: Entry, by puncture or minor incision, of instrumentation through
the skin or mucous membrane and any other body layers necessary to reach
the site of the procedure . . . Character: 3

1022   PART V  |  INPATIENT (HOSPITAL) REPORTING

 EXAMPLE
10903Z9 Drainage of fetal blood, percutaneous approach

Percutaneous Endoscopic
Percutaneous Endoscopic: Entry, by puncture or minor incision, of instrumenta- CODING BITES
tion through the skin or mucous membrane and any other body layers neces- In utero procedures can
sary to reach and visualize the site of the procedure . . . Character: 4 be performed on the
fetus by percutaneous
EXAMPLE endoscopic approach
using a fetoscope.
10Q04ZT Repair of the female reproductive system, products of concep-
tion, via percutaneous endoscopic approach

Via Natural or Artificial Opening

Via Natural or Artificial Opening: Entry of instrumentation through a natural or
artificial external opening to reach the site of the procedure . . . Character: 7

EXAMPLE
10J17ZZ Inspection of retained products of conception, vaginal approach

Via Natural or Artificial Opening Endoscopic

Via Natural or Artificial Opening Endoscopic: Entry of instrumentation through a
natural or artificial external opening to reach and visualize the site of the pro-
cedure . . . Character: 8

EXAMPLE
10S28ZZ Reposition of products of conception from fallopian tube to
uterus, via vaginal endoscopic approach

External
External: Procedure performed directly on the skin or mucous membrane and
procedures performed indirectly by the application of external force through
the skin or mucous membrane . . . Character: X

EXAMPLE
10E0XZZ Delivery of neonate, vaginal delivery, no assistance

YOU INTERPRET IT!

Interpret these statements from physicians’ documentation on the approach used to determine the
ICD-10-PCS approach term.
12. Endoscope was inserted into vagina and into the uterus: _______
13. Needle aspiration of amniotic fluid: _______
14. Transverse incision: _______
15. Vaginal delivery: _______
16. Laparoscopic entry into uterus for in vitro surgery: _______
 34.5  Obstetrics Devices: Character 6
Character Position Character Meaning
1 Section of the ICD-10-PCS book
2 Body system being treated (Pregnancy)
3 Root operation term
4 Body part (Products of Conception)
5 Approach used by physician
6 Device
7 Qualifier

As you can see, a character placed in the sixth position will identify a device that
will remain with the patient after the procedure has been completed. Remember, the
patient for whom the device is involved in care—in this section of ICD-10-PCS—is
the fetus . . . not the mother.
Monitoring Electrode . . . Character: 3
Other Device . . . Character: Y
No Device . . . Character: Z
Fetal monitoring can be performed either internally or externally. When done inter-
nally, the physician will place an electrode (electronic transducer) directly onto the
scalp of the fetus, typically using a natural opening approach (through the vagina/cer-
vix), with the intention of directly and continuously evaluating the fetal heart rate as
well as its variability between beats, particularly in relation to the uterine contractions
of labor. Another device, called an internal uterine pressure monitor (IUPM), may be
used in conjunction with internal fetal heart rate monitoring. Using a catheter inserted
via the vagina/cervix, an IUPM is placed inside the uterus, next to the fetus, to trans-
mit the readings of the contraction pressure to a nearby monitor.
External fetal heart rate monitoring can be accomplished with a handheld electronic
Doppler ultrasonic device, most often used at outpatient prenatal visits. Continuous
electronic fetal heart monitoring, typically used during labor and delivery, consists of
placing an ultrasound transducer on the mother’s abdomen, where it can transfer the
sounds of the fetal heart to a computer. The computer is able to show the heart pattern
on a screen as well as print it out on paper similar to that used during an EKG.

34.6  Obstetrics Qualifiers: Character 7

Character Position Character Meaning
1 Section of the ICD-10-PCS book
2 Body system being treated (Pregnancy)
3 Root operation term
4 Body part (Products of Conception)
5 Approach used by physician
6 Device
7 Qualifier

The seventh character is required. In some cases, there may be no more details to
add, so you will use the placeholder letter Z No Qualifier—the equivalent of “not
applicable.”

1024   PART V  |  INPATIENT (HOSPITAL) REPORTING

Extraction Procedures
During a delivery, if the physician uses forceps or another assisting mechanism, this
delivery becomes an extraction, and the additional detail will be reported with a
Qualifier character:
Low Forceps . . . Character: 3
Mid Forceps . . . Character: 4
High Forceps . . . Character: 5
Vacuum . . . Character: 6
Internal Version . . . Character: 7
Other . . . Character: 8
∙ Low forceps: The physician uses forceps to help the neonate the last short way out
of the birth canal; the baby’s head is visible from the outside.
∙ Mid forceps: Forceps are used to help the baby before the head has reached the
lower part of the birth canal.
∙ High forceps: A very unusual situation where forceps are used to delivery the baby
through the birth canal prior to engagement.
∙ Vacuum: The physician places a cup, attached to a vacuum pump, on the baby’s
head to guide the neonate through the birth canal.
∙ Internal version: The physician manually turns the fetus using his hand or fingers
through the dilated cervix.
Earlier you learned that a cesarean delivery is reported in ICD-10-PCS using the
root operation term extraction. For this procedure, the Qualifier character will report
Classical (c-section incision) . . . Character: 0
Low Cervical . . . Character: 1
Extraperitoneal . . . Character: 2
∙ Classical: Incision is made vertically, from the naval to the pubic line.
∙ Low cervical: Incision made transversely just above the pubic line; also known as
the bikini cut.
∙ Extraperitoneal: Incision is made into the lowest part of the anterior aspect of the
uterus.

EXAMPLES
You may read these words in the physician’s documentation:
“ . . . low transverse cesarean section . . .”
“ . . . Lower uterine segment was then scored in a curvilinear fashion . . .”
[extraperitoneal]
“ . . . A vertical incision was made in the umbilicus . . .” [classical]

CODING BITES
Drainage Procedures Read carefully! There
During amniocentesis, or any other drainage procedure performed on a pregnant are two different charac-
woman, the Qualifier character will explain exactly what was drained: ters available to report
the drainage of amniotic
Fetal Blood . . . Character: 9 fluid . . . therapeutic or
Fetal Cerebrospinal Fluid . . . Character: A diagnostic. Check the
Fetal Fluid, Other . . . Character: B documentation to deter-
Amniotic Fluid, Therapeutic . . . Character: C mine why the amniocen-
Fluid, Other . . . Character: D tesis was done.
Amniotic Fluid, Diagnostic . . . Character: U
 EXAMPLES
You might see these phrases and descriptions in physician documentation:
“ . . . second trimester amniocentesis . . .” [drainage of amniotic fluid for diag-
nostic/genetic testing]
“ . . . serial vesicocenteses will be performed to check the kidney function
(measuring urinary electrolytes in the fetus’s urine). A needle is inserted into
the fetal bladder and the urine is entirely removed . . .” [drainage of fetal fluid,
other]
“ . . .fetal blood sampling will be done to collect specimens for testing
. . .” [drainage of fetal blood]

Abortive Procedures
When the artificial termination of a pregnancy (abortion) is performed, the Qualifier
character will report the methodology:
Vacuum . . . Character: 6
Laminaria Laminaria . . . Character: W
Thin sticks of kelp-related Abortifacient . . . Character: X
seaweed, used to dilate the
cervix, that can induce abor- ∙ Vacuum: The use of aspiration using a cannula (tube) inserted into the uterus; also
tive circumstance during the known as suction curettage.
first 3 months of pregnancy. ∙ Laminaria: A small rod, created of dehydrated types of kelp, is inserted into the
Abortifacient
cervix for the purposes of dilation.
A drug used to induce an ∙ Abortifacient: A substance, using a pharmaceutical, used to induce expulsion of the
abortion. products of conception.

In Utero Procedures
The Qualifier character will report the body system that was repaired or trans-
planted during an in utero procedure performed on the fetus (root operation repair or
transplantation).
Nervous System . . . Character: E Hepatobiliary and Pancreas . . . N
Cardiovascular System . . . F Endocrine System . . . P
Lymphatics and Hemic . . . G Skin . . . Q
Eye . . . H Musculoskeletal System . . . R
Ear, Nose, and Sinus . . . J Urinary System . . . S
Respiratory System . . . K Female Reproductive System . . . T
Mouth and Throat . . . L Male Reproductive System . . . V
Gastrointestinal System . . . M Other Body System . . . Y

ICD-10-PCS
LET’S CODE IT! SCENARIO
PATIENT: ELICIA MORALISE
DATE OF DELIVERY: 05/29/2018
HISTORY OF PRESENT ILLNESS: The patient is a 26-year-old G1, P0 at 39-3/7 weeks with an EDD of 06/01/2018
based on a 6-week ultrasound. The patient presented to labor and delivery with complaints of contractions every
3 minutes and leaking of fluid since 0400 on 05/28/2018. The patient reports positive fetal movement and denies
vaginal bleeding. Prenatal care began at 9 weeks × 15 visits. Total weight gain was 37 pounds. The patient is A posi-
tive, rubella immune, GBS positive. She has no known drug allergies.

1026   PART V  |  INPATIENT (HOSPITAL) REPORTING

 Upon admission, vaginal exam was 1, 80%, and –1 station per the RN. Fetal heart tones were 124, positive long-
term variability, positive acceleration, and no decelerations. Uterine contractions every 2 to 3 minutes, 60 to 80
seconds and moderate to palpation. 
PLAN: Admit the patient to the labor and delivery unit. Dr. Lorrantz informed and agrees with plan. GBS protocol,
ampicillin. The patient encouraged to ambulate, shower, use the birth ball. Reassess in 3 to 4 hours or p.r.n.
LABOR PROGRESS: At 0900, the patient was pushing with contractions. She was feeling pressure but was still com-
fortable with the epidural. The patient stated that she was exhausted. The Pitocin was restarted at 2 mU as the RN
realized that the catheter had come loose from the patient’s IV and the Pitocin was not being delivered to the patient.
Pitocin currently now at 18 mU per minute. Contractions were every 2 to 6 minutes, 50 to 60 seconds long. Fetal
heart tones were 125, average variability, 15 × 15 accelerations with mild variable decelerations with good return
to baseline. Vaginal exam at 0830 hours was complete, 100%, with the head at the 0 station and the caput at +2
station. The patient appeared to be making some progress with pushing; however, Dr. Lorrantz was consulted and
was asked by the CNM to assess the patient after leaving an OR case. The plan was that the patient would continue
pushing provided fetal heart tones remained stable until Dr. Lorrantz was able to get out of the OR to evaluate her.
The plan was to consider vacuum extraction.
DELIVERY NOTE: The patient pushed extremely well and through excellent maternal efforts and frequent position
changes, the infant rotated and descended and normal spontaneous vaginal delivery occurred at 0950 hours in
the LOA position over intact perineum. Meconium-stained fluid was noted as the head came over the perineum and
Neonatology was called to the room. The mouth and nose were bulb suctioned on the perineum by the CNM. The
shoulders delivered easily and a nuchal cord loose x1 was noted and reduced with the delivery of the body. The cord
was immediately clamped x2 and cut by the father of the baby and the infant was taken to the warmer for evaluation
by Neonatology. The placenta delivered spontaneously at 0958 hours, was complete, had a 3-vessel cord, and was
in the Schultz fashion. Estimated blood loss was 200 mL. Pitocin was run open after the delivery of the placenta. The
vagina was inspected and a first-degree vaginal and left first-degree labial laceration were repaired with 2-0 chromic
and 3-0 Vicryl respectively. The fundus was firm, midline, and −2. There was light lochia. Infant’s Apgars were 6, 8,
and 9. Weight was 6 pounds 9 ounces. The mother and the infant were left in stable condition.

Let’s Code It!

Congratulations! A healthy baby was born. Now, let’s determine the accurate ICD-10-PCS code for the delivery.
From which section would you report the delivery of this baby? The baby is a product of conception, there-
fore, Obstetrics.
First character: Section: Obstetrics . . . 1
Only one option for the body system . . .
Second character: System: Pregnancy . . . 0
This is also straightforward. The documentation states, “normal spontaneous vaginal delivery.”
Third character: Root Operation: Delivery . . . E
The rest of this code will come together easily because there is only one option for each of the last four
characters:
Fourth character: Body Part: Products of Conception . . . 0
Fifth character: Approach: External . . . X
Sixth character: Device: No Device . . . Z
Seventh character: Qualifier: No Qualifier . . . Z
Now put it all together and report, with confidence, this ICD-10-PCS code:
10E0XZZ Natural, spontaneous vaginal delivery
Good job!
 34.7  Obstetrics Coding: Putting It All
Together
Throughout this chapter, you have learned about each of the seven components of
an ICD-10-PCS code used to report a procedure, service, or treatment on a pregnant
woman. Now, let’s put it all together and determine some codes all the way through.

ICD-10-PCS
LET’S CODE IT! SCENARIO
LaToya Donner, a 37-year-old female, is pregnant, G1 P0, second trimester (15 weeks, 3 days), and has been admit-
ted to have some tests, including an amniocentesis. Because she is categorized as eldergravida, Dr. Brummel is
performing this test to determine the health and well-being of the fetus.

Let’s Code It!

Let’s go through the steps of coding for ICD-10-PCS and determine the code or codes that should be reported
for this encounter between Dr. Brummel and LaToya Donner.
First character: Section: Obstetrics . . . 1
Second character: Body System: Pregnancy . . . 0
Third character: Root Operation: Drainage . . . 9
Remember the meaning and purpose of this procedure: amniocentesis (puncturing of the amnion) to drain amni-
otic fluid.
Fourth character: Body Part: Products of Conception . . . 0
Fifth character: Approach: Percutaneous . . . 3
Sixth character: Device: No Device . . . Z
Seventh character: Qualifier: Amniotic Fluid, Diagnostic . . . U
What is being drained? Amniotic fluid. Why? To test (diagnostics).
The ICD-10-PCS code you will report is
10903ZU Amniocentesis for prenatal testing
Good job!

ICD-10-PCS
LET’S CODE IT! SCENARIO
PATIENT NAME: YESSINA CATINA
PHYSICIAN: TRAVIS JONQUIN, MD
DATE OF ADMISSION: 05/28/2018
DATE OF DISCHARGE: 05/29/2018
ADMITTING DIAGNOSIS: Intrauterine pregnancy at 38 weeks and 5 days. Presented with contractions, leakage of
fluid, and decreased fetal movements that day.
HISTORY OF PRESENT ILLNESS/HOSPITAL COURSE: The patient is a 31-year-old G2, P0 female at 38 weeks and
5 days estimated gestational age who presented in labor. On vaginal examination, the patient was found to be 4 cm
dilated, 70% effaced, and –3 station, and the fetal heart tracing at that time was in the 140s with minimal long-term vari-
ability. She was admitted to Labor and Delivery for Pitocin augmentation and amniotomy. She continued to have a good
labor pattern and proceeded to deliver a viable 6-pound, 12-ounce male infant over an intact perineum with Apgars of 8
and 9 at 1 and 5 minutes. There were no nuchal cords, no true knots, and the number of vessels in the cord was three.
Her postpartum course was uncomplicated, and the patient was discharged to home in stable and satisfactory condition.

1028   PART V  |  INPATIENT (HOSPITAL) REPORTING

PROCEDURES PERFORMED: Normal spontaneous delivery and Pitocin augmentation.
COMPLICATIONS: None.
FINAL DIAGNOSIS: Status post normal spontaneous vaginal delivery at 38 weeks and 5 days.
DISCHARGE INSTRUCTIONS: Call for increased pain, fever, or increased bleeding.
DIET: Advance as tolerated.
ACTIVITY: Advance as tolerated. Pelvic rest for 6 weeks. Nothing to be inserted into the vagina for 6 weeks, i.e., no
tampons, douche, or sex.
Code for the delivery.

Let’s Code It!

Let’s go through the steps of ICD-10-PCS coding and determine the code to report for Dr. Jonquin’s support in
the delivery of Yessina’s baby.
First character: Section: Obstetrics . . . 1
Second character: Body System: Pregnancy . . . 0
This was documented as a vaginal delivery.
Third character: Root Operation: Delivery . . . E
The neonate was delivered, and this boy is a product of conception.
Fourth character: Body Part: Products of Conception . . . 0
There is only one option for each of the following three characters.
Fifth character: Approach: External . . . X
Sixth character: Device: No Device . . . Z
Seventh character: Qualifier: None . . . Z
Put the seven characters together to get the code to report:
10E0XZZ Delivery of products of conception, vaginally
Good work!

ICD-10-PCS
LET’S CODE IT! SCENARIO
PATIENT: ISABELLE CALAVERI
DATE: 11/15/18
PROCEDURE: Primary low segment transverse cesarean section
DESCRIPTION OF OPERATION: Due to concern that the umbilical cord was around the fetus’s neck, the patient was
brought to the operating room and placed on the table in supine position, and after adequate epidural anesthesia,
she was prepped and draped in the usual sterile fashion.
A Pfannenstiel incision was made with a clean scalpel. The incision was taken down the fascial layer with a clean
second knife. The fascial layer was incised transversely to the full length of the primary incision. The underlying
muscle bellies were dissected with blunt and sharp dissection. The muscle belly was split in the midline. The peri-
toneum was then grasped between 2 Kelly clamps and elevated. After ensuring no adherent bowel or bladder, the
peritoneum was nicked between clamps. The abdominal cavity was thus entered. The bladder flap was formed with
blunt and sharp dissection and then the uterus was scored in the lower uterine segment in transverse fashion, and
(continued)
 the incision was enlarged in elliptical fashion with bandage scissors. The infant was found to be in face presentation
with nuchal cord x1. Mouth and nose were suctioned prior to delivery of rest of the body. The cord was slipped over
the shoulders and then the infant was delivered. It was a living female with Apgars of 8 and 9. There was meconium,
but it was not thick. Cord pH was 7.30. The cord was doubly clamped, cut between the clamps, and the infant was
handed away to the pediatrician, Dr. Toliver. Cord bloods were taken.
The placenta was then manually separated. The edges of the uterine incision were then reapproximated with con-
tinuous running suture of #1 chromic catgut. The second imbricating layer was also sewn using #1 chromic catgut.
Good hemostasis was noted. The abdomen was cleaned of blood and clots. Tubes and ovaries were inspected and
found to be normal. Then, the abdomen was closed in layers after correct sponge, needle, and instrument counts.
The peritoneum was closed with continuous running suture of 0 chromic catgut. The muscle bellies were closed with
interrupted sutures of 0 chromic catgut. The fascia was closed with 2 continuous running sutures of 0 Vicryl begin-
ning at either angle of the incision intermittently overlapping the midline. The subcutaneous tissue was closed with
continuous running suture of 3-0 plain catgut, and the skin was closed with surgical staples. A sterile pressure dress-
ing was applied. Sponge, needle, and instrument counts were correct at the end of the procedure.
Matthew Ansara, MD

Let’s Code It!

Dr. Ansara performed a c-section to deliver Isabelle’s baby.
First character: Section: Obstetrics . . . 1
Second character: Body System: Pregnancy . . . 0
This was documented as a c-section. You have learned that ICD-10-PCS uses the term extraction.
Third character: Root Operation: Extraction . . . D
What has been extracted? The fetus, which is a product of conception.
Fourth character: Body Part: Products of Conception . . . 0
What was the approach the physician used? The documentation states, “A Pfannenstiel incision was made with
a clean scalpel.” This tells you the approach was open.
Fifth character: Approach: Open . . . 0
Was there a device involved in this procedure? No.
Sixth character: Device: No Device . . . Z
The Qualifier will report the type of incision used by the physician. The documentation states, “The fascial layer
was incised transversely.” You learned about the different incisions, and that this is known as a “low cervical.”
Seventh character: Qualifier: Low Cervical . . . 1
Put all seven characters together to get the code to report:
10D00Z1 Extraction of products of conception, open approach using low cervical incision
Good job!

Chapter Summary
The services, procedures, and treatments reported with codes from the Obstetrics
Section of ICD-10-PCS are all provided in a pregnant inpatient. The most impor-
tant thing to remember is that, for these procedures, the patient is the product of
conception—what is inside a pregnant patient.

1030   PART V  |  INPATIENT (HOSPITAL) REPORTING

 CHAPTER 34 REVIEW
CODING BITES
The Products of Conception
• The fertilized ovum:
Zygote: 0 to 2 weeks
Embryo: 2 to 8 weeks
Fetus: 8 weeks to birth
• Amnion: the innermost membrane, also known as the amniotic sac, that
encloses the fetus in utero and the amniotic fluid.
• Umbilical cord
• Placenta

You Interpret It! Answers

1. Drainage, 2. Extraction, 3. Resection, 4. Insertion, 5. Drainage, 6. Insertion, 7.
Abortion, 8. Extraction, 9. Transplantation, 10. Delivery, 11. Repair, 12. Via natural or
artificial opening endoscopic, 13. Percutaneous, 14. Open, 15. Via natural or artificial
opening, 16. Percutaneous endoscopic

CHAPTER 34 Obstetrics Section

Enhance your learning by

Let’s Check It! Terminology completing these exercises and

more at connect.mheducation.com!

Match each key term to the appropriate definition.

A. Abortifacient
1. LO 34.6    A drug used to induce an abortion. B. Laminaria
2. LO 34.3   The zygote, embryo, or fetus, as well as the amnion, umbilical cord, C. Products of Conception
and placenta.
3. LO 34.6   Thin sticks of special seaweed used to dilate the cervix that can induce
abortive circumstance during the first 3 months of pregnancy.

ICD-10-PCS
Let’s Check It! Concepts
Choose the most appropriate answer for each of the following questions.
1. LO 34.4   Within the Obstetric Section, character position 5 represents which of the following?
a. Body system b.  Root operation term
c. Approach d.  Device
2. LO 34.1   All of the codes reporting an Obstetrics procedure will begin with which section number?
a. 5 b.  4
c. 2 d.  1
3. LO 34.3   The products of conception include
a. zygote and embryo. b.  amnion and umbilical cord.
c. placenta. d.  all of these.
4. LO 34.2   All of the following are root operation terms in the Obstetrics Section except
a. abortion. b.  delivery.
c. irrigation. d.  inspection.
 5. LO 34.2   Within the Obstetrics Section, character position 5 Approach, the approach to an intrauterine cordocen-
CHAPTER 34 REVIEW

tesis would be which of the following?

a. Via natural or artificial opening b.  Percutaneous endoscopic
c. External d.  Open
6. LO 34.4   Inspection of retained products of conception, vaginal approach, would be coded
a. 10J17ZZ b.  10J18ZZ
c. 10J12ZZ d.  10J00ZZ
7. LO 34.5   Within the Obstetrics Section, character position 6 represents
a. body system being treated. b.  root operation.
c. device. d.  qualifier.
8. LO 34.6  During a delivery, the physician uses mid forceps for the extraction. This will be reported with the quali-
fier character
a. 6 b.  4
c. 5 d.  3
9. LO 34.6  The qualifier character that reports on an in utero procedure performed on the fetus’s eye is
a. E. b.  N.
c. M. d.  H.
10. LO 34.1  Within the Obstetrics Section, what is the one body system that is the gestational term?
a. 1 b.  0
c. 3 d.  5

Let’s Check It! Root Operation Definitions—Obstetrics

Refer to the ICD-10-PCS Appendix entitled “Root Operation Definitions.” Look for Root Operation Definitions for
Other Sections, Obstetrics, and match the ICD-10-PCS value for each Operation, Character 3, to its definition.
1. Delivery A. A
2. Removal B. D
3. Resection C. E
4. Abortion D. H
5. Inspection E. J
6. Insertion F. P
7. Repair G. Q
8. Reposition H. S
9. Transplantation I. T
10. Extraction J. Y

Let’s Check It! Guidelines

Refer to the Official ICD-10-PCS Obstetrics Section Guidelines and fill in the blanks accordingly.
Amniocentesis  retained  obstetric
all therapeutic  pregnant
Obstetrics Medical and Surgical  postpartum 
delivery  Endometrium  Extraction 

1032   PART V  |  INPATIENT (HOSPITAL) REPORTING

 1. Procedures performed on the products of conception are coded to the _____ section.

CHAPTER 34 REVIEW
2. Procedures performed on the _____ female other than the products of conception are coded to the appropriate root
operation in the _____ section.
3. _____ is coded to the products of conception body part in the Obstetrics section. Repair of _____ urethral lacera-
tion is coded to the urethra body part in the Medical and Surgical section. 
4. Procedures performed following a _____ or abortion for curettage of the endometrium or evacuation of _____
products of conception are _____coded in the Obstetrics section, to the root operation _____ and the body part
Products of Conception, Retained.
5. Diagnostic or _____ dilation and curettage performed during times other than the _____ or post-abortion period
are all coded in the Medical and Surgical section, to the root operation Extraction and the body part _____.

Let’s Check It! Rules and Regulations

Please answer the following questions from the knowledge you have gained after reading this chapter.
1. LO 34.2   Explain the difference between delivery and extraction; include the character that represents each.
2. LO 34.3   The Obstetrics section character position 4 focuses on three body parts, which are not specific anatomi-
cal sites. List the three body parts; include the character that identifies each.
3. LO 34.4   List the six approaches used in the Obstetrics section of ICD-10-PCS, explain each approach, and
include the character that identifies each approach.
4. LO 34.6   What does the Obstetrics section seventh character position present and is it required? 
5. LO 34.6   Explain what a cesarean section procedure is and include the root operation term used in ICD-10-PCS.

ICD-10-PCS

YOU CODE IT! Practice

Using the techniques described in this chapter, carefully read through the case studies and determine the most
accurate ICD-10-PCS code(s) for each case study.
1. Candy Moss, a 31-year-old female, is G1 P0, 8 weeks gestation. Candy requests an abortion due to genetic
problems in the fetus. She is admitted to the hospital, where a vacuum abortion is performed, via natural
opening.
2. Keren Medlin, a 29-year-old female, is admitted to Westward Hospital at 12 weeks gestation. Dr. Hanks per-
forms a repair to the fetus’s urinary system endoscopically, via natural opening.
3. Annie Charles, a 23-year-old female, G2 P1, at 40 weeks gestation in active labor, is admitted to Westward
Hospital. Dr. Downs assisted in a vaginal delivery, low forceps over midline episiotomy.
4. Loretta Smith, a 36-year-old female, G3 P2 at 38 weeks gestation, is admitted to Westward Hospital. Dr.
McWhirter changes a monitor electrode, vaginal approach.
5. Debbie Slay, a 29-year-old female, G1 P0, is admitted to Westward Hospital in labor. Dr. Atkinson inserts an
intrauterine pressure catheter, vaginal approach, to evaluate contractions. 
6. Rhonda Hart, a 19-year-old female, is admitted to Westward Hospital in labor at 41 weeks gestation, G1 P0.
AROM is performed and spontaneous vaginal delivery with intact perineum occurs 1 hour later, manually
assisted delivery. 
7. Laura McMillan, a 28-year-old female, at 39 weeks gestation, is admitted to Westward Hospital in labor; a
vaginal delivery occurs 6 hours later, vacuum assisted.
8. Latoya Medlin, an 18-year-old female, G1 P0, is admitted to Westward Hospital at 18 weeks gestation. Latoya
is requesting termination of pregnancy due to confirmed fetal anencephaly. Pregnancy was terminated by a
luminaria stick, which produced a complete abortion.
CHAPTER 34 REVIEW

9. Sherry Moore, a 29-year-old female, is admitted to Westward Hospital for an open in utero fetal mouth repair.
10. Janie Knight, a 16-year-old female, G1 P0, is admitted to Westward Hospital and Dr. Gifford performs an
amniotic fluid test for therapeutic purposes.
11. Sharon Heyward, a 24-year-old female, G2 P1 at 40 weeks gestation, is admitted to Westward Hospital.
Dr. Jessup performs a pelvic examination revealing an open, soft cervix. 
12. Kristi Williams, a 31-year-old female, is admitted to Westward Hospital in active labor at 41 weeks gestation.
Dr. Gerald assisted with a vaginal delivery, with high forceps, 4 hours later. 
13. Keyana Haulbrook, a 17-year-old female, G1 P0, 12 weeks gestation, is admitted to Westward Hospital to ter-
minate pregnancy due to a genetic defect in the fetus. Abortion was performed by hysterotomy technique.
14. Natalie Phillips, a 32-year-old female, 37.5 weeks gestation, G2 P1, is admitted to Westward Hospital for a
fetal spinal tap, percutaneous.
15. Eleanor Coaxum, a 26-year-old female, G1 P0, 32 weeks gestation, is admitted to Westward Hospital for a
fetal skin transplantation, via natural opening.

ICD-10-PCS
YOU CODE IT! Application
The following exercises provide practice in abstracting physicians’ notes and learning to work with documenta-
tion from our health care facility, Westward Hospital. These case studies are modeled on real patient encounters.
Using the techniques described in this chapter, carefully read through the case studies and determine the most
accurate ICD-10-PCS code(s) for each case study.

WESTWARD HOSPITAL
591 Chester Road
Masters, FL 33955
DISCHARGE SUMMARY
PATIENT: ALBERTS, SERITA
DATE OF ADMISSION: 03/05/18
DATE OF DISCHARGE: 03/17/18
ADMITTING DIAGNOSIS: 1.  Intrauterine pregnancy at 40 plus weeks.
2.  Active labor.
3.  History of two previous cesarean sections.
DISCHARGE DIAGNOSIS: 1.  Intrauterine pregnancy at 40 plus weeks.
2.  Active labor.
3.  History of two previous cesarean sections.
OPERATION: Repeat low transverse cesarean section.
FLUIDS: 2500 mL lactated Ringer.
ESTIMATED BLOOD LOSS: 300 mL.
URINE OUTPUT: 125 mL, clear and yellow.
DESCRIPTION OF OPERATION: The patient was identified and taken to the operating room. Appropri-
ate anesthesia was administered. The patient was placed in the dorsal supine position with a leftward
tilt and prepped and draped in the usual sterile fashion. Following that, a low Pfannenstiel skin inci-
sion was made with a #10 scalpel. This incision was carried down to the underlying layer of fascia with

1034   PART V  |  INPATIENT (HOSPITAL) REPORTING

 CHAPTER 34 REVIEW
the scalpel. The fascia was then nicked in the midline with the scalpel. This fascial incision was then
extended laterally with the Mayo scissors and pickups with teeth.
Following that, the superior aspect of the fascial incision was grasped with straight Kocher clamps x2,
tented up from the rectus muscles below and dissected away sharply with the scalpel and Mayo scis-
sors. This was repeated similarly to the inferior aspect of the fascial incision. Following that, the perito-
neum was identified below, grasped with hemostat x2, and entered sharply with Metzenbaum scissors.
After appropriate visualization of the bowel and bladder, the peritoneal incision was extended superiorly
and inferiorly. The bladder blade was then placed inferiorly and the vesicouterine peritoneum tented
up with the smooth pickups, incised with the Metzenbaum scissors, and this incision was extended
laterally.
Following that, the bladder blade was replaced deflecting the bladder anteriorly and inferiorly. The
#10 scalpel was taken in hand again, and a 3-cm low transverse area incision was then made. This inci-
sion was then extended laterally. Following that, the infant’s vertex was mobilized and delivered through
the incision in a direct OP position. The infant’s nasopharynx was suctioned with the bulb syringe and
then the rest of the infant was delivered along with fundal pressure.
Following that, the infant’s cord was clamped and cut and the infant was handed off to the awaiting
pediatricians. Following that, the placenta was spontaneously expressed. The uterus was then exterior-
ized and cleared of all clots and debris. The uterine incision was repaired with #1 chromic in a running-
locking fashion. The uterus was then returned to the abdominal cavity, and the abdominal cavity was
cleared of all clots and debris.
The uterine incision and the pelvic cavity were reinspected and excellent hemostasis was noted over-
all. The fascial incision was reapproximated with #0 Vicryl in a running fashion x2. Following that, the skin
was reapproximated with staples. The instrument, needle, and sponge counts were correct x2.
Benjamin Johnston, MD—2222
556845/mt98328: 03/17/18 09:50:16  T: 03/17/18 12:55:01

Determine the most accurate ICD-10-PCS code(s) for the c-section.

WESTWARD HOSPITAL
591 Chester Road
Masters, FL 33955
OPERATIVE REPORT
PATIENT: HUDSON, LYNN
ACCOUNT/EHR #: HUDSLY001
DATE OF ADMISSION: 17 March 2018
ATTENDING PHYSICIAN: Denny Stewart, MD
ANESTHESIA: Epidural type of delivery: NSVD
CONDITION OF PERINEUM: MLE
EPISIOTOMY: Midline performed
VAGINA/CERVIX: Intact
DELIVERED: Live, single-born female, weight 7 lb. 2 oz. @ 02:17
TYPE OF STIMULATION: Mouth suction
CHAPTER 34 REVIEW

CONDITION: Good
BIRTH INJURY: None
APGAR RATING: 1 min. = 9 . . . 5 min. = 9

Denny Stewart, MD-1234

558645/mt98328: 03/17/18 09:50:16  T: 03/17/18 12:55:01

Determine the most accurate ICD-10-PCS code(s) for the delivery.

WESTWARD HOSPITAL
591 Chester Road
Masters, FL 33955
OPERATIVE REPORT
PATIENT: CARROLL, DAWN
ACCOUNT/EHR #: CARRDA001
DATE OF ADMISSION: 21 MARCH 2018
ATTENDING PHYSICIAN: Steven Phifer, MD
In the 40th week of her first pregnancy, a 34-year-old woman arrived at Labor and Delivery at 5:00 a.m.
for a planned induction of labor due to mild, pregnancy-induced hypertension. After intravaginal place-
ment of misoprostol, the nurse observed her briefly and, at 9:00 a.m., discharged her from the unit. She
went for a walk with her husband in a park next to the hospital.
Patient’s membranes spontaneously ruptured, and she returned to the Labor and Delivery unit.
Patient’s vital signs were taken, and the fetal heart rate checked. The mother’s blood pressure was
182/97, but the nurse thought this was related to nausea, vomiting, and discomfort from the contractions.
The resident examined the mother, determined that her cervix was 5–6 cm, 90 percent effaced, and
the vertex was at 0 station. An internal fetal heart monitor was placed because the mother’s vomiting
and discomfort caused her to move around too much in the bed, making it hard to record the fetal heart
rate with an external monitor. The internal monitor revealed a steady fetal heart rate of 120 and no
decelerations.
The mother continued to complain of painful contractions and requested an epidural. Shortly after
placement of the epidural, the monitor recorded a prolonged fetal heart rate deceleration. The heart
rate returned slowly to the baseline rate of 120 as the nurse repositioned the mother, increased her
intravenous fluids, and administered oxygen by mask.
An epidural analgesia infusion pump was started. The fetal heart rate strip indicated another decel-
eration that recovered to baseline. The nurse informed the resident, who checked the tracing and told
her to “keep an eye on things.”
The primary nurse noted in the labor record that the baseline fetal heart rate was “unstable, between
100–120,” but she did not report this to the resident.
The nurse recorded that the fetal heart rate was “flat, no variability.” As the nurse was documenting
this as a nonreassuring fetal heart rate pattern, the patient expressed a strong urge to push and the
nurse called for an exam.
A resident came to the bedside, examined the mother, and noted that she was fully dilated with the
caput at +1. A brief update was written in the chart, but the clinician who had performed the exam was
not noted.

1036   PART V  |  INPATIENT (HOSPITAL) REPORTING

 CHAPTER 34 REVIEW
The mother was repositioned and began pushing.
The fetal heart rate suddenly dropped and remained profoundly bradycardic for 11 minutes. The
resident was called and attempted a vacuum delivery because the fetal head was at +2 station. The
attending then entered and attempted forceps delivery.
An emergency cesarean delivery was performed; the baby was stillborn. The physician identified a
uterine rupture that required significant blood replacement.

Steven Phifer, MD-4321

558645/mt98328: 03/21/18 1:50:16  T: 03/22/18 12:55:01

Determine the most accurate ICD-10-PCS code(s) for the c-section.

WESTWARD HOSPITAL

591 Chester Road

Masters, FL 33955

OPERATIVE REPORT

PATIENT: FAULDS, MAGGIE

ACCOUNT/EHR #: FAULMA001

DATE OF ADMISSION: 25 MARCH 2018

ATTENDING PHYSICIAN: Sandra Lindler, MD

ANESTHESIA: General 
Patient is in her 12th week of pregnancy. She presented to the emergency department with severe
cramping and vaginal bleeding. After examination the patient was diagnosed with an incomplete early
spontaneous abortion and a D&C was recommended. The patient was fully counseled as to the risks
and benefits of the D & C and admitted to the hospital. The patient agreed to the procedure.
The patient was then taken to the operating room and placed in a supine position on the operat-
ing room table. General endotracheal anesthesia was administered, and once adequate anesthesia
was demonstrated, the patient’s legs were then placed in candy cane stirrups. The patient was then
prepped and draped in the standard D&C surgical fashion.
The patient was placed in 10 degrees of Trendelenburg. The patient was given 100 mg of doxy-
cycline. The bladder was then decompressed and approximately 45 mL of urine was produced. A
weighted speculum was placed in the posterior vagina and the cervix was grasped with single-tooth
tenaculum. Uterus sounded to 8.2 cm. The cervix was then serially dilated with Hanks dilator. An 8 cm
straight suction curette was then introduced and a suction curettage was performed. Once all products
of conception were evacuated, a sharp curettage was performed until a gritty surface was appreciated
on all four quadrants of the uterus. No further bleeding was noted. Products of conception were then
examined on the back table, which was grossly consistent with products of conception.
The patient tolerated the procedure and anesthesia well, was awakened from anesthesia without
complications, and was transported to the recovery room in stable condition.

Sandra Lindler-6789
558645/mt98328: 03/25/18 09:50:16  T: 03/26/18 12:55:01

Determine the most accurate ICD-10-PCS code(s) for the extraction.

CHAPTER 34 REVIEW

WESTWARD HOSPITAL
591 Chester Road
Masters, FL 33955
OPERATIVE REPORT
PATIENT: HOFFMEIER, KATHLEEN
ACCOUNT/EHR #: HOFFKA001
DATE OF ADMISSION: 28 MARCH 2018
ADMITTING DIAGNOSIS: Right tubal ectopic pregnancy
PROCEDURE: Operative laparoscopy, right salpingectomy.
SURGEON: William G. Cohen, MD
ANESTHESIA: General
This 28-year-old female presents to the emergency room with vaginal bleeding and belly pain that gets
worse with movement. Patient states she is pregnant at approximately 8 weeks gestation, G1 P0. Ultra-
sound report showed a mass near the cul-de-sac. The patient denies any medical or surgical history. No
known allergies. Family history is noncontributory. The patient was admitted to the hospital.
The patient was taken to the OR, where general anesthesia was easily obtained. The patient was
then prepped and draped in a sterile fashion and placed in dorsal lithotomy position. A weighted specu-
lum was introduced into the patient’s vagina for cervical visualization. Once the cervix was visualized,
a single-toothed tenaculum was applied to the upper lip of the cervix, and acorn manipulator was intro-
duced into the patient’s cervix.
Attention was then drawn to the abdomen, where a 10 mm horizontal incision was done below the
umbilicus and carried down all the way to the fascia. Under direct visualization, a 10 mm trocar was
introduced into the patient’s abdomen. Once intraperitoneal placement was confirmed, pneumoperito-
neum was started. Opening pressure was 3 mmHg; pneumoperitoneum was obtained.
Once pneumoperitoneum was obtained, a second port was put two fingerbreadths above the pubic
symphysis, and under direct visualization, a 5 mm trocar was then introduced into the patient’s abdo-
men. The patient was placed in Trendelenburg position. Pelvic structures were revealed; ampullary
ectopic was noted on the right side with some amount of hemoperitoneum and moderate amount of
free fluid.
Attention was focused on the right fallopian tube, which initially was incised where the ectopic preg-
nancy was and products of conception were removed. Since no hemostasis was able to be obtained
from the incision site from the salpingostomy and due to the amount of dense adhesions on that fal-
lopian tube, decision was then made to proceed with right salpingectomy, so the IP ligament was
identified and fallopian tube was then grasped by the fimbria and incised from the mesosalpinx. Good
hemostasis was noted from the fallopian tube sites and the operative site. Specimen was then removed
from the patient’s abdomen. Copious irrigation was done and all clots and debris were removed from
the patient’s abdomen. Once good hemostasis was noted from the patient’s abdomen, pneumoperi-
toneum was deflated and all trocars were removed. Infraumbilical fascia was closed with 0 Vicryl and
interrupted suture. The skin was closed with 4-0 Vicryl. The right infrapubic and suprapubic ports were
closed with 0 Vicryl in running fashion, and third port, which was introduced two fingerbreadths above
the pubis symphysis and 6 cm in the midaxillary line, under direct visualization, was also closed with 4-0
Monocryl. Sponge, lap, and needle counts were correct x2. The patient was taken to the recovery room
in stable condition.

1038   PART V  |  INPATIENT (HOSPITAL) REPORTING

 CHAPTER 34 REVIEW
DIET: As tolerated.
PHYSICAL ACTIVITY: No heavy lifting. Pelvic rest.

William G. Cohen, MD-6543

558645/mt98328: 03/28/18 09:50:16  T: 03/29/18 12:55:01

Determine the most accurate ICD-10-PCS code(s) for the salpingectomy.

35 Placement through
Chiropractic Sections
Learning Outcomes
Key Terms
After completing this chapter, the student should be able to:
Administration
Extra-Articular LO 35.1 Recognize the details reported in the Placement—Anatomical
Extracorporeal Regions Section and Placement—Anatomical Orifices Section.
Measurement LO 35.2 Evaluate the details to determine the services reported from
Placement the Administration Section.
Somatic
LO 35.3 Determine the specifics required to build a code from the
Measurement and Monitoring Section.
LO 35.4 Interpret the documentation to report a service from the Extra-
corporeal or Systemic Assistance and Performance Section.
LO 35.5 Abstract the documentation to determine a code for a service
reported from the Extracorporeal or Systemic Therapies Section.
LO 35.6 Utilize knowledge to report a code from the Osteopathic
Section.
LO 35.7 Identify the details necessary to build a code from the Other
Procedures Section.
LO 35.8 Distinguish the services provided to determine reporting a
code from the Chiropractic Section.
LO 35.9 Analyze the documentation to build a complete and accurate
code(s) in ICD-10-PCS for sections 2–9.

Remember, you need to follow along in

ICD-10-PCS
  STOP! your ICD-10-PCS code book for an
optimal learning experience.

35.1  Reporting Services from

the Placement Section
Character Definitions
The meanings for the Placement Section characters are in the following table:

Character Position Character Meaning

1 Section of the ICD-10-PCS book
2 Anatomical region/orifices
3 Root operation term
4 Body region/orifice
5 Approach used by physician
6 Device
7 Qualifier

1040
You might have noticed that these are slightly different meanings for characters
2 and 4 than those in the Medical and Surgical Section and Obstetrics Section.

Character Position 1: Placement Section 2

Character Position Character Meaning
1 Section of the ICD-10-PCS book
2 Anatomical region/orifices
3 Root operation term
4 Body region/orifice
5 Approach used by physician
6 Device
7 Qualifier
The procedures reported with codes from this section explain the location of a device
either in or on a body region for protection, immobilization, stretching, compression,
or packing. These procedures are some that you are familiar with, such as application
of a splint to immobilize or a traction device to stretch a muscle. For the most part,
the devices in this section are “off the shelf,” so to speak, and not customized fabri-
cations. (More about these devices will be discussed when we get to that character
position.)

Character Position 2: Anatomical Region/Orifices

Character Position Character Meaning
1 Section of the ICD-10-PCS book
2 Anatomical region/orifices
CODING BITES
3 Root operation term
Remember, an anatomi-
4 Body region/orifice
cal orifice is a natural
5 Approach used by physician opening into the body;
6 Device for example, mouth,
nose, urethra.
7 Qualifier
There are only two body system options:
Anatomical Regions . . . Character: W
Anatomical Orifices . . . Character: Y

Character Position 3: Root Operation

Character Position Character Meaning
1 Section of the ICD-10-PCS book
2 Anatomical region/orifices
3 Root operation term
4 Body region/orifice
5 Approach used by physician
6 Device
7 Qualifier

The codes from the Placement Section only report procedures that are noninvasive,
meaning that the outer layer of the skin is not punctured and no incision is made.

CHAPTER 35  | 
 Change
Change: Taking out or off a device from a body part and putting back an identical
or similar device in or on the same body part without cutting or puncturing the
skin or a mucous membrane . . . Character: 0
Caution! This root operation term means the same as it does in the Medical and Sur-
gical Section and the Obstetrics Section; however, the character used to report this in
the Placement Section is different.

EXAMPLE
2W05X3Z Change external back brace

Compression
Compression: Putting pressure on a body region . . . Character: 1

EXAMPLE
2W1RX7Z Placement of intermittent pressure device on lower left leg

Dressing
Dressing: Putting material on a body region for protection . . . Character: 2

EXAMPLE
2W2EX4Z Placement of bandage on right hand

Immobilization
Immobilization: Limiting or preventing motion of an external body region
. . . Character: 3

EXAMPLES
2W3KX1Z Application of a splint to a left finger
2W5MX3Z Removal, G3 XL post-op knee brace, left leg

Packing
Packing: Putting material in a body region or orifice . . . Character: 4

EXAMPLES
2W48X5Z Packing to wound on right upper extremity
2Y41X5Z Packing of nasal cavities due to epistaxis 

Removal
Removal: Taking out or off a device from a body part . . . Character: 5
Read this carefully: As the description specifically states “device,” this can be used
only for this type of procedure—to remove a previously placed device. As you abstract
the physician’s notes, be cautious of the use of this term in documentation.

1042   PART V  |  INPATIENT (HOSPITAL) REPORTING

 Caution! This root operation term means the same as it does in the Medical and
Surgical Section and the Obstetrics Section; however, the character used to report
this in the Placement Section is different.

EXAMPLE
2W5TX0Z Removal of traction apparatus from left foot

Traction
Traction: Exerting a pulling force on a body region in a distal direction . . . 
Character: 6
Notice that Traction is presented as a root operation term as well as traction apparatus
that is offered as an option for the device used.

EXAMPLE
2W62X0Z Traction apparatus placed at neck

Character Position 4: Body Region/Orifice

Character Position Character Meaning
1 Section of the ICD-10-PCS book
2 Anatomical region/orifices
3 Root operation term
4 Body region/orifice
5 Approach used by physician
6 Device
7 Qualifier
The two body systems in this section (Anatomical Regions and Anatomical Orifices)
each have a list of applicable body regions and their characters.
Anatomical Regions
Head . . . Character: 0 Upper Arm, Right . . . A Lower Extremity, Right . . . L
Face . . . 1 Upper Arm, Left . . . B Lower Extremity, Left . . . M
Neck . . . 2 Lower Arm, Right . . . C Upper Leg, Right . . . N
Abdominal Wall . . . 3 Lower Arm, Left . . . D Upper Leg, Left . . . P
Chest Wall . . . 4 Hand, Right . . . E Lower Leg, Right . . . Q
Back . . . 5 Hand, Left . . . F Lower Leg, Left . . . R
Inguinal Region, Right . . . 6 Thumb, Right . . . G Foot, Right . . . S
Inguinal Region, Left . . . 7 Thumb, Left . . . H Foot, Left . . . T
Upper Extremity, Right . . . 8 Finger, Right . . . J Toe, Right . . . U
Upper Extremity, Left . . . 9 Finger, Left . . . K Toe, Left . . . V

Anatomical Orifices
Mouth and Pharynx . . . 0 Ear . . . 2 Female Genital Tract . . . 4
Nasal . . . 1 Anorectal . . . 3 Urethra . . . 5

CHAPTER 35  | 
 Character Position 5: Approach
Character Position Character Meaning
1 Section of the ICD-10-PCS book
2 Anatomical region/orifices
3 Root operation term
4 Body region/orifice
5 Approach used by physician
6 Device
7 Qualifier

This one is easy; there is only one choice. Remember that all procedures reported from
the Placement Section do not involve incisions or punctures. This means all of these
devices are external.
External Approach . . . Character: X

Character Position 6: Device

Character Position Character Meaning
1 Section of the ICD-10-PCS book
2 Anatomical region/orifices
3 Root operation term
4 Body region/orifice
5 Approach used by physician
6 Device
7 Qualifier

It makes sense that there are several options for the character to report a device because
Placement that is really the primary activity of this section: placement of a device.
To put a device in or on an
Traction Apparatus . . . Character: 0
anatomical site.
Splint . . . Character: 1
Cast . . . Character: 2
Brace . . . Character: 3
Bandage . . . Character: 4
Packing Material . . . Character: 5
Pressure Dressing . . . Character: 6
Intermittent Pressure Device . . . Character: 7
Wire . . . Character: 9
Other Device . . . Character: Y
No Device . . . Character: Z

EXAMPLES
You might see phrases such as these in the documentation:
“. . . and a short arm splint, right side, was applied. . . .”
2W38X1Z Immobilization using a splint, upper extremity, right
“. . .The new Philadelphia collar was removed . . .”
2W52X3Z Removal of neck brace

1044   PART V  |  INPATIENT (HOSPITAL) REPORTING

Character Position 7: Qualifier
Character Position Character Meaning
1 Section of the ICD-10-PCS book
2 Anatomical region/orifices
3 Root operation term
4 Body region/orifice
5 Approach used by physician
6 Device
7 Qualifier

There are no details reported by the Qualifier position, so the only option is Z No
Qualifier.

ICD-10-PCS
LET’S CODE IT! SCENARIO
Michael Shinto, a 31-year-old male, was in a fight at a bar and was punched in the face. Along with other injuries,
Michael’s lower jaw was dislocated. Dr. Northrop admitted Michael into the hospital due to internal bleeding. Once
in his room, Dr. Northrop took Michael to the procedure room to wire his jaw to immobilize it and permit it to heal.

Let’s Code It!

Let’s go through the steps of coding for ICD-10-PCS and determine the code or codes that should be reported
for this encounter between Dr. Northrop and Michael Shinto.
Which section will provide you with the details to report this procedure? Let’s think this through. Dr. Northrop
wired Michael’s jaw. Therefore, he placed wire . . . the Placement section.
First character: Section: Placement . . . 2
You have two choices for body system: Anatomical Regions or Anatomical Orifices. The jaw is not an orifice, so
the decision is straightforward.
Second character: Body Region: Anatomical Regions . . . W
What was the purpose of placing the wire? The documentation states, “to immobilize it.”
Third character: Root Operation: Immobilization . . . 3
Read the options in the Body Region column carefully. Which anatomical site comes closest because jaw is not
listed? Yes, the jaw is a part of the head, but it is also part of the face. Hmm. In this circumstance, we need to
read ahead a little bit, to the list shown in the column to the right for Device. You know for certain that wire was
used, and there is only an option for Wire on the row with Face, not Head. Therefore, you can tell which to report.
Fourth character: Body Region: Face . . . 1
It is logical that the wire was placed externally, and this is the only option you have for the fifth character. Nice.
Fifth character: Approach: External . . . X
You know that the device is Wire because the documentation states, “wire his jaw.”
Sixth character: Device: Wire . . . 9
There is only one option for the qualifier for this row on this Table.
Seventh character: Qualifier: No Qualifier . . . Z
The ICD-10-PCS code you will report is
2W31X9Z Wire jaw
Good job!

CHAPTER 35  | 
 35.2  Reporting Services from the
Administration Section
Character Definitions
The meanings for the Administration Section characters are shown in the following
table:

Character Position Character Meaning

1 Section of the ICD-10-PCS book
2 Physiological system or anatomical region
3 Root operation term
4 Body system or region
5 Approach used by physician
6 Substance
7 Qualifier

For the most part, these character positions have different meanings than the other sec-
tions you have already learned about.

Character Position 1: Administration Section 3

Character Position Character Meaning
1 Section of the ICD-10-PCS book
2 Physiological system or anatomical region
3 Root operation term
4 Body system or region
5 Approach used by physician
6 Substance
7 Qualifier

Procedures reported from the Administration Section will all begin with the
number 3.

Character Position 2: Physiological System/

Anatomical Region
Character Position Character Meaning
1 Section of the ICD-10-PCS book
2 Physiological system or Anatomical region
3 Root operation term
4 Body system or region
5 Approach used by physician
6 Substance
7 Qualifier

1046   PART V  |  INPATIENT (HOSPITAL) REPORTING

There are only three options for the second character:
Circulatory . . . Character: 0 [This is used for transfusion procedures.]
Indwelling Device . . . Character: C
Physiological Systems and Anatomical Regions . . . Character: E

EXAMPLE
Roy Shearmann, a 47-year-old male, was diagnosed with myelodysplastic syn-
drome several months ago when he presented with progressive pancytopenia.
Since admission, he has undergone treatment with antibiotics and has received
transfusion of nonautologous packed RBCs, administrated via peripheral vein, IV.
The patient continues on weekly Procrit. Code for the blood transfusion.
30233N1 Transfusion, nonautologous red blood cells, peripheral vein,
percutaneously

Character Position 3: Root Operation

Character Position Character Meaning
1 Section of the ICD-10-PCS book
2 Physiological system or anatomical region
3 Root operation term
4 Body system or region
5 Approach used by physician
6 Substance
7 Qualifier
There are only three root operation terms used to report procedures in this section:
Introduction: Putting in or on a therapeutic, diagnostic, nutritional, physiological,
or prophylactic substance except blood or blood products . . . Character: 0
Irrigation: Putting in or on a cleansing substance . . . Character: 1
Transfusion: Putting in blood or blood products . . . Character: 2

EXAMPLE
Illanya Sibgame, a pleasant 55-year-old female patient, is admitted to undergo
treatment for a non-Hodgkin lymphoma. While admitted, intrathecal chemo-
therapy, DepoCyt 50 mg (a low-dose interleukin-2 drug), was administered. She
did tolerate all treatments well with no complication noted, and once stable, was
made ready for discharge home.
3E0R303 Introduction of low-dose interleukin-2 antineoplastic, intrathecal

Character Position 4: Body System/Region

Character Position Character Meaning
1 Section of the ICD-10-PCS book
2 Physiological system or anatomical region
3 Root operation term
4 Body system or region
5 Approach used by physician
6 Substance
7 Qualifier

CHAPTER 35  | 
 Specifically for this section, the fourth character position will report the anatomical
site into which the substance is administered. Be careful. This may be different from
the site expected to benefit from the ultimate effect of this substance. For example, if
the substance is administered intradermally (such as an intradermal patch), the body
system/region would be skin and mucous membrane, whereas an IM (intramuscular)
injection would be reported as the muscle in this character position. IA (intra-arterial)
Administration or IV (intravenous) administrations would be reported to the peripheral artery or
To introduce a therapeutic, peripheral vein, respectively. However, if a catheter is used—for example, to travel to
prophylactic, protective, diag- administer the substance directly to a clot—this would be reported as a central artery
nostic, nutritional, or physi- or central vein, per the documentation.
ological substance.  Oddly, there is an exception. When an irrigating substance (such as saline solu-
tion) is administered into an indwelling device (reported as body system C Indwelling
Device), the body system/region will be Z None.

Character Position 5: Approach

Character Position Character Meaning
1 Section of the ICD-10-PCS book
2 Physiological system or anatomical region
3 Root operation term
4 Body system or region
5 Approach used by physician
6 Substance
7 Qualifier
The approaches for this section are those you have come to know: 0 Open, 3 Percuta-
CODING BITES neous, 4 Percutaneous Endoscopic, 7 Via Natural or Artificial Opening, 8 Via Natural or
If you want a refresher Artificial Opening Endoscopic, and X External.
on the different
approaches, you can Character Position 6: Substance
revisit the ICD-10-PCS
Medical and Surgical Character Position Character Meaning
Section chapter, 1 Section of the ICD-10-PCS book
section Medical/Surgi-
2 Physiological system or anatomical region
cal Approaches:
Character 5. 3 Root operation term
4 Body system or region
5 Approach used by physician
6 Substance
7 Qualifier
In this character position, you will identify the substance being administered. Be care-
ful! The Substance characters reported for Circulatory (second character 0) and those
reported for Physiological Systems and Anatomical Regions (second character E) have
CODING BITES different meanings for the same letters. This is a great example of why it is so impor-
Check out the appendix tant to read each table carefully and completely and to avoid assuming that the same
Substance Key/Sub- letter means the same from table to table, even in the same section.
stance Definitions in
your ICD-10-PCS code EXAMPLES
book as well as Physi-
cians’ Desk Reference 30***G* Administration, Circulatory, ***, Bone marrow, *
(PDR) or another drug 3E***G* Administration, Physiological Systems, ***, Other Therapeutic
index. Substance, *

1048   PART V  |  INPATIENT (HOSPITAL) REPORTING

Character Position 7: Qualifier
Character Position Character Meaning
1 Section of the ICD-10-PCS book
2 Physiological system or anatomical region
3 Root operation term
4 Body system or region
5 Approach used by physician
6 Substance
7 Qualifier

This character will provide additional detail about the substance, if necessary.

EXAMPLES
Autologous . . . Character: 0
Nonautologous . . . Character: 1
Oxazolidinones . . . Character: 8
No Qualifier . . . Character: Z

ICD-10-PCS
LET’S CODE IT! SCENARIO
Sean McRoyale, a 41-year-old male, was admitted into McGraw Hospital. Dr. Toller administered nonautologous
pancreatic islet cells, intravenously.

Let’s Code It!

Let’s go through the steps of coding for ICD-10-PCS and determine the code or codes that should be reported
for this encounter between Dr. Toller and Sean McRoyale.
From which section will you report this? The documentation actually tells you, where it states, “administered.”
First character: Section: Administration . . . 3
There are three choices, as you learned, for body system in this section. While it might make sense to think
that Circulatory would be correct when the documentation states, “intravenously,” as you read the Table, how-
ever, you can see that there is only one Root Operation Term under this body system, and this is Transfusion
[Putting in blood or blood products], and this does not fit at all. Next is Indwelling Device, and that does not fit
either. Therefore, the only realistic option is Physiological Systems and Anatomical Regions.
Second character: Physiological Systems and Anatomical Regions . . . E
You have only two options for a Root Operation Term for this body system in the Administration section: Intro-
duction and Irrigation. You know Irrigation [Putting in or on a cleansing substance] does not fit. And the follow-
ing details will help you confirm this decision.
Third character: Root Operation: Introduction . . . 0
The documentation states, “intravenously.” This means this substance was administered into a vein. This nar-
rows down the options to Central Vein or Peripheral Vein. Venipuncture is typically done in the cubital fossa
(inside the elbow), which includes three peripheral veins. Of course, in real life, when you are on the job, you
must confirm this with additional documentation or the provider. For now, we will accept this was done via a
peripheral vein.

(continued)

CHAPTER 35  | 
 Fourth character: Body Region: Peripheral Vein . . . 3
Venipuncture is performed percutaneously, directly into the vein.
Fifth character: Approach: Percutaneous . . . 3
There are many, many choices in this sixth character column. The documentation states, “pancreatic islet cells”
as the substance. Find it, and make certain it is on the same row as Peripheral Vein.
Sixth character: Substance: Pancreatic Islet Cells . . . U
What type of cells? The documentation states, “nonautologous.”
Seventh character: Qualifier: Nonautologous . . . 1
The ICD-10-PCS code you will report is
3E033U1 Introduction of nonautologous pancreatic islet cells, percutaneous, to peripheral vein
Good job!

35.3  Reporting Services from the

Measurement and Monitoring Section
Character Definitions
The meanings for the Measurement and Monitoring Section characters are shown
in the following table:

Character Position Character Meaning

1 Section of the ICD-10-PCS book
2 Physiological system
3 Root operation term
4 Body system
5 Approach used by physician
6 Function/device
7 Qualifier
For the most part, these character positions have different meanings than those in the
other sections you have already learned about.

Character Position 1: Measurement and Monitoring Section 4

Character Position Character Meaning
1 Section of the ICD-10-PCS book
2 Physiological system
3 Root operation term
4 Body system
5 Approach used by physician
6 Function/device
7 Qualifier
Procedures reported from the Measurement and Monitoring Section will all begin
with the number 4.

1050   PART V  |  INPATIENT (HOSPITAL) REPORTING

Character Position 2: Physiological System
Character Position Character Meaning
1 Section of the ICD-10-PCS book
2 Physiological system
3 Root operation term
4 Body system
5 Approach used by physician
6 Function/device
7 Qualifier
There are only two options for the second character:
Physiological Systems . . . Character: A
Physiological Devices . . . Character: B

Character Position 3: Root Operation

Character Position Character Meaning
1 Section of the ICD-10-PCS book
2 Physiological system
3 Root operation term
4 Body system
5 Approach used by physician
6 Function/device
7 Qualifier
There are only two root operation terms used to report procedures in this section.
Measurement: Determining the level of a physiological or physical function at a
point in time . . . Character: 0
Monitoring: Determining the level of a physiological or physical function repeti-
tively over a period of time . . . Character: 1

EXAMPLE
An ECG measures the electrical activity of the heart at one point in time, whereas
a Holter monitor continuously monitors the heart’s rhythms over 24–48 hours.
1. ECG reported with 4A02X4Z Measurement of cardiac electrical activity,
external
2. Holter reported with 4A12XFZ Monitoring cardiac rhythms, externally

Character Position 4: Body System

Character Position Character Meaning
1 Section of the ICD-10-PCS book
2 Physiological system
3 Root operation term
4 Body system
5 Approach used by physician
6 Function/device
7 Qualifier

CHAPTER 35  | 
 The specific body system being measured or monitored is identified by the character
Measurement in the fourth position. Note that this section includes measurement or monitoring of
To determine a level of a a patient’s metabolism, temperature, or sleep. These are reported with a body system
physiological or physical of Z None.
function.

EXAMPLES
Central Nervous System . . . Character: 0
Cardiac System . . . Character: 2
Respiratory System . . . Character: 9

Character Position 5: Approach

Character Position Character Meaning
1 Section of the ICD-10-PCS book
2 Physiological system
3 Root operation term
4 Body system
5 Approach used by physician
6 Function/device
7 Qualifier

The approaches for this section are those you have come to know: 0 Open, 3 Percuta-
neous, 4 Percutaneous Endoscopic, 7 Via Natural or Artificial Opening, 8 Via Natural or
Artificial Opening Endoscopic, and X External.

Character Position 6: Function/Device

Character Position Character Meaning
1 Section of the ICD-10-PCS book
2 Physiological system
3 Root operation term
4 Body system
5 Approach used by physician
6 Function/device
7 Qualifier

In this character position, you will identify the specific body function being measured or
monitored, such as rhythm (F) of the heart or pressure (B) of the blood within the veins.
This character may also report a device, such as a pacemaker (S) or defibrillator (T).
Characters are available for measuring and/or monitoring a patient’s metabolism
(6), temperature (K), or sleep (Q), such as a sleep study. These three functions use a
body system character of Z None.

EXAMPLES
4A0HXCZ External measurement of fetal heart rate
4A1ZXQZ 48 hour sleep study, external monitoring

1052   PART V  |  INPATIENT (HOSPITAL) REPORTING

Character Position 7: Qualifier
Character Position Character Meaning
1 Section of the ICD-10-PCS book
2 Physiological system
3 Root operation term
4 Body system
5 Approach used by physician
6 Function/device
7 Qualifier

This character will provide additional detail about either the body part or system or the
procedure performed.

EXAMPLES
4A10X4G Monitoring of central nervous system activity, intraoperatively,
external
4A143J1 Monitoring of peripheral pulse, venous, external

LET’S CODE IT! SCENARIO

ICD-10-PCS

Katrina Vales is a 17-year-old female with a history of asthma who was admitted with status asthmaticus. Once they
were able to stop the current attack, Dr. Giffen measures her respiratory volume using a spirometer.

Let’s Code It!

Let’s go through the steps of coding for ICD-10-PCS and determine the code or codes that should be reported
for this encounter between Dr. Giffen and Katrina Vales.
Which section? The documentation states, “Dr. Giffen measures. . . .”
First character: Section: Measurement and Monitoring . . . 4
Now, you have two choices for the body system: Physiological Systems or Physiological Devices. The measure-
ment was of Katrina’s respiratory function.
Second character: Body Region: Physiological Systems . . . A
You have two options for the root operation term: Measurement or Monitoring. The documentation states,
“Dr. Giffen measures. . . .”
Third character: Root Operation: Measurement . . . 0
What body system is being measured? The documentation states, “respiratory.”
Fourth character: Body System: Respiratory . . . 9
The documentation states, “using a spirometer,” meaning that you must know how a spirometer works to
determine the next character. Use your medical dictionary or Google to find the facts about this method.
Fifth character: Approach: External . . . X

(continued)

CHAPTER 35  | 
 The documentation states, “measures her respiratory volume. . . .”
Sixth character: Function/Device: Volume . . . L
On this row, there is only one option for the seventh character.
Seventh character: Qualifier: No Qualifier . . . Z
The ICD-10-PCS code you will report is
4A09XLZ Measurement of respiratory volume
Good job!

35.4  Reporting from the Extracorporeal or

Systemic Assistance and Performance Section
Character Definitions
The meanings for the Extracorporeal or Systemic Assistance and Performance
Section characters are shown in the following table:

Character Position Character Meaning

1 Section of the ICD-10-PCS book
2 Physiological system
3 Root operation term
4 Body system
5 Duration
6 Function
7 Qualifier

For the most part, the character positions for the Extracorporeal or Systemic Assis-
tance and Performance Section have similar meanings as in the other sections about
which you have already learned.

Character Position 1: Extracorporeal or Systemic Assistance

and Performance Section 5
Character Position Character Meaning
1 Section of the ICD-10-PCS book
2 Physiological system
3 Root operation term
4 Body system
5 Duration
6 Function
7 Qualifier

Procedures reported from the Extracorporeal or Systemic Assistance and Perfor-

mance Section will all begin with the number 5.

1054   PART V  |  INPATIENT (HOSPITAL) REPORTING

Character Position 2: Physiological System
Character Position Character Meaning
1 Section of the ICD-10-PCS book
2 Physiological system
3 Root operation term
4 Body system
5 Duration
6 Function
7 Qualifier
There is only one option for the second character:
Physiological Systems . . . Character: A

Character Position 3: Root Operation

Character Position Character Meaning
1 Section of the ICD-10-PCS book
2 Physiological system
3 Root operation term
4 Body system
5 Duration
6 Function
7 Qualifier
There are only three root operation terms used to report procedures in this section:
Assistance: Taking over a portion of a physiological function by extracorporeal
means . . . Character: 0
Performance: Completely taking over a physiological function by extracorporeal
means . . . Character: 1
Restoration: Returning, or attempting to return, a physiological function to its
original state by extracorporeal means . . . Character: 2

EXAMPLE
5A05221 Hyperbaric oxygenation of a wound, continuous (an example of
assistance because this is done to improve—or assist—the heal-
ing of the wound)

Character Position 4: Body System

Character Position Character Meaning
1 Section of the ICD-10-PCS book
2 Physiological system
3 Root operation term
4 Body system
5 Duration
6 Function
7 Qualifier

CHAPTER 35  | 
 The specific body systems being supported by these procedures are
Cardiac System . . . Character: 2
Circulatory System . . . Character: 5
Respiratory System . . . Character: 9
Biliary System . . . Character: C
Urinary System . . . Character: D

EXAMPLE
5A1D00Z Filtration of a single period of duration, urinary system (hemodi-
alysis takes over the physiological function of the urinary system
by extracorporeal means)

Character Position 5: Duration

Character Position Character Meaning
1 Section of the ICD-10-PCS book
2 Physiological system
3 Root operation term
4 Body system
5 Duration
6 Function
7 Qualifier
The fifth character position will report the length of time, or the number of times, the
patient received this treatment:
Single . . . Character: 0 [one time or one session]
Intermittent . . . Character: 1 [occasionally]
Continuous . . . Character: 2 [nonstop ongoing]
Less than 24 Consecutive Hours . . . Character: 3 [nonstop for a period of time]
24–96 Consecutive Hours . . . Character: 4 [nonstop for a period of time]
Greater than 96 Consecutive Hours . . . Character: 5 [nonstop for a period of time]
Multiple . . . Character: 6 [more than one time or one session]
Intermittent, Less than 6 hours per day . . . Character: 7
Prolonged Intermittent, 6–18 hours per day . . . Character: 8
Continuous, Greater than 18 hours per day . . . Chapter 9

EXAMPLE
After the surgery, Brandon was kept on a ventilator for 31 hours.
5A1945Z Respiratory ventilator, 24–96 consecutive hours

Character Position 6: Function

Character Position Character Meaning
1 Section of the ICD-10-PCS book
2 Physiological system
3 Root operation term
4 Body system
5 Duration
6 Function
7 Qualifier

1056   PART V  |  INPATIENT (HOSPITAL) REPORTING

In this character position, you will identify the specific physiological function occur-
ring during this procedure:
Filtration . . . Character: 0
Output . . . Character: 1
Oxygenation . . . Character: 2
Pacing . . . Character: 3
Rhythm . . . Character: 4
Ventilation . . . Character: 5

EXAMPLE
5A2204Z Restoration of heart rhythm, single event (performing CPR)

Character Position 7: Qualifier

Character Position Character Meaning
1 Section of the ICD-10-PCS book
2 Physiological system
3 Root operation term
4 Body system
5 Duration
6 Function
7 Qualifier
When a device or piece of equipment is used in the provision of the extracorporeal Extracorporeal
assistance or performance, the Qualifier will specify what was used: Outside of the body.

Balloon Pump . . . Character: 0

Hyperbaric . . . Character: 1
Manual . . . Character: 2
Membrane . . . Character: 3
Nonmechanical . . . Character: 4
Pulsatile Compression . . . Character: 5
Other Pump . . . Character: 6
Continuous Positive Airway Pressure (CPAP) . . . Character: 7
Intermittent Positive Airway Pressure (IPAP) . . . Character: 8
Continuous Negative Airway Pressure (CNAP) . . . Character: 9
Intermittent Negative Airway Pressure (INAP) . . . Character: B
Supersaturated . . . Character: C
Impeller Pump . . . Character: D
No Qualifier . . . Character: Z

ICD-10-PCS
LET’S CODE IT! SCENARIO
Linus Garza, a 63-year-old male, was in the hospital for surgery on his leg. During Linus’s admission, Dr. Reagan
ordered a CPAP machine to treat Linus’s obstructive sleep apnea, only at night.

Let’s Code It!

Let’s go through the steps of coding for ICD-10-PCS and determine the code or codes that should be reported
for this encounter between Dr. Reagan and Linus Garza for the CPAP treatment.

(continued)

CHAPTER 35  | 
 You already learned that extracorporeal means “outside of the body.” You also need to know how a CPAP
machine works.
First character: Section: Extracorporeal or Systemic Assistance and Performance . . . 5
There is only one body system option for this section.
Second character: Body System: Physiological Systems . . . A
A CPAP machine helps the body’s breathing; it does not breathe for the patient. Therefore, assistance is the
appropriate root operation term.
Third character: Root Operation: Assistance . . . 0
The CPAP assists the patient’s breathing, so this is the Respiratory system.
Fourth character: Body System: Respiratory . . . 9
How long was Linus to be using the CPAP continuously? The documentation states, “only at night,” therefore,
less than 24 hours.
Fifth character: Duration: Less than 24 Consecutive Hours . . . 3
There is only one option for the sixth character, but it fits because ventilation, in health care, is breathing.
Sixth character: Function: Ventilation . . . 5
What does CPAP stand for?
Seventh character: Qualifier: Continuous Positive Airway Pressure . . . 7
The ICD-10-PCS code you will report is:
5A09357 CPAP ventilation, less than 24 consecutive hours
Good job!

35.5  Reporting Services from the

Extracorporeal or Systemic Therapies Section
Character Definitions
The meanings for the Extracorporeal or Systemic Therapies Section characters are
shown in the following table:

Character Position Character Meaning

1 Section of the ICD-10-PCS book
2 Physiological systems
3 Root operation
4 Body system
5 Duration
6 Qualifier
7 Qualifier

For the most part, the character positions for the Extracorporeal or Systemic Thera-
pies Section have similar meanings as in the other sections about which you have

1058   PART V  |  INPATIENT (HOSPITAL) REPORTING

already learned. The difference between the procedures reported from this section and
those from the Extracorporeal or Systemic Assistance and Performance Section is
that these therapies do not involve the process of assisting a physiological function or
performing that function for the body.

Character Position 1: Extracorporeal or

Systemic Therapies Section 6
Character Position Character Meaning
1 Section of the ICD-10-PCS book
2 Physiological systems
3 Root operation
4 Body system
5 Duration
6 Qualifier
7 Qualifier

Procedures reported from the Extracorporeal or Systemic Therapies Section will all
begin with the number 6.

Character Position 2: Physiological Systems

Character Position Character Meaning
1 Section of the ICD-10-PCS book
2 Physiological systems
3 Root operation
4 Body system
5 Duration
6 Qualifier
7 Qualifier

There is only one option for the second character:

Physiological Systems . . . Character: A

Character Position 3: Root Operation

Character Position Character Meaning
1 Section of the ICD-10-PCS book
2 Physiological systems
3 Root operation
4 Body system
5 Duration
6 Qualifier
7 Qualifier

There are 11 root operation terms used to report procedures in this section.

CHAPTER 35  | 
 Atmospheric Control: Extracorporeal control of atmospheric pressure and com-
position . . . Character: 0
Decompression: Extracorporeal elimination of undissolved gas from body fluids
. . . Character: 1
Electromagnetic Therapy: Extracorporeal treatment by electromagnetic rays
. . . Character: 2
Hyperthermia: Extracorporeal raising of body temperature . . . Character: 3
Hypothermia: Extracorporeal lowering of body temperature . . . Character: 4
Pheresis: Extracorporeal separation of blood products . . . Character: 5
Phototherapy: Extracorporeal treatment by light rays . . . Character: 6
Ultrasound Therapy: Extracorporeal treatment by ultrasound . . . Character: 7
Ultraviolet Light Therapy: Extracorporeal treatment by ultraviolet light . . . 
Character: 8
Shock Wave Therapy: Extracorporeal treatment by shock waves . . . Character: 9
Perfusion: Extracorporeal treatment by diffusion of therapeutic fluid . . .
Character: B

∙ The root operation term decompression is specific to a hyperbaric chamber used

for treating decompression sickness, also known as the bends.
∙ When a hyperthermic procedure is used to treat a temperature imbalance, this is
the section from which to report the code. However, if hyperthermia is used as an
adjunct radiation treatment for a malignancy, this procedure is reported from the
Radiation Oncology Section (D).
∙ The procedure pheresis is used primarily for two purposes: (1) to treat a condition
during which too much of a specific blood component is produced by the body
(such as leukemia) and (2) to remove a blood product from donor blood for purposes
of transfusion to another patient, such as platelets.
∙ The phototherapy process removes blood from the patient into a machine that
exposes that blood to light rays, recirculates it, and then returns this blood to the
body.
∙ Note that Shock Wave Therapy is placed in the Tables section in numeric order (fol-
lowing table 8, Ultraviolet Light Therapy) and not in alphabetic order.

Character Position 4: Body System

Character Position Character Meaning
1 Section of the ICD-10-PCS book
2 Physiological systems
3 Root operation
4 Body system
5 Duration
6 Qualifier
7 Qualifier

The specific body systems being supported by these procedures are

Skin . . . Character: 0
Urinary . . . Character: 1
Central Nervous . . . Character: 2
Musculoskeletal . . . Character: 3
Circulatory . . . Character: 5
Respiratory System . . . Character: B

1060   PART V  |  INPATIENT (HOSPITAL) REPORTING

 Hepatobiliary System and Pancreas . . . Character: F
Urinary System . . . Character: T
None . . . Character: Z
Therapies such as atmospheric control, hyperthermia, and hypothermia are per-
formed on the entire body and, therefore, have a body system of Z None.

Character Position 5: Duration

Character Position Character Meaning
1 Section of the ICD-10-PCS book
2 Physiological systems
3 Root operation
4 Body system
5 Duration
6 Qualifier
7 Qualifier
The fifth character position will report the length of time, or the number of times, the
patient received this treatment:
Single . . . Character: 0 [one time or one session]
Multiple . . . Character: 1 [more than one time or one session]

Character Position 6: Qualifier

Character Position Character Meaning
1 Section of the ICD-10-PCS book
2 Physiological systems
3 Root operation
4 Body system
5 Duration
6 Qualifier
7 Qualifier
In this character position, there is one option for the 6AB Perfusion Table:
Donor Organ . . . Character: B
For all other Tables in this section, you have one option:
No Qualifier . . . Character: Z

Character Position 7: Qualifier

Character Position Character Meaning
1 Section of the ICD-10-PCS book
2 Physiological systems
3 Root operation
4 Body system
5 Duration
6 Qualifier
7 Qualifier

CHAPTER 35  | 
 When pheresis is performed, the Qualifier will specify what was used:
Erythrocytes . . . Character: 0
Leukocytes . . . Character: 1
Platelets . . . Character: 2
Plasma . . . Character: 3
Stem Cells, Cord Blood . . . Character: T
Stem Cells, Hematopoietic . . . Character: V
Ultrasound therapies performed on the circulatory system will utilize a Qualifier char-
acter to identify which specific vessels are being treated, when applicable:
Head and Neck Vessels . . . Character: 4
Heart . . . Character: 5
Peripheral Vessels . . . Character: 6
Other Vessels . . . Character: 7
No Qualifier . . . Character: Z
All other root operation terms (therapies) reported from this section have only one
option:
No Qualifier . . . Character: Z

ICD-10-PCS
LET’S CODE IT! SCENARIO
Nathan Teeger, a 17-year-old male, was out walking near the ski resort where he was vacationing. He fell into a soft
bed of snow and could not get out. The ski patrol took 5 hours to find him. At the hospital, Dr. Golden used hyperther-
mia to warm his body gently back to normal temperature. A single treatment was sufficient.

Let’s Code It!

Let’s go through the steps of coding for ICD-10-PCS and determine the code or codes that should be reported
for this encounter between Dr. Golden and Nathan Teeger for this therapy.
Hyperthermia, from outside of Nathan’s body, was used to help improve Nathan’s health. You learned that this
means it is a therapeutic procedure. Therefore, Extracorporeal or Systemic Therapies will be the section from
which you will report the code for this procedure.
First character: Section: Extracorporeal or Systemic Therapies . . . 6
There is only one option for body system in this section.
Second character: Body Region: Physiological Systems . . . A
The documentation states, “used hyperthermia.”
Third character: Root Operation: Hyperthermia . . . 3
Fourth character: Body System: None . . . Z
How many times did Dr. Golden use hyperthermia to treat Nathan? The documentation states, “A single
treatment. . . .”
Fifth character: Duration: Single . . . 0
Sixth character: Qualifier: None . . . Z
Seventh character: Qualifier: None . . . Z
The ICD-10-PCS code you will report is
6A4Z0ZZ Hyperthermia for temperature imbalance
Good job!

1062   PART V  |  INPATIENT (HOSPITAL) REPORTING

35.6  Reporting Osteopathic Services
Character Definitions
The meanings for the Osteopathic Section characters are shown in the following
table:

Character Position Character Meaning

1 Section of the ICD-10-PCS book
2 Anatomical regions
3 Root operation term
4 Body region
5 Approach
6 Method
7 Qualifier

The Osteopathic Section is very direct and straightforward.

Character Position 1: Osteopathic Section 7

Character Position Character Meaning
1 Section of the ICD-10-PCS book
2 Anatomical regions
3 Root operation term
4 Body region
5 Approach
6 Method
7 Qualifier

Procedures reported from the Osteopathic Section will all begin with the
number 7.

Character Position 2: Anatomical Regions

Character Position Character Meaning
1 Section of the ICD-10-PCS book
2 Anatomical regions
3 Root operation term
4 Body region
5 Approach
6 Method
7 Qualifier

There is only one option for the second character:

Anatomical Regions . . . Character: W

CHAPTER 35  | 
 Character Position 3: Root Operation
Character Position Character Meaning
1 Section of the ICD-10-PCS book
2 Anatomical regions
3 Root operation term
4 Body region
5 Approach
6 Method
7 Qualifier

There is only one root operation used when reporting osteopathic services:
Somatic Treatment: Manual treatment to eliminate or alleviate somatic dysfunction and
Related to the body, espe- related disorders . . . Character: 0
cially separate from the brain
or mind.
EXAMPLE
7W03X2Z General mobilization of the lumbar region

Character Position 4: Body Region

Character Position Character Meaning
1 Section of the ICD-10-PCS book
2 Anatomical regions
3 Root operation term
4 Body region
5 Approach
6 Method
7 Qualifier

The specific body regions supported by osteopathic services are

Head . . . Character: 0
Cervical . . . Character: 1
Thoracic . . . Character: 2
Lumbar . . . Character: 3
Sacrum . . . Character: 4
Pelvis . . . Character: 5
Lower Extremities . . . Character: 6
Upper Extremities . . . Character: 7
Rib Cage . . . Character: 8
Abdomen . . . Character: 9

EXAMPLE
7W06X8Z Isotonic muscle energy application to lower extremities

1064   PART V  |  INPATIENT (HOSPITAL) REPORTING

Character Position 5: Approach
Character Position Character Meaning
1 Section of the ICD-10-PCS book
2 Anatomical regions
3 Root operation term
4 Body region
5 Approach
6 Method
7 Qualifier
All osteopathic services use an external approach, reported with character X.

Character Position 6: Method

Character Position Character Meaning
1 Section of the ICD-10-PCS book
2 Anatomical regions
3 Root operation term
4 Body region
5 Approach
6 Method
7 Qualifier
In this character position, you will identify the specific method used by the doctor dur-
ing this session:
Articulatory-Raising . . . Character: 0
Facial Release . . . Character: 1
General Mobilization . . . Character: 2
High Velocity–Low Amplitude . . . Character: 3
Indirect . . . Character: 4
Low Velocity–High Amplitude . . . Character: 5
Lymphatic Pump . . . Character: 6
Muscle Energy—Isometric . . . Character: 7
Muscle Energy—Isotonic . . . Character: 8
Other Method . . . Character: 9

EXAMPLE
7W05X4Z Indirect treatment of the pelvic region

Character Position 7: Qualifier

Character Position Character Meaning
1 Section of the ICD-10-PCS book
2 Anatomical regions
3 Root operation term
4 Body region
5 Approach
6 Method
7 Qualifier

CHAPTER 35  | 
 There is only one option for this character in the Osteopathic Section:
No Qualifier . . . Character: Z

ICD-10-PCS
LET’S CODE IT! SCENARIO
Diane DeLucca, a 39-year-old female, was admitted due to a nerve condition in her face. After the results of the
tests were analyzed, Dr. Slack diagnosed her with Bell’s palsy. Dr. Slack, an osteopath, performed a facial release.

Let’s Code It!

Let’s go through the steps of coding for ICD-10-PCS and determine the code or codes that should be reported
for this encounter between Dr. Slack and Diane DeLucca for this treatment.
There is nothing related to facial release in the Alphabetic Index. The best clue you have here is that Dr. Slack
is an osteopath. For this section, you will find only one option presented for each of the first three characters.
First character: Section: Osteopathic . . . 7
Second character: Anatomical Regions . . . W
Third character: Root Operation: Treatment . . . 0
The treatment was applied to Diane’s face; however, this is not one of the options provided for the fourth char-
acter. There is one option that is close.
Fourth character: Body System: Head . . . 0
There is only one option for the fifth character.
Fifth character: Approach: External . . . X
What method did Dr. Slack use? The documentation states, “a facial release.”
Sixth character: Method: Facial Release . . . 1
Seventh character: Qualifier: None . . . Z
The ICD-10-PCS code you will report is
7W00X1Z Facial release
Good job!

35.7  Reporting from the Other

Procedures Section
Character Definitions
The meanings for the Other Procedures Section characters are shown in the follow-
ing table:

Character Position Character Meaning

1 Section of the ICD-10-PCS book
2 Body system
3 Root operation term
4 Body region
5 Approach
6 Method
7 Qualifier

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For the most part, the character positions for the Other Procedures Section have
similar meanings as in the other sections about which you have already learned.

Character Position 1: Other Procedures Section 8

Character Position Character Meaning
1 Section of the ICD-10-PCS book
2 Body system
3 Root operation term
4 Body region
5 Approach
6 Method
7 Qualifier

Procedures reported from the Other Procedures Section all begin with the number 8.

Character Position 2: Body System

Character Position Character Meaning
1 Section of the ICD-10-PCS book
2 Body system
3 Root operation term
4 Body region
5 Approach
6 Method
7 Qualifier

There are only two options for the second character:

Indwelling Device . . . Character: C
Physiological Systems and Anatomical Regions . . . Character: E

Character Position 3: Root Operation

Character Position Character Meaning
1 Section of the ICD-10-PCS book
2 Body system
3 Root operation term
4 Body region
5 Approach
6 Method
7 Qualifier

There is just one root operation term used to report procedures in this section.
Other Procedures: Methodologies that attempt to remediate or cure a disorder or
disease . . . Character: 0

CHAPTER 35  | 
 EXAMPLE
8C01X6J Collection of cerebrospinal fluid

Character Position 4: Body Region

Character Position Character Meaning
1 Section of the ICD-10-PCS book
2 Body system
3 Root operation term
4 Body region
5 Approach
6 Method
7 Qualifier

There are several body regions represented in this section.

EXAMPLE
Nervous System . . . Character: 1
Circulatory System . . . Character: 2
Head and Neck Region . . . Character: 9
Integumentary System and Breast . . . Character: H
Lower Extremity . . . Character: Y

Character Position 5: Approach

Character Position Character Meaning
1 Section of the ICD-10-PCS book
2 Body system
3 Root operation term
4 Body region
5 Approach
6 Method
7 Qualifier

The fifth character position, reporting the approach, will provide you with options
with which you have become familiar: 0 Open, 3 Percutaneous, 4 Percutaneous Endo-
scopic, 7 Via Natural or Artificial Opening, 8 Via Natural or Artificial Opening Endo-
scopic, and X External.

EXAMPLE
8E0W8CZ Procedure on trunk region, via natural or artificial opening
endoscopic, robotic-assisted

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Character Position 6: Method
Character Position Character Meaning
1 Section of the ICD-10-PCS book
2 Body system
3 Root operation term
4 Body region
5 Approach
6 Method
7 Qualifier
In this character position, you will identify the method employed during this procedure:
Acupuncture . . . Character: 0
Therapeutic Massage . . . Character: 1
Collection . . . Character: 6
Computer Assisted Procedure . . . Character: B
Robotic Assisted Procedure . . . Character: C
Near Infrared Spectroscopy . . . Character: D
Other Method . . . Character: Y

Character Position 7: Qualifier

Character Position Character Meaning
1 Section of the ICD-10-PCS book
2 Body system
3 Root operation term
4 Body region
5 Approach
6 Method
7 Qualifier
The Qualifier will provide additional details as available or necessary.
You can see from this list, the Qualifier options range from anesthesia to in vitro
fertilization to the use of imaging.

Anesthesia . . . Character: 0
In Vitro Fertilization . . . Character: 1
Breast Milk . . . Character: 2
Sperm . . . Character: 3
Yoga Therapy . . . Character: 4
Meditation . . . Character: 5
Isolation . . . Character: 6
Examination . . . Character: 7
Suture Removal . . . Character: 8
Piercing . . . Character: 9
Prostate . . . Character: C
Rectum . . . Character: D
With Fluoroscopy . . . Character: F
With Computerized Tomography . . . Character: G
With Magnetic Resonance Imaging . . . Character: H
No Qualifier . . . Character: Z

CHAPTER 35  | 
 ICD-10-PCS
LET’S CODE IT! SCENARIO
Gillian Petrovic, a 31-year-old female, just gave birth via c-section. The nurse provided a pump so that Gillian could
collect breast milk for the baby.

Let’s Code It!

Let’s go through the steps of coding for ICD-10-PCS and determine the code or codes that should be reported
for this procedure.
This is not a typical type of hospital procedure, so that might give you a good hint to start with this section,
Other Procedures.
First character: Section: Other Procedures . . . 8
There are two options for the second character: Indwelling Device or Physiological Systems and Anatomical
Regions. Gillian does not have an indwelling device related to this service, so this leaves one option.
Second character: Physiological Region: Physiological System and Anatomic Regions . . . E
There is only one option for the third character.
Third character: Root Operation: Other procedures . . . 0
Don’t decide too quickly for the body region. A woman’s breast is considered part of the integumentary system,
not the female reproductive system.
Fourth character: Body Region: Integumentary System and Breast . . . H
Pumping breast milk is done from outside of the body.
Fifth character: Approach: External . . . X
The pump “collects” the milk.
Sixth character: Method: Collection . . . 6
The qualifier explains what is being collected.
Seventh character: Qualifier: Breast Milk . . . 2
The ICD-10-PCS code you will report is
8E0HX62 Collection of breast milk
Good job!

35.8  Reporting Inpatient Chiropractic

Services
Character Definitions
The meanings for the Chiropractic Section characters are shown in the following table:

Character Position Character Meaning

1 Section of the ICD-10-PCS book
2 Anatomical regions
3 Root operation term
4 Body region
5 Approach
6 Method
7 Qualifier
The Chiropractic Section is very direct and straightforward.

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Character Position 1: Chiropractic Section 9
Character Position Character Meaning
1 Section of the ICD-10-PCS book
2 Anatomical regions
3 Root operation term
4 Body region
5 Approach
6 Method
7 Qualifier
Procedures reported from the Chiropractic Section will all begin with the number 9.

Character Position 2: Anatomical Regions

Character Position Character Meaning
1 Section of the ICD-10-PCS book
2 Anatomical regions
3 Root operation term
4 Body region
5 Approach
6 Method
7 Qualifier
There is only one option for the second character:
Anatomical Regions . . . Character: W

Character Position 3: Root Operation

Character Position Character Meaning
1 Section of the ICD-10-PCS book
2 Anatomical regions
3 Root operation term
4 Body region
5 Approach
6 Method
7 Qualifier

There is only one root operation used when reporting chiropractic services:
Manipulation: Manual procedure that involves a directed thrust to move a joint
past the physiological range of motion, without exceeding the anatomical
limit . . . Character: B

EXAMPLE
9WB1XBZ Non-manual manipulation of the cervical region

CHAPTER 35  | 
 Character Position 4: Body Region
Character Position Character Meaning
1 Section of the ICD-10-PCS book
2 Anatomical regions
3 Root operation term
4 Body region
5 Approach
6 Method
7 Qualifier

The specific body regions supported by chiropractic services are:

Head . . . Character: 0
Cervical . . . Character: 1
Thoracic . . . Character: 2
Lumbar . . . Character: 3
Sacrum . . . Character: 4
Pelvis . . . Character: 5
Lower Extremities . . . Character: 6
Upper Extremities . . . Character: 7
Rib cage . . . Character: 8
Abdomen . . . Character: 9

EXAMPLE
9WB7XKZ Manipulation of upper extremities, externally, with mechanical
assistance

Character Position 5: Approach

Character Position Character Meaning
1 Section of the ICD-10-PCS book
2 Anatomical regions
3 Root operation term
4 Body region
5 Approach
6 Method
7 Qualifier

All chiropractic services use an external approach, reported with character X.

Character Position 6: Method

Character Position Character Meaning
1 Section of the ICD-10-PCS book
2 Anatomical regions
3 Root operation term

1072   PART V  |  INPATIENT (HOSPITAL) REPORTING

 Character Position Character Meaning
4 Body region
5 Approach
6 Method
7 Qualifier
In this character position, you will identify the specific method used by the doctor dur-
ing this session:
Non-manual . . . Character: B
Indirect Visceral . . . Character: C
Extra-Articular . . . Character: D Extra-Articular
Direct Visceral . . . Character: F Located outside a joint.
Long Lever Specific Contact . . . Character: G
Short Lever Specific Contact . . . Character: H
Long and Short Lever Specific Contact . . . Character: J
Mechanically Assisted . . . Character: K
Other Method . . . Character: L

EXAMPLE
9WB4XFZ Manipulation of sacrum, external direct visceral method

Character Position 7: Qualifier

Character Position Character Meaning
1 Section of the ICD-10-PCS book
2 Anatomical regions
3 Root operation term
4 Body region
5 Approach
6 Method
7 Qualifier
There is only one option for this character in the Chiropractic Section:
No Qualifier . . . Character: Z

ICD-10-PCS
LET’S CODE IT! SCENARIO
Ethan Logan, a 49-year-old male, works in a warehouse and hurt his back. He was admitted into the hospital for
tests to determine the extent of the injury. While in the hospital, Dr. Maggun, a chiropractor, performed mechanically
assisted manipulation on his lumbar region.

You Code It!

Let’s go through the steps of coding for ICD-10-PCS and determine the code or codes that should be reported
for this encounter between Dr. Maggun and Ethan Logan.
The documentation tells you that Dr. Maggun is a chiropractor, so this is a good reason to turn to the Chiro-
practic section of ICD-10-PCS.

(continued)

CHAPTER 35  | 
 You will find only one option for each of the first three characters in this section.
First character: Section: Chiropractic . . . 9
Second character: Body Region: Anatomical Regions . . . W
Third Character: Root Operation: Manipulation . . . B
What region of Ethan’s body did Dr. Maggun treat?
Fourth character: Body Region: Lumbar . . . 3
There is only one option here for the fifth character, and it works because chiropractic treatments are done from
outside the body.
Fifth character: Approach: External . . . X
What method did Dr. Maggun use on Ethan? The documentation states, “mechanically assisted. . . .”
Sixth character: Method: Mechanically Assisted . . . K
Seventh character: Qualifier: None . . . Z
The ICD-10-PCS code you will report is
9WB3XKZ Chiropractic manipulation of the lumbar region using mechanical assistance
Good job!

35.9  Sections 2–9: Putting It All Together

Throughout this chapter, you have learned about each of the seven components of an
ICD-10-PCS code used to report a procedure, service, or treatment from these sec-
tions. Now, let’s put it all together and determine some codes all the way through.

ICD-10-PCS
LET’S CODE IT! SCENARIO
PATIENT: ALEX RENETTA
DATE OF ADMISSION: 06/14/2018
ADMITTING DIAGNOSIS: Crush fracture of left lower leg and foot
PAIN MANAGEMENT: The patient has stated that he is in severe pain. However, he is a recovering drug addict,
clean 7 years, and will not accept any narcotics.
Dr. Donnatelli, an acupuncture physician, came in and used acupuncture methodologies to result in anesthesia
effect for the left extremity. The patient was relieved by the treatment and the orthopedic surgeon was able to
manipulate and cast the leg.
Code for Dr. Donnatelli.

Let’s Code It!

Dr. Donnatelli used acupuncture to administer anesthesia so Alex could have his injury treated. As per the ICD-
10-PCS Alphabetic Index, this is reported from the Other Procedures section.
First character: Section: Other Procedures . . . 8
Second character: Physiological Systems and Anatomical Regions . . . E
Third character: Root Operation: Other Procedures . . . 0
Remember that anesthesia is a process that stops the transmission through the nervous system . . .

1074   PART V  |  INPATIENT (HOSPITAL) REPORTING

 Fourth character: Body Region: Nervous System . . . 1
Acupuncture is performed by inserting tiny needles gently into the epidermis.
Fifth character: Approach: Percutaneous . . . 3
Sixth character: Method: Acupuncture . . . 0
Seventh character: Qualifier: Anesthesia . . . 0
Put it all together and report code . . .
8E01300 Anesthesia administered using acupuncture methodologies
Good job!

ICD-10-PCS
LET’S CODE IT! SCENARIO
PATIENT: TRAVIS CLAYTON
PREOPERATIVE DIAGNOSES:
1. C5–6 facet fracture
2. Left C6 radiculitis
POSTOPERATIVE DIAGNOSES:
1. C5–6 facet fracture
2. Left C6 radiculitis
OPERATIONS PERFORMED:
Attempted closed reduction of vertebral fracture and subluxation with traction.
OPERATION: The patient was taken to the OR and placed in the supine position. Using 1% lidocaine and antibiotic
ointment, Gardner-Wells tongs were placed in line with the external auditory meatus approximately a centimeter
above the ear. The anesthesiologist, Dr. Mastrioni, administered conscious sedation. The patient tolerated the
placement of tongs very well.
Ten pounds of traction were then added and a lateral C-arm image obtained, which showed persistent subluxation.
Manual traction was then applied and maneuvers attempted with rotation as well as flexion and extension in an attempt to
reduce the fracture. However, persistent subluxation was noted, and the decision was made to proceed with open reduction.
The patient was then administered general anesthetic with use of in-line traction. SSEP and EMG monitoring leads
were placed. A Foley catheter was in place. Preoperative antibiotics were administered. SCDs were applied. The
patient’s arms were tucked to the side. The cervical spine and the left anterior iliac crests were prepped and draped
in the standard sterile fashion.

Let’s Code It!

Read the documentation of this procedure, and let’s take it step by step, one character at a time, to build the
correct code:
Traction is . . . placed onto the body, so . . .
First character: Section: Placement . . . 2
The neck is not an orifice, so you have one choice:
Second character: Anatomical Regions . . . W
Third character: Root Operation: Traction . . . 6
In this case, it may be easiest to look at the diagnosis to identify the specific body region being treated. The
documentation states, “C5–6 facet fracture,” which is in the neck.

(continued)

CHAPTER 35  | 
 Fourth character: Body Region: Neck . . . 2
Fifth character: Approach: External . . . X
Sixth character: Device: Traction Device . . . 0
Seventh character: Qualifier: No Qualifier . . . Z
Now, put it all together and report this ICD-10-PCS code:
2W62X0Z Traction apparatus, neck
Good job!

ICD-10-PCS
LET’S CODE IT! SCENARIO
Bruce Diaz, a 73-year-old male, was in a car accident and was admitted into the hospital with a concussion and
a fractured shoulder. His recent medical history reveals reduced renal function, so Dr. Wester ordered a session of
dialysis, to be done bedside. Teena Strunk came up with a mobile unit and performed the hemodialysis.

Let’s Code It!

Bruce had one hemodialysis session provided to him, bedside. Hemodialysis is when a machine does the job of
filtering the blood because the kidneys are not functioning properly. Turn to the ICD-10-PCS Alphabetic Index
and find
Hemodialysis 5A1D00Z
Remember, even though the Alphabetic Index has provided you with a complete code, you are required to
check all seven characters in the Tables section. Turn to the 5A1 Table:
First character: Section: Extracorporeal or Systemic Assistance and Performance . . . 5
Second character: Physiological Systems . . . A
The machine is taking over the function of the kidney, so this is the root operation term: Performance.
Third character: Root Operation: Performance . . . 1
Fourth character: Body System: Urinary . . . D
Fifth character: Duration: Single . . . 0
Sixth character: Function: Filtration . . . 0
Seventh character: Qualifier: No Qualifier . . . Z
Now put it all together and report this code, with confidence:
5A1D00Z External filtration of the urinary system, single session
Good work!

Chapter Summary
This chapter has given you the opportunity to walk through the Placement (2),
Administration (3), Measurement and Monitoring (4), Extracorporeal or Sys-
temic Assistance and Performance (5), Extracorporeal or Systemic Therapies (6),
Osteopathic (7), Other Procedures (8), and Chiropractic (9) sections of ICD-10-
PCS. You have seen how each character position is important to reporting all of the
pertinent details of a procedure, service, or treatment. You have learned that, in each
section, the same character can have a different meaning. However, you always have
the tables there to provide the options and their meanings to build the accurate code.

1076   PART V  |  INPATIENT (HOSPITAL) REPORTING

 CHAPTER 35 REVIEW
CODING BITES
Placement Section codes report procedures that put a device in or on an ana-
tomical site.
Administration Section codes report procedures and services that introduce
a therapeutic, prophylactic, protective, diagnostic, nutritional, or physiological
substance.
Measurement and Monitoring Section codes report those procedures that are
done to determine a level of physiological or physical function.
Extracorporeal or Systemic Assistance and Performance Section codes report
the use of equipment to support or actually perform a physiological function from
the outside of the body.
Extracorporeal or Systemic Therapies Section codes report the use of equipment
(machines) for a therapeutic purpose—other than assisting or performing a physi-
ological function.
Osteopathic Section codes report the provision of osteopathic manipulative
treatments.
Other Procedures Section codes report services including, but not limited to, acu-
puncture, in vitro fertilization, or simple suture removal.
Chiropractic Section codes report the provision of chiropractic manipulative
therapies.

CHAPTER 35 REVIEW
Placement through Chiropractic Enhance your learning by
completing these exercises and
more at connect.mheducation.com!

Sections
Let’s Check It! Terminology
Match each key term to the appropriate definition.
1. LO 35.4  Outside of the body. A. Administration
2. LO 35.1  To place a device in or on an anatomical site. B. Extra-articular
3. LO 35.3  To determine a level of a physiological or physical function. C. Extracorporeal
4. LO 35.6  Related to the body, especially separate from the brain or mind. D. Measurement
5. LO 35.8  Located outside a joint E. Placement
6. LO 35.2  To introduce a therapeutic, prophylactic, protective, diagnostic, nutri- F. Somatic
tional, or physiological substance.

Let’s Check It! Concepts

Part I: Placement (2), Administration (3), Measurement &
Monitoring (4)
Choose the most appropriate answer for each of the following questions.
1. LO 35.1  Within the Placement Section, character position 2 Anatomical Region/Orifices, Anatomical Orifices is
identified by which character?
a. Y b.  W c.  X d.  Z

CHAPTER 35  | 
 2. LO 35.1  Within the Placement Section, character position 3 Root Operation, Putting pressure on a body region
CHAPTER 35 REVIEW

(identified with number 1), is which of the following?

a. Dressing b.  Immobilization
c. Compression d.  Traction
3. LO 35.1  Within the Placement Section, character position 4 Body Region/Orifice, the upper extremity, right, is
identified by which character or number?
a. A b.  8
c. C d.  9
4. LO 35.1  Within the Placement Section, character position 5 Approach, which is the correct approach?
a. Open b.  Percutaneous
c. Via natural or artificial opening d.  External
5. LO 35.1  Johnny was playing at school and fractured his left arm. Dr. Keller applied a cast to Johnny’s left arm.
Within the Placement Section, character position 6 Device, what number identifies the cast?
a. 1 b.  2
c. 3 d.  4
6. LO 35.2  All procedures reported from the Administration Section will begin with which section number?
a. 1 b.  2
c. 3 d.  4
7. LO 35.2  Within the Administration Section, character position 2 Physiological System/Anatomical Region, an
indwelling device would be identified with which character or number?
a. 0 b.  C
c. E d.  X
8. LO 35.2  A blood transfusion would be reported from which section?
a. Obstetrics b.  Placement
c. Administration d.  Measurement and Monitoring
9. LO 35.2  Within the Administration Section, character position 4 Body System/Region, when an irrigating sub-
stance (such as saline solution) is administered into an indwelling device (reported as body system
Indwelling Device . . . C), the body system/region will be reported with which character?
a. Z b.  X
c. C d.  G
10. LO 35.2  Within the Administration Section, character position 7 Qualifier, Oxazolidinones is reported with
which character or number?
a. 1 b.  Z
c. 8 d.  X
11. LO 35.3  Within the Measurement and Monitoring Section, character position 6 represents which of the
following?
a. Physiological system b.  Body system
c. Function/device d.  Qualifier
12. LO 35.3  Within the Measurement and Monitoring Section, character position 2, a physiological device would be
represented by which of the following character or numbers?
a. A b.  1
c. B d.  2

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 13. LO 35.3  Within the Measurement and Monitoring Section, character position 3 Root Operation, determining the level

CHAPTER 35 REVIEW
of a physiological or physical function repetitively over a period of time (identified by number 1) is known as
a. an abortifacient. b.  monitoring.
c. measurement. d.  laminaria.
14. LO 35.3  Within the Measurement and Monitoring Section, character position 6, measuring a patient’s tempera-
ture would be reported with which character?
a. F b.  S
c. Q d.  K
15. LO 35.3  Within the Measurement and Monitoring Section, character position 6, a sleep study would be reported
with which character?
a. B b.  Q
c. X d.  Z

Part II: Extracorporeal or Systemic Assistance and Performance (5),

Extracorporeal or Systemic Therapies (6), Osteopathic (7), Other Pro-
cedures (8), and Chiropractic (9) Sections
1. LO 35.4  Within the Extracorporeal or Systemic Assistance and Performance Section, character position 6 repre-
sents which of the following?
a. Body system b.  Root operation term
c. Duration d.  Function
2. LO 35.4  Which of these is a term meaning “outside the body”?
a. Phototherapy b.  Extracorporeal
c. Extra-articular d.  Somatic
3. LO 35.4  All of the Extracorporeal or Systemic Assistance and Performance procedures will begin with which
section number?
a. 5 b.  4
c. 2 d.  1
4. LO 35.4  Within the Extracorporeal or Systemic Assistance and Performance Section, character position 3 Root
Operation, all of the following are root operation terms except
a. assistance. b.  performance.
c. manipulation. d.  restoration.
5. LO 35.5  Within the Extracorporeal or Systemic Therapies Section, character position 5 represents which of the
following?
a. Body system b.  Root operation term
c. Duration d.  Function
6. LO 35.5  Within the Extracorporeal or Systemic Therapies Section, character position 3 Root Operation, which of
the following is/are a root operation term(s)?
a. Atmospheric control b.  Hypothermia
c. Pheresis d.  All of these
7. LO 35.5  Within the Extracorporeal or Systemic Therapies Section, character position 4 Body System, number 3
represents which of the following?
a. Urinary b.  Central nervous
c. Musculoskeletal d.  Circulatory

CHAPTER 35  | 
 8. LO 35.5  Within the Extracorporeal or Systemic Therapies Section, character position 7 Qualifier, ultrasound ther-
CHAPTER 35 REVIEW

apies performed on the circulatory system, peripheral vessels, would be reported with which character or
number?
a. 6 b.  X
c. 5 d.  Z
9. LO 35.6  Within the Osteopathic Section, character position 6 represents which of the following?
a. Anatomical region b.  Method
c. Body region d.  Qualifier
10. LO 35.6  All of the Osteopathic Section procedures will begin with which section number?
a. 5 b.  4
c. 7 d.  1
11. LO 35.6  Within the Osteopathic Section, which of the following is an option for character position 3 Root Operation?
a. Treatment b.  Manipulation
c. Phototherapy d.  Electromagnetic therapy
12. LO 35.6  Within the Osteopathic Section, character position 6, which number identifies low velocity–high amplitude?
a. 0 b.  3
c. 5 d.  8
13. LO 35.7  All of the Other Procedures Section procedures will begin with which section number?
a. 5 b.  8
c. 7 d.  9
14. LO 35.7  Within the Other Procedures Section, character position 2 Body System, an indwelling device is identi-
fied with which of the following characters?
a. H b.  E
c. Y d.  C
15. LO 35.7  Within the Other Procedures Section, character position 5 Approach, a procedure performed via natural
or artificial opening is identified with which character or number?
a. 7 b.  3
c. 8 d.  X
16. LO 35.7  Within the Other Procedures Section, character position 6 Method, acupuncture would be identified
with which character or number?
a. B b.  6
c. 0 d.  D
17. LO 35.8  All of the Chiropractic Section procedures will begin with which section number?
a. 5 b.  8
c. 7 d.  9
18. LO 35.8  Within the Chiropractic Section, character position 2 Anatomical Regions, you have one option for the
character. Which of the following represents the anatomical regions?
a. B b.  W
c. X d.  Z
19. LO 35.8  Within the Chiropractic Section, character position 5 Approach, you have one option for the character.
Which of the following represents the approach?
a. Open b.  Percutaneous
c. Via natural or artificial opening d.  External

1080   PART V  |  INPATIENT (HOSPITAL) REPORTING

 20. LO 35.8  Within the Chiropractic Section, character position 6 Method, a long and short lever specific contact

CHAPTER 35 REVIEW
will be reported with which character?
a. G b.  F
c. J d.  L

Let’s Check It! Rules and Regulations

Please answer the following questions from the knowledge you have gained after reading this chapter.
1. LO 35.1  List the seven root operation terms used in the Placement Section, character position 3; explain each
root operation term and include the character that identifies each term.
2. LO 35.2  Within the Administration Section, character position 4, Body System/Region, there is an exception.
What is that exception?
3. LO 35.3  Within the Measurement and Monitoring Section, character position 3, Root Operation, what are the
root operation terms? Include the description and character identifier.
4. LO 35.4  List the seven Extracorporeal or Systemic Assistance and Performance Section character positions;
include each character’s meaning.
5. LO 35.8  Within the Chiropractic Section, character position 1 is identified by what section number?

ICD-10-PCS
YOU CODE IT! Practice
Using the techniques described in this chapter, carefully read through the case studies and determine the most
accurate ICD-10-PCS code(s) for each case study.
1. Marvin Dunham, a 68-year-old male, is admitted to the hospital with a deep laceration to the forehead.
Dr. Wallace applies a pressure dressing to his head to control the bleeding.
2. Tony Botnet, a 62-year-old male, has a nose bleed that will not stop bleeding. Tony’s hemoglobin has
dropped, so he is admitted to the hospital. Dr. Caulkins packed his nasal cavity, external approach, to control
the bleeding.
3. Harry Watson, a 32-year-old male, is admitted to the hospital with a hemoglobin of 5.6 g/dL. Dr. Hanks per-
forms a red blood cell transfusion, peripheral vein, percutaneous, nonautologous.
4. Angela Niles, a 58-year-old female, has been in the hospital for 3 days with a peritoneal cavity indwelling
device. Dr. Adams performs an irrigation of the device with irrigation substance, percutaneous approach.
5. Cynthia Yackey, a 9-year-old female, is admitted to Westward Hospital with an unexplained high fever.
Dr. Hamilton measures Cynthia’s temperature.
6. Steven Wallace, an 18-year-old male, wanted to join his college’s football team. The team physical examina-
tion revealed a cardiac abnormality. Steven is admitted to Westward Hospital, where Dr. Jefferson monitors
Steven’s total cardiac activity under stress.
7. Meagan Garrison, a 43-year-old female, presents today with shortness of breath and a dry cough. Dr. Mansfield
admits Meagan to the hospital and monitors her respiratory capacity, external approach.
8. Mason Dugan, a 57-year-old male, has been hospitalized for a week. Mason’s lungs were not performing; he
was placed on a respiratory ventilator 5 days ago.
9. Kwakita Sumwalt, a 39-year-old female, presents today in cardiac dysrhythmia. Dr. Tumbokon admits
Kwakita to Westward hospital and restores Kwakita’s normal sinus rhythm.
10. Barbara Bell, a 33-year-old female, has been in the hospital for 4 days. Barbara has been complaining of right
foot pain, so Dr. Harrison performs extracorporeal shockwave therapy, right heel, single treatment.

CHAPTER 35  | 
CHAPTER 35 REVIEW

11. Duncan Bowens, a 64-year-old male, has been hospitalized with diabetic polyneuropathy. He has also been
diagnosed with urinary incontinence. Today Duncan receives a single treatment of electromagnetic therapy
for his incontinence. Code today’s treatment.
12. Kimberly Morgan, a 59-year-old female, was in a car accident and has been hospitalized for 2 days. She is
currently having lower back pain. Today she receives an osteopathic treatment, lumbar region, low velocity–
high amplitude, external approach, to relieve the pain. Code today’s treatment.
13. Twanda Walters, a 34-year-old female diagnosed with trigeminal neuralgia, was admitted to Westward Hos-
pital for stereotacic radiosurgery, which is scheduled for later in the week. Today Twanda is in pain and
receives an acupuncture treatment, integumentary system, percutaneous approach, no qualifier. Code today’s
treatment.
14. Robert Thompson, a 16-year-old male, is admitted to the hospital with severe neck pain. Dr. Bell performs a
chiropractic manipulation of the cervical region, mechanically assisted, external approach, to try and relieve
the pain.
15. Susan Chapman, a 37-year-old female, is having chronic hip pain and has been admitted to Westward Hos-
pital. Dr. Dugan performs a chiropractic manipulation of the pelvic region with long and short lever specific
contact, external approach.

ICD-10-PCS
YOU CODE IT! Application
The following exercises provide practice in abstracting physicians’ notes and learning to work with documenta-
tion from our health care facility, Westward Hospital. These case studies are modeled on real patient encounters.
Using the techniques described in this chapter, carefully read through the case studies and determine the most
accurate ICD-10-PCS code(s) for each case study.

WESTWARD HOSPITAL
591 Chester Road
Masters, FL 33955
DISCHARGE SUMMARY
PATIENT: NATHANSON, MYRA
DATE OF ADMISSION: 05/30/18
DATE OF DISCHARGE: 06/01/18
ADMITTING DIAGNOSIS: Status asthmaticus
DISCHARGE DIAGNOSIS: 1. Status asthmaticus.
2. Bronchiolitis, empirically treated.
CONSULTANTS: None.
BRIEF HISTORY: The patient is a 17-year-old white female with known history of asthma since infancy,
possible environmental allergies, who presented with progressive wheezing and respiratory distress
for the past 2 days. The patient had been doing well on only p.r.n. medications per family’s report. How-
ever, just previous to admission, the patient was exposed to dust and other particles after moving into
a new house. After conservative treatment at home, the patient was brought into the emergency room,
where she did not improve on albuterol, Atrovent treatments, or intravenous steroids immediately. Initial
examination showed tachycardia of 128, rest tachypnea of about 35–40, and inspiratory and expira-
tory wheezes and rhonchi on lung examination. The patient was referred for admission for evaluation of
worsening asthma and possible pneumonia.

1082   PART V  |  INPATIENT (HOSPITAL) REPORTING

 CHAPTER 35 REVIEW
STUDIES: The admission chest x-ray showed clear lungs. Clean catch urine culture showed only mixed
skin flora.
HOSPITAL COURSE:
1. Status asthmaticus: The patient was admitted to the pediatric intensive care unit in moderate to
severe respiratory distress with continuous albuterol treatments, Atrovent treatments q.4 h., Decadron
intravenously, and empiric treatment of respiratory infection with azithromycin intravenously. The patient
responded to this aggressive treatment and within 1 day was transferred to the regular pediatric medi-
cal floor. The patient was afebrile with normal oxygen saturations and appearing much better. Before
discharge, she received asthma education and social counseling along with the family and was con-
nected with social work to help provide a home nebulizer for use.
2. Empiric respiratory infection treatment: The patient did not show any specific indications of pneumo-
nia or bronchitis by lab work; however, her initial physical examination showed possible pneumonia.
She was started on intravenous antibiotics and was transferred to oral antibiotics before discharge.
DISCHARGE DISPOSITION: To home.
DISCHARGE INSTRUCTIONS
ACTIVITY: Ad lib.
DIET: Regular, as appropriate for age.
MEDICATIONS: Zithromax for 2 remaining days, albuterol one dose nebulizer treatment q.i.d. and p.r.n.,
and Flovent 110 mcg two puffs b.i.d.
FOLLOW-UP: Follow up with primary care physician in 1 week.
Benjamin Johnston, MD—2222
556839/mt98328: 06/01/18 09:50:16  T: 06/01/18 12:55:01

Determine the most accurate ICD-10-PCS code(s) for the administration of the medications.

WESTWARD HOSPITAL
591 Chester Road
Masters, FL 33955
DISCHARGE SUMMARY
PATIENT: WARTTEL, JUDITH
DATE OF ADMISSION: 07/15/18
DATE OF SURGERY: 07/29/18
DATE OF DISCHARGE: 08/01/18
ADMITTING DIAGNOSIS: Peripheral vascular disease
DISCHARGE DIAGNOSIS: Peripheral vascular disease, status post right above-knee amputation.
PROCEDURES:
1.  Hyperbaric oxygen therapy.
2.  Hemodialysis.
3.  Lower extremity arterial Doppler.

CHAPTER 35  | 
CHAPTER 35 REVIEW

4. A 2D echocardiogram with left ventricular hypertrophy, inferior septal hypokinesis and mildly
impaired left ventricular function, sclerotic aortic valve, moderate mitral and severe tricuspid
insufficiency.
5. Lower extremity Doppler negative for deep venous thrombosis. Initial lower extremity Doppler posi-
tive for calf deep venous thrombosis in the right lower extremity.
DISCHARGE DIAGNOSES:
1.  Peripheral vascular disease, status post right above-knee amputation.
2.  End-stage renal disease.
3.  Non-insulin diabetes mellitus.
4.  Hypertension.
5.  Atrial fibrillation.
6.  Mild congestive heart failure.
7.  Protein depletion.
8.  Anemia of chronic disease and postoperative anemia.
9.  Hypothyroidism.
HOSPITAL COURSE: The patient was initially admitted with right lower extremity calf thrombosis and
cellulitis of the right calf. The patient was seen by renovascular surgery and infectious disease. At that
time, she was started on IV antibiotics. She was continued with hyberbaric oxygen therapy (HBO), which
had been performed as an outpatient. The patient had a repeat lower extremity Doppler, which did not
reveal DVT; anticoagulation was discontinued at that time. The patient was seen by the pain manage-
ment service. The patient was seen by cardiology for wide complex tachycardia that was self-limiting.
No further workup was warranted by cardiology other than echo at this time. The patient’s Coumadin
was stopped and she was placed on Plavix due to bleeding. The patient continued on IV antibiotics and
wound care. The patient’s family requested a second opinion on above-knee amputation, as they were
wishing for a below-knee amputation. Dr. Gerald saw the patient and advised the same. The patient
underwent an AKA by Dr. Gerald without significant complications.
The patient was somewhat weak after surgery. She will continue with HBO and antibiotics. She was
transferred to the floor from the PCU. She will continue with good pulmonary toilet. She was started
back on Plavix and Coumadin was not restarted. She continued on hemodialysis. Accu-Chek and slid-
ing scale insulin were performed. The patient was arranged for skilled nursing facility (SNF) placement;
however, prior to SNF placement, she slipped out of the bed and fell on her stump. Initial x-ray showed
possible fracture. CT showed no fracture. The patient also had a full spinal x-ray and right shoulder x-ray
performed without significant abnormalities. There was an area seen on the right shoulder x-ray, in the
right parotid region, that appeared calcified; however, the patient does wear a bridge and had it on at
the time of the x-ray, most likely representing these findings. I would recommend follow-up x-ray in 1
month of the right mandibular area to ensure this is unchanged.
The patient is discharged to skilled nursing facility at this time. She has finished HBO at this time. She
will continue with hemodialysis as an outpatient. She is no longer on antibiotics. She will continue with
blood sugar control. I still recommend a follow-up right mandibular x-ray in 3 to 4 weeks to ensure there
are no changes and this definitely was the patient’s bridge. She will follow with renovascular surgery, ID,
cardiology, and skilled nursing facility MD once discharged.
Roxan Kernan, MD—4444
556848/mt98328: 08/01/18 09:50:16  T: 08/01/18 12:55:01

Determine the most accurate ICD-10-PCS code(s) for the hyperbaric oxygen therapy and hemodialysis.

1084   PART V  |  INPATIENT (HOSPITAL) REPORTING

 CHAPTER 35 REVIEW
WESTWARD HOSPITAL
591 Chester Road
Masters, FL 33955
PATIENT: SHEPARD, JANIS
DATE OF ADMISSION: 01/14/18
ADMITTING DIAGNOSIS: Staghorn calculi
ATTENDING PHYSICIAN: Julio Yearlin, MD
Pt is a 69-year-old female who was admitted to the hospital with hematuria, nausea, and vomiting. A
routine ECG is taken today in preparation for the surgical removal of the stones, which is scheduled for
tomorrow.
Julio Yearlin, MD—9513
556848/mt98328: 01/14/18 09:50:16  T: 01/15/18 12:55:01

Determine the most accurate ICD-10-PCS code(s) for the EKG.

WESTWARD HOSPITAL
591 Chester Road
Masters, FL 33955
DISCHARGE SUMMARY
PATIENT: KENSINGTON, CHARLES
DATE OF ADMISSION: 01/15/18
DATE OF DISCHARGE: 01/17/18
ADMITTING DIAGNOSIS: Confusion, staring
DISCHARGE DIAGNOSIS: Possible TIA
This is an outpatient 58-year-old right-handed white male with a history of episodes of confusion and
staring. He had an abnormal EEG in the past.
Routine 18-channel digital EEG was obtained to rule out any seizure activity or focal abnormalities.
FINDINGS: Background rhythm during awake stage shows well-organized, well-developed, average
voltage 8 to 9 Hertz alpha activity in the posterior regions. It blocks with eye opening and it is bilater-
ally synchronous and symmetrical. No spike-and-wave discharges or any lateralizing abnormalities are
seen. Photic stimulation did not produce any abnormalities. Hyperventilation was performed for 3 min-
utes. No abnormalities were found during the procedure. Intermittent EMG artifacts were seen. Stage II
sleep was not achieved.
IMPRESSION: Normal awake study. No epileptiform discharges or any other paroxysmal activities or
focal abnormalities seen. Clinical correlation is recommended.
Kenzi Bloomington, MD—7777
556839/mt98328: 01/17/18 09:50:16  T: 01/17/18 12:55:01

Determine the most accurate ICD-10-PCS code(s) for the EEG.

CHAPTER 35  | 
CHAPTER 35 REVIEW

WESTWARD HOSPITAL
591 Chester Road
Masters, FL 33955
DISCHARGE SUMMARY
PATIENT: HELMSLEY, GRAYSON
DATE OF ADMISSION: 10/07/18
DATE OF DISCHARGE: 10/09/18
ADMITTING DIAGNOSIS: Abnormal liver function, weight loss
DISCHARGE DIAGNOSIS: Metastatic pancreatobiliary carcinoma and metastatic disease to the perito-
neal wall and the dome of the bladder
The patient is a 57-year-old male who was recently admitted to the hospital with significant weight loss
associated with abnormal liver function tests. A CAT scan of the abdomen and pelvis noted a large
mass in the tail of the pancreas and multiple hypodensities in the liver. He was seen in consultation
and was subjected to a CAT scan–guided liver biopsy. He was also subjected to tumor markers that
included a CEA and a CA19-9. He was noted to have markedly elevated CA19-9 at 2050. His CEA was
4.3 and his alfa-fetoprotein was less than 1.2.
The CAT-guided liver biopsy noted a high-grade infiltrating adenocarcinoma that was CK-7 and CAM
5.2 positive. The hepar antigen was negative. Based on this immunohistochemical staining, he was
noted to have a metastatic pancreatobiliary carcinoma. His staging workup with CAT scan of the chest
noted nonspecific mediastinal and axillary lymphadenopathy. The bone scan was essentially negative
for metastatic disease. The CAT scan of the pelvis noted an enlarged prostate with questionable inflam-
matory changes on the dome of the bladder. Based on this evaluation, he was diagnosed with meta-
static pancreatobiliary carcinoma and metastatic disease to the peritoneal wall and the dome of the
bladder.
Following his diagnosis, he was referred to me and has been started on palliative chemotherapy with
Gemzar. He has been tolerating Gemzar without much adverse effects. He was admitted to the hospital
early this morning with uncontrolled blood sugars. The most likely etiology of his uncontrolled blood
sugars is prednisone therapy.
Phillip Carlsson, MD—1111
556845/mt98328: 10/09/18 09:50:16  T: 10/09/18 12:55:01

Determine the most accurate ICD-10-PCS code(s) for the administration of the chemotherapy.

1086   PART V  |  INPATIENT (HOSPITAL) REPORTING

Imaging, Nuclear
Medicine, and Radiation
Therapy Sections
36
Learning Outcomes Key Terms
After completing this chapter, the student should be able to:
Densitometry
LO 36.1 Recognize the details reported from the Imaging Section. High Osmolar
LO 36.2 Evaluate the details to determine the correct code reported Intravascular Optical
from the Nuclear Medicine Section. Coherence
Low Osmolar
LO 36.3 Determine the specifics required to build a code from the
Radiation Therapy Section.
LO 36.4 Analyze all of the details to build an accurate seven-character
code for sections B, C, and D.

Remember, you need to follow along in

ICD-10-PCS
  STOP! your ICD-10-PCS code book for an
optimal learning experience.

36.1  Reporting from the Imaging Section

Character Definitions
The meanings for the Imaging Section characters are shown in the following table:

Character Position Character Meaning

1 Section of the ICD-10-PCS book
2 Body system
3 Root type
4 Body part (specific anatomical site)
5 Contrast
6 Qualifier
7 Qualifier

You might have noticed that character positions here have many of the same meanings
as for those in the Medical and Surgical Section. You learned a lot about imaging
services when you learned about coding from the Radiology Section of CPT, so you
have a bit of a head start for these procedures.
 Character Position 1: Imaging Section B
Character Position Character Meaning
1 Section of the ICD-10-PCS book
2 Body system
3 Root type
4 Body part (specific anatomical site)
5 Contrast
6 Qualifier
7 Qualifier

All of the codes from this section will begin with the letter B.

Character Position 2: Body System

Character Position Character Meaning
1 Section of the ICD-10-PCS book
2 Body system
3 Root type
4 Body part (specific anatomical site)
5 Contrast
6 Qualifier
7 Qualifier

The body systems of the Imaging Section are very similar to those you learned about
for the Medical and Surgical Section:
Central Nervous System . . . Character: 0
Heart . . . Character: 2
Upper Arteries . . . Character: 3
Lower Arteries . . . Character: 4
Veins . . . Character: 5
Lymphatic system . . . Character: 7
Eye . . . Character: 8
Ears, Nose, Mouth, and Throat . . . Character: 9
Respiratory System . . . Character: B
Gastrointestinal System . . . Character: D
Hepatobiliary System . . . Character: F
Endocrine System . . . Character: G
Skin, Subcutaneous Tissue and Breast . . . Character: H
Connective Tissue . . . Character: L
Skull and Facial Bones . . . Character: N
Non-Axial Upper Bones . . . Character: P
Non-Axial Lower Bones . . . Character: Q
Axial Skeleton, Except Skull and Facial Bones . . . Character: R
Urinary System . . . Character: T
Female Reproductive System . . . Character: U
Male Reproductive System . . . Character: V
Anatomical Regions . . . Character: W
Fetus and Obstetrical . . . Character: Y

1088   PART V  |  INPATIENT (HOSPITAL) REPORTING

Two things to remember:
∙ The dividing line between upper and lower is the diaphragm.
∙ The axial skeleton is the torso (the body) and the appendicular (non-axial) skeleton
is comprised of the extremities.

Character Position 3: Root Type

Character Position Character Meaning
1 Section of the ICD-10-PCS book
2 Body system
3 Root type
4 Body part (specific anatomical site)
5 Contrast
6 Qualifier
7 Qualifier
The root type describes the type of imaging technology being used:
Plain Radiography (X-ray) . . . Character; 0
Fluoroscopy . . . Character: 1
Computerized Tomography (CT Scan) . . . Character: 2
Magnetic Resonance Imaging (MRI) . . . Character: 3
Ultrasonography . . . Character: 4
∙ Plain Radiography (X-ray): Radiography is the use of electromagnetic radiation to
visualize the visceral aspects (internal structures) of the human body.
∙ Fluoroscopy: Fluoroscopy is the emission of continuous x-ray beams to produce a
real-time, dynamic image. High-density contrast agents, such as barium, might be
administered to enable comparative data.
∙ Computerized Tomography (CT Scan): An x-ray beam is emitted, aimed through the
anatomical site being studied, and then recorded by detectors. Then, the emissions
are reconstructed to create a two- or three-dimensional image—a cross-sectional
slice through the patient at a specific point. Each consecutive image is acquired at a
slightly different angle, providing a more complete picture of the internal aspects.
∙ Magnetic Resonance Imaging (MRI): Three-dimensional views of internal body
organs are created in real time, with greater visibility of variations within soft tis-
sues. This technique makes visualization of brain, spine, muscles, joints, and other
structures more detailed.
∙ Ultrasonography: Ultrasound, also known as ultrasonography, uses high-frequency
sound waves to capture cross-sectional images of visceral organs, including the
arteries, veins, and lymph nodes.

Character Position 4: Body Part

Character Position Character Meaning
1 Section of the ICD-10-PCS book
2 Body system
3 Root type
4 Body part (specific anatomical site)
5 Contrast
6 Qualifier
7 Qualifier

CHAPTER 36  | 
 From the brain to the toes, each body part is listed, specific to the body system in
conjunction with the root type.

EXAMPLES
Brain . . . Character: 0, under Central Nervous System, CT Scan
Coronary Artery, Single . . . Character: 0, under Heart, Fluoroscopy
Thoracic Aorta . . . Character: 0, under Upper Arteries, Plain Radiography
Abdominal Aorta . . . Character: 0, under Lower Arteries, MRI
Epidural Veins . . . Character: 0, under Veins, Plain Radiography

Character Position 5: Contrast

Character Position Character Meaning
1 Section of the ICD-10-PCS book
2 Body system
3 Root type
4 Body part (specific anatomical site)
5 Contrast
6 Qualifier
7 Qualifier

As you learned earlier in this textbook, there are several types of imaging procedures
performed with contrast materials. These materials may be barium or an iodine dye
that is injected to highlight or make the visceral organs and body parts more clearly
seen in the image.
High Osmolar High Osmolar . . . Character: 0
An ionic water-soluble iodin- Low Osmolar . . . Character: 1
ated contrast medium. Other Contrast . . . Character: Y
None . . . Character: Z
Low Osmolar
A non-ionic water-soluble ∙ High Osmolar: Also known as ionic contrast media. Examples include diatrizoate,
iodinated contrast medium. metrizoate, and iothalamate.
∙ Low Osmolar: Also known as organic or non-ionic contrast media. Examples
include iopamidol, ioxilan, and ioversol.

EXAMPLE
You might see something like this in the documentation about an MRI taken:
“. . . Multiplanar sagittal, coronal and axial images were obtained through the
left forearm prior to and following contrast administration using diatrizoate.
Markers have been placed near the patient’s indicated site of swelling, which
includes the dorsum of the distal left forearm and also over the wrist. . . .”

Character Position 6: Qualifier

Character Position Character Meaning
1 Section of the ICD-10-PCS book
2 Body system

1090   PART V  |  INPATIENT (HOSPITAL) REPORTING

 Character Position Character Meaning
3 Root type
4 Body part (specific anatomical site)
5 Contrast
6 Qualifier
7 Qualifier
As you can see, a character placed in the sixth position will identify an additional
detail specific to that table.
Unenhanced and Enhanced . . . Character: 0
Laser . . . Character: 1
Intravascular Optical Coherence . . . Character: 2 Intravascular Optical
None . . . Character: Z Coherence
A high-resolution, catheter-
based imaging modality used
Character Position 7: Qualifier for the optimized visualization
of coronary artery lesions.
Character Position Character Meaning
1 Section of the ICD-10-PCS book
2 Body system
3 Root type
4 Body part (specific anatomical site)
5 Contrast
6 Qualifier
7 Qualifier
The seventh character is required and may enable you to share additional details about
this specific imaging procedure:
Intraoperative . . . Character: 0
Densitometry . . . Character: 1 Densitometry
Intravascular . . . Character: 3 The process used to measure
Transesophageal . . . Character: 4 bone density, most often done
Guidance . . . Character: A to assess the patient’s risk for
None . . . Character: Z osteopenia or osteoporosis.

EXAMPLE
You might see something like this in the operative report:
“. . . The wire was then passed down to the superior vena cava without dif-
ficulty under direct fluoroscopy. . . .”
“. . . With fluoroscopy, the catheter was then checked. It was noted to be in
the superior vena cava just above the right atrium. . . .”

ICD-10-PCS
LET’S CODE IT! SCENARIO
Belinda Crandel, a 59-year-old female, has a family history of osteoporosis and was admitted into the hospital with
a hairline fracture of the right hip. Dr. Franklin took a plain radiographic densitometry of her right hip to see if osteo-
porosis was an ­underlying cause of the fracture.
(continued)

CHAPTER 36  | 
 Let’s Code It!
Let’s go through the steps of coding for ICD-10-PCS and determine the code or codes that should be reported
for the procedure that was performed.
First character: Section: Imaging . . . B
What body system was imaged? The documentation states, “her right hip,” which is a non-axial (not the head or
torso) lower bone.
Second character: Body System: Non-Axial Lower Bones . . . Q
What type of imaging was used? The documentation states, “plain radiographic.”
Third character: Root Operation: Plain Radiography . . . 0 (as in Zero)
Which specific body part was imaged? The documentation states, “her right hip.”
Fourth character: Body Part: Hip, Right . . . 0
There is no mention of any contrast being used, and there is only one option for the sixth character.
Fifth character: Contrast: None . . . Z
Sixth character: Qualifier: None . . . Z
The documentation does provide the detail for you to determine the accurate seventh character, where it states,
“densitometry.”
Seventh character: Qualifier: Densitometry . . . 1
The ICD-10-PCS code you will report is
BQ00ZZ1    Plain radiography densitometry, right hip
Good job!

36.2  Reporting from the Nuclear

Medicine Section
Character Definitions
The meanings for the Nuclear Medicine Section characters are shown in the follow-
ing table:

Character Position Character Meaning

1 Section of the ICD-10-PCS book

2 Body system

3 Root type

4 Body part

5 Radionuclide

6 Qualifier

7 Qualifier

1092   PART V  |  INPATIENT (HOSPITAL) REPORTING

Character Position 1: Nuclear Medicine Section C
Character Position Character Meaning
1 Section of the ICD-10-PCS book
2 Body system
3 Root type
4 Body part
5 Radionuclide
6 Qualifier
7 Qualifier
The procedures reported with codes from the Nuclear Medicine Section describe the use
of radioactive material administered into the patient’s body to enable the creation of an
image for further study. This modality is beneficial as a diagnostic tool for the assessment
of metabolic functions and/or a therapeutic tool for the treatment of pathologic conditions.
Note: When radioactive materials are used to treat malignancies, the procedure is
reported from the Radiation Therapy Section, discussed later in this chapter.

Character Position 2: Body System

Character Position Character Meaning
1 Section of the ICD-10-PCS book
2 Body system
3 Root type
4 Body part
5 Radionuclide
6 Qualifier
7 Qualifier
The character descriptors of body systems in this section are those with which you
have become familiar in this code set.

EXAMPLES
Central nervous system . . . Character: 0
Lymphatic and Hematologic System . . . Character: 7
Respiratory System . . . Character: B
Urinary System . . . Character: T

Character Position 3: Root Type

Character Position Character Meaning
1 Section of the ICD-10-PCS book
2 Body system
3 Root type
4 Body part
5 Radionuclide
6 Qualifier
7 Qualifier

CHAPTER 36  | 
 The codes from the Nuclear Medicine Section only report procedures that are nonin-
vasive, meaning that the outer layer of the skin is not punctured and no incision is made.
Planar Nuclear Medicine Imaging: Introduction of radioactive materials into the
body for single-plane display of images developed from the capture of radio-
active emissions . . . Character: 1
Tomographic (Tomo) Nuclear Medicine Imaging: Introduction of radioactive mate-
rials into the body for three-dimensional display of images developed from the
capture of radioactive emissions . . . Character: 2
Positron Emission Tomographic (PET) Imaging: Introduction of radioactive materials
into the body for three-dimensional display of images developed from the simul-
taneous capture, 180 degrees apart, of radioactive emissions . . . Character: 3
Nonimaging Nuclear Medicine Uptake: Introduction of radioactive materials into
the body for measurements of organ function, from the detection of radioac-
tive emissions . . . Character: 4
Nonimaging Nuclear Medicine Probe: Introduction of radioactive materials into
the body for the study of distribution and fate of certain substances by the
detection of radioactive emissions; or alternatively, measurement of absorp-
tion of radioactive emissions from an external source . . . Character: 5
Nonimaging Nuclear Medicine Assay: Introduction of radioactive materials into
the body for the study of body fluids and blood elements, by the detection of
radioactive emissions . . . Character: 6
Systemic Nuclear Medicine Therapy: Introduction of unsealed radioactive materi-
als into the body for treatment . . . Character: 7

Character Position 4: Body Part

Character Position Character Meaning
1 Section of the ICD-10-PCS book
2 Body system
3 Root type
4 Body part
5 Radionuclide
6 Qualifier
7 Qualifier
The list of body parts or systems for this section is similar to the list shown in the
Imaging Section. Combination descriptors—such as Ear, Nose, Mouth, and Throat—
as well as regions—such as Lower Extremity Veins, Right—are included along with
specific body parts, such as thyroid gland and spleen.

Character Position 5: Radionuclide

Character Position Character Meaning
1 Section of the ICD-10-PCS book
2 Body system
3 Root type
4 Body part
5 Radionuclide
6 Qualifier
7 Qualifier

1094   PART V  |  INPATIENT (HOSPITAL) REPORTING

The options in this list include the descriptors of radioactive materials—the source of
the radiation. Be careful—some of these are very similar. CODING BITES
Technetium 99m (Tc-99m) . . . Character: 1 If the documentation
Cobalt 58 (Co-58) . . . Character: 7 shows that more than
Samarium 153 (Sm-153) . . . Character: 8 one radiopharmaceuti-
Krypton (Kr-81m) . . . Character: 9 cal is used during one
Carbon 11 (C-11) . . . Character: B encounter, report a
Cobalt 57 (Co-57) . . . Character: C separate code for each
Indium 111 (In-111) . . . Character: D identified substance.
Iodine 123 (I-123) . . . Character: F
Iodine 131 (I-131) . . . Character: G
Iodine 125 (I-125) . . . Character: H
Fluorine 18 (F-18) . . . Character: K
Gallium 67 (Ga-67) . . . Character: L
Oxygen 15 (O-15) . . . Character: M
Phosphorus 32 (P-32) . . . Character: N
Strontium 89 (Sr-89) . . . Character: P
Rubidium 82 (Rb-82) . . . Character: Q
Nitrogen 13 (N-13) . . . Character: R
Thallium 201 (Tl-201) . . . Character: S
Xenon 127 (Xe-127) . . . Character: T
Xenon 133 (Xe-133) . . . Character: V
Chromium (Cr-51) . . . Character: W
Other Radionuclide . . . Character: Y
None . . . Character: Z
The Y Other Radionuclide option is available to report any newly approved radionu-
clides. It is recommended to append documentation to the claim using this character
to explain the specific radiation source utilized on the patient. And you may need to
report a HCPCS Level II code, if available, to specify the radionuclide.

Character Position 6: Qualifier

Character Position Character Meaning
1 Section of the ICD-10-PCS book
2 Body system
3 Root type
4 Body part
5 Radionuclide
6 Qualifier
7 Qualifier

This section has only one option for the character reported in the sixth position:
None . . . Character: Z

Character Position 7: Qualifier

Character Position Character Meaning
1 Section of the ICD-10-PCS book
2 Body system
(continued)

CHAPTER 36  | 
 Character Position Character Meaning
3 Root type
4 Body part
5 Radionuclide
6 Qualifier
7 Qualifier
There are no details reported by this Qualifier position, so the only option is . . .
None . . . Character: Z

ICD-10-PCS
LET’S CODE IT! SCENARIO
Oscar Farrell, an 83-year old male, was admitted into the hospital with dyspnea and chest pain. Dr. Lowenthal did a
PET imaging of his lungs and bronchi, using Fluorine 18.

Let’s Code It!

Let’s go through the steps of coding for ICD-10-PCS and determine the code or codes that should be reported
for this encounter between Dr. Lowenthal and Oscar Farrell.
If you don’t know, you can find PET imaging in the Alphabetic Index of ICD-10-PCS, which will direct you to
the Nuclear Medicine Section.
First character: Section: Nuclear Medicine . . . C
What body system was imaged? The documentation states, “his lungs and bronchi,” which are parts of the respi-
ratory system.
Second character: Body System: Respiratory System . . . B
What type of imaging was performed? The documentation states, “PET imaging.”
Third character: Root Type: Positron Emission Tomographic (PET) Imaging . . . 3
What specific body parts were imaged? The documentation states, “his lungs and bronchi.”
Fourth character: Body Part: Lungs and Bronchi . . . 2
What radionuclide was used? The documentation states, “Fluorine 18.”
Fifth character: Radionuclide: Fluorine 18 . . . K
No additional details are required, and you only have one option for each of the last two characters.
Sixth character: Qualifier: None . . . Z
Seventh character: Qualifier: None . . . Z
The ICD-10-PCS code you will report is this:
CB32KZZ  PET imaging of lungs and bronchi, with Fluorine 18
Good job!

36.3  Reporting from the Radiation

Therapy Section
Character Definitions
The meanings for the Radiation Therapy Section characters are shown in the follow-
ing table:

1096   PART V  |  INPATIENT (HOSPITAL) REPORTING

 Character Position Character Meaning
1 Section of the ICD-10-PCS book
2 Body system
3 Root type (Modality)
4 Treatment site
5 Modality qualifier
6 Isotope
7 Qualifier

Character Position 1: Radiation Therapy Section D

Character Position Character Meaning
1 Section of the ICD-10-PCS book
2 Body system
3 Root type (Modality)
4 Treatment site
5 Modality qualifier
6 Isotope
7 Qualifier
Procedures reported from the Radiation Therapy Section will all begin with the letter D.

Character Position 2: Body System

Character Position Character Meaning
1 Section of the ICD-10-PCS book
2 Body system
3 Root type (Modality)
4 Treatment site
5 Modality qualifier
6 Isotope
7 Qualifier
Again, the list for body system character descriptors in this section is very similar to
other sections’ lists for body systems.

Character Position 3: Root Type

Character Position Character Meaning
1 Section of the ICD-10-PCS book
2 Body system
3 Root type (Modality)
4 Treatment site
5 Modality qualifier
6 Isotope
7 Qualifier

CHAPTER 36  | 
 There are only four root types used to describe the modality of these procedures:
Beam Radiation . . . Character: 0
Brachytherapy . . . Character: 1
Stereotactic Radiosurgery . . . Character: 2
Other Radiation . . . Character: Y
∙ Beam Radiation: Also known as external beam therapy (EBT), it uses one or more
beams of high-energy x-rays directed at a patient’s tumor.
∙ Brachytherapy: This method uses radioactive seeds that are placed in, or near, the
tumor (internally). These seeds produce a high radiation dose in a limited manner,
directly to the tumor. Use of this process controls the radiation exposure to sur-
rounding, healthy tissues.
∙ Stereotactic Radiosurgery: This radiation methodology uses a focused high-power
energy on a small area of the body, sometimes using a tool known as a CyberKnife.
NOTE: Radiosurgery is not a surgical procedure; it is a treatment with no incisions
made into the body.

Character Position 4: Treatment Site

Character Position Character Meaning
1 Section of the ICD-10-PCS book
2 Body system
3 Root type (Modality)
4 Treatment site
5 Modality qualifier
6 Isotope
7 Qualifier
Consistent with other sections, these anatomical sites are very specific. NOTE: The
same character is used to identify different body parts throughout this section. It
changes from body system to body system.

EXAMPLES
Brain Stem . . . Character: 1, under Central and Peripheral Nervous System
Thymus. . . Character: 1, under Lymphatic and Hematologic System
Nose . . . Character: 1, under Ear, Nose, Mouth, and Throat
Bronchus . . . Character: 1, under Respiratory System

Character Position 5: Modality Qualifier

Character Position Character Meaning
1 Section of the ICD-10-PCS book
2 Body system
3 Root type (Modality)
4 Treatment site
5 Modality qualifier
6 Isotope
7 Qualifier

1098   PART V  |  INPATIENT (HOSPITAL) REPORTING

This character will provide additional detail about the modality.
Photons <1 MeV . . . Character: 0
Photons 1–10 MeV . . . Character: 1
Photons >10 MeV . . . Character: 2
Electrons . . . Character: 3
Heavy Particles (Protons, Ions) . . . Character: 4
Neutrons . . . Character: 5
Neutron Capture . . . Character: 6
Contact Radiation . . . Character: 7
Hyperthermia . . . Character: 8
High Dose Rate (HDR) . . . Character: 9
Low Dose Rate (LDR) . . . Character: B
Intraoperative Radiation Therapy (IORT) . . . Character: C
Stereotactic Other Photon Radiosurgery . . . Character: D
Plaque Radiation . . . Character: F
Isotope Administration . . . Character: G
Stereotactic Particulate Radiosurgery . . . Character: H
Stereotactic Gamma Beam Radiosurgery . . . Character: J
Laser Interstitial Thermal Therapy . . . Character: K

Character Position 6: Isotope

Character Position Character Meaning
1 Section of the ICD-10-PCS book
2 Body system
3 Root type (Modality)
4 Treatment site
5 Modality qualifier
6 Isotope
7 Qualifier
In this character position, you will identify the specific radioactive substance used dur-
ing this procedure.
Cesium 137 (Cs-137) . . . Character: 7
Iridium 192 (Ir-192) . . . Character: 8
Iodine 125 (I-125) . . . Character: 9
Palladium 103 (Pd-103) . . . Character: B
Californium 252 (Cf-252) . . . Character: C
Iodine 131 (I-131) . . . Character: D
Phosphorus 32 (P-32) . . . Character: F
Strontium 89 (Sr-89) . . . Character: G
Strontium 90 (Sr-90) . . . Character: H
Other Isotope . . . Character: Y
None . . . Character: Z

EXAMPLE
You may read something like these in the documentation:
“. . . Palladium 103 radioactive seeds were implanted according to the pre-
planned computer calculation—a total of 56 seeds through 16 needles, each
seed containing 1.04 mCi per seed. . . .”
“. .  .  We implanted a total of 54 iodine-125 radioactive seeds through
12 needles with each seed containing 0.373 millicurie per seed. . . .”

CHAPTER 36  | 
 Character Position 7: Qualifier
Character Position Character Meaning
1 Section of the ICD-10-PCS book
2 Body system
3 Root type (Modality)
4 Treatment site
5 Modality qualifier
6 Isotope
7 Qualifier

This character will report that this radiation treatment was provided during a surgical
procedure—or not.
Intraoperative . . . Character: 0
No Qualifier . . . Character: Z

ICD-10-PCS
LET’S CODE IT! SCENARIO
Richard Raddison has been having severe pain in his stomach and was admitted into the hospital for tests. It was
determined that Richard had malignant lesions in the fundus and pylorus areas of his stomach. Dr. Benjamin per-
formed brachytherapy on Richard Raddison’s stomach using Cesium 137, high dose rate.

Let’s Code It!

Let’s go through the steps of coding for ICD-10-PCS and determine the code or codes that should be reported
for this encounter between Dr. Benjamin and Richard Raddison.
Brachytherapy was provided, and you already know this is a type of radiation therapy.
First character: Section: Radiation Therapy . . . D
What body system was being treated? The documentation states, “his stomach,” which is a part of the gastroin-
testinal system.
Second character: Body System: Gastrointestinal System . . . D
What type of radiation therapy was used? The documentation states, “brachytherapy.”
Third character: Root Type: Brachytherapy . . . 1
What specific body part was treated? The documentation states, “his stomach.”
Fourth character: Treatment Site: Stomach . . . 1
What was the modality qualifier? The documentation states, “high dose rate.”
Fifth character: Modality Qualifier: High Dose Rate . . . 9
What isotope was used? The documentation states, “Cesium 137.”
Sixth character: Isotope: Cesium 137 (Cs-137) . . . 7
There is only one option to report for the seventh character.
Seventh character: Qualifier: None . . . Z
The ICD-10-PCS code you will report is this:
DD1197Z  Brachytherapy, stomach, high dose rate, Cs-137
Good job!

1100   PART V  |  INPATIENT (HOSPITAL) REPORTING

36.4  Sections B, C, and D: Putting
It All Together

ICD-10-PCS
LET’S CODE IT! SCENARIO
PATIENT: CARL BERGERON
ORDERING PHYSICIAN: Elias Madison, MD
HPI: Patient was admitted yesterday after falling in his office with no apparent reason. A 5 cm laceration on his scalp
confirms that he hit his head on the desk, as he fell.
IMAGING: MRI OF THE HEAD
The MRI of the head shows diffuse atrophy. There is no abnormality of the craniocervical junction. There is a small
probable mucus retention cyst in the inferior right maxillary sinus. The brainstem is grossly intact. There is a slight
increase in atrophy with regards to the left temporal lobe in comparison to the right. This is mild asymmetry, how-
ever. No large territorial defects are noted.
There is, however, noted on both the T2 and FLAIR images an area of very vague high signal along the left mid
lateral ventricle region. This area of white matter suggests some probable demyelination. This is brought up in par-
ticular because, when contrast was given, there was a very vague sliver of enhancement directly in that area. This
is seen on coronal imaging as well. This could be related to some collateral vessels and they are seen with contrast.
Collateral vessels will be necessary due to the absence of good flow to the left MCA and ICA distribution on the
left on the MRA, which will be described further following this report. Therefore, that is felt the most likely etiology.
Other etiologies on this very vague and subtle enhancement would be tumor or luxury blood flow around a recent
small ischemic insult. I would recommend that this simply be followed up over time in approximately 6 to 9 months
or sooner if symptoms change.
There is no other area of enhancement of concern that is noted. We do see some asymmetry to the vascular
venous drainage pattern with the gadolinium on the axial images in the posterior fossa and around the tempo-
ral lobe region on the left, which most likely again is related to the change in collateral flow to the left cerebral
hemisphere.
The IAC and cerebellopontine angle regions do not show masses. No enhancing abnormality is noted to suggest
an acoustic tumor. The inner ear and mastoid air cells are well aerated.
IMPRESSION:
1. Diffuse atrophy.
2. FLAIR and T2 weighted images suggest some ischemic high signal changes in the white matter adjacent to
the left lateral ventricle. In this area, with gadolinium, a small sliver of enhancement persists on both axial and
coronal images. This sliver of enhancement may be related to collateral blood flow or luxury perfusion or recent
ischemic insult. It could, though felt less likely, be related to mild enhancement of an underlying tumor. I feel this is
less likely, and in light of no change in clinical symptoms, I would recommend simply a repeat MRI with gadolinium
in approximately 6 to 9 months.
3. No other abnormal enhancement is noted.
4. There is a mild increase in atrophy with regards to the left temporal lobe when compared to the right; however,
this is diffuse and subtle.
5. The internal auditory canal and cerebellopontine angle regions are normal in appearance.
Lawrence Katenberg, MD, Radiology
Let’s Code It!
According to the documentation, Dr. Katenberg is interpreting an MRI done of Carl’s head. Let’s determine the
seven characters needed to build this code.
First character: Section: Imaging . . . B
Second character: Anatomical Regions . . . W

(continued)

CHAPTER 36  | 
 Third character: Root Operation: Magnetic Resonance Imaging (MRI) . . . 3
Fourth character: Body Part: Head . . . 8
Was contrast used? The documentation states, “when contrast was given.” There is only one choice to report
that contrast was used.
Fifth character: Contrast: Other Contrast . . . Y
Sixth character: Qualifier: Unenhanced and Enhanced . . . 0
Seventh character: Qualifier: None . . . Z
Now, put it all together and report, with confidence, this code:
BW38Y0Z    MRI, head, unenhanced and enhanced
Good work!

ICD-10-PCS
LET’S CODE IT! SCENARIO
The patient is a 71-year-old female who was admitted last night due to subacute progressive spasticity over the
last 7 months, increased difficulty walking, increased difficulty moving her right arm and hand, as well as increased
rigidity. Her primary care physician has taken multiple MRIs, which included contrast, and there did not seem to be
any abnormalities on his review. 
She was given a provisional diagnosis of cerebral palsy, which does not fit with the natural course of this disease,
as she was normal when she was a child. There seems to be an extrapyramidal as well as pyramidal component on
examination today, but I do not appreciate spastic paraparesis as she was previously evaluated to have. The time
course and progression of symptoms suggest a degenerative process with pyramidal and extrapyramidal component
that could be part of secondary parkinsonian spectrum disease. Perhaps there is a hereditary component to this.
I ordered lab work today to include ferritin, ceruloplasmin, copper, and liver function tests and Wilson disease
screening. Also, as per my earlier order, she has just had a PET imaging with C-11 of her brain.

Let’s Code It!

For this case, you are going to code for the PET imaging only. Remember, or use your medical dictionary, to confirm
that PET stands for Positron Emission Tomographic (PET) imaging, and find it in the ICD-10-PCS Alphabetic Index:
Positron Emission Tomographic (PET) Imaging
  Brain C030
Terrific! Turn to the C03 Table in your ICD-10-PCS code book and let’s determine the seven characters to build
a correct code:
First character: Nuclear Medicine . . . C
What body system includes the brain? The central nervous system . . . that’s right!
Second character: Central Nervous System . . . 0
Third character: Root Operation: Positron Emission Tomographic (PET) Imaging . . . 3
Fourth character: Body Part: Brain . . . 0
What radionuclide was used during this patient’s imaging? The documentation states, “with C-11.”
Fifth character: Radionuclide: Carbon 11 (C-11) . . . B
Sixth character: Qualifier: None . . . Z
Seventh character: Qualifier: None . . . Z
Now, you can put it all together and report, with confidence, this ICD-10-PCS code:
C030BZZ  PET imaging, brain, with Carbon 11 (C-11)

1102   PART V  |  INPATIENT (HOSPITAL) REPORTING

 ICD-10-PCS
LET’S CODE IT! SCENARIO
PATIENT: ERIC PERIQUINN
DATE OF PROCEDURE: 12/03/2018
PREOPERATIVE DIAGNOSIS: Adenocarcinoma of the prostate
POSTOPERATIVE DIAGNOSIS: Adenocarcinoma of the prostate
PROCEDURE PERFORMED: Prostate brachytherapy
SURGEON: Gerald Crenshaw, MD
ANESTHESIA: General anesthesia via laryngeal mask airway (LMA)
DRAINS: One 18-French Foley catheter per urethra
INDICATIONS FOR PROCEDURE: This patient has a recent diagnosis of adenocarcinoma of the prostate diagnosed
due to a very slowly rising PSA. His current PSA level is only 2.1, but prostate ultrasound biopsies were performed
showing adenocarcinoma of the prostate at the left base of the prostate, and two biopsies were positive out of eight
with a Gleason score of 6. Treatment options have been discussed, and he wishes to proceed with prostate brachy-
therapy. Informed consent has been obtained.
DESCRIPTION OF PROCEDURE: The patient was placed on the operating table in the supine position. General
anesthesia was administered via laryngeal mask airway. He was then placed in the dorsal lithotomy position and
sterilely prepped and draped in the usual fashion. The prostate ultrasound was inserted. The prostate was visualized
using the preplanned study as a guide. Low dose prostate brachytherapy was performed. The patient tolerated the
procedure well and had no immediate intraoperative or postoperative complications.
We implanted a total of 54 iodine-125 radioactive seeds through 12 needles with each seed containing 0.373 mil-
licurie per seed. During the procedure, the patient received 4 mg of Decadron IV and 400 mg of Cipro IV. Subsequent
fluoroscopy showed good distribution of the seeds throughout the prostate. The patient will have a CAT scan of the
pelvis and simulation for his seed localization. Total target dose is 14,500 cGy.
The patient will be discharged with prescriptions for Cardura 1 mg a day for a month with two refills and Tylenol
No. 3 one t.i.d. p.r.n. for pain, a total of 20, Pyridium Plus one b.i.d. for 10 days, Cipro 500 mg b.i.d. for 5 days, and
prednisone 10 mg t.i.d. for a week.
Discharge instructions were explained to the patient and his wife. He will return to see me in my office in 3 weeks
for a followup.

Let’s Code It!

Dr. Crenshaw performed brachytherapy, which is radiation therapy, on Eric. Turn in the ICD-10-PCS Alphabetic
Index to:
Brachytherapy [read down the long list until you get to . . . ]
  Prostate DV10
Turn to the DV1 Table to complete this code:
First character: Section: Radiation Therapy . . . D
Second character: Male Reproductive System . . . V
Third character: Root Operation: Brachytherapy . . . 1
Fourth character: Treatment Site: Prostate . . . 0
Was this high dose or low dose rate? The documentation states, “Low dose prostate brachytherapy.”
Fifth character: Modality Qualifier: Low Dose Rate . . . B
What isotope was used? The documentation states, “iodine-125 radioactive seeds.”

(continued)

CHAPTER 36  | 
CHAPTER 36 REVIEW

Sixth character: Isotope: Iodine 125 . . . 9

Seventh character: Qualifier: None . . . Z
Now, put it all together and, with confidence, report this code:
DV10B9Z   Low dose brachytherapy, prostate, with iodine 125
Really good work!

Chapter Summary
Imaging is a wonderful way for a physician to see inside the body to help determine a
diagnosis. Nuclear medicine techniques enable the assessment of metabolic functions
and can be used for either diagnostic or therapeutic purposes. And radiation therapies
provide an efficacious way to treat malignancy. When provided to a patient who has
been admitted into the hospital, these services and treatments are reported with a code
from one of these sections.

CODING BITES
For those Imaging, Nuclear Medicine, and Radiation Therapy services that use
pharmaceuticals, you will need an additional code to report more details about the
specific contrast material. You can find these drug codes in your HCPCS Level II
code book.
Examples
(Contrast) High Osmolar contrast material, up to 149 mg/ml iodine concentration,
per ml . . . code Q9958
(Contrast) Low Osmolar contrast material, 400 or greater mg/ml iodine concentra-
tion, per ml . . . code Q9951
(Radionuclide) Technetium 99m arcitumomab, diagnostic, per study dose, up to
45 millicuries . . . code A9568
(Isotope) Iodine I-125 serumalbumin, diagnostic, per 5 microcuries . . . code A9532

CHAPTER 36 REVIEW
Imaging, Nuclear Medicine, and Enhance your learning by
completing these exercises and
more at connect.mheducation.com!

Radiation Therapy Sections

Let’s Check It! Terminology
Match each key term to the appropriate definition.
1. LO 36.1  A non-ionic water-soluable iodinated contrast medium. A. Densitometry
2. LO 36.1  A high-resolution, catheter-based imaging modality used for the opti- B. High Osmolar
mized visualization of coronary artery lesions. C. Intravascular Optical
3. LO 36.1  The process used to measure bone density, most often done to assess Coherence
the patient’s risk for osteopenia or osteoporosis. D. Low Osmolar
4. LO 36.1  An ionic water-soluable iodinated contrast medium.

1104   PART V  |  INPATIENT (HOSPITAL) REPORTING

Let’s Check It! Concepts

CHAPTER 36 REVIEW
Choose the most appropriate answer for each of the following questions.
1. LO 36.1  Within the Imaging Section, character position 5 represents which of the following?
a. Body system b.  Contrast
c. Device d.  Qualifier
2. LO 36.1  All of the codes reporting an Imaging Section procedure will begin with what section letter?
a. A b.  B
c. D d.  F
3. LO 36.1  All of the following would be found within the Imaging Section, character position 3 Root Type, except
a. x-ray. b.  CT scan.
c. PET. d.  MRI.
4. LO 36.1  Within the Imaging Section, character position 6 Qualifier, which of the following are available options?
a. Unenhanced and enhanced b.  Laser
c. Intravascular optical coherence d.  All of these
5. LO 36.2  Within the Nuclear Medicine Section, character position 1 is identified by which of the following sec-
tion letters?
a. E b.  B
c. D d.  C
6. LO 36.2  Within the Nuclear Medicine Section, which character position represents the radioactive materials—
the source of the radiation being used?
a. 5 b.  4
c. 3 d.  2
7. LO 36.2  Introduction of radioactive materials into the body for three-dimensional display of images developed
from the capture of radioactive emissions, identified by the character 2, is known as
a. positron emission tomographic (PET) imaging. b.  planar nuclear medicine imaging.
c. nonimaging nuclear medicine uptake. d.  tomographic (tomo) nuclear medicine imaging.
8. LO 36.3  Within the Radiation Therapy Section, which character position describes the modality of the
procedure?
a. 5 b.  4
c. 3 d.  2
9. LO 36.3  Californium would be classified as
a. a treatment site. b.  an isotope.
c. a modality. d.  a qualifier.
10. LO 36.3  Within the Radiation Therapy Section, character position 7 Qualifier, which of the following characters
represents the radiation treatment provided during a surgical procedure?
a. Z b.  0
c. X d.  1

Let’s Check It! Rules and Regulations

Please answer the following questions from the knowledge you have gained after reading this chapter.
1. LO 36.1  List the five root types found within the Imaging Section, character position 3, including the character
that identifies each.

CHAPTER 36  | 
 Rev. Confirming Pages

2. LO 36.1  List the types of qualifiers found in the Imaging Section, character position 7, Qualifier; include the
CHAPTER 36 REVIEW

character that identifies each.

3. LO 36.3  When radioactive materials are used to treat malignancies, the procedure is reported from which
ICD-10-PCS section?
4. LO 36.2  List five types of radionuclides found within the Nuclear Medicine Section, character position 5; include
the character that identifies each.
5. LO 36.3  There are only four root types used to describe the modality in the Radiation Therapy Section, character
position 3. What are they? Include the character that identifies each.

ICD-10-PCS
YOU CODE IT! Practice
Using the techniques described in this chapter, carefully read through the case studies and determine the most
accurate ICD-10-PCS code(s) for each case study.
1. Edward Baker, a 26-year-old male, was riding his dirt bike and fell off, hurting his left ankle. Ed presents to
Westward Hospital, where Dr. Dyson takes an x-ray, without contrast, of the ankle. Dr. Dyson also notes
hemarthrosis and admits Ed to Weston Hospital. Code the x-ray.
2. Phoebe Eaddy, a 16-year-old female, complains of urinary dribbling and feels like her bladder is still full
after voiding. Phoebe was diagnosed with type 1 diabetes 3 years ago. Dr. Barbato admits Phoebe to Weston
Hospital and performs an ultrasound of Phoebe’s urethra, which reveals nerve damage caused by her diabetes.
Code the ultrasound.
3. Hugo Abbott, a 49-year-old male, has been diagnosed with osteosarcoma of his right knee. Hugo has been
having difficulty, so Dr. Simmons admits Hugo to Westward Hospital, where an MRI, without contrast, of his
right knee is performed.
4. Gregg Huggins, a 25-year-old male diagnosed with Graves’ disease, is admitted to the hospital for a planar
nuclear medicine imaging procedure of his thyroid gland, iodine 123 (I-123).
5. Hazel Baker, a 51-year-old female, is admitted to the hospital for a tomographic nuclear medicine imaging
procedure of her parathyroid glands, radionuclide—technetium 99m (Tc-99m).
6. Susan Gibbons, a 43-year-old female, is admitted to Westward Hospital for a positron emission tomographic
(PET) imaging procedure of the lungs and bronchi, radionuclide—fluorine 18 (F-18).
7. Glenda McMahon, a 41-year-old female, is admitted to the hospital due to severe abdominal pain. Dr. Har-
mon performed a liver and spleen tomography.
8. Joe Jefferson, a 72-year-old male, is admitted to the hospital with heart palpitations and edema of his legs and
feet. Dr. Moss performs a heart positron emission tomographic (PET) scan.
9. Frank Ogburn, a 48-year-old male, has unexplained skeletal pain and is admitted to Westward Hospital so
Dr. Cannon can perform a systemic nuclear medicine therapy whole body scan, strontium 89 (Sr-89).
10. Ozie Lewis, a 73-year-male, has been diagnosed with esophageal cancer. Ozie was admitted to Westward
Hospital for beam radiation therapy to the esophagus, photons 1–10MeV.
11. Jeff McCord, a 37-year-old male, was admitted to Westward Hospital 3 days ago and has been diagnosed with
lymphatic cancer. Today Jeff receives his first treatment of brachytherapy of the inguinal lymphatic nodes,
low dose rate, iridium 192 (Ir-192).
12. Harry Glover, a 38-year-old male, was admitted to Westward Hospital for sterotactic gamma beam radiosur-
gery on his eye.
13. Alna Lindsay, a 68-year-old female, was admitted to Westward Hospital today for brachytherapy of the hypo-
pharynx, low dose rate, iodine 125 (I-125) treatment.
14. Charles Medlin, a 31-year-old male, has been diagnosed with a lung tumor and was admitted to Westward
Hospital for stereotactic particulate radiosurgery.

1106   PART V  |  INPATIENT (HOSPITAL) REPORTING

saf28735_ch36_1087-1110.indd  1106 07/02/18 07:41 AM

 CHAPTER 36 REVIEW
15. Brandon Russell, a 37-year-old female, was admitted to Westward Hospital 2 days ago and has been diag-
nosed with osteosarcoma. Today she receives beam radiation therapy to the femur, photons >10MeV.

YOU CODE IT! Application

ICD-10-PCS

The following exercises provide practice in abstracting physicians’ notes and learning to work with documenta-
tion from our health care facility, Westward Hospital. These case studies are modeled on real patient encounters.
Using the techniques described in this chapter, carefully read through the case studies and determine the most
accurate ICD-10-PCS code(s) for each case study.

WESTWARD HOSPITAL
591 Chester Road
Masters, FL 33955
PATIENT: ALTERMANN, AMANDA
DATE OF ADMISSION: 8/01/18
DIAGNOSIS: Concussion
REFERRING PHYSICIAN: Jacob Huffman, MD
Pt is a 52-year-old female, who presented to the emergency room accompanied by her husband, Ron.
Pt is complaining of a severe headache and seeing stars. Her husband said she was standing on a lad-
der when she fell off, striking her head; she lost consciousness for approximately 3 minutes. Dr. Huffman
notes some disorientation, slurred speech, and a delay in response to his questions. Amanda is admit-
ted to the hospital with a concussion. A skull x-ray without contrast and brain MRI without contrast are
both performed.

Benjamin Johnston, MD—2222

556848/mt98328: 08/01/18 09:50:16  T: 08/01/18 12:55:01

Determine the most accurate ICD-10-PCS code(s) for the imaging procedure(s).

WESTWARD HOSPITAL
591 Chester Road
Masters, FL 33955

RADIOLOGIST REPORT
PATIENT: GRIFFTH, KERRAN
DATE OF ADMISSION: 08/19/18
DATE OF DISCHARGE: 08/23/18
PREOP DIAGNOSIS: Right ureteral obstruction secondary to colon cancer 
POSTOP DIAGNOSIS: Right ureteral obstruction secondary to colon cancer 
SURGEON: Roger Abernathy, MD
ANESTHESIA: Moderate sedation

CHAPTER 36  | 
CHAPTER 36 REVIEW

Operation:
1. Cystoscopy
2. Right retrograde pyelogram with contrast
3. Removal and replacement of double-J stent
HISTORY/INDICATIONS: This is a 32-year-old female with a history of colon cancer of the cecum and
secondary right ureteral obstruction who had a stent inserted a number of months ago. At this time, she
is in the hospital and it is time for a stent change. Consequently, the patient presents for the procedure.
PROCEDURE: The patient was taken to the operating room and there she was given midazolam, 0.5mg,
positioned in the dorsal lithotomy position, and the genitalia scrubbed and prepped with Betadine.
Sterile towels and sheets were utilized to drape the patient in the usual fashion. A cystoscope was intro-
duced into the bladder. The ureteral catheter was identified. It was grabbed and removed without any
difficulty. Subsequently, the cystoscope was reinserted into the bladder and the right ureteral orifice
was identified over a Pollack catheter. A glide wire was inserted into the right collecting system. Some
contrast was injected and a hydronephrotic right side was noted. Then, the wire was placed through the
Pollack catheter. With the wire in position, over the wire a 7 French 26 cm double-J stent was inserted.
Excellent coiling was noted fluoroscopically in the kidney and distally with a cystoscope. The bladder
was then drained and again it was inspected prior to removal. There was no evidence of any tumors or
lesions in the bladder. The stent was in good position. The cystoscope was removed and the patient
was taken to the recovery room awake and in stable condition.

Roger Abernathy, MD
556848/mt98328: 08/23/18 09:50:16  T: 08/23/18 12:55:01

Determine the most accurate ICD-10-PCS code(s) for the pyelogram.

WESTWARD HOSPITAL
591 Chester Road
Masters, FL 33955

RADIOLOGY SUMMARY
PATIENT: LACTANA, LAVINIA
DATE OF ADMISSION: 03/05/18
DATE OF DISCHARGE: 03/17/18
ADMITTING DIAGNOSIS: Bilateral breast asymmetry and ptosis, status post left lumpectomy and radia-
tion therapy for cancer.
DISCHARGE DIAGNOSIS: Bilateral breast asymmetry and ptosis, status post left lumpectomy and radia-
tion therapy for cancer.
This 41-year-old single female is status post surgery cleared for bilateral high dose brachytherapy with
palladium 103.
Patient tolerated her first treatment and was returned to her room.

Jennell Goren, MD
556845/mt98328: 03/17/18 09:50:16  T: 03/17/18 12:55:01

Determine the most accurate ICD-10-PCS code(s) for brachytherapy.

1108   PART V  |  INPATIENT (HOSPITAL) REPORTING

 CHAPTER 36 REVIEW
WESTWARD HOSPITAL
591 Chester Road
Masters, FL 33955
PATIENT: HARRINGTON, ROSA
DATE OF ADMISSION: 01/15/18
DATE OF DISCHARGE: 01/17/18
DIAGNOSIS: Appendicitis
ATTENDING PHYSICIAN: Dennis Beckham, MD
HISTORY OF PRESENT ILLNESS: This is a 39-year-old previously healthy female. She awoke this morn-
ing with pain in her abdomen. Her pain continued, periumbilical, and apparently now has traversed to
the right lower quadrant. On a 1 to 10 pain scale she states a 7 for pain. She has had some nausea and
vomiting. No history of inflammatory bowel disease, colon cancer, abdominal operations, or bleeding.
No urinary tract symptomatology.
PAST MEDICAL HISTORY: Noncontributory.
MEDICATIONS: None.
ALLERGIES: None.
SOCIAL HISTORY: No smoking.
FAMILY HISTORY: Unremarkable.
REVIEW OF SYSTEMS: As per ER intake chart.
PHYSICAL EXAMINATION:
HEENT: No scleral icterus.
NECK: Unremarkable.
HEART: No findings.
LUNGS: No findings.
ABDOMEN: Exquisite right lower quadrant tenderness. Positive focal rebound. No masses.
RECTAL: Unremarkable.
EXTREMITIES: Unremarkable.
LABORATORY AND DIAGNOSTIC STUDIES: White blood count is 25, otherwise unremarkable. An ultra-
sound of the appendix was performed. The patient has clear-cut possible retrocecal appendicitis.
RECOMMENDATIONS/PLAN: The patient has received antibiotics. The patient has consented to a lapa-
roscopic, possible open, appendectomy. She was counseled concerning the benefits and risks of the
surgery, including but not limited to bleeding, infection, death, and injury. All questions were answered
and she agreed to the procedure. We will place bilateral sequential compression devices and call
the operating room to have her scheduled as soon as possible.
Dennis Beckham, MD
556839/mt98328: 01/17/18 09:50:16  T: 01/17/18 12:55:01

Determine the most accurate ICD-10-PCS code(s) for the ultrasonography.

CHAPTER 36  | 
CHAPTER 36 REVIEW

WESTWARD HOSPITAL
591 Chester Road
Masters, FL 33955

HISTORY OF PRESENT ILLNESS ADMISSION

PATIENT: WAYFIELD, PORTER
DATE OF ADMISSION: 10/07/18
DATE OF DISCHARGE: 10/09/18
ADMITTING DIAGNOSIS: Cervical sprain C1–C7; lumbar strain L4–L5; multiple subluxation of cervical
spine. 
ATTENDING PHYSICIAN: Joanne Stafford, MD
This 31-year-old male was admitted after being involved in a two-car MVA 2 weeks ago. He saw his
family physician, Dr. Ashley Proctor, after experiencing constant neck pain radiating into the shoulders.
Pain medication and rest (no movement) provided temporary relief. Dr. Proctor suggested admission for
further evaluation.
In addition to neck pain, Pt states pain radiating across the lower back area beginning approximately
2 hours after the MVA. He states it hurts to move, bend, and walk. Pt denies similar pain in back or neck
before.
BP 122/85, P60. After review of patient history questionnaire, PE indicates general appearance is
age appropriate with average build and a protective gait. Normal lymph nodes: cervical; axillae; groin.
Upper and lower extremities appear normal with the exception of muscle strength in both arms and left
leg. Toe-walk exam rates 3 of 5. Limited-to-no ROM with pain C1–C7 and L4–L5. Pt exhibits spinal ten-
derness: cervical, dorsal, and lumbar. Evidence of edema: cervical and lumbar regions. Muscle spasms
evident: scalenes, traps, lat, and paraspinal.
Patient sent to Radiology for x-rays: cervical and lumbar. Radiologic results show multiple sublux-
ations of the cervical vertebrae with pain on movement. Dens and spinous process are intact. No breaks
or fractures. Lumbar spine is intact with no breaks or fractures.

JOANNE STAFFORD, MD
556845/mt98328: 10/09/18 09:50:16  T: 10/09/18 12:55:01

Determine the most accurate ICD-10-PCS code(s) for the imaging procedure(s).

1110   PART V  |  INPATIENT (HOSPITAL) REPORTING

Physical Rehabilitation
and Diagnostic Audiology
through New Technology
37
Sections
Learning Outcomes Key Terms
After completing this chapter, the student should be able to: Audiology
Biofeedback
LO 37.1 Recognize the details reported from the Physical Rehabilita- Detoxification
tion and Diagnostic Audiology Section. Psychotherapy
LO 37.2 Evaluate the details to determine services reported from the Rehabilitation
Mental Health Section. Substance Abuse
LO 37.3 Determine the specifics required to accurately report ser-
vices from the Substance Abuse Treatment Section.
LO 37.4 Interpret the documentation to report services from the New
Technology Section.
LO 37.5 Analyze documentation to report ICD-10-PCS codes from
sections F–X.

Remember, you need to follow along in

ICD-10-PCS
  STOP! your ICD-10-PCS code book for an
optimal learning experience.

37.1  Reporting Services from the

Physical Rehabilitation and Diagnostic
­Audiology Section
Character Definitions
The meanings for the Physical Rehabilitation and Diagnostic Audiology Section
characters are shown in the following table:

Character Position Character Meaning

1 Section of the ICD-10-PCS book
2 Section qualifier
3 Root type
4 Body system & region
5 Type qualifier
6 Equipment
7 Qualifier
 For the most part, these character positions have different meanings than in the other
sections you have already learned about.

Character Position 1: Physical Rehabilitation and Diagnostic

Audiology Section F
Character Position Character Meaning
1 Section of the ICD-10-PCS book
2 Section qualifier
3 Root type
4 Body system & region
5 Type qualifier
6 Equipment
7 Qualifier

Procedures reported from the Physical Rehabilitation and Diagnostic Audiology

section begin with the letter F.

Character Position 2: Section Qualifier

Character Position Character Meaning
1 Section of the ICD-10-PCS book
2 Section qualifier
3 Root type
4 Body system & region
5 Type qualifier
6 Equipment
7 Qualifier

There are only two options for the second character:

Rehabilitation Rehabilitation . . . Character: 0
Health care that is committed Diagnostic Audiology . . . Character: 1
to improving, maintaining, or
returning physical strength,
cognition, and mobility.
Character Position 3: Root Type
Audiology Character Position Character Meaning
The study of hearing, balance,
and related disorders. 1 Section of the ICD-10-PCS book
2 Section qualifier
3 Root type
4 Body system & region
5 Type qualifier
6 Equipment
7 Qualifier

The root type terms are unique to report procedures in this section.

1112   PART V  |  INPATIENT (HOSPITAL) REPORTING

 Under Rehabilitation, you will find these third character options:
Speech Assessment . . . Character: 0
Monitor and/or Nerve Function Assessment . . . Character: 1
Activities of Daily Living Assessment . . . Character: 2
Speech Treatment . . . Character: 6
Motor Treatment . . . Character: 7
Activities of Daily Living Treatment . . . Character: 8
Hearing Treatment . . . Character: 9
Cochlear Implant Treatment . . . Character: B
Vestibular Treatment . . . Character: C
Device Fitting . . . Character: D
Caregiver Training . . . Character: F
Under Diagnostic Audiology, you will find these third character options:
Hearing Assessment . . . Character: 3
Hearing Aid Assessment . . . Character: 4
Vestibular Assessment . . . Character: 5

Character Position 4: Body System & Region

Character Position Character Meaning
1 Section of the ICD-10-PCS book
2 Section qualifier
3 Root type
4 Body system & region
5 Type qualifier
6 Equipment
7 Qualifier
The specific body system being assessed or rehabilitated will be identified in this
character position. In some cases, these may not be specified, such as with some
speech assessment procedures or caregiver training. These are reported with a body
system of Z None.

EXAMPLES
Neurological System—Whole Body . . . Character: 3
Circulatory System—Upper Back/Upper Extremity . . . Character: 5
Genitourinary System . . . Character: N

Character Position 5: Type Qualifier

Character Position Character Meaning
1 Section of the ICD-10-PCS book
2 Section qualifier
3 Root type
4 Body system & region
5 Type qualifier
6 Equipment
7 Qualifier

CHAPTER 37  | 
 The character placed in this position will provide additional detail about the root type.

EXAMPLES
Under Root Type Speech Assessment, the fifth character may identify
Motor Speech (B) or Fluency (D)
while under Root Type Activities of Daily Living, the fifth character may report
Feeding/Eating (2) or Home Management (4)

Character Position 6: Equipment

Character Position Character Meaning
1 Section of the ICD-10-PCS book
2 Section qualifier
3 Root type
4 Body system & region
5 Type qualifier
6 Equipment
7 Qualifier
In this character position, you will report any equipment that was used during the
assessment or treatment.

EXAMPLES
F06Z9PZ Orofacial myofunctional speech treatment using a computer
F13ZC1Z Hearing assessment pure tone stenger, with audiometer

Character Position 7: Qualifier

Character Position Character Meaning
1 Section of the ICD-10-PCS book
2 Section qualifier
3 Root type
4 Body system & region
5 Type qualifier
6 Equipment
7 Qualifier
The only option in this position is
None . . . Character: Z

ICD-10-PCS
LET’S CODE IT! SCENARIO
Elias Garmine, a 67-year-old male, was admitted after having a stroke (CVA). Anita Cohen, a certified physical thera-
pist, is working with him on functional ambulation due to right-side hemiplegia.

1114   PART V  |  INPATIENT (HOSPITAL) REPORTING

 Let’s Code It!
Let’s go through the steps of coding for ICD-10-PCS and determine the code or codes that should be reported
for this encounter between Anita Cohen and Elias Garmine.
The documentation states that a certified physical therapist is performing the treatment, so this will lead you
to the Physical Rehabilitation Section.
First character: Section: Physical Rehabilitation & Diagnostic A
­ udiology . . . F
Second character: Section Qualifier: Rehabilitation . . . 0
What is the type of treatment, or for what purpose is this being done? The documentation states, “functional
ambulation,” which addresses motor function. Read carefully. This is motor treatment, not assessment.
Third character: Root Type: Motor Treatment . . . 7
Read the long list of body system/region options. You will note that none of them actually fits this circumstance.
Fourth character: Body Region: None . . . Z
What type of treatment is Anita providing to Elias? The documentation states, “functional ambulation.”
Fifth character: Type Qualifier: Gait Training/Functional ­Ambulation . . . 9
Did Anita use any equipment in her work with Elias? None is documented.
Sixth character: Equipment: None . . . Z
There is only one option for the seventh character.
Seventh character: Qualifier: None . . . Z
The ICD-10-PCS code you will report is this:
F07Z9ZZ Gait training/functional ambulation
Good job!

37.2  Reporting Services from the Mental

Health Section
Character Definitions
The meanings for the Mental Health Section characters are shown in the following
table:

Character Position Character Meaning

1 Section of the ICD-10-PCS book
2 Body system
3 Root type
4 Type qualifier
5 Qualifier
6 Qualifier
7 Qualifier

CHAPTER 37  | 
 Character Position 1: Mental Health Section G
Character Position Character Meaning
1 Section of the ICD-10-PCS book
2 Body system
3 Root type
4 Type qualifier
5 Qualifier
6 Qualifier
7 Qualifier
Procedures reported from the Mental Health Section will begin with the letter G.

Character Position 2: Body System

Character Position Character Meaning
1 Section of the ICD-10-PCS book
2 Body system
3 Root type
4 Type qualifier
5 Qualifier
6 Qualifier
7 Qualifier
There is only one option for the second character:
None . . . Character: Z

Character Position 3: Root Type

Character Position Character Meaning
1 Section of the ICD-10-PCS book
2 Body system
3 Root type
4 Type qualifier
5 Qualifier
6 Qualifier
7 Qualifier
There are 12 root types used in this section.
Psychological Tests: Include developmental, intellectual, psychoeducational, neu-
robehavioral, cognitive, neuropsychological, personality, and/or behavioral test-
ing . . . Character: 1
Crisis Intervention: Includes defusing, debriefing, counseling, psychotherapy, and/
or coordination of care with other providers or agencies . . . Character: 2
Medication Management: Analyzing and varying the dosage of medication to find
the most efficacious balance, especially when the patient is taking several differ-
ent pharmaceuticals . . . Character: 3

1116   PART V  |  INPATIENT (HOSPITAL) REPORTING

 Individual Psychotherapy: Includes behavior, cognitive, interactive, interpersonal, Psychotherapy
psychoanalysis, psychodynamic, psychophysiological, and/or supportive . . . The treatment of mental and
Character: 5 emotional disorder through
communication or psycho-
Counseling: Exploration of vocational interest, aptitudes, and required adaptive
logically rather than medical
behavior skills to develop and carry out a plan for achieving a successful voca-
means.
tional placement, enhancing work-related adjustment, and/or pursuing viable
options in training education or preparation . . . Character: 6
Family Psychotherapy: Remediation of emotional or behavioral problems pre-
sented by one or more family members when psychotherapy with more than one
family member is indicated . . . Character: 7
Electroconvulsive Therapy: Includes appropriate sedation and other preparation of
the individual . . . Character: B
Biofeedback: Includes electroencephalogram (EEG), blood pressure, skin tem- Biofeedback
perature, or peripheral blood flow, electrocardiogram (ECG), electrooculogram, Training to gain voluntary
electromyogram (EMG), respirometry or capnometry, galvanic skin response control of automatic bodily
(GSR) or electrodermal response (EDR), perineometry to monitor and regulate functions.
bowel or bladder activity and electrogastrogram to monitor and regulate gas-
tric motility . . . Character: C
Hypnosis: Induction of a state of heightened suggestibility by auditory, visual, and
tactile techniques to elicit an emotional or behavioral response . . .
Character: F
Narcosynthesis: Administration of intravenous barbiturates in order to release sup-
pressed or repressed thoughts . . . Character: G
Group Psychotherapy: Treatment of two or more individuals with a mental health
disorder by behavioral, cognitive, psychoanalytic, psychodynamic or psycho-
physiological means to improve functioning or well-being . . . Character: H
Light Therapy: Application of specialized light treatments to improve functioning or
well-being . . . Character: J

Character Position 4: Type Qualifier

Character Position Character Meaning
1 Section of the ICD-10-PCS book
2 Body system
3 Root type
4 Type qualifier
5 Qualifier
6 Qualifier
7 Qualifier
This character will explain whether the procedure was educational or vocational, pro-
viding more detail about the encounter. The descriptors presenting these additional
details will be represented by the same characters, but they change by the root type.

EXAMPLES
Developmental . . . Character: 0, under Psychological Tests
Interactive . . . Character: 0, under Individual Psychotherapy
Educational . . . Character: 0, under Counseling
Unilateral-Single Seizure . . . Character: 0, under Electroconvulsive Therapy

CHAPTER 37  | 
 Character Position 5: Qualifier
Character Position Character Meaning
1 Section of the ICD-10-PCS book
2 Body system
3 Root type
4 Type qualifier
5 Qualifier
6 Qualifier
7 Qualifier
The only option in this position is
None . . . Character: Z

Character Position 6: Qualifier

Character Position Character Meaning
1 Section of the ICD-10-PCS book
2 Body system
3 Root type
4 Type qualifier
5 Qualifier
6 Qualifier
7 Qualifier
The only option in this position is
None . . . Character: Z

Character Position 7: Qualifier

Character Position Character Meaning
1 Section of the ICD-10-PCS book
2 Body system
3 Root type
4 Type qualifier
5 Qualifier
6 Qualifier
7 Qualifier
The only option in this position is
None . . . Character: Z

ICD-10-PCS
LET’S CODE IT! SCENARIO
While in the hospital for repair of a stomach ulcer, Carlos Weiner, a 53-year-old male, was behaving oddly.
Dr. Albessi performed some neuropsychological testing.

1118   PART V  |  INPATIENT (HOSPITAL) REPORTING

 Let’s Code It!
Let’s go through the steps of coding for ICD-10-PCS and determine the code or codes that should be reported
for this encounter between Dr. Albessi and Carlos Weiner.
Psychological testing brings us to the Mental Health Section.
First character: Section: Mental Health . . . G
There is only one option for the body region in this section.
Second character: Body Region: None . . . Z
What was done? The documentation states, “neuropsychological testing.”
Third character: Root Type: Psychological Tests . . . 1
Specifically . . .
Fourth character: Type Qualifier: Neuropsychological . . . 3
There are no more details to be reported with the last three characters.
Fifth character: Qualifier: None . . . Z
Sixth character: Qualifier: None . . . Z
Seventh character: Qualifier: None . . . Z
The ICD-10-PCS code you will report is
GZ13ZZZ Neuropsychological testing
Good job!

37.3  Reporting from the Substance Abuse

Treatment Section
Character Definitions
The meanings for the Substance Abuse Section characters are shown in the following table:

Character Position Character Meaning

1 Section of the ICD-10-PCS book
2 Body systems
3 Root type
4 Type qualifier
5 Qualifier
6 Qualifier
7 Qualifier

Character Position 1: Substance Abuse Section H

Character Position Character Meaning
1 Section of the ICD-10-PCS book
2 Body systems

(continued)

CHAPTER 37  | 
 Character Position Character Meaning
3 Root type
4 Type qualifier
5 Qualifier
6 Qualifier
7 Qualifier
Substance Abuse Procedures reported from the Substance Abuse Treatment Section will all begin
Regular consumption of a sub- with the letter H.
stance with manifestations.
Character Position 2: Body Systems
Character Position Character Meaning
1 Section of the ICD-10-PCS book
2 Body systems
3 Root type
4 Type qualifier
5 Qualifier
6 Qualifier
7 Qualifier
There is only one option for the second character:
None . . . Character: Z

Character Position 3: Root Type

Character Position Character Meaning
1 Section of the ICD-10-PCS book
2 Body systems
3 Root type
4 Type qualifier
5 Qualifier
6 Qualifier
7 Qualifier
There are seven root operation terms used to report procedures in this section:
Detoxification Detoxification Services: Not a treatment modality but helps the patient stabilize
The process of removing toxic physically and psychologically until the body becomes free of drugs and the
substances or qualities. effects of alcohol . . . Character: 2
Individual Counseling: Comprising several techniques, which apply various strate-
gies to address drug addiction . . . Character: 3
Group Counseling: Provides structured group counseling sessions and healing
power through the connection with others . . . Character: 4
Individual Psychotherapy: Treatment of an individual with addictive behavior by
behavioral, cognitive, psychoanalytic, psychodynamic, or psychophysiological
means . . . Character: 5
Family Counseling: Provides support and education for family members of addicted
individuals. Family member participation seen as critical to substance abuse
treatment . . . Character: 6

1120   PART V  |  INPATIENT (HOSPITAL) REPORTING

 Medication Management: Monitoring or adjusting the use of replacement medica-
tions for the treatment of addiction . . . Character: 8
Pharmacotherapy: The use of replacement medications for the treatment of addic-
tion . . . Character: 9

Character Position 4: Type Qualifier

Character Position Character Meaning
1 Section of the ICD-10-PCS book
2 Body systems
3 Root type
4 Type qualifier
5 Qualifier
6 Qualifier
7 Qualifier
This character will add detail to the description of the root type.

EXAMPLES
12-Step . . . Character: 3, under Individual Counseling
Interactive . . . Character: 5, under Individual Psychotherapy
Nicotine Replacement . . . Character: 0, under Pharmacotherapy

Character Position 5: Qualifier

Character Position Character Meaning
1 Section of the ICD-10-PCS book
2 Body systems
3 Root type
4 Type qualifier
5 Qualifier
6 Qualifier
7 Qualifier
In this character position, the only option is
None . . . Character: Z

Character Position 6: Qualifier

Character Position Character Meaning
1 Section of the ICD-10-PCS book
2 Body systems
3 Root type
4 Type qualifier
5 Qualifier
6 Qualifier
7 Qualifier

CHAPTER 37  | 
 In this character position, the only option is
None . . . Character: Z

Character Position 7: Qualifier

Character Position Character Meaning
1 Section of the ICD-10-PCS book
2 Body systems
3 Root type
4 Type qualifier
5 Qualifier
6 Qualifier
7 Qualifier

In this character position, the only option is

None . . . Character: Z

ICD-10-PCS
LET’S CODE IT! SCENARIO
Harrison Argan has been in the New Horizons Substance Abuse Rehabilitation Hospital for 2 weeks now. Today,
Dr. Lerner meets with Harrison for medication management with his methadone maintenance treatment plan.

Let’s Code It!

Let’s go through the steps of coding for ICD-10-PCS and determine the code or codes that should be reported
for this encounter between Dr. Lerner and Harrison Argan.
For a patient that has been admitted to a Substance Abuse Rehabilitation Hospital, the section choice is clear.
First character: Section: Substance Abuse . . . H
There is only one option for the second character.
Second character: Body System: None . . . Z
What was Dr. Lerner doing for Harrison at this session? The documentation states, “for medication management.”
Third character: Root Type: Medication Management . . . 8
What specifics were focused on? The documentation states, “methadone maintenance.”
Fourth character: Type Qualifier: Methadone Maintenance . . . 1
There are no additional details to be reported with the last three characters.
Fifth character: Qualifier: None . . . Z
Sixth character: Qualifier: None . . . Z
Seventh character: Qualifier: None . . . Z
The ICD-10-PCS code you will report is
HZ81ZZZ Medication management for methadone maintenance
Good job!

1122   PART V  |  INPATIENT (HOSPITAL) REPORTING

37.4  Reporting from the New
Technology Section
Character Definitions
As you learned earlier, every ICD-10-PCS code has seven characters, and each charac-
ter position has a meaning. While all of these codes have the same number of charac-
ters, each section uses each character position differently. So, let’s review the meanings
for the New Technology Section characters:

Character Position Character Meaning

1 Section of the ICD-10-PCS book
2 Body system being treated
GUIDANCE
CONNECTION
3 Root operation term
Read the ICD-10-PCS
4 Body part (specific anatomical site)
Official Guidelines for
5 Approach used by physician Coding and Reporting,
6 Device/Substance/Technology D. New Technology
Section, subhead Gen-
7 Qualifier, if applicable eral guidelines, para-
You might have noticed that these are different meanings from those used in the graph D1.
Medical and Surgical and other sections.

Character Position 1: New Technology Section X

Character Position Character Meaning
1 Section of the ICD-10-PCS book
2 Body system being treated
3 Root operation term
4 Body part (specific anatomical site)
5 Approach used by physician
6 Device/Substance/Technology
7 Qualifier
The codes reported from the New Technology Section (X) are used to identify a specific
procedure. They are not to be used to add detail or information about a procedure reported
from another section, nor do they require any additional codes to supplement their mean-
ing. They are complete in and of themselves to explain what was provided to the patient.

Character Position 2: Body System Being Treated

Character Position Character Meaning
1 Section of the ICD-10-PCS book
2 Body system being treated
3 Root operation term
4 Body part (specific anatomical site)
5 Approach used by physician
6 Device/Substance/Technology
7 Qualifier

CHAPTER 37  | 
 Currently, in this section, there are only five body systems from which to choose:
Cardiovascular System . . . Character: 2
Skin, Subcutaneous Tissue, Fascia, and Breast . . . Character: H
Muscles, Tendons, Bursae and Ligaments . . . Character: K
Bones . . . Character: N
Joints . . . Character: R
Anatomical Regions . . . Character: W
Extracorporeal . . . Character: Y

Character Position 3: Root Operation

Character Position Character Meaning
1 Section of the ICD-10-PCS book
2 Body system being treated
3 Root operation term
4 Body part (specific anatomical site)
5 Approach used by physician
6 Device/Substance/Technology
7 Qualifier
The options are limited for the choice of this character, as well:
Assistance: Taking over a portion of a physiological function by extracorporeal
means . . . Character: A
Extirpation: Extirpation is a procedure where the physician is cutting out or taking
out solid matter from a body part . . . Character: C
Fusion: Joining together portions of an articular body part rendering the articular
body part immobile . . . Character: G
Introduction: Introduction is the process of putting in, or on, a substance for thera-
peutic, diagnostic, nutritional, physiological or prophylactic purposes. Blood and
blood products are excluded . . . Character: 0
Monitoring: Monitoring is described in ICD-10-PCS as the determination, repeat-
edly over a period of time, of the level(s) of a physiological or a physical function
. . . Character: 2
Replacement: Putting in or on biological or synthetic material that physically takes
the place and/or function of all or a portion of a body part . . . Character: R
Reposition: Moving to its normal location, or other suitable location, all or a portion
of a body part . . . Character: S

Character Position 4: Body Part

Character Position Character Meaning
1 Section of the ICD-10-PCS book
2 Body system being treated
3 Root operation term
4 Body part (specific anatomical site)
5 Approach used by physician
6 Device/Substance/Technology
7 Qualifier

1124   PART V  |  INPATIENT (HOSPITAL) REPORTING

The options for the body part that is the objective of this procedure are also limited in
number:
Cardiovascular System
Coronary Artery, One Artery . . . Character: 0 Innominate Artery and Left Common Carotid
Coronary Artery, Two Arteries . . . Character: 1 Artery . . . Character: 5
Coronary Artery, Three Arteries . . . Character: 2 Aortic Valve . . . Character: F
Coronary Artery, Four or More Arteries . . . Character: 3
Skin, Subcutaneous Tissue, Fascia, and Breast
Skin . . . Character: P
Muscles, Tendons, Bursae and Ligaments
Muscle . . . Character: 2
Bones
Lumbar Vertebra . . . Character: 0
Cervical Vertebra . . . Character: 3
Thoracic Vertebra . . . Character: 4
Joints
Knee Joint, Right . . . Character: G Thoracic Vertebral Joints, 2 to 7 . . . Character: 7
Knee Joint, Left . . . Character: H Thoracic Vertebral Joints, 8 or more . . . Character: 8
Occipital-Cervical Joint . . . Character: 0 Thoracolumbar Vertebral Joint . . . Character: A
Cervical Vertebral Joint . . . Character: 1 Lumbar Vertebral Joint . . . Character: B
Cervical Vertebral Joints, 2 or more . . . Character: 2 Lumbar Vertebral Joints, 2 or more . . . Character: C
Cervicothoracic Vertebral Joint . . . Character: 4 Lumbosacral Joint . . . Character: D
Thoracic Vertebral Joint . . . Character: 6
Anatomical Regions
Peripheral Vein . . . Character: 3
Central Vein . . . Character: 4
Mouth and Pharynx . . . Character: D
Extracorporeal
Vein Graft . . . Character: 4

Character Position 5: Approach

Character Position Character Meaning
1 Section of the ICD-10-PCS book
2 Body system being treated
3 Root operation term
4 Body part (specific anatomical site)
5 Approach used by physician
6 Device/Substance/Technology
7 Qualifier
This position’s character options should be familiar to you, at this point.
Open: An open approach is one that uses cutting through the skin or mucous mem-
brane and any other body layers necessary to expose the site of the procedure
. . . Character: 0
Percutaneous: A percutaneous approach is described by ICD-10-PCS as entry,
by puncture or minor incision, of instrumentation through the skin or mucous
membrane and any other body layers necessary to reach the site of the proce-
dure . . . Character: 3
Percutaneous Endoscopic: Entry, by puncture or minor incision, of instrumentation
through the skin or mucous membrane and any other body layers necessary to
reach and visualize the site of the procedure . . . Character: 4

CHAPTER 37  | 
 External: Procedures performed directly on the skin or mucous membrane and
procedures performed indirectly by the application of external force through the
skin or mucous membrane . . . Character: X

Character Position 6: Device/Substance/Technology

Character Position Character Meaning
1 Section of the ICD-10-PCS book
2 Body system being treated
3 Root operation term
4 Body part (specific anatomical site)
5 Approach used by physician
6 Device/Substance/Technology
7 Qualifier
The devices described in this column’s options are new and different from those most
of us have encountered. They are listed by the body system being treated.
Cardiovascular System
Cerebral Embolic Filtration, Dual Filter: Cerebral embolic dual-filtration units are
designed to protect the brain from injury caused by embolic debris, specifically
in patients diagnosed with aortic stenosis having a transcatheter aortic valve
replacement (TAVR) procedure . . . Character: 1
Orbital Atherectomy Technology: Orbital atherectomy is used to treat patients with
severely calcified coronary lesions as well as symptomatic peripheral arterial dis-
ease (PAD) within the major and branch arteries of the leg. The FDA also cleared the
orbital atherectomy system (OAS) to treat stenosis in synthetic arteriovenous shunts
that are often used to provide vascular access for dialysis patients . . . Character: 6
Zooplastic Tissue, Rapid Deployment Technique: The use of zooplastic tissue with
rapid deployment technique on an aortic valve can now be reported . . . Character: 3

Skin, Subcutaneous Tissue, Fascia, and Breast

Skin Substitute, Porcine Liver Derived: The use of porcine liver skin substitute can
now be reported accurately . . . Character: L
Muscles, Tendons, Bursae and Ligaments Concentrated Bone Marrow Aspirate . . .
Character: 0

Bones
Magnetically Controlled Growth Rod(s): Magnetically controlled growth rods are
new innovations, especially for children requiring spinal surgery for scoliosis.
Instead of sequential surgical procedures to adjust the rods as children grow,
the surgeon can use a magnetic device, in the office, to lengthen the rods, in just
minutes . . . Character: 3

Joints
Intraoperative Knee Replacement Sensor: Intraoperative sensors are a disposable
tibial insert used to aid orthopedic surgeons in placing prosthetic joint compo-
nents during knee replacement surgery . . . Character: 2
Interbody Fusion Device, Nanotextured Surface: The fusion of vertebral joints is
not new, but the use of the nanotextured surface is now reported with a code
built from this new table . . . Character: 9
Interbody Fusion Device, Radiolucent Porous . . . Character: F

Anatomical Regions
Ceftazidime-Avibactam Anti-infective: This is provided for the treatment of adult
patients with complicated intra-abdominal infections and complicated urinary tract

1126   PART V  |  INPATIENT (HOSPITAL) REPORTING

 infections including pyelonephritis caused by designated susceptible bacteria,
including certain Enterobacteriaceae and Pseudomonas aeruginosa . . . Character: 2
Idarucizumab, Dabigatran Reversal Agent: Idarucizumab is an antibody frag-
ment that was developed to reverse the anticoagulant effects of dabigatran
(Pradaxa) . . . Character: 3
Isavuconazole Anti-infective: This is used for the treatment of invasive aspergillosis
and treatment of invasive mucormycosis in patients 18 years and
older . . . Character: 4
Blinatumomab Antineoplastic Immunotherapy: This is used for the treatment of
patients with Philadelphia chromosome-negative relapsed or refractory B-cell
precursor acute lymphoblastic leukemia . . . Character: 5
Andexanet Alfa, Factor Xa Inhibitor Reversal Agent: Andexanet Alfa is a new drug that
reverses the blood-thinning reactions caused by Factor Xa inhibitors (an anticoagu-
lant that directly works on Factor X of the coagulation cascade in the blood), when a
Factor Xa has been administered in the wrong dosage or in error . . . Character: 7
Uridine Triacetate: Uridine triacetate is a new drug that, when taken orally, com-
bats the adverse effects of chemotherapy overdoses, as well as helps those
who manifest life-threatening toxicities within four days of having chemo-
therapy administered. Currently, this treatment is effective when fluorouracil or
capecitabine are the drugs causing this adverse effect . . . Character: 8
Defibrotide Sodium Anticoagulant: Defibrotide Sodium anticoagulant is adminis-
tered as a therapeutic treatment for patients diagnosed with hepatic veno-occlu-
sive disease (VOD) after having a hematopoietic stem cell transplantation (HSCT)
[also known as a bone marrow transplant] . . . Character: 9
Beziotoxumab Monoclonal Antibody: Beziotoxumab is a version of human mono-
clonal antibody designed to neutralize the toxin produced by the C. diff bacteria
which is known to possibly damage the patient’s intestinal walls . . . Character: A
Cytarabine and Daunorubicin Liposome Antineoplastic: Liposomal daunorubicin
may be helpful in overcoming multidrug resistance in high-risk acute leukemia
. . . Character: B
Engineered Autologous Chimeric Antigen Receptor T-cell Immunotherapy: Chi-
meric antigen receptor (CAR) therapy can be compared to autologous bone mar-
row transplantation. T cells are collected by apheresis, and then, expanded and
genetically modified . . . Character: C
Other New Technology Therapeutic Substance . . . Character: F

Extracorporeal
Endothelial Damage Inhibitor: Endothelial dysfunction describes manifestations
of cardiovascular risk including diminished production and reduced availability
of nitric oxide as well as the possible imbalance in the relative contribution of
endothelium-derived relaxing and contracting factors . . . Character: 8

Character Position 7: Qualifier

Character Position Character Meaning
1 Section of the ICD-10-PCS book
2 Body system being treated
3 Root operation term
4 Body part (specific anatomical site)
5 Approach used by physician
6 Device/Substance/Technology
7 Qualifier

CHAPTER 37  | 
 The reporting of these procedures will use the character 1 (the number one) or 2 (the
number two). Each year, this character will change as new codes are added to this
specific section. So, for 2017, the seventh character options are
New Technology Group 1 . . . Character: 1
New Technology Group 2 . . . Character: 2
New Technology Group 3 . . . Character: 3
The next year that innovations are approved and added to the code set, they will be
identified with a qualifier of 3. This will continue each year, as new details are placed
into the code set.

ICD-10-PCS
LET’S CODE IT! SCENARIO
Carl Terrosa, a 45-year-old male, has been trying to lower his cholesterol; however, he was diagnosed with two
severely calcified coronary lesions. He was admitted to the hospital so Dr. Garrison could perform orbital atherec-
tomy, a new technology to remove the calcification in two sites. Unlike some previous methodologies, this is per-
formed percutaneously, reducing the risk and Carl’s length of stay.

Let’s Code It!

Let’s go through the steps of coding for ICD-10-PCS and determine the code or codes that should be reported
for the procedure that was performed.
In the Alphabetic Index, look up
Orbital Atherectomy Technology X2C
Turn to the ICD-10-PCS Table beginning X2C
First character: Section: New Technology . . . X
The notes state the patient has “coronary lesions,” which are part of the cardiovascular system.
Second character: Body System: Cardiovascular System . . . 2
The removal of the calcification fits the definition of extirpation.
Third character: Root Operation: Extirpation . . . C
An “atherectomy” is the surgical removal of fatty deposits located in an artery.
Fourth character: Body Part: Coronary Arteries, Two Arteries . . . 1
The notes state the procedure was performed percutaneously.
Fifth character: Approach: Percutaneous . . . 3
The notes state that an orbital atherectomy system was used.
Sixth character: Device: Orbital Atherectomy Technology . . . 6
Seventh character: Qualifier: New Technology Group 1 . . . 1
The ICD-10-PCS code you will report is this:
X2C1361 Orbital Atherectomy Technology, extirpation, coronary arteries, two sites

37.5  Sections F–X: Putting It All Together

ICD-10-PCS
LET’S CODE IT! SCENARIO
PATIENT NAME: ALFREDO SUGERMAN
DATE OF EVALUATION: 11/16/2018
ATTENDING PHYSICIAN: Oscar Clarice, MD

1128   PART V  |  INPATIENT (HOSPITAL) REPORTING

HISTORY OF PRESENT ILLNESS: This is a 71-year-old male with a history of end-stage COPD, previous CVA, seizure
disorder, chronic headaches, and chronic pain syndrome who was admitted to the hospital yesterday for increas-
ing pain all over the body. He has also expressed feelings of severe depression, and a psychiatric consultation was
requested for evaluation of the same. The patient reports that he had been going through a lot for the past few
months. He was referring to his medical problems, chronic obstructive pulmonary disease, especially the pain all over
the body for which no clear organic reason has been found so far. He says that he is in pain all the time, constantly.
He is tired of it. He cannot take care of himself, and he was recently in a nursing home but had a bad experience over
there. He does not want to go back to the nursing home. He was living with a woman for 15 years, but she is not able
to take care of him. He was very helpless and hopeless, and he voices passive death wishes but denies any active
intentions. He says that he will never do that to himself. Patient admits to having insomnia and extremely depressed
crying episodes and reports very poor energy level, motivation, loss of interest, and feeling sad and unhappy all the
time. He had some depression symptoms in the past, related to the medical problems, and was placed on Lexapro
and Seroquel for sleep for the past few weeks, but it is not helping. Seroquel helped for his sleep, but he does not
want this medication as he knows this is an antipsychotic. He denies any delusions or hallucinations.
PAST PSYCHIATRIC HISTORY: No history of any psychiatric illness or psychiatric hospitalization or any suicidal
attempts in the past.
CURRENT MEDICATIONS: On admission, Protonix, Synthroid, Nitro-Dur patches, Tenormin 25 mg once a day, Ditro-
pan, Atrovent, Nasonex, multivitamins, Os-Cal, Bumex, Imdur, Micro-K, Lexapro 10 mg daily, magnesium oxide, Klonopin
0.25 mg every 12 hours, Seroquel 100 mg nightly, Phenergan p.r.n., and Pulmicort inhaler.
ALLERGIES: NONSTEROIDAL ANTI-INFLAMMATORY DRUGS AND SULFA DRUGS.
PSYCHIATRIC MENTAL STATUS EXAMINATION: The patient is a thinly built male who appears to be in moderate
distress from pain. He is generally cooperative and pleasant; he shows significant psychomotor retardation but no
agitation. He speaks in a very low volume voice. He is alert and oriented in all three spheres. Memory grossly intact in
all modalities. Speech is coherent. Mood is depressed, tearful, constricted affect. No evidence of any overt psychosis
or hypomania. He does have passive death wishes; however, he denies any active suicidal intentions or thoughts.
Insight and judgment questionable. Intellectual abilities in average normal range.
IMPRESSIONS: Neurobehavioral and cognitive status tests along with my observations lead to these impressions:
Axis I: Major depression, single episode, moderate to severe with anxiety component.
Axis II: Deferred.
Axis III: Chronic pain syndrome, narcotic dependence, chronic obstructive pulmonary disease, status post cere-
brovascular accident, and seizure disorder.
RECOMMENDATIONS: The patient does not appear to be responding to his current psychotropic medications, so
we will discontinue the Lexapro and Seroquel. Instead, we will use Effexor XR 37.5 mg once a.m. and also Desyrel
50 mg nightly. We will continue to monitor the patient closely.

Let’s Code It!

Dr. Clarice performed neurobehavioral and cognitive status psychological tests as a part of his evaluation of
Mr. Sugerman. Let’s work our way through the Mental Health Section . . . because this was a psychological evaluation.
First character: Section: Mental Health . . . G
Second character: System: None . . . Z
What did Dr. Clarice actually do? The documentation states, “PSYCHIATRIC MENTAL STATUS EXAMINATION.”
Third character: Root Operation: Psychological Tests . . . 1
Review the options for the fourth character in Table GZ1. The documentation states, “Neurobehavioral and
cognitive status tests.”
Fourth character: Type Qualifier: Neurobehavioral and Cognitive Status . . . 4
Fifth character: Qualifier: None . . . Z

(continued)

CHAPTER 37  | 
 Sixth character: Qualifier: None . . . Z
Seventh character: Qualifier: None . . . Z
Now, you can report this ICD-10-PCS code with confidence:
GZ14ZZZ Neurobehavioral and cognitive status psychological tests

ICD-10-PCS
LET’S CODE IT! SCENARIO
PATIENT: FRANCIS FREDERICKS
The patient had been seen by this department for a clinical swallowing evaluation. At that time, he had reported 3 to
4 months of coughing with liquids, approximately one time per week. He had a barium swallow, which showed one
episode of aspiration with appropriate cough response. Given the patient’s complaints of coughing with thin liquids
and possible reflux-related symptoms, an objective swallowing evaluation was recommended. However, the patient
chose not to follow up for further objective testing at that time. 
Admitted today for left side weakness, he is reporting that dysphagia has persisted, and now he feels as though
he can cough or choke several times a day with either liquids or solids. He is on a regular diet. He takes his pills with
water without difficulty. He has a reported 5- to 10-pound weight loss over the past several months that has been
unexplained. His physician has asked him to gain some weight to improve his nutritional status. He has no recent
history of pneumonia. The patient does complain of feeling as though he has sluggish passage of his meals and
sometimes this will cause him to stop eating early. He has a feeling of increased mucus with frequent throat clear-
ing throughout the day, and he complains of frequent heartburn. He is not on any proton pump inhibitor regimen at
this time.
PAST MEDICAL HISTORY: Coronary artery disease requiring LAD stent placement, hypertension, hyperlipid-
emia, asymptomatic right carotid stenosis, chronic anemia due to renal disease, chronic renal insufficiency that
is stable.
CLINICAL OBSERVATIONS: I am performing this swallow dysfunction study at the request of Dr. King. He uses a
walker due to knee trouble and the weakness, but he is brought to our office by an orderly in a wheelchair. He is fully
alert and oriented, slightly hard of hearing. He is able to provide a comprehensive history. Good speech intelligibility.
Vocal quality is slightly raspy, although otherwise within normal limits for age and gender.
ORAL PERIPHERAL EXAM: The patient has naturally present dentition, in poor condition. There is bilateral palatal
elevation, good lingual and labial strength and range of motion, and good ability to maintain intraoral pressure.
Cough is strong and unproductive. There is good hyolaryngeal elevation and excursion to palpation.
SWALLOWING EVALUATION: Administered p.o. trials of ice chips, thin puree, and particulate solid.
ORAL PHASE: The patient is able to self-feed appropriately. He has good bolus containment and timely anterior to
posterior transit with mildly delayed trigger of pharyngeal swallow overall. Question premature spillage with multiple
sips of thin liquids.
PHARYNGEAL PHASE: Audible and question slightly discoordinated swallowing pattern for multiple sips of thin liq-
uids. One swallow required for single sips of thin, puree, and particulate solids. No overt clinical signs or symptoms
of aspiration after any p.o. trial, although the patient reports that he had slight difficulty with the initial sip of water,
feeling like it might head down the wrong pipe.
SUMMARY AND IMPRESSION: The patient is an 87-year-old male with a several-year history of reported dys-
phagia to solids and liquids. This can happen several times per day. Clinically, he does not show significant overt
clinical signs of aspiration, although question discoordinated swallowing pattern for thin liquids, especially when
given larger quantities. This is likely consistent with the one incidence of symptomatic aspiration on a barium swal-
low in the past. The patient also complains of multiple symptoms that appear consistent with laryngopharyngeal
reflux, and these include increased mucus, throat clearing, and globus sensation. He reports frequent heartburn

1130   PART V  |  INPATIENT (HOSPITAL) REPORTING

and sensation of slow esophageal passage. At this time, would recommend objective testing to further evaluate
oropharyngeal swallowing mechanism to determine if coordination of swallowing pattern has been affected over
time. Further differential diagnosis would be considerable reflux in current complaints. The patient may benefit from
a proton pump inhibitor regimen if deemed appropriate by his physicians. At today’s session, discussed aspiration
precautions, especially given that the patient self-reported drinks multiple sips at a time. In addition, reflux precau-
tions were recommended, including sitting upright 90 degrees with all p.o. and for 1 hour after meals. The patient
was also counseled to monitor his nutritional intake. If he is indeed shortening meals due to sensation of sluggish
passage, would recommend multiple smaller meals a day rather than three large ones to allow for adequate nutri-
tional intake. The patient understands all given recommendations and is in agreement for a follow-up with an objec-
tive swallowing test.
RECOMMENDATIONS:
1. Regular diet with thin liquids.
2. Medications one at a time with water.
3. Further objective testing via modified barium swallow.
4. Upright 90 degrees with all p.o. and for 1 hour after meals.
5. Decrease bolus size and rate of presentation.
6. Single bites and single sips.
7. Consideration of proton pump inhibitor regimen if reflux is deemed by the patient’s physicians to be playing a role
in the patient’s current symptoms.
8. Further recommendations will be made pending outcome of objective study.
Gail Robbins
Speech-Language Pathologist

Let’s Code It!

This assessment contains a speech evaluation and a swallow study. Look in the ICD-10-PCS Alphabetic Index;
there is no listing for swallow or swallow study. Let’s try this:
Speech Assessment F00
At least it is a place to start, so turn to the F00 Table:
First character: Section: Physical Rehabilitation and Diagnostic Audiology . . . F
This makes sense. The category of speech and swallow studies is considered part of physical rehabilitation.
Second character: System: Rehabilitation . . . 0
Third character: Root Operation: Speech Assessment . . . 0
You may be thinking that this cannot be correct because this was really a swallow study. That’s good thinking,
but let’s continue to review the options in this Table before we go looking elsewhere.
Fourth character: Body System/Region: None . . . Z
Read carefully all of the options for the fifth character. Bedside Swallowing and Oral Function sounds close,
except the documentation states, “he is brought to our office by an orderly in a wheelchair.” This tells us this was
not done bedside. The next row has a good possibility that works:
Fifth character: Type Qualifier: Instrumental Swallowing and Oral Function . . . J
Review the options for the sixth character. This is straightforward.
Sixth character: Equipment: Swallowing . . . W
Seventh character: Qualifier: None . . . Z
When we take this coding process one step at a time, it is not as confusing as one might perceive. You can now
put this all together and, with confidence, report this code:
F00ZJWZ Instrumental swallowing and oral function assessment

CHAPTER 37  | 
 ICD-10-PCS
LET’S CODE IT! SCENARIO
George is a 19-year-old male, self-referred for inpatient treatment due to drug and alcohol abuse. He is currently
unemployed and homeless, and has charges pending due to a number of “bounced” checks written over the past
several months. George reports that both of his parents were drug addicts and he experienced physical, sexual, and
emotional abuse throughout childhood at their hands. His father died of liver disease at the age of 37.
George also reports that, at the age of 12, he was kicked out of his family’s home because his father suspected
that he was gay. Although they live in the same town, he has not had any contact with either parent for 7 years.
George describes his relationship with his younger sister as “fair.” He is not presently involved in a steady relation-
ship but does have a network of friends in the local gay community with whom he has been staying off and on. At
the time that he left home, George survived by becoming involved in sexual relationships with older men, many of
whom were also abusive. He has had numerous sexual partners (both male and female) over the past 7 years, has
traded sex for drugs and money, has had sex under the influence of drugs and alcohol, and has been made to have
sex against his will. George identifies himself as bisexual, not gay.
George first used alcohol at age 11, when he had his first sexual encounter with a man. He began using other
drugs, including inhalants and marijuana, by age 16 and amphetamines and cocaine by age 17. At 18, 3 months prior
to entering treatment, he began using crack.
This first individual counseling session was focused on this basic, interpersonal foundation to enable us to establish an
efficacious treatment plan. George is strong in his desire to get clean, and I have assured him that we can help him here.

Let’s Code It!

George has admitted himself into a substance abuse inpatient treatment program, and this is documentation of his first
individual counseling session. Turn to the Substance Abuse Treatment Section and let’s build an ICD-10-PCS code:
First character: Section: Substance Abuse Treatment . . . H
Second character: System: None . . . Z
Third character: Root Operation: Individual Counseling . . . 3
Fourth character: Type Qualifier: Interpersonal . . . 4
Fifth character: Qualifier: None . . . Z
Sixth character: Qualifier: None . . . Z
Seventh character: Qualifier: None . . . Z
Now, put it all together and, with confidence, report this code:
HZ34ZZZ Interpersonal-based individual counseling for substance abuse treatment

Chapter Summary
This chapter has given you the opportunity to walk through the Physical Rehabilita-
tion and Diagnostic Audiology (F), Mental Health (G), Substance Abuse Treat-
ment (H), and New Technology (X) sections of ICD-10-PCS. You have seen how
each character position is important to reporting all of the pertinent details of a proce-
dure, service, or treatment. You have learned that, in each section, the same character
can have a different meaning. However, you always have the Tables there to provide
the options and their meanings to build the accurate code.

CODING BITES
More Information:
Physical Medicine and Rehabilitiation
https://medlineplus.gov/ency/article/007448.htm
National Alliance on Mental Illness (NAMI)
https://www.nami.org/Learn-More/Treatment
Substance Abuse and Mental Health Services Administration
http://www.samhsa.gov/treatment

1132   PART V  |  INPATIENT (HOSPITAL) REPORTING

CHAPTER 37 REVIEW

CHAPTER 37 REVIEW
Physical Rehabilitation and Enhance your learning by
completing these exercises and
more at connect.mheducation.com!

Diagnostic Audiology through

New Technology Sections
Let’s Check It! Terminology
Match each key term to the appropriate definition.
1. LO 37.2  Training to gain voluntary control of automatic bodily functions. A. Abuse
2. LO 37.2  The treatment of mental and emotional disorder through communica- B. Audiology
tion or psychologically rather than medical means. C. Biofeedback
3. LO 37.3  Regular consumption of a substance with manifestations. D. Detoxification
4. LO 37.1  Health care that is committed to improving, maintaining, or returning E. Psychotherapy
physical strength, cognition, and mobility.
F. Rehabilitation
5. LO 37.1  The study of hearing, balance, and related disorders. 
6. LO 37.3  The process of removing toxic substances or qualities.

Let’s Check It! Concepts

Choose the most appropriate answer for each of the following questions.
1. LO 37.1  Within the Physical Rehabilitation and Diagnostic Audiology Section, character position 6 represents
which of the following?
a. Section qualifier b.  Type qualifier
c. Equipment d.  Qualifier
2. LO 37.1  Within the Physical Rehabilitation and Diagnostic Audiology Section, character position 2 Section
Qualifier, which of the following characters represents diagnostic audiology?
a. 0 b.  1
c. 2 d.  3
3. LO 37.1  Within the Physical Rehabilitation and Diagnostic Audiology Section, character position 3 Root Type,
which of the following characters represents a hearing aid assessment?
a. B b.  2
c. D d.  4
4. LO 37.2  All of the codes reporting a Mental Health Section procedure will begin with which section letter?
a. G b.  H
c. I d.  J
5. LO 37.2  Within the Mental Health Section, character position 3 Root Type, the encounter documents Includes
behavior, cognitive, interactive, interpersonal, psychoanalysis, psychodynamic, psychophysiological,
and/or supportive, identified by the character 5. This encounter is known as
a. psychological tests. b.  individual psychotherapy.
c. counseling. d.  crisis intervention.
6. LO 37.2  Within the Mental Health Section, which character position identifies whether the procedure was educa-
tional or vocational?
a. 2 b.  3
c. 4 d.  5

CHAPTER 37  | 
 7. LO 37.3  All of the codes reporting a Substance Abuse Treatment Section procedure will begin with which sec-
CHAPTER 37 REVIEW

tion letter?
a. F b.  H
c. J d.  K
8. LO 37.3  Within the Substance Abuse Treatment Section, the encounter documents Not a treatment modality but
helps the patient stabilize physically and psychologically until the body becomes free of drugs and the
effects of alcohol, represented by the character 2. This is known as
a. individual psychotherapy. b.  medication management.
c. pharmacotherapy. d.  detoxification services.
9. LO 37.3  Within the Substance Abuse Treatment Section, what character position adds detail to the description of
the Root Type?
a. 4 b.  5
c. 6 d.  7
10. LO 37.4  All of the codes reporting a New Technology procedure will begin with the section letter
a. Z b.  X
c. Y d.  W

Let’s Check It! Rules and Regulations

Please answer the following questions from the knowledge you have gained after reading this chapter.
1. LO 37.1  List the Physical Rehabilitation and Diagnostic Audiology Section, character position 2, Section Quali-
fier, options, including the character that identifies each.
2. LO 37.1  Within the Physical Rehabilitation and Diagnostic Audiology Section, character position 4, Body Sys-
tem and Region, if the encounter is for caregiver training, what would be the character assignment to
represent the encounter? 
3. LO 37.2  List six Mental Health Section, character position 3, Root Type, options; include the description and the
character that identify each. 
4. LO 37.3  Within the Mental Health Section, what does the character position 4, Type Qualifier, explain? 
5. LO 37.4  List the six New Technology Section, character position 6, Device/Substance/Technology, options;
include the description and the character that identify each. 

ICD-10-PCS

YOU CODE IT! Practice

Using the techniques described in this chapter, carefully read through the case studies and determine the most ac-
curate ICD-10-PCS code(s) for each case study.
1. Bennie Hallmon, a 67-year-old male, has been in Westward Hospital for a week and is showing signs of
deteriorating speech. Dr. Lindler performs a bedside swallowing and oral function speech assessment, no
equipment. 
2. Merry Gilbert, a 22-year-old female, was hospitalized 7 days ago due to an automobile accident resulting in
left hemiplegia. Dr. Tarrant performs an ADL home management assessment using assistive, adaptive, sup-
portive, and protective equipment.
3. Fred Copeland, a 14-month-old male, was admitted to Westward Hospital because he does not react to sudden
loud noises and has not begun to use simple words. Fred is diagnosed with severe sensorineural hearing loss
and has a multiple channel cochlear implant. Today, Dr. Cantey performs a cochlear implant rehabilitation
treatment. Code today’s session. 

1134   PART V  |  INPATIENT (HOSPITAL) REPORTING

 CHAPTER 37 REVIEW
4. Patricia Swartzenturber, a 23-year-old female, has been experiencing recurring episodes of vertigo and some hear-
ing loss. Dr. Wooton admits Patricia to Westward Hospital, where she is diagnosed with Meniere’s disease. Pat
complains of ringing in her ears. Dr. Wooton fits a tinnitus masker, no equipment used.
5. Vickie Fulmer, a 61-year-old female, presents to Dr. Derry with trembling and twitchy motions she states are
involuntary. Dr. Derry also notes diaphoresis and admits Vickie to the hospital, where she is later diagnosed
with generalized anxiety disorder. Today, while in the hospital, Vickie participates in an individual interpersonal
psychotherapy session. Code today’s session. 
6. Ralph Canopus, a 37-year-old male, was very agitated and restless and threatened suicide. Dr. Patterson admit-
ted Ralph to Westward Hospital, where he was diagnosed with major depression. Today, while in the hospital,
Ralph and his family participate in a family psychotherapy session led by Dr. Patterson. Code today’s session. 
7. AKA: Grover Humphrey, age unknown, male, was found wondering the streets with no memory or ability to rea-
son. A card with a name was found in one of his pockets. He was admitted to Westward Hospital, where
Dr. Hatfield performed a cognitive status psychological test. 
8. Hugo Parsons, a 15-year-old male, is brought to Westward Hospital by his parents. Hugo’s parents have noticed a
dramatic personality change recently as well as unexplained anger. Dr. Smyth completes a physical examination
and finds Hugo has a substance abuse issue. Dr. Smyth admits Hugo to Westward Hospital and begins detoxifi-
cation treatment. 
9. Jessica Abbott, a 41-year-old female, has been admitted to Westward Hospital for esophageal cancer. Jessica has
been smoking cigarettes since she was 16 years old. Dr. Barbato manages her nicotine replacement medication. 
10. Eloise Baker, a 56-year-old female, had been diagnosed as an alcoholic and is having severe delirium tremens
and seizures. Dr. Hewitt admits Eloise to Westward Hospital. Today, while in the hospital, Eloise participated in
a 12-step individual psychotherapy session. 
11. Edward Skipper, a 24-year-old male, has been diagnosed with human immunodeficiency virus (HIV). Ed
attends a post-test group counseling session held by Dr. Dyson at Westward Hospital.
12. Rinika Simms, a 72-year-old female, was admitted to Westward Hospital for a cerebral embolic filtration, dual
filter, left common carotid artery, new technology group 2. 
13. Thomas Balakrishnan, a 59-year-old male, has severe back pain. He was admitted to Westward Hospital for disc
fusion: lumbosacral, interbody fusion device, Nanotextured surface, open approach.
14. Margie Lewis, a 49-year-old female, was admitted to Westward Hospital and was diagnosed with invasive asper-
gillosis. Dr. Marten administers Isavuconazole anti-infective enzyme, peripheral vein, percutaneous, new tech-
nology group 1. 
15. John Hook, a 9-month-old male, was diagnosed with early onset scoliosis. John is admitted to Westward Hos-
pital for reposition of a thoracic, magnetically controlled growth rod, open approach, new technology group 2. 

ICD-10-PCS
YOU CODE IT! Application
The following exercises provide practice in abstracting physicians’ notes and learning to work with documentation
from our health care facility, Westward Hospital. These case studies are modeled on real patient encounters. Using
the techniques described in this chapter, carefully read through the case studies and determine the most accurate
ICD-10-PCS code(s) for each case study.

WESTWARD HOSPITAL
591 Chester Road
Masters, FL 33955
PROGRESS NOTES

CHAPTER 37  | 
CHAPTER 37 REVIEW

PATIENT: HOUGH, BETH

DATE OF ADMISSION: 05/30/18
DATE OF DISCHARGE: 06/01/18
ADMITTING DIAGNOSIS: Acute pyelonephritis caused by E. coli
DISCHARGE DIAGNOSIS: Acute pyelonephritis caused by E. coli
The patient is a 29-year-old female suffering with burning on urination. She stated she also noticed a fishy
odor after urination. The urinalysis and culture lab results showed positive for acute pyelonephritis caused
by E. coli. She was referred to me. I then admitted her to the hospital for treatment with Ceftazidime-
Avibactam Anti-infective, peripheral vein introduction.

Benjamin Johnston, MD—2222

556839/mt98328: 06/01/18 09:50:16  T: 06/01/18 12:55:01

Determine the most accurate ICD-10-PCS code(s) for the Ceftazidime-Avibactam Anti-infective. 

WESTWARD HOSPITAL
591 Chester Road
Masters, FL 33955
DISCHARGE SUMMARY
PATIENT: GILLINS, MARTIN 
DATE OF ADMISSION: 07/15/18
DATE OF SURGERY: 07/29/18
DATE OF DISCHARGE: 08/01/18
DIAGNOSIS: Left below-knee amputation
DISCHARGE DIAGNOSIS: Pt is a 67-year-old male with a history of peripheral arterial disease and
lower extremity bypass surgeries who was admitted with gangrene of left foot. The patient underwent
left below-knee amputation. 
PAST MEDICAL HISTORY: Hyperlipidemia and hypertension.
SOCIAL HISTORY: Lives with wife.
FAMILY HISTORY: Noncontributory.
PHYSICAL EXAMINATION: At the time of admission, the patient was afebrile. Vital signs are stable.
Temperature 97.7. Blood pressure 131/71. Oral mucosa was moist. Sclerae anicteric. Lungs: Bilaterally
clear to auscultation. Heart: Regular. Abdomen: Scaphoid. Right foot intact. Minimal erythema. Minimal
edema.
HOSPITAL COURSE: Dr. Norcross notes patient is medically stable. Compression was not used due
to the significant ischemia. The patient was placed on Avelox. Bowels moved on a regular basis. The
patient responded to rehabilitation well. Appetite is improving. Albumin was 2.7. Hemoglobin was 11.4.
The patient was able to perform all ADLs with supervision. Good range of motion was noted to the left
knee. No dehiscence was found. Wife will act as caregiver and was trained in wound care manage-
ment. The patient was discharged to wife.

1136   PART V  |  INPATIENT (HOSPITAL) REPORTING

 CHAPTER 37 REVIEW
MEDICATIONS: Avelox 400 mg daily, aspirin one tablet daily, Roxicodone 5–10 mg every 6 hours as
needed for pain, Cardizem 60 mg three times a day, Nitro-Dur patch daily, and Lanoxin 0.25 mg daily.
The patient will follow up with Dr. Norcross on Wednesday. A dry dressing, wrapping with Kling and
stockinette, no compression is to be maintained. The patient was prescribed front-wheel walker, 3-in-1
commode, shower chair, and ADL kit. The patient was prescribed home health nursing, physical therapy,
occupational therapy, and aide. The patient was also given a wheelchair. All instructions were given.

Karen Norcross, MD
556848/mt98328: 08/01/18 09:50:16  T: 08/01/18 12:55:01

Determine the most accurate ICD-10-PCS code(s) for the caregiver training. 

WESTWARD HOSPITAL
591 Chester Road
Masters, FL 33955
PATIENT: WRIGHT, ROBBIN
DATE OF ADMISSION: 03/05/18
DATE OF DISCHARGE: 03/17/18
ADMITTING DIAGNOSIS: Marijuana abuse
ATTENDING PHYSICIAN: Jennell Goren, MD
Robbin Wright, a 16-year-old female, presented to Dr. Goren complaining of a cough and a sore throat,
lasting about 1 week. She and her mother deny fever, nasal congestion, or runny nose. She says she feels
more tired than usual and her mom states that she hasn’t been getting out of bed to go to camp or any
other activities. Mom seems most worried that she is much less active than she usually is and that she has
been hanging out with her friends until late at night. Patient states that her “mom won’t get off my back.”
She admits that her grades had been dropping before summer break, and she quit the baseball team.
Mom leaves the room, and patient admits to smoking pot every day, usually several times a day, for the
past 8 or 9 months or so. She denies any other drug use and states smoking pot is “no big deal.”
After discussion with the patient and her parents, Robbin is admitted into a substance abuse hospital
to treat her high level of irritability and anxiety and for daily individual and group behavioral counseling.
Upon admission:
PE: Physical examination is remarkable only for a mildly erythematous throat without petechiae. Lungs
are slightly congested, and the rest of her exam is normal. Vital signs are also unremarkable. A rapid
strep screen is negative.
FIRST DAY—INDIVIDUAL COUNSELING: Discussion with patient about side effects and risks of abus-
ing pot. She states she has tried to quit but can’t make it through an entire day without smoking. It is
pointed out to her that her pot use is already having a negative impact on her life (absence and lack
of interest in school). We discussed options and methodologies for her quitting with reduced effects.
Blood is taken to record the levels of THC, and she agrees to regular surveillance.
Plan: Marijuana abuse behavioral counseling; daily individual counseling; daily group counseling.
Reevaluation after six (6) full days of residential treatment.

Jennell Goren, MD
556845/mt98328: 03/17/18 09:50:16  T: 03/17/18 12:55:01

Determine the most accurate ICD-10-PCS code(s) for the counseling.

CHAPTER 37  | 
CHAPTER 37 REVIEW

WESTWARD HOSPITAL
591 Chester Road
Masters, FL 33955
PHYSICAL REHABILITATION ASSESSMENT
PATIENT: LEWTER, GENE
DATE OF ADMISSION: 01/15/18
DATE OF DISCHARGE: 01/17/18
DIAGNOSIS: 1.  Acute myofascial strain.
      2.  Acute exacerbation of chronic low back pain.
SUBJECTIVE: The patient is a 47-year-old male. The patient came in for back pain. He was initially eval-
uated by Dr. Bruce Allen for back pain for the last 2 days. He said it was in the mid back, going down to
the left knee, with some paresthesias in the feet and numbness in the feet. Movement, remaining still,
and laying on a side seem to relieve pain. Lying directly on his back increases the pain. No problems
with urination. No fever or chills. No nausea, vomiting, or diarrhea. No abdominal pain.
PAST MEDICAL HISTORY: Significant for back injury. He had anterior fusion of L3–L4 in the past. He
has had multiple episodes, about one a month, since the surgery of exacerbation of his chronic back
pain. This typical pain pattern with numbness and radiation down the leg, he states, is nothing unusual
for the last multiple episodes. He has had no bladder or bowel dysfunction.
SOCIAL HISTORY: He is a smoker.
OBJECTIVE: The patient is alert, in no acute distress, obviously uncomfortable however. C-spine is neg-
ative. He is tender over the mid back, L2 through L4, with paravertebral muscle spasm that is palpable,
also quite tender. Decreased range of motion. The patient is alert and orientated x3. No motor deficits.
Strength 5/5. He does have diminished left patellar reflex. Decreased sensory on the left great and little
toes, medial aspect of the foot, and lateral aspect on the plantar surface of the foot. Sensory is intact.
INTERVENTION: Motor and nerve function assessment, range of motion, and joint integrity of lower
back and lower extremity were performed.
ASSESSMENT:
1. Acute myofascial strain.
2. Acute exacerbation of chronic low back pain.
PLAN: Percocet 5 mg 1–2 q. 4–6 hours as needed for pain, Soma one, three times a day, Indocin SR
75 mg b.i.d. with food. Follow up with the specialist who did his back surgery for reevaluation of his
increasing back pain over the last several years. Any acute problems, recheck sooner. Any problems
with bladder or bowel, recheck immediately.

Roberta Opell, PT
556839/mt98328: 01/17/18 09:50:16  T: 01/17/18 12:55:01

Determine the most accurate ICD-10-PCS code(s) for the motor function assessment.

WESTWARD HOSPITAL
591 Chester Road
Masters, FL 33955
HISTORY OF PRESENT ILLNESS ADMISSION

1138   PART V  |  INPATIENT (HOSPITAL) REPORTING

 CHAPTER 37 REVIEW
PATIENT: JETT, JAMES
DATE OF ADMISSION: 10/07/18
DATE OF DISCHARGE: 10/09/18
ADMITTING DIAGNOSIS: Schizophrenia and polysubstance abuse
HISTORY OF PRESENT ILLNESS:
This is a 27-year-old male with a history of schizophrenia and polysubstance abuse referred by his case
manager due to increased hallucinations, including auditory, and new onset of olfactory, gustatory, and
tactile hallucinations. Since the onset of the hallucinations, the patient has become acutely suicidal with
multiple plans. He has a history of polysubstance abuse with alcohol and crack but has been sober for
greater than 3 months and has been in rehab. He also complains of headaches recently. The patient
presented frightened and tearful and continued to endorse suicidal thoughts.
PAST PSYCHIATRIC HISTORY:
Paranoid schizophrenia, substance abuse.
PAST MEDICAL HISTORY:
Left shoulder injury with chronic pain and a seizure one time in the past.
FAMILY HISTORY:
The patient does have a brother with schizophrenia and a mother who died from complications of
diabetes.
SOCIAL HISTORY:
The patient currently is in rehab. Divorced. Did finish high school and went to junior college for a little
while but did not get a degree. He has been unable to hold a steady job for most of his life.
REVIEW OF SYSTEMS:
Included headache and some blurry vision. He denies constitutional symptoms. He denied chest pain,
difficulty breathing, GI symptoms, dysuria. He does endorse left shoulder pain. He denied any skin con-
ditions and he does endorse numbness of his distal feet.
MENTAL STATUS EXAMINATION:
Neurobehavioral and Cognitive Status Exam: Appearance and Behavior: He had good eye contact, well
groomed, fair hygiene. Speech and Language: Normal volume, tone and rate, nonpressured. Mood and
Affect: Mood was depressed and affect was congruent and restricted. Thought processes linear and
goal directed. Thought Content: He does have some paranoia, believing that people, including the doc-
tors, are experimenting on him. HI/SI: He denies currently having suicidal ideations. Perceptual Abnor-
malities: He reports visual, auditory, gustatory, and tactile hallucinations. Orientation: He is alert and
oriented x3. Memory and abstractions are fair. Fund of knowledge and IQ are average and insight and
judgment are limited and poor. His initial physical exam was significant for pain and decreased range
of motion in the left shoulder on passive abduction and extension and a mild paresthesia of the plantar
surface of his right second toe; otherwise, neurologic exam was normal.

JOANNE STAFFORD, MD
556845/mt98328: 10/09/18 09:50:16  T: 10/09/18 12:55:01

Determine the most accurate ICD-10-PCS code(s) for the cognitive status test.

CHAPTER 37  | 
38 Inpatient Coding
Capstone
Learning Outcomes
After completing this chapter, the student should be able to:
LO 38.1 Correctly abstract patient records to determine accurate cod-
ing using ICD-10-CM and ICD-10-PCS code sets.

Reporting the procedures provided to a patient who has been admitted into an inpa-
tient facility can cover a broad spectrum. The cases in this chapter will support your
learning using ICD-10-PCS procedure codes.
Remember, read carefully and completely.

CASE STUDY #1: NESTOR GONZALEZ

H&P
Nestor Gonzalez, a 69-year-old previously healthy male, was seen in my office with
a cough productive of thick purulent sputum of 3 days duration. Fever was present and
he reported dyspnea on exertion.
Vital signs—BP 96/60 mm Hg, P 116 beats/min, RR 24 breaths/min, T 103.5°F rectal.
On examination, he appeared acutely ill.
Lung examination revealed scattered ronchi, which were greater on the right than
the left.
I determined that the patient needed to be admitted into the hospital right away.
Upon admission: Bronchoscopic aspiration specimen culture, C&S, and gram stain.
Blood tests and sputum culture were ordered and a chest x-ray taken.
RESULTS: Chest x-ray showed increased opacity in the lung field indicating pneumonia,
as suspected; culture confirmed E. coli with Shiga toxin.
Dx: Community-acquired pneumonia due to Escherichia coli 0157 with Shiga toxin
Treatment: IV ciprofloxacin 300 mg q 12h, infused over 60 minutes
Dr. Ryan MacDoule

CASE STUDY #2: TINA LEBROCK

H&P
Patient is Tina LeBrock, a 71-year-old female with known unstable angina due to
coronary artery disease. During the week prior to admission, she underwent an outpa-
tient procedure of diagnostic heart catheterization. At the time of this heart catheteriza-
tion procedure, the patient was found to have occlusion of the left anterior descending
coronary artery in two separate locations.
Due to the findings from this diagnostic procedure, the patient is now admitted for
a scheduled percutaneous transluminal coronary angioplasty (PTCA) with a plan for
stent insertions. The patient also has known secondary diagnoses of hypertension,

1140
hyperlipidemia, and current tobacco use. The hypertension, hyperlipidemia, and unsta-
ble angina are currently being treated with medications.
The patient was taken to the procedure room and underwent a PTCA of the left ante-
rior descending coronary artery with insertion of two Taxus drug-eluting stents, one at
each occlusion site.
Dr. Lawrence Marcheon

CASE STUDY #3: GRAYSON CARLYLE

Patient: Grayson Carlyle 15 May 2018

MRN: C18-54662517
Surgeon: Annalissa Brubaker, MD
PRE-OPERATIVE: gonarthrosis deformans; four ipsilateral periprosthetic fractures
HPI: A 43-year-old otherwise healthy male patient with a diagnosis of osteoarthrosis
was admitted in 2015 for elective left-knee arthroplasty. He had a history of three non-
significant knee traumas, and an arthrotomy with synovectomy had been performed on
the left knee due to synovitis in 2016. His physical examination at admission showed
severe insufficiency of the medial collateral ligament and rotational instability of the left
knee joint. Other joints showed no abnormal findings.
X-ray revealed gonarthrosis deformans stage II with 5° varus angulation. The patient
underwent total arthroplasty (Allopro NPK, Switzerland) of the left knee on March 4,
2015. Postoperative x-ray revealed good alignment of the prosthesis; both components
were centered in the midline of the joint, and overall knee alignment was 8° in valgus.
Two 1-g prophylactic doses of the antibiotic cefuroxime were administered periopera-
tively. The patient developed a fever on the third postoperative day, and the same antibi-
otic was administered intravenously (750 mg three times a day, postoperative days 3–10).
The patient was discharged in good general condition on March 18, 2015, and he
had no medical problems during the outpatient follow-up period.
A year later, on May 26, 2016, the patient fell at home and was admitted to the hos-
pital with a supracondylar fracture of the left distal femoral metaphysis (displacement
in flexion and varus). Skeletal traction with 7 kg was applied primarily, and the patient
underwent surgery. The tibial component of the endoprosthesis was loose and was
removed; the femoral shaft was fixed with a dynamic condylar screw device, and a revi-
sion arthroplasty using a long-stem endoprosthesis was done.
The patient had no postoperative complications. The outpatient follow-up period
was uneventful, and after 3 months, he returned to work.
The patient started experiencing pain and swelling in his left knee joint approximately
1 year after the second surgery. An x-ray performed in August 27, 2017, showed radio-
lucency around the tibial component, which had also migrated anteroinferiorly. Based
on these findings and also on clinical and laboratory data, infection of the endopros-
thesis was diagnosed, and the patient was admitted for 1-stage revision arthroplasty.
Microbiological culture from joint aspirations showed the presence of Pseudomonas
aeruginosa sensitive to Tazocin (piperacillin sodium and tazobactam sodium), ceftazi-
dime, imipenem, amikacin, gentamicin, and ciprofloxacin.
The patient had surgery on September 1, 2017. Because the previous femoral supra-
condylar fracture was consolidated, the DCS fixator and endoprosthesis were removed
and revision arthroplasty with long-stem rotational endoprosthesis (Link Endo-Model Total
Hinge Knee) was performed. The tibial defect was additionally filled with 15-mm spacer.

CHAPTER 38  | 
 Microbiological cultures taken during surgery confirmed the diagnosis of P. aeru-
ginosa infection. During the hospital stay, antibiotics were administered intravenously
according to microbe sensitivity (antibiogram) and our infection protocol: gentamicin
240 mg once a day and ciprofloxacin 200 mg twice a day for the first 5 postoperative
days. Starting on the sixth postoperative day, gentamicin combined with ceftazidime
500 mg twice a day was administered, and was continued for 9 days.
The patient was discharged home with no complaints. He was prescribed oral rifampicin
300 mg twice a day for the next 2 months. Full weight-bearing was allowed after 6 weeks.
Three months later, the patient fell on a slippery street and sustained an axially dis-
placed fracture of proximal metaphysis of tibia and fibula. This time treatment was con-
servative: closed reduction was achieved and maintained in a long-leg cast. Follow-up
x-ray on December 14, 2017, showed that bone fragments were still in satisfactory
alignment and there was evidence of callus formation. The patient returned to work and
his usual activities in January 2018.
On March 9, 2018, the patient was admitted to the hospital again because of a spi-
ral dislocated fracture in left femoral distal diaphysis. The femur was shortened and
displaced axially in varus position. Skeletal traction (5 kg) was applied primarily, and
surgery was performed later. Offstripping of femoral periosteum in both fragments was
seen during surgery. Internal fixation of the left femoral bone was achieved with an AO
plate and screw. The patient recovered and was discharged on March 17, 2018. He
was told to limit weight-bearing for the next 2.5 months and to walk with crutches.
Unfortunately the patient didn’t follow these instructions, and the plate broke off the
bone in its distal part due to walking. An open reosteosynthesis (exchange of screws
and repositioning of the plate) was performed this morning (May 15, 2018).

CASE STUDY #4: DAMARIS ALBAQSHI

Patient: Damaris Albaqshi

Date of Admission: 11 June 2018
MRN: D9513597135
Attending Physician: Markesha Cacciola, MD
A 42-year-old female patient was admitted to the hospital with a swelling on the right
tibia. Past history revealed that the patient was operated upon 24 years ago for a patho-
logical fracture of the right tibia and the diagnosis at that time had been adamantinoma.
The preoperative radiograph of the right leg showed osteolysis of the bone and the
chest radiograph revealed lung metastases. Regional computed tomography (CT) of the
right leg showed that the tumor was invading the surrounding soft tissues. The cortex
appeared moderately expanded and attenuated. Bone scanning showed intensive pos-
itivity in the middle of the right tibia. The CT scan of the thorax demonstrated two lung
metastases. One of these was in close contact with the right anterior pulmonary artery
and the other was located in the left posterior lobe. Fine needle aspiration (FNA) biopsy
confirmed the diagnosis of adamantinoma of right tibia suggesting local recurrence.
The patient underwent surgery wherein the tumor was widely resected and the tibia
reconstructed with specific recombined osteosynthesis (salvage surgery). The patho-
logical examination of the excised tumor confirmed the diagnosis of adamantinoma set
by FNA biopsy. The histological examination revealed a multiforming adamantinoma
with basaloid, spindle cellular, and tubular characteristics. Examination of the adamanti-
noma that had been excised earlier revealed the same characteristics. The postopera-
tive period was without complications and the patient walked in 15 days.

1142   PART V  |  INPATIENT (HOSPITAL) REPORTING

CASE STUDY #5: MICHAEL DEMARCO

Patient: Michael DeMarco 14 July 2018

MRN: K3357151
Attending Physician: Cecilia Rowens, MD
HISTORY: A 4-year-old male with normal birth history and development with the excep-
tion of an episode of maternal hemiplegia during pregnancy. There is no significant
family history of any neurologic issues. His medical history is unremarkable except for
celiac disease that is treated with a gluten-free diet.
Six months ago, he developed scarlet fever and began to have episodes of right
hand tremor lasting 6 seconds with no alteration of consciousness. One month later, he
had more events and was taken to the local ED, where an EEG was performed.
The EEG showed a normal background with left centrotemporal spikes. A repeat EEG the
next day showed similar findings but recorded sleep and sleep activation of the discharges.
Due to these findings, he was placed on Zarontin. An MRI of the brain was performed
and was normal except for “slight signal alteration involving the posterior periventricular
white substance of both sides of a non-specific nature.” There was also opacification of
the sinuses and otomastoiditis.
There were no further episodes since but some “restlessness of his limbs” was
noticed in sleep. He then had two larger events this past month. He was then placed on
Depakote at 160 mg bid.
Family history:
Parents not related by blood. Mother with previous transitory left hemiplegia during
pregnancy. Father and 2-year-old brother apparently in good health. No familiarity with
epilepsy or mental retardation.
Medical background:
Born from normal spontaneous delivery at 39th week + 2.
No pre-, peri- and prenatal suffering reported. Good suction. Maternal breastfeeding
until 6 months, then regular weaning.
Psychomotor development within normal limits: Seated posture when 4½ months,
standing up when 11 months, first words when 6 months. Alvus and diuresis within
normal limits, feeding lacking in gluten due to celiac disease, sleep-wake rhythm within
normal limits. No allergies reported. Patient suffering from celiac disease.
Five months ago, an episode of scarlet fever was treated with antibiotic therapy.
One month later, having a temperature and under antibiotic therapy, the child started
to show short episodes characterized by right hand tremors, lasting approximately 6
seconds each, without any concomitant consciousness alterations.
His parents report that these episodes started about 7 months ago and they were
occasional. This time he showed a similar episode of tremors again and, therefore, his
parents took him to the emergency room.
The young patient was, therefore, hospitalized in a pediatric neurology ward where
a diagnosis of “Focal epilepsy of myoclonic nature in patient with normal psychomo-
tor development” was placed. During hospitalization, the following diagnostic medical
tests were carried out:
• Blood tests: within normal limits apart from Hb (Hemoglobin) 11.5 g/dl (v.n. 12–14),
MCV 68.8 fl (v.n. 75–85), Platelets 605 (v.n. 130–400), iron in the blood 45 mcg/dl
(v.n. 50–80).
• EEG: Left centrotemporal paroxysmal abnormalities with tendency to omo and con-
tralateral spreading in tracing with normal background rhythm.
• EEG during sleeping: 2 left centrotemporal paroxysmal abnormalities with tendency
to spreading and with activation when sleeping.

CHAPTER 38  | 
 Therefore, at discharge the patient underwent therapy with:
Zarontin 80 mg × 2 a day at 8 a.m. and 8 p.m. for 1 week
Zarontin 80 mg + 160 mg at 8 a.m. and 8 p.m. for 1 week
Zarontin 160 mg × 2 a day at 8 a.m. and 8 p.m. then continues.
Brain MRN is carried out under sedation and resulted within normal limits apart from
a “slight signal alteration involving the posterior peri-ventricular white substance of
both sides, of nonspecific nature, and bilateral otomastoiditis, opacification of maxillary
sinuses, of ethmoid cells and of sphenoidal sinuses bilaterally. Asymmetry of temporal-
basal superficial vessels, due to ectasia of a vessel on the left side, is observed.”
His parents noticed, when he was sleeping, a kind of limbs restlessness (arms and
legs) sometimes, after a few hours and early in the morning. Moreover, it often hap-
pened, and still happens, also in the evening (7 p.m.–8 p.m.) and, sometimes, also when
going to bed (between 9:30 p.m. and 10:30 p.m.) that the child complains he is cold,
repeating this several times.
In the current month he had his first two epileptic seizures. The first one occurred
while he was sleeping in the afternoon (he woke up catatonic, staring, with little
response to questions and, sometimes, mainly his right side was a bit rigid) and ended
after about 10 minutes when he fell asleep; when he woke up, the patient took about 2
hours to recover either his mood or his right eye and his stomach soreness.
The second one occurred in the morning when he was in the clinic to check ethosuxi-
mide dosage and to carry out a specialist follow-up visit. On awakening a 30-seconds-long
crisis occurred, with remarkable tremors to arms, legs, eyes, and twisted and munching
mouth.
Following these events, his physician changed the therapy, introducing the following
outline:
Depakin oral suspension 80 mg at 8 a.m. and 80 mg at 8 p.m. for 7 days
Depakin oral suspension 120 mg at 8 a.m. and 120 mg at 8 p.m. for 7 days
Depakin oral suspension 160 mg at 8 a.m. and 160 mg at 8 p.m. as maintenance
After 1 week of minimum dosage, no real crisis occurred; when sleeping, the child
unceasingly turns; he wriggles his lower and upper limbs, either at about 2 a.m. (in a
more intense way also for a half hour at intervals until he goes back to sleep) or at about
4/5 a.m. and on waking up for several minutes.
So there are two potential diagnoses:
1) Focal-Onset Epilepsy.
It is possible the patient has seizures that begin on the left side of his brain (which
would cause symptoms on the right side of the body like shaking of his right hand and
rigidity of his right side). These can potentially spread to the whole brain, causing the
whole body to shake, as was the case with his second seizure. The most important test
is the MRI, which showed no cause for the seizure (such as a tumor, stroke, or malforma-
tion). This is a good sign as there is a much better chance to outgrow seizures if the MRI
is normal. The findings in the sinuses and mastoid wouldn’t cause these seizures. They
are incidental findings but should be evaluated by an Ears/Nose/Throat doctor.

2) Benign Rolandic Epilepsy.

This is the most common epilepsy syndrome in childhood (not counting febrile seizures)
and begins anywhere from age 1–15 (but most commonly by age 7). The seizures are
similar to the partial seizures described above but can occur on either side and typi-
cally occur just after falling asleep or upon waking. The EEG is diagnostic and shows
centrotemporal spikes that are more frequent in sleep (similar to patient’s). These can
be only on one side or alternate between the sides on any given EEG. If they are only
on one side, then subsequent EEGs typically show discharges on the opposite side. All
children outgrow this type of epilepsy at puberty or before. The restlessness in sleep is

1144   PART V  |  INPATIENT (HOSPITAL) REPORTING

not epileptic and is common in children with epilepsy. They often have restless sleep or
even jerks of the extremities known as sleep myoclonus and this is benign.

TREATMENT: Child is admitted to the hospital for a 24-hour EEG.

DISCHARGE: The EEG shows the abnormalities to still be only on the left, confirming a
diagnosis of idiopathic focal-onset epilepsy. His normal development is very reassuring
and can be seen with this type of epilepsy. Some children with this type of seizures can
have some problems with attention/focus/memory as they get older, but this is usually
mild and gets better when the EEG normalizes.

CASE STUDY #6: POPPY BROWNING

Patient: Poppy Browning

DATE: 9 April 2018
MRN: A399523147
Physician: Carla Firmann, MD
Second hospitalization, 1 month later, following appearance of arising colics, diffi-
cult to treat with pain medications, high body temperature, and increase in inflamma-
tion ratings, symptoms consistent with picture of infective cholangitis. Therefore, the
picture was resolved with antibiotic therapy and with carrying out a papillotomy by
means of ERCP. Discharged under antibiotic therapy with Ciprofloxacin, Cortisone, and
Azathioprine.
Third hospitalization, 3 days after discharge from previous hospitalization, following
arising colics with progressive ultrasound scan dilatation of bile ducts and evidence
of dropsy of the gallbladder. Moreover, 48 hours following hospitalization, amylase
increase (600 UI/l) was detected. The IgG4 dosage (18 mg/dl) was within normal limits,
excluding a possible autoimmune hepatitis/pancreatitis syndrome.
ERCP performed with dilatation and cleaning of the common bile duct that involved
the spillage of corpuscular material and bile with purulent appearance bringing about
a fast improvement of symptomatology and a rapid reduction in the amylase values.
Later on, laparoscopic cholecystectomy was carried out. During postsurgery, after a
short period of wellness, the patient suffered from an abdominal pain. Reappearance
interpreted, at the beginning, as a light pancreatitis (treated with antibiotic therapy).
Subsequently, persisting painful crises were observed despite blood tests showing sub-
stantial stability.
Therefore, an MR cholangiography was carried out (images enclosed on CD) that has
revealed an appearance of intra- and extrahepatic bile duct dilatation, evident also at
common bile duct level where the picture seems to reveal a relevant stenosis: “Intrahe-
patic bile ducts with clear wall irregularity and with minimal stenosis followed by dilata-
tions in a picture to be related to the base pathology. Irregularity at the extrahepatic bile
ducts and at the common bile duct level too, the common bile duct distal region appears
moderately reduced in diameter, also in papillary region, also as a result of papillotomy.”
In the light of the aforesaid, a biliary stent was placed during ERCP in order to guar-
antee bile ducts patency. The clinical picture, after surgery, was stable with occasional
presence of pains involving mainly the right hypochondrium without any characteris-
tics of biliary colics. At discharge, blood tests showed evidence of improvement of the
hepatic cytolisys index (AST 28, ALT 38) with still elevated values of gammaGt (197)
and APC 2.02 mg/dl probably linked to the inflammatory pathology rather than to an

CHAPTER 38  | 
 infective event. Discharge with indication to follow a therapy with Deltacortene to scale
down the Azathioprine and antibiotic therapy with Augmentin.
Fourth hospitalization, 1 month later, in gastroenterology department for clinical test:
The patient reported slight painful crisis in epigastric region; at examinations APC nega-
tivization (0.59) and a further reduction in GGTs with transaminase substantially stable.
Therefore, the therapy with Amoxicillin + Clavulanic Acid was suspended and Metroni-
dazole 250 mg was prescribed three times a day every other week.
Fifth hospitalization during the same month, following an episode of infective chol-
angitis with blood tests that showed transaminase on the increase (ALT 248, AST 114,
GGT 281) with leukocytosis (WBCs 13,000, Neutrophils 88%, Lymphocytes 7.9%) and
elevated APC (4.48). Therapy started with Augmentin (1 g × three times a day) for
7 days and then end. At the end of the 7 days, preventive treatment prescribed with
Cotrimoxazole (tablet 160+800) one tablet twice a day.
Sixth hospitalization, 2 weeks after the previous one, following epigastric pain and
nausea, occurred after 1 day from Augmentin interruption and 1 day after the beginning
of therapy with Cotrimoxazole.
The most significant lab examinations at admission: CRP = 1.92 mg/dl; GGT 129 U/L;
AST = 29 u/l; ALT = 97 U/L.
Abdomen ultrasound scan with evidence of common bile duct dilatation. “Dilata-
tion of the proximal and medial segment of the common bile duct, with diameter up to
10 mm, in whose context binary images are appreciated referable to the well-known stent.
A moderate ectasia of intrahepatic bile ducts is connected, in particular in the left parts.”
To treat the severe painful symptomatology, a therapy with Ketorolac Tromethamine
90 mg in 250 cc in continuous infusion was started.
Because of the increase in the inflammation ratings and in the dilatation of the com-
mon bile duct at the abdominal ultrasound scan, supposing an occlusion of the biliary
stent with overlapped cholangitis, an antibiotic therapy has been started with Merope-
nem 1 g × 3 and a high osmolar ERCP was carried out.
ERCP didn’t show any materials obstructing the stent. Biliary washing was within
normal limits.
Therapy prescribed at home:
Augmentin (1 g × 3); Ciproxin (500 mg × 2); Folina 5 mg (one tablet every other day);
Deltacortene (25 mg daily); Azathioprine (100 mg daily); Lansoprazole (30 mg daily);
Ursodesossicolic Acid (300 mg three times a day).

CASE STUDY #7: DAVID CHANG

Patient: David Chang 13 February 2018

MRN: C55359541
Attending Physician: Evangeline DeRupo, MD
HPI: A 13-year-old boy had been well until 4 weeks before admission, when he devel-
oped a cough, periorbital edema, ankle swelling, headaches, and upper abdominal
discomfort. On admission, he was febrile with facial and ankle edema; there were gen-
eralized, superficial lymphadenopathy; numerous adventitial sounds in the lungs; and
mild hypertension (BP 140/110). His hemoglobin was 72 g/l with a normal white-cell
count and an erythrocyte sedimentation rate (ESR) of 137 mm/h. His blood urea was
high (27.5 mmol/l) with a low serum bicarbonate (13.6 mmol/l) and serum albumin (19
g/l). His creatinine clearance was 45 ml/min/m2 with urinary protein loss of 6.7 g/day.
His serum CH50 was low (14 U/ml; NR 25–45), as was his C3 level (0.20 g/l; NR 0.8–1.4);
his C4 level was normal (0.30 g/l; NR 0.2–0.4). A chest x-ray showed several rounded

1146   PART V  |  INPATIENT (HOSPITAL) REPORTING

opacities in both lungs. These were presumed to be infective and treated with amoxy-
cillin and flucloxacillin with resolution of the radiological findings.
The association of a low C3 with acute glomerulonephritis suggested acute post-
streptococcal disease as the most likely diagnosis, although no streptococci were iso-
lated and streptococcal antibodies were not raised. Over the following 3 weeks, his
blood urea fell but the proteinuria and hypertension persisted.
CURRENT ADMISSION: Although he feels better, he still has heavy proteinuria with
a low serum albumin (22 g/l; NR 35–50). Surprisingly, the serum CH50 and C3 levels
are still low at 18 U/ml and 0.4 g/l, respectively. This pattern was not consistent with
the working diagnosis. It suggested continued complement activation via the alternate
pathway, either due to some circulating activating factor or because of a regulatory
defect caused by absence of the inhibitors I or H. However, his serum levels of I and
H are normal. Electrophoresis of fresh serum and plasma showed the presence of C3
breakdown products and his serum was able to break down C3 in normal serum due to
the presence of C3 nephritic factor.
C3 nephritic factor shows a strong association with membranoproliferative glo-
merulonephritis, but not with acute poststreptococcal glomerulonephritis. Because
these conditions have different prognoses, a bilateral renal biopsy was performed
yesterday. The results show 11 glomeruli, all of which were swollen with proliferation
of mesangial, endothelial, and epithelial cells. On electron microscopy, the capillary
loops showed basement membrane thickening with electron-dense deposits within the
GBM. On immunofluorescence, intense C3 deposition is present in the GBM without
immunoglobulin staining. These appearances, together with the finding of circulating
C3 nephritic factor, are characteristic of membranoproliferative glomerulonephritis with
dense intramembranous deposits (type II MPGN). Alternate-day prednisolone 10 mg
PO per day was started, with prescription for 5 mg PO every other day for 30 days,
although this disease nearly always shows a slow progression to chronic renal failure.

CASE STUDY #8: MARYBELLE OSENKOWSKY

Patient: Marybelle Osenkowsky

Physician: Fiona McNally, MD
December 17, 2018
History
This 87-year-old female has been a patient of the McGraw Health Center and Clinic
since 2005. Chronic conditions: pernicious anemia, osteoarthritis, and urinary incon-
tinency. She is fully functional and fully independent. She provides care for her home-
bound husband, who has severe COPD. They live in a home chosen because it was
“close to the hospital” to ensure access to house calls for her husband.
In September 2005, the husband died as a result of respiratory arrest. Her only rela-
tive is a niece who talks with her about once a month. In October 2007, her home was
broken into and our patient was raped and robbed. She was taken to a local hospital
specializing in rape. Here, she is distressed, delusional, and reported to be very emo-
tionally distraught.
Examination
I saw the patient about 3 weeks after the rape in a community nursing home, where she
was moved after a 4-day stay at the hospital. She was very distressed, delusional, and
confused. She slowly improved over 2 months and was discharged to a senior living
center.

CHAPTER 38  | 
 In March of 2018, the patient was seen in the office. She is still very emotionally
unstable. She is crying, depressed (not suicidal), and stressed about her new home. She
wants to move to a different senior housing unit because it would be on the bus route,
making it easier to get around. She has also hired a middle-aged woman as a caregiver.
Today, 9 months after moving to the new facility, she becomes acutely ill with psy-
chotic symptoms and severe paranoia. She hallucinates that men and women are in her
bed and calls others all hours of the day. I admitted her into a hospitalized psychiatric
unit and she shows improvement over about 14 days without antipsychotic medication.
IV Haloperidol 2.5 mg q30 min x3h.
Diagnosis: Delusional disorder, Acute Post Traumatic Stress Disorder

CASE STUDY #9: ROGER WESTERMAN

Patient: Roger Westerman

Physician: LaTisha Rodriquez, MD
February 3, 2018
H&P
History:
05/13: trouble w balance × 1 year, fatigue, fall × 4 (retropulse × 3)
Walking slowly for few years—getting worse
Trouble going to standing from sitting position
No tremor, handwriting OK, no shuffling gait
Urinary incontinence without urgency—just leaks, not at night
Inattentive per wife
Cooks, but wife must redirect at times
Gave up driving 1 yr ago because he was nervous about his skills
Decline in function—no aerobics × 2–3 yrs
Depressive symptoms—had seen a psychiatrist for years. Had been on Prozac but it
“made him feel too great” and he gave it up
Overall, there had been a significant deterioration in function
Past Medical History
1996: Serial TIAs—anterior circulation symptoms—Carotid ultrasound (–), treated with
aspirin 81 mg qd
1998: Another TIA—ASA 325 mg. Repeat carotid ultrasound (–)
2003: Right hemisensory symptoms—Left thalamic infarct on MRI
2005: Neurology evaluation—problems with balance, coordination, reduced exercise
tolerance
February 1, 2018: MRI—mild prominence 3rd and lateral vents, periventricular white
matter changes, old left thalamic lacune. Low normal B12. Normal: TSH, folate, ESR,
CBC, HbA1C
Examination
SH: retired kindergarten teacher
Recently moved to an apartment house in the city
Requires help with instrumental activities of daily living
Physical Examination
Cranial nerves normal
Motor: normal × LUE extensor, LE flex 4/5
Normal tone, no cogwheeling, no shuffle, normal facies

1148   PART V  |  INPATIENT (HOSPITAL) REPORTING

3+ patellar DTR, 1+ ankles DTR, toes downgoing
• Retropulses with challenge
• Normal cerebellar exam
• Gait—ataxia present
Data and Scans
Review of head MRI/CTs from ’03, ’05, ‘06, ‘07:
Enlarging ventricles over time
Substantial white matter changes
Thalamic infarct
MRI, 02/01/2018 shows differential diagnosis of:
Sequelae of stroke (ataxia) vs. Normal Pressure Hydrocephalus
Surgery: Open procedure to insert monitoring device into cerebrum. Successful.
Code for monitoring device surgery.

CASE STUDY #10: KARL ATTENDA

DATE OF OPERATION: 05/15/2018

PREOPERATIVE DIAGNOSIS: Bilateral inguinal hernia
POSTOPERATIVE DIAGNOSIS: Bilateral inguinal hernia, direct
OPERATION PERFORMED: Laparoscopic bilateral inguinal hernia repair
SURGEON: Lawrence Podentale, MD
ANESTHESIA: General endotracheal
ESTIMATED BLOOD LOSS: Minimal
DESCRIPTION OF OPERATION: With the patient under general endotracheal anesthe-
sia, the abdomen was prepped with ChloraPrep solution and draped in the usual man-
ner. A transverse skin incision was made below and to the right of the umbilicus to
a length of approximately 4 cm. The incision was carried through the subcutaneous
tissue. Bleeders were cauterized. The right rectus sheath was identified and incised
lateral to the midline. The preperitoneal space was then developed following insertion
of a Spacemaker balloon, which was inflated under direct vision.
Following removal of the Spacemaker balloon, a #10 trocar was placed in the pre-
peritoneal space and the preperitoneal space was insufflated with CO2. Two #5 trocars
were placed in the lower midline. Video laparoscope was inserted in the preperito-
neal space. Landmarks including symphysis pubis, right Cooper ligament, and right
inferior epigastric vessels were identified. Dissection was then continued lateral to the
transverse abdominis muscle. The internal ring was then explored for the presence of
an indirect hernia sac. No indirect hernia sac was identified. The patient had a cord
lipoma, which was reduced under direct vision. Exploration of the medial space showed
a medial defect suggesting a direct hernia. A large size Bard 3D mesh was placed in
the preperitoneal space and anchored to the symphysis pubis and anterior abdominal
wall along the upper edge of the mesh with a stapler. The lower edge of the mesh was
affixed to the abdominal wall with Tisseel fibrin glue.
Following this, the left preperitoneal space was explored in the same fashion. Land-
marks including symphysis pubis, Cooper ligament, and inferior epigastric vessels were
identified. The dissection was continued laterally to the transverse abdominis muscle.
The internal ring was then explored for the presence of an indirect hernia sac. No indi-
rect hernia sac was identified. A cord lipoma was reduced. The patient was found to

CHAPTER 38  | 
 have a medial defect suggesting a direct hernia. A large size left 3D Prolene mesh was
then placed in the preperitoneal space and placed over the floor of the inguinal canal
and stapled to the symphysis pubis and anterior abdominal wall along the upper edge
of the mesh with a stapler.
The lower edge was anchored to the abdominal wall with Tisseel fibrin glue. The pre-
peritoneal space was then deflated. All trocars were withdrawn. The defect in the rectus
sheath was closed with figure-of-eight 0 Vicryl suture. The skin incisions were closed
with subcuticular 5-0 Monocryl suture. Sterile dressings were then applied. The patient
tolerated the procedure well and was brought to the recovery room in stable condition.
Needle and sponge counts were correct.
PROCEDURE: Laparoscopic repair of bilateral inguinal hernias
Lawrence Podentale, MD

CASE STUDY #11: KEASHA FROENMAN

DATE OF OPERATION: 06/07/2018

PREOPERATIVE DIAGNOSIS: Degenerative joint disease, left shoulder
POSTOPERATIVE DIAGNOSIS: Degenerative joint disease, left shoulder, with degen-
erative labral tear and chondral flap tear of glenoid
OPERATION PERFORMED: Arthroscopic exam of glenohumeral joint with arthroscopic
debridement of labral tears, chondroplasty, and microfracture of glenoid
SURGEON: Cassandra LeRoy, MD
ASSISTANT SURGEON: Rose Carter, MD
ANESTHESIA: General
DESCRIPTION OF OPERATION: The patient was brought to the operating room and
placed in a supine position on the operating room table. General anesthetic was admin-
istered. The left shoulder was prepped and draped in a sterile orthopedic fashion after
she was placed in a beach-chair position. A time-out was performed confirming left
shoulder pathology, and she also had 1 gram of Ancef administered intravenously. After
the sterile orthopedic prep and drape, a posterior stab wound was created and the
arthroscope was introduced into the glenohumeral joint. The joint was inspected. There
were degenerative changes of the labrum circumferentially. Through an anterior portal,
a full-radius resector was inserted and these areas debrided back to stable tissue and
this was supplemented with use of the ArthroCare wand on a setting of one. There was
a flap tear of the anterior portion of the mid glenoid region. This was easily displace-
able. Using a 4.2 full-radius resector, this was debrided back to stable tissue and then
an awl was used to microfracture the bone. The inflow pump was then stopped and
bloody fluid could be seen coming from the microfracture area. The undersurface of
the rotator cuff was inspected and found to be without pathology. The arthroscope was
then placed into the anterior portal, and through the posterior portal, the ArthroCare
wand and a full-radius resector were inserted and the most inferior aspect and posterior
aspect of the glenoid and labrum debrided. There were no frank tears of the posterior
labrum. The arthroscope was then placed in the subacromial space, which did appear to
be pristine. There was no evidence of impingement. All instruments were then removed
and the stab wounds were closed with a single Monocryl suture and Steri-Strips. Dry
sterile dressings were placed over the wound. The patient was placed in a shoulder
sling and then sent to the recovery room in stable condition.

1150   PART V  |  INPATIENT (HOSPITAL) REPORTING

CASE STUDY #12: REISHICA DECLERQUE

DATE OF ADMISSION: 09/09/2018

DATE OF DISCHARGE: 09/11/2018
DISCHARGE DIAGNOSES:
. Intrauterine gestation at term
1
2. History of two previous cesarean sections
3. Delivered viable male infant
4. Multiparity, fertility, desired sterilization

PROCEDURES PERFORMED:
. Repeat low transverse cesarean section
1
2. Bilateral tubal ligation
COMPLICATIONS: None
PERTINENT FINDINGS/HISTORY AND PHYSICAL: Refer to the detailed admission dictation.
The patient is a 35-year-old gravida 6, now para 3-0-3-3 female, who was admitted
at term for repeat cesarean section and sterilization. The patient had previous cesarean
sections for labor arrest, for an infant weighing 9 pounds 12 ounces, and elective repeat.
The patient strongly desired repeat cesarean section. She also wanted to have a tubal
ligation and signed the appropriate consent forms.  Patient is well aware of the risks,
options, failure rates, and permanency of sterilization procedures. Her antenatal course
was significant for development of A1 diabetes with blood sugars in excellent control,
on diet only. The patient declined genetic screening because of advanced maternal age.
LABORATORY INVESTIGATIONS: The patient’s admission hemoglobin was 11.1 with
hematocrit of 33.4 and platelet count 196,000. Her postoperative hematocrit was 32.2.
HOSPITAL COURSE: The patient was admitted on the morning of her scheduled surgery.
Detailed informed consent was again obtained. Under spinal anesthesia, uncomplicated
repeat low transverse cesarean section and bilateral tubal ligation were performed. A
viable male infant with Apgars of 9 and 9 with birth weight of 8 pounds 6 ounces was
delivered. The patient’s postoperative course was uneventful. She remained afebrile
with stable vital signs. She returned quickly to good ambulation and regular diet. She
had normal GI function return. Her incision healed nicely. Her lochia was light.
Discharge examination revealed negative HEENT, neck, heart, lung, extremities, and
abdominal examinations.
CONDITION ON DISCHARGE: Stable.
DISPOSITION: Discharged to home.
DISCHARGE INSTRUCTIONS:
ACTIVITY: Slow increase as tolerated. No heavy lifting. Strict pelvic rest.
DIET: Regular.
MEDICATIONS: Colace p.r.n., Tylenol p.r.n., and prenatal vitamins. The patient is breast-
feeding. Prescriptions for Percocet 325/5 tablets, #30, no refills, 1 to 2 p.o. q.4–6 h.
p.r.n. pain and ibuprofen 800 mg, #20, no refills, 1 p.o. q.8 h. p.r.n. pain.
Follow up as an outpatient in the office in 1 week.
The patient has received routine verbal instructions and agrees to comply. She
knows to contact us immediately should she develop any signs or symptoms of compli-
cations such as fevers, chills, drainage from the incision, abdominal distention, nausea,
vomiting, heavy vaginal bleeding, leg redness or swelling, chest pain, chest pressure,
or shortness of breath.

CHAPTER 38  | 
 CASE STUDY #13: WARREN ELLIS

DATE OF CONSULTATION: 11/16/2018
REFERRING PHYSICIAN: Charles Craigen, MD
REASON FOR CONSULTATION: Evaluation and management of painful lymphadenitis.
Thank you for this infectious disease consultation.
HISTORY OF PRESENT ILLNESS: The patient is a 41-year-old male who about 3 days
prior to admission noticed what appeared to be a painful inguinal lymph node on the
left that seemed to progressively increase in size. This started while on a business trip,
but after he returned to work, he noticed it became a lot more tender and swollen.
He finally presented to the emergency department after having a couple of days of
onset of fever and was admitted for further evaluation. The patient on arrival did have
a low-grade temperature of 100. He was started initially on Flagyl and Cipro, that was
changed to doxycycline and Rocephin, and now he is on Zithromax and vancomycin.
The patient does not have any known infection as far as he knows. The patient has
not had any exposure to tuberculosis, although he said that he has had weight loss and
some night sweats, but this has only started since the onset of his symptoms about
a week ago. He has not had any long-term weight loss or long-term night sweats or
cough. The patient had traveled for that weekend prior to getting his onset of symp-
toms, but he did not do any camping. He does have two cats at home but no obvious
cat bite or scratches as far as he knows. The patient has also been involved in a new
sexual relationship about several months ago and has not had an HIV test recently. He
had one 2 years ago that he reports was negative. No other history of sexually transmit-
ted diseases to his knowledge.
REVIEW OF SYSTEMS: Unremarkable other than mentioned above. The patient had
diarrhea 1 day prior to admission and currently still has diarrhea.
PAST MEDICAL HISTORY: Hypertension, history of kidney stones, depression, migraines.
PAST SURGICAL HISTORY: Cyst removed from the right leg.
ALLERGIES: No known allergies.
MEDICATIONS: List is currently reviewed and the antibiotics are listed above in the HPI.
SOCIAL HISTORY: The patient does not use tobacco, alcohol, or drugs. He is divorced
from his first wife but is living with a new girlfriend. He has four children, all of whom live
at home with him.
FAMILY HISTORY: Negative for immune dysfunction.
PHYSICAL EXAMINATION: General: The patient is alert and oriented and in no acute
distress. He is afebrile. Temperature 96.5, pulse 70, respirations 19, and blood pres-
sure 115/73. HEENT: Pupils are equal and reactive. Head is normocephalic and atrau-
matic. Sinuses are nontender. Oropharynx is clear without lesions. Neck: Supple without
lymphadenopathy. Heart: Regular rate and rhythm. Lungs: Clear to auscultation bilater-
ally. Abdomen: Soft, nontender, and nondistended with no rebound or guarding. Good
bowel sounds are heard. Genitourinary: The left groin reveals tender adenopathy.
There is definite swelling and a mass felt in the left inguinal area. There is no obvious
cut or scratches seen. The rest of the inguinal area appears fairly unremarkable without
lesions or blisters seen. Lower extremities are without edema, clubbing, or cyanosis,
and appeared normal. Skin: Reveals no rashes. Neurologic: Grossly nonfocal.
LABORATORY DATA: Laboratory data have been reviewed and showed an ele-
vated white count of 16. There is a band neutrophilia of 27%. Liver function tests are

1152   PART V  |  INPATIENT (HOSPITAL) REPORTING

unremarkable. Creatinine is normal. UA is unremarkable. Chlamydia and gonorrhea
DNA probe are negative.
DIAGNOSTIC STUDIES: CT of the abdomen was done that was unremarkable. There
is a nonspecific enlargement of a lymph node within the left inguinal region as seen on
the CT of the pelvis.
IMPRESSION:
1. Painful lymph node lymphadenitis with a broad differential.
2. Diarrhea, which is new onset, right before admission.

DISCUSSION: The differential is broad. This could be suppurative bacterial process,

which is usually due to staph and strep. It is less likely to be tularemia or Yersinia. We
also need to consider fungal, TB, and sexually transmitted diseases including HIV. We
also need to consider cat scratch disease.
RECOMMENDATIONS:
. I will do a percutaneous biopsy of the inguinal mass.
1
2. We will order HIV antibody and quantitative viral load.
3. We will check Bartonella antibodies as well as Chlamydia trachomatis titers.
4. We will check PPD.
5. Check Clostridium difficile toxin.
6. Daptomycin antibiotic to replace the vancomycin.
We will continue to follow. Thank you for asking us to participate in this patient’s care.
**Code for the biopsy of the inguinal mass.**

CASE STUDY #14: HILLARY ROMINEY

DATE OF STUDY: 02/22/2018
ORDERING PHYSICIAN: Harrison Brady, MD
DATE OF INTERPRETATION OF STUDY:
Echocardiogram was obtained for assessment of left ventricular function. The patient
has been admitted with diagnosis of syncope. Overall, the study was suboptimal due to
poor sonic window.
FINDINGS:
. Aortic root appears normal.
1
2. Left atrium is mildly dilated. No gross intraluminal pathology is recognized, although
subtle abnormalities could not be excluded. Right atrium is of normal dimension.
3. There is echo dropout of the interatrial septum. Atrial septal defects could not be
excluded.
4. Right and left ventricles are normal in internal dimension. Overall left ventricular sys-
tolic function appears to be normal. Eyeball ejection fraction is around 55%. Again,
due to poor sonic window, wall motion abnormalities in the distribution of lateral
and apical wall could not be excluded.
5. Aortic valve is sclerotic with normal excursion. Color flow imaging and Doppler
study demonstrates trace aortic regurgitation.
6. Mitral valve leaflets are also sclerotic with normal excursion. Color flow imaging and
Doppler study demonstrate trace to mild degree of mitral regurgitation.

CHAPTER 38  | 
 7. Tricuspid valve is delicate and opens normally. Pulmonic valve is not clearly seen.
No evidence of pericardial effusion.
CONCLUSIONS:
. Poor quality study.
1
2. Eyeball ejection fraction is 55%.
3. Trace to mild degree of mitral regurgitation.
4. Trace aortic regurgitation.

CASE STUDY #15: ELENA BEVERLY

DATE OF ADMISSION: 03/01/2018

DATE OF DISCHARGE:  03/09/2018
DISCHARGE DIAGNOSES:
AXIS I:
. Bipolar disorder, depressed, with psychotic features, symptoms in remission.
1
2. Attention deficit hyperactivity disorder, symptoms in remission.
AXIS II: Deferred.
AXIS III: None.
AXIS IV: Moderate.
AXIS V: Global assessment of functioning 65 on discharge.
REASON FOR ADMISSION: The patient was admitted with a chief complaint of suicidal
ideation. The patient was brought to the hospital after her guidance counselor found
a note the patient wrote, which detailed whom she was giving away her possessions
to when she dies. The patient told the counselor that she hears voices telling her to
hurt herself and others. The patient reports over the last month these symptoms have
exacerbated. The patient had a fight in school recently, which the patient blames on the
voices. Three weeks ago, she got pushed into a corner at school and threatened to cut
herself and others with a knife. The patient was suspended for that remark.
PROCEDURES AND TREATMENT:
. Individual cognitive and group psychotherapy.
1
2. Psychopharmacologic management.
3. Family therapy conducted by social work department with the patient and the
patient’s family for the purpose of education and discharge planning.

HOSPITAL COURSE:  The patient responded well to individual and group psycho-
therapy, milieu therapy, and medication management. As stated, family therapy was
conducted.
DISCHARGE ASSESSMENT: At the time of discharge, the patient is alert and fully ori-
ented. Mood euthymic. Affect broad range. She denies any suicidal or homicidal ide-
ation. IQ is at baseline. Memory intact. Insight and judgment good.
PLAN:  The patient may be discharged as she no longer poses a risk of harm towards
herself or others. The patient will continue on the following medications: Ritalin LA 60 mg
q.a.m., Depakote 500 mg q.a.m. and 750 mg q.h.s., Abilify 20 mg q.h.s. Depakote level on
date of discharge was 110. Liver enzymes drawn were within normal limits. The patient
will follow up with Dr. Petrikas for medication management and Dr. Sanders for psycho-
therapy. All other discharge orders per the psychiatrist, as arranged by social work.

1154   PART V  |  INPATIENT (HOSPITAL) REPORTING

PART VI
REIMBURSEMENT, LEGAL, AND
ETHICAL ISSUES
INTRODUCTION
A professional coding specialist’s responsibilities may not stop when the last code is
determined. Remember, the codes you determine are used on requests for payment,
known as reimbursement claims. Whenever money is involved, there are always legal
and ethical issues attached, and you must familiarize yourself with all of the aspects
for doing a complete and professional job for your facility, whether it is a small physi-
cian’s office or a huge hospital. Understanding these components ensures that you will
have a career draped in honesty, integrity, and success.
 39
Key Terms
Reimbursement

Learning Outcomes
Automobile Insurance After completing this chapter, the student should be able to:
Capitation Plans
LO 39.1 Define the role of health insurance and managed care plans
Centers for Medicare
& Medicaid Ser- in the delivery of health care services.
vices (CMS) LO 39.2 Identify and define the types of health insurance plans.
Dependents LO 39.3 Explain the types of compensation used in health care
Diagnosis-Related reimbursement.
Group (DRG) LO 39.4 Describe the information available for proper coding from
Disability
NCCI edits and NCD and LCD.
Compensation
Discounted FFS LO 39.5 Utilize Place-of-Service and Type-of-Service codes as
Electronic Media required.
Claim (EMC) LO 39.6 Create a system for organizing claims, understanding deni-
Electronic Remittance als, and filing appeals.
Advice (ERA)
Eligibility Verification
Episodic Care
Explanation of Ben-
efits (EOB) 39.1  The Role of Insurance in Health Care
Fee-for-Service (FFS) A health insurance policy is a contractual agreement between an insurance carrier
Plans (company) and an individual related to health care issues. And the basis of this con-
Gatekeeper tract is risk. Insurance is just like gambling in Las Vegas. Basically, the insurance
Health Care company is betting that a certain event will not happen to you, such as you getting
Health Maintenance sick. If that happens, it would have to pay your medical bills. On the other side of the
Organization table, you are betting (by paying an insurance premium) that you will have a major
(HMO) illness or health catastrophe. Think about it—if you knew for a fact that you would
Insurance Premium never get ill or have any injury, and would only have to go to the doctor for your annual
Liability Insurance checkups, would you pay all that money every month for insurance premiums? Of
Managed Care course not. You are betting that you will, at some point, get all that money back, when
Point-of-Service (POS) you need it to pay for some type of treatment.
Preferred Provider When managed care was developed, the health insurance industry realized that it
Organization (PPO) could lower its risk (and save money) if it could keep people healthy by encouraging
Remittance Advice them to go to the doctor for regular checkups, tests, and so forth. This thinking cre-
(RA) ated a major change in the health insurance industry and in the medical care industry,
Third-Party Payer increasing the focus of health care delivery to include preventive care, rather than only
Tracer therapeutic (medical) care.
TriCare Medical care is the identification and treatment of illnesses and injuries—in other
Usual, Customary, and words, whatever a health care provider does to help you with a health problem or con-
Reasonable (UCR) cern that you have (Figure 39-1).
Workers’ Preventive care is provision of services designed to prevent the problem from mani-
Compensation festing (developing) or to discover it in early stages when it is more easily corrected.
Preventive care includes well-baby visits (Figure 39-2), screenings, diagnostics, and
Insurance Premium routine checkups.
The amount of money, often The term health care refers to a combination of these two types of services.
paid monthly, by a policyholder
or insured, to an insurance
company to obtain coverage.

1156
 Managed Care
A type of health insurance
coverage that controls the
care of each subscriber (or
insured person) by using a pri-
mary care provider as a cen-
tral health care supervisor.

Health Care
The total management of an
individual’s well-being by a
health care professional.

CODING BITES
FIGURE 39-1  Treatment of a broken leg is an example of medical care  Medical Care + Preven-
©ERproductions Ltd/Blend Images LLC RF
tive Care = Health Care

FIGURE 39-2  Well-baby visits are an example of preventive care 

©Picture Partners/AGE Fotostock RF

EXAMPLES
Dr. Michaelson examines Paul and gives him a shot of antibiotics to help Paul get
rid of an infection. The doctor has identified Paul’s illness and is treating that ill-
ness. This is medical care.
Dr. Calavari knows Katrina works at a day care center and gives her a flu shot
to help her avoid getting the flu. The doctor is preventing Katrina from becoming
ill. This is preventive care.

We all know that every organization needs to have money coming in so that it can
stay in business. The physician provides a service to his or her patients and expects CODING BITES
to be paid for those services. That money is what keeps a practice open and allows it
to pay your salary. If enough people don’t pay their bills, then an office must lay off The process of getting
people (and that could mean you!). Or you might not be able to get that next raise, even information and submit-
if you deserve it. ting claims to the third-
By now, you understand how important all of this information is and how you have party payer is key to the
a personal stake in completing claim forms correctly. As you transfer information from survival of your health
patient registration forms and other documents, be certain to care facility and all the
people it employs.
∙ Double-check your work to make sure it is accurate.
 ∙ Confirm that the form is completely filled out, with no necessary information
missing.
∙ Verify the spelling of every name and the accuracy of every number.
It all must be absolutely correct.
Most third-party payers, including Medicare, prefer claim forms to be submitted
Electronic Media Claim (EMC) electronically. An electronic media claim (EMC), also called an electronic claim, is
A health care claim form that evaluated more quickly than a print claim form. Accepted claims are paid faster. Years
is transmitted electronically. ago, it was not unusual for health care facilities to wait 4 to 6 months to receive pay-
ment from an insurance company. With electronic claims, this time has been reduced
to 2 to 3 weeks.
Increased use of technology in this process also means that there is an excellent
chance a computer will be reviewing your claim form. During the initial processing
of a claim you have sent, the computer will only compare letter to letter and number
to number, looking for an exact match to the letters and numbers in their files. Then,
claims with errors, such as invalid policy numbers or missing information, will be
rejected and returned to you.

EXAMPLE
The computer cannot scan your claim form and say, “Oh, I can see this is a typo.
They really meant to put a W instead of a U.” No, all the computer knows is that
the letter is supposed to be a U and it is not. And the claim will be rejected.

The Participants
Essentially, there are three participants in each health care encounter, or visit:
CODING BITES
Party #1: The health 1. The physician or health care provider.
care provider 2. The patient—the person seeking services.
Party #2: The patient 3. The insurance carrier covering the costs of health care activities for the patient.
Party #3: The insurance
carrier Some people get their health insurance policies through a program at their place
of employment, some through the government, and others directly with the insurance
carriers as individual policyholders. It doesn’t matter very much to the health care
Third-Party Payer facility. In any case, a third-party payer will pay, in part, the patient’s bills for ser-
An individual or organization vices that your facility will provide. Health insurance carriers are often referred to as
that is not directly involved in third-party payers. This means that someone not directly involved in the health care
an encounter but has a con- relationship is paying for the service. The health care provider is party #1, the patient
nection because of its obliga- is party #2, and the insurance carrier is party #3—the third party. Therefore, the insur-
tion to pay, in full or part, for
ance company is the third-party payer.
that encounter.

39.2  Types of Insurance Plans

There are many types of health plans that people may purchase, or contract for, with
companies that specialize in insurance.

Health Maintenance Organization (HMO)

Health Maintenance In a health maintenance organization (HMO), members, also called enrollees, pre-
Organization (HMO) pay for health care services. The members are encouraged to get preventive treatment
A type of health insurance to promote wellness (and keep medical costs down). In addition, each member has a
that uses a primary care phy- primary care physician (PCP), also known as a gatekeeper. The PCP is responsible
sician, also known as a gate- for monitoring the individual’s well-being and making all decisions regarding care. It
keeper, to manage all health
is the PCP who determines if a specialist is required for a certain evaluation or pro-
care services for an individual.
cedure. When this occurs, it is the PCP who is responsible for completing the patient

1158   PART VI  |  REIMBURSEMENT, LEGAL, AND ETHICAL ISSUES

referral form and getting approval from the HMO for the patient to visit the specialist. Gatekeeper
Generally, HMOs do not require a patient to satisfy a deductible before benefits begin. A physician, typically a fam-
(See the section Individual Insurance Contributions later in this chapter.) ily practitioner or an internist,
who serves as the primary
care physician for an indi-
CODING BITES vidual. This physician is
HMOs use a “home base” concept, with a primary care physician (PCP), also responsible for evaluating
and determining the course
known as the gatekeeper, serving as the central base to supervise each individu-
of treatment or services, as
al’s health care.
well as for deciding whether
or not a specialist should be
Preferred Provider Organization (PPO) involved in care.

In a preferred provider organization (PPO), physicians, hospitals, and other health Preferred Provider
Organization (PPO)
care providers join together and agree to offer services to members of a group (often
A type of health insurance
called subscribers) at a lower cost or discount. These plans usually permit the individ-
coverage in which physicians
ual subscriber (the patient) to choose the physician or specialist to see, with a discount provide health care services
for staying in the network by using a physician who is a member of the plan. If the to members of the plan at a
individual chooses a physician who does not belong to the network, or is not partici- discount.
pating with that PPO, the individual will pay a penalty or receive less of a discount
in the cost of those services. This can give the individual more control over his or her
health care. It can save time and money, as well.
Some PPO plans require the patient to satisfy a deductible first before benefits
begin. (See the section Individual Insurance Contributions later in this chapter.) Typi-
cally, a higher deductible will translate into a lower monthly premium for this type of
insurance coverage.

EXAMPLE
If a person covered under a PPO plan is having problems sneezing and knows the
problem is his or her allergies, the individual can choose an allergist—a provider
who specializes in the treatment of allergies—from the PPO network without hav- CODING BITES
ing to go to his or her primary care physician for a referral. If the plan were an PPOs typically Permit
HMO, the person would have to make an appointment with the PCP first, in order the Patient to Opt (or
to get the referral to the allergist. Then, the person could make an appointment to choose) his or her physi-
see the allergist. cian or specialist.

Point-of-Service (POS) Plan

Giving individuals a little more flexibility, a point-of-service (POS) plan is almost a Point-of-Service (POS)
combination of an HMO and a PPO. Each insured person has a primary care physician A type of insurance plan that
(PCP) and a list of providers that participate in the HMO. When health care provid- will allow an HMO enrollee
ers within the HMO network are used, the insured pays only a regular co-payment to choose his or her own
amount or a small charge. There is no deductible or co-insurance payment involved. nonmember physician at
a lower benefit rate, cost-
However, this plan may also include a self-referral option, in which the individual
ing the patient more money
insured can choose to go to an out-of-network provider. In that case, the individual out-of-pocket.
may be responsible for paying both a deductible and a co-insurance payment.

CODING BITES
POS plans combine features of an HMO and a PPO.

Federal Government Plans

Centers for Medicare & Medicaid Services (CMS)
In 1977, the Health Care Financing Administration (HCFA, pronounced hic-fah)
was created to coordinate federal health services programs. On July 1, 2001, HCFA
 FIGURE 39-3  Medicare.gov, the official U.S. government site for Medicare 
Source: Medicare.gov

Centers for Medicare & Med- became the Centers for Medicare & Medicaid Services (CMS). Many health care
icaid Services (CMS) professionals still refer to this agency as “HicFah” and to the CMS-1500 claim form
The agency under the Depart- as the “HicFah 1500.” Old habits take a while to change. At least you now understand
ment of Health and Human that these two acronyms refer to the same federal organization.
Services (DHHS) in charge of Medicare is a national health insurance program that pays, or reimburses, for
regulation and control over
health care services provided to those over the age of 65 (see Figure 39-3). In addi-
services for those covered by
Medicare and Medicaid.
tion, this plan may cover individuals who are under the age of 65 and are permanently
disabled (such as the blind), as well as those with end-stage renal disease (ESRD)
who are suffering from permanent kidney failure and require either dialysis or a kid-
CODING BITES ney transplant.
MedicaRE = REtired Medicaid is a plan that pays for, or reimburses, medical assistance and health care
people (who are over services for people who are indigent (low-income) (see Figure 39-4). The program
the age of 65)  is jointly funded by the federal and state governments. Each state government then
administers its own plan. This means that each state determines who is eligible and
MedicaID = InDigent, or
what services are covered. It is important to know that each state has its own require-
low-income, individuals
ments, in case you have a patient that has just moved to your state. Each state may even
have a unique name or term for its program. For example, in California the program is
called Medi-Cal.

TriCare TriCare
A government health plan that TriCare offers the most common health care plans you will encounter when caring
covers medical expenses for for individuals in the military and their families (see Figure 39-5). This program was
the dependents of active-duty formerly known as CHAMPUS.
service members, CHAMPUS-
TriCare was created to help the following individuals receive better access to
eligible retirees and their
families, and the dependents of
improved health care services:
deceased active-duty members. ∙ Active-duty service members (ADSM), also known as sponsors.
Dependents ∙ The dependents (spouses and children) of ADSMs.
Individuals who are sup- ∙ Surviving spouses and surviving children of deceased ADSMs.
ported, either financially or
with regard to insurance cov- ∙ Retired service members, their spouses, and their children.
erage, by others. ∙ Surviving spouses and children of deceased retired members.

1160   PART VI  |  REIMBURSEMENT, LEGAL, AND ETHICAL ISSUES

 Final PDF to printer

FIGURE 39-4  Medicaid.gov, the official U.S. government website of Medicaid 

Source: Medicaid.gov

FIGURE 39-5  TriCare.mil, the official U.S. government website of TRICARE 

Source: Tricare.mil

TriCare was created to provide health care benefits for the dependents of those
serving in the uniformed services and retirees.  ADSMs are those from any of the
seven uniformed services, including the U.S. military (the Army, Navy, Air Force,
Marine Corps, and Coast Guard), as well as those serving in the Public Health
Service, National Guard and Reserve, and the National Oceanic and Atmospheric
Administration (NOAA). Eligibility for TriCare is determined by the services and
information is maintained in the Defense Enrollment Eligibility Reporting System
(DEERS). 

Other Insurance Plans Workers’ Compensation

An insurance program that
Workers’ compensation is an insurance program designed to pay the medical costs covers medical care for those
for treating those injured, or made ill, at their place of work or by their job. This injured or for those who
includes injuries resulting from a fall off a ladder while performing a job-related become ill as a consequence
task, getting hurt in an accident while driving a company car on a business trip, or of their employment.

saf28735_ch39_1155-1184.indd  1161 12/01/17 07:57 AM

 developing a lung disorder caused by toxic fumes in the office. Generally, a workers’
compensation plan covers only specific medical bills, such as laboratory bills, physi-
cians’ fees, and other medical services. Most often, lost income is not covered by this
policy. Each state oversees the workers’ compensation contracts with particular insur-
ance carriers.
Disability Compensation Disability compensation is an insurance plan that reimburses disabled individuals
A plan that reimburses a cov- for a percentage of what they used to earn each month. This plan does not pay physi-
ered individual a portion of his cians’ bills or for therapy treatments. A disability plan only provides insureds with
or her income that is lost as a money to replace a portion of their lost paycheck because they are unable to work.
result of being unable to work Disability payments might come through a federal government agency such as the
due to illness or injury.
Social Security Administration, or patients may have a private insurance plan (such as
AFLAC).

YOU INTERPRET IT!

Joe Hines works as an electrician for a small company. One day, he falls off a ladder at work and injures
his back severely. He is taken to the emergency room by ambulance, and the attending physician
orders x-rays and a CT scan. The tests confirm that Joe’s spine is broken in two places and a cast is
applied around Joe’s entire torso. After a week in the hospital, Joe is discharged. The physician’s dis-
charge orders state that Joe is to stay in bed for 7 months, in traction, while the fracture heals. A home
health agency is contracted to provide a trained health care professional to go to Joe’s house to care
for him and attend to his needs around the clock.
1. In this scenario, what type of insurance will be responsible for the payment of each of Joe’s
expenses due to this accident?

Liability Insurance Liability insurance is commonly part of a person’s homeowners or business own-
A policy that covers loss or ers insurance. This type of policy covers losses to a third party caused by the insured
injury to a third party caused or something owned by the insured. In other words, the insurance company will pay
by the insured or something for, or reimburse for, any harm or damage done to someone else (not a member of the
belonging to the insured. household or the business).

YOU INTERPRET IT!

Sarah goes over to Margaret’s house for dinner. After a delicious meal, Sarah walks toward the door to
leave and go home. As she turns to say goodnight to Margaret, Sarah trips and falls. Margaret calls the
paramedics, and, at the hospital, the x-rays ordered by the attending physician confirm that Sarah has
indeed broken her wrist. A cast is applied, and Sarah is sent home with a prescription for pain medica-
tion. The attending physician advises Sarah to see her primary care physician in 1 week for a follow-up.
2. What type of insurance will cover Sarah’s medical expenses?

YOU INTERPRET IT!

Kyle, a fifth-grade student, slipped down the stairs at school. Typically, the school’s liability policy would
cover the damage, or medical expenses. The school is the insured, and the student is the third party.
3. If a faculty member and a student are walking through the cafeteria of the school and both slip and
fall, what types of policies will cover any injuries that might be caused by the fall?

1162   PART VI  |  REIMBURSEMENT, LEGAL, AND ETHICAL ISSUES

 Automobile insurance might become an issue for your office if you treat someone Automobile Insurance
for an injury that was caused by the individual’s involvement in an automobile acci- Auto accident liability cover-
dent. Full-coverage automobile policies usually include liability insurance that covers age will pay for medical bills,
these expenses. lost wages, and compensation
for pain and suffering for any
person injured by the insured
Details Are Required in an auto accident.
As you can see from all this information, different types of insurance policies might
be responsible for an individual’s medical treatment. Therefore, in your job as medical CODING BITES
insurance coder/biller, you must make certain that if an individual comes to the pro-
And you need these
vider for treatment for an injury (rather than an illness), you must find out the details
details for determin-
of how and where the injury occurred. This will help determine which carrier will
ing the external cause
cover the charges.
codes, too!

39.3  Methods of Compensation

There are several payment plans that insurance carriers (third-party payers) use to pay
physicians and other health care providers for their services.

Fee-for-Service (FFS) Plans

In fee-for-service (FFS) plans, the insurance company pays the health care provider Fee-for-Service (FFS) Plans
for each individual service supplied to the patient, as reported by the procedure codes Payment agreements that out-
listed on the claim, according to an agreed-upon price list (also known as a fee sched- line, in a written fee schedule,
ule). When the physician’s office agrees to participate in the plan, it is also agreeing exactly how much money the
to provide services and accept the amount of money indicated on that schedule for insurance carrier will pay the
physician for each treatment
each of those services. This is like going to a restaurant with an à la carte menu. The
and/or service provided.
menu lists a price for each item: the salad, the roast beef, the apple pie. The restaurant
accepts the amount of money the guest pays for each item received. Different plans
may pay different amounts of money for one particular service, just as different restau-
rants may charge different amounts for a similar dish.
Sometimes, when one insurance carrier pays a provider at a lower rate than other
carriers, it is referred to as a discounted FFS. In a typical discounted FFS, the pay- Discounted FFS
ments are reduced from the physician’s regular rate. This is similar to the discount you An extra reduction in the rate
might get at a store when showing your student ID card—you get a discount because charged to an insurer for ser-
you are a member of the school. vices provided by the physi-
cian to the plan’s members.

EXAMPLE
Three people, each with a different insurance carrier, go to the same physician for
a flu shot (injection). Insurance carrier #1 has agreed to pay the physician $20 for
giving the injection. Insurance carrier #2 has agreed to pay the physician $22.50,
and insurance carrier #3 has agreed to pay the physician $18 for the same injec-
tion. Your office should charge all patients the same amount. This is known as the
charged amount. However, insurance carriers working with your office on a fee-
for-service contract will pay only the amount stated on their fee schedule. That’s
all they will pay and no more. This is called the allowed amount.
Capitation Plans
Agreements between a phy-
sician and a managed care
Capitation Plans organization that pay the
physician a predetermined
With capitation plans, the insurance company pays the physician a fixed amount of amount of money each month
money for every individual covered by that plan (often called members or subscrib- for each member of the plan
ers) being seen by that physician. Physicians get this amount of money every month, who identifies that provider
as long as they are listed as the physician of record (primary care physician (PCP)) as his or her primary care
for that individual. Whether the insured person goes to see that physician once, three physician.
 times, or not at all during a particular month, the physician’s office will be paid the
CODING BITES same amount. This plan is like the dinner special at your local restaurant. You pay one
CAPitation plans pay price, which includes soup, salad, all-you-can-eat entrée, and dessert. If you don’t eat
by the cap. One cap your soup, you do not pay any less; if you get seconds on the entrée, you do not pay
goes on one head, any more.
and the insurance car-
rier is going to pay the Episodic Care
physician for each cap,
or head—that is, per An episodic care agreement between insurer and physician means the provider is paid
person. one flat fee for the expected course of treatment for a particular injury or illness. This
is like the meal deal of health care. One package price includes all of the services and
treatments necessary for the proper care of the patient’s condition in accordance with
the accepted standards of care.
Episodic Care
An insurance company pays a
provider one flat fee to cover
the entire course of treatment EXAMPLE
for an individual’s condition. Audrey Callahan fell off her bicycle and broke her arm. The x-ray shows that it is
a simple, clean fracture and the physician applies a cast. The doctor schedules a
follow-up appointment for her and expects that she will not need much other atten-
tion until the cast comes off in 6 weeks. At that time, an x-ray will confirm that the
fracture has healed properly and the cast will be removed. This entire sequence of
events, and treatment, is very predictable for a routine simple fracture. Therefore,
the insurance company has agreed to pay the physician one flat fee for this event,
rather than having the physician’s office file a claim for each procedure and service
individually: the first encounter; the first x-ray; the application of the cast; the follow-
up encounter; the last encounter; the last x-ray; and removal of the cast.
Audrey Callahan’s physician is being reimbursed under an episodic care agree-
ment with the insurance carrier.

Diagnosis-Related Group Diagnosis-related groups (DRGs) are a type of episodic care payment plan used
(DRG) by Medicare to pay for treatments and services provided to beneficiaries who have
An episodic care payment been admitted into an acute care hospital (inpatients). DRGs are categorized by the
system basing reimburse- principal (first-listed) diagnosis code and take into consideration elements such as
ment to hospitals for inpatient the patient’s age and gender and the presence of any complications or manifesta-
services upon standards of
tions (additional diagnoses or conditions). You read more about DRGs in the chapter
care for specific diagnoses
grouped by their similar usage
titled Inpatient (Hospital) Diagnosis Coding.
of resources for procedures,
services, and treatments. Patient/Beneficiary Out-of-Pocket Contributions
Patients with insurance policies often contribute to reimbursing providers for their
health care services, in addition to paying monthly premiums. The following are the
most common methods used for the individual’s payments:

Usual, Customary, and Rea- 1. Co-payment (also known as the co-pay). The co-payment is usually a fixed amount
sonable (UCR) of money that the individual will pay each time he or she goes to a health care pro-
The process of determining a vider. It may be $10, $15, $20, or more. Each policy is different. As a matter of fact,
fee for a service by evaluating the co-pay on the same policy for the same patient may be different, depending on
the usual fee charged by the whether this is a visit to a family physician, a specialist, or the hospital.
provider, the customary fee
2. Co-insurance. Co-insurance is different from the co-payment because it is based
charged by most physicians
in the same community or
on a percentage of the total charge rather than a fixed amount. The percent-
geographical area, and what age that the patient pays is most often calculated on the usual, customary, and
is considered reasonable by reasonable (UCR) charge that has been determined for this type of visit or pro-
most health care profession- cedure. Frequently, the individual is required to pay 20% of the total allowed
als under the specific circum- amount by the physician or facility, but that might differ for various types of poli-
stances of the situation. cies and carriers.

1164   PART VI  |  REIMBURSEMENT, LEGAL, AND ETHICAL ISSUES

 3. Deductible. This is the amount of money that patients must pay, out of their own
pockets, before the insurance benefits begin. The deductible might be as little as
$250 or as much as $1,000 or more. Patients have to pay the total amount until they
have paid the whole deductible for that calendar year. After that, they will usually
pay just the co-payment and/or the co-insurance amount.

CODING BITES
The various amounts for the co-pay, the co-insurance, and the deductible are
good examples of why it is so essential that you contact the insurance carrier for
every patient to verify the patient’s coverage and eligibility for certain procedures
and treatments and to see if the deductible has been met for the year.

MACRA
Medicare Access and CHIP Reauthorization Act (MACRA) has been designed
to reward health care providers for quality patient care and to ultimately reduce costs.
As a part of this, the Quality Payment Program was also implemented. This program
incorporates important advances to ensure that electronic health information will be
available when and where clinicians need it so optimal care can be provided.
The Quality Payment Program includes two paths:
∙ Advanced Alternative Payment Models (APMs)
∙ Merit-Based Incentive Payment System (MIPS)
Both of these paths require use of certified EHR technology to exchange information
across providers and with patients to support improved care delivery, including patient
engagement and care coordination. In addition, this program requires EHR manufac-
turers to publish application programming interfaces (API), which increase interoper-
ability (making it easier for software programs such as smartphone apps to access
information from other programs) for certified health IT.
Physicians have options and began participating in this program as early as January
2017.

39.4  NCCI Edits and NCD/LCD

National Correct Coding Initiative (NCCI)
The CMS developed the National Correct Coding Initiative (NCCI) to reinforce accu-
rate and proper coding in addition to preventing reimbursement of inaccurate amounts
as the result of noncompliance coding methods in Part B claims (physician and outpa-
tient services). This system was founded with coding policies based on
∙ The official coding guidelines, as published in American Medical Association’s
CPT code book.
∙ National (NCD) and local (LCD) policies and edits.
∙ Coding guidelines developed by national societies.
∙ Analysis of standard medical and surgical practices.
∙ Review of current coding practices.
There are two types of edits within the NCCI focus: PTP and MUE.

Procedure-to-Procedure (PTP) Edits

Within the long lists of procedures, services, and treatments performed by health care
providers, there are those that cannot, or should not, be provided to the same patient
on the same date of service. CMS computers evaluate submitted claims to look for
 pairs of codes being reported that are known to be mutually exclusive procedures, also
known as procedure-to-procedure (PTP) edits.

EXAMPLE
23680 Open treatment of shoulder dislocation, with surgical or anatomical
neck fracture, with manipulation
20690 Application of a uniplane (pins or wires in 1 plane), unilateral, external
fixation system
These codes report two procedures that would not be performed at the same time
for the same patient, according to the standards of care. This is an example of a
PTP edit.

Medically Unlikely Edits (MUE)

The purpose of the NCCI medically unlikely edits (MUE) is to prevent improper
payments when services are reported with incorrect units of service. An MUE for a
HCPCS/CPT code is the maximum units of service that a provider would report under
most circumstances for a single beneficiary on a single date of service. 

EXAMPLE
72270 Myelography, 2 or more regions, radiological supervision and
interpretation
The MUE edit for this code is a maximum of one for a patient per date of service
because the code description states “two or more.” Therefore, reporting this code
more than once for the same patient on the same date would not be accurate.

National Coverage Determinations (NCD) and Local

Coverage Determinations (LCD)
In some circumstances, a National Coverage Determination (NCD) is created to
clearly establish the criteria for coverage of an item or service applicable to all Medi-
care beneficiaries nationwide. When there is no NCD, there may be a Local Coverage
Determination (LCD) in effect. An LCD is a decision by a fiscal intermediary (FI) or
carrier as to when and for what reasons a particular service or item is covered in that
area (a state or region). The Medicare Coverage Database (MCD), available at www.
cms.gov (see Figure 39-6), contains all NCDs and LCDs in a searchable database.
Virtually all third-party payers issue coverage determinations valid nationally or in
a particular state or locale. Therefore, you should have the ability to verify coverage
for an item or service prior to providing it, and certainly before creating and submit-
CODING BITES ting the claim.
Submitting a claim for Once you find a coverage determination on the service or item the physician wants
a service or item not to provide to the patient, you can obtain the details about the criteria for coverage.
covered by the patient’s In this Medicare NCD on Adult Liver Transplantation (Figure 39-7), the procedure
policy is considered would be categorized (BENEFIT CATEGORY) as an Inpatient Hospital Service.
fraud . . . even if it gets Next, the section ITEM/SERVICE DESCRIPTION is provided to ensure that everyone
paid. It is your respon- understands precisely what procedure, service, or item is being discussed. Read fur-
sibility to know! Not the ther down the page to the section INDICATIONS AND LIMITATIONS OF COVERAGE: B.
patient. Not the doctor. NATIONALLY COVERED INDICATIONS and you can see the diagnoses considered as
You, the professional medically necessary for this procedure. Earlier in this text, you learned about medical
coding specialist. necessity in the chapter Introduction to the Languages of Coding. The next section
clarifies what types of FOLLOW-UP CARE will be covered, as well.

1166   PART VI  |  REIMBURSEMENT, LEGAL, AND ETHICAL ISSUES

 GUIDANCE
CONNECTION
Go to the Medicare
Coverage Database:
https://www.cms.gov/
medicare-coverage-
database/overview-and-
quick-search.aspx
On the right side is the
Quick Search bar to
sort through all National
Coverage Determina-
tions (NCDs) and Local
Coverage Determina-
tions (LCDs).

FIGURE 39-6  National Coverage Determinations (NCDs) Alphabetic Index  Source:

CMS.gov

FIGURE 39-7  NCD for Adult Liver Transplantation (in part)  Source: CMS.gov

39.5  Place-of-Service and

Type-of-Service Codes
Place-of-Service Codes
Place-of-Service (POS) codes are used on professional claims to identify the specific
location where procedures, services, and treatments were provided to the patient.
 Place of Place of Service
Service Code(s) Name Place of Service Description
01 Pharmacy A facility or location where drugs and other medically related items and ser-
vices are sold, dispensed, or otherwise provided directly to patients.
02 Telehealth The location where health services and health-related services are provided or
received, through a telecommunication system.
03 School A facility whose primary purpose is education.
04 Homeless Shelter A facility or location whose primary purpose is to provide temporary housing to
homeless individuals (e.g., emergency shelters, individual or family shelters).
05 Indian Health Service A facility or location, owned and operated by the Indian Health Service, that
Free-Standing Facility provides diagnostic, therapeutic (surgical and nonsurgical), and rehabilita-
tion services to American Indians and Alaska Natives who do not require
hospitalization.
06 Indian Health Ser- A facility or location, owned and operated by the Indian Health Service, that
vice Provider-Based provides diagnostic, therapeutic (surgical and nonsurgical), and rehabilitation
Facility services rendered by, or under the supervision of, physicians to American Indi-
ans and Alaska Natives admitted as inpatients or outpatients.
07 Tribal 638 Free- A facility or location, owned and operated by a federally recognized American
Standing Facility Indian or Alaska Native tribe or tribal organization under a 638 agreement, that
provides diagnostic, therapeutic (surgical and nonsurgical), and rehabilitation
services to tribal members who do not require hospitalization.
08 Tribal 638 Provider- A facility or location, owned and operated by a federally recognized American
Based Facility Indian or Alaska Native tribe or tribal organization under a 638 agreement, that
provides diagnostic, therapeutic (surgical and nonsurgical), and rehabilitation
services to tribal members admitted as inpatients or outpatients.
09 Prison/Correctional A prison, jail, reformatory, work farm, detention center, or any other similar
Facility facility maintained by either federal, state, or local authorities for the purpose of
confinement or rehabilitation of adult or juvenile criminal offenders.
10 Unassigned
11 Office Location, other than a hospital, skilled nursing facility (SNF), military treat-
ment facility, community health center, state or local public health clinic, or
intermediate care facility (ICF), where the health professional routinely pro-
vides health examinations, diagnosis, and treatment of illness or injury on an
ambulatory basis.
12 Home Location, other than a hospital or other facility, where the patient receives care
in a private residence.
13 Assisted Living Congregate residential facility with self-contained living units providing assess-
Facility ment of each resident’s needs and on-site support 24 hours a day, 7 days a week,
with the capacity to deliver or arrange for services including some health care
and other services.
14 Group Home A residence, with shared living areas, where clients receive supervision and
other services such as social and/or behavioral services, custodial service, and
minimal services (e.g., medication administration).
15 Mobile Unit A facility/unit that moves from place-to-place equipped to provide preventive,
screening, diagnostic, and/or treatment services.
16 Temporary Lodging A short-term accommodation such as a hotel, camp ground, hostel, cruise ship,
or resort where the patient receives care, and that is not identified by any other
POS code.

1168   PART VI  |  REIMBURSEMENT, LEGAL, AND ETHICAL ISSUES

 Place of Place of Service
Service Code(s) Name Place of Service Description
17 Walk-in Retail Health A walk-in health clinic, other than an office, urgent care facility, pharmacy, or
Clinic independent clinic and not described by any other Place-of-Service code, that is
located within a retail operation and provides, on an ambulatory basis, preven-
tive and primary care services.
18 Place of A location, not described by any other POS code, owned or operated by a public
Employment-Worksite or private entity where the patient is employed, and where a health professional
provides ongoing or episodic occupational medical, therapeutic, or rehabilita-
tive services to the individual.
19 Off-Campus Outpa- A portion of an off-campus hospital provider-based department that pro-
tient Hospital vides diagnostic, therapeutic (both surgical and nonsurgical), and rehabilita-
tion services to sick or injured persons who do not require hospitalization or
institutionalization.
20 Urgent Care Facility Location, distinct from a hospital emergency room, an office, or a clinic, whose
purpose is to diagnose and treat illness or injury for unscheduled, ambulatory
patients seeking immediate medical attention.
21 Inpatient Hospital A facility, other than psychiatric, that primarily provides diagnostic, therapeutic
(both surgical and nonsurgical), and rehabilitation services by, or under, the
supervision of physicians to patients admitted for a variety of medical conditions.
22 On-Campus Outpa- A portion of a hospital’s main campus that provides diagnostic, therapeutic
tient Hospital (both surgical and nonsurgical), and rehabilitation services to sick or injured
persons who do not require hospitalization or institutionalization.
23 Emergency A portion of a hospital where emergency diagnosis and treatment of illness or
Room—Hospital injury is provided.
24 Ambulatory Surgical A freestanding facility, other than a physician’s office, where surgical and diag-
Center nostic services are provided on an ambulatory basis.
25 Birthing Center A facility, other than a hospital’s maternity facilities or a physician’s office, that
provides a setting for labor, delivery, and immediate post-partum care as well as
immediate care of newborn infants.
26 Military Treatment A medical facility operated by one or more of the Uniformed Services. Military
Facility Treatment Facility (MTF) also refers to certain former U.S. Public Health Ser-
vice (USPHS) facilities now designated as Uniformed Service Treatment Facili-
ties (USTF).
27–30 Unassigned N/A
31 Skilled Nursing A facility that primarily provides inpatient skilled nursing care and related
Facility services to patients who require medical, nursing, or rehabilitative services but
does not provide the level of care or treatment available in a hospital.
32 Nursing Facility A facility that primarily provides to residents skilled nursing care and related
services for the rehabilitation of injured, disabled, or sick persons, or, on a regu-
lar basis, health-related care services above the level of custodial care to other
than individuals with intellectual disabilities.
33 Custodial Care A facility that provides room, board, and other personal assistance services,
Facility generally on a long-term basis, and that does not include a medical component.
34 Hospice A facility, other than a patient’s home, in which palliative and supportive care
for terminally ill patients and their families are provided.
35–40 Unassigned N/A

(continued)
 Place of Place of Service
Service Code(s) Name Place of Service Description
41 Ambulance—Land A land vehicle specifically designed, equipped, and staffed for lifesaving and
transporting the sick or injured.
42 Ambulance—Air or An air or water vehicle specifically designed, equipped, and staffed for lifesav-
Water ing and transporting the sick or injured.
43–48 Unassigned N/A
49 Independent Clinic A location, not part of a hospital and not described by any other Place-of-
Service code, that is organized and operated to provide preventive, diagnostic,
therapeutic, rehabilitative, or palliative services to outpatients only.
50 Federally Qualified A facility located in a medically underserved area that provides Medicare
Health Center beneficiaries preventive primary medical care under the general direction of a
physician.
51 Inpatient Psychiatric A facility that provides inpatient psychiatric services for the diagnosis and
Facility treatment of mental illness on a 24-hour basis, by or under the supervision of a
physician.
52 Psychiatric Facility— A facility for the diagnosis and treatment of mental illness that provides a
Partial Hospitalization planned therapeutic program for patients who do not require full-time hospital-
ization, but who need broader programs than are possible from outpatient visits
to a hospital-based or hospital-affiliated facility.
53 Community Mental A facility that provides the following services: outpatient services, includ-
Health Center ing specialized outpatient services for children, the elderly, individuals who
are chronically ill, and residents of the CMHC’s mental health services area
who have been discharged from inpatient treatment at a mental health facility;
24-hour-a-day emergency care services; day treatment, other partial hospital-
ization services, or psychosocial rehabilitation services; screening for patients
being considered for admission to state mental health facilities to determine the
appropriateness of such admission; and consultation and education services.
54 Intermediate Care A facility that primarily provides health-related care and services above the
Facility/ Individu- level of custodial care to individuals but does not provide the level of care or
als with Intellectual treatment available in a hospital or SNF.
Disabilities
55 Residential Substance A facility that provides treatment for substance (alcohol and drug) abuse to live-
Abuse Treatment in residents who do not require acute medical care. Services include individual
Facility and group therapy and counseling, family counseling, laboratory tests, drugs
and supplies, psychological testing, and room and board.
56 Psychiatric Residen- A facility or distinct part of a facility for psychiatric care that provides a total
tial Treatment Center 24-hour therapeutically planned and professionally staffed group living and
learning environment.
57 Nonresidential Sub- A location that provides treatment for substance (alcohol and drug) abuse on an
stance Abuse Treat- ambulatory basis. Services include individual and group therapy and counsel-
ment Facility ing, family counseling, laboratory tests, drugs and supplies, and psychological
testing.
58–59 Unassigned N/A
60 Mass Immunization A location where providers administer pneumococcal pneumonia and influenza
Center virus vaccinations and submit these services as electronic media claims, paper
claims, or using the roster billing method. This generally takes place in a mass
immunization setting, such as a public health center, pharmacy, or mall but may
include a physician office setting.

1170   PART VI  |  REIMBURSEMENT, LEGAL, AND ETHICAL ISSUES

 Place of Place of Service
Service Code(s) Name Place of Service Description
61 Comprehensive Inpa- A facility that provides comprehensive rehabilitation services under the super-
tient Rehabilitation vision of a physician to inpatients with physical disabilities. Services include
Facility physical therapy, occupational therapy, speech pathology, social or psychologi-
cal services, and orthotics and prosthetics services.
62 Comprehensive Out- A facility that provides comprehensive rehabilitation services under the super-
patient Rehabilitation vision of a physician to outpatients with physical disabilities. Services include
Facility physical therapy, occupational therapy, and speech pathology services.
63–64 Unassigned N/A
65 End-Stage Renal A facility, other than a hospital, that provides dialysis treatment, maintenance,
Disease Treatment and/or training to patients or caregivers on an ambulatory or home-care basis.
Facility
66–70 Unassigned N/A
71 Public Health Clinic A facility maintained by either state or local health departments that provides
ambulatory primary medical care under the general direction of a physician.
72 Rural Health Clinic A certified facility that is located in a rural medically underserved area that
provides ambulatory primary medical care under the general direction of a
physician.
73–80 Unassigned N/A
81 Independent A laboratory certified to perform diagnostic and/or clinical tests independent of
Laboratory an institution or a physician’s office.
82–98 Unassigned N/A
99 Other Place of Other place of service not identified above.
Service

Type-of-Service Codes
In addition to providing pre-categorization of procedures, Type-of-Service (TOS)
codes are also used to ensure that procedures, services, and treatments, along with the
Place-of-Service codes, are used to determine appropriateness of location and service.

Type of Service Indicators

0 Whole Blood
1 Medical Care
2 Surgery
3 Consultation
4 Diagnostic Radiology
5 Diagnostic Laboratory
6 Therapeutic Radiology
7 Anesthesia
8 Assistant at Surgery
9 Other Medical Items or Services
A Used DME
B High Risk Screening Mammography
C Low Risk Screening Mammography
D Ambulance
E Enteral/Parenteral Nutrients/Supplies
 Type of Service Indicators
F Ambulatory Surgical Center (Facility Usage for Surgical Services)
G Immunosuppressive Drugs
H Hospice
J Diabetic Shoes
K Hearing Items and Services
L ESRD Supplies
M Monthly Capitation Payment for Dialysis
N Kidney Donor
P Lump Sum Purchase of DME, Prosthetics, Orthotics
Q Vision Items or Services
R Rental of DME
S Surgical Dressings or Other Medical Supplies
T Outpatient Mental Health Treatment Limitation
U Occupational Therapy
V Pneumococcal/Flu Vaccine
W Physical Therapy

39.6  Organizing Claims: Resubmission,

Denials, and Appeals
One thing that is very important for a professional insurance biller to do is to keep
track of all the claims sent out on behalf of his or her medical facility, whether it
is a physician’s office or a hospital. Even with the help of computers and clearing-
houses, a claim can get lost. It happens on occasion with letters sent through the
CODING BITES post office, and it can happen electronically as well. One little power surge or a
You are responsible for computer with a virus can make your claim disappear. The only way you may know
following up on every about this happening is the absence of a response, such as a payment, a statement
claim you send. of rejection, or a denial. Therefore, you have to keep track of every claim form you
submit.
The following are two simple steps for staying organized.
1. Keep a log of every claim as you send it. If you are using a clearinghouse, you will
receive a report, listing all the claims sent (complete with date and time sent) and to
which payer they were forwarded. Place these notices in a file folder on your com-
puter’s desktop or print out these reports and place them in a three-ring binder or
another type of file. If you are sending claims directly from your office, you should
create a separate master index for logging in this information. If you prefer, you can
keep a master index in a notebook on your desk and handwrite a notation for each
claim you send, indicating the following:
∙ Carrier name (the third-party payer to whom you sent the claim)
∙ Patient name
∙ Date of service
∙ Date and time you sent the claim
2. Build into your schedule a specific day and time each week for following up claims.
When you set an appointment with yourself, such as every Friday at 9 a.m., or Mon-
days after the morning staff meeting, you will reduce the number of times that your
workday will prevent you from doing this. It is so easy to say, “Once a week I am
going to follow up on the claims” and just never have the time for this very impor-
tant task. Each week, or as often as required by the number of claims you send out,
go over the list and separate the claims into three “piles”:

1172   PART VI  |  REIMBURSEMENT, LEGAL, AND ETHICAL ISSUES

 ∙ Pile 1: Claims that have been paid by the insurers
∙ Pile 2: Claims for which you have received rejection or denial notices
∙ Pile 3: Claims for which you have received no notices or payment

Pile 1: Claims That Have Been Paid by the Insurers

The HIPAA Health Care Payment and Remittance Advice is the electronic transmis-
sion of this payment, using HIPAA-approved secure data sets. The transmission has
two parts: the transaction and the document.
∙ The document is a remittance advice (RA) or an electronic remittance advice Remittance Advice (RA)
(ERA). Some health care professionals also refer to this document as an explana- Notification identifying details
tion of benefits or EOB. However, an EOB is sent to the patient or beneficiary, not about a payment from the
the provider. third-party payer.
∙ The transaction is an electronic funds transfer (EFT) that sends the payment directly Electronic Remittance Advice
into your facility’s bank account, like a direct deposit. (ERA)
Remittance advice that is sent
The RA will provide all the details of this payment, including to the provider electronically.
∙ The exact amount of monies your office is receiving Explanation of Benefits (EOB)
∙ For which patient Another type of paper remit-
tance advice, more typically
∙ For which procedures performed
sent to the policyholder. How-
∙ On which service dates ever, some in the industry use
the term EOB interchangeably
Once you are certain that a claim has been approved and your office has received
with RA.
payment from the third-party payer, the first thing you should do is mark this claim as
paid in your master index. Be very careful when doing this.
When you enter the deposits into the computer (and into the bank, if the funds were
not electronically transferred), you must be very diligent. You might have two claims
for the same patient for different dates or two patients with the same name or similar
names. You do not want to mark the wrong claim paid and leave the wrong claim
marked unpaid. This will cause a lot of confusion and aggravation in dealing with the
insurance carrier.

Pile 2: Claims for Which You Have Received Denial Notices

You have learned how to avoid many denied claims by checking, double-checking,
and triple-checking your work. Make certain that
1. Insurance coverage is confirmed (eligibility verification).
2. All the information (such as policyholder and policy number) is entered correctly.
3. The best, most appropriate codes are used.
4. Medical necessity has been established by those codes.
5. All the information has been correctly placed on the correct claim form.
Despite doing everything correctly, some claims are denied and come back unpaid.
However, this does not mean that you either have to go after the guarantor for the
money or have your office go without the money it deserves. There are many reasons
an insurance carrier, or payer, may deny a claim. Let’s review some of the most com-
mon reasons for a claim to be denied and what you can do about it.

Denied Due to Office Personnel Error

If you discover that the claim has been denied by the insurance carrier due to an error
made by you or someone in your office, this can be fixed. Simply find out what the
error was and correct it.
Compare the policy number on the claim to the copy of the insurance card that you
made when the patient was seen in your office for this encounter. It is important that
 you specifically check it against the copy taken at the encounter for which this claim
CODING BITES form is billing the insurance company. The patient may have been in your office more
Get into the habit of dat- recently with a new policy because his or her insurance changed between the most
ing the copy you make recent visit and the visit for which this claim was submitted.
of the insurance card You might find that, when you keyed the number into the computer, you inad-
each time the patient vertently switched two numbers. It can happen when you are in a busy, hectic, noisy
comes in to see the office with many people talking to you at the same time.
physician. If you find that the policy number matches the ID card, you will have to continue
looking for the typo, going over the claim form one box at a time to check every piece
of information that was entered. Once you find the error, all you have to do is correct
it and resubmit a corrected claim form.
CODING BITES You should have caught the error when you double-checked your work, but .  .  .
Make certain that you OK. It happens. You have wasted time (and if you are using a clearinghouse, you have
mark a resubmission wasted money as well), and you have delayed payment to your office, but follow the
with the words “Cor- third-party payer’s procedure for resubmitting corrected claims and the money will
rected Claim” so there is arrive.
no mistake that you are
not double billing (which EXAMPLES
is against the law).
The policy number or a CPT code is invalid (nonexistent) because it was entered
improperly.
Anyone could look at the number 546998823 and accidentally key in
546999823.

Denied Due to Lack of Coverage

You look at the denial notice and it doesn’t make sense. You have documentation in the
Eligibility Verification file that, when you called for eligibility verification, the insurance carrier representa-
The process of confirming tive confirmed that the patient’s coverage was valid and the policy carried no exclu-
with the insurance carrier that sions. The co-payment, co-insurance, and deductible were also confirmed. However,
an individual is qualified for the claim was returned as denied, with the reason that the patient was not covered.
benefits that would pay for What may have happened is that, between your verification of the patient’s cov-
services provided by your
erage and the arrival of the claim at the insurance carrier’s office, the policy was
health care professional on a
particular day.
canceled or changed. When your claim arrived, the computer, or the person, simply
looked at the file, saw that the policy was no longer in effect, and therefore denied the
claim. If this is the case:
1. You will need to send a letter, not make a phone call, to the insurance carrier. In the
letter, carefully state the date and time of the eligibility verification and the name
of the insurance representative who told you the patient was covered for services
by your office. (Make certain your office’s procedure for eligibility verification
includes the documentation of all of these details for just this reason.) Emphasize
the date of the phone call or print out the electronic verification, as well as the
date(s) of treatment or service, and attach a fresh printout of the claim form.
2. Before you mail this letter, call the company and confirm the name, title, and
address of the employee responsible for receiving your appeal request. If you send
this information to the wrong person, it may get lost within the company or, at the
very least, it will delay your satisfaction of this issue.
3. Make certain you keep copies of everything, and follow up in a week or two if you
have not heard from the insurer.
In other cases, claims have been denied because the individual’s policy was can-
celed prior to your treatment and the insurance representative did not have (or did not
tell you) up-to-date information. Therefore, your office provided treatment based on
misinformation. As a matter of policy, typically the insurance carrier will claim that
its staff member’s confirmation of coverage does not represent a guarantee that your
office will be paid. Again, you do not want to take no for an answer.

1174   PART VI  |  REIMBURSEMENT, LEGAL, AND ETHICAL ISSUES

 Both federal and state courts have ordered insurance carriers to pay claims based on
their statements of eligibility at the time treatment and services were provided. These
courts have established that the insurance representative’s, or the electronic, confirma-
tion of benefits serves as encouragement to the physician, or other provider, to offer
that treatment or service.
When you think about it, if the insurance carrier had stated that the patient did not
have coverage at the time you called for verification, your office may have chosen to
not see the patient, to not take an x-ray, or to ask the patient to pay cash at that time.
The fact that the insurance carrier told you, or a member of your office, that they
would pay the claim encouraged your physician to treat the individual and reasonably
expect to be paid for his or her work. Again, you must do the following:
1. Write a letter of appeal to the appropriate person at the insurance company, stating
all the details of the verification conversation.
2. If your office does eligibility verification electronically, you should copy the print-
out of the electronic confirmation and attach it to the letter.
3. Always keep hard copy (paper) documentation or notes indicating to whom you
spoke, what was said, and the date and time of the conversation.
If your appeal is denied again, your office may need to enlist the services of an
attorney. The bottom line is that your office is entitled to this payment, but there are
times you may need to fight for it.

Denied Due to Lack of Medical Necessity

Should your office receive a denial based on lack of medical necessity, there are some
things you must do:
1. Go back and confirm the diagnosis (ICD-10-CM) and procedure (CPT or ICD-10-PCS)
codes that appear on the claim form are the best, most accurate codes.
a. There is a possibility that there was a simple error in keying in the code (such as
transposing two of the numbers or leaving off a digit). More than once, a health
care office and a patient have gone through months of arguing with the insurance
carrier for the coverage of a procedure, only to find that the entire problem was a
simple typographical error.
b. Perhaps there was an error in coding. Go back and look at the physician’s notes.
Start from the beginning and recode the encounter. If there is another coder in
your office, you might ask him or her to look at the notes and code the diagnosis
and procedure(s). Then compare the other coder’s determination of the best, most
appropriate codes with yours. If you come up with different and/or additional
codes this time, you might go ahead and resubmit the claim with the new codes.
Or this review might confirm that the codes were correct on the original claim.
c. Review the linking of the procedure codes to diagnosis codes (CMS-1500 Box
24E). Confirm the links are correct.
2. Contact the insurance carrier and get a written copy of its definition of medical
necessity, or check its website and print it out. Often the list of criteria for medical
necessity consists of any treatment or service that
a. Is commonly performed by health care practitioners (considered accepted stan-
dard of care) for the treatment of the condition, illness, or injury as indicated by
the diagnosis code(s) provided.
b. Is provided at the most efficient level of care that ensures the patient’s safety.
c. Is not experimental.
d. Is not elective.

Using the criteria for medical necessity from the insurance carrier that denied the
claim (different carriers may have different criteria), review the patient’s health
 record to confirm that this individual and this particular encounter meet all of the
requirements. Again,
∙ Double-check the diagnosis and procedure codes to make certain they all accu-
rately represent what occurred during that visit.
∙ Call and speak with the claims examiner to identify exactly what he or she
thought the problem was with the claim. This conversation may give you some
insight into what you should be looking for as you review the patient’s chart.
∙ Get support materials from your health care professionals, particularly the attend-
ing physician on this case. Copies of articles or pages from credible sources, such
as The Merck Manual, the New England Journal of Medicine, or other qualified
sources of research, will help support your claim.
∙ If this patient encounter was the result of another provider referring the indi-
vidual to your physician for additional treatment, the referring physician might
agree to write a letter supporting your office.
3. Write a letter to the third-party payer’s appeals board, or to whomever the claims rep-
resentative instructs you to send the documentation, outlining all of the information
you have gathered to corroborate specifically why the denial should be overturned.
a. Include copies of supporting documentation, such as pages from the National
Library of Medicine’s website or a letter from the referring provider.
b. In addition, request that a qualified health care professional licensed in the area
of treatment or service under discussion be the one to review your appeal. This
may provide a more agreeable opinion as to the medical necessity of your claim
and get it approved.

EXAMPLE
Christopher Novack, a 67-year-old male, is seen by his family physician after stat-
ing that he was driving to his office earlier and felt so dizzy he had to pull over.
While waiting for the dizziness to pass, he felt his heart beating rapidly, and he
began to sweat. He was worried that he was having a heart attack and came right
over to see Dr. Bennetti.
Dr. Bennetti, knowing that Chris had been diagnosed with type 2 diabetes melli-
tus, checked his glucose levels and found them to be grossly abnormal, causing the
dizziness and sweating. He administered an injection of insulin. Then, Dr. Bennetti
checked Chris’s heart with a 12-lead EKG. The results were negative.
When you perform your medical necessity review, you can see that the code
for type 2 diabetes mellitus will justify the glucose test and the injection of the
insulin.
However, if you do not have a second diagnosis code for his rapid heartbeat,
the claim would be rejected. Without the code for rapid heartbeat, there is no
medical justification provided on the claim form for performing an EKG.

Denied Due to Preexisting Condition

A denial on the grounds that the patient was treated for a preexisting excluded condi-
tion or illness reinforces the need for accurate confirmation of eligibility before the
patient is seen and treated by the physician. If, in fact, your physician is about to
treat a patient for a specific diagnosis, you must determine if the insurance carrier has
excluded that condition, illness, or injury from coverage. This should be done during
the eligibility verification. However, if you get to the point at which a submitted claim
has been denied due to a preexisting condition that has been excluded, you still have
several options to try to get your claim paid:
1. Start by reviewing the diagnosis code. There may be a difference in the diagnosis
codes, now and for past treatment, making your claim valid.

1176   PART VI  |  REIMBURSEMENT, LEGAL, AND ETHICAL ISSUES

 2. Request a copy of the insurance carrier’s definition of a preexisting condition. Once
you clearly understand the requirements, you will be able to better analyze the
details of this claim and its validity.
3. A review of the patient’s past medical records may also assist you in appealing this
denial. Examining specific diagnosis codes and physician’s notes’ diagnostic state-
ments may find an opportunity to justify the insurance carrier’s coverage of this
claim.
When you have the information to support your claim, write an appeal letter outlin-
ing why the denial should be reversed.

Denied Due to Benefit Limitation on Treatment by an Assistant

Some medical offices have physician’s assistants and nurse practitioners treat patients
for routine examinations, vaccinations, and other medical services. However, some
insurance carriers limit the types of treatments and services for which they will pay
when provided by a health care worker who is not a licensed physician. There are a
couple of approaches to appeal this type of denial.
1. Begin by authenticating the qualifications of the person who provided the service
or treatment. You will also want to reinforce, in your appeal, that having this health
care professional perform this procedure, under the supervision of the licensed phy-
sician, was the most cost-efficient way to provide the service to the patient.
2. Obtain a copy of the carrier’s written policy regarding treatment to patients by
assistants and search for language that specifically denies payment for services pro-
vided by a professional with the credentials of your staff member. If you do not find
any such language, your appeal letter should include that the insurance carrier’s
policy does not specifically exclude services provided by this level of professional.

Subsequent Denials
There are additional steps that can be taken to appeal a second or third denial. Some-
times an insurance carrier will deny a claim, hoping that you will give up and it will
not have to pay. However, most of the time, subsequent denials are just a matter of poor
communication between the insurance carrier and the health care facility. Remember,
although it is an insurance carrier’s responsibility and obligation to pay claims, it is
also its responsibility and obligation to protect its assets from fraud. Primarily, it is
this intention that creates the circumstance of a falsely denied claim. However, after
you have exhausted all efforts within the insurance carrier’s organization to get the
carrier to see your side and pay the claim, you have additional options:
1. Many states have state boards and/or review panels for this type of situation. Expe-
rienced health care providers, with varying areas of specialization, sit on these
review boards. Their duty is to go over all the details of the case; examine the
patient’s health record, the claim form, and all other documentation; and evaluate
the insurance carrier’s basis for denying the claim. They have the right, empowered
by the state government, to override the insurance carrier’s decision and force the
carrier to pay the claim. Bringing an appeal to this type of review board is an option
to both health care professionals and individuals alike.
2. If the patient is covered under an employer’s self-insured health plan, the state
board is usually not an option for appeal. However, the federal government oversees
and regulates self-insured plans and can provide you with an appeals process. At
the very least, these insurers are required to have an in-house appeal board that will
hear your case.
Surprisingly, you have an excellent chance of winning an appeal when you han-
dle it properly. Researchers have found very high success rates for providers who file
appeals. Therefore, if a claim is denied, it is worth the time to look into the reasons for
denial and possibly exercise the right to appeal.
 Writing Letters of Appeal
When a claim has been denied and you have gathered all the documentation to support
your position that the denial is incorrect, you need to write a formal letter of appeal.
This letter should contain the following:
Recipient: Call the third-party payer and get the name, title, and address of the
person to whom you should address this letter. Make certain you double-check the
spelling of the person’s name—don’t assume. Even a name as straightforward as
John can also be spelled Jon or Jahn. Just ask!
RE: In the space between the recipient’s name and address, and the salutation, you
need to include identification regarding the person to whom this letter refers. This
should be indented to your one-inch tab position. The details that should be shown
in this area of the letter are
Patient Name:
Policyholder Name:
Policy Number:
Date(s) of Service:
Claim Number:
Total Amount of Claim: $
Salutation: Always begin the letter with a proper business salutation to the recipient
by name. For example, Dear Mr. Smith: or Dear Ms. Jones (followed by a colon).
Avoid generic salutations such as To Whom It May Concern unless the insurance
carrier will not release the name of the person designated to receive appeal letters
and has instructed you to address this letter to a department or title.
Paragraph 1: State briefly and directly why you are writing this letter. This is a
summary or condensed version of the rest of the letter. Be factual, not emotional.
Be specific about when and/or how you were informed that the claim was denied
and the reasons stated by the insurance carrier for the denial. This paragraph is to
make certain that you and the reader of this letter are on the same page (pardon the
pun!). It is difficult to capture and retain someone’s attention to what you are saying
if he or she doesn’t know to what or whom you are referring.

EXAMPLES
1. Our claims service representative, Raul Vega, told us that the above claim was
denied due to a lack of medical necessity. This letter is an official notice that we
wish to appeal this decision.
2. On November 3, 2018, our office received a notice stating that the above-
mentioned claim was denied because of lack of coverage. This letter is to
appeal this decision.

Paragraph 2: Itemize all the facts/evidence you have to support your position that
you should be paid. Explain what documentation you have to encourage them to
change their minds and approve/pay your claim. This list may contain highlights
from the physician’s notes outlining why the procedure was medically necessary.
You might include statistics proving that this procedure is no longer considered
experimental but is now widely accepted as the new standard of care. Attach
copies (never originals) of documents that contain the information and refer to
those attachments in this portion of the letter. In reality, this section of the let-
ter may need to be longer than one paragraph. Write what you need to establish
your rationale, but remember that this is not creative writing. Do not use flowery
language or get long in your explanation. Be direct and to the point and include
just the facts.

1178   PART VI  |  REIMBURSEMENT, LEGAL, AND ETHICAL ISSUES

 EXAMPLES
1. As you can see in the attached documentation, the x-rays confirmed that the
patient had a compound fracture requiring immediate surgery.
2. On Thursday, September 4, 2018, at 1:35 p.m. Eastern, I spoke with Emma
Longwood in your Eligibility Verification department, who confirmed that
Mr. Smith was fully covered by your HMO plan for the following procedures. . . .

Paragraph 3: Use paragraph 3 (the last paragraph) to clearly define where this dis-
cussion should go next. Of course, you want them to just reconsider and pay the
claim; however, you will need to keep this a bit more open-ended. Offer to pro-
vide any additional documentation the insurance carrier may feel necessary. Supply
your contact information (office phone number, e-mail address, fax number) even if
it is right there on the letterhead. Set an appointment generally (i.e., “I will call you
next week”) to follow up with this person. The purpose of this statement is to keep
this appeal moving in a direction toward acceptance and payment. You do not want
this letter to get buried on a busy desk. In addition, mark your calendar and call
when you said you would. It is your responsibility to keep this issue on the top of
the insurance carrier’s priority list. You know that old saying, “The squeaky wheel
gets the grease.” This means that those that speak up get the attention.

EXAMPLES
1. If you need any more information, to bring this to a quick resolution, please
contact me at . . . .
2. I will call you at the end of the week to discuss this matter further. In the mean-
time, if you need to contact me, please do so at . . . .

Closing and Signature: All business letters should contain a closing, as well as
the signature and title of the person sending the correspondence. Sincerely or Sin-
cerely yours (followed by a comma) are the most common closings. After leaving
four lines blank to make room for your signature, key in your full name. Directly
underneath your name, key in your title (e.g., Insurance Specialist). If you are going
to attach copies of important documentation to this letter, you need to note this
under your signature. Leave one empty line under your title, and key in Enclo-
sure or Enclosures or Enc. This notation points the recipient to the additional pages
included in the envelope.

Pile 3: Claims for Which You Have Received

No Notices or Payment
If a reasonable time has passed after sending a claim and you have received no notices
or payment, you will need to follow up with the insurance carrier. (The term reason-
able time is specifically defined by each third-party payer.)
1. Go to the third-party payer’s website and check the status of the claim, or call and
speak with someone in customer service to determine which examiner or represen-
tative will be handling your claim. Try to confirm that he or she has received your
claim by getting a date and time of receipt and ask which staff member received it.
If you cannot get this information, or you get a vague statement, such as “Oh, I’m
sure we have it somewhere. We are very busy. We’ll get to it soon,” you will need to
take the next step.
2. Go back over all the paperwork that accompanied claims paid by this carrier in the
same time frame, such as an electronic remittance advice (ERA), or a remittance
 advice (RA). There may have been a mistake and the wrong claim was marked paid
in your file (meaning that this claim has really already been paid) and it is another
claim that is still outstanding.
3. Once you are certain the insurance company has not responded to this claim in any
Tracer way, you may need to send a tracer, also known as a duplicate billing or second
An official request for a third- submission.
party payer to search its sys-
tem to find a missing health Most insurance carriers require you to wait a specific number of days or weeks after
claim form. It is also a term the original date of submission before you are permitted to send a tracer claim. Check
used for a replacement health with the carrier, as each may have a different waiting period. This second version of
claim form resubmitted to the same claim must be marked “Tracer.” This is to make sure that the insurance car-
replace one that was lost. rier knows you are not attempting to bill a second time for the same services. Double
billing is against the law; however, sending a bill a second time because you believe
that the first claim has been lost is good business.
Make a note in your master index of the date and time that you refiled the claim.
That way, you can follow up again if you need to.

Chapter Summary
A fundamental part of an insurance coding and medical billing specialist’s job is to
work with the insurance companies that will reimburse your health care facility for
the services and procedures you provide to your patients. You need to understand
how your facility will be paid (such as fee-for-service, capitation, or episodic care); be
able to distinguish among the types of policies (such as HMOs, PPOs, and managed
care policies, as well as Medicare, Medicaid, and TriCare plans); and quickly identify
which is responsible for sending payment to you. This will help your billing efforts be
more efficient and get paid more quickly.
The procedures you develop and abide by for tracking the health insurance claim
forms you submit is almost as important as the coding process itself. Some health
care offices do not have a routine for handling situations, such as lost claims or denied
claims. However, you must realize how important this is to the overall financial well-
being of your facility.
When you are organized, and keep a tracking log of all the claims you submit,
your work is easier and your success rate is higher. Appealing denied claims is a part
of your career, and it is an important part of the entire medical billing and insurance
claims process.

CODING BITES
The basic reimbursement methods are applicable across all types of health
care, and include capitation, fee for service, episodic (global) payment, and cost
reimbursement.
It is the provider’s responsibility to confirm the method of reimbursement prior
to providing services.
For more information on the newest program, MACRA, go to
https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-
Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/MACRA-MIPS-
and-APMs.html

You Interpret It! Answers

1. Workers’ compensation and disability compensation, 2. Margaret’s liability insur-
ance, 3. Facility member = workers’ compensation; student = school’s liability
insurance

1180   PART VI  |  REIMBURSEMENT, LEGAL, AND ETHICAL ISSUES

CHAPTER 39 REVIEW

CHAPTER 39 REVIEW
Reimbursement Enhance your learning by
completing these exercises and
more at connect.mheducation.com!

Let’s Check it! Terminology

Match each term to the appropriate definition.

Part I
1. LO 39.2  A physician, typically a family practitioner or an internist, who serves A. Automobile Insurance
as the primary care physician for an individual. This physician is B. Capitation Plans
responsible for evaluating and determining the course of treatment or
C. Centers for Medicare
services, as well as for deciding whether or not a specialist should be
& Medicaid Services
involved in care.
(CMS)
2. LO 39.1  A type of health insurance coverage that controls the care of each sub-
D. Dependents
scriber (or insured person) by using a primary care provider as a cen-
tral health care supervisor. E. Disability
Compensation
3. LO 39.2  A type of health insurance that uses a primary care physician, also
known as a gatekeeper, to manage all health care services for an F. Discounted FFS
individual. G. Episodic Care
4. LO 39.2  A policy that covers loss or injury to a third party caused by the insured H. Fee-for-Service (FFS)
or something belonging to the insured. Plans
5. LO 39.1  The total management of an individual’s well-being by a health care I. Gatekeeper
professional. J. Health Care  
6. LO 39.3  An insurance company pays a provider one flat fee to cover the entire K. Health Maintenance
course of treatment for an individual’s condition. Organization (HMO)
7. LO 39.2  The agency under the Department of Health and Human Services L. Insurance Premium
(DHHS) in charge of regulation and control over services for those
M. Liability Insurance
covered by Medicare and Medicaid.
N. Managed Care
8. LO 39.3  Payment agreements that outline, in a written fee schedule, exactly how
much money the insurance carrier will pay the physician for each treat-
ment and/or service provided.
9. LO 39.3  An extra reduction in the rate charged to an insurer for services pro-
vided by the physician to the plan’s members.
10. LO 39.1  The amount of money, often paid monthly, by a policyholder or
insured, to an insurance company to obtain coverage.
11. LO 39.2  Auto accident liability coverage will pay for medical bills, lost wages,
and compensation for pain and suffering for any person injured by the
insured in an auto accident.
12. LO 39.3  Agreements between a physician and a managed care organization that
pay the physician a predetermined amount of money each month for
each member of the plan who identifies that provider as his or her pri-
mary care physician.
13. LO 39.2  A plan that reimburses a covered individual a portion of his or her income
that is lost as a result of being unable to work due to illness or injury.
14. LO 39.2  Individuals who are supported, either financially or with regard to
insurance coverage, by others.
 Part II
CHAPTER 39 REVIEW

1. LO 39.6  An official request for a third-party payer to search its system to find A. Electronic Media Claim
a missing health claim form. It is also a term used for a replacement (EMC)
health claim form resubmitted to replace one that was lost. B. Electronic Remittance
2. LO 39.3  The process of determining a fee for a service by evaluating Advice (ERA)
the usual fee charged by the provider, the customary fee charged by C. Eligibility Verification
most physicians in the same community or geographical area, and what
D. Explanation of Benefits
is considered reasonable by most health care professionals under the
(EOB)
specific circumstances of the situation.
E. Point-of-Service (POS)
3. LO 39.6  Remittance advice that is sent to the provider electronically.
F. Preferred Provider
4. LO 39.2  A type of insurance plan that will allow an HMO enrollee to choose his
Organization (PPO)
or her own nonmember physician at a lower benefit rate, costing the
patient more money out-of-pocket. G. Remittance Advice
(RA)
5. LO 39.1  An individual or organization that is not directly involved in an encoun-
ter but has a connection because of its obligation to pay, in full or part, H. Third-Party Payer
for that encounter. I. Tracer
6. LO 39.6  Another type of paper remittance advice, more typically sent to the J. TriCare
policyholder. However, some in the industry use the term EOB inter- K. Usual, Customary, and
changeably with RA. Reasonable (UCR)
7. LO 39.2  A type of health insurance coverage in which physicians provide health L. Workers’ Compensation
care services to members of the plan at a discount.
8. LO 39.2  A government health plan that covers medical expenses for the
dependents of active-duty service members, CHAMPUS-eligible
retirees and their families, and the dependents of deceased active-
duty members.
9. LO 39.2  An insurance program that covers medical care for those injured or for
those who become ill as a consequence of their employment.
10. LO 39.1  A health care claim form that is transmitted electronically.
11. LO 39.6  The process of confirming with the insurance carrier that an individual
is qualified for benefits that would pay for services provided by your
health care professional on a particular day.
12. LO 39.6  Notification identifying details about a payment from the third-party
payer.

Part III
1. LO 39.2  May cover medical expenses caused by a car accident. A. Co-payment
2. LO 39.2  Preferred provider organization. B. DRG
3. LO 39.3  A fixed amount paid each visit by the individual. C. Fee-for-Service
4. LO 39.3  Payment, per service provided, from the insurance company. D. PPO
5. LO 39.2  A government program for indigent and needy people. E. Medicaid
6. LO 39.3  An episodic-care payment system basing reimbursement to hospitals F. Auto Insurance Policy
for inpatient services upon standards of care for specific diagnoses
grouped by their similar usage of resources for procedures, services,
and treatments.

1182   PART VI  |  REIMBURSEMENT, LEGAL, AND ETHICAL ISSUES

Let’s Check It! Concepts

CHAPTER 39 REVIEW
Choose the most appropriate answer for each of the following questions.
1. LO 39.1  Medical care is defined as
a. identification and treatment of illness and/or injury.
b. services to prevent illness such as a routine checkup or wellness visit.
c. laboratory services.
d. only those services performed by a medical doctor.
2. LO 39.2  An organization that depends on the services of a gatekeeper is
a. a preferred provider organization.
b. Medicare.
c. a health maintenance organization.
d. a not-for-profit hospital.
3. LO 39.3  A capitation plan pays the provider
a. per specific service.
b. per member every month.
c. for treatments in a hospital only.
d. one flat fee per illness or condition.
4. LO 39.2  Medicare is a government plan that covers primarily
a. military personnel. b.  poor and needy.
c. those over the age of 65. d.  government employees.
5. LO 39.4  When CMS computers evaluate submitted claims to look for pairs of codes being reported that are
known to be mutually exclusive procedures, this is also known as _____ edits.
a. LCD b.  NCD
c. PTP d.  MUE
6. LO 39.2  TriCare provides health care benefits for the dependents of
a. state workers.
b. those serving in the uniformed services.
c. athletes.
d. health care workers.
7. LO 39.5  What specific location does POS code 23 identify?
a. Urgent Care Facility b.  Assisted Living Facility
c. Telehealth d.  Emergency Room—Hospital
8. LO 39.6  The HIPAA Health Care Payment and Remittance Advice is the electronic transmission of payment,
using HIPAA-approved secure data sets. The transmission has two parts: the _____ and the _____.
a. claim, transaction b.  transaction, document
c. document, claim d.  date, carrier name
9. LO 39.3  When an individual pays a percentage of the total charge, it is called the
a. deductible. b.  co-payment.
c. co-insurance. d.  premium.
10. LO 39.2  CMS stands for
a. Centers for Medical Services. b.  Corporation of Medical Systems.
c. Centers for Medicare & Medicaid Services. d.  Cycle of Medical Selections.
 Let’s Check It! Which Type of Insurance?
CHAPTER 39 REVIEW

Match the situation with the type of insurance that would cover the expenses. Answers
may be used more than once.
A. Health Insurance 1. LO 39.2  Mrs. Matthews, a teacher at Medical Coder Academy, slipped in her
B. Workers’ Compensation office, fell, and hurt her back.
C. Medicaid 2. LO 39.2  Ralph broke his leg and must be in traction for 9 months. What plan
will help him pay his rent and electric bill?
D. Disability
Compensation 3. LO 39.2  Mary Lou was at the mall, shopping for a birthday present, when she
slipped on a wet floor and broke her hip.
E. Liability Insurance
4. LO 39.1  Keith was walking down the stairs in his house, fell over his son’s toy,
F. TriCare
and twisted his ankle.
G. Automobile Insurance
5. LO 39.2  Marlene was driving to work when another car hit her from behind.
H. Medicare The EMTs took her to the hospital with a sprained ankle and sore neck.
6. LO 39.2  Harvey caught a cold when he went fishing last weekend.
7. LO 39.2  Jared enrolled in the insurance coding program at the local college.
While leaving after his first class, another student bumped into him, he
banged his head on a shelf, and he got a scalp laceration.
8. LO 39.2  At home after his 85th birthday party, Jack tripped on the rug, fell, and
broke his hip.
9. LO 39.2  Suzette’s husband is in the Marines. She is pregnant with their first
child.
10. LO 39.2  James is out of work and has no prospects. He is broke and has a really
bad sore throat.

Let’s Check It! Rules and Regulations

Please answer the following questions from the knowledge you have gained after reading this chapter.
1. LO 39.4  What does NCCI stand for and what is its purpose?
2. LO 39.4  What is a procedure-to-procedure edit, who performs it, and when is it performed?
3. LO 39.4  What is the purpose of medically unlikely edits?
4. LO 39.6  What does it mean when a claim is denied due to an office personnel error and can it be corrected?
5. LO 39.6  What should you do if your office receives a claim denial due to lack of medical necessity?

1184   PART VI  |  REIMBURSEMENT, LEGAL, AND ETHICAL ISSUES

Introduction to Health
Care Law and Ethics 40
Learning Outcomes Key Terms
After completing this chapter, the student should be able to: Administrative Laws
Civil Law
LO 40.1 Identify the sources for directives governing behavior. Coding for Coverage
LO 40.2 Understand the rules for ethical and legal coding. Common Law
LO 40.3 Apply the requirements of the False Claims Act. Covered Entities
LO 40.4 Translate the components of the Health Insurance Portability Criminal Law
and Accountability Act’s Privacy Rule. Disclosure
Double Billing
LO 40.5 Elaborate the responsibilities of the Health Care Fraud and
Executive Orders
Abuse Control Program. HIPAA’s Privacy Rule
LO 40.6 Adhere to the codes of ethics of our industry. Mutually Exclusive
LO 40.7 Analyze the reasons for creating a compliance plan. Codes
Protected Health
Information (PHI)
Release of Informa-
tion (ROI)
40.1  Sources for Legal Guidance Statutory Laws
The health care industry is responsible for providing services to maintain and repair Supporting
the human body. For all of those providing health care services, the federal and state Documentation
governments have crafted and enacted laws and regulations designed to ensure honest, Unbundling
safe, and appropriate behaviors from all involved. In addition, these laws and regula- Upcoding
tions provide a remedy—compensation or restitution—when individuals step outside Use
of these approved boundaries. As a health care professional, you must be familiar with
the government’s directives so you can conduct yourself and your facility accordingly.
This text is written to provide you with the necessary foundation of legal and ethical
knowledge and understanding to support a successful career in health care. This chap-
ter will introduce you to the basic concepts.

The Federal Register

The Federal Register is the daily journal of the U.S. federal government. The Office of
the Federal Register (OFR), in conjunction with the U.S. Government Printing Office
(GPO), created and maintains the website version of this publication.
Created in 1935, the Federal Register’s purpose is to inform “citizens of their rights
and obligations, documents the actions of Federal agencies, and provides a forum for
public participation in the democratic process.” Included in its contents are execu-
tive orders, presidential proclamations, policy statements, proposed rules, notices of
scheduled hearings, and other government actions.
Take a look at a small section of the Federal Register in Figure 40-1 and access the
full Federal Register at https://www.federalregister.gov/.

Sources of Directives
Many different types of laws and regulations exist to direct certain behaviors of those
individuals working in health care, on both the clinical side and the administrative
side. Federal and state governments and their agencies initiate these directives.
 FIGURE 40-1  U.S. Congress’s Federal Register showing official details relating to
the Privacy Act (in part)  Source: gpo.gov

There is a hierarchy established that sets the level of authority, which begins at the
top with the U.S. Constitution as the first and foremost directive. In 1787, at the Con-
stitutional Convention in Philadelphia, Pennsylvania, the Constitution of the United
States was determined to be the highest and foremost of enacted law. Article VI of the
Constitution states:
“This Constitution, and the Laws of the United States which shall be made in
Pursuance thereof; and all Treaties made, or which shall be made, under the
Authority of the United States, shall be the supreme Law of the Land; and
the Judges in every State shall be bound thereby, any Thing in the Constitu-
tion or Laws of any State to the Contrary notwithstanding.”
Following the U.S. Constitution is federal law—those laws established by the U.S.
Congress. State constitutions, state statutory laws, and then local laws complete the
bottom tiers.
Statutory Laws Statutory laws, most often referred to as statutes, are created and enacted by the
Laws that are enacted by fed- federal and state legislatures (Congress). Members of Congress are responsible for
eral and state legislature. writing the law. Then, once passed by votes in the House and the Senate, it is said to
be “enacted.” Because federal statutes take precedence over state statutory laws, state
and local legislatures are not permitted to enact a law that contradicts any current fed-
eral law. This way, no one has to worry about which law takes dominance because this
order of priority is already established.
There are circumstances, however, where the federal law provides some flexibility
in behavior and the state law is more exact about the required behavior. In these cases,
the state law would take precedence. For example, the federal law commonly called
HIPAA’s Privacy Rule (Health Insurance Portability and Accountability Act) empow-
ers a health care provider to use his or her judgment whether or not to reveal protected
health information to authorities when a patient is diagnosed with a contagious dis-
ease. However, virtually every state has a law that makes the reporting to authorities of
a patient diagnosed with a contagious disease mandatory. The state law does not con-
flict with the federal law; it is actually more specific in its directive about behavior, so
it overrules the federal law. This example is one that illustrates how important it is for
all health care professionals to be familiar with both federal and state laws that govern
their job responsibilities.

EXAMPLES
The Emergency Medical Treatment and Active Labor Act (EMTALA)
The Affordable Care Act (ACA)
Equal Employment Opportunity Act (EEO)

1186   PART VI  |  REIMBURSEMENT, LEGAL, AND ETHICAL ISSUES

 Executive orders are official documents issued by the president of the United Executive Orders
States to set policy. They do not require approval from the legislature (Congress); Official policies issued by the
however, they are issued, typically, under statutory authority and, therefore, have the president of the United States.
full effect and force of a federal statute. The federal courts have upheld this.
Common law, also referred to as case law, is created by a judicial decision made Common Law
during a court trial. These decisions, documented in law books for local, state, and Also known as case law, this
federal court cases, create precedence—they establish a position. If you have ever is created by judicial decisions
watched a television show or movie with a court scene, you might remember the attor- made during court trials.
neys stating something like, “In Brown v. the Board of Education. . . .” This statement
refers to a specific court case (Brown v. the Board of Education) and the decision made
by that presiding judge. Those decisions are already accepted by the court, and there-
fore provide the current presiding judge with an established opinion.
You can see an example of the use of case law in the small portion of the Supreme
Court opinion shown in Figure 40-2, the last three lines. A previous case—PLIVA, Inc.
v. Mensing, 564 U.S. __ —is cited and this document goes on to explain the decision
determined in that case and how it is related to this current case.

EXAMPLES
United States v. Windsor
Mutual Pharmaceutical Co. v. Bartlett
Adoptive Couple v. Baby Girl

Administrative laws are those created and monitored by administrative agencies Administrative Laws
that have been given the responsibility to oversee specific areas, such as health care. Also known as rules and regu-
The creation and implementation of specific rules and regulations have been delegated lations, these are created and
to those agencies created by Congress, under the Administrative Procedures Act, so adjudicated by administrative
each agency can ensure its assigned tasks can be accomplished. For example, Congress agencies given authority by
Congress.
created the Centers for Disease Control and Prevention (CDC) as an administrative
agency of the federal government to oversee issues related to contagious diseases. The
CDC, therefore, has the authority to establish rules and regulations and to enforce those
regulations (as long as they are consistent with the statute under which the agency was
created). One of these rules is the mandated reporting of infectious diseases. Several
surveillance information systems are used to enable the required reporting of these
diagnoses; some are direct to the CDC while others are channeled through state depart-
ments of health first. However, if a particular diagnosis of an infectious disease is not
reported, as required, the CDC has the authority to take action for noncompliance.
In Figure 40-3, you can see a screen shot of the website Regulations.gov. This web-
site provides you with a searchable database of all federal agency regulations.

EXAMPLE
Centers for Medicare & Medicaid Services (CMS) has established its “rules of par-
ticipation” for health care participating providers.

Criminal law seeks to control the behavior of people and companies when their Criminal Law
actions are related to the health, welfare, and safety of an individual or property with Laws governing the behavior
the intention of protecting public order. Criminal activity is divided into two types, of the actions of the popula-
determined by the severity of the infraction: misdemeanors and felonies. tion related to health and
well-being.
∙ A misdemeanor is a lesser offense, such as driving under the influence, public nui-
sances, and certain traffic violations. These infractions are adjudicated in local
courts and are punishable with fines, penalties, and possible sentences of incarcera-
tion to county jail for up to 364 days.

CHAPTER 40  | 
 (Slip Opinion) OCTOBER TERM, 2012 1

Syllabus
NOTE: Where it is feasible, a syllabus (headnote) will be released, as is being
done in connection with this case, at the time the opinion is issued. The syl-
labus constitutes no part of the opinion of the Court but has been prepared by
the Reporter of Decisions for the convenience of the reader. See United States
v. Detroit Timber & Lumber Co., 200 U.S. 321, 337.

SUPREME COURT OF THE UNITED STATES

Syllabus

MUTUAL PHARMACEUTICAL CO., INC. v. BARTLETT

CERTIORARI TO THE UNITED STATES COURT OF
APPEALS FOR THE FIRST CIRCUIT
No. 12-142. Argued March 19, 2013—Decided June 24, 2013

Federal Food, Drug, and Cosmetic Act (FDCA) requires manufacturers to gain Food and
Drug Administration (FDA) approval before marketing any brand-name or generic drug in
interstate commerce. 21 U. S. C. §355(a). Once a drug is approved, a manufacturer is pro-
hibited from making any major changes to the “qualitative or quantitative formulation of the
drug product, including active ingredients, or in the specifications provided in the approved
application.” 21 CFR §314.70(b)(2)(i). Generic manufacturers are also prohibited from
making any unilateral changes to a drug’s label. See §§314.94(a)(8)(iii), 314.150(b)(10).
In 2004, respondent was prescribed Clinoril, the brand-name version of the nonsteroidal
anti-inflammatory drug (NSAID) sulindac, for shoulder pain. Her pharmacist dispensed a
generic form of sulindac manufactured by petitioner Mutual Pharmaceutical. Respondent
soon developed an acute case of toxic epidermal necrolysis. She is now severely disfigured,
has physical disabilities, and is nearly blind. At the time of the prescription, sulindac’s label
did not specifically refer to toxic epidermal necrolysis. By 2005, however, the FDA had rec-
ommended changing all NSAID labeling to contain a more explicit toxic epidermal necroly-
sis warning. Respondent sued Mutual in New Hampshire state court, and Mutual removed
the case to federal court. A jury found Mutual liable on respondent’s design-defect claim
and awarded her over $21 million. The First Circuit affirmed. As relevant, it found that
neither the FDCA nor the FDA’s regulations pre-empted respondent’s design-defect claim.
It distinguished PLIVA, Inc. v. Mensing, 564 U. S. ___—in which the Court held that failure-
to-warn claims against generic manufacturers are pre-empted by the FDCA’s prohibition on
changes to generic drug labels—by . . .

FIGURE 40-2  The use of case law is cited in this Supreme Court opinion regard-
ing a drug approval case  Source: Supreme Court of the United States Syllabus

∙ A felony is much more serious. This is a crime in violation of state or federal law
and often carries a sentence of anywhere from 1 year to life in prison. Health care
claims that are fraudulent and abusive of the reimbursement system constitute
criminal activity and are an example of a felony. The Department of Justice, in con-
junction with states’ attorneys general, investigates accusations of these improper
actions.
In Figure 40-4, you can see a release from the FBI reporting a guilty plea from a
Civil Law man in Ohio who was investigated and found guilty of criminal activity—involving
Laws that govern the relation- billing Medicare and Medicaid for home health care services.
ships between people, and Civil law governs the conduct of those involved in a relationship: between private
between businesses. companies, individuals, and sometimes the government. Most often, a civil complaint

1188   PART VI  |  REIMBURSEMENT, LEGAL, AND ETHICAL ISSUES

FIGURE 40-3  A snapshot of the website Regulations.gov, which offers a search-
able database of federal agency rules and regulations  Source: Regulations.gov

Orange Man Pleads Guilty to Health Care

Fraud Charges Related to Overbilling
Medicaid and Medicare by $2.5 Million

U.S. Attorney’s Office Northern District of Ohio

April 15, 2013 (216) 622-3600
A man who lives in Orange, Ohio, admitted to overbilling Medicaid and Medicare by more
than $2.5 million, said Steven M. Dettelback, United States Attorney for the Northern Dis-
trict of Ohio.
Divyesh “Davis” C. Patel, age 39, pleaded guilty to one count of conspiracy to commit
health care fraud and four counts of health care fraud. Patel is expected to be sentenced
later this year.
“This defendant enriched himself and his company by flouting rules designed to protect
the public,” Dettelbach said.
“Mr. Patel defrauded the taxpayers by scamming Medicaid and Medicare,” said Stephen
D. Anthony, Special Agent in Charge of the FBI’s Cleveland Field Office. “Waste, fraud,
and abuse take critical resources out of our health care system and contribute to the rising
cost of health care for all Americans.”
Patel was the owner and president of Alpine Nursing Care, Inc.

FIGURE 40-4  A brief summary of a case where a man pleads guilty to health care
fraud  Source: “Orange Man Pleads Guilty to Health Care Fraud Charges Related to Overbilling Medicaid and Medi-
care by $2.5 Million,” FBI, U.S. Attorney’s Office, April 15, 2013.

or lawsuit will result from one party accusing the other of failure to comply with the
terms of a contract. There are many instances of contractual relationships throughout
the health care industry. Physicians and health care facilities may contract with a man-
aged care organization; some facilities use contract workers to fill in for staff members
on vacation; a family may contract with a home health care agency for services to
a homebound patient; and the federal government may contract for health care ser-
vices from a professional that does not include direct patient care. Figure 40-5 shows
specific language that may be included in one of these contracts. The violation of a
patient’s confidentiality falls into this category because, in the United States, privacy

CHAPTER 40  | 
 FIGURE 40-5  A partial example of language used in a contract for health care
services that does not always include direct patient contact  Source: Acquisition.gov

is considered a civil right. This is why an alleged violation of privacy laws is handled
through the Office of Civil Rights (OCR) within the Department of Health and Human
Services (DHHS) of the federal government.

40.2  Rules for Ethical and Legal Coding

As a coder, you have a very important responsibility—to yourself, your patients, and
your facility. The work you do results in the creation of health claim forms and other
reports that are legal documents. What you do can contribute to your facility staying
healthy (businesswise) or being fined and possibly shut down by the Office of the
Inspector General and your state’s attorney general. You might make an error that
could cause a patient to be unfairly denied health insurance coverage. It is important
that you clearly understand the ethical and legal aspects of your position. Following
are some issues, with regard to the ethics and legalities of coding, with which you
should become very familiar.
1. It is very important that the codes indicated on the health claim form represent the
services actually performed and the reasons why they are provided as supported by
the documentation in the patient’s health record. Don’t use a code on a claim form
Supporting Documentation without ensuring the supporting documentation is there in the file.
The paperwork in the patient’s
file that corroborates the
codes presented on the EXAMPLE
claim form for a particular Coral Robinson’s file indicates that Dr. Longmire ordered a blood test to determine
encounter. whether or not she is pregnant. There is no report showing the results of the test.
You see Dr. Longmire, and he tells you that Coral is pregnant and you should go
ahead and code that diagnosis so the claim can be sent in. He promises to place
the lab report and update the notes in her file later. Until the physician documents
in the patient’s chart that the patient is pregnant, you are not permitted to code
the pregnancy.

1190   PART VI  |  REIMBURSEMENT, LEGAL, AND ETHICAL ISSUES

 2. Some health care providers may improperly encourage coding for coverage. This Coding for Coverage
term refers to the process of determining diagnostic and procedural codes not by Choosing a code on the basis
the accuracy of the code but with regard to what the insurance company will pay of what the insurance com-
for or “cover.” That is dishonest and is considered fraud. If you find yourself in an pany will cover (pay for) rather
office or facility that insists you “code for coverage” rather than code to accurately than accurately reflecting the
truth.
reflect the documentation and the services actually performed, you should immedi-
ately discuss your situation with someone you trust. Some providers will rationalize
the process by saying they are doing it so the patients can get the treatment they
really need paid for by the insurance company. Altruism aside, it is still illegal and,
once discovered, financial penalties and possible jail time can be assessed.

EXAMPLE
Corbin Bloom wants a nose job (rhinoplasty); however, he cannot afford it. The
insurance carrier will not pay for cosmetic surgery, so the coder changes the code
to indicate that Corbin has a deviated septum requiring surgical correction so that
the insurance carrier will pay for the procedure. That is coding for coverage and is
fraud.

3. If you find yourself in an office or facility that insists that you include codes for pro-
cedures that you know, or believe, were never performed at a level of intensity or
complexity as described by the code, this might be fraudulent behavior known as
upcoding—the process of using a code that claims a higher level of service, or a more Upcoding
severe illness, than is true. Upcoding is considered falsifying records. Even if all you Using a code on a claim form
do is fill out the claim form, you are participating in something unethical and illegal. that indicates a higher level
of service or a more severe
aspect of disease or injury
EXAMPLE than that which was actual
Erica Forney, a 69-year-old female, in the hospital for a broken hip, had her and true.
glucose level checked by the nurse, and it was at an abnormal level. Dr. Magnus
ordered additional tests to rule out diabetes mellitus. Coding that Erica has diabe-
tes is upcoding her condition and will fraudulently increase reimbursement from
Medicare by changing the diagnosis-related group (DRG). In addition, placing a
chronic disease on her health chart when she doesn’t have it will cause her prob-
lems later on.

4. It is not permissible to code and bill for individual (also known as component) ele-
ments when a comprehensive or combination (bundle) code is available. This is
referred to as unbundling and is illegal. Unbundling
Coding the individual parts of
For Medicare billing, refer to the Medicare National Correct Coding Initiative
a specific diagnosis or proce-
(CCI), which lists standardized bundled codes. The CCI is used to find coding dure rather than one combina-
conflicts, such as unbundling, the use of mutually exclusive codes, and other unac- tion or bundle that includes all
ceptable reporting of CPT codes. When these errors are discovered, those claims of those components.
are pulled for review and may be subject to possible suspension or rejection.
Mutually Exclusive Codes
Codes that are identified as
EXAMPLE those that are not permitted
Dr. Hayden’s notes indicate that Rico was experiencing nausea and vomiting. to be used on the same claim
form with other codes.
Instead of coding R11.2 Nausea with vomiting, the coder unbundles, coding
R11.0 Nausea alone and R11.11 Vomiting alone. Double Billing
Sending a claim for the sec-
ond time to the same insur-
5. If you resubmit a claim that has been lost, identify it as a “tracer” or “second sub- ance company for the same
mission.” If you don’t, you might be found guilty of double billing, billing the procedure or service, pro-
insurance company twice for a service provided only once. This also constitutes vided to the same patient on
fraud. the same date of service.

CHAPTER 40  | 
 6. You must code all conditions or complications that are relevant to the current
CODING BITES encounter. Separating the codes relating to one specific encounter and placing them
Always read the com- on several different claim forms over the course of several different days is neither
plete description in legal nor ethical. It not only indicates a lack of organization of the office but also
the provider’s notes in can cause suspicion of duplicating service claims, known as double billing. Even
addition to referenc- if you are reporting procedures that were actually done for diagnoses that actually
ing the encounter form exist, remember that the claim form is a legal document. All data on that claim
or superbill, and then form, including dates of service, must be accurate. Do not submit the claim form
carefully find the best until you are certain it is complete, with all diagnoses and procedures listed. If it
available code that sup- happens that, after you submit a claim, an additional service provided comes to
ports medical neces- light (such as a lab report with an extra charge that didn’t come across your desk
sity according to the until after you filed the claim), then you must file an amended claim. While not ille-
documentation. gal because you are identifying that the claim contains an adjustment, most third-
party payers really dislike amended claims. You can expect an amended claim to be
scrutinized.
All the activities mentioned here are considered fraud and are against the law.
It is not worth breaking the law and being charged with any of these penalties just
to hang onto a job.

Office of the Inspector General (OIG) Workplan

The Office of the Inspector General (OIG), in the Department of Health and Human
CODING BITES Services, is the agency that investigates and prosecutes failure to comply with the
legal requirements for coding. The OIG plans in advance, for the upcoming year,
Office of the Inspector
what specific violations will be reviewed and investigated. This is valuable informa-
General (OIG)
tion to support the development of internal policies and procedures as well as foci
https://oig.hhs.
for internal audits. When you can uncover and correct coding and billing errors
gov/reports-and-
BEFORE the federal or state auditors show up, this lessens fines and penalties
publications/work-
considerably.
plan/index.asp
The workplan is released each year by October 1 for the upcoming calendar year.
It is subsectioned by the type of facility affected, so you don’t have to read through
everything to find that which applies to your organization. Sometimes the issue is
directly related to billing and coding; others may be more administrative.

EXAMPLES
Hospitals
Intensity-Modulated Radiation Therapy
We will review Medicare outpatient payments for intensity-modulated radiation
therapy (IMRT) to determine whether the payments were made in accordance
with Federal requirements. IMRT is an advanced mode of high-precision radio-
therapy that uses computer-controlled linear accelerators to deliver precise
radiation doses to a malignant tumor or specific areas within the tumor. Prior OIG
reviews have identified hospitals that have incorrectly billed for IMRT services. In
addition, IMRT is provided in two treatment phases: planning and delivery. Certain
services should not be billed when they are performed as part of developing an
IMRT plan.
Selected Inpatient and Outpatient Billing Requirements
We will review Medicare payments to acute care hospitals to determine hospitals’
compliance with selected billing requirements and recommend recovery of over-
payments. Prior OIG reviews and investigations have identified areas at risk for
noncompliance with Medicare billing requirements. Our review will focus on those
hospitals with claims that may be at risk for overpayments.

1192   PART VI  |  REIMBURSEMENT, LEGAL, AND ETHICAL ISSUES

 EXAMPLE
Home Health Services
Medicare Home Health Fraud Indicators
We will describe the extent that potential indicators associated with home health
fraud are present in home health billing for 2014 and 2015. We will analyze Medi-
care claims data to identify the prevalence of potential indicators of home health
fraud. The Medicare home health benefit has long been recognized as a program
area vulnerable to fraud, waste, and abuse. OIG has a wide portfolio of work
involving home health fraud, waste, and abuse.

40.3  False Claims Act

The federal False Claims Act (FCA) was enacted by Congress to make the submission
of a claim to a federal agency containing false information an illegal act. After this law
was put into place, virtually every individual state passed its own version. This means
that an individual may be charged with violation of both the federal law AND the state
law, magnifying the fines, penalties, and consequences of this fraudulent behavior.

Who Is Liable?
Which staff members are responsible for ensuring that a facility or provider complies
with FCA? All individuals and facilities that are involved in the creation and submis-
sion of claims—requests for reimbursement—based on coverage provided by govern-
mental programs, such as Medicare or Medicaid, are responsible for complying with
this law. Legally, these entities are referred to as federal contractors. Some people read
the word contractor and immediately think of construction projects. However, in these
cases, this phrase refers to one signing a contract to do business with a government
program, that is, a participating provider. The Department of Justice takes enforce-
ment of the FCA seriously. (See Figure 40-6 for just one example.)

Department of Justice Office of Public Affairs FOR IMMEDIATE

RELEASE Monday, February 6, 2017
Healthcare Service Provider to Pay $60 Million to Settle Medicare and
Medicaid False Claims Act Allegations
A major U.S. hospital service provider, TeamHealth Holdings, as successor in interest to
IPC Healthcare Inc., f/k/a IPC The Hospitalists Inc. (IPC), has agreed to resolve allega-
tions that IPC violated the False Claims Act by billing Medicare, Medicaid, the Defense
Health Agency and the Federal Employees Health Benefits Program for higher and more
expensive levels of medical service than were actually performed (a practice known as
“up-coding”), the Department of Justice announced today. Under the settlement agreement,
TeamHealth has agreed to pay $60 million, plus interest.
“This settlement reflects our ongoing commitment to ensure that health care providers
appropriately bill government programs vital to patient health care,” said Acting Assistant
Attorney General Chad A. Readler of the Justice Department’s Civil Division. The government
contended that IPC knowingly and systematically encouraged false billings by its hospitalists,
who are medical professionals whose primary focus is the medical care of hospitalized patients.
Specifically, the government alleged that IPC encouraged its hospitalists to bill for a higher
level of service than actually provided. IPC’s scheme to improperly maximize billings allegedly
included corporate pressure on hospitalists with lower billing levels to “catch up” to their peers.

FIGURE 40-6  An extract from a press release from the Department of Justice con-
cerning a case enforcing the False Claims Act  Source: “Justice Department Recovers Nearly $6 Billion
from False Claims Act Cases in Fiscal Year 2014,” Department of Justice, Office of Public Affairs, November 20, 2014.

CHAPTER 40  | 
 What Is a Claim?
Needless to say, this law requires the proper behavior of individuals filing claims for
reimbursement. So, let’s begin with the FCA’s specific definition of what a claim is:
“a demand for money or property made directly to the Federal Government or to a
contractor, grantee, or other recipient.”*
Under the requirements of the individual state governments, this would be a demand
for reimbursement from the state government or other entity within.

The Knowledge Requirement

In addition, this law includes a “knowledge requirement.” This portion of the law states
that the simple action of submitting a claim with false information is not a violation. The
individual must know that the information on the claim is false. What does “know” mean?
∙ Actual knowledge . . . knowing for a fact that the information is false.
∙ Willful ignorance, also known as deliberate ignorance . . . those who should know
due to their job position, training, or responsibilities within the organization with
regard to filing the claim but purposely don’t ask about the validity of the informa-
tion, or ignore the falsity of the information.
∙ Disregard of the truth or falsity . . . behavior that exhibits an indifference to con-
firming that the information is true.

EXAMPLES
Actual knowledge:
“I know that the procedures documented in the patient’s record were not actu-
ally performed.”
Willful ignorance:
“I don’t know for a fact, and I don’t want to know.”
Disregard of the truth:
“It’s not my concern. I just do what I am told.”

Essentially, this means that an individual is required to comply with this law if, as part of
his or her job, the individual knows the accuracy of the information on the claim, or should
know the accuracy of the information. If your job involves anything to do with the creation
and submission of a claim to any third party, it is your responsibility to know for a fact that
the information is true. And no court will accept your excuse that you “didn’t know.”

The Qui Tam Provision

The qui tam provision within the FCA, commonly known as the Whistleblower Stat-
ute, empowers private citizens (typically those who work within organizations that
do not comply) to file a lawsuit on behalf of the federal or state government against
the facility for noncompliance. Sadly, there are health care professionals who will not
listen to a staff member explaining that a particular behavior or sequence of actions is
not legal. The intent of this statute is to recruit those honest individuals who witness
an organization that is committing, or encouraging, fraudulent activities to step up and
help to stop the illegal actions by reporting the fraud or filing a qui tam suit.
The government knows how scary and difficult it can be to come forward. There-
fore, they reward the person or persons reporting the fraud with a percentage of the
total amount recovered by the federal or state government as a result of the qui tam
lawsuit. This reward can be anywhere from 15% to 30%.
*Source: Federal False Claims Act, Department of Justice.

1194   PART VI  |  REIMBURSEMENT, LEGAL, AND ETHICAL ISSUES

 EXAMPLE CODING BITES
“Of the $3.8 billion the department recovered in fiscal year 2013, $2.9 billion Want more details about
related to lawsuits filed under the qui tam provisions of the False Claims Act. qui tam lawsuits? Here
During the same period, the department paid out more than $345 million to is an interesting article:
the courageous individuals who exposed fraud and false claims by filing a qui “Top 10 Tips for Qui
tam complaint.” Tam Whistleblowers,”
http://www.justice.gov/opa/pr/justice-department-recovers-38-billion-false- from the National Law
claims-act-cases-fiscal-year-2013 Review:
http://www.
natlawreview.com/
40.4  Health Insurance Portability and article/top-10-
tips-qui-tam-
Accountability Act (HIPAA) whistleblowers

The Health Insurance Portability and Accountability Act of 1996, known as HIPAA
(pronounced hip-aah), was enacted by the federal government and directly applies to CODING BITES
you as a coding professional. Like most federal laws, HIPAA covers many different
Be very careful when
issues and concerns. The Privacy Rule is one part of this law that you are obligated to
writing or typing this
know and understand.
acronym. It is HIPAA . . .
one P and two As.
HIPAA’s Privacy Rule
HIPAA’s Privacy Rule was written to protect an individual’s privacy with regard HIPAA’s Privacy Rule
to personal health information, without getting in the way of the flow of data that is A portion of HIPAA that
necessary to provide appropriate care for that patient. Essentially, the lawmakers tried ensures the availability of
to make certain that a patient’s information is easily accessible to those who should patient information for those
have access to it [such as the physician, insurance coder and biller, and therapist] who should see it while pro-
tecting that information from
and, at the same time, keep it secured against unauthorized people [such as potential
those who should not.
employers, coworkers, or neighborhood gossips] so that they do not see things they
have no business seeing.

Who Is Responsible for Obeying This Law

HIPAA’s Privacy Rule went into effect on April 14, 2003, and concerns every physi-
cian’s office, clinic, hospital, and health insurance carrier—every type of business that
is directly involved in the delivery of and/or payment for health care services, no matter
how big or small. The largest of corporations owning hundreds of hospitals around the
country and an office with one physician working alone are all included. HIPAA calls
these businesses covered entities, and they all must comply with the terms of the law. Covered Entities
Covered entities are divided into three categories: Health care providers, health
plans, and health care
∙ Health care providers clearinghouses—businesses
∙ Health plans that have access to the per-
sonal health information of
∙ Health care clearinghouses
patients.
You probably already know the definition of a health care provider: any person or
organization that gives health care services as the primary business purpose.

EXAMPLE
Health care providers as defined by HIPAA: physicians, dentists, hospitals, clinics,
pharmacies, laboratories, and so on.

Health plans are described as organizations that provide and/or pay for health care
services as their main reason for being in business. They include health insurance
carriers, HMOs, employee welfare benefit plans, government health plans (such as

CHAPTER 40  | 
 TriCare, Medicare, and Medicaid), and group health plans provided through employ-
CODING BITES ers and associations. It doesn’t matter whether the plan is offered to an individual or a
Respecting a patient’s group—all companies offering this coverage are included.
privacy is also a sign
of respect for the per-
EXAMPLE
son. When you are the
patient, you want to be Health care plans as defined by HIPAA: Medicare, Medicaid, TriCare, BlueCross
treated with respect. So BlueShield, Prudential, and so on.
following HIPAA’s Pri-
vacy Rule is not just the In addition, technology has created another type of organization involved in this
law of the United States; process, called a health care clearinghouse. These companies help process electronic
it is the law of treating health insurance claims. Medical billing services, medical review services, and health
people fairly. information management system companies are included in this definition.

EXAMPLE
Health care clearinghouses as defined by HIPAA: National Clearinghouse, NDC
Electronic Claims, WebMD Network Services, and others.

The workforces of covered entities are also included under HIPAA. A covered enti-
ty’s workforce consists of every person who is involved with the company—full time,
part time, volunteer, intern, extern, physician, nurse, assistant—and this has nothing
to do with whether they are paid. Everyone must comply with the terms of this law.

CODING BITES EXAMPLE

HIPAA’s Privacy Rule is A covered entity’s workforce as defined by HIPAA: full-time staff members, part-
mostly about protecting time staff members, volunteers, interns, externs, janitorial staff members, and so
your patient’s privacy. on.

What This Law Covers

You are certainly familiar with the topic of doctor–patient confidentiality. It means
that anything a patient tells his or her doctor must be kept private. The doctor is not
allowed, under most circumstances, to reveal to anyone what was said. This includes
family members, parents (in many cases), and friends. This is important so that an
individual will feel comfortable being open and honest and tell the physician things
that are very, very personal, possibly even embarrassing or private facts that this per-
son has never told anyone else. However, in order for the physician to properly treat
this individual, the physician must know everything.
In order for you to do your job properly, you have access to all this confidential
information. You need to know very personal and private facts about every one of your
patients in order to accurately report the data.
You know what is wrong with them (their diagnoses) now and in the past; you know
why they came to see this health care provider and why they saw others before they
came to your facility; and you know what the health care provider thinks (observations
and impressions) about these patients, as well as what has been done, is being done,
and will be done to treat them. You know all these things because you have access to
patients’ health care records, including all the physician’s notes. HIPAA calls this per-
Protected Health
sonal health care information (past, present, and future conditions) individually iden-
Information (PHI) tifiable health information. In other words, it is information that anyone could look at
Any patient-identifiable health and know exactly which individual is being discussed—one specific person. Specific
information regardless of pieces of data, called protected health information (PHI), are pieces of information
the form in which it is stored related to an individual that must be kept confidential, the grouping of facts that might
(paper, computer file, etc.). have someone say, “Oh, I know him! Oh, and he has that!”

1196   PART VI  |  REIMBURSEMENT, LEGAL, AND ETHICAL ISSUES

 EXAMPLE
Nicholas is a patient of Dr. Molinaro, and the information inside his chart (paper or
electronic) consists of his records, charts, lab reports, and physician’s notes docu-
menting everything Nicholas has ever discussed with his physician. Karyn needs all
this information to do her job as the office’s coding specialist. At this moment, Karyn
has stepped away from her desk. Nicholas’s file is sitting on Karyn’s desk, lying open.
From the color of the folder, even from a distance, it is obvious that this is a patient
of Dr. Molinaro’s. The top piece of paper indicates that his patient has been diagnosed
with a sexually transmitted disease. At this point, any unauthorized person couldn’t
really know whose chart this is because Dr. Molinaro has hundreds of patients.
Right above the diagnosis anyone can see that this patient is a male. Although
this will eliminate some of Dr. Molinaro’s patients, there are still too many to know
for certain.
Upon closer examination of the paperwork in the folder, anyone could see that
this male patient with the sexually transmitted disease lives on Main Street in Our
Town, Florida. The list of Dr. Molinaro’s patients that is being referred to is getting
very short now.
In the upper right corner, anyone can see Dr. Molinaro’s male patient, who lives
on Main Street, Our Town, Florida, who has a sexually transmitted disease, was born
on June 13, 1985. Oh my, did you know Nicholas lives on Main Street in Our Town,
and his birthday is June 13th? It must be Nicholas who has that terrible disease!
Did Karyn fulfill her responsibility to protect Nicholas’s privacy? What could she
have done differently to ensure that this patient’s PHI was protected?

Nicholas’s private health record is no longer private. His diagnosis of a sexually

transmitted disease is health information. After discovering his gender, address, and
birth date, someone can connect this diagnosis directly to one particular person. All
these details, and any other pieces of information like these, are protected to be private
under the law. This means that all this information is confidential, and it is against the
law for you to reveal any of it, with only a few exceptions:
1. You can tell other health care professionals who are directly involved in the course
of doing your job.
2. You can tell someone when given written permission from the patient to do so.
3. You can tell in situations, as outlined in the law, based on “best professional judgment.”

The Use and Disclosure of PHI

HIPAA’s Privacy Rule is very specific as to how you can handle the PHI that you work
with every day. The guidelines offer two terms to describe how you might deal with
these data.
The term use (with regard to HIPAA) means that the information is being shared Use
between people who work together in the same office and need to exchange PHI in The sharing of information
order to better serve the patient. between people working in
the same health care facility
for purposes of caring for the
EXAMPLE patient.
You are getting ready to code the diagnosis for Herman Farber’s recent visit and need
additional information. You speak with the attending physician, Dr. Yaw, to discuss
Herman’s PHI so that you can make certain you find the best, most appropriate diag- Disclosure
nosis code. You are using that patient’s PHI because the information is being shared The sharing of information
between you and the physician in the same office for the benefit of the patient. between health care profes-
sionals working in separate
entities, or facilities, in the
The second term is disclosure. HIPAA defines the term disclosure to mean that PHI course of caring for the
is being revealed to someone outside the health care office or facility. For example, you patient.

CHAPTER 40  | 
 prepare a health insurance claim form to send to the patient’s insurance company so it
will pay your office for the procedures provided. On that claim form, you must put the
patient’s full name and address, birth date, diagnosis codes, and procedure codes. As
you learned earlier in this chapter, each piece of data is not necessarily confidential.
When you put all this information together in one place, it becomes PHI because this
health information (diagnosis and procedure codes) is now connected to a specific per-
son (identified by the name, address, birth date, etc.) on one piece of paper. However,
you must disclose this information to the insurance carrier in order to get paid. You are
disclosing the information because the insurance company personnel who will read this
claim form do not work for your health care facility—they are an outside company.

EXAMPLE
Dr. Royan indicates that his patient, Caleb Carter, needs some lab work. Dr. Royan
will use Mr. Carter’s PHI in his orders for which tests should be performed. Then
you need to call the laboratory and disclose Mr. Carter’s PHI (his name and diag-
nosis) along with what specific tests should be performed by the lab.

Remember that everyone in your office and everyone at the insurance carrier and
the lab is a member of a covered entity’s workforce. You are all bound by the same
terms of the HIPAA law and cannot reveal any patient’s PHI, except under particular
circumstances (such as use and disclosure), unless you have the patient’s written per-
mission (Figure 40-7).

Getting Written Approval

In most situations, other than those already mentioned, the health care provider must get
a patient’s written permission to disclose the PHI. Although there are many preprinted
Release of Information (ROI) Release of Information (ROI) forms that your office or facility may purchase, the Pri-
The form (either on paper or vacy Rule of HIPAA insists that all these documents have the following characteristics:
electronic) that a patient must
sign to give legal permission 1. Are written in plain language (not legalese) so that the average person can under-
to a covered entity to disclose stand what he or she is signing.
that patient’s PHI. 2. Are very specific as to exactly what information will be disclosed or used.
3. Specifically identify the person or organization that will be disclosing the information.
4. Specifically identify the person(s) who will be receiving the information.
5. Have a definite expiration date.
6. Clearly explain that the person signing this release may retract this authorization in
writing at any time.
Figure 40-8 is an example of a form that your facility might use for this purpose.

HHS.gov Health Information Privacy U.S. Department of Health & Human

Services

$750,000 HIPAA SETTLEMENT UNDERSCORES THE

NEED FOR ORGANIZATION WIDE RISK ANALYSIS
The University of Washington Medicine (UWM) has agreed to settle charges that it poten-
tially violated the Health Insurance Portability and Accountability Act of 1996 (HIPAA)
Security Rule by failing to implement policies and procedures to prevent, detect, contain,
and correct security violations. The settlement includes a monetary payment of $750,000, a
corrective action plan, and annual reports on the organization’s compliance efforts.

FIGURE 40-7  A partial summary of a case where HIPAA violations cost a health
care facility big money  Source: “$750,000 HIPAA Settlement Underscores the Need for Organization Wide
Risk Analysis,” HHS Press Office, December 14, 2015.

1198   PART VI  |  REIMBURSEMENT, LEGAL, AND ETHICAL ISSUES

 FORM APPROVED: OMB NO. 0917-0030
IHS-810 (4/09) DEPARTMENT OF HEALTH AND HUMAN SERVICES Expiration Date: 4/30/2016
FRONT Indian Health Service See OMB Statement on Reverse.
AUTHORIZATION FOR USE OR DISCLOSURE OF PROTECTED HEALTH INFORMATION
COMPLETE ALL SECTIONS, DATE, AND SIGN

I. I, , hereby voluntarily authorize the disclosure of information from my

health record. (Name of Patient)

II. The information is to be disclosed by: And is to be provided to:

NAME OF FACILITY NAME OF PERSON/ORGANIZATION/FACILITY

ADDRESS ADDRESS

CITY/STATE CITY/STATE

III. The purpose or need for this disclosure is:

Further Medical Care Attorney School Research
Personal Use Insurance Disability Other (Specify)

IV. The information to be disclosed from my health record: (check appropriate box(es))
Only information related to (specify)

Only the period of events from to

Other (specify) (CHS, Billing, etc.)
Entire Record

If you would like any of the following sensitive information disclosed, check the applicable box(es) below:
Alcohol/Drug Abuse Treatment/Referral HIV/AIDS-related Treatment
Sexually Transmitted Diseases Mental Health (Other than Psychotherapy Notes)
Psychotherapy Notes ONLY (by checking this box, I am waiving any psychotherapist-patient privilege)
V. I understand that I may revoke this authorization in writing submitted at any time to the Health Information Management Department, except to the
extent that action has been taken in reliance on this authorization. If this authorization was obtained as a condition of obtaining insurance coverage or
a policy of insurance, other law may provide the insurer with the right to contest a claim under the policy. If this authorization has not been revoked, it
will terminate one year from the date of my signature unless a different expiration date or expiration event is stated.

(Specify new date)

I understand that IHS will not condition treatment or eligibility for care on my providing this authorization except if such care is:
(1) research related or (2) provided solely for the purpose of creating Protected Health Information for disclosure to a third party.
I understand that information disclosed by this authorization, except for Alcohol and Drug Abuse as defined in 42 CFR Part 2, may be subject to
redisclosure by the recipient and may no longer be protected by the Health Insurance Portability and Accountability Act Privacy Rule [45 CFR Part 164]
, and the Privacy Act of 1974 [5 USC 552a].

SIGNATURE OF PATIENT OR PERSONAL REPRESENTATIVE (State relationship to patient) DATE

SIGNATURE OF WITNESS (If signature of patient is a thumbprint or mark) DATE

This information is to be released for the purpose stated above and may not be used by the recipient for any other purpose. Any person who knowingly and willfully requests
or obtains any record concerning an individual from a Federal agency under false pretenses shall be guilty of a misdemeanor (5 USC 552a(i)(3)).
PATIENT IDENTIFICATION NAME (Last, First, MI) RECORD NUMBER

ADDRESS

CITY/STATE DATE OF BIRTH

PSC Graphics (301) 443-1090 EF

FIGURE 40-8  Example of authorization form to release health information  Source: Department of Health and Human Services,
Form IHS-810 (4/09)

CHAPTER 40  | 
 Permitted Uses and Disclosures
The Privacy Rule outlines six circumstances in which health care professionals are
permitted, with or without written patient permission, to use their best professional
judgment as to whether or not they should use and/or disclose a patient’s PHI.
1. To the individual. Health care professionals can use their best professional judg-
ment to decide whether or not a patient should be told certain things contained in
his or her health care record. Questions come up especially when mental health
issues and terminal conditions (when a patient is almost certain to die in the near
future) are concerned and there is doubt if the patient can deal with the medical
facts. In almost all cases, providing patients with their own PHI is allowed.
2. Treatment, payment, and/or operations (TPO). This means that health care pro-
fessionals are free to use and/or disclose PHI when it comes to making decisions,
coordinating, and managing the treatment of a patient’s condition.
In addition, PHI can be disclosed for payment activities, such as billing and
claims processing, as mentioned earlier in this chapter. In this description, the term
operations refers to the health care facility’s own management of case coordination
and quality evaluations.

EXAMPLE
A physician needs to be able to discuss PHI details with a therapist so that,
together, they can establish a proper course of treatment for the patient.

3. Opportunity to agree or object. This relates to a more informal situation where the
patient is present and alert and has the ability to give verbal permission or not with
regard to a specific disclosure.
One important point to remember: Although it is much easier to simply ask
someone for his or her oral approval than to go get a form and make the patient sign
first, it is in your best interest to get written approval whenever possible. People’s
memories may fail, or they may change their mind later about what they really did
tell you. If there is nothing on paper, you cannot prove what was said. For your own
protection, get it in writing whenever possible!

EXAMPLE
Asher Grimm is about to hear Dr. Brant explain his test results. Asher’s wife is in
the waiting room. Dr. Brant may ask Asher if it is okay to invite his wife in and per-
mit her to hear this information, too. Asher can then say, “Yes, that is fine” or “No,
I don’t want her to know about this.” Dr. Brant then must abide by what the patient
requests.

4. Incidental use and disclosure. As long as reasonable safeguards are in place, this
CODING BITES portion of the rule addresses the fact that information might accidentally be used or
Incidental is close to disclosed during the regular course of business.
the word accidental—if
someone accidentally
EXAMPLE
overhears what you say.
Dr. Holloway comes out of an examining room and approaches Nurse Miller stand-
ing at the desk. This is a back area, and patients are not generally in this hallway,
so Dr. Holloway speaks to the nurse in a normal tone of voice to instruct her on
preparing Mrs. Hunter for a procedure. All of a sudden, another patient comes
around the corner, lost on her way back to the waiting room, and overhears the
conversation.

1200   PART VI  |  REIMBURSEMENT, LEGAL, AND ETHICAL ISSUES

 This is called incidental use and is understandable in a working environment; there-
fore, it is not considered a violation of the law.
However, it is important for conversations like this to include only the minimum
necessary PHI to accomplish the goal. Minimum necessary refers to the caution
that should be used to release only the smallest amount of information required to
accomplish the task and no more. Not only is it unnecessary to release more, it is
unprofessional.

EXAMPLE
In the hallway outside the exam room, the physician would only need to say,
“Serita, please prepare Mrs. Hunter for her examination.” She would not need
to include other details about Mrs. Hunter, such as, “Serita, please prepare Mrs.
Hunter for her examination. You know she has a terrible rash on her thighs. I sus-
pect that it’s poison ivy. However, it could be a sexually transmitted disease. We’ll
have to find out how many sexual partners she has had in the last 6 months.” All
that extra information is unnecessary to the proper care of Mrs. Hunter at this
moment.

5. Public interest. There are times when the public’s best interest may prompt disclos-
ing what you know about a patient. Very often, this is mandated by state laws, which
would then take priority over the federal HIPAA law. In other words, if the federal
law says you are allowed to tell, and your state’s law says you must tell—then, you
must! These situations include the reporting of suspected abuse (child abuse, elder
abuse, neglect, domestic violence) and the reporting of sexually transmitted and
other contagious diseases. You are included in the health care team and must think
about the community, which must be warned if someone is walking around with a CODING BITES
contagious (communicable) disease. Most states require notification to the police in Remember that, when
cases where the patient has been shot or stabbed. It is your responsibility to find out there is a state or fed-
what the laws are in your state and how to correctly file a report. eral mandate to report
If the physician does not report suspected child abuse of one of your patients, it (that means you have no
is your obligation to pick up the phone and call. choice; you must report
to the proper author-
6. Limited data set. For research, public health statistics, or other health care oper- ities), this does not
ations, PHI can be revealed, but only after it has been depersonalized. In other apply only to the physi-
words, if the data that connect this information to a specific individual are removed cian of your practice but
or blacked out, the information is no longer individually identifiable health infor- also applies to you.
mation, so it does not need to be protected any longer.

EXAMPLE
You can release a health record that has no name, address, telephone number,
e-mail address, Social Security number, or photographs attached to it. Even certain
physician’s notes can be released after they have been stripped of personal data.
Following is a sample portion of a record that can be shown without fear of violat-
ing anyone’s privacy:
“_____ is 33 years old. Back in April, _____ was in a motor vehicle acci- CODING BITES
dent while he was on the job. _____ is complaining about some neck This law simply assures
pain. _____ has tingling into the left hand.” every person coming to
The example above is a direct quote from the medical record of an actual patient your health care facility
after the specified direct identifiers have been removed. You cannot connect this that his or her personal
health information to any one particular person. Therefore, the information is no and private information
longer protected and can be used for research and in other ways that may help will be protected and
the community. treated with respect.

CHAPTER 40  | 
 Privacy Notices
HIPAA instructs all its covered entities to create policies and procedures with regard
to the use and disclosure of PHI. In addition, the law actually states that, once policies
and procedures are developed, the facilities must follow these policies. Copies of the
written policy must be given to every patient and posted in a general area where it can
be seen by all patients.
Notices of Privacy written in compliance with HIPAA’s Privacy Rule must contain
the following points:
1. A full description of how the covered entity may use and/or disclose a patient’s PHI.
2. A statement about the covered entity’s responsibility to protect a patient’s privacy.
3. Complete information about the patient’s rights, including contact information for
the Department of Health and Human Services (DHHS), should the patient wish to
lodge a complaint that his or her privacy was violated.
4. The name of a specific employee of the covered entity, who must be named as pri-
vacy officer. This person’s name, as well as contact information, must be included
in the written notice to handle patients’ questions and complaints.
The covered entity must receive written acknowledgment from each patient stating
that he or she received the written privacy practices notice. This is usually one of the
papers that a patient has to sign when going to a health care facility for the first time.
One of the most important aspects of this portion of the Privacy Rule is that the law
specifically says that the covered entity not only has to create these policies and proce-
dures but also has to abide by them. If it doesn’t, it is considered to be in violation of
federal law and punishable by fines and/or imprisonment.
Although some health care staff members feel that HIPAA and its Privacy Rule are
a pain in the neck, think about what this law actually means: respecting your patients’
privacy and dignity. Isn’t that what you expect from your health care professionals
when you go for help? It is not enough that only the doctor be bound to protect the
patient’s information as confidential because the doctor is no longer the only person
who has access. Your health care facility is no place for gossip. You might find this
person’s hemorrhoids funny or that person’s rash gross. As a professional, you should
not be concerned with entertaining your friends with your patients’ private circum-
stances. How would you feel if it were your personal problem that your health care
team members were giggling about with their friends? Or you might consider tell-
ing your brother that his girlfriend came in with a sexually transmitted disease. You
cannot! Everyone is entitled to privacy. As difficult as it may be, you must remain a
professional.

CODING BITES
Just because you can take a look at any patient’s chart doesn’t mean you should.
In your facility, you will probably be granted permission to access patients’ charts
so you can do your work. Under certain circumstances you may be tempted
to look, not for your job but because the patient is your friend or neighbor or a
celebrity. You may think no harm is being done, just caring or curiosity. But there is
harm, and you are prohibited, by law, to do this.
Back in October 2007, 27 employees of a New Jersey hospital were fired or
put on suspension for looking at George Clooney’s file after he was brought into
the emergency department (ED) following a motorcycle accident.
You could be the president of the hospital and have your best friend come into
the ED of your hospital. Without specific permission from that patient, you would
be forbidden from looking at the record. Every individual has the right to make
his or her own decision about who should know what about his or her own health
information.

1202   PART VI  |  REIMBURSEMENT, LEGAL, AND ETHICAL ISSUES

Violating HIPAA’s Privacy Rule
Any individual who discovers that his or her privacy has been misused or disclosed
without permission can file a complaint with the Department of Health and Human
Services (DHHS) that the health care provider, health plan, or clearinghouse has not
followed HIPAA’s regulations. When writing this law, Congress included specifica-
tions for both civil and criminal penalties to be applied against any covered entity that
fails to protect its patients’ PHI. These penalties include fines—up to $250,000—and
up to 10 years in prison (Figure 40-9).
A covered entity is responsible for any violation of HIPAA requirements by any of
its employees, business associates, or other members of its workforce, such as interns
and volunteers. Generally, the senior officials of the covered entity may be punished
for the lack of compliance; however, middle managers and staff members are not
exempt.

HHS requires California medical center

to protect patients’ right to privacy

FOR IMMEDIATE RELEASE HHS Press Office

Thursday, June 13, 2013 (202) 690-6343
News Release
Shasta Regional Medical Center (SRMC) has agreed to a comprehensive corrective action plan to settle a U.S.
Department of Health and Human Services (HHS) investigation concerning potential violations of the Health Insurance
Portability and Accountability Act (HIPAA) Privacy Rule.
The HHS Office for Civil Rights (OCR) opened a compliance review of SRMC following a Los Angeles Times article
which indicated two SRMC senior leaders had met with media to discuss medical services provided to a patient. OCR’s
investigation indicated that SRMC failed to safeguard the patient’s protected health information (PHI) from
impermissible disclosure by intentionally disclosing PHI to multiple media outlets on at least three separate occasions,
without a valid written authorization. OCR’s review indicated that senior management at SRMC impermissibly shared
details about the patient’s medical condition, diagnosis and treatment in an email to the entire workforce. In addition,
SRMC failed to sanction its workforce members for impermissibly disclosing the patient’s records pursuant to its
internal sanctions policy.
“When senior level executives intentionally and repeatedly violate HIPAA by disclosing identifiable patient
information, OCR will respond quickly and decisively to stop such behavior,” said OCR Director Leon Rodriguez.
“Senior leadership helps define the culture of an organization and is responsible for knowing and complying with the
HIPAA privacy and security requirements to ensure patients’ rights are fully protected.”
In addition to a $275,000 monetary settlement, a corrective action plan (CAP) requires SRMC to update its policies and
procedures on safeguarding PHI from impermissible uses and disclosures and to train its workforce members. The CAP
also requires fifteen other hospitals or medical centers under the same ownership or operational control as SRMC to
attest to their understanding of permissible uses and disclosures of PHI, including disclosures to the media.

The Resolution Agreement can be found on the OCR website at:

http://www.hhs.gov/ocr/privacy/hipaa/enforcement/examples/shasta-agreement.pdf

FIGURE 40-9  A press release from the Department of Health and Human Services with details about violators of
HIPAA facing consequences  Source: “HHS requires California medical center to protect patients’ right to privacy,” U.S. Department of Health and
Human Services, June 13, 2013.

CHAPTER 40  | 
 Civil Penalties
1. $100 with no prison for each single violation of a HIPAA regulation with a maxi-
mum of $25,000 for multiple violations of the same portion of the regulation during
the same calendar year.

EXAMPLE
You tell your best friend that Oliver Tesca, whom you both went to school with,
came into your physician’s office and tested positive for a sexually transmitted dis-
ease. You, of course, swear her to secrecy. Later that day, she bumps into Oliver’s
fiancée and feels obligated to tell her about Oliver’s condition. Oliver puts two and
two together, after his fiancée breaks up with him, and he files a complaint that
you disclosed his PHI without permission. You and/or your physician is fined $100.

Criminal Penalties
2. Up to $50,000 and up to 1 year in jail for the unauthorized or inappropriate disclo-
sure of individually identifiable health information.

EXAMPLE
After you are fined the $100 civil penalty for the inappropriate disclosure of Oliver
Tesca’s PHI, you and/or your physician is charged with criminal penalties for the
same disclosure, including a fine of $50,000 and a year in jail.

3. Up to $100,000 and up to 5 years in prison for the unauthorized or inappropriate

disclosure of individually identifiable health information through deception.

EXAMPLE
Your best friend since high school, Sally-Anne Hoskins, just got a great job as a
pharmaceutical representative. To help her, you give her a list of 250 patients
from your facility who have been diagnosed with diabetes so she can advertise
her company’s new drug to them. You and she both know this is illegal, so you
tell Sally-Anne that you got permission from each of the patients to release the
information (and that is a lie). After a patient complains to DHHS, the investiga-
tion discovers your relationship with Sally-Anne. You and your physician are fined
$100,000 per occurrence (that’s for each person on the list), as well as sentenced
to 5 years in prison. FYI: 250 × $100,000 = $25 million!

4. Up to $250,000 and up to 10 years in prison for the unauthorized or inappropriate

disclosure of individually identifiable health information through deception with
intent to sell or use for business-related benefit, personal gain, or hateful detriment.

EXAMPLE
A famous television star is a patient of the physician’s office down the hall from
yours. You get a call from a tabloid newspaper offering you $50,000 for any infor-
mation on the celebrity’s health. So you call the manager of the pathology lab
and tell him you are filling in at the other physician’s office and need test results
for Mr. TV. Then you call the tabloid reporter and tell him what you found out. You
used deception (you lied about working in the other physician’s office) to gain PHI,
which you then sold for personal financial gain. You (and possibly your physician)
are fined a quarter of a million dollars and sentenced to 10 years in prison—
definitely not worth it!

1204   PART VI  |  REIMBURSEMENT, LEGAL, AND ETHICAL ISSUES

Refusing to Release Patient Information
Sometimes, it seems that everyone agrees with the importance of protecting a patient’s
privacy until he or she asks for someone’s details and is refused. It happens with par-
ents and spouses all too often, and you must be prepared for how to say “no” and deal
with the impact that may ensue.
When asked why you will not release details about a man’s wife or mother’s teenage
daughter, educate the individual with the facts. Frequently, simply replying, “That is
our policy” accomplishes little more than infuriating them, so instead, explain why you
cannot share the information. Explain that health care staff are all required, by federal
law, to protect our patients’ privacy with no exceptions. Say that, as soon as possible, he
or she should speak with the patient and enable the patient to tell the story about his or
her health care encounter. Ask nicely for the individual’s understanding.

40.5  Health Care Fraud and

Abuse Control Program
The Health Insurance Portability and Accountability Act (HIPAA) created the Health
Care Fraud and Abuse Control Program (HCFACP). This program, under the direc-
tion of the attorney general and the secretary of the DHHS, acts in accordance with
the Office of the Inspector General (OIG) and coordinates with federal, state, and
local law enforcement agencies to discover those who attempt to defraud or abuse the
health care system, including Medicare and Medicaid patients and programs.
By catching those who submitted fraudulent claims, approximately $2.3 billion was
won or negotiated by the federal government during fiscal year 2014. The federal govern-
ment deposited approximately $1.9 billion to the Medicare Trust Fund in fiscal year 2014,
plus more than $523 million of federal Medicaid funds were brought into the U.S. Trea-
sury. Since it was created in 1997, the HCFACP has collected more than $27.8 billion for
the Medicare Trust Fund—money improperly received by health care professionals filing
fraudulent claims. The statistics show that for every $1 spent to pay for these investiga-
tions and prosecutions, the government actually brings in about $4 in money returned.
Also, in 2014, 496 criminal indictments were filed in health care fraud cases, and
805 defendants were convicted for health care fraud–related crimes, resulting in 734
defendants convicted of health care fraud–related crimes. In addition, 782 new civil
cases were filed and 957 more civil matters were pending during this same year. These
investigations also prohibited 4,017 individuals and organizations from working with
any federally sponsored programs (such as Medicare and Medicaid). Most of these were
as a result of convictions for Medicare- or Medicaid-related crimes, including patient
abuse and patient neglect, or as a result of providers’ licenses having been revoked.
When you look at these 2014 numbers, you can see that people are being caught
trying to get money for health care services to which they are not entitled. This is an
important reminder that if individuals try to get you to participate in illegal or unethical
behaviors, the question is not “Will you be caught?” but “When will you be caught?”

CODING BITES
From Fact Sheet: The Health Care Fraud and Abuse Control Program Protects Con-
sumers and Taxpayers by Combating Health Care Fraud, dated February 26, 2016.
“In Fiscal Year (FY) 2015, the government recovered $2.4 billion as a result
of health care fraud judgements, settlements and additional administrative
impositions in health care fraud cases and proceedings. Since its inception in
1997, the Health Care Fraud and Abuse Control (HCFAC) Program has returned
more than $29.4 billion to the Medicare Trust Funds. In this past fiscal year, the
HCFAC program has returned $6.10 for each dollar invested.”
Source: justice.gov

CHAPTER 40  | 
 40.6  Codes of Ethics
There are two premier trade organizations for professional coding specialists. Each
has published a code of ethics to guide members of our industry on the best profes-
sional way to conduct themselves.

American Health Information Management

Association Code of Ethics
The American Health Information Management Association (AHIMA) is the preem-
inent professional organization for health information workers, including insurance
coding specialists. The AHIMA House of Delegates designated the elements as being
critical to the highest level of honorable behavior for its members.
In this era of reimbursements based on diagnostic and procedural coding, the profes-
sional ethics of health information coding professionals continue to be challenged. Stan-
dards of ethical coding practices for coding professionals were developed by AHIMA’s
Coding Policy and Strategy Committee and approved by AHIMA’s board of directors.

GUIDANCE CONNECTION
AHIMA Code of Ethics
This Code of Ethics sets forth ethical principles for the health information management
profession. Members of this profession are responsible for maintaining and promoting
ethical practices. This Code of Ethics, adopted by the American Health Information Man-
agement Association, shall be binding on health information management professionals
who are members of the Association and all individuals who hold an AHIMA certification.
The following ethical principles are based on the core values of the American
Health Information Management Association and apply to all health information
management professionals. Health information management professionals must:
1. Advocate, uphold, and defend the individual’s right to privacy and the doc-
trine of confidentiality in the use and disclosure of information.
2. Put service and the health and welfare of persons before self-interest and
conduct themselves in the practice of the profession so as to bring honor to
themselves, their peers, and the health information management profession.
3. Preserve, protect, and secure personal health information in any form or
medium and hold in the highest regard the contents of the records and other
information of a confidential nature, taking into account the applicable stat-
utes and regulations.
4. Refuse to participate in or conceal unethical practices or procedures.
5. Advance health information management knowledge and practice through
continuing education, research, publications, and presentations.
6. Recruit and mentor students, peers, and colleagues to develop and
strengthen a professional workforce.
7. Represent the profession accurately to the public.
8. Perform honorably health information management association responsibili-
ties, either appointed or elected, and preserve the confidentiality of any privi-
leged information made known in any official capacity.
9. State truthfully and accurately their credentials, professional education, and
experiences.
10. Facilitate interdisciplinary collaboration in situations supporting health infor-
mation practice.
11. Respect the inherent dignity and worth of every person.
Reprinted with permission from the American Health Information Management Association. Copyright ©2015
by the American Health Information Management Association. All rights reserved. No part of this may be repro-
duced, reprinted, stored in a retrieval system, or transmitted, in any form or by any means, electronic photo-
copying, recording, or otherwise, without the prior written permission of the association.

1206   PART VI  |  REIMBURSEMENT, LEGAL, AND ETHICAL ISSUES

AHIMA Standards of Ethical Coding
Coding is one of the foundational functions of the health information management
department. As complex as is the process of coding accurately, there are multipart,
intricate regulations that impact that process. In addition, professional coding spe-
cialists must make ethical decisions that would benefit from an appropriate and
knowledgeable source. The AHIMA Standards of Ethical Coding are presented to all
members of the industry to support their ethical and legal decisions and behaviors, as
well as to reinforce and evidence the commitment of coding professionals to integrity.
These Standards are offered for use to all AHIMA members or nonmembers, in all
types of health care facilities and organizations.

GUIDANCE CONNECTION
AHIMA Standards of Ethical Coding
Coding professionals should:
1. Apply accurate, complete, and consistent coding practices that yield quality
data.
2. Gather and report all data required for internal and external reporting, in
accordance with applicable requirements and data set definitions.
3. Assign and report, in any format, only the codes and data that are clearly and
consistently supported by health record documentation in accordance with
applicable code set and abstraction conventions, and requirements.
4. Query and/or consult as needed with the provider for clarification and addi-
tional documentation prior to final code assignment in accordance with
acceptable healthcare industry practices.
5. Refuse to participate in, support, or change reported data and/or narrative
titles, billing data, clinical documentation practices, or any coding related
activities intended to skew or misrepresent data and their meaning that do
not comply with requirements.
6. Facilitate, advocate, and collaborate with healthcare professionals in the pur-
suit of accurate, complete and reliable coded data and in situations that sup-
port ethical coding practices.
7. Advance coding knowledge and practice through continuing education,
including but not limited to meeting continuing education requirements.
8. Maintain the confidentiality of protected health information in accordance
with the Code of Ethics.
9. Refuse to participate in the development of coding and coding related tech-
nology that is not designed in accordance with requirements.
10. Demonstrate behavior that reflects integrity, shows a commitment to ethical
and legal coding practices, and fosters trust in professional activities.
11. Refuse to participate in and/or conceal unethical coding, data abstraction,
query practices, or any inappropriate activities related to coding and address
any perceived unethical coding related practices.
Reprinted with permission from the American Health Information Management Association. Copyright ©2015
by the American Health Information Management Association. All rights reserved. No part of this may be repro-
duced, reprinted, stored in a retrieval system, or transmitted, in any form or by any means, electronic photo-
copying, recording, or otherwise, without the prior written permission of the association.

AAPC Code of Ethical Standards

American Academy of Professional Coders (AAPC) is an influential organization in
the health information management industry. Its members, and their certifications, are
well respected throughout the United States and the world. Its Code of Ethical Stan-
dards also illuminates the importance of an insurance coding and billing specialist’s
exhibiting the most ethical and moral conduct.

CHAPTER 40  | 
 GUIDANCE CONNECTION
AAPC Code of Ethical Standards
Members of the American Academy of Professional Coders shall be dedicated
to providing the highest standard of professional coding and billing services to
employers, clients and patients. Professional and personal behavior of AAPC
members must be exemplary.
AAPC members shall maintain the highest standard of personal and profes-
sional conduct. Members shall respect the rights of patients, clients, employers
and all other colleagues.
Members shall use only legal and ethical means in all professional dealings and
shall refuse to cooperate with, or condone by silence, the actions of those who
engage in fraudulent, deceptive or illegal acts.
Members shall respect and adhere to the laws and regulations of the land and
uphold the mission statement of the AAPC.
Members shall pursue excellence through continuing education in all areas
applicable to their profession.
Members shall strive to maintain and enhance the dignity, status, competence
and standards of coding for professional services.
Members shall not exploit professional relationships with patients, employees,
clients or employers for personal gain.
Above all else we will commit to recognizing the intrinsic worth of each member.
This code of ethical standards for members of the AAPC strives to promote
and maintain the highest standard of professional service and conduct among its
members. Adherence to these standards assures public confidence in the integ-
rity and service of professional coders who are members of the AAPC.
Failure to adhere to these standards, as determined by AAPC, will result in the
loss of credentials and membership with the American Academy of Professional
Coders.
Copyright © 2014, American Academy of Professional Coders. All rights reserved. Reprinted with permission.

40.7  Compliance Programs

A formal compliance program has been strongly recommended by the OIG (Office of
Inspector General) of the DHHS (Department of Health and Human Services) to help
all health care facilities establish their organizations’ respect for the laws and their
agreement to follow the direction from those laws. However, there are certain health
care providers for whom this is not only suggested but mandated by law.
The Deficit Reduction Act of 2005, which went into effect January 1, 2007, man-
dates a compliance program for all health care organizations that receive $5 million
or more a year from Medicaid. This law is very specific that the facility’s compli-
ance program include written guidance and policies about employees’ responsibilities
under the False Claims Act.
On March 23, 2010, President Obama signed the Patient Protection and Affordable
Care Act into law. Among the many other elements of health care covered by this law,
there is a provision in Section 6401 that providers participating in Medicare and Med-
icaid create compliance programs. This includes physicians’ offices and suppliers.
A compliance program will officially create policies and procedures, establish the
structure to adhere to those policies, set up a monitoring system to ensure that it works,
and correct conduct that does not comply. The foundation of the compliance program
is the creation of an organizational culture of honesty and compliance with the laws;
the discouragement of fraud, waste, and abuse; the discovery of any fraudulent activi-
ties as soon as possible using internal policies and audits; and immediate corrective
action when fraud and abuse do occur.

1208   PART VI  |  REIMBURSEMENT, LEGAL, AND ETHICAL ISSUES

 The federal sentencing guidelines manual provides a seven-step list of the compo-
nents of an effective compliance program.

GUIDANCE CONNECTION
Federal Sentencing Guidelines Manual: The Seven Steps to Due Diligence
1. Establish compliance standards and procedures
2. Assign overall responsibility to specific high-level individual(s)
3. Use due care to avoid delegation of authority to individuals with an inclination
to get involved in illegal actions
4. Effectively communicate standards and procedures to all staff
5. Utilize monitoring and auditing system to detect non-compliant conduct
6. Enforce adequate disciplinary sanctions when appropriate
7. Respond to episodes of non-compliance by modifying program, if necessary
Source: United States Sentencing Commission. (2014, November 1). 2014 USSC Guidelines Manual, ussc.gov

Chapter Summary
Knowing your legal and ethical responsibilities as a health care professional will give
you a strong foundation for a healthy career. HIPAA’s Privacy Rule, along with the
codes of ethics from both AHIMA and AAPC, should help guide you through any
challenges.
For all of those providing health care services, the federal and state governments
have crafted and enacted laws and regulations designed to ensure honest, safe, and
appropriate behaviors from all involved. The Federal Register is the daily journal of
the U.S. federal government, used to inform citizens of the actions of the federal gov-
ernment. The hierarchy established for the levels of authority begin with the U.S. Con-
stitution, followed by federal statutory law, state constitutions, state statutory laws,
and local laws. Executive orders, issued by the president of the United States, have the
same authority as federal statutes. Common law, also known as case law, is created by
a judicial decision made during a court trial and it establishes precedence. Administra-
tive laws are the rules and regulations established by administrative agencies in their
efforts to encourage compliance so they can complete their assigned tasks. The viola-
tion of criminal law may be a misdemeanor (lessor offense) or a felony (more serious
offense). Civil laws govern the conduct of two individuals or entities in a contractual
agreement or a civil wrongdoing, known as a tort.
Confidentiality, honesty, and accuracy are the watchwords that all health informa-
tion management professionals should live by.

CODING BITES
Medical records, also known as patient charts, whether in paper or electronic
form, are legal documents. As business records, they can be used as evidence in
a court of law, and can be required by issuance of a subpoena duces tecum.
As per the HIPAA Privacy Rule, a “designated record set” must be specified
by each health care organization. Essentially, this is a collection of files (paper or
electronic) that include:
• the medical records and billing records about individuals maintained by, or for,
a covered health care provider;
• the enrollment, payment, claims adjudication, case study, or medical manage-
ment record systems maintained by or for a health plan; or
• documentation used for the provider or plan to make decisions about
individuals.

CHAPTER 40  | 
 CHAPTER 40 REVIEW
CHAPTER 40 REVIEW

Introduction to Health Care Enhance your learning by

completing these exercises and
more at connect.mheducation.com!

Law and Ethics

Let’s Check It! Terminology
Match each term to the appropriate definition.
1. LO 40.2  Choosing a code on the basis of what the insurance company will cover A. Administrative Law
(pay for) rather than accurately reflecting the truth. B. Coding for Coverage
2. LO 40.1  Laws governing the behavior of the actions of the population related to C. Common Law
health and well-being.
D. Covered Entities
3. LO 40.2  Coding the individual parts of a specific diagnosis or procedure rather
E. Criminal Law
than one combination or bundle that includes all of those components.
F. Disclosure
4. LO 40.1  Official policies issued by the president of the United States.
G. Double Billing
5. LO 40.1  Also known as rules and regulations, these are created and adjudicated
by administrative agencies, given authority by Congress. H. Executive Orders
6. LO 40.4  Health care providers, health plans, and health care clearinghouses— I. HIPAA’s Privacy Rule
businesses that have access to the personal health information of J. Protected Health Infor-
patients. mation (PHI)
7. LO 40.4  Any patient-identifiable health information regardless of the form in K. Statutory Laws
which it is stored (paper, computer file, etc.). L. Supporting
8. LO 40.1  Laws that are enacted by federal and state legislature. Documentation
9. LO 40.2  Using a code on a claim form that indicates a higher level of service M. Unbundling
or a more severe aspect of disease or injury than that which was actual N. Upcoding
and true.
O. Use
10. LO 40.4  A portion of HIPAA that ensures the availability of patient informa-
tion for those who should see it while protecting that information from
those who should not.
11. LO 40.4  The sharing of information between people working in the same health
care facility for purposes of caring for the patient.
12. LO 40.4  The sharing of information between health care professionals working
in separate entities, or facilities, in the course of caring for the patient.
13. LO 40.1  Also known as case law, this is created by judicial decisions made dur-
ing court trials.
14. LO 40.2  The paperwork in the patient’s file that corroborates the codes pre-
sented on the claim form for a particular encounter.
15. LO 40.2  Sending a claim for the second time to the same insurance company
for the same procedure or service, provided to the same patient on the
same date of service.

Let’s Check It! Concepts

Choose the most appropriate answer for each of the following questions.
1. LO 40.4  The intent of HIPAA’s Privacy Rule is to
a. protect an individual’s privacy.

1210   PART VI  |  REIMBURSEMENT, LEGAL, AND ETHICAL ISSUES

 b. not interfere with the flow of information necessary for care.

CHAPTER 40 REVIEW
c. restrict health care professionals from doing their jobs.
d. protect an individual’s privacy and not interfere with the flow of information necessary for care.
2. LO 40.4  Protected health information (PHI) is
a. any health information that can be connected to a specific individual.
b. a listing of diagnosis codes.
c. current procedural terminology.
d. covered entity employee files.
3. LO 40.4  According to HIPAA, covered entities include all except
a. health care providers. b.  health plans.
c. health care computer software manufacturers. d.  health care clearinghouses.
4. LO 40.4  The term use per HIPAA’s Privacy Rule refers to the exchange of information between health care
personnel
a. and health care personnel in other health care facilities. b.  and family members.
c. in the same office. d.  and the pharmacist.
5. LO 40.4  The term disclosure per HIPAA’s Privacy Rule refers to the exchange of information between health
care personnel
a. and health care personnel in other covered entities. b.  and family members.
c. in the same office. d.  and the patient.
6. LO 40.4  Which of the following is not a covered entity under HIPAA?
a. County hospital b.  BlueCross BlueShield Association
c. Physician Associates medical practice d.  Computer technical support
7. LO 40.6  There are two premier trade organizations for professional coding specialists. Each organization has a
code of ethics to guide members on the best professional way to conduct themselves. These two organi-
zations are
a. AHIMA and OFR. b.  GPO and AAPC.
c. AHIMA and AAPC. d.  HIPAA and EEO.
8. LO 40.4  According to HIPAA’s rules and regulations, a covered entity’s workforce includes
a. only paid, full-time employees.
b. only licensed personnel working in the office.
c. volunteers, trainees, and employees, part time and full time.
d. business associates’ employees.
9. LO 40.4  HIPAA’s Privacy Rule has been carefully crafted to
a. protect a patient’s health care history.
b. protect a patient’s current medical issues.
c. protect a patient’s future health considerations.
d. all of these.
10. LO 40.4  A written form to release PHI should include all except
a. specific identification of the person who will be receiving the information.
b. the specific information to be released.
c. legal terminology so it will stand up in court.
d. an expiration date.

CHAPTER 40  | 
 11. LO 40.4  Those who are permitted to file an official complaint with DHHS are
CHAPTER 40 REVIEW

a. health care providers. b.  any individual.

c. health plans. d.  clearinghouses.
12. LO 40.4  Penalties for violating any portion of HIPAA apply to
a. patients. b.  patients’ families.
c. all covered entities. d.  health care office managers.
13. LO 40.3  An individual who files a false claim can be charged for violations by
a. federal law. b.  state law.
c. both federal and state law. d.  Filing a false claim is not a violation of law.
14. LO 40.1  DHHS stands for
a. Department of Home and Health Services.
b. Division of Health and Health Care Sciences.
c. Department of Health and Human Services.
d. District of Health and HIPAA Systems.
15. LO 40.2  Changing a code from one that is most accurate to one you know the insurance company will pay for is
called
a. coding for coverage. b.  coding for packaging.
c. unbundling. d.  double billing.
16. LO 40.2  Unbundling is an illegal practice in which coders
a. bill for services never provided.
b. bill for services with no documentation.
c. bill using several individual codes instead of one combination code.
d. bill using a code for a higher level of service than what was actually provided.
17. LO 40.2  Upcoding is an illegal practice in which coders
a. bill for services never provided.
b. bill for services with no documentation.
c. bill using several individual codes instead of one combination code.
d. bill using a code for a higher level of service than what was actually provided.
18. LO 40.2  Medicare’s CCI investigates claims that include
a. unbundling.
b. the improper use of mutually exclusive codes.
c. unacceptable reporting of CPT codes.
d. all of these.
19. LO 40.5  During fiscal year 2014, the federal government won or negotiated approximately _____ billion from
those who submitted fraudulent claims.
a. $1.3 b.  $1.75
c. $2.3 d.  $2.5
20. LO 40.7  According to the federal sentencing guidelines manual, all of the following are components of the seven
steps to due diligence for an effective compliance program except
a. establish compliance standards and procedures.
b. assign overall responsibility to specific high-level individual(s).
c. utilize monitoring and auditing system to detect noncompliant conduct.
d. cease disciplinary sanctions.

1212   PART VI  |  REIMBURSEMENT, LEGAL, AND ETHICAL ISSUES

Let’s Check It! Rules and Regulations

CHAPTER 40 REVIEW
Please answer the following questions from the knowledge you have gained after read-
ing this chapter.
1. LO 40.4  Why was HIPAA’s Privacy Rule written?
2. LO 40.2  Explain double billing. Is it permissible practice for a professional cod-
ing specialist?
3. LO 40.1  Explain civil law in relation to the health care industry.
4. LO 40.3  What is the False Claims Act’s definition of a claim and what is the
knowledge requirement?
5. LO 40.7  What are the federal sentencing guidelines manual’s seven steps to due
diligence for an effective compliance program?

YOU CODE IT! Application

Following are some health care scenarios. Determine the best course of action that you, as the health information
management professional for the facility, should take. Identify any legal and/or ethical issues that may need to be
considered and explain how you would deal with the situation.

PRADER, BRACKER, & ASSOCIATES

A Complete Health Care Facility
159 Healthcare Way • SOMEWHERE, FL 32811 • 407-555-6789
PATIENT: HOLLAND, FELECIA
ACCOUNT/EHR #: HOLLFE001
DATE: 04/26/18
Attending Physician: Oscar R. Prader, MD
This 31-year-old female is 32 weeks pregnant. She presents today in tears. She is suffering from hem-
orrhoids and cannot stand it anymore. The pain and itching are making life difficult for her, as it hurts to
sit for any length of time, and she cannot sleep. As it is difficult for her to lie on her stomach, due to the
pregnancy, she can only find some comfort by either walking around or lying on her side. She is asking
(more like begging) for a hemorrhoidectomy—a simple surgical procedure that can be done in the office
and will almost immediately provide her with complete relief.
The correct CPT code for the treatment of Felecia’s condition is
46260 Hemorrhoidectomy, internal and external, 2 or more columns/groups
However, Felecia’s insurance carrier will not pay for a hemorrhoidectomy with a diagnosis that indicates
there are no complications. According to the insurance customer service representative, it will only pay
in full for the procedure
46250 Hemorrhoidectomy, external, 2 or more columns/groups
Felecia’s husband, Ben, is a civilian who works for a defense contractor and is currently in Iraq support-
ing the troops. Money is tight for the family because Ben’s paycheck has been delayed due to a mix-up
in paperwork when he was transferred to the Middle East. There is no way they can afford to pay cash
for the hemorrhoidectomy.

All you need to do is change the one number of the code and Felecia can have the relief she so desperately needs.
As the professional coding specialist in this office, what should you do?

CHAPTER 40  | 
CHAPTER 40 REVIEW

PRADER, BRACKER, & ASSOCIATES

A Complete Health Care Facility
159 Healthcare Way • SOMEWHERE, FL 32811 • 407-555-6789
PATIENT: OKONEK, MARC
ACCOUNT/EHR #: OKONMA001
DATE: 08/12/18
Attending Physician: Andrew Bracker, MD
As the coding specialist for this facility, you are given the chart for this patient after his recent encounter
with Dr. Bracker. On the face sheet you notice that Dr. Bracker has indicated the procedure provided to
this patient to be Excision dermoid cyst, nose; simple, skin, subcutaneous. However, there is nothing at
all in the rest of the documentation, including the encounter notes and lab reports, to support medical
necessity for this procedure.

As a professional coding specialist in this office, what should you do?

PRADER, BRACKER, & ASSOCIATES

A Complete Health Care Facility
159 Healthcare Way • SOMEWHERE, FL 32811 • 407-555-6789
PATIENT: RIALS, ELIZABETH
ACCOUNT/EHR #: RIALEL001
DATE: 12/08/18
Attending Physician: Oscar R. Prader, MD
Today, Tonya Baliga comes into your office. She states that she is Elizabeth Rials’s sister and that she
has been asked by her sister to collect a copy of her complete medical record. Ms. Baliga tells you that
her sister has moved to another town and needs the records for an upcoming medical appointment with
her new doctor. She hands you a printout of an e-mail, supposedly from Ms. Rials, to serve as documen-
tation that she should have the records.

As a professional coding specialist in this office, what should you do?

PRADER, BRACKER, & ASSOCIATES

A Complete Health Care Facility
159 Healthcare Way • SOMEWHERE, FL 32811 • 407-555-6789
PATIENT: SINGELTON, SANDRA
ACCOUNT/EHR #: SINGSA001
DATE: 03/13/18
Attending Physician: Andrew Bracker, MD
The patient is a 17-year-old female who came in for counseling on birth control.

1214   PART VI  |  REIMBURSEMENT, LEGAL, AND ETHICAL ISSUES

 CHAPTER 40 REVIEW
Today, Angela Thurman came into the office. She stated that she is Sandra’s mother and found an
appointment card for this facility in her daughter’s jeans. She demands to know why her daughter came
to see the physician. She is angry and frustrated and states that she will not leave until she is told why
her daughter saw the doctor.

As a professional coding specialist in this office, what should you do?

PRADER, BRACKER, & ASSOCIATES

A Complete Health Care Facility
159 Healthcare Way • SOMEWHERE, FL 32811 • 407-555-6789
PATIENT: EVERFIELD, CARL
ACCOUNT/EHR #: EVERCA001
DATE: 06/28/18
Attending Physician: Oscar R. Prader, MD
The patient came to see the physician because he hates his nose. His self-esteem is very low and, as a
teenage boy, he has developed severe social anxiety. His family does not have the money to pay for a
rhinoplasty (nose job) and the only way that the insurance company will pay for this cosmetic surgery is
for medical necessity, such as a deviated septum.
You have been told to code the diagnosis of deviated septum to support medical necessity for the
rhinoplasty. The doctor and office manager both tell you that this is the “right” thing to do.

As a professional coding specialist in this office, what should you do?

CHAPTER 40  | 
APPENDIX

E/M Coding Rubric Worksheet

Begin by narrowing down the entire E/M chapter to the appropriate subsection:

Step 1. Location New Patient/Initial Established /Subsequent

Office/Outpatient 99201–99205 99211–99215
Hospital—Observation 99218–99220 99224–99226
Hospital—Inpatient 99221–99223 99231–99233
Emergency Department 99281–99285
Nursing Facility 99304–99306 99307–99310
Domiciliary (Assisted Living) 99324–99328 99334–99337
Home Services 99341–99345 99347–99350

New Patient/ Established/

Step 2. Key Components Initial Subsequent
History

Problem-Focused: Chief complaint; brief history of present illness or problem.

Expanded Problem-Focused: Chief complaint; brief history of present illness;

problem-pertinent system review
Detailed: Chief complaint; extended history of present illness; problem-pertinent
system review extended to include a review of a limited number of additional
systems; pertinent past, family, and/or social history directly related to patient’s
problem(s).
Comprehensive: Chief complaint; extended history of present illness; review of
systems that are directly related to the problem(s) identified in the history of the
present illness plus a review of all additional body systems; complete past, family,
and social history.

CodePath: For more information on determining level of history, see Let’s Code It!
Chapter 23, Section 23.4 Types of E/M Services – Level of Patient History (beginning
on page 648).

1216
 New Patient/ Established/
Step 3. Key Components Initial Subsequent
Physical Examination
Problem-Focused: A limited exam of the affected body area or organ system
Expanded Problem-Focused: A limited exam of the affected body area or organ
system and other symptomatic or related organ system(s)
Detailed: An extended exam of the affected body area(s) and other symptomatic
or related organ system(s)
Comprehensive: A general multisystem exam -or- a complete exam of a single
organ system

CodePath: For more information on determining level of Physical Examination, see

Let’s Code It! Chapter 23, Section 23.4 Types of E/M Services – Level of Physical
Examination (beginning on page 650).

New Patient/ Established/

Step 4. Key Components Initial Subsequent
Medical Decision-Making
Straightforward: Minimal number of possible diagnoses and/or treatment options;
minimal quantity of information to be obtained, reviewed, and analyzed; and mini-
mal risk of significant complications, morbidity, and/or mortality
Low Complexity: Limited number of possible diagnoses and/or treatment options;
limited quantity of information to be obtained, reviewed, and analyzed; and lim-
ited risk of significant complications, morbidity, and/or mortality
Moderate Complexity: Multiple number of possible diagnoses and/or treatment
options; moderate quantity of information to be obtained, reviewed, and analyzed;
and moderate risk of significant complications, morbidity, and/or mortality
High Complexity: Extensive number of possible diagnoses and/or treatment
options; extensive quantity of information to be obtained, reviewed, and analyzed;
and high risk of significant complications, morbidity, and/or mortality

CodePath: For more information on determining level of Medical Decision-Making,

see Let’s Code It! Chapter 23, Section 23.4 Types of E/M Services – Level of Medical
Decision-Making (beginning on page 652).

Combining Multiple Levels in One Code

Once you have determined what level of history was taken, what level of physician
exam was performed, and what level of MDM was provided by the physician as docu-
mented in the case notes, this all needs to be put together into one code. When all
three key components point to the same code, this is a piece of cake. But what about
when the three levels point toward different E/M codes? How do you mesh them all
into one code? The CPT guidelines state, “… must meet or exceed the stated require-
ments to qualify for a particular level of E/M service.”
You must find the one level that is satisfied by ALL THREE levels of care when
you are reporting for a NEW patient, or TWO out of THREE for established patients.
Find the only code that has ALL THREE levels equal to or greater than the code’s key
component descriptors, as identified on your above worksheets, to determine which
one E/M code should be reported.

CodePath: For new Patients … You can only code as high as your lowest key component.
GLOSSARY

Anatomical Site  A specific location within the anatomy (body).

A Anemic  Any of various conditions marked by deficiency in red
Ablation  The destruction or eradication of tissue. blood cells or hemoglobin.
Abnormal Findings  Test results that indicate a disease or Anesthesia  The loss of sensation, with or without consciousness,
condition may be present. generally induced by the administration of a particular drug.
Abortifacient  A drug used to induce an abortion. Anesthesiologists  Physicians specializing in the administration of
Abortion  The end of a pregnancy prior to or subsequent to the anesthesia.
death of a fetus. Angina Pectoris  Chest pain.
Abstracting  The process of identifying the relevant words or Angiography  The imaging of blood vessels after the injection of
phrases in health care documentation in order to determine the contrast material.
best, most appropriate code(s). Anomaly  An abnormal, or unexpected, condition.
Abuse  Regular consumption of a substance with manifestations. Antibodies  Immune responses to antigens.
Abuse  This term is used in different manners: (a) extreme use of Antigen  A substance that promotes the production of antibodies.
a drug or chemical; (b) violent and/or inappropriate treatment of
another person (child, adult, elder). Anus  The portion of the large intestine that leads outside the body.
Accessory Organs  Organs that assist the digestive process and are Anxiety  The feelings of apprehension and fear, sometimes
adjacent to the alimentary canal: the gallbladder, liver, and pancreas. manifested with physical manifestations such as sweating and
palpitations.
Accommodation  Adaptation of the eye’s lens to adjust for varying
focal distances. Approach  The path the physician took to access the body part
upon which the treatment or procedure was targeted.
Acute  Severe; serious.
Arthrodesis  The immobilization of a joint using a surgical
Administration  To introduce a therapeutic, prophylactic, technique.
protective, diagnostic, nutritional, or physiological substance.
Arthrography  The recording of a picture of an anatomical joint
Administrative Laws  Also known as rules and regulations, these after the administration of contrast material into the joint capsule.
are created and adjudicated by administrative agencies given
authority by Congress. Arthropathy  Disease or dysfunction of a joint [plural:
arthropathies].
Advanced Life Support (ALS)  Life-sustaining, emergency care
provided, such as airway management, defibrillation, and/or the Articulation  A joint.
administration of drugs. Ascending Colon  The portion of the large intestine that connects
Adverse Effect  An unexpected bad reaction to a drug or other the cecum to the hepatic flexure.
treatment. Assume  Suppose to be the case, without proof; guess the intended
Agglutination  The process of red blood cells combining together details.
in a mass or lump. Asymptomatic  No symptoms or manifestations.
Allogeneic  The donor and recipient are of the same species, e.g., Atherosclerosis  A condition resulting from plaque buildup on
human → human, dog → dog (also known as an allograft). the interior walls of the arteries, causing reduced blood flow; also
Allotransplantation  The relocation of tissue from one individual to known as arteriosclerosis.
another (both of the same species) without an identical genetic match. Atrium  A chamber that is located in the top half of the heart and
Alphabetic Index   The section of a code book showing all codes, receives blood.
from A to Z, by the short code descriptions. Audiology   The study of hearing, balance, and related disorders.
alphanumeric  Containing both letters and numbers. Autologous  The donor tissue is taken from a different site on the
Ambulatory Surgery Center (ASC)  A facility specially designed same individual’s body (also known as an autograft).
to provide surgical treatments without an overnight stay; also Automobile Insurance  Auto accident liability coverage will
known as a same-day surgery center. pay for medical bills, lost wages, and compensation for pain and
AMCC  Automated Multi-Channel Chemistry—Automated organ suffering for any person injured by the insured in an auto accident.
disease panel tests performed on the same patient, by the same Avulsion  Injury in which layers of skin are traumatically torn
provider, on the same day. away from the body.

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Axis of Classification  A single meaning within the code set; Carrier  An individual infected with a disease who is not ill but
providing a detail. can still pass it to another person; an individual with an abnormal
gene that can be passed to a child, making the child susceptible to

B disease.
Cataract  Clouding of the lens or lens capsule of the eye.
Bacteria  Single-celled microorganisms that cause disease.
Category I Codes  The codes listed in the main text of the CPT
Basic Life Support (BLS)  The provision of emergency CPR, book, also known as CPT codes.
stabilization of the patient, first aid, control of bleeding, and/or
Category II Codes  Codes for performance measurement and
treatment of shock.
tracking.
Basic Personal Services  Services that include washing/bathing,
Category II Modifiers  Modifiers provided for use with
dressing and undressing, assistance in taking medications, and
Category II CPT codes to indicate a valid reason for a portion of a
assistance getting in and out of bed.
performance measure to be deleted from qualification.
Behavioral Disturbance  A type of common behavior that
Category III Codes  Codes for emerging technology.
includes mood disorders (such as depression, apathy, and
euphoria), sleep disorders (such as insomnia and hypersomnia), Catheter  A thin, flexible tube, inserted into a body part, used to
psychotic symptoms (such as delusions and hallucinations), and inject fluid, to extract fluid, or to keep a passage open.
agitation (such as pacing, wandering, and aggression). Cecum  A pouchlike organ that connects the ileum with the large
Benign  Nonmalignant characteristic of a neoplasm; not infectious intestine; the point of connection for the vermiform appendix.
or spreading. Centers for Medicare & Medicaid Services (CMS)  The agency
Benign Prostatic Hyperplasia (BPH)  Enlarged prostate that under the Department of Health and Human Services (DHHS) in
results in depressing the urethra. charge of regulation and control over services for those covered by
Biofeedback   Training to gain voluntary control of automatic Medicare and Medicaid.
bodily functions. Cerebral Infarction  An area of dead tissue (necrosis) in the brain
Bladder Cancer  Malignancy of the urinary bladder. caused by a blocked or ruptured blood vessel.
Blepharitis  Inflammation of the eyelid. Cerebrovascular Accident (CVA)  Rupture of a blood vessel
causing hemorrhaging in the brain or an embolus in a blood vessel
Blister  A bubble or sac formed on the surface of the skin,
in the brain causing a loss of blood flow; also known as stroke.
typically filled with a watery fluid or serum.
Certified Registered Nurse Anesthetist (CRNA)  A registered
Blood  Fluid pumped throughout the body, carrying oxygen and
nurse (RN) who has taken additional, specialized training in the
nutrients to the cells and wastes away from the cells.
administration of anesthesia.
Blood Type  A system of classifying blood based on the antigens
Character  A letter or number component of an ICD-10-PCS
present on the surface of the individual’s red blood cells; also
code.
known as blood group.
Chelation Therapy  The use of a chemical compound that binds
Body Part  The anatomical site upon which the procedure was
with metal in the body so that the metal will lose its toxic effect.
performed.
It might be done when a metal disc or prosthetic is implanted in
Body System  The physiological system, or anatomical region, a patient, eliminating adverse reactions to the metal itself as a
upon which the procedure was performed. foreign body.
Bulbar Conjunctiva  A mucous membrane on the surface of the Chief Complaint (CC)  The primary reasons why the patient has
eyeball. come for this encounter, in the patient’s own words.
Bulla  A large vesicle that is filled with fluid. Cholelithiasis  Gallstones.
Burn  Injury by heat or fire. Chondropathy  Disease affecting the cartilage [plural:
chondropathies].
C Choroid  The vascular layer of the eye that lies between the retina
and the sclera.
Capitation Plans  Agreements between a physician and a managed
care organization that pay the physician a predetermined amount of Chronic  Long duration; continuing over an extended period of
money each month for each member of the plan who identifies that time.
provider as his or her primary care physician. Chronic Kidney Disease (CKD)  Ongoing malfunction of one or
Carbuncle  A painful, pus-filled boil due to infection of the both kidneys.
epidermis and underlying tissues, often caused by staphylococcus. Chronic Obstructive Pulmonary Disease (COPD)  An ongoing
Carcinoma  A malignant neoplasm or cancerous tumor. obstruction of the airway.
Care Plan Oversight Services  E/M of a patient, reported in Ciliary Body  The vascular layer of the eye that lies between the
30-day periods, including infrequent supervision along with sclera and the crystalline lens.
preencounter and postencounter work, such as reading test results Civil Law  Laws that govern the relationships between people, and
and assessment of notes. between businesses.
Class A Finding  Nontraumatic amputation of a foot or an integral management of a patient’s specific health concern. A consultation
skeletal portion. is planned to be a short-term relationship between a health care
Class B Finding  Absence of a posterior tibial pulse; absence or professional and a patient.
decrease of hair growth; thickening of the nail, discoloration of Cornea  Transparent tissue covering the eyeball; responsible for
the skin, and/or thinning of the skin texture; and/or absence of a focusing light into the eye and transmitting light.
posterior pedal pulse. Corneal Dystrophy  Growth of abnormal tissue on the cornea,
Class C Finding  Edema, burning sensation, temperature change often related to a nutritional deficiency.
(cold feet), abnormal spontaneous sensations in the feet, and/or Corrosion  A burn caused by a chemical; chemical destruction
limping. of the skin.
Classification Systems  The term used in health care to identify Covered Entities  Health care providers, health plans, and health
ICD-10-CM, CPT, ICD-10-PCS, and HCPCS Level II code sets. care clearinghouses—businesses that have access to the personal
Clinical Laboratory Improvement Amendment (CLIA)  Federal health information of patients.
legislation created for the monitoring and regulation of clinical CPT Code Modifier  A two-character code that may be appended
laboratory procedures. to a code from the main portion of the CPT book to provide
Clinically Significant  Signs, symptoms, and/or conditions present additional information.
at birth that may impact the child’s future health status. Criminal Law  Laws governing the behavior of the actions of the
Closed Treatment  The treatment of a fracture without surgically population related to health and well-being.
opening the affected area. Critical Care Services  Care services for